KINGDOM OF GOD HOSPITAL, LOS ANGELES,CA 900000. INTERDISCIPLINARY KADEX.
Age/Sex: 51years old female.
Account # Q678000543.
Status: Inpatient admission.
Medical Record number: Q00557813096.
Location: General surgery unit.
Attending doctor : Don’thate,Big.
Patient name: Pinsol,Great.
Alert and oriented x4.
No respiratory distress.
02 at 2liter NC,saturation of 94%.
Is patient risk for falls No.
Patient at risk for Suicide: No.
Isolation status : Standard precautions.
Do patient have advanced Directive No.
Copy of advanced Directive on the chart. Primary Diagnosis:Gallbladder Removal. Secondary diagnosis: diabetes mellitus, hypothyroidism, hypertension.
Diet: Clear liquid diet.Tolerating well.
No bowel movement, not passing gas.Voiding well using the bathroom.
Ambulates with steady gaits to the bathroom. Medications:
Norco 10/325mg po Q4hours prn pain.
Dilaudid 0.5mg IV Q3hours prn severe pain. Zofran 4mg IV Q4hours prn nausea/Vomiting. D51/2NS at 75ml/hour to right ac via pump .Right hand saline lock 20guage,patent/clean/dry.
Plans : Patient will be discharged home in am.
Will continue to monitor and follow doctor’s orders.