INPATIENT FACE SHEET

WEST, KEITHIPCase010Dr. BLACKAdmission:02/09/YYYYDOB: 05/23/YYYYROOM: 331DATE TIME TREATMENTS & MEDICATIONS TIME NURSES’ NOTES02/10/YYYY1830 In tent. Little fussy.Reviewed and Approved: O. Richards, RNATP-B-S:02:1001261385: O. Richards, RN(Signed: 02/10/YYYY 06:31:29 PM EST)2000 Evening care given. Took Gatorade. Intent sleeping.Reviewed and Approved: O. Richards, RNATP-B-S:02:1001261385: O. Richards, RN(Signed: 02/10/YYYY 08:04:19 PM EST)2230 Sleeping quietly. Respirations even andregular. Loose congestive cough.Reviewed and Approved: O. Richards, RNATP-B-S:02:1001261385: O. Richards, RN(Signed: 02/10/YYYY 10:33:33 PM EST)02/11/YYYY Wednesday 2400 Sleeping in croup tent. Respirationseasy and regular.0100-0500Reviewed and Approved: J. Dobbs, RNATP-B-S:02:1001261385: J. Dobbs, RN(Signed: 02/11/YYYY 12:02:16 AM EST)Sleeping.Reviewed and Approved: J. Dobbs, RNATP-B-S:02:1001261385: J. Dobbs, RN(Signed: 02/11/YYYY 05:00:46 AM EST)97.9 – 152 - 36 0600 Sleeping in croup tent. Respirationseasy and regular. Had moderate amount ofbrown, hard constipated stool.02/11/YYYY 0800 97.9 – 152 - 36Regular diet without milkReviewed and Approved: J. Dobbs, RNATP-B-S:02:1001261385: J. Dobbs, RN(Signed: 02/11/YYYY 06:02:36 AM EST)0800 Awake. 1 soft stool. Ate well atbreakfast. Bath given. Dr. Moore in toexam. Out of tent.Reviewed and Approved: V. South, RNATP-B-S:02:1001261385: V. South, RN(Signed: 02/11/YYYY 08:03:00 AM EST)1000 Content in crib. Tolerates out of tentwell. Clear nasal drainage.Reviewed and Approved: V. South, RNATP-B-S:02:1001261385: V. South, RN(Signed: 02/11/YYYY 10:11:48 AM EST)1200 Ate well at lunch. Parents here. Dr.Moore in to exam child and talked withparents. Patient to go home.Reviewed and Approved: V. South, RNATP-B-S:02:1001261385: V. South, RN(Signed: 02/11/YYYY 12:06:09 PM EST)1300 Discharge. Refer to discharge summarysheet.GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234Reviewed and Approved: V. South, RNATP-B-S:02:1001261385: V. South, RN(Signed: 02/11/YYYY 01:01:01 PM EST)