The Incident- Medical Records

Home

The Incident

Ambulance Run Report

ER Record

Physician's Notes from Emergency Dept

Dr. Croaker Discharge Summary

Dr. Croaker Physician's Order Sheet

Initial EKG

Dr. Croaker Progress Notes

Chest X-Ray

Dr. Croaker Lab

Nursing Notes

Morning EKG

Readmit

Code Note

Autopsy

The Cast

The Natural History of a Lawsuit

Legalities

2/13/1999 St. Jennifers Med Center - Dr. Croaker Physician's Order Sheet

1. Admit to ICU cardiac monitor.
2. Activity bed rest with comode advances ordered per activity progression guide.
3. Routine vital signs every 4 hours while awake.
4. Daily weights, I&O, Folery prn.
5. Coronary diet, low sodium liquid, advance to 4 gm sodium, low cholesterol, high fiber, no milk products.
6. Oxygen at 4-5 liters, nasal cannula. Reduced to 1-2 liters, nasal cannula if past history of COPD. Renew after eight hours.
7. Lab: CPK on admission at 8 hours and 16 hours. APTT, Protime, Potassium, HGB, Chem strip, Cholesterol. Draw lipid panel on fasting, electrolytes. EKG on admission, daily x 2 and prn with pain.
8. Initiate code blue procedures for cardiac and/or respiratory emergencies follow ACLS protocols.
9. IV D5W TKO. Heplock flush with MS every 12 hours.
10. Medications: Anticoagulation, ASA qd. Constipation: MOM 30 cc's prn pain. M.S. 1-5 mg. IV prn. Nitroglycerin gr 1/150 S.L. every 5 minutes per nursing protocol. Sedation: Xanax 0.5 mg. h.s. Arrhythmia: Follow ACLS guidelines.
11. May use angina acute MI care pathway.
12. Thrombolytic therapy: No.
13. Lopressor Protocol: No.
14. Capoten: No.
2/13/1999 18:30 St. Jennifers Med Center - Dr. Croaker Physician's Order Sheet Change IV to D5 NS at 125 cc's per hour.
2/14/1999 St. Jennifers Med Center - Dr. Croaker Physician's Order Sheet Tylenol 325 mg 1-2 p.o. q. 4 hours p.r.n.
2/14/1999 Discharge home. Follow up appt for stress test Mon a.m. Take nitro Instruct re emergency care.