Patient Name: Judy Jones Physician: Annette Parks, Diagnosis: Pneumonia MD/Medical Team B Age: 85 Type of Operation: None Allergies: Sulfa Gender: Female History: Hypertension, cervical Fall Precautions: High Height: 5’7” spondylosis, hyperlipidemia, and Isolation Precautions: Standard Weight: 115 lbs dementia (short term memory Restraints: No Major Support: Daughter Karen issues, sequencing and executive Diet: Regular Jones functioning deficits) Phone: 555-555-5555 Advanced Directives: No Karen (daughter) 555-555-5566 Monitoring Medication Respiratory Vital signs Q4h Oral medications Incentive spirometry 10 times – Call if heart rate is greater than every hour while awake 120 beats/min Social History Consults Treatments Widowed Lives at home with her daughter Karen Her two sons live approximately one hour away Race: Religion: Baptist Medication brought from home: None Diagnostic Studies Activities of Daily Living Discharge Planning As tolerated, self-directed Transfer to Rehabilitation Center tomorrow
Patient Name: Judy Jones Physician: Annette Parks, MD/Medical Team B Diagnosis: Pneumonia Age: 85 Gender: Female Height: 5’7” Weight: 115 lbs Major Support: Daughter Karen Jones Phone: 555-555-5555 Karen (daughter) 555-555-5566 Type of Operation: None History: Hypertension, cervical spondylosis, hyperlipidemia, and dementia (short term memory issues, sequencing and executive functioning deficits) Advanced Directives: No Allergies: Sulfa Fall Precautions: High Isolation Precautions: Standard Restraints: No Diet: Regular Monitoring Vital signs – Q4h Call if heart rate is greater than 120 beats/min Medication Oral medications Respiratory Incentive spirometry 10 times every hour while awake Social History Widowed Lives at home with her daughter Karen Her two sons live approximately one hour away Race: Religion: Baptist Medication brought from home: None Consults Treatments Diagnostic Studies Activities of Daily Living As tolerated, self-directed Discharge Planning Transfer to Rehabilitation Center tomorrow
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