492 CASE SCENARIO. GROUND LEVEL FALL.

KINGDOM OF GOD HOSPITAL LOS ANGELES,CALIFORNIA 900000.INTERDISCIPLINARY KARDEX. Age/Sex: 64years female.

Admission date:03/21/21 @0430am.

Status : Inpatient admission.

Account Number: Q00269542.

MR # Q0006999328.

Location: MedTelemetry.

Room 42116.

Attending doctor: Tumtum,Worry.

Patient name: Monica Woodutter.

Allergy: NKDA.

Primary diagnosis: S/P Spinal Fusion by neurosurgery doctor Exceptional Tional MD. ( Ground level fall. Fell at home on 03/21/21@ 0230am)Posterior dressing intact/ dry and clean.

Secondary doctor: Htn,dm,hypothyroidism. Isolation Status: Standard precautions.

Is patient at risk for falls: yes.

Do patient have advance Directive:No.

Copy of advance Directive on the chart. Suicidal risk: No.

Transportation: bed.

Room air.Cough and deep breathe.

Incentive Spirometry every 1hour while awake

Doctor orders:

Physical therapy for evaluation and treatment. Transfer to Skilled Nursing Facility rehabilitation when medically stable.

Diet: Carb controlled cardiac health Mechanical Soft diet.

Follow up with Neurosurgery in 2- 3 weeks. Follow up with her Primary Care Physician in 12 weeks. CBC with differential, LFT ,Chem 7 in laboratory tests: WBC: 6.9.

H/H9.3/30.8%.

K=3.7.

NA: 138.

Medications: Norco 5/325mg 2tablets po Q6hours prn pain.

Tylenol 650mg po prn temperature.

Dilaudid 0.5mg IV Q3hours prn pain. Morphine sulfate 4mg IV Q4hours prn pain. Zofran 4mg IV Q4hours prn nausea/Vomiting. Hydrochlothyzide 25mg po Qday.

Colace 100mg po Qday.

Zosyn 3.375gm IV Q8hrs.

Accucheck Qac/Qhs.

0.9NS @ 75ml/hour right hand patent ,clean and dry.