LOBAL
MEDICAL
Global Care Medical Center
100 Main St, Alfred NY 14802
(607) 555-1234
Hospital No. 999
Patient Name and Address
INPATIENT FACE SHEET
PIRE, SALLY
Gender Race
F
Marital Status
S
Patient No.
IPCase006
1122 CHERRY STREET
ALMOND, NY 14804
Date of Birth
Age
Maiden
Occupation
Name
06/23/YYYY
60
ΝΑ
Nurses'
Aide
Admission Date
Time
06-30-YYYY
12:45
Discharge Date Time
07-07-YYYY
Length of Stay
Telephone Number
10:00
05 DAYS
(607) 000-4397
Guarantor Name and Address
PIRE, SALLY
1122 CHERRY STREET
ALMOND, NY 14804
Guarantor Telephone No.
(607) 000-4397
Admitting Physician
John Black, MD
Attending Physician
John Black, MD
Primary Insurer
New Age Insurance
Diagnoses and Procedures
Principal Diagnosis
Bacterial Pneumonia
Secondary Diagnoses
Arteriosclerotic cardiovascular disease
Principal Procedure
Relationship to Patient
Self
Service
ME
Next Of Kin Name and Address
PIRE, JACOB
556 MILL STREET
ALMOND, NY 14804
Next of Kin Telephone Number
(607) 555-7676
Admit Type
ΝΑ
Relationship to Patient
BROTHER
Room Number/Bed
0371
Admitting Diagnosis
Bacterial pneumonia
Policy and Group Number
PW 6790456
Secondary Insurer
NEBC
Policy and Group Number
229162171
ICD Code
Secondary Procedures
Discharge Instructions
Activity:
Diet:
Follow-Up:
Bed rest
☐ Light
☐ Usual
Unlimited
☑Other: As tolerated.
☑Regular
Call for appointment
Low Cholesterol
☐ Low Salt □ ADA
☑Office appointment on 07-14 ☐ Other:
☐
Calorie
Special Instructions:
Attending Physician Authentication:
Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 06/30/YYYY 01:00:00 PM EST)
Permission to reuse granted by Alfred State College and Michelle A. Green.
1| Page PIRE, SALLY
IPCase006
Dr. BLACK
I, Sally Pire
Admission: 06/30/YYYY
DOB: 06/23/YYYY
ROOM: 0371
CONSENT TO ADMISSION
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: Sally Pire
ATP-B-S:02:1001261385: Sally Pire
(Signed: 06/30/YYYY 01:45:05 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: 06/30/YYYY 01:45:05 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: Sally Pire
ATP-B-S:02:1001261385: Sally Pire
(Signed: 06/30/YYYY 01:47:05 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: 06/30/YYYY 01:48:05 PM EST)
WITNESS: Global Care Medical Center Staff Member
Permission to reuse granted by Alfred State College and Michelle A. Green.
2| Page PIRE, SALLY
IPCase006
GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234
Admission: 06/30/YYYY
DOB: 06/23/YYYY
ROOM: 0371
ADVANCE DIRECTIVE
Dr. BLACK
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.
1. Have you been provided with a copy of the information called
"Patient Rights Regarding Health Care Decision?"
2. Have you prepared a “Living Will?" If yes, please provide the
Hospital with a copy for your medical record.
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.
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.
5. Do you desire to execute a Living Will/Durable Power of
Attorney? If yes, refer to in order:
1.
2.
a. Physician
b. Social Service
c. Volunteer Service
YES
No
PATIENT'S INITIALS
Χ
☑
☑
X
HOSPITAL STAFF DIRECTIONS: Check when each step is completed.
Verify the above questions where answered and actions taken where required.
If the "Patient Rights" information was provided to someone other than the patient, state reason:
3.
4.
5.
Name of Individual Receiving Information
Relationship to Patient
If information was provided in a language other than English, specify language and method.
Verify patient was advised on how to obtain additional information on Advance Directives.
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: Sally Pire
ATP-B-S:02:1001261385: Sally Pire
(Signed: 06/30/YYYY 01:48:05 PM EST)
Signature of Patient
Date
Reviewed and Approved: Andrea Witteman
ATP-B-S:02:1001261385: Andrea Witteman
(Signed: 06/30/YYYY 01:49:05 PM EST)
Permission to reuse granted by Alfred State College and Michelle A. Green.
3| Page PIRE, SALLY
Signature of Hospital Representative
Date
GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234
IPCase006
Dr. BLACK
Admission: 06/30/YYYY
DOB: 06/23/YYYY
ROOM: 0371
PATIENT HISTORY
PROBLEMS: 1. Arteriosclerotic cardiovascular disease; 2. Past history of alcoholism; 3.
Past history of hypokalemia; 4. Past history of gastritis.
MEDICATIONS: Lanoxin 0.125 milligrams a day
Lasix 20 milligrams a day
Klotrix tablets 1 tablet three times daily
PAST MEDICAL HISTORY: Patient has had some problems with alcohol in the past and a
history of gastritis due to excessive alcohol intake. She had a fractured wrist last year
potentially a secondary injury due to excessive inebriation. She also has recently been
put on Lanoxin and Lasix, apparently for arteriosclerotic cardiovascular problems, as she
experienced mild angina. Subsequent to her second admission in YYYY, she was referred to
General Hospital for further evaluation and treatment of her abnormal liver function
studies. It was determined at that time that she did not have an active process.
ALLERGY TO ASPIRIN
FAMILY HISTORY: History of alcoholism on mother's side and cardiovascular disease on
father's side. Brother has had heart attack related to coronary artery disease.
SOCIAL HISTORY: She works as a nurse's aide. She's a moderate smoker. Denies heavy
drinking, but we are not quite sure about that.
DD: 06/30/YYYY
DT: 07/01/YYYY
Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 06/30/YYYY 06:05:44 PM EST)
Physician Name
Permission to reuse granted by Alfred State College and Michelle A. Green.
4|Page PIRE, SALLY
IPCase006
Dr. BLACK
Admission: 06/30/YYYY
DOB: 06/23/YYYY
ROOM: 0371
DISCHARGE SUMMARY
ADMISSION DATE: 06/30/YYYY DISCHARGE DATE: 07/07/YYYY
ADMISSION DIAGNOSIS: 1. Viral pneumonia; 2. Arteriosclerotic cardiovascular
disease; 3. Past history of alcoholism; 4. Past history of hypokalemia; 5. Past
history of gastritis.
DISCHARGE DIAGNOSES: Pneumonia. Arteriosclerotic cardiovascular disease.
SUMMARY: This is a 61-year-old white female who has been doing fairly well
recently until the onset of an upper respiratory infection with a cough,
recurrent chills, sweats, fever. She tried to work, was unable to. Her
temperature went to 102. Abdominal x-ray showed a pneumonia, and I felt that she
should be admitted for further evaluation and treatment.
Work-up has included a chest x-ray which revealed a small area of infiltrate in
the lingular of the right side compatible with an acute pneumonia; a follow-up
study is suggested. Repeat chest x-ray showed bilateral pneumonia, clearing;
however, there was a remaining area of consolidation in the lateral portion of
the middle lobe. Her urine showed a specific gravity of 1.015, albumin and sugar
were negative, white blood cells rare, red blood cells 0-6. White count 15,000.
Hemoglobin 11.8, hematocrit 34.8, segmented cells 52, lymphocytes 18, monocytes
12, eosinophils 3, and 5 band cells. Complete blood count was normal. Sodium 137,
potassium 3.4, carbon dioxide 27, chloride 97, alkaline phosphatase 10.4, blood
sugar 81, cholesterol 138, Serum glutamic oxalacetic transaminase 42, Lactate
dehydrogenase 260, creatinine 0.4, calcium 8.3, phosphorus 2.2, bilirubin 1.2,
total protein 6.1, albumin 3.2, uric acid 0.5. Sputum culture grew out a 1+
enterobacter. Cardiogram was reported as showing sinus tachycardia; this later
slowed down clinically.
She was started originally on Ampicillin 500 milligrams, four times a day,
Intermittent positive pressure breathing. She was continued on her Lanoxin 0.125
a day, Lasix 20 milligrams a day, Klotrix tablets 1 tablet three times a day. Her
temperature stayed up, her Ampicillin was stopped, and she was switched to
Enalapril 500 milligrams, four times a day. Now her temperature has been normal
for 48 hours. She feels better, and her cough has lessened. She is up ambulatory,
and she is anxious to go home. She is being discharged at this time on E-Mycin
333 milligrams, three times a day and Afrin nasal spray. She will continue on her
Lanoxin 0.125 milligrams a day, Lasix 20 milligrams a day, and should be seen in
follow-up in the office early next week.
DD: 06/30YYYY
DT: 07/01/YYYY
Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 06/30/YYYY 05:44:18 PM EST)
Physician Name
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.
5| Page/n Assignment instructions:
IHP 310 Milestone Two Guidelines and Rubric
Overview
In this milestone, you will submit your review of a recent
patient chart located in the Final Project Patient File. You
will discuss the reason for the patient's visit, including the
symptoms, signs, and potential treatment.
Specifically, the following critical elements must be
addressed:
Recent Visit Analysis
Explain why the patient has returned to the doctor's office.
What symptoms and signs is the patient experiencing?
Analyze the new symptoms and signs to determine whether the
past diagnosis is still a reasonable conclusion or could have
been a misdiagnosis. Use specific information from both the
recent visit and the patient history to inform your analysis.
Based on the new signs, symptoms, and potential diagnosis (if
the doctor has made a new diagnosis), discuss what new or
potential treatments would be appropriate. Why?
What to Submit
This milestone should be at least 2 pages in length and
submitted as a Word document. All sources should be in APA
format.
Milestone Images
-
Browse 246,276 Stock Photos, Vectors, and
Video Adobe Stock
Milestone 2 Tips/Advice for Completion
To start, please remember that these assignments build on each
other-so Milestone 2 continues where Milestone 1 left off:
Explain why the patient has returned to the doctor's office.
What symptoms and signs is the patient experiencing? Page 6 of
the patient file explains that this admission is her 2nd
admission. It's an overview of the pneumonia and why it brought
her to be admitted.
Analyze the new symptoms and signs to determine whether the
pneumonia diagnosis is still a reasonable conclusion or could have been a misdiagnosis. Are the past diagnosis and current
symptoms possibly something else (i.e. you had to give examples
of alternate diagnosis in Milestone 1) i.e. COPD, CHF, . NOT
viral vs bacterial pneumonia. Use specific information from
both the recent visit and the patient history to inform your
analysis. Use symptoms and tests that have been completed to
determine the above.
Based on the new signs, symptoms, and potential diagnosis.
Discuss what new or potential treatments (not what was done in
the chart) would be appropriate. Why? Basically, if another.
diagnosis could have been made or if you can prove that the
chart supports another diagnosis, or you think the doctor made
the wrong diagnosis, etc. Remember your alternate diagnosis.
Why do you think what you think?
Regardless of what you conclude, you must have supportive
literature and to support and help explain why you came to your
conclusion.
NOTE:
Needs to be APA style, double spaced.
Must be cited and references included.
And please no plagiarism.
