444 west third street sex: dayton, ohio 45402-1460...

Patient Name: Date of Birth: Sex: Health Record Number: Account Number: Patient Type: Race:

Admit Date· 04/01/20xx

Admitting Diagnosis

Final (Principal) Diagnosis

Sarah Tonin 04/01/28 years ago F 144247

Inpatient Caucasian

Secondary Diagnoses and Complications

Operations/Procedures

Date Discharged: 04/03/20xx

Sinclair Memorial Hospital 444 West Third Street

Dayton, Ohio 45402-1460

.. ~ .. ..... . . . . . """'!:i

CODES

SIGNATURE OF ATTENDING PHYSICIAN DATE

[8] DISMISSED 0 EXPIRED 0 DISMISSED-ICF 0 DISMISSED TO SNF 0SIGNED SELF OUT 0 DISMISSED SPECIALITY UNIT 0 DISMISSED TO ANOTHER HOSPITAL 0 DISMISSED TO HOME UNDER 0 DISMISSED- OTHER

ADV DIRECTIVES: Y or N ADMITTING PHYS: Helen Loss, D.O. FAMILY PHYS: Henry Kostic, M.D.

INSURANCE INFORMATION: PATIENT EMPLOYER

HOME HEALTH CARE

ATTENDING PHYS: Helen Loss, D.O.

1::. 1 CARRIER : 0 MEDICARE 0 MEDICAID [8] : Medicaid HMO POLICY HOLDER: INSURED'S EMPLOYER: GROUP NAME: GROUP NUMBER: POLICY#: EFFECTIVE DATE:

2ND CARRIER: 0 MEDICARE 0MEDICAID D: POLICY HOLDER: INSURED'S EMPLOYER: GROUP NAME: GROUP NUMBER: POLICY#: EFFECTIVE DATE:

3RD CARRIER: 0 MEDICARE 0 MEDICAID 0 : POLICY HOLDER: INSURED'S EMPLOYER: GROUP NAME: GROUP NUMBER: POLICY#: EFFECTIVE DATE:

1

( , _

Sinc(air :Memoria( J-fosyita( 444 West 'lfiircf Street 'Dayton, Ofiio 45402

Obstetric Discharge Summary Maternal I Newborn Record System

Admitting Diagnosis 0 _____ _ Reasons Foi Admission on Date Time

0 Onset of Labor

0 Induction of Labor

0 Spontaneous Abortion

----------- -------0 Preterm Labor 0 __________________ _

Cesarean Section 0 Primary)1"Repeat

0 Tubal Ligation

0 Observation/Evaluation

0 Fetal Status

0 Medical Complications

0 Vaginal Bleeding

0 ROM 0 Premature 0 Prolonged 0 Obstetric Complications

Prenatal Procedures 0 Cerclage 0 Ultrasound # ______ _

0 NST O CST

0 Amniocentesis

O CVS 0 PUBS

0 None 0 Management of Medical Complications

0 Management of Obstetric Complications

Intrapartum Procedures Del --· :-,.,_.~...!-++ D vndelivered 0 Spontaneous Vaginal Delivery rean Delivery 0 Primaryp epeat

0 VBAC 0 Cesarean: Low Cervical, Transverse

0 Episioto.my: D Cesarean: Low Cervical ." Vertical

0 Vacuum Extraction D Cesarean: Classical

0 Forceps (Low) (Mid) 0 Cesarean: Hysterectomy

0 Rotation to 0 Uterine Exploration

0 Breech Extraction (Partial) (Total) 0 Tubal Ligation 0 Forceps to Extract Breech 0 Anesthesia ___________________ _

0 Curettage 0 ---------------

Postpartum/Operative Complications ~me 0 Transfusion 0 RHo (D)(ig 0 Tubal Ligation 0 Rubella lg __________ __

Ll Curettage 0 Antibiotics 0 [] ___________ _

Postpartum/Operative Complications )Gone r J __ Perineal Laceration ~ ] Psychological Maladaptation

1 (Vaginal) (Cervical) Laceration

r.J Pelvic Infection

~ Drug Transfus1on React1on

Eclamps1a

r' Unnary Infection

~~ Pulmonary Infection :·-, Wound Infection

0 Hematoma 0 Spinal Headache

Discharge Diagnosis 0 Amnionitis

0 Antepartum Bleeding

0 Failed Induction

0 False Labor

0 Hyperemesis Gravidarum 0 Placenta Previa

0 Postterm Pregnancy

0 Preeclampsia

1 Hemorrhage C Ulenne

~ Retained Placenta

:~· Phlebitis [] Morbidity (undetermined) 0 _____________ _

~rm Pregnancy-Delivered

/ D Premature Labor D Preterm Delivery

0 Postterm Delivery

0 PROM x Hours

D Spontaneous Abortion

0 Incompetent Cervix 0 __________________ ....,.., D __________________ __c_;

Comments

Circumcised 0 No ~ ~(DW-, q;rr

Discharge ~Mother 0 Other--------

Complications 0 No ~ Discharge Information Medication [] None

(or)

Pain

Diet

~(srte _ ______ -+------lntensity o \ i"

none h ig~1est :.. Routine

(or) --,..-------;..----------0 Unrestricted I ()

(or) -----+1 _;_I\+'-. ...,-'-1-'-' 4± ..._\4\,.._ . .J--=---D Routine / ' ~

(or) -------+------------

Activity

Instructions

Discharge to D Home (or) ------,----f----,-,-,------Follow up in --+----

2

Sinc{air Memoria{ Jfosyita{ 444 West 'lfiirc[ Street 'Dayton, Ofiio 45402

----~(:~----~----PATIENT IDENTIFICATION

Dayton, Ohio

Health History Summary

Pati€nt 's narm~ ...................... ....

Hon1e f.\ddress ............................................. ..

Date: •.· / . 1 • Race or Marital Years Age__ birth ______ ethnicity ______ Religion _ _______ status _____ _ married Education ___ _ Social Security Work Home number ______________ Occupation _______________ Tel. no. Tel. no. ______ _

Alternate Relation Work Home contact ----------------,---..,.,-----to patient ________ Tel. no. Tel. no. ______ _ Referring Attending

Medical History Check and detail positive findings including date and place of treatment. Precede findings by reference number.

1. Congenital anomalies .... .. .... .. .. .. ... . 8- .... D <..,i.l£ f ~ 2. Genetic diseases ............... ......... . -9 ..... ~ .(_

1 If r!.£

3. Multiple births .. ...... .. ....... .... ......... MB ..... ~ 7 . ,#..l . 4. Diabetes mellitus ............... .. ....... .-Q_ .. UY rj U-<.J<..J!.-( fl((J F 5. Malignancies ...... .. ..... .. .. ................. ~/.

6. Hypertension .. .. ........................... .. ...B~ ... :t£;1/~ F 7. Heart dis~ase ..... .... .... .. ... ,.zi ....... . ..Q ..... o f) &.! F 8. Rheumatrc fever ... .f}l..i/.r ........ -0 ~ fJ ~ 9. Pulmonary disease ......... ........ ...... '§:.r f.1 . ' ((_<._..

10. Gl problems .. .. .. ... .............. .. .... ...... \1..6 't.'L.l( l(p . 11 . Renal disease ..... .. ........... .. ............ .8 .... .0 12. Genitourinary tract problems .. .. ...... bOJ----13. Abnormal uterine bleeding ............ !:11-----· 14. Infertility .................... .. .. .... .. ........ .,.,a-r- . . ...;;_, 15. Venereal disease ........................... fd'. .. & ~ 16. Phlebitis, varicosities .. ......... .. ...... .. ..1-.f]-1---

17. Neurologic disorders .................. .. .. Q .. § .7 ...,1_

18. Metabol./endocrine disorders .. .. .. ...B:-:-... lif ft1. /T 19. Anemia/hemoglobinopathy .. .. ....... .ld ..... O 20. Blood disorders ......... ..... ............. ,LJ 0 21 Drug abuse .. ... .... .. .. . ............ ... o·":vtt.~·~d I Cf1 11-¥' 22.~alcohol use .................... ~ 1 f/Ljc/ tf.;f / / 23 ~us drseases ...... . . ..... ~ , 1 /t /.- 1 1

24. Operatrons/accrdents.... .. .... :,_..Q"" itA1/...t'-(. .tt:.JI A .. f..t.4ff. /{., C 25. Allergies/meds sensitivity .......... . ,...Q m Krt 26. Blood transfusions .. ..... ........ .. ... .... .,Q--. . . '-f- ;J . fi! 27. Other hospitalizations ....... .. ........ :./l-x...e./JtA tJ .££L:.j<..W.,_

Preexisting Risk Guide Indicates pregnancy/outcome at risk 31 . 0Age<15or>35 32. 0 <8th grade education 33. 0 Cardiac disease (class 1 or II) 34. 0 Tuberculosis, active 35. 0 Chronic pulmonary disease 36. 0 Thrombophlebitis 37. 0 Endocrinopathy

0 Epilepsy (on medication) 39. 0 Infertility {treated) 40. 0 2 abortions (spontaneous/induced) 41. 0 2::.,? deliveries

0 Previous preterm or SGA infants 0 Infants 2:,4,000 gms 0 Isoimmunization (ABO, etc.) 0 Hemorrhage during previous preg. 0 Previous preeclampsia 0 Surgically scarred uterus 0 Preg. without familial support 0 Second pregnancy in 12 months

Smoking (2:.1 pack per day)

51 . 0 --'------------52. 0 ----::----=------53. 0 -----------

Indicates pregnancy/outcome at high risk

54. 0 Age 2:,40 55. 0 Diabetes mellitus 56. 0 Hypertension 57. 0 Cardiac disease (class Ill or IV) 58. 0 Chronic renal disease ~: . :: ·: :: ::::::::::::::::::.: .. .. ........ o ..... o t'~uf'?t

0 Congenital/chromosomal anomalies 5-----"''r-------r------.....lo..------.,..------r--....W..I...O~::...-'"f"':~,...-~~:;n 0 Hemoglobinopathies

. l J lso.immunization (Rh) t-----J._...._._ __ .,..__~-+--..._,,......_...._..,.._..._.-,.;;.;;;~-~---'+',;,.;;;.+f...,---to.::. 0 Alcohol or drug abuse

6

7

8

63. LJ Habitual abortions Ll lncompetent cervix [] Prior fetal or neonatal death

3

(

Sinc[air .Memoria[ Jfosyita[ 444 'West Tfiin£ Street 'Dayton, Ofiio 45402 PATIENT IDENTIFICATION

Dayton, Ohio

Initial Pregnancy Profile Date: me I day I yr

• • 'Check and detail po$jtiV6 H1story Smce LMP (/) ~ . >oz -;;7 ,, , ~> ""·%~} ·' .. •.

1 Heartaches ... .............. ... .......... 8"" ~ '"'" omiting ...................... B' ' "

3 alpain ................ ..... ~ 4. Urinary complaints ...... ...... .... :-8·--rm 5. Vaginal discharge ................... ..a-----f " 6. Vaginal bleeding .................... ~ 7. Edema (specify area) ............. ~.

8. Febrile episode ....................... :B--i 9. Rubella exposure ..................... 9---

10. Other viral exposure .. .... .... ...... 9--- . 11 . Radiation exposure .... .. ............ g.--- ~ 12. 0 13. 0 14. Contraception prior

to conception

Last used: ___ r:_cr,_· 1_,_1$_-"_l_>_·r __

Pa1ient's nama

Initial Physical

SYSTEM Check and 'detail till abnormalfindi~~; ·t;~iow. Use ~renee numbers, 17. Skin .. ............................ .

18. EENT ..... .............. ......... .

19. Mouth .......................... ..

20. Neck ............................ ..

21. Chest.. ......................... .

22. Breast.. ........................ .

23. Heart ......................... ..

24 Lungs .... ..

25. Abdomen ..

26 Musculoskeletal . . .. . ..

27. Extremities ..

28. Neurologic ....

Pelvic Examination

29. Ext ge'litalia ..

30. Vagina .... ... ..

31. Cervix .. .. ..................... .

32. Uterus (describe) ...... ..

33. Adnexa .............. .. ........ .

34. Rectum .................. .. .... .

35. Other ........................... .

36 Diag. conj .

D

D

D

D

D

0

0

:::J

D

D

D

0

D

D

37 Shape sacrum -----

38 s.s. notch

39 Ischial spines

Bony 40 Pubic 41 Trans 42 Post 43 Coccyx arch -----.:--- outlet sag. diam ______ _

Pelvis 44 Classification 0 Android 0 Anthropoid 0 Platypelloid

45 Estimation 0 Borderline D Contracted

15. Nutritional Assessment

Adequate 0 Inadequate Nutritional counseling

16. Medications Since LMP

0 Exposure to Drugs

v

v

I I

I

4

Sinc{air :.Memoria{ J-iosyita{ 444 West 'lfiinf Street 1Jayton, Ofiio 45402

~ ....... · ............ ~~r, .....,....'-"~---:-----PA_T...,..IE~f IDENTIFICATION -----,

Prenatal Flow Record

Dayton, Ohio Patient's name _ _ =

Has no known risk Is "at risk" Is at high risk

Continuing Risk Assessment Guida {revise RISK STATUS) Date At risk factor Date High Risk factors

_ I_ Uterine/cervical malformation _ !_ Diabetes mellitus _I_ Suspect Pelvis _!_Hypertension _ I_ Rh Negative (nonsensitized) _ I_ Thrombophlebitis _ !_ Anemia (Hct<30%: Hgb< 1 0%) _I_ Herpes (type 2) _I_ Venereal disease _ I_ Rh sensitization _ 1 _ Acute pyelonephritis ~ I_ Uterine bleeding _ I_ Failure to gain weight _ I_ Hydramnios _I_ Abnormal presentation _I_ Severe preeciampsia _ 1 _ Postterm pregnancy _I_ Fetal growth retardation _I_ Alcohol use _I_ Premature rupt. membranes _ 1 _ _I_ Multiple pregnancy (preterm) _I_ _I_ Alcohol and drug abuse

_!_ _I_ ----------_ !_ _I_ ----------_/_ I

I

;--I

l I I +

I I 'l +

I I I +

I I I +

I I I +

I I ·' I +

I I / +

DS-2694 00/00 Physician's signature

Result

Return visit Sig .

5

Sinc{air :Memoria{ J-fosyita{ 444 West Tfiirr£ Street 'Dayton, Ofiio 45402

Osteopathic Musculoskeletal Examination of the Hospitalized Patient

1. AntJPost. Spinal Curves: I N D

Cervical Lordosis 0 1Lr 0 Thoracic Kyphosis 0 fJ 0 Lumbar Lordosis 0 0 0

!-Increased N-Normal D-Decreased

Scoliosis (Lateral Spinal Curves)

~ None 0 Sitting 0 Functional 0 Standing 0 Mild 0 Prone/Supine 0 Moderate 0 Lateral Recumbent 0 Severe 0 Unable to Examine

Reasons:

3. SOMATIC DYSFUNCTIONS CORRELATE WITH:

D Traumatic D Rheumatological 0 Orthopedic 0 EENT 0 Neurological 0 Cardiovascular D Viscera somatic 0 Pulmonary D Primary Ms-Skeletal 0 Gastrointestinal D Activities of Daily Living 0 Genitourinary D Other 0 Congenital

4. PEDS ONLY: a. Cranium:

Fontanelles: Anterior Posterior Patent/closed

@ Overnding Sutures Present/absent

b. Ambulat1on:

L1 Walks 0 Sits unassisted 0 Crawls [J F1olls over

CHIEF COMPLAINT: I .__A./}

Instructions: Complete Boxes #1 - 3 (#4 Pediatrics Only)

2. SEVERITY KEY:

0 = No SD or background (BG) levels

1 = Minor TART more than BG levels

2 =TART obvious (R&T esp) +1- symptoms

3 = Symptomatic, R and T very easily found, "key lesion"

Head (739.0) !21 D Neck (739.1) ~ D Thoracic T1-4 (739.2) D

TS-9 D T1 0-12 D

Lumbar (739.3) D Sacrum Coccy eal (739.4) D Pelvis/Innominate/ Pubis (739.5) I2J D

R Extremity (lower)

L (739.6) D R

Extremity (upper) L (739.7) tJ 0

Ribs (739.8) [3 r c--1

Other I Abdomen (739.9) 0 LJ

D D D D 0 D

D

D

0

0 0

0

ASSESSMENT TOOLS:

D 0 0 0 0 0

0

0

0

0 0

[]

T =Tenderness A = Asymmetry R = Restricted Motion

Active Passive

T =Tissue Texture Changes

Physician Signature· _,__ _ _____ -==-.., Date :_~....l...f-/--l./-+"/tl._~ ----

6

Name: DOB :

Adm. Date:

FIRST ASSISTANT :

Sine fair Memoria{ J{osyita{ 444 West Tfiirc[ Street 'Dayton, Ofiio 45402

MRN: Acct#: Fac: VS Rm: 1202 Date of Surgery : 04/01/20JI Disc Date:

ANESTHES I A : Spinal anesthetic.

PREOPERATIVE DIAGNOSES : Intrauterine pregnancy 40 weeks , previous Cesarean section x2.

POSTOPERATIVE DIAGNOSES : Intrauterine pregnancy 40 weeks, previous Cesarean section x2.

PROC: A repeat low- transverse cesarean section .

PROCEDURE TECHNIQUE : This 28-year-old female was taken to the operating room , placed in supine position after having a spinal anesthetic placed . She had a Foley catheter sterilely placed and she was sterilely prepped and draped . She was checked for adequate analgesia, when this was assured, a low Pfannenstiel skin was subsequently made through the previous skin scar. The incision was carried down through the anterior abdominal wall in the usual fashion and entrance into the abdominal cavity was then achieved. Bladder blade was then positioned. The lower uterine bladder flap was then developed off the lower uterine segment, bladder blade was repositioned. A low uterine transverse incision was subsequently made. Incisions of the intrauterine cavity was noted clear fluid. With the aid of a device, one pull was utilized to deliver the infant through the lower uterine segment vertex. The infant's nasopharynx was suctioned . No nuchal cord. Remaining infant delivered without difficulties . Cord was doubly clamped and fired , and the infant given t o the nursery personnel present at the time o f delivery. The co r d b l ood was obta i ned. Placenta was ma n uall y extracted fr om t he uterus. The uteru s was e xterna lize d to t h e abd omen. Old blood and fragments were removed from the lower uterine segment. The lower uter i ne segment was then reapproximated using a runn1ng lock stitch of 0 Vicryl at ~he f1rst layer approximating the myometrial layer and second layer was utilized to imbricate this first layer. Several figure-of-eight sutures were olaced along the suture line for hemostasis. The uterus was placed bac~ 1ntra-abdom1nally. Pelvic lavage was performed with hemostasis being assured. The bladder flap was then reapproximated using 3-r Vicryl. Pelvic .avage was once again performed. The abdominal wall was then closed in usual £ash1on w~th the f1rst layer approx1mating •he peritoneum. Tne same suture was u~ilized to reapproximate the rectus abdom1n1s muscle. Anterior rectus fascia was reapproximated by using 0 V1cryl starting laterally and t1ed midline . Subcu was closed with 3 - 0 Vicryl. Irrigation had been performed throughout all the closure layers and the skin was c l o s ed wi th a runn i ng st itch o f 4- 0 Monocryl . Dermabo nd was app l ied . All blood c l o t s remo ved fr om v agina, which was minimal . Urine draining yellow clear fluid at the completion of procedure. Estimated blood loss 300 cc. She was taken to the recovery room in satisfactory condition.

PROC RPT Page 1 7

Sinc{air Memoria{ J-fosyita{ 444 West Tfiirci Street

--,

1Jayton, Ofiio 45402

Name: ......... l'jj MRN: ~I?Qi:UeC?f Acct: • Job#:

GROSS PATHOLOGY: This is a 28-year-old gravida 5, para 2-0-2-2 with an EDC of 03/27, previous C-sections x2 was brought back for elective repeat Csection. She had the above procedure performed. Delivered a viable male infant through the lower uterine segment. The uterus, tubes, and ovaries were unremarkable. No tubal ligation was performed at this time. Estimated blood loss 300 cc. Urine draining yellow yellow clear fluid at ~~------ ~ completion of procedure.

0 : T: P:

04/01/2 04/01/2 04/01/20

Job #: ..gy;n a a•

08:05:11 15:05:59 15:40:00PM

PROC RPT Page 2 8

Sinc{air Jvtemoria{ J{osyita{ Treatment Consent-Information Release-Financial Statement

Facility:

CONSENT FOR TREATMENT : The patient or his agent, recognizing the need for hospital care, consents to hospital services

as ordered by the attending physician, including emergency, outpatient, observation, and inpatient care, anesthesia,

laboratory procedures, medical or surgical treatment, x-ray examination or other hospital services rendered under the

general and specific instructions of the physician.

CONSENT TO RELEASE INFORMATION: Authorization is given to K~ ~ fl!llil? 3 u•· !frko!tconsisting of'~· !1aiJIIJli1811IIJII!II .. and -~~ Center and affiliated

and hospital records to any~loyee, facility or

affiliate, to any insurer, government agency, health care provider or facility or a.11y ether entitjp for the purpose of

{a)obtaining payment for hospital, medical or other services or products provided to the patient, {b)discharge planning

and future hospital, medical or nursing care, {c)permitting independent health care providers or their designees who

have provided services to or for the patient, access to information needed for billing purposes and filing of claims

with insurers or other third-party payers, {d)disclosing identification data to affiliated foundations for charitable

purposes, {e)disclosing data for health care services monitoring, assessment and improvement or for state, federal, or

local regulatory compliance, or {f)for legal consultation, risk management and quality assurance purposes . This auth

orization includes records which may contain information concerning care of psychiatric conditions, drug or alcohol

abuse, HIV test results, AIDS and/or AIDS related conditions .

ASSIGNMENT OF INSURANCE BENEFITS: In consideration of the hospital , medical, and nursing care given to the patient, and

in the event the patient is entitled to hospital and/or medical benefits said benefits are hereby assigned to the

hospital . authorize payment to be made directly to the .acility providing care and treatment .

PHYSICIAN CARE: The pat ient will be under the professional care of a doctor called the attending or ordering physician,

who arranges the services for care and treatment of the patient . The attending/ordering physician is usually selected

by the patient, or the patient's agent, but may, under unusual or emergency circumstances be otherwise selected .

NOTICE: Physicians who render professional services to you in a are independent practitioners and are

not employees or agents of the~facil ity . ls not responsible for the acts or omissions of the physicians that

3re not directed or controlled by the~entity providing care and treatment.

fiNANCIAL AGREEMENT: The undersigned agree that the patient, and guarantor if any, in consideration of the services to

~e rendered to the patient, is/are individually obligated to pay the full account of th~ntity providing care and

treatment upon the patient's discharge, or sooner if requested. Because NO ..... entity extends credit , the undersigned

~derstands all accounts for the patient are due in full at the time of service to the patient. Individuals may be elig

ible to receive basic, medically necessary hospital-level services at reduced or no cost if family income is at or below

:he federal poverty guidelines.

<ALUABLES: We recommend that the patient send home, or leave at home any personal valuables on their person at the time

)f treatment , service or admission . However, for the convenience of the patients, a safe is available without charge if

1ecessary. Therefore the hospital shall not be liable for the loss or damage to any personal proper ty {including cloth

eng) <lf the patient's brought into the hospital unless it is deposited in the facility safe for safe keeping.

lTHERo l h'lve received a copy o• ··.h Not1ce o~ Privacy Practice dnd Patient Bill of Rights with gnevance process,

1i s:-.. ati•ln gu1de lines 1 contact numbers 1 ~' state a gene 1es, and 1nform<1t ion on smoking cessation.

~ have read the i terns above, or i · • s read to me, or expla~ned t.o >:he satisfaction of the undersigned patient or

L~-~· and agree to the terms hereof

litness

Rela t ionship to Patient

Reason unable to sign {if applicable)

MRII: ifll. •••· Name:

Acct II: ,... . • 11 DOB : 01/08/

9

Sinc{air Memoria{ J{osyita{ 444 VVest J(hirc(Street ~~~------~-----------r--~o~o~N~o~ri~M~PR~IN~r~A~s~ov~E~T~HI~s~LI~NE~------------------

1Jayton, Ohio 45402

PHYSICIAN'S ORDERS

The Pharmacy may dispense another identical drug, unless specifically ordered otherwise.

GS0002U (02/07)

2. _______________ _

3. ________________ _

4. _______________ _

ORDERS & TREATMENTS

PHYSICIAN'S ORDERS 10

{ ( ~r-~~~~---------------~~-~~~~~~~~~~~ Sinc{air Jvlemoria{ Jfosyita ALLERGIES: LINE

444 West 'lliircf Street Dayton, Oliio 45402

PHYSICIAN'S ORDERS

The pharmacy may dispense another identical drug, unless specifically ordered otherwise.

2. Nausea:

5. Reversal:

1. __________ _

2. __________ _

3. __________ _

4. __________ _

11

'·

Sinc(air Jvlemoria( J{osyita( 444 West 'lfiira Street 1Jayton, Ofiio 4 5402

ELECTRONIC ORDER REPORT

ALLERGIES: DIPHENHYDRAMINE

CC: C/S REPEAT

Entry Location: _. •••

ORD NUM:9, PSAD-C-SECTION ADMISSION ONCE,MAX ACTIONS: 1

PRG- TRM;PREV C SECT

NW/New(Start date 04/01/2 0639 - No Stop Date found - )

Ordered By: ~l I uall&LC.t . DO (Electronic

ORD NUM:10 ,C-SECTION ADMIT LABS (DONE WITH ADMIT) cent,

NW/ New(Start date 04/01/2~ 0639 - No Stop Date found - )

Ordered By: DO (Elec troni c

ADMITTING: ,~~--~~~----~~

Session Start: 04/01/20 0639

Session Stop: 04/01/2

Run Date : 04/01/2

0639

0640

ORD NUM:ll ,PLACE AMNIO AND us REPORTS ON CHART ONCE,MAX ACTIONS: 1

NW/New (Start - No Stop Date found -)

Ordered By :~~~~im DO (Elec t r onic

ORD NUM:12, VITAL SIGNS AND FHT ' S ON ADMISSION cent,

0639 - No Stop Dat e f ound -) NW/ New (Start date 04 / 01/2 0

Ordered By:~~-~-~~~li~ DO (Ele c tronic

ORD NUM:13, ELECTRONIC FETAL MONITORING ONCE,MAX ACTIONS: 1

NW/New( Start date 04/ 0l/2 tiJ 0639 - No Stop Dat e f ound -)

Ordered By : 1.. ' ' DO (Electronic

ORD NUM:14,DIET-NPO- (NOTHING BY MOUTH) meals,

NW/New(Start date 04/01/2~ 0639 - No Stop Date found -)

Ordered By: . " ' , DO (E lectronic

ORD NUM: 15. c- SECTION ABDOMINAL P REP ONCE' MAX ACTIONS: 1

NW/New(Start date 04 /0 1/2 - . 0639 - No Stop Date found -)

Ordered By: , DO (Electronic

,~L NJM ;, ANTI EMBOLIC STOCKINGS PRE-OP con::.,

NW/New(Start date 04/01/2 0639 · No Stop Date found -)

Jrdcr•" ~-~ !'l,,. .. _.i!!!I'I!IEiiiiiii'iiiiiYtt'•••sll·_.l.il* DO

Adm1tted: 04/01/2

HT: 5 ft 7 in WT: 174 lbs

Age : 2 8 Sex: F

)QB: 01/08/~

(Electronic

3 ozs

DO

DO

Signed By: ····-~~ DO

Signed By: 41lla.~~,.~~~~~~ DO

Signed By: ·····~~~~~~~IJ!IJJ!j)J. DO

Signed By -~- ~- --~~~~--~~~~~~-~~" DO

MRN:

Account: NS Room/Bed : l LDY 1390A


\

/

PAGE 01

12


( .,..........._.

Sinc{air :Memoria{ J{ospita{ 444 West Tfiircf Street 'Dayton, Ofzio 45402


L

CC: C/S REPEAT ADMITTING: .... iM.$ 'Rif'l?.0'

Entry Location: r til I • .

ORD NUM:23, P/O C-SECTION VITAL SIGNS - SEE ORD REF cont.

NW/New(Start date 04/01/2~ 0806 7 No Stop Date found 7)

Ordered Byi<J· i!M!!tlifilllftllllif'.· DO (Electronic )

ORD NUM:24, CHECK FUNDUS C-SECTION cont,

NW/New(Start date 04/01/20 0806 - No Stop Date found 7)

Ordered By<:·?J!I!!I.!l'!IJIIi!!!l!l!lll• DO (Electronic

ORD NUM:25, NOTIFY PHYSICIAN OF EXCESS LOCHIA RUBRA cant,

NW/New(Start date 04/01/2 '

Ordered By !Iii' Wj-iltl!IIJII[M~ DO

0806 7 No Stop Date found -)

(Electronic

ORD NUM:26, REMOVE ABDOMINAL DRESSING IN AM cant,

NW/New(Start date 04/01 /2 0 0806 - No Stop Date found -)

Ordered By:~• DO (Electronic

ORD NUM:27, ABDOMINAL BINDER cant,

as needed

NW/New(Start date 04 /01/20

Ordered By~.llbbiZSSIIII .. a!&WBr.< DO

0806 7 No Stop Date found -)

(Electronic

ORD NUM:28, REMOVE STAPLES FROM INCISION cont.

a t time of discharge

NW/New(Start date 04/01/2

Ordered By f!IIJI!!I!J!l!!!!I!'I•~J> DO

0806 - No Stop Date found -)

(Electronic

ORD NUM:29,P LACE STERI STRIPS cont,

at time of discharge

N"I'I/New(St.art date 04/01/2 0806 - lio Stop Date found ·1

Clrdered By· lfl IB k DO (Electronic

Adm1tted: 04/01/2 HT: 5 ft

Ag e: 28

DOB: 01/0

7 i n WT: 174 lbs

Sex: F

3 ozs

Session Start: 04/01/20


Run Date : 04/01/20

Signed By: :r tlJ££ •ww. DO

Signed By: •••••• DO

Signed By: -·~~~-~~- DO

Signed By: ......... DO

Signed By: ~--~~~~~~--~DO

Signed By: 'Ill!&, . DO

Signed By· ~llllllll .. • DC.

MRN:

Account: ~ NS Room/Bed:

~ , ELECTRONIC ORDER REPORT

0805

0811

0812

PAGE 01

13

ALLERGIES : DIPHENHYDRAMINE

Sinc{air Memoria{ J{osyita{ 444 West Third Street 'Dayton, Ofiio 45402


CC: C/S REPEAT ADMITTING:AIIIIIIIIIII~~~o

Entry Location : Tllbi P

ORD NUM:3o, ACTIVITY AS TOLERATED cant,

NW/New(Start date 04/01/2~806 - No Stop Date found -)

Ordered By ='ll!lltililliU 1•1 H. DO (Electronic

ORD NUM: 14, DIET-NPO- (NOTHING BY MOUTH) meals,

ID/DC'D(Start date 04/01/2. 0806 -H)

Ordered By: ~*&*llaiii?.ZIIIILLSLLS • DO (Paper Chart)

NW/New(Start date 04/01/2011 0639 - Stop date 04/01/2 0806 -H)

Ordered By:~· ~~~~~~~~~la~~~~~ DO (Electronic )

ORD NUM:31, DIET-FULL LIQUID DIET meals,

ID / DC'D(Start date 04/01/ 20 0808 -H)

(Paper Chart)

NW/ New(Start date 04 / 01 / 20 0806 - Stop date 04/ 01 / 20 0808 -H )

Ordered By: tllllllliliJ DO (Electronic )

ORD NUM:32, ADVANCE DIET AS TOLERATED cont,

NW/ New(Start dat~' ~4 / 01/2~080 6 -No St op Date f ound-)

Ordered By , DO (Elec tronic

ORD NUM: 33, FOLEY CATHETER TO STRAIGHT DRAINAGE cont ,

NW/New (Start date 04/ 01/20. 0806 - No Stop Date found -)

Orde red By: ~I&MI~~~~ DO (Electronic )

ORD NUM:34,DC FOLEY IN 8 HRS- UA , C&S F IRST I F ORDER cont.

Obtain UA, C&S before de' i.ng if ordered

NW/ New(Start date 04/01/ 2

Adm1tted: 04/01/20

DO

0806 - No St.op Date foUDd -)

(Electronic

HT: 5 ft 7 in WT: 174 lbs 3 ozs

Age: 28 Sex: F

DOB : 01/08/~

04/01/2 1 04/01/2 ' 04/0!/2 ....

Session Start:

Session Stop :

Run Date :

, DO

Signed By: USER PAPER-CHART


Signed By : .,. ..... .,,,, DO

Signed By: ........ DO

Signed By: · ···-DO

Signed By: i.«JliJIJI!Ii. DO


0805

0811

0812

PAGE 02

14


(

'~

Sinc[air Memor ia[ J{osyita[ 444 West Thircf Street Day ton, Ohio 45402


L

CC: C/S REPEAT ADMITTING: ........ DO

Entry Location : :t:!M-••IIIIU .. IWr

ORD NUM:3s, STRAIGHT CATH X 1 UNABLE TO VOID x 12hrs cont,

NW/New(Start date 04/01/20 ; 0806 - No Stop Date found - )

Ordered By: DO (Elec t ronic

oRD NUM:36, COMPLETE CURRENT IV AT 200 ML/HR, THEN cont.

NW/ New(Start date 04/01/20~ 0806 - No Stop Date found - )

Ordered By: ~llllllllll· DO (El ectronic

ORD NUM:37, IV DEXTROSE 5% AND 1/2 NS AT 125 ML/HR cont,

NW/ New (Start date 04 / 01/2

Ordered By ·····~If, DO

0806 - No Stop Date found - )

(Electronic )

ORD NUM:38, DC IV IN AM IF STABLE cont.

NW/New (Star t date ·04/01/ 2 · 0806 - No Stop Date f ound - )

Ordered By llJ44#!1'*111!111\CY, DO (Electronic

Session Start:

Session Stop:

!tun Date :

04/01/210 0805 04/01/2 0811

04/01/2 0812

Signed By: .......... DO

Signed By: t!!l!lllilf!ililflll•iiiJI DO

Signed By: ,tfllllllfl·-· DO

Signed By: W#l!lii·£2·-···Jir,ti'\; DO

ORD NUM:39, 0RDER ANTIBODY TITRE- I F RhNEG & BABY POS ONCE,MAX ACTIONS: 1

Give RhoD Immune Globulin if indicated

NW/New (S t art date 0 4/ 0 1/2~080 6 · - No Stop Da t e found -)

Ordered By.zt~•••••1f'-· DO (Electronic Signed By~ .. -..-11111Mt

ORO NUM:40,PB-HOME HEALTH CARE VISIT IF ELIGIBLE ONCE,MAX ACTIONS: 1

OB patient


Ordered By: DO


(Electronic

ORD NUM:4l,SEQUENTIAL COMPRESSION DEVICES cont.

NW/New(Start date 04/01 /2 0806 - No Stop Date found -)

Ordered By .... ., 'Rf DO (E l ectroni<-

Signed By:

DO

DO

DO

Admitted: 04/0l7/~2~~r--------------------------------------------------jiijiiiiiiiiiiiiiiij~--------------------------


MRN: ~!:!::: ... Account: Age: 28 Sex: F

DOB: 01/08/~ . , NS Room/Bed: PAGE 03

E LECTRONI C ORDER REPORT

15

(


CC: C/S REPEAT

Sinc{air :Memoria{ J{osyita{ 444 West Tftira Street 'Dayton, Ohio 45402


ADMITTING: ...... ... DO

Session Start: 04/01/2 0805

Entry Loca tion: YP&&b&#z•a Session Stop: 04/01/20

Run Date : 04/0 1/20

ORD NUM:42,CALL:DVT PROPHYLAX INDICATED & NO ORDER cent,

Notify Physician

NW/New(Start date 04/0l/20~ 0806 - No Stop Date found -)

Ordered By,....... ~~ Signed By: IT .JI.J liP , DO (Electronic

ORD NUM :43, LAB-CBC W/DIFF - COMPLETE BLOOD COUNT Qty: 1' ONCE,MAX ACTIONS: 1

date ID/DC'D(Start 04/01/20 ''

0811 -H)

Ordered By: DO (Paper Chart)

NW/New(Start date 04/02 /20. 0500 - Stop date 04 / 02/2"' 0500 -H)

Ordered By . DO ( ectronic )

ORD NUM:44, P/O C-SECTION VITAL SIGNS - SEE ORD REF cent,

NW/New(Start date 04/01/20 , 0807 - No Stop Date found -)

Ordered By !Ill. ···--·l!j-, DO (Electronic

ORD NUM:45, CHECK FUNDUS C-SECTION cent,

NW/New(Start date 04/01/20 0807 - No Stop Date found -)

Ordered By:.iilfM!Iitlii'IM!i! ll' DO (Electronic

ORD NUM:46, NOTIFY PHYSICIAN OF EXCESS LOCHIA RUBRA cent,

NW/New(Start date 04 / 01/20

Ordered By:U!fRIJM~ft' · DO


(Electronic

ORD NUM:47 , REMOVE ABDOMINAL DRESSING IN AM cent,


Or dered By Wlllllii•IJI••• DO

0807 - No Stop Date found - )

(Electronic

ORD NUM:48, ABDOMINAL BINDER cent,

as needed

NW/ New(Start date 04/01/20 0807 - No Stop Date found -)

Ordered By ti!il!!lllllli!l···· DO ( E l ectron~ c

Admitted: 01/01/

5 ft 7 1n WT: 174 lbs 3 ozs

Age : 28 Sex: F

DOB: 01 /0 8/ 1


Signed By: liJb . a: Y , DO

Signed By: ! .. $ ••• , .. , DO

Signed By: ······~ DO

Signed By:1!iii······ DO

Signed By: ~····· DO

S1gned By : ••••. DO

MRN:

Account: NS Room/Bed:


0811

0812

PAGE 04

16

Sinc{air Memoria{ J{osyita{ 444 West Tfiirc{ Street Vayton, Ohio 45402



CC: C/S REPEAT

Entry Location: .IIII!IIJIPl!l\

ORD NUM:49, REMOVE STAPLES FROM INCISION cant,


NW/New (Start date ~4/0l/24 0807 - No Stop Date found -)

Ordered B · • DO (Electronic

ORD NUM: so, PLACE STERI STRIPS cant,

at time of discharge ~


Ordered B DO (Electronic

ORD NUM:Sl, ACTIVITY AS 'I;OLERATED cant,

NW/New(Start date 04/0l/20 , ., 0807 - No Stop Date found -)

Ordered By~ DO (Electronic

ORD NUM:52, DIET-FULL LI~ID DIET meals,

ID/DC ' D(Start date 04/0l/2~ 0809 - H)

Ordered By ·fl!.~~~~· fflllll!l!ll!liJJt DO

NW/New(Start date 04/01/20' 080 7 - Stop date 04/01/2

Ordered BV,······· DO

(Paper Chart )

0809 -H)

(Electronic )

ORD NUM:53,ADVANCE DIET AS TOLERATED cant,

NW/New(Start date 04/0l/20[ ' 0807 - No Stop Date found -)

Ordered B"· .~ D ~~Fr.tiM'-~, (Electronic

ORD NUM:S4,FOLEY CATHETER TO STRAIGHT DRAINAGE cant , 4

NW/New(Start date 04/0l/20 0807 - No Stop Date found -) t•

Ordered B ·.-' DO (Electronic )

ORD NUM:ss,DC FOLEY IN 8 HRS -UA, C&S FIRST IF ORDER cant

Oltai,-, UA, C&S !:lef .•·e dc'ing _, 0ydered

NW/New(Start date 04/01/2~ 0807 - No

·")rdc·H-d Hy ..... I!S!ill!l§;·l· DO

; Admltted- 04/01/2

Stop Date found -)

{E lectronic


Age: 2 8 Sex: F

DOB: 01/08

ADMITTING: ·~~~~ .... ~. Session Start: 04/01/2


Run Date : 04/01/2

Signed By: ....... ~~!!!!~- DO

Signed By: tlfiiJIIIIJ!'·, DO

Signed By: ' DO


Signed By: DO

DO

Signed By:

.)( ..


DO

0805

0811

0812

PAGE 05

17


C-Sinc{air :Memoria{ J{osyita{ 444 West Thirc( Street 1Jayton, Ohio 45402


CC: C/S REPEAT ADMITTING: ,. .......... ~ DO

Entry Location:

ORD NUM:56, STRAIGHT CATH x 1 UNABLE TO VOID x 12hrs cont,

NW/New(Start date 04/01/20~0807 -No Stop Date found -)

Ordered By:f)g ••• p DO (Electronic )

ORD NUM :57,COMPLETE CURRENT IV AT 200 ML/HR, THEN cont,

NW/New(Start date 04/01/2,~ 0807 - No Stop Date found -)

Ordered By:d IJ-IIm Q DO (Electronic )

ORD NUM:58,IV DEXTROSE 5% AND 1/2 NS AT 125 ML/HR cont,


Ordered By: DO


(Electronic )

ORD NUM:59, DC IV IN AM IF STABLE cont,

NW/New(Start date 04/0l/241t 0807 - No Stop Date found -)

Ordered By , DO (Electronic

Session Start:

Session Stop:

Run Date : 04/01/20 -

Signed By:····~J.II!-I!tt, DO

Signed By: Ql!\l!JI!MIIIIIf1,.DO

Signed By""!llflllllllii!,III··=~DO

ORD NUM:6o, ORDER ANTIBODY TITRE-IF RhNEG & BABY POS ONCE,MAX ACTIONS: 1

Give RhoD Immune Globulin if indicated

NW/New(Start date 04 / 01 /2~ 0807 - No Stop Date found -)

Ordered By:~ R 11M• DO (Electronic Signed By : •ti IIU!..,t DO

ORD NUM:6l,PB-HOME HEALTH CARE VISIT IF ELIGIBLE ONCE ,MAX ACTIONS: 1

OB patient


Orde red By: DO


(Electronic

ORD NUM: 62, CALL: DVT PROPHYLAX I NDI CATED & NO ORDER cent,

Notify Physician

lm/New(Start date 04/01/2

Ordered By :IJiiilliillrilf

Admitted 04/01/2~

DO


(Electronic )


Age: 28 Sex: F

DOB: 01/08/1-

Signed By:~ii{liljj(MIIJ •• jiW

DO


0805

08 11

08 12

PAGE 06

18

Sinc[air Memoria[ J{osyita[ 444 West 'lfiira Street 'Dayton, Ohio 45402



CC: C/S REPEAT

Entry Location : BPI&2~

ORD NUM :63, P/O C-SECTION VITAL SIGNS - SEE ORD REF cont,

NW/New(Start date 04/01/20~0809 - No Stop Date found -)

Ordered By (Electronic )

ORD NUM:64, CHECK FUNDUS C-SECTION c ont,

NW/New(Start date 04/01/20,., 0809 - No Stop Date found -)

Ordered B , DO (Electronic

ORD NUM:6s, NOTIFY PHYSICIAN OF EXCESS LOCHIA RUBRA cont,


Ordered B) b [j'ip -~t, DO (Electronic

ORD NUM :66, REMOVE ABDOMINAL DRESSING IN AM cont,

NW/New(Start date 04/01/2~ 0809 - No Stop Date found - )

Ordered By--@?S'~ DO (Electronic

ORD NUM:67, ABDOMINAL BINDER c ont,

as needed


Ordered By : V''i!l · 1Ui•L• DO (Electronic

ORD NUM :6s ,REMOVE STAPLES FROM INCISION cont ,

a t time o f d i scharge

NW/New(Start date 04/ 01 / 20 0809 - No Stop Date found -)

Ordered By ~= llll .. li~~ DO (Electronic

ORD NUM :69, PLACE STERI STRIPS cont,

at t i me of discharge

NW/ New (Sta rt da.te 04/01/2 . 0809 - No Stop Date found ·I

Ordered By !tflilllliiiJIIIilfiiW DO (Electronic

ADM! TTING : ~>{!dlddliiiJ···~

Session Start: 04/01/2

Session Stop: 04/01 / 2

Run Date :

Signed By ::'Jlllf!lllli!JIII\i.M~r,. DO

S i gne d By :······rt, DO

Signe d By~~ DO

Signed By: ·~~~~-~- .~,I!J,~-.. ~'· DO

Signed By·- ~~~~~~· DO

s.gned By -~ifiti'M·jil~ DC

DO

0805

ORll

0812

cdmitted: 04/01/2~;---------------------------------------------------~~--.. --~~--~~~--~----------------------------IT: 5 ft 7 in

ge: 28 Sex: F

0 8 : 01/0 8 /1

WT: 174 lbs 3 ozs MRN : '•2 UD IR J Account : MMIJJJt• NS Room/Bed: ~~11 .. 1111~- ~

ELECTRONIC ORDER REPORT PAGE 07

19

IF DICTATING DISCHARGE SUMMARY ON UNIT, USE THIS FORM TO DICTATE MEDICATIONS FROM. IF DICTATING DISCHARGE SUMMARY lATER DICTATE FROM THE LOGICARE MEDICATION SUMMARY.

PATIENT HEIGHT 11 · PATIENT wEIGHT I'll/ IPs (KG)

Do have any Medication, X-Ray Dye, Food, Environmental, Latex Allergies?

0 NO KNOWN ADVERSE REACTIONS OR ALLERGIES S -- List below and include the type of reaction

ALLERGY AND TYPE OF REACTION ALLERGY AND TYPE OF REACTION

DATE I TIME RECONCILING NURSE SIGNATURE

ADDITIONAL DISCHARGE MEDICATION ORDERS

·-------------------------------------------· Patients with a diagnosis of Ml, Heart Failure, Open Heart Surgery, or Percutaneous Coronary lnteJVention (PCI) : Evidence Based Medicine and National Quality Measures recommend these patients be on Aspirin, Beta Blockers, Ace Inhibitors (ACEI) or Angiotension Receptor Blocker (ARBs).

Product name Dose Frequency

- -·--------···-·-·-·-------·-·--____j_ __________ j ________ ,, ____ . __ , ___ _ ! i I - ---- -.-1 -----r-·

Route or Topical Site

~ --- --- -

--~~ -----I - 1 - -

_----=---~~-=-+~~~----= I ----- .... __ ----- ·--· -- ·-----+-----r _:_:::- -:-:---= - -- -----

~~~~~-~~~~~~~~~~~------Sinc{air Memoria{ J{ospita{

PHYSICIAN ADMISSIONAND DIS'CFfARGE MEDICATION RECONCILIATION ORDERS K7510-010 ~FRONT ©K-IdU .... IllPI ' u"""

...... -------· /28

Page __ of __ 20


CC: C/S REPEAT

Sinc[air Jvlemoria[ J{osyita[ 444 West Thircf Street 'Dayton, Ohio 45402


ADMITTING:

Session Start: 04/01/2 · 0805

oRD NUM:63, P/O C-SECTION VITAL SIGNS - SEE ORD REF cent,


Ordered By ,qQ]jl!U!IIIJI• DO (Electronic )

ORD NUM:64, CHECK FUNDUS C-SECTION cent,

NW/New(Start date 04/01/2 0' 0809 - No Stop Date found -)

Ordered BY'=••· .. ··~ DO (Electronic

ORD NU!-1:6s, NOTIFY PHYSICIAN OF EXCESS LOCHIA RUBRA c e nt,

NW/New(Start date 04 / 01/2~0809 - No Stop Date found -)

Ordered By :1 DO (Electronic

ORD NUM:66, REMOVE ABDOMINAL DRESSING IN AM cent,

NW/ New(Start date 04/01/2~ 0809 - No Stop Date found -)

Ordered By:•; S !IIIJU'f DO (Electronic

ORD NUM :67, ABDOMINAL BINDER c ent,

as needed

NW/ New(Start

Ordered By: _.. •• lilllllfijoo. 0809 - No Stop Date found -)

(Electronic

ORD NUM :68, REMOVE STAPLES FROM INCISION cent ,


NW/New (Start date 04/01/20 . 0809 - No Stop Date found -)

Ordered By:·!''C'Iiiii •• !J DO (Electronic

ORD NUMo69, PLACE STERI STRIP S cent,


NW/New(StarL date 04/01/20 0809 - No Stop Date found -)

Ordered RY 'tldllJI£1&811••1EIIIb -1118; EJ0

Admitted: 04/01/~

HT· 5 ft 7 in WT: 174 lbs

Age: 28 Sex: F

DOB: Ol/08/ .

(Electronic

3 ozs


Run Date : 04/0 1/2 '

Signed By,'- H Ill. DO

Signed By: .-...... If.:. DO

Signed By: DO

Signed By DO

DO

Signed By: ~~~~llllll DO

MRN:

Account: NS Room/Bed :


0811

0812

PAGE 07

21

(

t~" = '-=-

Sinc(air :Memoria( J{osyita( 444 West 'Third Street Vayton, Oliio 45402



CC: C/S REPEAT

Entry Location:

ORD NUM:7o, ACTIVITY AS TOLERATED cont,


Ordered By:•UJMiil!mlili .I .aaoo 0809 - No Stop Date found -)

(Electronic

ORD NUM:7l, DIET-FULL LIQUID DIET meals,


Ordered By: •lilll!illl.l£11 4!lifli!.lll DO (Electronic

ORD NUM:72, ADVANCE DIET AS TOLERATED cont,


Ordered By:S2t E ..... DO (Electronic

ORD NUM:73, FOLEY CATHETER TO STRAIGHT DRAINAGE cent,


Ordered By :oi • .... MN!Iflllll;; DO (Electronic )

ORD NUM:74, DC FOLEY IN 8 HRS-UA, C&S FIRST IF ORDER cont,

Obtain UA, C&S before dc'ing if ordered

NW/New(Start date 04 / 0l /2 0tr 0809 - No Stop Date found -)

Ordered By :J!I!II&II•M•Ifi&, DO (Electronic

ORD NUM:7s,STRAIGHT CATH x l UNABLE TO VOID x l2hrs cont,

NW/New(Start date 04/0l/20 4l 0809 - No Stop Date found -)

Ordered By . DO (Electronic

ORD NUM :76,COMPLETE CURRENT I V AT 2 0 0 ML / HR , THEN cont,

No St op Date f ound -)

(Electronic

ORD NUM: 77, IV DEXTROSE 5% AND 1/2 NS AT 125 ML/ HR cont

NW/NewiStart date 04/0l/2

0rdered By~~~ .. ~~

Adm1tted. 04/01/2

DO

0809 No Stop Dat~ fo~~d

(Electronic


Age : 2 8 Sex : F

DOB : 0 1/0 8

ADMITTING:._~~~~~~~~ .. Session Start: 04/01/2


Run Date 04/01/2

signed By: ~Mth•-..oo

Signed By:.,'lii . • !III!III!IIJa,.po

Signed By:·~ .•. MMiiil.l*' · ··a DO

Signed By: ·~~~~~~~~~~~·' DO

Signed By: ,.! $'JIM l DO

Signed By : DO

Signed By: ....... ,DO

Signed By


c.

DO

0805

0811

0812

PAGE 0 8

22

,~

ALLERGIES: DI PHENHYDRAMINE

f f= ~·

Sinc{air Jvlemoria{ J{osyita{ 444 West Thira Street 'Dayton, Ohio 45402


CC: C/S REPEAT

En t ry Locat ion: ~ .. ~~~

ADMITTI NG: . ••m• & •, DO

Ses s ion St art: 04/01/2 J


Run Da te : 04/01/2rJ.

0805

0811

0812

ORD NUM:78, DC IV IN AM IF STABLE cont .


Or dered By~-~-· DO (Electronic

ORD NUM:79, 0RDER ANTIBODY TITRE-IF RhNEG & BABY POS ONCE,MAX ACTIONS: 1

Give RhoD Immune Gl obul in i f ind icated

NW/New(Start date 04/01/20,0809 - No Stop Date found -)

Order ed By: ~l~d~JIIIIr DO (Electronic Signed By: MIIIJ~·, . DO

ORD NUM:80 , PB-HOME HEALTH CARE VISIT IF ELIGIBLE ONCE,MAX ACTIONS: 1

OB patient


Or de r ed By: d f(I!.Mllf. ', DO (Electronic

ORD NUM:81, MEDICATION COMMENT Dose : 1 EACH, IV, q24hr,

USE DURAMORPH PROTOCOL X 24 HR

NW/New (Start date 04 / 01/2~ 0810 - Stop date 04 / 02/2011 0809 -S )

Ordered By: mqt 111111 . DO (Electronic )

Current Status: AU/Pending

Signed By: DO

ORD NUM:82, METHY LERGONOV INE 0.2MG /ML AMP I N J Dose: 0.2 MGS, IM, prnq8, PRN,MAX ACTION

EXCESSIVE VAG BLEEDING, IF NO HTN (MAY GIVE X 2 DOSES)


NW/New(Start date 04/0l/20~' 0810 - No Stop Date found -H)

Ordered By:~, DO (Electronic) Signed By: --~~lilll!llllf!~, DO

ORD NUM: 8 3, METHYLERGONOVINE 0 • 2MG 'l'AB Dose: 0. 2 MGS, PO, prnq8, PRN, MAX ACTIONS: 6

EXCESSIVE VAG BLEEDING, IF NO HTN 18 HOURS AFTER LAST IM DOSE)

NW/New(Start date 04/01/2 - 0810 - No Stop Date found -H)

Ordered r:vi."~ DO (Electronic}

Admitted: 04/01/2~ HT: 5 ft 7 in

Age: 2 8 Sex: F

DOB: 01/08/1~

WT: 174 lbs 3 ozs

Current Status· AU / Pending

·• ,_ .. ,, ... MRN: ra •1 zr Account .t4t••••-r N S Room/Bed: 1\ID1l,,ll!il.f


PAGE 09

23

ALLERGIES: DIPHENHYDRAMI NE

Sinc{air Jvlemoria{ Jfosyita{ 444 West Tfiircf Street Dayton, Ofiio 45402


CC: C/S REPEAT ADMITTING: "'')iiilllililiillliilllifMiii~t~DO

Entry Location: i' .... t\l Session Start: 04/01/20 0805


Run Date : 04/01 / 20

0811

0812

ORD NUM:84,LANOLIN EMOLLIENT OINTMENT TOPICAL Dose: 1 APPS, TP, PRN, PRN,

TO BREASTS PRN, APPLY TOPICALLY IF BREASTFEEDING

NW/New(Start date 04/01/20,..0810 - No Stop Date found -H)

Ordered By:J!lll-tH23JIJi' DO (Electronic)

ORD NUM:85, IBUPROFEN TAB 800 MG Dose: BOO MGS, PO, prnq8, PRN,

OFFER EVERY 8 HOURS


Ordered By :11!111·~--· DO

DO NOT EXCEED 3200MG/24 HOURS

0810 - No Stop Date found -H)

(Electronic)


Signed By: PAUL PAWLOSKY, DO

Current Status: AU/ Pending

Signed By: !.J!I .. Lii!iiJfJ!IWi•· DO

ORD NUM : 86, ACETAMINOPHEN/CODEINE #3 TAB 300/30MG Dose: 1 to 2 TABS, PO, prnq4, PRN,

PAIN

NW/New(Start date 04/02/2~ 0809 - Stop date 04/07/2 0900 -S)

Ordered By :t'llii!!U£•tllii!lillllil. •u-•. DO (Electronic)

ORO NUM:87,HYDROCODONE/APAP TAB Dos e : 1 t o 2 TABS , PO, prnq4 , PRN ,

FOR PAIN MAX DOSE 8 PER DAY

NW/New(Start date 04/02/2 . 0809 - Stop date 04/07/20 , ' 0900 -S)

Or dered By:UQ$ tO. DO (Electronic)

Current Sta t us: AU/ Pending

DO

Curre n t Status : AU/ Pending

Si gned By : ,. .. ll .. lllll DO

ORO NUM:BB, KETOROLAC INJ 3 0MG/ ML V IAL Dose: 15 to 30 MGS, IM, prnq6, PRN,

FOR SEVERE PAIN


Ordered By~~~~~~l'~~

Admitted. 04/01/

DO NOT USE WITH MOTRIN

0809 - Stop date 04i03/ 2

DO


0809 -S)

{Electronic ) S1gned By: ...... DO

HT: 5 ft 7 in WT: 174 lbs J ozs MRN: Age: 28 Sex: F

DOB: 01/08/

Account : ~~--.. ~~ NS Room/Bed:


PAGE 1 0

24

Sinc{air :Memor ia{ Jfosyi ta{ 444 YVest 'lliira Street 'Dayton, Oliio 45402



CC: C/S REPEAT

Entry Location: lffl.(;i .. ...,..

ORD NUM:89 ,0NDANSETRON INJ 2 MG/ML PF VIAL Dose: 4 MGS, IV, prnq8, PRN,

FOR NAUSEA/VOMITING

NW/New{Start date 04 / 02/20- 0809 - No Stop Date found - H)

Ordered By:>). ilfJ!IIrJIIIIIfll.lillw.., DO {Electronic)

ORD NUM:9o, ZOLPIDEM TAB 10 MG Dose: 10 MGS, PO, prnhs, PRN,

INSOMNIA

NW/ New {Start date 04 / 02 /2 0 • 0809 - No Stop Date found - H)

ADMITTING :

04/0l / 2, , ~Rns 04/01/20 0811

04/01/2 0812

Session Start:

Session Stop:

Run Date :


DO


Ordered By;'IIJIIIIJ····- {El ectr oni c) Signed By: ·:i· ..... .. DO

ORD NUM:9l ,CETYLPYRIDINIUM/MENTHOL LOZENGE Dose: 1 EACH, PO, PRN, PRN,

NW/New {Start date 04 / 01/2

Ordered B DO

0 810 - No Stop Da te f ound -H)

{Elec t r onic) Signed By:


ORD NUM: 92, SENNOSID ES/DOCUSATE 8 . 6 /SOMG T AB Dose: 1 to 2 TABS, PO, prnqd , PRN,

CONSTIPATION

Current Status : AU/Pending

NW/New{Start date 04/01/20. 0810 - No Stop Date found -H)

Ordered By11JII···· DO {Electronic) Signed By : llllitj1Ji!lfi8Ji~ DO

ORD NUM : 93, SIMETHICONE TAB CHEWABLE 80 MG Dose: 160 MGS, PO, prnq6, PRN,

INDIGESTION

NW/ New{Start date 04/01/2

Ordered By: , DO


{Electronic}


Signed By: 11= ;zai!lfo DO

dmitted: 01/01/20, ~~~~~~~~~~~~~~~~~~jJS~~~~~~~~-J~P~~~-~~~·~~~~~~~~~~~~~~~~~-T: 5 ft 7 1n WT: 174 lbs 3 ozs MRN:

Account: ~~~===~lll!llll NS Room/Bed : "'! Je: 28 Sex: F

' lB: 01/08 /.

PAGE 11

ELECTRONI C ORDER REPORT

25


CC: C/S REPEAT

Entry Location: ~ii~

I c

Sinc[air :Memor ia[ Jfosyita[ 444 West Tfi ira Street 'Dayton, Ofii o 4 5402


Session

Session

Run Date :

ORD NUM:94, MAG & AL HYDROX/SIMETH EXTRA-STR SUSP Dose: 30 MLS, PO, prnq6, PRN,

INDIGESTION USE FOR MYLANTA

OA05

0811

0812



Ordered By:(!· m!!Mlii •• IJ. f(~ DO


(El ectronic ) Signed By: '¥ !J ll na. DO

ORD NUM:9S, BISACODYL SUPPOSITORY lOMG Dose: 10 MGS, RECTAL, PRN, PRN,

IF REQUESTED

NW/ New (Start date 04 / 01 /~ 0810 - No Stop Date found - H)

Ordered By. " , DO (Electronic )

ORD NUM:96, 0XYTOCIN Dose: 20 UNITS, IV, 125.0 rnl/hr, TITRA, PRN,

OXYTOCIN 20 UNITS/LR lOOOML, MAX 200ML/HR POST PARTUM BLEEDING

OXYTOCIN 20 UNITS,

RINGERS SOLUTION, LACTATED 1000 MLS,

NW/ New(Start date 04 / 01/2 . 0810 - No Stop Date found -H)

Ordered B ,DO (Written)

ORD NUM:97, SEQUENTIAL COMPRESS I ON DEVI CE S cont,

NW/New( Start da t e 04/ 01/2 . 080 9 - No Stop Da te found -)

Ordered By: DO (Electronic

ORD NUM:9a,CALL :DVT PROPHYLAX INDICATED & NO ORDER cont,

Notify Physician


Ordered By: DO


(Electronic


Signed By :,..£


Current Status:

Signed B)X1l.lfillliii!MI!!J~$DO

ORD NUM:9<?J,LAB-CBC W/DIFF - COMPLETE BLOOD COUNT Qty: 1, ONCE,i'IIAX ACTIONS: l


Orden~d By

drnitted: 04/0lt~


(Electronic Signed B)~········lt!)C

T: 5 ft 7 in WT: 174 lbs 3 ozs MRN: •'!>

Ac c o unt: ~~~=~~;~··~·: -~ NS Room/Bed :

3e: 28 Sex: F

JB: 01/0S&IIf

EL ECTRONIC ORDER REPORT PAGE 12

26

Sinc[air Memoria[ Jfosyita[ 444 'West T'fz ira Street 'Dayton, Oliio 45402



CC: C/S REPEAT

Entry Location: is tOll

ORD NUM:17, INSERT PERIPHERAL IV: #18- #20 ANGIOCATH cont,

NW/New(Start date 04/01/20 ' 0639 - No Stop Date found -)

ADMITTING:

Session Start:

Session Stop :

Run Date :

..

DO

04/01/2 , 0639 04/01/2 0639 04/01/20 0640

Ordered By·~ .. IJlliiiiiJIIIi.M,; DO (Electronic ) Signed By: iii!fiilllil.llliJilj··· DO

ORD NUM:18, LACTATED RINGERS AT 125 ML/HR cont,


Ordered By:-<· •••••····~ DO (Electronic Signed By: jl······~~·- DO

' ORD NUM:19, FOLEY CATHETER-INSERT PRE-OP ONCE,MAX ACTIONS: 1

NW/New(Start 0639 - No Stop Date found -)

Ordered By~~~MI~~~~~~~~ .. ~ DO (Electronic Signed By: 4dlfillllill•······ DO

ORD NUM:20, IF AP RECORDS NOT AVAIL-CALL DR OFFICE ONCE, MAX ACTIONS: 1 NW/New(Start - No Stop Date found -)

Ordered B:~~IIIIIIII .... ~~~J DO

Admitted: 04/01/ HT : 5 ft 7 1n WT: 174 lbs

Age: 28 Sex: F

DOB : 0 1 /08~

3 ozs

(Electronic Signed By:~-lil~ifiiillllllfli •• DO

'•

MRN : ~~~~~~ Account:

NS Room/Bed:

ELECTRONIC ORDER REPORT PAGE 02

27

c Sinc(air Memoria( J-fosyita( 444 West 'lfiira Street 'Dayton, Ofiio 454 0 2

COMPREHENSIVE PLAN OF CARE INTEGRATED PROGRESS NOTE

AT -Art Therapist C - Case Manager

Ch - Chaplain D - Dietician/Diet Technician

ET - Enterostomal Therapist

FORM GS0380U (03/07)

LC - Lactation Consultant N - Nursing

OT - Occupational Therapist 0 - Other (specify in code)

PT- Physical Therapist

P - Physician RT - Recreational Therapist

R - Respiratory SP- Speech Therapist SS - Social Service

blue

28

./ /=

Sine fair :Memoria( J-{osyita( b 444 'West Tfiirc{ Street

Dayton, ofiio 45402 Physician's L & D Progress Entry

Entry Time: 4/1/2 05:25

Pt. Admit Date : 04/01 · 06:19 EDT

EDC: 03/27 Gestational Age: 40.8

Fetal Monitor Strip Reviewed:ves

FHTs

Fetal Monitor Strip Status: Active

Contractions:

Intrapartum Procedures:

Admit Plan : CSection

L & D Progress Notes:

Gravida Term Preterm AB Living 5 2 2

Membrane Rupture

Patient Seen: Yes Vitals Reviewed: VS_WNL

Labor Curve ReYiewed:1 1 d t• t<eason .or n uc ton:

pt to LQ. for repeat c/s without tubal. previous c/ s x2 . pt counseled on r/ b/c/a and pros/cons and accepts. will proceed with c/s.

Documentation by:

Sinc(air :Memoria( J-{osyita( ~ I'U'1

__ ... - -, .

444 'West Tfiircf Street MR# • ,,. 1 Acct#

'Dayton, Ofiio 45402 DOB ' Age 28

Date Printed 4/1/2.06:21 h UNIT LD-.r .

Bed 1390-A Printed By : DO Attending : ·- Adm Date:

I'J'c, "" :c;·::.~:- :~;' .,

' 1.!: ' ", !

sinc(air :Memoria( J-fosyita( Physician's L & D Progress Entry 444 'West Tfiircf Street 'Dayton, Ofiio 45402

04/0l;f'06:19 EDT

,, ·~ '

·'

Page 1 29

I also understand that m) surgeon or his agent may wke photographs and/or videotape the surgery. The usc\\ ill he only tor medical.

~cientitic. {lr cuucati\lnal purposes. !VIy identity i~ not to be revealed by the pictures or descripti1-e te:-as accompanying them .

I authorize release of my social security number if necessary. w enahlc..IS •• III!EP . ...., Sinc[air Jvlemoria[ J-fosy ita [ ' to meet regulatory requirements or the Safe Medical Devices or other federa l or state laws. •

I undcrst<Jnd that an) ONR (Do Not Resuscitate) {>rdcr is automatically rescinded Juring the operating and recovery period. I am

:1ware that the practice l'f medicine and surgery is nt>l an o :act scicnr:•:. <Jnrl I acknowledge that no guarantees have been made to me

as to the resu lts or trcatmenL~ or examination in the hospiwl.

I have read the above and have had the ·appropriate procedure(s) explained to me in detail. all questions have been ansvven;d to my

to the performance of the designated proccdurc(sl.

-----·---------f----·-·:_f ____ · --Date

'

Signature or RelativeiRepresentativeior Parent/Guardian's signature necessary if patient ts under 18 years of age and not an

emancipated minor. if patient is incompetent. or i r patient is unconsciou s l.i r required):

Relationship to patient Date

_____ i-:!:: Date

DS-2679 Page 2 of 2 05-07

30

L WOMEN'S CENTER at

Sinc{air :M.emoria{ J{ospita{ 444 West Tfiirc[ Stree t Dayton, Ofiio 45402

( .

Stamper

Labor and Delivery Consents INFANT CARE CONSENT

{

Infant's follow-up Physician is: _...~..U~f'I:...../I..__:....VI~O~·uJ:.:.._h...~...--___________ _

have designated __ O_n..:..-5_ {_-te __________ for the care of my infant. Physician's Name

I presently do not have a physician to care for my infant for the initial physical examination or discharge of my infant. I understand that a physician on staff of · · · ,\_o/ill care for my infant, for a fee, while in the hospital. I understand that findings at the time o · examination~and discharge are inclusive only of hospitalization. I understand that I am responsible for obtaining appropriate continuing medical care for my infant, including making an appointment for a check-up for my infant, based on the advice of my infant's examining physician.

BIRTH INFORMATION RELEASE

-tJPermfs"'si;n is hereby granted for Sinc{air .Jvtemoria{to release information to:

TELEPHONE INQUIRIES

V YES __ NO Concerning the Mother of Infant. This includes general condition, Room and telephone numbers.

ONLY THE INFORMATION MARKED YES MAY BE RELEASED.

CONSENT FOR PHOTOGRAPHS, AUDIO AND VIDEO TAPING

hereby give consent for family members and/or friends to photograph, audiotape, and videotape myself and my by during our hospital stays. I understand that the physicians and/or hospital employees included in such

· activities must give their verbal consent. ! also understand that the activities must be discontinued upon the request of the physician and/or the hospital employee. In connection therewith , I hereby release and agree to hold harmless Sinc[air :M.emoria[- and Family Health Center, its personnel. representatives, attending physicians and any other persons involved , from any liability concerning the taking or use of said photographs, audiotaping and/or videotaping.

RELATIONSHIP __ 'S;:_:1_ .. ~_/ _/-_~ --------

DATE lf// ~ TIME -------

DS-1379 1/11

31

Regional Anesthesia Orders Soinal I Eoidural I Extremity Sinc{air_ _.1vteJ?1oria{ J-fosyita[

The pat~ has received ~ .J t"L1 ..,EfDuramorph 0 DepoDur dntrathecal 0 Epidural :f'vmg a( "Jot'_

0 Continuous ~ngle-shot _______ regional anesthetic~_;:;;---J

Epidural 0 catheter D Level. _____ _

j This protocol will remain in effect until on·,..-,-,----,---,---..,..---,----j During this period no additional narcotics or sedatives are to be given to the patient unless ordered by or cleared with the Anesthesia on-call.

These orders ~ meet this requirement. j IV access must be maintained during this time period. j Elevate head of bed 30 degrees first 24 hours. Infusion solution: (prepared by 0 Pharmacy I 0 Anesthesia with preservative-free 0.9% NaCI)

Local Anesthetic (Methylparaben Free) D Bupivacaine 0 Ropivacaine 0 Lidocaine D Mepivicaine 0 Nesacaine Concentration %

Narcotic D Fentanyl 0 Morphine meg or mg /ml Amount or Concentration mg __ I __ %

j j j

0 Other .,--------,-,---c-:----:-,.,..--,---:--:-~-=----:--Run infusion @ __ ml.hr, then titrate in 1 ml/hr increments to comfort. Range to ml/hr. Inspect catheter site q 8 hrs - Notify anesthesia if catheter dislodged, excessive redness, discolored discharge. If lower extremity numbness or inability to move the lower extremities, stop the infusion and notify anesthesia on-call.

Patient Assessments Vital Signs: P, R, BP, 02 sats before procedure·,

BP q 3-5 min for 15 minutes following placement, t11en q 15 minutes x4, then q 30 minutes or more often if indicated

Aldrete Score: Obtain baseline prior to Epidural insertion, At beginning of recovery and prior to transfer or change of status (see key below for specifics)

Pain status: Every 4 hours Position change: Every hour as tolerated while awake Duramorph: After insertion, place on continuous oxygen monitoring,

Document 02 sats q 15 minutes x 8 until recovery complete Continue documenting 02 sats & Respirations q hour x 12.

if any additional narcotics given post-op, continue

Pain

documenting 02 sats and Resp . q hour for 24 hours. if 02 sat 92% or less, place 02 via nasal cannula @ 2-6 liters and call anesthesia.

~-= Tylenol 650 mg PO/PR q 4 hrs PRN r:-:: Toradol 30 mg IV q hrs. hold If Creatintne > 1.4 [' Celebrex 100 mg 1-2 tablets PO BID PRN Oj)arvocet N-1 00 1-2 tablets PO q 4 hrs PRN E1 jicodin 5/325 1-2 tablets PO q 4 hrs PRN efPercocet 5/325 1-2 tablets PO q 4 hrs PRN

Itching G?Benad~ mg IV/PO q 4 hrs PRN (Hold if pt 2 65 y/o) 0 Vistaril __ mg IM/PO q 4 hrs PRN (Hold if pregnancy or Asthma)

arcan 0.1 mg Sub-Q q 2 hours PRN Nubain 5mg IV/Sub-0 q 6 hrs PRN

~~ Zofran mg IV q 6 hrs PRN 0 Reglan 1 mg IV q 6 hrs PRN 0 Scopolamine Transdermal patch T q days 0 Other~------

Respiratorv I Sensory Peoressipn If Resp 8, give Narcan 0.1 mg IV. Repeat Q 5 min. PRN. Notify Anesthesia on-call Immediately.

Urinary Retention D Straight catheter 0 Other_

the Anesthesia on-call for any pain

k you .

Signed: __ _

Date: ___ -&

TOTAL MODIFIED ALDRETE SCORE= 10 IF .::;,5 NOTIFY PHYSICIAN 6-7 Remain in Acute Care Setting* 8-10 Transfer to Unit or Discharge *Must include at least a 2 in respirations or a return to baseline SCORE

Respirations Deep breath, cough freely Dyspnea or limited breathing Apnea

2 Blood Pressure BP=20mm Hg Pre-anesth. level 2 BP=20-50mm Hg Pre-anesth. 1 BP= 50mm Hg Pre-anesth. level o

Consciousness Fully Aware Arousable

2 1 0

Oximeter 02 Sat >92 on R/A 2 02 Sat >90 w/02 1

Activity Scores Able to move 4 Extremities = 2 Able to move 2 Extremities = 1 Able to move 0 Extremities = 0 0 Not Responding 02 Sat <90 w/02 o

DS-2783 8/09 32

{

reassessed immediately preop and frt to proceed with planned

J..=:..:..:::...:...:.:.:::...:...=...:.:..-.J---+--+---+---lf---1---.J-----+--+---t---f---lf----l ~=~:: :::~:~::"::nned

~=~:.:.:.._..t---+---=-~---+-----lf-----+-----lf------+----1f----+----lf------+---1 ~PIN At: o 7of/ j!YL L·07t3

~-----------4----~----~---+----4---~~--~----+----1----~----r----+----~ (/I : 07t f{

'011r ~~~~+-r-~'---1--+--+-1---+--+-+---+-----t--+------1 f""'" 017,()

• X

e Ci

0

HR

START 180 ANES 170 START 160 OP 150 END 140 OP 130

END 120

ANES 110 100

RESP. 90 80

0

0'

c.:

Position: Sitting 0 Lateral

Levji:.Jdi-S ~~~~~~~~~~~~~~=~=t=t=~=~=~=~=~~~~=~=t=t=~=~=~=~=~~~~=~=~=~=t=~=~=~=~=~~~~=~~ cfJterile Prep /), ci 1% Lidocaine to skin/SO _t/_ml

Needle:

Loss of resistance with (for epidural):

OAir O Saline

Djes D No

[ii(ves D No

~.j-~'"'-4--t-..f-..;.4-f.~_,.-f-I-I-I~~~I-+-+-+-+-+++++-+-+-+-+-+-I-I-1H Paresthesia: 0 Yes 0 No

l~+-+-+-++-f-+-+-+~-+-f-I-I-I~~I-I-+-+-+-+-+++++-+-+-+-+-+-I-I-1H 0 Catheter advanced __ em r & Secured I Dressed

Epidural Test dose: ___ ml

~+-+-+-++..f-~..:j.l*~~-f-1-1-1~~1-1-+-+-+-+-+++++-+-+-+-+-+-1-1-H LJ Lidocaine 1.5% with epi ~~d-+~d-+~~-t~~--f-l-l-lf--f--f--1-t-t-t-~~~~~+-+-+-t-t-t-i-l-,ri O rnher· __________ _

~~+--HH-++-If-*--+H-~~-1-I-If--f--+--1-i-1-i--t-+++++-+--+-+-t-t-t-i........JH Bolus: __ ml Rop1vaca1ne 0.2% & Fentanyl 2.5 mcg/ml

Other:------

N/G /

Insensible -.,,1!/;___ __ _ TOTAL __ / _ __ _

08 ANESTHESIA RECORD

Applicable Items: [/'Arms Tucked

~_Armboards ~ Pressure points j 'd I

D Vent O TV: __ O R _ _ _

E~ 3 D yLeads !6 NIBf'lD L [!)' R

~Arm 0 Forearm

D)lerve Stim

0 Radial 0 Axillary O AIIens. ___ _

0 Fowlers I protected

0 Lateral O Air Blanket

0 Fluid Vllarmer

0 Intubation-Size __ _

0 Oral 0 Nasal 0 Bilat Breath Sounds

0 Taped 0 Atraumatic 0 ETC02 +

O BIS

~Eyes: O CVP/PA

0 Lubed 0 Taped

Ds-2491 6104

D SCCOz Absorption

0 <;6z Analysis

&'Pulse Oximetry 33

Entry Time: 4/1/20

Allergies Drugs/Medications: Yes

Foods: No Latex:

Diagnosis/Procedures Pre-Op Ox:

Surgical Procedures : CSection Post-Op Diagnosis:

Anesthesia Type:

08:00

FHT's in OR: 128

OR Room #:

ASA: Two Time Antibiotic

(_

Anesthesia Type other: Given: 04/01/ 07:09 EDT Times Time C/S Called:

Patient in OR Start/ Arrive Time:

Stop/Depart Time:

Personnel Anesthesiologist: M.D.

AAMsthesiologist) Surgeon:~ II/

Assistant: Pediatrician:

Neonatologist: 0 1 l

Resident: others in OR:

Arrival/ Position/Settings Mode of Arrival:

Mental/Emotional State: Sensory Limits:

Aids/Pros Removed : Position :

Safety Equip used : Verification of Patient and Procedure:

Drains/ Dressings

Drains: Drain (A) Type /Size:

Drain (A) Location: Drain (B) Type/Size:

Drain (B) Location:

EBL (cc's):

Anesthesia Surgery

CRNA:

Circulator: ••lllililiiiiiiiMIIRN Cirulator Relief:

Scrub Tech: Nolen Scrub Relief: SCN Nurse:

Dressings Applied: Dressings Types:

Dressings Other types: Secured with:

Secured with Other: Foley: Yes Foley Size: N/A Inserted by: mcd

Bovie Pad Location: LAT

Surgical Procedure . . verification Checklist:1. __ Conft,2._Check,3 ._Commu,4._Conft

Sinc{air .Jvl.emoria{ :J-fosyita{-----, r-------------------, 444 'West Thirc£ Street Dayton, Ohio 45402

Date Printed

Printed By :

1/8/1

LD

Labor & Delivery Surgical Record

MR#

Age 28

Bed 1390-A

Adm Date 04/01/./1.

34

Lab ~ -==-:X DeliverYc:'urgical AS: ~~rd ,_.

Transfer Transfer Condition:

Transported by:

Operative Site: Intact

Surgical Wound Classification:

Prep PREP Solution

CLIPPER Complete

SCRUB Betadine

PAINT

Electrocautery I Equipment/Settings Electrocautery: Yes

Type Instrument#

ESU OR RM#l = KN013963 OR RM#2 = KN051760

Anes. Unit OR RM# 1 = KN032366 OR RM#2 = KN002184

Dinamap OR RM#l = KN054469 Monitor OR RM#2 = KN053682

Dinamap OR RM#l = KN054470

PulseOx OR RM#2 = KN053683

Fetal Monitor OR RM#l = KN054513 OR RM#2 = KN016403

Counts IX -ray flrrigants

Items/Counts First Second

Instruments

Sponges

Needles

Blades

Transfered To: Transfered to other:

Location COMPLETED BY:

Peri/Abd pt

Peri/Abd

OR Room#: 1

Coag # Cut# Pad Site Post-Op

50 50 WNL

Third Xrays taken for Incorrect count?

All counts correct: Yes,Circ/Scr

Specimens/Cultures Specimens Obtained:

Specimen (A) Type: Specimen (A) Site: Specimen (B)Type: Specimen (B) Site:

Sinc[air Memoria[ J-fosyita[ 444 W est 'Tfiira Stree t Dayton, Ofiio 45402

Date Printed 09: 30

Pr inted By :

Cultures Taken: Culture (A) Type: Culture (A) Site:

Culture (B) Type: Culture (B) Site:

DOB 1/8/11/111

Labor & Delivery Surgical Record

None

MR#

Acct# 0 ••••

Age 28

Bed 1390-A

Adm Date 04/01/tl

35

~ r ing Labor an~~elivery Re ... 'r-~ L

Maternal Labor/Delivery Informaton EDC:03/27.

Deliver Doctor:IJII···~, D.O.

Anesthesiologist:

Anesthetist:

Delivery Anesthesia: Spinal

Meds in Delivery:

nnC!'o• -* I ~a...-.-. -··--.. -· ........ _ ...... Complete Cerv Dilate: 04/01 . 07 :13 EDT

ROM Method: Artificial

ROM Date/Time: 04/01/.07:10 EDT

Oxytocin: N/A

Labor Anesthesia:

EBL (cc's): 300

NRT: :t• IS

Other Personnel: rl'll It i Pt. Trfd to: N/ A

Vaginal Delivery

Laceration Type/Ext.: None

Other Laceration:

EXT TOCO: Yes

EXT US: Yes

FSE:

IUPC:

C- Section Delivery

Pr i mary Indication: Repeat Elective

Other Primary Indicat:

Secondary Indication:

Other Second Indicat:

Labor: N/A

Maternal Complications Delivery_ Complications: None

Other Complications:

Delivery Comments:

/N/A

Sinc{air Jvtemoria{ J{osyita{ 444 West Third" Street 'Dayton, Ohio 45402

Date Printed

Printed By :

G/ 5 P/ 2

Delivery/Circulating RN:

Scrub N

Resident:

Nurse Midwife:

No. of Babies in Womb: 1

Amniotic Fluid Color: ; Fluid Clear

Amniotic Fluid Odor : Normal

Amniotic Fluid Amount: Moderate

Cervical Ripening Agent:

Other Cerv Ripening Agent:

Stage 1:

Stage 2:

Stage 3 :

Total Time in Labor:

Episiotomy: Sutures:

Hrs

0 Hrs

0 Hrs

Hrs

None Vicryl

3

0

min

min

min

min

Baseline Count: Final Count: Sharps 10

Sponge (4x4s)

Sponge (RayTec) 10

Sharps 10 Sponge (4x4s)

Sponge (RayTec) 10

Urgency: Scheduled

Elective: Elective

L/ 2

Incision: Lower Uterine Transverse

Other Incision:

. '

• Attending :

SAI-Jik'·

Incidence: Repeat

MR# ···-~~~ Acct# .. I.IJM

Age 28

Bed 1390-A

Adm Date 04/0dl:r T

Nursing Labor and Delivery Record Page 1 36

.. t • b L . I" rt~"mg La or a~)e 1very Re

Baby A Delivery Information

Delivery Date: 04/01

ROM Date Time: 04/ 01

07 : 16 EDT

07 : 10 EDT

Method of Delivery: Scheduled C/Section

Born en Route: No

VBAC: N/ A

Forceps: N/ A

Vacuum Extraction; Successfui

Vacuum Extract # pulls:

Vacuum min-sec p/pull:

Baby 'A' Information Sex: Male 40 (wks}/US

GA at Delivery/Status: 40 .5

IDBand#: ....

MR#JI8£ IIJI.II Suction: Mouth,Nose

Co;;ditlon: Stabie

Outcome: Liveborn

Term

Birth Weight: 3741 (grams)

8 (lbs) 4 (oz)

Wks/LMP

cc's

Vacuum Pressure appl:

Presentation: Cephalic

Cephalic Position: Vertex

Breech Positon: N/A

Length: 53 .3 (em) 21.00 ( in)

Head Circ. (in): 15.0

Vertex Position: Direct Occipital Anterior

Scalp pH:

Placenta Deliv Time: 04/01.,. 07 :16 EDT

Placenta Deliv Method: Manual Removal

Placenta Status:

Placenta Disposition:Routine_

Cord Blood Taken: Yes

Bank/Donate Info:

Neonatology Called: Yes

Apgars

Time 1 Min 5 Min 10 Min

Heart Rate >100 >100

GBS (+/Ukn} Tx'd X:

Delivery Comments:

Stnc air :Memoria 444 West T fiirci Street 'Dayton, Ofiio 45402

Date Printed 4/1/2. 09:41

Resp Effort Cry Cry

osyita{

Printed By: 1111 ....... !iJii RN

,.

Muscle Tone Active Active

DOB

~ UNIT

1/

LD

Chest Circ. (in):

Abd Circ. (in):

# Cord Vessels: 3

Nuchal Cord:N/A

Other Nuchal:

True Knot:

Cord pH:

Transfered to:

Reflex Cry Cry

MR#

Acct#

Age r~ Atte~

Bed ~

(art.)

Color BodyPink Body Pink

Wit,-Mi .••••.

28

1390-A

Adm Date 04/ 01/. n~> · t'l EDT . .

. . Nursmg Labor and Dehvery Record

(ven.)

Score 9 9

~ •.

Page 2

I

I I

37

N,..., ing Labor an .. .=-. .Jelivery Rec~

Baby A Information Continued

Complications

Infant Complications:None

Other Complications:

IU Death: Neonate Death:

Resuscitation: Tactile,Bulb

Medications:

Assessment Respiratory Rate Deliv: 40

Respirations Type: Normal

Physical Findings: WNL

Other Phys Findings:

Congenital Anomalie(s): None Apparent

Other Congen Anom:

Sinc{air Jvlemoria{ J-iosyita{ 444 W est ThircfStree t 'Dayton, Ohio 45402

Date Printed 4/1/2" 09:41

Printed By: .•• II lfl.djg;,}N

DOB 1/8/

Nursing Labor and Delivery Record

Age 28

Bed 1390-A

Adm Date

Page 3 (EOD) 38

Sinc[air :Memoria[ J-fosyita[ \ --. \.

Demographics

County: 012 Race: hite_

Religion: ••• ill. Other Religion: Father's Name: ••••

Father of Baby Involved: Yes Next of Kin Information

Next of Kin Name:Jiillli...,_ Next of Kin Relationship: grandmother

Labor & Delive-:y Admission Reco d F ~

Age: 28 Zip Code: •••

Home Telephone: (4Jii"'ll®ilruai6 Work Te hone:

Martial Education (yrs):

SSN: Occupation:

Other Occupation:

Next of Kin Telephone, ...... ,

Person acctbqrized to re'ease patient's pur 'Persona' Hea'Hz Tgfqcmatigg) Name:

Pregnancy Information G/ 5 P/ 2 T/2 Pt/ SAB/2 lAB/

EDC: 03/27

Allergies

Height: 67.0 (in) Weight (pre-pregnancy): 130

EGA per Dates: 40.8 EGA per Ultrasound:

Medication Allergies: Yes Benadryl - hyper reaction Food Allergies: No

Environmental Allergies: Yes metals - rash Latex Allergies: Latex rash, itching

Allergies Potential Latex Allergies: No

Medications Prenatal/Prescription Meds

Prenatal Medications: None

Herbal Supplements: None Prescription/OTC Meds: No

Medication 1: Medication 2: Medication 3: Medication 4 : Medication 5:

Alcohol /Smoking/Drug Use Alcohol Use: No

Advised to Stop Alcohol: Alcohol Comments:

Cigarette Use: YES Advised to Stop Smoking: Yes

Smoking Comments: 1 pack per day Marijuana Use: No

How Long Used (yrs)?: PreviousTreatment:

Marijuana Comments: Cocaine/Crack Use: No

How Long Used (yrs)?: PreviousTreatment:

Cocaine/Crack Comts: Other Illicit Drugs: No

Illicit Drug Comments: Communication

Primary Language: English

Communication Barriers: None

Sinc[air .'Jvlemoria{ J-fosyita{ 444 'West 'lhircf Street 1Jayton, Ohio 45402

Date Printed

Printed By:

Pharmacy

Smoking Cessation Literature Offered:

Avg Alcohol Consumption:

Avg Cigarettes Smoked: > 10 per day

How often Marijuana used: Date Last Used:

How often Cocaine used: Date Last Used:

English Abilities:

MR# ,.

Acct# UNIT LD

Age 28 Attending:

p Bed 1390-A

Page 1

W\1'

L/2

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39

Sinc[ai'!:_;!1en:!:oria[ .J{osyita[ Labor & Deliv~ Admission Ret ord,

Antepartum Procedures Procedures Done: Ultrasound AP Procedures Comments: US x 4, WNL

Vaccines

Labs

Influenza: No Pneumococcal: No

Tetanus: Uncertain

When: When: When:

Blood Type/Rh: A Pos Group B Strep: Negative

RPR/VDRL: Nonreactive Rubella/Titer: Immune

Chlamydia: No HIV+ Exposure/Results: Negative

Rhogam this pregnancy: N/A HbSAg: Negative

TB Exposure: Denies Chickenpox: Non Susceptible Gonorrhea: Negative

Herpes: Denies (No HX) Pt offered HIV test: PrevDone Lab Comments: Qf).l

I Date HbSAg drawn: 09/07 tClh-1- 1

Prenatal Care Histor Month of 1st PN Visit: 0

Support Person: Prenatal Classes Attend: No Pain Management Plans: None

Plans for L & D: None

Cultural/Spiritual Practices Practices to Incorp in Care: No Describe Cultural Practices:

Diet to Incorp in Care: No Describe Dietary Practice:

Living Situation/Discharge Planning

Pans E B: ·

Adequate PN Care: AdqPNC Relationship: Sigf_Oth

Anesthesia Plans:Spinal Pediatrician: Onsite

Circumcision Requested: Yes Feeding Preference: Breast

Tubal Ligation: No

Tubal Authorization Signed: N/A

Living Arrangements: House Person to_ Help_after D/C·~ Adequate Access to: Electric,Heat,Refrigeration,Piumbing/Running water,Pflone, 1 ranspol'tatiO"'''""""'

Person Taking Pt Home: Using Community Resource: es

If YES, please specify: medical card Outside Agency /Soc1al or Caseworker: No

If YES, please specify: Car Seat: Yes WIC: Yes

Adoption Requested: No Help Required to Obtain Car Seat: Agency Handling Adpt: Pt Contact w/Infant after Birth:N/A

Adolescent Screening Pt Grade in School:

A~e of Father Of Baby: Fam1ly Response to Preg:

Orientation and Safety:

Plans Regarding School: FOB Involvement:

Other Support:

Dry Marker Board (Nurse & Ph_'s),Call ligt1t,Bed operation/ Telephone/Teievislon, Mea is/ Vrsitmg hours,Ident1ty bands with Baby ,Employee verification ,Instucted on Mother and Baby safety in room and unit,Side Rails X2 ONLY1Given Admission Folder with all Hospital Information

Page 2

rnc arr ' [Jfc em orr a osyita [ _ ....... 444 West Thin£ Street

~.~ .. 'Dayton, Ohio 45402 MR# O§J~ll•'

DOB 1/~ - Acct# oeuu••-.r UNIT LD

4/ 1/ 2,06:22 Age 28

Date Printed Attending :

nvtAI!lfAk#·· Bed 1390-A Printed By:

04/01 .. _.. PP!!WP

Adm Date 06 : 19EDT

40

vosr:er:nca1 n1sr:ory S inc ~a i~,_,IQiBP.rtlfSIP.ei•very AdPI\J~§Nil' JJJ~'ilbruption: No

F ·me Anomaly: No F_. Bre. .eding Hx: Yes Gestational ~{''3tes: No Incompeten vix: No

In ertility: No Hx of Previous CSection:Yes

IUGR: No

Macrosomia: Yes DES:

Hx Stillborn: No Hx Neonatal Death: No

OB Hx Comments:

Systems Review HEENT Heart Lungs Breast Abdomen GI Extremities Teeth Skin Neurologic Comments:

Normal Normal Normal Normal

Normal Norma! Normal Normal Normal Normal has abdominal hernia

Infectious History Chlamydia: No

Genital Herpes: No

Hepatitis: No Gonorrhea: No

Infectious Hx Comments:

Previous Pt HX

Previous HX 1: Previous HX 2:

Bronchit Migraine

PIH:No

Previous Surgeries: hernia repair 2008, previous c/s x 2

Risk Assessments Morse Fall Risk Assessment

No No None Yes Normal

History of Falls Secondary Diagnosis Ambulatory Aid IV/Hgparin Lock Gaitt 1 ransferring Mental Status Morse Fall Risk Score

Oriented to own ability Low Risk

z.nc atr :Jvlemoria ( J-losyita( 444 West ThiraStreet Dayton, Ohio 45402

Date Printed 4/1/20.6: 22

Printed By: ~~

'_,._, .

-

,;.

~~

PTL/PROM: No PP Depression: No

PP Hemorrhage: No

Syphillis: No Tuberculosis: No

Human Papilloma Virus: No HIV/AIDS: No

DVT Risk Assessment Freely Ambulating

;;ii..'!£!.""~'" ~~

' ··-··· -'

DOB

Yes

MR# Uiff!IM

Page 3 (EOD)

1/~' Acct# a., •• Ill

UNIT LD Age 28

Attending:

~L Bed 1390-A

Adm Date 04/01 06:19EDT

' .. ~ •"'• '% «'

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41

444 west third street sex: dayton, ohio 45402-1460...

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