SOLUTION: he final project for this course is a medical scribe portfolio in which you assume the role of a med

1

HCM 205 Final Project Guidelines and Rubric

Overview
Medical terminology refers to medical terms that are used in the art and science of medicine. It is a specialized language that originates as far back as 460 to
377 B.C. during the era of Hippocrates (Rice, 2015). Medical language is used to describe human body components, processes, conditions, and procedures. In the
healthcare industry, medical terminology is the standardized method of communication for all healthcare professionals (Banova, 2013). In a clinical
environment, understanding medical terminology makes communication, interpretation, and documentation of patient information faster and easier. As a HIM
professional, this skill allows for increased efficiencies with organizing, reporting, and analyzing healthcare information, as well as billing for patient services. It is
therefore essential for healthcare professionals to be fluent in medical terminology to ease clinical proceedings and more efficiently and effectively facilitate
patient treatment (Banova, 2013).

For your final project, through a realistic approach, you will assume the role of a Medical Scribe for a healthcare facility to complete a Medical Scribe Portfolio. A
Medical Scribe is an individual trained in medical documentation who assists a physician throughout the workday (Medical Scribe-The Job Description, 2015).
More specifically, the primary goal of a Medical Scribe is to assist the physician in increasing efficiency and productivity, and allowing the physician to focus full
attention on the patient (Medical Scribe-The Job Description, 2015). In the final project, you will complete a series of tasks that you would likely perform daily as
a medical scribe, and document these tasks in the Final Project Portfolio Template. Your first assignment is to assist the physician in documenting notes from a
patient’s medical record. Second, you will review medical documents for accuracy in spelling, interpretation, and diagnosis. Your third and final assignment is to
review patient records and use this information to educate the patient about his/her medical records and diagnosis. Throughout your project, you will use a
recording tool, such as Vocaroo, to record your pronunciation of the medical terms. The preferred format is to utilize Vocaroo, but if you use an alternate
method, upload a separate file with the recording. These activities are designed to guide you in the application of medical terminology as it relates to the clinical
world. The final product will be submitted in Module Eight.

References
Banova, B. (2013, March 20). The Language of Healthcare: Learning Medical Terminology. Retrieved from American Institute of Medical Sciences & Education:

https://www.aimseducation.edu/blog/the-language-of-healthcare-learning-medical-terminology/
Medical Scribe-The Job Description. (2015). Retrieved from American Healthcare Documentation Professionals Group:

https://www.ahdpg.com/medical-scribe-the-job-description/
Rice, J. (2015). Medical Terminology for Health Care Professionals. Upper Saddle River, NJ: Pearson.

In this assignment, you will demonstrate your mastery of the following course outcomes:

2

● HCM-205-01: Apply medical terminology to body systems and medical specialties for documenting patient information [BS.HIT.CORE.01]

● HCM-205-02: Interpret medical records and reports for translating key patient information [BS.HIT.CORE.01]

● HCM-205-03: Communicate medical terminology by using accurate spelling and effective pronunciation [BS.HIT.CORE.01]

Prompt
For your final project, you will assume the role of a medical scribe in a healthcare organization. You will complete a series of tasks that a medical scribe would
complete in the field on a daily basis, and document these tasks in the Final Project Portfolio Template. You will submit your completed template to your
instructor. To begin, you will assist a physician in documenting notes from a patient record by building medical terms, ensuring the terms are spelled correctly.
You will also provide a recording of the pronunciation of the terms. Second, you will review medical documentation in a patient record to ensure accuracy. You
will identify inaccuracies of spelling and interpretation, and provide the accurate spelling and revised SOAP note. For your third task, you will gather information
to be used by the physician to educate a patient on their diagnosis. You will interpret the medical record to identify key terms, and then break down, define, and
pronounce these terms. Note that these terms will all be constructed terms. To complete your task, you will provide a final summary of the diagnosis.

For support on using Vocaroo, refer to the Vocaroo Tutorial.

Specifically, the following critical elements must be addressed:

I. Documenting Patient Information: To begin your day, a physician has asked you to assist in documenting his notes from Patient Record One. The

physician has bolded the words or phrases that need interpreting in the Progress Notes. Based on these notes, build the medical terms that are

described, and add these to the Final Project Portfolio Template, making sure that each term is spelled correctly. Then, using a recording tool, such as

Vocaroo, record the medical terms. Add your recording to the Final Project Portfolio Template.

A. Build medical terms by using the appropriate word parts.

B. Be sure that the medical terms are spelled accurately.

C. Provide the effective pronunciation of the medical terms.

II. Reviewing Records for Accuracy: In the second part of your day, you will review medical documentation to ensure all information is accurate. Your task

is to review the SOAP note in Patient Record Two to ensure all medical terms are spelled correctly, and that the interpretation of the notes are accurate,

based on the patient’s diagnosis and result of relevant vitals. Document your review of the record in the Final Project Portfolio Template.

A. Identify the medical terms that are spelled incorrectly in the note.

B. Provide the accurate spelling for the medical terms.

3

C. Identify inaccuracies of interpretation in the SOAP note, and explain why the elements you identified are inaccurate.

D. Explain how to revise the SOAP note to include the correct medical terms and an accurate documentation of the patient’s diagnosis.

III. Interpreting Patient Information: To end your day, a physician has asked you to gather information she can use to educate a patient on how to interpret

their medical record and diagnosis. She has asked you to focus specifically on the History & Physical exam section of Patient Record Three, and the list of

medical terms she has compiled from the record. This list is located in the Final Project Portfolio Template. Note that each term the physician has listed

is a constructed term. Be sure to include a recording of the pronunciation of the medical terms in your Final Project Portfolio Template, using a tool such

as Vocaroo.

A. Break the medical terms into their word parts, and define each word part.

B. Define each medical term. Note: you previously defined the word parts, but now you will define each medical term as a whole.

C. Provide the effective pronunciation of the medical terms.

D. Explain the guidelines for building medical terms, providing specific examples using the terms from the patient record.

E. Provide a summary for the patient that clearly and succinctly describes the patient’s diagnosis detailed in the medical record.

Final Project Rubric

Guidelines for Submission: Submit the completed Final Project Portfolio Template to your instructor. Be sure to include files of your recordings of the
pronunciation of medical terms, using a tool such as Vocaroo.

Critical Elements Exemplary Proficient Needs Improvement Not Evident Value

Documenting Patient
Information: Build

Terms

N/A

(100%)

Builds medical terms by using
the appropriate word parts

(100%)

Builds medical terms, but does
not use appropriate word parts
for all medical terms
(70%)

Does not build medical terms

(0%)

11.2

Documenting Patient
Information: Spelled

N/A

(100%)

Spells medical terms accurately
(100%)

Spells medical terms with some
inaccuracies
(70%)

Does not spell medical terms
accurately
(0%)

5.5

Documenting Patient
Information:

Pronunciation

N/A

(100%)

Provides the effective
pronunciation of the medical
terms

(100%)

Provides the pronunciation of
the medical terms, but with gaps
in effectiveness or accuracy
(70%)

Does not provide the effective
pronunciation of the medical terms

(0%)

5.6

4

Reviewing Records for
Accuracy: Spelled

Incorrectly

N/A

(100%)

Identifies the medical terms that
are spelled incorrectly in the
note

(100%)

Identifies medical terms that are
spelled incorrectly in the note,
but does not identify all terms,
or has gaps in accuracy

(70%)

Does not identify the medical
terms that are spelled incorrectly
in the note

(0%)

5.5

Reviewing Records for
Accuracy: Accurate

Spelling

N/A

(100%)

Spells identified terms accurately

(100%)

Spells identified terms, but with
inaccuracies

(70%)

Does not spell identified terms
accurately

(0%)

5.5

Reviewing Records for
Accuracy: Inaccuracies

of Interpretation

Meets “Proficient” criteria and
explanation shows a
sophisticated ability to interpret
medical records

(100%)

Identifies inaccuracies of
interpretation in the SOAP note,
explaining why the identified
elements are inaccurate

(100%)

Identifies inaccuracies of
interpretation in the SOAP note,
explaining why the identified
elements are inaccurate, but
response has gaps in detail,
logic, or accuracy

(70%)

Does not identify inaccuracies of
interpretation in the SOAP note

(0%)

11.1

Reviewing Records for
Accuracy: Revise Note

N/A

(100%)

Explains how to revise the SOAP
note to include the correct
medical terms and an accurate
documentation of the patient’s
diagnosis

(100%)

Explains how to revise the SOAP
note to include medical terms
and documentation of the
patient’s diagnosis, but with
gaps in accuracy

(70%)

Does not explain how to revise the
SOAP note to include the correct
medical terms and an accurate
documentation of the patient’s
diagnosis

(0%)

11.1

Interpreting Patient
Information: Word

Parts

N/A

(100%)

Breaks the medical terms into
their word parts, defining each
word part

(100%)

Breaks the medical terms into
their word parts, defining each
word part, but does not define
all terms, or has gaps in accuracy
(70%)

Does not break the medical terms
into their word parts, defining each
word part

(0%)

11.1

Interpreting Patient
Information: Define

N/A

(100%)

Defines constructed medical
terms

(100%)

Defines constructed medical
terms, but with gaps in clarity or
accuracy
(70%)

Does not define constructed
medical terms

(0%)

11.1

5

Interpreting Patient
Information:

Pronunciation

N/A

(100%)

Provides the effective
pronunciation of the medical
terms

(100%)

Provides the pronunciation of
the medical terms, but with gaps
in effectiveness or accuracy

(70%)

Does not provide the effective
pronunciation of the medical terms

(0%)

5.6

Interpreting Patient
Information:
Guidelines

Meets “Proficient” criteria and
examples provided demonstrate
a sophisticated awareness of
how to apply guidelines for
building medical terms

(100%)

Explains the guidelines for
building medical terms,
providing specific examples
using the terms from the patient
record

(100%)

Explains the guidelines for
building medical terms, but with
gaps in accuracy or support

(70%)

Does not explain the guidelines for
building medical terms

(0%)

11.1

Interpreting Patient
Information: Summary

Diagnosis

Meets “Proficient” criteria and
summary shows a sophisticated
ability to condense medical
information into consumable
terms

(100%)

Provides a summary for the
patient that clearly and
succinctly describes the patient’s
diagnosis detailed in the medical
record

(100%)

Provides a summary for the
patient that describes the
patient’s diagnosis detailed in
the medical record, but is
verbose, or has gaps in clarity or
accuracy

(70%)

Does not provide a summary for
the patient that describes the
patient’s diagnosis detailed in the
medical record

(0%)

5.6

Total 100%

1

HCM 205 Final Project Guidelines and Rubric

Overview
Medical terminology refers to medical terms that are used in the art and science of medicine. It is a specialized language that originates as far back as 460 to
377 B.C. during the era of Hippocrates (Rice, 2015). Medical language is used to describe human body components, processes, conditions, and procedures. In the
healthcare industry, medical terminology is the standardized method of communication for all healthcare professionals (Banova, 2013). In a clinical
environment, understanding medical terminology makes communication, interpretation, and documentation of patient information faster and easier. As a HIM
professional, this skill allows for increased efficiencies with organizing, reporting, and analyzing healthcare information, as well as billing for patient services. It is
therefore essential for healthcare professionals to be fluent in medical terminology to ease clinical proceedings and more efficiently and effectively facilitate
patient treatment (Banova, 2013).

For your final project, through a realistic approach, you will assume the role of a Medical Scribe for a healthcare facility to complete a Medical Scribe Portfolio. A
Medical Scribe is an individual trained in medical documentation who assists a physician throughout the workday (Medical Scribe-The Job Description, 2015).
More specifically, the primary goal of a Medical Scribe is to assist the physician in increasing efficiency and productivity, and allowing the physician to focus full
attention on the patient (Medical Scribe-The Job Description, 2015). In the final project, you will complete a series of tasks that you would likely perform daily as
a medical scribe, and document these tasks in the Final Project Portfolio Template. Your first assignment is to assist the physician in documenting notes from a
patient’s medical record. Second, you will review medical documents for accuracy in spelling, interpretation, and diagnosis. Your third and final assignment is to
review patient records and use this information to educate the patient about his/her medical records and diagnosis. Throughout your project, you will use a
recording tool, such as Vocaroo, to record your pronunciation of the medical terms. The preferred format is to utilize Vocaroo, but if you use an alternate
method, upload a separate file with the recording. These activities are designed to guide you in the application of medical terminology as it relates to the clinical
world. The final product will be submitted in Module Eight.

References
Banova, B. (2013, March 20). The Language of Healthcare: Learning Medical Terminology. Retrieved from American Institute of Medical Sciences & Education:

https://www.aimseducation.edu/blog/the-language-of-healthcare-learning-medical-terminology/
Medical Scribe-The Job Description. (2015). Retrieved from American Healthcare Documentation Professionals Group:

https://www.ahdpg.com/medical-scribe-the-job-description/
Rice, J. (2015). Medical Terminology for Health Care Professionals. Upper Saddle River, NJ: Pearson.

In this assignment, you will demonstrate your mastery of the following course outcomes:

2

● HCM-205-01: Apply medical terminology to body systems and medical specialties for documenting patient information [BS.HIT.CORE.01]

● HCM-205-02: Interpret medical records and reports for translating key patient information [BS.HIT.CORE.01]

● HCM-205-03: Communicate medical terminology by using accurate spelling and effective pronunciation [BS.HIT.CORE.01]

Prompt
For your final project, you will assume the role of a medical scribe in a healthcare organization. You will complete a series of tasks that a medical scribe would
complete in the field on a daily basis, and document these tasks in the Final Project Portfolio Template. You will submit your completed template to your
instructor. To begin, you will assist a physician in documenting notes from a patient record by building medical terms, ensuring the terms are spelled correctly.
You will also provide a recording of the pronunciation of the terms. Second, you will review medical documentation in a patient record to ensure accuracy. You
will identify inaccuracies of spelling and interpretation, and provide the accurate spelling and revised SOAP note. For your third task, you will gather information
to be used by the physician to educate a patient on their diagnosis. You will interpret the medical record to identify key terms, and then break down, define, and
pronounce these terms. Note that these terms will all be constructed terms. To complete your task, you will provide a final summary of the diagnosis.

For support on using Vocaroo, refer to the Vocaroo Tutorial.

Specifically, the following critical elements must be addressed:

I. Documenting Patient Information: To begin your day, a physician has asked you to assist in documenting his notes from Patient Record One. The

physician has bolded the words or phrases that need interpreting in the Progress Notes. Based on these notes, build the medical terms that are

described, and add these to the Final Project Portfolio Template, making sure that each term is spelled correctly. Then, using a recording tool, such as

Vocaroo, record the medical terms. Add your recording to the Final Project Portfolio Template.

A. Build medical terms by using the appropriate word parts.

B. Be sure that the medical terms are spelled accurately.

C. Provide the effective pronunciation of the medical terms.

II. Reviewing Records for Accuracy: In the second part of your day, you will review medical documentation to ensure all information is accurate. Your task

is to review the SOAP note in Patient Record Two to ensure all medical terms are spelled correctly, and that the interpretation of the notes are accurate,

based on the patient’s diagnosis and result of relevant vitals. Document your review of the record in the Final Project Portfolio Template.

A. Identify the medical terms that are spelled incorrectly in the note.

B. Provide the accurate spelling for the medical terms.

3

C. Identify inaccuracies of interpretation in the SOAP note, and explain why the elements you identified are inaccurate.

D. Explain how to revise the SOAP note to include the correct medical terms and an accurate documentation of the patient’s diagnosis.

III. Interpreting Patient Information: To end your day, a physician has asked you to gather information she can use to educate a patient on how to interpret

their medical record and diagnosis. She has asked you to focus specifically on the History & Physical exam section of Patient Record Three, and the list of

medical terms she has compiled from the record. This list is located in the Final Project Portfolio Template. Note that each term the physician has listed

is a constructed term. Be sure to include a recording of the pronunciation of the medical terms in your Final Project Portfolio Template, using a tool such

as Vocaroo.

A. Break the medical terms into their word parts, and define each word part.

B. Define each medical term. Note: you previously defined the word parts, but now you will define each medical term as a whole.

C. Provide the effective pronunciation of the medical terms.

D. Explain the guidelines for building medical terms, providing specific examples using the terms from the patient record.

E. Provide a summary for the patient that clearly and succinctly describes the patient’s diagnosis detailed in the medical record.

Final Project Rubric

Guidelines for Submission: Submit the completed Final Project Portfolio Template to your instructor. Be sure to include files of your recordings of the
pronunciation of medical terms, using a tool such as Vocaroo.

Critical Elements Exemplary Proficient Needs Improvement Not Evident Value

Documenting Patient
Information: Build

Terms

N/A

(100%)

Builds medical terms by using
the appropriate word parts

(100%)

Builds medical terms, but does
not use appropriate word parts
for all medical terms
(70%)

Does not build medical terms

(0%)

11.2

Documenting Patient
Information: Spelled

N/A

(100%)

Spells medical terms accurately
(100%)

Spells medical terms with some
inaccuracies
(70%)

Does not spell medical terms
accurately
(0%)

5.5

Documenting Patient
Information:

Pronunciation

N/A

(100%)

Provides the effective
pronunciation of the medical
terms

(100%)

Provides the pronunciation of
the medical terms, but with gaps
in effectiveness or accuracy
(70%)

Does not provide the effective
pronunciation of the medical terms

(0%)

5.6

4

Reviewing Records for
Accuracy: Spelled

Incorrectly

N/A

(100%)

Identifies the medical terms that
are spelled incorrectly in the
note

(100%)

Identifies medical terms that are
spelled incorrectly in the note,
but does not identify all terms,
or has gaps in accuracy

(70%)

Does not identify the medical
terms that are spelled incorrectly
in the note

(0%)

5.5

Reviewing Records for
Accuracy: Accurate

Spelling

N/A

(100%)

Spells identified terms accurately

(100%)

Spells identified terms, but with
inaccuracies

(70%)

Does not spell identified terms
accurately

(0%)

5.5

Reviewing Records for
Accuracy: Inaccuracies

of Interpretation

Meets “Proficient” criteria and
explanation shows a
sophisticated ability to interpret
medical records

(100%)

Identifies inaccuracies of
interpretation in the SOAP note,
explaining why the identified
elements are inaccurate

(100%)

Identifies inaccuracies of
interpretation in the SOAP note,
explaining why the identified
elements are inaccurate, but
response has gaps in detail,
logic, or accuracy

(70%)

Does not identify inaccuracies of
interpretation in the SOAP note

(0%)

11.1

Reviewing Records for
Accuracy: Revise Note

N/A

(100%)

Explains how to revise the SOAP
note to include the correct
medical terms and an accurate
documentation of the patient’s
diagnosis

(100%)

Explains how to revise the SOAP
note to include medical terms
and documentation of the
patient’s diagnosis, but with
gaps in accuracy

(70%)

Does not explain how to revise the
SOAP note to include the correct
medical terms and an accurate
documentation of the patient’s
diagnosis

(0%)

11.1

Interpreting Patient
Information: Word

Parts

N/A

(100%)

Breaks the medical terms into
their word parts, defining each
word part

(100%)

Breaks the medical terms into
their word parts, defining each
word part, but does not define
all terms, or has gaps in accuracy
(70%)

Does not break the medical terms
into their word parts, defining each
word part

(0%)

11.1

Interpreting Patient
Information: Define

N/A

(100%)

Defines constructed medical
terms

(100%)

Defines constructed medical
terms, but with gaps in clarity or
accuracy
(70%)

Does not define constructed
medical terms

(0%)

11.1

5

Interpreting Patient
Information:

Pronunciation

N/A

(100%)

Provides the effective
pronunciation of the medical
terms

(100%)

Provides the pronunciation of
the medical terms, but with gaps
in effectiveness or accuracy

(70%)

Does not provide the effective
pronunciation of the medical terms

(0%)

5.6

Interpreting Patient
Information:
Guidelines

Meets “Proficient” criteria and
examples provided demonstrate
a sophisticated awareness of
how to apply guidelines for
building medical terms

(100%)

Explains the guidelines for
building medical terms,
providing specific examples
using the terms from the patient
record

(100%)

Explains the guidelines for
building medical terms, but with
gaps in accuracy or support

(70%)

Does not explain the guidelines for
building medical terms

(0%)

11.1

Interpreting Patient
Information: Summary

Diagnosis

Meets “Proficient” criteria and
summary shows a sophisticated
ability to condense medical
information into consumable
terms

(100%)

Provides a summary for the
patient that clearly and
succinctly describes the patient’s
diagnosis detailed in the medical
record

(100%)

Provides a summary for the
patient that describes the
patient’s diagnosis detailed in
the medical record, but is
verbose, or has gaps in clarity or
accuracy

(70%)

Does not provide a summary for
the patient that describes the
patient’s diagnosis detailed in the
medical record

(0%)

5.6

Total 100%

Permission to reuse granted by Alfred State College and Michelle A. Green

Global Care Medical Center
100 Main St, Alfred NY 14802
(607) 555-1234
Hospital No. 999

INPATIENT FACE SHEET

Patient Name and Address Gender Race Marital Status Patient No.

LONG, BETH
4983 REED STREET
ALMOND, NY 14804

F W M IPCase001
Date of Birth Age Maiden

Name
Occupation

12/17/YYYY 30 Short Clerk

Admission Date Time Discharge Date Time Length of Stay Telephone Number

04/26/YYYY 1350 04/30/YYYY 1150 04 DAYS (607)555-3319
Guarantor Name and Address Next Of Kin Name and Address

LONG, BERNIE
4983 REED STREET
ALMOND, NY 14804

LONG, BERNIE
4983 REED STREET
ALMOND, NY 14804

Guarantor Telephone No. Relationship to Patient Next of Kin Telephone Number Relationship to Patient

(607)555-3319 Husband (607)555-3319 Husband
Admitting Physician Service Admit Type Room Number/Bed

John Black, MD 369
Attending Physician Admitting Diagnosis

John Black, MD Fever of undetermined origin
Primary Insurer Policy and Group Number Secondary Insurer Policy and Group Number

Diagnoses and Procedures ICD Code

Principal Diagnosis

Acute Pyelonephritis

Secondary Diagnoses

Dehydration

Principal Procedure

Secondary Procedures

Discharge Instructions
Activity:  Bed rest  Light  Usual  Unlimited  Other:
Diet:  Regular  Low Cholesterol  Low Salt  ADA  _____ Calorie

Follow-Up:  Call for appointment  Office appointment on  Other: To be seen for a follow up in
office in one week

Special Instructions: None
Attending Physician Authentication: Reviewed and Approved: John Black MD

ATP-B-S:02:1001261385: John Black MD
(Signed: 4/30/YYYY 2:20:44 PM EST)

Permission to reuse granted by Alfred State College and Michelle A. Green

LONG, BETH

IPCase001

Dr. BLACK

Admission:04/26/YYYY

DOB: 12/17/YYYY

ROOM: 369

CONSENT TO ADMISSION

I, Beth Long hereby consent to admission to the Global Care Medical Center (ASMC) , and I further consent to such
routine hospital care, diagnostic procedures, and medical treatment that the medical and professional staff of ASMC may
deem necessary or advisable. I authorize the use of medical information obtained about me as specified above and the
disclosure of such information to my referring physician(s). This form has been fully explained to me, and I understand its
contents. I further understand that no guarantees have been made to me as to the results of treatments or examinations done
at the ASMC.

Reviewed and Approved: Beth Long
ATP-B-S:02:1001261385: Beth Long
(Signed: 4/26/YYYY 2:12:05 PM EST)

Signature of Patient

Signature of Parent/Legal Guardian for Minor

Relationship to Minor
Reviewed and Approved: Andrea Witteman
ATP-B-S:02:1001261385: Andrea Witteman
(Signed: 4/26/YYYY 2:12:05 PM EST

WITNESS: Global Care Medical Center Staff Member

CONSENT TO RELEASE INFORMATION FOR REIMBURSEMENT PURPOSES
In order to permit reimbursement, upon request, the Global Care Medical Center (ASMC) may disclose such treatment
information pertaining to my hospitalization to any corporation, organization, or agent thereof, which is, or may be liable
under contract to the ASMC or to me, or to any of my family members or other person, for payment of all or part of the
ASMC’s charges for services rendered to me (e.g. the patient’s health insurance carrier). I understand that the purpose of any
release of information is to facilitate reimbursement for services rendered. In addition, in the event that my health insurance
program includes utilization review of services provided during this admission, I authorize ASMC to release information as is
necessary to permit the review. This authorization will expire once the reimbursement for services rendered is complete.

Reviewed and Approved: Beth Long
ATP-B-S:02:1001261385: Beth Long
(Signed: 4/26/YYYY 2:14:17 PM EST)

Signature of Patient

Signature of Parent/Legal Guardian for Minor

Relationship to Minor
Reviewed and Approved: Andrea Witteman
ATP-B-S:02:1001261385: Andrea Witteman
(Signed: 4/26/YYYY 2:16:24 PM EST

WITNESS: Global Care Medical Center Staff Member

Permission to reuse granted by Alfred State College and Michelle A. Green

GLOBAL CARE MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234

LONG, BETH

IPCase001

Dr. BLACK

Admission: 04/26/YYYY

DOB: 12/17/YYYY

ROOM: 369

ADVANCE DIRECTIVE

Your answers to the following questions will assist your Physician and the Hospital to respect your wishes regarding your
medical care. This information will become a part of your medical record.

YES NO PATIENT’S INITIALS

1. Have you been provided with a copy of the information called
“Patient Rights Regarding Health Care Decision?”

X

2. Have you prepared a “Living Will?” If yes, please provide the
Hospital with a copy for your medical record.

X

3. Have you prepared a Durable Power of Attorney for Health
Care? If yes, please provide the Hospital with a copy for your
medical record.

X

4. Have you provided this facility with an Advance Directive on a
prior admission and is it still in effect? If yes, Admitting Office
to contact Medical Records to obtain a copy for the medical
record.

X

5. Do you desire to execute a Living Will/Durable Power of
Attorney? If yes, refer to in order:
a. Physician
b. Social Service
c. Volunteer Service

X

HOSPITAL STAFF DIRECTIONS: Check when each step is completed.

1.  Verify the above questions where answered and actions taken where required.

2.  If the “Patient Rights” information was provided to someone other than the patient, state reason:

Name of Individual Receiving Information Relationship to Patient

3.  If information was provided in a language other than English, specify language and method.

4.  Verify patient was advised on how to obtain additional information on Advance Directives.

5.  Verify the Patient/Family Member/Legal Representative was asked to provide the Hospital with a copy of the
Advanced Directive which will be retained in the medical record.

File this form in the medical record, and give a copy to the patient.

Name of Patient Name of Individual giving information if different from Patient
Reviewed and Approved: Beth Long

ATP-B-S:02:1001261385: Beth Long
(Signed: 4/26/YYYY 2:35:05 PM EST)

Signature of Patient Date

Reviewed and Approved: Andrea Witteman
ATP-B-S:02:1001261385: Andrea Witteman
(Signed: 4/26/YYYY 2:35:47 PM EST

Permission to reuse granted by Alfred State College and Michelle A. Green

Signature of Hospital Representative Date

GLOBAL CARE MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234
LONG, BETH

IPCase001

Dr. BLACK

Admission: 04/26/YYYY

DOB: 12/17/YYYY

ROOM: 369

DISCHARGE SUMMARY

ADMISSION DATE: 04/26/YYYY DISCHARGE DATE: 04/30/YYYY

ADMISSION DIAGNOSIS: Fever of undetermined origin.

DISCHARGE DIAGNOSIS: Acute pyelonephritis.

SUMMARY: This 30 year old white female had high fever off and on for
several days prior to admission without any localizing signs or symptoms.
Preliminary studies done as an outpatient were unremarkable except to
indicate an infection some place. She was ultimately seen in the office,
temperature was 103 to 104. She was becoming dehydrated, washed out, weak,
tired, and she was admitted for further workup and evaluation.

Workup included a chest x-ray, which was normal. Intravenous pyelogram was
also normal. Blood culture report was normal. Urine culture grew out
Escherichia coli greater than 100,000 colonies. Throat culture was normal.
One blood culture did finally grow out an alpha strep viridans.

I talked to Dr. Burke about this and we decided on the basis of her
clinical condition and the fact that this did not grow on all bottles it
was more likely a contaminate. Urine showed a specific gravity of 1.010,
albumin 1+, sugar and acetone were negative, white blood cells 6 to 8, and
red blood cells 1 to 2. White count 13,100, Hemoglobin 12, hematocrit 35.1,
segmental cells 81, lymphocytes 11, monocytes 5, eosinophils 1, bands 2.
Mononucleosis test was negative. Alkaline phosphatase 127, blood sugar 125,
sodium 142, potassium 4.7, carbon dioxide 30, chloride 104, cholesterol
119, Serum glutamic oxaloacetic transaminase 41, lactate dehydrogenase 151,
creatinine 0.9, calcium 9.8, phosphorus 3.3, bilirubin 0.6, total protein
6.8, albumin 4.0, uric acid 6.5. Electrocardiogram was reported as normal.

She was started on intravenous fluids, intravenous Keflex, her temperature
remained elevated for approximately 48 hours and now has been normal for
the last 48 to 72 hours. She feels better, hydration is better, eating
better, no urinary symptoms. She’s being discharged at this time on Keflex
500 four times per day, increased fluid intake. To be seen in follow up in
the office in 1 week.

DD: 04/30/YYYY Reviewed and Approved: John Black MD

ATP-B-S:02:1001261385: John Black MD
(Signed: 5/1/YYYY 2:24:44 PM EST)

DT: 05/01/YYYY Physician Authentication

Permission to reuse granted by Alfred State College and Michelle A. Green

GLOBAL CARE MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234

Permission to reuse granted by Alfred State College and Michelle A. Green

LONG, BETH

IPCase001

Dr. BLACK

Admission: 04/26/YYYY

DOB: 12/17/YYYY

ROOM: 369

HISTORY & PHYSICAL EXAM

ADMISSION DIAGNOSIS: Fever undetermined etiology, pyelonephritis, dehydration, and
possible urinary tract infection.

CHIEF COMPLAINT: Chills and fever, and just feels lousy for the last 5 days.

HISTORY OF PRESENT ILLNESS: The patient began to run a temperature on Sunday, had no other
complaints whatsoever. She has not felt like eating for the past 5 days and only taking in
fluids and Aspirin. She was seen in the office on 4/24 with 98 degree temperature but she
had just taken Aspirin. At that time physical exam was negative but she had an 18,300
white count. The white count was repeated the next day and found to be 13,400 with
temperature elevated at 102-103 unless she was taking Aspirin. She was seen in the office
again today, continues to feel lousy and now she has some pain in the left upper flank
area posteriorly, she is being admitted to the hospital for a workup with a temperature of
103.

FAMILY HISTORY: Negative for cancer, tuberculosis, diabetes, she has a brother with mild
epilepsy.

PAST HISTORY: She has only been admitted for delivery of her 2 children, otherwise she has
always been in excellent health without any problems. She smokes 15-20 cigarettes a day
and has done so for the last 15 years. She doesn’t drink. She uses no other drugs.

SOCIAL HISTORY: She lives at home with her husband and 2 children. There are no apparent
problems.

REVIEW OF SYSTEMS: Normal except for the history of the present problem.

GENERAL: Shows a cooperative young lady. She shows no pain. She is 30 years old. WEIGHT:
113 lb. TEMPERATURE: 103 oral PULSE: 102 RESPIRATIONS: 18

SKIN: Pink, warm, dry, no evidence of rash or jaundice.

HEENT: Head symmetrical. No masses or abnormalities. Eyes react to light and
accommodation. Extraocular movements are normal. Sclera is clear. Ears, tympanic membranes
are not injected. Mouth and throat are negative. NECK: Supple. No lymph notes felt. No
thyromegaly.

CHEST: Clear to percussion and auscultation. HEART: Normal sinus rhythm. Not enlarged.

ABDOMEN: Soft. She is tender under the left costal margin with no enlargement of any
organs. She has pain to percussion in left upper flank area.

PELVIC & RECTAL: Deferred.

EXTREMITIES: Normal. Peripheral pulses are normal.

DD: 04/26/YYYY Reviewed and Approved: John Black MD

ATP-B-S:02:1001261385: John Black MD
(Signed: 4/26/YYYY 2:24:44 PM EST)

DT: 04/26/YYYY Physician Authentication

GLOBAL CARE MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234

Permission to reuse granted by Alfred State College and Michelle A. Green

LONG, BETH

IPCase001

Dr. BLACK

Admission: 04/26/YYYY

DOB: 12/17/YYYY

ROOM: 369

PROGRESS NOTES

Date Time Physician’s signature required for each order. (Please skip one line between dates.)

04/27/YYYY 1450 Chief complaint: left flank pain; fever.

Diagnosis: (1)Inflammation of the kidney and renal
pelvis; (2)the loss or deprivation of water from the
body; rule out (3)kidney stones

Plan of Treatment: Admit. Hydration with intravenous
Ancef.
Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 4/27/YYYY 2:50:55 PM EST)

04/28/YYYY 1110 Bacteria in the (4)blood culture. Alpha strep, not
viridans, clinically.

Improving. Has (5)genital and urinary infection; urinary
tract infection.
Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 4/28/YYYY 11:14:07 AM EST)

04/29/YYYY 1140 Patient feels better; still complains of left flank and

back pain.

SUBJECTIVE: Patient without (6)fever vital signs.

OBJECTIVE: HEAD/EYES/EARS/NOSE/THROAT: (7)Eardrum of left
ear somewhat dull yellowish.

Throat: slight redness of the (8)skin.

Heart: regular rate and rhythm, without murmur.

Back: positive left costovertebral angle tenderness.

Abdomen: mild left upper quadrant.

ASSESSMENT/PLAN: 1) Probable left pyelonephritis. Rule
out stone. 2) Positive streptococcal bacteremia. Possibly
secondary to pyelonephritis. Possible other source?
(9)Localized collection of pus which could occur in any
part of the body – doubt.

(10)X-ray record of kidney, renal pelvis, ureters, and
bladder is okay.

Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 4/29/YYYY 11:40:32 AM EST)

Permission to reuse granted by Alfred State College and Michelle A. Green

GLOBAL MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234

LONG, BETH

IPCase001

Dr. BLACK

Admission: 04/26/YYYY

DOB: 12/17/YYYY

ROOM: 369

DOCTORS ORDERS

Date Time Physician’s signature required for each order. (Please skip one line between
dates.)

04/26/YYYY 1400 Complete blood count and mononucleosis test. Urinalysis.
Urine for culture and sensitivity. Throat culture.
Blood culture every one-half hour times two until next
temperature increases to 101 degrees. Chest x-ray done as
outpatient. Electrocardiogram. SCG #2. Electrolytes.
Full liquids as tolerated. Intravenous fluids, 50-100
cubic centimeters per hour. Tylenol 2 tabs every 4 to 6
hours as needed for elevated temperature. Ancef 500
milligrams intravenous every 6 hours (after cultures are
obtained. History and physical examination report
dictated.
Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 4/26/YYYY 2:04:00 PM EST)

Permission to reuse granted by Alfred State College and Michelle A. Green

04/27/YYYY 1110 Please schedule for intravenous pyelogram, Monday morning.
Soft diet as tolerated. Strain urine.
Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 4/27/YYYY 11:24:52 AM EST)

04/29/YYYY 1515 Discontinue intravenous fluids in morning. Discontinue

Ancef in morning. Start on Keflex, 500 milligrams four
times per day in morning on April 30.
Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 4/29/YYYY 3:24:00 PM EST)

04/30/YYYY 1315 Discharge to home.

Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 4/30/YYYY 1:16:32 PM EST)

GLOBAL CARE MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234

LONG, BETH

IPCase001
DR. BLACK

Admission: 04/26/YYYY

DOB: 12/17/YYYY
ROOM: 369

LABORATORY DATA

SPECIMEN COLLECTED: 04/26/YYYY SPECIMEN RECEIVED: 04/26/YYYY

TEST RESULT FLAG REFERENCE

URINALYSIS

DIPSTICK ONLY

COLOR YELLOW

SPECIFIC GRAVITY 1.010 ≤ 1.030

GLUCOSE NEGATIVE ≤ 125 mg/dl

BILIRUBIN NEGATIVE ≤ 0.8 mg/dl

KETONE TRACE ≤ 10 mg/dl

BLOOD TRACE 0.06 mg/dl hgb

Permission to reuse granted by Alfred State College and Michelle A. Green

PH 6.5 5-8.0

PROTEIN NORMAL ≤ 30 mg/dl

UROBILINOGEN NORMAL ≤ -1 mg/dl

NITRITES NEGATIVE NEG

LEUKOCYTE NEGATIVE ≤ 15 WBC/hpf

WHITE BLOOD CELLS 6-8/hpf **H** ≤ 5/hpf

RED BLOOD CELLS 1-2/hpf ≤ 5/hpf

BACTERIA MANY **H** 1+(≤ 20/hpf)

URINE PREGNANCY TEST Negative

≤ = less than or equal to

≥ = greater than or equal to

mg/dl = milligrams per deciliter

hgb = hemoglobin

/hpf = per high power field

***End of Report***

GLOBAL MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234

LONG, BETH

IPCase001

Dr. BLACK

Admission: 04/26/YYYY

DOB: 12/17/YYYY

ROOM: 369
LABORATORY DATA

Permission to reuse granted by Alfred State College and Michelle A. Green

SPECIMEN COLLECTED: 04/26/YYYY 1450 SPECIMEN RECEIVED: 04/29/YYYY 1814

TEST RESULT

BACTERIOLOGY OTHER ROUTINE CULTURES

SOURCE: Blood Cultures

SMEAR ONLY:

CULTURE

1st PRELIMINARY No bacteria seen at 24 hours.

2nd PRELIMINARY

FINAL REPORT Strep viridans

SENSITIVITIES 1. S AMIKACIN NITROFURANTOIN

R = Resistant AMPICILLIN 1. R PENICILLIN G

S = Sensitive CARBENICILLIN POLYMYXIN B

CEFAMANDOLE SULFISOXAZOLE

CEFOXITIN 1. S TETRACYCLINE

1. R CEPHALOTHIN TRIMETHOPRIM

1. S CHLORAMPHENICOL 1. S VANCOMYCIN

1. S CLINDAMYCIN

1. S ERYTHROMYCIN

1. S GENTAMICIN

KANAMYCIN

1. S METHICILLIN

NALIDIXIC ACID

GLOBAL CARE MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234

Permission to reuse granted by Alfred State College and Michelle A. Green

LONG, BETH

IPCase001

Dr. BLACK

Admission: 04/26/YYYY

DOB: 12/17/YYYY

ROOM: 369
LABORATORY DATA

SPECIMEN COLLECTED: 04/26/YYYY 1504 SPECIMEN RECEIVED: 04/29/YYYY 1814

TEST RESULT

BACTERIOLOGY OTHER ROUTINE CULTURES

SOURCE: Blood culture

SMEAR ONLY:

CULTURE

1st PRELIMINARY No bacteria seen at 24 hours

2nd PRELIMINARY No growth seen on 24 hour subculture

FINAL REPORT

***End of Report***

GLOBAL CARE MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234

LONG, BETH

IPCase001

Dr. BLACK

Admission: 04/26/YYYY

DOB: 12/17/YYYY

ROOM: 369
LABORATORY DATA

Permission to reuse granted by Alfred State College and Michelle A. Green

SPECIMEN COLLECTED: 04/26/YYYY 1450 SPECIMEN RECEIVED: 04/26/YYYY 1746

BLOOD CHEMISTRY

TEST REFERENCE RESULT
ACID PHOSPHATASE 0.0-0.8 U/I

ALKALINE PHOSPHATASE 50-136 U/I 127

AMYLASE 23-85 U/I

LIPASE 4-24 U/I

GLUCOSE FASTING 70-110 mg/dl

GLUCOSE Time collected 125

BUN 7-22 mg/dl

SODIUM 136-147 mEq/1 142

POTASSIUM 3.7-5.1 mEq/l 4.7

CARBON DIOXIDE 24-32 mEq/l 30

CHLORIDE 98-108 mEq/l 104

CHOLESTEROL 120-280 mg/dl 119

SERUM GLUTAMATE PYRUVATE
TRANSAMINASE

3-36 U/I

SERUM GLUTAMIC
OXALOCETIC TRANSAMINASE

M-27-47 U/I F-22-37 U/I 41

CREATININE KINASE M-35-232 U/I F-21-215 U/I

LACTATE DEHYDROGENASE 100-190 U/I 151

CREATININE M-0.8-1.3 mg/dl F-0.6-1.0 mg/dl 0.9

CALCIUM 8.7-10.2 mg/dl 9.8

PHOSPHORUS 2.5-4.9 mg/dl 3.3

BILIRUBIN-DIRECT 0.0-0.4 mg/dl

BILIRUBIN-TOTAL Less than 1.5 mg/dl 0.6

TOTAL PROTEIN 6.4-8.2 g/dl 6.8

ALBUMIN 3.4-5.0 g/dl 4.0

URIC ACID M-3.8-7.1 mg/dl F-2.6-5.6 mg/dl 6.5

TRIGLYCERIDE 30-200 mg/dl

U/I = International Units
g/dl = grams per deciliter
mEq = millequivalent per deciliter
mg/dl = milligrams per deciliter

GLOBAL CARE MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234

LONG, BETH

IPCase001

Dr. BLACK

Admission: 04/26/YYYY

DOB: 12/17/YYYY

ROOM: 369
LABORATORY DATA

Permission to reuse granted by Alfred State College and Michelle A. Green

SPECIMEN COLLECTED: 04/26/YYYY 1505 SPECIMEN RECEIVED: 04/28/YYYY 1957

TEST RESULT

BACTERIOLOGY OTHER ROUTINE CULTURES

SOURCE: Urine

SMEAR ONLY: 1+ white blood cells, 4+ gram negative rods

CULTURE

1st PRELIMINARY 1. CC = >100,000 Escherichia coli

2nd PRELIMINARY

FINAL REPORT 1. CC = >100,000 Escherichia coli

SENSITIVITIES 1. S AMIKACIN 1. S NITROFURANTOIN

R = Resistant 1. R AMPICILLIN PENICILLIN G

S = Sensitive 1. R CARBENICILLIN POLYMYXIN B

› = greater than 1. S CEFAMANDOLE 1. R SULFISOXAZOLE

1. S CEFOXITIN 1. R TETRACYCLINE

1. S CEPHALOTHIN 1. S TRIMETHOPRIM

1. R CHLORAMPHENICOL VANCOMYCIN

CLINDAMYCIN

ERYTHROMYCIN

1. S GENTAMICIN

KANAMYCIN

METHICILLIN

NALIDIXIC ACID

GLOBAL CARE MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234

LONG, BETH

IPCase001

Dr. BLACK

Admission: 04/26/YYYY

DOB: 12/17/YYYY

ROOM: 369

LABORATORY DATA

Permission to reuse granted by Alfred State College and Michelle A. Green

TIME IN: 04/26/YYYY 1450 TIME OUT: 04/26/YYYY 1746

COMPLETE BLOOD COUNTS DIFFERENTIAL

TEST RESULT FLAG REFERENCE

WHITE BLOOD CELL 13.1 4.5-11.0 thou/ul

RED BLOOD CELL 3.99 5.2-5.4 milliliter/ upper
limit

HEMOGLOBIN 12.0 11.7-16.1 grams per
deciliter

HEMATOCRIT 35.1 35.0-47.0 %
MEAN CORPUSCULAR VOLUME 87.9 85-99 factor level
MEAN CORPUSCULAR HEMOGLOBIN 30.2
MEAN CORPUSCULAR HEMOGLOBIN
CONCENTRATION

34.3 33-37

RED CELL DISTRIBUTION WIDTH 11.4-14.5
PLATELETS 355 130-400 thou/ul

SEGMENTED CELLS % 81
LYMPHOCYTES % 11 20.5-51.1
MONOCYTES % 5 1.7-9.3
EOSINOPHILS % 1

BAND CELLS % 2

Thou/ul= thousand upper limit

***End of Report***

GLOBAL CARE MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234

Permission to reuse granted by Alfred State College and Michelle A. Green

LONG, BETH

IPCase001

Dr. BLACK

Admission: 04/26/YYYY

DOB: 12/17/YYYY

ROOM: 369

RADIOLOGY REPORT

Date of X-ray: 04/29/YYYY

REASON: Fever of unknown origin.

TECHNICAL DATA: No known allergies. 100 milliliter infusion through
intravenous – no reaction noted.

INTRAVENOUS PYELOGRAM: A plain film taken prior to the intravenous
pyelogram shows no shadows of urological significance.

Following the intravenous injection of contrast material, serial films
including anterior-posterior and oblique views show that both kidneys are
normal in size and configuration. The right kidney is slightly ptotic and
there is some buckling of the right proximal ureter. However, I do not
think that this finding is clinically significant. The visualized course
of the distal ureters are both normal. The bladder is well visualized on a
delayed film and is within normal limits. There is a small amount of
urinary residual on the post voiding film.

CONCLUSION: Essentially normal intravenous pyelogram.

DD: 04/29/YYYY Reviewed and Approved: Randall Cunningham MD
ATP-B-S:02:1001261385: Randall Cunningham MD
(Signed:4/29/YYYY 2:24:44 PM EST)

DT: 04/29/YYYY

GLOBAL CARE MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234

Permission to reuse granted by Alfred State College and Michelle A. Green

LONG, BETH

IPCase001

Dr. BLACK

Admission: 04/26/YYYY

DOB: 12/17/YYYY

ROOM: 369

EKG REPORT

Date of Electrocardiogram: 04/26/YYYY Time of Electrocardiogram: 1600

Rate 90

Sinus rhythm normal. PR

.12

QRSD .68

QT .32

QTC

— Axis —

P

QRS

T

Reviewed and Approved: Dr. Steven J. Chambers,
M.D.
ATP-B-S:02:1001261385: Dr. Steven J. Chambers,
M.D. (Signed:4/29/YYYY 2:24:44 PM EST)

GLOBAL CARE MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234

Permission to reuse granted by Alfred State College and Michelle A. Green

LONG, BETH

IPCase001

Dr. BLACK

Admission: 04/26/YYYY

DOB: 12/17/YYYY

ROOM: 369

GRAPHIC CHART

DAY IN HOSPITAL 1 2 3 4
DATE 04/26/YYYY 04/27/YYYY 04/28/YYYY 04/29/YYYY

PULSE
(•)

TEMP
(X) 0400 0800 1200 1600 2000 2400 0400 0800 1200 1600 2000 2400 0400 0800 1200 1600 2000 2400 0400 0800 1200 1600 2000 2400

140 106

130 105

120 104

110 103

100 102 X X

90 101 • • X • • X • • •
80 100 X • • • • • X X • • • • •
70 99 X X X • • X
60 98.6 • X X X X X X X X

50 98 X

40 97

30 96

20 95

RESPIRATION 20 20 16 20 20 18 16 20 20 20 20 18 16 16 20 18 16 20 18 18

BLOOD PRESSURE
0800

1600

110/65
0800

110/70
1600

112/68
0800

100/70
1600

110/70
0800

108/68
1600

1200
102/60

2000
90/60

1200
90/65

2000
110/69

1200
110/70

2000
105/68

1200
95/72

2000

WEIGHT 5’8” 141#

DIET Full liquid Full liquid Soft Soft

APPETITE 50% 50% 100% 100% 30% 90% 75% 100% 100% 100% 80%

BATH Self Self Self Self

INTAKE/OUTPUT 7-3 3-11 11-7 7-3 3-11 11-7 7-3 3-11 11-7 7-3 3-11 11-7

IN
TA

K
E

ORAL FLUIDS 600 100 650 1350 200 600 1170 100 850 440

IV FLUIDS 500 600 600 850 550 650 650 1050 700 600

BLOOD

8-HOUR TOTAL 1100 700 1250 2200 750 1250 1820 1150 1550 1040

24-HOUR TOTAL 1800 4200 4220 2590

O
U

TP
U

T

URINE 800 600 1100 750 650 700 1175 700 1000 900

STOOL 2 loose

EMESIS

NASOGASTRIC

8-HOUR TOTAL 800 600 1100 750 650 700 1175 700 1000 900

24-HOUR TOTAL 1400 2500 2575 1900

GLOBAL MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234

Permission to reuse granted by Alfred State College and Michelle A. Green

LONG, BETH

IPCase001

Dr. BLACK

Admission: 04/26/YYYY

DOB: 12/17/YYYY

ROOM: 369

GRAPHIC CHART

DAY IN HOSPITAL 5
DATE 04/30/YYYY

PULSE
(•)

TEMP
(X) 0400 0800 1200 1600 2000 2400 0400 0800 1200 1600 2000 2400 0400 0800 1200 1600 2000 2400 0400 0800 1200 1600 2000

2400

140 106

130 105

120 104

110 103

100 102

90 101
80 100 X
70 99
60 98.6 •

50 98

40 97

30 96

20 95

RESPIRATION 20

BLOOD
PRESSURE

0800

1600

1200
102/60

2000

WEIGHT 5’8” 141#

DIET Full liquid

APPETITE 50%

BATH Self

INTAKE/OUTPUT 7-3

IN
TA

K
E

ORAL FLUIDS

IV FLUIDS

BLOOD

8 HOUR TOTAL

24 HOUR TOTAL

O
U

TP
U

T

URINE

STOOL

EMESIS

N-G

8 HOUR TOTAL

24 HOUR TOTAL

GLOBAL MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234

Permission to reuse granted by Alfred State College and Michelle A. Green

Permission to reuse granted by Alfred State College and Michelle A. Green

LONG, BETH

IPCase001

Dr. BLACK

Admission: 04/26/YYYY

DOB: 12/17/YYYY

ROOM: 369

MEDICATION ADMINISTRATION RECORD

SPECIAL INSTRUCTIONS:

MEDICATION (dose and route)
DATE: 04/26 DATE: 04/27 DATE: 04/28 DATE: 04/29

TIME INITIALS TIME INITIALS TIME INITIALS TIME INITIALS

Ancef 500 mg IV q6° 0600 — 0600 — 0600 JD 0600 JD

(started before 1200 — 1200 VS 1200 JD 1200 HF

cultures obtained) 1800 OR 1800 HF 1800 OR 1800 OR
2400 JD 2400 OR 2400 OR 2400 OR

mg = milligrams
IV = intravenous

PRN Medications:

Tylenol 2 tabs by mouth 1930 OR 0435 JD 0520 JD 0600 JD

daily 4 to 6 hours as 1100 VS 1230 HF
needed for increased 1830 HF
temperature

PRN = as needed

INITIALS SIGNATURE AND TITLE INITIALS SIGNATURE AND TITLE INITIALS SIGNATURE AND TITLE
VT Vera South, RN GPW G. P. Well, RN
OR Ora Richards, RN PS P. Small, RN
JD Jane Dobbs, RN
HF H. Figgs RN

GLOBAL CARE MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234

Permission to reuse granted by Alfred State College and Michelle A. Green

LONG, BETH

IPCase001

Dr. BLACK

Admission: 04/26/YYYY

DOB: 12/17/YYYY

ROOM: 369

MEDICATION ADMINISTRATION RECORD

SPECIAL INSTRUCTIONS:

MEDICATION (dose and route)
DATE: 04/30 DATE: DATE: DATE:

TIME INITIALS TIME INITIALS TIME INITIALS TIME INITIALS

Keflex 500 milligram 0800 HF

four times a day

…

Permission to reuse granted by Alfred State College and Michelle A. Green

ALFRED STATE MEDICAL CENTER

100 MAIN ST, ALFRED NY 14802

(607) 555-1234

HOSPITAL #: 000999

INPATIENT FACE SHEET

PATIENT NAME AND ADDRESS GENDER RACE MARITAL STATUS PATIENT NO.

GIBBON, Andrew

22 Market Street

Alfred, NY 14802

M W M Case05

DATE OF BIRTH MAIDEN NAME OCCUPATION

08-19-YYYY N/A Retired

ADMISSION DATE TIME DISCHARGE DATE TIME LENGTH OF STAY TELEPHONE NUMBER

04-27-YYYY 13:00 04-29-YYYY 00:00 02 DAYS (607) 555-4500

GUARANTOR NAME AND ADDRESS NEXT OF KIN NAME AND ADDRESS

GIBBON, Andrew

22 Market Street

Alfred, NY 14802

GIBBON, Cynthia

22 Market Street

Alfred, NY 14802
GUARANTOR TELEPHONE NO. RELATIONSHIP TO PATIENT NEXT OF KIN TELEPHONE NUMBER RELATIONSHIP TO PATIENT

(607) 555-4500 Self (607) 555-4500 Wife

ADMITTING PHYSICIAN SERVICE ADMIT TYPE ROOM NUMBER/BED

Alan Norris, MD Medical 2 0362/02

ATTENDING PHYSICIAN ATTENDING PHYSICIAN UPIN ADMITTING DIAGNOSIS

Alan Norris, MD 100G02 Chest pain

PRIMARY INSURER POLICY AND GROUP NUMBER SECONDARY INSURER POLICY AND GROUP NUMBER

Medicare

DIAGNOSES AND PROCEDURES ICD CODE

PRINCIPAL DIAGNOSIS

Chest Pain,, Etiology Unknown

SECONDARY DIAGNOSES

Hypertension

Arteriosclerotic cardiovascular disease

with arteriosclerosis

Status post myocardial infarction

PRINCIPAL PROCEDURE

SECONDARY PROCEDURES

TOTAL CHARGES: $ 4,855.65

ACTIVITY:  Bedrest  Light  Usual  Unlimited  Other:

DIET:  Regular  Low Cholesterol  Low Salt  ADA  _____ Calorie

FOLLOW-UP:  Call for appointment  Office appointment on  Medications: Procardia, Isordil, Vasotec, Inderal, Alorol, Aspirin.

SPECIAL INSTRUCTIONS: See Dr. Derby next week Do not take Dyazide until you see Dr. Derby.

Signature of Attending Physician: Alan Norris, MD

Permission to reuse granted by Alfred State College and Michelle A. Green

GIBBON, Andrew

Case05

Dr. Norris

Admission: 04-27-YYYY

DOB: 08-19-YYYY

ROOM: 0362

CONSENT TO ADMISSION

I, Andrew Gibbon hereby consent to admission to the Alfred State Medical Center (ASMC) ,
and I

further consent to such routine hospital care, diagnostic procedures, and medical treatment that the
medical and professional staff of ASMC may deem necessary or advisable. I authorize the use of medical
information obtained about me as specified above and the disclosure of such information to my
referring physician(s). This form has been fully explained to me, and I understand its contents. I further
understand that no guarantees have been made to me as to the results of treatments or examinations
done at the ASMC.

Andrew Gibbon September 20, YYYY

Signature of Patient Date

Signature of Parent/Legal Guardian for Minor Date

Relationship to Minor

Andrea Witteman September 20, YYYY

WITNESS: Alfred State Medical Center Staff Member Date

CONSENT TO RELEASE INFORMATION FOR REIMBURSEMENT PURPOSES
In order to permit reimbursement, upon request, the Alfred State Medical Center (ASMC) may disclose
such treatment information pertaining to my hospitalization to any corporation, organization, or agent
thereof, which is, or may be liable under contract to the ASMC or to me, or to any of my family members
or other person, for payment of all or part of the ASMC’s charges for services rendered to me (e.g. the
patient’s health insurance carrier). I understand that the purpose of any release of information is to
facilitate reimbursement for services rendered. In addition, in the event that my health insurance
program includes utilization review of services provided during this admission, I authorize ASMC to
release information as is necessary to permit the review. This authorization will expire once the
reimbursement for services rendered is complete.

Andrew Gibbon September 20, YYYY

Signature of Patient Date

Signature of Parent/Legal Guardian for Minor Date

Relationship to Minor

Andrea Witteman September 20, YYYY

WITNESS: Alfred State Medical Center Staff Member Date

Permission to reuse granted by Alfred State College and Michelle A. Green

ALFRED STATE MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234

GIBBON, Andrew

Case05

Dr. Norris

Admission: 04-27-YYYY

DOB: 08-19-YYYY

ROOM: 0362

ADVANCE DIRECTIVE

Your answers to the following questions will assist your Physician and the Hospital to respect your
wishes regarding your medical care. This information will become a part of your medical record.
YES NO PATIENT’S INITIALS

1. Have you been provided with a copy of the
information called “Patient Rights Regarding Health
Care Decision?”

X AG

2. Have you prepared a “Living Will?” If yes, please
provide the Hospital with a copy for your medical
record.

X AG

3. Have you prepared a Durable Power of Attorney for
Health Care? If yes, please provide the Hospital with
a copy for your medical record.

X AG

4. Have you provided this facility with an Advance
Directive on a prior admission and is it still in effect?
If yes, Admitting Office to contact Medical Records to
obtain a copy for the medical record.

X AG

5. Do you desire to execute a Living Will/Durable
Power of Attorney? If yes, refer to in order:
a. Physician
b. Social Service
c. Volunteer Service

X AG

HOSPITAL STAFF DIRECTIONS: Check when each step is completed.

1.  Verify the above questions where answered and actions taken where required.

2.  If the “Patient Rights” information was provided to someone other than the patient, state
reason:

Name of Individual Receiving
Information

Relationship to Patient

3.  If information was provided in a language other than English, specify language and method.

4.  Verify patient was advised on how to obtain additional information on Advance Directives.

5.  Verify the Patient/Family Member/Legal Representative was asked to provide the Hospital
with a copy of the Advanced Directive which will be retained in the medical record.

File this form in the medical record, and give a copy to the patient.

Permission to reuse granted by Alfred State College and Michelle A. Green

Name of Patient Name of Individual giving information if different from Patient
Andrew Gibbon September 20, YYYY

Signature of Patient Date

Andrea Witteman September 20, YYYY

Signature of Hospital Representative Date

ALFRED STATE MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234

Permission to reuse granted by Alfred State College and Michelle A. Green

GIBBON, Andrew

Case05

Dr. Norris

Admission: 04-27-YYYY

DOB: 08-19-YYYY

ROOM: 0362

SOAP DOCUMENTATION

Date 27 Apr YY

Subjective CHIEF COMPLANT: 72 yr. old gentleman of Dr. K. Derby’s who presents with chest pain.

HISTORY OF PRESENT ILNESS: Mr. Gibbon is a very cheery sort of fellow. He is very pleasant.

He looks as though he probably should be running some sort of hardware store commercial. He states

that today while he was preparing breakfast, in the restroom he suffered some chess discomfort. He is

a little bit vague as to where his chest really is. He felt it in his back, he felt it in his jaw. He took a

couple of Nitroglycerine in sequence three minutes apart and felt better. Apparently, this has been

occurring a little more frequently recently. All these things are nebulous. If it wasn’t for his wife I

think he would deny everything. According to his wife, he has been having more frequent episodes

and has gained a fair amount of wait over the winter. He has had little physical activity. His pastor

who is with him and often serves as his spokesman, stated that he had hunted this past fall without

having to take any medication. However, he said the pace was quite controlled and he really didn’t do

very much in the way of heavy exercise. The patient has a history of an mycocardial infraction in

1981. Underwent catheterisation. Apparently, no surgery was necessary. There is also some question

about him having a lot of indijestion from time to time and it is not clear whether it is cardiac or GI.

Because of his prior cardiac history, the progression of his chest pane, the uncertainty of its origin, he

will be admitted for further evaluation and treatmant.

PAST MEDICAL HISTORY: Is essentially that listed above.

SOCIAL HISTORY & FAMILY HISTORY: The patient is married. Doesn’t smoke, although he had

in the past. Doesn’t drink. There is no disease common in the family.

Objective REVIEW OF SYSTEMS: Negative.

VITAL SIGNS: Temperature of 97.6 (Normal = 96.6 – 100.6), pulse is 65 (Normal = 60 – 100),

respirations 18 (Normal = 12 – 20), blood pressure 118/78 (Normal = 120/80 or below).

HEAD: Normocephalic.

ENT: Eyes -sclera and conjunctiva normal. PERRL, EOM’s intact. Fundi reveal arteriolar narrowing.

ENT are unremarkable.

NECK: Supple. No thyromegaly. Carotids are 2 out of 4. No bruits, no jugular venous distention.

CHEST: Symmetrical. Clear to auscultation and percussion.

HEART: Regular rhythm without any particular murmurs or gallops.

ABDOMEN: Nontender. No organomegaly. Bowel sounds normal activity. No bruits or masses.

BACK: No CVA tenderness nor tenderness to percussion over the spinous processes.

GENITALIA: Normal male.

RECTAL: Good sphincter tones. Stool is hemoccult negative. Prostate is normal in size.

EXTREMITIES: No cyanosis, clubbing or edema. Pulses equal and full.

NEUROLOGIC: Is physiologic.

Assessment l) Chest pain, etiology to be determined

2) Hypertension

3) Tachypnea

4) Bradycardia

Plan Schedule for stress test 4/28, 1230 if possible

Permission to reuse granted by Alfred State College and Michelle A. Green

GB US R/O stones

Reg diet

Alan Norris, MD

ALFRED STATE MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234

GIBBON, Andrew

Case05

Dr. Norris

Admission: 04-27-YYYY

DOB: 08-19-YYYY

ROOM: 0362

PROGRESS NOTES

Date (Please skip one line between dates.)

4-27-YY Chief Complaint: Unstable angina.

Diagnosis: Unstable angina.

Plan of Treatment: See orders.

Discharge Plan: Home – No services needed

Alan Norris, MD

4/28/YY Pt has had no pain overnight. Plan to get pt up and walking,. Treadmill Thursday if no pain. BG studies today.

Alan Norris, MD

4/29/YY Treadmill – pt not able to achieve goal. Shortness of breath.

Alan Norris, MD

Permission to reuse granted by Alfred State College and Michelle A. Green

ALFRED STATE MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234

Permission to reuse granted by Alfred State College and Michelle A. Green

GIBBON, Andrew

Case05

Dr. Norris

Admission: 04-27-YYYY

DOB: 08-19-YYYY

ROOM: 0362

DOCTORS ORDERS

Date Time Physician’s signature required for each order. (Please skip one line between dates.)

4-27-YY 1330 TELEMETRY PROTOCOL

1. Saline lock, insert and lfush every 24 hours and PRN

2. EKG with chest pain x 1

3. Oxygen 3 1/min. via nasal cannula PRN for chest pain.

4. Chest Pain: NTG 0.4mg SL q 5 min x 3.

5. Bradycardia: Atropine 0.5mg IV q 5 min to total of 2mg for symptomatic heart rate

(Pulse less than 50 or 60 with decreased BP and/or PVC’s)

6. PVC’s: Lidocaine 50mg IV push

Start drip 500cc D5W Lidocaine 2 gm @ 2mg/Min (30cc/hr) for greater

than 6 PVC’s per men or 3 PVC’s in a row.

7. V-Tach: (If patient is hemodynamically stable)

Lidocaine 50mg IV push.

Start drip 500cc D5W Lidocaine 2 gm @ 2mg/min (30cc/hr)

(If unstable) Cardiovert at 50 watt seconds

8. V-fig:Immediately defibrillate at 200 watt seconds, if not converted:

Immediately defibrillate at 300 watt seconds, if not converted;

Immediately defibrillate at 360 watt seconds, if not converted: Start CPR

Give Epinephrine (1:10,000) 1 mg IC push

Give Lidocaine as per V-Tach protocol

9. Asystole/EMD: Begin CPR

Epinephrine (1:10,000) 1mg IV push

Atropine 1 mg IV push if no response with Epinephrine

10. Respiratory arrest: Intubation with mechanical ventilation.

11. Notify Physician for chest pain or arrhythmias requiring treatment.

R.A.V. T.O. Dr. Norris/M. Higgin, R.N.

Alan Norris, MD

ALFRED STATE MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234

Permission to reuse granted by Alfred State College and Michelle A. Green

GIBBON, Andrew

Case05

Dr. Norris

Admission: 04-27-YYYY

DOB: 08-19-YYYY

ROOM: 0362

DOCTORS ORDERS

Date Time Physician’s signature required for each order. (Please skip one line between dates.)

27 Apr YY 1340 Inderal 40 mg qid

Procardia XL 60 mg q day

Isordil 10 mg qid

Vasotec 2.5 mg q day

Schedule for stress test 4/28, 1230 if possible

GB US R/O stones

Reg diet

Up in room

Alan Norris, MD

27 Apr YY 1645 Reschedule for treadmill for 1230, 29 Apr YY.

Hepatobiliary scan tomorrow.

Alan Norris, MD

28 Apr YY 0830 Ambulate in hall ad lib.

Lytes. SCGII in a.m.

Alan Norris, MD

28 Apr YY 1610 Inderal 20 mg po qid

Lytes. SCGII in a.m.

Alan Norris, MD

ALFRED STATE MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234

Permission to reuse granted by Alfred State College and Michelle A. Green

GIBBON, Andrew

Case05

Dr. Norris

Admission: 04-27-YYYY

DOB: 08-19-YYYY

ROOM: 0362

LABORATORY DATA

SPECIMEN COLLECTED: 04-29-YYYY SPECIMEN RECEIVED: 04-29-YYYY

TEST RESULT FLAG REFERENCE

Glucose 97 70-110 mg/dl

BUN 12 8-25 mg/dl

Creatinine 1.0 0.9-1.4 mg/dl

Sodium 135 L 135-145 mmol/L

Potassium 4.2 3.6-5.0 mmol/L

Chloride 97 L 99-110 mmol/L

CO2 30 21-31 mmol/L

Calcium 9.3 8.8-10.5 mg/dl

WBC 4.7 4.5-11.0 thous/UL

RBC 5.80 5.2-5.4 mill/UL

HGB 17.0 11.7-16.1 g/dl

HCT 50.1 35.0-47.0 %

Platelets 102 L 140-400 thous/UL

Protime 11.4 11.0-13.0

PTT 21 < 32 seconds

***End of Report***

ALFRED STATE MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234

Permission to reuse granted by Alfred State College and Michelle A. Green

GIBBON, Andrew

Case05

Dr. Norris

Admission: 04-27-YYYY

DOB: 08-19-YYYY

ROOM: 0362

LABORATORY DATA

SPECIMEN COLLECTED: 04-29-YYYY SPECIMEN RECEIVED: 04-29-YYYY

URINALYSIS

URINE DIPSTICK

DIPSTICKONLY

COLOR STRAW

SP GRAVITY 1.010 1.001-1.030

GLUCOSE NEGATIVE < 125 mg/dl

BILIRUBIN NEGATIVE NEG

KETONE NEGATIVE NEG mg/dl

BLOOD NEGATIVE NEG

PH 7.5 4.5-8.0

PROTEIN NEGATIVE NEG mg/dl

UROBILINOGEN NORMAL NORMAL-1.0 mg/dl

NITRITES NEGATIVE NEG

LEUKOCYTES NEGATIVE NEG

WBC RARE 0-5 /HPF

RBC — 0-5 /HPF

EPI CELLS RARE /HPF

BACTERIA — /HPF

CASTS. — < 1 HYALINE/HPF

***End of Report***

ALFRED STATE MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234

Permission to reuse granted by Alfred State College and Michelle A. Green

GIBBON, Andrew

Case05

Dr. Norris

Admission: 04-27-YYYY

DOB: 08-19-YYYY

ROOM: 0362

NUCLEAR MEDICINE REPORT

Reason for Ultrasound (please initial): R/o stones

Date Requested:

Transport:  Wheelchair  Stretcher  O2  IV
 IP  OP  ER
 PRE OP  OR/RR  Portable

HEPATOBILIARY SCAN: Following injection of isotope there is prompt

demonstration of the liver, gallbladder, biliary system and small bowel.

This would indicate no significant obstruction of either the cystic or the

common duct.

CONCLUSION: Normal hepatobiliary scan.

ABDOMINAL ULTRASOUND: Multiple real time images show that the gallbladder

is of normal size with evidence of any stones or wall thickening.

Portions of the kidneys, spleen, pancreas and upper aorta are demonstrated

and are unremarkable.

CONCLUSION: Normal ultrasound

DD: 04-28-YYYY D. Lane

DT: 04-29-YYYY D. Lane, M.D.

ALFRED STATE MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234

Permission to reuse granted by Alfred State College and Michelle A. Green

GIBBON, Andrew

Case05

Dr. Norris

Admission: 04-27-YYYY

DOB: 08-19-YYYY

ROOM: 0362

EKG REPORT

Date of EKG 04-27-YYYY Time of EKG 11:42:03

Rate 61

Abnormal: Old inferior M.I.

Nonspecific ST-T changes.

No old tracings for comparison.

Clinical correlation needed.

PR 158

QRSD 64

QT 383

QTC 386

— Axis —

P 1

QRS -27

T 28

Bella Kaplan, M.D.

Name of Physician

ALFRED STATE MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234

Permission to reuse granted by Alfred State College and Michelle A. Green

GIBBON, Andrew

Case05

Dr. Norris

Admission: 04-27-YYYY

DOB: 08-19-YYYY

ROOM: 0362

TREADMILL STRESS TEST

Date of EKG 04-29-YYYY Time of EKG 13:00

Protocol Manual Time 6 : 41
Age 72 Rate 116, 78% of Expected Max (148)
Race Caucasian BP 13/85
Sex Male Stage 3
Ht 66 in. Speed 3.4
Wt 160 lbs. Grade 14 . 0
Opt 362 RPP 156
Rate 92 METS 6 . 4
BP 110/70 Inconclusive. Pt developed dyspnea, probably due to

Inderal. No change on EKG to suggest ischemic

disease.
Bella Kaplan, M.D.

Name of Physician

Permission to reuse granted by Alfred State College and Michelle A. Green

Permission to reuse granted by Alfred State College and Michelle A. Green

ALFRED STATE MEDICAL CENTER

100 MAIN ST, ALFRED NY 14802

(607) 555-1234

HOSPITAL #: 000999

INPATIENT FACE SHEET

PATIENT NAME AND ADDRESS GENDER RACE MARITAL STATUS PATIENT NO.

HUNTER, Dilbert

543 Yukon Trail

Alfred NY 14802

M W M Case02

DATE OF BIRTH MAIDEN NAME OCCUPATION

09-22-YYYY N/A Unemployed

ADMISSION DATE TIME DISCHARGE DATE TIME LENGTH OF STAY TELEPHONE NUMBER

04-26-YYYY 15:20 04-29-YYYY 10:10 03 DAYS (607) 555-6632

GUARANTOR NAME AND ADDRESS NEXT OF KIN NAME AND ADDRESS

Hunter, Anita

543 Yukon Trail

Alfred NY 14802

Hunter, Anita

543 Yukon Trail

Alfred NY 14802
GUARANTOR TELEPHONE NO. RELATIONSHIP TO PATIENT NEXT OF KIN TELEPHONE NUMBER RELATIONSHIP TO PATIENT

(607) 555-6632 Wife (607) 555-6632 Wife

ADMITTING PHYSICIAN SERVICE ADMIT TYPE ROOM NUMBER/BED

William Ruddy, MD Medical 2 0366/01

ATTENDING PHYSICIAN ATTENDING PHYSICIAN UPIN ADMITTING DIAGNOSIS

William Ruddy, MD 100T32 Rule out pneumonia.

PRIMARY INSURER POLICY AND GROUP NUMBER SECONDARY INSURER POLICY AND GROUP NUMBER

Empire Plan 352656388

DIAGNOSES AND PROCEDURES ICD CODE

PRINCIPAL DIAGNOSIS

Acute Bronchitis

SECONDARY DIAGNOSES

COPD

Asthma

 B.P.

PRINCIPAL PROCEDURE

SECONDARY PROCEDURES

TOTAL CHARGES: $ 2,692.74

ACTIVITY:  Bedrest  Light  Usual  Unlimited  Other:

DIET:  Regular  Low Cholesterol  Low Salt  ADA  _____ Calorie

FOLLOW-UP:  Call for appointment  Office appointment on  Other:

SPECIAL INSTRUCTIONS:

Signature of Attending Physician: William Ruddy, MD

Permission to reuse granted by Alfred State College and Michelle A. Green

HUNTER, Dilbert

Case02

Dr.Ruddy

Admission: 04-26-YYYY

DOB: 09-22-YYYY

ROOM: 0366

CONSENT TO ADMISSION

I, Dilbert Hunter hereby consent to admission to the Alfred State Medical Center
(ASMC), and I further consent to such routine hospital care, diagnostic procedures, and medical treatment that the medical
and professional staff of ASMC may deem necessary or advisable. I authorize the use of medical information obtained about
me as specified above and the disclosure of such information to my referring physician(s). This form has been fully
explained to me, and I understand its contents. I further understand that no guarantees have been made to me as to the
results of treatments or examinations done at the ASMC.

Dilbert Hunter September 20, YYYY

Signature of Patient Date

Signature of Parent/Legal Guardian for Minor Date

Relationship to Minor

Andrea Witteman September 20, YYYY

WITNESS: Alfred State Medical Center Staff Member Date

CONSENT TO RELEASE INFORMATION FOR REIMBURSEMENT PURPOSES
In order to permit reimbursement, upon request, the Alfred State Medical Center (ASMC) may disclose
such treatment information pertaining to my hospitalization to any corporation, organization, or agent
thereof, which is, or may be liable under contract to the ASMC or to me, or to any of my family members
or other person, for payment of all or part of the ASMC’s charges for services rendered to me (e.g. the
patient’s health insurance carrier). I understand that the purpose of any release of information is to
facilitate reimbursement for services rendered. In addition, in the event that my health insurance
program includes utilization review of services provided during this admission, I authorize ASMC to
release information as is necessary to permit the review. This authorization will expire once the
reimbursement for services rendered is complete.

Dilbert Hunter September 20, YYYY

Signature of Patient Date

Signature of Parent/Legal Guardian for Minor Date

Relationship to Minor

Andrea Witteman September 20,

YYYY

WITNESS: Alfred State Medical Center Staff Member Date

Permission to reuse granted by Alfred State College and Michelle A. Green

ALFRED STATE MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234

HUNTER, Dilbert

Case02

Dr.Ruddy

Admission: 04-26-YYYY

DOB: 09-22-YYYY

ROOM: 0366

ADVANCE DIRECTIVE

Your answers to the following questions will assist your Physician and the Hospital to respect your
wishes regarding your medical care. This information will become a part of your medical record.
YES NO PATIENT’S

INITIALS

1. Have you been provided with a copy of the
information called “Patient Rights Regarding Health
Care Decision?”

X DH

2. Have you prepared a “Living Will?” If yes, please
provide the Hospital with a copy for your medical
record.

X DH

3. Have you prepared a Durable Power of Attorney for
Health Care? If yes, please provide the Hospital with
a copy for your medical record.

X DH

4. Have you provided this facility with an Advance
Directive on a prior admission and is it still in effect?
If yes, Admitting Office to contact Medical Records to
obtain a copy for the medical record.

X DH

5. Do you desire to execute a Living Will/Durable
Power of Attorney? If yes, refer to in order:
a. Physician
b. Social Service
c. Volunteer Service

X DH

HOSPITAL STAFF DIRECTIONS: Check when each step is completed.

1.  Verify the above questions where answered and actions taken where required.

2.  If the “Patient Rights” information was provided to someone other than the patient,
state reason:

Name of Individual Receiving
Information

Relationship to Patient

3.  If information was provided in a language other than English, specify language and
method.

4.  Verify patient was advised on how to obtain additional information on Advance
Directives.

5.  Verify the Patient/Family Member/Legal Representative was asked to provide the
Hospital with a copy of the Advanced Directive which will be retained in the medical
record.

Permission to reuse granted by Alfred State College and Michelle A. Green

File this form in the medical record, and give a copy to the patient.

Name of Patient Name of Individual giving information if different from Patient

Dilbert Hunter
September 20, YYYY

Signature of Patient Date

Andrea Witteman September 20, YYYY

Signature of Hospital Representative Date

ALFRED STATE MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234

HUNTER, Dilbert

Dr.Ruddy

Admission: 04-26-YYYY

DOB: 09-22-YYYY

ROOM: 0366

HISTORY & PHYSICAL EXAM

CHIEF COMPLAINT: Shortness of breath.

HISTORY OF PRESENT ILLNESS: The patient is a 55 yr. old gentleman with severe COPD with asthma and hypertension, who

had developed an acute bronchitis about a week ago and five days ago was started on Ampicillin taking his usual 500 mg. t.i.d. This

did not help, and he was started on a Medrol Dose-Pak but he had already been taking Prednisone. The patient had increa sing

shortness of breath the last 24 hours and came in. He had to stop four times to walk from the parking lot into the office due to

increasing shortness of breath. He has some orthopnea, paroxysmal nocturnal dyspnea with it , which is typical for a flare up of his

COPD with asthma and especially if infected. The patient has severe allergies to nonsteroidals causing him almost an anaphyla ctic

type of reaction and with severe shortness of breath and had one respiratory arrest requiring intubation for that pa rticular problem.

PAST MEDICAL HISTORY: General health has been good when he is in between his breathing attacks. Childhood diseases -no

rheumatic or scarlet fever. Adult diseases-no TB or diabetes. Has had recurrent pneumonias. Operations: hemorrhoidectomy.

MEDICATIONS: At this time include Lasix 40 mg. daily. Calan 80 mg. t.i.d. Prednisone 10 mg. daily. Vasotec 10 mg. daily.

Theolair 250 b.i.d. Allopurinol 300 mg. daily. Proventil and Azmacort 2 puffs q. i .d.

ALLERGIES: Nonsteroidal antiinflammatory drugs, including aspirin.

SOCIAL HISTORY: Does not smoke or drink.

FAMILY HISTORY: Noncontributory.

REVIEW OF SYSTEMS: Head: no headaches, seizures or convulsions. EENT reveals rhinorrhea and allergies, particularly with

sinusitis. Chest and heart: see HPI. GI: no nausea, diarrhea, constipation. GU: no dysuria, hematuria, nocturia. Extremities: no

edema. Has a lot of arthritic problems getting along with Tylenol at this time.

GENERAL APPEARANCE: The patient is a middle-aged gentleman who is short of breath at rest.

VITAL SIGNS: Temperature is 97, pulse is 60, respirations 24, blood pressure 146/68. Weight 254 lbs.

SKIN: Normal color and texture. No petechiae or ecchymoses.

HEENT: Normal cephalic. No mastoid or cranial tenderness. Eyes, pupils equal and reactive to light and accommodation. Extra-

ocular muscle function intact. Funduscopic examination within normal limits. Ears: no inflammation or bulging of the drums. Nose:

no inflammation, though there is same clear rhinorrhea. Mouth: no inflammation or exudate.

NECK: Supple. No adenopathy. Trachea in the midline. Thyroid normal. Carotids 2/4 with no bruits.

CHEST: Symmetrical.

LUNGS: There are wheezes heard throughout the lung fields with rhonchi and rales at the right base.

HEART: Regular rhythm. Sl 2/4, S2 2/4, with no S3, S4 or murmurs.

BACK: No CVA or spinal tenderness.

ABDOMEN: Soft. No organomegaly, masses, or tenderness to palpation or percussion. Normal bowel sounds.

GENITALIA: Normal external qenitalia.

Permission to reuse granted by Alfred State College and Michelle A. Green

RECTAL: Good sphincter tone. No mucosal masses. Stool hemoccult negative. Prostate 2+ with no nodules.

EXTREMITIES: Peripheral pulses 2+. No edema, cyanosis or clubbing.

NEUROLOGIC: Within normal limits.

IMPRESSION: 1) Asthma with acute bronchitis and bronchospasm.

2) Hypertension.

DD: 04-26-YYYY William Ruddy, MD
DT: 04-27-YYYY William Ruddy, MD

ALFRED STATE MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234

HUNTER, Dilbert

Case02

Dr.Ruddy

Admission: 04-26-YYYY

DOB: 09-22-YYYY

ROOM: 0366

PROGRESS NOTES

Date (Please skip one line between dates.)

4/26/YYYY Chief Complaint: Shortness of breath.

Dx: COPD, asthma, acute brohchitis.

Plan of Treatment: See physician orders.

Discharge Plan: Home. William Ruddy, MD

4/27/YYYY Pt. is less SOB today but still has considerable wheezing. Will cont same

meds

until I get results of culture and sensitivity. William Ruddy, MD

Permission to reuse granted by Alfred State College and Michelle A. Green

ALFRED STATE MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234

HUNTER, Dilbert

Case02

Dr.Ruddy

Admission: 04-26-YYYY

DOB: 09-22-YYYY

ROOM: 0366

DOCTORS ORDERS

Date Time Physician’s signature required for each order. (Please skip one line between
dates.)

4/26/YYYY 1525 CBC, UA, ABG and CXR; NAS diet; Saline Lock

Ancef 1 gm q 8

Solumedrol 125mg q 6 IV

Calan 80mg Tid

Vasotic 10mg daily

Theodur 300mg Bid (q 12)

Allopurinol 300mg daily

Proventil and Azmacort

puffs qid – do own Rx
William Ruddy, MD

R.A.V. V.O. Dr. Ruddy/J.Anderson, RN

4/26/YYYY 1720 Cancel ABG. Do RA

oximetry.

R.A.V. T.O. Dr.

Ruddy/E. Blossom RN

4/26/YYYY 1720 O2 2L/Ne R.A.V. T.O. Dr.

Ruddy/E. Blossom RN

4/27/YYYY 1320 Tylenol 650mg po q 4

prn pain

R.A.V. T.O. Dr. Ruddy/H.

Figgs RN

Permission to reuse granted by Alfred State College and Michelle A. Green

4/28/YYYY 1020 1) D/C IV

2) Ceftin 250mg P.O. BID

3) Prednisone 20mg

P.O.
William Ruddy, MD

4) Walk hall as

tolerated

R.A.V. T.O. Dr.

Ruddy/E. Blossom RN

William Ruddy, MD

4/28/YYYY 0900 DC O2 R.A.V. T.O. Dr. Ruddy/H. Figgs RN

4/29/YYYY 1200 Discharge – dict later William Ruddy, MD
ALFRED STATE MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234

HUNTER, Dilbert

Case02

Dr.Ruddy

Admission: 04-26-YYYY

DOB: 09-22-YYYY

ROOM: 0366

LABORATORY DATA

SPECIMEN COLLECTED: 04-26-YYYY SPECIMEN RECEIVED: 04-26-YYYY

URINALYSIS

URINE DIPSTICK

DIPSTICKONLY

COLOR STRAW

SP GRAVITY 1.010 1.001-1.030

GLUCOSE NEGATIVE < 125 mg/dl

BILIRUBIN NEGATIVE NEG

KETONE NEGATIVE NEG mg/dl

BLOOD NEGATIVE NEG

PH 7.5 4.5-8.0

PROTEIN NEGATIVE NEG mg/dl

UROBILINOGEN NORMAL NORMAL-1.0 mg/dl

NITRITES NEGATIVE NEG

LEUKOCYTES NEGATIVE NEG

WBC RARE 0-5 /HPF

RBC — 0-5 /HPF

EPI CELLS RARE /HPF

BACTERIA — /HPF

Permission to reuse granted by Alfred State College and Michelle A. Green

CASTS. — < 1 HYALINE/HPF

***End of Report***

ALFRED STATE MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234

HUNTER, Dilbert

Case02

Dr.Ruddy

Admission: 04-26-YYYY

DOB: 09-22-YYYY

ROOM: 0366

LABORATORY DATA

SPECIMEN

COLLECTED:

04-26-YYYY SPECIMEN RECEIVED: 04-26-YYYY

CBC S DIFF

TEST RESULT FLAG REFERENCE

WBC 7.4 4.5-11.0 thous/UL

RBC 5.02 **L** 5.2-5.4 mill/UL

HGB 15.0 11.7-16.1 g/dl

HCT 45.8 35.0-47.0 %

MCV 91.2 85-99 fL.

MCHC 32.8 **L** 33-37

RDW 15.2 **H** 11.4-14.5

Platelets 165 130-400 thous/UL

MPV 8.4 7.4-10.4

Permission to reuse granted by Alfred State College and Michelle A. Green

LYMPH % 21.1 20.5-51.1

MONO % 7.8 1.7-9.3

GRAN % 71.1 42.2-75.2

LYMPH x 103 1.6 1.2-3.4

MONO x 103 .6 **H** 0.11-0.59

GRAN x 103 5.3 1.4-6.5

EOS x 103 < .7 0.0-0.7

BASO x 103 < .2 0.0-0.2

ANISO SLIGHT

***End of Report***

ALFRED STATE MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234

HUNTER, Dilbert

Case02

Dr.Ruddy

Admission: 04-26-YYYY

DOB: 09-22-YYYY

ROOM: 0366

RADIOLOGY REPORT

Initial Diagnosis/History: COPD

Date Requested: 04-26-YYYY

Transport:  Wheelchair  Stretcher  O2  IV
 IP  OP  ER
 PRE OP  OR/RR  Portable

CHEST: PA and lateral views reveals the heart and mediastinum to be

normal. The lungs are hyperinflated with flattening of the diaphragms and

disorganization of the interstitial markings secondary to chronic

disease. There is also some old pleural thickening at the left base

laterally. Since our previous study of 4-30-92, an area of atelectasis

has developed in the middle lobe. I do not know if this is of any current

significance. No areas of consolidation or any pleural effusions are

visible.

DD: 04-26-YYYY Philip Rogers

DT: 04-27-YYYY Philip Rogers

Permission to reuse granted by Alfred State College and Michelle A. Green

ALFRED STATE MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234

HUNTER, Dilbert

Case02

Dr.Ruddy

Admission: 04-26-YYYY

DOB: 09-22-YYYY

ROOM: 0366

MEDICATION ADMINISTRATION RECORD

SPECIAL INSTRUCTIONS:

MEDICATION (dose and route)

DATE: 04-26 DATE: 04-27 DATE: 04-28 DATE: 04-29

TIME INITIALS TIME INITIALS TIME INITIALS TIME INITIALS

ANCEF 1GM Q 8 0800 VT 0800 VT 0800 HF

1600 JD 1600 OR D/C

2400 P.S. 2400 P.S. D/C

SOLUMEDROL 125 MG IV 1

6
0600 GPW 0600 GPW 0600 GPW

1200 GPW 1200 VT D/C

1800 JD 1800 OR D/C

2400 GPW 2400 GPW D/C

CALAN 80 MG TID 0800 VT 0800 VT 0800 HF 0800 HF

1300 VT 1300 VT 1300 HF D/C

1800 JD 1800 JD 1800 OR 1800 JD

VASOTEC 10MG DAILY 0800 JD 0800 JD 0800 HF 0800 HF

THEODUR 300MG Q 12 0800 JD 0800 JD 0800 HF 0800 HF

2000 JD 2000 JD 2000 OR 2000 JD

Permission to reuse granted by Alfred State College and Michelle A. Green

ALLOPURINOL 300MG DAILY 0800 JD 0800 JD 0800 HF 0800 HF

SALINE FLUSH P EACH USE 0800 JD 0800 JD D/C

CEFTIN 250MG PO BID 0800 HF 0800 HF 0800 HF 0800 HF

1600 JD 1600 JD 1600 JD

D/C

INITIALS SIGNATURE AND TITLE INITIALS SIGNATURE AND TITLE INITIALS SIGNATURE AND TITLE

VT VERA SOUTH, EN GPW G. P. WELL, RN

OR ORA RICHARDS, RN P.S. P. SMALL, RN

JD JANE DOBBS, RN

HF H. Figgs RN
ALFRED STATE MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234

HUNTER, Dilbert

Case02

Dr.Ruddy

Admission: 04-26-YYYY

DOB: 09-22-YYYY

ROOM: 0366

PATIENT PROPERTY RECORD

I understand that while the facility will be responsible for items deposited in the safe, I must be
responsible for all items retained by me at the bedside. (Dentures kept the bedside will be labeled,
but the facility cannot assure responsibility for them.) I also recognize that the hospital cannot be
held responsible for items brought in to me after this form has been completed and signed.

Dilbert Hunter September 20, YYYY

Signature of Patient Date

Andrea Witteman September 20, YYYY

Signature of Witness Date

I have no money or valuables that I wish to deposit for safekeeping. I do not hold the facility
responsible for any other money or valuables that I am retaining or will have brought in to me.

I have been advised that it is recommended that I retain no more than $5.00 at the bedside.

Dilbert Hunter September 20, YYYY

Signature of Patient Date

Andrea Witteman September 20, YYYY

Signature of Witness Date

Permission to reuse granted by Alfred State College and Michelle A. Green

I have deposited valuables in the facility safe. The envelope number is .

Signature of Patient Date

Signature of Person Accepting Property Date

I understand that medications I have brought to the facility will be handled as recommended by my
physician. This may include storage, disposal, or administration.

Signature of Patient Date

Signature of Witness Date

ALFRED STATE MEDICAL CENTER  100 MAIN ST, ALFRED NY 14802  (607) 555-1234