ROOM NAME AGE/ RELIGION CHIEF DIAGNOSIS SPECIAL ENDORSEMENT FOR LABORATORIES

NO. OF SEX COMPLAINTS

PATIENT
(INITIAL
S ONLY)
803 A.T. 76/ Roman Epigastric pain Chronic Calculous Cholecystitis V/S q4h Lap Chole Poss. Open 12/6
M Catholic Without IVF 8AM
No allergies
804 R. B. 5 /M Roman Fever, cough, PCAP-B V/S q4h N/A
Catholic vomiting
806 N. D. 69/ F Roman Fever UTI V/S q4h N/A
Catholic Obstructive Uropathy, Post With FBC
Spinal Cord Compression S/P
FUSIO 11/11/22 S/P BT #1
808 K. T. 9/F Roman Abdominal T/C Acute Appendicitis N/A
Catholic pain 7/10
809 L. C. 45 / Roman Hypogastric Obstructive Uropathy Sec to I&O qshift N/A
F Catholic pain, dysuria Cervical CA V/S q4h
Cervical CA locally advanced With Nephrostomy tube left and right

S/P Bilateral Nephrostomy

Insertion
810 W. D. L 31 / Roman N/A Potts Diseases T10- T11 I&O qshift Laminectomy, PSF T8-T12
M Catholic V/S q4h 12/5 TF 1st case of Dr.
Condor
811 C. M. 65 / Born Fall Fractured, Closed, Complete, I&O qshift ORIF IMN Prox Humerus
F Again Displaced, Humeral Neck, Left, V/S q4h Left 12/5 TF biopsy of
Christian Soft Tissue Contusion CBS TID AC and HS tongue mass (est. 12
midnight)
813 L. A. 73 / Roman Left sided Acute CVD Infarct Right MCA I&O qshift RPT CXR PA in AM 12/5/22
M Catholic weakness territory (NIHSS 5) V/S q4h L
Type 2 Diabetes
814 V. C. 61 / Roman Slurring of T/C CVD Infarct, HCVD I&O qshift Triple Lumen II Catheter
M Catholic speech, Fall, V/S q2h 11/22/22 @ 12:00 noon –
DOB @ No IVF Refused
Bipedal edema
 FBC Insertion- Refused Urinalysis – PD
Intubation- Refused with Waiver
ICU Admission – Refused Sensitivity Study for
Proteus Mirabilis Isolate –
RX
816 M. A. 78 / Roman DOB CAP HR TT Shirley attached to MV with following settings: N/A
M Catholic T/C Aspiration Pneumonia MODE: ACPCV
ARF Type 2 BUR: 12%
ARDS FI02: 40%
R/O Pulmonary Embolism PEEP: 8
HCVD; CAD PCONTROL: 12
IT: 0.7 RISE: 2
ITRIG: 2L/min

CBS ACBF/ACL, HS with own Gluc

With FBC
With Tracheostomy
Tracheo care qshift
817 L. K. M. 1/ Roman Coughing, PCAP- C V/S q4h N/A
M Catholic Asthma O2 @ 0.5LPM via NC
818 R. D. 75 / N/A Pain both Degenerative Osteoarthritis V/S q4h
F knees both knees O2 @2LPM via NC

S/P Total Knee Replacement With Pacemaker

Bilateral With Eggcrate
820 J. L. 33 / N/A Fever + LBM T/C UTI V/S q2h Stool Exam (2,3) – STL
M
821 E. J. 58 / Roman Lower back HNP L4-L5 Severe Left V/S q4h 2D Echo L 12/5/22 7am
F Catholic pain Secure 1 unit PRBC of Pt’s blood type properly
screened and crossmatched for possible or use of For TLIF L3—L4- L5 – S1
BRF (+) 12/5/22 @7:30am

822 M. B. 56 / Roman Oliguria To Consider Chronic Kidney I&O qhourly Urine Albumin and Urine
M Catholic Disease V/S qhourly Crea Ration {MICRAL
To consider Anemia secondary CBS TID AC & HS (MALB)} – STL
to Number 1
 To consider Chronic Heart With FBC Sputum Gene Xpert – STL
Failure FC 1 Sputum GSCS, Sputum AFB
–L

2D Echo – L
UTZ WAB with Prostate – L
12/5/22 in AM
823 M.P. 88 / Roman Fever and Septic Encephalopathy I&O qhourly Sputum GSCS STL
F Catholic chills secondary to Aspiration V/S q4h
Pneumonia O2 @ 3-4LPM via NC
CBS q6h
Abdominal Girth q6am: 123cm

Position: Trendelenburg

Secure 1-unit PRBC of pt’s BTPSC as Standby use-

With BRF (-)
With NGT
With FBC
824 A.P. 66 / Roman Abdominal Septic Shock I&O qshift Lap Chole Poss. Open
M Catholic pain HCVD V/S q2h 12/6/22
nd
DM Type 2 CBS TID AC Meals and HS TF 2 case (TURP) Est. 4pm
O2 @ 2LPM via NC

Secure 2 units PRBC of pt’s blood type- With BRF (+)

With infusion pump – ER
826 A.C. 55 / Roman Abdominal Breast CA Stage 3, Left with I&O qshift 2DED 12/5 L Mon
F Catholic pain, Jaundice Liver Metastasis V/S q4
S/P Mastectomy Left December U/A, Urine GSCS – STL
2021 CBC TID AC Meals and HS PROCAL, NA, Blood Culture
T/C Covid19 Infection O2 @ 5LPM via NC X1 – STL
HCVD DM Type 2
Save Left Arm CXR-AP (Portable) -RX
With NGT

With infusion pump – ICU

 Secure Donor for platelet Apharesis – With BRF (-)
827 D. T. 52 / Roman Right lower To Consider Acute Appendicitis O2 @ 2-3LPM via NC PRN CBC q12h (12am/12pm) –
M Catholic quadrant pain, CKD Stage 4 secondary to DM Defer
Abdominal Nephropathy and Hypertension With AVF Left
pain Nephrosclerosis Save Left Arm
Allergic to Allopurinol
S/P Colonoscopy
S/P HD#4; S/P BT #4
828 P. C. 50 / Roman Light Vertebral Artery Dissection I&O qshift Cerebral Angiogram
M Catholic headedness S/P Cerebella Infarct 2020 V/S q4 Monday 12/5/22 @8am
and increased Allergic to mongos and crustaceans
HR
829 A.B. 64 / Roman Increasing Obstructive Uropathy Sec to I&O qshift PCN Left 12/5 6pm
M Catholic creatinine Nephrolithiasis, Left AKI Sec #1 V/S q4 (Tentative)
HPN
CBS q6h while NPO

Pls secure 1-unit PRBC of pt’s blood type properly

screened ad crossmatched for possible or use with 1
unit @ BB
831 A. M. A 13 Roman Hyponatremia, Congenital Adrenal Hyperplasia V/S q2h Serum Cortisol – L Mon in
days Catholic hyperkalemia I&O qshift AM 12/5/22 (Sendout CHH)
/M Weight patient daily

CBS q6h

With Phototherapy with cardiac monitor c/o CSSD

832 I. A. G. 5/F Roman DOB, Cough 3 PCAP B I&O qshift N/A
Catholic days V/S q4
O2 @ 2LPM via NC
With pulse oximeter at bedside
833 H. H. 49/ Roman For coronary R/O CAD V/S q4 Coronary Angiogram 12/5
M Catholic angiogram TF 1st case
ROOM NAME AGE/ RELIGION CHIEF DIAGNOSIS SPECIAL ENDORSEMENT FOR LABORATORIES
NO. OF SEX COMPLAINTS
PATIENT
 (INITIAL
S ONLY)
803 A.T. 76/ M Roman Epigastric pain Chronic Calculous V/S q4h Lap Chole Poss. Open 12/6 8AM
Catholic Cholecystitis Without IVF
No allergies
806 N. D. 69/ F Roman Fever UTI V/S q4h N/A
Catholic Obstructive Uropathy, Post With FBC
Spinal Cord Compression
S/P FUSIO 11/11/22 S/P BT
#1
808 K. T. 9/F Roman Abdominal T/C Acute Appendicitis V/S q4 N/A
Catholic pain 7/10
810 W. D. L 31 / M Roman N/A Potts Diseases T10- T11 I&O qshift @OR
Catholic V/S q4h
811 C. M. 65 / F Born Fall Fractured, Closed, I&O qshift ORIF IMN Prox Humerus Left 12/5 TF
Again Complete, Displaced, V/S q4h biopsy of tongue mass (est. 12
Christian Humeral Neck, Left, Soft CBS TID AC and HS midnight)
Tissue Contusion
812 S.P. 75 / F Roman DOB CHF V/S q4 AV Duplex of BLE- L AM
Catholic HCVD O2 @2LPM NC
HYPOKALEMIA
With FBC
813 L. A. 73 / M Roman Left sided Acute CVD Infarct Right I&O qshift N/A
Catholic weakness MCA territory (NIHSS 5) V/S q4h
Type 2 Diabetes Mellitus
814 V. C. 61 / M Roman Slurring of T/C CVD Infarct, HCVD FBC Insertion- Refused Triple Lumen II Catheter
Catholic speech, Fall, Intubation- Refused with Waiver 11/22/22 @ 12:00 noon – Refused
DOB @ ICU Admission – Refused
Bipedal edema Urinalysis – PD

Sensitivity Study for Proteus Mirabilis

Isolate – RX
815 P. B. 30/ M Roman Seizure Cavernoma, Right Frontal V/S Q4 EEG – L 10AM
Catholic Lobe With 4-point restraint
816 M. A. 78 / M Roman DOB CAP HR TT Shirley attached to MV with following CXR PA IN AM 9PORT) - L
Catholic T/C Aspiration Pneumonia settings:
 ARF Type 2 MODE: SPONT
ARDS FI02: 35%
R/O Pulmonary Embolism PSV: 10
HCVD; CAD PEEP: 6

CBS ACBF/ACL, HS with own Gluc

With Condom Catheter

With Tracheostomy
Tracheo care qshift
817 L. K. M. 1/M Roman Coughing, PCAP- C V/S q4H N/A
Catholic Asthma
818 R. D. 75 / F N/A Pain both Degenerative V/S q4h N/A
knees Osteoarthritis both knees O2 @2LPM via NC

S/P Total Knee With Pacemaker

Replacement Bilateral With Eggcrate
820 R.N.M 57 / M N/A DOB CAPMR O2 @3-5LPM VIA NC Sputum GSCS and GeneXpert STL
HCVD
DM II CBS ACBF AND 2HPD

CBS Q4H ON NPO

V/S qhourly

Allergy to Penicillin
821 E. J. 58 / F Roman Lower back HNP L4-L5 Severe Left V/S q4h N/A
Catholic pain O2 @ 2LPM VIA NC until AM
S/P TLIF
With FBC
With EasyPump
822 M. B. 56 / M Roman Oliguria To Consider Chronic Kidney I&O qhourly Sputum Gene Xpert – STL
Catholic Disease V/S qhourly Sputum GSCS, Sputum AFB – L
To consider Anemia CBS TID AC & HS
secondary to Number 1
To consider Chronic Heart With FBC
Failure FC 1
823 M.P. 88 / F Roman Fever and Septic Encephalopathy I&O qhourly CT Scan Brain Plain- PD
 Catholic chills secondary to Aspiration V/S q4h
Pneumonia O2 @ 3-4LPM via NC Sputum GSCS STL
CBS q6h
Abdominal Girth q6am: 122cm

Secure 1-unit PRBC of pt’s BTPSC as

Standby use- With BRF (-)
With NGT
With FBC
824 A.P. 66 / M Roman Abdominal Septic Shock I&O qshift Lap Chole Poss. Open 12/6/22
Catholic pain HCVD V/S q2h TF 2nd case (TURP) Est. 4pm
DM Type 2 CBS TID AC Meals and HS
O2 @ 2LPM via NC

Secure 2 units PRBC of pt’s blood type-

With BRF (+)
With infusion pump – ER
825 B.R. 20 / M N/A Difficulty Neglected Left Open V/S q4 Debridement Left Patellar Tendon Poss
walking, Patellar Tendon Rupture VAC 12/6 10AM
tenderness
U/A STL
828 P. C. 50 / M Roman Light Vertebral Artery Dissection I&O qshift N/A
Catholic headedness S/P Cerebella Infarct 2020 V/S q4
and increased Allergic to mongos and crustaceans
HR S/P cerebral Angiogram
829 A.B. 64 / M Roman Increasing Obstructive Uropathy Sec I&O qshift 2DED L AM
Catholic creatinine to Nephrolithiasis, Left AKI V/S q4
Sec #1
HPN CBS q6h while NPO

S/P PCNL Standby Esmolol 50 mg/ vial at bedside

(+)

With FBC
830 O.F. 2/F Roman Age with DHN V/S q4 N/A
Catholic
831 A. M. A 13 days Roman Hyponatremia, Congenital Adrenal V/S q2h N/A
 /M Catholic hyperkalemia Hyperplasia I&O qshift
Weight patient daily

CBS q6h

With Phototherapy
832 I. A. G. 5/F Roman DOB, Cough 3 PCAP B I&O qshift N/A
Catholic days V/S q4
O2 @ 2LPM via NC PRN
833 H. H. 49/ M Roman For coronary R/O CAD V/S q4 N/A
Catholic angiogram
S/P Coro Angio
ROOM PATIEN DIET
T
803 A.T. DAT
804 R. B. DAT
806 N. D. DAT +1
BANANA PER
MEAL
808 K. T. LOW FAT
809 L. C. DAT
810 W. D. L DAT

NPO 6AM
811 C. M. SOFT
813 L. A. 1550 KCAL/DAY
<50% CHO,
<40% CHON,
<2.3G NACL,
<4G K, <200MG
CHOLESTEROL,
NO SIMPLE
SUGARS, NO
DAIRY
PRODUCTS
DIVIDED IN 3
MEALS AND
SNACKS
814 V. C. DAT, LOW SALT
816 M. A. DAT, LOW SALT,
LOW FAT, HBV
PROTEIN (50
GMS, LOW
PURINE, LOW
PHOSPHORUS)
WITH SAP
NO BANANA,
MAY GIVE
PAPAYA
INSTEAD
817 L. K. M. DAT
818 R. D. LOW SALT, LOW
FAT
820 J. L. DAT
821 E. J. DAT

NPO PMN
822 M. B. LSLF NON-OILY
DIET

LOFI 1L/DAY
823 M.P. 1200 CALORIES
IN 1000ML 0
PROTEIN 40 GM
FAT DIET
824 A.P. SOFT

LOFI 1L/DAY
826 A.C. 1425 KCAL PER
DAY <50% CHO,
<40% CHON,
<200MG
CHOLESTEROL,
<4G NA, <2G K,
NO SIMPLE
SUGARS
DIVIDED IN 3
MEALS + 2
SNACKS + 1 EGG
WHITE PER
MEAL
ENSURE 6
SCOOPS +
BENEPROTEIN 2
SCOOPS IN
200CC WATER
TID IN
BETWEEN
MEALS (PS)
827 D. T. UREMIC DIET

LOFI 800-1L/
DAY
828 P. C. DAT

NPO PMN

ALLERGY TO
MONGOS AND
CRUTACEANS
829 A.B. DAT

CLEAR LIQS
10AM
NPO AT 4PM
831 A. M. A BREASTFEEDING
832 I. A. G. DAT
833 H. H. DAT

NPO PMN

ROOM PATIEN DIET 811 C. M. SOFT

T CLEAR LIQS 8
803 A.T. DIET W/ SPECS AM, NPO 2PM
806 N. D. DAT +1 812 S.P. LSLF W/ SAP
BANANA PER
MEAL LOFI 800C/DAY
808 K. T. LOW FAT 813 L. A. 1550 KCAL/DAY
810 W. D. L DAT <50% CHO,
<40% CHON,
NPO 6AM <2.3G NACL,
 <4G K, <200MG
CHOLESTEROL,
NO SIMPLE
SUGARS, NO
DAIRY
PRODUCTS
DIVIDED IN 3
MEALS AND
SNACKS
814 V. C. DAT, LOW SALT
815 P. B. DAT
816 M. A. DAT, LOW SALT,
LOW FAT, HBV
PROTEIN (50
GMS, LOW
PURINE, LOW
PHOSPHORUS)
WITH SAP
NO BANANA,
MAY GIVE
PAPAYA
INSTEAD
817 L. K. M. DAT
818 R. D. LOW SALT, LOW
FAT
820 R.N.M NPO TEMP

LOFI 1.3L/DAY
821 E. J. DAT
822 M. B. LSLF NON-OILY
DIET

LOFI 1L/DAY
823 M.P. 1200 CALORIES
IN 1000ML 0
PROTEIN 40 GM
FAT DIET
824 A.P. SOFT
LOFI 1L/DAY
825 B.R. DAT

NPO PM
828 P. C. DAT

ALLERGY TO
MONGOS AND
CRUTACEANS
829 A.B. DAT
830 O.F. SFF
NO OILY, SPICY,
LOW FATTY
FOODS
831 A. M. A BREASTFEEDING
832 I. A. G. DAT
833 H. H. DAT

NPO PMN
ROOM PATIENT’S CATEGORIES CLASSIFICATION RATIONALE
NO. NAME OF CARE OF CATEGORIES
803 A.T. C1 L1 - Requires minimal medical treatment
nursing interventions but close
supervision
- Does not exhibit unusual symptoms,
non-emergent
804 R. B. C1 L1 - Requires minimal medical treatment
nursing interventions but close
supervision
- Non- emergent and does not exhibit
unusual symptoms
806 N. D. C4 L4 - Requires continuous observation and
intervention. Requires frequent and
intensive medical observation and
treatment
- V/S and I&O needs to be monitored
frequently
808 K. T. C1 L1 - Requires minimal medical treatment
nursing interventions but close
supervision
- Does not exhibit unusual symptoms,
non-emergent
809 L. C. C1 L1 - Requires minimal medical treatment
nursing interventions but close
supervision
- Does not exhibit unusual symptoms,
non-emergent, about to be discharged
810 W. D. L C1 L1 - Requires minimal medical treatment
nursing interventions but close
supervision
- Does not exhibit unusual symptoms,
non-emergent
811 C. M. C2 L2 - Requires moderate nursing observation
and intervention but requires minimal
medical treatment
- Needs some assistance in ADLs
812 S.P. C3 L3 - Requires frequent, close nursing
observation and intervention and
requires moderate medical
intervention
- Oxygen therapy @2LPM NC
813 L. A. C1 L1 - Requires minimal medical treatment
nursing interventions but close
supervision
- Does not exhibit unusual symptoms,
non-emergent
814 V. C. C3 L3 - Requires frequent, close nursing
observation and intervention and
requires moderate medical
 intervention
- `V/S more than 3 times per shift, needs
close observation
815 P.B. C4 L4 - Requires continuous observation and
intervention. Requires frequent and
intensive medical observation and
treatment
- With 4-point restraint
816 M. A. C4 L4 - Requires continuous observation and
intervention. Requires frequent and
intensive medical observation and
treatment
- Needs continuous observation
817 L. K. M. C3 L3 - Requires frequent, close nursing
observation and intervention and
requires moderate medical
intervention
- With continuous oxygen therapy
818 R. D. C4 L4 - Requires continuous observation and
intervention. Requires frequent and
intensive medical observation and
treatment
- Close observation, may have significant
changes anytime
820 J. L. C1 L1 - Requires minimal medical treatment
nursing interventions but close
supervision
- Does not exhibit unusual symptoms,
non-emergent
821 E. J. C4 L4 - Requires continuous observation and
intervention. Requires frequent and
intensive medical observation and
treatment
- Close observation, may have significant
changes anytime
822 M. B. C4 L4 - Requires continuous observation and
intervention. Requires frequent and
intensive medical observation and
treatment
- Close observation, may have significant
changes anytime
823 M.P. C4 L4 - Requires continuous observation and
intervention. Requires frequent and
intensive medical observation and
treatment
- Close observation, may have significant
changes anytime
824 A.P. C3 L3 - Requires frequent, close nursing
observation and intervention and
requires moderate medical
 intervention
- Continuous oxygen therapy, V/S
monitored more than 3 times per shift
825 B. R. C1 L1 - Requires minimal medical treatment
nursing interventions but close
supervision
- Newly admitted
826 A.C. C4 L4 - Requires continuous observation and
intervention. Requires frequent and
intensive medical observation and
treatment
- Guarded code, many medication, V/S
monitored closely, expired
827 D. T. C1 L1 - Requires minimal medical treatment
nursing interventions but close
supervision
- Discharged
828 P. C. C1 L1 - Requires minimal medical treatment
nursing interventions but close
supervision
- Discharged
829 A.B. C1 L1 - Requires minimal medical treatment
nursing interventions but close
supervision
- Does not exhibit unusual symptoms,
non-emergent
830 O.F. C1 L1 - Requires minimal medical treatment
nursing interventions but close
supervision
- Newly admitted
831 A. M. A C3 L3 - Requires frequent, close nursing
observation and intervention and
requires moderate medical
intervention
- Cardiac monitor present, V/S
monitored 3 times per shift
832 I. A. G. C3 L3 - Requires frequent, close nursing
observation and intervention and
requires moderate medical
intervention
- Continuous oxygen therapy
833 H. H. C4 L4 - Requires continuous observation and
intervention. Requires frequent and
intensive medical observation and
treatment
- Guarded code