7/18/1940
76yr F
Heart Failure, COPD
make sure to go in the backdoorPatient Phone
Caregiver
6mo Admits
1
6mo ER
--
Last Visit
Today
Ethnicity
White
Program
UHC
PCP
Due 2 days ago
Due tomorrow
Due in 4 days
Schedule for
in 10 days
Patient's daughter called me to ask if she can get more oxygen as she is running low.
5 days ago
This 76-year-old woman has dyspnea due to COPD. She understands her diagnosis and prognosis. She and her daughter made it quite clear that they do not want to suffer and would like to be cared for at home. They would like no heroic or extraordinary measures used to keep her alive.
10 days ago
Hi guys, Thanks for meeting with the team today and going through the proposals we saw. This goes on until it’s truncated.
Feb 24
|
Name
|
Role
|
Date
|
|
|---|---|---|---|
|
Julianne Whelan
|
Nurse
|
11/23/2016
|
|
|
Gwen Jones
|
Doctor
|
11/26/2016
|
|
|
Betsy Mason
|
Social Worker
|
3/1/2017
|
|
Date
|
Level
|
Entered by
|
|
|---|---|---|---|
|
12/20/20163/1/2017
|
High
Medium
|
Julianne Whelan
|
|
Name
|
Description
|
|
|---|---|---|
|
Major Concern
|
Lorem ipsum dolor sit amet, consectetur adipiscing elit.
|
|
|
Diagnoses
|
COPD (primary)
Heart Failure |
|
|
History of Present Illness
|
Lorem ipsum dolor sit amet, consectetur adipiscing elit.
|
|
Medication
|
Reaction
|
|
|---|---|---|
|
Penicillin
|
Rash
|
|
|
Ciprofloxacin
|
Shortness of Breath
|
|
Medication
|
Dose
|
Frequency
|
|
|---|---|---|---|
|
Trazodone
|
50 mg PO BID
|
Daily
|
|
|
Bisacodyl
|
10 mg PO BID
|
As needed
|
|
|
Levomepromazine
|
25 mg PO BID
|
Daily
|
|
|
Metoclopramide
|
10 mg PO BID
|
Daily
|
|
|
Prednisolone
|
5 mg PO BID
|
Twice Daily
|
|
Visit
|
BP
|
HR
|
Temp
|
RR
|
O2
|
Height
|
Weight
|
|---|---|---|---|---|---|---|---|
|
12/20/2016
Julianne Whelan |
120/80
|
96
|
96.5
|
44
|
96
|
80
|
120
|
|
Visit
|
Exam
|
ADL
|
PPS
|
ESAS
|
Patient
|
Caregiver
|
Living Conditions
|
|---|---|---|---|---|---|---|---|
|
1/16/2017
Julianne Whelan |
|||||||
|
12/29/2016
Julianne Whelan |
|||||||
|
12/20/2016
Julianne Whelan |
|
Date
|
Name
|
Added by
|
|
|---|---|---|---|
|
2/20/2017
|
Julianne Whelan
|
|
Type
|
Value
|
|
|---|---|---|
|
Gender
|
Female
|
|
|
DOB
|
7/18/1940
|
|
|
Photo
|
||
|
Member ID
|
123456789
|
|
|
Program
|
ProHealth
|
|
|
Primary Language
|
English
|
|
|
Marital Status
|
Married
|
|
|
Race/Ethnicity
|
White
|
|
|
Religion
|
Baptist
|
|
|
Special Instructions
|
Make sure to go in the backdoor
|
|
Type
|
Value
|
|
|---|---|---|
|
Address
|
123 Main Street NY, NY 123456
|
|
|
Phone
|
555-555-5555 (Mobile)
333-333-1234 (Home)
|
|
Name
|
Relationship
|
Phone
|
Email
|
|
|---|---|---|---|---|
|
Maria
|
Daughter - Main Caregiver
|
|
Name
|
Relationship
|
Phone
|
Email
|
|
|---|---|---|---|---|
|
Jessica
Good Sheperd Hospice |
Private Hire Home Heath Aide
|
|
Name
|
Practice
|
Phone
|
Fax?
|
|
|---|---|---|---|---|
|
Dr. John Smith
|
215-123-4567
|
|
Type
|
DNR
|
Date
|
|
|---|---|---|---|
|
MOLST
|
Yes
|
12/20/2016
|
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