Edward C Newman Record

Sundance HealthCare SystemsSundance HealthCare SystemsSundance HealthCare SystemsSundance HealthCare SystemsSundance HealthCare SystemsPainted Valley, USAPainted Valley, USAPainted Valley, USAPainted Valley, USAPainted Valley, USA

NAME X-RAY NO.

DOCTOR DATE

REGION EXAMINED

M.D.RADIOLOGIST'S SIGNATURE

© 2003. American Health Information Management Association. All rights reserved.

Newman, Edward C.Dr. William J. WainwrightCoronary care unit# 012502

Indications: SOB

CHEST: There is mild to moderate pulmonary vascular congestion. There is mild bilateral interstitialedema. The findings are less prominent than on 1-1-xx. No focal consolidation is seen inthe lungs.

WCR/smb

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Newman, Edward C. 47932

Dr. W. J. Wainwright 8/14/xx

CHEST X-RAY

Sundance Medical CenterPainted Valley, USA

Patient's Signature Date Time Attending Physician

a.m.p.m.

I have read the above instructions and received a copy of them. They were explained to me and all myquestions were answered satisfactorily.

Instructions: Please follow the instructions given below. This is an important part of your continuedrecovery. If, after reading the instructions, you have any questions please ask your physician/nurse forclarification.

Diet:

Medications:

Activity:

Follow-Up:

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DISCHARGE INSTRUCTIONS SHEET© 2003. American Health Information Management Association. All rights reserved.

Mr. Newman has an appointment to see me in the office in approximately

two weeks for recheck. He should call or come in sooner if he has any questions or

problems prior to that appointment.

1500 calorie ADA, no added salt diet.

Diazepam 20 mg p.o. q.h.s., albuterol and Atrovent nebulizers q.d. and p.r.n., Lasix 160

mg p.o. b.i.d.; Theo-Dur 200 mg q.a.m., 300 mg q.h.s.; Imdur 30 mg (1/2 tab) q.h.s., Pilocarpine 4% 1

drop O.D. q.i.d., nitroglycerin 0.4 mg sublingual p.r.n. chest pain, oxygen 2 to 4 liters per minute per nasal

cannula. Diabetes meds will be: Humulin N 64 U a.m., Humulin N 36 U p.m. and Humalog sliding scale:

Accu-Chek less than 100 = 0,Accu-Chek 101 - 130 = 3,Accu-Chek 131 - 170 = 5,Accu-Chek 117 - 220 = 8,

Accu-Chek 221 - 300 = 12,Accu-Chek 301 - 400 = 15,Accu-Chek less than 400 = 18.

As tolerated.

Edward C. Newman 8/14/xx 6:45 ��

Newman, Edward C.Dr. William J. WainwrightCoronary care unit

# 012502


��


# 012502

Physician Orders and Progress NotesForm # _ _ _ _© 2003. American Health Information Management Association. All rights reserved.

78 y.o. male with severe COPD, IDDM,

ASHD admitted with increased dyspnea.

See H&P. Wainwright

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8/14 Admit to CCU per Dr. Wainwright.

DX: CHF, COPD.

Condition stable

Vitals q.4h. while awake, daily weight.

�� 0010 ALL: PCN -> Hives

Diet - No added salt

Activity Up to BR

IV saline lock

Meds: Lasix 80 mg IV now

Humulin N 64 U SQ q.a.m.

Humulin N 36 U SQ q.p.m.

Humalog 12 U AC t.i.d.

Hold if BS <120

Theo-Dur 200 mg p.o. b.i.d.

Lasix 160 mg p.o. b.i.d.

EC ASA 1 p.o. daily

Imdur 60 p.o. q.h.s.

Diazepam 10 mg p.o. q.h.s.

Clorazepate 15 mg q.h.s.

nitroglycerin 0.4 mg SL p.r.n. chest pain

Pilocarpine 4% ophthalmic drops 1 drop O.D. q.i.d.

0011 O2 - keep sats above 88%

�� 0012 Albuterol nebs q.i.d. p.r.n.

O2 ��


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# 012502


8/15 LAB: CBC, CMP, theo level, UA, TSH

Lisinopril 20 mg p.o. q.a.m.

EKG �done ER

CXR state, check if done ER

P-8 in a.m. 8/15

Oximetry daily while on O2

Foley to gravity ��

8/15 May request Valium 10 mg q.h.s. p 3 hr p.m. x1

Accu-Chek q.i.d.

EKG in a.m.

Atrovent inhaler two puffs q.i.d.

��

8/15 Change Atrovent inhaler to SVN’s q.i.d.

v.o. Dr. Wainwright/rla ��

8/15 @ 0945 Humalog q.i.d. S.S.

< 100 = 0

101 - 130 = 3

131 - 170 = 5

171 - 220 = 8

221 - 300 = 12

301 - 400 = 15

D/C H.s. Chlorazepate

Inc Diazepam to 20 mg p.o. q.h.s.

Ativan 2 mg p.o. t.i.d. p.r.n. anxiety

Up walking ��

8/15 @ 1410 D/C Humalog 12 u a.c. t.i.d.

T.O. Sally Mertz, RPO ��

Progress Note: 8/15

Social Services report from yesterday

indicated pt currently uses no services.

Will follow.

W. Scarlett, MSW

8/15 Breathing easier

110/60, P 80

Lungs clear, distant BS

Heart - regular

Abd soft

Ext no edema

Weight down 6 #

- CHF

- IDDM

Increase activity

Monitor O2 sats

Dr. Wagner

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# 012502


8/16 @ 0650

MOM 30 cc p.o. QP p.r.n.

S.O. Dr. Wainwright, A. May, RN

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8/16 D/C Foley, D/C CCU, D/C IV

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8/16 Discharge

Meds: Humulin N 64 U a.m.

Humulin N 36 U p.m.

Humalog sliding scale

Accu-Chek

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Units

< 100 = 0

101 - 130 = 3

131 - 170 = 5

171 - 220 = 8

221 - 300 = 12

301 - 400 = 15

> 400 = 18

Diazepam 20 mg p.o. q.h.s.

albuterol & Atrovent SVN’s q.i.d. & p.r.n.

Lasix 160 mg p.o. b.i.d.

Theo-Dur 200 mg q.a.m., 300 mg q.h.s.

Imdur 30 mg (1/2 tab) q.h.s.

Pilocarpine 4% 1 drop O.D. q.i.d.

nitroglycerin 0.4 mg SL p.r.n. chest pain

O2 2 to 4 L/m N.C.

Appt. my office - 2 wks

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��© 2003. American Health Information Management Association. All rights reserved.


# 012502

8/14/xx

0805 Admission Admitted to CCU-3 per w/c from ER. Settles into bed with no c/o @ present.

See admission sheet. HRM, RN ��

0845 Foley catheter inserted. Tolerated well. ��

0900 Lisinopril 20 mg p.o. now given per order, Lasix 80 mg IV now given per order.

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1000 Visiting with wife in room. No c/o at present. ��

1300 Dozing in bed quietly. ��

1500 Visiting in room with family. No c/o. ��

1900 Summary Appetite good. Denies pain. Resting quietly. Wife @ bedside. Rhythm unchanged.

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2200 Summary Uneventful evening, denies pain. Does become SOB with activity, respirations

easy @ rest. No c/o. ��

8/15/xx

0115 SOB Resting awake in bed, had “Charley Horse” in leg. Better now, but dyspneic, resp

30/m et breathing rapidly, feels winded. LS dim throughout with left base crackles. Patient

quite anxious. ��

0115 SVN with albuterol 0.5 cc given. ��

0130 Breathing easier, increased air exchange throughout. Lungs fields with bibasilar crackles now.

Feeling better, remains anxious. ��

0150 Valium 10 mg p.o. repeated ��

0600 Awakened for assessment, had been sleeping. Becomes dyspneic on exertion with mild

dyspnea with rest. LS remains dim throughout. Crackles lower 1/2 left and 1/4 left.

Admits to feeling SOB, wants treatment. ��


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8/15/xx


# 012502

0615 SVN given with albuterol and atrovent ��

0625 Feeling better after treatment. Increased air exchange to lung fields though crackles remain,

still has c/o feeling slightly SOB. ��

0630 Lasix 160 mg p.o. given ��

0800 Resting well. Upon awakening slightly SOB. Sats 91-92% on 2 liters. Dim LS with faint

bibasilar crackles. BS pos, Abd. neg. Ext. no edema. VS stable. Patient alert & oriented.

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0830 Wife here. Patient eating. No c/o. ��

1000 Resting now. Resp. more at ease. ��

1030 Explained new S.S. insulin to patient and wife. No c/o, questions.

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1230 Stable. Resting. Resp. easy. ��

1300 Tried pt on 1L O2/NC, sats decrease to 87%. Increased to 2L/NC, sats 95%. Amb with

2LO2, 2 assist & Sat monitor on, 100 Fahrenheit. Sats to 92%. Back to room & up in chair.

Did get slightly dyspneic with amb. More rested in chair. Sats back up 95% when sitting.

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1400 Back to bed with 2LO2. Sats 98%. No c/o. Restful. Lights out for a bit. Call light placed.

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1450 Resting with easy, snoring like resp. Wife in room. ��

1600 Pt awake & talkative. Denies any discomfort. Resp easy at rest. Still has coarse rales in bases

bilaterally. Color pink. Sats in mid 90’s on 2L. No pedal edema. C/o some weakness.

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8/15/xx


# 012502

1830 Appetite good. Assisted to ambulate 100 ft in hall with 2 assist & cont O2. Only slight

staggered steps at times. Otherwise gait steady. To BR but unable to have BMO.

Passed flatus. Had prune juice with supper. ��

1930 VSS, resting quietly, denies physical c/o. Lungs diminished BS, O2 decreased 1/4 lit with

some crackles, dec 1/4 lit SO2 96% @ 2L/NC. Re AP, inc pulses x 2, no c/o. Soft abd,

Pos BS x 4, Foley patent with clear yellow urine. ��

2030 Bath done, cares done. Linen changed. ��

2050 Accu � Accu � 105, pt given Humalog 3 units. Pt h.s. snack.

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2105 SVN SVN with V.S. Albuterol & Atrovent given, tolerated well.

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8/16/xx

0200 Sleeping in bed, breathing easily. ��

0115 SVN with albuterol 0.5 cc given. ��

0130 Breathing easy, good air exchange. Lungs fields with only minor crackles. No c/o at

this time. ��

0640 Feels better after treatment. Improving air flow in all lung fields. Foley catheter removed.

IV discontinued. ��

0700 Up to BR, voids well. ��

0800 Dr. Wainwright visits, discharge order written and discharge instructions given. Patient resting

well. Blood sugar 130, vital signs stable. Ext. no edema. VS stable. Patient alert & oriented.

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0830 Wife here. Patient eating. No c/o. Breakfast, eats well, somewhat short of breath while

eating, otherwise no dyspnea, no c/o. ��


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8/16/xx

1045 Discharge instructions discussed with patient and wife. They voice understanding. Will

follow up with Dr. Wainwright at his office in two weeks. ��

1115 Discharged per wheelchair, escorted to car. ��


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24 Hour Urine 0 - 30for Microalbumin

Sundance HealthCare Systems Painted Valley, USA

Component Normal First Second Third FourthDate

Color Yellow

Character Clear

Spec Gravity 1.020 or less

Leukocytes Negative

Nitrates Negative

PH 5-6

Protein Urine Negative

Glucose Urine Negative

Ketones Urine Negative

Urobilinogen 0 - 1 mg/dl

Bilirubin Urine Negative

Occ Blood Urine Negative

WBC/HPF 0 - 5

RBC/HPF 0 - 5

Epitheial

Casts/LPF

Crystals

Amorphorus

Mucous

Yeast Cells Negative

Bacteria Negative

Sent for Culture: Y / N Y / N Y / N Y / N

Form L-9001 (5/01) pa URINALYSIS© 2003. American Health Information Management Association. All rights reserved.

Yellow

Clear

1.015

Negative

Negative

5.2

Negative

Negative

Negative

Negative

Negative

Negative

3 - 5

Few

15-20 Hylalin

Newman, Edward C. 78 CCU #2 # 012502

Dr. William J. Wainwright 8/14/xx 7734-2002

08/14/xx

Sundance HealthCare SystemsPainted Valley, USA

Medication and Hosp Day Hosp Day Hosp Day Hosp DayDate of Order Route #1 # #3 #4

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

MEDICATION PROFILE© 2003. American Health Information Management Association. All rights reserved.


Lisinopril 40 mg p.o. q.a.m. 08 SMB SGA

Theo-Dur 200 mg p.o. b.i.d. 08 ams SMB KJN

21 nmr kl

Lasix 160 mg p.o. b.i.d. 08 ams 1200 SMB KJN

17 pvm rlw KJN

EC ASA 1 p.o. daily 08 ams SMB KJN

Imdur 60 p.o. q.h.s. 21 nh kl

Diazepam 10 mg p.o. q.h.s. 21 nh see D’s below

Pilocarpine 4% 1 gtt OD q.i.d. 08 / SMB KJN

12 pvm SMB

16 mds swb

21 taf ko

Clorazepate 15 mg q.h.s. 21 wlk dcd 8/15

Diazepam 20 mg p.o. q.h.s. 21 / ko

8/14 8/15 8/16

Diagnosis: CHF, COPDAllergies: Penicillin

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Lipid Profile

Total Choles 100 - 200

HDL 40 - 80

LDL 66 - 130

Triglycerides 50 - 150

HG A1C 4.0 - 6.0

PSA 0.0 - 4.0


Chemistry 10

Sodium 135 - 145

Potassium 3.5 - 5.3

Chloride 100 - 110

CO2 23 - 29

Glucose 80 - 116

BUN 12 - 20

Creatinine 0.6 - 1.3

Total Bili 0.0 - 1.3

Albumin 3.5 - 5.0

Calcium 8.2 - 10.1

ALP 56 - 112

AST 0 - 27

ALT 14 - 26

Total Protein 6.0 - 8.0

Theo 10.0 - 20.0

TSH 0.4 - 6.2

Form L-9003 (5/01) pa CHEMISTRY© 2003. American Health Information Management Association. All rights reserved.

143 143

4.4 3.8

100 100

35 H 36 H

238 H 91

27 H 35 H

1.5 H 1.6 H

0.7

3.9

9.8 9.4

58

21

18

6.6

8.2 L

1.9

08/14/xx 08/15/xx



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Hematology

WBC (x 103) M/F 4.3 - 11.0

RBC (x 103) M 4.6 - 6.2

F 4.2 - 5.4

Hgb (g/dl) M 12 - 18

F 12 - 16

HCt (%) M 40 - 54

F 36 - 47

MCV (x 103) M 80 - 94

F 82 - 100

MCH (x 103) M/F 26 - 33

MCHC (%) M/F 31 - 36

PLT (x 103) M/F 150 - 375

Differential

Band 0 - 6%

Seg 46 - 82%

Lymph 13 - 37%

Mono 4 - 12%

Eosin 0 - 5%

Baso 2 - 2%

NRBC

Atyp Lymph

Meta

Myelo

Pros

Blast

Form L-9003 (5/01) pa HEMATOLOGY© 2003. American Health Information Management Association. All rights reserved.

10.4 H

4.25

13.6

40.6

95.7

32.0

33.4

76

15

4

3

3 H

08/14/xx




Form 9427 (8/00) mr HISTORY & PHYSICAL

SignatureDr.



CHIEF COMPLAINT: Shortness of breath.

HISTORY OF PRESENT ILLNESS: This patient is a 78-year-old resident of Podunk Center. He has along-standing history of severe COPD, insulin-dependent diabetes mellitus and ASHD and status post MI’s.

According to the patient he has been severely short of breath over the past several months. Apparently this hasincreased over the past two days and yesterday it severely limited his ability to get up and walk around. Duringthe night last night, at approximately 5:00 a.m., he had a severe episode of shortness of breath. He receivedtwo nebulizer treatments and his wife turned his home oxygen up wide open. Despite this, however, he re-mained severely short of breath. His wife then called 911 and he was brought to the ER via ambulance.

The patient denies substernal chest pain. He states that he has gained approximately five pounds over the pastcouple of weeks. He also admits to swelling of both ankles at the end of the day.

PAST MEDICAL HISTORY: Several episodes of COPD in the past. He has also been admitted with MI’sat age 66 and again in September, three years ago. He has had congestive heart failure and long-standinginsulin-dependent diabetes mellitus. He has glaucoma and chronic blindness in his right eye. He has a history oflong-standing noncardiac chest pain. He has also had peptic ulcer disease.

PAST SURGICAL HISTORY: He is status post T&A, hemorrhoidectomy x 2, colonoscopy withpolypectomy in six years ago which revealed a tubular adenoma, right inguinal herniorrhaphy four years ago,another colonoscopy repeated three years ago. He had a TURP in 1981 for benign prostatic hypertrophy.

MEDICATIONS: Humulin N 64 units in the morning and 64 units in the evening. Humalog sliding scale t.i.d.,usually taking 14 to 16 units at mealtimes. He also takes Theo-Dur 200 mg b.i.d., Lasix 160 mg a.m. and 80mg at noon q.d. Ecotrin 325 mg q.d. Pilocarpine 4% ophthalmic drops 1 drop right eye q.i.d., Imdur 60 mgq.h.s., Diazepam 10 mg q.h.s., Clorazepate 15 mg q.h.s., nitroglycerin 0.4 mg sublingual p.r.n. chest pain,albuterol and Atrovent nebulizer q.i.d. and p.r.n. He is on home O2 routinely at 2 liters per minute per nasalcannula.

ALLERGIES: Penicillin causes a rash.

HABITS: 150 pack year history of cigarette smoking. He is currently a nonsmoker, does not drink alcohol.

FAMILY HISTORY: The patient is married and is a retired teacher. He lives in Podunk Center with his wifewho also has had some health problems, including atrial fibrillation. They have three children in the area.

REVIEW OF SYSTEMS:General: No seizures or syncope. He has had the weight gain as mentioned above.HEENT: No recent change in hearing or vision. He does have the glaucoma as mentioned above.


Form 9427 (8/00) mr HISTORY & PHYSICAL

SignatureDr.



Respiratory: As above.Cardiac: See HPI.GI: No nausea, vomiting, diarrhea, constipation, hematochezia or melena.GU: No burning, hematuria or recent UTI. He states that he does have nocturia one to two times per night.Musculoskeletal: Negative.Neurologic: He has been depressed over his breathing difficulties.

PHYSICAL EXAMINATION:General: This is a well-developed, well-nourished 78-year-old white male, sitting up on the examining tablewith oxygen running. He appears in no acute distress at this time.Vital Signs: Blood pressure 144/72, pulse 108, respirations 38, temperature 96.4 degrees Fahrenheit. Weight190 pounds.Skin: Anicteric, warm and dry. Face is slightly flushed at this time.Heent: Shows clear TMs. Pupils equal, round and reactive to light on the left. There is evidence of cornealdystrophy on the right. Oropharynx is clear.Neck: Supple, no cervical lymphadenopathy.Chest: Lungs have slight crackles in the right mid-lung field and base, clear on the left.Heart: Regular rate and rhythm without murmur or gallop.Abdomen: Normal bowel sounds, soft and nontender. No masses, hernias or organomegaly noted.Genitalia: External genitalia is normal.Extremities: Warm and well perfused. There is trace edema bilaterally. Pedal pulses are palpable.Neurologic: Motor and strength are 5/5 bilaterally. DTRs are symmetrical.Psych: Affect is more flat than typically seen. Recent and remote memory are good. Judgement and insightare intact. Does seem to be slightly depressed.

LABS: Chest x-ray shows cardiomegaly and evidence of vascular redistribution consistent with CHF. EKGshows normal sinus rhythm at a rate of 94 beats per minute. There is evidence of an old anterior MI and an oldinferior MI. No acute appearing ST-T wave changes. Sodium is 143, potassium 4.4, BUN 27, creatinine 1.5,glucose 238. CBC shows white count 10,400 with a normal differential, hemoglobin 13.6, hematocrit 37.9.

ASSESSMENT:1. A 78-year-old white male with cor pulmonale and congestive heart failure secondary to his severe

chronic obstructive pulmonary disease and coronary artery disease.2. Arteriosclerotic heart disease with history of previous myocardial infarctions and congestive heart failure.3. Chronic glaucoma with right eye blindness.4. Chronic insomnia.5. Insulin-dependent diabetes mellitus.6. Benign prostatic hypertrophy, status post transurethral resection of prostate.

PLAN: The patient will be admitted to the CCU. Monitor his O2 saturations, provide oxygen as necessaryand diurese him.

D&T: 8/14/xx

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Date _____________ _____________ _____________ _____________Time 3 6 9 12 15 18 21 24 3 6 9 12 15 18 21 24 3 6 9 12 15 18 21 24 3 6 9 12 15 18 21 24

105 ...................................................................................................................................................

104 ...................................................................................................................................................

103 ...................................................................................................................................................

102 ...................................................................................................................................................

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100 ...................................................................................................................................................

99 ...................................................................................................................................................

98 ...................................................................................................................................................

97 ...................................................................................................................................................

96 ...................................................................................................................................................

95 ...................................................................................................................................................

Pulse

Resp.

B/P ___/___| ___/___| ___/___ ___/___| ___/___| ___/______/___| ___/___| ___/___ ___/___| ___/___| ___/______/___| ___/___| ___/___ ___/___| ___/___| ___/______/___| ___/___| ___/___ ___/___| ___/___| ___/___

Weight: ______ | _______ ______ | _______ ______ | _______ ______ | _______

In ______| ______| ______ ______| ______| ______ ______| ______| ______ ______| ______| ______ Out ______| ______| ______ ______| ______| ______ ______| ______| ______ ______| ______| ______

Diet ______| ______| ______ ______| ______| ______ ______| ______| ______ ______| ______| ______Appetite______| ______| ______ ______| ______| ______ ______| ______| ______ ______| ______| ______

GRAPHIC SHEET© 2003. American Health Information Management Association. All rights reserved.

08/14 08/15 08/16

195.7 194.9 193.3 192.6 190.4

Newman, Edward C.Dr. Dr. William J. WainwrightCoronary care unit

# 012502

93 102 89 88 86 76

38 20 21 24 20 18

143 72 144 62 136 74 140 78 110 60 122 76 122 78

ADA ADA ADA ADA ADA ADAGood Fair Fair Good Good Fair

Patient's Name

Birth Date Age

Street Address

Phone Number

Hospital Number

Sex Marital Status State Zip County

City

Patient's Occupation

Soc. Sec. #

Name

Address

Relationship

Phone No.

Responsible for Account

Religion

Date Admitted Time AMPM

Date Discharged Time AMPM

Date of Last Admission Name & Address of Any Institution From Which Discharged in Last 60 Days

Admitting Physician

Aitemding Physician

Consultant


Notify InEmergency

Room

Race

Ethnicity

Admitting Diagnosis (Within 24 Hours) ICD-9-CM CODESICD-9-CM CODESICD-9-CM CODESICD-9-CM CODESICD-9-CM CODES

Principal Diagnosis

Secondary Diagnoses

Complications

Operative Procedures (Date & Title)

Discharged Alive ____ Died ____ Autopsy Yes ____ No ____

Physician Signature

This is a simulated health record created and intended for educational purposes only. All scenarios, names, demographic information, medical events, and dataportrayed herein are fictitious. No identification with or similarity to actual persons, living or dead, or to actual events or entities is intended or should beinferred. Any similarity to actual persons or events is purely coincidental.© 2003. American Health Information Management Association. All rights reserved.

ADMISSION SUMMARY SHEET

Newman, Edward C. 2720 Mountain View # 012502

04/01/xx 78 Devils Lake 701 801-7734

M Married N.D. 58301 Ramsey CCU #2

504-59-3132 Methodist W

Teacher (Retired) Non-Hispanic

Mildred Wife Self

2720 Mountain View, Devils Lake 701 801-7734

8/14/xx 0645 08/16/xx 1111

2/29/xx N/A

Dr. William J. Wainwright

Dr. William J. Wainwright

Cor pulmonale and congestive heart failure secondary to severe chronic obstructivepulmonary disease and coronary artery disease.

1. Congestive heart failure complicating severe chronic obstructive pulmonary disease.

2. Arteriosclerotic heart disease with history of myocardial infarctions.3. Insulin-dependent diabetes mellitus.4. Glaucoma.

�

��

CONDITIONS OF ADMISSIONCONDITIONS OF ADMISSIONCONDITIONS OF ADMISSIONCONDITIONS OF ADMISSIONCONDITIONS OF ADMISSION

1. CONSENT TO HOSPITAL CAREI am presenting myself for admission to St. Jude’s Medical Center. I voluntarily consent to the rendering of medicalcare which is determined to be necessary or beneficial in the professional judgement of my physician. This includesroutine diagnostic procedures and medical treatment by authorized agents and employees of the Hospital, and by itsmedical staff, or their designees.

I acknowledge that no guarantees have been made to me as to the effect of such examination or treatment on mycondition.

2. AUTHORIZATION TO RELEASE INFORMATIONI authorize St. Jude’s Medical Center to release such information from my medical record as may be necessary forthe completion of the hospital’s or my physician’s claims for reimbursement to my insurance company or agency. IUNDERSTAND THAT DISCLOSURE MAY INCLUDE DIAGNOSES AND OPERATIONS OR PROCEDURES PER-FORMED AND THAT, AT THE REQUEST OF MY INSURANCE COMPANY OR AGENCY, MY COMPLETE MEDI-CAL RECORD MAY BE SUBJECT TO REVIEW. IN ADDITION, I UNDERSTAND THAT COPIES OF MY RECORDMAY BE OBTAINED BY MY INSURANCE COMPANY OR AGENCY.

3. ASSIGNMENT OF BENEFITSIn consideration of the services received or to be received for this admission to St. Jude’s Medical Center, I assign allinsurance benefits due me. I further warrant that the hospital shall be entitled to the full amount of its charges. Anycredit balance resulting for any reason will be applied to other existing accounts. This also assigns benefits toAnesthesia Consultants, PC.

I hereby agree to pay any and all hospital charges that exceed or that are not covered by my hospitalization insur-ance coverage. This assignment shall be irrevocable.

4. VALUABLES DISCLAIMERI understand that St. Jude’s Medical Center maintains a safe for the safekeeping of money and valuables. I, also,understand that I assume full responsibility for any and all of my valuables, money, clothing, dentures, and otherpersonal items while a patient in the hospital unless deposited with the Hospital for safekeeping.

Valuables Deposited with the Hospital YES NO

5. REQUEST FOR FACILITY ACCOMMODATIONSI agree to pay to the Hospital any difference between the semi-private rate provided by my hospitalization insuranceand the Hospital charges for a private accommodation. I understand that private accommodations are more expen-sive than the room rate payable by my hospitalization insurance and that it is my responsibility to pay the difference.

I request a Private Room YES NO

This document has been fully explained to me, and I certify that I understand its contents and agree to it freely.

AMDATE TIME PM Patient or authorized person

Witness Relationship

Guarantor/Insured Certificate Holder

Signature is not that of the patient because: ( ) patient is a minor

( ) other reason (specify):

��

��

�

�

Patient's Name

Birth Date Age

Street Address

Phone Number

Hospital Number

Sex Marital Status State Zip County

City

Patient's Occupation

Soc. Sec. #

Name

Address

Relationship

Phone No.

Responsible for Account

Religion

Date Admitted Time AMPM

Date Discharged Time AMPM

Date of Last Admission Name & Address of Any Institution From Which Discharged in Last 60 Days

Admitting Physician

Aitemding Physician

Consultant


Notify InEmergency

Room

Race

Ethnicity

Admitting Diagnosis (Within 24 Hours) ICD-9-CM CODESICD-9-CM CODESICD-9-CM CODESICD-9-CM CODESICD-9-CM CODES

Principal Diagnosis

Secondary Diagnoses

Complications

Operative Procedures (Date & Title)

Discharged Alive ____ Died ____ Autopsy Yes ____ No ____

Physician Signature

This is a simulated health record created and intended for educational purposes only. All scenarios, names, demographic information, medical events, and dataportrayed herein are fictitious. No identification with or similarity to actual persons, living or dead, or to actual events or entities is intended or should beinferred. Any similarity to actual persons or events is purely coincidental.© 2003. American Health Information Management Association. All rights reserved.

ADMISSION SUMMARY SHEET

Patient's Name: Last Name First Name Middle Initial Home Phone Admission Date Med.Rec. Number

Address: State Zip Age Sex Date of Birth Civil Status Religion

Employer: Occupation: Soc. Sec. #

Address: Phone No: Notify Press Yes No

Responsible Party: Occupation: Family Doctor:

Address: Phone No: Notified Yes No

Brought In By: ___ Self

Name of Insurance Company Policy No. ___ Police ___ Fire

Address of Insurance Co. ___ Relative ___ Other

Notified: Relative Relationiship: By Whom Race:

Police Coroner Time a.m./p.m. Ethnicity:

BRIEF HISTORY: (If accident, state where, when & how injured; if illness describe):

a.m.p.m.

S M W D Sep

Account Number:

Condition on Admission:

Good ____ Fair ____

Poor ____ Shock ____

Coma ____ Hemorrhage ____

Vital Signs:

Temp. ____

Pulse ____

Resp. ____

B.P. ____/____

Normal Other System Inventory:

� � Mental/Emotional

� � Status:

� � Skin

� � Respiratory

� � Cardiovascular.

� � Musculoskeletal:

� � Gastrointestinal

� � Genitourinary

� � Neurological

� � EENT

PHYSICIAN'S REPORT: History & Physical Findings:

Diagnosis:

Treatment (including medications):

Disposition of Case:

Referred to Dr. Date:

Instructions to Patient:

Form # _ _ _ _ Patient's Signature Date Time Attending Physician


EMERGENCY ROOM / OUTPATIENT RECORD

Newman, Edward C. 701 801-7734 08/14 # 012502

Devils Lake N.D. 58301 78 M 04/01 MethodistRetired Teacher 504-59-3132Tokyo, ND

Admitted to CCU, LAB: CXR, EKG, CBC, PO2 (Theo Old charts

per Dr. Wainright / Ries RN) A: Acute exacerbation of asthma / LVF.

Lasix 20 mg IV

P: Admit to CCU.

Mildred Wife Agathie Chrsty

No No 0645

Alfred E. Newman Teacher Dr. WainwrightDevils Lake, ND 801-7734

Medicare AP 504-39-3132Hooterville, ND

xx

xx

96.4 Height: 72"108 Weight: 19048 SAO2 96%143 72

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Allergies: Penicillin Patient Medications: See attached sheet.

78-year-old male to ER per ambulance. Awoke at 0600 with acute respiratory distress. Hx COPD. Did home nebulizers

without relief. Ambulance called for transport. Second neb started et finished en route. Accu � done also “200”. Currently

mildly dyspneic, respirations 38, lungs slightly et moderate diminished. SAO2 98% on 2 liter p.m. NC. ??? Rhythm NS without

ectopics. 0725 Saline lock 22 g 28 mm Jelco started L hand - Lasix 80 mg IV push. Lock flushed per protocol NUB.

0730 Dr. Wainwright in to examine patient.

0740 Admit Coronary care unit .

0810 Patient to floor in W/C per RN

Increasing shortness of breath 6:00 a.m. No chest pain. No cough. Has been on

home O2. O2 sat on 2LNC 96% Pulse increased,

Adm H: CHF RR 28 pm

ASHD Heart: WNL.

Lungs: Expiratory wheezes bilaterally.

Lower extremity edema 1+.

Edward C. Newman 8/14/xx 6:45 ��

Simulated record. ©2003. American Health Information Management Association. All rights reserved.

PATIENT:

A.M.DATE: DATE: P.M.

1. I, (or ) acting for )

knowing that I, (or ) am (is) suffering from a condition requiring emergency or out patient care do herebyvoluntarily consent to such care encompassing diagnostic procedures and medical treatment by Dr.his assistants or his designees as is necessary in his judgement.

2. I am aware that the practice of medicine and surgery is not an exact science and I acknowledge that no guarantees have been made to me as to the resultof treatments or examination in the hospital.

3. This form has been fully explained to me and I certify that I understand its contents.

Witness Signature of Patient

(If patient is unable to consent or is a minor, complete the following):Patient (is a minor years of age) is unable to consent because

Witness Closest Relative or Legal Guardian


Patient's Name: Last Name First Name Middle Initial Home Phone Admission Date Med.Rec. Number

Address: State Zip Age Sex Date of Birth Civil Status Religion

Employer: Occupation: Soc. Sec. #

Address: Phone No: Notify Press Yes No

Responsible Party: Occupation: Family Doctor:

Address: Phone No: Notified Yes No

Brought In By: ___ Self

Name of Insurance Company Policy No. ___ Police ___ Fire

Address of Insurance Co. ___ Relative ___ Other

Notified: Relative Relationiship: By Whom Race:

Police Coroner Time a.m./p.m. Ethnicity:

BRIEF HISTORY: (If accident, state where, when & how injured; if illness describe):

a.m.p.m.

S M W D Sep

Account Number:

Condition on Admission:

Good ____ Fair ____

Poor ____ Shock ____

Coma ____ Hemorrhage ____

Vital Signs:

Temp. ____

Pulse ____

Resp. ____

B.P. ____/____

Normal Other System Inventory:

� � Mental/Emotional

� � Status:

� � Skin

� � Respiratory

� � Cardiovascular.

� � Musculoskeletal:

� � Gastrointestinal

� � Genitourinary

� � Neurological

� � EENT

PHYSICIAN'S REPORT: History & Physical Findings:

Diagnosis:

Treatment (including medications):

Disposition of Case:

Referred to Dr. Date:

Instructions to Patient:

Form # _ _ _ _ Patient's Signature Date Time Attending Physician


EMERGENCY ROOM / OUTPATIENT RECORD



Form 4101 (10/01) mr ELECTRCARDIOGRAM

Cardiologist Signature


NEWMAN, Edward C. # 012502

Age 78 CCU

Dr. D. J. Wagner 8-14-xx a.m.

MECHANISM: Normal sinus rhythm

RATE: 94 beats per minute

AXIS Left axis deviation. P-R-T axes 68 - 55 116

PW: Are broadened. P-R interval 162 ms

COMPLEXES: Normal voltage. Left ventricular hypertrophy with QRS widening. Left atrialenlargement. QT/Qtc 317/398 ms. QRS interval is 118 ms.

TW: Nonspecific ST and T-wave abnormality.

COMMENT: Abnormal EKG, possible lateral ischemia. Old anterior MI. No change fromprevious EKG.

DJW/bgSt. Luke’sD&T: 8-14-xx

��


Form 9055 (3/98) him DISCHARGE SUMMARY© 2003. American Health Information Management Association. All rights reserved.

NEWMAN, Edward C.Dr. William J. WainwrightCoronary care unit# 012502

DISCHARGE SUMMARY:

This patient is a 78-year-old gentleman from Podunk Center. He was admitted because of increasing problemsassociated with his chronic congestive heart failure, COPD, diabetes and ASHD. The patient was experiencingincreasing dyspnea associated with the CHF. He was given an IV and increased dose of Lasix. Following thisthe patient diuresed approximately five pounds during his hospitalization. Both his O2 saturations and breathingsteadily improved.

Two days after admission he was feeling much better. He had been up walking and was having no chest pain.

He is being discharged in improved condition.

DISCHARGE MEDICATIONS:Diazepam 20 mg p.o. q.h.s., albuterol and Atrovent nebulizers q.i.d. and p.r.n., Lasix 160 mg p.o. b.i.d.; Theo-Dur 200 mg q.a.m., 300 mg q.h.s.; Imdur 30 mg (1/2 tab) q.h.s., Pilocarpine 4% 1 drop O.D. q.i.d., nitroglyc-erin 0.4 mg sublingual p.r.n. chest pain, oxygen 2 to 4 liters per minute per nasal cannula. For his diabetes hewill be on Humulin N 64 U a.m., Humulin N 36 U p.m. and Humalog sliding scale as follows:Accu-Chek less than 100 = 0,Accu-Chek 101 - 130 = 3,Accu-Chek 131 - 170 = 5,Accu-Chek 171 - 220 = 8,Accu-Chek 221 - 300 = 12,Accu-Chek 301 - 400 = 15,Accu-Chek more than 400 = 18.

FOLLOW-UP: Mr. Newman has an appointment to see me in the office in approximately two weeks forrecheck. He should call or come in sooner if he has any questions or problems prior to that appointment. He isto check his weights on a daily basis at home and if he gains more than two pounds from his discharge weight heis to call me at once or come into the ER or walk-in clinic.

FINAL DIAGNOSIS:1. Congestive heart failure complicating severe chronic obstructive pulmonary disease.2. Arteriosclerotic heart disease with history of myocardial infarctions.3. Insulin-dependent diabetes mellitus.4. Glaucoma.

PROCEDURES: None.

COMPLICATIONS: None.

DJW/sgsD&T: 8/16/xx ��

Documents

Edward C Newman Record