IPCase001 Medical Record Example

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 ű²´ ÃÆÇ ³º²È ¹É´ ¿±³¸´µ ¶±·´ ʾ¾Â˱²³Ãµ LONG, BETH 4983 REED STREET ALMOND, NY 14804 12/17/ 1992 30 Short Clerk ¹¸·³»»³Ãµ ű²´ Ì ³·´ ų»¾È±ºÉ´ ű²´ Ì ³·´ Í´µÉ²ÈÃÆÁ²± Ì´À ´ËÈõ´ ¶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 ´ËÈõ´ ¶ÃÄ ½´À ±²³Ãµ»È ³Ë²Ã°±²³´µ² ¶´" ² ÃÆ# ³µ Ì´À ´ËÈõ´ ¶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´ ½Ã÷ ¶Â·!´º%Ç´¸ John Black, MD 369 ¹²²´µ¸³µÉ°È »³¾ ³±µ ¹¸·³²²³µÉų±ÉµÃ»³» John Black, MD Fever of undetermined origin °º³·±º &µ»Âº´º °ÃÀ ³¾ ±µ¸ ¼ºÃÂ˶·!´º Á´¾Ãµ¸±º &µ»Âº´º °ÃÀ ³¾ ±µ¸ ¼ºÃÂ˶·!´º °±²³´µ¶·¶ ²´¸ ¹ºµ»·¸¼º·¶ ½¾° ¾µ¸· °º³µ¾ ³Ë±Àų±ÉµÃ»³» Acute Pyelonephritis Á´¾Ãµ¸±º ų±ÉµÃ»´» Dehydration °º³µ¾ ³Ë±À°ºÃ¾´¸Âº´ Á´¾Ãµ¸±º °ºÃ¾´¸Âº´» ų»¾È±ºÉ´ &µ»²ºÂ¾ ²³Ãµ» ¹¾ ²³$ ³² : ° Bed rest ° Light ° Usual ° Unlimited ° Other: ų´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

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  ² ¹Á¸°·³Ã µ ij¼ 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