MIRACLE HILL MEDICAL CENTER

DASHBOARD ELECTRONIC HEALTH RECORDS

PROFILE
HEALTH ASSESMENT
VITAL SIGNS
MEDICATIONS
HEALTH HISTORY
LABORATORY RESULTS
ALERT FLAGS
ORDERS
TREATMENT PLANS
PROGRESS NOTES
BILLING
L CENTER

RONIC HEALTH RECORDS

⬅ PATIENT'S PROFILE
↪
Patient's Name: (Last Name, First Name, Middle Rosos, Kurt
Birthday: September 29, 2002
Hospital Registration #: #1007
Religion: Seventh-day Adventist
Address: 67 Sangguniang Purok Malayo
Date of Admission: November 2022
Runny nose, Pain in the diaphragm while coughing wi
Chief of complaint: 9 out of 10 pain scale, Increased in body temperature
Muscle pain, Sleep deprivation
Admitting Diagnosis: N/A

Other Diagnosis: N/A

Allergies: (Food,Scents, Particles,Meds, Others)N/A
Reaction to Allergies: N/A

Contact in Case of Emergency:

Name:
Address: 67 Sangguniang Purok Malayo
Cellphone / Landline #: 9359410063
 PATIENT'S PROFILE

sos, Kurt
PATIENT IDENTITY
ptember 29, 2002
007
venth-day Adventist
Sangguniang Purok Malayo
vember 2022
nny nose, Pain in the diaphragm while coughing with a
out of 10 pain scale, Increased in body temperature,
uscle pain, Sleep deprivation
A

A
A
A

Sangguniang Purok Malayo

59410063
 ⬅ HEAD TO TOE ASSESSMENT
↩ ↪
ASSESSMENT CONDUCTED BY:
LOC UPPER EXTREMITIES
Alert / Right arm (full ROM) FALSE
Drowsy / other:
Lethargic / Left arm (full ROM) FALSE
Stuporous / other
Coma /
ORIENTATION
Person
Place LOWER EXTREMITIES
Time Right leg (full ROM) TRUE
other:
Left leg (full ROM) TRUE
VITALS other:
Temperature37.9 C
BP 130/90 GENERAL ASSESSMENT
RR 17 cycle per minut Weight 60 kilograms
PR 78 beats per minu Height 5'4 feet
BMI 22.9-Normal
HEAD
is even,with the
Hair hair being thick. PAIN ASSESSMENT
symmetrical and Acute /Chronic Acute
Nose smooth Intensity (1-10) 6 out of 10
redness Location Head
Eyes observed. Duration 1 week
dryness or Characteristics
Scalp lesions Precipitation
no unusual Frequency
Face movements. Non-verbals
tongue is Relief Factors OTC drugs
Lips smooth,
Lips are smooth 3 days without
getting adequate
glossy,pale and Sleep sleep.
Teeth/gums no lesions
observed
NECK
Supple TRUE SKIN ASSESSMENT
Full ROM As the clients TRUE Description
swallows, the neck
Other: moves symmetrically.
The patient's skin tone range ranges
from light brown to a very dark shade of
brown, and from a ruddy pink to a very
light shade of pink. There are no visible
lesions, rashes, or wounds. Upon
palpating the client's skin,the moisture is
consistent in all places, including skin
folds. The temperature is aldo consistent
 The patient's skin tone range ranges
CHEST from light brown to a very dark shade of
brown, and from a ruddy pink to a very
Palpation Abnormal light shade of pink. There are no visible
Unequal chest
Remarks lesions, rashes, or wounds. Upon
expansion
Auscultation Abnormal palpating the client's skin,the moisture is
Patient's breath
consistent in all places, including skin
Remarks sounds are
folds. The temperature is aldo consistent
crackles
ABDOMEN across the entire surface of the skin,
Inspection which has a smooth texture and no
Auscultation edema. The skin is instantly return to its
normal state after being lightly pinched.
Palpation
 ⬅
↩ ↪ VITAL SHEET
DATE : DATE:
SHIFT: AM PM NIGHT PRN AM
TIME TAKEN:
BP:
TEMP:
TEMP ROUTE
PR:
RR:
O2 SAT:
PAIN SCALE:
VITAL SHEET
DATE: DATE:
PM NIGHT PRN AM PM NIGHT PRN
 ⬅
↩ ↪
MEDICAL ADMINISTRATION

Legend

DATE GIVEN MEDICATIONS DOSAGE

DMINISTRATION RECORD

GIVEN DELAYED
NOT GIVEN DISCONTINUED

REMARKS
 ⬅
↩ ↪ HEALTH HISTORY

Dashboard
Surgery
Past Medical Surgery
Date Type Results

Family Health History

Allergies

Past Medication

Allergies

Type Status
HEALTH HISTORY

Family Health History

Medical Family Status

HYPERTENSION Grandfather (FAlive

Medication

Type Status
 ⬅ 18, F
↩ ↪
Pending Requisitions Order lab

Waiting Results
Provider 🟥
Test 🟥 -
Pending Dr. Review

Lab Instructions
All Lab Results

Pending Requisitions
Not Performed Entry Date Test Lab
Not Performed -
Not Performed
Not Performed
Not Performed
Not Performed
Not Performed
Not Performed

Waiting Results
Pending
-
-

Review
Pending
-
 18, February 2023

Laboratory Results

Visit Date Lab Test Results

-

Provider
 ⬅ CLINICAL ALERT
↩ ↪

DATE USER EVENT STATUS CLINICAL ALERT

CLINICAL ALERT
 ⬅
↩ ↪

DATE PROBLEM SHORT TERM GOALS

 PLAN OF CARE

M GOALS APPROACHES DATE EVALU

EVALUATION GOALS MET
↩
⬅
↪ ORDER M
PAST MEDICATION
DOCTORS ORDERNAME OF PHYSICIADATE DRUG NAME
ORDER MANAGEMENT
PAST MEDICATION CURRENT MEDICATION
DATE DOSE STATUS DRUG NAME DATE
CURRENT MEDICATION
DOSE STATUS
 ⬅
↩ ↪ PROGRESS
DATE STATUS REMARKS
 ⬅ BILLING
↩ ↪
Date Service Charge

TOTAL
0