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~SSM

HEALTH - CARE

DePaul Health Center


Affidavit

2006 Missouri ; Quality Award Recipient

12303 DePaul Drive' St. Louis, MO 63044-2588' (314) 344 6000 phone' www.ssmdepaul.com

Before me, the undersigned authority, personally appeared Julie Leigh, RHIT, who, being me duly sworn, deposed as follows: My name is Julie Leigh, RHIT. I am of sound mind, capable of making this affidavit, and personally acquainted with the facts herein stated: I am custodian of the records of SSM DePaul Health Center. Attached hereto are

CtJ:;;

pages of records

frorrP~

/J7aJi.Lfu

These~ages

are kept by SSM DePaul Health Center in the regular course of business, and it was the regular course of business of SSM DePaul Health Center for an employee or representative of SSM DePaul Health Center with knowledge of the act, event, condition, opinion, or diagnosis recorded to make the record or to transmit information thereof to be included in such record; and the record was made at or near the time of act, event, condition, opinion, or diagnosis. The records attached hereto are the original:or exact duplicates of the original.

In witness whereof, I have hereunto subscribed my name and affixed my official , 2009. seal this ;)6 day of

mat

f&M 1dl flwm,(Signed) J /


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~~_~~!I!!I!I!_'
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PLAINTIFF'S EXHIBIT

--. --. KAREN M. PAYNE Notary PubliC-Notary Seal State or Missouri, St louis County Commission # 05535024 My COmmlss~)es Aug 7, 2009
~

~
~

'fA

GilI'

Missioll : THROUGH OUR EXCEPTIONAL HEALTH CARE SERVICES , WE REVEAL THE HEALING PRESENCE OF GOD .

DATESTARTED ,O.O<D. ZOO:} PREVIOUS 24 If0: Intake (Mpvt ISOLATION: 0 Special Conllict 0 Contact 0 Neutropenic 0 Airborne 0 Droplet 0 _ _ __ StAlE KEY: 0 Berl 0 Standing 0 W/ChaJr 0 Sling ornER PRECAUnONS: 0 Safety-Fall 0 Bleeding 0 Aspiration 0 Seiz.ure 0 YesterdBy'1 wI. _ _ _ KG T003,/,8 wi. KG (please reconcile welgllt difference II greatllt lfIan 2.5 kg.}
i Temp
: Pv~~ iRil>';,

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

/1J}er:

fP

24 HI

H'b"
i

'-'ft'
/ / //. / /
100
i

W/P

IBP
,0?J;11

v--" ~ft:11 >< >,/ / / ' / / /" i// 1//


'tOO

l..:l.p

V /
1 ,

~~ V' / /
Irv
ff. ...

.::.

// //

/ ' ../ ' , / / / /


Time

IOn,!Aat~

I02 dellvenog iWlil:e


-'

,i\

iLL\'

,
i

IBeosil.le glucose Dr 'PUL!E REaP TIME ,F"" J:i;M

Til!

mE

DP
'//'.'

Iflll.~

flU P ! Tfllf

lMf , lP
1/"-'
i/-:r
!

[PULSE HI 3P

~/
.,-/'

I.e",

~l'v.....",n"K~
" ."'''
v
,,,,(

/'

~/'

.r/-'

~I
DINNER

OIl11fl)
S~TIC

111 IE
~f'
"r'/

I [TIME Dr
.,-rr"
~_/-

SealtUn,

i .-

()b$~rva1iD

0-

FII!I~Tlnn

,/-----

_r/-'

LUNCH

/,/

_-,,,r
HS SNACK

Oa&"ibe;
l~clllion.

\'ZQC

\0/

00"'/6
IlRfHE
Amounl

U.~ln'iDf~

lY~

ftibX

...

,.,.,

ORAL

"'Ot

n:tUIIW~

OTHER

GMl
--' --

If
Amount

fWSfl
Amount

~.
AmellOl
Amlllillt

To Coon!

0700 OSOO 090 100 Jj lJ l1H r01)


I

i V' I

Amount

I\mwrn

ArT'.(Jlmt

AmLifl1lq,

Sedalll1n L
.. -

120
130

:?>IcD
''>

._,

1400
i

lSOO 1500

.,

1700
1300

i2 hi
SuI1 fotal;;

)fJO
,
i

---"

(Q,Cl) ... __
12 ~f
lot~1

12 hI Tot~1 P3fenwr1i _~ To COUllt 'I \}(15 1900 i


2(160 2101J 220(1
Z~OO

(i(al/!u(\c _ _

12

~I

Shift lMaxa

'J~)
,.

-.~

--- ---

--- --- - - - -

BEHAvt( AN ~ Ami i ~ Emo.


1= Ineff 11- 0_1

1{ h' :'iMl "Jili)'ll

INTERVE
1. R.aa&&u 2. R.Jt19(

3. Guldan
.01, C9~1J!

5. E!lablll

2406
0100
:

6. Enl:'{)Uf 7. Encour

0200
O~

IVO

Z;o

.-,

0400
050D

0000
12hr Sub fQ!hl~

Y"U
~

1""1

..

.P~,

_. ___

-_."12 nr Tala! OliJVTuw _ _ f"', _


:---

I? Ilr Toni

---------/7nrl
12 hi Shift Ol!1put
'~'"''-'."'

12 hr Shift Intake

FllItD QUlVflLEfflS: 10l .... , .. 30nL

4 02 (1/2 cup)
B til

. 120ml (3/4 cup) .. ,180ml

lwinfvloul hour lolal ~ 80z (1 cup) .. , .. , . ,240mt--"' . j 12 Ol (soda!


c~n}

r'"

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PATIENT LABEL

D'-'1'-' br.1'V...

MARCH,PHlLLIP
072'1400691

~SSM
Ii E A l T
it

"

Fo

~-

DePaul Health Center


,-

DF:PAUL }lEJ'>.L'l'H CENTER

1101l1l1l1U11I11111
MED OS24-Ql

I/P
10/0')./07 0007~8298

._._..

cYIJ
Iof t A L T

24 HOUR MEDICAL/SURGICAl.. PATIENT CARE RECQRD


DPM100Cl-071 (71;:007) PAGE 1 OF 6

MELKAV~RI,SONIA

10/02/1976 3lY

T1

DPM-l00C

DePaul Medical Records/Phillip H. March

000001

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

DATf STARTED

24

APP '" Aswrl~ I'illfl (Jf%ent


BCI1ilviol~

Sits I
Site

Timll
R311ng Scorn #

Site
#01

Soale USM 01
ObnfVallon

1'1
~.

Function 1;;0111 .'


DtS1;ribe:

Location,
lIellavior or API' Qualily
Frequ8flI;V
AlIlJlavirting Far:lof&

SellaliGn Level
IntBrnotion!s}

Initial,

BEHAVIOR I PSYCHOLOGICAL
BEHAVfOR{FIESPONSE;S;
A" - ArWouo
~

= I'ma,jl)m.j PiWeu

J ;::: IneffKtiVO f;~pins o = o.velopm<ml.llmpalrm9m

e - Conlinuo<lS Crying DE = Dopf04":5tun G = Gri&'1I1l1l


l = Lethar..,ic
Olh~'
~.

M " Mul1lple 1\"'1<;,,"1

u ~ Un,&.pOMlva
CO. Com"",",,,
Cf '" COl/nlli ... Impalrm9111 R = R"$1!a~
o - OVtitsUfTl1JlaledfOveMctive

Cf) - c"l'Ilusadlrnsori anl"d

O"P ..

Dklr~ptivo

Patmn1

H - HttlluCintlli!ln"J (}.lu~iiJn:J
W
~

OS - IhMupliYo

Dalibilralaly Withholding

Inlo

SigoHioanl OIn.r T - Thfeal6fling Plly,,,cal

1M Impulsiyo B - SJe!iplng

o ~ CalnVUui.,

A = Al!&flIlon S86;;""0

HamVCombal'v.

COP = COOp'316tt,.. LA - LeH AnXiOUs

INTEIWENTI',/iS:
2.
!5
"$di_V~n

1. Run",.r,. p.tle", I S;9,,~'eanl

9
\0

3. GuId.nee
4. CDnsfstMt FnY'konmol1t t Routine E..stahf~~h fll;>ltmninnd limofrBmns rm carti naMb:: ~Iloouragf) "erlJali.aiion
~~r.

1, 12

Off~f fr;>qUGnI brief CONGCI 14 Ptovfd-e in1ormetion to lnCf9S.stllevElJ .of Und9-1PtRndJng J5. Erx:ou-rag9 mmily t.o bring in fumHi<lf objocts 15 p",.ido ..laxation wHIT music. Im.~ry, deap bt/!lIthing. praY.f, m~di<>~lioll17. E,'OOur8(19 norma! s;ooo cyc,i& tfy usinG inalfoet 1'9/111"9 aflar oar. 1E.

RttOOOnl I RomolM>le I Re.,.ling fa,,!.


D-tll'entional acti. . . Hi~ Pro;:Jctiva mmtsurM

Reas.a.s! Reque.lion I SOOlI ctmllGation


t:.\abflsh boundariatl

6.

7. [';flCI)",ag;, paJitnl .,,111 ChlC;\f\;m milkinglQr

1J. OMll8n loom i Limitinlllollch f I'Ii9ds Qu<&l "9n 10 d.",...... p~lltnr. ret"Onn to sl1mvllltO"

11/. Pr<;><id" ,llIan.Na $o<:urily and 'oW mei....'ru \0 mintmlu OehlW!or.1 prob~"'~

~.

PA TlENT LABEl

~~~&!DPM"OOO~7'

DePaul Health Center

o ".
DP~

24 HOU~ MEDICAL/SURGICAL PATIENT CARE RECORD


(7!2(07) PAGE 2 OF B

DePaul Medical Records/Phillip H. March

000002

24 HOUR MED'CAL/SURGICAL PATIENT CARE RECORD


AC
Po

26
Site #1

38 56

Site #2 Site #3
# 01 an&mpls for IV IOslart

I: ~
t fli NOT
Sf = Shnj!t (am-r-II

1fT
ill. -O'I'.IOIa~Q
lfr:_T!lpJi_~I/j,.~

lEFT

0
Sl f OL! TLC
~:I~T

w
x

JlrHil:alc Im;aflf)!l of
NMixwplOwdfi<i

R Lenglh _ _ cm

e z
::::J

9 I-

Irsflriion Dale

Dressing change date

w
Z

PATIENT LABEL
DEPJl.UL HEALTH CENTER

MARCH, PHILLIP
0727400691 24 HOUR MEDICA\"/sUAGICAL PATIENT CARE RECORD

11111111111111111111
MED 0524 -01

lip

10/02/1976 31Y M 10/02(07 MELKAVE!U, SONIA N 0007H12;l6

o " ..
DPM

DPY.1000-071 (712007) PAGE 3 OF B

DePaul Medical Records/Phillip H. March

000003

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD


ACUITY LEVEL ACUITY TOTALS
Points 26-37 3855 56-70 Level 1 2 3 4 5

DATE STARTED

Patient Care ----,----------------------,--.--.


Subtotal Section ''fJ('

Record

to. fifo. :Z0!>.1-

Subtotal Section "8"


Subtotal Section TOTAL POINTS
-

"e"

71-83
8495

96120

ACUITY LEVEL

7 SItter 0 121+ + ReQUIRES FURTHER OOCUMIONTATION


NOTE; If more than onv Ifffl1 on
Ii

Iin8. circhJ the _"rvie<.> indica\"d.

~SSM
~ [" "
t

1 11

A ft ~ ...

DePaul Health Cellter

24 HOUR MEOICAI./SURGICAL PATtENT CARE RECORD


DPMl000-071 (7I2007) PAGE 4 OF B

DePaul Medical Records/Phillip H. March

000004

r:;j~~~.~~~,~AUSURGICAL
I

PATIENT CARE RECORD

DATE STARTED

24
KY

Aple
Abr~

?ertl

AA

w\
Motor r6spom e
(Ahnormaillfl(inn. Extension, Flaccid, LocaRzBS, None,
SPastic, Streng, Wt:ak,

5-S
D-I:

Cole

WD.Wilhdra'l's)

Safll

PED
TED

~
SC[;~

sec
AVI
Spec~y

abno,mal ilfeatll sounds on diagram.

Brut

(Absent, De! reaslNl, CRackles,


RlJO/lClli, Wt eezes, Cua.'Se)

Hen
eM Exit Ore:
POSTERIOR

AM
Atldl
80,,"
BillA Ab!

Last FlaIl

I StO!

~;. Ostc
StOl

~,
5101
NEe

~~

PATI~NT LAB~L

OS11

o
H

SSM DEPAUL HEALTH CENTER 24 HOUR ME01CALiSUROICAL PAnENT CARE. RECORD


DPMl000'(}71 (712007) PAGE 5 OF B
OP~

DePaul Medical Records/Phillip H. March

000005

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

OI\TE STARTED

/o/b A22/ I

24
Tim

AAbsent
WWeak S>SfrOllg

ftcl1

DDoppler
Color temp
re.~

liMe!
S9n~atinn

is pain
Ume!

Wit ltd fred Il\lI t CJI):

less man 3 !t 'lY<E;

Foot-s

skin 'l.y.}11!I wil!! h~l ~ ?m"~ tfOOtotooctl.OmJilO &wQfIDlll In nol~.

YOidi"
'Ull~ Alll10n

No,""

Freljlll

T " If'C~ 1 =, I

CSI (\I
~-!tD C(

Stira
Oraim

Hsk

Til

DePaul Health Center


f7/2OO7J PAGE 6 OF 8

DEPAUL HEALTH CENTER

MARCH, PHILLIP

1111111111111111111101

t= o
" F

I/l.'

0727400691 ~mD 0524-01 .10/02/1976 31Y t.il 10/02/07 J'.1ELl"..AVERI, SONIA N ()00748296

DPI

DePaul Medical Records/Phillip H. March

000006

24 HOUR MEDICAl/SURGICAL PATIENT CARE RECORD


KEY; ,/ WN;.!B or

task compfetllQ

* '" Sue additional oommaols

DATE STARTED

2
F
0
In S:
A

Use botdad kay tatter rt indicated

0 G
A
A

ALTERO SKIN/WOlHlO KEY:


PU '" PlessLffc ulcer

A
D

= Abr~sion
~

I
L

= InCiSi~n
=lilcAl'atiM

, If preswre ulcer. lis1 Sta{je I. II. III. IV, Uftslaqeable


V N

BL - Blister BR = Bruise
E

R
T8

'" Rl.l3h

"lfoHT [VMOlIS sU.is, insuff:cieru;y) =Neumpa1t1!c vice (diabetic)

Va~.clilar

arlell~1

Denuded erythema

EX
H

== b;c!Jnat!oo = HRm;{IO!Th1

WA = Well appflJ)'imi!teu 0 = Other

= T~J1j! hum

[HesSing:

55 - Stell sltjp~
D
~ ll;rl))~t"'fllJ

C = GfMatiO<l B = SlnuQh

WOtlM BIIIUy:
E~char

:> Staples OTA ~ OI'""lu


I'!
DI
~

" Rl!1@Il!lon MlUftS Dry and intaci

il'

E =

Surrou1ldfn~ S~ln I = ~!l",,' Ii = [r'lm.lll. M = Ma.erllivfI


=

Key:

Drftlna~8

G S SS

= (;'-.Hi
=

'!\'Pe:

Drlllnsge Amc;unt:
~t;;

=);,an!
SOlan

Serl)lJS $ SWU'.''ll"''<)<JU. M
L

OIhtJ

C - f;Y"Jlol,iHall<

PU = PliflJl81lt

_____ 0

Other

D = Slwdy
Y

=MM1()ilmBI'I snaps =Otl!f _ _ __


YI H

= 'fRllrm

= MOOlifale - Lalge - CYjli!JIi~

o = OHm

= ClUsly

rIme

"e ,,0.

<!It.:-: ..~lJ~~r;;D:re:'.:ln:AT~w;;;OU;;;mI;Jrs;;;;~;;ri~~j;TA;;;~~Odiidao;rI-----~T:,"=a:lm=e=n~j------T//i;;In,dkablS
0""

Bini

No Chtng. TImi ,nd Inlllill

RelllSllument

~SSM.
ft I! ... \. T
~

. .: ... A

DePaul Health Center


a

2,1 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD


DPM-l001l-071 (712007) PAGE 7 OF

0727400691 MED 0524~Ol 10/02/1976 31Y M 10/02/07 MELKAVERI,SONtA N 000748298

111111111111111 MARCH,PHILLIP

DEPAUL HEALTH CENTER

rip

DePaul Medical Records/Phillip H. March

000007

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

Ass~s Ill' WlOliOflql w~u bel l1\!.


ark) s~te~f

comlor!

TO!L~Ung

0 iere~ esery 7
---------~>--+-4-~~.--~+_4__+~--~+__r_+~--+_4__r_+~r_+_4__r~~

!~ UmI!1! Awl!! Hnlrflnl


1 G()n1(lan; ;ruhl\l'SU1lID1~!<ir, 2 et>.;.'l1i <> ill""",\< 00ltffl!WUij It< {co..,.1 "'"" Ie. IV. If. ",'I: i

",(meAl HsPiun fin RCilfalll!


I ?IOIft! VI af\lil{.iI airwly ~,)':!i~r M\'\:tn *1<'I.rl (o9 ' fl1.1i(J1;-1in i'OOtI1r.Utl.lt'litlafMiM hiht:$)
patte:I1ts'
(iUff'&1t

!~

IiNlralUl frtUGiilltln (;wnelll ~m:: anll fe@'r~, (I.e OL wn:l1t ~~-e, etc.}
(.') '" oru;o1m bu, ..
lar~ ti'~,(:tffit.wl

3 &m1<OM ;r,ta! Mar,poillloos

{OW n",s~.

1;13',00> ~P!lt'~1

Il

o~119N .te I /leiitjO>!Oll\;ru!)lJ

M.toltn !IlmiVe '"~. ()i IIMl ~s~WIi<lI \() 100 liMlmllfil (]/ tile
CIJO;c1.lron (tI.g . &ula rourw I}f oolrikn
ill h)"I1,\lir~l}
m~:.ltft1B >\t1u\;mw.h<i!~JH

with li:"J(n~

",""la, fcllowlIlJ

TIIalHel!lilg I\eJ I Ur,Jlt>loc<>ooolct!m .. 2 CQnl to ~ul $I WIlts, in .., e{" J Admw mOllfll:it6; rist 01 fill"lUry

,.!y

!,kdl;l1i1 n "<l~"lioo
OiWS'Ofll !tlNAy (l\J(;~UOS. "Ioeo. W;l1~, OlJ,IC m.)

PiuitnVfirmy WtH;1i\ion
AbO birnl"lSl<in S\~tSfStJ1 ...~Ita$flQl>et

" Safety 01 p!liell! WI'lO are itl<:ap.11<liO from an mpry Of ""'>'0>1 prOCR<hll1 w-hi1 \'Yrnlld f,ufwJ lm:thp-j ~qw y J Hw,y 1"'lV6 e-l.l:tt'"f9"Ve mov>:mr.m I>cr",. it is rookalv "W'0llIlal<! {e g , <!X!lWIily
frac!U~1 !if 1'aSCi1!l' 3'J!l)~~'l

1 Rca-SUfI fUl u!':5\fm 2 A3y.!Smen! Oint f"m~~ J Tnal ,**t ~eG~"'Y 1 H!t~'tIor r8!f.it.~ f ferrmai

All",""",,,!~) _~dI~

S'J.\ife"

a~

(<lOperllflil .\1>1 ratU"nI ,,11:l<JVOd

01 harm to se~ Of w-ef! (let (Jen""",l\I


H8SlJ.!1mS}

BEHAVIORAL RI'STRNIITS'

{)\lief

rre<1U'ts I1llIf2Un OOI'Utnentau"'l

9 O\Iler

N t'f4CBO of!<! 10 rdllll.. inDical.,; 'I!3S"" hi.~ ,td\>.1!'J '@J~\r.d

AC11V1TY

sse" sC\t;;OC Commo')" KlY D = Oar'll1e C = Chay


A; Ambulate

B; 8eU

P{}SITIOIIING

KEY

~SSM
titAL'"'~ARt:

DEPAUL HEALTH CENTER

DePaul Health Center

;!4 HOUR MEDICAUSURGICAL PATIENT CARE RECORD


DPM-l (I{lO-071 (712007) PAGE 8 OF 6

MARCH/PHILLIP 0727400691 MED 0524-01 10/02/1976 31Y M 10/02/07

1111111111111111111

1/ P

MELKAVERI/SONIA N 000748298

DePaul Medical Records/Phillip H. March

000008

~SSM

H E A l T H . CAR E"

DEPAUL HEALTH CENTER 12303 DEPAUL DR. BRIDGETON, MO 63044


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'",TlfliT "AM MD Aool\65 .OC SEC ,,0

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STATION

II'lJOM NO.
052401

51'1

rI
CC

ADMISSION RECORD
lIP

PAT TV~

I I000748298
eY

ImIT _151\

LK

PATIENT EMPlOYfR

iRfPttONE

"Q.

MARGH,PHILLIP NORMANDY
QUIoR."l OR
~AM!

XXX-XX-S699
Hltl'rtO"lt >to

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O't 8310 HAWKESBURY


MO 63121
OliO .DOfl"

IS14}522-SnO
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MARCH ,PHIlliP

XXXXX-8699
1 ~LE ~ IDr... ~ NU

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8310 HAWKESBURY NORMANDY MO 63121

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(314)5228730
R!I.... TION

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MARCH,I<IMSERL Y
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IlIAGlIOSISiCO'A!'t.AIN r

730.:WOSTEOMYElITfS NOS-UNSPEC
LA.;. A"'t1.SIQN DATE
LOCATION

09t1f.lI07
M'ECl("At COMMU1

I
9792J2

n.
ACCIl)EN1

f'CC1D<~~ W<. Rt,!

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DAUfTlME

11111 tllll" 1111111111111


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JlOMfTTRI<l P>{YSICIAN

RAHMAN,ANWER Z
1066 EXECUTIVE PKWY CREVE COEUR MO 6~14'
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SUITE 105
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(314)317-0600

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SUITE 105

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SHAREO t:AAf PHYSICIAN:

SCHM10T,RICHARD U 12303 DEPAUL DRIVE MO 63Q44 BRIDGETON


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997075
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lllSUR,IHiCE COMMENTS;
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CQt,1(MU.Il~

PHYSICIAN OFFJCE C9PY

10/02/2007 01 :58:3

DePaul Medical Records/Phillip H. March

000009

DISCHARGE SUMMARY
PAHENT: MARCH, PHILLIP MR#: 000748298 ADMIT DATE: 10/02/2007 ACCT#: 0727400691 DISCH DATE: \"t>\~ \ ,:n DaB: 10/0211976 PHYSICIAN: SONIA N. MElKA'{;;::E.:.-:R2I,~M.:..:..:.D=.:._ _ _ _ _ _ ._R.:..:..:O:...0,,-,M.:..:..:...:_05;..,;.2.:..:..:4_ _ _~

POSSIBLE DATE OF DISCHARGE: 10/05/2007.


DISCf lARGE DIAGNOSES: Lett mandible osteomyelitis. 2 Gram-negative bacteremia likely secondary 10 PIC line. 3 Hypertension.

PROCEDURES DONE DURING HOSPITAL COURSE: PIC Hne

pli'lCRrl1RI1t.

HOSPITAl. COURSE: The patient was a 3'I-year-old African Amffric81l rnale wiltl a past medical history of left mandible osteomyelitis after a stab injury to the jaw and hardwafe placement at Barnes Jewish Hospi1al The hardware that was placed in the mandible was removed at a later time due to infection complications and the patient was diagnosed with osteomyelitis of the jaw durin9 his last admission He was sent home on IV antibiotics However, the patient came back with increasing fevers and he \VRS found 10 have gram-negative bacteremia. It was likely secondary 10 a PIC line infection. So, the PIC line was removed and his antibiotics were changed 1o clindamycin and aztreonam per Dr. Zinser's recommendations. He was also given Neupogen since he had neutropenia likely drug-induced. His white count is now up to 15 likely secondary to the Neupogen effect.

We WIt! recheck a eBC and the patient has been afebrile although his white count is high. If patient has a repeat esc on Monday and the results wil! be faxed to Or. Zinser ane social work arranged tor home antibiotics. The patient will be discharged home with a repeat on Monday and the results to be followed up by Dr. Zinser. Also, the antibiotics 8ztreonam and clindamycm will be given until November 1,2007 and the patient is to follow up with Or. Zinser with In 2 weeks.

esc

DISCHARGE MEDICATIONS: 1 Pepcld 20 mg p.o. daily. 2 Norvasc 5 mg p.o. daily. :1 Altreonam 2 grams intravenous every 8 hours, 4 Ciindfunycln 900 mg Intravenous every 8 hours. Vicodin 5/500 one tablet every 6 hours as needed. 5
DISCHARGE ACTIVITY As tolerated.

FOLLOW UP INSTRUCTIONS: Repeat CBC on Monday with results to be faxed to Dr. Zinser. Follow up wHh Ek Zinser in ~ weeks DISPOSITION. The patient will be dIscharged pending arrangement of home antibiotics ADDENDUM: The patient's antibiotics hHve been changed to clindamycin and Meropenem per 10, Per social work. home antibiotics could not be arranged, since reportedly the patient has been noncompliant. However. Ihe patient denies noncompliance and states that he had been compliant with all of his IV medications. Social work is to arrange for horne antibiotics and if coverage for home anHbiotics Is arranged, the patient witl be discharged home today. It has been emphasized to the patient about being complaint wIth his antibiotics or the consequences mIght Incluoe even trismus and inability to lake p.o. The patient was advised to be compliant and he has been

MEDICALfSURGICAL DISCHARGE SUMMARYDP

, Page 1 of 2

DePaul Medical Records/Phillip H. March

000010

DEPAUL HEALTH CENTER


PATtENT: MARCH, PHILLIP

DISCHARGE SUMMARY

MR#: 000748298

-~----

emphasized on the impor1ance of cofnpliance. He will be discharged home today on Mflropenem and cllndarnycin till november i 1 if horne IV antibiotics can be arrcmged.

This document has been reviewed and signed by SONIA MELKA VERI

Sign

O~ternme:

10/10/2007 11 :58PM EST

SONIAN. MELKAVERI, MD SNM:256 - 2040469/253 D: 10105/2007 4 '48 PM T: 10/6/2007 11 :31 PM E:l 0111/200709:03 AM

cc:
SONIA N. MELKAVERI, M.D

MEDICAUSURG'CAL DISCHARGE SUMMARY-OP

- Page 2 of 2

DePaul Medical Records/Phillip H. March

000011

Patient Discharge Instructions


Flu Immunization Given, -';"";"'--:"=-i'If7-' Pneumonia Immunization Given '.' Discharge disposition: Home Care AgenCY:! " .~ __ U _'_-=--._......J..-I'_ _~_ _ _ _ _ -:=---_--'-:'::i,':-:-,::,:...-v_ (}';S - C l(,t,,;> PR~~CRfPTIONS; 0 None WiWritten t:l ~iven to Patient 0 Called to .p~armacy MEqrcA TlONS; See Discharg~ Home Medi~at;on List attach_ed _ _ _ _ _ _ _ __ WORK: 0 Return to. work in days OfO _ _ _ _,_ _ _ _ _~_ _ _ _ __ Activfty: . aintaj~ u~uaj physical activity, Pace activities and plan for rest periods, Restrictions Oi t: ~--------~------------------~-Discharge diagnosis:

(i , \' ,

~
o

CJ Modified Dlet _ _--=_____

Regular Diet

InstrUctions given by Dietician Smoking: Do not smoko/Avoid second hand smoke Smoking cessation Information provided and reviewed for patients who smoke. Worsening of symptoms - Call your physician if any of the following apply to you: A fever greater than 1000F or Chills Exce~sive redness Qf unusual dfainage at A worsening cough with sputum that is green surgical site or yellow or broody Excessive bleeding at surgical site * Worsening shortness of breath, with Of Unrelieved pain without activity NumbnessmnglinglChanges in color of Swollen ankles or hands affected area Weight Monitoring ;fyQu~ave;f:ieartQr Kidney failUre Weigh youfselfthe fficitnlng~ft~(yougethorne;-ai1~(f~ilyaftergoing to the bathroom and before breakfast. Notify yourdoctor,:of.welghtgaltJ of 3 ormotepoUhdsin ont;~day 0[5 pounds in 5 days, FOlLOWUP CARE: Bring alf mt\.dlcatlons with you 10 your appointment. Cal! for appointment with Dr.( \ i- lid? Phone # to be seen inJ.. weeks ,0 Call for aepoinfment with Dr.:;;;41vh,/t) Phone #, J '3;.;> to be seen in)JYw:.:::e..;:.ec..:.Ks::-_ ADD~TlONAL INSTRUCTJONS: . " 35~ 77ft7 C \ f'I 0.0, \'1'i c.. 1 I) \ V VlJ1 I \ IO"f _~

fT)e no

p ~ t") e

fY\

C~c.,/Cf'rlP
Physician Signature:

V l....ih. '\-\.t ('It t I)-:teVt'J'i 1Y1or-\6.~1 ~1 n:'..S1. d~ k0r2-()S:.<...(~-s(yT$cfJ(.rt\


\

J, \

l! \

Belongings returned: !D None

o Home medications o Other:

o Glasses

o No signature needed see orders Dentures o Hearing Aid(s) a Assistive device


Significant Other
to:

Actual time

pa~nature .L:::)' -\-~ < - . Date: /6'~, --y J tJ 'Home


0
Other

These instructions have been..te.l.!iewed with me and my questions have been an.swt'red. .

DI~harged

Mode

Of Discharge:

NurseDv")C.(I::d, ""'"

[J Phone # atrer diSCharge)) Escorted by;

;TI730
;'i:<ii;';''i.~'; ...J..~"t..:.~~'~ "

CJ we 0 Ambulatory
Q
Stretcher
"I-.:.:.U ~~.. :~ ;;-0,~.;i~':"~

DEPAUL HEJI.LTH CENTER


Patient Discharge Summa .
11/2005

,(

Make 2 COPieS oft/us/urm, Onglna/form to chart.

.,'

MARCH, PHTLL,IP 072' OC'r:;~Jl l'lED 0524 .. 01

IIIIIIIIIIIIIIRII
'.., 31 Y

lip

(101

M 10/02/07

'------------------------MEI--

. "':,SONIA N 0007<l829<1

DePaul Medical Records/Phillip H. March

000012

H
DePaul Health Center 123~3 DePaul Drive PAGE NOMBER: 1
ESTIMATED

DISCHARGE TIME:

Please circle: Discharge Mads or POEt-op Mads Bridgeton,MO 63044 Patient Active ~edication List {YES NO) Account Number, 0727400691
NURSE PHONE EXT:

Patient Name:

MARC~,PHILLIP

Room Nurobr: 0524-01

Date: 10/08/2007 Attending physician: MELKAVE~.SONIA N Patient Allergies: No Known Drug P.Jlergies Continue? Medication Generic Name(Brand Name) with Directions
, AM

DePaul Medical Records/Phillip H. March 000013

Noon

PH

Bedtime

Scheduled Medications

*.~*.

l~O l~O
23

FAMOTIDINE(PEPCID)20 MG BY MOUTH ONCE DAILY BEFORE A MEAL


AMLODIPINE(NORVASC)5 MG BY MOUTH Daily
GlVEN AS: (1)

GIVEN AS:

(1) 20 MG TABLET

x
X X

5 MG TABLET

7 YES VODIUM CHLORIDE BACT

o. 9't (BACTE:RIOSTATICl 3

ML INTRAVENOUS EVERY 8 HOURS

SNO

CLINDJ\.MYCIN(CLE:OCIN) (CLEOICIN) 900 MG INTRAVENOOS EVERY 8 HOURS

* * EVERY

HOURS

26 YES

r~ ~ SODtuM

CHLORIDE BACT 0.9% (EACTERIOSTATIC) 30 ML INTRAVENOOS EVERY

HOcrR.S

2@NO

MEROPENEM{MERREM) 1 GM INTRAVENOOS EVERY 8 HOURS


INTRAM:CJSCUW\.R PNEUMOCOCCAL VAt:;.
X

** EVERY 8 HOURS

12 YESVNEUMOCOCCAI. VACCINE POLYVALEN (GIVE) 1

....... ,.... As Needed Medications ........

>

PHYSICIAN SIGNATURE IS REQUIRED ONLY ON THE LAST PAGE OF THIS MEDICATION LIST Medication Substituted per Hos~ital Approved Formulary Sub8titu~ion

pilot Form 4/2005

- . ".
~.

"f-

- ., '/-"

'F . .. -''- Cl, \,\:::-, L'I-<.)I l'.'Tl:l " . ~. '-;.:; . .:'. Y/;~'-.;
J

,r

.~-.-.--~_

i/,_IG

"'---7--!-T: J

-', : l~ ~""' . ~1t.: ___~ __

H
DePaul Health Center ~2303 DePaul Drive

PAGE NUMBER: 2
ESTIMATED DISCHARGE TIME:
NUBS E: PRONE EXT:

Please circle: Discharge Meds or

Po~t-op

Meds
Pat~ent

Bridgeton,MO 63044 Active Kedication List

(YES NO)

Account Number: 0727400691 Patient Name: MARCH,PHILLIP Room Number, 0524-01 Da~e: 10/08/2007 Attending physician: MELKAVERI,SONIA N patient Allergies: No Known Drug ~lergies

DePaul Medical Records/Phillip H. March 000014

Continue? Medication Generic

~arne(Brand

Name) with Directions

r AM

J ~oon

PM

Bedtime

-~~-------------------------3~-----------------------------------.---.-------------------------------.-----------------8~O ACETAH:rnoPHEN(l'YLENO~ Bl'! MOUTH Everyftts pm GIVEN AS, (2) 325 MG TABL.ET I I I
27

----------

C/' FOR PAIN 29 YES~ZOLPIDEM{AMBIEN)10


INSOMNIA

~o

aYDROCODONE/APAP 5/SQOMG CVICODIN 5jSOOMG)

1 TAB BY MOUTII EVERY 6 HOURS

AS NEEDED

I
MG BY MOUTa AT BEDTIME AS NEEDED
GIVEN J;S;
(1)

10 MG TABLET

11
19

YE~DIPHENRYDRAHINE(BENADRYL)25
YE~ROMORPBONE

MG INTRAVENOUS EVERY 6 HOORS

AS NEEDED

HCL (DILJ\ODIDll .MIG INTRAVENOUS EVERY 4 HOURS AS NEEDED

*.*.* Held Scheduled Medications


10

~.*-*

YESG
>

-CLARIFY PENICILLI}f() 1 TJUlLET B MOmH *CLARIFY ADMINISTRATION FREQUENCY

,,*

9: 00 ! - *CLARIFY ADM]

= Medication

PHYSICIAN SIGNATURE IS REQOIRED ONLY ON THE LAST PAGE OF THIS MEDICATION LIST substituted per Hospital Approved Formulary Substitution

pilot Form 4/2005

H
Depaul HealLh Center 12303 DePaul Drive

PAGE NlJMBER: 3
ESTIMATED DISCHARGE TIME: NURSE PHONE EXT:

Please circle: Discharge Meda or Post-op Weds Bridgeton,KO 63044 Patient Ac~ive Medication List (YES NO)
Account Number: 0727400691 Patient Name; MARCH,PHILLIP Room Number: 0524-01

Date: 10/08/2007 Attending Physician: MELKAVERI,SOHIA N Patient Allergies: No F~own Drug Allergies
Continue? Medication Generic Name(Brand Namel with Directions
------~-----------------------------------------------------

DePaul Medical Records/Phillip H. March 000015

I
WIT~

AM

Noon

PM

Bedti~

14 YES

OXICILLIN-CLAVULANATE(AUGMENTIN)875 MG BY MOUTH TWICE DAY

----------------------._--------------------- ----------------------------.
MEALS GrvEN AS: (1) 875 MG TABLET

j
Additional arders

Ff~

f)y_

W\..

~2- UJ-e~

___________ C __ G_C_I_~~F

_~

--------------------------_.._..._._....- ....._.----._--------------Physician Signature:

6).\ _____
~

____ vate/Time

Nurse Signature:

.____ Date/Time

Readback Confirmed [ 1

PHYSICIAN SIGNATURE IS REQUI:RJID ONLY ON TIiE LAST PAGE OF THIS .MEDICATION LIST
> " Medication Substi tuted per Hos.pi tal. Approved FO:ntlulary Subst:i. tut i.on

Pilot Form 4/2005

H
DePaul Health Center 12303 DePaul Drive PAGE NUMBER: 1
ESTIMATED DISCHARGE
T~E:

Please circle: Discharge Meds or Post-op Mede Eridgeton,MO 63044 Patient Active Medication List {YES NO}

NORSE PHONE EXT:

Account Number: 0727400691 Patient Name: MARCH,PHILLIP


Room Number: 0524-01

Date, 10/05/2007 Attending Physician; MELKAVERI.SOHIA N Patient Allergies: No Known Drug ~lergie5
Continue? Medication Generic Name (Bramd 1;ramel with Directions

DePaul Medical Records/Phillip H. March 000016

AM I Noon

PM

Bedtime

Scheduled Medications **.**

L3~O
7 YES
2:2

PAMO'In'NE""C'D)20 MO BY
MG BY

MOOTH

ONCE DAI.Y BEFORE A MRAL


Daily
GIVEN AS,

GIVEN AS, (1( TO

Me

TABLET

x x
x
X
X

l~O AMLODIPINE(~ORVASC)5

MOQT~

(1)

5 MG TABLET

@
;-. "

@
NO

SODIUM CHLORIDE BACT 0.9% (BACTHRIOSTATIC) 3 ML INTRAVENOOS EVERY 8 HOURS


AZ'rREONAM(AZACTAM) (AZACTMI.) 2 GM INTRAVENOUS EVERY 8 HOURS

+tQ.Q (( (0 \
.L

*.. EVERY a HOURS


(

2 3~O

CLINDAN'lCIN (CLEOCIN) [CLEOICIN) 9'00 JotG INTRAVENOUS 'E'\73RY 8 HOURS

I LXX...

Ill)

. {(

EVERY 8 HOURS

26 YES 00DIUM CHLORIDE BACT 0.9% (BACT'ERIOSTATICl 30 ML INTRAVENOOS EVERY


12 YESJ PNEUMOCOCCAL VACCINE POLYVALEN (GIVE) 1
~

HOURS

x
x

IN'l'RAMUSCULAR PNEUMOCOcCAL VAC


~.***

.. *.

As Needed Kedications

PHYSICIAN SIGNATURE IS REQUIRED ONI,Y ON THE LAST PAGE OF THIS MEDICATION LIST Medication Substituted per H05wital Approved Formulary SUbstitution

Pilot Form 4/2005

H
DePaul Heal~h Center 12303 DePaul Drive
PAGE NUMBER: 2

ESTnMATED DISCHARGE
NURSE PHONE EXT:

TI~E:

Please circle: Discharge

M~d8

or

Po~t-op

Mads Bridgeton,MO 63044 Patient Active Medication List (YES NO)

Account Number: Patient Name: ROom NUmber: Date: Attending Physician: Patient Allergies:

0727400691 MARCH, PHILLIP 0524-01 10/05/2007 MELKAVERI,SONIA N No Known Drug Allergies

DePaul Medical Records/Phillip H. March 000017

Continue? Medication Generic Name (Braud Name) with Directions

AM

Noon

I p* I

Bedtime

8 YES NO

-~-------------------------------------------------------------------------------------------------------------------------------------1>CETAMlNOPHEN{TYLENOL}650 MG BY MOUTH Every 4hrs prn GIVEN AS: (2) 325 MG TABL:ET I Ii, I
YES NO lfYDROCODONE/APAP 5/500MGCVICOIJIN 5/50011(0) FOR PAIN 1 'l'M BY MOOTH EVERY 6 HOURS AS NE'ED:ED

I
j

11 YES

~IPHENHYDRAMlNE (BENADRYL) 25

MG INTRAVENOUS EVERY 6 HOURS

AS NEEDED

19

YES~ROMORPHONE

aCL{DlLAunID)l MG INTRAVENOUS EVERY 4 HOORS AS NEEDED


W

** Reld Scheduled Medications

1Q

YE~CLARIFY

PENICILLIN(ll TABLET BY MOUTS *CLARIFY

~NlSTRATION

FREQUENCY GIVEN AS. (I) 875 MG TABLET

.. w

9 :00 AM -

*CLl\RIFY ADMJ

14

YES~OXICILLIN-CLAVULANATE(ATIGMENTIN)87S

MG BY MOUTH TWICE DAY WITH MEALS

>

= Medication

PHYSICIAN SIGNATURE IS REQUIRED ONLY ON THE LAST PAGE OF THIS MEDICATION LIST Substituted per Hospital Approved Formulary Substitution

Pilot Form 4/2005

H
DePaul Health Center 12303 DePa~l Drive

PAGE NUMBER: 3
BSTIMATED DISCHARGE TIME:
NURSE PHONE EXT:

Plea.se circle: Discharge Meds or post-op :Meds Bridgeton,MO 63044 Patient Active Medication List (YES NO)

Account Number: Patient Name: Room Number: Date: Attending Physician: Patient Allergies:

0727400691 MARCH. PHILLIP 0524-01 10/05/2007 MELKAVERI, SONIA. N No Known Drug Allergies

DePaul Medical Records/Phillip H. March 000018

Continue? Medication Generic Nallle (Sran.d Name) wit.h Directions

AM

Noon

PM

Bedtime

Additional Orders

(!be

trw

.-~-

C/\i~ r ~r Or- - LM/LDe0 C~ ...............:::.......::......:.:::::...--------. -c ~.:_l:~...Y.~y._._~~__:z.._(_>e.e. __ h ___________


;I
---l~""'-'-'--"'-'-'--"'-:-"'-'-""""""-'

c0c
------_.._--Physician Signature: Nurse Signature:

v\.

M~~. ~

9<xv..rr
I {

ED fu ~;.ci2J

by clu~

~......-:=:
.

Date/Ti.e
Date/Time

t%$o-/o7
Readback Confirmed [ ]

>

PHYSICIAN SIGNATURE IS REQUI~D ONLY ~ THE LAST PAGE OF THIS MEDICATION LIST Medication Substituted per Hos:pit.al Approved Formulary Suh5tit~tion

Pilot Form 4/2005

,'M~

,.:f BE DISPENSED IN ACCOFIDANCE WITH THE

.-J\.

HERE "-Y

PHYSICIANtS ORDERS

.LERGIES

z,
PATIENT WEIGHT c::>
o

1. 'O~I!Y' in~ati of
'V"n~' in,1?~<i
AN<ay~

gl

'qo' y

5, 'Mon:hlne'lM1aad 01 'MS04'
1,1. 'Ml!9~Sium sultala' InSfila[J of 'MgS04'

3. No traillng W~ (1mg n011Jlmo)

4.
Kos 0 lobs
PATieNT

use leadlnillsros

7. 'Every oit1sr dl!}" m8ll!ad of '0.0.0: B. 'MeG' IMt4ad (lj "11ft

HEIGHT

{O. lmonoUmg}

9, 'InttrmtlonJl 00'15" IMtesd 01 'Ill"

ORDERS

~J'
.f

\.

J \ \

.\~f

--

~SSM
H E A L T H . CAR
SlM-1000Ofj5 4i2007

PATtENT LABEL

f~

)EPAUL HEALTH CI$NTEl{


''1ARC'l-f, PI1TLLH'

IUn81mrIIlIlUlJiflllfi
NED 052: 01

012740069J
PHYSICIAN'S ORDERS

TIP

10/02/1;176 J1Y
~"ELY.AVERI,SON1A

M ll'/02/0? N OOD74A798

DePaul Medical Records/Phillip H. March

000019

DRuG MAY BE DISPENSCD IN ACCORDANCE W1TH THF

.........

4FRE .....",

PHYSICIAN'S ORDERS
L 'OlEy' iMIMI! of "qd' 2, Un~~ in?l~arl ~ 'u' 3. tm n'aillno lams (lmg not I DmQl 4. AIw~,ys use leading Z8(oa ({J.lmg not .Irng)
5. 'IIJQfphino" ins!&ao or "MS04' 6. 'Mavn~slum suffate' Inst~iHJ 1II'MtfSD4' 1. 'Every other day" instead 01 "Q.O.O: 8. "MGG" in~wad Qf -"g' 9. "Inlernat-onal uni\$" insteal1 !If "IU'

PATfENT LABEL

'\."
PHYSICIAN'S ORDERS
SLM1000065 (4i20U7j

-'

'\ I,

,',

J'!~'!\~~~IUIIURU
072'1400691 MED

'JRPAUL HEALTH CENTER

I/P

0524 - 01
000'14 S298

i.'.)/02/1976 31 Y
RAH1>',AN I ,AN1'1RR Z

M 10/02/07

DePaul Medical Records/Phillip H. March

000020

DRUG MAY BE DISPS'{$I;I) IN ACCORDANCl: '/.1TH n-lE ,....J\. HOSPITAL HRE: '0/

PHYSICIAN'S ORDERS
, _ "Daily' instea<llJf 'qd' 2. \lops' instead of 'u' 3. tic lraifrng l$r08 (1 mg not l.Omg) 4. Always UU leaOIrQ zeros (0.1100 net .1 m{l)

5 'Mo!phfne' Inmid 01 'MSQ4' 6. 'Magneslum ttIlfLilu' Instead oj 'MqS04' 7. 'E~&ry alharday' instead oI'O.O.D.' 8. 'MeG' Instead of 'IlQ'

9. 'InlematiallHlun!ls'lniload of "IU'

~SSM
H E A L T H . CAR
SlM-l000065 (412D07)

DEPAUL HEALTH CENTER MARCH/PHILLIP

11I!llIIIIlIlIWIIIUDI

riP
O()O?48::!98

E~

0727400691 M~0 O~24-01 10/02/1976 31Y M 10/02/07

HAlINAN,ANWER Z
PHYSICIAN'S ORDERS

DePaul Medical Records/Phillip H. March

000021

DRUG MAY BE DISPENSfV IN ACCOflOANCE WIT'" THF

r-'>..

HOSPITAL FORMUlARY

M UNLESS CHECKED HERE ......",.

PHYSICIAN'S ORDERS
1. 'O;lily' instead 01 'qd' 2. "Units' insltad of V

a.
PATIENT kEIGHT
~

No tfailing

zeros (1mO MI1.0mil)

4. Alway, use leading l&1l&

rO.1mllIlOUmll)

5. 'MO!Jlhlne' instead of '1,1604' 6. 'M8jln8Slum $\I!tat~ in~teat! 61 "MgS04' 7. 'Every o\her oay' iMtead of 'QO D,' 6. 'MeG' instead 01 'jig' 9. "Internationll UfIlts' inswad 01 'IU'

DePaul Medical Records/Phillip H. March

000022

PHYSICIAN'S ORDERS
1. 'Oaily' Instead 01 '(!d'

2,

'!)f\!!~' i11~Qad

91 "u"

PATIENT 1tE1GHT Q

3 Nn tlallfngZ!f08 (imp noll.0m~) 4. Ah'lays use lea1!/ng ZtloS (O.lmg not.lmQ)

'MllIjlhil1e'lnste~d Qf 'MS04' 6. 'Magnssium sulfate' ins!l!l!d 01 "MqSD4" 7. "Every oU1er ,jay' \fl$\e<ld of "a.o.o." ~. 'MeG' imt~ad of '1J1J" 9. "International uhits' insleild Qf 'Ill'

5.

~SSM
SLM-1OOO-065 (4/2007)

PATIENT LABEL

H ~ A ~ T H e A R EO<

PHYSICIAN'S ORDERS

DePaul Medical Records/Phillip H. March

000023

PERIPHERALLY INSERTED CENTRAL CATHETER ORDERS


,..-----._.-----------,

Insert Pice line catheter by Vascular Access RN. Enter in HBOC under Department Consults,

AII~rgies.:

Assessment:
Obtain consenl for Peripherally Inserted Central Catheter If unable to place Pice hoe by Vascular Access Nurse, refer patient to Interventiona1 Radiology,

11.

Diagnostics:
a

..J-k::z.'l- /,,' "t"-..... _/ ~

Call Physician for INR 4,25 and lor platelet count < 25,000 . STAT one view portable chest x-ray post Pice insertion (tip verification in vena cava) Repeat STAT one view portable chest x-ray if PICC is repositioned Radiologist/Physician to confirm PIce placement prior to use.

III. Medications:

Use lidocaine Hydrochloride 1 % inject intraderrnally to produce wtleal to locally anesthetize site. Flush eaclliumen of Pice with 10 ml sterile NS IVP: before and after medication I solution administration before and after blood product administration every 8 hours (regardless of continuous tV infusion) when obtaininy blor.xi sample, discard small red tube, then obtain sample. Upon completion, pUlse ftush with 20 ml sterile NS IVP PRN to determine patency

N.

Treatment~

Place transparent tegaderm dressing and biopatch at time of line InsertJon. Change .' dreSSing after every 7 days and PRN If the integrity of the dressing is compromised. Document in progress notes and on flowsheet ).
NO BP OR NEEDLE STICK IN PIce ARM DO NOT USE ANY SYRINGE SMALLER THAN 10 ml WHEN lNJECTING IN PICC\~

/1) ;)
~

I agree with the above ordf:ni with fire exceptJon of those crossed through.

\jt

Date: _ _ _ _ _ Tlme:~_ _ __ Physltian_ _ _~~_ _ _ __

\pI

Tl100 noted_ __

RN__________~~_

~SSM
~f

1 t t 111 . t 1'1"

DePaul Health Center

DEPAUL HEA.LTH CEN1'ER


MARCH, PHILLIP

1llllllilimmillUI

rip

PIce Orders 712007

0721400691 MED 0524-01 10/02(1976 31Y M 1.0/02/07 MELKAVERT,SONIA ~ 000748298

DePaul Medical Records/Phillip H. March

000024

ORVG MAY B DISPfNl)ED IN AGGOHUANGE WITH THE ...-'. HlORI; ....."..

PHYSICIAN'S ORDERS
1. 2. 3. 4. 'Daily' inst!1ad of "Qd' 'UnJts'lnsre.d or 'u'
No lli1ll1r1g zeros (lmO Tlol1.Om9J

5. 'MOfllhiW' umealj Of 'MS04'


6. 7. 8. 9. 'MaljlWS!UTll suNare' iflStead (If ''''9804' 'EVVIY otII6nlay" IlISttad Of '0.0.0." 'MeG' imttad o/'l1lJ' 'I/1tWlilllonal unils' Instead of 1U'

AlwJYs ua.lvading ~el1n (O.lmg not .1mo)

~SSM
H E A L T H . CAR
SlM1(l()(}.065 (412007)

PATIENT l.AEJEL

E~

OEPAUL HEALTH
0727400691

~fi~!~t~"}l~~lgU
10/02/1976 31Y
RARf<1Jl.N,AfMER Z

C~N1'ER

r/p
OODi48298

MED 05~4-01
M 10/02/07

PHVSICIAN'S ORDERS

DePaul Medical Records/Phillip H. March

000025

ORUG MA" BE Dl3I'ENSED IN ACCQROANCF WlTH THe

PHYSICIAN'S ORDERS
1. 'Dairy' l!13leao 01 -qrJ"

'Un~s'I!13lead

01 y

PATIENT HEIGhT

">

3. 110 tralHng !ero~ (1mg ~Oll,Omgl .1. AJ'.%ys use leading ~elOs (O.lmg flOt.ll1lQl

5. 'MQrphfm'lnstead Qf "MSO"6. 'Ma!/l1aslum sulf8lti' insl~iJl 01 -MqS04" 7. 'Ever; othe!~" in.!~ao 01 "00.0a. "MCG-Illstead of "iJIJ" 9. 'Intllfnational units" iIIslilall 1)1 'IU'

~SSM
H E A L T H . CAR
SLM-H)OO-065 (4/2(07)

PATIENT LABEL

E~

DEPAUL HEALTH CENTER MARCH,PHILLIP

IIDIIIIIIIIIIIIIIIIII

I/P

PHYSICIAN'S

O~OERS

0727400691 MBD 0524 .O~ , 10/02/197631Y N 10/~0;2f07r RAH~~,ANWER 3 OOO!482~~

DePaul Medical Records/Phillip H. March

000026

Emergency Department Admission Orders


Patient Name:

Ph; \\~p fvw-vL

a) j os--/u., ~.'.J--'f Diagnosis' _~__~_ _ _ _ _~


(}-'-I

-t~~~tl~~t -~d~ii ~o ;Eit1~di~i'


Physician: ();

OS-l;f~i~~i --0T ~I~~~t~ --03NO~h' (1~;t~'r~Gdl~;~ -leu) -. 0 leu


OSurgical 0 Telemetry

-.-- -- . --_--i .. -...... --... -.-.-.. ---.-.. .-.. --.,,--a o


Q
C,9de Status Full Resuscitation

Outpatient (Observation) admit to: 0 Medical

~ 't\"<-"''''.__ c.-,nsults:-f)r ~t""5~ U '.____

\:--.-1, .!.<[-'~ ::

rAne~le0~

DNR - Continue Madlcal Therapy

~~~~==~~~~==~~--~~

r,
II.

o o o o

13'"

ASSESSMENT 0 Obtain Previous Medical Records Vital signs every 5.=hours x ~ then routine [::J Oximetry 1&0 0 DAify Weights LJ Cardiac Monitoring
ADOITrON~L DIAGNOSTICS ~ ..~

a' esc~'
CMP

\'\
0
CXR

PT
PIT

EKG

E'l_ _ _ _ ..._ _

III.

g/ ~/ ___ --\
IV.
TREATMEN S

E1" (.I\"'n~~.,

Fingerstick Glucose U AC & HS n every ___ ._ hour:> MEDICATIONS CJ Initiate Sliding Scale Insulln Orders Continue Home Medications checked "Yes' on Home Medication SheeVOrders. c::( acetaminophen (Tylenol) 650 rng PO ovel)' 4 hours PRN mild pain or fever> 101.5F (J DVT prophylaxis:_... .. .--_ _~_ _

JA~_ (vf?~ ~ 1f!1~""'_~_

~:ty~} _illf.6.:;r t

OJ

'.

IVfluids _ _ erSnline Lock ~V: .. ' Oxygen at _ _ ... _~Iilertl per____ . _ _ _ _ Call physician if 02 SH! <~ 0/0 . !:l Foley 0 NG to ::>uclion Diat: 0 NPO id1fegular.~r 0 _ _ _ cafor:!9 ADA 0 _ _ . ____

Activity; 0 Bedrest 0 BRP f...


oSee Addlt'7al Physici~n Qrd~r~
Date:

0
.

sse

ErUp tJ(J lib 0


J_~.

I'"

/J cj) ttL Tirne:~_~PhYSiCian_f/~Yf~ WV?____


_ _ Time NoteJ: ____ . RN _____ -t?\~

Transcribed by:

________________________~fo~/~~~I-p--

Orders scanned to Pharmacy Date

\D/1;

~Vl

Time..Q.l..:~ Inilials,{:7 ~JJ ~~


DEPAUL HIP"'" TH

CENTER ~SSM DePaul Health Center II'BiI PHILP~"'I


HlHTII'~UI

MARCH,

07274QO~91

ERS

ERO

ED AdmissionOrder.-; 3-2005

10/02/1976 30Y ,

00748298

EMERGENCY PHYSICrMAolO/Ol/07

DePaul Medical Records/Phillip H. March

000027

HOME MEDICATION LIST ORDER SHEET

to latex? a No 0 UnSUr8 (NOIi:


Yes -Describe"""";';'_---:-_ _ _ _ _-:--_-:-_ _ _ _-:-------:Ch~c;k the box below if you have ever experienced runny nose, tearing, sneezing, or Itching aftar: a Denlall/ntemal exams 0 Contact with rubber gloves/products a blowing up bal/oons 0 Use of condoms or diaphragm Chl;lStl1Uts, kiwi
blood thinning products, oVBrthe-cOull ter medbatiOln.

risk)

Answering "yes" to any of these require initiatJon of Latex Allergy Protocol Chart labeled Allergy armband

Home Health Services being used? 0 Yes CI No If yes, Name Typ& _-:-~_ __ Sources of information: OPatien! 0 Medication Bot1!es 0 Patient's Family 0 Mad List 0 Doctor's Office o Pharmacy Name Pharmacy Number [J Old Chart 0 Other:
Route or topical site Frequency Last 00$(1

Comments

DYes DYes DYes DYes DYes


I

D Hold 0 Hold 0 Hold


FOR
~ss

These checked oroers will only become active when authorized by Physician.
Medicl'llions/h9rballvitimlm; will l;e dispenw(1 m accord/lfTca with tile hopil8i lormuiary Non-formula hetJlslvif!min:> mil be hold during hospital stay. Resume all'N ClIO

/7..

!-lome Med Usl \...R_e_c_Of_de_d_b-'-Y_ _+-___-'

Date:

I.J'

1-

Time:

(~

Physician:

...;;.~

dirt'it;1Br1lJy the physicil;l[l

Date: Time: Scanned to PhalT1lacy Date:

t~ l- 01

li~'"

Nurse: T;me:o 0/-' --,-n-iu-al-s-!).h;-T,f"" .+-:-------0 / -S

o Readback confirmed

Home Medication Orders 3/06

DePaul Medical Records/Phillip H. March

000028

PNEUMOCOCCAL VACCINE NURSING ASSESSMENTI PROTOCOL

. ./

It'?,) eq Tlme:O St.f.? Assessment completed by: l;x$~ flt.I . .~ DePaul Health Unter . rs~n~di;e~ -- Dilllliu.llitl
Date:

: Initials.

--I

ER

I MARCH t PHILLIP

IIp

- - - - - - - - - - - - - - ... 07.27400691

RAH~~/ANWER Z

MED 0524-01 10/0211976 31Y M 10/02/07

000748298

DePaul Medical Records/Phillip H. March

000029

DEPAUL HEALTH CENTER


HtSTORV AND PHYSICAL
PATIENT: MARCH, PHilLIP ADMIT DATE: 10/0212007 DOB: 10[02/1976 PHYSICIAN: SONIA N. MELKAVERI, MD.

MR#: 000748298 ACCT#: 0727400691 ROOM: 0524

CHIEF COMPLAINT: Fevers and Jaw pain. HISTORY OF PRESENT ILLNESS: The patient IS a 3'I-year-old, African American male with

past medical hi3tory Qf g 1;ltab injury in the jaw in April and had all internal fixation at Barnes In May that was complicated by infection of the hardware so the hardware was removed in July
The pallent has had prior visits to DePaul Hospital and he had IV antibiotics given and during the last admission was diagnosed with osteomyelitis of the jaw and was sent home on home antibiotics, I.e, Unasyn. The patient now returns back with complaints of increasing pain in the jaw and also fevers of 102 to 10'1. He denies any other complaints like cough. chest pain, shortness of breath, or nausea, vomiting, or abdomina! pflin. He did have ehnls and a high fAver and h was getting home heal1h visit him at home for IV antibiotiCS and for the Pice linf~ care. PAST MEDICAL HISTORY; Jaw injury, stalus post ORIF and removal of hardware, and osteomyelitis of the jaw on antibiotics.

ALlERGfES; No known drug allergies.


HOME MEDICATIONS: Unasyn.

SOCIAL HISTORY: He lives with his Mom. Denies any history of smoking, occasional alcohol.

no IV drugs.
FAMILY HISTORY: Noncontributory.

REVIEW OF SYSTEMS: GENERAL: Fevers and chills present. RESPIRATORY: No cough, nn shortness of breath. CARDIOVASCULAR: No chest pain. no palpitations. GASTROINTESTINAL No nausea. no vomiting, no diarrhea. GENITOURINARY: No hematuria. no dysllna. ENDOCRINE: No history of diabetes. NEUROLOGICAL: No history of eVA. The rest of the review of systems are negative other than what has been in the HPI
PHYSICAL EXAMINATION: VITAL SIGNS: On admiSSion blood pressure 138/96, respirations 21. pulse 76, temperature 98.7, recorded temperatures of 101 he$ been seen in the ch'ni. GENERAL Well developed. well nourished, African American male In no acute distress. HEENT: Minimal jaw swelling preSnt. RESPIRATORY: Bileterallungs clear to auscultation. No craCl<les. CARDIOVASCULAR: S1 an9 $2 normal with regular rate and rhythm. ABDOMEN: Soit, nontender, non distended, normal bowel sounds. EXTREMITIES: Lower extremities no pedal edema. Strength 4-5/5 diffuse, LABORATORY DATA: On admission: chest x-ray shows no acute infiltrate. White count 6.5, hemoglobin 11.8, hematocrit 33.4. platelets 114. Blood cultures 2 out of Z positive for gram negative bacilli. UA is negative. Troponin less than 0.1 Sodium 138, potassIum 3.3, chloride 103, bicarbonale 27, BUN 13, creatinine 1 :1. Alkaline phosphatase 73. ALT 13, AST 24. INR 1. ASSESSMENT AND PLAN: 1 Possible sepsis secondary to gram negative bacilli likely from jaw osteomyelitis. Currently is on Unasyn. We will switch to Zosyn IV, repeat blood cultures, and consult Infectious Disease. 2 Jawosteomyelitls Start on Zosyn. 3 Pain control on morphine p.r.n.

MEDICAL/SURGICAL HISTORY AND PHYSICAL-DP

- Page 1 of 2

DePaul Medical Records/Phillip H. March

000030

DEPAUL HEALTH CENTER


PATIENT: MARCH. PHILLIP
4 5

HISTORY AND PHYSICAL MR#: 000748298

Hypertension. Restart on Norvasc. The patient apparently not taking Norvasc at home. Prophylaxis. Place sequential compression device and proton pump inhibitor.

This document has been reviewed and signed by SONIA MELKAVERI Sign DatelTime: 10/02/2007 10:34PM EST

SONIA N. MELKAVERI. M.D.


SNM: 168 - 2036802 0: 10/02/20072:24 PM T: 10/2/20074:02 PM E: 10/03/200709:13 AM

cc:

SONIA N. MELKAVERI. M.D.

MEDICAUSUROICAI- HISTORY AND PHYSICAL-DP

Page 2 of 2

DePaul Medical Records/Phillip H. March

000031

,
INTERDISCIPLINARY HISTORY AND PROGRESS NOTES

~ g

~----~----~--------------------------~------------~~~~~--------------

~SSM
H E A L T H . CAR
SLMl00U003 (612003) 02 FRONT

E~

DEPAUL HEALTH CENTER


W\RCH, PHILLIP D 0524-vl 0727400691 ME M lO/02/07 10/02/1976 31~ 00074829&

1111111111\1111111

Ip

INTERDISCIPLINARY HISTORY & PROGRESS NOTES

AAHMAN,ANWER

DePaul Medical Records/Phillip H. March

000032

INTERDISCIPLINARY HISTORY AND PROGRESS NOTES

~SSM
H E A L T H CAR

DEPAUL HEALTH CENTER


I/P 0727400691 MED 0524-01 lO/O~/1976 J]Y M 10/02/07 RAllM!\N,ANWER Z 000748298
~1ARCH, PHILLIP

E~

IIIIIIIIIIIII.,IIIIH

INTERDISCIPLINARY HISTORY PROGRESS NOTES

SlM-1000003 (Gi2003) 02 BACK

DePaul Medical Records/Phillip H. March

000033

INTERDISCIPLINARY HISTORY AND PROGRESS NOTES


Dill~

Time

NOTES MUST BE SiCNfD

II...

~t--

'.~.,.J ( "1

--O\~
'/'

4-.'1,,', .: ( f /VLGU

I"

l'A/\Q.Y
L \ L '-L.l.!.S
(,\.)
-

\c"'/-&,

C~_}l.A/\~ c'c.(:Xb &':/- ~).G l'3BiQs


. j

CbkV CQ.Qu..'A.
'.

l(;O'{ f.2A-

)}
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':';1. <.:
~ ...\

.. " /

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;'0
\

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f~

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, .: .:; ,i-.:.. L

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A ,

/
I

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PATIENT 1.4BEL

tYl:;SSM
H

E A L T ..

c; A R E"

DEPAUL HEALT11 CEN1'ER

MARCH,PHILLIP
INTEADISCIPLINARY HISTORY & PROORESS NOTES

111111111111111111

lfP

f"llID 0')21\-01 172'/400691 LO/02/1976 31.Y M 10/02/07 000748298 ;{AHt-1AN,ANWER Z

SLM1000003 (612003) 02 FRONT

DePaul Medical Records/Phillip H. March

000034

INTERDISCIPLINARY HISTORY AND PROGRESS NOTES

~SSM
H E A L T H ' CAR EINTeRDISCIPLINARY HISTORY & PROGRESS NOTES
SLM1000a03 (B12003) 02 BACK

DEPA.UL HEALTH CENTER


l'!.i\l\CH, PHIl.LIP
RJ~MAN,PEW8R

1011111l1l1lllnlilB
Z

rip
000748298

0727400691 MED 0524-01 10/02/1976 31Y !vI 10/02/07

DePaul Medical Records/Phillip H. March

000035

P[RIPHERAlLY INSERTED r;:ENTRAl CATHFTEfl/MIDLlNE CATt1ETER INSERTION PROCEDURE NOTE

Insortion

--- ------- ---- ---Tile risks and benefits or the procedure were explained to patient. -*
Consent was obtained. .

A-~'J(. t..../
.1

2 Patient Identifiers and lime Out performed with


Midline Information

__ 2 e I t. u

~v "C> '. N1'f P'\.

Brand 13 t'-4- D ~....... E-L. v (/ "" "f>l-J-..>..- .....


Gauge/French 5' FnLUmens ~ lumen 0 Double lumen 0 Triple lumen

REF

7818508 RERE0772

Procedure:: The sltewas prepped and draped in a sterile fashion. Under sterile conditions per hospital policy, ~.'l,. ml 1% lidocaine was injected Intradermally to produce wheal. PIce placed using modified Seldinger

technique.
Site:

~ left

'@itsi!9)eln X

Cepl:lalis fe"", !nternallength

Blachibl

~eill

Catheter trimmed

Ye~Len9th tf~ ..... Mark


oe;5l.::.."""
~r- IO~ 4-t:t!----~

if?

Mark Externl;Jl

Mark

.. +,3. vC: -S t r-t.""

Arm Circumference RI Number of attempts: I

PIce tip verification by CXR and order for use needed prior to using PIce.
Patient tolerated procedure lit (Jar tfr.r P

p.,..

T7 C"'ft

12fJ?'H 60."'"~ ~ '-., .

Flush Protocol ~
Each lumen of th<lElCe'lMidline flu~ith 10ml NS IVP Positive blood return in aU lumens. ~ ~ No_ _ __

Comments:

"PII. :z.'NZ-E"-

f?t~ (!l~r ~{L

if?

~-vvtSvr
and staff oovcatoo on PICC care.

gc..

Patient Education: Patient receiveo Pice booKlet and card. PIce sign placed at head of bcd. Patient

Date: ro\c+loe(

~SSM ,.II
.. , , l

t ... ,"

DePaul Health Center

DEPAUL HEALTH CENTER

~!I!~'J~l~I!III'I~

rip

Pice Procedure Note 8/007

')7271J00691 MED 0524 01 10/02/1976 31Y M 10/02/07


f-tl!:LKAVERI, SONIA N OOO'/48~q8

DePaul Medical Records/Phillip H. March

000036

Silicone Valved

Pice

I his f)..1!iellllvj,; a ~erGroshol'lg CaIMI'"


!m.urll]<;1Oft

by' _

~~f.c U/~ ....... -

_dlf/"~

_(ffaTO)

LolNo

r:;:::c:-d!!, ---==- ~.:!:_77:_


(1f>5lYbmIClN''Cii,,'narr''''i

When cleanln9 the exit ",it,:


120.
, VLlllil: lVl <S-C~(jff ttl1Q' lo I ;c;spitat rW'otO{',Q(

Naw Important Information:


\.onuad rneala $.ilf"-Itj b&wf'Ame-o III bodyftif11s,)l'rat{Jt~ pncr t~1 PQ\-"/Bf lllJfCtlQ'ff Wflrnmg F3w.xf. to \'ibnn r-C.(l.1f W Tf~a to [x,1..jy tftln~::'OtaUll~' prktf to Pflwe1 fI'IH('fl(;<." rf~Jy r~-sutI III eatfl&ll'f fa~<l<'
l/1<',JOH}ll5ty f~~l the Paw@rGro&OOngCdVv.>te.r (.jm~q a t{j Wf'011..1fW" Sylm\y.~ &nd ~hJ{'I!.e r(lfru:4 S''i'lhne pld)( to ,!fie lf1 rr.ntIEt(~ty h~mir.g l\iO comphiit.'O ("j( ptl'HP.i ""0.'1;t{;j)n sbrkE''.i '!tJo.~j ",i-1I111~F.tre thu ~M{["J;r:y (j~ Iix' PowerGrosflollQ Caltr"J!1)f (\.11Q flf'Am! (j;!fn.~9u (p the callclet: f/E:-:GlfJ.lf'Ce 1(; flo mog ;nn'1 If\<.jit.'''l1~ p:;vh;1l Of cnipwte call'ct1 QO.,il~%)

Ute cHarh"....,in\"'JlJ ~lj.x:()(l.nt$ aPf:1i~if p(l1,iltin~(r rodu!JJ to .;:!tt<.n U"'1t1 t'.1)f gl,e
."""' f1

the [;;llh@!Gr

A~.{]i.\> '.\11 ~kr<l!ur!>':f ~l~!I~alih&-t1j1-l<:S. to

ary l;~lf'npt~!"Hf{".. belom ,fppryiT10 l"e!:.';~'.>f'4J

C&theter Maintenance
.. ! ml flY'.sh . an'!1
r'.acl"; V:'tI-:
(II

Do not
d~'atel j

pt{)C~"d'
p!;{'>r

with O'<"YI.'E>r ~hm YtKh/lnW c01u3'j"Jf> h.ki teen W..mfng! r .aAUl/l to ef')<;'..,.t;f,! ,:..ah)fof:Y <}f (\'19 Pawertirosnoni
tv f',(t<.+..'ef lH~':'~'Or' '(,!ld~s

:>flo,: "

Csth('4t'%

m,lY !~~',A

lJ\

':-<1'I1"""ll'r 'aql,r~

week fU1'!'~e,rj~'I?J 1"..<8E-1!J.l3e;1; ,j(1-<.PlitiJ 10 ml flush att&i ;lrtN1t'"1.,] NO)-j, It hbO.(j 10; iii {~Ca!hr:llff, <.p ,tllEl vow,~ lfijl'r.t.\'II'l at ('(){j\f<if.# WJ:!"(}I.a (th(! r\o8i!rfi.;? fj{ :telJoi\ttw.s aaa-p!(,f j

D<,;nu! f'.cJ}6'1i tho?ln'::AlrtVJ1\a.ik~at(i 014 ft(\ljt, wa(nl~: f'O'..';T"i' lf1eGlill rrmch,r,w, DlB'$S!,Jm !tn)'Ni\j f.et1iUf(> 'nHy ,'1Q'~ preVi.mll"He-f ~:'H~''i:;'\tlli::a!iOf1 01 ,3l"1 {l'X},J.;.1io.d Citth::kl, whf,:n ~nay c,~c:,p
cathe1!:r fS!lViB

20 mt ftu-sh . pno;
iTO.1J}t!N

t,'

I V~t'",,'Xl ~.:.(\fll~li'4J

Warning: t)'cr.r:f.lvq tj)11 tTV':I,:rin1!l'l11 f~H" 11(1 ,)'" 'nJj'Se(" pt~jJ trl3UfJ PSI, may re;S';.Jl1 in ('stilet&! (nJfuH:' dnti/cr
rvW'!di.:' ,"~nt

(]I

ill ma:o::~n:Jrtl

Gi'1Uidf'f

nu

aJlf'( TPN (thto n6t'lflf? rlt;.:'t)k:u::~r.

Watnmg:ft'0Vl-erGroN1DngC;11hP..1.e1

tv.] 1"JSIT!t:.ll,(~1 for (QUline m.aittfrr'3,f.c..fI. A!nHY:S !}u'53~ ...lIth 10nnalsiul'j{'.


{;oJ(~"l,Ilt Ul'611t<;fflJcb(}p~>

for

lb~

DO Hen VS~ A S'I'RlGl' '-"MAlI.!;R THAN 1U M\'I

1f.7Q,J'OlrtiJ other care iUZ'.trv.:;tflbrJ,

1'l'l;\\I-;Bf11)n ft'l ~~ i-rriechalol t:.Ofltr.t'l'l mtsdill' imph:-'!~!he l:.iltt.<:!terS flu-t1I\' KI YtlifiS1ail.,i !lw ~:rOG~hJfF.' Qut (kNl3 N,J) nopty aDj.J{f.lOr~atetu~~ ct 11:1, ph)C;>~ twe tOf :J patt0,ubr pa~e"t A svrtahly lfMru:d c4o"",,,n '. ref4'''''sill'. (,:. """,..ting if',t.'

f).a~th ';IIHUS {~ a pa~if'lf as

Jt ow~.ams

to n pt'.m1~f ~',~CI'I'Oq p1OCwlU'e

Powvr InjectIon Procedure:


1 nB~ the U1~:Oic(I/.'1I':i '.d'telo&':', cap fro'" Jhe p.,lWi1fOrQshong G;-ilhefer ? Attacll;) 10 m~ IN talg1 :<i'finge (g:\e'j ""l\.1J,+}teri\e I'4J ffial s;,lff ::l A.~tuI.'dQ 11)( adtXl.I..fi\le tn)()d I~-tll(n lH'ld 'ril}<..<fCUS Y flUSh ttll) C6tn~ \.,>\lh the ifi'" 10 ff'>I u1 !(l.eft\o,) r!l. 'lrITU.\! S3wn~ Warning! r aihJfI! (Q ':Hlf,.lHe p.a~el',(, of It'i'H t.'SI/1o{,3t \yiCf ~) pD't'i'VI
T

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L'ljecfu.;tfl ~~'Jdli~: may [t~iUit if) c;ttt'miGr 1.'nh.IfO, 4 !)el""i> "I""'>./" " Allilch the 0<'- "';,"CI"," davit.'C 10 the """"'~/f'sI'!on"
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Wa't11i:ng:~ [.xcfwdlll9 if)j:"ma'<IT(~iln fl(;,./ I<1(e 01~' i ~~. OJ ~ m.a.ll.rrrtP"f> pret;,$.\!03 i)f ;jC{J Pli, may rEs:ul1 In o:a{h{t(4'.-r fail{J(8 ~;M{or <C.;ilhe~-r (ill
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i:,np ern

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PowerGrosnong Ca{tM.fD{

DePaul Medical Records/Phillip H. March

000037

INTERDISCIPLINARY HISTORY AND PROGRESS NOTES


Date

Time

INOTES MUST BE SIGNE{)

''',' V'J(L~

. tp D(, - Leti

I(<-r 1) (r.. c L\:~C V\i~~.i.l


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INTERDISCIPLINARY HISTORY & PROGRESS NOTES

SLMl000f)(l3 (6r.!003) 02 FRONT

DePaul Medical Records/Phillip H. March

000038

INTERDISCIPLINARY HISTORY AND PROGRESS NOTES

~SSM
H E A L T H ' CAR
SLM-1000003 (6f2003) 02 BACK

E~

DEPAUL HEALTH CENTER


~~CHrPHILLIP

11011111111111111

INTERDISCIPLINARY HISTORY & PROGRESS NOTES

r/p
000748298

0727400691 MED 0524 01 10/02/1976 31 M 10/02/07


RAHf'Wl,At\lWBR Z

DePaul Medical Records/Phillip H. March

000039

INTERL._ .,.,UNARY HISTORY AND PROGRESS NOTES

~----~----~--------------------------r-------------~~~~~--------------

~SSM THe
HEA L A R
SLMl000-003 (6/2003) 02 FRONT

DEPAUL HEALTH CENn:l{

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INTERDISCIPLINARY HISTORY 8& PROGRESS NOTES

t>IARCH, PHILLIP 0727400691 MEn 05/.4-0)

IIIIIIIIIIIIIIIIIJI

rip

10/02/l976 JIY

M 10/02/07

t-lEY,KAVERI, SONIl\ N 000748298

DePaul Medical Records/Phillip H. March

000040

INTERDISCIPLINARY HISTORY AND PROGfl. . ~ ....,orES


Dall'

Time

I NOTES MUST BE SiGNED

I-

Gf0 b.oc-&.VQVf.A/~O~

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INTERDISCIPLINARY HISTORY & PROGRESS NOTES

0727400691 MED 0521-01 10/02/1976 3lY M 10/02/07 f'.1ELKAVER.l., SONt.n. N OOQ74B2Sl3

DePaul Medical Records/Phillip H. March

000041

INTERDISCIPLINARY HISTORY AND PROGRESS NOTES

'~--.

;----~--~~~~--~--------~----------~~~~----------DEPAUL HEALTH CENTER


!t?\RCH, l;'HILLIP

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lip

"727400691
INTERDJSCIPLINARY HISTORY & PROGRESS NOTES

MEO 05~4-01

10/02/1976 31Y M 10/02/07 MELKAVh:RI,SONIA N 000748298

SLM1000 003 (1l12003} 02 FRONT

DePaul Medical Records/Phillip H. March

000042

INTERDISCIPLINARY HISTORY AND PROGRESS NOTES

;1

~SSM
SLM 1000003 {6t200:3j 02 BliCK

H E A L T H - CAR E"

INTEI'lOI$CIPUNARY HISTORY & PROGRESS NOTES

DePaul Medical Records/Phillip H. March

000043

INTERDISCIPLINARY HISTORY AND PROGRESS NOTES

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DePaul Medical Records/Phillip H. March

000044

INTERDISCIPLINARY HISTORY AND PROGRESS NOTES

~SSM
SLM-l000-003 (612003) 02 BACK

H E A L T H . CAR EW

INTERDISCIPLINARY HISTORY & PROGRESS NOTES

DePaul Medical Records/Phillip H. March

000045

INTERDISCIPLINARY HISTORY AND PROGRESS NOTES

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DePaul Medical Records/Phillip H. March

000046

INTERDISCIPLINARY HISTORY AND PROGRESS NOTES

~SSM
H E A L T H SLM-l000-003 (6/2003) 02 BACK

CAR E~

INTERDISCIPLINARY HISTORY & PROGRESS NOTES

DePaul Medical Records/Phillip H. March

000047

DEPAUL HEALTH CENTER


CONSULTATION REPORT PATIENT: MARCH, PHILLIP ADM'T DATE: 10/02/2007 CONSULT DATE; 10/02/2007 ATTENDING PHYS; SONIA N. MElKAVERI, M.D. CONSUL TlNG PHYSICIAN: PHILLIP G. ZINSER, M.D.

MR#: 000748298 ACCT#: 0727400691 DOB: 10/02/1976 ROOM: 0524

INfECTIOUS DISEASE CONSULTATION

REASON FOR CONSULTATION: Evaluation of fever.


SUBJECTIVE: This is a 31-year-old man with a history of hypertension. He had a stab wound to his left jaw earlier this year. He sustained a fracture to the left mandible. He had open reduction and internal fixation. He developed a hardware infection which had a partial response to antibiotics. The hardware was removed May 22, 2007at Barnes. At that time cultures grew strep anginosls, strap intermedills, and Eikenella corrodens. He returned to DePaul on September 19, 2007 with recurrence of swelling and pain in the same area. MRI of the jaw showed an osteomyelitis of his left mandible ramus. I consulted wi1h the surgeons at Barnes. He was discharged on IV Unasyn and was \0 follow-up with the surgeon at Barnes. He was discharged with a 6 weel< course of IV Unasyn through a PICC line. The patient is readmitted on October 2, 2007 with a 2 day history of increased pain in his jaw and fevers to 1Q2.7. He was admitted and switched from Unasyn to Zosyn. His fevers are improved and he feels much improved. His jaw pain improved on the previous hospltatization with the Unasyn. His swelling improved with Unasyn. His blood cultures are growing a Gram-negative bacteria at this lime. He reports that he did leave the Gap off of his Pice line. I suspect that the Pice line is infected at this point. He, however, teels improvei;l with the Z05yn. ALLERGIES: The patient's list of allergies reveals he has no known drug allergies. MEDICATIONS: His current list of medications includes: 1 Famotidine. 2 Acetaminophen. 3 Diphenhydramine. 4 Morphine, 5 Zosyn. PAST MEDICAL AND SURGICAL HISTORY; As above. SOCIAL HISTORY: He drinks alcohol. He does not lise tobacco or recreational street drugs. OBJECTIVE: VITAL SIGNS: The patient's T max is 102.7, pulse 92, respirations 21, blood pressure 152/91, saturating 100% on room air. Most recent temperature is 100.5. GENERAL: The patient is alert, awake, and orIented. H~ENT: Oropharynx is claar. Therr~ is no obviQu~ swelling in his face. HEART: Regular rate and rhythm. LUNGS: Clear to auscultation bilalerally. ABDOMEN' Soft, nontender, and nondislBnded. Normoacti'le bowel sounds. EXTREMITIES: The Pice in his left arm is without cording or signs of inflammation. LABORATORY DATA: The patient's white blood cell count is 7000 with 91% segments. 2% bands, hematocrit 33, platelets 114,000. Creatinine 1.1. Liver function tests normal. Urinalysis negative. Chest x-ray negative. CK 235 Blood cultures from 10/01f2007 are growing Gramnegative bacilli. ASSESSMENT:

MEDICAUSURGICAL CONSULTATION REPORT-DP

- Page 1 of 2

DePaul Medical Records/Phillip H. March

000048

OEPAUL HEALTH CENTER PATIENT: MARCH, PHILLIP

CONSULTATION REPORT MR#: 000748298

Left mandible osteomyelitis after stab wound. Cultures at Barnes grew streptococcus anginosis, streptococcus intermedius, and EikeneHa corrodens, Fever \Q 102.7 with left shift and increased pain and Gram-negative bacteremia. The peripherally inserted central catheter line 15 the lil<ely source as the patient left tile cap off the peripherally inserted central catheter line. He is feeling improved with the Zosyn.

RECOMMENDATIONS: 1 Discontinue Pice and culture tip. 2 Peripheral IV. 3 Follow-up blood cultures.
Of nole, Ihe patient also says th(:lt he has only missed 1 dose of Unasyn and that was yesterday. Thank you tor allowing me \0 participate
In

this patient's care.

This document has been nwiewed and signed by PHilLIP ZlNSER Sign Date/Time: 1Of03/2007 2:17PM EST

PHILLIP G. ZINSER,

M.D.

PGZ:356 - 20~7051
0: 10/02/20075:24 PM T: 10/2f2007 9:46 PM E: 10/03/200717:01 PM

cc:
SONIA N, MELKAVERI, M.D.

MEDlCAUSU RGICAL CONSULTATION REPORT ~DP

- Page 2 of 2

DePaul Medical Records/Phillip H. March

000049

SSM DEPAUL EMERGENCY FLOW SHEET RECORD Name: March, Phillip Age: 30Y MR: 000748298 Acet: 0727400691
VITAL SIGNS User DAGN CKEE DKIN

DateiTime 10/0200:08 10/0123:04


10/0121 :09

BP

152188 148/85
173/94

PULSE 80 93 104

RESP 16 26 20

TEMP 101.7 102.8 102.5

PA1N 3
8/1(}

02 SAT TIME 100 on ra 0008 99% on RA 2304 100% on RA 2107

Name: March, Phillip Age: 30Y MR: 000748298 Acct: 0727400691 Prepared: Tue Oct 2 01 :39:00 2007 by Dave ~ 1ew, Page: 1

DePaul Medical Records/Phillip H. March

000050

SSM DEPAUL EMERGENCY RECORD


Complaint: Chills
Triage TIme: Man Oct 01 200721 :09

Name: March, Phillip


Age: M30 Wt: 73.9 Kg (est.) MedRec:000748298 AcctNum: 0727400691

--------------TRIAGE DATA------------Age: 30 Male


Kg Weight: 73.9 (est) PhysIcians;
None Pcp Emergency Physicians WAITING

Source: Home

By: Car
Urgency: ESI3 Room:
(2107)

Paln;6/10

e~Sat: 1QO'%/RA

HPI BLANK (23:47 RSCH)


CHIEF COMPLAINT: Patient has ongoing history of complications apparently from the repair of 8 jaw

fracture. He has had a devlce apparently get Infec.md...replaced, and was Bdmitted late Septemb~r for apparently jaw qS~.!Q...myeJlti$. !iere tanightwith fever and int~ed pam.. --

HTSTORIAN: History obtained from patient.

TIME COURSE: Onset of symptoms reported as gradual. SEVERITY: Maximum severity is moderate. Currently symploms are moderate.

KNOWN ALLERGIES
No known drug allergies.

HISTORY
MEDICAL HISTORY (21 :35 JWHI): History of hY2]lrlensiOn, Pa1'ent is n'?r:'~~rnp.I~a.ntwith \re~ent,

Stabbed in left race April 26th, 2007. History of hypertension, Patient is noncompliant with treatment, ..
PSYCHIATRIC HISTORY (21:35 JWHI): No previous psychiatric history. No previous psychiatric history. No previous psychiatric history. No previous psychiatric history... SURGICAL HISTORY (21 :35 JWHI):. Jaw Repair, plate left ja~. rag"l!.lrepair f?atient's previo\fs -

surgical history is not relevant tOJ.he ';:..!I.s~,.Jaw.Repair..~te ~ft Jaw. facial repair. PatJent'$ previous Surgical HlstoryTsnot relevant to the eaee.. ' SOCIAL HISTORY (21 :35 JWHI): Denies drug abuse, Lives al home with family, Denies alcohol abuse,

Denies tobacco ..
FAMILY HISTORY (21 :35 JWHI): Family history is not contributory to this case. Family history is not

contributory to this case. Family history is nQt contributory to this caS8 ..

NOTES (21 :35 JWHI): Agree with nursing records .


MEDICAL HISTORY (23:49 RSCH): History of hypertension, law osteomyelitis. SURGICAL HISTORY (23:49 RSCH): jaw fracture repairs. SOCIAL HISTORY (23:49 RSCH): Denies alcohol abuse, Denies tobac<:o abuse. FAMIL Y HISTORY (23:49 RSCH): Family history Is no1 contributory to this case. NOTES (23:49 RSCH): Nursing records reviewed.

ROS (23:48 RSCH) NOTES: see hpj.otherwise negative.


ALL SYSTEMS NEGATIVE: All systems were reviewed and are negative except as described above.

Prepared: Tue Oct 02 2001 01 :38 by D"fIvtl Agnew, Page: 1 of 9


SSM DePaul HtJIIlth Center

DePaul Medical Records/Phillip H. March

000051

11111 I! 11111 IlIlt 111111111111111111111111111111

III

Ililt Iltli

[Itll ~m ~11111111 ~Ililim II1II ~ ~ 11111 1111111111


Name: March, PhilUp Age: M30 Wt 73.9 Kg (est) MedRec:000746298 Acc1Num: 0727400691

SSM DEPAUL EMERGENCY RECORD


ADDITIONAL TRIAGE (Mon Oct 01 2007 21 :09 DKIN)

COMMENT (Man Oct 01 200721 :09 OKIN): Pt has PICC line to 1raat jaw infection. COMPLAINT (Man Oct 01 200721 :09 DKIN) PROVIDERS (Mon Oct 01 2007 21 ;09 DKIN): TRIAGE NURSE: Deborah King, BSN, CHARGE NURSE: Julie Sanchez, RN. ADMISSION (Man Oct 01 200721 :09 DKIN) PATIENT (Mon Oct 01 200721:09 DKIN): NAME: Phillip March, DOB: Sat OCl 02 1976, RACE: Black, Code: NO, Trauma: "NO, Work Comp.: NO, Heal Related: NO, SSN: 493788699, ZIP CODE: 63121, HEIGHT: 182cm, PHONE: 314522-8730, MEDICAL RECORD NUMBER: 000748298, ACCOUNT NUMBER: 0727400691, IBEX NUMBER: 20071001210950ADT. PREVIOUS VISIT ALLERGIES (Mon Oct 01 2007 21 :09 DKIN): No known drug allergies. VITAL SIGNS (Man Oct 01 200721 :09 DKIN) FALL RISK (21 :35 JWHI): TIME: 2133, Gender (Male), Get up and go test: Able to rise in a single movement. ASSESSMENT: (21:35 JWH1): The GCS total is 15, CIO FEVER AND CHILLS THAT ONSET TODAY, CIO LEFT JAW PAIN. RECIEVING IV ANTIBIOTICS VIA PIce LINE. IMMUNIZATIONS (21:35 JWHI): Last tetanus shot received less than 5 years ago. TB Screening (21 :35 JWHI): Denies T8 screening. Domestic Violence (21 :35 JWHI): Not Appiicable. TREATMENTS IN PROGRESS (21:35 JWHI): No treatment, Protocols: RIO Sepsis.

PHYSICAL EXAM (23:49 RSCH)


CONSTITUTIONAL: Vital signs reviewed, Comfortable, Alert and oriented X 3, Patient is febrile. HEAD: Atraumatic, Normocephalic. EYES: Pupils equal and reactive to light, No discharge from eyes, Extraocular muscles intact. Sclera are normal, Conjunctiva are norma\. NECK: Normal ROM, No jugular venous distention, No meningeal signs, Cervical spine non-tender. RESPIRATORY/CHEST; Chest is n9n-tender, Breath sounds normal, No respiratory distress. CARDIOVASCULAR: RRR, No murmurs, No rub, No gallop. ABDOMEN: Abdomen is non-tender, No masses, Bowel sounds normal, No distension, No peritoneal signs. BACK: There is no CVA Tenderness, There is no tenderness to palpation, Normal inspection. UPPER EXTREMITY: Inspection normal, No cyanosis/clubbing/edema, Normal range of motion. LOWER EXTREMITY: Inspection normal, No cyanosis/clubbing/edema, No calf tenderness, Normal range of motion, NEURO: GCS is 15. No focal motor deficits, No focal sensory deficits, No cerebellar defici1s. PSYCHIATRIC: Oriented X 3, Normal affect.

LAB INTERPRETATION (23:51 RSCH)


INTERPRETATION: Normal esc. Decreased PotaSSium, otherwise Chemistry normal, Normal Cardiac enzymes, Normal PT/PTT. Urinalysis is normal.

J2SAT INTERPRETATION (23:49 RSCH)


02SAT: 02 saturation reading 99%, 02 AMT: R.A., 02 Sat normal, Nona needed,
Pr~pared:

Tue Oct 02 2007 01:38 by Dave Agnew, Pay~; 2 of 9


SSM Of/Paul Heaith Center

DePaul Medical Records/Phillip H. March

000052

SSM DEPAUL EMERGENCY RECORD


RESULTS
LAB (22:45 D '", LOOD GASES W/L YTES PANEL Oct 01 200722:09,

Name: March, Phillip


Age: M30 Wt: 73.9 Kg (est.) MedRec:000748298 AcctNum: 0727400691

pH, Arteri .511 pH Units Ref Range (7.38-7.42), PCO Hg Ref Range (38-42), P02 98.9 mm Hg Ref Range (75-100), BE -1.1 mmol/L Ref Range (-2-2), 02 SaturatIon 98.1 % Ref Range (92-98.5}, Hgb 12.3 gmldl Ref Range (12-18), 02 Content 16.9 % Ref Range (15-23). Sodium, arterial bId 134.5 L mmoVL Ref Range (135-145), Potassfum, arterial blood 3.28 L mmollL Ref Range (3.3-5.3), Comment ER, HB0297.1 H % Ref Range (94.97), HBCO 0.6 %, Ref Range (0.01.5), MetHgb 0.4 % Ref Range (0.0-3.0),
Calclum.ionized 1.12 mmol/L Re1 Range (1.10-1.33),

Glu 95 mg/dl Ret Range {80-120), Hct 36 % Ref Range (36-54).


HHb 1.9 % Ref Range (0.0-5.0), HC03 20.7 L mmol/L Ref Range (22-29), Fi02 21,0, Site RB. tC02 21.5 L mmolfL Ref Range (23.027.0). (22:45 DAGN): esc WITH MANUAL OIFF OC1 01 200722:33. WBC 8.1 1000/mm3 Ref Range (4. 5-".0).

RBC 4.69l

,axe Ref Range (4.7-6.1).

Hgb 12.7 L gmldl Ref Range (13.0-18.0), .tict as.9 L % R~f Rgn9~ (~9.Q-!?4.0),
MeV 76.5 fl Ref Range (80.0-99.0), MCH 27.1 pg Ref Range (25.031.0), MCHC 35.4 gm/dl Ref Range (32.0-36.0). ROW 15.6 H % Ref Range (11.5-14.5), Platelets 159 1000/mm3 Ref Range (130.0-400.0). (22:45 DAGN): PT Oct 01 200722:39, PT 10.4 seconds Ref Range (9.711.1), 1NR 1.0 Ref Range (0.9-1.1), INR Therapeutic Range Conventional Anticoagulatlon:INR 2.0-3.0 INR Therapeutic Range Intensive Anticoagulation:lNR 2.53.5. (22:45 DAGN): PTT Oct 01 200722:39, APTT 22.5 l seconds Ref Range (23.0-34.0). (22:45 DAGN): CK Oct 01 200722:45, CK 235 H UlL Ref Range (55.0170.0). (22:50 RSCH): WITH MANUAL DIFF Oct 01 200722:47.

cse

Prepared: TUB Oct 02200701:38 by Dave Agnew, Page; 3 Qf 9 SSM OePaul Health Cenlef

DePaul Medical Records/Phillip H. March

000053

SSM DEPAUL EMERGENCY RECORD


wec 8.1
1000/mm3 Ref Range (4.5-11.0),
RBC 4.69 L 10X6 Ref Range (4.7-6.1). Hgb 12.7 L gmldl Ref Range (13.0.18.0), Het 35.9 L % Ref Range (39.0-54.0),
MCV 76,5 fl Ref Range (80.0-99.0), MCH 27.1 pg Ref Range (25.0-31.0), MCHC 35.4 gm/dl Ref Range (32.0-36.0), RDW 15.6 H % Ref Range (11.5-14.5), Platelets 159 1000/mm3 Ref Range (130.0-400,0),

Name: March, Phillip


Age: M30 Wt: 73.9 Kg (est.) MedAec:000748298 AcctNum: 0727400691

Segs 91 H % Ref Range (40.070.0), Bands 2 % Ref Range (0.0-5.0), lymphs 5 L % Ref Range (22.0-40.0), Aty Lymphs 2 % Ref Range (0.0-9.0), RBC Morph 1+ Poikilocytosis. Pit Es1 Normal. (22:57 RSCH): COMPREHENSIVE M~TABOUC PANEL Oct 01200722:53, BUN 13 mg/dl Ref Range (9.0-20.0), Sodi IL Ref Range (137-145), Po ssl m 3.3 L Eqil Ref Range (3.6-5.0), Chlo . IL Ref Range (98.0-107.0). Glucose 94 mg/dl Ref Range (75-; 10), Creatinine 1.1 mg/dl Ref Range (0.81.5), AST/SGOT 24 U/L Ref Range (17.0-59.0). Alk Phos 73 U/L Ref Range (38,0126.0) I Calcium 8.8 mg/dl Ref Range (8.4-10.2), Bilirubin 0.8 mg/dl Ref Range (O.21.3), Albumin 4.7 gmJdl Ref Range (3.55.0). Prot Tolal7.1 gm/dl Ref Range (6.3-8.2),
~7 mEq/L Ref Range (22.0-30.0). AL T/SGPT 13 L. UfL Ret Range (21.0-72.0), GFR 101.1 m!lmin/1.73m2. (23:00 RSCH): TROPONIN-I Oct 01 2007 22:57, Troponin 1<.0.10 ng/ml Ret Aange (SEE BElOW). Normal <0.10

C02

Gray Zone 0.10-0.99 Positive >-1.00. (23:00 RSCH): CKMB Oct 01 200722:59, CKM8 <0.2 ng/ml Ref Range (0,0-0,0), In1erpretationCKMB An abrupt riselfall of CKMB over 24 hours is an acute injury Interpretation-CKMB pattern. (23:00 RSCH): UR1NALYSIS DIPST1CK AUTO Oct 01 2007 23:00, Color YELLOW 1 Turbidity CLEAR I Spec Graviiy 1.010 Ref Range (1 .005-1 .0300}.
Prepared: TUB Ocl 02 200701 :38 by Oaw Agnew. Page: 4 of 9 88M DePaul Hltalth Center

DePaul Medical Records/Phillip H. March

000054

SSM DEPAUL EMERGENCY RECORD


pH 7.0 pH Units Ref Range (4.6-8.0), leukocyte neg lui Ref Range (Negative), Nitrite neg Ref Range (Negative). Protein. UA neg mg/dl Ref Range (Negative), Glucose,UA norm mgldl Ref Range (Normal). Klitone neg mg/dl Ref Range (Nega1ive), Urobilinogen norm Ehrlich Units Ref Range (Normal). Bili Qual neg mg/dl ReI Range (Negative), BloodfUA neg lui Ref Range (Negative).

Name: March, Phillip


Age: M30 WI: 73.9 Kg (est.) MedRec:00074B296 AcctNum: 0727400691

RADIOLOGY INTERPRETATION (23:51 RSCH) CHEST: Interpretation of chesl X-ray shows, chest x-ray negative, no infiltrates, no pneumothorax, no
hemothorax, no masses, no cardiomegaly, no CHF, no effusion, no free air.

DOCTOR NOTES (23:51 RSCH) TEXT: Admitting for iv abx and consultation ..
DNV: Discussed this case with Dr. Rahman, the on call physician. PATIENT ~LAN: The patient will be admi11ed to the hospital.

DIAGNOSIS (Tue Oct 02 2007 00;38 RSCH) FINAL: PRIMARY: Jaw osteomyelitis, ADDITIONAL: fever. DISPOSITION (Tue Oct 02 2007 00:38 RSCH)
PATIENT: X-RAY/CT Follow-up: NO, Critical Care: "None, Doctor ~rocadures: NO, Disposition: Admit Medical, Condition; Stable.

MEDICAT'ON SERVICE
Acetaminophen (21 :46 AMAJ): Order: Acetaminophen: 975 mg : By Mouth

Tim8: 2146
Notes: vo/rbo
Qrg~r~~: Mon Oct 01 200721 :46

Ordered by: Angela Majino. M.D. Entered by: Andra Kofahl, EMTP Mon Oct 01 200721 :46 Documented as given by: Andra Kofahl, EMT-P Mon Oct 0' 200721:47 MEDICATION, Time given: 2146, Given in amoun1 and via route as prescribed, Amount given: 975mg, Site: Medication administered P.O., Correct patient, time, rO~J1e, dose and medica1ion confirmed prior to administration, Patient advised of actions and side-effects prior 10 administration, Allergies confirmed and medications reviewed prior to administration. Benadryl (Tue Oct 02200700:13 RSCH): Order: Benadryl : 50mg : By Mouth Time: 0013 POTENTIAL MODERATE INTERACTION Morphine SuHate POTENTIAL MODERATE INTERACTION Neuronlin Notes: verbal order, read back Ordered: Tue Ocl 02 2007 00:13
Prepared: Tue Oct 022007 01 :38 by Dave Agnew, Page: 5 of 9
SSM DePaul Health Genter

DePaul Medical Records/Phillip H. March

000055

SSM DEPAUL EMERGENCY RECORD

Name: March, PhiUip Age: M30 73.9 Kg (est) MedRec:000748298

wt:

AcctNum: 0727400691

Oroered by: Richard Schmidt, MD Entered by: Christine Keena, BSN Tue Oct 02 2007 00:13 Acknowledged by: Christine Keens, BSN Tue Oct 02200700;13 Documented as given by: Christine Keene. BSN Tue Oct 02 200700;14 MEDICATION, Time given: 0013, GiVen in amount and via route as prescribed, Amount given: SOmg. Site: Medication administered P.O., Correct patient, time, route, dose and medication confirmed prior to administration, Patient advised of aclions and side-eHeets prior to administratIon, Allergies conflrmM and medloations reviewed prior to administration, Administered by CMK, RN, Patient in position of comfort, . Cart in lowest position, Family at bedside. 3:46 RSCH): Order: Morphine Sulfate: 4 mg : IV Push Repeat: ever in utes PRN pain AL MODERATE INTERACTION Neurontln Ordered: Man Oct 01 2007 23:46 Ordered by: Richard Schmidt, MD Entered by: Richard Schmidt, MO Mon Oct 01 200723:46 Acknowledged by: Christine Keens, SSN Mon Oct 01 200723:47 Documented as given by: Andra Kofahl, EMTP Mon Oct 01 200723:56 MEDICATION, Time given: 2355, Given In amount and via route as prescribed, Amount given: 4mg, IVP, Slowly, Catheter placement confirmed via flush prior to administration, IV site without signs or symptoms of infiltration during medica1ion administralion, No swelling during administratlon, No drainage during administration, IV flushed after administration, Correct patient, time, route, dose and medication confirmed prior to administration, Patient advised of actions and side-effects prior to administration, Allergies d and medications reviewed prior to administration. Unasyn :46 RSCH): Order: Unasyn : 3 grams: IV Piggy Back 00: Mon Oct 01 200723:46
Ordered by: Richard Schmidt, MD

Enterad by: Richard Schmidt, MD Mon Oct 01 2007 23:46 Acknowledged by: Christine Keene, BSN Man Oct 01 2007 23:47 DocumentfilQ as given by; .Angr9. KQtahl, EMT-P Tue Oct 02200700:1' MEDICATION, Time given: 0011, Given in amount and via route as prescribed, Amauni given: 3 grams,lV site 1. Medication administered into right wrist, Drfp/IVPB, Premixed, via pump tubing. at 200 ml/hr, Catheter placement confirmed via flush prior to admlnlstraiion, IV site without signs OF symptoms of infiltration during medicalion administration, No swelling during administration, No drainage during administration, IV flushed after administration, Correct patient, time, route, dose and medication confirmed prio( 10 administration, Patient advised of actions and side'effects prior to administration, Allergies confirmed and medications reviewed prior to administration, Administered by CMK. RN, Patieni in position of comfort, Side rails up, Cart in lowest pos\llon, Family at bedside.

PRESCRIPTION: No Documented Prescriptions NURSING ASSESSMENT: TUBES AND PORTS (22:08 DAGN)
TIME: PICC line noted. to Lefl arm, No signs/symptoms of Intection.

NURSING ASSESSMENT: SKIN (22:09 DAGN)


Prepared: TUB Ocl 02 2007 01 :38 by Dave Agnew, Page: 6 of 9
SSM DePaul Health C6nter

DePaul Medical Records/Phillip H. March

000056

SSM DEPAUL EMERGENCY RECORD


TIME ASSESSED: Patianl was assessed at 2205.

Name: March, Phillip


Age; M30 WI: 73.9 Kg (est.) MedRec: 000748298 AcctNum: 0727400691

CONSTITUTIONAL: Patient arrives ambulatory with steady gait to treatment area, History obtain@d from patient, Pa1ient is cooperative, Patient Is alert and oriented x 3, Patient is well-groomed, Skin color is normal. Skin temperature is hot. SKIN; No rashes present, No Drainage. No obvious signs of skin trauma.

NURSING PRoceOURE; SEDSIOE RADIOLOGY (21:54 TMO)


TIME: Procedure was performed a1 2150. Portable x-ray pertormed of

chest

NURSING PROCEDURE: NURSE NOTES (21:54 AKOF)


TIME: Time: 2145. pl ambulates to Rm 2 c/o fever and chills. pt has not treated fever at home. pt demanding warm blanke1s, I explained to pt that we will get him a light cover aHer he changes into a gown, pt

non-compliant. . NURSING PROCEDURE: NURSE NOTES (21 :55 AKOF)


TIME: Time: 2155, x-ray at bedside tor CXR. pt still has noi changed

into gown ..

\JURSING PROCEDURE: NURSE NOTES (21 :58 AKOF)


TIME: Time: 2157, RT at bedside for ABG (per protocol).

NURSING PROCEDURE: IV (22:35 AKOF)


TIME: Procedure was performed at 2220,20 gauge catheter inserted. Into right Hand, with 2 attempts, Saline lock established, Labs drawn at time of placemlitnt, Blood cultures drawn al time of placement, After placement no swelling noted at site, no drainage noied at site, 2x3 ensure dressing applied.

NURSING PROCEDURE: ADDENDUM (22:42 DAGN)


TIME: Procedure was performed at 2205, Below is a reassessment, Pt skin assessment miSSing and saline lock attached a\ time of assessment

PIce Line had and cap

NURSING PROCEDURE: BEDPAN/URiNAL (22:51 DAGN)


TIME: Procedure was performed at 2250, Urinal used, Patient voided 300 ce, ml per bedpan/urinal, Urine specimen collected.

NURSING PROCEDURE: IV (23:00 CKEE) TIME: Procedure was performed at 2300, O.9NS 1 Liter hung, 1st bag hung, IV bolus of 1000 ml est~bllshed. at
1000 ml/hr, via primary tubing, via gravl1y tUbing, via pump tubing, After placement no swelling noted at site, no drainage noted at site,
SAFETY: Side rails

up, Cart in lowest positlon.

NURSING PROCEDURE: CARDIAC MONITOR (23:01 CKEE) TIME: Procedure was performed a\ 2300, Patient placed on cardiac monito" Patient placed on non-invasive blood
pressure monitor, Pulse Oximetry Multiple, Patient on cardiac monnor showing Normal Sinus, Strip charted, Disposable cuff, Rate: 96, Alarms set and on. SAFETY: Side rails up, Cart in lowes1 position.
Prepared: Tue Oct 02 ZOO? 01 :36 by Dave Agnew, Page: 7019
SSM DePaul Health Canter

DePaul Medical Records/Phillip H. March

000057

SSM DEPAUL EMERGENCY RECORD


NURSING PROCEDURE: NURSE NOTES (23:02 CKEE)
TIME: Time: 2301, Dr, Schmidt at bedside to see pt.

Name: March, Phillip


Age: M30 W1: 73.9 Kg (est.) MedRec:000748298 AcctNum: 0727400691

NURSING PROCEDURE: NURSE NOTES (23:16 DAGN)


TIME: Time: 2316. IV infusing pI resting,

NURSING PROCEDURE: LAB DRAW (Tue Oct 022007 DAGN)


TIME: Procedure was performed at 2358, and labs sent from Left PICC line. with 1 attempt, Blood cultures senl, 10 ce blood draw for waste from Pice line, Then 10 cc blood draw for Be PICC line flushed with

10cc of NS then See of Heparin per Pt per horns care..

NURSING PROCEDURE: NURSE NOTES (Tue Oct 02 2007 00;09 DAGN)


TIME: Time: 0006, lVF dlc'd sl maintained Unasyn Infused through IV Pump.

NURSING PROCEDURE: NURSE NOTES (Tue Oct 02200700:10 DAGN)


TIME: Time: 0010, Patient is imprOVing, Patient in no apparent distress, Patient states decreased pain, Patient res1ing quietly, Familya1 bedside.

NURSING PROCEDURE: ADMISSION (Tue Oct 02 2007 01 :38 DAGN)


TIME: Bed assigned at 0104, Report called at 0125, Patient admitted at 0033, Pt admitted to room, 524, Patient Acuity Level Was NON-Urgent. Pa1iant admitted to mad-surg unit, Report called/faxed to 5 North 524, Parmedlc, Transported with personal belongings.

ADMIN
DIGITAL SIGNATURE (21 :47 AKOF): Kofahl, EMT-P, Andra. (21 :55 AKOF): Kofahl, EMT-P. Andra. (21 :58 AKOF): Kofahl, EMT-P, Andra.

(22;090AQN}: Agnew lI Dave,


(22:42 DAGN): Agnew" Dave. (22:51 DAGN): Agnew" Dave. (23:02 CKEE): Keene, BSN, Christine. (Tue Oct 022007 DAGN): Agnew" Dave. (Tue Oct 02 200700:10 DAGN): Agnew" Dave. (Tue Oct 02 2007 00:38 RSCH): Schmidt, MD, Ricllard. (Tue Oct 02 200701 :38 DAGN): Agnew" Dave. PATIENT DATA CHANGE (21:44): A08 67727831 by Inleriace, Payment 90, AdmiUing Doctor: Pcp None, Attending Doctor: Richard U Schmidt. (22:30): AOS 67728758 by Interface. Admitting Doctor: Pcp None, Attenoing Doctor: Richard U Schmidt. (22:43DAGN): Primary Nurse changed from (none} to Dave Agnew,. (22:49 RSCH): Attending changed from (none) to Richard Schmidt. MD. (23:02): AOa 67729397 by Interface, Admi11ing Doctor: Pcp None. Attending Doctor: Richard U Schmidt. (23:05): AOe 67729442 by (nterface, Admitting Doctor: Zinser Phillip G. Attending Doctor: Richard U Schmidt.
Prepaled: Tue Oct 02 2007 01 :36 by Dava Agnew, Paye: 8 of 9
SSM DePaul Health
C~n!ef

DePaul Medical Records/Phillip H. March

000058

SSM DEPAUL EMERGENCY RECORD

Name: March, Phillip Age: M30 Wt: 73.9 Kg (est.) MedRec: 000748296 AcctNum: 0727400691

(23;06): AOS 67729481 by Interface. Admitting Doctor: Zinser Phillip G. Attending Doctor: Richard U Schmidt. (Tue Oct 02 2007 01 :05 JSAN): Admit Room: 524, Admit Area: full admIt, Payment: (none). KEY: AKOF:=Kofahl, EMT-P, Andra AMAJ;::MaJlno, M.D., Angela CKEE=Keene, BSN, Christine DAGN=Agnew" Dave DKIN=Kin9, BSN, Deborah JSAN=Sanchez, RN, Julie JWHI=White, RN, JeBl'lnet1e RSCH=Sehmidt. MDt Richard TMO=Ohlms, Tricia

Prepared:

TU9

Oct 02 2007 01 :38 by Dave Agnew, Page; 9 of \:1


SSM DePaul Health Center

DePaul Medical Records/Phillip H. March

000059

SSM DEPAUL CLINICAL SUMMARY RECORD


HPIBLANK

Name: March, Phillip Age: M30 Wt: 73.9 Kg (est.) AcctNum: 0727400691

MedRec:OQ0748298

CHIEF COMPLAINT: Patient has ongoing hIstory of complications apparently from the repair of II jaw fracture. He has had a device apparently get infected, replaced, and was admitted late September for apparently jaw osteomyelitis. Here tonight with fever and Increased paIn .. HISTORIAN: History obtained from patient. TIME COURSE: Onset of symptoms reported as gradual. SEVERITY: Maximum severIty IS moderate, Currently symptoms are moderate.

HISTORY MEDlCAL HISTORY: History of hypertension, Patient is noncompliant with treatment, Stabbed in left face April 26th, 2007. History of hypertension, Patient Is noncompliant with treatment, . PSYCHIATRIC HISTORY: No previous psychiatric history. No previous psychiatric history. No previous psychiatric history. No prevIous psychiatric history... SURGICAL HISTORY: Jaw Repair, pillte left Jaw. f.cial repair. Patient's previous surgical history Is not relevant to the case. Jaw Aepalr, plate lett jaw. facial repair. Patient's previous surgical history Is
not relevant to the case. SOCIAL HISTORY: Denies drug abuse, Lives at home with family, Denies alcoho' abuse, Denies tobaGGO

FAMILY HISTORY: Family history is not contributory to this case. Family history Is not contributory to this case. Family hIstory is not contributory 10 this case .. NOTES: Agree with nursing records . MEDICAL HISTORY: History of hypertension, Jaw osteomyelitis. SURGICAL HISTORY: Jaw fracture repairs, SOCIAL HISTORY: Denies alcohol abuse, Denies tobacco abuse. FAMILY HISTORY: Family history is not contributory to this case. NOTES: Nursing records reviewed.

ROS
NOTES: see hpl.otherwlse negative. ALL SYSTEMS NEGATIVE: All syslems were reviewed and are nega11ve except as described above.

PHYSICAL EXAM CONSTITUTIONAL: Vital signs reviewed, Comfortable, Alert and oriented X 3, Patient 115 febrile. HEAD: Atraumatic, Normooephalic. EYES: Pupils aqual and reactive to light, No discharge from eyes, Extraocular muscles intact, Sclera are normal. Conjunctiva are normal. NECK: Normal ROM, No jugular venous distention, No meningeal signs, Cervical spine non-tender. RESPIRATORY/CHEST: Chest is non-tender, Breath sounds normal, No respiratory distress. CARDIOVASCULAR: RRR, No murmurs, No rub, No gallop. ABDOMEN: Abdomen is non-tender. No masses, Bowel sounds normal, No dls1ension, No peritoneal signs. BACK: There is no CVA Tenderness, There is no tenderness to palpation, Normal inspection. UPPER EXTREMITY: Inspection normal, No cyanosis/clubbing/edema, Normal range of motion. LOWER EXTREMITY: Inspection normal. No cyanosis/clubbing/edema, No calf tenderness, Normal range of
Prepared: Tue Oct 02 200701 :38 by Dave Agnew, Page: 1 of 3
SSM DePaul H&lIflh Clmter

DePaul Medical Records/Phillip H. March

000060

SSM DEPAUL CLINICAL SUMMARY RECORD

Name; March, Phillip


Age: M30 Wt: 73.9 Kg (est.) MedRec:000748298 AcctNum: 0727400691

motion. NEURO: GCS is 15, No focal motor deficits, No focal sensory deficits, No cerebellar deficits. PSYCHIATRIC: Oriented X 3, Normal affect.

DOCTOR NOTES TEXT: Admitting for iv abx and consultation .. DNJ: Discussed this case with Dr. Rahman, the on call physician.
PATIENT PLAN: The patlent will be admined to the hospital.

DIAGNOSIS
FINAL: PRIMARY: Jaw osteomyelitis, ADDITIONAL: fever.

DISPOSITION
PATIENT: X-RAY/CT Followup: NO, Critical Care: 'None. Doctor Procedures: NO, Disposition: Admit Medical, Condition: Stable.

MEDICATION SERVICE
Acetaminophen: Order: Acetaminophen: 975 mg : By Mouth Time: 2146 Notes: vo/roo Ordered: Mon Oct 01 200721 :46 Ordered by: Angela Malina, M.D. Entered by: Andra Kofahl. EMT-P Mon Oct 01 200721:46 Documented as given by: Andra Kofahl, EMT -P Mon Oct 01 2007 21:47 MEDICATION, Time given: 2146, Given in amount and via route as prescribed, Amount given: 975mg, Site: Medication administered P.O., Correct patient, time, route, dose and medication confirmed prior to administration, Patient advised of actIons and side-effects prior to administration, Allergies confirmed and medications reviewed prior to administration. B@nadryl: Order: Bsnadry! ; 50mg ; By Mouth Time: 0013 PQT!;;NTIAL MODERATE INTERACTION Morphine Sulfate POTENTIAL MODERATE INTERACTION Neurontin Notes: verbal order, read back Ordered: Tue Oct 02 200700;13 Ordered by: Richard Schmidt, MD Entered by; Christine Keene, BSN Tue Oct 022007 00:13 Acknowledged by: Christine Keene, BSN Tue OCt 02 2007 00:13 Documented as given by: Christine Keene, BSN Tue Oct 02 2007 00:14 MEDICATION, Time given: 0013, Given in amount and via route as prescribed, Amount given: 50mg, Site: Medication administered P.O., Correct patient, time, route, dose and medication confirmed prior to administration, Patient advised of actions and side-effects prior to administration, Allergies confirmed and medications reviewed prior to administration, Administered by CMK, RN, Patient in position of comfort, Side rails up. Cart in lowest position, Family at bedside. Morphine Sulfate: Order: Morphine Sulfate: 4 mg : IV Push
Pmpared: Tue Oct 02 2007 01:38 by Dave Agnew. Page; 2. m 3
SSM OaPa1,J1 Health Center

DePaul Medical Records/Phillip H. March

000061

Ilitl 1111111111 11111 Illlt 111111111111'111111111111 I1111111t1

11m ~m Ifl~ lllllllijl" III Iml 11111 II ItIII III !IIII


Name: March, Phillip
Age: M30 Wt: 73.9 Kg (est.) MedAec:OOQ748298 AcctNum: 0727400691

SSM DEPAUL CLINICAL SUMMARY RECORD

Repeat: every 30 minutes PRN pain POTENTIAL MODERATE INTERACTION Neurontin Ordered: Mon Oct 01 200723:46 OrdereD by: Richard Schmidt, MD Entered by: Richard Schmidt, MD Mon Oct 01 2007 23;46 Acknowledged by: Christine Keene, BSN Man Oct 01 2007 23:47 Documented as given by: Andra Koiahi, EMT-P Mon Oct 01 200123:56 MEDICATION, Time given: 2355. Given In amount and via route as prescribed. Amount given: 4mg, IVP, Slowly, Catheter placement confirmed via flush prior to administration, IV site without signs or symptoms of infiltration during medication administralion. No swelling during administration, No drainage during administration, IV flushed after administration, Correct patient, time. route, dose and medication confirmed prior 10 administration, Patient advised of actions and sida-Bffects prior to administration, Allergies confirmed and medications reviewed prior to administration. Unasyn: Order: Unasyn : 3 grams: IV Piggy Back Ordered: Mon Oct 01 2007 23:46 Ordered by: Richard Schmidt, MD Entered by: Richard Schmidt, MD Mon Oct 01 2007 23:46 Acknowledged by: Christine Keene, BSN Mon Oct 01 200723:47 Documented as given by: Andra Kotahl, EMT-P Tue Oct 02 200700:11 MEDICATION, Time given: 0011. Given in amount and via route as prescribed. Amount given: 3 grams, IV Site 1. Medication adminls1ered into right wrist, DrlpllVPB, Premixed. via pump tUbing, at 200 mllhf. Catheter placement confirmed via flush prior to administra1ion, IV site without signs or symptoms of infiltration during medication administration, No swelling during administration, No drainage during administration, IV flushed after administration, Correct patient, time, route, dose and medication confirmed prior to administration, Patient advised of actions and side-effec1s prior to administration, Allergies confirmed and medications reviewed prior to administration, Administered by CMK, RN, Patient in position ot comfort, Side rails up, Cart in lowest position, Family at bedside,

PRESCRIPTION: No Documented P~$criptlons

Prepared: Tue Oct 02 200701 :38 by Dav& Agnew, Page: 3 of:3


SSM DePaUl Health Center

DePaul Medical Records/Phillip H. March

000062

SSM DEPAUL RECORD

Name: March, Phl1lip


Age: M30 WI: 73.9 Kg (est.) MedRec:000748298 AcctNum: 0727400691

Prepared: TU8 Oct 02 2007 01 :38 by Dav1t AQf1ew, Page: 1 of , SSM DePaul Health Center

DePaul Medical Records/Phillip H. March

000063

Emergency'.'

t)$j,f,ifYJllOutnsion Protocol

I. ASseSSMeNT OlMln Piev/~'AIr.~~.t,.=~~~~~~~~;~'~~::~}f~:~ .. "."' . ~ .,...."" . fate greater than 100 ReeplratofY rate Notify p~dan for 181ften 36<'(98.8F). greater than 20. Tem~riltul'8 . Cardlao Monttortng, OXItnetlry, Notify phyaielen If dJ~I~;F;''':i;Wf~i;tl0

II.CIA N08TICS
~~~"x2~~~I~~:~~~~P~.~
~~tNt1llte

or 2 peripheral sites.

cae Wtth ~U'I dlf, eMl~Ol


1;1 phosphorus, mal~nelsl~~lli:lil~
s.er.um lactic. acid.

~putu~"'l,n &.

fY!... ,e;P'f.a?:1NR

)a

J..~ TSH&frOO:T4
[J Wound culture &it. $tool gU!e(l- rodel
1:3,' weC}ge8bJr ttran 10,000 or greater Ulan Notify phyelcf8n fo(:.c""dlnli~'a~l~~""'. 5% bande, pfelelebS '_than 100,;000d_4. 'i!lftUlHhlll"'"3i.urine output 1888 than :10 mllhour.

U'~CXR
tJ
III.

OROAN DY!!lFUI\lCT10N,:,:t:-<; i ;\!~i!f.',lA'~i4f~i::~f.:~",~~'t:

IV.

TREATMENTS Insert 2 peripheral Foley catheter. IV fluId, 11lter norlmalj&a'!lne'otA.!~)'11l1 liter of normal nllne. iEX"lljfdi.~s~ If SSP 1888 than 90 Qfl ~~J~
V860prftSOra & conUt1u'!id:~!~

than gO or MAP lese than 65 Infuae a second phySlclan for


pos8i~e

centraillne,

,\.

C Oxygen at --ooi-;....,..~ .,:


V. ME01CATIONS

vop.....OI"l SSP,. . ihtn to Of Ulilif UHa~


~~~~__"lcgJ'mln titrate to MAP greater

than 65 or

a dopamine 400 mgl2S('m!~'nottKiIJSlilJl

.';~~tiiit .ui~-:R~- .
"

j0727400691 ERS '110/02/1976 30Y M 10/01/07 :SMBRGENCY,PHYSICIA00074829B


I

DePaul Medical Records/Phillip H. March

000064

v.

MEDICATIONS: Antllmlc"'bJ~l * Af1 doses are based on crctt '>'::!l'~;:

of tnftotion
~~dtust

for renal function.

Patient's weight '''.''-'''''''~i!oI'

AJUt)UfI allagtntamldn par pharmacy

o
1:1

'and $Very hours Qba gentamlc4n per

,110","". otproftoxactn (Cipro) 400 mg

. per pna,nna<:y protocol (rounded to

and eVery 6hOura. , metronidazole (Flagyt)

L,'
,(rounded to fl4lilr6St 250 mg; max

o o

CJ Other: _ _-+...........

ff ..

lt'i::~'"."'~'1 MARCH / PHILLIpl.11


"

liUi.a-~;"m;~~/~976
0727400691 ERS _ ERQ

30Y

M 10/01/07

RNCY,PHYBICIAOQ074829S

DePaul Medical Records/Phillip H. March

000065

Emergency D,ediiltr"ff
\Itt. Ventilator Settings;

i:

Mode: _ _ ",..,'...----1

VNL ' .Additional Orde,.

'-,

I'

I have reviewed end ag~ \\ilth,tht ... "IPvru.'"" i ,~' '

7ffxCtlfPtfcm of those cros~ through.

DIIe:\9

{l.\;;r- T'mt;ii. ~
p'

Transcribed by',______........,...-.........~~,'~t:.,Orders scanned to har""1GY'<I;)lf!

RN .. "

In"I~~'

'.

'

,: /11
MARCH, PHILLIP

DEPAUL HEALTH CENTER ERQ

0727400691 BRS 10/02/1976 30Y 14 10/01/07 EMERGENCY,PHYSICIA000748298

: /. "~

DePaul Medical Records/Phillip H. March

000066

trRIAOe REtORD
.. "," ... >

SSMDIPAUL.

~: Maroh.PhlIIJp Aae: M30 Wt 73.~ Kg (e$t.) M""ecI~: 000748298 AtctNum: 0127400691

. tt~., .: E$I,.3..
( 8P:173194 \ __, : T:1'();~.6

. oom:
. No

Compllff\i:ChI.lIs ~_ Time: Mon 6c1 01 ~' .' ~Honi$ y; oar' '.

2007 .
..

'.

. .W~. ._ne: . .'4J


'.'Si'. R:20

...... 73.9 (Nt.)

. .' Em.rgen9Y PhySJclans

~ltai.,_.;: (2101)
KNOWN ALLE.AOIIS known drug aflergles.

PtYohf,itrlo n~gfY. No .tJ4)ujtj !SU'1Gtl~ UID,.....r.\i :~. n9JIItRlJ"p:tl

';SOCtAL HISTOAV;:hnIA drUg ' .

r not~.nt~t~Oi~"~.-"'''',; no.,,.~nt,o ~#~. .'

,-. J,N01es: Ag.... WIth nanlnt recc~.

fFAMILY HISTOij:'MtIffn",en'll;;
tt1_~.

.,

,.mliy:l\lltor;IAIIIMltlli6!

(Mqn lCOMMENT (Mon' oei Ol2001 ~ .1 rnbnkIPli\-",'


~COMPLAINT (Moo

I ~DDmONAL TRIAGE

Oct 01 2007 ~

'PROVIDeRS (Mon OCtQ12QQ1~1


, Julkt Sanohe.t, AN. . !ADMISSION (Man Oct 01 2007 'PATIENT (Moo OCt 01 200721 ; Code: NO, Trauma: -NO. HEiGHT: 182cm.-PHONe: 31452:2-8780.1 0727400691. ISEX NUM8ER: ~710tJ12' jPREVIOUS VISll Au.eA~~le$~(M~~ri 'VITAL SIGNS (MOn Oot 01' 'FALL RISK (21;3,5 JWHl): TIME.:'21:~i('.m

. \ movtment..

'.

rSSe'seMt:NT: (21 :SS'JWHII: f ONSET TOOAY. C/Q LEFT

DePaul Medical Records/Phillip H. March

000067

' ,/_:;-;{~tt:;:~~i:~~~t~~Y.,>"
" , ~"''<l'~,

,,~iiii;~~~;!;.!r.,~~> .

r::i~;:;':i~ "

,,' ,4f'1'..'~:k~\T~

i~t,';,

1IIIIIIm il~M IWI.IIIIIII. '~t~~,'~h!',.l1lllllllllmll


1,
Age: M,30 Wt; 73.9 Kg (est.) SSM DEPAUL : ' ~,,4f~ld~L l(E(}(}f:{:}~lI-:itI,W:l~:' '" MedRte: 000748298 t1~;~,<';J~!t;,:,-,:,:< ',:; : tRIAGE RECORD AcctNum: 0727400691 ~----------------~ ~~~ ~~--~~.-------------ilMMUNlZATlONS (21:36 JWHI): '~:.~~~~ r:~
T6 Screening (21:35 JWHJ): Domestic Vlolence (21 :36 JWHI): N011;AI:lIPI

':' :'6fh~,~'~'~('~;'i,{):}}\iiil' ,',

':, jJi~<),d:M~I~g, f.jd; ssf.i:?

'"ii.,', ,1\f!o!V!i'm!;),::ro;t;, ~::, .' ','

'

Nanw." March, Phillip

..

,"cn"",,,-,',;,-,,;--,,,,!!?,,,,

JTREA~ENTS

IN PROGReSS (21

PRESCRIPTION: No DocMn1tnttfd:,PlbjI

',_", i DKIN-Klng, aSH, Deb<>rah ,JW'H"~Wf.l

KEY:

,.

,~:';';!~:':

'
'
Ij,

';

',;)"r.;'iti.\ H,)I~~!gu: t-it.:}. ~~N,

.". /{~.

,att:~iy\1.';~~~r\f:~~J~~ '"':'"

<lr:::~{:f,.~L iIi~9}iliiNl.JBlt

, 'A~~)r

DePaul Medical Records/Phillip H. March

000068

No Patient Admitted

EXAM2

l~

PHILIPS

DePaul Health Csnter

Page 1 (last)

DePaul Medical Records/Phillip H. March

000069

No Patient AdmItted

EXAM2

PHILIPS

DePaul Health Center

Page 1 (last)

DePaul Medical Records/Phillip H. March

000070

RHYTHM ANALYSIS MOUNT SHEET


~;::

.j"\

w4""
.....;

~:} ',,:::: c' ".,......


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.}

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C."
'-'

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HIO.J':Cl y,
nUfll\n PAl il\i~ lC

\r;,01.[1

a.r-0~

(0

(0

~ f"/~~':-)

a .....

".,

'"""~N

t,cM"- "-1.O~1J) (') " t'i{'Qr..... 0 0 T""


-,;-~ .. ~

u').;:o '!' ....


.('.(-,;-

...11 0 r--. "'J T""


I I

.,--- q")

~ i.f) ',- r-,a

'::J r:"; :. '-.:


!

CJ 1,,-:' :..~) 'oJ ,..... ,- - l:"'"

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~tl ~ U.

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'J)

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MOO

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.~

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~~

....

CO

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X o
!

W;!;(..>OUUJ

t:!rollJQ.

a. '"- Q.J; m

a o:roow::'=
IJ;Z; ...

......-:.n

.:,o:x: r:J:_.:l -""10 r,.. J:

t~

..J

UJ /--

~ ~'~:I
.....

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N

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<-'

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...J

I-

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~-

ffi
:::
~
Q.

"""''''~''''

'...J:iii <.:>

c::(~uo c,:;.

,'t.

a. c.. Q.Z :.: (.) <:) <J u.. u.. .....

~-.o<>~-r

:;.0

X:t:.--.c
"'~

l-...

rAldal "at!)
I

I Vent Rat'!J !

Pl1lnfeNai I
Signilhlf9

IQRS lnt~!Vall
(

I
- ... f 1-\1
~

, Rhyll'm

IDaie

H"

I d.'

.'Id~!~"

tmt
~;/

1'10:'

,if "r:

t..,m

-t:, .

!'

---,
!

qhm

---_. ---,

'.i

,---- .....
:,.I flT

-"-~------

IAtrJa! Ride I
Rhythm

JVent RaWl
1

PR m!lJrvai!
Signature

IOR."$:hJlur'l;atl
IDlI(l

lOT Iflle.vilfT

!Time

~~

I Vent Rate I
J
Signature

~
~

OR$ Interval!
are- ---r,""oC-

____

FI-_T_'''k,~(V-''~I------

Rhythm

______________________________

-11;"_,._n_~_____-,

PATlI:NT L AHf-I

~SSM

H E A L T H e A R E-

RHYTHM ANALYSIS SHEET

0 7 27400691 ERS10/02/1976 30Y M 10/01/07

JlII.I II. CH,PHILLIP

D~PAUL HEALTH CENTER

ERQ

EMERGENCY,PHYSICIA00074829B

mt

uual a us,

111!1lln.

,a;
000071

DePaul Medical Records/Phillip H. March

RHYTHM ANALYSIS MOUNT SHEET


i;f

'11

i\

1\' '
~) l~/,

(It 1 I(~/

II

II" ;,"1.[\1 Ad,'(,ilkd

t'\H

f'

rlll

1" ... <1

, ------._-_.-

------.--_ .._.-

"', I

!, ,",
.') 'I

,n
IVJ1htR~QI

--,'
PRmtflrlial1
SiQMlturc

AlriaHtlltt7
RtJylhm

LQRSJ/'j9ivafl j

IOTlnr>trvalj

Dul"

Tims

\
i .\

_ _. - - . ! L .

B -----" ___----'1:.._-

.. _II~_. _ _ _'-

,I

[:

1
II

---"---

'I.I

Alrlal R.31O

.~--------~----~

Alrial

Ri1I~

rVentRatol

?R lnlsrvllll
~iqnab.He

LC.1M~ mH.t.fVt

I
Rhythm
I

1
PATINT LA8EL

~SSM
H E A L T H . CAR

I ,

E~

11I D\i s MARCH, PHiLLIP

R~TH

CENTER
ERO

RHYTHM ANALYSIS MOUNT SHEET

0727400691 ER M 10/01/07 10/02/1976 ~;ICIA00074a29a

EMERGENCY, I>

DePaul Medical Records/Phillip H. March

000072

Patient Report Porfl1

0&1<- t) ~'-//e--f~'i
Htstory:

,L~- p,~

.i ~

+ ~

'Z,.~' ... ~<:!c-i'd?'

tJ-rnJ

Patient from:..wrHome o Nur5ing Home 0 Physeoian Otfioo o Hospital a Other: Home Med List
Med

ThrHl: aVes C No

No

DBPAUL HEALTH CENTER

MARCH,PHILLIP 0727400691 ERa10/02/1976 JOY

1111111

ERQ

M 10/01/07

EI>1ERGENC'i, I?HYS ICIAOO 07 48298

DePaul Medical Records/Phillip H. March

000073

o Muillple trauma o High risk OB


o
ReadmIssion within 30 days

II Abuse victim

t. Drug overdose A Substance abUS8 _ _ _ _ _ _ _ __


o History of substance abuse

o On 7 or more mlldlcallons d yYlQ ,


~ antibiotic or alimentation Tx o Dacumt~ ulcer o Ostomy patient

o Dehydralion/Malnutrition

df

o Admission within 1-3 months

o Progressive dlsMsa with impairment a Contagious disease

o Comatose condition
o

Mental status changell Dialysis patient at_ _ _ _ _ ~_ __

~ Pneumovac; Date: ~Iu Vacclne: Date:

-e- Q ca/'I1)../i P A

..J

Uvss alone andlor frail


Uves with spouse

o Liv611in: o , story home o Apartment


Number of stairs
Na~:

e
-

yV\ .0 \

-1-.~J., 1\

Family member dependent on you/ Nlleds arrangement for care _

11 06 under aoe'8

0 :2 story hom6

Over the age of 65 0 11 Suspected abuse and/or lleqlBcI


i1 Needs financial assistance

31

\4-'

o Occupation;
o
Umitations imposed by il/nBllll: Needs assistance in peiforming ADls:

to enter _ _ _ __

tl HOm6Ie$~

o Admission frQm(to nurSing home:


d Inadequate support:

o Clinic patient
Where;

a
A

-,-;:,

_________ _ __________

o V6teran-------~ ~ Family counseling needed f> -j - A-

0 Mobility 0 Feeding 0 Hygiene 0 Dressing 0 ToUeting 0 Transportation

'-' Previous Social Service Intervention


Ll. Financial assistance nsedM for medications

o Home Heal1h
Of iacifity:

0 Home IV Therapy

0 Home DME jiTranSPoIiatiOr]

Pl!ln_=--;;....;:;.;""--'--'-'---'-...::.j~_ _ _ _ _ _ _ _ _ __

0 Hospice

0 Hospital - Acute

Ho~ital

Psychiatric

0 Hospital. VA/Fe&ral
0 Nursing Home- Private Pay/Cus10dlal

o LTAC (long Term Acute Care Hospital) 0 Rehab o Resldential/Assisled Livingllntennediate Care Facility

0 SNF

0 Other _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

o Facility holding bed

0 PatienVFamlly confirms relurning to same taclll1y


~

Drnhsr________.___________________

____________________________________________

REFERRALS (REFER TO NURSING ASSESSMENT)

o Psycho~oci61 assessment request&d 0 Long term acute care ~_ _ _ _ _._ _ _ _ _ _ _ _ _ _~_ _ _~_ _ _ __ o Residential care _____________________

PAriENT LA8EL

~SSM

H E A l T H e ARE"

DEPAUL HEAliTH CENTER

MARCH, PHII.LIP
CASE MANAGEMENT SCREENINGIDISCHARGE PLANNING

llIIllllllUlllll

I/ P
000748298

0727'.1 00691 I-lED 0524 - 01 10/02/1976 31Y M 10/02/0"1


RAHMAN, AN1>1ER Z

DePaul Medical Records/Phillip H. March

000074

CASE MANAGEMENT SCREENING/DISCHARGE PLANNING

DISCHARGE DISPOSITION

Home

0 Hnme Health

0 Home IV Therapy 0 Hospital - Acute

[J Home DMl:

0 Transportation Plan
0 Hospital VNFederaI 0 SNF

Type of {acility:

0 Hospice

Hospital - Psychiatric

o LTAC (Long Term Mule Care Hospital} 0 Rtlhab o Rtlsidenlial/Assi&ted UvinyJin1ermediate Care Facility

0 Nursing Horne- Privata Pay/Custodial 0 Other _ _ _ _ _ _ _ _~_ _ _ _~_ _ _ _ __

, o Other_ _

o Facility holding bed

0 Patlertt/Family confirms returning \0 same facifity


PATIENT L48El.

~SSM
SlM8570-001 (12/2004) BACK

H E A I. T H CAR E~

CASE MANAGI:MENT SCREENINGIDISCHARGE PLANNtNG

. \0

DePaul Medical Records/Phillip H. March

000075

r;5

ADMISSION DATA BASE ------go p.::t.

IAdmiwion Oat! t O/-:'-{OT 0;.1.0

Patient has lhe following AdVance DireCtive:

0 See entity sp!>ciHc lorm (I.e., Essence, Intent) 0 See Progress Note~ Is inforffia1i",!1 ~\il! Yi!iQ? bl Yttli 0 No RlOqu&sleolO bring In copy? 0 Yes From whom _ _ _ _ _ _ _ _ _ _ _ _

o Copy in chan

0 Durable Power of Attorney for Healthcaffi 0 Health CalEl Directive

c _ _ _ _ _ __

HEALTH HISTORY (Check any that apply)


~--------------

BOLD SYMBOLS (* ,.

+ , ) IND/CATE REFERRAL NEEDED ON BACK PAGE


hx: 0 Heart attack VaSCular disease Pacemaker/DefiGrillalor Congestive Heart Faiture , o Heart mUfmurNalvular disease SLS: 0 Chest pain. Angina Frequency: Last episode: _ _ _ __

o AJzheimer's!Dementia

o Arthritis D Back/Hip/Knee

o Diabetes *
controlled by:

blli316eding problem DBlnod clol ~ Blood pressure problem Blood transfuSion Date: _______

o Breathing problem
~

o SUbcutaneous pump o Oral Hypoglycemic o Diel


Elevatl;td cholesterol

C insulin

o o o

o Chronic pain prior to ad mission ( _


Slle: _ _ _ _ _._ _ __
Chronic Pain Management D Pregnant/Lactating. If pregnant, due date: D Prostate problems o Reproductive problems
Last mens1rua! Wiod; 0

/10)

o Emotional problems
o Anxiety

o o ora. ~ o Wheezil19

OAsll1ma Bronchitis o COPDlEmphysema Sleep Apnea/CPAP

o Glaucoma o Heart dj~ease o Heart surgery


Dat.e:

o Depression o Suicidal thoughts/plan


o

o Palpitatlons
OEdema
Where:

N/A

o Sensory problem o Hearing 0 Vision

o Skin probfe1TI8 ...


DRash

D Cough/spulum production

o Shortness Of breath

o VRE

Frequency: _____ _ Hepaiitls Infectious/Communicable Disease.

o Skin fisK score 18 or l~lls + o Pressure ulcer Stage 3 or 4

0 MRSA 0 C, diff

When: ______ Locatlon:

o Cancer

Shol'lness of breath OCCUf5 at rest ___ wllh normal activity ___# of ftigtlts of stairs climbed ___# oj blocks walked Home oxygen

o Nonhealing wound ... o Other _ _ _


R(!ferral Orders.

o Unstageable wound

~.=-=,--.--

__

o Stone o Neurologica! problems o Seizures


o
FreQuency: ____~_ _ __ Last episode: Stroke/TIA frequency: _ __

o Kidney diseasa o Dialysis

o IV Davlce o:e::-port, Pice. etc.)

Contact physician for ET1Wound Nur

o Sexually transmitted disease


o Oslomy. Date last 8M; _ _ __ Thyroid problems Urinary problems

o Stomach/Sowel problems +

o GERD/Acid Rellux

D Chemo/Radiation o Chipped or loose teeth

o o

Re~fit exposure 10:

11 you cheGk any of the Hbovl, pl@,ui@d8Scribe: ____________._____________~_ _ __

o Other:

E Chicken pox 0 Hepatitis

Last episode:

Nauso<1/Vomi\ing

o Family problem1;i with am,~thesia


DEPAUL HEALTH CENTER
~mRcH(PHrLL!p

~SSM eH E A l T H . CAR
ADMISSION DATA BASE

1IIIIIIIIIIIIIIai

liP

0727400691 MED 0524-01 10/02/] 976 3lY M 10/02/07


RJ'iliMAN I ANh'ER Z O O 0 74 82 98

DePaul Medical Records/Phillip H. March

000076

ADMISSION DATA BASE

---'----i

tit Na fllferrll ind1c1\ed


{

Pttl&l\!r8qult'

. - - - - - - - - ;;;;;;;;;;;;;;;;;::::::;=~===-===:::..f 0
J~~!:!.~~~~~ 0

o 11!16!lguDf. Wfj~ll~

o SlIIge 3 or 4 PI~Uut. ulcer o NGn~.shna~unc

C11n(r.' NutrHton

Skln Rip SeOf~ (1118 Of I,n

o PI'flITI'1IfTF o I'nJllim (IlOt cleijyefill9) G/' Wtriflg o ~tlent nqutll

o o o o o

Rllllallail1fa ApptalWl o11111111ll1Ii1IotI lJIIpllftlled WI 5. 10 IbJ Of m~ltlhfttb Clmlge In appttita mQrt! 111111 6 dtyi If/V/tJ 3 days Of more IJ/ffiCllIIy c!Iewlng/1Wall1lwing

Live in' Who do

. 0 Apartment (J ResIdential howsin9 0 Nursing home Iive\';11h" . . ~"~ _ _ _ _ _ _ _ _ _ _ -_ _ _ _ _ __

o NfllolklwWo Olallellt 0111 o Majllf surveIl (0'1&1 15 Yelrs 016) o lfistory 01 bJnat/ll: lurgery
remnl imlifiitll1l

o Ikwly Dr Vllbetic

MID you al home now? f;<NO 0 Ye~ N\\rnesfAgencies _ ._ _ _ _ _- - - Difficulty wi actlvmes of dally lIVing? J~ No 0 vas Explain: _ _ _ _ _ _ _ _ _ _ _ _ _ __ Difficulty AmQulajing I Transf9mng1 No D Yos '" Explain: _ _ _ _ _ _ _~ _ _ _ _ __ if yes dua 10 paln, explaln: _ _ _ _- _ _ _ _ _ _ _ _ _ _ _ ~_ _ _ _ _ _ __

Do you plan to return to your home Irol1'1 the hospital? Transportation available? lives 0 No

%l. Vas

0 No. If fl'J. explain:

o IIlslory ~f MR&A.tVRE/C. am
o IV navlee (PoflI'ICC. tIc.)

InfAAlion ContIgl Potltive TB $(:I88nlnglSkin tnt

Does anyone

f51

o R~ttl1t eXf~wle
HD leWn! tndtClm4

'" ContKt pbysfclan for PT{OTISpeedl Referral Ordaf's

PSYCHOSOCIAL/ SPIRITUAL
Do you have any spet:;lal conCQrns aboul baing in the

. Do you Mve tiny spiritual canCI/Tn:;'? ~ No 0 vas +


Any special
O~er

Have you htld any lll"jO( chanr:les {job. move, dillerte, deal", ate.) In your life recently"

hospital'] ~ No 0 Yes. _ _......,._ __ ~ No 0 Ves ~ ____ _

r{!ngiOUS~C!tural factOfS~!9d 10 care? ~ No


None 0 DiffiGully falling ru!e;p ___
~4-

. _________

Sleeping problomt'..

DYes 0 Difficulty staying asleep

_____ .

_ _ _ _ _ _ . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___

bf'H~ refemlln(!lcl!led { -- TqbAm c.,.ation ..

o PSliaol fieQlIlIst o Spiritual Con"I'~'

o POGI PmgnOilt o Stlllms PIOCiduralSurll8fl o AgY1ln~e ()I,ecli~ A$$InaflCI

+ pntpral Cam + o AntlGilJll1811 CopinQ DI11Itllily

o Utellln !all 12 roonllli


Snntol

cOIl1rOIl/plO.l5odi(m do you or your partner use? _ _ __


yQ\J r!'!~!ly

did n9t want to? 0 No 0 Yes.

=~

_____
.-------1

SJryi$' _

o No
FORM COMPLETED BY (If other than RN)

DYes

o Elderly/frllY IIvlnv alooe


0 Home!lmlOi$placeo

o Pallenl Rtqullt

o Nwsioll Heme PlfClmtnl

o SlIfpeG!!<i AbuwNevlKl
Poulblf HQllI\I Aulslilltl!

~SSM
H E A L T H . CAR ADMISSION DATA BASE
SLM-l00G059 (3/2007) BACK

PATiENT !.PBEL

DEPAUL HEALTH CENTER


twlARCH, PHILLIP

E~

IUlIIIUIIIIIIIIIIU

liP

0727400691 MED 0524-01 10/02/1976 31Y M 10/0'2./07 000'748299 RAHMAN f AN'iTER Z

DePaul Medical Records/Phillip H. March

000077

ADMISSION ARRIVAL SHEET

for help to get up

smOking policy

~..mefgeney light 8R/shower ~lsitirT9 hours

ARRIVAI.INFOIfMATION COMPLETED

,If other than nllJ1le)


YGs No
Q

BY(22wk eke"f! L.Pnti


~N11PRE
LL patients the following questions:
--~-----------~==---==

I 0 ~;2 '0- 7
DATE

0/5
TIME"

(p

SUICIDE SeAEENINC

.iC Have you ever Inoo 10 harm yourself in the past'? Explain ._ _ _ ___
. Are you here because

you l11ed to harm yourself? Explain _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __


Q

In the PM! wee!<, have you bean haVing thoughts about harming yours&1f? ElCplalfl

Physician notifled

YOU EVER BEEN EMOTIONALLY. PHYSICALl.Y, OR SEXUALLY ABUSED?

rN0 EVfD(;NCE OF PHYSIGAL. SEXUAl. OR PSYCHOLOGICAL ABUS~ NOTED.


U EVIDENCE OF POTENTIAL ABUSE NOTED BUT NOT SUSPECTED.
SPECIFY EVIOENCE _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ._ _ _ __

I.J Hotline called

specify: _ _ _ _ _ __

COMFORT STRATEGIES USED (PrIor 10 admission)

q'10'
PAIN FUNCTION GOAL

!
II pain present, complete Pain Assessment
~~tion

0'/0

1i!INFORMATIOff GIVEN ON RIGHTS AND RESPONS,efUTIES


OF PAIN MANAGEMENT

of PBtiBnI FIOW'Jf18Gt.

To be completed by an RN.

PLAN OF CARE

PATIENT/SIGNIFICANT OTHER INVOLVED IN THE CARE PLAN DEVELOPMENT. "t,i'VES :J NO explain: _ _ _ _ _ _ _ _ __

FORM COMPLETION INI=ORMATION


L.PH~

Form completed

Signature:f)-Lu J~<',.,........

l?t.-

Date; /0

(!

i!=( ~7

Time:

6/ 4- f

(If completed oy LPN, RN review and plan of care development required)

RN: u Form completed


Slgnature:J;fu

~)~\) pN
TIme:

Adm. data reviewed '-IPlan of care/Care pathway developed

Dare:rfJl ;).! 01

e}2.3L)~
~----

----,--- ------

------------~

PATIENT LABfl

-------'

rYl:iSSM
H E A L T H . CAR
ADMISSION ARRIVAL SHEeT

E~

Diiia 11
Mt(RCH PltILLIP
Q72740(}691

'1'H cSNTER
ERQ

ERS 10/01/07 10/02/ 1976 3H~~ICI~000748298 EMERGENCY,P

DePaul Medical Records/Phillip H. March

000078

ADMISSION ARRIVAL SHEET

Cardlovascularl Hematological
Reeptratory{ InffK:tlou~ Disease

JlfNo proDlem Identified

Musculoekeletal
fj Exception as below

Reprodudlve
U Exception as below Wour\d/Sklnl

.6No prODlem Identified


gfNo proh!am identified

~o problem identified o Exception as below

No problem identlfl&d

GliNutrltlon

6 No problem Identified a Exception as below


a EXC6plion as belOW

Mucous Membrllne PeycholSoctali Splrltuill

~o problem identified

Q Exwptlor. as below

Dale:

/0,10 zi-?

. Time:

tP/y r

PATIf-NT /..ABEL

~SSM e
H
ADMISSION ARRIVAL SHEET
SLM-\OOO-058 (7/2007) BACK

DEPAUL HahLTH CENTER


MARCH/PHILLIP
0727400691

A L T H . CAR E-

t11
ERS

ERQ

i~~~~~~:P~~~ICIAOQ074e29B

10/01/07

DePaul Medical Records/Phillip H. March

000079

INTERDISCIPLINARY CARE PATHWAYS@ GENERIC


MEDICAL H'~TORY

At ~r-Pe."',f

SPECIMENS TO BE COLLECTED

INITIAL DISCHARGE PLA.N

I,.,";

U,eiF t~

6-;l:-J:;L,rnt-if fiJ -

" t{{Y
Op,TE I~!.,l.,

piHome with stgllltlcMt other

o SNF/ACF o
o Other
DAILY LABS

Rehab

'~ u5{, L ""'....",,f' ~

OIHome Health

I
CONSULTS
PHYSICIANS

NAME

DEPARTMENTS f NURSING DATE NAME

/'-'

/' ~f'LoL.l' L

Admitted with
pressure ulcer? DYes 0 No
SPECIALTY EQUIPMENT
Date;

Type:

lsola1lon:
Pneumovax Yfitar: Flu vaccine year:

ttftW'W
t,\'\A
ld 't'jT~'7, .

D1AGNOSIS/PROCEDURl,

HT

5:..///

I-

Ost..Q.." mV 'tl J f. f.f JN" fr M.. r"

,
p'

~ VVJ;{~

t:

AI {..v'("'r I

,-

WT

Il~~ IbJ
DATE

'1 '//1(
ALLERGIES

CODE STATUS

..

I
I

-,1 FuJI resuscitation

o DNR medical management


D DNR comfort measures

---

IV KjJiJ

Advance directives? 0 Yes 0 No


Gopy in

chart?

EJ Yes 0 No

Is there anyone who should not receive general condition lnfonnation? DYes DNo Family/Significant other designated to receive medical information:

None

Name

o POA

Name
Phone
PATIENT LABEL.

POA

Phone

INTERDISCIPLINARY CARE PATHWAYS~ - GENERIC

o PM.. 1000-024 (;,{2Q06\ PAGE 1 OF 6

COPYRIGHT j997 8SM KEALTH CARE

DePaul Medical Records/Phillip H. March

000080

PLAN OF CARE
PROBLEMS I OUTCOMES I INTERVENTIONS
DATE I

INITIALS

Plac@ initials and oate that probhtma afe identified 11'1 left column. All identlfled problems mUlit be evaluated whether Outcome Is Met or Unmet at time of dlschar~e by placing Qillt IlI1Q initials In ~pprOprllllt Golumn, It Outcomg ia mtt prior to dlacharge. pinel:! datil And initialll in Met oo-Iumn. Place'" in bo)( by inferventions appropriate to patient. Write in addltlonal interventioN; dG needed In blank !ilpaces.

OOTCOMES

Met Unmel

P..obl.m: Alteration In Neurological Status


Age specifll; consideration in Elderly Adults: Dlminis/led muscle strength. Deg9norative lJone andlor joinl change$, DOCfCo.sed hearing. w/On and balar1l,;e.

Ovtcomw. The patient wUf exp.rlence a atabllIzatlon 01 neurolov1cal Impairment.

o Assess for Fall RIsk BID ' lni1iah~ Full Precautions for Fall Risk Score of 15 or higher. o Ass\}ss llilvel of cons<;:iOLJsnesS and motor junction livery shift and PAN, o Encourage achjevemen1 of ADL's as appropriate to the neurologieal impairment.
,
Age spqcific con.siderolion In Elderly Adults: Weakened T8Splrarory muscles, t;J~t;rw{l{#6d 1({IlQ tiS3U! BlaST/city. OU100m8: Re~tl'8topY tunctlcm will be within normaillmlt$ for patient. Intwlventfons; , POtlilion patient for maximum ventilation efficiency, Monitor VS I breath :lounds I oxirrwtry every shift and PRN, D Administer treatments I ol(ygen j ABGs as ordered, PrOVide fluid intake 10 liquify <lecrellons - Suction secretions as neceaslll)'.

Interventkms:

Problem! Alteratron In 0llYgenatlon / Respl..atory FunctIon

o o

Problem; AJI.,atlon In ComfortlPaJn Manag4tment

iO/~L
1f,-

Age specific consid~rat;on In Elderfy Adults: PossilJle Idiosyncratic effects f(vITI m~aica(irm~

l1ue 10 agsrelalfld cha~s

In i1ooorption. mmabolism Ilnd GXoretibfJ. Outcome, PaUent exhibIt. I state$ acfaquate rell.f of dl"omfort.
~~aen pallent'" polin level every 4 hours.
~voIve patient in cars by disC',IlIsing methods 01 pain reli",l. ~ate interventiol'lS (inclLlding non-pharmacologic) IIppropri<lte for pain/discomfort.

jnt~rventioni;

Assess pain level nnd rasponse within 60 minutes of intervention.

Problem: Alteration In NutrltJon

nut,ltlon8' Intake It I Outcome: Patlont'S 0 ,

Age sp8Gific consideration ill Elderly AduilJ; Diminished appetite, ponJt8lsis and digestive iuioes and denlltion changes. fliCeQrS thai ill8V jmprQv~ food InlakQ; Position patient upright - Offer smaller. more frequent nlt;lfl.is - Modifieri food consistency, i.e,. pureed / soft
.pproprl~te fOl

metabolIc ne9d$.

o o o

Interventions: Nutrition Consult enterea in HBOC, 0 Monitor hydrallon status Ass"'!3ll enteral fef/wng toleranGe A311~1l1l lor swallowing J chewing ditfieulty - Allsis! patient wllh meala as needed. Assess I Record dietary lottllle with each meal - Provide I record dietary supplenwnts I HS snacks. Record Dnily Weights - R@port une-xplained weIght changes >3 Kq from prayiOilll d;!y.

Problem: Alteration fn Cardiovascular Status


Ago specific con$ldcration in Elderly Adults: Drminish&d cardiac force I blo()d flow to brain.

Outcume: Pattent wlll "

o R&cord inlal<e and output every shift and PRN I Dally weighls and rapor1 ywiances. o Asus$ vital 8lgm, peripheral pulses and c-arplllary retill every shift and PRN.
D
Administer medlcaflons I blood products
<IS

tnttlrventions

hemodynamically stab'"

ordered WId monitor effects.

Problem: Alteration In Skin Int81iJrlty


Age specifiC cans/deration In Elderly Adults: Skin dry and less 8Jastic

Outcome; Patfent will maintain Or Improve skin Integrity.


Intervention\>; him patient every 2 hours - OVOid shearing - Keep skill dean and dry, Photograph and measure wounds on admission, every Monday, and on Qischarge, D Prollfeta wound \;1;\r& p~r Skin Car@ Plan {S.e !lag!! 8) 0 NutrHion Consult enlered

PrDb.bml Pot.nth,1 or Actual

rnfe~tlon

jO\J.\l;n
~

Age sp~"itic considuration in Eldor/y Adults; Decreasod renalll.lnction - nOIe /Bb vlllu8$ related to antibiotic dosing

~lize iSQlation precautions:

~9I'1tlon8:

Outoome: SIgna and symptoms of Infection are recognized. p,.cauUona are utllll,",.

0 CQntaGt 0 Special Respiratory AssenlReport signs and &ymptoms of infeclion every ~hrft and PRN,

D/oplat

PATtEN! LABEl.

~SSM
HE"" l 'H
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0521-01 M 10/02/07
I./p

INTERDISCfPl..lNARY CARE PATHWAYS' GENERIC

000748296
DPMl00Q-024 (M'OOB) PAGe 2 OF II COPYRIGHT 1997 SSM HeALTH CARF

DePaul Medical Records/Phillip H. March

000081

PLAN OF CARE
PROBLEMS j OUTCOMES /INTERVENTIONS
PATEl INITIALS
Place initials and dote thaI problem!> are identified in lett column. All idllntified pn~bl~mll m~H,1 9~ evaluated whether Outcome Is Met or Umnet at time 01 dischorge by placing dale and initicds In appropriate column. If Outcome 1$ met prior to discharge. place date and initiwa itj Met ~otumn. Place y' in box by inlerventions appropriate to patient Write in addition a! interventions as needed in blank space~.
OUTCOMES

Mei Unmet

o o

Problem: Alteration In ElimInation Age specific consideratiun in Elderly Adul/s: Diminished pRristBlsis, kidllcy function. Outc;ome: Patient regains normal elimination patterns for age and disease process. Interventions; 0 D Offer tollallng every 2 houY$. Assess bowel sounds, abdominal distention andior dis.comfort every shift and PAN. D Record freque-ncy and chamcteristics of ~toc;>1. Repol1 if no stool tc;>r >3 days. Record intake and output "very shift and PRN I HejlQrt abnormal lab vt!lues, Problem: Knowledge Deficit

Ago ~pMifI{) eonsid9wuon in Eldsrly AdUlls: StlnoOf}' and CQgr!illw impairments, 0 1 \

"\0'1
ptr

Ou\,.:!)me; Patient and/or (Jignlflcant other Involved in plan of c::are ! demO'nstrate understanding O'f procedures / disease / medication. / and d'soharge inllti'uctlon5. ~tvenuons 0
~ssess baselin~ knowledge and preferred learning method of palian! I signlicant other, ~rovide educational material at patientl~ignificant other level olllllderstanding, ~!jsess patient;' signilicant other for under!1tandlng after leaching. Provide instruction on sate and effe.;;live use of mildlcal equipment.

Problem! Anxiety { Spiritual l1i'liturluIPl;c$


Age specific consideration in Elderly Adults: F;;Sf of loss of conlrol. decfinmg neallh and/or approachin,q death, changes in economIc St;ic(Jri~y I SOCial slaWS Outcome; Patienl/Slgnlflc;ant ottler demonstrates ability 10 (;ope and Identifies available re$ouroes, Interventions: 0 Fncourage verbalfz:ation 01 te<lfs elnd particlpation In <;>Ne. Decrease sensory tltin1uli - provide quiet I'!nvironmen1 ~ Dim Ihe hall'Mty lights alief 10 PM. Pustoral Care referral entered. Palli...tive eme referral entered.

o o
o

Problem: Qlyeemia Imbalance

Ago speclflc consideration in Elderly A(fl,l/ls: Dccre,'1BBd renal runction. metabolic rille.
Outoome: Patient'S blood glucose is within aceeptable range.

o Implement Hypoglycemia ProwCQI. o Implement Insulin Protocols as ordelBd.


o

Interventions'

-~

Monitor I Record fingerntici: glucose values \)~alwtes Educator Gon:lu!t enterad.

[1.$

ordered and PRN.

Problem; Alter~tion In Mobility / Activity Intolerance A90 specific consideration in Elderly Adults: Diminished muscle srrength, Degenerative bone andlor ioinf chEmges, DecreaSed hearing, vi:;ion .1nd tJ;llancEt. Outcomel Patient maintains or Improlles mobility I ac11vity level.

o AS$Ir.t patient 10 partiCipate in ADL's within limlts 01 impairment o Advance activity as ordered tolerated. o PT to assesS fun~tiona! <lbilily und provide appropriate adaptive dl/vices
j

Interventions;

Problem: Alteration in Safety Age (5{JftGifi9 CQn$id!!riilliprl ill Elderly Adults; SensQry and cognitlw Impairments, Outcome: Patient remain'll in a safe environment and frtlfl O'f phY$iejf 'iijuiV.
O~ o Aa~s$ fQr F!'II\ Hisk BID -Initiate Fall PrE>cGulions for F..lI Ri"k Soore or \5 or hi9h~r. o Provide appropriate satety equipment / deVIces und in&lrlJcHons Hue,
InterventiohS:

101

Implament plolecllVe status (VaV)

Problem: Oukome;
!ntervel'ltions:

I
PATIENT LABEL

~SSM

HJ:AI.THCARE."

DePaul Health Center

VEPAUJ.., HEALTH CENTER


r<1AR,CH 1 PHJLLIP

INTERDISCIPLINARY CARE PATHWAYS"'- GENERIC

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UPM-1000-024 (512006) PAGE 3 OF 8 COPYRIGHT 1997 SSM HEALTH CARE

MED 05Z4-01 M 10/02/07 RAHMAN,ANWER Z OQ07~8298


10/02/19-/6 31Y

0727400691

DePaul Medical Records/Phillip H. March

000082

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o 'Vls) assessed and in place less than 96'

o IV(s) assessed and in place less than 96'

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DF'M-l000-024 (5;2006, PAGE 6 OF 8 COPYRlGJiT 1997 SSl~ I,EAUlH CARE

10/02/1976 31Y

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DCare Planning with Pt'SO (A)

o Care Planning with PtfSO (P)

o Care Planning with PtiSO (P)

o Care Planning with PUSQ (A)

oeere Plannijng with PtiSO (A)

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Copied by _ _ _ _ __

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___________

DEPh~~ ~EALT~ CENTER

W..F.CH, PHILLIP
INTEHDISCIPlINAAY CARE PATHWAYS". GENERIC
nc .. ""'I1.MA .C;!~MI\.

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MED 0524-0l

0727400691

10/02/1976 31Y RAHMA.N,AN"'E~ Z

M lC/'J2/0 7 000748298

PLAN OF CARE POTENTIAL ALTERATION rN SKIN INTEGRITY

I DAn:: I
I '

PROBLEMS I OUTCOMES I INTERVENTIONS


Place initials and date that problems are identified in left column, All Identified prQblems must be evE\luated whether Outcome Is Mel or Unmet at time of discharge by placing (jate and initials in appropriate column. If Qt.l!t;;Qm~ 13 milt prior to dixtllUge, plac@ data anti inltia~ 1ft Met I1Qlumn. r:>lace Ii' in box by interventiwls appropriate to palienl Wrtte in additional Intervention::! as needed in blank spaces.

OUTCOMES

INITIALS

Met Un root

Owtc;ome Goals:
Skin Integrity is malntalned. Patients at risk are identllied and IntervelltiOlls inillated.

Prf1ChBCkBd items are initiated for all plflienls.

Skin Integrity ptan for all patients

0' Complete Braden Scale on admission, then daily.


~
ASSWIS skin upon admission and every shift, especially bony prominences and skin fo/ds.
0(

E:! RccQrd any reOfl@!lS lhar dO!!i not di!lap~af Within 30 minutes
~ Reposi1iIJn at least every 2 hours.

any break in skin ihtegrity.

0' Apply 10110n Immecli~tely after bathing. Use moisturizing cream for dTy skm.
Avoid massaging over bony prominence!'; and discolomdlhyperemic areas.

ri1 Keep boo clean. dry. ana tree ot wrlnl-jes. Ii1 flamove antiembolism hose, sequential stockings, <lnd heel protectors every shih tor &> Imnutes to ass6sslegs. feel. and heels. 51 Minimize ;jilin 6xpasure 10 moisture from Inconfiflenc&, perspiralfon. or wound drainage. Ii1 E:otablish a bowel and bladder progrEUTl by assisting the patient to the balhfQom or bedskte commode every two hours, unless
contraindicatea.

~ Skin cleansing at time of Soiling with perineal cleanser with minimal friction and apply protective barrier cream.

0' Lhrrit usa of adhesive products on thin. fragile skin and apply skin sleeves PAN. 1!1' Float heels ott bed with pillows placed undar the length at thlO' lower legs. activate heel sl.Ispenslon On Tola! Care Bad {leU}, an<.fiOT
sflplico.tion of heel protectors.

~ Instruct patient and family on causes and prevention of skin breakdown. sources of pre~re, Iflclion. and shearing.

Record on

Patient Eduvalloll Form.

I I

o InitJate individualized IUtning schedule mInimum o/I1'rery 2 hours ill ~a {livelY 1 hour in chair. o Consider use ot pressure relieving cushion.
o
D

o
o

Skin integrity plan for "At Risk" populations Braden SCOre ie or re$$ Place orange sign {PUPl on the door of room Imllcatlng patient Is high risk tar sl'.m breakdown.

PQsitlon pallen! in a 30 degree lateral position and avoid positionIng directly Oil trochanter. Consldar use of lifting devices 10 move and reposition pallent such as lift shet<1s. trapeze, and Air Pal to prevent frlctlon and strear. Maintain head

ID
1-----'--

o Use pillows/wedges 10 pad bony prominences from ctirecl pressure. especiaUy between kne~.
Consider use 01 urinary or tecal collection devlc'e to conlaln urlne or stoot. LImit use 01 diapers.

or bed <;It lhe lowest degree Qf elevallon consistent wffn medical cQndition.

SUpPQt1 surface per WOO N\JIse Specialist _ _ _ _ _ _ _ _ _ _~_ _ _ _ _ _ _ _ _ _~~_ _ _ __


Nut/ilion consult entered.

!v1edications: Use liQ~ln~ Hrdroctnotide 1 % inject intradermaUy to produce wheal to locally


anesthetize site. Flush each lumen of Pice with 10 ml sterile NS IVP: before and 8'ter medication I solution administration before and a :ter blood product administration every 8 hOUI!> (regardless of continuous IV infusion) when obtaliilng blood sample, discard small red tube, then obtam sample. Upon completion, oulse nush with 20 ml sterile NS IVP PRN to dete :mine patency
i

LABEL

Treatment:

Place transparent tegaderrn dressing and blopatch at lime of !ine insertion. Change l./I? dressing after every 7 days and PRN if the integrity of the dressing is compromise~~/o12/07 Document in p'ogress notes and on flowsheet : )0748298 NO BP OR NEEDLE STICK IN PiCe ARM _ DO NOT USE ANY SYRINGE SMALLER THAN 10 mt WHEN INJECT1NG IN Plcq ~~>r_"'<_."'_

i .

DePaul Medical Records/Phillip H. March

000087

INTERDISCtPL.INARY CARE PATHWAYS@- GENERIC


MEDICAL HISTORY

/t II)
~/l~ I tfV-.i-"-

./

SPECIMENS TO BE COLLECTED

INITIAL DISCHARGE PLAN


"

1.0 Home with significam other

L>}G:_-&iI0.'WJ

'.

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o SNF/ACf o o other
DAILY LABS
c

Rehab

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't

t.11-. >.' \;!-..,C ( 11 if5 .. 11 <. .';;' (" b

rtr/ Hom~Health

CONSULTS

OATE

PHYSICIANS ! NAME

(q')

/ i

:)1 ~- \, "
(J.-J

.-,

DEPARTMENTS I NURSING DATE NAME

I
Admitlsd wllh

I
0
Yes DNo

pressure ulcer?

SPECIALTY EOUIPMENT

Dale:
Type:

Isolation:

Pneumovax year: Flu vaccin.. year:

~(;J~~'J
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QIAGNOSISIPROCEOURE
>

HT

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WT

7V/-~
DATE

~di~; ~'-~71 ~ h -1.....U-) ICV-v- {L ttr:.-\..c C

(Af' (~l(-,
II

_'.

~"_

CfulSTATUS

ALLERGIES

full resuscitation

o DNR madical management - - o DNR comfort measures


Advanc8 directives?

N{:;l\ft

0 Yes 0

No

Oopy in en9.r1? DYes

0 No
medl~allnforma1ion:

Is ther.. anyone whC) should nol receive general condition in1orma1ion? [J Yss oNo

Family/Significan1 olher designated 10 receive


Name Phone

o None
Name Phone

o POA

POA

DSPAUL HEALTH CENTER

tYIOSSM DePaul Health Center


H A '"" 1 H e ... R E-

INTERDfSCIPL1NARV CARE PATHWAY~ .. GENERIC

fl1ARCH,PHJLLIP I/P 0727400691 MED 0524-01 10/02/19"16 31Y M loio2/07 f-1ELKAVERI, SONIA N 000748298

IIIDIIIIIIIDlllllllnl~

DPM-1000-0?4 (5i2006) PAGE I Of- 8 COf'YR1G1lT 1997 SSM Hl::AiTH CARE

DePaul Medical Records/Phillip H. March

000088

PLAN OF CARE
,---

DATE!

PROBLEMS I OUTCOMES I INTERVENTIONS


Plae!'; Ini!iul~ und date thaI problems are identified In I$tt cofumn. Ail ,r/Qntifi"d problems musl be evaluated whether Outcome is M~t or Unmet af time 01 di'3<;;harge by pfacing date and imlifll3 In IIpproprlate colulnn. If Ouleo~e is met prior 10 discharge, place ciale and initials in Mel column. Ptal'e v In I:>ox by int~rvenliollJ appropriafe to pailenl Write iI1 addltlol'laf intervenlionll 115 needed in blank space:>.

OUTCOMES

INITIALS

Met

Unmet

Problem: Alteration

A.Qa "'IJtICitil~ CO/1:JlulN<llion in Elrferi'y Adults: Viminished muscle streng/II, OegenBl'fltlv(J bollO and/or joint changes, Decrc>osao' 11{;!IHm,q. Vi:~10n and billa(J{.;e.

'n Neurological Status

Outcome: The patl('nt will experience a stablH&lItion of neurofogical fmpalrment.


I I

I
I

I I
I

o o Io
!

Intervention;;: [j , P.ss~sr, for Fall Hisk BID InitiRte Frill Pre<;;IIvtions for Fall Rink Scor~ of 15 or higher. Ihsess level of consdolwness and motor function every ahil1 and PAN Encourage achievement of ADL's as appropriate 10 the neurological irnp'lirment.
A't~r..tjon

Problem:

In Oxygenation I Re.splratory Function

Ago apecifia aonsirifw'Ition in Elderlv Adults: Weakened respiratory muscles, D?qr?.{j(;rJ IUHglf:iSU8

eJ8stiGity.

Outcome: Respiratory iunctlon will be within normallimft:s for patient.

o o U o

InW\,.;nliens; LJ , _ PositiOI1 p<ltienllor maximum vantil'llion effjci~ncy MOllItor VS ! breath wtmds i ol.imetry every shiff and PRN. Administer treatmento / oxygen J A8Gs a5 order~, IJrovi(;!e Iluici intake to liquify seem-nons Suction secrelions as necesaary.
Probl~m:

I~l

Alteration in Comfort/Pain Management

I1gc $1J~'iI," consirferation lil ElrJerly Adul/!'; Possibi<! Idic;syncralic effects from m~r;/i{;,/i.ti(}nli ttl Bosom/inn. moiabohsl1I lind excretion

due f'J (lglJ-f@la{flc1 changes

I
I

Io

IntElVUlllprls fJ ___ .________ ;\:;SIIS3 patient's pain level every .. hours Involv!! patient in ewe by discussing nll?tl'lods o! pain relief inil'a!~ inll'rVIO'nlion$ (i!"tcluding I)on pharmacologic) approprmte for painfdi&comfort Ar.[.J)oO pain level and respons", withm 60 mmules 01 ;ntJ?rv9I1tion.

Outeom~

Patient exhibits I states <ldequate relie' of discomfort.

I
I I
!
I

Problem: Alteration in Nutrition

I
I

Age sr>t?nili<: conf;ide/f;ttron in Eiderly"dulls. OlminishBrJ ilppetito. pf}(is1alsis and digestive juices and d8nffllon change!;. FiretO{$ 11121 {(jilV lmproVp. f09d ilJ/<lke: Position pfl/ient upright - Ofter smaller. more frequent mBals - Modifiod foor:! COl)s1:~tem:y I.e. pilmfh7 i soft,

Outc.oms! Plitientls nutritiona' Intake is appropriate for metabolic: n_ds.


Interventions

I o

o Nutrition Consult ent9red in H80C', [J Monitor hydrulion stalus o Ass&ss Imt"ral fesdlng tolerance o A!;sess lor sW.!Howing I chewing difficulty -A(l~ist patient with meals as neeQ\ld. o Assess i Record dietary !ntaka with each meal - Provide I record dietalY supplements f HS snacks.
n&cord naity Weights - neporl unexpluined weight changes ;-3 K9 from pr~vlous day.

! Outeome: Patient will be hemodynamically stable.


D

Problemf AlwrBllon In CardioYilseular Status


Interve!1lion~

Age specilia conSideratiOn III E/df:rly Adult."!.' Diminis/led carrifac force I blood flow to brain.

R,,,oord mlake and output every shift llnd PRN I Daily weights and report varmnces. I\$U"'~S vital signs, peripheral pulses and carpillary relill every $hifl and PRN. Administer medioltiom i blood prociuctr. il~ ord~red and monilOi effects.

Problem: Alteration In Skin Integrity


Age s{.,ecillc considRration 111 EI<./t!rly AduJt,~ Skin dfy ami /t;SS a/aS/ic.

o
o

Oulc<Jme: Patient wilt maintain Of' improve skIn Integrfty. Inlervenfiom' U Tum palient every 2 hours - avoid :;h9aring -I<cep skin cleB(] and dry.
Photograph and measuro wuunds on admission. every Monday. and on discharge. Pr"'1ide wound C3fO p!n Skin Car~ Pll'lfI (SM page 8) Nulr!ilon Consuii entered

\~W
i

Probl&m; Potenticlll or Actual Infection

Io
Io

l.

Age 6pc'Clfic c()nslder.Qfion In Elci<!rly Adufls: Decrel'l.$cd lena! function ~ norc lab valuE'S related to antibiotic dosing Outcome: SI~S and symptoms of infeethm are r$cognized. PreGliullons are utilized. Il1lervention$' U Utilize iaolation precautionr. 0 C~ntact Special 0 HBspiratory 0 Dropl~t AG~\'3SHeporl sign~ and ~ymptoms 01 Infection evsry shift ll1d PRN,

Dil TlFNT

LABEL

~SSM
HfAlrN
l'Anr

DePaul Health Center

J!P~~f!!~llla"l

DEPAUL HEALTH CBNTRR

INTERDISCIPLINARY CARE PATHWAY~ GENERIC

0727400591 MED 0524'01 10/02/1976 31Y M 10/02/07 NBLKAVERI,SONIA N 000748298

I/p

DPM-I OOOO!f.I (h!:!OOB) PAC,e 2 01' (} C( )f'YHIGHT 1997 SSM HI-I\U H CAnE

DePaul Medical Records/Phillip H. March

000089

PLAN OF CARE
PROBLEMS I OUTCOMES I INTERVENTIONS
DATEr

INITIALS

Plar,;e initials and date that problems are idefltifiedin left column. All idenlified problems mUl.!t be eV<llunled whether Outcomw is Met or Unmet at lime 01 discharge by placing date and initials in appropriate column. If Oulcome IS mel prior lo discharge, place date And initial~ in MGt column. Place ..... in box by interventions appropriate \0 patient Write in additional interventions as needed in blank sp(lces,

OUTCOMES

Met

Unmet

I
i

Problem: Altef'stiOf1 in Elimination


Age spr;lcific eonsi(ieriltion in EhJeriy Adults' Dimif1i!~hed per;sttlISls, kidney ftinction.

Pattent regaIns normal elimination pattel'nlf for ag9 and disease proee!50s. I Ou1eomel Il'1terven'ion~: 0 ___

D D
I

o Offer toiieling every 2 hOW3.

.. -

Ass,"sG bowel soundS. abdominal dl91entiQn and10r discomlort -:very shift and PRN.

lIecord !requeflcy and charactenstic5 of slool. Re-port If no stoellor "3 dnys Record Intake nnd outPUT every shill and PRN ! Report abnormal iab values.

Proble.ml Knowledge Defieit

I qO')

Io

o o

Age 5J]CGt'fiC ContiiaffUIfion in {;!(j(,lrly fldulIs: SMSOry and co9nilivo imptllrments Outcome: Patient and/or lilgntfieanl other Involved in plan of eare I demonstrate of proGedures I dlsea$e I medielilltions { and discharge instruotions. Interventions D ~__ . AaBN;s baslllin~ knowledge nf1d preferred learning method 01 patient f signtlcant other. D Provide edllcalional material at patIent/significant other level of :.md>Jrutanding. Assess pnlienli significant other tor l.lodemta/1ding after teachln9' Provide in3truction on safe and effective 1.l5e of mediC-'ll equipment.

underslandlng

Problem; Anxle" I Splf'itual Disturbances


Age apcoific consideration in E/uel/y Adults.' Fear of loss 0/ COIlIIOI. dodinmg htlalth in Bcono/me seGurity / social sill Ius,

and/or approaching death, cnanges

o o
o o

Oulcome: Patrent/Significant other demon$trates ability to cope and icfentlflell Bvallable rHources. Interven lion.s, 0 Encouragll verbullzation of fears and participation in care. Decrease sensory llllmuli - provide qui'" environment - Dim the hallway lights alter 10 PM, Pastoral eMil referral entered, Pallitltive Care referral entered

I I

Pt-oblem: Glyeemia Imbalance I Age speoific consideration frl Eldorly Ad!llt,~, Decreasel.i renal fllnetion, metabolic rille. Outcome: Pat14~nt's blood gluCO$e is within Bceeptabte range. Interventions: D. ImplemO'nt Hypo91ycemia ProtocoL Implement In1julin Protocols as ordered, Monitor I Record fingersti<:>k glliGose valuea aa order-:d and PRN. C Dial>ele!; Educator Consult ",nlered,

o o
o

o o o

Problem: Alteration in Mobility I Aetivity lntolerllnee Age specific cOnli/ueration in EldArly Adu!ls: Diminishod musc!fl strength, DegenerallVe bonA and/or fOlnt c;'flallge;;;. Decrea5ed hearing, viSIon and balance Outcome: Patient maintains or Improves mobiliiy I activity level. Intervention5: D_ Assist patient to participate in ADl's within limlt$ of impairment AdvanCe activity as ordered,' tolerated. PT to a3SeS$ functional abilily and provide appropriate adaptive device!';,

PrOblem! Alteralfon In Safety


Age specific (;onsideratioll Tn Elderly AdIJlrs: Sensory and cognitive impairments.

o o

Outcomet Pattent remaIns in a safe envIronment :ll\d freo 61 phllslea'lnJury. Interventions: 0 _ Assess lor rail Risk BID -Init,ate Fall rrecauti'~rl& for F~II Risk Score 011 b or higher. ProVide appropriate safeiy equipment ; devlce~ alia in(!!ructieM fe' UtQ, Implement protective status \VOV),

Problem: Outcome:

..
-

----

Interventionz;

".-rI~AIT

I ABEL

OI"I:;SSM DePaul Health Center


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1ARCH, PHILLIP
0'/27,100691
MELKAV. "

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MED OS/4-()1
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DEPAUL HEALTH CEN

10/02/1976 31

INT~RD1SCIPLlNA.RY CARE PATHWAYS~ GENERIC

ERI,~ONrA

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. :lO/02/07 000 7 18298

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DPM1000 024 {S!20(0) PAGE 3 OF 8 COPYRIGHT 1*7 SSM HEAllH CARE

DePaul Medical Records/Phillip H. March

000090

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IV(s) assessed and in place less thaJT1 96

lV(s) assessed and in place less than 96"

o IV(s) assessed and In p'ace less than 96"

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DePaul Medical Records/Phillip H. March


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DePaul Healt-h Center

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, 07274010691

1 DEP.;;'UL

HEALTH CENTER

INTERDiSCIPUNARY CARE PATHWAYS~ GENEIRIC

Ill' MED 0524-01 ; 10/02/1976 31Y 1'1 lO/02/07 ; HElLYJ\VERI SON IA

N 000748298

000091

DPM100(}'024 (&12006) PAGE ~ OF 8 COPYRIGHT HI97 SSM HEALTIH CARE

DePaul Medical Records/Phillip H. March 000092


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a Care Planning with PtlSO (A) o Care Planning with PIlSO (P}
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Care Planning with Pt'SO (A) OCare Planning wittl PtlSO (P)

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Copied by _ _ __

R. ,.-

RN ReI/jew

MARCY-!. PHILLIP
072740C59~

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10/0:2/07
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INTEROISClPUNARY CARE PATHWAYS"- GE'NERIC


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~O/02/1976 31Y

MED 0524-01L

MELKAVERI,SONIA N

o IV(s) assessed and in place Jess than 96

IV(s) assessed and in place less than

96~

o IV(s} assessed and in place Jess than 96i"

DePaul Medical Records/Phillip H. March


PATiENT LABFI

DEPAUL HEALTf! CENTER

INTERDISCIPLINARY CARE PATHWAYS"- GENEIRIC

MARCH r P!!lLLIP 1/ P 0727400691 MED 0524-01 07 lO/,CZ/1976 nY M lc/nl MELKAVERl,SONlA N 000748298

111111111111111111

000093

Of'M-l000-024 (512006) PAGE S OF 8 COPYRIGHT 1997 SSM HEALTIHCAAE

DePaul Medical Records/Phillip H. March 000094


t1 ell .. 1'"

o Care Planning with PtlSO (Al


OCare Planning with PtlSO (P)

o Care Planning wi1l1 Pt'SO (A) o Care Planning with PtiSO (P)

OCare PlannUng with PtiSO (A) OCare Planning with PtiSO {P)

~SSM
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DePaul Health Center


PAGE 7 OF II COPYRIGHT 1997 SSM HEJlltTH CARE.

DEPAUL
Copiedby _ _ _ __
RN Re\liew _ _ _ _ _ _

HE~TH

CENTER
I!?

M..ll.RCH, PHILLIP
0127400691

11I1.lllllIllftl
MED OS24-01

INTERDISCIPUNARY CARE PATHWAYS, GENERIC


r.1>..... ,M(l./l~t. f<;P!lOil\

~C/ :12/1976 31Y

M 10/02/07

MELKA\lERI., SON:i:A N 00074113298

PLAN OF CARE POTENTIAL ALTERATION IN SKIN INTEGRITY

I I

PROBLEMS I OUTCOMES { INTERVENTIONS


DATE I

INITfALS

Place initials and dal!;! that problems are identified in left column. Ailiderllifi&d problems musl be evaluated Whether Outcome Is Met or Unmel at time of discharge by placing date and initials in approprll\l$ corumn. If Outcome i3 ml't prior to discharge, plaM dale and inilials in Met column. PI.ace v in box by interventions approprIate to patient Write in additional intelVentions <G needed in blank spaces.

OUTCOMES

Mel

Unmet

Outcome 00al51
Skin Integrity is maintained . Patient$ at risk are Identified and Interventions initiated.

Prec:hBcked items <Ire mitiat8d for All pallfml-s.

Skin Integrity plan fer 1111 patients [if Complete Bradltn Scale on admission, 1f1en daily. !if Asse~ skin upon admission and every shift, especially bony prominences

and skin folds.

~ Record any reClnG(;-slhat M{!~ Mt disappear wlihin 30 minutes or any break in skin integrity,
[If Reposilion at least every 2 houts.
~ Apply IOlion Immedia1elf after bathing. Use moisturizing cream lor drl'skin.

I!?f Avoid massaging over bony promlf1ences and discolored/hyperemic areas,


/i1Keep bed clean, dry, and free of wrinkles.

It'!' Remove anliembolism t1Ose, seqlJential stockings, and heel plOtectors every sl1ift lor 30 minutes to I'IS:5ltSS legs, feel, and heels.

fi1 Minimize skin Elxposur~ to ffl!'JlstUl'e from incOhtinence, perspiration. or wound drainage,
!i1 EstabliSh a bowel and bladdel program by assisting the patient 10 the bat/lroom or bedside commode every two hours, unless
contrainctkaled.

Shill cleansing at time of soiling with perineal cleanser with mInlmai friction and apply protective barrier cream

fi5 limIt llOO of aQhesive products on thin, fmglle skin and apply skin sleeves PRN. !If FlOi'll heels oft bed with pillows placed under the length of the lowar legs, activate heel slispension on Total Care Bed (fCU), and/or

l
!

application of heel protectors

fi?f

Inst/utt patienl and family on causejj and prevention of skin breakdown, sources of pressure, friction, (lnd shearing. Recora on Pallenl EdUcation Form

Skin Integrity plan tor "At Ai$k" popillations. Brillden score 1U or less

o o

Place orange sign (PUP) on the door 01 room indicating patient j~ high risk tor skin breakdown.
Iniliate IndMdualize<l turning schedule minimum of every ~ hoUls In Wdl every I hour in chair. Consider llse of pressure relieving cushion.

o Position patienr in a 30 degree lateral pol.lltlon lind avoid positioning directly on trochanter. o Consider use of Ulting devices to move and reposition patient such as lilt sheets, trapeze. am:! Air Pal to preven( triction and shear.
Maintain he8d at bed at Ihe lowest degree at elevation consistent with Use pmows/wedges to

medical condition.

P"d bony prominences from direct presswe, especiaUy between knees.

o Consider use of urinary Qr fecal collection device to contain urine or stool. Limit use ot diapers, o Supportsurlace per woe NUlSe Specialist ___________________._________________ o NutrlUon consuff entered,
Other'nterventlons ________________________________________________________________

~------------------PATtENT LABEL

O~SSM
HI!AllH CliRi

DePaul Health Center

DEPAUL HEALTH CENTER MARCH,PHlLLrp

1111111111111.
MED

INTEROISCIPUNARV CARE PATHWAYS" GENERIC

0727400691

0524~Ol

rip

10/02/1976 31Y

M 10/02/07

r-.fELMVERJ:, SONIA N 000'148298


DPM'100iJ-O~J4

(5!2000} PAGE B OF B COPYRIGHT 1997 SSM HEALTH CARE

DePaul Medical Records/Phillip H. March

000095

INTERDISCIPLINARY PATIENT/FAMILY EDUCATION RECORD


INITIAL. ASSESSMENT

.r:r None
~

Ph,.JSlea' BarrIers to Learning: CJ Vls!Qn CJ Hearing

0 Language

0 Difficutly Reading (explain) _, _ _ _ _ _ _ _ _ _ _ _ _ _ 0 Wri1ing {explain} _ _ _ _ _ _ _ _ _ _ __ 0 Development level requiring intelVention (explain) _ _ _ _ _ __

o Other
..E"rNone

Barriers 10 Learning: 0 Anxiety 0 Anger 0 Denia.l SIlWtual Barriers to Learning:

E~tfon8r

0 Depression
0 Olher

0 Confusion

0 Other _ _ _ _ _.

Grief

0 Guilt

0 Lack 01 hope

_~

_ _ _. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
0 Caregiver 0 Other _ _ _~_ _ _ _ __

Barriers to Compliance: None 0 Meal preparation 0 Transportation

0 Financial

Re'!iloU3 and/or Cultural Burrlers, to Learning:


..erNone
1.

0 Ye~ Explain _ _

Wh~ is the easiest way for you to learn? Reading 0 Listening ..erl)emonstratlon 0 Other _ _ _ _ _ _ _ _ _ _ _ __

0 Pictures

2. W~ are your learning needs at ~ time?

.tl Disease process

0 Diet Community resources 0 Rehabilitation Who should we involve in your teaching process?

o Use of equipment

nMedications

o Other __,_ _

o Pre/Post-op teaching

~1I0W-UP treatment

Ar:tivity/Exllrcis8
Admission Advanced dlrectjve~ Comm. (~sources {}Iagnostlc te$1$ Dmf/NPQ Disease managemerrl

Disease process
Disr.narge Information Dressings fall prevenhon Foflow-up c.are

Home care services


Incenliv!> spirometry Infant careifeedlng

Medications
Ml]nitors

Post JIllrtum teaching Pre-op teaching

SignSfSx Smoking Cessallon

Treatments

Wound (.are

IsolatiOn precautroos
IV~lnjr.r,tions

Mouth care Oulpatient programs

Pain fH1H120ement
Plan of oaTIl Post-op le3ciling

PSyCh!lsocial needs ReslIllfllls Risk ractors


Room orientation Safety

Social wvlce
Spiritual needs

Surgery
TCDIl Te(ls

Foley
FOrx!fDrug 1f1101acliofls

Labor mamlQemenl MDf

RtaCfin688: (1) S!ahl$ re-ady (.2) R&qlfflsIs delay (3) Conlulled (<ll Sedated (5) Cognitive inabilIty (6) Ll1l11rn.r: PT = PaMn! P = Parent F Fathat D = Daughter(s) 0 ~ Others M", MOlher SP '" SpoLJ~e S Son(s) MlJlllod: A _ Audicl'l>6uaJ D = Demonstration E = Explanation C Group ClasS H=H<lndoul T=TelephonelExplanatiOn

erIOSSM DePaul Health Center


He"LT"'~1\N"

DEl?AUI" H.I:;ALTH CENTER

r>iARCH, PHILLIP

IIUlllIHllffllflllllIB

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INTERDISCIPLINARY PATIENT/FAMLLY EDUCATION RECORD


OPM-10COQ60 (1212004) FRONT

RAHM.~, AN'I'lER Z

0727400691 MEO 0524-01 10/02/1976 3lY M 10/02/07


000'74829B

DePaul Medical Records/Phillip H. March

000096

INTERDISCIPUNARY PATIENT/FAMILY EDUCATION RECORD


POTENTIAL TEACHING TOPICS
ACllvity/fxflrclsf Admission Advanced dir&Ctlves Comm. resources Oiagnostic teslS DieVNPO Disea~ man.'I!)6menl Disease proc.8SS Discharge inlormation Dressings Fan prevenlion FOllow-lip care foley fOOdlDrll\llntaractions Home care SfJrvlCBS Incentivit liplrome")! Iman! can~lFeedlng Isolation precautions IV'slinjecliollS Labor mana'Jllment MOl Medications Monitors 1'ost parium teaching Pre-op teachiTllJ Psychosocial needs Restraints Risk factors Room onerllalkm Safety SignslSx Treatments

Mouth Cllre
Oulpatient programs Pain management Plan of care Postop teacl1ing

Date

SllI1lslure f Tille

,~

l:

Teacll!ng Content I DiSCharge Pans (May place slicker here)

D_
SOGi1!iaCfviGv
Spiritual needs Surgery TeDa

Smoking Cessalk1n

Woond ,are

Tens

Present? Yes or No

Family

OUTCOME -~~-f;

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Readin$s: (1) States ready (2) ReQUests delay (3) Confu~EKJ (4) Sedated (5) COgnitive Inability (H) Refused (7) Already knowledgtlahle leamer: PT" Patient P ~ Parent F", Father D" Daugtller(s} 0 = OIDers M = Mother SP = Spouse S = Son(s) Method: A = A\Jdlovi~l.I111 l)" Demoostratlon E = Explanation C" Group Clast; H=Handout T=TelephOnelExplanatlOn

~$~lrf-

DePaul Health Center

DEPAUL HEAI,TH CENTER MARCH, PIUT,T.1P T/ P 0727400691 ~rnD 0524-01 10/02/1976 31 y l'1 10/02/0 'I
RAHt4AN.~iER

IWIIIIIIIIIIIIIII
Z

INTf:JmrSCJPLINARY PATLEN'I'lFAMlLY EDUCATION RECORD


DPM1000-060 (1212OC'4) BACK

000748298

DePaul Medical Records/Phillip H. March

000097

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DePaul Health Center

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22,0(;

lO/06/07 00;00 to 10/OS/07 23;59

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DePaul Medical Records/Phillip H. March

000098

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Adm: 10/02/07

DePaul Health Center


RRTCGfITON, MO

Covers Doses from,


10/08/07 00:00 to 10/08/07 23:59

Medication Administration Reco~~


Printed: 10/0'1/0'1 22:00

page; 2 (more meds follow ..

DePaul Medical Records/Phillip H. March

000099

W'" u
~tart

ONSCHEDTJLEP MXIlICATION ORDlmS

(cont.)

Spec~al t----::-c- -

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Instruotions; 5topl-"Dfll\l! [}nfi~fRoute/CommentlJ


ACBTAMT NOl'HF'.N .12 5 1-1(; TllliL<-'j' TYLI>I'KlL :1;2 5V.c TABLET
~ so

------J

-- . -1

lC/02
C-l'.)U

------------------------+--q4h
fIJi)

fr~gyen'Cy

QQQO-07~Q

Needed

FU(

V
03(}1)

!vo,.."

w.;/2

TALBT

[ORAL)

IUT lH i I d pA I n or fevel- greater than lCl.Sr

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10/1'1'

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HYDROMORl?110Nl:: H(;!J HI')b\;'nOH TH1AI mm lHG/H1L r~lP t:QU1V DOser 1 MG/t MI.

AS Needed
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I
,
1

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REAS~; E~!;

It! 10 lS p..nNtITFS TV

I~

TrON!'.!' \XICl> 1S NEEDEn.

LJJ _ Lt RilA
=

G.Q.

Site COdES fJT = r.j


RT

1o{0 - !<c. V.Q.

Rt, ThifJh

Rt. Upper Ab-j.

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1M.

l.J\ .,. Lt. A.:ttn RA = ~t . Arm LLA Lt. u;.>.'er ADd ELA - Kt,. Lower Al:x!.
Th~gh

0524-01 5N MARCl{,PHILLIP

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ur: !".ELKAVERI,SONIA N

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DePa~l He~lth

0J~;'-e'::::r""-I>-Q-e-~eS-from:
10/06/07 00:00 to 10/08/07 2):59

Medioation Administration Record


PrHttut:l: Hl/fl7/07 ~d:i}U
~lAR

bXXI)::;E'TON. HO

------------------------------

Page;

(Bnd of

DePaul Medical Records/Phillip H. March

000100

lSPe~j .. 1

r--"'.
Ord#

..
Instructionlil;
Stop

SCHEDULED

MEDICA'~ON

ORDERS

------0731"1530

Gtarc
"\10/02 0900

F-'" iJLug/D<.,'1"'/Ruut-e-:-;'"CC-o-mm-e-n-c-s------r::"l":';ll~:f' OQOO-Q7l\)


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1

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lIM}
PNf:lJN()0)Cc,o,L VACntHl iiAS 1Jt:t::N URDER8D TO BE GIVE ON ['AY J 01< AT DJ.s(:}li'lRGV T F' fl!;:f0R<: DAY j , VACCINE [)."),sp.g ARB IN 'TlIe

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~

"l,,,d.ic~tions

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?,lfIi

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I
f

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1 Si\..e: Codes

~ 0 JP]iftT---~
,

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: --

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R\.IA

LT - Lt.

I T . l/i., TIl1.lJh

Rt, lIr',,'" I'JJd


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: "

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t\ \ ,

I f

Prim:ep:

i.';/()~/07

~2:00

10/07/07 00: 00 to 10/07/07 23: 59

---------------------

Page: 1 (mQn mads follow ...

DePaul Medical Records/Phillip H. March

000101

,"
spvc1al-Instructions,
orrllJ'Ti:;t,an.
'<5 ..T. 1I1j(lq
1400

DC1UWULIID MEDICATION ORDBRS

(cont.)

k "

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---,-,

Codes
1JJ '" Lt. 0,0 RU _ Rt. U .0. l-iT RT
'='

Lt. 'Thl4h Rl ThirJh

RUle ., I<'t. Up""" Abd Wi\ .. 1,[ Upper A.bd.

"LA

we.

HLiI = HI

0524-01 MARCH, PHILLIP

l~lAA

Vel'jflerl lly'

f.,fiJi- K

1.)0El:

10/02/76

Age:

- - - ; - - - - 1 AOOO?'! 9290

31Y Sex: 14 Adm; 10/02/07 Dr, ~'1ELAAVERI, SOlHA N

Allergiesl m:A Medication


AdminiBtr~tion

19,_~/J 1 ::15 :~
DePa~l

Health Center

Record

PllnLf:-'lt rO/Of/o-, 2Z.rn)

10/07/07 00100 to 10/07/07 23:59

Fa~el

2 (more medB follow.,.

DePaul Medical Records/Phillip H. March

000102

r-- '-~----------~-ON-S-CH-KD-UL-ED-MRllICATION I-speci-;l-r truct ion~


OJ:! I
.-~-

ORDERS

(cont.)

" ...... .-

, Ordll -~IR

St.art. ' Stop


lo/o:!
GiGO

Drug/Do8e/Rout~/CommQnt~

-..

ACh'YAN1NOPHEN 325 to.J TADLIIT

,G

FLK

loose,

TYLENOL 325MG l'i\B!"!::'!'

650 MGf 2 TABLET

for /f,ild pain or fever gre.Jter

~,/
1:")11
{,.:A f3

than

lOl,~r'

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I

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I'VSH SLI.ML,'f OV",R 1 M!NlJ'l'll RE.i\BSESS IN 10-10, ~lHJ\lrl'S 10' M~J)TTTON"', [)()'~E IS NEEDED

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~

S.Lt.t.: Code's
LA
RA

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Ann

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LUll = r,t

llpp" ,

/lId,

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- - - - - - - -... - J - - - + - _ . - - - - -

0524-01 SN MARCH,PHILLIP
DOB, ]0/0;>'/7(:'

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BR IJX;t;T()N, W)

--l A~,le_r_q_i_e_ii_I_NKA

_ _ _ _ _ _ _ _ _-:-_ _ __

Covers Doses from:


10/07/07 00:00 t~ 10/07/07 23:59

Medication Administration Record


Pr~nted:

1Q/06/07 22:00
<En~

page. 3

f MAR

DePaul Medical Records/Phillip H. March

000103

----------------------------10
.G

. . -.------------------------~----------------------------~ "'''* ft_ SCHEDULED ~IEDICATrON ORDERS w ......

i 10/02
0900

'CLARIFY PENICILLIN

TABLET

frequency IlOO[i-G7}IJ I Q7H-l~~'J l:;Jl;lJS? -----~~--------~----------------~I'------------------+--------------~


'C1J\K I'MO

[ ____ I

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* . . "".~~.'* .... ~ ,."'.*

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, r

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.. ..---:::--:---::--::::-:-+----------1 Order On Hold +t-+'t'+++++++++'i-+

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AZTREONAN(AZACTAM) 2 GM
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/
0007 10/02
'..'oQ\'

[lEFOR!! DAY ). VACCINE OOS'I':S "'R1'l IN THR I1EDICATION RlZl'IUGllP.ATQR, PLEASE FILL ()(fl' '),Hb! CHAXGI$ SHEET WH8N GIVlil'/.

SODIUM C'HLOlIrng RAC1' 0, 9~


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OBH

1400

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MedL'>ato1l9 A<'e Given Then 2m1 Be Con' Md ;,iter' ~ledication Administration

Site
LU
~

codes
RA.
LLA Lt

--~I
LJ\ ..
~

I
i

0.0

RU - i~'C. U.t~. XI:A .. Rt Upp.. r

1.1' Lt. Tr,igh RT - Rt. -:!'t!lqh


Abd.

Lt. Al~fT\ HI. lU'[tI

WI,

L,t.

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0524-01
~~~----~~~--~MARCH,FHILLI?

5N
Aqe:

A0727400691
31'{
Sex, t1 }I.dm; 10/02/07 MKLK.AVE:RI,SONIA N

1l0H

1 O/O~</76

-----------------~A000748298

Dr,

,MAR V"",fl"d hy'

------------------.--1
DePaul Health Center

Allergin; NKA

Coveru

Oo~e~

from:

Medioation Administration Record


l'rint~;

10/05/(17 "~,QO
m.~s

flRl00RTON, ['10

10(06/07 OOtOO to 10/06/07 23:59

page: 1 (more

follow ...

DePaul Medical Records/Phillip H. March

000104

r-------------~~~~~~~~~~~~~----.-

SCHEDOLlUl MEDICATION ORDBRS

... - - - - - - - - - - - - - - - - - - - ,
(cont:.) ... ",."

~--.--------~------------------------------~--------------------------------------~

Special Inatructions.
ordU Start
, O/()4
140{)

Stop

Drug!Doge./Routtl/commEmt!l
SODIll!<1 CHLORlm: BACT D _" ' N()ll~l"L flAl.TNP. lNJ!K'l'lt)N
[IV)

0000-073~~~_ 0731-1530
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,
!

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.' .

Site Codes
LlJ f\U

=
~

Ll.

ll.Q.

J.T

Lt .
~I

Thigh
Thigh

LA ,
RA "

!.JC. Arm
Re. Arm

F;Ul\ -

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l6Z~ !J.L
I
-~

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l/'

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RT = Rt. u.\). Re. Upper Abd Lt. uppel:' Abo.

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0524-01 5N MARCH,PHILLIP

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Sl':'.,it : M Adm: .lll/O:!/O I t4i':LKAVERI ,SONIA N

1,H"R

verUied bi

~_~_.

\L1~t-~-+--Cen~er

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--

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10/02/76

Age;

31'/
Dr;

-_ ...
._ _ _ _ _
Covers Doses from.

AOO[J748298

_J J.

A_l.

1er 9. ie.9'

IDepaul Healtn

Medication Aaministration Record


23:5~
Printed'

BRIDJE'ION, NO

10/06/07 OOtOO to 10/05/07

i3ge: 2

(mo~e

la/oslO? ;;:;,M mads follow ..

DePaul Medical Records/Phillip H. March

000105

~P.ci"
O,.d~
"A

.........

tlNSCHEDUJ.1ID NEDIC,l\.TION ORDERS

(cont.l

fr." . . . .".

Instructiona:
BtaL'e
1!}fD2
010fl

Stop

DfUgi'Dl.jue!Ro\lrg/l'omm~mtg
\AC1ITIIHINOPHEN " 5 MI, TJ\BLE'l' nJ.. :;.'NOL 32 51>10 TABLSl' !bose: 650 Mel:! TJUlLBT
[Ol:

D t'J..K

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I 1M ,..,"
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ifreCIUC'.Il_C_Y--+_ _1I_U_U_U_-_O_7_J_I1_
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JJ;')27

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greater

cha n 101.5"

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~:iv'J

J),PHI': NHYDRI\HlIll!;

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I .---+-~---!q6hPl'l1
lAS
tiem I.."1

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Dose: 25 MC/O, 5 ML

[IV)

p "" "'o;-r ' '"!'SL

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PAIN
h~";w

;'MORPliON~

INJECT1{)1:

----~----------~

/{p

,: tl.'O

[ITl .AlmlC lw.;/IHL AM\, IiQUlV

All N""dad

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iDose:

1 MG/l ML

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I I

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1750 Sf:'

NOllf.lhL S i\L W!'!


PUS H Sl,oWf.V OVER 1 MINU'J'b:

REASSllSS IN

l()

lS MHIIITES IE'

l\IDIJ1'J'LONAL OOSIl 1$ NEEDED_

I
I I
I
!

t---------. L1---"''''====
LU . Lt. V,O,

81 te Codes
LA Lt, Am LT ~ l.t.. Thigh AA~ Rt. Arm RU ~ Ht, D,O. RT RI:.. Thi4h RllA ~ Rt, uppel:' Abd. LLA Lt . T.o'n'er i\bd. RLlI . Rio, LOWCT A.bd. LUll ~ I,l.. lJpper Abct.

Init

0524-01
----------------~MARCH,PHILLI P

5N
Age:

A072740Q691

f-'-t-

iDepaUl Health Center

Mi\R

v!!rified Pi

YB:

~I

-1----1 -

008, 10/02/'{fi A0007'18298

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lDWrE:'C:OQ:iJ

Allerg:l.olJ: m<:A
~

._i_________~__
~ledl.ea.t1on

Covers Doses from:

Adml.nl.Btrat~on ReCO~d
Pr {J)ted: IV/\Y*.,,/07 ];t ,00

LU~ HX; -rc:'N ,_I-IC_v_ _ _ _ _ __

10/05/07 00:00 tQ 10/06/07 23:59

Pagel

(End of MAR

DePaul Medical Records/Phillip H. March

000106

ft"lt

1----:---::-- -- -Ordll 3ta rt

Spectal Instruetionst
Stop

- .--. - - . - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 1

SCHEDULED I"..xIJICATION ORDERS

... "

I.

Drug

y-+___ Q IDo't;c:"/Routci Camlllcn t u ______-+I_f_f_e_. _tl_e_!l_c_ oo_o_fl_-_o_7_3_0_-+___ o_73_1_-_1_5_3_0 __


TABLET
IOlVW]

+-1_ _

1_5_1_1-_"_,1_5_9_-1
1_ _ _ 1

ICLAJ<Il'Y PENICILLIN

eLM l'RZO

! _ _ _l

! ___l

i!Dolle,

'X'JlBl..1n'

clarify dose and frequency

--+----j----+---------------- -- _._._- .AML0D1PINB 5 Me TABLE']'


NQRVASC
5~

TAD EQI.1IV

IDolle. & .U:C/l 'fAa4B'T


, ,

[OIW.I
BID W/HEAL 4'++H i-+ ......... +t .. ttt't Order On Hold

. .... -..- + - - - - j - - - - - - - - - - - - - - - - - - + - - - - - - . __ . _.- ._._-_._lIMOlCI CILL I n- CLJ\VU'L.1.NATl! 87 5 bIG TAELIST

E' I
0022
PSL

10/01

"'+.i--t-t't+t+tti-++

0700

'\

AUGxmrIN 815 'l'MlLl'l' HQU

,. 10/0'1 11/01 1800 : 2H9

!l\zTltEON.AJ.l-{iihCrNl)
SaDIUM CL
Q.9~

2 GH

Q8K
(IV)

~T

100 ML

\\l"'"

~).~<:I-:'>

I
0023
nSL

! 10/04
1900

llioi
2359

'"

II"fUIIO t>ver, 30 Mitlutea r:e(l'igerate


,.!

I
!

ICLINOAMYCHHCLEOCIN) 900 .ra/Ii /IlL


SODIUM CKLORTD3 O. H ,0 ML IIV)

----r~~~DC\
;.1

I
II

-,---~~----+~:--' 13 ___._1 1.'m. "tt\" ~ :)~}Ot.


~
j

C\\

~ I

I I

. ..- - - + - - - 1 - - - + - - - - - - - - - - - - - - - - - 1 - - - - - - 1 , - - - - - - - - + - - - - - - - - - - - - .
~()13

"

ilnfU." Ov"r, J 0 MilluteS


Relrlgerat2

eli

1
OD [J!1jEAL

%' I

l0/02

FilNOTlDINE 20 11 TJ>.J;lLlIT
1'J.;!'ClO 'J<JI1G TAl:l ;,;QULV

rs
I'LK

I
1

llIdO

"Dose:

20

Mell

TABLET

(ORAL]

OO::':i
CA.G '7T

10/0. nqOIl

l'Nf:OMQCOCCAL FDLYVALEN (JrVE ON Dl\Y 3 OR hT DISCHAJ{Gti

VACCINE

PNlW

I "ACT

lOGE

"i'I";
!~

__ l

IIlaue:

[lloS]

I
Q()07

'.,

,'Nt:'JI10(1JC(;AL VACClNE f'.AS BEEN QRDEREDj

:~:EG~~~ ~ll ~~~CiN~R C:;~E~';;:;"7;\'!:1


t~F.DTO"TT()N' RRpR1f:P.R"TOR.

-t----+----+---~

~~

I I
III

rr.FJI.RE F. ILLI 00'1' TlIE CHl<ll.GE SHEET WHEN C I VRJ'i

Iv/U:!
f'hOil

l>\)I>LUM CtiLOXIlJE BAC,,], (). 9\

.... - - - - - - - _ _ : _ - - - - - - + - - - - ----+--------1----------1--,-,-:-:---. -.-.. "...


IN,1EGTIOll OS!!

I _,
II'

DO::~W':'

O(;~J
f'

'qOO

S!\LINE

[IV]

at

?'\1~

I I I 1------+---+------. --~-----+-!
l\:n(l ,'\teel:

lflll /'IS !?very a Hew-s llnle.33 Hedi-cations Al.'e :Jiven Then .lm! be.f~t'"e.

~jedlcatlQn I\d"'~nl"t,.ation

------+,-------.-- ... "

__ l _______

-,~

__. ____________
U.Q
U. Q '

________________
Lt Thiqll - Rt. Thi'.lh
LLh

____

________

S:ee Codes
W~LL

LT
RT

I ....
~

1.1

AflH

Rf) _ R':.

RVI, - Rt,

Vppe l' Alxl.

LUf,

Lt.

vpper Abd.

!(Li1.

I..t..

RA l<t. hoOWer Abd.

AT'"

I<t.

Lower' At-d.

------4J~~~~~~~~~~----~MARCH,PHILLIP

0524-01

5N

A07?7400691

I
!)ex, 11
~1EL"AVERI,

DOS

10/02/76

Age. 3lY
Dr.

l-~------------jAOOU74 8298

Adm. lO!02/ O GONIi'. N

1-----+------------------------4
DePaul Health Center

Allergiesl NKA

Covers Doses from,

Medication Administration Record

________

~--------------~____________________

10/05/07 00:00 tQ 10/05/07

Prj "Cud' 1 a/01/r7 22: 1)0 23;S~ Page: 1_ _ (more rneds follow .. _ ______________ _____ _____ _____ _____ _ _J

DePaul Medical Records/Phillip H. March

000107

I 1,speCial
",

Instructions: ord~ sr.op I.n:ug/Do""'/HOvi,,~ !t;;9ffiffi_~_Il_t_Il~_ _ _ _ _ rl_t_"r_'f:_.r_ll_It'_nl~O~"O10l(i~ SOl.lLU~l CHLORTriF. lJAeT


NOll~IA1.

'

SCIJ:EDULIID MJ:i:UICATION ORDERS

-------07JJE}O

(COtlt _)

o,n

IN>JECT.iON

IORH
II

'060C'

HO(J

SI'.LINE (IV)
~

Pose,

J "R!:NCH

liM!, Q12HRS
~Mt..

S FRENCH -

Q8HRS

lOML l'If'T8R Ml!IJlt:ATIONS liND TVP1l5 Ir.


CONTlNIJOUS FLUTD TS NOT llUN?lING

"-+--I

-" . ----'---." ,~I___-

S.1lt.: Codes

r-- . _.,. IMi'.R V~r'ifi~d

i~ t.~ t+7"C..--.--~~==~-'-=-=-----------~--.~~:~-=1,~-,--S-l.;<J'-rl-<t_t.;.;~-re-:-~----~---+~----~-+I-o':::-~', "''''


..

-l

LlJ:

n,u
RIJA .

Lt U,C' P,t _ U, Q.

LT" Lt 'l'hlgl1 K'l' - Rt: _ Tt. j'll!

fA ~ f " , hrm RA R~ _ h,"lI\


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Kt.

lipps. Me:1

"'5N
Age;

1M

'u 31Y

"A:::'::'"
Adm: 10/02/07
Re~ord

L~,

Alxl,

,
J

~---~~-------+-."

1 MARCH,PHII~LIP

-----------1-by:
/

I I
,_

- - DOB: 10/02/76
11000740299

8;'1<: M

Dr, MBLY..AVERI, SONIA N

_ _ _ _ _ _ _ _ _-i"'lle,rgiea' NItA

DePaul Health Cent@r

Covers Doses from;

Medication Administration

l'Lint.od: 10/01/07 ?:l ,fin

10/05/07 00;00 tQ 1Q/05/07 23:59

page; 2 (more meda follow ...

DePaul Medical Records/Phillip H. March

000108

,--------------------_.--~s-p--e-c~i-a-l--I-n-B-t-r-~--c-t-i-o-n-B--:--------------Ordff
;3
,G ,'II.'
.~~

UNSCKKDULKD MaDICATION ORDERS (cont./


--~

------------------------------------,
*.~

------~--------------------------~
i

Start
lO/G2
!)l{)()

Stop

Ur-ug/Dose/RolltE!/Comm,mt_"

F! "~l\!<;fl'; Y

QQQQ OnQ
----

on.-l.~JO

f"'-'OO""~ ,., ~ ' ' ,. .


TYLENUL 3Z!'>w.; Ti\BV;-r
GB,

'11h
AB
[ORALI
I
tk~f.'(hx'

l~Jl-<lJ:i~

650 MC/2 TABLET

\
flO11 CAG

to~

ffllld pain Or fever

grell<;;e~-

than Iv1 . ~["

IC/O?
OJ(}C

jliTPHP;NHYf"lRAMlNE

n.x
0027
P;ilL yw<;

IN,JECTrON OENIIDIWL ;C(H-IG/lI-lL 'flU Eoury

qGhprnAs Needed
!IV)
q~hpr~

D1\;:)~

U~S

poee: 45 XQ/O.S ML
10/04 2209

1---JlYDlIOCOtlONlli/APhP
\
VI~QP~1l ~/~QQMG
DOSO:

CH

~~
--

S/SOOMG 1 TAB TABLB'l'

1M!

~~!1!Y

hi
[OUL)

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1 TAB/l TABLET FOR PI.TN

---_.
1)0.;1
PLK

10/0,
210/';'

H?

H'(Ul'/'iJXI'll'JNi> H1..'L Uhi \,;Cj'l ON DILIIUDIlJ LHG!L'lL mil ROUT'!

QIH

--~-9J

A.,; NtJ,-,"iL,tl
[IV]

I Cj;',
I:' ()

'-,

Dose: 1 I'.GIl ML

.- '5:6 - - - - ----------ll
at
I

O~Wl'"

HlI.W.oMOKI'H0Nl> lWJ IN H!l1L

NOFJ1i\L fil\l,IN?;

,'(i~ C\~
' \p '-\)

l\J'0rYlJ
~--~-~-- --

1---+--+--- + - - - - - - - - - - - - + - ;.nr>JTJONIU. OOSE IS NEEDED_

"11_'1-'.S ")W'l ,Y OVRll 1 "II N1ITE REASiE5. IN 10 15 1""!'h'l)'TE~ IF

(,

'!

+'
!
I

~---i----J-----~-------------------------~~------r_-LV

-------i-------------L-~--------._4 Sllf~ EodU!:;l O.Q. Lt, Thigh LT LA Lt. Arm KU ~ Kt_ v.U. p-; - Kt. A"f1', ringr, Iff = Rt i.l]\ "" Lr.. Lv.}'....''P.l ,I\.bd. RUi\ = He _ Upp"''- l\ixl RL.1>, ~ Rt _ [A''''':;) Al;>t;l LUll = L,t. r)pP';l' PM.
=

__

Lt.

5N
Age;

A07274006:Jl

MAR Verifiert by:

3lY Sex;~! Adm; 10/02/C'7 Dr; MELAAVER I, SON!'!>. N

D8Pa~1

Health Center 10/05(07 00:00 to 10/05/07 23:59

Medication AdminiBtration Record


i'Tinted, 10/04/07

no

Page; 3 (End of MAR

DePaul Medical Records/Phillip H. March

000109

SCHEDULED MEDICATION ORDERD

Sp';~ial Instrl,ll;tions:
Oraij r $ta.l:'t

w.o.0731.-15JO
.
[ - - -I
)

------1
lql-~~

Stop

D~l\-'J-:/-oo-ge--;iF.-,o-u-t-e-{7'/c-'o-,,-,n'!p.qtg.

'\~lO;O-2-+---j-'CL1UtIl"I'
;; 0900

Fre.quency

0000'013 o

PENICILLIN
TABLE'!'

TARL1!T

"c:x...'\R
lltAl.)

1'1lEQ

I- l ..

r_ _ _ l
.,.. ......... '"'" .. ,..0-

IDose 1

I OOiT'
1>015
<:liD
l"LK

Iff/'
rf\'f
~

01.,,,, do"

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+ ...

"." ..

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l'hTI E'N'l'S OWN SUPPl.t'l

""'" tency
DlIn.
\)~OQ

MOQ

10/03
NORV1I!1C' 5MG l'M BOVIV Dose I 5 MO/l 'l'Aa"1n'
(ORAL]

11>/03

CS
PU

0700

--+I\MO---X-I-C-Ij.-j.-I-H---C-I,AvtJLAW\'1'R 815 MQ l'MLl!:I' lI.UwmNTIN 875 TABLJIT !!QV


Dose, 8'15 MGil TAIII..IIT
M{J

itD W!MEAI..

.++++++++++++

C\f I t+++
I
I

Ortler 0.. Hold

... +t-t-t-+-++-t ++t++

1>

fORAL]
R/MEAL

. (Hill

I l')/U;':

~lSv
r ."

I
I

FAM01:IDINli: JIJ

TIIRT,F:T !ORl\L)

0630

%30

"lr

ijwJ

1'l>I'CID 20M(; TAB EQUIV Dose: 20 Nell TABI..ST

vl)l'J ", 10/0."]1(;('8 CS 11~or, 2)S)

iP1H;RACILL1N/TIIZO !'PO J 375 GMf~Q ~1L

I'

'(11;

~:

I 03G.

~I
LC

Itnfu.", ov.r;~~~ll,I.I;Ji:Il'---~t""--., ~ "efl.e

fez

IDO:~'~
I

Ip,"n~;JMOr:r'("Al

VACCINB P0LVI\LEN
,l 'll<

t
I

r" Ith

[fPI
HOlJR$

I
0600

i 01
I
I_ _ _1

LiOU

1900 235']-

CH

Oh r.A1

Ar

[)f!WHAIlCE

[UI!

, PNEU

I
I
I

I
f

I J~f ):':-:-;'0702l~l}lm"
I

i
.

Pl\'Elilt:x:nro.L VAO:nm RA!; HERN OlH>l"RED T', Ill': GIVE '.IN VAY J t'K 111' DT>;<:HARGE 1 F RFFDP" C,~y ). VA'}'.:lNE !X;SF'}; NUl IN THh Io1I:PIGl,110N I-!EFRH~"PlnOll Pr,W,SE nLL
)V! THO: CHMIel': SHITET WilEN

!
'

I
I
I
HOD

Ch1

I ('0,)0 I

"'LX

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<J.n

nl.TF.r-r-TO-'N-~-tI-O-f.l-H----jl)~60w\l------lll
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I'm i.

Nt;

EVer}~

a-

HOurs Un I t~HS

14cdica(ions Are (Jiven 'I'll!!" ~ml Detore l'Jld After Medicatil)1l Administration

KCI

]00
--<J-lo"-'.'-"",,--=_f_. I

L
Site Codes

: CH
U

I jtf,L/<:' I .,
Lt.

"''''"u,;- . - =--1 ('itt d~lt:\


----- ---~---~.

J
~ -'

\ I

'U '. Lt v.Q. LT R!), I)", 1rt' RUA kt. npl',:r N:x1

i".

Thi'Jb
Thlgb LLA Lt.

LA

ftc

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U:IWP.l

RI ..
At~d

p'nr

um - u

"p,e,-

'<'---':'~
Age;

J ,OWl.' r

Abd.

/7Jp.) MN/ verifie:!J by, ;;/'"

1= 1-.--------'--'---

0524 -01 5N - - " MARCH,PHILLIP


DOB: 10/02/76

AO'!:d740069l
J.IY Rp.x! M
A'JIn:

10/02/07

AO(l!)74B298

Dr:

/1hLKAVERI, SONIA N

Allergies! NKA
, DePaul Heal th Center

""<-=---";=-=--=--==--r'/W

.d!Mi3.;;'; ,./ ~.
Covers DQs;T"from:

----j

Medication Administratiort Record


Pr ;"ted, lr</OJ/O'l J:.I,UO

RRI[(;ETQN. NO

-------------------

10/04/07 00:00 to 10/04/07 23:59

Page: 1 (more meds follow,. ,

DePaul Medical Records/Phillip H. March

000110

~__~_~__________~______________________UN __S_CH __ED ____ ULED

MEDICATION ORDERS {coot.}

* 1H-2J9

~:-r~---,~--,-----~-'--~--~------

special Instructions: . 9nit S~"n St;\iP grugiIlo5e/tioutr./Cnmmr:llt:J

I
I

I frequency
[ORAL)

0000-07]0

10/02 0100

0,)11

10102
03'::V)

f
f

'~RTAHTNOPllRN

12~ ~l'} TAllLIIT

TYLW()L J15r~G TADLET 110: 650 KG/~ TAeLlIT

Iq4h
As Needed

tor If I I I rJ fk1 1 n thzm 101 511

01

(ever greilter

::;AG
!"LX

Iff.

DfPHENHWI'.AJ1.LNli WJh'GI'lDN tlt;NAllRYl.. 50HGilHL VIlIL f.QllTV Dose: 25 Me/o.5 ML

q6hFrn

As Heeded
(IV]

~T

12W)

/If! /lJ1?
Q4H

OOH

10/03
~100

Ml' YLK

KYOROMORPHONE MeL INJlSCTIOl'l DIWtUDID lMGilblli AMF IlQUIV


OOB&I

All N@f!d@d
(lit)

Cf.l

1 KG/l HI.

DJ-MJ

\::-{

\036
(11

m I i.IT!>
~/)RMAL

HYDROI'lOR?HONE IMC HI lOt4L

~jl ~/$b

SALIm;; PUSH SLQWI.t1 \NI>K 1 MINUTE Ry..,,<;SESS IN 10 -Pi MTNIITRS T I" AnnrTrONAL f'>..')SB IS NEEDED.
--~--------------~--------------+------------

Sit.e Codes
LU" Lt. U.Q. KV" l<t. V.Q.
RUI\ Rt. UPI""

Ul' RT I<l>d.

Lt. Thl';lh Rt. T!1i"h


LLA Lt.

l...'> = Lt
Ill'. - PI wYler hlJd

If-,[

_I-,-n_i-'-_t:~~~~~~~~:i_9~1"~

___ tU_l_'e __ - -_-_-_-_

---i-'::=C':-h"'T"--~-'-c=---~Jl:.L+'~~<Ci!~:i!~~---------l

[JIi>.

Lt. UPPN' AbcL

RLA

Rt. L.:l~I' i'JXl

0 5 2" _ 0 1

5N

A 07274006 91

-11

I MARCH, PHILLIP
-------j-C-----....J_

I
I
!

- . WlJ.l ve l' i f i ed by:

/lJttJ

DOB: lO/02/76 A000749298


NKA

Ay'~:

31Y Sex: t4 Adm: 10/02/0711 Dr; MELKAVCRI.SONIA N

___-,-______--; All&rgies,

IDePaul
[ tlkHXJt:iF.iN, NO

Medic~~iQn Admini8t~~tion Reco~d


Pnn~ed

10/0J /<)7

10/04/07 00:00 to 10/04/07 23;59

~age: 2 (End of MAR


. . -------

QO

DePaul Medical Records/Phillip H. March

000111

ft . . . . .

SCHEDULED MEDICATION ORDBRS


Frequ@ncy

Special Instructions:
0~dfl
'-..
'-"

gt~yt

~t~p

Drug/DuUfl./JlOutl'!/Comment
'.CLARlri
Dose I

I~

1{J/02
O!JOO

.G

.. -------~-+-----4-------+P!!nClt.t.:m TABLI'l' I - - -) I- - -) I
_ _ o.

JOOO=07)0

I
I

.-

0731-1530
{ 1

1 TAlII.Jrl'

[Ol'.ALl

".""Ji' .... ~ .... t .. *-. ......

I jPATIENTS

CMN SUPPl.Y

c::'cl1,Hy .;toss and I't'equency

-0-0-1-'- -1"O-/-O-1-+---!-~ir7CILLIN- CLAVULl\.tIA"'TE--5-7-5-MG-T-I\.il-Lln'---+jj-"-J;l-W-'(:-~-"--+"-"-+-+-"-"+~+-+-+-+-+-+-+.. -++-4+.-+... -.--o-r-=-de-r-o-,, 'Hold


C'S TLIC

0700

AUGMRNTTW 975 TABLP:'T EQU

P__50;
10/02
O~:jo

97 5

I'! ~(l TAllLll'l' _ _ _ _ _ _I_ORAL~_I_t_~:-----t:__._--_ri-.:.,r . _ _ _ _ _ ..


a
KG TAIIIJn'

OOD
CS

P'l\)IO'l'YD.'tNl!! J

on

l1(MEAL

P!N!'I'!i ! OW: 'I'M! P.el'JTV

()

ILl<:
10/02 1900

-t,D_'O_B_e_:_2_0_MG_I_l.,...-T._~_LlIT-:-_ _...,--,-_.,--{_O_RAL __ 1 +-:-----1-:---..


10/08
2J59
(IV)

PIPEl\AClLLm!T1u;o /B:lO J.J7S

~/sO

"t..,,"

XL

Q 6 HOlJRS

0600

Infu5e Ove!:' , )0 Minutes

tf

1200

----\----

1 RefrigeratE! ; - - - , - - - .....

0012
r-.NJ
K

PQn,
!
1

qIVE

on

DAY 'l OR AT D1:SClI.r.RGI!


(lMJ

i lNKO VJ\C i

(~~..... J

PNI'J.J110r.OCCIIL VI\CC1NJ,; HAS tlliliN OKUERED/ TO B8 C f VF. ON n~ Y 1 OR "T DISC'HJl.Ht;1:: BEFORE DAY }. VACC'NE OOSE'.5 P$J7, 11'1 THY-I MBt>l':A'l'lON x),;,',UGERATOR. F:'llA$!l I'lLLI "lIT nil': CHlU,GE SHEET hhL'N iJ!VU{.

Ifj
I

000'1 CliO
V'Ll(

---c-..l---isQ.~l\114 ~'HWRIDIl
I
NORMAL. SALINII

llA<'T O.

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! QSH
,

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RA
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l'\ffH

f!~rm

Lt. In.~..E~gnatu[c

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.

w''''~r

1.1x\ .

Lower AtKl.

I
NAll Verified

SN
DOE; :;'0/02/,6 . - - - - - - 1 - - - - 4 - - - - - - - - - - - - - - - 1 ' l'.oon48 2 >lS
Aye:

A0727400691

by >;I

f"f~.JUW~

Ai

)lY Sex, M Adm, 10/02/07 Dr: NELKAVERI,SONTI\ N

L.-:i! ,
Allergies: NKA

IOI.3!~
DePaul Health Center
BR1VGl!.TI.lH. ~KJ

Medication Administration Reoord


Printed: lu/u3/!)1 ;12,.)0

10/03/07 00:00 to 10/03/07 23:59

Fagel 1 (more meds follow ..

DePaul Medical Records/Phillip H. March

000112

Special
Ord#
,G
I'Ll':

""

.......

UNSCltEDULED MlWICATION ORDl!RS

(cent.)

Instructions;

9Eai:t
" lo/o2

Gto~_

D!'UlJ/Dos(l/I(Qut@fcomment!l
ACBTl\MINOPKEIl 32S KG T1.llLB'I'
,

FrequenGY
q"h

QO~Q'

on_ 0

!l7Jl-1510

1531 2359

,---

0100

TYLBNOL 32SMC TABLET 01;'" 650 MG!2 TABl.1rr


for fI\i H1 pa.l.O than 1~q ,,~

As needed
[ORAL)

0QiL
CAG
I'LX

~ 1-'10/02 0)00

or tever g:re.at er
q~bp=

Il'IlENHYPlWiIINIS
DOlle:

INJBCTii:m aBADRYL 50HG/lML VIAL SOOIV


35 IIC/!)'5 KL
[IV)

Ae.t:::tei!.:;,
,::\.,1 ,-lot)
All ~rl!l!d@d

~yto';
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CAG
I'Ll(

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0524-0l
MARCH, PHILLIP
00&: 10/{)')/76

5N
Age: )lY

A072740069l

S,:",

Adm;

10/02/07

l;AWffill)j(1-'
-

i,iLL..

A0007482913

Dr; MELIC"NERI, SON III N

Allergi.e1\!; NKA

.1QjP7
10/03/07 00,00 to 10/03/07 23;59

1::,:~::",Healtn C~nter
! ARHX1ETON: ."10 _ _ _ _ _ _ _ _ __

DePaul Medical Records/Phillip H. March

000113

. . . . . 011

SCimDULBD MEOICl\TION ORDERS

Special Instructions: Ord# Otar1: Sr.<;>p Drug/DoseiRaule/comments

Freq"<;'n,,'y
"CLAR PRBQ !Ol!J\I.)

0000- Q7JO

G731-1530
[___1

l'i31-2J'3'.i

:0
.JO

10/02

.CLAJUl'Y Pl!NIcrLLYN

TABLET

I ogee
ue: 1 TAllLIIT

---

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1 - - -1
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PATTRNrS OWN SUPPLY ...................... it.;-j-'j.-':ti

clarify
QOO~

do~e

and h'equency
2TIH&S/DA~ +++~

CAG
I'Ll':

10/02 0900

lO/QS
235~

875 MG TABLBT AUGMBh'TIN 875 TABLET BQU


[OR1lLj

XLCILLIN-CLA~Ta

On HQld ++++

++++

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+++~

+~.+

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10/02
0600

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1-'"

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10:;

---

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SN

A0727400691

______~~~~~~~~~~~~v~ ______~

MARCH,PHILLIP
DOB, In/0%/76 Ag(;: 3lY Dr; Sex:

~______~/=~~/a='~iU}~~~_0PO_'._'~~~~~:~=====~__
PePaul Health Center Covers Doses from:

M~ VerHie~ l:iY(yl{\6~~ U .

'-~1\I'_

I I
.

..

~l

Adm:

10/02/01

1'\000748298

RAHM.lU~,ANWh!f( ~

AUel:'g1

.s: NKA

Medication Administration Record


fl'inted; 10/01./01 lI,,:tJl

__________~

10(02/07 00: 00 to 10/02/07 23: 59

------~----------------~-

Page; l. (more mads foUQw ...

DePaul Medical Records/Phillip H. March

000114

~s
I

'---------------------------------.~.-.-*~t------~-----------------------------------------------------------------.

"e c ~a 1

UNSCHEDULED MEDICATION ORDERS

(cont.)

--111

urdJl
l'8 ,i'< FLf{

",. .-

Inetru.ctionB'
Start
iO/ .....1. OHl(\
i

Stop

Dr ugJD ogeJRout@(Comm@nr
'L "J25MU TNlL,,"r ITLBNO

Frequency
q4h
1'.:5 Nee.je<j
!OlU\Lj

0000= 07)0

07Jl=lS}O

1531,2355 ... -_. .. .~~. -.~

ACE' fAMHIOl>HEN 325 1<'13 TABL!:!'

Pos e: 65 () MG/2 TABLI':l'


f or mi 1d pain Oz' fever 'Jreacer tlltin 1 01.:;,
...

drtY

0006
CAG

10/07
0100

!Jill( !'HTNR

n.I'

flORPHI NE lOMe/1ML lIMPULE

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l.MJhh~(L.

052401 5N MARCH/PHILLIP

--

OOB: 10/02/76
AOOI}74B2911

Age; 31Y

Dr,

5 '-'x, 1-1 Adm: lO/(l;</O'I PJlJ! I<!AN ,A...!i>-iER Z

Allergies: NXA

DePaul HeAlth Center


BRllJGE'l'UN. 1'1)

Covers Doses from,


10/02/07 00100 to 10/02/07 23:59

.. Medic&~ion Administr~tion

Record

Pdntcd' 10/0'/07 02,01 Pa9'e: ::I ('End 0 f MAR

DePaul Medical Records/Phillip H. March

000115

24 HOUn MEDICAL/SURGICAL PATIENT CARE RECORD

OCT 08 2007
DATE STARTED _ _ _ _ __

24 ..

PREVIOUS 24 110: Int~k~ Olltput ISOLARON: 0 Special Contact 0 Contact 0 NeutropenIC 0 Airborn!! 0 Droplet 0 _ _ __ SCALf KEY: 0 Bed 0 Slamliflg 0 W/C94i~\l ,P!f;IER PRECAUTIONS: 0 Salety-Fan 0 Bleeding 0 Aspiration 0 Seizure 0 _ _ _ _ _ __ Yuterday's WI. _ _ _ KG TOOlly'i ~ /NG (rinse recom:ile weight d1fftH&IICe IIqreater than 2.5 k~.~
Far.af;

IIPP"

BRos.de gitltose

-Rating S
61' il'Ul6E REV lffM!'
TIIIi~

Time

!III TIMf IE
fnttj ~

Dr
./~'
~,-,.,

rum .IIESP I ffMP

'IME

Bf
,/",f'

Il'1ll U IlIDITi !MJlA MTHD

//
"/,,
~-

/:.7

es~
" t.kL'II
TYPE

//"

--~
LUNCH I

//'/

a
U
DINNER
lIRlNE
Amount Amount

i TIME
BY
/.-"
~/,,,

TIM
P

STATIC

>~-

.--/
~.

Bf'

rDU~fib

~, OlllOlVa
Fun~jjDn

r--lllcalion Eltlla,lor
f--Uuailly

--'/

//
HlI ~ 'At!(

8HEM FAST

,,, Count i - _ - t - _ - - +_ _t-_A.m !-----------c+-_____ -; ,_ount-+---A--,-,-moun\,-\-A--'-'..ffiOun-,--+i_Am_ounJ f7


;

"""'" --

ORAIJTlIlJf ffEDINGS ORAl. TF FLUSH ..

OTllfR

r-aM
Fr&Qu&nt
'-----

I\moll~t

Amount

Alli~VI\1

Aml.!Frtlq.

Aggr3'1t1
~

""-

18:

S~d~lion

190
;00
110

:
i
I

-'

1230
1300

--~----~----+---r----1---_+---~----~----+--

Intervenl

In ruin

i--.

HOD 1500 1600


-

---

-.
'SfHAV
AN
~Ar

CiiMMi

1HO 18DO

.__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ..
--- --- --- --- --- ---j

Sub

12r"
r(}1aI~

1~ hr Tolal Parenler d .. ___


ToCO(Ini 1900 lOOO
21l1li

i Hr Tnlill i'lrai}iune _ __ .----~---l 12 hr Shilt Intake

1? hI SMt Output

E:= tme I .. h>ef!,

t1-o..,

----+_----~--~----_+----~----~----+_----~--_4-----

e----INTER~

2ZIl.o.

2, Aa<!lt a Guide

1. A~.."

2JCa
0100
C300 .64UU
--~---4----_+----~----4_----~--~~--_4----_+---~----+_----~--~----_+----_+----~----+_----r_

4,

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5. E&lab

... --

6. Ene<
7. Ent<l4

~ .~
Patl~ntI

121lr
SuoT~\.lis

- - - - _ _ - - - - _ _ _ _ _ _ _ _ _ _ _ _ 1_
12

Interveo'
--- --- --- --- --- ---j

12m Ma!I'HI'l!!ielli _ _

nr Total OraHllba _ _
12 III ~jllH /IJldk~

r ---,n.",,- , , ... _, IOlal

;--.-

Respom
-

TWfnlyfllUf hour t~tal

FWID EQUIVAlE,rrS: 1 ar ...... 3CmL

4 oz (1/2 cuP) . 120mL (j oz (3/4 cup) " ,180mL

801

(1 GUP) . , 240ml 12 oz (5008-1 call) " 360ml

PATIENT LABEL

o IT't'SSM
H
I[

A \. f

tI}. 1t [.'

DePaul Health Center

DEPAU1., HEALTH CENTER

24 HOUR MEDICAl/SURGICAL PATIENT CARE RECORD


DPM-1 QOO-()11 (W2007) PAGE 1 OF 6

fo1l\RCH, PHU,LIP II I? 0727400691 MED 0524-01 10/02/1976 31Y M 10/02/07 MELKAVRRI,SONIA N 000746298

IIIIIIIBIIIIIUIOIIIIUIII

~
DPM-100

ti t: ... L ] --<-j

.. ~

DePaul Medical Records/Phillip H. March

000116

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

17 ~pioo,"1 18 PeA 19 Preemptive

Na
~ Sit
Sit
Sit
/I

;,
APP", lI.Ssllrr.e

pain plC".,cn

Ikhavior>
Tlm~

20 Continuous annlge,slc !IlluSIOil 21 othaf'

~n'!YWI'

flallllll S(;ore.if
~V.f~ l1K~

gr

OllSll\'lIllon funtllon Goal #

Demille: location,
Bellavlor or A'P
Qustlfy
Fre~lIency

A\l\lravallrrl) FIctors

Sedalion bvel
Inlervenliarr(s I

Inili!!&

BEHAVIOR I PSYCHOLOGICAL
BEHAVIOR,'RESPONSES:
M
~

Muiliple Aequ ..t

AN =: Anxfoun E = Emo~"n.1

C ~ Conlinuow Crying

I-

DIOI190<; tnil~clivl' I) ~ D\IV;lQpln~n!~llmpa"m~nl

copin9

DE _ aOplon!?/> G ~ GrI!>Vfng
l LethaTQlr:

co. ComMo",

u - (ffln'i\>Q1l5;Ve

co -

CQn1\JuatDi.Qrtinlllll

OP - OillUPlillG

H~ l-/ailu(lI\atiOll./ Oeklli~.
W - Otlflb"!ltGly \VIIhlloldlng
A Mention Soaklflll

OS
"I
~

CI ~ Cognhlve ImpDlmteN R ~ Resile,., o Overstimu!ateofOvEt(&amive

= Oisrupliya

P~II1inl

1m"

Slgnmcant Ot!l~1

1M ImPlllij,'9 S = Sleeping Q R Calml(Mel


CO p
LA

1hrtanlng Physics! Harm/Comb<lU""

= las. An<lo\l.

~ C~p9'&1tv.

INTERVENTIONS: I, fI....urar~b P.t,em! Sf~nrll~~pl


AtOtftCliQ>' QulUlne. 4 ConSiflMI E~v!ronmonl J l1oU1;n~
~.
2~

Olh~'

6. II, 10. 11

12 e-a.1abUsh rn-eintAfned tfmt1'tfRmas for cafe need! 11 it E.ncouraQl+ vorbafil.aHof! 7. fnc-ouf~f' pa,lItJfll with tt-oc&i-o:-n makiHQ for cata naoob

1Ii, pr~yer, m.dicallon 17. Erco(lflll,}" no,rnal.l.ep cycl. by ".mglnlll,act Ilgl\lIog da'" 16. Dar'wn fOom { Umittng touch f 19 OU:ie1liiyn to owruafi6 paHtJltf6 rOOprntS6 to sUlnu.iallorl

Offer IreqlltfTI ~riaf ~ont.~l Prowe intormiluon ", m~f\I~'9 Ityel of un(/~r.tandlr~ EncoulI\l' t~jly 10 br,ng in '"miliar PrOVide feclllJ(alion with musIC. Im19"'Y, deep or.allllng,

1~,

A.orlan! I flamollval. i Ae.laltnij 'aol.


VMf<.lonal aeliviloe. Pr,,"otiV8 mUfuro. AU.~, II1t(julion I S k clari~cal"''' establish bo,,"d,,(i~ Provide if1t.ansiv9 MK!tlrily IInri sAfety fflflRF..UteS to m~fljmjz.lt Infhavloral pmulems

otj.",.

1~,

ott.,

PATIENT LABEL

~SSM :c
., ,
~

L- l' H

Ii Jt ! ..

DePaul Health Center

10/02/1976
HELKAVERI

PI~!fl!"DUD 0727400691
MARClJ,

DEPAUL Hl<:AI 1' ~ H CENTER

111111111

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD


DPMl00(}.()"1 (7i2007) PAGE 2 OF 8

s6NIA N M 10/02/07 00074829B


1Y
OPI

MED 05 24-01

lip

DePaul Medical Records/Phillip H. March

000117

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

24
ACU
Poin 26-3

38-5
Site #1
56-7 71-8 84-9

SKe #2
Sr.e #3
it 01 attempts hi IV rcstarl

96-1 121+ RE(


NOTE:

FRONT

RT

BACK RT
N ]

(~

.$1. -5iog.'Ik1fTll~

)
Ii

~:c=_r.;::~:;

f-----{-=S:":L=IQ=L=I=T=LC=+=-====+S'::'L-=/=D=L=j=TL=C+~===+~===j
P R

w
x

I rl
t~,\~

j//

insertion - Date _____ LenQlh _ _ em

Dressing change data ______

:z -w

>-

CS :r::

II

DEl'AUL .HEALTH CEN'rER

t-lARCH, PHTLLIP

JIIIIIIIIIIIIIIIIIOIL

liP

~SSM
iif'ALIU tARe

DePaul Health Center


a

0727400691 MED 0~24-01 10/02/1976 ny M 10/02/07


f1.1ELKAVERI,SONIA N 000748298

~
H

24 HCtUR MEDICAl/SURGICAL PATIENT CARE RECORD


OPM'1000'{)71 (7/2007) PAGE 3 OF

DPM

DePaul Medical Records/Phillip H. March

000118

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD


Patient Care Acuity Record
.-----.----.-------------------~.---.--.

DATE STARIJ~T

0 8 7007

ACUITY LEVEL

ACUITY TOTALS Subtotal SectIon "A"

Points
2637

Level
1

Meuicalivn~

as-55
56-70
7183

Subtotal Section "8" 2 ~--------------------~_+~ 3 Subtotal Section "e"

.MI
t

'FI us oolt Ie

L""" .vitlivu! Medicalivns


~

lirJ! ,.-'>l!,
Ql

..:"

Annrnorh""

[7 or more)
(~\

8495 96120
121+

4 TOTAL POINTS 5 r---------------------~_+~ 6 ACUITY LEVEL


7 Sitter 0

+ \lar in! IAltlcalMs

+ huIll!lle

\/PR'. anli IUP'"

+ on'I''''''
t

+
led

i.,-+-=R==EC=U=IR=E!;j-FU=RT=H-:!:e:-:;::-R-;:o::::COC==U=M=E=NT=A=TtC=N~-----'-' NOTE: If more than one item Qn " line, circle the ~..rvic.. indicated.

~ingle

+ MUl1lDle
EmI)llOR: ~)lIrt

~r~lce
1-1+u\Js
t
t
'e~{

/
hips
I ..

Dnerrtalton to Unit

10

Intake & : wllll meal!'S~ up tray . OuIDuI


..
fln( udes CaIe of tile tulle)

+ Emotfonal DIstress
+ OcvtiopmerrtaJ Impaimlent +-cQvnitlv~ Impalrment _ .....

. ............-... -.--------+-,!..::...-1f--.:.,:,~
Crying

il

I cnllre meill time Otal fe04: r....u 01 more meals

~Mtiple

e.aohmo Iutr ion

..

,ou
l

Care

+ + _ethil!uW 1+ 1+ 1+ 1+ 1+ 19UIlilf
I

. . . ---"-':':::0'-+---'-" o'--l
10 10 10 10

, tnt t sedated)

lIlO

If1\! Imormallon
I <t'
\JC

+
)then;

,en "'uno

Ball! with assist

I+

I: ~actl!lD
1

!tllarene
I

. i2 .t: ll.!e~[So=!JSi~ rooul~[()dl'-----+-.:;;--:'+"...;;-},....,


,

I+

ht~Rl~r

19.
~1I8nt

iel1ew lall of C re \\ til

Ino

no

+ Recelitive

!laths

.. - i----

1------ - - - - .

I I .. --~1----------------~1~----------__----~__--------__--__4
I I
PATIENT LABEL

~SSM
I'IEA1.Ttt

(AJl.I-

DePaul Health Center


a

24 HOUR MEDICAL/SURGICAL PA.TIENT CA.RE RECORO


OPM-l000-071 (712007) PAGE 4 OF

MRD 05 lip 10/02/1976 31; 24-01 fIlRLKAVERI SON);' M 10/02/07 , A N 000148298

MARCH, 0727~00691

DlmBlllliTH PHTL~I!""'II

C8NTER

DePaul Medical Records/Phillip H. March

000119

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD


KEY: .f WHt:$ or task completed

DATE STARTED _ _ _~~__

* = See addiUonal comments

Use bolded key letter if indicated

OCT 087007

Ii,
I'

Specify ahnormal breath sounds on diagrRm.


(A~ent. D~reaw~.

CRackles,

Rhonchi. Wheezes, coarse)

POSTERIOR

POSTERIOR

DEP~UL HEALTH CENTER


tJiARCH. PHILLIP

1ll1111111111"11I11

07274006~~ t-~D lO/02/197bS03~lA


MELKAVRI,

524~Ol ~ 10/07./07 N 000748299

Ip

SSM DEPAUL HEALTH CENTER 24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD


OPM-1QOO-071 (7(2007) PAGE'- 5 OF 8

DePaul Medical Records/Phillip H. March

000120

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD


KEY:
,I WNCs or task completed

24

= See additional cQmments

U~e

boltled key leiter If Indicated

Peripheral PUISf S
AAbSQflt

W-Weak

h&al
Ul1I1a,

'-Strong
I)-Doppler
ColQr temp sen laliar)
VlIi'_ - Ul, boo p., .. cap ~V~., ~ thifl :~ Ij.~'" U~tP..., , S>.ffl w.r"l VlJ\.~ lui te~il'
[N,nl II)

Is llaJr
Unne FouH

; oon I(i tw:h


9

YOW,

atJrC"mal n note~
~r-IOM

SUpra
AbMr Freq'J.

T = TracR 1 -1+

em (d lIeo (:{

1 - - - - - - - _ . _ . _ .. ---. _.
Sandbag _ _ Ills. Site: _ __
(Temp, perm) 5[6: _ __

Bilateral

13 '" removed

If Ski

~
~

---

~SSM
fi E A l. 1 11 ' ( A " i

DePaul Health Center

~!!~J~'~RUI.tn

DEPAUL HEALTH CENTER


IIF

O!

...

24 HOUR MEDICAUSUROICAl PATIENT CARE RECORD


OPM-1000-071 (7!2007) PAGE 6 OF B

0727400691 ['tED 0524-01 1U/02/1976 31t M 10/02/07

MELKAVERI.SONIA N 000748299
DPM

DePaul Medical Records/Phillip H. March

000121

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD


1(1: ,/ WNt i or lasl< complf.11ert

*=

DATE STARTED _ _ _ _ _ __

OCT 08 ?007

$00 addrtlonal comments

Use bolded key lanar " Indicated

Alit O,l
Gel
Adl

Adl
AAll

81j1l

TV

PI:
As

an.
fie Re
Flu

Tui

Re

------t-t-:-:::t--t--t--+-+-t---t--+--+--+-+---1f---t--++-+-+--I-l-+-++-l
Irs on' R I L
Bllat~al

AlIlI
I I

2 ( 3 !
I

4 I

5 I

AlTfllED SKIH/WOUIIO KEY:


PU - Pressure \l1r./ II pre.sure ulc~r, 1i,1 Siagli I. II. III. IV, UNSldQeilble V - VascuiRr ulcer (veoo~ sta$ls. ar lerial InwlilCiellcy) N = fleuropal'nic ulcer (diattetlc)

A = Abrasion ElL = Btisrer BlI - BrUiSC D = OarnidM E = Eryl!!tima IX = ~,r,(lri3fion H = Kem~1Dma


Surr~ufldln9

= Inctsllll1
- Liic6flItion
=

fi I

L R
TB

7 I

Tape oom WA '" 'Ilea approximated


-

Rash

9 1

Ret.

= Other

Drenlno:
55 D
~

Wound 5W Key:
Ii ..
t.~arHJ~Jbi'}r.

Sic" ';uiVo
Sla~';\",

= tntar1

Skin Key: OralnaOlll\'pe:


G
$

- Dsrm31JlinO

S
E

- Sl<lvgh
:::c

E - trWoem.
M -;:; M:Kt!n1ion

OTA = Open In air ft =' flelenUon 3uluftS


Df
= Ilry .lrnJ 101"_1

II

= ('JlWl = SflOUS

Or8inaQQ Amllvnl:
SC

Ro
Rn
A~

= ,,".,01

S
L

- Smal
= lllfQe

{tidl2.1

o -

88 = SeroS;tnlJ1'C<efHS III

= MM8(;l!a
- CfWI~"

G1haT

o-

C - CY3fiotleJDar1<
gUI~1

PU

pv!ul~m

Po'

I
Y
C;

- Woolly
- Yeiow

C;

Hi
Ca
0\1

M
o

=Monioomery 3lrap.
= Om!'r

o Treatmenl

= Cl""lr

O!htf _ _ _ __

Iinoieate, Rean8umsIJI No ChlflQe lima Ind IIlltlal1

BlI
TQ

Sit

10
All
O~

!sf

~SSM
H
. , 1 He -

-~--~-~------DEPAUL

DePaul Health Center

HARCH, PHILL!P

11I1I1.UIUIII.!uI~

HEALTH CENTER
IIp

(!
HI

0727400691

24 HOUR MEDICAUSUROICAL PATIENT CARE RECORD


OPM-1QQO-l)71 (712007) PAGE 7 OF 8

MED 0524-01 10/02/1976 3lY Tv! 10/02/07 r-mLKAVERI,SONIA N 000748298

OF

DePaul Medical Records/Phillip H. March

000122

24 HOUR MEDICAL/SURGICAL PAT1ENT CARE RECORD

MEDICAL I SURGICAL RESTRAINT KEY


flIWICAL f\eawn Il!1 Rc!lmln!
e(~I)'lPlf::u}l1m?lSu~&OO

GI\o!liI' III I!1imll"~~ ~s_1l!< IrH\'ll, r.eeo fe' w, n, ,~,.) tITMU1ffi1lillaJ nWlIII'..mQrr~ (r~ar rww> ~HI'i'ln, sp<'m
,;:;! ~'l~. '~~j
"~l1fur-.ttITattO:l

P'I)i<lt'J'" a.11lW air'l<.y 0011'0' !l:<voeR O~ry (e.g., !O


m~ ul1dfJ1rJ.l..'lt;te~'fI:JI~tl~eJ

flU\[lflll ~911H1I? iJocu""n' trrM aMi !tame, (i.e,: 91..


P"tfUHf. ~;lt{tn!iil...

lIlal 6e"2Je Kex UrOO!t Til ~} lor s;My

lot!4%.)

atc..)

M~Ul,1ifi im.,il~ krr.,; if.~. t<MtoliillQ Ulf ttelw-Ill 01 t~~

(,(1 in OOi>:af.rm "'" imiG<!W" followtq


nm~

omRuf tnr,,1iH.l.1H (ft. 9., wto E{]Jil(..t me-cr~c~0::11d!lr1fli"!jl!dl;lJa I.J hyd,;tht'llil


~Jtlt:s")-'

of n;;trfWt),

di!MstG wrm i')Mner

2 Cent '" PIli '" Ilk.", .. '"'. "Ic ~ "Hr~ty \UI1l(!jU1IiIM !W; (,f relll\lrr
4 M~ IIJ rll"""" "''''''"\()'. J;; !i COCil6lll1iYe aM r~5tront r(f'OO)'w S Of hunll tlJ ';cH t~ iJlhl;::! s; (f..P.ll fiP.h:i'r1flJJ!
R!}str-a.fflSj
Otn~ !fNIUlTS mnati~r

~SQllfiif(~slr""l

e-Yavalion OiYU(ll)IIa\ mm,." (MClruP$, v~.~;. war.<s, mu,;" <Ie \

Me~{Jlioll

'i

nll''''.r{, wlm.Fa .. ~attalf(j Iroln an iIlNry Q1 S<JtQca! W(J('OVUI" who \'1m") "vlh)! iwlll8' ;,'py rt tt$Y haw ~'Num
"i!~ly

AS".65smant I!JM Iramas


T,;;d fJ;\a.,.. lmqtlllfa:;y
~1Ot rCQUifctl fur f-CimWill

M*"'' '

InCwmti1l a~'(lIf Ills nWk~( 'p;liop"n(<: (U U ' ",ben..,y

Ir "''foJfes Of ,OUlaJ' s"~rirll

o BEHAVIORAL nrSTllAltiT$:

d_tlt't!ure:ul.lltNl)

~I

~I
I

B
g

Bee = BMSUIA Cnmmooo

= 8~

PA TINT LABEL
POSITIONING

o-

= Am1JtdMfl = [fane
C~alr

KEY

DEPAUL BEAr,

~SSM

W I A. l 1 H . tAR , ..

DePaul Health Center


.~~~~. --~~~-

MARCH, 07~7100691'

11111111111 CE1'lTER PHILLtpllll1


3~~D 0524-01
M

lip

24 HOUR MEDICAl.!SURGICAl PATIENT CARE RECORD


DPMl000071 (7/2007) PAGE B OF B

MELKJ\Vf>~JU SONI
,~

10/02/1976

A N 000748298

10 /02/07

'"

,---

----000123

DePaul Medical Records/Phillip H. March

24 HOUR MEDICAUSURGICAL PATIENT CARE RECORD DATESTARTED PREVIOUS 24 vo; Infaxe J70~ Output ~e...P ISOLAnON: 0 SpeCial Contact 0 Gonmct 0 NsutmpflniC 0 AlrbOme 0 Droplet [J SCALE J(F{; 0 Bed 0 Stooding 0 W/GhHIf 0 Sling OTHER PRECAUnOfiS: 0 Safety-Fall 0 Bleeding 0 Aspiralion 0 Seizure 0 Yesterday's 1111. _ _ _ KCl Today'$ wt. KG (PleBse llIl;ij/lCUe nlDbI dllfer&nc:e II grealer than 2.5 kg.)
T8~
PlJist
....

10 -J-07

_~_ _

24 H

lln~7)
irn~~

~"DJl!.m
1

iJ;_ _ _ _ _ __
:I(

Funclion I
DIIECriblJ:

loeatian.
O'OlVior
au.Hty OflAlITlIBf FEEnINGS TF fLUSH _~mQunt Arrnlh'11! Amount , URlKf
Amount Arnouril Amount

DTIIR

tyrE
To Gount

I-l.\f(f")

10m

11M
An1(J(lO!
AmD~nt

Amount

ArrdjFrsq

0700

11/JI

0900

O_8_00_-r---.-r----~--~--_;-~~~.\~--~

.01'""'\

1000 1200
1300

so

"'
l

\0-A J

.-

Sedallon I
'nferventh

1(,/ 1

~~bh~ota!s
To Count

_________

rr:t Q
12 hr Shiftlntakl:

'___

I_ _ _

pt!.AJ;J7~ ______
12 hI Stlll\ Outpul

1, hi TOlal Pilftll!erill _

12 hi Tnt!1 n,r:~:II,{f .:... ",,,h~PL-::-=::-;:'_ _ _~

~gOO

3 0ltO

.. _ -+---1----/-----+---1---+_-----r--~----+----r----~--~-!
-r----+-~--r_---+----~----+_-

~oo .22011
~

~: ____ -+:__~r___~--_+_ _~~_ _+i


---~~~~~----r_---+-----I-----+---

t;e>

:
I

-- -+-_<~0-t-~_+---t-_ _+---+_
0600
Pllr

StloTotals - - - ~----------~a'C1HCral

I<oil

--I---~

- - - ---- - - - - - - - - - - - -

12 hi lOla!

__

12 hr

Tol~f Or~VTuhe

_ __ 1,llr SMtln\akc r - - - - - i

12 hr Shift Ou!pul

.~U",,

"" .vv. ..u.

l.s~O

Twenty-IOUI hour lolal

FLUID EQUIVALENTS:

1 01

..

_ 30ITi

4 01 (112 cuP) . __ 120ml Boz (314 cup) .. 180ml

8 01 (1 CLIp) _. , _. _ _240mL

12 OZ (sooa-l can) _. 360ml

DEPAUL HEALTH CENTER


lip !>lARCH, PHTLLIl? 0727~00691 MED O~24-01 10/02/19 7 6 31Y M 10/02/07 t-tELKAVERI, SONIJ\ N 000748298

~SSM DePaul Health Center - - - - - ...-----------------}t

11111111111111.

e " L T n

C It J

e"

---:-t\J
!'~~
DPM;ooa

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD


DPM-1000007; (7/:!OO7) PAGE 1 OF 8

DePaul Medical Records/Phillip H. March

000124

24 HOUR MEDICAL/SURGICAL PAT-=-I:::E=-N-=--:T_C=A~R~E~R=E~C-=O....:....R::..::D_---.:::.:.:.::..::..:.:.:.:..:.:~===:::::=::::::===;

17 Epidural
18 PCA

19 PTeemptlve
Jn~lge~Ha

UP", Issume

20 C{)IlDI1UQaS

r.JIn pr1!!.et\t

ana1gesic MluslOO 21 OIlier'

IIl;haV1OfS

11me

Scal~

li6C1 or

ObfflVll\lO'l

Det~ibe:

lD~i\l!ln.

B&llavior 0

Friqllincy
ABgrlVl1il\<J Factlln;

SOO3mm lll'lel
Ift1ervulloll(!)

fnttlals

BEHAVIOR I PSYCHOLOGICAL
BEHAVIOR/RESPONSES; AN .. AnxtIU'
E - EmotioNI
I ..
In~If&C' Ne

Oi.tr.~.

III = Multiple Rt<j\lU' C .. ContlnUOUg GIVing DE _ [}apmss!on


G., Grtaving

U .. V",osponlSM> CO .. COl!lt~l.
CI _ C<>3l\4JO& Impalrmen!

H ~ Ka~U~NltiM,r Delwiens W Os8b"lIt&1y Withhold1rl'J


Info A AIt'tot\Qn

co -

CcnllJ..<IILlI"orilmtad

DP DimUptiVD Patient

OS .. T

Dit.fllf}lI~b

1M - Impulalv& 8 - Stooping
Q ~ Calm/Ouial

Sil/nincant otll",
~ Thr&al~ing

coping D Davelt lpmental ~m palrm-ent

L = le\h,;'gio
Oth~r

R -R"""m'lS

o _ OV\Jr~t'lmutatedlO\+'BrBRcllve

Sft~lng

Physical HllrmlComlllli<9

CDI' CooJ.,,,,all.a ~ -l.lru!

An'''''J'

INTERVENTlONS:
j fleau,"al>C~' Patient f Sigl\1fteant 2, Rat1lr8cUan a l)uidaflllS 4. CO"";,,, m! Environrn.nt ! Routine

8. 9
1Q.
j

Oft~1 fril1!<I,ml brlilf oontact 14. Provid-i' information to incr-8aiB lewl of Und6>f6Iandi-ng 1!!I El1CO\Ira~$ fAmily 10 bring in familiar cbjects 15 Pro,to. '~IMallon wilh mv.k:, ima~.'Y. Ii""? br~;Uhing, praYilf. mvoicaUon 17

R.",tent i

R~I'I\Otlvote

! A9$!allng IMt.
I Sock ciRriflcolion
rneaS\ire~

Divlill'6kmal ae-tivltl00. Proaoli.... rna.suras


~8aSS9SS I R~qua.\ion

5.
7

ij, encoumg$

E!itabi~h mall1lulHa.ti Hma;ramos verVwiZaHon

iur cam

rmed~

'2, Enooura.ga normal ~Iwo -cycie by usIng In-d"1f.tt lf9hllng after datil.
13
D.a;kon room l Umning tOUGh l QUf&l slgn 10 dOOfe-aoo pahani':r ro~PQna.a to s1imufmfnrl

, 6 Esta;l)hstl oot.mdaris6
19

PrQV1=e int,"I1-5}\'i iecurity iinfJeafe.t)'


to mtl'\lrnlZe t-e-hlviOfi\J pfo-bfCJmSi

[nCQUfUge palfl.9nt Yir1h (;fi'CI$fOIi mahi.ng tor Qa/Q m~ud&

PATIENT LABEL

l
(
I

DEPAUL }!EALTH CEN'I''.!.R

~SSM
KEI'-Lri

(;I'-fl.('"

DePaul Health Center

I IP MARCH,PHILLIP 0524-01 on74006:H M~D '1 10/02/07 MELK.J\VERI ,

111111111111111111110

2< HOUR MeDICAL/SURGICAL PATIENT CARE RECORD


DPM 1O{)(Hl71 {7i11007) PAGE 11 OF 8

lO/02/1976S;~ip. ~

000748298
c'

DePaul Medical Records/Phillip H. March

000125

HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

24 H
ACUIT
POints 26-37 38-55
56-70~

Silel2
Site #3

71-83\ 84-95

96-i2C
121+ + ReaUI
NOTE; If

- ------------+-1-+--1
II 01 attempts lor IV (estal I

RT

(r--

, ),/,
I /

o
tq~

5
SL I DLITLC

u
v
Dr~sjno

w
x

trA:al1f;f) nf

RIGHT
p

!l~
f

N041int pr~i1fJf{1

lnseltlon Oat!l _ _ _ _ Len!]lh _ _ em

change date _ _ _ __

vlW!

PATIENT LABEL

DEPAUL HEALTH CENTER

~SSM
" i Ii t. J ti

<:"

Ii E-

DePaul Health Center

MARCH, PHILLIP
0727400691

IRlIIIIIIlI1IUIIIIII~
NED Ob24-01

Tip

~
H

24 HOUR MEDICAUSURGICAL PATIENT CARE RECORD


! DPM-1OQCKl71 (712)07) PAGE 3 OF 8

10/02/1976 31Y

M 10/02/07

!>1ELKJ>.VERI,SONTA N 000746298

2'

DePaul Medical Records/Phillip H. March

000126

24 HOUR MEDICAl/SURGICAL PATIENT CARE RECORD


Patient Care
ACUIT'! LEVEL ACUITY TOTALS
A
P

Record

DATE STARTED

{O 0 -0-:3

Points
2637 38-55

L~vel

Subtotal SMti<)f1 ''N'


Subtotal Section "8" Subtotal Section "CO
7

1 2

E;V-t
B~
I

56-70
71-83

3 4
5

8495

TOTAL POINTS

96-120
121+
NOTE: If

6 ACUITY LEVEL 7 Sitter 0

+ REQUIRES FURTHER OOCI)MENTATIOtf more lhan one item on a line, c:irclo !he servfce Indicated,

..

11

DBl'AtJL HEALTH CEN'PER

~SSM
HIiA-"TK'CAh.E

---

DePaul Health Center

, JIIHmi1l1J1fltfi1lf1111N .vtARCR, PHTLLIP


0727~00691

rip

24 HOUR MEDICAUSURGICAL PATIENT CARE RECORD


OPM-l000"l71 (7/2007) PAGE 4 OF &

MED 0524-01 1,010 d /1 97 6 31 y ttl 1 0 / 0 2 I 0 7 ~'!F.L1CAV8RI, SONIA 1>1 000'74A298

DePaul Medical Records/Phillip H. March

000127

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD


KEY: '" WN l:s 0( 1asl<. rompleled

DATE STARTE[l

0 ~J -6 2

* '" See

~dditiomll comments

Use bolded key letter if in\licated

Confllsed. Lethargic.

~
fr.

,\\

Ire
01
01

s
A
Specify abr ormaJ breath sounds on diagram. (Absent. Decreased, CRackles, RhonchI. V#lMieze$, Coarse)
B

H
C

A
A

,
L

B B

s.
[

Ii
T C

COmmiJnt,
PAT/HIT LABH

Time

Loclltion

WHlw ~~

C C

SSM DEPAUL HEALTH CENTER

24 HOUR MEDICAl/SURGICAL PATIENT CARE RECORD


DPM-10*J71
(7/~007)

PAGE 5 OF B

01

DePaul Medical Records/Phillip H. March

000128

24 ftOUR MEDICAL/SURGICAL PATIENT CARE RECORD


m. ,f WNl:s :If task cumpleted

* = Se'i! adrjltlonal comments

DATE STARTED

ID~

)'01-

USlJ

balded key latter if indicated

KEY:

24 I .I;
I

Pertpheral pulse';
A-Absent W-WBak
S.SlTong
D-Dnpplsr
UIiIl8 c~
isp~

FautH

Color temp sel1"ation


,"lel ~lIaIl>eUpI/lj;:C$ii "US ~S! 9ian J t<cl no, slM Wam'I 'k'l'ih M !i.e1S~

Urilla c(

'Wl-sn
Voit1ir<\l

M 10 tJlf.iI U.!mt.
itMnNHn r<>:.!!

Iliprap
AtmOfm FWllJat CAl {deJ
UIl1JCCII

D = f/{Jo. T - Tfece 1 = 14

Suprn P

SklOW1.'

Jnulldic
DIa~ MI.!OU~

Skin iflt1 Haslprr


Wwnd'

If skin'

OStomies; 0 lIe)s!o1llY 0 COlOstumy


Stoma red and
IT ois!

Appliance intact

~SSM e1-1 f A 1 , Joi '


!; ,

III:

DePaul Health Center


DPM-H

24 HOliR MEDICAL/SURGICAL PATIENT CARE RECORD


OPM-l000'()71 (712007) PAGE 6 OF 8

DePaul Medical Records/Phillip H. March

000129

24 HOUR MEDICAl/SURGICAL PATIENT CARE RECORD

OATESTARTED

ID~-D7

24

AmflEP 8KINfWOUND kEY: PU - Pressure ulcer

= Allra~!on = OArllldw

8L

V
N

I{ p((:c~wrc UK'Jii. list SIalIC I, II, II" rv, UN.~tilgAable V'd3tul&/ ulet:! (VB/lUllS Slll>lS, i!llllIi~1

Gislsr BR .. Bruise

=N~uropathic ufter (diabelic)


G

i05ulliciantvl

E .. Erythema EX = FlI'corialion H = Hemalom~


I

- Rash TB = Tapa burn WA =- WeD ~ppr~xilf!al~J o = Qlhllf _ _ _ __


Dralniljj6 Amount:

I L R

= 1rn;ISIQn

Lacerallon

DremR\I: 1111 : "I.n <lI1r'"


D IS

Wound Sed Key: = t-=Jt .l:1111,~1IOn

Surroundl"u Skin Key: Drainage Type:

-~mtbond St~l)les

= Siougli
~

= lnlM;1

f-sct",

0'"
'" M

OpMloail
Rl,'1~TlliGlr YI~lt'

'" = PA;u;ernUI)f1

= Erythema
Olilln

G = GrAM 81: $ = Seroos $ 8$ = Serol'<IlrpiM1)1!t"

= SC,1nt
= Sma!

: Mru1"'''le
a

OIMI

o-

CranOlle<'Oari<

PU - Purularll

, , - LlIge

It
Y C

- 61l1'Jli,(
- W-Ilow = Ou,lv

C~~l!J\l~

Df

- Dry and intaGt


~

o
Wuund Bad

MU!ll'IV"""v .UaJ>
_ _ __

-Ol~E<

o -

Other _ _ _ __

/ Inrfioalel

Rta$$enmell1

No CIIllI9f Time amI Initials '

L-?-t~-L T-L"-$--~-ML-._-D---Le-R-"a---"uL-l-R--1-e-'a-l-tAL-'J-C---'-en-ter--'--.....-L---~~~~!~P~~~~~ 24
24 HOUR MEOICALJSURGICAL PATIeNT CARE RECORD
OPM,1000-071 (7{2oo7) PAGE 7 OF 8

DEPAUL HEALTH CENTER


01 I

IP

OJ
H I

1~/~2/1975 3l r1 10/0')/07 MELKAVER1, SONIA N 000748298


DPM-

DePaul Medical Records/Phillip H. March

000130

24 HOUR MEDICAL/SURGICAL PATtENT CARE RECORD

MEDICAl R"itD' 1m Rpstliilnt


1 r,(Jl'il$hAHionst'rl'"'&JOOf"'l5l(1l1
Gh~ i)l ~f ffi;t!.' -tt:fh:1~:mw!

""'fjY'! WURhn
Q

Trla[.IltlUE..ru
1 l.h:'ij)~ t~} uUH1r,y,,::1 io!

Crlwrnlm:wt.i

HllW'l~AJ~J.o-f,-'-'

R:t (r~f;~, nt.M 10r N. Tf ~t.i (rw..ar ~jr're~ '$tati!.t !to-ffiJi

1 ProIe>l an artlf,,1<! arway",ilio, (11,11<" dcllmv it fTulf>l,t-n r.Nli"JJ;}.dl.(ltlJbuctrucll!Joosl

!~

O!)tAnlli'l"It

6lJ1t ill1d !:ea1nfl'. {j.f" Pt.

lW~nt

IPause, etc.'
OOJ {tliJt.dl!S j(!g{JWi(PJ

,af-aty

,'"" I-J,I, ele

MaiO!aY\ invl6lV1 hn:az. 01 tooes P-h.-("",Rli{li-~d h. . Ijx.' tI '(Ultmcnt 'lf trw paitSoh.' (,-vrv~ a,riMiw \t! tl . :;l-,k' 'lwn;c of !'IutntUlfl,
fi,,"ci(;::",}i:lffl ;uk';ui!;u,AkHl r]f h'(il~liQn}

(.,If III eOJ,.,{4ti01l

CO"i I? wll at lUCKlS. 1m!. 81<;

iteM! a.ttu~~ "'nth \p,,)ilir.t


1 ~a.t'~)f' ffl'! (r;~;jlailll

Ad,it!

,1lJII11J~,tr3t~

OW 01 !e!~IJry

[1(,l~HJGn;V;l{

k\lly (tudJu1n, 't'1l.It:rx- wallis,

f1lIi$l>:,

etc,:

P~@.fl./tamti) 1~.hJf.,Ul:(it"

Silft/ 01 natWM; wt", "" Inr-'p,,;I"""; II"", <n inlWV Cl s~al 'l'ihu t'~~J-t.1 S1INcr f!Jrw mtJPJ ~ !ttc:j Mvt ~:tr.-e-s~.we "'\f'C" 00"1 helo'" ~ I> n1W1Cai', apfiIepriJ!l, {e.Q .. Bt1rOm~1
~~!.f.Il;f:U!JH:'

~ frame' ~ T,,$, 'W'.1\le ftellllfnCy 4 Oeh,\101 reqUlt.t fer .. moy.1


JrH~VllJl\Al

ki""",,,,,,m

4 A~ 10 n"OO',t <lre5WtQ5 WlU1.,. eK 5 Cflrti1~J;;fwl! ,J..d -rw.tra.ird flJmMG"O:

6 Of harm \Q i\!t !]I O(l!&;& 1 .... 1!.t"''''''~


f<es\l;iil!l';)

AM ttTIGtriSl m u"",,,,/\\el-,f:!e,,,,,'iI WI
0\",,01'

"iClIlft$ or 'Iasw., &lJ"It'flfSj


. eVA "'In

R!nRMHTS'

Other (~QWlel

n:llHti>~ dlltl'O"",IMil"')

ACllVln
KEY

a ~ Bad BSO [J~dSidP, Cammol1e A = Ambula!s

POSITIOHING

:-ll:!PAUl. HEALTH CENTER

e;;:; CI'2J(

D ; OafVJIe

KEY

" 1111 .1111111111111111 RH


I'tARCH. PHILLIP

riP

~SSM
It ~ " I.. 1 ti

R p""

DePaul Health Center

0727400691

10/02/19'76 31Y t... 10/02/0'7 MELKAVEIU, SONI.A N 000'748298

MEW 0524-01

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD


OPM-1000-071 (7f2Q07j PAGE B OF B

DePaul Medical Records/Phillip H. March

000131

24 HOUn MEDICAL/SURGICAL PATIENT CARE RECORD

DATE STARTED

/~ '01

PREVIOUS 24 110; lollike Output ISOLATION: 0 Special Contact 0 Contact 0 Neutropenic 0 Alrtorns 0 Droplet 0 _ _ __ SCALE KEY: 0 Bed 0 Standing 0 W/Chair 0 SUng OTHER PRECAUTIONS: 0 Safatt-FaH 0 Breeding 0 Aspiration 0 Seizure 0 _ _ _ _ _ __ Yesterday's wt. _ _ KG Today's wi. KG (Plalle reconcile weight differente If greater than 2.5 ~,l
Temp
PIII~e

Rasp
Bf'

"-----')T
6e!iverir'll dev;c~

<w"I"
~r ~
~
I
,,/

1X')

I<\.'~ V
b

'fJ
J

.~
/~

l,/ / / .,/ / ' ./-,,' Ail :~ ......./


1lJ)(

IZ
,/'
//" . / / ./,/

, / / ,/~ / /

/ . ,/"" / / l,/'
".-

102,at

IfJ2% I Rille
! 02

III ~

19(; ~

.nft ,v

'1>
n~~

Iq1c

Time
A.Ilf111 S

1V1'
'IME
51'
-,/-'

TIM I

SP
! ~~.,.

lum RUil TEMI

fiJI
.,r'~
,//'

IJ1UU

. ftnp ! Tfllf
j
j

IrUi

RlBf

EMP

OfITIIO Tim
STATIC
0-

SP
-,//-

TIM BP
_/'~'

Scale Ul P
Ohern
fllftclior 08scrihl
L'it8UOr

i,~'-

~,---/~~'
~,.,/

i _,_.".

-",,.,./'
6REAKFA~T

'L

~~/

/~
///

E~
.I~kM

U
Dlt/HER

~~/

YJ;n.. -ttl)!,

!
I

!J
.....

P+.f;!
()
Almvnl

LUNCII

ItS ItACK

t;;6%
URINE

Ka'\
../

BelIfviQ
Oll3lily

..

TYPE
ioCol/ot

OIlA JTOOE FffO !NBS ORAL IF fWSII


Amcunt
/"l r J.\

OntER

BM
Am'>mll

AffiQvnt

Amount

AnwulIl

Am.!Unl

Amwn!

AmQUflt

AmlJF,~q.

0700 0800 0900 i00n -'1100

.....

Vq1I

...-

S!iallm'
Intervcn

V()f

12fm
1300
1~OO

Lf!((j
f--

vdxl
Vel,x f

1600

1600
HOI! 18Cn
12111

Vd,d
------

Suo Tmals _ _ _
j

2 III Total PHlCII((, al _ _

Tn

Gourl! 1900 lOUD

12 hr IO\ai OraVTube _ _ 12 hI Shilt Intake

----------12 ,,, SItII Oulput

aSHA'

AN -fl
E
~

I~

Elf mel

II'LC'
2.l./0
r---..

D = Di

iNTER
I. R..a,

r-_~100
2700

__

2. Redl 3. Gulc
.",

23110
!---z,(Ill)

4. Con
5 E51a

6 Ene.
7. nCt

(/100

0<'00
03~~_ 04nO

G500
IMiDO
12 hi Sub Totals .-

tfoV
- - - - --- --1? nr TotJi
(1f~llTuna _

"_0-

12 111 lol;tl Parentml _ _

--- --- --- - - - - - - 12 hr Shift IMpiA

12 hi Siull Inlak
' .... ,f1"'U

''''Uf ""'''

FWID EQUIVAlENTS: loz ... .3JmL

402 (112 cup) . .1:?Omt 6 m (3/4 cup) .. 180ml

B ol(1 CUp) ... ..240ml 12 Ot (soda-1 can) .. 36QmL

Twentyltor !tour 10111


PAnENT LABEl

~SSM
Ii [" A l
"{

'J

R 1:-

DePaul Health Center


a

DEPAUL, nKALT!I CENTER

MARCH. PIULLJP

-1lliliUlftlll111111D .
MED OtJ24-01_

I
I

24 HOUR M!:OlCAL/SLlROICAL PATIENT CARE RECORD


DPM10DO-071 17/2007) PAGE 1 OF

on'1401)691

10/0:</1976 31'1 tvt l%Llo? t-iELAAVERI. SON1A N 000748298


DPM-1(

DePaul Medical Records/Phillip H. March

000132

24 HOUR MEDICAUSURGICAL PATIENT CARE RECORD

DATE STARTED

10 -5-0'
Kt

US
Aching
8untllQ

SA Sleep, easy to arouse


1 Awake .nd ~16ft
2 SliQltlly Of\lwsy. ca:.y ttl arw:.c 3 FrEqll~nlty drowsy. arousable. eyes drift CIoMd during r.onvarsation (woslOef reduclftQ oplolll dCl$1l) 4 SQmnQ~nl, dlfhWn \0 ilfOV~~

~~~~!~j CV Cramping I= Cru~illnD


APP '" lis::ull'.e pain Jl(eselll BAhavim); Dl'lI Gnawing
Heavy
P~~svre

1 MeOication 2 AmolilaMn

3 Rl:pv,ifion
4 Rl!lal<;!1illn
$ CWI1"liI Statements

ActiVity
PrOOl\lurt
O~

Re~

9 Heat 10l:nlrt 1 t Music 12 Touch tlJ Imager/

17 EpkJural
18 PCA

N~

19 Pii!emllbve

analgesia
anal!les~

!:g
Sf

20 CllflIinuous

6 PrayeriMeditatioo
7 Spirtlllal Cite

14 MaS$Hge 15 DistraCTiOn
16 Ed;.,eari<m

inlv.iQ(l

21 Olhu'

8 Oee,p

BI~Jlnil1g

Sr

TIme fll!lQO Score #


#

Stile Used or
ObserYall~n
h~CliQn

&oa' #

DescrIbe:

LovatiDB.
Bellaviar or I PI'

SIldatlon LUll
Inlervenlin!l:}

IfIilialt
COMMENT:i:
--------------------------------------------------------------------------------~

BtHAVIOR/RESPONSES: AN ~ An.lo"" E - Emn\lolBI Di.lr"".


I ;;:. InaffD-ctiv<) Coping

M - MuHipl. RoquMit

U - Unrpon."",

co

ConmsGdIOI&ori.nled

OP Oisfupiiv. Pollanl

1M ImpulSive

C - ConlmUO\l6 C'Ymg
DE ~ OGp!HilOO

00 - Comatou
CI ~ CQ~mHlW Imp;urm9nl

H-

HalllJ~lOllliQn&!

Deiusione

oS - Diarllptive
Si~ni1lcill\l

StlKipil19

GL

=:

O&/9bpmfmta-J tmp .')lrm8n1

(J "~v"'9 ~ l.e(fl.fQl~

R ~ Rnm.s.
0 O~'J1Im\lia~ct!Ovtfea~t"'e

INTERVENTIONS:

--------------------------e.
9,

W ~ D911beralGly Wlfl\hol<lil\~ Into A - Anentlon Snl<in<j

Othel

T - Thf9Jla","9 Pf'YSI"a'

'1almfComballve

Q - Calm/Qulit COP - CQOQ"a\!1I9 U\ ~ ~$S AnXlO\l$

1. RDftS"&um<lCo PntiDm! Significf}nt Ofhuf 2. Rudi,edlc,', l. (juro"n"" ~. Coruolil8rt Enwonmeml ROUim8 :>. E'tablish ma'nlalned Umeframes IQr ~afl ~. EncourSlIt v&m.lI~atlon

OHo-r troquont brlU! c:onhict 14 RoO'rtnnt I RemuUv.1.t0 1 RQmntJllg foo1r:; Provide iniormallon \0 inOr&869 ~a,,.ef of llPdil:n:01amJ!rY~ 16. DJvaf~wN11 8-eH-vl11otJ5 10. Encourags 1amiJy to bnn-Q m lamiUar oblOC1S '8 i"lr{lactlV9 rTt63sum.& 11, I'rQ'IiQe rela.\&IIOn ' ' 1111 muolc, Imag9f)1, g"~ b(~I~,lfI\l, prayer. meak;<lllon 17, R.aHe~. f Req'Je61ion I S ~ clarnioalion 12. E"ncDuflIge normal fleop cyele ~y USIng Indlrec! li9hti~ alt91 dark 1U. E"$la~h bVundal\as nHds 13. Darken foom I ~Jmkll\g IQUch I l~. P(Qvlae int@n$lvt ,"CU(rty and .. I&ty m~n",~. Olliat olgn to ooc,,,,,.e "",1<101'3 "'''PClM5 10 otlmul.Uon to mlnlml b.h.vlo",1 probl""'~ 7. enoourall" pRtl",,' wKI1 ooal.!on m.1<ln!l!or C"I'. na~M

PATlENr i..AfJL

L
IIp

DEPAUL HEALTH CENTER

~SSM e: \.
K
~

1 11

"A 1\ !:-

DePaul Health Center

MARCH/PHILLIP

111111111111111111

0727400691 MED 0524-01 lo/02/1916 31Y M 10/02/07

24 IiOUR MEDICAll$URGICAl PATIENT CARE RECORO


OPM-1000-071 (7/2007) PAGE 2 OF B

MELKAVERI,SONIA N 000748298
OF.'

DePaul Medical Records/Phillip H. March

000133

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

fA(

rPa 26
38
56

71 84 96 12
NUT

+ RI

FRONT

/--

I)
;\ 1
~-l~~
,D): \

-',\
(
: /

LT

(}
I

-'~

~} II
I
,I

(twl "

) ~ C

J/
~l.W
I

! !

Ii r

I I
L
J

1"'( \ J,
K
I \

SL

= S~Jt; Lrr~1
UouhM !,:miN

Di. -

0
SUDllTLC

nc; JriplelvnlCf'

\1\
\

SL! OLi TlC


R
T

IU-V

I:)

E c::

/nIficJI' $QcaHOif t:J Ii liP k>f.) wortdfd

nJBIIT !
p

5 z

E\ \

i",

4~'I

Insertion - D~'e
Ann circumference
ern

LenQth _ _ cm

Orassing change date

\-------\.

--

---~-----

PATIENT LABEL

~SSM c.
}1 (" A. L T H

-A JI: I!'"

DePaul Health Center

DEPAUL HEALTH CRNTBR


MARCH, PHILLIP
07274006~1

11l1l1!ll11l1l1~llmR

1/1'

...

1.1ED 052/1-01

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD


DPM1000-{)71 (7/2007) PAGE 3 OF 6

10/02/1976 JIY 11 10/02/07 MELKAVERI,SON.[A N 000748298


DPM~

DePaul Medical Records/Phillip H. March

000134

24 HOUR MEDrCAWSURGICAL PATIENT CARE RECORD


Patient Care Acuity Record
A ACUITY LEVEL
Points
26-37
Level 1 2

DATE STARTED

Iii <; oJ

ACUITY TOTALS
Subtotal Section "A" Subtotal Section "8"

!;

38-55 5670
71-83
B4-95

'17
J~
i4{,

3 4
5

Subtotal Section
TOTAL POINTS ACUITY LEVEL
Silter 0

"e"

9S12n 121+
,~ -~

6
7

0-

RQ\JJ RES FUFlTHER OOCUMENTATION

NOTE: 11 more than ooe ilem on a line, clfOla lhe service indicated.

J
~EPAUL

~SSM
Hl"AlfH 1,6"..-

HEALTH CENTER
I/P

DePaul Health Center

!'lARCH, PHTLLIP

ImllllllJlIl!HllUftlD

~4

HOUR MEO'CAUSURGICAL PATIENT CARE RECORD

077.7400691 M8D 0524-01 10/02/1876 31Y M 10/02/07 MEL KIWERI , SONIA N 00074B298

DPM10>lQ071 (712007) PAGE 4- OF II

DePaul Medical Records/Phillip H. March

000135

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

II'

DAlE STARTED

&.

Spaclfy abnormal brea1h sounds on diagram

(Absent, Ilecre ased, CRackles,


RhonGhL Wheezes, Coarse)

POSTERIOR

POSTERIOR

PATIENT LABEL

CfIIlliluS

DEPAUL HEALTH CENTER MARCH/PHILLIP


072~400691

111111111111111010

rip

~
I (
(
D

I:,...,.

MED 0524-01 10/02/1976 3lY M 10/02/07

SSM DEPAUL HEALTH CENTER 24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD


DPM-l00c-OT1 (712007) PAGE 5 OF8

f.fELKAVERIf SONIA N 000748298

DePaul Medical Records/Phillip H. March

000136

DATE STARTED

I () .<;;'OJ

24 HI
KEY: " WN

TIme

A-Absent W-Weak S-Slroog


!:I-Doppler

Fecal Man;
l100e cl~a( Is paInless. Urme CQiQrt
FOlll-.~millli

Color temp sensation


VrR - Ill;
t>!;C ",.:

cap

iP.tdl$~!h;1!l3~_tlf'i1 ....

Uln W3lm wI. IuI1 lens a(I\lll

II; !{IJd. Ol)1ilJ!! ii1m!)lmll1" nCla.,

Yolding, I

lUiirnpuon
IIMormaiu
2 ..

B = IInn~

Frequency.
elll {descril Roo coooUlI

T
1

Trw..t

3+

= 1+-

" 4+

Suprd9UiliI Oriliflllgtl (v

Skin warm
J;lllrufir.~

Diaphorebc
ML'COm Il1I Skin InIli<;t

He,:l procte

K~klfj wi~

{:
~

RJfr)

DEPAUL HEALTH CENTER

~SSM DePaul Health Center --------------------------------H A L T Jot


. C A ,

,-

M.lillCH I PHILLIP

1IIIIlfllBmIJIIUn

1/ P

0727400691

MED 0524-0J
M 10/02/07
DPM-1{)(J(

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD


DPM-\OOO-071 (7(;1007) PAGE 6 OF!!

10/02/1976 31Y

MELKAVERI,SONIA N 000748298

DePaul Medical Records/Phillip H. March

000137

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD


KEY: .( WNl:I Qr task completed

* - sea additional comments

DATE STARTED

10 c; .OJ

I),. bQJded key lettar it inctiollted

Syn

Me
Oil< Ger

Adr
Adr
M1i

Aitt

Ilfi-il
,

"

ALTERED Sl<lNtwOIlNO KEY: PI) ~ Pres,uT(' ~Ict( If pre~sute ulw, lis! St2ge I. It III, IV. UMstagellbie
V
~

A ElL 8R
I)

~ ~1~ISC

= B~Sl~r

'" AQr;;$tOO

VasGulJf ulcer (venOIiS ,tasK inStlffiCincy) = N<!ll'Walltc VICer (G.atlebc)

,rlenal

E
U

= ORtludM = Erytltema = hconallon


Hp.maloma
Q
$

= tn[.i~inn I = LacenWlJ1l L R '" Ras<~ T8 = Tall~ b~m

WA .. Well APf.tMm,11ao 0 Ollier


Dnrinagt Amount $0 = Stanl I I : Sman
M

~e

H
I

DrnsillO: .S ~ Steli slnps

= De",,,,buHt/
SlapiRs Open 10 lIir

Wound BIll Key: Q = Gram.r4ton ~ :w,"Oh


,. - EsChar

SUfloundlnv Skin lIey: DralnagD Type;

= Inl~('1

II ~ OTA R " DJ M

() = OIlleJ

H&llltlthJ!l MJ1IJ1ll~

ory and Intact


O1Mr~

o '" Om

E - [tyillema M ~ M'ter;~O<l C; = CyanOOciD'';

88

= brfM = S~'UlJ'J = S"rlSJngwofOus

PU - PlJnJiem Il = 11!\l9!1y Y - YellOw

I.

=La,9\'
-

- Mootnlle
CQpi9~~

p,

!<

_ M{Ii1l!)<lmery waps

____

= Giusti
~,

_________

o
s

,/ 1nII1~a1f1 R.-neumanl No ChJflie Time and Inillals

1
,.

~SSM

H I A \. T H . C A. it Fo.-

DePaul Health Center ._--------

DEPAUL HEAVfH CENTER

I"lARCH, PHILLIP
072 74 00691

IIUIllIIDIlIIIIIII'~

TIP

24 HOUR MEOICAL/$URGICAl PATIENT CARE RECORD


DPM1000071 (712007) PAGE 7 OF 8

MED 0524-01

lO/02/19'J6 31Y

M 10/02/07
D

ME.Ll<.AVERI, ,sONIA N 000718298

DePaul Medical Records/Phillip H. March

000138

I
I

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

Toilaling Off8f10 mAry Z>


RR~fl'1nr.R

---.--- ----- - -_.-.--- ---- ---1----+--+-+_.1---+--1---1-Ii! rRIAL RElEk'iE

ftJt.mJk!u Up1J1

tv "YRS H,Jlrfipl
Sla~Qn, ~~ial

"KAt. Hugo fpr R'furot


1 FTOIert an MiliCi,. 'irway y,M!! _ . dof,,,.ry (e.Q . to m~'I1Ia!" BfulOlJ2tlUtVIraa.aal(\Ib<Si

nul@lo! flImlf;m
(luw"wrrtli<,,,,,,.,d!cil"!C'.(ic Ill. pwert 1'1l'J1Il'~. etc.)
Df me
(,1j .. ed"<.u~n Ilo: "ale~ jo~~winv teMt &~~t'd wlfu It.\m!r. j f!I>",,"" ff< rnlr.!ia!

filalRelm; Key
, Unlble lO '.W.>tt lor ~.II.t'J
:> ()d b) tH.Jf1 ,11 !(dT(;"~. ~]~J. Wi

1 Cooman.onsl"'l;SuIlYI>I\J!l Z CiflIlGe Ij/;J, ....alI ~ R>. (l'H..at M~O tCli IV:]f. e%:.l
~ En\1roflfl1fltt I

"",.(lIlt. att

maNwlatlc{Jt (/ltar lilUlel

~'<Un im<aWe ton Iii tI.>bts emnTilllO \lJt 9~4tntfll !lit6nl>' ,urr~OI ~~tion (q" 1C.'~ ~QW'I~ Of rMtlbO!l.

) ActMty 1~~1!1f! rISk Of

rtllliWl'

R~;lit'! or~.t)M('

_.Iion .dmli,,,[ra(,,,' or "yd<i!loo)


3 Sal!1;' of J>~nts '11M flJ~ ID<:apac~~tll kNlI an "wry or nr7c~1
IJIltBdU'! 'liM "'Gall !.utlet IU'lh.. lIIjurt "
IHl)'tlt{l\ffrJ hai.QH:!"II \(; ~1~atr "'f~l:\,lf.~n1t:

4 l.jlef\fiI~ 10 "Jl""'~

5 Me1icaUQIl t IllJuaii(m " llt'itlS1~naf a _IMI tOdWOOS. ",J!;OS. WiJ!ICS. muSI!. tiC.)

thay hive ."'."'..


(e: U. ~Ihf!"nly

? A:'.!.~~"".tuV:l~ lilHtl fnltm;~ 3 Trial IP..IN$e lre<l'.lfIlCY 4 n~~"If rwui1ee 100lemovaJ

"""""1', M"O>l<. t:i<;


femore.l
(t.t:f\' Rt1!<'fr'1U1.;f

~.re

aoo

r~!lJ'a;nl
~!ht'.f(,

6 fl1 t,Mln lfi ttttf W

I 7 PaI,fw/fami' tdaCJ1iC11

lleiflJainl>l

1 01.",

run DM:,f&.i!\ s"",e~;Se1ire!e.sl1'9!i1l!

ffactums: or V.Imw sUIW:!OOs}

BEIIAVlORAl RUTIWIITS.

1W~..n !lcn""'~1

'11'", ;mif1:kil>C

L Ifttilied anu in

vla~~

u t/ul applicable

"CTlVlrY

Krf

D =OanwB C - Crnur

B ~ ~c(/ BSC = Bedside Commode A = Mmldate

POSITlOHlNS

KEY

S P

L = Lell
=
~

= Hignt = Rack

Self Proos

DEPAUL HEALTH
MARCH, PHILLIP 0727400691

~SSM r
" tAL y tt '

~- A ~

DePaul Health Center

IlIIa.,IIII.RENTER IIR

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD


OI'M 1000'171 (7/2007) PAGE B OF B

MED 0524-01 MELKAVERr6s~~IY M 10/02/07 I A N 00074829S

10/02/197

lip

DePaul Medical Records/Phillip H. March

000139

24 HOUR

MEDICAL/SU~GlCJ).L PATIENT CARE RECORD

._ __ SCALE KEY: 0 Bed 0 StaoojlllJ 0 ~WG~ir e1llrlg OTHER PRECAUTIONS: 0 SafelY-FaR 0 BleedjrJjj 0 Aspiration 0 Seizure 0 _ _ _ ___ Ynlerday's wi. , = = - KG Today'i wi. K.G (fl~ue rO~QnGlle Wlli9ht dlllrlrOD\l{J if greater Ihln l.~ kg.1

PflfV10US N 110: intake

111D

Outp\lt ~ ISIlLATlON: D Special Contact 0 Contact D NeutropenIc 0 Alrborn 0 Droplet 0

DATESTAATED

tol~! 16l

24

hM

APP

Time
RatllIg

Scalf l

Dbserv
funnlio

Onelit LotallG Behavl(

UA~

OlHEfI
~ ~. ~AiOOUnl
Anll fFt~Q

Fraque,
8M

1JflAl

TF

FLUSH
_Amourn

--+----1---'--'-" Amnum'--+----.!'----'fll0UIll

Am01~

AmQVnt

Sedafio

--+---~~---+-

Inltrver

lnilialt

.-

--+----+---4- --12 hI.

S~b T,~alO -'I.1L

11\1,

rrn"r- - - - 1'-Vp~

- - - - - - ---17 nr Shill Imokc

1- -- -

- - - __ _

12 hI 101.11 P3reolefli ~
To CUlint 19UO

12 hr rQt~1 Olii1fTvbe

r'

1i /J ()

._---

BEHA\
AN
~

Al

f:)}(..t'

12 hr Shift nlJt~ , - -

--------i

E; Em 1=Ir>.d

00""

INTERI
I Reu

n~o

--'-

.-

, Rodl, 3, Guid
4. COns
~. E..tat 6. !;IY.9\

2aUD
240-0

J"J-lJ

--olCO

IOu
I'IF:/)

--~----~-f-----l---_+_

IV

7.

En~O~

-~---+----+

~ ~ ~Ol

--!-----+----I---

- - - l - - - - l - - - - + - ---

,--

~Jr_--~~~---

~:;~otJIS --- d....,..:..~~7)_ - - - ---12hrToraIY;lrBnW;1 _ _ ltlTfTotaIOrill/Tulrli_....


12 hr Shift
-n.

.'I!fD-- -- flIl1J - - -"'t,t,e r~ ""--,'-i ...... l.'I'k~-l


, loti I

-- - - ---- 13: fl..!) a.1I1J


PATiENT L4BfL

12 fir ShiftOutpul

.~. ,-

Twuoly-four hB~r IlItll

flUID EQUIVAlEHrS:

4 oz (1/2 cup) ... 12(}ml

8 Ol (1 cup) . , .

240mL

lor. .. .

. 30ml

{\ oz (3/4 cup) . ' , '80mL

12 02 (sodal canl ' 360rnL

~SSM
HeAlTH'~"'~[

DePaul Health Center


e

24 HOUff MEDICAL/SURGICAL PATIENT CARE RECORD


DPMl00G-071 (7:21)07) PAGE 1 OF

~mD OS21-01 10/02/1976 31Y M 10/02/07

~~~~'~p~1111I "
0727400691

DEPAUL HEALTH CENTER


lip

~
J;

All

RAHMAN,ANWER Z

000748298
DPM-100

DePaul Medical Records/Phillip H. March

000140

24 HOUR MEDICAl/SURGI CAL PATIENT C=-:A,-=-:R,-=-:E~R::-=E=-:C=---:O=-:R~D=----~----.:o=AT~:...:ES::.:.::TA::.:.:RT.:::ED======;

24

AclJing

Burning
A .... = AWlml pain present
B~hav:orG

1 Medlcalion
2 Amhulaliflll

Cg = Crus hin\) DuM


Gn~wing

Ct'~Olpi1l9

5<Ohtlv drowsy

e~,v to

Mouse

3 f,equ\.1'tlly UHJII'Sy.

alou~dble. ~y~,

drift closed during conve(~aoon


(tenlld.r rtaLKlng opiold dOle)
4 SomnOlsnr l1itticun to Jl'Olise

Heavy
pres$(Jre

3 4 II 6 7 B

HcpOSiUOIi

Relaxation
Calmmq Statements Prd)'l!liM<ditaihn Spiritual Care De&p Brea1l1mg

9 10 11 12

Heal C:nlrt
MUSIC

17 Epidural
18 PGA

19 Pret!mlJ\Nt

Toucll

an<lgaSi.

13 Imagery

14 Mir;sag~ , S DiStraction HI FctuCJtlVn

20 Continuous ana~~ic infusion 21 OI1!er'

Sits

Site;

'TIme
RlIIfRg Score #

# 01

Seale Used

Dr

Obrerva1fen
fllll~lioll

Goal #

FJI R1

Oemille;
\.&calIO!!,

Bel\avio I or API' Ilualily

Aggravating facton

8edation teyel
1!I1&l'VflllliDlI(&)

Inltlals

BEHAVIOR I PSYCHOLOGICAL
BEHAVIOR/RESPONSES; AN ~ Al\xiM
E ~ EmollonalrlilNi$
I", Inelf&<:U". Clpir>9

M ; MulflPl. Rtq ...ut C = COntll1UC\l$ Crying DE = o"PI'&"lon G '" Grlavlng


L

U ~ UnrwPl'nsiv;

CO = ComalGJi CI = Ct'gMm Impairment

CD ~ Con1u.~dJOj'Q(i.nl.d H - Hlitucilltti(!n41 Delu$lone


W ~ OtllberRlely WI1Mholtling

I) P

= Oisrupllws Patron!
[)j~fuptiv9 S~OIfI'.n1

1M -Impul:ij..~

tiS -

Ii: SI&llphlg

o;

Oev.lQpm~nl.IImP.r'm~nt

= Lclha'!JiG

o;
II.
j

R-

fleS119~S

O.",&!im"lale..1I0","eactNa

Inlo I< = /\I\&r'II<", Seeking

T ~ Th,,,aten,ng

OIlier
Phy~i"al

o - Ca\m!Quj~1
COP
~

Cooperative
An~io\l$

HaIQVCOmo.llV~

LA - Lan

INTERveNTIONS:
1, Rea..u.... "". -Val,,,nl! Sognifical'>\ 011> ...
2. Re<l!'8c1l0n

3. Guido"."

e.

4 C,,~sI"nI e.vlronm<m' f Roull"" ~, El!:tahiish m5i'llainod timehamJ;J.-S for care flOOds


EnWllra\l~

9. Provid& information to .nCn,ase I~ , ot und.r.\mdmg lQ. Encourlg" family to brIng In fAmIliar objects

OIIvr 'n.qwnt briiir OQIl(aot


PrQV1ct~

4 R(Jf)lhmll RemQCtvafe l RestnUnR (sots


DivBlsiaf1at acti... i1ios

15

I,

relaxation with m".iC, 1mA9~f' d""p br.alhln9, pr~y~r,

16 JIIrO-OOIi\I'Q Illsas.urez:t mwlcab<1O 17. KU$li1!e I fI~qw61/Qn I Sook cl.tl!"'a~o'l


m"'O$ur",~

v-f(QalkalIOll

j2 11

7. En_OIl,age pl<lient wilh QGCieiQn ",,,,I<lnll f<rr car. n<>ali.

QUill! stgn 10

Errooumgo no'm'" "O<IP cycl~ by tlslng fnalrect ftl/Iltino ..tt~r dark 18. ESlablrsh bound8ri8ll Dmkon r"om llimitmg louch l I S Provir.\e I"len.iv& l~~uri1y And .afety OOOfQ900 paUunt'.:I T85paflS[} to stimutntiol1 to mlnlmlu lh.."tor'" proMsm)

t ,
I

PATJEI\IT LAOEL

DEPAlTL ~EALTH CENTER

~SSM
H : .. l ,. l-i

.c.\ _ t"

DePatd Health Center


ij

24 HOUR MEOICAl/SURGICAL PATIENT CARE RECORD


OPM-1000-0n (712007\ PAGE l! OF

l'lARCH, PHILLll? OT27400B91 ,-lED 0524-01 07 tJ! 10/02/ 10/02/1976 3H 00074B298 i<AHl"'J\N ,ANWER 7.

1111111111111111111

IjP

0!1
" A

DPM-'

DePaul Medical Records/Phillip H. March

000141

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

Site #'2
SITe #3

I~

~
N(

# 01 attem:lts for IV restart

e ;::
t:

:II

~.

:2
II.

...

C >
:::c

PATIENT LABEL

DEPAUL HEALTH CENTER

~SSM
ttE"-tTH

C41\.

DePaul Health Center


e

24 HOUR MEDICAl/SURGICAL PATIENT CARE RECORD


DPM-l000-071 (712007) PAGE 3 OF

HAReH, PHILL,IF lip 0727400691 MED 052l-01 :10/02/1976 3lY M 10/02/07 t{Aftf-W\f I .lI ..NWER zoe 0 74 8 2 9 8

IUIIIIIlIIIUOIIID

o
" f

ON

DePaul Medical Records/Phillip H. March

000142

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD


Patient Care
A

DATE STARTED _ _ _-

__

Record

ACUITY LEVEL ACUITY TOTALS '----Points 26-37 38-55 56-70 71-B3 84-95 96-1211
Lwei

Subtotal Section

"Ai;

2 3
4

1 Subtotal Section "8"


Subtotal Section
i

"e"

!'Vi ~~
"

6 ACUITY L.eVeL
I

5'

TOTAL POINTS
I

)&' ?~
If

121+ 7 I Sitter 0 + REQUIRES FURTHER DOCUMENTATION


~:--

NOTE; If

n1Of&

than one irem on a line, cirele the service Indicated.

I
I

f
'!

:J
"

.i

PATIENT lABEL

DEPAUL HEALTH CENTER

~SSM
l1f.lTH C"R(

DePaul Health Center


------

24 HOUR MEDICAl/SURGICAL PATIENT CARE RECORD


DPM-1(100-071 (7f2007) PAGE 4 OF 8

MARCH, ?HILLIP IIP 0727400691 HED 0524 -01 10/02/1976 J1Y Ell 10/02/07 HAHMAN, AN\,/BR Z 00074B~9S

IIIUWIIIIIIIIIDOBIU

DePaul Medical Records/Phillip H. March

000143

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

DATE STARTED _ _ _ __

24

i:~r~ "SHiii~iriiiiiiiiil~~
I.....

ZJml~=~l1Bt;

v . /
/

iLOe
n,

ConfuSed, Lethargic.

V
DHI;w~n $;k,rrAf1\

Speech (Apl1aslc,
!

Moves'"
r1.o\JJr response

,witil
ARM

t./

!R / ./
1/ L

(Abnormal OOXIOrl. Extension.

flaccid, LOf;il!lze~. None, SPa$tic, 81rong. W~aIi.

WDWithdraws)

'HAND
Size

fR"' V/ .~ W,' t.) L ,/

/" 175

/1// 1//
/1

[J

/ ii/ iii
;i

GRIPS

inemors
PUPIL SCAlE
B-flflsk

l~< j/' J/ //

// v/ /i i//1//1/ V/ /f / 1/." / 1,// ,/1// 1// // 1 ,/l ,/,iL/' 1// / 1// Vi 1/ c/ Ii 1//1/ 1// Vi ii' 1// 1./ 1/ /
:'
' .

/' /
/

/'
jl

.// //

'

./

I//i

1/

1//

1///

L// :/ / i// //
[,

$.StJC9ish

I nm In>''' :Jmm 4"""

ffl~d C-Sw,}l~rV
Clrmo IDysphagia

/iff."

e
flmm
I

lo'~/ 1// L/ I/o' l/" 1//" l./ 1// ~/ 1.// L

/".

//'

/ / [/' ~/

l// 1// l'/ .../' ~/' L,./L/'1,/1/' L/


:

ReacUon

1mm

!.~" // 1//
L

,// 1./,"'-

1// 1// 1.,/ // 1// 1//' 1'//t./ ~/ l.// 1/,,' l",'' ' [,./ 1// ,// ,,/ ,.././1//1/'1,/1I
+--'

Sa

Pa

la,oeDn' Ah.""tl

, TE

1Numbness Ilingllng
IOL''''UIINIi

R~

rv~w' 11'1

all lobes clear

~~

Abnormal b'eath sounds


Specify abmrmal breath sounds on diagram.
(Ab~~nt,

TIME

D lcr~a$ed,

CRackle~,

Rhonchi. Whe.nes. Coarse)

= --, A, ,nE\ t:==' r--:j


FfJ ~ JE ~ ~
TIME

TE
S(

lm1 tI ~ ~ ~

S(

r;=::j:
R

V-',

~/----..."
L

I'
4

~
CI E> Df
~

,..L
i

POSTERIOR

POSTERIOR

R86Pifalgry l1ffurt \lnlabor611


Abnormal mspJratory effort
OYSpr\l!3 (on Exertion, at Rest)

vi
At, Bi
Sf A

Cough-

1- .---

i Cough and deep breath

InGonliYe ~Jlrome1er It mL I fI reps


I Sputum
!

c'/~

.. /

I'."

.. -"

.,."r

,.,r ~.-""

~--" [-". [.,"

>'

1--/ I .. r ' i,"'"

.,'"

."J'

"J'

. ,...,
,

.,,- i,.,r' i."

L,
A

,.-

(dHSCribeamouflt colO!,

SI
C
N II

Suctiun (Nasal, Oral, Tracfl) TraeR care o Trach type _ _ _ Size o CPA? [) BIPA? S8IIlngs
Y1InllflllUI 9""II1I1J,

0 GMV 0 SIMV

11

" .. i~;;"wl .. " ...,,~

(ytlrilled per Qr\lcr)

o
S

Comments

..
lint:ll IUDtlI

PATIENT LABEL

o
a

TIme

LtlCatioll

Will~r Seal

&uctiun

Crepitus

Drainage

/'
,1/
L--l.- .

DEPAUL HEALTH CENTER HAReH,PHILLIP lip 0727'100691 MED 0524-01 10/02/1976 31Y M 10/02/07 R.l\,FiMl\N,ANWI::R Z 000748298

III 111111IIIIUIIIIII1

//
SSM DEPAUL HEALTH CENTER 24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

OPM-\OOO{)71 (7/2007) PAGE 5

OF 6

.!

D'

DePaul Medical Records/Phillip H. March

000144

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD


Nfl:' I
WN~6 tlr task completed

DATE STARTED _ _ _ _ __

* = See additional comments

24 t
,.,
TIm,

Un bolaed key letter II Indicated

PMfJMral pUlse,
AAbsam
W-Weak

FlulM
IJiinacll is pBinllJ
lhinu !;\:
Foul-Sir

IHtrung D-Doppler Colortgmp sans.ltion


WI' 1(,011...." u%!l r;w
~I!$HlYI3SI!:,rnlS

sUJ warm Vttil-;1tJij ~iS'"!

gC41llJ IOiJCU!tJIO!
JtmocJm.llfllmt;--s

Vuldiog juprap

AhflMm
II - None
Fr~Quer,

T '"
, 1:1:

Tlat~ 1i

eBi (ds!
Iliao cor\
&iPl3 !JI

Drainaoc

If skill,

~SSM
.... " " l T H

r; .. R E

DePaul Health Center

DEPAUL HEALTH CENTER


t"1ARCH, PHILLIP

IIIDIIIIIBIIUIUIIIB

riP

24 HOUR MEDICALJSURGICAL PATIENT CARE RECORD


DPMIOOO-071 (7/2Q07) PAGE 6 OF B

0727400691 MED 0524-01 lO/OJ!/1.976 3lY M 10/02/07


ME!,KAVERl, SONIA N 000748298

DePaul Medical Records/Phillip H. March

000145

24 HOUR MEDICAl/SURGICAL PATIENT CARE RECORD

DATE STARTED _ _ _ _ __

24

ALTEflfO SKIN.NKlUHD KEY:


PU
~

Pr&O'.wo ui<;1!1 If pressurR ulOSr list Stage I. II.

A = A/)rSSI<)" 81. ~ Bfisler

I
L

= Incision

III.

DR

IV. UN~\a'Jeable

V
N

Va~culilr llirer (venOL'5

sla3i:., arterinl

D i

= Denuolio
:: flyllK~ila

=Bru~e

=
~

'li$ulli:;i~flCY) Np'If(oJ)JthlC u:~c' (uilcetli:)

EX - [:.CM.lion H '"' HoHllltoma


I I:

; l;Jccralicl1 - RaSh = lavo bum WA ~ WAil ap/lIa<lnlillcd o '"' other

TB

Orvisfng:
I.e
"

Wound Bed
G -

5I<;rl >VlPS

K~y: Gt.i\,'lltl;lUOtl

Sutl'UUilding SkID = Intact

K~y:

[}rain~'

- [)fi(Il1~Mr;l

; SIOUOh

= l'rylfi~I1H
O1hEJ

5
OTA

= (J!'<f,n 10 ail
~
~

; SmpleS

I: = rs(har

o-

Olhei

A
Ell

Ilelenlioo SUM,
and ,,111';1 Monl2Qfner'l sIn!>,

o -

M = Mactration C - GY-J"~WO.rt

~ !If)

M Q

=\.liw _ _ __
Odor

Time

Sll~

He.

D,ell$ln:oTww~lIu~n~dTs;;;;;;;;;;;;ii;~~;
B~

o "!lIi~1 ------Treatment

$ II PU B Y C

~ fi,,,,,,,' $0 .. - SeHlJS 5 ~ ~ SJ.,fQS<fJ!,)U!neous M - Pu"Mrd L = Bk'1OOi' C -: Yailo\"Y ~

Tylle:

Draillage Arouulll:
S~am

=Mot1llrali: =ur9~
GQJ)JQ'rJ

Smail

CrusI)'

_ _ _ _~

YIN

./ Iwjl~1e3 ReaSSBssmenl No thanue Time am! Inl1lals

AI

~SSM
H rAt. r "
I; "

R E

DePaul Health Center

DEPAUL HEALTH CENTER

MARCH/PHILLIP
24 HOllR MEDICAl/SUf:lGICAL PATIENT CARE RECORD
DPM-1OOO-Ol1 (7/20Ql) PAGE 7 OF B

IIDlllllnmllllUn
MED
F

lip

0727400691

0524-01
DPM-l(

10/02/1.976 31Y M 10/02/07 ttlELKAVERI SONIA N 000748298

DePaul Medical Records/Phillip H. March

000146

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

MEDICAL flcs!on Ill!' He8!'BI!l!


'\ PfJ1!Rt'".t;1l')
it"'hii-t~\.I ;itf.,.<~'i ,'l~JdI(Jt (l~YftP.'1l

HnflBlnl flll!!i!l!!l!n
(tt1lj-."l1.>Y (f4.f1-, in
Docume(~

lrIBI HC!J:l!!!l KeY


1 lJm.1l!o 10 com,,,,! klr <M.1y

iimf

aoo ~nfi'. iLt.: Ct.

mail\t"" ,rnlol,.dmMr.m.d uibosl


3
tflV~!}jIHWl

ut It%ffli.ll.I%I.tfufj~ (rlt'iY jro~~j~:; ~rkIl'J, :;fv;nil!

~lJliqllt ~'l

2 M.llIain iIrWA'I'i! Im~ fJf IUOOI, I'Slimall!) tt:t: Iff<3tmffln nllittl ltJ1lt.ml!~' WfH'.H( ('Wh11c11 {!J iJ . w1e ~..m\n;t of IlU!fllil)fl,
IT'!a,,al<)n ~2IiC<I 01 ~ytIf"QI1I

J)Ufll!. SIlQ...e. eIC.} (.... ) iii eOIK.aiifm box im15::..nff. tfl~frHin9

4 I\o.hty Ofie ".~km

5 Mf:iOCiWU1! t.yd;:!;nJI)l! fi rkffll~';ir,!i ,ttINJV {lttt;\u;n;

)."tx"f?,f,r., >II~{\.~ rj~I~,"jr.

p.-k.)

P"helll'F',"'~

"i1;,;lii"

R,ltcly ol ,r.1iiin~-; who arE ~ll.:'ip.,,:~atfi.d fti\m ,i::Il l~Off fl( r,Hfljc;d p""",hfC "'no would .uffCI iniwv if lw/ 1\;;"" ",e~"iv. "",,_Ill otiOle nif n>e<lital!y !pproooale (t.9 . txt/tnt.;

jvur; WS(;us><xl ..lh refV"", 1 Rea_ler ftSi"in 1 Am~smffi( lirnt llaffi<!s

eon. ~J Wi ~I rutre~. I,un elC. J Al:1My OO!lY.m!r.iW> flI~ 01 fill!\;IIIy


Z
4 ~1I;tllpi"ll IQ f~ dt'~1\i15. WU'l'S. e1c.
~

t.:c:l:>erdh'l6.aM f&S-1rdlot rmnlWtt)


(,~

,,,,tho,

3 1rUlleiUSt j(tQUenty .f RerrJ,l<\r ff.Quilt:d fiX {ffHnval

6 01 'lim !Q >eli Qf Ul'~'


RP.~Ir.Iinl.)

6eh6v,QraI

'rac\t)(es Of 'iaY.A1l<r SUt(;1lliet)

7 Ofw Vtl;teS II'.JIllivr Mt1lll1M1Jtion)


"If. wi1h

ACTI\'ITY <EY

A = Ambulate D ~ D<I!1ql~ C= Cllat

sse - Bedside Commooe

Bell

POSITIONING
I(fY

DEPAUL H

ef'I:;SSM DePaul Health Center


K E A l T 1 C A It
E~

liP tJiARCH, PHILLlP D 0524-01 '0727400691 3~~ H 10/02/ 07

\1111111..,

EAUTR CENTER 1ltllllllMl 11111\\

2' HOUR MEOICAL./SURGICAl. PATIENT CARf RfCORD


DPMl000071 (712007) PAGe B OF 8

lo/02/1~76

NIA N 000748~98

MEliIZAVBR1, SO

DePaul Medical Records/Phillip H. March

000147

24 HOUB MEDICAL/SURGICAL PATIENT CARE RECORD

DATE STARTED

/0 -3-07

24 ..

PREVIOUS 24 I/O: Inlake Oulput ISOLATION: 0 Spetia! Contact 0 Contact 0 Neutropenic 0 AlrtJOrns 0 Droplet 0 _ _ __ SCALE KEY; 0 e,d 0 Standmg 0 W!Crnm 0 Sling OTHER PRECAUTIONS: 0 Safely-Faft 0 Bleeding 0 Aspiflltion 0 Seizure 0 _ _ _ _ _ __ YestertlaY'$ wt. _ _ _ KG Today's wI. KG IPlealle reconcilo w&lght dl~(ence rr grllilter thlln Z.5 kg.)

Temp
1-1

J~ ~I :",'1 i" P:.....::..IlIi.A-----+--F.~II---+---+-+l-"'~+--+-!---+ru~-+--+-+--+-~~~i"--+--+---j -..

IReS?

lap
02 sal
02%/H~tc

02
n~E

8r
///

1'1.111

flU P Tmr

lME

.. pr jrum
/,/

1113r

:mr

311TII3 }lllf
STAnc
0-

TIM
BP

~~
TYPE
070U

, tilkCn

...

Bl'
/",.--

$GlIl. Ui Obsel"lal
Fun~ticn

....-./'
.~/
~'

L~
LUNCt!.

....-'.,.
~.

~~~~~~~~~~~~~~~~-~F, .. OSI
~

~~:;

~ 9
.1

....../~

Oe1lcribe

IUlfAKFAST

DIHNER_

Ht SRAQ;

lflt'stian

!~tli

~7

L~\

~/p

B.bavior
Quality

ORAl./TUBE FEEDINGS Tf FLUSH P.rnDlJOI flmOUlll /lmount

imiNE

I)Tfflfl
Amuont
.

Ftaquftnt
Am~un\

DRAI.

Amuvf<\

Amount

Amuun!

. Amount

8M A.mtJfn:Q_

Agoriul
Sedalion
Inlervenl

h.~

1)800

~)

RfU' 'II

11)00 1100

I WhC'\
~--

- ..

lZ00
laW 1400

--

i'l

.>?

t't

(/1<"'-' ~
- .. ~ ...- - - - + - - - - l

1500

6EHAV
AH~

Es

Em,

Ar

1900 ZOOO

o ~ D....
INTER\
1. A~I\"
~.

I_I"~H.

2100
2200

Aetllr

2100
2400 011lO

3 Cuidl 4. Con"
5_ E&llIt

,i}V
_ I _ - _ + _ - _ + _ - _ 1 _ - . __

5. Enco
7. Enco

1--.:..:.:..:.(fZOD*--__+--~+-_-+-_

6aOn

I-

D400 0500 0600

f'5?

ti.

.....

1)fL V J... l
IZ Total Or~VTub

. 12 It,. /ff.Y 'lvbTolals . 12!11 Tulli! Pdlilmer 11 _ _

r- - - - - -tv4 01 (1/2 cup) .. 120rnL 5 01 (3/4 cup). 1eOmL

~~ - - - 1 - - - - - - - - - - - - - -

urClv

....

~2 hr SMI

12 hi ShiM Oulptl!

f j ('\. '"'

Twentyleur hour 11l1S,


fLUID eIlUIVAlEflrS: 1 01 . . 30mL

"J1(.)

Ii 2..

Tw~nlylour

huur I~I~I
PATIENT LABEL

AIl,P~'

8 Ol (1 cup) . _...... 240Hll 12 or (sod~- i can) .. 360mL

~SSM DePaul Health Center r e -r"- - - - - - - - - - - - - - - - - - H A l ,. Ii


I< R

DEPAUL HEALTH CENTER I'lARCH, PHILLIP


0727400691

/11111111111111
f<]

lip

24 HOU:; MEDICAl/SURGICAL PATIENT CARE RECORD


DPIA-1000-071 (7f2007) PAGE 1 OF 8

MED 0524 -01

10/02/1976 _HY

1.0/02/07

RAHMAN,ANWER Z

000749298

DePaul Medical Records/Phillip H. March

000148

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

DAlE STARTED

A,hillg Buminn

SA Sl?ep. easy 10

IIroo,e
3IUUsaUIe.
ey~s

1 Medk'alion
:il

]~~!!i!~~
APP '" AS:,\JIIIC pain pre~~1 ct

1 Awake and .181'1


2 ShQhny drOWSy, easy to Mouse

CnlT1lling Cg '" CrUsI!lng


01111
GllilWllIg HA3Vy

:J
AclJvdy
Procedure ()(hgr'

Freq~tiflily dH1W~Y,

Rest

Behaviors
TIme Rlfing $cvr~ II
$~alv

drift closed during conversaboli (tllnsldar reDucing apicid dote)


4 SOf'MOlent. difficulllO arOll~.e

;, 4 II 6 7
8

Am!JlJ!alinr. RCPO$.loon Relax31iCfn Calmin9 StatemenlS Prayer/Mooilobull Splrltull Cars

9 Hl;al 10 Cold
11 MusIC

17 Epidmal

18 peA
19 Preemptive

12 Touch
13 Imagory

analgesia
70

Pr.,'$we

neep f\rathmg

14 Massage 15 Distraction
16 Edrw;!li,ln

anaJ(lCSi(: 21 Olher'

ConHnu~u~ i'~uSion

St

Sr
#

Und ~r

ObselViition func1hm Baa #


[)lIstfibt:

Locaiion.

Behnier or ,.pp
QuaDty

Sedition Ltvnl

i I:
InitialS

L
L

!L

BEHAVIOR / PSYCHOLOGICAL
BEHAVIOR/RESPONSES: -E
I
D

"'" - AnKioll'
~

= EmQlioRll DisJross

M - Multiple R&queol C = COI'I\ll\\lO\lS CrylfIQ

U - Unre5pon.ive
CO~ ~matO$9

[IE

O_p"-nion

CI .; CQgnitiva Impair",.nl

= D";."'fJ'l\90lallmpaJ(0\~'"

b,.lIooU., copffig

G", Gt1...100 l ; L.lhaJgl~

R" ResUen o ; Ov,,,,Umuiared!OWlraaClJ,'e

w = Oolib&rlJolV WithhQId'''''
Info A ; ArtBn1!Qn
$n~lng

C~ - C<ml...... dID ,,"omled H ~ Haff~IMljon~f Da{v,jon$

DP - PltiNPliW
~ ~

pa~<mt

1M -lmpuloiVII

Dim)J)tiVa
Significant Other

Slttping

T ; Threattnlng Phvs!Cal

H"rmi'Coml:>alive

Q - Calm/Qui,!! COP" COOjlatiV& tA .. les. AnwlOll~

INTERVEN'UONS;
1. R9ifStnJr,sHce - Pannt I Signmesnt Olhb( 2. Redlreelicn 3. Gufdtnce 4. C9f1iifl,nt Ellvironm,jOll RIUJO", S. EJlabli.h 'flain1alned tlmslrame, for eare neeo, 6. EnOOlllftg. vBroa.llzallon 1 EflCQurng:l pnlien\ with (100t:'1ll;Jn mrurlng for C'.Jl~ naed-:J

11.

e. Olla, f'squall! hri.f co"lacl 14. Rooriaflt f Remotivate I Restating tu-ct-& ProvidE> inform.ilon to in<:rea." J&vlll of u,1<IoTGt,,"dil'lg 15. Divarsionai a-ot.vitias 10. Encourage lamrly 10 Mag In tammar objecTS 16. Proactive m&'i:liure,. 11. Provicl" r"faxiltion wflh rrome. un~g"ry, 11"9 1I,"lhmll, pfl.Yir. mildicali90 17. Rn$ns~ I RilQVUlion I (iNk clarifi<;~lion 12. ~CQ"".ge normalalefip cVC~ by using In<llrecl "ghtino aM! d.(k 1e. t:stabUsh boundari., 13. Oark.n room I LImning touch I 19 Provlde Inlen.l", S&CUrll and 3!l1My m&",",.,
Qulat '1igo to
d~etUI.e

p;,donl's

ra;lpo~

tn olimutntion

t(l mInimize ~ha'Viatnl probl8m~

MTlnlT I ARFI

DEPAUL HEALTH CENTER

~SSM
.f'(

& 1. I. 1 Jot

(;. I, ~ l"

DePaul Health Center


a

MARCH,!'HILLIP
0727400691

IIIIIIIIII.D.

I'-tED 0524-01 1'-1 1.0/02/07 RAH?1AN r AIDIER Z 000748298

rIp

10/02/1976 31Y

C
H

24 HOUR MEDICAl/SURGICAL PATIENT CARE RECORD


DPM1000-071 (712007) PAGE 2 OF

DP

DePaul Medical Records/Phillip H. March

000149

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

24
ACl.

Poir
26-3 38-5 56-7

8H
96-;
121
+
REI

71-~

NOTE

liTHER
FROWT

RT

r-N

~.\+

I{.

~t}p

J
/

~~j.

lIb K\\. \
I

J)
J

, I

(_.

BACK

.~
I

LT
Sl.

= Sh,"'~<mm

UL - /)I)ufIIIlUIfllfli

nC=II/fJICilimw
IMicale Ii!cHIiM QI
NflONlRPJ}1WdirJ

SL.I DL.! TL.C


RIGHT
P

SLlDLlTlC
R T

S . ~tW~

Ins8l1lon Oats

length _~ r.rn

Dressing change date

G
E

PATIENT LABEL

~SSM

l'tIAI.T""'AfLe"

DePaul Health Center

Jf!~'A'PTtIIID 0727400691 MED 0524-01


10/02/1976 31Y
Rl\HMAN, A."N"WER Z
1"1

DEPAUL HEALrH C'ENr!?R

rip

0. H"
DPM

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD


DPMl000-011 (712007) PAGE 3 Of 8

10/02/07
000749298

DePaul Medical Records/Phillip H. March

000150

~OUR MEDICALJSURGICAL PATIENT CARE RECORD Patient Care Acuity Record


,---_.

DATE STARTED

!b ,3 -07

ACUITY LEVEL

ACUITY TOTALS
Subtotal Section "8" - ....
-~

Points
26-S7

levDl Subtotal Section liN'


1
2 3 4

3855
56-70

Subtotal Section
TOTAL POINTS ACUITY lEVEL

He"

DV
~

'Ch

~~~~~

71-83
84-95

Sitter 0 ~ + REQUIA"ES FURTHER DOCUMENTATION


NOTE; II more than ona iTem on a line, circle the l18fVice indicated.

951.20

5 6 7

?,q

g-

DEP1\UL HEALTH CENTBR

~SSM
.. E" ...

l T I C A R.""

DePaul Health Center

2~

HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

MARCH/PHILLIP I/P 0127400691 MED 0524-01 10/02/1976 31Y M 10/02/07 RAHMk~,ANWER Z 000748298

1111111111111111111

DPM-1000471 (712007) PAGE 4 OF 8

DePaul Medical Records/Phillip H. March

000151

f5(

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD


KEY: '"
WNI~$

OATE STARTEO

':3 .-01
f.t,
At

I)r ta$k complete<l

IAlert. nriAfllM~ tAlI""'" M,;'m.M"


f

~~:~DD~~~~~_~m~_~~~_

* '" See additional commen1s


V' Y

Use bolded key lener if indicated

IJI~~~ltI

ILOG ISpeech clear

Confused. Lethargic.

Pc

ISpeech (Aphasic. Delayed, $lurred)


IMoves iIIllfilf1lll11llttl>
Motor response

Iv
./

oJ
~

A w S p.

(Abnormal !laxion. Extension,


Flaccid, LQJ;altzes. Hono,

SPastic, StronQ, We~t


WD-Wrthdnws)

GRIPS

ITremor.
1S-!!rIsk

PUPIL SCAI.E

S.Slugylsh 1nm zmm

C-~~ll>'''. C!(Jsed
1m",

Hi'~

.
JIllIl1

e.
1mOl
Ilm",
7rnm

t/ L?3' 1// J/ 1,/1,/1// 1//1/ 1,/ t/t/ 1,,/ L/ I,A 1/ 1// 1/'1,/1// 1// ~/ 1;/ l/ ~i{ l/ 2) / 1// 1// 11/' 1/' 1/1/ .// / l"/ 13 1/' 1/'1/ 1/!/1//1/ 1/' HAND IF:/: I/S 1// 1/ / 1// 1// 1// 1//1//1// 1/ 1,/ /~ /' /' 1//' ./ [1/ v/ ~//
ARM LEG

1/ L

IR/;'

Cc
1'!1'
r~ji

[//

!lu

!fjI
leI

1('/

Ii

jJ/

[i

S,ze

~. 1//'1//
'L

./

"

.,'

I.
'.

//

V V' / /

.'

J'

I,'

/' ',//

j/
to'/

Iv l,/ / / l//
./,/

.J

ReaCUr,lO

I;,

,.' . L [/ t,

j.

1/" L/ 1// , /

"'l./' [., 1// L/ 1/

1,//

.... / . / /

l//

1//

lDvspha{Jia iPrp'f'nl
i

Ah""nll

Numbness! TInglirlll.

R/L_
!

Posterior

alllooos clear

Abnormal breath sounds


Specify abo Jrmal breath sounds on diagram.

TIME

~ ~1m1m IE ~

a3D1

(Absent. D'lcreased. CRackles. Rhonchi, Wheeres. Coarse)

,~~:
L POSTERIOR

, gs
R
~

m ~
2

Il

TIME

~ DEam II
1

AI
Sr

H(

5~
l

V-----"

~~"
R

v------'"

3
4

CI

POSTERIOR

I" I n~.II."IUlY ./lUI!

UIll~UIJI'U

Iv

Abnormal fE splratory effort Dyspna3 (Ou Exertion. a1 Rest)

i Cough ICouqh and ,Jeep breath


Incentive spirometer # mL I # reps
~ -,' .'

~B:

i"" i .."" .. I . "'" 1-"

1-'"

j ... , .- 1-" ..

. ;' " f""'- ~ .."-'. ~".,-- f,r" ~/'" I,,'.... 1-,'" I,,"" L,r-- I?,.. I"f" I,,"" I,.,'''' l" 1,/ 1

I Sputum {dalcrtoll amount. Golor, I Suction (Nasai, Oral, Tracn) I Trael1 care

~
FI
81

Be A

La

o Trach Iype.

1-----.. , . I VenUlator SeltlOOff: 0 eMV 0 SIMV


! Verrtilalar . 1-----"

___ Size CI CPAP Cl Sf PAP Settln9s

NI

.~
.,'

(verified per arder)

..... -

---

m
si
$1
N

Comment;

Time

Locallon

Water Seal

CHEST TUBES Suction ..'"

Crepitus

Drainage

DEPAUL
0727400691

PATIENT LABEL

01
01

j/ ,./'
--"

HEAJ~TH

C~NTER

MARCH,PHILLIP

1101111111111111.'11
!VlED 0524-01

liP 10/02/07
000748298
DF

SSM CEPAUL H!ALTH CENTER

--

... -

,.,/

24 HOUR MEDICAUSURGICAl PATIENT CARE RECORD


DPM1000-IJ71 (7f2007) PAGE 5 OF 8

10/02/1976 31Y IWIMAN,ANWER Z

DePaul Medical Records/Phillip H. March

000152

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD


KEY: .I WNVs or task completed
= See additional comments Use bolded key letter if indicated

OATESTAflTEO

/0-3 '07

A-Absent
..Weak S-Stf(JIlV D-Doppfer Coloriemp sfnsalion
Will c 11;" l.e1 f"\' OJp !IMlt It!ll!\tn 3 ''ItlMl. sUn ~:JttTt wlh hi fiMSJ
~lalGiitlI ~1Im.a
amJOO1I~ m 11Ott:1

I! .. flu,,! T ~ Trw, 1 ~ 1+

II,

I.
I

~.
f

;)F;PAUL Hl:::ALTH CENTER

DePaul Health Center


(7/2007) PAGE 8 OF 8

MARCH, PHILLIP

11I1I.fIfIlIIJlIIIII~D1

lip
0007'18298

0. "
DPI

0"/27400691 l'fED 0524 -01 10/02/1;176 JIY M J-Q/02/07


RAHMJ'IJiI,ANWER Z

DePaul Medical Records/Phillip H. March

000153

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

MEDICAL I SURGICAL RESTRAINT KEY


~Pjl\RI\W!(!I!'iI!ilnl
1 t:f1HWilI'On "!tt}'Supetl'ts:~Qn

Ml!!C!l 8ymB [ill Ry"rujllt


1 Pmlf5:1 all 3J1ttitrlJ alfWir'f arn~or OXNtn ddvtl')' ft_tJ ' ffilJnl.&n tfidd!;;h:.rrl{Ilm(;i1affl1ub-ii50)

SIPt);"' di&lUQQ

DIal Rtkm

K ..

2 Clw", cr f(1 'MaW iX'~Wl* III (rt-MI. [lffi! lor ~1. 11'. lk.1 ,nWMtrhl!1!li m"'IIpulat_ Inw ""_ 51""00. sp.. .."iW cal !;'Jill. .1<.)
\ HMIityMttI':uwI>

to
~

!lm:Um>r1t U/rlij all<lleanwr. (i.e pt,


tiL'JI e:n1~ ~:tlruiffi>

ftlf.. )

M.1hlLlal inn6-N"& fmn Of h)=OO~ fS-$W\tJ~ to tilt 1rea1metJ1 C1 ,.hienh{ f::a"Yfti\t tY'tfUifton tft.-Q ' soti SClUf(,8 01 ntHotK.'1:t), jnl(~<ir.atioo aljfl~'Ie.JJ"lti1)f1 w IlJ(\l";\oon)

(.I) In ro,nl1OO lllIl itur.;""" 1"IIJw'1(J

I \JfJ.Ic)lt t~ tMUac! f(ll lately ? COil!. 10 PIli at rubes iI!()';. ctc

ntmS dl\CJ.111N WiIIllawner


I fmS(lI\ fiJl
~slr.lml

3 Acll'<lty ~!Il"I"'tratiS liil: ql r""wry


4
~~ brCSliO"rod't~:>it~, fil~#ij-~>.

f.k

[I ~;lli.Qn f '(attJ~ti:OO

v \lrI~11_1: CJI'/lly (MCl<n.>ts. <I(!Ias. v..alis IOU%. ,'I<;)


7 ~ifatr; Y e~~itioJn JIM niMtr!~>lln ~'e~.,e;jlt'l="," h:lt
Ot/l~.

1 j;&ly o!
'acn~es

paII'flI~

wno M! IiKiIjl'lt~.teo from "" i.,eiY 0' suroJ<;al

2 A5s"""'~!ml trnfl1ts

C&~ratr~

a<1d r~iI1i;1!l ~

pnx:cJjljft' Wliij WfJ{tld tiHff-p; hJf Ilta UijU'y tl tht')' ha-va e,,-c-e&Sllt

3 To;,! rffi.l'" h,''l'''.''''''


4 seillM@ IUlIllfW

lTl(!.rmern l1olfole ~ is modcoll, dWWll,i"1'I (00. ',.ltfemJy

t,,, ""'OJ'"

01 haIm to ~cH U1lJjhc<~ (~ Rttl1wifJ(;\j


.,lra!l1!.)

or 'lastWili sufge1'tS)

A!:TMTY I{EY

DEPAUL HEALTH CENTER

~SSM
~ f

.... I. T J\

'V A k

.-

DePaul Health Center

r1ARCH, PHILLIP

2t . HOUR MEDICAl/SURGICAL PATIENT CARE RECORD


DPMl000011 (1/2007) PAGE B OF B

I/F t)727400691 MED 0524-01 'L0/02/1976 31Y M 10/02/07 000748298 lUUH-1AN. 1\NWER Z

11111111111111111111

DePaul Medical Records/Phillip H. March

000154

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD


PREVIOUS 24 1/1); Intake OU!j)vt _ _ _

DATE STARTED

/CJ . c9- '/)7

241

I!lOLAnOH: 0 Special Contact 0 Contact 0 Nevtropenic 0 AjrbOln6 0 Droplet 0 _ _ ._ _

YeJllmll,y's wI.!J
Temp , ?Wse

SCALE KEY: 0 BeQ 0 Sfandillg 0 W/ChaJr 0 Sling OTHER PRECAUTIONS: 0 Salety-Fall 0 Bleeding 0 Aspiration 0 Seizure 0 _ _ _ _ __ I g,~ Today'll wt. KG (pleillle reconcile wltlght difference if grealer IIntll 2.5 ~.)

(,?

10".(.:. q"l
.2\
I

Iq~

~I
~/

~
lW

Iii?
102%/ Rate

l,\5l.., l/r /"'- . / / V 1-,// / / v / V/ V

1/ / , / . /... v/ ~C,/ L/ k::: l / , / ' / /-- ~_/' 7

IWO
liP
_~_,,,,-,
-/

"

02 d~Ji\l1!flllj OOVfC"
Bedside glucoSfi

Rf
11[$1'

I !!!E. .,"~ II
......
--'~'
;

In!'''''

~UlU

ITEM,

11' ~E

BP

!i'Ulif

""p

110 / ______ 8P " " " " ....


.//'

-,---.,..----~AI(FAST

.-------,---~-'
...
~

n.PHiTI.'
$lmC
If

lei}

flatillll'

11M
p

Snl9U P
DfiS1HYl

,..-/

.~
~)

~//

~-------

----/
LUNCH

.~'

DINNEI\"
IE

,~/ H5 SNACK

.----/

__

BP
/"~

funcliOi

txP.{J. I;(f:
J

I PC1 L![J

htaiu:ll

"
mOl!NGS Tf FLUSH
. Amollnt

R p/A-IIJ rJ
V

Bellavlo OIIalily

PIR<II"".!

_f}RAVT~E

. URtHE
An~t

Jl!I!ER
IJM
Amrnmt
!\moun!
: .0.111000\

TYPf

~:~

"1
-

i
-

ORAl. Amovnt

AmOlJni

Arnllunr

AmCJOl

Am)Jfreq.

~
~~.
1200
1300

Se1l3litJI
~-{.Cr
\.'-"'

X\
()(~

IntrIVlIll

UP

<1 1",(
:~,..

Initiali COMMI

1406 1500
~OO 1700

,BJU/,

')(-_\ v

....,
'iV

,~
<;./

t...r
""""

rx\

1100

S\lb Totals ~ 11 hi 12 I1r Total f".u~lllef If


To Count 1900
.-

.E~-it- _ _ - - - - - - - 12111 Toti! Oranuoo _ _ t


1;> hr Shiln"lItke

---

--------12 hr :,hiftQtltput

.:.-.s00
>-

=~~
0100

W()

.-r----

'vJ.L!A,fA-

"
"

lJ
L

fI

OlOO
(
[

!J'

i~

I
ij

---~.

121lr

Suu Tlltllls

----~-

1? hi TotJI P.ucillefill _

1~ h. Tolal OrilllfubJ; _ _
17 hr Shill I<ltake
r~.four

--

~----

.---~--

--

f /" .tr"O

hour 111111

,,",

...,..

12 hr Shift OutPlrt
~~

....

, ".....

FW!D [QtIIVAlE~ T8:


10z ..... .30'TlL

4 Ol (1/2 cup) .. 120mL 6 oz (314 cup) ... 'llDml

B oz (1 cuP) ....

. 240mL 12 oz (soda-1 can) .. 31l0mL

.
MARCH I PRll,LIP
0'12740069l

PATIENT LABEL

DEPAUL HEALTH CENTER

~SSM
1'!EALlH

eA.RI!

DePaul Health Center


- - .. - - - - ---

1 1I111111111110U II

. I/P
000',48298

tYA
H f

a, L l

Z4 HOUll MEDICAL/SURGiCAL PATIENT CARE RECORD


DPM100<Hln (7,2007) PAGE 1 OF a

MED 0524 - 01 10/02/1976 3lY M 10/02/07

RAHMAN 1 ANWRR Z

DPM-l00

DePaul Medical Records/Phillip H. March

000155

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

DATESTAATED

;tiJ~t)'/

241

APP

= A:l50ml

paIn pl~6nt
BRhavinrs

11m.
R8t1~Sme#

S~e "
# of,

SCilla Used ~r OllimallOll


hnCllon Goaf II DesCllbe:

FR, RT

location, Behavior nr APr


Quality

Frequ,ncy
AllflllIflllIng F"lm

Sedalion bYel

Inh:r'll1nthmhl
In~i31s

COMMENTS;

BEHAVIOR I PSYCHOLOGICAL
8EHAVIOR/RESPONSES,
III
~

Mulliplo R"'I"001

AN", Aru"'... E - Emo1lomd [,isIr~s


I '" I""lfucti,.., C'pm9 o '" OovBlopm&rial Im~.irrnllnj

C - Con1inuou~ Crying DE = O;lprntiQI'I


G
~

Grt....ing

I.; 1.$Ihf!rQi<;

U = Unnw"omJ"a CO= COmato" CI ~ C<;gnitr1i1'mpiirm91'1l R = R6SI!&"

co = ConfuwdlDiwri<>nl<td H = Haliveillation&i D ..lu$loml


W - D;I!lb."'1e1y WiUlnolclil1\l
Inl<> A ; A"""llOn S'vktnQ

Of'

= Di.,UpW9 Palienl
Slgnifi""nI Otl>er T_atlnlng Phys.eal

1M'" Imp",.ivo

OS = OisruptivG
T

10- Slttf)ir1g
0- C-'mlQ\!i9I
COP

o ~ OvImUmul'l~dfOvv",actlv.
Offo.r fraquont bria1 oon1m::1

HarmlC'XTttnllvi
f4 RotJtiunt

I.A

= L*n AnxiOUI

=Coo~r.1t~&

INTERVENTIONS:
1. Roooaumnc:u Jlalloni J S.lgniflcarn OIhDf

a-

I RamoHY1!to J "Rnstating faC1s

2. Realreotitm 3.. Ciuidanctr


~.
~.

9. ProlltdQ in1armation to h~(OOb'-D I{fllel o.f tJoderstanl1ing 10. Encou,al/" tamar 10 !>flOl/'" IannI , object.

15 16

DivnGtonal a-C:tivi1ie~ ProacUve. m9RtiUfQS

COOlilitllnt E<wlronm.n! I RoV1U1.

II, Provld& r.taxatlon wilh rnu~K. imitg9ly. deep Ilr9Wl\l/. pra\illr. m&(/IC11100 17.

I;

Elllbiish ma;m.inlldlimefrimps for care needs 12. Encourage norm&lsleep cycle Dy uSing Indlr"lilQh1in9 aflQl' dark E1WQLY~& vl"ballzmi(m 1S O"r'.~n room I Umfllng touch I 7. Enoourag1O pntilml wnh <lecl.ton ITlI\klnll for OOID noem. Q,jlet .111" to p~tl;>nf'. '""pon." 1<> .Umutation

0;1""'8.'"

Reasi~1 I RlK\Ue$llon l Se~k claril'l(;<lUcn 18. "5m1>1I5h boundllles HI Provide lot~n!lv. IIX'tJ'lIy and ,Moly "'989me$ 10 mlnimlr8 bat-a""",' prohfem3

PATIENT LABEL

~SSM
K
~ ~

DEPAUL HEALTH CENTER

L- T K " t. #I. R

~.

DePaul Health Center

MARCH,PHILLIP

IIIUIIDII.IIIRII~

r/p

{2'
H A

24 H('UR MEDlCAUSURGICAl PAT(ENT CARE RECORD


DPM1000-071 (1/2007) PAGE 2 OF 8

072740069l MED 0524-01 10/02/1976 31Y M 10/02/0'/ 000748238 RAHJ'.1}:I.N I ANWER Z


OPM

DePaul Medical Records/Phillip H. March

000156

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

S~e

#3
Nt

# 01 attempts for IV rBstart

"~'

1,

I--

~, ",)
\ \

BACK
,M LT

t-!-(-:-:::-, -It/IJIJ-lum-:~_---t-0 _ _ _---t-0_______-!-s_ _---:---t-u....,


TLC-Tril!l</(JIllI!"

{, J

tjFilJ

, /,':fJ

\\1\

SLIDlfTlC

SLiDLITLC

Insertion Date _ _ _ _ Lenqlh _ _ em


Arm circumlerence
em

Dresslf1(l changs daIs _ _ _ __

,
I

i , I:

PATIENT LABEl

DEPl\UL HEALTH CENTER

~SSM a r
It
It \,

K ' (. /II "

r-

DePaul Health Center

MARCH, PHILLIP
0727400691 lO/02/1~7&
RAH~~IANWER

IUIIIIIIIIIIIIIIIIII
I-IED 0524 - 01

II P

24 HOUR MEDICAl/SURGICAL PATlENT CARE RECORD


DPM-1()(){'~71

31Y Z

M 10/02/07 000746298

(712007) PAGE 3 OF 8

DePaul Medical Records/Phillip H. March

000157

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD


Patient .Care
ACUIlY LEVEL

DATE STARTED

I() ';;., 'tJ I

Record

Points
2637

level Subtotal SMtlon ''A''


1

ACUfTY TOTALS .. -

C,

38-55
5670
7183

2
3 4 5

Subtotal Section

~Bn

~f

Subtotal Section "C"

1
I/O.
,'r!
! i

84-95 96-120
121+

TOTAL POINTS
Sitter 0

6 ACUiTY LEVEL
7

.;

f'ATlOlT LABL

! - -+ ReQUIRES fURTHER DOCUMENTATION

NOTE: If mom than OfleltefTl on a hne, circle thD sorvice indicated.

~SSM
H l " L. T H

'O),,,~ ..

DePaul Health Center

IIII~IIIIIIIIIJIII'I' MARCH,PHILLIP

DBPAUL HEALTH

CENT~R

lip

24 HOUR MEDICAl/SURGICAL PATIE:NT CARE RECORD


DPM-1000-{;7' (7/2007) PAGE 4 OF 8

0727400691 MED 052{j-Ol 10/02/1976 31Y M 10/02/07 RAHMAN,ANWER Z 000748298

000158

DePaul Medical Records/Phillip H. March

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD


KEY: ./ WNl:!. or task c()mpkJted

DATE STARTED

16 ;J-07

24
KE'I

*=

See additional comments

U5e bolded key let1ef if indiCalQ'd

},piC Abn
Peril
AA w-\

$S
D-[

Cole
VlNl It;JIIf

s~iO~
[illili

al>10

San

pac
T[

TEE
Se[

Se[

AV
SpllcHy abnormal breath sou nos 011 diagram (Absent, Decreased, CRackles, Rhonchi. Wt'6llZ11S, CQars6) Bru Her

CAl Exit Dre


L POSTERIOR
A

POSTEI'lIOR

Abnormal respirlilOlY effort


Dyspnea (on Elrertion. al Rest)

Ati~ AM
Bo~

Bov

Ab: r-

~
~

Las'

IBa

Tut ! , OS!

I Sto

rSlo
~

PAr/ENT LABEL

lOS!

DEPhUL HEALTH CENTER MARCH,PHILLIP rip 0727400691 MEn 0524-01 10/02/1.976 3lY M 10/02/07

IIIIIIIIDIIIIIIIYII

SSM DEPAUL HEALTH CENTER

24 HOUR MEDICAL/SURGICAL PAT1~T CARE RECORD


DPM-l00().{l;'1 (1121)01) PAGE 5 OF 8

RAHMAN,AWnEg z

00074S29~
OP~

DePaul Medical Records/Phillip H. March

000159

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD


KEY: .' WNls
Of

DATE STARTED

task complel6d

* = See additional comments

/0 'r:?: n

2l!
KEY;

Use balded key letter if indicated

...

Peripheral pu ses
A-Absent WWeak
S-Strong a-DopplHc
Urtr isp
llrir
FOl

Color temp s'lnsation


I'INl _ Nail bed
)~It.

tap

VQi IVI

Abr
pm

CBI

!leQ
Su~

Ora

11:

~SSM
MIA1.fK

(AIIt'-

DePaul Health Cerlter

DEPAUL HEALTH CENTER


MARCH, PHILLIP

rlnIDIIIYJIIIIIIIUII~

rip
000748298

o ",
DP

24 HOUR MEDICAlfSURGICAL ~AT1ENT CARE RECORD


DPM-l000-<l11 (712007) PAGE 6 OF 6

RAHMAN,ANi~ER Z

0727400691 MED 0524-01 10/02/1976 3lY M 10/02/07

DePaul Medical Records/Phillip H. March

000160

24 HOUR MEDICAL/SURGICAL PAT.ENT CARE RECORD


KEY: .; WNE:1I !;II luk compllttlld
'" SiMI Ilddltl!;lrn'll !;ommlmN Use bolded key leller if indiGated

DATE STARTED

10 OL '0 7

24 t

Urll1e CViClflClanly

BIQo\ly ClOt .sC\l!!ll,'Ilt


Arl\Jli~,

FOUIsmelling CI.GUIly Olner YQiQing,

FuJw.
Re!ef Oon,

IUMjiiJIlie ealll.
Abl1Dlmal urinaryvli6ing paltem' Inellntinenl,
FIl't[Jellty,
U!~Clll'"

Dysuria

AtTEflfD SKlNtWOUHO IIEY: PU ~ Pressure ulcer If jlTe,.,;ure ulcer. list Stage I. II, III.

'" 1it>r,1$JOn

ItL

. Blistar

L
R T8

= IncIsion
~

laceration
R;rsh

IV, UNstagtable V
N
55

'" Vasculaf ulcer (venous ,\\Isis, art~rial

=Neuropathic ulcer (diabetic) = STiIfi sr!!ps = Oermabood =i)laple<;


O~n

\m;lJfficiMcy)

SR ~ Brui~~ D - Denuded E '" EI ,'!hcm~ EX = Excoriafioo H = HemaloTllil


Sunournljl\~ I IrJaCl

Tape bum

o
= GrAAn

WA '" Well ~jljlI~;\imaIQd

=(IlMI _ _ __
Drainage Amount:

Oresslng: D
8

Wond Sad Key: Q = GrarwllliM S : Slough


E
e

E<dw
O'J~l

E II

= = ErytIlema

Sflln lay: D.alnage Typa:

o
S 88

liIe = St.
5

=:

M1r..e:abon

OTA -

to all

o -

= 59JO"fl()lllre!","
L
~

SelOUs

= Smilli
~ M01li!ram

R
DI

= R~!~lIligll ~U!IIfCO

C - Cyall!lWDark _ _ _ _ _ <I '" Oliln

PU - P.'<1.Jlenl

- WrO$

'" 61w4y

'"

(;QIIlWJ

=Mo"I~~.".y ;\fav>
Drainage YIN

- Dry an-.J IfIlaCl

-Otner _ _ __

Y C

- '{flilow ~ C1u>ly - DtM, _ _ _ __


R~assenmefll

TillUl

Sit! .l~.

[)reulllfl
"

WDlmd
Bed

I}ralnage Amount ot Odor


Type

Tim e BAli Initials

ONR C{

eI~SSM
H II ,. L T
.joI , .; \

R ,"

DePaul Health Center

IWlllllIlIlIIIOn MARCH/PHILLIP

DEPAUL

HEAL1~

CENTER
lip

.~
H E A I

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD


DPMmOO-<l71 7/2007) PAGE 7 OF a

0727400691 MED 0524 -01 10/02/1976 JIY t1 10/02/07 RAHMAN,ANWER Z 000748298

DPM1

DePaul Medical Records/Phillip H. March

000161

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

~r:d

mAvgtA Rt2ifllru

MoDICA!. RlJ.iqft 101 Bw,atn\


I PrOk'{.1 all nftiftUa il..ir,'4ar OJH1!Qf a;(~n I!ehH'f {e.g.. 10

1 Cl)mpaJnQwm!l'~pe-IVis!OO

GocUIru!rtf

Rlt:trJlot fdU1fiUoo OntR aM1 i,:,o,;f(i!1


c(l')

IWI Hrtl!;nft KBy


(1.1\

pl

<

2 Cl/ir. '" tJ n"",1r 001>:,,,,,,,,, Rl: glcd, reed r." rV TF, eI: )
:\ Fflvi!{inmeort.,j H!Ull~tJ..JHf.1fl!J (ec::11 rvtS1!'j >Jt.tiIQJl,

'Jwxlal

moInIain en001RI<:In&i1tWh.'ltJ tutts) , ~t6flt.Wl ul'IJo;-lor-e HIt!.,: Of IJ.d.'(,"J C'3:SCilt41 to tht' trNtmcn1 01 {tJ!l
patkot"
OL"~!l1 "\)!l<ii<i~" (~.q.

V'f'",'I. ,~... tl'SC.

I
2
~

i)nai}ie

to cOlltract Ii.\!

saf~1

VI'" oWV~iWon OC'II'lllt<lH tG!oAng


atiN Oli(illl!O With
le.m~r

e..~. In p.al 3' h>h,.;. &n,,, It


An/firf {ltJT)<j/\WftC) (.Sh Of f!i1ljlllY
Co~m!1ve

cailt<llt eli 1
:\
5

Rr~.Jl~y Of~.'J
nrri:ls~\ll

f.Jtu.vI

$* $CV~~ of l'>'.arfuo.',

meOkil!lon B&nlllilt'alln 0' hydr.t,l)Jlj


{fUlj.,~llt~

1 RnS0l11O!(Wram\
'.I. As5a~J11!l1l YIfAA h,l!Tw':!\

M~'lk,'t~(Hl ..t;"AB;)lI{~

tr:1idy

0tltlif., w,1lk5

I!\:l!~l:

t:k)

~Mif:ntif,]m

iy oot:r-..310l

S"rcty p.r,:nts who arc inc'f'l,iIale" fr"", .n i!liulY (jf !uflliw IllQteQij," who \I'cuid svtkr (",lIltr.l i lnty t<AVt fXCt.<i'l mQ\,~leN. belm it Ii 1!ltO,.Il!y awo:m!le (e.o.. erut!l'll1y
frK..w8s or Ya-sttl~r S\Jf9'ftrif..~)

0'

,.,1IBrrtr'l m roo.,.,. <YWif'!}f.. ""\$.'. i<lr. eM re,l!2ln' WllO'fe<l


{~.Fp.

1 111\11 "'.,,"'" Im'l'!!',!!"" 4 eetlav!}. reqil~eO !(jf remM.1

B Uf rurm In !\Ait (jj ftft\P.{.~

R...t'~:>jH)f<l1

nestri!Mt$j

AN! UlildOl.' i~n sls,m''ilif.lreiilm\j tPil

OOtu.

4 PrI)le<t1he bfi\in ml\llY p;W<1 110<\1 1\Kt!W tnjUt)' [Il-Q eVA ""lh
pa'alyhlS

o nH"VlllMlIl'iSTlWNT1;
(t15 f(Jfl dl)t~nrr~ittUJH

or Man trdUfIU W!l1l.001....1 ~""'J

s"" .<lOiliolldllwwst'Ollt lill

iii, Sea

ACTIV TV

BSC= 6edsi<le Commoot


A = Ambulate
C = Cha1
D '" Olingill

, EY

POSITIONING KEY

R = Right L - Left
5 = Self P", PlUne

D - Back

~SSM
" " Ii t 1

C" R ['"'

DePaul Health Center

MARCH,1?HTLLJP

DifliiilllilillCENTER 1111
MED 0

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD


DPM1000071 (7/2007) PAGE 8 OF e

F.AHMAN~~E~l~

lO/02(

0727400691

524-01 Iv! 10/02/07

rip

000748298

DePaul Medical Records/Phillip H. March

000162

~!I~S~4~o~,n~ED'_CAL~::p~RGICALI~!!!~~S~r.:!~~ ~:~~~?upenjc Ail~~;~eS~R;!~!et ~o 'j -07


0
SCALf KEY: 0 B XI 0 Standing 0 W/Chair 0 Sltng OTHER PRECAUTIONS: 0 Slll!rty.fall 0 Bleeding 0 0 Seizure 0 _ _ _ _ _ __ Yetlerdar's WI. _ _ _ KG T~day'& wi, 16{d IB'S-mf (Please reGDnoile weight tiifleJeflce It greater tllan 2.5 kO.)
. T~mp

24 H

Aspiration

PuIsB
Re('p BP

02S2l
02%.!FM~

//

y/

/ / ' , / / / / r ,,/~

r'-"
IVL

'.

.....,"~

TlMI

'I,lm

RESP TEMI

----~

l// / / / / ./.,:: V l:7'" / / V

..--

----

?;?,
~

"11L

I//' l-/ / / , / f ~ ~/r [ / / / i/,/r V"

;;2.1

)riJ 'fJ./i

filii.

T1M!;

liP

'PilLS

RESP TiMP

TIME

BP
/"/

PU~E RE8f TEMPO

."" ""~!!. ""


11

~~ . . /.<

~r

r"r/

~
//

....-r'-,...-r"
....-~r

.~
D

...

Rating S

DfiTHO
STATIC

TIME

iTlME

BP
/,/

II!'
.-r""

....-/

"""
liS SNACK

~~

BREAI fAST
i

LUNCH

DINNER

!
I
I

takcl1

I
ORAVTIJBf FfEDIN(;S ORAl Tf fl.Ustl Amcun\ Amoun! Amount

QUlIIlI'(

URItIE
AlllW(ll

OTHER

TYP~
fuCOUll1

Frellnn

8M
A,'1(l\Jlll. Amount

_AnlUn1

Amnunj

AmnunI

Am1JFf6Q

"g;rava
Sellall~l

0700
0800
-

~~~~.
1100

-"I

I)

mil
1300
~oo

1\ !J ....

OV
,\

1'00
1600

1700
1800
Sub Totlf&

"
~

/'

I'

m I" ''/:..
,/'

.1

.0 rrvv .."....--

l.

---

..--'

.-

Inlu\'~~

lniliils

\2hr

_______

._ - -

1211r Total ParenTB al


10 (10<,1"1

12 I~ lolal Oralrrub~ _ _ 12 hI Shift Intake

----------_
12 hr Shift OUlnlll

~OO

ZODll
2100

INTE~ 1. liaR' 2 IWd

2200 1300

a.

Gul(

4. Con

2400
0100

.. -

ri. Eow

e,

En 7. Em:.

0200
0300

04UO
050(1

..
._._--12 hI 101<11
Or~\'Tiih
----~---

Benavl

0'00

12 hI S'Jr,TotaI5 _ _ _ _ _ _ ..
12 hr Tolal f'wenlu1!: _ _

.-

__
,

Pa1I8n ImerV8 Respo

12 h'

Sh'!lll1l~\~

12 fir Shift Output


.... "'1
lUUl

IWltllty-lllUJ llOullolal

"u'" tolal
PATIENT LABEL

fLUID EQUIVALE 1m:

10l

.. 3JmL

4 OZ (1/Z cup) . , 120mL 180mL 6 02 (3/4 cup)

8 (II (1 cup) , .. , '. . c40mL


12
Dl

(soda-I can) '. 360mL

.
D~PAUL

~SSM
N ! A L,. Ii C.

I/P 0727400691 MED 0524-01 lQ/Q2/1976 31Y M 10/02/0'/ L -_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ANVlER _ _ _ _Z ____ _ _ _ _ _ _ _ _ _ _ _ _ _~., 000748298 RAHMAN. OPM-1000-071 17/2007) PAGE 1 OF 8
24 HOllR MEDICA!..JSURGICAL PATIENT CARE RECORD
j

---

f:'"

DePaul Health Center


.

HEALTH CENTER

.-

1IIIIIIlIIIUIBIIIIIDU MARCH,PHILLIP

OPMi1!i

DePaul Medical Records/Phillip H. March

000163

24 HOUR MEDICAl/SURGICAL PATIENT CARE RECORD

DATE STARTED

1 Medicabon 2 AmbulaMn SliVlllly (\Iowsy. ea'J{ to arouse


APP

9 Heat 10 Culd
11 MUSit

11 Fnldurol

t8 PGA

3
6

R~jlosltlOn

tS Preempd'll!
analq5'J

= .~S"'Jtl~

pam pre,ent BellavlOrs

A{,!j,ity

Re st

3 rrequently owwsy. arQvsab!e. eyes rtriH c1n;;Ro during f.OrwersatiGn


(consider re6uclnu oplQ!!I don)

4 Remtion II Calmtn9 StJI!<rnRn!~


PfaycliMc(i,t~wn

12 louch 13 imagery 14 Mm.3a~


15 [liSlI.Clr;'''

20 Continuous
anal~jC

infusiOn

PrGt8dur6 Other'

4 SVlIlllub)nt. olHiovff tv .J(ousa

e rHtap Br~alhrng

7 SplrttuaJ CalB

21 OtIwr'

16 E(!ucatron

Time
Rating SC:N' f1
S~BIf UiieiJ9r ObijrvaliQD Fun~tiDn

aDa/II

Ot6cribe: location.
B.havil)f er APr

!~

Quallly
frequ~cy

Sidalln Leval
IQwlYentk n{ s J
IFliUill~

BEHAVIOR I PSYCHOLOGICAL
. BEHAVIORlRE8PONSES:
r.I

AN Am lOllS
E. Emelle""IOililfasfi 1= Inol1",II." C<lping o ~ !l<I.il<>pmvnlol Impolrmer11

C .. Conllnl)Oua Crying
DE ; Dep",,,,,lon 0 Q Gri.v;n" l = L9tn"'9ic

=MU!\lpte fl8Qu.n

\J " Unrespons"'"

CO Comilt"ic
CI - C"9nil;v& Imp<lirnwnl R - Re.ilow 0 = OV~filim-.t~djOV'ilr8a~v"

r-------------------~------------------------IHTERVI;NTlONS:
1 R"""",,,..,,,,C6 Palillnll 2. Rediruotion
3, \3Yidatf(;&
SI~ni!lcanI

CD = Co"tu."dlOl."".nto<f H = HlllIIIQlnvtiQnlll "'~I~~I~M W - Oe~lXIfl>te!y Wrthholdin9 Info A ~ Allent,on S"lrlng

OJ>
o~

Oitruptivo Pallel1l DI.lUpl",. Signlilcant Olh .. , T = TtIPeBlenlng PI1yslcal

1M - ImpulWi.

S = SIplng

Q ~ C"lmiO",,,1
COP CODf"'ffliive LA = Le"" AmlolJ.
Re$!atin~

HArmfComhafj'iil

----------------------------------~
14. Reorien! f RemOlivate I
Div6fGIonai aClivitiOl
Proactive meN/ulet

OIMr

t;.

Offe, tt~quomt Met contRDI

lact$

4, Con&IHenl Environment I Rol.lllne

!>. ~~u.bish milnWMo Umif,limes to, eMi nood. e Enco",o.". wroaIJzaI!,,"


7, EncuUl'lIgll p;1tinnt with dOOiSior\ making. ror cars
n8ea~

9. Pro"I!Ie Inform~jlo" 10 I"""""", 1 ....1 of ""dDfGlandil1(j 15. 10. EnOOUf"l}" family '" bring in familist objoota lfi. II. Pruvi"" ,qI"""Uon w~" llruslc, imall"'Y. d.... p brealhlng, prllysr. meQlcAtion 17. 12. j;;;cuiilagi! ij(jll\\al ~lNp eytllllly uviflli/ ifl(!I~lli~lltll\g iIItil' !llIk HI 13. Oarluln roOm I Wmitlnglouch I 19,
QII191 s!9n to

Re&SlBI J AlIqtIe~ll<!n I Seek clartflc..Uon

dee.el>" rn.1!eon f6:lPOfl3e 1<> .!im,rt.tf<m

""I1!JIIJh 0001\{1ftI1!i PfQVtd9 Inlu051vu .ecurltv and rely mW6ur". lu rninimu.e bahaviora' f.'ro-ol .. m~

PATIENT LAill'L

O1!'t?SSM DePaul Health Center


H Ii ~ t. T
jo(

(A. R 1-

;~4

HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

OPMI000'()71 (712007) PAGE 2 OF 8

DePaul Medical Records/Phillip H. March

000164

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

Site #1
Sfte#2 Site #3
# of atternpts lor IV restart

)".-.

-\

BACK LT
Sl. SlflfjtJ htWffll
()L~()~_

I Sll Dl ITlC
LcrT
0

S
Sll DL/TLC

j }

/'1 ( l
~'h'

l\
K

lie

iii

T'~I1h~ "WlPJf

Sl! DL/TLC

\\1\
.IIJJJ~

Itnm.':t}f(.' ~.:~."Y1f1JU ttl'

RlGlH
P A

IV flIl ,'<0$ (ffcwk<l.

l[i

J /

IE\ \\

V
Dresslo~

Insertion - Datil
Ann oireumfomnce

Length~. "

em

ChanQ& date

em

I._-L______~--________._---PATIENT LABEL

~SSM
H eo: 4. i.

1i

A. R -

DePaul Health Center ._----------------

DEPAUL HEALTH CENTER


V~CH,PHI~LTP

(4 HOUR MEDICALiSURGICAL PATIENT CARE RECORD


DPM100)'071 (7{2(07) PAGE 3 OF 8

07274006~1 MEP OS~IO/02/07 10/02/1916 31Y M 000748296 R.n.HI<1NI ,~WER Z

11111111111111111 ~.]

1/?

DePaul Medical Records/Phillip H. March

000165

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD


Patient Care Record

PATE STARTED

I0- /o~

AcunYlEVEL _.'
Poin~

ACUITY TOTALS
C---

lev@1 Subtotal Seetion 'W'


1

26-37 38-55
56-70

2 3
4

Subtotal Section "S"


Subtotal Section "C"
TOTAL POINTS

{LS

71-8$
84-95

7
.1, 7

96-12U 121+

5 6
7

ACUITY LEVEL
Sitter 0

+ REQUIRES FURTHER DOCUMENTATION NOTE: If ilIora than on8 ilem on II line, circle 1M servico indicated.

PATiENT LAtJEL

~SSM
Ii [ ,\ l T If

----,,---

CAR" 1-

DePaul Health Center

DEPAUL HEALTR CENTER


!'ffiRCIl, PHILLIP
072'140069:1.

1IIIIIIIIIRUILIal

lIP

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD


OPM-1000Q71 (7/20071 PAGE 4 01' 8

MED 0524-01 10/02/:1.976 JlY 1'1 10/02/1)7 R~MAN,ANWRR Z 0007q8298

DePaul Medical Records/Phillip H. March

000166

24 HOUR MEDICAUSURGICAL PATIENT CARE RECORD


KEY: I WNt:::; or tasK CQmpleted

DATE STARTED

!O L .c57
K

:=

See addl1lQnlll comments.

Use bold&Q key letter If indicat;)(j

~
r\

,
"
Motor re.'qIOHSB
(Aboormal flllxion, I!xtension, flar,eid, Ll)Calizes. MOfIC, SPastic, Strong, Weak,

Wo.Withcraws}

TIME

Specify aI. normal brealh sounds on dlagram.

(Absent, OecmaS(lo, CRackles. "hOllChi, 'Vflll6lBS. GQarse)

POSTERIOR

POSTERIOR

A~nurmal

respiratorj effort Oyspneu ,on Exertion, at Rest)

PATIENT LABEL

DEPAUL HEALTH CENTER


~rHIPHILLIl?

11U1I1I1111I1II1111

II p

SSM DEPAUL HEALTH CENTER 24 HOUR MEDlCAl,!SURGICAl PATIENT CARE RECORD DPM-l(l{O-{l71 (7/2007) PAGE 5 OF a

0727400691 MEO 0524-01 10/02/1976 31Y M 10102/07 RAH~,Am1ER Z 0007487.96

DePaul Medical Records/Phillip H. March

000167

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD


KE't. .; WNLS or task completed

2
K

:=

See addi1\Qoltl comments

I~r:tl

I::~~:!:~rl.
LOC
Conll1Sed. Lellla[9ic.
, Speech (AJlIasic. Delayed. 6iurred)
i

r:; m III! lEI III m~ 1& _ _

USliI bolded key letter ii indicated

-~ V
Iv

~Ilrl

A
A
p

Mans all,,,,, Gil.'!*',., "i'..'1 equal strength


Motor reSrmlJl!B

ARM R,<
LEG

(A/l(lormal flexion. E!tlension. Flaccid, L')Calires. Hooo. SPastic. ;itrong, Weak,


WD.Wrthcraws)
Tremofll

V/
.i

/
/1/

;/

-.~/'~" 1/,/ /
GRIPS L

R/~ 1/'/ /

/
/

// 11/l,/I //
i'

//

//

// / ; / ,//

1//l/' V 1// [//[;/ l'~' l/ 1,/


;/
[.. /(

// 1/ 1// Ii // ~/ l/i VI .// ~(/ ~' ii/ i/i / / // // lL/ 11/ 1/' ,// / // L/ // 1//1// l'/" ~/' V/
,/1 /,1 // ,/ //

1,/ 1/'1//

1//

Iv

l-

f---

PUPil SCALE
B.firlsk

8-SI1190i~ I""" !!wm 3m'" 4mm

.
6mm

',fixed

C-SvroIleJII Close<! 5,,,m

ee
7"."
..

Size

l/~' ~,/ / / / / / ,/ // //
.L

IR Reaction l?~/

/"J'

1//1/'/ ~/ l//I//1.//~/ ~/I// 1.// ~/ ~/ //


~/ /
~>'/
I
I

1//' / /

,/ / / ' ./ ..... 1/,/l,,/ 1/' l/


//

1//

://

~I~ I
~
,f

."

/"'/

l/

,..// l///

1//1/l/' !.././ ,'//


- -

~(preSB!lI. AuSen!)

IirotlP
rv.,,,,,u,
Spec~v

~'Ti~

l i L _
,,~

am r;m 1m

Abnorl11al breath sounds

TIME

a\l1ormal oreath soundS on diagram,

(Absent, Decreased, CRackles, Rhonchi, Wf'.WlllS. Coarse)

:rl~~
L

~\

~ ~ ~RImID~ IB Btl m
~

Iv

""E

~;~ a~
"
5
~

(~

~~3
R

~4
POSTERIOR

POSTERIOR

,wV/'",",' ,

.unlaoored

.-V

Abnurmal respirator; "ffort


Dyspnea :on Exertion. at Rest)
i

Cough \.
. breath
t[\miiyg Sfji100WIN

ICough an'j

fI mL f /I reps
. color.

.",J

__,r-

.".' i ,r

1,,/' 1,.,,'/1,.,-' 1"'/ .,.-/ ~"'/ ~r/ ,,/

",/'

1,/'

.. , /

. - . - ' ,~~<

_/~

,/

.. - , /

J/

f/'" i

e /'

Sputum ."'"

E(iNaSal. Oral, TfllChi

Tmcli care
o Trach 1'pf< _ _

Size

V~/T1ilatol settlng {verllied per oroer)

o CPAP 0 BlPAP n. '0'""'''''" '''''''''Y~;

-'---

ICMV DSIMV

Comments

n;;;-

CHESTTUBS

PATIENT LABEL
Cf~

location

Waler Sl1al

Suction

.D~

/'
//

DI<.:PAUL HEALTH CBNTER


l-tARCH, PHILLIP 012H00691 lv\ZD 0524-01

111111111111111181
t,\

I/P

//
SSM DEPAUL HEALTH CENTER

24 HOUR MEDICAl/SURGICAL PATIENT CARE RECORD


DPM-1{l(O-U7' (7/2007) PAGE: 5 OF a

]0(02/1976 31'1'
R.fI}lMAN, WiER Z

10/02/07 0OO748?98

DePaul Medical Records/Phillip H. March

000168

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD


KEY: I WNL:s Qr tfik completlld
...

DATE STARTED

_-"-/'=0'--1/,-([2",,,,',-,,-_

24
TIr

= Sve additional commenbi

Use bolded key leiter if indicaled

Pelipheflll pub;s AAbscnt

WWeak
SStrong
D-O~ppler

Urifle
Is pal

Color t~mp sl;r.sa!lon


VlNl- NaltlOOllliLtlO
rr,M:t>;lts'!i!han
3~WIfB

$'.W".1111 w4J1 fiji *"Ia


ton to t""ch Dnn tt
<llillMmi," 001'$

Urirn: Fo"l Voldl JYjlf.


AllI10

FraQ\

CO! {I lleo c
SVJlft Orain

seDS

=on

0 := removed

DIALYSIS ACCESS

----~-

SIIJoI

"'au...
Diap: Muc(
Skin I Heet
WOOf

AV fisltJla/Grat Site:
BruWTtlltfl Hemo access

---~=;;;....j~..-*--*--;.J--4--;>+-*--;>I-+-J-*--+--;.J---+--;>I-,*--="-:.I-....,.t.--;.I-""!---;>I-+~--:l

CAPD calheier
II sk

-, I

l
E o
H ,

DEPAUL

~EALTH

r~CH,PHIL~IP

11101111111111[1111118

CENTER I/P

24 HOVR MEDlCAL'SURGICAL PATIENT CARE RECQRD


DPMl0000r (7/2007) PAGE B OF 8

MED 0524-01 M lO/02/CI7 RAHMAN,Am~ER Z 000748298 0727400691


10/02/1976 31Y

. j

DPM

DePaul Medical Records/Phillip H. March

000169

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD


KEY: .' WNL:s or task completsd

DATE STARTED

La

i (J7

~ See additional comments

Use balded key leiter If indicated

II skin with airef8liOllS: IrnJlcale sites with numbers on ligures

ALTERED SKtNIWOUKD kEY: PU Pt~S:;UIa ulee! If r.ressure W;er, fiSt Stage I. II, III,

BL 8ft

V
N

= Vastular uker (venou~ slJsi;. ",ten.1

IV, Ultstageable

= NeuropaUlic ulcer (Oia~efic)


= Ot'tlna!Ju,,"
- Stoplas

insufficiency)

Dressing:
5$ - Sterl SWpl

WOllnd Bed Kty: a - uramn.lion


S
=

SIlIfOl.lll~lng

"

D I! = E,yUrema iiI ::0 FxtoRlfion = HemiJloma

- Abrasion Otister = llrviSC = DSlllIflRd

I
L

Te

,.,lncisMI = larlYalion : Rash % TaP'l bum

WA 0

= Well apPfo~jmared = Other


DrIIlnigt AmoWll:
IIC ~ SI.""I!

D
$

SI<WlIIi

OTA - OlWntlJalI
R
DI
M

o = OO,er _ _ __
Time SNe No. Omaing Wound SUJfIlundlng Oralnagl Anllllml III Odor I/e~ Skin Tvpe Ur8inallo YI H
Tt~lmenl

= Ri!lMtim ' 'Itiff'_' = iily and IfIlact = Monll)(llMfY Jraf'~

Ii = Es..-:hll () = OWr

J Ii

= Inlacl = Etythema
Ull1"

Skin lIer: DllIillllg' Typt: G = Gtaun

II

- Strous

M Macer.1oon

C - CyanotlclOa1\i

= CfU~1y o = Othflf
C

111 = S"w"illly"iIY_'JU1 lit PU - Punll!mt L B ; 61001!y C ., = Y6hw

= LM06

Small Mwer.te

= C<lJ;lous

.' IMI~alet

lIeo$$1i$$melll

ND GII1n9fl Time and Initials

~SSM
IoIfAt,.T--I,ARi

DePaul Health Center

DEPAUL HEALTH CENTER MARCH,PHILLIP IIP 0727400691 MED 0524~Ol 10/02/1976 31Y f'l 10/02/07 000748298 RAHNAN,ANWER Z

1IIIIIIIIDWIIIlIIBU

III HOUR MEDtCAUSURG1CAL PATIENT CARE RECORD


DPM-1000.Q71 (7f2007) PAGE 7 OF 8

DePaul Medical Records/Phillip H. March

000170

24 HOUR MEDICAL/SURGICAL PATI ENT CARE RECORD

MEDICAL
~i.&d 19 Aypltt

BluhohD

MWlCAL 8 ..... t9r 6tlltl\1I1


I Pmtcr1 an artlf~ll flct!W{fy ur~<"r;! Ul)'~\ de!<\.iWf {e \J 11\

Rntralfti

EttU!@t1t1n

Hi;!! RehrJg!
tJ)-!Co~NfIl.Q

Key
!lt1tr~~ t;ftet..

1 4iJmparl'l'Jfi JT-p!;j~s;un

Ooc.menl tiro, 1110 Iwnw, (ie' ~l.


wetll.i~H,eI';;
~/l d1

i ,-h,hie to CCn\<lt! jo, ulety


2 Gcrtl lJ) ,ujjl .. " P.:1f.

2 Cnar.qf 0( IJ I1'inItl (>Ol1'""S{.q-~ ii' lfHI'J! OMi! 1Uf IV, 1r tIc,) 3 EMUorlll1e~laJ msn'9l'lat.iG<l1 IMa! W!H SlallCfl, 9PfC~j

elU 1;gIL Q! ;.)


'1 Rt<I~' ooe'~n
~.!lOnmmliln

DMls.II1Ai act","/ (!w.UijDS, vw.w, wall:s. muSIC, etc i


PaIl!l>tlfl!l1lye.l~~

AN billQeI,S\i)n ~1>MV"~1-rMa$"9 ~tt 0lh\'I;

man:w fl1OOlrfQla<'l,y,,,n.et ",1)<)11 2 t.hinhin ~WX':';NlJrlW'S vr bAre~>ttl;:'.Itilh.1j IfJ Ill"" tft',;~IM'\l otlt'.a Plll~\1' CVlTsnt cornll!iun (e ~. ~ Soti'CC vi rlJII)illil, 1T'~31iO" atministlalOO 01 hy(!ta~Q!1) 3 Sa1tty of p.al~':-lI!S ViM woe uiVlJJwMt"ll hon!.m I:1ljwy ()f fdJI~~jJ Ploceaure ...flo w~~1d wfW rWlll~1 "lv!)' 4 theY 00\', ~:":<'S>M: rnn\'1!l1l".J\! helOfe ~ 1J1IJ~i>aJy iI\1Pf~\1l{ (~"L ~remily 1m,"".,; (If \'aSCU!.:1i S'J'VO""S) 4 P~ltYv1 me ~I.in inivty Nlient limn f'JiU',M le.g,. eVA wl\lI flJ"l),,;it or hOld iflurna ...,111 .d("'Jon~ injuries}

,rouGtifrii bol' 1ld\{;lt!6

~"Hl"i d~5t"u~'~ i ~11lj ~Hnfr

)
.4

~r.\Nitr ~nsi.,.tes rtsKaf ru'l{ury


AIf~jmpi1u hI t~IIHW.llt~Mi\li,:. f;H~IM!"S. ..r.

t ReasOfJ fer rcstr-Dint 2 A!$tSWINlt time lranllH

3 Trtil rewa~s

fl~_1

5 (Mpe!illv>. aM

r<~rs",!

lelThlY<:Q

I,

4 EI.M;1VH)f fRQ:(JirlJO IOf f8lf'tllV.af

""I)'

BEHAVIORAL RESTRA.fIlTS:

AtTfllfT'l KEY

p(}SmON11I6

KEY

DEPAUL HEJU/1'H CENTER

~SSM.
HJ:A1.TH-"'AR~

DePaul Health Center

MARCH,PHILLIP I/~ 0727400691 MED 0524-01 10/02/1976 31Y rot 10/02/07


RAHMAl~.

IIII~IIIIIIIDJI.~'DU
ANWER Z

24 HOUR MEDlCALJSUHGlCAL PATIENT CARE RECORD


DPM-'(J(){~07'

00074829B

(7/2001) PAGE B OF B

DePaul Medical Records/Phillip H. March

000171

DePaul Health Center

12303 DEPAUL DR.


Tue Oct 09,
Di~~hat"g~

BRIDGETON, MO 63044 2007 06: 12 anl


HEr~TOLOGY-Page

Cumulative Trend Report from 10/01/07 2158 to 10/08/07 0415


MAR~,PHILLIP

Patient Name: Med Rec #:


Dis Date

000748298
10/0a/07

Adm, 10/02/07

Phys-Service:
979457 903572

NELKAVERI,SONIA N - HEDICAL I/P

BLOOD CELL COUNT/DIFFERENTIAL

Result: UnitB;
Low Refer: High Ref:

Platelet

Hgb

Ret

IOOO/mm3
130.0 400.0

gm(dl
13.0 1B.0

RBC 10:\6

MeV

~;i;~/~~-;~~~i---~~~-----I--~~~;----~I--~;~~----~I--~~~~----~I-----;~~~-------~I
10/07/07 10/06/07 10/05/07 10/05/07 , '04/07

39,0 54,0

4.'7 6.1

80.0 99.0

03401 03201 15451 04401 0510

03/07 04551 10/02/07 0614


10/01/07 22201

249 219 191 177 159 137 114


159

I I

I
I LI
1

11.B 12.7 12.1 12.3 12,0 11.4 11.8 12.7

L
LI Ll
LI

LI
L

LI

34.0 36.8 35.7 35.4 35.0 32.9 33.4 35.9

L L L

L
L

LI

LI LI

4.42 11.78 4.62 4.57 4.59 4.30 4.41 4.69

LI LI
L

76.9 77.0 77.3 77.5

LI
LI
L

L
L L L

Ll

76.3
76,5 75.7 76.5

LI
L

BLOOD CELL COUNT/DIFFERENTIAL.

Result;
Units: Lo\ol Refer: High Ref: 10/0a/07 10/07/07 10/06/07 10/05/07 10/05/07

MCR pg
25.0 31.0
._ft~-----

t<'lCHC
gm/dl 32.0 36,0
~

RDW
%

~lBC

Carr WBC
iOOO/mm3

11.5

____________

14.5 I 11. 0 _________ ______________________


~

iOOO/mm~

4.5
-------------------------

0415

0340 0320 1545

26.8 26,7
26.6

34.9
34.7
34,5

26.2
26.9 26.1. 26.5

33.9
34,7

Ool40 - - '04/07 0510

3'1.3
34,7

03/07 0455 10/02/07 0614 10/01/07 2220

26.8
27.1

35,3
35,4

lS.S 15.6 15.5 1S.7 IS.7 15.6 15.S 15.6 15.6

~I
HI

HI

8.6
12.0
14,

HI

15.1

~I

HI HI HI
HI

15.3 3.2
3,8 6,5

~I LI

8,1

ELOOD CELL COUNT/DIFFERENTIAL ..

R'ult: Units;

~~;~~~~~:~~!:\---~~:~---:j---~~:~--:~-I,---~~:~--:~il----~:~---~-II-------::~-------I
10/06/07 0320

L~w Refer:

I
I

I-

Gran
%

Lymph
%

40.0

22.0

Mono
%

I
I

Ega
%

I
1

Eal::l9

~~
0.0

2.0

I I

0.0

71

&HI

16

&L

&

&

MARCH,PHILLIP
000746298 (M-IO/02/76) Dr. MELKAVERI. SONIA N"

Alexander Babich, M.D. ** DO NOT DISCARD **


*Dischaz'ge Curnulative Trend Report

DePaul Medical Records/Phillip H. March

000172

DePaul Health Center


12303 DEPAUL DR.

BRIDGETON, MO 63044 Tue Oct 09, 2007 06:12 am


HEM1>.TOLOGY-Page 2

Discharg@ Cumulativ@ Tr@nd R@port from 10/01/07 2158 to 10/08/07 0415


Patient Name: Med Rec #:
MARCH, PHILLIP

000748298
10/08/07

Adm: 10/02/07
I/P

Dis Date Phys-Service;

MELKAVERI,80NIA N - MEDICAL

BLOOD CELL COUNT/DIFFERENTIAL .. Result:


lJnit~i Lo ..... Refer;

(Cant)

Gran
~

Lympb
~

Nona
'l; 2.0

Bos 't
0.0
6.0

High Ref;

I ------------------------------------------------------------------------------,*0.0

40.0 70.0

22.0

Baso \
0.0
3.0

10.0
7.5

10/05/07 1545

73.9

H
&

10/05/07 0440 1 10/04/07 10/03/07 0455 10/02/07 06141 J'" ''11/07 22201

0511

62 26.9 56'.5

18.0 20 53.4 28.7

&L
H

96.5
91

HI
&HI

e.o
5

6 15.3 13.2

&

H H

0.4 2 2.5

0.2

&1
1.9 0.8

&Li

LI

5.2

0.8 0.0

0.3

BLOOD CELL COUNT/DIFFERENTIAL ...

Units: Low Refer:


High Ref:
1

Result:

Bands % 0.0
5.0

Met~s
0.0
1.0

'<1 y elo%8

I Promy;lO

~Q

Blas~s
~

II

0.0
1.0

I
I

0.0
0.0

0.0
0.0

~~~~i~~~-:~;~j---~~----.!il----~-----~-II-----------II-----------j-----------------I
10101/07 2220

&

BLOOD CELL COUNT/DIFFERENTIAL ....

P - 'ul t
::s:

Aty

Lyrnp
%

Plasma C
%

Othe..
%
0.0

NRI3C
/100 liBe

I I
j

Low Refer:
High Ref:

0.0
9.0

0.0

I I ~~/;~i;;-;;;;i----;-----~i-----------------------------------------------------1
0.0 0.0

f'l'LARCH
Ale~ander

PHILLIP

000748298

Babich, M,D.
*~

*k DO NOT DISCARD

(rt1-10/02/76)

*Discharge Cumulative Trend Report

Dr. MELKAVERI,SONIA N

DePaul Medical Records/Phillip H. March

000173

DePaul Health Center

12303 DEPAUL DR.


Die~harge

BRIDGETON, MO

63044 HEMATOLOGY-Page 3 Adm: 10/02/07

Tue Oct 09, 2007 06:12 am

Cumulative Trend Report from 10/01/07 2158 to 10/08/07 0415


MARCH,

Patient Name: Med Rec #: Dis Date Phya-Service:


979157 903572

PHILLIP 000748298

10/08/07

MELKAVERI,SONIA N - MEDICAL r/p

BLOOD CELL COUNT/DIFFERENTIAL .....


Resu 1 t :

iInit:;};

Low Refer:
High Ref:

10/06/07 03201 Normal 10/05/07 0440 # 10/01/0722201 #

I I I ~;!;;/~;-~~~~-l-;~~~;~---~I-----------'-----------'-----------1-----------------1 10/07/07 0340 Normal &1 1 I I I


&.

I
I

RBC Morp

NBC Morp

I
I

PIt Est

- - - - - - 1 15/07 0440 CBC 10/01/07 2220 CBC - - - - - - - - 10/06/07 0320lcBC NITH HANUAL DIFF-Comment: Manual Differential correlates

Normal &1 I - - - - - - - Spec if i c Commen t. B - - - - - - - - - - - - - 1'1ITH MAl'IUAL DIFF-RBC Morp: Slight Microcyt;es *&.* WITH r~~AL DIFF-RBC Morp: 1+ Poikilocytosis *&* - - - - - - - General Comments - - - - - - - - - - - - - -

&1

&

I
-

-I

clinically with electronic differential provided. *&*

t1ARCH, PHILLIP

000748298

Alexander Babich, M.D. *~ DO NOT DISCARD **


"Discharge Cumulative Trend Report

(1<1-10/02/76 )

Dr. MELKAVERI,SONIA N

DePaul Medical Records/Phillip H. March

000174

12303 DEPAUL DR.

DePaul Health Center BRIDGETON, rotO 63044 Tue Oct 09, 2007 06:12 am COAGULATION-Page 4 Adm: 10/02/07 N - MEDICAL I!P

Disoharge CUmulative Trend Report from 10/01/07 2158 to 10/08/07 041S


Patient Name: Med Rec #: Dis Date Phys-Service:
979157 903572

MARCH,PHILLIP 000748298 10/08/07


MELY~VERI,SONIA

ROUTINE COAGULATION Result:

PT
I
10.8

INR

Units;
Low Refer;
High Ref:

A.PT!
1:ieGQnd1:i

Fibrinogen I

1.1

I 1

24.0
31.0

ms/dl
200
I
400

I
I

~~~~f~~~-~~~~I--~~~~-----f---~~;-----i--~~~~----~I-----------1-----------------1
- - - - - - - - - - - - - - - - General Comments - - - - - - - - - - - - - 10/01/07 2220 PT-INR Therapeutic Range: Conventional Anticoagulation: n~R :2.0-3.0 Intensive Anticoagulation:INR 2.5-3.5

-I

HARCH,PHILLIP 00074B298

Alexander Babich, M.D.

** DO NOT DrSCARP ** *Discharge C1.1m1.l1ative Trend Report

(M-IO/02!76) Dr. MELKAVERI,SONIA N

DePaul Medical Records/Phillip H. March

000175

DePaul Health Center 12303 DEPAUL DR. BRIDGETON, MO 63044 Tue Oct 09, 2007 06;12 am

Discharge
Patient Name: Med Rae iI: Dis Date

Cumulativ~

Trend Report from 10/01/07 2158 to 10/08/07 0415


CHEMISTRY-Page 5 Adm: 10/02/07

MARCH, PHILLIP 000748298 10/08/07

Phys-Sarvice:
979457 903572

MELKAVERI, SONIA N - MEDICAL r/p

ROUTINE CHEl\tISTRY

Result:

Glucose

Unit5i
Low Refer;
High Ref; 10/06/07 10/05/07 0440 10/04/07 0511 10/03/07 0455
10/01/07 22201

m9/.jl
75 110
78 109

I I
I

Sodium

Potassium

Chloride

CO2
mSqjlo 22.0 30.0
29 31 26
28

mflq(L
137
145
137

mfiq(L
3.6 5.0

m1:iq!L
98.0 107.0
104
L
L L

I I

------------------------------------------------------ ----~-~--------------

0331

87
78 94

I
I

140

136 13B 138

LI

I
I

4.5

3.6 3.3
3.0 3.3

102 102 101


103

---II
H!

27

ROUTINE CHEMISTRY.

~~~:~~~~~, I :i~l
10/04/07 05101 10/03/070455\ 10/01/07 22201
7

~~iii
LI
I
l.l 1.3 1.1

C:ift~m I Ph~~1~n"
8.8 8.1 8.8

Ma~i1tum I

:g~g~:~~-~!~~i---~~------i---i:~---------:::-----i-----------------------------1
10 13

LI

I I

ROUTIUE CHEI-1ISTRY .. Result:

ts: Lvv.' Refer:


High Ref:

I
I

Tot Prot

Albumin

ALT/SGPT

grn/dl
6.3! 8.2 I

gm/dl
3.5 5.0

~~j~~~~;-:!!:j---;-~-----i---::~----------:-----~----i:------i------~~---------I
10/04/07 05101 10/03/07 04551 10/01/07 22201 6.6 6,9 7.1
11,

I I

U/L 21.0
72.0

I I

AST/SGOT U!L 17.0


59.0

Alk ph05

I I

V!L
38.0 126.0

I
I I

4.2

~,5

4.7

B H 13

L 1.1 L

17

l7 24

I
I

;is
73

59

I
I

rvtARCH, PHILLIP

000748298

Alexander Babich, M.D. ** DO NOT DISCARD ** *Discharge Cumulative Trend Report

(M-10/02/76) Dr. MELKAVERI,SONIA N

DePaul Medical Records/Phillip H. March

000176

12303
Die~harge

DePaul Health Center DEPAUL DR. BRIDGETON, MO 63044 Tue Oct 09, 2007 06:12 am
CHEMISTRY-Page 6 Adm: 10/02/07

CUMulative Trend Repo?t f?om 10/01/07 2158 to 10/08/07 0415


MARCH,PHILLIP
000748298

Patient Name: I-ted Rec t1;


Dis Date

10/08/07

Fhya-Se:rvice:
979457 903572

MELKAVERI,SONIA N - MEDICAL lip

ROUTINE

CHEMIS~~Y

...

Result: Tot Bili Conjug Bil Uncon Bili Dir Bili GGT Unite; mg/dl mg/dl mg/dl mg/dl U/L Low Refer: 0.:;: 0.0 0.0 0.0 8.0 1.3 0.3 High Ref: l.1 0.4 78.0 1 ------------------------------------------------------------------------------10/06/07 10/05/07 10/04/07 10/03/07 10/01/07 03301 04401 0510 0455 2220\
0.2 <!O.l

<0.1 0.2 0.8

I
ROUTINE CHEMISTRy ....
Triglyc

Result:.: Units:
Low Refe.I':

Chol~st

mg/dl
120.0 200.0

mg/dl
0.0 250.0

High Ref:
10/01/07 2220j

LDH U/L 313.0 618.0

CK

Uric Acid

U/L
55.0 170.0
235

mg/dl
3.5 8.5

HI

CARDIAC TESTING. Result : Units:


Low Refer:

High Ref: 5:0 110.0 ____________________________________ ww. _______________ _________________________

CK-MB ng/ml
0 0
I

Myoglobi ng/ml
0 a

I
1

__ 0~/~7_2:2~1 _ _ _ _ _ _ 10/01/07

~O~2_

General

comm~nts

_ _ _ _ _ _ _

_ _____

2Z20ICKMB-Interpretation-CK~m: ~1 abrupt rise/fall

I I

of CKME over 24 hours is an acute injury pattern.

MARCH, PHILLIP 00074B298

Alexander Babich, M.D. ** DO NOT DISCARD ** *Discharge Cumulative Trend Report

(M-10/OZ/76) Dr. MELKAVERI,SONIA N

DePaul Medical Records/Phillip H. March

000177

DePaul Health Center 12303 DEPAUL DR. BRIDGETON, MD 63044 Tue Oct 09, 2007 06:12 am

Discharge Cumulative
Patient Name: Med ReC #: Dis Date Phys-Service:

T~end

Report from 10/01/07 2158 to 10/08/07 0415


CHEMISTRY-Page 7 Adm: 10/02/07

MARCH,PHILLIP 000748298 10/08/07 MBLKAVERI,SONIA N - MEDICAL I/P

979457 903572 In: 10/01/07 2225 Out: 10/01/Q7 ~257 ColI Time: 10/01/07 2220 OI'der Phys: SCHMIDT, RICHARD U
Result Name

TROPONIN-I

Spec: Blood Heparin PST Techa; V-AK TLMURAT


(A0727400691/3861791)

*STAT*STAT*STAT*
Result
Reference Range

Troponin I(ng/ml):

<0.10

Normal Gray Zone Positive

<0.10 0.10-0.99 >=1.00

MARCH, PHILLIP 000748298

Alexander Babich, M.D. ** DO NOT DISCARD **


*Discharge CUmulative Trend Report

(M-IO/02/76)

Dr. MELKAVERI,SONTA N

DePaul Medical Records/Phillip H. March

000178

DePaul Health Center 12303 DEPAUL DR. BRIDGETON, MO 63044 Tue Oct 09, 2007 06:12 am Discharge Cumulative Trend Report from 10/01/07 2158 to 10/09/07 0415 Patient Name: l<1ARCH, PHILLIP URINE ANALYSIS- Page 8 Med Ree if: 000748298 Adm: 10/02/07 Dis Date 10/03/07 Phys-Service: MELKAVERI, SONIA N - Jl.IED!CAL I/P 979457 997075 903572

URINALYSIS
Result:

Color ,
t

Clarity

Spec Grav
1,0005

pH

Units:
Low Refer:

pH UnitB
4.6

~~:~-~~:~----~--------------------------=~~~~~---!----~~~----!-----------------I 10/01/07 2250 I YELLOW CLEAR I 1. 010 I 7.0 I I


URINALYSIS.
P~sult:

Leukoc:yt

Nit.rite Negative

Prot.ein

Glucose

Ketone

.ls:

mg/dl
Negative

mg/dl
Negative

Ref Range:

Negative
neg

Normal

10/01/07 22501

neg

neg

norm

neg

URINALYSIS ..
Result:

urobilin

Bilirubin

Blood

Units:
Ref Range:

E~~~,~~~
norm

I
I

Ne:~~;e
neg

I Neg~~~ve I
I
neg

I
J

10/01/07 22501

-------------------------------------------------------------------------------1
I

MARCH/PHILLIP 000748298

Alexander Babich, M.D. ** DO NOT DISCARD **


*Discharge Cumulative Trend Report

(1'1-10/02/76) Dr. MELKAVERI,SONIA N

DePaul Medical Records/Phillip H. March

000179

DePaul Health Center 12303 DEPAUL DR. BRIDGETON, r>10 53044 Tue Oct 09, 2007 06:12 am Discharge Cumulative Trend Report from 10/01/07 215S to 10/08/07 o4is Patient Name: MARCH,PHILLIP MICROBIOLOGY-Page 9 000748298 r'led Rec #: Adm: 10/ 0 '2./ 07 Die Date 10/06/07 Phys-service: MELKAVERI/SONI~ N - MEDICAL rip

379457 997075 903572

CULTURE BLOOD

Source: Blood (Mi Coll. Time: 10/03/07 0455 In at: 10/03/07 0540 Order Phys: ZINSER/PHILLIP G Out at: 10/04/07 08tl Preliminary 1 (3863626J

Aeet #: A0727400691

Techs

V-NT Tech$!
T$MR

* * CULTURE * *

No Growth
Performed by: SSM Health Care Lab - SMHC

CULTURE BLOOD Source: Blood (M) Acct #; A0727400691

ColI. Time: 10/03/07 0455 In at: 10/03/07 0539 Order Phys: ZINSER,PHILLIP G

Teehs

V-NT
Techs: TSMR

Out at: 10/04/07 0841

Preliminary 1 [3863828]

* * CULTURE * *

No Growth
Performed by: SSM Health Care Lab - SMHC
>~

CULTURE CATH TIP

~~

Sou ... ce~ Cath Tip ColI. Time; 10/02/07 1754 In at: 10/02/07 1754 Order Phys: MELKAVERI,SONIA N
~lt

Acct #: A0727400691
Techs VNUR
Techs: TSMH

at: 10/04/07 0805

Final

[3863380)

************CULTURE*****~******

No growth. Performed by; SSt'! Health Care Lab - SNHC

VJ\RCH, PHILLI? 000748298

Alexander Babich, M.D. ** DO NOT DISCARD ** *Discharge cumulative Trend Report

0>1-10/02/76 ) Dr. MELKAVERI,SONIA N

DePaul Medical Records/Phillip H. March

000180

DePaul Health Center 12303 DEPAUL DR. BRIDGETON, MO 63044 Tue Oct 09, 2007 06:12 am
Dieehar9~

CUMulative Trend Report from 10/01/07 2158 to 10/08/07 0415


MARCH, PHILLIP 000749298 10/0a/07 MELKAVERI,SONIA N - MEDICAL I/P

Patient Name: Med Rec #: Dis Date Phys-service:

MICROBIOLOGY-Page 10 Adm: 10/02/07

979457 997075 903572

CULTURE BLOOD

Source: Blood (M) CoIl. Time: 10/01/07 2355 In at: 10/02/07 0001 Order Phys: scmHDT / RICHA.RD U

Acct #: A0727400691 Techs V-AK


Techs: TSMH

Out at: 10/05/07 1345

Final

[3861785)

CORRECTED - 10/08/07 1409 '/(

aerobic bottle time to detection 6.4hrs anaerobic bottle time to detection 6.9hr9
****~~******CULTURE************

*"'PANIC REPORT"''''
~~lled

toltime Grace 10/2/07 1110

(mls) rbr

KLEBSIELLA PNEUMONIAE (KL PNEUMONIA) Growth from 2 of 2 bottles two sets drawn
(MIC - ug/ml)

KL PNEUMONIA
R R S
T

Amp/Sulbact.am: Ampici 11 in:

>=32/16
>",}2

Aztnwnam:
Cefazolin: Ceftazidime: cipt"ofloxacin: Gentamicin: Imipenem: Levofloxacin: P;p/Tazobactam: .methop:r:im/Sulf:

c.=8 16
<",8

S S S S S R S

<;0.5
<~O.5

<=4

<=1 >=128

"",10

Performed by: SSM Health Care Lab - SMHC

f-iARCH, PHILLIP 000748Z98

Alexander Babich, M,D. *'" DO NOT DISCARD "'* "'Discharge Cumulative Trend Report

Dr,

(1'1-10/02/76) MELKIWERI, SONIA N

DePaul Medical Records/Phillip H. March

000181

Depaul Health Center 12303 DEPAUL DR. BRIDGETON, MO 63044 Tue Oct 09, 2007 06:12 am Discharge Cumulative Trend Report from 10/01/07 2159 to 10/Oa/07 0415 Patient Name: M.l\RCH, PHILLIP MICROBIOLOGY~Page 11 Med Ree tt: 000748298 Adm: 10/02/07 Dis Date 10/08/07
Phys~Service:

MELKAVERI,SONIA N - MEDICAL IIp

979457 997075 903572

CULTURE URINE

Coli. Time: 10/01/07 2250 Order Phys: SC~1IDT(RICHARD


O~t

Source; Urine (M) In at: 10/01/07 2255 U Final [3861788J

Acct #: A0727400691
Techs V-DJA

at:

10/04/07 1129

Techs; TSMH

1t '" ....

No growth.

* * * * * * * *"CULTURE* '" '" *" * * I d * *"


Performed by: SSM Health Care Lab - SMHC

CULTURE BLOOD Source: Blood (M) Coll. Time: 10/01/07 2220 In at: 10/01/07 2225 ol."der Phys: SCHMIDT (RICHARD U

Acct #; A0727400691 Techs V-AK


Tachs: TSMH

Out at: 10/OS/07 0625

Final

[3861786J

"'''CULTURE'"'"

No Growth

Performed by: SSM Health Care Lab - SMHC

MARCH,PHILLIP
000748298

Alexander Babich, M.D. ** DO NOT DISCARD **


*Discharge Cumulative Trend Report

(M-IO/02/76)

Dr. MELRAVERI,SONIA N

DePaul Medical Records/Phillip H. March

000182

DePaul Health Center 12303 DEPAUL DR, BRIDGETON, MO 63044 Tue Oct 09 , 2007 06:12 am

Discharge Cun\ulative Trei'l.d Report from 10/01/0'1 2158 to 10/c8/c7 0415


Patient Name:
r.1ed Ree #: Dis Date Phys-service:
MARCH, PHILLIP
000748298

BLOOD GAS ANALYS-Page 12


Adm; 10/02/07

10/08/07 MELKAVERI 1 SONIA N - f>1EDICAL lip

979457 997075 903572

ARTERIAL BLOOD GASES

Result:

ART PH

PC02

Units:
Low Refer:

pH Unit

High Ref:

------------------------------------------------------------------------------1
10/01/07 21581 7.511

7.38 7.42

I
HI

mm Hg
38

I
LI

P02

Base Exo

02 Satur

mm Hg
75 100
98.9

mmol!L

42
26.5

-2.0 2.0
-1.1

~ 92 98.5
98.1

I'

ARTERIAL BLOOD GASES.


R-

'ul t:
~s:
I

Hgb

gm/dl

02 Cant \

I
I

H802
%

HBCO
I
%
1

Met.hemoglobin %
1

~~~~~~;~~~ ___ l _____ ~; ____ l ____ ~~ _____ l ____ :~: ____ l ____ ~~~ ____ 1_______ ~~~ _______
10/01/07 215S1 12.3
1

16.9

97.1

HI

0.6

0.4

ARTERIAL BLOOD GASES ..

ARTERIAL BLOOD GASES ...


Reaul t.: RC03

Units: Low Refer:

mmol/L
1

22

mg/dl
80

Glu

HHb % 0.0

mmol/L 23.0

tC02

I
=
=

I
F

~~~~-~~~~----!---~~----!----~~~----!----~:~----!---~~:~----!-----------------1 10/01/07 21581 20.7 L! 95 I 1.9 I 21.5 LJI I


" -

= = = = = =

Gen@ral

Comm@nts

= = = =

=i

10/01/07 2l5SIBLOOD GASES W/LYTES PANEL-Comment: ER

MARCH,PHILLIP
000746298

Alexander Babich. M.D.


.+ DO NOT DISCARD *+ "'Discharge Cumulative Trend Report

(1'1-10/02/76) Dr. MELKAVERI,SONIA N

DePaul Medical Records/Phillip H. March

000183

DePaul Health Center 12303 DEPAUL DR. BRIDGETON, r40 63044 Tue Oct 09, 2007 06:12 am Die~h~rg~ CUmulative Trend Rep~?t from 10/01/07 2159 to 10/09/0? 0415 Patient Name: MARCH,PHILLIP BLOOD GAS ANALYS-Page 13 r-led Rec 1*: 00074829!3 Adm: 10/02/07 Dis Date 10/08/07 Phys-service: MELKAVERI,SONIA N - MEDICAL I/P 979457 997075 903572 ARTERIAL BLOOD GASES .... Resul t:

Units:

Temp.

~~;~~~!~~:---!-----------!-----------!-----------------------!-----------------I I I I I I
10/01/07 21581 21. RB

Fi02

Site

Resp Rat

CPAP

------------------------------1'" '07/07 0500

PENDING TEST

------------------------------Cancelled Patient discharged Cancelled DUPLICATE ORDER Partial Partial Cancelled ORDERED IN ERROR

CSC W AUTO DlFF

)4/07 10/03/07 10/03/07 10/02/07 10/02/07 10/02/07 10/01/07


i

0510 0455 0455


1645

eBC W AUTO DlFF


c..'UL'I'URE BLOOP CULTURE BLOOD CULTURE BLOOD

1643
1643

CULTURE ROUTINE
CULTURE BLOOD CULTURE SPUTUM

Cancelled Patient discharged


Cancelled ORDERED IN ERROR Cancelled Patient discharged

2146

!1P>RCH, PHILLIP 000748298

Alexander- Babich, 1-1. D.

**

DO NOT DISCARD ** kDischargB Cumulative

(l<1-10102/76 )
T~end

Report

Dr. MELKAVERI,SONIA N

DePaul Medical Records/Phillip H. March

000184

DePaul Health Center 12303 DEPAUL DR, BRIDGETON, MO 63044 Tue Oct 09, 2007 06:12 am

Discharge CUm Incomplete Work Listing from 10/01/0? 2158 to 10/08/07 0415
Patient Name: Med Rec #: Dis Date
Phys-Service:
MARCH, PHILLIP Page 14

000748298 10/0S/07

Adm: 10/02/07
N -

MELKAVERI,SONIA

MEDICAL r/p

979457 997075 903572

Accession
Number

Collection Test Name


CULTURE BLOOD

Spec Type Blood (Ml Blood (ttl)

Dace & Time


10/03/07 0455 10/03/07 0455

Status Partial

:3 863826
3863828

CULTURE BLOOD

Partial

End of Report ********************************************************************************

HARCH,PHILLIP
000748298

Alexander Babich, M.D.


** DO NOT DISCARD ** *Discharge Cum Incomplete Nork Listing

(M-IO/02/76 )

Dr. MELKAVERI,SONIA N

DePaul Medical Records/Phillip H. March

000185

Depaul Health Center 12303 DEPAUL DR. BRIDGETON, MO 63044 Tue Oct 09, 2007 06:12 am

Discharge Cumulative Trend Report from 10/01/07 2158 to 10/08/07 0415


Patient Name: Med Rec #: Dis Date Phys-Service:
979457 903572
~~CH,PHILLIP

000748298 10/08/07 1'1ELKAVERI,SONIA N - MEDICAL

Notification-page 15 Adm: 10/02/07


lip

LABORATORY CANCELLED AND SPECIMEN REJECTED TESTS


I.I.**SPECIMEN CANCELLED****

AGcn; J6656U Spec: Blood priority: ROUTINE


Test Name: CBC W AUTO DIFF Cancelled: 10/04/07 0550

Acct;

A07~74QQ9~l

COllected: 10/04/07 0510 Ord Phys: MELKAVERI,SONIA N

Cancellation Reason: DUPLICATE ORDER


End of Report

l\ll\RCH, PHILLIP 000748298

Alexander Babich, M.D. "'* PO NOT DISCARD ** "Discharge cumulative Trend Report

(lvf-10/02/76)

Dr. MELKAVERI,SONIA N

DePaul Medical Records/Phillip H. March

000186

DePaul Health Center


12303 DEPAUL DR. BRIDGETON, MO 63044 Tue Oct 09[ 2007 06:12 am

Discharge CUm Incomplete Work Listing from 10/04/07 0800 to 10/07/07 0315
Patient Name:
I\ied Rec #:

MARCH, PHILLIP

Page 15

000748298
10/0a/07 MELKAVERI,SONIA N - MEDICAL I/P
~03572

Adm: 10/02/07

Dis Date
Phys-Service:

979457 977240

Accession Number
3863826

Test Name

Spec Type

Collection Date & Time


10/03/07 0455
10/03/07 0455

Status
Partial

3663828

CULTURE BLOOD CULTURE BLOOD

Blood (M)

Blood (Hl

Partial

End of Report
**~************************************************************************~****

r<IARCH, PHILLIP

00074.8298

Alexander Babich, M.D.


DO NOT DISCARD

**

(1.1-10/02/76,

*Discharge Cum Incomplete Work Listing

Dr, MELKAVERI,SONTA N

DePaul Medical Records/Phillip H. March

000187

DePaul Health Center Wed Oct 10, 2007 06:09 am Post Discharge Work Report

Pat Name;

unit #/Acct #:
Dis Date Phys-Service:
979457 903572

MARCH/PHILLIP OOQ74829B/A0727400691 10/08/07


f,lfELKAVERI, SONTA N I"iEDIC.~L

Page:
I/P

CULTURE BLOOD Specimen; Blood {r,lfl Coll. Time: 10/03/07 0455 In at: 10/03/07 0540 Ordering Phys; ZINSER/PHILLIP G
Out at: 10/09/07 0730
F ina 1 ( 3 8 6 3 82 6]

Acct
Techs

j:I;

A0727400691
V-vlT

Techs: TSMH

* * CULTURE * *

No Growth Perfoxmed by: SSH Healt.h Care Lab - SMHC

CULTJRE BLOOD ~c specimen: Blood (f>') CoIl. Time: 10/0J/07 0455 In at; 10/03/07 0539 Acct #: A0727400691 Techs V-WT Ordering Phys: ZINSER/PHILLIP G

Out at: 10/09/07 0730

Final

[3863828 J

'J'echs: TSMH

* * CULTURE* *

NO Growth pe;t-formed by: SSM Health Care Lab - SNHC

End of Report - 10/10/07 06:09

MARCH/PHILLIP 000748298/A0727400691 Alexander Babich.


kpost

M.D.

I/P 10/08/07
U>l-lO/02/76) Dr. I'<1ELKAVERI,SONIA N

Discharge t'lork Report

DePaul Medical Records/Phillip H. March

000188

12303 DePaul Drive

DEPAUL HEALTH CENTER Bridgeton, HO 63044 DIAGNOSTIC Il-1AGING


Med Rec # A000748296 1'.CCT: A0727400691

Name:

J'-1.ARCH, PHTLLIP

DJB:

10/02/76 Age:

31Y

Sex: M

Pt Local-ion:

5N-0524~01

Date; 10(04 (07 1601

MELAVERI,SONIA N 1066 EXECUTTVE PARKWAY SUITE 105

CREVE COEUR
Exam Xl{ CHEST ONE VIEW PORTl\BLE

NO 63141

Check-In U
00010746

Ol-der Dia9no.siz Ord Diag: V67 _ 59-FOLLOV1-UP EXAM NEC

CHEST SINGLE VIEW

INDICATION; osteomyelitis, PIce line pl"cement.. FINDINGS: A single view pr..>ltable AP upright ex.:tminZltion of the chest, 1608 houl's, >hclWs oil PIce line has been placed via t:he right upper ext.remity. The distal end i:o direcl.ed into the .:tnticip.:tted location of the mid superior venoil cava.

NQ other changes .:tre :Jeen ,'!hen compared to the. pri or chest radiograph of
10/1/2003.

The lung fields are clear. The heart size is at the upper limits of

normal.
IMPRESSION

In.terval placement of a PICe 1ine, the tip of which is directed int.o the! anticipated location of the mid superior ven.:t CiJ.va. Read By- ANDRE !:i STR.3EI>1BOSZ H.D. Releaced By- l\NDRE S STl";;;EMBOSZ I'1.D. Released Date Time- 10/04/01 1611
Transcriptionist- BEM

ADM:

r-tF:J,"KAVERI, SONIA N
~rNSER,PHILLIP

ATT: Nl!:LKAVERI,SONIA N
CON: ZTNS'RR,PHILLIP G

REF;
~ep:

SCP:

FINAL

Page

DePaul Medical Records/Phillip H. March

000189

DEPAUL HEALTH CENTER 12303 DePaul Drive Bridgeton, NO 63044 DIAGNOSTIC IMP~ING

Name: t1ARCH, PHILLIP DOB: 10/02/76 Age; 31Y Date; 10/01/07 2151

!l1ed Rec # A000748298

ACCT: A0727400691

,sex; M

Pt Loca.t.ion; 5N-0524-01
SCHNIDT,RICHARD IJ 12303 DEPAUL DRIVE Etl!ERGENCY DE PT BRIDGETON MO 63044

Exam
XR CHEST ONE VIEW PORT.lillLE

Check-In If
00010232

Ord Diag:

Order Diagnosis 786.50-ClIEST PJl..IN NOS

Chest one view portable. Indic'::'I.tion; Fever and chills and javi pain. Findings: A frontill view of the che<lt compared to prior of 9-24-07 shows tlie lungs to be well expanded and clear. The heart size is normal.
No change has occ;urre.d.

Impression: No acute infiltrate.


Re.J.d By - f1ATTHEW W STADN'iK M. D. Relea sed By- !l1ATTHEW W STADNYK M. D. ReleaDed Date Time- 10/02/07 1008 Transcriptionist- sTn~

A.DI'1;
REF:

RAHMAN / ANI-lEI<. Z

ATT:

RAHMAN, ANWER Z

PCP:

ZINSER/PHILLIP G

CON: SCP:

ZINSER/PHILLIP G

FINAL

Page

DePaul Medical Records/Phillip H. March

000190

"J?"~~!!:dt.Jr~

Consent to Medi(y.lJ and Related Health Cals; I request and consent to too medical cafe, diagnos1ic and treatmenl as determined necessary by mvphysiclanfs) Of hls/her assIstants. J acknowledge th~ care I receive while in this facility is under the <fJ(~ction o[my phYSician(s}. This facility is noTrespoilsftil1> for tho acts Or omissioos of my physician(s).

Mediga' and Allied Health Car~ Providers: I have boon informed and understand that the Physidan(sl providing to me in this facifity, such as my personal Physician{sJ, RadioIoglsls. Pathologists, Anesthesiologisl. Consulting PhY$lclans, Surgeons and other Allied Health Care Providers such as ~ntj.5ts and P3ychologists are independent contractors and ant not employoes or agents 01 this facility unless 0 erwisE/ specificalty identified.
$efVj~es

Teachfng Programs: I understand this facility may. from tima to tima. anter into greements with academic medical. nUI,sing and allied health programs. 8acau8o of the$6 agreaments, residents, Inter ,medical students, nun,iog students and various allred hI!Jallh plOfession students, may participate in my care. f agreo to participate in these programs, but have the right to limit my patticipation at any time. Re'!M! 91 Information; 'understand this facility will make l)very fJffort 10 treat my medical information as cl;mfidential; howeVQf, I realfz6 information must be shared with providars and/Of individuals involved tn my care or tn the payment of my cam, J undorstand this will inc Iud., information found in my medfeal record. I agree to the refease of information in my medical record, and to the actual medical record documents, to the extent necessary for the following purposes:
...} I have received the Nor.icf.! of Privacy Practices on this visitladmis$ion or previous one. I understand I can reque:rt another copy at any Hme.
8

b.J

to any medical and/or health care providers responsible for my care while in this fooilitY and
if transft-fred to another facility for care, to th!iltacifity and its carEl providers.

c.)

to those responsible fOf collecting and those resposibJe for the payment ot my care. Trns may include a person. government agen<:y, iostlf<lnce company, health plan or employer sponsored group plan. This is for the purpose of verifying insurance benefits for pr8certifiGiltion and axtfl/1ded stay review andlor the paymcllt of tha cost of my cere. to utilize for internal medical care studies and quality Implovemant a.ctivitie4. to compty with the Federal Safe M6dical Device Act 01 1990 and other requIred state and fader.:!1

d.) Cl.)

reporting.
Mcdicarp/ChamgusfTricilra Right!!.; rt oppticab-I&. I acknowledge receipt of tho Medicare/ChampusfTrictlfe Letter explaining my rights as a patient of this facility. I understand this includes my right to request a ravi(lw. Patient fUgb1:1: I acknowledga acces!l to the Patient Rights information explaining my rights as a pationt of this hcllity. Porsonal froper:\y; I have been informed and understand this facility will not be liable for any loss of unless it is irwl:fltoriod and pieced in a secured area maintained by !hls facility.
my

porsonal

property

fi.wmlU!:t fqr PhysicIan Services, Medical ,apd Relqted Care: Il)nd&(stand thaI all phYSician sarvicas ara billed separately from lOa facility chi.lrges. I 3l1ree to pay th$ charges incurred fOl Ih~ carO I receive as ordered by my phYiician(s) at this

facility. I guarante8 full payment 01 all charges unloss restrie-ted by Medicare, Medicaid or contractual arrangements botween my insuranco company and this facilitY.

~SSM
H E A L

H .

GAR E-

r.

"12303 DEP)\UL DR. BRIOG ETON. MO 63044

.\UL HEALTH CENTER

DePaul Medical Records/Phillip H. March

000191

Assiql)glAAtqt Be-efits: I hereby authorIZe and assign payment to this facility of aoy type of reimbursement or paymoo{ duu from Medicare, MedicaId, or any other third party payor, for llny and all cost incuued for my medical and rebned care at this facWty ond/or by the independent contractors providing services at this facility.

and t#lat would not change this agr~emant Of be coosklfod a discharge by Medicars. my agreement to the procediog al any timB by written notifieDtion to this fBcility.

I havo liar/any uno/e.ar Itcmt Bxplaln~d to me ond t.ll1derfitami its contents and accept its terms. , onaeritand that new account numbefs may bo issued for toUow up serv/Gas related to this admi.s.sionitfealment
I underStand I may wltildraw

AckHuwledgement of Under$tru\dlnq a~Gtli!:!t; {certify thai I have N}8d and understand the preceding agleement.

Patient's Signature

OR
Date

S1gna tu,elJl~latio~hip Do t e (Parent/legal GuarmanlResponsible Person/

Second Witness Signature


(If Or.vrelephonelP8tient Mark)

Date

Date ~

/E? /

f)?

DEPAUL HEALTH CENTE

MARCH I PIULLIP 0727400591 ERG


10/02/1976 30Y

,1

I.

_R
ERQ

EMFRGENCY/PHYSICIAOO~~~~~

M1

DePaul Medical Records/Phillip H. March

000192

PATiENT BELONGINGS VERIFICATION LOG

Page _ _ _ ot

07
SIGNATURE OF RECEIVING STAFF
DENTURES oe o Upper 0 Lower 0 Pariial U At

Date of Transfer: Date of Oischar e:


SiGNATURE OF TfIANSFERRlOO STAff
ROOM#:

Date of Transfer: Date of Discharge:


SIONATURE OF TRAN~FERR!NG $TAFF

MEMBER; -----::-::=-c-=--::-----I MEMBER: TIM!;: ROOM #TIME:


l1om~ -~-~r---------------------r-~----

MEMBER: _______~~~--__----TIME: ROOM


#~

DENTLIAES 0 None 0 Upper 0 Lower n Par1!::!) 0 At home

ono 0 With patient 0 At home

GLASSES 0 None U With Piltient 0 At home


CONTACTS 0 NOM 0 With patien1
HEARING AID

.----------~~~~-----------------

DENTURES 0 None 0 Upper 0 wHer U Partial 0 At home

GLASSES 0 None

one 0 With patient 0 At home 1--------HEp.RING AID U Left 0 Right 0 None

r----~~-----------------~-----

n With patient

0 AI home

n At home

CONTACTS 0 None 0 With palien! 0 At home


HEARING AID 0 Left 0 Right 0 None

~ome

_-r~I_ _ _ _ _ _+O_A_t_hO_m_e_______________
ORTHOPEDIC DEVICE 0 None 0 At home 0 cane LJ walker 0 prosthesis
JEWELRY (Description) 0 Watch
oR~W

LAft 0 Right 0 None

0 At home
ORTHOPEDIC DEVICE 0 None 0 cane n walker 0 prosthesis
JEWELRY (Description)

ORTHOPEDIC DEVICE one 0 At home cano 0 walker 0 proslhasis ne

JEWELRY (Description) o Watch

0 None

0 None

0 Walch
oru~~

o~gW

Other-

0 Other:

0 Other:

o Sent 10 5eGurHy
CLOTHING {MUST write description} n None Q Hat/Scarf o oa1/Sweater hoes (>16<.k. (l..~J) 4-t1"t,i sJ..,.~ Stockings/Socks SllppafsJAobe ~Iacks - JiJ t! ~ oI!..-"",'" S

o Sent 10 SflGurlty
CLOTHING (MUST write des(;riplion) o HatJ5cati o CoatlSwealer U Shoes o Stockings/Socks Slippers/Robe

Q $ent IQ l;jecurity

o None

o o
o

o o Pants/Slacks O~Blouse pv~l> ,!-T.,.,.,') nlt/ely..-", o Shirt/6louse

f6

CLOTHING (MUST write description) o HaVScarf Coat/Sweater Shoes o Stockings/Socks o Slippen./RQbe

o o

Underclothes

Underclothes

o Shirt/Blouse o UnderClothes

o PantslSlOlcks

J'cell phone
I

OTHER VALUABLES (D!!scnptionJ o Laptop computer oOthar

0 None

OTHEAVALUABlES
D Cell phone

(Description)

0 Non6

OTHt;;R VAl.VABlES (De~Qrip1iQn) U Cell phone

0 None

o Other _ _~_ _ _ _ __
Item(s) S611t homa _____

Laptop CompO!fir

o Laptop computer o o\her _ _ _ _

_ _ _ _ _ _ _ __

1------I 0 ilam(s) sent home ____________

o llern(s) sent home _______~__


U Sent horne with _____________

I-~--o Sent home with o Sent 10 Security


HC}ME MEDICATIONS
~ome 0 Pharmacy

o Sent home wilh _ _ _ _ _ _ __ o Sent to Security o None o Home


HOME MEDICATIONS 0 Pharmacy

o Senl 10 Security
HOME MEDICATIONS o Home 0 PhannaGY

None

0 None

amily as;;;umes final responsibility for belongings that are brought TO hospital

Ptjlamily 385umes final responsibilfty for belongings that Eire brought 10 hospital

o PtJlamily assumes final rasponsibility lor


belongings that are brooght 10 hospital SIGNATURE OF FATIENT / RESPONSIBLE PEASON UPON ARRIVAL:

SIGNATURE OF PATIENI / RESPONSIBLE


PERSON UPON ARRIVAL:

SIGNATURE OF PATIENT f RESPONSIBLE PERSON UPON ARRIVAL:

SIGNATURE OF RECEIVING STAFF MEMBER

SIGNATURE OF RECEIVING STAFF MEM6ER;

TIME: ____ RECEI.VING ROOM #:

.. _____ TIME: _ _ _ RECEIVING ROOM #!

TIME:

RECEIVING ROOM if:

~~SSM

COMPLETE A NEW FORM FOR TWO OR MORE TRANSFERS AND FILE WITH ORIGINAL. KEEP AT BEDSIDE AND PLACE IN DISCHARGE SECTION OF CHART. DEPAUL HBALTH CENTER
H E J. \. T H e A R e-

Ml'~~,!,!~nl. 0727400691 ERS _

PATIENT BELONGINGS VERIFICATION LOG


SLMl00QOTS (612007) FRONT

10/02/1975 30Y

ERQ M 10/01/07

EHERGENC,PRYSICIA00074829S

DePaul Medical Records/Phillip H. March

000193

TRANSFER CHECKLIST
INITIAL IN DATE COLUMN WHEN EA CH ITEM COMPLETED DATE DATE DATE

If Item Not Applicable} rec:o rd NtA In box.


'-

..
from Room # -....

TRANSFERRING DEPARTMENT

If transferring from Telemetry - Remove monitor


~nter transfer

into computer

Make sure that labels are place~ on all documents in the chart at time of transfer Communicate daily and pending labs

I Medication Reconciliation completed

-.-

Place MAR, Interdisciplinary Plan of Care/Care Path way, &Educa1ion Record in chart Place today's 24-hour record and all bedside flow sheets in chart Place Wound Tracking log in front of char!
-

-_.-

----r,

.~

Complete Patient Belongings Verification Log (on front) and place at bedside

I Take any old charts or thinned records wi1h patient to new room
I Place any Non-Pyxis mads and IV mads in plastiC bag and clip to chart
Notify Attending and Consulting Physicians of roo m change.

_.

-"

I
-

_._-----

INotlfy Family of new room number and print name


Name of Transporter:

0I family

.-

member in date column

----

..

RECEIVING OEPARTMENT

To Room #
--_..

Document date and time patient arrived in new department Document patient status on arrival to unit

_---.,._-

Place New Room Number on chart


'."-

Prinl new labels and place in front of chart


..
~

Ensure daily and pending labs are ordered


Label blank Physicians Orders & Progress Notes and place In proper sections altha chart
',--

SIGNATURE
..

/NIT

S/GNATURE

INIT

SIGNATURE

IN'T

-"_.-

~SSM
H E A L T H

PATIENT LABEL

C A. R E"

PATIENT BE:LONGINGS VERIFICATION lOG


SLM-l0DO-073 (6/2007) 8,A.CK

DePaul Medical Records/Phillip H. March

000194

PERIPHERALLY INSERTED CENTRAL CATHETER CONSENT

I,

2i'::t-- '- rr, hA,fo1ec-1, agree to have a penpherally inserted central cathnter (PICC) inserted, , "2 "''''P';f#f''Z-Kh'~~nd lor associate has ordered the I understand t~at my phys~cian, Dr.
tj

placement by a PICC certified RN. I understand that the insertion of a Pice is an invasive procedure, which is accompanied by possible risks, including, but not limited to: Insertion-associated: Unsuccessful catheter insertion; bleeding. swelling, or discomfort at venipuncture (insertion sits); catheter malposition or migmtiol"l: eardiac arrhythmias {irregular

pulse). Post insertion-associated: Phlebitis or venous thrombosis (clot), catheter occlusion, catheter or
insertion site infection, catheter breakage/rupture, The Pice certified RN win insert the specialize catheter into a specific vein under ultrasound guidance.

The benefits of and alternatives to Pice placement, as well as alternative methods of administration of the therapies of treatment have been explained to me, Including, but not limited to: Preservation of peripheral veins; longef (indefinite) dwell time of PICC; avoiding surgical catheter insertion; the therapy or treatment prescribed requires a central vein catheter. After the procedure and for the entire time my Pice is in place, I must report the follovling symptoms: Swelling, redness, soreness, wetness or drainage at the venipuncture (insertion site) or dressing, fever, chills, movement of the catheter in or out of my arm, shortness of breath, sounds of rushing of water in my ear on the same side of the catheter, exposure of the catheter outside of the sterile dressing andfor breakage of the catheter.
To reduce or eliminate the chance of the above risks from occurring, I agree to the care and maintenance instructions (no repe1itive motion of lifting weight [In excessive of 5Ibs.] of the PICC extremity); and to the prescribed schedule for therapy administration, catheter dressing changes, flushes, and cap changes, or catheter discontinuance. I also agree that I will not allow anyone to draw blood from above my Pice on the same arm, I have been informed of my right to ask questions or voice any concerns I have about the procedure and have received answers to my questions/concerns. I haye.(ead (or have'had read to me), and understand the consent.
( !

Patient's ~lgn.afufe
,,!Mle

OR
DatefTirnQ Signature/Relationship OatefTime

, _ too

h;J.J witnes~ed lhe pati~nt's signature on this lorm by which the patienl acl\llQwleQges that he/she has rec.erved adequ3te, infDnnatiol\ p"",d", 'f!"~("" phY""'"

., ' ' ',

/(/I11//~7 I?~
Da{emme Second Witness' Sig1lature DalelllfT1'i!

PJSSM DePaul Health Center


'II. ( J t t M
.(

DEPAUL HEALTH CENTER lip 0727400691 NED 0524-01 lO/02/1976 3lY r>1 10/02/07
I-1ELKAVERI, SONIA N OOU748298
r~RCH,PH1LLIP

l ,.

111111111111111111

PICC Consent 7/2007

DePaul Medical Records/Phillip H. March

000195

~SSM
"co",,, NO
I-

H E A L T H ' CAR E~

DEPAUL HEALTH CENTER 12303 DEPAUL DR. BRIDGETON, MO 63044

0902200197
r'M'f/iT NAME mo

~o1~':~~~:A~~-::~ I ~~ 11~:~;;,':'~~ 13::


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055401

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ADMISSION RECORD

ec r ~AT T'f~l
liP

BY

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000748298
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MARCH, PHILLIP H 8310 HAWJ(~SBURY DR SAINT lOUIS MO 63121-'005

(3141393-1241
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let MARCH,PHILLIP H
i

G\lAHAIHOH NAME AHll AODilESS

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ENGLISH

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I

ARRIVAl MO[},

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PAT

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N i N O N

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------.j

Auy<",i,lt,.,,,-,c;iVC, -

SALEM,MOUNER
1066 ExeCUTIve PKWY CREVE coeUR MO 63141
Ole
(314l317~0600
AnrNDiNG PHYSICMU

903693 SUITE 105

REfEMj~

PHYljClll#

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ore
PftlYARY CARE f)-lYHCiAN lAX

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PCP,NONE DEPAUL BRIDGETON

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SUITE 105

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1066 EXECUTIVE PKWY

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MO

12303

DRIVE
MO

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63044
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63141
,'A")I;'

(314)317.0600

3143170606 977803

t)f(.

EMfRGEIlCY CAP,. PHYS'CI,,",I

StiMi1 eMf !'!iYSt<;;I/Ifl

MAJINO,ANGElA R 12303 DEPAUL DRIVE MO 63044 BRIDGETON


"Fro

EMERGENCY DEPT
FA)I;'

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WS Z TE1.tPi-iOtif

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SELF PAY NO INSURANCE

10/02/76
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POL.

IIJ.IS~'R<O

MARCH, PHILLIP H
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lORN Itr{fi.-\lRO~

POl<

pnt#

IN!l\JRAIICE COMMfHTS,

i I

01/22/2009 08;48:Ll

DePaul Medical Records/Phillip H. March

000196

DEPAUL HEALTH CENTER


DISCHARGE SUMMARY
PATIENT: MARCH, PHILLIP H ADMIT DATE: 01/22/2009 DISCH DATE: PHYSICIAN: MOUNER SALEM, M.D. MR#: 000748298 AceT#: 0902200197

DOB: 10102/1976
ROOM: 0564

PRIMARY DIAGNOSIS: Left facial cellulitis. SECONDARY DIAGNOSES: 1 Hypertension, untreated. 2 History of chronic parn of the left mandible. 3 History of osteomyelitis of the left mandible. 4 Status post open reduction and In1emal fixation from a stab injury complicated by hardware infection and removal. 5 History of liposuction. ALLERGIES: None. DISCHARGE MEDtCATIONS: 1 Neurontin 200 mg t.i.d. 2 Keflex 500 mg p.o. q.Ld. The patient Is supposed to be on a course for three weeks. 3 Pareoest 5/325 one to two tablets every 6 hours as needed. 4 Norvase 5 mg daily. SIGNIFICANT STUDIES: MRI of the face shmved no evidence of osteomyelitis. It was an otherwise unremarkable MRI of the face. There was no cystic or solid soft tissue mass at the area of Interest and no significant superfi9i~1 or deep soft tissue edema, There was normal bone marrow signal intensity withovt evidence of _ _ _ _ or bone marrow replacement. CONSULTANT:

Dr.

Zinser.

HOSPITAL COURSE: The patient is a 32-year-old gentleman admitted with increasing left facial pain and ~welling and had previous admissions for this for facial cellUlitiS, and has a previous history of osteomyelitis after infection of hardware that was placed after a stab Injury in the left face, The patient has not been on any of hfs medications incluoing his antihypertensive and he was apparently supposed to be Neurontin, which he stopped taking due to followup issues. The patient has not followed up wlth ENT at Barnes. He was evaluated for possible osteomyeliUs. Here his MRI was unremarkable. Clinically he was better. His white count was nomlal and he has been afebrile. Upon discussIon with infectious disease, we will switch him from Zosyn to Keflex to complete a three-week course. Follow up with ENT at Barnes was again emphasized to the patient. He is also to follow up with a primary care physician. He was given referral to the John C. Murphy Clinic and 30-day prescriptions for his Norvasc, Neurontin, with Pereoee! and Keflex for his cellulitis. Tile patient understands his followup instructions and agrees to comply.

All qU8stions answered.


DISCHARGE ACTrVITIES: As tolerated. The patient is not to drive or operate heavy machinery while taking Narcotic medications. D'SCHARGE DIET; Regular diet.

This document has been reviewed and signed by MOUNER SALEM Sign DatefTime: 01/27f2009 11 :22PM EST

MEDICAUSURG'CAL DISCHARGE SUMMARY-OP

- Page 1 of 2

DePaul Medical Records/Phillip H. March

000197

DEPAUL HEALTH CENTER


PATIENT: MARCH, PHILLIP

DISCHARGE SUMMARY

Ii

MR#; 000748200

MOUNER SALEM. M.D. MS:1-221 ,2468932 0: 1/26/2009 11:33 AM T; 1/2612000 12;07 PM E: 01/28/200909:01 AM

cc:
MOUNER SALEM. M.D.

MEDICAL/SURGICAL DfSCHARGE SUMMARY-DP

Page 2 of 2

DePaul Medical Records/Phillip H. March

000198

Patient Discharge Jnstructio'ns


Discharge diagno~ls: ,';
", ~_ "i \ \ . . ,.,.;......A.
f .....

'Ar t ' i"\ "


i_
<.

I -' j,'V '- I.- iI (''\ ~/' ,',

Discharge disposition:

I""'.t., .~", .. , \.
None O'Written

Flu Immunization Given ,\ j ,/ Pneumonia Immunization GiVel1) I ( / Home Care Agency:

PRESCRIPTIONS:

Cl

a Given to Patient

Q Call~d to pharmacy

,--

MEDICATIONS: See Discharge Home Mer:J=-ic::..:a:..:::ti::=:o.:.:.Il...::L"::::js:-:.t~a.:.:tta~c;;.;.h.;..;e:..=d'-r=---:--::;>"'r:-,,..,...-:-_ _ _ __ WORK: 0 Return to work in days or Ut(/\;)

a pt&" pWS(

Ilr' j;all for appointment with Dri~)a'l,.hO f~' i C1 [f'h~ne # Iir' Call for a ointment with 0 'inLt )1." Phone # />.'J.J..::r;/II{)
ADDITIONAL INSTRUCTIONS:

FOllOW.UP CARE: Bring all m~dicatlons with you to your appointment.


to be seen in _ _ _weeks to be seen in t..f weeks

IPhysician Signature:
o
o
I' , __ ~.i

o No Signature needed see orders

Dentures 0 Hearing Ald(s) 0 Assis1ive device Belongings returned; 0 None Cl Glas~~ !) lb' . -~ ,, __J.... Home medicltions tl Other: ~ [' \',\ <' These in$tructions have been reviewed wit me and my questions have been answered. Patient Si
......... ----.~
Di~charged to

Si njfjcant Other

Other --------------~~ Phone # after discharge':l;1':i . 1.)'// Escorted b ;

~ Home

Mode:

'i";

~mbulatory
Stretcher

I)EPAUL HEALTH CENT.b:R

,/ tr1is 1 fiarm. 0 r;ginalflorm to CIwr!. Copy (1902200197 Jt.1a ke 2 copies oJ _0/02/1976

~~CH,PHILLIP

liIIOftlillUllllIlI1 H
ERS
M

1/ p
1

32Y i;ALEt.,j, t-lOUNER

0554- Cl 01/22/09 000748:2 98

DePaul Medical Records/Phillip H. March

000199

PAGE:

J.

DePaul Health Center


12303 DePaul Drive

Bridget.on. MO 63044 Fatient's Discharge Home Medication Liat


Account: Number: 0902200J.97
Patient Name: MARCH,PHILLIP B

Room Number: 0554-01 Date! 01j26j2CJ09 Attending Physician: SALEM,MOUNER

Patient Allergies: No Known Drug Allergies

DePaul Medical Records/Phillip H. March 000200

l>1edication Generic Name [Br.and Name) with Di:rec.t.ioos

AM

Noon

PM " Bedtime

*.~.*

Scheduled Medications .-

AMLODIFINE(NORVASC)

5 MG BY MOUTH Daily

TAKE:

(1) 5 MG TABLET
TAKE. (2) 100 MG CAPSULE
~SOLE

I X

GABAPENTIN(NEORONTIN) 200 MG BY MOUTH 3. Times a Day

x
x

x
x

CEPHALEXIN{KEFLEX) 500 MG BY MOUTH 4 TIMES A DAY

TAKE: (11 500 MG


**~

-*.** As Needed Medications


OXYCODONE/ACET

5/325MG(PERCOCET-S) *1-:2 TABS BY MOU'I'H EVERY 6 HOURS AS NEEDED

AS NEEDED FOR FAIN

IF YOO HAVE ANY MEDICATIONS AT HOME WHICH DO NOT APPEAR ON THIS LIST.,
REMEMBER TO DISCARD OLD MEDICATIO:N LIS'TS AND UPDATB YOUR PHARMACY

PLEASE CHECK WITH OUR PRIMARY PlnlSrC!AN BEFORE RESONING THEM.

PAGE:

:<

DePaul Health Cen~er 12303 DePaul Drive


Bridgeton. MO 63044

patient's Discharge Home Medication List


Account Number: 0902200197 Patient Name; MARCH,PHILLIP Room Number: 0554-01 Date: 01/26/2009 Attending Physician: SALEM, MOONER

Patient Allergies: No Known Drug Allergies

DePaul Medical Records/Phillip H. March 000201

Medication Generic Name (Brand Narr.e) with Directions

AM

Noon

EM

I Bedtime

Additional Orders

IF YOO HAVE ANY MEDICATIONS AT HOKE WHI:CH DO NOT APPEAR ON THIS LIST. PLEASE CHECK WITH YOUR PRIMARY PHYSICIAN BEFORE RESUMING THEM. REMEMBER TO DISCARD OLD MEDICATION LISTS AND UPDATE YOUR PHARMAcY

+
Please

H
DePaul Health Center 12303 DePaul Drive circle: Discharge
Meds or Post-op Mads PAGE NlJ!!!BER: 1

ESTIMATED DISCRARQE TIME:

Bridgeton,NO 63044 Patient Active Medication List (YES NO) Account Number: 0902200197 Patient Namel MARCR,PHILLIP EI

NURSE: PRONE EXT:

Room Number; 0554-01 Date: 01/26/2009


Attending Physician: SALEM, Momum.

DePaul Medical Records/Phillip H. March 000202

patient Allergies: No Known Drug Allergies


Continue? Medication Generic Name (Brand Name) with Directions

AM

Noon

PM

Bedtime

**r.** Scheduled Medications ***.*

15~

NO

QABAFENTIN (NEURONTmll:O:C MG BY MOUTH :3 Times a Day


OOCUSATE SODIUM(COLACE)1ClIO MG BY MOUTH 2 Times a Day

ZDO

GIVEN AS:

tI) lOa MG CAPSULE


(1) 100 MG CAPSULE LF

x
x

x x

16 YES@

GIVEN AS:

DO NOT CRUSH - TASTE 7 YES

g;

PIPERACILLIN TAZOBACTAM (ZOlSYN) 4, 5 GM INTRAVENOIJS EVERY 6 HOURS

**
X

EVERY 6 HOURS

11 YES SODIUM CHLORIDE BACT O.9%(SODIUM)3 KL INTRAVENOUS EVERY B HOORS

**-,**
9 YES
OXYCODONE/ACET

As Needed

Medications ...... * ..

S/325MG(PERCOCET-SJ 2 TAB BY .MOlITH Every 4brs pm

FOR PAIN

PHYSICIAN SIGNATt1R.E IS REQOTRED ONLY ON 1'HE LAST PAGE: OF THIS MEDICATION LIST
>

pilot Form 4/2 aas

Medication Substituted per HOSlpital. Approved Formulary Substitution

H
Depaul Health Center 12303 DePaul Drive

PAGE :NUMBER: 2
EST~TED

DISCHARGE TIME:

Please circle: Discharge Meds or Pos.t-op .Meds

Bridgeton,MO 63044 Patient. Active Medication List (YES NO)


Account Number: 0902200197 Pat:ient Name. MARCH,PHILLIP H

NURSE PHONE EXT:

Room Number; 0554-01


Date: 01/26/2009

Attending Physician: SALEM,~OUNER Patient Allergies, No Known Drug A.llergies


Continue? Medication Generic Name {Bran.d Name) with Direct.ions

DePaul Medical Records/Phillip H. March 000203

AM

Noon

PM

II

Bedtime

10 YES ~ ACETAMINOPHEN(TYLENOL)650 MG BY MOUTH EVE~Y 4 HOURS AS NEEDED 13 YES

_.. -- - - -?'f1- -- - -- - - ........ - - - _.. _.. -- -- - - - .. - _.. - - .. _.. - .... - ...... - .... _.... - _.. - - -- - _.. - _.. -- _.. "" .. - - - - - - - - - - -- - - - - - - _.. - - - - - ....... - _.. - - - - --- _.. - _.. - - - - - - - _.... - - - - - - -GIVEN AS; (2) 325 MG TABLET I i I I I

HYDROMORPHONE HCL(DlLAUDID) 1 M'G IWTRIWENOUS EVERY 4 HOURB AS NBEDED

BREAKTHROUGH PAIN
l.4 YES@ DIPHENHYDRAMINE (BENADRYLI 50 MG INTRAVENOUS EVERY 4 HOURS AS NEEDED

ITCHING Additional Orders

M. f1:r2--.C~h'r /ft-/t/~ _____.____ ~rVMt 5~ ,OfLd4.----------.

1<~:4 f'"
p&1wrd

Q)'b

--------"--_._--,',--,-----

5:!32-! /-Z-

--,-,--_._-,-----------------_._----_.

PHYSICIAN SIGNATURE IS :REQUIRED ONLY ON THE LAST PAGE OF THIS MEDICATION LIST
>

pilot Form 4/2005

Medication Substituted per

Hos~ita1

Approved Formulary Substitution

H
DePaul Health Center 12303 DePaul Drive

PAGE lNUMBER; 3

ESTIMATED DISCHARGE TIME.


NORSE PHONE EXT:

Please circle: Discharge :Meds or Pos:t-op Meds Bridgeton,MO 63044 Patient Active Medication List (YES NO)
Account N\,UIlber:
09a2200~97

Patient Name: Room Number: Date: Attending Physician! Patient Allergies:

MARCH,PHILLIP H

0554-01 01.126/2009
SALEI4, MOUNER

DePaul Medical Records/Phillip H. March 000204

No Known Drug Allergies

Continue? Medication Generic

Name,(~~
4

--;~~:::~~-;:~~:~:~::-----~~~~-------~---------~:~:~~~~:---------------------------------------------------------------------NUrse Signature:
~.""_.._____. __Dat e/Time

1/

Name) with Directions

AM

Noon

PM

Bedtime

Readback Confirmed [ ]

PHYSICIAN SIGNATURE IS REQUIRED ONLY ON "THE LAST PAGE OF THIS MEDICATION LIST

Pilot Form 4/2005

,.

Medication Substituted per Hos;pital. Approved Formulary Substitution

HOME MEDICATION LIST ORDER SHEET


,--- ---------- --------I 0 No Known Allerg '.
j
~()I Jrr("o

('\f I"fr.. rr ... ., . -d;"v"l

Patient

o o

Medication Bottles Family/Significant Other Medication Lis! Physician's Office Pharmacy Name,_ _ __ Phone Num.:b.=e:.:r

ONo
AU Col

====_-.
over~th8.count8r.

h@mal s Innlofl'II"IRte
Dose
Route or tapir.al site
Frequency -.

cOlnDlletE~d

for each medication Including


last Dose
Date
Time

Continue?
[J

Drug Name

Yos

Hold

DYes

o t,ald
o
[J

Yes

Hold Hold

[J Yes

Cl Yes
[J
y~s

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o HOld
o Ho!d
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o Yes
DYes
Q Yes Q Yes

\0~)

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U Hold

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a
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Checked orders will only become active when authorized by Physician


MtJolcetion,Vherbdvvitaminfj will Of, di$pefWffd in BCGorriilnc@ wililltll;! l)oDit8i fMfflUIl'if)'

Home Med List

R@eon%tJ by:

Date
Dale

1/';Q,!tJ'I

Time t>} /:;


Time

.~I:._.?h..

Y_SiciavaCif . ./i.}C~'()--c9m
') :- }

: ..Nu~~e

0 Readback confirmed

-"..

'#

, 0 Scanned

~SSM DePaul Health Center


., " " t> , , '

DE:PAUL HEALTH cGENTR ~~~~'H~!PA.'II ERQ


0902200197

HOITlI:l Medication Orders 8/2008

10/02/1976 32Y

ERSM

01/22/09

BMERGENCY,PHYSICIA000748298

DePaul Medical Records/Phillip H. March

000205

] ,") ,,1>
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'~ Address
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DEANO,____________________

Physician Office Phone Nurn.I:ler


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DePaul Medical Records/Phillip H. March

'~
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DePaul Medical Records/Phillip H. March

lg~

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000207

~~SM. DePlltd~(jiiii/~'-'?:7'-' jf,,"".' '.> '\"

:$ ~;'.'.> i'~ . 'Stl=i ~ :'<..;f.l::$ "''''V'W 'M-~~

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8"'{~G':eou~O ~Ai::orIONAl .W:.::URI~"" faAl~Re31t~E t'Rff~T!;D ~~ llH~ B,\Ci\

IMPORTANT
1, 'Dillly' IIlS(ijdU of

REMINDERS

"!!d'

;:, 'IInrt:i" 1II.1wll ul "It


3, Nu U.RIOg lerus (1 fIlV l1ul 1,Clug)
PATIl'NT \...EIGHT q

o K.,5

Cl Lbs

PATIENT HEiGHT q

4, IItvtays use leHdinu le'us (O,lmg not, lmgl

5, <MQIpf1tfro' IIlstcad 01 'MS04' a, "MagM.III!T! Ma\~' jlWt~~g Ql 'Mii~iJ4' r 'Every OIlier Ga',. ll1slcaQ Of -a,OD, 8, 'MGl;' ifl,lead 0/ '!JQ' 9, 'Inlelflabooa! ullils' inslood of 'IU"

1~IT"ll1rm:

mo 1lA&~ RJii ACOJIVC,

fO INOlcm T!lrpno.r c<lDm

ORDERS

~SSM
H E A L T H ' CAR E
W

nPl\UL HB7\J,l'H CENTER

- ImOlltllDlllllfllllUI PHLLLIP H
MAR~H

lip

PHYSICIAN'S ORDERS
SLM1000-005 (4/2007)

0902200197 ERS 0554-01 10;02(J 976 3ZY M 01/22/09


SALRM, 1"'.oU1~ER O(}U']" 8298

DePaul Medical Records/Phillip H. March

000208

,H.OSPITAl FOI1MUL~Y SYSTEM UNLESS CHECKEO HERE ....... ....,...

:.o,DR7'U;:-;;Qo;;:MA;;,;Y~BE:,::.:O::::.IS",",PE;..:.:NS..:;EP...::':..:.:N:;.;;ACC..::;;.;.;:Ofl;;;,.;OA:.::.N..::;'CE.;;;;V..;:..V'T.;:;;:H:;.;TH.;.:;e;.;.:::.."~p'-AllERGIES

__l'~J~tglAN 'S ORDE RS


IMPORTANT

REMINDERS

01 'Qd' 6, l,In~~< in.5\f?d r.f 'If 3, No lr.Ifting lAfru: (l mg not 1 Omg) ~, Always 1J38 laatll11g wos
PATIeNT WBariT r?

t 'Daily"

in~ao

o Kos

Cl Lbs

PATIENT HECHT q REAO


AC~ fQK

(O.lmg noumq)

5, 6 7 8, g,

'Morphllle' instead of 'MS04 wHale" Instead of 'M~S04' '('/ery olh!lf day' Instead 01 '0,0,0.' 'MeG' insteao cf '/lu' 'Imernationlil units" (n>l~ad (II 'IU'
't~eslUm

liill tAL U[f4: TO Uirr.C:ATf TRff'SOfff ~n-rli

IiC<;!iII'!;'f

ORDERS

ANTIBIOTIC ORDER RENEWAL


Accord\ng to Depaul Health Center's antibiotic stop order polioy, the follow1fig antibiotic ordem are schedy!~g to

elq)lre on \ \ ~~ \ ~
PsUent
~ W-lJr-

p,~ase revie",: your ,patle~t': cflnlcal response and renew, revisel or dISCOntinue ttl antibiotic orders accordingly, Thank You
~ '-..:: ".:.

f'

Room Numblr _ __

S!5.~

t:.t>~\4P

DP$-3901-991-819&
I.

__----~--------~<4Q~~~~----~b
H ' CAR E~

PATIENT LABEL

H " "

DBPAUL HEALTH CENTER

I\1ARCH,PHILLIP II

IlIIlIDlBlflllllflllllH
~RS

lip

0902200197
PHYSICIAN'S ORDERS
SLM-l000-OO!5 (4/2007)

0554-01
r.,

10/02/1976 37Y SALEM I MOUNEi<

0] /:I.:J.I09 0007 'J 8298

DePaul Medical Records/Phillip H. March

000209

HOSPITAL fORMUJ.AqySYSn;", VM.E$$ CHCCKCD HERE._""'~=_ _ _..:.-::.~-=..::..-=-:.:;.

DRUB MAY 6EDiSI'ENSfO IN ACCQRDANC5.WTTH lHE

,....l\.

PHYSICIAN'S ORDERS
IMPORTANT REMINOERS
5. "Murphine' h1slead vi "1.1$04' 6. 'MaVf16sium sulfalo" instead 01 'M9S0~' i. 'EYe!)' othu day' instead 01 'ODO:

ALLERGIES
1 2. 3 4.
f'IIfIEN I I'I1OIGHT
~

'Oaily' instead of 'q<j' 'Unhs' instead of 'u' No t:aihlJ leiOS (Hnq 1101 LOmQi AN,ays u~e Icooing WO,
(0 lmy Ilflt lmq)

IJ Kg. 0 Lb$

PATIENT HECHT
RiAn lAC' ra~ AC~\''f\,\C~

<>
u?,;vm

a 'MeG' Instaa<1 of '/Jq' 9. "IniHm300nallJntls" Instead 01 "!U'

l's'iltl't. HtRt

fQmo-lCJtJtT!Uf'llOH~

ORDERS

~SSM
SLM' 100{)'[166 (4/2007)

PA TfENT LABEL

H E A L T H . CAR E'"

DEPAUL HBAL'l:'H

PHYSICIAN'S ORDERS

S1\.LEM,MOUNER

CENTER MAl{CH f PHILLIP I"'" 0902200~97 ER" lip S 10/02/1976 32Y ~554-01

1IIIIlIIIIrIlilIfIlll

01/22/09 00(1'148298

DePaul Medical Records/Phillip H. March

000210

D QuaUtle$ for pneumococcal vaccine, Pneumococcal vaccine 0.5 milM will be administered on day 3 In AM or at disct1arg~ {when discharged betor~ day 3} per protocol unless countermanded by order of the physician with documented medIcal reason fever 101"F or for the vaccination.

*11 patient meets criteria for Pneumococcal vaccination but year of Il1lt PneumGOc;eal VlJl;ctne
Is not obtainable by Nursfng and/or Case Manager, vaccine should be given and recorded.

+CDC/AClP Recommendations MMWR 1012006

Yea
(j

Disqualifying Fadora (One or more Yes responses)


Already received flu vaccine this season

at 1:; 4

t:!:.I:

2~
I~

8---

AHergy to eggs, contact solution (thimerosal) or merthiolate


Patient Refusal Code Status: DNR: Comfort Measures Only

Q/ Allergic reaction to flu vaccine

U :l 'ii :- I
c~

Yea,;,
0

:','luaIU'jij'g;;lfiotors" (Oni:or':mora"'.Yssrssrioosss)..
50 years of age or older Heart Disease COPO/Asthma Diabetes

.........:.........

. ..

1:1
0

lJ

0
0

Renal Failure
Immunocompromised (i.e. on chronic steroids, chemotherapy)

:l_

Ei:
"," .f" ..;.; ...' .,i

Nursing Home or long Term Care Facility resident


Pregnant andlor newly delivered female Q 0088 not qualify for flu vaccine. D Qualifies for Influenza vaccine, Influenza vaccine 0,5 milM will be admlnlstere<l on day 3 In AM or at discharge (when discharged before day 3) per

;,;b:":",~t ..
':"~'
.'/

,,::',

C'

. '"

,,:~~:.:!
...

'
,':i\',

,>~. protocol unleas countermanded by order of the physician with documented . '';''''"i medical reason (I.e. fever' 01 "F or greater) lor wlthl).etl:llnrnhe vaccination .

essrDePaul Health Center r~.~~;';'tl~~~ ,,-. -, ~,11,1


Date:
D
HlIT~

'1.:l...,..

Time:

tJC1 00

Aneaament completed by: [J!tfL'-L/\


InitIals:

A.

A.

....,

HU

pneumocoo:allflu 91 2008

L ________.____

E- AUL HEALTH CENTER


1

0902200197 BRS 05~4-01 I. 10/02/1976 J2Y M 01/22/09

MARCH, PHILLIP H I D

SALEM, MOUNER

00074B298

DePaul Medical Records/Phillip H. March

000211

ASSESSMENT" ORDltS
(:
~-

DEPkUL HEALTH CENTER


'\,'... . .

..

'.:.'

MUIt\iTE~,. 8fl097

'0902200197 ERS 05S4-0~ , 10/02/19'16 32Y III 01/2'2/09


I SALEM, t-iOUNER 000748298

rv1ARCH I PHILLIP H

11111111111111.

r/p

DePaul Medical Records/Phillip H. March

000212

.1
}'

f . ;
[.
.:'

r"~'~""';""':'~1~1l~~

. ~ ..,~!~..;.l .':';'.I..l!oo;,.,."'; ..>-\>;,I,;".,4{.; I<i.,~~~

':~ ~~ .;:,-,~ \ ,
.

L. . . . . ~:.'"'..
__ ... " ..t.~"

"
'{

DePaul Medical Records/Phillip H. March

000213

EMERGENCY DEPARTMENT ADMISSION ORDERS

,~:_t!_~.~~. ~:.~~: . . . ~~.~n~_!.~.f..n._._~_~__:'~:~ .....n___ n. _____ n....................~~~.?~~~~~~..(1L~:.~:::(~_i_. __ ._.~::!I. ~.I' +i s


j Inpatient admit to: 0 Medical
. r . ' ~~_ r _ ... - --- -_. --. --

[) surgical
-" . __ 0_
0. _____ -

0 Telemetry [J 3 North (Intermediate leU) 0 Surgical

0 leu
<. _______ . . . . _ . . . . . . . . .

i Outpatient (Observation) admit to: )i(Medical i


Ph Sielan:

0 Telemetry
,t ................................ 1, ___ "
____

S~.ST~ r1' ... ,. _

"

". /

i' ,6.Fun ReSU5citation


o

Code Status

~ 10m ---_._-------------.,

.--._ _ _ _ co_n_s_u_lts_::..

~~_Z::.........:\:....!!V\...:...-".J>~e;r=---JL--::+-_ _ _ _ _ _ _ _.

Allergies:

o DNR - Continue Medical Therapy


DNR - Comfort Measures

Plac~on Care'pathwaY:D Acute Cardiac OCongeeiiveHeart Faflure' 0 Acute pu~onary

II.

~
.
!

SSESSMENT

Vita! signs every

0 Obtain Previous Medica' Records .-L hours x ~ then routine


0 Daily Weights

0 I&0

)!:( Oxime1ry o Cardiac Monitoring

ADDITIONAL DIAGNOSTICS

DCBC

OCXR

o CMP
OPT

o EKG
C _ _ _ _ _ _ ....._______
0 AC & HS 0 every _ _ hours

o PTT o Flngerstick Glucose


Ill. MEDICATIONS ~

Z" s '7 ~ .,. 5" j

-:r.

v'r '5

cp b

fvr~

o Imttate Sliding Scale Insulin Orders


)(continue Home Medications checked "Yes" on Horne Medic.'3tion She;;;t/Orders, )aacetamlnophen (Tylenol) 650 mg PO every 4 hours PRN mild pain or fever greater than 101.5F

);r .C (l '(\~ tY\ c..i n (.,o0:V .:! U PB Q '5 M- 5 'm Phrc<> c e,{ fL (5 2.J; if Ms PDQ i.{ b-rs pro pc. ij{)
IV. TREATMENTS

o DVT prophylaxis:

,,~

I I.

o IV fluids _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ '>tg Saline Lock


o Oxygen at
liters per_ _ _ _ _ _ CaH physician jf 02 Sat less than ~~%, 0 Regular 0 _ _ _ calorie ADA 0

Cl Foley 0 N13 to suction


0 NPO 0 Bedrest ~ SRP

~ I-t(.r).&c..:.. ..,.\.:...:(-...:::c~~-'-t---,-Su..o ..... f-J...+


0 _ _ _ _ _ _ _ __

if)

Activity:

sse

0 Up ad lib

'0 o See Additional PhYSician Orders


Date: Time: of;, So Physician: t~ Transcribed by: _ _ _ _ _ _ _ _ _ Time Noted:;:;P-

t{2-2-/0'1

~ -:~ ~

--'l

Orders scanned to Pharmacy. Date: _ _ _ _ _ TimB:

Inltlals: _ _ _ __

E A L T H e A. R t'"

SSM DePaul Health Center

~EPAOL

Jl~~'!!!AIJII 0902200197 ERS10/02/1976 32Y

HEALTH CENTER

S> EJ

ED ADMISSION ORDERS

M 01/22/09

EMERGENCY,PHYSICIA00074B298

DPM ..UOO-I~5 (tOl2007)

DePaul Medical Records/Phillip H. March

000214

DEPAUL HEAlTH CENTER


HISTORY AND PHYSICAl
PATIENT: MARCH, PHILLIP H ADMIT DATE: 01/22/2009 MR#: 0007462~98 ACCT#: 09022 7 ROOM: 0554

OOB: 10/0211976
PHYSICIAN: MOUNER SALEM, M.D.

REASON FOR ADMISSION: Left facial pain and swelling,

HISTORY OF PRESENT ILLNESS: This 15 a 32y~arold gentleman with a history of stab injury to the lfilft fflce in 2007 followed by fixation complicated by hardware infection requiring removal in July 2007. The patient has had a previous history of osteomyelitis. The patient hM also had problems wfth chronic pain. He states that the pain has gotten much worse. though, In the left
face along with the swelling. He denies fevers or chills. No drainage from his mouth or his nares. No ear drainage. He has not had any neck stiffness. No headache. His pain 1s primarily in the left face. He denies any radiation of this pain into the neck or shoulder. He denies any chest pain or shortness of breath, abdominal pain, nausea, or vomiting, No bloody stools or blackcolored stools, hematuria, dysuria, or frequency. REVIEW OF SYSTEMS: Otherwise negative, except as mentioned In the HPI. PAST MEDICAL HISTORY: Previous history of osteomyelitis of the left mandible, status post open reduction and internal fixation for a stab injury; hypertension; chronic pain since his facial injury; history of hardware removal; history of liposuction. ALLERGtES: None,

MEDICATIONS: The patisnt currently takea no medication accordIng to the medical records. He
states he is on Neurontin, however. ALLERGIES: None. SOCIAL HISTORY: He is a nonsmoker. He drinks alcohol primarily on weekends. He denies any illicit drug use. He works as a private investigator. PHYSICAL EXAMINATION: YITAL SIGNS: Temperature is 97,7. Pulse Is 68. Btood pressure is 1581108. Saturations are 100% on room air. GENERAL: He is well nourished. well developed. and in 110 apparent distress. He is sitting upright in bed. Every time he sn~ezeSt however, he does note a lot of pain In his left face. HEENT: ENT examination otherwise reveals anicteric sclerae. Extraocular movements are intact, Pupils are equal. round, and react to tight. Mucosa is moist. Oropharynx appears normal. No evidence of drainage, pus, or Significant dental deformities. NECK: Supple WIthout bruits or adenopathy. He has a wellhealed scar behind the left mandible. There is tenderness to palpation of the left race and left manoible. There is no crepltance noted or fluctuance. HEART: Regular rate and rhythm without any gallops. murmurs, or rubs. LUNGS: Clear to auseultation bilaterally without wheeze, ftJlee, Qf rhonchi. ABDOMEN: Soft, nontender, and nondistended. No organomegaly is noted. Bowel sounds are present. EXTREMIT1ES: Without cyanosis, clubbing or edema. The patient appears to be scratching his arms and legs and back since com ing up to the floor. LABORATORY DATA: Labs have been reviewed. ASSESSMENT AND PLAN: 1 This is a 32-year-Old gentleman who comes in with possible facial cellulitis. Preliminary report 6uggested celluliti$ However, the final CT report i& not Indicative of any acute changes. We will review with Radiology and Infectlol;s Diseases. Continue empiric

MEDICAUSURGlCAL HISTORY AND PHYS,CAl-DP

Page 1 of 2

DePaul Medical Records/Phillip H. March

000215

DEPAUL HEALTH CENTER


PATIENT! MARCH, PHILLIP H

HISTORY ANO PHYSICAL


MR#: OQQ74a2~6

antibiotic for nQW, He does appear to have some facial sweJling. however. An Infectious Diseases evaluation will be obtained. Pain control, He appears to have problems with pain CQntroi chronically with multiple emergency room visits to this hospital according to our records.

Ttlls document has been reviewed and signed by MOUNER SALEM

Sign OatefTime; 01/22/2009 11 :42 PM EST


MOUNER SALEM, M.D. MS:1-t862466880 D: 1/2212009 10:39 AM T: 1/22/200910:49 AM E: 01/231200909:01 AM

cc;
MOUNER SALEM, M.D.

MEDICAl/SURGICAL HISTORY AND PHYSICALDP

- Page 2 of 2

DePaul Medical Records/Phillip H. March

000216

INTERDISCIPLINARY HISTORY AND PROGRESS NOTES

I--~--~--------------~------~~~~------~SSM
H E A L T H . CAR E"

INTERDISCIPLINARY HISTORY & PAOGRESS NOTES

DePaul Medical Records/Phillip H. March

000217

INTERDISCIPLINARY HISTORY AND PROGRESS NOTES

~SSM eH E A L T H . CAR
INTERDISCIPLINARY

HtSTORY & PROGRESS NOTes

SLMl000-003 (6120031 02 BACK

DePaul Medical Records/Phillip H. March

000218

INTERDISCIPLINARY HISTORY AND PROGRESS NOTES

~SSM
H E A L T H . CAR E
Sl..M1000-00J (6/2003) 02 FRONT

DEPAUL HEALTH eEN'fER

INTERDISCIPLINARY HISTORY lit PROGRESS NOTES

--

r/p t,'[/\RCH, PHILLIP 11 0902200197 ERS 05~401 . LO/02/1976 32'l M 01/22/?09


$ALl::r.1, MOUNER Q00'{4{;l_98

!III0nlllltliRlIIJIIJI

DePaul Medical Records/Phillip H. March

000219

INTERDISCIPLINARY HISTORY AND PROGRESS NOTES

~SSM
SLMl O(){)-D03 (6f2003) 02 BACK

H E A L T H . CAR E-

DEPAUL HEALTH CENTER

INTERDISCIPLINARY HISTORY & PROGRESS NOTES

JJ!~~f~'~l~IJIII

rip

090220Q19'l ERS 0554-01 . 1010211~n6 32Y fllf 01/22/09 SAT,EM, MOUNER OOOH8298

DePaul Medical Records/Phillip H. March

000220

INTERDISCIPLINARY HISTORY AND PROGRESS NOTES

f""te() 1. - ,2,<o..

OlTlme: ~

SSM DEPAUL PASTORAL CARE

OPM-6471-W2 (&LOOS}

~r-IRITUAL ASSESSMENT: ld1'fritial 0 Follow-up DJ~eterral 0 Trauma 0 Code 0 Death 0 _ _~-_______


DISTRESS; 0 Anger 0 Fear 0 ~us 0 _~jlty 0 Pain 0 Grief O _ _ _ _ _~____ - _ _ __ RESOURCES: 0 Gratitude Q1'fGst~ ~ ope .!d1'Ositive Image 01 Gad 0 Family/Friends 0 Church 0

SERV\CtS: 0 Sacraments
Notes:

~'<t T '\ {.- rb'i~;P-f~/I( S"f11'rt ----------------------------------------~ /~ _________ - ____ --____________ - _Chaplain: lC/Zt:f~ ~
A- {

.ayertG}SUpport 0 Literature 0 Suppor1 To FQmily P ~~==---------ADVANCE DlR CTIVES: _0 Yes !:iN0 Unkn wn b,&Patient 0 19<ippro~riat tAsk 0 ---/-"~---r-----'--~-~'7
J IJ fl , IJ
-

h----~----~------------------------~------------~~~T~~~NT~L~AB~E~L--------------

~SSM

DEPAUl, HEALTH CEJ-ITElI.

HfAL.TH-CARe

INTERDISCIPLINARY HISTORY & PROGRESS NOTES

t'lARCH, PHILLIP H TIF 0902200197 ERS OS54-01 10/02/1976 32Y ~\ 01/22/09


SAL~M,MOUNER

tllJlIDUIDlllllflllllU

000746298

DePaul Medical Records/Phillip H. March

000221

INTERDISCIPLINARY HISTORY AND PROGRESS NOTES

~SSM
H E A L T H . CAR
SLM1000003 (6f2003) 02 BACK

DEPAUL HEALTH CENTER


r>1APCH 1 PHILLI P H TIp 09022~0l!J7 ERS 0554 -01 ]~O/02;l976. 3?Y M 01/22/09
SAl.EN, MOVNER 000'1 .. 82 98

E~

IUlIII0l1ll11ll1l1181

INTERDISCIPLINARY HISTORY 8. PROGRESS NOTES

DePaul Medical Records/Phillip H. March

000222

DEPAUL HEALTH CENTER


CONSULTATION REPORT

PATIENT:

MARCH, PHILLIP H

ADMIT DATE: 01/22/2009 CONSULT DATE: 01/23/2009


ATTENDING PHYS: MOUNER SALEM, M.D. CONSULTING PHYSICIAN: PHILLIP G. ZINSER, M.D.

MR#: 000748298 ACCT#: 0902200197


DOS: 10/02/1976 ROOM: 0554

REASON fOR CONSULTATION: Evaluation of left facial pain and swelling.


jaw in 2007,

SUBJECTIVE: This is a 32-year-old with a history ot hypertension. He had a stab wound to his He sustained 8 fracture to the left mandible. He had open reduction and internal fixatlon. He developed a hardware Infection. He had a partial response to antibiotics. The hardware was removed on 09/2212007 at Barnes. At that time, cultures grew strep ang/nosis, strap intermedius, and < >. He returned to DePaul on September 19,2007, with swelling. MRI showed osteomyelitis of his left mandible ramus. He was discharged on IV Unasyn to follow up at Barnes. He was readmitted in Octobef of 2007 with increased pain and fever. His blood cultures at that time grew Klebsiella. It was determined that he had a PIce line infection. The PIce line wa~ removed and he improved with Zosyn and has done well since that time. The patient has had chronic pain which he rates as a 6 out of 10 since that time.

The patient returns and was admitted on January 22, 2009, with a 2-day history of some increased swelling and Increas~ pain at the sits. He denies fevers, chills, sweats, nausea, vomiting, diarrhea. cough, phlegm, phlegm production, or he<:'ldache. He was admitted and started empirlCl3l1y on Zosyn and clindamycln. He feels unimproved at this point. He had a CT of the face without contrast which showed chronic bony changes but no acute changes or infection. His white blood carl count was normal. He has not had fevers.

ALLERGIes: The patient's list of allergies Includes that he has no known drug allergIes.

PAST MEDICAL AND SURGICAL HISTORY: The patient's past medical and surgical history are as above. In addition, he has history of VRE colonlzatJon. He also hal> history of liposuction.
HOME MEDICATIONS; He reports Neurontin.
His Ii$t of medications here tn the hospital Include1 Gabapentin. 2 Acetaminophen. 3 Diphenhydramine. 4 Hydromorphone. 5 Cfindamycin. 6 Zosyn.
SOCIAL HISTORY: He does not use tobacco. He drinks alcohol prlmarily on weekends, He denies any illicit dru~ use. HI;} wQrKS a~ a private investigator.

OBJECTIVE: VITAL SIGNS: The patient's temperature maximum is 97.8, The pulse Is 66. The respirations 18. The blood pressure Is 147/96. The saturation is 100% an room air, GENERAL: The patient is awake, alert, and oriented. The patient Is Sitting up in bad. HEAD: He has some chronic swefllng on the left side of his face from changes In the $hape of his mandible secondary to his previous history. He has a nodule on his left cheek where he evidently has a clip still in place from previous surgeries. This has been a site of problem~ previously. He has tenderness in that area. There Is no redness, warmth, induration, or bagginess. It is hard to know if there is any increased swelling from his baseline. The neck Is supple with a full range of motion. The pupils are equal, round, and reactiVe to light. The oropharynx is clear. The uvula rises midline. LUNGS: Tile lungs are clear to auscultation bilaterally with good ajr movement. HEART: The

MEOICAUSURGICAL CONSULTATION REPORT.DP

- Page 1 of 2

DePaul Medical Records/Phillip H. March

000223

DEPAUL HEALTH CENTER


PAT'ENT; MARCH, PHllUP H

CONSULTATtON REPORT

MRtI: 000748298

heart has a regular rate and rhythm. ABDOMEN; The abdomen is soft, nontender, and nondisten(jed. Normoactive bowel sounds. EXTREMITIES; There is no peripheral edema. There is no chording. There are no rashes. There is no decubiti.
LABORATORY DATA: The patient's white blood cell {;Qunt Is 7000 with 53% neutrophfls, and 37% lymphocytes. The hematocrit is 42. The platelets are 282,000. The creatinine: is 1.4. CT of the face shows no acute changes. Review of previous hospitalizations reveals history of VRE colonization and Klebsiella bacteremIa In 2007.

ASSESSMENT: 1 History of left facial stab wound with mandible osteal In the past treated and with hard removal in the past and with hardware removal in the past. A cUp remains. 2 Acute on chronic pain and swelling.
RECOMMENDATfONS; f MRf of the face with contrast.

3
4

Follow up with Barnes ENT. Oiscontlnue clindamyctfl for now. Continue Zosyn pendIng the results of the MRI.

Thank you for allowing me to participate in this patient's care.

This document has been reviewed and signed by PHILLIP ZINSER

Sign DatefTime: 01f25120098:20AM EST PHILLIP G. ZINSER, M.D. PGZ:1-190 ~ 2467787 0: 1/23/200912:32 PM T; 1/231200912:57 PM E: 01/25/200909:01 AM

cc:
MOUNER SALEM. M.D.

MEOJCAUSURGICAL CONSULTATION REPORT~DP

- Page 2 of 2

DePaul Medical Records/Phillip H. March

000224

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DePaul Medical Records/Phillip H. March

000225

E,m ergency .nepartme~t Or(],ers beneral Chlefcompla1t@,~<Jcui~_


Drugs must he dispensed in accorda1lce wilh tht: hospit1l1

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tbl~ary system.

I.

Assessment: Notify physician if SDP < 90 or >; 95, or heart rate < 60 or > 120 1 or for oecrcas mental status PulHe oximetry (notify physician fN Sa02 <9211;;') and Temperature recorded Asses:'; women of childbearing age for pregnftUl.:'Y st~tu:; and perform urine beta 1 for any possibility of pregnancy

II.

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-~--------

....... ~~--+--

V.

Tylenol 1 gram po for Temp> 1OQ.} or PRN pain

Nutrition:

VI.

NPO

AdditionaJ Oruen:

o
I have revIewed and agree with the above orders wilh {he f:};cqJtion of (hose crossed rhrough.

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~

MARCH/PHILLIP H
0902200197

DEPAUL HEALTH CENTER 1

111.11
ERS-

ERQ

1.0/02/1976 32Y M 01/22/09 EMERGENCY, PHYS1ClAO0074SH8

DePaul Medical Records/Phillip H. March

000226

Name; March, Phillip H

SSM DEPAUL EMERGENCY RECORD


Complaint: Swelling/Pain Of Jaw

Age: M32 Wt: 76,2 Kg (est.) MedRec:000748298 AcctN um: 0902200197

- - - - - - - - - - - - - - T R I A G E DATA----................- - - - - - Triage Time: Thu Jan 22200902:12 Source: By: Car Urgency: ESI3 Room: WTG-RM
Vital Signs: (0210) BP:128/85

Age: 32

Male

Kg Weight: 76,2 (est.) PhysIcians: None Pcp Emergency Physicians

P:72

T:98.9

Pain:?

Sat: 99/ra

R:20

HPI JAW PAIN (05:23 AMAJ) CHIEF COMPLAINT: Patient presents for the evaluation of Jaw pain. left,
HISTORIAN: History obtained from patient. TIME COURSE: Onsel of symptoms reported as gradual, Onset was 2 days ago, Patient currently has symptoms, Complaint Is worse, Complaint is constant. LOCATION: Pain most severe in left mandible, Posterior radiation. QUALITY; Pain is throbbing. No different from patient's previous epIsodes. EXACERBATED BY: Patient's condition exacerbated by chewing, speaking. RELIEVED BY: Patient's condition relieved by nothing. NOTES: Pt has hlo osteomyelitis of the jaw after an assault/stabbing In the area; feels/looks slmUar but he is without fever ..

KNOWN ALLERGIES Morphine, No known drug allergies, HISTORY


MEDICAL HISTORY (Thu Jan 22200902:12 DMH): Stabbed In left face April 28th, 2007. jaw osteomyelitis . $ee RN notes ..

PSYCHIATRIC HISTORY (Thu Jan 22 200902:12 DMF/): No previous pgyehistrie history. No previous
psychiatric history. No previous psychiatric history ...
200~ 02: 1~ OMHj; Jaw Repair, plute feft jaw. facial repair. Patient's previous surgical history is not relevant to the case. Jaw Repair, plate left Jaw. facIal repair. Patient's previous surgical history Is not relevant to the case. Jaw fracture repairs. Jaw Repair, pla1e left Jaw. facial repair L Jaw surgery, harware removal, chronic osteomyefitls. see RN notes .. SOCIAL HJSTORY (Thu Jan 22 2009 02:12 DMH); Denies al~ohol abuse, Denies tobacco abuse, Denies drug abuse, Patient consumes alcohol socially, DenIes smoking, Patient consumes arcohol socially, Denies drug abuse, Lives at home with family, Denies alcohol abuse, Denies tobacco. Denies alcohol abuse, DenIes tobacco abuse. Denies smoking, Patient consumes alcohol socially, Denies drug abuse, Lives at home with family, Denies alcohol abuse, Denies tobacco. Denies alcohol abuse, Denies toba~co abuse. Denies alcohol abuse, Denies tobacco abuse, Denies drug abuse. Denies alcohol abuse, Denies tobacco abuse, Denie6 drug abuse . FAMILY HISTORY (Thu Jan 22 2009 02:12 DMH): Family history Is not contributory to this case, Family history is not contributory to this case. Family history Is not contributory to this case. Family hi8tory is

SURGICAL HISTORY (Thu Jan 22

Prepared: Thu Jan 22200907;43 by Charle BlaesIng, RN Page: 1 of 7


$$M DePaul Health Center

DePaul Medical Records/Phillip H. March

000227

SSM DEPAUL EMERGENCY RECORD

Name: March, Phillip H


Age: M32 Wt: 76,2 Kg (est.) MedRec:000748298 AcctNum: 090Z200197

not contributory to this case, Family history is not contributory to this case, Family history is not contributory to this cass. Family history IS not contributory to this case .. NOTES (05:23 AMAJ): Nursing records reviewed, Agree with nursing records, Nursing notes reviewed at the time this note entered; any nursing or paramedic notes charted after that time not reviewable unfen directly

communicated to this M.D.,

ROS (05:23 AMAJ)


CONSTITUTIONAL: No fever, No chills. ENT: Historian reports otalgIa, No hearing changes, No sore throat, No dysphagia, No dysphonia, No drooling, No voice changes. RESPIRATORY: No SOB, GI: No abdominal paln, No nausea, No vomiting, ALLERGIC/IMMUNOLOGIC: No frequent Infections, No poor healing. ALL SYSTEMS NEGATIVE: All relevant systems reviewed and all negative excep1 for the above.

!\DDITIONAL TRIAG&; (Thu Jan 22200902:12 DMH)


COMPLAINT PROVIDERS: TRIAGE NURSE: Donna Hogan. ADMJSSION PATIENT: NAME; Phillip H March, DOB: Sat Oct 021976, RACE; Black, Code: NO, Trauma: "NO, Work Comp.: NO, Heat Related: NO, SSN: 493788699, ZIP CODE: 63121, HErGHT: , 82cm, PHONE: 314393-1241, MEDICAL RECORD NUMBER; 000748298, ACCOUNT NUMBER: 0902200197,lBEX NUMBER: 20090122021203ADT. PREVIOUS VISIT ALLERGIES: No known drug allergies, NOTES:Total score is: 0, Confusion (3), No Increased Risks patient, dh. ASSESSMENT: 8110, GCS Eye Opening: Spontaneously (4), GCS Verbal Response: Orientedlconversive (5), GCS Motor Response: Obeys comands(6), The GCS total is 15, pain in 11,* jaw with swelling and burning that started 2 days ago, Pf has hi{ of osteomyelItiS in left jaw, pt afebrile. IMMUNIZATIONS: Immunizations up 10 date, Last tetanus sho1 recaived less than 5 ye~r~ ggg, TB SCRtENING: Denies iB screening. DOMESTIC VIOLENCE: No domestic violence,

EDUCATIONAUCULTURAL BARRIERS: No educational/cultural barriers,


TREATMENTS IN PROGRESS: No treatment, Protocols: General Chief Complaint. VITAL SIGNS

PHYSICAL EXAM (05:25 AMAJ)


CONSTITUTIONAL: Vital signs reviewed, Alert and orian1ed X 3, Patient appears uncomfortable, HEAD: Atraumatic, Normocephalic. EYES: Sclera are normal, Conjunctiva are normal. ENT: External ear normal, no nasal deformity, No stridor, not injected, no pharyngeal swelling, no pharyngeal asymmetry. mucus membranes mOist, No drooling, Able to handl~ secretions. No tongue elevation, no abcess, no dental fractures, Sinuses non-1ander, No erythema, No swelling, Trismus present, edema over L mandibular body and angle, extending back to just anterior to ear; no induration or drainage, no r1uctuance. NECK: Normal ROM, No jugular venous dis1ention,
Prep!lred: Thu Jan 22 200907:43 by Cherie Biassing. RN Pagl1: 2 of 7 SSM DePeui Health Center

DePaul Medical Records/Phillip H. March

000228

SSM DEPAUL EMERGENCY RECORD

Name; March. Phillip H

Age: M32 Wt: 76.2 Kg (est.)


MedRec: 000748298 AcctNlIm: 0902200197

RESPIRATORY/CHEST: Chest is non-tender, Breath sounds normal, No respiratory distress. CARDIOVASCULAR: RRR, No murmurs, No rub, No gallop. UPPER EXTREMITY: Inspection normal. No cyanosis/clubbing/edema, Normal rangs of motion.

LAB INTERPRETATrON (05;25 AMAJ)


INTERPRETATION: 1 reviewed the lab results, All labs normal.

02SAT INTERPRETATION (05:25 AMAJ)


02SAT: 02 satura1ion reading 99%, 02 AMT: R.A., 02 Sat normal, None needed.

RESULTS
LAB (04:50 AMAJ): CBC W AUTO DIFF Jan 22 2009 04:48, WBC 6.8 1000/mm3 Ref Range (4.511.0). Hgb 14.0 gm/dl Ref Range (13.0-18.0), Hct 41.5 % Ref Range (39.{)"S4.0),
PIa,1!ilI~ts

2821000/mm3 Ref Range {130.G-400.0).

(04:53 DAGN): CSC W AUTO DIFF Jan 22 2009 04:48, RBC 4.96 10X6 Ref Range (4.7-6.1), MeV 83.7 fl Ref Range (80.0-99.0}, MCH 28.2 pg Ref Range (25,O-31.0), MCHC 33.7 gm/dJ Ref Range (32.0-36.0), RDW 13.9 % Ref Range <1' .5-14.5), Gran 53.4 % Ref Range (40.0-70.0),

Lymph 37.1 % Ret Range (22.0-40.0),


Mono 8,4 % Ref Range (2.0-10.0), Eos 0.7'% Ref Range (O.O-S.O}, Baso 0.4 % Ref Range (0.0-3.0),

Manual DiH Not Indicated, Absolute Neutrophll3.62 1000/mm3 Ref Range (1.8-7.7}. (05:03 OAGN): BASIC MeTABOLIC PANEL jan 22200905:02, BUN 16 mg/dl Ref Range (9.0-20.0),

Sodium 140 mEq/L Ref Rang@ (137145),


Potassium 3.7 mEq/L Ref Range (3.6-5.0), Chloride 100 mEqlL Ref Range (98.0-107.0), C02 27 mEq/L Ref Range (22.0-30.0). Anion Gap 12.8, Glucose 74 L mg/d. Ref Range (75-110), CreatinIne 1.4 mg/df Ref Range (0.8-1.5), Calcium 9.5 mg/dl Ref Range (8.4-10.2), GFR 75.5 mVmin/1. 73m2.

RAOrOLOGY INTERPRETATION (06:49 AMAJ)


HEAD: Interpretation of the facial CT shows, c/w facial cellulitis. INTERPRETER: Preliminary review of CT by Radiologist.
Prepared; Thu Jan 22 2009 07:43 by Cherie Blaesing, RN Pag&; 3 of 7

SSM DePau! Health Center

DePaul Medical Records/Phillip H. March

000229

1I11! ijm

11'fllllllll/JIII~1111111I1" ~m mIt 11111


Name: March, Phillip H
Age: M32 Wt: 76.2 Kg (est) MedRac:000748298 AcctNum: 0902200197

SSM DEPAUL EMERGENCY RECORD


DOCTOR NOTES (06:50 AMAJ)

TEXT: Considering complicated hx with osteomyelitis and now cellufitis on CT, wUl admit for IV abx to IPC . INTERVENTIONS; Antibiotics administered:, Clindamycln, Antibiotics were given IV. DATA REVIEWED: Reviewed radiology films.

OTHER HISTORY: Other history obtained from: reviewed prior patient visil fscords.
PATIENT STATUS: Patient has stabllzed since admission.

DIW: Discussed this case with Dr. Salem, the on call physician.
PATrENT PLAN: The patient will be admitted to the hospital. Initial physician orders were written for patient as discussed with admitting physician.

DIAGNOSIS (07=25 AMAJ)


FINAL: PRIMARY: Factal CelluUtis, ADDfTIONAL: .

)ISPOSITION (07:25 AMAJ)


PATIENT: X-RAY leT Follow-up: YES, Critical Care: YNone, Doctor Procedures: NO. Disposition: Admit Medical. Condition: Stable.

MEDICATION SERVICE
8enadryl (05:43 AMAJ): Order: BenadryJ : 25 mg ; IV Push Time: 0320

Notes;

v~rb

Ordered: Thu Jan 22 2009 05:43 Ordered by: Angela Majino. M.D.
Entered by: Dave Agnew, RN Thu Jan 22200905:43 Documented as given by: Dave Agnew, RN Thu Jan 22 2009 05:43 MEDICATION, Time given: 0543, Given in amount and via route as prescribed, Amount given: 25mg, IVP. Rapidly, Caiheler plaoement confirmed via flush prior 10 administration, IV siie without signs or symptoms Of inflitration during medication adminisiratlon. No sW9111ng during administration, No drainage during administration, IV flushed after administration, Correct patient, time, route, dose and medication confirmed prior to adminis1ration, Patient advised of actions and slde-~Heet$ prior to administration, Allergies confirmed and medications reviewed prior to administration. Benadryl (03:23 AMAJ): Order: Benadryl : 25 mg : rv Push Time: 0320 POTENTIAL MODERATE INTERACTION Morphine Sulfate Notes: vorb Ordered: Thu Jan 22 200903:23 Ordered by: Angela Majino. M.D. Entered by; Dave Agnew, RN Thu Jan 22200903:23 Documented as given by: Dave Agnew, RN Thu Jan 22 2009 03:24 MEDICATION. Time given: 0320. Given in amount and via route as prescribed, Amount given: 25 mg, IV site 1, IVP, SlOWly, Catheter placement confirmed via flush prior to administration, IV sile without signs or symptoms of infiltraiion during medication administration, No swelling during administration, No drainage
Prepared: Thu Jan 22 200$ 07:43 by Ch~rie Blaesing, RN Page: 4 of 7 SSM DePaul Health Center

DePaul Medical Records/Phillip H. March

000230

IlItllllllllltJ II filiI "Ill fli filii II fJlll IIll11J111111111I1

11m 11m Iml II III Ifill I Jlllmlll IIlltllf II fill

~j

SSM DEPAUL EMERGENCY RECORD

Name: March, Phillip H Age: M32 Wt: 76.2 Kg (est.) MedRec:000748298 AcctNum: 0902200197

during administration, IV flushed 'Ifter administration, Correct patient, time, route, dose and medication confirmed prior to administration, Patient advised of actions and side-effects prior to administration, Allergies confirmed and medications reviewed prior to administration. CJindamycin Phosphate {06:27 AMAJ}: Order: Gfindamycin Phosphate: 600 mg : IV Piggy Back Ordered: Thu Jan 22 2009 06:27 Ordered by; Angela Majino. M.D. Enter9d by: Angela Majina, M.D. Tl'lu Jan 22 200906:27 Documented as given by: Dave Agnew, RN Thu Jan 22 200906:35 MEDICATION, Time given: 0635. Given in amount and via route as prescribed. Amount given: 600mg. IV site 1, DripllVPB, Premixed, Catheter placement confirmed via flush prior 10 admlnistra1ion, IV site without signs or symptoms 01 infiltration during medication administration, No swelling during administration, No drainage during administratton, IV flushed atter administration, Corree;! patient, time, route. dose and medication confirmed prior to admInistration, Patient advised 01 actions and side-effects prior to administration, Anergies confirmed and medications reviewed prior to administration. Dilaudid (04: 16 AMAJ): Order: Dilaudid : 1 mg : IV Push POTENTIAL MODERATE INTERACTION Benadryl Ordered: Thu Jan 22 2009 04:16 Ordered by: Angela Majlno, M.D. Entered by: Angela Majino, M.D. Thu Jan 22 2009 04:16 Documented as given by: Dave Agnew, RN Thu Jan 222009 04:46 MEDICA liON, Time given: 0415. Amount given: 1 mg, IV site 1, Catheter placement confirmed via flush prior to administration, IV site without signs or symptoms of infiltration dUring medication administration, No swelling during administration, No drainage during administration, IV flushed after administration, Correct patient. time, route, dose and medication confirmed prior to administration, Patrent advised of actions and side-effects prior to administration, Alierg'les confirmed and medications reviewed prior to administration. Morphine Sulfate (03:16 MOOR): Order: Morphine Sulfate: 4 mg : IV Push Time: 0310 Notes: vorb Ordered: ihu Jan 22 200903:16 Ordered by: Duane Moore, MD Entered by: Dave AgMw, RN Thu Jan 22200903:16 Documented as given by: Dave Agnew, RN Thu Jan 22200903:16 MEDICATION, Time given: 0310, Given in amount and via route as prescribed, Amount given; 4 mg, IV site

1.
: Follow Up (03:25 DAGN): Time: 0315, Attending physician aware. Dr. Majino, Pi complains of ilching after administration of IV morphine.

PRESCRIPTION: No Documented Prescriptions

NURSING ASSESSMENT: FOCUSED (03:14 DAGN)


NOTES: Pt has left taclal swelling, pt rates 10/10 pain . PAIN SCALE: left mandibular Jaw, swelfing and pain. EYES: Eyes are PERRL.
Prepared: Thu Jan 22200907:43 by Cherie 6mesing, RN Page: 5 01 7 SSM DePaul H"al1h Center

DePaul Medical Records/Phillip H. March

000231

SSM DEPAUL EMERGENCV RECORD

Name: March. Phillip H


Age: M32 Wt: 76.2 Kg ,est.) MedRec:000748298 AcctNum: 0902200197

NEURO: Orientation: Alert, Behavior: Cooperative, Coherent. GCS: GCS Eye Opening: Spontaneously (4), GGS Verbal Response: Orientedlconversive (5), GGB Motor Response: Obeys comands(6), The GCS total is 15. MUSCULOSKELETAL: Good ROM. SKIN: Skin is cool, Skin is dry.

NURSING ASSfSSMI:NT: NURSES NOTE (04:52 DAGN)


TIME ASSESSED: Time: 0430, Patient is improving, Patient in no apparent distress. Patient states decreased pain, Patient resting quietly.

NURSING ASSESSMENT: NURSES NOTE {05:43 DAGN}


TIME ASSESSED: Time: 0540, Pl comprains of i1ching.

NURSING ASSESSMENT: NURSES NOTE (06:36 DAGN)


TIME ASSESSED: Patient is improving, Patient in no apparent distress, Patient states decreased pain,

Patient resting quietly.


NURSING PROCEDURE: IV (03:15 DAGN)
TIME: Procedure was performed at 0305.20 gauge catheter inserted, into It~ft Forearm, with 1 attempt, Saline lock established.

NURSING PROCEDURE: TRANSPORT TO TESTS (05:22 DAGN)


TIME: Procedure was performed at 0520, Patient transported to CT scan, via ambula1ory, accompanied by Nurse.

NURSING PROCEDURE: 8LANK CHART (05:24 PENG)


TIME: Procedure was performed at 05:23, GT maxiHofacial completed by RK and ZE.

NURSING PROCEDURE: NURSE NOTES (07:10 CBlA)


TIME: Time: 0700, assumed pt care sleeping at present rasp even and nonli3bored no distress.

NURSING PROCEDURE: NURSE NOTES (07:31 CBlA) TIME: Time: 0730.


VITAL SIGNS: BP: 130, /90. Pulse: 72, Resp: 16.

NURSING PROCEDURE: INTAKE AND OUTPUT (07:42 CBLA)


TrME: Intake output performed, at 0740, PO Intake(ml): 240, IV IntaKe(ml): 100, Total IntaKe: 340, Taial Output: O.

NURSING PROCEDURE: ADMISSION (07:43 CBLA)


TIME: Bad assigned at 0730, Report called at 0740, Patient admitted at 074;~. 554, Patient Acuity Level Wa$ Urgent, Patient admitted to medsurg unlt, Report called/faxed to sheila, Patient transported via cart, Accompanied by transport, Transported with personal belongings.

ADMIN
Praparad: Thu Jan 22 20Q9 07;43 by Cherie Blaesing. AN Pa9~; 6 SSM DePaul Health Canter

01 7

DePaul Medical Records/Phillip H. March

000232

1111111111111111111111111 111111111111 flllllIl

"IfI1111111111

11111 'till 11m llflllilif 11111 1If1l1f11J

~lfI ""111111

SSM DEPAUL EMERGENCY RECORD


DIGITAL SIGNATURE (03;14 DAGN); Agnew, RN, Dave. (03:15 DAGN): Agnew. RN, Dave. (03:25 DAGN): Agnew, RN, Dave.

Name: March, Phllflp H Age: M32 Wt: 76.2 Kg (est.)

MedRec:000748298
AcctNum: 0902200197

(04:53 DAGN): Agnew. RN. Dave.


(05:22 DAGN): Agnew. RN. Dave. (05:44 DAGN): Agnew, RN, Dave.

(06:36 DAGN): AgMw, RN, Dave.


(07:43 CBLA): Blaesing. RN. Cherie. PATIENT DATA CHANGE (03:47 AMAJ): A1tending changed from (none) to Angela Majino, M.D. (03:57): AOe 86231928 by Interface, Payment: 00, Admitting Doctor: Pcp None, Attending Doctor: Physicians Emergency. (04:02): A08 86232029 by Interlace, Admitting Doctor: Pcp None, Attending Doctor: Physicians Emergency. (07:36 HWE1): Admit Room: 554 r, Payment: (none).

KEY:

AMAJ=MaJlno, M.D., Angela C8LA=BlaQsing, RN, Cherie DAGN=Agnew, RN, Dave DMH=Hogen, Donna
HWE1=West, RN, Heather MOOR=Moore, MD, Duane PENG-Engleman, Paul

Prepared: Thu Jan 22 2009 07:43 by Cherie Blaesing, RN Page: 7 of 7 SSM DaPaul HMllh Canter

DePaul Medical Records/Phillip H. March

000233

1111111

m /I m '/111111111111111 lfl IIIJI 11 IfI IIIJI 11111 11111

IlJII1IfIJ ij IIIIIIfIII 1IIIIIIltI 11111111 11m 1 fill


Name: March, PhllUp H Age: M32 Wt; 76.2 Kg (est.) MedRec:000748298 AcctNum: 0902200197

~J

SSM DEPAUL CLINICAL SUMMARY RECORD


HPIJAW PAJN

CHIEF COMPLAINT; Patient presents for the evaluation of jaw pain, left. HISTORIAN: History obtained from pa1ient. TIME COURSE: Onset of symptoms reported as gradual, Onset was 2 daye ago , Patient currently has symptoms, Complaint i8 worse, Complaint Is constant.

LOCA nON: Pain most severe in lett mandlbfe, Posterior radiation.


QUALITY: Pain is throbbing, No different from patient's previous episodes. EXACERBATED BY: Pa1ient's condition exacerbated by chewing, speaking. RELIEVED BY: Patient's condition relieved by nothing. NOTES: Pt has hlo osteomyelitis of the jaw after an assault/stabbing in the area; feels/looks similar but he its without fever"

HISTORY
MEDICAL HISTORY; Stabbed in left face April 28th, 2007. jaw osteomyelitis. , see RN notes ..

PSYCHIATRIC HISTORY: No previous psychiatric history. No previous psychiatric history. No pf'evious


psychiatric history... SURGICAL HISTORY; Jaw Repair, pla~e left jaw. facial repair, Patient's previou5 surgical hIstory Is not rerevant to the case. Jaw Repair, plate left jaw. facial repair, Patient's previous surgical history is n01 relevant to the case. jaw fracture repairs. Jaw Repair, pfate left Jaw. facial repair . L jaw surgery, harware remova', chronic osteomyelitis. see RN notes .. SOCIAL HISTORY: Denies alcohol abuse, Denies tobacco abuse, Oenies drug abuse, Patient consumes alcohol socially, DenIes smoking, Patient consumes alcohol socially, Denies drug abuse, LIves at home with family, Denies alcohol abuse, Denies tobacco. Denies alcohol abuse, Denies tobacco abuse. Denies smoking, Patient consumes arcohol socially. Denies drug abuse, Lives at home with family, Denies alcohol abuse, Denies tobacco. Denies alcohol abuse, Denies tobacco abuse. Denies alcohol abuse, Denies tobacco abuse, Denies drug abuse. Denies alcohol abuse, Denies tobacco abuse, DenIes drug abuse .. FAMIL Y HISTORY; Family history is not contributory to this case, Family history is not contributory to this case. Family history Is not contributory to this case. Family history Is not contributory to this case. ~amily history Is not contributory to this case. Famfly history is not contributory to this case. Family history Is not contributory to this case .. NOTES: Nursing records revlewael, Agree with nursing records, NUrsing notes reviewed at the Ume this note entered; any nursing or paramedic notes charted after that time not reviewable unless directly communicated to this M.D..

ROS
CONSTITUTIONAL: No fever, No chills. ENT; Historian reports otalgia, No hearing changes, No sore throat, No dysphagia, No dysphonia, No drOOling, No voice changes. RESPIRATORY: No SOB.

GI: No abdominal pain, No nausea, No vomiting.


ALLERGIC/IMMUNOLOGIC: No frequent injections, No poor healing. ALL SYSTEMS NEGATIVE: An relevant systems reviewed and all negative except for the above.

Prepared; Thu Jan 22200907:43 by Chefie Btae!iioy, AN Page; 1 01 4 SSM DePaul Health CenlE/(

DePaul Medical Records/Phillip H. March

000234

SSM DEPAUL CLINICAL SUMMARY RECORD


PHYSICAL EXAM

Name: March. PhillIp H Age: M32 Wt; 76.2 Kg (est.)

MedRec:Q00748298
AcctNum: 0902200197

CONSTITUTIONAL: Vital signs reviewed. Alert and oriented X 3. Patient appears uncomfortable. HEAD: Atraumatic. Normocephalic. EYES: Sclera are normal, Conjunctiva are normal. ENT: External ear normal, no nasal deformity. No stridor, no1 Injected, no pharyngeal swelling, no phaIYngeal asymmetry. mucus membranes mois1, No drooling. Able to handle secretions, No tongue elevation. no abcess, no denIal fractures. Sinuses non"tsnder, No erythsma, No swelling, Trismus present, edema over L mandibular body and angle, extending back to Just anterior to ear; no Induration or drainage, no fluctuance. NECK: Normal ROM, No jugular venous distention. RESPIRATORY/CHEST: Chest is non-tender, 8reath sounds normal, No respira10ry distress. CARDIOVASCULAR: RRR, No murmurs. No rub, No gallop. UPPER EXTREMITY; Inspection normal, No cyanosis/clubbing/edema, Normal range of motion.

DOCTOR NOTES
TEXT: ConSidering compficafed hx with osteomyelitis and now cellulitis on eT, will admit for IV abx to

,PC..
INTERVENTIONS: Antibiotics administered:, Clindamycin, Antibiotics were given IV. DATA REVIEWED: Reviewed radiology films. OTHER HISTORY: 01her history obtained from: reviewed prior patient visit records. PATIENT STATUS: Patient has stablized since admission. Df\N: Discussed this case with Dr. Salem, the on call physician. PATIENT PLAN: The patient will be admitted to the hospital, InitiaJ phYSician orders were written for patient as discussed with admitting physician.

DtAGNOSrS FINAL: PRIMARY: Facial Cellulitis, ADDITIONAL: .

DISPOSITION
PATiENT: X-RAY/CT Follow-up: YES, Critical Care: None. Doctor Procedures: NO. Disposition: Admit

Medical, Condition: Stable.

M!;CICATION SERVICE
Benadryl: Order: Benadryl : 25 mg ; lV Push Time; 0320 Notes: vorb Ordered: Thu Jan 22 2009 05:43 Ordered by: Angela Majino, M.D. Entered by: Dave Agnew, AN Thu Jan 22 2009 05:43 Documented as given by: Dave Agnew, RN Thu Jan 22 2009 05:43 MEDICATION. TIme given: 0543, Given in amount and via route as prescribed, Amount given: 25mg, IVP. Rapidly, Catheter placement confirmed via flush prior to administration. IV site without signs or symptoms of infiltration during medication administration, No swefllng during administration, No drainage during administration, IV flushed after administration. Correct patient, time, route, dose and medication confirmed prior to adminlstra1ion, Patient advised of actions and sideettects prior to administration, Allergies
Prepared: Thu Jan 22 2009 07:43 by Cherie Blaesing, RN Page; 2 of 4 SSM DePaul Health Cenler

DePaul Medical Records/Phillip H. March

000235

Name: March. Phillip H

SSM DEPAUL CLINICAL SUMMARY RECORD

Age: M32 Wt: 76.2 Kg (est.) MedRec: 000748298 AcctNum: 0902200197

confirmed and medications reviewed prior to administration. Benadryl: Order: Benadry/ : 25 mg : IV Push Time: 0320 POTENTIAL MODERATE INTERACTION Morphine Sulfate No1es: vorb Ordered: Thu Jan 22 2Q09 03:23 Ordered by: AngeJa Majino, M.D. Entemd by: Dave Agnew, RN Thu Jan 22 200903:23 Documented as given by: Dave Agnew, RN Thu Jan 222009 03:24 MEDICATION, Time given: 0320, Given in amount and via route 85 prescribed, Amount given: 25 mg, IV site 1, IVP, Slowly. Catheter placement confirmed via flush prior to administration, IV site without signs or symptoms of infiltration during medication administration. No swelling during administration, No drainage during administration, IV flushed atter administration, Correct patient, time, route, dose and medicaiion confirmed prior 10 administration, Patien1 advised of actions and sIde-effects prior to adminis1ration, Allergies confirmed and medications reviewed prior to administration. Clindamycin Phosphate: Order: Clindamycin Phosphate: 600 mg : rv Piggy Back Ordered: Thu Jan 22 200906:27 Ordered by: Angela Mallno, M.D. Entered by: Angela Majino, M.D. Thu Jan 22 2009 06:27 Documenled as given by: Dave Agnew, RN Thu Jan 22200906:35 MEDICA TlON Time given: 0635, Given in amount and via routEl as prescribed, Amount given: 600mg, IV site 1. Drip/lVP8, Premixed, Catheter placement confirmed via flusn prior to administration, IV site without signs or symptoms of Infiltration during medication administration, No swelling during administration, No drainage during administration, IV flushed after administration, Correct patient time, route, dose and medication confirmed prior to administration, Patient advised of actions and side-effects prior to administration, Allergies con1irmed and m@dications reviewed prior to administration. Dilaudid: Order: Dilaudid : 1 mg : IV Push POTENTIAL MODERATE INTERACTION Benadryl Ordered: Thu Jan 22 200904:16 Ordered by; Angela Majino, M.D. Entered by; Angela Majino, M.D. Thu Jan 22 200904:16

Docummlad as given by: Dave AgMw, RN Thu Jan 22 2009 04;46


MEDICATION, Time given: 0415, Amount given: 1 mg. IV site 1, Catheter placement confirmed via flush prior to administration. IV site without signs or symptoms of inilttration during medication administration. No swelling during administration, No drainage during administration, IV flushed after administration, Corract patient, time, route, dose and medication confirmed prior to administration, Patient advised of actions and side-effects prior to administration, Anergies confirmed and medioations reviewed prior to administration. Morphine Sulfate: Order: Morphine Sulfate: 4 mg : IV Push Time: 0310

Notes: vQrb
Order8d: Thu Jan 22 2009 03:16 Ordered by: Duane Moors, MD Entered by: Davs Agnew, RN Tl1u Jan 22 200903;16
Prepare<J: Thu Jan 22 2009 07:4:) by Cherie BII\~sjng. RN Page:.3 of 4 SSM DePaul Health Center

DePaul Medical Records/Phillip H. March

000236

11111 ,JltJ Ifill II m 1ff)1 IJIII 1\ tIl 11111

J/I~ Ifill

11111 1/11/ Name: March, Phillip H Age: M32 wt: 76.2 Kg (est.) MedRec: 000748298 AcctNum: 0902200197

SSM DEPAUL CLINICAL SUMMARY RECORD


f

Documented as given by: Dave Agnew. RN Thu Jan 22200903:16 MEDICATION Time given: 0310. Given in amount and via route as prescribed. Amount given: 4 mg, IV site
1.

: Follow Up: Time: 0315, Attending physician aware, Dr. Majino, Pt complains of itching after administration of IV morphine.

PRESCRIPTION: No Documented Prescriptions

Prepared: Thu Jan 22 2009 07;43 by Cherie 6laesing, RN


SSM DePaul Health Center

Pag~;

4 of 4

DePaul Medical Records/Phillip H. March

000237

SSM DEPAUL RECORD

Name: March, Phillip H Age: M32 Wt: 76.2 Kg (est.) MedRac:000748298 AcctNum: 0902200197

Prepared; Thu Jan 22 200907:43 oy Cherie BIassing. RN Pugs: 1 Of 1

SSM DePa1.11 Health Cent&r

DePaul Medical Records/Phillip H. March

000238

VltC

1/22/2008 5:59 AM

PAGt

1. I

Fax !:)erver

DePaul Hospital (SSM)

Preliminary Radiology Report


Name: MARCH, PH!LLlP

~iA~~;: ..... .. . VIRTUAL RADIOLOGIC"


,
~

866-941-5695
Date: lf22f2009

Age: 32Years M
MRN: 000748298

Requesting Physician: Dr Majino

DOS:! Of2/1976
Number of Images

Procedure
CT SOFT TISSUE NECK

Accession

1226218K

159

Provided Clinical History: pi'lln In left jaw with swelling and burning that altllted 2 days ago Pt has hx of osteomyelitis in
left jaw

or of the neck with contrast;


History as provided: Pain in left jaw with swelling and burning that started 2 days ago. Pt has HX of osteomyelitis in left jaw ct maxillofacial wI contrast
Findings: There is mild soft tissue swelling along the left side facial soft tissues centered over the subcutaneous fat overlying the masseteric muscle. There are postsurgical clips adjacent to the left the carotid bifurcation. There js no identified focal collection or abscess. No bone erosion. There are some irregularIties and sclerotic change involving the left mandibular ang'e, The larynx and epiglottis are within normal limits. No evidence of tonsillar abscess. No airway shift or significant narrowing. No cetvicallymphadenopathy.

The visualized paranasal sinuses are aerated. Small polyp or mucous retention cyst left maxillary
sinus base. Improssion: Fundus compatible with remote left mandibular osteomyelitis.

There is no acute erosion or abscess identified. Nonspecific left-sided facial soft tissue swelling suggestive of cellulitis.
Thank you for allowing us to participate in the care of your patient.

If a slgn,flGupl is found between the preliminary .llnd final Interpretations of tlljs study. pleas", fax becK this rorm V>lth a :;01>1 of the officiai repc OJ contact VRe office so lhat
ap~opnate

o.l~crepancy

QUALITY ASSURANCE

action may be taken

Interpret alion;

Agree

Disagree

VRC dayt!lne arlrninls!nn,ve contact nun1bf'fs:


Fax 9521l35-255~ 1 el .. phone: 952-392~ 1100

Altered Plit/gnt Cara:

Yeo..

No

CONFIDENTIALITY STATEMENT

ThiS transltl/SSlon is confidentisl lind is mlendt:(f 10 be 8 priVileged ~'OmmlJnt~fltiO!1. It is intended only frx the USI'! Of 1h8llddre.~see. Ar:ces$ to //lis meSSif9t' by anyone else is unsuthonzed. tr you {Ire noi the intended rBcipitm/, any disc/owre. wP'tinr;. distribution IT any aelJOII l3iHITI, or omitted /0 btl fake/) in refisllce on II is prohibited find ffilIy be unlawftil If you feceivea (his cammonicatloll In error, please noli!>1 tiS by telepholle. 30 (hal return
of tfjs doculm'n/ to U~ csn b(l arranged

Pagfl1 of 2

DePaul Medical Records/Phillip H. March

000239

VRC

1/22/2009 5:59 AM

lJAGE

2 1 2

Fax Server

DePaul Hospital (SSM)

; .....:~~~ VlRrUAL RADIOLOGIC" -:.;;;:,"


...
866-941-5695

. ... .....'

Preliminary Radiology Report


Name: MARCH. PHILLIP

Age: 32Yc:ars M

Date: 1122/2009
DOS: 10/211976 Number of Images

Requesting Physician: Dr Ma)irlO


Procedure CT SOFT TISSUE NECK

MRN: 000748298

Accession 1226218K

159

Provided Clinical History: pain


left jaw

In

left jaw with swelling and burning that started 2 days ago Pt has hx of osteomyeiitis in

Dictated and Authenticated by: Boden, Tom, M.D.

112212009

5~57

AM Central Time

11 a Significant dlscr",pa flCY is found between the pr<;!fiminary and fin a! Interprelpiions of trJs study. please fax bllck this form ',~jth a copy of the official report qr contact VRe office so that apP'ooriate aclion may be taken

QUALITY ASSURANCE Interpretation: Agree

Ols<llIrn

VRC daytime administrative conlae! numbers'


FllX 952935-2551 Telephone: 952-392-1100

Altered Patient Care:

Yes

No

CONFIDENTIALITY STATEMENT

Tilis (HlIlsmi.Slon i! confidentl918JlQ IS Intended 10 be 8 privilege<! communication It is inlef)QeQ Qnly for the 11M! of thd 8ddl~ssec. Access 10 this Illessage by Iln>'one else is un(Ju!horize(J If )'011 are not 1M mtende<i (sc/pien/, any disclos\.ve, 'np),ing, distribution or any aclion taken, or oml!litd 70 L", titken in reiiance on if is prohibited lind may be unlawful If you r(!ceived fhM cOtnnl!illfre/JOfl i~ error, plt};)&o notify I/S Ily le/vpham:, so thai r~tllrn of !hI;; document /0 u,~ can be Olfl2ngoo

DePaul Medical Records/Phillip H. March

000240

11111 11111 /JIII/llfl II If lit I) rll11111 11 IIllflJI

~l

'II~ Iriff

mJlllltllltl1

~1tI ~m ijllf 1I1~ If 111 Ilfll rmlliffl


Name: March, Phillip H
Age: M32 Wt: 76.2 Kg (est.) MedRec: 000748298 AcctNum: 0902200197
iiiiiiiiiiiio

SSM DEPAUL TRIAGE RECORD


--------------TRIAGE
Complaint: Swelling/Pain Of Jaw
Triage Time: Thu Jan 22 2009 02: 12 Source: By: Car Urgency: ESI-3 Room: WTG-RM Age: 32

DATA-----------.. . .
Male
Kg Weight: 76.2 (est)

Physicians:
None Pcp Emergency Physicians

Vital Signs: (0210)


BP:128f85

P:72 Pain:7
Sat:99/ra

R:20

T:98.9

KNOWN ALLERGIES
No known drug allergies.

HISTORY (Thu Jan 22 2009 02;12 OM H) MEDICAL HISTORY: Stabbed in left face April 28th, 2007. jaw osteomyelitis . see RN notes.. PSYCHIATRIC HISTORY: No previous psychiatric history. No previous psychiatric history. No previous
psychiatrIc hIstory.. SURGICAL HISTORY; Jaw Repair, plate left Jaw. facial repair. Patienfs previous surgical history is not relevant to the case. Jaw Repair, plate left jaw. facia' repair. Patient's previous surgical history is not relevant to the case. jaw fracture repairs. Jaw Repair, plate teft jaw. facIal repair . L Jaw 8urgery, harware removal, chronic osteomyeUtls. see RN notes . SOCIAL HISTORY: Denies alcohol abuse, Denies tobacco abuse, Den/ea drug abuse, Patlent consumes alcohol soclaJly, Denies smoking, Patient consumes alcohol socially, DenIes drug abuse, Lives at home with famjly, Denies alcohol abuse, Denies tobacco. Denies alcohol abuse, Denies tobacco abuse. DenIes smoking, Patient consumes alcohol socially, Denies drug abuse, lives a1 home with family, DenIes alcohol abuse, Denies tobacco. Denies alcohol abuse, Den;es tobacco abuse. Denies alcohol abuse, Denies tobacco abuse, Denies drug abuse. Denies alcohol abuse, Denies tobacco abue6, Denies drug abuse .. FAMIL Y HISTORY: Family history Is not contributory to this case, Family history is not contributory to this case. Family hl,t9ry I~ n9t contributory to thff) caGe, Family hiatory i3 not contributory to this case. Family history fs not contributory 10 this case. Family history is not contributory to this case. Family history is not contributory to this case ..

ADDITIONAL TRIAGE (ThU Jan 22 200902:12 DMH)


COMPLAiNT

PROVIDERS: TRIAGE NURSE: Donna Hogan.


ADMISSION PATIENT: NAME: Phillip H March, DOB: Sat Oc1 021976, RACE: Black, Code: NO, Trauma: 'NO, Work Comp.: NO, Heat Related: NO, SSN: 493788699, ZIP CODE: 63121. HEIGHT: 182cm, PHONE: 314393-1241, MEDICAL RECORD NUMBER: 000748298, ACCOUNT NUMBER: 0902200197, IBEX NUMBER: 20090 122021203ADT. PREVIOUS VISIT ALLERGIES: No known drug allergies. NOTES:Total score is: 0, Contusion (3), No Increased Risks patient, dh, ASSESSMENT: 8/10, GCS Eye Opening: Spontaneously (4), GCS Verbal Response: Oriented/conversive (5),

Prepared: Thu Jan 22 2009 02: 12 by Donna Hogan Paga-: 1 012 SSM DePaul Health Center

DePaul Medical Records/Phillip H. March

000241

11111 jlllllllil

IIIIIIIIIIIIIIIIIIIIIIIIIII'~ 11111 11111 1/111

IltrlllflJ IIJIIllm IIIJJ IIIIII'IIIIIIIIIIIIIIII~ mil


Name: Maroh, Phillip H Age: M32 Wt 76.2 Kg (est.)
AcclNum:

SSM DEPAUL TRIAGE RECORD

MedRec:00074B29B 0902200197

GCS Motor Response; Obeys comands(6), The GCS total is 15. pain in leit Jaw with swelling and
burning tha1 s1arted 2 days ago. P1 has hx 0# osteomyelitis in lett Jaw. pt afebrile. IMMUNIZATIONS: Immunizations up to date, Last tetanus shot received less than 5 years ago. TB SCREENING: Denies TB screening. DOMESTIC VIOLENCE: No domestic violence. EDUCATIONAUCUl TURAL BARRIERS: No educational/cultural barriers. TREATMENTS IN PROGRESS: No treatment, Protocols: General Chief C"mplaint. VITAL SIGNS

PRESCRIPTION: No Documented Prescriptions

KEY:
DMH""Hogan, Donna

Prepared: TI1U Jan 222009 02: 12 by [)()nna Hogan Page: 2 of 2 SSM DePaul Health Center

DePaul Medical Records/Phillip H. March

000242

SSM DEPAUL EMERGENCY FLOW SHEET RECORD Name: March, Phfflip Age: 32:Y MIR: 000748298 Acct: 0902200197
VITAL SIGNS User

DatelTime
01/22 07:31 01/2202:12

BP
130/90
128/85

PULSE

RESP

TEMP

PAIN
7

02SAT
99 on ra

TIME
0210

CBlA

DMH

72 72

16 20

98.9

DePaul Medical Records/Phillip H. March 000243


Name: March, Phillip Age: 32Y MR: ,000748298 Acc1: 0902200197 Prepared: Thu Jan 22 07:43:10 2009 Iby Cherie Blaesing, AN

Page; 1

ADMISSION ARRIVAL SHEET

UNIT ORIENTATION; Instruction ellplain<Jd ROOM ORIENTATION: Instructlan ftxp161ned


T

~pastoral servlceli

~ Aslong for help to gel up

CillIlIght nurse

Call hght pall'l

No smoking policy

qVisiting hour$
--t Sirlfl rails

Call IIghl - tu~eting

; Comlon Rounds ~ Telephone

. Tel(;l~.!___-;-U_8_8_0_'b_eO_c_O-:!lI,_fol_S ..........c--_,E"me_f_ge_n_C_Y_ligh_t.... B_Rl_S_ho_w_e_1_ __

ARRIVAL INFORMATION COMPLETED BY


(If otl1.r Illsn nurse)

S=IG=N=AT=lIR=~--.;;:::::;:::;.~f.\~S::.::OY\~_O:.::..~=p--=--....L1\....l..--

i~21d/O 7_====--=--=--=----l

Ask ALL palient,. the following Qll_e_SI_io_rllI_:_ _- -_ _ __ Y$S No


Q

CJ
Ll

l
.

Have you ellef tHed 10 harm yourse~ in the past? Explain _ _ Are YOIl here because you tried to harm yourself? Explain _ _ _ _ __ Y61:'C:,id:n;no=tm:8::d'-l In lhe past week. have you been having thought,. Elbout harming yourself? Explain .--:--========..:::.===--==-;:):...P.::h:

BEING EMOTIONALLY, PHYSICALLY OR SEXUALLY ABUSED?

:::J NO EVIDENCE OF PHYSICAl. SEXUAL, OR PSYCHOLOGICAL ABUSE NOi~O.


CI EVIDENCE OF POTENTIAL ABUSE NOTED BUT NOT SUSPECTED. SPECIFY EVIDENCE _ _ _ _ _ _ __

:J Hotline called
specify: _

RATIONALE _ _ _ ._ _ _ _ _-

_ _ _ _ _ _ _ _ _ _ __

PI\TIENT/FAMILY/SIGNIFICANT OTHER INVOLVED IN Tl"IE CI\RE PLAN DEVCI.OPMfNT. U

ves

LPN:

i.J

Form completed

Slgnnture:

Date:

Time:

(If completed by LPN, RN review and plan at care developmlmt required)

RN: efJU+l-l~!~tecttp+Mm data reviewed ~of

Signature:
Date: \ I
I
,

l_~~
' 7 ')

'2- -It
(

'(l

,______--.j\

care/Care

pathway developed

r<-----..../

Time:

c'~ . , \ U / C ~ ..,
PATIENT LABEl

~SSM
ADMISSION ARRIVAL SHEET
SLM1000050 (6/2008) FRONT

H E A l T H ' CAR EW

DEPAUL HEALTH CENTER

liP 0902200197 ERS 0554-01 '10/02/1976 32Y N 01/22/09


SALEf4, !40UNER 000748298

r1ARCH, PHILLIP H

IIIUIIIIIIIOIIIIIII

DePaul Medical Records/Phillip H. March

000244

ADMISSION ARRIVAL SHEET


SYSTEM REVIEW
Neurological CardloV8SGtJIBri HemalolOcgleal Resplraloryl Infectlous Ditleaae Gl/Nutrlllon

Q No problem idenlifiad
;:) No problem identified

..i Exception a:; be/ow


:.J E](ception
U Excep!Jofl
BS

au
Musculoskeletal Reproductive

Identified idantlli9d
identified

Q Exception

811

below

U Exception as I;Jljlow
Q E:Kception

below
below Wound/Stdn/ Mucous

as

oelow

o N'J problem identified


Q No problem identiliecl

<IS

IJ Exception liS below

o No problem i<lentffied o Exception as below


a ExceptIon as below
Sldn RIU Sooto: 18 or '"' petilfll I, Jl Q FellOw 8AJn C4re Protocol fo1 SCOIl1 0(
'8 Of less. (Post prolOCOl.it tMdsidft.) NlIlrfti()n;V oonwlt
(if nol previously obl&llllld.)

EENT

rt,,,

Protllam
Potonhal

problem

No apPiiIanl
prohlem

Tlma Score em Admission. twice daily. and with changes In condllion/actMty or assBSsed risk factors .

*'Score of 3 or gealef IndlCOItes ~~~~~~~~=-=-------'~-----'-=I ./C--+---""-d---i----l possible Fall RiSk. If nVllIing judgmtWlt
~

.------,;C-.-l---+---+

diffel'li from aeont obtained, dOCllment ._~_~ rel!.S()n code from list beIQw;

Date: ~bo<"'~...;..L.-- Time:

_l,,-,t...:..1_IL~//_

PATiENT LABEl.

~SSM
H E A L T H . CAR
ADMtSSION ARRIVAl.. SHEET

L._..-AUL J-I.EALTH CEI'lTER

E~

MARCH,PHILLIP H 090220019 7 ER8 0554-01


10/02/1976 32Y
SALE~t1,

1I1111111111111mllliR
t.l
MOUNER

rip

01/22/09 000748298

,LM 1000-058 {6f200a,; BACK

DePaul Medical Records/Phillip H. March

000245

0 Durable Pow of Attorney fur HeaItt1care 0 HRtIh Cant Olr&Ctlve 0 See tifl1ily sptlCifio form (I.e., Essence, Intent) 0 See Progre68 Notw \la.IIrI1OIrm!klnsIiU valid? a VI)& 0 No r~~~to blInQ In copy? 0 Yes From;Whom _ _......-_..........,_....-__--.-,.....,.,.,...-,-~..",_hu the fQllQwlng AdVance Ditectlve;
in chart

HEAl.TH HISTORY (Check any that apply)


BOLD SYMBOL.S

., + ,. _ ) INDICATE REFERRAL. NEEDED ON BACK


hx: 0 Hwrt attack

o BleedIng problem o Blood c!ot


o Blood tran$fusion
!l& 0
Asthma

o Arthritis 0 Ba<;k!Hip/Knee
o Blood pressure problem
Oate: _ _ __

o Alzheimer's/Dementla

o Diabetes * +
controlled by: insulin

o o Subcutaneous pump o Oral Hypoglycemic


DDiet

o Pacemaker/Defibrillator o Congestive Hearl Failure. o Heart murmurNalvular disease


~ 0 Chest

o Vascular disease

o Chronic pain prior to admission ( _


Site: _ _ _ _ _ _ _ __

110)

o Pregnant/Lactating.

o Chronic Pain Managtlmenl


If pregnant. due date: _ _ _ __

o Breathing problem

o Sleep ApnewCPAP
OT6. SiS; 0 Wheetlng

o Bronchitis o COPD/Emphysema

o Emotional problems o Anxiety o Depression


o HBart surgery
Date;

Elevated chQlesterol

pain. Angina Frequency: Last episode: ______ Palpitations

o Prostate problems o Reproductive problems


Lasl menstrual parlod:

0 N/A

o Sensory prOblem

o Glaucoma

o SUic1dalllloughts!p1an

OEdema Where:

Frequency:

o Heart disBase

o Cough/sputum production

o Hepalilis o InlectiousJCommunicuble Disease. o VRE 0 MRSA 0 C. dfff


When: Location:

o Hearing 0 Vision o Skin problems. + o Rash o Skin riSk soore 18 or isss


o Unstageable wound o Nonhealing wound o Other _ _ _ _ _ _ __
CJ Pressurl;! ulcer Stage 3 or 4

Shortness of breath Shortness of breath occurs at: rest _._ with normal activity _ _iF of flights of stairs climbed

o Chamo/Radialion

o Home oxygen o Cancer

# Of blocks walked

o Dialysis o Stone lJ Neurological problems o Seizures


o
Frequen"y: _ _ _ _ __ Last episode: Siroke/TIA Frequency: Last epIsode: ____~_ __

o Kidney disease.

o IV Devics (i.e .. POrt. PICe, ale.)

o o
o o

o Chipped or loose leeth

Contacl physician for ET/Wound Nunse Referral Orders Sexually transmitted disea~ Stomach/Bowel problems GERO/Acid Reflux Ostomy. Date \asl 8M: _ _ __ Thyroid problams UrInary problems

o o

Recent ex~ur8 to: 0 Chicken pox 0 Hepatitis

I:! O!fl~r; _--"""""'=~,===;-_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __


If you check any of the above, please describe: _ _ _ _ _ _ _ _ _ __

o Naus<;;aNomiting

o Family problems with anl7slhasia


DEPAUL HEALTH CENTER
t4ARCH,PHILLIP H

~SSM e
H E A \. T H . CAR
W

1IIInlllll'I0011l11l1

rip
000748298

ADMISSION DATA BASE


SLMl000-059 (4{2008) FRONT

ERS 0554-01 10/02/1976 32Y I't 01/22/09


Si\L,EM, {v'lOT]NER

0902200197

DePaul Medical Records/Phillip H. March

000246

ADMISSION DATA BASE

~~~~~~9~!!!!~~~

---.,--,.,...---1 0 8/000 Sugar 1I1l11" G/l1lI 01161 300 ~~I DlAbelAA KWH "*

"* o N6 iIIofiHiirmg 01 bf9G!lll1glT

---+---1 0 Htwly Dr DialJelil:

------1----, 4lA'fo REFERRAL IlIDltATfD


o ltiltOl"l Of CHI'

- - - ; - - - - 1 0 Pallenlnqutd o tllJlfln pump

'" CtrdlAc Rehab "

O~etllf4f/uesj
~ RffERRAlIHDIGAlH)

o Slilgs 3 Of 4 jnuurtllfCer o Htn~II6aIInD woulld o UIl5t11l1lfble \IrOul!d o Sain RIsk SCOTt ot 18 or 1m


~~~::~~~~~~ 0 AIliJearanG'e 01 mllmrtrttlDn

CJJn!eJ1 Hytrlflon

o R811allallu"
o

Uapllllll14WT Q 101blOrllllffr'2-a

D DiffiGlflty GltnilngfiWlllowlng

o N/VID 3 ~ CI' mora


DPPHfWfIITl'

o Cllwn91 In JIIIletile m~ro OIan athf$

o Preonam (niillll!MrillQJ ar laota\fl!; o Pallenl requ~$l

Uve in:

Apartmant

Residential housing

Nursing home

Other.

Who do you livlo' wilt1?

(1ItIP '?e IF
0 Yes Narrms!Agencias _ _ _ __

0 No . . If no. explain: _ _ _ _ _ _ _ _ __

Do you pr,m to return TO your home from the nospil<ll? )il'Y65 Transportation 8vaifabk,'?,>:2J Yes 0 No Does anyone holp you at home now? ENo Diffic\.Ilty Ambulating f lrans1erring? .19'No

o Ullplllnllid majQt lW,gwy

o HoIIoIIawlltI1 {ljabttic (Jlel

o N8w1y Ox Dia~ic

011 -70 yearl old) o H lory of btrI11", tv/very

() REFtlIIW. INDiCATED
Inftet/Pn Ct)!!lro!

o I'omiYe T8 :lClUllqlSkin !Itt


IY

o HII!I1ry 01 MR3A/Vf1E1t, iliff

Difficulty wI actlvnles of rlilily lIVing? )g No 0 YQS

Yes

If

yes due to pain, explain; - ; ~;;;t;;;-;;Y;leI.;n _______

* Explain: _ _ _ _ __

Explain: _ _ _ _ _ _ _ _ _ _ __

~
o

v!tt (Pmf, PlCt;, fro.)


~

!;lint elj3ol1lre RfFfftRAL INtJrCATED

Do you have any specral concerns aboui being in the hospital?

13 No
YIt~

0 Yes

Hllve you had any major crr.l(jges (jOb, mova, dlvQrce, death, 61(;,) h) yuur life recently?;o No 0 Yes ~_ _ _ _ _ Do you have any ,piritual concem~'? ~o 0 Yes + ___~ _____________~ Any special religious/cullurEl factors reiateo 10 care? 0 No Sleeping oroqlems: Other (.'/f..1t,-<

t;J.Ro REfERRAL IIfOItATED + paslor@! Core +

o P91iem lIequttt o MalfiGaUon edu~11I1lI'I o CJJItq&m mQ1ls

_ _ _ _ _ _ __

rj1 Olfficulry falhng <lslt;!ep U Difficulty staying asIS,,!)

o AIlfu;jpated Cuplllg OIIIl&utty o PGIlr PfllflllCltlt o &eoout ProudurW8ufOiI)' o AOvJl1ee DUtCliYt A$3istinva o f'a11~nl Req ~"I
COII;erns IIffERML INDICATED

How do you get along with your family? Have you over hflQ ~x7 b]

;#

,<,,-3,

N'J ~lYes, hoW old Wlilrfl you Wh!lll yall 'Ir$! /lad 56X7---,''--':;;.z. _ _ __
0 No .K! Yes . A-" ))

o [friO In 1.,112 fflQnlIii

.. Job,"" C&s.;OOjnn ..

What kind 01 bi"" C'.Qnlrollp(Qtection do YI)U or your p!trtner U$f,1? _ Have you ",ver had 56' when you really tlid nol wan1 to?

if liV fi?h-,-'''''~/ _ __

o Ptlltm R'Qullst o NO flfFRIIA1IHnI~TfIJ

Have y6u

ever lei[ so sad thaI you trlought about killing yuurself?

.;0

No

0 Yes

[}-'I"tlysiCian Notified

COMPLETED BY (if other than_R_N..:..)_ __

-.----1 0

o P1fl.nt ReqllGsl o SiIMtyIil'lU 1Iw1~ alii ns


H4m~I\lJJt'OlspfJCtd
~unl!lo
!~

50cilj stN19Q ..

- - - - - - ..--.~-____t 0

5
o

Sl1l

IIDmtI Placemerll AhllwHaglec;t

oREffllRAlIHIlICATEIl

lillie liMit .m!stanoe

~SSM
H E A
~

DEPAUL

HEALTH CENTER

T H . CAR

E~

ADMISSION DATA BASE


SLMl00{)-059 14f2W8) [JACK

rIARC} .-

IllllnlUlIlllIIlll"l t PHILLIP H
r

I! L'
0 () 0 '{ 4 9 291;\

090220019 ~
10 I 02 ! 1 97 f>

ERS

SAl,Et'\. MOUNER

?2Y

"

055~ -01 1>1 01/22/09

DePaul Medical Records/Phillip H. March

000247

CASE MANAGEMENT SCREENING/DISCHARGE PLANNING


Primary Social Worker: lor Social Service intervention,
{j;; Tri9ger for Social Serv'ice i'nIterren'tiond

o Multiple trauma
o High risk 06 o Readmission within 30 days o Admission within t -3 monlhs o Progressive disease with impairment o Contagious disease

f:l Aouse

victim

l:J. Drug overdo;;e !'J. Substance abuse

o History of substance abuse


o
Comatose condition OMental stalu;J changes

o DehydrabonlMalnutritlon o On 7 or more medications o IV anlibiolic or alimentation Tx


o Decubitus ulcer

o Ostomy patIent

o Dialysis patient al _ _ _ _ "'


A
Family member dependent on Needs arrangement for care

o Flu Vaccine: Oate:


youl
A 06 under age t 8

Pneumovac: Date: --'-~ <~~~;rz::::::C1(

o l.ives e ; e; and/or ' frail


'Ith s
-f',\AI..IY6'S I

use or family ,

o O'ler the age 01 65


A Suspected abuse and/or neglsnt
{j Needs financial as:>istance

o Occupation:
o Limitations imposed by Illness.'
0 Mobility 0 Feeding 0 Hygiene 0 DresSing 0 Toil811ng 0 Tran:JPortallon
A Prevlou,> SOCial Ser.'lce Intervention A Financial asSistance needed for medlcallollS
~O Needs assistance in performing ADL5:

1 story home

0 2 story home

o Apartment
Number

or stairs to enter _ _ _ _ __

Homeless

o Admission from/to nursing home:


Name' /:. Inadequate support

o Clinic patieol
Whem:

/
~

o veteran-I'l Family counseling needed

=----__._ '

<....

o Equipment used: _ _ __
'~~;anspon.ation Plan ---~....s=7I'-.JL--'-'''''''''''~.....-::------0
Hospital VA/Feder, I Private PayiCustodi / 0 SNF 0 Other _ _ _ _ _ _ _ _ _ _ __

o Home IV Therapy
Type of fuc/lity:

0 Home DM!;;

HOSpice

Hospital Acute

Hospital' Psychiatric 0 Rehab

o LTAC (Long Term Acute Care HospitaQ


Patlan'tIF~lI'Y1lllv

o ResidentialfAssisted Ulling/lntermediate Care FaCIlity


cOllfirms retuming 10 same facUity

DEPAUL HEAL'l.'H CENTER

SALEM, MOONER

"lARCH, PHILLIP H rip 0902200197 ERS 055'1-01 10/02/1976 32Y 1'1 01/22/09
OO0?4829R

1111111111111111

DePaul Medical Records/Phillip H. March

000248

CASE MANAGEMENT SCREENING/DISCHARGE PLANNING


ADDITIONAL NOTES

f..-.-----~----

t--~----_-=----=----=-----~-~-----r-----i
i

~----------~~~~~--------~-------~
----1

DISCHARGE DISPOSITION

I 0 Homf! 0 HQme H!H!l!h


Type of faciliry: 0 Hosplc!7

Q Home IV TMrapy
0 Hospital - Acute

bl Home QME
0 Rehab

0 TrlIn!iportatlon PIBn _ _ _ _ _ _ _ _ _ _~ _ _ _ _ _ __
0 Hospital- VAiFederal
0 Nursing Home- Private Pay/Custodial 0 SNF

0 Hospital - Psychiatric

o LTAC (Long Term Acute Care Hospital)


1 0 Facility hOlding bed

o Residential/Assisted Livmg/lntermediate Cars FaclUty


0 Patlent[Family confirms returning to aarTIct facUity

0 Other _ _ _ _ __

o Other
PATIENT LABEL

~SSM
H e A L T H . CAR
SlM~8570-OO1

E~

CASE MANAGEM!;NT SCREeN'NQ/OISCHARG~ PLANNING


(12/2004) BACK

DePaul Medical Records/Phillip H. March

000249

INTERDISCIPLINARY CARE PATHWAYS


MEDICAL HISTORY SPECIMENS

GENERIC
INtTIAl DISCHARGE PLAN

(Vt! n-!S~ tv {J(A. M

TO BE COLLEOTED

(i) IA c.L

Home with significant other

1------=-== _ _ _ _ _

, I ~l,

I - - , - - - - ---~
DAilY LABS
,'I

0 SNFIACF

0 Rehab

0 Other

o Home Health

_ _ _

,_~
CONSULTS DEPARTMENTS I NURSING

MRSA/VRE screen sent

"""ft.
c. diffioile sent
Results
/SOLATlON: Special Contact

f
o Airbome
o Droplet

PHYSICIANS

DATE

NAME

I'"

-,),,'1.-01 '

DJ-

'7' U "'" n,l",r"

l'

1(;

DATE

NA;;re--

<J I'

o o Contact

Pneumovax year:

Flu vaccine year:


AdmittBd with pressure ulcer? 0 Yes

SPECIALTY EQUIPMENT
Date:
Type:
/---.,-- - - - - - - - - - --l

___ _ ---.l _____


DIAGNO,SIS/PROCEDURE

_ __

:~O-~-:-~A-:U-S-_WT ~~
~n resuscitation
o ONR medical management o DNA com Ion mflasure~
Advance directives? 0 Yes

CJ?/Ik / III S (Il.....b/ F''!


N

/71

--I

--I

;;?"-

"1

I ALLERGMIES

i - - - - - - - -~- - - - - - - - - - - - - -~- - - - '

Copy in chart? 0 Yas 0 No


Is there anyone who should not receive general condition information? 0 Yes !l;M\Io

-----

Family/Significant other designated to receive medical information: Name


Phone

~~~
Name
Phone

0 POA

OPOA

~SSM
H A L T Ii

r. A R IE"

DePaul Health Center


COPYRIGHT 1007 S:;>M HEALTH

DEPJl.l,JL HEALTH C!=:NTEH


r.tn.RC!{, Plllf..,LIP H

1~111f111J IBIIII ftiIIWII"

liP

fNTffiO,SCIPUNAAY CARE PATHWAYS- GENERIC


OPMlOOO024 (912007) PAGe 1 OF 8

CARE

SALEM', McmmR

09C2200197 ERS 0<;'<;'1,01 10'(' ~ I ; 970 3<!l' M Ol,'22!09 000748298

DePaul Medical Records/Phillip H. March

000250

-1 DATE! ' IN L
\

T----i

PLAN OF CARE
--PROBLEMS/OUTCOMES/INTERVENTIONS

IT/A S

place l!1itlals and dote th~ proble';'S are Identiflecf In l~ft cOlu~n. . AI( lutlntified problem must be evaluated whetne, Outcome 1$ Mal or Unmel at time of dillhruy6 by p~ d3te and imltats in appropriate column If Oulc.ome is mal pnor to di5charg~, place date and lnitlflls on Mit ooIumn. Place .( In bnx by I!1to;lfVomlion~ appropriate to palient. Wril& IT1 E!ddltkinallnle1Vt9ntlons as needed 10 blank spaces.

OUTCOMES

Met UnmQi

I Problem: Alteration In Neurologh::al StatU$

I I

Age~pcclfic cOllsideration

in Elderly Adutrs: Diminished muscla strength, degfilnsraUve l)on8 and/or jolnl changlJS, decreased hearing, vi!'.ion and balallce. Outcome: The patient will experlet1te a sta~lIIzatlon of n.vrol~lcat Impairment.

InlervQntions: 0 o Assess for Fall Risk BID . Initiate Fall p~(tcautions 101 Fall Risk Score 01 '\ 5 or higher: j 0 ASGass level of conscioLIsna5s and motor function every stHIt and pm. j U Encourage achievement 01 AOL's as appropriate to the neurologicallmpairment.

ProMem: Afterlltlon In OxygenatIon f RtsplUltOry F"n~to!'l Age specific consideration in Elderly Advlts: Waakened rasp/ratoIY musc{e$. d&creased lung tissue elaStiCity.

Outcome: Respiratory funct\on will be- within normaillmlts for patlent.


lrtervenlions: 0 o Pos1t1on paH~~j~an\!laljOf1 effiCIency. Mvnitor VS/breath sounds/oximetry every shift and prn. D Administer IrealmenI5/0);)lgen/A6G'$ as ordered. [1 Provide fluid intake to liquify secretions Suction secretions as necessary.

P,oblem~ Alteration In Comfon/Paln MDnagomant Age specific consideration In Elderly Adults: Possible idiosyncratio effects from medications due fa "garelatcd cilanges in absorption, metabolism, and excretion. Outcome: Patient exhibits/states adequate relief of dhu;omfot1. Interventions: 0 o Assess patienfs pain level q 4 h o U f S . - - Jnvoive patient in care by disOllSSing rne1hods of pain reliat Initiate intervenlions (including (lOn-pharmacologic) appropriate for pain/discomfort ASSe-ii"S pain level ancl response wilhin 60 minutes of intervention,

o
o o

I
I

Problem: Alteration In Nutrition Age speoilic cQllsideratlon In Efderfy AdUFU5; Oiminlshed appetite, peristalsis and digestive ;UiC8S ancJ danlilion changos, Facl.9(s t~DrDVB load IntaKe' Position patient uprighl- Offer smalJer, mors frequent mNls ModilifJd load cooslstency i.e., pureed/soft,

OutcQme: Patient nut,t11onal Intake Is appropriate for met.bone nods. Inter'lenlion:>. 0 U Nutrition Consult ef~HBOC 0 Monitor hydration status 0 Assess enteral feeding tolerance

o o
o

Assess fI~r swallowrng/chewing difficulty AsSist patient with meals as needed. Assess/Record di~\ary intake With each meal Provid6/record dietary supplemonts/HS snaCKs. Record DaHy Weights report unexplained weight changes greater than 3 kg from previous day.
Cardloya~\lle,

Problem: Alteration In
'f\I~rventJons.

Status

AgfJ specific cOllslderatiOfl in Elderly Adults: DU71Inishad cardiac force I blood floW Outcome: PAtIent will be hemotlynamh:ally stabt.

to bfEl;n.

'.J Record Intake i\I1d output every shiftand pm/daily weIghts ano report variances.

LJ Assess vil;>1 signs, peripheral pulses, and capillary r81ii1 every shift and pm
Administer medications/bloud products as ordered and monitor effects,

-------------1'

Age specific conSideration iff Elderly Adulls:


I ntBrventions: [J

,U, l I ~~ sk'{~ dry and less fJiastlc. Outeom&: Patlll"' will !n!!lntain or Improve skin Integnty.
o Tum pattent evr;'.fY 2 h~ld shearing - Keep skin clean Bnd dry. Photograph and mea~ure wounds on admission, every Monday, and on di'SCflarge. Provide wound care per Skin Care Protocol (see page 8) 0 Polential alteration in akin integrity

Problem~ AlteratIon in Skin Integrity

o o
1'\ 'II 'V

\\

_ _ _ _ _ _ _ _~

'V ~ Age SreC;ff,'C consideration In Eldeily AdU,ilS,; Decreased renal 'unction nClte lab values relatsd to antibiotic dosing.
Interventions: (y" l!,VMt'- h.,~J 11.-J--<' (U,~S'p; . 0 Utilize Isolation precautions: Cl Contac--'-t-o;:;....,~rp-a--'Cl:::.:'a::..I-D-R-=-e<i=--pj;::~ra::;.t-Jry'---":O.c"'D:..r-o-p-1et------------!

C Probtam: f'otentlal or Actual "tfactlon

Outcome: Signs ,n1l symptom~ of Infection are fe':9(Jnb:ed. Prel:&.UIlons

81'9

utJIIJ:IId.

Assesr.freport :>igns and symptoms of Infection every shift and pm.


_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _~__

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _~_ _ _ _~_ _ _ _J

~SSM
UEAl.Tti
'A~E:

DePaul Health Center


COPYRIGHT 1997 SSM HEA,LTH CARE

DEPAUL HEALTH CENTER


MARCH, PHII,LIP H

11'111111811111
ERS 0554-01
M

0902200197
INTERDISCIPLINARY CARE PATHWAYS" G;NCRIC
DPMl000024 i9120(7) PAGE 2 OF 8

liP

10/02/1976 32Y
SfI.LEM, MOUNRR

01/22/09

000748298

DePaul Medical Records/Phillip H. March

000251

PLAN OF CARE
PROBLEMS/OUTCOMES/INTERVENTIONS DATE/ INITIALS
PI(tCe Initials and date (hal problcl!ls are idt<nlified in I~ cofumn. All identified problem must 1.>e evalu;lIed wtlether OutW'T1'i: i:l Mflll)( UnTIl@t 111 lime or digel'tafM by piacing date and '!'Iilials In appropriate column If Outcome is mot priol to dfr-charge, placE! dille fino initials on Met column. Place ". in box hy Interven!ion~ ~jJprUDriate 10 patient Writ" if) addlnonal inieJVentions as needed In bl;lnk spaces.
Prob'~m: Alteration In Elimination Age specific conSideration in Elderly Adults: Diminisheri pensli;ifsls, i<idnc.v function. Outcom~: PatIent re9111n~ normal elimination patterns for agl!l and dlsvase proceSlt. IntalYentions: 0

OUTCOMES
I-

Met

unmetl

I !
--

0
[J

Offer tolleling Avery 2 hours


Assess bower sounds, (;Ibdominal dist~ntion and/or discomfolt every shIft and prn. Record frequency and characteristic!; of stool. Report if no stool for more than 3 days, Record inlaklc! anel outpul every shift and pm. Report abnormal lao values.
St:ii~'Ory

0 0

\ .... ,""" .......... n..-"," Agll !Jp'cific (;onsider{l(/on in ldfJriy AduJis: and cognitive ~ Outcome, ....n' an. "' ~.n,"..n' .'ha, mvu'ved in p''" of ....I.~.nsVa .. n......n_ rv~i procedureS!di~ease/medlcafjon&/and discharge
ir.1pairments.
('

of

Instructions.

I
i

!
1

I
l

InlelYentlons: 0 0 Assess basellnc knowiedge and prefArred learning method ot palienl/significanl other. fJ Provide eell/cationa! material (ll J,Jatient/sign,ficant other lovel of under:;tandmg. Assess patiant/$Igmlicanl other for undArstandiog after te(lchrng. 0 PrOVide Instruction on sate and effective use of Inedical aqwpnwnt.

.---

I
I

I I I
I

I Probl.m: Anxiety/SpIritual Oisturban~e$


! changes In economic sec(I(ityls(){;la/ status
o

Age specific cOIlSlderation in E/de/ly Adults' Fl:flr of loss Qf control, dncimmg health iJ/ldlor approacllfng da~th.

I OutCQme: Patlent/slgnlrlcant othli!f dem o."strattl5 abmly to cope and l<hIntlfies available resources.
! Intervenljons: n ~_ n Encourage verbah.li;l!ion of tears (;Ind P?!rtlclpalion in care
______

I I __

Decrease sensory stimuli provide qUiet environment Dim 1/11;: Pastoral Care referral entered. [J Palliative Care rafeml! enterM GlyoomiB Imbalance

hallway IIgl1t:; alter

10 p.m.

Problem:

Age specific consiUefHtiolJ in Eidf;rly Adults, DeoreasAd ronal funclfOll, mMl;Joolic rate. CXItc0ftJ8: Patient's blood glueosa Is within a"~ptable range.
lntBlventions: 0 Implement Hypoglycemia Protocol. Implement Insulin Protocols <IS ordered, n Monitor/record fingerstick glucoSt! values as orderarf Md pm. Diabetes Edllcator Consult entered,

o o

------- ---------.------

Problem: Altli!ratlon in MobllUy/ActMty Intolerance


Age ,specific consideration in Elderly Adults: Diminisher.J muscle lJ/renglh, degenefativa bone am:J[or jaint chBngeB, decreased hearirJIJ, visi()n and Q<l/ance.

Outcome: Patient's malntaios or Improv&s mobillty/acllvlty level.


In!elYfmtJons; 0 Assist patilJntlo participate in ADLs within iimils of impillf~Advance actIvity as Ordered/tolerated. PT to assess function",! abHily and provide approplialc adaptive dellicl1s.

o o o

---------

PrOblem: Alteration in Safety , AgR .~per:lfic COflRidEifatiM ifj Elderly Aduils: SensolY (;Ind cognitrve impairments.
I,'

Outcome: Patient remains In a safe envIronment and free of physlcalln/ury.


0

!lnteIY9ntions: U

!
I

I I

J;i
CARE

! I0

i 0

_ _ _ _ _ __ AssfiSs lor F'cil Risk BiD hlltiate FilII Precautions for Fali Rif:'; Score of f 5 or higller, Provlde appropriatfl &afoty t>qulpmenlidwlc6s il'1d IP&Iri.!clions lor tJ,<! Implement prolective status (Victim of Violence)

Problem;

----- ._--- ------ -----

Outcome: -

L
HEAllJf

------ -----

int9I'1/ent_io_n_s._._-_-_-_-___ -__ _=___-_-_-,::-_-__ _-.:-_-_--_-~-__-_-_-_-_=__-_-:.. ____ -~::---

~SSM

DePaul Health Center


e
COPYRIGHT 19E17 SSM HEALTH CARE

JP!I,I~1!'~JlI'111
0902200197
lO/02/B76 32Y

DEPAUL HEALTH CENTER

r.l P
000748298

ERS 0554-01
M 01/'22/09

INTERDISCIPLINARY CARE PATHWAYS' GENERIC


OPM-1QOO.024 (9/2007} PAGE 3 OF

SALEM, MOUNER

DePaul Medical Records/Phillip H. March

000252

f..V 5'
If-D

,~.j$

/2..,Dl\ rifle
J.~L-"

~I>

i:w~~

/)+0

DcW..~ pJ

_, _____L _ _ _ _,
~"t 5ei /f~0 l:)(L1
l

Insertion dale

Insertion date

I 0 TLC 0 PIce 0 Midline I 0 Other -.,..,-,:-;:--::----:c=---------~it=eri~f ~ 00ttgC~2l Insertion date 2.

At;;

d.e.f=

t1v..V

DePaul Medical Records/Phillip H. March 000253

jruu.?r S--(J fl ;1:-3

4h/;,~1F1

I!..::r.. HA ~ ~. ~T\+n. f+

471/

(h(:'C

c1 ()

SL

51-

S~L-

PATIENT LABEL

INTa!:DISCIPUNARY CARf' PAll-IWAVS- GElIERIC


Df>M-1000-024 (912007) PAGE 4 OF a COP'I'RIGHT 1991 SSM HEALTH CARE

DePaul Medical Records/Phillip H. March 000254

gR{J

$f2-,r

73ll/::;
I~ /)

lie! ilk:)
o Care Planning with PtfSO (A) o Care Planning with PtlSO [Pi

J-L3

J-rt3

o Care Planning will1 PI/SO (Al


. 0 Care Planning with Pt'SO (I')

o Care PlaJln1nlg wit" PllSO (p)

o Care Planning witt1 ptl$O (A)

~SSM
.... f! A I.. T H . (
-A

ft

t'"

DePaul Health Center


COPYRIGHT 1997 SSM HE.A.LlI'M CARE

Copied by _ _ _ _ __

RN Review _ _ _ _ __

DEPAUL HEALTH CENTER


MARCH, PlitT.LIP H

IIIBIIIIIIIRIII
ERS

IiF
0007'*8:298

INTERDISCIPLINARY CARE PArnWAYS" - GI;HERjC

09D2200197

DPM-tOOC-<l24 i9/2007) f'I:IGE 5 OF 8

10/02/1975 32Y SALEM,MOtlNER

055,",-0,M 0:;./22/09

~qu/
TLC 0 Pice 0 Midline DO~ __~~~--_=--_ _ _ _- - - - - - - - - o PerlphtlrallV (less than 12j Site Insertion date

f--JS "-'---w

o TLC 0 PICC 0 Midline DOther ____________


o

____________________

Peripheral IV (less than 72) I Sita __"C_ _ _ _c'~,_>_>_ _ _ Insertion elate

DePaul Medical Records/Phillip H. March

'SL
PATIENT LABEL

~SSM e
~

l4 L t

..

' C 1>. fl '"

DePaul Health Center


e
COf"w'l'lIGHT 1997 SSM HEALTH CARE

000255

IHTEROISCIPUNARV CARE PATHWAYS . GENERIC


DPM-1000-024 (9/2007) PAGE B OF

DePaul Medical Records/Phillip H. March 000256

1'::1

f. ()
W
o Care Planning wilh PI/SO (A) o Care Planning wjth Pt'SO (p)
,/', ,1
; ,I

;0.1

Clef

o Care Plao ning with P\.ISO (A) o Care Planning with P\.ISO (PJ

o Care Plannirng wrth ptjSO (A) o Care Plannil'lg with Pt/SO (P)

1'../ '-'

/,' r/ /1 :~Y.-; "/; '-

/,IJ

,/1

-RoY

DEPAUL HEALTH CENTER


Copied by
IN'rEROISCIPUNARY CARE PATHWAYS - GEN!;RIC
DPM-1QOO.(I24 (9}2007} PAGE 1 OF 8 COPYRIGH, 1991 SSM HEAlJ'H CARE

RN Review _ _ _ _ __

t'1F-.RCH, PHILLIP H

11111111111111.
32Y
]),1

liP
C1/22/0
9

'

0902200:9 7

~0/02!".J.976

HRS 0554-01

SALEM, MOUNER

aCQ748298

PLAN OF CARE POTENTIAL ALTERATION IN SKIN INTEGRITY

I I gAT~1
I

PROBL.EMS/OUTCOMESIlNTERVENTIONS
Place initials and date that problems lire identified in left column. Ali identl1ied problem mutt be evaJuutBd whilher Oulcome if> Mat Qf IJmn~t il,1 tim& of discharge by placing date and initials In appropriate column. 1f Outoot'lla it; met prior to discharge. place date and initill\$ on Met column. Place .; in bOl( by interventions appropriete to patient. Wrlte in additional interventions as needed in blank spaces.

OUTCOMES

INITIALS

Met

Unmet

Ou1eoma Goals: Skin integrity is maintained. Patients at risk aiEl idenlifiad and interventions initiated, Prochooked items are initiated tor all patients.
SkIn Integrfty plan for all patlent$

. i\ j

l' ~1i \,\- l I 0


't
0

621 Complete Braden Scale on admission. then daily. 0 AS$~sS skin upon admission and @verj shift 65pecially pony prominences and sllin folds. 0 Record any redness that doas not disappear withm 30 minU1es or Bny break in skin integrity,
Reposition

at IBaSI every :2 hours.

I0
i

Apply lotion immediately after bathing. Use moisturizing cream tor dry skin. Avoid massaging over bony prominences and

dlscolor~fhyperemic areas.
and heel protectors every shift for 30 minU1es 10 assess le\js. fast and hwls.

I
1

0 K(/ep bed clean, dry, and free of wrinkles. ~ Remove antiembQII~rn hose, sequential ~tockings,

0
i
II

Minimi..<:6 skin exposure to moisture from Incontinence, perspiration, or wounO drainage.

Establish a bowsl and bladder program by assisting the patient 10 the bathroom or bedside commode BvelY two hours, unless 1 contraindicated,

Ii] Skin cleansing at lime 0"1 soiling with perineal cleanser with minimal friction and apply protectlve barrier cream.
Dt ~

Limit use at adhwive proQucts on thin, fragile skin and apply skin slelilves PRN, Float heels off bed With pillows placed under the length of the lower legs. actlvatfi heel and/or application of heel protectors.

ttl

suspenslon on Total Care Bed (ICU).

III

Ins1ruct patient and family on causes and prevention 01 skin breakdown, sources 01 pressure, friction. and shearing, Record on

Patilmt Education Form.

o o o o o

Skin Inhtgrlly plan for "At Rl$k" populations - Braden score HI or lese
Place sign (PUP)

On the door of room

indicating patient is high (isk

tor skin oreakdown.

Initiate individualized turning schedule minimum 01 every 2. hourS In bed I every i hour in chair. Consider use of pressure radislribul!on equipment per orders/protoGol. Position proient in a 30 degree lateral position and avoId posi1ionlng direcUy on trochanter. Consider use of lifting devici;lS 10 move and reposilion patient

!Ouch as 11ft sheets. trapeze, and Air Pal to

pl'Bvent frtcUon and

sMar.
Maintain head 01 bed at the lowest degree of elevation consistent with medical condllioo. Use pll!ows/WQdges to pad bony prominences trom direct pressure. especially between knees, ConSider use 01 urinary or f{!Ca1 collection devi('.e to cont<lin urine or slool. Limit lise of diapers, Support 5uriace per

woe Nwsa and/of protocol

NulritiQn com,Ylt

!;'n\~red

Obtain bar\atrlc support surface per protocol.


I

Other Irtterventtons _ _ _ _ _ _ _ _~~ _ _ _ _ _ _ _____________._ _ _ _ __

l
Ii

----'-.

I------~-------------

~SSM
~

A L T H . C A

f-

DePaul Health Center


COPYRIGHT 1997 SSM HEALTH CARE

ngpAUL HEALTH CENTER


NA.HeR, PHILLIP n

IIIIDIIiMINIIIUI

r/p

0902200197
INTEflD!SCIPUNARY CARe: PATHWAYS G"ENfRIC
OPM1000024 (912007) PAGE 6 OF 6

ERS 0554-01 ] O/O'2./l976 32Y M 01/22/09

SALEM, MOUNER

00074.8298

DePaul Medical Records/Phillip H. March

000257

INTERDISCIPLINARY PATIENT/FAMILY EDUCATION RECORD


1N1TIAL ASSESSMENT PhysIcal Barriers to learning;
,ti,None 0 Vision 0 Heanng 0 Language Dlfficutly - Reading (explain) _ _ _ _ _ _ _ _ _ _ _ _ __ o Writing (explain) _ _ _~__~________ Dsvelopmen11evei requiring intervention (explain) __________________________________ Other _____________________________________

o
o o

emotional Barriers to Learning:

? None

0 Anxiety

0 Anger

0 Denial

0 Depression

0 Confusion

0 Other _____________

Spiritual Barriers to Learning: ~None 0 Grief 0 Guill 0 Lack of hope

DOlher_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
0 Other -=~_ _ _ _ _ _ _ __

,D Nona 0

Home Barriers to Compliance:

Meal

prepar~tlon

0 Transportation 0 Finilnt;;!al bl Caregiver

Religious and/or Cultural Barriers to learning: DYes - Explain


Wl'Iat Is the easiest way for you to learn? !d11eading B-(Istenlng Q-Piclures o Demonstration 0 other ____________ Wha1 Bre your leaming needs at this time? o Disease process 0 Medlcations Follow-un treatment o Use of equipment 0 Disl PralPosl-Op teachinQ o Other Community resources

Who Should we invol~~~temlT11rnr:hil;1g

0i~8ase pTOGeS~

Discharge information
At1vanced \lireGllVCS
fl(A~Sin\lS

Home care services InccrrtJVe splwmatry


100Mt C3fl!/fetIQing

COffiro resources
Oiagnosbc tests

fan preventton Follow-up care


foley FoodjDrug
inletac~ons

llieliNP(I

OiSaasB fMnagem~nt

IS(llau(lfl pf!ICau!ions IV-sflnjeL11U1lS Labor managemp.nt MOl

M(lmto!$ Mouth care Outpaflent prOOf am~

Post pMtllfll teaching Ple-op teaChing Psychosocial neeo:; ReSlraints

SlqnslSx

Snllli<lno Cessahon
Social service !>\Jlfllual n~eds
SUtgRry

Pain mamtg~l\1cnl
Plan of care

RIgk factors
Room ori~ntalion Safety

TeDS
Teds

Post 'OD tea~1!iJ1y

"~~~Wa~:=:_!?~--C:!~~~~~~~P~a:!t~ie~n!.t~In~formation guide given information reviewed with

. . . -----++-f--

<;:fl)nldnn cessation
---'---'-----

A9adil1on: (1) Siaies ready (2) nequesl, (]olay i:J) Conlused (4) SUU<flfld (f>j Cognitive i,,!'L>ilily {fi} Retuseo (7) NrvwJ;l knnw\Mgeao\e Leame" 1'T = Palient P ~ Parent F ~ Father 0 = Daughteris) 0 = Others M,. MOU10t SP ~ 5pOU56 5,. Son(f.} Method; A' Audlovi"JIlI D .. C;"monSlration E,. E.<pl,'''''tiM C ~ Croup Cla% H=_H_atl_o_'O_U_l_T_=_"_el..,;ej)_h_O_M_fE_-xp_:_,_la_n3_tl_oo _ _ _ _ _ _ _ _ _ _ _---'

~SSM.
nEAl..THC.RE

DePaul Health Center

DEPAUL HEALTH CENTER l'lARCH , PHILLIP H l!P 0902200197 ERS 0554-01 10/02!1976 3~Y M 01/22/09 SALRM.MOUNER 000748298

1111011111111111101

INTERDISCIPUNARY PATIENT/FAMILY EDUCATION RECORD


OpMl000-00Q (1Q12007) FRONT

DePaul Medical Records/Phillip H. March

000258

~'.

-r: ~/> C.>

'7-~)'

C';'

5
AcVvilyihercl'i!!
Admissl(lo Advanced directives Camm. resol/rces Diagnosnc tests D.4t(lNPO

INTERDISCIPLINARY PATIENT!FAMILY EDUCATION RECORD


O~VIl~tJ ~rnG!tss
Di5r,harg~

Intormation

~D>.
''>1"'-Y.pI8ce~r
..6

Dressings FBII prBYftntion Follow-up carll Foley

POTENTIAL TEACHING TOPICS Home car~ S8rv1G!X MedicaUuns Post parlurn l~aGhinll PrMp rgacnmg l(lcenliv(I spirometry Monitors Infant care/Feeding Moutl1 car~ Psychosocial needs
Isolation precautions

SignsfSx
Smoking Cessation Social service Spiritual need& Surgery TeDS

Tr~atments

Wound care

iV's/lnlecliQfls LebO! manl(jl1ment

Oulpalillnt proorams Pain man1fgement Plan ot care

Reslraints
Risk factof1 Room orientation

... 'n".:.' "'. . ..;;. i.: ." . <'''~''''~l:' . . . . . . "",)~


1Od' ....'._ ,:">;i\,."
'"

'~" . ' .c)'eSilr~.


",

II

~ Readln".:

(1) Stmcu ready (2) Rsque,;ls dul<lY (3) Confu:~oo (4) Sedatec (aj CogMlve i!lliJjty i6) Relus&1 (7) Already Leamer. PT = Paliel'lt P ~ Parenl F ~ Fathe. 0 ~ DBUQhler(s) 0". Omers M = Molher SF '" Spous~ S'~ SOCIis) Method: A '" AudIOvisual D '" Demonstration E = E'planat,on C - Gro,m Class H= Handout T= TOlephone/ExplanatiOn

knowledgA-~bIO

~SSM
H E It \. T "

C It R E-

DePaul Health Center

DEPAUL HEALTH CENTER


r1AJl.CH, PHILLIP H lip 0902200197 ERS 0554-01 10/02/1976 32Y 1>1 01/22/09

iIBIIIIIl.JII.llnG

INTERDISCIPLINARY PATIENTfFAMILY EDUCATION RECORD


uPM,l00Q.060 (1012007) BACK

SALEM. MOUNER

000748298

DePaul Medical Records/Phillip H. March

000259

Special Instructions I

, -. .

SCHEDULRD M3DICATION ORDS:R.S


-----------

---------

\ Ordll
16

,{\./
f7LK

I
I

I Start
01{2>,

Stop

Drug/nose!Route/Coll,,,,pnts
P)CUSATS SOUHl11 ),,00 W; CIU'SULE Ll' COLACE 1 OO~J (.'AP EQUIV

l.'reqUency
aTlMBS!OkY

0000-0730

07)1-lS30

15)1-21",':1

2100

~
I
01/22

tnou:

1M Hell CAl'SI,lli8 Ll'

(ORALl

!Xl NOT CRUSH - Tl.s'!'!'

OOl!>

TID

JAN
1'1K
DUli'!

ll~OO

n~D ~1200

'!
I

01/2';

()l!:!~
71<;'i

(ORAl.l

Q 6 HUURS

0000
11"'c,

[Ivl

., i

iOU

(A./'J

l
!

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COD

,[)L~/
0811
fIVl
Glve 3m]
~vely

.A 0600

\' 01/2:<

1()!'!99
;\ 'vv

I
1-

hours unlp.ss

m"dicacion<1

'J1'_'

given t.hen 3ml W;

admlriist.ro1. \ nel

ii.~)! () X .1
<"

(11'" i.

'J j\ t I
I
(

I ",
I

It, 1

I'
,
~

~
'

J_
LV Lt, U.O,

'i'. Cade,
L'r" L~
l{t,

Thigh

LA - Ll

l\rm
Arlft

"'U ~ kE, UQ RT' Rtll'. ~ r:t, Upper 1,h.1.

rhiqh
1,\.

hII - i'\;,
wwer Abd,

Ll.A -

I ',~",uc,__
I"
t')

MAR. IJC'IJflRa-b-}-,-.------

~; "

~ Wt~~z=i 0:"::-:: """ AbO,s ,~-" '::-:2-7-0-1-9-7!' -.-J


MARCH, PHILLlP H
DOB, 10/02/7b 11.000749298 Age, 32Y Si>X: N A<.im, Dr, SALSN,1-1Q(}NER

f1i(22j09

rD-e-p-a~u~l-Health

I l.'

/,' ~

t, , /

I ~ ~/~fJ/{ _"_
:t {,

Allergiesl NKA

"

Center

Covers Doses from:

M~di~&tion
23~59

Adminigtration

ReQQ~

--------------

01/26/09 00:00 to 01/26/09

-----------,-----------

P~inted, Ol/2S/o~ 22:00 :Page: 1. (more meds fol.low ...

DePaul Medical Records/Phillip H. March

000260

.. *,..
Special Instructions I
o-;:ctjf! Sl;;art
it>

ONSCHEIJi1LED MEDICATION OWERS

(conl:..)

"
1531-2}S9

I ~~~ ! U~QO r~~'~~~~~ ~~~mT=~l' I I .I 1 I , i I I ~YnRl\l11NC I~


(

1 Stop

DrUg/Do15e/Route/Commen'b

FrequICI1<!y
C>4H As Needed

0000- 073 (l

0131-1510

01/22

C~UNOPHFli ,;,~

I''fJ TADLE'T

IOAAL}

POI' MI1.n PAIN OR

?OR 'l't;MP GREATER 'THAN 101.5

)1

hllW
FL}(

01i 110

INJECTION tlENADRYL 50MGjH1L VTAL EQUIV


!iQ

----tI~
[IVJ
[xv)

Q4H
AS Needed

se,

Melli

!C.

I
"Q13
,1,\N

!
I
Ol/n
ll()(l

TTCHlNU

H,DROHOF1f>HONE t!{;J"

Q4H

M M'.!ec\f.,Jj

Fl.!:

FOR PArt{

+
Site CrJQt;'''
[JJ -

-+

~j

I
Lt. 1.1.0, JW, Re, 1.1.0

LT " Ll:. TI"'gh RT - Re, 'fbiqL

LA - Lt, Arm AA - Rt, Al'lll

RDA !{t. Upper


LlJ,o. Lt,

Alxl, Upper Abd,

LLI\ - Lt, Lo"e1" Filld, RLA - Rr. UJwe. i\bd,

0554.-01
------I

56
Age:

A0902200197
01/22/09

MAl<CH, PHILLIP 1I
32Y Sex: 14 Adm: Dr, SALFJM. MOUNER

DOl3: 10/02/76 --------;A00074S29B I.'IAP. Verified by:

,. ,~:J.:tL- I /24 [?f


DePaul Health Center
p.!nl)G~T()N,

----------\

Alle.rqie!l: NKA

Covers Doses froml 01/26/09 00:00 to 01/26/09 23:59

Medication AdmlnietratiOr.
___________

------------------

.'10

~rinLed: Oi/2~/o9 22:0~J Pag... , 2 (End of MARl

R8eo~

DePaul Medical Records/Phillip H. March

000261

~ ~~tnBtructionsl

.......

SCHEDULE MEDICATION QlU)RRS

...... ,.

---------OOUO-07JO

urdU
lG

Stet< t

St.op

Druy!Dose/Route!Comment.s
lCUANn: lK)DIUl-1 100 MG CAPSULE LI'
COLACE 1 n(}~;:; CAP EQU1V

I~
I
JAN

I I

>1'1 FLK

I
I
1
'1

861 100 Me/l


rD NUl CRUSH

CAPS~

LY

[ORALl

./

G~AP'l\pnL.LN
: 0900! ,

I I ..
1

TAf:TE

POTEMl'.lAL FALL lli

100 l",c

NrJJl101ITtN 100~1G CAP

'-"-PS-U-L~J:;-'- - (ORAL}

~K

lib

!'l.u

FLK
DO.'}l
eGD

/
Dl!L2 ) ;lnO

i'
Il3~9
;)1/28

loolle, 100 !'.G/l CM'BIJLl'l

IP1PEAACILLIN

-~-----~ TA7flR1H.':iAM 4..5 GM/1:)~1

~fL

Q G HOllFS

vO

l"00lt
(.'t';O

I
I

/1

,IV 1

l"fuse Over. 30 Kiuuteii

Refrigerate
(WI

I:-\h,'t!
Ofi0Q

I
I

01(-2-2-+----+S-0-fJrfii1 eHw!\Ull!: MeT n.-Ij-\-j-N-J-E-CrrON


06/00 }',('RMAL SALlNE
t)Q. . . ,

1-,

I I
I

IIV I Give :Jnll Every

t&

hours Ul If!SS

med.icationg tin, glven then ~ml NS ooivre and aftcT "'f<dication adm ini st.rQ t i t)l1

,
__ ---L-.

~
LV
RUFI.
~

I
slgnature
-e
~

Lt. !lQ,
RI:..
~

~
LT' ~~, -

I.
Lt. Thlgh
LA -

Site C'odt'ls
l{t,

RU LlT~ ~

tl.Q.

1'lliyll
~

I.! . i\rm AA" Rt. A1III

Kt. upp<lr ;'I)e\.

Lt,

Upper Abd.

LUI KLA

I.c. Lo.,~r AM. Rt. 1 "war Ab<l.

./'

0554-01
DOB: 10/02/7
AOOO748\1~8

.,,;. ,,1'-1

E-1-'-'t-j-b,-' , .. -[ ("

~r-

I
! I

i---~~--I
i

MAR.CH, PHIL LIP H

ss
J2Y

A09Q2200197
Sex, M AdM: 01/22/09

Agc~

Dr, SALEI-i. HOtJNEIl

--1
JAllergiea, NXA
!

Covers Doses f-r-o-m-:~-----

Medie&tion Administration ReCQ~~!


Prl['c"d;

----..;..--

01/25/09 00:00 to 01/25/09 23:59

Page: 1 (more medo

Dl/?4IC~

fOll~

22;00

DePaul Medical Records/Phillip H. March

000262

._ _ 1

.site
UJ ~ Lt. U.O.

Code~

T.T = Lt. Thigh

LA = Lt

"-,m
/lJ."!!\

RU h. U.I,.I. RT = ilt. Thigh RUA ~ RL. uppel' Abd. LLA - Lt.


WA _ Lt. Ilppel' AN. RLh
~

U,,,,.. r

111'1 "

R~,

Abd.

I<t. Lowt'!' i'J>d.

printLd~

tHi24JQ~~ 27.~[;U

DRICGElnN, NU

------

-------

01/25/09 00:00 to 01/25/09 23:59

~agel

(Bnd of ~J

DePaul Medical Records/Phillip H. March

000263

~9peCial Instructione:
. 0t'd#
.>16
ABW

; ---

- - - - __

~S_CHED_ UI..BIl

MEDICA'l'ION ORDERS

.... U

----

I
I 'I
I

I StarL i
01/2)
2100

Stop

I
Ii

~SAn SO;Im! 100 I'.G C'A1'~t-'


I
I
i COLACE lOONa ~oae, 100 Mall
IX)

D-r-u-g-;I-Do-se-/Route/Comm~~--

Frequell_c_ ,1 _ _O_OOO-07JO Y-r


2TlMBS;nM'

~1-1~_J_O_-+_ 1531-2:\59

, I

VloK

CAPBULJI! LP
TASTE

CAP EQIHV

loltAL.l

~_

JOilOO

21\000

VJ

I.

l-~-'~-'l-,s-i ~~~~i
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OOO? CG[J 01/22
ll~\Y

I
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NOT CRUSH

I'''!~~:~~/~~D: ~:~SiJLE-~-08e, 100 MG/l CAi's"LB

PO'l'EtTP hL !,'ALL. RISK "0

T 1D ---Ir- - -'

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U91}O

13~

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;

!I'IPlillACTLLIN'TAl!.OB"rr-lIM~-4-.-5-G-M-/100
IllfuBe ov ... , 3D Hirultes
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IIV,}

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I
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~
QBH -

('4

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NQFJ.1AL SII.L1Nl>
Of

n. 9\

INJEr.nrA~

HOO

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L,-

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1

....

(;,ve Jrnl

ev<.'1

medicd.!.l.ons are glv~r, ther. 3m} NS

~ n~.'lt'9 \)"i~::l I
!'1K'thca:;i<,ln

,iL .)

~n

before rind after

I- i

adj'!',i~~lgtCatlcn

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l_!_
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----:

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----. --.--Site CorlE'S

I
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~,-+ 1---1.

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-~---

______ Lr,-

---1-1-;;;; 1-~_gBdtur~----' I t ~h
l

1 ~~h
!

l.U " Lt.


"

~~ ,U;~;~er A~~
Upper iilid

U Q.

L'r
v

L~ T1'i~,l. ~'j~
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LUJI - ! !

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L;;\l ~ ~i ~'"
Lower'

"

~.,t _ lA~<'

~1

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----.

----

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'-I

'-

fLr~-1

;............--+-

--_.

'"lli Vp.rit ied by,

't;

1..)

lV,-

V~~DOB:

--------1

0554-01 56 MARCH. l'HILr,!~ H


Ag"': 32'{ Dr:

A.0902200197

10/02/76 1\000'141>:.198

SALE~t,~tOUNEP.
Se)<, M

AdlU, 01/22/09 II

{~I!-.{~~l~r741Iqj
DePaul Health Center
DF.IDGF:~ON,

I'

di ;~

___~_

,___

Allerg ie8: NKA

Covers Doses froml

Medioation Administration

RecDrd

Print ..d: 01!23!V9 22:00

'-------

:-\0

---~--

------

01/24/09 00 I 00 to 01/24/09 23: S9

----

______ P_&_g_e! 1 (more

med~

follo~

DePaul Medical Records/Phillip H. March

000264

r ___.

_____
I
I

~_.~_"_UNSCH_Et>_UL_IID_ MlIDICATION

ORD __ B._R_S__ {_oo_nt ,_)_ _ __

9peCial InstructionSl O~'dH I StaIl I Stop 1 Dr_-U_-g-I-DO-s-e-l-p.u"te./cO;!lnlenLu.~=,It.}

j P~equenci'

ooeo07Ju

07:n-l~JO

01-12~

eel)
fU

i l)900 ,

}-

I , I
i

i \AC'f;1'l\H1NOPl1S'1 3 ~'\ 1"'", TiillLET 'I'YLF'NrnJ J25MQ TAP-LET iOO'UlI ~5D MG/2 T~Lr:T

iORAL]

I I

IQ4H
A.s NeEded

POl( MILD rA1N

OR
P{)P. Tl::MP Cl'.RA'l'ER Ti'.AN lQ 1 S
INJl!!CTJ:-O-N---

AllW YU

0014

:11

01/22
HOD

\no"",

r-

IDII'~lNB

&RNAnRVL ~OHa/lML VIAL KQUrV


50 MG/l ML I TCIHNG

I~_~--+--O-L~;H!)
(lV)

C;-~;

~_

I ~l~ iOXYCOL1(.lNE/ACir 5/31St>!G 09{)O I Pr.RC0Co.'T-5 TAB RQUl v I I'Ll( I i F61!&l J TJ.B/2 TABliJn' 1,1/ I' POI< P"TN I- --l.- - - '10') JU
J

I~
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I I "' J ' I
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JAN

nr

I 110(;

I
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_____
Dl/n
_'!Jll.olt,oRPIlDNE lK'L INJE{:nON D1LAVVIO lMC/1ML p~p EQUTV Dose I 1 MOil ML
BRltAKTHROOOH PA!N

'14!!

hE t;eeaeo
[Ivl

ot,!J~
C ..._/

1/

lHLV'l'E llYDnC-MQRPH'JNE Ill' ltMI.


IlflRMllL SALINE

PUGH ,sr.oWL'l OVEn 3 5 >UNUfES


1

"M-l'-.>Jj~L-ET~'--ii t!1-h---,
lltAL}

+'.
I'

I
\ I

A!5 NEeded

I
I

~-----t-

I !
"

I I

I I

l L
I -----(1 I ~ verif--ie-d~b-Y-'-'---------1/
I
"'..R

C;' , --l
:i.

._s~_.~at_ur:-

_ _ _ tl\1J

~Illi; I---g-l-g-n.-d-t\~r",e I.' J{,vJSJI -rV L-/\.-':J"---__

Site Codel:! LU Lt. V.Q, 1.1' Lt;.. l"hiqlt Rtf : P l U ,Q ' RT R Rt, 1'hir;h RUA ~ J,. Upper J\bO LLA - Lt. !/L!\ LUA - Lt. Upper Alx!. " t<:t.
d

.l_.
LA " Lt
<

A110

- H. Anli

Lower AJ:.d. Lower ,\bct,

-1

----+l-=t; I

-r---- ---1\ G\ vi. U ..l'{/-v I (1


to

-~--j

-1::~::::::~
---,

-j MARCH ~H:ILLIP H ~-'--j "''''''.' lO/02,i76 Ag,


I
UVD

0554-01

5S

A0902200197

NM

D~;

:!~'f

Sex,

Ad""

Gl/22/09

SALt:M,MOUNER

I ' - . . ---+-,!L\t;.Liu JjZ}j{;j 1i;~ . .

.____ .

DePaul Health Center


FlRHlGE'lUU. Me

Covers poses from:


01/24/09 00;00 01/24/09 23:59

Medication Adrninistratiofi Reaord


printed 01/.3io')

I
I

I'

n,oo

~---------.---------.---------.---------~

hge:

(End of MAR

DePaul Medical Records/Phillip H. March

000265

~-~" -' Instru(!tiontJl


~Special
.

Medicacion ORDRRS
_~__

r:l,'d~
JOB CGO

IStdl~
101/21\

Drug/PODe/Route/C('jn'lments

____'
IlL

Frequency
QSK

I l
JW
l'1d(

I 01/22
HOO

i 23S~

CLINPAUYCUHCLBOCnll

600

ua/4

SOl)IOM C'lrt.ORIDi O. ~\ '>0 ML

I IV)

I''''fol '
G007 CCO

900

m
01/2B

....":::,:':::.
IOJlALJ
U'ltRACrLLIN-'r.A.ZOBAC'fAM'--"-,S-GM-/IOO HI. (IVI

01/:12 1200

Q 6 HQURS

GOOD 0600.

2359

tvJ 6J

!Ilao

/-tv'-

I
0011
eGD

In!U8@ Ovari }g
1<eh'iCj"n.te

Mi~~~~~

0600

Y
! ,

r
II!

!IODIUid GHWRLDIS
NOlUf,J. se

~g \I.~"

INJHC."l'ION

0600

s.u.nm

-~.t-- ~i'

Give 3ml every 8 '''}\H'e l'oedic6tianh are given then 3ml N$ befot'C iHtO after medJ..ca._lo:1

unl~:~1
yl

,'I:

I ~ ~ 31

' cr/4'r: ~

lad:~/r>!,i_:""'~,-'o _ll3-, "


1'.,)

l~
l

I-,
I

, ,I_~ __i
I
I

1J1 Dv

~.yv'"

j
1

I
~

I
I
J

I-J- U ,
, I

I I
I (

~- L_ I
------

I ,L-_
~R'~~.,_
,"

Site cod-esLT Lt. Th.l-.)b R'T ..; Rl. 'i'high


LA ~,
Lc"~<" c

E
'u'l.

i -'----r/ ,1'?:~

_Sign.ll"r~ _ _ .

--........-.-

'_-'.'.1 ---t- _-,-,_ . .~ - .. __ - ~_

_"" _ _

l--+-,---~
Verified by':

I-i.

-Wn-!J.t:.'.'FJ-I~..J2''jJ-;;;;/
'?Lt4 --

j----r'Ioil

-_.-----~.3l g 0dLllce

I ----i
.

,~.~. i"J ,,~U.':)


,:c,

Ll

{\nTh

- Rt. Aim
I\bd, i\bd

RtJl>.
LCl\

'JPP': 1 t\bd.

1.111 "

Lt. '.;pper Aid.

)'c.

RlP. _ Rt

L0Wt'T

0554-01 ~ v{)~Li-~"'J,~__ ~------' MARCH, PHILL!ll

-I-----"!,-

---

_=_'_~== __,' _-~.-,

5S

11.0902200197

DOB: 10/07./76 AU0074929B

Age: Dr: .l2'l SAL[':t4.MOUNER ElL'X, M Adm,

01/22/09

j~llergi.eBl
Covers Doses from:
t.o

NKA

_ _ _ ,_ _ _

Medication Administration Rlcord


Prlntw:
Dl/22/0~ ~2

nO

01/23/09 00:00 --------,

01/23/09 23:59

----- -----

Page;

1 (Il\or& mads follow ...

DePaul Medical Records/Phillip H. March

000266

Siee Codes
LU
RU
~ln~l~'t~___

I _.J
Th,yll
LA Lt, Arm 1'.A - RI. hl"m Lt,
Rt

.
E

1J'~ , Rt, V,Q,


)"

M;.

RT

RUA, = Rt: .

Rignature

WJI.

upper hb<J.
Upper Md.

Lt , Tlugh

Rt

"LA RLA =

Lower Ate
t "' ... er

-----

Ab:I.

0554-0l 58 MARCtt,PHI!.LIP H
DOB; lO/0:l!76 1\00074629B Age:
~\?'{

A0902200197
Sex: M Adm;

Ol/2?/D9

"R Verified by'

DL' 8ALErl, MOtJNEH

t----a_~_r-jl,-'......~_, /V'_I_/.2li=....=O",-'1
Depaul Health center

=---=--,-_L,

Allergies: NKA

Covers Doaea from;

~dication Administration Record


p, inted. (>1/"./09 ~2'l'O g_8_: 2 I End of MAR I _________ p_a_

01/23/09 00:00 to 01/23/09 23:59

DePaul Medical Records/Phillip H. March

000267

I 1 _ _-

_ _ _ __

!Spe~ial Instructions:

"rdl!

I
!

Start

Joe
CGD

I 1400

I 01/22[- 01/28
235~

I St~;p lDrug/PooE/Rouce/C(Jo~I
LIWAK1CLN(CLBOCllI)
6~O KG/. ML

-r
Itvl

Ke4ic~tion

ORDXRS
Y

.......
ouoo-ono
O?Jl-1S30

"'-ll-;'Quenc IOF
<>

BonIOM CHLORIDS 0.9\ ,0 ML


~O lo1in\1~es

:Iufuse Over,

I
Q 6 1I00ltS

Refrige[Le
0001 CGD 01/22 llOO

j l

(nne
2359

PIPE'RACIl.I.IN-TlIZOBA<:rM 4" S

cav 100

ML

lYV1
Yuf UJle OVer, 3 \) 16inutee

I OIiDO [
I I
I

01/22

-t- !
I
I '

I I r I I

Refl-ig,u'a t t'
MCT 0.9' UlJ1!C'l'ION

--+--ODIUM CHLORIDE
OOlt/'N.
~~P!!
~61

oal!

INJ
Q~y~ 3ml l}'I.:'p.ry a hOU1-~ D.nle-s9 ml'<lications un, given then ,",1 NS l~fore and ufte!" rnedL:atiol1 administral ion

1v~
.-~

I ------+-

I I
I
I

I
i

LJ
l;

~~. --- ---..L_._ i!~


w L~.

Site Codes
lJf Lt Tr,'gh
Thlqi. RT - Rt.
LA. Lt. RA 4 f}l.
].0'"."

l'
Arm Al'"ff(

D_C>
U.Q

Ii

41!

&-l-~-/)-S- ,?ture I "

rf(; ;/" - __
'\)<

I'_,it --~-j RUA = Rt vpper JIb!. e ' LUI< ~ LL. Upper Abd_

RU" Kt.

i<.~--_-I-' --+-!-~_~~---.__

+-_ _ 5~jLgl..:.:I<'lture

~ ~~~~~'ILLIP ~S
DOB: lo/02/7G ----lA00074B29H
Allargies: NKA

-\-.___

wu" - I.' k'-'A "nt

LOwer Abd. ADd.

_,

A090220019"Ol/n/09

Age,

Verified by:

32'1 Sex.: /<I Adm; Dr: gALEN, MOUN8R

!o8paUl Heal.th

----------------Covers Doses from I


00: 00 to 01/22/09 23! 59

Medication Adminisb-aHon Record

V.a Ol/22/Q~ tIll<IDGtt'TON. ----------------------------------

.------------------------------

l'ay.e: ~

Princed, {more meds follow

Olj~~/O~ O~,OO

DePaul Medical Records/Phillip H. March

000268

~pe~ia~

c=I'Ll!:

0r:dj!

I Start

Instructions:
Stop Drug/Done/\{ol.lte/Co",roents
CE'l'AMINOl'lmN 32~ MG T.AIILIn

ONSCHIIDULBD MlIDICATION ORDml5 (cont.)

~~o ~~~~2

I
I
\

,I
{O.R.U.I

----

Frequency

I
I

oooo-ono

Q41l

'I"lLlIOOL ~ 2 5 fiG 'rAB"'B1' se: 650 Maj2 'I'MU!T

A.a N&e~d

I -------------_. \

0731-1530

153i-2~
--+-----

I
i

'

I
\'
01/22
0900

'OOQ'9

-!

'caD

'~-'llhf7 ~~i:;~~';~ !Mj _:;~Yhr;


I
I
I

~'OR ~!lL1)

P"IN

OR !,OR TU>1.P GREAT!,;R TIIAN 101. 5-

l'
I Q4-b.---'
As Needed

IOXYCOOONl'l/ACBT
PKRCOCET-5 T1Il!

5/32SMC 1 TAiiTiBLET-

~~UIV

I! ! I i I
!

~i ~r{.i -jJ~/rv ~ut/;~ /f C~/~J.

\/~2-t-z7f
j
.
I

'

Iht--Qf IV-tM rV!'lln-.....


I ,
I l

I I

I
~

Sit.e Codes
I.!J
KU RUA.

I
LA -

~ I P;S~-_-'-r-..--,-+I_l~n" I
-~II

",='llie.
--

--

-==r:':::-~, "pe'AM,.
H
Dr:

LI,
Rt,

U.i,/.

LT

Lt. Thigh
L1A.

n.t n ,0.

RT - RL

l'pper Abd.

Tt,igl1 AA Rt, Arr.'. Lt. L"Wer At'(j

J..C, Arm

'
II,

'"' -

",:'::,7:'97 -i
Adm: 01/22/09

.w ,i
--~--...:..

--~=-- J MARCH/PHILLIP
AODO'I48299

DOB: 10/02/ 7 6

Age, 32Y

SALEM,IlOUNSR

Se",: M

W, /erified by:

AllergietH N1I:A

_________~J~/=-~-~
De~a~l

_ ___~_
Covers Doses from:
01/22/09 00:00 to 01/22/09 23:59
Medication Administration ~ecord
prIntEd, olta/o9 09,00 Page. 2 (Rnd. of MAR

gea1th Center
/>'10

~l<.i{X;ll'rON,

DePaul Medical Records/Phillip H. March

000269

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

~~-l'uI$t

PflEVf()US 24 VO: Intake Output Yesrerday's wi. KG Thdav's WI.

SCALE KEY: 0 Bed 0 Standing n W/Chalr 0 SUng KG !please reconcile weight dlfferenc:. It grealtr tbaft 7.5 ag.)

,(v

...............
IL1// ~/ ~/ 1//IL/'/1/1/ // L // ./ /~
PULSE

DATE STAHTEO

Ra.<;p

6P --" 02 sat

-'
02% i R.te

,-

/" l!t t / / !./ l~// l/~ //' .,//1 / Cl'7

:f ?
n

0, Urkltllll\l deVIce

~
i

If
lm1
~

Bl'llslOli gltlcose

TIME

T&MP

PUlSI

RUi>

8P

~i

SAT

Tille

TEMP

RUI'

IP

.//

/'
//

//
//
f)

'OUI ~
lIQ
DINNEIl

TIME
Jlt' l'

ITIME
,lIP
P

//

,//
,//-

U'"'-"'""''''''''~
, \~ laxe"
TYPE
D700

/'
LUNCH
I

/'

BIlEAKFtsT

N(
)

0/ \
ORAl /rUSE FEEDltlGS

,
I
t

./
HS.5ftACI(

UR NE VOID
~,

OTHER

Ilfl'fi

ORAL

TF

RUSH

8M

~:

( 0('1',\
'""-vv

JJr:.
I

1000
,-

I
-

~
13110 14(1) 1500

1600 J}OO
1300
12 Ill'

ilEHAVK
All- ,atJlI

Sub TotaJr.

12 hr total paremaral _ _

- -

--

12 hr \ol?J n'ol,'lIhe _ _ 12 ~r sh/11,m.1vl

--

-~

--- ----I

--

-~----

------12 hi shiH uulpul

,.

E ~ Elld I-~
O. Ovvti

1911:Q
2110n

ItlrelWI
1. At-..

~-~;~:
2JDC

2. Atdf

3 Guidon
~
6,

cniIl
Encwto

5. EaIobIiI
7,~
=:

~"~
02DO

oaoo
M!!!l
0500

1)600
12hr Sub Tutals

12 hi InIal flilrenteral _ _

-----12 hI Mal
:mllL

(}[~Vluoo

_ _ 12 hr shNtintake
'8VD" " " , ....

-- - -

----- ---I
I

---~

! 2 hr shltt output

~i Iota!

FLUID fQUIVALEt. TS:

1 Ol

.... ,

4 OZ IV, cup), 120rnL 60z (3/4 cup) _.. 1S0mL

B oz [1 cup) " . , .. , , 240ml 12 oz [sodi!-1 can) ,360ml

.
090220019"

"""~IH"l"'"
PATIENT LARFI

."", ......, I

tY/bSSM DePaul Health Center


II CAL
"f

DEPAUL HE&irfi CENTEt{ MARCH, ?HrLI,lP H


10/02/1976 3':), SJ>.Lr:l<\', t>10U1-lER

C ... R E"

IIiIDIDII1IUU.IIIIM
PRS 0554-01

I/f!

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD


DPMl00Q-()71 (5,<'008, PAbE 1 OF B

M 01/22/09 0007LJ 8Z~~


DPM-10c0

DePaul Medical Records/Phillip H. March

000270

RGICAL PATIENT CARE RECORD

DATE

24

+
pam PH,S!>'l!

BehaviOrs Time

illSI' [}al,

Insl
Oa~

+
+

Haling SfOrt /I

Scale Usell er
O~ervatlon

Iflst ~I

PfJ
F1

Function Gild I II
Ducri~t:

R:

Locatiun, BtflMviar IIf ,\PP

Quality

Fn,quenev
fl~gr1!Yalino ';actor~

StllaUttnLml
tnrervcRlilln{ II
Inilial~

BEHAVIOR I PSYCHOLOGICAL
BeHAVIOR/REsponses:

AN

1r

AOljOU;

'" - MUlI.pI9 H"qutisl C - C<llltinUQU~ Crying

II

= vnra!ponsr/a

CD
W A

C<lIlM6(l/DiWi;tntgd

~lj -

Oliruplll1l
Siglilit;~nl Olh~

E =- Ernnfimtlf D;tifJP.-r.:~ I : IIletlet.ii-vH cUt.-Vty o - l.,,,,,.lop nentollmp",r~

OE ~ ~Pf~S$\"" CO ~ Orievlr>(>
l - t'lltlrugit.',

o Ove-'5iimvl~led;O<Jere-notivB
6,
~

CO - ComalQSe CI ; CoQni(i'~ ImpWimet>l R = R.~!le""

H .:. ttaIJu;;UlaliOml Dt'lusons

= Artention SI;-.ek\ng

= Oelloorately W]mllOl(!!ng lnlo

T = TNealenlng Phy";,,,,1
HRlmfCof'l'\tm~t,,-e

o " Ca!f1\'OWel

S - Sfeepmo

COP = Cooperative

DP ;;;: Os&ruptr....e PatiEmf

lM

'<:

Impu1.?J.... rR~oriEflt

LA '" les~ A.m:.ious ()o:-\"1.flr

IIIITERVENTIDNS:
1 AfraSSwat Ce . f'atfefi! 2. Hftdlr5{;tlu-1
f

';)iijnffit8r\1 OlhtJr

3 Qu,d/lr>

4. CoMslsten En1"<Jnmenll Rcut~


5~

Es(Qb\$h ll\a;"I';r\~Q 1;n\f!raillH I~, c.ere iiHas


En-cctJrag-11
veroflltZ"fl.t~oo
dl';1(;::i~mn

Vrr&llfeQIJ,wl briel cont.c1 PfO~tP~ inform~l!On to IO;fease ie''fel of understandin-J encourage family 10 "'ring in Jar",i1\! <'lY~. 11. PrOvi(le r~liI><atiM wnh mvsic, Imagery d~ ..p bl~alhing. pray~r. meQicl>non
10.

14 ~ 15,
1o,

I A~mW<ats i Rs.lating

lat;\~

~!vejsiGnat a-cuvttje~

PrOaet<,,~ meJ\SV(~$

17

ne&l1$l''l'l1 OI'QuesllQn ! Seek cla(lr.ea~on


~;lil)jl;;jfi Doliniiaf'"~ PfQV;rlO ininnr.hm ~.ncwity ami ~"lfnly IHI"!m~ln~'.
Iv fJWl!OJIL-e- I)ftff3'1lOfal prObhtiHS

1~ EnC6Uiaqe iiWfI8I91eep cycle by lising iiiii..ec! li{jlilifi!j atilt oM,


13 Darkan rcom : t fmfliniJ tOllch

I
to
~i)("fH.1!.dtnm

113
10

FnooV(<*gl p-UHp.nt \ ...".111

m.,t!lfl9 fm cam fl,flf'..!1;r;

QiI~~t ~;i!Jl\ 10 t1m.:re3~ fmh~Hr:; fI:"~:;4-Jur!::.'"H

~SSM
H

E" A L T M

ARE"

DePaul Health Center


DEPAUL HEALTH CENTER

2<' HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

rip MAACH,PHILLIP H 0902200197 ERS 0554-01 10/02/1976 32Y M 01/22/09


SALEM. ?40UNER
000748298
DP

111.UlDmllll~.IIIUI

DPM1QOO.071 (512008) PAGE 2 OF

DePaul Medical Records/Phillip H. March

000271

HOUR MEDfCAL/SURGtCAL PATIENT CARE RECORD

24

(nse<tioo Date:

["Irso Llill.;
Dr~_

+ Site #:1
!nse100lJ

Oalfl
FRONT
RT ('

[}alp.:

-"t
\

fRONT
LT

. BACK
I

BACK
/~-

RT

-\
j
I

LT
Q

~~ 'ti'

IJ
I

\v\

\ )~
~

"h;lj

/(

I .If

I)

\-\

I I

SLIDLlTLC
R

'u

! v ___ ---I

lnserllon Dale
Arm clrcumlcrcncc em

length _ _ cm

Dressing change date

f----+--------------------------------------------------l

PATIENT LABEL

~SSM e
i4 A 1.. l' >4

~ '/to ~ (I""

DePaul Health Center

DEPAUL HEALTH CENTER


MARCil, PHILLIP H rip 090220019" FRS 0554 -01 10/02/1976 32Y N 01/22/09
S;:''LF,101. MOUNER 00074l;j298

11111111111111

2" HOUR MEDICAUSUAGICAl PATIENT CARE RECORD

DPMl()(XH)71 (512008) PAGE 3 OF a

DePaul Medical Records/Phillip H. March

000272

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD


Use bOidlfl1 Key letter" lr.dfca1ed

DATE STARTED

= See additional commEnts in NUr56S' NOles

!RQ\I~i

lR\luoos {ep, SNT i~}


B6dres1 Independen1 Positioning: R-AIgllt LLeft fI~ack S-Sell PProne

,.... lim
I,

:im
~
'P'

if\

IS
"'"'\
'-- ._. ,--- ,....

IH.n.B.
-i

n.

:H~a!soff

bM Chair Daollie SSG

~ Transfef assist

~ SB!\ x1 x2 x3 min mod

.~
J

.'

I,t:,

Self 'Assisl 2i\ssist device walksr C3n~

..

..

~II!Q~ WI' loth

,,,I,

(# Fset. Steps)

: A~"'"k.;, 1 comments

ROM . Ext IRA. LA, RL, LL All}

I~~h~n Asgist ~ml1let1! $Howe, r eell chanoed

i.::>
V

(q

J:~~a~~~:al
"arc

- - - - 1.

5
,

.. . _--

Den1l1re care

Self AssiSl Comolele A$~i$t Complete


Self Assist Complete

t~

I ShW9
~~ care

Self Assist Complete


Self Assist Compiete

lSi" bath
i

SlilgS I Splints I Cast RA, LA, RL, U

IK-Ilad / lee packs ICP''!l Set1ings


. . . . . f'.

Rt. Ilt.

I~"'o, "~,;,~, hip I knee


ITra:tk>n
Caliligrt 1 Phone in reach
~I I"Hlli
!I

,,u

and on

Weighl

wttllin reHch

~~
0/

../
,/

t/ ,/

.u,

Sld~

ral s: x2 x3 x3 PI.

~Qussted

)e X

'XI

-""
!

liP hano
i Ailergy

o Verified and ill place


~al1d

o Verified ant! in place


...

iDNR cede status bane

ilso/allo"

N'

"0

band

o Verified and in place o Verified and in place o Veliiled am!' piace


o Neutropenic

o Verified and in place


o Verlfied and 1n placs
0 Not applicable

__ ._--

0 Not applicable

0 Not appiicahie
--,--~-.-

o Vrifip.o and in piacR o No! applicable


,._.

ISOLAnON: 0 Special contact 0 Contact


.r-..

0 .l\i!uome Ll Urople\ 0

- .
.

"'--'--

OTHER PRECAUTIOtIS: 0 Satsty/fall 0 Bleeding 0 AspiratlUli 0 Sellure 0


'TI' I t: 'i SHIFT J l(J'ftALS I (~ ')\'t1 A )L,({!/.!t\) r/C--j

.... _._ .

INITIALS!

' TITLE / SHifT

INITIALS!

! TITLE ! SHIFT

f{'-.-\{
I

""'

J1f ~~\y\ (.:{-J 0.. l

.,.

~SSM
h (:
F, \.

T H

-C A R f"

DePaul Health Center

.
Q902Z00197

tJAIf!::N( L4BEL

DEPAUL HEALTH CENTER


I'tARCH, PHILLIP H

24 HOUR MEDICAl./SURGICAl PATIENT CARE RECORD

I/P ERS 055401 10/02/1976 32'i M 01/22/09


000748298

1111111111111111

SALEH, t40mlEk
DPMlooo-071 (5/2006) PAGE 4 Of 8

DePaul Medical Records/Phillip H. March

000273

r:;!.~~~~,~:ICAUSURGICAL
I Speech
I Speech

PATIENT CARE RECORD

DATE STARTED

Apical hs:
Abnormal

Pacemakt clear
(Aphasic, Delayed, slurred)
.11

'1./
.J.

Periphera

I Moves

AAbsen1 W-We3k

WIIfl equal sfJIlnjJl/l

1/

S--Strong
D-Doppjt

Motor respons6
(Abnormal f\exlon. EXtenSion,

Color lelr
VIM - flal
,~f<!,

Flaccld,

Local!z8~,

None,

SPaSlie, &1rang, Weak,


WDW1t!ldrawsl
Tremors

ir>s In
~

!km warm
:tIR,i)tln.~

1i000Iotoocr
III

J3 '"
T

Sandbag
TEDS
... -+---i---j--!-4--l

TEDS

,UI~"""YI" (PreslMt. Absent)

Numbness I Tir)gH 19

seDs
SCDS

Atmormal breath! ou nds Specify abnormal breath soul1ds nn diagram

TIME

(Absent, Decrea>ell, CRackles. Rhonchi, Wheez( $, CoarSe)


AbIfnmsr

Abdnmto'
POSTERIOR
Re.ivS,,[)irllltDl,1V 7

Bowel s( Bowel sc

effort. IIflfabored

Absent
Last 8Mf

Abnormal reBpiratJrl effort Dyspnea {Oil Exertion, at Res1}


I

Cnuuh ,-

~,.
...- . -

Hilus f'i
Stool api

I Cough

and d8tP tfeaitl

Incentive splrome:.er tt ml/ # f1lllS


Sputum {tiescnbe amou!1I, color,

o GlUb
NG lube
Iilag! B

I Suction (Nasal, (lrai. Trllch)


Trach care

I
!

o Trach lype _ _ _ Size _~~~

~ GPIl.P

.""..........,,, ....\s: 0

I I I ii ! I ! IlWAP _S!tti~9S --~==--t--+-I-t--++-+-if-+-+-+-t-t-+-+-+~f-+-+-+--f-+-+-+--l


C~W

Tube fee Ostomle: Stoma rf


Stoma: I

.0 SIMV

,."motu! OOIl;"~ ~e~<ified

per order}

Necrotic Ostomy
Ostomy

Comments
PAHtN! LABEL

CHEST TUBES
TIma

Locallon

Wain S~1l1

Su~IIDn

Drainage

DE.\?AUL HEALTH CENTER


M.A.l\CH, PHILLIP H

1IIIIIIIIIIIIIlflD

rip
000748298
DPM-ioe

/
SSM DEPAUL HEALTH CENTER
~4

0902200197 ERS 0554-01 10/02/19'16 32Y M 01/22/09


SALEM. Tv!OUNER

HOUR MEDICAUSURGICAL PATIENT CARE RECORD

DPMlOOO.{)71 (t/2OO8) PAGE 5 OF B

DePaul Medical Records/Phillip H. March

000274

MEDICAL/SURGICAL PATrENT CARE RECORD

DATE STARTED

24,..

Time

tYIJOSSM DePaul Health Center


If ! " 1. 1 H

I.

"

DEPAUL l-fEALTH CENTER


MARCri, PHILLIP H

111111111111111111111
ERS 0554-01
H

rip
01/22/09 000748298

0902200197
24 HOUR MEDICAl/SURGICAL PATIENT CARE RECORD

~
Ii i

A I. 1

10/02/19'16 32Y

S,l,LEl-l, MOUNER

2
DPM-l000-

!000-071 (512008) PAGE 6 OF 8

DePaul Medical Records/Phillip H. March

000275

DATE STARTED
oil

.J<i

'~1'.

--+--------------------------------~

Or.inage (vaginal, pa lilB)

SKIN RISK SCORE SUMMARY (Circle score In each area and total. Assessment frequency: once par day.) Actlvtty

Mobility

fmtlon i Sk

Skin Risk Score: 18 ur I..., plllf8nt Is at rISk n FQJIow SIcIn CIro ProtocfJf for scm of 18 or less, o MJ/J'itiQ(W OOI1S111/ (if not prevlQlJS/y ootaJlTtd.)

ALTERED SK.IN/WOUND KEY:


PU '" Pm.s\Ife uiceJ II pressure uli;Br, li~1 IV . UNsta!J1!abl~
St~!JIlI,

- Inc{SiQfl

BL
II. III,

an
o

- Laceration

" Ra:;11
TB = Tilf1e burn

V
N
S5
D

Vasc.lJlar ,ar.!)I' ivetlO'Js staSI!"', arlenal

lIIsuf!il;itncy) = t{;mmp;!tIliC ulcer (!iabebcl


~

D I! EX
SftrIOUR~IBU

WA = Wei! 3Pproxim8led = Dlhllr _ _ _ __

Dressln,,:

= Osrmlbond
~ St.~~es
~

SWi sHip.

n = Gr1!1101!U(Jl1
S E
~ ~

Wound Ra4 Key:


Slough

E$char

Frill,
,,'

\ i I , . , \ .

OTA " OPlln tn ~" R ~ ~1~on eulUllS

o = Othe.

Skin Key: Ofai~lIOe TvP1l: Q = GnlAn Ii: = E,yU.",,,. S = SSfOU9 M .- MacBr~Mn aa = Snrm'''"!lHli1\lOJU; C - Cyal1l1ticiOarx PU = Purulenl

"

Draina9i Amognt
SC:
$
~

- Intact

Scant

- Smafi

M L
C

MoOtrote - La/ge

_____ 0

~ Ollt~,

H!o\l<ly
~'elfJW

= Cupiuw

DI M

D,y and ..lad

y
o

Monicomerr ~trd~

~OIl1n

_ _ __

o '" Cru,i'j
- Olllar

TIme

N AU.,t<:! D ' Wound ISulTOUlaJlinvl !;Ir!!!"!!8!! Affi1!ygl qf !1!!gr S.. n8 (I, SilnlWuulll! Tonmg Bed' Type Dralnane YIN ('Sligt!

Tfei1iiienl

InlliulG6

RUDUllumcnl

No ChallilB Time and Initials

!.---+---~---r-----------------------------__+----~---------;

~
1 Ganp,3lHfl

2 ttw'llOf. 3 EnwOllml
CSfi

'QII1,

4 H6'airty Ofl

5 Mw,a\icl
6 Oi;'Er!iOn!

7 PlIienvfal

o O\hl;,
Rcltfill~t~l,I.

AIl<I!>Jn<l~

~SM
HfiAI.-T"'-CARIi

DePaul Health Center

DEP~UL HEALTH CENTBR


I>'lARCH PHILLIP H

24 HOUR MEOICAL/SURG,CAL PATIENT CARE RECORD


DPM-looo-071 (5 /2008) PAGE 7 OF 6

1111111111111111111111

J,/P

090220019 7 1'0/02/ 1976

SALEI'L t40UNER

0554-01. ER5 t<1 01/22/09 32Y 00074829 8

DePaul Medical Records/Phillip H. March

000276

HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

Nutrition
very puor Probably

Frl1::llon & Sh~lIr


Problem Potllntial I

Skin Rlik Scors: Is" Ihan H. plltlen( Is at risk o F(J!Iow Still Cafe Protocol for score l~ss

adequate Adaqu"te 3 Excellent 4

problem No appmonl problem

til.Jn H,. W()SI prototOl al bMLId? i Nutrttonal consult (iJ not pr&viOuS~' obtained.) ~CorC

SCOrfi of 9 or greatar indicates


.. - - t - - - poaafble Fall Risk, If nursing ;udgment

a Fall Pl'Ovol1ll<>n Infotm.lttion


snoot revlswed/relmorooo

---::;--------';--;--+---f--+-----, differs frum SCQfe obtaJrwd. docum&nt


reason code from list below:

o rllli rl'k ImlGlllllt In place

tAi~~~J;j;~:n;~I-----MMiiE!liiiltA~lUflJUGnIQr1ltl!!tlnl
1 Pm;"", OJ! aT ~fi<;ii<l airwiIY amIIm O'<\'!}On o.!iWlV (e.g., 10 malOlilin WOOlTStllolgl'VlCMel lU()fS)

Sl$lIJ1nt EgViatbp
Oocfll'lltrit iiHlf: <Hid !t+tIt\~.
( )
(11jc

TllaJ !Idem Mt'


1ft

~b210 (~ru)}

conlr1(t for safety


fil~,eit;

~mlfOmr<lilntaf mar~J 1113Mm (rw.J:( iitif,;.:f. stifitJ!I-. BfHtt;Jl

r:ilJlii(jhl till: I 1\J!'JI1ly orunt~!irnl


!'~tM

? M,iutJin l1ill<n,h-e line'J u; bAIt3 (,"'l!ieIliY.1l IT} k tr~atmf~ pal",,!>' em,wt tnf.oilJon (e.Q ,~\lOOlC~ oj rrut,alilA,
~m

~f the

~"lJrd, '1'<'110", cte.) ~i eQUc~llD', box l!\Oicalts fOio,,"n{I

2
4

10 rltAI.lIfUDe:;',

leffiS (Ii'IV.I~ ",il' le~m~.

3 AtlNty demonS1'ol1es

ri,~

01 ,eilljUry

miMu.uoo or l\yI1talronj

1 Keuoo 101 rest,.,nl


2' Astf.o&-eJ-nlll hm~ fl~f;l1a;; ~ Tlwt t~(lH! rrL'QlJt'~1c:Y 4 Behavior fe:QwetJ fO-! r~)VJ~

'tlt~fl4ltlj ~J li!i!~l.,..t dl1}~iH~.r~ 'J;i}:t;"u:~. Lt.

,vatwtJo,
~1it;'~'SeNrtle"Hll

tctl,it, 1)3(.1tobs, Y<00<>5, ",.'I<s maile . .tc.1 7 f'a';>..lI\'1i1IDil't ~~,~/('Qfl '


OWI~I\IJ

R.1Illly nll,,'!f<ll!:; wi", ive """'Piv;i!al1l tWIn an ni"'Y or ",*.!I sulk! 1111 \he! injury ~ 1Mi' tim m:tsse l1WIerr",nlllelore" is >m~oi1:ally tll'''t'llnillt (e~, e>Vmlitf

CO'~r4!lve

and restraint Itmo\'W


nr (!!t(:f!(f; if.~ RF.h<ivilU:ti
!!;tfr',ttf.if dm:url~(j1tldJ:!.\tl}

or=J.Jo", I'h. _

B Ut mfm to
IleWeiJlt~)

~a

5 ;Iix! DIMe;!S" 9 ()U;w'

1.'<11

1,.nm. Qrv<-s.vw ~,~ijuieil


4 Prowct!IIE /)1il. In}J1y pa!1ent 110m '",Ihe! ,"r-J'Y Ie g, eVA w,tll pm!)',;; CI h..ao l,aum. wllh .~$Mr'11 il\~)

SW "dimiur.al t!oVlm~ for


Q1~

BEKAVIOfW. RSlIWNTS:

7 f!tr:ffff i1liqtirW.
lli;1

N rme4mXlIO",J~rirlQi'aturea.son
r.~.,t f~\eO

Rctw"n drmoMl.ntioo 3, :M~r<al-eas-e

mn dlJl:>llmerua{)On

tYl':;SSM DePaul Health Center


HlAL1li
~ARI"

DEPAUL HEALTH CENTER


l't1A.RCH,PHILI,IP H

24 HOIJR MEDICAL/SURGICAL PATIENT CARE RECORD


DPM1000-071 r,.j2008) PAGE 8 OF 8

111111111111_
ERS 0554-01
t>1

l/f>
01/22/09
00074 B2 98

OQ0220Q197

10/02/1976 32Y
SAl<Et-1, NOUNER

DePaul Medical Records/Phillip H. March

000277

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD


PflEV10US 241/0: Intake OutPjll

DATESTARTEO

JAN 2 S 2[109

24 I-

~~
Resp.
I-BP
E~.I,lh

SCALE KEY: 0 Sed 0 Standing 0 W/Chair 0 SYng

Ob"N31
Bed~.de

glucose

ITIME
~
~p

._'-p
Ve.crlb~

f"'/

loeatlGn
8e~lIvkJr

/
//"

Quality

HS SNACtI
frequent

IYPS
0700
1-0 =8(l{},-+_ _. _

ORAl.

O~=FEEDINlS TF FUlSH

VOIO

URINE r J-J"" [/
I

OTHER

1M

DiDO
1000 1100 1200 130()

.-

Initials

L~

i40()
150()

.&O~

'600
12 hr

t--.---~-----+----~----~~~+_----~--_4---~-~~ 1700 I&BJ IU) 1800


lOI~lS

Sub

&ei:J_
12 hr tolal ofaVblDe .
(

;tJ-5 V
-......
....,..,

1// ,.J.rJ
/:J 'rJ..;;>r>..

5I!!HAl,j AN ~ AI

12 111 \otdl parenteral

',Mr <lla~a

--------12 or gflit! outpul

E.;=:. E"rn(
I .. !11c.ff, D - \"'<r,

Illc9C:i

1900 20110

INTERI

~dl t;.

/U/

1 Rh~~ 2, H6dir ~r GY~Qi


.'j,

2300

5 c:..ac 6. EneD

CQ~

011'10
0200 0300 0400

J~

.-....
,'--::-'
j

7 FOJ,lI}

....

A('YtJ - ..

..

Wz....
t;7)[

FWID EOUIVAlENrS: 10z " .. > " 30nL

4 cz (1/2 cup) , . 120mL


T

801. (1 cup} ... , .... '240mL

PATIENT LABL

.,..,

6 nz (3/4 cup) .. 180ml

1201 (&Oda-1 can) .. 360ml


DBP~UL HEALTB C~NTER
II'J\RCH, PHILLIP ~

~ "

..

~SSM
H E ~ L '1 U C 0\. r:I

r"'

DePaul Health Center

IIIiIllBIII1I1I1II~11
ERQ
1>1

liP
01/22/ 09 000'/48298
DPM-100

24 HOllR MEDICAL{SURGICAL PATIENT CARE RECORD


DPM-lUOO-071 [b!2OC'8} PAGE 1 OF 8

0902200197

05~'l-Ol

10/02/1976 nY
SALBM, I<lOUNER

DePaul Medical Records/Phillip H. March

000278

24 HOUR MEDICAl/SURGICAL PATIENT CARE RECORD

DATE STARTE& '

,.

2009
Kf
IJ~

1 Medir.\1tion 2 Aml!uJaUUlI 3 Reposition

17 Epidural 18 peA

+
N(
1m
t}a

19 Preemplr,e
analge~iJ

4 RelaY.aflOfl 5 Calming Statements


pain pl1lse 11

20

Con~I1\1M

Prayar!M~rnlation

analgesic intusiQo
21 Olflllr'

Bellaviors

e !}e~p BreHUliuy

7 Splrnual Care

Time
Rallllll S~Of8 #
Scale Used 0r Observation

+
1m Oa

+
In!
D~

tE
'.'F

Funtlhn Goal if
Duerib&:

location.
Behnior
01

IPP

Quality
FreQuenc}
Aggravating Facwrs

I
InlervenliDn("i
lrli\ial~

BEHAVIOR I PSYCHOLOGICAL
BI!MAVIOR/RESPONSES:

AN

I=

e. ::

=An.iO""

= MUlUPla R&q~;,l
~ D~reni<v>
c-.1ievin~

C - GiJnlmoous Cryin"
Of

EWUJt,(lH ft Dlliul:1':i-!. fnetf6LtfV-' I COPtHg

UnrespollSivil CO " Ccm~\05~ CI = Cognltke imp!llrmom


~

co - ConfureOJOlsotiented

os - ObrupWe

S
Oth~f

H ..

G ;:

~ ~ lie-\'~~:p

nental Imp',!3:rm'Ool

L - LeJhar}f.c

o ...

Aeatless O;''erQl1mu!;7d-erlJCrJN"C'm:tivo

W = Deliber1!lly WithholdlnQ Inlo A - Attennon Sl:'eking


P1iti.~t

HaJjuC!f1i1Uon~

Oe!vSiQn5

6IQniHcant

= S!eePIn\J

I)

= CelmfQule!
Coo""ra~v"

T = Thr "",inq Physical

OP '" Dmflln!;vt"}

j..{arm.lC.omhoHve fM = Impl,h;'1H

LA - t Crl-!t Am:ln~.m
O\t'tUf

COP -

fNTERVEN nONS: 1. Reat.U!".dIlCii" Falrent f :>hJrlllJCiln1 Ull1el


2. Rt:OfftC1fc,n

J,

G\>i(!~~t
RQ<.Alf)~

6. Oll~, fi~Q\.i.ni Q.-",! ,-OfIt,,\ 9. Prov:de lntorma\bn to incr-eas-e le'fe'. cf und-erstan-din"Q 10, Cnc{}Yr~. family 10 bilng in familiar obi~U ,, I~ 13 P,ovid9 i~lI>.a!iQt\ wit" m~~~.lma9~ry. (I~~p Nealhlng. preyer. moolCHtiDn ~il.;oofiVje Mirnm sleep t9aii by iiSiii~ ~ii~lJiiii ~ltiF <liii~ Dmkon room! lllTiiilng H:H~ J

14
1,

Reorient! RemottVale i RestatIng {acts


OiYertiOI'f$l ~~liv'~e$
r>tOtl~i;~
pjl1je~sli

4.. C:>I1;SIs-1e-nt (m-(lronme-nt !

E$t~i)I;$~ nt'nj,).;';e<jltmel,"MH 16, tiii~ MM. Enco:JfaQ 3 v8'b-aHzatorl FI"\{'~OHrn01 p.ni((;nf wah rW...r:-~l(H1 ma~mu kv. !'.;,JH IIlllid~,

,"cb'.el

17

\e
IB
'9

Reassess J Ra!lu&9tl.on j S-eev

"'e'w.,

{'lBrlfj~.atlon

no; ;ni'~'\noij

OU>H( ~.J.frl to i...htf.:It!-3he fkI.1~IH1r!3 fcspcns.!t \0 b\ij)\l1ial:otl

ID

PrtlYldn in\p.nKflH };ffr,'\Jjliy iiHd ~h;l, 1n&-a-Wri!5 !"Hn~ll\l& OOt"!3ViO(al probt&n\6

~SM
HE-ALTW'C"'1t1

DePaul Health Center


DEPAUL HEALTH CENTER
S !>LEN, MOUNER

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

MARCB,PHILLIP H rip 0902200197 ERS 0554-01 10/02/1976 32Y M 01/22/09


00074B2~8

IllDlIJllllllllllllln

OPM'1000~l7i

(S/200e) PAGE 2 OF 8

DePaul Medical Records/Phillip H. March

000279

....--HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

24 HC

!)rsg.

Date:
Dr~g

Dille

PIce
FRONT RT

(-

FRONT -~, LT

BACK

SL/OllTLC

if till!

jill 1/

IJ

\ \

\I

RT

!.,~'\

\~
~)

!J
411l

u
)(

~ wi

fu.e {JI(r.<..tled.

! \~ ~1I\t

Insertion Date
Arm Glrcumference

.___ Length _ _ em

Dressing change date _ _ _ __

em

PATIENT LABEL

~SSM.
k:51.\.1)t CIroRi

DePaul Health Center

DEPAUlJ HEALTH CEUTER

~
II?

H E. It. I

24 HOUR MEOICALfSURGICAL PATIENT CARE RECORD

IIIIIIIIIIIIBIIIIU MARCH,PHILLIP H
0902200197 SALEM, NOUNER ERS
0554~Ol

10/02)1976 32Y
DPM-IOOO-D71

t'l

01/22/09

000748298
DPM-l0!

\:5 '2()J8) PAGE 3 OF 8

DePaul Medical Records/Phillip H. March

000280

24 HOUR MEnll"'AljSURGICAL PATIENT CARE RECORD


Use bolded key letter i/ inole8te4.

DATE STARTED

' r"lt

'.

"

"~"' ....., comments

in f'lUTS6S NOle$

ROIJIlds
; (CP, "OIT
_",.1.

.~~
V?
t
)

, Badrest

IV'

JSI

If''

rlJ' V

!~J
bd

I.,..
~~

"J

Wq

lW'

'A~
1----

IB-Back
I

"'..... '.'~.
(In

L-left

I:t"" Ir I-1:3

I't"'
~

H.O.B.

deoreesi

IHeels off bed


1130016
. IfilnSTer

LS

r; 5 ....::,

sse

.. _----

r-

1-<:

I;;;
1-0:::::

l> ~ -< r-

xl x2 x3 min moo 2-Asgisl

Cane

ICRutches
I m.bm-.

WI'

'M,

I a"'''UI<llIln

II # Feet. Steps) I,imbulaliofl comments IHOM Ext IRA. LA. Ill. LL AU)

IBatlY"il'lsslst GomDlte
I bed changed
11ikin care

IA

SHower

1.3
.

I-

'6

tn I [lentaVOrai
~

Denture cafe Self Assist Complete

j..::

--:

I;:~" =: :: ~:::
I f'eti/Caln care I !;Itz. bath
Self Assist Complote Sell Assist Comolete

I~ IC)

I~ilin!ls i Splims! Gast

RA, LA, ilL, LL


. . ...

I ~~oad lice Dacks It!ICPMSetlinQs I~ (:l"\'o(;u11 re-lced and on IIJJduC\(JrJll!low Ilolal hip i knee
11"'~ti""
,W.illht

Atilt

/
./
./

/'

! .......

./'

./'
~

"...,/
I'

I Calilioht J Phone in roach

.~

~::b;eLOW oostlion
ToDet ng offered
.... . ..

/'
/'

L
V'

v
v

~ L~ V //
/'
/!/

/
./

VVV

-..

~.

'/ V
v

ISide I ails:
110 hald

l2 x3 )(3 Pt. r!>Quested

K?
~,.

~:z..

~'L ....
in p!ace

~ ~..
Not applicalJle

. . , 4Y _--!. ". ,Vertffed


.

t ,-place . ./

V / 1/ / !/ / ' II( I)VX' I'l!,i""

;/

// /

/'
/

....

1 ADaruv baml
IOI~ ;_~~_>li!tus bafld. ______
iSO!allOn precauUons tland

in place
[j

o Verified and in place

o ,,,,,,,,,,, nit" in place

o Verified aMinplacp.

0 Not anniicabli:i 0 Not allDl,call1e

i 0 Verified and in piace 0 Not applicable

o Verified and If! place

ISOl4TION: 0 SOBclal contact 0 Contact 0 Neutropenlr. 0 AlrMrna 0 Drnplet 0 OTHER PRECAUTIONS! 0


p

Saf61wr~\I

0 BlftadinQ 0 ASpiration 0

S~12ure

0
TITlE!~Hlf!

INI~l~1

;I TIm / SHIfT

INITIALS I

Jt!I!!ALS I

!
-'

TITLE I SHlf~

II)' lI",I;1i;;.AICA ~,../ J..k C.i?7 f1 A/"J / ' ).r-'\.-.


'-j:.f///~~

/7

//
f.4--A.

/7

v," v.LI~ -l~.If.l'......

~SSM r
H I" A 1. H . , ARt

DePaul Health Center

PATIENT LABE

DEPal.illllllll
sALEM.I<10uNER

H CENTER

LIP

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

J.'!CH, PHU,LlP H 0554 -01 0902200~.9:. ~RS M 01/22/09 lO/02/~97~ 3~Y 000748296

DP~J1000-071

(5!2008) PAGE 4 OF 8

DePaul Medical Records/Phillip H. March

000281

r-24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD


KeY: WNls
Ia~k

DATE STARTED

241
KEY:

compieted

S2~ u"",l" "u, '"""" .. ,,. in

Nur;;!i,' N(lle~

US~

boWed key letler if indicated

,}.;1~~;t~::iCl
i.6.lerl nit.ml.,.J ~'l Follows .MMm2nrlo LOC (COmatme, Contused, LeUlargic,
~

mlllmDl_mllm~p:
I
V

:JUi!mUimJ.i~
I
I;

Apical
Abnon

Pacem
Periph'
A-Ahs WWe

i/
!

v'

Speech (Aphasic, Delayed, Slurred)

./

Moves all extreloi!ies wiIh ~qual strell\l1h


Motol response
(AboorJl1alll~on, E~tenslon,

v
/

II

ARM LEG
HAND GRIPS

,~< 1/

Flaccid. Locait:es, None.

SPastiC, Dong, Weak.


WIJ-WlllIdraw: I
_..

I~,< V/

,/' / / / / / / / ,/ /1 // /

1,,/
/

'1//1/

~,< i / // ,,/ / ./V/ ,/i1//


I/~

1/ 1/

1//il/ ,/1 ,// //


,/ ,,/

1//l/ >/ // .,,/'

// //' / /f 1./ Ii /

,:/ 1-,,>

SSlrc

/
)

j/ 1,//

iTremors

1/'1/ !// ,/'


.,,/
/.oJ

1/ 1,//

1//1//1//
/i

1,/

./f

// , / /1 ./ 1// /! // // :// //
/ / ,.1/
/

D-Oaf

Color I
WNl =
flJllV,,!';,11J!

// [// !//
//
,,/

sJon WII'
IOl(V!\
~m,

~SCALE .
a-ansk
'-Fitad

s~StuOOiS"h tmro 2mm Jmm 4mm

~SWcl1NV
CWsed

~mn'

e
6mrn

Size

// "// .// / / .,,/ l/l,/V 1/. . :/., / / / / /,/1//1/'


.,,./

i//' /,/ /,/ // /


[/" ~// /./ / / ,,../
!

1//
Salldb

Reaction

7mm

l"~: 'l

// .,/ / / /

1// /

,/

!// l//
!

,//

l//
!

l/'/

1/"

rEDS rEDS
SGDs

I f)v"nh~n'" 1---, .
L

fPr/,o.nt l!.h'Rnll

Ti!.llUfl'J

SGDs

A/L_

IPostefiof

all lObes clear

Abnormal Drealh sou nos Spetily abnormal breatll sounds 0/1 diaUfllm,
{Abgent Decmased, CRackles, Rlmnchl, Whulzes, coarse}

1m~ ~ ~~ ~ ~IIIEm~DJ Em lEa m

TIME

=
i{

m
-......
1

;(\ ~'
/POSTERIOR R

TIME 2

5,,-___

Hv '
4
--"r'..' ~,..
/

V---":;

~
~~
R

J
4

Abdon Abdorr

~
L

POSTERIOR

A6$j)lratory ~"JI \ UII'CW'MU


Atillormal resp ratory effort O),spnea (on exertion, at Resl)
.... _. __ .

(V

SowQt Bowel Abse. Last Bl


Flatus Stool

, CouUh
i

Nonproductive)

CouOh arid de~ p bre.ath ... _.. .. . Inwntive spirnneter # mll it reps
Sputum (d~scl'be amQunt tO~or.' co~s'sten~YL

"./

k'" ["./

~,.-'

I' -'

",/

1 .. / .. !"/I'
I

./

.-

OGt
./

/'

,/

,,'

"J"

/1,/"

!,./' ,"

NGlul
Bay /

~uctlon (Nas41. Oral. Trach)


Trach care o Trach type _ _ Size

TUGe I
Dston Storm

o CPAP
I

0 B PAP Settings
I

Slom.
N~tr(

Ventilator Set!illQ$: 0 CMV 0 SIMV


,1:n~,v, o~tti:.~

(verified per oroel')

Ostorr

Comments

Osrorr

.CHEST TUBES
Tlmil
LoraUlm

I'AlltN I Vlt'J;1.

! Wat&r Ssal

Su~tI(m
/'/

Crepitus

Oralnage

//

//
SSM DEPAUL HEALTH CENTER 24 HOUR MEDICAUSURGICAL PATiENT CARE RECORD
OPM-l(){)(}"()71 (S/ZOO8} PAGE 5 OF 8

0902200197 10/02/1976

~~~'~!Viki,ii'ER
3;~v 05 54-01
1'1

DEPAUL

o
tip

H ,

SALEM,MOUNER

01/22/09
0007"18298
DPM'

DePaul Medical Records/Phillip H. March

000282

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

....

-----------------------------------------------------------------~
OATESTARTfD

'1

24

A-Ab.~l!nl

W-Weak
$-511"00\] D-DOilplar
C~or

temp s( nsatlon

wm. - r,;ajI Iwa ~ "I: ""!'


r.w.I.!<i 1M" 1 "0< ~jj~
>NIl w;vm w!e1 to r s..n)."

oon III lO')(jl "'" "*,,

Droll

o
w!

IU

~"

"'\

DePaul Health Center


~~UR1atCJu..PATIENT CARE ReCORD

DePaul Medical Records/Phillip H. March

000283

24 I

A
~

Pressure UICllf

BL
8A

= 11CtSlOll = Llcllration

It ilIssure ulcer, list St~gA I, II, III,

= 8rui.e
o
"Hcm~loma
Or~jnloe T~;
Q

IV, UNstawallw
V N .- YlSCulal ulcer (v4lnous StaSIS, arterial inSlIfliCivilCY) .. Noorop3thic U!(,RI idi3heticj Wlund Oed Kay; = GranolailQll S = iilr.<luh
Q

= Ra>n
111 = T.lfIS bum WA = I'/eU appro;jmated

D Oenu1!ed EO E,yUI!IIrtU EX ~ EKconalion

'" ather _ _ _ __ Drllinllg1 Amllllllt:


ac "SC<1Il1 $ Smail M =Mvw, ..!v L - Largs ~ = Co~iqus

"

DruslRg:
I:l

sa = Sk,; sbij.,~
- DerflUtlimtl
~ SI~p1n

SurroUnding Skin Key: I - Inta,1


It ~ Erfjl"~lIll M . MacEr~ll()O C CY"lIJtirlOark 0 ~ OIhu

lr' \ { M - M91l!~~Y Wilill ~ - clum 1---"'1'""----,-----..----..-----. .._-.:\.~'-L:o~..::=:..'U:U:'1'~==;=:.....-----------~O~-== rP.hM Mired l'lUlrfl)UiildiflUI [IraIAaqe AmoUJII 01 Odor l"di~all6 R~~'~~"mtn! Dl'lulnll Wound 1 Trntmslll Tlmv lliluNlI; ~l.Il\'WUind No Ctrange Time and Inilis.ls ('S1aqe) Bed Typt [lralnllll6 "( I N

llfI.) ) I ' \ I

I, . f

\ : I

rrr"

-,

j { i I

I
j

'

~"I\

~Fn...

= E~th3r
= !.~M,

S
BS

: -.,~ I !,

OTA - Opan 10 air 0 R " Re1Bfltlon iUtulE5 CI nry an~ JnlaDI

PU ~ Purul~r,t "tiIoMy V '/e!',(lW

= Gf6~.n = SelOtJ's = ~pm"""iJ'w~,)iJS

!llJwmJ:
1 emfsll
~

2 Ctr1J!O l;:rrvuc

Gml<

4 lW3!t:

~SSM " e

A L T H C A A. ,.,.

DePaul Health Center

DEPAUl, HE ltLTH C!SN'rER

/118111

24 HOUR MEDICALfSURGICAl PATIENT CARE RECORD


DPM10(1)-071 (512008) PAGE 7 OF 6

0902200197 10/02/1976

MARCH I

PH~!~I~.'.II w
32
RS
M

r/p
01/22/09

o .. ,
DPM,11

0554-01 000748298

SALEM, MOUNER -Y

DePaul Medical Records/Phillip H. March

000284

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

DATE

SCORE (Circle score in each area and total.)


Mol_lure
Constantly moist Very rnoisl

/JIEfIIGAL RmOl! lor RUf/tlnl


\ rroteet an arlJhrml a'4WUY i'I:f~Y~;\ f!f,,'JM'ofl'i;:'1t3f myqp;.,tltlOl:"""I& {nt-tr n!,lfS-eS ita-\1OIl SlJ~O&l
tI~/1JP-f1 r~.->f'f?f>'

fit q 10

maml',. e'to!(acn,e\fVacn~~l \I!~osl


<ill! Iig'<i
J~:

Ilntrtln! &1v;tlWr O'J-CUfrtf;ilt tinw ~r...Q ~{i'le I'''' puent $~OlJ${', I!H' '!
i
1

ma! BI!,u. !ty


~!I

1Jr..tltl! Iv r.l.l'1llt ..'ni !fir Mtft,

MamtEtrl /lTy,j,'i-;c hllt.l,~;"~ l\!hf.;-, ~9t.f..Jl.lv"tJ In !h;5 u&atmt'o! Of tM ptttN'S' r;vrrent roMnfll{,Q, SO!/..! sr,Hni~ ul !~'illiflifilJ
me4t'~blin ar:fl1iS!rabotl 01 nvQrav~nJ

I '" 1~.iCOli)n C"nfl<iiC Itt! lCliowI'9


wittl
~..a-tntf
R.~'~";{1I! h"1) (t:f.!IJ,'tlt

CvITI 10 0"' 1IlJQes. IrnlS,

e1C

!tij.'llS (hsclJS-&-j

Aattity f}<:JWYI~bMfJ,
M"'~t~o

(L'i~ rof fRtIl;Uf)'

10 lWIO\'e ~jnsilm. $11'",,,,,

ef.;

Ao;s:t'...smmll

Iflif. kllf~h

3 Safe.rv vl
6 Ut'i'&'SfiJl16 actl'ftly (b!c;;mIJS. '.1JeM. Vra.!1s. f!1l,.l-SU.!. ~tt i

Oif~rn\~ hilt i.t-Jf ~lf..1f"'1L~.1if'J1 fn};ll

an AIWj 0,- S-4..rg:-i1;a!


It-lye f...tf.-t:-;',fJYF:

Tli'l~

ltiease fre(}Jencv

Ctmp$j a11.11 100 fat1ra!M fifJln{t't~

ClOC-.!d'iJle 1'w11o. wo-uid suffer tu;thrr !.ltllify illjlt1

I Pritl1\lf~m'YWmll\l!l

i1lDwn;:n1 ("ltCf, rt is ,ne<1ic8tl _"a~ (e.q ..'1rorri~

4 O~1 reQweo for "~\1ii

Oillaffill leil 0' o~" (see 80M"""!


Ra-iJtti~ll1.)

lfact."s U1 vaSCltM ~"r9<flH) ~ P7Qlvet I.e tUiII "'Iary pall,rn from iU'!i1er injmy (e ~ eVA wi;' P3Illysil <,f M;;C lfJurna with aMffiGl1Ii1"jOI~ll

0 &EIiA~IORAL R~31RAfNTS: ilM nUlon,1 ftow<M<l1for


'<~"',",,I"IIrn.

7 Olhfl i(e~L;(tS "{frai1'''' GlW<IT>ernaliooj H P'e'.!:,,-d ttMt to ftfmOOr ioo!O;at6-S reUM tri.>!

"""Wr""lJ"'"

~SSM
~

i A l. T K t A 1\ ,-

DePaul Health Center

24 HOUR MEDICAUSURGICAL PATIENT CARE RECORD


OPM100 ),,071 (5/2008} PAGE 6 OF 6

DePaul Medical Records/Phillip H. March

000285

GICAL PATIENT CARE RECORD


SCALE KEY: 0 Bed 0 Standing 0 W/Chair 0 Sling

24 H

(Plllil>8 recondlB weillht difference if greater than 2.5 kg.1

lima
Raung Sc

Seale UU
OOUMII
Fvn~lIgn

D'nrl~9:

lll'JIlion, BebllvinT
Ilua!lly
Fr6qu8l1~~ ~lIravall

BEHAVI
AN -An: t ~ E>;,Q 1- inetf-e

12 h! lQt~1

olaV\vb~

De,,;

INTERV
1. Rean
2
~

r1<!";,e
GW,!a.

4 Coiii,
5 ""iahl
B, EI1U)U

7. tOC.UU

12 hr lotal parenreral

FLUID EOUlIIAlENlS: 1 oz ... . .. 30rqL

4 OZ (1/2 CUP). . 120mL 6 Ul (3(4 cup}. . 1 BOmL

DEPAUL HEALTH CBN~ER


Z4 HOUR MEOICAWSURGICAL PATIENT CARE RECORD
DPM-l000-o71 (5J:WOO) PAGE 1 OF 6

MARCH, PHILLIP H . riP 09QZ2001 97 ERS 055 4 -01 10/ 02 /19'76 32Y r4 01/.22/..r~ '~'UNER OOOI48~9B SALEM,l')v

1IIIIItlI1IIIIIIIO

DPM-10Q(

DePaul Medical Records/Phillip H. March

000286

24 HOUR MEDICAl/SURGICAL PATIENT CARE RECO~R~D=--_~oAT~E::'.!.:slA:!.!.!RT~Jf}~tf==-7-:=_O==09'=l

24

APP .. AsSUlli pain presenl

'r!Sfrt
Dei":

+.s
+

Behaviors

Time
Rallnv Scort Ii
S~Il18 Ut!d 01

Inw!
Oate

+ 51
Insert
~alR

O~1Y80on

I fu Rcllon lioal i'


D:ll$tflbe:

FRO

RT
Loctlion.
Behavior or APf'
Q~alily
frvqVfn~y

Aggrantlng fiClOrt

SedaJil/n Ulvol

Inlsrvenflonlsl
lniffllq

BEHAVIOR I PSYCHOLOGICAL
BEHAVIOR/RESPONSES:
flit ~,>\!.Jlhp!e:

R101 l"t'~N

U = UnrU90n.'''G

co HDP

CllnfWJP.-..d!OhO(l..eTIt"d

O~

" (I,>Nl>lwe

& ~ 51eelling

AN"' An'J(ll15
E = EmO!;O",,1 Diwes-;

C - OJntIflUOUE Cry"'tI DE - OeP1U!;lOfi


G _ G"""ing

CO .. Com.lI1!)Sa
CI == C..ognitiVR tmp.Rtfme-nt fit = R~t{Bmi o - O1t:l"blil'w..tl.:1iurVOvP,I-eactwe
Off~

Ha!lu(;iah.i.u.nr~.v

Oeh..t'3km5

SignikMl Ott""
T - Th,e~le"'f19 PhY' "'~! Hartn/CQl'noati'te
1M ... Impl.Jlsl'r'e

a = GiUm!O\.llel
COP:: Cf.NI(mr,,!lve> LoA - lss AOXHlU!i O\h$,

I IneHectl,.. Cvl"f19
o
=

W - D.hb", atafy Wi!hlmhlinfj tnlo A - AttiJ".'"'1tOn ~-ea~ing


~

Oe.-lI?fopmen:at Impannent

L - Lelhetgic

INTERVf NTIOnS:
t
3

--------------------------fr.e.q;Jent Mer c-ontaei 10

O<srupt<ve Pab9n!

Rea'S"St. rance- Pat:ent t Sigmtcanl Dlllel


L'ot~isfnnl

R<:rlin>cUo"
Glm.J.'1f'CC

'l.

FrrnrCl:flrneof j flo-vtloc

~. E!IIaBlI&I1 milillii"mil time/r.,,1e. lor til'. ft, Enco-ura--g& veb3.Ii.3Jinn 7 tocouraoe pa n~rn Wfth OOcmlf.Jfl m<lki"~ for

""ed.
cate r,e-e-(it

"L Heollejj(! Rrl:mQt;v"l1f f Aest8finy facts 1:' Orva-rfitonal.ic'{;vil.inr. 16, Pn~a-t.hve O1ras\..ile~ 11 P,nvlrie reiaxatjDTl with rnvs{{;, Ima\,liry. doop brE-athh~1J' pmyE'l. !T'2.dlc--dtkhl 17 Rea$~'H! "'~~Y.~'!9~~ ! ~f}~1h c.t~Jfifj991fGfi 12. EnccumUf! normal.s!eeo C',-..:;le by usino indiroict tHJhting aftel d",k 18 Estilly,ith b-ounOa-n~5 1:J_ Uark&fl fOom I Limitlrlg tmmh J i g Pm'>.'i.J:':Ie fntel'l~ive s.ecurity i1ld 'Sataty o"'.tJ'a~'..Jlti\i Ql,nel $lQil to d&cleasl;: patienf's response tQ ltmUiAttOl'l !\1 minimize behifv.oral pfCblems
Provide- b"\JO!mStionto lr<:r&$6e: le\'i)1 0' undtJHtlduiinq

FnCDurege family to br1nQ in famllfar Obj6'C1t.

fYl:;SSM. DePaul Health Center


H f .. t T
}oj . ': "

R E

DEPAUL HEAI,TH CENTEl{


24 HC'UR MEDICAL/SURGICAL PATIENT CARE RECORD

111111111111110 MARCH,PHILLIP H

~ "
rip

..

0902200197 ERS 0554-01 10/02/1976 32Y M 01/22/09 SALEM,MQUNER 000718298

DPM-l000-071 ()/2000) PAGE 2 OF 8

DPMl0(

DePaul Medical Records/Phillip H. March

000287

24 HOUR MEDICAL/SURGICAL PATJENT CARE RECORD

JAN 2 5

'.

241

BACK
RT

<')

S1 ;:;

!1fl;!)tP lJ)men

Lt> I

(1
i;<\

Dt - Vrobffl ~tJ/jrtlf

nc = frliJitl''''>e1I
IMitalt IoC~1l)I1 cJ

0 SLI DUTLe

SLi DLITlC
R T

'I ["IN h1ftr rli}'''~''fi

!liGHT
p

I(

Insertion Date Arm circulllhmmcl!

Lenglh _ _ cm em

DressioQ change !liil!!

PATIENT lABE"L

~SSM
M l A L. t lit' '
~

/, tI t

DePaul Health Center

DEPAUL HEALTH CENTER


t;!.ARCH, PH!LLIP H

1IIIIIIlflliliDI
ERS 0554-01
M

I/'P
24
01/22/09
0007~8298

24 HOUR MEDICAL/SURGICAL. PATIENT CARE RECORD

0902200197 SALEM,MOUNER

10/02/1976 32Y
15l2OOa) PAGE 3 OF 8

D?M 1000-

DePaul Medical Records/Phillip H. March

000288


~SSM e.
)o!

A I. T H

'A

,-

DePaul Health Center

24 HOUR MEDICAL/SURGICAl PATIENT CARE RECORD

000289

DPM-1{XJO-or (5/2008) PAGE 4 OF 8

DePaul Medical Records/Phillip H. March

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD


PftEV I0US 24 liD; IntaKe Ynf.rday's wI. _ _ _ KG

JAN 2 4 2009
DATE STARTED

, I

24t-1

Output ____ SCALI: KEY; 0 Bed 0 Standing 0 W/C"air Cl Sling T~4ay'$ wt. KG (Plea$$ reClInl.lilll weigh1 ditferenl.le If grealerlhan 2.5 kg.)

~DI.-.q~_II.~ra
. Pvise
Rasp

.f::>

'I
~/

~1

J '}

~x
}

i8P
02 ~a!

9h
l:rl:~~
i

0h

/' ~/1///

~/

l// /1 .~ / /1,,/' / / 1// /1 ~ ~/ ..,/ / / 1/ / / / / qJ: ~ 91


Kif

bl~

..!., J

Timt
RIling S;

._-02 ooiivenng deviee 1---Oedside glutose

02% !Rale

I~'

ill
J>ULSE

"

Bti/eUil
011"1"1811
Fu~ct!OB

!~181

AESP

Bf

!OzJATi

n~

TfMP

RES!'

Sf'

D2 SiT

/"

//
//

~Diet-;; ,"M",U\I<: <0<""'11 IfF"


,taken

~;
//

//
L~N';H

I~ tiC?
DINNER

OIllHO

T1M~

II'

TIME

/ ../'
,,/
nt1 ,V"

... //
./ ,,/

l'

Ouc;rJl)a:
LooatlDn,

BehavIor
lIuality

,f~Lklruej{ I()~!!~ c.. ')'tuIt- !

'''''''''"
IVPB

/)

i8NACK

IV

{
mOl
, mlR..

/~O
URItIE

r 1.1.1'1

.c::
VOID

A.

,.1'./
~

()1pgjlt

ffEDIKGS

TYPE
il70fl OSOC
090n

ORAL

If

FUI8H

.I!t

Sedation
11T!8rv~nl

10IJO

Initials
IiJrTrt1 -It:

1100

not)

M..

noo
1400
150D

1(1:'0

29;)
/

\J~A

V. I
aEHAV

~1800
;,"'.:'
12 hr SUb TOlalS - - - - - -~-----12 hr tolal ofa\ituOt _ _ 12 hr shift intakA I 12 lir total PllrHniellil

XI
~t..i;:L

__ . ____
12 hr ~l!ift oulpul

t~i)
I
""'--'"

~~.~(

E - En-, 1= iniff'

--

iJ _ Oev

1900 21100 ?100

INTER.
.11. lL :j\ ~!V

4/1fJ I v

\.

R~~~

~I

2. Redin
J. Gut:)! 4 Co~1 5. E$IRI:>

22M

-}::~
01DO
I
I

6. F,,,,,,,

i)-f.)

7. Etl!..l"l1.

~~:
040C
_~~OO
SubTotals

>1UU
1)0
~

(teDO 12hr

_______

.~
. ,hll( i

'1~f.-1
r'/~--

111

12 hr total parenteral

_ 1? hr IOt.1i oraVlube

---= tl

- - - -

~---

I~~V

12 nr sfillt OUlpUt

T';'.".,,-.y., " total


FUIID EQI)IV~LENTS: 1 Ol .... 30 nL

LW()

4 oz (1/2 cup) .. 120mL


6 liZ (3/4 GUp) . . 180rnt

8 Ol (i cup) . .. .. . 240mL

'""~'"J''U'''
PATIENT LABEL

iIUIlrUllllt

I fA-':' I~

12 oz (soda -1 can) .. 360ml

~SSM
HEALT" CAtRC

DePaul Health Center

DEPAUL HEALTH CENTER

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD


D?M-WOOWl (512008) PAGE 1 OF 6

rip MARCH,PHILLiP H 0:102200197 ERS 0554-01 10/02/1976 32Y N 01/22/09 000748298 SALEr>1, MOUNER
D?Ml00

IIRIHIIIR11111tillill

DePaul Medical Records/Phillip H. March

000290

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

.!AN 2 4 2009 i42 .


DAlE STARTE,.O~-=======;

Aching

:J~~!!~~j Cg C"lImpin~ ~ Crushing


APP", Assume
~,~tn

Faces

Duming
DUll Gnawing

SA

S~ep.

eilSY to arou,e

1 Medication

17 Epidural
18 peA

t Awake and alef!

:2

vesem

Rssl

Betlal/i)IS

Hcavy
Pressure

2 S~htl'J Of1)Wsy, a~sy In ~rouse 3 FroquentlY dIVWSY, amusable, eyes drift closeQ during (XIIlVtlfSilliun (conEldar rellucln; oplol4 don)

3 4 Relaxation

Amb\ll~liun A6Posi~0Il

t 9 Prr.-cmpUve
analgesia

5 Calming S\aiem~nh
G Prayar/li.1!ditallnn 7 Spmrua! Care

11 Deep Bn.:alpjllg

20 Connnuous anal9!lSic ~lf\1$iOI1 2' Ol1\ar'

Tim8

S~'e

Usell vr

Obaemtlion
Functilll Goal #
Ol$crlh: Locallo I, BeltaviH or APP
QusJ1ty

Ffequellcy

Setlaliun level
Inlent IIIMls}
lp~il!s

BEHAVIOR f PSYCHOLOGICAL
BEHAV10R!R~SPONSES:

M; ,.1u"'plo Roqt.'I>sj
C ~ COnllflll{llJS (,'Yfl()
DE ;:::: f)-r:PWfll'if.lltt
G

AN - ,\r,,<iOl1~
i ... Eno\JonallJ4-stres;i I - Int: tfoct!'fe Copmg

co" C.ofll"lot;"
CI -

Unrrn;[lrv"'iv",
Co-~ostlY-a !rn.pa;rmEmt

CD - (JonIUE1>OfUlOOn&nfaa H ~ HshJon.I'JI151 DelUsfJfl5

05 -

Cwupwe
6ignnlcanlO\!la1

S = Slel>PinQ
Q GillmlQI,inl

= GntfV1fllJ R - H~Uttij5 A ;;: Atlentio.'l ~-e-e-kmO HrumlComhnii'i~: LA - LeW"d,HJI;IOU-6f-0_=_D'N __ elOpm __e_n_l"'__lm~p_a-I"_n~_n_l__~_=_L_"'_rta._,O_ .... __ _ _ _ _ O_~_Qy_.,__'b_mu_.'lated!Ovefe~:.. ~:::::t<':.:'~_...:D:::!'_-::..:Di::S~I\J:P:::tl</:::E..:p:.a=lie~-n~1_ _ _--.:IM::..:~:..:ln::tF=u"":.::'ff=___ _ _...:::U:'he:':,.,::;:=:::::====_l
INTEIWNTIONS;
1 Hal lji'8jJra.nCi P~tl9nl I S~nifjc-2.nt -~r
Roe<'loct~

W - OeH}era-tei'(\VithhO!(1ifl.g tn1c

T = ThreateninQ Phyrkal

COP

~ Gunpe~ali\'e

GUljance
Esobtfsn ms.in1Rined t;mefmmf7~ fm
f;\"Vt:

~f)

11
p-t!eli~

12

Em otlf'Elge "nrh",!iTalinn 7 En( mm'rr~ ~llhenl 'nith .atKf5!On makmg tOT ca."e n&ed-e:

13. O~k$n ty"m I Wm-itmg i--o~h t QI.Hit i"i"gn tv (1i'1&$$-e- pe.tienl's 11?SpOnSe to !;:(imul;lfinn

Of1er frf.l!Ql.a?nt hrifll cnnJani Providn infnrmab...lo to Increase level QI1Jm:::~H;tj.l1rJlnQ Ell{~UUH:iye laJ"(liiy to tHing Hl famcbtlf G-~~Ch Pro-vIde reil)c,a110n wrth OlUSH:i, ImI1l'981y, d~ b:(-eat"m-f~1, pf3'ler, me,oit:tation EOnvu.r"1I0 rtfl1'llli ~"P cycl. by V51n~ i"tJir~l ~gh\lnil ~I!l>r <lMk

14

Recnent (fiem-'Jlr(~1t'
Diverl~on-e.l ~}... Il!e:-s

n~'Mttlllg facts

15 15 17
HI

Proact-Ne measJJrE'-S Rp.a9~ie6S f Req.fG-stio-n I

S~dl d;l1lfl{~alIOH

13 J:'m'5!;Liii; fiiilimimiHr.
Pruvidl1 !(lhmSlVB wcunty an-d ~afety meaSvre-s,
'0 mu'tlrntla t}ehavlQ-fal problems

~SSM
M Ii l. l. t H 1; . . . . '"-

DePaul Health Center

DEPAUL HEALTH CENTER


MARCH, P!-iILLIP H

IIIDnIIlIlIlIUIl.I~

riP

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

0902200197 ERS 0554-01 10/02/1976 32Y M 01/22/09 000749299 SALEM, t'lOUNER

DPM 1000-071 (5/2008) PAGE 2 OF 8

DePaul Medical Records/Phillip H. March

000291

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD


IV ACCESS

Abs~nce 01 I1ilJ1WS5.

DATE STARTED

JAN: 2 4 200S

pain, drainage, swelling. l/lakilGB of noid and appropriarely secured,

= See adtJitional C<lmmell\S In Nurses' Notss

MY ~~r it irl'Ji~le~, ~ = TubillQ Chllll1l60 0 - Dmsfilna r.lW1il6G tatll sft. dt"umlnt; Lonatl~n Code I Type ot Fluids and Rate I SL=Sallne Look

On'g. Date

o 0 ~c-~L~;~~::::: I---+S-'l=}=DL=='==T=LCC+---==
P R

V
~

x
_ _ __

Inserlmn Dale _ _ _ _ LengttJ _ _ em Arm circuJlIfeHlllC8


em

Dressing chang8 date

Cal
OVl

Bel
Te>l

Sid

!Q.;
~

ON
Iso

IS[

OT

PATIENT LABEL

DPI

DePaul Medical Records/Phillip H. March

000292

- - -...

---------DATE STARTED'

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD


Use balded key letter Kirnjfcated.
r.

JAN 2 .4 2009
<l Q
< -~
....

c,

,Ari."

. #1 Nurses' Notes

-"'l-L~fI

>Ie?, SNT iritlals)


Bedretil . Independent
Posili(lfling; R-Right

~
g

11
~

Itt-'

11'
5

IH.O.B, (in dtllTaasj IHaelsofl be(J .. IChaJr DamNS lise


~ ""'~'" assist ~ SBA ,xl x2 )(3 .mill mod
HI~siSl Z-fl~~iSl
I

IB-Sack

~~lltl'Prone

.n \J\

....

IvY

IIlV _. IV"

J"Kb

~ ([\~~("[\h

t'
5

f
~

1/r~

/tf

/
4-

-';>

'5

r-

,/'
-'

,.... ,,-. {

lV

Y ..--

~.
t I

fS

15

1.5

.5

S.

'3

AlllbulaUon(leViee

-~~

...

Caml

FEllt, stepS)

....

LA. HL. LL All) l:!l.IllIDtlm 5Kowtlf


[",
"nn.

S,/

ISkin care
n.

.;

I::~""
I I

: Peri/Cillo cart Sell Assist CompletA ' Sltz o2th Se(t Assist Complete Slings f SpHl1ts I Cast HI" LA, Ill. It .
!

:; ::: ~:::
.
. IWeigh! .
i

Dsntufa cue Self ASsist Complete

.s.:
~

5'

! !

.'\

~
,
- r--

K-pad I Ice packS

1"_
,ff

l:I CPM ~,fittinQS

.....

Rt I Lt.
I

re-iced and on
.lIow "'-"-""

ITola! tiP
IT, .

IGali Iighll PIlOIH; in reach


I~HJ"'U ,qUI':

,
;'

...
/

/
r

./

/
~

within reach

.'"'

. 1/

i-1
i"

Bed locksrll ToileUfl!l oiered

..'II

'"
i-Z

./

""

","'"

~ilS;. X2 x3 x3 P1. requested

!~l
~ "",

,;1...
in place

V,Z

Vz..,v

X~ :,....-

r:

<

,/ /
~.

'/ /' /
./

[Xtv

~band

!~ifiedllm i in place

tb

~
-

IAilergy Ilalld
!

o \lArifi~Ji ,nil in place


o Verified and in place 0 Not a~e

DNR code status band

o Verified and in place o Verified and in place


o Ventlad and in place

Cl No! appliGdtJle

IIsolation n"'~'''rti,,",

band
co~tacl

o Verified and in place 0 Nol HJlPlicllbie

0 Nol applicable

lSOLATIOII: 0 Special

0 Contact 0 Neutropenic 0 Airborne 0 Droplet 0

OTIiER PHECAUTIONS: 0 SBielyJFaIl 0 Bleeding 0 Asplra"on 0 Seilure 0

INiTIALS I

. / TITLE I SHIfT

INITIALS!

:/TITLE I SHIFT

INITIALS /

i.!ITLEJ SHIFT

----':K ~q~i".J {$J

0'1 ~ \ '"'
~

)GtJt.Qh~ 6

JJA III::N' LAlil::L

01!lJt)SSM DePaul Health Center


}lEAlfWc.\RE

DEPAUL HEALTH CENTER r"lARCH, PHILLTP H


O~O2200197

1IDIllfIIIII1IOIIBI

;!4 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

1/1'

ERS 0554 ~Ol 10/02/1976 32Y t-1 01/22/09

SALEM , W~lUNER
OPM10(lO-071 (512008) PAGE 4 Or 8
r

0OO74R298

DePaul Medical Records/Phillip H. March

000293

124
I",

HOUR MEDICAWSURGICAl PATIENT CARE RECORD


WNCa or i."~
"mnnl~j~1

rHl
DATE STARTED

21 2009
Api
Abi
PHI

K~

,<> w

PI NUises' Noles

Use ooi(/ed key leiter il nnlicaled

~ Aliii't. O~filijd 12.


Follows comman<ls. contused, Lelllargic, I LOC
~"VY

l1~~J:I~~~[lEm_mllJ_mlBl j Iv l/ II
U

~~~J:%J[firm

,V'V

ISpa6th (A~haslc, Delayed, Slurred) IMoves all elptreml1les with equal strenglll
Motor resp( nse , ARM (Abnonnal flexion. Extension,

l/
Iv'
1/

r=
/'

Iv
/

Pel

A
W

Flaccid, Localizes. None, SPastiC, Strong. WeJK


wa-WrthdI3WS)
~ Tremors

LEG

GRIPS
PUPil SCAl.E
S-SlulI9ish

HAND i~/{

i;/( 1/
1/
1;/1/
'L

i,~ L Ii 1./'

V
1/
!

1/
:
<'

1/
Ii
./

L/ 1/ 1//
1/

1 ../
/
I

1// 1//
il/'

.,/
1/

1/ 1/
i/i

1/ 1/ [/ 1,/ 1// 1// 1/ 1// j/ 1/ i / / V


/1
,//

1/ If

II 1//1//1// 1.// 1// 1,//1//


/

sI:

/; / I'

1/ 1/ 1/ 1/ / 1/ l/ l//1//v//
l'// ",/' ,/'

1/

1/ 1/ 1/ 1/ \// 1//1/' 1/

1//

D-

Co
IVIi

,oN
.!all

lion

B-6Ii'lo.

101m 2mm 3ilm, 'fmlll

.
11m", 7m",

Ffir.ed

CSwoten/ CloSt''' ,min

ee

Size

1//

t." / / 1/" ;/'

Reaction

i/i. ,"" i.'

111

1// 1// Iv/ !/' 1.,/ 1//L/' t./' ,,/ 1// le/ l/ V/ / l./1/ t/i1//1/ l/ 1,,/ 1,,/ 1,,// 1/,/l/ 1/' I~// 1// l// l.. . 1//
,//
//

Sa

/ v''''

TE TE

IDysptlagia lPresem. Absenl)


INumbness, Tingling
I ~, ..b' oJ",,,

SC

II

n,/~"'"''''

Abnormal b'eath sounds

TIME

f!J I ~ tim EmIII~ ~ ~ ~m


5

SC

;3 t; ~

Specify abn)nnai brealfl sounds on diagram.

(Absent. D:creased. CRackles.


Rhonchi,
Wheel~s,

Coarse)

,(\fr L---~ ~~'


~-----.
L

TIME

~-"---"""-l
R

Ii

'~P' 9'
V----'"
l
"u;:"t:tt'\.'

= = =
Ab

~~ <l
R

Ab
80 Bo

POSTERIOR

IRespiratory effort I1l1lahorAri


Abnormal rt!spiratory effort Dyspnea {(}1 ExertIOn_ at Rest)

1/
I I
I

..;

At
La:
H~

1/,,,,,,...
y~.

ICough and deep breath


Incentive Sllirometer # mL / # reps
~,/

, Sti

o
1'/ ~,/ f,-' f'/

k"

~,/

k/ 1,'-' ~,/ ~,/ [0/ k"

~.,/

\ .. / k l.' l./ lr/ If

If f'

f'

k-"

III(
B,

ISputum (dliSCllhe amount, color,


I t:iiif.liiiii INu.l, Oral. Trath)
Trach cafe

fu
OE

o '!tach type _ _ _ Size


o CPA?
~]

BIPAP Senings

SI SI
N

...... ~.w, "'w .....\t


Comments

0 CMV 0 SIMV
'ord~r)

IVenlliator setting I'O;:!:OU v

Os 0,

liNt)1 rutltl:l

Tim.}

lOGalion

!Wal.r Seal

Suction

"l>'

Crepitu&

Drainage

.
I I

. PATlfNT LABfl.
CE.N'l'~R

DEPAlTL HEALTH

,,/
/

110111I1111111II.,li HARCH,PHTLLI? H

r!p

.. /

SSM DEPAUL HEALTH CENTER 24 HOUR MEOICAUSURGICAL PATIENT CARE RECORD


DPMl0001171 (5i2008) PAGE 5 OF B

0902200197 ERS 0554-01 10/02/1976 32Y IYl 01/22/09 SALEt-1,1-10UNER 000748298


OP

DePaul Medical Records/Phillip H. March

000294

HOUR MEDICAUSURGICAl PATIENT CARE RECORD

DATE STARTED

24

-H~
Fo1ey insert

Peripheral pulses
A-Absent
W-W~ak

S-StrolllJ

~bruir~

Fre~Jj(;y.i

I)-Doppler
Cotor temp sensation
1'.1'"
~

Gal (desertl

lieu eQildiJ~

IW bi pii!~.: <"I'

r#M illS thJJl ~ !~Qfldl

S'JPfil P'Jb~

Roo til tomn L'tr<ne


abii~flW

Drahage (v

in nob N",IV

B '"

T ,. flacc

1 " 1+

JJundiCf
Di~elk

Mucwlme
SldnlrPi:t,
!'.eel PfllCle

o Ar.r.u:ml o Othtr
W1)\IIIO vac

ill
o Pump used

Tlm8

~$~M.

DePaul Health Center

DEPAPL HEALTH CENTER MARCH/PHILLIP H


0902200197 ERS

IIOUIIIIIIIIIIIIIII
055~-Ql

lip
01/22/09
00074 B290

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

lO/02/1976 32Y '::.r...LEN,I'40mlER

1'1

DPMiooo-o71 (51.:008) PAGE 6 OF

OPM100

DePaul Medical Records/Phillip H. March

000295

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

DATE STARTED . . '

f ~ III

? L1

':':-:"~~
L, ,

24

Skin

RIa~ S~re:

18 Dr 181a. patient ISlItrllk

o Follow SIrIn Clire Prolm:ol (or score of 18 or /e3s.


o NutJitionJl Cl)nsu/l (if not pm1lJ1Jsty Qbtiill~d.)

ALTBiED SKINJWDUHD KEY: PU = Pr8Sstlr~ uJr.6r * II pressure ulcer. list Stage . II. fII. IV, UNSIJge<lore

V
H

- Vascular ulw {venous stasis. artertal


11l5ufflciellcv}

- NeurOJ)athic ulcer (alallelic)


WQUll~

EX
H
SurrDundln~

..

.L DR
D

R TB '" Tape wm WA = WJj :lPProxim~lf.ri o '"' OUler _ _ _ __

Oruning;
lOa '" 5Ie,; ~"i;"

n
5
DI

= Siaule<;

oennat>on.j

OTA - Open 10 a~ fI = R~I""U~"i w(v'~'i

G Gral'.ilaliuu 51 - SlOugh E E,drd! o - Olher

= =

iJed Kev;

Skin Key: Drainage Tyjl~

D ra lnJge Amount:

I = illl.cI E - EfYll1em.

M ::;:

Ma~~"ah\.!fI
Cy~wot!C:O~fl'

G = Gr~~" SO - &e,m! I 59ro"; II Sm.lf S 8 = SerQS~ngunlW\JO M = Motrerate

=
0

= Ory.;rd ,"Mr!
Monl~Qmery
~

C ::::
=

PU

PI/flilAnl
i~iIiJ",

~ (.lD)1l

DIm,

B y

= Bloody
5

- Co;lIoV$

'"

,nils

G -

UIIW

o = Other

Cru~ty

! II~ Clt~noe Time amllnlllal,

!n~!~'w~

R~!m!m@n!

~SSM
HE" L 1 H C It. fl

e"

DePaul Health Center


PAGE 7 OF

c ".
DPM

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD


DPM-1000-()71
(~/2008)

DePaul Medical Records/Phillip H. March

000296

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

Cornp\uloly immobile Very limited


4 Slightly limited

Nutrition Very poor


Probal>ly

Frl~IrJn

& ShVIIT

Probll>m

POIBnlial

adilquata

Adequate
E"cellenl

prOOll1m No .'Ipparsnl
problem .3

SH:in Risk SCOTS! leslIlttllll 16 paUlin! 18 III (tak o Foliow $kto GJlfi Pru!O>~nI for score !es:; than , & (pOS1 /lfotocoi at OOoSII;'7)

Nolimililtk""

Nutritional CllHS1.dt (.1 n01 prevloH;;ly (!bta/ned ) Score

--------"'---+--1

--+--+----1

nScore of 3 or greater Indlcat9 possible FIlI1 Risk. If nursing judgment differs from scant obtained. document reason oode from !1st below:

o 1'1111 PrlOYflnllon Informallon


.\iheet revlaw.dfrelnforwd

o Fall risk bracele! In piau

~uont9[

BRiM'nl

fIg.bala! Educt!IM
C"lCIlIlWItllilr.. lild IoJlntI. i.LI pt.

1 l'ro!<ct

"'Biotalo iMctiaw<liM<arjt,<l illi>t>'


r.tri,-ftIVnenU!
Cli!~'ll.U;,j
ma~...on~

'0'" \#<:i;\! ""N.Y an!lio< Oc<ygM C~~'W'I \q .. I,)


cml)I~

(nNf nusSe>. staHoo

!~-;..tJ

Mllinti'li,) IHvasa !;i;nt5 Oi' 11.1te.s esst"ntiaJ to It\.c hl;3bljN~ rtf th"t;

panf<\\S'

c""nt... !l<Q,. stle s~"'Ct of nWiiion,

,HMlIt/{Ml\lJJlf\
~nontvilu".k"

meCiVltl!]n atlminhiufi-Ull m h}'dfdtro-m

1 Rf:a:;nn tor r6S1f~ 2 A~;Sli1OOl tt.1\it tfUrnlS

'''T6 d!s,"$,f/J "Hh tWM"

par!!>!. Sll'mr. vi<; l t }It\: e--iil..'CttiOii i>J)1 ir\d;attt:; fi,lffrMfHJ

J@I8MR1 (,ry 1 UMble \Q Cir.C1 It< saloly


7 fml, ID WI aI tu~\, tint!. e1~ AIlvIW i1#nCfis1.mte~ fffik oj r8~y
Nfffll\(IDJ Ii> rt'Wlr <!It!~1.

W'.uc>, "'"

IlmliiOMl KI!\;"ty (l)lclouiJ., ,idff , wall<S. llIl.'<i<:. dc, I


f1j,!tI\I"~ew-Alilm

lib<! \>I!I$>.1!ti<in .la:ver.-~ ,rolUS"O !ler.


I)!lu'

3 Salcty oJ tblliMt. "t,) on in>.ptOOU !rom 211 'ijIHY nr 51i1r-cal 3 TrtlJ ",1,,.,,,, Itffflancy pr()"..oo\lf~ woo ..'oul<l wnw hlflMl !lIu<y Dilley haw U'''OS~'<1! ileJ\l~jj)f reQ'J'cr! '1)1 lMvemuil bitm IT is n'"",""', ",~lt (t,g. tlCfrtmhv Iraduret Dr 'i1IstUal slIfqeliesJ .0 8fliAVIORAL RSTllAINTS, ~ PI_I \/;~ m.io !nlUIY (I,II''''lI trom I<Ji'th lnio/y (e~,. eVA 'IIiIh ~...ddlliMa! flowSllee1 !W ll~iS 01 11:"" lr.IUIT1il wiU, .'l!1<I1!i<maI IDjufl1!S) '11.'lll"in,_nt,w

too;>-erathtc
6
P~laiflt'l

~1JId Ie.,>::;lialn tiJ'liilfed

,,,,,,",,1

mhltm j<) ~t <)f Ol1l,rl Is'" Sd",Wtlf.ll

7 IJlhfj (rtquifn nartalrJt Coc\l!llCflcali""1 N r~cea noJ<! Itt "lI1me' irnl1t<1lw r~a!Q/l
~'~--'-''3!lel101cd

CI4?.)SSM DePaul Health Center


MIALTlI
[#",,,,1:

DEPAUL HEALTH CENTER l!P t4ARCH, PHILLIP 1'1 O~02200197 ERS 0554-0110/02/1976 3~'i M ol/Z2/o~
Shl.-Sf-1, tvl0UNER

11111111111111111

24 HOUR MEDICAL/SURGICAL. PATIENT CARE RECORD

:iDI'M-1~71

000748298

(5J2003) PAOlO 8 OF B

DePaul Medical Records/Phillip H. March

000297

24 HOUR
Ye$terclllY', wi.

I\n ....

II(

~AI l~lIRGICAL
Outour.

PATIENT CARE RECORD

PREVIOUS 241,0: Intake

f-

~~~
~ r~
tlP
(l~

KG Today',

rI

fJ . KG

SCALE KEY: 0 Bed 0 Standing 0 'II/Chair 0 Sling (Plme ret:oncile wtigbllHlfartflce II greater than 2.5 kg.)

IResp,
I---

\~ F:? ~ 1,// 1/' 1/

.A

'ft'

sal

C ~
~

fJ2"t.[Hatc

P-t
Resp
SF

tL~ 1// I/)t t;H hA'/ -, 1//1/' 1// 1//L>l~(~~// 1//1/' c~

..- \-1'(

DATE STARTED

j 2009 JAN i. "

24 I

' 'C'9

,r.J\

IO? r.eIl.llflIlg aWOl


t Redside qlucosc

~
I

1/1.// / 1/1/l2
FvnCliGI

11m
1--

nM~

l1:MP , PULSE

Iat SAT

nME

TEMP

I'lIlSf

RiSI'

III'

IOl

t-----

I
I

~/ //
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12 hr

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p~ttr Sub Ta1al~

121u tot~1 parenlera

-=- _

12111 1o1al UlavWl.I~ _

J-ti U ,~~ .{
nlJ
"'~'''r'1YW'

--

,lor shltt "l!U~O


"uul

I -I.e "h V - - - - -

. _ - - -12-slHlt -uulpU(
i"

Ii

UV

fLUID fOUIVALE,rrs:

401 (1/2 cup) .,. 120ml

10z ..... , 30mL

Ii m (3/4 cup) ... 1SOmL

lOUltl B 02 (1 cup) ....... 240mL 12 oz (~Dda-1 can) .. 360ml

'ft,,.,my"uu r lIIIur lolal


~I\

nr;M7 I

~Rl:J

DEPAUL. HEALTH CENTER

C4JC;SSM DePaul Health Center


lit t: It L f i t ,

A II; .-

HARCB, PHILLIP H 0902200197 BRoS 05'14-01

llillDflIIIIDfillftUII
I"

r!p

24 HOUR MEDICALJSURGICAL PATIENT CARE RECORD


DPM-l000071 (51200(1) PAGE 1 OF B

10/02/1976 32Y
SAT,Ej\1, MOUNER

01/22/09 OClO74ti298
Df'M-l00

DePaul Medical Records/Phillip H. March

000298

p3L~ IFe$eot Behavi,rs

lima
Raling Sr.or~
Observaton
/I

Scale Us-Hl or
FuacUOR Goal Ii
!)n~rlbe:

llIcatio1l,
Beh!vilH Qr

Qliailly Frequ8DI: I

3~dalion

.eJ1:1

BEHAVIOR I PSYCHOLOGICAL
BEHAVIOR/RESPONSES: AN - Am.1Du> Ii ~ EmO'lOflalUmUess I - '"a/f~AlY'i; Copmg o a Oeve-Jopmentallmpairmffit
R,,'lllOo' C - CoolltlUOuS CIY'1\j DE - D"IF~~'on
Q - GJ!8\'ing l letharg'BG

~ Mulh~'"

~ Ul1Te9p""'I,~

CO =Cum.tMe
CI ~ G<J<Jn~im Imra-wmant 1'1- Resli>iS&

CtI ~ Conlu8W1Dioo.ienled H " lIatluelnationti ()~lUsiQn& w ~ Oelibe,alely WiJhh?lding Info


/I.

os -

Olsr\'ptive

s~ Plly""""

S1etpmg

Si!l,,;f.mnl 01"",
T - nua"{fliflY 1M - ImPUI"''''
j

o - O.,.er~11t'f)u!aled!Oittr~a(jiv(:

=MentiOn Se<!k:mg

HarrrutJombalwe

Q ; CaimJOui~\ COP - Grope,alive LA =< l {Y.}:S AnXlOUS


0.1",.
f~t$

",. - OlSfuptlve ?alient

INTERVl:N110NS;
2 3

1 Rl'iIHII'i\fl<;e - t'.\Jan! I ::Il\lnih",,, ,I o.lll'! nedir&;l(On


G''';(!frio~

6
!}
j

Offer freCfJe-nt brief cont.a:-et ProvlOO Into,malll'" to i"Crease ,&Vel of IJn(f~.st>Ad1f19

Rem,,,,,1 / n~mO\lv"t.1 Re.Ilwr'9


DW'.;m;ional
Pffh.,.r,tiy{'
~OiNiti&3
m~aSUfe-9

1~
1ft

n E'lW'JIUI'lP. iafTlll'lIO Dr,,,," In familiar oiljecfs

4 Cons:!t tent E-rr':"oflment.' R~l.*"Q

., ~ijmi,;l1,1i malf\laIMalJiMI,W>\e. for car. ne~d, B Enc.:nu (lOr. v"am<1hZ-fHlcn


7 Encuu a~ fhl'h~nl
'Hidl n~n"Sif;m

ITlRkmg to.( cart

""""i

1!J

tj Pm \<, ml.",tion Vl~h mu.II;, lm~gfff, d~ep txealhir>9. pra'iiL mroca!;oll 12. EnootHa&'e IJUfltlfl; ulrnp cyde by using lrvj~tllOhllno- a'l'1e-r Cark lJarken mom Ila-rminy k. 1./dl / Qll~t &.fgn ~o d-~faa6o patiflnl's (\;;'&PUfI:;if! tn ~timHJilfion

17. Rf'.a~tnSti I Rr.quruJMn f See-\! c.iaritC'.I1it)r'! 1l:l. EstabflSh Luutkladm;

l!/.

PrQ-vi~

lntensiv-s secunh' .tIld H::.tlnly

rnr:n~~p.s

to mm!ffia~ b~avlQHtf PfoblttrnB

~SSM
Ii' E' A L T H t~

II 11-

DePaul Health Center


DEP.r...UL l-lEALTH CENTER

24 HOUR MEDICALISURGICAL PATIENT CARE RECORD

MARCH,PHILLTP H

IIllHllllllflllllll1II

Tip

0902200197 ERS D554-01 10/02/1976 321' r4 01/22/09 000748298 SALEf.1,MOUNER


DPM- tOO(}-071 (S{2000) PAGE g OF 8

DePaul Medical Records/Phillip H. March

000299

HOUR MEDICAl/SURGICAL PATIENT CARE RECORD

w
R
_ _ _ _ Langlh _ _ ell!

- ...

---~

... ---------~-----

~SSM e
'H ! A \ f H
A lilt

e'"

DePaul Health Center


I

24 HOUR MEDICAL./SlIRQICAl PATIENT CARE RECORD

DPM\f 00-071 (5/2008) PAGE 3 OF' 6

DePaul Medical Records/Phillip H. March

000300

24 HOUR MEDIl"!AI
Use blllded key leJter " iOOICatell

1~IIRGICAl

PATIENT CARE RECORD


II
II

VAIl;

IIIKltV

JAN 2 q 2009 - "


,(U '.// ~

See additlOna,",im",""to
t. ..
I

'''~,~v" NOle,

IRUllllfl3
i

Rdunds (GP. SNT Inillals)


/

'lJ VI

B&jresl . Independent Po';i1iolllng; It-Right Heft IIBack SSelf PProlle i H.O,B, (In dSgr1!6S)

LV '/II [VV L'''' ,\ V1

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x1

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.X? x3 min mod ____


device walker Cane
WE' I.th

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/

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1

Arq!mlaoon SeN 1Assist Z.Assisl


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Self Assist Complete SHower

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Self ASSist Complete
Sell Assist Complete
i.P"!

Skirt care

fTJI f)"nhlln",1

CI
Hail care

Self Assist Cornplate IShava IPeniCath car~ Self Assist Complete Sell Assist Complete ISIlz oatil ISlings! Splints t Cast RA, LALRltLl

...?'h
i
i

f.I Crvocuff re-l'Ald and on I_"~ "",ow '" p"" ITotal hip i knee Plecaullons
'Tr3.:tlon . . . WA!nht

cpr" Setlin!)s

FIt! LL

/
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reach

.Ov~rbec tabla within reach BetJlocted j low position


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./

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....-..
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I

o Verified and in place

0 Not applicable

Iso!atiOr precautions band

o Ven'tiert and in piac6 ....

tJ Verified and in piacB 0 NOl appilc.1~

ISOLATION: 0 Special Gont3r,j 0 Contllct 0 Nf.utmpenic 0 Airborne 0 Droplet 0 OTHER PRECAUTIONS: 0 SalHfyffali 0
INITIA~1 BlH~!lin!l

0 Aspiration 0 SHlzurH 0
I

./ TITLE I SHIFT

,lNRlftLS

TJT1J:V IiIllfJ

/tNITIALS/

JITLE/SHIFT

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I'/."Y/I./);, ",171~

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UA A M. J.I tf \d ( v ..... .......

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DePaul Health Center

""let

DBPAUL .HEALy.
0902200197 10 /02/ ~976

~!AR~H, l?HILL I.I?

ENr JIIIIllIIl1rIlIIII P,R H lIE

3i~S

lip

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

SALE!>l,MOUNER

0554 01 M OJ/2.?/09 000748298

DPM-j'JOo-071 (S/ZOOS) PAGE 4 OF 8

30
DePaul Medical Records/Phillip H. March 000301

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

,JAN, J 2009
DAlE STARTED

24

Peri

A-P W-1

'-S
(AbnonnallieKion, Extension, FlaccId, LOl:altzes, Nonp" Gok
\VIR

p-c
reiil!,
<lUn '

SPastic;, 51rong, W~IIk, WD-W'ilhdfllws)

tioot
~bn1)

Abnormal bn:ath sounds

TIME

Specify abnmTlal tneath sounds on dIagram, (Abserlt, Decreased, CRackles.

Rhoncnl, Wheazes, Coarssj

POSTERIOR

POSTERIOR

Abnormal re:;plratory eflDrt (}yspnea (on Ixeruall, at Res!)

o
"

DEPAUL HE}:>.LTH CENTER


~CH, PHILLIP H

1111111111111111
M

0902200197
1

HEALTH CENTER 24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD


SSM DEPAUL
D?M,1000-071 (5/2Ow"8) PAGE 5 OF B

0 I n 2/1 9 7 6 32 y

ERS 055~-~~

I! P

0 0..1 .. ~ / 0 9,

GALEM,MOONER

000748298
DPM,

DePaul Medical Records/Phillip H. March

000302

DATE STARTED

241-l

--

A-Absent

W,W&af<
S-S1rong

D-Doppler

Color Wnp sansltlOI1


v.a fJ,;r 0.11 0*:
~ I$$$!l!i~

:'p

3 SOCOiId.: tat warm ",'lh ~ s:en'J.-J


li:Jl1!l1rnr)1 !)!!C;1n
~l'tr,IJ.iS:

II = NCl'e T = fraee 1 = I-t-

11 skin w

TIme

~SSM
tt C'" J L

-r

CAR

C"

DePaul Health Center

DEPAUL HEALTH CENTER

r'!!~!~~~RD!IIID

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

TIP 0902200197 ERS 0554-01 10/02/1976 32Y M 01/22/09 SALRt-l, MOUNER 000748290

w. ,

DPM-100Q.{)71 [512008) PAGE \1 OF 6

DePaul Medical Records/Phillip H. March

000303

JAN ) 3 "LOOS
1 -

DATE STARTED

24 t

At.lHQIHI<II wioary Vllidino Ilatu:rn; InWlIin~IlL Frequencv, Retl1ntion, Urgency, DywrJa

If skin II>1\ll aJ!erah lOS iJ1,:licalB siles willl

nU~$

00 f'QUTes

ALTEIltD SKUI,lWOUNO KEY: PU = f're:;:;ull! ul(:", If preswre ulcer, liSt s~ I, II. In,

1\
11ft

BL = Blister
D E
EX

=AbraSion
Denuded - Erylilctlla

= BIUlsi;' = ~xcotiatinn

L
R

= InCiSIon = Laceration
=

Rash

IV, UNstageabla
v
H
= \I~scular

vlcer (VQIlOUS ,ta~"s,

altNi~1

= ileurQjlillhlC ulcc' (C1ab'~Uc)


Q "

Insutfldency)

TD - Tape bum WA - Well appfUxiHmle<J o = OthP.r


IJflIift~e Amu un!: IiC "SGaI\l

'" HClllllwma

SS
D

1,1f1-)

[fr.,,!
i

= Dr"'Mbotlll - Staples OTA = (li'l1' 10 ai, o R = Rlity,,{lOO SU!u;~S


s
DI

!lreHino: Sten slti~

WOUlId Bed K~I': Granulatkm


~ Olh~'

lkItroundlnll $iin Key; Draill,1Oe Type; I - In!aL! Q - Green


E = EfyO~,'I," '" - Myoel~n01\ C '" Cyaootic![mk
S
liS

S : SlouQit E - ESCMr

= SelO(Js

= SMOSJ!1(Jl1,nsOlit

S
M

=Mor.tltalA
~ L.,~

Sm,ll

,I!,

U
TimB

o - om~r

= DIY ami inlacl = Mr'!1\gllf%fY ~~J~

o = OIhAt

PU ~ Puruleni ~ Rlnnrty

L C

CD!>""'

o Yrntmllflt

Y - '18lww C - "!ij;ly
O1I1"J
In~lea!al

Reamn,m1snt

H D Ckan~e TIme aru! 'Jllllal1

MtmIJJ
1 COI<1C

2 OWi
0: tm-i,f(
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5 M,,'1il

6
7 g

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P,~ip..

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Rel(lmd

~SSM

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DePaul Health Center

DEPAUL HEALTH CENTER MARCH, PHILLIP H


0902200197
10/02/1976 32Y

IIIIIIIIIIIIIOIIIIID

01
III>
O?M-l

" t .

24 HOUR MEDICAl/SURGICAL PATIENT CARE RECORD


DPM-1000-071 {5/2008} PAGE 7 OF 8

ERS 0554-01 M Qlln/o9 SALEM,MQUNER 000748298

DePaul Medical Records/Phillip H. March

000304

HOUR MEDICAl/SURGICAL PATIENT CARE RECORD

DATE

STARTEJAN L ~ 2009

Potential

prablM1

:>

No apparent 4 I prOblem 3

:"'",,+I-(}-r---t---+--j possible Fan Risk. If nursing judgment


differs from ~Ie ob1ained. document
IBason corle from Ilt below:

. ~"1f=~~~-l tt800m af S Dr gl'Gatar indiMiGfl

PtJSO EOllcatJor every 24' + pm

Uied 10 Avoltt /\e1l'RIM


C~n"Jns!lctMp~",~",
~

MEP'C!L Bruen fqr RtiWtinl I Pro~;:{'l an ~tif\C.jal iUWi.l'{ ilfal"W' O'ft'get1 !JcnltWV !e.g:.~ to
m$r~"t\

BJUJlW fUuFftU9!t
Q~..H1Y~1'::j 1m;; ..mi 1r.. ,rMf VZllfHl. >pot"". ole.)

Ida! RoJ,a! K,
(I ~

fA,

I iJn!lllla tQ CqntranlQf

~allty

\)",,,, ('( otb";nBIe I>o!til""",, fO' Ut.....1 r'ffi! I", iV, IU\c I
f-mln.lll.li~JqJ 1H'1niJ-~j~~bun" <<!Ii~Qhl.

IMolTatNeWlCUtllvlleS)

IIl:t:f.lJ rJljf'1t;':Il!.atil]o.

S~.{Xill

et<)
;iljl.-~q

R1;?ity(\"'J11~(jOl

2 f<.tllfi;J:n l'I'taSfi('"!r.es or ttlttr.s e-S~llb311!i It!e- tl'~.a!frwrn (l'fllw {llli"'" CW1t1( ,t\'lll~on (I.g . 10'.< S!laC1 c! J\lI!riMn. mea.tgtlOo a(lmln;S!BIioo OIl1fll'a~1)II1
SRf-d't u1 Pflknts will) GoT ~n;:8fac{atcd fm:n. an lruL1:l)' or shl!fc"i!l
p'~~4",e \I'M w00l4 lu"er 'I,l/t~ loy! II !!Ity naYe elteSSIV! {J\(t'ffiltn1 belCle i\ " meq,'~ll'i iliPlwn<.tt fe,g., Mil/lilt;

( ) " e<lb'C~tlo. 1>0< iMlc.tes lO'lO-AAf\{!

corn

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a1 tubeS. tr~s, eft

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fi~V".jn

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tilt fW(3<nt

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ate

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AS5c.eSStn$\l !.lfHf. !flm~.5 Tli,if tt,k.bt !lI;!QiJ~IV,:y


Bchl1Y~f JE'UiWed flY r~no'(af

COO:p>Jrah'ic Uf'ti restraJ"<t lel1"tO'le'IJ

\A\'8fSt-maJ ach,

~IJ!''lr.'''Juh.~. 'o'lt1ffl)!" h"j~.}~ !iNf.ic. ttlt;

~ai>;nVlomjy '" ocalJW

Of IIwn IQ .<It Cl C!trerS (100 !lell>lWil.' f\<;"IO!!1i'1


c'lt::et ffW'.JH85 l'ldffiltwe dGcumerMboJI)

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4

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PUlIJS~

from tUfth!f fnlUfY

it Q

C 8fHAVIOAAl RESTRAiNTS,
(V,t,l.

'Hltl'l

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fIOWltl?,e\ tOt

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nUmWf

Mf,<des

ftiiSl}!l

.dd;.iGr.lllfiUMS,

~SSM
Ki;"LTH
';"R~

DePaul Health Center

DEPAUL HEALTH CENTER


1/1' MARCH, PHILLIP H 0902200191 ERS 0554"01 lO/02/1976 32Y 1-1 01/22/ 09 SALEM,1-10tn-lER ()0074B298

1IIIIIIIlUIIIIIIDft

24 HOUR MEDICAlJSURGICAL PATIENT CARE RECORD


OPM-1000-0n (512008) PAGE 8 OF 8

DePaul Medical Records/Phillip H. March

000305

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

DATE STARTED

1/t-1.) [J 1

24 H

Time

Rallng s( SCalt U"


ObUf'IB!
~edsiOe

glucose

ftll\~tiOn

nNE

TEf41'

I'UlSI

1181'

81'

02~AT

TI~

TEMP

PULSI

RE~P

8P

:::;

/ /
I
L)Ul~1h

[~SATI ORTtlO IllME SlAnC gp

ITIME
p
lIP P

O\!J(lOOtl;

0--

//

//

LocatlOll,:
Behav,tm"

!!!~
,.: taken

/"/
~~E~KfA!!.

MHIJ1~r-q

.......

//
I
UIltNE

HCL
iii 9
DINNER

_//

~
HS SNACK

Quallly FrellUIIIC

LJ
....U\I

TYPE

liPS

ORAL

"V"" ,~..""'....
T1'

'HER
8M
lIe3allon

flUSH

VOlt)

0800

'"'ervent
IllfUahi

C90tl
~ __ ~_~_+ ____~/~O~i[~)~_~__~____~~~__ _ ~, J-..:l~40{)-+-_ _ -+'---------1i--_-!-\.).......-,-'{r)"--h_'if/-f1Lf-t.l-l----__ ..1500 .. _ -+----t---\-:;-o;:-r:~l-=(...A\'---'-''-t''-+---_-+_ _+-_-+-__ _ 1600 1;.....\( '\
1008 1100 ;~~

' '\l1J

1800
12 hr Sub Mills

BEHAV
AN - Ai'
E~{;l(){

fntlfE

D. De'.'

'900 2000

INTER'4
1.~1

2. R9illl;!

1100
1200 2300
010 02110

W"-I( )

3.
4.

G,ikll
Co-n~;:i

5. Etlan
Q_ ~nGO'

i. !:n'OI

0400
0500

IJ / 1'I'V II , I ---4---~i--~~)~~V~--_+--~~U~~-A~/~__ 1

0600

-.

---12 msMrOUlpuf
TwnenlY-IlIllr ho~lolill

- I- -...,.-0 U
~

I I I () 0
\

fW1D EQUIVALElrTS;

4 Ol (1/2 cup) , . , 120mL

1 02 , , , , ' , 3(lmL

6 ox (3/4 C\lPJ .... 18{)rnL

8 oz (1 cop) _, . , " ,240ml 12 Ol (s{)dlll can) , 360mL

DEPAUL HB:ALTH CENTER


W\RCH, !?HILLIP Ii

os ..
"

~SSM

H l A l 'f H . ( A " Ii-

DePaul Health Center

1011.'111111110111110
ERS U554-01
M

IIP
01/~2/09
OOO-!482'1B

0902200197

24 HOUR MEDICAUSURGICAL PATIENT CARE RECORD


DPM-l000-071 {!.!2000} PAGE 1 Of" a

10/02/1976 321' SAl,EM, MQUNER

DePaul Medical Records/Phillip H. March

000306

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

DATE STARTED

1 MedicJ.tiQn 2 AmbulilliQn

8 HB<l1

17 Epidmal

10 ~Id

f8 peA

3 Reposition

11 Music
12 Touch 13 IIIIU!J'lfY 14 Massage
, & OiSfr,1cti(l11

19 Preemptive
,1nal1l~J

APP'.

ASSltma pain Ilf6;8111

4 f\ol;,l)(ation 5 Ca\rni~ Statements I> Prny~r/MRdit~ticm


7 Spiritual Cale & Deep BreathinQ

20

CUllljmlUus

Bcllawurs

::u Other'

analgesic Infusion

HI Education

Time
Haling Sec fe #

8cale Used 0'


Obt8Mfluo

FuncUlln GQ~I #

Ouclios:
lOt31iM,
B~hpYiQr

or AI'P

StdallOll hve! Inlervention!$!

8El1AVIORjRI!SPONSI!S:

M -

MUil!p~ >l~ueSl

U == unrespOnsfv&

CD - Conluse!liVisone,.,;d

os In!c>
1M

Di+ruPliV1>

s -

5Ie"pjn~

AN", Am 0:'1;

e=

Ernulhma.l

D~;llH-.'i'l"i

C - Contm<iOU~ Crring DE ~ D,II~WC"


G ..
r..r4~",i,":g

CO - Comatose
CJ .. COQni'ir~i' Impuifmenl R = Re3~e5.'

H "" Halklcmallcmi OelVSl0l15

w=

!l;gn1f.cwl Olh~[
T = Thr{1&t(l'nlng Pnv-sk'al HEI:!m/C-omooH'r'e:=

o~n""re.'e''I WI!l>l>ol<!ln,~

Q i i CalmlO'MI COP = CooperaliYe


LA =(}fhr.-r

~ m~!lethCapng

Q - Vfl'l'~i Jpm1i.phtllmp~Hment

L - '..emarQ'('

o - Ovelsti-mt~ruoof-o;e:reocliye
Uff6f {la-quem
bn~l

A = Attention s...l<ing OP .. rr.Sf"'Plt~ P.n1<p.nt

le~"J An:tiQVS

!fT\p~t~ve

! ~.

INTERVE NTIONS: ~:~:~Il~~e. ?al>en{! ~:HV!ljb(-dnl o~rltH


10 11

contact

14

H~OMn\ i

ftamo1lVat. t R&Si~l'-<9 I'Cl~


f.>~ek

PrOlflO& ;nf-O-~lI<ahon 10 ;ncr~Me ~'1-et of

l.1nOen:tanOIfl9

;S. Oo"'an~e

4, Ccn-s-iYent En\'-irOM,ent f Rout!:ne S E)litblil,h rnwn!~ih~ I\me/rari\til IOi t~~ n~to; 6. EIlOOUHge Ye,t>1!li,,,,ion
7
FnOUl.ff~"l

1(>
13

EnoouraQ6 famlf't 10 wing in familiar objec~5 Provide relaxation .,nit 11\\1$"" im~~ry< d~~p b,eaihmq, prayer. mMicat",n Ei\6bi;;ge MifiitJ SiMP eyCle liy u!Wig IN!ifeCl ~ghfJijg fi~'j ,lfiik
Darn-an room i LlmHing 1CU{fll Oil~nt !;jun In ti'!l!fl~m pallnrlfH' r~~'lOnl{H hl ~;l.lI'nLilalJ(}Jl

1!J, tt; 17 1ij 1(1

Ol\teisicnat act\\iIttes

neassea, / neqvestQf' ! E.l.o 1i IiooMi\iI8

Pro-actNe Illeitsvr-es

!jo-ilication

pil1ienf with cWci-a;iOn milking fnr cnTn nnr:rls

Pr{llJldQ imen:!1lvo ~1}('.urny ~nrt ~nlcly mOO$~t'r.~ Iv HlU!IHI4-TH ut!lla\tiUfHI J-l,uillems

'.i 'j

~SSM
11 E Ai t T '" . ,

A R I'"

DePaul Health Center


DEPAUL HEALTH CENTER MARCH,PHILLIP ~
090220019<{

Z4 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

111111111111116 54-01
ERS

11 p

sALl{H. I>'lOUN1!:R
OPM100)-()71 (512000) PAce 2 OF a

lo/02/19~6 32Y

~S 01/22/09
Q00148298

DePaul Medical Records/Phillip H. March

000307

sc

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

24

OIsg.
Oat~

+ SIlo #3
I1\smo
DM~~

",l)} ~\.. -iOC~W_kIn~-oI. J-R_I!1_HT-, S_L


" I l-_fmJi_CilI_f

BACK

8ACK

_{ D .... L_'_TLC--l_ _ _---L_SL_I_D_L_'T_L.,.;:C-L-_ _ _..I..W _ _ _-I

I.J VU~,

.,

\\\

\~, \

WNlWIeDfDWd.d

T ___ V

In:;ertioll' Date _ _ _ _ Length _ _ em

Dressing change datll _ _ _ __

Arm circumference

em

PATIENT LABEL

~SSM
H E __ l - H G
R

f"

DePaul Health Center

;!4 HOUR MEOICALISURGICAL. PATIENT CARE RECORD

~J!I~~~~"~~ll'1
0902200197
10/02/1976 32Y

DEPAUL HEALTH CENTER


ERS 0554-01
I/ P

M ul/n /09

SALEM, MOUNER
DPM-l000-071 (512006) PAGE 3 OF 6

000'148298
DI

DePaul Medical Records/Phillip H. March

000308

~SSM
H I< l T ... ~

A R

~.

DePaul Health Center

DEPAUL HEALTH CENTER


~~CHfPHILL1P

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

H lip 0902200197 ERS OS~401 10/02/1976 32Y M 01/22/09


SALEM, MOUNER
OOQ7482~e

II I 1110111111 Imil IUml

DPM-1fOO-071 (512006) PAGE 4 OF 8

DePaul Medical Records/Phillip H. March

000309

~4 HOUR MEDICALISURGICAL PATIE~~.:!RE.~~:ORD


I

DATE STARTED

2.!

I,

Ap
Ab
Pal

Pel

A W'
5'

D
Co
WN f;!i
~ld~

ti"lfl
aM

Sa
TE
TE

SC

se

Abnormal b'ealh sounds

TIME

Specijy abnormal brea1h soon(/s on dia9[am.


(Absent, D ~croaSed,
CRac~jes,

Rhonchi. wheezes, Coarse)


~b

Abi
POSTERIOR

80 60 At

Lal
Fla

SI(

Nt
B!

Ttl
Os SI(

511
NI

Oll
Os

DBPAUL HEALTH CENTER


~~CH,PHrLLJP H lip 09 02200197 "'RS 0554 -01 10/02/1976 3 ~2v Sl\LEM,/I1UUNBR. M Ul/22/09 0007482;18
DPI

1111111111111111111

SSM DEPAUL HEALTH CENTER 24 HOUR MEOICAUSURGICAL PATI~NT CARE RECORD


DPM' 000-( 7'1 (5/2000) PAGE 5 OF 8

DePaul Medical Records/Phillip H. March

000310

HOUR MEDICAl/SURGICAL PATIENT CARE RECORD

DATE STARTED

241
lI1l!ec

lmlli
Urine c ,ouI-S)
Yll1dr\

SWfiI
Foie'y U

Abilolf
FrMuf
Cal (dl

Color temp seIHa\foo


WNl - /Iill toed pirl;; C;\lJ ~-l ~iS tMn" 3 j!}t ~~jll.t. stiIt...rot mfllull'ln..-

Ullal!i1.lI.O'.1cril'1
a'D~II\II'IIlct6,.

8 = NOlIe T = Trace

TIn

~SSM
M &: A
~ j

ti

A II IE"

DePaul Health Center

DEPAUL HEALTH CENTER


I'IARCH I PHILLIP H

IlIlIUlIlIlIllIUlflllR
ERS 0554-01

rip
0007<18298

0902200197
BALm,!, fIlOUNER

10/02/1976 32Y
24 tlOUR MEDICAWSURGICAL PATIENT CARE RECORD

M 01/22/09

o
I

DPM10Q0.071 (512008) PAGE e OF 8

DPM

DePaul Medical Records/Phillip H. March

000311

L4_L_/~"IL RGICAL PATIENT CARE RECORD


..

DATE STARTED

FA
Ani

Hi\!
AlII

An. An' Alt. ~~


Dla
13\11

pal
YE>~

Ant
Bel
~LTERO

SKUf!W{)UNO kEY:
~wssur~

A
BL

pu- Pressure ulcer


11
V
~ ~

ulcc!.

~st ~\a,-e

I, It. III,
ar\eriai

IV, UNmgAilhlA Vasculat ulcer (v~nQU, imiufficiflncy)

SR D

sl;,!si~,

E
EX

= E"(t0fl31iOr.
= Hematoma

= 8li~ter = Bruise = f}enljd~rJ = E[)'f.1ema

A!Jr,lSIOf\

I
L

= IncIS"'''

R = Rash TB Tape hum WA = W~II aPliro~imHt.d

= L~r.9r~tinn

Allf

'" Other _ _ _ __
!JrlljnU\J~

Neumllillhic ulcer (di.b\!!ic)

f } \ , \ff-t ! i i
t,..:'

I):~
~)

nrl
'
i, "

DI1I~no: liS = SIan 5lrips

D
B

=Dernubood
ll"tenllQf' MUles .. Ory arnl ill!act
Mqnlll.~nllry

o = BfiUMJatmn
S = SlOugh E ~ i':'1..f'.n;:u

WDUlld !fEd Ite,(;

Surrounflao Skin Key; Oraiaag:e Type:


I = Inloct E - Erymema M = Ma(;erati(HJ

=lIUpI."
=

sc G = GmfJl $ $ - Sero\Il S . . . SNos:t.HQtHneous M


PU .. f>tIruiern B ~ 8!ouJy y = VilIlcw L C

Amuunt:

&-;JI)i

5m3Ji
~

Modc-ra\c

OTA=~to~r

0 - 0\I1e<

II DI

C - C\'a!101icJDari; Or Olh"r

- LalQE

;; Cwkl!JS

Wilil'

Other

o
T'Dlllmanl

G '" CruSl'j
~.

Olher

Flu

Time

Alt./Vd W d 1,1111 Nt!. UllllWeun6 DlGttm~ oun

(TSU9')

lied

IQ;ulYOullcllng IV

Odor

YIN

Indkates

Rmni~!!1'n!

Toi

No ChanlJe TIme an41nitlal,

~ \ (

2 (
~

! ,

4 I 5 r
6 i

7 I 8 , 9 ,
Fh.<i!

~SSM
If E .. I.- ,.

t4

C- A 1\ i

DePaul Health Center

DEPAUL HRALTH CENTER


I"lARCH I PHTLLIP H IlP 09022001517 ERS 05::''4-01 10/02/1976 32Y f'l 01/22/09 SALEM I MOUNEK 000748296

IlllJIUllllflilDlJl1lI

24 HOUR MEDlCAUSVRGICAl PATIENT CARE RECORD


DPM" 1000-071 {5/200B) PAGE 7 OF 8

DP

DePaul Medical Records/Phillip H. March

000312

Skin AllSk .ijCOff<: 10.810 then 16 pllt!iIf}tl61lt risk Follow ~Kin Care Prmocol tor score I<!~; than 16. (Pust p,otocOl at CW,\oo.j NutllllOn31 conSlAt (if no! pr8vinus!y obtaln~d.j SCQr~

,...J;:;:::"'-+-":;;:'"'--oi HSOOftJ of 3 or greater indicat88


- - l - - - f - - - l po~lble Fall Risk. If nursing judgmarrt
~~------~--f..--l--+--4~--l

o fall Pr$vllBlIon information


III,et revl~wedllalnfQn;lXt

dlffers from score oblalnvQ. oocument -f---!----+--l----i reason code from fit;! below:

n Fall rIsk bractllelln placo

~J.lnf It Avgli RnlrJlnl 1 ~nonsMI'i$..,p~c,isi<m


C~rr~'vTW,t(JlJ;crw'lIj~lP"-tIJ1

Jr.",,,,,,, ..JItol fl""'~1i""~,


Ctlill1/,l. en:)
~.~! fjr!

,"""-'Io<fl. ItfllG.) VIR.v lHIr"as ">IUi. SIlI!cta!

'100" 6'1'90 l2! RHUlin! Ptotett u amffti9l a-lTway a-lldiur U.Kygf,'lI tkWi/j.lJ (e Q' to m.i"lain ~OOov;u:ha..'IlmI!alI!liIle~)
Maiillih IlWiWlIm.. "' lul,,'" """"".~ to Ii.. Ir"arm'" OlIn. pali~ ClJ(rn! cOOdiIi<ln Ie,} .. s~~ source 01 nu!,""!!.
rm<litallOn
a&n<lISV~ll'Jn ! n1Qml~)

Rmlmia' EducaJloo

mat BeJel" Ko,


1
UnilhJ~

DocumllflltinlCilfl'a""fIl' {i". pl..


(laIent ~OllSe. e\I;)

hI f:rmhar.t too sat;t'"!

\) in ed\KlI~{)fll)oJ; i~icales IQl1owi.oi


ltffi"n.\ dis.-rus56d ...... !#i !ell'Mt,
I Rr';;\WJi fru ut<;1f3-.ifd" '2 Assessment wne ft.W~~i

Z
3: 4

~\. to

pul a1 loOtl. ~ .."

~t,.

Artivil)' {~Il(ltM;d&;; f~ ~ ffi:llJiJri


Atwl~

10 rffi'lCHe ~res~1, stmlf." ck

-rt'?;Ju;*inn

Ur~"~M;tl a(Jr~-gy

{b.xn..t-s. wltos. waL~s. mu~~. de.}

Safety of p~tkJ'fii woo arc 1rn-.f.{J\wltrded IIMl an ii~Jlr'i or SUCij%li pro;;ell\!l~ ~1\(l WIl'Jld S\lfWf tu!l>1'1 inil'ry illhc,/I.JVf, ."',,;;"',.

J Tria! rtl.ase Irr;'!ucIl<Y


4
eell~',*

rj)a{l~iatl\-"B 2fid r~stn.int f6ffi{ive-o

reqwtd for femQwl

Of Mrm to setf Of o-lhe(o; {s.ct' BuoaV"tvr,li


Re;;lnil~')

P_'dfllily'<loc~iGf'

m<lI'M'.enl t~lIIe tt ~ mmaiy awoprtalB t~ .. ewerrvty


~

a IW flir,JilI!S;w ~lee,~t.'>eit'elt.t"1 be~ 9 ____________________


~~:

____

~a""m; III ,,,scular SlJrI"",a&) .\ ~f(itCltl;e trw ,"jUry pJl;t,llllom filI1li<I


jl.1falr<is '" Il8aO ItAIlIllJ

W IOf\S\l'lWn

!t~rtltan

"iPv 1M. eVA wlUI ".11\ Jddil~nZ1 ~Mlu)

0 nH~VIORAl A[STRAINU: ~.. '<l<l'",",iI""''Sh,'' 1o.

OUr,! (feqLil1ls namtN~ dl)<lJmcrlrrt;VIl)


N Pi;l<~f,-d
llP1J

to flUmtiw !l1OltatfS ttasOfl


"",i

~SSM
1'1

E A L. T tt .

I; ,.,

fi E"

DePaul Health Center

DEPfl.UL HEfl.LTH CENTER


MARCH,PHILLIP H
09022Q0197

IIIIIIIDIIIOIIIIIII
ERS 0554"01
f>1

lip
Ol/:J~/09

24 HOUfi MEOICALJSURGICAL PATIENT CARE RECOfiD


DPMl(QO.071 (5/;:>008) PAGE B OF B

10/02/1976 32Y SALElvl, MOUl'lER

000748299

DePaul Medical Records/Phillip H. March

000313

DePaul Health Center 12303 DEPAUL DR, BRIDGETON, MO 63044 Tue Jan 27, 2009 05:47 am

Di9Chal'ge Cumulative Trend Report from 01/22/09 0300 to 01/23/09 1045


'ent Name; {'. Rec If: Dis Date Phys-Selvice:
p

MARCH/PHILLIP H 000148298 01/26/09 S~LEMJMO[rnER EMERGENCY

Ad~~

HEMATOLOGY-Page 1 01/22/09

903693 903572 917259 BLOOD CELL COUNT/DIFFERENTIAL


Result~

Platelet

Hgb

I
I I
Ii

Het

RBC

t1CV

; Low Refer: High Ref:


01/23/09 1045 01/22/09 0300

Unit~

lQOO/mmJ
130.0
400.0

gm/<J.l
13.0

1
39.0 54.0

lOXQ
4.7

t:l
80.0 99.0

211 282

18.0 I 6.1 I I --~------------------------------------------------I 13.4 14.0 40.6 41.5

4.77
4.96

i I

B5,1 83.7

BLOOD CELL COUNT/DIFFERENT!AL,

uui~!~:
01/23/09 10451
01/22/09 03001

~t~;
.J~

Low Refer: 25.0 High Ref: I 31.0 _____________________


28.1 28.2

32.0 11.5 I 4.5 I 36.0 14.5 I 11.0 ______________________________ _________________________

;~7~1

I
I I

RD~ -~l:o~~~m3 I
I I
5.3 6.8

I
I I

;~~~/:~~

l'
1

I !

33.0 33,7

14.4 13,9

BLOOD CELL COUNT/DIFFERENTIAL ..

~~~~;~;
L(lw Re fer: High Ref:

Gra~
40 ' 0 70,0

Lymi h

Mon~
I
2 .0 10,0

EO:
I
0 0 6:0

Bas~

I
I
I

22 " 0
qO.O

0 "0 3.0

-"------------~------------------------------------~--~--------------------I 01/23/09 1045 48,7 i 39,'1 . 9,3 I l.S i 0.8 I 0- ":,2/09 0300 53.4 I 37,1 8,'1 0.7 I 0,4 ,
"BLOOD CELL COUNT/DIFFERENTIAL . . . .

Result:

RRC Harp

I1BC Morp

plt Est

Aba

Neut
1.8 7.7

Ab Eos

units:
Low Refer:

lOOO/ntm3

1000/mm3
0.0 0.5

High

R~f;

------1
01/23/09 10451 01/22/09 0300
2.57 3.62

I I I I
!

t4ARCH, PHILLIP H 000748298


Alexander
k'

B~bich,

M.D.
""k

DO NOT DISCARD

,charge C1.1mulati ve Trend Report

Dr.

(N-IO/02/76l SALE1<T, r>10UNER

DePaul Medical Records/Phillip H. March

000314

DePaul Health Center


12303 DEPAUL DR. BRIDGETON! tvlO
63044

Tue Jan 27, 2009 05:47 am

DiBchaz'ge Cumulative Trend Report from 01/22/08 0300 to 01/23/09 1045 MARCH, PHIL[,IP H 'ent Name: HE~~TOLOGY-Paqe 2 000'/48298 Ad'll: 01/22/09 11. Rec #: 01/26/09 Dis Date SALEM I 1,IOUNER - EMERGENCY Phys-Service;
p

Out:

903693 903572 ~1725~ In: 01/23/09 1138


01/23/09 1223

----------------------------------

SEDIMENTATION RATE,

I'IESTERGREN

Spec: Blood
Techs: V - if/T Tf'4VI LLD

ColI Time: 01/23/09 1045---------------------------------Order Phys: SALEM,MOUNER lA0902200197/4665606] Result Name Result Reference Range

Sed Rate. westergren (mm/Hrl :

NARCH,PHILLIP H 000748298 Alexander Babich, M.D.


ry~

NOT DISCARD

**

,charge Cumulative Trend Repol:"t

(1'1-10/02/76) Dr. SALEM I MQI,JNER

DePaul Medical Records/Phillip H. March

000315

DePaul Health
12303 DEP[\UL DR.

Centc~

Tue Jan 27, Di8ChJxgo Cumulative Tn~nd R@port from 01/22/09 O]OJ to 01/23/09 1045
r
',ent Name: MARCll, PHILLIP H

BRIDGETON, l'<IO 63044 2009 05:47 am

CHEMISTRy-p",ge 3

Rec #: Dis Date Phys-Service: 90369] 903572

000748298 01/26/09
SALEM,MOv~ER
91'!25~

Adm: 01/22/09 - EMERGENCY

.ROUTINE CHEMISTRY.

lPotassium IChloride C02 GPR I I mEq/L I mEq/L mEq/L ml/min/l .73m2 Lo..-, Refer: 75 ~37 1 3.6 I 98.0 22.0 110 115 I 5.0 I 107.0 30.0 I High Ref: -------------------------_._---------------------------------------------------,i Result:
lJn,i~~;

"Glucose m:l/gl

Sodium
mEq/L

I'

01/22/0903001

74

LI

140

3.7

100

27

75.5

ROUTINE CHEMISTRY.

l1e:

BUN

Creat

Calcium

Phosphorus

1. _ s: Low Refer: High Ref:

--------- ------------------------------------------------.--------------------1
16

mg/dl 9.0 20.0

mg/dl 0.8
1.:'

mg/dl 8.4 10.2 9.5

mg/d.1 2.5 4.5

I
I I

IYlagnesium
mg/dl 1.6 2.3

I I
i

01/22/09 03001

1.4

I !

ROUTINE CHEMISTRY .....


I ..

It ':'

Anion C.:\p

CA/ALB

Vnits:
Low Re[e:c:

High Ref:

I globulin I gm/dl

p../G Ratio

BUN/Creat

-------------------------.---------------------------- -------------------------1 01/22/0903001 12.8 I I I ! I


---------------------------PENDING TEST "-.----------------------------

End of Report

!'lARCH, PHILLIP H 000748298

Alexander Babich, N.D. ... DO NOT DISCARD ** Jcharge Cumulative Trend Report

(t'I-IOj02/76) Dr. SALE"'1, MOUNER

DePaul Medical Records/Phillip H. March

000316

DePaul Health Center 12303 DEPAUL DR. BRIDGETON, I-m

630014

Tue Jan 27, 2009 05:47 am

Disenat'ge Cum
:ent Name; Rec #:

Il'\~ompletp.

Work Listing from 01/22/09 0300 to 01/23/09 1045


Page 4 Adm: 01/22/0 9

MARCH, PHILLIP H

00074 8298
01/26/09 SALEt1, MOUNER E1>1ERGENCY

Dis D.;tte

Phys-Ser'vice:

903693

97~803

903572 917259
Collection

Ac(;t;ss.lon Number

Test Name

Spec Type

Da<;:e & Time

StatUG

A***".* ***************************W**************** **ttttt******************

All other lalJ work has been complet.ed Final reportl * **.*******************************.************.******** *********************

..

*****.*******~*~****.*

End of Report ********.***.***********************************'*******

MARCH,PHILLIP H
000748298
Alex~nder

Babich, M.D. ~O NOT DISCARD ** JChal-gc Cum Incomplete vlork T"istlng

(l'-l-lO/o2/76) Dr. SALEM, r10l,;'NER

DePaul Medical Records/Phillip H. March

000317

l'lARCH, PHILLIP H

Room:
O'-'fc:

58- 0554 - 01
EI>1ERGENCY

Phys; SALEM,MOilliER \-u;:sul t name


End

LABORATORY Pat #; A0902200197 Collected: 01/23/09 1045 Accessioned: 01/23/09 113B Completed: 01/23/09 1223 Result
of Report!

TEMP

Birch Date:
V-WT
[4665606)

10/02/76

TMVILLD

Spec. Type: Blood R.eference Range C-15

sed Rate, WS9tergren(mm/Hr: 1

*FINAL
~OJ69~ ~03577. ~17259

SEDTfIfENTATION RATE, 'ilESTERGREN

1/23/09 1223

He

DePaul Medical Records/Phillip H. March

000318

!llARCH 1 PHILLIP H

Room:
prvc:

53-0554-01

EMERGENCY Phys; SALF.M,MOUNER ~~dult name Result


WBC(1000/mm: RBC(10X6) : Hgb(gm/dl) ; Hct{%) :
5.3 4.77

LABORATORY TEMP Pat U; A0902200197 Birth Date: 10/02/76 TEVANCE Collected: 01/23/09 1045 V-WT Accessioned: 01/23/09 1138 14665606) Completed: 01/23/09 1152 Spec. Type: Blood Ref Range Result name Result Ref Range

4.5-11.0

Baso(t) ;

0.8

0,0-3.0

4.7-6.1

Manual DiEf:
Absolu(lOOO/mm:

Not Indicated
2.57 1.8-7.7

13.4
10.6 85.1 28.1

13.0-19.0
39.0-54.0 80.0-99.0 25.0-31.0 32.0-36.0
11.~-14.5

MCV(fl) ;
f.1CH(pg) :

MCHC (gm/dli :
RDW{%) ;

3].0 14.4
211

Platel(lOOO/mm:
Gran
(~)

130.0-400.

Lymph (%) : Mono (%) ;

48.7 .39.7 9.3


1.5
91725~

Eos (%) : *FINAL 903693 ~Q3572


~vom;

40.0-70.0 22.0-40.0 2.0-10.0 0.0-6.0


CBe 'tJ AUTO DIFF

01/23/09 1152
TEt,!P

rIC
LABORATORY

C'H,PHILLIP H
58-0554-01
EtvlERGENCY S rye:

Pat #: A0902200197 E!irth Date; 10/02/'16 CollecLed: 01/23/09 1045 V - vJT TEVANCE

Accessioned: 01/23/0'3 1138 (4565606]


Completed: 01/23/09 1152 E;pec. Type; Blood Ref Range Result name Hesult Ref Range

Ord Phys; SALEM,MOt~ER Result name Result

End of Repol.-t ~

~NAL

CBC W AUTO DIPF

01/23/09 1152

903693 903572 917259 HC

DePaul Medical Records/Phillip H. March

000319

Department of Radiology

INPATIENT MRI SAFETY FORM - PRE-SCAN METAL SCREENING


.... Contact MRI (314) 344-2778
Last

Nama:tJe<. V-L..--t"-'/ d

First Date ot Birth:

Today's Date:

~/O 1"

Nam.:~'J kl,\ if
/'0 -;) -

M.I. _ _ Height: _ _ __
Weight: Sex:

/t.

J"V'.:

This section is to be completed by the nurse.

No
~

Yes

1. Has the patient had an Invasive procedure since filling out this form?
2.
Does the patient have a pacemaker IICD?

",./

3. Does the patient have a sandbag?

1.

Have you ever had surgery or any similar invasive procedure? If yes, please list:

}[NO
__No

Yes

~pe: __------------------------------- Date: __


Type: _ _ __ 2.

Have you ever had any previous MRI Studies? If yes, please identity: Part Dale FaclillylLocation

--- ~ Gt3.

!y

_ _ _ _ _ _ _ _ _ _ _ _ _ _ Date: _ _ _ _ __

v(.s

~ _ 'Je'CVl

\'

Of

J"V
__ No __ Yes

Have you ever worked with metal (grinding, fabricating, etc.) or ever had an injury to the eye involving a metallic object (metallic sliver, Shavings. foreign body)? If y~. please describe: _________________ ~_ _ _ _ _ __ Are you currently taking or have you recently takenany~Qjcatlon7 If yes, please list: ~ i--re...d .\" t ~
Do you have anemia or any disease that affects your blood, a history of renal disease or seizures? If yes, please describe: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Do you have any drug allergIes? If yes, please list: ______________

4.

5.

Yes

6.

JNO
~NO

Yes

7.

Have you ever had asthma, allergic reaction, respiratory disease, or other reaction describe: _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Yes

to a con1rast medium or dye used for a MRI or CT examination'? If yes, please

FEMALE PATIENTS
8. 9. Are you pregnant or experfenclng a late menstrual periOdl;d' _ _ _ Date 01 last menstrual period: ;/Ar/ro ast fSiJding? reatments?
No

Yes

No

Yes
Yes

10. Are you taking any type of fertility medication or h

WfetJUty

No

DEPAUL HEALTB C~NTER


l-tARCH,
INPATIENf MRI SAFETY fORM - PRE-SCAN METAL SCREENING
DPM-4201-001 (10!2005} FRONT

111111111111111111101 PHTLLIP H

liP

[OVER

0902200197 ERS 0554 01 lO/02/l976 32Y t.1 01/22/09 SALEM,I-10m~~R 000-/48295

DePaul Medical Records/Phillip H. March

000320

Some of the following items may be hazardous to your safety and some can interfere with the MRI examination. Please check the correct answer for each of the following:
_Yes Yes
~Yes

Yes Yes _Yes Yes

No No No No No No

No
No No No No No No No No No

_Yes __ Yes
_Yes

_Yes
~Yes

_Yes Yes Yes I_Yes

Cardiac pacemaker Implanted cardiac defibrillator Brain aneurysm clip(s) Carotid artery vascular clamp Neurostimulatof Insulin or infusion pump Implanted drug infusion device Bone growth/fusion stimulator Cochlear, otologic, or ear implant Any ~ype of prosthesis (eye, penile, etc,) Heart valve prosthesis Artificial limb or joint Electrodes (on body, head or brain) Intravascular sIems, filters or coils Shunt (spinal or intraventricular) Vascular access port and/or catheter

Please mark on the figure below, the location of any Implant or metal inside of or on your body.

Yes

No

SwanGanz catheter
Any implant held in place by a magnet Transdermal delivery system (Nitro) IUD or diaphragm Tattooed makeup (eyeliner. lips, etc,) Body piercing ';~~ Any metal f,agments Internal pacing wires Aortic clip Metal or wire mesh implants Wire sutures or surgical staples Harrington rods (spine) Meta! rods in bones Joint replacement BonelJoint pin, screw, nail, wire, plate Hearing aid (REMOVE BEFORE MRI) Dentures (REMOVE BEFORE MRI) Breathing disorder MOlion disorder Claustrophobia Anxiety

No Yes No Yes Yes No Yes ...i=-Yes =No No Yes Yes No Yes No Yas No Yes No No Yes Yes No Yes No No Yes Yes No No Yes Yes No Yes No Yes Yes

..v

Before your MRI, please remove all meta/He objects, including keys, hair pins, barrettes, jewelry, watch, safety pins, paperclips, money clip, credIt cards, coIns, pens, belt, metal buttons, cellular phones, beepers, pocket knife, and cfothing with meta/In the material.

Other:
Please explain:

during the MRI examination. __ Physician

~~~is
""'

are required 10 wear earplugs or earphones


~ Other

STAFF SIGNATURES:

-iltL{!t{t4'LLlLM&~~-;JJ"M
Nursa

jRadiologist (Metal Approved)


Extension it

~~~M-

DePaul Health Center

PATIENT LABEL

INPATIENT MRI SAFETY FORM 1'~.sCA."'I METAl. SCREENING


OPM4201Q01 (1012005) BACK

DePaul Medical Records/Phillip H. March

000321

PATIENT BELONGINGS VERIFICATION LOG

Page _ _ _ of _ __

-~

ORTHOPEDIC DEVICE 0 None 0 At home Q oan~ CJ W'k~r Q pp~~!!W{!i

ORTHOPEDIC DEVICE 0 None 0 At homo Q Cww g W~!~~r g PfQl!t~!PjlJ

JEWELRY (DescriptIon)

o Watch

o Ring(s)

o Other:

o Watch o Ring{s)
o Other:

JEWELRY (Description)

0 None

JJ::WELRY (DescriptiOn) DWatch

0 None

o Ring(;I) o Other:

o Sant to Security
CLOTHING (MUST write description)

o SMt t~ Security
0 None

o Sanl to Saeurlty
0 None

o Hat/Scarf o Coat/Sweater

9 6liflperS/Ro~
~5fSIa(lk$
14 Shltftl?louse
d<Underc!othes

Stockings/Socks

o o o o o

CLOTHING (MUST write description) o HaV$cart Coal/Sweater Shoes Stockings/Socks CJ SlJpper<lfRobe o Pantl;lSlacks Shlrt/Blouse Underclothes

o Haf/Scarl o Coat/Sweater
CJ Shoes

CLOTHING {MUST write description)

0 Ncne

o Underclothes

o Slippers/Roba o Pants/Slacks o Shirt/Blous6

o Stockings/SOCkS

o
o

phon'! .J. Laptop computer Olher

VALUAIU.ES (Descriptinnj

o No 118

OTHER VALUABLES (Description)

o Cell phont! o laptop cnmputer o Other _ _ _ _ _ _~~

0 None

o Other

o Cell phone o Laptop computer

OTHER VALUABLES (Description)

0 NOM

ITEM (5) SENT HOME


-~---~-----~~----I --------~~-----

SENT HOME

_~~__

o Sent home with _ _ _ _ _ _ _ __ D Sent home \\f~h _ _ __ o Sent to Security _ _ _ _ _ _ _ __ o Sent to Security _ _ _ _ _ _ _ _ __
o
HOMEM

o None

HOMe MEDICATIONS

!J None

8ent home 0 Pha.rmacy

Sent home 0 Pharmacy

None
Sent home 0 Pharmacy

PtJ1amlly assumes final responsibility for belongings thai !lrB broughl 10 hospital

o PVfamily assomesnnal responsibility for


belongings Ihat are brought to hospital

!J PVlamily ~umes final responsibility fOf belongings that are brought to hospital
StGNATURE OF PATIENT / RESPONSIBLE PERSON UPON ARRIVAL I DISCHARGE:

SIGNATURE OF PATIENT f RESPONSIBLE

SIGNATURE OF PATIENT I RESPONSIBLE PERSON UPON ARRIVAL f DISCHARGE:


..,,,,,,,,"', vr,LO OF RECEIVING STAFF MEMBER;

SIGNATURE OF RECEIVING STAFF MEMBER:

TIME:

RECEIVING ROOM #.

TIME:

RECE1VING ROOM If'

COMPLETE A NEW FORM FOR TWO DR MORE TRANSFERS AND FILE WITH ORIGINAL KEEP AT BEDSIDE AND PLACE IN DISCHARGE SItTiON OF CHART.

PATIENT BELONGINGS VERIFICATION LOG SLM1000-073 (lV2007) FRONT

DePaul Medical Records/Phillip H. March

000322

TRANSFER CHECKLIST
INITIAL IN DATE COLUMN WHEN EACH ITEM COMPLETED If Item Not Appllcabfe, record NJA In box. DATE DATE

DATE

TRANSFERRING DEPARTMENT

From Room II

If transferring from Telemetry Remove monitor Enter transfer Into computer Make sure that labels are placed on all documents in the chart at time of transfer Communicate daily and pending labs
i--------------------------t---~----------

t-M_e_Q_ica_tl_on_RQ_C_Qo_C_iliat_---'_Qn_C_Q_m_-P_'el_eQ _ _ _~---------+--------t-----t----------~
Place MAR, Interdisciplinary Plan Qr Care/Care Pathway, & Education Rei:ord in chart
f-------------~------------i--------l---------

I
i
!

I
-- - - - .~--+'----___j

f-------------------------------+----~-----+----

Place today's 24hour record and all bedside flowsheets in chart Place Wound Tracking log In front of chart

I----------------~----------+---.---------+:------

.-----------

(0(\ front) and place at bedside i I f - - - - - - - - - - - - - - - - - - - - - - - - - 1 - - - - - - ., ...- j - - - - - - - - j - - - - - - I

Complete Patient Belongings Verification LOQ

I-t_a_ke_a_n_y_O_ld_c_h_ar_ts_o_r_th_in_n_ed_r_e_co_rd_s_w_i_th_p_a_tie_n_tt_o_n_ew_ro_o_m _ _ _ _ _ _r--_._._._ ..__


Place any NonPyxis meds and IV mads in plastic bag and clip to chart

j - I '_ _ _ _

--j-_ _ _- - I

f - - - - - - - - - - - - - - - - - - - - - - - - - 1 - - - - - - - - - - - ------r---------j

Notify Attending and Consulting Physici(lns of room change.


-----.-----------~-~~-------_t_-----_+_----+---

.... - -

-- .. -

Notify Family of new room number and print name of family member in date column

-- - - - - - - - - - - - - - - - - - - - - - - - + - - - - - - t - - - - - - f - - - - - .-----

Name of Transporter:
--------------=R:---:-E--=C-=E--lV---.:-::N:-:G-D--E::-:P-'A-R-T-M-E-N-T----To-R-o-om-#--t--------t-~---t-------j

---------.:.::::..::.=::.:...:.:..:.=:..-=..::::..::..::.:..::..:::::=..:.:...----..:..:....:..:::.::.:...:.:..--4=====j=====9=====l Document date and time patient arrived in new department f----- - - - - - - - - - - - - - - - - - - - - - - - - - i - - - - - - + - - - -.... --t-----___j Document patient s1atus on arrival to unit
Place New Room Number on chart
t----

- - -------1

- - - - - - - - - - - - - - - - - - - - - J - - - - - - - - - - - i - - - - - ,.-.. - - l - - - - - - - j

Print new labels and place in front of chart


Ensure daily an~ pending labs are ordered

I - - - - _.. _---------------------f-------t-----+

Label blank Physicians Orders &Progress Notes and place in proper sections of the Ch~r! ~ _____------'_ _ _ _--'-_ _ _ _-'

~
--

SIGNATURE.
.. -

I/Nrrt

SJGNATURE

INfT

-" ... --SfGNATURE

INIT

--_ ....

I
~-

..

..

~SSM
SLM-'OOQ073 (12/2007) BACK

DEPAUL HEALTH CENTER


,,,,,,,--",CH, PHILLIP H 090 22(;0197 ERS 0554-01 Tip 101 02 11976 32Y 1-1 01/22109 SALE~1, f'10UNEF. 00 O'J 4 82 98

J",ltlllllllllill

H E A L T H ' CAR E-

PATIENT BELONGINGS VERIFICATION lOG

DePaul Medical Records/Phillip H. March

000323

CONDITIONS OF ADMISSION AGREEMENT


Consent to Admil;slon: I request end consI;'m to admission.
Con~Qnt

to Medical and Related Health Care: I request and consent to the medical care, diagnostic and treatment

procedures as determined necessary by my physician!s! or hisfher assistants. I acknowledge the care f rttG6jY6
while in this facility is under the direction of my physician(s). This tacility is not responsible for the acts or omissions of my physician(s). Medical and Allied Health Care Providers: I have been informed and understand that the Physician{:ll providing ~lilrvh;:~~ tQ me in this facility, 5uGh as my personal Physician(s), Radiologists, Pathologists, Anesthesiolosist, Consulting Physicians, Surgeons and other Allied Health Care Providers f;uch as Dentists and PsychologIsts are independent comrac~o(s and are not employees or agents of thIs facilIty unless otherwise specifically identified. Teaching Programs; I understand this facility may, from time to time, enter into agreements with academic medical, nursing and tlHied health programs. Because of these agreements, fcsiol:nts, interns, medical students, nursing ~tudents and various allied health profession students, may panicipate in my care. I agree to participate in these programs, but have the right to limit my participation at any time.

Release of Information: I understand tllis facility will makQ evory effon to treat my medical infofmation as confidential; however, I realize information must be shared with provider:;; andfor individuals involved in my care or in the payment of my care. I understand this will include information found in my medical record. I agree to the release of information in my medical record, and to the actual medical record documents, to the extl:nt necessary for the foUowing pvrposes:
a.)

I have received the Notice of Privacy Practices on this visitiadmission or a previous one, I under:H!md I can request BrJ<}ther copy at any time,

b.)
c.)

to any meoleal and/or health care providers responsible for my

CilfQ

whilo in this facility and

if transferred to another facility for care, to that facility and its care providers.
to those responsible for collecting and those resPQnsible for the payment of my care. This may include a person, government agency, insurance company, health plan or employer sponsored grOllp plan. This Is tor the purpose of verifying insurance benefits for precertification and extended stay review andlor the payment of the cost of my care, to utilize for internal medical care studies and quality imprOVement activities.

d.)

e,)

to comply with the Federal Safe Medical Device Act of 1990 <lnd other required state and federal
reporting.

MedlcarefChampuslTricarIJ Rights: If applicable, I acknowledge receipt of the Medicare/Ch!impuslTricare Lt:lter expJaining my rights as a patient of this facility. f understand this includes my right to request <I revIew.

Patient RighlS: I acknowledge acceS8 to the Patient Rights information explaining my rights as a patient of t his facility.
Personal Property: I have been informed and understand thi .. facility will not be liable lor any loss of property unless it is inventoried and placed in a secured area maintained by thi:;; faclilly.

mv personal

Payment for Physician Servlclt!t Medical Bnd Related Care: I understand that all pflysician services are billed separately from the facility charges. I agree to pay the charges incurred for the caffl I receive as ordered by my physiclan{sl at thIS facility. J guarantee full payment of all charges unless restricted by Medicare, Medicaid 01 c:ontrilctuill arrangements between my insurance company and this facility.

~SSM
H fr A L T 1-1

P{ftient Name; MARCH,PHILUP H

CAR E-

Mod/cill Rl,lcord If: 000748298


Aooount If: 0902200197
Typa ERa
Date of ServiC<t:

DEPAUL HEALTH CENTER


12303 DEPAUL DR,

01/22/09 02:00

BRIDGETON, MO 63044

Anendll'lg Physicilln;

EMERGENCY,PHYSIC1A
{Comlmmd -on reverso si!ffH

DePaul Medical Records/Phillip H. March

000324

D.ssignment of Benefits; I her&by authome end assign payment to this facility of any type of reimbursement r payment due from Medicare, Medicaid. or any other third party payor, for any and all cost incurred for my medical and related care at this facility and/or by the inrlepsndant contractors providing services at this facility. AcknowledaftfDent of Understanding ReceiPt; I c8rtJfy that I have read tmd understand the pretNJding agrf1fJment.

I have /tad any unc/qlJr items explained to me Imd understand its contents and sooept its terms. I understand that new account numbers mAY be Issued for follow up services related to this admission/treatment
and that would not change this agreement
QI

my agreement to the preceding

tit

any time by written notification to this

be considred a discharge by Medicare. facility.

I understand I may withdfaw

(~_I._~/_ _-------~~----
Patient-;; Signature
M~H.PHILLIP

~/.-...--:>

Date
000748298

."---

H 0902200197

Signa1Ure/Relationship

Date

(Parent/Legal Guardian/Responsible Person)

~cJr\ _____~_._
Second Witness Signature
(if OrallTelephone/Pati&nt Mark)

/1 dJ-b,'
I

Date

Date

Date

DePaul Medical Records/Phillip H. March

000325

12303 DEPAUL DR. ~SSM BRIDGETON, MO 63044 O;~~:~~;4S I ,~:~,:s~:~:Af;O:;; !~: 11~:~;;;;:: 13~: [: R':~ :$ r:::" I >rAl")';1 'm~No
DEPAUL HEALTH CENTER
H E"
~

L T H . CAR

e-

ADMISSION RECORD

ffi

'~~~~~M:;:~~L~l;;.~"

xx~O.C:~~;~9EI
ilW'IIor<U.O

'!""-"."r;To n;;;;TJ,F"''';o;p,7(lOVYt;ER;----L. ----...l...-...L--.....l.--L~TTIr;"'C;;p"""";;:;N:;o."'";;;')-..::.....j

rCo~ IPA~;;~ I~~ 1000748298'1,


!
H.(}',/j

8310 HAWKESSURY DR SAINT l.OUIS MO 63121-1005

I
LillUJ

(3141393-1241
C;Ui\I\i\NTCfI EUPl.C'rrM

r-~~c~v~.r~~~';T~nR~N~.A7M7~'k~~D .. AOO~A~fnS~----------------~~~~--~ SfJCoFCIIO C/) XXX-XX-a69H 1 ~~ MARCH.PHllllP H c: W ~ 8310 HAWKESBURY DR THEP'<C.11 NO. > (314)393-1241 SAINT LOUIS MO 631Z1-10QS 0 \
~
RlAl!ON

I
WEf'IlOIlHO,

~
~
(tn4TIVf {FMPt(iYER

Ocr:tJf>AT1m~

I.;]
REl..).,TlV

UJ l NAME ANi),A-U''''"'''\n;rr,N-S~----------''''''==='-'--I SOC,S!C.flQ

~!;bF

!
1 .fPH\.-'lttE ta,l

MARCH,K1MBERLY

r--+-7-8-0-.6-_-F-E-v-E-R-jji,.. ... "".'.N'"O~~'~.!.~'G~('~' P~'''''AI'''N'''".- - - - - - -... IA.,.,e~c~ib~.f~~~~\~'VX~~R(~l-.J IA""r:UllW'


lAsr ACMISS'Ofi
[;,/<1'(

UA HlTiMf

A!JM

IT;EI~mJilC

'1

h'7<:~=~~f"T7<O"TIii'W-------''''----L...-----...L----r~..L...~--..J.,_-;;;;"""Oi<r,__;;k_:__1=""""""L--_ _.....j

l
j

tOCJ.nON

--1-

INf

E2 !
~ i

~At (.(A1:J.,1P,r:-

10113/07

INF

I AJ;lVA"~E m!lt~"."
'n,

~1\I\:~~OD
t1:COM PilfF"

O~~A
ICHUACH
NOli

~<}P""'!v~'

PAT (.t..A

I
!

(H5!;IIA!'\.f DATfmME

12774 eO~NKER LANE !.I BRIDGETON MO 63044 ~ ( H ' (314)291.7997 FAX 3147391471 I ATHNCi-NC FrfVStCI)S.N ~ ZINSER.PHILLIP (3 90~572

iE 1/~O~1J1T1NG Pj"'iYS\C'~"J'>J Z i ZINSER,PHILLIP G

-------------~------------r~,~1 l",,,,;;;,,,0?,;",;;;,,V.Yf"'11C=o,,,,,",,'j- - - - - . L_ _ _ _ _ _ _ _.L..._ _ __

10/15/07 23:59

I
1 .
I'

' l

903572

OfC
fRlMAHV (;...AHL j.'HY$l(lAN'

ZINSER,PHILLIP G

903512

W ~

~ ~

12774 BOENKER LANE BRIDGETON MO 63()44 u'c (314)291-7997


'MFR';ENi:V CAR N'Yl>ClAN

fAX

12774 BOENKER LA_N_E __________ BRIDGETON MO _ 63044 3147391471 OfC, i3141291-7997 '''', 3147391471 "-------------~---I-I..,~""HA=!\!''"D."C~A'''I\,'"'FH'''-''''',.''''.,""w""",-

~_____-illl

OFC

I)fr.Ifff, ! n:LEPH:O~i ~I-o,

fAX;
CQf'F

f--~'

iU!,".,un.Mlf.F 1

lN$VMNCE 2-

'"S 2 HI.PIlt' NO

JAY UMANSKI

!
I

SELF PAY NO INSURAflCE

100150
f'C'

(JRP

CtRP' 'NSUO<D

GiIl'l

MARCH.PHIlUP H

IN>'JIlW

MARCH,PH~lL!P

"""
coot
PC.
c."qp

1
'''is 4 a ....!:YHtHU
Nt)

~
I

POll

COUt

_""_'M
reI

Gil<'

POLO
~NsvnE-O

I I I

'H6UF\J:O,

INSUAANC.f: COMMtt.iTS.

---------------------------

1f1S'..)R.'.N(.'t

t.:or.u..1Ui 1S

I
03/25/2009 15:32:30

DePaul Medical Records/Phillip H. March

000326

DePaul Health Center


12303 D!!:PAUL DR.

Wed Mar 25,


P

BRIDGETON, MO 63044 2009 03:41 pm


Page~

Name: #/Acct #:

Outpatient Summaxy ~eport MARCH,PHILLIP H 00074B29B/A0728800245

Reg DaLe: 10/15/07

Loc:

O/P
ZINSER,PHILLIP G - INFUS:WN CENTER

Dis Date: 10/1S/07

Phys-Service:
903572

****** **~**~~~********~t.***t**4.*t**W*~*******************I****~**********
In: 10/15/07 1437 --------------------------------O\lt; 10/15/07 1458 I COl'lPREHENSIVE r<IETABOLIC PANEL I Coli Time: 10/15/07 1420--------------------------------OL'der Phys: ZINSF.R, PHILLIP G Spec; Blood
Teets; V-NM TLSCHWC
(AO'i28600245/3883092)

Result Name
nUN (mq/dl)
!

Result
9 139

ReferGm oe Range
9.0-20.( 137-145 3,6-5.0 98,0-10: .0 75-110 0.8-1.S 17.0-59.0 38.0-12E .0
8.4-10.~

Sodium (mEq/L)

potassium(mEg!L) ;
Chloride (mEq!L) ;

GluCO:;lC (rug/dl) : Creatinine(mg/dl) :


p

3.6 103 86 0.9


24

JSGOT(U/L) :
Phos (U/L) :

CCilcium(mg/dl} : Silirl-tbin (mg!dl) ; ,ZI,lbumin(gm!dl) : PJ:ot Tota1(gm/dl) ; CO2 (mEq!L) :

77 9.4
0,5

4.7 7.5 28
[U/L) :

ALT/SGf'T CFR \ml/min/ 1. 73m2) :

II L

0.2-1.3 3.5-5.0 6.3-g.2 22.0-30. 0 21.0-72. 0

126.6

Out.: 10/15/07 14:;5 esc i'1 hUTO DIFF I ColI Time; 10/15/07 1420 ----------.-------Ol:-der' Phys: ZUISER, PHILLIP G
ResulL N",me
io,/T"~{1000/mm:

In:

10/15/07 1437

-----~----------.-

Spec: Blood
Techs, V-m4 TLTALLEU

lAO"2 8 8002 4 5/ 3 BB3 092J Rel,ult


271;

Result 8.1 4.31 12.6

l~ef

Range

Result Name
Platel (IooO/mm: Gran(%) ! Lymph (%) :
t4ono (%-) : Eos {!I;} :
Basort) :

Ref Range 130.0-400,0

10X6) : rIgo (gm/ dl) : Bct (%) ;


1

4.5-11.0 4.7-6.1 13.0-18.0

77 9 H 16,9 L
5,1)

fY1CV (fl) ;

36.6 L 76.1 1,

39.0-54.0
80.0-99.0

o .'J
0.:1 No; 6 .~9

Mi;H (pg) :
r4CHC (gm!dl) :
Im~oJ(%) :

26.2 34.4 15.4 H

25.0-31.0
32.0-36.0

Manual DiU;
Abeolu (lOOO/mm:

40.0-70.0 22,0-40.0 2.0-10.0 0.0 6.0 0.0-3.0 Indi.cated

11.5-14.5

End of Report - 03/25/09 15;41

alp
.patient Summary Report

MARCH,PHILLIP -1 000748298/A0723B00245
n'1-10/02!76) Dr. ZlNSER,PHILLIP G

DePaul Medical Records/Phillip H. March

000327

~SSM eH E A
~

DEPAUL HEALTH CENTER

12303 DEPAUL DR.

T H . CAR

ACUX;N' NO

AOM1~X>~

DAr, I TIM

BRIDGETON, MO 63044

F(;

IlIA!' or

''I'''H

! I
AGE

ADMISSION RECORD
-

SEX

PAC.

lAS tR\lICE/ SrA""N] IlOOl\...lO


S DX

0731000262
IZ

11106/07

O!.!:~O

95

10/02/1976

32Y

P,;TtEtH NAME AM) i\P-DRSS

WC SEC'!;Q

PA-TIENl EMfTLQYtH

r IfA~;;PE 115:8/000;;;298
cr
TEl!;?W)NlO

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P
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Name:
#/Acct #;

DePaul Health ~enter 12303 DEPAUL DR. BRIDGETON, r,10 63044 Wed Mar 25, 2009 03:42 pm Outpatient Summacy Report MARCH,PHILLIP H OUOJ4829B!A0731000262 Reg Date

Page: 1 11/06(07
11/06/07

Loc:

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In: 11/06/07 1025 --------------------------------Out: 11/06/07 104B I COMPREHENSIVE METABOLIC PANEL! ColI Time: 11/06/07 1000--------------------------------Order Phys: ZINSER/PHILLIP G

Spec: Blood
Techr:;; V-Nt-1 TLPRETT
fAO"31000262/3917916)

Result Name
BUN

Result
12 136 L 3.9
102

(mg/dl) :

Sodium (mEq/T.) : PotassiumlmEq/LI: ChloridelmEq/L) : Glucose (ms/dl): Credtininclmg/dll


I"
1

9.0-20.0 137-145 3.6-5.0 98.0-10".0


75-110 0.8-1.5 17.0-59 0

78
1.0

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Calcium(mg/dl) : BiliLubin (mgidl) : l,lbuml.n (gm/d1) : Prot Totallgm/dll:


C02 (mEq/L) :

27 75 9.1 1.0
'1.5

38.0-121>.0
8.4-10.:: 0.2-1.3 3.5-5.0

7.0
31 H

6.3-8.2 22.0-30 0
21.0-72 0

ALT/SGPT
GFR (ml/min/ 1. 73m2) :

(U!LI :

11 L

112.1

:n: 11/06/0~ 1025 Out: 11/06/07 1010 Coll Time: 11/06/07 1000
Order Phys! ZINSER, PHILLIP G
Result Name
\V" ..., ( 1000/ mm : 1 10X6) ;

------------- --

CDC W AUTO .cIFF

Sp@c; Blood
Techs: V-N!>1 TEViI,NCE
(AO'131000262/3917916]

-------------------

Result
4,1 L
4.80 13.1 37.3 L 77.7 L 27.3 15.1 ':'5.5 H

Ref Range
4.5-11.0 '1.7-6.1
13.0-18.0

Result Name

Re;,ult

Ref Range
130.0-400.0

Hgo(gm/dl) :
Hct (%) :

1;1CV (E1) :

39.0-54.0 BO.0-99.0
25.0-31. 0

Platel (lOOO/mm: Gran (%) : LYIT.ph ( 'l; l : Mono (%) :


Eos (%) :
Baso(%) :

17l
53.8 35.1
9. '7

40.0-70.0 22.0-40.0
2.0-10.0

D.7
O. 7 2.

0.0-6.0
0.0-3.0

NCH (pgl :
~/ICHC

(gm/dl) ;

rWW(*) ;

32.0-36.0 11.5-14.5

Manual Diff: AbE'olu{lODO/mm;

No: Indicated

End of Roport - 03/25/09 15:42

I>'IARCH I PHILLIP

alp
.patient Summary Report

0007'1S298!A073 L000262
(t1-10/02/76)
ZINSER,PHI~LIP

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DePaul Medical Records/Phillip H. March

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03f2512009 15:32:45

DePaul Medical Records/Phillip H. March

000330

DEPAUL HEALTH CENl'l!;R


123J3
U~Paul

Drive

Bridgeton, MO 61044

DIAGNOSTIC IMAGING

2:

MARCH, PHILLIP H
Sex:

Med Rec #
M

~000748~9R

ACCT; 1'.0731100362

D8D: 10/02/76 Age: 32Y


n~t~: 11/07/0~

Pt LOG'<ltior: *o/P

2119

ZINSER,PHILLIV (
12774 BOENKER BRIDGETON
LtN~

1>10 63044

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h~s

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t.0

t.he

Tn r.()mparison to Lhc study of 9/19/2007 then~ iR interval :l.rlpI:0VemellL in Lhe bone marrow abnorma! ; ty within the LefL mandibLe .:.nd th~: abnormal signal wi th:i n the left iHo.S:';ctCI' muscle ,:>n the st.l.ldy of 11/7,2007. l1oweve.r !;li'3u1fic.:;mt cignal ab'101'mallty does perBi:;L wi(.hin (heGe GtJ.'uctures nn t.h~ study 11//(2007 wbLch is an unusual tinding given r.hR long Lime course cine;;- therapy 1!aR initiated aild L'6mail1:; worriGome (ur a persistent inflamm~tnry process,

or

Fi nc:lings discussed with Dr. ZinSel" on 11/12/200" at: 10: 50 J\ddendum Read By- NOANAl'J 1'1 ~Il)l),lQJ 1'1. D. )'>.ddp.ndum Released t3y. NOANAN \<1 SID:>IQI M.D. Addendum Releasp.ci Date Time- 11/l2/07 1053 l\ddenc:ltlm TranscL'lpLionist- NWS M.J. NWS M.D.

il

m.

r1RI f.:.\ce with ar.d w.1t-.hout eonLx:dst

11/7/2007

lndic 0 tion: Left m.:tndihlliar pain. History of prior trauma h \,.::.th Gurgie;': rF.pair ill. Mal' 2007. Infecthm. OsreornYf.'litis.

April 2007,

l,,::chnicjl.,e: The flelri-of"/:ie'd 1;; upLlmizcd u, evall.late the S'nlctl1r~8 of the tacp ,'lild nc;t t.he il11;:r<J.cl.'~mi-'ll ijtructures. Imaging in tll~ s<v;jitt.al, ."!xlal. and core,r."l plane vl.']S pf!rformed utlli.:.;ing both T1 pr~- and pcctcontrMi; Rna STIR iJllctgin9, Ihog 90r;;t;i;Qntrast;, 1'1 'R \'11' h~i;;-l2\'\p-p"<;:;;;$$Q as weJ.:e O\n o,xiCil ",nd corona 1 Tt precontrast :oequcnce. 16 CC ':;Jf Omniscan go.dc,lin~um con~:rilst \'IdS uLilizcd for the postconr.1'.;1S1"'. scan.
Findin'.:JG'

REVISION -

Arlct~ndLrn

X 1 DUPLICATE

Page

DePaul Medical Records/Phillip H. March

000331

DFPJl.m, HE.7;LTH Cmr::~ER L!30J L.leL'"ul Drive Bl"irigl'ton. DLZI,(;NOSTIC Il\IAGllIG

MO 63044

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Pt Loco,tior.: "O/p ZlNSeR, PHILLI[l

Uat0: 11/07/07 2:19

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63041

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101(1878-70263

There 1= marked edema and enhancement. wlthin the left 11lt1~;;;t;Ler muscle adj':\cE'l1t tCI the let!: manrlihular ramu~. Additionally. there :.;; R\lbcutaneou~ :;;vfL tissue ,-,welling and skin thif:ken1.ng of th(; left [<l(.;t;! in thic regIon. i\ci<iltlonallYI ill-det:in'Old infl",nllnLltorr chan;!", 1.S seen \vl t.hln tile dee;;; left; fuce near the caro': Id 6he.;!t.h. The flow vOlds o[ the jugul':ir 'I"ein and carotid are maintalned, TlJere is bonc mint-C'w edema and <"e'1h.'inr:F:ment wi thin tIll.:! 1t.:f',. I1k,ndiblll",y r~mus and neck "ri rh ilreas of c',;n;'tical in(\;.ctlw;:r:ness. 'The lnflammatocy findings arc glez-d'et' than '~ype("ted g~. \'en th~ remclLe HdLuL'e of the trClurna ,~nd surgery ,:tnd ; s
',,}orrisc)me {CL HkU'ldibul . ll.
C:Gte~:;mj"ell.tis

',lith

2t~~0r.iated

left

ma~!::H;::!tel

myositis and Thert: .:U"e


flO

reg'on~l

cellulitis.

foc.)l f hud collect.i ons r.o suggest Qu"cess,

Blooming iirtifact is seen in the region of the left mandibu .ar condyle compdLiblc I.d th retained met all i c fragm=nt.
No other fuel of <;,bnormal ::;ignal il3 8een I"ithin the face. There: is no other sitec of abnorma 1 Rignal within the mandible. There i l l no abnorma 1 sign.3i \"ithin the m~x.ill"". The par_"'pharyngeal 60ft t.issues dre unLemoOlrkClble. The tongue and peritonsill.~r cegions Llre nc.rm.ll in signal and m0rpr)Ology.
Impression: findings uTe '.'Iorricome for lett mandibular oHteufH'y'el.i.Lis invohrin9 the ram\IC and neck \.;j th an associated left masseter myositi, and regional cellulitia as dot~iled above.

Relea8",d By-

KC<ld By- NCAj,1.1;.,.'1 VI SIDDTQT t4.D. brO.!lj'IAN W SIDDiQI Ilf. D.

Reled~t.:d D~te

Time- 11;08/07 1?D?


Page 2

Tranc:.cl-iptionir;r.- SVN
RE,VI:3T01J - .l\ddenduill X 1 DUPLICATE

DePaul Medical Records/Phillip H. March

000332

DEPl\UL HEALTH CENTER


12303 Df.'P"1l1 Drive Brid<]et()l1, DIAGNOSTTC H1AGING
r"10 6]044

M.ll.RCH,PH1LLIP H
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DePaul Medical Records/Phillip H. March

000333

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ooe
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I~JS

I1T.tF-HO-Nf VO

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I

SELF PAY NO INSURANCE

10f02f76
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an).!

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1j~P'

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~N-';\llf~"'{

1-=1)11

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MARCH,PHII.I.IP H
I t.,UJ.MrUf'>

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I
I

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.'--'~-

I '''SUlw,a (0"1,1("15:

PHYSICIAN OFFICE COpy

12/26/2007 21 :35: 1

DePaul Medical Records/Phillip H. March

000334

DEPAUL HEALTH CENTER


DISCHARGE SUMMARY
PATIENT: MARCH, PHILLIP H ADMIT DATE: 12/26/2007 DISCH DATE: 12/28/2007 PHYSICIAN: SONIA N. MELKA VERI, M.D. MR#: 000748298 ACCT#: 0736000302 DaB: 10/02/1976 ROOM: 0530

DISCHARGE DIAGNOSES: 1 Osteomyelitis of the mandible on the left side.

2 3 4

Hypertension.
Chronic pain. Impression narcotic-seeking.

PROCEDURES DONE DURING HOSPITAL COURSE; CT scan of the facial bones, CONSULTANTS; 1 Or. Kennedy with infectious diseases. 2 Dr, Gunapooti with pain management. HOSPITAL COURSE: The patient is a 31-year-old African American male with a past medical history of left mandible osteomyelitis after a stab Injury to the face and open reduction internal fixation with removal of the hardware. The patient was seen by Dr. Zinser as an outpatient and he has been on an extended course of antibiotics, Meropenem and clindamycin, The patient came in saying that he has had increased swelling and pain in the left side of the jaw. The patient insisted that he get intravenous BenadryJ and not p,o. Benadryt for itching from the pain medications and also insisted that he get intravenous Dilaudid. He used to take other p.o. medications. There was suspicion narcotic-seeking as well. Infectious disease was consulted and Dr. Kennedy that he continue the Meropenem and the cllndamycin for his osteomyelitis as per Dr. Zinser's orders. Home health care has already been set up and social work contacted them in his home. Infusion orders will be restarted and he will follow up with Dr. Zinser as an outpatient. He will be sent home on Vi cod in for his pain controL He has been asked to follow up with the John C. Murphy Clinic and the pain management clinic for his pain control. DISCHARGE MEDICATIONS: 1 Norvase 5 mg p.o. daily. 2 Meropenem 500 mg intravenous eVery 8 hours as per home infusion orders per Dr. Zinser. 3 Vicooin 5/500 2 tablets p.o. every 4 hours p.r.n. 4 CHndamycin 600 mg intravenous every 8 hours as per home infusion orders per Dr. Zinser, DISCHARGE DIET: A regular diet. DISCHARGE ACTfVlTY: As tolerated.

DISeHARGE INSTIWCiIONS: Follow up with Dr. Zinser. The patient is to call 291-7997 for an appointment in 1 to Z weeks. Follow up with John C Murphy Clinic in 1 week.

MEDICAL/SURGICAL DISCHARGE SUMMARY.Df'

- Page 1 of 2

DePaul Medical Records/Phillip H. March

000335

DEPAUL HEALTH CENTER


PAT!ENT: MARCH, PH!LLIP H MR#;

DISCHARGE SUMMARY
OQQ74~2ge

SONIA N. MElKAVERI, M.D. SNM:1-256 - 2118270

0: 12/28/2007 5: 12 PM T: 12/29/2007 7:15 PM E: 1212912007 22:00 PM

co:
IMRAN A. HANAFL M.D.

MEDICAUSURGICAL DISCHARGE SUMMARY-DP

.Page2of2

DePaul Medical Records/Phillip H. March

000336

)i? I;)
DEPAUL HEALTH CENTER
DISCHARGe SUMMARY
PATIENT= MARCH, PHILLIP H ADMIT DATE: 12f26/2007 DISCH DATE: 12/2812007 PHYSICIAN: SONIA N. MELKAVERI, M.D. MR#: 000748298 AceT#: 0736000302 DOB; 10/02/1976 ROOM: 0530

DISCHARGE DIAGNOSES: Osteomyelitis of the mandible on the left side. 1 2 Hypertension. 3 Chronic pain. 4 Impression narcotic-seeking. PROCEDURES DONE DURING HOSPITAL COURSE: CT scan of the facial bones.

CONSULTANTS; 1 Dr. Kennedy with infectious diseases. 2 Dr. Gunapooti with pam management. HOSPITAL COURSE: The patient is a 31-year-old African American male with a past medical history of left mandible osteomyelitis after a stab injury to the face and open reduction internal fixation wittl removal of the hardware. The patient was seen by Dr. Zinser as an outpatient and he has been on an extended course of antibiotics. Meropenem and clindamycin. The patient came In saying that he has had increased sweJling and pain in the left side of the jaw. The patient insisted that he get intravenous Benadryl and not p.o. Benadryl for itching from the pain medications and also Insisted lhat he get intravenous Dilaudid. He used to take other p.o.

medications. There was suspicion narcotlcseeking as well. Infectious disea36 wa~ consulted
and Dr. Kennedy that he continue the Meropenem and the clindamycin for his osteomyelitis as per Dr. Zinser's orders. Home health care has already been set IIp and social work contacted them in his home. Infusion orders will be restarted and he will follow up with Dr. Zinser as an outpatient He will be sent home on Vicodin for his pain control. He has been asked to foHow up with the John C. Murphy Clinic and the pain management clinic for hiS pain contro/. DISCHARGE MEDICATIONS: 1 Norvasc 5 mg p.o. daily. 2 Meropenem 500 mg intravenous every 8 hours as per home infusion orders per Dr. Zinser. 3 Vlcodin 51500:2 tablets p.o. every 4 hours p.r.n. 4 Cllndamycin 600 mg intravenous every 8 hours as per home infusion orders per Dr. Zinser.

DISCHARGE DIET: A regular diet.


DISCHARGE ACTIVITY: As tolerated.

DISCHARGE INSTRUCTIONS: Follow up with Dr. Zif"lSer. The patient is to ea1l291-7997 for an
. appointment in 1 to 2 weeks. Follow up with John C. Murphy Clinic in 1 week

This document has been reviewed and signed by SONIA MELKAVERI Sign DatelTime: 01/22/2008 10:56PM EST

MEDICAUSURGICAL DfSCHARGE SUMMARYDP

- Page 1 of 2

DePaul Medical Records/Phillip H. March

000337

OEPAUL HEALTH CENTER


PATIENT; MARCH, PHlll,.lP H

DISCHARGE SUMMARY

MR#: 000748298

SONIA N. MELKAVERI, MD. SNM:1-256 - 2118270 0: 12/28/20075:12 PM T: 12/29/20077;15 PM E; 01/23/2QOa Q9:03 AM

cc:
IMRAN A. HANAFI, M.D.

MED1CALlSURGICAL DISCHARGE $UMMARY-DP

- Page 2 of 2

DePaul Medical Records/Phillip H. March

000338

Patient Oi$Gh~rg~ In~tru~tk>ns


Discharge diag nosis: Discharge disposition

Flu Immunization Given _ _~_ Pneumonia Immunization Given ---~~=---~Home Care Agency:

~------.-

.. -.--.- ..

PRESCRIPTlON~.~__g.J"~me 0 Written 0 Given 10 Patient .~ Called to pha~~~_cy~_ _ MEDICA nONS: See Di~ch~r9.e Horne Medication List attached WORK: 0 Return to work in days or 0

Activity:

Maintain

usual Restrictions

physical activity Pac~ activities and plan for rest pgriods

rt~egUlar Diet Modified Diet _ _ _ _ _ _ _ _ _ __


o Instructions given by Dietician Smoking: Do not smoke/Avoid second hand smoke
Smoking cessation inforrwtion provided and

revIewed for patients who smoke .

. Worsening of symptoms - cart your physician if any of the fonowing apply to you: A fever greater than 100F or cnills Excessive redness or unusual drainage at
A worsening cough with sputum that is green or yellow or bloody Worsening shortness of breath, with or without activity Swolfen ankfes or hands
it

surgical site Excessive bleeding at surgical site

Unrelieved pain
NumbnessrnnglingfChanges in color Qf affected area

Weight Monitoring it you have H6art or Kidney Failure


Weigh yourself the morning after you get home and daily after going to the bathroom and before

breakfast. Notify your doctor of w~.!Rblg_ain of 3 or more pounds in one day or 5 pounds in 5 days.

LLOW.UP CARE; Bring all ~youto yourappointmenL I') Call for appointment with Dr. Phone # to be seen in ~weekS Call for a ointment with Or. Phontl # to be seen in weeks

Physician Signature:

CJf.liHigna Cite needed see orders.

Belon9ings returned: 0 None 0 Glasses 0 Denture~ 0 H~~ring Aid($) CJ Assistive dev!c~ o Home medications 0 Other: These instrucfcm~:. Jl~~.~\leRl'~iewed with me and my questions have been answered.
Patienf Si

'It;r~' ~

~
DiSCharged to

SI nificant Other
Home Other---------~~~,-----Phone # after discharge ____~_ Escorted b ;

Date:

C ~~-----

Actual time Of Discharge. _ _ _ __

Nurse

o o

Mode:

o I:l o

we
Ambulatory Stretcher

i11ii iili ikf~l=fj#:ie;lli~R~'IJi.ttlg:j=:;i,.\t.ft;ii'iUil~~fll!l'fiI~~Q~ ;!!7 ' ",.J!1I!.re JP:::====== DEPAUL

HEALTH CEN'I'BR

)
j

1/ P 0736000302 rilED 0530-01 10/02/1976 31Y M 12/26/07 ~------------------------------------------ HANAFI,IMRAN A 00074829~

.--..:..;;.=:..;;.;;==..::..=;~=-~===---------------~

Make 2 copies ofLhisf.or-m. Originalfonn to chart, Co .

11111f111UII.11I111 MARCil, PHILLIP H

DePaul Medical Records/Phillip H. March

000339

H
DePaul Health Center 12303 Depaul Drive
PAGE tmNBER: 1 ESTIMATED DISCHARGE TIME:

Please circle! Discharge Meds or post-op Meds Bridgeton,NO 63044 Patient Active Medication List (YES NO) Account Number: 0736000302 Patient Name: MARCH,PHILLIP H Room Number: 0530-01 Date: 12j2e/2007 Attending Physician: HANAFI.:tMRAN A Patient Allergies: No Y~own Drug Allergies
NURSE: PHONE EXT:

DePaul Medical Records/Phillip H. March 000340

Continue? Medication Generic Name(Brand Narne) with Directions

I AM I Noon I PM I Bedtime I

Scheduled Medications **-

AMLODIPINE(NORVASC)5 MQ BY MOUTH Daily


11

GIVEN AS:

(1)

5 KG TABLET

SODIUM CHLORIDE

O.9%(NO~

SALINE} 1000 ML

INTRA~OUS

13

MEROPENEM(MERRBM)5DO MG INTRAVENOUS EVERY 8 HOURS

-o~
.-*.~

*.r*_ As Needed Medications


19@-0
HYDROCODONE/APAP 5/500MG{VICODIN 5/S00MGl

~~
FOv~
GIVEN AS: (1) 0.1 KG TABLET

* EVERy a HOURS

2 TAB BY MOUTH Every 4hrsprn

23

YES~ONIDlNE(CATAPRESiO.l

MG BY KOUTH EVERY 6 HOURS

AS NEEDED

B YES

~ROMORPHONE

MeL (DILAODIJ)) 0.5 MG INTRAVENOUS Every 4hrs pm

PHYSICIAN SIGNATURE IS REQUIRED ONLY ON THE LAST PAGE OF THIS MEDICATION LIST
:>

Pilot Form 4/2005

= Medication Substituted per HOSlpital. Approved Formulary Substitut:ion

H
DePaul Health Center 12303 DePaul Drive
PAGE NUMBER: 2

ESTIMATED DISCHARGE TXME: NURSE PHONE EXT:

P1ease circle: Discharge Meds or Post-op Mads Bridgeton.MO 63044 Patient Active Medication List (YES NO) Account Number: Patient Name: Room Number: Date: Attending Physician: Patient Allergies: 0736000302 MARCH, PHILLIP H 0530-01 12/28/2007 HANAFI,IMRAN A No r~own Drug Allergies

DePaul Medical Records/Phillip H. March 000341

Continue? Medication Generic Name (Brand Name) with Directions

I
AS NEEPED
AS NEEDED

.AM

Noon

PM

Bedtime

9 YES
10 YE
22 YE

ROME"l'HAZINE(PHENERGAN)12.5 MG INTRAVENOUS EVERY (; HOURS

E1'OROLAC (TORADOL) (TORADQL) 30 IMG INTRAVENOUS EVERY 6 HOURS IFHENHYDRAMr.NE(EENADRYL}25 KG INTRAVENOUS EVERY 6 HOURS

AS NEEDED

leW
:>

Held Scheduled Medications *****


CLINDAMYCIN(CLEOCIN} (CLEO'CIN) 600 KG INTRAVENOUS EVERY 8 HOURS

--i7 r~ ~a~

. . EVERY

HOURS

p-~
PHYSICIAN SIGNATURE IS REQUI.RED ONLY ON THE LAST PAGE OF THIS MEDICATION LIST

Pilot Form 4/2005

Medication Substituted per Hos:pital Approved Formulary Substitution

H
DePaul Health Center 12303 D@Paul Drive

PAGE NUMBER: 3 ESTIMATED DISCHARGE TIME: NURSE PHONE EXT:

Please circle: DiBcharge Meds or

poet~op

!Meds
Patien~

Bridgeton,MO 63044 Active Medication Liat {YES Nol

Account Number: Patient Name: Room Number: Oate: Attending Physician: Patient Allergies:

0736000302 MARCH. PHILLIP H 0530-01 12/28/2D07 HANAFI.IMRAN A No Known Drug Allergies

DePaul Medical Records/Phillip H. March 000342

Continue? Medication Generic Name (Bran,d Name) with Directions

I
~

AM

Noon

PM

Bedtime

Additional Orders

t.t

-..-.-.-.......-...---..- ... -------.........----.-.-.-----!-\.-.-...--.-.~-.--.


f0GJ-~

\)y _

___

2A i -lC{U

tJ\;aF1:~

~-~----------

------------..-...-----------

------..--.. ------------------_.
Physician Signature:

:fjA-~

Date/Time

(?{2>6[

7
Readback Confirmed [ ]

Nurse Signature:

Date/Time _ _ _.

PHYSICIAN SIGNATURE IS JREQUIIRED ONLY ON THE LAST PAGE OF THIS MEDICATION LIST Medication Substituted per Hospital Approved Formulary Substitution

pilot Form 4/2005

ORUGMAVBCDISPENSf:DINACCORDANC[.VfTHIHS PHVSfCfAN'S ORDERS ~~~~~~~~~~~ IMPORTANT

REMIND~RS

i 'Oaily' Instead til "qd'

'l, 'Unit5' instead of V


3 No trailing wros (lJTll1 noll.0mg) 4. Always HtAI&adiflg IQlVS (O.!rT1'J nat .1ma)

PAT/riNT HEIGHT c;>

5. 'Morphine' irlllftlad of "1.1804" 6. 'M3~nium ~UIta16' li\I,lbid of 'MgS04' 7. 'Every otllel oay' f0Sl9ad Of '0.0.0," a "MCG' in~toad oI'U'l 9. 'IntemmQrW umb" in,ltad 01 'Ill"

~SSM
H E A L T H . CAR E
PHYSICIAN'S ORDERS
SLM' OOO0fS5 (4/2007)

PA TlENT LABfL
DEPAUl. HE.AJ.,TH CENI'ER

MARCH, PHILLIP H
':lANAFT, INR.l\N A

IIIfBfiltllflmUlMlIJDH

lip

0736000302 MEV 0530-01 10/02/1976 3lY 1"1 12/26/07


a007'i8298

DePaul Medical Records/Phillip H. March

000343

DRUG MAY BE Di$PCNSfD IN ACC;<JROAN"F WHH TH

PHYSICIAN'S ORDERS
1. "Dally' InSlftad 01 'qO" 5. 'Morphil\9' instead 01 'MS04'

Z, "b'nlto IMIOOd ot V
3, No tralllng ~~IOS (1"'1/ nol 1.0rw) 4. Always usslRa(!inq leJ\lS

6. 'MJgJ1lIsium sulfate' insteoo of 'MgSO~'


7. 'EVftry O1Irer day' Insieau 01'0.0.0.' 6. 'MeG' insl~aa ot '119" 9.Inlemallonallllllts.lr.ste~dor.IV

(O,lmgr.ot.l mnl

~ss
SLMl000-0GS (41'2007)

H E A l T H ' CAR

DePaul Medical Records/Phillip H. March

000344

DRUO MAY tiE OfSPENS~~S~ ACCORDANCE WITH ~~RE

PHYSICrAN 7S ORDERS
1. 'Daily" Instead of "qd'

5, 'Morphine' Insli!ad of 'MS{J4"

Z, 'Uafif inattad of .~'


3, No fTailiCl\l zelos (lmq no! 1.0fngl 4. Always use leading lS/OS
PATIENT HEiGHT .:::>

6, 'Mauoolum wffJflf illsteJll ot "1,1\1504'


7. "EveT)' ather day" Instead of '0.00.' 8. 'MeG' instead III 'jig'

(O.lmg not.1mq}

DEPAIJ1, HRALTH CENTER

fvIMCH, PHTT,LIP H

1IIIUfIjlliDDUILUIll
,1

r /p

0736000302
PHYSICIAN'S ORDERS
SLMl000-065 (112007)

MED 0530-01
1')./26/07 OOO'/4879B

10/02/19""16 31Y HANAF 1. IMRAN A

DePaul Medical Records/Phillip H. March

000345

l'lRUC~I"'YOCD1SPt'I:;~i.J1NACCORD"N'~fwnHTHE DH~o~I<PErr~A~l~~~~'~~'~'~~G~H~F\'~'K~'E~o~H~ER~E~~==~______

PHYSICIAN'S ORDERS ----------1


1. "Dady"
m~tNd

IMPORTANT

REMIND

01 "Qd"

.'i "MOfphine" II1steatl 01 "M504'

? .~"'~" !n~t~i!d 3

V! y

fi "MaallmJm suJjijlE" rn3teSd 01 "MgS04"


7. "EVAry o~r day' ;I1$lcad ul "Q.O.o" B. "MeG" in>lBJ\1 01 "I1Y" 9. "International Units" ill~teall 01 "IU'

4.
PATIENT HEIGH: Q
__

, '-----.

~SSM e r
H A L
SLM1OOO065 (7!200fi)

PA TIENT LABEL

H . CAR E-

DRPAUL HEALTH CENTEH MARCH,PHILLIP H T/P 073(,000302 MED 0530-01 10/02/1976 31Y 1<1 12/26/07 HANAFl, IHFAl'J A 000748299

IIIIDUIJlDflJllllDl1I

PHYSICIAN'S OROERS

DePaul Medical Records/Phillip H. March

000346

DRUG MlW BE DlSr'CN(;J:D iN ACCOHUANCI' WiTH TH. HOSPITA~ FOAMln.ARY SYSTEM HEME

c~D

PHYSICIAN'S ORDERS
1. "Dally' instead of 'qd' (, "Unns" Instead of "\I' 3. No lrailiflllZSlllS (Img 1101 jOmg) 4. Nways use lea\lillQ l1Iro,
5. 'MOI]lhiflll' inslaad o/'MS04'

.'

G. 'MtQMlUm sulfata' In5ltl~d of 'Ml}5(W


7. 'EV~IY !!VJif dlly" Inst&ad of '0.0.0' a. 'MeG" iJlSteaQ 01 'w' 9, '!ntfmatloI1aI urJts Instead of 'fU'
.

PATIENll't'EIGHT

*
TIME;

o Kg>

Dlb~
""'~.~n

PATIENT HEIGHT 0;;'

(O.lmgno'1mg)

I.....

J~.~T~.

,,"M'

DERS

".........,"',

t)I':JJJ~.
f').
'j)

I
NURSING REfERRALS (based on nursing p$sessment/no physician order required) U
Diabetes

!\,~

kD
Q

Nur~~
Q

Pastoral

Care Allergies:

ET NulSB
Clinical Nutrition Infection Control

0 Social Service
PharmaQY /

d,

A '7 ~,..,6..1 ~'F/<-J ../),

I I

Height:
Code Status:
DPM'TM-(}~2

Weight:

Pneumovac year:

P
RN/LPN

Date;

(8/200.)

( j) Li,."jjl
t:~i) /.fi~ J
.~-r-

.t;.

('

1/ c?I--~

k ) ; . },.

. .~.-~

..

/:~ l(/;

,.I ~ ".- ;::--

//

'-

I'.

'\'"

"\,

" ".
,

~\
.\.
\.

\
\,
\
'\

'\

\\

\.

\.\,

'\
,"",
"

~SSM
H
~
!1 (12 4 007 l SL /.1-1000 1 00

PATIENT LABEL

A L T H . CAR E-

DEPAUL HEALTH CENTER ~0)~

PHYSICIAN'S ORDERS

ERQ MARCH, PHILLIP H 0736000302 ERS 10/02/1976 3lY M 12/26/07 EMERGENcy,PRYSICIAOOO748298

111111

DePaul Medical Records/Phillip H. March

000347

Vancomycin Dosing Protocol Physician Orders


The followmg standing orders shall be initialed by the pharmacist upon receipt of physIcian's order for vancomycin protocol. Vancomycin prolocol details and references are available in the pharmacy department.

Indication for vancomycin


Patient's Age: _3_1_
Actual Body Waight (A8W): Ideal Body Weight (18W):
Curren! serum crealinine:

-~C< (. \<...Q /J(J..LLJ CRJJ..JlJ.-JL ( h ~


M_ Height: Sex; __

71.0

inches

ABW

....L2:.L
~

Ibs:: kg

73.0

kg
_--,-,12=..:3~_ ml/mln

Calculated creatinine clearance (Clcr):

Medication Orders (derived for this patient from the tables befow): 1. Vancomycin 1250 mg IVPB Initial loading dose (infuse over 1.5 hours), THEN 2. Vancomycin 1000 mg IVPB every 12 hours (Infuse over 1 hours), ~~ beginning 12 hours after the loading dose. 3. Vancomycin trough levet to be drawn 30 min prIor to the AM dose on 1LJ!
Other orders'

'lnitialization Proiocol Dosing Table~ (see actual orders above)

Initial Dose

Mainl Doses
(-15rnqfk!)

Patient's

weiaht

(~20mgfkj'J)

.:.;M""a;.:;in~t""e:..;;na::..:n.:..::c:.:::e....::D::..:o""s:..::in=-.!QI-",n!-"te"-rv,-"a,,,I;_ _ _ _ _ _ _ _ _ _-if

ABW'( 45kg: ABW 46-.60kg: ABW 6O-76kg: ABW 7S-90kg: ABW> 90kg:

750 mg , 1000 mg , 1250 mg , 1500 mg 2000 mg

then then then Ihen then

500 mg 750 mg 1000 mg 1250 mg 1500 mg

Clcr> 50 mt/min and age <75: Q 12 hOUfS Clcr;:. 50 mlfmin and age :.",75: q 24 hours Cler 2050 ml/min: q 24 hours Clcr <20 mllmln; One time Initial dose. maint dose orders to follow

Pharmacist will evaluate laboratory data and provide writt8n orders for dose and/or interval adjustments with the goal to attain trough vancomycin levels within the target range of approximately 1520 meg/ml for hospital-acquired pneumonia anD 10-15 mcgfml for other indications, Pharmacist will provide written orders for appropriate laboratory monitoring pertaining to vancomycin dosing. Cancel serum levels If vancomycin IS disconiinued.

vancomycin

Duralion of therapy will be determined by th@ physician.

Deviations from protocol guidelines will be explained In the progress notes.

i Ordering Physician's &gnalure: _ _ _ _ _ _ _ _ _ __

~SSM 'NWMJil*.PU
H ~ A L l J1
.

e A R E'

March, Phillip 736000302 530

VANCOMYCIN DOSING PROTOCOl PHYSIC1AN ORDERS


SU,I....,< ... (02/05)

DePaul Medical Records/Phillip H. March

000348

EMERGENCY DEPARTMENT ADMISSION ORDERS


""ti."Name:

~f~ t p~"\\"~

Dlagnos~

(Pll.,tb

1---I-~p~ti;~t-;d~it-1~;--f.(M~di;~i-D-s~;~;~~i"o--T~j'~'~~~';;"'O-3"N~rt;'''{i;~t~';~~'d;;;~-i'c'v)'-''D'icu''_

!~~:::::"'_(~;1:~~;~_10' rJ~~i~.~I_~~::::~D_T~~~.~
Code Status

-~

10 DNR
I.

ull Resuscitation , 0 DNR - Continue Medical Therapy

. _f?. .

J ::1J
..1

_~~

r--AII.-rgi8s-,

~-+)-~-- . _ - -- - "-~------'l

- Comfort Measures

._

~
ASSESSMEN o 1& 0

o Acute Cardiac

0 C()1l9E1stive Heart Failure 0 Acute Pulmonary

~ital signs every ~ hours X _ _ then


. ADDITIONAL DfAGNOSTICS

~Obtain Prev;outj Mecficai Recorda


routine
0 Dally Weights

o Oximetry o Cardiac Monitoring

~
S

CSC

MP OPT

DCXR
0 EKG 0 _ _ _ _ _ _ _ _ __
0 AC & HS 0 every _ _ hours

DPTT

o Fingerstick Glucose
1fI. MEDJCATrONS

IV. TREATMEN

o IV ffUidS. _ _ _ 10_~---->@~---Jlu.,Z....:.c:'......;...:M=L,+j.I.Ll-,-r_ __
. _ _llters per

Saline Lock

o Oxygen at _

Call physician If 02 Sat less than ___%,

((E

~egUlar ~~,_.l_ ea!o,ie ADA 0 ~_ _ _ _ _ __ ktMty 0 Bedrest ~BRP 0 Sse 0 Up ad lib 0 _ _~_ _ _ __
. . 0 NPO

FO/@YONGtosuetlonf.!.-:V>

Date: 12Transcribed by: _ _ _ _ _ _ _ __

Physician

Time Noted: RN,_ _ _ _ _ _ _ __


Tima:, __ ' _ _ __

S&,. &~/
if"
',t.~,----....

Orders ,anned to Pharmacy - Date:

Initials: _ _ _ _~

/ :2115
~~MOPM2000-19S (10/2007)

'\~_ : .', ...r... '

t! ... '\)

DePaul Health Center

ED ADMISSION OROERS

DePaul Medical Records/Phillip H. March

000349

HOME MEDICATION LIST ORDER SHEET


I---C----------~---~----~-----~~~~-------

--------

p
-----------~~------------,_,

Other

rIsk) DYes -descflb"-,.-_...-.,.___________

Ch4!!Ck the bol( below it you have ever &xperlenced 'u~-n~y=n-o-s-e=.t=earing. sneezing, Of Itching after:
Dfmta/llntemal exams lJ Contact with rubber gloves/product'S U blowing up balloons Q Use 01 condoms or diaphragm
bal1Bn,as avclca<1os. water

Antlwering 'yeo' to any of

kiwi

o Allergy armband
supplements (list only wrrent mecJ~1

these require initiation of Lat~x Allergy Protocol Chart labeled

Homo H~'th Services being used? 0 y@!; 0 No ff yes, Name Ty~ -:-____~-Sources of information: CJPatltml U Mooicalion Bottles 0 PH!lent's Family CJ Med List U Doctor's Office o Pharmacy Name _ _ Pharmacy Number U 01<1 Chart U Other
La~t

Dose

Comments

H~meM

~'&Jictllionslltf)rbalivftJml"s lYIh b'!' di$psnsed in 8c;;Qfl:J~n(;tj Wil./I /hI! hap/t


Non-fQrmulary

These checked orders will only become active when authir tq by pnysiGldn

Record~d

315"

Dg!e~~

h8rb~l$/vifim;"s Tlme.zw!L ___


Time: ______

IVtll bi! h"k/ dUring, """'''

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__

Date _ _ __

Nurse' _ __

o Readback confirmed

10 Ph"",acy Dote' _ _ _Time': ____ 'nitia/s_ _

1111111.11111 MARCH/PHILLIP H

DEPAUL HEALTH CENTER

-.S3'A
ERQ

(/

0736000302 ERS10/02/1976 31Y M 12/26/07 EMERGERCY,PRYSICIA000748298

DePaul Medical Records/Phillip H. March

000350

\'

...

DEP~UL

HEALTH CENTER

IlfJllIllllIllllIl1II I\1ARCH, PHILLIP H


0736000302
: J!ANAl".l, IHRA.. N P.

rip
000'/48298

f\1ED 0530-01 10/02/1976 31Y 1'1 u/26jrn

DePaul Medical Records/Phillip H. March

000351

DEPAUL HEALTH CENTER


I,lARCH, PHILLIP H . 0736000302 MED I 10/02/1976 311:' I HANAFI, n'lRAN A

11111.111.1111111111

;"f',t~~:~~r
DePaul Medical Records/Phillip H. March

.
000352

UMOCOCCAL VACCINE NURSfNG ASSESSMENTI PROTOCOL

~r r~orded.

Is not obtainable by Nursing and/or Cas. Manager, vaCQine ehould be given and
+CDc/ACIP R9COmmlH1detlons MMWH 1012006

Flu VaCI[;lne Nun~lng Ass~ess:melr\t If)rot~()Col

[J . Qualifies for influenza vaccine. Influenza vaocine 0.5 mf 1M wilt be administered on day 3 in NIl or at discharge (When discharged before day 3) per protocol unlC'ts$ countennanded by order of the physlolan with documented.

medfcal reason (Le. fever 101"F or

forwlthttoldlng the vaccination.

Dat~;12b.(JQ

Time: tl2.Jt

j--

Ass&ssment completed by:

6[.u~d.Jv----

~~_,_. _______
ERQ

.q_

~~~~ DePaul Health Center i~n-~----~


Pneumococcal/flu

:1DiiI..~ ~
d073 (; 0 b03 ~2
'

AssessIlPro(o~1 9/2007

MARCfI~~n If
10/02/1976 31Y

ERS-

! EMERGSNCY,PHYSIClA00074S298
DePaul Medical Records/Phillip H. March 000353

M ~2/26/07

TOBACCO USE INTERVENTION PROTOCOL ORDERS


AS1jJeSsment: (RN/lPN to fill in appropriate spaces) "l;a-- Has not use tobacco pwdlJcts. .0 ClgsleHes per day _"_~_ _ /0 SpiVsmokeless tobacco (can/pouch per day) _ Pipe/cigar (number per day) _ _ _ _ ~~_ _ Not currently uSing, date paUen! reported stopped tobacco USB: _-----;-_,,-_ _ __ fl' i '. ('. .",,/ II ,I. C'1. ' i _""(I 1 Assessment completed by; ':1 '\" ;"" \ l...-RN Date:./ I, i; " flme:~

I.

!;

r
\

II.

8ehaviorallntQrY{:ntign;
RN/LPN recommends ending tobacco use or continuing with abstinence. Provide smoking cessation patient education maferials

Excrusion Criteria for nicotine replacement therapy: (select all that apply) o Patient has known allergy to nicotine patch, o Patient is already on nicotine replacemen[ product.

Cl

Pafient refused nicotine replacement therapy

J)

Educational Consult Enter Respiratory Therapy Consult in HaDe for smoking oducation

1ft. Medication Intervention:


(PRESCRfBfNG A NICOTINE PATCH FOR PATieNTS UNDER THE AGE OF 18 Yf:ARS CONSTfTUTES AN OFF LABEL USE OF THE DRUG, PRESCRIBING THrS MEDICA nON WfLL BE LEFT TO THE DISCRETfON OF THE AITENDfNGPHYSrCfAN, IF USED. THE STRENGTH OF THE NICOTINE PATCH SHQULDNOTEXCEEO 21MG UNLESS' EXCEPTIONAL CfRGUMSTANCES DETERMINE OTHERWISE)

o
o o o

less than 20 cigarettes per day or less than olle can/pouch per week (pipe/spit/smokefess tobacco) nicoline patch (Nicoderm CO) 7 mg applied to skin every morning, remove old pafch. 20-30 cigarettes per day or 1 can/pouch per week {prpelspltlsmokeless tobacco) nicotine patch (Nicoderm CO) 14 mg applied to skin every morning, remove old patch. 31-40 cigarettes per day: or 2 cans/pouches per week (pipe/spit/smokeless tobacco) nicofine patch (Nlcoderm QVCQ) 21 mg applied (0 skin every morning, remove old patch. Consult pharmacy for other nicotine replavement options

#f nIcotine crmtrafndicated:

o o o

Other _ _ _ _ _ _ _ _ _~_ _ _ _ _ _ _ _~_ __

bupropion extended release 150 mg PO daily times 7 days, then 300 mg PO daily.

Cri~i~

!ntQrvention:

Acute agitation due to nicotine wjthdrawal


Other ____~_____________________________

alprazopam (Xanax) _

mg PO every 6 hours as needed for agitation,

I agree with the above orders with the exception or Ihose crossed through or NOT CHECKED

DATE:

TIME: _ _ _

PHYSICIAN:_~_ __

TRANSCRIBED BY:
Scanned to pharmacy

TIME NOTED:

~__

RN: _ _ _ _ _ _ __

Date: _ _ _ _ Time.' _ _ _ _ Initials _~~_

DEPAUL HEALTH CENT8R MJ\.RCH, PHILLIP H


TO-nACCO INTERVENHON PRfJTOCOL 11/2212006
0736000302
10/02/1976 31Y HANAFI, TMRAN A

IIIIIIIIIIIIIIIIIIBIO
MED 0530-01

III>
OOD'f4B298

M 12/26/UI

DePaul Medical Records/Phillip H. March

000354

DEPAUL HEALTH CENTER


HISTORY PATIENT: MARCH, PHILUP H

AND PHYSICAL
MR#: 000748298 ACCT#: 0736000302 ROOM: 0530

ADMIT DATE: 12126/2007 DOB: 10/02/1976


PHYSICIAN: SONIA N. MELKAVERI, M.D.

CHIEF COMPLAINT: Left law swelling and pain. HISTORY OF PRESENT ILLNESS: The patient is a 31-year-old African American male with a past medical history of n9nCQmpiiance r left mandible osteomyelitis, and hypertension, who came into the emergency room with complaints of increasing swelling in the left jaw, associated with pain the last 2 days. The patient has a history of a stab injury to the left jaw. status post open reduction and internal fiJ<ation done at Barnes, which was infected and later had removal of the hardware. He was admitted to DePaul Hospital and diagnose<l with left mandible osteomyelitis and ha5 been on extended course of antibiotics, on Meropenem and Clindamycln. He was seen by Dr. Zinser as and outpatient. He Is currently on IV antibiotics and lie states that for the past 2 day~; his pain on the I~ft side of the Jaw has been increasing with increased swelling. He denies any fevers or chills. He has no chest pain. he has no shortness of breath. no nauSea OF vomiting. He has no abdominal pain, no diarrhea, no constipation. No other history. No other current complaints.

PAST MEDICAL HISTORY: 1 Left mandible osteomyelitis.

:2

Hyperten~ion.

ALLERGIES: No known drug aHergies. MEDICATIONS; 1 Clindamycin 600 mg IV Hd. 2 Merrern 300 mg IV t.i.d. SOCfAL HISTORY: He lives with hIs mother. No history of smoking, no alcohol. No drug abuse. FAMILY HISTORY; Noncontributory to the patient.

REVIEW OF SYSTEMS: As per HPI.


PHYSICAL EXAMINATION: VITAL SIGNS: On admission - blood pressure 136/90, pulse 64, temperature 98, respirations'S. Pulse oximetry 100% on room air. GENERAL: Well developed, well nourished, African American male, in no acute distress. HEENT: Cervical lymphadenopathy I}resent. No redness appreciated on the left mg\nglbls. LUNGS: Bilateral lungs clear to auscultation. No crackles. CARDIOVASCULAR: 51. S2 normal, regular rate and rhythm. A6DOMEN: Soft, nontender. Nondistended. Normal bowel sounds. EXTREMITIES: Lower extremities no pedal edema. LABORATORY DATA: On admission, sodium 138, potassium 3.9, chloride 103, bicarb 31, BUN 12, creatinine 1. Glucose 77. AST 125 1 alki3l1ne phosphatase 60. AL T 48. White count 4.9, hemoglobin 12.3, hematocrit 35.2, platelet count 214,000. CT of the facial bones shOWS no evidence of acute injury and i6 unchanged from the previous study. Blood cultures shOwed no growth. ASSESSMENT AND PLAN: 1 Jaw pain, history of left Jaw osteomyelitis. Continue current antibiotics. Vancomycin has been added. CT maxillofacial bones dId not show any change. Infectious disease has been consulted. Question if needs MRI of the mandible/facial bones.

MEDICAU5URGICAL HISTORY AND PHYSICALDP

- Page 1 of:2

DePaul Medical Records/Phillip H. March

000355

OEPAUl HEALTH CENTER


PATIENT: MARCH, PHILLIP H
2
3

HISTORY AND PHYSICAL

MR.#:

000748298

Hypertension. The patient is really noncompliant with medications. Continue to monitor blood pressure and add Norvasc. Pain control. Will start on Vicodin. Consult pain management. Prophylaxis. Place sequential compression devises.

SONIA N. MELKAVERI, M.D. SNM:1-327 - 2116784 D: 12/27/200712:33 PM

T: 12/27/20071:09 PM E: 12/271200714:02 PM
cc:
IMRAN A. HANAFI. M.D.

MEOICAUSURGICAL HISTORY ANO PHYSICALOP

Page2of2

DePaul Medical Records/Phillip H. March

000356

OEPAULHEALTHCENTE~
HISiORY AND PHYSICAL
PATIENT: MARCH, PHILLIP H ADMIT DATE: 12f26f2007 DOB: 10/02/1976 PHYSICIAN: SONIA N. MELKAVERI, M.D.

ata,8

MR#: 000748298 ACCT#: 0736000302

ROOM: 0530

CHIEF COMPLAINT: Left jaw swelling and pain. HISTORY OF PRESENT ILLNESS: The patient is a 31-year-old African American male with a past medical hi~tory Qf nQn<;;ornpliance, left mandible osteomyelitis, and hypertension, who came into the emergency room with complaints of increasing swelling in the left jaw, associated with pain the last 2 days. The patient has a history of a stab injury to the left jaw. status post open reduction and internal fixation done at Barnes, which was infected and later had removal of the hardware. He was admitted to DePaul Hospital and diagnosed with left mandible osteomyelitis and has been on extended course of antibiotics, on Merapenem and Clindamycin He was seen by Dr. Zinser as and outpatient. He is currerttly on IV antibiotics and he states that for the past 2 days, his pain on the left side of the jaw has been increasing with increased swelling. He denies any fevers or chills. He has no chest pain, he has no shortness of breath, no nausea or vomiting. He has no abdominal pain, no diarrhea, no constipation. No other history. No other current complaints.

PAST MEDICAL HISTORY: 1 Left mandible osteomyelitis. 2 Hypertension.


ALLERGIES: No known drug allergies.

MEDICATIONS: 1 Cfindamycin 600 mg IV U.d 2 Merrem 300 mg IV t.i.d.


SOCIAL HISTORY: He lives with his mother No history of smokmg, drinks alcohol over the weekends. No drug abuse.

FAMtL Y HISTORY: NonGontributory to the patient.


REV!EW OF SYSTEMS: As per HPI.

PHYSICAL EXAMINATION: VITAL SIGNS: On admission - blood pressure 136/90, pulse 64. temperature 98, respirations 18. Pulse oximetry 100% on room air. GENERAL: Well developed, well nourished, African American male, in nQ \:lCUtB distress. HEENT: Cervical lymphadenopathy present. No redness appreciated on the left mandible. LUNGS: Bilateral lungs clear to aY~C\lltation. No crackles. CARDIOVASCULAR: S1, S2 nomlal, regular rate and rhythm. ABDOMEN: Soft, nontender. Nondistended. Normal bowel Munds. EXTR~M1T1ES: Lower extremities no pedal edema.
LABORATORY DATA: On admission, sodium 136, potassium 3.9, chloride 1Q3. bicarb 31, BUN 12, creatinine 1, Glucose 77. AST 125, alkaline phosphatase 60, ALT 48. White count 4.9, hemoglobin 12.3, hematocrit 35,2, platelet count 214,000. CT of the facial bones shows no evidence of acute injury and is unchanged from the previous study. Blood cultures showed no growth,

ASSESSMENT AND PLAN:

MEDICAL/SURGICAl HISTORY AND PHYSICAl-DP

- Page 1 of 2

DePaul Medical Records/Phillip H. March

000357

DEPAUL HEALTH CENTER

HI$TORY AND PHYSICAL

PATlENT! MARCH, PHILLIP H

MR#; 000748298

2 3
4

Jaw pain, history of left jaw osteomyelitis. Continue current antibiotics. Vancomy<:in has been added. CT maxillofacial bones did not show any change. Infectious disease has been consulted. Question if needs MRI of the mandible/facial bones. Hypertension. The patient Is really noncompliant with medications. Continue to monitor blood pressure and add Norvasc. Pain control. Will start on Vlcodin. Consult pain management. Prophylaxis. Place sequential compression devises.

This docurnen1 has been reviewed and signed by SONIA MElKAVERI Sign DatefTime: 01f2212008 10:57PM EST SONIA N MELKAVERI, M.D.

SNM:1-327 2116784 0: 12/27/2007 12:33 PM


T: 12/27/20071:09 PM E: 01/23/200809:05 AM

cc:
IMRAN A. HANAFl. M.D.

MEOICAUSURGICAL HISTORY AND PHYSICAL-DP

- Page 2 of 2

DePaul Medical Records/Phillip H. March

000358

INTERDISCIPLINARY HtSTORY AND PROGRESS NOTES


Dale

Time

I NOTES MUST BE S/CiNI:O

z3

~----~----~----------------------~------------~~~~-------------

~SSM
H e A l T H . CAR
E~

DEP~UL

HEALTH CRNTBR

INTERDISC1PLINARY HISTORY &. PROGRESS NOTES

1111111111111111111 t-'IARCH, PHILLIP H

rip

0736000302 !I!ED 0530-01 10/02/197631Y M 12/26/0'1 HANAF'I, U1RAN A 000'148299

SLM\OOO-003 (6/2003j <l2 FRONT

DePaul Medical Records/Phillip H. March

000359

INTERDISCIPLINARY HISTORY AND PROGRESS NOTES


Date

Tillie

I NOTES !.iUST BE SIGNED

_ Date: \ ;...

-TI l?7 Time: ~

SSM DEPAUL PA TORAl CARE

NOles:~~~~.~"~~.~Q~~'d~\ ~;~( - ~.~~~~~~~~,~,~~~~~.~,~~~~~i~~~,:{~~l~~/~~~~;~:~~:~r __ fl" 1(; 1> 4 fl\~' :';1 .:~/ ~ ~2


f

SPIRITUAL ASSESSMENT: 01n1tial 0 Follow-up Referral 0 Trauma 0 Code 0 Death 0 _~_ _ _ _ _ _ __ - DISTRESS: 0 Anger 0 Fear 0 Anxious 0 lonely 0 Guilty 0 Pain 0 Grjef D _ _ _ _ _ _ _ _~______ ~ RESOURCES; 0 Gratitude 0 Tr~ Ho . Po~itive Image of God ~mi!y/FriendS 0 Church 0 ~=_ _=~_ _ SERVICES; 0 Saeram~nts ~yers.., Support 0 Literature 0 Support To Family 0 _ _ _ _ _ _._ _ _ _ _ __ - ADVANC DIRECTIVES: 0 Va No 0 Unknown by Patient 0 Inappropriafe to Ask 0_-,------,_ _, _ _ _----:-_ __
(.'-=-i--.d-_

,Cl

C;

iii'!

;, \""

cl4Cil""

Chaplain:

~,1

:I V

SI.M1 OOQ-003 (6f2G03) 02 BACK

DePaul Medical Records/Phillip H. March

000360

INTERDISCIPLINARY HISTORY AND PROGRESS NOTES

~ ----~----~----------------------~------------~~~~~------~~---

~SSM
H E A L T H . CAR
SLM1000-003 (612003) 02 FRONT

E~

DEPAUT, HEALTH C'RNTEP.


MAl~CH, PHILLIP H
r

INTERDISCIPLINARY HISTORY & PROGRESS NOTES

liP OJ36000302 MED 0530-01 lO/02/lY I6 3lY 1'1 12/26/0"


000"148298

1IlIIlff111111BIlftilltl

l1J\l'1Af'I, TMRAN A

DePaul Medical Records/Phillip H. March

000361

INTERDISCIPLINARY HISTORY AND PROGRESS NOTES

~SSM
H E A L r H . CAR
SLM1000003 (Ot20()3t 02 BACK

E~

INTERDISCIPLINARY HISTORY & PROGRESS NOTES

DePaul Medical Records/Phillip H. March

000362

INTERDISCIPLINARY HISTORY AND PROGRESS NOTES


Dilte

Time

\ NOTES MUST BE SIGNED

I ~----~----~----------------------T-------------~~~LA~B~R-------------~SSM
H E A L T H . CAR

DEPAUL HEALTH CENTER


MARCH PHILLIP H

~-

IHlUIUlIlIIlltlllUlil1

INTERCISC1PLlNARV HISTOFIYa. PROGRESS NOTES

07J60~0302 MED OS30-0J_ 10 / 02/J9763lY M 12/26/ 01 HAi~AF11 .LHRAN 1\ OOO'l4B29ll

1;-' L

DePaul Medical Records/Phillip H. March

000363

INTERDISCIPLINARY HISTORY AND PROGRESS NOTES


Dale

TUlle

INOTES MUSf Bt SI(iNED

PA 71ENT LABEL

~SSM
HEALTH

DEPAUL H5ALTH C&NTER

CAR

E~

INTERDISCIPI.INARY HISTORY & PROGRESS NOTES

rip MARCH/PHILLIP H MED 0530-01 0736000302 10/02/1976 3lY r,l 12/26/07


HANAFI, lMR1\N A

1IIIIIIIIUlDl.III~U

000748298

SLMl00o.003 (612003) 02 BACK

DePaul Medical Records/Phillip H. March

000364

DEPAUL HEALTH CENTER


CONSULTATION REPORT
PATIENT: MARCH, PHILLIP H ADMIT DATE: 12126/2007 CONSULT DATE: 12/27/2007 ATTENDING PHYS: IMRAN A. HANAFI. M,O. CONSULTING PHYSICIAN: MICHAEL J. KENNEDY, M.D. MR#: 000748298 ACCT#: 0736000302 DOB: 10/02/1976 ROOM: 0530

REASON FOR CONSULTATION:

Evaluate patient with chronic left mandibular osteomyelitis.

SOURC E: The patient's current Inpatient medical record and old infectious disease consult note and the patient himself

HtSTORY OF PRESENT ILLNESS: A 31-year-old African Am eriean male with a history of hypertension and stab injury to his left face/jaw reQuiring surgery with hardware placement at Barnes Jewish Hospital. The patient subsequently developed infection and had the hardware removed and has since had a chronic left mandibular osteomyelitis. He Is currently being treated with IV clindamycin and meropenem until mid January for his osteomyelitis and has a Pice line in his right upper arm. The patient frequently presents to emergency rooms complaining of increased left jaw pain and swelling. He presented to DePaul Hospital Emergency Room yesterday with complaints of two days of increased left facial pain and swelling but no other systemic symptoms, He was continued on his current IV antibiotics and vancomycin was added. He was admitted for further evaluation and treatment and I was asked to see him for antibiotic management. A CT scan of the face was unchanged from prior and did not reveal any new sign of infection. He has been afebrile with a normal white cell count and cultures from the blood have been negative. The patient denies fevers. chills, sweats, nausea, vomiting, diarrhea, constipaUon, chest pain, shortness of breath, productive cough, sinusitis, otitis, pharyngitis, abdominal pain, dysuria, blood in his urinH or stool, rashes, headache, visual changes, oral lesions Of thrush. arthralgias, myalgias, back pain or problems with his PICC line site He recently had a gram ne9stive rod bacteremia secondary to P1CC line infection so his PICC line was removed and he was put on his current antibiotics.
Al.LERGIES: No known medica! allergies,

MEDICATIONS: At home, Clindamycin. 2 Meropenem.

CUrrent Inpatient medications include 1 Clindamycin. 2 Meropenem. J VancQmyv in .

PAST MEDICAL HlSTORY: As per HPI. He denies other medical problems Of surgical history.
FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: He is single, has four children, he works as a bounty hunter. He denies tobacco, drinks occasional alcohol. He denies recreational drug use. He denies TB exposure. He has one tattoo.
REVIEW OF SYSTEMS: As per HPI, otherwise negative. PHYSICAL EXAMINATION; GENERAL: Well-developed, well-nourished young AfricanAmerican male In no apparent distress. VITAL SIGNS: Temperature 98.4 degrees, pulse 57, respirations 18, blood pressure 162/115, Sa02 98% on room air. SHEE NT: Skin is warm and

MEOICAU5URGICAL CONSULTATION REPORTOP

- Page 1 of 2

DePaul Medical Records/Phillip H. March

000365

DEPAUL HEALTH CENTER


PATIENT: MARCH, PHILLIP H

CONSULTATtON REPORT MR#: 000746298

dry. No lymphadenopathy. Head IS normocephalic and atraumatlc except for some mild to
moderate left facial swelling. There is no overlying erythema or fluctuance. Eyes - pupils were equal, round, and reactive to light and accommodation. Extraocular muscles are intact. Sclerae and conjunctivae are anIcteric. Oropharynx Is clear. No orallesion~ or thrush He has good dentltlon. NECK: Supple, soft, flO lymphadenopathy, no JVO, no bn.ritti, no thyromegaly, no meningismus. LUNGS: Clear to auscultation. HEART: RegUlar rate and rhythm with a soft systolic murmur. Pulses +2/4. ABDOMEN: Soft, nontender, nondistended, normoactive bowel sounds. No appreciable hspatosplenomegaly. EXTREMITIES; No clubbing, cyanosis or edema. No evidence of peripheral emboli or an active synovitis. The right upper extremity PICC line site is benign. There is no inguinal or A)(illary Iyml'hadenopathy. BACK: No costovertebral angle or

spinal tenderness.
LABORATORY AND XRAY DATA: White blood cell count 4.9,43% neutrophils, hemoglobin and hematocri112.3 and 35.2, MeV 80, plateletcoun1214,OOO. Sodium 136, potassium 3.9, chloride 103, C02 31, BUN 12, creatinine 1, glucose 77, AST 125. Blood cultures x2 are negatIve. CT scan of the face is unchanged from prior with no new evidence of infection.

IMPRESSION: 1 ChroniC left mandibular osteomyelitis, status post hardware removal. Prior cultures at Barnes grew Streptococcus anginosis, StreptococC\ls intermedius and Eikenella corrodens. He is currently on IV clindamycin and IV meropenem until mid January. 2 Chronic left jaw pain/suspect narcotic-seeking behavior. 3 Hypertension.
RECOMMENDATIONS: Would discontinue vancomycin. 2 Continue cllndamyein and meropenem IV as directed by Dr. Zinser with hoTTie health therapy. 3 Would use ice or heat to the left face PJ.n. for swelling. At this time, it 15 okay to discharge him home with his current home IV antibiotics as previously ordered and to follow up with Dr. Zinser as an outpatient when he returns from vacation. I will sign off. Thank you for allowing me to participate in the care of your patlent. At this time, ! will sign off but please feel free to call me with any questions.

MICHAE!'" J, KENNEDY, M.D.


MJK:418-2117298 0: 12/27/20078:04 PM T: 12127/20079:24 PM E: 12/27/200722:01 PM

cc:
IMRAN A. HANAF1, M.D.

MEOICAUSURGICAL CONSULTATION REPORT-DP

- Page 2 of 2

DePaul Medical Records/Phillip H. March

000366

DEPAUL HEALTH CENTER


CONSULTATION REPORT PATIENT! MARCH, PHILLIP H AOM'T DATE: 12/26/2007 CONSULT DATE: 1212712007 ATIENDING PHYS: IMRAN A. HANAFI, M.D. CONSULTING PHYSICIAN: MICHAEL J. KENNEDY, M.D.

MR#: 000748298
ACCT#: 0736000302 DOS: 10/02/1976

ROOM: 0530

REASON FOR CONSULTATION: Evaluate a patient with chronic left mandibular osteomyelitis.

SOURCE: The

patlent'~ current inpaUent medical record, an old Infectious disease consult note

and the patient himself. HISTORY OF PRESENT ILLNESS: A 31-year-Old African American male with a history of hypertenSion and stab Injury to his left face/jaw requiring surgery with hardware placement at Barnes Jewish Hospital. The patient subsequently developed infection and had the hardware removed and has since had a chronic left mandibular osteomyelitis. He Is currently being treated with IV clindamycln and meropenem until mid January for his osteomyelitis and has a PICC line in his right upper arm. The patient frequently presents to emer99ncy (ooms complaining of Increased left jaw pain and sweHlng. He presented to DePaul Hospital Emergency Room yesterday with complaints of two days of increased left facial pain and swelling but no other systemic symptoms. He was continued on his current IV antibiotics and vancomycin was added. He was admitted for further evaluation and treatment and I was asked to see him for antibiotic management. A CT scan of the face was unchanged from prior and did not reveal any new sign of infection. He has been afebrile with a normal white cell count and cultures from the blood nave been negative. The patient denies fevers, chills, sweats, nausea, vomiting, diarrhea. constipation, chest pain, shortness of breath, productive cough, Sinusitis, otitis, pharyngitis, abdominal pain. dysuria, blood in his urine Dr stool, raahes, headache, visual f.,ilsnges. oral lesions or thrush, arthralgias, myalgias, back pain or problems with his Pice line site. He recently had a gram negative rod bacteremia secondary to Pice line InfectIon so his PICC tine was removed/replaced and he was put on his current antibiotics by Dr. Zinser. ALLERGIES: No known medical allergies. MEDICATIONS: At home, 1 Cllndamycin. 2 Meropenem. Current Inpatient medications include 1 Cllndamycin. 2 Meropenem.

:3

Vancomycin.

PAST MEDICAL HISTORY: As per HPI. He denies other medical problems or surgical history. FAMIL Y HISTORY: Noncontributory.

SOCIAL HISTORY: He is Single, has four children, he works as a bounty hunter. He denies tobacco and drinks occasional alcohol. He denies recreational drug use. He dentes T8 exposure. He has one tattoo. REVIEW OF SYSTEMS: As per HP1, othef'INise negative.

PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished young AfricanAmerican male in no apparent di$l(ess. VITAL SIGNS: Temperature 98.4 degrees, pulse 57. respirations 18, blood pressure 162/115, Sa02 98% on room air- SHEENT: Skin is warm and

MEP1CAU5URGICAL CONSULTATION REPORT-OP

- Page 1 of 2

DePaul Medical Records/Phillip H. March

000367

DEPAUL HEALTH CENTER


PATIENT~

CONSULTATION REPORT

MARCH, PHILLIP !1.-'--__________ M_R_#_:..:.-00:-0_74_8_2..:.-98 ___~....__~

dry, No ~ymphadenopathy, Head is normocephalic and atraumatic except for some mild to moderate left facial swelling. There is no overlying erythema or fluctuance. Eyes - pupils were equal, round, and reactive to Ilght and accommodation. Extraocular muscles are intact. Sclerae and conjunctivae are anicteric. Oropharynx Is clear, No oral lesions or thrush. He has good dentition. NECK: Supple, soft, no lymphadenopathy, no JVD t no bruit~, no thyromegaly, no meningismus. LUNGS; Clear to auscultation. HEART: Regular rate and rhythm with a soft systolic murmur. Pulses '1-2/4. ABDOMEN: Soft, nontender, nondistended, normoactive bowel sounds. No appreciable hepatosplenomegaly. EXTREMITIES: No clubbing, cyanosis or edema. No evidence of peripheral emboli or an active synovitis, The right upper extremity Pice line sIte is benign. There is no Inguinal or axillary lymphadenopathy, BACK: No G05tovertebra! angle Qr

spinal tenderness.
LABORATORY AND X-RAY DATA: White blood cell count 4.9, 43% neutrophils, hemoglobin and hematocrit 12.3 and 35,2, MeV 80, platelet count 214,000. Sodium 136, potassium 3.9, chloride 103, C02 31, BUN 12, creatinine 1, glucose 77. AST 125, Blood cultures x2 are negative. CT scan of the face is unchanged from prior with no new evidence of infection. IMPRESSION: 1 Chronic left mandibular osteomyelitis. status post hardware removal. Prior cultures at Barnes grew Stftlptococcus sanginosis. Streptococcus intermedius and Eikenel\a corrodens. He is currently on IV cllndamycin and IV meropenem until mid January. 2 Chronic left jaw painfsuspect narcotic-seeking behavior. 3 Hypertension.
RECOMMENDAT~ONS;

1
2

Would discontinue vancomycin.


Continue cUnoamycin and meropenem IV as directed by Dr. Zinser with home health therapy. Would use ice or heat to the left face p.r.n. for swelling. At this time. it is okay to ct\sch~rge him home with his current home IV antibiotics as previously ordered and to follow up with Dr. Zinser as an outpatient when he retums from vacation. Thank you for allowing me to participate in the care of your patient. At this time. I wi\! sign off but please feel tree to call me with any questions.

This document has been reviewed and signed by MICHAEL KENNEDY Sign Datemme: 0111112008 3:58PM EST

MICHAEL J. KENNt;DY M.D.


j

MJK:418 - 2117298 0: 12/27/20078:04 PM T: 1Zf27/2007 9:24 PM E: 01111/200817:01 PM cc: tMRAN A. HANAFI. M.D.

MEDICAL/SURGICAL CONSULTATION REPORT -DP

- Page 2 of 2

DePaul Medical Records/Phillip H. March

000368

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DePaul Medical Records/Phillip H. March

000369

SSM DEPAUL. EMERGENCY FLOW SHEET RECORD Name: March, Phillip Age: 31 Y MR: 000748298 Acct: 0736000302
VITAL SIGNS
User MEE CBLA

DateiTime
12/2618:53 121'2615:47

BP 159/105 1 50198

PULSE 63 65

RESP 20 16

TEMP 98.4 98.4

PAIN 9 9

02 SAT TIME 100 on ra 1845 100 on ra 1544

Name: March, Phillip Age:: 31Y MR: 000748298 Acct: 0736000302 Prepared: Wed Dec 26 21 :25:29 2007 by Julie "''lInchez, RN

Page: 1

DePaul Medical Records/Phillip H. March

000370

--------------TR'AGE DATA----""""""'-------Complaint: Facial Swelling And Pain


Triage Time: Wed Dec 26 2007 15:47

SSM DEPAUL TRIAGE RECORD

Name: March, Phittip H Age: M31 wt: 73.5 Kg

MedRec:00074629a

AcctNum: 0736000302

Room;

Source: By: Carried Urgency; ESI-3

Age: 31

Male

Kg Weight: 73.5 Physicians:


Phillip G Zinser Emergency Physicians

WAITING

Vital Signs: (1544) BP;150198


T:98.4

Paln:9

P:65

Sat: 1OOlra

R:16

KNOWN ALLERGIES
No known drug allergies.

HISTORY (Wed Dec 262007 15:47 CBLA) MEDICAL HISTORY: Hlstory of hypertenoion, Patieflt is noncompliant with treatment, Stabbed In left face
April 28th..L20QZ History of hypertension, Patient is noncompliant with treatment, History of h~n8ion, jaw oeteomyentls. HAS Pice LINE FOR IV ANTIBIOTIC. History of hypertension, Patient's noncompllant witlHr~fment, Stabbed-InlelHace April 28th; 2001. History of hypertension, Patient is noncompliant with treatment, ' History of hypertension, Jaw osteomyelitis. HAS Pice LINE
FOR IV ANTIBIOTIC.. PSYCHIATRIC HISTORY; No previous psychiatric history. No previous psychiatric history. No previous
history~revlous

psychlatric history. No previous psychiatric

psychiatric history.

SURGICAL HISTORY: Jaw Repair, plate left jaw. facial repair. Patient's previous surgical history is
not relevant to the case. Jaw Repair, plate left jaw faCial repaIr. Patient's prevloutlYr9ical history Is not relevant to the case. iawJracture repairs. Jaw Repair, plate left Jaw. fac'al repair .... SOe1A1.HISTORY: Denies smoking, PatIent Consumes lllcohol soclaUy, oen'eg~buse, LIves at home with family, Denies alcohol abuse, Denies tobacco, Denies alcohol abuse, Denies tobacco abuse. Denies smokIng, Patient consumes alcohol socially, Denies drug abuse, Lives at home with family, Denies alcohol abuse, Denies tobacco. Denies alcohol Bbua&, Dentes tobacco abuse. FAMILY HISTORY: Family history i1S not contributory to this case. Family hlstory is not contributory to this case. Family history is not contributory to this caee. F@ffiJly history Is not contributory to this case . NOTES; Nursing records reviewed, Agree with nursing records, Nursing records revlewed 1 Agree with nursing records, Agree wit" nursing records. Nursing records reviewed. Nur&ing records reviewed..

ADDIT10NAL TRIAGE (Wed Dec 26 200715:47 CBLA)


COMPLAINT
PROVIDERS: TRIAGE NURSE: Cherie Blaesing, RN.

ADMISSlON PATIENT: NAME: Phillip H March, DaB: Sat Oct 021976, RACE: Black, Code; NO, Trauma; "NO, Work Comp.: NO, Heat Related: NO, SSN: 493788699, ZIP CODE: 63121, HEIGHT: i82cm, PHONE:
314387-8122, MEDICAL

RECORD NUMBER: 000748298,

ACCOUNT NUMBER: 0736000302, IBEX NUMBER:

20071226154742ADT,
Prepared; Wed Dec 26 2007 15:46 by Cherie 6Ia&slng. RN Page: , SSM DePaul Health Center

of 2

DePaul Medical Records/Phillip H. March

000371

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~IIJ ~1If IIffl !lItllf!ll 11111


Name: March, Phillip H

SSM DEPAUL TRIAGE RECORD

Agf1: M31

MsdRec:000746298 AcctNum: 0736000302

wt: 73.5 Kg

PREVIOUS VISIT ALLERGIES: No known drug allergies. FALL RISK: TIME: 1544, Gender (Male), Score: 1. ASSESSMENT: 9, GCS Eye Opening: Spontaneously (4), GCS Verbal Response: Oriented/conversive (5), GCS Motor Response: Obeys comands(6). The GCS total is 15, GO It side facial swelling for a while states has been stabbed and got infection and1.akes iv an1ibiotics at home pi has pice line. TB SCREENING: Denies TB screening . .-~ DOMESTIC VIOLENCE: The presence of domestic vIolence is unknown. EDUCATIONAUCULTURAL BARRIERS; NQ educational/cultural barriers. TREATMENTS IN PROGRESS: No trealment VITAL SIGNS

PRESCRIPTION: No Documented Prescriptions

KEY:
CBLA=Blaeslng, RN, Cherie

Prepared; Wed Dec 26 2007 15:48 by Cherie Bla~!iling, AN Page;;1 of 2 SSM DePaul Health Canler

DePaul Medical Records/Phillip H. March

000372

SSM DEPAUL EMERGENCY RECORD


Complaint: Facial Swelling And Pain
Triage Time: Wed Dec 26 2007 15:47 Source:
BV; Carried

Name: March, PhI/lip H


Age: M31

Wt: 73.5 Kg MedReG: 000748298

AcctNum: 0736000302

--------------------------~TRIAGEDATA---------------------------

Age: 31

Male

Kg Weight: 73.5 Physicians:


Phillip G Zinser

Urgency: ESI-3 Room: Vital Signs: (1544) BP:t50f98 T:98.4

Emergency Phys icians


WAITING

P:65

R:16
Sat:100/ra

Paln:9

HPI BLANK (19:26 AMAR)


CHIEF COMPLAINT:

The patient pr~sents with worsening left sided jaw pains. He reports having a history

of a broken iaw with sev~ral s.urgeries for repairs. He reports a history Of bone infections and Is currently

undergoing antibiotic t-herapy via PICG line leyeralifmeSdany: He reportscurrently taking clindamycln and merrem. He reports that the swe~ In hl~ law is worsening, and that the pain is Increasing., HISTORIAN; History obtaIned from p a t i e n t . -----------. TIME COURSE: Onset of symptoms reported liS gradual, Complaint is worse, Complaint is persistent. SEVERITY Maximum severity is moderate, Currently symptoms are moderate,

KNOWN ALLERGIES No Known drug allergies.

HISTORY
MEDICAL HISTORY (Wed Dec 26 2007 '5:47 CBLA): History of hypertenslon, Patient Is noncompliant with

treatment, Stabbed In left face April 28th, 2007. History of hypertension, Patient is noncompliant with treatment, . History of hypertension, Jaw osteomyelitis. HAS Pice LINE FOR IV ANTlBIOTIC. History of hypertension, Patient is noncompliant with treatment, Stabbed In left f~~~ April 28th, 2007. HIstory of hypertension, Patient Is noncompliant with treatment, . History of hypertension, law
ost6omy~lltis. HAS LINE FOR IV ANTIBIOTIC .. PSYCHIATRIC HISTORY (Wed Dec 26200715:47 CBLA): No previous psychiatric history. No previous

PIce

psvchlatric history, No previous psychiatric history. No previous psychiatric history .. No previous psychi9tric htstory .. SURGICAL HISTORY (WAd Dec 26 200715:47 CBLA): Jaw Repair, e!me __1ett iaY'l...J~!!l!.r~..pair. Patient's previous surgical history is not relevant to the cast[:;'~wJlepair, plate letUaw~1 repair. Patient's prevlou& suf'gical hislciryTi not relevant to the case. Jaw fracture repairs. Jaw Repair, plate lett law. facial repair':":_----. .-_. - --' .. SOCIAL HISTORY (Wed Oec 26 2007 15:47 CBLA): Oenles smoking, Patient consumes alcohol socially, Denies drug abuse, Lives at home with family, Denies alcohol abuse. Denies tobacco. Denies alcohol abuse, Denies tobacco abuse. Denies smokIng, Patient consumes alcohol socially, Denies drug abuse, Lives at home with family, Denies alcohol abuse, Denies tobacco. Denies alcohol abuse, Denies tobacco abuse.. FAMIL Y HISTORY (Weo Oec 26 2007 15:47 CBLA): Family history is not contributory to this case. Family

Prepared: Wed Dec 26 2007 <:1 :25 by Julie Sanchez, RN Page: 1 of 7


SSM CJePaul Health Cenler

DePaul Medical Records/Phillip H. March

000373

11m 11II! Imt IlIllIllll 1/lJIIl fIlII III 11111 lllll 1111111111

SSM DEPAUL EMERGENCY RECORD

Name: March, Phillip H Age: M31 WI: 73.5 Kg MedRec:000748298 AcctNum; 0736000302

history is not contributory to this case. Family history is not contributory 10 this case Family hlSlOry is n01 contrib\Jtory to this case .. NOTES (Wed Dec 26 2007 15:47 CBLA): Nursing records reviewed, Agree with nursing records, Nursing records reviewed, Agree with nursing records, Agree with nursing records. Nursing records reviewed. Nursing records reviewed .. (19;ZG AMAR): Nursin~ records reviewed, Agree with nursing records.

ROS (19:26 AMAR)


ALL SYSTEMS NEGATIVE; All systems were reviewed and are negative except as described above.

ADDITIONAL TRIAGE (Wed Dec 26 2007 15:47 CBLA)


COMPLAINT PROVIDERS; TRIAGE NURSE: Cherie 8Iaes[ng. RN. ADMISSION PATIENT: NAME: Phillip H March. DOB: Sat Ocl 021976. RACE: Black, Code: NO, Trauma: -NO, WorK Comp.: NO, Heat Related: NO, SSN: 4937B8699, ZIP CODE: 83121, HEIGHT: 1B2cm, PHONE: 314387-8122, MEDICAL RECORD NUMBER: 000748298, ACCOUNT NUMBER: 0736000302, IBEX NUMBER: 20071226154742ADT. PREVIOUS VISIT ALLERGIES: No known drug allergies. FALL RISK: TIME: 1544. Gender (Male), Score: 1. ASSESSMENT: 9, GCS Eye Opening: Spontaneously (4). GCS Verba! Response: Oriented/conversiv8 (5), GCS Motor Response: Obeys Gomands(6). The GCS total is 15, co It side facial swelling for a while states has been stabbed and got infectIon and takes iv antibiotics at horne pI has pice hne. TB SCREENING: Danies TB screening. DOMESTIC VIOLENCE: The presence of domestic violence is unknown. EDUCATIONAUCULTURAL BARRIERS: No educational/cultural barriers. TREATMENTS IN PROGRESS: No treatment VITAL SIGNS

PHYSICAL EXAM (19:27 AMAR)


CONSTITUTIONAL: Vita! signs reviewed, Comfortable, Alert and oriented X 3, Hypertensive. HEAD: Atraumatic, Normocephalic. EYES: Pupils equal and reactive to light, No discharge from eyes, Extraocular muscles intact, Sclera are normal, Conjunctiva are normal. ENT: tender over left posterior lower molars. Swellin9 and tenderness present over the angle of the mancH~le. ~);VTcMa<len6patny~t.. NECK: Normal ROM, No meningeal signs. RESPIRATORY/CHEST: Chest is non lender, Breath sounds normal, No respiratory distress. CARDIOVASCULAR: RRR, No murmurs, No rub, No gallop. ABDOMEN: Abdomen is non1ender, No masses, BowE:'l1 sounds normal, No distension, No peritoneal signs. UPPER EXTREMITY: Inspection normal, No cyanosis/clubbing/edema, Normal range of motion. LOWER EXTREMITY: Inspection normal, No cyanosis/clubbingJedema, No calf tenderness, Normal range of molion.
Preparso: Wed Dec 26 2007 21 :25 by Julie Sanchez, RN Page: 2017
SSM DePaul Health Cantor

DePaul Medical Records/Phillip H. March

000374

lllllllllf ItIII tflllll ~lllIlIlllflllllllf III 11111 It Ilf '11f!


SSM DEPAUL EMERGENCY RECORD
LAB INTERPRETATION (19:27 AMAR)
INTERPRETATION: I reviewed the lab results.

Name: March, Phillip H


Age: M31 Wt: 73.5 Kg MedRec:000748298 AcctNum: 0736000302

NEURO: GCS is 15, No focal motor deficils. No tocal sensory deficits, No cerebel19r deficits.

RESULT5 (19:04 AMAR)


LAB: CBC W AUTO DIFF Dec 26 2007 16:25, WBC 5.3 1000/mm3 Ref Range (4,5-11.0), RBC 4,75 TOX6 Ref Range (4,7-6,1). Hgb 13.2 gmJdl Ref Range (13.0-16.0), Hot 37.7 L % Ref Range (39.0-54.0),

MeV 79.4 L 11 Ref Range (80.0-99,0),


MCH 27.8 pg Ref Range (25.0-31.0), MCHC 35.0 gm/dl Ref Range (32.0-36.0), ROW 14.5 % Ref Range (11.5-14.5), Platelets 220 1000/mm3 Ref Range (130,0-400.0), Gran 66.0 % Ref Range (40.0-70.0),

Lymph 20.2 % Rei Range (22.0-40.0),


Mono 7.2 % Ref Range (2.0-10.0), Eos 0.2 % Ref Range (0.0-6.0), Baso 0.4 % Rei Range (0.0-3.0), Manual Diff Not Indicated. Absolute Neutrophil 3.48 1000/mm3. : COMPREHENSIVE METABOLIC PANEL Dec 26 200716:41, BUN 11 mg/dl Rei Range (9.0-20.0), Sodium 137 mEqfL Ref Range (137-145). Potassium 4.1 mEq/L Ref Range (3.6-5.0), Chloride 103 mEq/L Ref Range (98.0-107.0),

Glucose 73 L mg/dl Ref Rang~ (7$-110),


Creatinine 0.9 mg/dl Ref Range (0.8'1,5), AST/$GOT 174 H Ufl. Ref Range (17.0-59.0), Alk Phos 68 U/L Ret Range (38.0-126.0). Calcium 8,B mg/dl Ref Range (8.4-10.2), Billrubin 0.5 mg/dl ReI Range (0,2-1.3). Albumin 4.4 gm/dl R~f Range (3.5-5.0), Prot Tolal 6.8 gm/dl Ref Range (6.3-8.2),

C02 32 H mEqll Ref Range (22.0-30.0),


AL T/SGPT 71 U/L Ref Range (21.0-72.0), GFR 126.6 mllmin/1.73m2. : CBC W AUTO DIFF Dec 26 200716:25, wac 5.3 'OOO/mm3 Ret Range (4.5-11.0), RBC 4.7510X6 Rei Range (4.7-6.1), Hgb 13.2 gm/dl Ref Range (13.0-18.0). Hct 37.7 L % Ref Range (39.0-54.0),
Prepared: Wed Dec 26 2007 4:1 ;25 by JUlie Sanchoz, RN Page: 3 of 7
SSM DePaul Health Cer11er

J7S
DePaul Medical Records/Phillip H. March 000375

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SSM DEPAUL EMERGENCY RECORD


Mev 79.4 L fl Ret Range (80.0-99.0). MCH 27.8 pg Ref Range (25.0-31.0). MCHC 35.0 gm/dl Ref Range (32.0-36.0), RDW 14.5 % Ref Range (11.5-14.5), Platelets 220 10001mm3 Ref Range {130.0-400.0}, Gran 66.0 % Ref Range (40.0-70.0), Lymph 26.2 % Ref Range (22.0-40.0), Mono 7.2 % Ref Range (2.0-10.0), Eos 0.2 % Ref Range (0.0-6.0), Baso 0.4 % Ref Range (0.0-3.0),
Manual Diff Not Indicated,

Name: March, Phillip H


Age: M31 W1: 73.5 Kg MedRec:000748298 AcctNum: 0736000302

Absolute Neutrophil 3.48 1000/rnm3,


: COMPREHENSIVE METABOLIC PANEL Dec 26 200716:41, BUN 1i mg/dl Ref Range (9,020.0), Sodium 137 mEq/l Ref Range (137-145), Potassium 4.1 mEq/L Ref Range (3.6-5.0), Chloride 103 mEq/L Ref Range (98.0-107.0),

Glucose 73 L mgldl Ref Range (75-110),


Creatinine 0.9 mg/dl Ref Range (0.8-1.5).

AST/SGOT 174 H Ull Ref Range (17.0-59.0).


Aik Phos 68 U/L Ref Range (38.()'126.0), Calcium 8.8 mg/dl Ref Range (8.4-10.2). Bilirubin 0.5 m\1/dl Ret Range {D.2-1.3}. Albumin 4.4 gm/dl Ref Range (3,55,0), Prot Tolal 6,8 gm/dl Ref Range (6.3-8.2), C02 32 H mEq/l Ref Range (22.0-3Q.0), ALTiSGPT 71 U/L Ref Range ,21.0-72.0), GFR 126.6 mllmin/1.73m2.

DOCTOR NOTES (20;15 AMAR) TEXT: D/w Dr. Siddiqui from 10 and will admit to IPC ..
PATIENT PLAN: The patienl

wm be admitted to the hospital.

DIAGNOSIS (20:04 AMAR) FINAL: PRIMARY: Cellulitis, ADDITIONAL: Facial Swelling, DISPOSITION (20:04 AMAR)
PATIENT: X-RAY/CT Follow-up: YES, Critical Care~ 'None. Doctor ProcedUres: NO, Disposition: AdmIt Medical, Condition: Improved.

MEDICATION SERVICE
Banadryl (21 :05 AMAR): Order: Banadryl : 25mg : IV Push POTENTIAL MODERATE INTERACTION Diiaudid POTENTIAL MODERATE INTERACTION Phenergan
Prepared: Wed Dec 26200721 :25 by Julie Sanchez, RN Page: 40t 7 SSM DePaul Heallh CentEr

370

DePaul Medical Records/Phillip H. March

000376

SSM DEPAUL EMERGENCY RECORD

Name; March, Phillip H


Age: M31 Wt: 73.5 Kg MedRec: 000748298 AcctNum: 0736000302

Ordered: Wed Dec 26 2007 21 :05 Ordered by: Alan Martin, MD Entered by: Julie Sanchez, RN Wed Dec 26 2007 21 :05 Documented as given by: Julie Sanchez. RN Wed Dec 26200721 :06 MEDICA nON. Time given: 1935. Given in amount and via route as prescribed. Catheter placement confIrmed via flush prior to administration. IV site without signs or symptoms of infiltration during medication administration. No swelling during administration. No drainage during administration, IV flushed ",fter administration. Correct patient, tIme, route, dose and medication confirmed prior to administration, Patient advised of actions and side-effects prior to administration, Allergies confirmed and medications reviewed prior to administration. Clonldine (21 :17 AMAR): Order: C!onidine : 0.1 mg : By Mouth POTENTIAL MODERATE INTERACTION Senadry\ POTENTIAL MODERATE INTERACTION Dilaudid POTENTIAL MODERATE INTERACTION Phenergan Ordered: Wed Dec 26 2007 21 :17 Ordered by: Alan Manin, MD Entered by: Julie Sanchez, RN Wed Dec 26 2007 21 :17, Dilaudld (19:28 AMAR): Order: Dilaudld: 1 mg: IV Pust) Ordered: Wed Dec 26 2007 19:28 Ordered by: Alan Manin, MD Entered by: Alan Martin, MD Wed Dec 26 2007 19:28 Documented as given by: Julie Sanchez. RN Wed Dec 26 2007 19:35 MEDICATION. Time given: 1930, Given in amount and via route as prescribed, Catheter placement confirmf;Jd via flush prior to administration. IV site wi1hout signs or symploms of infiltration during medica1ion administration, No swelling during administration, No drainage during administration, IV flushed after administration, Correct patient. time, route, dose and medication confirmed prIor to administration, PaUent advised of actions and side-effects pnor to administration. Allergies confirmed and medications reviewed prior to administration. Phenergan (19:28 AMAR); OrQ~r: Phenergan: 12.5 mg : IV Push POTENTIAL MODERATE INTERACTION Dilaudid Ordered: Wed Dec 26 2007 19:28 Ordered by: Alan Marlin, MD Entered by: Alan Martin, MD Wed Dec 26 200719:28 Documented as given by: Julie Sanchez, RN Wed Dec 26 2007 19:36 MEDICATION, Tima given: 1930, Given in amount and via rOt,lte as prescribed. Catheter placement con1irmed via Hush prior to administration, IV site without signs or symptoms of infiltration during medication administration, No swelling during adrninistration, No drainage during administration, IV flushed after administration, Correct patient, time, route, dose and medication confirmed prior to administration, Patient advised of actions and sideef1ects prior to administration. Allergies confirmed and medications reViewed prior to administration. Vancomycin Hydochloride (20:05 AMAR): Order: VancomYCin Hydochloride : 1 gm : IV Piggy B~ck Ordered: Wed Dec 26 2007 20:05 Ordered by: Alan Martin, MD Entered by: Alan Martin, MD Wed Dec 26 2007 20;05 .
Prepared: Wed Dec 26 2007 2125 by Julie Sanchez. RN page: 5 of 7 SSM DePaul Health Center

DePaul Medical Records/Phillip H. March

000377

IlllI/lltl ijllll1lt1lltl1 ~I~ ttllt IJ~lll~1 mIl 11m


SSM DEPAUL EMERGENCY RECORD
PRESCRIPTION: No Documented Prescriptions
NURSING ASSESSMENT: NURSES NOTE (18:48 MEE)
TIME ASSESSED: Time: 1830, ambulatory to rm 6,

Name: March, Phillip H


Age: M31 WI: 73,5 Kg MedRec: 000748298 AcctNum: 0736000302

NURSING ASSESSMENT: FOCuSED (18:53 MEE)

pt states he had stab wound on upperleft upper cheek with repeated bone Infections and treatment with IV antibIotics via pic line at home. pt states despite this treatment he continues to have pain in left side of face and have intermittent episodes of swelling. this time the $welling began yesterday. currently pain at 9/10. NURSING DIAGNOSIS: left face pain and swelling.
NOTES: TIME ASSESSED: Patient was assessed at 1845. PAIN SCALE: On 21 scale 0-10 patient rates pain as 9, Quahly 01 pain is pressure, achIng. VITAL SIGNS: BP: 159,/105, Pulse: 63. Rasp: 20, Temp: 96.4, Pain: 9, 02 sat: 100. ra, Time: ~845. EYES: Eyes are PERRL. NEURO: Orientation: Alert, Orientel.i. Behavior: Cooperative, No weakness present, No numbness present, Coherent. GCS: GCS Eye Opening: Sponlaneously (4), GCS Verbal Response: Oriented/conl/arsive (5). GCS Motor Response: Obeys comands(6), The GCS total is '5. RESPIRATORY: Breath sounds:, Brealh sounds are clear. blla1erally. ABDOMEN: Abdomsn is non-tender, Abdomen is soft, Abdomen is flat, Bowel sounds present. MUSCUL.OSKELET AL: Good ROM, Normal pulses, SKIN: Skin is warm, Skin is dry, Skin color is normal. SAFETY: Side rails up, Cart in lowest position, Call light Within reach.

NURSING ASSESSMENT: NURSES NOTE (19:52 JSAN) TIME ASSESSED: Time: 1925. Assumed care of pI. Pl in no distress but is c/o fascial swelling and pain on right jawline into neck i'HlB. Pt is NQ x 3 1 h~art tones regular, lun~$ clear. SIP elevated at this time.
pain rx ordered.

NURSING PROCEDURE: LAB DRAW (16:09 eSLA)


TIME: Procedure was performed at 1609, Blood obtained from PICC labs sent, with 1 attempt, Blood cultures sent.

NURSING PROCEDURE: ADMISSION (21 :25 JSAN)


TIME: Report called at 2120, PI. admitted to room, 530, Patient admitted to med-surg unit, Report called/faxed to JudY,RN, Patient transported wheelchair.

ADMIN
DIGITAL SIGNATURE (16:10 CBLA): Blaesing, RN, Cherie. i21 :25 JSAN): Sanchez, RN. Julie. PATIENT DATA CHANGE (18:31): A08 70912600 by Interface. Payment: 90, Admitting Doctor: Zinser PhllHp G, AUending Doctor: Physicians Emergency,
Prepared: Wed Dec 25 2007 21 :25 by Julie Sancho'll, RN Puge: 6 of 7
SSM DePaUl lil'tlllt'l Center

DePaul Medical Records/Phillip H. March

000378

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Name: March, Phillip H Age: M31 Wt: 73.5 Kg MedRec:000748298 AcctNum: 0736000302

SSM DEPAUL EMERGENCY RECORD


Emergency.
(19:04 AMAR): Attending changed from (none) to Alan Martin, MD. (21 :08 JSAN): Admit Room: 530, Admit Area: full admit, Payment: (none).

(18:36): Aoa 70912659 by Interface, Admitting Doctor: Zinser Phillip G, Attending Doctor: Physicians

KEY:
AMAR:::Martln, MD, Alan CBLA=Blae$lng, AN, Cherie

JSAN=Sanonez, RN, Julie MEE=Etherldge, RN; Marilyn

Prepared: Wed Dec 26 2007 2125 by Julie Sunvhe7, RN Page: 7017


SSM DePaul Heal\l1 Center

DePaul Medical Records/Phillip H. March

000379

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SSM DEPAUL CLINICAL SUMMARY RECORD


HPIBLANK

Name: March, Phillip H Age: M31 Wt: 73.5 Kg MedRec: 000748298 AcctNum: 0736000302

CHIEF COMPLAINT: The patient pres~mts with worsening left sided jaw pains. He reports having a history of a broken jaw with several surgeries for repairs. He reports a. history of bone Infections and is currently undergoing antIbiotic therapy via PIce line severa' times daily. tie reports currently taking clindamycin and merrem. He reports that the swetHng In his jaw is worsening, and that the pain is Increasing.. HISTORIAN: History obtained from patient. TIME COURSE: Onset of symptoms reported as gradual, Complaint Is worse, Complaint is persistent. SEVERITY: Maximum severity is moderate, Currently symptoms are moderate.

HISTORY
MEDICAL HISTORY: HIstory of hypertension, Patient is noncompliant with treatment, Stabbed in left face April 28th, 2007. History of hypertension, Patient is noncompliant wIth treatment,. History of hypertension, jaw osteomyelitis. HAS Pice LINE FOR IV ANTIBIOTIC. History of hypertension, Patient Is noncompliant with treatment, Stabbed in left face April 28th, 2007. HIstory of hypertension, Patient Is noncompliant with treatment, . History of hypertension, jaw osteomyelitIs. HAS Pice LINE
FOR IV ANTIBIOTIC..

PSYCHIATRIC HISTORY: No previous psychiatric history. No previous psychiatric history. No previous psychiatric history. No previous psychiatric history .. No previous psychiatriC history.. SURGICAL HISTORY: Jaw Repair, plate left jaw. facial repair. Patient's previous surgical history Is not relevant to the case. Jaw Repair, plate left law. facial repair. Patient's previous surgical history Is not relevant to the case. jaw fracture repairs. Jaw Repair, plate left taw. facial repair ... SOCIAL HISTORY: Denies smoking. Patient consumes alcohol socially, Denies drug abuse, Lives at home with famlty, DenIes alcohol abuse, Oenles tobacco. Denies alcohol abuse. Denies tobacco abuse. Denies smoking, Patient consumes alcohol SOCIally, Denies drug abuse, Lives at home with famIly, Denies alcohol abuse, Dentes tobacco. Denies alcohol abuse, Denies tobacco abuse .. FAMILY HISTORY: family hi$t9ry j~ not contributory to this case. Family history is not contributory to this case. Family history is not contributory to thIs case. Family history is not contributory to this
C{J$~ .

NOTES: Nursing records reviewed, Agree with nursing records, Nursing records reViewed, Agree with nursing records, Agree with nursing records. Nursing records reviewed. NUfsing records reviewed .. ; Nursing records reviewed, Agree with nursing records.

ROS
ALL SYSTEMS NEGATIVE: All systems were reviewed and are negative except as described above.

PHYSICAL EXAM
CONSTITUTIONAL: Vital signs reviewed, Comfortable, Alert and oriented X 3, Hypertensive. HEAD: Atraumatic, Normocephalic. EYES: Pupils equal and (EJactive to light, No discharge from eyes, Extraocular muscles intact, Sclera are normal, Conjunciiva are normal. ENT: tender over left posterior lower molars.
Prepared: Wed Dec 26 2007 21 :25 by Julie Sanchez:, RN Page: 1 oj 3
SSM D!tP~ul Health CantaT

DePaul Medical Records/Phillip H. March

000380

Ilft/tlllllllll tlllllltllliJIlllfJI111J1 tlllllltllllllllllJI


SSM DEPAUL CLINICAL SUMMARY RECORD
Name: March, Phillip H
Age: M31 Wt: 73.5 Kg MedRec:000748298 AcctNum: 0736000302

Swelling and tenderness presenl over the angle at the mandible. Cervical adenopathy present.. NECK: Normal ROM, No meningeal signs. RESPIRATORY/CHEST: Chest is non-tender, Breath sounds normal, No respiratory distress. CARDIOVASCULAR: RRR, No murmurs. No rUb, No gallop. ABDOM~N; Abdomen is non-tendi:n, No masses, Bowel sounds normal, No distension, No peritoneai signs. UPPER EXTREMITY; Inspection normal, No cyanosIs/clubbing/edema. Normal range of motion. LOWER EXTREMITY: Inspec1ion normal, No cyanosis/clubbing/edema, No calf tenderness. Normal range of motion. NEURO: GCS is 15. No focal motor delicits, No local sensory de1icits, No cerebellar deficits.

DOCTOR NOTES
TEXT: O/w Dr. Siddiqui from ID and will admit to IPC .. PATIENT PLAN: The patient will be admitted to the hospital.

DIAGNOSIS
FINAL: PRIMARY: Cellulitis. ADDITIONAL: Facial Swelling.

DISPOSITION
PATIENT: X-RAY/CT Follow-up: YES. Critical Care: 'None. Doctor Procedures: NO. Disposition: Admit Medical, Condition: Improved.

MEDICATION SERViCE
Benadryl: Order: Benadryl : 25mg : IV Push POTENTIAL MODERATE INTERACTION Dilaudid POTENTIAL MODERATE INTERACTION Phenergan Ordered: Wed Dec 262007 21 :05 Ordered by: Alan Martin, MD Ent8red by: Julie Sanche~. RN WftQ b)E;lG 26 2007 21 :05 Documented as given by: Julie Sanchez, RN Wed Dec 26 2007 21 :06 MEOICATION ! Time given: 1935. Given in amoun1 and via route as prescribed, Catheter placement confirmed via flush prior to administration, IV site without signs or symptoms of infiHraUon during medication administration, No swelling during administration, No drainage during administration. IV flushed after administrahofl. Correct patient, time, route, dose and medication confirmed prior to administration, Patient advised of actions and side-effects prior 10 administration. AllergIes confirmed and medications reviewed prior to administration. Clonidine: Order: Clonldine : 0.1 mg : By Mouth POTENTIAL MODERATE INTERACT10N Banadryl POTENTIAL MODERATE INTERACTION Di!audid POTENTIAL MODERATE INTERACTION Phenergan Ordered: Wed Dec 26 2007 21: 17 Ordered by: Alan Martin, MD Entered by: JUlie Sanchez, RN Wed Dec 26 2007 21 :17 , Dilaudid: Order: Di!audid: 1 mg: IV Push
Prepared' Wed Dec 26 2007 21 :25 by Juli~ SMchBZ, RN Page' 2 of 3 SSM DeP~ul Heollh Center

DePaul Medical Records/Phillip H. March

000381

llltlllllll! III rIllllltll1l Jl! 1111111 JJ/ tlill 11111 II lIt IIIll

SSM DEPAUL CLINICAL SUMMARY RECORD

Name: March, Phillip H


Age: M31 Wt: 73.5 Kg MedRec:000748298 AcctNum: 0736000302

Ordered: Wed Dec 26 200719:28 Ordered by: Alan Martin, MD Entered by: Alan Maf1in. MD Wed Dec 262007 19:28 Documented as given by: Julie Sanchez. RN Wed Dec 26 2007 19:35 MEDICATION, Time given: 1930. Given in amount and via route as prescribed. Catheter placement confirmed via flt,Jsh prior to administration, IV site without signs or symptoms of infiltration during medication adminislration. No swelling during administration. No drainage during administration, IV 11ushed after administration, Correct patient, time, route, dose and medication confirmed prior to administration, Patient advised of actions and side-effects prior to administration, Allergies coniirmed and medications reviewed prior to adminlstration. Phenergan: Order: Phenergan : 12,5 mg : IV Push POTENTIAL MODERATE INTERACTION O\laudid Ordered: Wed Dec 26 200719:28 Ordered by: Alan Martin, MD Entered by: Alan Martin, MD Wed Dec 26 200719:28 Documenled as gIVen by: Julie Sanchez, RN Wed Dec 26 200719:36 MEDICATION, Time given: 1930, Given in amount and via route as prescribe(.l, Catheter placement confirmed via flush prior to administra1ion, IV site without signs or symptoms of infiltration during medication administration, No swelling during administration, No drainage during administration. IV flushed after administration, Correct patient, time, roule. dose and medication confirmed prior to administration, Patient advised of actions and Side-effects prior to administration, Allergies confirmed and medications reVlf:lwed prior to administration, Vancomycin Hydochloride: Order: Vancomycin Hydochloride ; 1 gm ; IV Piggy Back Ordered: Wed Dec 262007 20:05 Ordered by: Alan Martin, MD Entered by: Alan Martin, MD Wed Dec 26 2007 20:05 .

PRESCRIPTION: No Documented Prescriptions

Pr9par~u:

Wed Dec 262007 212G by Julie Sa,ncheT, RN Page: 3 of .3


SSM DePaul Hlffil1h Conter

DePaul Medical Records/Phillip H. March

000382

IIIII 11111

lillt 111111111111 til IItJllllll 111/1 1/111 11111 f!1I!


Name: March, Phillip H Age: M31 WI: 73,5 Kg MedRec: 000748298 AcctNum: 0736000302

SSM DEPAUL RECORD

Prepar9d: Wed Dec 262007 Z1 :25 by Julie SBnch~z, RN Page:


SSM DePaul Haanl1 Center

1 of

DePaul Medical Records/Phillip H. March

000383

Emergency Department Orders General Chief Complaint


Drugs must be
disp~nsed

Allergies:

in accordance ,.. ith the hospitnj formulnry sys(e>m.

1.

Assessment: Nutify physician if SBP <: 90 or> 195, or heart rate < 60 or> 120, or for decreas Inentru stalus Pulse oximetry (notify physician for Sa02 <92%) and Temperature recorded Assess women ofchiIdberuing age for pregnancy status and perform urine beta Ifor any possibility of pregnancy

II.

III.

VI.

Additional Orders:

DEPAlJL HEAL'l'H CEN1'ER

MJl,RCH PHILLIP H
0736000302 10/02/ 1976 sRS

\111".111
~

ERQ

Et-mRGENCY,P

3H;~ICIA00074B298

12/26/07

DePaul Medical Records/Phillip H. March

000384

pi\tient Report Form

POA

Social History:
Cardiac Rhythm:

~----!...:...-~---';o--r-I-----~--~':"'--Fo-J"..oC.--------IASA

Current PaIn Score:


Abnormal Assessment Findings:

Last Med given:

Acute MI given @ Beta Blocker;

f1U1j

~'Qt)v"g/Lv;-..s:.',
Pertinenl/AbnormallablX-ray Results CKlCKM8
Next Draw

". Isolation:O None 0 Airborne D roplst 0 Contact {J Spacial Contact VRE C dif MRSAlVRE Screen date: - sDIts: MRSA

Troponin

Next Draw

IV Type
Size:
Intake:

a Peripheral 0

TL

ICC

tart Date:

Site:
Rate:

Fluids runnin : . . . /

PT/INR
ABG's

PH

Cl Rectal tube/FMS

OCAPD

o other;

Site:

Thrill: DYes U No

DYes U No Old Records? OYes D No Department: Question call #;

leted? UYes

No

-SSM DePaul,Health Center


.(HI',
tA~f

Jf~~!~!P~I"1 0736000302 SRS-

DEPAUL HEALTH CENTER


>

ERQ

Patient Roport Form 920Q7

10/02/1976' 31y M 12/26/07 EMERGENCy,PHYSICrA0007482~8

DePaul Medical Records/Phillip H. March

000385

ADMISSION DATA BASE


Name

_____ B_OLD SYMBOLS (*

o Alzheimer'slOementia
o o Blo{)d clot
o
(J Arlhritis . 0 Back!Hip/Knee Bleeding problem

o Diabetes *
CQntrofled by:

+ - -)
!JA;

INDIC~TE REFERRAL NEEDED ON BACK PAGE. --~-----l

Blood pressure problem 1-Blood transfusIon Dale; _ _ _ __ Breathing problem hx: 0 Asthma Bronchitis o COPD/Emphysema Q Sleep ApnealCPAP

o Emotional problems

o Diet o Elevated cholesterol o Anxiety

o Insulin o SubCU1aneous pump o Oral Hypoglycemic


~

o Vascular disease o Pacemaker/Dafibrillator o Congestive Heart Failure' o Heart mllfml,lrNalvular disease


0 Chest pain, Angina
Frequency: _ _ _ _ __ Last episode> _______ D Palpitations OEdema Where: _ _ __ Frequency: HepatItis Infectious/Communicable Disease.

0 Heart attack

o Chronic pain prior to admiSSion ( _


Site: _ _ _ _ _~_

flO)

o ChrOi'lic Pam Management


o

OTB. S.; 0 Wheezing

o Cough/spulum productiOli
o Shortness of breath

o Glaucoma o Heart disease o Heart surgery


Date!

o Depression o SUicidal thoughls{plafl

o o Sensory problem

PregnanVLactaling If pregnant. due date: _ _ _ __ Prostate problems Reproductive problems Last menstrual period: 0 N/A

o H~ring 0 Vision o Skin problems

o o

o VRE
When:

o Rash o Skin risk 5C<lre \ 8 or IMS o Pressure ulcer Stage 3 or 4

0 MRSA 0 C. diff

(J I)nstageable wound o Nonhealing wound

Shortness 01 breath occurs al: r6$t ~_ ,-6th normal actNity _ _ If of II\ghts 01 slalrs dimbed
~_ #

Location: _ _---,'""""~..._
~N

Device (i.e.,

Contat physicIan
Referral Ordvfs

o Other - - - - = - c c : - - - : fOT

ETtWound Nur$e

D Kidney disease.

of tlloGks walked

o Chipped or loose teeth


Rllcent exposure 10: 0 Chicken pox 0 Hepatills

o ChemolRadiailon

o Canc~r

Home oxygen

o Neurologic.al prOblems o Seizures


Frequency: _ _ _ _ _ _ __

o DialySis o Slone

o Sexually transmitted disease o SlomachiBowei problems.


o
GERD/Acid Reflux

C Ostomy.
Date last 8M: _ _ __

Last episode: [) StrokelllA


Frequency:~---.

o ThyrOId problems

o Urinary problems

Last episode:

------..,...-c-~--....,....---~ If you check anyof1he above, please describe: ]lL~7 "S.L.i,L",. /0, j>col- .J.. ; c
IT
~

o Other: ==~_ _ _ -----~~rc

---,--_---.,._-.,_ "7---~:__~
F!.J
,J
ji

Ci,:,jr
I

{'J

JI1U

I: Ie,;

1/" "o NausQa,Nomlling o Family problvms with llneslhesia


DEPAUL HEALTH CENTER

Q
j

~~., 1v\ ~..

o KOPTiQf

~SSM
ADMISSION DATA BASE

H E A L T H . CAR E-

I MARCH,l?HILLIP H

ERQ

0736000302 ERS10/0-;./1976:UY M 12/26/07

EMERGENCY,PHYSlCIA00074S298

DePaul Medical Records/Phillip H. March

000386

ADMrSSION DATA BASE

" Cardiac BIMb '#


o ffltlGry ofCHF

-_._--''--.., 0 l'lIlient r'q1IflU

n.CI..Jv,________ ____ _____"r .____


~

No Muml Indlclllll ellola! Nytrltlon 0 SIJ!l13 nr 4 1Ir8S$UnI ulter 0 Nonheallltl 'IiIOUlIJ!

[I Unsl30ealJltJ \Wund

o Persi3lent cough ~ 3 wesks and suspiciouS chest x-ray + 2 the following: o Coughing up blood 0 Past T8 e~posure o Night sweats 0 Unsxplained weight loss
Type _._.
13~1 use

-:s~~~~~~~ 0 R8~Jlliif!Jfe

o Skin IUsk S~ore DIll or IIISS


o Uf19l1nttd WT 6 fO Iblllf mDrtl2 won;
o ~nranct 01 malnutrltloll

o N/Y/D 3

o ChlllGlI m&\lpefil8 IIlOru Jbin eclays

~.

AmountlFreq. -= )', (,...,

'< \ ~

I Cigar.

10

Tobacco? 'm f-lo 0 Yas '.. crgar~tte. Pipe. Chew (circle one) Cunei'll UfiRr (wlin IMl 1201(>$') 0 Former u~ef
Last use

i Street Drugs? i TYPR _ _ _ _ _~


'AmounVFreq. _. ___ _

o Prtgn3ll1 (flot dlllvwinQl or I.Icta1h1g o /'alienI reque;!


o Newly DJ Dllbftlc o Major mgery !uv8r 75 yeDJ1 old)
e IllfeqHon Control.
o Hillar; lit bJrlalIil: IUlVflry [J No relel1al imll~BII!d

._ _ i AmOllntlFreq

, La:n use

==:::-_=........--= o "01 1011owi1\i Dt.blIlIi: Olaf

llvo in:

INITIAL DISCHARGE PLANNING I HOME ENVIRONMENT I FUNCTIONAL SCREENING 0 HQ\lsll '\rApartmenl 0 Re3idential housing 0 Nvrslng home- 0 Other _ _ _ _ _ __

Do you plan TO roturn to your home frmn'the hospital? ~es 0 N01llt If no, explain: _ Trilnspor1illic.n 1;lvailable? !Sl. Ves 0 No . Does anyone help you at hOme now? . ~o 0 V",s Names/AgenCies Difficulty wi activities 01 daily hYing? ijf'No 0 Yes Explain: _ __~_ _ _ _ _ __ Difficulty .to.mbulalJllg I Transferring? No 0 YtiS Explain: _~_ _ _ _ __ if yf'lS 00", tv pain, expla!n. ____~____

Who do you live wirh? ... C\

Lc-.,.""

~--~

o PlISltlve T8 sJ;f'eaIllncr"3k1n t811


o
Hi~vrv

0'1 MRSA/IlHE/C. dill

';tI

o III O'>Ylce (""rt, Nee, ct,,) o fitCllIl1 npDWJll


relerrallmUClled

... Contact Pfilfslc:!an

o Chllfilt In mIdI
Do YOL! hav'.' any special concerns about being in the h05pilf!l?

o I'tliMl R,qml o liIafftatirm taucallon


No refel1l1l
ill1li~.ted

EIlIImml

Have you had ;my major Changes tiob, ~"ve. divoroo, dealh,
Do you have any spiritual concerns?

~o 0

Yes

+ ,
~o

.
0
Yas _ _ _ _ _ __

I Any special religious!cullural factors related to care?

Sleep,ng problems: ~pne 0 Difficulty faHing asleop Other _ _ _ _ _ _ _ _~_ _ _ _ __

Difficulty staying asleep

Paslorsl Csrt + AnUcfpal1f Coping Difficulty rOOr fro!lllosb Serious ProoedmiSurvery OlrllGtlve .\tsltlallCf

ADOLESCENT INTERVIEW (14-17 years old)

o Splrttu., COltEern1

l'lIU~nl

RtqIIltsl

IHev';!

j How do
What

get-~lung with your fa


ha
<;>x?

o Nil fe1errlll lfl1iil:J18d


.. Tobaceg CeHition ...

'.

'>

Qil !lV!!f

0 No

Y8, how &.1 wartlyou when you

K!nd oj birth ontrollprOle Ion do you or


''JX

Hav you ever had 'I Hav you ever felt

o Physician Notit!(ld
o PatlMt
0

when y}lu really did not w 'n! to? [J No 9'~'m" {lad ~ you thought aboui ~ Ii~g y,~~~!;llf1 0 No 0 Yas

Y~rp"nner use? --.L-.

Il~ex'l ~

"

o Ute!! In IMI12 IDGlllbs .~ o PaUenl Rtlqunl ' __ ~ r6felfill iMlcaled '=9\;===-=~~/':'---- ~illl tfilej \ _~_ __ o Pali~nl Reqlieil
o Ehlerlylfrail fi'liRIl alolle
.-.-----i 0 HOID!les$/nispliClid
-----~---I

tit

------FORM C<?MPlETEO BY {If other tha_"_R_N.....;>'--_ _ __


Hospital

Staff 0

Other

o SUiptteled ADm/Neglect
[)
Ponlbl~ H~mt

0 NUlling Home Placement


Hl) relerra! ill4llealtd

ASilstanca

SIOUA1URE

~SSM
ADMISSION DATA BASE
SlM.10c0-OS9 {!I/2007) BACK

DEPAUL HEALTH CENTER


1 MAACH,PHII..I..IP H
0736000302
EMERGEN ......

0 11
ERS -

H E A L T H CAR E"

ERQ
12/26/07

lO/02/1~6p'H3yl~IC~AOOQ748298

DePaul Medical Records/Phillip H. March

000387

--,~'=;;--T'-"'-'--'-'"'-'~------1.
In&trotfOn flxpiflfned

FROM 0 Home U ED :.J PACU Q DIs. office


'oJ ACUl8

i MODE

IRES~ (~

care

;:) Other:

IS? 79Z,-:;~

ILr=~::l;St:.:.:..:re::.:lc::.:h&::.r-':;:":";:;~:::::=t=TI=~==-1
IOTIiER

.;;) Vile

UNIT OFflENTATION Mf>~r(11 s~fVlCes l.,.I-Cillllghl' nurse oetilrh!;lhl pam ~Ilighl . \oi!&tlng ~king for help 10 g",I up smoking policy ~~ 1~lIs ,JJ-Wlephone ~JeVISjon conlrol ~:LU8e of bed controls u.-Em6lgenGy light BRfshowllr ~ng hOUfll U'fomlort Rounds

ARRlVAL INFORMATION
(If other tnen nurse)

COMPLE1ED-By-JJ~' -)'-/1-(-',-. 6-C-/"-7-/-/


-.
SIGNATURE

t.{s

/;? 90tn dl5t:;~


DATE TIME

SUICIDE SCREENING
Viol!S ~
I..J

~==~----====~------

Ask ALL patiHnts the following questions:

.{;J, Have you over tried 10 harm YOUfself in tht! p(l~t? Explain _ _ _ _ __ Are YOLi hers bllClluse you tried to harm yOU($&1I'? Explain _ _ _ _ _ _ _ _ _ _ _ _ _ _ _~_ _ _ _ _ _ _ _ _~_
In the past w1;Jek, have you been havinA thoughts about

..

harming,,-y'.'o=u=rs=<U~I'!~Ex=p::la:ln__ =-=-=-=-=-:..:=====-====~~==:"::==-.j HAVE YOU EVER BEEN EMOTIONALLY. PHYSICALLY, OR SEXUALLY ABUSED?
Q Hotline called specify: _ _ _ _ _ _ _ __

~ NO EVIDENCE OF PHYSICAL, SEXUAL, OR PSYCHOLOGICAL ABUSE NOTED.

EVIDENCE' OF POTENTIAL ABUSE NOTED BUT NOT SUSPECTED, SPECIFY EVIDENCE _ _ _~_ _ _ _ ___

RATIONALE
Q

ABUSE SUSPECTED, COMMENTS:

o Soc,al SeNiee notified


PAIN MANAGEMENT
P N SCALEjOBSEAVATlON .t:!umeric 0 Behavior o Faces rating 0 Assume pain present
Ol~r

PAJNLEVEL

COMFORT STRATEGIES OSEO (Prior to admi3slon)

ATPR~~
PAIN FUNCTION
GOAL,)

Q INFORMATION GIVEN

_________________

ON RfGHTS AND

RESPONSIBILITIES
OF PAIN MANAGEMENT

If pain plOsem, comp/1JiS Pain Assessment Se~lioll of Patient Flowl'Jh&et.

To be completed by all RN.

PLAN OF .CARE

>

PATIENT/SIGNIFICANT OTHER INVOLVED IN THE CARE PLAN DEVELOPMENT. J'PfES 0 NO explain: _ _ _ _ _ _ _ _ _ _ _ __

FORM COMPLETION INfORMATION


: ~ Form Ii/eFfll9letet1 1'.;,f"...,J..,I{
Signature:

{,Lu;:.,.... .;:(:,":. ',',,--

\),j..l

Date: ) JL. j. ) Time: :2./ I ;f~' (If completed by LPN, RN review and plan of elfre development required)
, RN:

):6

~,' Signature: ________"\.'


,

Form

comp'et~<1 \iA~m ?ata reviewed

~'4.i,--'..j1.)!-ll"i'>:":\"',-,_.,_c....;;._~_ _ _ _ _~_ _

!7i

Q Plan of care/Care pathway developed

Date:'

1;~L

Jr"

, Time:

L-.

'

PATlI;NT LABEL

~SSM
ADMISSION ARRIVAL SHEET
SU.l1000-OSB (7!2007) FRONT

DEPAUL HEALTH CENTER


MARCH,PHILLIP H ERQ 0736000302 ERS10/02/1976 31Y M 12/26/07 EMERGENCY,PHYSICIAOOQ748298

11.111111

H E A L T H e A R E-

DePaul Medical Records/Phillip H. March

000388

ADMISSION ARRIVAL SHEET


.
NeurOlogical CardiovIl9CuillTI

SYSTEM REVIEW

No probh.m identified

Q Exception as below Q Excention as below Q Exception as below Q Exception as below

au
Musculoskeletal
Repro(:luCllve

o No problem Identffled o ExoopUon as b(llow


Q No pro~lem Identlfled
I,J Exception as below

Hematologloal
Respiratoryl
Infectious Disease

::::l No problem identified

Q No probt<m1 idl/ntlfied

Q ExceptIon as below

o No proolem identified
Q No prOblem identified

GIJNutrltioll
EENT

Wound/Sldn} Mucou, Membrane

o No problem identified o Exception 6$ below

PsyehOfSoclal1
Spiritual

Compll;!tefy

limil~d

t
,.3
",",-'

CCnSlantly moist

Bedtas!

Very poor
PrOIlaIJly

PrOblem

VlJry ilffliloo
Slightty limile6
No
I .....pmrmen!

2 VtJry mo!!)!

(4.,

Oc~u&i<.Jna!ly moist (~

2 Cnalrfll8t
WalK$ OCCaSionally
Walks frequelllly
4

adequate .e"
Adequate (3
ExcaJienf 4

Rarely mois!

r'rtctlon & ShUT I Silfl Rille Sc<lre: 18 (J( IMa Jl'IIEInt I. at n$l( 1 I Q Fallow SJdn Ca~ Pr%coI for ~ of Potential HI or IllSl. IPM pr%(;01 Mi bedsIde.) problem Nutrltktn<il consult No apparent (II nor P'f1Violl~ty obts/ned.)

problem

Score~

T1me

L2.t

a::

HENDRICH II FALL RISK SCORE' Score on adlllls",,,,,, IWI"" d<uly, and WIth changes III conal!lon actl~ll\I OJ """,..",,('.1 "sl< meto,s.

II)

RIsk Factor

1---"""---+--"""----1 0 Fall risk brllcekliin place ~or. of 5 or greater"" Fall RIsJ(

o FilII Prevention information Sh!l@1

Signature: _________

-+'~_'__~_;VJ...t._;_\_".....::::-".._ _ _ _ _ _
)

Date:

TIme:

~_-,>.l _ _ __

2.{I'r-

PATIENT LABEL

~SSM
H E A L T H ' CAR
AOMISSION ARRIVAL SHE!:T
SLM1000{)58 (7/2007) BACK

E~

DEPAUL HEALTH CENTER

MARCH, PHILLIP

0736000302 ERS10/02/1976 3lY M 12/26/07 EMERGgNCY,PHYSICIA000746298

/1111-11 H ~ERQ

DePaul Medical Records/Phillip H. March

000389

INTERDISCIPLINARY CARE PATHWAYS~ - GENERIC


~.

'nJ MEDICAL HISTORY


<.(Vt",

( ~'r 'S-\'(." " ~'( (" . (,1'

/.',ltJi:,' ~Ck .' ~,tll-t:'t ii<' '1 {'\

f:'- {,', ( . I)
-1?C;C{
1

SPECIMENS TO BE COLLECTED
,
i

INITIAL DISCHARGE PLAN

o Home with significant other


o SNF/ACF o Rehab

free - (R' fA'-'vr1~'

DAILY lABS

o Other

o Home Health

MRSAIVAc screen sent


Results C. difficila sent
Results

PHYSICIANS

DATE

NAME

CONSULTS DEPARTMENTS I NURSING DATE NAME ...'1'r-- :f/'1

/1-/t&'
o Droplet o Airborne t if>"
lJ!f,.

])/

~~

o Spacial Contac1 o Contact

D)z(:"

/v~fn;~>1

::ifllJ
(a

t) /l(~

(h::'in 7L

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Pneumovax year: Flu vaccine year:

Admitt~Q Mih pressure Ulcer1~ Yes~o


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Type:
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C*TATUS
Full resuscitation

ALLERGIES

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o DNR medical management

o DNA com/ort measures


Advance directives? [J Yes 0 No Copy in chart? 0 Yas 0 No Is there anyone who should not receive general condition Information? 0 Yes 0 No FamllY/Signlfilin1 Otherd8si~~ted to ,)OOlve madical information: 0 None Name
Phone

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Name Phone

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MED 0530-01

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0736000302

INTEROISCIPLINARY CARE PATHWAYS' GcNI:RIC


DFMl000~4

10/02/1 976 31 Y Hl>.NAFT, H1RAN A

M 12 /2 G!~o J 000148 L 98

(912007) PAGE 1 OF 6

COPYRIGHT 1997 SSM HEALTH eMt:!

DePaul Medical Records/Phillip H. March

000390

..

PLAN OF CARE
PROBLEMS/OUTCOMES/INTERVENTIONS OUTCOMES

DATE!

INITIALS

Place initials and data Ihal problems (Iff; identlfltfd In left co4umn. All idGntlliil'Q prQb!~m multt bu Ilva!uated wh~lh8r Oulcomi II M@t or Unmet al time of CIlIWI'I!

hy placing dale and


Met Unmat

initials in appropriate column. " OUlcomw is met prior to discharge. philcv dllte and Initials on Ahtl)(Jf\lmn. Place ./ in box by Int&Nsntions appropriate to patient. Write in additional Int8MJ!1tlons as nmed in bl8nk spaces.

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Problttll1! Alteration In NeurofagJcal Status Age specific conslderatkm in fdefl'y Adults: Diminished muscle strength, degenerative ~ end/Of joim changetl, der:rellsad /'tearing. vision and balllncB. Outcome: The patient will expBl'lene. a stabilization af neurologIcal fmpatrment. Interventions: 0 Assess for Fall Risk BID Initiale Fall Pracautl1Jna for Fall Risk Score of 15 or hlgh!)r. 0 Assess level 01 consciousness and motor function every shift snd pm. i 0 Encourage achievement 01 ADL's as appropriate to the neurologleallmpalmlant.

I Age specific conSiderB!lon In Eld()rty Adults: WeaKened msp;rotory muscles, d&ctMsBd lUng tiS$/JIJ ~luticity.
Outcome: Respiratory functIon will be within nannaJ .'ml1s for patlenL
0 o Position patlant for maximum ventilation ~fficiency. Monitor VS/breath ~o\lnds/oxlmetry every shift and prn. D Administer treatments/oxygen/AOO's as ord~red. Provide Ouid intake to liquify secretions Suction tWcretions as necessary.

) Problem! AlteraUnn '" Oxygenation I Rttsplratory Function

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! In!9NenlionG: 0

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Problem: AUerallon In ComfQrt/f'flln Managent9nt Age specific consideration in Elderly Adults: PossIble idiosyncratic effects from mOOicalJons due to ag&-relateci changes ill flbsorption, metabolism, and excretion. Outcome: Patient exfllblts/stlltes adequatll relIef of discomfort. Interventions: 0 AS6eSS patient's pain lavel q 4 hours. 0 Involve patient in care by dlscvssing methods of paIn relief. 0 Initiate interventions {including nOn'Pharmacofogic) appropriate for pain/discomfort. Assess pain leve! and response within 60 minutes of intsNantion.

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Problem: AHwatJon In NutrHlon


Age speGitic consideration in Elderly Adufts: Diminished apputits, perlsf4l$;s and digestive jufces line! d8ntitJon changes. FactDrs that may improye food intaktt" Position patient upright Offer smaller, more ff8qUf1nt meals Modified food consistency l.fJ., pureed/soft. Outcome: Patient nutrfUonal .ntake Is approprIate for ~Ifc ,*",s.. Interventions: 0 Nutrition Consult enlsrad in HBOC !:l Monitor hydration sta1l,.1$ D As!e$s enteral feeding tolerance o ASS&5S tor swallowing/chewing difficulty Assist patIent with me\IIil as needed. 0 Assess/Record dietary intake with each meal Provide/record dietary JlupptementslHS linacl{i. o Record Daily Weights. rsport unexplained weight changes greater than 3 kg from previous day.

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Probfem: Alteration In Cardiovascular Statu$ Age specifiC consideration in Elderly Adl.Jlfs: Diminished GtJrdlac force I blood /Jow to bt&ln. Outoomit: Patl.nt will be hemodynamically stablv. Interventions: 0 0 Record Intake and output every shift and pm/daily weignts and report variances, Assess vital signs, peripheral pulses, and capillary refill every shift and pm. Administer rnedicatlol'lil/blood P!oducts as ordered and monitor eff8cts.

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Problem: AfteraUon In Skin fntegrlty Age specifio consideration in Elderly Adults: Skin dry and 18;$ efastic. Outcome: Patient wfJI maintain or fmprove skin Integrity. Int~!V!!nt!on; Cl Turn patIent every 2 hours avoid shearing Keep skin clesn and dry. o Photograph and measure wounds on admiSSion, every Monday. and on dlsChBfg&. 0 Provide wound care per Skin CarB Protocol (s~ page B) o Potential aitaralionin .ktn inteQrfty

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PrOblerm Potentl.' or Actua' Infection


Age speCific consideration In Elderly AdfJlts~ Decreased renal function nota lab valUfi rvlBl8d to antibJofic do!iiflfl. Outcome: Slgnll and $ymptoms of Infection are recoqnlzed. Pl'4tCautlon$ eN vttltUd. ~arventions: 0 Utiliz& isolation precautIons: [') Contact 0 Spada! 0 RaspiratOf}' 0 Droplet ASM5s/report signs and symptoms of infection every shift and pm.

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~SSM
HEALTH,t;:ARE"

DePaul Health Center


a
COPYRIGHT 1997 SSM HEALTH CARE

DEPAUL HEAL'H CENTER

INTERDISCIPLINARY CARE PATHWAYS" . GENERIC


OPM1~024 (9/2007) PAGE 2 OF

HARCH,PHILLIP H 0736000302 MED 0530-01


lo/0Z/l9763lY RANAFI,IMRAN A 1'1

11II11111I.llllnl

rip

12/26/07

000748298

DePaul Medical Records/Phillip H. March

000391

PLAN OF CARE

PROBLEMS/OUTCOMES/INTERVENTIONS
Placo initi(!ls and date thaI problems are identified in lett column. All iti9f1liliod probl!lm musi b!e !evaluated Whathllf Ou\wrn9 !$ MAt or Unmel at lirne of discl1arge by placing <;late ann initial:, in o.pproprlate column. II OutCome Is mel prp:!! 10 Olscnarq8. place date and initials on Met column PI"r,e ./ In box by interventions appropriate to paliAnt, Write in aUClit\,)nal intBrvenlions a, needed in blank spaces.

DATE! ilNITIALS

OUTCOMES Met Unmet

Problem: Alteration In Elimination


1 Age specific considertllion ill Elderly Adults: OlrlllTllshed peris/alsis, krc1ney function. , Outcome: Patlant regains norm,,1 elimination patterns for liSe and disease process. IIlWIY~nllons' 0 o Offer loilating every 2 hours. U AsSess bowel sOl.inds, abdominal distention ana/or rtiscomlort evelY shift a"d pm
Record frequency and characteristiCS of stool. Report if no stool for more than 3 day:> RQcord j"take and output every shift and pm Report abnormal lab values.

!0

I0

I Problem: Knowledge Oet\clt Age specifiG con$ide~<!ltiDn in Elderly Adults: SfIflsOry am.! cognitive JmpBirment;;. Outcome: Patient and or $Ignlflcant othtlf Involved in plan of care/demonstrate unclen,wndlng of procedures/dls9I1se/medlcatlons/and discharge Instructions.
Interventions:

o o o

U Assess baseline knowledge and prtlferred leQming method 01 patient/significant other.


Provide educational material al palient/signil!<;wt other level 01 understandinq. Assess patient/significant other for understandinq after teaching. Provide instruction on sate and effeoti::'!l._u_s_e_O_f_m_tl_d_I_Ca_l_e_q.;..u-,ip:...m_B_n_t________________--4_ _ _ ----l

Problem: Anxiety/Spiritual Dlsturban(l8s


Age :spf;loific consldaratlon if) Elderly Adults: FeBr of 10$s of control. declining hearth andlor approaching death, chtirlgas in economic secUlity!soclaJ status.

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Outcome: Patient/signlfleant oth.r demonstrates ability to cope and Identifies available resources. Interventions: 0 o Encourage verbalization of lears amJ participation in care. o [lecreafitl sensory stimuli - provlde quiet onvironmem . Dim lhe hallway lights after 10 p.m

o o

Pastoral Care relerral entered. Palilative Care referral entered,

Pr(lblem: Glycemia Imbalance Age speciric consideration in Elderly Adu/ls: Decreased renal function, metaoo(;c rate. Outcome; Patient's blood glucose Is withIn acceptable ranga. Interventions: 0

o o

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Implement HYflog1ycemia Protocol Implement Insuhn Protocols as oroared. [J Monitor/rer,ord fingerstlck glucose value<i as ordered "nd pm Diabetes Educator COi'lSull entered.

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Problem: AJt91Oltiofl In Mobility/Activity Intolerance Age speciltc r;onsJOeri.ltion in Eidetly Adults' Diminished muscle strength, degellerilf!Ve bone and/or fOill! changes, decrMMd hearing, VISion and balance,

Outc:ome: Patient's main1ains


!ntervemionG: 0 U

Of improves

mobilltyfacttvlty level.

0 __

_ _ _ _ _ __

Assist patient to participate in ADLs Within IlnHS of impairment. Adll,mca aclivlty as ordcred;toIArnled. ,OPT to Clssess functional ability and provide appropriate adaptive devices.

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Prob!tm; A,,~ratlon in Safety


Age spectfic Qonsideralion in Eldef(Y Adults: Sensory tifld cognltlve impairments.

Out.:ome; PlItient remains in a safe envIronment and free of physIcal Injl.lry.

lntervgntions: 0 _-,-__

o Assess lor Fall RiSK BID - Iniliale Fan Prsr:autions for Fall Risk Score of 15 or higher. f1 Provide appropriate safety l;>quipmenf/devices and instruction