1. Date of admission 2. Date/time of

1. Date of admission 2. Date/time of discharge 3. Age of patient: 4. What is the 3 digit diagnosis-related group (DRG) number for this patient’s admission? 5. Does the patient have allergies? 6. What is the admission type (classification) for this patient? 7. What is the patient’s surgical history? 8. How much does patient weigh? 9. How many doses of Ibuprofen did the patient receive? 10. What was his O2 (oxygen) saturation rate on 10/6/92 11. How old is patient’s child? 12. What were the patient’s vital signs on their first day of hospitalization? 13. What did patient eat on 10/8 for lunch? 14. What was the reason the patient requested a nutritional consultation? 15. What was the rate of oxygen the patient was using upon admission? 16. What medication was the patient discharged on? 17. For discharge planning, was the patient provided with any referrals or equipment for at home use? 18. Per nursing documentation, how many pillows does the patient use to sleep? 19. What is the primary diagnosis listed in the nursing care plan? Image transcription text ADMISSION DATE: 10/6/92 DISCHARGE DATE: 10/13/92 HISTORY OF_PRESENT ILLNESS: The patient is 42 year … Show more Image transcription text Admitted: 10-06-92 HISTORY : CHIEF COMPLAINT: The patient is . forty-two year old, white, male admitted with ac… Show more Image transcription text HISTORY AND PHYSICAL CONTINUED PAGE 2 by Rodney Ying, M.D. and Warren C. Litts, Jr., M.D. regarding this indi… Show more Image transcription text HISTORY AND PHYSICAL CONTINUED PAGE 3 determine any jugular venous diste . ion .. CHEST: Remarkable for ma… Show more Image transcription text Saratoga s Hospital NONE Nutritional Screening/ Assessment 309 . .. . Name_ Age 42 Diagnosis Diet Rx 1500 cal 1… Show more Image transcription text Saratoga Hospital NONE Nursing Admission Form Instructions 1. To be completed by RNs 2.”To be completed within … Show more Image transcription text NONE History Physical Data Base Fall Risk Assessment Skin Out Q Not at risk Check the risk factors present excess 1. Pr… Show more Image transcription text = See Progress Notes 1LITI VAILL I LUTE SINCE I N/A = Not Applicable. DATE TIME FOCUS DATE: 1792 7 AM – 3 P… Show more Image transcription text 10 13 02 THE SARATOGA HOSPITAL PATIENT DISCHARGE INSTRUCTIONS . DATE: 10/13/4 1. Discharge to: 2…. Show more

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