Sample Charting
Case of Cerebrovascular Accident
07-10-06 7am-3pm
7:05 > Received on bed, asleep c D5LRs 1L @ KVO, 400 cc level
>c SD of D5W ½ L + amps hydralazine and 4amps clonidine, regulated @ 10 ugtts/min, 450 cc level received
>incoherent, restless, BP 80/50
>Obtunded, GCS 11/15; patient always attended to prevent fall
>muscle strength 4/5, hypoactive reflex; always assisted
>c slurred speech, sometimes inappropriate
> Morning care done
8:30am>seen and examined by Dr. Dumlao c orders made and carried out
>discussion given on the nature of disease, possible complications of the disease process and fall prevention measures
>SD of D5W + 4amps clonidine and 4amps hydralazine on standby due to decreased BP
>Patient on close watch
>Still on low fat, low salt diet, able to consume half of the served meal
>Latest v/s taken and recorded BP= 90/60 PR=68
3:00pm>endorsed accordingly
Zena Yelena Shimmery, SN
Diagnosis: R/O Prostate CA
07-10-06 7am-3pm
7:05am >received on semi-fowler’s position, awake
>complained of tolerable Low Back Pain, 5/10 on Numerical Pain Intensity Scale
>Hot Compress applied on lower back for 15 min, reported relief
>no report of hematuria and dysuria
>c tender hypogastric area
8:30am>Seen and examined by Resident on duty with new orders made and carried out
8:55am>Result of BUN, Crea attached to chart, ROD notified
1:00pm>IVF of D5LRs 1 L inserted aseptically on L hand regulated @ KVO
>for Transrectal Biopsy c UTZ guidance of Prostate tomorrow (11-23-04)
>Surgery Resident on duty/Anesthesiologist on duty notified of the procedure
>for KUB-IVP tomorrow
>Health teachings given to patient/SO about the nature of disease, the procedure and the need for biopsy
>NPO post midnight instructed
>KUB-IVP preparation instructed
>Latest BP taken, 110/90
> endorsed accordingly to NOD
Zena Yelena Shimmery, SN
07-10-06 7am-3pm
7:05 > Received on bed, asleep c D5LRs 1L @ KVO, 400 cc level
>c SD of D5W ½ L + amps hydralazine and 4amps clonidine, regulated @ 10 ugtts/min, 450 cc level received
>incoherent, restless, BP 80/50
>Obtunded, GCS 11/15; patient always attended to prevent fall
>muscle strength 4/5, hypoactive reflex; always assisted
>c slurred speech, sometimes inappropriate
> Morning care done
8:30am>seen and examined by Dr. Dumlao c orders made and carried out
>discussion given on the nature of disease, possible complications of the disease process and fall prevention measures
>SD of D5W + 4amps clonidine and 4amps hydralazine on standby due to decreased BP
>Patient on close watch
>Still on low fat, low salt diet, able to consume half of the served meal
>Latest v/s taken and recorded BP= 90/60 PR=68
3:00pm>endorsed accordingly
Zena Yelena Shimmery, SN
Diagnosis: R/O Prostate CA
07-10-06 7am-3pm
7:05am >received on semi-fowler’s position, awake
>complained of tolerable Low Back Pain, 5/10 on Numerical Pain Intensity Scale
>Hot Compress applied on lower back for 15 min, reported relief
>no report of hematuria and dysuria
>c tender hypogastric area
8:30am>Seen and examined by Resident on duty with new orders made and carried out
8:55am>Result of BUN, Crea attached to chart, ROD notified
1:00pm>IVF of D5LRs 1 L inserted aseptically on L hand regulated @ KVO
>for Transrectal Biopsy c UTZ guidance of Prostate tomorrow (11-23-04)
>Surgery Resident on duty/Anesthesiologist on duty notified of the procedure
>for KUB-IVP tomorrow
>Health teachings given to patient/SO about the nature of disease, the procedure and the need for biopsy
>NPO post midnight instructed
>KUB-IVP preparation instructed
>Latest BP taken, 110/90
> endorsed accordingly to NOD
Zena Yelena Shimmery, SN
