IPCase001 Medical Record Example

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Houston Community College *

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93486

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Medicine

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Apr 3, 2024

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Global Care Medical Center 100 Main St, Alfred NY 14802 (607) 555-1234 Hospital No. 33-0879 ° ±²³´°µ±´ ¶ ³·µ ¸ ¹µµ´ °±²³´µ² ¶±·´ ±µ¸ ¹¸¸º´»» ¼´µ¸´º ½±¾´ ¿±º³²±ÀÁ²±²Â» °±²³´µ² ¶ÃÄ F W M IPCase001 Å±²´ ÃÆÇ ³º²È ¹É´ ¿±³¸´µ ¶±·´ Ê¾¾ÂË±²³Ãµ LONG, BETH 4983 REED STREET ALMOND, NY 14804 12/17/ 1992 30 Short Clerk ¹¸·³»»³Ãµ Å±²´ Ì ³·´ Å³»¾È±ºÉ´ Å±²´ Ì ³·´ Í´µÉ²ÈÃÆÁ²± Ì´À ´ËÈÃµ´ ¶Â·!´º 0 4 /26/ 2022 1350 0 4 /30/ 2022 1150 04 DAYS (607)555-3319 ¼Â±º±µ²Ãº ¶±·´ ±µ¸ ¹¸¸º´»» ¶´" ² ÊÆ# ³µ ¶±·´ ±µ¸ ¹¸¸º´»» LONG, BERNIE 4983 REED STREET ALMOND, NY 14804 LONG, BERNIE 4983 REED STREET ALMOND, NY 14804 ¼Â±º±µ²Ãº Ì´À ´ËÈÃµ´ ¶ÃÄ ½´À ±²³Ãµ»È ³Ë²Ã°±²³´µ² ¶´" ² ÃÆ# ³µ Ì´À ´ËÈÃµ´ ¶Â·!´º ½´À ±²³Ãµ»È ³Ë²Ã°±²³´µ² (607)555-3319 Husband (607)555-3319 Husband ¹¸·³²²³µÉ°È »³¾ ³±µ Á´º$ ³¾´ ¹¸·³² Ì Ë´ ½ÃÃ· ¶Â·!´º%Ç´¸ John Black, MD 369 ¹²²´µ¸³µÉ°È »³¾ ³±µ ¹¸·³²²³µÉÅ³±ÉµÃ»³» John Black, MD Fever of undetermined origin °º³·±º &µ»Âº´º °ÃÀ ³¾ ±µ¸ ¼ºÃÂË¶Â·!´º Á´¾Ãµ¸±º &µ»Âº´º °ÃÀ ³¾ ±µ¸ ¼ºÃÂË¶Â·!´º °±²³´µ¶·¶ ²´¸ ¹ºµ»·¸¼º·¶ ½¾° ¾µ¸· °º³µ¾ ³Ë±ÀÅ³±ÉµÃ»³» Acute Pyelonephritis Á´¾Ãµ¸±º Å³±ÉµÃ»´» Dehydration °º³µ¾ ³Ë±À°ºÃ¾´¸Âº´ Á´¾Ãµ¸±º °ºÃ¾´¸Âº´» Å³»¾È±ºÉ´ &µ»²ºÂ¾ ²³Ãµ» ¹¾ ²³$ ³² : ° Bed rest ° Light ° Usual ° Unlimited ° Other: Å³´²’ ° 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 ÁË´¾ ³±À&µ»²ºÂ¾ ²³Ãµ» : None ¹²²´µ¸³µÉ°È »³¾ ³±µ ¹Â²È´µ²³¾±²³Ãµ’ Reviewed and Approved: John Black MD ATP-B-S:02:1001261385: John Black MD (Signed: 4/30/YYYY 2:20:44 PM EST) Internal Medicine Urgent #1234 #1234 N10, B96.20 R50.9 due to E. coli infection E86.0 Smoker F17.210 x x Blue Cross/Blue Shield 456978 None N/A

LONG, BETH IPCase001 Dr. BLACK Admission:04/26/YYYY DOB: 12/17/YYYY ROOM: 369 · º±¸µ±´ ´ º ³ »¼°¸¸°º± 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 C ONSENT T O R ELEASE I NFORMATION F OR R EIMBURSEMENT P URPOSES 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 G LOBAL C ARE M EDICAL C ENTER ² 100 M AIN S T , A LFRED NY 14802 ² (607) 555-1234

LONG, BETH IPCase001 Dr. BLACK Admission: 04/26/YYYY DOB: 12/17/YYYY ROOM: 369 ³ »½³±·µ » °¾µ·´°½µ 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. Y ES N O P ATIENT ’ S I NITIALS 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 H OSPITAL S TAFF D IRECTIONS : Check when each step is completed. 1. ³ Verify the above questions where answered and actions taken where required. 2. ³ If the “Patient Rights” information was provided to someone other than the patient, state reason: Name of Individual Receiving Information Relationship to Patient 3. ³ If information was provided in a language other than English, specify language and method. 4. ³ Verify patient was advised on how to obtain additional information on Advance Directives. 5. ³ 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 Signature of Hospital Representative Date G LOBAL C ARE M EDICAL C ENTER ² 100 M AIN S T , A LFRED NY 14802 ² (607) 555-1234

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LONG, BETH IPCase001 Dr. BLACK Admission: 04/26/YYYY DOB: 12/17/YYYY ROOM: 369 » °¸·¹³¾¿µ ¸ À¼¼³¾Á 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 G LOBAL C ARE M EDICAL C ENTER ² 100 M AIN S T , A LFRED NY 14802 ² (607) 555-1234

LONG, BETH IPCase001 Dr. BLACK Admission: 04/26/YYYY DOB: 12/17/YYYY ROOM: 369 ¹ °¸´º¾Á Â ² ¹Á¸°·³Ã µ Ä³¼ 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 G LOBAL C ARE M EDICAL C ENTER ² 100 M AIN S T , A LFRED NY 14802 ² (607) 555-1234

LONG, BETH IPCase001 Dr. BLACK Admission: 04/26/YYYY DOB: 12/17/YYYY ROOM: 369 ² ¾º¿¾µ¸¸ ± º´µ¸ 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: pyelonephritis; dehydration; rule out renal calculus. 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 Alpha strep in blood culture. Not viridans, clinically. Improving. Has genitourinary 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: Afebrile vital signs. OBJECTIVE: HEAD/EYES/EARS/NOSE/THROAT: Tympanic membrane of left ear somewhat dull yellowish. Throat: slight erythema. 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? Abscess – doubt. Intravenous pyelogram 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) G LOBAL M EDICAL C ENTER ² 100 M AIN S T , A LFRED NY 14802 ² (607) 555-1234

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LONG, BETH IPCase001 Dr. BLACK Admission: 04/26/YYYY DOB: 12/17/YYYY ROOM: 369 » º·´º¾¸ º ¾»µ¾¸ 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) 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) G LOBAL C ARE M EDICAL C ENTER ² 100 M AIN S T , A LFRED NY 14802 ² (607) 555-1234

LONG, BETH IPCase001 DR. BLACK Admission: 04/26/YYYY DOB: 12/17/YYYY ROOM: 369 Ã ³Åº¾³´º¾Á » ³´³ S PECIMEN C OLLECTED : 04/26/YYYY S PECIMEN R ECEIVED : 04/26/YYYY ´ µ¸´ ¾ µ¸ÀÃ´ ¶ Ã³¿ ¾ µ¶µ¾µ±·µ 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 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*** G LOBAL M EDICAL C ENTER ² 100 M AIN S T , A LFRED NY 14802 ² (607) 555-1234

LONG, BETH IPCase001 Dr. BLACK Admission: 04/26/YYYY DOB: 12/17/YYYY ROOM: 369 Ã ³Åº¾³´º¾Á » ³´³ SPECIMEN COLLECTED: 04/26/YYYY 1450 SPECIMEN RECEIVED: 04/29/YYYY 1814 ´ µ¸´ ¾ µ¸ÀÃ´ 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 G LOBAL C ARE M EDICAL C ENTER ² 100 M AIN S T , A LFRED NY 14802 ² (607) 555-1234

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LONG, BETH IPCase001 Dr. BLACK Admission: 04/26/YYYY DOB: 12/17/YYYY ROOM: 369 Ã ³Åº¾³´º¾Á » ³´³ SPECIMEN COLLECTED: 04/26/YYYY 1504 SPECIMEN RECEIVED: 04/29/YYYY 1814 ´ µ¸´ ¾ µ¸ÀÃ´ 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*** G LOBAL C ARE M EDICAL C ENTER ² 100 M AIN S T , A LFRED NY 14802 ² (607) 555-1234

LONG, BETH IPCase001 Dr. BLACK Admission: 04/26/YYYY DOB: 12/17/YYYY ROOM: 369 Ã ³Åº¾³´º¾Á » ³´³ ° ±²³´µ ²¶ ³ ·¸¸²³¹²º » 04/26/YYYY 1450 ° ±²³´µ ²¶ ¼ ²³²´½²º » 04/26/YYYY 1746 ÅÃºº» ·¹µ¼°¸´¾Á ´ µ¸´ ¾ µ¶µ¾µ±·µ ¾ µ¸ÀÃ´ 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 G LOBAL C ARE M EDICAL C ENTER ² 100 M AIN S T , A LFRED NY 14802 ² (607) 555-1234

LONG, BETH IPCase001 Dr. BLACK Admission: 04/26/YYYY DOB: 12/17/YYYY ROOM: 369 Ã ³Åº¾³´º¾Á » ³´³ ° ±²³´µ ²¶ ³ ·¸¸²³¹²º » 04/26/YYYY 1505 ° ±²³´µ ²¶ ¼ ²³²´½²º » 04/28/YYYY 1957 ´ µ¸´ ¾ µ¸ÀÃ´ 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 G LOBAL C ARE M EDICAL C ENTER ² 100 M AIN S T , A LFRED NY 14802 ² (607) 555-1234

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LONG, BETH IPCase001 Dr. BLACK Admission: 04/26/YYYY DOB: 12/17/YYYY ROOM: 369 Ã ³Åº¾³´º¾Á » ³´³ ¹´µ ² ´¶» 04/26/YYYY 1450 ¹´µ ² ·¾¹» 04/26/YYYY 1746 ·º¼²Ãµ´µ ÅÃºº» ·ºÀ±´¸ »°¶¶µ¾µ±´°³Ã ´ µ¸´ ¾ µ¸ÀÃ´ ¶ Ã³¿ ¾ µ¶µ¾µ±·µ 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*** G LOBAL C ARE M EDICAL C ENTER ² 100 M AIN S T , A LFRED NY 14802 ² (607) 555-1234

LONG, BETH IPCase001 Dr. BLACK Admission: 04/26/YYYY DOB: 12/17/YYYY ROOM: 369 ¾ ³»°ºÃº¿Á ¾ µ²º¾´ 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 a nterior- p osterior 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 G LOBAL C ARE M EDICAL C ENTER ² 100 M AIN S T , A LFRED NY 14802 ² (607) 555-1234

LONG, BETH IPCase001 Dr. BLACK Admission: 04/26/YYYY DOB: 12/17/YYYY ROOM: 369 µÆ¿ ¾ µ²º¾´ Date of Electrocardiogram: 04/26/YYYY Time of Electrocardiogram: 1600 Rate 90 PR .12 QRSD .68 QT .32 QTC -- Axis -- P QRS T Sinus rhythm normal. 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) G LOBAL C ARE M EDICAL C ENTER ² 100 M AIN S T , A LFRED NY 14802 ² (607) 555-1234

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LONG, BETH IPCase001 Dr. BLACK Admission: 04/26/YYYY DOB: 12/17/YYYY ROOM: 369 ¿ ¾³²¹°· · ¹³¾´ 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 0800 1600 110/65 0800 110/70 1600 112/68 0800 100/70 1600 110/70 0800 108/68 1600 BLOOD PRESSURE 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 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 INTAKE 24- HOUR TOTAL 1800 4200 4220 2590 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 OUTPUT 24- HOUR TOTAL 1400 2500 2575 1900 G LOBAL M EDICAL C ENTER ² 100 M AIN S T , A LFRED NY 14802 ² (607) 555-1234

LONG, BETH IPCase001 Dr. BLACK Admission: 04/26/YYYY DOB: 12/17/YYYY ROOM: 369 ¿ ¾³²¹°· · ¹³¾´ 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 0800 1600 BLOOD PRESSURE 1200 102/60 2000 WEIGHT 5’8” 141# DIET Full liquid APPETITE 50% BATH Self INTAKE/OUTPUT 7-3 ORAL FLUIDS IV FLUIDS BLOOD 8 HOUR TOTAL INTAKE 24 HOUR TOTAL URINE STOOL EMESIS N-G 8 HOUR TOTAL OUTPUT 24 HOUR TOTAL G LOBAL M EDICAL C ENTER ² 100 M AIN S T , A LFRED NY 14802 ² (607) 555-1234

LONG, BETH IPCase001 Dr. BLACK Admission: 04/26/YYYY DOB: 12/17/YYYY ROOM: 369 ¼ µ»°·³´°º± ³ »¼°±°¸´¾³´°º± ¾ µ·º¾» S PECIAL I NSTRUCTIONS : D ATE : 04/26 D ATE : 04/27 D ATE : 04/28 D ATE : 04/29 M EDICATION (dose and route) T IME I NITIALS T IME I NITIALS T IME INITIALS T IME I NITIALS 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 I NITIALS S IGNATURE AND T ITLE I NITIALS S IGNATURE AND T ITLE I NITIALS S IGNATURE AND T ITLE 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 G LOBAL C ARE M EDICAL C ENTER ² 100 M AIN S T , A LFRED NY 14802 ² (607) 555-1234

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LONG, BETH IPCase001 Dr. BLACK Admission: 04/26/YYYY DOB: 12/17/YYYY ROOM: 369 ¼ µ»°·³´°º± ³ »¼°±°¸´¾³´°º± ¾ µ·º¾» S PECIAL I NSTRUCTIONS : D ATE : 04/30 D ATE : D ATE : D ATE : M EDICATION (dose and route) T IME I NITIALS T IME I NITIALS T IME INITIALS T IME I NITIALS Keflex 500 milligram 0800 HF four times a day I NITIALS S IGNATURE AND T ITLE I NITIALS S IGNATURE AND T ITLE I NITIALS S IGNATURE AND T ITLE 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 G LOBAL C ARE M EDICAL C ENTER ² 100 M AIN S T , A LFRED NY 14802 ² (607) 555-1234

LONG, BETH IPCase001 Dr. BLACK Admission: 04/26/YYYY DOB: 12/17/YYYY ROOM: 369 ° ±´¾³½µ±ºÀ¸ ´ ¹µ¾³²Á ¾ µ·º¾» Time Solution & Amount Medication Added Injection Site & Mode Rate IV & CVP Redress Site Changed q 48 hours Nurse’s Initials Remarks 4/27 1400 1000 cubic centimeter none #209 Cathalin left arm 100 cubic centimeter per hour JD 4/28 0100 1000 cubic centimeter none added 100 cubic centimeter per hour HF 4/28 1300 1000 cubic centimeter none same 100 cubic centimeter per hour JD 4/29 2400 1000 cubic centimeter ---- ---- 100 cubic centimeter per hour OR 4/29 1330 Intravenous site sore Discontinued JD 4/29 1340 1000 cubic centimeter none #209 Cathalin left antecubital 100 cubic centimeter per hour JD 4/30 2400 1000 cubic centimeter 100 cubic centimeter per hour OR 4/30 0900 1000 cubic centimeter 100 cubic centimeter per hour HF 4/30 2200 1000 cubic centimeter 100 cubic centimeter per hour VT 4/31 0750 Intravenous discontinued HF 150 cubic centimeters remaining in bag. Needle removed intact. No signs of infiltration or redness at site. Nurse’s Signature Vera South RN (VT) Ora Richards RN (OR) H. Figgs RN (HF) Jane Dodds RN (JD) G LOBAL M EDICAL C ENTER ² 100 M AIN S T , A LFRED NY 14802 ² (607) 555-1234

LONG, BETH IPCase001 Dr. BLACK Admission: 04/26/YYYY DOB: 12/17/YYYY ROOM: 369 ² ³´°µ±´ ² ¾º²µ¾´Á ¾ µ·º¾» 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. Reviewed and Approved: Beth Long ATP-B-S:02:1001261385: Beth Long (Signed: 4/26/YYYY 2:24:44 PM EST Signature of Patient Reviewed and Approved: Andrea Witteman ATP-B-S:02:1001261385: Andrea Witteman (Signed: 4/26/YYYY 1:44:00 PM EST Signature of Witness 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. Reviewed and Approved: Beth Long ATP-B-S:02:1001261385: Beth Long (Signed: 4/26/YYYY 1:46:44 PM EST Signature of Patient Reviewed and Approved: Andrea Witteman ATP-B-S:02:1001261385: Andrea Witteman (Signed: 4/26/YYYY 1:48:28 PM EST Signature of Witness I have deposited valuables in the facility safe. The envelope number is . Signature of Patient Signature of Person Accepting Property 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 Signature of Witness G LOBAL C ARE M EDICAL C ENTER ² 100 M AIN S T , A LFRED NY 14802 ² (607) 555-1234

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LONG, BETH IPCase001 Dr. BLACK Admission: 04/26/YYYY DOB: 12/17/YYYY ROOM: 369 ± À¾¸µ¸ ± º´µ¸ DATE TIME TREATMENTS & MEDICATIONS TIME NURSE’S NOTES 4/26/YYYY 1400 A 30 year old female admitted to room 369 services of Dr. Black. Oriented to room and call system. Urine culture sent to lab. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 4/26/YYYY 2:00:10 PM EST) 4/26/YYYY 1430 Resting in bed. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 4/26/YYYY 2:30:23 PM EST) 1530 Resting comfortably in bed. Intravenous infusing well. Temperature decreased to 99°. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 4/26/YYYY 3:31:00 PM EST) 1930 Tylenol, 2 tablets by mouth for increased temperature. 2000 Vitals taken. Temperature increased to 103. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 4/26/YYYY 8:04:05 PM EST) 2045 Refused backrub. States she gets chilled and then too warm. Face is flushed at present. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 4/26/YYYY 8:45:44 PM EST) 2215 Appears asleep. Respirations even. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 4/26/YYYY 10:15:17 PM EST) 2330 Temperature 100.1. Pulse 80. Respirations 16. 2330 Sleeping. Awakened for vital signs. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs, RN (Signed: 4/27/YYYY 11:30:34 PM EST) 4/27/YYYY Saturday 0200 Sleeping. Respirations even. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs, RN (Signed: 4/27/YYYY 2:24:20 AM EST) 0405 102.7 – 100 - 20 0415 Awake. Vital signs taken. Skin warm to touch. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs, RN (Signed: 4/27/YYYY 4:15:04 AM EST) 0430 Tylenol tabs 2 by mouth for increased temperature. Intravenous infusing well. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs, RN (Signed: 4/27/YYYY 4:31:44 AM EST) 0600 Resting quietly. Skin cooler. 0600 Temperature – 100.2 Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs, RN (Signed: 4/27/YYYY 6:00:02 AM EST) G LOBAL M EDICAL C ENTER ² 100 M AIN S T , A LFRED NY 14802 ² (607) 555-1234

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LONG, BETH IPCase001 Dr. BLACK Admission: 04/26/YYYY DOB: 12/17/YYYY ROOM: 369 ± À¾¸µ¸ ± º´µ¸ DATE TIME TREATMENTS & MEDICATIONS TIME NURSE’S NOTES 0730 Temperature decreased. Vital signs stable. States feels better. Intravenous infusing well. Voiding without difficulty. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs, RN (Signed: 4/27/YYYY 7:30:16 AM EST) 4/27/YYYY 0800 Ate all of breakfast. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 4/27/YYYY 8:00:41 AM EST) 0830 Patient took shower with bag over intravenous site. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 4/27/YYYY 8:30:28 AM EST) 1000 Moves well. Walking to day room to smoke. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 4/27/YYYY 10:01:03 AM EST) 1130 Temperature 104 1130 Complains of chills. Temperature increased. Lying in bed. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 4/27/YYYY 11:30:44 AM EST) 1700 Up as desired to smoke. Supper taken fair. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 4/27/YYYY 5:00:17 PM EST) 1800 Complains of feeling ‘shaky’ and felt fever coming on. Temperature = 102. Charge notified and patient given Tylenol 2 tabs. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 4/27/YYYY 6:02:41 PM EST) 2000 Patient complains of ‘sweats.’ Patient’s skin moist & warm. Temperature = 100.3. Encouraged to drink fluids. Voiding well. No sediment or stones strained from urine. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 4/27/YYYY 8:00:10 PM EST) 2200 Awake. No stones strained from urine. Temperature at 2200 – 98.4. Skin less diaphoretic. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 4/27/YYYY 10:00:51 PM EST) 4/27/YYYY 2330 Temperature 98.1. Pulse 72. Respirations 20. 2330 Awake. Reading. No complaints offered. Intravenous infusing well. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs, RN (Signed: 4/27/YYYY 11:30:16 AM EST) G LOBAL M EDICAL C ENTER ² 100 M AIN S T , A LFRED NY 14802 ² (607) 555-1234

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LONG, BETH IPCase001 Dr. BLACK Admission: 04/26/YYYY DOB: 12/17/YYYY ROOM: 369 ± À¾¸µ¸ ± º´µ¸ DATE TIME TREATMENTS & MEDICATIONS TIME NURSE’S NOTES 4/28/YYYY Sunday 0200 Sleeping at present. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs, RN (Signed: 4/28/YYYY 2:00:35 AM EST) 0500 Awakened for vital signs. Temperature increased. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs, RN (Signed: 4/28/YYYY 5:02:00 AM EST) 0520 Tylenol tabs 2 by mouth for increased temperature. Medicated. Intravenous infusing well. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs, RN (Signed: 4/28/YYYY 5:20:18 AM EST) 0630 Sleeping at present. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs, RN (Signed: 4/28/YYYY 6:30:16 AM EST) 0730 Awake for vitals. Ambulatory in hall. Ate 90% of breakfast to bathroom for shower. Sitting out of bed in a chair. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 4/28/YYYY 7:30:00 AM EST) 1200 Ate 75% of lunch. Ambulatory. To day room to smoke. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 4/28/YYYY 12:03:00 PM EST) 1400 All urine strained. No calculi noted. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 4/28/YYYY 2:00:40 PM EST) 1530 In day room visiting. Vitals taken. Intravenous infusing well. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 4/28/YYYY 3:30:04 PM EST) 4/28/YYYY 1830 Ambulatory as desired. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 4/28/YYYY 6:30:35 PM EST) Sunday 1930 Vitals taken. Temperature decreased. Preparation effective. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 4/28/YYYY 7:30:06 PM EST) No calculi noted 2030 Refused backrub. Clear juice taken. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 4/28/YYYY 8:30:17 PM EST) Large amount white sediment. 2200 Resting in bed. Awake. Television on. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 4/28/YYYY 10:00:44 PM EST) G LOBAL M EDICAL C ENTER ² 100 M AIN S T , A LFRED NY 14802 ² (607) 555-1234

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LONG, BETH IPCase001 Dr. BLACK Admission: 04/26/YYYY DOB: 12/17/YYYY ROOM: 369 ± À¾¸µ¸ ± º´µ¸ DATE TIME TREATMENTS & MEDICATIONS TIME NURSE’S NOTES 2330 Temperature 99.4. Pulse 92. Respirations 20. 2330 Awake. Resting quietly. Intravenous infusing well. Vital signs taken. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs, RN (Signed: 4/28/YYYY 6:30:16 AM EST) 4/29/YYYY Monday 0200 Sleeping at present. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs, RN (Signed: 4/29/YYYY 2:00:42 AM EST) 0400 Temperature 97.3. Pulse 80. Respirations 16. 0400 Sleeping. Skin warm & dry. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs, RN (Signed: 4/29/YYYY 4:00:10 AM EST) 0545 Tylenol, 2 tablets by mouth for headache. 0630 Out of bed to bathroom for self morning care. Ready for X-rays. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs, RN (Signed: 4/29/YYYY 6:30:44 AM EST) 0730 Vital signs stable. Temperature decreased. Denies discomfort. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 4/29/YYYY 7:30:00 AM EST) 0800 Took all of clear liquids for breakfast. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 4/29/YYYY 8:03:00 AM EST) 1000 Down for test. Intravenous infusing well. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 4/29/YYYY 10:00:47 AM EST) 1200 Took all of lunch. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 4/29/YYYY 12:03:00 PM EST) 1400 Resting quietly in bed at this time. Had better day. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 4/29/YYYY 2:03:00 PM EST) 4/29/YYYY 1511 Monday 1530 Resting, watching TV. Intravenous infusing. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 4/29/YYYY 3:30:44 PM EST) 1600 Denies any discomfort. Temperature decreased. Ambulatory in hall to dayroom. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 4/29/YYYY 4:01:13 PM EST) 1730 Patient took 60% of supper. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 4/29/YYYY 5:30:55 PM EST) G LOBAL M EDICAL C ENTER ² 100 M AIN S T , A LFRED NY 14802 ² (607) 555-1234

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LONG, BETH IPCase001 Dr. BLACK Admission: 04/26/YYYY DOB: 12/17/YYYY ROOM: 369 ± À¾¸µ¸ ± º´µ¸ DATE TIME TREATMENTS & MEDICATIONS TIME NURSE’S NOTES 4/30/YYYY Tuesday 1800 Ambulatory to dayroom Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 4/30/YYYY 6:00:44 PM EST) 1900 Resting on bed; husband in. Intravenous infusing. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 4/30/YYYY 7:00:03 PM EST) 2000 Bedtime care refused. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 4/30/YYYY 8:00:49 PM EST) 2215 Patient resting, watching television. Had a good evening. Reviewed and Approved: O. Richards, RN ATP-B-S:02:1001261385: O. Richards, RN (Signed: 4/30/YYYY 10:15:22 PM EST) 4/30/YYYY Tuesday 2400 Asleep. Intravenous infusing well at 100/hr. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs, RN (Signed: 4/30/YYYY 2:24:44 PM EST) 0200 Continues to sleep. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs, RN (Signed: 4/30/YYYY 2:00:00 AM EST) 0400 Temperature 97.8. No evidence of calculi in urine . 0400 Continues to sleep. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs, RN (Signed: 4/30/YYYY 4:00:12 AM EST) 0600 Slept well. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs, RN (Signed: 4/30/YYYY 6:00:44 AM EST) 4/30/YYYY Tuesday 0730 Awake and alert. Skin pink and warm to touch. Respirations 16 per minute and even. Reviewed and Approved: J. Dobbs, RN ATP-B-S:02:1001261385: J. Dobbs, RN (Signed: 4/30/YYYY 7:30:26 AM EST) 0750 Intravenous discontinued needle intact. See flow sheet. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 4/30/YYYY 7:50:47 AM EST) 0800 Patient resting quietly Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 4/30/YYYY 8:00:00 AM EST) 0930 Patient states she has no pain. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 4/30/YYYY 9:30:00 AM EST) 0945 Ambulatory to day room. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 4/30/YYYY 9:45:47 AM EST) G LOBAL M EDICAL C ENTER ² 100 M AIN S T , A LFRED NY 14802 ² (607) 555-1234

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LONG, BETH IPCase001 Dr. BLACK Admission: 04/26/YYYY DOB: 12/17/YYYY ROOM: 369 ± À¾¸µ¸ ± º´µ¸ DATE TIME TREATMENTS & MEDICATIONS TIME NURSE’S NOTES 4/30/YYYY 1015 Strained urine. No signs of calculi 800 cubic centimeters. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 4/30/YYYY 10:15:11 AM EST) 1130 Returned to room. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 4/30/YYYY 11:30:33 AM EST) 1150 Discharged to home. Reviewed and Approved: V. South, RN ATP-B-S:02:1001261385: V. South, RN (Signed: 4/30/YYYY 11:50:40 AM EST) G LOBAL M EDICAL C ENTER ² 100 M AIN S T , A LFRED NY 14802 ² (607) 555-1234

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LONG, BETH IPCase001 Dr. BLACK Admission: 04/26/YYYY DOB: 12/17/YYYY ROOM: 369 ± À¾¸°±¿ » °¸·¹³¾¿µ ¸ ´³´À¸ ¸ À¼¼³¾Á 1. AFEBRILE: X Yes No 2. WOUND: Clean/Dry Reddened Infected NA 3. PAIN FREE: X Yes No If “No,” describe: 4. POST-HOSPITAL INSTRUCTION SHEET GIVEN TO PATIENT/FAMILY: Yes X No If NO, complete lines 5-8 below. 5. DIET: X Regular Other (Describe): 6. ACTIVITY: X Normal Light Limited Bed rest 7. MEDICATIONS: Prescriptions given to patient. 8. INSTRUCTIONS GIVEN TO PATIENT/FAMILY: Appointment as needed. 9. PATIENT/FAMILY verbalize understanding of instructions: X Yes No 10. DISCHARGED at 1150 Via: X Wheelchair Stretcher Ambulance Co. Accompanied by: Vera South, RN to Front desk COMMENTS: G LOBAL M EDICAL C ENTER ² 100 M AIN S T , A LFRED NY 14802 ² (607) 555-1234

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