KINGDOM OF GOD HOSPITAL , LOS ANGELES,CA 900000.
Age/Sex 83years female.
Account number: Q009897234.
Admission Status: Inpatient admission.
Attending doctor : Don’thate,Big. Allergy:NKDA.
Primary diagnosis: L2,L3 Fracture ,NSTEMI. Secondary diagnosis:Dementia, Failure to Thrive.
Isolation Status: Standard Precautions.
Is patient at risk for falls: Yes.
Do you have advance Directive:No.Copy of advance Directive on the chart .
Room air with saturation of 95%.
Cardiac Heart Health diet.
Alert and oriented ×1,vocal but does not make sense.Pulled out saline lock.
New saline lock 20guage,patent/clean/dry left arm.
Performed Straight catheter as ordered 800ml of clear yellow urine. Straight catheter Q6hours.
Incontinent of stool x2 during day shift. Laboratory tests:
Medications:Norco 10/325mg po Q4 prn pain.
Dilaudid 0.5mg IV Q3hours prn pain.
Zosyn 3.375gm IV Q8hrs.
0.9NS at 75ml/hr left forearm 20guage,patent/clean/dry.