records.
records.
This 42 year old gentleman was admitted on January 7th, and expired on January 15. He was admitted with progressive tachycardia, hemoptysis and dyspnea. Please see his admission history and physical exam for details.…
Andrew Rider of Michigan Insurance Company referred this file for medical case management. Instructions were given to meet with John Pero and assist with coordination of appropriate and related medical care, and identify needs to facilitate recovery.…
On 10/11/17, Room 370 feels okay, and his daughter has been in the room with him. The CT scan revealed an outlet obstruction in Room 370. Room 370 was placed on antibiotics, and his IV Levaquin has been switched out to Zosyn. Most importantly, Room 370 has an appointment to…
Upon review of camera C244 Port 3 at 5:18:29 P.M, Shift Supervisor Enmanuel Cabrera saw a dark gray Jeep Grand Cherokee park very closely next to Eric’s Audi. At 5:24:31 P.M when the jeep moved forward out of the parking spot, S/S Cabrera was able see a scratch on the black Audi that was caused by the Jeep. The Jeep then circles around to the front of the building where S/S Cabrera believes that the individual picks up an associate. Due to the fact that camera C073 is not operational, S/S Cabrera was not able to see the associate that got into the Jeep.…
This is a 47-year-old female with a 1/28/2008 date of injury. A specific mechanism of injury has not been described.…
This patient was admitted for shortness of breath, fever and chills. He has a history of cystic fibrosis, with secondary diabetes.…
A unit medical record is recommended or must be maintained for every resident in a long term care facility. With a unit record, the patient is assigned a medical record number on the first admission to the facility. This number should be used to incorporate both the previous admissions and the current admission, giving the most comprehensive picture of the resident’s medical history and therapy. The previous records should be readily accessible to staff for use in the assessment and care planning process. Without this problems could arise and the patient gets medication they may be allergic to or a diagnosis that is inadequate.…
When the provider determines that an event date (ARD of any clinical assessment, entry date, and discharge date) or item A0310 (type of assessment) is inaccurate the provider must inactivate the record in the QIES ASAP system, then complete and submit a new MDS 3.0 record with the correct event date or type of assessment, ensuring that the clinical information is accurate. (Long-Term Care Facility Resident Assessment Instrument User’s Manual, MDS 3.0, Page 5-12.)…
Nightingale Community Hospital (NCH) is committed to upholding the core values of safety, accountability, teamwork, and community. In preparation for the upcoming readiness audit, NCH will be launching a corrective action plan in direct response to the recent findings in the tracer patient. Background information on the tracer patient is as follows: 67 year old female postoperative patient recovering from a planned laparoscopic hysterectomy turned open due to complications. Patient developed infection that formed an abscess and was readmitted to the hospital for surgical abscess removal and central line placement for long term IV antibiotics. The tracer methodology was employed when auditors reviewed this patient’s course. Many things were done well and right with this patient and NCH is pleased to know that the majority of items analyzed with this patient proved that NCH was in compliance with regulatory standards; however, there were some troublesome areas that we need to focus on. The primary focus area that we will put our energies into will be the fact that there was not a history and physical completed on the patient within 24 hours of admission, and in fact it was greater than 72 hours before one was completed. The Joint Commission mandates standards that are to be met in order to maintain compliance. Standard PC.01.02.03 states that history and physicals must be documented and placed in the patient’s medical record within 24 hours of admission and prior to procedures involving conscious sedation or anesthesia. History and physicals are also considered in compliance if documented 30 days prior to procedures as long as there are no changes documented or the changes in status are specifically noted. (Joint Commission Update, n.d.)…
GENERAL: The patient is a well-developed, well-nourished male who appears to be in moderate distress with pain and swelling in the upper left arm. Vital signs: Blood pressure 140/90, temperature 98.3 degrees Fahrenheit, pulse 97, respiration 18.…
The patient was transported from home by her daughter-n-law. According to patient daughter-n-law she has been complaining of pains in her right leg approximately one day. Family administered daily pain medications that did not help the condition of her persisting pain. After pain persisted daughter in law later brought the patient in to the emergency room for examination.…
His vital signs are as follows: BP 172/100, heart rate 92, and a temp of 102.2 F. The results from the lab results are as followed: RBC 3.1 million, WBC 22,000, K+ 5.4 mEq/L, Ca 6.8 mg/dL, phosphate is 4.3 mEq/L, urea is 37 mg/dL, creatinine 2.0 mg/dL, albumin is 2.9 mg/dL, and pH is 7.29 after these abnormal labs a Chemistry Panel was drawn. Labe results of the Chemistry Panel are as followed: Protein 1.7 gm/24 hours, GFR of less than 30 ml/minute, and urine sediment showed presence of gram negative bacilli, presence of white blood cells, presence of red blood cells, and granular and waxy casts.…
Spend 1:1 time with the child to allow them time to get to know you and build a relationship…
6. An initial inpatient consultation occured. The consultation consisted of a detailed history, detailed exam, and a MDM of low complexity. The E/M code will be 99253.…
CS540 series is better and improved form of Plantronics. It is a new wireless headset design that is comfortable and easy to handle. As it is an enhanced form of Plantronics and designed in such a way that it provides multitasking feature to its users as it can connect the user up to 350 feet from the desk that it can perform activities and controls with your fingertips. Plantronics CS540 is the new form of Plantronics and it takes the place of Plantronics CS55 and the Plantronics CS50 family. Plantronics CS540 carries a weight of only 21 grams and considers to the lightest headset. This series of Plantronics is the good source of communication and its talk…