Placental abruption is when the placenta separates early from the uterus, in other words separates before childbirth. It occurs most commonly around 25 weeks of pregnancy. Symptoms may include vaginal bleeding, lower abdominal pain, and dangerously low blood pressure.
if you were transcribing this report- how would the appropriate and ac.docxMaxd78Pipero
if you were transcribing this report, how would the appropriate and accurate use of obstetrical terminology support the following in performing their jobs:
ICD-10-CM/PCS coders
Nurses
Physicians Painted Valley, USA
Montero, Elena C Dr. Amber Shephard 126 #706203
PREPARTUM STANDING ORDERS
1.
2.
3.
Check fetal heart tones and vital signs.
Urinalysis
CBC
4
Call physician.
Perineal prep Fleets or soft suds enema as ordered. h.
5.
7.
NPO except for ice chips.
8. 5% D/W in Labor Room. Infuse at 150cc/hour. 9. Notify physician of progress for sedation order.
10. Apply fetal monitor.
11. May be up to shower if not in active labor,
bleeding, or fetal distress.
12. May administer oxygen at 10 liters per mask
for fetal distress then notify physician.
Amber Shephard
Delivery Room
11/14/xx
I 2 Pitucin U10 in IV after delivery of placenta. If no TV, Pitocin U10 IM.
Amber Shephard
11/14/xx S:31pm Adruit and follow routine
orders. Breast feeding Amber Shephard
11/14/xx 11:30pm Delivered 23 year old
99. No lacerations.Normal vaginal delivery.
G2P1 NSVD 7 lb. 140z, female Apgars Female infant with Apgars of 9 and 9 in LOA.Estimate blood Inss: 300 ml. Afchrile Placenta delivered spontaneously.
Midline episiotomy with repaired with Ethilon.
Amber ShephardPainted Valley Antepartum testing
Sonography
Amniocentesis
Age under 16 or over 40 Gravida 1 with age 35-
Rh negative
Rubella exposure
Use of drugs:[D
History of High Risk Complications
Difficult labor, delivery or puerperium
Cesarean section
Stillborn or 3 or more abortions
Neonatal death
Live births under 5 pounds Toxemia or hypertensive disease
Immediate infant distress injury None
Diabetes mellitus
Genital infection
Urinary tract infection
Premature by dates
Over 2 weeks past FDC
Excessive weight gain None
4:25 pm
No
Obstetric Admission
Date
11/14/xx 125/60
Time
BP
Temp
98.8
20
Resp Induction
140)
yes yes
Lahor
No
Hour
Onsel 11/14 Date 0835 time 0800 time
Tast meal
11/14
Date
Membranes
intact
ruptured 165
Height
Weight
Other
Yes
consents
Signed
Condition:
Good
Fair
Critical
Gr
Para
L Ab 0 Stillborn
Blood Group 0
Rh Neg
LNMP
2/13/xx
LDC neg
Weeks Now 37
Prenatal visits Yes
No
Current Medications None
56"
None
Allergies
Previous Labor History Previous anesthetics
History of blood transfusions.
OK
Comments:
OK
time
initials
Prep
Enemar
5:15
LAB:
5:15
IV:
5:15
time
FT.
Antepartum testing
Sonography
Amniocentesis
Age under 16 or over 40 Gravida 1 with age 35-
Rh negative
Rubella exposure
Use of drugs:[D
History of High Risk Complications
Difficult labor, delivery or puerperium
Cesarean section
Stillborn or 3 or more abortions
Neonatal death
Live births under 5 pounds Toxemia or hypertensive disease
Immediate infant distress injury None
Diabetes mellitus
Genital infection
Urinary tract infection
Premature by dates
Over 2 weeks past FDC
Excessive weight gain None
4:25 pm
No
Obstetric Admission
Date
11/14/xx 125/60
Time
BP
Temp
98.8
20
Resp Induction
140)
yes yes
Lahor
No
Hour
Onsel 11/14 Date 0835 time 0800 time
.
Placental abruption is when the placenta separates early from the uterus, in other words separates before childbirth. It occurs most commonly around 25 weeks of pregnancy. Symptoms may include vaginal bleeding, lower abdominal pain, and dangerously low blood pressure.
if you were transcribing this report- how would the appropriate and ac.docxMaxd78Pipero
if you were transcribing this report, how would the appropriate and accurate use of obstetrical terminology support the following in performing their jobs:
ICD-10-CM/PCS coders
Nurses
Physicians Painted Valley, USA
Montero, Elena C Dr. Amber Shephard 126 #706203
PREPARTUM STANDING ORDERS
1.
2.
3.
Check fetal heart tones and vital signs.
Urinalysis
CBC
4
Call physician.
Perineal prep Fleets or soft suds enema as ordered. h.
5.
7.
NPO except for ice chips.
8. 5% D/W in Labor Room. Infuse at 150cc/hour. 9. Notify physician of progress for sedation order.
10. Apply fetal monitor.
11. May be up to shower if not in active labor,
bleeding, or fetal distress.
12. May administer oxygen at 10 liters per mask
for fetal distress then notify physician.
Amber Shephard
Delivery Room
11/14/xx
I 2 Pitucin U10 in IV after delivery of placenta. If no TV, Pitocin U10 IM.
Amber Shephard
11/14/xx S:31pm Adruit and follow routine
orders. Breast feeding Amber Shephard
11/14/xx 11:30pm Delivered 23 year old
99. No lacerations.Normal vaginal delivery.
G2P1 NSVD 7 lb. 140z, female Apgars Female infant with Apgars of 9 and 9 in LOA.Estimate blood Inss: 300 ml. Afchrile Placenta delivered spontaneously.
Midline episiotomy with repaired with Ethilon.
Amber ShephardPainted Valley Antepartum testing
Sonography
Amniocentesis
Age under 16 or over 40 Gravida 1 with age 35-
Rh negative
Rubella exposure
Use of drugs:[D
History of High Risk Complications
Difficult labor, delivery or puerperium
Cesarean section
Stillborn or 3 or more abortions
Neonatal death
Live births under 5 pounds Toxemia or hypertensive disease
Immediate infant distress injury None
Diabetes mellitus
Genital infection
Urinary tract infection
Premature by dates
Over 2 weeks past FDC
Excessive weight gain None
4:25 pm
No
Obstetric Admission
Date
11/14/xx 125/60
Time
BP
Temp
98.8
20
Resp Induction
140)
yes yes
Lahor
No
Hour
Onsel 11/14 Date 0835 time 0800 time
Tast meal
11/14
Date
Membranes
intact
ruptured 165
Height
Weight
Other
Yes
consents
Signed
Condition:
Good
Fair
Critical
Gr
Para
L Ab 0 Stillborn
Blood Group 0
Rh Neg
LNMP
2/13/xx
LDC neg
Weeks Now 37
Prenatal visits Yes
No
Current Medications None
56"
None
Allergies
Previous Labor History Previous anesthetics
History of blood transfusions.
OK
Comments:
OK
time
initials
Prep
Enemar
5:15
LAB:
5:15
IV:
5:15
time
FT.
Antepartum testing
Sonography
Amniocentesis
Age under 16 or over 40 Gravida 1 with age 35-
Rh negative
Rubella exposure
Use of drugs:[D
History of High Risk Complications
Difficult labor, delivery or puerperium
Cesarean section
Stillborn or 3 or more abortions
Neonatal death
Live births under 5 pounds Toxemia or hypertensive disease
Immediate infant distress injury None
Diabetes mellitus
Genital infection
Urinary tract infection
Premature by dates
Over 2 weeks past FDC
Excessive weight gain None
4:25 pm
No
Obstetric Admission
Date
11/14/xx 125/60
Time
BP
Temp
98.8
20
Resp Induction
140)
yes yes
Lahor
No
Hour
Onsel 11/14 Date 0835 time 0800 time
.
Biological screening of herbal drugs: Introduction and Need for
Phyto-Pharmacological Screening, New Strategies for evaluating
Natural Products, In vitro evaluation techniques for Antioxidants, Antimicrobial and Anticancer drugs. In vivo evaluation techniques
for Anti-inflammatory, Antiulcer, Anticancer, Wound healing, Antidiabetic, Hepatoprotective, Cardio protective, Diuretics and
Antifertility, Toxicity studies as per OECD guidelines
A Strategic Approach: GenAI in EducationPeter Windle
Artificial Intelligence (AI) technologies such as Generative AI, Image Generators and Large Language Models have had a dramatic impact on teaching, learning and assessment over the past 18 months. The most immediate threat AI posed was to Academic Integrity with Higher Education Institutes (HEIs) focusing their efforts on combating the use of GenAI in assessment. Guidelines were developed for staff and students, policies put in place too. Innovative educators have forged paths in the use of Generative AI for teaching, learning and assessments leading to pockets of transformation springing up across HEIs, often with little or no top-down guidance, support or direction.
This Gasta posits a strategic approach to integrating AI into HEIs to prepare staff, students and the curriculum for an evolving world and workplace. We will highlight the advantages of working with these technologies beyond the realm of teaching, learning and assessment by considering prompt engineering skills, industry impact, curriculum changes, and the need for staff upskilling. In contrast, not engaging strategically with Generative AI poses risks, including falling behind peers, missed opportunities and failing to ensure our graduates remain employable. The rapid evolution of AI technologies necessitates a proactive and strategic approach if we are to remain relevant.
Safalta Digital marketing institute in Noida, provide complete applications that encompass a huge range of virtual advertising and marketing additives, which includes search engine optimization, virtual communication advertising, pay-per-click on marketing, content material advertising, internet analytics, and greater. These university courses are designed for students who possess a comprehensive understanding of virtual marketing strategies and attributes.Safalta Digital Marketing Institute in Noida is a first choice for young individuals or students who are looking to start their careers in the field of digital advertising. The institute gives specialized courses designed and certification.
for beginners, providing thorough training in areas such as SEO, digital communication marketing, and PPC training in Noida. After finishing the program, students receive the certifications recognised by top different universitie, setting a strong foundation for a successful career in digital marketing.
The French Revolution, which began in 1789, was a period of radical social and political upheaval in France. It marked the decline of absolute monarchies, the rise of secular and democratic republics, and the eventual rise of Napoleon Bonaparte. This revolutionary period is crucial in understanding the transition from feudalism to modernity in Europe.
For more information, visit-www.vavaclasses.com
Acetabularia Information For Class 9 .docxvaibhavrinwa19
Acetabularia acetabulum is a single-celled green alga that in its vegetative state is morphologically differentiated into a basal rhizoid and an axially elongated stalk, which bears whorls of branching hairs. The single diploid nucleus resides in the rhizoid.
Operation “Blue Star” is the only event in the history of Independent India where the state went into war with its own people. Even after about 40 years it is not clear if it was culmination of states anger over people of the region, a political game of power or start of dictatorial chapter in the democratic setup.
The people of Punjab felt alienated from main stream due to denial of their just demands during a long democratic struggle since independence. As it happen all over the word, it led to militant struggle with great loss of lives of military, police and civilian personnel. Killing of Indira Gandhi and massacre of innocent Sikhs in Delhi and other India cities was also associated with this movement.
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Date/ shift
Aug 10, 2010
6:00am-2:00pm
9:20am
- Please admit to
pedia ward B
- Please secure
consent for
admission
management
- TRP q4 include Bp
and record please
- Monitor I&O cc/cc
q shift record
please
- Diet as Tolerated
- IVF D5 0.3 NaCl
1liter to run KVO
- Diagnostics:
Chest x-ray
CBC
Urinalysis
ECG
- Place water out
for respiratory
distress and any
informed s/sx and
please refer to
PROD
- Please inform
PROD readmission
once at ward.
- Please Refer
accordingly
10:20am
- Admitted a 13y/o
girl with a chief
complaint of
edema on low
extremities
- Conscious
- Vital signs taken
and recorded
- Seen and
examined
- Consent for
admission and
management
secured
- D50.3NaCl 1L to
run at KVO
hooked and
regulated at
desired rate
- DAT die
- CXR PA follow up
results
- CBC P follow up
results
- Urinalysis Follow
up results
- ECG don result
attached to chart
- Medication
prescribed
3. - Therapeutics:
Furosemide 25mg
thru IV q8
Cefuroxime 750mg
TIV q8
- Monitor Vital signs
include Bp and
record
- Monitor I&O cc/cc
q shift and record
- Pedia ward nurse
on duty informed
- Fixed and brought
to ward
- Needs attended
- Endorsement
10:40am
- Include egg whites
– 3 egg whites to
be mixed with milk
3x/day
- Strict I &O
monitoring cc/cc
- Lab results BUN,
CREA
12:30pm
- Trans. in patient
PROD per via
stretcher
accompanied by
NOD
- w/ IVF 900cc
- Conscious
- O2 inhaler 3-4
LAM via face mask
- Cont. on DAT diet
- CXR PA follow up
results
- CBC P follow up
results
- Urinalysis Follow
up results
- ECG don result
attached to chart
- endorsed
2:00pm-10:00pm 2:45pm
- received patient
on bed with IVF @
4. 50cc
- conscious
- on DAT diet
- O2 inhalation w/
ongoing @3lpm
via facemask
- CXR PA ff up
results
- CBC PC ff up
results
- Urinalysis ff up
results
- ECG tracing
attached to chart
for efficient
reading
- Vital signs take
and recorded
- afebrile
- Due meds given
- Needs attended
- endorsed
10:40pm
- received on bed
w/ IVF @940cc
- conscious
- DAT diet; include 3
egg whites to be
mixed with milk 3x
a day
- O2 inhalation
ongoing @ 3-
4LPM via
5. facemask
- endorsed
- CXR PA ff up
results
- CBC PC ff up
results
- Urinalysis ff up
results
- ECG tracing
attached to chart
for efficient
reading
- BUN, CREA for w/
request
- Vital signs take
and recorded
- Due meds given
- Needs attended
Aug. 11,2010
6:00am-2:00pm
10:15 am
- May mean off to
O2 inhalation
- Please facilitate
pending labs
- Continue present
meds and
management
- Please refer
7:00am
- Received o bed w/
ongoing IVF 800cc
- Conscious
- DATT diet include
3 egg whites 3x a
day to be mixed
w/ milk
- w/O2 inhalation 3-
4Lpm via
facemask
- CXR PA ff up
results
- ECG tracing
attached to chart
6. - BUN, CREA ff up
results
2:00pm-10:00pm 2:50pm
- Received o bed w/
ongoing IVF 110cc
- Conscious
- DATT diet include
3 egg whites 3x a
day to be mixed
w/ milk
- w/O2 inhalation 3-
4Lpm via
facemask
- CXR PA ff up
results
- ECG tracing
attached to chart
- BUN, CREA ff up
results
- Vital signs
recorded
- needs attended
- Endorsed
10:00pm
- Received o bed w/
ongoing IVF 780cc
- Conscious
- DAT diet include 3
egg whites 3x a
day to be mixed
w/ milk
- w/O2 inhalation 3-
4Lpm via
facemask
7. - CXR PA ff up
results
- ECG tracing
attached to chart
- BUN, CREA ff up
results
- Vital signs
recorded
- afebrile
- due meds given
- needs attended
- Endorsed
Aug 12, 2010
6:00am-2:00pm
9:00 am
- Revised present Iv
to PNSS 500cc +
30mcg NaCl to run
for 24hrs x 2 doses
- Continue present
meds and
management
- Please refer
6:25am
- Received o bed w/
ongoing IVF 720cc
- Conscious
- DAT diet include 3
egg whites 3x a
day to be mixed
w/ milk
- ECG tracing
attached to chart
- BUN, CREA ff up
results
- Seen and
examined by Dr.
Velasco
2:00pm-10:00pm 2:30pm
- Received o bed w/
ongoing IVF 720cc
- Conscious
- DAT diet include 3
egg whites 3x a
day to be mixed
8. w/ milk
- ECG tracing
attached to chart
- Vital signs taken
and recorded
- Afebrile
- Needs attended
10:00pm-6:00am 10:30pm
- Received o bed w/
ongoing IVF 200cc
- Conscious
- DAT diet include 3
egg whites 3x a
day to be mixed
w/ milk
- ECG tracing
attached to chart
- Vital signs taken
and recorded
- Afebrile
- Needs attended
Aug. 13,2010
6:00am-2:00pm
8:10am
- Continue DAT diet
- Lanoxin ).25mg/ta
b ½ tab 2x a day-
hold for HR<80
- Start Salbutamol
NEB INED every
12hrs.
- Continue present
meds and
management
- Please refer
6:00am
- Received pt. on
bed w/ IVF @
270cc level
- Conscious
- On DAT diet to
include 3 egg
whites 3x a day to
be mixed w/ milk
- ECG tracing
attached to chart
- Repeat Na+
9. correction for
request
8:10am
- Seen and
examined by Dra.
Velasco order
meds and
continue
management
- Vital signs taken
and recorded
- Needs attended
- endorsed
2:00pm-10:00pm 2:40pm
- received on bed
w/ IVF @ 130cc
level
- conscious
- on DAT diet to
include 3 egg
whites 3x a day to
be mixed w/ milk
- ECG tracing for w/
request
- Vital signs taken
and recorded
- #3PNSS
500c+30mcg NaCl
X24 hook as to
follow
- Due meds given
- Needs attended
- Endorsed
10:00pm-6:00am 10:00pm
10. - received on bed
w/ IVF @ 470cc
level
- conscious
- on DAT diet to
include 3 egg
whites 3x a day to
be mixed w/ milk
- ECG tracing for w/
request
- Repeat serum Na+
correction
- Vital signs taken
and recorded
- Due meds given
- Needs attended
- Endorsed
Aug. 14, 2010
6:00am-2:00pm
8:50am
- Continue present
meds and
management
- Please refer
6:00am
- Received patient
on bed w/ IVF of
390cc level
- Conscious
- On diet as
tolerated to
include 3egg
whites TID to be
mixed w/ milk
- ECG tracing
attached to chart
- Request serum
Na+ correction for
w/ request
10:30am
- Salbutamol neb
8:50am
- Seen and
11. 1nebule for 1 dose
- Re-assessment
after 30mins
- Please refer
examined by Dr.
Macapulay w/
order made and
carried out
- Vital signs taken
and recorded
10:30am
- Referred to
Dr.Velasco w/
order made and
carried out
- Due meds given
11:20am
- Informed
Dr.Velasco
- Needs attended
2:00pm-10:00pm 3:10pm
- IVF: D5 0.3 NaCl
500cc to run at
KVO
- Refer
2:30pm
- received patient
on bed w/ IVF @
200cc level
- Conscious
- On diet as
tolerated to
include 3egg
whites TID to be
mixed w/ milk
- ECG tracing
attached to chart
- Request serum
Na+ correction for
w/ request
- Vital signs taken
and recorded
- Due meds given
12. - Needs attended
10:00pm
- Received pt. on
bed @140cc level
- Asleep
- On diet as
tolerated to
include 3egg
whites TID to be
mixed w/ milk
- ECG tracing
attached to chart
- Repeat serum Na+
correction for
request due
@3:30am
(8/15/2010) ff up
result
Aug. 15,2010 12:00pm
- D/c Cefuroxime
- Start ceftazidime
770mg TIV q8
ANST
- Cont. Other meds
and management
- Refer
6:00am
- Received pt. on
bed w/ IVF @
490cc level
- Conscious
- On diet as
tolerated to
include 3egg
whites TID to be
mixed w/ milk
- ECG tracing
attached to chart
- Repeat serum Na+
correction ff. up
result
12:00nn
13. - Seen and
examined by Dr.
Aganiza w/ new
orders made and
carried out
- Vital signs taken
and recorded
- Due meds given
- Needs attended
2:10pm
- Received pt. on
bed w/ IVF @
100cc level
- Conscious
- On diet as
tolerated to
include 3egg
whites TID to be
mixed w/ milk
- ECG tracing
attached to chart
- Repeat serum Na+
correction ff. up
result
10:30pm
- Received pt. on
bed w/ IVF @
290cc level
- Conscious
- On diet as
tolerated to
include 3egg
whites TID to be
mixed w/ milk
14. - ECG tracing
attached to chart
- Repeat serum Na+
correction ff. up
result
- Vital signs taken
and recorded
- Afebrile
- Needs attended
Aug. 16,2010 9:00am
- start with
pediasure
2glasses/day
- start with
multivitamins +
Iron cap 1cap daily
- rpt CXR(APL) today
compare w/
previous result
done
- cont. Ceftazidime
IV & other oral
meds
- refer
7:00am
- Received patient
on bed w/ IVF @
400cc level
- Conscious
- On diet as
tolerated to
include 3egg
whites TID to be
mixed w/ milk
9:00pm
- ECG tracing
attached to chart
- Seen and
examined by Dr.
Aganiza w/ order
made and carried
out
- Rpt. CXR for w/
request today;
15. compare w/
previous plate
(8/10/10)
- Afebrile
- Due meds given
- Needs attended
2:00pm-10:00pm 2:00pm
- received pt. on
bed w/ IVF @
340cc level
- conscious
- On diet as
tolerated to
include 3egg
whites TID to be
mixed w/ milk;
include pediasure
2glasses daily
- Vital signs taken
and recorded
- Afebrile
- Due meds given
- Needs attended
10:00pm
- Received patient
on bed w/ IVF @
850cc level
- Conscious
- On diet as
tolerated to
include 3egg
whites TID to be
mixed w/ milk
- ECG tracing
16. attached to chart
- Afebrile
- Due meds given
- Needs attended
Aug.17,2010 - ff up rpt CXR (APL)
- cont. Present
meds and
management
- refer
6:00pm
- Received patient
on bed w/ IVF @
400cc level
- Conscious
- On diet as
tolerated to
include 3egg
whites TID to be
mixed w/ milk
- ECG tracing
attached to chart
- Vital signs taken
and recorded
- Due meds given
9:30am
- Seen and
examined by Dr.
Aganiza w/ order
made and carried
out
- Needs attended
2:00pm-10:00pm 2:00pm
- received pt. on
bed w/ IVF @
800cc level
- conscious
- On diet as
tolerated to
include 3egg
17. whites TID to be
mixed w/ milk;
include pediasure
2glasses daily
- Vital signs taken
and recorded
- Afebrile
- Due meds given
- Needs attended
10:00-6:00pm 10:00pm
- received pt. on
bed w/ IVF @
300cc level
- conscious
- On diet as
tolerated to
include 3egg
whites TID to be
mixed w/ milk;
include pediasure
2glasses daily
- Vital signs taken
and recorded
- Afebrile
- Due meds given
- Needs attended
Aug. 18,2010
6:00am-2:00pm
9:40am
- may reinsert IV
- continue present
meds and
management
- please refer
6:00am
- Received patient
on bed w/ IVF @
350cc level
- Conscious
- On diet as
tolerated to
include 3egg
18. whites TID to be
mixed w/ milk
- ECG tracing
attached to chart
- Vital signs taken
and recorded
- Due meds given
9:00am
- Seen and
examined by Dr.
Aganiza w/ order
made and carried
out
- Needs attended
2:00pm-10:00pm 3:10pm
- IVF to ff: D5 0.3
NaCl 500cc to run
at KVO
- Please refer
2:10pm
- Received patient
on bed w/ IVF @
100cc level
- Conscious
- On diet as
tolerated to
include 3egg
whites TID to be
mixed w/ milk
- ECG tracing
attached to chart
- Vital signs taken
and recorded
- Due meds given
10:00pm-6:00am - Received patient
on bed w/ IVF @
50cc level
- Conscious
- On diet as
19. tolerated to
include 3egg
whites TID to be
mixed w/ milk
- ECG tracing
attached to chart
- Vital signs taken
and recorded
- Due meds given
12:30am
- #5 D5 0.3
NaCl@KVO
hooked as to
follow
- Meds attended
Aug.19,2010
6:00am-2:00pm
6:00am
- Received patient
on bed w/ IVF @
450cc level
- Conscious
- On diet as
tolerated to
include 3egg
whites TID to be
mixed w/ milk
- ECG tracing
attached to chart
- Seen and
examined by Dra.
Velasco w/ orders
made and carried
out
- Repest k+ for
request
20. - Vital signs taken
and recorded
- Due meds given
2:00pm-10:00pm 8:55pm
- For repeat K+
- Cont. meds and
management
- Please refer
2:00pm
- Received patient
on bed w/ IVF @
400cc level
- Conscious
- On diet as
tolerated to
include 3egg
whites TID to be
mixed w/ milk
- ECG tracing
attached to chart
- Vital signs taken
and recorded
- Due meds given
10:00pm-6:00am 10:00pm
- Received patient
on bed w/ IVF @
340cc level
- Conscious
- On diet as
tolerated to
include 3egg
whites TID to be
mixed w/ milk
- ECG tracing
attached to chart
- Request K+ for
request; result is
relayed to Dra.
Concepcion
21. - Vital signs taken
and recorded
- Due meds given
Aug.20,2010
6:00am-2:00pm
9:35am
- Start Vit.B
complex 1 tab OD
- Cont. meds and
management
- Please refer
6:15am
- Received patient
on bed w/ IVF @
260cc level
- Conscious
- On diet as
tolerated to
include 3egg
whites TID to be
mixed w/ milk
9:30am
- ECG tracing
attached to chart
- Seen and
examined by Dra.
Velasco
- Vital signs taken
and recorded
- Due meds given
2:00pm
- Received patient
on bed w/ IVF @
180cc level
- Conscious
- On diet as
tolerated to
include 3egg
whites TID to be
mixed w/ milk
- ECG tracing
attached to chart
22. - Vital signs taken
and recorded
- Due meds given
11:15pm
- Received patient
on bed w/ IVF @
135cc level
- Conscious
- On diet as
tolerated to
include 3egg
whites TID to be
mixed w/ milk
- ECG tracing
attached to chart
- Vital signs taken
and recorded
- Due meds given
- Needs attended
Aug.21,2010
6:00am-2:00pm
8:05am
- For issuance of
clinical abstract
- Cont. meds and
management
- Please refer
6:00am
- Received patient
on bed w/ IVF @
60cc level
- Conscious
- On diet as
tolerated to
include 3egg
whites TID to be
mixed w/ milk
- ECG tracing
attached to chart
8:00am
- Seen and
examined by Dra.
23. Macapulay w/
orders made and
carried out
- Vital signs taken
and recorded
- Due meds given
2:00pm
- Received patient
on bed w/ IVF @
10cc level
- Conscious
- On diet as
tolerated to
include 3egg
whites TID to be
mixed w/ milk
- ECG tracing
attached to chart
- Vital signs taken
and recorded
- Due meds given
- Needs attended
10:00pm-6:00am 4:00pm
- IVF to ff.
D50.3NaCl 500cc
as KVO
10:35pm
- Received patient
on bed w/ IVF @
490cc level
- Conscious
- On diet as
tolerated to
include 3egg
whites TID to be
mixed w/ milk
- ECG tracing
attached to chart
24. - Vital signs taken
and recorded
- Due meds given
- Needs attended
Aug.22,2010 10:30am
- For repeat CXR
APL tom. 7:00am
- Cont. meds and
management
- Please refer
6:35am
- Received patient
on bed w/ IVF @
450cc level
- Conscious
- On diet as
tolerated to
include 3egg
whites TID to be
mixed w/ milk
- ECG tracing
attached to chart
-
10:30am
- Seen and
examined by Dra.
Velasco orders
made and carried
out
- Repeat CXR APL
w/ request
- Vital signs taken
and recorded
- Due meds given
- Needs attended
2:00pm-10:00pm 2:55pm
- Received patient
on bed w/ IVF @
500cc level
- Conscious
25. - On diet as
tolerated to
include 3egg
whites TID to be
mixed w/ milk
- ECG tracing
attached to chart
- Vital signs taken
and recorded
- Instructed pt. and
mother not to
drink colas
- Due meds given
- Needs attended
10:00pm-6:00pm 10:00pm
- Received patient
on bed w/ IVF @
340cc level
- Conscious
- On diet as
tolerated to
include 3egg
whites TID to be
mixed w/ milk
- ECG tracing
attached to chart
- Repeat CXR APL
tom. @ 7:00am
- Vital signs taken
and recorded
- Afebrile
- Due meds given
- Needs attended
Aug.23,2010 6:30am 6:00pm
26. 6:00pm-2:00pm - Cont. meds and
management
- Please refer
- Received patient
on bed w/ IVF @
500cc level
- Conscious
- On diet as
tolerated to
include 3egg
whites TID to be
mixed w/ milk
- ECG tracing
attached to chart
- Repeat CXR APL
for w/ request,
due today; done
follow
6::30pm
- Seen and
examined by Dra.
Velasco orders
made and carried
out
- Vital signs taken
and recorded
- Due meds given
- Needs attended
2:00pm-10:00pm 2:35pm
- Received patient
on bed w/ IVF @
210cc level
- Conscious
- On diet as
tolerated to
include 3egg
whites TID to be
27. mixed w/ milk
- ECG tracing
attached to chart
- Repeat CXR APL
follow up results
- Vital signs taken
and recorded
- Afebrile
- Due meds given
- Needs attended