INPATIENT FACE SHEET

WEST, KEITHIPCase010Dr. BLACKAdmission:02/09/YYYYDOB: 05/23/YYYYROOM: 331DATE TIME TREATMENTS &MEDICATIONS02/09/YYYY1700 Temperature 101.3 Tylenol60 milligrams by mouthTIMENURSES’ NOTES1615 8-month old white male admitted to room331 in tent for possible pneumonia. Underservices of Dr. Black. Throat andNasopharynx culture done. Blood work andchest x-ray done. Parents in. Patient’sface flushed. Hot to touch. Taped forurinalysis.Reviewed and Approved: O. Richards, RNATP-B-S:02:1001261385: O. Richards, RN(Signed: 02/09/YYYY 04:20:32 PM EST)1630 Given bottle Gatorade. Took very smallamount of coup. In tent sleeping.Reviewed and Approved: O. Richards, RNATP-B-S:02:1001261385: O. Richards, RN(Signed: 02/09/YYYY 04:32:09 PM EST)1830 Sleeping. Respirations even/regular.Slightly rapid. Occasional congestivecough. Took small amount of Gatorade.02/10/YYYY2000 Temperature 99.3 Dr. Mooreis in.TuesdayTemperature 97Reviewed and Approved: O. Richards, RNATP-B-S:02:1001261385: O. Richards, RN(Signed: 02/09/YYYY 06:32:19 PM EST)2000 Evening care given. In tent. Patient is alittle fussy. Mother with patient.Reviewed and Approved: O. Richards, RNATP-B-S:02:1001261385: O. Richards, RN(Signed: 02/09/YYYY 08:07:33 PM EST)2230 Sleeping quietly. Respirations even andregular.Reviewed and Approved: O. Richards, RNATP-B-S:02:1001261385: O. Richards, RN(Signed: 02/09/YYYY 10:34:33 PM EST)2400 Sleeping in croupette. Awakened for vitalsigns and medicine. Respirationscongested, rate 36. Occasional congestedcough. Nose irrigated and suctioned asordered. Had yellow nasal drainage. Motherwith patient.0015 Sudafed 2.5 centimeters 0015Reviewed and Approved: J. Dobbs, RNATP-B-S:02:1001261385: J. Dobbs, RN(Signed: 02/10/YYYY 12:03:28 AM EST)Given for congestion. Back in tent.Reviewed and Approved: J. Dobbs, RNATP-B-S:02:1001261385: J. Dobbs, RN(Signed: 02/10/YYYY 12:17:28 AM EST)0100 Sleeping. Respirations remain slightlycongested.Reviewed and Approved: J. Dobbs, RNATP-B-S:02:1001261385: J. Dobbs, RN(Signed: 02/10/YYYY 01:03:28 AM EST)GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234