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  • Unlabored. RA/NC - L/min Tender. N/V. urinal/BR/FC/ Incont/ Aspiration

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    shell
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    This document contains medical notes from a patient's hospital stay. It includes assessments of the patient's vital signs, neurological status, cardiovascular and respiratory systems, gastrointestinal and genitourinary systems, and mobility. It also notes the patient's incision, skin, diet, and medication administration over multiple days. The notes track the patient's progress and include documentation from doctors, nurses, and physical therapists.

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    Final Stanford

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    This document contains medical notes from a patient's hospital stay. It includes assessments of the patient's vital signs, neurological status, cardiovascular and respiratory systems, gastrointestinal and genitourinary systems, and mobility. It also notes the patient's incision, skin, diet, and medication administration over multiple days. The notes track the patient's progress and include documentation from doctors, nurses, and physical therapists.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    34 views9 pages

    Unlabored. RA/NC - L/min Tender. N/V. urinal/BR/FC/ Incont/ Aspiration

    Uploaded by

    shell
    This document contains medical notes from a patient's hospital stay. It includes assessments of the patient's vital signs, neurological status, cardiovascular and respiratory systems, gastrointestinal and genitourinary systems, and mobility. It also notes the patient's incision, skin, diet, and medication administration over multiple days. The notes track the patient's progress and include documentation from doctors, nurses, and physical therapists.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    of 9

    Dx

    VS Neuro: A&Ox__, NV checks: CSM intact, no neuro deficits CARDIO: WNL, denies CP RESP: LSCTA, breathing is even and unlabored. RA/NC___L/min GI/GU: BS, flatus, BM, LBM ____ distended, tender. N/V. urinal/BR/FC/ Incont/ aspiration prectn. Diet R/CL/NPO

    Prblm by acuity PLAN/FU/Comment New Orders Future procedure Contact Rx documented

    Day

    F/DN

    MD __________ round __ D/c date______ ALL: IV rate ___ml/h soln: IV rate ___ml/h soln: Flu/PNA, test reading

    SKIN: Warm, DI SCD INCISION: staples MOBL/PRCTN: Fall / hip prctn OT walk gait Adlib WBAT NWB Asst max/mod

    MEDS
    VS/NEURO I&O-dtv? 1 2 3 4 PCA

    10

    11

    12

    notes

    Dx

    VS Neuro: A&Ox__, NV checks: CSM intact, no neuro deficits CARDIO: WNL, denies CP RESP: LSCTA, breathing is even and unlabored. RA/NC___L/min GI/GU: BS, flatus, BM, LBM ____ distended, tender. N/V. urinal/BR/FC/ Incont/ aspiration prectn. Diet R/CL/NPO

    Prblm by acuity PLAN/FU/Comment New Orders Future procedure Contact Rx documented

    Day

    F/DN

    MD __________ round __ D/c date______ ALL: IV rate ___ml/h soln: IV rate ___ml/h soln: Flu/PNA, test reading

    SKIN: Warm, DI SCD INCISION: staples MOBL/PRCTN: Fall / hip prctn OT walk gait Adlib WBAT NWB Asst max/mod

    MEDS
    VS/NEURO I&O-dtv? 1 2 3 4 PCA

    10

    11

    12

    notes

    Dx

    VS Neuro: A&Ox__, NV checks: CSM intact, no neuro deficits CARDIO: WNL, denies CP RESP: LSCTA, breathing is even and unlabored. RA/NC___L/min GI/GU: BS, flatus, BM, LBM ____ distended, tender. N/V. urinal/BR/FC/ Incont/ aspiration prectn. Diet R/CL/NPO

    Prblm by acuity PLAN/FU/Comment New Orders Future procedure Contact Rx documented

    Day

    F/DN

    MD __________ round __ D/c date______ ALL: IV rate ___ml/h soln: IV rate ___ml/h soln: Flu/PNA, test reading

    SKIN: Warm, DI SCD INCISION: staples MOBL/PRCTN: Fall / hip prctn OT walk gait Adlib WBAT NWB Asst max/mod

    MEDS
    VS/NEURO I&O-dtv? 1 2 3 4 PCA

    10

    11

    12

    notes

    Dx

    VS Neuro: A&Ox__, NV checks: CSM intact, no neuro deficits CARDIO: WNL, denies CP RESP: LSCTA, breathing is even and unlabored. RA/NC___L/min

    Prblm by acuity PLAN/FU/Comment

    Day

    GI/GU: BS, flatus, BM, LBM ____ distended, tender. N/V. urinal/BR/FC/ Incont/ aspiration prectn. Diet R/CL/NPO MD __________ round __ D/c date______ ALL: SKIN: Warm, DI SCD INCISION: staples MOBL/PRCTN: Fall / hip prctn OT walk gait Adlib WBAT NWB Asst max/mod Flu/PNA, test reading IV rate ___ml/h soln: IV rate ___ml/h soln: 10 11

    New Orders Future procedure Contact Rx documented

    F/DN

    MEDS
    VS/NEURO I&O-dtv? 1 2 3 4 PCA

    12

    notes

    Dx

    VS Neuro: A&Ox__, NV checks: CSM intact, no neuro deficits CARDIO: WNL, denies CP RESP: LSCTA, breathing is even and unlabored. RA/NC___L/min GI/GU: BS, flatus, BM, LBM ____ distended, tender. N/V. urinal/BR/FC/ Incont/ aspiration prectn. Diet R/CL/NPO

    Prblm by acuity PLAN/FU/Comment New Orders Future procedure Contact Rx documented

    Day

    F/DN

    MD __________ round __ D/c date______ ALL: IV rate ___ml/h soln: IV rate ___ml/h soln: Flu/PNA, test reading

    SKIN: Warm, DI SCD INCISION: staples MOBL/PRCTN: Fall / hip prctn OT walk gait Adlib WBAT NWB Asst max/mod

    MEDS
    VS/NEURO I&O-dtv? 1 2 3 4 PCA

    10

    11

    12

    notes

    Dx

    VS Neuro: A&Ox__, NV checks: CSM intact, no neuro deficits CARDIO: WNL, denies CP RESP: LSCTA, breathing is even and unlabored. RA/NC___L/min GI/GU: BS, flatus, BM, LBM ____ distended, tender. N/V. urinal/BR/FC/ Incont/ aspiration prectn. Diet R/CL/NPO

    Prblm by acuity PLAN/FU/Comment New Orders Future procedure Contact Rx documented

    Day

    F/DN

    MD __________ round __ D/c date______ ALL: IV rate ___ml/h soln: IV rate ___ml/h soln: Flu/PNA, test reading

    SKIN: Warm, DI SCD INCISION: staples MOBL/PRCTN: Fall / hip prctn OT walk gait Adlib WBAT NWB Asst max/mod

    MEDS
    VS/NEURO I&O-dtv? 1 2 3 4 PCA

    10

    11

    12

    notes

    Dx

    VS Neuro: A&Ox__, NV checks: CSM intact, no neuro deficits CARDIO: WNL, denies CP RESP: LSCTA, breathing is even and unlabored. RA/NC___L/min GI/GU: BS, flatus, BM, LBM ____ distended, tender. N/V. urinal/BR/FC/ Incont/ aspiration prectn. Diet R/CL/NPO

    Prblm by acuity PLAN/FU/Comment New Orders Future procedure Contact Rx documented

    Day

    F/DN

    MD __________ round __ D/c date______ ALL: IV rate ___ml/h soln: IV rate ___ml/h soln: Flu/PNA, test reading

    SKIN: Warm, DI SCD INCISION: staples MOBL/PRCTN: Fall / hip prctn OT walk gait Adlib WBAT NWB Asst max/mod

    MEDS
    VS/NEURO I&O-dtv? 1 2 3 4 PCA

    10

    11

    12

    notes

    Dx

    VS Neuro: A&Ox__, NV checks: CSM intact, no neuro deficits CARDIO: WNL, denies CP RESP: LSCTA, breathing is even and unlabored. RA/NC___L/min GI/GU: BS, flatus, BM, LBM ____ distended, tender. N/V. urinal/BR/FC/ Incont/ aspiration prectn. Diet R/CL/NPO

    Prblm by acuity PLAN/FU/Comment New Orders Future procedure Contact Rx documented

    Day

    F/DN

    MD __________ round __ D/c date______ ALL: IV rate ___ml/h soln: IV rate ___ml/h soln: Flu/PNA, test reading

    SKIN: Warm, DI SCD INCISION: staples MOBL/PRCTN: Fall / hip prctn OT walk gait Adlib WBAT NWB Asst max/mod

    VS/NEURO I&O-dtv? 1 2 3 4 PCA

    MEDS

    10

    11

    12

    notes

    08 09 10 11 12 13 14

    PCA check? Verify

    PCA check? Verify

    PCA check? Verify

    PCA check? Verify

    15 16 17 18 19 pump- clear pump- clear pump- clear pump- clear

    MD notes

    RN notes

    PT CM

    Problem by acuity

    Plan

    Follow up

    Comments

    5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

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