INPATIENT FACE SHEET

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WEST, KEITHIPCase010Dr. BLACKAdmission:02/09/YYYYDOB: 05/23/YYYYROOM: 331 Date Time Physician’s signature required for each order. (Please skip one line between dates.)02/09/YYYY 1650 Admit to service Dr. BlackAdmitting diagnosis: BronchiolitisVitals every shiftCoup tent with oxygen continuous and while sleepingDaily weightComplete Blood CountUrinalysisChest x-ray to rule out pneumoniaMilk-free diet. Encourage fluids, Gatorade.Sudafed 2.5 centimeters 4 times a day as needed forcongestionAmoxicillin 125/5 centimeters 4 times a dayNasopharynx and throat culturesPlease call Dr. Moore when blood work and x-ray aredone.Reviewed and Approved: Mary Stanley RNATP-B-S:02:1001261385: Mary Stanley RN(Signed: 02/09/YYYY 04:54:07 PM EST)02/09/YYYY 1700 1 grain aspirin or 1 grain Tylenol by mouth orsuppository every 4 hours as needed.Reviewed and Approved: Mary Stanley RNATP-B-S:02:1001261385: Mary Stanley RN(Signed: 02/09/YYYY 04:54:07 PM EST)02/09/YYYY 2315 Please do nose irrigation with normal saline 2-3 dropsin each nostril – then suction with bulb syringe andneeded.Reviewed and Approved: Mary Stanley RNATP-B-S:02:1001261385: Mary Stanley RN(Signed: 02/09/YYYY 11:54:07 PM EST)GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234
WEST, KEITHIPCase010Dr. BLACKAdmission:02/09/YYYYDOB: 05/23/YYYYROOM: 331 Date Time Physician’s signature required for each order. (Please skip one line between dates.)02/11/YYYY 1300 Discharge.Force fluidsSaline nose drops and suctionAmoxicillin 125/5 centimeters three times a dayReturn to clinic one weekSummary dictated.Reviewed and Approved: Fred Moore MDATP-B-S:02:1001261385: Fred Moore MD(Signed: 02/11/YYYY 01:05:52 PM EST)GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234
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INPATIENT FACE SHEET

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