William C. Roentgen - learntoday

Sundance Sundance HealthCare HealthCare Systems
Systems
Painted Painted Valley, Valley, USA
USA
NAME X-RAY NO.
DOCTOR DATE
REGION EXAMINED
Indications: SOB
© 2003. American Health Information Management Association. All rights reserved.
RADIOLOGIST'S SIGNATURE
Newman, Edward C.
Dr. William J. Wainwright
Coronary care unit
# 012502
CHEST: There is mild to moderate pulmonary vascular congestion. There is mild bilateral interstitial
edema. The findings are less prominent than on 1-1-xx. No focal consolidation is seen in
the lungs.
WCR/smb
Newman, Edward C. 47932
Dr. W. J. Wainwright 8/14/xx
CHEST X-RAY
William C. Roentgen
M.D.

Sundance Medical Center
Painted Valley, USA
Instructions: Please follow the instructions given below. This is an important part of your continued
recovery. If, after reading the instructions, you have any questions please ask your physician/nurse for
clarification.
Diet:
Medications:
Activity:
Follow-Up:
1500 calorie ADA, no added salt diet.
Patient Name:
Physician:
Room No.
Mr. Newman has an appointment to see me in the office in approximately
two weeks for recheck. He should call or come in sooner if he has any questions or
problems prior to that appointment.
Diazepam 20 mg p.o. q.h.s., albuterol and Atrovent nebulizers q.d. and p.r.n., Lasix 160
mg p.o. b.i.d.; Theo-Dur 200 mg q.a.m., 300 mg q.h.s.; Imdur 30 mg (1/2 tab) q.h.s., Pilocarpine 4% 1
drop O.D. q.i.d., nitroglycerin 0.4 mg sublingual p.r.n. chest pain, oxygen 2 to 4 liters per minute per nasal
cannula. Diabetes meds will be: Humulin N 64 U a.m., Humulin N 36 U p.m. and Humalog sliding scale:
Accu-Chek less than 100 = 0,
Accu-Chek 101 - 130 = 3,
Accu-Chek 131 - 170 = 5,
Accu-Chek 117 - 220 = 8,
As tolerated.
Accu-Chek 221 - 300 = 12,
Accu-Chek 301 - 400 = 15,
Accu-Chek less than 400 = 18.
I have read the above instructions and received a copy of them. They were explained to me and all my
questions were answered satisfactorily.
a.m.
p.m.
Patient's Signature Date Time Attending Physician
Edward C. Newman 8/14/xx 6:45 William J. Wainwright
DISCHARGE INSTRUCTIONS SHEET
© 2003. American Health Information Management Association. All rights reserved.
Newman, Edward C.
Dr. William J. Wainwright
Coronary care unit
# 012502

Sundance Medical Center
Painted Valley, USA
Date/
Time
Orders
8/14 Admit to CCU per Dr. Wainwright.
DX: CHF, COPD.
Condition stable
Vitals q.4h. while awake, daily weight.
William J. Wainwright
0010 ALL: PCN -> Hives
Diet - No added salt
Activity Up to BR
IV saline lock
Meds: Lasix 80 mg IV now
Humulin N 64 U SQ q.a.m.
Humulin N 36 U SQ q.p.m.
Humalog 12 U AC t.i.d.
Hold if BS

Sundance Medical Center
Painted Valley, USA
Date/
Time
Orders
8/15 LAB: CBC, CMP, theo level, UA, TSH
Lisinopril 20 mg p.o. q.a.m.
EKG üdone ER
CXR state, check if done ER
P-8 in a.m. 8/15
Oximetry daily while on O2
Foley to gravity William J. Wainwright
8/15 May request Valium 10 mg q.h.s. p 3 hr p.m. x1
Accu-Chek q.i.d.
EKG in a.m.
Atrovent inhaler two puffs q.i.d.
William J. Wainwright
8/15 Change Atrovent inhaler to SVN’s q.i.d.
v.o. Dr. Wainwright/rla William J. Wainwright
8/15 @ 0945 Humalog q.i.d. S.S.
< 100 = 0
101 - 130 = 3
131 - 170 = 5
171 - 220 = 8
221 - 300 = 12
301 - 400 = 15
D/C H.s. Chlorazepate
Inc Diazepam to 20 mg p.o. q.h.s.
Ativan 2 mg p.o. t.i.d. p.r.n. anxiety
Up walking William J. Wainwright
8/15 @ 1410 D/C Humalog 12 u a.c. t.i.d.
T.O. Sally Mertz, RPO Sall;y J. Mertz, RPO
Form # _ _ _ _
Physician Orders and Progress Notes
© 2003. American Health Information Management Association. All rights reserved.
Newman, Edward C.
Dr. William J. Wainwright
Coronary care unit
Progress Notes # 012502
Progress Note: 8/15
Social Services report from yesterday
indicated pt currently uses no services.
Will follow.
W. Scarlett, MSW
8/15 Breathing easier
110/60, P 80
Lungs clear, distant BS
Heart - regular
Abd soft
Ext no edema
Weight down 6 #
- CHF
- IDDM
Increase activity
Monitor O2 sats
Dr. Wagner
William J. Wainwright

Sundance Medical Center
Painted Valley, USA
Date/
Time
Orders
8/16 @ 0650
MOM 30 cc p.o. QP p.r.n.
S.O. Dr. Wainwright, A. May, RN
William J. Wainwright
8/16 D/C Foley, D/C CCU, D/C IV
William J. Wainwright
8/16 Discharge
Meds: Humulin N 64 U a.m.
Humulin N 36 U p.m.
Humalog sliding scale
Accu-Chek
William J. Wainwright
Units
< 100 = 0
101 - 130 = 3
131 - 170 = 5
171 - 220 = 8
221 - 300 = 12
301 - 400 = 15
> 400 = 18
Diazepam 20 mg p.o. q.h.s.
albuterol & Atrovent SVN’s q.i.d. & p.r.n.
Lasix 160 mg p.o. b.i.d.
Theo-Dur 200 mg q.a.m., 300 mg q.h.s.
Imdur 30 mg (1/2 tab) q.h.s.
Pilocarpine 4% 1 drop O.D. q.i.d.
nitroglycerin 0.4 mg SL p.r.n. chest pain
O2 2 to 4 L/m N.C.
Appt. my office - 2 wks
William J. Wainwright
Form # _ _ _ _
Physician Orders and Progress Notes
© 2003. American Health Information Management Association. All rights reserved.
Newman, Edward C.
Dr. William J. Wainwright
Coronary care unit
Progress Notes # 012502

Date/
Time
Sundance Medical Center
Painted Valley, USA
Nursing Progress Notes
Nursing Progress Notes
© 2003. American Health Information Management Association. All rights reserved.
Newman, Edward C.
Dr. William J. Wainwright
Coronary care unit
# 012502
8/14/xx
0805 Admission Admitted to CCU-3 per w/c from ER. Settles into bed with no c/o @ present.
See admission sheet. HRM, RN Brenda Kellye, RN
0845 Foley catheter inserted. Tolerated well. Brenda Kellye, RN
0900 Lisinopril 20 mg p.o. now given per order, Lasix 80 mg IV now given per order.
Brenda Kellye, RN
1000 Visiting with wife in room. No c/o at present. Brenda Kellye, RN
1300 Dozing in bed quietly. Brenda Kellye, RN
1500 Visiting in room with family. No c/o. Brenda Kellye, RN
1900 Summary Appetite good. Denies pain. Resting quietly. Wife @ bedside. Rhythm unchanged.
Leslie Scorch, RN
2200 Summary Uneventful evening, denies pain. Does become SOB with activity, respirations
easy @ rest. No c/o. Leslie Scorch, RN
8/15/xx
0115 SOB Resting awake in bed, had “Charley Horse” in leg. Better now, but dyspneic, resp
30/m et breathing rapidly, feels winded. LS dim throughout with left base crackles. Patient
quite anxious. Robert K. Russo, RN
0115 SVN with albuterol 0.5 cc given. Robert K. Russo, RN
0130 Breathing easier, increased air exchange throughout. Lungs fields with bibasilar crackles now.
Feeling better, remains anxious. Robert K. Russo, RN
0150 Valium 10 mg p.o. repeated Robert K. Russo, RN
0600 Awakened for assessment, had been sleeping. Becomes dyspneic on exertion with mild
dyspnea with rest. LS remains dim throughout. Crackles lower 1/2 left and 1/4 left.
Admits to feeling SOB, wants treatment. Robert K. Russo, RN

Date/
Time
8/15/xx
Sundance Medical Center
Painted Valley, USA
Nursing Progress Notes
Nursing Progress Notes
© 2003. American Health Information Management Association. All rights reserved.
Newman, Edward C.
Dr. William J. Wainwright
Coronary care unit
# 012502
0615 SVN given with albuterol and atrovent Robert K. Russo, RN
0625 Feeling better after treatment. Increased air exchange to lung fields though crackles remain,
still has c/o feeling slightly SOB. Robert K. Russo, RN
0630 Lasix 160 mg p.o. given Robert K. Russo, RN
0800 Resting well. Upon awakening slightly SOB. Sats 91-92% on 2 liters. Dim LS with faint
bibasilar crackles. BS pos, Abd. neg. Ext. no edema. VS stable. Patient alert & oriented.
Brenda Kellye, RN
0830 Wife here. Patient eating. No c/o. Brenda Kellye, RN
1000 Resting now. Resp. more at ease. Brenda Kellye, RN
1030 Explained new S.S. insulin to patient and wife. No c/o, questions.
Brenda Kellye, RN
1230 Stable. Resting. Resp. easy. Brenda Kellye, RN
1300 Tried pt on 1L O2/NC, sats decrease to 87%. Increased to 2L/NC, sats 95%. Amb with
2LO2, 2 assist & Sat monitor on, 100 Fahrenheit. Sats to 92%. Back to room & up in chair.
Did get slightly dyspneic with amb. More rested in chair. Sats back up 95% when sitting.
Anne Odinson, RN
1400 Back to bed with 2LO2. Sats 98%. No c/o. Restful. Lights out for a bit. Call light placed.
Anne Odinson, RN
1450 Resting with easy, snoring like resp. Wife in room. Anne Odinson, RN
1600 Pt awake & talkative. Denies any discomfort. Resp easy at rest. Still has coarse rales in bases
bilaterally. Color pink. Sats in mid 90’s on 2L. No pedal edema. C/o some weakness.
Leslie Scorch, RN

Date/
Time
Sundance Medical Center
Painted Valley, USA
Nursing Progress Notes
8/15/xx
1830 Appetite good. Assisted to ambulate 100 ft in hall with 2 assist & cont O2. Only slight
Nursing Progress Notes
© 2003. American Health Information Management Association. All rights reserved.
Newman, Edward C.
Dr. William J. Wainwright
Coronary care unit
# 012502
staggered steps at times. Otherwise gait steady. To BR but unable to have BMO.
Passed flatus. Had prune juice with supper. Leslie Scorch, RN
1930 VSS, resting quietly, denies physical c/o. Lungs diminished BS, O2 decreased 1/4 lit with
some crackles, dec 1/4 lit SO2 96% @ 2L/NC. Re AP, inc pulses x 2, no c/o. Soft abd,
Pos BS x 4, Foley patent with clear yellow urine. Leslie Scorch, RN
2030 Bath done, cares done. Linen changed. Leslie Scorch, RN
2050 Accu ü Accu ü 105, pt given Humalog 3 units. Pt h.s. snack.
Leslie Scorch, RN
2105 SVN SVN with V.S. Albuterol & Atrovent given, tolerated well.
Leslie Scorch, RN
8/16/xx
0200 Sleeping in bed, breathing easily. Robert K. Russo, RN
0115 SVN with albuterol 0.5 cc given. Robert K. Russo, RN
0130 Breathing easy, good air exchange. Lungs fields with only minor crackles. No c/o at
this time. Robert K. Russo, RN
0640 Feels better after treatment. Improving air flow in all lung fields. Foley catheter removed.
IV discontinued. Robert K. Russo, RN
0700 Up to BR, voids well. Robert K. Russo, RN
0800 Dr. Wainwright visits, discharge order written and discharge instructions given. Patient resting
well. Blood sugar 130, vital signs stable. Ext. no edema. VS stable. Patient alert & oriented.
Brenda Kellye, RN
0830 Wife here. Patient eating. No c/o. Breakfast, eats well, somewhat short of breath while
eating, otherwise no dyspnea, no c/o. Brenda Kellye, RN

Date/
Time
Sundance Medical Center
Painted Valley, USA
Nursing Progress Notes
8/16/xx
1045 Discharge instructions discussed with patient and wife. They voice understanding. Will
follow up with Dr. Wainwright at his office in two weeks. Brenda Kellye, RN
1115 Discharged per wheelchair, escorted to car. Brenda Kellye, RN
Nursing Progress Notes
© 2003. American Health Information Management Association. All rights reserved.
Newman, Edward C.
Dr. William J. Wainwright
Coronary care unit
# 012502

Patient Family Name First Name Age Room No. Hosp. No.
Newman, Edward C. 78 CCU #2 # 012502
Attending Physician Date Lab. No.
Dr. William J. Wainwright 8/14/xx 7734-2002
24 Hour Urine 0 - 30
for Microalbumin
Sundance HealthCare Systems Painted Valley, USA
Component Normal First Second Third Fourth
Date 08/14/xx
Color Yellow
Character Clear
Spec Gravity 1.020 or less
Leukocytes Negative
Nitrates Negative
PH 5-6
Protein Urine Negative
Glucose Urine Negative
Ketones Urine Negative
Urobilinogen 0 - 1 mg/dl
Bilirubin Urine Negative
Occ Blood Urine Negative
WBC/HPF 0 - 5
RBC/HPF
Epitheial
Casts/LPF
Crystals
Amorphorus
Mucous
0 - 5
Yeast Cells Negative
Bacteria Negative
Yellow
Clear
1.015
Negative
Negative
5.2
Negative
Negative
Negative
Negative
Negative
Negative
3 - 5
Few
15-20 Hylalin
Sent for Culture: Y / N Y / N Y / N Y / N
Form L-9001 (5/01) pa URINALYSIS
© 2003. American Health Information Management Association. All rights reserved.

Sundance HealthCare Systems
Painted Valley, USA
Diagnosis: CHF, COPD
Allergies: Penicillin
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Medication and Hosp Day Hosp Day Hosp Day Hosp Day
Date of Order Route 8/14 #1 8/15 # 8/16#3
#4
Lisinopril 40 mg p.o. q.a.m. 08 SMB SGA
Theo-Dur 200 mg p.o. b.i.d. 08 ams SMB KJN
21 nmr kl
Lasix 160 mg p.o. b.i.d. 08 ams 1200 SMB KJN
MEDICATION PROFILE
© 2003. American Health Information Management Association. All rights reserved.
17 pvm rlw KJN
EC ASA 1 p.o. daily 08 ams SMB KJN
Imdur 60 p.o. q.h.s. 21 nh kl
Diazepam 10 mg p.o. q.h.s. 21 nh see D’s below
Pilocarpine 4% 1 gtt OD q.i.d. 08 / SMB KJN
12 pvm SMB
16 mds swb
21 taf ko
Clorazepate 15 mg q.h.s. 21 wlk dcd 8/15
Diazepam 20 mg p.o. q.h.s. 21 / ko
Newman, Edward C.
Dr. William J. Wainwright
Coronary care unit
# 012502

Sundance HealthCare Systems Painted Valley, USA
Patient Family Name First Name Age Room No. Hosp. No.
Newman, Edward C. 78 CCU #2 # 012502
Attending Physician Date Lab. No.
Dr. William J. Wainwright 8/14/xx 7734-2002
Component Normal First Second Third Fourth
Date 08/14/xx 08/15/xx
Chemistry 10
Sodium 135 - 145
Potassium 3.5 - 5.3
Chloride 100 - 110
CO2 23 - 29
Glucose 80 - 116
BUN 12 - 20
Creatinine 0.6 - 1.3
Total Bili 0.0 - 1.3
Albumin 3.5 - 5.0
Calcium 8.2 - 10.1
ALP 56 - 112
AST 0 - 27
ALT 14 - 26
Total Protein 6.0 - 8.0
Theo 10.0 - 20.0
TSH 0.4 - 6.2
Lipid Profile
Total Choles 100 - 200
HDL 40 - 80
LDL 66 - 130
Triglycerides 50 - 150
HG A1C 4.0 - 6.0
PSA 0.0 - 4.0
143 143
4.4 3.8
100 100
35 H 36 H
238 H 91
27 H 35 H
1.5
0.7
3.9
H 1.6 H
9.8 9.4
58
21
18
6.6
8.2 L
1.9
Form L-9003 (5/01) pa CHEMISTRY
© 2003. American Health Information Management Association. All rights reserved.

Sundance HealthCare Systems Painted Valley, USA
Patient Family Name First Name Age Room No. Hosp. No.
Newman, Edward C. 78 CCU #2 # 012502
Attending Physician Date Lab. No.
Dr. William J. Wainwright 8/14/xx 7734-2002
Component Normal First Second Third Fourth
Date 08/14/xx
Hematology
WBC (x 103 ) M/F 4.3 - 11.0
RBC (x 103 ) M 4.6 - 6.2
F 4.2 - 5.4
Hgb (g/dl) M 12 - 18
F 12 - 16
HCt (%) M 40 - 54
F 36 - 47
MCV (x 103 ) M 80 - 94
F 82 - 100
MCH (x 103 ) M/F 26 - 33
MCHC (%) M/F 31 - 36
PLT (x 103 ) M/F 150 - 375
Differential
Band 0 - 6%
Seg 46 - 82%
Lymph 13 - 37%
Mono 4 - 12%
Eosin 0 - 5%
Baso
NRBC
Atyp Lymph
Meta
Myelo
Pros
Blast
2 - 2%
10.4 H
4.25
13.6
40.6
95.7
32.0
33.4
76
15
4
3
3 H
Form L-9003 (5/01) pa HEMATOLOGY
© 2003. American Health Information Management Association. All rights reserved.

Sundance HealthCare Systems
Painted Valley, USA
CHIEF COMPLAINT: Shortness of breath.
Form 9427 (8/00) mr HISTORY & PHYSICAL
© 2003. American Health Information Management Association. All rights reserved.
Dr.
Newman, Edward C.
Dr. William J. Wainwright
Coronary care unit
# 012502
HISTORY OF PRESENT ILLNESS: This patient is a 78-year-old resident of Podunk Center. He has a
long-standing history of severe COPD, insulin-dependent diabetes mellitus and ASHD and status post MI’s.
According to the patient he has been severely short of breath over the past several months. Apparently this has
increased over the past two days and yesterday it severely limited his ability to get up and walk around. During
the night last night, at approximately 5:00 a.m., he had a severe episode of shortness of breath. He received
two nebulizer treatments and his wife turned his home oxygen up wide open. Despite this, however, he remained
severely short of breath. His wife then called 911 and he was brought to the ER via ambulance.
The patient denies substernal chest pain. He states that he has gained approximately five pounds over the past
couple of weeks. He also admits to swelling of both ankles at the end of the day.
PAST MEDICAL HISTORY: Several episodes of COPD in the past. He has also been admitted with MI’s
at age 66 and again in September, three years ago. He has had congestive heart failure and long-standing
insulin-dependent diabetes mellitus. He has glaucoma and chronic blindness in his right eye. He has a history of
long-standing noncardiac chest pain. He has also had peptic ulcer disease.
PAST SURGICAL HISTORY: He is status post T&A, hemorrhoidectomy x 2, colonoscopy with
polypectomy in six years ago which revealed a tubular adenoma, right inguinal herniorrhaphy four years ago,
another colonoscopy repeated three years ago. He had a TURP in 1981 for benign prostatic hypertrophy.
MEDICATIONS: Humulin N 64 units in the morning and 64 units in the evening. Humalog sliding scale t.i.d.,
usually taking 14 to 16 units at mealtimes. He also takes Theo-Dur 200 mg b.i.d., Lasix 160 mg a.m. and 80
mg at noon q.d. Ecotrin 325 mg q.d. Pilocarpine 4% ophthalmic drops 1 drop right eye q.i.d., Imdur 60 mg
q.h.s., Diazepam 10 mg q.h.s., Clorazepate 15 mg q.h.s., nitroglycerin 0.4 mg sublingual p.r.n. chest pain,
albuterol and Atrovent nebulizer q.i.d. and p.r.n. He is on home O2 routinely at 2 liters per minute per nasal
cannula.
ALLERGIES: Penicillin causes a rash.
HABITS: 150 pack year history of cigarette smoking. He is currently a nonsmoker, does not drink alcohol.
FAMILY HISTORY: The patient is married and is a retired teacher. He lives in Podunk Center with his wife
who also has had some health problems, including atrial fibrillation. They have three children in the area.
REVIEW OF SYSTEMS:
General: No seizures or syncope. He has had the weight gain as mentioned above.
HEENT: No recent change in hearing or vision. He does have the glaucoma as mentioned above.
Signature

Sundance HealthCare Systems
Painted Valley, USA
PLAN: The patient will be admitted to the CCU. Monitor his O2 saturations, provide oxygen as necessary
and diurese him.
D&T: 8/14/xx
Dr.
Signature
Form 9427 (8/00) mr HISTORY & PHYSICAL
© 2003. American Health Information Management Association. All rights reserved.
Newman, Edward C.
Dr. William J. Wainwright
Coronary care unit
# 012502
Respiratory: As above.
Cardiac: See HPI.
GI: No nausea, vomiting, diarrhea, constipation, hematochezia or melena.
GU: No burning, hematuria or recent UTI. He states that he does have nocturia one to two times per night.
Musculoskeletal: Negative.
Neurologic: He has been depressed over his breathing difficulties.
PHYSICAL EXAMINATION:
General: This is a well-developed, well-nourished 78-year-old white male, sitting up on the examining table
with oxygen running. He appears in no acute distress at this time.
Vital Signs: Blood pressure 144/72, pulse 108, respirations 38, temperature 96.4 degrees Fahrenheit. Weight
190 pounds.
Skin: Anicteric, warm and dry. Face is slightly flushed at this time.
Heent: Shows clear TMs. Pupils equal, round and reactive to light on the left. There is evidence of corneal
dystrophy on the right. Oropharynx is clear.
Neck: Supple, no cervical lymphadenopathy.
Chest: Lungs have slight crackles in the right mid-lung field and base, clear on the left.
Heart: Regular rate and rhythm without murmur or gallop.
Abdomen: Normal bowel sounds, soft and nontender. No masses, hernias or organomegaly noted.
Genitalia: External genitalia is normal.
Extremities: Warm and well perfused. There is trace edema bilaterally. Pedal pulses are palpable.
Neurologic: Motor and strength are 5/5 bilaterally. DTRs are symmetrical.
Psych: Affect is more flat than typically seen. Recent and remote memory are good. Judgement and insight
are intact. Does seem to be slightly depressed.
LABS: Chest x-ray shows cardiomegaly and evidence of vascular redistribution consistent with CHF. EKG
shows normal sinus rhythm at a rate of 94 beats per minute. There is evidence of an old anterior MI and an old
inferior MI. No acute appearing ST-T wave changes. Sodium is 143, potassium 4.4, BUN 27, creatinine 1.5,
glucose 238. CBC shows white count 10,400 with a normal differential, hemoglobin 13.6, hematocrit 37.9.
ASSESSMENT:
1. A 78-year-old white male with cor pulmonale and congestive heart failure secondary to his severe
chronic obstructive pulmonary disease and coronary artery disease.
2. Arteriosclerotic heart disease with history of previous myocardial infarctions and congestive heart failure.
3. Chronic glaucoma with right eye blindness.
4. Chronic insomnia.
5. Insulin-dependent diabetes mellitus.
6. Benign prostatic hypertrophy, status post transurethral resection of prostate.
William J. Wainwright

Sundance HealthCare Systems
Painted Valley, USA
Date _____________ 08/14 _____________ 08/15 _____________ 08/16
_____________
Time 3691215182124 3691215182124 3691215182124 3691215182124
105 ...................................................................................................................................................
104 ...................................................................................................................................................
103 ...................................................................................................................................................
102 ...................................................................................................................................................
101 ...................................................................................................................................................
100 ...................................................................................................................................................
99 ...................................................................................................................................................
98 ...................................................................................................................................................
97 ...................................................................................................................................................
96 ...................................................................................................................................................
95 ...................................................................................................................................................
Pulse
Resp.
93 102 89 88 86 76
38 20 21 24 20 18
B/P ___/___| 143 72 144 ___/___| 62 136 ___/___ 74 ___/___| 140 78 ___/___| 110 60 122 ___/______/___| 76 122 78 ___/___| ___/___ ___/___| ___/___| ___/___
___/___| ___/___| ___/___ ___/___| ___/___| ___/______/___| ___/___| ___/___ ___/___| ___/___| ___/___
In ______| ______| ______ ______| ______| ______ ______| ______| ______ ______| ______| ______
Out ______| ______| ______ ______| ______| ______ ______| ______| ______ ______| ______| ______
Weight: ______ 195.7 | _______ 194.9 ______ 193.3 | _______ 192.6 ______ 190.4 | _______ ______ | _______
Diet ______| ______| ADA ______ ADA ______| ADA ______| ADA ADA ______ ______| ADA ______| ______ ______| ______| ______
Appetite______| ______| Good ______ Fair ______| Fair ______| Good Good ______ ______| Fair
______| ______ ______| ______| ______
GRAPHIC SHEET
© 2003. American Health Information Management Association. All rights reserved.
Newman, Edward C.
Dr. Dr. William J. Wainwright
Coronary care unit
# 012502

Patient's Name
Birth Date Age
Street Address
Sex Marital Status State Zip County
Soc. Sec. #
Patient's Occupation
Notify In
Emergency
Address
Name
City
Religion
Relationship
Phone No.
Hospital Number
Phone Number
Responsible for Account
Date Admitted
8/14/xx
Time
0645
AM
PM
Date Discharged
08/16/xx
Time
1111
AM
PM
Date of Last Admission Name & Address of Any Institution From Which Discharged in Last 60 Days
Admitting Physician
Aitemding Physician
Sundance Sundance HealthCare HealthCare Systems
Systems
Painted Painted Valley, Valley, USA USA
USA
Newman, Edward C. 2720 Mountain View # 012502
04/01/xx 78 Devils Lake 701 801-7734
Consultant
Room
M Married N.D. 58301 Ramsey CCU #2
504-59-3132 Methodist W
Race
Ethnicity
Teacher (Retired) Non-Hispanic
Admitting Diagnosis (Within 24 Hours) ICD-9-CM ICD-9-CM ICD-9-CM CODES
CODES
Principal Diagnosis
Secondary Diagnoses
Complications
Operative Procedures (Date & Title)
Mildred Wife Self
2720 Mountain View, Devils Lake 701 801-7734
2/29/xx N/A
Dr. William J. Wainwright
Dr. William J. Wainwright
Cor pulmonale and congestive heart failure secondary to severe chronic obstructive
pulmonary disease and coronary artery disease.
1. Congestive heart failure complicating severe chronic obstructive pulmonary disease.
2. Arteriosclerotic heart disease with history of myocardial infarctions.
3. Insulin-dependent diabetes mellitus.
4. Glaucoma.
ü
Discharged Alive ____ Died ____ Autopsy Yes ____ No ____
William J. Wainwright
ADMISSION SUMMARY SHEET
Physician Signature
This is a simulated health record created and intended for educational purposes only. All scenarios, names, demographic information, medical events, and data
portrayed herein are fictitious. No identification with or similarity to actual persons, living or dead, or to actual events or entities is intended or should be
inferred. Any similarity to actual persons or events is purely coincidental.
© 2003. American Health Information Management Association. All rights reserved.

CONDITIONS CONDITIONS OF OF ADMISSION
ADMISSION
1. CONSENT TO HOSPITAL CARE
I am presenting myself for admission to St. Jude’s Medical Center. I voluntarily consent to the rendering of medical
care which is determined to be necessary or beneficial in the professional judgement of my physician. This includes
routine diagnostic procedures and medical treatment by authorized agents and employees of the Hospital, and by its
medical staff, or their designees.
I acknowledge that no guarantees have been made to me as to the effect of such examination or treatment on my
condition.
2. AUTHORIZATION TO RELEASE INFORMATION
I authorize St. Jude’s Medical Center to release such information from my medical record as may be necessary for
the completion of the hospital’s or my physician’s claims for reimbursement to my insurance company or agency. I
UNDERSTAND THAT DISCLOSURE MAY INCLUDE DIAGNOSES AND OPERATIONS OR PROCEDURES PER-
FORMED AND THAT, AT THE REQUEST OF MY INSURANCE COMPANY OR AGENCY, MY COMPLETE MEDI-
CAL RECORD MAY BE SUBJECT TO REVIEW. IN ADDITION, I UNDERSTAND THAT COPIES OF MY RECORD
MAY BE OBTAINED BY MY INSURANCE COMPANY OR AGENCY.
3. ASSIGNMENT OF BENEFITS
In consideration of the services received or to be received for this admission to St. Jude’s Medical Center, I assign all
insurance benefits due me. I further warrant that the hospital shall be entitled to the full amount of its charges. Any
credit balance resulting for any reason will be applied to other existing accounts. This also assigns benefits to
Anesthesia Consultants, PC.
I hereby agree to pay any and all hospital charges that exceed or that are not covered by my hospitalization insurance
coverage. This assignment shall be irrevocable.
4. VALUABLES DISCLAIMER
I understand that St. Jude’s Medical Center maintains a safe for the safekeeping of money and valuables. I, also,
understand that I assume full responsibility for any and all of my valuables, money, clothing, dentures, and other
personal items while a patient in the hospital unless deposited with the Hospital for safekeeping.
Valuables Deposited with the Hospital YES NO
5. REQUEST FOR FACILITY ACCOMMODATIONS
I agree to pay to the Hospital any difference between the semi-private rate provided by my hospitalization insurance
and the Hospital charges for a private accommodation. I understand that private accommodations are more expensive
than the room rate payable by my hospitalization insurance and that it is my responsibility to pay the difference.
I request a Private Room YES NO
This document has been fully explained to me, and I certify that I understand its contents and agree to it freely.
August 14, xx 0645 Edward C. Newman
AM
DATE TIME PM Patient or authorized person
Marilyn Flemming
Witness Relationship
Signature is not that of the patient because: ( ) patient is a minor
( ) other reason (specify):
ü
ü
Guarantor/Insured Certificate Holder

Patient's Name
Birth Date Age
Street Address
Sex Marital Status State Zip County
Soc. Sec. #
Patient's Occupation
Notify In
Emergency
Address
Name
Date Admitted Time AM
PM
City
Religion
Relationship
Phone No.
Date Discharged Time AM
PM
Hospital Number
Phone Number
Responsible for Account
Date of Last Admission Name & Address of Any Institution From Which Discharged in Last 60 Days
Admitting Physician
Aitemding Physician
Sundance Sundance HealthCare HealthCare Systems
Systems
Painted Painted Valley, Valley, USA USA
USA
Consultant
Room
Race
Ethnicity
Admitting Diagnosis (Within 24 Hours) ICD-9-CM ICD-9-CM ICD-9-CM CODES
CODES
Principal Diagnosis
Secondary Diagnoses
Complications
Operative Procedures (Date & Title)
Discharged Alive ____ Died ____ Autopsy Yes ____ No ____
ADMISSION SUMMARY SHEET
Physician Signature
This is a simulated health record created and intended for educational purposes only. All scenarios, names, demographic information, medical events, and data
portrayed herein are fictitious. No identification with or similarity to actual persons, living or dead, or to actual events or entities is intended or should be
inferred. Any similarity to actual persons or events is purely coincidental.
© 2003. American Health Information Management Association. All rights reserved.

Sundance HealthCare Systems
Painted Valley, USA
EMERGENCY ROOM / OUTPATIENT RECORD
Account Number:
Patient's Name: Last Name First Name Middle Initial Home Phone Admission Date a.m. Med.Rec. Number
Newman, Edward C. 701 801-7734 08/14 p.m. # 012502
Address:
Devils Lake
State
N.D.
Zip
58301
Age
78
Sex
M
Date of Birth
04/01
Civil Status
S M W D Sep
Religion
Methodist
Employer: Retired Occupation: Teacher Soc. Sec. # 504-59-3132
Address: Tokyo, ND
Phone No: Notify Press Yes No
Responsible Party: Alfred E. Newman Occupation: Teacher Family Doctor: Dr. Wainwright
Address: Devils Lake, ND Phone No: 801-7734
Notified Yes No
Brought In By: ___ xx Self
Name of Insurance Company Medicare Policy No. AP 504-39-3132
___ Police ___ Fire
Address of Insurance Co. Hooterville, ND
___ Relative ___ Other
Notified: Relative Mildred Relationiship: Wife By Whom Agathie Chrsty Race:
Police No Coroner No Time 0645 a.m./p.m. Ethnicity:
BRIEF HISTORY: (If accident, state where, when & how injured; if illness describe)
:
78-year-old male to ER per ambulance. Awoke at 0600 with acute respiratory distress. Hx COPD. Did home nebulizers
without relief. Ambulance called for transport. Second neb started et finished en route. Accu ü done also “200”. Currently
mildly dyspneic, respirations 38, lungs slightly et moderate diminished. SAO2 98% on 2 liter p.m. NC. ??? Rhythm NS without
ectopics. 0725 Saline lock 22 g 28 mm Jelco started L hand - Lasix 80 mg IV push. Lock flushed per protocol NUB.
0730 Dr. Wainwright in to examine patient.
0740 Admit Coronary care unit .
0810 Patient to floor in W/C per RN
Allergies: Penicillin Patient Medications: See attached sheet.
Condition on Admission:
Good ____ Fair ____ xx
Poor ____ Shock ____
Coma ____ Hemorrhage ____
Vital Signs:
Temp. 96.4 ____ Height: 72"
Pulse 108 ____ Weight: 190
Resp. 48 ____ SAO2 96%
B.P. 143 ____/____ 72
Normal Other System Inventory:
o o Mental/Emotional
o o Status:
ü
o o Skin
ü
o o Respiratory
ü
ü
ü
ü
ü
ü
o o Cardiovascular.
o o Musculoskeletal:
o o Gastrointestinal
o o Genitourinary
o o Neurological
PHYSICIAN'S REPORT: History & Physical Findings:
Increasing shortness of breath 6:00 a.m. No chest pain. No cough. Has been on
home O2. O2 sat on 2LNC 96% Pulse increased,
Adm H: CHF RR 28 pm
ASHD Heart: WNL.
Diagnosis:
Lungs: Expiratory wheezes bilaterally.
Lower extremity edema 1+.
Treatment (including medications):
Disposition of Case: Admitted to CCU, LAB: CXR, EKG, CBC, PO2 (Theo Old charts
per Dr. Wainright / Ries RN) A: Acute exacerbation of asthma / LVF.
Referred to Dr. Lasix 20 mg IV Date:
Instructions to Patient:
P: Admit to CCU.
Edward C. Newman 8/14/xx 6:45 William J. Wainwright
o o EENT
Form # _ _ _ _ Patient's Signature Date Time Attending Physician
Simulated record. ©2003. American Health Information Management Association. All rights reserved.

PATIENT:
A.M.
DATE: DATE: P.M.
1. I, (or ) acting for )
knowing that I, (or ) am (is) suffering from a condition requiring emergency or out patient care do hereby
voluntarily consent to such care encompassing diagnostic procedures and medical treatment by Dr.
his assistants or his designees as is necessary in his judgement.
2. I am aware that the practice of medicine and surgery is not an exact science and I acknowledge that no guarantees have been made to me as to the result
of treatments or examination in the hospital.
3. This form has been fully explained to me and I certify that I understand its contents.
Witness Signature of Patient
(If patient is unable to consent or is a minor, complete the following):
Patient (is a minor years of age) is unable to consent because
Witness Closest Relative or Legal Guardian
Simulated record. ©2003. American Health Information Management Association. All rights reserved.

Sundance HealthCare Systems
Painted Valley, USA
EMERGENCY ROOM / OUTPATIENT RECORD
Account Number:
Patient's Name: Last Name First Name Middle Initial Home Phone Admission Date a.m.
p.m.
Med.Rec. Number
Address: State Zip Age Sex Date of Birth Civil Status Religion
S M W D Sep
Employer: Occupation: Soc. Sec. #
Address: Phone No: Notify Press Yes No
Responsible Party: Occupation: Family Doctor:
Address: Phone No: Notified Yes No
Brought In By: ___ Self
Name of Insurance Company Policy No. ___ Police ___ Fire
Address of Insurance Co. ___ Relative ___ Other
Notified: Relative Relationiship: By Whom Race:
Police Coroner Time a.m./p.m. Ethnicity:
BRIEF HISTORY: (If accident, state where, when & how injured; if illness describe)
:
Condition on Admission:
Good ____ Fair ____
Poor ____ Shock ____
Coma ____ Hemorrhage ____
Vital Signs:
Temp. ____
Pulse ____
Resp. ____
B.P. ____/____
Normal Other System Inventory:
o o Mental/Emotional
o o Status:
o o Skin
o o Respiratory
o o Cardiovascular.
o o Musculoskeletal:
o o Gastrointestinal
o o Genitourinary
o o Neurological
PHYSICIAN'S REPORT: History & Physical Findings:
Diagnosis:
Treatment (including medications):
Disposition of Case:
Referred to Dr. Date:
Instructions to Patient:
o o EENT
Form # _ _ _ _ Patient's Signature Date Time Attending Physician
Simulated record. ©2003. American Health Information Management Association. All rights reserved.

Sundance HealthCare Systems
Painted Valley, USA
NEWMAN, Edward C. # 012502
Age 78 CCU
Dr. D. J. Wagner 8-14-xx a.m.
MECHANISM: Normal sinus rhythm
RATE: 94 beats per minute
AXIS Left axis deviation. P-R-T axes 68 - 55 116
PW: Are broadened. P-R interval 162 ms
COMPLEXES: Normal voltage. Left ventricular hypertrophy with QRS widening. Left atrial
enlargement. QT/Qtc 317/398 ms. QRS interval is 118 ms.
TW: Nonspecific ST and T-wave abnormality.
COMMENT: Abnormal EKG, possible lateral ischemia. Old anterior MI. No change from
previous EKG.
DJW/bg
St. Luke’s
D&T: 8-14-xx
Form 4101 (10/01) mr ELECTRCARDIOGRAM
© 2003. American Health Information Management Association. All rights reserved.
Donald J. Wagner
Cardiologist Signature

Sundance HealthCare Systems
Painted Valley, USA
DISCHARGE SUMMARY:
Form 9055 (3/98) him DISCHARGE SUMMARY
© 2003. American Health Information Management Association. All rights reserved.
NEWMAN, Edward C.
Dr. William J. Wainwright
Coronary care unit
# 012502
This patient is a 78-year-old gentleman from Podunk Center. He was admitted because of increasing problems
associated with his chronic congestive heart failure, COPD, diabetes and ASHD. The patient was experiencing
increasing dyspnea associated with the CHF. He was given an IV and increased dose of Lasix. Following this
the patient diuresed approximately five pounds during his hospitalization. Both his O2 saturations and breathing
steadily improved.
Two days after admission he was feeling much better. He had been up walking and was having no chest pain.
He is being discharged in improved condition.
DISCHARGE MEDICATIONS:
Diazepam 20 mg p.o. q.h.s., albuterol and Atrovent nebulizers q.i.d. and p.r.n., Lasix 160 mg p.o. b.i.d.; Theo-
Dur 200 mg q.a.m., 300 mg q.h.s.; Imdur 30 mg (1/2 tab) q.h.s., Pilocarpine 4% 1 drop O.D. q.i.d., nitroglycerin
0.4 mg sublingual p.r.n. chest pain, oxygen 2 to 4 liters per minute per nasal cannula. For his diabetes he
will be on Humulin N 64 U a.m., Humulin N 36 U p.m. and Humalog sliding scale as follows:
Accu-Chek less than 100 = 0,
Accu-Chek 101 - 130 = 3,
Accu-Chek 131 - 170 = 5,
Accu-Chek 171 - 220 = 8,
Accu-Chek 221 - 300 = 12,
Accu-Chek 301 - 400 = 15,
Accu-Chek more than 400 = 18.
FOLLOW-UP: Mr. Newman has an appointment to see me in the office in approximately two weeks for
recheck. He should call or come in sooner if he has any questions or problems prior to that appointment. He is
to check his weights on a daily basis at home and if he gains more than two pounds from his discharge weight he
is to call me at once or come into the ER or walk-in clinic.
FINAL DIAGNOSIS:
1. Congestive heart failure complicating severe chronic obstructive pulmonary disease.
2. Arteriosclerotic heart disease with history of myocardial infarctions.
3. Insulin-dependent diabetes mellitus.
4. Glaucoma.
PROCEDURES: None.
COMPLICATIONS: None.
DJW/sgs
D&T: 8/16/xx
William J. Wainwright