{ "audience" : "student", "createdAt" : "2026-10-13T12:00:00-07:00", "entries" : [ { "envelope" : { "appName" : "ChartSlate", "audience" : "student", "createdAt" : "2026-09-25T19:44:22.331008+00:00", "exportVersion" : "1", "kind" : "casePackage", "package" : { "case" : { "activities" : [ ], "id" : "docucare-skills lab-rocio-doe", "learningLevel" : "Skills Lab", "panels" : { "assessments" : [ { "dateTime" : "2025-02-18T17:00:00", "id" : "rocio-doe-assessment-1", "label" : "Neuro", "summary" : ": Neuro\nAdditional Notes / Additional Notes: A & O x 4" }, { "dateTime" : "2025-02-18T17:00:00", "id" : "rocio-doe-assessment-2", "label" : "Cardio", "summary" : ": Cardio" }, { "dateTime" : "2025-02-18T17:00:00", "id" : "rocio-doe-assessment-3", "label" : "Respiratory", "summary" : ": Respiratory\nAdditional Notes / Additional Notes: Weak cough" }, { "dateTime" : "2025-02-18T17:00:00", "id" : "rocio-doe-assessment-4", "label" : "Vascular Access", "summary" : ": Vascular Access\nLocation: Right Intrajugular (IJ)\nType: Central Line, Double Lumen\nDate Inserted Date: 02/18/2025\nSite Description: Secured with tegaderm\nDressing: Clean, dry and intact." } ], "labs" : [ { "category" : "Partial Thromboplastin Time (PTT)", "collectedDateTime" : "2025-02-18T17:00:00", "flag" : "Unverified", "id" : "rocio-doe-lab-1", "referenceRange" : "23.5-37.5-1.20", "result" : "40", "test" : "PTT (sec)" }, { "category" : "Partial Thromboplastin Time (PTT)", "collectedDateTime" : "2025-02-18T17:00:00", "flag" : "Unverified", "id" : "rocio-doe-lab-2", "referenceRange" : "23.5-37.5-1.20", "result" : "128", "test" : "PTT (sec)" } ], "medications" : [ { "doseRouteFrequency" : "20 Intravenous (IV) q4h (Every 4 hours), Every 4 hours", "drug" : "furosemide", "id" : "rocio-doe-med-3", "notes" : "20mg/2ml Source due: 2/18/2025 17:00 Furosemide dose is 20 without a dose unit. Stock concentration 20 mg/2 mL does not establish whether the prescribed amount is mg or mL; clarify.", "orderedBy" : "Pending per John, Admitting Physician", "orderedDateTime" : "2025-02-18T17:00:00", "section" : "Scheduled", "status" : "Held — clarification required" }, { "doseRouteFrequency" : "5000 units IVP x1 (1 time only), 1 time only", "drug" : "heparin sodium", "id" : "rocio-doe-med-4", "notes" : "5000 units/1ml Source due: 2/18/2025 17:00 Heparin bolus is held with the infusion pending verification of the intended anticoagulation protocol and baseline result.", "orderedBy" : "Pending per John, Admitting Physician", "orderedDateTime" : "2025-02-18T17:00:00", "section" : "Scheduled", "status" : "Held — clarification required" }, { "doseRouteFrequency" : "1000 units/hr (10 mL/hr at source 25,000 units/250 mL) Intravenous (IV) cont.", "drug" : "heparin sodium", "id" : "rocio-doe-med-5", "notes" : "Heparin infusion 25,000 units/250 ml in 0.9 Nacl High Alert Medication: Double Check Initial dose (Units/HR) Heparin: 1000 units/hr PTT 39.4 or less increase by 200 units/hr Repeat PTT in 6 hr PTT 39.5-60.4 increase by 100 units/hr Repeat PTT in 6 hr PTT 60.5-80.4 increase by 50 units/hr Repeat PTT in 6 hr PTT 80-.5-120.4 NO CHANGE (THERAPEUTIC GOAL aPTT) Repeat PTT in 6 hr PTT 120.4 or greater hold infusion for 2 hrs repeat PTT in 2 hrs Source due: 2/18/2025 17:00 Do not initiate or titrate from the unresolved source protocol: aPTT 120.4 belongs to both no-change and hold ranges; malformed 80-.5 boundary, absent restart instructions, and two discordant PTT values share one timestamp. Initial rate is documented for review only.", "orderedBy" : "Pending per John, Admitting Physician", "orderedDateTime" : "2025-02-18T17:00:00", "section" : "Scheduled", "status" : "Held — clarification required" } ], "notes" : [ { "id" : "rocio-doe-allergy", "summary" : "Source allergy table contains no entries. Allergy status is not documented; an empty table does not establish no known allergies.", "type" : "Allergy documentation" }, { "author" : "Jane , Registered Nurse", "dateTime" : "2025-02-18T17:00:00", "id" : "rocio-doe-note-1", "summary" : "S 76 y/o female admitted for PICC line infection & sepsis. B History of ovarian cancer and pt is receiving chemotherapy. PICC line was removed. Temporary CVD was placed d/t sepsis and hemodynamically unstable on admission. A V. S. stable- 98.4, 84, 22, 132/84 O2 sat 98% on RA pain 0/10 A & O x 4 Right intrajugular (IJ) CVD double lumen Heart regular rate and rhythm. Peripheral pulses strong bilaterally. Cap refill <3 seconds. Lungs sounds clear bilaterally R Patient has an order for a repeat blood culture to be drawn now. It has been seven days since the last CVD dressing change.", "type" : "Nursing - Shift" }, { "author" : "John , Admitting Physician", "dateTime" : "2025-02-18T17:00:00", "id" : "rocio-doe-note-2", "summary" : "The patient complains of crushing chest pain. Plan to start Heparin GTT. See orders", "type" : "Physician Notes" }, { "id" : "rocio-doe-section-current-care-providers", "summary" : "Jane | Registered Nurse\nJohn | Admitting Physician", "type" : "Current Care Providers" }, { "id" : "rocio-doe-clarification-5", "summary" : "Skills Lab simulation ID SL-001. Original DocuCare MRN: 112358. Original fixed simulation dates and stated scenario ages are retained; DOB-derived age may disagree. Source records are preserved for faculty review.", "type" : "Chart clarification" }, { "id" : "rocio-doe-clarification-6", "summary" : "Furosemide dose is 20 without a dose unit. Stock concentration 20 mg/2 mL does not establish whether the prescribed amount is mg or mL; clarify.", "type" : "Chart clarification" }, { "id" : "rocio-doe-clarification-7", "summary" : "Heparin bolus is held with the infusion pending verification of the intended anticoagulation protocol and baseline result.", "type" : "Chart clarification" }, { "id" : "rocio-doe-clarification-8", "summary" : "Do not initiate or titrate from the unresolved source protocol: aPTT 120.4 belongs to both no-change and hold ranges; malformed 80-.5 boundary, absent restart instructions, and two discordant PTT values share one timestamp. Initial rate is documented for review only.", "type" : "Chart clarification" }, { "id" : "rocio-doe-clarification-9", "summary" : "PTT 40 and 128 seconds have identical timestamps and malformed reference 23.5-37.5-1.20. Neither was selected as the current result.", "type" : "Chart clarification" }, { "id" : "rocio-doe-clarification-10", "summary" : "Blood culture and central-line care intent retained. Chest pain note and sepsis narrative need chronological reconciliation.", "type" : "Chart clarification" } ], "orders" : [ { "author" : "Pending per John, Admitting Physician", "category" : "Nursing", "dateTime" : "2025-02-18T17:00:00", "id" : "rocio-doe-order-1", "orderText" : "Blood culture sample collection; x1 (1 time only), 1 time only; Stat; Source due: 2/18/2025 17:00", "status" : "Active" }, { "author" : "Pending per John, Admitting Physician", "category" : "Nursing", "dateTime" : "2025-02-18T17:00:00", "id" : "rocio-doe-order-2", "orderText" : "Central venous access device dressing change; x1 (1 time only), 1 time only; Routine; Source due: 2/18/2025 17:00", "status" : "Active" }, { "author" : "Pending per John, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2025-02-18T17:00:00", "id" : "rocio-doe-order-3", "orderText" : "furosemide; 20 Intravenous (IV); q4h (Every 4 hours), Every 4 hours; Scheduled; 20mg/2ml Source due: 2/18/2025 17:00 Furosemide dose is 20 without a dose unit. Stock concentration 20 mg/2 mL does not establish whether the prescribed amount is mg or mL; clarify.", "status" : "Held — clarification required" }, { "author" : "Pending per John, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2025-02-18T17:00:00", "id" : "rocio-doe-order-4", "orderText" : "heparin sodium; 5000 units IVP; x1 (1 time only), 1 time only; Scheduled, Stat; 5000 units/1ml Source due: 2/18/2025 17:00 Heparin bolus is held with the infusion pending verification of the intended anticoagulation protocol and baseline result.", "status" : "Held — clarification required" }, { "author" : "Pending per John, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2025-02-18T17:00:00", "id" : "rocio-doe-order-5", "orderText" : "heparin sodium; 1000 units/hr (10 mL/hr at source 25,000 units/250 mL) Intravenous (IV); cont.; Cont. Infusion, Stat; Heparin infusion 25,000 units/250 ml in 0.9 Nacl High Alert Medication: Double Check Initial dose (Units/HR) Heparin: 1000 units/hr PTT 39.4 or less increase by 200 units/hr Repeat PTT in 6 hr PTT 39.5-60.4 increase by 100 units/hr Repeat PTT in 6 hr PTT 60.5-80.4 increase by 50 units/hr Repeat PTT in 6 hr PTT 80-.5-120.4 NO CHANGE (THERAPEUTIC GOAL aPTT) Repeat PTT in 6 hr PTT 120.4 or greater hold infusion for 2 hrs repeat PTT in 2 hrs Source due: 2/18/2025 17:00 Do not initiate or titrate from the unresolved source protocol: aPTT 120.4 belongs to both no-change and hold ranges; malformed 80-.5 boundary, absent restart instructions, and two discordant PTT values share one timestamp. Initial rate is documented for review only.", "status" : "Held — clarification required" } ], "overview" : { "height" : "", "isolationIndicator" : "Standard", "religion" : "" }, "vitals" : [ { "bloodPressure" : "132/84", "dateTime" : "2025-02-18T17:00:00", "heartRate" : 84, "id" : "rocio-doe-vital-1", "oxygenDevice" : "Room Air", "respiratoryRate" : 22, "spo2" : "98", "temperature" : "98.4 °F (37 °C), 37 °C Oral" } ] }, "patient" : { "admitDateTime" : "2025-02-18T17:00:00", "admittingDiagnosis" : "PICC line infection and sepsis", "allergies" : [ ], "attending" : "John, Admitting Physician", "chartDisplayName" : "Doe, Rocio", "codeStatus" : "", "dob" : "7/16/1950", "history" : { "chiefComplaint" : "76 y/o female admitted for PICC line infection & sepsis. She has a history of ovarian cancer and pt is receiving chemotherapy.", "pastMedicalHistory" : [ ], "pastSurgicalHistory" : [ ], "socialHistory" : [ "Age: 76 Years" ] }, "mrn" : "SL-001", "sex" : "Female", "simulatedFullName" : "Rocio Doe", "unit" : "RCC Hospital" }, "setting" : "RCC Hospital", "snapshots" : [ { "activityIds" : [ ], "id" : "rocio-doe-current", "notes" : "Captured dated chart history; source relative dates anchored to chart opening. Progressive release not recreated.", "scenarioTime" : "2025-02-18T17:00:00", "sourcePath" : "DocuCare instructor chart: Rocio Doe", "title" : "Captured chart" } ], "subtitle" : "Learning Lab practice record", "tags" : [ "Skills Lab", "DocuCare migration", "Learning Lab" ], "title" : "Rocio Doe" }, "packageId" : "docucare-skills lab-rocio-doe-review-v1", "privacy" : { "containsRealPHI" : false, "defaultStorage" : "local-document-package", "networkRequired" : false, "simulatedOnly" : true, "warning" : "Simulated education only. Not for clinical care. Review conflicting, held or undocumented findings with lab faculty." }, "schemaVersion" : "2.0", "source" : { "system" : "DocuCare Enhanced instructor chart capture" }, "workingNames" : [ "ChartSlate" ] } }, "id" : "skills lab-rocio-doe", "instructions" : "Choose this patient for simulated chart-review practice. Check the name, date of birth and simulated MRN; review notes, assessments, vital signs, orders and medications. Identify missing or conflicting information and discuss it with lab faculty. Held or discontinued medications are not active administration tasks.", "title" : "Rocio Doe" }, { "envelope" : { "appName" : "ChartSlate", "audience" : "student", "createdAt" : "2026-09-25T19:44:22.331008+00:00", "exportVersion" : "1", "kind" : "casePackage", "package" : { "case" : { "activities" : [ ], "id" : "docucare-skills lab-jane-dee", "learningLevel" : "Skills Lab", "panels" : { "assessments" : [ { "dateTime" : "2025-02-18T13:00:00", "id" : "jane-dee-assessment-1", "label" : "GI", "summary" : ": GI\nAdditional Notes / Additional Notes: Right abdominal vertical incision ~ 12 cm long. Staples intact. Minimal erythema and edema. No ecchymosis noted. Moderate serosanguinous drainage on dressing. Wound edges well approximated.\nLast Bowel Movement / Last Bowel Movement Date: 02/18/2025\nLast Bowel Movement / Last Bowel Movement Time: 13:00" } ], "labs" : [ ], "medications" : [ { "doseRouteFrequency" : "1 tab Oral (PO) q6h (Every 6 hours), Every 6 hours", "drug" : "HYDROcodone bitartrate–acetaminophen", "id" : "jane-dee-med-2", "notes" : "1 tablet = 5 mg/325 mg PRN pain 2-5 on pain scale Source due: PRN", "orderedBy" : "Pending per Dr. Kno, Admitting Physician", "orderedDateTime" : "2025-02-18T13:00:00", "section" : "PRN", "status" : "Active" }, { "doseRouteFrequency" : "2 tabs Oral (PO) q6h (Every 6 hours), Every 6 hours", "drug" : "HYDROcodone bitartrate–acetaminophen", "id" : "jane-dee-med-3", "notes" : "1 tablet - 5/325 mg PRN pain 6-10 on pain scale Source due: PRN Severe-pain order says two 5/325 tablets (10/650 mg total) but nursing note says Norco 10/325. Product and total acetaminophen dose require clarification.", "orderedBy" : "Pending per Dr. Kno, Admitting Physician", "orderedDateTime" : "2025-02-18T13:00:00", "section" : "PRN", "status" : "Held — clarification required" } ], "notes" : [ { "id" : "jane-dee-allergy", "summary" : "Source allergy table contains no entries. Allergy status is not documented; an empty table does not establish no known allergies.", "type" : "Allergy documentation" }, { "author" : "Sean , Registered Nurse", "dateTime" : "2025-02-18T13:00:00", "id" : "jane-dee-note-1", "summary" : "S: 57 y/o female with 2-day post-op right ascending colectomy for CA B: Pt. needs surgical incisional sterile wound cleansing and dressing once per shift. Can be medicated for pain 30 min to 1 hr before dressing change with Norco 5/325 for pain 2-5/10 scale or Norco 10/325 for pain 6-10/10 scale. A: A&OX4, Skin appropriate for ethnicity, warm and dry. T 99.0, P 88, R 14, BP 128/89, pulse ox 98% RA. Pain 7/10 scale in incisional area. Lungs CTAB. Heart S1 S2, no murmurs or irregular rhythm. Abdomen soft with hypoactive bowel sounds. Right abdominal vertical incision ~ 12 cm long. Staples intact. Minimal erythema and edema. No ecchymosis noted. Moderate serosanguinous drainage on dressing. Wound edges well approximated. R: Premedicate for pain. Change dressing during next shift.", "type" : "Nursing - Shift" }, { "id" : "jane-dee-section-current-care-providers", "summary" : "Dr. Kno | Admitting Physician\nSean | Registered Nurse", "type" : "Current Care Providers" }, { "id" : "jane-dee-clarification-4", "summary" : "Skills Lab simulation ID SL-002. Original DocuCare MRN: 358132. Original fixed simulation dates and stated scenario ages are retained; DOB-derived age may disagree. Source records are preserved for faculty review.", "type" : "Chart clarification" }, { "id" : "jane-dee-clarification-5", "summary" : "Severe-pain order says two 5/325 tablets (10/650 mg total) but nursing note says Norco 10/325. Product and total acetaminophen dose require clarification.", "type" : "Chart clarification" }, { "id" : "jane-dee-clarification-6", "summary" : "Wound care is q24h in order but once per shift in nursing note. Preserve both for clarification.", "type" : "Chart clarification" }, { "id" : "jane-dee-clarification-7", "summary" : "Chief complaint is preoperative; nursing note is postoperative day 2 with the same chart timestamp.", "type" : "Chart clarification" } ], "orders" : [ { "author" : "Pending per Dr. Kno, Admitting Physician", "category" : "Nursing: Procedure", "dateTime" : "2025-02-18T13:00:00", "id" : "jane-dee-order-1", "orderText" : "Clean abdominal wound with sterile normal saline and apply sterile dressing to incisonal site.; q24h (Every 24 hours), Every 24 hours; Routine; Source due: 2/18/2025 13:00", "status" : "Active" }, { "author" : "Pending per Dr. Kno, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2025-02-18T13:00:00", "id" : "jane-dee-order-2", "orderText" : "HYDROcodone bitartrate–acetaminophen; 1 tab Oral (PO); q6h (Every 6 hours), Every 6 hours; PRN; 1 tablet = 5 mg/325 mg PRN pain 2-5 on pain scale Source due: PRN", "status" : "Active" }, { "author" : "Pending per Dr. Kno, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2025-02-18T13:00:00", "id" : "jane-dee-order-3", "orderText" : "HYDROcodone bitartrate–acetaminophen; 2 tabs Oral (PO); q6h (Every 6 hours), Every 6 hours; PRN; 1 tablet - 5/325 mg PRN pain 6-10 on pain scale Source due: PRN Severe-pain order says two 5/325 tablets (10/650 mg total) but nursing note says Norco 10/325. Product and total acetaminophen dose require clarification.", "status" : "Held — clarification required" } ], "overview" : { "height" : "", "isolationIndicator" : "Standard", "religion" : "" }, "vitals" : [ { "bloodPressure" : "128/89", "dateTime" : "2025-02-18T13:00:00", "heartRate" : 88, "id" : "jane-dee-vital-1", "oxygenDevice" : "Room Air", "respiratoryRate" : 7, "spo2" : "98", "temperature" : "99 °F (37 °C), 37 °C Oral" } ] }, "patient" : { "admitDateTime" : "2025-02-18T13:00:00", "admittingDiagnosis" : "Postoperative ascending colectomy for colon cancer", "allergies" : [ ], "attending" : "Dr. Kno, Admitting Physician", "chartDisplayName" : "Dee, Jane", "codeStatus" : "", "dob" : "7/6/1969", "history" : { "chiefComplaint" : "57 y.o. Female admitted as pre op for ascending colectomy procedure—history of colon cancer.", "pastMedicalHistory" : [ ], "pastSurgicalHistory" : [ ], "socialHistory" : [ "Age: 57 Years" ] }, "mrn" : "SL-002", "sex" : "Female", "simulatedFullName" : "Jane Dee", "unit" : "RCC Hospital" }, "setting" : "RCC Hospital", "snapshots" : [ { "activityIds" : [ ], "id" : "jane-dee-current", "notes" : "Captured dated chart history; source relative dates anchored to chart opening. Progressive release not recreated.", "scenarioTime" : "2025-02-18T13:00:00", "sourcePath" : "DocuCare instructor chart: Jane Dee", "title" : "Captured chart" } ], "subtitle" : "Learning Lab practice record", "tags" : [ "Skills Lab", "DocuCare migration", "Learning Lab" ], "title" : "Jane Dee" }, "packageId" : "docucare-skills lab-jane-dee-review-v1", "privacy" : { "containsRealPHI" : false, "defaultStorage" : "local-document-package", "networkRequired" : false, "simulatedOnly" : true, "warning" : "Simulated education only. Not for clinical care. Review conflicting, held or undocumented findings with lab faculty." }, "schemaVersion" : "2.0", "source" : { "system" : "DocuCare Enhanced instructor chart capture" }, "workingNames" : [ "ChartSlate" ] } }, "id" : "skills lab-jane-dee", "instructions" : "Choose this patient for simulated chart-review practice. Check the name, date of birth and simulated MRN; review notes, assessments, vital signs, orders and medications. Identify missing or conflicting information and discuss it with lab faculty. Held or discontinued medications are not active administration tasks.", "title" : "Jane Dee" }, { "envelope" : { "appName" : "ChartSlate", "audience" : "student", "createdAt" : "2026-09-25T19:44:22.331008+00:00", "exportVersion" : "1", "kind" : "casePackage", "package" : { "case" : { "activities" : [ ], "id" : "docucare-skills lab-jeffrey-sage", "learningLevel" : "Skills Lab", "panels" : { "assessments" : [ { "dateTime" : "2025-02-18T15:00:00", "id" : "jeffrey-sage-assessment-1", "label" : "Neuro", "summary" : ": Neuro\nEye Opening: Spontaneously\nMotor Response: Obeys Verbal Command\nVerbal Response: Oriented X 3" }, { "dateTime" : "2025-02-18T15:00:00", "id" : "jeffrey-sage-assessment-2", "label" : "Cardio", "summary" : ": Cardio" }, { "dateTime" : "2025-02-18T15:00:00", "id" : "jeffrey-sage-assessment-3", "label" : "GI", "summary" : ": GI\nLast Bowel Movement / Last Bowel Movement Date: 02/18/2025\nLast Bowel Movement / Last Bowel Movement Time: 17:00" }, { "dateTime" : "2025-02-18T15:00:00", "id" : "jeffrey-sage-assessment-4", "label" : "Respiratory", "summary" : ": Respiratory" }, { "dateTime" : "2025-02-18T15:00:00", "id" : "jeffrey-sage-assessment-5", "label" : "Musculoskeletal", "summary" : ": Musculoskeletal\nAdditional Notes / Additional Notes: Dizziness when standing" }, { "dateTime" : "2025-02-18T15:00:00", "id" : "jeffrey-sage-assessment-6", "label" : "Clean/Dry/Intact Skin Assessment", "summary" : "No findings entered in visible fields." } ], "labs" : [ { "category" : "Other", "collectedDateTime" : "2025-02-18T15:00:00", "flag" : "Normal", "id" : "jeffrey-sage-lab-1", "result" : "Positive", "test" : "O" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2025-02-18T15:00:00", "flag" : "Normal", "id" : "jeffrey-sage-lab-2", "referenceRange" : "4.0-9.0", "result" : "5", "test" : "WBC (10 x 3/uL)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2025-02-18T15:00:00", "flag" : "Low", "id" : "jeffrey-sage-lab-3", "referenceRange" : "3.90-4.98", "result" : "3", "test" : "RBC (mill/cumm)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2025-02-18T15:00:00", "flag" : "Low", "id" : "jeffrey-sage-lab-4", "referenceRange" : "12.0-15.5", "result" : "6", "test" : "Hemoglobin (gm/dL)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2025-02-18T15:00:00", "flag" : "Low", "id" : "jeffrey-sage-lab-5", "referenceRange" : "35-45", "result" : "28", "test" : "Hematocrit (%)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2025-02-18T15:00:00", "flag" : "Normal", "id" : "jeffrey-sage-lab-6", "referenceRange" : "81-93", "result" : "85", "test" : "MCV (fL)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2025-02-18T15:00:00", "flag" : "Normal", "id" : "jeffrey-sage-lab-7", "referenceRange" : "28-35", "result" : "30", "test" : "MCH (pg)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2025-02-18T15:00:00", "flag" : "Normal", "id" : "jeffrey-sage-lab-8", "referenceRange" : "33-37", "result" : "35", "test" : "MCHC (gm/dL)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2025-02-18T15:00:00", "flag" : "Normal", "id" : "jeffrey-sage-lab-9", "referenceRange" : "11.4-15.2", "result" : "13", "test" : "RDW (%)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2025-02-18T15:00:00", "flag" : "Normal", "id" : "jeffrey-sage-lab-10", "referenceRange" : "140-400", "result" : "146", "test" : "Platelet Count (1000/mm3)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2025-02-18T15:00:00", "flag" : "Normal", "id" : "jeffrey-sage-lab-11", "referenceRange" : "6.0-11.1", "result" : "8", "test" : "Mean Platelet Volume (MPV) (fL)" } ], "medications" : [ ], "notes" : [ { "id" : "jeffrey-sage-allergy", "summary" : "Source allergy table contains no entries. Allergy status is not documented; an empty table does not establish no known allergies.", "type" : "Allergy documentation" }, { "author" : "Megan Han , Registered Nurse", "dateTime" : "2025-02-18T15:00:00", "id" : "jeffrey-sage-note-1", "summary" : "S : 33 y.o male admitted for fall, s/p right femur fracture repair. Report just received from PACU. No complications in surgery, PACU, or anesthesia. Medicated with Morphine for 8/10 pain in PACU 20 min ago. Current pain is 3/10. EBL 600 ml in surgery. B: No past medical history A : A & O x 4 and drowsy, easily arousable. V. S. stable- Temp. 97.6, HR 105, RR 15, BP 98/50, O2 sat 97%. No respiratory distress. Lungs clear bilaterally. Heart rate/rhythm regular. Pulses present all extremities, 2+. IV in Left AC infusing NS at 100 ml/hr. PACU nurse initiated new IV order prior to transfer. Bowel sounds hypoactive in all quadrants. Foley catheter emptied in PACU prior to transfer. UOP is approximately 50 ml/hour in PACU. R femur dressing is dry and intact. JP drained emptied in PACU prior to transfer– 150 mL sanguineous drainage. R Initiate post-op orders. Continue to monitor for pain, bleeding, and breathing. Place on O2 2 L/min. nasal cannula if SpO2 < 92%.", "type" : "Nursing - Shift" }, { "id" : "jeffrey-sage-section-current-care-providers", "summary" : "Megan Han | Registered Nurse\nShelia Jon | Admitting Physician", "type" : "Current Care Providers" }, { "id" : "jeffrey-sage-clarification-4", "summary" : "Skills Lab simulation ID SL-003. Original DocuCare MRN: 123456. Original fixed simulation dates and stated scenario ages are retained; DOB-derived age may disagree. Source records are preserved for faculty review.", "type" : "Chart clarification" }, { "id" : "jeffrey-sage-clarification-5", "summary" : "Major source conflict: chief complaint describes rectal bleeding and ulcerative colitis, while shift note describes postoperative femur fracture with surgical blood loss and no medical history. No narrative was silently rewritten.", "type" : "Chart clarification" }, { "id" : "jeffrey-sage-clarification-6", "summary" : "CBC hemoglobin 6, hematocrit 28, RBC 3 and indices are internally inconsistent. Preserve values; verify intended CBC before release.", "type" : "Chart clarification" }, { "id" : "jeffrey-sage-clarification-7", "summary" : "Blood type is entered as test O / result Positive. Source lacks a formal ABO/Rh label and compatibility documentation; do not infer a completed crossmatch.", "type" : "Chart clarification" } ], "orders" : [ { "author" : "Pending per Shelia Jon, Admitting Physician", "category" : "Blood Product Administration", "dateTime" : "2025-02-18T15:00:00", "id" : "jeffrey-sage-order-1", "orderText" : "Blood and blood product transfusion; x1 (1 time only), 1 time only; Routine; 1 unit of PRBCs. Source due: 2/18/2025 15:00", "status" : "Active" }, { "author" : "Pending per Shelia Jon, Admitting Physician", "category" : "Blood Product Administration", "dateTime" : "2025-02-18T15:00:00", "id" : "jeffrey-sage-order-2", "orderText" : "Type and Cross; x1 (1 time only), 1 time only; Routine; Source due: 2/18/2025 15:00", "status" : "Active" }, { "author" : "Pending per Shelia Jon, Admitting Physician", "category" : "Laboratory", "dateTime" : "2025-02-18T15:00:00", "id" : "jeffrey-sage-order-3", "orderText" : "Hemoglobin and Hematocrit; x1 (1 time only), 1 time only; Routine; Repeat H/H 2 hours post blood tranfusion. Source due: 2/18/2025 15:00", "status" : "Active" } ], "overview" : { "height" : "", "isolationIndicator" : "Standard", "religion" : "" }, "vitals" : [ { "bloodPressure" : "118/76", "dateTime" : "2025-02-18T15:00:00", "heartRate" : 98, "id" : "jeffrey-sage-vital-1", "oxygenDevice" : "Room Air", "respiratoryRate" : 18, "spo2" : "86", "temperature" : "97.8 °F (37 °C), 37 °C Oral" } ] }, "patient" : { "admitDateTime" : "2025-02-18T15:00:00", "admittingDiagnosis" : "Rectal bleeding with ulcerative colitis — conflicting postoperative note", "allergies" : [ ], "attending" : "Shelia Jon, Admitting Physician", "chartDisplayName" : "Sage, Jeffrey", "codeStatus" : "", "dob" : "7/14/1993", "history" : { "chiefComplaint" : "33 y.o. Male with rectal bleeding x 3 days. History of ulcerative colitis with recent exacerbation.", "pastMedicalHistory" : [ ], "pastSurgicalHistory" : [ ], "socialHistory" : [ "Age: 33 Years" ] }, "mrn" : "SL-003", "sex" : "Male", "simulatedFullName" : "Jeffrey Sage", "unit" : "RCC Hospital" }, "setting" : "RCC Hospital", "snapshots" : [ { "activityIds" : [ ], "id" : "jeffrey-sage-current", "notes" : "Captured dated chart history; source relative dates anchored to chart opening. Progressive release not recreated.", "scenarioTime" : "2025-02-18T15:00:00", "sourcePath" : "DocuCare instructor chart: Jeffrey Sage", "title" : "Captured chart" } ], "subtitle" : "Learning Lab practice record", "tags" : [ "Skills Lab", "DocuCare migration", "Learning Lab" ], "title" : "Jeffrey Sage" }, "packageId" : "docucare-skills lab-jeffrey-sage-review-v1", "privacy" : { "containsRealPHI" : false, "defaultStorage" : "local-document-package", "networkRequired" : false, "simulatedOnly" : true, "warning" : "Simulated education only. Not for clinical care. Review conflicting, held or undocumented findings with lab faculty." }, "schemaVersion" : "2.0", "source" : { "system" : "DocuCare Enhanced instructor chart capture" }, "workingNames" : [ "ChartSlate" ] } }, "id" : "skills lab-jeffrey-sage", "instructions" : "Choose this patient for simulated chart-review practice. Check the name, date of birth and simulated MRN; review notes, assessments, vital signs, orders and medications. Identify missing or conflicting information and discuss it with lab faculty. Held or discontinued medications are not active administration tasks.", "title" : "Jeffrey Sage" }, { "envelope" : { "appName" : "ChartSlate", "audience" : "student", "createdAt" : "2026-09-25T19:44:22.331008+00:00", "exportVersion" : "1", "kind" : "casePackage", "package" : { "case" : { "activities" : [ ], "id" : "docucare-skills lab-tomas-esposito", "learningLevel" : "Skills Lab", "panels" : { "assessments" : [ { "dateTime" : "2025-02-17T14:00:00", "id" : "tomas-esposito-assessment-1", "label" : "HEENT", "summary" : ": HEENT" }, { "dateTime" : "2025-02-18T02:00:00", "id" : "tomas-esposito-assessment-2", "label" : "HEENT", "summary" : ": HEENT" }, { "dateTime" : "2025-02-18T13:00:00", "id" : "tomas-esposito-assessment-3", "label" : "HEENT", "summary" : ": HEENT" }, { "dateTime" : "2025-02-17T14:00:00", "id" : "tomas-esposito-assessment-4", "label" : "Neuro", "summary" : ": Neuro\nEye Opening: Spontaneously\nMotor Response: Obeys Verbal Command\nVerbal Response: Oriented X 3" }, { "dateTime" : "2025-02-18T13:00:00", "id" : "tomas-esposito-assessment-5", "label" : "Neuro", "summary" : ": Neuro\nEye Opening: Spontaneously\nMotor Response: Obeys Verbal Command\nVerbal Response: Oriented X 3" }, { "dateTime" : "2025-02-18T02:00:00", "id" : "tomas-esposito-assessment-6", "label" : "Neuro", "summary" : ": Neuro\nEye Opening: Spontaneously\nMotor Response: Obeys Verbal Command\nVerbal Response: Oriented X 3" }, { "dateTime" : "2025-02-17T14:00:00", "id" : "tomas-esposito-assessment-7", "label" : "Cardio", "summary" : ": Cardio\nDevices / Cardiac Monitor / Cardiac Rhythm: Atrial fibrillation" }, { "dateTime" : "2025-02-18T13:00:00", "id" : "tomas-esposito-assessment-8", "label" : "Cardio", "summary" : ": Cardio\nDevices / Cardiac Monitor / Cardiac Rhythm: Atrial fibrillation" }, { "dateTime" : "2025-02-18T02:00:00", "id" : "tomas-esposito-assessment-9", "label" : "Cardio", "summary" : ": Cardio\nDevices / Cardiac Monitor / Cardiac Rhythm: Atrial fibrillation" }, { "dateTime" : "2025-02-17T14:00:00", "id" : "tomas-esposito-assessment-10", "label" : "GI", "summary" : ": GI\nDiet Tolerance / Diet Tolerance: Other\nDiet Tolerance / Diet Tolerance, Other value: Good\nLast Bowel Movement / Last Bowel Movement Date: 06/19/2012\nLast Bowel Movement / Last Bowel Movement Time: 04:00" }, { "dateTime" : "2025-02-18T13:00:00", "id" : "tomas-esposito-assessment-11", "label" : "GI", "summary" : ": GI\nDiet Tolerance / Diet Tolerance: Other\nDiet Tolerance / Diet Tolerance, Other value: Good\nLast Bowel Movement / Last Bowel Movement Date: 06/19/2012\nLast Bowel Movement / Last Bowel Movement Time: 04:00" }, { "dateTime" : "2025-02-18T02:00:00", "id" : "tomas-esposito-assessment-12", "label" : "GI", "summary" : ": GI\nDiet Tolerance / Diet Tolerance: Adequate\nLast Bowel Movement / Last Bowel Movement Date: 02/16/2025\nLast Bowel Movement / Last Bowel Movement Time: 13:00" }, { "dateTime" : "2025-02-17T14:00:00", "id" : "tomas-esposito-assessment-13", "label" : "GU", "summary" : ": GU\nDate Inserted Date: 02/17/2025\nVolume in Balloon: 0" }, { "dateTime" : "2025-02-18T13:00:00", "id" : "tomas-esposito-assessment-14", "label" : "GU", "summary" : ": GU\nVolume in Balloon: 0" }, { "dateTime" : "2025-02-18T02:00:00", "id" : "tomas-esposito-assessment-15", "label" : "GU", "summary" : ": GU\nDate Inserted Date: 02/17/2025\nVolume in Balloon: 0" }, { "dateTime" : "2025-02-17T14:00:00", "id" : "tomas-esposito-assessment-16", "label" : "Respiratory", "summary" : ": Respiratory\nOxygen Delivery Method / Oxygen Delivery Method: Room Air" }, { "dateTime" : "2025-02-18T13:00:00", "id" : "tomas-esposito-assessment-17", "label" : "Respiratory", "summary" : ": Respiratory\nOxygen Delivery Method / Oxygen Delivery Method: Room Air" }, { "dateTime" : "2025-02-18T02:00:00", "id" : "tomas-esposito-assessment-18", "label" : "Respiratory", "summary" : ": Respiratory" }, { "dateTime" : "2025-02-17T14:00:00", "id" : "tomas-esposito-assessment-19", "label" : "Mental Health", "summary" : ": Mental Health" }, { "dateTime" : "2025-02-18T13:00:00", "id" : "tomas-esposito-assessment-20", "label" : "Mental Health", "summary" : ": Mental Health" }, { "dateTime" : "2025-02-18T02:00:00", "id" : "tomas-esposito-assessment-21", "label" : "Mental Health", "summary" : ": Mental Health\nStressors / Stressors, Other value: Isolation" }, { "dateTime" : "2025-02-17T14:00:00", "id" : "tomas-esposito-assessment-22", "label" : "Musculoskeletal", "summary" : ": Musculoskeletal" }, { "dateTime" : "2025-02-18T13:00:00", "id" : "tomas-esposito-assessment-23", "label" : "Musculoskeletal", "summary" : ": Musculoskeletal" }, { "dateTime" : "2025-02-18T02:00:00", "id" : "tomas-esposito-assessment-24", "label" : "Musculoskeletal", "summary" : ": Musculoskeletal" }, { "dateTime" : "2025-02-17T13:10:00", "id" : "tomas-esposito-assessment-25", "label" : "Pain Scale", "summary" : ": Pain Scale\nOnset Date: 02/17/2025\nOnset Time: 13:10\nPain Rating: 0 - No Pain" }, { "dateTime" : "2025-02-17T14:00:00", "id" : "tomas-esposito-assessment-26", "label" : "Pain Scale", "summary" : ": Pain Scale\nPain Location: lower extremities\nOnset Date: 02/17/2025\nOnset Time: 14:00\nPain Frequency: Intermittent\nType Of Pain: Acute\nPain Goal: 3\nPain Scale Used: 0-10\nPain Rating: 4" }, { "dateTime" : "2025-02-17T14:00:00", "id" : "tomas-esposito-assessment-27", "label" : "Site/Wound", "summary" : ": Site/Wound\nRegion: Leg\nSpecific Location: Shin, Medial, Left\nType: Arterial Ulcers\nLength: 5.5\nWidth: 2\nDepth: 0.4\nDescription: Oval shaped wound, reddened at base, draining thick yellow drainage with foul odor. 5.5 cm X 2 cm X 0.4 cm depth\nPeri-Wound Area: dry\nDressing and Wound Care: Clean with NS, dry, sterile dressing with Telfa" }, { "dateTime" : "2025-02-17T14:00:00", "id" : "tomas-esposito-assessment-28", "label" : "Site/Wound", "summary" : ": Site/Wound\nRegion: Leg\nSpecific Location: Shin, Right\nType: Rash, Erythematous\nLength: 7\nWidth: 6\nDepth: 0\nDescription: Reddened, inflamed area, appears weeping 7cm X 6 cm\nPeri-Wound Area: dry\nDressing and Wound Care: Telfa with dry, sterile dressing" }, { "dateTime" : "2025-02-17T14:00:00", "id" : "tomas-esposito-assessment-29", "label" : "Vascular Access", "summary" : ": Vascular Access\nLocation: Left forearm\nType: Peripheral IV\nDate Inserted Date: 02/17/2025\nSize: 20 gauge\nSite Description: Clean, dry and intact. Saline locked\nDressing: Tagaderm\nNotes: IV started after 1 attempt. Tolerates well without complaints." }, { "dateTime" : "2025-02-17T14:00:00", "id" : "tomas-esposito-assessment-30", "label" : "ADLs", "summary" : ": ADLs\nADL Assessment / ADL Assessments / Bed mobility: Independent\nADL Assessment / ADL Assessments / Transfer: Independent\nADL Assessment / ADL Assessments / Walking: Independent\nADL Assessment / ADL Assessments / Dressing: Independent\nADL Assessment / ADL Assessments / Eating: Independent\nADL Assessment / ADL Assessments / Toilet use: Independent\nADL Assessment / ADL Assessments / Personal hygiene: Independent\nADL Assessment / ADL Assessments / Bathing: Independent" }, { "dateTime" : "2025-02-17T14:00:00", "id" : "tomas-esposito-assessment-31", "label" : "Morse Fall Risk", "summary" : ": Morse Fall Risk\nMorse Fall Risk Total Score: 35\nResults: Moderate Risk (25–50)" }, { "dateTime" : "2025-02-18T02:00:00", "id" : "tomas-esposito-assessment-32", "label" : "Morse Fall Risk", "summary" : ": Morse Fall Risk\nMorse Fall Risk Total Score: 35\nResults: Moderate Risk (25–50)" }, { "dateTime" : "2025-02-18T13:00:00", "id" : "tomas-esposito-assessment-33", "label" : "Morse Fall Risk", "summary" : ": Morse Fall Risk\nMorse Fall Risk Total Score: 35\nResults: Moderate Risk (25–50)" } ], "intakeOutput" : { "documentedIntakeTotalMl" : 3015, "documentedNetMl" : 325, "documentedOutputTotalMl" : 2690, "intakeEntries" : [ { "amountMl" : 1000, "id" : "tomas-esposito-intake-1", "time" : "2025-02-17T21:00:00", "type" : "Other Intake Fluids" }, { "amountMl" : 375, "id" : "tomas-esposito-intake-2", "time" : "2025-02-18T13:00:00", "type" : "Other Intake Fluids" }, { "amountMl" : 780, "id" : "tomas-esposito-intake-3", "time" : "2025-02-17T21:00:00", "type" : "Oral Intake" }, { "amountMl" : 860, "id" : "tomas-esposito-intake-4", "time" : "2025-02-18T03:00:00", "type" : "Oral Intake" } ], "outputEntries" : [ { "amountMl" : 1200, "id" : "tomas-esposito-output-1", "time" : "2025-02-17T21:00:00", "type" : "Urine" }, { "amountMl" : 1490, "id" : "tomas-esposito-output-2", "time" : "2025-02-18T13:00:00", "type" : "Urine" } ] }, "labs" : [ { "category" : "Complete Blood Count with differential", "collectedDateTime" : "2025-02-17T14:00:00", "flag" : "High", "id" : "tomas-esposito-lab-1", "referenceRange" : "4.0-9.0", "result" : "20.2", "test" : "WBC (10 x 3/uL)" }, { "category" : "Complete Blood Count with differential", "collectedDateTime" : "2025-02-17T14:00:00", "flag" : "Normal", "id" : "tomas-esposito-lab-2", "referenceRange" : "3.90-4.98", "result" : "4.1", "test" : "RBC (mill/cumm)" }, { "category" : "Complete Blood Count with differential", "collectedDateTime" : "2025-02-17T14:00:00", "flag" : "Normal", "id" : "tomas-esposito-lab-3", "referenceRange" : "12.0-15.5", "result" : "13", "test" : "Hemoglobin (gm/dL)" }, { "category" : "Complete Blood Count with differential", "collectedDateTime" : "2025-02-17T14:00:00", "flag" : "Normal", "id" : "tomas-esposito-lab-4", "referenceRange" : "35-45", "result" : "36", "test" : "Hematocrit (%)" }, { "category" : "Complete Blood Count with differential", "collectedDateTime" : "2025-02-17T14:00:00", "flag" : "Normal", "id" : "tomas-esposito-lab-5", "referenceRange" : "140-400", "result" : "220", "test" : "Platelet Count (1000/mm3)" }, { "category" : "Complete Blood Count with differential", "collectedDateTime" : "2025-02-17T14:00:00", "flag" : "High", "id" : "tomas-esposito-lab-6", "referenceRange" : "40-70", "result" : "75", "test" : "Neutrophils (%)" }, { "category" : "Complete Blood Count with differential", "collectedDateTime" : "2025-02-17T14:00:00", "flag" : "Normal", "id" : "tomas-esposito-lab-7", "referenceRange" : "10-20", "result" : "15", "test" : "Lymphocytes (%)" }, { "category" : "Complete Blood Count with differential", "collectedDateTime" : "2025-02-17T14:00:00", "flag" : "Unverified", "id" : "tomas-esposito-lab-8", "referenceRange" : "5", "result" : "10", "test" : "Monocyte Percentage (%)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2025-02-17T14:00:00", "flag" : "Normal", "id" : "tomas-esposito-lab-9", "referenceRange" : "135-145", "result" : "137", "test" : "Sodium (mEq/L)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2025-02-17T14:00:00", "flag" : "Normal", "id" : "tomas-esposito-lab-10", "referenceRange" : "3.5-5.1", "result" : "4.0", "test" : "Potassium (mEq/L)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2025-02-17T14:00:00", "flag" : "Normal", "id" : "tomas-esposito-lab-11", "referenceRange" : "98-107", "result" : "105", "test" : "Chloride (mEq/L)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2025-02-17T14:00:00", "flag" : "Normal", "id" : "tomas-esposito-lab-12", "referenceRange" : "22-29", "result" : "23", "test" : "CO2 (mEq/L)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2025-02-17T14:00:00", "flag" : "High", "id" : "tomas-esposito-lab-13", "referenceRange" : "70-99", "result" : "110", "test" : "Glucose (mg/dL)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2025-02-17T14:00:00", "flag" : "Normal", "id" : "tomas-esposito-lab-14", "referenceRange" : "6-20", "result" : "10", "test" : "Blood Urea Nitrogen (mg/dL)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2025-02-17T14:00:00", "flag" : "Normal", "id" : "tomas-esposito-lab-15", "referenceRange" : "0.50-1.00", "result" : "0.8", "test" : "Creatinine (mg/dL)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2025-02-17T14:00:00", "flag" : "Normal", "id" : "tomas-esposito-lab-16", "referenceRange" : "8.4-10.5", "result" : "9.2", "test" : "Calcium (mg/dL)" }, { "category" : "Other", "collectedDateTime" : "2025-02-17T16:00:00", "id" : "tomas-esposito-lab-17", "result" : "Pending", "status" : "Pending", "test" : "Blood Cultures" }, { "category" : "Other", "collectedDateTime" : "2025-02-17T16:00:00", "id" : "tomas-esposito-lab-18", "result" : "Pending", "status" : "Pending", "test" : "Wound Cultures" }, { "category" : "Other", "collectedDateTime" : "2025-02-18T12:00:00", "flag" : "High", "id" : "tomas-esposito-lab-19", "result" : "Positive", "test" : "Left leg" }, { "category" : "Other", "collectedDateTime" : "2025-02-18T12:00:00", "flag" : "High", "id" : "tomas-esposito-lab-20", "result" : "Positive", "test" : "Right leg" } ], "medications" : [ { "doseRouteFrequency" : "2.5 mg Oral (PO) q24h (Every 24 hours), Every 24 hours", "drug" : "warfarin sodium", "id" : "tomas-esposito-med-12", "lastGiven" : "2025-02-18T01:00:00", "nextDue" : "2025-02-19T01:00:00", "notes" : "Source due: 2/19/2025 01:00 No INR result was supplied in captured laboratory records; do not infer a therapeutic INR.", "orderedBy" : "Pending per Tom Rankle, Admitting", "orderedDateTime" : "2025-02-17T13:00:00", "section" : "Scheduled", "status" : "Active" }, { "doseRouteFrequency" : "1 Gm/250mL Intravenous (IV) q12h (Every 12 hours), Every 12 hours", "drug" : "vancomycin hydrochloride", "id" : "tomas-esposito-med-13", "lastGiven" : "2025-02-18T02:00:00", "nextDue" : "2025-02-18T14:00:00", "notes" : "Vancomycin trough after 4th dose Source due: 2/18/2025 14:00 Source says trough after the fourth dose. Exact level timing and monitoring strategy need clarification; infusion duration is absent.", "orderedBy" : "Pending per Tom Rankle, Admitting Physician", "orderedDateTime" : "2025-02-17T13:00:00", "section" : "Scheduled", "status" : "Active" } ], "notes" : [ { "id" : "tomas-esposito-allergy", "summary" : "Penicillin | Medication | Anaphylaxis | | | 2/17/2025 13:05", "type" : "Allergy documentation" }, { "id" : "tomas-esposito-family-health-history", "summary" : "Disease/Condition / Disease/Condition: Heart Disease\nFamily Member / Family Member: mother\nAge at Diagnosis / Age at Diagnosis: 40-49 years\nDeceased / Deceased: No", "type" : "Family Health History" }, { "dateTime" : "2025-02-18T12:00:00", "id" : "tomas-esposito-lab-note-3", "summary" : "Positive for methicillin-resistant staphylococcus aureus", "type" : "Other laboratory notes" }, { "id" : "tomas-esposito-mar", "summary" : "warfarin sodium 2.5 mg Oral (PO) | q24h (Every 24 hours), Every 24 hours | 2/17/2025 13:00 | ", "type" : "Home medication history" }, { "author" : "Tammy Vinet , Registered Nurse", "dateTime" : "2025-02-18T13:00:00", "id" : "tomas-esposito-note-1", "summary" : "Report given to oncoming nurse. Assessment documented. Encouraged patient to ambulate. Notified John Heidrich APRN of positive cultures for MRSA.", "type" : "Nursing - Event" }, { "author" : "May Grable , Registered Nurse", "dateTime" : "2025-02-18T13:00:00", "id" : "tomas-esposito-note-2", "summary" : "S: 46 y.o. male admitted for bilateral lower extremity cellulitis. Presented to ER with bilateral leg pain and wounds to lower extremities that started 1 week ago and has progressively gotten worse. B: Wounds to lower extremities began with redness and became progressively more painful. States got some abrasions to lower extremities after working in the yard and clearing out debris. Hx of atrial fibriallation. Takes warfarin at home. A: Vital signs stable, no fever. Lungs: Clear bilaterally, no respiratory distress. Heart: S1, S2, no murmur, on telemetry. Skin: LLE - wound noted that is red with yellow drainage, quarter in size. RLE - shin area red with a superficial wound draining clear serous fluid. R: IV antibiotics. Dressing changes every 12 hours and consult wound care nurse. +MRSA", "type" : "Nursing - Shift" }, { "author" : "Matthew Roberts , Admitting Physician", "dateTime" : "2025-02-17T14:15:00", "id" : "tomas-esposito-note-3", "summary" : "Chief Complaint: Pt presents with bilateral leg pain and wounds to lower extremities. History of Present Illness: This is a 46 year old male presenting with bilateral lower extremity pain, erythema, mild edema, and wounds. Pt states the symptoms started about a week ago and progressively worsened. Started with redness and progressively painful. Patient admitted to getting some abrasions while working in his yard and clearing out debris. Past Medical History: atrial fibrillation Allergies: PCN Medications: warfarin 2.5 mg po qd GENERAL APPEARANCE: The patient is alert, awake, and oriented. VITAL SIGNS: Initially, temperature 98.2, pulse 72, respiration 14, blood pressure 112/72, and O2 saturations on room air 99%. HEENT: Head exam normal. Eyes, ears, nose, and throat are normal. NECK: Supple. No JVD. Respiratory: Lungs clear, no work of breathing CV: S1 and S2, regular. No murmur. ABDOMEN: Soft, benign, and nontender. EXTREMITIES: Left lower extremity has oval shaped wound, reddened at the base, yellow odorous drainage. 5.5cm X 2cm X 0.5cm Right lower extremity reddened and inflamed, superficial 7cm x 6cm . weeping serous drainage. Pulses intact full range of motion. Labs: WBC 20.2, H/H normal, blood glucose 110 Plan/Assessment: 1. Cellulitis: wound culture, blood culture, start vancomycin with trough ordered post 4th dose. Wound dressing changes Q12 with NS, dry sterile dressing and telfa pad. Consult WOC nurse. 2. Afib: continue warfarin, cardiac monitoring", "type" : "Physician Notes" }, { "author" : "May Grable , Registered Nurse", "dateTime" : "2025-02-17T14:00:00", "id" : "tomas-esposito-note-4", "summary" : "Left forearm PIV #20 started without difficulty. Blood cultures and ordered labs drawn and sent to lab. Wound culture collected from lower extremity wounds via sterile technique as ordered and sent to lab. Assessment documented.", "type" : "Nursing - Event" }, { "id" : "tomas-esposito-mar-history-9", "summary" : "2/18/2025 01:00 Tammy Vinet, Registered Nurse Yes", "type" : "Medication administration history — warfarin sodium" }, { "id" : "tomas-esposito-mar-history-10", "summary" : "2/17/2025 14:30 May Grable, Registered Nurse Yes\n2/18/2025 02:00 Tammy Vinet, Registered Nurse Yes", "type" : "Medication administration history — vancomycin hydrochloride" }, { "id" : "tomas-esposito-section-current-care-providers", "summary" : "James Kohler | Registered Nurse\nJohn Heidrich APRN | Nurse Practitioner\nMatthew Roberts | Admitting Physician\nMay Grable | Registered Nurse\nTammy Vinet | Registered Nurse\nTom Rankle | Admitting Physician\nTravis Trent | Registered Nurse", "type" : "Current Care Providers" }, { "id" : "tomas-esposito-clarification-12", "summary" : "Skills Lab simulation ID SL-004. Original DocuCare MRN: 984521. Original fixed simulation dates and stated scenario ages are retained; DOB-derived age may disagree. Source records are preserved for faculty review.", "type" : "Chart clarification" }, { "id" : "tomas-esposito-clarification-13", "summary" : "No INR result was supplied in captured laboratory records; do not infer a therapeutic INR.", "type" : "Chart clarification" }, { "id" : "tomas-esposito-clarification-14", "summary" : "Source says trough after the fourth dose. Exact level timing and monitoring strategy need clarification; infusion duration is absent.", "type" : "Chart clarification" }, { "id" : "tomas-esposito-clarification-15", "summary" : "Source title is CNSL_NRN-11/NVN-42_Scavenger Hunt/Documentation - Fundamentals_Tomas Esposito. Matched to Skills Lab assignment by patient, activity, course-owner copy and assignment badge; exact assigned-copy mapping still requires confirmation.", "type" : "Chart clarification" }, { "id" : "tomas-esposito-clarification-16", "summary" : "Earlier pending wound culture entries and later MRSA-positive results are retained as chronological records.", "type" : "Chart clarification" }, { "id" : "tomas-esposito-clarification-17", "summary" : "Source left-leg wound dimensions differ across narratives; retain observed measurements rather than substitute a single size.", "type" : "Chart clarification" } ], "orders" : [ { "author" : "Pending per Tom Rankle, Admitting", "category" : "Not specified", "dateTime" : "2025-02-17T13:00:00", "id" : "tomas-esposito-order-1", "orderText" : "Blood culture sample collection; x1 (1 time only), 1 time only; Routine", "status" : "Discontinued" }, { "author" : "Pending per Tom Rankle, Admitting", "category" : "Not specified", "dateTime" : "2025-02-17T13:00:00", "id" : "tomas-esposito-order-2", "orderText" : "Venipuncture; x1 (1 time only), 1 time only; Routine; CBC and BMP", "status" : "Discontinued" }, { "author" : "Pending per Tom Rankle, Admitting", "category" : "Laboratory", "dateTime" : "2025-02-17T13:00:00", "id" : "tomas-esposito-order-3", "orderText" : "Wound culture specimen collection; x1 (1 time only), 1 time only; Routine", "status" : "Discontinued" }, { "author" : "Pending per Tom Rankle, Admitting Physician", "category" : "Laboratory", "dateTime" : "2025-02-17T13:00:00", "id" : "tomas-esposito-order-4", "orderText" : "Venipuncture; Stat; Vancomycin trough after fourth dose Source due: 2/17/2025 13:00", "status" : "Active" }, { "author" : "Pending per Tom Rankle, Admitting", "category" : "Medical-Surgical", "dateTime" : "2025-02-17T13:00:00", "id" : "tomas-esposito-order-5", "orderText" : "Pulse oximetry; q4h x1 (Every 4 hours, 1 time only), Every 4 hours, 1 time only; Routine; Source due: 2/17/2025 13:00", "status" : "Active" }, { "author" : "Pending per Tom Rankle, Admitting", "category" : "Medicine", "dateTime" : "2025-02-17T17:00:00", "id" : "tomas-esposito-order-6", "orderText" : "Physical Therapy Evaluation; x1 (1 time only), 1 time only; Routine; Continue routine nursing care, physical therapy to increase ambulation, case management to arrange discharge. Source due: 2/17/2025 17:00", "status" : "Active" }, { "author" : "Pending per Tom Rankle, Admitting Physician", "category" : "Nursing", "dateTime" : "2025-02-17T13:00:00", "id" : "tomas-esposito-order-7", "orderText" : "Oxygen administration; x1 (1 time only), 1 time only; Routine; O2 via NC to keep sats > 92%. Titrate as needed Source due: 2/17/2025 13:00", "status" : "Active" }, { "author" : "Pending per John Heidrich APRN, Nurse Practitioner", "category" : "Nursing", "dateTime" : "2025-02-18T13:00:00", "id" : "tomas-esposito-order-8", "orderText" : "Personal protective equipment (PPE), putting on; cont.; Routine; Source due: 2/18/2025 13:00", "status" : "Active" }, { "author" : "Pending per Tom Rankle, Admitting", "category" : "Nursing: Activity", "dateTime" : "2025-02-17T13:00:00", "id" : "tomas-esposito-order-9", "orderText" : "Wound assessment and Care q12; q12h (Every 12 hours), Every 12 hours; Routine; Clean wounds with NS, apply dry, sterile dressing and Telfa Source due: 2/17/2025 13:00", "status" : "Active" }, { "author" : "Pending per Tom Rankle, Admitting", "category" : "Nursing: Monitoring", "dateTime" : "2025-02-17T13:00:00", "id" : "tomas-esposito-order-10", "orderText" : "Cardiac monitoring; cont.; Routine; Source due: 2/17/2025 13:00", "status" : "Active" }, { "author" : "Pending per Tom Rankle, Admitting", "category" : "Nursing: Monitoring", "dateTime" : "2025-02-17T13:00:00", "id" : "tomas-esposito-order-11", "orderText" : "Vital Signs q4h; q4h (Every 4 hours), Every 4 hours; Routine; Source due: 2/17/2025 13:00", "status" : "Active" }, { "author" : "Pending per Tom Rankle, Admitting", "category" : "Pharmacy", "dateTime" : "2025-02-17T13:00:00", "id" : "tomas-esposito-order-12", "orderText" : "warfarin sodium; 2.5 mg Oral (PO); q24h (Every 24 hours), Every 24 hours; Scheduled; Source due: 2/19/2025 01:00 No INR result was supplied in captured laboratory records; do not infer a therapeutic INR.", "status" : "Active" }, { "author" : "Pending per Tom Rankle, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2025-02-17T13:00:00", "id" : "tomas-esposito-order-13", "orderText" : "vancomycin hydrochloride; 1 Gm/250mL Intravenous (IV); q12h (Every 12 hours), Every 12 hours; Scheduled; Vancomycin trough after 4th dose Source due: 2/18/2025 14:00 Source says trough after the fourth dose. Exact level timing and monitoring strategy need clarification; infusion duration is absent.", "status" : "Active" } ], "overview" : { "height" : "72 in / 182.9 cm", "isolationIndicator" : "Contact", "religion" : "Catholic", "weightKg" : 83.9 }, "vitals" : [ { "bloodPressure" : "112/72", "dateTime" : "2025-02-17T14:00:00", "heartRate" : 72, "id" : "tomas-esposito-vital-1", "oxygenDevice" : "Room Air", "respiratoryRate" : 14, "spo2" : "99", "temperature" : "98.2 °F (37 °C), 37 °C Oral" }, { "bloodPressure" : "110/70", "dateTime" : "2025-02-17T18:00:00", "heartRate" : 89, "id" : "tomas-esposito-vital-2", "oxygenDevice" : "Room Air", "respiratoryRate" : 16, "spo2" : "98", "temperature" : "98.4 °F (37 °C), 37 °C Oral" }, { "bloodPressure" : "112/72", "dateTime" : "2025-02-17T22:00:00", "heartRate" : 88, "id" : "tomas-esposito-vital-3", "oxygenDevice" : "Room Air", "respiratoryRate" : 18, "spo2" : "98", "temperature" : "98.9 °F (37 °C), 37 °C Oral" }, { "bloodPressure" : "108/68", "dateTime" : "2025-02-18T02:00:00", "heartRate" : 90, "id" : "tomas-esposito-vital-4", "oxygenDevice" : "Room Air", "respiratoryRate" : 18, "spo2" : "95", "temperature" : "99.2 °F (37 °C), 37 °C Oral" }, { "bloodPressure" : "114/74", "dateTime" : "2025-02-18T06:00:00", "heartRate" : 92, "id" : "tomas-esposito-vital-5", "oxygenDevice" : "Room Air", "respiratoryRate" : 18, "spo2" : "94", "temperature" : "99.4 °F (37 °C), 37 °C Oral" }, { "bloodPressure" : "116/76", "dateTime" : "2025-02-18T10:00:00", "heartRate" : 101, "id" : "tomas-esposito-vital-6", "oxygenDevice" : "Room Air", "respiratoryRate" : 20, "spo2" : "94", "temperature" : "100.1 °F (38 °C), 38 °C Oral" } ] }, "patient" : { "admitDateTime" : "2025-02-17T13:00:00", "admittingDiagnosis" : "Cellulitis", "allergies" : [ { "id" : "allergy-c982f5e288944dbe", "reaction" : "Anaphylaxis", "severity" : "Not documented", "substance" : "Penicillin" } ], "attending" : "Tom Rankle, Admitting Physician", "chartDisplayName" : "Esposito, Tomas", "codeStatus" : "Full Code", "dob" : "10/20/1979", "history" : { "chiefComplaint" : "Pt complains of \"pain and wounds to lower extremities\". States he has a history of atrial fibrillation.", "pastMedicalHistory" : [ "General Medical History / Disease/Condition / : Pneumonia", "General Medical History / Disease/Condition / : Atrial fibrillation", "Transfusion History / Previous Blood Transfusion?: No", "Pain History / History of Chronic Pain?: No", "Screenings / TB Screening (Tuberculosis), Tuberculosis: Yes", "Screenings / Result: Negative" ], "pastSurgicalHistory" : [ ], "socialHistory" : [ "Age: 46 Years", "Home Situation / Patient Living Situation: Home", "Home Situation / Lives With: Spouse", "Education / Highest Grade Completed: Bachelor's Degree-College", "Education / Able to Read?: Yes", "Education / Able to Write?: Yes", "Nicotine Use / Is patient exposed to second-hand smoke?: No", "Alcohol Use / Alcohol Status: Nondrinker", "Drug Use / Illicit Drug Use Status: Nonuser", "Violence Screening / Does Patient Feel Safe at Home?: Yes", "Violence Screening / Does Patient Feel Safe in Current Environment (Work, School, etc.)?: Yes", "Violence Screening / Has Anyone Ever Hurt Patient Emotionally, Physically, or Sexually?: No", "Nutritional Screening / Recent Weight Lost Without Trying?: No", "Nutritional Screening / Decreased Appetite?: No", "Nutritional Screening / Does patient have diabetes?: No", "Nutritional Screening / Last Bowel Movement Date: 02/16/2025", "Exercise Screening / Exercise Frequency: Rarely", "Exercise Screening / Was Patient Counseled on Exercise?: No", "Mental Health Screening / Does Patient Have Frequent Feelings of Hopelessness/Helplessness?: No", "Mental Health Screening / Does Patient Have Thoughts of Harming Self?: No", "Sexual Activity / Sexually Active?: Yes", "Sexual Activity / Partners: Women", "Sexual Activity / Number of Partners in Last 3 Months: 1", "Sexual Activity / Uses Protection?: No", "Sexual Activity / Ever Treated for a Sexually Transmitted Disease?: No", "Other Safety Measures / Seatbelt Use?: Always", "Other Safety Measures / Bicycle/ATV/Motorcycle Helmet Use?: Always", "Other Safety Measures / Sun Protection?: Always", "Other Safety Measures / Working Smoke Detectors in the Home?: Yes", "Other Safety Measures / Working Carbon Monoxide Detectors in the Home?: Yes", "Other Safety Measures / Working Fire Extinguisher in the Home?: Yes" ] }, "mrn" : "SL-004", "sex" : "Male", "simulatedFullName" : "Tomas Esposito", "unit" : "Mercy Hospital — Room 412" }, "setting" : "Mercy Hospital — Room 412", "snapshots" : [ { "activityIds" : [ ], "id" : "tomas-esposito-current", "notes" : "Captured dated chart history; source relative dates anchored to chart opening. Progressive release not recreated.", "scenarioTime" : "2025-02-18T14:00:00", "sourcePath" : "DocuCare instructor chart: Tomas Esposito", "title" : "Captured chart" } ], "subtitle" : "Learning Lab practice record", "tags" : [ "Skills Lab", "DocuCare migration", "Learning Lab" ], "title" : "Tomas Esposito" }, "packageId" : "docucare-skills lab-tomas-esposito-review-v1", "privacy" : { "containsRealPHI" : false, "defaultStorage" : "local-document-package", "networkRequired" : false, "simulatedOnly" : true, "warning" : "Simulated education only. Not for clinical care. Review conflicting, held or undocumented findings with lab faculty." }, "schemaVersion" : "2.0", "source" : { "system" : "DocuCare Enhanced instructor chart capture" }, "workingNames" : [ "ChartSlate" ] } }, "id" : "skills lab-tomas-esposito", "instructions" : "Choose this patient for simulated chart-review practice. Check the name, date of birth and simulated MRN; review notes, assessments, vital signs, orders and medications. Identify missing or conflicting information and discuss it with lab faculty. Held or discontinued medications are not active administration tasks.", "title" : "Tomas Esposito" }, { "envelope" : { "appName" : "ChartSlate", "audience" : "student", "createdAt" : "2026-09-25T19:44:22.331008+00:00", "exportVersion" : "1", "kind" : "casePackage", "package" : { "case" : { "activities" : [ ], "id" : "docucare-skills lab-stacy-diaz", "learningLevel" : "Skills Lab", "panels" : { "assessments" : [ { "dateTime" : "2025-02-18T19:00:00", "id" : "stacy-diaz-assessment-1", "label" : "Cardio", "summary" : ": Cardio" }, { "dateTime" : "2025-02-18T19:00:00", "id" : "stacy-diaz-assessment-2", "label" : "GU", "summary" : ": GU\nDate Inserted Date: 02/18/2025\nVolume in Balloon: 0" }, { "dateTime" : "2025-02-18T19:00:00", "id" : "stacy-diaz-assessment-3", "label" : "GU", "summary" : ": GU\nDate Inserted Date: 02/18/2025\nVolume in Balloon: 0" }, { "dateTime" : "2025-02-18T19:00:00", "id" : "stacy-diaz-assessment-4", "label" : "Musculoskeletal", "summary" : ": Musculoskeletal" }, { "dateTime" : "2025-02-18T19:00:00", "id" : "stacy-diaz-assessment-5", "label" : "Pain Scale", "summary" : ": Pain Scale\nPain Location: Left Hip\nOnset Date: 02/18/2025\nOnset Time: 19:00\nPain Frequency: Constant\nType Of Pain: Acute\nPain Goal: 2\nPain Scale Used: 0-10\nPain Rating: 4" } ], "intakeOutput" : { "documentedIntakeTotalMl" : 0, "documentedNetMl" : -350, "documentedOutputTotalMl" : 350, "intakeEntries" : [ ], "outputEntries" : [ { "amountMl" : 350, "id" : "stacy-diaz-output-1", "time" : "2025-02-18T19:00:00", "type" : "Urine" } ] }, "labs" : [ ], "medications" : [ ], "notes" : [ { "id" : "stacy-diaz-allergy", "summary" : "NKA | Medication | | | Bertha | 2/18/2025 19:00", "type" : "Allergy documentation" }, { "author" : "Bertha , Registered Nurse", "dateTime" : "2025-02-18T19:00:00", "id" : "stacy-diaz-note-1", "summary" : "S- Stacy Diaz, age 68, was recently admitted to the hospital and is awaiting surgery for an ORIF of the left hip. B- Client has a history of falls and fell at home on the way to the restroom. Last void was 10 hours ago. A- Vital signs – 98.1, 85, 16, 141/82 O2 sat 98% on RA 4/10 pain (left hip) Heart- RRR, peripheral pulses present bilaterally Lung- clear bilaterally, no cough GU: Bladder is distended. A bladder scan shows there is 350 mL of urine in the bladder after straight catheterization. R- Insert an indwelling catheter and obtain a sterile specimen.", "type" : "Nursing - Shift" }, { "id" : "stacy-diaz-section-current-care-providers", "summary" : "Bertha | Registered Nurse\nVo, J. MD | Admitting Physician", "type" : "Current Care Providers" }, { "id" : "stacy-diaz-clarification-4", "summary" : "Skills Lab simulation ID SL-005. Original DocuCare MRN: 123456. Original fixed simulation dates and stated scenario ages are retained; DOB-derived age may disagree. Source records are preserved for faculty review.", "type" : "Chart clarification" }, { "id" : "stacy-diaz-clarification-5", "summary" : "Nursing note says bladder volume 350 mL after straight catheterization; exact sequence and residual need confirmation.", "type" : "Chart clarification" } ], "orders" : [ { "author" : "Pending per Vo, J. MD, Admitting Physician", "category" : "Dietary", "dateTime" : "2025-02-18T19:00:00", "id" : "stacy-diaz-order-1", "orderText" : "NPO; x1 (1 time only), 1 time only; Routine; Source due: 2/18/2025 19:00", "status" : "Active" }, { "author" : "Pending per Vo, J. MD, Admitting Physician", "category" : "Nursing", "dateTime" : "2025-02-18T19:00:00", "id" : "stacy-diaz-order-2", "orderText" : "Indwelling urinary catheter (Foley) insertion, assigned female at birth; x1 (1 time only), 1 time only; Stat; Source due: 2/18/2025 19:00", "status" : "Active" }, { "author" : "Pending per Vo, J. MD, Admitting Physician", "category" : "Nursing", "dateTime" : "2025-02-18T19:00:00", "id" : "stacy-diaz-order-3", "orderText" : "Indwelling urinary catheter (Foley) care and management; cont.; Routine; Source due: 2/18/2025 19:00", "status" : "Active" }, { "author" : "Pending per Vo, J. MD, Admitting Physician", "category" : "Nursing", "dateTime" : "2025-02-18T19:00:00", "id" : "stacy-diaz-order-4", "orderText" : "Urine specimen collection for culture and sensitivity, adult assigned female at birth; x1 (1 time only), 1 time only; Routine; Source due: 2/18/2025 19:00", "status" : "Active" } ], "overview" : { "height" : "", "isolationIndicator" : "Standard", "religion" : "" }, "vitals" : [ { "bloodPressure" : "141/82", "dateTime" : "2025-02-18T19:00:00", "heartRate" : 85, "id" : "stacy-diaz-vital-1", "oxygenDevice" : "Room Air", "respiratoryRate" : 16, "spo2" : "98", "temperature" : "98.1 °F (37 °C), 37 °C Oral" } ] }, "patient" : { "admitDateTime" : "2025-02-18T19:00:00", "admittingDiagnosis" : "Left hip fracture after fall; awaiting ORIF", "allergies" : [ ], "attending" : "Vo, J. MD, Admitting Physician", "chartDisplayName" : "Diaz, Stacy", "codeStatus" : "", "dob" : "7/7/1958", "history" : { "chiefComplaint" : "68 y.o. Female admitted for s/p fall on her way to the restroom. She has a known history of falls. No known medical history.", "pastMedicalHistory" : [ ], "pastSurgicalHistory" : [ ], "socialHistory" : [ "Age: 68 Years" ] }, "mrn" : "SL-005", "sex" : "Female", "simulatedFullName" : "Stacy Diaz", "unit" : "RCC Hospital" }, "setting" : "RCC Hospital", "snapshots" : [ { "activityIds" : [ ], "id" : "stacy-diaz-current", "notes" : "Captured dated chart history; source relative dates anchored to chart opening. Progressive release not recreated.", "scenarioTime" : "2025-02-18T19:00:00", "sourcePath" : "DocuCare instructor chart: Stacy Diaz", "title" : "Captured chart" } ], "subtitle" : "Learning Lab practice record", "tags" : [ "Skills Lab", "DocuCare migration", "Learning Lab" ], "title" : "Stacy Diaz" }, "packageId" : "docucare-skills lab-stacy-diaz-review-v1", "privacy" : { "containsRealPHI" : false, "defaultStorage" : "local-document-package", "networkRequired" : false, "simulatedOnly" : true, "warning" : "Simulated education only. Not for clinical care. Review conflicting, held or undocumented findings with lab faculty." }, "schemaVersion" : "2.0", "source" : { "system" : "DocuCare Enhanced instructor chart capture" }, "workingNames" : [ "ChartSlate" ] } }, "id" : "skills lab-stacy-diaz", "instructions" : "Choose this patient for simulated chart-review practice. Check the name, date of birth and simulated MRN; review notes, assessments, vital signs, orders and medications. Identify missing or conflicting information and discuss it with lab faculty. Held or discontinued medications are not active administration tasks.", "title" : "Stacy Diaz" }, { "envelope" : { "appName" : "ChartSlate", "audience" : "student", "createdAt" : "2026-09-25T19:44:22.331008+00:00", "exportVersion" : "1", "kind" : "casePackage", "package" : { "case" : { "activities" : [ ], "id" : "docucare-skills lab-dopinder-pooja", "learningLevel" : "Skills Lab", "panels" : { "assessments" : [ { "dateTime" : "2025-02-18T15:30:00", "id" : "dopinder-pooja-assessment-1", "label" : "Pain Scale", "summary" : ": Pain Scale\nPain Location: (L) Kidney\nOnset Date: 02/18/2025\nOnset Time: 15:30\nPain Duration: 2 days\nPain Frequency: Constant\nType Of Pain: Acute\nPain Scale Used: 0-10\nPain Rating: 10 - Unbearable Pain\nNotes: Right Flank and Groin" }, { "dateTime" : "2025-02-18T15:40:00", "id" : "dopinder-pooja-assessment-2", "label" : "Vascular Access", "summary" : ": Vascular Access\nLocation: (R) Forearm\nType: Peripheral IV\nDate Inserted Date: 02/18/2025\nSize: 18 ga\nSite Description: CDI, no s/s of IV related complications\nDressing: Transparent\nNotes: Good blood return, flushes easily." } ], "intakeOutput" : { "documentedIntakeTotalMl" : 0, "documentedNetMl" : -100, "documentedOutputTotalMl" : 100, "intakeEntries" : [ ], "outputEntries" : [ { "amountMl" : 100, "id" : "dopinder-pooja-output-1", "time" : "2025-02-18T15:30:00", "type" : "Urine" } ] }, "labs" : [ { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2025-02-18T12:30:00", "flag" : "Low", "id" : "dopinder-pooja-lab-1", "referenceRange" : "135-145 mEq/L", "result" : "133", "test" : "Sodium (mEq/L)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2025-02-18T12:30:00", "flag" : "Normal", "id" : "dopinder-pooja-lab-2", "referenceRange" : "3.5-5.0 mEq/L", "result" : "5", "test" : "Potassium (mEq/L)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2025-02-18T12:30:00", "flag" : "Normal", "id" : "dopinder-pooja-lab-3", "referenceRange" : "100 = 108 mEq/L", "result" : "102", "test" : "Chloride (mEq/L)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2025-02-18T12:30:00", "flag" : "Low", "id" : "dopinder-pooja-lab-4", "referenceRange" : "24 - 30 mEq/L", "result" : "16", "test" : "CO2 (mEq/L)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2025-02-18T12:30:00", "flag" : "Normal", "id" : "dopinder-pooja-lab-5", "referenceRange" : "70-110 mg/dL", "result" : "98", "test" : "Glucose (mg/dL)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2025-02-18T12:30:00", "flag" : "High", "id" : "dopinder-pooja-lab-6", "referenceRange" : "8 - 25 mg/dL", "result" : "40", "test" : "Blood Urea Nitrogen (mg/dL)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2025-02-18T12:30:00", "flag" : "Normal", "id" : "dopinder-pooja-lab-7", "referenceRange" : "0.6 - 1.5 mg/dL", "result" : "1.3", "test" : "Creatinine (mg/dL)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2025-02-18T12:30:00", "flag" : "Normal", "id" : "dopinder-pooja-lab-8", "referenceRange" : "3.4 - 7 mg/dL", "result" : "6.8", "test" : "Uric Acid" }, { "category" : "Hepatic Panel", "collectedDateTime" : "2025-02-18T12:30:00", "flag" : "High", "id" : "dopinder-pooja-lab-9", "referenceRange" : "10 -35 u/L", "result" : "87", "test" : "ALT (SPGT) (IU/Liters)" }, { "category" : "Hepatic Panel", "collectedDateTime" : "2025-02-18T12:30:00", "flag" : "High", "id" : "dopinder-pooja-lab-10", "referenceRange" : "14- 20 u/L", "result" : "53", "test" : "AST (SGOT) (IU/Liters)" }, { "category" : "Hepatic Panel", "collectedDateTime" : "2025-02-18T12:30:00", "flag" : "Normal", "id" : "dopinder-pooja-lab-11", "referenceRange" : "0.3-1.0 mg/dL", "result" : "0.9", "test" : "Bilirubin, total (mg/dL)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2025-02-18T12:30:00", "flag" : "Unverified", "id" : "dopinder-pooja-lab-12", "referenceRange" : "4,500 - 11,000/mm3", "result" : "19.5", "test" : "WBC (10 x 3/uL)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2025-02-18T12:30:00", "flag" : "Normal", "id" : "dopinder-pooja-lab-13", "referenceRange" : "13 - 18 g/100 mL", "result" : "15.5", "test" : "Hemoglobin (gm/dL)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2025-02-18T12:30:00", "flag" : "Normal", "id" : "dopinder-pooja-lab-14", "referenceRange" : "37 - 49%", "result" : "46", "test" : "Hematocrit (%)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2025-02-18T12:30:00", "flag" : "Normal", "id" : "dopinder-pooja-lab-15", "referenceRange" : "140 - 400 X 103 mm3", "result" : "200", "test" : "Platelet Count (1000/mm3)" }, { "category" : "Urinalysis", "collectedDateTime" : "2025-02-18T16:00:00", "flag" : "High", "id" : "dopinder-pooja-lab-16", "referenceRange" : "1.005-1.030", "result" : "1.040", "test" : "Specific gravity" }, { "category" : "Urinalysis", "collectedDateTime" : "2025-02-18T16:00:00", "flag" : "High", "id" : "dopinder-pooja-lab-17", "referenceRange" : "Negative", "result" : "2+", "test" : "Protein" }, { "category" : "Urinalysis", "collectedDateTime" : "2025-02-18T16:00:00", "flag" : "High", "id" : "dopinder-pooja-lab-18", "referenceRange" : "Negative", "result" : "3+", "test" : "RBC" }, { "category" : "Urinalysis", "collectedDateTime" : "2025-02-18T16:00:00", "flag" : "High", "id" : "dopinder-pooja-lab-19", "referenceRange" : "Negative", "result" : "1+", "test" : "WBC" } ], "medications" : [ { "doseRouteFrequency" : "100mg Oral (PO) q24h (Every 24 hours), Every 24 hours", "drug" : "allopurinol", "id" : "dopinder-pooja-med-12", "nextDue" : "2025-02-18T16:00:00", "notes" : "Source due: 2/18/2025 16:00", "orderedBy" : "Pending per Dr. B Jackson, Admitting Physician", "orderedDateTime" : "2025-02-18T16:00:00", "section" : "Scheduled", "status" : "Active" }, { "doseRouteFrequency" : "500mcg Oral (PO) q12h (Every 12 hours), Every 12 hours", "drug" : "colchicine", "id" : "dopinder-pooja-med-13", "nextDue" : "2025-02-18T16:00:00", "notes" : "Source due: 2/18/2025 16:00", "orderedBy" : "Pending per Dr. B Jackson, Admitting Physician", "orderedDateTime" : "2025-02-18T16:00:00", "section" : "Scheduled", "status" : "Active" }, { "doseRouteFrequency" : "1 Gm Intravenous Piggyback (IVPB) q24h (Every 24 hours), Every 24 hours", "drug" : "cefTRIAXone sodium", "id" : "dopinder-pooja-med-14", "notes" : "Source due: 2/18/2025 16:00 Two antibiotics are active while narrative says no infection; penicillin angioedema is documented. Clarify infection indication, intended regimen, allergy assessment and infusion preparation.", "orderedBy" : "Pending per Dr. B Jackson, Admitting Physician", "orderedDateTime" : "2025-02-18T16:00:00", "section" : "Scheduled", "status" : "Held — clarification required" }, { "doseRouteFrequency" : "750 mg Intravenous Piggyback (IVPB) q24h (Every 24 hours), Every 24 hours", "drug" : "levoFLOXacin", "id" : "dopinder-pooja-med-15", "notes" : "Source due: 2/18/2025 16:00 Two antibiotics are active while narrative says no infection; penicillin angioedema is documented. Clarify infection indication, intended regimen, allergy assessment and infusion preparation.", "orderedBy" : "Pending per Dr. B Jackson, Admitting Physician", "orderedDateTime" : "2025-02-18T16:00:00", "section" : "Scheduled", "status" : "Held — clarification required" }, { "doseRouteFrequency" : "4 mg Intravenous (IV) q4h (Every 4 hours), Every 4 hours", "drug" : "Morphine", "id" : "dopinder-pooja-med-16", "notes" : "IV push, slow injection, every 4 hours PRN pain > 6/10. Hold and call provider if respiratory rate < 10 breaths/min or SBP < 90 mmHg Source due: PRN", "orderedBy" : "Pending per Dr. B Jackson, Admitting Physician", "orderedDateTime" : "2025-02-18T16:00:00", "section" : "PRN", "status" : "Active" }, { "doseRouteFrequency" : "4mg Intravenous (IV) q6h (Every 6 hours), Every 6 hours", "drug" : "ondansetron", "id" : "dopinder-pooja-med-17", "notes" : "PRN Nausea or vomiting Source due: PRN", "orderedBy" : "Pending per Dr. B Jackson, Admitting Physician", "orderedDateTime" : "2025-02-18T16:00:00", "section" : "PRN", "status" : "Active" }, { "doseRouteFrequency" : "650mg Oral (PO) q6h (Every 6 hours), Every 6 hours", "drug" : "acetaminophen", "id" : "dopinder-pooja-med-18", "notes" : "PRN temperature greater than 37.8 C (100.4 F) Source due: PRN Fever threshold 37.8 C does not equal the parenthetical 100.4 F; clarify intended threshold.", "orderedBy" : "Pending per Dr. B Jackson, Admitting Physician", "orderedDateTime" : "2025-02-18T15:30:00", "section" : "PRN", "status" : "Active" }, { "doseRouteFrequency" : "0.4mg Intravenous (IV) q3min (Every 3 minutes), Every 3 minutes", "drug" : "naloxone hydrochloride", "id" : "dopinder-pooja-med-19", "notes" : "Administer IV push undiluted over 30 seconds PRN for respiratory depression, respiratory rate < 10 bpm. Monitor patient and repeat dose every 2-3 minutes if needed Source due: PRN", "orderedBy" : "Pending per Dr. B Jackson, Admitting Physician", "orderedDateTime" : "2025-02-18T15:30:00", "section" : "PRN", "status" : "Active" }, { "doseRouteFrequency" : "30mg Intravenous (IV) q6h x1 (Every 6 hours, 1 time only), Every 6 hours, 1 time only", "drug" : "ketorolac tromethamine (oral, nasal, injection)", "id" : "dopinder-pooja-med-20", "lastGiven" : "2025-02-18T15:30:00", "notes" : "PRN pain 4-7. Discontinue after 5 days Source due: PRN", "orderedBy" : "Pending per Dr. B Jackson, Admitting Physician", "orderedDateTime" : "2025-02-18T16:00:00", "section" : "Scheduled", "status" : "Discontinued" }, { "doseRouteFrequency" : "125 ml per hr Intravenous (IV) cont.", "drug" : "sodium chloride 0.9%", "id" : "dopinder-pooja-med-21", "lastGiven" : "2025-02-18T15:30:00", "notes" : "Source due: cont.", "orderedBy" : "Pending per Dr. B Jackson, Admitting Physician", "orderedDateTime" : "2025-02-18T15:30:00", "section" : "Scheduled", "status" : "Active" } ], "notes" : [ { "id" : "dopinder-pooja-allergy", "summary" : "Betadine | Medication | Contact Dermatitis | | | 2/18/2025 15:30\nPenicillin | Medication | Angioedema | | | 2/18/2025 15:30", "type" : "Allergy documentation" }, { "author" : "K Chambers , Registered Nurse", "dateTime" : "2025-02-18T15:00:00", "id" : "dopinder-pooja-note-1", "summary" : "Situation: Dopinder Pooja is 45-year-old male who arrived in the ED 3 hours ago with right-side flank pain and blood in his urine. He is being evaluated for kidney stones. Background: The patient was diagnosed with gout 10 years ago and has a history of frequent exacerbations. He is prescribed to take allopurinol for prevention and colchicine for acute episodes. His compliance with this regimen is unknown at this time. The patient has a history of obesity, and his BMI is 34.9. He lives alone. His sister is his healthcare proxy; she is geographically his closest family member but lives several hours away. Her phone number is in the chart. Assessment: The patient rates his pain as a 10/10. He describes it as a stabbing pain in his right side and in his groin. He was given 30 mg of ketorolac IV in triage about 30 minutes ago; his pain has not improved following this dose. He has a peripheral IV in his right arm with a current infusion of 0.9% sodium chloride at 125 mL/hour. He also reports small amounts of blood in his urine as of today. Upon arrival to the ED, a bedside urine analysis revealed moderate hematuria; no infection was noted. Standard admission labs were drawn and are still pending. During the assessment it was noted that the patient does not seem to have showered or bathed in a few days, and his clothes seem to be dirty. Recommendation: You will need to continue to evaluate and treat the patient’s pain, monitor his renal function, and review the labs that were drawn on admission. After his pain is better managed, he should be assessed for safety and the ability to care for himself.", "type" : "Nursing - Shift" }, { "author" : "Dr. B Jackson , Admitting Physician", "dateTime" : "2025-02-18T14:00:00", "id" : "dopinder-pooja-note-2", "summary" : "Admission Note: History of Chief Complaint: Client came to the emergency department with severe right flank pain that has worsened over the last 2 days. He also reports red blood in his urine as of today. Past Medical History: The client has a history of frequent exacerbations of gout, diagnosed 10 years ago, and obesity, BMI 34.9. He reports he has had 3-4 episodes of gout pain in the last few months. He is prescribed to take allopurinol for prevention and colchicine for acute episodes. Social History: Client lives alone. His closest relative and healthcare proxy is his sister, who lives several hours away. Assessment: General: appears painful, non-toxic Pain: Rates pain 10/10 in right flank and groin region GU: UA reveals hematuria, no signs of infection Hygiene: appears client has not bathed or showered in a few days, clothes are dirty Plan: 1. Initiate IV access - done 2. 30mg Ketorolac IV - done 3. Labs - UA, BMP, CBC, hepatic panel 4. Pain Management 5. Strain Urine 6. NPO 7. Consider Urology Consult", "type" : "Physician Notes" }, { "id" : "dopinder-pooja-mar-history-4", "summary" : "2/18/2025 15:30 Aimee Jones, Registered Nurse Yes", "type" : "Medication administration history — ketorolac tromethamine (oral, nasal, injection)" }, { "id" : "dopinder-pooja-mar-history-5", "summary" : "2/18/2025 15:30 Aimee Jones, Registered Nurse Yes", "type" : "Medication administration history — sodium chloride" }, { "id" : "dopinder-pooja-section-current-care-providers", "summary" : "Aimee Jones | Registered Nurse\nDr. B Jackson | Admitting Physician\nK Chambers | Registered Nurse", "type" : "Current Care Providers" }, { "id" : "dopinder-pooja-clarification-7", "summary" : "Skills Lab simulation ID SL-006. Original DocuCare MRN: 7270066. Original fixed simulation dates and stated scenario ages are retained; DOB-derived age may disagree. Source records are preserved for faculty review.", "type" : "Chart clarification" }, { "id" : "dopinder-pooja-clarification-8", "summary" : "Two antibiotics are active while narrative says no infection; penicillin angioedema is documented. Clarify infection indication, intended regimen, allergy assessment and infusion preparation.", "type" : "Chart clarification" }, { "id" : "dopinder-pooja-clarification-9", "summary" : "Two antibiotics are active while narrative says no infection; penicillin angioedema is documented. Clarify infection indication, intended regimen, allergy assessment and infusion preparation.", "type" : "Chart clarification" }, { "id" : "dopinder-pooja-clarification-10", "summary" : "Fever threshold 37.8 C does not equal the parenthetical 100.4 F; clarify intended threshold.", "type" : "Chart clarification" }, { "id" : "dopinder-pooja-clarification-11", "summary" : "Used AMY VERMILLION course-owner copy titled Copy of LL_IV Push/IVPB_Dopinder Pooja; exact assigned-copy identity should be confirmed.", "type" : "Chart clarification" }, { "id" : "dopinder-pooja-clarification-12", "summary" : "Narratives and labs predate recorded admission and use inconsistent elapsed times. Fixed timestamps retained.", "type" : "Chart clarification" }, { "id" : "dopinder-pooja-clarification-13", "summary" : "Discontinued ketorolac and its historical administration retained, not reactivated.", "type" : "Chart clarification" } ], "orders" : [ { "author" : "Pending per Dr. B Jackson, Admitting Physician", "category" : "Consult", "dateTime" : "2025-02-18T15:30:00", "id" : "dopinder-pooja-order-1", "orderText" : "Consult: Urology; x1 (1 time only), 1 time only; Routine; Consult: Urology for renal calculi Source due: 2/18/2025 15:30", "status" : "Active" }, { "author" : "Pending per Dr. B Jackson, Admitting Physician", "category" : "Dietary", "dateTime" : "2025-02-18T15:30:00", "id" : "dopinder-pooja-order-2", "orderText" : "Nothing by mouth; cont.; Routine; NPO - except medications Source due: 2/18/2025 15:30", "status" : "Active" }, { "author" : "Pending per Dr. B Jackson, Admitting Physician", "category" : "ED", "dateTime" : "2025-02-18T15:30:00", "id" : "dopinder-pooja-order-3", "orderText" : "Venipuncture; x1 (1 time only), 1 time only; Stat; Labs: BMP, Hepatic Profile, CBC Source due: 2/18/2025 15:30", "status" : "Active" }, { "author" : "Pending per Dr. B Jackson, Admitting Physician", "category" : "Laboratory", "dateTime" : "2025-02-18T15:30:00", "id" : "dopinder-pooja-order-4", "orderText" : "Clean-catch (midstream) urine collection, male; x1 (1 time only), 1 time only; Stat; UA, C& S Source due: 2/18/2025 15:30", "status" : "Active" }, { "author" : "Pending per Dr. B Jackson, Admitting Physician", "category" : "Nursing", "dateTime" : "2025-02-18T15:30:00", "id" : "dopinder-pooja-order-5", "orderText" : "Admission; x1 (1 time only), 1 time only; Routine; Admit to Med Surg Source due: 2/18/2025 15:30", "status" : "Active" }, { "author" : "Pending per Dr. B Jackson, Admitting Physician", "category" : "Nursing: Activity", "dateTime" : "2025-02-18T15:30:00", "id" : "dopinder-pooja-order-6", "orderText" : "Out of bed with Assistance; cont.; Routine; Source due: 2/18/2025 15:30", "status" : "Active" }, { "author" : "Pending per Dr. B Jackson, Admitting Physician", "category" : "Nursing: Monitoring", "dateTime" : "2025-02-18T15:30:00", "id" : "dopinder-pooja-order-7", "orderText" : "Vital Signs; q4h (Every 4 hours), Every 4 hours; Routine; Call HCP for HR >120 bpm or <60 bpm Blood Pressure >160/90 mmHg or <100/60 mmHg SpO2 < 92% RR <10 bpm Source due: 2/18/2025 15:30", "status" : "Active" }, { "author" : "Pending per Dr. B Jackson, Admitting Physician", "category" : "Nursing: Monitoring", "dateTime" : "2025-02-18T15:30:00", "id" : "dopinder-pooja-order-8", "orderText" : "Intake and output measurement; q4h (Every 4 hours), Every 4 hours; Stat; Call provider if urine output less than 30 mL per hour Source due: 2/18/2025 15:30", "status" : "Active" }, { "author" : "Pending per Dr. B Jackson, Admitting Physician", "category" : "Nursing: Monitoring", "dateTime" : "2025-02-18T15:30:00", "id" : "dopinder-pooja-order-9", "orderText" : "Strain all urine; cont.; Routine; Strain all urine Source due: 2/18/2025 15:30", "status" : "Active" }, { "author" : "Pending per Dr. B Jackson, Admitting Physician", "category" : "Nursing: Monitoring", "dateTime" : "2025-02-18T15:30:00", "id" : "dopinder-pooja-order-10", "orderText" : "Cardiac monitoring; cont.; Routine; Continuous telemetry with ambulatory monitor Source due: 2/18/2025 15:30", "status" : "Active" }, { "author" : "Pending per Dr. B Jackson, Admitting Physician", "category" : "Nursing: Monitoring", "dateTime" : "2025-02-18T15:30:00", "id" : "dopinder-pooja-order-11", "orderText" : "Pulse oximetry; cont.; Routine; Continuous pulse oximetry Source due: 2/18/2025 15:30", "status" : "Active" }, { "author" : "Pending per Dr. B Jackson, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2025-02-18T16:00:00", "id" : "dopinder-pooja-order-12", "orderText" : "allopurinol; 100mg Oral (PO); q24h (Every 24 hours), Every 24 hours; Scheduled; Source due: 2/18/2025 16:00", "status" : "Active" }, { "author" : "Pending per Dr. B Jackson, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2025-02-18T16:00:00", "id" : "dopinder-pooja-order-13", "orderText" : "colchicine; 500mcg Oral (PO); q12h (Every 12 hours), Every 12 hours; Scheduled; Source due: 2/18/2025 16:00", "status" : "Active" }, { "author" : "Pending per Dr. B Jackson, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2025-02-18T16:00:00", "id" : "dopinder-pooja-order-14", "orderText" : "cefTRIAXone sodium; 1 Gm Intravenous Piggyback (IVPB); q24h (Every 24 hours), Every 24 hours; Scheduled; Source due: 2/18/2025 16:00 Two antibiotics are active while narrative says no infection; penicillin angioedema is documented. Clarify infection indication, intended regimen, allergy assessment and infusion preparation.", "status" : "Held — clarification required" }, { "author" : "Pending per Dr. B Jackson, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2025-02-18T16:00:00", "id" : "dopinder-pooja-order-15", "orderText" : "levoFLOXacin; 750 mg Intravenous Piggyback (IVPB); q24h (Every 24 hours), Every 24 hours; Scheduled; Source due: 2/18/2025 16:00 Two antibiotics are active while narrative says no infection; penicillin angioedema is documented. Clarify infection indication, intended regimen, allergy assessment and infusion preparation.", "status" : "Held — clarification required" }, { "author" : "Pending per Dr. B Jackson, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2025-02-18T16:00:00", "id" : "dopinder-pooja-order-16", "orderText" : "Morphine; 4 mg Intravenous (IV); q4h (Every 4 hours), Every 4 hours; PRN; IV push, slow injection, every 4 hours PRN pain > 6/10. Hold and call provider if respiratory rate < 10 breaths/min or SBP < 90 mmHg Source due: PRN", "status" : "Active" }, { "author" : "Pending per Dr. B Jackson, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2025-02-18T16:00:00", "id" : "dopinder-pooja-order-17", "orderText" : "ondansetron; 4mg Intravenous (IV); q6h (Every 6 hours), Every 6 hours; PRN; PRN Nausea or vomiting Source due: PRN", "status" : "Active" }, { "author" : "Pending per Dr. B Jackson, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2025-02-18T15:30:00", "id" : "dopinder-pooja-order-18", "orderText" : "acetaminophen; 650mg Oral (PO); q6h (Every 6 hours), Every 6 hours; PRN; PRN temperature greater than 37.8 C (100.4 F) Source due: PRN Fever threshold 37.8 C does not equal the parenthetical 100.4 F; clarify intended threshold.", "status" : "Active" }, { "author" : "Pending per Dr. B Jackson, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2025-02-18T15:30:00", "id" : "dopinder-pooja-order-19", "orderText" : "naloxone hydrochloride; 0.4mg Intravenous (IV); q3min (Every 3 minutes), Every 3 minutes; PRN; Administer IV push undiluted over 30 seconds PRN for respiratory depression, respiratory rate < 10 bpm. Monitor patient and repeat dose every 2-3 minutes if needed Source due: PRN", "status" : "Active" }, { "author" : "Pending per Dr. B Jackson, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2025-02-18T16:00:00", "id" : "dopinder-pooja-order-20", "orderText" : "ketorolac tromethamine (oral, nasal, injection); 30mg Intravenous (IV); q6h x1 (Every 6 hours, 1 time only), Every 6 hours, 1 time only; Discontinued; PRN pain 4-7. Discontinue after 5 days Source due: PRN", "status" : "Discontinued" }, { "author" : "Pending per Dr. B Jackson, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2025-02-18T15:30:00", "id" : "dopinder-pooja-order-21", "orderText" : "sodium chloride 0.9%; 125 ml per hr Intravenous (IV); cont.; Cont. Infusion; Source due: cont.", "status" : "Active" } ], "overview" : { "height" : "71 in / 180.3 cm", "isolationIndicator" : "Standard", "religion" : "Unknown/not stated", "weightKg" : 113.4 }, "vitals" : [ { "bloodPressure" : "154/90", "dateTime" : "2025-02-18T15:30:00", "heartRate" : 112, "id" : "dopinder-pooja-vital-1", "oxygenDevice" : "Room Air", "respiratoryRate" : 22, "spo2" : "95", "temperature" : "98.6 °F (37 °C), 37 °C Oral" } ] }, "patient" : { "admitDateTime" : "2025-02-18T15:30:00", "admittingDiagnosis" : "Renal calculi", "allergies" : [ { "id" : "allergy-7bdb825a8d505ae3", "reaction" : "Contact Dermatitis", "severity" : "Not documented", "substance" : "Betadine" }, { "id" : "allergy-77416e93c61879b7", "reaction" : "Angioedema", "severity" : "Not documented", "substance" : "Penicillin" } ], "attending" : "Dr. B Jackson, Admitting Physician", "chartDisplayName" : "Pooja, Dopinder", "codeStatus" : "Full Code", "dob" : "7/27/1981", "history" : { "chiefComplaint" : "\"My right flank and groin hurt really bad. It's been going on for about two days, but has gotten worse instead of better. When I went to the bathroom there was blood in my urine\"", "pastMedicalHistory" : [ "General Medical History / Disease/Condition / : Gout, long-term care", "General Medical History / Disease/Condition / : Obesity, long-term care", "General Medical History / Notes: 10 year history of gout. States 3-4 episodes in the last few months. Prescribed allopurinal and colchicine for gout management/exacerbations" ], "pastSurgicalHistory" : [ ], "socialHistory" : [ "Age: 45 Years", "Home Situation / Patient Living Situation: Home", "Home Situation / Lives With: Alone", "Education / Able to Read?: Yes", "Education / Able to Write?: Yes", "Nutritional Screening / Last Bowel Movement Date: 02/18/2025", "Other Safety Measures / Notes: Client lives alone, sister is the healthcare proxy. She is geographically his closest family member but lives several hours away." ] }, "mrn" : "SL-006", "sex" : "Male", "simulatedFullName" : "Dopinder Pooja", "unit" : "Riverside City Virtual Hospital — Room ED — Bed 5" }, "setting" : "Riverside City Virtual Hospital — Room ED — Bed 5", "snapshots" : [ { "activityIds" : [ ], "id" : "dopinder-pooja-current", "notes" : "Captured dated chart history; source relative dates anchored to chart opening. Progressive release not recreated.", "scenarioTime" : "2025-02-18T16:00:00", "sourcePath" : "DocuCare instructor chart: Dopinder Pooja", "title" : "Captured chart" } ], "subtitle" : "Learning Lab practice record", "tags" : [ "Skills Lab", "DocuCare migration", "Learning Lab" ], "title" : "Dopinder Pooja" }, "packageId" : "docucare-skills lab-dopinder-pooja-review-v1", "privacy" : { "containsRealPHI" : false, "defaultStorage" : "local-document-package", "networkRequired" : false, "simulatedOnly" : true, "warning" : "Simulated education only. Not for clinical care. Review conflicting, held or undocumented findings with lab faculty." }, "schemaVersion" : "2.0", "source" : { "system" : "DocuCare Enhanced instructor chart capture" }, "workingNames" : [ "ChartSlate" ] } }, "id" : "skills lab-dopinder-pooja", "instructions" : "Choose this patient for simulated chart-review practice. Check the name, date of birth and simulated MRN; review notes, assessments, vital signs, orders and medications. Identify missing or conflicting information and discuss it with lab faculty. Held or discontinued medications are not active administration tasks.", "title" : "Dopinder Pooja" }, { "envelope" : { "appName" : "ChartSlate", "audience" : "student", "createdAt" : "2026-09-25T19:44:22.331008+00:00", "exportVersion" : "1", "kind" : "casePackage", "package" : { "case" : { "activities" : [ ], "id" : "docucare-skills lab-jonah-dinerman", "learningLevel" : "Skills Lab", "panels" : { "assessments" : [ { "dateTime" : "2025-02-18T16:00:00", "id" : "jonah-dinerman-assessment-1", "label" : "Cardio", "summary" : ": Cardio\nSkin Color and Description / Skin Color Details: Redness to left lower extremity" } ], "labs" : [ ], "medications" : [ { "doseRouteFrequency" : "1000mg Oral (PO) q24h (Every 24 hours), Every 24 hours", "drug" : "metFORMIN hydrochloride", "id" : "jonah-dinerman-med-1", "nextDue" : "2025-02-18T16:00:00", "notes" : "First dose at 09am Source due: 2/18/2025 16:00 First-dose instruction says 09:00 but source due time is 16:00; schedule needs reconciliation.", "orderedBy" : "Pending per Dr. Jan, Admitting Physician", "orderedDateTime" : "2025-02-18T16:00:00", "section" : "Scheduled", "status" : "Active" }, { "doseRouteFrequency" : "5 mg Oral (PO) q24h (Every 24 hours), Every 24 hours", "drug" : "glyBURIDE", "id" : "jonah-dinerman-med-2", "nextDue" : "2025-02-18T16:00:00", "notes" : "Source due: 2/18/2025 16:00", "orderedBy" : "Pending per Dr. Jan, Admitting Physician", "orderedDateTime" : "2025-02-18T16:00:00", "section" : "Scheduled", "status" : "Active" }, { "doseRouteFrequency" : "200 mg Oral (PO) q8h (Every 8 hours), Every 8 hours", "drug" : "gabapentin", "id" : "jonah-dinerman-med-3", "nextDue" : "2025-02-18T16:00:00", "notes" : "2 (100 mg) tablets Source due: 2/18/2025 16:00", "orderedBy" : "Pending per Dr. Jan, Admitting Physician", "orderedDateTime" : "2025-02-18T16:00:00", "section" : "Scheduled", "status" : "Active" }, { "doseRouteFrequency" : "10 mg Oral (PO) q24h (Every 24 hours), Every 24 hours", "drug" : "benazepril hydrochloride", "id" : "jonah-dinerman-med-4", "notes" : "Source due: 2/18/2025 16:00 Benazepril and losartan are both active. Clarify intended single renin–angiotensin therapy; neither replacement is guessed. Dual blockade increases renal impairment, hypotension and hyperkalemia risk. Label: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=9949448f-c3b9-44ee-94ed-c1aca8c90f39", "orderedBy" : "Pending per Dr. Jan, Admitting Physician", "orderedDateTime" : "2025-02-18T16:00:00", "section" : "Scheduled", "status" : "Held — clarification required" }, { "doseRouteFrequency" : "50 mg Oral (PO) q24h (Every 24 hours), Every 24 hours", "drug" : "losartan potassium", "id" : "jonah-dinerman-med-5", "notes" : "Source due: 2/18/2025 16:00 Benazepril and losartan are both active. Clarify intended single renin–angiotensin therapy; neither replacement is guessed. Dual blockade increases renal impairment, hypotension and hyperkalemia risk. Label: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=9949448f-c3b9-44ee-94ed-c1aca8c90f39", "orderedBy" : "Pending per Dr. Jan, Admitting Physician", "orderedDateTime" : "2025-02-18T16:00:00", "section" : "Scheduled", "status" : "Held — clarification required" }, { "doseRouteFrequency" : "1.5 Gm Intravenous Piggyback (IVPB) q6h (Every 6 hours), Every 6 hours", "drug" : "ampicillin sodium–sulbactam sodium", "id" : "jonah-dinerman-med-6", "nextDue" : "2025-02-18T16:00:00", "notes" : "Source due: 2/18/2025 16:00", "orderedBy" : "Pending per Dr. Jan, Admitting Physician", "orderedDateTime" : "2025-02-18T16:00:00", "section" : "Scheduled", "status" : "Active" } ], "notes" : [ { "id" : "jonah-dinerman-allergy", "summary" : "Source allergy table contains no entries. Allergy status is not documented; an empty table does not establish no known allergies.", "type" : "Allergy documentation" }, { "author" : "Dr. Jan , Admitting Physician", "dateTime" : "2025-02-18T16:00:00", "id" : "jonah-dinerman-note-1", "summary" : "S Jonah Dinerman, age 63, was recently diagnosed with diabetes. B Diagnosed with Type II DM 3 days ago after being admitted with left lower extremity cellulitis. A Vital signs – 98.1, 85, 16, 141/82 O2 sat 98% on RA 1/10 pain Blood glucose 160 Heart- RRR, peripheral pulses present bilaterally Lung- clear bilaterally, no cough Skin- Redness to left lower extremity, +2 pitting edema, no exudate. Does complain of numbness and tingling to bilateral lower extremities. R Administer meds, monitor blood glucose, and conduct diabetic teaching.", "type" : "Nursing - Shift" }, { "id" : "jonah-dinerman-section-current-care-providers", "summary" : "Dr. Jan | Admitting Physician\nRita | Registered Nurse", "type" : "Current Care Providers" }, { "id" : "jonah-dinerman-clarification-4", "summary" : "Skills Lab simulation ID SL-007. Original DocuCare MRN: 235813. Original fixed simulation dates and stated scenario ages are retained; DOB-derived age may disagree. Source records are preserved for faculty review.", "type" : "Chart clarification" }, { "id" : "jonah-dinerman-clarification-5", "summary" : "First-dose instruction says 09:00 but source due time is 16:00; schedule needs reconciliation.", "type" : "Chart clarification" }, { "id" : "jonah-dinerman-clarification-6", "summary" : "Benazepril and losartan are both active. Clarify intended single renin–angiotensin therapy; neither replacement is guessed. Dual blockade increases renal impairment, hypotension and hyperkalemia risk. Label: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=9949448f-c3b9-44ee-94ed-c1aca8c90f39", "type" : "Chart clarification" }, { "id" : "jonah-dinerman-clarification-7", "summary" : "Benazepril and losartan are both active. Clarify intended single renin–angiotensin therapy; neither replacement is guessed. Dual blockade increases renal impairment, hypotension and hyperkalemia risk. Label: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=9949448f-c3b9-44ee-94ed-c1aca8c90f39", "type" : "Chart clarification" } ], "orders" : [ { "author" : "Pending per Dr. Jan, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2025-02-18T16:00:00", "id" : "jonah-dinerman-order-1", "orderText" : "metFORMIN hydrochloride; 1000mg Oral (PO); q24h (Every 24 hours), Every 24 hours; Scheduled; First dose at 09am Source due: 2/18/2025 16:00 First-dose instruction says 09:00 but source due time is 16:00; schedule needs reconciliation.", "status" : "Active" }, { "author" : "Pending per Dr. Jan, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2025-02-18T16:00:00", "id" : "jonah-dinerman-order-2", "orderText" : "glyBURIDE; 5 mg Oral (PO); q24h (Every 24 hours), Every 24 hours; Scheduled; Source due: 2/18/2025 16:00", "status" : "Active" }, { "author" : "Pending per Dr. Jan, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2025-02-18T16:00:00", "id" : "jonah-dinerman-order-3", "orderText" : "gabapentin; 200 mg Oral (PO); q8h (Every 8 hours), Every 8 hours; Scheduled; 2 (100 mg) tablets Source due: 2/18/2025 16:00", "status" : "Active" }, { "author" : "Pending per Dr. Jan, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2025-02-18T16:00:00", "id" : "jonah-dinerman-order-4", "orderText" : "benazepril hydrochloride; 10 mg Oral (PO); q24h (Every 24 hours), Every 24 hours; Scheduled; Source due: 2/18/2025 16:00 Benazepril and losartan are both active. Clarify intended single renin–angiotensin therapy; neither replacement is guessed. Dual blockade increases renal impairment, hypotension and hyperkalemia risk. Label: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=9949448f-c3b9-44ee-94ed-c1aca8c90f39", "status" : "Held — clarification required" }, { "author" : "Pending per Dr. Jan, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2025-02-18T16:00:00", "id" : "jonah-dinerman-order-5", "orderText" : "losartan potassium; 50 mg Oral (PO); q24h (Every 24 hours), Every 24 hours; Scheduled; Source due: 2/18/2025 16:00 Benazepril and losartan are both active. Clarify intended single renin–angiotensin therapy; neither replacement is guessed. Dual blockade increases renal impairment, hypotension and hyperkalemia risk. Label: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=9949448f-c3b9-44ee-94ed-c1aca8c90f39", "status" : "Held — clarification required" }, { "author" : "Pending per Dr. Jan, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2025-02-18T16:00:00", "id" : "jonah-dinerman-order-6", "orderText" : "ampicillin sodium–sulbactam sodium; 1.5 Gm Intravenous Piggyback (IVPB); q6h (Every 6 hours), Every 6 hours; Scheduled; Source due: 2/18/2025 16:00", "status" : "Active" } ], "overview" : { "height" : "", "isolationIndicator" : "Standard", "religion" : "" }, "vitals" : [ { "bloodPressure" : "141/82", "dateTime" : "2025-02-18T16:00:00", "heartRate" : 85, "id" : "jonah-dinerman-vital-1", "oxygenDevice" : "Room Air", "respiratoryRate" : 16, "spo2" : "88", "temperature" : "97.6 °F (36 °C), 36 °C Oral" } ] }, "patient" : { "admitDateTime" : "2025-02-18T16:00:00", "admittingDiagnosis" : "Diabetes mellitus (type 2)", "allergies" : [ ], "attending" : "Dr. Jan, Admitting Physician", "chartDisplayName" : "Dinerman, Jonah", "codeStatus" : "", "dob" : "7/5/1963", "history" : { "chiefComplaint" : "Jonah Dinerman is a 63 year old male admitted for diabetes exacerbation. The patient is a newly diagnosed with Type II DM 3 days ago after being admitted with left lower extremity cellulitis.", "pastMedicalHistory" : [ ], "pastSurgicalHistory" : [ ], "socialHistory" : [ "Age: 63 Years" ] }, "mrn" : "SL-007", "sex" : "Male", "simulatedFullName" : "Jonah Dinerman", "unit" : "RCC Hospital" }, "setting" : "RCC Hospital", "snapshots" : [ { "activityIds" : [ ], "id" : "jonah-dinerman-current", "notes" : "Captured dated chart history; source relative dates anchored to chart opening. Progressive release not recreated.", "scenarioTime" : "2025-02-18T16:00:00", "sourcePath" : "DocuCare instructor chart: Jonah Dinerman", "title" : "Captured chart" } ], "subtitle" : "Learning Lab practice record", "tags" : [ "Skills Lab", "DocuCare migration", "Learning Lab" ], "title" : "Jonah Dinerman" }, "packageId" : "docucare-skills lab-jonah-dinerman-review-v1", "privacy" : { "containsRealPHI" : false, "defaultStorage" : "local-document-package", "networkRequired" : false, "simulatedOnly" : true, "warning" : "Simulated education only. Not for clinical care. Review conflicting, held or undocumented findings with lab faculty." }, "schemaVersion" : "2.0", "source" : { "system" : "DocuCare Enhanced instructor chart capture" }, "workingNames" : [ "ChartSlate" ] } }, "id" : "skills lab-jonah-dinerman", "instructions" : "Choose this patient for simulated chart-review practice. Check the name, date of birth and simulated MRN; review notes, assessments, vital signs, orders and medications. Identify missing or conflicting information and discuss it with lab faculty. Held or discontinued medications are not active administration tasks.", "title" : "Jonah Dinerman" }, { "envelope" : { "appName" : "ChartSlate", "audience" : "student", "createdAt" : "2026-09-25T19:44:22.331008+00:00", "exportVersion" : "1", "kind" : "casePackage", "package" : { "case" : { "activities" : [ ], "id" : "docucare-skills lab-nicholas-soros", "learningLevel" : "Skills Lab", "panels" : { "assessments" : [ { "dateTime" : "2025-02-17T15:10:00", "id" : "nicholas-soros-assessment-1", "label" : "HEENT", "summary" : ": HEENT" }, { "dateTime" : "2025-02-18T03:00:00", "id" : "nicholas-soros-assessment-2", "label" : "HEENT", "summary" : ": HEENT" }, { "dateTime" : "2025-02-17T15:10:00", "id" : "nicholas-soros-assessment-3", "label" : "Neuro", "summary" : ": Neuro" }, { "dateTime" : "2025-02-18T03:00:00", "id" : "nicholas-soros-assessment-4", "label" : "Neuro", "summary" : ": Neuro" }, { "dateTime" : "2025-02-17T15:10:00", "id" : "nicholas-soros-assessment-5", "label" : "Cardio", "summary" : ": Cardio" }, { "dateTime" : "2025-02-18T03:00:00", "id" : "nicholas-soros-assessment-6", "label" : "Cardio", "summary" : ": Cardio" }, { "dateTime" : "2025-02-17T15:10:00", "id" : "nicholas-soros-assessment-7", "label" : "GI", "summary" : ": GI\nAdditional Notes / Additional Notes: 1800 cal ADA 2 gm Sodium diet\nDiet Tolerance / Diet Tolerance: Adequate\nLast Bowel Movement / Last Bowel Movement Date: 02/17/2025\nLast Bowel Movement / Last Bowel Movement Time: 14:00" }, { "dateTime" : "2025-02-18T03:00:00", "id" : "nicholas-soros-assessment-8", "label" : "GI", "summary" : ": GI\nAdditional Notes / Additional Notes: 1800 cal ADA 2 gm Na+ diet Mr. Soros returned for his next check-up, he had gained 5 additional pounds and reported being ?too old? to worry about diet and exercise. ?You can control my diabetes with medication, right?\nDiet Tolerance / Diet Tolerance: Excellent\nLast Bowel Movement / Last Bowel Movement Date: 02/17/2025\nLast Bowel Movement / Last Bowel Movement Time: 15:00" }, { "dateTime" : "2025-02-17T15:10:00", "id" : "nicholas-soros-assessment-9", "label" : "GU", "summary" : ": GU\nDate Inserted Date: 02/17/2025\nVolume in Balloon: 0" }, { "dateTime" : "2025-02-18T03:00:00", "id" : "nicholas-soros-assessment-10", "label" : "GU", "summary" : ": GU\nDate Inserted Date: 02/17/2025\nVolume in Balloon: 0" }, { "dateTime" : "2025-02-17T15:10:00", "id" : "nicholas-soros-assessment-11", "label" : "Respiratory", "summary" : ": Respiratory\nOxygen Delivery Method / Oxygen Delivery Method: Room Air" }, { "dateTime" : "2025-02-18T03:00:00", "id" : "nicholas-soros-assessment-12", "label" : "Respiratory", "summary" : ": Respiratory\nOxygen Delivery Method / Oxygen Delivery Method: Room Air" }, { "dateTime" : "2025-02-17T15:10:00", "id" : "nicholas-soros-assessment-13", "label" : "Mental Health", "summary" : ": Mental Health" }, { "dateTime" : "2025-02-18T03:00:00", "id" : "nicholas-soros-assessment-14", "label" : "Mental Health", "summary" : ": Mental Health" }, { "dateTime" : "2025-02-17T15:10:00", "id" : "nicholas-soros-assessment-15", "label" : "Musculoskeletal", "summary" : ": Musculoskeletal" }, { "dateTime" : "2025-02-18T03:00:00", "id" : "nicholas-soros-assessment-16", "label" : "Musculoskeletal", "summary" : ": Musculoskeletal" }, { "dateTime" : "2025-02-18T03:00:00", "id" : "nicholas-soros-assessment-17", "label" : "Clean/Dry/Intact Skin Assessment", "summary" : "No findings entered in visible fields." } ], "labs" : [ { "category" : "HbA1c", "collectedDateTime" : "2025-02-17T15:00:00", "flag" : "High", "id" : "nicholas-soros-lab-1", "referenceRange" : "4-5.6", "result" : "7.3", "test" : "HbA1c (%)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2025-02-17T15:00:00", "flag" : "Normal", "id" : "nicholas-soros-lab-2", "referenceRange" : "3.5-5.0", "result" : "3.6", "test" : "Albumin (dL)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2025-02-17T15:00:00", "flag" : "Normal", "id" : "nicholas-soros-lab-3", "referenceRange" : "7 to 17", "result" : "11", "test" : "Anion gap" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2025-02-17T15:00:00", "flag" : "Normal", "id" : "nicholas-soros-lab-4", "referenceRange" : "7 to 30", "result" : "29", "test" : "BUN (mg/dL)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2025-02-17T15:00:00", "flag" : "Normal", "id" : "nicholas-soros-lab-5", "referenceRange" : "8.1-10.1", "result" : "8.3", "test" : "Calcium (mg/dL)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2025-02-17T15:00:00", "flag" : "Normal", "id" : "nicholas-soros-lab-6", "referenceRange" : "23-30", "result" : "25", "test" : "Carbon dioxide (mEq)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2025-02-17T15:00:00", "flag" : "Normal", "id" : "nicholas-soros-lab-7", "referenceRange" : "98-108", "result" : "99", "test" : "Chloride (mEq)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2025-02-17T15:00:00", "flag" : "Normal", "id" : "nicholas-soros-lab-8", "referenceRange" : "0.6-1.4", "result" : "1.2", "test" : "Creatinine (mg/dL)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2025-02-17T15:00:00", "flag" : "High", "id" : "nicholas-soros-lab-9", "referenceRange" : "70-100", "result" : "288", "test" : "Glucose (mg/dL)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2025-02-17T15:00:00", "flag" : "Normal", "id" : "nicholas-soros-lab-10", "referenceRange" : "1.7-2.6", "result" : "1.8", "test" : "Magnesium (mEq/Liter)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2025-02-17T15:00:00", "flag" : "Normal", "id" : "nicholas-soros-lab-11", "referenceRange" : "3.5-5.0", "result" : "3.9", "test" : "Potassium (mEq/Liter)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2025-02-17T15:00:00", "flag" : "Normal", "id" : "nicholas-soros-lab-12", "referenceRange" : "135-145", "result" : "144", "test" : "Sodium (mEq/Liter)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2025-02-17T15:00:00", "flag" : "Normal", "id" : "nicholas-soros-lab-13", "referenceRange" : "6.4-82", "result" : "19", "test" : "Total protein (grams/dL)" }, { "category" : "Lipid Panel", "collectedDateTime" : "2025-02-17T15:00:00", "flag" : "High", "id" : "nicholas-soros-lab-14", "referenceRange" : "Less than 200", "result" : "240", "test" : "Total Cholesterol (mg/dL)" }, { "category" : "Lipid Panel", "collectedDateTime" : "2025-02-17T15:00:00", "flag" : "High", "id" : "nicholas-soros-lab-15", "referenceRange" : "Less than 150", "result" : "180", "test" : "Triglycerides (mg/dL)" }, { "category" : "Lipid Panel", "collectedDateTime" : "2025-02-17T15:00:00", "flag" : "Low", "id" : "nicholas-soros-lab-16", "referenceRange" : "Greater than 40", "result" : "20", "test" : "HDL Cholesterol (mg/dL)" }, { "category" : "Lipid Panel", "collectedDateTime" : "2025-02-17T15:00:00", "flag" : "High", "id" : "nicholas-soros-lab-17", "referenceRange" : "Less than 100", "result" : "160", "test" : "LDL Cholesterol" }, { "category" : "Complete Blood Count with differential", "collectedDateTime" : "2025-02-17T15:00:00", "flag" : "Normal", "id" : "nicholas-soros-lab-18", "referenceRange" : "4.0-9.0", "result" : "8.9", "test" : "WBC (10 x 3/uL)" }, { "category" : "Complete Blood Count with differential", "collectedDateTime" : "2025-02-17T15:00:00", "flag" : "Normal", "id" : "nicholas-soros-lab-19", "referenceRange" : "3.90-4.98", "result" : "4.0", "test" : "RBC (mill/cumm)" }, { "category" : "Complete Blood Count with differential", "collectedDateTime" : "2025-02-17T15:00:00", "flag" : "Normal", "id" : "nicholas-soros-lab-20", "referenceRange" : "12.0-15.5", "result" : "14.4", "test" : "Hemoglobin (gm/dL)" }, { "category" : "Complete Blood Count with differential", "collectedDateTime" : "2025-02-17T15:00:00", "flag" : "Normal", "id" : "nicholas-soros-lab-21", "referenceRange" : "35-45", "result" : "38", "test" : "Hematocrit (%)" }, { "category" : "Complete Blood Count with differential", "collectedDateTime" : "2025-02-17T15:00:00", "flag" : "Normal", "id" : "nicholas-soros-lab-22", "referenceRange" : "81-93", "result" : "90", "test" : "MCV (fL)" }, { "category" : "Complete Blood Count with differential", "collectedDateTime" : "2025-02-17T15:00:00", "flag" : "Normal", "id" : "nicholas-soros-lab-23", "referenceRange" : "28-35", "result" : "32", "test" : "MCH (pg)" }, { "category" : "Complete Blood Count with differential", "collectedDateTime" : "2025-02-17T15:00:00", "flag" : "Normal", "id" : "nicholas-soros-lab-24", "referenceRange" : "33-37", "result" : "35", "test" : "MCHC (gm/dL)" }, { "category" : "Complete Blood Count with differential", "collectedDateTime" : "2025-02-17T15:00:00", "flag" : "Normal", "id" : "nicholas-soros-lab-25", "referenceRange" : "11.4-15.2", "result" : "15", "test" : "RDW (%)" }, { "category" : "Complete Blood Count with differential", "collectedDateTime" : "2025-02-17T15:00:00", "flag" : "Normal", "id" : "nicholas-soros-lab-26", "referenceRange" : "140-400", "result" : "300", "test" : "Platelet Count (1000/mm3)" }, { "category" : "Complete Blood Count with differential", "collectedDateTime" : "2025-02-17T15:00:00", "flag" : "Normal", "id" : "nicholas-soros-lab-27", "referenceRange" : "6.0-11.1", "result" : "7.0", "test" : "Mean Platelet Volume (fL)" }, { "category" : "Complete Blood Count with differential", "collectedDateTime" : "2025-02-17T15:00:00", "flag" : "Normal", "id" : "nicholas-soros-lab-28", "referenceRange" : "40-70", "result" : "57", "test" : "Neutrophils (%)" }, { "category" : "Complete Blood Count with differential", "collectedDateTime" : "2025-02-17T15:00:00", "flag" : "Normal", "id" : "nicholas-soros-lab-29", "referenceRange" : "10-20", "result" : "12", "test" : "Lymphocytes (%)" }, { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2025-02-17T15:00:00", "flag" : "Normal", "id" : "nicholas-soros-lab-30", "referenceRange" : "135-145", "result" : "140", "test" : "Sodium (mEq/L)" }, { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2025-02-17T15:00:00", "flag" : "Normal", "id" : "nicholas-soros-lab-31", "referenceRange" : "3.5-5.1", "result" : "3.8", "test" : "Potassium (mEq/L)" }, { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2025-02-17T15:00:00", "flag" : "Normal", "id" : "nicholas-soros-lab-32", "referenceRange" : "98-107", "result" : "100", "test" : "Chloride (mEq/L)" }, { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2025-02-17T15:00:00", "flag" : "Normal", "id" : "nicholas-soros-lab-33", "referenceRange" : "22-29", "result" : "29", "test" : "CO2 (mEq/L)" }, { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2025-02-17T15:00:00", "flag" : "High", "id" : "nicholas-soros-lab-34", "referenceRange" : "70-99", "result" : "200", "test" : "Glucose (mg/dL)" }, { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2025-02-17T15:00:00", "flag" : "Normal", "id" : "nicholas-soros-lab-35", "referenceRange" : "6-20", "result" : "8", "test" : "Blood Urea Nitrogen (mg/dL)" }, { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2025-02-17T15:00:00", "flag" : "Normal", "id" : "nicholas-soros-lab-36", "referenceRange" : "0.50-1.00", "result" : ".80", "test" : "Creatinine (mg/dL)" }, { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2025-02-17T15:00:00", "flag" : "Normal", "id" : "nicholas-soros-lab-37", "referenceRange" : "8.4-10.5", "result" : "9.0", "test" : "Calcium (mg/dL)" }, { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2025-02-17T15:00:00", "flag" : "Normal", "id" : "nicholas-soros-lab-38", "referenceRange" : "6.4-8.4", "result" : "7.0", "test" : "Total Protein (gm/dL)" }, { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2025-02-17T15:00:00", "flag" : "Normal", "id" : "nicholas-soros-lab-39", "referenceRange" : "3.5-5.2", "result" : "4.0", "test" : "Albumin (gm/dL)" }, { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2025-02-17T15:00:00", "flag" : "Normal", "id" : "nicholas-soros-lab-40", "referenceRange" : "0.0-1.2", "result" : ".8", "test" : "Total Bilirubin (mg/dL)" }, { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2025-02-17T15:00:00", "flag" : "Normal", "id" : "nicholas-soros-lab-41", "referenceRange" : "0-32", "result" : "30", "test" : "AST (U/L)" }, { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2025-02-17T15:00:00", "flag" : "Normal", "id" : "nicholas-soros-lab-42", "referenceRange" : "35-105", "result" : "65", "test" : "Alkaline Phosphate (U/L)" }, { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2025-02-17T15:00:00", "flag" : "Normal", "id" : "nicholas-soros-lab-43", "referenceRange" : "0-33", "result" : "30", "test" : "ALT (U/L)" } ], "medications" : [ { "doseRouteFrequency" : "25 mg Oral (PO) q8h (Every 8 hours), Every 8 hours", "drug" : "captopril", "id" : "nicholas-soros-med-6", "lastGiven" : "2025-02-18T07:00:00", "nextDue" : "2025-02-18T15:00:00", "notes" : "Hold for SBP < 100 Source due: 2/18/2025 15:00", "orderedBy" : "Pending per James E. Davis, Primary Care Provider", "orderedDateTime" : "2025-02-17T15:00:00", "section" : "Scheduled", "status" : "Active" }, { "doseRouteFrequency" : "180 mg Oral (PO) q24h (Every 24 hours), Every 24 hours", "drug" : "dilTIAZem hydrochloride ER", "id" : "nicholas-soros-med-7", "lastGiven" : "2025-02-17T15:00:00", "nextDue" : "2025-02-18T15:00:00", "notes" : "Hold for HR < 60 Source due: 2/18/2025 15:00", "orderedBy" : "Pending per James E. Davis, Primary Care Provider", "orderedDateTime" : "2025-02-17T15:00:00", "section" : "Scheduled", "status" : "Active" }, { "doseRouteFrequency" : "1000 mg Oral (PO) q12h (Every 12 hours), Every 12 hours", "drug" : "metFORMIN hydrochloride", "id" : "nicholas-soros-med-8", "lastGiven" : "2025-02-18T03:00:00", "notes" : "Source due: 2/18/2025 15:00 Order is 1,000 mg q12h, physician plan 1,000 mg daily, previous visit 500 mg twice daily. Clarify intended regimen.", "orderedBy" : "Pending per James E. Davis, Primary Care Provider", "orderedDateTime" : "2025-02-17T15:00:00", "section" : "Scheduled", "status" : "Held — clarification required" }, { "doseRouteFrequency" : "Sliding scale Subcutaneous (SC) ", "drug" : "Humalog insulin (lispro)", "id" : "nicholas-soros-med-9", "lastGiven" : "2025-02-18T04:00:00", "notes" : "Based on blood glucose monitoring AC & HS per sliding scale: Glucose Level 150-200 2 units 201-250 4 units 251-300 6 units 301-350 8 units > 351 Call HCP Source due: PRN Scale omits exactly 351 mg/dL: 301–350 receives 8 units, >351 calls HCP. Source home list also conflicts on timing and insulin class. Clarify scale before use; do not infer a dose for an uncovered value.", "orderedBy" : "Pending per James E. Davis, Primary Care Provider", "orderedDateTime" : "2025-02-17T15:00:00", "section" : "PRN", "status" : "Held — clarification required" } ], "notes" : [ { "id" : "nicholas-soros-allergy", "summary" : "Source allergy table contains no entries. Allergy status is not documented; an empty table does not establish no known allergies.", "type" : "Allergy documentation" }, { "id" : "nicholas-soros-family-health-history", "summary" : "Disease/Condition / Disease/Condition: Heart Disease\nFamily Member / Family Member: Father\nAge at Diagnosis / Age at Diagnosis: Unknown\nDeceased / Deceased: Yes\nDisease/Condition / Disease/Condition: Diabetes/Pre-Diabetes/Metabolic Syndrome\nFamily Member / Family Member: Father\nAge at Diagnosis / Age at Diagnosis: Unknown\nDeceased / Deceased: Yes\nDisease/Condition / Disease/Condition: Hypertension\nFamily Member / Family Member: Mother\nAge at Diagnosis / Age at Diagnosis: Unknown\nDeceased / Deceased: Yes\nDisease/Condition / Disease/Condition: High Cholesterol\nFamily Member / Family Member: Sister\nAge at Diagnosis / Age at Diagnosis: 50-59 years\nDeceased / Deceased: No", "type" : "Family Health History" }, { "id" : "nicholas-soros-patient-teaching", "summary" : "Diabetes Diet | 2/17/2025 15:00 | 2/17/2025 15:00 | Patient | Pt will maintain recommended metabolic outcomes, including glucose and A1C levels; LDL cholesterol, HDL cholesterol, and triglyceride levels; blood pressure; and body weight. | | | Reinforce Patient Teaching\nQuitting Smoking | 2/17/2025 15:00 | 2/17/2025 15:00 | Patient | | | | Reinforce Patient Teaching", "type" : "Patient Teaching" }, { "id" : "nicholas-soros-mar", "summary" : "captopril 25 mg Oral (PO) | q8h (Every 8 hours), Every 8 hours | 2/17/2025 15:00 | \ndiltiazem hydrochloride 180 mg Oral (PO) | q24h (Every 24 hours), Every 24 hours | 2/17/2025 15:00 | \nInsulins (short-acting) See protocol Subcutaneous (SC) | q4h x1 (Every 4 hours, 1 time only), Every 4 hours, 1 time only | 2/17/2025 15:00 | Sliding scale: Pre-meal or Bedtime Humalog Insulin Glucose Level 150-200 2 units 201-250 4 units 251-300 6 units 301-350 8 units > 351 Call HCP\nmetformin hydrochloride 1000 mg Oral (PO) | q12h (Every 12 hours), Every 12 hours | 2/17/2025 15:00 | ", "type" : "Home medication history" }, { "author" : "F. Morales , Registered Nurse", "dateTime" : "2025-02-18T03:00:00", "id" : "nicholas-soros-note-1", "summary" : "S: 68-year-old male with newly diagnosed type 2 DM and known hypertension. Presenting for uncontrolled BG levels and not feeling well. B: Patient has a history of hypertension and was recently diagnosed with type 2 DM. He is self-monitoring his blood glucose and reports average readings in the 200s. Current medications include captopril and diltiazem. A: Patient denies blurred vision, chest pain, shortness of breath, or abdominal pain. Vital signs are stable. Physical exam reveals normal findings except for some scattered seborrheic keratoses. Recommendation: Monitor blood glucose levels and normalize. Monitor BP Teaching", "type" : "Nursing - Shift" }, { "author" : "F. Morales , Registered Nurse", "dateTime" : "2025-02-17T16:00:00", "id" : "nicholas-soros-note-2", "summary" : "During follow up visit three months after being diagnosed with diabetes mellitus, type II, patient expressed need for further teaching regarding diet and exercise. Reviewed glucometer training, and patient demonstrated ability to take his own blood sugar. Patient verbalized rationale for glucose monitoring, and when to notify a physician, as well as blood glucose normal levels. Reviewed exercise regiment options to find a plan the patient would be open to complying with. Patient agreed to go on a thirty minute walk five times a week. Reviewed patient's diet, and referred to a dietitian at the patient's request. Patient expressed desire to lose five pounds a month until a target BMI of 23 is met.", "type" : "Source note (type not documented)" }, { "author" : "F. Morales , Registered Nurse", "dateTime" : "2025-02-17T15:00:00", "id" : "nicholas-soros-note-3", "summary" : "Mr. Nicholas Soros, a 68-year-old patient newly diagnosed with diabetes, in the clinic. He is 50 pounds overweight at 191 pounds, and his health history revealed the need for major dietary changes and an exercise program. The interdisciplinary team devised a plan to help Mr. Soros better manage his diabetes through planned weight reduction and regular exercise. Education provided on diet and exercise, and smoking cessation.", "type" : "Nursing - Admission" }, { "author" : "James E. Davis , Primary Care Provider", "dateTime" : "2025-02-17T15:00:00", "id" : "nicholas-soros-note-4", "summary" : "Subjective: 68 year old caucasian male with PMH: HTN, recently diagnosed with type 2 DM. Patient here for follow up and states he is doing fine. He denies, blurred vision, chest pain, SOB, abdominal pain. He has been self monitoring his glucose with average in \"200's\" per patient. Current medications include: captopril ,diltiazem NKDA Social History: current smoker, 1-3 drinks of alcohol/ week, no illicit drug use Objective: Vital Signs: 150/88, 98 HR, 24 RR, 92% RA, 98.9 GENERAL: Awake, alert, in no acute distress. HEENT: PERRLA. There is no jaundice, cyanosis or pallor. Funduscopic evaluation shows a flat optic disk with normal retinas. NECK: Supple. Negative JVD. Negative carotid bruit. No thyroid enlargement. LUNGS: Clear to auscultation bilaterally. HEART: RRR. No murmurs. ABDOMEN: Soft, positive bowel sounds. No hepatosplenomegaly. EXTREMITIES: Negative clubbing, cyanosis or edema. Good range of motion. LYMPHATICS: Negative lymphadenopathy in the cervical, axillary or inguinal areas. SPINE: Normal curvature and normal range of motion. SKIN: Some scattered seborrheic keratoses, but there are no signs of skin cancer or melanomas. NEUROLOGIC: A&OX3, speech clear Lab Data: See diagnostics. Assessment and Plan: 1. Type 2 DM. Comprehensive eye examination by an ophthalmologist or optometrist recommended. start metformin 1000 mg po qd 2. Hypertension. continue home meds, smoking cessation", "type" : "Physician Notes" }, { "id" : "nicholas-soros-mar-history-9", "summary" : "2/18/2025 07:00 F. Morales, Registered Nurse BP 142/89 Yes", "type" : "Medication administration history — captopril" }, { "id" : "nicholas-soros-mar-history-10", "summary" : "2/17/2025 15:00 F. Morales, Registered Nurse HR 88 Yes", "type" : "Medication administration history — dilTIAZem hydrochloride ER" }, { "id" : "nicholas-soros-mar-history-11", "summary" : "2/18/2025 03:00 F. Morales, Registered Nurse Yes", "type" : "Medication administration history — metFORMIN hydrochloride" }, { "id" : "nicholas-soros-mar-history-12", "summary" : "2/18/2025 04:00 F. Morales, Registered Nurse Blood glucose 323 covered with 8 units Yes", "type" : "Medication administration history — Humalog insulin (lispro)" }, { "id" : "nicholas-soros-section-immunizations", "summary" : " Birth to Adult Immunizations: Influenza, Td/Tdap, MMR 1, MMR 2, Rubella\n Titers: N/A\n2/17/2025 15:00 | Birth to Adult Immunizations: Influenza, Td/Tdap, MMR 1, MMR 2, Rubella Titers: N/A", "type" : "Immunizations" }, { "id" : "nicholas-soros-section-previous-visits", "summary" : "Diabetes mellitus, type 2 | Pothole Memorial | Patient diagnosed with Diabetes mellitus, type 2. Education provided regarding exercise, diet, and blood glucose control. Patient verbalized understanding and agreed to adhere to therapeutic recommendations.Written diet and medication instructions given with prescription for metformin 500mg PO BID | 1/18/2025 15:00 | 1/18/2025 15:00\nHypertension | Pothole Memorial | Patient was admitted with acute Hypertension and was newly diagnosed with DM type II | 12/19/2024 15:00 | 12/22/2024 15:00", "type" : "Previous Visits" }, { "id" : "nicholas-soros-section-current-care-providers", "summary" : "F. Morales | Registered Nurse\nJames E. Davis | Primary Care Provider\nS. Wolf | Dietary/Nutrition", "type" : "Current Care Providers" }, { "id" : "nicholas-soros-clarification-16", "summary" : "Skills Lab simulation ID SL-008. Original DocuCare MRN: 897645321. Original fixed simulation dates and stated scenario ages are retained; DOB-derived age may disagree. Source records are preserved for faculty review.", "type" : "Chart clarification" }, { "id" : "nicholas-soros-clarification-17", "summary" : "Order is 1,000 mg q12h, physician plan 1,000 mg daily, previous visit 500 mg twice daily. Clarify intended regimen.", "type" : "Chart clarification" }, { "id" : "nicholas-soros-clarification-18", "summary" : "Scale omits exactly 351 mg/dL: 301–350 receives 8 units, >351 calls HCP. Source home list also conflicts on timing and insulin class. Clarify scale before use; do not infer a dose for an uncovered value.", "type" : "Chart clarification" }, { "id" : "nicholas-soros-clarification-19", "summary" : "Insulin administration note says glucose 323 was covered with 8 units; historical event retained despite unresolved current scale.", "type" : "Chart clarification" }, { "id" : "nicholas-soros-clarification-20", "summary" : "Three-month follow-up narrative is timestamped one hour after newly diagnosed admission; timeline needs review.", "type" : "Chart clarification" } ], "orders" : [ { "author" : "Pending per James E. Davis, Primary Care Provider", "category" : "Not specified", "dateTime" : "2025-02-17T15:00:00", "id" : "nicholas-soros-order-1", "orderText" : "Blood glucose monitoring; Routine; 15 minutes prior to meals and at bedtime. Source due: 2/17/2025 15:00", "status" : "Active" }, { "author" : "Pending per James E. Davis, Primary Care Provider", "category" : "Dietary", "dateTime" : "2025-02-17T15:00:00", "id" : "nicholas-soros-order-2", "orderText" : "1800 calorie ADA diet with 2 gm sodium; Routine; Source due: 2/17/2025 15:00", "status" : "Active" }, { "author" : "Pending per James E. Davis, Primary Care Provider", "category" : "Nursing", "dateTime" : "2025-02-17T15:00:00", "id" : "nicholas-soros-order-3", "orderText" : "CAD Risk Factor Assessment and Teaching; cont.; Routine; Source due: 2/17/2025 15:00", "status" : "Active" }, { "author" : "Pending per James E. Davis, Primary Care Provider", "category" : "Nursing", "dateTime" : "2025-02-17T15:00:00", "id" : "nicholas-soros-order-4", "orderText" : "Diabetic Teaching and Lifestyle Changes; cont.; Routine; Source due: 2/17/2025 15:00", "status" : "Active" }, { "author" : "Pending per James E. Davis, Primary Care Provider", "category" : "Nursing: Monitoring", "dateTime" : "2025-02-17T15:00:00", "id" : "nicholas-soros-order-5", "orderText" : "Relaxation and stress management techniques; cont.; Routine; Source due: 2/17/2025 15:00", "status" : "Active" }, { "author" : "Pending per James E. Davis, Primary Care Provider", "category" : "Pharmacy", "dateTime" : "2025-02-17T15:00:00", "id" : "nicholas-soros-order-6", "orderText" : "captopril; 25 mg Oral (PO); q8h (Every 8 hours), Every 8 hours; Scheduled; Hold for SBP < 100 Source due: 2/18/2025 15:00", "status" : "Active" }, { "author" : "Pending per James E. Davis, Primary Care Provider", "category" : "Pharmacy", "dateTime" : "2025-02-17T15:00:00", "id" : "nicholas-soros-order-7", "orderText" : "dilTIAZem hydrochloride ER; 180 mg Oral (PO); q24h (Every 24 hours), Every 24 hours; Scheduled; Hold for HR < 60 Source due: 2/18/2025 15:00", "status" : "Active" }, { "author" : "Pending per James E. Davis, Primary Care Provider", "category" : "Pharmacy", "dateTime" : "2025-02-17T15:00:00", "id" : "nicholas-soros-order-8", "orderText" : "metFORMIN hydrochloride; 1000 mg Oral (PO); q12h (Every 12 hours), Every 12 hours; Scheduled; Source due: 2/18/2025 15:00 Order is 1,000 mg q12h, physician plan 1,000 mg daily, previous visit 500 mg twice daily. Clarify intended regimen.", "status" : "Held — clarification required" }, { "author" : "Pending per James E. Davis, Primary Care Provider", "category" : "Pharmacy", "dateTime" : "2025-02-17T15:00:00", "id" : "nicholas-soros-order-9", "orderText" : "Humalog insulin (lispro); Sliding scale Subcutaneous (SC); PRN; Based on blood glucose monitoring AC & HS per sliding scale: Glucose Level 150-200 2 units 201-250 4 units 251-300 6 units 301-350 8 units > 351 Call HCP Source due: PRN Scale omits exactly 351 mg/dL: 301–350 receives 8 units, >351 calls HCP. Source home list also conflicts on timing and insulin class. Clarify scale before use; do not infer a dose for an uncovered value.", "status" : "Held — clarification required" } ], "overview" : { "height" : "67 in / 170.2 cm", "isolationIndicator" : "Standard", "religion" : "Christian", "weightKg" : 88.9 }, "vitals" : [ { "bloodPressure" : "150/88", "dateTime" : "2025-02-17T15:00:00", "heartRate" : 98, "id" : "nicholas-soros-vital-1", "oxygenDevice" : "Room Air", "respiratoryRate" : 24, "spo2" : "92", "temperature" : "98.9 °F (37 °C), 37 °C Tympanic" }, { "bloodPressure" : "148/90", "dateTime" : "2025-02-18T15:00:00", "heartRate" : 92, "id" : "nicholas-soros-vital-2", "oxygenDevice" : "Room Air", "respiratoryRate" : 16, "spo2" : "96", "temperature" : "98.2 °F (37 °C), 37 °C Tympanic" } ] }, "patient" : { "admitDateTime" : "2025-02-17T15:00:00", "admittingDiagnosis" : "Diabetes mellitus, type 2", "allergies" : [ ], "attending" : "Not documented", "chartDisplayName" : "Soros, Nicholas", "codeStatus" : "Full Code", "dob" : "1/12/1958", "history" : { "chiefComplaint" : "Nicholas is a 68-year-old patient newly diagnosed with diabetes. His initial assessment revealed that he was about 50 pounds overweight due to poor diet and lack of exercise. A plan was developed to help Mr. Soros better manage his diabetes through planned weight reduction and regular exercise. Return today for a follow up visit.", "pastMedicalHistory" : [ "General Medical History / Disease/Condition / : Hypertension, long-term care", "General Medical History / Disease/Condition / : Diabetes mellitus (type 2), long-term care", "General Medical History / Disease/Condition / : Hyperlipidemia", "General Medical History / Disease/Condition / : Major depression", "Transfusion History / Previous Blood Transfusion?: No", "Transfusion History / Does Patient Know His/Her Blood Type?: No", "Pain History / History of Chronic Pain?: No" ], "pastSurgicalHistory" : [ "Previous Surgical Procedures / Surgical Procedure: Hernia Repair", "Previous Surgical Procedures / Year / Year: 2010", "Previous Surgical Procedures / Surgical Procedure: Bilateral Total Knee Replacement", "Previous Surgical Procedures / Year / Year: 2009" ], "socialHistory" : [ "Age: 68 Years", "Home Situation / Patient Living Situation: Home", "Home Situation / Lives With: Alone", "Education / Highest Grade Completed: High school", "Education / Able to Read?: Yes", "Education / Able to Write?: Yes", "Nicotine Use / Packs per Day: 1", "Nicotine Use / # of Years: 50", "Nicotine Use / : Medium", "Nicotine Use / # of Times per Day: 20", "Nicotine Use / # of Years: 50", "Nicotine Use / Desire to Quit: Medium", "Nicotine Use / Tobacco cessation counseling given?: Yes", "Nicotine Use / Is patient exposed to second-hand smoke?: No", "Alcohol Use / Alcohol Status: Current user", "Alcohol Use / Number of Drinks per Week: 1-3", "Alcohol Use / Has Patient Ever Been Diagnosed With or Treated for Alcohol Abuse?: No", "Drug Use / Illicit Drug Use Status: Nonuser", "Drug Use / Has Patient Ever Been Diagnosed With or Treated for Drug Abuse?: No", "Violence Screening / Does Patient Feel Safe at Home?: Yes", "Violence Screening / Does Patient Feel Safe in Current Environment (Work, School, etc.)?: Yes", "Violence Screening / Has Anyone Ever Hurt Patient Emotionally, Physically, or Sexually?: No", "Nutritional Screening / Recent Weight Lost Without Trying?: No", "Nutritional Screening / Decreased Appetite?: No", "Nutritional Screening / Does patient have diabetes?: Yes, Type 2", "Nutritional Screening / Diabetes/Nutrition consult offered?: Yes", "Nutritional Screening / Home Diet Considerations, Other value: 1800 cal ADA, 2 gm sodium diet", "Nutritional Screening / Stool Frequency: 1/day", "Nutritional Screening / Last Bowel Movement Date: 02/17/2025", "Nutritional Screening / Notes: Patient admits to being non-compliant with newly prescribed diet, exercise and smoking cessation regimen.", "Exercise Screening / Exercise Frequency: Rarely", "Exercise Screening / Duration of Exercise: 15 mins", "Exercise Screening / Intensity: Mild", "Exercise Screening / Type(s): walking around block in nerighborhood", "Exercise Screening / Was Patient Counseled on Exercise?: Yes", "Mental Health Screening / Does Patient Have Frequent Feelings of Hopelessness/Helplessness?: No", "Mental Health Screening / Does Patient Have Thoughts of Harming Self?: No", "Mental Health Screening / Notes: Patient states he has a history of depression. Has been taking anti-depressive medication and states he is feeling \"ok\".", "Sexual Activity / Sexually Active?: No", "Sexual Activity / Ever Treated for a Sexually Transmitted Disease?: Unknown", "Other Safety Measures / Seatbelt Use?: Sometimes", "Other Safety Measures / Working Smoke Detectors in the Home?: Unknown", "Other Safety Measures / Working Carbon Monoxide Detectors in the Home?: Yes", "Other Safety Measures / Working Fire Extinguisher in the Home?: Yes" ] }, "mrn" : "SL-008", "sex" : "Male", "simulatedFullName" : "Nicholas Soros", "unit" : "Health Clinic — Room 807 — Bed 1" }, "setting" : "Health Clinic — Room 807 — Bed 1", "snapshots" : [ { "activityIds" : [ ], "id" : "nicholas-soros-current", "notes" : "Captured dated chart history; source relative dates anchored to chart opening. Progressive release not recreated.", "scenarioTime" : "2025-02-18T15:00:00", "sourcePath" : "DocuCare instructor chart: Nicholas Soros", "title" : "Captured chart" } ], "subtitle" : "Learning Lab practice record", "tags" : [ "Skills Lab", "DocuCare migration", "Learning Lab" ], "title" : "Nicholas Soros" }, "packageId" : "docucare-skills lab-nicholas-soros-review-v1", "privacy" : { "containsRealPHI" : false, "defaultStorage" : "local-document-package", "networkRequired" : false, "simulatedOnly" : true, "warning" : "Simulated education only. Not for clinical care. Review conflicting, held or undocumented findings with lab faculty." }, "schemaVersion" : "2.0", "source" : { "system" : "DocuCare Enhanced instructor chart capture" }, "workingNames" : [ "ChartSlate" ] } }, "id" : "skills lab-nicholas-soros", "instructions" : "Choose this patient for simulated chart-review practice. Check the name, date of birth and simulated MRN; review notes, assessments, vital signs, orders and medications. Identify missing or conflicting information and discuss it with lab faculty. Held or discontinued medications are not active administration tasks.", "title" : "Nicholas Soros" }, { "envelope" : { "appName" : "ChartSlate", "audience" : "student", "createdAt" : "2026-09-25T19:44:22.331008+00:00", "exportVersion" : "1", "kind" : "casePackage", "package" : { "case" : { "activities" : [ ], "id" : "docucare-skills lab-rita-smith", "learningLevel" : "Skills Lab", "panels" : { "assessments" : [ ], "labs" : [ ], "medications" : [ ], "notes" : [ { "id" : "rita-smith-allergy", "summary" : "Source allergy table contains no entries. Allergy status is not documented; an empty table does not establish no known allergies.", "type" : "Allergy documentation" }, { "author" : "Lina RN , Registered Nurse", "dateTime" : "2025-02-18T04:00:00", "id" : "rita-smith-note-1", "summary" : "S 76 y/o female admitted for pneumonia B History of ischemic stroke, diabetes, hypertension, and CAD. A V. S. stable- 98.4, 84, 22, 132/84 O2 sat 93% on 2L NC pain 0/10 on objective pain scale. A & O x 0 Saline lock in right forearm. Heart regular rate and rhythm. Peripheral pulses strong bilaterally. Cap refill <3 seconds. Lungs course crackles bilaterally with a weak cough R Patient is requiring oral and nasopharyngeal suctioning every 3-4 hours and it has been 4 hours.", "type" : "Nursing - Shift" }, { "id" : "rita-smith-section-current-care-providers", "summary" : "Chan, T. | Admitting Physician\nLina RN | Registered Nurse", "type" : "Current Care Providers" }, { "id" : "rita-smith-clarification-4", "summary" : "Skills Lab simulation ID SL-009. Original DocuCare MRN: 12345. Original fixed simulation dates and stated scenario ages are retained; DOB-derived age may disagree. Source records are preserved for faculty review.", "type" : "Chart clarification" }, { "id" : "rita-smith-clarification-5", "summary" : "Narrative calls for oral/nasopharyngeal suctioning but only oxygen appears in structured orders. No new suction order fabricated.", "type" : "Chart clarification" } ], "orders" : [ { "author" : "Pending per Chan, T., Admitting Physician", "category" : "Nursing: Monitoring", "dateTime" : "2025-02-18T04:00:00", "id" : "rita-smith-order-1", "orderText" : "Oxygen administration; cont.; Routine; Keep saturation > 92 % Source due: 2/18/2025 04:00", "status" : "Active" } ], "overview" : { "height" : "", "isolationIndicator" : "Standard", "religion" : "" }, "vitals" : [ { "bloodPressure" : "132/84", "dateTime" : "2025-02-18T04:00:00", "id" : "rita-smith-vital-1", "oxygenDevice" : "Nasal Cannula", "respiratoryRate" : 22, "spo2" : "93", "temperature" : "98 °F (37 °C), 37 °C Oral" } ] }, "patient" : { "admitDateTime" : "2025-02-18T04:00:00", "admittingDiagnosis" : "Pneumonia", "allergies" : [ ], "attending" : "Chan, T., Admitting Physician", "chartDisplayName" : "Smith, Rita", "codeStatus" : "", "dob" : "7/27/1950", "history" : { "chiefComplaint" : "76-year-old female admitted for pneumonia with a history of ischemic stroke, diabetes, hypertension, and CAD.", "pastMedicalHistory" : [ ], "pastSurgicalHistory" : [ ], "socialHistory" : [ "Age: 76 Years" ] }, "mrn" : "SL-009", "sex" : "Female", "simulatedFullName" : "Rita Smith", "unit" : "RCC Hospital" }, "setting" : "RCC Hospital", "snapshots" : [ { "activityIds" : [ ], "id" : "rita-smith-current", "notes" : "Captured dated chart history; source relative dates anchored to chart opening. Progressive release not recreated.", "scenarioTime" : "2025-02-18T04:00:00", "sourcePath" : "DocuCare instructor chart: Rita Smith", "title" : "Captured chart" } ], "subtitle" : "Learning Lab practice record", "tags" : [ "Skills Lab", "DocuCare migration", "Learning Lab" ], "title" : "Rita Smith" }, "packageId" : "docucare-skills lab-rita-smith-review-v1", "privacy" : { "containsRealPHI" : false, "defaultStorage" : "local-document-package", "networkRequired" : false, "simulatedOnly" : true, "warning" : "Simulated education only. Not for clinical care. Review conflicting, held or undocumented findings with lab faculty." }, "schemaVersion" : "2.0", "source" : { "system" : "DocuCare Enhanced instructor chart capture" }, "workingNames" : [ "ChartSlate" ] } }, "id" : "skills lab-rita-smith", "instructions" : "Choose this patient for simulated chart-review practice. Check the name, date of birth and simulated MRN; review notes, assessments, vital signs, orders and medications. Identify missing or conflicting information and discuss it with lab faculty. Held or discontinued medications are not active administration tasks.", "title" : "Rita Smith" }, { "envelope" : { "appName" : "ChartSlate", "audience" : "student", "createdAt" : "2026-09-25T19:44:22.331008+00:00", "exportVersion" : "1", "kind" : "casePackage", "package" : { "case" : { "activities" : [ ], "id" : "docucare-skills lab-greg-wilson", "learningLevel" : "Skills Lab", "panels" : { "assessments" : [ { "dateTime" : "2025-02-18T02:00:00", "id" : "greg-wilson-assessment-1", "label" : "HEENT", "summary" : ": HEENT\nAdditional Notes / Additional Notes: Gag reflect intact Able to swallow independently" }, { "dateTime" : "2025-02-18T14:00:00", "id" : "greg-wilson-assessment-2", "label" : "Clean/Dry/Intact Skin Assessment", "summary" : "Notes: Turgor tented Dry flaky skin" } ], "intakeOutput" : { "documentedIntakeTotalMl" : 0, "documentedNetMl" : 0, "documentedOutputTotalMl" : 0, "intakeEntries" : [ { "amountMl" : 0, "id" : "greg-wilson-intake-1", "time" : "2025-02-17T14:00:00", "type" : "Oral Intake" } ], "outputEntries" : [ ] }, "labs" : [ ], "medications" : [ { "doseRouteFrequency" : "20 mg Nasogastric (NG) q24h (Every 24 hours), Every 24 hours", "drug" : "lisinopril", "id" : "greg-wilson-med-4", "lastGiven" : "2025-02-17T14:00:00", "nextDue" : "2025-02-18T14:00:00", "notes" : "Source due: 2/18/2025 14:00", "orderedBy" : "Pending per Ban, Benjamin , Admitting Physician", "orderedDateTime" : "2025-02-17T14:00:00", "section" : "Scheduled", "status" : "Active" }, { "doseRouteFrequency" : "81 mg Nasogastric (NG) q24h (Every 24 hours), Every 24 hours", "drug" : "aspirin", "id" : "greg-wilson-med-5", "lastGiven" : "2025-02-17T14:00:00", "nextDue" : "2025-02-18T14:00:00", "notes" : "Source due: 2/18/2025 14:00", "orderedBy" : "Pending per Ban, Benjamin , Admitting Physician", "orderedDateTime" : "2025-02-17T14:00:00", "section" : "Scheduled", "status" : "Active" }, { "doseRouteFrequency" : "20 mg Nasogastric (NG) q12h (Every 12 hours), Every 12 hours", "drug" : "famotidine", "id" : "greg-wilson-med-6", "lastGiven" : "2025-02-18T02:00:00", "nextDue" : "2025-02-18T14:00:00", "notes" : "Source due: 2/18/2025 14:00", "orderedBy" : "Pending per Ban, Benjamin , Admitting Physician", "orderedDateTime" : "2025-02-17T14:00:00", "section" : "Scheduled", "status" : "Active" }, { "doseRouteFrequency" : "4 mg Intravenous (IV) q6h (Every 6 hours), Every 6 hours", "drug" : "ondansetron", "id" : "greg-wilson-med-7", "lastGiven" : "2025-02-18T07:00:00", "notes" : "PRN n/v Source due: PRN", "orderedBy" : "Pending per Ban, Benjamin , Admitting Physician", "orderedDateTime" : "2025-02-17T14:00:00", "section" : "PRN", "status" : "Active" } ], "notes" : [ { "id" : "greg-wilson-allergy", "summary" : "NKA | Medication | | | Stefanie | 2/17/2025 14:00", "type" : "Allergy documentation" }, { "author" : "Jasper, Stefanie , Registered Nurse", "dateTime" : "2025-02-18T14:00:00", "id" : "greg-wilson-note-1", "summary" : "S- Greg Wilson, age 64, was recently admitted to the hospital for anorexia, fatigue, and is malnourished. B- Client has a history of being treated for pancreatic cancer and has recently completed six months of chemotherapy. He is unable to hold down solid foods for the past 6 weeks and continues to experience episodes of nausea and vomiting. A- Vital signs – 97.8, 82, 18, 123/84 O2 sat 98% on RA 0/10 pain ENT- gag reflex intact, able to swallow on his own, dry mucous membranes Skin: turgor tented, dry flaky skin Heart- RRR, peripheral pulses present bilaterally Lung- clear bilaterally, no cough Musculoskeletal: Moves all extremities equally, weakness in lower extremities. BMI: 18 R- Insert NG tube. Once placement is verified via Chest Xray, begin continuous feeding Glucerna at 30 ml/hr. All meds to go through NGT.", "type" : "Nursing - Shift" }, { "id" : "greg-wilson-mar-history-3", "summary" : "2/17/2025 14:00 Jasper, Stefanie, Registered Nurse Yes", "type" : "Medication administration history — lisinopril" }, { "id" : "greg-wilson-mar-history-4", "summary" : "2/17/2025 14:00 Jasper, Stefanie, Registered Nurse Yes", "type" : "Medication administration history — aspirin" }, { "id" : "greg-wilson-mar-history-5", "summary" : "2/18/2025 02:00 Jasper, Stefanie, Registered Nurse Yes", "type" : "Medication administration history — famotidine" }, { "id" : "greg-wilson-mar-history-6", "summary" : "2/18/2025 07:00 Jasper, Stefanie, Registered Nurse Yes", "type" : "Medication administration history — ondansetron" }, { "id" : "greg-wilson-section-immunizations", "summary" : " Birth to Adult Immunizations: Influenza, Td/Tdap, Pneumococcal\n Titers: N/A\n2/17/2025 14:00 | Birth to Adult Immunizations: Influenza, Td/Tdap, Pneumococcal Titers: N/A", "type" : "Immunizations" }, { "id" : "greg-wilson-section-current-care-providers", "summary" : "Ban, Benjamin | Admitting Physician\nJasper, Stefanie | Registered Nurse", "type" : "Current Care Providers" }, { "id" : "greg-wilson-clarification-9", "summary" : "Skills Lab simulation ID SL-010. Original DocuCare MRN: 123456. Original fixed simulation dates and stated scenario ages are retained; DOB-derived age may disagree. Source records are preserved for faculty review.", "type" : "Chart clarification" }, { "id" : "greg-wilson-clarification-10", "summary" : "Feeding order starts at 10 mL/hr and advances by 10 every 12 hours to 30; note says begin at 30. Preserve titration order and clarify narrative. Flush instruction Q4 lacks an explicit time unit.", "type" : "Chart clarification" }, { "id" : "greg-wilson-clarification-11", "summary" : "Nursing recommendation says all medications via NG, while ondansetron order is IV. No route conversion inferred.", "type" : "Chart clarification" }, { "id" : "greg-wilson-clarification-12", "summary" : "Tube placement confirmation is required by source note, but no confirmation result was supplied. No feeding clearance fabricated.", "type" : "Chart clarification" } ], "orders" : [ { "author" : "Pending per Stefanie, Registered Nurse", "category" : "Dietary", "dateTime" : "2025-02-18T14:00:00", "id" : "greg-wilson-order-1", "orderText" : "Glucerna; cont.; Routine; Start at 10 ml/hr Then increase by 10 ml/hr Q12h Until goal of 30ml/hr is reached. Check residuals Q4h. Flush with 30 ml of sterile water Q4 Source due: 2/18/2025 14:00", "status" : "Active" }, { "author" : "Pending per Ban, Benjamin , Admitting Physician", "category" : "Dietary", "dateTime" : "2025-02-17T14:00:00", "id" : "greg-wilson-order-2", "orderText" : "NPO, all meds via NGT; cont.; Routine; Source due: 2/17/2025 14:00", "status" : "Active" }, { "author" : "Pending per Ban, Benjamin MD, Admitting Physician", "category" : "Nursing", "dateTime" : "2025-02-18T14:00:00", "id" : "greg-wilson-order-3", "orderText" : "Nasogastric tube; x1 (1 time only), 1 time only; Stat; Source due: 2/18/2025 14:00", "status" : "Active" }, { "author" : "Pending per Ban, Benjamin , Admitting Physician", "category" : "Pharmacy", "dateTime" : "2025-02-17T14:00:00", "id" : "greg-wilson-order-4", "orderText" : "lisinopril; 20 mg Nasogastric (NG); q24h (Every 24 hours), Every 24 hours; Scheduled; Source due: 2/18/2025 14:00", "status" : "Active" }, { "author" : "Pending per Ban, Benjamin , Admitting Physician", "category" : "Pharmacy", "dateTime" : "2025-02-17T14:00:00", "id" : "greg-wilson-order-5", "orderText" : "aspirin; 81 mg Nasogastric (NG); q24h (Every 24 hours), Every 24 hours; Scheduled; Source due: 2/18/2025 14:00", "status" : "Active" }, { "author" : "Pending per Ban, Benjamin , Admitting Physician", "category" : "Pharmacy", "dateTime" : "2025-02-17T14:00:00", "id" : "greg-wilson-order-6", "orderText" : "famotidine; 20 mg Nasogastric (NG); q12h (Every 12 hours), Every 12 hours; Scheduled; Source due: 2/18/2025 14:00", "status" : "Active" }, { "author" : "Pending per Ban, Benjamin , Admitting Physician", "category" : "Pharmacy", "dateTime" : "2025-02-17T14:00:00", "id" : "greg-wilson-order-7", "orderText" : "ondansetron; 4 mg Intravenous (IV); q6h (Every 6 hours), Every 6 hours; PRN; PRN n/v Source due: PRN", "status" : "Active" } ], "overview" : { "height" : "", "isolationIndicator" : "Standard", "religion" : "" }, "vitals" : [ { "bloodPressure" : "144/84", "dateTime" : "2025-02-18T13:00:00", "heartRate" : 82, "id" : "greg-wilson-vital-1", "oxygenDevice" : "Room Air", "respiratoryRate" : 18, "spo2" : "98", "temperature" : "97.2 °F (36 °C), 36 °C Oral" } ] }, "patient" : { "admitDateTime" : "2025-02-17T14:00:00", "admittingDiagnosis" : "Malnutrition", "allergies" : [ ], "attending" : "Ban, Benjamin , Admitting Physician", "chartDisplayName" : "Wilson, Greg", "codeStatus" : "", "dob" : "7/1/1962", "history" : { "chiefComplaint" : "64 y.o. male admitted for anorexia, fatigue and malnourished. He has a history of pancreatic cancer and completed 6 months of chemotherapy. The patient has had nausea and vomiting x 6 weeks.", "pastMedicalHistory" : [ "General Medical History / Disease/Condition / : Pancreatic Cancer" ], "pastSurgicalHistory" : [ ], "socialHistory" : [ "Age: 64 Years" ] }, "mrn" : "SL-010", "sex" : "Male", "simulatedFullName" : "Greg Wilson", "unit" : "RCC Hospital" }, "setting" : "RCC Hospital", "snapshots" : [ { "activityIds" : [ ], "id" : "greg-wilson-current", "notes" : "Captured dated chart history; source relative dates anchored to chart opening. Progressive release not recreated.", "scenarioTime" : "2025-02-18T14:00:00", "sourcePath" : "DocuCare instructor chart: Greg Wilson", "title" : "Captured chart" } ], "subtitle" : "Learning Lab practice record", "tags" : [ "Skills Lab", "DocuCare migration", "Learning Lab" ], "title" : "Greg Wilson" }, "packageId" : "docucare-skills lab-greg-wilson-review-v1", "privacy" : { "containsRealPHI" : false, "defaultStorage" : "local-document-package", "networkRequired" : false, "simulatedOnly" : true, "warning" : "Simulated education only. Not for clinical care. Review conflicting, held or undocumented findings with lab faculty." }, "schemaVersion" : "2.0", "source" : { "system" : "DocuCare Enhanced instructor chart capture" }, "workingNames" : [ "ChartSlate" ] } }, "id" : "skills lab-greg-wilson", "instructions" : "Choose this patient for simulated chart-review practice. Check the name, date of birth and simulated MRN; review notes, assessments, vital signs, orders and medications. Identify missing or conflicting information and discuss it with lab faculty. Held or discontinued medications are not active administration tasks.", "title" : "Greg Wilson" }, { "envelope" : { "appName" : "ChartSlate", "audience" : "student", "createdAt" : "2026-09-25T19:44:22.331008+00:00", "exportVersion" : "1", "kind" : "casePackage", "package" : { "case" : { "activities" : [ ], "id" : "docucare-skills lab-david-gordon", "learningLevel" : "Skills Lab", "panels" : { "assessments" : [ { "dateTime" : "2025-02-18T16:00:00", "id" : "david-gordon-assessment-1", "label" : "Neuro", "summary" : ": Neuro" }, { "dateTime" : "2025-02-18T16:00:00", "id" : "david-gordon-assessment-2", "label" : "Cardio", "summary" : ": Cardio" }, { "dateTime" : "2025-02-18T16:00:00", "id" : "david-gordon-assessment-3", "label" : "GI", "summary" : ": GI\nLast Bowel Movement / Last Bowel Movement Date: 02/18/2025\nLast Bowel Movement / Last Bowel Movement Time: 16:00" }, { "dateTime" : "2025-02-18T16:00:00", "id" : "david-gordon-assessment-4", "label" : "Respiratory", "summary" : ": Respiratory" }, { "dateTime" : "2025-02-18T16:00:00", "id" : "david-gordon-assessment-5", "label" : "Musculoskeletal", "summary" : ": Musculoskeletal\nAdditional Notes / Additional Notes: C-Collar in place, no tenderness to cervical palpation. Right wrist with external fixator intact. Pin insertion sites without swelling, redness or drainage. Good CSM distally. Right femur in straight skeletal alignment. Skeletal traction pins intact. Insertion sites without swelling, redness or drainage. Good CMS distally." } ], "labs" : [ ], "medications" : [ { "doseRouteFrequency" : "0.5 mg Intravenous (IV) q4h (Every 4 hours), Every 4 hours", "drug" : "HYDROmorphone hydrochloride", "id" : "david-gordon-med-1", "notes" : "7-10 Severe Pain Source due: PRN", "orderedBy" : "Pending per Jane MD, Admitting Physician", "orderedDateTime" : "2025-02-18T16:00:00", "section" : "PRN", "status" : "Active" } ], "notes" : [ { "id" : "david-gordon-allergy", "summary" : "Source allergy table contains no entries. Allergy status is not documented; an empty table does not establish no known allergies.", "type" : "Allergy documentation" }, { "author" : "Douglas , Registered Nurse", "dateTime" : "2025-02-18T16:00:00", "id" : "david-gordon-note-1", "summary" : "S 27 y/o male in off-road motocross motorcycle accident sustained closed fracture of right femur. In 15 lbs of skeletal traction. Also, right open fracture of wrist with external fixator. B Was out in Glamis dunes when he went over a high hill and landed wrong fracturing right femur and right wrist. Had full motocross gear and full helmet. Took Mercy Air rescue to find him and transport to Level 1 Trauma Center, stabilized and went to OR. No LOC. No neuro deficits. A A&OX4. Remembers the accident. Skin appropriate for ethnicity, warm and dry. T 98.8, P 92, R 16, BP 112/72, Pulse ox 96% RA. Pain 7/10 scale. Neck in cervical collar, no tenderness to cervical palpation. Lungs CTAB. Heart S1 S2 no murmurs or irregular rhythm. Abd. soft, non-tender w/good bowel sounds all quads. Right wrist with external fixator intact. Pin insertion sites without swelling, redness or drainage. Good CSM distally. Right femur in straight skeletal alignment. Skeletal traction pins intact. Insertion sites without swelling, redness or drainage. Good CMS distally. R Needs pin care to wrist external fixator site per shift. Medicate prior to doing pin care.", "type" : "Nursing - Shift" }, { "id" : "david-gordon-section-current-care-providers", "summary" : "Douglas | Registered Nurse\nJane MD | Admitting Physician\nJanice | Registered Nurse", "type" : "Current Care Providers" }, { "id" : "david-gordon-clarification-4", "summary" : "Skills Lab simulation ID SL-011. Original DocuCare MRN: 581321. Original fixed simulation dates and stated scenario ages are retained; DOB-derived age may disagree. Source records are preserved for faculty review.", "type" : "Chart clarification" }, { "id" : "david-gordon-clarification-5", "summary" : "Narrative calls for pin-site care every shift but no structured pin-care order exists; no new order fabricated.", "type" : "Chart clarification" } ], "orders" : [ { "author" : "Pending per Jane MD, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2025-02-18T16:00:00", "id" : "david-gordon-order-1", "orderText" : "HYDROmorphone hydrochloride; 0.5 mg Intravenous (IV); q4h (Every 4 hours), Every 4 hours; PRN; 7-10 Severe Pain Source due: PRN", "status" : "Active" } ], "overview" : { "height" : "", "isolationIndicator" : "Standard", "religion" : "" }, "vitals" : [ { "bloodPressure" : "112/72", "dateTime" : "2025-02-18T16:00:00", "heartRate" : 90, "id" : "david-gordon-vital-1", "oxygenDevice" : "Room Air", "respiratoryRate" : 16, "spo2" : "92", "temperature" : "98.2 °F (37 °C), 37 °C Oral" } ] }, "patient" : { "admitDateTime" : "2025-02-18T16:00:00", "admittingDiagnosis" : "Right femur and right wrist fractures after motorcycle accident", "allergies" : [ ], "attending" : "Jane MD, Admitting Physician", "chartDisplayName" : "Gordon, David", "codeStatus" : "", "dob" : "7/22/1999", "history" : { "chiefComplaint" : "27 y/o male brought in by Mercy Air rescue in with prolonged location, unable to find the patient. The patient fell off- road motocross motorcycle and sustained a closed fracture of right femur and right open fracture of wrist. The patient was found down in Glamis dunes. Per family friend he went over a high hill and landed wrong fracturing right femur and right wrist. The patient is in c-spine precautions, he is stabilized and sent to OR. No LOC. No neuro deficits.", "pastMedicalHistory" : [ ], "pastSurgicalHistory" : [ ], "socialHistory" : [ "Age: 27 Years" ] }, "mrn" : "SL-011", "sex" : "Male", "simulatedFullName" : "David Gordon", "unit" : "RCC Hospital" }, "setting" : "RCC Hospital", "snapshots" : [ { "activityIds" : [ ], "id" : "david-gordon-current", "notes" : "Captured dated chart history; source relative dates anchored to chart opening. Progressive release not recreated.", "scenarioTime" : "2025-02-18T16:00:00", "sourcePath" : "DocuCare instructor chart: David Gordon", "title" : "Captured chart" } ], "subtitle" : "Learning Lab practice record", "tags" : [ "Skills Lab", "DocuCare migration", "Learning Lab" ], "title" : "David Gordon" }, "packageId" : "docucare-skills lab-david-gordon-review-v1", "privacy" : { "containsRealPHI" : false, "defaultStorage" : "local-document-package", "networkRequired" : false, "simulatedOnly" : true, "warning" : "Simulated education only. Not for clinical care. Review conflicting, held or undocumented findings with lab faculty." }, "schemaVersion" : "2.0", "source" : { "system" : "DocuCare Enhanced instructor chart capture" }, "workingNames" : [ "ChartSlate" ] } }, "id" : "skills lab-david-gordon", "instructions" : "Choose this patient for simulated chart-review practice. Check the name, date of birth and simulated MRN; review notes, assessments, vital signs, orders and medications. Identify missing or conflicting information and discuss it with lab faculty. Held or discontinued medications are not active administration tasks.", "title" : "David Gordon" }, { "envelope" : { "appName" : "ChartSlate", "audience" : "student", "createdAt" : "2026-09-25T19:44:22.331008+00:00", "exportVersion" : "1", "kind" : "casePackage", "package" : { "case" : { "activities" : [ ], "id" : "docucare-skills lab-victoria-laney", "learningLevel" : "Skills Lab", "panels" : { "assessments" : [ { "dateTime" : "2025-02-18T16:00:00", "id" : "victoria-laney-assessment-1", "label" : "GI", "summary" : ": GI\nLast Bowel Movement / Last Bowel Movement Date: 02/18/2025\nLast Bowel Movement / Last Bowel Movement Time: 16:00" }, { "dateTime" : "2025-02-18T16:00:00", "id" : "victoria-laney-assessment-2", "label" : "GI", "summary" : ": GI\nLast Bowel Movement / Last Bowel Movement Date: 02/18/2025\nLast Bowel Movement / Last Bowel Movement Time: 16:00" } ], "labs" : [ ], "medications" : [ ], "notes" : [ { "id" : "victoria-laney-allergy", "summary" : "Source allergy table contains no entries. Allergy status is not documented; an empty table does not establish no known allergies.", "type" : "Allergy documentation" }, { "author" : "Sarah , Registered Nurse", "dateTime" : "2025-02-18T16:00:00", "id" : "victoria-laney-note-1", "summary" : "S: 62 y/o female with 2-day post-op Stage III adenocarcinoma tumor removal of small bowel. Has a permanent ileostomy. B: Pt. had some vague abdominal discomfort for several months. Saw her PMD, who ordered a CT w/contrast, and found the tumor and metastasis. Met with a surgeon last week and had pre-op ostomy training with a wound/ostomy nurse. A: A&OX4. Appears sad. Skin appropriate for ethnicity, warm and dry. T 97.6, P 95, R 16, BP 134/89 Pulse ox 98% on RA, pain 4/10 scale. Lungs CTAB. Heart S1 S2 no murmurs. Abd. Soft with hypoactive bowel sounds. Ileostomy stoma noted to the right mid abdomen. Stoma pink with mild serosanguinous drainage noted in a drainage bag. Skin appears intact around the ostomy appliance. Runny, moderate amount, medium brown stool in drainage pouch noted. R: Empty drainage pouch when 1/3 to 1/2 full before changing the appliance every 3-5 days. Teach pt. how to change appliance every time it is done.", "type" : "Nursing - Shift" }, { "id" : "victoria-laney-section-current-care-providers", "summary" : "Dr Kno | Admitting Physician\nSarah | Registered Nurse", "type" : "Current Care Providers" }, { "id" : "victoria-laney-clarification-4", "summary" : "Skills Lab simulation ID SL-012. Original DocuCare MRN: 123456. Original fixed simulation dates and stated scenario ages are retained; DOB-derived age may disagree. Source records are preserved for faculty review.", "type" : "Chart clarification" }, { "id" : "victoria-laney-clarification-5", "summary" : "Chief complaint says preoperative; nursing note says postoperative day 2. Staging describes stage III and metastasis without location; no cancer restaging inferred.", "type" : "Chart clarification" }, { "id" : "victoria-laney-clarification-6", "summary" : "No structured medication or other orders present; narrative ostomy instructions retained.", "type" : "Chart clarification" } ], "orders" : [ ], "overview" : { "height" : "", "isolationIndicator" : "Standard", "religion" : "" }, "vitals" : [ { "bloodPressure" : "134/89", "dateTime" : "2025-02-18T16:00:00", "heartRate" : 95, "id" : "victoria-laney-vital-1", "respiratoryRate" : 16, "spo2" : "98", "temperature" : "97.6 °F (36 °C), 36 °C Oral" } ] }, "patient" : { "admitDateTime" : "2025-02-18T16:00:00", "admittingDiagnosis" : "Postoperative small-bowel tumor resection with ileostomy", "allergies" : [ ], "attending" : "Dr Kno, Admitting Physician", "chartDisplayName" : "Laney, Victoria", "codeStatus" : "", "dob" : "7/30/1964", "history" : { "chiefComplaint" : "62 y/o female admitted pre operatively for Stage III adenocarcinoma tumor removal of small bowel. She began to experience abdominal discomfort for five months. Dr. Chan her primary doctor at RCC primary care clinic ordered a CT scan with contrast which revealed a Stage III adenocarcinoma tumor with metastasis. No known family history of cancer.", "pastMedicalHistory" : [ ], "pastSurgicalHistory" : [ ], "socialHistory" : [ "Age: 62 Years" ] }, "mrn" : "SL-012", "sex" : "Female", "simulatedFullName" : "Victoria Laney", "unit" : "RCC Hospital" }, "setting" : "RCC Hospital", "snapshots" : [ { "activityIds" : [ ], "id" : "victoria-laney-current", "notes" : "Captured dated chart history; source relative dates anchored to chart opening. Progressive release not recreated.", "scenarioTime" : "2025-02-18T16:00:00", "sourcePath" : "DocuCare instructor chart: Victoria Laney", "title" : "Captured chart" } ], "subtitle" : "Learning Lab practice record", "tags" : [ "Skills Lab", "DocuCare migration", "Learning Lab" ], "title" : "Victoria Laney" }, "packageId" : "docucare-skills lab-victoria-laney-review-v1", "privacy" : { "containsRealPHI" : false, "defaultStorage" : "local-document-package", "networkRequired" : false, "simulatedOnly" : true, "warning" : "Simulated education only. Not for clinical care. Review conflicting, held or undocumented findings with lab faculty." }, "schemaVersion" : "2.0", "source" : { "system" : "DocuCare Enhanced instructor chart capture" }, "workingNames" : [ "ChartSlate" ] } }, "id" : "skills lab-victoria-laney", "instructions" : "Choose this patient for simulated chart-review practice. Check the name, date of birth and simulated MRN; review notes, assessments, vital signs, orders and medications. Identify missing or conflicting information and discuss it with lab faculty. Held or discontinued medications are not active administration tasks.", "title" : "Victoria Laney" }, { "envelope" : { "appName" : "ChartSlate", "audience" : "student", "createdAt" : "2026-09-25T19:44:22.331008+00:00", "exportVersion" : "1", "kind" : "casePackage", "package" : { "case" : { "activities" : [ ], "id" : "docucare-skills lab-jack-don", "learningLevel" : "Skills Lab", "panels" : { "assessments" : [ { "dateTime" : "2025-02-18T15:00:00", "id" : "jack-don-assessment-1", "label" : "Neuro", "summary" : ": Neuro" }, { "dateTime" : "2025-02-18T15:00:00", "id" : "jack-don-assessment-2", "label" : "Cardio", "summary" : ": Cardio" }, { "dateTime" : "2025-02-18T15:00:00", "id" : "jack-don-assessment-3", "label" : "Respiratory", "summary" : ": Respiratory" }, { "dateTime" : "2025-02-18T15:00:00", "id" : "jack-don-assessment-4", "label" : "Site/Wound", "summary" : ": Site/Wound\nRegion: Leg\nSpecific Location: Calf, Medial, Left\nType: Rash, Erythematous\nLength: 0\nWidth: 0\nDepth: 0" } ], "labs" : [ ], "medications" : [ ], "notes" : [ { "id" : "jack-don-allergy", "summary" : "Source allergy table contains no entries. Allergy status is not documented; an empty table does not establish no known allergies.", "type" : "Allergy documentation" }, { "author" : "Roger , Registered Nurse", "dateTime" : "2025-02-18T15:00:00", "id" : "jack-don-note-1", "summary" : "S: 63 y.o, was recently diagnosed with diabetes and his meal tray just arrived. B: Diagnosed with Type II DM 3 days ago after being admitted with left lower extremity cellulitis. Client continues to pick at the dressing covering the left lower extremity cellulitis. A: Vital signs – 98.1, 85, 16, 141/82 O2 sat 98% on RA 1/10 pain Heart- RRR, peripheral pulses present bilaterally Lung- clear bilaterally, no cough Skin- Redness to left lower extremity, +2 pitting edema, no exudate. R: Apply soft wrist restraint to right upper extremity.", "type" : "Nursing - Shift" }, { "id" : "jack-don-section-current-care-providers", "summary" : "Jon Chaffee | Admitting Physician\nRoger | Registered Nurse", "type" : "Current Care Providers" }, { "id" : "jack-don-clarification-4", "summary" : "Skills Lab simulation ID SL-013. Original DocuCare MRN: 123456. Original fixed simulation dates and stated scenario ages are retained; DOB-derived age may disagree. Source records are preserved for faculty review.", "type" : "Chart clarification" }, { "id" : "jack-don-clarification-5", "summary" : "Restraint order lacks duration, monitoring and release criteria. Note describes picking at a dressing; rationale, alternatives and local restraint policy require instructor review before this becomes a student procedure.", "type" : "Chart clarification" } ], "orders" : [ { "author" : "Pending per Jon Chaffee, Admitting Physician", "category" : "Nursing", "dateTime" : "2025-02-18T15:00:00", "id" : "jack-don-order-1", "orderText" : "Restraint application, limb; x1 (1 time only), 1 time only; Routine; Source due: 2/18/2025 15:00", "status" : "Active" } ], "overview" : { "height" : "", "isolationIndicator" : "Standard", "religion" : "" }, "vitals" : [ { "bloodPressure" : "141/82", "dateTime" : "2025-02-18T15:00:00", "heartRate" : 85, "id" : "jack-don-vital-1", "oxygenDevice" : "Room Air", "respiratoryRate" : 16, "spo2" : "92", "temperature" : "98 °F (37 °C), 37 °C" } ] }, "patient" : { "admitDateTime" : "2025-02-18T15:00:00", "admittingDiagnosis" : "Left lower extremity cellulitis", "allergies" : [ ], "attending" : "Jon Chaffee, Admitting Physician", "chartDisplayName" : "Don, Jack", "codeStatus" : "", "dob" : "7/29/1963", "history" : { "chiefComplaint" : "63 year old male admitted for lower extremity cellulitis. No known history.", "pastMedicalHistory" : [ ], "pastSurgicalHistory" : [ ], "socialHistory" : [ "Age: 63 Years" ] }, "mrn" : "SL-013", "sex" : "Male", "simulatedFullName" : "Jack Don", "unit" : "RCC Hospital" }, "setting" : "RCC Hospital", "snapshots" : [ { "activityIds" : [ ], "id" : "jack-don-current", "notes" : "Captured dated chart history; source relative dates anchored to chart opening. Progressive release not recreated.", "scenarioTime" : "2025-02-18T15:00:00", "sourcePath" : "DocuCare instructor chart: Jack Don", "title" : "Captured chart" } ], "subtitle" : "Learning Lab practice record", "tags" : [ "Skills Lab", "DocuCare migration", "Learning Lab" ], "title" : "Jack Don" }, "packageId" : "docucare-skills lab-jack-don-review-v1", "privacy" : { "containsRealPHI" : false, "defaultStorage" : "local-document-package", "networkRequired" : false, "simulatedOnly" : true, "warning" : "Simulated education only. Not for clinical care. Review conflicting, held or undocumented findings with lab faculty." }, "schemaVersion" : "2.0", "source" : { "system" : "DocuCare Enhanced instructor chart capture" }, "workingNames" : [ "ChartSlate" ] } }, "id" : "skills lab-jack-don", "instructions" : "Choose this patient for simulated chart-review practice. Check the name, date of birth and simulated MRN; review notes, assessments, vital signs, orders and medications. Identify missing or conflicting information and discuss it with lab faculty. Held or discontinued medications are not active administration tasks.", "title" : "Jack Don" }, { "envelope" : { "appName" : "ChartSlate", "audience" : "student", "createdAt" : "2026-09-25T19:44:22.331008+00:00", "exportVersion" : "1", "kind" : "casePackage", "package" : { "case" : { "activities" : [ ], "id" : "docucare-skills lab-mike-johnston", "learningLevel" : "Skills Lab", "panels" : { "assessments" : [ { "dateTime" : "2025-02-18T16:00:00", "id" : "mike-johnston-assessment-1", "label" : "Cardio", "summary" : ": Cardio\nSkin Color and Description / Skin Color Details: Redness to left lower extremity" }, { "dateTime" : "2025-02-18T16:00:00", "id" : "mike-johnston-assessment-2", "label" : "Respiratory", "summary" : ": Respiratory" } ], "labs" : [ { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2025-02-18T16:00:00", "flag" : "High", "id" : "mike-johnston-lab-1", "referenceRange" : "4.0-9.0", "result" : "12", "test" : "WBC (10 x 3/uL)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2025-02-18T16:00:00", "flag" : "Normal", "id" : "mike-johnston-lab-2", "referenceRange" : "3.90-4.98", "result" : "4", "test" : "RBC (mill/cumm)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2025-02-18T16:00:00", "flag" : "Low", "id" : "mike-johnston-lab-3", "referenceRange" : "12.0-15.5", "result" : "11", "test" : "Hemoglobin (gm/dL)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2025-02-18T16:00:00", "flag" : "Low", "id" : "mike-johnston-lab-4", "referenceRange" : "35-45", "result" : "33", "test" : "Hematocrit (%)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2025-02-18T16:00:00", "flag" : "Normal", "id" : "mike-johnston-lab-5", "referenceRange" : "140-400", "result" : "140", "test" : "Platelet Count (1000/mm3)" }, { "category" : "Other", "collectedDateTime" : "2025-02-18T16:00:00", "flag" : "Unverified", "id" : "mike-johnston-lab-6", "result" : "12", "test" : "Vancomycin" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2025-02-18T16:00:00", "flag" : "Normal", "id" : "mike-johnston-lab-7", "referenceRange" : "135-145", "result" : "136", "test" : "Sodium (mEq/L)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2025-02-18T16:00:00", "flag" : "Low", "id" : "mike-johnston-lab-8", "referenceRange" : "3.5-5.1", "result" : "3.2", "test" : "Potassium (mEq/L)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2025-02-18T16:00:00", "flag" : "Normal", "id" : "mike-johnston-lab-9", "referenceRange" : "98-107", "result" : "98", "test" : "Chloride (mEq/L)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2025-02-18T16:00:00", "flag" : "Normal", "id" : "mike-johnston-lab-10", "referenceRange" : "22-29", "result" : "24", "test" : "CO2 (mEq/L)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2025-02-18T16:00:00", "flag" : "High", "id" : "mike-johnston-lab-11", "referenceRange" : "70-99", "result" : "105", "test" : "Glucose (mg/dL)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2025-02-18T16:00:00", "flag" : "High", "id" : "mike-johnston-lab-12", "referenceRange" : "6-20", "result" : "24", "test" : "Blood Urea Nitrogen (mg/dL)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2025-02-18T16:00:00", "flag" : "High", "id" : "mike-johnston-lab-13", "referenceRange" : "0.50-1.00", "result" : "2.1", "test" : "Creatinine (mg/dL)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2025-02-18T16:00:00", "flag" : "Normal", "id" : "mike-johnston-lab-14", "referenceRange" : "8.4-10.5", "result" : "9", "test" : "Calcium (mg/dL)" } ], "medications" : [ { "doseRouteFrequency" : "400 mg Intravenous Piggyback (IVPB) q12h (Every 12 hours), Every 12 hours", "drug" : "ciprofloxacin", "id" : "mike-johnston-med-1", "nextDue" : "2025-02-18T16:00:00", "notes" : "Dilute in 200 ml Normal Saline Source due: 2/18/2025 16:00 Ciprofloxacin infusion duration and renal dose assessment are missing; creatinine 2.1 is above the source range. Verify preparation, infusion rate and renal dosing before use.", "orderedBy" : "Pending per Dr. Cho, Admitting Physician", "orderedDateTime" : "2025-02-18T16:00:00", "section" : "Scheduled", "status" : "Active" }, { "doseRouteFrequency" : "40 mg Intravenous (IV) q6h (Every 6 hours), Every 6 hours", "drug" : "methylPREDNISolone", "id" : "mike-johnston-med-2", "nextDue" : "2025-02-18T16:00:00", "notes" : "Available: 40 mg/ml Source due: 2/18/2025 16:00", "orderedBy" : "Pending per Dr. Cho, Admitting Physician", "orderedDateTime" : "2025-02-18T16:00:00", "section" : "Scheduled", "status" : "Active" }, { "doseRouteFrequency" : "100 ml per hr Intravenous (IV) cont.", "drug" : "sodium chloride 0.9%", "id" : "mike-johnston-med-3", "nextDue" : "2025-02-18T16:00:00", "notes" : "Source due: 2/18/2025 16:00", "orderedBy" : "Pending per Dr. Cho, Admitting Physician", "orderedDateTime" : "2025-02-18T16:00:00", "section" : "Scheduled", "status" : "Active" } ], "notes" : [ { "id" : "mike-johnston-allergy", "summary" : "NKA | Medication | | | Jessica | 2/18/2025 16:00", "type" : "Allergy documentation" }, { "author" : "Jessica , Registered Nurse", "dateTime" : "2025-02-18T16:00:00", "id" : "mike-johnston-note-1", "summary" : "S: Mike Johnston, age 74, was recently diagnosed with pneumonia B: History of COPD A: Vital signs – 100.2, 85, 16, 148/82 O2 sat 98% on RA 0/10 pain Heart- RRR, peripheral pulses present bilaterally Lung- clear bilaterally, no cough Skin- Redness to left lower extremity, +2 pitting edema, no exudate. R: Administer 0.9% NaCl to infuse at 100 ml/hr, Administer Methylprednisolone IVP, Administer Ciprofloxacin IVPB", "type" : "Nursing - Shift" }, { "id" : "mike-johnston-section-current-care-providers", "summary" : "Dr. Cho | Admitting Physician\nJessica | Registered Nurse", "type" : "Current Care Providers" }, { "id" : "mike-johnston-clarification-4", "summary" : "Skills Lab simulation ID SL-014. Original DocuCare MRN: 123581. Original fixed simulation dates and stated scenario ages are retained; DOB-derived age may disagree. Source records are preserved for faculty review.", "type" : "Chart clarification" }, { "id" : "mike-johnston-clarification-5", "summary" : "Ciprofloxacin infusion duration and renal dose assessment are missing; creatinine 2.1 is above the source range. Verify preparation, infusion rate and renal dosing before use.", "type" : "Chart clarification" }, { "id" : "mike-johnston-clarification-6", "summary" : "Vancomycin result 12 has no unit or reference and no active vancomycin order.", "type" : "Chart clarification" }, { "id" : "mike-johnston-clarification-7", "summary" : "Pneumonia narrative includes lower-leg cellulitis findings without corresponding diagnosis; retained for review.", "type" : "Chart clarification" } ], "orders" : [ { "author" : "Pending per Dr. Cho, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2025-02-18T16:00:00", "id" : "mike-johnston-order-1", "orderText" : "ciprofloxacin; 400 mg Intravenous Piggyback (IVPB); q12h (Every 12 hours), Every 12 hours; Scheduled; Dilute in 200 ml Normal Saline Source due: 2/18/2025 16:00 Ciprofloxacin infusion duration and renal dose assessment are missing; creatinine 2.1 is above the source range. Verify preparation, infusion rate and renal dosing before use.", "status" : "Active" }, { "author" : "Pending per Dr. Cho, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2025-02-18T16:00:00", "id" : "mike-johnston-order-2", "orderText" : "methylPREDNISolone; 40 mg Intravenous (IV); q6h (Every 6 hours), Every 6 hours; Scheduled; Available: 40 mg/ml Source due: 2/18/2025 16:00", "status" : "Active" }, { "author" : "Pending per Dr. Cho, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2025-02-18T16:00:00", "id" : "mike-johnston-order-3", "orderText" : "sodium chloride 0.9%; 100 ml per hr Intravenous (IV); cont.; Cont. Infusion; Source due: 2/18/2025 16:00", "status" : "Active" } ], "overview" : { "height" : "", "isolationIndicator" : "Standard", "religion" : "", "weightKg" : 100 }, "vitals" : [ { "bloodPressure" : "148/82", "dateTime" : "2025-02-18T16:00:00", "heartRate" : 85, "id" : "mike-johnston-vital-1", "oxygenDevice" : "Room Air", "respiratoryRate" : 16, "spo2" : "90", "temperature" : "100.2 °F (38 °C), 38 °C Oral" } ] }, "patient" : { "admitDateTime" : "2025-02-18T16:00:00", "admittingDiagnosis" : "Pneumonia", "allergies" : [ ], "attending" : "Dr. Cho, Admitting Physician", "chartDisplayName" : "Johnston, Michael", "codeStatus" : "", "dob" : "7/9/1952", "history" : { "chiefComplaint" : "Mike Johnston, age 74, was recently diagnosed with pneumonia, with a history of COPD.", "pastMedicalHistory" : [ ], "pastSurgicalHistory" : [ ], "socialHistory" : [ "Age: 74 Years" ] }, "mrn" : "SL-014", "sex" : "Male", "simulatedFullName" : "Michael Johnston", "unit" : "RCC Hospital" }, "setting" : "RCC Hospital", "snapshots" : [ { "activityIds" : [ ], "id" : "mike-johnston-current", "notes" : "Captured dated chart history; source relative dates anchored to chart opening. Progressive release not recreated.", "scenarioTime" : "2025-02-18T16:00:00", "sourcePath" : "DocuCare instructor chart: Mike Johnston", "title" : "Captured chart" } ], "subtitle" : "Learning Lab practice record", "tags" : [ "Skills Lab", "DocuCare migration", "Learning Lab" ], "title" : "Mike Johnston" }, "packageId" : "docucare-skills lab-mike-johnston-review-v1", "privacy" : { "containsRealPHI" : false, "defaultStorage" : "local-document-package", "networkRequired" : false, "simulatedOnly" : true, "warning" : "Simulated education only. Not for clinical care. Review conflicting, held or undocumented findings with lab faculty." }, "schemaVersion" : "2.0", "source" : { "system" : "DocuCare Enhanced instructor chart capture" }, "workingNames" : [ "ChartSlate" ] } }, "id" : "skills lab-mike-johnston", "instructions" : "Choose this patient for simulated chart-review practice. Check the name, date of birth and simulated MRN; review notes, assessments, vital signs, orders and medications. Identify missing or conflicting information and discuss it with lab faculty. Held or discontinued medications are not active administration tasks.", "title" : "Michael Johnston" }, { "envelope" : { "appName" : "ChartSlate", "audience" : "student", "createdAt" : "2026-09-25T19:44:22.331008+00:00", "exportVersion" : "1", "kind" : "casePackage", "package" : { "case" : { "activities" : [ ], "id" : "docucare-skills lab-jamie-gutierrez", "learningLevel" : "Skills Lab", "panels" : { "assessments" : [ { "dateTime" : "2025-02-18T07:00:00", "id" : "jamie-gutierrez-assessment-1", "label" : "Neuro", "summary" : ": Neuro\nAdditional Notes / Additional Notes: A/O x 0" }, { "dateTime" : "2025-02-18T07:00:00", "id" : "jamie-gutierrez-assessment-2", "label" : "Cardio", "summary" : ": Cardio" }, { "dateTime" : "2025-02-18T07:00:00", "id" : "jamie-gutierrez-assessment-3", "label" : "Respiratory", "summary" : ": Respiratory" }, { "dateTime" : "2025-02-18T07:00:00", "id" : "jamie-gutierrez-assessment-4", "label" : "Vascular Access", "summary" : ": Vascular Access\nLocation: Right forearm\nType: Peripheral IV\nDate Inserted Date: 02/18/2025\nSize: 20\nSite Description: Clean dry and intact\nDressing: tegaderm" } ], "labs" : [ ], "medications" : [ ], "notes" : [ { "id" : "jamie-gutierrez-allergy", "summary" : "Source allergy table contains no entries. Allergy status is not documented; an empty table does not establish no known allergies.", "type" : "Allergy documentation" }, { "author" : "John , Registered Nurse", "dateTime" : "2025-02-18T07:00:00", "id" : "jamie-gutierrez-note-1", "summary" : "S 72 y/o with pneumonia B History of ischemic stroke. The patient has a tracheostomy. A V. S. stable- 98.4, 84, 22, 132/84 O2 sat 90% on 40% FiO2, 0/10 on objective pain scale. A & O x 0 Saline lock in right forearm. Heart regular rate and rhythm. Peripheral pulses strong bilaterally. Cap refill <3 seconds. Lungs course crackles bilaterally with a weak cough R Patient is requiring suctioning every 3-4 hours and it has been 4 hours. Patient will also need trach care.", "type" : "Nursing - Shift" }, { "id" : "jamie-gutierrez-section-current-care-providers", "summary" : "Dr. Meta | Admitting Physician\nJohn | Registered Nurse", "type" : "Current Care Providers" }, { "id" : "jamie-gutierrez-clarification-4", "summary" : "Skills Lab simulation ID SL-015. Original DocuCare MRN: 123456. Original fixed simulation dates and stated scenario ages are retained; DOB-derived age may disagree. Source records are preserved for faculty review.", "type" : "Chart clarification" }, { "id" : "jamie-gutierrez-clarification-5", "summary" : "Nursing note labels vital signs stable despite SpO2 90% on 40% oxygen, below source ordered goal >92%; preserve as a cue requiring assessment.", "type" : "Chart clarification" }, { "id" : "jamie-gutierrez-clarification-6", "summary" : "Suction order q4h conflicts with Q4 PRN note. Need an assessment-based indication clarified; no automatic suction schedule invented.", "type" : "Chart clarification" } ], "orders" : [ { "author" : "Pending per Dr. Meta, Admitting Physician", "category" : "Nursing", "dateTime" : "2025-02-18T07:00:00", "id" : "jamie-gutierrez-order-1", "orderText" : "Tracheostomy suctioning; q4h (Every 4 hours), Every 4 hours; Routine; Q4 PRN Source due: 2/18/2025 07:00", "status" : "Active" }, { "author" : "Pending per Dr. Meta, Admitting Physician", "category" : "Nursing", "dateTime" : "2025-02-18T07:00:00", "id" : "jamie-gutierrez-order-2", "orderText" : "Tracheostomy tube cannula and stoma care; q24h (Every 24 hours), Every 24 hours; Routine; Q AM Source due: 2/18/2025 07:00", "status" : "Active" }, { "author" : "Pending per Dr. Meta, Admitting Physician", "category" : "Nursing", "dateTime" : "2025-02-18T07:00:00", "id" : "jamie-gutierrez-order-3", "orderText" : "Oxygen administration; cont.; Routine; Trach mask at 40% keep sats greater then 92%. Source due: 2/18/2025 07:00", "status" : "Active" } ], "overview" : { "height" : "", "isolationIndicator" : "Standard", "religion" : "" }, "vitals" : [ { "bloodPressure" : "132/84", "dateTime" : "2025-02-18T07:00:00", "heartRate" : 84, "id" : "jamie-gutierrez-vital-1", "oxygenDevice" : "Trach Collar", "respiratoryRate" : 22, "spo2" : "90", "temperature" : "98.4 °F (37 °C), 37 °C Oral" } ] }, "patient" : { "admitDateTime" : "2025-02-18T07:00:00", "admittingDiagnosis" : "Pneumonia", "allergies" : [ ], "attending" : "Dr. Meta, Admitting Physician", "chartDisplayName" : "Gutierrez, Jaime", "codeStatus" : "", "dob" : "7/12/1954", "history" : { "chiefComplaint" : "Mr. Gutierrez is a 72 y/o male admitted with pneumonia. The patient has a history of ischemic stroke resulting in tracheostomy tube placement.", "pastMedicalHistory" : [ ], "pastSurgicalHistory" : [ ], "socialHistory" : [ "Age: 72 Years" ] }, "mrn" : "SL-015", "sex" : "Male", "simulatedFullName" : "Jaime Gutierrez", "unit" : "RCC Hospital" }, "setting" : "RCC Hospital", "snapshots" : [ { "activityIds" : [ ], "id" : "jamie-gutierrez-current", "notes" : "Captured dated chart history; source relative dates anchored to chart opening. Progressive release not recreated.", "scenarioTime" : "2025-02-18T07:00:00", "sourcePath" : "DocuCare instructor chart: Jamie Gutierrez", "title" : "Captured chart" } ], "subtitle" : "Learning Lab practice record", "tags" : [ "Skills Lab", "DocuCare migration", "Learning Lab" ], "title" : "Jamie Gutierrez" }, "packageId" : "docucare-skills lab-jamie-gutierrez-review-v1", "privacy" : { "containsRealPHI" : false, "defaultStorage" : "local-document-package", "networkRequired" : false, "simulatedOnly" : true, "warning" : "Simulated education only. Not for clinical care. Review conflicting, held or undocumented findings with lab faculty." }, "schemaVersion" : "2.0", "source" : { "system" : "DocuCare Enhanced instructor chart capture" }, "workingNames" : [ "ChartSlate" ] } }, "id" : "skills lab-jamie-gutierrez", "instructions" : "Choose this patient for simulated chart-review practice. Check the name, date of birth and simulated MRN; review notes, assessments, vital signs, orders and medications. Identify missing or conflicting information and discuss it with lab faculty. Held or discontinued medications are not active administration tasks.", "title" : "Jaime Gutierrez" } ], "format" : "org.chartslate.case-collection", "id" : "rcc-learning-lab-practice-2026-10-13", "summary" : "15 simulated patient records for independent Learning Lab practice. Open a patient, review the chart and current orders, verify identifiers, and discuss findings with lab faculty. All patients are available after import.", "title" : "Learning Lab", "version" : 1 }