{ "audience" : "student", "createdAt" : "2026-09-25T19:44:43Z", "entries" : [ { "envelope" : { "appName" : "ChartSlate", "audience" : "student", "createdAt" : "2026-09-25T19:44:36.705927+00:00", "exportVersion" : "1", "kind" : "casePackage", "package" : { "case" : { "activities" : [ ], "id" : "docucare-n11-raj-hassan", "learningLevel" : "N11", "panels" : { "assessments" : [ ], "labs" : [ { "category" : "Other", "collectedDateTime" : "2026-09-25T11:39:00", "flag" : "High", "id" : "raj-hassan-lab-1", "referenceRange" : "138-148", "result" : "150", "test" : "NA" }, { "category" : "Other", "collectedDateTime" : "2026-09-25T11:39:00", "flag" : "Low", "id" : "raj-hassan-lab-2", "referenceRange" : "3.5-5.0", "result" : "3.2", "test" : "K" }, { "category" : "Other", "collectedDateTime" : "2026-09-25T11:39:00", "flag" : "High", "id" : "raj-hassan-lab-3", "referenceRange" : "1.3-2.1", "result" : "2.2", "test" : "Mg" }, { "category" : "Other", "collectedDateTime" : "2026-09-25T11:39:00", "flag" : "Low", "id" : "raj-hassan-lab-4", "referenceRange" : "96-106", "result" : "90", "test" : "CL" }, { "category" : "Other", "collectedDateTime" : "2026-09-25T11:39:00", "flag" : "High", "id" : "raj-hassan-lab-5", "referenceRange" : "7-18", "result" : "25", "test" : "BUN" }, { "category" : "Other", "collectedDateTime" : "2026-09-25T11:39:00", "flag" : "High", "id" : "raj-hassan-lab-6", "referenceRange" : "0.6-1.2", "result" : "2.3", "test" : "creatinine" }, { "category" : "Other", "collectedDateTime" : "2026-09-25T11:39:00", "flag" : "Normal", "id" : "raj-hassan-lab-7", "referenceRange" : "8.8-10", "result" : "10", "test" : "Calcium" }, { "category" : "Other", "collectedDateTime" : "2026-09-25T11:39:00", "flag" : "High", "id" : "raj-hassan-lab-8", "referenceRange" : "70-110", "result" : "140", "test" : "Glucose" }, { "category" : "Other", "collectedDateTime" : "2026-09-25T11:39:00", "flag" : "High", "id" : "raj-hassan-lab-9", "referenceRange" : "289-308", "result" : "345", "test" : "Osmolality" }, { "category" : "Other", "collectedDateTime" : "2026-09-25T11:39:00", "flag" : "High", "id" : "raj-hassan-lab-10", "referenceRange" : "4.5-10", "result" : "11.5", "test" : "WBC" }, { "category" : "Other", "collectedDateTime" : "2026-09-25T11:39:00", "flag" : "Normal", "id" : "raj-hassan-lab-11", "referenceRange" : "4.5-5.5", "result" : "5.3", "test" : "RBC" }, { "category" : "Other", "collectedDateTime" : "2026-09-25T11:39:00", "flag" : "High", "id" : "raj-hassan-lab-12", "referenceRange" : "13.5-16.5", "result" : "18", "test" : "Hgb" }, { "category" : "Other", "collectedDateTime" : "2026-09-25T11:39:00", "flag" : "High", "id" : "raj-hassan-lab-13", "referenceRange" : "41-50", "result" : "55%", "test" : "Hct" }, { "category" : "Other", "collectedDateTime" : "2026-09-25T11:39:00", "flag" : "High", "id" : "raj-hassan-lab-14", "referenceRange" : "less than 14.5", "result" : "17", "test" : "RDW" }, { "category" : "Other", "collectedDateTime" : "2026-09-25T11:39:00", "flag" : "Normal", "id" : "raj-hassan-lab-15", "referenceRange" : "80-100", "result" : "100", "test" : "MCV" }, { "category" : "Other", "collectedDateTime" : "2026-09-25T11:39:00", "flag" : "Normal", "id" : "raj-hassan-lab-16", "referenceRange" : "26-34", "result" : "34", "test" : "MCH" }, { "category" : "Other", "collectedDateTime" : "2026-09-25T11:39:00", "flag" : "Normal", "id" : "raj-hassan-lab-17", "referenceRange" : "31-37", "result" : "37", "test" : "MCHC" }, { "category" : "Other", "collectedDateTime" : "2026-09-25T11:39:00", "flag" : "Normal", "id" : "raj-hassan-lab-18", "referenceRange" : "100-450", "result" : "425", "test" : "Platelets" } ], "medications" : [ { "doseRouteFrequency" : "4-8mg Sublingual (SL) q6h", "drug" : "ondansetron", "id" : "raj-hassan-med-8", "notes" : "prn nausea Source due: PRN Source order requires clarification: ondansetron is specified as sublingual without formulation; do not infer an orally disintegrating formulation.", "orderedBy" : "Dr. Lewis, Admitting", "orderedDateTime" : "2026-09-25T11:19:00", "section" : "PRN", "status" : "Active" }, { "doseRouteFrequency" : "100 ml per hr Intravenous (IV) cont.", "drug" : "sodium chloride", "id" : "raj-hassan-med-9", "nextDue" : "2026-09-25T11:19:00", "notes" : "Source due: 9/25/2026 11:19 Source order requires clarification: sodium chloride concentration is unspecified.", "orderedBy" : "Dr. Lewis, Admitting", "orderedDateTime" : "2026-09-25T11:19:00", "section" : "Scheduled", "status" : "Active" } ], "notes" : [ { "id" : "raj-hassan-allergy", "summary" : "demerol | Medication | rash | | Jess Stebbins | 9/25/2026 11:19", "type" : "Allergy documentation" }, { "author" : "Jess Stebbins , Registered Nurse", "dateTime" : "2026-09-25T11:34:00", "id" : "raj-hassan-note-1", "summary" : "A 52-year-old patient has just arrived in the Emergency Department with complaints of severe abdominal pain, nausea, and vomiting over the last few days. His abdomen is distended. A small bowel obstruction is suspected. He has poor skin turgor and dry mucous membranes. He has not urinated since yesterday. He has felt “dizzy” and “weak” all evening. He thought it might be the flu, but decided to come in because the stomach pains were getting worse. He has signed informed consent for treatment, orders have been written, labs have been drawn, and an IV placed. Lab results have not arrived yet.", "type" : "Nursing - Admission" }, { "id" : "raj-hassan-section-current-care-providers", "summary" : "Dr. Lewis | Admitting\nJess Stebbins | Registered Nurse\nSarah Nguyen | Patient Access Specialist", "type" : "Current Care Providers" }, { "id" : "raj-hassan-reconciliation-4", "summary" : "Source reconciliation: age 52 follows demographics and admission note; library description says 22. The source CBC labels appear transposed. Adapted Hgb is 18 (source unit not documented), reference 13.5–16.5; adapted Hct is 55%, reference 41–50. This label correction is inferred from units and reference intervals; original source retained for review.", "type" : "Chart clarification" } ], "orders" : [ { "author" : "Dr. Lewis, Admitting", "category" : "Not specified", "dateTime" : "2026-09-25T11:34:00", "id" : "raj-hassan-order-1", "orderText" : "Venipuncture; x1 (1 time only), 1 time only; Stat; CBC, Chemistry Source due: 9/25/2026 11:34", "status" : "Active" }, { "author" : "Dr. Lewis, Admitting", "category" : "ED", "dateTime" : "2026-09-25T11:34:00", "id" : "raj-hassan-order-2", "orderText" : "IV catheter insertion; x1 (1 time only), 1 time only; Stat; Source due: 9/25/2026 11:34", "status" : "Active" }, { "author" : "Dr. Lewis, Admitting", "category" : "ED", "dateTime" : "2026-09-25T11:34:00", "id" : "raj-hassan-order-3", "orderText" : "IV bag preparation; x1 (1 time only), 1 time only; Stat; Source due: 9/25/2026 11:34", "status" : "Active" }, { "author" : "Dr. Lewis, Admitting", "category" : "ED", "dateTime" : "2026-09-25T11:34:00", "id" : "raj-hassan-order-4", "orderText" : "Oxygen administration; cont.; Stat; Oygen via nasal cannula to maintain SpO2 greater than 92% Source due: 9/25/2026 11:34", "status" : "Active" }, { "author" : "Dr. Lewis, Admitting", "category" : "ED", "dateTime" : "2026-09-25T11:34:00", "id" : "raj-hassan-order-5", "orderText" : "NPO; cont.; Stat; Source due: 9/25/2026 11:34", "status" : "Active" }, { "author" : "Dr. Lewis, Admitting", "category" : "ED", "dateTime" : "2026-09-25T11:34:00", "id" : "raj-hassan-order-6", "orderText" : "Nasogastric tube insertion; cont.; Stat; Insert Nasogastric tube to low intermittent suction Source due: 9/25/2026 11:34", "status" : "Active" }, { "author" : "Dr. Lewis, Admitting", "category" : "Nursing: Monitoring", "dateTime" : "2026-09-25T11:19:00", "id" : "raj-hassan-order-7", "orderText" : "ECG monitoring; cont.; Routine; Source due: 9/25/2026 11:19", "status" : "Active" }, { "author" : "Dr. Lewis, Admitting", "category" : "Pharmacy", "dateTime" : "2026-09-25T11:19:00", "id" : "raj-hassan-order-8", "orderText" : "ondansetron; 4-8mg Sublingual (SL); q6h (Every 6 hours), Every 6 hours; PRN; prn nausea Source due: PRN Source order requires clarification: ondansetron is specified as sublingual without formulation; do not infer an orally disintegrating formulation.", "status" : "Active" }, { "author" : "Dr. Lewis, Admitting", "category" : "Pharmacy", "dateTime" : "2026-09-25T11:19:00", "id" : "raj-hassan-order-9", "orderText" : "sodium chloride; 100 ml per hr Intravenous (IV); cont.; Cont. Infusion; Source due: 9/25/2026 11:19 Source order requires clarification: sodium chloride concentration is unspecified.", "status" : "Active" }, { "author" : "Dr. Lewis, Admitting", "category" : "Radiology", "dateTime" : "2026-09-25T11:34:00", "id" : "raj-hassan-order-10", "orderText" : "Abdominal series X Ray; x1 (1 time only), 1 time only; Stat; Source due: 9/25/2026 11:34", "status" : "Active" } ], "overview" : { "height" : "67 in / 170.2 cm", "isolationIndicator" : "Standard", "religion" : "Mormon", "weightKg" : 70.3 }, "vitals" : [ { "bloodPressure" : "84/48", "dateTime" : "2026-09-25T11:24:00", "heartRate" : 114, "id" : "raj-hassan-vital-1", "oxygenDevice" : "Room Air", "respiratoryRate" : 26, "spo2" : "91", "temperature" : "98.8 °F (37 °C), 37 °C Oral" } ] }, "patient" : { "admitDateTime" : "2026-09-25T11:19:00", "admittingDiagnosis" : "r/o small bowel Intestinal obstruction", "allergies" : [ { "id" : "allergy-20238f34ad891183", "reaction" : "rash", "severity" : "Not documented", "substance" : "demerol" } ], "attending" : "Dr. Lewis, Admitting", "chartDisplayName" : "Hassan, Raj", "codeStatus" : "Full Code", "dob" : "12/17/1973", "history" : { "chiefComplaint" : "Complaining of abdominal pain and vomiting that began 1-2 days ago. He has also noted some “swelling” in his abdomen and feels bloated. Has had a poor appetite, admits to not eating or drinking much for the past few days because of an “upset stomach.” He had a bowel movement about 3 days ago which contained blood and mucus.", "pastMedicalHistory" : [ ], "pastSurgicalHistory" : [ "Previous Surgical Procedures / Surgical Procedure: cholecystectomy", "Previous Surgical Procedures / Surgical Procedure: appendectomy", "Previous Surgical Procedures / Surgical Procedure: right inguinal hernia repair" ], "socialHistory" : [ "Age: 52 years", "Nutritional Screening / Last Bowel Movement Days: 0", "Nutritional Screening / Last Bowel Movement Relative To Timing Based On: before student launches assignment" ] }, "mrn" : "PCS81300", "sex" : "Male", "simulatedFullName" : "Raj Hassan", "unit" : "ED — Room 5 — Bed a" }, "setting" : "ED — Room 5 — Bed a", "snapshots" : [ { "activityIds" : [ ], "id" : "raj-hassan-current", "notes" : "Captured dated chart history; source relative dates anchored to chart opening. Progressive release not recreated.", "scenarioTime" : "2026-09-25T11:34:00", "sourcePath" : "DocuCare instructor chart: Raj Hassan", "title" : "Captured chart" } ], "subtitle" : "N11 practice record", "tags" : [ "N11", "DocuCare migration" ], "title" : "Raj Hassan" }, "packageId" : "docucare-n11-raj-hassan-review-v1", "privacy" : { "containsRealPHI" : false, "defaultStorage" : "local-document-package", "networkRequired" : false, "simulatedOnly" : true, "warning" : "Simulated educational record only. Not for clinical care. Review the chart and faculty directions before practice." }, "schemaVersion" : "2.0", "source" : { "system" : "DocuCare Enhanced instructor chart capture" }, "workingNames" : [ "ChartSlate" ] } }, "id" : "n11-raj-hassan", "instructions" : "Open the assigned patient chart. Confirm name, DOB and MRN; review allergies, notes, vitals, labs, orders and the MAR. Discuss missing or conflicting information with faculty. Held and discontinued medications are for review and are not active administration tasks. Scenario dates are historical. Follow your faculty directions.", "title" : "Raj Hassan" }, { "envelope" : { "appName" : "ChartSlate", "audience" : "student", "createdAt" : "2026-09-25T19:44:36.705927+00:00", "exportVersion" : "1", "kind" : "casePackage", "package" : { "case" : { "activities" : [ ], "id" : "docucare-n11-rachel-williams", "learningLevel" : "N11", "panels" : { "assessments" : [ { "author" : "Ayoka Reed, RN, Registered Nurse", "dateTime" : "2026-09-21T20:42:00", "id" : "rachel-williams-assessment-1", "label" : "HEENT", "summary" : ": HEENT\nHead / Size/Shape / Head Size/Shape: Symmetric\nHead / Recent Trauma: Yes\nHead / Hair: Fine\nEars / Right Ear: Intact\nEars / Left Ear: Hearing device present\nEyes / Left Eye: Normal/clear\nEyes / Right Eye: Normal/clear\nEyes / Left Eye: Symmetrical\nEyes / Right Eye: Symmetrical\nNose / Character / Nose Character: Symmetrical\nMouth/Throat / Teeth: Present\nMouth/Throat / Teeth: Dentures\nMouth/Throat / Oral Mucosa: Pink\nMouth/Throat / Pharynx: Normal\nMouth/Throat / Lymph Nodes / LymphNodes: Non-tender" }, { "author" : "Ayoka Reed, RN, Registered Nurse", "dateTime" : "2026-09-19T21:42:00", "id" : "rachel-williams-assessment-2", "label" : "HEENT", "summary" : ": HEENT\nHead / Size/Shape / Head Size/Shape: Symmetric\nHead / Recent Trauma: Yes\nHead / Hair: Fine\nEars / Right Ear: Intact\nEars / Left Ear: Impaired\nEars / Left Ear: Hearing device present\nEars / Left Ear: Normal\nEars / Right Ear: Normal\nEyes / Left Eye: Normal/clear\nEyes / Right Eye: Normal/clear\nEyes / Left Eye: Symmetrical\nEyes / Right Eye: Symmetrical\nNose / Character / Nose Character: Symmetrical\nNose / Obstruction / Nose Obstruction: Absent\nNose / Septum / Nose Septum: Intact\nMouth/Throat / Teeth: Present\nMouth/Throat / Teeth: Dentures\nMouth/Throat / Oral Mucosa: Normal\nMouth/Throat / Oral Mucosa: Pink\nMouth/Throat / Pharynx: Normal\nMouth/Throat / Lymph Nodes / LymphNodes: Non-tender" }, { "author" : "Nicholas Timerly, Registered Nurse", "dateTime" : "2026-09-20T08:42:00", "id" : "rachel-williams-assessment-3", "label" : "HEENT", "summary" : ": HEENT\nHead / Recent Trauma: Yes\nHead / Hair: Fine\nEars / Right Ear: Right Ear Pain\nEars / Left Ear: Hearing device present\nEars / Left Ear: Normal\nEars / Right Ear: Normal\nEyes / Left Eye: Normal/clear\nEyes / Right Eye: Normal/clear\nEyes / Left Eye: Symmetrical\nEyes / Right Eye: Symmetrical\nNose / Character / Nose Character: Symmetrical\nNose / Obstruction / Nose Obstruction: Absent\nNose / Septum / Nose Septum: Intact\nMouth/Throat / Teeth: Present\nMouth/Throat / Teeth: Dentures\nMouth/Throat / Oral Mucosa: Normal\nMouth/Throat / Oral Mucosa: Pink\nMouth/Throat / Pharynx: Normal" }, { "author" : "Ayoka Reed, RN, Registered Nurse", "dateTime" : "2026-09-20T20:42:00", "id" : "rachel-williams-assessment-4", "label" : "HEENT", "summary" : ": HEENT\nHead / Size/Shape / Head Size/Shape: Symmetric\nHead / Hair: Fine\nEars / Right Ear: Intact\nEars / Left Ear: Hearing device present\nEars / Left Ear: Normal\nEars / Right Ear: Normal\nEyes / Left Eye: Normal/clear\nEyes / Right Eye: Normal/clear\nNose / Character / Nose Character: Symmetrical\nNose / Obstruction / Nose Obstruction: Absent\nNose / Septum / Nose Septum: Intact\nMouth/Throat / Teeth: Present\nMouth/Throat / Teeth: Dentures\nMouth/Throat / Oral Mucosa: Normal\nMouth/Throat / Oral Mucosa: Pink\nMouth/Throat / Pharynx: Normal" }, { "author" : "Nicholas Timerly, Registered Nurse", "dateTime" : "2026-09-21T08:42:00", "id" : "rachel-williams-assessment-5", "label" : "HEENT", "summary" : ": HEENT\nHead / Size/Shape / Head Size/Shape: Symmetric\nHead / Hair: Fine\nEars / Right Ear: Intact\nEars / Left Ear: Hearing device present\nEars / Left Ear: Normal\nEars / Right Ear: Normal\nEyes / Left Eye: Normal/clear\nEyes / Right Eye: Normal/clear\nEyes / Left Eye: Symmetrical\nEyes / Right Eye: Symmetrical\nNose / Character / Nose Character: Symmetrical\nNose / Obstruction / Nose Obstruction: Absent\nNose / Septum / Nose Septum: Intact\nMouth/Throat / Teeth: Present\nMouth/Throat / Teeth: Dentures\nMouth/Throat / Oral Mucosa: Normal\nMouth/Throat / Pharynx: Normal" }, { "author" : "Nicholas Timerly, Registered Nurse", "dateTime" : "2026-09-22T08:42:00", "id" : "rachel-williams-assessment-6", "label" : "HEENT", "summary" : ": HEENT\nHead / Size/Shape / Head Size/Shape: Symmetric\nHead / Hair: Fine\nEars / Right Ear: Intact\nEars / Left Ear: Hearing device present\nEyes / Left Eye: Normal/clear\nEyes / Right Eye: Normal/clear\nNose / Character / Nose Character: Symmetrical\nNose / Obstruction / Nose Obstruction: Absent\nNose / Septum / Nose Septum: Intact\nMouth/Throat / Teeth: Present\nMouth/Throat / Teeth: Dentures\nMouth/Throat / Oral Mucosa: Normal\nMouth/Throat / Oral Mucosa: Pink\nMouth/Throat / Pharynx: Normal" }, { "author" : "Ayoka Reed, RN, Registered Nurse", "dateTime" : "2026-09-21T20:42:00", "id" : "rachel-williams-assessment-7", "label" : "Neuro", "summary" : ": Neuro\nOrientation / Quick Orientation: / Quick Orientation: Person, Time, Place, Situation\nPupils / Both Eyes (OU: Oculus Uterque, both eyes), OU: Oculus Uterque, both eyes / Size / Both Eye Size: 4\nPupils / Both Eyes (OU: Oculus Uterque, both eyes), OU: Oculus Uterque, both eyes / Reaction / Both Eye Reaction: Round\nPupils / Both Eyes (OU: Oculus Uterque, both eyes), OU: Oculus Uterque, both eyes / Reaction / Both Eye Reaction: Brisk\nPupils / Both Eyes (OU: Oculus Uterque, both eyes), OU: Oculus Uterque, both eyes / Reaction / Both Eye Reaction: Accommodation\nHearing: Assistive Device\nStrength / LUE (Left Upper Extremity), Left Upper Extremity: Moves Upon Request in Left Upper Extremity\nStrength / RUE (Right Upper Extremity), Right Upper Extremity: Moves Upon Request in Right Upper Extremity\nStrength / LLE (Left Lower Extremity), Left Lower Extremity: Weak Movement Upon Request in Left Lower Extremity\nStrength / RLE (Right Lower Extremity), Right Lower Extremity: Moves Spontaneously in Right Lower Extremity\nBehavioral/Emotional: Cooperative" }, { "author" : "Ayoka Reed, RN, Registered Nurse", "dateTime" : "2026-09-19T21:42:00", "id" : "rachel-williams-assessment-8", "label" : "Neuro", "summary" : ": Neuro\nOrientation / Quick Orientation: / Quick Orientation: Person, Time, Place, Situation\nPupils / Both Eyes (OU: Oculus Uterque, both eyes), OU: Oculus Uterque, both eyes / Size / Both Eye Size: 4\nPupils / Both Eyes (OU: Oculus Uterque, both eyes), OU: Oculus Uterque, both eyes / Reaction / Both Eye Reaction: Round\nPupils / Both Eyes (OU: Oculus Uterque, both eyes), OU: Oculus Uterque, both eyes / Reaction / Both Eye Reaction: Brisk\nPupils / Both Eyes (OU: Oculus Uterque, both eyes), OU: Oculus Uterque, both eyes / Reaction / Both Eye Reaction: Accommodation\nHearing: Assistive Device\nStrength / LUE (Left Upper Extremity), Left Upper Extremity: Moves Upon Request in Left Upper Extremity\nStrength / RUE (Right Upper Extremity), Right Upper Extremity: Moves Upon Request in Right Upper Extremity\nStrength / LLE (Left Lower Extremity), Left Lower Extremity: Weak Movement Upon Request in Left Lower Extremity\nStrength / RLE (Right Lower Extremity), Right Lower Extremity: Moves Spontaneously in Right Lower Extremity\nBehavioral/Emotional: Calm\nBehavioral/Emotional: Cooperative\nEye Opening: Spontaneously\nMotor Response: Obeys Verbal Command\nVerbal Response: Oriented X 3" }, { "author" : "Nicholas Timerly, Registered Nurse", "dateTime" : "2026-09-20T08:42:00", "id" : "rachel-williams-assessment-9", "label" : "Neuro", "summary" : ": Neuro\nOrientation / Quick Orientation: / Quick Orientation: Person, Time, Place, Situation\nPupils / Both Eyes (OU: Oculus Uterque, both eyes), OU: Oculus Uterque, both eyes / Size / Both Eye Size: 4\nPupils / Both Eyes (OU: Oculus Uterque, both eyes), OU: Oculus Uterque, both eyes / Reaction / Both Eye Reaction: Round\nPupils / Both Eyes (OU: Oculus Uterque, both eyes), OU: Oculus Uterque, both eyes / Reaction / Both Eye Reaction: Brisk\nPupils / Both Eyes (OU: Oculus Uterque, both eyes), OU: Oculus Uterque, both eyes / Reaction / Both Eye Reaction: Accommodation\nHearing: Intact\nHearing: Assistive Device\nStrength / LUE (Left Upper Extremity), Left Upper Extremity: Moves Upon Request in Left Upper Extremity\nStrength / RUE (Right Upper Extremity), Right Upper Extremity: Moves Upon Request in Right Upper Extremity\nStrength / LLE (Left Lower Extremity), Left Lower Extremity: Weak Movement Upon Request in Left Lower Extremity\nStrength / RLE (Right Lower Extremity), Right Lower Extremity: Moves Spontaneously in Right Lower Extremity\nBehavioral/Emotional: Calm\nBehavioral/Emotional: Cooperative\nEye Opening: Spontaneously\nMotor Response: Obeys Verbal Command\nVerbal Response: Oriented X 3" }, { "author" : "Ayoka Reed, RN, Registered Nurse", "dateTime" : "2026-09-20T20:42:00", "id" : "rachel-williams-assessment-10", "label" : "Neuro", "summary" : ": Neuro\nOrientation / Quick Orientation: / Quick Orientation: Person, Time, Place, Situation\nPupils / Both Eyes (OU: Oculus Uterque, both eyes), OU: Oculus Uterque, both eyes / Size / Both Eye Size: 3\nPupils / Both Eyes (OU: Oculus Uterque, both eyes), OU: Oculus Uterque, both eyes / Reaction / Both Eye Reaction: Round\nPupils / Both Eyes (OU: Oculus Uterque, both eyes), OU: Oculus Uterque, both eyes / Reaction / Both Eye Reaction: Brisk\nPupils / Both Eyes (OU: Oculus Uterque, both eyes), OU: Oculus Uterque, both eyes / Reaction / Both Eye Reaction: Accommodation\nStrength / LUE (Left Upper Extremity), Left Upper Extremity: Moves Upon Request in Left Upper Extremity\nStrength / RUE (Right Upper Extremity), Right Upper Extremity: Moves Upon Request in Right Upper Extremity\nStrength / LLE (Left Lower Extremity), Left Lower Extremity: Weak Movement Upon Request in Left Lower Extremity\nStrength / RLE (Right Lower Extremity), Right Lower Extremity: Moves Spontaneously in Right Lower Extremity\nBehavioral/Emotional: Calm\nBehavioral/Emotional: Cooperative" }, { "author" : "Nicholas Timerly, Registered Nurse", "dateTime" : "2026-09-21T08:42:00", "id" : "rachel-williams-assessment-11", "label" : "Neuro", "summary" : ": Neuro\nOrientation / Quick Orientation: / Quick Orientation: Person, Time, Place, Situation\nPupils / Both Eyes (OU: Oculus Uterque, both eyes), OU: Oculus Uterque, both eyes / Size / Both Eye Size: 3\nPupils / Both Eyes (OU: Oculus Uterque, both eyes), OU: Oculus Uterque, both eyes / Reaction / Both Eye Reaction: Round\nPupils / Both Eyes (OU: Oculus Uterque, both eyes), OU: Oculus Uterque, both eyes / Reaction / Both Eye Reaction: Brisk\nPupils / Both Eyes (OU: Oculus Uterque, both eyes), OU: Oculus Uterque, both eyes / Reaction / Both Eye Reaction: Accommodation\nHearing: Assistive Device\nStrength / LUE (Left Upper Extremity), Left Upper Extremity: Moves Upon Request in Left Upper Extremity\nStrength / RUE (Right Upper Extremity), Right Upper Extremity: Moves Upon Request in Right Upper Extremity\nStrength / LLE (Left Lower Extremity), Left Lower Extremity: Weak Movement Upon Request in Left Lower Extremity\nStrength / RLE (Right Lower Extremity), Right Lower Extremity: Moves Spontaneously in Right Lower Extremity\nBehavioral/Emotional: Calm\nBehavioral/Emotional: Cooperative" }, { "author" : "Nicholas Timerly, Registered Nurse", "dateTime" : "2026-09-22T08:42:00", "id" : "rachel-williams-assessment-12", "label" : "Neuro", "summary" : ": Neuro\nOrientation / Quick Orientation: / Quick Orientation: Person, Time, Place, Situation\nPupils / Both Eyes (OU: Oculus Uterque, both eyes), OU: Oculus Uterque, both eyes / Size / Both Eye Size: 4\nPupils / Both Eyes (OU: Oculus Uterque, both eyes), OU: Oculus Uterque, both eyes / Reaction / Both Eye Reaction: Round\nPupils / Both Eyes (OU: Oculus Uterque, both eyes), OU: Oculus Uterque, both eyes / Reaction / Both Eye Reaction: Brisk\nPupils / Both Eyes (OU: Oculus Uterque, both eyes), OU: Oculus Uterque, both eyes / Reaction / Both Eye Reaction: Accommodation\nHearing: Assistive Device\nStrength / LUE (Left Upper Extremity), Left Upper Extremity: Moves Upon Request in Left Upper Extremity\nStrength / RUE (Right Upper Extremity), Right Upper Extremity: Moves Upon Request in Right Upper Extremity\nStrength / LLE (Left Lower Extremity), Left Lower Extremity: Weak Movement Upon Request in Left Lower Extremity\nStrength / RLE (Right Lower Extremity), Right Lower Extremity: Moves Spontaneously in Right Lower Extremity\nBehavioral/Emotional: Calm\nBehavioral/Emotional: Cooperative" }, { "author" : "Ayoka Reed, RN, Registered Nurse", "dateTime" : "2026-09-21T20:42:00", "id" : "rachel-williams-assessment-13", "label" : "Cardio", "summary" : ": Cardio\nHeart Tones: S3\nPulses / All: + 1 in All\nEdema / LLE (Left Lower Extremity), Left Lower Extremity: 2+\nEdema / RLE (Right Lower Extremity), Right Lower Extremity: 2+\nCapillary Refill / LUE (Left Upper Extremity), Left Upper Extremity: < 3 sec in Left Upper Extremity\nCapillary Refill / RUE (Right Upper Extremity), Right Upper Extremity: < 3 sec in Right Upper Extremity\nCapillary Refill / LLE (Left Lower Extremity), Left Lower Extremity: > 3 sec in Left Lower Extremity\nCapillary Refill / RLE (Right Lower Extremity), Right Lower Extremity: > 3 sec in Right Lower Extremity\nSkin Color and Description: Dry\nSkin Color and Description: Intact\nSkin Color and Description: Fragile" }, { "author" : "Ayoka Reed, RN, Registered Nurse", "dateTime" : "2026-09-19T21:42:00", "id" : "rachel-williams-assessment-14", "label" : "Cardio", "summary" : ": Cardio\nHeart Tones: S1, S2\nHeart Tones: Regular\nHeart Tones: S3\nPulses / All: + 1 in All\nEdema / All: 2+\nCapillary Refill / LUE (Left Upper Extremity), Left Upper Extremity: < 3 sec in Left Upper Extremity\nCapillary Refill / RUE (Right Upper Extremity), Right Upper Extremity: < 3 sec in Right Upper Extremity\nCapillary Refill / LLE (Left Lower Extremity), Left Lower Extremity: > 3 sec in Left Lower Extremity\nCapillary Refill / RLE (Right Lower Extremity), Right Lower Extremity: > 3 sec in Right Lower Extremity\nSkin Color and Description: Appropriate for ethnicity\nSkin Color and Description: Warm\nSkin Color and Description: Dry\nSkin Color and Description: Intact" }, { "author" : "Nicholas Timerly, Registered Nurse", "dateTime" : "2026-09-20T08:42:00", "id" : "rachel-williams-assessment-15", "label" : "Cardio", "summary" : ": Cardio\nHeart Tones: S1, S2\nHeart Tones: Regular\nHeart Tones: S3\nPulses / All: + 1 in All\nEdema / All: 2+\nCapillary Refill / LUE (Left Upper Extremity), Left Upper Extremity: < 3 sec in Left Upper Extremity\nCapillary Refill / RUE (Right Upper Extremity), Right Upper Extremity: < 3 sec in Right Upper Extremity\nCapillary Refill / LLE (Left Lower Extremity), Left Lower Extremity: > 3 sec in Left Lower Extremity\nCapillary Refill / RLE (Right Lower Extremity), Right Lower Extremity: > 3 sec in Right Lower Extremity\nSkin Color and Description: Appropriate for ethnicity\nSkin Color and Description: Dry\nSkin Color and Description: Intact" }, { "author" : "Ayoka Reed, RN, Registered Nurse", "dateTime" : "2026-09-20T20:42:00", "id" : "rachel-williams-assessment-16", "label" : "Cardio", "summary" : ": Cardio\nHeart Tones: S1, S2\nHeart Tones: Regular\nHeart Tones: S3\nPulses / All: + 1 in All\nEdema / All: 2+\nCapillary Refill / LUE (Left Upper Extremity), Left Upper Extremity: < 3 sec in Left Upper Extremity\nCapillary Refill / RUE (Right Upper Extremity), Right Upper Extremity: < 3 sec in Right Upper Extremity\nCapillary Refill / LLE (Left Lower Extremity), Left Lower Extremity: > 3 sec in Left Lower Extremity\nCapillary Refill / RLE (Right Lower Extremity), Right Lower Extremity: > 3 sec in Right Lower Extremity\nSkin Color and Description: Appropriate for ethnicity\nSkin Color and Description: Dry\nSkin Color and Description: Intact" }, { "author" : "Nicholas Timerly, Registered Nurse", "dateTime" : "2026-09-21T08:42:00", "id" : "rachel-williams-assessment-17", "label" : "Cardio", "summary" : ": Cardio\nHeart Tones: S1, S2\nHeart Tones: Regular\nHeart Tones: S3\nPulses / All: + 2 in All\nEdema / All: 2+\nCapillary Refill / LUE (Left Upper Extremity), Left Upper Extremity: < 3 sec in Left Upper Extremity\nCapillary Refill / RUE (Right Upper Extremity), Right Upper Extremity: < 3 sec in Right Upper Extremity\nCapillary Refill / LLE (Left Lower Extremity), Left Lower Extremity: > 3 sec in Left Lower Extremity\nCapillary Refill / RLE (Right Lower Extremity), Right Lower Extremity: > 3 sec in Right Lower Extremity\nSkin Color and Description: Warm\nSkin Color and Description: Dry\nSkin Color and Description: Intact" }, { "author" : "Nicholas Timerly, Registered Nurse", "dateTime" : "2026-09-22T08:42:00", "id" : "rachel-williams-assessment-18", "label" : "Cardio", "summary" : ": Cardio\nHeart Tones: S1, S2\nHeart Tones: Regular\nHeart Tones: S3\nPulses / All: + 2 in All\nEdema / All: 2+\nCapillary Refill / LUE (Left Upper Extremity), Left Upper Extremity: < 3 sec in Left Upper Extremity\nCapillary Refill / RUE (Right Upper Extremity), Right Upper Extremity: < 3 sec in Right Upper Extremity\nCapillary Refill / LLE (Left Lower Extremity), Left Lower Extremity: > 3 sec in Left Lower Extremity\nCapillary Refill / RLE (Right Lower Extremity), Right Lower Extremity: > 3 sec in Right Lower Extremity\nSkin Color and Description: Appropriate for ethnicity\nSkin Color and Description: Warm\nSkin Color and Description: Dry\nSkin Color and Description: Intact" }, { "author" : "Ayoka Reed, RN, Registered Nurse", "dateTime" : "2026-09-21T20:42:00", "id" : "rachel-williams-assessment-19", "label" : "GI", "summary" : ": GI\nAbdominal Description / All: Flat\nGI Symptoms: None\nBowel Sounds / All: Present\nDiet Tolerance / Diet Tolerance: Adequate\nLast Bowel Movement / Last Bowel Movement Days: 1\nLast Bowel Movement / Last Bowel Movement Hours: 0\nLast Bowel Movement / Last Bowel Movement Minutes: 0\nLast Bowel Movement / Last Bowel Movement Relative To Timing Based On: after admission" }, { "author" : "Ayoka Reed, RN, Registered Nurse", "dateTime" : "2026-09-19T21:42:00", "id" : "rachel-williams-assessment-20", "label" : "GI", "summary" : ": GI\nAbdominal Description / All: Non-distended\nAbdominal Description / All: Flat\nAbdominal Description / All: Soft\nAbdominal Description / All: Non-tender\nGI Symptoms: Nausea\nBowel Sounds / All: Present\nDiet Tolerance / Diet Tolerance: Adequate\nLast Bowel Movement / Last Bowel Movement Days: 0\nLast Bowel Movement / Last Bowel Movement Hours: 0\nLast Bowel Movement / Last Bowel Movement Minutes: 0\nLast Bowel Movement / Last Bowel Movement Relative To Timing Based On: after admission" }, { "author" : "Nicholas Timerly, Registered Nurse", "dateTime" : "2026-09-20T08:42:00", "id" : "rachel-williams-assessment-21", "label" : "GI", "summary" : ": GI\nAbdominal Description / All: Non-distended\nAbdominal Description / All: Flat\nAbdominal Description / All: Soft\nAbdominal Description / All: Non-tender\nGI Symptoms: Nausea\nBowel Sounds / All: Present\nDiet Tolerance / Diet Tolerance: Adequate\nLast Bowel Movement / Last Bowel Movement Days: 0\nLast Bowel Movement / Last Bowel Movement Hours: 0\nLast Bowel Movement / Last Bowel Movement Minutes: 0\nLast Bowel Movement / Last Bowel Movement Relative To Timing Based On: after admission" }, { "author" : "Ayoka Reed, RN, Registered Nurse", "dateTime" : "2026-09-21T08:42:00", "id" : "rachel-williams-assessment-22", "label" : "GI", "summary" : ": GI\nAbdominal Description / All: Non-distended\nAbdominal Description / All: Soft\nAbdominal Description / All: Non-tender\nGI Symptoms: None\nBowel Sounds / All: Present\nDiet Tolerance / Diet Tolerance: Adequate\nLast Bowel Movement / Last Bowel Movement Days: 0\nLast Bowel Movement / Last Bowel Movement Hours: 0\nLast Bowel Movement / Last Bowel Movement Minutes: 0\nLast Bowel Movement / Last Bowel Movement Relative To Timing Based On: after admission" }, { "author" : "Nicholas Timerly, Registered Nurse", "dateTime" : "2026-09-22T08:42:00", "id" : "rachel-williams-assessment-23", "label" : "GI", "summary" : ": GI\nAbdominal Description / All: Non-distended\nAbdominal Description / All: Soft\nAbdominal Description / All: Non-tender\nGI Symptoms: None\nBowel Sounds / All: Present\nLast Bowel Movement / Last Bowel Movement Days: 0\nLast Bowel Movement / Last Bowel Movement Hours: 0\nLast Bowel Movement / Last Bowel Movement Minutes: 0\nLast Bowel Movement / Last Bowel Movement Relative To Timing Based On: after admission" }, { "author" : "Ayoka Reed, RN, Registered Nurse", "dateTime" : "2026-09-21T20:42:00", "id" : "rachel-williams-assessment-24", "label" : "GU", "summary" : ": GU\nUrinary Symptoms: None\nUrine Color: Yellow\nUrine Character: Clear\nUrinary Elimination: Voiding w/o Difficulty\nDate Inserted Days: 0\nDate Inserted Relative To Timing Based On: after admission\nVolume in Balloon: 0" }, { "author" : "Ayoka Reed, RN, Registered Nurse", "dateTime" : "2026-09-19T21:42:00", "id" : "rachel-williams-assessment-25", "label" : "GU", "summary" : ": GU\nUrinary Symptoms: Incontinence, Stress\nUrine Color: Yellow\nUrine Character: Clear\nUrinary Elimination: Voiding w/o Difficulty\nDate Inserted Days: 0\nDate Inserted Relative To Timing Based On: after admission\nVolume in Balloon: 0" }, { "author" : "Nicholas Timerly, Registered Nurse", "dateTime" : "2026-09-20T08:42:00", "id" : "rachel-williams-assessment-26", "label" : "GU", "summary" : ": GU\nUrinary Symptoms: Incontinence, Stress\nUrine Color: Yellow\nUrine Character: Clear\nUrinary Elimination: Voiding w/o Difficulty\nDate Inserted Days: 0\nDate Inserted Relative To Timing Based On: after admission\nVolume in Balloon: 0" }, { "author" : "Ayoka Reed, RN, Registered Nurse", "dateTime" : "2026-09-20T20:42:00", "id" : "rachel-williams-assessment-27", "label" : "GU", "summary" : ": GU\nUrinary Symptoms: Incontinence, Stress\nUrine Color: Yellow\nUrine Character: Clear\nUrinary Elimination: Voiding w/o Difficulty\nDate Inserted Days: 0\nDate Inserted Relative To Timing Based On: after admission\nVolume in Balloon: 0" }, { "author" : "Nicholas Timerly, Registered Nurse", "dateTime" : "2026-09-21T08:42:00", "id" : "rachel-williams-assessment-28", "label" : "GU", "summary" : ": GU\nUrinary Symptoms: None\nUrine Color: Yellow\nUrine Character: Clear\nUrinary Elimination: Voiding w/o Difficulty\nDate Inserted Days: 0\nDate Inserted Relative To Timing Based On: after admission\nVolume in Balloon: 0" }, { "author" : "Nicholas Timerly, Registered Nurse", "dateTime" : "2026-09-22T08:42:00", "id" : "rachel-williams-assessment-29", "label" : "GU", "summary" : ": GU\nUrinary Symptoms: None\nUrine Color: Yellow\nUrine Character: Clear\nUrinary Elimination: Voiding w/o Difficulty\nDate Inserted Days: 0\nDate Inserted Relative To Timing Based On: after admission\nVolume in Balloon: 0" }, { "author" : "Ayoka Reed, RN, Registered Nurse", "dateTime" : "2026-09-21T20:42:00", "id" : "rachel-williams-assessment-30", "label" : "Respiratory", "summary" : ": Respiratory\nOxygen Delivery Method / Oxygen Delivery Method: Room Air\nSputum / Color: None\nSputum / Amount: None\nRespiratory Symptoms: Difficulty Breathing with Activity\nBreath Sounds / Right Upper Lobe: Clear\nRespirations: Regular" }, { "author" : "Ayoka Reed, RN, Registered Nurse", "dateTime" : "2026-09-19T21:42:00", "id" : "rachel-williams-assessment-31", "label" : "Respiratory", "summary" : ": Respiratory\nSputum / Color: None\nRespiratory Symptoms: Shortness of Breath\nRespiratory Symptoms: Difficulty Breathing with Activity\nBreath Sounds / Right Upper Lobe: Clear\nRespirations: Regular" }, { "author" : "Nicholas Timerly, Registered Nurse", "dateTime" : "2026-09-20T08:42:00", "id" : "rachel-williams-assessment-32", "label" : "Respiratory", "summary" : ": Respiratory\nOxygen Delivery Method / Oxygen Delivery Method: Room Air\nSputum / Color: None\nSputum / Amount: None\nRespiratory Symptoms: Shortness of Breath\nRespiratory Symptoms: Difficulty Breathing with Activity\nBreath Sounds / Right Upper Lobe: Clear\nRespirations: Regular" }, { "author" : "Ayoka Reed, RN, Registered Nurse", "dateTime" : "2026-09-20T20:42:00", "id" : "rachel-williams-assessment-33", "label" : "Respiratory", "summary" : ": Respiratory\nOxygen Delivery Method / Oxygen Delivery Method: Room Air\nSputum / Color: None\nSputum / Amount: None\nRespiratory Symptoms: Shortness of Breath\nRespiratory Symptoms: Difficulty Breathing with Activity\nBreath Sounds / Right Upper Lobe: Clear\nRespirations: Regular" }, { "author" : "Nicholas Timerly, Registered Nurse", "dateTime" : "2026-09-21T08:42:00", "id" : "rachel-williams-assessment-34", "label" : "Respiratory", "summary" : ": Respiratory\nOxygen Delivery Method / Oxygen Delivery Method: Room Air\nSputum / Color: None\nSputum / Amount: None\nRespiratory Symptoms: Difficulty Breathing with Activity\nBreath Sounds / Right Upper Lobe: Clear\nRespirations: Regular" }, { "author" : "Nicholas Timerly, Registered Nurse", "dateTime" : "2026-09-22T08:42:00", "id" : "rachel-williams-assessment-35", "label" : "Respiratory", "summary" : ": Respiratory\nOxygen Delivery Method / Oxygen Delivery Method: Room Air\nSputum / Color: None\nSputum / Amount: None\nRespiratory Symptoms: Difficulty Breathing with Activity\nBreath Sounds / Right Upper Lobe: Clear\nRespirations: Regular" }, { "author" : "Ayoka Reed, RN, Registered Nurse", "dateTime" : "2026-09-21T20:42:00", "id" : "rachel-williams-assessment-36", "label" : "Mental Health", "summary" : ": Mental Health\nBehavior / Affect: Appropriate\nStressors: Hospitalization\nCoping: Well" }, { "author" : "Ayoka Reed, RN, Registered Nurse", "dateTime" : "2026-09-19T21:42:00", "id" : "rachel-williams-assessment-37", "label" : "Mental Health", "summary" : ": Mental Health\nAdditional Notes / Additional Notes: Social Work to see regarding any at home needs.\nBehavior / Affect: Appropriate\nStressors: Hospitalization\nCoping: Well\nConsult: Social Work" }, { "author" : "Nicholas Timerly, Registered Nurse", "dateTime" : "2026-09-20T08:42:00", "id" : "rachel-williams-assessment-38", "label" : "Mental Health", "summary" : ": Mental Health\nBehavior / Affect: Appropriate\nStressors: Hospitalization\nCoping: Well" }, { "author" : "Ayoka Reed, RN, Registered Nurse", "dateTime" : "2026-09-20T20:42:00", "id" : "rachel-williams-assessment-39", "label" : "Mental Health", "summary" : ": Mental Health\nBehavior / Affect: Appropriate\nStressors: Condition\nStressors: Hospitalization\nCoping: Well" }, { "author" : "Nicholas Timerly, Registered Nurse", "dateTime" : "2026-09-21T08:42:00", "id" : "rachel-williams-assessment-40", "label" : "Mental Health", "summary" : ": Mental Health\nBehavior / Affect: Appropriate\nStressors: Hospitalization\nCoping: Well" }, { "author" : "Ayoka Reed, RN, Registered Nurse", "dateTime" : "2026-09-21T20:42:00", "id" : "rachel-williams-assessment-41", "label" : "Musculoskeletal", "summary" : ": Musculoskeletal\nMusculoskeletal Symptoms: Pain\nMuscle Tone / Strength / LUE (Left Upper Extremity), Left Upper Extremity: Active Assistive Range of Motion in Left Upper Extremity\nMuscle Tone / Strength / LLE (Left Lower Extremity), Left Lower Extremity: Active Assistive Range of Motion in Left Lower Extremity\nMuscle Tone / Strength / RUE (Right Upper Extremity), Right Upper Extremity: Active Range of Motion in Right Upper Extremity\nMuscle Tone / Strength / RLE (Right Lower Extremity), Right Lower Extremity: Active Range of Motion in Right Lower Extremity\nWeight Bearing / Gait / Posture: Unsteady\nDevices: Cane" }, { "author" : "Ayoka Reed, RN, Registered Nurse", "dateTime" : "2026-09-19T21:42:00", "id" : "rachel-williams-assessment-42", "label" : "Musculoskeletal", "summary" : ": Musculoskeletal\nMusculoskeletal Symptoms: Pain\nMusculoskeletal Symptoms: Joint Swelling\nMusculoskeletal Symptoms: Joint Stiffness\nMuscle Tone / Strength / RUE (Right Upper Extremity), Right Upper Extremity: Normal strength in Right Upper Extremity\nMuscle Tone / Strength / RLE (Right Lower Extremity), Right Lower Extremity: Normal strength in Right Lower Extremity\nMuscle Tone / Strength / LUE (Left Upper Extremity), Left Upper Extremity: Movement against resistance, but less than normal in Left Upper Extremity\nMuscle Tone / Strength / LLE (Left Lower Extremity), Left Lower Extremity: Movement against gravity, but not against added resistance in Left Lower Extremity\nMuscle Tone / Strength / LUE (Left Upper Extremity), Left Upper Extremity: Active Assistive Range of Motion in Left Upper Extremity\nMuscle Tone / Strength / LLE (Left Lower Extremity), Left Lower Extremity: Active Assistive Range of Motion in Left Lower Extremity\nMuscle Tone / Strength / RUE (Right Upper Extremity), Right Upper Extremity: Active Range of Motion in Right Upper Extremity\nMuscle Tone / Strength / RLE (Right Lower Extremity), Right Lower Extremity: Active Range of Motion in Right Lower Extremity\nWeight Bearing / Gait / Posture: Unsteady\nDevices: Cane" }, { "author" : "Nicholas Timerly, Registered Nurse", "dateTime" : "2026-09-20T08:42:00", "id" : "rachel-williams-assessment-43", "label" : "Musculoskeletal", "summary" : ": Musculoskeletal\nMusculoskeletal Symptoms: Pain\nMusculoskeletal Symptoms: Joint Stiffness\nMuscle Tone / Strength / RUE (Right Upper Extremity), Right Upper Extremity: Normal strength in Right Upper Extremity\nMuscle Tone / Strength / RLE (Right Lower Extremity), Right Lower Extremity: Normal strength in Right Lower Extremity\nMuscle Tone / Strength / LUE (Left Upper Extremity), Left Upper Extremity: Movement against resistance, but less than normal in Left Upper Extremity\nMuscle Tone / Strength / LLE (Left Lower Extremity), Left Lower Extremity: Movement against gravity, but not against added resistance in Left Lower Extremity\nMuscle Tone / Strength / LUE (Left Upper Extremity), Left Upper Extremity: Active Assistive Range of Motion in Left Upper Extremity\nMuscle Tone / Strength / LLE (Left Lower Extremity), Left Lower Extremity: Active Assistive Range of Motion in Left Lower Extremity\nMuscle Tone / Strength / RUE (Right Upper Extremity), Right Upper Extremity: Active Range of Motion in Right Upper Extremity\nMuscle Tone / Strength / RLE (Right Lower Extremity), Right Lower Extremity: Active Range of Motion in Right Lower Extremity\nWeight Bearing / Gait / Posture: Unsteady\nDevices: Cane" }, { "author" : "Ayoka Reed, RN, Registered Nurse", "dateTime" : "2026-09-20T20:42:00", "id" : "rachel-williams-assessment-44", "label" : "Musculoskeletal", "summary" : ": Musculoskeletal\nMusculoskeletal Symptoms: Pain\nMusculoskeletal Symptoms: Joint Stiffness\nMuscle Tone / Strength / RUE (Right Upper Extremity), Right Upper Extremity: Normal strength in Right Upper Extremity\nMuscle Tone / Strength / RLE (Right Lower Extremity), Right Lower Extremity: Normal strength in Right Lower Extremity\nMuscle Tone / Strength / LUE (Left Upper Extremity), Left Upper Extremity: Movement against resistance, but less than normal in Left Upper Extremity\nMuscle Tone / Strength / LLE (Left Lower Extremity), Left Lower Extremity: Movement against gravity, but not against added resistance in Left Lower Extremity\nMuscle Tone / Strength / LUE (Left Upper Extremity), Left Upper Extremity: Active Assistive Range of Motion in Left Upper Extremity\nMuscle Tone / Strength / LLE (Left Lower Extremity), Left Lower Extremity: Active Assistive Range of Motion in Left Lower Extremity\nMuscle Tone / Strength / RUE (Right Upper Extremity), Right Upper Extremity: Active Range of Motion in Right Upper Extremity\nMuscle Tone / Strength / RLE (Right Lower Extremity), Right Lower Extremity: Active Range of Motion in Right Lower Extremity\nWeight Bearing / Gait / Posture: Unsteady\nDevices: Cane" }, { "author" : "Nicholas Timerly, Registered Nurse", "dateTime" : "2026-09-21T08:42:00", "id" : "rachel-williams-assessment-45", "label" : "Musculoskeletal", "summary" : ": Musculoskeletal\nMusculoskeletal Symptoms: Pain\nMusculoskeletal Symptoms: Joint Stiffness\nMuscle Tone / Strength / RUE (Right Upper Extremity), Right Upper Extremity: Normal strength in Right Upper Extremity\nMuscle Tone / Strength / RLE (Right Lower Extremity), Right Lower Extremity: Normal strength in Right Lower Extremity\nMuscle Tone / Strength / LUE (Left Upper Extremity), Left Upper Extremity: Movement against resistance, but less than normal in Left Upper Extremity\nMuscle Tone / Strength / LLE (Left Lower Extremity), Left Lower Extremity: Movement against gravity, but not against added resistance in Left Lower Extremity\nMuscle Tone / Strength / LUE (Left Upper Extremity), Left Upper Extremity: Active Assistive Range of Motion in Left Upper Extremity\nMuscle Tone / Strength / LLE (Left Lower Extremity), Left Lower Extremity: Active Assistive Range of Motion in Left Lower Extremity\nMuscle Tone / Strength / RUE (Right Upper Extremity), Right Upper Extremity: Active Range of Motion in Right Upper Extremity\nMuscle Tone / Strength / RLE (Right Lower Extremity), Right Lower Extremity: Active Range of Motion in Right Lower Extremity\nWeight Bearing / Gait / Posture: Unsteady\nDevices: Cane" }, { "author" : "Nicholas Timerly, Registered Nurse", "dateTime" : "2026-09-22T08:42:00", "id" : "rachel-williams-assessment-46", "label" : "Musculoskeletal", "summary" : ": Musculoskeletal\nMusculoskeletal Symptoms: Pain\nMuscle Tone / Strength / RUE (Right Upper Extremity), Right Upper Extremity: Normal strength in Right Upper Extremity\nMuscle Tone / Strength / RLE (Right Lower Extremity), Right Lower Extremity: Normal strength in Right Lower Extremity\nMuscle Tone / Strength / LUE (Left Upper Extremity), Left Upper Extremity: Movement against resistance, but less than normal in Left Upper Extremity\nMuscle Tone / Strength / LLE (Left Lower Extremity), Left Lower Extremity: Movement against gravity, but not against added resistance in Left Lower Extremity\nMuscle Tone / Strength / LUE (Left Upper Extremity), Left Upper Extremity: Active Assistive Range of Motion in Left Upper Extremity\nMuscle Tone / Strength / LLE (Left Lower Extremity), Left Lower Extremity: Active Assistive Range of Motion in Left Lower Extremity\nMuscle Tone / Strength / RUE (Right Upper Extremity), Right Upper Extremity: Active Range of Motion in Right Upper Extremity\nMuscle Tone / Strength / RLE (Right Lower Extremity), Right Lower Extremity: Active Range of Motion in Right Lower Extremity\nWeight Bearing / Gait / Posture: Unsteady\nDevices: Cane" }, { "author" : "Ayoka Reed, RN, Registered Nurse", "dateTime" : "2026-09-19T21:42:00", "id" : "rachel-williams-assessment-47", "label" : "Pain Scale", "summary" : ": Pain Scale\nPain Location: left knee and wrist\nOnset Days: 0\nOnset Hours: 0\nOnset Minutes: 0\nOnset Relative To Timing Based On: after admission\nPain Frequency: Constant\nType Of Pain: Acute\nPain Goal: 2\nAggravating Factors: Movement\nAlleviating Factors: Rest\nPain Scale Used: 0-10\nPain Rating: 3\nPain Characteristics: Aching\nPain Characteristics: Dull" }, { "author" : "Ayoka Reed, RN, Registered Nurse", "dateTime" : "2026-09-19T21:42:00", "id" : "rachel-williams-assessment-48", "label" : "Braden Scale", "summary" : ": Braden Scale\nSensory Perception (ability to respond meaningfully to pressure-related discomfort) / Sensory Perception: Slightly Limited Responds to verbal commands, but cannot always communicate discomfort or the need to be turned. OR has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities.\nNutrition (usual food intake pattern) / Nutrition: Adequate Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products) per day. Occasionally will refuse a meal, but will usually take a supplement when offered OR is on a tube feeding or TPN regimen which probably meets most of nutritional needs.\nMobility (ability to change and control body position) / Mobility: No Limitation Makes major and frequent changes in position without assistance.\nActivity (degree of physical activity) / Activity: Walks Occasionally Walks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair.\nMoisture (degree to which skin is exposed to moisture) / Moisture: Rarely Moist Skin is usually dry, linen only requires changing at routine intervals\nFriction-Shear / Friction Shear: No Apparent Problem Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair.\nBraden Scale Total Score: 20\nResults: Low Risk" }, { "author" : "Ayoka Reed, RN, Registered Nurse", "dateTime" : "2026-09-20T20:42:00", "id" : "rachel-williams-assessment-49", "label" : "Braden Scale", "summary" : ": Braden Scale\nSensory Perception (ability to respond meaningfully to pressure-related discomfort) / Sensory Perception: Slightly Limited Responds to verbal commands, but cannot always communicate discomfort or the need to be turned. OR has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities.\nNutrition (usual food intake pattern) / Nutrition: Adequate Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products) per day. Occasionally will refuse a meal, but will usually take a supplement when offered OR is on a tube feeding or TPN regimen which probably meets most of nutritional needs.\nMobility (ability to change and control body position) / Mobility: Slightly Limited Makes frequent though slight changes in body or extremity position independently.\nActivity (degree of physical activity) / Activity: Walks Occasionally Walks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair.\nMoisture (degree to which skin is exposed to moisture) / Moisture: Rarely Moist Skin is usually dry, linen only requires changing at routine intervals\nFriction-Shear / Friction Shear: No Apparent Problem Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair.\nBraden Scale Total Score: 19\nResults: Low Risk" }, { "author" : "Ayoka Reed, RN, Registered Nurse", "dateTime" : "2026-09-21T20:42:00", "id" : "rachel-williams-assessment-50", "label" : "Braden Scale", "summary" : ": Braden Scale\nSensory Perception (ability to respond meaningfully to pressure-related discomfort) / Sensory Perception: Slightly Limited Responds to verbal commands, but cannot always communicate discomfort or the need to be turned. OR has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities.\nNutrition (usual food intake pattern) / Nutrition: Adequate Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products) per day. Occasionally will refuse a meal, but will usually take a supplement when offered OR is on a tube feeding or TPN regimen which probably meets most of nutritional needs.\nMobility (ability to change and control body position) / Mobility: Slightly Limited Makes frequent though slight changes in body or extremity position independently.\nActivity (degree of physical activity) / Activity: Walks Frequently Walks outside room at least twice a day and inside room at least once every two hours during waking hours.\nMoisture (degree to which skin is exposed to moisture) / Moisture: Rarely Moist Skin is usually dry, linen only requires changing at routine intervals\nFriction-Shear / Friction Shear: No Apparent Problem Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair.\nBraden Scale Total Score: 20\nResults: Low Risk" }, { "author" : "Ayoka Reed, RN, Registered Nurse", "dateTime" : "2026-09-19T21:42:00", "id" : "rachel-williams-assessment-51", "label" : "Site/Wound", "summary" : ": Site/Wound\nRegion: Leg\nSpecific Location: Knee, Anterior, Left\nType: Abrasion\nErythema\nBruising\nLength: 4\nWidth: 2.5\nDepth: 0\nDescription: bruising noted to left knee. Abrasion approximately 4cm X 2.5 cm.\nPeri-Wound Area: Pink\nDressing and Wound Care: None - open to air" }, { "author" : "Ayoka Reed, RN, Registered Nurse", "dateTime" : "2026-09-19T21:42:00", "id" : "rachel-williams-assessment-52", "label" : "Vascular Access", "summary" : ": Vascular Access\nLocation: right hand\nType: Peripheral IV\nDate Inserted Days: 0\nDate Inserted Relative To Timing Based On: after admission\nSize: #20\nSite Description: clean, dry, intact\nDressing: Tegaderm transparent dressing" }, { "author" : "Ayoka Reed, RN, Registered Nurse", "dateTime" : "2026-09-19T21:42:00", "id" : "rachel-williams-assessment-53", "label" : "ADLs", "summary" : ": ADLs\nADL Assessment / ADL Assessments: Bed mobility\nADL Assessment / ADL Assessments / Bed mobility: Independent\nADL Assessment / ADL Assessments: Transfer\nADL Assessment / ADL Assessments / Transfer: Limited assistance\nADL Assessment / ADL Assessments: Walking\nADL Assessment / ADL Assessments / Walking: Limited assistance\nADL Assessment / ADL Assessments: Dressing\nADL Assessment / ADL Assessments / Dressing: Independent\nADL Assessment / ADL Assessments: Eating\nADL Assessment / ADL Assessments / Eating: Independent\nADL Assessment / ADL Assessments: Toilet use\nADL Assessment / ADL Assessments / Toilet use: Limited assistance\nADL Assessment / ADL Assessments: Personal hygiene\nADL Assessment / ADL Assessments / Personal hygiene: Supervision needed\nADL Assessment / ADL Assessments: Bathing\nADL Assessment / ADL Assessments / Bathing: Supervision needed\nDiet Consumption: 50%\nCommunication: Short-term memory intact\nCommunication: Long-term memory intact\nCommunication: Has ability to understand\nCommunication: Has ability to make self understood" }, { "author" : "Ayoka Reed, RN, Registered Nurse", "dateTime" : "2026-09-21T20:42:00", "id" : "rachel-williams-assessment-54", "label" : "ADLs", "summary" : ": ADLs\nADL Assessment / ADL Assessments: Bed mobility\nADL Assessment / ADL Assessments / Bed mobility: Independent\nADL Assessment / ADL Assessments: Transfer\nADL Assessment / ADL Assessments / Transfer: Supervision needed\nADL Assessment / ADL Assessments: Walking\nADL Assessment / ADL Assessments / Walking: Limited assistance\nADL Assessment / ADL Assessments: Dressing\nADL Assessment / ADL Assessments / Dressing: Independent\nADL Assessment / ADL Assessments: Eating\nADL Assessment / ADL Assessments / Eating: Independent\nADL Assessment / ADL Assessments: Toilet use\nADL Assessment / ADL Assessments / Toilet use: Supervision needed\nADL Assessment / ADL Assessments: Personal hygiene\nADL Assessment / ADL Assessments / Personal hygiene: Independent\nADL Assessment / ADL Assessments: Bathing\nADL Assessment / ADL Assessments / Bathing: Independent\nDiet Consumption: 75%\nCommunication: Short-term memory intact\nCommunication: Long-term memory intact\nCommunication: Has ability to understand\nCommunication: Has ability to make self understood" }, { "author" : "Ayoka Reed, RN, Registered Nurse", "dateTime" : "2026-09-19T21:42:00", "id" : "rachel-williams-assessment-55", "label" : "Morse Fall Risk", "summary" : ": Morse Fall Risk\nDoes the patient have a recent history of falling?: Yes Patient has fallen at any point during this admission or there is an immediate history of falls (e.g., from seizures or impaired gate prior to admission)\nDoes the patient have secondary medical diagnoses?: No\nAre ambulatory aids used?: Uses crutches/cane/walker Patient uses crutches, a cane, or a walker\nDoes the patient have an intravenous apparatus or a heparin lock inserted?: Yes\nWhat is the patient’s gait?: Weak Patient is stooped but is able to lift the head while walking and does not lose balance; steps are short and the patient may shuffle\nWhat is the patient’s mental status (related to ambulatory abilities)? Determine the patient’s own self-assessment of his/her ability to walk. You may ask the patient, “Are you able to go to the bathroom alone or do you need assistance?”: Normal/oriented to own ability Patient’s reply judging his or her own ability to walk is consistent with the ambulatory order\nMorse Fall Risk Total Score: 70\nResults: High Risk (51 or higher)" }, { "author" : "Ayoka Reed, RN, Registered Nurse", "dateTime" : "2026-09-20T20:42:00", "id" : "rachel-williams-assessment-56", "label" : "Morse Fall Risk", "summary" : ": Morse Fall Risk\nDoes the patient have a recent history of falling?: Yes Patient has fallen at any point during this admission or there is an immediate history of falls (e.g., from seizures or impaired gate prior to admission)\nDoes the patient have secondary medical diagnoses?: No\nAre ambulatory aids used?: Uses crutches/cane/walker Patient uses crutches, a cane, or a walker\nDoes the patient have an intravenous apparatus or a heparin lock inserted?: Yes\nWhat is the patient’s gait?: Weak Patient is stooped but is able to lift the head while walking and does not lose balance; steps are short and the patient may shuffle\nWhat is the patient’s mental status (related to ambulatory abilities)? Determine the patient’s own self-assessment of his/her ability to walk. You may ask the patient, “Are you able to go to the bathroom alone or do you need assistance?”: Normal/oriented to own ability Patient’s reply judging his or her own ability to walk is consistent with the ambulatory order\nMorse Fall Risk Total Score: 70\nResults: High Risk (51 or higher)" }, { "author" : "Nicholas Timerly, Registered Nurse", "dateTime" : "2026-09-20T08:42:00", "id" : "rachel-williams-assessment-57", "label" : "Morse Fall Risk", "summary" : ": Morse Fall Risk\nDoes the patient have a recent history of falling?: Yes Patient has fallen at any point during this admission or there is an immediate history of falls (e.g., from seizures or impaired gate prior to admission)\nDoes the patient have secondary medical diagnoses?: No\nAre ambulatory aids used?: Uses crutches/cane/walker Patient uses crutches, a cane, or a walker\nDoes the patient have an intravenous apparatus or a heparin lock inserted?: Yes\nWhat is the patient’s gait?: Weak Patient is stooped but is able to lift the head while walking and does not lose balance; steps are short and the patient may shuffle\nWhat is the patient’s mental status (related to ambulatory abilities)? Determine the patient’s own self-assessment of his/her ability to walk. You may ask the patient, “Are you able to go to the bathroom alone or do you need assistance?”: Normal/oriented to own ability Patient’s reply judging his or her own ability to walk is consistent with the ambulatory order\nMorse Fall Risk Total Score: 70\nResults: High Risk (51 or higher)" }, { "author" : "Nicholas Timerly, Registered Nurse", "dateTime" : "2026-09-21T08:42:00", "id" : "rachel-williams-assessment-58", "label" : "Morse Fall Risk", "summary" : ": Morse Fall Risk\nDoes the patient have a recent history of falling?: Yes Patient has fallen at any point during this admission or there is an immediate history of falls (e.g., from seizures or impaired gate prior to admission)\nDoes the patient have secondary medical diagnoses?: No\nAre ambulatory aids used?: Uses crutches/cane/walker Patient uses crutches, a cane, or a walker\nDoes the patient have an intravenous apparatus or a heparin lock inserted?: Yes\nWhat is the patient’s gait?: Weak Patient is stooped but is able to lift the head while walking and does not lose balance; steps are short and the patient may shuffle\nWhat is the patient’s mental status (related to ambulatory abilities)? Determine the patient’s own self-assessment of his/her ability to walk. You may ask the patient, “Are you able to go to the bathroom alone or do you need assistance?”: Normal/oriented to own ability Patient’s reply judging his or her own ability to walk is consistent with the ambulatory order\nMorse Fall Risk Total Score: 70\nResults: High Risk (51 or higher)" }, { "author" : "Ayoka Reed, RN, Registered Nurse", "dateTime" : "2026-09-21T20:42:00", "id" : "rachel-williams-assessment-59", "label" : "Morse Fall Risk", "summary" : ": Morse Fall Risk\nDoes the patient have a recent history of falling?: Yes Patient has fallen at any point during this admission or there is an immediate history of falls (e.g., from seizures or impaired gate prior to admission)\nDoes the patient have secondary medical diagnoses?: No\nAre ambulatory aids used?: Uses crutches/cane/walker Patient uses crutches, a cane, or a walker\nDoes the patient have an intravenous apparatus or a heparin lock inserted?: Yes\nWhat is the patient’s gait?: Weak Patient is stooped but is able to lift the head while walking and does not lose balance; steps are short and the patient may shuffle\nWhat is the patient’s mental status (related to ambulatory abilities)? Determine the patient’s own self-assessment of his/her ability to walk. You may ask the patient, “Are you able to go to the bathroom alone or do you need assistance?”: Normal/oriented to own ability Patient’s reply judging his or her own ability to walk is consistent with the ambulatory order\nMorse Fall Risk Total Score: 70\nResults: High Risk (51 or higher)" }, { "author" : "Nicholas Timerly, Registered Nurse", "dateTime" : "2026-09-22T08:42:00", "id" : "rachel-williams-assessment-60", "label" : "Morse Fall Risk", "summary" : ": Morse Fall Risk\nDoes the patient have a recent history of falling?: Yes Patient has fallen at any point during this admission or there is an immediate history of falls (e.g., from seizures or impaired gate prior to admission)\nDoes the patient have secondary medical diagnoses?: No\nAre ambulatory aids used?: Uses crutches/cane/walker Patient uses crutches, a cane, or a walker\nDoes the patient have an intravenous apparatus or a heparin lock inserted?: Yes\nWhat is the patient’s gait?: Weak Patient is stooped but is able to lift the head while walking and does not lose balance; steps are short and the patient may shuffle\nWhat is the patient’s mental status (related to ambulatory abilities)? Determine the patient’s own self-assessment of his/her ability to walk. You may ask the patient, “Are you able to go to the bathroom alone or do you need assistance?”: Normal/oriented to own ability Patient’s reply judging his or her own ability to walk is consistent with the ambulatory order\nMorse Fall Risk Total Score: 70\nResults: High Risk (51 or higher)" } ], "intakeOutput" : { "documentedIntakeTotalMl" : 2700, "documentedNetMl" : -400, "documentedOutputTotalMl" : 3100, "intakeEntries" : [ { "amountMl" : 600, "id" : "rw-in-0", "time" : "2026-09-20T07:42:00", "type" : "Oral" }, { "amountMl" : 400, "id" : "rw-in-1", "time" : "2026-09-20T20:42:00", "type" : "Oral" }, { "amountMl" : 700, "id" : "rw-in-2", "time" : "2026-09-21T07:42:00", "type" : "Oral" }, { "amountMl" : 300, "id" : "rw-in-3", "time" : "2026-09-21T20:42:00", "type" : "Oral" }, { "amountMl" : 700, "id" : "rw-in-4", "time" : "2026-09-22T08:42:00", "type" : "Oral" } ], "outputEntries" : [ { "amountMl" : 800, "id" : "rw-out-0", "time" : "2026-09-20T07:42:00", "type" : "Urine" }, { "amountMl" : 500, "id" : "rw-out-1", "time" : "2026-09-20T20:42:00", "type" : "Urine" }, { "amountMl" : 800, "id" : "rw-out-2", "time" : "2026-09-21T07:42:00", "type" : "Urine" }, { "amountMl" : 600, "id" : "rw-out-3", "time" : "2026-09-21T20:42:00", "type" : "Urine" }, { "amountMl" : 400, "id" : "rw-out-4", "time" : "2026-09-22T08:42:00", "type" : "Urine" } ] }, "labs" : [ { "category" : "Basic metabolic panel", "collectedDateTime" : "2026-09-19T22:42:00", "flag" : "Normal", "id" : "rachel-williams-lab-1", "referenceRange" : "135–145 mEq/L", "result" : "135", "test" : "Sodium" }, { "category" : "Basic metabolic panel", "collectedDateTime" : "2026-09-19T22:42:00", "flag" : "Normal", "id" : "rachel-williams-lab-2", "referenceRange" : "3.5–5.1 mEq/L", "result" : "3.5", "test" : "Potassium" }, { "category" : "Basic metabolic panel", "collectedDateTime" : "2026-09-19T22:42:00", "flag" : "Normal", "id" : "rachel-williams-lab-3", "referenceRange" : "98–107 mEq/L", "result" : "102", "test" : "Chloride" }, { "category" : "Basic metabolic panel", "collectedDateTime" : "2026-09-19T22:42:00", "flag" : "Normal", "id" : "rachel-williams-lab-4", "referenceRange" : "22–29 mEq/L", "result" : "29", "test" : "CO2" }, { "category" : "Basic metabolic panel", "collectedDateTime" : "2026-09-19T22:42:00", "flag" : "Normal", "id" : "rachel-williams-lab-5", "referenceRange" : "70–99 mg/dL", "result" : "90", "test" : "Glucose" }, { "category" : "Basic metabolic panel", "collectedDateTime" : "2026-09-19T22:42:00", "flag" : "Normal", "id" : "rachel-williams-lab-6", "referenceRange" : "6–20 mg/dL", "result" : "7", "test" : "BUN" }, { "category" : "Basic metabolic panel", "collectedDateTime" : "2026-09-19T22:42:00", "flag" : "Normal", "id" : "rachel-williams-lab-7", "referenceRange" : "0.50–1.00 mg/dL", "result" : "0.7", "test" : "Creatinine" }, { "category" : "Basic metabolic panel", "collectedDateTime" : "2026-09-19T22:42:00", "flag" : "Normal", "id" : "rachel-williams-lab-8", "referenceRange" : "8.4–10.5 mg/dL", "result" : "9.4", "test" : "Calcium" }, { "category" : "Basic metabolic panel", "collectedDateTime" : "2026-09-20T20:42:00", "flag" : "Normal", "id" : "rachel-williams-lab-9", "referenceRange" : "135–145 mEq/L", "result" : "136", "test" : "Sodium" }, { "category" : "Basic metabolic panel", "collectedDateTime" : "2026-09-20T20:42:00", "flag" : "Low", "id" : "rachel-williams-lab-10", "referenceRange" : "3.5–5.1 mEq/L", "result" : "3.4", "test" : "Potassium" }, { "category" : "Basic metabolic panel", "collectedDateTime" : "2026-09-20T20:42:00", "flag" : "Normal", "id" : "rachel-williams-lab-11", "referenceRange" : "98–107 mEq/L", "result" : "99", "test" : "Chloride" }, { "category" : "Basic metabolic panel", "collectedDateTime" : "2026-09-20T20:42:00", "flag" : "Normal", "id" : "rachel-williams-lab-12", "referenceRange" : "22–29 mEq/L", "result" : "26", "test" : "CO2" }, { "category" : "Basic metabolic panel", "collectedDateTime" : "2026-09-20T20:42:00", "flag" : "Normal", "id" : "rachel-williams-lab-13", "referenceRange" : "70–99 mg/dL", "result" : "75", "test" : "Glucose" }, { "category" : "Basic metabolic panel", "collectedDateTime" : "2026-09-20T20:42:00", "flag" : "Normal", "id" : "rachel-williams-lab-14", "referenceRange" : "6–20 mg/dL", "result" : "10", "test" : "BUN" }, { "category" : "Basic metabolic panel", "collectedDateTime" : "2026-09-20T20:42:00", "flag" : "Normal", "id" : "rachel-williams-lab-15", "referenceRange" : "0.50–1.00 mg/dL", "result" : "0.8", "test" : "Creatinine" }, { "category" : "Basic metabolic panel", "collectedDateTime" : "2026-09-20T20:42:00", "flag" : "Normal", "id" : "rachel-williams-lab-16", "referenceRange" : "8.4–10.5 mg/dL", "result" : "9.3", "test" : "Calcium" }, { "category" : "Basic metabolic panel", "collectedDateTime" : "2026-09-21T20:42:00", "flag" : "Normal", "id" : "rachel-williams-lab-17", "referenceRange" : "135–145 mEq/L", "result" : "136", "test" : "Sodium" }, { "category" : "Basic metabolic panel", "collectedDateTime" : "2026-09-21T20:42:00", "flag" : "Low", "id" : "rachel-williams-lab-18", "referenceRange" : "3.5–5.1 mEq/L", "result" : "3.3", "test" : "Potassium" }, { "category" : "Basic metabolic panel", "collectedDateTime" : "2026-09-21T20:42:00", "flag" : "Normal", "id" : "rachel-williams-lab-19", "referenceRange" : "98–107 mEq/L", "result" : "100", "test" : "Chloride" }, { "category" : "Basic metabolic panel", "collectedDateTime" : "2026-09-21T20:42:00", "flag" : "Normal", "id" : "rachel-williams-lab-20", "referenceRange" : "22–29 mEq/L", "result" : "28", "test" : "CO2" }, { "category" : "Basic metabolic panel", "collectedDateTime" : "2026-09-21T20:42:00", "flag" : "Normal", "id" : "rachel-williams-lab-21", "referenceRange" : "70–99 mg/dL", "result" : "90", "test" : "Glucose" }, { "category" : "Basic metabolic panel", "collectedDateTime" : "2026-09-21T20:42:00", "flag" : "Normal", "id" : "rachel-williams-lab-22", "referenceRange" : "6–20 mg/dL", "result" : "13", "test" : "BUN" }, { "category" : "Basic metabolic panel", "collectedDateTime" : "2026-09-21T20:42:00", "flag" : "Normal", "id" : "rachel-williams-lab-23", "referenceRange" : "0.50–1.00 mg/dL", "result" : "0.8", "test" : "Creatinine" }, { "category" : "Basic metabolic panel", "collectedDateTime" : "2026-09-21T20:42:00", "flag" : "Normal", "id" : "rachel-williams-lab-24", "referenceRange" : "8.4–10.5 mg/dL", "result" : "9.2", "test" : "Calcium" }, { "category" : "Basic metabolic panel", "collectedDateTime" : "2026-09-22T20:42:00", "flag" : "Normal", "id" : "rachel-williams-lab-25", "referenceRange" : "135–145 mEq/L", "result" : "137", "test" : "Sodium" }, { "category" : "Basic metabolic panel", "collectedDateTime" : "2026-09-22T20:42:00", "flag" : "Low", "id" : "rachel-williams-lab-26", "referenceRange" : "3.5–5.1 mEq/L", "result" : "3.2", "test" : "Potassium" }, { "category" : "Basic metabolic panel", "collectedDateTime" : "2026-09-22T20:42:00", "flag" : "Normal", "id" : "rachel-williams-lab-27", "referenceRange" : "98–107 mEq/L", "result" : "100", "test" : "Chloride" }, { "category" : "Basic metabolic panel", "collectedDateTime" : "2026-09-22T20:42:00", "flag" : "Normal", "id" : "rachel-williams-lab-28", "referenceRange" : "22–29 mEq/L", "result" : "27", "test" : "CO2" }, { "category" : "Basic metabolic panel", "collectedDateTime" : "2026-09-22T20:42:00", "flag" : "Normal", "id" : "rachel-williams-lab-29", "referenceRange" : "70–99 mg/dL", "result" : "83", "test" : "Glucose" }, { "category" : "Basic metabolic panel", "collectedDateTime" : "2026-09-22T20:42:00", "flag" : "Normal", "id" : "rachel-williams-lab-30", "referenceRange" : "6–20 mg/dL", "result" : "12", "test" : "BUN" }, { "category" : "Basic metabolic panel", "collectedDateTime" : "2026-09-22T20:42:00", "flag" : "Normal", "id" : "rachel-williams-lab-31", "referenceRange" : "0.50–1.00 mg/dL", "result" : "0.8", "test" : "Creatinine" }, { "category" : "Basic metabolic panel", "collectedDateTime" : "2026-09-22T20:42:00", "flag" : "Normal", "id" : "rachel-williams-lab-32", "referenceRange" : "8.4–10.5 mg/dL", "result" : "9.2", "test" : "Calcium" }, { "category" : "BNP", "collectedDateTime" : "2026-09-19T22:42:00", "flag" : "Normal", "id" : "rachel-williams-lab-33", "referenceRange" : "<100 pg/mL", "result" : "99", "test" : "BNP" }, { "category" : "BNP", "collectedDateTime" : "2026-09-20T20:42:00", "flag" : "High", "id" : "rachel-williams-lab-34", "referenceRange" : "<100 pg/mL", "result" : "100", "test" : "BNP" }, { "category" : "BNP", "collectedDateTime" : "2026-09-21T20:42:00", "flag" : "Normal", "id" : "rachel-williams-lab-35", "referenceRange" : "<100 pg/mL", "result" : "99", "test" : "BNP" }, { "category" : "BNP", "collectedDateTime" : "2026-09-21T20:42:00", "flag" : "Normal", "id" : "rachel-williams-lab-36", "referenceRange" : "<100 pg/mL", "result" : "99", "test" : "BNP" } ], "medications" : [ { "doseRouteFrequency" : "20 mg PO q24h", "drug" : "Furosemide", "id" : "rw-med-1", "nextDue" : "2026-09-22T20:42:00", "notes" : "", "orderedBy" : "Richard Lee, MD", "orderedDateTime" : "2026-09-22T20:42:00", "section" : "Scheduled", "status" : "Active" }, { "doseRouteFrequency" : "10 mEq PO q24h", "drug" : "Potassium chloride", "id" : "rw-med-2", "nextDue" : "2026-09-22T20:42:00", "notes" : "", "orderedBy" : "Richard Lee, MD", "orderedDateTime" : "2026-09-22T20:42:00", "section" : "Scheduled", "status" : "Active" }, { "doseRouteFrequency" : "5 mg PO q4h PRN", "drug" : "Hydrocodone bitartrate", "id" : "rw-med-3", "nextDue" : "2026-09-20T20:42:00", "notes" : "As needed for pain.", "orderedBy" : "Richard Lee, MD", "orderedDateTime" : "2026-09-20T20:42:00", "section" : "PRN", "status" : "Active" } ], "notes" : [ { "id" : "rachel-williams-allergy", "summary" : "NKA, medication category, documented by Ayoka Reed, RN at 2026-09-19 21:42 in source allergy table.", "type" : "Allergy documentation" }, { "id" : "rachel-williams-family-health-history", "summary" : "Disease/Condition / Disease/Condition: Heart Disease\nType / Type: CAD\nFamily Member / Family Member: Father\nAge at Diagnosis / Age at Diagnosis: 60 years and older\nDeceased / Deceased: Yes\nDisease/Condition / Disease/Condition: Heart Disease\nType / Type: Cardiomyopathy\nFamily Member / Family Member: Mother\nAge at Diagnosis / Age at Diagnosis: 50-59 years\nDeceased / Deceased: Yes\nDisease/Condition / Disease/Condition: Diabetes/Pre-Diabetes/Metabolic Syndrome\nType / Type: Type II Diabetes\nFamily Member / Family Member: Mother\nAge at Diagnosis / Age at Diagnosis: 50-59 years\nDeceased / Deceased: Yes\nDisease/Condition / Disease/Condition: Hypertension\nFamily Member / Family Member: Father\nAge at Diagnosis / Age at Diagnosis: 50-59 years\nDeceased / Deceased: Yes", "type" : "Family Health History" }, { "author" : "Ayoka Reed, RN , Registered Nurse", "dateTime" : "2026-09-22T20:42:00", "id" : "rachel-williams-note-1", "summary" : "Assisted pt with ambulation using cane. While ambulating pt states, \"Oh dear I feel dizzy.\" Pt began to fall toward RN, but pt assisted to chair without injury. Vital Signs documented.", "type" : "Nursing - Event" }, { "author" : "Richard Lee, MD , Admitting Physician", "dateTime" : "2026-09-21T20:42:00", "id" : "rachel-williams-note-2", "summary" : "Pt injured her left knee and wrist when she fell on an icy sidewalk. She has been on the ortho/neuro unit for several days. She has a history of cardiomyopathy. Prior to discharge, pt requires physical therapy and cane-walking instructions.", "type" : "Physician Notes" }, { "author" : "Richard Lee, MD , Admitting Physician", "dateTime" : "2026-09-21T20:42:00", "id" : "rachel-williams-note-3", "summary" : "PROGRESS NOTE: Hospital Day #2 PROGRESS NOTE Hospital Day #1 S: \"I'm still getting dizzy when I am standing up and walking\" My hip and wrist aren't as sore as when I first got here\". O: afebrile, HR 92, RR 16, BP 102/60, Sats 98% on room air. 3lb weight loss since admission Patient AO X 4, states feeling dizzy at times. Muscle tone decreased in LUE and LLE 4/5. S1, S2, with S3, +1 peripheral pulses, +2 pitting edema in lower extremities. Lung sounds diminished in lower bases but clear throughout all fields, no signs of respiratory distress. BNP WNL, BMP values normal except for potassium at 3.3. States SOB with exertion. Adequate dietary intake, active bowel sounds in all quadrants, states occasional nausea. Voiding without difficulty, requires assistance to bathroom for ambulation. A: 1. Syncope of unknown origin 2. Hypokalemia 3. Muscle Strength weakness 4. Cardiomyopathy P: BMP today with Potassium level of 3.3. Will begin potassium supplement 10 meq orally later today. PT continues to work with patient for strengthening and conditioning. Ambulate in hallways with cane 3-4 times a day. Labs in the AM, will re-evaluate for potential discharge tomorrow.", "type" : "Physician Notes" }, { "author" : "Richard Lee, MD , Admitting Physician", "dateTime" : "2026-09-20T20:42:00", "id" : "rachel-williams-note-4", "summary" : "PROGRESS NOTE Hospital Day #1 S: \"I'm still feeling sore, but I'm able to tolerate the pain. I'm a little dizzy when I stand up, but that happens sometimes\". O: Vitals: T 97.7 oral, HR 92, RR 22, BP 104/64, Sats 97% on room air Patient AO X 4, states feeling dizzy at times. Muscle tone decreased in LUE and LLE 4/5. S1, S2, with S3, +1 peripheral pulses, +2 pitting edema in lower extremities. Lung sounds diminished in lower bases but clear throughout all fields, no signs of respiratory distress. BNP WNL, BMP values normal States SOB with exertion. Adequate dietary intake, active bowel sounds in all quadrants, states occasional nausea. Voiding without difficulty, requires assistance to bathroom for ambulation. A: 1. Syncope of unknown origin 2. Muscle Strength weakness 3. Cardiomyopathy P: PT to work with patient for strengthening and conditioning. Ambulate in hallways with cane. PT to work with patient on use of cane with walking. Labs in the AM, will re-evaluate for potential discharge in next 1-2 days.", "type" : "Physician Notes" }, { "author" : "Richard Lee, MD , Admitting Physician", "dateTime" : "2026-09-20T04:42:00", "id" : "rachel-williams-note-5", "summary" : "Admission Note: S: \"I fell while I was walking and landed on my left hip and wrist\" They are so sore that I thought I may have broke something\". \"I've been dizzy lately when walking, this time I think it caused me to fall\" O: Patient lives alone, widowed, arrived in ED 7 hours ago via ambulance. Alert and pleasant, able to answer questions without hesitation or confusion. Past Medical History: Cardiomyopathy Past Surgical History: None Home Medications: Furosemide 20mg PO daily HEENT: Sclera clear, no visual trauma to head, teeth and dentures intact, no drainage from ears or nose, HOH in left ear, hearing aid present. NEURO: AO X 4, denies HA or striking head when she fell. Muscle strength decreased in LUE and LLE when resistance applied. Assisted ROM for LLE and LUE movement. RUE and RLE muscle tone 5/5 with active ROM intact. Patellar DTR's +2 CARDIAC: S1, S2 with additional S3, +1 peripheral pulses bilaterally in all extremities, CRT < 3 sec in RUE and RLE, CRT > 3 sec in LLE and LUE. +2 pitting edema in lower extremities bilaterally. Skin pink, warm, dry, no clubbing of fingernails. RESP: No signs of distress, lungs clear to auscultation in upper fields bilaterally. Lung sounds diminished in the bases bilaterally. Sats 97% on room air. GI: Abdominal soft, flat, non-tender with active bowel sounds in all quadrants bilaterally GU: Voiding without difficulty. Urine clear, yellow without odor PSYCH: Alert, cooperative, calm, denies OCD tendencies, depression, or anxiety MUSCULO: Moves LLE and LUE when asked, RUE and RLE move independently. Muscle tone to LLE and LUE 4/5 and RUE and RLE 5/5. Unsteady gait, uses cane for ambulation. Joint pain and stiffness present in LUE and LLE. INTEG: Skin pink warm, dry, loose turgor. Abrasion on left knee 4 X 2.5cm with dried blood, erythema and bruising. No decubitus ulcerations observed over any skin surfaces. A: Geriatric patient with syncope event. Possible causes dehyrdration, electrolyte imbalance, TIA, arrhythmia P: Plan to admit to hospital medicine floor for observation. Will obtain BNP, BMP to assess for heart failure or electrolyte imbalance. Consult to cardiology if needed. Consult to OT/PT for strengthening and can walking training.", "type" : "Physician Notes" }, { "id" : "rachel-williams-reconciliation-8", "summary" : "Weight reconciliation: dated standing weights were120 lb on 9/19 at 21:42,118 lb on 9/20 at 20:42,117 lb on 9/21 at 20:42. Latest117 lb (53.1 kg) used in overview; source demographics header145 lb conflicts with the dated trend and should be reverified.", "type" : "Chart clarification" } ], "orders" : [ { "author" : "Richard Lee, MD", "category" : "Nursing", "dateTime" : "2026-09-21T20:42:00", "id" : "rw-order-1", "orderText" : "Cane use training. q8h. Ambulate every shift with cane assistance.", "status" : "Active" }, { "author" : "Richard Lee, MD", "category" : "Physical therapy", "dateTime" : "2026-09-21T20:42:00", "id" : "rw-order-2", "orderText" : "Assistive device — cane. Once. Cane walking instructions by physical therapy.", "status" : "Active" }, { "author" : "Richard Lee, MD", "category" : "Laboratory", "dateTime" : "2026-09-19T21:42:00", "id" : "rw-order-3", "orderText" : "BNP. q24h every morning.", "status" : "Active" }, { "author" : "Richard Lee, MD", "category" : "Laboratory", "dateTime" : "2026-09-19T21:42:00", "id" : "rw-order-4", "orderText" : "BMP. q24h every morning.", "status" : "Active" }, { "author" : "Richard Lee, MD", "category" : "Nursing activity", "dateTime" : "2026-09-19T20:42:00", "id" : "rw-order-5", "orderText" : "Orthostatic blood pressure. STAT once. Measure BP and pulse supine, sitting, standing. Notify provider if SBP drops >20 or DBP >10.", "status" : "Active" }, { "author" : "Richard Lee, MD", "category" : "Nursing monitoring", "dateTime" : "2026-09-19T21:42:00", "id" : "rw-order-6", "orderText" : "Vital signs. q12h.", "status" : "Active" }, { "author" : "Richard Lee, MD", "category" : "Nursing monitoring", "dateTime" : "2026-09-19T21:42:00", "id" : "rw-order-7", "orderText" : "Intake/output. q12h.", "status" : "Active" }, { "author" : "Richard Lee, MD", "category" : "Medicine", "dateTime" : "2026-09-22T20:42:00", "id" : "rw-med-order-1", "orderText" : "Furosemide: 20 mg PO q24h. ", "status" : "Active" }, { "author" : "Richard Lee, MD", "category" : "Medicine", "dateTime" : "2026-09-22T20:42:00", "id" : "rw-med-order-2", "orderText" : "Potassium chloride: 10 mEq PO q24h. ", "status" : "Active" }, { "author" : "Richard Lee, MD", "category" : "Medicine", "dateTime" : "2026-09-20T20:42:00", "id" : "rw-med-order-3", "orderText" : "Hydrocodone bitartrate: 5 mg PO q4h PRN. As needed for pain.", "status" : "Active" } ], "overview" : { "height" : "64 in / 162.6 cm", "isolationIndicator" : "Standard", "religion" : "Christian", "weightKg" : 53.1 }, "vitals" : [ { "bloodPressure" : "110/70", "dateTime" : "2026-09-19T21:42:00", "heartRate" : 90, "id" : "rw-vital-1", "oxygenDevice" : "Room air", "respiratoryRate" : 16, "spo2" : "96%", "temperature" : "98.2 °F oral" }, { "bloodPressure" : "108/68", "dateTime" : "2026-09-20T08:42:00", "heartRate" : 88, "id" : "rw-vital-2", "oxygenDevice" : "Room air", "respiratoryRate" : 18, "spo2" : "97%", "temperature" : "98.3 °F oral" }, { "bloodPressure" : "104/64", "dateTime" : "2026-09-20T20:42:00", "heartRate" : 92, "id" : "rw-vital-3", "oxygenDevice" : "Room air", "respiratoryRate" : 22, "spo2" : "97%", "temperature" : "97.7 °F oral" }, { "bloodPressure" : "104/60", "dateTime" : "2026-09-21T08:42:00", "heartRate" : 90, "id" : "rw-vital-4", "oxygenDevice" : "Room air", "respiratoryRate" : 16, "spo2" : "98%", "temperature" : "97.8 °F oral" }, { "bloodPressure" : "102/60", "dateTime" : "2026-09-21T20:42:00", "heartRate" : 92, "id" : "rw-vital-5", "oxygenDevice" : "Room air", "respiratoryRate" : 16, "spo2" : "97%", "temperature" : "98 °F oral" }, { "bloodPressure" : "100/58", "dateTime" : "2026-09-22T08:42:00", "heartRate" : 91, "id" : "rw-vital-6", "oxygenDevice" : "Room air", "respiratoryRate" : 18, "spo2" : "97%", "temperature" : "98.1 °F oral" }, { "bloodPressure" : "102/60", "dateTime" : "2026-09-22T20:42:00", "heartRate" : 82, "id" : "rw-vital-7", "oxygenDevice" : "Room air", "respiratoryRate" : 16, "spo2" : "95%", "temperature" : "98.7 °F" } ] }, "patient" : { "admitDateTime" : "2026-09-19T20:42:00", "admittingDiagnosis" : "Cardiomyopathy", "allergies" : [ ], "attending" : "Richard Lee, MD", "chartDisplayName" : "Williams, Rachel", "codeStatus" : "Full Code", "dob" : "2/6/XX", "history" : { "chiefComplaint" : "", "pastMedicalHistory" : [ "General Medical History / Disease/Condition / : Cardiomyopathy (dilated)", "General Medical History / Date Diagnosed / Date Diagnosed: 04/29/2018", "General Medical History / Active: Active", "Transfusion History / Previous Blood Transfusion?: No", "Transfusion History / Does Patient Know His/Her Blood Type?: No", "Pain History / History of Chronic Pain?: No", "Screenings / Mammogram: Yes", "Screenings / Result: Normal" ], "pastSurgicalHistory" : [ "Previous Surgical Procedures: No prior surgical history" ], "socialHistory" : [ "Age: 80 years", "Home Situation / Patient Living Situation: Home", "Home Situation / Lives With: Alone", "Education / Highest Grade Completed: College", "Education / Able to Read?: Yes", "Education / Able to Write?: Yes", "Nicotine Use / Cigarettes: Nonsmoker", "Nicotine Use / Chewing Tobacco: Nonuser", "Nicotine Use / Cigars/Pipe: Nonsmoker", "Nicotine Use / Is patient exposed to second-hand smoke?: No", "Alcohol Use / Alcohol Status: Nondrinker", "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?: Yes", "Nutritional Screening / Does patient have diabetes?: No", "Nutritional Screening / Stool Frequency: Daily", "Nutritional Screening / Stool Description: Formed", "Nutritional Screening / Last Bowel Movement Days: 1", "Nutritional Screening / Last Bowel Movement Relative To Timing Based On: before student launches assignment", "Exercise Screening / Exercise Frequency: 2-3 days per week", "Exercise Screening / Duration of Exercise: 30 mins", "Exercise Screening / Intensity: Mild", "Exercise Screening / Type(s): Walking", "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?: 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?: Sometimes", "Other Safety Measures / Sun Protection?: Sometimes", "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" : "44490067", "sex" : "Female", "simulatedFullName" : "Rachel Williams", "unit" : "Bon Secours — Room 400 Bed 1" }, "setting" : "Bon Secours — Room 400 Bed 1", "snapshots" : [ { "activityIds" : [ ], "id" : "rachel-williams-current", "scenarioTime" : "2026-09-22T20:42:00", "sourcePath" : "DocuCare instructor chart: Rachel Williams", "title" : "Captured chart" } ], "subtitle" : "N11 practice record", "tags" : [ "N11", "DocuCare migration" ], "title" : "Rachel Williams" }, "packageId" : "docucare-n11-rachel-williams-review-v1", "privacy" : { "containsRealPHI" : false, "defaultStorage" : "local-document-package", "networkRequired" : false, "simulatedOnly" : true, "warning" : "Simulated educational record only. Not for clinical care. Review the chart and faculty directions before practice." }, "schemaVersion" : "2.0", "source" : { "system" : "DocuCare Enhanced instructor chart capture" }, "workingNames" : [ "ChartSlate" ] } }, "id" : "n11-rachel-williams", "instructions" : "Open the assigned patient chart. Confirm name, DOB and MRN; review allergies, notes, vitals, labs, orders and the MAR. Discuss missing or conflicting information with faculty. Held and discontinued medications are for review and are not active administration tasks. Scenario dates are historical. Follow your faculty directions.", "title" : "Rachel Williams" }, { "envelope" : { "appName" : "ChartSlate", "audience" : "student", "createdAt" : "2026-09-25T19:44:36.705927+00:00", "exportVersion" : "1", "kind" : "casePackage", "package" : { "case" : { "activities" : [ ], "id" : "docucare-n11-rosa-wang", "learningLevel" : "N11", "panels" : { "assessments" : [ { "author" : "Callee Poston, Registered Nurse", "dateTime" : "2026-09-20T21:08:00", "id" : "rosa-wang-assessment-1", "label" : "HEENT", "summary" : ": HEENT\nHead / Size/Shape / Head Size/Shape: Symmetric\nHead / Recent Trauma: No\nHead / Hair: Fine\nEars: Not assessed\nEyes / Left Eye: Normal/clear\nEyes / Right Eye: Normal/clear\nEyes / Left Eye: Symmetrical\nEyes / Right Eye: Symmetrical\nEyes / Left Eye: Left Eye Average Convergence\nEyes / Right Eye: Right Eye Average Convergence\nNose / Character / Nose Character: Symmetrical\nNose / Obstruction / Nose Obstruction: Absent\nNose / Septum / Nose Septum: Intact\nMouth/Throat / Teeth: Present\nMouth/Throat / Oral Mucosa: Normal\nMouth/Throat / Pharynx: Normal" }, { "author" : "Susan Snapple, Registered Nurse", "dateTime" : "2026-09-21T09:08:00", "id" : "rosa-wang-assessment-2", "label" : "HEENT", "summary" : ": HEENT\nHead / Size/Shape / Head Size/Shape: Symmetric\nHead / Recent Trauma: No\nHead / Hair: Fine\nEars: Not assessed\nEyes / Left Eye: Normal/clear\nEyes / Right Eye: Normal/clear\nEyes / Left Eye: Symmetrical\nEyes / Right Eye: Symmetrical\nEyes / Left Eye: Left Eye Average Convergence\nEyes / Right Eye: Right Eye Average Convergence\nNose / Character / Nose Character: Symmetrical\nNose / Obstruction / Nose Obstruction: Absent\nNose / Septum / Nose Septum: Intact\nMouth/Throat / Teeth: Present\nMouth/Throat / Oral Mucosa: Normal\nMouth/Throat / Pharynx: Normal\nMouth/Throat / Lymph Nodes / LymphNodes: Non-tender" }, { "author" : "Tom Bailey, Registered Nurse", "dateTime" : "2026-09-21T21:08:00", "id" : "rosa-wang-assessment-3", "label" : "HEENT", "summary" : ": HEENT\nHead / Size/Shape / Head Size/Shape: Symmetric\nHead / Recent Trauma: No\nEars: Not assessed\nEyes / Left Eye: Normal/clear\nEyes / Right Eye: Normal/clear\nEyes / Left Eye: Symmetrical\nEyes / Right Eye: Symmetrical\nEyes / Left Eye: Left Eye Average Convergence\nEyes / Right Eye: Right Eye Average Convergence\nNose / Character / Nose Character: Symmetrical\nMouth/Throat / Teeth: Present\nMouth/Throat / Oral Mucosa: Normal\nMouth/Throat / Pharynx: Normal\nMouth/Throat / Lymph Nodes / LymphNodes: Non-tender" }, { "author" : "Rose Windy, Registered Nurse", "dateTime" : "2026-09-22T09:08:00", "id" : "rosa-wang-assessment-4", "label" : "HEENT", "summary" : ": HEENT\nHead / Size/Shape / Head Size/Shape: Symmetric\nHead / Recent Trauma: No\nHead / Hair: Fine\nEars: Not assessed\nEyes / Left Eye: Normal/clear\nEyes / Right Eye: Normal/clear\nEyes / Left Eye: Symmetrical\nEyes / Right Eye: Symmetrical\nEyes / Left Eye: Left Eye Average Convergence\nEyes / Right Eye: Right Eye Average Convergence\nNose / Character / Nose Character: Symmetrical\nMouth/Throat / Teeth: Present\nMouth/Throat / Oral Mucosa: Normal\nMouth/Throat / Pharynx: Normal\nMouth/Throat / Lymph Nodes / LymphNodes: Non-tender" }, { "author" : "Krystal House, Registered Nurse", "dateTime" : "2026-09-22T21:08:00", "id" : "rosa-wang-assessment-5", "label" : "HEENT", "summary" : ": HEENT\nHead / Size/Shape / Head Size/Shape: Symmetric\nHead / Recent Trauma: No\nHead / Hair: Fine\nEars: Not assessed\nEyes / Left Eye: Normal/clear\nEyes / Right Eye: Normal/clear\nNose / Character / Nose Character: Symmetrical\nNose / Obstruction / Nose Obstruction: Absent\nNose / Septum / Nose Septum: Intact\nMouth/Throat / Teeth: Present\nMouth/Throat / Oral Mucosa: Normal\nMouth/Throat / Pharynx: Normal\nMouth/Throat / Lymph Nodes / LymphNodes: Non-tender" }, { "author" : "Krystal House, Registered Nurse", "dateTime" : "2026-09-22T21:08:00", "id" : "rosa-wang-assessment-6", "label" : "Neuro", "summary" : ": Neuro\nOrientation / Quick Orientation: / Quick Orientation: Person, Time, Place, Situation\nPupils / Both Eyes (OU: Oculus Uterque, both eyes), OU: Oculus Uterque, both eyes / Size / Both Eye Size: 4\nPupils / Both Eyes (OU: Oculus Uterque, both eyes), OU: Oculus Uterque, both eyes / Reaction / Both Eye Reaction: Brisk\nPupils / Both Eyes (OU: Oculus Uterque, both eyes), OU: Oculus Uterque, both eyes / Reaction / Both Eye Reaction: Accommodation\nHearing: Intact\nStrength / LUE (Left Upper Extremity), Left Upper Extremity: Moves Upon Request in Left Upper Extremity\nStrength / RUE (Right Upper Extremity), Right Upper Extremity: Moves Upon Request in Right Upper Extremity\nStrength / LLE (Left Lower Extremity), Left Lower Extremity: Moves Upon Request in Left Lower Extremity\nStrength / RLE (Right Lower Extremity), Right Lower Extremity: Moves Upon Request in Right Lower Extremity\nBehavioral/Emotional: Calm\nBehavioral/Emotional: Cooperative\nEye Opening: Spontaneously\nMotor Response: Obeys Verbal Command\nVerbal Response: Oriented X 3" }, { "author" : "Rose Windy, Registered Nurse", "dateTime" : "2026-09-22T09:08:00", "id" : "rosa-wang-assessment-7", "label" : "Neuro", "summary" : ": Neuro\nOrientation / Quick Orientation: / Quick Orientation: Person, Time, Place, Situation\nPupils / Both Eyes (OU: Oculus Uterque, both eyes), OU: Oculus Uterque, both eyes / Size / Both Eye Size: 5\nPupils / Both Eyes (OU: Oculus Uterque, both eyes), OU: Oculus Uterque, both eyes / Reaction / Both Eye Reaction: Brisk\nHearing: Intact\nStrength / LUE (Left Upper Extremity), Left Upper Extremity: Moves Upon Request in Left Upper Extremity\nStrength / RUE (Right Upper Extremity), Right Upper Extremity: Moves Upon Request in Right Upper Extremity\nStrength / LLE (Left Lower Extremity), Left Lower Extremity: Moves Upon Request in Left Lower Extremity\nStrength / RLE (Right Lower Extremity), Right Lower Extremity: Moves Upon Request in Right Lower Extremity\nBehavioral/Emotional: Calm\nBehavioral/Emotional: Cooperative\nEye Opening: Spontaneously\nMotor Response: Obeys Verbal Command\nVerbal Response: Oriented X 3" }, { "author" : "Tom Bailey, Registered Nurse", "dateTime" : "2026-09-21T21:08:00", "id" : "rosa-wang-assessment-8", "label" : "Neuro", "summary" : ": Neuro\nOrientation / Quick Orientation: / Quick Orientation: Person, Time, Place, Situation\nPupils / Both Eyes (OU: Oculus Uterque, both eyes), OU: Oculus Uterque, both eyes / Size / Both Eye Size: 4\nPupils / Both Eyes (OU: Oculus Uterque, both eyes), OU: Oculus Uterque, both eyes / Reaction / Both Eye Reaction: Brisk\nHearing: Intact\nStrength / LUE (Left Upper Extremity), Left Upper Extremity: Moves Upon Request in Left Upper Extremity\nStrength / RUE (Right Upper Extremity), Right Upper Extremity: Moves Upon Request in Right Upper Extremity\nStrength / LLE (Left Lower Extremity), Left Lower Extremity: Moves Upon Request in Left Lower Extremity\nStrength / RLE (Right Lower Extremity), Right Lower Extremity: Moves Upon Request in Right Lower Extremity\nBehavioral/Emotional: Calm\nBehavioral/Emotional: Cooperative\nEye Opening: Spontaneously\nMotor Response: Obeys Verbal Command\nVerbal Response: Oriented X 3" }, { "author" : "Callee Poston, Registered Nurse", "dateTime" : "2026-09-20T21:08:00", "id" : "rosa-wang-assessment-9", "label" : "Neuro", "summary" : ": Neuro\nOrientation / Quick Orientation: / Quick Orientation: Person, Time, Place, Situation\nPupils / Both Eyes (OU: Oculus Uterque, both eyes), OU: Oculus Uterque, both eyes / Size / Both Eye Size: 4\nPupils / Both Eyes (OU: Oculus Uterque, both eyes), OU: Oculus Uterque, both eyes / Reaction / Both Eye Reaction: Round\nPupils / Both Eyes (OU: Oculus Uterque, both eyes), OU: Oculus Uterque, both eyes / Reaction / Both Eye Reaction: Brisk\nHearing: Intact\nStrength / LUE (Left Upper Extremity), Left Upper Extremity: Moves Upon Request in Left Upper Extremity\nStrength / RUE (Right Upper Extremity), Right Upper Extremity: Moves Upon Request in Right Upper Extremity\nStrength / LLE (Left Lower Extremity), Left Lower Extremity: Moves Upon Request in Left Lower Extremity\nStrength / RLE (Right Lower Extremity), Right Lower Extremity: Moves Upon Request in Right Lower Extremity\nBehavioral/Emotional: Calm\nBehavioral/Emotional: Cooperative\nEye Opening: Spontaneously\nMotor Response: Obeys Verbal Command\nVerbal Response: Oriented X 3" }, { "author" : "Susan Snapple, Registered Nurse", "dateTime" : "2026-09-21T09:08:00", "id" : "rosa-wang-assessment-10", "label" : "Neuro", "summary" : ": Neuro\nOrientation / Quick Orientation: / Quick Orientation: Person, Time, Place, Situation\nPupils / Both Eyes (OU: Oculus Uterque, both eyes), OU: Oculus Uterque, both eyes / Size / Both Eye Size: 4\nPupils / Both Eyes (OU: Oculus Uterque, both eyes), OU: Oculus Uterque, both eyes / Reaction / Both Eye Reaction: Round\nPupils / Both Eyes (OU: Oculus Uterque, both eyes), OU: Oculus Uterque, both eyes / Reaction / Both Eye Reaction: Brisk\nHearing: Intact\nStrength / LUE (Left Upper Extremity), Left Upper Extremity: Moves Upon Request in Left Upper Extremity\nStrength / RUE (Right Upper Extremity), Right Upper Extremity: Moves Upon Request in Right Upper Extremity\nStrength / LLE (Left Lower Extremity), Left Lower Extremity: Moves Upon Request in Left Lower Extremity\nStrength / RLE (Right Lower Extremity), Right Lower Extremity: Moves Upon Request in Right Lower Extremity\nBehavioral/Emotional: Calm\nEye Opening: Spontaneously\nMotor Response: Obeys Verbal Command\nVerbal Response: Oriented X 3" }, { "author" : "Callee Poston, Registered Nurse", "dateTime" : "2026-09-20T21:08:00", "id" : "rosa-wang-assessment-11", "label" : "Cardio", "summary" : ": Cardio\nHeart Tones: S1, S2\nHeart Tones: Regular\nPulses / All: + 3 in All\nEdema / All: Absent\nCapillary Refill / All: < 3 sec in All\nSkin Color and Description: Warm\nSkin Color and Description: Dry" }, { "author" : "Susan Snapple, Registered Nurse", "dateTime" : "2026-09-21T09:08:00", "id" : "rosa-wang-assessment-12", "label" : "Cardio", "summary" : ": Cardio\nHeart Tones: S1, S2\nHeart Tones: Regular\nPulses / All: + 3 in All\nEdema / All: Absent\nCapillary Refill / All: < 3 sec in All\nSkin Color and Description: Warm\nSkin Color and Description: Dry\nSkin Color and Description: Intact" }, { "author" : "Tom Bailey, Registered Nurse", "dateTime" : "2026-09-21T21:08:00", "id" : "rosa-wang-assessment-13", "label" : "Cardio", "summary" : ": Cardio\nHeart Tones: S1, S2\nHeart Tones: Regular\nPulses / All: + 3 in All\nEdema / All: Absent\nCapillary Refill / All: < 3 sec in All\nSkin Color and Description: Warm\nSkin Color and Description: Dry\nSkin Color and Description: Intact" }, { "author" : "Rose Windy, Registered Nurse", "dateTime" : "2026-09-22T09:08:00", "id" : "rosa-wang-assessment-14", "label" : "Cardio", "summary" : ": Cardio\nHeart Tones: S1, S2\nHeart Tones: Regular\nPulses / All: + 3 in All\nEdema / All: Absent\nCapillary Refill / All: < 3 sec in All\nSkin Color and Description: Warm\nSkin Color and Description: Dry\nSkin Color and Description: Intact" }, { "author" : "Krystal House, Registered Nurse", "dateTime" : "2026-09-22T21:08:00", "id" : "rosa-wang-assessment-15", "label" : "Cardio", "summary" : ": Cardio\nHeart Tones: S1, S2\nHeart Tones: Regular\nPulses / All: + 3 in All\nEdema / All: Absent\nCapillary Refill / All: < 3 sec in All\nSkin Color and Description: Warm\nSkin Color and Description: Dry\nSkin Color and Description: Intact" }, { "author" : "Callee Poston, Registered Nurse", "dateTime" : "2026-09-20T21:08:00", "id" : "rosa-wang-assessment-16", "label" : "GI", "summary" : ": GI\nAdditional Notes / Additional Notes: Stool report per patient. Constipation for 2 days. Vomiting prior to admission.\nAbdominal Description / LLQ (Left Lower Quadrant), Left Lower Quadrant: Dressings\nAbdominal Description / RLQ (Right Lower Quadrant), Right Lower Quadrant: Dressings\nAbdominal Description / All: Distended\nAbdominal Description / All: Soft\nGI Symptoms: Nausea\nGI Symptoms: Constipation\nGI Symptoms: Weight loss\nBowel Sounds / All: Present\nDiet Tolerance / Diet Tolerance: Other\nDiet Tolerance / Diet Tolerance, Other value: Fair\nDescription: Liquid\nColor: Brown\nLast Bowel Movement / Last Bowel Movement Days: 0\nLast Bowel Movement / Last Bowel Movement Hours: 0\nLast Bowel Movement / Last Bowel Movement Minutes: 0\nLast Bowel Movement / Last Bowel Movement Relative To Timing Based On: after admission" }, { "author" : "Susan Snapple, Registered Nurse", "dateTime" : "2026-09-21T09:08:00", "id" : "rosa-wang-assessment-17", "label" : "GI", "summary" : ": GI\nAbdominal Description / LLQ (Left Lower Quadrant), Left Lower Quadrant: Dressings\nAbdominal Description / RLQ (Right Lower Quadrant), Right Lower Quadrant: Dressings\nAbdominal Description / LLQ (Left Lower Quadrant), Left Lower Quadrant: Firm\nAbdominal Description / RLQ (Right Lower Quadrant), Right Lower Quadrant: Firm\nAbdominal Description / LLQ (Left Lower Quadrant), Left Lower Quadrant: Tender\nAbdominal Description / RLQ (Right Lower Quadrant), Right Lower Quadrant: Tender\nGI Symptoms: Abdominal pain\nGI Symptoms: Flatulence\nBowel Sounds / All: Present\nDiet Tolerance / Diet Tolerance: Other\nDiet Tolerance / Diet Tolerance, Other value: Poor\nLast Bowel Movement / Last Bowel Movement Days: 0\nLast Bowel Movement / Last Bowel Movement Hours: 0\nLast Bowel Movement / Last Bowel Movement Minutes: 0\nLast Bowel Movement / Last Bowel Movement Relative To Timing Based On: after admission" }, { "author" : "Tom Bailey, Registered Nurse", "dateTime" : "2026-09-21T21:08:00", "id" : "rosa-wang-assessment-18", "label" : "GI", "summary" : ": GI\nAbdominal Description / LLQ (Left Lower Quadrant), Left Lower Quadrant: Dressings\nAbdominal Description / RLQ (Right Lower Quadrant), Right Lower Quadrant: Dressings\nAbdominal Description / LUQ (Left Upper Quadrant), Left Upper Quadrant: Non-distended\nAbdominal Description / RUQ (Right Upper Quadrant), Right Upper Quadrant: Non-distended\nAbdominal Description / LLQ (Left Lower Quadrant), Left Lower Quadrant: Non-distended\nAbdominal Description / RLQ (Right Lower Quadrant), Right Lower Quadrant: Non-distended\nAbdominal Description / LLQ (Left Lower Quadrant), Left Lower Quadrant: Tender\nAbdominal Description / RLQ (Right Lower Quadrant), Right Lower Quadrant: Tender\nGI Symptoms: Belching\nGI Symptoms: Abdominal pain\nGI Symptoms: Flatulence\nBowel Sounds / All: Present\nDiet Tolerance / Diet Tolerance: Other\nDiet Tolerance / Diet Tolerance, Other value: Good\nLast Bowel Movement / Last Bowel Movement Days: 0\nLast Bowel Movement / Last Bowel Movement Hours: 0\nLast Bowel Movement / Last Bowel Movement Minutes: 0\nLast Bowel Movement / Last Bowel Movement Relative To Timing Based On: after admission" }, { "author" : "Rose Windy, Registered Nurse", "dateTime" : "2026-09-22T09:08:00", "id" : "rosa-wang-assessment-19", "label" : "GI", "summary" : ": GI\nAbdominal Description / LLQ (Left Lower Quadrant), Left Lower Quadrant: Dressings\nAbdominal Description / RLQ (Right Lower Quadrant), Right Lower Quadrant: Dressings\nAbdominal Description / All: Round\nAbdominal Description / All: Non-tender\nBowel Sounds / All: Present\nDiet Tolerance / Diet Tolerance: Adequate\nDescription: Soft\nColor: Brown\nLast Bowel Movement / Last Bowel Movement Days: 2\nLast Bowel Movement / Last Bowel Movement Hours: 0\nLast Bowel Movement / Last Bowel Movement Minutes: 0\nLast Bowel Movement / Last Bowel Movement Relative To Timing Based On: after admission" }, { "author" : "Krystal House, Registered Nurse", "dateTime" : "2026-09-22T21:08:00", "id" : "rosa-wang-assessment-20", "label" : "GI", "summary" : ": GI\nAdditional Notes / Additional Notes: Patient not eating adequately. Complains of abdominal pain and distention.\nAbdominal Description / LLQ (Left Lower Quadrant), Left Lower Quadrant: Wounds\nAbdominal Description / RLQ (Right Lower Quadrant), Right Lower Quadrant: Wounds\nAbdominal Description / LLQ (Left Lower Quadrant), Left Lower Quadrant: Dressings\nAbdominal Description / RLQ (Right Lower Quadrant), Right Lower Quadrant: Dressings\nAbdominal Description / All: Distended\nAbdominal Description / All: Firm\nAbdominal Description / All: Tender\nBowel Sounds / All: Present\nDiet Tolerance / Diet Tolerance: Inadequate\nLast Bowel Movement / Last Bowel Movement Days: 0\nLast Bowel Movement / Last Bowel Movement Hours: 0\nLast Bowel Movement / Last Bowel Movement Minutes: 0\nLast Bowel Movement / Last Bowel Movement Relative To Timing Based On: after admission" }, { "author" : "Callee Poston, Registered Nurse", "dateTime" : "2026-09-20T21:08:00", "id" : "rosa-wang-assessment-21", "label" : "GU", "summary" : ": GU\nUrinary Symptoms: None\nUrine Color: Yellow\nUrine Character: Clear\nUrinary Elimination: Indwelling Catheter\nDate Inserted Days: 0\nDate Inserted Relative To Timing Based On: after admission\nCatheter Size: 14\nVolume in Balloon: 10\nSite Description: Post op foley cath in place. Draining clear yellow urine" }, { "author" : "Susan Snapple, Registered Nurse", "dateTime" : "2026-09-21T09:08:00", "id" : "rosa-wang-assessment-22", "label" : "GU", "summary" : ": GU\nUrinary Symptoms: None\nUrine Color: Yellow\nUrine Character: Clear\nUrinary Elimination: Indwelling Catheter\nDate Inserted Days: 0\nDate Inserted Relative To Timing Based On: after admission\nCatheter Size: 14\nVolume in Balloon: 10\nSite Description: Post op foley cath in place. Draining clear yellow urine" }, { "author" : "Tom Bailey, Registered Nurse", "dateTime" : "2026-09-21T21:08:00", "id" : "rosa-wang-assessment-23", "label" : "GU", "summary" : ": GU\nUrinary Symptoms: None\nUrine Color: Yellow\nUrine Character: Clear\nUrinary Elimination: Indwelling Catheter\nDate Inserted Days: 0\nDate Inserted Relative To Timing Based On: after admission\nCatheter Size: 14\nVolume in Balloon: 10\nSite Description: Post op foley cath in place. Draining clear yellow urine. Plan to remove later today." }, { "author" : "Rose Windy, Registered Nurse", "dateTime" : "2026-09-22T09:08:00", "id" : "rosa-wang-assessment-24", "label" : "GU", "summary" : ": GU\nAdditional Notes / Additional Notes: Foley removed. Patient offers no complaints. Patient instructed to call for help before using bathroom. Urine collection container placed in toilet.\nUrinary Symptoms: Oliguria\nDate Inserted Days: 0\nDate Inserted Relative To Timing Based On: after admission\nVolume in Balloon: 0" }, { "author" : "Krystal House, Registered Nurse", "dateTime" : "2026-09-22T21:08:00", "id" : "rosa-wang-assessment-25", "label" : "GU", "summary" : ": GU\nAdditional Notes / Additional Notes: Patient unable to void. Bladder palpable. Bladder scan notes 600mL urine retained. Will notify MD.\nUrinary Symptoms: Oliguria\nUrinary Symptoms: Urinary Retention\nUrinary Elimination: Inability to Void\nDate Inserted Days: 0\nDate Inserted Relative To Timing Based On: after admission\nVolume in Balloon: 0" }, { "author" : "Callee Poston, Registered Nurse", "dateTime" : "2026-09-20T21:08:00", "id" : "rosa-wang-assessment-26", "label" : "Respiratory", "summary" : ": Respiratory\nOxygen Delivery Method / Oxygen Delivery Method: Room Air\nSputum / Color: None\nSputum / Amount: None\nRespiratory Symptoms: None\nBreath Sounds / Right Upper Lobe: Clear\nRespirations: Regular" }, { "author" : "Susan Snapple, Registered Nurse", "dateTime" : "2026-09-21T09:08:00", "id" : "rosa-wang-assessment-27", "label" : "Respiratory", "summary" : ": Respiratory\nOxygen Delivery Method / Oxygen Delivery Method: Nasal Cannula\nOxygen Delivery Method / Nasal Cannula Flow in liters per minute: 2\nSputum / Color: None\nSputum / Amount: None\nBreath Sounds / Right Upper Lobe: Clear\nRespirations: Regular" }, { "author" : "Tom Bailey, Registered Nurse", "dateTime" : "2026-09-21T21:08:00", "id" : "rosa-wang-assessment-28", "label" : "Respiratory", "summary" : ": Respiratory\nOxygen Delivery Method / Oxygen Delivery Method: Room Air\nSputum / Color: None\nSputum / Amount: None\nBreath Sounds / Right Upper Lobe: Clear\nRespirations: Regular" }, { "author" : "Rose Windy, Registered Nurse", "dateTime" : "2026-09-22T09:08:00", "id" : "rosa-wang-assessment-29", "label" : "Respiratory", "summary" : ": Respiratory\nOxygen Delivery Method / Oxygen Delivery Method: Room Air\nSputum / Color: None\nSputum / Amount: None\nRespiratory Symptoms: None\nBreath Sounds / Right Upper Lobe: Clear\nRespirations: Regular" }, { "author" : "Krystal House, Registered Nurse", "dateTime" : "2026-09-22T21:08:00", "id" : "rosa-wang-assessment-30", "label" : "Respiratory", "summary" : ": Respiratory\nOxygen Delivery Method / Oxygen Delivery Method: Room Air\nSputum / Color: None\nSputum / Amount: None\nRespiratory Symptoms: Other\nBreath Sounds / Right Upper Lobe: Clear\nRespirations: Regular" }, { "author" : "Callee Poston, Registered Nurse", "dateTime" : "2026-09-20T21:08:00", "id" : "rosa-wang-assessment-31", "label" : "Mental Health", "summary" : ": Mental Health\nBehavior / Affect: Appropriate\nStressors: Condition\nStressors: Hospitalization\nStressors: Diagnosis\nStressors: Procedure\nCoping: Well" }, { "author" : "Susan Snapple, Registered Nurse", "dateTime" : "2026-09-21T09:08:00", "id" : "rosa-wang-assessment-32", "label" : "Mental Health", "summary" : ": Mental Health\nBehavior / Affect: Appropriate\nStressors: Condition\nStressors: Hospitalization\nStressors: Diagnosis\nStressors: Procedure\nCoping: Well" }, { "author" : "Tom Bailey, Registered Nurse", "dateTime" : "2026-09-21T21:08:00", "id" : "rosa-wang-assessment-33", "label" : "Mental Health", "summary" : ": Mental Health\nBehavior / Affect: Appropriate\nStressors: Condition\nStressors: Hospitalization\nStressors: Diagnosis\nStressors: Procedure\nCoping: Well" }, { "author" : "Rose Windy, Registered Nurse", "dateTime" : "2026-09-22T09:08:00", "id" : "rosa-wang-assessment-34", "label" : "Mental Health", "summary" : ": Mental Health\nBehavior / Affect: Appropriate\nStressors: Condition\nStressors: Hospitalization\nStressors: Diagnosis\nCoping: Well" }, { "author" : "Krystal House, Registered Nurse", "dateTime" : "2026-09-22T21:08:00", "id" : "rosa-wang-assessment-35", "label" : "Mental Health", "summary" : ": Mental Health\nAdditional Notes / Additional Notes: Anxious related to pain of inability to void.\nBehavior / Affect: Anxious\nStressors: Condition\nCoping: Fair" }, { "author" : "Callee Poston, Registered Nurse", "dateTime" : "2026-09-20T21:08:00", "id" : "rosa-wang-assessment-36", "label" : "Musculoskeletal", "summary" : ": Musculoskeletal\nMusculoskeletal Symptoms: None\nMuscle Tone / Strength / All: Normal strength in All\nMuscle Tone / Strength / All: Active Range of Motion in All\nWeight Bearing / Gait / Posture: Independent" }, { "author" : "Susan Snapple, Registered Nurse", "dateTime" : "2026-09-21T09:08:00", "id" : "rosa-wang-assessment-37", "label" : "Musculoskeletal", "summary" : ": Musculoskeletal\nMusculoskeletal Symptoms: None\nMuscle Tone / Strength / All: Normal strength in All\nMuscle Tone / Strength / All: Active Range of Motion in All\nWeight Bearing / Gait / Posture: Independent" }, { "author" : "Tom Bailey, Registered Nurse", "dateTime" : "2026-09-21T21:08:00", "id" : "rosa-wang-assessment-38", "label" : "Musculoskeletal", "summary" : ": Musculoskeletal\nMusculoskeletal Symptoms: None\nMuscle Tone / Strength / All: Normal strength in All\nMuscle Tone / Strength / All: Active Range of Motion in All\nWeight Bearing / Gait / Posture: Independent" }, { "author" : "Rose Windy, Registered Nurse", "dateTime" : "2026-09-22T09:08:00", "id" : "rosa-wang-assessment-39", "label" : "Musculoskeletal", "summary" : ": Musculoskeletal\nMusculoskeletal Symptoms: None\nMuscle Tone / Strength / All: Normal strength in All\nMuscle Tone / Strength / All: Active Range of Motion in All\nWeight Bearing / Gait / Posture: Steady" }, { "author" : "Krystal House, Registered Nurse", "dateTime" : "2026-09-22T21:08:00", "id" : "rosa-wang-assessment-40", "label" : "Musculoskeletal", "summary" : ": Musculoskeletal\nMusculoskeletal Symptoms: None\nMuscle Tone / Strength / All: Normal strength in All\nMuscle Tone / Strength / All: Active Range of Motion in All\nWeight Bearing / Gait / Posture: Steady" }, { "author" : "Krystal House, Registered Nurse", "dateTime" : "2026-09-20T21:13:00", "id" : "rosa-wang-assessment-41", "label" : "Pain Scale", "summary" : ": Pain Scale\nOnset Days: 0\nOnset Hours: 0\nOnset Minutes: 5\nOnset Relative To Timing Based On: after admission\nPain Rating: 0 - No Pain" }, { "author" : "Susan Snapple, Registered Nurse", "dateTime" : "2026-09-21T09:08:00", "id" : "rosa-wang-assessment-42", "label" : "Pain Scale", "summary" : ": Pain Scale\nPain Location: Abdomen\nOnset Days: 0\nOnset Hours: 0\nOnset Minutes: 0\nOnset Relative To Timing Based On: after admission\nPain Frequency: Constant\nType Of Pain: Acute\nPain Goal: 1\nAggravating Factors: Movement\nAggravating Factors: Breathing\nAlleviating Factors: Rest\nPain Scale Used: 1-10\nPain Rating: 4\nPain Characteristics: Throbbing\nPain Characteristics: Dull\nNotes: Medicated for pain" }, { "author" : "Susan Snapple, Registered Nurse", "dateTime" : "2026-09-21T09:08:00", "id" : "rosa-wang-assessment-43", "label" : "Braden Scale", "summary" : ": Braden Scale\nSensory Perception (ability to respond meaningfully to pressure-related discomfort) / Sensory Perception: No Impairment Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort.\nNutrition (usual food intake pattern) / Nutrition: Probably Inadequate Rarely eats a complete meal and generally eats only about 1/2 of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement. OR receives less than optimum amount of liquid diet or tube feeding.\nMobility (ability to change and control body position) / Mobility: Slightly Limited Makes frequent though slight changes in body or extremity position independently.\nActivity (degree of physical activity) / Activity: Walks Occasionally Walks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair.\nMoisture (degree to which skin is exposed to moisture) / Moisture: Occasionally Moist Skin is occasionally moist, requiring an extra linen change approximately once a day.\nFriction-Shear / Friction Shear: No Apparent Problem Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair.\nBraden Scale Total Score: 18\nResults: At Risk (15–18)" }, { "author" : "Tom Bailey, Registered Nurse", "dateTime" : "2026-09-21T21:08:00", "id" : "rosa-wang-assessment-44", "label" : "Braden Scale", "summary" : ": Braden Scale\nSensory Perception (ability to respond meaningfully to pressure-related discomfort) / Sensory Perception: No Impairment Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort.\nNutrition (usual food intake pattern) / Nutrition: Adequate Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products) per day. Occasionally will refuse a meal, but will usually take a supplement when offered OR is on a tube feeding or TPN regimen which probably meets most of nutritional needs.\nMobility (ability to change and control body position) / Mobility: Slightly Limited Makes frequent though slight changes in body or extremity position independently.\nActivity (degree of physical activity) / Activity: Walks Frequently Walks outside room at least twice a day and inside room at least once every two hours during waking hours.\nMoisture (degree to which skin is exposed to moisture) / Moisture: Occasionally Moist Skin is occasionally moist, requiring an extra linen change approximately once a day.\nFriction-Shear / Friction Shear: No Apparent Problem Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair.\nBraden Scale Total Score: 20\nResults: Low Risk" }, { "author" : "Callee Poston, Registered Nurse", "dateTime" : "2026-09-20T21:08:00", "id" : "rosa-wang-assessment-45", "label" : "Braden Scale", "summary" : ": Braden Scale\nSensory Perception (ability to respond meaningfully to pressure-related discomfort) / Sensory Perception: No Impairment Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort.\nNutrition (usual food intake pattern) / Nutrition: Probably Inadequate Rarely eats a complete meal and generally eats only about 1/2 of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement. OR receives less than optimum amount of liquid diet or tube feeding.\nMobility (ability to change and control body position) / Mobility: Slightly Limited Makes frequent though slight changes in body or extremity position independently.\nActivity (degree of physical activity) / Activity: Walks Occasionally Walks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair.\nMoisture (degree to which skin is exposed to moisture) / Moisture: Occasionally Moist Skin is occasionally moist, requiring an extra linen change approximately once a day.\nFriction-Shear / Friction Shear: No Apparent Problem Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair.\nBraden Scale Total Score: 18\nResults: At Risk (15–18)" }, { "author" : "Rose Windy, Registered Nurse", "dateTime" : "2026-09-22T09:08:00", "id" : "rosa-wang-assessment-46", "label" : "Braden Scale", "summary" : ": Braden Scale\nSensory Perception (ability to respond meaningfully to pressure-related discomfort) / Sensory Perception: No Impairment Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort.\nNutrition (usual food intake pattern) / Nutrition: Adequate Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products) per day. Occasionally will refuse a meal, but will usually take a supplement when offered OR is on a tube feeding or TPN regimen which probably meets most of nutritional needs.\nMobility (ability to change and control body position) / Mobility: No Limitation Makes major and frequent changes in position without assistance.\nActivity (degree of physical activity) / Activity: Walks Frequently Walks outside room at least twice a day and inside room at least once every two hours during waking hours.\nMoisture (degree to which skin is exposed to moisture) / Moisture: Rarely Moist Skin is usually dry, linen only requires changing at routine intervals\nFriction-Shear / Friction Shear: No Apparent Problem Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair.\nBraden Scale Total Score: 22\nResults: Low Risk" }, { "author" : "Krystal House, Registered Nurse", "dateTime" : "2026-09-22T21:08:00", "id" : "rosa-wang-assessment-47", "label" : "Braden Scale", "summary" : ": Braden Scale\nSensory Perception (ability to respond meaningfully to pressure-related discomfort) / Sensory Perception: No Impairment Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort.\nNutrition (usual food intake pattern) / Nutrition: Probably Inadequate Rarely eats a complete meal and generally eats only about 1/2 of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement. OR receives less than optimum amount of liquid diet or tube feeding.\nMobility (ability to change and control body position) / Mobility: No Limitation Makes major and frequent changes in position without assistance.\nActivity (degree of physical activity) / Activity: Walks Occasionally Walks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair.\nMoisture (degree to which skin is exposed to moisture) / Moisture: Rarely Moist Skin is usually dry, linen only requires changing at routine intervals\nFriction-Shear / Friction Shear: No Apparent Problem Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair.\nBraden Scale Total Score: 20\nResults: Low Risk" }, { "author" : "Callee Poston, Registered Nurse", "dateTime" : "2026-09-21T03:08:00", "id" : "rosa-wang-assessment-48", "label" : "Site/Wound", "summary" : ": Site/Wound\nRegion: Torso\nSpecific Location: Midline\nType: Incision\nSutures Present\nLength: 4\nWidth: 0\nDepth: 0\nDescription: Post Op dressing covering site. No drainage on dressing.\nPeri-Wound Area: pink\nDressing and Wound Care: Post op surgical dressing dry and intact" }, { "author" : "Callee Poston, Registered Nurse", "dateTime" : "2026-09-20T21:08:00", "id" : "rosa-wang-assessment-49", "label" : "Vascular Access", "summary" : ": Vascular Access\nLocation: Right forearm\nType: Peripheral IV\nDate Inserted Days: 0\nDate Inserted Relative To Timing Based On: after admission\nSize: 20\nSite Description: No edema, erythema, or drainage noted. No complaints regarding site.\nDressing: Clean, dry, and intact." } ], "intakeOutput" : { "documentedIntakeTotalMl" : 5275, "documentedNetMl" : 1150, "documentedOutputTotalMl" : 4125, "intakeEntries" : [ { "amountMl" : 350, "id" : "rosa-wang-intake-1", "time" : "2026-09-21T11:08:00", "type" : "Oral Intake" }, { "amountMl" : 575, "id" : "rosa-wang-intake-2", "time" : "2026-09-22T08:08:00", "type" : "Oral Intake" }, { "amountMl" : 350, "id" : "rosa-wang-intake-3", "time" : "2026-09-22T20:08:00", "type" : "Oral Intake" }, { "amountMl" : 1000, "id" : "rosa-wang-intake-4", "time" : "2026-09-21T07:08:00", "type" : "IVPB & IV Push" }, { "amountMl" : 1000, "id" : "rosa-wang-intake-5", "time" : "2026-09-21T17:08:00", "type" : "IVPB & IV Push" }, { "amountMl" : 1000, "id" : "rosa-wang-intake-6", "time" : "2026-09-22T03:08:00", "type" : "IVPB & IV Push" }, { "amountMl" : 1000, "id" : "rosa-wang-intake-7", "time" : "2026-09-22T13:08:00", "type" : "IVPB & IV Push" } ], "outputEntries" : [ { "amountMl" : 1200, "id" : "rosa-wang-output-1", "time" : "2026-09-21T08:08:00", "type" : "Urine" }, { "amountMl" : 1825, "id" : "rosa-wang-output-2", "time" : "2026-09-21T20:08:00", "type" : "Urine" }, { "amountMl" : 1100, "id" : "rosa-wang-output-3", "time" : "2026-09-22T08:08:00", "type" : "Urine" }, { "amountMl" : 0, "id" : "rosa-wang-output-4", "time" : "2026-09-22T20:08:00", "type" : "Urine" } ] }, "labs" : [ { "category" : "Complete Blood Count with differential", "collectedDateTime" : "2026-09-21T21:08:00", "flag" : "Normal", "id" : "rosa-wang-lab-1", "referenceRange" : "4.0-9.0", "result" : "7.0", "test" : "WBC (10 x 3/uL)" }, { "category" : "Complete Blood Count with differential", "collectedDateTime" : "2026-09-21T21:08:00", "flag" : "Normal", "id" : "rosa-wang-lab-2", "referenceRange" : "3.90-4.98", "result" : "4.0", "test" : "RBC (mill/cumm)" }, { "category" : "Complete Blood Count with differential", "collectedDateTime" : "2026-09-21T21:08:00", "flag" : "Normal", "id" : "rosa-wang-lab-3", "referenceRange" : "12.0-15.5", "result" : "13", "test" : "Hemoglobin (gm/dL)" }, { "category" : "Complete Blood Count with differential", "collectedDateTime" : "2026-09-21T21:08:00", "flag" : "Normal", "id" : "rosa-wang-lab-4", "referenceRange" : "35-45", "result" : "38", "test" : "Hematocrit (%)" }, { "category" : "Complete Blood Count with differential", "collectedDateTime" : "2026-09-21T21:08:00", "flag" : "Normal", "id" : "rosa-wang-lab-5", "referenceRange" : "81-93", "result" : "85", "test" : "MCV (fL)" }, { "category" : "Complete Blood Count with differential", "collectedDateTime" : "2026-09-21T21:08:00", "flag" : "Normal", "id" : "rosa-wang-lab-6", "referenceRange" : "28-35", "result" : "30", "test" : "MCH (pg)" }, { "category" : "Complete Blood Count with differential", "collectedDateTime" : "2026-09-21T21:08:00", "flag" : "Normal", "id" : "rosa-wang-lab-7", "referenceRange" : "33-37", "result" : "35", "test" : "MCHC (gm/dL)" }, { "category" : "Complete Blood Count with differential", "collectedDateTime" : "2026-09-21T21:08:00", "flag" : "Normal", "id" : "rosa-wang-lab-8", "referenceRange" : "11.4-15.2", "result" : "12", "test" : "RDW (%)" }, { "category" : "Complete Blood Count with differential", "collectedDateTime" : "2026-09-21T21:08:00", "flag" : "Normal", "id" : "rosa-wang-lab-9", "referenceRange" : "140-400", "result" : "250", "test" : "Platelet Count (1000/mm3)" }, { "category" : "Complete Blood Count with differential", "collectedDateTime" : "2026-09-21T21:08:00", "flag" : "Normal", "id" : "rosa-wang-lab-10", "referenceRange" : "6.0-11.1", "result" : "7.0", "test" : "Mean Platelet Volume (fL)" }, { "category" : "Complete Blood Count with differential", "collectedDateTime" : "2026-09-21T21:08:00", "flag" : "Normal", "id" : "rosa-wang-lab-11", "referenceRange" : "40-70", "result" : "50", "test" : "Neutrophils (%)" }, { "category" : "Complete Blood Count with differential", "collectedDateTime" : "2026-09-21T21:08:00", "flag" : "Normal", "id" : "rosa-wang-lab-12", "referenceRange" : "10-20", "result" : "12", "test" : "Lymphocytes (%)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2026-09-21T21:08:00", "flag" : "Normal", "id" : "rosa-wang-lab-13", "referenceRange" : "135-145", "result" : "140", "test" : "Sodium (mEq/L)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2026-09-21T21:08:00", "flag" : "Normal", "id" : "rosa-wang-lab-14", "referenceRange" : "3.5-5.1", "result" : "4.0", "test" : "Potassium (mEq/L)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2026-09-21T21:08:00", "flag" : "Normal", "id" : "rosa-wang-lab-15", "referenceRange" : "98-107", "result" : "100", "test" : "Chloride (mEq/L)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2026-09-21T21:08:00", "flag" : "Normal", "id" : "rosa-wang-lab-16", "referenceRange" : "22-29", "result" : "25", "test" : "CO2 (mEq/L)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2026-09-21T21:08:00", "flag" : "Normal", "id" : "rosa-wang-lab-17", "referenceRange" : "70-99", "result" : "89", "test" : "Glucose (mg/dL)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2026-09-21T21:08:00", "flag" : "Normal", "id" : "rosa-wang-lab-18", "referenceRange" : "6-20", "result" : "14", "test" : "Blood Urea Nitrogen (mg/dL)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2026-09-21T21:08:00", "flag" : "Normal", "id" : "rosa-wang-lab-19", "referenceRange" : "0.50-1.00", "result" : ".62", "test" : "Creatinine (mg/dL)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2026-09-21T21:08:00", "flag" : "Normal", "id" : "rosa-wang-lab-20", "referenceRange" : "8.4-10.5", "result" : "9.0", "test" : "Calcium (mg/dL)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-22T21:08:00", "flag" : "High", "id" : "rosa-wang-lab-21", "referenceRange" : "4.0-9.0", "result" : "9.9", "test" : "WBC (10 x 3/uL)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-22T21:08:00", "flag" : "Normal", "id" : "rosa-wang-lab-22", "referenceRange" : "3.90-4.98", "result" : "4.0", "test" : "RBC (mill/cumm)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-22T21:08:00", "flag" : "Normal", "id" : "rosa-wang-lab-23", "referenceRange" : "12.0-15.5", "result" : "13.0", "test" : "Hemoglobin (gm/dL)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-22T21:08:00", "flag" : "Normal", "id" : "rosa-wang-lab-24", "referenceRange" : "35-45", "result" : "38", "test" : "Hematocrit (%)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-22T21:08:00", "flag" : "Normal", "id" : "rosa-wang-lab-25", "referenceRange" : "81-93", "result" : "83", "test" : "MCV (fL)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-22T21:08:00", "flag" : "Normal", "id" : "rosa-wang-lab-26", "referenceRange" : "28-35", "result" : "30", "test" : "MCH (pg)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-22T21:08:00", "flag" : "Normal", "id" : "rosa-wang-lab-27", "referenceRange" : "33-37", "result" : "35", "test" : "MCHC (gm/dL)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-22T21:08:00", "flag" : "Normal", "id" : "rosa-wang-lab-28", "referenceRange" : "11.4-15.2", "result" : "13", "test" : "RDW (%)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-22T21:08:00", "flag" : "Normal", "id" : "rosa-wang-lab-29", "referenceRange" : "140-400", "result" : "250", "test" : "Platelet Count (1000/mm3)" } ], "medications" : [ { "doseRouteFrequency" : "40mg Subcutaneous (SC) q24h", "drug" : "enoxaparin sodium", "id" : "rosa-wang-med-6", "lastGiven" : "2026-09-22T20:30:00", "nextDue" : "2026-09-23T20:30:00", "notes" : "Source due: 9/23/2026 20:30", "orderedBy" : "James Jones, Surgeon", "orderedDateTime" : "2026-09-20T21:08:00", "section" : "Scheduled", "status" : "Active" }, { "doseRouteFrequency" : "5 mg Oral (PO) q24h", "drug" : "zolpidem tartrate", "id" : "rosa-wang-med-7", "notes" : "PRN for sleep Source due: PRN", "orderedBy" : "James Jones, Surgeon", "orderedDateTime" : "2026-09-20T21:08:00", "section" : "PRN", "status" : "Active" }, { "doseRouteFrequency" : "100 ml per hr Intravenous (IV) cont.", "drug" : "1000ml .9% normal saline", "id" : "rosa-wang-med-8", "lastGiven" : "2026-09-22T13:08:00", "notes" : "Source due: cont.", "orderedBy" : "James Jones, Surgeon", "orderedDateTime" : "2026-09-21T21:08:00", "section" : "Scheduled", "status" : "Active" }, { "doseRouteFrequency" : "1Gram IVPB q12h x1 (Every 12 hours, 1 time only), Every 12 hours, 1 time only", "drug" : "ceftriaxone sodium", "id" : "rosa-wang-med-11", "lastGiven" : "2026-09-20T22:08:00", "notes" : "", "orderedBy" : "James Jones, Surgeon", "orderedDateTime" : "2026-09-21T21:08:00", "section" : "Scheduled", "status" : "Discontinued" }, { "doseRouteFrequency" : "2-4milligrams IV q2h", "drug" : "morphine sulfate", "id" : "rosa-wang-med-12", "lastGiven" : "2026-09-22T19:08:00", "notes" : "PRN pain. Hold for BP less than 100 systolic or respirations less than 12. Source due: PRN", "orderedBy" : "James Jones, Surgeon", "orderedDateTime" : "2026-09-20T23:08:00", "section" : "PRN", "status" : "Active" } ], "notes" : [ { "id" : "rosa-wang-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" : "rosa-wang-family-health-history", "summary" : "Disease/Condition / Disease/Condition: Cancer\nType / Type: colon\nFamily Member / Family Member: father\nAge at Diagnosis / Age at Diagnosis: Unknown\nDeceased / Deceased: Yes\nDisease/Condition / Disease/Condition: Kidney Disease\nFamily Member / Family Member: mother\nAge at Diagnosis / Age at Diagnosis: Unknown\nDeceased / Deceased: Yes", "type" : "Family Health History" }, { "author" : "Krystal House , Registered Nurse", "dateTime" : "2026-09-22T21:08:00", "id" : "rosa-wang-note-1", "summary" : "Primary care provider notified of palpable bladder (3 cm below umbilicus) and patient's inability to void. ; 600 ml of urine noted with bladder scan. Physician ordered insertion of indwelling foley catheter and urine specimens for C & S and urinalysis.", "type" : "Nursing - Event" }, { "author" : "James Jones , Surgeon", "dateTime" : "2026-09-21T21:08:00", "id" : "rosa-wang-note-2", "summary" : "Rosa, a 72-year-old female patient diagnosed with colorectal cancer on the unit recovering from abdominal surgery (colon resection) and receiving antibiotic therapy for a wound infection.", "type" : "Physician Notes" }, { "author" : "Tom Bailey , Registered Nurse", "dateTime" : "2026-09-21T21:08:00", "id" : "rosa-wang-note-3", "summary" : "Dr. Jones visited and examined patient. Dressing removed, incision well approximated some erythema noted. New DSD placed.", "type" : "Nursing - Event" }, { "id" : "rosa-wang-mar-history-6", "summary" : "9/21/2026 21:08 Tom Bailey, Registered Nurse Yes\n9/22/2026 20:30 Krystal House, Registered Nurse Yes", "type" : "Medication administration history — enoxaparin sodium" }, { "id" : "rosa-wang-mar-history-7", "summary" : "9/20/2026 22:08 Rose Windy, Registered Nurse Yes\n9/21/2026 07:08 Callee Poston, Registered Nurse Yes\n9/21/2026 18:08 Tom Bailey, Registered Nurse Yes\n9/22/2026 03:08 Susan Snapple, Registered Nurse Yes\n9/22/2026 13:08 Rose Windy, Registered Nurse Yes", "type" : "Medication administration history — 1000ml .9% normal saline" }, { "id" : "rosa-wang-mar-history-8", "summary" : "9/20/2026 22:08 Rose Windy, Registered Nurse Yes", "type" : "Medication administration history — ceftriaxone sodium" }, { "id" : "rosa-wang-mar-history-9", "summary" : "9/21/2026 09:08 Susan Snapple, Registered Nurse Yes\n9/22/2026 09:08 Rose Windy, Registered Nurse Yes\n9/22/2026 19:08 Rose Windy, Registered Nurse Yes", "type" : "Medication administration history — morphine sulfate" }, { "id" : "rosa-wang-section-immunizations", "summary" : " Birth to Adult Immunizations: Influenza, Td/Tdap\n Titers: N/A\n9/20/2026 21:08 | Birth to Adult Immunizations: Influenza, Td/Tdap Titers: N/A", "type" : "Immunizations" }, { "id" : "rosa-wang-section-current-care-providers", "summary" : "Callee Poston | Registered Nurse\nJames Jones | Surgeon\nKrystal House | Registered Nurse\nRose Windy | Registered Nurse\nSusan Snapple | Registered Nurse\nTom Bailey | Registered Nurse", "type" : "Current Care Providers" } ], "orders" : [ { "author" : "James Jones, Surgeon", "category" : "Dietary", "dateTime" : "2026-09-20T21:08:00", "id" : "rosa-wang-order-1", "orderText" : "Clear liquids-Advance diet as tolerated; cont.; Routine; Source due: 9/20/2026 21:08", "status" : "Active" }, { "author" : "James Jones, Surgeon", "category" : "Laboratory", "dateTime" : "2026-09-22T21:08:00", "id" : "rosa-wang-order-2", "orderText" : "Urine specimen collection from an indwelling urinary catheter (Foley); x1 (1 time only), 1 time only; Routine; Source due: 9/22/2026 21:08", "status" : "Active" }, { "author" : "James Jones, Surgeon", "category" : "Laboratory", "dateTime" : "2026-09-20T21:08:00", "id" : "rosa-wang-order-3", "orderText" : "Venipuncture-CBC daily, BMP x1 tomorrow; q24h (Every 24 hours), Every 24 hours; Routine; BMP next day; CBC daily Source due: 9/20/2026 21:08", "status" : "Active" }, { "author" : "James Jones, Surgeon", "category" : "Nursing", "dateTime" : "2026-09-20T21:08:00", "id" : "rosa-wang-order-4", "orderText" : "Sequential compression therapy; cont.; Routine; Source due: 9/20/2026 21:08", "status" : "Active" }, { "author" : "James Jones, Surgeon", "category" : "Nursing: Monitoring", "dateTime" : "2026-09-21T21:08:00", "id" : "rosa-wang-order-5", "orderText" : "Intake and output assessment; cont.; Routine; Source due: 9/21/2026 21:08", "status" : "Active" }, { "author" : "James Jones, Surgeon", "category" : "Pharmacy", "dateTime" : "2026-09-20T21:08:00", "id" : "rosa-wang-order-6", "orderText" : "enoxaparin sodium; 40mg Subcutaneous (SC); q24h (Every 24 hours), Every 24 hours; Scheduled; Source due: 9/23/2026 20:30", "status" : "Active" }, { "author" : "James Jones, Surgeon", "category" : "Pharmacy", "dateTime" : "2026-09-20T21:08:00", "id" : "rosa-wang-order-7", "orderText" : "zolpidem tartrate; 5 mg Oral (PO); q24h (Every 24 hours), Every 24 hours; PRN; PRN for sleep Source due: PRN", "status" : "Active" }, { "author" : "James Jones, Surgeon", "category" : "Pharmacy", "dateTime" : "2026-09-21T21:08:00", "id" : "rosa-wang-order-8", "orderText" : "1000ml .9% normal saline; 100 ml per hr Intravenous (IV); cont.; Cont. Infusion; Source due: cont.", "status" : "Active" }, { "author" : "James Jones, Surgeon", "category" : "Surgerical", "dateTime" : "2026-09-23T05:38:00", "id" : "rosa-wang-order-9", "orderText" : "Ambulation, progressive; cont.; Routine; Doing well post operative day two, will get out of bed and ambulated. Dressing removed, incision looks good. No fever. Source due: 9/23/2026 05:38", "status" : "Active" }, { "author" : "James Jones, Surgeon", "category" : "Surgery", "dateTime" : "2026-09-22T21:08:00", "id" : "rosa-wang-order-10", "orderText" : "Indwelling urinary catheter (Foley) insertion, female; x1 (1 time only), 1 time only; Routine; Source due: 9/22/2026 21:08", "status" : "Active" }, { "author" : "James Jones, Surgeon", "category" : "Surgical", "dateTime" : "2026-09-21T21:08:00", "id" : "rosa-wang-order-11", "orderText" : "ceftriaxone sodium; 1Gram IVPB; q12h x1 (Every 12 hours, 1 time only), Every 12 hours, 1 time only; Discontinued", "status" : "Discontinued" }, { "author" : "James Jones, Surgeon", "category" : "Surgical", "dateTime" : "2026-09-20T23:08:00", "id" : "rosa-wang-order-12", "orderText" : "morphine sulfate; 2-4milligrams IV; q2h (Every 2 hours), Every 2 hours; PRN; PRN pain. Hold for BP less than 100 systolic or respirations less than 12. Source due: PRN", "status" : "Active" } ], "overview" : { "height" : "62 in / 157.5 cm", "isolationIndicator" : "Standard", "religion" : "Baptist", "weightKg" : 70.3 }, "vitals" : [ { "bloodPressure" : "122/82", "dateTime" : "2026-09-20T21:08:00", "heartRate" : 76, "id" : "rosa-wang-vital-1", "oxygenDevice" : "Room Air", "respiratoryRate" : 14, "spo2" : "100", "temperature" : "98.4 °F (37 °C), 37 °C Oral" }, { "bloodPressure" : "126/78", "dateTime" : "2026-09-21T01:08:00", "heartRate" : 72, "id" : "rosa-wang-vital-2", "oxygenDevice" : "Room Air", "respiratoryRate" : 14, "spo2" : "99", "temperature" : "98.8 °F (37 °C), 37 °C Oral" }, { "bloodPressure" : "120/72", "dateTime" : "2026-09-21T09:08:00", "heartRate" : 74, "id" : "rosa-wang-vital-3", "oxygenDevice" : "Room Air", "respiratoryRate" : 12, "spo2" : "100", "temperature" : "98.6 °F (37 °C), 37 °C Oral" }, { "bloodPressure" : "124/74", "dateTime" : "2026-09-21T21:08:00", "heartRate" : 78, "id" : "rosa-wang-vital-4", "oxygenDevice" : "Room Air", "respiratoryRate" : 14, "spo2" : "100", "temperature" : "98.4 °F (37 °C), 37 °C Oral" }, { "bloodPressure" : "130/80", "dateTime" : "2026-09-22T09:08:00", "heartRate" : 76, "id" : "rosa-wang-vital-5", "oxygenDevice" : "Room Air", "respiratoryRate" : 12, "spo2" : "100", "temperature" : "98.2 °F (37 °C), 37 °C Oral" }, { "bloodPressure" : "134/84", "dateTime" : "2026-09-22T21:08:00", "heartRate" : 86, "id" : "rosa-wang-vital-6", "oxygenDevice" : "Room Air", "respiratoryRate" : 18, "spo2" : "99", "temperature" : "98.4 °F (37 °C), 37 °C Oral" } ] }, "patient" : { "admitDateTime" : "2026-09-20T21:08:00", "admittingDiagnosis" : "Colorectal cancer", "allergies" : [ ], "attending" : "James Jones, Surgeon", "chartDisplayName" : "Wang, Rosa", "codeStatus" : "Full Code", "dob" : "12/12/XX", "history" : { "chiefComplaint" : "72 year old female admitted for colon resection with dx of colon cancer", "pastMedicalHistory" : [ "General Medical History / Disease/Condition / : Pneumonia", "General Medical History / Resolved: Resolved", "General Medical History / Disease/Condition / : Cellulitis", "General Medical History / Resolved: Resolved", "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: Total abdominal hysterectomy", "Previous Surgical Procedures / Year / Year: 2000", "Previous Surgical Procedures / Surgical Procedure: Cesarean section", "Previous Surgical Procedures / Year / Year: 1970" ], "socialHistory" : [ "Age: 72 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 / Cigarettes: Former Smoker", "Nicotine Use / Packs per Day: 1", "Nicotine Use / # of Years: 40", "Nicotine Use / Date Quit: 2000", "Nicotine Use / Chewing Tobacco: Nonuser", "Nicotine Use / Cigars/Pipe: Nonsmoker", "Nicotine Use / Is patient exposed to second-hand smoke?: No", "Alcohol Use / Alcohol Status: Nondrinker", "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?: Yes", "Nutritional Screening / Amount Lost: 5 lbs", "Nutritional Screening / Decreased Appetite?: Yes", "Nutritional Screening / Does patient have diabetes?: No", "Nutritional Screening / Stool Frequency: twice per day", "Nutritional Screening / Stool Description: Loose", "Nutritional Screening / Last Bowel Movement Days: 2", "Nutritional Screening / Last Bowel Movement Relative To Timing Based On: before student launches assignment", "Exercise Screening / Exercise Frequency: 1 day per week", "Exercise Screening / Duration of Exercise: 15 mins", "Exercise Screening / Intensity: Mild", "Exercise Screening / Type(s): Walking, cleaning house", "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" ] }, "mrn" : "125789", "sex" : "Female", "simulatedFullName" : "Rosa Wang", "unit" : "Graceland Hospital — Room 936 — Bed 1" }, "setting" : "Graceland Hospital — Room 936 — Bed 1", "snapshots" : [ { "activityIds" : [ ], "id" : "rosa-wang-current", "notes" : "Captured dated chart history; source relative dates anchored to chart opening. Progressive release not recreated.", "scenarioTime" : "2026-09-22T21:08:00", "sourcePath" : "DocuCare instructor chart: Rosa Wang", "title" : "Captured chart" } ], "subtitle" : "N11 practice record", "tags" : [ "N11", "DocuCare migration" ], "title" : "Rosa Wang" }, "packageId" : "docucare-n11-rosa-wang-review-v1", "privacy" : { "containsRealPHI" : false, "defaultStorage" : "local-document-package", "networkRequired" : false, "simulatedOnly" : true, "warning" : "Simulated educational record only. Not for clinical care. Review the chart and faculty directions before practice." }, "schemaVersion" : "2.0", "source" : { "system" : "DocuCare Enhanced instructor chart capture" }, "workingNames" : [ "ChartSlate" ] } }, "id" : "n11-rosa-wang", "instructions" : "Open the assigned patient chart. Confirm name, DOB and MRN; review allergies, notes, vitals, labs, orders and the MAR. Discuss missing or conflicting information with faculty. Held and discontinued medications are for review and are not active administration tasks. Scenario dates are historical. Follow your faculty directions.", "title" : "Rosa Wang" }, { "envelope" : { "appName" : "ChartSlate", "audience" : "student", "createdAt" : "2026-09-25T19:44:36.705927+00:00", "exportVersion" : "1", "kind" : "casePackage", "package" : { "case" : { "activities" : [ ], "id" : "docucare-n11-jeremiah-stein", "learningLevel" : "N11", "panels" : { "assessments" : [ { "author" : "Mary Jate, Registered Nurse", "dateTime" : "2026-09-22T20:59:00", "id" : "jeremiah-stein-assessment-1", "label" : "HEENT", "summary" : ": HEENT\nHead / Size/Shape / Head Size/Shape: Symmetric\nHead / Recent Trauma: No\nEars: Not assessed\nEyes / Left Eye: Normal/clear\nEyes / Right Eye: Normal/clear\nEyes / Left Eye: Symmetrical\nEyes / Right Eye: Symmetrical\nEyes / Left Eye: Left Eye Average Convergence\nEyes / Right Eye: Right Eye Average Convergence\nNose / Character / Nose Character: Symmetrical\nNose / Obstruction / Nose Obstruction: Absent\nNose / Septum / Nose Septum: Intact\nMouth/Throat / Teeth: Present\nMouth/Throat / Oral Mucosa: Pale\nMouth/Throat / Oral Mucosa: Dry\nMouth/Throat / Pharynx: Normal\nMouth/Throat / Lymph Nodes / LymphNodes: Non-tender" }, { "author" : "Mary Jate, Registered Nurse", "dateTime" : "2026-09-22T20:59:00", "id" : "jeremiah-stein-assessment-2", "label" : "Neuro", "summary" : ": Neuro\nOrientation / Quick Orientation: / Quick Orientation: Person, Time, Place, Situation\nPupils / Both Eyes (OU: Oculus Uterque, both eyes), OU: Oculus Uterque, both eyes / Size / Both Eye Size: 4\nPupils / Both Eyes (OU: Oculus Uterque, both eyes), OU: Oculus Uterque, both eyes / Reaction / Both Eye Reaction: Brisk\nBehavioral/Emotional: Calm\nEye Opening: Spontaneously\nMotor Response: Obeys Verbal Command\nVerbal Response: Oriented X 3" }, { "author" : "Mary Jate, Registered Nurse", "dateTime" : "2026-09-22T20:59:00", "id" : "jeremiah-stein-assessment-3", "label" : "Cardio", "summary" : ": Cardio\nHeart Tones: S1, S2\nHeart Tones: Regular\nPulses / All: + 3 in All\nEdema / All: Absent\nCapillary Refill / All: < 3 sec in All\nSkin Color and Description: Warm\nSkin Color and Description: Dry\nSkin Color and Description: Intact\nSkin Color and Description: Pale" }, { "author" : "Mary Jate, Registered Nurse", "dateTime" : "2026-09-22T20:59:00", "id" : "jeremiah-stein-assessment-4", "label" : "GI", "summary" : ": GI\nAdditional Notes / Additional Notes: 2-3 loose BM?s/ day\nAbdominal Description / All: Flat\nAbdominal Description / All: Soft\nGI Symptoms: Diarrhea\nBowel Sounds / All: Hyperactive\nDiet Tolerance / Diet Tolerance: Other\nDiet Tolerance / Diet Tolerance, Other value: Fair\nDescription: Liquid\nColor: Brown\nLast Bowel Movement / Last Bowel Movement Days: 0\nLast Bowel Movement / Last Bowel Movement Hours: 0\nLast Bowel Movement / Last Bowel Movement Minutes: 0\nLast Bowel Movement / Last Bowel Movement Relative To Timing Based On: after admission" }, { "author" : "Mary Jate, Registered Nurse", "dateTime" : "2026-09-22T20:59:00", "id" : "jeremiah-stein-assessment-5", "label" : "GU", "summary" : ": GU\nAdditional Notes / Additional Notes: patient states urine dark in color and strong odor\nUrinary Symptoms: None\nUrine Color: Amber\nUrine Character: Concentrated\nUrine Odor / Urine Odor: Strong\nDate Inserted Days: 0\nDate Inserted Relative To Timing Based On: after admission\nVolume in Balloon: 0" }, { "author" : "Mary Jate, Registered Nurse", "dateTime" : "2026-09-22T20:59:00", "id" : "jeremiah-stein-assessment-6", "label" : "Respiratory", "summary" : ": Respiratory\nOxygen Delivery Method / Oxygen Delivery Method: Room Air\nSputum / Color: None\nSputum / Amount: None\nRespiratory Symptoms: None\nBreath Sounds / Right Upper Lobe: Clear\nRespirations: Regular" }, { "author" : "Mary Jate, Registered Nurse", "dateTime" : "2026-09-22T20:59:00", "id" : "jeremiah-stein-assessment-7", "label" : "Mental Health", "summary" : ": Mental Health\nBehavior / Affect: Appropriate\nStressors: Condition\nStressors: Hospitalization\nStressors: Diagnosis\nCoping: Well" }, { "author" : "Mary Jate, Registered Nurse", "dateTime" : "2026-09-22T20:59:00", "id" : "jeremiah-stein-assessment-8", "label" : "Musculoskeletal", "summary" : ": Musculoskeletal\nMusculoskeletal Symptoms: None\nMuscle Tone / Strength / All: Normal strength in All\nWeight Bearing / Gait / Posture: Independent" }, { "author" : "Mary Jate, Registered Nurse", "dateTime" : "2026-09-22T20:59:00", "id" : "jeremiah-stein-assessment-9", "label" : "Pain Scale", "summary" : ": Pain Scale\nOnset Days: 0\nOnset Hours: 0\nOnset Minutes: 10\nOnset Relative To Timing Based On: after admission\nPain Rating: 0 - No Pain" }, { "author" : "Mary Jate, Registered Nurse", "dateTime" : "2026-09-22T21:04:00", "id" : "jeremiah-stein-assessment-10", "label" : "Braden Scale", "summary" : ": Braden Scale\nSensory Perception (ability to respond meaningfully to pressure-related discomfort) / Sensory Perception: No Impairment Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort.\nNutrition (usual food intake pattern) / Nutrition: Very Poor Never eats a complete meal. Rarely eats more than 1/3 of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement OR is NPO and/or maintained on clear liquids or IV’s for more than 5 days.\nMobility (ability to change and control body position) / Mobility: No Limitation Makes major and frequent changes in position without assistance.\nActivity (degree of physical activity) / Activity: Walks Frequently Walks outside room at least twice a day and inside room at least once every two hours during waking hours.\nMoisture (degree to which skin is exposed to moisture) / Moisture: Occasionally Moist Skin is occasionally moist, requiring an extra linen change approximately once a day.\nFriction-Shear / Friction Shear: No Apparent Problem Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair.\nBraden Scale Total Score: 19\nResults: Low Risk" }, { "author" : "Mary Jate, Registered Nurse", "dateTime" : "2026-09-22T21:04:00", "id" : "jeremiah-stein-assessment-11", "label" : "Clean/Dry/Intact Skin Assessment", "summary" : "Timing Based On: I have assessed this patient’s integumentary system and his/her skin is clean, dry, and intact. *\nNotes: Current Braden score with current poor nutrition status x several days" }, { "author" : "Mary Jate, Registered Nurse", "dateTime" : "2026-09-22T20:59:00", "id" : "jeremiah-stein-assessment-12", "label" : "Vascular Access", "summary" : ": Vascular Access\nLocation: Right antecubital\nType: Peripheral IV\nDate Inserted Days: 0\nDate Inserted Relative To Timing Based On: after admission\nSize: 18\nSite Description: No edema, erythema, or drainage. No signs or symptoms of infection.\nDressing: Clean, dry, and intact.\nNotes: Tolerated well." } ], "intakeOutput" : { "documentedIntakeTotalMl" : 120, "documentedNetMl" : 20, "documentedOutputTotalMl" : 100, "intakeEntries" : [ { "amountMl" : 120, "id" : "jeremiah-stein-intake-1", "time" : "2026-09-22T21:04:00", "type" : "Oral Intake" } ], "outputEntries" : [ { "amountMl" : 100, "id" : "jeremiah-stein-output-1", "time" : "2026-09-22T20:59:00", "type" : "Urine" } ] }, "labs" : [ { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-22T21:04:00", "flag" : "Normal", "id" : "jeremiah-stein-lab-1", "referenceRange" : "4.0-9.0", "result" : "8.0", "test" : "WBC (10 x 3/uL)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-22T21:04:00", "flag" : "Normal", "id" : "jeremiah-stein-lab-2", "referenceRange" : "3.90-4.98", "result" : "4.2", "test" : "RBC (mill/cumm)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-22T21:04:00", "flag" : "High", "id" : "jeremiah-stein-lab-3", "referenceRange" : "12.0-15.5", "result" : "16.2", "test" : "Hemoglobin (gm/dL)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-22T21:04:00", "flag" : "High", "id" : "jeremiah-stein-lab-4", "referenceRange" : "35-45", "result" : "47", "test" : "Hematocrit (%)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-22T21:04:00", "flag" : "Normal", "id" : "jeremiah-stein-lab-5", "referenceRange" : "140-400", "result" : "310", "test" : "Platelet Count (1000/mm3)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2026-09-22T21:04:00", "flag" : "Low", "id" : "jeremiah-stein-lab-6", "referenceRange" : "135-145", "result" : "130", "test" : "Sodium (mEq/L)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2026-09-22T21:04:00", "flag" : "Low", "id" : "jeremiah-stein-lab-7", "referenceRange" : "3.5-5.1", "result" : "3.3", "test" : "Potassium (mEq/L)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2026-09-22T21:04:00", "flag" : "Low", "id" : "jeremiah-stein-lab-8", "referenceRange" : "98-107", "result" : "90", "test" : "Chloride (mEq/L)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2026-09-22T21:04:00", "flag" : "Normal", "id" : "jeremiah-stein-lab-9", "referenceRange" : "22-29", "result" : "23", "test" : "CO2 (mEq/L)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2026-09-22T21:04:00", "flag" : "Normal", "id" : "jeremiah-stein-lab-10", "referenceRange" : "70-99", "result" : "80", "test" : "Glucose (mg/dL)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2026-09-22T21:04:00", "flag" : "Normal", "id" : "jeremiah-stein-lab-11", "referenceRange" : "6-20", "result" : "20", "test" : "Blood Urea Nitrogen (mg/dL)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2026-09-22T21:04:00", "flag" : "Normal", "id" : "jeremiah-stein-lab-12", "referenceRange" : "0.50-1.00", "result" : "1.0", "test" : "Creatinine (mg/dL)" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2026-09-22T21:04:00", "flag" : "Normal", "id" : "jeremiah-stein-lab-13", "referenceRange" : "8.4-10.5", "result" : "9.4", "test" : "Calcium (mg/dL)" }, { "category" : "Urinalysis", "collectedDateTime" : "2026-09-22T21:09:00", "flag" : "Normal", "id" : "jeremiah-stein-lab-14", "referenceRange" : "Pale yellow-amber", "result" : "Amber", "test" : "Color" }, { "category" : "Urinalysis", "collectedDateTime" : "2026-09-22T21:09:00", "flag" : "High", "id" : "jeremiah-stein-lab-15", "referenceRange" : "Clear to slightly hazy", "result" : "Hazy", "test" : "Clarity" }, { "category" : "Urinalysis", "collectedDateTime" : "2026-09-22T21:09:00", "flag" : "High", "id" : "jeremiah-stein-lab-16", "referenceRange" : "1.005-1.025", "result" : "1.030", "test" : "Specific gravity" }, { "category" : "Urinalysis", "collectedDateTime" : "2026-09-22T21:09:00", "flag" : "Normal", "id" : "jeremiah-stein-lab-17", "referenceRange" : "Negative", "result" : "negative", "test" : "Ketones" }, { "category" : "Urinalysis", "collectedDateTime" : "2026-09-22T21:09:00", "flag" : "Normal", "id" : "jeremiah-stein-lab-18", "referenceRange" : "Negative", "result" : "negative", "test" : "Glucose" }, { "category" : "Urinalysis", "collectedDateTime" : "2026-09-22T21:09:00", "flag" : "Normal", "id" : "jeremiah-stein-lab-19", "referenceRange" : "4.5-8.0", "result" : "7.9", "test" : "pH" }, { "category" : "Urinalysis", "collectedDateTime" : "2026-09-22T21:09:00", "flag" : "Normal", "id" : "jeremiah-stein-lab-20", "referenceRange" : "Negative", "result" : "negative", "test" : "Protein" }, { "category" : "Urinalysis", "collectedDateTime" : "2026-09-22T21:09:00", "flag" : "Normal", "id" : "jeremiah-stein-lab-21", "referenceRange" : "Negative", "result" : "negative", "test" : "Blood" }, { "category" : "Urinalysis", "collectedDateTime" : "2026-09-22T21:09:00", "flag" : "Normal", "id" : "jeremiah-stein-lab-22", "referenceRange" : "Negative", "result" : "negative", "test" : "Bilirubin" }, { "category" : "Urinalysis", "collectedDateTime" : "2026-09-22T21:09:00", "flag" : "Normal", "id" : "jeremiah-stein-lab-23", "referenceRange" : "0.2-1.0 EU/dL", "result" : "0.2", "test" : "Urobilinogen" }, { "category" : "Urinalysis", "collectedDateTime" : "2026-09-22T21:09:00", "flag" : "Normal", "id" : "jeremiah-stein-lab-24", "referenceRange" : "Negative", "result" : "negative", "test" : "Nitrite" }, { "category" : "Urinalysis", "collectedDateTime" : "2026-09-22T21:09:00", "flag" : "Normal", "id" : "jeremiah-stein-lab-25", "referenceRange" : "Negative", "result" : "negative", "test" : "Leukocyte ester" } ], "medications" : [ { "doseRouteFrequency" : "2-4 milligrams PO q4h", "drug" : "loperamide hydrochloride", "id" : "jeremiah-stein-med-4", "notes" : "two to four milligrams orally as needed every four to six hours for diarrhea as needed Source due: PRN", "orderedBy" : "Edward C. Room, University Clinic Physician", "orderedDateTime" : "2026-09-22T20:59:00", "section" : "PRN", "status" : "Active" }, { "doseRouteFrequency" : "5 mg Oral (PO) q8h", "drug" : "prochlorperazine", "id" : "jeremiah-stein-med-7", "notes" : "Source due: PRN", "orderedBy" : "Edward C. Room, University Clinic Physician", "orderedDateTime" : "2026-09-22T21:19:00", "section" : "PRN", "status" : "Active" } ], "notes" : [ { "id" : "jeremiah-stein-allergy", "summary" : "No known drug allergies | Medication | | | Edward C. Room | 9/22/2026 21:19", "type" : "Allergy documentation" }, { "author" : "Edward C. Room , University Clinic Physician", "dateTime" : "2026-09-22T20:59:00", "id" : "jeremiah-stein-note-1", "summary" : "22-year-old man who is a senior in the premed program at a large state university. He is currently an honors student and plans to take the MCAT examination in 2 weeks. His overwhelming ambition is to be accepted into a prestigious medical school and to become a psychiatrist History of occasional problems with diarrhea since his junior year in high school; self-treatment with kaolin and pectin (Kaopectate) and limiting his food and fluid intake; believes diarrhea is stress related; no medical evaluation to date. Has had two or three loose, watery bowel movements per day for the past week, with urgency and occasional fecal incontinence; believes this is related to anxiety about performance on MCAT and his need for good grades; always thirsty but afraid to drink much; urine output is decreased, and he noted that urine is darker in color and has a stronger odor.", "type" : "Physician Notes" }, { "author" : "Mary Jate , Registered Nurse", "dateTime" : "2026-09-22T20:59:00", "id" : "jeremiah-stein-note-2", "summary" : "Patient received to clinic See full assessment in tabs, labs drawn & sent. Denies SOB/chest pain. Reports slight dizziness if he stands up to quick - reminded to call for help if he needs to get out of bed, only crampy abdominal pain which persists for past 3 days. Nausea but no vomiting or diarrhea at this time.", "type" : "Nursing - Event" }, { "id" : "jeremiah-stein-section-immunizations", "summary" : " Birth to Adult Immunizations: Influenza, Td/Tdap, MMR 1, MMR 2\n Titers: N/A\n9/22/2026 20:49 | Birth to Adult Immunizations: Influenza, Td/Tdap, MMR 1, MMR 2 Titers: N/A", "type" : "Immunizations" }, { "id" : "jeremiah-stein-section-current-care-providers", "summary" : "Edward C. Room | University Clinic Physician\nMary Jate | Registered Nurse", "type" : "Current Care Providers" } ], "orders" : [ { "author" : "Edward C. Room, University Clinic Physician", "category" : "Dietary", "dateTime" : "2026-09-22T20:59:00", "id" : "jeremiah-stein-order-1", "orderText" : "Diet - clear liquids if tolerated; cont.; Routine", "status" : "Pending" }, { "author" : "Edward C. Room, University Clinic Physician", "category" : "Emergency Room", "dateTime" : "2026-09-22T20:59:00", "id" : "jeremiah-stein-order-2", "orderText" : "IV catheter insertion; x1 (1 time only), 1 time only; Routine; Source due: 9/22/2026 20:59", "status" : "Active" }, { "author" : "Edward C. Room, University Clinic Physician", "category" : "Emergency Room", "dateTime" : "2026-09-22T20:59:00", "id" : "jeremiah-stein-order-3", "orderText" : "Intravenous fluid administration; x1 (1 time only), 1 time only; Routine; D5 1/2NS infuse one liter over 30 minutes Source due: 9/22/2026 20:59", "status" : "Active" }, { "author" : "Edward C. Room, University Clinic Physician", "category" : "Emergency Room", "dateTime" : "2026-09-22T20:59:00", "id" : "jeremiah-stein-order-4", "orderText" : "loperamide hydrochloride; 2-4 milligrams PO; q4h (Every 4 hours), Every 4 hours; PRN; two to four milligrams orally as needed every four to six hours for diarrhea as needed Source due: PRN", "status" : "Active" }, { "author" : "Edward C. Room, University Clinic Physician", "category" : "Laboratory", "dateTime" : "2026-09-22T20:49:00", "id" : "jeremiah-stein-order-5", "orderText" : "Venipuncture- CBC and BMP; x1 (1 time only), 1 time only; Routine; Source due: 9/22/2026 20:49", "status" : "Active" }, { "author" : "Edward C. Room, University Clinic Physician", "category" : "Nursing", "dateTime" : "2026-09-22T20:59:00", "id" : "jeremiah-stein-order-6", "orderText" : "Ambulate ad lib; cont.; Routine; Source due: 9/22/2026 20:59", "status" : "Active" }, { "author" : "Edward C. Room, University Clinic Physician", "category" : "Pharmacy", "dateTime" : "2026-09-22T21:19:00", "id" : "jeremiah-stein-order-7", "orderText" : "prochlorperazine; 5 mg Oral (PO); q8h (Every 8 hours), Every 8 hours; PRN; Source due: PRN", "status" : "Active" } ], "overview" : { "height" : "74 in / 188 cm", "isolationIndicator" : "Standard", "religion" : "Christian", "weightKg" : 77.1 }, "vitals" : [ { "bloodPressure" : "100/60", "dateTime" : "2026-09-22T20:54:00", "heartRate" : 92, "id" : "jeremiah-stein-vital-1", "oxygenDevice" : "Room Air", "respiratoryRate" : 18, "spo2" : "98", "temperature" : "99.8 °F (38 °C), 38 °C Oral" } ] }, "patient" : { "admitDateTime" : "2026-09-22T20:49:00", "admittingDiagnosis" : "Gastroenteritis", "allergies" : [ ], "attending" : "Edward C. Room, University Clinic Physician", "chartDisplayName" : "Stein, Jeremiah", "codeStatus" : "Full Code", "dob" : "4/19/2004", "history" : { "chiefComplaint" : "Emergency Room Presenting Note: HPI: 22 y/o black male arrived in ER with nausea, vomiting and diarrhea x 3 days. Wt: 170 lbs ( 4 pounds less than the patient's normal weight) Ht: 6 ft 2 in Past Medical and Surgical History: Not remarkable No known drug allergies Vitals: Temp: 99.8 F. BP: 100/60 HR: 92 Resp: 18 SaO2: 96% on R/A Physical Assessment: Neuro: Alert and oriented CV: Regular, no murmur No edema, pulses equal all extremities Resp: Lungs clear to auscultation GI: Nausea, vomiting & diarrhea stools x 3 days, Abdominal tenderness all quadrants, patient reports \"crampy\" pain. no distention noted, bowel sounds hyperactive, stool heme neg. Weight 4 pounds less than normal GU: WNL Integ: Skin and membranes pale and dry Psychosocial: College student who lives at home with his mother. Non-Smoker. Reports moderate alcohol use: 4-7 alcoholic beverages per week. Orders placed, labwork pending Plan: IV rehydration, control N/V/D and discharge to home", "pastMedicalHistory" : [ "General Medical History: Denies prior medical problems", "Transfusion History / Previous Blood Transfusion?: No", "Transfusion History / Does Patient Know His/Her Blood Type?: No", "Pain History / History of Chronic Pain?: No", "Screenings / TB Screening (Tuberculosis), Tuberculosis: No", "Screenings / MDRO Infection Screening (Multidrug-Resistant Organisms), Multidrug-Resistant Organisms: No" ], "pastSurgicalHistory" : [ "Previous Surgical Procedures: No prior surgical history" ], "socialHistory" : [ "Age: 22 years", "Home Situation / Patient Living Situation: Other", "Home Situation / Patient Living Situation, Other value: Campus", "Home Situation / Lives With: Other family member", "Education / Highest Grade Completed: College Student", "Education / Able to Read?: Yes", "Education / Able to Write?: Yes", "Nicotine Use / Cigarettes: Nonsmoker", "Nicotine Use / Chewing Tobacco: Nonuser", "Nicotine Use / Cigars/Pipe: Nonsmoker", "Nicotine Use / Is patient exposed to second-hand smoke?: Unknown", "Alcohol Use / Alcohol Status: Current user", "Alcohol Use / Number of Drinks per Week: 4-7", "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?: Yes", "Nutritional Screening / Amount Lost: 5 pounds related to vomiting & frequent stools", "Nutritional Screening / Decreased Appetite?: Yes", "Nutritional Screening / Does patient have diabetes?: No", "Nutritional Screening / Stool Frequency: daily", "Nutritional Screening / Stool Description: Loose", "Nutritional Screening / Stool Description: Watery", "Nutritional Screening / Last Bowel Movement Days: 0", "Nutritional Screening / Last Bowel Movement Relative To Timing Based On: before student launches assignment", "Nutritional Screening / Notes: Patient states that he has had numerous loose to liquid stools over the past 3 days", "Exercise Screening / Exercise Frequency: 2-3 days per week", "Exercise Screening / Duration of Exercise: 60 mins", "Exercise Screening / Intensity: Moderate", "Exercise Screening / Type(s): plays basketball with friends", "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", "Other Safety Measures / Seatbelt Use?: Always", "Other Safety Measures / Bicycle/ATV/Motorcycle Helmet Use?: Always", "Other Safety Measures / Sun Protection?: Sometimes" ] }, "mrn" : "44352", "sex" : "Male", "simulatedFullName" : "Jeremiah Stein", "unit" : "University Clinic — Room 6 — Bed 0" }, "setting" : "University Clinic — Room 6 — Bed 0", "snapshots" : [ { "activityIds" : [ ], "id" : "jeremiah-stein-current", "notes" : "Captured dated chart history; source relative dates anchored to chart opening. Progressive release not recreated.", "scenarioTime" : "2026-09-22T21:04:00", "sourcePath" : "DocuCare instructor chart: Jeremiah Stein", "title" : "Captured chart" } ], "subtitle" : "N11 practice record", "tags" : [ "N11", "DocuCare migration" ], "title" : "Jeremiah Stein" }, "packageId" : "docucare-n11-jeremiah-stein-review-v1", "privacy" : { "containsRealPHI" : false, "defaultStorage" : "local-document-package", "networkRequired" : false, "simulatedOnly" : true, "warning" : "Simulated educational record only. Not for clinical care. Review the chart and faculty directions before practice." }, "schemaVersion" : "2.0", "source" : { "system" : "DocuCare Enhanced instructor chart capture" }, "workingNames" : [ "ChartSlate" ] } }, "id" : "n11-jeremiah-stein", "instructions" : "Open the assigned patient chart. Confirm name, DOB and MRN; review allergies, notes, vitals, labs, orders and the MAR. Discuss missing or conflicting information with faculty. Held and discontinued medications are for review and are not active administration tasks. Scenario dates are historical. Follow your faculty directions.", "title" : "Jeremiah Stein" }, { "envelope" : { "appName" : "ChartSlate", "audience" : "student", "createdAt" : "2026-09-25T19:44:36.705927+00:00", "exportVersion" : "1", "kind" : "casePackage", "package" : { "case" : { "activities" : [ ], "id" : "docucare-n11-millie-delong", "learningLevel" : "N11", "panels" : { "assessments" : [ { "author" : "Holly Brown, Registered Nurse", "dateTime" : "2026-09-22T14:06:00", "id" : "millie-delong-assessment-1", "label" : "HEENT", "summary" : ": HEENT\nHead / Size/Shape / Head Size/Shape: Symmetric\nHead / Recent Trauma: No\nHead / Hair: Fine\nEars: Not assessed\nEyes / Left Eye: Normal/clear\nEyes / Right Eye: Normal/clear\nEyes / Left Eye: Symmetrical\nEyes / Right Eye: Symmetrical\nEyes / Left Eye: Left Eye Average Convergence\nEyes / Right Eye: Right Eye Average Convergence\nNose / Character / Nose Character: Symmetrical\nNose / Obstruction / Nose Obstruction: Absent\nMouth/Throat / Teeth: Present\nMouth/Throat / Oral Mucosa: Normal\nMouth/Throat / Pharynx: Normal\nMouth/Throat / Lymph Nodes / LymphNodes: Non-tender" }, { "author" : "Holly Brown, Registered Nurse", "dateTime" : "2026-09-22T14:06:00", "id" : "millie-delong-assessment-2", "label" : "Neuro", "summary" : ": Neuro\nOrientation / Quick Orientation: / Quick Orientation: Person, Time, Place, Situation\nBehavioral/Emotional: Calm\nBehavioral/Emotional: Cooperative\nEye Opening: Spontaneously\nMotor Response: Obeys Verbal Command\nVerbal Response: Oriented X 3" }, { "author" : "Holly Brown, Registered Nurse", "dateTime" : "2026-09-22T14:06:00", "id" : "millie-delong-assessment-3", "label" : "Cardio", "summary" : ": Cardio\nHeart Tones: S1, S2\nHeart Tones: Regular\nPulses / All: + 2 in All\nEdema / All: Absent\nSkin Color and Description: Appropriate for ethnicity\nSkin Color and Description: Warm\nSkin Color and Description: Dry\nSkin Color and Description: Intact" }, { "author" : "Holly Brown, Registered Nurse", "dateTime" : "2026-09-22T14:06:00", "id" : "millie-delong-assessment-4", "label" : "GI", "summary" : ": GI\nAbdominal Description / All: Flat\nAbdominal Description / All: Soft\nAbdominal Description / All: Tender\nBowel Sounds / All: Present\nDiet Tolerance / Diet Tolerance: Adequate\nDescription: Soft\nLast Bowel Movement / Last Bowel Movement Days: 0\nLast Bowel Movement / Last Bowel Movement Hours: 0\nLast Bowel Movement / Last Bowel Movement Minutes: 0\nLast Bowel Movement / Last Bowel Movement Relative To Timing Based On: after admission" }, { "author" : "Holly Brown, Registered Nurse", "dateTime" : "2026-09-22T14:06:00", "id" : "millie-delong-assessment-5", "label" : "GU", "summary" : ": GU\nUrinary Symptoms: None\nUrine Color: Yellow\nUrine Character: Clear\nDate Inserted Days: 0\nDate Inserted Relative To Timing Based On: after admission\nVolume in Balloon: 0" }, { "author" : "Holly Brown, Registered Nurse", "dateTime" : "2026-09-22T14:06:00", "id" : "millie-delong-assessment-6", "label" : "Respiratory", "summary" : ": Respiratory\nOxygen Delivery Method / Oxygen Delivery Method: Room Air\nSputum / Color: None\nSputum / Amount: None\nRespiratory Symptoms: None\nBreath Sounds / Right Upper Lobe: Clear\nRespirations: Regular" }, { "author" : "Holly Brown, Registered Nurse", "dateTime" : "2026-09-22T14:06:00", "id" : "millie-delong-assessment-7", "label" : "Mental Health", "summary" : ": Mental Health\nBehavior / Affect: Appropriate\nStressors: Condition\nStressors: Hospitalization\nStressors: Diagnosis\nCoping: Well" }, { "author" : "Holly Brown, Registered Nurse", "dateTime" : "2026-09-22T14:06:00", "id" : "millie-delong-assessment-8", "label" : "Musculoskeletal", "summary" : ": Musculoskeletal\nMusculoskeletal Symptoms: None\nMuscle Tone / Strength / All: Normal strength in All\nWeight Bearing / Gait / Posture: None" }, { "author" : "Holly Brown, Registered Nurse", "dateTime" : "2026-09-22T15:06:00", "id" : "millie-delong-assessment-9", "label" : "Pain Scale", "summary" : ": Pain Scale\nPain Location: Abdomen\nOnset Days: 0\nOnset Hours: 0\nOnset Minutes: 0\nOnset Relative To Timing Based On: after admission\nType Of Pain: Acute\nPain Goal: 0 - No Pain\nAggravating Factors: Movement\nAggravating Factors Comments: Irrigation and dressing change\nAlleviating Factors: Rest\nAlleviating Factors: Medication\nAlleviating Factors: Immobility\nPain Rating: 5 - Moderate Pain\nPain Characteristics: Aching\nPain Characteristics: Throbbing\nPain Characteristics: Sore\nNotes: Patient has a midline incision with staples" }, { "author" : "Holly Brown, Registered Nurse", "dateTime" : "2026-09-22T14:06:00", "id" : "millie-delong-assessment-10", "label" : "Braden Scale", "summary" : ": Braden Scale\nSensory Perception (ability to respond meaningfully to pressure-related discomfort) / Sensory Perception: No Impairment Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort.\nNutrition (usual food intake pattern) / Nutrition: Excellent Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation.\nMobility (ability to change and control body position) / Mobility: No Limitation Makes major and frequent changes in position without assistance.\nActivity (degree of physical activity) / Activity: Walks Occasionally Walks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair.\nMoisture (degree to which skin is exposed to moisture) / Moisture: Rarely Moist Skin is usually dry, linen only requires changing at routine intervals\nFriction-Shear / Friction Shear: No Apparent Problem Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair.\nBraden Scale Total Score: 22\nResults: Low Risk" }, { "author" : "Holly Brown, Registered Nurse", "dateTime" : "2026-09-22T15:06:00", "id" : "millie-delong-assessment-11", "label" : "Site/Wound", "summary" : ": Site/Wound\nRegion: Torso\nSpecific Location: Abdomen, RLQ\nType: Incision\nErythema\nBruising\nStaples Present\nLength: 3\nWidth: 0.25\nDepth: 0\nDescription: Midline incision with staples, moderate amounts of purulent drainage with foul odor\nDressing and Wound Care: Abdominal dressing in place, changed prn, irrigated with saline four times a day." }, { "author" : "Holly Brown, Registered Nurse", "dateTime" : "2026-09-22T14:06:00", "id" : "millie-delong-assessment-12", "label" : "Vascular Access", "summary" : ": Vascular Access\nLocation: Left forearm\nType: Peripheral IV\nDate Inserted Days: 0\nDate Inserted Relative To Timing Based On: after admission\nSize: 20 g\nSite Description: Clean dry and intact\nDressing: tagaderm\nNotes: Hep locked" } ], "intakeOutput" : { "documentedIntakeTotalMl" : 730, "documentedNetMl" : 730, "documentedOutputTotalMl" : 0, "intakeEntries" : [ { "amountMl" : 250, "id" : "millie-delong-intake-1", "time" : "2026-09-22T20:06:00", "type" : "IVPB & IV Push" }, { "amountMl" : 480, "id" : "millie-delong-intake-2", "time" : "2026-09-22T20:06:00", "type" : "Oral Intake" } ], "outputEntries" : [ ] }, "labs" : [ { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-22T14:06:00", "flag" : "High", "id" : "millie-delong-lab-1", "referenceRange" : "4.0-9.0", "result" : "15.0", "test" : "WBC (10 x 3/uL)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-22T14:06:00", "flag" : "Normal", "id" : "millie-delong-lab-2", "referenceRange" : "3.90-4.98", "result" : "4.0", "test" : "RBC (mill/cumm)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-22T14:06:00", "flag" : "Normal", "id" : "millie-delong-lab-3", "referenceRange" : "12.0-15.5", "result" : "12.2", "test" : "Hemoglobin (gm/dL)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-22T14:06:00", "flag" : "Normal", "id" : "millie-delong-lab-4", "referenceRange" : "35-45", "result" : "37.0", "test" : "Hematocrit (%)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-22T14:06:00", "flag" : "Unverified", "id" : "millie-delong-lab-5", "referenceRange" : "140-400", "result" : "250,00 (source entry; clarify numeric value)", "test" : "Platelet Count (1000/mm3)" }, { "category" : "Other", "collectedDateTime" : "2026-09-22T15:06:00", "id" : "millie-delong-lab-6", "result" : "Pending", "status" : "Pending", "test" : "wound culture and sensitivity" } ], "medications" : [ { "doseRouteFrequency" : "5/300 mg Oral (PO) q6h", "drug" : "oxycodone hydrochloride–acetaminophen", "id" : "millie-delong-med-7", "lastGiven" : "2026-09-22T15:21:00", "notes" : "PRN pain Source due: 9/22/2026 21:21 Source PRN pain instruction governs use; product and 5/300 mg strength still require clarification.", "orderedBy" : "Christopher Thomas, Admitting Physician", "orderedDateTime" : "2026-09-22T15:16:00", "section" : "PRN", "status" : "Active" }, { "doseRouteFrequency" : "500 mg Oral (PO) q6h", "drug" : "levothyroxine sodium", "id" : "millie-delong-med-8", "lastGiven" : "2026-09-22T18:18:00", "notes" : "fluoroquinolone antibiotic - take 4 times a day with or without food. Source due: 9/23/2026 00:18 Do not administer from this conflicting order. Source drug label is levothyroxine sodium, 500 mg PO q6h, but instructions call it a fluoroquinolone antibiotic. Intended drug, dose, units and frequency require prescriber/pharmacy clarification; no substitute is inferred.", "orderedBy" : "Dr. Shelley Kole, Consulting Physician", "orderedDateTime" : "2026-09-22T14:06:00", "section" : "Scheduled", "status" : "Held — clarification required" } ], "notes" : [ { "id" : "millie-delong-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" : "millie-delong-family-health-history", "summary" : "Family History: Denies knowledge of significant family history", "type" : "Family Health History" }, { "author" : "Holly Brown , Registered Nurse", "dateTime" : "2026-09-22T15:06:00", "id" : "millie-delong-note-1", "summary" : "Patient admitted from emergency department, nursing assessment as charted. Moderate amounts of purulent drainage coming from a midline incision with staples. Skin surrounding the surgical wound is erythematous and warm to touch. Wound cleansed with normal saline as per physician order, covered with a dry dressing. Patient complained of an increase in abdominal pain after the dressing change. Attending physician notified of abdominal pain and wound appearance. Wound, ostomy, and continence nurse consulted. Contact isolation and wound culture results pending.", "type" : "Nursing - Admission" }, { "id" : "millie-delong-mar-history-4", "summary" : "9/22/2026 15:21 Holly Brown, Registered Nurse Pain med administered for incisional pain Yes", "type" : "Medication administration history — oxycodone hydrochloride–acetaminophen" }, { "id" : "millie-delong-mar-history-5", "summary" : "9/22/2026 14:06 Sally Malty, Registered Nurse Barcode won't scan; med administered. Yes\n9/22/2026 18:18 Holly Brown, Registered Nurse Yes", "type" : "Medication administration history — levothyroxine sodium" }, { "id" : "millie-delong-section-immunizations", "summary" : " Birth to Adult Immunizations: Influenza, Td/Tdap, MMR 1, MMR 2\n Titers: N/A\n9/22/2026 14:06 | Birth to Adult Immunizations: Influenza, Td/Tdap, MMR 1, MMR 2 Titers: N/A", "type" : "Immunizations" }, { "id" : "millie-delong-section-previous-visits", "summary" : "Abdominal Pain | Mercy Hospital | Emergency department visit resulting in a diagnostic laparotomy. | 9/17/2026 14:06 | 9/18/2026 14:06", "type" : "Previous Visits" }, { "id" : "millie-delong-section-current-care-providers", "summary" : "Bruce Squires | Admitting\nChristopher Thomas | Admitting Physician\nColleen Stratton | Wound Care Nurse\nDr. Shelley Kole | Consulting Physician\nHolly Brown | Registered Nurse\nSally Malty | Registered Nurse", "type" : "Current Care Providers" }, { "id" : "millie-delong-reconciliation-9", "summary" : "Do not administer from this conflicting order. Source drug label is levothyroxine sodium, 500 mg PO q6h, but instructions call it a fluoroquinolone antibiotic. Intended drug, dose, units and frequency require prescriber/pharmacy clarification; no substitute is inferred.", "type" : "Chart clarification" }, { "id" : "millie-delong-reconciliation-10", "summary" : "Platelet count source field is 250,00 with reference 140–400 (1000/mm3). Numeric value requires clarification. Wound culture is pending; it is not interpreted as normal.", "type" : "Chart clarification" } ], "orders" : [ { "author" : "Christopher Thomas, Admitting Physician", "category" : "Consult", "dateTime" : "2026-09-22T15:16:00", "id" : "millie-delong-order-1", "orderText" : "Wound assessment; x1 (1 time only), 1 time only; Routine; Consult with Wound and Ostomy Nurse re: surgical incision infection. Source due: 9/22/2026 15:16", "status" : "Active" }, { "author" : "Christopher Thomas, Admitting Physician", "category" : "Consult", "dateTime" : "2026-09-22T14:06:00", "id" : "millie-delong-order-2", "orderText" : "Consult; x1 (1 time only), 1 time only; Routine; Infectious Disease consult with Dr. Kole Source due: 9/22/2026 14:06", "status" : "Active" }, { "author" : "Christopher Thomas, Admitting Physician", "category" : "Laboratory", "dateTime" : "2026-09-22T14:06:00", "id" : "millie-delong-order-3", "orderText" : "CBC; x1 (1 time only), 1 time only; Routine; Source due: 9/22/2026 14:06", "status" : "Active" }, { "author" : "Christopher Thomas, Admitting Physician", "category" : "Laboratory", "dateTime" : "2026-09-22T14:06:00", "id" : "millie-delong-order-4", "orderText" : "Wound culture specimen collection; x1 (1 time only), 1 time only; Routine; Source due: 9/22/2026 14:06", "status" : "Active" }, { "author" : "Christopher Thomas, Admitting Physician", "category" : "Nursing: Activity", "dateTime" : "2026-09-22T14:06:00", "id" : "millie-delong-order-5", "orderText" : "Wound irrigation and dressing change; q6h (Every 6 hours), Every 6 hours; Routine; Irrigate wound with normal saline QID and cover with dry dressing Source due: 9/22/2026 14:06", "status" : "Active" }, { "author" : "Christopher Thomas, Admitting Physician", "category" : "Nursing: Monitoring", "dateTime" : "2026-09-22T14:06:00", "id" : "millie-delong-order-6", "orderText" : "Contact precautions; cont.; Stat; Source due: 9/22/2026 14:06", "status" : "Active" }, { "author" : "Christopher Thomas, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2026-09-22T15:16:00", "id" : "millie-delong-order-7", "orderText" : "oxycodone hydrochloride–acetaminophen; 5/300 mg Oral (PO); q6h (Every 6 hours), Every 6 hours; Scheduled, Stat; PRN pain Source due: 9/22/2026 21:21 Use PRN for pain; verify product/strength. Source Scheduled/Stat timing is inconsistent.", "status" : "Active" }, { "author" : "Dr. Shelley Kole, Consulting Physician", "category" : "Pharmacy", "dateTime" : "2026-09-22T14:06:00", "id" : "millie-delong-order-8", "orderText" : "levothyroxine sodium; 500 mg Oral (PO); q6h (Every 6 hours), Every 6 hours; Scheduled; fluoroquinolone antibiotic - take 4 times a day with or without food. Source due: 9/23/2026 00:18 Do not administer from this conflicting order. Source drug label is levothyroxine sodium, 500 mg PO q6h, but instructions call it a fluoroquinolone antibiotic. Intended drug, dose, units and frequency require prescriber/pharmacy clarification; no substitute is inferred.", "status" : "Held — clarification required" } ], "overview" : { "height" : "64 in / 162.6 cm", "isolationIndicator" : "Contact", "religion" : "Methodist", "weightKg" : 83 }, "vitals" : [ { "bloodPressure" : "118/64", "dateTime" : "2026-09-22T14:06:00", "heartRate" : 90, "id" : "millie-delong-vital-1", "oxygenDevice" : "Room Air", "respiratoryRate" : 18, "spo2" : "99", "temperature" : "101 °F (38 °C), 38 °C Oral" }, { "bloodPressure" : "120/78", "dateTime" : "2026-09-22T18:06:00", "heartRate" : 88, "id" : "millie-delong-vital-2", "oxygenDevice" : "Room Air", "respiratoryRate" : 14, "spo2" : "98", "temperature" : "99 °F (37 °C), 37 °C Oral" } ] }, "patient" : { "admitDateTime" : "2026-09-22T14:06:00", "admittingDiagnosis" : "Wound Infection", "allergies" : [ ], "attending" : "Bruce Squires, Admitting", "chartDisplayName" : "Delong, Millie", "codeStatus" : "Full Code", "dob" : "6/12/1982", "history" : { "chiefComplaint" : "c/o pain, redness, swelling and thick green, foul smelling drainage from laparotomy incision site. surgery was five days ago. Temperature 101 degrees orally.", "pastMedicalHistory" : [ "General Medical History: Denies prior medical problems", "Pain History / History of Chronic Pain?: No", "Screenings / TB Screening (Tuberculosis), Tuberculosis: No", "Screenings / MDRO Infection Screening (Multidrug-Resistant Organisms), Multidrug-Resistant Organisms: No", "Screenings / Pap Smear: Yes", "Screenings / Result: Normal", "Screenings / Mammogram: Yes", "Screenings / Result: Normal" ], "pastSurgicalHistory" : [ "Previous Surgical Procedures / Surgical Procedure: Diagnostic Laparotomy 5 days ago" ], "socialHistory" : [ "Age: 44 years", "Home Situation / Patient Living Situation: Home", "Home Situation / Lives With: Alone", "Education / Able to Read?: Yes", "Education / Able to Write?: Yes", "Nicotine Use / Cigarettes: Nonsmoker", "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", "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 / Stool Frequency: daily", "Nutritional Screening / Stool Description: Formed", "Nutritional Screening / Last Bowel Movement Days: 1", "Nutritional Screening / Last Bowel Movement Relative To Timing Based On: before student launches assignment", "Exercise Screening / Exercise Frequency: 2-3 days per week", "Exercise Screening / Duration of Exercise: 30 mins", "Exercise Screening / Intensity: Moderate", "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: Men", "Sexual Activity / Number of Partners in Last 3 Months: 0", "Sexual Activity / Uses Protection?: Yes", "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?: No" ] }, "mrn" : "66775", "sex" : "Female", "simulatedFullName" : "Millie Delong", "unit" : "Mercy Hospital — Room 514 — Bed Q" }, "setting" : "Mercy Hospital — Room 514 — Bed Q", "snapshots" : [ { "activityIds" : [ ], "id" : "millie-delong-current", "notes" : "Captured dated chart history; source relative dates anchored to chart opening. Progressive release not recreated.", "scenarioTime" : "2026-09-22T21:06:00", "sourcePath" : "DocuCare instructor chart: Millie DeLong", "title" : "Captured chart" } ], "subtitle" : "N11 practice record", "tags" : [ "N11", "DocuCare migration" ], "title" : "Millie DeLong" }, "packageId" : "docucare-n11-millie-delong-review-v1", "privacy" : { "containsRealPHI" : false, "defaultStorage" : "local-document-package", "networkRequired" : false, "simulatedOnly" : true, "warning" : "Simulated educational record only. Not for clinical care. Review the chart and faculty directions before practice." }, "schemaVersion" : "2.0", "source" : { "system" : "DocuCare Enhanced instructor chart capture" }, "workingNames" : [ "ChartSlate" ] } }, "id" : "n11-millie-delong", "instructions" : "Open the assigned patient chart. Confirm name, DOB and MRN; review allergies, notes, vitals, labs, orders and the MAR. Discuss missing or conflicting information with faculty. Held and discontinued medications are for review and are not active administration tasks. Scenario dates are historical. Follow your faculty directions.", "title" : "Millie Delong" } ], "format" : "org.chartslate.case-collection", "id" : "docucare-n11-course-review-v1", "summary" : "Five N11 simulated patient charts in one download. Choose a patient after importing the bundle. Records are available offline after import.", "title" : "N11", "version" : 1 }