KINGDOM OF GOD HOSPITAL, LOS ANGELES,CALIFORNIA 900000.
Age/Sex Age/Sex 28years old Male.
Account number Q00093299.
Status: Inpatient admission.
Location: Trauma Department.
RESUSCITATION STATUS :Full code. Primary diagnosis:Motor vehicle accident.Fell asleep and hit the tree/ Bilateral acetabular fractures, facial laceration.
Isolation Precautions: Standard Precautions.
Is patient at risk for falls: Yes. Star falling, yellow signs in place.Yellow gown and yellow ID.
02 @2liter NC. Saturation of 94%.
Do patient have advance Directive:No. Copy of advance Directive on the chart.
Operating Room:Facial fracture surgery today. ORIF Right ankle 04/01/21..Splint with IMMOBILER in place.
High income.Not quality for support.
NPO × MEDICATION.
Facial stitches removed. Right zygomatic complex fracture repaired .
Voiding well using the urinal.
Bowel movement ×2 today.
External fixation right leg.
Merrem 1mg IV Q8hrs.
Vancomycin 1gm IV Q12hours.
Dilaudid 0.5mg IV Q3hours prn pain.
Norco 10/325mg po Q4hours prn pain.
Flexeril 5mg po Q8hours prn muscle spasms. 0.9NS @ 125ML/Hour.
Urinal at the bedside.
Discharge to Acute Rehabilitation when stable.