Chief Complaint: DOB and chronic

Patients Name: Dela Cruz, Juan Jose cough

Date: 04/01/2015 Time: 07:20AM

Date of Birth: July 10, 1951 Age: 55 years old

PIN: 108004 Height: 170cm

Attending Physician: Dr. Pascual, Erick Weight: 78 kg

(Cardiologist)

Past Medical History: Diabetes Mellitus, Allergies: NKA

Hypertension

Medication Reconciliation:metformin 500mg 2x a day, losartan 50mg/tab once a day in

AM, amlodipine 5 mg once a day in PM

Healthcare Providers Admitting Orders Nurses Notes

Notes

04/01/15 07:22am Admit under the service of Dr. 04/01/15 07:30

Pascual
ER Medicine Notes S- matagal na akong may
Vital Signs every 4 hours ubo
S- Reported experiencing
cough since February 2015 Low salt, Low fat, Diabetic O- with crackles bibasal of
with some blood in sputum, Diet lungs, with coughing
with low grade fever episodes
CXR-PA
O- (+) expiratory wheezes A- Ineffective airway
on left base, (+) crackles on For CBC, Na, K clearance
both base of the lungs
CBG now, then 3x a day pre- P- attain improvement in
A- CAP-MR t/c PTB r/o COPD, airway clearance after 2
meals and at bedtime
HPN, DM hours
Start PNSS 1 liter to run for
P- Antibiotic treatment I- INTERVENTIONS
16 hours

1.
PPD 5000 units

Start piperacillin -
tazobactam3.375g IV every
2.
8 hours after negative test
dose.

Paracetamol 500mg/tab 1 tab

3.
every 4 hours as needed for
fever > 37.8

Continue metformin, losartan

4.
and amlodipine c/o patient

1
 Dr. Pascual / Dr. Salazar Refer to Dr. Tamondong for 5.
(MROD1) pulmo co-management

6.
Dr. Pascual / Dr. Salazar

Compute mL/hr for PNSS

Compute gtts/min for PNSS

Compute for the patients BMI (3 points)

Explain the policy regarding brought in medication

PPD is given via

Compute mL/dose for piptaz

Compute for dose/day

Where does the medications stored in the unit?

What is the frequency of changing the soluset?

True or False: Soluset must be labeled with patients name and the antibiotics only

2
 Healthcare Providers Notes Orders

04/01/15 09:00am Thank you for the referral

Pulmo Referral Notes Dr. Tamnondong informed of referral

S -Patient is not in distress, no episode of Start Quadtab (HRZES) 1 tab now then once a
DOB day
O - (+) rashes, (-) wheezes, (+) cough
episode, (+) crackles bibasal Start azithromycin 500mg IV in 250mL D5W
A - CAP-MR t/c PTB r/o COPD, HPN, DM once a day to run for 2 hours
P antibiotic therapy
Facilitate CXR as ordered now

Increase OFI

Dr. Tamondong / Dr. Salazar

True or false: In administering quadtab, your patient should be on full stomach.

What health teaching will you provide to your patient regarding quadtab?

Knowing the side effect of azithromycin, what additional exam or test would you
recommend to the doctor and why?

Healthcare Orders Nurses Notes

Providers Notes
04/01/2015 09:30am
Pulmo Notes
S- Patient is not in distress, Discontinue azithromycin
no episode of DOB
O - (+) rashes, (-) wheezes,
non-tender abdomen
A - Hypersensitivity reaction
probably due to antibiotic
therapy
P - Control of allergic
reaction, Discontinuation of
azithromycin, Continue
piptazantibiotic therapy
Dr.Estrella (pulmo fellow)
04/01/2015 09:30am
S- 15 mins after infusion of
azithromycin patient
Give diphenhydramine complained of pruritus
50mg now O- rashes on the neck and
Continue piptaz to
upper extremities
complete 5 days A- allergic reaction; risk for
impaired skin integrity
P- no wounds will develop
Dr. Tamondong / Dr. during the course of allergic
Estrella reaction
I- INTERVENTIONS
1.
LATE ENTRY
Kindly facilitate creatinine 2.
and ECG.
3.
Dr. Salazar
4.

You know that the medication order is incomplete. What are the components of a
complete medication order?

3
 Healthcare Providers
Notes
04/01/2015 11:45am
Cardio MROD Notes
S-Family reported increase in
sleeping time
O- CXR showed some
pulmonary nodules but not
conclusive for PTB, BP 80/50
on dynamap, RR 26, PR 99,
irregular rhythm, temp 38.7
A- CAP-MR, COPD, r/o PTB,
DM, HPN
P- Continue hydration and
antibiotics
Dr. Salazar
Orders Nurses Notes
Increase IVF to run for 8 04/01/2015 12:00pm
hours S- relatives reported episode
Sputum GS/CS of chills
AFB smear x 2 days O- body temp of 38.7, dry
oral mucosa, dry skin, warm
Dr. Tamondong / Dr. to touch
Salazar A- hyperthermia
P- attain normal body
Hold all anti-hypertensive temperature after 4 hours
medications. I- INTERVENTIONS
CBG now (101) 1.
Take heart rate on one full 2.
minute 3.
Once at room, refer to Dr. 4.
Saniel for IDS co- 5.
management
May transfer to room. Transferred patient to room
1101
Dr. Pascual / Dr. Salazar

During the treatment course, a group of VA victims was rushed into the TMC Emergency
department. 20 victims came from the accident happened at C5. 6 of them are unconscious
so the emergency doctors treated the patient as subdural hematoma. 150 of Mannitol IV
push is given to patient A.

The ER nurse should activate what kind of code?

How does the ER activate this code?
Who are the involved staffs when this code was activated?
True or False: Mannitol is an example of potassium sparing diuretics.
What changes in VS of a patient with an increased intracranial pressure?
1.
2.
3.
The symptoms above are known as the _________________

PATIENT TRANSFERRED TO ROOM 1101

Enumerate 6 things to orient during Nurses Notes

admission based on PDAF:
04/01/2015 01:00pm
1.
S- relatives reported history of fall 2 months
2. ago, although withmoderate body weakness
on lower extremities patient opt to walk
3. alone without any use of any ambulatory
aids
4.
O- oriented to date and time
5.
- Morse fall score? _______________
6.

4
 A- Risk for fall

The 2 most important person to inform of P- will maintain free from fall within hospital
admission stay

1. I- INTERVENTIONS

2. 1.

2.

Compute for BMI (170cm and 78kgs) 3.

4.

5.

6.

Give the 6 factors that contribute to the possibility of fall.

1. If the patient was tagged as a high

The form utilized by TMC for fall
assessment:
You have to do fall risk assessment
for your high risk patient every
risk for fall, you know that there is
additional official tool utilized by the
TMC, what do we call it?
Based on this form, what is the
frequency of checking your patient
who is high risk for fall

2.

Who accomplishes the nutritional forms?

You know that your patient is frail, if he has how many risk factors?

During the handover, IV site label is not available, you know that IV line should be
change every

3.

4.

5. Healthcare 6. Orders 7. Nurses Notes

Providers Notes
8. 04/01/2015 25. 36.04/01/2015
2:20pm 26. 2:10pm
9. Pulmo MROD Remove and transfer IV 37.S- angsakit ng

5
 Notes line kamayko,
10.S-in pain at IV site Give parecoxib 40mg IV parangnamamaga
6/10 now only as per patients
11.O- (+) redness, (+) 27. report
swelling, (+) 28. - Described as continuous
warmth, temp 37.2 29. burning pain at 4-6/10,
12.A- infiltration with 30.Dr. Bisnar (MROD started 30 mins ago at the
phlebitis 2) IV site, increases pain
13.P- for IV line re- 31. during hand movement
insertion 32. and decreases by rest
14. Thank you for the 38.O-with guarding
15.Dr. Bisnar referral. behavior and facial
16.04/01/2015 Patient seen and grimace, with
5:00pm examined redness on the IV
17.IDS Notes Continue current site, and warm to
18.S- decreased pain antibiotic regimen touch
Refer to Dr. Abad for PICC
score 2/10 39.A- acute pain
19.O- with total of 6 IV line insertion 40.P- decreases pain to
attempted insertions 33. 2/10 or better after 2
20.A- infiltration with 34. hours
phlebitis; CAP-MR, 35.Dr. Saniel 41.I-5
COPD, t/c PTB INTERVENTIONS
21.P- central line 1.
insertion, continue 42.
antibiotic therapy 2.
43.
22.
3.
23. 44.
24.Dr. Saniel / Dr. 4.
Agoncillo 45.
5.
46.

47. Health Care 48. Orders 49. Nurses Notes

Providers Notes
50. 63. 70.04/01/2015
51. 64. 04:15pm
52. 04/01/2015 65. Informed Dr. Abad via text
05:00pm Thank you for the referral message of referral
53. Surgery Notes Patient seen and Informed SROD via phone
54. S- patient is known
examined call
diabetic and hypertensive For STAT PICC line under 71. S- anungmga
55. O- referred due to
local anesthesia preparations para
multiple unsuccessful IV
No pre-meds sagagawing procedure
insertion No fasting required
56. A- phlebitis with sakin?
Confirm schedule at 72. O- seen asking the
infiltration, CAP, COPD, t/c
surgery suite relatives
PTB prep at OR
57. P- central line 73. A- readiness for
66. enhanced health
insertion
58. 67. management
59. 68. 74. P- he will be ready
60. 69.Dr. Abad / Dr. Mora for the immediate procedure
61. (SROD 2) within 15 minutes
62. Dr. Abad
75. I- INTERVENTIONS
1.

6
 76.
2.
77.
3.
78.
4.
79.
5.
80.
6.
81.
82.E- patient has been
fully prepared and
transferred safely to
OR
83.

PICC line stands for:

On a traditional PICC line, there are 3 ports. Identify their purposes:
Who are allowed to extract blood on PICC line?
What are the forms needed for the scheduled procedure?
1.
2.
3.
How many times can a nurse attempt IV insertion?

84.Healthcare 85.Orders 86.Nurses Notes

Providers Notes

87.04/01/2015 106. 123.

08:30pm
107. 124. 04/01/2015
88.Surgery Notes 09:00pm
May use PICC line for
89.S- procedure medications and other IV 125.
tolerated well, with purposes as ordered.
minimal pain on the Received patient post PICC
insertion site Flush the ports regularly line insertion at the left
arm, with yellow, violet and
90.O- able to move left Provide PICC line care white port easily flushed
arm with no bleeding with 10mL PNSS each port.
noted Respectfully signing out of
case (IV meds resumed)
91.A- s/p PICC line
insertion Refer back when needed Facilitated left arm
92.P- continue antibiotic precaution
regimen as ordered,
108.
PICC line care 126.
93.
109.
94. 127.
95.
110. Dr. Abad / Dr.
96.
Apeles (SROD 3) 128. 04/02/2015
97. 12:00am
98.
111.

7
 99.
112. 129. S-
100. 04/02/2015 paranghingalsiyangh
12:10am 113. uminga as reported
by the relatives
101. MROD Notes 114.
130. O- RR 28, uses
102. S-minimal pain 115. accessory muscles
on the site during respiration
116.
103. O- referred 131. A- Impaired
due increased RR and 117. breathing pattern
DOB
Resume and administer IV 132. P- eupna will
104. A- s/p PICC medications as previously attain after 2 hours
line insertion, CAP- ordered.
MR, COPD, t/c PTB 133. I-
Continue to monitor
105. patients body 1.
temperature
134.
Check spot 02 now
2.
118.
135.
119.

120. Dr. Agoncillo

136.
121.

122.
137.

Pending sputum gs/cs sent

to laboratory as ordered

138. What additional form you have to send to the laboratory for sputum gs/cs?

Upon checking, o2 sat level is at 90%, what is your initial nursing action?

Post-operatively the nurse in charge should prepare the following for PICC line care.

True or False: The NIC can change the dressing of the punctured site.

True or False: PICC line is an example central catheter. PICC can be used for
hemodialysis.

1.

2. Healthcare 3. Orders 4. Nurses Notes

8
 Providers Notes

5. 04/02/2015 04:10am 11. 16.04/02/2015 04:00am

6. O- o2 sat 90%, K 2.9 Increase o2 to 9 LPM 17.FORMULATE

PRIORITY SOAPI (10
7. A- CAP-MR, COPD, t/c MHBR POINTS)
PTB
Start combivent 1 neb 18.S-
8. P-increase o2 support, every 6 hours and as
awaiting results of needed for DOB 19.
GS/CS
Hook patient to continuous 20.O-
9. pulse ox
21.
10. Start ceftriaxone 2 grams
IV once a day for 5 days 22.A-

Start patient on KCl 23.

40meqs in 1 liter PNSS to
run for 8 hours 24.P-

12. 25.I- INTERVENTIONS

13. 1.

14. 26.

15.Dr. Estrella (Pulmo) 2.

27.

3.

28.

4.

29.

5.

30.

31.

Will you follow the doctor's order regarding oxygen support?

32.

Explain the process of requisition and administration of combivent for 5 points.

9
33.

Explain briefly the process of requesting IVF for compounding for 5 points.

34.

Explain the process of potassium chloride drip administration for 5 points.

35.

36.

37.Healthcare 38.Order True or False: Patient should

Providers Notes be placed on contact
precaution. _______________
45.04/03/2015 53.
07:00pm 39.
Discontinue previous
46.S- still with episode order of antibiotics What are the 5 moments of
of cough as reported (ceftriaxone and piptaz) hand washing?

Start ertapenem 1 gram1.

IV every 24 hours
2.
54.
3.
55.
4.
56.
5.
57.Dr. Saniel / Dr.
Agoncillo 40.

True or False: Chlorhexidine

2% is given to patient on
contact precaution for 3
days. _________

PPE needed for the case

patient.

41.

Explain the process of

10
47.O- decrease crackles requesting ertapenem (5
and wheezes left points)
lung, (-) AFB day1
and day2 42.

48.A- CAP-MR, MRSA 43.

sputum, COPD
44.
49.P- shift IV antibiotics

50.

51.Dr. Agoncillo

1. Spec 2. Sputu
imen m
3. Gra
m 4. nega
stain tive
5. WBC 6. few
7. Gra
m (-)
bacil 8. mode
li rate
9. orga 10. S.
nism aureu
: s
11. spu
tum
colo
ny
coun 12. >50,
t: 000
13. Susceptibility
report
14. ami
kaci
n 15. S
16. ceft
riaxo
ne 17. R
18. pip
eraci
llin 19. R
20. taz
obac
tam 21. R
22. erta
pene
m 23. S
24. mer
open
em 25. S
52.

59.

11
60.

61. Healthcare 62.Orders 63.Nurses Notes

Providers Notes

64. 81. 99.04/03/2015

08:00pm
65. 82.
First dose of ertapenem
66. 83. administered without any
signs of allergic reaction.
67. 84.
Asleep, vital signs as
68. 85. follows: 110/70, RR 23, PR
101, temp 37
69. 86.
100.
70. 87.
101. 04/03/2015
71. 88. 10:15pm

72. 89. Received patient asleep

73.04/03/2015 90.CODE WHITE 102. S-

10:30pm ORDERS mmmmddddmmghh
hg as per patients
74.CFOD Notes CODE For iSTAT Na, K, Ca, Mg response
WHITE
ABG now 103. O- only
75.S- GCS =_____ (E___, responds and
V___, M___) CBC, PT, aPTT withdraws to pain, o2
sat 88%
76.O- 88-90%, bilateral Stat Cranial MRI with IV
crackles, distended contrast 104. A- ineffective
neck vein cerebral tissue
Start aspirin 320 mg now perfusion
77.A- CAP-MR, MRSA, then 80mg once a day
COPD, r/o cerebral 105. P- the
thromoembolism, patient will attain
Give furosemide 40mg IV
pulmonary optimal o2 saturation
now
congestion
106. I-
Increase o2 support to
INTERVENTIONS
4LPM

1. Referred to MROD
Shift combivent to
and CFOD
salbutamol 1 neb every 4
hours RTC
2.

91.
107.

92.

12
 78.P- hemodynamic 93.Dr. Estanislao 3.
stability
94. 108.
79.
95. 4.

Activate code blue 109.

96. 5.

97. 110.

98.Dr. Estanislao 6. Code white activated

111.

112.

80.Dr. Estanislao 113.

(cardio fellow)
114.

115.

116.

117.

118.

Explain the proper documentation of critical value for 5 points.

119.

Interpret the ABG result: ________________________

Considering that code team was already in the room, as the NIC, do you still need to
call 88 to activate code blue? Explain for 3 points.

120.

121.

13
122. Healthcare 123. Orders 124. Nurses
Providers Notes Notes

125. 04/03/2015 143. 04/03/2015 149. FORMULATE

11:00pm 10:46pm SOAPI (10 points)

126. CODE BLUE 144. CODE BLUE Code blue activated

NOTES ORDERS
150. S-
127. O- RBC 4.51, Start CPR
WBC 16.00, platelet 151.
284, hct 0.36, hgb Intubate patient now (mech
110, Na 134, K 3.5, vent setting: vt 624, flow 152. 0-
crea 288 and other rate 70lpm, RR 10, Fio2
blood results are 50%) 153.
normal, o2 sat
decreased to 81 Start dexmedetomidine 154. A-
despite of o2 support, (precedex) 0.3mcg/kg/hr
pulseless (5.6mL/hr) 155.

128. A- CAP-MR, Start CPR 156. P-

COPD, desaturation,
r/o CVD infarct, sepsis 157.
Fast drip 300mL PNSS then
regulate to 8 hours
129. P- 158. I-
hemodynamically
Chest-xray PA now
stable, continue
1.
antibiotic therapy
Hook to cardiac monitor
159.
130.
145.
2.
131.
146.
160.
132. Dr.
Agoncillo 147.
3.

133. Continue CPR

161.

134. 04/04/2015 Insert FC, monitor I&O

accurately 4.
12:00am

162.
135. CODE BLUE Insert NGT and shift current
NOTES diet to peptamen
1400kcal 1:5 dilution 5.

136. O- pulseless every 4 hours with 50mL

flushing pre and post 163.
but with normal
rhythm at cardiac feeding.
164.
monitor
Monitor CBG pre-feeding
165. 04/04/2015
137. A- CAP-MR,
Discontinue metformin and 01:30am
COPD, desaturation,
r/o CVD infarct, start apidra 3 units every

14
 sepsis, cardiac arrest feeding. Hold for CBG less Patient intubated, with
than 99. bilateral and equal breath
138. P- sound
hemodynamically Start lantus 12 units once a
stable, continue day. 166.
antibiotic therapy
Defer cranial MRI for now 167.
139.
Repeat ABG 1 hour post- 168. 04/04/2015
140. intubation 03:12am

141. Dr. Discontinue all antibiotics Transferred patient to ICU

Agoncillo isol1
Start vancomycin 1 gram IV
142. every 8 hours

Transfer to ICU

148. Dr.
Agoncillo

What are your nursing responsibilities in handling foley catheter?

1.

2.

3.

Give 4 signs and symptoms of red-man syndrome

1.

2.

3.

4.

Explain the blood requisition and transfusion processes for 5 points.

Compute for the amount of NGT feeding per delivery for 5 points

Explain the process of insulin administration for 5 points

High quality CPR based on 2015 guideline for BLS?

169.

ECG lead placement

15
 170. V1 - 173. V4 -

171. V2 - 174. V5 -

172. V3 - 175. V6-

176.

For 5 points. What is the patients cardiac electrical activity? __________________

177.

178. Healthcare 179. Orders 180. Nurses

Providers Notes Notes

181. 04/08/2015 189. 193. FORMULATE

09:10am PRIORITY SOAPI
May extubate now (10 points)
182. PULMO /
CCM NOTES For standby intubation post-extubation

183. O- o2 sat decrease salbutamol neb to 194. S-

99%, no episode of every 8 hours
desaturation for 3 195.
days. (-) fever, (+) Monitor hemodynamics
purplish discoloration every 1 for 4 hours, then 196. 0-
on sacral area left every 2 hours for 8 hours,
and non-blanchable then every 4 hours 197.
redness on right thereafter
sacrum 198. A-
Discontinue precede drip
184. A- CAP-MR, 199.
CVD infarct, MRSA,
Apply calmoseptine lotion
COPD 200. P-
on affected area 2x a day
and every after diaper
185. P- 201.
change
forextubation, for
transfer to regular 202. I-
If hemodynamically stable
room if stable for 24 INTERVENTIONS
for 24 hours, may transfer
hours
to regular room tomorrow.
1.
186.
Continue to monitor I&O
203.
187.
provide oral care
2.
188. Dr. Cinco
190.
204.
191. Dr. Tamondong /
Dr. Cinco / Dr. Estrella 3.

192. 205.

16
 4.

206.

5.

207.

The form utilized by TMC in assessing the patients risk for pressure ulcer.

The form used by TMC in assessing the patients pressure ulcer.

True or False: Braden score of 18 and above makes the patient high risk for pressure
ulcer.

What are the factors in developing pressure ulcer?

1. 4.

2. 5.

3.

17
 6.

Give 5 nursing interventions in managing moisture

1.

2.

3.

4.

5.

6.

7.

8. Healthcare 9. Orders 10.Nurses Notes

Providers Notes

11.04/09/2015 26. 40.

08:00am
27. What is the patients
12.MROD NOTES current GCS? E ___, V ___,
May transfer to regular M ___.
13.S- oriented to date room
and time, (-) DOB Compute the mL of
Resume all anti- feeding per delivery for 5
14.O- clear breath hypertensive points.
sounds, no fever for
3 days, stable 24 Shift feeding to 41.
hours post peptamen 1400 kcal 1:1
intubation, dilution every 4 hours 42.
spontaneous eye with 30 ml flushing pre
opening, knows the and post feeding, with 43.
date and time but additional 40 ml flushing
confused where he in between feeding 44.
is and obeys
command 28. 45.

15.A- CAP-MR 29. Dr. Pascual 46.

resolving, COPD,
MRSA, pulmo 30. 47.04/09/2015
congestion resolved 12:00pm
 16.P- continuation of 31.
Transferred patient to
antibiotic therapy room 1111, MROD and
May transfer to regular Aps informed of transfer
17.Dr. Bisnar room
48.S- may
18. Continue apidra and sugatsiyasalikod as
lantus verbalized by
19. relative
Continue meds as ordeed
20. 49.O- with purplish
Suction secretions as discoloration on
21. needed sacral area left and
non-blanchable
22.04/09/2015 32. redness on right
09:00am sacrum
33.Dr. Cinco /
23.PHARMACY Dr. Agoncillo 50.A- impaired skin
REVIEW OF MEDS integrity
34.
24.Ht 170cm, wt 51.P- no additional
69kgs breakage on
35.
patients skin within
1. Ertapenem 1 gram Iv hospital stay
May transfer to regular
every 24 hours for 7 days room
(LD 4/10) 52.I- INTERVENTIONS
Continue ertapenem to
2. Apidra 3 units pre- complete 7 days (last
feeding dose 04/10)
53.
3. Lantus 12 units OD May have sips of water

4. Amlodipine 5mg/tab OD
Refer patient to wound care
in PM 54.

36.
5. Losartan 50mg/tab 1 tab
OD inPM
37.Dr. Saniel
55.
6. Calmoseptine apply to
38.
affected area 2x a day
and as needed for pain
39.
56.
7. Salbutamol 1 neb every 8
hours

25. 57.
 Endorsed to unit nurse

Informed wound care of

the referral

58.

Explain and differentiate the stages of pressure ulcer for 2 points

Compute the total amount of water given in a 24 hour shift.

59.

Compute the patient's current BMI for 3 points

Compute the ideal urine output of patient for 8 hour shift for 3 points

60.

Compute the ideal urine output of patient in a day for 3 points

61.

62.

63.Healthcare 64.Orders 65.Nurses Notes

Providers Notes

66.04/10/2015 73. 77.FORMULATE

10:00am SOAPIE (10
74. points)
67.IDS
Administer antibiotic until 78.S-
68.S- (+) episode of today then discontinue
loose stool, 3x since 79.
6am May lift up contact
precaution 80.0-
69.O-(+) good skin
turgor, (-) no signs Starting tomorrow start 81.
of dehydration, (-) cefuroxime 500mg/tab 1
abdominal pain, K tab 2x a day for 7 days. 82.A-
3.4, Na 142.
70.A-multiple loose Start racecadotril 83.
stool, CAP-MR 500mg/cap 1 cap 3x a
resolved, COPD day until stools are 84.P-
formed
71.P- discharge 85.
planning Stool charting pls
86.I-
72. Remove FC
1.
Continue PICC line care
2.
OOC from 4/11 to 4/15,
Dr. Destura to cover. 3.

75. 4.

76. Dr. Salazar / Dr. 5.

Saniel
87.

88.

89.

90.

91.Healthcare 92.Orders 93.Nurses Notes

Providers Notes

94. 103. 108. 04/10/2015

07:00am
95. 104.
109. WOUND
96.04/10/2015 105. CARE NOTES
12:00pm
Remove NGT and shift diet Thank you for the referral
97.CARDIO NOTES to LSLF DM diet
SAP pls Applied duoderm on
98.S-comfortable Will sign out of case, Dr. affected area
Tamondong to be the main
99.O-BP 120-140s, HR AP. Pls. turn patient side to side
80s, (-) palpitations Refer to DM center for
every 2 hours
insulin administration and
100. A-COPD, education
Continue calmoseptine
Home meds: metformin
HPN, DM, CAP-MR application as ordered.
500mg/tab BID,
 amlodipine mg OD PM,
resolved losartan 50mg/tab OD AM, 110.
apidra 3 units SC
101. P-discharge 106. 111. Betty La-
process 107. Dr. Pascual fea, RN

102. 112.

113. 04/10/2015
12:15pm

Informed DM center of
the referral

NGT removed as ordered

114.

115.
Julia Roberts, RN

116.

117.

118.

119.

120.

121. Healthcare 122. Orders 123. Nurses

Providers Notes Notes
136.
124. 04/11/2015 May go home IDS wise 142. 04/11/2015
08:00am Continue cefuroxime as 11:00am (10
ordered to complete 7 points)
125. IDS days.
Follow up 4/30 MATI 1121 143. S-
126. 4-6pm. maybabayad na
137. kami sa baba nurse.
138. Dr. Saniel / Nasan and
127.
Dr. Destura philhealth form
139. niyo?.
128.
MGH pulmo wise
Home meds: seretide
129. 144. O- with MGH
500mcg diskus 1 puff 3x
 a day then gargle after
130. use orders
Follow up after 2 weeks.
131. 140. 145. A-
141. Dr.
132. Tamondong 146.

133. 147. P-

134. 04/11/2015 148.

10:00am
149. I-
135. PULMO INTERVENTIONS

150.

151.

152.

153.

154.

155.

156.

Explain the discharge process for 10 points.

157.