EmpowerSystems Electronic Health Record User Guide

EmpowerSystems Electronic Health Record User Guide

empower Inpatient+Ambulatory

Notes .............................................................................................................................................................................................. 5

Chapter 1: Implementation Overview ................................................................................................................................. 6

PHASE I – Project Kickoff & Assessment .................................................................................................................... 6

PHASE II – Application Development ......................................................................................................................... 8

PHASE III – Testing, Training, & Technical Readiness ................................................................................................ 8

PHASE IV – Go Live .................................................................................................................................................... 9

PHASE V – Post Go Live Assessment & Transition ..................................................................................................... 9

Chapter 2: System Technological Requirements and Specifications ...................................................................... 10

Basic Architectural Design ....................................................................................................................................... 10

Hardware & Support Software Specifications ......................................................................................................... 12

Health Insurance Portability and Accountability Act (HIPPA) .................................................................................. 17

Empower Inpatient™ Workstation Setup ................................................................................................................ 18

Empower Ambulatory™ Workstation Setup ............................................................................................................ 19

Chapter 3: Training of Physicians, Nurses, and Support Staff ..................................................................................20

Ongoing Training ..................................................................................................................................................... 20

Chapter 4: Inpatient + Ambulatory Workflow Perspectives ....................................................................................... 21

Chapter 5: General Clinical Documentation ................................................................................................................... 24

Physicians, Nurses and Staff Documentation .......................................................................................................... 24

Discharge Instructions (Pre-Written) ....................................................................................................................... 25

Prescription Writer & e-Prescribing ......................................................................................................................... 25

Drug to Drug Interaction and Allergy Detection ...................................................................................................... 27

Table Editor ............................................................................................................................................................. 28

Automatic Paging System ....................................................................................................................................... 28

Medication Reconciliation/History .......................................................................................................................... 29

Chapter 6: Personalization Policy and Procedures ...................................................................................................... 30

Supplemental Services ............................................................................................................................................. 30

Chapter 7: Coding and Billing ............................................................................................................................................... 31

Empower Inpatient+Ambulatory™ Calculation of RN Level of Service (LOS) ........................................................... 32

Physician LOS Calculation ........................................................................................................................................ 38

Chapter 8: Medical Records and Health Information Security .................................................................................. 41

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Image File (Empower PDF Chart)............................................................................................................................. 41

PDF Storage/Document Management System ........................................................................................................ 42

Security for Personal Health Information ................................................................................................................ 43

Chapter 9: Reporting and Data Mining ............................................................................................................................ 46

Empower Report + Alert Writer ............................................................................................................................... 48

Training Options .................................................................................................................................................. 51

Getting Started with Standard Reports ................................................................................................................... 52

Meaningful Use Reports .......................................................................................................................................... 60

Chapter 10: General User Manual ....................................................................................................................................... 61

Chapter 11: Nurse/Medical Assistant User Manual ..................................................................................................... 69

Chapter 12: Provider User Manual ..................................................................................................................................... 88

Chapter 13: Interfaces ........................................................................................................................................................... 108

Registration (ADT) ................................................................................................................................................. 108

Diagnostic Results ................................................................................................................................................. 109

Order Entry (CPOE/Automated Unit Secretary) ..................................................................................................... 109

Diagnostic Results & Order Entry Testing .............................................................................................................. 109

Empower HL7 Orders and Results Interface Specifications ................................................................................... 111

Appendix 1A: Hospital Staff Contact Information ....................................................................................................... 127

Appendix 1B: Implementation Project Timeline Check List ..................................................................................... 128

Appendix 2A: Business Agreement ................................................................................................................................ 133

Appendix 3A: Empower RN Skills Verification ............................................................................................................ 134

Appendix 3C: Empower MD Skills Verification ............................................................................................................ 136

Appendix 3D: Physician Electronic Signature............................................................................................................... 137

Appendix 4A: Computer Documentation Abbreviations .........................................................................................138

Appendix 9A: Empower Table Names and Descriptions ..........................................................................................142

Appendix 13A: Workflow Procedure for CPOE Interface: Post Go-Live ................................................................ 147

Appendix 13B: Hospital Order Entry Problem Log Sheet ......................................................................................... 148

Appendix 13C: Diagnostic Results Interface Workflow - Post-Go Live ................................................................ 150

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Appendix 13D: Hospital Diagnostic Results Problem Log Sheet ............................................................................. 151

Technical Support Guidelines .............................................................................................................................................156

Client Support Quick Start Guide ........................................................................................................................... 160

Empower Inpatient Sample Chart ................................................................................................................................. 168

Empower Inpatient Summary Chart for Faxing ........................................................................................................ 232

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Notes

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Chapter 1: Implementation Overview

The Empower Inpatient+Ambulatory™ Implementation Manual will guide your facility through the EmpowerSystems™ (Empower) implementation process. This manual begins with an overview of the implementation process, and is then divided into specific chapters that address the various aspects of the Inpatient/Ambulatory setting.

The Empower Inpatient+Ambulatory™ implementation process is designed to be a seamless and expedient approach to transitioning physicians, nurses, and staff from a handwritten and/or dictation-based environment to the Empower chart. This project will involve various hospital/clinic departments and personnel throughout the stages in the implementation process. A description of the five phases of the Empower Inpatient+Ambulatory™

implementation process is included in Appendix 1B . It is important that the project teams of

both Empower and the host hospital maintain clear lines of communication at all times.

EmpowerSystems™ commits to a successful implementation, having been through this process many times. This manual addresses both the common processes that all settings share as well as the unique variances in workflow processes, Inpatient/Ambulatory initiatives, and policies and procedures specific to any one institution. In addition to this manual, the Empower

Inpatient+Ambulatory™ process requires conveniently scheduled meetings or calls between all parties involved in the implementation.

PHASE I – Project Kickoff & Assessment

Identifying the Inpatient/Ambulatory Resources and Contact Information

In order for Empower to execute the implementation process, it is necessary to identify all key

individuals to ensure proper communication. To this end, please complete Appendix 1A and

return to your Empower Project Manager within 1 week of the agreement.

Empower Implementation Team Contact Information

The Empower personnel assigned to your facility during the implementation process are available and can be contacted at any time if questions or issues arise. All communication should include your assigned project manager as they are responsible for the coordination and completion of your Empower Inpatient+Ambulatory™ implementation and they have a team of resources available to meet your needs. Your designated Empower Project Manager will also

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empower Inpatient+Ambulatory provide you with a list of contacts should there come a time that you need to contact another individual for a specific issue.

Creating an Implementation Timeline and Project Strategy

The first priority in the implementation process is to create an action plan and timeline. Please

familiarize yourself with the sample timeline ( Appendix 1B ) to ensure that we are coordinated

with all steps of the Implementation process. Your Empower Project Manager will work with your identified Project Manager to review this document to both create deadlines and identify resources.

Schedule the First Meeting

Introduce leadership, discuss resources, and detail a preferred time frame for implementation.

Computer Hardware and Support Software Purchasing

This is a time intensive task which can delay the entire implementation if not undertaken early, so we recommend that this step occur on a parallel path with other Empower timelines. If the

Inpatient/Ambulatory Departments are unable to purchase these items, the Empower Project

Manager may purchase and install these items with payment terms detailed at that time.

Inpatient/Ambulatory IT Responsibilities

Empower software can be connected and configured in about 1 week, once provided with highspeed internet access. After this, the hospital IT staff copies the Empower software (the

Empower launcher) onto each client computer. The Empower Inpatient+Ambulatory™ software will reside in a shared folder on the hospital network. Each client computer must be configured to login to the hospital network and to print the chart on a laser printer in the appropriate work station.

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Establish a Go Live Date

The Empower Go Live date (a.k.a. First Product Usage or FPU) serves as a rallying point for all parties involved to establish both milestones and deadlines. Once a Go Live date is designated, it should not be changed. Hence it is crucial that all parties adhere to the timeline.

PHASE II – Application Development

Hardware and Software Configuration/Setup

The hospital IT staff is responsible for operating system and support software installation and system connectivity. Once Empower has been provided remote access to the hospital system, the Empower Inpatient+Ambulatory™ system setup will proceed.

Provide Hospital Data

During Phase I, your Project Manager will provide samples of required data to that can be used to customize Empower Inpatient+Ambulatory™ system to your sites needs. Empower will complete this customization and configure the server to prepare for system testing and use.

Interface Development and Go Live Preparation

Interface development and testing should occur parallel to Empower training sessions and implementation. This process can start after Empower has been provided with a high-speed internet connection available to the computer servers, and after the hospital has deployed the client computers with Empower to the training room and the respective clinical departments.

For more information on interfaces, see Chapter 13 .

PHASE III – Testing, Training, & Technical Readiness

Empower trains all physicians, nurses, and staff members on the system in accord with the

hospital workflow, policies, and procedures (See Chapter 4 ). Empower provides on-site training

for SuperUsers over a period of several days during which trainees will be provided with lectures, discussion, and practice on the Empower Inpatient+Ambulatory™ system. Empower physician training is web-based in order to accommodate their potential schedule limitations.

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Full details on training parameters can be found in

Chapter 3 . It is recommended that a

computer lab be set up for the training of SuperUsers. After scheduling both the Go Live and the training sessions, these dates cannot be changed without incurring a significant charge by the hospital.

PHASE IV – Go Live

The Empower Go Live will occur on a Tuesday morning after nurse shift change. On the day of

Go Live, an Empower team representative will inspect the computer server and work stations, as well as the printers, tracking systems, and all relevant areas. During implementation, workflow and methods of communication will not change, but the transition from paper to computer (Empower) documentation will be immediate. The physician and nurses will enter all clinical documentation, including physician and nurse notes, diagnostic and medical orders, diagnostic results, vital signs, discharge instructions, and prescriptions, on computers at the time of Go Live.

PHASE V – Post Go Live Assessment & Transition

The Empower Go Live team will be onsite in the inpatient/ambulatory setting around the clock until a time that users are deemed comfortable with the software. The Empower team will assist the physicians, nurses, and staff with documentation and navigation of the system. After the Empower team departs, Empower will still be "on-site" at the hospital, but in a remote, virtual environment.

Empower provides technical support both by phone and via remote connectivity in order to respond to questions from front end users. There are many advanced methods to fully maximize the systems' functionality, and Empower wants to be certain that the

Inpatient/Ambulatory setting takes full advantage of all of the operational efficiencies

(including Meaningful Use) that are built into the system. However, this process takes time and may not all occur during the Go Live week. The Empower team will assign a project/account manager as the long-term resource for questions and needs regarding Empower. Empower senior management also visits its partner hospitals on a regular basis to assist the hospital with not only any issues that may have developed, but also with leveraging many of the new and advanced features of Empower software.

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Chapter 2: System Technological Requirements and Specifications

The hospital should provide all of the computer hardware and support software detailed in this chapter. Please forward any questions regarding the following to Empower prior to installation.

No software substitutions can be made. Hardware requirements provided below are the minimum for small Inpatient/Ambulatory settings. Mid to large sized facilities generally require a more substantial configuration. Clients should consider increasing the devices performance features if additional software is to be used concurrently with Empower.

Basic Architectural Design

Below is the typical Empower Inpatient™ architecture design and network configuration.

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Below is the typical Empower Ambulatory™ architecture design and network configuration.

Scanner

Physician

Office

Printer

Remote

Connection

Empower Office

Server

Scanner

Physician

Office

Printer

Remote

Connection

Network Specifications

The Empower Inpatient+Ambulatory™ software system can function in any network environment, e.g. Star Configuration, Cluster, Citrix, however Empower performs maximally in a

Star network configuration. In more complex hospital networks, although there is greater risk that there might be unforeseen software glitches, Empower is committed to resolving any issue that impedes physician and nursing documentation.

Remote Connectivity

The Empower Inpatient+Ambulatory™ software system requires high-speed internet connections to the server and remote software connectivity, either Microsoft Remote

Desktop/Terminal Services or PC Anywhere, to each client computer. The Empower

Inpatient+Ambulatory™ software system utilizes only software-based, but not hardware-based,

VPN products.

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Hardware & Support Software Specifications

The hospital will need and should provide the following computer hardware and support software:

SERVER HARDWARE – Live SQL

Structure

2 Clustered Servers for Redundancy of LIVE System. Attached to SANS with sufficient storage for Scans/PDFs. Size of SANS dependent on amount of scanning and patient Volume. Recommend at least 2TB with expansion for future growth.

2 Quad-Core CPU or higher Machine CPU / Speed MHx

RAM

Hard Drive Space

64 GB or Higher

200GB+ Local Server RAID (partitioned with 30GB for Op-Sys Partition, remainder in Data Partition)

DVD-RW Drive Optical Drive

Monitor

Uninterruptible Power Supply

17” Flat Screen

UPS sufficient for both clustered servers in case of brown-out – APC 1500 or higher

TCP / IP

Ethernet Card

*Recommendation for 100+ Beds

2x Intel® Xeon® E7-4870 2.40 GHz, 30M Cache, 6.4 GT/s QPI, Turbo, HT, 10C

SERVER HARDWARE – Test, Application, and Interface Servers (Virtual Machines)

Machine CPU / Speed MHx

2 Quad-Core CPU

16 GB or Higher except Terminal Server need 64GB

RAM

Hard Drive Space 200GB+ Local Server RAID (partitioned with 30GB for Op-Sys Partition, remainder in Data

Partition)

SERVER HARDWARE – Terminal Server (VM)

2 Quad-Core CPU or higher

Machine CPU / Speed MHx

RAM 64 GB or Higher

Hard Drive Space

Optical Drive

200GB+ Local Server RAID (partitioned with 30GB for Op-Sys Partition, remainder in Data

Partition)

DVD-RW Drive

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Monitor

Uninterruptible Power Supply

Ethernet Card

17” Flat Screen or other functional equivalents

UPS dedicated to TS in case of brown-out – APC 1500 or higher

TCP / IP

SERVER SUPPORT SOFTWARE – Live SQL

Requirements

Windows Server 2008 R2 x64 or newer, SQL Server 2008 or newer (with Windows/SQL licenses for needed computers or Terminal Service Licenses) with SQL Studio manager and all client/workstation tools installed. Microsoft Office 2007 (ONLY – not newer)

Professional (with Access 2007 full version) installed.

NOTES

Configuration Benefits

Support

Virtual Machine configuration of supporting servers will incur licensing costs, but yield substantial savings and offer increased flexibility in the long term.

Empower supports virtual servers, however we do not recommend a virtual machine for the

LIVE SQL environment. The Test, Application, Interface, PDF generator server(s) could be

VMs if the client so desires.

SERVER HARDWARE – Live SQL – Enhanced Capacity Recommended for 100+ Bed Facilities

Structure

2 Clustered Servers for Redundancy of LIVE System. Attached to SANS with sufficient storage for Scans/PDFs. Size of SANS dependent on amount of scanning and

Inpatient+Ambulatory™ Volume. Recommend at least 2TB with expansion for future growth.

2x Intel® Xeon® E7-4830 2.13 GHz, 24M, 6.4 GT/s QPI, Turbo, HT, 8C

Machine CPU / Speed MHx

RAM

128 GB or Higher

Hard Drive Space

200GB+ Local Server RAID (partitioned with 30GB for Op-Sys Partition, remainder in Data

Partition)

DVD-RW Drive

Optical Drive

Monitor

17” Flat Screen

Uninterruptible Power Supply

UPS sufficient for both clustered servers in case of brown-out – APC 1500 or higher

Ethernet Card

TCP / IP

*Recommendation for 100+ Beds

2x Intel® Xeon® E7-4870 2.40 GHz, 30M Cache, 6.4 GT/s QPI, Turbo, HT, 10C

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SERVER SUPPORT SOFTWARE – Test, Application, Interface Servers

TEST / APPS Server/ Terminal

Server

PDF Generator

Windows Server 2008 R2 x64, SQL Server 2008 with SQL Studio manager and all client/workstation tools installed.

Software for PC Access

Adobe Acrobat Standard version 7 or newer installed. Microsoft Office 2007 Professional

(with Access 2007 full version) installed.

Remote desktop/Terminal services enabled for remote access

Anti-Virus Software – hospital standard

Virus Software

Additional Software Microsoft Office 2007 Professional (for Word and Access)

Additional Licenses

Microsoft SQL Server Enterprise or Standard Edition and Client Access Licenses (CALs) for Windows Server

(for workstations requiring access to server)

SERVER SUPPORT SOFTWARE – Terminal Server

Terminal Server

Software for PC Access

Windows Server 2008 R2 x64. Microsoft Office 2007 Professional (with Access 2007 full version) installed, and Adobe Acrobat.

Remote Desktop/Terminal services enabled for remote access. Remote Desktop licenses are required for every computer used in Inpatient, Ambulatory, and ED units, Hospital

Administration, etc.

Anti-Virus Software – hospital standard

Virus Software

Additional Software

Additional Licenses

Microsoft Office 2007 Professional (for Word and Access)

Microsoft SQL Server Enterprise or Standard Edition and Client Access Licenses (CALs) for Windows Server

(for workstations requiring access to server)

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WORKSTATION HARDWARE

Machine CPU / Speed MHz

RAM

Hard Drive Space

Monitor

1 Dual-core CPU or higher

1GB minimum

40GB 7200RPM IDE HD

17” or larger flat screen for desktop space efficiency (1024x768 recommended resolution for appropriate Empower viewing)

USB optical or laser mouse and keyboard

Mouse / Keyboard

Ethernet Card

Scanner (required)*

Tablet PC for Signature Capture

(required)*

TCP / IP

Cannon DR 2010C / DR 2510C / DR 3010C / Flatbed 101 Add-On

Panasonic CF-H1 / with Cradle CF-VEBH11

WORKSTATION SUPPORT SOFTWARE

Operating Systems Software

Additional Software

Additional Software

Windows XP SP2+ (with Windows Paint installed so graphic filters are functional on workstation for viewing scanned documents)

Microsoft Access 2007 Runtime (free). *This can be modified based on Terminal Server infrastructure as chosen by client.

Adobe Acrobat Reader version 7 or newer (free)

Virus Software

Anti-Virus Software – hospital standard

The majority are basic recommendations. * Requirements are noted as such. Empower supports a large variety of hardware/software configurations and hospital/office size and volume may dictate changes needed in specifications.

Hardware & Third Party Software

Empower Systems™ does not recommend a hardware vendor or provide hardware to Hospital.

Hospital is responsible for the purchase, installation, and maintenance of any hardware required for the product. Empower Systems™ does not recommend any third party software, except for software listed on Hardware & Support Software Specifications (above).

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Backup & Anti-Virus Software

Empower Systems™ does not recommend a backup vendor or provide backup software to Hospital.

Hospital is responsible for the proper backup of critical dictionaries, files, and point-to-point interfaces. Hospital is responsible for properly restoring backup files in case of a system error or crash. Empower Systems™ does not recommend an antivirus software vendor or provide antivirus software for the product. Hospital is responsible for the purchase, installation, and maintenance of the antivirus software.

*Scanner & Tablet PC Requirements

For all Inpatient and Ambulatory units Empower Systems™ requires specific scanner models

(Cannon DR 2010C / DR 2510C / DR 3010C / Flatbed 101 Add-On) for general use and Tablet PC

(Panasonic CF-H1 / with Cradle CF-VEBH11) for signature capture. If a hospital, or unit within the hospital, decides to utilize an alternate Scanner or Tablet PC, there will be $225/hour fee for

Empower Systems™ to configure the unapproved device on the hospital network.

Database Backup Options

The hospital is responsible for all software backup and for all recovery of clinical data in the

Empower software system. Empower utilizes Microsoft SQL Server software for management and storage of clinical data which allows several options for data storage. Empower’s Microsoft

SQL Server backup includes:

› Tape cassette

› Local hard drive/directory

› Network hard drive/directory (required)

› RAID hard drives (required)

The frequency of data backup can be adjusted depending on the speed and quality of the hospital computer server hardware. The data back up intervals include:

› 1 hour

› 6 hours

› 12 hours

› 24 hours

› Microsoft SQL software replication: real-time

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The hospital can also implement redundant (mirror) computer servers for data backup.

Although this increases hardware costs, it essentially guarantees that the Empower servers will never be down due to a hard drive issue.

Software Updates & Patches

Empower deploys the software system updates and patches when the system is approved. The hospital then has 14 days to test the software and accept all Empower updates and software patches. If the hospital refuses the patches or updates then the Empower software live database deployment may be delayed for as long as six to even twelve months. The Project

Manager will coordinate with the hospital to ensure that this 14 day period will have the highest probability of success.

Health Insurance Portability and Accountability Act (HIPPA)

Empower is compliant with HIPAA (Health Insurance Portability and Accountability Act) of 1996.

Empower requires a user login ID and password for access and, in addition, the passwords can be set to require changing at pre-set time intervals. Empower tracks all users’ names and the dates and the times that they access any clinical information. Empower also has an automatic log-off that also can be set to particular time interval. For additional security-related logistics,

please refer to Chapter 8 .

The hospital must sign a Business Associate Agreement with Empower in order to be HIPAA compliant. The hospital should provide Empower with this before the Go Live. The clinic may also use the Business Associate Agreement in

Appendix 2A . The hospital should provide

Ambulatory users with a business agreement also.

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Empower Inpatient™ Workstation Setup

Windows XP Workstations vs. Windows 2000 - Windows 2000 requires MDAC 2.8 or newer to be installed, whereas Windows XP has this built-in by default.

Note: The local workstation must have read/write/modify access to a "C:\Empower" folder. The launcher will create and use this as long as the logged-in user has permissions to create/write to that directory.

Please complete the following while logged in as an administrator.

 Access 2003 or 2007 Runtime, or Access 2003 or 2007 (and no other installed version of Access) which is available on the original full Office 2003 CD in the directory

[cdrom]:\FILES\ACCRT\ACCESSRT.MSI.

 Adobe Acrobat Reader (for printing pre-printed discharge instructions only) o Immediately after installation, please launch the Adobe Reader. This will prompt the "license" screen for acceptance. Please click "accept". If the 'Accept' button is not clicked, then in the future the "license" pop-up will not be visible behind the Empower Inpatient+Ambulatory™ program, and hence it will appear as though the system is not responding, when in fact the system is waiting for a response to the pop-up.

 All client/workstations must have MS Paint installed (or some graphics program that is considered an OLE Server) in order to print signatures.

 "Empower Launcher" Shortcut o Locate the "Empower Launcher" link on the server within the ECDS shared directory. o Copy this link/shortcut to the local workstation into the "All Users" desktop. By using this shortcut the most current version of Empower software will be automatically updated.

 Empower Certificate o Locate the file "Empower_Certificate.spc" on the server within the ECDS shared directory. o Right-click on Empower_Certificate.spc and choose <INSTALL> o Choose <NEXT> o Click <Place all certificates in the following store> o Choose <Trusted Root Certification Authorities> o Click <OK>, <NEXT>, and <FINISH>

 When the Empower software is run for the first time, it will ask about the security certificate.

Please select the check box to install the certificate. It will never ask again for that workstation.

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The certificate is a security feature for any software that runs VBA code in order to insure that the code is from a secure source and has not been modified by a virus or other source. If the inpatient users all have unique network logins, then installation of the certificate to all users at once is more challenging. The simplest method to accomplish the installation is to install the certificate (and all other settings described above) for a default user profile. Then copy the entire profile, including all associated files, to the default profile, then delete the user accounts on the workstation. When the users log in again, it will use the default profile's setup certificate.

 For workstations requiring PDF Browser and/or Custom Reporter, locate the "PDF Browser" link and/or the "Empower Reporter" on the server within the ECDS shared directory, and copy this link/shortcut to the local workstation "All Users" desktop.

 Install .NET 1.1 or newer. This is not required for workstations that are going to run the

Empower Inpatient™ program alone.

 Empower Inpatient™ references the Windows "default printer" for non-specialized printing.

Please be certain that the default printer is defined.

Maintenance of Hardware & Support Software

If any additional computers need to be loaded with the Empower Inpatient+Ambulatory™ software, simply follow the initial setup checklist of the Empower client computers and both hardware and software specifications.

Empower Ambulatory™ Workstation Setup

The hospital will provide a terminal/remote desktop server.

 Open Remote Desktop Connection and enter the Computer and Username supplied by the hospital. Please enter a password if needed.

 For ease of access, a shortcut may be saved on the desktop

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Chapter 3: Training of Physicians, Nurses, and Support Staff

Empower is designed to be both comprehensive and user-friendly. Most physicians and nurses who are comfortable emailing or surfing the Web require very little training. Agency or temporary staff needs only a brief 15-30 minute in-service. Empower provides on-site training for SuperUsers. These administrative users then train all nursing and ancillary staff. Physician training is provided by Empower via web-based sessions in an effort to accommodate physicians’ limited schedule availability. Physicians can join their scheduled session from any location with internet access and a phone connection. The hospital is responsible for scheduling physician training, segmented in 90 minute sessions. While more than one physician can be trained at once, we recommend no more than a 4:1 ratio.

On-site SuperUser training will be scheduled during the implementation process and is coordinated between the project managers. It is recommended that a training environment/computer lab is available with a maximum computer to trainee ration of 1:2.

After scheduling the Empower Go Live and training sessions, these dates cannot be altered without the hospital incurring a significant expense. SuperUsers will be identified and instructed on the process of maintaining and creating new user accounts in Empower. These SuperUsers should be able to capture physician signatures via Tablet PC for input to Empower. If the hospital would prefer Empower to load all physician signatures, this can be accommodated at a

standard billable rate, provided a completed "Physician Electronic Signature Form" ( Appendix

3D ) accompanies the request. If physician signatures are not uploaded to the system, charts will

print without physician signatures. It is advisable that the hospital provide this form to the

Medical Staff Office so that they can include the collection of this information in the physician credentialing process.

Ongoing Training

The hospital must identify a resource (Empower SuperUser) to be responsible for training of new physicians, nurses and ancillary staff after the initial Empower training and Go Live have been completed. This individual will be responsible for all additional clinical staff training.

Empower has provided the following skills verification templates for documentation of education records. For User-Specific Manuals, please see Chapters 10-12.

Appendix 3A: Empower MA/RN Skills Verification

Appendix 3B: Empower Registration Skills Verification

Appendix 3C: Empower Provider Skills Verification

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Chapter 4: Inpatient + Ambulatory Workflow Perspectives

The inpatient and ambulatory workflow is affected by many internal (registration, medical assistants, etc.) and external (laboratory, radiology, medical records, coding, insurance companies, billing, etc.) factors. There are many different types of workflow:

Clinical evaluation of the patient (medical assistants, nurses, physicians)

Clinical documentation (medical assistants, triage, nurses, physicians)

Clinical communication (medical assistants, triage, nurses, physicians, unit clerks, ancillary staff)

Registration

Order entry

Diagnostic results

Collating and distributing the chart to medical records

Collating and distributing the notes to inpatient units and attending physicians

Collating and distributing the notes to hospital and physician coders and/or billers

Empower takes a phased approach to implementing the Inpatient and Ambulatory systems in order to minimize the impact on all departments. During the Empower Go Live, the greatest impact will be on the physician and nursing documentation. All other aspects of the Inpatient and Ambulatory workflow will remain virtually the same. The workflow process related to collating and distributing the chart will remain unchanged as the current handwritten chart will simply be replaced with a computer-generated chart.

Registration workflow process will be impacted depending on the type of interface design that

is articulated in Chapter 13 . CPOE will change the unit clerk’s workflow and responsibilities as

their role changes from entering data/orders into the inpatient ordering system to simply auditing/confirming the order when received electronically in the inpatient information system.

The diagnostic results workflow process for laboratory and possibly radiology should continue

as usual. Please review the Diagnostic Results section also in Chapter 13.

The collation and distribution of the inpatient chart will initially occur with a printed hard copy.

The inpatient chart will also be converted to an image file (PDF), which will be electronically stored on the inpatient network. If the hospital has a document imaging system (Care Center,

Chart Script, etc.), then the hospital could work with that vendor to import the Empower PDF so that it can be accessed throughout the Inpatient setting.

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The Empower Project Manager assigned to your site will help assess and decide the best way to integrate Empower into your workflow process. Because Empower can function in many different workflow scenarios, it will take some time to see which workflow processes work best for your institution.

The following agenda should be reviewed with your Empower team:

1. Registration - Quick Reg/Full Reg

a. Role of Greeter b. Role of Registration c. Role of Triage Nurse/Medical Assistant d. Full Registration

2. Paper Chart/Clipboard

a. Temporary Triage (Emergency Department) b. Other documents, signatures, results

3. Primary Nursing Documentation

a. Use of Empower Response column in Medical Interventions b. Use of Empower Clinical Notes; assessments, social information, repeat assessments c. Repeat Vital Signs - interface option to consider d. Frequent Vital Signs - Print strips, mount and scan OR nurse enters e. Scanning

4. Tech, MA, Unit Secretary

a. Vital Signs b. Point of Care - EKG, Glucose Check, Urine Dips, and Blood draws c. Notifications d. Bed Assignments e. Nurses Notes - i.e. splint applied (discussion) f. Order Entry g. Interface Impact on Job Descriptions

5. Disposition Determined by Physician

a. No disposition can be done until the chart is finalized by a physician. b. Discharge Instructions driven by physician, nurse can add information. c. Physician can print many parts of the chart.

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6. Chart Completion by Nurse/MA

a. Consider: Complete entire chart, print entire chart and disposition patient. b. Consider: For discharged patient, print discharge instructions, return and complete documentation and print entire chart.

7. Bed Management

a. Bed Manager Feature: Who is responsible? Charge Nurse, Floor/ED Nurse, Tech,

Secretary? b. Patient brought to exam room from waiting room: Who is responsible? Tech,

MA, Triage RN, Primary RN, other c. Inpatient/ED room changes: Who is responsible?

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Chapter 5: General Clinical Documentation

Physicians, Nurses and Staff Documentation

The transition from paper to computer (Empower) documentation is immediate. Physicians and nurses will enter all clinical documentation on computers at the time of Go Live. The clinical information includes the physician and nursing notes, diagnostic and medical orders, vital signs, discharge instructions, and prescriptions. The initial workflow and communication of information will remain unchanged. A clipboard or binder can still be the center of communication between physicians and nurses until a comfort level is established with documenting in and communicating with computers.

After the nurse completes the triage for a patient, a printed hard copy of the triage note will be placed on the clipboard or binder which is then given to the physician or put in the chart rack.

The same will be true for physicians when documenting diagnostic and medical orders, a printed hard copy will be placed on the chart and given to the nurse or unit clerk to execute.

When lab results are printed, they will be collated on the ED clipboard or binder for the physician to review. As the CPOE (Computer Physician Order Entry) and diagnostic interfaces go live, this workflow will change (this will be addressed in

Chapter 13 ). As the patient is

dispositioned, a printed chart of the entire patient encounter will be sent to medical records or, if the patient is being admitted, with the chart to the floor. After the hospital reaches a certain comfort level with the Empower printed chart, the hospital can reassess the current workflow and start moving towards a completely paperless environment.

Point-of-Care Diagnostic Testing

Empower captures all clinical information in the Inpatient and Ambulatory settings, including point-of-care testing (glucose scan, urine pregnancy, quick hemoglobin, etc.) ordered by physicians and nurses. Nurses and staff should document the point-of-care tests in the

Diagnostic/Results or Nursing Notes sections. Test name and result should be documented in the diagnostic form for physician review.

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Demographics Printout

Empower has the ability to automatically print demographics Information, which can serve as a notification to the registration clerk, providing them with the patient’s name, date of birth, exam room number, and other clinical information.

Discharge Instructions, Clinical Summary, and Physician Follow Up

The staff, using Empower, also can provide patients with information about the follow up physician upon discharge. The staff can document the PCP or specialist’s name, office address and office phone number in Empower. The hospital or clinic must provide Empower with contact information for the physicians and specialists in an electronic format. Other physicians and clinics can always be added as needed via the Empower Table Editor or the Discharge Page.

Empower also has the capability to automatically fax and/or email the entire note to the referred physician, regardless of whether that physician in an Empower user.

Discharge Instructions (Pre-Written)

When a patient is discharged, Empower can print pre-written diagnosis specific discharge instructions, prescriptions, and a clinical summary of their care in, if needed, a variety of different languages. For those facilities that develop their own custom discharge instructions,

Empower can add content as provided in a Microsoft Word document.

In addition to Empower’s multilingual Discharge Instruction content, our partnership with

ExitCare™ provides clients with access to robust discharge instructions in English and Spanish.

Additional languages are available from ExitCare™ for an annual fee based upon hospital volume. ExitCare™ is an industry leader in providing comprehensive, user-friendly, visually engaging content to ED, Inpatient, and Ambulatory environments.

Prescription Writer & e-Prescribing

Empower has a one-click prescription writer, which lists the name, dosage, and route of the medication from one single database in order to expedite documentation of the prescription.

The database used is nationally recognized as an industry leader. If a medication is not listed in the prescription writer, simply contact your Project Manager and the new medication can

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empower Inpatient+Ambulatory quickly and easily be added. The prescription writer can also be used to send prescriptions electronically to the pharmacy. The prescriptions are sent via fax numbers that can be added at anytime by the clinic or by your Empower representative.

Bed Control Notification of Admission and Transfers

Empower can also automatically notify Bed Control about all hospital admissions done through the emergency department and all transfers within the hospital.

There are three notifications that can be transmitted to Bed Control:

1.

2.

3.

Automatic page providing the following information: patient name, gender, diagnosis, bed assignment, and admitting physician.

Electronic notification over the hospital network printing the following information: patient name, gender, diagnosis, bed assignment, and admitting physician.

An Empower tracking board can be placed in Bed Control displaying the following information: patient name, gender, diagnosis, bed assignment, and admitting physician.

Order Sets (Guidelines, Protocols, etc.)

Empower has both Diagnostic and Medical Order sets that can be customized to each hospital and physician office. Empower will automatically check-off diagnostic tests on the diagnostic and medical order forms when choosing these order sets from the medical order section. To view the current default diagnostic and medical order sets in Empower, go to the medical order section and choose from Standard Order Set. Modifications or additions to the order sets can be done by a Super User or by an Empower Project Manager.

Admission Orders and Clinical Pathways

Empower allows the physician to enter admission orders or hospital-specific clinical pathways.

The Admission Orders functionality is similar to the Standard Order Sets listed above. This is an optional feature. Please communicate with your Empower Project Manager regarding activation/de-activation of this feature. The following clinical pathways currently are deployed to all hospitals. These are fully customizable and can be expanded or deleted.

Congestive Heart Failure

Pnemonia

Hyperglycemia

Hypoglycemia

Chest Pain

Stroke

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Drug to Drug Interaction and Allergy Detection

The Smart Technology in Empower employs drug-to-drug interaction and allergy detection for the patient’s home medications, medications administered in the office, and the medication given as a prescription. This Smart Technology, however, only works if the nurses and physicians use the correct information and spelling. Our large medicine database also includes hyper-allergenic substances. We encourage users to use this list. When writing orders or prescriptions, physicians have the ability to override both the drug-to-drug interaction and the allergy detection alerts if necessary.

The Empower database, although not all-inclusive, will still identify the vast majority of most drug-to-drug interactions. These drug-to-drug interaction and allergy detection prompts are not meant to replace a physician’s clinical judgment. The hospital pharmacy is responsible for maintaining and updating the information in the Empower database, and the pharmacy staff can be provided with access to the Empower table editor for system maintenance.

Scanning Procedure and Outside Information

Empower charts can be imported into the hospital document imaging system (PCI, Care Center, etc.) without having to scan the chart. As the patient is dispositioned from either the ED or

Inpatient setting, the chart is converted to a PDF file with a naming convention chosen by the

hospital (see Chapter 8 ). This chart image file can then be imported into the hospital document

management system. The Empower chart does not need to be scanned, as it is part of the hospital database and, therefore, the hospital document management system.

Certain clinical information, however, is generated and captured outside of the Empower documentation system (e.g. ambulance run sheet, nursing home transfer sheet, insurance and patient identification card, etc.). Empower recommends this information be scanned at the point of care, and this scanned information will then be included in the PDF chart.

Alternatively, through HL-7 and integration, much of this information can be transferred to a patient’s chart electronically.

Abbreviations

Empower has all appropriate Joint Commission-compliant abbreviations. Certain hospitals have created documentation policies that go beyond Joint Commission abbreviations as there may be the potential for confusion between physicians and hospital staff using a handwritten

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empower Inpatient+Ambulatory medical record. Empower believes that some of these policies are outdated, and when applying abbreviations to the printed document we recommend that the hospital review the Empower abbreviations and if the hospital concludes that the abbreviations are acceptable, then the hospital should change the policy on documentation to include the Empower abbreviations for computer-generated charts. Although not all physicians practicing at the hospital are hospital employees, the hospital would still retain control of certain aspects of the program as the servers are housed at the hospital. If the hospital still opts not to utilize Empower abbreviations, then the hospital can designate a resource to use the table editor to change the abbreviations or instruct hospital employees to only use approved abbreviations. Empower employs smart technology to secure information related to risk management, government compliance and coding. Modifying or deleting information in the Empower tables could cause certain features to malfunction, or system errors could arise. A list of the Empower

abbreviations is available in Appendix 4A.

Table Editor

Empower is installed with pre-populated lookup tables that contain the common clinical terminology used by physician and nurses. Each field on an Empower form has a lookup table.

The internal table editor allows the Super User physicians, nurses and designees to customize these tables to reflect the clinical words and statements most commonly used in that institution or office. The table editor is a very powerful tool as it affords the administrators of the system immediate change capabilities in the database. For this reason, Empower recommends formal discussions and training prior to a user making any changes to the system.

The Empower table editor does not provide access to anything that would potentially affect the systems smart technology. Empower recommends populating, but not deleting, tables. If there are any questions, please contact Empower support or your project manager.

Automatic Paging System

Empower has a paging system that will automatically page hospital staff, technicians, bed control, physicians, respiratory therapy, and any others. And as the patient leaves the ED and is transported to the floor, a page can automatically be transmitted to a nurse supervisor or resident physician with all pertinent patient information.

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Medication Reconciliation/History

Empower is a Comprehensive ONC Certified Product, and uses an active medication list and true medication reconciliation in accordance with Joint Commission requirements for NPSG 8B.

The medication reconciliation report can accurately and completely provide a complete list of the patients’ medications for both hospital admissions and hospital discharges, provided the information is properly entered into the Empower Inpatient system. The report contains the home medications as entered into Empower Medication Table and prescription medication also as entered. Active and inactive medications are also listed, as required, as are all medications dispensed in the hospital. On discharge, the home medication table will clearly display all active medications.

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Chapter 6: Personalization Policy and Procedures

Although the Empower personalization policy does not allow the deletion of any items from the lookup tables, it does allow unlimited additions, which provides the inpatient and ambulatory setting with maximum benefit while at the same time retaining the user-friendliness, the risk management features, and the single database features of Empower.

During the Data Collection & Application Development phase of the implementation, Empower will populate the tables and generate templates with the information provided by the physicians and staff prior to the Go Live. Once the Empower table editor is available to selected

Super User staff and administration, Empower will provide them with instruction to manage the lookup tables. Empower retains the right to limit or expand the availability of certain tables, and your Empower Project Manager is always available to discuss any adjustments to the table editor. Any request for customization that requires changes to the Empower "Source Code" is considered a Supplemental Services project. Examples of such projects may include additions, alterations, or deletions to the following:

Screen/Print Layout

Labels, fields, or check boxes

Functionality such as logic, reminders, or required fields driven by individual clinic policies or mandates

If a user request is in alignment with a documented government compliance mandate, then there is no fee for the service. If, however, it is considered a custom or special project, then a written request must be communicated to Empower that includes the scope of the project and any deliverables. Empower will then provide a Statement of Work (SOW) and timeline estimate for testing and delivering the project.

Supplemental Services

Empower is available to complete custom development requests which are supplemental to the standard licensing and maintenance services as stipulated in the client contract. Based on a client request, Empower will assess the scope of work involved and develop a Statement of

Work (SOW) including relevant development costs and associated maintenance fees. Your

Empower project manager can provide you with a full list of supplemental services offered.

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Chapter 7: Coding and Billing

The Empower Inpatient+Ambulatory™ system can code the physician (professional) Level of

Service (E & M Evaluation and Management) with accuracy if the clinicians provide the appropriate documentation. In addition, Empower can also assign ICD-9 and CPT codes to diagnoses and procedures if the correct documentation is provided. It has been Empower’s experience that certain physicians and physician groups prefer to use certain ICD-9 and CPT codes, whereas other coders at different facilities and or physician groups may prefer other codes. Empower has been designed to customize the ICD-9 and CPT codes to the preference of the individual coders at the facility/hospital or within the physicians group. The Empower table editor allows the facility/hospital and physicians group coders to modify the ICD-9 and CPT codes that are ultimately assigned to the patient’s chart. This allows the human coder to become more familiar or comfortable with Empower because they can assign their preferred codes.

In addition, Empower provides a secondary diagnosis. The secondary diagnosis is based on provider input or past medical history. The secondary diagnoses sometimes are not very specific (i.e., cancer, psychiatric, etc.) because the patient is unable to give specific details about a medical problem. Certain secondary diagnoses are more specific (hypertension, asthma, etc.) that are documented in the chart. These secondary diagnoses are listed in Past Medical

History, but can be labeled inactive, chronic, or resolved. Many times the physician might treat the patient for chronic medical problem exacerbation (high blood pressure, etc.), but not document hypertension as a primary diagnosis. It can be added in Assessments as a secondary, tertiary, etc. diagnosis. This approach allows the facility coders to capture hypertension as a diagnosis. If the hospital coders do not agree with this approach, then just instruct the physicians not to use additional assessments.

The physician LOS is based on the algorithm (point system) created by CMS (Center for

Medicaid and Medicare). The Empower algorithm for coding the physician LOS was created and supervised by a consulting company that is certified by both AHIMA and CCS-P.

Furthermore, it has been Empower experience in working with physician and facility coders around the country that there are gray areas and black and white areas with respect to coding.

Coding the gray areas of the chart includes three types of human coders: conservative, middleof-the-road, and aggressive. Empower takes the position that aggressive coding is ideal, as long as it is supported by clinical documentation. Empower recognizes that certain coders who code the physician and coder/billers might not agree with Empower coding at times.

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Empower Inpatient+Ambulatory™ Calculation of RN Level of Service (LOS)

CMS does not currently outline a specific method of assigning nursing levels of service (LOS) as they do with physician LOS. Under the current arrangement, CMS allows individual facilities to implement their own methods of determining LOS, provided all 6 levels are identified (99281,

99282, 99283, 99284, 99285 and 99291). It is expected that all charts are consistently evaluated using the hospital’s approved methodology.

Empower has a method built in that provides a “suggested” nursing LOS as designed by our expert coding resources. Empower also includes customizable features to allow individual facilities to adjust the calculation to their approved standards. These customizable features are further detailed below and are preceded by an asterisk (*).

Preliminary RN LOS Calculation

DiagScore (i.e. “Diagnostics”, see Figure 1) – this “score” is determined by the total number of diagnostics ordered for the patient. Any diagnostics that are indicated as “cancelled” or

“refused” are EXCLUDED from this total.

IntScore (i.e. “Medical Orders” see Figure 1) – this “score” comes from how many interventions are ordered for the patient. Any interventions that are “cancelled” or “refused” are EXCLUDED from this total.

Example:

RN LOS

5

DiagScore

6

Tests

Diagnostic

+

IntScore Total Score

7 Medical

Interventions

=

13 (Total Score).

tblluRNLOSCoding

lngID intLevel intLow intHigh

1

2

3

4

5

6

1

2

3

4

5

6

0

1

1

5

10

15

0

1

6

11

16

99

Total Score =

Which falls between

RN LOS =

13

5

10&16

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*Every hospital has the table above available to them for adjustment of the Low/High ranges to determine the LOS. If you are inclined to alter this table, please use caution and remain cognizant of the systems logic. Please note the overlapping of numbers to be inclusive of the end result (e.g. If you change the 11 to 13 you would need to change the number 10 to 12). If you have questions or concerns regarding the editing of this or any other table in Empower please contact your Empower Project Manager.

Exceptions for RN LOS

Once Empower calculates the preliminary RN LOS, the level of service is still subject to the

“exception” list as detailed below.

Intervention Exception

Within the Medical Orders/Intervention table allows for hospital-defined entries, which may not warrant inclusion in the RN LOS calculation. It is for this reason there is an exclusion column to identify interventions the hospital would like to individually omit from this calculation when chosen from the list.

Admission Exception

The RN LOS can be calculated secondarily by the type of unit the patient is admitted to or if IV interventions take place.

4

6

6

6

6

tblluRNLOSExceptions

intLevel vchType vchCriteria

4 A PYSCH

4 A DETOX

I

A

A

A

A

ICU

CCU

Tele

Telemetry

*This exception table is also customizable for the client. The names of the units can be changed, added or omitted as well as the levels of service indicated for admission to a specific unit.

Currently there are two exceptions that could alter the RN LOS.

vchType A stands for Admit or Transfer to these units. For example, a patient that is admitted to Psych or Detox would be coded to LOS 4 in this area.

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vchType I stands for IV interventions. For example if a patient receives IV medications the chart would be coded to LOS of 4 in this area.

Final Exception and Calculation of RN LOS

Empower takes the Preliminary RN LOS and compares it to the Exceptions for RN LOS as described above and “suggests” the level that is the greater of the two. Finally, in the case of an admitted or transferred patient to a general medical floor or any unit other than those in the above exception table will receive a LOS=5. This becomes your recommended Empower RN LOS that appears on the EmpowerSystems™ chart.

Figure1

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Nursing Level of Service

The Nursing Level of Service (LOS) reflects the patient’s acuity and the amount of nursing time and skill level that is required to manage the patient in the emergency department.

RN LOS 1 reflects nursing skill level to manage a non-urgent patient. This is represented when no diagnostic or medical orders are executed.

RN LOS 2 reflects nursing skill level to manage a low acuity patient. The nursing intervention and skills are only required for a single diagnostic order, specimen collection, or medical interventions.

RN LOS 3 reflects nursing skill level to manage a semi-urgent patient. The nurse must intervene and execute skills that require multiple Diagnostic Orders, Specimen Collections and/or Medical Interventions.

RN LOS 4 reflects nursing skill level to manage an urgent patient. The nurse must intervene and execute skills that require multiple Diagnostic Orders, Specimen Collections and/or Medical

Interventions with IV Insertion or extensive documentation such as Psychiatry or Detox

Admissions.

RN LOS 5 reflects nursing skill level to manage an emergent patient. The nurse must intervene and execute skills that require multiple Diagnostic Orders, Specimen Collections and/or Medical

Interventions with IV Insertion and extensive documentation for a general hospital admission.

RN LOS 6 reflects nursing skill level to manage a potentially critical or critical patient. The nurse must intervene and execute skills that require multiple Diagnostic Orders, Specimen

Collections and/or Medical Interventions with IV Insertion an extensive cardiac monitoring or

Intensive Care Unit level of management.

The EmpowerSystems™ RN LOS coding is accurate if the nurse documents all nursing procedures, medications and hospital supplies in the medical intervention section of Empower ED™. The

EmpowerSystems™ RN LOS will be down-coded if the Nurse documents any nursing procedures, medications and hospital supplies in the primary nursing note.

The RN LOS can be adjusted to reflect a hospital’s approach to coding (conservative, middle of the road or aggressive). In all approaches to coding, the documentation will support the

RN LOS.

ICD-9 Codes will be applied to all Diagnosis when the physician chooses directly from the

EmpowerSystems™ look up tables. If the physician enters a diagnosis by free-texting in the field, then no ICD-9 code will be applied.

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Clinical Examples of Nursing LOS with Automated Coding

LOS 1

•24-year-old male presents for medical clearance after MVA. Patient has no complaints.

Patient is triaged and there are no other nursing interventions. Patient is discharged home.

LOS 2

•55-year-old male has pain on urination. Patient is triaged, urine collected and sent to the laboratory. Patient is discharged home with a prescription and diagnosis of Urinary

Tact Infection.

LOS 3

•17-year-old female presents with ankle pain after a fall. RN Intervention: Urine

Collection for Pregnancy Test, X-Ray, Short Leg Post Mold and Crutches. Patient is discharged home with a prescription for pain medication with a diagnosis of Ankle

Avulsion Fracture.

LOS 4

•4-month-old boy presents with fever of 104°. RN Intervention: IV Insertion, Blood

Collection, Urine Collection and Anti -Pyretic PO. Patient is discharged home with a prescription for fever with a diagnosis of Viral Syndrome.

LOS 5

•55-year-old male Diabetic presents with fever and leg redness. RN IV Insertion, Blood

Collection, Urine Collection. Antibiotics infused and patient is admitted to general medical floor of the hospital with a diagnosis of Cellulitis.

LOS 6

•78-year-old female with Coronary Artery Disease presents with Chest Pain. RN

Intervention: IV Insertion, Blood Collection, ECG, Chest X-Ray, Sublingual Nitroglycerin,

Nitroglycerin Drip, Aspirin and Heparin Infusion. Patient admitted to the ICU with a diagnosis of Unstable Angina.

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Coding Grid of Common ED Diagnoses

RN Work Load

Diagnosis

High BP-Transient

Medical Clearance

Otitis Media w/o fever

Tactile Fever

Wound Check

Contusion

Otitis Media with fever

Pharyngitis

Strain

Toothache

URI

UTI

Asthma Mild

Conjunctivitis

DUB

Laceration

Migrane

x

VagBleeding w/o Pregnancy

x

Abdominal Pain

Asthma Mod

Asthma Mod/Severe

x x x

Dehydration

Kidney Stone

VagBleeding w/ Pregnancy

CVA

Hip Fracture

x x x x x

Hyperglycemia

Incomplete AB

Pneumonia

PyleoNephritis

Threatened AB

Angina

Chest Pain

CHF

Intracranial Bleed

Sepsis

Syncope

x x x x x x x x x x x x x x x x x x x x x

RN LOS 1

RN LOS 1

RN LOS 1

RN LOS 1

RN LOS 1 x

No

Intervention x x x x x x x x x x x x x x x x x x x x x x x x x x

RN LOS 2

RN LOS 2

RN LOS 2

RN LOS 2

RN LOS 2

RN LOS 2 x x

RN LOS 2 x x

Single

Intervention x x x x x x x x x x x x x x x x x x

RN LOS 3

RN LOS 3 x x x x x x x x x x x x x

RN LOS 3

RN LOS 3

RN LOS 3

RN LOS 3

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Multiple

Interventions x x x x x x x x x x x x x

RN LOS 4

RN LOS 4

RN LOS 4

RN LOS 4

RN LOS 4

RN LOS 4 x x x x x x x x x x x x x x x x x x

IV Insertion

IV Medicine

Admission/

Transfer

General

Medical Floor

Admission/

Transfer

Tele, CCU.ICU x x x x x x x x x x x

RN LOS 5

RN LOS 5

RN LOS 5

RN LOS 5

RN LOS 5 x x

RN LOS 5

RN LOS 5 x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x

RN LOS 6

RN LOS 6

RN LOS 6

RN LOS 6

RN LOS 6

RN LOS 6 x x x x x x x x x x x x x x x x

empower Inpatient+Ambulatory

Physician LOS Calculation

Levels of service are determined based on three factors:

History o HPI-History of present illness o PFSH-Past medical, family and social history o ROS-Review of systems

Examination

Medical Decision-Making o Number of diagnosis or management options o Amount or complexity of data to review o Risk of complication or death if condition goes untreated

Empower draws this information from structured fields within the system, and then determines a suggested level of service. Levels of service should be audited or reviewed by a certified medical professional. The method Empower uses in determining medical decision-making is based on CPT guidelines and the “Marshfield Rules” as suggested by CMS.

Empower breaks down the medical decision-making in the following manner:

Number of Dx’s and Management options:

No diagnostic tests = Level 3

One Diagnostic test = Level 4

Two or more diagnostic tests = Level 5

Amount and/or Complexity of Data Reviewed:

Lab tests (1pt)

Radiology (1 pt)

EKG/PO2/PEFR/Cont PO2/Cardiac Monitor (1 pt)

PCP Consult (2 pts)

Review of old medical records/old EKG (1 pt)

Additional hx from PD/FD/Family/NH/Friend (2pts)

<2 pts=Level 1

2 pts=Level 2

3 pts=Level 3

3 pts=Level 4

4 pts=Level 5

Risk of Complications, Morbidity and/or Mortality:

Diagnostic tests

Medical intervention x x x x x x x x

Admission or transfer to Gen Med Floor x

Admission or transfer to Tele, ICU or Surgery x

I II II III IV V

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Empower then uses this formula to determine the preliminary “suggested” physician LOS:

Number of Dx and Management mgmt options

+ Amount and/or Complexity of data reviewed

+ Risk of Complications, Morbidity and/or Mortality

= Total divided by 3 (i.e. averaged) = Preliminary “suggested” Level of service

For example:

Number of dx and mgmt options = Level 3

Amount and/or complexity of data reviewed = Level 4

Risk of Complications, Morbidity and/or Mortality = Level 2

3+4+2=9 divided by 3 (averaged) = 3 or preliminary “suggested” level 3

In addition to this formula Empower compares the preliminary “suggested” level of service to the exception list seen below and determines a secondary “suggested” level of service. The higher of these two levels is the one that is used for the final “suggested” level of service provided HPI (history of present illness), ROS (Review of Systems), PFSH

(Past medical, Family and Social history) and Examination are documented appropriately to support the “suggested” level per the 1995 CMS guidelines.

Empower Exceptions

Level 5 Exceptions

Admission for Psych if documented Suicidal, Homicidal, or unable to care for self

Blood/Urine + EKG + Radiology Test

Level 4 Exceptions

2 or more Diagnostic Panels e.g. CBC, Chem7, Liver Profile

1 or more CAT scans, MRI, Ultrasound or Nuclear Medicine diagnostics ordered

1 or more IV, IVP, or IVPB ordered

3 or more Standard Tests

2 or more Albuterol Txordered

1 hour or longer Albuterol Txordered

Chem20, Trauma panel, MI Panel, CVA Panel, CMP or Comprehensive Metabolic Panel, ICU/CCU

Panel, Chest Pain Panel or Abdominal Pain Panel ordered

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Level 3 Exceptions

1 or more IM, PO, SQ orders

1 or more Prescriptions given at discharge

Discharge Instructions include pre-written instruction for Head Injury

Admission for Detox

1 Diagnostic Panel e.g. CBC, Chem 7, Liver Profile

Crisis Evaluation. Psychiatric Evaluation

The example above identifies this chart could have been coded a Level IV based on Medical

Decision Making. However, it would be down coded to a Level I if the physician does not review and provide additional documentation of History and Physical Exam to support the

MDM.

Every physician sees this screen when they ‘Set Ready to Print.’ It offers the provider the opportunity to complete any documentation that may have been overlooked initially.

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Chapter 8: Medical Records and Health Information Security

According to hospital policy and procedures, the hospital Medical Records department is responsible for the security and storage and of the medical record. Although Empower is not responsible for this security, it still provides a moderate to high level of HIPAA compliant security. For additional security, the Empower chart can be locked for any period of time that the hospital may require.

Although Empower is not responsible for medical record storage, it can still provide a very accurate back up copy, and can also provide the hospital with a hard copy of the chart should

Medical Records prefer the traditional paper chart. Additionally, Empower will provide an electronic PDF image of the chart for storage in an electronic format which can also be uploaded into a hospital document imaging and management system. Each chart is an individual file that is labeled with the patient’s name and account number so that the image file can be imported directly into the patient’s electronic health record. Additionally, as the chart is an image file, it does not need to be scanned into the hospital document imaging and management system, instead it is automatically imported into the Empower EHR.

Image File (Empower PDF Chart)

As it is much easier to “hack” into a database and alter information than it is to modify a paper document or image file, Empower believes that the security of the clinical information is better preserved when the information is stored as a hard copy document or image file as opposed to discrete data stored in a database.

Because clinical information is dynamic, Empower allows clinicians to update or modify certain clinical information until the chart is locked and the patient has been dispositioned. In order for

Empower smart technology to work correctly, the patient record must contain current and accurate information.

At this time, Empower does not track edits or updated information unless it is documented in

Additional Clinical Information and/or Exam Notes section of the physicians chart, or in the

Clinical Notes section of nursing chart. If the hospital wants to be aware of all edited or updated information, the staff should document all new information in the Repeat Exam or

Nursing Notes sections. Empower can also lock the entire chart after a certain period of time has passed since the patient has been dispositioned from the ED and the chart has been printed. It can also configure different lockout times for each Inpatient, ED, and Ambulatory

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empower Inpatient+Ambulatory module. If this feature is desired, simply notify the Empower Project Manager and Empower will be configured for this task.

PDF Storage/Document Management System

After a patient is dispositioned, the chart is converted into an Adobe PDF file and sent to a network location dictated by the hospital. The location is configurable, and it can be anywhere on the hospital’s network where the Empower server has write access to the directory. The PDF file name can be formatted in 1 of 6 different ways:

Naming Convention

<account number>.pdf

<patient id>.pdf – Empower unique ID

<lastname><firstname>.pdf

<account number><patient name>.pdf

<lastname><firstname><accountnumber>.pdf

<medical record>_<account number>.pdf

(note the underscore)

Example

123456789.pdf

JD-1-18-2008-15:6.pdf doejohn.pdf

123456789doejohn.pdf

Doejohn123456789.pdf

MR9999_123456789.pdf

The format must apply to all PDFs and cannot be changed. There cannot be different formats for different patients. However, additional copies can be made using a different format. For example, the medical records department may require that a file is named one way, while the billing department may require it named another. In these cases, two sets of the patients charts are created, and the copies can be directed anywhere that the Empower server has write access to the directory and the format options are the same options listed above. The local network administrator can determine the file location. Once exported to the network, the PDF chart is available for the hospital to import into any hospital document management system.

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Security for Personal Health Information

Per ONC-ATCB EHR Certification requirements, Empower provides client administrators with a variety of tools to configure security settings per their institution’s security policy for personal health information. Please refer to the following examples:

Password Length: Can require users to select an 8 character minimum requirement.

Password Complexity: Can require users to use upper/lowercase letters plus digits and punctuation.

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Maximum Number of Passwords Kept: Able to store 5 total, or for a 12 month period, whichever occurs first.

Force Password Change Based on Time Parameters: Can require users to update their password every

180 days.

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Maximum Number of Login Attempts Before Access Blocked: Can set this to 5 attempts.

Auto-Lock Account after Predetermined Time Period: For example, 15 minutes.

Require User to Change Password Upon Resets: This can be set upon expiration of the user account

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Chapter 9: Reporting and Data Mining

Empower Administrative Tools, or Admin Tools, provides a snapshot of the more common statistics. Designated Super Users can be provided with access to the Administrative Tools.

These tools can assist administrators in identifying data that may need further analysis through other reports, available via the Report + Alert Writer. Custom reports can provide answers to virtually any data-driven question, and can be created by your Super Users or requested through your Project Manager if the complexity is outside the normal scope.

Empower Admin Tools track the following information, keeping in mind that all time flow studies are dependent on the accuracy of the entered data.

Operation Performance Index (OPI) Studies

Daily Census

Average Length of Stay of discharged patients

Average Length of Stay of admitted patients

Average time to triage patients

Average time from waiting room to exam room

Average time for a physician into an exam room

Average time for a nurse to execute a diagnostic or medical order

Inpatient/ED Statistics

Total discharges

Total admissions

Total admissions to Telemetry

Total admissions to ICU

Total admissions to Pediatrics

Total admissions to Psychiatry

Total admissions to General Medical floors

Total left without being seen (LWBS)

Total left Against Medical Advice (AMA)

Total transfers

ED stays greater than 12 hours

Total city ambulance runs

Total private ambulance runs

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ED Log

Triage time

Patient name

Gender

Physician

Nurse

Diagnosis

Medical record number

Account number

Disposition

Disposition time

Using the complex report writer, specialized ED logs with any desired information, such as patient contact information or insurance information, can also be generated.

Naturally, the accuracy of any report is dependent on the quality of the documentation input to

Empower. Education regarding both the data elements required and the reporting methods used in order to generate complex reports will be provided during the GoLive and Post GoLive phases of the Empower implementation. In addition, chart audits will provide education and feedback to the front end users about the quality of the documentation, which will further enhance the accuracy of Empower reporting.

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Empower Report + Alert Writer

Perspective + Goals

As the technological advancements of Empower’s ONC Certified EHR continue to evolve, our remains delivering user-friendly technology that allows our Inpatient, Ambulatory, and ED clients to be self-sufficient and independent in as many aspects of EHR administration as possible. Medical Order Sets, Hospital Forms, and Formulary Management are several of the core elements under the direct control of you, the Super User. In keeping with this philosophy,

Empower is proud to announce that with respect to report and alert writing (aka Clinical

Decision Support Rule) our clients can now design their own reports and alerts in an autonomous fashion. The goal is to minimize, and possibly eliminate, costs to the hospital for custom report and alert development. The end result of this initiative is to enable our clients to become self-sufficient and to avoid the added expense of external report writing software and

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party data mining services.

Convenient Accessibility

The Empower Report + Alert Writer is an integrated tool built on SQL Server Best Practices with a user-friendly front-end, allowing Clinical and IT leadership to write limitless reports and alerts, without the need for in-depth programming knowledge. Once reports are written, they can be run once or saved as recurring reports for future convenience.

The Empower Report + Alert Writer is a role-based tool which can be launched from within

Empower by simply clicking the "Report Writer" button. The user will then choose either of the following options to launch whichever tool is desired.

1. Report Writer

2. Alert Writer

Powerful Functionality

Hospital staff with the designated Empower administrative rights can write any report or alert in real-time.

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Examples of Reports

Quality Reports

Government Compliance Reports

Operational Efficiency Reports

Disease Management Reports

Documentation Reports for Coding and Billing

Meaningful Use Reports and Compliance

Physicians Productivity Reports

Hospital Staff Productivity

Examples of Alerts

Myocardial Management, Compliance, and Contraindications Alerts (Beta Blocker, Door to

Balloon Time, etc.)

Congestive Heart Failure Management, Compliance, and Contraindications Alerts (Ace Inhibitor, etc.)

Pneumonia Management, Compliance, and Contraindications Alerts (Appropriate Antibiotics)

Stroke Management, Compliance, and Contraindications Alerts, etc.

Surgical Care Improvement Project (SCIP) Management, Compliance, and Contraindications

Alerts

Disease Management, Compliance, and Contraindications Alerts (Diabetes HbA1C Tracking, etc.)

Setting Expectations

Each hospital and their staff will have different levels of proficiency with the Report + Alert

Writer based upon familiarity of SQL functionality, hospital unit-specific clinical documentation methods, specialized clinical workflow, and related communication systems (hospital forms, medical order sets, etc.).

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A realistic expectation is that hospital staff that are proficient with Empower EHR clinical documentation (front-end) and database (back-end) will be able to efficiently create a vast array of Reports and Alerts. Examples may include the following:

Patient Lists with Medical Disease and Specific Diagnosis (MRSA, VRE Positive Patients)

Patient Lists with Medical Disease Management Compliance

Doctors Lists with Medical Disease Management Compliance

Hospital Staff Lists with compliance of completing hospital forms

Diagnostic Test: Lists of Abnormal Tests

Hospital Forms Lists: Completed Forms (Restrains, Care Plan, etc.)

Hospital Order Sets List based on Diagnosis Management and Compliance

Alerts for Abnormal Vital Signs

Alerts for Correct Antibiotics based on Diagnosis

Alerts for Abnormal Diagnostic Test

Alerts for Documenting Correct Coding Information

Alerts for SCIP Compliance based on Type of Surgery

For hospital clinical and IT staff with minimal knowledge in SQL, Clinical

Documentation/Workflow, and Database Structure requiring the following types of highly complex reports, the hospital may prefer to engage the Empower reporting team:

Calculation Reports (i.e. reports involving time)

Complex Clinical Documentation Reports

Complex Workflow Reports

Complex Communication Reports.

Category Reports (Medications)

Printing Reports, Faxing Reports, Email Reports

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Recommended Knowledge Foundations

Empower’s ONC Certified EHR participates in the practice of medicine between doctors and hospital staff by providing comprehensive clinical documentation services, complicated communication notifications, and supporting complex workflow systems. Empower recommends each hospital clinical unit (ICU, Telemetry, Labor & Delivery, Emergency

Department, Pediatrics, etc.) designates a clinical administrator and an IT database expert to attend on-site training for the Empower Report + Alert Writer. This combination of clinical and technological expertise will assist both parties in mastering program functionality. In order to be proficient with the Report + Alert Writer, the hospital staff will need a basic foundation of

SQL Server names and functions as well as Empower’s database table structure. The SQL, or

Structured Query Language, has a special purpose in programming language designed for managing and displaying data in relational database management systems . Prior to receiving web-based or on-site training, we recommend attendees read the publication "Teach Yourself

SQL in 10 Minutes (3rd Edition).”

Training Options

Standard Introduction

Each Empower hospital receives 1 hour of complimentary web-based product demonstration and general training. Additional training is recommended in order to maximize use of the

Report + Alert Writer.

On-Site Sessions

Hospitals can purchase on-site training sessions for 5 person groups of clinical administrators and IT staff led by Empower Report + Alert experts. On-site training delivers impactful results as clients receive hands-on experience with the product and detailed guidance by our experts. The

$12,500 fee for this option includes five (5) business days of training at eight (8) hours per day.

Web-Based Sessions

If on-site training is not preferred due to staff’s schedule limitations or a desire to invest in training over a longer period of time, intensive web-based training sessions are offered.

Trainees benefit from the same Empower team of Clinical (physician/nurse) and IT experts, but in a remote setting accomplished by Hamachi VPN connection and Glance interactive web software. In addition, web sessions will be recorded and provided to clients so they can refer

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Delegated Option

While the Report + Alert Writer is an exciting tool for our clients, some may prefer to have

Empower design highly complex reports for them. For this option, the standard rate of

$225/hour applies.

Getting Started with Standard Reports

When administrative access is given, a Report Writer button will appear on the patient roster screen. When this program is launched, a list of reports will appear with their corresponding descriptions listed to the right, as shown below.

Report List View

Select a report from the drop down menu on the left, specify a start and end date, then select the Run button located to the right. Results are then displayed in a panel below.

Multi-Facility

If the facility has multiple sites, then a report can be generated which contains an additional field located below the date range that will list the names of all of the facilities. It cannot be left blank.

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Reports

The standard reports are generally complex queries involving multiple tables, frequently containing many nested subqueries and multiple search criteria. The listing of reports presented in this overview reflects what is available as of this writing, but there are always more reports being developed and added. In general, new reports are created in order to address a generally accepted need among clients. Reports based on data in structured fields are more likely to be developed and implemented sooner than reports based on free-text fields.

There are over one hundred different reports, as sample of which is listed below.

72 Hour Returns

Admit/Transfer Statistics

Ambulance Patients

ASA Beta Blockers

Audit Utilities

Business Reports

Call Backs

Conscious Sedation LWCT/AMA

Disposition Statistics

Disposition Statistics Peds

Fast Track

Hourly Statistics

Log

Ambulance Patient Report

Standard Report Name

LWBS All

LWBS Call Back

LWBS Insurance

LWBS Peds

LWCT Conscious Sedation

Messages

Narcotics

Narcotics Rx

Non-Finalized

Non-Registered

Notifications

Nurse Efficiency

Nurse Patients

PCP Log

Pharmacy Usage

Pneumonia Antibiotic Timeliness

Press Ganey Provider Dispositions

Provider Efficiency

QA Conscious Sedation

QA Ortho

QA Restraints

Registration Report

Summary Statistics

Time To MD Summary

Triage Acuity Summary

Zone Statistics

The Ambulance Patient Report identifies all of the patients brought in by ambulance within a given time frame. It contains the following fields:

Service Date: Date and time that the patient’s record was started in Empower.

Squad (Ambulance, EMS): The name of the ambulance provider that transported the patient.

DOB: Date of Birth

Age: Patient’s Age

vchPatientID: This field contains either the Empower generated patient ID or a number provided by the hospital’s ADT system.

MR#: Facility’s medical record number

Chief Complaint: This is the chief complaint as entered by the MD rather than from Triage.

SS#: Social Security number.

Dx: all of the diagnoses the MD makes on this visit.

Insurance Name: all of the insurance companies that cover the patient.

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ASA Beta Blockers Report

This reports the compliance with the aspirin and beta blocker protocol for acute myocardial infarction. The results of this report can sometimes be skewed by the actions of the first responders, who often administer these medications prior to arrival without subsequently entering that information properly into Empower. This can be corrected using manual overrides that reconcile the information without having to modify any patient data. While most of the fields in this report are self-explanatory items such as name, age, and gender, other report fields include:

In Time: The time that the patient was added to Empower.

Medical Record Number: The hospital’s medical record number

Account Number: The hospital’s account number

ASA Given: Yes or No

Beta Blockers Given: Yes or No

Include and Exclude: This will allow the user to record whether the patient was give aspirin, beta blockers, or both. This does not alter the record in any way, it simply instruct the program to omit or include that particular piece of information when calculating the statistics.

Calculations

Total MI Cases refers to the total number of patients diagnosed with acute myocardial infarction.

Both the ASA and the Beta Blocker columns contain two numbers. The first number is the total number of patients with acute myocardial infarction treated with the medication, the second number is the percentage of patients with acute myocardial infarction treated with the medication .

Disposition Statistics Report

The Disposition Statistics Report analyses the patient disposition data during a specified date/time range. Dispositions could include main ED discharges and admissions, and other areas such as fast track discharges and admissions. Performance statistics can be calculated for each category, with the exception of Left Without Being Seen, Registration Error and No

Disposition.

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Disposition Aggregates

DispoType: The disposition category, such as admit, discharge or transfer.

DispoTypeCount: The total number of patients counted in that category.

Exclusions: The total number of patients whose data was not considered due to either manual exclusion or automatic exclusions.

LengthOfStay_HrsMins: The average length of stay for patients in a specific category expressed in hours and minutes.

Triage_HrsMins: The average length of time from the point that the Empower chart was started to the point that the triage note was started, expressed in hours and minutes.

ExamRoom_HrsMins: The average length of time from the point that the Empower chart was started to the point that the patient was assigned to an exam room.

DoorToMD_HrsMins: The average length of time from the point that the Empower chart was started to the point that the MD begins the patient assessment.

MDToExamRoom: The average length of time from the point that the patient is placed in the exam room to the point that the MD begins the physical exam.

Dispo_HrsMins: The average length of time from the point that the MD documents the physical exam to the point that the MD sets the patient’s disposition.

MDFinish_HrsMins: The average length of time from the point that the MD documents the physical exam to the point that the MD sets the chart ready to print.

Print_HrsMins: The average length of time from the point that the MD sets the chart ready to print to the point that the chart gets printed.

2SD_* columns: These are the second standard deviations of the raw average based on all data not excluded. Empower recalculates the average excluding any value that lies outside of the second standard deviation value. Those outside of the two standard deviations are flagged as outliers in the Disposition Data section.

Disposition Data

Outlier: This result will be either NO or will have one or more codes indicating what indicator lies outside of the two standard deviations, such as ER, which would indicate ExamRoom, DMD, which would indicate DoorToMD, TR, which would indicate Triage, or LOV, which would indicate

Length of Visit.

Exclusion: Yes, or Y, if the record is excluded for any reason, otherwise N for No. This makes it easy to locate the specific records using a single filter.

Negative Time: Yes or No. If a time calculation results in a value that is < -15 minutes, the record is marked as an exclusion.

Triage Acuity: The triage level of urgency.

TriageAcuityValue: The numerical equivalent of the triage assessment, ranging from high to low or vice versa, depending on preference.

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Disposition: The disposition type that the record was assigned based on the actual disposition.

LengthOfStay: The length of time from the point that the chart was started to the point that the chart was printed, expressed in hours and minutes.

Triage_HrsMins: The length of time from the point that the chart was started to the point that the patient was triaged, expressed in hours and minutes.

ExamRoom_HrsMins: The length of time from the point that the chart was started to the point that the patient was placed in an exam room.

DoorToMD_HrsMins: The length of time from the point that the chart was started to the point that the MD documented the patient’s physical exam.

MDStart_HrsMins: The length of time from the point that the patient was placed in an exam room to the point that the MD documented the physical exam.

Dispo_HrsMins: The length of time from the point that the MD documented the physical exam to the point that the MD documented the disposition.

MDFinish_HrsMins: The length of time from the point that time the MD documented the physical exam and the point that the MD sets the chart ready to print.

Print_HrsMins: The length of time time from the point that the MD set the chart ready to print to the point that the chart is actually printed.

Include and Exclude: Data can be manually included or excluded. This does not alter the record in any way, it simply instruct the program to omit or include that particular piece of information when calculating the statistics.

Comments: This is a place for a reviewer to make any comments about a particular chart. These comments will be viewable and editable by other users, but the comments cannot be seen outside of the application. The field can contain up to approx. 4000 characters of information.

ED Hourly Statistics Report

The hourly statistics report shows the patient population for each hour of the day within any given date range. This provides a means of examining patient flow during the day. The report consists of a data grid, with each row in the grid corresponding to a single day and each cell in the row corresponding to an hour within that day. There are two buttons located about the data grid. One button is the Census View, which shows the total number of patients in the ED for each hour of the day. The other button is the In & Out view, which consists of an upper grid with the number of patients entering the ED during each hour, and a bottom grid with the number of patients leaving the ED during each hour.

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Log

The Log is a listing of all of the patients that were seen in the ED during a specified time. Some definitions associated with this report include:

Room: The exam room in which the patient was placed after triage. In some cases, rather than a room number, the symbol WR is displayed, indicating that the patient was sent back to the waiting room after triage.

MOA: Mode of Arrival. The method (ambulance, police, walk in, etc.) in which the patient arrived at the ER.

Triage Nurse: Triage nurse initials.

Care Nurse: Primary nurse initials.

First Nursing Note: Time of the first nursing note for the patient.

First Phys Exam: Time that the MD performed the physical exam.

LWBS All and LWBS Peds Report

The LWBS All report lists all patients with a disposition of LWBS, or Left Without Being Seen, within a specified time frame. The LWBS Peds report does likewise for pediatric patients.

What qualifies as an LWBS?

Patients who were entered into the system but left before they were seen by an MD may be legitimately tagged as LWBS. If a patients get to an exam room and then leaves, an MD may see the patients name listed in the exam room and, believing that a patient is there waiting to be seen, enter the patient’s chart to look at the triage note. This will generate physician documentation for the patient despite the fact that the patient left and was never seen. At this point, the MD should simply set the disposition to LWBS and remove the patient from the tracker. MDs should not enter a repeat exam for these patients. A chart with both a LWBS disposition and a repeat exam is a documentation inconsistency that will cause the chart to be placed on the Non-Finalized report for review by administration.

MD Documentation: This field will have an “X” if there is a Physical Exam time in the patient’s chart. It does not mean that there is a Repeat Exam. Any records on this report will meet the definition of an LWBS.

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Narcotics Report

The Narcotics Report lists all of the narcotic orders in the ED. There is also a report for narcotic prescriptions. The report gives the patients name, the date of the visit, the medication given, the ordering physician, the dispensing nurse, and the order location, or where injection was given. It also lists whether the order was cancelled or refused, along with any nursing comments.

Non-Finalized Chart Report

Non-Finalized charts are inactive charts that are no longer on the patient tracking screen but were never printed. Other non finalized charts include:

Improper assignment of LWBS or a LWCT patient: As mentioned earlier, the database makes certain assumptions about LWBS charts. Charts with the LWBS disposition and a repeat exam will flag the chart as a problem. In this case, charts should be set either LWCT (Left Without

Completing Treatment), Eloped, Left Without Notifying ED Staff, Left AMA or anything else that indicates that the MD did in fact see the patient.

Discharged patients on which charts were not printed: One common nursing practice is to print the patient’s discharge instructions, discharge the patient, and then return later to complete the chart. This increases the possibility that charts will get removed from the patient tracking system without ever being printed. They will then show up on the Non-Finalized report.

Inactive, non-printed charts with repeat exams: If a repeat exam is performed, the chart should then be printed or reprinted. Otherwise, it will appear on the Non-Finalized report.

Nurse Patients Report

The Nurse Patients Report identifies all of the nurses that documented on patient chart during a certain timeframe. Likewise, it can report all of the patients one which a single nurse documented during a certain timeframe. There are 3 possible roles a nurse might fill with a patient in the ED:

Primary: The nurse recorded as the primary care nurse for the patient.

Auxiliary: A nurse that documented on the chart other than the primary care nurse, such as charge nurses or float nurses.

Triage: A nurse whose only documentation on the record is related to triage.

A nurse could conceivably be counted as both primary and triage, or auxiliary and triage. The primary and auxiliary roles take precedence over the triage role. A nurse will be listed only once for each patient and in the highest role applicable.

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Pneumonia Antibiotics Timeliness Report

This report analyses compliance with the Pneumonia Antibiotics Protocol. The report analyses patients who were admitted to the hospital with a diagnosis of pneumonia, detailing the length of time from the patient arrival to the administration of the first dose of antibiotics. Therefore, the nurse must diligently document the time that the antibiotics were given, rather than the time that they were signed off on the chart. If antibiotics were given within 4 hours, the < 4

hours column will say ‘Yes.’ If antibiotics were first given later than four hours, the < 4 hours column will say ‘No.’ If antibiotics were not given, the < 4 hours column will remain blank.

Provider Efficiency Report

The Provider Efficiency Report looks at specific points in the patient flow for either physicians or midlevel providers. All of the fields in this report are identical to the fields with the same names in the Disposition Statistics Report, but are calculated on a ‘per provider basis’ rather than a

‘per disposition basis.’

Summary Statistics Report

The Summary Statistics Report is a collection of printable reports. The Summary of Operational

Statistics Report presents the aggregate data from the Disposition Statistics, Non-Finalized,

LWBS and Pneumonia Antibiotics Timeliness reports in a printable format. Similarly, the Zone

Statistics Report and Provider Efficiency Reports are printable versions of the aggregate data in the electronic reports of the same names.

Zone Statistics Report

The Zone Statistics report is designed for emergency department that are divided into zones.

This report presents the same data as the Disposition Statistics Report, but breaks that data down by zone.

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Meaningful Use Reports

As the Government is attempting reform the health care system, a set of standards has been established for Electronic Healthcare/Medical Records (EHR/EMR). The Office of the National

Coordinator for Health Information Technology (ONC) enforces these standards. Empower has been Comprehensively Certified for its EHR (Inpatient, Ambulatory, ED) by the Drummond

Group since 2010.

Using Empower’s ONC Certified EHR allows users to be eligible for stimulus funds and incentive payments provided that Meaningful Use can be demonstrated. To monitor Meaningful Use,

Empower has developed a real-time tool to measure and report Meaningful Use at different locations and settings. When the Meaningful Use threshold is met for a specific target, the report and generated numerical fields have a Green background. When a threshold is not met, the corresponding field is Red:

MU Threshold: Inpatient

MU Threshold: Ambulatory

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Chapter 10: General User Manual

This is an overview of how information is captured within Empower Inpatient+Ambulatory™ in order to provide perspective to users whose primary purpose is acquiring information from, rather than entering information into, the Empower system.

INTRODUCTION

The Empower Inpatient+Ambulatory™ computer documentation system was created by clinically experienced physicians and nurses. The program merges technological information with medical information to create a real-time documentation system that improves communication and enhances patient flow. Empower has been recognized in the past as “a success story and role model” by the Joint Commission, and we continually monitor and adopt the changing Joint Commission standards in order to ensure continuing compliance. The system also ensures compliance by prompting the physician or nurse at various HCFA mandated junctions, electronically applying the physicians signature, and ensuring follow up by faxing the chart to the primary care provider or specialists office.

The program is dynamic and flexible, and can be customized to the needs of various physicians, nurses, and inpatient/ambulatory settings. Empower is also an inexpensive alternative to costly transcription or verbal documentation. This program, unlike others, is not template based, but rather is based on a single, free formed chart that is populated by the physician’s or nurse’s description of the patient’s history, physical exam, diagnostic tests, medical orders, and clinical summary to provide an accurate EMR, or electronic medical record.

The Empower chart reflects the company’s philosophy of ‘One patient, One Chart, One

Database.’ There is no need to collate several separate charts or pieces of charts into one record at the end of the patient encounter. Empower provides all the tools necessary in order to document the patient’s clinical information while simultaneously caring for the patient. The software is written such that it follows the patient stepwise through the healthcare system, beginning with the registration process and ending with the discharge instructions.

Navigation

Starting the Empower Inpatient+Ambulatory™ Program

Click on the EmpowerSystems™ icon on the desktop.

Log In with the ID provided by your system administrator.

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Patient Tracking Board (Universal View)

The opening screen is the Patient Tracker, which lists all of the active patients. This tracker can be configured to meet the needs of nearly any department. It can list the patient’s name, room number, the treating or primary physician, the primary nurse, the disposition, the number of hours that patient has been in the hospital, or many other pieces of data. It also contains indicators that detail the registration, diagnostic, and order status. The initials of the physician and primary nurse caring for the patient are displayed alongside the name of each patient. The tracker provides a conduit to a nearly any location in the patient’s chart, and can be customized or modified as the need arises

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Examples of Trackers

Radiology

Provider Efficiency

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Registration

Security

Waiting Room

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ICU

NICU

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For Administrative and Clinical users, the tracker will have active control buttons to launch different aspects of the program. These grey control buttons at the bottom of the screen are user specific and are determined by the system administrator. They allow users to perform various tasks such as to adding or deleting patients, adding or deleting staff, changing passwords, accessing old records, or many other desired functions. Examples of these functions include,

Add Patient allows patients to be added to Empower. It also bypasses the live system interface, so patients can be added during system down time, and test patients can be added for educational or demonstration purposes

Admin Tools provides administrators access to specific non-clinical functions.

Change Password allows a user to change their password at any time. Every user is expected to understand that their password is their electronic signature, and must be protected at all.

Log Out should be used whenever the documentation is completed or the workstation is not in use.

Old Records allows previous charts to be viewed. Users can search by a patients name or partial name or their medical record number.

The Current User is displayed at the bottom left corner of the tracking board.

Documentation Methods

The four types of fields used for Empower documentation are:

Drop-down Boxes that allow users easily to scroll through tables by typing the first few characters of the desired word. If a particular word is not found, information can be free texted.

Multi-select Boxes function like a drop-down box, but also allow words to be strung together.

Check Boxes simply let the user check a prewritten statement or field.

Free-Text Fields allow information to be manually entered via keyboard or voice-recognition technology.

The system automatically populates all time fields with the time that the data was entered. The time fields can be changed to reflect different times by clicking in the time field and entering the corrected time using military or twenty four hour format.

Physician Note

This page contains the current physician note, consults, latest vital signs, and other information.

There is also a Physician Note List that lists all previous SOAP notes. This area can also be filtered.

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History/Subjective (Provider)

The fields in this area that are highlighted in blue are required to be complete by government agencies for risk management safeguards and correct physician billing. Acronyms used are common and include

PMHx = Past Medical History

SoHx = Social History

FmHx = Family History

Admission/Assessment (Nurses)

The nursing staff documents the above listed histories, and also the patient’s allergies, current and previous medications, skin integrity, nutrition status, advance directives, and fall, DVT, and self harm risk assessment in this area. The language of documentation can be customized to suit Joint Commission terminology and any particular preferences of the patient care setting.

Exam/Objective (Provider)

This area documents the patient’s physical exam. There are check boxes that allow the physician to enter a normal exam statement, multi select fields that provide pre-written abnormal findings, and areas for free text entry. Repeat Exams are required prior to completing a chart.

Lacerations/Procedures (Provider)

Laceration repair and other procedures are documented by the physician in this area in language appropriate for coding. Free-text entry is again permitted.

Diagnostic Results (Provider and Nurse)

This screen contains diagnostic laboratory results and it also contains a link to the PACS radiology system. Results will auto-populate into the field when the laboratory interface is active. Some of the fields have a diagnostic interpretation area for the physician to complete, as such completion is sometimes required for correct physician billing. The auto populated results will not overwrite the provider’s interpretation. The results can be filtered, and in addition to the results, this screen also lists both the time that the specimen was collected by the staff and the time that the specimen was received by the laboratory.

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Assessment/Plan Medical Orders (Provider and Nurse)

The first patient assessment will come from the subjective section of the patients chart.

Subsequent assessments can be entered by the providers. When the assessment is selected from the list, the site-defined codes will also be included in the PDF Chart.

Common diagnostic orders are placed by checking the box near the name of the test. Less common studies are ordered from the Diagnostic Orders drop down box, and pharmacy orders are also selected from the corresponding drop down box. Non-standard orders can also be selected or free texted in the Other Medical Orders and Comments. Standard Order Sets are specific sets of diagnostics and, in some cases, treatments that can be ordered with a single check box. These sets are hospital specific and can also be selected from a drop down list. In addition, if the physician chooses to admit the patient, the admission orders can also be selected individually or in order sets.

Location and Response of IV Insertion or Insertion of Drains on the Input Form, Output Form, or

Nursing Notes allows the nurse an area to document the details of these procedures. The nurse is prompted for certain required information, such as the IV completion time, before closing the chart. Only a nurse or Unit Secretary can document cancelled or refused medical orders by clicking on the respective medical order status field. If an order is placed by a nurse, she must also assign a provider to this order. The provider will then be prompted to sign these orders prior to completing the chart.

Clinical Notes (Nurse Enters/MD Views)

This is divided into two sub-forms:

I. Clinical Notes, a personalized form that includes Chief Complaint, History, Limited Nurse Physical

Exam, and Government Agency and JCAHO required documentation

II. Vital signs

Nurses' notes are displayed in chronological order. Documentation is completed by using either site-specific phrases or free-text entry. The institution can also create forms for documentation which can also replace pre-printed paper forms and protocols currently in use.

Vital Signs (Nurse Enters/MD Views)

By clicking on the vital signs and the pop-up box, vital signs can be viewed and entered. These can also be trended. A patient monitor interface can be used and the latest vital signs from the monitor will be displayed for viewing and any needed correction prior to saving. The nurse is

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Intake (Nurse enters/ Provider Views)

These values can be filtered and totaled during different time frames.

Output (Nurse enters/ Provider Views)

These values can be filtered and totaled during different time frames.

Scan/View Scan (Physician and Nurse)

Previous scans can be viewed from any computer, and those computers directly connected to scanners can also scan documents into the system.

Pharmacy RN Tasks (Physician and Nurse)

Medications ordered and dispensed are documented and displayed in this area. If a pharmacy interface is used, this information can be auto-populated.

Print Orders (Physician and Nurse)

Prints a hard copy of all diagnostic and medical orders. This can be used at the bedside to verify a patient identity, by unit secretaries to enter orders or transmit orders to ancillary departments.

Notifications (Physician and Nurse)

The physician or nurse can document the notification of other physicians, consultants, or other agencies. Response time can also be documented.

Discharge Instructions (Physician and Nurse)

Discharge Diagnosis is imported to this screen from the provider’s assessment. Diet, activity, and any other instruction are also chosen. The patients follow up physicians, complete with address and phone numbers, are also assigned. All instructions are available in different languages.

Discharge RX- Prescriptions (Physician)

The physician can select prescription medications by clicking on an empty box in the Home

Medication section. Typing at least two characters into the pop up box will prompt Empower to access the medication database, and as more characters are typed, the program will drill

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empower Inpatient+Ambulatory down to more specific options. Selected prescriptions print with an electronic signature when the nurse prints the chart. Prescriptions can also be faxed or E-Prescribed.

Finalize Chart (Physician)

When the disposition is complete the physician can select the 'Finalize Chart' button. This prompts the risk management features to scan the chart for incomplete documentation and allows the physician to view the estimated level of service assigned to the chart. The physician can then review the documentation and make any required additions or corrections prior to completion of the chart.

Print (Nurse)

After the physician finalizes the chart, the nurse can print the entire chart by clicking the ‘Print

Menu’ button and then selecting the ‘Print All’ button. All previously printed or temporary hard copies of the chart should be discarded in accordance with Medical Records policies. The nurse can also print the Clinical Summary or Medication Reconciliation page for the patient to keep, in accordance with Meaningful Use guidelines.

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Chapter 11: Nurse/Medical Assistant User Manual

The Empower Inpatient+Ambulatory™ computer documentation system was created by clinically experienced physicians and nurses. The program merges technological information with medical information to create a real-time documentation system that improves communication and enhances patient flow. Empower has been recognized in the past as a success story and role model by the Joint Commission, and we continually monitor and adopt the changing Joint Commission standards in order to ensure continuing compliance. The system also ensures compliance by prompting the physician or nurse at various HCFA mandated junctions, electronically applying the physician’s signature, and ensuring follow up by faxing the chart to the primary care provider or specialist’s office.

The program is dynamic and flexible, and can be customized to the needs of various physicians, nurses, and inpatient/ambulatory settings. Empower is also an inexpensive alternative to costly transcription or verbal documentation. This program, unlike others, is not template based, but rather is based on a single, free formed chart that is populated by the physician’s or nurse’s description of the patient’s history, physical exam, diagnostic tests, medical orders, and clinical summary to provide an accurate EMR, or electronic medical record.

The Empower chart reflects the company’s philosophy of ‘One Patient, One Chart, One

Database.’ There is no need to collate several separate charts or pieces of charts into one record at the end of the patient encounter. Empower provides all the tools necessary in order to document the patient’s clinical information while simultaneously caring for the patient. The software is written such that it follows the patient stepwise through the healthcare system, beginning with the registration process and ending with the discharge instructions.

Empower Inpatient+Ambulatory™ Nursing/MA Documentation

Starting the Program

Click on the Empower icon on the desktop.

Log In is provided by your system administrator.

The Patient Tracker will appear as the opening screen.

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Empower Inpatient™ Patient Roster

The following columns appear on the tracker, and can be modified as desired:

Acuity is based on the Emergency Severity Index (ESI) 5 level system. Empower also has customizable tables for hospitals that use a different system. The ESI 5 level is assigned in

Triage:

ESI Level

1

2

3

4

5

CATEGORY COLOR

Resuscitation RED

Emergent RED

Urgent YELLOW

Not urgent

Referred

GREEN

GREEN

Patient Name appears on the tracker when entered by the ADT interface or the ‘Add a Patient’ button.

Age appears on the tracker when the date of birth is entered by the ADT interface or the‘Add a

Patient’ button.

Chief Complaint is initially populated with the complaint entered by the ADT. It is updated by the chief complaint from the Triage Clinical Note and fianlly replaced by the chief complaint on the physicians note.

MD Name identifies the doctor caring for the patient with the physicians initials.

RN Name identifies the primary nurse caring for the patient. By double clicking in this box, a pop up screen will appear with the list of nurses’ names. Clicking on the appropriate name will set the corresponding initials to appear in the box. The initials will also populate any orders or notes entered. This field should be updated when the primary nurse is changed.

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Disposition is entered by the doctor or nurse on the discharge screen and populated into this field.

Exam Room is populated with the room number from the triage clinical note unless another room number is entered by clicking on the box and selecting a room.

Bed Assignment provides an area to enter the inpatient room number where appropriate. It also functions as a "sticky note”, by clicking on the box a pop up field appears that allows 18 characters of free text which will also appear on the tracker. This can be used to notify of ISOL or other information.

Time in ER in Hours and Minutes. The box appears Green for patients who have been in the department less than three hours, Yellow for patients who have been in the department for more than three but less than five hours, and Red for patients who have been in the department for more than five hours.

Diagnostic and Medical Orders has five columns, each with one of the following designations:

U = Urine

B = Blood

E = EKG and other diagnostics like Pulse Ox & Peak Flow.

R = Radiology

M = Medical Interventions like an IV or medication

.

When orders are entered, an Orange box with the letter N, for New, is displayed in the box.

When the order has been completed, the box turns Purple and displays the letter E to reflect that the order has been executed.

The R, D, C, X, U columns are interface columns and reflect the following chart status issues:

R = Registration, this box will display green when the full registration process is complete.

D = Diagnostics, this box will display yellow when all diagnostic tests are complete.

C = Critical Values, this box will display a red C to notify clinicians of critical/abnormal lab values.

X= Radiology Results, box will display yellow when a radiologic study is completed and uploaded into the PACS system

U= Unit Clerk, when the Unit Secretary signs off on orders that have been entered in the Core system (CPOE is not active) or checks to make sure orders cross into the Core system.

Admit To displays the name of the doctor to whom the patient is admitted.

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Chart Status appears Red while the chart is incomplete, or Green when ready for disposition.

When the physician finalizes the chart, Empower’s risk management functionality scans the chart and provides prompts for the physician to complete all necessary documentation. Doing so will change the status box to Green and the word ‘ready’ will appear inside of the box, after which the nurse can Print and close the chart. The nurse is likewise prompted to complete any required documentation prior to completing the chart.

Filtering/Sorting the Tracker

Filters can be applied to limit the patients displayed selecting from the drop-down fields ‘Name

Search’, ‘Location Search’, ‘MD Search’, ‘Disposition’, or ‘Exam Room’. To remove any of the filters, select ‘All’ from the drop-down fields.

Sorting can be done on any column by right-clicking and choosing a sort option.

Patient Name appears on the tracker when generated by the ADT interface or by using ‘Add a

Patient.’

Age as entered when date of birth entered by the ADT interface or by using ‘Add a Patient.’

Gender as entered by the ADT interface or by using ‘Add a Patient.’

New/Established is populated by clicking on the box once. Who will do this will be determined by your workflow.

Exam Room is populated by clicking in the box once. Who will do this will be determined by your workflow.

Appointment Time/Appointment Status entered by the ADT interface or by clicking in the box

(Appointment Status only)

Time in Office is calculated in minutes when the patient is placed on the Roster.

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Triage is answered by clicking the box and choosing the correct answer. This can be used to communicate with the practitioner that the patient is ready to be seen.

Complaint/Message is populated by clicking on the box once. This area is free text.

MD Name column identifies the doctor taking care of the patient by their name via dropdown menu.

Disposition is entered by the doctor on another screen.

Orders: When new orders are entered, an Orange box with an N is displayed. When the order has been noted Complete, the box turns Purple with an E to reflect the order has been executed.

Filtering /Sorting the Tracker: Filters can be applied to show a Patient Name who has been put on the Patient Roster.

Empower Patent Roster Buttons

Depending on the level of access, less buttons will be available

Current User:

This displays the current person logged into the system.

Add a Patient

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In the ‘Live’ environment the patient names will be entered into the hospital core HIS system or

Practice Management software using a short registration, which will flow via the interface into the Empower Patent Roster. If the interface is not Live or there is a core HIS downtime, this method can also be used.

For education and in the ‘Test’ environment, users can enter patients using the ‘Add a Patient’ button in the lower left of the Patient Tracker screen.

Click the ‘Add a Patient’ button and enter the name, birth date (age will automatically populate) and gender. If the patient has previously been in the hospital system, their demographic information will already be in the database. Click ‘Save Record’ and the Triage screen will open.

The Medical Record Number can be added later and is a required field to close the chart.

If the patient cannot be found, this is a new patient to the database. For new patients; enter the name, birth date (age will automatically populate) and gender. Click ‘Save and Record’ and

Empower will generate a new Medical Record.

After Clicking Save and Record, the staff member will be taken to the Demographics section in

Empower.

Old Records

On the Patient Tracker screen click ‘Old Records.’ Type in a patient name or portion of the name, or a MR number and click ‘Search.’ Click on the desired name/visit date and on the bottom click ‘View PDF Chart’ to view a chart. Click ‘View Patient’s Empower Chart’ to view the

Empower record. ‘Return to Tracker’ can be clicked if the patient was inadvertently removed.

Addendums can be made to the chart in ‘View Chart’ by the Nurse in the Nurses Notes or the

Physician in the Repeat Exams at any time. After any changes are made, the electronic PDF chart will need to be regenerated by highlighting the patient record in ‘Old Records’ and click the box to regenerate the PDF, which is the official patient medical record.

Addendums to any other area of the chart must go through administration or medical records so the chart can be opened (unlocked). If this is deemed necessary, Empower will contact and coordinate and provide step-by-step instructions to complete this.

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Administrative Tools

The use of these tools is designed for the clinic’s Empower administrators and designees for data collection and will be taught in detail by Empower Training Specialists during Go Live.

Edit Staff: This button is used by administrators to add new associates or change the level of access for current associates. For deleting associates, please make them Inactive.

Form Builder: This button is used to build forms for Clinical Notes. These are the forms and templates available in Clinic Notes/Nursing Notes section. Super Users will have training on this feature prior to Go Live.

Table Editor: This button is used to manipulate certain tables add or delete items. Please see

Appendix 9A for the list of tables.

Messaging: Empower has an internal email system used to communicate to other Empower users. The ‘Messages’ button gives the user access to this function. The recipient must acknowledge that they have READ ALL MESSAGES immediately when they first login prior to taking care of patients. This ensures that every user must read and acknowledge all policy and procedure changes and will not be able to use the system until they have. Instructions for an admin user to send a message are as follows:

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Click on MESSAGES.

Select the Nurse or Doctor from the drop down list OR select ALL.

Click in the white box and compose your message.

Click SEND.

If you have a MESSAGE, this screen will be the first to appear after you log in.

An audit of these Messages is available in the Empower Report Writer for reference.

Note: This message functionality is designed for internal policy communications and will not function or connect to any other email system.

Duplicate Patients

Inevitably, for whatever reason, there will be a duplicate patient record. There are two major concerns to be acknowledged and one way for them to be expeditiously addressed in

Empower.

1. Orders with an erroneous account number will fail to interface.

2. Empower does not and will not provide merge functionality for clinical data.

The following process will quickly and easily remove the erroneous account so clinical data is

ONLY entered on the one record and provide a solution to correct/update demographics.

Below is an example of a duplicate patient “Empower, Manual”. It is easy to identify the top chart is in error by the amount of time on the Roster and the lack of information.

Upon this discovery, immediately click in the ‘Disposition’ column to remove the erroneous chart from the tracker.

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Checking off ‘Duplicate Patient/Registration Error’ will prevent this record from being included in the ED’s statistics.

To correct the demographics in case the original clinical chart was in error, go to the ‘Patient

Demographics’ screen in Empower and enter the correct Account Number. If Empower has received an interface message with the same account number, you will receive a message similar to the following:

The Import/Update Demographics function can be used on any active patient in Empower.

Open the Patient Chart:

Click on the Patient Name and the chart will open to the Medical

Orders screen.

Gray Control Buttons:

At the bottom of each screen you will see gray buttons. Click on these buttons to move through the various portions of the chart. Each one acts as a ‘Save’ button from the current screen.

Vital Signs

Admitting Weight and Height: This is the weight of the patient on their initial visit. Click the box to enter information. Information can be entered in kilograms or pounds.

Visit Vital Signs are entered by single clicking the any box in the empty row (1 st

). A new Vital

Sign box will open and information is entered by clicking in the specific box or using the tab button to progress to the next box.

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Admission Assessment empower Inpatient+Ambulatory

This includes all pertinent information to begin care of the patient. Fill in all pertinent fields by double-clicking on the specific box. Past Medical History, Social History, Family History, and

Allergies are added by single clicking on them from the list on the left. The box on the bottom can be used as a drop down table or free text. Information required for Meaningful Use is also required in Empower.

Selected situations can be commented, changed, or deleted by double clicking on the text.

After information is satisfactorily completed, click on the Save button

Home Medication: Clicking on this field will open a Home Medication window. Clicking on the first empty row will open the Add a Medication Window.

Start typing the Medication Name, after two characters, a drop-down menu will appear. The more characters types, the more specific the options become. This will give a list of the medications in our databank with different dosages. Choose the medication, dosage, and route most appropriate by single click. The boxes with an error require a choice from a pre-populated list.

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When satisfied, click Save and Return to return to Home Medication or click ‘Add Another

Medication’ to do so. In the Home Medication Window, push the Save Button to return to the

Admission/Assessment page.

Allergies/Medications: It is imperative to select the from the drop-down list as the Empower

Smart Technology features include allergy detection and cross-reactivity. Although free-text is allowed for the rare medications/substances not included in the tables, Empower may not identify potential allergies or Drug to Drug Interactions.

Intake Fluids

In this area, anything given to the patient is documented. To enter medication, single click on the first empty row. The new window called Intake Documentation opens. Empower will automatically time stamp, but this can be changed if needed by clicking in the box. The

Medicine/Device Type is the name of what is given. This is a dropdown menu with no free text.

Dosage/Rate is for infusion therapy (IV). Route/Site is how the medicine is given. Amount is free text with the unit type after. Residual is any amount wasted. The comments section is the area where site, lot number, and expiration can be documented.

Demographics

This button will open a window with different tabs. If the ADT Interface is active, it should be populated. The information can be entered manually.

Admissions: This tab will give information about PCP, Consults, and reason for the visit.

Patient Information: As noted by the name, this is where the patient’s Address and Employer is entered.

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Insurance: Clicking on the open spot will open a second window where the patient’s Insurance information is entered. For patients with multiple insurances, ‘Add Another Repeat Exam’ is used to add until complete. Click ‘Save and Record’ when completed.

Person to Notify: This tab is used to enter Power of Attorney information.

Next of Kin: This tab is used to enter Next of Kin, as sometimes, it is not the same as Power of

Attorney. Individual clinics will determine which will be used if it is the same.

Guarantor: This information is usually reserved for Pediatric patients or Workman’s

Compensation

Diagnostic Results

Diagnostics are those tests done to determine what is wrong with the patient. These tests results will either come from the hospital, scans, or entered in the office. Use the PACS button to connect to the hospital to review the actual image.

To view a result, single click on that result.

To enter a result, click on the 1 st

line (empty). A second window will open up. The nurse has the option of free texting or choosing the Diagnostic Name from the drop down menu. The result can also be entered in the Diagnostic Interpretation via free text or the drop down menu.

Results can be filtered using the drop down menu. Keep in mind that if a test was not performed, it will not be in the drop down.

PHARMACY/RN Task

Select desired medication. If not an IV or Liquid medicine, enter 0 in the amount field. Ensure all other information is correct (Date, Time, Route). Save work using appropriate tab. For

Medications that have to be double signed (ex. Heparin or Insulin), document the name of the

Nurse who also signed in the Comments Field. The Filters at the top can filter by Time/Route,

Drug Name, or Type.

To verify that Medications have been charted, go to the Intake Screen. The Medication entered from the Pharmacy/RN Task should be listed. If it is not on the Intake Screen, enter per Intake

Instructions. Discontinued medications will be highlighted in Orange at the bottom of the screen.

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Clinical Notes

Nurses Notes: In this area, Nurses and Medical Assistants will document their own assessments and observations. Single click on the 1 st

row to open a large pop-up form with several options for documenting. On the right is large white box where the user can free-text any type of note.

In the upper left corner is a drop-down table. Templates and phrases can be selected from the drop-down and they flow to the

white box on the right. It is possible to use a combination of dropdown phrases and free-text.

Medical Orders

Medical Orders are those interventions that make the patient feel better. This is an interactive screen, which allows nursing to enter any Intervention or any Diagnostic Test. To sign medical orders, single click on Clinical Staff or Clinical Staff Time. A new pop-up window will open up and the option to sign on one order or all orders is available. (The time can be modified if needed) In the Order Status area, a new window will pop up to document completion, refusal, or cancellation.

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Entering Medical Orders: Click in the white box to open a pop-up form for entering orders.

The user can enter orders by clicking the box and using the drop-down menu or free text. The

Diagnostic Order drop-down includes all of the commonly ordered radiology tests. Pharmacy

Orders drop-down includes common medication. Other Medical Orders and Comments dropdown is an area for orders not previously used or free text. It is necessary to choose a practitioner to assign the order. If a diagnostic test is ordered by selecting from the lists in

Medical Orders, it will flow to the Diagnostics Screen where the results will interface and populate the result fields.

Scan Documents

To scan or view scanned documents click ‘Scan Documents.’ To scan; place the document in the scanner, choose a scan type, and click ‘Scan.’ To view other scanned documents, the

‘Previous’ Button will scroll through individual scans or there is the ability to filter through the

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empower Inpatient+Ambulatory drop-down menu. Documents can be viewed on any computer, but scanning can only be done at the computer directly connected to the scanner.

Patient List

This button will return the user to the Patient Roster.

Print

The Print button will open a window to give the different options to print. There is one Default printer assigned during set up, but there are other options if multiple printers have been installed. In addition, a dedicated prescription printer can be added.

Patient Reports

Information from visits and anticipatory guidance reports are generated from this button.

Please see Chapter 9.

Vitals Reassessment

Empower has the ability to prompt the RN to obtain another set of Vital Signs with certain Chief

Complaints. The Chief Complaints are chosen by the site administrator using the Table Editor.

Choosing Chief Complaint and Associated Symptoms in the Table List or tblluPhysChiefComplaintAsx in Table Information displays the correct Table. Setting the column booRepeatVitals to True for the specific complaint will trigger the prompt.

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Upon Print All for that Chief Complaint, a message will appear to prompt for another set of

Vital Signs.

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MD Screens

This screen allows the user to view the practitioner’s overview and review notes. These notes will be from the hospital, consultants, and the practitioner.

Discharge Instructions

In this area; practitioners, nurses, and medical assistants will select information to give to the patient as they leave the office.

Discharge Diagnosis: This is determined by the practitioner as is read only.

Diet Instructions: Double-click in the box to open up the options. Users can select from options or free text and save. Double-click on a selected item to delete or add text.

Activity Instructions: Double-click in the box to open up the options. Users can select from options or free text and save. Double-click on a selected item to delete or add text.

Prewritten Discharge Instructions: Double-click in the box to open up the options. Users can select from options by double-clicking from the list. If instructions are not in the list, use the drop-down box for other options. Once the proper instructions are found, use the ‘Add to List’

Button. Once all the instructions needed are selected, use the ‘Save and Close’ Button.

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Language: This drop-down menu will select the language the instructions are printed out.

English is the default.

Follow-Up List: In this area, follow up appointments and referrals to certain providers can be given to patients. Click on the first open the input box. Using the drop-down box, a prepopulated list of physicians with demographic information will fill the rest of the fields. Users can also free-text in any field if a practitioner is not in the list.

Discharge Rx: In the bottom right-hand corner is a button labeled ‘Discharge Rx’. This will open the e-prescribing feature of Empower Inpatient+Ambulatory™. Practitioners will select which medication is to be prescribed. These medications populate the Selected Meds field. Use the drop-down menu Fax Locations to select the pharmacy. The ‘Fax Meds’ button will place the prescription in the Fax Queue. When finished, the ‘Close’ button will end e-prescribing. This is also the area that Medication Reconciliation will be completed.

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Print Orders

Click ‘Print Orders’ to print a hard copy of the Medical and Diagnostic orders for pharmacy, for the nurse to use when multiple orders need to be carried out and to verify patient identity at the bedside.

Tips

Left-click on the Disposition field for a patient will bring up a red screen asking if you wish to remove the patient from the screen. You can click Yes/No. The patient record is always stored in Old Records.

To switch between Empower and another program, open the other program first and then

Empower. Use ALT/TAB to switch between the two programs.

Throughout Empower Inpatient+Ambulatory™, there are message boxes and labels to instruct a user on how to use particular section or provide the correct documentation.

To access a particular field and document information, simply left-click with the mouse.

Review your entries and always click the Save button when it appears, as long as the correct information has been entered.

Certain fields are required fields. The computer will prompt with a message box and by highlighting the required field in red if you have forgotten to enter required information.

If you are uncertain of what to do or have selected the wrong patient, you can always click the

'Patient List' button to return to the Patient Roster.

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Chapter 12: Provider User Manual

Introduction

The Empower Inpatient+Ambulatory™ computer documentation system was created by clinically experienced physicians and nurses. The program merges technological information with medical information to create a real-time documentation system that improves communication and enhances patient flow. EmpowerSystems™ has been recognized in the past as a success story and role model by the Joint Commission, and we continually monitor and adopt the changing Joint Commission standards in order to ensure continuing compliance.

The system also ensures compliance by prompting the physician or nurse at various HCFA mandated junctions, electronically applying the physicians signature, and ensuring follow up by faxing the chart to the primary care provider or specialists office.

The program is dynamic and flexible, and can be customized to the needs of various physicians, nurses, and inpatient/ambulatory settings. Empower Inpatient+Ambulatory™ is also an inexpensive alternative to costly transcription or verbal documentation. This program, unlike others, is not template based, but rather is based on a single, free formed chart that is populated by the physician’s or nurse’s description of the patient’s history, physical exam, diagnostic tests, medical orders, and clinical summary to provide an accurate EMR, or electronic medical record.

The Empower chart reflects the company’s philosophy of ‘One Patient, One Chart, One

Database.’ There is no need to collate several separate charts or pieces of charts into one record at the end of the patient encounter. Empower Inpatient+Ambulatory™ provides all the tools necessary in order to document the patient’s clinical information while simultaneously caring for the patient. The software is written such that it follows the patient stepwise through the healthcare system, beginning with the registration process and ending with the discharge instructions.

Starting the Program

Click on the Empower icon on the desktop.

Log In is provided by your system administrator.

Initial password is ‘welcome’.

When you log in with this password you will be prompted that your password has expired.

Click ‘yes’ and enter your new password.

Write down this log in and password.

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Empower Inpatient™ and Empower ED™ Patient Roster

The following columns appear on the tracker, and can be modified as desired:

Acuity is based on the Emergency Severity Index (ESI) 5 level system. Empower also has customizable tables for hospitals that use a different system. The ESI 5 level is assigned in

Triage:

3

4

5

ESI Level

1

2

CATEGORY COLOR

Resuscitation RED

Emergent RED

Urgent

Not urgent

Referred

YELLOW

GREEN

GREEN

Patient Name appears on the tracker when entered by the ADT interface or the ‘Add a Patient’ button.

Age appears on the tracker when the date of birth is entered by the ADT interface or the ‘Add a

Patient’ button.

Chief Complaint is initially populated with the complaint entered by the ADT. It is updated by the chief complaint from the Triage Clinical Note and finally replaced by the chief complaint on the physicians note.

MD Name identifies the doctor caring for the patient with the physicians initials.

RN Name identifies the primary nurse caring for the patient. By double clicking in this box, a pop up screen will appear with the list of nurses’ names. Clicking on the appropriate name will set the corresponding initials to appear in the box. The initials will also populate any orders or notes entered. This field should be updated when the primary nurse is changed.

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Disposition is entered by the doctor or nurse on the discharge screen and populated into this field.

Exam Room is populated with the room number from the triage clinical note unless another room number is entered by clicking on the box and selecting a room.

Bed Assignment provides an area to enter the inpatient room number where appropriate. It also functions as a "sticky note”. By clicking on the box, a pop up field appears that allows 18 characters of free text. This note will appear on the tracker, and can be used for ISOL or other information.

Time in ER in hours and minutes. The box appears Green for patients who have been in the department for less than three hours, Yellow for patients who have been in the department for more than three but less than five hours, and Red for patients who have been in the department for more than five hours.

Diagnostic and Medical Orders section has five columns, each with one of the following designations:

U = Urine

B = Blood

E = EKG and other diagnostics like Pulse Ox & Peak Flow.

R = Radiology

M = Medical Interventions like an IV or medication.

When orders are entered, an Orange box with the letter N, for New, is displayed in the box.

When an order has been completed, the box turns Purple and displays the letter E to reflect that the order has been executed.

The R, D, C, X, U columns are interface columns that reflect the following:

R = Registration, this box will display green when the full registration process is complete.

D = Diagnostics, this box will display yellow when all diagnostic tests are complete.

C = Critical Values, this box will display a red C to notify clinicians of critical/abnormal lab values.

X = Radiology Results, box will display yellow when a radiologic study is completed and uploaded into the PACS system

U = Unit Clerk, when the Unit Secretary signs off on orders that have been entered in the Core system (CPOE is not active) or, for those with direct order entry, checks to make sure that orders have crossed into the Core system.

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Admit To displays the name of the doctor to whom the patient is admitted.

Chart Status appears red until the chart is complete. When the chart is ready for disposition, it appears green. When the ED physician finalizes the chart, the Empower ED™ risk management program scans the chart for incomplete documentation, and then guides the physician through the completion of all necessary documentation. Completing the documentation will change the status box color to green, and the word ‘Ready’ will appear within the box. The nurse can then print and close the chart, and is likewise prompted to complete any required documentation.

Filtering/Sorting the Tracker

Filters can be applied to limit the patients displayed by selecting from the drop-down fields

‘Name Search’, ‘Location Search’, ‘MD Search’, ‘Disposition’, or ‘Exam Room’. To remove the filters, select ‘All’ from the drop-down fields. Sorting can be done on any column by rightclicking on the column heading and choosing a sort option

Empower Ambulatory™ Patient Roster

Patient Name appears on the tracker when generated by the ADT interface or by using ‘Add a

Patient.’

Age as entered when date of birth entered by the ADT interface or by using ‘Add a Patient.’

Gender as entered by the ADT interface or by using ‘Add a Patient.’

New/Established is populated by clicking on the box once.

Exam Room is populated by clicking in the box once.

Appointment Time/Appointment Status is entered by the ADT interface or by clicking in the box (Appointment Status only).

Time in Office is calculated in minutes from the time that the patient is placed on the Roster.

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Complaint/Message is free-texted by clicking on the box.

MD Name uses a dropdown menu to identify the name of the doctor caring for the patient.

Disposition is entered by the doctor on their documentation screen and crosses over to the tracking board.

Orders displays an orange box with a letter N when new orders are entered. When the order has been completed, the box turns purple with a letter E to reflect that the order has been executed.

Open the Patient Chart

Clicking on a patients name open the patients chart and navigate to the opening screen, the subjective part of the patient encounter.

Data Entry and Navigation

Drop-Down Boxes: Clicking on the small arrow on the right side of the scroll box will open the drop-down menu. Typing the first few letters begins the auto-fill process and the list scrolls to area of the menu that most closely matches the typed entry.

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Pop-Up Forms: If a white box with no arrow appears, click in the white space and a pop-up form appears. This provides a Drop-Down list and a blank area to free text.

Check Boxes: These allow the user to click a small box to acknowledge a prewritten statement.

Tab and Enter Keys: Using ‘Tab’ or ‘Enter’ on the keyboard will move the cursor from one field to the next. Fields can also be navigated by left-clicking the mouse in the appropriate box.

Required Fields: Empower has certain required fields, and when a user attempts to close the chart, the computer will guide them with a message and red highlight to the required area of documentation.

Gray Control Buttons: At the bottom of each screen are grey buttons which serve to move through the various portions of the chart. The current screen is automatically saved when moving from one screen to the next.

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Subjective

Subjective: This is the chief complaint and is a required field. It can be selected from the list for easier coding or manually entered. If uncertain of the chief complaint, select ‘Waiting

Evaluation’ as a temporary complaint and return to the field at a later time. Also, in the interest of time, this can be entered and then the user can move on to Diagnostic and Medical Orders and return to complete the Subjective and Physical Exam when time permits. If a history is not attainable due to the patients’ condition, select the phrase ‘Hx unattainable due to Tx urgency or poor historian’ in ‘Assoc Sxs/Pertinent Hx’. This phrase will effect coding to a Level 5 in the

ED without requiring the completion of all of the fields.

Review of Systems: These can be entered individually, or the ‘All Systems Negative’ box can be checked and then the individual positive items can be detailed separately. There is also a free text box for additional comments.

Additional Comments: This area can be used for more detailed histories or physician templates.

Past Medical History: This area auto-populates with the information obtained in the

Admission/Assessment area. Additional information can be added by checking the appropriate boxes or clicking in the white box and free texting under ‘Other PMHx.’

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Social and Family History: Check appropriate boxes or click in the white boxes labeled ‘Other’ to add more information. Smoking status is required to meet Meaningful Use.

Physical Exam

To document the Physical Exam check the box on the left to populate a normal statement for that system. Clinking on the arrow to the right, or beginning to free text, causes drop-down tables appear. If an appropriate exam is not found in the drop down list, the physical findings can be free texted.

The ‘Date/ Time’ of the exam will default to the time of documentation. If this differs from the actual time of the exam, it can be entered if different by clicking in the time box and entering the time in military time with no punctuation, e.g. 2:00 PM is entered as 1400.

Repeat or Additional Notes

Check boxes are available for required EMTALA discharge statements, transfers, AMA and

LWBS. Click in the white box to free-text a repeat exam or provide additional information regarding the physical exam. Phrases can also be selected from the drop-down box.

Laceration Procedures

Laceration details such as location, length, shape, depth, wound exploration and procedure must be selected from the drop-down lists to provide the required documentation for appropriate reimbursement. The additional comments allows free texting of additional details.

Other Procedures

Procedures must be selected from the list, and free-text is not permitted due to coding regulations. Free texting may be done in the ‘Additional Comments’ section.

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High Risk Chief Complaints

Empower can improve Clinical Documentation with certain Chief Complaints. These High Risk

Chief Complaints are identified in the Subjective box of the History/Subjective portion of the

Emergency Note. Once the Chief Complain is entered, a Pop-up window opens and the

Practitioner is able to document statements to manage and decrease risk in the Emergency

Note.

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The First Section: Differential Diagnosis

This area is the medical problems considered with the Chief Complaint. Clicking on one of the problems removes it from the list and, therefore, documentation. Please note the general popup screen-shot compared to the one above. Pulmonary Embolus, AAA, Myocarditis, and

Pericardial Effusion have all been removed. The rest of the problems left populate to the

Physical/Objective Section (Blue Arrow) Please Note, once removed these problems must be manually entered.

The Second Section: History of Pertinent Negatives

This area documents negative history of the patient. If the patient does have a history of these issues, clicking on that one will remove it from documentation in the History/Subjective Section in Patient/Family Denies. Please note Fx CAD/Aortic Dissection/PE, SLE, and Diabetes have been removed. Please Note, once removed this negative history must be manually entered.

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The Third Section: Physical Exam Pertinent Negatives

This area documents a Normal Physical Exam. If there are abnormalities that conflict with these statements, they should be removed. The history left will populate to the Physical/Objective

Section (Red Arrow above). Please Note, once removed these history must be manually entered.

The Fourth Section: Consider Diagnostic Studies and Interventions

Unlike the other Sections, this is for display as is Read-Only. These orders will NOT be placed, nor will there be any documentation of these orders in the chart.

The bottom of the pop-up has two buttons.

Ignore will not import any documentation into the chart. Add To Patient Chart will import the

Documentation to the areas specified above.

The High Risk Chief Complaints are editable. Edits can be made to age, gender, Chief Complaint, and any of the Sections. In addition, new High Risk Chief Complaints can be added. Please contact your Empower Support Personnel to learn more.

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Diagnostic Results

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Abnormal Values will appear in red on the top of the screen.

The interface will populate all laboratory results. If the laboratory result interface is not active, then the provider will need to interpret enter all results. For certain diagnostics such as the EKG or radiological studies, the provider will need to provide their own interpretation. Drop-down statements or free text may be used.

To view results, click into Result Interpretation. Once in this screen, results can be trended.

Clicking on any diagnostic or medical intervention (U B E R M) will navigate to the appropriate diagnostic or medical Intervention screen.

Assessment/Plan Medical Orders

The initial Assessment/Diagnosis is taken from the initial Subjective complaint. It can be changed at any time, and additional Assessments can be added as needed.

Each Assessment has a section for comments, start date, priority, and status.

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Medical Orders

Click on the white box to open Medical Orders.

Common Diagnostic Tests: Orders are entered by clicking the appropriate box and then selecting from the drop-down menu. The menu can be customized to the institution. If the appropriate test is not found, then free texting can be used.

Diagnostic Order: This drop-down menu contains the most commonly ordered laboratory and radiology tests.

Pharmacy Orders: This drop-down menu contains the most commonly used medications. This field is locked to the Empower Smart Technology medication database to ensure that Drug-

Drug Interactions and Potential Allergy Alerts are active.

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When a weight-based medication dose is selected from the list, the dosage will be automatically calculated by Empower.

Other Medical Orders and Comments: This is an area for orders not found elsewhere. Orders can be free texted in this area. However, when orders are free texted, the results do not flow back to the diagnostics screen. It is recommended that free texting is avoided where possible as it can impact data capture and reporting. Contact your system administrator if any additions to the lists are required.

IVF: This drop-down menu lists of all common IV therapies.

O2: This drop-down menu includes all common methods of oxygen delivery.

Standard Order Sets: Open the ‘Medical Orders’ field by clicking on the white box. The standard order sets are in the bottom field. Clicking on this box opens a drop down menu that contains all of the order sets for the institution.

After selecting an order set it can be adjusted by clicking on items are not needed, and then selecting ‘Add to Chart’.

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Admitting Orders: (Optional) If the Emergency Department physicians write the admitting orders, then this feature can be used. It functions the same as Medical Orders when selecting

Standard Order Sets

If additional orders are needed, then click ‘Add Another Plan’ and add any other necessary orders or order sets. When all desired Diagnostic and Medical Orders have been added, click

‘Save and Close’. If the hospital does not have an order interface, the designated staff will then enter those diagnostics into the core system.

Disposition

This is found on the Assessment/Plan Medical Orders screen at the bottom. Disposition and

Condition must be selected from the drop-down box. For admissions, enter the name of the admitting physician, which can be selected from the list.

Notifications

This is also found on the Assessment/Plan Medical Orders screen. Click the gray button to bring up the Notifications screen and select a doctor from the list or free text the name of the admitting physician. This will auto-populate a statement regarding the notification of admission, discharge, or referral.

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Discharge Instructions

Discharge Instructions can be accessed from any screen. The practitioner is required to select an Assessment/Diagnosis. The initial Subjective complaint appears as the initial diagnosis, but the physician must then choose a diagnosis that reflects the results of the diagnostics.

The follow-up physician can be selected from the list, or alternatively, the Add/Edit can be used to enter a physician that is not on the list.

Additional instructions can be added by clicking in the white box. They can be selected from the drop-down menu or manually entered.

Empower offers pre-printed, instruction sheets for most common diagnoses using a quick pick list or a drop-down menu that has several thousand options. Double-clicking on the desired instructions moves the topic to the box on the opposite side. After all of the appropriate instructions have been selected, click ‘Save and Close’.

ExitCare™ discharge instruction content (English & Spanish) is integrated within this view.

Additional ExitCare™ languages are available, at an annual fee based on hospital volume.

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Prescription Writer

Click the gray box for Discharge Rx, which brings up the Prescription Writer screen. It also includes the Drug-to-Drug Interaction Alert and the Potential Allergy Alert. Select a prescription from the list.

The prescription writer can also be used to document work or school releases. The prescription writer is the ideal software to function in this dual manner because it automatically lists the name of the patient and the date that the medical care was provided, along with the physician’s signature. Typical statements for a work or school release can be added using the

Table Editor.

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Ready to Print

When the visit is complete, the provider can complete the chart by clinking ‘Finalize Chart.’

Clicking this button will initiate Empower’s Smart Technology and will prompt the user for any missing documentation. When this is complete, it will be illustrated on the tracker that the chart has been closed. The nurse then completes the printing process.

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Complete the information required and click ‘Finalize’ again. Continue this process until you reach the following screen.

This screen allows you to return to HPI or Physical Exam and will highlight identified deficiencies.

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Choose ‘Review MDM’ if you are interested in the systems calculation for MDM.

Once you have successfully set the chart ‘Ready to Print’ nursing will see the Chart Status on the Tracker and disposition the patient.

Congratulations! You have now completed the Empower chart.

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Chapter 13: Interfaces

Empower interfaces to the hospital’s core HIS using an HL7 engine or Scripting interface. The

HL7 interface has been the most reliable and least expensive to maintain, and the Empower

HL7 interface engine can be modified to any specifications set forth by the hospital. Empower can also build interfaces through other methods such as Scripting.

The following interfaces are included with the purchase of the Empower system.

Registration (ADT)

Diagnostic Results

CPOE (Computer Physician Order Entry)

Empower PDF Chart Export

Charge capture

The charge capture interface is usually not executed until a thorough chart review process has been completed in order to identify any gaps in the documentation. This is because the charges are identified by the documentation of items and procedures using the Empower lookup tables, and if documentation of these items in the tables is poor, then the cost/benefit ratio of the automated charge capture may be determined by the hospital to be too low to justify its use. Empower requires that the Registration, Diagnostic Results, and Order Entry interfaces to be built prior to Go Live.

Registration (ADT)

There are three options for the registration interface, each of which has a different impact on the registration and triage workflow. Registration Interface design and workflow options are listed below in order of recommendation:

1. A short registration is completed in the hospital registration software, which creates an

Empower chart through the interface, which is then followed up with full registration.

2. All patients are registered with a short form in Empower and the interface passes that information to the hospital registration software and assigns an account number.

3. Patients are registered separately in Empower and hospital registration software. Empower provides a unique patient identifier. The Registration Clerks then enters that unique patient identifier in a designated field on the patient chart which allows the interface to synchronize the

Empower patient record with the hospital registration software. This is not recommended due to the high failure rates and other issues that can occur when information is manually entered.

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The Empower Implementation team will discuss these options with the hospital team in order to assist in determining which registration interface is best.

Diagnostic Results

Empower is a clinical documentation tool intended to replace the clinician’s pen and paper, and not the official laboratory record. The hospital is to provide the laboratory dictionary

(mnemonics, codes, messages, etc.) from the Health Information System which is then mapped by Empower.

Empower, working as the clinician’s pen, affords the clinical administrator the discretion to identify which tests or components are clinically significant and are to be included as part of the

Empower order process. Empower references the provided Abnormal/Critical flags from the host interface so that any site-specific variations will be identified and highlighted. Each individual physician should still look at each laboratory value rather than rely exclusively on the systems prompts.

Order Entry (CPOE/Automated Unit Secretary)

The Empower order entry interface is designed so that instead of the unit secretary manually ordering diagnostic tests from the hospital menus, Empower electronically orders the same diagnostic tests. Unlike other systems that require specific ancillary questions to be answered prior to accepting an order, Empower provides 3 options for satisfying such requirements:

1. Empower can automatically answer “relevant” clinical information if the information is already documented in Empower, for example, whether the patient is pregnant or taking coumadin.

2. Empower can provide default responses to standard questions, for example, a question such as how the patient is transported may always be answered as portable.

3. The clinician and manually enter the answers to the questions.

Diagnostic Results & Order Entry Testing

Empower has successfully implemented a multitude of interfaces with numerous systems.

Experienced Empower clinicians reference the dictionaries provided and match them with the tables in Empower to complete the mapping process. The hospital team will also be provided with a spreadsheet of this mapping to review. This will not only reduce any translation errors but also expedite the testing process. Even with this process, however, there is always the chance that there may still be unintentional errors created in the interfaces between the clinicians’ language and the hospital dictionaries. Empower policies, which should be

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The following appendixes are provided to identify and communicate any problems with the interfaces during and after the Go Live:

Appendix 13A: Workflow Procedure for CPOE Interface – Post Go-Live

Appendix 13B: Hospital Order Entry Problem Log Sheet

Appendix 13C: Diagnostic Results Interface Workflow - Post-Go Live

Appendix 13D: Hospital Diagnostic Results Problem Log

Empower PDF Chart Export

As mentioned in Chapter 8 , the Empower final chart is formatted in an Adobe PDF file. This file

is generated from the Empower App Server and stored on the network drive provided. The file is then available for the hospital to import to their document management system. This task may be contracted with Empower, please refer to the signed contract for clarification.

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Empower HL7 Orders and Results Interface Specifications

Subject to change during development

Order/Result Processing

Understanding order and result identification and the stages of the order life cycle is crucial to ensure the proper implementation of the orders and results interfaces.

Orders in Empower are identified by the order number. The outbound interface identifies the order with a “placer order number” that can be generated at the time a new order is created by the outbound interface. Ancillary systems use their own schemes to generate “filler numbers” which are sent to the inbound Results interface. Both of these numbers are associated through a translation table to the

Empower order number. The Orders interface is able to send both full orders (with order placer number) and order requests (without the placer number).

In the case of an interface to a single lab system, full orders will be sent out with a generated placer number, and results from the lab system will be processed.

CPOE Interface to Lab System

Orders (ORM^O01)

Results (ORU^R01)

When interfacing to an Order Master System which handles the generation of order numbers for multiple lab systems, Empower will send out order requests without a placer number. The Order

Master System will then send back an Order Confirmation message with the generated order number, and forward the original order to the appropriate system. The Lab System will then send the results directly to Empower which will be associated with the order number received by the Order Confirmation message.

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CPOE Interfaces to Order Master System

Order Identification

The value of the ancillary systems “filler number” is determined entirely by the ancillary system. The value of the “placer number” can be generated by one of the following strategies.

Standard Foreign Order Number Strategy (Default)

This strategy sets the Empower “placer number” to the same value as the ID of the record in the

Empower database table. i.e. 12345

System Specific Foreign Order Number Strategy

This strategy sets the Empower “placer number” to “EMPOWER-“ plus the value of the ID of the record in the Empower database table. i.e. EMPOWER-12345

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Creation of New Order by Empower

The Empower “placer number” is created for the new order. The ancillary system should fill in this placer number in the placer field for all subsequent messages about this order.

Order Status Change

Status changes are usually only sent by the ancillary system. These should be sent with an order control code of SC. Currently the inbound interface supports transitions to in-progress and completed.

Order Cancellation

Cancellations are a special kind of status change. They should be sent as an order message with a CA order control code.

Outbound Orders

The Outbound Orders interface will send HL7 2.2.

The Outbound Orders interface will send the following message trigger events.

Trigger Events

O01 General Order Message

Supported Order Control Codes

NW

NA

CA

SC

New Order

Number Assign

Cancel Order Request

Status Changed

Although the Outbound Orders interface is HL7 2.2 compliant, some segments and fields will not be used for this interface implementation. Listed below are the various triggering events and segments that include data that will be sent from Empower. This subset of HL7 segments is offered only to show which segments are important for this implementation.

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Message Definitions

O01

General Order Message

MSH Message Header

PID Patient Identification

PV1 Patient Visit

AL1 Allergy Information

ORC Common Order

OBR Observation Request Segment

OBX Observation/Result

Inbound Results

The Inbound Results interface will receive HL7 2.2 or 2.3 ORU messages from the Interface Engine and will store clinical data necessary to perform the Results Viewing functions of Empower.

The Inbound Results interface will accept the following message trigger events.

Trigger Events

R01

Unsolicited Transmission of an Observation

Although the Inbound Results interface is HL7 2.3 compliant, some segments and fields will not be used for this interface implementation. Listed below are the various triggering events and segments that include data that will be stored in Empower. This subset of HL7 segments is offered only to show which segments are important for this implementation. The Inbound Results interface can accept messages that contain any segment listed in the HL7 2.3 standard.

Message Definitions

R01

Unsolicited Transmission of An Observation

MSH Message Header

PID Patient Identification

PV1 Patient Visit

ORC Common Order

OBR Observation Request Segment

NTE Notes and Comments

OBX Observation/Result

NTE Notes and Comments

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Outbound Charges

The outbound charges interface sends real-time charges information to a Billing System.

The Outbound Charges interface will send the following message trigger events.

Trigger Events

P03 Post Detail Financial Transactions

Although the Outbound Charges interface is HL7 2.2 compliant, some segments and fields will not be used for this interface implementation. Listed below are the various triggering events and segments that include data that will be sent from Empower Inpatient+Ambulatory™. This subset of HL7 segments is offered only to show which segments are important for this implementation.

Message Definitions

P03

Post Detail Financial Transactions

MSH Message Header

EVN Event Type

PID Patient Identification

FT1 Financial Transaction

Segment Definitions

MSH

SEQ LEN DT OPT RP# ELEMENT NAME

1 1 ST R

2 4 ST R

3 180 HD

Field separator

Encoding characters

Sending application

4 180 HD

5 180 HD

6 180 HD

7 26 TS

Sending facility

Receiving application

Receiving facility

Date/Time of message

NOTES

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SEQ LEN DT OPT RP# ELEMENT NAME

8 40 ST

9 7 CM R

Security

Message type

10 20 ST R

11 3 PT R

12 8 ID R

Message control ID

Processing ID

Version ID

13 15 NM

14 180 ST

15 2 ID

16 2 ID

17 2 ID

18 6 ID

19 60 CE

Sequence number

Continuation pointer

Accept acknowledgement type

Application acknowledgement type

Country code

Y/3 Character Set

Principal Language of Message

EVN

SEQ LEN DT OPT RP# ELEMENT NAME

1 3 ID B

2 26 TS R

Event type code

Date/Time of event

3 26 TS

4 3 IS

5 60 XCN

6 26 TS

Date/Time planned event

Event reason code

Operator ID

Event Occurred

PID

SEQ LEN DT OPT RP# ELEMENT NAME

1 4 SI

2 20 CX

Set ID – Patient ID

Patient ID (External ID)

3 20 CX R Y*

Patient ID (Internal ID)

4 20 CX Y

Alternate Patient ID

5 48 XPN R Y

Patient Name

6 48 XPN

7 26 TS

8 1 IS

9 48 XPN

10 1 IS

11 106 XAD

12 4 IS

13 40 XTN

14 40 XTN

15 60 CE

16 1 IS

17 3 IS

18 20 CS

Y

Mother’s Maiden Name

Date of Birth

Sex

Patient Alias

Race

Y

Patient Address

County Code

Y

Phone Number – Home

Y

Phone Number – Business

Language – Patient

Marital Status

Religion

Patient Account Number

NOTES

NOTES

Duplicated in MSH

NOTES

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SEQ LEN DT OPT RP# ELEMENT NAME

19 16 ST

20 25 DLN

SSN Number – Patient

Driver’s Lic. Num – Patient

21 20 CX

22 3 IS

23 60 ST

Y

Mother’s Identifier

Ethnic Group

Birth Place

24 2 ID

25 2 NM

26 4 IS

27 60 CE

28 80 CE

29 26 TS

30 1 ID

Y

Multiple Birth Indicator

Birth Order

Citizenship

Veterans Military Status

Nationality

Patient Death Date and Time

Patient Death Indicator

PV1

SEQ LEN DT OPT RP# ELEMENT NAME

1 4 SI

Set ID – Patient Visit

2 1 IS R

3 80 PL

4 2 IS *

Patient Class

Assigned Patient Location

Admission Type

5 20 CX

6 80 PL

7 60 XCN

8 60 XCN

9 60 XCN

Y

Y

Y

Pre-admit Number

Prior Patient Location

Attending Doctor

Referring Doctor

Consulting Doctor

10 3 IS *

11 80 PL

12 2 IS

13 2 IS

14 3 IS *

15 2 IS

16 2 IS

17 60 XCN

18 2 IS *

19 20 CX

Hospital Service

Temporary Location

Pre-admit Test Indicator

Readmission Indicator

Admit Source

Y

Ambulatory Status

VIP Indicator

Y

Admitting Doctor

Patient Type

Visit Number

20 50 FC

21 2 IS

22 2 IS

23 2 IS

24 2 IS

25 8 DT

26 12 NM

27 3 NM

28 2 IS

Y

Financial Class

Charge Price Indicator

Courtesy Code

Credit Rating

Y

Contract Code

Y

Contract Effective Date

Y

Contract Amount

Y

Contract Period

Interest Code

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MRG

SEQ LEN DT OPT RP# ELEMENT NAME

1 20 CX R Y

Prior Patient ID - Internal

2 20 CX Y

Prior Alternate Patient ID

3 20 CX

4 20 CX

5 20 CX

6 20 CX

7 48 XPN

Prior Patient Account Number

Prior Patient ID - External

Prior Visit Number

Prior Alternate Visit ID

Prior Patient Name

NK1

SEQ LEN DT OPT RP# ELEMENT NAME

29 1 IS

30 8 DT

Transfer to Bad Debt Code

Transfer to Bad Debt Date

31 10 IS

32 12 NM

33 12 NM

Bad Debt Agency Code

Bad Debt Transfer Amount

Bad Debt Recovery Amount

34 1 IS

35 8 DT

36 3 IS

37 25 CM

38 2 IS

39 2 IS

40 1 IS B

41 2 IS

42 80 PL

43 80 PL

Delete Account Indicator

Delete Account Date

Discharge Disposition

Discharged to Location

Diet Type

Servicing Facility

Bed Status

Account Status

Pending Location

Prior Temporary Location

44 26 TS

45 26 TS

46 12 NM

47 12 NM

48 12 NM

49 12 NM

50 20 CX

51 1 IS

52 60 XCN

Admit Date/Time

Discharge Date/Time

Current Patient Balance

Total Charges

Total Adjustments

Total Payments

Alternate Visit ID

Visit Indicator

Y

Other Healthcare Provider

SEQ LEN DT OPT RP# ELEMENT NAME

1 4 SI R

Set ID

2 48 XPN

3 60 CE

4 106 XAD

Name

Relationship

Address

5 40 XTN

6 40 XTN

7 60 CE

Phone Number

Business Phone Number

Contact Role

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NOTES

NOTES

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SEQ LEN DT OPT RP# ELEMENT NAME

8 8 DT

9 8 DT

Start Date

End Date

10 60 ST

11 20 JCC

12 20 CX

13 60 XON

Job Title

Job Code/Class

Employee Number

Organization Name

GT1

SEQ LEN DT OPT RP# ELEMENT NAME

1 4 SI R

2 250 CX

Set ID

Guarantor Number

3 250 XPN R

4 250 XPN

5 250 XAD

Guarantor Name

Guarantor Spouse Name

Guarantor Address

6 250 XTN

7 250 XTN

8 26 TS

9 1 IS

10 2 IS

11 250 CE

12 11 ST

13 8 DT

14 8 DT

15 2 NM

Guarantor PhNum-Home

Guarantor PhNum-Business

Guarantor Date/Time of Birth

Guarantor Sex

Guarantor Type

Guarantor Relationship

Guarantor SSN

Guarantor Date - Begin

Guarantor Date - End

Guarantor Priority

16 250 XPN

17 250 XAD

18 250 XTN

19 250 CX

20 2 IS

21 250 XON

22 1 ID

23 250 CE

24 26 TS

25 1 ID

26 250 CE

27 10 CP

28 3 NM

29 250 CX

30 250 CE

31 8 DT

32 8 DT

33 2 IS

34 2 IS

Guarantor Employer Name

Guarantor Employer Address

Guarantor Emp. Phone Number

Guarantor Employee ID Number

Guarantor Employment Status

Guarantor Organization Name

Guarantor Billing Holding Flag

Guarantor Credit Rating Code

Guarantor Death Date And Time

Guarantor Death Flag

Guarantor Charge Adj Code

Guarantor Household Income

Guarantor Household Size

Guarantor Employer ID Num.

Guarantor Marital Status Code

Guarantor Hire Eff. Date

Employment Stop Date

Living Dependency

Ambulatory Status

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SEQ LEN DT OPT RP# ELEMENT NAME

35 250 CE

36 250 CE

Citizenship

Primary Language

37 2 IS

38 250 CE

39 1 ID

Living Arrangement

Publicity Code

Protection Indicator

40 2 IS

41 250 CE

42 250 XPN

43 250 CE

44 250 CE

45 250 XPN

46 250 XTN

47 250 CE

48 2 IS

49 20 ST

Student Indicator

Religion

Mother's Maiden Name

Nationality

Ethnic Group

Contact Person's Name

Contact Person's Telephone Num.

Contact Reason

Contact Relationship

Job Title

50 30 JCC

51 250 XON

52 2 IS

53 2 IS

54 50 FC

55 250 CE

Job Class/Code

Guarantor Employer's Org. Name

Handicap

Job Status

Guarantor Financial Class

Guarantor Race

IN1

SEQ LEN DT OPT RP# ELEMENT NAME

1 4 SI R

2 250 CE R

Set ID – IN1

Insurance Plan ID

3 250 CX R Y

Insurance Company ID

4 250 XON Y

Insurance Company Name

5 250 XAD Y

Insurance Company Address

6 250 XPN

7 250 XTN

8 12 ST

9 130 XON

10 12 CX

11 250 XON

12 8 DT

13 8 DT

Y

Y

Y

Y

Insurance Co. Contact Person

Insurance Co Phone Number

Group ID

Group Name

Insured’s Group Emp. ID

Y

Insured’s Group Emp. Name

Plan Effective Date

Plan Expiration Date

14 250 CM

15 3 IS

16 250 XPN

17 2 IS

18 26 TS

19 250 XAD

Authorization Information

Plan Type

Y

Name of Insured

Insured’s Relationship to Patient

Insured’s Date of Birth

Y

Insured’s Address

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SEQ LEN DT OPT RP# ELEMENT NAME

20 2 IS

21 2 IS

Assignment of Benefits

Coordination of Benefits

22 2 ST

23 2 ID

24 8 DT

Coord. of Ben. Priority

Notice of Admission Flag

Notice of Admission Date

25 2 ID

26 8 DT

27 2 IS

28 15 ST

29 26 TS

30 250 XCN

31 2 IS

32 2 IS

33 1 NM

34 1 NM

Report of Eligibility Flag

Report of Eligibility Date

Release Information Code

Pre-Admit Cert(PAC)

Verification Date/Time

Verification By

Type of Agreement Code

Billing Status

Lifetime Reserve Days

Delay Before L.R. Day

35 8 IS

36 15 ST

37 12 CP

38 12 CP

39 4 NM

40 12 CP

41 12 CP

42 250 CE

43 1 IS

44 250 XAD

45 2 ST

46 8 IS

47 3 IS

48 2 IS

49 250 CX

Company Plan Code

Policy Number

Policy Deductible

Policy Limit – Amount

Policy Limit – Days

Room Rate –Semi Private

Room Rate – Private

Y

Insured’s Employment Status

Insured’s Sex

Y

Insured’s Employer Address

Verification Status

Prior Insurance Plan ID

Coverage Type

Handicap

Insured’s ID Number

IN2

SEQ LEN DT OPT RP# ELEMENT NAME

1 250 CX Y

Insured’s Employee ID

2 11 ST

3 250 XCN

4 1 IS

Y

Insured’s SSN

Insured’s Employer Name

Employer Information Data

5 1 IS

6 15 ST

7 250 XPN

8 15 ST

9 250 XPN

10 20 ST

Y

Y

Y

Mail Claim Party

Medicare Health Ins Card No.

Medicaid Case Name

Medicaid Case Number

Champus Sponsor Name

Champus ID Number

121

NOTES

NOTES

empower Inpatient+Ambulatory

SEQ LEN DT OPT RP# ELEMENT NAME

11 250 CE

12 25 ST

Dependent of Champus Recipient

Champus Organization

13 25 ST

14 14 IS

15 2 IS

Champus Station

Champus Service

Champus Rank/Grade

16 3 IS

17 8 DT

18 1 ID

19 1 ID

20 1 ID

21 1 ST

22 250 XPN

23 30 ST

24 8 IS

25 250 CX

Champus Status

Champus Retire Date

Champus Non-Avail Cert on File

Baby Coverage

Combine Baby Bill

Blood Deductible

Y

Special Coverage Approval Name

Special Coverage Approval Title

Y

Non-Covered Insurance Code

Y

Payor ID

26 250 CX

27 1 IS

28 250 CM

29 250 CM

30 250 CM

31 2 IS

32 2 IS

33 250 CE

34 250 CE

35 2 IS

36 250 CE

37 1 ID

38 2 IS

39 3 IS

40 250 XPN

41 250 CE

42 3 IS

43 1 IS

44 8 DT

45 8 DT

46 20 ST

47 20 JCC

48 2 IS

49 250 XPN

50 250 XTN

51 2 IS

52 250 XPN

53 250 XTN

Y

Y

Y

Payor Subscriber ID

Eligibility Source

Room Coverage Type/Amount

Policy Type/Amount

Daily Deductible

Living Dependency

Ambulatory Status

Y

Citizenship

Primary Language

Living Arrangement

Publicity Indicator

Protection Indicator

Student Indicator

Religion

Mother’s Maiden Name

Nationality

Ethnic Group

Marital Status

Insured’s Employment Start Date

Insured’s Employment Stop Date

Job Title

Job Code / Class

Job Status

Y

Employer Contact Person Name

Y

Employer Contact Person Phone No.

Employer Contact Reason

Y

Insured’s Contact Person’s Name

Y

Insured’s Contact Person Phone No.

NOTES

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empower Inpatient+Ambulatory

SEQ LEN DT OPT RP# ELEMENT NAME

54 2 IS

55 8 DT

Y

Insured’s Contact Person Reason

Relationship to the Patient Start Date

NOTES

56 8 DT

57 2 IS

58 250 XTN

Y

Relationship to the Patient Stop Date

Insurance Co. Contact Reason

Insurance Co. Contact Phone No.

59 2 IS

60 2 IS

61 250 CX

62 2 IS

63 250 XTN

64 250 XTN

65 250 CE

66 2 ID

67 2 ID

68 2 ID

69 250 XON

70 250 XON

71 250 CE

72 250 CE

Y

Y

Y

Y

Policy Scope

Policy Source

Patient Member Number

Guarantor’ Relationship to Insured

Insured’s Telephone No – Home

Y

Insured’s Telephone No – Bus.

Military Handicapped Program

Suspend Flag

Copay Limit Flag

Stoploss Limit Flag

Insured Organization Name and ID

Insured Employer Org. Name and ID

Race

HCFA Pat. Relationship to Insured

ORC

SEQ LEN DT OPT RP# ELEMENT NAME

1 2 ID R

2 22 EI C

3 22 EI C

Order Control

Placer Order Number

Filler Order Number

4 22 EI

5 2 ID

6 1 ID

7 200 TQ

8 200 CM

Placer Group Number

Order Status

Response Flag

Quantity/Timing

Parent

9 26 TS

10 120 XCN

11 120 XCN

12 120 XCN

13 80 PL

Date/Time of Transaction

Entered By

Verified By

Ordering Provider

Enterer’s Location

14 40 XTN

Y/2 Call Back Phone Number

15 26 TS

Order Effective Date/Time

16 200 CE

17 60 CE

Order Control Code Reason

Entering Organization

18 60 CE

19 120 XCN

Entering Device

Action By

NOTES

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empower Inpatient+Ambulatory

OBR

SEQ LEN DT OPT RP# ELEMENT NAME

1 4 SI C

Set ID – OBR

2 75 EI C

Placer Order Number

3 75 EI R

4 200 CE

5 2 ID

6 26 TS C

7 26 TS C

Filler Order Number

Universal Service ID

Priority

Requested Date/Time

Observation Date/Time

8 26 TS C

9 20 CQ

Observation End Date/Time

Collection Volume

10 60 XCN Y*

Collection Identifier

11 1 ID

Specimen Action Code

12 60 CE

Danger Code

13 300 ST C

14 26 TS

Relevant Clinical Info.

Specimen Received Date/Time

15 300 CM

Specimen Source

16 80 XCN Y*

Ordering Provider

17 40 XTN

Y/2 Order Callback Phone Number

18 60 ST

19 60 ST

20 60 ST

21 60 ST C

22 26 TS

Placer Field 1

Placer Field 2

Filler Field 1

Filler Field 2

Results Rpt/Status Change Dt/Tm

23 40 CM

24 10 ID C

25 1 ID

26 400 CM

27 200 TQ

Charge To Practice

Diagnostic Serv. Section ID

Result Status

Parent Result

Y*

Quantity/Timing

28 150 XCN

Y/5 Result Copies To

29 150 CM

Parent Number

30 20 ID

31 300 CE

32 200 CM

Y*

Transportation Mode

Reason for Study

Principal Result Interpreter

33 200 CM

34 200 CM

35 200 CM

36 26 TS

37 4 NM

Y

Y

Y

Assistant Result Interpreter

Technician

Transcriptionist

Scheduled Date/Time

Number of Sample Containers

38 60 CE

39 200 CE

40 60 CE

Y

Transport Logistics of Coll. Sample

Y

Collector’s Comment

Transport Arrange. Responsibility

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empower Inpatient+Ambulatory

SEQ LEN DT OPT RP# ELEMENT NAME

41 30 ID

42 1 ID

43 200 CE Y

Transport Arranged

Escort Required

Planned Patient Transport Comment

NOTES

OBX

SEQ LEN DT OPT RP# ELEMENT NAME

1 10 SI

Set ID – OBX

2 2 ID R

3 590 CE R

Value Type

Observation Identifier

4 20 ST C

5 65536 * C Y

Observation Sub-Id

Observation Value

6 60 CE

Units

7

8

9

10

11

12 26

13 20

14 26

15 60

10

5

5 NM

5 ID

1

ST

ID

References Range

Y/5 Abnormality Flags

ID R

Y

Probability

Nature of Abnormal Test

Observation Result Status

TS

ST

TS

CE

16 80 XCN

17 60 CE Y

Date Last Obs. Normal Values

User Defined Access Checks

Date/Time of the Observation

Producer’s Id

Responsible Observer

Observation Method

AL1

SEQ LEN DT OPT RP# ELEMENT NAME

1 4 SI R

Set ID – AL1

2 2 IS

3 60 CE R

4 2 IS

5 15 ST

6 8 DT

Allergy Type

Allergy Code/Mnemonic/Description

Allergy Severity

Allergy Reaction

Identification Date

NTE

SEQ LEN DT OPT RP# ELEMENT NAME

1 4 SI

Set ID - NTE

2

3

8 ID

64k FT Y

Source of Comment

Comment

NOTES

NOTES

NOTES

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empower Inpatient+Ambulatory

FT1

SEQ LEN DT OPT RP# ELEMENT NAME

1 4 SI

Set ID – FT1

2 12 ST

3 10 ST

4 26 TS R

Transaction ID

Transaction Batch ID

Transaction Date

5 26 TS

6 8 IS R

7 80 CE R

8 40 ST B

9 40 ST B

Transaction Posting Date

Transaction Type

Transaction Code

Transaction Description

Transaction Description – Alt

10 6 NM

11 12 CP

12 12 CP

13 60 CE

14 60 CE

15 12 CP

16 80 PL

17 1 IS

18 2 IS

19 60 CE

20 120 XCN

21 120 XCN

22 12 CP

23 22 EI

24 120 XCN

25 80 CE

Y

Transaction Quantity

Transaction Amount – Extended

Transaction Amount – Unit

Department Code

Insurance Plan ID

Insurance Amount

Assigned Patient Location

Fee Schedule

Patient Type

Diagnosis Code

Performed By Code

Ordered By Code

Unit Cost

Filler Order Number

Entered By Code

Procedure Code

NOTES

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empower Inpatient+Ambulatory

Appendix 1A: Hospital Staff Contact Information

Identifying hospital leadership and the implementation team whose resources will be impacted by Empower is essential to its success. Please complete the table below within one week of contract signing and email it to the Empower Project Manager assigned to your hospital.

Title

Administration

CEO

CFO

CIO

CNO

COO

Directors/Managers

Billing

ED Medical Director

ED Nurse Manager

Information Systems

Laboratory

Marketing/Public Relations

Medical Records

Pharmacy

Quality Assurance

Radiology

Registration

Risk Management

Other Key Project Resources

Clinical Analyst

Hardware Specialist

Interface Resource or

Company

Network Administrator

Project Manager

SQL/Database Admin

Systems Analyst

Unit Clerk/s

Name Phone Email

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Appendix 1B: Implementation Project Timeline Check List

Status Task SubTask/Checklist

Phase I - Project Kickoff + Assessment

Introductory Call: Project Team Agenda to Include

Identify potential weekly phone conference

Project Packet

Prepared/Shipped

Identify potential target Go-Live date

Identify potential changes to standard project plan

Materials to include

PM to PM Call

Implementation Manual

Reference Material

Projected Project Timeline

Agenda to Include

Confirm Packet receipt

Review Packet

Set expectations and identify resources

IT Conference Call

Hardware

Connectivity

Security

Interfaces

Timeline

Specs

Purchase Hardware

Team Conference Call Agenda to Include

Identify registration interface capabilities

Choose EmpowerSystems™ Kick Off Meeting

Identify Hospital Workflow Team

Phase II- Data Collection and Application Development

Provide Hospital Data

Laboratory Dictionary

Radiology Dictionary

128

Resource

EmpowerSystems™

EmpowerSystems™

EmpowerSystems™

EmpowerSystems™

PM

PM

PM

PM

PM

PM

PM

PM

EmpowerSystems™+

Hosp IT

EmpowerSystems™+

Hosp IT

EmpowerSystems™+

Hosp IT

EmpowerSystems™+

Hosp IT

EmpowerSystems™+

Hosp IT

EmpowerSystems™+

Hosp IT

EmpowerSystems™+

Hosp IT

Hospital

Everyone

Everyone

Everyone

Hospital

Hospital

Hospital

Hospital

empower Inpatient+Ambulatory

Status Task

Optional

Optional

SubTask/Checklist

ED Charges Nursing Inventions/Procedures and RN LOS

Dictionary

Question and Responses Laboratory

Question and Responses Radiology

PCP Demographic and Contact Information with Fax

Number and secure Email addresses

EM Physicians Signature and DEA Number and HIS Order

Entry Identification Number

List of ED staff and HIS logins

List of ED room numbers

List of Triage Categories

Sample messages for interfaces

Map of zones/exam rooms

Hardware Received

Operating System and Support Software Installation

Hospital Confirms MS Operating System Never Logs Off user to prevent PDF Generator Shut Down

Hospital Confirms MS Operating System Password Never

Changes to prevent PDF Generator Shut Down

EmpowerSystems™ submits Scanner DLL for Hospital

Hospital Installs MS Internet Information Services(IIS) & open SMTP Ports or provide Email Exchange Server-and

/Provide SMTP Address

Hospital Installs Scanner DLL and Tests Scanning into

EmpowerSystems™

Hospital Installs EmpowerSystems™ Launcher on every

Client Computer from the ECDS Shared Folder

System Connectivity

Hospital Installs Support Software on Server for MS

Operating System 2000 must install Microsoft Data

Access Components (MDAC) 2.8 and also install Dot Net

Framework 1.1 or greater (XP OS already has these tools)

Hospital Sets the Display Screen on Computer Monitor

1024x768 resolution

Hospital Provides High Speed Internet Access VPN (Only

MS Virtual or Cisco VPN) with Logins and Passwords

Hospital Provides High Speed Internet Access Remote

Software connection (Only MS Remote Desktop or PC

Anywhere) and with Logins and Passwords

EmpowerSystems™ Software Installation Test and Live

Install EmpowerSystems™

Resource

Hospital

Hospital

Hospital

Hospital

Hospital

Hospital

Hospital

Hospital

Hospital

Hospital

Hospital

Hospital

EmpowerSystems™

Hospital

EmpowerSystems™+

Hosp IT

Hospital

Hospital

Hospital

Hospital

Hospital

Hospital

EmpowerSystems™

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empower Inpatient+Ambulatory

Status Task

Optional

Optional

SubTask/Checklist

Install EmpowerSystems™ Table Editor

Install EmpowerSystems™ Complex Report Writer

Install and Tests Faxing Software to PCP Offices

Install and Tests Emailing Software to PCP Email

Accounts

Install PDF Generator

Test Automatic EmpowerSystems™ Pager

EmpowerSystems™ Table

Building

CPOE/Charge Capture

EmpowerSystems™ will Order Diagnostic Tests using hospitals mnemonics

EmpowerSystems™ will identify the correct Diagnostic

Diagnostic Results Table

Results using the hospitals mnemonics

Phase III - Testing, Training, and Technical Readiness

Workflow and Training

Resource

EmpowerSystems™

EmpowerSystems™

EmpowerSystems™

EmpowerSystems™

EmpowerSystems™

EmpowerSystems™

EmpowerSystems™

Discuss Workflow Issues on Site Evaluation

Determine Nurse Onsite Training Dates

Send Nurses Training Power Point Presentation Starter

Kit

Choose Physician Internet Training Dates

Send Physician Training Power Point Presentation Starter

Kit

Training Nurses-Hospital Coordinate and schedule Nurse

Training

Training Physicians-Hospital Coordinate and schedule

Physician Training

Deadline for Front end user training

EmpowerSystems™

EmpowerSystems™-

SF

EmpowerSystems™-

SF

EmpowerSystems™-

SF

EmpowerSystems™-

SF

EmpowerSystems™-

SF

EmpowerSystems™-

SF

EmpowerSystems™-

SF

EmpowerSystems™-

SF

EmpowerSystems™-

SF

EmpowerSystems™ Meeting

Meet to discuss EmpowerSystems™ impacts departments

EmpowerSystems™ meets and presents

EmpowerSystems™ to Hospital Coders

EmpowerSystems™ meets and presents

EmpowerSystems™ to Laboratory Director

EmpowerSystems™ meets and presents

EmpowerSystems™ to Radiology Director

EmpowerSystems™ meets and presents

EmpowerSystems™

EmpowerSystems™

EmpowerSystems™

EmpowerSystems™

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empower Inpatient+Ambulatory

Status Task SubTask/Checklist

EmpowerSystems™ to Pharmacy Director

Resource

Interface Build and Test

Phase IV - Go-Live

Go Live Countdown

EmpowerSystems™ Go Live

EmpowerSystems™ meets and presents

EmpowerSystems™ to HIM

EmpowerSystems™ meets and presents

EmpowerSystems™ to QA and Risk Management

EmpowerSystems™ meets and presents

EmpowerSystems™ to Registration and Unit Clerks

Hospital imports ED PDF Chart using Hospital Document

Imaging & Management System

Registration Interface Building and Testing-

EmpowerSystems™ Portion

Registration Interface Building and Testing-Hospital

Portion

Diagnostic Results interface Building and Testing-

EmpowerSystems™ Portion

Diagnostic Results interface Building and Testing-

Hospital Portion

CPOE/Charge Capture Interface testing-Always Last

Interface to be Built & Tested-EmpowerSystems™

Portion

CPOE/Charge Capture Interface testing-Always Last

Interface to be Built & Tested-Hospital Portion

Monday Walk Through

Pre-Go Live task list

Arrange for office near or a computer in ED with remote software connection to EmpowerSystems™ Server for support

Tracking Systems Installation for other ED areas and

Departments During Go Live Week

EmpowerSystems™ Go Live

Install EmpowerSystems™ Table Editor on assigned

Hospital Employee Computers During Go Live Week

Train Hospital Employee on EmpowerSystems™ Table

Editor During Go Live Week

Optional Configure BioAlert (If requested)

Phase V - Post GoLive Assessment and Transition

EmpowerSystems™ Senior

Checkout meeting During Go

Go Live Evaluation and Review

EmpowerSystems™

EmpowerSystems™

EmpowerSystems™

Both

Interface Team

Interface Team

Interface Team

Interface Team

Interface Team

Interface Team

EmpowerSystems™

PM

Hospital IT

EmpowerSystems™

EmpowerSystems™

EmpowerSystems™

TBD

EmpowerSystems™

EmpowerSystems™

Admin + Hosp Exec

131

empower Inpatient+Ambulatory

Status Task

Live Week Thursday

CPOE/Charge Capture Interface

Go Live

SubTask/Checklist

See EmpowerSystems™ Implementation Manual

Resource

Team

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empower Inpatient+Ambulatory

Appendix 2A: Business Agreement

This agreement is between EmpowerSystems™ (Empower) and the hospital.

Empower will be accessing confidential healthcare information on the medical evaluation and treatment of patients in the Emergency Department:

Empower agrees to the following:

To treat patient healthcare information as confidential.

To use the information only for the purpose of providing the service for which ECDS is under contract with the hospital.

To disclose the information only to the business/business associate’s employees who need access to the information in order to provide the services under the contract and who have signed an agreement requiring those employees to keep the information in confidence.

To return the information in usable form upon request or upon completion of the work contract.

SIGNATURES:

Hospital Representative: ___________________________________

Date: __________________

Empower Representative: ___________________________________

Date: __________________

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Appendix 3A: Empower RN Skills Verification

Trainee Name: ___________________________________ Date: _______________

Training verified by: ___________________________________________________

General

 Log In and Change Password

 Add Patient (ex. John Doe)

 Modify patient tracker by nurse, by room number, change from alphabetical order to room number order, how to change initials from one primary RN to another, put multiple patients in one room, change room number.

 Enter information in Triage I to expedite care of critical patient:

 PCP: unk

 Chief Complaint: Unk or, i.e. Chest Pain

 Infection Control: Unk

 Allergies: Unk

 Return to Patient Tracking

 Complete Triage I, II, and III. Understands JCAHO requirements and rationale.

 Note diagnostic orders within the scope of job description and hospital policy.

 Document individual medical orders/interventions and use of standard order sets.

 Document verbal orders per hospital policy.

 Document response/cancel/refused to medical orders/interventions.

 Document nursing note, change time, change date.

 Document nursing diagnosis/expected outcome/goal achieved and rationale

 Document consulting physician notifications.

 View scan and delete scanned documents.

 View physician assessments, and old records.

 View/modify discharge instructions and check prescriptions.

 Print all, temporary triage, and respond to prompts, print chart.

 Understands safety prompts are built into the print menu.

 Understands the prompt for abnormal VS and appropriate use of override.

 Print copies of orders for ancillary, RN and ED use. med/pharmacy orders.

 Medication Reconciliation process in EmpowerSystems™.

 Demonstrates use of bed manager.

 Edit ED Staff (Super-User)

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Appendix 3B: Empower Tech Skills Verification

Trainee Name: ___________________________________ Date: _______________

Training verified by: ___________________________________________________

General

 Log In and Change Password

 Add Patient (ex. John Doe)

 Modify patient tracker by nurse, by room number, change from alphabetical order to room number order, how to change initials from one primary RN to another, put multiple patients in one room, change room number.

 Enter Repeat Vital Signs, noting ability to change time and date

 Note diagnostic orders within the scope of job description and hospital policy. (For UC/ ED Tech see hospital policy to be determined)

 Document nursing note, change time, change date. add note in Nurses Notes within scope of job description.

 Document consulting physician notifications.

 View scan and delete scanned documents.

 View physician assessments, and old records.

 Print copies of orders for ancillary, RN and ED use. med/pharmacy orders.

 Demonstrates use of bed manager.

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empower Inpatient+Ambulatory

Appendix 3C: Empower MD Skills Verification

Trainee Name: ___________________________________ Date: _______________

Training verified by: ___________________________________________________

Login & Tracking Board

 Log In and Change Password

 Name appears in lower left corner

Review Tracking Board

 Adding initials

 Sort by initials

 Sort by Exam Room

 N and E for UBERM

 R, D and C

 Viewing Labs

 Gray buttons

 Room number sort

Select Patient

 Chief Complaint (must select from the list)

 Social History

 Use of lists, the art of scrolling

 Free-text guidelines

Reviewing the chart

 Review Triage (3 screens)

 View Old Records

 View Nurses Notes and Repeat Vital signs

 Responses to Medical Interventions

 Scanned documents

Physical Exam

 Left side is normal statements

 Right side is more options

 Repeat Physical Exams

Diagnostics

 Check boxes

 Nonstandard Tests

 Reviewing Results (with & without Interface)

 Print Nurses Orders (Consider CPOE)

 Only able to choose from lists

Medical Interventions

 Standard Order Sets

 Ordering Diagnostics in Medical Interventions

 Verbal orders/Orders entered by nursing

 Avoid free-text if able

 Acknowledging verbal/nursing orders

 Print Nurses Orders (Consider CPOE)

 Medication Allergy Alert

 Medication Interaction Alert

Lacerations and Other Procedures

 Coding impact

 IV infusion time

 Choosing from lists only

Notifications

 Trauma requirement

 Use of N/A

Diagnoses

 Coding impact

 Chief complaint as default first diagnosis

 Required second diagnosis

Discharge Instructions

 Additional Information

 Prescription Writer

 Work and School Release

Set Chart Ready to Print

 Smart Technology

 Scoring Chart

 Medical Decision Making

Chart Addendums

 Culture/Rad/Other follow up

 Return Patient to Tracker

 Document in Repeat Physical Exam

 Remove from tracker and PDF is updated

 Transcription guidelines

 Table Edits per hospital designee

 Report Writer

 Chart Audits by Super-users

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empower Inpatient+Ambulatory

Appendix 3D: Physician Electronic Signature

Empower will automatically sign the ED chart and prescriptions (if allowed by your state pharmacy board) for the physician.

First, Middle, Last Name, Credentials___________________________________________________

Please Print Legibly: ex. John Q. Medicine, DO

DEA Number ____________________(If preferred to be electronically included on Rx)

User ID ____________________(Usually same as host HIS system)

Start Date __________________

Physician Signature/s

Please sign your name

below

exactly as you would like it to appear as this will be digitized and imported into the system.

***Please avoid writing on the lines***

Additional boxes are “just in case” if used, identify preferred signature.

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Appendix 4A: Computer Documentation Abbreviations

LRF

LPF

RIF

RMF

RRF

RPF

FB c

S

RLE

LLE

RUE

LUE

BLE

LIF

LMF

LNMP

PVD

SLE

HD MWF

HD T Th S

LD

LD

SOB

DOE

PND

CAD

HTN

CHF

CVA

L

R

B

XRT

Abbreviation

History

HA

GU

GI

ENT

Interpretation

Headache

Genitourinary Tract

Gastrointestinal Tract

Ear Nose Throat

Coronary Artery Disease

Hypertension

Congestion Heart Failure

Cerebral Vascular Accident

Left

Right

Bilateral

Radiation Treatment

Last Normal Menstrual Period

Peripheral Vascular Disease

Systemic Lupus Erythematosus

Hemodialysis Mon Wed Fri

Hemodialysis Tues Thur Sat

Last Dose

Last Drink

Shortness of Breathe

Dyspnea on Exertion

Paroxysmal Nocturnal Dyspnea

Foreign Body

With

Without

Right Lower Extremity

Left Lower Extremity

Right Upper Extremity

Left Upper Extremity

Bilateral Upper Extremity

Left Index Finger

Left Middle Finger

Left Ring Finger

Left Pinky Finger

Right Index Finger

Right Middle Finger

Right Ring Finger

Right Pinky Finger

138

Abbreviation

NA

Assx

BLE

Abbreviation

Physical Exam

General Appearance

Neck

ROM

TMG

SQ

Cardiac

DEM

SEM

RRR

IRR

Lung

L

R d/c

MMM

DMM

PERRL

EOMI

NT

O

Ox1

Ox2

Ox3

Skin

No Abbreviations

HEENT

HEENT

FB

TM

BS

CTA

Ret

Poor AM

“+”

“-“ empower Inpatient+Ambulatory

Interpretation

Non-Applicable

Associated Symptoms

Bilateral Lower Extremity

Interpretation

Alert

Oriented

Oriented Self

Oriented Self & Time

Oriented Self, Time & Place

Head Ears Eyes Nose Throat

Foreign Body

Tympanic Membrane

Left

Right discharge

Moist Mucous Membranes

Dry Mucous Membranes

Pupils Equal Round Reactive Light

Extra Ocular Muscles Intact

Non-Tender

Range of Motion

Thyroid Megaly

Subcutaneous

Diastolic Ejection Murmur

Systolic Ejection Murmur

Regular Rate Rhythm

Irregular Rate Rhythm

Breath Sounds

Clear too Auscultation

Retractions

Poor Air Movement

Positive

Negative

139

BS

WNL

RLQ

LLQ

RUQ

LUQ

BUQ

BLQ

PS c

Abbreviation

Chest Wall

LLSB

RLSB

BLSB

Abdomen

s

Dist

Genital Exam

Cx

CMT

Ut

Adx

“+”

“-“

CxOs

Extremities

BLE

RLE

LLE

RUE

LUE

BLE

LIF

LMF

LRF

LPF

RIF

RMF

RRF

RPF

AC Joint

DIP

PIP empower Inpatient+Ambulatory

Interpretation

Left Lower Sternal Border

Right Lower Sternal Border

Bilateral Lower Sternal Border

Bowel Sounds

Within Normal Limits

Right Lower Quadrant

Left Lower Quadrant

Right Upper Quadrant

Left Upper Quadrant

Bilateral Upper Quadrant

Bilateral Lower Quadrant

Peritoneal Signs

With

Without

Distention

Cervix

Cervical Motion Tenderness

Uterus

Adnexa

Positive

Negative

Cervical Os

Bilateral Lower Extremity

Right Lower Extremity

Left Lower Extremity

Right Upper Extremity

Left Upper Extremity

Bilateral Upper Extremity

Left Index Finger

Left Middle Finger

Left Ring Finger

Left Pinky Finger

Right Index Finger

Right Middle Finger

Right Ring Finger

Right Pinky Finger

Acromio-Clavicular Joint

Distal Inter Phalanges

Proximal Inter Phalanges

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LLE

RUE

LUE

BLE

2pt

PP

Prop

NL

SLR

XSLR

PROM

CBR

Neuro

MMG

Ext

MAE=B

BLE

RLE

F/N intact

H/S

GSS intact

Miscellaneous

CM

Abbreviation

IP

MCP

DIPJ

PIPJ

IPJ

MCPJ

MTP

MTPJ

BP

RP

FP

PP

DP

PT

AROM

Exp empower Inpatient+Ambulatory

Interpretation

Inter Phalanges

Meta Carpal Phalanges

Distal Inter Phalanges Joint

Proximal Inter Phalanges Joint

Inter Phalanges Joint

Meta Carpal Phalanges Joint

Meta Tarsal Phalanges

Meta Tarsal Phalanges Joint

Brachial Pulse

Radial Pulse

Femoral Pulse

Popliteal Pulse

Dorsal is Pedis Pulse

Posterior Tibialis Pulse

Active Range of Motion

Partial Range of Motion

Capillary Blood Refill

Major Muscle Groups

Extremity

Moves All Extremities Equal Bilaterally

Bilateral Lower Extremity

Right Lower Extremity

Left Lower Extremity

Right Upper Extremity

Left Upper Extremity

Bilateral Upper Extremity

Two point discrimination

Pin Prick

Proprioception

Normal

Straight Leg Raise

Cross Straight Leg Raise

Finger to Nose Intact

Heel/ Shin Intact

Gross Sensory System Intact

Cardiac Monitor

Explored

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Appendix 9A: Empower Table Names and Descriptions

The Empower look-up tables are listed below. These tables are pre-populated with the common clinical terminology used by physician and nurses when documenting on the chart. In addition, some tables are used by the smart technology built into Empower. The hospital will have an Empower table editor only to those tables not affected by the smart technology. Each field on an Empower form is connected to a look-up table. The hospital can identify the look-up table that is connected to a field on the form by reading the table description and then finding it on the Empower forms. Empower recommends only populating tables and not deleting tables. tblluALDrugs tblluApplicationSettings tblluBelongDiagnostic tblluDiagMapping tblluDIRx tblluDIRxRefills tblluDischInstAddComments tblluDischInstrFollowUpOther tblluDischInstWorkSchool tblluDischInstWorkSchoolRestriction tblluDrug2Drug tblluERSort tblluExamRoom tblluGenGender tblluGenLanguage tblluGenLivesWith tblluGenLowMedHigh tblluGenNegPos tblluGenPlace tblluGenTimeUnits tblluGroups tblluHospital tblluLabResultsABG tblluLabResultsAmylaseLipase tblluLabResultsBloodCulture tblluLabResultsBMPChem7 tblluLabResultsCardiacMarkers tblluLabResultsCBC

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This table contains drug allergy and classification

This table contains the on and off switch for certain hospital specific features in EmpowerSystems™.

This table Check Boxes on the physician diagnostic form with specific tests.

This table groups certain diagnostic studies in order for smart technology to functions

This is table contains the physician prescriptions

This table documents the number of default refills

This table conditions prewritten statements for the additional comments on the discharge form.

This table contains prewritten discharge instructions name and maps it to the hospital preferred name

This table contains information on when to return to work or school

This table contains information on any work or school restrictions or limitations.

This table contains drug to drug information and group classifications.

This table allows areas in the emergency department to be designated and sort on the tracking system.

This table lists all exam rooms in the emergency department

This table lists the patient gender options.

This table lists different languages a patient might speak.

This table list the different types of living arrangements.

This table lists the options for the assessing the Patient's, Parent or

Child readiness to learn.

This table contains the yes or no options for physician review of systems.

This table list options for the triage I injury location field.

This table list options for physician HPI onset of symptoms

Allows EmpowerSystems™ to assign role base options

This table contains the on and off switch for certain hospital specific features in EmpowerSystems™.

This table contains the different types of result interpretations for the diagnostic study ABG.

This table contains the different types of result interpretations for the diagnostic study Amylase & Lipase

This table contains the different types of result interpretations for the diagnostic study Blood Culter

This table contains the different types of result interpretations for the diagnostic study Basic Metabolic Panel/Chem7/Asterix

This table contains the different types of result interpretations for the diagnostic study Cardiac Markers

This table contains the different types of result interpretations for the diagnostic study CBC

tblluLabResultsCTScan tblluLabResultsEKG tblluLabResultsETOH tblluLabResultsGeneral tblluLabResultsGlucoseScan tblluLabResultsHgB tblluLabResultsLiverProfile tblluLabResultsPeakFlow tblluLabResultsPTPTT tblluLabResultsPulseOximetry tblluLabResultsQuantBHCG tblluLabResultsURHCG tblluLabResultsUrinalysis tblluLabResultsUrineCulture tblluLabResultsUrineDip tblluLabResultsUrineTox tblluLabResultsUSNucScan tblluLabResultsXRay tblluLabTestsGeneral tblluLabTestsRadStudies tblluLabTestXRay tblluMap2Map tblluMediMap tblluNursingDx tblluNursingOutcome tblluNursingPhrase tblluOrderLocation tblluPEDefaults tblluPhysAbdAppearance tblluPhysAbdBowelSounds tblluPhysAbdTenderness tblluPhysBack tblluPhysCardiac tblluPhysChest2 tblluPhysChestWall empower Inpatient+Ambulatory

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This table contains the different types of result interpretations for the diagnostic study Advance Radiology Studies

This table contains the different types of result interpretations for the diagnostic study EKG

This table contains the different types of result interpretations for the diagnostic study ETOH

This table contains the different types of result interpretations for the diagnostic study non standard studies

This table contains the different types of result interpretations for the diagnostic study point of care glucose scan

This table contains the different types of result interpretations for the diagnostic study point of care hemoglobin

This table contains the different types of result interpretations for the diagnostic study Liver Function Studies

This table contains the different types of result interpretations for the diagnostic study Peak Flow

This table contains the different types of result interpretations for the diagnostic study Pt& PTT

This table contains the different types of result interpretations for the diagnostic study Pulse Ox

This table contains the different types of result interpretations for the diagnostic study quantitative BHCG

This table contains the different types of result interpretations for the diagnostic study urine pregnancy

This table contains the different types of result interpretations for the diagnostic study urinalysis

This table contains the different types of result interpretations for the diagnostic study Urine Culture

This table contains the different types of result interpretations for the diagnostic study Point of Care Urine Dip Stick

This table contains the different types of result interpretations for the diagnostic study urine Toxicology

This table contains the different types of result interpretations for the diagnostic study

This table contains the different types of result interpretations for the diagnostic study ABG

This table contains the different types non standard diagnostic tests

This table contains the different types advanced radiology tests.

This table contains the different types plain x-rays

This table maps hospital dictionary to the physician dictionary for diagnostic results

This table maps hospital dictionary to the physician dictionary for diagnostic orders

This table lists the options for Nursing Diagnosis

This table lists the options for Nursing Outcomes

This table lists the options for prewritten phrases in the Nursing

Note.

This table lists the options in the medical order section for Location-

Response-Quantity field.

This defines the default normal physical exam (physician and nurse) based on patient age.

This table lists the options in the physical exam for abdominal appearance.

This table lists the options in the physical exam for abdominal auscultation.

This table lists the options in the physical exam during abdominal palpation.

This table lists the options in the physical exam during of the back.

This table list the options in the physical exam for cardiac auscultation

This table list the options in the physical exam for lung auscultation

This table list the options in the physical exam for chest wall palpation

tblluPhysChiefComplaintAsx tblluPhysCondition tblluPhysDiagnosis tblluPhysDisposition tblluPhysDuration tblluPhysExacerbatingFactors tblluPhysExtrAppearance tblluPhysExtremityLocation tblluPhysExtremityPulses tblluPhysExtremityROM tblluPhysExtrPain tblluPhysExtrSubLocation tblluPhysFrequency tblluPhysGeneralAppearance tblluPhysGU tblluPhysHEENT tblluPhysInterventions tblluPhysIVF tblluPhysLacerationDepth tblluPhysLacerationExploration tblluPhysLacerationLength tblluPhysLacerationLocation tblluPhysLacerationProcedure tblluPhysLacerationShape tblluPhysLocation tblluPhysLungs tblluPhysLymphatics tblluPhysNeck tblluPhysNeuroCoordination tblluPhysNeuroMotor tblluPhysNeuroSensory tblluPhysOnset tblluPhysOxygen tblluPhysPharmacyOrders tblluPhysPMHx tblluPhysProcedures tblluPhysQuality tblluPhysRadiations tblluPhysSkin tblluPulseLabel empower Inpatient+Ambulatory

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This table lists the options in the Triage and Physician for chief complaint.

This table lists the options in the physical exam for condition on disposition.

This table list the options in the for diagnosis

This table list the options in the medical intervention for disposition

This table lists the options in the history for duration of symptoms.

This table list the options in the in history for symptoms exacerbation and improving factors

This table lists the options in the physical exam for extremity appearance.

This table lists the options in the physical exam for identifying a particular area on the extremity.

This table lists the options in the physical exam for extremity circulation.

This table lists the options in the physical exam for extremity range of motion.

This table lists the options in the physical exam for extremity during palpation.

This table list the options in the physical exam for identifying a specific area on the extremity

This table lists the options in the in history for symptom frequency.

This table lists the options in the physical exam for general appearance.

This table lists the options in the physical exam for genital area.

This table lists the options in the physical exam for Head, Eyes, Ears,

Nose and Throat.

This table lists the options in medical interventions for medical orders.

This table lists the options in medical interventions for intravenous fluids.

This table lists the options in the laceration note for laceration depth.

This table lists the options in the laceration note for laceration exploration.

This table list the options in the laceration note for laceration length

This table list the options in the laceration note for laceration location

This table lists the options in the laceration note for laceration procedure.

This table lists the options in the laceration note for laceration description.

This table list the options in the history for location of symptoms

This table list the options in the physical exam for lung auscultation

This table lists the options in the physical exam for lymphatic system.

This table lists the options in the physical exam for the neck.

This table lists the options in the physical exam for coordination.

This table lists the options in the physical exam for nerve motor skills.

This table list the options in the physical exam for the nerve sensory evaluation

This table list the options in the history for onset of symptoms

This table list the options in medical interventions for oxygen requirements

This table list the options in admission orders for medication

This table lists the options in the history for other past medical history.

This table list the options in the laceration note for physician procedures.

This table lists the options in the history for quality of the symptoms.

This table lists the options in the history for radiation of the symptoms.

This table lists the options in the physical exam for the skin.

This table lists the options Vital Section/Heart Rate for the location of

tblluQuestionResponse tblluQuestions tblluRepeatExamPhrases tblluResponses tblluRiskCC tblluRiskDiagStudies tblluRiskDiffDx tblluRiskPertHxNeg tblluRiskPertPhysNeg tblluRNCharges tblluRNLOSCoding tblluRNLOSExceptions tblluRoleGroup tblluRoles tblluSecondaryDiagnosis tblluSecondaryDiagnosisMap tblluStandardOrders tblluTriageAgeIncrements tblluTriageAllergies tblluTriageArrivalMode tblluTriageAssesment tblluTriageAssessedDisability tblluTriageComaEye tblluTriageComaMotor tblluTriageComaVerbal tblluTriageDailyLiving tblluTriageExtrPulses tblluTriageExtrROM tblluTriageGoingHomeWith tblluTriageHistorian tblluTriageImmUTD tblluTriageInfectious tblluTriageIntervention empower Inpatient+Ambulatory

145 a specific pulse.

This table lists the mapping of the question and responses to the core

HIS.

This table list the options in the Diagnostic Order Entry for questions that are requested by the core HIS.

This table lists the options in the physical exam for prewritten repeat physician examinations.

This table list the options in the Diagnostic Order Entry for answers that are requested by the core HIS

This table lists the options in the High Risk Chief Complaints for symptoms.

This table lists the options in the High Risk Chief Complaints for diagnostic studies and medical interventions.

This table list the options in the High Risk Chief Complaints for differential diagnosis.

This table lists the options in the High Risk Chief Complaints for pertinent negatives in history.

This table list the options in the High Risk Chief Complaints for pertinent negatives in physical exam

This table lists the mapping of the facility charges to the core HIS.

This table list the options for setting the criteria to calculate the RN level of Service

This table lists the options to set the exceptions when calculating the

RN level of Service.

This table lists which groups are role based.

This table lists what roles have been set for the group.

This table lists secondary diagnosis and ICD9 that will print on ED chart.

This table maps the check boxes in past medical history to a secondary diagnosis.

This table lists the items which will display in the diagnostic and medical order sets.

This table lists the options in the triage history for duration of symptoms.

This table list the options in the triage history for allergy to medication, animals etc.

This table list the options in the triage I history for the patient mode of arrival to the hospital.

This table list the options in the triage I history for the patient assessment and acuity.

This table lists the options in the triage III assessment of disability.

This table lists the options in the triage II physical exam Glasgow coma sale eye opening.

This table lists the options in the triage II physical exam Glasgow coma sale motor function.

This table lists the options in the triage II physical exam Glasgow coma sale verbal function.

This table lists the options in the triage III for assessment of daily living needs.

This table lists the options in the triage II physical exam for extremity circulation.

This table lists the options in the triage II physical exam for extremity range of motion.

This table lists the options in the triage III for assessment of the patient transportation home.

This table list the options in the triage I history for the person providing the medical information on the patient.

This table list the options in the triage I history for the immunization history.

This table list the options in the triage I history for the patient infectious disease assessment.

This table lists the options in the triage III for the patient fall assessment.

tblluTriageLivingConditions tblluTriageMedDetailInfo tblluTriageMeds tblluTriageNutrition tblluTriageOBLabel tblluTriagePainScale tblluTriagePlan tblluTriagePsychStatus tblluTriageSkinColor tblluTriageStaffStatus tblluTriageTransportMode empower Inpatient+Ambulatory

This table lists the options in the triage III for assessment of how the patient lives.

This table list the options in the triage I history for how the medications arrived at the hospital.

This table lists the options in the triage history for home medication.

This table lists the options in the triage II physical exam for nutritional assessment.

This table list the options in the triage I history for pregnancy assessment.

This table list the options in the triage I history for pain assessment

This table lists the options in the triage III for the disposition plan.

This table lists the options in the triage II physical exam for general appearance.

This table lists the options in the triage II physical exam for skin color.

This table list the options in the triage I history for the physician assessment on the medical staff.

This table list the options in the triage I history for the patient mode of arrival in the ED.

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Appendix 13A: Workflow Procedure for CPOE Interface: Post Go-Live

The following is the recommended workflow procedure to implement during and post Go Live for

Empower CPOE Interface.

Reason

Even though the Empower CPOE Interface is working, sometimes and by accident, the wrong mnemonic was provided by the hospital, mapped incorrectly, or an unexpected question was not answered correctly or deactivated. In either case, when Empower passes the Hospital’s Health Information System

(HIS) this incorrect or missing information that is required to order the diagnostic study, the CPOE will fail for this particular order. This procedure is implemented to immediately identify any failed CPOE orders, correct, and to fine-tune the interface. Furthermore, this procedure is designed to prevent any delays in the medical evaluation of ED patients that require diagnostic studies.

Procedure

1. After the physician orders diagnostic studies with the Empower CPOE interface, a printed hard copy of the diagnostic studies will be generated, placed on a clip board and submitted to the

Unit Clerk.

2. The Unit Clerk will open the diagnostic portion of the patient’s account in the Hospital’s Health

Information System (HIS).

3. The Unit Clerk will compare the Diagnostic Orders generated in the Hospital’s Health

Information System (HIS) by the CPOE interface against the printed Hard Copy of the Diagnostic

Orders generated by the physician.

4. If the Unit Clerk identifies missing or incorrect diagnostic studies, the unit clerk will immediately update the Diagnostic Orders in the diagnostic studies portion of the patient’s account in the

Hospital’s Health Information System (HIS).

5. The Unit Clerk will also keep a log of any missing or incorrect diagnostic studies ordered through the CPOE Interface.

6. The CPOE Interface Log will track the Patient’s Name, Empower Diagnostic Study Name and the

Hospitals Mnemonic (Message).

7. The clinical administration will fax the log to Empower at (312) 276-8116 or email to [email protected]

so that the discrepancies can be corrected when future diagnostic studies are ordered through the interface (thereby fine-tuning the Empower CPOE interface).

The hospital will also have to assign a resource that EmpowerSystems™ can train how to update the Empower Order Entry Tables.

The procedure can be terminated after 90 days or until resolution of all discrepancies between the CPOE interface and the Printed Diagnostic Physician Orders.

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Appendix 13B: Hospital Order Entry Problem Log Sheet

Document all interfaced orders that do not pass through the Order Entry interface between Empower and Health Information

System. Please complete each row.

Patient Name Account Number Empower Order Name Hospital Code

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Appendix 13C: Diagnostic Results Interface Workflow - Post-Go Live

The following is the recommended workflow procedure to implement after the Go Live Date for

Empower Diagnostic Results Interface.

Reason

Even though the Empower Diagnostic Results Interface is working, sometimes and by accident the wrong diagnostic mnemonic or result was provided by the hospital. In either case, when Empower receives the diagnostic mnemonic and/ or results from the Hospital’s Health Information System (HIS), this incorrect or missing information will prevent Empower from displaying the correct diagnostic mnemonic or results to the physician. This procedure is implemented to immediately identify any failed or incorrect diagnostic mnemonic or results, correct, and to fine-tune the Diagnostic Results Interface.

Furthermore, this procedure is designed to prevent any delays in the delivering the diagnostic results information to the physician in order to expedite the clinical evaluation and the patient’s disposition.

Procedure

1. The physician will compare the Diagnostic Results generated off the printer from the Hospital’s

Health Information System (HIS) with the Diagnostic Results that are placed into Empower by the Hospital’s Health Information System (HIS).

2. If the physician identifies missing or incorrect diagnostic results, the physician will immediately update the Diagnostic results in the chart in the diagnostic studies section of Empower.

3. The physician will also keep a Log of any missing or incorrect diagnostic results identified from the Diagnostic Results Interface.

4. The Diagnostic Results interface Log will track the Patient’s Name and the Diagnostic Results

Name.

5. The clinical administration will fax the log to Empower at (312) 276-8116 or via email at [email protected]

so that the discrepancies can be corrected for future diagnostic results that are acquired through the interface (thereby fine-tuning the Empower Diagnostic Results interface).

6. The Diagnostic Results Interface Log will track the Patient’s Name, Empower Diagnostic Study

Name and the Hospitals Diagnostic Results Mnemonic/code.

The procedure can be terminated after 90 days or until resolution of all discrepancies between the

Diagnostic Results Interface into Empower and the Printed Diagnostic Results from the Hospital’s Health

Information System (HIS).

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Appendix 13D: Hospital Diagnostic Results Problem Log Sheet

Document all interfaced orders that do not pass through the Order Entry interface between Empower and Health Information

System. Please complete each row.

Patient Name Account Number Empower Order Name Hospital Code

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Empower User Troubleshooting Guide

User Issues

The screen is black, unable to enter anything.

Solution

Unable to type numbers using the numeric keys.

Make sure the "Num Lock" is on.

Check all connections and make sure the computer is plugged in.

Make sure the computer is turned on. If it is just one computer, this is an issue for your internal IT Department. If it is all computers, consult your internal IT Department before calling EmpowerSystems™.

Forgotten Password or new user without a log in or password.

Document scanned into incorrect chart.

Unable to close/print a chart due to abnormal or repeat vital signs.

Contact internal Account Administrator who has the ability to

Add/Edit Staff.

A scan entered into the wrong patient can be deleted using the

‘Delete Scan’ button and scanned into the correct chart.

Abnormal Vital Signs allows the user to "Override" and print/close the chart. It is a gray button at the bottom center. Repeat Vital Signs are required for certain chief complaints. The override button does not appear. You must enter a repeat set of VS. If this is not possible, document NA in all VS fields (NA/NA for BP) You can type See NN in the Pain field and make an explanation of why in the NN. This will come back as an abnormal Vital Sign and the user can "Override" and print/close the chart.

Unable to close/print a chart due to request for "Trauma

Notification".

The user should document NA in the notification screen for the simple trauma diagnosis that does not require a notification.

Request to merge charts for patients entered twice.

EmpowerSystems™ does not merge charts. This is a user issue. Those involved must manually remove documentation from the incorrect chart and re-enter into the correct chart. This can be done using copy and paste. The incorrect chart can be removed from the Tracker by clicking on the Disposition field.

New PCP to add to the system.

This can be done on the Discharge Instruction page (Add/Edit New

Provider). This is also managed by the internal Account Administrator via table editing.

Request for Discharge

The option for Discharge Instructions only opens when the disposition

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User Issues

Table edits and additions.

Solution instructions for a patient being

Transferred.

of Discharge is selected by the ED physician.

The hospital has designated staff to do these edits. Write request in the EmpowerSystems™ notebook for consideration. The additions/edits will be done internally.

You will need to change the Display Settings on that computer. Log out of EmpowerSystems™ and click "Start" in the lower left corner.

• Click Settings

• Click Control Panel

EmpowerSystems™ screen too small or too large, you can't see all the fields or unable to click some of the gray buttons.

• Click Settings

• Click Settings tab at top

• Set resolution to 1024x768 by moving your mouse on the little arrow until you see these numbers.

• Apply and Save

Contact a super-user or Internal IT if you need assistance.

Plasma Screen blank or displays incorrect information or lacks information.

Check connections; make sure it is turned on. Reboot the computer attached to this. Try all of this prior to calling the help line.

Time incorrect on the computer.

Log out of EmpowerSystems™ and right-click on the time display and change to the correct time. Contact internal IT if unable to change the time.

Lab Results not crossing to

EmpowerSystems™ or crossing slowly.

All lab diagnostics must be selected from the drop down tables if entered in Medical Interventions. If a blood test shows on the

Medical Interventions screen it was free-texted and that text is not mapped. Cancel the incorrect and re-enter appropriately.

If the test does appear in diagnostics contact the lab and then call the help line regarding this interface issue.

Patients not crossing to

Contact your IT department with patient examples and if they

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EmpowerSystems™ via the

ADT interface. (or crossing slowly)

determine it is not an internal problem, they should contact

EmpowerSystems™ Technical Support.

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Technical Support Guidelines

In an effort to allow Emergent calls to take precedence over Non-Emergent calls and provide more appropriate and efficient customer service, our Emergency phone support is an automated system, monitored by our technical support staff. Callers will be routed through a call script to ascertain if the issue is a true emergency and if the appropriate troubleshooting by hospital IT has been completed prior to selecting the option to leave an Emergent message for our team to respond to.

The Emergent Emergent Support Line

(877) 222-3237

is intended only to be available to hospital IT departments or designated EmpowerSystems™ clinical administrators so that appropriate on-site troubleshooting is completed prior to contacting EmpowerSystems™. The IT team should rule out network outages, hardware resources/availability, and integration prior to contacting

EmpowerSystems™ on an emergent basis to avoid financial penalties.

Empower Definition of an Emergency

Clinicians in the ED unable to document on one or more patients currently active in the ED, or complete integration failure between Empower and your Core Hospital Information System (ex: ADT failure,

Orders or Results not crossing for multiple patients).

Examples NOT Considered Emergencies

Forgotten Passwords or New User Setup – Your hospital system administrator has been provided training to manage user accounts in Empower.

Printing Problems – Empower has been set up at each site to work to the specifications identified during implementation. Any issues concerning printing should be managed through your IT department, as this is unlikely to be a result of Empower.

Interface Orders or Results on an Individual Patient – Unless this issue applies to multiple patients, open a Non-Emergent ticket on our support site and include specific examples to include MR#,

Account#, Date of Service, Test Examples, and what should have crossed.

Physician Signatures – As of v1.7.5, Empower provided your hospital with the ability to capture and manage all signatures via tablet PC. If you have not already done so, please make arrangements to acquire a tablet PC for this purpose, as we will no longer be accepting faxed signatures for processing.

PDF Generation – Empower employs notification technology to let us know when/if our PDF process is interrupted. This can naturally occur due to network errors and will be corrected quickly during normal business hours.

By calling the Emergent Emergent Support Line

(877) 222-3237

, selecting the correct option, and leaving a voice message will notify the technician on duty 24/7. This automated process takes approximately 15-

20 minutes to receive a response. Again, our Non-Emergent ticket system is always available by visiting www.empower.md

and choosing ‘Support’ in the top right corner of the web page. Additional details are on the proceeding pages. Please contact your Empower Project Manager if your team is unsure of the login and password.

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Empower Emergent Support Matrix

PRIORITY

METHOD DEFINITION

Emergent Emergent

Call Line

System Completely

Down

Issue Affecting

Entire System

Physicians Cannot

Document at All on

Any Patients

UPDATES

Continuous as

Information

Becomes Available

Management

Attention Required

ESCALATION

Within 2 Hours from

Initial Contact

RESOLUTION

4 Hours from Initial

Contact

Critical

Main Empower

Server Failure

Emergent

Call Line

System Up with

Degraded

Functionality

Entire Interface

Functionality Down for All Patients

Interface Server

Failures

Every 2 Hours Until

Resolved

Within 4 Hours from

Initial Contact

6 Hours from Initial

Contact

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Empower Non-Emergent Support Matrix

PRIORITY METHOD DEFINITION

High

Online

Ticketing

System

System Operational with Minor

Functionality Loss

Minor Subsystem

Functionality

Failures

Limited Data Entry /

Access Issues

General High Impact

Bug Fixes

UPDATES

Upon Resolution or

Weekly Until

Resolved

Medium

Online

Ticketing

System

Peripheral

Application Server

Failures

Minor Operational

Issues Without

Immediate Patient

Documentation

Impact

Report Requests

Upon Resolution or

Weekly Until

Resolved

Low

Online

Ticketing

System

Enhancement

Requests

General Assistance,

Information,

Training and Other

Service Requests

Upon Resolution or

Weekly Until

Resolved

ESCALATION

Within 24 Business

Hours from Contact

Within 36 Business

Hours from Contact

Within 48 Business

Hours from contact

RESOLUTION

32 Business Hours

Depending Upon

Scope and

Complexity

40 Business Hours

Depending Upon

Scope and

Complexity

80 Business Hours

Depending Upon

Scope and

Complexity

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Empower Escalation + Notification Matrix

ACTION

Identify Escalation Level

VP of Project

Management/First level

Support Team Notified

Notification Sent to Various

Levels of Mgt

Customer Informed of

Escalation Status

Second Level Support Team

Notified and Activated

Notification Sent to Operations and Various Levels of Mgt

Executive Mgt Notification

VP of Project Mgt/Executive

Mgt Contacts the Client

Scheduled Issue Status

Conference Call

Post Mortem & Follow-Up

RESPONSIBILITY

Site Support Rep (owner)

Site Support Rep (owner)

Site Support Rep (owner)

Site Support Rep (owner)

VP of Project Management

VP of Project Management

VP of Project Management

VP Proj Mgt/Exec Mgt

Empower and Client Technical and Project Mgt Teams

Site Support Rep/VP of Project

Mgt

RESPONSE TIME

Immediate

30 minutes after escalation

30 minutes after escalation

30-60 minutes after escalation

4 hrs after escalation

Every 2hrs and with issue updates

6 hrs after escalation

24 hrs after escalation

As needed

1 week after issue closure

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Client Support Quick Start Guide

Empower’s Non-Emergent Support System is a web-based portal that can be reached by selecting the

‘Support’ button atop any page of the website, or simply Click Here and bookmark the URL.

Locating the Support System

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Login

empower Inpatient+Ambulatory

 Each User at the hospital will have his own login and password. Use your email address as your login. Your initial password will be "welcome".

 Select ‘Remember Me’ and Click the ‘Log in’ button.

 Please reset your password immediately upon first entry.

For quick reference, please bookmark the login page in your web browser.

Support Center

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empower Inpatient+Ambulatory

Upon Login, you will see the Support Center page. From here you have these options:

1. View Tickets

Here you can View your existing Tickets.

2. Submit a Ticket

Submit a new support ticket here.

3. Knowledgebase

Access the empower Knowledge base here this will also interact with you automatically during a new ticket creation process.

4. News

News releases about the Empower and its products.

5. My Account

Located on the right task bar. Change your account settings and password here.

Reset Your Password

Click on the change password button in the My Account section.

Enter your old and new passwords and click Submit.

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empower Inpatient+Ambulatory

By clicking on My Account you can change your email and name settings.

Submit a Ticket

Select the appropriate Ticket Type for the issue you want to submit:

Clinical Issue

Any issues of a clinical nature where clinical workflow, terminology or resources are involved.

Billing + Coding

Any issues for review by our Coding+Billing team can be posted here.

Technical Issue

Any issues of a technical nature where programmers would most like need to be involved

Interface Issues

Any issues involving interfaces between your Empower system and your HIS/Ancillary systems/Devices

Sales

Any question you would like relayed to our sales team can be posted here.

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empower Inpatient+Ambulatory

Report Request

Any Report-related request or inquiry.

You must fill in the required fields (with *) and then fill out the body of the ticket with whatever specifics apply.

Knowledgebase

From this example you can see that our new knowledge base will try to recognize as you type in the body of the ticket and suggest articles from our knowledge base. This is a work in progress and will improve as time goes on and more articles are added to the knowledge base.

Upload File(s)

You can upload files to the ticket by browsing your computer to the file you would like to upload.

Add Recipients

You can add recipients who are not currently in the system to the ticket in the space provided and they will then be copied on all replies for that ticket only.

164

empower Inpatient+Ambulatory

See Example below of required fields and completed content (similar to an email).

The site will show you the information once the ticket is entered.

Viewing Existing Tickets

Select the "view tickets" option from the main client support page after logging in.

You will be taken to a page with a list of all the tickets that you have submitted. (If you are an Empower support administrator - which most users are- you will see all tickets submitted from your hospital.)

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empower Inpatient+Ambulatory

You can click on the ticket number to open the text of a particular ticket. You can also click on the headings at the top (last update, last replier, status, priority, department) to sort by that field.

Once you click the ticket number, the ticket will open with all of the replies in the body of the ticket.

From here, you can add an update, ask another question, provide necessary information, change the status or the priority and post the reply. The reply will go to the appropriate Empower team member.

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empower Inpatient+Ambulatory

Knowledgebase

If you go back to the main support page, you can also access the Knowledgebase by clicking the link for knowledge base:

You will be directed to the Knowledgebase , which will show categories for articles that pertain to

Empower functionality and technical issues. From here you can select the article you are interested in.

You may also be directed to the article when you are submitting a ticket (as explained previously).

You are now ready to submit, track, and monitor Non-Emergent tickets for your facility! We hope this guide will serve you well as you familiarize yourself with this user-friendly resource. As always, your

Empower project manager is available to discuss more specifics surrounding your Non-Emergent issues.

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empower Inpatient+Ambulatory

Empower Inpatient Sample Chart

168

Patient Demographics

Admission Data

Account Number Medical Record Admit Date Admit Time EMR MD

5/23/2011 15:33

Reason For Visit SHORTNESS OF BREATH

Other Doctors AHMED,ZAFAR ; ,

Comments

Patient Data

Patient Name Date of Birth Social Security

45380 AHMED, ZAFAR

MN Visit Dx

Race Sex

Primary Care MD

45380 AHMED, ZAFAR

Religion Marital

Admit Clerk

Maiden Name Patient Email

F BAP M

Address 1

Address 2

City

Employer

Address 1

Address 2

City

UNEMPLOYED

Insurance Data

Insurance Name

WELLCARE

Address 1 P.O. BOX 31372

Address 2 CLAIMS

City TAMPA

Insurance Name

MEDICAID ILLINOIS

Address 1 CLAIMS DEPT

Address 2 PO BOX 19132

City SPRINGFIELD

Person To Notify Data

Name

State IL

State

Subscriber

State FL

Subscriber

State IL

I

Relationship

Zip 60406

Zip

Phone

Occupation UNEMPLOYED

Phone

Subscr ber Relationship

Zip 336313372 Phone

Subscr ber Relationship

Zip 62794 Phone

Policy Number

Policy Number

Group Number

Group Number

Fin Class Auth Number

13

Fin Class Auth Number

13

Address 1

Address 2

City

Name

State

Relationship

M

Zip Phone Business Phone

Address 1

Address 2

City

Guarantor Data

Name

State Zip

Relationship

Phone

Social Security Employer

Business Phone

Occupation

Address 1

Address 2

City

Name

Address 1

Address 2

City

Next Of Kin Data

Name

Address 1

Address 2

City

State IL

State IL

State

I

Relationship

Zip

Relationship

S

Phone

Social Security Employer

Zip 60406

Zip

Phone

Phone

Business Phone

Occupation

Business Phone

Business Phone

1 of 2

Patient Demographics

Name

Address 1

Address 2

City State

Relationship

Zip Phone Business Phone

2 of 2

Metro South Medical Center

Patient Name Age DOB Gender

Female

Allergies: nka

Race

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

Room 4SO:421-01

BMI

27.9

Admission Assessment

Past Medical History

cardiomyopathy

Hypercholesterolemia diabetes refuse flu shot, pneumovax

Bronchitis

Congestive Heart Failure

Hypertension

DC AICD MEDTRONIC (MAY 13,2010)

Family History

Unknown family history

Home Medications - Admission

Aspirin 325 mg Tab, Daily

Weight

85.7

kg

Height

Social History

Lives at home with Family

Smoker Former

Alcohol use- 10 years ago

Todd 773-552-3246

Allergies

nka

Chlordiazepoxide 25 mg Cap, At Bedtime as needed

Colace 100 mg Cap, Twice Daily as needed

Colchicine 0.6 mg Tab, Twice A Day

Coreg 25 mg Tab, Twice A Day

Digoxin 0.25mg PO, Daily

Enalapril 20mg PO, 1 tablet, Twice A Day

Glipizide 10 mg Tab, Twice A Day

HUMALOG 6units After Meals Subcutaneous, 6 UNITS, Three times daily AFTER Meals

Insulin Detemir SubQ, 20 units, At Bedtime

Lasix 80 mg Tab, Twice A Day

Pepcid 20 mg Tab, Twice A Day

Reglan 10 mg Tab, Three Times A Day

Simvastatin 40 mg Tab, Daily

Warfarin 5 mg Tab, Daily

Zithromax 250mg PO, Daily

75.26

cm

Advance Directives

No living will

No existing POA healthcare

No organ and tissue donor

Fall Risk

4=YES-Current/Historical

Confusion/disorientation/Impulsivisity

0=NO-Current/Historical Symptomatic Depression

0=NO-Altered elimination

0=NO-Dizziness/vertigo

0=NO-Male gender

0=NO-Anti-epileptics taken

0=NO-Benzodiazepines taken

Metro South Medical Center

Patient Name Age DOB Gender

Female

Allergies: nka

Race

Nutrition

No - Poor appetite more than 5 days

Yes - Less than 50% usual intake past 7 days

No - Recent unintentional weight loss more than 10 lbs past month

No - Diarrhea, vomiting, Hyperemesis more than 7 days

No - Receives nutrition via feeding tube or IV

No - Open, draining wounds or pressure ulcers

No - New onset diabetes

No dietary consult indicated at present

Suicide Self Harm Risk

NO - Previous psychiatric DX

NO - Prior thoughts self harm

NO - Chronic physical pain/distress

NO - Recent unemployment

NO - Recent loss of loved one

NO - Symptoms or diagnosis Post Partum depression

No further screening needed

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

Room 4SO:421-01

3= Multiple attempts but successful

TOTAL SCORE= 5 or more

HIGH FALL RISK PATIENT

Skin Integrity

4=Sensory no limits

3=Skin occasionally moist

4=Skin rarely moist

3=Walks occasionally

3=Slight limit mobility

2=Inadequate nutrition

3=No apparent problem

NO RISK - score 19 or more

VTE/DVT

Patient is on maintenance anticoagulation, no further assessment needed at this time.

Metro South Medical Center

Patient Name Age DOB Gender

Female

Race

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

Allergies: nka

MD Notes

Room 4SO:421-01

MD Name AHMED, ZAFAR

History / Subjective

Date of Note 05/23/2011 18:25 Note Type HISTORY AND PHYSICAL

HPI Paragraph: Patient with 62 year old lady was admitted to hospital from my office because of multiple problems. She has been having weight gain and increasew in abdominal girth. She was very short of breath exertional, and progressively worsening functional status. At office she had blood glucose of 23, which inmproved to 47 upon use of a Sugar tablet. She had an episode of syncope a week ago..

Other Notes:

Review of Systems NOT Covered in HPI:

ENT: Neg,Heart: Pos,Resp: Pos,GI: Neg,GU: Neg,Skin: Neg,Neuro: Pos,Psych: Neg,Musculoskeletal: Neg,Endocrine:

Pos,Hematologic/Lymphatic: Neg,Allergic/Immunologic: Neg,Constitutional Sxs: Neg,Eyes: Neg,

Exam / Objective

Date/Time of Exam: May 23 2011 6:25PM

GA: Knows month,and day,not date or year,knows the name of President, knows that she's in the office

Skin: No pallor/ rashes warm & moist

HEENT: PERRL EOMI Moist Mucous Membranes No Icterus

Neck: NT Full ROM No JVD

Lung/Chest Wall: Lungs-Lungs CTA No Ret/Chest Wall-Chest Wall NT, AICD in place

Cardio Vascular: RRR No M

Abdomen: Palpation-Tenderness-None/BS-BS-NL/No Bruits/Abd Appearance-No Pulsating Masses

Neuro: Motor-Major Muscle Groups 5/5/Sensory-Gross Sensory Intact/Coordination-

Back: NT no CVAT

GU: Normal

Extremity: Location-Low Ext Bilateral/Pain-Tenderness-None/Sub Location-/Appearance-No Edema/ROM/Pulses-CBR < 2 sec

Lymphatics: No LAD

Repeat/Additional Exams:

May 23 2011 6:25PM AHMED, ZAFAR - Reviewed pertinent diagnostic tests, vital signs, and clinical notes

Assessment / Plan (Problem List)

SYNCOPE AND COLLAPSE(780.2)

Likely from Cardio,myopathy, vs low glucose, needs Pacemaker check

AICD check

Congestive Heart Failure(428.0)

Acutre Systolic, follow up chest X ray and BNP

PT INR stat and at AM

SHORTNESS OF BREATH(786.05)

Likely secondary to CHF, r/out MI, check BNP, and Cardioplogy evaluation

Weakness (Nos)(780.79)

Weakness and Fatigue, likely from advanced Cardiomyopathy, has EF of 10%. Needs PT OT

Hypoglycemia in diabetic, unspecified(250.80)

Check Glucose, monitor off Insulin and oral agents.

Other Medical Orders/Additional Comments

Home Med Recon Continue - Aspirin 325 mg Tab, Daily

Home Med Recon Continue - Chlordiazepoxide 25 mg Cap, At Bedtime as needed

Home Med Recon Continue - Colace 100 mg Cap, Twice Daily as needed

Home Med Recon Continue - Colchicine 0.6 mg Tab, Twice A Day

Home Med Recon Continue - Coreg 25 mg Tab, Twice A Day

Metro South Medical Center

Patient Name Age DOB Gender

Female

Race

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

Room 4SO:421-01 Allergies: nka

Home Med Recon Continue - Glipizide 10 mg Tab, Twice A Day

Home Med Recon Continue - Lasix 80 mg Tab, Twice A Day

Home Med Recon Continue - Pepcid 20 mg Tab, Twice A Day

Home Med Recon Continue - Reglan 10 mg Tab, Three Times A Day

Home Med Recon Continue - Simvastatin 40 mg Tab, Daily

Home Med Recon Continue - Warfarin 5 mg Tab, Daily

Electronically signed and authenticated by the Following Physicians AHMED, ZAFAR Specialty Internal Medicine

Metro South Medical Center

Patient Name Age DOB Gender

Female

Race

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

Allergies: nka Room 4SO:421-01

MD Name KASON, THOMAS T

History / Subjective

Date of Note 05/24/2011 8:11 Note Type CONSULTATION

HPI Paragraph: Patient with Pt c/o CHF Sx: PND,DOE,baseline SOB, leg edema. No recent syncope. No ICD shocks. No palps. No chest pain. Had cath in 2000 SFH: normal corns/LVEF=5%. Had ICD generator changed May 2010. Sees Dr.

Tierney..

Other Notes: ECG: 100% electronic vent pacing.

Exam / Objective

Date/Time of Exam: May 24 2011 8:11AM

GA: Awake A&Ox3

Skin: No pallor/ rashes warm & moist

HEENT: PERRL EOMI Moist Mucous Membranes No Icterus

Neck: JVD Mild

Lung/Chest Wall: Lungs-crackles L=R at bases/Chest Wall-Chest Wall NT

Cardio Vascular: RRR No M

Abdomen: Palpation-Tenderness-None/BS-BS-NL/No Bruits/Abd Appearance-No Pulsating Masses

Extremity: Location-Low Ext Bilateral/Pain-Tenderness-None/Sub Location-/Appearance-Edema-Mild/ROM/Pulses-CBR < 2 sec

Repeat/Additional Exams:

May 24 2011 8:11AM KASON, THOMAS T - Reviewed pertinent diagnostic tests, vital signs, and clinical notes

Assessment / Plan (Problem List)

CHF - Acute on Chronic Systolic(N/A)

Needs IV diuresis. Would like to add an ACEI or ARB but her Cr is increasing. Need to watch CMP in AM. Continue coreg. BP too low 90/70 for hydralazine or imdur.

ICD(N/A)

Mgmt by Dr. Tierney. Agree with interrogation. Syncopal episode one week ago does not sound cardiac - but interrogation will tell if VT or VF involved.

Chronic coumadin use(N/A)

Interrogation confirms Afib and no shocks. So syncopal episode one week ago probably related to blood sugar.

NIDCM(N/A)

Normal corns by cath 2000 but LVEF=5% at that time. Has ICD.

DIABETES(648.03)

management per PCP

MITRAL VALVE DISORDER(424.0)

Moderate MR. Not a surgical candidate due to extremely low LVEF.

tricuspid regurg(N/A)

Mod to severe. Again, not an operative candidate.

HTN(401.9)

continue home meds.

Hyperlipidemia(272.4)

home meds.

Other Medical Orders/Additional Comments

Lasix 80mg IVP, , bid, 2 Day(s)

Hold PO lasix - we will use IV lasix

Metro South Medical Center

Patient Name Age DOB Gender

Female

Race

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

Allergies: nka

AM labs = CMP

Electronically signed and authenticated by the Following Physicians

Room 4SO:421-01

KASON, THOMAS T Specialty Cardiology

MD Name HARRIS, RICHARD G

History / Subjective

Date of Note 05/24/2011 9:53 Note Type PROGRESS NOTE

HPI Paragraph: Patient with remains hypoglycemic. Feels better though and denies any current SOB.

Other Notes:

Exam / Objective

Date/Time of Exam: May 24 2011 9:53AM

GA: Awake A&Ox3

Skin: No pallor/ rashes warm & moist

HEENT: PERRL EOMI Moist Mucous Membranes No Icterus

Neck: NT Full ROM No JVD

Lung/Chest Wall: Lungs-Lungs CTA No Ret/Chest Wall-Chest Wall NT

Cardio Vascular: RRR No M

Abdomen: Palpation-Tenderness-None/BS-BS-NL/No Bruits/Abd Appearance-slightly distended

Neuro: Motor-Major Muscle Groups 5/5/Sensory-Gross Sensory Intact/Coordination-

Extremity: Location-Low Ext Bilateral/Pain-Tenderness-None/Sub Location-/Appearance-No Edema/ROM/Pulses-CBR < 2 sec

Repeat/Additional Exams:

May 24 2011 9:53AM HARRIS, RICHARD G - Reviewed pertinent diagnostic tests, vital signs, and clinical notes

Assessment / Plan (Problem List)

Acute on Chronic Systolic Heart Failure with Severe Cardiomyopathy (EF 10%)(N/A)

continue IV Lasix. May need Dobutamine

HCCI consult

bmp in am

Weakness (Nos)(780.79)

PT and OT ordered

Hypoglycemia in diabetic, unspecified(250.80)

remains hypoglycemic

IVF: D5 0.9NS with 10meq kcl at 70cc/hr

Acute Renal Failure(N/A)

suspect due to prerenal azotemia/diuretic medications. May need nephrology consultation

consult Dr. Ventura

SYNCOPE AND COLLAPSE(780.2)

Likely from Cardio,myopathy, vs low glucose, needs Pacemaker check

Electronically signed and authenticated by the Following Physicians HARRIS, RICHARD G Specialty Internal Medicine

Metro South Medical Center

Patient Name Age DOB Gender

Female

Race

Allergies: nka

MD Name VENTURA, SALVATORE C

History / Subjective

HPI Paragraph: Patient with Consult Dictated.

Other Notes:

Exam / Objective

Date of Note

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

05/24/2011 11:15

Room 4SO:421-01

Note Type CONSULTATION

Assessment / Plan (Problem List)

Non-Oliguric Acute Renal Failure(N/A)

2nd to ischemic ATN; probably has chronic ischemic nephropathy. R/O diabetic nephropathy. Suggest dobutamine

Rx. No indications for dialysis at this time.

Insert Foley

Urine analysis and urine culture

STAT Renal Ultrasound

Serum immunoelectrophoresis

Chem 7 at 6 PM today

Renal Panel tomorrow AM

Do renal ultrasound at bedside due to hypoglycemia

Hold colchicine: notify Dr. Harris

NIDCM/ICD/Parox A Fib/MR(N/A)

Start Dobutamine if OK with Dr. Kason

Hypoglycemia/NIDDM/Hyperlipidemia(N/A)

Stop Glipizide

H/O Hypertension(N/A)

Electronically signed and authenticated by the Following Physicians VENTURA, SALVATORE C Specialty Nephrology

Metro South Medical Center

Patient Name Age DOB Gender

Female

Race

Allergies: nka

MD Name SALVATORE C VENTURA

History / Subjective

CONSULTATION

Other Notes:

MetroSouth Medical Center

12935 South Gregory Street

Blue Island, Illinois 60406

Date of Note

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

05/24/2011 11:27

Room 4SO:421-01

Note Type CONSULTATION

CONSULTATION

MR#:

DATE OF BIRTH:

PT:

ACCT#:

DISCH:

ADMIT DATE: 05/23/2011

_____________________________________________________________________

____

CONSULTANT: SALVATORE VENTURA, M.D.

ATTENDING: ZAFAR AHMED, M.D.

DATE OF CONSULTATION: 05/24/2011

REASON FOR CONSULTATION: I am asked to see this patient by Dr.

Harris for evaluation of elevated creatinine concentration.

HISTORY: is a woman with

long-standing nonischemic dilated cardiomyopathy. She was admitted

to MetroSouth Medical Center Hospital for evaluation of increasing

abdominal girth, increasing leg swelling, and shortness of breath.

Her symptoms were complicated by one episode of syncope one week

prior to the admission. Upon admission, she was found to have severe

hypoglycemia, and this is being corrected with adjustment of her

diabetic medications and with administration of IV sugar.

denies prior history of renal disease or nephrolithiasis.

She does not have flank pain, gross hematuria, dysuria, nor urinary

incontinence. However, review of computer records indicates that her

creatine concentration measured between 1.3 and 1.5 mg/dL during the

last year. It measured 1.33 mg/dL on 05/05/2011. Today, it measures

1.8 mg/dL.

PAST MEDICAL HISTORY:

1. Hypertension for 10 years.

2. Non-insulin-dependent diabetes mellitus for one year.

3. Hyperlipidemia.

4. ICD implant in 2000, replacement on 05/13/2010.

5. Paroxysmal atrial fibrillation.

6. Mitral regurgitation.

7. Nonischemic dilated cardiomyopathy complicated by congestive

heart failure.

Metro South Medical Center

Patient Name Age DOB

Allergies: nka

Gender

Female

Race

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

Room 4SO:421-01

MEDICATIONS: Lasix 80 mg IV b.i.d., Librium 25 p.o. q.h.s.,

colchicine 0.6 mg p.o. b.i.d., Coreg 25 mg p.o. b.i.d., Glucotrol 10

mg p.o. b.i.d., Pepcid 20 mg p.o. b.i.d., Reglan 10 mg p.o. t.i.d.,

Zocor 40 mg p.o. q.h.s., Colace 100 mg p.o. b.i.d., aspirin 325 mg

p.o. daily, and Coumadin dose daily.

Page of

MetroSouth Medical Center

12935 South Gregroy Street

Blue Island, Illinois 60406

CONSULTATION

MR#: ACCT#:

ALLERGIES: None.

SOCIAL HISTORY: The patient is married without children. The

patient has a history of smoking cigarettes at a rate of one package

per day between 14 and 52 years of age. She also reports drinking

alcohol excessively between her teen years and 52 years of age. She

does not abuse drugs.

FAMILY HISTORY: Mother is living and well. Father died of unknown

cause. Two brothers and two sisters are living and well.

REVIEW OF SYSTEMS: The patient denies headache, recent acute change

in vision, or hearing. She reports slurred speech during

hypoglycemic episodes. She denies chest pain, chest pressure, or

cough but does complain of orthopnea and paroxysmal nocturnal

dyspnea. She becomes short of breath easily upon exertion. She

denies nausea, vomiting, loss of appetite, abdominal pain, change in

bowel habits, melena, or passage of blood per rectum. GU system is as

described above. She complains of leg swelling.

PHYSICAL EXAMINATION:

General: The patient is alert, cooperative, in no distress, and

sitting upright.

Vital Signs: She weighs 85.9 kg, temperature is 97.4, pulse is 72,

blood pressure is 110/83, and respiratory rate is 24.

HEENT: Head is normocephalic. Both pupils are round and reactive to

light. Extraocular movements are intact. Conjunctivae are pink.

Mucous membranes of the oropharynx are moist.

Neck: Supple. Adenopathy is absent. Carotid pulses are weak but

symmetrical. Bruits are absent.

Chest: Lung fields are remarkable for diminished air entry in both

lower lobes.

Heart: Exam reveals S1, S2, and a 2/6 systolic murmur at the left

sternal border. Pericardial rub is absent.

Breast: Examination is deferred.

Abdomen: Slightly distended and slight fullness is evident. Bowel

sounds are present. The abdomen is soft and nontender. I do not

Metro South Medical Center

Patient Name Age DOB Gender

Female

Race

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

Room 4SO:421-01 Allergies: nka

feel masses.

GU: Examination is deferred.

Rectal: Examination is deferred.

Extremities: Both lower extremities are edematous to the knees. The

sacrum is edematous.

Neurologic: Examination is remarkable for the absence of asterixis.

LABORATORY TESTS: White blood count is 5.4, hemoglobin 14.7,

potassium is 3.9, and albumin is 3.5.

IMPRESSION:

1. has nonoliguric acute renal failure that is most

Page of

MetroSouth Medical Center

12935 South Gregroy Street

Blue Island, Illinois 60406

CONSULTATION

MR#: ACCT#:

likely secondary to ischemia-induced acute tubular necrosis. Causes

of renal ischemia include hypotension and cardiomyopathy. I

recommend dobutamine therapy if acceptable with Cardiology

consultant. The patient also has a component of chronic ischemic

nephropathy related to her heart disease. A workup to evaluate for

possible diabetic nephropathy will be initiated. I recommend a Foley

catheter, urinalysis and urine culture, renal ultrasound, and serum

immunoelectrophoresis. Chemistries will be monitored. No acute

indications for dialysis.

2. Nonischemic dilated cardiomyopathy, status post implantable

cardioverter-defibrillator implant, paroxysmal atrial fibrillation

and mitral regurgitation are being managed by HCCI. As discussed

above, dobutamine therapy is suggested.

3. Hypoglycemia, superimposed on history of non-insulin-dependent

diabetes mellitus and hyperlipidemia, is being managed by primary

care physician. I recommend discontinuation of glipizide/Glucotrol.

5. History of hypertension in the past.

PLAN: As above.

Thank you. I will follow with you.

APPROVED ELECTRONICALLY BY

Salvatore C. Ventura, M.D. ON Wed May 25 15:55:44 CDT 2011

_________________________________

SALVATORE VENTURA, M.D.

cc:AHMED, ZAFAR

Metro South Medical Center

Patient Name Age DOB Gender

Female

Race

Allergies: nka

VENTURA, SALVATORE

MT: V_DV_MST13

DD: 05/24/2011 11:27 AM

DT: 05/24/2011 09:25 PM

ID: 1231869

JOB: 97262

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

Room 4SO:421-01

Page of

Exam / Objective

Assessment / Plan (Problem List)

Electronically signed and authenticated by the Following Physicians SALVATORE C VENTURA Specialty Nephrology

Metro South Medical Center

Patient Name Age DOB Gender

Female

Race

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

Allergies: nka Room 4SO:421-01

MD Name VENTURA, SALVATORE C

History / Subjective

Date of Note 05/25/2011 6:03 Note Type PROGRESS NOTE

HPI Paragraph: Patient with Evaluation of renal failure..

Other Notes: Urine output is good by foley. Mild SOB at rest. No chest pain. No N & V/abdominal pain.

Exam / Objective

Date/Time of Exam: May 25 2011 6:03AM

GA: Sitting upright in no distress. She is tachypneic

Lung/Chest Wall: Lungs-Diminished with crackles at both bases

Cardio Vascular: Paced, S1, S2. No rub

Abdomen: Palpation-Soft/BS-Good/Abd Appearance-Flank fullness

Neuro: Motor-No asterixis

Extremity: Location-Legs/Appearance-Edematous

Repeat/Additional Exams:

May 25 2011 6:03AM VENTURA, SALVATORE C - Reviewed pertinent diagnostic tests, vital signs, and clinical notes

Assessment / Plan (Problem List)

Non-Oliguric ARF 2nd Ischemic ATN(N/A)

Most likely has "chronic" ischemic nephropathy 2nd to cardiomyopathy. Urine analysis: 30 mg/dl protein. Urine

Culture: pending. Renal Ultrasound: negative. [Creatinine] improved on dobutamine drip. Will stage the CKD with a 24 hour urine collection. She may need hemodialysis for fluid management: patient is aware.

Start 24 hour urine for creatinine clearance and protein.

Chem 7 at 5 PM today

Renal panel tomorrow AM

LVEF=10%/ICD/Parox A Fib/MR(N/A)

Very volume overloaded: pleural effusions, ascites and peripheral edema.

Stop IV fluids if OK with Dr. Harris

Double concentrate IV Dobutamine

Increase Lasix to 100 mg IV Q 8 hours

NIDDM/Hyperlipidemia(N/A)

Per PMD

Electronically signed and authenticated by the Following Physicians VENTURA, SALVATORE C Specialty Nephrology

Metro South Medical Center

Patient Name Age DOB Gender

Female

Race

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

Allergies: nka Room 4SO:421-01

MD Name FOCHESATTOFILLHO, LUCIANO

History / Subjective

Date of Note 05/25/2011 8:38 Note Type PROGRESS NOTE

HPI Paragraph: Patient with no New Complaints, alert and awake this am, having hypogycemic episodes still.

Other Notes:

Review of Systems NOT Covered in HPI:

All other systems reviewed and negative.,ENT: Neg,Heart: Neg,Resp: Neg,GI: Neg,GU: Neg,Skin: Neg,Neuro: Neg,Psych:

Neg,Musculoskeletal: Neg,Endocrine: Neg,Hematologic/Lymphatic: Neg,Allergic/Immunologic: Neg,Constitutional Sxs:

Neg,Eyes: Neg,

Exam / Objective

Date/Time of Exam: May 25 2011 8:38AM

GA: Awake A&Ox3

Skin: No pallor/ rashes warm & moist

HEENT: PERRL EOMI Moist Mucous Membranes No Icterus

Neck: NT Full ROM +ve JVD

Lung/Chest Wall: Lungs-coarse, w decreased sounds bil in the lower fields/Chest Wall-Chest Wall NT

Cardio Vascular: RRR No M S3 S4 Rub

Abdomen: Palpation-Tenderness-None/BS-BS-NL/No Bruits/Abd Appearance-No Pulsating Masses distended w clear signs of ascites

Neuro: Motor-Major Muscle Groups 5/5/Sensory-Gross Sensory Intact/Coordination-

Extremity: Location-Low Ext Bilateral/Pain-Tenderness-None/Sub Location-/Appearance-No Edema/ROM/Pulses-CBR < 2 sec

Repeat/Additional Exams:

May 25 2011 8:38AM FOCHESATTOFILLHO, LUCIANO - Reviewed pertinent diagnostic tests, vital signs, and clinical notes

Assessment / Plan (Problem List)

Acute on Chronic Systolic Heart Failure with Severe Cardiomyopathy (EF 10%)(N/A)

HCCI and renal on the case. Severly depressed EF w massive vol overload. On dobutamine (dose changed noted).

Lasix increased by Dr Ventura. d/c IV fluids (switch D5 to D50 prn). Possible paracentesis (therapeutic) if discomfort increases even with appropriate diuresis (which I don’t expect to have a significant effect on her ascites volume). Possibility of HD there as raised by Dr Ventura.

Acute Renal Failure(N/A)

previous Cr 1.2-1.38. US noted. Some kind of underlying CKD w superimposed ATN sec to extremely depressed EF, likely. CKD w/u by renal noted.

SYNCOPE AND COLLAPSE(780.2)

symptomatic hypoglycemia? Cont to have "sugar issues". D50 prn as above, accuchecks q 4 hrs. Awaiting interrogation to r/o ventricular event. HCCI on the case.

Hypoglycemia in diabetic, unspecified(250.80)

as above plus PO intake encouraged, Nursing staff to assist pt w feeding.

HTN(401.9)

Hypercholesterolemia(272.0)

DM(N/A)

Weakness (Nos)(780.79)

PT/OT.

Other Medical Orders/Additional Comments

accu Checks q 4 hrs

Nursing staff to assist pt w feeding.

Metro South Medical Center

Patient Name Age DOB Gender

Female

Race

Allergies: nka

cbc, cmp, magnesium, pt/ptt/inr in am

warfarin - pharmacy to dose, , N/A

Electronically signed and authenticated by the Following Physicians

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

Room 4SO:421-01

FOCHESATTOFILLHO, LUCIANO Specialty Internal Medicine

Metro South Medical Center

Patient Name Age DOB Gender

Female

Race

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

Allergies: nka Room 4SO:421-01

MD Name Milenkovic, Steven Robert/KASON, THOMAS T

History / Subjective

Date of Note 05/25/2011 9:13 Note Type PROGRESS NOTE

HPI Paragraph: Patient with Mildly sob just with conversation. States that she slept flat with 2 pillow last evening and woke up once with PND.

Other Notes:

Exam / Objective

Date/Time of Exam: May 25 2011 9:13AM

GA: Awake A&Ox3

Skin: No pallor/ rashes warm & moist

HEENT: PERRL EOMI Moist Mucous Membranes No Icterus

Neck: NT Full ROM (+) JVD

Lung/Chest Wall: Lungs-Diminished bibasilar/Chest Wall-Chest Wall NT

Cardio Vascular: RRR 4/6 HSM

Abdomen: Palpation-Tenderness-None/BS-BS-NL/No Bruits/Abd Appearance-Distended

Neuro: Motor-Major Muscle Groups 5/5/Sensory-Gross Sensory Intact/Coordination-

Extremity: Location-Low Ext Bilateral/Pain-Tenderness-None/Sub Location-/Appearance-+ Edema/ROM/Pulses-CBR < 2 sec

Repeat/Additional Exams:

May 25 2011 9:13AM Milenkovic, Steven Robert - Reviewed with Physician Assistant Agree with HPI PE Assessment and Plan

Assessment / Plan (Problem List)

CHF - Acute on Chronic Systolic(N/A)

Would like to add an ACEI or ARB but her Cr is increasing. Continue coreg. BP too low 90/70 for hydralazine or imdur. Would continue inotropic rx for another 24-48hrs. IV Lasix per Nephrology.

BNP in am.

appears euvolemic. Change dose of enalapril 10mg po bid

OK to DC home from cardiac standpoint. F/U with Dr. Erickson in 1 week, coumadin clinic in 1 week.

1.2liter/day fluid restriction at home

Normal Corns via Cath '00(N/A)

Severe MR(N/A)

Not a surgical candidate due to extremely low LVEF.

DIABETES(648.03)

management per PCP

HTN(401.9)

continue home meds.

Hyperlipidemia(272.4)

home meds.

ICD(N/A)

Mgmt by Dr. Tierney. Agree with interrogation. Syncopal episode one week ago does not sound cardiac - but interrogation will tell if VT or VF involved.

Chronic kidney disease(N/A)

Staging currently in progress.

Other Medical Orders/Additional Comments

Kdur 40MEq po x 1 now then 20mEq po daily

chem 6 in 1 week

D/C dobutamine

Metro South Medical Center

Patient Name Age DOB Gender

Female

Allergies: nka

Race

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

Room 4SO:421-01

Prescriptions Provided to Patient

Potassium Chloride 20meq PO 1 tablet Daily 30 6

Electronically signed and authenticated by the Following Physicians Milenkovic, Steven Robert/KASON, THOMAS T

Date of Note 05/25/2011 14:46

Specialty Cardiology

Note Type PROGRESS NOTE MD Name VENTURA, SALVATORE C

History / Subjective

HPI Paragraph: Patient with Chart Review.

Other Notes:

Exam / Objective

Assessment / Plan (Problem List)

Non-Oliguric ARF 2nd Ischemic ATN(N/A)

Most likely has "chronic" ischemic nephropathy 2nd to cardiomyopathy. Urine Culture: pending. [Creatinine] improved. Await staging.

LVEF=10%/ICD/Parox A Fib/MR(N/A)

NIDDM/Hyperlipidemia(N/A)

Electronically signed and authenticated by the Following Physicians VENTURA, SALVATORE C Specialty Nephrology

Metro South Medical Center

Patient Name Age DOB Gender

Female

Race

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

Allergies: nka Room 4SO:421-01

MD Name VENTURA, SALVATORE C

History / Subjective

Date of Note 05/26/2011 6:20 Note Type PROGRESS NOTE

HPI Paragraph: Patient with Evaluation of renal failure.

Other Notes: Urine output is good in response to IV lasix. Patient is incontinent of urine at times. She denies SOB but still has increased abdominal girth/discomfort. She has severe leg swelling. No chest pain nor N & V.

Exam / Objective

Date/Time of Exam: May 26 2011 6:20AM

GA: Supine, no distress

Lung/Chest Wall: Lungs-Diminished at bases

Cardio Vascular: Paced, S1, S2. No rub

Abdomen: Palpation-Soft, nontender/BS-Good/Abd Appearance-Distended; flank fullness

Neuro: Motor-No asterixis

Extremity: Location-Legs/Appearance-Edematous

Repeat/Additional Exams:

May 26 2011 6:20AM VENTURA, SALVATORE C - Reviewed pertinent diagnostic tests, vital signs, and clinical notes

Assessment / Plan (Problem List)

Non-Oliguric ARF/CKD 2nd Ischemic Nephropathy(N/A)

[Creatinine] improved to 1.62 mg/dl with supportive care. Patient refuses foley and she is incontinent of urine: unable to stage her CKD. Dialysis for Rx of cardiomyopathy complicated by renal failure and refractory, severe fluid retention was discussed with patient. She does not wish to consider dialysis as a treatment option at this time. I will sign off case.

Remove patient name from Dr. Ventura's list.

LVEF=10%/ICD/Parox A Fib/MR(N/A)

Medical managment per HCCI.

NIDDM/Hyperlipidemia(N/A)

Per PMD

Electronically signed and authenticated by the Following Physicians VENTURA, SALVATORE C Specialty Nephrology

Metro South Medical Center

Patient Name Age DOB Gender

Female

Race

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

Allergies: nka Room 4SO:421-01

MD Name Milenkovic, Steven Robert/KASON, THOMAS T

History / Subjective

Date of Note 05/26/2011 9:10

HPI Paragraph: Patient with Still looks volume overloaded but denies sob/orthopnea.

Other Notes:

Note Type PROGRESS NOTE

Exam / Objective

Date/Time of Exam: May 26 2011 9:10AM

GA: Awake A&Ox3

Skin: No pallor/ rashes warm & moist

HEENT: PERRL EOMI Moist Mucous Membranes No Icterus

Neck: NT Full ROM No JVD

Lung/Chest Wall: Lungs-Crackles bibasilar/Chest Wall-Chest Wall NT

Cardio Vascular: RRR 3/6 HSM

Abdomen: Palpation-Tenderness-None/BS-BS-NL/No Bruits/Abd Appearance-No Pulsating Masses

Neuro: Motor-Major Muscle Groups 5/5/Sensory-Gross Sensory Intact/Coordination-

Extremity: Location-Low Ext Bilateral/Pain-Tenderness-None/Sub Location-/Appearance-No Edema/ROM/Pulses-CBR < 2 sec

Repeat/Additional Exams:

May 26 2011 9:10AM Milenkovic, Steven Robert - Reviewed with Physician Assistant Agree with HPI PE Assessment and Plan

Assessment / Plan (Problem List)

CHF - Acute on Chronic Systolic(N/A)

Would like to add an ACEI or ARB but her Cr is increasing. Continue coreg. BP too low 90/70 for hydralazine or imdur. IV Lasix per Nephrology.

Chem 6 and BNP in am.

D/C IV Lasix after pm dose and restart 80mg po BID in am of 5/27.

Normal Corns via Cath '00(N/A)

DIABETES(648.03)

management per PCP

Severe MR(N/A)

Not a surgical candidate due to extremely low LVEF.

HTN(401.9)

continue home meds.

Hyperlipidemia(272.4)

home meds.

ICD(N/A)

Mgmt by Dr. Tierney. Agree with interrogation. Syncopal episode one week ago does not sound cardiac - but interrogation will tell if VT or VF involved.

Chronic kidney disease(N/A)

Staging currently in progress.

Electronically signed and authenticated by the Following Physicians Milenkovic, Steven Robert/KASON, THOMAS T Specialty Cardiology

Metro South Medical Center

Patient Name Age DOB Gender

Female

Race

Allergies: nka

MD Name FOCHESATTOFILLHO, LUCIANO

History / Subjective

DISCHARGE SUMMARY

Other Notes: Admit Date: 5/23/2011 3:33:00 PM

Discharge Date: Patient Not Yet Discharged

Date of Note

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

05/26/2011 9:25

Room 4SO:421-01

Note Type DISCHARGE

Discharge Diagnosis

Acute on Chronic Systolic Heart Failure with Severe Cardiomyopathy (EF 10%)

AICD in place

PAF

ECHO EF 10% and severe MR

ARF/CKD - Cr at discharge ~ 1.55

HTN

Hypercholesterolemia

DM

Hypoglycemia in diabetic, unspecified

Procedures

Consultants/Specialty

VENTURA,SALVATORE C : Nephrology

AHMED,ZAFAR : Internal Medicine

KASON,THOMAS T : Cardiology

HARRIS,RICHARD G : Internal Medicine

Milenkovic,Steven Robert : Cardiology

FOCHESATTOFILLHO,LUCIANO : Internal Medicine

Discharge Diet

Cardiac Diet : Renal Diet : 1800 Calorie ADA Diet

Dicharge Activity

Activity As Tolerated

Additional Discharge Instructions

Click here to add instructions : CHF - Patient was given instruction on diet, exercise, weight monitoring, activity level, follow up and what to do if symptoms worsen.

Follow Up MDs

AHMED, ZAFAR NULL 12:00:00 AM IN 1 WEEK

Erickson, Kurt W, M.D. 2338 New Street NULL Blue Island IL 60406 (708) 824-1114 12:00:00 AM IN 2 WEEKS

Patient Medication List

Aspirin 325 mg Tab, 1 tablet, Daily

Colace 100 mg Cap, 1 tablet, Twice Daily as needed

Coreg 25 mg Tab, 1 tablet, Twice A Day

DOCUSATE SODIUM, 100 MG, 2x a day as needed

Enalapril 10mg PO, 1 tablet, Twice A Day, starting taking in 1 week

FAMOTIDINE, 20 MG, 2 times a day 0900,2100

HUMALOG 6units After Meals Subcutaneous, 6 UNITS, Three times daily AFTER Meals

Insulin Detemir SubQ, 20 units, At Bedtime

Lasix Oral, 100 mg, Twice A Day

Potassium Chloride 20meq PO, 1 tablet, Daily

Reglan 10 mg Tab, Three Times A Day

Simvastatin 40 mg Tab, Daily

Metro South Medical Center

Patient Name Age DOB Gender

Female

Race

Allergies: nka

Warfarin 5 mg Tab, Daily

ZALEPLON, 10 MG, at bedtime as need 2100

Exam / Objective

Assessment / Plan (Problem List)

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

Room 4SO:421-01

Electronically signed and authenticated by the Following Physicians FOCHESATTOFILLHO, LUCIANO Specialty Internal Medicine

Metro South Medical Center

Patient Name Age DOB Gender

Female

Race

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

Allergies: nka

Diagnostic Results

Ordering

Staff

AHMED, ZAFAR

AHMED, ZAFAR

AHMED, ZAFAR

AHMED, ZAFAR

AHMED, ZAFAR

AHMED, ZAFAR

AHMED, ZAFAR

AHMED, ZAFAR

AHMED, ZAFAR

AHMED, ZAFAR

AHMED, ZAFAR

Date/Time

Resulted

Diagnostic

Name

05/23 16:28 Glucose monitor

Result Interpretation

BGM-194

Room 4SO:421-01

Reviewed

By

05/23 19:01 XR CHEST ONE

VIEW PORTABLE

05/24 5:00 VITAMIN B12

05/24 5:00 FOLATE

05/23 18:51 CBC W AUTO DIFF

05/23 18:51 PT

INT-2.80,PT-31.6

KASON,

THOMAS T

McCabe, RN,

Janet

KASON,

THOMAS T

05/23 18:51 COMPREHENSIVE

METABOLIC PANEL

NA-144,K-3.9,CL-108,CO2-23,BUN-49,CREAT-1.80,GLUCOSE-

44,AGAP-13,AG RATIO-0.9,BUNCR-27,GLOBTOT-4.1,ALB-3.5,TPROT-

7.6,CA-9.4,ALT-<16,AST-40,ALKPHOS-57,GFR-36.7,TBILI-1.6

05/23 18:52 CK + CKMB

CK1-147

05/23 19:10 CKMB

05/23 18:52 TROPONIN I

MBINDEX-4.1,CKMB-6

TROPU-0.10

05/23 19:26 CBC W AUTO DIFF

05/23 22:46 EKG - Preliminary

WBC-5.5,RBC-5.63,HGB-15.9,HCT-48.5,PLTCT-183,MCV-86.2,MCHC-

32.7,RBCMORPH-Slight Anisocytosis Microcytosis Macrocytosis

Poikilocytosis Target Cells,MANDIFFDONE-Man diff not indicated,BASOS-0.3,EO-0.9,MONOS1-9.4,LYMPH-18.9,NEUTRO-

70.5,MPV-9.1,RDW-21.3,MCH-28.2

McCabe, RN,

Janet

McCabe, RN,

Janet

McCabe, RN,

Janet

Critchett, RN,

Daisyrenee

Date/Time

Reviewed

05/24 8:18

05/23 21:54

05/24 8:22

05/23 21:46

05/23 21:46

05/23 21:46

05/24 8:26

AHMED, ZAFAR

AHMED, ZAFAR

AHMED, ZAFAR

AHMED, ZAFAR

AHMED, ZAFAR

AHMED, ZAFAR

AHMED, ZAFAR

AHMED, ZAFAR

AHMED, ZAFAR

05/23 21:07 Glucose monitor

05/24 2:52 CK + CKMB

05/24 3:06 CKMB

05/24 2:52 TROPONIN I

BGM-94

CK1-164

MBINDEX-4.3,CKMB-7

TROPU-0.10

KASON,

THOMAS T

05/24 5:00 PT

INT-2.60,PT-29.3

05/24 5:00 COMPREHENSIVE

METABOLIC PANEL

NA-CANCELED,K-CANCELED,CL-CANCELED,CO2-CANCELED,BUN-

CANCELED,CREAT-CANCELED,GLUCOSE-CANCELED,AGAP-CANCELED,AG

RATIO-CANCELED,BUNCR-CANCELED,GLOBTOT-CANCELED,ALB-

CANCELED,TPROT-CANCELED,CA-CANCELED,ALT-CANCELED,AST-

CANCELED,ALKPHOS-CANCELED,GFR-CANCELED,TBILI-CANCELED

05/24 5:00 VITAMIN B12

FOLATE

05/24 5:00 CBC W AUTO DIFF

WBC-5.4,RBC-5.26,HGB-14.7,HCT-44.8,PLTCT-182,MCV-85.1,MCHC-

32.7,RBCMORPH-Few Anisocytosis; Slight Poikilocytosis

Ovalocytes Target Cells Burr Cells,MONOS-14,LYMPHS-15,BANDS-

2,SEGS-69,MANDIFFDONE-Man Diff Done,MPV-9.5,RDW-21.2,MCH-

27.9

05/23 18:51 TSH

TSH-2.078

KASON,

THOMAS T

Blazek, RN,

Patricia Marie

05/24 8:00

05/24 8:12

05/24 13:51

Metro South Medical Center

Patient Name

Allergies: nka

UNKNOWN,

PHYSICIAN

AHMED, ZAFAR

HARRIS,

RICHARD G

AHMED, ZAFAR

AHMED, ZAFAR

AHMED, ZAFAR

AHMED, ZAFAR

AHMED, ZAFAR

AHMED, ZAFAR

AHMED, ZAFAR

AHMED, ZAFAR

Age DOB

05/23 20:17 VIRTUAL

RADIOLOGIC

PRELIM REPO

05/24 10:52 CK + CKMB

Gender

Female

Race

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

Room 4SO:421-01

McCabe, RN,

Janet

05/24 1:41

History:Progressively worsening functional status, episode of syncope 1 week ago, weakness/fatigue. H/o aicd, cardiomyopathy, hypercholeserolemia, diabetes, bronchitis, chf, htn

Technique: Axial images from a CT study of the brain were performed without IV contrast. No prior study.

Findings: Mild age -related cerebral and cerebellar atrophy. Minor chronic small vessel ischemic disease in the periventricular white matter. Bilateral basal ganglia calcifications. No acute intracranial hemorrhage. No mass effect, midline shift or sulcal effacement. Ventricular system and cisternal spaces are unremarkable.

Imaged mastoid air cells and paranasal sinuses are clear.

No acute calvarial fracture.

Impression: Atrophy and chronic small vessel ischemic disease changes, as outlined above.

No acute intracranial hemorrhage. No CT evidence of acute ischemic change.

CK1-133

05/24 7:48 B-TYPE

NATRIURETIC

PEPTIDE

05/24 6:31 COMPREHENSIVE

METABOLIC PANEL

BNP-2444

NA-145,K-4.1,CL-107,CO2-27,BUN-51,CREAT-1.88,GLUCOSE-

53,AGAP-11,AG RATIO-0.9,BUNCR-27,GLOBTOT-3.9,ALB-3.4,TPROT-

7.3,CA-9.1,ALT-18,AST-41,ALKPHOS-55,GFR-34.9,TBILI-1.5

05/24 6:32 VITAMIN B12

FOLATE

05/24 1:21 Glucose monitor

FOLATE-14.6,B12-1894

BGM-71

05/24 5:47 Glucose monitor

05/24 9:42 Glucose monitor

05/24 11:18 Glucose monitor

05/24 10:18 CKMB

BGM-68

BGM-54

BGM-70

MBINDEX-4.5,CKMB-6

05/24 5:00 HEMOGLOBIN A1C

HA1C-7.1

KASON,

THOMAS T

KASON,

THOMAS T

Critchett, RN,

Daisyrenee

KASON,

THOMAS T

05/24 8:12

05/24 8:12

05/24 15:26

05/24 8:12

Metro South Medical Center

Patient Name Age DOB

Allergies: nka

AHMED, ZAFAR 05/23 19:01 XR CHEST 2

VIEWS

Gender

Female

Race

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

CHEST, TWO VIEWS:

ACCESSION: 0142076

CLINICAL INDICATION: Shortness of breath. Congestive failure.

COMPARISON: One view chest 05/06/2011.

TECHNIQUE: AP and lateral upright two view chest, 1955 hours, 05/23/2011.

FINDINGS: Heart size is moderately increased with multichamber enlargement.

The aorta is tortuous and calcified. A left ICD seen with right atrial and right ventricular leads. Heart size is moderately increased. Hazy opacity at the right costophrenic angle and at the left base as well as blunting of the posterior left costophrenic angle indicates bilateral pleural effusions with subjacent airspace disease such as atelectasis, infiltrate, or basilar congestive change. Left hemidiaphragm is indistinct on the lateral and frontal view. The mid and upper lungs are essentially clear.

IMPRESSION: BIBASILAR PLEURAL EFFUSIONS AND SUBJACENT

ATELECTASIS OR

INFILTRATE OR BASILAR CONGESTIVE CHANGE. MODERATE

CARDIOMEGALY. LEFT ICD WITH

RIGHT ATRIAL AND RIGHT VENTRICULAR LEADS. APPEARANCE IS

SIMILAR TO THE

PREVIOUS EXAMINATION OF 05/06/2011.

Room 4SO:421-01

HARRIS,

RICHARD G

05/24 9:53

_________________________________

Harry R. Platt, M.D.

APPROVED ELECTRONICALLY BY

Harry R. Platt, M.D. ON Tue May 24 13:04:14 CDT 2011 cc:AHMED, ZAFAR

PLATT, HARRY

MT: ASR

DD: 05/24/2011 08:17 AM

DT: 05/24/2011 09:54 AM

ID: 1231783

JOB: 1231783

Metro South Medical Center

Patient Name Age DOB Gender

Female

Race

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

Allergies: nka

AHMED, ZAFAR 05/23 19:01 CT BRAIN W/O IV

CONTRAST

CT SCAN OF THE BRAIN WITHOUT IV CONTRAST:

ACCESSION: 0142077

CLINICAL INDICATION: Shortness of breath. Syncope.

Worsening functional status for 1 week. Weakness and fatigue. Cardiomyopathy.

ICD. Diabetes.

Bronchitis. Congestive failure. Hypertension.

FINDINGS: Mild prominence of the cortical sulci are noted.

There are physiologic calcifications in the basal ganglia. Mild low attenuation white matter changes suggest minimal small vessel white matter chronic ischemia including the basal ganglia regions. There are calcifications in the carotid siphons and vertebral arteries. Bone window settings appear normal.

IMPRESSION: MINIMAL SMALL VESSEL WHITE MATTER CHRONIC

ISCHEMIC CHANGE. NO

HEMORRHAGE OR OTHER FOCAL INTRACRANIAL LESIONS SEEN

OTHERWISE.

(PQRI: CT WITHIN 24 HOURS OF PRESENTATION. NO HEMORRHAGE,

ACUTE INFARCTION,

OR ABNORMAL MASS ON THIS STUDY).

Room 4SO:421-01

McCabe, RN,

Janet

05/24 1:41

_________________________________

Harry R. Platt, M.D.

APPROVED ELECTRONICALLY BY

Harry R. Platt, M.D. ON Tue May 24 13:08:54 CDT 2011 cc:AHMED, ZAFAR

PLATT, HARRY

MT: ASR

DD: 05/24/2011 08:58 AM

DT: 05/24/2011 10:02 AM

ID: 1231794

JOB: 1231794

AHMED, ZAFAR

VENTURA,

SALVATORE C

05/24 5:03 Glucose monitor

05/24 14:04 URINALYSIS

ROUTINE AUTO

AHMED, ZAFAR

AHMED, ZAFAR

05/24 14:42 Glucose monitor

05/24 16:05 Glucose monitor

BGM-62

HYALINE-21-50,MUCUSURINE-OCCASSIONAL,EPITHLIAL-11-20,WBC.-

0-3,RBC.-0-3,LEUKOURINE-NEG,UROBILURINE-NORMAL,NITRITE-

NEG,UBLD-TRACE,BILIURINE-NEG,KETURINE-NEG,UGLUC-

NEG,PROTEINUA-30,PHURINE-5.0,SPCGRAVITY-1.007,CHARACTER-

CLEAR,COLORURINE-YELLOW

BGM-107

BGM-108

Bayless, RN,

Michel

05/24 15:06

Metro South Medical Center

Patient Name Age DOB Gender

Female

Race

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

Allergies: nka

VENTURA,

SALVATORE C

05/24 11:23 US RETROPERI

KIDNEY/BLADDER

ULTRASOUND OF THE RETROPERITONEUM, KIDNEY, BLADDER:

ACCESSION: 0142219

HISTORY: BUN 51, creatinine 1.88.

COMPARISON STUDY: None.

FINDINGS: The right kidney measures around 10.5 cm in length x 4.6 x 4.3 cm in diameter. The left kidney measures around 10.0 cm in length x 4.8 x 4.1 cm in diameter. There is no hydronephrosis or mass of either kidney. Renal parenchyma is preserved.

There is free fluid in the abdomen.

Foley catheter is present in the bladder which cannot be otherwise evaluated.

IMPRESSION:

1. NO MASS OR HYDRONEPHROSIS OF EITHER KIDNEY. NO ACUTE

RENAL ABNORMALITIES.

ASSESSMENT OF PARENCHYMAL ECHOGENICITY IS SOMEWHAT LIMITED

ON THE RIGHT WITH

QUESTION OF SLIGHT INCREASED ECHOGENICITY. THE LEFT RENAL

ECHOGENICITY APPEARS

NORMAL.

2. ASCITES IN FOUR QUADRANTS.

Room 4SO:421-01

Critchett, RN,

Daisyrenee

05/24 18:58

_________________________________

Liisa L. Laakso, D.O.

APPROVED ELECTRONICALLY BY

Liisa L. Laakso, D.O. ON Tue May 24 17:40:40 CDT 2011 cc:LAAKSO, LIISA

MT: ASR

DD: 05/24/2011 04:20 PM

DT: 05/24/2011 05:24 PM

ID: 1232037

JOB: 1232037

AHMED, ZAFAR

VENTURA,

SALVATORE C

AHMED, ZAFAR

AHMED, ZAFAR

AHMED, ZAFAR

05/24 18:52 CK + CKMB

CK1-121

05/24 18:00 RENAL FUNCTION

PANEL

05/24 20:44 Glucose monitor

NA-144,K-3.9,CL-108,CO2-25,BUN-49,CREAT-1.75,GLUCOSE-

57,AGAP-11,BUNCR-28,CA-9.3,PHOS-5.4,ALB-3.5,GFR-37.9

BGM-64

05/25 3:16 Glucose monitor

05/25 5:33 Glucose monitor

BGM-153

AHMED, ZAFAR 05/24 22:59 Glucose monitor

BGM-117

*HCCI-

CARDIOLOGISTS

VENTURA,

SALVATORE C

VENTURA,

SALVATORE C

05/25 5:00 COMPREHENSIVE

METABOLIC PANEL

05/25 5:00 PHOSPHOROUS

05/25 5:00 IFE PANEL

AHMED, ZAFAR 05/24 22:02 Glucose monitor

IFEINT-CANCELED,SPEINTERPT-CANCELED,IGM-CANCELED,IGA-

CANCELED,IG_G-CANCELED,GAMMA-CANCELED,BETA-CANCELED,ALPHA2-

CANCELED,ALPHA1-CANCELED,ALB-CANCELED,TPROT-CANCELED

BGM-68

BGM-140

*HCCI-

CARDIOLOGISTS

VENTURA,

SALVATORE C

05/25 7:30 COMPREHENSIVE

METABOLIC PANEL

NA-146,K-3.6,CL-108,CO2-25,BUN-47,CREAT-1.67,GLUCOSE-

99,AGAP-13,AG RATIO-1.0,BUNCR-28,GLOBTOT-3.6,ALB-3.6,TPROT-

7.2,CA-9.1,ALT-21,AST-35,ALKPHOS-64,GFR-40.0,TBILI-1.5

05/25 7:30 PHOSPHOROUS

PHOS-5.0

05/25 9:10 EKG - Preliminary

VENTURA,

SALVATORE C

FOCHESATTOFIL

LHO, LUCIANO

05/26 5:00 RENAL FUNCTION

PANEL

05/25 9:48 PT INT-3.19,PT-36.1

VENTURA,

SALVATORE C

05/25 6:03

Metro South Medical Center

Patient Name Age DOB Gender

Female

Race

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

Allergies: nka

VENTURA,

SALVATORE C

05/25 7:31 IFE PANEL

PATHREVIEW-Reviewed and approved by Dr. A. Handelsman,

Pathologist,IFEINT-No monoclonal proteins identified.,SPEINTERPT-Serum Protein Electrophoresis shows an essentially normal electophoretic pattern.,IGM-63,IGA-

262,IG_G-1810,GAMMA-1.65,BETA-0.82,ALPHA2-0.73,ALPHA1-

0.27,ALB-3.33,TPROT-6.8

NA-142,K-4.1,CL-107,CO2-25,BUN-48,CREAT-1.62,GLUCOSE-

189,GFR-41.4,AGAP-10,BUNCR-30,CA-8.7

Room 4SO:421-01

VENTURA,

SALVATORE C

AHMED, ZAFAR

AHMED, ZAFAR

AHMED, ZAFAR

05/25 17:00 BASIC

METABOLIC PNL

(CA TOTAL)

05/25 11:06 Glucose monitor

05/25 16:29 Glucose monitor

05/25 21:09 Glucose monitor

BGM-115

BGM-291

BGM-193

FOCHESATTOFIL

LHO, LUCIANO

FOCHESATTOFIL

LHO, LUCIANO

FOCHESATTOFIL

LHO, LUCIANO

05/26 5:00 MAGNESIUM

05/26 5:00 PHOSPHOROUS

MAG-1.5

PHOS-4.3

*HCCI-

CARDIOLOGISTS

05/26 5:00 COMPREHENSIVE

METABOLIC PANEL

NA-146,K-4.1,CL-109,CO2-24,BUN-46,CREAT-1.55,GLUCOSE-

131,AGAP-13,AG RATIO-0.9,BUNCR-30,GLOBTOT-3.6,ALB-3.1,TPROT-

6.7,CA-8.8,ALT-18,AST-33,ALKPHOS-54,GFR-43.6,TBILI-1.4

05/26 5:00 B-TYPE

NATRIURETIC

PEPTIDE

05/26 5:00 PT PTT

BNP-1429

PTT-42.0,INT-3.30,PT-37.8

Blazek, RN,

Patricia Marie

Milenkovic,

Steven Robert

FOCHESATTOFIL

LHO, LUCIANO

FOCHESATTOFIL

LHO, LUCIANO

VENTURA,

SALVATORE C

05/26 5:00 CBC W AUTO DIFF

05/24 14:04 CULTURE URINE

WBC-4.7,RBC-5.24,HGB-15.0,HCT-45.3,PLTCT-146,MCV-86.5,MCHC-

33.1,COMMENT10-slt enlarged plt,RBCMORPH-Slight

Anisocytosis Polychromasia Poikilocytosis Burr Cells

Spherocyte Target Cells Schistocytes,MANDIFFDONE-Man diff not indicated,BASOS-0.3,EO-2.4,MONOS1-10.3,LYMPH-

20.1,NEUTRO-66.9,MPV-9.5,RDW-21.8,MCH-28.6

Specimen: Urine Cath

Collected: 05/24/2011 14:00

Blazek, RN,

Patricia Marie

Status: Final Last Updated: 05/26/2011 11:33

05/26 8:50

05/26 9:04

05/26 8:50

Culture Result (Final)

Colony Count <10,000 COL/ML

Isolate 1 (Final)

Streptococcus agalactiae (Group B)

AHMED, ZAFAR

MILENKOVIC,

STEVEN

MILENKOVIC,

STEVEN

MILENKOVIC,

STEVEN

05/26 11:24 Glucose monitor

05/27 5:00 BUN

05/27 5:00 LYTES (NA K CL

CO2)

05/27 5:00 B-TYPE

NATRIURETIC

PEPTIDE

05/27 5:00 CREATININE MILENKOVIC,

STEVEN

FOCHESATTOFIL

LHO, LUCIANO

05/27 5:00 PT

BGM-186

INT-CANCELED,PT-CANCELED

Metro South Medical Center

Patient Name Age DOB Gender

Female

Race

Allergies: nka

Medical Orders

MD Name MD Time

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

Room 4SO:421-01

Medical Orders

micu standing orders Phone order written/repeated/verified per AHMED, ZAFAR

Clinical Staff

Clinical Staff

Time

Order Status

Bayless, RN, Michel 05/23 18:31 Secretary Completed

CRITICAL CARE/TELEMETRY ADMISSION ORDER SET per AHMED, ZAFAR MD

Bayless, RN, Michel 05/23 18:37 Secretary Completed

MEDICATION ORDERS per AHMED, ZAFAR MD Bayless, RN, Michel 05/23 18:37 Secretary Completed

Acetaminophen 650mg oral every 4 hours as needed for fever more than 101 degrees F or pain - notify physician if no relief in 1 hour per AHMED, ZAFAR MD

Bayless, RN, Michel 05/23 18:37 Secretary Completed

Colace 100mg oral as needed at bedtime for constipation per AHMED, ZAFAR MD

Bayless, RN, Michel 05/23 18:37 Secretary Completed

Milk of magnesia 30ml oral as needed for constipation per AHMED, ZAFAR MD

Bayless, RN, Michel 05/23 18:37 Secretary Completed

Mylanta 30ml oral as needed for indigestion per

AHMED, ZAFAR MD

Bayless, RN, Michel 05/23 18:37 Secretary Completed

Nitroglycerin gr1/150 sublingual as needed - may repeat x 3 every 5 minutes if systolic BP more than 90 per AHMED, ZAFAR MD

Bayless, RN, Michel 05/23 18:37 Secretary Completed

Sonata 10mg oral as needed at bedtime for sleep if under age 65 and over 50kg reduce dose to 5mg if over 65 or under 50kg per AHMED, ZAFAR MD

Tigan 200mg Intramuscular every 6 hours as needed for nausea per AHMED, ZAFAR MD

Bayless, RN, Michel 05/23 18:37 Secretary Completed

Bayless, RN, Michel 05/23 18:37 Secretary Completed

GENERAL NURSING ORDERS per AHMED, ZAFAR MD Bayless, RN, Michel 05/23 18:37 Secretary Completed

Obtain vascular access with PIVL and flush per protocol per AHMED, ZAFAR MD

Bayless, RN, Michel 05/23 18:37 Secretary Completed

Bayless, RN, Michel 05/23 18:37 Secretary Completed Daily weight every morning and record per AHMED,

ZAFAR MD

Oxygen at 2l/minute - titrate as needed per AHMED,

ZAFAR MD

Bayless, RN, Michel 05/23 18:37 Secretary Completed

Record Intake and output every shift per AHMED,

ZAFAR MD

Bayless, RN, Michel 05/23 18:37 Secretary Completed

Bedrest with BRP per AHMED, ZAFAR MD Bayless, RN, Michel 05/23 18:37 Secretary Completed

Continuous Cardiac Monitor per AHMED, ZAFAR MD Bayless, RN, Michel 05/23 18:37 Secretary Completed

Bayless, RN, Michel 05/23 18:37 Secretary Completed Notify Physician if no relief after first 2 doses of NTG for acute chest pain per AHMED, ZAFAR MD

Institute ACLS Protocols for sustained symptomatic arrhythmias per AHMED, ZAFAR MD

Bayless, RN, Michel 05/23 18:37 Secretary Completed

Notify physician of all arrhythmia events, actions and current status as soon as possible per AHMED,

ZAFAR MD

Bayless, RN, Michel 05/23 18:37 Secretary Completed

Initiate Potassium and Magnesium replacement protocols as needed per AHMED, ZAFAR MD

Bayless, RN, Michel 05/23 18:37 Secretary Completed

DIET per AHMED, ZAFAR MD

DIAGNOSTIC TESTING per AHMED, ZAFAR MD

Bayless, RN, Michel 05/23 18:37 Secretary Completed

Bayless, RN, Michel 05/23 18:37 Secretary Completed

Repeat Troponin level 8 hours after first draw x 1 per

AHMED, ZAFAR MD

Bayless, RN, Michel 05/23 18:37 Secretary Completed

Repeat CK-MB level every 8 hours after first draw x 2 per AHMED, ZAFAR MD

Bayless, RN, Michel 05/23 18:37 Secretary Completed

PCXR STAT if not done in ED per AHMED, ZAFAR MD Bayless, RN, Michel 05/23 18:37 Secretary Completed

12 lead EKG - STAT if not done in ED per AHMED,

ZAFAR MD

Bayless, RN, Michel 05/23 18:37 Secretary Completed

12 lead EKG daily x 2 per AHMED, ZAFAR MD Bayless, RN, Michel 05/23 18:37 Secretary Completed

Metro South Medical Center

Patient Name

Allergies: nka

AHMED, ZAFAR

AHMED, ZAFAR

AHMED, ZAFAR

AHMED, ZAFAR

AHMED, ZAFAR

AHMED, ZAFAR

AHMED, ZAFAR

AHMED, ZAFAR

AHMED, ZAFAR

AHMED, ZAFAR

AHMED, ZAFAR

Age DOB Gender Race

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

05/23/2011 18:40

05/23/2011 18:42

05/23/2011 18:42

05/23/2011 18:42

05/23/2011 18:42

05/23/2011 18:42

05/23/2011 18:42

05/23/2011 18:43

05/23/2011 18:43

05/23/2011 18:43

05/23/2011 18:43 cbc, cmp, tsh, ua, urcl, trop, cpk, STAT Phone order written/repeated/verified per AHMED, ZAFAR

HGB A1C, VIT B12, FOLIC, CBC, CMP IN AM Phone order written/repeated/verified per AHMED, ZAFAR

CPK AND TROP Q8HRS Phone order written/repeated/verified per AHMED, ZAFAR

Brain CT WITHOUT contrast STAT Phone order written/repeated/verified per AHMED, ZAFAR

Chest X-ray PA/lateral STAT Phone order written/repeated/verified per AHMED, ZAFAR

PT/OT TO CONSULT WHEN CLEARED BY

CARDIOLOGY Phone order written/repeated/verified per AHMED, ZAFAR

Bayless, RN, Michel

Bayless, RN, Michel

Bayless, RN, Michel

Bayless, RN, Michel

Bayless, RN, Michel

Bayless, RN, Michel

Room 4SO:421-01

05/23 18:39 Secretary Completed

05/23 18:41 Secretary Completed

05/23 18:42 Secretary Completed

05/23 18:42 Secretary Completed

05/23 18:42 Secretary Completed

05/23 18:43 Secretary Completed

HOLD ALL DIABETIC MEDICATIONS UNTIL NOTIFIED

BY Z AHMED Phone order written/repeated/verified per AHMED, ZAFAR

Bayless, RN, Michel 05/23 18:43 Secretary Completed

HOLD LOW DOSE SLIDING SCALE UNTIL PATIENTS

BLOOD SUGAR IS GREATER THAN 150 Phone order written/repeated/verified per AHMED, ZAFAR

Bayless, RN, Michel 05/23 18:44 Secretary Completed

Bayless, RN, Michel 05/23 18:44 Secretary Completed Renal Diet Phone order written/repeated/verified per

AHMED, ZAFAR

CONSULT Dr. IAFFALDANO Phone order written/repeated/verified per AHMED, ZAFAR

Bayless, RN, Michel 05/23 18:45 Secretary Completed

Acc Check QID Phone order written/repeated/verified per AHMED, ZAFAR

Bayless, RN, Michel 05/23 18:47 Secretary Completed

Admit to Telemetry Unit per AHMED, ZAFAR MD Burge, RN, Patricia 05/23 19:03 Secretary Completed

Initiate MICU order set per AHMED, ZAFAR MD Burge, RN, Patricia 05/23 19:03 Secretary Completed

Initiate electrolyte replacement order set per AHMED,

ZAFAR MD

Burge, RN, Patricia 05/23 19:03 Secretary Completed

Change diet from renall to diabetic Phone order written/repeated/verified per AHMED, ZAFAR dc iv fliuds; order # 23 from Mar Phone order written/repeated/verified per REYNOLDS, ALBERT no coumadin today Phone order written/repeated/verified per FOCHESATTOFILLHO,

LUCIANO

Critchett, RN,

Daisyrenee

05/24 7:07 Secretary Completed

Bahena, RN, Cecilia 05/26 3:52 Secretary Completed

Kane Rph, Richard 05/26 11:59 Secretary Completed

AICD check

Home Med Recon Continue - Aspirin 325 mg Tab,

Daily

Bayless, RN, Michel

Bayless, RN, Michel

05/23 18:58 Secretary Completed

05/23 18:49 Secretary Completed

Home Med Recon Continue - Chlordiazepoxide 25 mg

Cap, At Bedtime as needed

Bayless, RN, Michel 05/23 18:49 Secretary Completed

Home Med Recon Continue - Colace 100 mg Cap,

Twice Daily as needed

Bayless, RN, Michel 05/23 18:48 Secretary Completed

Home Med Recon Continue - Colchicine 0.6 mg Tab,

Twice A Day

Bayless, RN, Michel 05/23 18:49 Secretary Completed

Home Med Recon Continue - Coreg 25 mg Tab, Twice

A Day

Bayless, RN, Michel 05/23 18:49 Secretary Completed

Bayless, RN, Michel 05/23 18:49 Secretary Completed Home Med Recon Continue - Glipizide 10 mg Tab,

Twice A Day

Home Med Recon Continue - Lasix 80 mg Tab, Twice

A Day

Bayless, RN, Michel 05/23 18:49 Secretary Completed

Bayless, RN, Michel 05/23 18:48 Secretary Completed Home Med Recon Continue - Pepcid 20 mg Tab,

Twice A Day

Home Med Recon Continue - Reglan 10 mg Tab,

Three Times A Day

Home Med Recon Continue - Simvastatin 40 mg Tab,

Daily

Bayless, RN, Michel

Bayless, RN, Michel

05/23 18:49 Secretary Completed

05/23 18:48 Secretary Completed

Metro South Medical Center

Patient Name Age DOB Gender

Female

Race

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

Allergies: nka

AHMED, ZAFAR

AHMED, ZAFAR

HARRIS, RICHARD G

KASON, THOMAS T

KASON, THOMAS T

KASON, THOMAS T

HARRIS, RICHARD G

HARRIS, RICHARD G

HARRIS, RICHARD G

HARRIS, RICHARD G

05/23/2011 18:43

05/23/2011 18:46

05/24/2011 7:45

05/24/2011 8:19

05/24/2011 8:20

05/24/2011 8:20

05/24/2011 9:55

05/24/2011 9:55

05/24/2011 9:57

05/24/2011 9:58

Room 4SO:421-01

Home Med Recon Continue - Warfarin 5 mg Tab, Daily Bayless, RN, Michel 05/23 18:48 Secretary Completed

PT INR stat and at AM bnp level now

Lasix 80mg IVP, , bid, 2 Day(s)

Hold PO lasix - we will use IV lasix

AM labs = CMP

HCCI consult bmp in am consult Dr. Ventura

Bayless, RN, Michel

Bayless, RN, Michel

Bayless, RN, Michel

Bayless, RN, Michel

Bayless, RN, Michel

Critchett, RN,

Daisyrenee

05/23 18:49 Secretary Completed

05/24 8:15

05/24 8:36

05/24 8:36

05/24 8:36

Secretary Completed

Secretary Completed

Secretary Completed

Secretary Completed

05/24 10:23 Secretary Completed

Bayless, RN, Michel 05/24 10:22 Secretary Completed

Critchett, RN,

Daisyrenee

05/24 10:03 RN Completed

IVF: D5 0.9NS with 10meq kcl at 70cc/hr

Insert Foley

Critchett, RN,

Daisyrenee

05/24 10:03 Secretary Completed

Bayless, RN, Michel 05/24 12:15 Secretary Completed VENTURA, SALVATORE

C

05/24/2011 11:16

VENTURA, SALVATORE

C

05/24/2011 11:16

VENTURA, SALVATORE

C

05/24/2011 11:16

VENTURA, SALVATORE

C

05/24/2011 11:17

VENTURA, SALVATORE

C

05/24/2011 11:17

VENTURA, SALVATORE

C

05/24/2011 11:17

VENTURA, SALVATORE

C

05/24/2011 11:18

VENTURA, SALVATORE

C

05/24/2011 11:18

VENTURA, SALVATORE

C

05/24/2011 11:25

VENTURA, SALVATORE

C

05/24/2011 11:26

KASON, THOMAS T 05/24/2011 12:14

HARRIS, RICHARD G

AMIN, PARAG K

VENTURA, SALVATORE

C

VENTURA, SALVATORE

C

05/24/2011 13:55

05/24/2011 22:11

05/25/2011 6:07

05/25/2011 6:07

VENTURA, SALVATORE

C

05/25/2011 6:07

VENTURA, SALVATORE

C

05/25/2011 6:08

VENTURA, SALVATORE

C

05/25/2011 6:09

VENTURA, SALVATORE

C

05/25/2011 6:09

FOCHESATTOFILLHO,

LUCIANO

05/25/2011 6:34

Urine analysis and urine culture

STAT Renal Ultrasound

Serum immunoelectrophoresis

Chem 7 at 6 PM today

Renal Panel tomorrow AM

Start Dobutamine if OK with Dr. Kason

Do renal ultrasound at bedside due to hypoglycemia

Stop Glipizide

Hold colchicine: notify Dr. Harris

Renal panel tomorrow AM

Stop IV fluids if OK with Dr. Harris

Double concentrate IV Dobutamine

Increase Lasix to 100 mg IV Q 8 hours change accucheck Q4hours Phone order written/repeated/verified per FOCHESATTOFILLHO,

LUCIANO

Bayless, RN, Michel

Bayless, RN, Michel

Bayless, RN, Michel

Bayless, RN, Michel

Bayless, RN, Michel

Bayless, RN, Michel

Bayless, RN, Michel

Bayless, RN, Michel

Bayless, RN, Michel

OK to start Dobutamine at 5mcg/kg/min Phone order written/repeated/verified per KASON, THOMAS T

Critchett, RN,

Daisyrenee

05/24 12:14 Secretary Completed

Inpatient status from the start Phone order written/repeated/verified per HARRIS, RICHARD G

Blazek, RN, Patricia

Marie

05/24 13:55 Secretary Completed

D50 ivp x1 stat Phone order written/repeated/verified per AMIN, PARAG K

Bahena, RN, Cecilia 05/24 22:11 RN Completed

Bahena, RN, Cecilia 05/25 6:51 Secretary Completed Start 24 hour urine for creatinine clearance and protein.

Chem 7 at 5 PM today Bahena, RN, Cecilia 05/25 6:51 Secretary Completed

Bahena, RN, Cecilia

Bahena, RN, Cecilia

Bahena, RN, Cecilia

Bahena, RN, Cecilia

Bahena, RN, Cecilia

05/24 11:41 Secretary Completed

05/24 12:15 Secretary Completed

05/24 11:40 Secretary Completed

05/24 11:40 Secretary Completed

05/24 11:40 Secretary Completed

05/24 12:15 Secretary Completed

05/24 12:15 Secretary Completed

05/24 11:40 Secretary Completed

05/24 11:40 Secretary Completed

05/25 6:51

05/25 6:51

05/25 6:50

05/25 6:51

05/25 6:34

Secretary Completed

Secretary Completed

Secretary Completed

Secretary Completed

Secretary Completed

Metro South Medical Center

Patient Name Age DOB Gender

Female

Race

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

Allergies: nka

FOCHESATTOFILLHO,

LUCIANO

FOCHESATTOFILLHO,

LUCIANO

FOCHESATTOFILLHO,

LUCIANO

05/25/2011 6:39

05/25/2011 6:39

05/25/2011 6:40 give one amp of d50 ivp now Phone order written/repeated/verified per FOCHESATTOFILLHO,

LUCIANO stop iv fluids Phone order written/repeated/verified per FOCHESATTOFILLHO, LUCIANO call for blood sugar below 80 Phone order written/repeated/verified per FOCHESATTOFILLHO,

LUCIANO accu Checks q 4 hrs

Bahena, RN, Cecilia

Bahena, RN, Cecilia

Bahena, RN, Cecilia

05/25 6:39

05/25 6:39

05/25 6:40

Room 4SO:421-01

Secretary Completed

Secretary Completed

Secretary Completed

FOCHESATTOFILLHO,

LUCIANO

FOCHESATTOFILLHO,

LUCIANO

FOCHESATTOFILLHO,

LUCIANO

FOCHESATTOFILLHO,

LUCIANO

Milenkovic, Steven

Robert

FOCHESATTOFILLHO,

LUCIANO

05/25/2011 8:46

05/25/2011 8:55

05/25/2011 9:02

05/25/2011 9:03

05/25/2011 9:15

05/25/2011 9:30

Nursing staff to assist pt w feeding.

cbc, cmp, magnesium, pt/ptt/inr in am warfarin - pharmacy to dose, , N/A

BNP in am.

White, RN, Carina

White, RN, Carina

White, RN, Carina

White, RN, Carina

White, RN, Carina

05/25 8:55

05/25 8:55

05/25 9:26

05/25 9:26

05/25 9:26

Secretary Completed

Secretary Completed

Secretary Completed

Secretary Completed

Secretary Completed

FOCHESATTOFILLHO,

LUCIANO

SHIN, HENRY

SHIN, HENRY

SHIN, HENRY

SHIN, HENRY

SHIN, HENRY

SHIN, HENRY

05/25/2011 11:09

05/25/2011 11:28

05/25/2011 11:28

05/25/2011 11:28

05/25/2011 11:33

05/25/2011 11:34

05/25/2011 11:34

FOCHESATTOFILLHO,

LUCIANO

05/25/2011 12:13

VENTURA, SALVATORE

C

05/25/2011 18:30

VENTURA, SALVATORE

C

05/26/2011 6:29

Milenkovic, Steven

Robert

05/26/2011 9:15

Milenkovic, Steven

Robert

FOCHESATTOFILLHO,

LUCIANO

FOCHESATTOFILLHO,

LUCIANO

FOCHESATTOFILLHO,

LUCIANO

05/26/2011 9:15

05/26/2011 9:26

05/26/2011 9:33

05/26/2011 9:33

Pt/INR now & daily am while on coumadin per coumadin phcy protocol Phone order written/repeated/verified per FOCHESATTOFILLHO,

LUCIANO

Kannankeril, Jaya J.

05/25 9:30 Secretary Completed

No COUMADIN today per coumadin phcy protocol

Phone order written/repeated/verified per

FOCHESATTOFILLHO, LUCIANO

Kannankeril, Jaya J.

appears euvolemic. Change dose of enalapril 10mg po bid

White, RN, Carina

05/25 11:09 Secretary Completed

05/25 12:08 Secretary Completed

05/25 12:08 Secretary Completed OK to DC home from cardiac standpoint. F/U with Dr.

Erickson in 1 week, coumadin clinic in 1 week.

White, RN, Carina

1.2liter/day fluid restriction at home White, RN, Carina 05/25 12:08 Secretary Completed

Kdur 40MEq po x 1 now then 20mEq po daily chem 6 in 1 week

D/C dobutamine d/c foley Phone order written/repeated/verified per

FOCHESATTOFILLHO, LUCIANO foley CATH for 24 hour urine collection Phone order written/repeated/verified per VENTURA, SALVATORE

C

Remove patient name from Dr. Ventura's list.

White, RN, Carina

White, RN, Carina

White, RN, Carina

White, RN, Carina

White, RN, Carina

White, RN, Carina

05/25 12:08 Secretary Completed

05/25 12:08 Secretary Completed

05/25 12:08 Secretary Completed

05/25 12:13 Secretary Completed

05/25 18:30 Secretary Completed

05/26 8:18 Secretary Completed

Chem 6 and BNP in am.

D/C IV Lasix after pm dose and restart 80mg po BID in am of 5/27.

Discharge Home pt's bp > 100 of systolic going home on low dose ACEI and BB

White, RN, Carina

White, RN, Carina

White, RN, Carina

White, RN, Carina

White, RN, Carina

05/26 9:16

05/26 9:16

Secretary Completed

Secretary Completed

05/26 10:43 Secretary Completed

05/26 10:43 Secretary Completed

05/26 10:43 Secretary Completed

Admit to

MD MD Time RN RN Time

Disposition

Condition

Metro South Medical Center

Patient Name Age DOB Gender

Female

Race

Allergies: nka

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

Room 4SO:421-01

Vitals

Taken at Taken by

05/23 17:24 Burge, RN,

Patricia

05/23 17:25 Burge, RN,

Patricia

05/23 19:45 McCabe, RN,

Janet

05/23 21:19 Shatteen, PCP,

Angie E.

Temp Pulse Resp BP

Oral 97.8

70 20 122/79

Oral 97.8

69

Oral 95.1

68

20

24

124/91

132/70

Pulse

Ox

Pain

Scale

100% Denies pain

98% Denies pain

Denies pain

PCP entry

05/23 23:22 Shatteen, PCP,

Angie E.

Oral 97.4

71

05/24 0:00 McCabe, RN,

Janet

05/24 1:30 McCabe, RN,

Janet

72

05/24 6:01 Shatteen, PCP,

Angie E.

20 102/77 94%

24 97/89

PCP entry

Denies pain

Denies pain

PCP entry

PCP entry 05/24 6:01 Shatteen, PCP,

Angie E.

05/24 9:42 Critchett, RN,

Daisyrenee

0

05/24 9:57 Bayless, RN,

Michel

05/24 11:00 Garza, PCP, l

Ana

05/24 11:20 Garza, PCP, l

Ana

05/24 13:45 Bayless, RN,

Michel

05/24 14:00 Bayless, RN,

Michel

05/24 14:32 Critchett, RN,

Daisyrenee

05/24 14:36 Critchett, RN,

Daisyrenee

05/24 14:48 Bayless, RN,

Michel

05/24 14:51 Critchett, RN,

Daisyrenee

05/24 15:00 Garza, PCP, l

Ana

05/24 15:36 Critchett, RN,

Daisyrenee

05/24 16:08 Garza, PCP, l

Ana

05/24 16:21 Critchett, RN,

Daisyrenee

05/24 17:07 Critchett, RN,

Daisyrenee

05/24 17:38 Critchett, RN,

Daisyrenee

05/24 17:41 Bayless, RN,

Michel

05/24 17:52 Critchett, RN,

Daisyrenee

Ax 94.2

Ax 94.5

R 96.9

69

69

69

69

73

71

69

69

69

71

70

71

110/83 95%

20 118/83

20

109/85

134/91

128/92

124/89

137/97

121/89

134/96

131/93

140/97

110/79

123/88

Denies pain

PCP entry

PCP entry

Denies pain

Denies pain

Denies pain

PCP entry

PCP entry

Denies pain

85.9

Wt

(kg)

Wt.

Chg.

Ht.

(cm)

BMI

Head

Circ.

(cm)

EGA USEGA LMP

LMP

Status

Comments

pt on roomair pt on roomair

Vpacing Room

Air

ACCU

[email protected]

94

0

Vpacing Room

Air

Paced Room A accu [email protected]

62 accu [email protected]

68 accucheck 54

Notified Dr.

Harris

2L nasal cannu

70acc acc 107

108 acc paced

Metro South Medical Center

Patient Name Age DOB Gender

Female

Race

Allergies: nka

05/24 18:07 Critchett, RN,

Daisyrenee

05/24 18:23 Critchett, RN,

Daisyrenee

05/24 18:37 Critchett, RN,

Daisyrenee

05/24 18:37 Bahena, RN,

Cecilia

05/24 18:52 Critchett, RN,

Daisyrenee

05/24 18:52 Bahena, RN,

Cecilia

05/24 19:35 Bahena, RN,

Cecilia

05/24 19:52 Bahena, RN,

Cecilia

05/24 20:14 Bahena, RN,

Cecilia

05/24 20:49 Wylie,, PCP,

Elana

05/24 20:52 Bahena, RN,

Cecilia

05/24 21:59 Bahena, RN,

Cecilia

05/24 22:01 Bahena, RN,

Cecilia

69

69

71

71

72

72

76

75

Oral 97.6

76

69

72

118/90

109/88

126/93

126/93

129/87

129/87

103/68

110/78

20 103/68

116/86

107/78

Denies pain

PCP entry

Denies pain

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

Room 4SO:421-01 paced accu=64 rn notified accucheck 68 after apple juic with 2 sugars and cheese crackers

05/24 22:51 Bahena, RN,

Cecilia

05/24 22:55 Bahena, RN,

Cecilia

05/24 22:59 Wylie,, PCP,

Elana

05/24 23:31 Wylie,, PCP,

Elana

05/24 23:56 Bahena, RN,

Cecilia

05/25 0:51 Bahena, RN,

Cecilia

05/25 1:51 Bahena, RN,

Cecilia

05/25 2:51 Bahena, RN,

Cecilia

05/25 3:16 Bahena, RN,

Cecilia

05/25 3:52 Bahena, RN,

Cecilia

05/25 4:52 Bahena, RN,

Cecilia

05/25 5:23 Wylie,, PCP,

Elana

05/25 5:52 Bahena, RN,

Cecilia

05/25 6:32 Wylie,, PCP,

Elana

05/25 6:52 Bahena, RN,

Cecilia

05/25 7:59 White, RN,

Carina

69

69

Oral 97.5

69

69

69

72

69

69

69

72

69

Oral 97.4

69

132/94

119/89

18 119/89

115/90

134/90

129/93

142/89

109/81

112/91

139/91

119/84

16 119/74

PCP entry

PCP entry

Denies pain

PCP entry

PCP entry

Denies pain

86.6

0.7

repeat accu=1 unable to obta o2 rn notified

Accucheck 153 accu=117 pt in bed room air. Dobutamin infusing at

5mcg/kg

Metro South Medical Center

Patient Name Age DOB Gender

Female

Race

Allergies: nka

05/25 10:32 White, RN,

Carina

05/25 11:08 Garza, PCP, l

Ana

05/25 15:16 Garza, PCP, l

Ana

05/25 16:30 Garza, PCP, l

Ana

R 95.5

68

69

70

05/25 20:21 Bahena, RN,

Cecilia

05/25 21:00 Fontillas, PCP,

Arthur

Oral 97.7

69

05/26 1:00 Fontillas, PCP,

Arthur

05/26 1:05 Fontillas, PCP,

Arthur

05/26 5:00 Fontillas, PCP,

Arthur

05/26 8:35 White, RN,

Carina

Oral 97.8

69

Oral 97.9

75

05/26 11:40 Yang, PCP, Hai

L

Oral 97.4

69

16 127/87 95%

18 127/87 98%

18 111/79

20 123/86

22 130/90 99%

16 107/74 96%

20 130/91 95%

PCP entry

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

Denies pain

Room 4SO:421-01 dobutamine dr

12.8 mg hour.

115 acc

PCP entry

PCP entry

Denies pain

PCP entry

PCP entry

PCP entry

PCP entry

Denies pain

PCP entry

88.2

1.6

291 acc afib;ra

Accu-check =

193

Accu-check =

211

Room Air

Accu-check =

153 pt is on rroom accucheck 186

Metro South Medical Center

Patient Name Age DOB Gender

Female

Race

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

Allergies: nka

Clinical-InterDisciplinary Notes

Date/Time

05/23/2011 16:42

Note Type

ADMISSION

Clinical Note

Nursing - Admission - CORE MEASURES ASSESSMENT (Rev 01/06/11):

05/23/2011 16:42

05/23/2011 16:43

05/23/2011 16:43

ADMISSION

ADMISSION

WOUNDS

Room 4SO:421-01

Staff

Burge, RN, Patricia

Have you had a flu shot this season (List date or answer no)-No--refuses

Have you had the pneumonia vaccine (Pneumovax) in the past 10 years? (List date or answer no)-No--refuses

Do you smoke?-Not anymore

If reformed smoker, how long ago did you quit?-N/A

Does anyone at home smoke?-No - Patient and family were directed to smoking cessation information anyway

Nursing - Admission - DVT/VTE PROPHYLAXIS SCREENING (Rev 1/7/10):

Is the patient on maintenance anticoagulation (warfarin, heparin or fondaparinux)?-Yes - No further assessment needed at this point. Order baseline INR if takes Warafin and not already done

The baseline INR =-No baseline INR done - order placed. See diagnostics, will monitor

Nursing - Admission - FALL RISK ADMISSION INTERVENTIONS:

Burge, RN, Patricia

Burge, RN, Patricia

TOTAL SCORE from admission assessment- = 5 or more - STANDARD AND HIGH RISK

INTERVENTIONS AS NOTED BELOW

Standard precautions initiated-Includes initial and ongoing fall risk education, safe room set-up including call light in reach and not dangling, moving furniture on non-exit side of bed, side rails up x2, bed locked and low, adequate lighting and room is clear of clutter.

Nursing - Admission - FIRST WOUND ASSESSMENT (rev 11/04/10): Burge, RN, Patricia

WOUND ASSESSMENT-No wounds at this time, no further assessment needed.

TOTAL NUMBER OF WOUNDS NOTED UPON ADMISSION-N/A - no wounds present upon admission

SECOND TIER WOUND ASSESSMENT CONDUCTED BY-Second RN Name -Michele

EQUIPMENT-Pressure relief cushion

WOUND ASSOCIATED PAIN-N/A

WOUND TREATMENT-N/A

Metro South Medical Center

Patient Name

Allergies: nka

05/23/2011 16:44

05/23/2011 16:47

Age

ADMISSION

ADMISSION

DOB Gender

Female

Race

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

Nursing - Admission - RISK ASSESSMENT SCREENS:

Room 4SO:421-01

Burge, RN, Patricia

FUNCTIONAL SCREENING-Completed as follows

PT - Transferring-Requires assistance - person

PT - Ambulation-Completely independent

OT - Bathing-Requires assistance - person

OT - Dressing-Requires assistance - person

OT - Toileting-Requires assistance - person

OT - Feeding-Completely independent

SP - Communication-Effective

SP - Swallowing-Effective

SPIRITUAL/CULTURAL NEEDS-completed as follows

Religious beliefs-Baptist

Is your faith/spirituality an important part of your life?-No

Will being in the hospital interfere with any religious or cultural practices?-No

Do you have any specific requests to meet your spiritual/Cultural needs during hospitilization-No

PSYCHOSOCIAL NEEDS-assessed as follows

Are there any special difficulties produced by this hospitalization?-No

EDUCATIONAL NEEDS-assessed as follows

Current Illness-chf, htn

Treatment plan-meds

Medications-No needs

Pain management-No needs

Medical equipment-No needs

Nutrition/Diet-No needs

Rehabilitative techniques-No needs

Community resources-No needs

Personal hygiene/grooming-No needs

ASSETS/BARRIERS TO PLAN OF CARE-assessed as follows

Does patient have previous experience or knowledge related to reason for this hospitalization-

Asset - Good knowledge base on diagnosis

Patient emotional/relational support system-Asset - Good support system in place with family/friends

Hearing-Asset - Normal hearing or corrected with hearing aides

Vision-Asset - Has normal vision or has corrected vision

Language-Asset - Speaks and understands English

Physical-Asset -Describe

Cognition/Mental status-Barrier - Describe -aox2

Cultural/Religious-No barrier

Does patients appearance demonstrate poor hygiene, malnutrition and/or dehydration-No

Does patient appear frightened or intimidated in the presence of caregiver?-No

Does the patient have unexplained bruises, lacerations, abrasions, burns, head injuries, sprains or fractures?-No

Nursing - Admission - REFERRAL ASSESSMENT: Burge, RN, Patricia

Lives alone or with non-capable caregiver and needs post acute care-No

Currently uses home care devices-No

Lives in a nursing home or imtermediate care facility-No

New CVA diagnosis-No

New CABBG dignosis-No

Patient in foster care system-No

Active substance abuse confirmed by tox screen-No

Drug overdose/Attempted suicide-No

Unidentified patient-No

Undomiciled-No

New joint replacement/Amputee/Fracture-No

New HIV diagnosis-No

HX mental retardation-No

Suspected abuse/neglect-No

New Head/Spinal cord injury-No

Single parent under age 17 or adoption request-No

Pregnancy - High risk/Complicated pregnancy-No

Domestic abuse suspected or confirmed-No

New ostomy-No

PEG tube insertion-No

Terminal illness-No

New dialysis patient-No

Metro South Medical Center

Patient Name

Allergies: nka

05/23/2011 16:49

05/23/2011 19:03

05/23/2011 19:45

05/23/2011 19:45

05/23/2011 19:45

Age DOB Gender

Female

Race

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

ADMISSION

SHIFT NARRATIVE

NURSING

ADLs

VASCULAR ACCESS

Nursing - Admission - PATIENT ASSESSMENT (rev 11/04/10):

Room 4SO:421-01

Burge, RN, Patricia

Patient arrived on unit via-Wheelchair

Admit Source-Direct Admission

Transmission precautions indicated upon admission-Standard precautions indicated and followed

ORIENTATION TO ROOM/UNIT-Patient/significant other oriented to room and unit including the intial plan of care, call light and bed/TV controls, Bathroom and emergency call light, phone and was provided with an admission packet.

BELONGINGS-were inventoried and documented on belongings form, patient/family signature obtained.

Previous Hospitalizations-MSMC

CHIEF COMPLAINT-chf

SUMMARY OF HISTORY OF PRESENT ILLNESS-chf, htn, dm

Summary of prior treatment for present illness-meds

PAIN ASSESSMENT-Patient denies pain now

Patient personal acceptable level of pain is?-N/A

Location of pain?-N/A

Type of discomfort?-N/A

Comfort measures provided include?-quiet environment, warm blankets and distraction

Does patient use any alternative therapies?-N/A

PHYSICAL ASSESSMENT-was completed as noted below;

Mental status-Awake but disoriented (describe) -

Skin-Pink, warm and dry - capillary refill is brisk

Oral Mucosa-Lips and tongue are moist

Neck-Trachea is midline, no JVD is noted

Lung sounds-Clear to ascultation bilaterally

Retractions-No retractions are noted

Nasal flaring-is not present

Stridor-No stridor is heard

Abdomen-is hard,distended and non tender

Bowel sounds-Quiet bowel sound are heard x 4 quadrants

Lower extremities bilaterally-2 + edema is noted

Pedal pulses-are strong bilaterally

Pupils-Equal and reactive

Hand grasps-Strong and equal bilaterally

Ability to Move - right arm-strong

Ability to Move - left arm-strong

Ability to Move - right leg-moderate

Ability to Move - left leg-moderate

Tubes/Drains/Ostomy/Trach-None of these devices are present

Venous access device-None present on admission

Nursing - Serial - SHIFT END NOTE (new 4/19/11): Burge, RN, Patricia

Medical Orders review-I have reviewed and as appropriate carried out all medical orders during my shift, except those orders endorsed to the oncoming RN and/or are scheduled in the future

Diagnostic test review-I have reviewed all pertinent diagnostic data as available and appropriate during my shift

Patient report given and patient care endorsed to-Janet RN

Nursing - Serial - SHIFT NARRATIVE NOTE (new 6/29/10) Recvd pt awake, alert, oriented to place and person, questionable on time. Denies pain. Vpacing on monitor.

Nursing - Serial - SHIFT HYGIENE/ADL (rev 05/05/11):

McCabe, RN, Janet

McCabe, RN, Janet

TURN FREQUENCY-Patient able to reposition self frequently in bed

ACTIVITY-Bedrest with BRP

FEEDING-Self

COUGH AND DEEP BREATHING EXERCISES-Done every 2 hours while awake

EQUIPMENT – VTE (Venous Thromboembolism) Prophylaxis-N/A

LIST VTE PROPHYLAXIS CONTRAINDICATION (if applicable)-N/A

Nursing - Serial - SHIFT MULTIPLE LINE ASSESSMENT (rev 12/21/09):

PIVL Site 1 Location-Left AC Fossa pivl

PIVL Site 1 dressing label-date/Time placed - 20g 5-23

PIVL Site 1 Inspection-Site is clean and dry without redness, drainage or swelling

Patient's central venous access device continues to be necessary due to-N/A

McCabe, RN, Janet

Metro South Medical Center

Patient Name

Allergies: nka

05/23/2011 19:45

05/23/2011 19:45

05/23/2011 19:45

05/23/2011 19:50

05/23/2011 19:52

05/23/2011 19:53

05/23/2011 20:15

05/23/2011 21:20

05/23/2011 22:30

05/24/2011 0:00

Age DOB Gender

Female

Race

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

Room 4SO:421-01

McCabe, RN, Janet ASSESSMENT

WOUNDS

VASCULAR ACCESS

NURSING

SPIRITUAL CARE

PLAN OF CARE

NURSING

NURSING

NURSING

SKIN ASSESSMENT

Nursing - Serial - SHIFT NURSING ASSESSMENT (rev 11/04/10):

Transmission Precautions-Standard

O2 Type/Liter Flow-Room Air

Rhythm Strip Interpretation-Paced Rhythm

LOC-Awake, Alert and Oriented x 2

Affect-Calm

Eye Opening-4 spontaneous

Verbal Response-5 Alert and Oriented X 2

Motor Response-6 obeys commands

Pupils-reacts

Ability to Move - right arm-moderate

Ability to Move - right leg-moderate

Ability to Move - left leg-moderate

Ability to Move - left arm-moderate

Skin Color-Normal

Skin Temperature-cool

Skin Moisture-Dry

Skin turgor-non-tenting

Respirations-Unlabored

Breath Sounds Right-Clear

Breath Sounds Left-Clear

Retractions-No retractions noted

Abdomen-distended, firm, non tender

Bowel Sounds-Active x 4 quadrants

Pedal Edema Right-2 plus Moderate 1/2 inch

Pedal Edema Left-2 plus Moderate 1/2 inch

Pedal Pulses Right-1 plus = Barely palpable

Pedal Pulses Left-1 plus = Barely palpable

Nursing - Serial - SHIFT WOUND ASSESSMENT (rev 05/06/10):

WOUND ASSESSMENT-No wounds at this time, no further assessment needed.

TOTAL NUMBER OF WOUNDS-# wounds = 0

EQUIPMENT-Pressure relief mattress on bed

WOUND ASSOCIATED PAIN-N/A

WOUND TREATMENT-N/A

Nursing - Focused - IV START NOTE (new 12/21/09):

Peripherally Inserted Vascular Lock- was established as follows

Site used for start-Left AC Fossa

Device Type/Size-Other - 20g butterfly

Lock attached, secured with tape, line flushed easily after insertion.-Bioocclusive dressing applied, site was labelled with device type/size, start time, date and initials.

Patient tolerance-Patient tolerated procedure well.

Pt to CT scan with RN, monitor per w/c, also went to chest xray

Spiritual Care - Assessment:

Religious affiliation-Christian

Interventions - Prayer/scripture-pt received pryer and encouragement; appreciated the visit

Spiritual Care - Interdisciplinary Plan of Care:

INTERVENTION-Spiritual care assessment completed and emotional needs identified

OUTCOME-Accepts spiritual interventions and counseling

Returned from CT Scan per w/c, assisted back to bed.

Accucheck = 94, no coverage ordered.

Dr. Cusick called with consult, no new orders received.

Nursing - Serial - DAILY BRADEN SKIN ASSESSMENT:

Sensory Perception-= 4 - No impairment

Moisture-4 - Rarely Moist

Activity-3 - Walks Occasionally

Mobility-3 - Slightly Limited

Nutrition- = 4 - Excellent

Friction and Shear- = 3 - No apparent problem

Total Score-= 19 or more - No interventions needed at present - continue to monitor

McCabe, RN, Janet

McCabe, RN, Janet

McCabe, RN, Janet

Carney, PhD, Phillita

T.

Carney, PhD, Phillita

T.

McCabe, RN, Janet

McCabe, RN, Janet

McCabe, RN, Janet

McCabe, RN, Janet

Metro South Medical Center

Patient Name

Allergies: nka

05/24/2011 0:00

05/24/2011 0:00

05/24/2011 0:00

05/24/2011 0:00

05/24/2011 0:10

05/24/2011 1:30

05/24/2011 1:40

Age DOB Gender

Female

Race

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

FALL RISK

ADLs

VASCULAR ACCESS

ASSESSMENT

NURSING

NURSING

NURSING

Nursing - Serial - SHIFT FALL RISK ASSESSMENT/INTERVENTIONS (rev 12/10/10):

Room 4SO:421-01

McCabe, RN, Janet

Currently/History of - Confusion/Disorientation/Impulsivisity-Yes = 4

HX Depression with active symptoms at present-No = 0

Altered elimination (Frequency/Urgency/Incontinence/Diuretics)-Yes = 1

Currently/History of - Dizziness/Vertigo-Yes = 1

Male Gender-No = 0

Currently taking anticonvulsants (check MAR)-No = 0

Currently taking benzodiazepines (check MAR)-No = 0

Mobility assessment reveals (Get up and Go Test)-Patient needs to push up but successful in 1 attempt = 1

TOTAL SCORE- = 5 or more - STANDARD AND HIGH RISK INTERVENTIONS AS NOTED BELOW

Standard precautions initiated-Includes initial and ongoing fall risk education, safe room set-up including call light in reach and not dangling, moving furniture on non-exit side of bed, side rails up x2, bed locked and low, adequate lighting and room is clear of clutter. If high risk, additional interventions below

High risk precautions initiated-Includes Appropriate signage posted in room, chart labels on, Fall risk ID band applied, red slippers provided, hourly rounding done, proactive bladder program established and exit alarms are in place and active.

Nursing - Serial - SHIFT HYGIENE/ADL (rev 05/05/11): McCabe, RN, Janet

TURN FREQUENCY-Patient able to reposition self frequently in bed

ACTIVITY-Bedrest with BRP

FEEDING-Self

COUGH AND DEEP BREATHING EXERCISES-Done every 2 hours while awake

EQUIPMENT – VTE (Venous Thromboembolism) Prophylaxis-N/A

LIST VTE PROPHYLAXIS CONTRAINDICATION (if applicable)-N/A

Nursing - Serial - SHIFT MULTIPLE LINE ASSESSMENT (rev 12/21/09):

PIVL Site 1 Location-left upper arm pivl

PIVL Site 1 dressing label-date/Time placed -2-23 20g

PIVL Site 1 Inspection-Site is clean and dry without redness, drainage or swelling

Patient's central venous access device continues to be necessary due to-N/A

Nursing - Serial - SHIFT NURSING ASSESSMENT (rev 11/04/10):

McCabe, RN, Janet

McCabe, RN, Janet

Transmission Precautions-Standard

O2 Type/Liter Flow-Room Air

Rhythm Strip Interpretation-Paced Rhythm

LOC-awake, alert oriented to person always, unsure of time and place intermittently

Affect-Calm

Eye Opening-4 spontaneous

Verbal Response-see above

Motor Response-6 obeys commands

Pupils-reacts

Ability to Move - right arm-moderate

Ability to Move - right leg-moderate

Ability to Move - left leg-moderate

Ability to Move - left arm-moderate

Skin Color-Normal

Skin Temperature-warm

Skin Moisture-Dry

Skin turgor-non-tenting

Respirations-Unlabored

Breath Sounds Right-Clear

Breath Sounds Left-Clear

Retractions-No retractions noted

Abdomen-distended firm non tender

Bowel Sounds-Active x 4 quadrants

Pedal Edema Right-2 plus Moderate 1/2 inch

Pedal Edema Left-2 plus Moderate 1/2 inch

Pedal Pulses Right-1 plus = Barely palpable

Pedal Pulses Left-1 plus = Barely palpable

Medication Administration Record Reconciled and Verified

Found pt sitting on side of bed, states "I want to go to the bathroom" Skin cool, dry. Speech somewhat slurred. Hand grasps equal, moderate strength. Accucheck done = 71. B/p 97/89 hr

72. Pt denies pain. Pt placed on bedpan, pt did not appear strong enough to walk to bathroom.

Bladder scan done, 409ml in bladder.

Pt able to drink about 1/3 glass OJ with a packet of sugar, unable to void on bedpan, removed.

McCabe, RN, Janet

McCabe, RN, Janet

McCabe, RN, Janet

Metro South Medical Center

Patient Name

Allergies: nka

05/24/2011 2:00

05/24/2011 4:00

05/24/2011 5:05

05/24/2011 5:48

05/24/2011 6:45

05/24/2011 8:00

05/24/2011 8:00

05/24/2011 8:00

Age DOB Gender

Female

Race

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

NURSING

NURSING

NURSING

NURSING

SHIFT NARRATIVE

SKIN ASSESSMENT

FALL RISK

VASCULAR ACCESS

Found pt standing at foot of bed on way to bathroom, assisted to bathroom with 2 RN's. Pt voided and had bm, flushed before rn could see results. Walked back to bed. Speech clearer now. Pt states she feels better, requesting and given graham crackers. Sitting up in bed watching tv.

No major changes from previous assessment, patient remains neurologically and hemodynamically stable

Accucheck = 62, pt took rest of oj with sugar and then another 120ml of orange juice. Speech not slurred now, pt warmer and dry. Drinking readily with the straw.

Room 4SO:421-01

McCabe, RN, Janet

McCabe, RN, Janet

McCabe, RN, Janet

Accucheck rechecked = 68. Pt warm and dry, speech clear, initiating conversation. Denies pain.

Watching tv.

Nursing - Serial - SHIFT END NOTE (new 4/19/11):

McCabe, RN, Janet

McCabe, RN, Janet

Medical Orders review-I have reviewed and as appropriate carried out all medical orders during my shift, except those orders endorsed to the oncoming RN and/or are scheduled in the future

Diagnostic test review-I have reviewed all pertinent diagnostic data as available and appropriate during my shift

Patient report given and patient care endorsed to-Daisy, RN

Nursing - Serial - DAILY BRADEN SKIN ASSESSMENT: Bayless, RN, Michel

Sensory Perception-= 3 - Slightly Limited

Moisture-3 - Occasionally moist

Activity-3 - Walks Occasionally

Mobility-3 - Slightly Limited

Nutrition-3 - Adequate

Friction and Shear- = 3 - No apparent problem

Total Score-= 19 or more - No interventions needed at present - continue to monitor

Nursing - Serial - SHIFT FALL RISK ASSESSMENT/INTERVENTIONS (rev 12/10/10): Bayless, RN, Michel

Currently/History of - Confusion/Disorientation/Impulsivisity-Yes = 4

HX Depression with active symptoms at present-No = 0

Altered elimination (Frequency/Urgency/Incontinence/Diuretics)-Yes = 1

Currently/History of - Dizziness/Vertigo-No = 0

Male Gender-No = 0

Currently taking anticonvulsants (check MAR)-No = 0

Currently taking benzodiazepines (check MAR)-No = 0

Mobility assessment reveals (Get up and Go Test)-Patient needs to push up but successful in 1 attempt = 1

TOTAL SCORE- = 5 or more - STANDARD AND HIGH RISK INTERVENTIONS AS NOTED BELOW

Standard precautions initiated-Includes initial and ongoing fall risk education, safe room set-up including call light in reach and not dangling, moving furniture on non-exit side of bed, side rails up x2, bed locked and low, adequate lighting and room is clear of clutter. If high risk, additional interventions below

High risk precautions initiated-Includes Appropriate signage posted in room, chart labels on, Fall risk ID band applied, red slippers provided, hourly rounding done, proactive bladder program established and exit alarms are in place and active.

Nursing - Serial - SHIFT MULTIPLE LINE ASSESSMENT (rev 12/21/09): Bayless, RN, Michel

PIVL Site 1 Location-Left AC Fossa

PIVL Site 1 dressing label-Date/Time placed - 20g 5/23

PIVL Site 1 Inspection-Site is clean and dry without redness, drainage or swelling

Patient's central venous access device continues to be necessary due to-N/A

Metro South Medical Center

Patient Name

Allergies: nka

05/24/2011 8:00

05/24/2011 8:00

Age

ASSESSMENT

WOUNDS

DOB Gender

Female

Race

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

Room 4SO:421-01

Bayless, RN, Michel Nursing - Serial - SHIFT NURSING ASSESSMENT (rev 11/04/10):

Transmission Precautions-Standard

O2 Type/Liter Flow-Room Air

Rhythm Strip Interpretation-Paced Rhythm

LOC-Awake but confused

Affect-Calm and cooperative

Eye Opening-4 spontaneous

Verbal Response-4 Confused or disoriented

Motor Response-6 obeys commands

Pupils-equal and reactive

Ability to Move - right arm-moderate

Ability to Move - right leg-moderate

Ability to Move - left leg-moderate

Ability to Move - left arm-moderate

Skin Color-Normal

Skin Temperature-cool

Skin Moisture-Moist

Skin turgor-non-tenting

Respirations-Even and unlabored

Breath Sounds Right-Diminished

Breath Sounds Left-Diminished

Retractions-No retractions noted

Abdomen-Round, firm

Bowel Sounds-Active x 4 quadrants

Pedal Edema Right-2 plus Moderate 1/2 inch

Pedal Edema Left-2 plus Moderate 1/2 inch

Pedal Pulses Right-1 plus = Barely palpable

Pedal Pulses Left-1 plus = Barely palpable

Nursing - Serial - SHIFT WOUND ASSESSMENT (rev 05/06/10):

WOUND ASSESSMENT-No wounds at this time, no further assessment needed.

TOTAL NUMBER OF WOUNDS-N/A - no wounds present upon assessment

EQUIPMENT-Pressure relief mattress on bed

WOUND ASSOCIATED PAIN-N/A

WOUND TREATMENT-N/A

Bayless, RN, Michel

Metro South Medical Center

Patient Name

Allergies: nka

05/24/2011 8:38

05/24/2011 8:46

Age

OCCUPATIONAL

THERAPY

PLAN OF CARE

DOB Gender

Female

Race

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

Occupational Therapy - Inpatient Evaluation:

Compensatory strategies for safety practiced in ADL/activity --Yes

Reason for referral-Weakness

PRIOR LEVEL OF FUNCTION-Independent ADL's prior to admission, pt lives with husband

Precautions-cardiac, safety

Subjective-"I feel unsteady."

OBJECTIVE ADL Feeding-Modified independent

Toileting-Standby assist

UE Dressing-Standby assist

LE Dressing-Standby assist

UE Bathing-Standby assist

LE Bathing-Standby assist

Grooming-Standby assist

Functional Communication-Able to communicate needs

Splinting/Adapted Equipment-Per pt, she was not using a device PTA. Recommend a tub transfer bench with back rest for home use.

Assessment-This 62 y/o female presents with general weakness, decreased ADL skills, decreased BUE strength, decreased balance with transfers, and mild decrease in endurance. Pt was cooperative during initial eval and would benefit from OT to improve overall strength and

ADL skills.

Goals-1. Pt will practice gentle AROM exs for ADL needs. 2. Pt will demonstrate clothing retrieval from closet. 3. Pt will demonstrate energy conservation techniques for daily living.

Potential for reaching These Goals-Excellent

DISCHARGE RECOMMENDATIONS-Home with HHC OT

Treatment Plan-ADL's, ROM, Strengthening

Treatment Plan discussed with-Patient

Treatment frequency-3-5 times weekly

UE PROM-WFL

UE AROM-3/4 ROM at Bilateral shldrs, otherwise WFL

Hand function-Functional for feeding

LUE strength-3+/5

RUE strength-3+/5

Muscle Tone-Hypertonic

Sensation-Functional for ADL's

PAIN present level-Denies pain

Left UE Fine Motor Coordination-Opposes all digits

Right UE Fine Motor Coordination-Opposes all digits

Balance sitting - static-Good

Balance sitting - dynamic-fair

Balance standing - static-Fair

Balance standing - dynamic-Standby assist/ minimal assist

Sitting tolerance-Greater than 60 minutes

Standing tolerance-Approximately 1 minute with unilateral hold

Endurance-Fair for function

COGNITION-Oriented X 3

STM-Intact

LTM-Intact

Problem solving-fair

Judgement/Safety-fair

PERCEPTION Visual tracking-Intact

Neglect-none

Body image/scheme-intact

Spatial relationships-Reads clock

R/L discrimination-intact

BED MOBILITY/TRANSFERS Rolling-Standby assist

Supine<>Sit-Standby assist

Toilet transfer-Standby assist/minimal assist

Sit<>Stand-Standby assist Time: 45 min

Occupational Therapy - INTERDISCIPLINARY PATIENT/FAMILY EDUCATION PLAN OF CARE:

Special Learning Needs-No special learning needs identified

Educational Need-Treatment/Plan

Readiness to Learn-Accepting/Attentive

Teaching Method-Activity Based

Response to Teaching-Acknowledges understanding

Patient/Family taught the following-Compensatory strategies

Room 4SO:421-01

Barder, OT, Jennifer

Barder, OT, Jennifer

Metro South Medical Center

Patient Name

Allergies: nka

05/24/2011 8:46

05/24/2011 9:45

Age

PLAN OF CARE

EP LAB

DOB Gender

Female

Race

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

Room 4SO:421-01

Barder, OT, Jennifer Occupational Therapy - Interdisciplinary Plan of Care:

INTERVENTIONS-Assess functional skills performance

OUTCOMES-Maximize independence in daily living skills

Nursing - Focused - EP LAB DEVICE INTERROGATION (rev 5/13/11):

CURRENT DEVICE FUNCTION-Normal ICD Function

COMPANY-Medtronic

DEVICE STORED EVENTS/NOTES-No stored events

DATE OF IMPLANT-May 13, 2010

MODE-VVIR

UPPER RATE-120

LOWER RATE-70

ICD CURRENT PARAMETERS VT-OFF

ICD CURRENT PARAMETERS VF->200 BPM

ICD CHARGE TIME (seconds)-9.1 SECS

BATTERY CHARGE (volts)-3.13V

UNDERLYING RHYTHM-Other -DEPENDANT

ATRIAL SENSING AMPLITUDE (mv)-0.4mv

VENTRICULAR SENSING AMPLITUDE (mv)-unable to obtain

LV SENSING AMPLITUDE (mv)-na

ATRIAL IMPEDENCE (ohms)-703 OHMS

VENTRICULAR IMPEDENCE (ohms)-323 OHMS

LV IMPEDENCE (ohms)-NA

RV SHOCK IMPEDENCE (ohms)-42 OHMS

SVC SHOCK IMPEDENCE (ohms)-58 OHMS

ATRIAL THRESHOLD (volts)-unobtainable

VENTRICULAR THRESHOLD (volts)[email protected] 0.40ms

LV THRESHOLD (volts)-NA

ATRIAL % PACED-0

VENTRICULAR % PACED-97.3 %

LV % PACED-NA

PROGRAMMING CHANGES-Program changes made -RA UNDERSENSING

ADDITIONAL COMMENTS- INCREASED SENSITIVITY TO 0.15mv

Bartkus, RN, Carol A

Metro South Medical Center

Patient Name

Allergies: nka

05/24/2011 9:56

05/24/2011 10:09

Age DOB Gender

Female

Race

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

PHYSICAL THERAPY Physical Therapy - Inpatient Evaluation:

PLAN OF CARE

Room 4SO:421-01

Bohanek, MPT, Amy

Reason for Referral-Weakness, gait training and prevent deconditioning

PRECAUTIONS-High fall risk precautions

Prior Level of Function-Per pt, she was Ind with all mobility tasks and ADLs PTA without a device.

Social History from-Home with Husband (who also has medical issues).

Ambulation devices-None

Level of Orientation-A + O x 3; Responses delayed at times

Observation-+Telemetry, +IV

Stairs-Yes

SUBJECTIVE-Pt reported, "This water just got in my legs overnight." Stated she had SOB with activity.

Present Pain Level-0

Range of Motion-Limited B shoudlers and slightly in B LE due to edema; Otherwise, WFL.

Strength-Approx. 3/5 to 3+/5 grossly.

Sensation/Proprioception-She denied any numbness / tingling.

Coordination-Fair-/Fair

Balance Sitting - static-Good/Fair +

Balance Sitting - dynamic-Good/Fair +

Balance Standing - static-Fair

Balance Standing - dynamic-Fair -/Fair

Bed Mobility - Supine<>Sit-Not assessed as pt was already up in the bathroom Ind upon entry.

Transfers Sit<>Stand-CGA

Transfers Bed<>Chair-CGA

Gait Device Used-HHA

Assist Needed-CGA

Distance-25'

Gait Analysis-Unsteady (Although, pt refused to use an assistive device); Decreased cadence and step length.

Endurance-Fair -. Pt reported SOB with activity. Unable to get an accurate O2 sat as her hands were too cold.

Instructions provided on fall safety-Yes (Verbal)

ASSESSMENT-Pt required encouragement to participate in the PT Eval and responses were delayed at times. She presented with general deconditioning and impaired gait, but was reluctant to use an assistive device despite PT suggestion. She would benefit from continued skilled PT to improve general strength, endurance, and balance needed for more safe & Ind functioning.

Goals/Time Frame-(3-5 days) Improve bed mobility to Sup A.

Goals/Time Frame-(3-5 days) Improve transfers to Sup A.

Goals/Time Frame-(3-5 days) Increase ambulation to Sup A x 150' with or without device and

O2 sats > 90% on RA.

Potential for Physical Therapy-Fair+

Discharge Recommendations-Home with possible Home PT. Pt may need an assistive device for home use.

Treatment goals and plan were discussed and developed with patient and/or family-Yes

INTERVENTIONS PLANNED - Bed Mobility->

Range of Motion Exercise->

Transfer Training->

Endurance Training->

Gait Training->

Balance Exercises->

Treatment Frequency-3-5 X per week

Total TX Time-38 - 52 minutes

Physical Therapy - INTERDISCIPLINARY PATIENT/FAMILY EDUCATION PLAN OF CARE: Bohanek, MPT, Amy

Special Learning Needs-No special learning needs identified

Educational Need-Rehabilitation Techniques

Readiness to Learn-Accepting/Attentive

Teaching Method-Explanation/Discussion

Response to Teaching-Follow up needed - plan

Patient/Family taught the following-Fall prevention tips, physical therapy plan of care and home exercise program

Metro South Medical Center

Patient Name

Allergies: nka

05/24/2011 10:10

05/24/2011 11:49

05/24/2011 12:17

05/24/2011 13:55

05/24/2011 13:56

05/24/2011 14:03

05/24/2011 14:25

Age

PLAN OF CARE

ASSESSMENT

NURSING

CASE MANAGER

CASE MANAGER

NURSING

DOB

CHF RESOURCE

NURSE

Gender

Female

Race

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

Physical Therapy - Interdisciplinary Plan of Care:

PHYSICAL THERAPY Assess transfers->

Assess bed mobility->

Assess gait->

Instruct in home exercise program->

OUTCOME - Increase exercise independence->

Increase independence of mobility->

Increase safety->

Nursing - Serial - SHIFT NURSING ASSESSMENT (rev 11/04/10):

Room 4SO:421-01

Bohanek, MPT, Amy

Bayless, RN, Michel

Transmission Precautions-Standard

O2 Type/Liter Flow-Nasal Cannula-2L

Rhythm Strip Interpretation-Paced Rhythm

LOC-Awake but confused

Affect-Calm but uncooperative

Eye Opening-4 spontaneous

Verbal Response-4 Confused or disoriented

Motor Response-6 obeys commands

Pupils-equal and reactive

Ability to Move - right arm-moderate

Ability to Move - right leg-moderate

Ability to Move - left leg-moderate

Ability to Move - left arm-moderate

Skin Color-Normal

Skin Temperature-cool

Skin Moisture-Moist

Skin turgor-non-tenting

Respirations-Even and unlabored

Breath Sounds Right-Diminished

Breath Sounds Left-Diminished

Retractions-No retractions noted

Abdomen-Soft and non-tender

Bowel Sounds-Active x 4 quadrants

Pedal Edema Right-2 plus Moderate 1/2 inch

Pedal Edema Left-2 plus Moderate 1/2 inch

Pedal Pulses Right-1 plus = Barely palpable

Pedal Pulses Left-1 plus = Barely palpable

Nursing - Serial - SHIFT NARRATIVE NOTE (new 6/29/10)- sent Dr Harris an Empower message regarding the D/C of the Colchicine

Case Management - INITIAL ASSESSMENT:

Bayless, RN, Michel

Blazek, RN, Patricia

Marie

Severity of illness =-chf on imaging

Intensity of service =-dobutamine drip

Comments --meets inpt criteria.

CLINICALS FAXED TO WELLCARE. 877-844-8538. REF # 8876538. NOT EQ HEALTH

SOLUTIONS CALL FOR ADMIT DX 786.05. Direct admit tele from pmd office with sob, wt gain and increase in abd girth. In office bg 23, improved to 47 after glucose tab. Also relates hx syncope 1 wk ago. Pmh: cardiomyopathy, dm, chf, htn, aicd. Bun 49, cr 1.8, gluc 44, ct brain neg for acute changes, cxr - bibasilar pleural effusions/congetive changes. 97.8-70-20-122/79-

100%ra. Paced rhythm.Admit orders - standing orders, card consult, ac qid, lasix 80 iv bid. Per pmd - syncope, chf. Per card - chf, no acei or arb d/t cr. 5/24 bnp 2444, gluc 54, bun 51, cr

1.88. renal consult. Renal us pending. 94.2ax-69-20-118/83-95% 2l nc. Paced rhythm. Lasix iv bid, dobutamine drip. Dcp - home. f/u d/c needs as pt progresses.

Nursing - Serial - SHIFT NARRATIVE NOTE (new 6/29/10)- foley inserted. 100cc clear dark yellow urine out upon insertion. Ua and urcl sent to lab

Blazek, RN, Patricia

Marie

Bayless, RN, Michel

CHF CONSULT: CHF teaching done, brochure provided. Neice was present for teaching, states pt was admitted for edema, sob and altered mental status. Has been living with husband and using canned and processed foods. Heart failure overview discussed along with 2 gm sodium

/64 oz fluid restrictive diet, medication, excersise, weight monitoring/recording,symptom recognition/ when to notify physician. Page 7 of carepath was provided. Sodium monitoring and recording was established as discharge goal. A follow up call will be made post discharge. Neice is a nurse and was very recptive to information discussed. Pt is verbally responsive but confused.

Hackett, RN, Ginny

Metro South Medical Center

Patient Name

Allergies: nka

05/24/2011 17:25

05/24/2011 19:18

05/24/2011 20:00

05/24/2011 20:00

05/24/2011 20:00

Age

ASSESSMENT

NURSING

FALL RISK

DOB

SHIFT NARRATIVE

SKIN ASSESSMENT

Gender

Female

Race

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

Nursing - Serial - SHIFT NURSING ASSESSMENT (rev 11/04/10):

Transmission Precautions-Standard

O2 Type/Liter Flow-Room Air

Rhythm Strip Interpretation-Paced Rhythm

LOC-Drowsy

Affect-Calm

Eye Opening-4 spontaneous

Verbal Response-5 Alert and Oriented X 3

Motor Response-6 obeys commands

Ability to Move - right arm-strong

Ability to Move - right leg-moderate

Ability to Move - left leg-moderate

Ability to Move - left arm-strong

Skin Color-Normal

Skin Temperature-cool

Skin Moisture-Moist

Skin turgor-non-tenting

Respirations-Even and unlabored

Breath Sounds Right-Diminished

Breath Sounds Left-Diminished

Retractions-No retractions noted

Abdomen-Round, firm

Bowel Sounds-Active x 4 quadrants

Pedal Edema Right-2 plus Moderate 1/2 inch

Pedal Edema Left-2 plus Moderate 1/2 inch

Pedal Pulses Right-1 plus = Barely palpable

Pedal Pulses Left-1 plus = Barely palpable

Nursing - Serial - SHIFT END NOTE (new 4/19/11):

Room 4SO:421-01

Bayless, RN, Michel

Bayless, RN, Michel

Medical Orders review-I have reviewed and as appropriate carried out all medical orders during my shift, except those orders endorsed to the oncoming RN and/or are scheduled in the future

Diagnostic test review-I have reviewed all pertinent diagnostic data as available and appropriate during my shift

Patient report given and patient care endorsed to-CeCe RN

Nursing - Serial - SHIFT NARRATIVE NOTE (new 6/29/10) patient received aler and orientedx3; Pt denies cp and sob; Pt is paced; See assessment area; d5.9ns with 20kcl

@70cc/hr; Dobutamine @ 12.7/hr infusing without complications to lac iv site; +Blood return noted to LAC Iv site; Will monitor

Nursing - Serial - DAILY BRADEN SKIN ASSESSMENT:

Bahena, RN, Cecilia

Bahena, RN, Cecilia

Sensory Perception-= 4 - No impairment

Moisture-4 - Rarely Moist

Activity-3 - Walks Occasionally

Mobility-3 - Slightly Limited

Nutrition-3 - Adequate

Friction and Shear-3 - No Apparent Problem

Total Score-= 19 or more - No interventions needed at present - continue to monitor

Nursing - Serial - SHIFT FALL RISK ASSESSMENT/INTERVENTIONS (rev 12/10/10): Bahena, RN, Cecilia

Currently/History of - Confusion/Disorientation/Impulsivisity-No = 0

HX Depression with active symptoms at present-No = 0

Altered elimination (Frequency/Urgency/Incontinence/Diuretics)-Yes = 1

Currently/History of - Dizziness/Vertigo-No = 0

Male Gender-No = 0

Currently taking anticonvulsants (check MAR)-No = 0

Currently taking benzodiazepines (check MAR)-No = 0

Mobility assessment reveals (Get up and Go Test)-Patient needs to push up but successful in 1 attempt = 1

TOTAL SCORE- = 4 or less - STANDARD FALL RISK INTERVENTIONS AS NOTED BELOW

Standard precautions initiated-Includes initial and ongoing fall risk education, safe room set-up including call light in reach and not dangling, moving furniture on non-exit side of bed, side rails up x2, bed locked and low, adequate lighting and room is clear of clutter. If high risk, additional interventions below

High risk precautions initiated-N/A

Metro South Medical Center

Patient Name

Allergies: nka

05/24/2011 20:00

05/24/2011 20:00

05/24/2011 20:00

05/24/2011 20:00

05/24/2011 20:45

05/24/2011 22:11

05/24/2011 23:00

05/25/2011 0:00

05/25/2011 3:16

05/25/2011 3:20

05/25/2011 4:15

05/25/2011 6:12

05/25/2011 7:30

Age DOB Gender

Female

Race

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

ADLs

VASCULAR ACCESS

WOUNDS

ASSESSMENT

NURSING

NURSING

NURSING

NURSING

NURSING

NURSING

NURSING

NURSING

NURSING

Nursing - Serial - SHIFT HYGIENE/ADL (rev 05/05/11):

TURN FREQUENCY-Patient able to reposition self frequently in bed

ACTIVITY-Bedrest with BSC

Nursing - Serial - SHIFT MULTIPLE LINE ASSESSMENT (rev 12/21/09):

Room 4SO:421-01

Bahena, RN, Cecilia

Bahena, RN, Cecilia

PIVL Site 1 Location-Left AC Fossa

PIVL Site 1 dressing label-Date/Time placed - lac 20 5/23

PIVL Site 1 Inspection-Site is clean and dry without redness, drainage or swelling

Patient's central venous access device continues to be necessary due to-N/A

Nursing - Serial - SHIFT WOUND ASSESSMENT (rev 05/06/10): Bahena, RN, Cecilia

WOUND ASSESSMENT-No wounds at this time, no further assessment needed.

TOTAL NUMBER OF WOUNDS-N/A - no wounds present upon assessment

EQUIPMENT-Pressure relief mattress

WOUND ASSOCIATED PAIN-N/A

WOUND TREATMENT-N/A

Nursing - Serial - SHIFT NURSING ASSESSMENT (rev 11/04/10): Bahena, RN, Cecilia

Transmission Precautions-Standard

O2 Type/Liter Flow-Room Air

Rhythm Strip Interpretation-Atrial Fib

LOC-Awake, Alert and Oriented x 3

Affect-Calm and cooperative

Eye Opening-4 spontaneous

Verbal Response-5 Alert and Oriented X 3

Motor Response-6 obeys commands

Pupils-equal and reactive

Ability to Move - right arm-strong

Ability to Move - right leg-strong

Ability to Move - left leg-strong

Ability to Move - left arm-strong

Skin Color-Normal

Skin Temperature-warm

Skin Moisture-Dry

Skin turgor-non-tenting

Respirations-Even and unlabored

Breath Sounds Right-Clear

Breath Sounds Left-Clear

Retractions-Intercostal

Abdomen-Round;soft ascites

Bowel Sounds-Active x 4 quadrants

Pedal Edema Right-1 plus Mild 0-1/4 inch

Pedal Edema Left-1 plus Mild 0-1/4 inch

Pedal Pulses Right-1 plus = Barely palpable

Pedal Pulses Left-1 plus = Barely palpable blood sugar 64; Patient asymptomatic; Patient given apple juice with sugar and sandwich; Will monitor

Dr Amin notified of accucheck; Orders received and initiated

Accucheck 140

Nursing - Serial - SHIFT NURSING ASSESSMENT (rev 11/04/10):Transmission Precautions-

Standard,O2 Type/Liter Flow-Room Air,Rhythm Strip Interpretation-Atrial Fib,LOC-Awake, Alert and Oriented x 3,Affect-Calm and cooperative,Eye Opening-4 spontaneous,Verbal Response-5

Alert and Oriented X 3,Motor Response-6 obeys commands,Pupils-equal and reactive,Ability to

Move - right arm-strong,Ability to Move - right leg-strong,Ability to Move - left leg-strong,Ability to Move - left arm-strong,Skin Color-Normal,Skin Temperature-warm,Skin Moisture-Dry,Skin turgor-non-tenting,Respirations-Even and unlabored,Breath Sounds Right-Clear,Breath Sounds

Left-Clear,Retractions-Intercostal,Abdomen-Round;soft ascites,Bowel Sounds-Active x 4 quadrants,Pedal Edema Right-1 plus Mild 0-1/4 inch,Pedal Edema Left-1 plus Mild 0-1/4 inch,Pedal Pulses Right-1 plus = Barely palpable,Pedal Pulses Left-1 plus = Barely palpable

Accucheck 153

Iv noted leaking; left arm iv dc'd

After 5 unsuccessfuls attempt by Rey Rn; 22g placed to rfa by Stacey Rn from Er

Weight 85.4; dobutamine @5mcg/kg/min=12.8cc/hr

Medication Administration Record Reconciled and Verified

Bahena, RN, Cecilia

Bahena, RN, Cecilia

Bahena, RN, Cecilia

Bahena, RN, Cecilia

Bahena, RN, Cecilia

Bahena, RN, Cecilia

Bahena, RN, Cecilia

Bahena, RN, Cecilia

Bahena, RN, Cecilia

Metro South Medical Center

Patient Name

Allergies: nka

05/25/2011 7:30

05/25/2011 8:01

05/25/2011 8:05

05/25/2011 8:06

05/25/2011 8:27

05/25/2011 8:32

05/25/2011 8:33

Age DOB Gender

Female

Race

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

SHIFT NARRATIVE

NURSING

SKIN ASSESSMENT

PLAN OF CARE

PLAN OF CARE

FALL RISK

VASCULAR ACCESS

Nursing - Serial - SHIFT END NOTE (new 4/19/11):

Room 4SO:421-01

Bahena, RN, Cecilia

Medical Orders review-I have reviewed and as appropriate carried out all medical orders during my shift, except those orders endorsed to the oncoming RN and/or are scheduled in the future

Diagnostic test review-I have reviewed all pertinent diagnostic data as available and appropriate during my shift

Patient report given and patient care endorsed to-Carina Rn

Additional shift end comments --Carina Rn aware to start 24 urine;stop iv fluids; give amp of d50; initiate new double concentration dobutamine; initiate new lasix dosage

Nursing - Serial - SHIFT NARRATIVE NOTE (new 6/29/10) pt in bed, drowsy awaken with verbal stimuli, oriented x 2-3, forgetful. Pt has Dobuatime 5mcg/kg/min - 12.8 ml/hr infusing via pump into right forearm pvil, site patent and intact. Pt foley to gravity draining clear amber urine. Pt has trace edema, mild discoloration. Pt abd distended, bowel sound patent. Pt oriented to use call light, sr x 2 up bed locked and low position for safety. Cont to monitor.

Nursing - Serial - DAILY BRADEN SKIN ASSESSMENT:

White, RN, Carina

White, RN, Carina

Sensory Perception-= 4 - No impairment

Moisture-4 - Rarely Moist

Activity-1 - Bedfast

Mobility-3 - Slightly Limited

Nutrition-2 - Probably Inadequate

Friction and Shear-3 - No Apparent Problem

Total Score-= 15 - 18 - Mild risk - Initiated at risk interventions

White, RN, Carina

White, RN, Carina Nursing - Serial - DAILY INTERDISCIPLINARY POC:

Care Plan per Care Path Protocol->24 hour urine, dobutamine drip and monitor io

KNOWLEDGE INT See Interdisciplinary Patient/Family Instruction Form->

DISCHARGE PLANNING INT->pending

SKIN INT Monitor skin integrity->dry and intact

PAIN INT Monitor pain using pain scale->denies at this time

O2 therapy->room air

Elevate HOB->30 degree

Assess mobility->up as with assistance

Assess transfers->assistance x 1-2

Assess gait->slightly unsteady need assistance x 1

Nursing - Serial - SHIFT FALL RISK ASSESSMENT/INTERVENTIONS (rev 12/10/10): White, RN, Carina

Currently/History of - Confusion/Disorientation/Impulsivisity-No = 0

HX Depression with active symptoms at present-No = 0

Altered elimination (Frequency/Urgency/Incontinence/Diuretics)-Yes = 1

Currently/History of - Dizziness/Vertigo-No = 0

Male Gender-No = 0

Currently taking anticonvulsants (check MAR)-No = 0

Currently taking benzodiazepines (check MAR)-No = 0

Mobility assessment reveals (Get up and Go Test)-Patient makes multiple attempts but is successful = 3

TOTAL SCORE- = 4 or less - STANDARD FALL RISK INTERVENTIONS AS NOTED BELOW

Standard precautions initiated-Includes initial and ongoing fall risk education, safe room set-up including call light in reach and not dangling, moving furniture on non-exit side of bed, side rails up x2, bed locked and low, adequate lighting and room is clear of clutter. If high risk, additional interventions below

High risk precautions initiated-Includes Appropriate signage posted in room, chart labels on, Fall risk ID band applied, red slippers provided, hourly rounding done, proactive bladder program established and exit alarms are in place and active.

Nursing - Serial - SHIFT MULTIPLE LINE ASSESSMENT (rev 12/21/09): White, RN, Carina

PIVL Site 1 Location-Right Forearm

PIVL Site 1 dressing label-Date/Time placed -5/23

PIVL Site 1 Inspection-Site is clean and dry without redness, drainage or swelling

Patient's central venous access device continues to be necessary due to-Multiple IV drug and/or fluid therapy requiring central venous access

Metro South Medical Center

Patient Name

Allergies: nka

05/25/2011 8:33

05/25/2011 8:49

05/25/2011 8:59

05/25/2011 9:01

05/25/2011 9:02

05/25/2011 9:06

ADLs

Age

ASSESSMENT

WOUNDS

NURSING

NURSING

DOB

CASE MANAGER

Gender

Female

Race

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

Nursing - Serial - SHIFT HYGIENE/ADL (rev 05/05/11):

Room 4SO:421-01

White, RN, Carina

TURN FREQUENCY-At this time repositioned to left side, padding placed between bony prominences

ORAL CARE-Assist

PERI CARE-Assist

FOLEY CARE-Complete

SKIN CARE-Assist with skin cleaning and moisturizing

ACTIVITY-Up in chair

FEEDING-Set-up and assist

COUGH AND DEEP BREATHING EXERCISES-Done every 2 hours while awake

EQUIPMENT - Incentive spirometry-Done every one hour while awake

EQUIPMENT – VTE (Venous Thromboembolism) Prophylaxis-SCD's in place and functioning

LIST VTE PROPHYLAXIS CONTRAINDICATION (if applicable)-N/A

TRACH CARE-none

SITZ BATH-N/A

Case Management - PROGRESS NOTE: Blazek, RN, Patricia

Marie

Intensity of service-dobutamine drip

Discharge plan --home.

Comments --chf, syncope. 97.4-69-16-119/74. atr fib. Dobutamine drip, lasix increased to 100 mg iv q 8, d50 iv x 2 for ac 64-153. 24 u/a cr clearance pending.

Nursing - Serial - SHIFT NURSING ASSESSMENT (rev 11/04/10): White, RN, Carina

Transmission Precautions-Standard

O2 Type/Liter Flow-Nasal Cannula

Rhythm Strip Interpretation-Paced Rhythm

LOC-Drowsy

Affect-Calm and cooperative

Eye Opening-3 to voice

Verbal Response-4 Confused or disoriented

Motor Response-4 flexion withdrawal

Pupil right-2mm

Pupil left-2mm

Pupils-equal and reactive

Ability to Move - right arm-moderate

Ability to Move - right leg-moderate

Ability to Move - left leg-moderate

Ability to Move - left arm-moderate

Skin Color-Normal

Skin Temperature-warm

Skin Moisture-Dry

Skin turgor-tenting

Respirations-Unlabored

Breath Sounds Right-Diminished

Breath Sounds Left-Diminished

Retractions-No retractions noted

Abdomen-Distended

Bowel Sounds-Active x 4 quadrants

Pedal Edema Right-1 plus Mild 0-1/4 inch

Pedal Edema Left-1 plus Mild 0-1/4 inch

Pedal Pulses Right-2 plus = Palpable Disappears with Pressure

Pedal Pulses Left-2 plus = Palpable Disappears with Pressure

Nursing - Serial - SHIFT WOUND ASSESSMENT (rev 05/06/10): White, RN, Carina

WOUND ASSESSMENT-No wounds at this time, no further assessment needed.

TOTAL NUMBER OF WOUNDS-N/A - no wounds present upon assessment

EQUIPMENT-Pressure relief mattress

WOUND ASSOCIATED PAIN-Patient has pain - see clinical notes and/or vitals table for pain assessment

WOUND TREATMENT-N/A

Nursing - Serial - SHIFT NARRATIVE NOTE (new 6/29/10) 24 hour urine for protein and creat, foley on ice.

White, RN, Carina

Nursing - Serial - SHIFT NARRATIVE NOTE (new 6/29/10) pt up in the chair, warm fingertips, pulse ox placed on middle finger right hand.

White, RN, Carina

Metro South Medical Center

Patient Name

Allergies: nka

05/25/2011 9:50

05/25/2011 9:52

05/25/2011 9:57

05/25/2011 10:00

05/25/2011 10:54

05/25/2011 11:09

05/25/2011 12:34

05/25/2011 16:30

Age DOB Gender

Female

Race

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

ADLs Nursing - Serial - SHIFT HYGIENE/ADL (rev 05/05/11):

Room 4SO:421-01

Garza, PCP, l Ana

NURSING

PHYSICAL THERAPY

NURSING

NUTRITION

PHARMACY

TURN FREQUENCY-Patient able to reposition self frequently in bed

ORAL CARE-Self

SKIN CARE-Self

ACTIVITY-Up in chair-brp

FEEDING-Self

Nursing - Serial - SHIFT NARRATIVE NOTE (new 6/29/10)pt pulse ox is 97-98 after 15 minutes of monitor continously.

S: Pt was resting in supine upon entry. Stated she felt "better" today. O: Pt was able to perform bed mobility tasks with SBA using the rail. She stood with CGA and ambulated x 15' no device with CGA. She then requested to use the bathroom and was assisted there with CGA. Left pt on the toilet as she needed to have a BM. RN aware. A: Pt had 2 LOB during short distance ambulation today, but continues to refuse PT suggestion regarding the use of an assistive device to improve dynamic balance and safety. She is a high fall risk and would benefit from continued skilled PT to achieve more safe & Ind functioning. P: Continue POC. Treatment time:

10 minutes func ther ex.

White, RN, Carina

Bohanek, MPT, Amy

Nursing - Serial - SHIFT NARRATIVE NOTE (new 6/29/10) Dr Shin in to see pt discontinue

Dobutamine Drip and pt pull foley, no tramua noted to vagina area , order to discontinue foley, pt intructed to use bathroon and void in hat provided.

NUTRITION: CHF Diet Instruction completed. Pt up in chair on RD visit. CHF Resource DI noted and reinforced to pt. RD reviewed 2gm Na diet, 64ounce Fluid Restriction and Wt Monitoring.

Educational materials including Sample Menu and RD phone number provided. Advised pt to have husband or daughter, who shops and preps meals to review and contact RD w/any questions or concerns. Currently pt tolerating Diabetic diet w/good appetite/intake. RD to follow up low risk per protocol.

Pharmacy - Coumadin Dosing Note New Dose:

White, RN, Carina

Burke, RD, LDN,

Paula

Kannankeril, Jaya J.

NURSING

VASCULAR ACCESS

Coumadin consult was received on a-Female 62 years old

INR-3.19

Hgb/Hct-14.7/44.8

Platelets-182

Coumadin Dose-No coumadin today.

We will continue to follow and adjust therapy as needed for an INR goal of-2-3

Nursing - Serial - SHIFT NARRATIVE NOTE (new 6/29/10) Pt aunt (Inez and Loretta) into see pt, called to stated she will need a ride home, pt has no order from primary for discharge, on cardiologist. Pt w ill probably be discharge tommorw. Spoke with her aunts, pt is forgetful at time, almost pull out foley. Spoke with Dr lucanio keep to until tommorrow, monito in place.

Calll liight near, pt encouraged to use calll light if needing assistance. Pt bed lock and low postion for safety, cont to monil

Nursing - Serial - SHIFT MULTIPLE LINE ASSESSMENT (rev 12/21/09):

White, RN, Carina

White, RN, Carina

PIVL Site 1 Location-Right Forearm

PIVL Site 1 dressing label-Date/Time placed -5/23

PIVL Site 1 Inspection-Site is clean and dry without redness, drainage or swelling

Patient's central venous access device continues to be necessary due to-Multiple IV drug and/or fluid therapy requiring central venous access

Metro South Medical Center

Patient Name

Allergies: nka

05/25/2011 16:30

05/25/2011 16:32

05/25/2011 18:31

05/25/2011 18:32

05/25/2011 19:45

05/25/2011 19:51

05/25/2011 20:00

05/25/2011 20:00

Age

ASSESSMENT

NURSING

NURSING

NURSING

NURSING

NURSING

NURSING

DOB

SHIFT NARRATIVE

Gender

Female

Race

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

Nursing - Serial - SHIFT NURSING ASSESSMENT (rev 11/04/10):

Room 4SO:421-01

White, RN, Carina

Transmission Precautions-Standard

O2 Type/Liter Flow-Room Air

Rhythm Strip Interpretation-Normal Sinus Rhythm

LOC-Awake, Alert and Oriented x 3

Affect-Calm

Eye Opening-3 to voice

Verbal Response-5 Alert and Oriented X 3

Motor Response-6 obeys commands

Pupil right-2mm

Pupil left-2mm

Pupils-equal and reactive

Ability to Move - right arm-moderate

Ability to Move - right leg-moderate

Ability to Move - left leg-moderate

Ability to Move - left arm-moderate

Skin Color-Normal

Skin Temperature-cool

Skin Moisture-Dry

Skin turgor-non-tenting

Respirations-Unlabored

Breath Sounds Right-Clear

Breath Sounds Left-Clear

Retractions-No retractions noted

Abdomen-Distended

Bowel Sounds-Active x 4 quadrants

Pedal Edema Right-1 plus Mild 0-1/4 inch

Pedal Edema Left-1 plus Mild 0-1/4 inch

Pedal Pulses Right-2 plus = Palpable Disappears with Pressure

Pedal Pulses Left-2 plus = Palpable Disappears with Pressure

Nursing - Serial - SHIFT NARRATIVE NOTE (new 6/29/10) restart 24 hour urine agiain, pt forgetting to urinate in the hat., explain needed for test of the kidney for tom. Ana pcp aware pt need protein and creat clearance 24 hour restart again. Cont to monior.

White, RN, Carina

Nursing - Serial - SHIFT NARRATIVE NOTE (new 6/29/10) please monitor pt 24 hour collection,keep foley intact to help collect uinre. Pt forget to save urine otherwise, per Dr

Venture.

Nursing - Serial - SHIFT END NOTE (new 4/19/11):

White, RN, Carina

White, RN, Carina

Medical Orders review-I have reviewed and as appropriate carried out all medical orders during my shift, except those orders endorsed to the oncoming RN and/or are scheduled in the future

Additional shift end comments --pt in bed alert and oriented, forgetful at time, to save urine, although hat bathroon for her collected 24 hour urine. Pt dobutamne discontinue pvil in left arm pvil in place. Pt pain free. And new foley to help collect urine.

Rn to bedside; No foley noted ; Patient refusing foley insertion; Patient explained importance of foley and md recommending foley; Patient continues to refuses and states it hurts

Bahena, RN, Cecilia

Dr Ventura notified of patient refusing foley and informed Rn if possible to place foley and attempt to collect 24 hour urine with or without foley; Rn informed if 24 hour urine unable to be collected secondary to patient's confusion; Dr Ventura stated will address with patient and primary md in am

Bahena, RN, Cecilia

Bahena, RN, Cecilia Nursing - Serial - SHIFT NARRATIVE NOTE (new 6/29/10) Patient received alert and oriented x3; Pt denies cp and sob; Pt is sr; See assessment area; Refer to carenotes for assessment; patient reinstructed on saving urine

Nursing - Serial - DAILY BRADEN SKIN ASSESSMENT:Sensory Perception-= 4 - No impairment,Moisture-4 - Rarely Moist,Activity-3 - Walks Occasionally,Mobility-3 - Slightly

Limited,Nutrition-3 - Adequate,Friction and Shear-3 - No Apparent Problem,Total Score-= 19 or more - No interventions needed at present - continue to monitor

Bahena, RN, Cecilia

Metro South Medical Center

Patient Name

Allergies: nka

05/25/2011 20:00

05/25/2011 20:00

05/25/2011 20:00

05/25/2011 20:00

05/25/2011 20:00

05/25/2011 21:00

05/26/2011 0:00

05/26/2011 0:00

05/26/2011 1:00

Age DOB Gender

Female

Race

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

NURSING

NURSING

VASCULAR ACCESS

NURSING

ASSESSMENT

NURSING

NURSING

NURSING

NURSING

Room 4SO:421-01

Nursing - Serial - SHIFT FALL RISK ASSESSMENT/INTERVENTIONS (rev

12/10/10):Currently/History of - Confusion/Disorientation/Impulsivisity-No = 0,HX Depression with active symptoms at present-No = 0,Altered elimination

(Frequency/Urgency/Incontinence/Diuretics)-Yes = 1,Currently/History of - Dizziness/Vertigo-No

= 0,Male Gender-No = 0,Currently taking anticonvulsants (check MAR)-No = 0,Currently taking benzodiazepines (check MAR)-No = 0,Mobility assessment reveals (Get up and Go Test)-Patient needs to push up but successful in 1 attempt = 1,TOTAL SCORE- = 4 or less - STANDARD FALL

RISK INTERVENTIONS AS NOTED BELOW,Standard precautions initiated-Includes initial and ongoing fall risk education, safe room set-up including call light in reach and not dangling, moving furniture on non-exit side of bed, side rails up x2, bed locked and low, adequate lighting and room is clear of clutter. If high risk, additional interventions below,High risk precautions initiated-N/A

Bahena, RN, Cecilia

Bahena, RN, Cecilia Nursing - Serial - SHIFT HYGIENE/ADL (rev 05/05/11):TURN FREQUENCY-Patient able to reposition self frequently in bed,ACTIVITY-Bedrest with BSC

Nursing - Serial - SHIFT MULTIPLE LINE ASSESSMENT (rev 12/21/09): Bahena, RN, Cecilia

PIVL Site 1 Location-Right Forearm

PIVL Site 1 dressing label-Date/Time placed -5/25 22g

PIVL Site 1 Inspection-Site is clean and dry without redness, drainage or swelling

Patient's central venous access device continues to be necessary due to-N/A

Nursing - Serial - SHIFT WOUND ASSESSMENT (rev 05/06/10):WOUND ASSESSMENT-No wounds at this time, no further assessment needed.,TOTAL NUMBER OF WOUNDS-N/A - no wounds present upon assessment,EQUIPMENT-Pressure relief mattress,WOUND ASSOCIATED

PAIN-N/A,WOUND TREATMENT-N/A

Nursing - Serial - SHIFT NURSING ASSESSMENT (rev 11/04/10):

Bahena, RN, Cecilia

Bahena, RN, Cecilia

Transmission Precautions-Standard

O2 Type/Liter Flow-Room Air

Rhythm Strip Interpretation-Atrial Fib

LOC-Awake, Alert and Oriented x 3 and forgetful

Affect-Calm and cooperative

Eye Opening-4 spontaneous

Verbal Response-5 Alert and Oriented X 3

Motor Response-6 obeys commands

Pupils-equal and reactive

Ability to Move - right arm-strong

Ability to Move - right leg-strong

Ability to Move - left leg-strong

Ability to Move - left arm-strong

Skin Color-Normal

Skin Temperature-warm

Skin Moisture-Dry

Skin turgor-non-tenting

Respirations-Even and unlabored

Breath Sounds Right-Clear

Breath Sounds Left-Clear

Retractions-No retractions noted

Abdomen-Soft and non-tender

Bowel Sounds-Active x 4 quadrants

Pedal Edema Right-1 plus Mild 0-1/4 inch

Pedal Edema Left-1 plus Mild 0-1/4 inch

Pedal Pulses Right-1 plus = Barely palpable

Pedal Pulses Left-1 plus = Barely palpable

Due to patient's previous hypoglycemic events; will hold insulin coverage

Medication Administration Record Reconciled and Verified

Nursing - Serial - SHIFT NURSING ASSESSMENT (rev 11/04/10):Transmission Precautions-

Standard,O2 Type/Liter Flow-Room Air,Rhythm Strip Interpretation-Atrial Fib,LOC-Awake, Alert and Oriented x 3 and forgetful,Affect-Calm and cooperative,Eye Opening-4 spontaneous,Verbal

Response-5 Alert and Oriented X 3,Motor Response-6 obeys commands,Pupils-equal and reactive,Ability to Move - right arm-strong,Ability to Move - right leg-strong,Ability to Move - left leg-strong,Ability to Move - left arm-strong,Skin Color-Normal,Skin Temperature-warm,Skin

Moisture-Dry,Skin turgor-non-tenting,Respirations-Even and unlabored,Breath Sounds Right-

Clear,Breath Sounds Left-Clear,Retractions-No retractions noted,Abdomen-Soft and nontender,Bowel Sounds-Active x 4 quadrants,Pedal Edema Right-1 plus Mild 0-1/4 inch,Pedal

Edema Left-1 plus Mild 0-1/4 inch,Pedal Pulses Right-1 plus = Barely palpable,Pedal Pulses Left-

1 plus = Barely palpable

Due to patient's hypogylcemic events will hold coverage; will recheck blood sugar in am

Bahena, RN, Cecilia

Bahena, RN, Cecilia

Bahena, RN, Cecilia

Bahena, RN, Cecilia

Metro South Medical Center

Patient Name

Allergies: nka

05/26/2011 5:00

05/26/2011 5:53

05/26/2011 6:14

05/26/2011 6:43

05/26/2011 6:45

05/26/2011 8:18

05/26/2011 8:20

05/26/2011 8:21

05/26/2011 8:24

ADLs

Age

NURSING

NURSING

NURSING

NURSING

PLAN OF CARE

PLAN OF CARE

DOB

SHIFT NARRATIVE

SKIN ASSESSMENT

Gender

Female

Race

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

blood sugar 153; will monitor

Patient noted incontinent of urine; 24 hour urine incomplete and terminated; Will inform Dr

Ventura when he rounds

Dr Ventura aware of 24hour urine incomplete and terminated

Nursing - Serial - SHIFT END NOTE (new 4/19/11):

Room 4SO:421-01

Bahena, RN, Cecilia

Bahena, RN, Cecilia

Bahena, RN, Cecilia

Bahena, RN, Cecilia

Medical Orders review-I have reviewed and as appropriate carried out all medical orders during my shift, except those orders endorsed to the oncoming RN and/or are scheduled in the future

Diagnostic test review-I have reviewed all pertinent diagnostic data as available and appropriate during my shift

Patient report given and patient care endorsed to-Carina Rn

Nursing - Serial - SHIFT HYGIENE/ADL (rev 05/05/11): Fontillas, PCP, Arthur

TURN FREQUENCY-Patient able to reposition self frequently in bed

ORAL CARE-Self

PERI CARE-Self

FOLEY CARE-N/A

SKIN CARE-Self

ACTIVITY-Assist - BRP

FEEDING-Self

Nursing - Serial - SHIFT NARRATIVE NOTE (new 6/29/10) I want to go today, pt stated. Pt refused foley and up in the chair. Alert and oriented x3. pt void per brp, pivil right arm patent and intact, flushes well. Pt denies any pain and in no distress. Pt understand about monitor her input and output when she return home on fluid restriction. Call light, tray table and phone near bedside

Nursing - Serial - DAILY BRADEN SKIN ASSESSMENT:

White, RN, Carina

White, RN, Carina

Sensory Perception-= 4 - No impairment

Moisture-4 - Rarely Moist

Activity-2 - Chairfast

Mobility-4 - No Limitations

Nutrition-3 - Adequate

Friction and Shear-3 - No Apparent Problem

Total Score-= 19 or more - No interventions needed at present - continue to monitor

Nursing - Serial - DAILY INTERDISC. PATIENT/FAMILY EDUCATION POC:

Special Learning Needs-No special learning needs identified

Educational Need-Medications

Readiness to Learn-Accepting/Attentive

Teaching Method-Explanation/Discussion

Response to Teaching-Follow up needed - plan

Patient/Family taught the following- discuss filuid restriction upon discharge, monitor kidneys and blood count for coumadin

Nursing - Serial - DAILY INTERDISCIPLINARY POC:

Care Plan per Care Path Protocol->possible discharge in today

KNOWLEDGE INT See Interdisciplinary Patient/Family Instruction Form->

DISCHARGE PLANNING INT->pending for today

SKIN INT Monitor skin integrity->dry and intact

PAIN INT Monitor pain using pain scale->denies

O2 therapy->roomair

Elevate HOB->30degree

Assess mobility->u p as lib chair

Assess transfers-can transfer self

Assess gait->steady

White, RN, Carina

White, RN, Carina

Metro South Medical Center

Patient Name

Allergies: nka

05/26/2011 8:25

05/26/2011 8:27

05/26/2011 8:28

05/26/2011 8:35

05/26/2011 9:50

05/26/2011 10:43

05/26/2011 11:02

Age DOB Gender

Female

Race

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

ADLs

VASCULAR ACCESS

Nursing - Serial - SHIFT HYGIENE/ADL (rev 05/05/11):

TURN FREQUENCY-Patient able to reposition self frequently in bed

ORAL CARE-Self

PERI CARE-Self

FOLEY CARE-N/A

SKIN CARE-Assist with skin cleaning and moisturizing

ACTIVITY-Bedrest

FEEDING-Self

COUGH AND DEEP BREATHING EXERCISES-N/A

EQUIPMENT - Incentive spirometry-N/A

EQUIPMENT – VTE (Venous Thromboembolism) Prophylaxis-N/A

Nursing - Serial - SHIFT MULTIPLE LINE ASSESSMENT (rev 12/21/09):

Room 4SO:421-01

Yang, PCP, Hai L

White, RN, Carina

ASSESSMENT

WOUNDS

PIVL Site 1 Location-Right Forearm

PIVL Site 1 dressing label-Date/Time placed -

PIVL Site 1 Inspection-Site is clean and dry without redness, drainage or swelling

Nursing - Serial - SHIFT NURSING ASSESSMENT (rev 11/04/10):

Transmission Precautions-Standard

O2 Type/Liter Flow-Room Air

Rhythm Strip Interpretation-Atrial Fib

LOC-Awake, Alert and Oriented x 3

Affect-Calm and cooperative

Eye Opening-4 spontaneous

Verbal Response-5 Alert and Oriented X 3

Motor Response-6 obeys commands

Pupil right-2mm

Pupil left-2mm

Pupils-equal and reactive

Ability to Move - right arm-moderate

Ability to Move - right leg-moderate

Ability to Move - left leg-moderate

Ability to Move - left arm-moderate

Skin Color-Normal

Skin Temperature-cool

Skin Moisture-Moist

Skin turgor-non-tenting

Respirations-Unlabored

Breath Sounds Right-Clear

Breath Sounds Left-Clear

Retractions-No retractions noted

Abdomen-Soft

Bowel Sounds-Active x 4 quadrants

Pedal Edema Right-No edema noted

Pedal Edema Left-No edema noted

Pedal Pulses Right-2 plus = Palpable Disappears with Pressure

Pedal Pulses Left-2 plus = Palpable Disappears with Pressure

Nursing - Serial - SHIFT WOUND ASSESSMENT (rev 05/06/10):

White, RN, Carina

White, RN, Carina

NURSING

RESPIRATORY

WOUND ASSESSMENT-No wounds at this time, no further assessment needed.

TOTAL NUMBER OF WOUNDS-N/A - no wounds present upon assessment

EQUIPMENT-Pressure relief mattress

WOUND ASSOCIATED PAIN-N/A

WOUND TREATMENT-N/A

Nursing - Serial - SHIFT NARRATIVE NOTE (new 6/29/10) pt sister( loretta) at bed side will like POT paper sign today if chaplin available.

Respiratory - Assessment/Plan of Care:

White, RN, Carina

Kennerson, RT, Carol

PHYSICAL THERAPY

Oxygen-nc on sb

Attempted to see pt in the AM for therapy, although she adamantly refused as she is scheduled for d/c to home later today. Will monitor.

Bohanek, MPT, Amy

Metro South Medical Center

Patient Name Age DOB Gender

Female

Race

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

Allergies: nka

05/26/2011 11:30

05/26/2011 11:30

05/26/2011 11:59

05/26/2011 12:33

05/26/2011 15:22

05/26/2011 15:24

VASCULAR ACCESS

NURSING

PHARMACY

SPIRITUAL CARE

NURSING

NURSING

Nursing - Serial - SHIFT MULTIPLE LINE ASSESSMENT (rev 12/21/09):

PIVL Site 1 Location-Right Forearm

PIVL Site 1 dressing label-Date/Time placed -

PIVL Site 1 Inspection-Site is clean and dry without redness, drainage or swelling

Patient's central venous access device continues to be necessary due to-N/A

Nursing - Serial - SHIFT NARRATIVE NOTE (new 6/29/10) pt resting in chair, sister( loretta) call for pickup discharge home per md's. Pt is stable, pain free and accucheck with normal liimits.

Pharmacy - COUMADIN NOTE FOLLOW UP DOSING:

Room 4SO:421-01

White, RN, Carina

White, RN, Carina

Kane Rph, Richard

The patient chart and current labs-have been reviewed

INR level-3.30

Pharmacy plan-Hold Coumadin dose for today and repeat INR in AM

We will continue to follow and adjust as needed for an INR goal of-2.5 - 3.5

At bedside with pt.Introduced myself to pt as Chaplain Chapman and explained the purpose of my visit. That a family member has called this chaplain and said she wanted Power of Attorney Health Care done for pt.Pt stating she already has a Power of Attorney Health

Care.Pt states she does not need Power of Attorney Health Care.Pt states she does not want

Power of Attorney Health Care.

Chapman, Leland N.

Nursing - Serial - SHIFT NARRATIVE NOTE (new 6/29/10) pt telemonitor remvoed,. Pivl cover with 2x2 to stop bleeding. Pt explain about meds and discharge instruction regarding CHF, fluid restriction at home 1.2 ml.

White, RN, Carina

White, RN, Carina Nursing - Serial - SHIFT NARRATIVE NOTE (new 6/29/10) request wheelchair for discharge cf# 19641 response time 16 minutes.

Nursing - Focused - DISCHARGE NOTE (rev 12/10/10): White, RN, Carina 05/26/2011 15:43 DISCHARGE

Notifications By MD

Patient is aware of the plan of care to discharge-Patient was made aware of plan of care to discharge and verbalized understanding

Vascular access device(s)-PIVL D/C'd with catheter intact, dressing applied to site, no bleeding.

Indwelling drains-None

Belongings including any home meds if applicable-Were gathered and packed by family - inventory verified and signature obtained

General Discharge Instructions-Patient not able to receive instructions. After care instructions relayed to care provider who verbalized goo understanding, had no questions unanswered, agrees to comply.

Special Discharge Instructions-CHF Discharge instructions - Patient was given instruction on diet, exercise, weight monitoring, activity level, follow up and what to do if symptoms worsen.

Transportation arrangements-Patient going home with family

Patient was discharged to-Home with family

Patient left unit-Accompanied by transporter via wheelchair

Notifications By RN

No Notification Documentation

MD Notified

Harris, Richard G,

M.D.

Ventura, Salvatore C,

M.D.

Page Time

05/24 9:45

Num

Pages

1

05/24 10:02

Response

Time

Metro South Medical Center

Patient Name Age DOB Gender

Female

Race

Allergies: nka

Intake

Start Time

05/23 21:41

05/23 21:41

05/23 21:41

End Time Staff

McCabe, RN, Janet

Medicine/Device Type

COLCHICINE

McCabe, RN, Janet CARVEDILOL

McCabe, RN, Janet GLIPIZIDE

05/23 21:42

05/23 21:42

05/23 21:42

05/23 21:43

05/24 9:40

05/24 9:40

05/24 9:40

05/24 9:40

05/24 9:40

05/24 10:00

05/24 10:10

05/24 14:00

05/24 15:44

McCabe, RN, Janet FUROSEMIDE

McCabe, RN, Janet FAMOTIDINE

McCabe, RN, Janet METOCLOPRAMIDE HCL

McCabe, RN, Janet SIMVASTATIN

Bayless, RN, Michel FAMOTIDINE

Bayless, RN, Michel METOCLOPRAMIDE HCL

Bayless, RN, Michel COLCHICINE

Bayless, RN, Michel CARVEDILOL

Bayless, RN, Michel FUROSEMIDE

Critchett, RN,

Daisyrenee

Bayless, RN, Michel D5W/0.9% NACL

Bayless, RN, Michel DOBUTAMINE 500MG/250 D5W

Bayless, RN, Michel METOCLOPRAMIDE HCL

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

Room 4SO:421-01

POTASSIUM CHLORIDE / D5W/0.9% NACL

Dosage/

Rate

0.6 MG-

25 MG-

10 MG-

80 MG-

20 MG-

10 MG-

40 MG-

20 MG-

10 MG-

0.6 MG-

25 MG-

80 MG-

70 ml/hr

70ml/hr

250 ML-

10 MG-

Route/

Site

ORAL

ORAL

HELD DOSE

ORAL

ORAL

ORAL

ORAL

ORAL

ORAL

ORAL

ORAL

IV Push

INTRAVENOU

S

IV

Amt.

5 ML

Residual Comments

5 ML

0 ML

5 ML as ordered until seen by

Dr. Ahmed rescheduled due to tests

5 ML

5 ML

5 ML

1 Tablet

1 Tablet

1 Tablet

1 Tablet

8 ML

0 ML

0 ML

1000

500

Vitals Time:

05/24 09:57,

BP: 110/83,

Pulse: NA,

Respiration: N

Vitals Time:

05/24 09:57,

BP: 110/83,

Pulse: NA,

Respiration: N

Vitals Time:

05/24 09:57,

BP: 110/83,

Pulse: NA,

Respiration: N

Vitals Time:

05/24 09:57,

BP: 110/83,

Pulse: NA,

Respiration: N

Vitals Time:

05/24 09:57,

BP: 110/83,

Pulse: NA,

Respiration: N

Vitals Time:

05/24 14:48,

BP: NA/NA,

Pulse: NA,

Respiration: N

Vitals Time:

05/24 09:57,

BP: 110/83,

Pulse: NA,

Respiration: N

INTRAVENOU

S

0 ML

ORAL 1 Tablet

250

Vitals Time:

05/24 15:00,

BP: 121/89,

Pulse: 69,

Respiration: 20

Metro South Medical Center

Patient Name

Allergies: nka

05/24 18:01

05/24 18:02

05/24 18:17

05/24 21:11

05/24 21:11

05/24 21:11

05/24 21:11

05/25 7:00

05/25 7:00

05/25 9:25

05/25 9:27

05/25 9:27

05/25 9:28

05/25 9:28

Age DOB

Bayless, RN, Michel

Bayless, RN, Michel

Garza, PCP, l Ana

Bahena, RN,

Cecilia

Bahena, RN,

Cecilia

Bahena, RN,

Cecilia

Bahena, RN,

Cecilia

Bahena, RN,

Cecilia

White, RN, Carina

White, RN, Carina

White, RN, Carina

White, RN, Carina

Gender

Female

Race

WARFARIN SODIUM

FUROSEMIDE

PO Fluids

CARVEDILOL

FAMOTIDINE

METOCLOPRAMIDE HCL

SIMVASTATIN

IV Fluids

FUROSEMIDE

FAMOTIDINE

METOCLOPRAMIDE HCL

CARVEDILOL

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

5 MG-

80 MG-

25 MG-

20 MG-

10 MG-

40 MG-

ORAL 1 Tablet

Room 4SO:421-01

Vitals Time:

05/24 17:41,

BP: NA/NA,

Pulse: NA,

Respiration: N

INTRAVENOU

S

8 ML Vitals Time:

05/24 17:41,

BP: NA/NA,

Pulse: NA,

Respiration: N

PO Fluids 120 ML no appetite

HELD DOSE 0 ML

ORAL

ORAL

ORAL

IV

IV

0 ML

0 ML

0 ML

840 ML

152.5 ML

Vitals Time:

05/24 20:49,

BP: NA/NA,

Pulse: NA,

Respiration: N

Vitals Time:

05/24 20:49,

BP: NA/NA,

Pulse: NA,

Respiration: N

Vitals Time:

05/24 20:49,

BP: NA/NA,

Pulse: NA,

Respiration: N

Vitals Time:

05/24 20:49,

BP: NA/NA,

Pulse: NA,

Respiration: N

12 hour night shift

12 hour nights Bahena, RN,

Cecilia

White, RN, Carina

DOBUTAMINE 500MG/250 D5W,250 ML,

,INTRAVENOUS,AS needed,,DOBUTAMINE 500MG/250ML

D5W,KASON, THOMAS T

POTASSIUM CHLORIDE 20 MEQ-

100 MG-

20 MG-

10 MG-

25 MG-

ORAL

INTRAVENOU

S

ORAL

ORAL

ORAL

1 Tablet

0 ML

1 ML

1 Tablet

1 Tablet

Vitals Time:

05/25 16:30,

BP: NA/NA,

Pulse: NA,

Respiration: N

Vitals Time:

05/25 07:59,

BP: 119/74,

Pulse: 69,

Respiration: 16

Vitals Time:

05/25 07:59,

BP: 119/74,

Pulse: 69,

Respiration: 16

Vitals Time:

05/25 07:59,

BP: 119/74,

Pulse: 69,

Respiration: 16

Vitals Time:

05/25 07:59,

BP: 119/74,

Pulse: 69,

Respiration: 16

Metro South Medical Center

Patient Name

Allergies: nka

05/25 9:28

05/25 9:28

05/25 9:28

05/25 9:29

05/25 16:00

05/25 16:20

05/25 16:28

05/25 17:00

05/25 18:01

05/25 18:45

05/25 21:00

05/25 21:00

05/25 21:00

05/25 21:00

Age DOB

White, RN, Carina

White, RN, Carina

White, RN, Carina

White, RN, Carina

White, RN, Carina

White, RN, Carina

White, RN, Carina

White, RN, Carina

White, RN, Carina

White, RN, Carina

Bahena, RN,

Cecilia

Bahena, RN,

Cecilia

Bahena, RN,

Cecilia

Bahena, RN,

Cecilia

Gender

Female

FUROSEMIDE

FUROSEMIDE

FUROSEMIDE

ASPIRIN

Race

POTASSIUM CHLORIDE

METOCLOPRAMIDE HCL

FUROSEMIDE

FUROSEMIDE

ENALAPRIL MALEATE

CARVEDILOL

FAMOTIDINE

METOCLOPRAMIDE HCL

SIMVASTATIN

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

WARFARIN PHARMACY DOSING

80 MG-

80 MG-

80 MG-

325 MG-

40 MEQ-

10 MG-

1 -

80 MG-

80 MG-

10 MG-

25 MG-

20 MG-

10 MG-

40 MG-

PO Fluids

IV Push

IV Push

ORAL

ORAL

ORAL

HELD DOSE

IV Push

IV Push

ORAL

ORAL

ORAL

ORAL

0 ML

0 ML

0 ML

1 Tablet

Room 4SO:421-01

Vitals Time:

05/25 07:59,

BP: 119/74,

Pulse: 69,

Respiration: 16

Vitals Time:

05/25 15:16,

BP: 111/79,

Pulse: 70,

Respiration: 18

Vitals Time:

05/25 16:30,

BP: NA/NA,

Pulse: NA,

Respiration: N

Vitals Time:

05/25 07:59,

BP: 119/74,

Pulse: 69,

Respiration: 16

2 Tablet

1 Tablet

0 ML

0 ML

0 ML

1 Supp

0 ML

0 ML

Vitals Time:

05/25 16:30,

BP: NA/NA,

Pulse: NA,

Respiration: N

Vitals Time:

05/25 15:16,

BP: 111/79,

Pulse: 70,

Respiration: 18

Vitals Time:

05/25 15:16,

BP: 111/79,

Pulse: 70,

Respiration: 18 inr 3.19

Vitals Time:

05/25 16:30,

BP: NA/NA,

Pulse: NA,

Respiration: N

Vitals Time:

05/25 16:30,

BP: NA/NA,

Pulse: NA,

Respiration: N

Vitals Time:

05/25 15:16,

BP: 111/79,

Pulse: 70,

Respiration: 18

Vitals Time:

05/25 21:00,

BP: NA/NA,

Pulse: NA,

Respiration: N

Vitals Time:

05/25 21:00,

BP: NA/NA,

Pulse: NA,

Respiration: N

0 ML

ORAL 0 ML

Metro South Medical Center

Patient Name Age DOB

Allergies: nka

05/26 1:03

05/26 1:09

05/26 8:24

05/26 9:17

05/26 9:17

05/26 9:17

05/26 9:17

05/26 9:17

05/26 9:17

05/26 9:18

05/26 11:50

Bahena, RN,

Cecilia

Bahena, RN,

Cecilia

Gender

Female

FUROSEMIDE

Race

ENALAPRIL MALEATE

Yang, PCP, Hai L PO Fluids

White, RN, Carina POTASSIUM CHLORIDE

White, RN, Carina

White, RN, Carina

ENALAPRIL MALEATE

FAMOTIDINE

White, RN, Carina METOCLOPRAMIDE HCL

White, RN, Carina

White, RN, Carina

White, RN, Carina

White, RN, Carina

CARVEDILOL

FUROSEMIDE

ASPIRIN

FUROSEMIDE

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

100 MG-

10 MG-

20 MEQ-

10 MG-

20 MG-

10 MG-

25 MG-

80 MG-

325 MG-

100 MG-

INTRAVENOU

S

HELD DOSE

PO Fluids

10 ML

0 ML

360 ML

Room 4SO:421-01

Vitals Time:

05/25 21:00,

BP: NA/NA,

Pulse: NA,

Respiration: N error in documentation

was not given breakfast 100%

ORAL 1 Tablet

ORAL

ORAL

ORAL

ORAL

HELD DOSE

ORAL

INTRAVENOU

S

PO Fluids

1 Tablet

1 Tablet

1 Tablet

1 Tablet

0 ML

1 Tablet

0 ML

360 ML

Vitals Time:

05/26 08:35,

BP: 107/74,

Pulse: 75,

Respiration: 16

Vitals Time:

05/26 08:35,

BP: 107/74,

Pulse: 75,

Respiration: 16

Vitals Time:

05/26 08:35,

BP: 107/74,

Pulse: 75,

Respiration: 16

Vitals Time:

05/26 08:35,

BP: 107/74,

Pulse: 75,

Respiration: 16

Vitals Time:

05/26 08:35,

BP: 107/74,

Pulse: 75,

Respiration: 16

Vitals Time:

05/26 08:35,

BP: 107/74,

Pulse: 75,

Respiration: 16 start in am

Vitals Time:

05/26 08:35,

BP: 107/74,

Pulse: 75,

Respiration: 16

Vitals Time:

05/26 11:40,

BP: 130/91,

Pulse: 69,

Respiration: 20 lunch 100% 05/26 12:30

Output

Date/Time

05/24/2011 2:00

Yang, PCP, Hai L PO Fluids

Staff

McCabe, RN, Janet

Output Type

Urine Output

05/24/2011 6:02

05/24/2011 16:00

05/24/2011 18:01

Shatteen, PCP, Angie E.

Urine Output

Garza, PCP, l Ana

Garza, PCP, l Ana

Urine Output

Urine Output

Amount (ml)

0

Comments

up to bathroom, voided and had stool, pt flushed before rn saw results

0 brpx 3

200

150 foley foley

Metro South Medical Center

Patient Name Age DOB Gender

Female

Race

Allergies: nka

05/25/2011 5:23

05/25/2011 11:00

05/25/2011 22:02

05/26/2011 0:30

05/26/2011 3:00

05/26/2011 5:00

05/26/2011 14:19

Wylie,, PCP, Elana

White, RN, Carina

Fontillas, PCP, Arthur

Fontillas, PCP, Arthur

Bahena, RN, Cecilia

Fontillas, PCP, Arthur

Yang, PCP, Hai L

Urine Output

Urine Output

Stool

Urine Output

Urine Output

Urine Output

Urine Output

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

650

240

0

350

300

0

0 foley d/c foley soft brown yellow urine commode yellow urine bsc

BRP, didn't save urine brp

Room 4SO:421-01

Metro South Medical Center

Patient Name Age DOB Gender

Female

Race

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

Room 4SO:421-01 Allergies: nka

Medication Reconciliation

Med Recon Type

ADMISSION

Med Type

HOME MEDS

Medication

Aspirin 325 mg Tab, Daily

ADMISSION

ADMISSION

HOME MEDS

HOME MEDS

Chlordiazepoxide 25 mg Cap, At Bedtime as needed

Colace 100 mg Cap, Twice Daily as needed

DISCHARGE

DISCHARGE

DISCHARGE

DISCHARGE

DISCHARGE

DISCHARGE

DISCHARGE

DISCHARGE

DISCHARGE

DISCHARGE

DISCHARGE

DISCHARGE

DISCHARGE

DISCHARGE

DISCHARGE

DISCHARGE

DISCHARGE

ADMISSION

ADMISSION

ADMISSION

ADMISSION

ADMISSION

ADMISSION

ADMISSION

ADMISSION

ADMISSION

ADMISSION

ADMISSION

ADMISSION

ADMISSION

DISCHARGE

DISCHARGE

DISCHARGE

HOME MEDS

HOME MEDS

HOME MEDS

HOME MEDS

HOME MEDS

HOME MEDS

HOME MEDS

HOME MEDS

HOME MEDS

HOME MEDS

HOME MEDS

HOSPITAL MEDS

HOSPITAL MEDS

HOSPITAL MEDS

HOSPITAL MEDS

HOSPITAL MEDS

HOSPITAL MEDS

HOME MEDS

HOME MEDS

HOME MEDS

HOME MEDS

HOME MEDS

HOME MEDS

HOME MEDS

HOME MEDS

HOME MEDS

HOME MEDS

HOME MEDS

HOME MEDS

HOME MEDS

HOME MEDS

HOME MEDS

HOME MEDS

Colchicine 0.6 mg Tab, Twice A Day

Coreg 25 mg Tab, Twice A Day

Digoxin 0.25mg PO, Daily

Enalapril 20mg PO, 1 tablet, Twice A Day

Glipizide 10 mg Tab, Twice A Day

HUMALOG 6units After Meals Subcutaneous, 6 UNITS, Three times daily AFTER Meals

Insulin Detemir SubQ, 20 units, At Bedtime

Lasix 80 mg Tab, Twice A Day

Pepcid 20 mg Tab, Twice A Day

Reglan 10 mg Tab, Three Times A Day

Simvastatin 40 mg Tab, Daily

Warfarin 5 mg Tab, Daily

Zithromax 250mg PO, Daily

Aspirin 325 mg Tab, 1 tablet, Daily

Colace 100 mg Cap, 1 tablet, Twice Daily as needed

Coreg 25 mg Tab, 1 tablet, Twice A Day diagnostic test to be completed, , One Time

DOCUSATE SODIUM, 100 MG, 2x a day as needed

Enalapril Maleate Oral, 2.5 mg , Twice A Day

FAMOTIDINE, 20 MG, 2 times a day 0900,2100

HUMALOG 6units After Meals Subcutaneous, 6 UNITS, Three times daily AFTER Meals

Insulin Detemir SubQ, 10 units, At Bedtime

Lasix Oral, 100 mg, Twice A Day

Potassium Chloride 20meq PO, 1 tablet, Daily

Simvastatin 40 mg Tab, , Daily

Warfarin 5 mg Tab, , Daily

ZALEPLON, 10 MG, at bedtime as need 2100

ASPIRIN,325 MG, ,ORAL,daily

CARVEDILOL,25 MG, ,ORAL,2 times a day ,

CHLORDIAZEPOXIDE HCL,25 MG, ,ORAL,at bedtime as need

DOCUSATE SODIUM,100 MG, ,ORAL,2x a day as needed

ENALAPRIL MALEATE,10 MG, ,ORAL,2 times a day ,

FAMOTIDINE,20 MG, ,ORAL,2 times a day ,

Status

CONTINUE

CONTINUE

CONTINUE

CONTINUE

CONTINUE

CONTINUE

CONTINUE

CONTINUE

CONTINUE

CONTINUE

CONTINUE

CONTINUE

CONTINUE

CONTINUE

DISCONTINUE

DISCONTINUE

DISCONTINUE

DISCONTINUE

DISCONTINUE

DISCONTINUE

CONTINUE

CONTINUE

CONTINUE

CONTINUE

CONTINUE

CONTINUE

CONTINUE

CONTINUE

CONTINUE

CONTINUE

CONTINUE

CONTINUE

CONTINUE

CONTINUE

CONTINUE

CONTINUE

Allergies: nka

DISCHARGE

DISCHARGE

DISCHARGE

DISCHARGE

DISCHARGE

DISCHARGE

DISCHARGE

DISCHARGE

DISCHARGE

DISCHARGE

DISCHARGE

DISCHARGE

Metro South Medical Center

Patient Name Age DOB

HOSPITAL MEDS

HOSPITAL MEDS

HOSPITAL MEDS

HOSPITAL MEDS

HOSPITAL MEDS

HOSPITAL MEDS

HOSPITAL MEDS

HOSPITAL MEDS

HOSPITAL MEDS

HOSPITAL MEDS

HOSPITAL MEDS

HOSPITAL MEDS

Gender

Female

Race

12935 South Gregory Street Blue Island, IL 60406-2428 (708) 597-2000

Insurance

WELLCARE

Admitting

Weight

85.7kg

Admitting

Height

175.26cm

Medical Record Account

FUROSEMIDE,100 MG, ,INTRAVENOUS,every 8 hrs

METOCLOPRAMIDE HCL,10 MG, ,ORAL,3 times a day

POTASSIUM CHLORIDE,20 MEQ, ,ORAL,daily

SIMVASTATIN,40 MG, ,ORAL,at bedtime

WARFARIN PHARMACY DOSING,1 , ,ORAL,daily

ZALEPLON,10 MG, ,ORAL,at bedtime as need

ACETAMINOPHEN,650 MG, ,ORAL,every 6hr as needed

ALUM-MAG HYDROXIDE-SIMETHICONE,30 ML, ,ORAL,AS needed

ATROPINE SULFATE,1 MG, ,INTRAVENOUS,AS needed

MAGNESIUM HYDROXIDE 15%,10 ML, ,ORAL,AS needed

NITROGLYCERIN,0.4 MG, ,SUBLINGUAL,AS needed

TRIMETHOBENZAMIDE HCL,200 MG, ,INTRAMUSCULAR,every 6hr as needed

Room 4SO:421-01

DISCONTINUE

DISCONTINUE

DISCONTINUE

DISCONTINUE

DISCONTINUE

DISCONTINUE

DISCONTINUE

DISCONTINUE

DISCONTINUE

DISCONTINUE

DISCONTINUE

DISCONTINUE

empower Inpatient+Ambulatory

Empower Inpatient Summary Chart for Faxing

232

empower Inpatient+Ambulatory

233

empower Inpatient+Ambulatory

234

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