{ "audience" : "student", "createdAt" : "2026-09-25T19:44:51Z", "entries" : [ { "envelope" : { "appName" : "ChartSlate", "audience" : "student", "createdAt" : "2026-09-25T19:44:44.067559+00:00", "exportVersion" : "1", "kind" : "casePackage", "package" : { "case" : { "activities" : [ ], "id" : "docucare-n12-valerie-cucina", "learningLevel" : "N12", "panels" : { "assessments" : [ { "author" : "K Chambers, Registered Nurse", "dateTime" : "2022-04-20T00:30:00", "id" : "valerie-cucina-assessment-1", "label" : "Neuro", "summary" : ": Neuro\nAdditional Notes / Additional Notes: Client asking for dead husband, reoriented easily to present situation\nOrientation / Awareness of: / Awareness of: Person\nOrientation / Awareness of: / Awareness of: Place\nBehavioral/Emotional: Confused\nEye Opening: Spontaneously\nMotor Response: Obeys Verbal Command\nVerbal Response: Conversation Confused" }, { "author" : "K Chambers, Registered Nurse", "dateTime" : "2022-04-20T00:00:00", "id" : "valerie-cucina-assessment-2", "label" : "GI", "summary" : ": GI\nGI Symptoms: Epigastric pain\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" : "K Chambers, Registered Nurse", "dateTime" : "2022-04-19T23:00:00", "id" : "valerie-cucina-assessment-3", "label" : "Vascular Access", "summary" : ": Vascular Access\nLocation: (R) Forearm\nType: Peripheral IV\nDate Inserted Days: 0\nDate Inserted Relative To Timing Based On: after admission\nSize: 18 ga\nSite Description: CDI, no s/s of IV related complications\nDressing: Transparent\nNotes: Good blood return, flushes easily. 1000mL 0.9% sodium chloride bolus started" } ], "intakeOutput" : { "documentedIntakeTotalMl" : 1000, "documentedNetMl" : 850, "documentedOutputTotalMl" : 150, "intakeEntries" : [ { "amountMl" : 1000, "id" : "valerie-cucina-intake-1", "time" : "2022-04-20T00:00:00", "type" : "IVPB & IV Push" } ], "outputEntries" : [ { "amountMl" : 150, "id" : "valerie-cucina-output-1", "time" : "2022-04-20T00:00:00", "type" : "Urine" } ] }, "labs" : [ { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2022-04-19T23:30:00", "flag" : "Low", "id" : "valerie-cucina-lab-1", "referenceRange" : "13 - 18 g/100 mL", "result" : "6.0", "test" : "Hgb" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2022-04-19T23:30:00", "flag" : "Low", "id" : "valerie-cucina-lab-2", "referenceRange" : "37 - 49%", "result" : "24", "test" : "Hct" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2022-04-19T23:30:00", "flag" : "Unverified", "id" : "valerie-cucina-lab-3", "referenceRange" : "4,500 - 11,000/mm3", "result" : "6 (source unit/scale requires clarification)", "test" : "WBCs" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2022-04-19T23:30:00", "flag" : "Normal", "id" : "valerie-cucina-lab-4", "referenceRange" : "140 -400 X 103 mm3", "result" : "150,000", "test" : "Platelets" }, { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2022-04-19T23:30:00", "flag" : "Normal", "id" : "valerie-cucina-lab-5", "referenceRange" : "135 -145 mEq/L", "result" : "144", "test" : "Na" }, { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2022-04-19T23:30:00", "flag" : "Normal", "id" : "valerie-cucina-lab-6", "referenceRange" : "3.5-5.0 mEq/L", "result" : "5", "test" : "K" }, { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2022-04-19T23:30:00", "flag" : "High", "id" : "valerie-cucina-lab-7", "referenceRange" : "100 -108 mEq/L", "result" : "109", "test" : "CL" }, { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2022-04-19T23:30:00", "flag" : "Normal", "id" : "valerie-cucina-lab-8", "referenceRange" : "8 - 25 mg/dL", "result" : "18", "test" : "BUN" }, { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2022-04-19T23:30:00", "flag" : "High", "id" : "valerie-cucina-lab-9", "referenceRange" : "0.6 - 1.5 mg/dL", "result" : "1.8", "test" : "Creatinine" }, { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2022-04-19T23:30:00", "flag" : "Normal", "id" : "valerie-cucina-lab-10", "referenceRange" : "24 - 30 mEq/L", "result" : "24", "test" : "CO2" }, { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2022-04-19T23:30:00", "flag" : "Normal", "id" : "valerie-cucina-lab-11", "referenceRange" : "70-110 mg/dL", "result" : "100", "test" : "Glucose" }, { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2022-04-19T23:30:00", "flag" : "High", "id" : "valerie-cucina-lab-12", "referenceRange" : "1.5-2.0 mEq/L", "result" : "3", "test" : "Mg" }, { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2022-04-19T23:30:00", "flag" : "Normal", "id" : "valerie-cucina-lab-13", "referenceRange" : "8.5-10.5 mg/dL", "result" : "10", "test" : "Calcium Total" } ], "medications" : [ { "doseRouteFrequency" : "1 unit Intravenous (IV) x1 (1 time only), 1 time only", "drug" : "Packed Red Blood (PRB) Cells Unit #1", "id" : "valerie-cucina-med-19", "lastGiven" : "2022-04-20T00:50:00", "notes" : "2 units of packed red blood cells - first unit started in emergency department.", "orderedBy" : "Dr. Taylor Lilly, Admitting", "orderedDateTime" : "2022-04-19T23:10:00", "section" : "Scheduled", "status" : "Discontinued" }, { "doseRouteFrequency" : "1 unit Intravenous (IV) x1 (1 time only), 1 time only", "drug" : "Packed Red Blood Cells (PBR) Unit #2", "id" : "valerie-cucina-med-20", "nextDue" : "2022-04-19T23:10:00", "notes" : "2 units of packed red blood cells - first unit started in emergency department Source due: 4/19/2022 23:10", "orderedBy" : "Dr. Taylor Lilly, Admitting", "orderedDateTime" : "2022-04-19T23:10:00", "section" : "Scheduled", "status" : "Active" }, { "doseRouteFrequency" : "80mg Intravenous (IV) x1 (1 time only), 1 time only", "drug" : "pantoprazole sodium", "id" : "valerie-cucina-med-21", "lastGiven" : "2022-04-19T23:00:00", "notes" : "IVP X1 dose, then start continuous infusion.", "orderedBy" : "Dr. Taylor Lilly, Admitting", "orderedDateTime" : "2022-04-19T23:10:00", "section" : "Scheduled", "status" : "Discontinued" }, { "doseRouteFrequency" : "8mg/250NS Intravenous (IV) cont.", "drug" : "pantoprazole sodium", "id" : "valerie-cucina-med-22", "notes" : "8 mg/hr continuous infusion Source due: cont. Do not administer from this unresolved source order. Pantoprazole infusion source dose 8mg/250NS conflicts with instruction 8 mg/hr; total drug amount, diluent volume and pump rate require clarification.", "orderedBy" : "Dr. Taylor Lilly, Admitting", "orderedDateTime" : "2022-04-19T23:10:00", "section" : "Scheduled", "status" : "Held — clarification required" }, { "doseRouteFrequency" : "50mg Intravenous (IV) x1 (1 time only), 1 time only", "drug" : "octreotide acetate", "id" : "valerie-cucina-med-23", "notes" : "followed by 50 mcg/hr continuous infusion for 72 hours Source due: 4/19/2022 23:00 Do not administer from this unresolved source order. Source octreotide orders conflict: bolus is entered as 50 mg, its instruction specifies a subsequent 50 mcg/hr infusion, and the separate infusion is 50 mL/hr without concentration. Verify intended bolus units, infusion concentration and rate; no conversion from mL/hr to mcg/hr is inferred.", "orderedBy" : "Dr. Taylor Lilly, Admitting", "orderedDateTime" : "2022-04-19T23:00:00", "section" : "Scheduled", "status" : "Held — clarification required" }, { "doseRouteFrequency" : "1 gram Intravenous (IV) q12h (Every 12 hours), Every 12 hours", "drug" : "cefTRIAXone sodium", "id" : "valerie-cucina-med-24", "nextDue" : "2022-04-19T23:00:00", "notes" : "Source due: 4/19/2022 23:00", "orderedBy" : "Dr. Taylor Lilly, Admitting", "orderedDateTime" : "2022-04-19T23:00:00", "section" : "Scheduled", "status" : "Active" }, { "doseRouteFrequency" : "4 mg Intravenous (IV) q6h (Every 6 hours), Every 6 hours", "drug" : "ondansetron", "id" : "valerie-cucina-med-25", "notes" : "Source due: PRN", "orderedBy" : "Dr. Taylor Lilly, Admitting", "orderedDateTime" : "2022-04-19T23:00:00", "section" : "PRN", "status" : "Active" }, { "doseRouteFrequency" : "125 ml per hr Intravenous (IV) cont.", "drug" : "sodium chloride", "id" : "valerie-cucina-med-26", "lastGiven" : "2022-04-20T00:00:00", "notes" : "Source due: cont. Infusion concentration not supplied in this order; prior 0.9% bolus does not establish current bag concentration.", "orderedBy" : "Dr. Taylor Lilly, Admitting", "orderedDateTime" : "2022-04-19T23:10:00", "section" : "Scheduled", "status" : "Active" }, { "doseRouteFrequency" : "50 ml per hr Intravenous (IV) cont.", "drug" : "octreotide acetate", "id" : "valerie-cucina-med-27", "notes" : "Source due: 4/19/2022 23:00 Do not administer from this unresolved source order. Source octreotide orders conflict: bolus is entered as 50 mg, its instruction specifies a subsequent 50 mcg/hr infusion, and the separate infusion is 50 mL/hr without concentration. Verify intended bolus units, infusion concentration and rate; no conversion from mL/hr to mcg/hr is inferred.", "orderedBy" : "Dr. Taylor Lilly, Admitting", "orderedDateTime" : "2022-04-19T23:00:00", "section" : "Scheduled", "status" : "Held — clarification required" } ], "notes" : [ { "id" : "valerie-cucina-allergy", "summary" : "NKA | Medication | | | K Chambers | 4/19/2022 23:00", "type" : "Allergy documentation" }, { "author" : "Dr. Taylor Lilly , Admitting", "dateTime" : "2022-04-20T01:00:00", "id" : "valerie-cucina-note-1", "summary" : "Situation: Valerie Cucina is a 78-year-old woman being admitted for an upper gastrointestinal bleed. Background: The patient was brought to the ED by ambulance after being found on the floor, lethargic but responsive. Her daughter Fran noticed blood stains on her clothing and in the bathroom. She reports that her mother is generally in good health, except for osteoarthritis in bilateral knees that has worsened over the past 2 years. The daughter reported to EMS that her mother takes prescribed ibuprofen 400 mg three times a day to manage her arthritic knee pain. The daughter suspects her mother was taking over-the-counter acetaminophen and aspirin as well. Her daughter is in the waiting room. The patient has been evaluated within the last 6 months for signs and symptoms of depression and possible dementia. She was prescribed sertraline hydrochloride 20 mg for depression, which was diagnosed after the death of her husband 1 year ago. Assessment: Her vital signs on arrival to the ED were blood pressure 80/50, heart rate 120, sinus tachycardia, respiration rate 26, and saturation of 90% on room air. After receiving 1 L of NaCl 0.9% over an hour and 2 L O2 nasal cannula, her vital signs responded as follows: blood pressure 100/60, heart rate 110, respiration rate 24, and saturation of 94% on 2 L O2 NC. The patient is lethargic but arousable to touch. She is expressing some confusion about how she got to the hospital, and she is oriented to person and place only. She keeps asking for her husband (deceased); she is easily reoriented. The patient recalls having abdominal pain and feeling sick before falling. She had a head CT, which was negative for any signs of bleeding. An NG tube was inserted with low intermittent wall suction. After NGT initiation, 300 mL of dark coffee ground emesis was collected. Her hemoglobin and hematocrit were 6 g/100 mL and 24%. The patient is NPO. Recommendation: The patient is scheduled for an endoscopy within the hour. She has 2 units of PRBC ordered to transfuse; the first unit was started about 10 minutes ago and is infusing now. She will need to be monitored every 5 minutes for 15 minutes and then every 15 minutes for the duration of the transfusion, per hospital policy. Her preoperative checklist and informed consent are complete.", "type" : "Nursing - Shift" }, { "author" : "Dr. Taylor Lilly , Admitting", "dateTime" : "2022-04-19T23:45:00", "id" : "valerie-cucina-note-2", "summary" : "Client found on bathroom floor by daughter who called 911. EMS arrived and observed blood stains on client's clothing and in the bathroom. Client presents to ED with confusion and lethargy. Daughter present and is the historian for the client. Social History: Client is recently widowed (1 year ago) and is retired. Daughter states client does not smoke, ingest alcohol, or use illegal drugs. Daughter states client lives alone but that family and neighbors visit the client daily, especially since the loss of her husband a year ago. Past Medical History: Osteoarthritis - seeing orthopedic surgeon every 6 months. Started on 400mg ibuprofen orally TID three months ago. Also started on a PPI at that time for gastric mucosal protection. Daughter did not recall the name of the medication. Major Depression: Evaluated and screened for depression 6 months ago, as well as possible dementia. Started on sertraline 25mg orally daily. Home Medications: Ibuprofen 400mg oral TID Sertraline 25mg oral daily Acetaminophen (daughter suspects client is taking this medication currently) Aspirin (daughter suspects client is taking this medication currently) Assessment: Vital signs as follows - BP 80/50, HR 120 - sinus tacycardia, RR 26, SpO2 90% on room air. Neuro: oriented to person and place, moaning, lethargic, confused. Asking for dead husband, but easily reoriented. Arousable to touch. Plan: 1. NPO 2. IV Fluid bolus - started by EMS 3. Head CT 4. NG insertion to LIS 5. Endoscopy to find source of bleeding (STAT) 6. Labs : BMP, PT/PTT/INR, CBC 7. GI Consult 8. Admit to Intermediate Care Unit 9. Blood Products depending on labs", "type" : "Physician Notes" }, { "id" : "valerie-cucina-mar-history-4", "summary" : "4/20/2022 00:50 K Chambers, Registered Nurse Yes", "type" : "Medication administration history — Packed Red Blood (PRB) Cells Unit #1" }, { "id" : "valerie-cucina-mar-history-5", "summary" : "4/19/2022 23:00 K Chambers, Registered Nurse Yes", "type" : "Medication administration history — pantoprazole sodium" }, { "id" : "valerie-cucina-mar-history-6", "summary" : "4/21/2022 05:00 K Chambers, Registered Nurse Yes", "type" : "Medication administration history — pantoprazole sodium" }, { "id" : "valerie-cucina-mar-history-7", "summary" : "4/20/2022 00:00 K Chambers, Registered Nurse Yes", "type" : "Medication administration history — sodium chloride" }, { "id" : "valerie-cucina-section-current-care-providers", "summary" : "Dr. Taylor Lilly | Admitting\nK Chambers | Registered Nurse", "type" : "Current Care Providers" }, { "id" : "valerie-cucina-clarification-9", "summary" : "Pantoprazole infusion source dose 8mg/250NS conflicts with instruction 8 mg/hr; total drug amount, diluent volume and pump rate require clarification.", "type" : "Chart clarification" }, { "id" : "valerie-cucina-clarification-10", "summary" : "Source octreotide orders conflict: bolus is entered as 50 mg, its instruction specifies a subsequent 50 mcg/hr infusion, and the separate infusion is 50 mL/hr without concentration. Verify intended bolus units, infusion concentration and rate; no conversion from mL/hr to mcg/hr is inferred.", "type" : "Chart clarification" }, { "id" : "valerie-cucina-clarification-11", "summary" : "Source octreotide orders conflict: bolus is entered as 50 mg, its instruction specifies a subsequent 50 mcg/hr infusion, and the separate infusion is 50 mL/hr without concentration. Verify intended bolus units, infusion concentration and rate; no conversion from mL/hr to mcg/hr is inferred.", "type" : "Chart clarification" }, { "id" : "valerie-cucina-clarification-12", "summary" : "Medication history reconciliation: physician note and structured history document sertraline 25 mg daily; nursing SBAR says 20 mg. Verify home dose. Initial BP is 99/50 in flowsheet versus 80/50 in both narratives; both source records retained.", "type" : "Chart clarification" } ], "orders" : [ { "author" : "Dr. Taylor Lilly, Admitting", "category" : "Consult", "dateTime" : "2022-04-19T23:10:00", "id" : "valerie-cucina-order-1", "orderText" : "Consult: Gastroenterology; x1 (1 time only), 1 time only; Routine; Consult gastroeneterology for gastric bleeding Source due: 4/19/2022 23:10", "status" : "Active" }, { "author" : "Dr. Taylor Lilly, Admitting", "category" : "Dietary", "dateTime" : "2022-04-19T23:10:00", "id" : "valerie-cucina-order-2", "orderText" : "NPO; cont.; Routine; NPO Source due: 4/19/2022 23:10", "status" : "Active" }, { "author" : "Dr. Taylor Lilly, Admitting", "category" : "ED", "dateTime" : "2022-04-19T23:00:00", "id" : "valerie-cucina-order-3", "orderText" : "Pulse oximetry; q10min (Every 10 minutes), Every 10 minutes; Stat; Obtain with Vital Signs Source due: 4/19/2022 23:00", "status" : "Active" }, { "author" : "Dr. Taylor Lilly, Admitting", "category" : "Emergency Dept.", "dateTime" : "2022-04-19T23:00:00", "id" : "valerie-cucina-order-4", "orderText" : "Type and Cross Match; x1 (1 time only), 1 time only; Stat; 2 Units Packed Red Blood Cells (PRBCs) Source due: 4/19/2022 23:00", "status" : "Active" }, { "author" : "Dr. Taylor Lilly, Admitting", "category" : "Laboratory", "dateTime" : "2022-04-19T23:10:00", "id" : "valerie-cucina-order-5", "orderText" : "Venipuncture; x1 (1 time only), 1 time only; Routine; Labs: BMP PT/PTT/INR Source due: 4/19/2022 23:10", "status" : "Active" }, { "author" : "Dr. Taylor Lilly, Admitting", "category" : "Laboratory", "dateTime" : "2022-04-19T23:10:00", "id" : "valerie-cucina-order-6", "orderText" : "Venipuncture; q6h (Every 6 hours), Every 6 hours; Routine; CBC every 6 hours Source due: 4/19/2022 23:10", "status" : "Active" }, { "author" : "Dr. Taylor Lilly, Admitting", "category" : "Nursing", "dateTime" : "2022-04-19T23:10:00", "id" : "valerie-cucina-order-7", "orderText" : "Admission; cont.; Stat; Admit to Intermediate Care Unit Source due: 4/19/2022 23:10", "status" : "Active" }, { "author" : "Dr. Taylor Lilly, Admitting", "category" : "Nursing", "dateTime" : "2022-04-19T23:10:00", "id" : "valerie-cucina-order-8", "orderText" : "SBAR communication; cont.; Routine; Report urinary output less than 30mL/hr Source due: 4/19/2022 23:10", "status" : "Active" }, { "author" : "Dr. Taylor Lilly, Admitting", "category" : "Nursing: Activity", "dateTime" : "2022-04-19T23:10:00", "id" : "valerie-cucina-order-9", "orderText" : "Code management; cont.; Routine; Code Status: Full Code Source due: 4/19/2022 23:10", "status" : "Active" }, { "author" : "Dr. Taylor Lilly, Admitting", "category" : "Nursing: Activity", "dateTime" : "2022-04-19T23:10:00", "id" : "valerie-cucina-order-10", "orderText" : "IV catheter insertion; x2 (2 times only), 2 times only; Routine; Peripheral IV X 2 (20 gauge or larger) Source due: 4/19/2022 23:10", "status" : "Active" }, { "author" : "Dr. Taylor Lilly, Admitting", "category" : "Nursing: Activity", "dateTime" : "2022-04-19T23:10:00", "id" : "valerie-cucina-order-11", "orderText" : "Blood and blood product transfusion; x1 (1 time only), 1 time only; Routine; Call provider for signs and symptoms of blood transfusion reaction Source due: 4/19/2022 23:10", "status" : "Active" }, { "author" : "Dr. Taylor Lilly, Admitting", "category" : "Nursing: Monitoring", "dateTime" : "2022-04-19T23:10:00", "id" : "valerie-cucina-order-12", "orderText" : "Vital Signs; q4h (Every 4 hours), Every 4 hours; Stat; Vital Signs every 4 hours with continuous telemetry monitoring Source due: 4/19/2022 23:10", "status" : "Active" }, { "author" : "Dr. Taylor Lilly, Admitting", "category" : "Nursing: Monitoring", "dateTime" : "2022-04-19T23:10:00", "id" : "valerie-cucina-order-13", "orderText" : "Oxygen Administration; cont.; Routine; Oxygen to keep SpO2 > 92% Source due: 4/19/2022 23:10", "status" : "Active" }, { "author" : "Dr. Taylor Lilly, Admitting", "category" : "Nursing: Monitoring", "dateTime" : "2022-04-19T23:10:00", "id" : "valerie-cucina-order-14", "orderText" : "Intake and output measurement; q4h (Every 4 hours), Every 4 hours; Routine; Source due: 4/19/2022 23:10", "status" : "Active" }, { "author" : "Dr. Taylor Lilly, Admitting", "category" : "Nursing: Monitoring", "dateTime" : "2022-04-19T23:10:00", "id" : "valerie-cucina-order-15", "orderText" : "Cardiac monitoring; cont.; Routine; Continuous telemetry monitoring Source due: 4/19/2022 23:10", "status" : "Active" }, { "author" : "Dr. Taylor Lilly, Admitting", "category" : "Nursing: Monitoring", "dateTime" : "2022-04-19T23:10:00", "id" : "valerie-cucina-order-16", "orderText" : "Blood pressure measurement; q4h (Every 4 hours), Every 4 hours; Routine; Blood pressure monitoring every 4 hours and PRN Source due: 4/19/2022 23:10", "status" : "Active" }, { "author" : "Dr. Taylor Lilly, Admitting", "category" : "Nursing: Monitoring", "dateTime" : "2022-04-19T23:10:00", "id" : "valerie-cucina-order-17", "orderText" : "Weight measurement; q24h (Every 24 hours), Every 24 hours; Routine; Daily Weight Source due: 4/19/2022 23:10", "status" : "Active" }, { "author" : "Dr. Taylor Lilly, Admitting", "category" : "Nursing: Monitoring", "dateTime" : "2022-04-19T23:10:00", "id" : "valerie-cucina-order-18", "orderText" : "Vital Signs; Routine; Vital signs per protocol during blood transfusion Source due: 4/19/2022 23:10", "status" : "Active" }, { "author" : "Dr. Taylor Lilly, Admitting", "category" : "Pharmacy", "dateTime" : "2022-04-19T23:10:00", "id" : "valerie-cucina-order-19", "orderText" : "Packed Red Blood (PRB) Cells Unit #1; 1 unit Intravenous (IV); x1 (1 time only), 1 time only; Discontinued; 2 units of packed red blood cells - first unit started in emergency department.", "status" : "Discontinued" }, { "author" : "Dr. Taylor Lilly, Admitting", "category" : "Pharmacy", "dateTime" : "2022-04-19T23:10:00", "id" : "valerie-cucina-order-20", "orderText" : "Packed Red Blood Cells (PBR) Unit #2; 1 unit Intravenous (IV); x1 (1 time only), 1 time only; Scheduled; 2 units of packed red blood cells - first unit started in emergency department Source due: 4/19/2022 23:10", "status" : "Active" }, { "author" : "Dr. Taylor Lilly, Admitting", "category" : "Pharmacy", "dateTime" : "2022-04-19T23:10:00", "id" : "valerie-cucina-order-21", "orderText" : "pantoprazole sodium; 80mg Intravenous (IV); x1 (1 time only), 1 time only; Discontinued; IVP X1 dose, then start continuous infusion.", "status" : "Discontinued" }, { "author" : "Dr. Taylor Lilly, Admitting", "category" : "Pharmacy", "dateTime" : "2022-04-19T23:10:00", "id" : "valerie-cucina-order-22", "orderText" : "pantoprazole sodium; 8mg/250NS Intravenous (IV); cont.; Scheduled; 8 mg/hr continuous infusion Source due: cont. Pantoprazole infusion source dose 8mg/250NS conflicts with instruction 8 mg/hr; total drug amount, diluent volume and pump rate require clarification.", "status" : "Held — clarification required" }, { "author" : "Dr. Taylor Lilly, Admitting", "category" : "Pharmacy", "dateTime" : "2022-04-19T23:00:00", "id" : "valerie-cucina-order-23", "orderText" : "octreotide acetate; 50mg Intravenous (IV); x1 (1 time only), 1 time only; Scheduled, Stat; followed by 50 mcg/hr continuous infusion for 72 hours Source due: 4/19/2022 23:00 Source octreotide orders conflict: bolus is entered as 50 mg, its instruction specifies a subsequent 50 mcg/hr infusion, and the separate infusion is 50 mL/hr without concentration. Verify intended bolus units, infusion concentration and rate; no conversion from mL/hr to mcg/hr is inferred.", "status" : "Held — clarification required" }, { "author" : "Dr. Taylor Lilly, Admitting", "category" : "Pharmacy", "dateTime" : "2022-04-19T23:00:00", "id" : "valerie-cucina-order-24", "orderText" : "cefTRIAXone sodium; 1 gram Intravenous (IV); q12h (Every 12 hours), Every 12 hours; Scheduled, Stat; Source due: 4/19/2022 23:00", "status" : "Active" }, { "author" : "Dr. Taylor Lilly, Admitting", "category" : "Pharmacy", "dateTime" : "2022-04-19T23:00:00", "id" : "valerie-cucina-order-25", "orderText" : "ondansetron; 4 mg Intravenous (IV); q6h (Every 6 hours), Every 6 hours; PRN, Stat; Source due: PRN", "status" : "Active" }, { "author" : "Dr. Taylor Lilly, Admitting", "category" : "Pharmacy", "dateTime" : "2022-04-19T23:10:00", "id" : "valerie-cucina-order-26", "orderText" : "sodium chloride; 125 ml per hr Intravenous (IV); cont.; Cont. Infusion; Source due: cont.", "status" : "Active" }, { "author" : "Dr. Taylor Lilly, Admitting", "category" : "Pharmacy", "dateTime" : "2022-04-19T23:00:00", "id" : "valerie-cucina-order-27", "orderText" : "octreotide acetate; 50 ml per hr Intravenous (IV); cont.; Cont. Infusion, Stat; Source due: 4/19/2022 23:00 Source octreotide orders conflict: bolus is entered as 50 mg, its instruction specifies a subsequent 50 mcg/hr infusion, and the separate infusion is 50 mL/hr without concentration. Verify intended bolus units, infusion concentration and rate; no conversion from mL/hr to mcg/hr is inferred.", "status" : "Held — clarification required" }, { "author" : "Dr. Taylor Lilly, Admitting", "category" : "Radiology", "dateTime" : "2022-04-19T23:10:00", "id" : "valerie-cucina-order-28", "orderText" : "Schedule Endoscopy; x1 (1 time only), 1 time only; Stat; STAT Endoscopy Source due: 4/19/2022 23:10", "status" : "Active" } ], "overview" : { "height" : "62 in / 157.5 cm", "isolationIndicator" : "Standard", "religion" : "", "weightKg" : 63.5 }, "vitals" : [ { "bloodPressure" : "99/50", "dateTime" : "2022-04-19T23:00:00", "heartRate" : 120, "id" : "valerie-cucina-vital-1", "oxygenDevice" : "Room Air", "respiratoryRate" : 26, "spo2" : "90", "temperature" : "98.5 °F (37 °C), 37 °C Oral" }, { "bloodPressure" : "100/60", "dateTime" : "2022-04-20T00:00:00", "heartRate" : 110, "id" : "valerie-cucina-vital-2", "oxygenDevice" : "Nasal Cannula", "respiratoryRate" : 24, "spo2" : "94", "temperature" : "98.6 °F (37 °C), 37 °C Oral" } ] }, "patient" : { "admitDateTime" : "2022-04-19T23:00:00", "admittingDiagnosis" : "Peptic ulcer disease", "allergies" : [ ], "attending" : "Dr. Taylor Lilly, Admitting", "chartDisplayName" : "Cucina, Valerie M", "codeStatus" : "Full Code", "dob" : "1/1/XX", "history" : { "chiefComplaint" : "Daughter found client on the floor in her home at 1800 today. Client is responsive but moaning and lethargic. EMS reports blood stains on her clothing and in the bathroom where she was found.", "pastMedicalHistory" : [ "General Medical History / Disease/Condition / : Osteoarthritis, long-term care", "General Medical History / Active: Active", "General Medical History / Disease/Condition / : Major depressive disorder", "General Medical History / Active: Active", "General Medical History / Notes: Client taking ibuprofen 400mg TID orally for past 3 months. Client also taking sertraline 25mg daily orally for depression.", "Pain History / History of Chronic Pain?: Yes", "Pain History / Location: Both knees", "Pain History / Does Patient Take Medication for Pain?: Yes", "Pain History / Which Medication(s)?: 400mg Ibuprofen three times a day", "Pain History / For How Long?: Past 3 months" ], "pastSurgicalHistory" : [ "Previous Surgical Procedures: No prior surgical history" ], "socialHistory" : [ "Age: 78 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", "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", "Drug Use / Illicit Drug Use Status: Nonuser", "Nutritional Screening / Last Bowel Movement Days: 0", "Nutritional Screening / Last Bowel Movement Relative To Timing Based On: before student launches assignment", "Mental Health Screening / Notes: Client evaluated in the last 6 months for signs and symptoms of depression and possible dementia. Prescribed sertraline 25mg for depression diagnosis after the death of her husband 1 year ago." ] }, "mrn" : "PCS10100", "sex" : "Female", "simulatedFullName" : "Valerie Maria Cucina", "unit" : "Holy Cross Hospital — Room 4 — Bed A" }, "setting" : "Holy Cross Hospital — Room 4 — Bed A", "snapshots" : [ { "activityIds" : [ ], "id" : "valerie-cucina-current", "notes" : "Captured dated chart history; source relative dates anchored to chart opening. Progressive release not recreated.", "scenarioTime" : "2022-04-20T01:00:00", "sourcePath" : "DocuCare instructor chart: Valerie Cucina", "title" : "Captured chart" } ], "subtitle" : "N12 practice record", "tags" : [ "N12", "DocuCare migration" ], "title" : "Valerie Cucina" }, "packageId" : "docucare-n12-valerie-cucina-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" : "n12-valerie-cucina", "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" : "Valerie Maria Cucina" }, { "envelope" : { "appName" : "ChartSlate", "audience" : "student", "createdAt" : "2026-09-25T19:44:44.067559+00:00", "exportVersion" : "1", "kind" : "casePackage", "package" : { "case" : { "activities" : [ ], "id" : "docucare-n12-max-renfrow", "learningLevel" : "N12", "panels" : { "assessments" : [ { "author" : "Mark C. Collins, Primary Care Provider", "dateTime" : "2027-01-26T11:43:00", "id" : "max-renfrow-assessment-1", "label" : "Pain Scale", "summary" : ": Pain Scale\nOnset Days: 123\nOnset Hours: 0\nOnset Minutes: 0\nOnset Relative To Timing Based On: after student launches assignment\nPain Rating: 0 - No Pain" } ], "labs" : [ ], "medications" : [ { "doseRouteFrequency" : "20mg Intravenous (IV) x2 (2 times only), 2 times only", "drug" : "Labetalol", "id" : "max-renfrow-med-7", "notes" : "1st line: q15 min x 2 BP goal <160/100 Source due: PRN", "orderedBy" : "Mark C. Collins, Primary Care Provider", "orderedDateTime" : "2026-09-25T11:38:00", "section" : "PRN", "status" : "Active" }, { "doseRouteFrequency" : "5 ml per hr Intravenous (IV) cont.", "drug" : "Nicardipine", "id" : "max-renfrow-med-8", "notes" : "Second line: If BP unresponsive to Labetolol 20mg x2, start Nicardipine drip 5 mg/hr titrate 2mg/q15 to BP <160/100 Source due: 9/25/2026 11:38 Do not administer from this unresolved source order. Source rate is 5 mL/hr but instructions say 5 mg/hr with titration 2mg/q15; concentration, titration units and maximum rate are incomplete. Verify protocol before administration.", "orderedBy" : "Mark C. Collins, Primary Care Provider", "orderedDateTime" : "2026-09-25T11:38:00", "section" : "Scheduled", "status" : "Held — clarification required" } ], "notes" : [ { "id" : "max-renfrow-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" : "max-renfrow-family-health-history", "summary" : "Family History: Denies knowledge of significant family history", "type" : "Family Health History" }, { "id" : "max-renfrow-mar", "summary" : "enalaprilat 2.5 mg Oral (PO) | q24h (Every 24 hours), Every 24 hours | 9/25/2026 11:38 | \nfurosemide 40 mg Oral (PO) | q24h (Every 24 hours), Every 24 hours | 9/25/2026 11:38 | ", "type" : "Home medication history" }, { "author" : "Susan Smith , Registered Nurse", "dateTime" : "2026-09-25T11:43:00", "id" : "max-renfrow-note-1", "summary" : "65 y/o male (70 in, 245 lb) moved to ED Bed 4 after arrival. Patient has changed into gown and is connected to cardiac monitor showing sinus tachycardia. Alert and oriented x3, reports severe headache and blurred vision. Daughter at bedside. Initial VS obtained (see flowsheet). IV access and provider orders pending. Fall precautions initiated.", "type" : "Nursing - Progress Note" }, { "author" : "Susan Smith , Registered Nurse", "dateTime" : "2026-09-25T11:38:00", "id" : "max-renfrow-note-2", "summary" : "Max Renfrow, a 65-year-old male, BIBA to the ED with hypertensive, 198/118 mmHg, from outside clinic. He reports a sudden onset of severe headache, blurred vision, and chest tightness while at home. He admits to taking his home blood pressure medications (lisinopril and hydrochlorothiazide) irregularly over the past week.", "type" : "Nursing - Admission" }, { "author" : "Mark C. Collins , Primary Care Provider", "dateTime" : "2026-05-25T11:38:00", "id" : "max-renfrow-note-3", "summary" : "Patient at clinic due to feeling tired. BP elevated, has been trending upwards over past 2 years. Recheck of BP was 160/98. Educated on diet, exercise, effects of smoking and need for medical intervention for hypertension. Patient willing to try to increase exercise, change to a lower fat, lower sodium diet, but stated he was not ready to quit smoking. Prescribed enalaprilat 2.5mg and furosemide 40mg for daily use. Will see patient again in 3-6months.", "type" : "Physician Notes" }, { "id" : "max-renfrow-section-immunizations", "summary" : " Birth to Adult Immunizations: Influenza, Td/Tdap, Varicella, MMR 1, MMR 2, Rubella, Pneumonia\n Titers: N/A\n9/25/2026 11:38 | Birth to Adult Immunizations: Influenza, Td/Tdap, Varicella, MMR 1, MMR 2, Rubella, Pneumonia Titers: N/A", "type" : "Immunizations" }, { "id" : "max-renfrow-section-previous-visits", "summary" : "Hypertension | Howey Clinic | States has had times feels more tired than usual. VS taken BP152/84, R 20, HR 88, Temp 97.6. | 5/25/2026 11:38 | 5/25/2026 11:38", "type" : "Previous Visits" }, { "id" : "max-renfrow-section-current-care-providers", "summary" : "Mark C. Collins | Primary Care Provider\nSusan Smith | Registered Nurse", "type" : "Current Care Providers" }, { "id" : "max-renfrow-clarification-10", "summary" : "Source rate is 5 mL/hr but instructions say 5 mg/hr with titration 2mg/q15; concentration, titration units and maximum rate are incomplete. Verify protocol before administration.", "type" : "Chart clarification" }, { "id" : "max-renfrow-clarification-11", "summary" : "Home medication reconciliation required: older clinic note and MAR list oral enalaprilat 2.5 mg plus furosemide 40 mg; newer ED admission lists lisinopril and hydrochlorothiazide without doses. Enalaprilat is documented in official labeling as an IV product. Do not infer substitution with enalapril or activate either home regimen without clarification.", "type" : "Chart clarification" }, { "id" : "max-renfrow-clarification-12", "summary" : "Timeline clarification: pain assessment is source-dated 123 days after launch and must not be interpreted as the current pain score. Clinic history and ED presentation describe different encounter settings.", "type" : "Chart clarification" } ], "orders" : [ { "author" : "Mark C. Collins, Primary Care Provider", "category" : "Not specified", "dateTime" : "2026-09-25T11:38:00", "id" : "max-renfrow-order-1", "orderText" : "IV Access; x1 (1 time only), 1 time only; Stat; Large-bore peripheral IV ×2 Source due: 9/25/2026 11:38", "status" : "Active" }, { "author" : "Mark C. Collins, Primary Care Provider", "category" : "Not specified", "dateTime" : "2026-09-25T11:38:00", "id" : "max-renfrow-order-2", "orderText" : "Labs – STAT CMP, CBC, troponin; x1 (1 time only), 1 time only; Stat; Source due: 9/25/2026 11:38", "status" : "Active" }, { "author" : "Mark C. Collins, Primary Care Provider", "category" : "Not specified", "dateTime" : "2026-09-25T11:38:00", "id" : "max-renfrow-order-3", "orderText" : "UA; x1 (1 time only), 1 time only; Stat; Source due: 9/25/2026 11:38", "status" : "Active" }, { "author" : "Mark C. Collins, Primary Care Provider", "category" : "Not specified", "dateTime" : "2026-09-25T11:38:00", "id" : "max-renfrow-order-4", "orderText" : "12 Lead ECG; x1 (1 time only), 1 time only; Stat; Source due: 9/25/2026 11:38", "status" : "Active" }, { "author" : "Mark C. Collins, Primary Care Provider", "category" : "Not specified", "dateTime" : "2026-09-25T11:38:00", "id" : "max-renfrow-order-5", "orderText" : "BP; q15min (Every 15 minutes), Every 15 minutes; Stat; q15min until BP <160/100, then q30min Source due: 9/25/2026 11:38", "status" : "Active" }, { "author" : "Mark C. Collins, Primary Care Provider", "category" : "Not specified", "dateTime" : "2026-09-25T11:38:00", "id" : "max-renfrow-order-6", "orderText" : "Neuro Checks – q1h (level of consciousness, pupils, headache, vomiting) – hold for cerebral edema protocol if changes; cont.; Routine; Q15 first hour, Q30 for 2 hours, then hourly until BP stabilized. Source due: 9/25/2026 11:38", "status" : "Active" }, { "author" : "Mark C. Collins, Primary Care Provider", "category" : "Pharmacy", "dateTime" : "2026-09-25T11:38:00", "id" : "max-renfrow-order-7", "orderText" : "Labetalol; 20mg Intravenous (IV); x2 (2 times only), 2 times only; PRN, Stat; 1st line: q15 min x 2 BP goal <160/100 Source due: PRN", "status" : "Active" }, { "author" : "Mark C. Collins, Primary Care Provider", "category" : "Pharmacy", "dateTime" : "2026-09-25T11:38:00", "id" : "max-renfrow-order-8", "orderText" : "Nicardipine; 5 ml per hr Intravenous (IV); cont.; Cont. Infusion; Second line: If BP unresponsive to Labetolol 20mg x2, start Nicardipine drip 5 mg/hr titrate 2mg/q15 to BP <160/100 Source due: 9/25/2026 11:38 Source rate is 5 mL/hr but instructions say 5 mg/hr with titration 2mg/q15; concentration, titration units and maximum rate are incomplete. Verify protocol before administration.", "status" : "Held — clarification required" } ], "overview" : { "height" : "70 in / 177.8 cm", "isolationIndicator" : "Standard", "religion" : "Baptist", "weightKg" : 111.1 }, "vitals" : [ { "bloodPressure" : "215/118", "dateTime" : "2026-09-25T11:45:00", "heartRate" : 93, "id" : "max-renfrow-vital-1", "oxygenDevice" : "Room Air", "respiratoryRate" : 26, "spo2" : "100" }, { "bloodPressure" : "202/84", "dateTime" : "2027-01-26T11:43:00", "heartRate" : 74, "id" : "max-renfrow-vital-2", "oxygenDevice" : "Room Air", "respiratoryRate" : 12, "spo2" : "99", "temperature" : "98.2 °F (37 °C), 37 °C Oral" } ] }, "patient" : { "admitDateTime" : "2026-09-25T11:38:00", "admittingDiagnosis" : "Hypertension", "allergies" : [ ], "attending" : "Mark C. Collins, Primary Care Provider", "chartDisplayName" : "Renfrow, Max", "codeStatus" : "Full Code", "dob" : "7/3/1961", "history" : { "chiefComplaint" : "Presents today with continuing times of feeling tired and at times when standing up becoming dizzy.", "pastMedicalHistory" : [ "General Medical History / Disease/Condition / : Hypertension", "General Medical History / Active: Active", "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: 65 years", "Home Situation / Patient Living Situation: Home", "Home Situation / Lives With: Spouse", "Education / Highest Grade Completed: High School", "Education / Able to Read?: Yes", "Education / Able to Write?: Yes", "Nicotine Use / Cigarettes: Current Smoker", "Nicotine Use / Packs per Day: 1.5", "Nicotine Use / # of Years: 30", "Nicotine Use / : Low", "Nicotine Use / Tobacco cessation counseling given?: No", "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?: No", "Nutritional Screening / Does patient have diabetes?: No", "Nutritional Screening: Other", "Nutritional Screening / Home Diet Considerations, Other value: High fat and increase sodium", "Nutritional Screening / Stool Description: Loose", "Nutritional Screening / Last Bowel Movement Days: 0", "Nutritional Screening / Last Bowel Movement Relative To Timing Based On: before student launches assignment", "Exercise Screening / Exercise Frequency: Rarely", "Exercise Screening / Duration of Exercise: 30 mins", "Exercise Screening / Intensity: Mild", "Exercise Screening / Type(s): Walking around yard", "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?: Sometimes", "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" : "44365", "sex" : "Male", "simulatedFullName" : "Max Renfrow", "unit" : "Howey Clinic — Room 3" }, "setting" : "Howey Clinic — Room 3", "snapshots" : [ { "activityIds" : [ ], "id" : "max-renfrow-current", "notes" : "Captured dated chart history; source relative dates anchored to chart opening. Progressive release not recreated.", "scenarioTime" : "2026-09-25T11:43:00", "sourcePath" : "DocuCare instructor chart: Max Renfrow", "title" : "Captured chart" } ], "subtitle" : "N12 practice record", "tags" : [ "N12", "DocuCare migration" ], "title" : "Max Renfrow" }, "packageId" : "docucare-n12-max-renfrow-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" : "n12-max-renfrow", "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" : "Max Renfrow" }, { "envelope" : { "appName" : "ChartSlate", "audience" : "student", "createdAt" : "2026-09-25T19:44:44.067559+00:00", "exportVersion" : "1", "kind" : "casePackage", "package" : { "case" : { "activities" : [ ], "id" : "docucare-n12-lucille-howard", "learningLevel" : "N12", "panels" : { "assessments" : [ { "author" : "Lauren Spye, RN, Registered Nurse", "dateTime" : "2019-11-07T14:00:00", "id" : "lucille-howard-assessment-1", "label" : "HEENT", "summary" : ": HEENT\nHead / Size/Shape / Head Size/Shape: Symmetric\nHead / Recent Trauma: No\nEars / Left Ear: Intact\nEars / Right Ear: Intact\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: Bridge(s)\nMouth/Throat / Oral Mucosa: Normal\nMouth/Throat / Oral Mucosa: Pink\nMouth/Throat / Pharynx: Normal\nMouth/Throat / Lymph Nodes / LymphNodes: Non-tender" }, { "author" : "Lauren Spye, RN, Registered Nurse", "dateTime" : "2019-11-07T14:00:00", "id" : "lucille-howard-assessment-2", "label" : "Neuro", "summary" : ": Neuro\nOrientation / Awareness of: / Awareness of: Person\nOrientation / Awareness of: / Awareness of: Place\nOrientation / Awareness of: / Awareness of: 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 / Right Eye (OD: Oculus Dexter, right eye), OD: Oculus Dexter, right eye / Size / Right Eye Size: 5\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: Weak Movement Upon Request in Left Lower Extremity\nStrength / RLE (Right Lower Extremity), Right Lower Extremity: Weak Movement Upon Request in Right Lower Extremity\nBehavioral/Emotional: Calm\nBehavioral/Emotional: Cooperative" }, { "author" : "Lauren Spye, RN, Registered Nurse", "dateTime" : "2019-11-07T14:00:00", "id" : "lucille-howard-assessment-3", "label" : "Cardio", "summary" : ": Cardio\nHeart Tones: S1, S2\nPulses / All: + 2 in All\nEdema / All: Trace\nCapillary Refill / All: < 3 sec in All\nSkin Color and Description: Appropriate for ethnicity\nSkin Color and Description: Dry\nSkin Color and Description: Intact" }, { "author" : "Lauren Spye, RN, Registered Nurse", "dateTime" : "2019-11-07T14:00:00", "id" : "lucille-howard-assessment-4", "label" : "GI", "summary" : ": GI\nAbdominal Description / All: Non-distended\nAbdominal Description / All: Soft\nAbdominal Description / All: Tender\nGI Symptoms: Nausea\nGI Symptoms: Abdominal pain\nBowel Sounds / All: Present\nDiet Tolerance / Diet Tolerance: Adequate\nDescription: Formed\nColor: Brown\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: before admission" }, { "author" : "Lauren Spye, RN, Registered Nurse", "dateTime" : "2019-11-07T14:00:00", "id" : "lucille-howard-assessment-5", "label" : "GU", "summary" : ": GU\nUrinary Symptoms: Incontinence, Stress\nUrine Color: Yellow\nUrine Character: Clear\nUrinary Elimination: Voiding with Difficulty\nDate Inserted Days: 0\nDate Inserted Relative To Timing Based On: after admission\nVolume in Balloon: 0" }, { "author" : "Lauren Spye, RN, Registered Nurse", "dateTime" : "2019-11-07T14:00:00", "id" : "lucille-howard-assessment-6", "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" : "Lauren Spye, RN, Registered Nurse", "dateTime" : "2019-11-07T14:00:00", "id" : "lucille-howard-assessment-7", "label" : "Mental Health", "summary" : ": Mental Health\nAdditional Notes / Additional Notes: Social Services to talk with patient regarding any home care needs\nBehavior / Affect: Appropriate\nStressors: Condition\nStressors: Hospitalization\nCoping: Fair\nConsult: Social Work" }, { "author" : "Lauren Spye, RN, Registered Nurse", "dateTime" : "2019-11-07T14:00:00", "id" : "lucille-howard-assessment-8", "label" : "Musculoskeletal", "summary" : ": Musculoskeletal\nMusculoskeletal Symptoms: Pain\nMusculoskeletal Symptoms: Joint Stiffness\nMuscle Tone / Strength / LUE (Left Upper Extremity), Left Upper Extremity: Normal strength in Left Upper Extremity\nMuscle Tone / Strength / RUE (Right Upper Extremity), Right Upper Extremity: Normal strength in Right Upper Extremity\nMuscle Tone / Strength / LLE (Left Lower Extremity), Left Lower Extremity: Movement against resistance, but less than normal in Left Lower Extremity\nMuscle Tone / Strength / RLE (Right Lower Extremity), Right Lower Extremity: Movement against resistance, but less than normal in Right Lower Extremity\nMuscle Tone / Strength / LLE (Left Lower Extremity), Left Lower Extremity: Active Assistive Range of Motion in Left Lower Extremity\nMuscle Tone / Strength / RLE (Right Lower Extremity), Right Lower Extremity: Active Assistive Range of Motion in Right Lower Extremity\nMuscle Tone / Strength / LUE (Left Upper Extremity), Left Upper Extremity: Active Range of Motion in Left Upper Extremity\nMuscle Tone / Strength / RUE (Right Upper Extremity), Right Upper Extremity: Active Range of Motion in Right Upper Extremity\nWeight Bearing / Gait / Posture: Steady\nWeight Bearing / Gait / Posture: Independent" }, { "author" : "Lauren Spye, RN, Registered Nurse", "dateTime" : "2019-11-07T13:30:00", "id" : "lucille-howard-assessment-9", "label" : "Pain Scale", "summary" : ": Pain Scale\nPain Location: Abdomen\nOnset Days: 0\nOnset Hours: 6\nOnset Minutes: 0\nOnset Relative To Timing Based On: before admission\nPain Frequency: Intermittent\nType Of Pain: Acute\nPain Goal: 3\nAggravating Factors: Movement\nAggravating Factors: Coughing\nAlleviating Factors: Rest\nPain Scale Used: 0-10\nPain Rating: 6\nPain Characteristics: Aching\nPain Characteristics: Burning\nPain Characteristics: Radiating" }, { "author" : "Lauren Spye, RN, Registered Nurse", "dateTime" : "2019-11-07T14:00:00", "id" : "lucille-howard-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: 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: 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" : "Lauren Spye, RN, Registered Nurse", "dateTime" : "2019-11-07T14:00:00", "id" : "lucille-howard-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. *" }, { "author" : "Lauren Spye, RN, Registered Nurse", "dateTime" : "2019-11-07T14:00:00", "id" : "lucille-howard-assessment-12", "label" : "Morse Fall Risk", "summary" : ": Morse Fall Risk\nDoes the patient have a recent history of falling?: No Patient has not fallen recently\nDoes the patient have secondary medical diagnoses?: Yes\nAre ambulatory aids used?: Bed rest/nurse assist Patient walks without a walking aid (even if assisted by a nurse), uses a wheelchair, or is on bed rest and does not get out of bed at all\nDoes the patient have an intravenous apparatus or a heparin lock inserted?: Yes\nWhat is the patient’s gait?: Normal/bed rest/immobile Patient walks with head erect, arms swinging freely at the side, and striding without hesitation\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: 35\nResults: Moderate Risk (25–50)" } ], "intakeOutput" : { "documentedIntakeTotalMl" : 0, "documentedNetMl" : -100, "documentedOutputTotalMl" : 100, "intakeEntries" : [ ], "outputEntries" : [ { "amountMl" : 100, "id" : "lucille-howard-output-1", "time" : "2019-11-07T13:40:00", "type" : "Urine" } ] }, "labs" : [ { "category" : "Urinalysis", "collectedDateTime" : "2019-11-07T14:00:00", "flag" : "Normal", "id" : "lucille-howard-lab-1", "referenceRange" : "Pale yellow-amber", "result" : "amber", "test" : "Color" }, { "category" : "Urinalysis", "collectedDateTime" : "2019-11-07T14:00:00", "flag" : "High", "id" : "lucille-howard-lab-2", "referenceRange" : "Clear to slightly hazy", "result" : "cloudy", "test" : "Clarity" }, { "category" : "Urinalysis", "collectedDateTime" : "2019-11-07T14:00:00", "flag" : "High", "id" : "lucille-howard-lab-3", "referenceRange" : "1.005-1.025", "result" : "1.030", "test" : "Specific gravity" }, { "category" : "Urinalysis", "collectedDateTime" : "2019-11-07T14:00:00", "flag" : "High", "id" : "lucille-howard-lab-4", "referenceRange" : "Negative", "result" : "trace", "test" : "Ketones" }, { "category" : "Urinalysis", "collectedDateTime" : "2019-11-07T14:00:00", "flag" : "Normal", "id" : "lucille-howard-lab-5", "referenceRange" : "Negative", "result" : "neg", "test" : "Glucose" }, { "category" : "Urinalysis", "collectedDateTime" : "2019-11-07T14:00:00", "flag" : "Normal", "id" : "lucille-howard-lab-6", "referenceRange" : "4.5-8.0", "result" : "7.5", "test" : "pH" }, { "category" : "Urinalysis", "collectedDateTime" : "2019-11-07T14:00:00", "flag" : "High", "id" : "lucille-howard-lab-7", "referenceRange" : "Negative", "result" : "trace", "test" : "Protein" }, { "category" : "Urinalysis", "collectedDateTime" : "2019-11-07T14:00:00", "flag" : "High", "id" : "lucille-howard-lab-8", "referenceRange" : "Negative", "result" : "Large", "test" : "Blood" }, { "category" : "Urinalysis", "collectedDateTime" : "2019-11-07T14:00:00", "flag" : "Normal", "id" : "lucille-howard-lab-9", "referenceRange" : "Negative", "result" : "negative", "test" : "Bilirubin" }, { "category" : "Urinalysis", "collectedDateTime" : "2019-11-07T14:00:00", "flag" : "Normal", "id" : "lucille-howard-lab-10", "referenceRange" : "0.2-1.0 EU/dL", "result" : "negative", "test" : "Urobilinogen" }, { "category" : "Urinalysis", "collectedDateTime" : "2019-11-07T14:00:00", "flag" : "High", "id" : "lucille-howard-lab-11", "referenceRange" : "Negative", "result" : "Moderate", "test" : "Nitrite" }, { "category" : "Urinalysis", "collectedDateTime" : "2019-11-07T14:00:00", "flag" : "High", "id" : "lucille-howard-lab-12", "referenceRange" : "Negative", "result" : "Positive", "test" : "Leukocyte ester" }, { "category" : "Other", "collectedDateTime" : "2019-11-07T14:00:00", "id" : "lucille-howard-lab-13", "result" : "pending", "status" : "Pending", "test" : "Urine Culture" } ], "medications" : [ { "doseRouteFrequency" : "2 grams Intravenous (IV) q12h (Every 12 hours), Every 12 hours", "drug" : "cephalexin", "id" : "lucille-howard-med-7", "notes" : "Source due: 11/7/2019 13:00 Do not administer from this unresolved source order. Source cephalexin 2 g IV q12h conflicts with the oral formulation and documented Cefzil/penicillin urticaria. Verify intended antibiotic, route, dose and allergy plan; no substitute is inferred.", "orderedBy" : "Brian Memphis, MD, Admitting Physician", "orderedDateTime" : "2019-11-07T13:00:00", "section" : "Scheduled", "status" : "Held — clarification required" }, { "doseRouteFrequency" : "4mg Intravenous (IV) q6h (Every 6 hours), Every 6 hours", "drug" : "Ondansetron", "id" : "lucille-howard-med-8", "notes" : "Source due: PRN", "orderedBy" : "Brian Memphis, MD, Admitting Physician", "orderedDateTime" : "2019-11-07T13:00:00", "section" : "PRN", "status" : "Active" }, { "doseRouteFrequency" : "40 ml per hr Bladder Irrigation cont.", "drug" : "amphotericin B (conventional) desoxycholate", "id" : "lucille-howard-med-9", "nextDue" : "2019-11-07T16:00:00", "notes" : "50 mg in 1,000 mL sterile H2O for bladder irrigation Source due: 11/7/2019 16:00", "orderedBy" : "Brian Memphis, MD, Admitting Physician", "orderedDateTime" : "2019-11-07T16:00:00", "section" : "Scheduled", "status" : "Active" }, { "doseRouteFrequency" : "75 ml per hr Intravenous (IV) cont.", "drug" : "Lactated Ringer’s", "id" : "lucille-howard-med-10", "nextDue" : "2019-11-07T15:00:00", "notes" : "Source due: 11/7/2019 15:00", "orderedBy" : "Brian Memphis, MD, Admitting Physician", "orderedDateTime" : "2019-11-07T15:00:00", "section" : "Scheduled", "status" : "Active" } ], "notes" : [ { "id" : "lucille-howard-allergy", "summary" : "Cefzil | Medication | Urticaria | | Lauren Spye, RN | 11/7/2019 14:00\nPenicillin | Medication | Urticaria | | Brian Memphis, MD | 11/7/2019 13:00", "type" : "Allergy documentation" }, { "id" : "lucille-howard-serial-weights", "summary" : "2019-11-07T13:30:00: 215 lb (98 kg), 98 kg Standing scale", "type" : "Weight history" }, { "author" : "Brian Memphis, MD , Admitting Physician", "dateTime" : "2019-11-07T16:00:00", "id" : "lucille-howard-note-1", "summary" : "Pt c/o nausea and vomiting. Pt NPO. IV fluids ordered. Triple-lumen urinary retention catheter for continuous bladder irrigation with amphotericin B ordered.", "type" : "Physician Notes" }, { "author" : "Brian Memphis, MD , Admitting Physician", "dateTime" : "2019-11-07T14:00:00", "id" : "lucille-howard-note-2", "summary" : "Pt admitted for a severe urinary tract infection (UTI). Pt has a history of urinary retention and UTIs. Pt is overweight with a history of heart failure.", "type" : "Physician Notes" }, { "id" : "lucille-howard-section-current-care-providers", "summary" : "Brian Memphis, MD | Admitting Physician\nLauren Spye, RN | Registered Nurse", "type" : "Current Care Providers" }, { "id" : "lucille-howard-clarification-6", "summary" : "Source cephalexin 2 g IV q12h conflicts with the oral formulation and documented Cefzil/penicillin urticaria. Verify intended antibiotic, route, dose and allergy plan; no substitute is inferred.", "type" : "Chart clarification" } ], "orders" : [ { "author" : "Brian Memphis, MD, Admitting Physician", "category" : "Not specified", "dateTime" : "2019-11-07T14:00:00", "id" : "lucille-howard-order-1", "orderText" : "Bladder irrigation with medicated solution; cont.; Routine; Source due: 11/7/2019 14:00", "status" : "Active" }, { "author" : "Brian Memphis, MD, Admitting Physician", "category" : "Not specified", "dateTime" : "2019-11-07T13:45:00", "id" : "lucille-howard-order-2", "orderText" : "Indwelling urinary catheter (Foley) insertion, female; x1 (1 time only), 1 time only; Routine; Triple lumen urinary catheter for retention and bladder irrigation Source due: 11/7/2019 13:45", "status" : "Active" }, { "author" : "Brian Memphis, MD, Admitting Physician", "category" : "Not specified", "dateTime" : "2019-11-07T14:00:00", "id" : "lucille-howard-order-3", "orderText" : "NPO; cont.; Routine; Source due: 11/7/2019 14:00", "status" : "Active" }, { "author" : "Brian Memphis, MD, Admitting Physician", "category" : "Nursing: Monitoring", "dateTime" : "2019-11-07T13:30:00", "id" : "lucille-howard-order-4", "orderText" : "Intake and output assessment; cont.; Routine; Source due: 11/7/2019 13:30", "status" : "Active" }, { "author" : "Brian Memphis, MD, Admitting Physician", "category" : "Nursing: Monitoring", "dateTime" : "2019-11-07T14:00:00", "id" : "lucille-howard-order-5", "orderText" : "Vital Signs; q4h (Every 4 hours), Every 4 hours; Routine; Source due: 11/7/2019 14:00", "status" : "Active" }, { "author" : "Brian Memphis, MD, Admitting Physician", "category" : "Nursing: Procedure", "dateTime" : "2019-11-07T15:00:00", "id" : "lucille-howard-order-6", "orderText" : "IV catheter insertion; x1 (1 time only), 1 time only; Routine; Source due: 11/7/2019 15:00", "status" : "Active" }, { "author" : "Brian Memphis, MD, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2019-11-07T13:00:00", "id" : "lucille-howard-order-7", "orderText" : "cephalexin; 2 grams Intravenous (IV); q12h (Every 12 hours), Every 12 hours; Scheduled; Source due: 11/7/2019 13:00 Source cephalexin 2 g IV q12h conflicts with the oral formulation and documented Cefzil/penicillin urticaria. Verify intended antibiotic, route, dose and allergy plan; no substitute is inferred.", "status" : "Held — clarification required" }, { "author" : "Brian Memphis, MD, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2019-11-07T13:00:00", "id" : "lucille-howard-order-8", "orderText" : "Ondansetron; 4mg Intravenous (IV); q6h (Every 6 hours), Every 6 hours; PRN; Source due: PRN", "status" : "Active" }, { "author" : "Brian Memphis, MD, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2019-11-07T16:00:00", "id" : "lucille-howard-order-9", "orderText" : "amphotericin B (conventional) desoxycholate; 40 ml per hr Bladder Irrigation; cont.; Cont. Infusion; 50 mg in 1,000 mL sterile H2O for bladder irrigation Source due: 11/7/2019 16:00", "status" : "Active" }, { "author" : "Brian Memphis, MD, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2019-11-07T15:00:00", "id" : "lucille-howard-order-10", "orderText" : "Lactated Ringer’s; 75 ml per hr Intravenous (IV); cont.; Cont. Infusion; Source due: 11/7/2019 15:00", "status" : "Active" } ], "overview" : { "height" : "66 in / 167.6 cm", "isolationIndicator" : "Standard", "religion" : "", "weightKg" : 95.3 }, "vitals" : [ { "bloodPressure" : "120/72", "dateTime" : "2019-11-07T13:30:00", "heartRate" : 96, "id" : "lucille-howard-vital-1", "oxygenDevice" : "Room Air", "respiratoryRate" : 18, "spo2" : "95", "temperature" : "99.6 °F (38 °C), 38 °C Oral" }, { "bloodPressure" : "118/70", "dateTime" : "2019-11-07T14:00:00", "heartRate" : 98, "id" : "lucille-howard-vital-2", "oxygenDevice" : "Room Air", "respiratoryRate" : 20, "spo2" : "97", "temperature" : "99.8 °F (38 °C), 38 °C Oral" }, { "bloodPressure" : "116/70", "dateTime" : "2019-11-07T14:30:00", "heartRate" : 100, "id" : "lucille-howard-vital-3", "oxygenDevice" : "Room Air", "respiratoryRate" : 17, "spo2" : "95", "temperature" : "100.2 °F (38 °C), 38 °C Oral" } ] }, "patient" : { "admitDateTime" : "2019-11-07T13:00:00", "admittingDiagnosis" : "Urinary tract infection (lower)", "allergies" : [ { "id" : "allergy-a64c2e591720e96b", "reaction" : "Urticaria", "severity" : "Not documented", "substance" : "Cefzil" }, { "id" : "allergy-ccb4a8d294b37dfa", "reaction" : "Urticaria", "severity" : "Not documented", "substance" : "Penicillin" } ], "attending" : "Brian Memphis, MD, Admitting Physician", "chartDisplayName" : "Howard, Lucille", "codeStatus" : "Full Code", "dob" : "7/3/1941", "history" : { "chiefComplaint" : "Patient seen in ED for complaints of abdominal pain, urinary retention. Patient states \"My belly has started to hurt more and more. There is a lot of burning when I go to the bathroom\"", "pastMedicalHistory" : [ "General Medical History / Disease/Condition / : Heart failure", "General Medical History / Active: Active", "General Medical History / Disease/Condition / : Urinary tract infection (lower)", "General Medical History / Active: Active", "Transfusion History / Previous Blood Transfusion?: Unknown", "Transfusion History / Does Patient Know His/Her Blood Type?: No", "Pain History / History of Chronic Pain?: Yes", "Pain History / For How Long?: 15 years", "Pain History / Location: Lower Back and Legs", "Pain History / Does Patient Take Medication for Pain?: Yes", "Pain History / Which Medication(s)?: acetaminophen when needed" ], "pastSurgicalHistory" : [ "Previous Surgical Procedures: No prior surgical history" ], "socialHistory" : [ "Age: 78 years", "Home Situation / Patient Living Situation: Assisted living", "Home Situation / Lives With: Alone", "Education / Highest Grade Completed: High School", "Education / Able to Read?: Yes", "Education / Able to Write?: Yes", "Nicotine Use / Cigarettes: Nonsmoker", "Nicotine Use / Chewing Tobacco: Nonuser", "Nicotine Use / Cigars/Pipe: Nonsmoker", "Alcohol Use / Alcohol Status: Current user", "Alcohol Use / Number of Drinks per Week: Less than 1", "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: Every other day", "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: Rarely", "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?: Always", "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" : "8470013", "sex" : "Female", "simulatedFullName" : "Lucille Howard", "unit" : "St. Luke's Hospital" }, "setting" : "St. Luke's Hospital", "snapshots" : [ { "activityIds" : [ ], "id" : "lucille-howard-current", "notes" : "Captured dated chart history; source relative dates anchored to chart opening. Progressive release not recreated.", "scenarioTime" : "2019-11-07T15:00:00", "sourcePath" : "DocuCare instructor chart: Lucille Howard", "title" : "Captured chart" } ], "subtitle" : "N12 practice record", "tags" : [ "N12", "DocuCare migration" ], "title" : "Lucille Howard" }, "packageId" : "docucare-n12-lucille-howard-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" : "n12-lucille-howard", "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" : "Lucille Howard" }, { "envelope" : { "appName" : "ChartSlate", "audience" : "student", "createdAt" : "2026-09-25T19:44:44.067559+00:00", "exportVersion" : "1", "kind" : "casePackage", "package" : { "case" : { "activities" : [ ], "id" : "docucare-n12-susan-rockwell", "learningLevel" : "N12", "panels" : { "assessments" : [ { "author" : "Molly Tibets, Registered Nurse", "dateTime" : "2026-09-24T11:16:00", "id" : "susan-rockwell-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 / Septum / Nose Septum: Intact\nMouth/Throat / Teeth: Present\nMouth/Throat / Oral Mucosa: Normal\nMouth/Throat / Oral Mucosa: Pink\nMouth/Throat / Oral Mucosa: Moist\nMouth/Throat / Pharynx: Normal\nMouth/Throat / Lymph Nodes / LymphNodes: Non-tender" }, { "author" : "Molly Tibets, Registered Nurse", "dateTime" : "2026-09-25T10:46:00", "id" : "susan-rockwell-assessment-2", "label" : "HEENT", "summary" : ": HEENT\nHead / Size/Shape / Head Size/Shape: Symmetric\nEyes / Left Eye: Normal/clear\nEyes / Right Eye: Normal/clear\nEyes / Left Eye: Symmetrical\nEyes / Right Eye: Symmetrical\nEyes / Left Eye: Intact\nEyes / Right Eye: Intact\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: Pink\nMouth/Throat / Oral Mucosa: Moist\nMouth/Throat / Pharynx: Normal\nMouth/Throat / Lymph Nodes / LymphNodes: Non-tender" }, { "author" : "Molly Tibets, Registered Nurse", "dateTime" : "2026-09-24T11:16:00", "id" : "susan-rockwell-assessment-3", "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: Intact\nStrength / LUE (Left Upper Extremity), Left Upper Extremity: Moves Spontaneously in Left Upper Extremity\nStrength / RUE (Right Upper Extremity), Right Upper Extremity: Moves Spontaneously in Right Upper Extremity\nStrength / LLE (Left Lower Extremity), Left Lower Extremity: Moves Spontaneously 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" : "Molly Tibets, Registered Nurse", "dateTime" : "2026-09-25T10:46:00", "id" : "susan-rockwell-assessment-4", "label" : "Neuro", "summary" : ": Neuro\nOrientation / Awareness of: / Awareness of: Place\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: Intact\nStrength / LUE (Left Upper Extremity), Left Upper Extremity: Moves Spontaneously in Left Upper Extremity\nStrength / RUE (Right Upper Extremity), Right Upper Extremity: Moves Spontaneously in Right Upper Extremity\nStrength / LLE (Left Lower Extremity), Left Lower Extremity: Moves Spontaneously 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" : "Molly Tibets, Registered Nurse", "dateTime" : "2026-09-24T11:16:00", "id" : "susan-rockwell-assessment-5", "label" : "Cardio", "summary" : ": Cardio\nHeart Tones: S1, S2\nHeart Tones: Regular\nPulses / All: + 1 in All\nEdema / All: Trace\nCapillary Refill / All: < 3 sec in All\nSkin Color and Description: Appropriate for ethnicity\nSkin Color and Description: Warm\nSkin Color and Description: Dry\nSkin Color and Description: Intact" }, { "author" : "Molly Tibets, Registered Nurse", "dateTime" : "2026-09-25T10:46:00", "id" : "susan-rockwell-assessment-6", "label" : "Cardio", "summary" : ": Cardio\nHeart Tones: S1, S2\nHeart Tones: Regular\nPulses / All: + 2 in All\nEdema / All: 2+\nCapillary Refill / All: < 3 sec in All\nSkin Color and Description: Appropriate for ethnicity\nSkin Color and Description: Warm\nSkin Color and Description: Dry" }, { "author" : "Molly Tibets, Registered Nurse", "dateTime" : "2026-09-25T11:46:00", "id" : "susan-rockwell-assessment-7", "label" : "Cardio", "summary" : ": Cardio\nAdditional Notes / Additional Notes: Left calf tenderness, warmth and redness\nHeart Tones: S1, S2\nHeart Tones: Regular" }, { "author" : "Molly Tibets, Registered Nurse", "dateTime" : "2026-09-24T11:16:00", "id" : "susan-rockwell-assessment-8", "label" : "GI", "summary" : ": GI\nAbdominal Description / All: Round\nAbdominal Description / All: Soft\nAbdominal Description / All: Non-tender\nGI Symptoms: None\nBowel Sounds / All: Present\nDiet Tolerance / Diet Tolerance: Excellent\nDescription: Formed\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" : "Molly Tibets, Registered Nurse", "dateTime" : "2026-09-25T10:46:00", "id" : "susan-rockwell-assessment-9", "label" : "GI", "summary" : ": GI\nAbdominal Description / All: Distended\nAbdominal Description / All: Round\nAbdominal Description / All: Soft\nAbdominal Description / All: Non-tender\nGI Symptoms: Flatulence\nBowel Sounds / All: Hypoactive\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" : "Molly Tibets, Registered Nurse", "dateTime" : "2026-09-24T11:31:00", "id" : "susan-rockwell-assessment-10", "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\nCatheter Size: 14\nVolume in Balloon: 10\nSite Description: Foley catheter placed using sterile technique. Clear yellow urine obtained in catheter. Balloon inflated with 10mL water. Patient tolerated with minimal discomfort. Patient aware that foley catheter will stay in place for approximately 24 hours before being removed." }, { "author" : "Molly Tibets, Registered Nurse", "dateTime" : "2026-09-25T10:46:00", "id" : "susan-rockwell-assessment-11", "label" : "GU", "summary" : ": GU\nUrine Color: Yellow\nUrine Character: Clear\nDate Inserted Days: 0\nDate Inserted Relative To Timing Based On: after admission\nCatheter Size: 14\nVolume in Balloon: 10\nSite Description: Removed at this time. Patient due to void in 8 hours" }, { "author" : "Molly Tibets, Registered Nurse", "dateTime" : "2026-09-24T11:16:00", "id" : "susan-rockwell-assessment-12", "label" : "Respiratory", "summary" : ": Respiratory\nSputum / Color: None\nRespiratory Symptoms: None\nBreath Sounds / Right Upper Lobe: Clear\nRespirations: Regular" }, { "author" : "Molly Tibets, Registered Nurse", "dateTime" : "2026-09-25T10:46:00", "id" : "susan-rockwell-assessment-13", "label" : "Respiratory", "summary" : ": Respiratory\nSputum / Color: None\nSputum / Amount: None\nRespiratory Symptoms: None\nBreath Sounds / Right Upper Lobe: Clear\nBreath Sounds / Right Upper Lobe: Anterior\nBreath Sounds / Right Upper Lobe: Posterior\nRespirations: Regular" }, { "author" : "Molly Tibets, Registered Nurse", "dateTime" : "2026-09-25T11:46:00", "id" : "susan-rockwell-assessment-14", "label" : "Respiratory", "summary" : ": Respiratory\nAdditional Notes / Additional Notes: Oxygen initiated, Sats 93%\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\nRespiratory Symptoms: Shortness of Breath\nRespiratory Symptoms: Difficulty Breathing at Rest\nRespiratory Symptoms: Other\nRespiratory Symptoms / Respiratory Symptoms, Other value: Chest Pain\nBreath Sounds / Right Upper Lobe: Clear\nRespirations: Regular\nRespirations: Labored" }, { "author" : "Molly Tibets, Registered Nurse", "dateTime" : "2026-09-25T11:46:00", "id" : "susan-rockwell-assessment-15", "label" : "Mental Health", "summary" : ": Mental Health\nAdditional Notes / Additional Notes: Patient complaining of tenderness in left calf followed by SOB and chest pain. Patient anxious, provider at bedside. Patient educated on possible DVT, diagnostics needed, and treatment plan. Emotional support provided to patient.\nBehavior / Affect: Anxious\nBehavior / Affect: Fearful\nStressors: Condition\nCoping: Fair" }, { "author" : "Molly Tibets, Registered Nurse", "dateTime" : "2026-09-24T11:16:00", "id" : "susan-rockwell-assessment-16", "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\nWeight Bearing / Gait / Posture: Independent\nDevices: None" }, { "author" : "Molly Tibets, Registered Nurse", "dateTime" : "2026-09-25T10:46:00", "id" : "susan-rockwell-assessment-17", "label" : "Musculoskeletal", "summary" : ": Musculoskeletal\nMusculoskeletal Symptoms: None\nMuscle Tone / Strength / LUE (Left Upper Extremity), Left Upper Extremity: Normal strength in Left Upper Extremity\nMuscle Tone / Strength / All: Active Range of Motion in All\nWeight Bearing / Gait / Posture: Steady\nWeight Bearing / Gait / Posture: Independent" }, { "author" : "Molly Tibets, Registered Nurse", "dateTime" : "2026-09-24T18:46:00", "id" : "susan-rockwell-assessment-18", "label" : "Pain Scale", "summary" : ": Pain Scale\nPain Location: Lower Abdomen\nOnset Days: 0\nOnset Hours: 0\nOnset Minutes: 45\nOnset Relative To Timing Based On: after admission\nPain Duration: 45-60 seconds\nPain Frequency: Intermittent\nType Of Pain: Acute\nPain Goal: 3\nAggravating Factors: Movement\nAlleviating Factors: Rest\nPain Scale Used: 0-10\nPain Rating: 6\nPain Characteristics: Dull\nNotes: Round Ligament Pain" }, { "author" : "Molly Tibets, Registered Nurse", "dateTime" : "2026-09-25T10:46:00", "id" : "susan-rockwell-assessment-19", "label" : "Pain Scale", "summary" : ": Pain Scale\nPain Location: Lower Abdomen\nOnset Days: 0\nOnset Hours: 6\nOnset Minutes: 0\nOnset Relative To Timing Based On: after admission\nPain Frequency: Intermittent\nType Of Pain: Acute\nPain Goal: 3\nAggravating Factors: Movement\nAggravating Factors: Coughing\nAggravating Factors: Breathing\nAlleviating Factors: Rest\nAlleviating Factors: Medication\nPain Scale Used: 0-10\nPain Rating: 5 - Moderate Pain\nPain Characteristics: Aching\nPain Characteristics: Burning" }, { "author" : "Valerie Smith, Registered Nurse", "dateTime" : "2026-09-24T14:46:00", "id" : "susan-rockwell-assessment-20", "label" : "Site/Wound", "summary" : ": Site/Wound\nRegion: Torso\nSpecific Location: Abdomen, LLQ\nType: Incision\nOther\nLength: 4\nWidth: 1\nDepth: 0\nDescription: Transverse Low Abdominal incision\nPeri-Wound Area: warm, dry, pink, no signs of cellulitis\nDressing and Wound Care: CDI, small shadow in lower left corner. Circled drainage - serous" }, { "author" : "Molly Tibets, Registered Nurse", "dateTime" : "2026-09-24T11:16:00", "id" : "susan-rockwell-assessment-21", "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. *" }, { "author" : "Valerie Smith, Registered Nurse", "dateTime" : "2026-09-24T11:46:00", "id" : "susan-rockwell-assessment-22", "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: 16 gauge\nSite Description: clean, dry, no signs of infection or inflitration\nDressing: Transparent, CDI" }, { "author" : "Molly Tibets, Registered Nurse", "dateTime" : "2026-09-24T11:46:00", "id" : "susan-rockwell-assessment-23", "label" : "Morse Fall Risk", "summary" : ": Morse Fall Risk\nDoes the patient have a recent history of falling?: No Patient has not fallen recently\nDoes the patient have secondary medical diagnoses?: Yes\nAre ambulatory aids used?: Uses furniture Patient walks clutching onto furniture for support\nDoes the patient have an intravenous apparatus or a heparin lock inserted?: Yes\nWhat is the patient’s gait?: Normal/bed rest/immobile Patient walks with head erect, arms swinging freely at the side, and striding without hesitation\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: 65\nResults: High Risk (51 or higher)" }, { "author" : "Raina Cheema, OB-GYN", "dateTime" : "2026-09-24T11:46:00", "id" : "susan-rockwell-maternity-contractions-source-24", "label" : "Maternity Contractions", "summary" : "Contraction Type: Irritability\nContraction Intensity: Mild\nBraxton Hicks Contractions: Present\nCervical Dilation: 2\nEffacement: 50\nFetal Station: -3\nMembranes Ruptured: No\nNot Present" }, { "author" : "Molly Tibets, Registered Nurse", "dateTime" : "2026-09-24T11:16:00", "id" : "susan-rockwell-maternity-vitals-source-25", "label" : "Maternity Vitals", "summary" : "Mother / Maternal Position: Supine\nMother / Cervical Dilation: 2\nMother / Effacement: 50\nMother / Fetal Station: -3\nMother / Monitor Type: External\nMother / Contraction Type: Irritability\nMother / Contraction Intensity: Mild\nMother / Resting Tone: Soft\nBaby / Monitor Type: External\nBaby / Fetal Heart Rate: 140\nBaby / Baseline Rate: Regular\nBaby / Variability: Moderate = 6–25 BPM\nBaby / Accelerations Presence: Present\nBaby / Accelerations Details: Periodic\nBaby / Decelerations Presence: Absent" } ], "labs" : [ { "category" : "Urinalysis", "collectedDateTime" : "2026-05-21T10:31:00", "flag" : "Normal", "id" : "susan-rockwell-lab-1", "referenceRange" : "Pale yellow-amber", "result" : "Yellow", "test" : "Color" }, { "category" : "Urinalysis", "collectedDateTime" : "2026-05-21T10:31:00", "flag" : "Normal", "id" : "susan-rockwell-lab-2", "referenceRange" : "Clear to slightly hazy", "result" : "Clear", "test" : "Clarity" }, { "category" : "Urinalysis", "collectedDateTime" : "2026-05-21T10:31:00", "flag" : "Normal", "id" : "susan-rockwell-lab-3", "referenceRange" : "1.005-1.025", "result" : "1.02", "test" : "Specific gravity" }, { "category" : "Urinalysis", "collectedDateTime" : "2026-05-21T10:31:00", "flag" : "Normal", "id" : "susan-rockwell-lab-4", "referenceRange" : "Negative", "result" : "neg", "test" : "Ketones" }, { "category" : "Urinalysis", "collectedDateTime" : "2026-05-21T10:31:00", "flag" : "Normal", "id" : "susan-rockwell-lab-5", "referenceRange" : "Negative", "result" : "neg", "test" : "Glucose" }, { "category" : "Urinalysis", "collectedDateTime" : "2026-05-21T10:31:00", "flag" : "Normal", "id" : "susan-rockwell-lab-6", "referenceRange" : "4.5-8.0", "result" : "7.8", "test" : "pH" }, { "category" : "Urinalysis", "collectedDateTime" : "2026-05-21T10:31:00", "flag" : "Normal", "id" : "susan-rockwell-lab-7", "referenceRange" : "Negative", "result" : "neg", "test" : "Protein" }, { "category" : "Urinalysis", "collectedDateTime" : "2026-05-21T10:31:00", "flag" : "Normal", "id" : "susan-rockwell-lab-8", "referenceRange" : "Negative", "result" : "neg", "test" : "Blood" }, { "category" : "Urinalysis", "collectedDateTime" : "2026-05-21T10:31:00", "flag" : "Normal", "id" : "susan-rockwell-lab-9", "referenceRange" : "Negative", "result" : "neg", "test" : "Bilirubin" }, { "category" : "Urinalysis", "collectedDateTime" : "2026-05-21T10:31:00", "flag" : "Normal", "id" : "susan-rockwell-lab-10", "referenceRange" : "0.2-1.0 EU/dL", "result" : "neg", "test" : "Urobilinogen" }, { "category" : "Urinalysis", "collectedDateTime" : "2026-05-21T10:31:00", "flag" : "Normal", "id" : "susan-rockwell-lab-11", "referenceRange" : "Negative", "result" : "neg", "test" : "Nitrite" }, { "category" : "Urinalysis", "collectedDateTime" : "2026-05-21T10:31:00", "flag" : "Normal", "id" : "susan-rockwell-lab-12", "referenceRange" : "Negative", "result" : "neg", "test" : "Leukocyte ester" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-05-21T10:46:00", "flag" : "Normal", "id" : "susan-rockwell-lab-13", "referenceRange" : "4.0-9.0", "result" : "8", "test" : "WBC (10 x 3/uL)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-05-21T10:46:00", "flag" : "Normal", "id" : "susan-rockwell-lab-14", "referenceRange" : "3.90-4.98", "result" : "4", "test" : "RBC (mill/cumm)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-05-21T10:46:00", "flag" : "Normal", "id" : "susan-rockwell-lab-15", "referenceRange" : "12.0-15.5", "result" : "12.1", "test" : "Hemoglobin (gm/dL)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-05-21T10:46:00", "flag" : "Normal", "id" : "susan-rockwell-lab-16", "referenceRange" : "35-45", "result" : "36.1", "test" : "Hematocrit (%)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-05-21T10:46:00", "flag" : "Low", "id" : "susan-rockwell-lab-17", "referenceRange" : "81-93", "result" : "80", "test" : "MCV (fL)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-05-21T10:46:00", "flag" : "Low", "id" : "susan-rockwell-lab-18", "referenceRange" : "28-35", "result" : "27", "test" : "MCH (pg)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-05-21T10:46:00", "flag" : "Low", "id" : "susan-rockwell-lab-19", "referenceRange" : "33-37", "result" : "32", "test" : "MCHC (gm/dL)" }, { "category" : "Other", "collectedDateTime" : "2026-05-21T10:46:00", "flag" : "Normal", "id" : "susan-rockwell-lab-20", "referenceRange" : "Negative", "result" : "Neg", "test" : "Syphilis" }, { "category" : "Other", "collectedDateTime" : "2026-05-21T10:46:00", "flag" : "Normal", "id" : "susan-rockwell-lab-21", "referenceRange" : "Negative", "result" : "Neg", "test" : "Gonorrhea" }, { "category" : "Other", "collectedDateTime" : "2026-05-21T10:46:00", "flag" : "Normal", "id" : "susan-rockwell-lab-22", "referenceRange" : "Negative", "result" : "Neg", "test" : "Chlamydia" }, { "category" : "Other", "collectedDateTime" : "2026-05-21T10:46:00", "flag" : "Normal", "id" : "susan-rockwell-lab-23", "referenceRange" : "Negative", "result" : "Neg", "test" : "HIV" }, { "category" : "HbA1c", "collectedDateTime" : "2026-05-21T10:46:00", "flag" : "Normal", "id" : "susan-rockwell-lab-24", "referenceRange" : "0.0-6.4", "result" : "6", "test" : "Glycohemoglobin (%)" }, { "category" : "Other", "collectedDateTime" : "2026-06-11T10:31:00", "flag" : "High", "id" : "susan-rockwell-lab-25", "referenceRange" : "60-100mg/dl", "result" : "180", "test" : "Glucose" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-24T11:16:00", "flag" : "Normal", "id" : "susan-rockwell-lab-26", "referenceRange" : "4.0-9.0", "result" : "8.8", "test" : "WBC (10 x 3/uL)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-24T11:16:00", "flag" : "Normal", "id" : "susan-rockwell-lab-27", "referenceRange" : "3.90-4.98", "result" : "4.79", "test" : "RBC (mill/cumm)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-24T11:16:00", "flag" : "Normal", "id" : "susan-rockwell-lab-28", "referenceRange" : "12.0-15.5", "result" : "12", "test" : "Hemoglobin (gm/dL)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-24T11:16:00", "flag" : "Normal", "id" : "susan-rockwell-lab-29", "referenceRange" : "35-45", "result" : "38", "test" : "Hematocrit (%)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-24T11:16:00", "flag" : "Normal", "id" : "susan-rockwell-lab-30", "referenceRange" : "81-93", "result" : "83", "test" : "MCV (fL)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-24T11:16:00", "flag" : "Normal", "id" : "susan-rockwell-lab-31", "referenceRange" : "28-35", "result" : "35", "test" : "MCH (pg)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-24T11:16:00", "flag" : "Normal", "id" : "susan-rockwell-lab-32", "referenceRange" : "33-37", "result" : "35", "test" : "MCHC (gm/dL)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-24T11:16:00", "flag" : "Normal", "id" : "susan-rockwell-lab-33", "referenceRange" : "140-400", "result" : "190", "test" : "Platelet Count (1000/mm3)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-25T10:46:00", "flag" : "Normal", "id" : "susan-rockwell-lab-34", "referenceRange" : "4.0-9.0", "result" : "8.9", "test" : "WBC (10 x 3/uL)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-25T10:46:00", "flag" : "Normal", "id" : "susan-rockwell-lab-35", "referenceRange" : "3.90-4.98", "result" : "4.6", "test" : "RBC (mill/cumm)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-25T10:46:00", "flag" : "Low", "id" : "susan-rockwell-lab-36", "referenceRange" : "12.0-15.5", "result" : "11", "test" : "Hemoglobin (gm/dL)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-25T10:46:00", "flag" : "Low", "id" : "susan-rockwell-lab-37", "referenceRange" : "35-45", "result" : "33", "test" : "Hematocrit (%)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-25T10:46:00", "flag" : "Normal", "id" : "susan-rockwell-lab-38", "referenceRange" : "140-400", "result" : "180", "test" : "Platelet Count (1000/mm3)" } ], "medications" : [ { "doseRouteFrequency" : "200units/kg Subcutaneous (SC) q24h (Every 24 hours), Every 24 hours", "drug" : "dalteparin sodium", "id" : "susan-rockwell-med-24", "nextDue" : "2026-09-25T10:46:00", "notes" : "Source due: 9/25/2026 10:46", "orderedBy" : "Dr. Kahn, OB-GYN", "orderedDateTime" : "2026-09-25T10:46:00", "section" : "Scheduled", "status" : "Active" }, { "doseRouteFrequency" : "5mg Intravenous (IV) x1 (1 time only), 1 time only", "drug" : "morphine sulfate", "id" : "susan-rockwell-med-25", "nextDue" : "2026-09-25T10:46:00", "notes" : "Source due: 9/25/2026 10:46", "orderedBy" : "Dr. Kahn, OB-GYN", "orderedDateTime" : "2026-09-25T10:46:00", "section" : "Scheduled", "status" : "Active" }, { "doseRouteFrequency" : "30mg Intravenous (IV) q6h x4 (Every 6 hours, 4 times only), Every 6 hours, 4 times only", "drug" : "ketorolac tromethamine (oral, nasal, injection)", "id" : "susan-rockwell-med-26", "lastGiven" : "2026-09-25T09:46:00", "notes" : "30mg Ketorolac every 6 hours X 24 hours", "orderedBy" : "Raina Cheema, OB-GYN", "orderedDateTime" : "2026-09-24T10:46:00", "section" : "Scheduled", "status" : "Discontinued" }, { "doseRouteFrequency" : "650mg Oral (PO) q6h (Every 6 hours), Every 6 hours", "drug" : "acetaminophen", "id" : "susan-rockwell-med-27", "lastGiven" : "2026-09-25T10:46:00", "nextDue" : "2026-09-25T16:46:00", "notes" : "Administer 1 hour after Ketorolac. Do not exceed 4000mg in a 24 hour period of time from all sources. Source due: 9/25/2026 16:46", "orderedBy" : "Raina Cheema, OB-GYN", "orderedDateTime" : "2026-09-24T10:46:00", "section" : "Scheduled", "status" : "Active" }, { "doseRouteFrequency" : "600mg Oral (PO) q6h (Every 6 hours), Every 6 hours", "drug" : "ibuprofen", "id" : "susan-rockwell-med-28", "nextDue" : "2026-09-25T16:46:00", "notes" : "To be initiated at least 6 hours after Ketorolac completed. Not to exceed 2400mg in a 24 hour period of time from all sources. Source due: 9/25/2026 16:46", "orderedBy" : "Raina Cheema, OB-GYN", "orderedDateTime" : "2026-09-24T10:46:00", "section" : "Scheduled", "status" : "Active" }, { "doseRouteFrequency" : "1 tab Oral (PO) q24h (Every 24 hours), Every 24 hours", "drug" : "Prenatal Vitamin", "id" : "susan-rockwell-med-29", "lastGiven" : "2026-09-25T10:46:00", "nextDue" : "2026-09-26T10:46:00", "notes" : "Source due: 9/26/2026 10:46", "orderedBy" : "Raina Cheema, OB-GYN", "orderedDateTime" : "2026-09-24T10:46:00", "section" : "Scheduled", "status" : "Active" }, { "doseRouteFrequency" : "2 cap Oral (PO) q24h (Every 24 hours), Every 24 hours", "drug" : "Senna-S", "id" : "susan-rockwell-med-30", "lastGiven" : "2026-09-25T10:46:00", "nextDue" : "2026-09-26T10:46:00", "notes" : "Source due: 9/26/2026 10:46", "orderedBy" : "Raina Cheema, OB-GYN", "orderedDateTime" : "2026-09-24T10:46:00", "section" : "Scheduled", "status" : "Active" }, { "doseRouteFrequency" : "1mg Intravenous (IV) q2h (Every 2 hours), Every 2 hours", "drug" : "HYDROmorphone hydrochloride", "id" : "susan-rockwell-med-31", "lastGiven" : "2026-09-24T16:46:00", "notes" : "For pain > 6/10 Source due: PRN", "orderedBy" : "Raina Cheema, OB-GYN", "orderedDateTime" : "2026-09-24T10:46:00", "section" : "PRN", "status" : "Active" }, { "doseRouteFrequency" : "5/325mg Oral (PO) q4h (Every 4 hours), Every 4 hours", "drug" : "HYDROcodone bitartrate/acetaminophen", "id" : "susan-rockwell-med-32", "lastGiven" : "2026-09-25T00:46:00", "notes" : "For moderate pain >4/10. Start with 1 tab PO every 4 hours PRN Pain. Repeat dose X 1 if pain unrelieved in 60 minutes and then in 4 hours move to 2 tabs PO every 4 hours PRN pain Source due: PRN", "orderedBy" : "Raina Cheema, OB-GYN", "orderedDateTime" : "2026-09-24T10:46:00", "section" : "PRN", "status" : "Active" }, { "doseRouteFrequency" : "4mg Intravenous (IV) q6h (Every 6 hours), Every 6 hours", "drug" : "ondansetron", "id" : "susan-rockwell-med-33", "notes" : "For nausea or vomiting Source due: PRN", "orderedBy" : "Raina Cheema, OB-GYN", "orderedDateTime" : "2026-09-24T10:46:00", "section" : "PRN", "status" : "Active" }, { "doseRouteFrequency" : "5mg Oral (PO) q24h (Every 24 hours), Every 24 hours", "drug" : "zolpidem tartrate", "id" : "susan-rockwell-med-34", "lastGiven" : "2026-09-25T04:46:00", "notes" : "Administer at HS every night as needed for insomnia, may repeat X 1 in 30 minutes if ineffective Source due: PRN Do not administer from this unresolved source order. Source permits repeating zolpidem after 30 minutes. Official tablet labeling specifies a single nightly dose with no same-night readministration; clarify the order, especially with concurrent opioid orders.", "orderedBy" : "Raina Cheema, OB-GYN", "orderedDateTime" : "2026-09-24T10:46:00", "section" : "PRN", "status" : "Held — clarification required" }, { "doseRouteFrequency" : "0.2mg Oral (PO) q4h (Every 4 hours), Every 4 hours", "drug" : "methylergonovine maleate", "id" : "susan-rockwell-med-35", "notes" : "PRN Boggy uterus with minor bleeding Source due: PRN", "orderedBy" : "Raina Cheema, OB-GYN", "orderedDateTime" : "2026-09-24T10:46:00", "section" : "PRN", "status" : "Active" } ], "notes" : [ { "id" : "susan-rockwell-allergy", "summary" : "NKA | Medication | | | Susan Johnson | 9/24/2026 10:51\nNKA | Food | | | Susan Johnson | 9/24/2026 10:51", "type" : "Allergy documentation" }, { "id" : "susan-rockwell-provider-review-of-systems", "summary" : "Constitutional (e.g., fever, weight loss) / Notes: Smiling, states being ready to have the baby today.\nHEENT / Notes: Denies congestion, cough, SOB, dyspnea, orthopnea\nCardiovascular / Notes: Denies palpitations, fatigue, SOB. States dependent edema at times by end of day, resolves overnight.\nRespiratory / Notes: Denies SOB, dyspnea, cough\nGastrointestinal / Notes: Denies nausea, vomitting, diarrhea, good appetite\nGenitourinary / Notes: Denies frequency, hesitancy, burning. Denies flank pain\nMusculoskeletal / Notes: Denies falls, unsteady gait\nIntegumentary (skin and/or breast) / Notes: Denies rashes, burns, blisters, or open wounds\nNeurological / Notes: Denies HA, dizziness, blurry vision\nPsychiatric / Notes: Smiling, denies compulsive or obsessive thoughts, denies depression, mania, suicidal ideation\nEndocrine / Notes: Denies increased appetite, increased thirst, or increased urination. Positive for gestational diabetes, using Metformin to control glucose levels.\nHematologic/Lymphatic / Notes: Denies lymphadenopathy, bruising, petechial rash, infections\nAllergic/Immunologic / Notes: NKA", "type" : "Provider Review Of Systems" }, { "id" : "susan-rockwell-family-health-history", "summary" : "Disease/Condition / Disease/Condition: Hypertension\nFamily Member / Family Member: Grandfather\nAge at Diagnosis / Age at Diagnosis: 50-59 years\nDeceased / Deceased: No", "type" : "Family Health History" }, { "id" : "susan-rockwell-serial-weights", "summary" : "2026-09-24T10:51:00: 232 lb (105 kg), 105 kg Standing scale", "type" : "Weight history" }, { "dateTime" : "2026-06-11T10:31:00", "id" : "susan-rockwell-lab-note-5", "summary" : "1 hour result", "type" : "Other laboratory notes" }, { "author" : "Molly Tibets , Registered Nurse", "dateTime" : "2026-09-25T14:46:00", "id" : "susan-rockwell-note-1", "summary" : "S: My left leg is really sore and feels warm. It hurts to touch it. I'm having a hard time catching my breath, my chest hurts O: Lung sounds clear bilaterally in all fields, Sats 93%, BP 128/74, P 108, Patient anxious, tachypneic RR 24, Left calve edematous, swollen, reddened, warm to touch A: Suspect DVT and PE, alerted Heatlhcare provider and have at bedside P: Continuous pulse oximetry placed, O2 via Nasal Cannula at 2LPM, Healthcare provider at bedside now, performing ultrasound of left extremity for possible DVT. Orders for 5mg Morphine IV and 200 units dalteparin/kg SQ daily. Preparing medications at this time.", "type" : "Nursing - Event" }, { "author" : "Raina Cheema , OB-GYN", "dateTime" : "2026-09-24T17:46:00", "id" : "susan-rockwell-note-2", "summary" : "SURGICAL NOTE: PREOPERATIVE DIAGNOSES: 1. Term pregnancy. POSTOPERATIVE DIAGNOSES: 1. Term pregnancy PROCEDURE: 1. Repeat low-transverse cesarean section. ANESTHESIA: Spinal/epidural with good effect. FINDINGS: Delivered vigorous male infant from cephalic presentation. Apgars 9/9. Birth weight 9 pounds 3 ounces. Infant suctioned with a bulb upon delivery of the head and body. Cord clamped and cut and infant passed to pediatric team present. Complete placenta manually extracted intact with three vessel cord. ESTIMATED BLOOD LOSS: 500 mL. COMPLICATIONS: None. URINE OUTPUT: Per anesthesia records. Urine cleared postoperatively. IV FLUIDS: Per anesthesia records. The patient tolerated the procedure well and was taken to the recovery room in stable condition with stable vital signs. OPERATIVE TECHNIQUE: The patient was placed in a supine position after spinal/epidural anesthesia. She was prepped and draped in the usual manner for repeat cesarean section. A sharp knife was used to make a Pfannenstiel skin incision at the site of the previous scar. This was carried through the subcutaneous tissue into the dense fibromuscular and fascial layer with a sharp knife. This incision was extended laterally with Mayo scissors. Dense fibromuscular layer was encountered from the patient's previous surgeries. Upon entry, incision was entered into the serosal and partial muscular layer of the anterior uterus. Fascia was previously separated superiorly and inferiorly from the muscular layer. The uterus was then incised using a sharp knife and low transverse incision. This was extended with bandage scissors. The infant was delivered easily from a cephalic presentation. Bulb suction was done following delivery of the head and body. The cord clamped and cut and the infant passed to pediatric team present. Cord segment and cord blood was obtained. Complete placenta manually extracted intact with three vessel cord. Vigorous male infant, Apgars 9/9, weight 9 pounds 3 ounces. Complete placenta with three vessels retrieved. Uterus was exteriorized from the abdominal cavity. Wet lap applied to the fundus and dry lap used to remove the remaining membranous tissue from the lining. Pennington clamps placed at the uterine incision angles and the inferior incision lip. A #1 chromic suture closed the uterus in running continuous interlocking closure. Good hemostasis upon completion of the closure. Laparotomy pads placed in the posterior cul-de-sac to remove any blood or clots. The uterus was returned to the abdominal cavity, after using #1 chromic suture to close the anterior uterine incision, that was partial thickness through the serosal end of the muscular layer at midline adhesion. This was closed with chromic suture in a running continuous interlocking closure with good hemostasis. The uterus was returned to the abdominal cavity. Left and right gutters examined and found to be clean and dry. Evaluation of the low uterine segment incision revealed continued hemostasis. Oozing was encountered in the inferior bladder of dissection and 2-0 chromic suture in running continuous fashion, partial thickness of the bladder to control the oozing at this site was successfully done. Interceed was then placed on the low uterine incision and the low anterior uterine aspect. The midline rectus including peritoneum was re-approximated with simple interrupted chromic sutures. Irrigation of the muscular layer with good hemostasis noted. The fascia was closed with #1 Vicryl in a running continuous closure. Subcutaneous tissue was irrigated, additional hemostasis with Bovie cautery. The skin was closed with staples.", "type" : "Physician Notes" }, { "author" : "Raina Cheema , OB-GYN", "dateTime" : "2026-09-17T10:46:00", "id" : "susan-rockwell-note-3", "summary" : "38 week prenatal appointment: Client seen weekly since 34 week gestation. Weekly NST's reactive and BPP's 8/10 - 10/10. Glucose readings 90 - 110mg/dL fasting on 1000mg Metformin. Client verbalizing frustrations over third trimester discomforts. Reviewed need to remain pregnant through 39 weeks due to effects of diabetes on fetal lung maturity. Planned cesarean section scheduled for 39th week gestation. Will see client next week for c-section. Reviewed signs of labor and instructed to go to Labor and Delivery for any signs of labor.", "type" : "Physician Notes" }, { "author" : "Raina Cheema , OB-GYN", "dateTime" : "2026-08-06T10:46:00", "id" : "susan-rockwell-note-4", "summary" : "Client seen every two weeks since 26 week gestation. Now at 32 weeks. Metformin increased to 1000mg at last visit. NST to be completed at each visit. No other concerns discussed. Reviewed glucose readings and nutritional diary. Metformin adjusted due to increasing fasting blood sugar readings. Client to return in 2 weeks.", "type" : "Physician Notes" }, { "author" : "Raina Cheema , OB-GYN", "dateTime" : "2026-06-18T10:46:00", "id" : "susan-rockwell-note-5", "summary" : "Patient at clinic for 3 hour GTT, which demonstrated high levels on two of four testing times. Patient aware that she is considered a gestational diabetic. Patient upset, but open to education. Will have nursing staff review how to monitor blood glucose levels. Patient states she does not want to use insulin but would rather utilize oral medications. Prescription for Metformin 500mg daily given to patient. Will recheck levels in one week.", "type" : "Physician Notes" }, { "author" : "Lisa Johnson , Nurse Practitioner", "dateTime" : "2026-06-18T09:26:00", "id" : "susan-rockwell-note-6", "summary" : "Patient instructed to test glucose levels first thing in the morning, before lunch and dinner and 1 hour after each meal. Patient understands she will be testing her blood 6 times a day. Patient expressed concern over being able to \"poke\" herself. Encouragement given and options for gestational diabetes treatment provided.", "type" : "Nursing - Event" }, { "author" : "Valerie Smith , Registered Nurse", "dateTime" : "2026-06-18T09:21:00", "id" : "susan-rockwell-note-7", "summary" : "Reviewed how to obtain blood sample for glucose testing. Demonstrated location on finger for using lancet device. Reviewed need to wash hands prior to testing, swipe area with alcohol wipe, dry with cotton ball or gauze and then use lancet on outer aspect of fingertip. Reviewed how to apply blood to glucose monitoring strip and insert into glucose monitoring machine. Return demonstration by patient with corrections for areas to place lancet. Prescription for monitor and strips given to patient. Patient to return in 1 week. Patient instructed to record all glucose levels and bring to each appointment.", "type" : "Nursing - Event" }, { "author" : "Valerie Smith , Registered Nurse", "dateTime" : "2026-06-11T10:31:00", "id" : "susan-rockwell-note-8", "summary" : "Patient given 50 gram Oral Glucose solution to consume. Patient educated to remain in waiting room until 1 hour has past and then blood testing will be performed. Will check on patient in 30 minutes.", "type" : "Nursing - Event" }, { "author" : "Raina Cheema , OB-GYN", "dateTime" : "2026-06-11T09:16:00", "id" : "susan-rockwell-note-9", "summary" : "Oral glucose tolerance test results 180mg/dl. Will schedule 3 hours GTT. Patient aware. Discussed treatment plan of carbohydrate controlled diet, exercise, glucose monitoring before meals and 1 hour after meals, and possible metformin or insulin use if blood glucose levels elevate. Patient resistant to insulin use. Will treat with Metformin first if needed.", "type" : "Physician Notes" }, { "id" : "susan-rockwell-mar-history-15", "summary" : "9/24/2026 11:01 Valerie Smith, Registered Nurse Yes\n9/24/2026 15:46 Valerie Smith, Registered Nurse Yes\n9/24/2026 21:46 Valerie Smith, Registered Nurse Yes\n9/25/2026 03:46 Valerie Smith, Registered Nurse Yes\n9/25/2026 09:46 Molly Tibets, Registered Nurse Yes", "type" : "Medication administration history — ketorolac tromethamine (oral, nasal, injection)" }, { "id" : "susan-rockwell-mar-history-16", "summary" : "9/24/2026 16:46 Valerie Smith, Registered Nurse Yes\n9/24/2026 22:46 Valerie Smith, Registered Nurse Yes\n9/25/2026 04:46 Molly Tibets, Registered Nurse Yes\n9/25/2026 10:46 Molly Tibets, Registered Nurse Yes", "type" : "Medication administration history — acetaminophen" }, { "id" : "susan-rockwell-mar-history-17", "summary" : "9/24/2026 10:46 Valerie Smith, Registered Nurse No\n9/24/2026 16:46 Valerie Smith, Registered Nurse Receiving Ketorolac No\n9/24/2026 22:46 Valerie Smith, Registered Nurse Receiving Ketorolac No\n9/25/2026 04:46 Valerie Smith, Registered Nurse Receiving Ketorolac No\n9/25/2026 10:46 Valerie Smith, Registered Nurse Receiving Ketorolac No", "type" : "Medication administration history — ibuprofen" }, { "id" : "susan-rockwell-mar-history-18", "summary" : "9/25/2026 10:46 Valerie Smith, Registered Nurse Yes", "type" : "Medication administration history — Prenatal Vitamin" }, { "id" : "susan-rockwell-mar-history-19", "summary" : "9/25/2026 10:46 Valerie Smith, Registered Nurse Yes", "type" : "Medication administration history — Senna-S" }, { "id" : "susan-rockwell-mar-history-20", "summary" : "9/24/2026 10:46 Valerie Smith, Registered Nurse Yes\n9/24/2026 12:46 Valerie Smith, Registered Nurse Yes\n9/24/2026 16:46 Valerie Smith, Registered Nurse Yes", "type" : "Medication administration history — HYDROmorphone hydrochloride" }, { "id" : "susan-rockwell-mar-history-21", "summary" : "9/24/2026 18:46 Valerie Smith, Registered Nurse 2 tabs given Yes\n9/25/2026 00:46 Molly Tibets, Registered Nurse 2 tabs given Yes", "type" : "Medication administration history — HYDROcodone bitartrate?acetaminophen" }, { "id" : "susan-rockwell-mar-history-22", "summary" : "9/25/2026 04:46 Molly Tibets, Registered Nurse 1tab Yes", "type" : "Medication administration history — zolpidem tartrate" }, { "id" : "susan-rockwell-section-previous-visits", "summary" : "Diabetes mellitus (type 2) | Roane Health Complex | Client presented for 3 hour glucose challenge yesterday. Failed two of four screenings. Seen today by HCP and RN Valerie. Reviewed results, risks related to pregnancy due to + diabetes. Reviewed nutritional changes that need to take place, how to count carb grams, how to perform blood glucose checks. Reviewed insulin use versus oral agent. Client stated concern regarding injecting self with insulin. Requested trying oral agents first. Discussed use of Metformin during pregnancy. Client receptive to using Metformin. WIll start at 500mg, with adjustments as needed. Client to visit with RN next week. Plan for next appointment in 2 weeks due to new diagnosis of gestational diabetes. | 6/21/2026 10:46 | 6/21/2026 10:46\nPregnancy (first trimester, normal) | Roane Health Complex | Initial consult after positive home pregnancy test. Regular periods for past 3 months. Estimated gestational age at this visit - 6 weeks. Prescription for prenatal vitamins given to patient as well as confirmation statement of pregnancy for WIC. Reviewed signs and symptoms of ectopic pregnancy, and remedies for 1st trimester pregnancy symptoms. Questions answered. | 5/21/2026 10:46 | 5/21/2026 10:46\nPregnancy (first trimester, normal) | Roane Health Complex | Initial meeting with Dr. Cheema. Reviewed OB-GYN Clinic practices related to rotating through providers during prenatal visits. Reviewed past OB history of cesarean section due to failure to progress. Reviewed current BMI of 38 and risk factors associated with obesity in pregnancy. Reviewed not gaining more than 20lbs during current pregnancy. Reviewed plan to obtain Hemoglobin A1C at this visit, along with other prenatal labs. Patient verbalized understanding. Plan to provide consult to the hospital nutritionalist. Plan for 12 week testing and ultrasound, Quad screen at 16 weeks and fetal survey at 20 weeks. | 6/18/2026 10:46 | 6/18/2026 10:46\nPregnancy (second trimester, normal) | Roane Health Complex | 12 week visit for first trimester screenings. Laboratory testing completed. Also reviewed initial prenatal panel results with patient. Plan for additional lab tests at 16 weeks. | 7/2/2026 10:46 | 7/2/2026 10:46\nPregnancy (second trimester, normal) | Roane Health Complex | Patient to clinic for 16 week screenings. Quad screening completed. Will call patient with results. | 7/30/2026 10:46 | 7/30/2026 10:46\nPregnancy (second trimester, normal) | Roane Health Complex | 20 week fetal survey completed. Scans to OB for interpretation. Patient aware that OB will call with results and send letter stating findings as well. | 8/27/2026 10:46 | 8/27/2026 10:46\nPregnancy (second trimester, normal) | Roane Health Complex | Client presented for Oral Glucose Tolerance Test (OGTT). 50gram glucose load administered. Blood Glucose 1 hour later 180mg/dL. Client counseled on results and need for 3 hour Glucose Tolerance Test. Prenatal appointment completed, education given on upcoming testing as well as 3rd trimester discomforts. Encouraged refresher childbirth course. | 6/11/2026 10:46 | 6/11/2026 10:46\nPregnancy (third trimester, normal) | Roane Health Complex | Client seen every two weeks since 26 week gestation. Now 32 weeks gestation. Metformin increased to 1000mg at last visit. NST to be completed at each visit. No other concerns discussed. Reviewed glucose readings and nutritional diary. Metformin adjusted due to increasing fasting blood sugar readings. Client to return in 2 weeks. | 8/6/2026 10:46 | 8/6/2026 10:46\nPregnancy (third trimester, normal) | Roane Health Complex | Client seen weekly since 34 week gestation. Weekly NST's reactive and BPP's 8/10 - 10/10. Glucose readings 90 - 110mg/dL fasting on 1000mg Metformin. Client verbalizing frustrations over third trimester discomforts. Reviewed need to remain pregnant through 39 weeks due to effects of diabetes on fetal lung maturity. Planned cesarean section scheduled for 39th week gestation. Will see client next week for c-section. Reviewed signs of labor and instructed to go to Labor and Delivery for any signs of labor. | 9/17/2026 10:46 | 9/17/2026 10:46", "type" : "Previous Visits" }, { "id" : "susan-rockwell-section-current-care-providers", "summary" : "Dr. Kahn | OB-GYN\nLisa Johnson | Nurse Practitioner\nMolly Tibets | Registered Nurse\nRaina Cheema | OB-GYN\nValerie Smith | Registered Nurse", "type" : "Current Care Providers" }, { "id" : "susan-rockwell-section-relevant-history", "summary" : "Relevant Medical History (Last updated by Susan Johnson, Nurse Practitioner on 9/24/2026 10:51) Help - What Relevant Medical History (Last updated by Susan Johnson, Nurse Practitioner on 9/24/2026 10:51) means / No relevant medical history\nRelevant Medical History (Last updated by Susan Johnson, Nurse Practitioner on 9/24/2026 10:51) Help - What Relevant Medical History (Last updated by Susan Johnson, Nurse Practitioner on 9/24/2026 10:51) means / Maternal History / Gravida: 2\nRelevant Medical History (Last updated by Susan Johnson, Nurse Practitioner on 9/24/2026 10:51) Help - What Relevant Medical History (Last updated by Susan Johnson, Nurse Practitioner on 9/24/2026 10:51) means / Maternal History / Number of Term Births: 1\nRelevant Medical History (Last updated by Susan Johnson, Nurse Practitioner on 9/24/2026 10:51) Help - What Relevant Medical History (Last updated by Susan Johnson, Nurse Practitioner on 9/24/2026 10:51) means / Maternal History / Number of Preterm Births: 0\nRelevant Medical History (Last updated by Susan Johnson, Nurse Practitioner on 9/24/2026 10:51) Help - What Relevant Medical History (Last updated by Susan Johnson, Nurse Practitioner on 9/24/2026 10:51) means / Maternal History / Number of Abortions: 0\nRelevant Medical History (Last updated by Susan Johnson, Nurse Practitioner on 9/24/2026 10:51) Help - What Relevant Medical History (Last updated by Susan Johnson, Nurse Practitioner on 9/24/2026 10:51) means / Maternal History / Number of Living Children: 1\nRelevant Medical History (Last updated by Susan Johnson, Nurse Practitioner on 9/24/2026 10:51) Help - What Relevant Medical History (Last updated by Susan Johnson, Nurse Practitioner on 9/24/2026 10:51) means / Maternal History / Hx of Abnormal Ultrasound: No\nSocial History (Last updated by Lisa Johnson, Nurse Practitioner on 9/24/2026 10:46) / Prenatal Care / Started Prenatal Care: 2/6/2026\nSocial History (Last updated by Lisa Johnson, Nurse Practitioner on 9/24/2026 10:46) / Prenatal Care / Prenatal Preparation: Started prenatal care at 6 weeks gestation.\nSocial History (Last updated by Lisa Johnson, Nurse Practitioner on 9/24/2026 10:46) / Alcohol Use / Alcohol Consumption During Pregnancy: No\nSocial History (Last updated by Lisa Johnson, Nurse Practitioner on 9/24/2026 10:46) / Drug Use / Illicit Drug Use During Pregnancy: No", "type" : "Relevant History" }, { "id" : "susan-rockwell-section-risks-screenings", "summary" : "Blood Screening / Type: O+\nRisks / Hepatitis B Screening: Negative\nRisks / HIV Status: Negative\nRisks / Syphilis Screening/VDRL (Venereal Disease Research Laboratory), Venereal Disease Research Laboratory: Negative\nRisks / Herpes/Warts Active Lesions: No\nRisks / Gonococcus Screening: Negative\nRisks / Chlamydia Screening: Negative\nRisks / Group B Streptococcus (GBS): Negative\nRisks / Rubella Immunity: Immune\nRisks / Diabetes: Yes\nRisks / Type: Gestational\nRisks / Fasting Blood Sugar: 110\nRisks / Genetic Concerns: None\nRisks / Pertinent Maternal Illness: Obese\nRisks / High Risk Pregnancy: Yes\nRisks / Notes: Considered High Risk due to BMI 38 prior to pregnancy and history of previous cesarean section.\nWarning Signs / Vaginal Spotting, Bleeding, or Discharge: Absent\nWarning Signs / Urination Sensation: Non-painful\nWarning Signs / Vomiting: Not present\nWarning Signs / Abdominal Pain: Absent\nWarning Signs / Contraction Occurrence: Absent\nWarning Signs / Calf Pain: Absent\nWarning Signs / Sudden Weight Gain: Absent\nWarning Signs / Edema: Yes\nWarning Signs / Location: Ankles and Feet after standing for 8 hours\nWarning Signs / Headache with Visual Changes: Absent\nWarning Signs / History of Right Upper Quadrant Pain: Absent", "type" : "Risks/Screenings" }, { "id" : "susan-rockwell-section-contractions-dilation-effacement", "summary" : "Contraction Type | Irritability\nContraction Intensity | Mild\nContraction Frequency (min) | \nContraction Duration (sec) | \nResting Tone | \nBraxton Hicks Contractions | Present\nCervical Dilation (cm) | 2\nEffacement (%) | 50\nFetal Station | -3\nMembranes Ruptured | No\nAmniotic Fluid | Not Present", "type" : "Contractions/Dilation/Effacement" }, { "id" : "susan-rockwell-section-intrapartum", "summary" : "Intrapartum Maternal Antibiotic Therapy / Group B Streptococcus (GBS): Negative\nMembrane: Not Present\nIntrapartum Maternal Antibiotic Therapy / Other Medications Given\nRelevant Medical History Help - What Relevant Medical History means / No relevant medical history\nAbdominal binder application (Links to Lippincott’s Nursing Procedures and Skills), Links to Lippincott’s Nursing Procedures and Skills | x1 (1 time only), 1 time only | N/A | Apply Dale Binder per patient request\nAbdominal Dressing Removal | x1 (1 time only), 1 time only | N/A | May remove dressing POD #1\nacetaminophen (Links to clinical content from Lippincott’s Nursing Advisor), Links to clinical content from Lippincott’s Nursing Advisor | q6h (Every 6 hours), Every 6 hours | 9/25/2026 10:46 | Administer 1 hour after Ketorolac. Do not exceed 4000mg in a 24 hour period of time from all sources.\nAmbulation, progressive (Links to Lippincott’s Nursing Procedures and Skills), Links to Lippincott’s Nursing Procedures and Skills | cont. | N/A | Dangle at night on day of surgery. Progress to QID ambulation on POD #1\nAssessment, general survey (Links to Lippincott’s Nursing Procedures and Skills), Links to Lippincott’s Nursing Procedures and Skills | q8h (Every 8 hours), Every 8 hours | N/A | N/A\nCesarean birth postoperative care (Links to Lippincott’s Nursing Procedures and Skills), Links to Lippincott’s Nursing Procedures and Skills | cont. | N/A | N/A\nComplete Blood Cell Count without Differential | x1 (1 time only), 1 time only | N/A | POD #1\ndalteparin sodium (Links to clinical content from Lippincott’s Nursing Advisor), Links to clinical content from Lippincott’s Nursing Advisor | q24h (Every 24 hours), Every 24 hours | N/A | N/A\nFundal assessment, postpartum (Links to Lippincott’s Nursing Procedures and Skills), Links to Lippincott’s Nursing Procedures and Skills | cont. | N/A | Fundal Assessment every shift following post-delivery assessment protocol completed\nHYDROcodone bitartrate?acetaminophen (Links to clinical content from Lippincott’s Nursing Advisor), Links to clinical content from Lippincott’s Nursing Advisor | q4h (Every 4 hours), Every 4 hours | 9/25/2026 00:46 | For moderate pain >4/10. Start with 1 tab PO every 4 hours PRN Pain. Repeat dose X 1 if pain unrelieved in 60 minutes and then in 4 hours move to 2 tabs PO every 4 hours PRN pain\nHYDROmorphone hydrochloride (Links to clinical content from Lippincott’s Nursing Advisor), Links to clinical content from Lippincott’s Nursing Advisor | q2h (Every 2 hours), Every 2 hours | 9/24/2026 16:46 | For pain > 6/10\nibuprofen (Links to clinical content from Lippincott’s Nursing Advisor), Links to clinical content from Lippincott’s Nursing Advisor | q6h (Every 6 hours), Every 6 hours | 9/25/2026 10:46 | To be initiated at least 6 hours after Ketorolac completed. Not to exceed 2400mg in a 24 hour period of time from all sources.\nIncentive spirometry (Links to Lippincott’s Nursing Procedures and Skills), Links to Lippincott’s Nursing Procedures and Skills | q2h (Every 2 hours), Every 2 hours | N/A | Every 2 hours while awake, encourage 10 breathes per episode of use\nIndwelling urinary catheter (Foley) care and management (Links to Lippincott’s Nursing Procedures and Skills), Links to Lippincott’s Nursing Procedures and Skills | cont. | N/A | N/A\nIndwelling urinary catheter (Foley) removal (Links to Lippincott’s Nursing Procedures and Skills), Links to Lippincott’s Nursing Procedures and Skills | x1 (1 time only), 1 time only | N/A | May discontinue urinary catheter on POD #1 if output adequate\nIntake and output assessment (Links to Lippincott’s Nursing Procedures and Skills), Links to Lippincott’s Nursing Procedures and Skills | cont. | N/A | Monitor I&O every 2 hours. Alert provider if output < 120ml/4hr\nIV catheter removal (Links to Lippincott’s Nursing Procedures and Skills), Links to Lippincott’s Nursing Procedures and Skills | x1 (1 time only), 1 time only | N/A | May remove IV Catheter after 1st POD if hemodynamically stable and tolerating PO fluids\nketorolac tromethamine (oral, nasal, injection) (Links to clinical content from Lippincott’s Nursing Advisor), Links to clinical content from Lippincott’s Nursing Advisor | q6h x4 (Every 6 hours, 4 times only), Every 6 hours, 4 times only | 9/25/2026 09:46 | 30mg Ketorolac every 6 hours X 24 hours\nmethylergonovine maleate (Links to clinical content from Lippincott’s Nursing Advisor), Links to clinical content from Lippincott’s Nursing Advisor | q4h (Every 4 hours), Every 4 hours | N/A | PRN Boggy uterus with minor bleeding\nmorphine sulfate (Links to clinical content from Lippincott’s Nursing Advisor), Links to clinical content from Lippincott’s Nursing Advisor | x1 (1 time only), 1 time only | N/A | N/A\nNotify Provider | cont. | N/A | Notify Provider of: Temp great than 38 degrees C SBP <90 or >140 DBP <60 or >90 Pulse <50 or >100 Resp Rate <12 or >26 Sats <95% on room air Heavy Bleeding Dyspnea, SOB, Chest Pain Calf pain, tenderness, edema, erythema\nondansetron (Links to clinical content from Lippincott’s Nursing Advisor), Links to clinical content from Lippincott’s Nursing Advisor | q6h (Every 6 hours), Every 6 hours | N/A | For nausea or vomiting\nOxygen administration (Links to Lippincott’s Nursing Procedures and Skills), Links to Lippincott’s Nursing Procedures and Skills | cont. | N/A | Start with nasal cannula at 2LPM - 4LPM to maintain Sats > 95%. If unable to achieve with nasal cannula, change to NRB mask at 10LPM\nPain assessment (Links to Lippincott’s Nursing Procedures and Skills), Links to Lippincott’s Nursing Procedures and Skills | q8h (Every 8 hours), Every 8 hours | N/A | Assess pain every shift or more often if necessary\nPain management (Links to Lippincott’s Nursing Procedures and Skills), Links to Lippincott’s Nursing Procedures and Skills | cont. | N/A | N/A\nPostpartum Assessment | q8h (Every 8 hours), Every 8 hours | N/A | Postpartum assessment every shift after completing post-delivery assessment protocol\nPrenatal Vitamin | q24h (Every 24 hours), Every 24 hours | 9/25/2026 10:46 | N/A\nRegular Diet | cont. | N/A | N/A\nSenna-S | q24h (Every 24 hours), Every 24 hours | 9/25/2026 10:46 | N/A\nSequential compression therapy (Links to Lippincott’s Nursing Procedures and Skills), Links to Lippincott’s Nursing Procedures and Skills | cont. | N/A | SCD's until fully mobile\nType & Match | x1 (1 time only), 1 time only | N/A | Type and Match 2 units PRBC's on call to OR\nVenipuncture (Links to Lippincott’s Nursing Procedures and Skills), Links to Lippincott’s Nursing Procedures and Skills | x1 (1 time only), 1 time only | N/A | For CBC without Diff, T & S\nVital Sign Monitoring | q4h (Every 4 hours), Every 4 hours | N/A | Vital Signs every 4 hours till discharged, after Post Operative Vital sign protocol completed\nzolpidem tartrate (Links to clinical content from Lippincott’s Nursing Advisor), Links to clinical content from Lippincott’s Nursing Advisor | q24h (Every 24 hours), Every 24 hours | 9/25/2026 04:46 | Administer at HS every night as needed for insomnia, may repeat X 1 in 30 minutes if ineffective", "type" : "Intrapartum" }, { "id" : "susan-rockwell-section-labor-vital-signs", "summary" : "Maternal Position | Supine\nCervical Dilation (cm) | 2\nEffacement (%) | 50\nFetal Station | -3\nMonitor Type | External\nContraction Type | Irritability\nContraction Frequency (min) | \nContraction Duration (sec) | \nContraction Intensity | Mild\nResting Tone | Soft\nContraction Intensity (IUPC) | \nMVU (IUPC) | \nResting Tone (IUPC) | \nFetal Heart Rate (bpm) | 140\nBaseline Rate | Regular\nVariability | Moderate = 6–25 BPM\nAccelerations Presence | Present\nAccelerations Details | Periodic\nDecelerations Presence | Absent\nDecelerations Details | \nInterventions | \nOther Interventions | ", "type" : "Labor Vital Signs" }, { "id" : "susan-rockwell-section-delivery", "summary" : "Maternal / Membrane / Rupture: Artificial\nMaternal / Membrane / Placenta Delivery: Manual\nMaternal / Post Birth Maternity History / Gravida: 2\nMaternal / Post Birth Maternity History / Number of Term Births: 2\nMaternal / Post Birth Maternity History / Number of Preterm Birth: 0\nMaternal / Post Birth Maternity History / Number of Abortions: 0\nMaternal / Post Birth Maternity History / Number of Living Children: 2\nBaby / Delivery Type: Caesarean\nBaby / 1-Minute Apgar: 8\nBaby / 5-Minute Apgar: 9\nBaby / Gender: Male\nBaby / Neonate Weight: 4168\nBaby / Neonate Length: 55\nBaby / Head Circumference: 35\nBaby / Cord Blood Collected?: Yes\nBaby / Number of Vessels: 3", "type" : "Delivery" }, { "id" : "susan-rockwell-clarification-31", "summary" : "Source permits repeating zolpidem after 30 minutes. Official tablet labeling specifies a single nightly dose with no same-night readministration; clarify the order, especially with concurrent opioid orders.", "type" : "Chart clarification" }, { "id" : "susan-rockwell-clarification-32", "summary" : "Obstetric history clarification: antepartum G2P1 and delivery G2P2 refer to different stages. Gestational diabetes is documented in prenatal notes and maternity screening despite general-history denial of prior medical problems. Postpartum suspected thromboembolism event is source-dated three hours after chart opening; staged release is not implemented.", "type" : "Chart clarification" } ], "orders" : [ { "author" : "Raina Cheema, OB-GYN", "category" : "Laboratory", "dateTime" : "2026-09-24T11:16:00", "id" : "susan-rockwell-order-1", "orderText" : "Type & Match; x1 (1 time only), 1 time only; Routine; Type and Match 2 units PRBC's on call to OR Source due: 9/24/2026 11:16", "status" : "Active" }, { "author" : "Raina Cheema, OB-GYN", "category" : "Laboratory", "dateTime" : "2026-09-25T10:46:00", "id" : "susan-rockwell-order-2", "orderText" : "Complete Blood Cell Count without Differential; x1 (1 time only), 1 time only; Routine; POD #1 Source due: 9/25/2026 10:46", "status" : "Active" }, { "author" : "Raina Cheema, OB-GYN", "category" : "Laboratory", "dateTime" : "2026-09-24T11:16:00", "id" : "susan-rockwell-order-3", "orderText" : "Venipuncture; x1 (1 time only), 1 time only; Routine; For CBC without Diff, T & S Source due: 9/24/2026 11:16", "status" : "Active" }, { "author" : "Raina Cheema, OB-GYN", "category" : "Nursing", "dateTime" : "2026-09-25T10:46:00", "id" : "susan-rockwell-order-4", "orderText" : "Regular Diet; cont.; Routine; Source due: 9/25/2026 10:46", "status" : "Active" }, { "author" : "Raina Cheema, OB-GYN", "category" : "Nursing", "dateTime" : "2026-09-24T10:46:00", "id" : "susan-rockwell-order-5", "orderText" : "Cesarean birth postoperative care; cont.; Routine; Source due: 9/24/2026 10:46", "status" : "Active" }, { "author" : "Raina Cheema, OB-GYN", "category" : "Nursing: Activity", "dateTime" : "2026-09-24T10:46:00", "id" : "susan-rockwell-order-6", "orderText" : "Indwelling urinary catheter (Foley) removal; x1 (1 time only), 1 time only; Routine; May discontinue urinary catheter on POD #1 if output adequate Source due: 9/24/2026 10:46", "status" : "Active" }, { "author" : "Raina Cheema, OB-GYN", "category" : "Nursing: Activity", "dateTime" : "2026-09-24T10:46:00", "id" : "susan-rockwell-order-7", "orderText" : "IV catheter removal; x1 (1 time only), 1 time only; Routine; May remove IV Catheter after 1st POD if hemodynamically stable and tolerating PO fluids Source due: 9/24/2026 10:46", "status" : "Active" }, { "author" : "Raina Cheema, OB-GYN", "category" : "Nursing: Activity", "dateTime" : "2026-09-24T10:46:00", "id" : "susan-rockwell-order-8", "orderText" : "Sequential compression therapy; cont.; Routine; SCD's until fully mobile Source due: 9/24/2026 10:46", "status" : "Active" }, { "author" : "Raina Cheema, OB-GYN", "category" : "Nursing: Activity", "dateTime" : "2026-09-24T10:46:00", "id" : "susan-rockwell-order-9", "orderText" : "Ambulation, progressive; cont.; Routine; Dangle at night on day of surgery. Progress to QID ambulation on POD #1 Source due: 9/24/2026 10:46", "status" : "Active" }, { "author" : "Raina Cheema, OB-GYN", "category" : "Nursing: Activity", "dateTime" : "2026-09-24T10:46:00", "id" : "susan-rockwell-order-10", "orderText" : "Abdominal Dressing Removal; x1 (1 time only), 1 time only; Routine; May remove dressing POD #1 Source due: 9/24/2026 10:46", "status" : "Active" }, { "author" : "Raina Cheema, OB-GYN", "category" : "Nursing: Monitoring", "dateTime" : "2026-09-25T10:46:00", "id" : "susan-rockwell-order-11", "orderText" : "Notify Provider; cont.; Routine; Notify Provider of: Temp great than 38 degrees C SBP <90 or >140 DBP <60 or >90 Pulse <50 or >100 Resp Rate <12 or >26 Sats <95% on room air Heavy Bleeding Dyspnea, SOB, Chest Pain Calf pain, tenderness, edema, erythema Source due: 9/25/2026 10:46", "status" : "Active" }, { "author" : "Raina Cheema, OB-GYN", "category" : "Nursing: Monitoring", "dateTime" : "2026-09-24T10:46:00", "id" : "susan-rockwell-order-12", "orderText" : "Indwelling urinary catheter (Foley) care and management; cont.; Routine; Source due: 9/24/2026 10:46", "status" : "Active" }, { "author" : "Raina Cheema, OB-GYN", "category" : "Nursing: Monitoring", "dateTime" : "2026-09-24T10:46:00", "id" : "susan-rockwell-order-13", "orderText" : "Assessment, general survey; q8h (Every 8 hours), Every 8 hours; Routine; Source due: 9/24/2026 10:46", "status" : "Active" }, { "author" : "Raina Cheema, OB-GYN", "category" : "Nursing: Monitoring", "dateTime" : "2026-09-24T10:46:00", "id" : "susan-rockwell-order-14", "orderText" : "Pain management; cont.; Routine; Source due: 9/24/2026 10:46", "status" : "Active" }, { "author" : "Raina Cheema, OB-GYN", "category" : "Nursing: Monitoring", "dateTime" : "2026-09-24T10:46:00", "id" : "susan-rockwell-order-15", "orderText" : "Pain assessment; q8h (Every 8 hours), Every 8 hours; Routine; Assess pain every shift or more often if necessary Source due: 9/24/2026 10:46", "status" : "Active" }, { "author" : "Raina Cheema, OB-GYN", "category" : "Nursing: Monitoring", "dateTime" : "2026-09-24T10:46:00", "id" : "susan-rockwell-order-16", "orderText" : "Vital Sign Monitoring; q4h (Every 4 hours), Every 4 hours; Routine; Vital Signs every 4 hours till discharged, after Post Operative Vital sign protocol completed Source due: 9/24/2026 10:46", "status" : "Active" }, { "author" : "Raina Cheema, OB-GYN", "category" : "Nursing: Monitoring", "dateTime" : "2026-09-24T10:46:00", "id" : "susan-rockwell-order-17", "orderText" : "Intake and output assessment; cont.; Routine; Monitor I&O every 2 hours. Alert provider if output < 120ml/4hr Source due: 9/24/2026 10:46", "status" : "Active" }, { "author" : "Raina Cheema, OB-GYN", "category" : "Nursing: Monitoring", "dateTime" : "2026-09-24T10:46:00", "id" : "susan-rockwell-order-18", "orderText" : "Postpartum Assessment; q8h (Every 8 hours), Every 8 hours; Routine; Postpartum assessment every shift after completing post-delivery assessment protocol Source due: 9/24/2026 10:46", "status" : "Active" }, { "author" : "Raina Cheema, OB-GYN", "category" : "Nursing: Procedure", "dateTime" : "2026-09-24T10:46:00", "id" : "susan-rockwell-order-19", "orderText" : "Abdominal binder application; x1 (1 time only), 1 time only; Routine; Apply Dale Binder per patient request Source due: 9/24/2026 10:46", "status" : "Active" }, { "author" : "Raina Cheema, OB-GYN", "category" : "Nursing: Procedure", "dateTime" : "2026-09-24T10:46:00", "id" : "susan-rockwell-order-20", "orderText" : "Incentive spirometry; q2h (Every 2 hours), Every 2 hours; Routine; Every 2 hours while awake, encourage 10 breathes per episode of use Source due: 9/24/2026 10:46", "status" : "Active" }, { "author" : "Raina Cheema, OB-GYN", "category" : "Nursing: Procedure", "dateTime" : "2026-09-25T10:46:00", "id" : "susan-rockwell-order-21", "orderText" : "Oxygen administration; cont.; Routine; Start with nasal cannula at 2LPM - 4LPM to maintain Sats > 95%. If unable to achieve with nasal cannula, change to NRB mask at 10LPM Source due: 9/25/2026 10:46", "status" : "Active" }, { "author" : "Raina Cheema, OB-GYN", "category" : "Nursing: Procedure", "dateTime" : "2026-09-24T10:46:00", "id" : "susan-rockwell-order-22", "orderText" : "Ambulation, progressive; cont.; Routine; Dangle at night on day of surgery. Progress to QID ambulation on POD #1 Source due: 9/24/2026 10:46", "status" : "Active" }, { "author" : "Raina Cheema, OB-GYN", "category" : "Nursing: Procedure", "dateTime" : "2026-09-24T10:46:00", "id" : "susan-rockwell-order-23", "orderText" : "Fundal assessment, postpartum; cont.; Routine; Fundal Assessment every shift following post-delivery assessment protocol completed Source due: 9/24/2026 10:46", "status" : "Active" }, { "author" : "Dr. Kahn, OB-GYN", "category" : "Pharmacy", "dateTime" : "2026-09-25T10:46:00", "id" : "susan-rockwell-order-24", "orderText" : "dalteparin sodium; 200units/kg Subcutaneous (SC); q24h (Every 24 hours), Every 24 hours; Scheduled, Stat; Source due: 9/25/2026 10:46", "status" : "Active" }, { "author" : "Dr. Kahn, OB-GYN", "category" : "Pharmacy", "dateTime" : "2026-09-25T10:46:00", "id" : "susan-rockwell-order-25", "orderText" : "morphine sulfate; 5mg Intravenous (IV); x1 (1 time only), 1 time only; Scheduled, Stat; Source due: 9/25/2026 10:46", "status" : "Active" }, { "author" : "Raina Cheema, OB-GYN", "category" : "Pharmacy", "dateTime" : "2026-09-24T10:46:00", "id" : "susan-rockwell-order-26", "orderText" : "ketorolac tromethamine (oral, nasal, injection); 30mg Intravenous (IV); q6h x4 (Every 6 hours, 4 times only), Every 6 hours, 4 times only; Discontinued; 30mg Ketorolac every 6 hours X 24 hours", "status" : "Discontinued" }, { "author" : "Raina Cheema, OB-GYN", "category" : "Pharmacy", "dateTime" : "2026-09-24T10:46:00", "id" : "susan-rockwell-order-27", "orderText" : "acetaminophen; 650mg Oral (PO); q6h (Every 6 hours), Every 6 hours; Scheduled; Administer 1 hour after Ketorolac. Do not exceed 4000mg in a 24 hour period of time from all sources. Source due: 9/25/2026 16:46", "status" : "Active" }, { "author" : "Raina Cheema, OB-GYN", "category" : "Pharmacy", "dateTime" : "2026-09-24T10:46:00", "id" : "susan-rockwell-order-28", "orderText" : "ibuprofen; 600mg Oral (PO); q6h (Every 6 hours), Every 6 hours; Scheduled; To be initiated at least 6 hours after Ketorolac completed. Not to exceed 2400mg in a 24 hour period of time from all sources. Source due: 9/25/2026 16:46", "status" : "Active" }, { "author" : "Raina Cheema, OB-GYN", "category" : "Pharmacy", "dateTime" : "2026-09-24T10:46:00", "id" : "susan-rockwell-order-29", "orderText" : "Prenatal Vitamin; 1 tab Oral (PO); q24h (Every 24 hours), Every 24 hours; Scheduled; Source due: 9/26/2026 10:46", "status" : "Active" }, { "author" : "Raina Cheema, OB-GYN", "category" : "Pharmacy", "dateTime" : "2026-09-24T10:46:00", "id" : "susan-rockwell-order-30", "orderText" : "Senna-S; 2 cap Oral (PO); q24h (Every 24 hours), Every 24 hours; Scheduled; Source due: 9/26/2026 10:46", "status" : "Active" }, { "author" : "Raina Cheema, OB-GYN", "category" : "Pharmacy", "dateTime" : "2026-09-24T10:46:00", "id" : "susan-rockwell-order-31", "orderText" : "HYDROmorphone hydrochloride; 1mg Intravenous (IV); q2h (Every 2 hours), Every 2 hours; PRN; For pain > 6/10 Source due: PRN", "status" : "Active" }, { "author" : "Raina Cheema, OB-GYN", "category" : "Pharmacy", "dateTime" : "2026-09-24T10:46:00", "id" : "susan-rockwell-order-32", "orderText" : "HYDROcodone bitartrate/acetaminophen; 5/325mg Oral (PO); q4h (Every 4 hours), Every 4 hours; PRN; For moderate pain >4/10. Start with 1 tab PO every 4 hours PRN Pain. Repeat dose X 1 if pain unrelieved in 60 minutes and then in 4 hours move to 2 tabs PO every 4 hours PRN pain Source due: PRN", "status" : "Active" }, { "author" : "Raina Cheema, OB-GYN", "category" : "Pharmacy", "dateTime" : "2026-09-24T10:46:00", "id" : "susan-rockwell-order-33", "orderText" : "ondansetron; 4mg Intravenous (IV); q6h (Every 6 hours), Every 6 hours; PRN; For nausea or vomiting Source due: PRN", "status" : "Active" }, { "author" : "Raina Cheema, OB-GYN", "category" : "Pharmacy", "dateTime" : "2026-09-24T10:46:00", "id" : "susan-rockwell-order-34", "orderText" : "zolpidem tartrate; 5mg Oral (PO); q24h (Every 24 hours), Every 24 hours; PRN; Administer at HS every night as needed for insomnia, may repeat X 1 in 30 minutes if ineffective Source due: PRN Source permits repeating zolpidem after 30 minutes. Official tablet labeling specifies a single nightly dose with no same-night readministration; clarify the order, especially with concurrent opioid orders.", "status" : "Held — clarification required" }, { "author" : "Raina Cheema, OB-GYN", "category" : "Pharmacy", "dateTime" : "2026-09-24T10:46:00", "id" : "susan-rockwell-order-35", "orderText" : "methylergonovine maleate; 0.2mg Oral (PO); q4h (Every 4 hours), Every 4 hours; PRN; PRN Boggy uterus with minor bleeding Source due: PRN", "status" : "Active" } ], "overview" : { "height" : "64 in / 162.6 cm", "isolationIndicator" : "Standard", "religion" : "Christian", "weightKg" : 100.7 }, "vitals" : [ { "bloodPressure" : "126/76", "dateTime" : "2026-09-24T10:51:00", "heartRate" : 78, "id" : "susan-rockwell-vital-1", "oxygenDevice" : "Room Air", "respiratoryRate" : 20, "spo2" : "98", "temperature" : "98.8 °F (37 °C), 37 °C Oral" }, { "bloodPressure" : "124/72", "dateTime" : "2026-09-24T14:46:00", "heartRate" : 80, "id" : "susan-rockwell-vital-2", "oxygenDevice" : "Room Air", "respiratoryRate" : 20, "spo2" : "98", "temperature" : "98.2 °F (37 °C), 37 °C Oral" }, { "bloodPressure" : "120/68", "dateTime" : "2026-09-24T18:46:00", "heartRate" : 72, "id" : "susan-rockwell-vital-3", "oxygenDevice" : "Room Air", "respiratoryRate" : 18, "spo2" : "99", "temperature" : "98.4 °F (37 °C), 37 °C Oral" }, { "bloodPressure" : "128/82", "dateTime" : "2026-09-25T02:46:00", "heartRate" : 80, "id" : "susan-rockwell-vital-4", "oxygenDevice" : "Room Air", "respiratoryRate" : 18, "spo2" : "98", "temperature" : "98.6 °F (37 °C), 37 °C Oral" }, { "bloodPressure" : "124/76", "dateTime" : "2026-09-25T06:46:00", "heartRate" : 88, "id" : "susan-rockwell-vital-5", "oxygenDevice" : "Room Air", "respiratoryRate" : 20, "spo2" : "97", "temperature" : "98.4 °F (37 °C), 37 °C Oral" }, { "bloodPressure" : "130/78", "dateTime" : "2026-09-25T10:46:00", "heartRate" : 82, "id" : "susan-rockwell-vital-6", "oxygenDevice" : "Room Air", "respiratoryRate" : 20, "spo2" : "97", "temperature" : "99 °F (37 °C), 37 °C Oral" }, { "bloodPressure" : "128/74", "dateTime" : "2026-09-25T11:46:00", "heartRate" : 108, "id" : "susan-rockwell-vital-7", "oxygenDevice" : "Room Air", "respiratoryRate" : 24, "spo2" : "93" } ] }, "patient" : { "admitDateTime" : "2026-09-24T10:46:00", "admittingDiagnosis" : "Cesarean Section (Planned)", "allergies" : [ ], "attending" : "Raina Cheema, OB-GYN", "chartDisplayName" : "Rockwell, Susan", "codeStatus" : "Full Code", "dob" : "7/19/XX", "history" : { "chiefComplaint" : "\"I'm here for my scheduled c-section. I can't believe we are having the baby. It's a lot different when this is planned versus being in labor. I made sure to not eat anything for at least 6 hours, and I did not take my metformin this morning", "pastMedicalHistory" : [ "Maternal History / Gravida: 2", "Maternal History / Number of Term Births: 1", "Maternal History / Number of Preterm Births: 0", "Maternal History / Number of Abortions: 0", "Maternal History / Number of Living Children: 1", "Maternal History / Hx of Abnormal Ultrasound: No", "General Medical History: Denies prior medical problems", "Obstetric Medical History: Denies prior obstetric problems", "Transfusion History / Previous Blood Transfusion?: No", "Transfusion History / Does Patient Know His/Her Blood Type?: Yes", "Transfusion History / Blood Type: O+", "Pain History / History of Chronic Pain?: No", "Screenings / TB Screening (Tuberculosis), Tuberculosis: Unknown", "Screenings / MDRO Infection Screening (Multidrug-Resistant Organisms), Multidrug-Resistant Organisms: Unknown", "Screenings / Pap Smear: Yes", "Screenings / Result: Normal", "Screenings / Mammogram: No", "Screenings / Other: No" ], "pastSurgicalHistory" : [ "Previous Surgical Procedures / Surgical Procedure: Cesarean Section", "Previous Surgical Procedures / Year / Year: 2015" ], "socialHistory" : [ "Age: 27 years", "Home Situation / Patient Living Situation: Home", "Home Situation / Lives With: Other family member", "Education / Highest Grade Completed: 12", "Education / Able to Read?: Yes", "Education / Able to Write?: Yes", "Prenatal Care / Started Prenatal Care Days: 231", "Prenatal Care / Started Prenatal Care Relative To Timing Based On: before student launches assignment", "Prenatal Care / Prenatal Preparation: Started prenatal care at 6 weeks gestation.", "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 Consumption During Pregnancy: No", "Alcohol Use / Has Patient Ever Been Diagnosed With or Treated for Alcohol Abuse?: No", "Drug Use / Illicit Drug Use During Pregnancy: No", "Drug Use / Has Patient Ever Been Diagnosed With or Treated for Drug Abuse?: No", "Drug Use / Drug Screening: N/A", "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?: Unknown", "Nutritional Screening / Stool Frequency: 1-2 days", "Nutritional Screening / Stool Description: Formed", "Nutritional Screening / Last Bowel Movement Days: 3", "Nutritional Screening / Last Bowel Movement Relative To Timing Based On: before student launches assignment", "Exercise Screening / Exercise Frequency: Daily", "Exercise Screening / Duration of Exercise: 30 mins", "Exercise Screening / Intensity: Moderate", "Exercise Screening / Type(s): Walking", "Exercise Screening / Was Patient Counseled on Exercise?: Yes", "Mental Health Screening / Does Patient Have Frequent Feelings of Hopelessness/Helplessness?: No", "Mental Health Screening / Does Patient Have Thoughts of Harming Self?: No", "Sexual Activity / Sexually Active?: Yes", "Sexual Activity / Partners: Men", "Sexual Activity / Number of Partners in Last 3 Months: 1", "Sexual Activity / Uses Protection?: No", "Sexual Activity / Ever Treated for a Sexually Transmitted Disease?: No", "Sexual Activity / Notes: Pregnant at this time.", "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" : "MR45903", "sex" : "Female", "simulatedFullName" : "Susan Rockwell", "unit" : "Roane Health Complex — Room 7002" }, "setting" : "Roane Health Complex — Room 7002", "snapshots" : [ { "activityIds" : [ ], "id" : "susan-rockwell-current", "notes" : "Captured dated chart history; source relative dates anchored to chart opening. Progressive release not recreated.", "scenarioTime" : "2026-09-25T11:46:00", "sourcePath" : "DocuCare instructor chart: Susan Rockwell, Postpartum", "title" : "Captured chart" } ], "subtitle" : "N12 practice record", "tags" : [ "N12", "DocuCare migration" ], "title" : "Susan Rockwell, Postpartum" }, "packageId" : "docucare-n12-susan-rockwell-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" : "n12-susan-rockwell", "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" : "Susan Rockwell" }, { "envelope" : { "appName" : "ChartSlate", "audience" : "student", "createdAt" : "2026-09-25T19:44:44.067559+00:00", "exportVersion" : "1", "kind" : "casePackage", "package" : { "case" : { "activities" : [ ], "id" : "docucare-n12-olivia-jones", "learningLevel" : "N12", "panels" : { "assessments" : [ { "author" : "Tim Kane, Registered Nurse", "dateTime" : "2026-09-25T10:52:00", "id" : "olivia-jones-assessment-1", "label" : "HEENT", "summary" : ": HEENT\nHead / Size/Shape / Head Size/Shape: Symmetric\nEars: Not assessed\nEyes / Left Eye: Normal/clear\nEyes / Right Eye: Normal/clear\nEyes / Left Eye: Symmetrical\nEyes / Right Eye: Symmetrical" }, { "author" : "Tim Kane, Registered Nurse", "dateTime" : "2026-09-25T10:52:00", "id" : "olivia-jones-assessment-2", "label" : "Neuro", "summary" : ": Neuro\nAdditional Notes / Additional Notes: Patellar deep tendon reflexes +4 bilaterally\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: 2\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: Moves Upon Request in Left Lower Extremity\nStrength / RLE (Right Lower Extremity), Right Lower Extremity: Moves Upon Request in Right Lower Extremity\nBehavioral/Emotional: Cooperative" }, { "author" : "Tim Kane, Registered Nurse", "dateTime" : "2026-09-25T10:52:00", "id" : "olivia-jones-assessment-3", "label" : "Cardio", "summary" : ": Cardio\nHeart Tones: S1, S2\nPulses / All: Absent in All\nEdema / LUE (Left Upper Extremity), Left Upper Extremity: 1+\nEdema / RUE (Right Upper Extremity), Right Upper Extremity: 1+\nEdema / LLE (Left Lower Extremity), Left Lower Extremity: 2+\nEdema / RLE (Right Lower Extremity), Right Lower Extremity: 2+\nCapillary Refill / All: < 3 sec in All\nSkin Color and Description: Appropriate for ethnicity" }, { "author" : "Tim Kane, Registered Nurse", "dateTime" : "2026-09-25T10:52:00", "id" : "olivia-jones-assessment-4", "label" : "GI", "summary" : ": GI\nGI Symptoms: Nausea\nGI Symptoms: Epigastric pain\nGI Symptoms: Weight gain\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" : "Tim Kane, Registered Nurse", "dateTime" : "2026-09-25T10:52:00", "id" : "olivia-jones-assessment-5", "label" : "GU", "summary" : ": GU\nUrine Color: Amber\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" : "Tim Kane, Registered Nurse", "dateTime" : "2026-09-25T10:52:00", "id" : "olivia-jones-assessment-6", "label" : "Respiratory", "summary" : ": Respiratory\nSputum / Amount: None\nBreath Sounds / Right Upper Lobe: Clear\nRespirations: Regular" }, { "author" : "Tim Kane, Registered Nurse", "dateTime" : "2026-09-25T10:52:00", "id" : "olivia-jones-assessment-7", "label" : "Mental Health", "summary" : ": Mental Health\nBehavior / Affect: Appropriate\nStressors: Condition\nStressors: Hospitalization\nCoping: Well" }, { "author" : "Tim Kane, Registered Nurse", "dateTime" : "2026-09-25T10:52:00", "id" : "olivia-jones-assessment-8", "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" : "Tim Kane, Registered Nurse", "dateTime" : "2026-09-25T10:52:00", "id" : "olivia-jones-assessment-9", "label" : "Pain Scale", "summary" : ": Pain Scale\nPain Location: headache\nOnset Days: 0\nOnset Hours: 6\nOnset Minutes: 0\nOnset Relative To Timing Based On: before admission\nPain Duration: continuous\nAggravating Factors Comments: A constant headache - not relieved with acetaminophen.\nPain Rating: 5 - Moderate Pain\nPain Characteristics: Dull" }, { "author" : "Maggie Reed, Registered Nurse", "dateTime" : "2026-09-25T09:52:00", "id" : "olivia-jones-assessment-10", "label" : "Pain Scale", "summary" : ": Pain Scale\nPain Location: Headache\nOnset Days: 0\nOnset Hours: 3\nOnset Minutes: 0\nOnset Relative To Timing Based On: after admission\nPain Frequency: Constant\nType Of Pain: Acute\nPain Goal: 0 - No Pain\nAggravating Factors: Movement\nAggravating Factors: Coughing\nAggravating Factors: Eating\nPain Rating: 4\nPain Characteristics: Throbbing\nPain Characteristics: Sore" }, { "author" : "Tim Kane, Registered Nurse", "dateTime" : "2026-09-25T10:52:00", "id" : "olivia-jones-assessment-11", "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: 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: 22\nResults: Low Risk" }, { "author" : "Tim Kane, Registered Nurse", "dateTime" : "2026-09-25T10:52:00", "id" : "olivia-jones-assessment-12", "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. *" }, { "author" : "Tim Kane, Registered Nurse", "dateTime" : "2026-09-25T10:52:00", "id" : "olivia-jones-assessment-13", "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 guage\nNotes: Ringers Lactate at 125 mL/hours started." }, { "author" : "Sara Anderson, OB/Gyn Physician", "dateTime" : "2026-09-25T10:22:00", "id" : "olivia-jones-maternity-contractions-source-14", "label" : "Maternity Contractions", "summary" : "Contraction Type: Irregular\nContraction Intensity: Mild\nBraxton Hicks Contractions: Present\nEffacement: 0\nFetal Station: -3\nNotes: Questionable SROM, will complete Amnisure testing to determine if BOW ruptured. Cervix fingertip dilated, not effaced, -3 station." }, { "author" : "Tim Kane, Registered Nurse", "dateTime" : "2026-09-25T09:52:00", "id" : "olivia-jones-maternity-vitals-source-15", "label" : "Maternity Vitals", "summary" : "Mother / Maternal Position: Supine\nMother / Effacement: 0\nMother / Monitor Type: External\nMother / Contraction Type: Irregular\nMother / Contraction Intensity: Mild\nBaby / Fetal Heart Rate: 135\nBaby / Baseline Rate: Regular\nBaby / Variability: Moderate = 6–25 BPM\nBaby / Accelerations Presence: Present\nBaby / Accelerations Details: Periodic\nBaby / Decelerations Presence: Absent\nNotes: Patient admitted for worsening signs of preeclampsia. Placed on monitor, initiating physician orders." } ], "labs" : [ { "category" : "Other", "collectedDateTime" : "2026-04-10T09:52:00", "flag" : "Normal", "id" : "olivia-jones-lab-1", "result" : "O+", "test" : "Blood Type" }, { "category" : "Other", "collectedDateTime" : "2026-04-10T09:52:00", "flag" : "Normal", "id" : "olivia-jones-lab-2", "referenceRange" : "negative", "result" : "Neg", "test" : "HIV" }, { "category" : "Other", "collectedDateTime" : "2026-04-10T09:52:00", "flag" : "Normal", "id" : "olivia-jones-lab-3", "referenceRange" : "negative", "result" : "Neg", "test" : "Group B Strep" }, { "category" : "Other", "collectedDateTime" : "2026-04-10T09:52:00", "flag" : "Normal", "id" : "olivia-jones-lab-4", "referenceRange" : "negative", "result" : "neg", "test" : "Gonorrhea/Chlamydia GC/CT" }, { "category" : "Other", "collectedDateTime" : "2026-04-10T09:52:00", "flag" : "Normal", "id" : "olivia-jones-lab-5", "referenceRange" : "non-reactive", "result" : "NR", "test" : "Syphilis Treponemal IGA" }, { "category" : "Other", "collectedDateTime" : "2026-04-10T09:52:00", "flag" : "Normal", "id" : "olivia-jones-lab-6", "referenceRange" : "Immune", "result" : "Imm", "test" : "Rubella" }, { "category" : "Other", "collectedDateTime" : "2026-04-10T09:52:00", "flag" : "Normal", "id" : "olivia-jones-lab-7", "referenceRange" : "negative", "result" : "neg", "test" : "CMV" }, { "category" : "Other", "collectedDateTime" : "2026-04-10T09:52:00", "flag" : "Normal", "id" : "olivia-jones-lab-8", "referenceRange" : "negative", "result" : "neg", "test" : "Hepatitis A" }, { "category" : "Other", "collectedDateTime" : "2026-04-10T09:52:00", "flag" : "Normal", "id" : "olivia-jones-lab-9", "referenceRange" : "negative", "result" : "neg", "test" : "Hepatitis B" }, { "category" : "Other", "collectedDateTime" : "2026-04-10T09:52:00", "flag" : "Normal", "id" : "olivia-jones-lab-10", "referenceRange" : "negative", "result" : "neg", "test" : "Hepatitis C" }, { "category" : "Other", "collectedDateTime" : "2026-04-10T09:52:00", "flag" : "Normal", "id" : "olivia-jones-lab-11", "referenceRange" : "negative", "result" : "neg", "test" : "Herpes Simplex Virus" }, { "category" : "Other", "collectedDateTime" : "2026-08-14T09:52:00", "flag" : "High", "id" : "olivia-jones-lab-12", "referenceRange" : "85-135 mL/min", "result" : "154", "test" : "creatinine clearance" }, { "category" : "Other", "collectedDateTime" : "2026-08-14T09:52:00", "flag" : "High", "id" : "olivia-jones-lab-13", "referenceRange" : "less than 150 mg/24 h", "result" : "greater than 450 mg/24 h", "test" : "protein" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-25T11:52:00", "flag" : "High", "id" : "olivia-jones-lab-14", "referenceRange" : "4.0-9.0", "result" : "12.0", "test" : "WBC (10 x 3/uL)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-25T11:52:00", "flag" : "High", "id" : "olivia-jones-lab-15", "referenceRange" : "3.90-4.98", "result" : "5", "test" : "RBC (mill/cumm)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-25T11:52:00", "flag" : "Low", "id" : "olivia-jones-lab-16", "referenceRange" : "12.0-15.5", "result" : "10", "test" : "Hemoglobin (gm/dL)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-25T11:52:00", "flag" : "Low", "id" : "olivia-jones-lab-17", "referenceRange" : "35-45", "result" : "30", "test" : "Hematocrit (%)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-25T11:52:00", "flag" : "Normal", "id" : "olivia-jones-lab-18", "referenceRange" : "81-93", "result" : "90", "test" : "MCV (fL)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-25T11:52:00", "flag" : "Normal", "id" : "olivia-jones-lab-19", "referenceRange" : "28-35", "result" : "28", "test" : "MCH (pg)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-25T11:52:00", "flag" : "Low", "id" : "olivia-jones-lab-20", "referenceRange" : "33-37", "result" : "12", "test" : "MCHC (gm/dL)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-25T11:52:00", "flag" : "Normal", "id" : "olivia-jones-lab-21", "referenceRange" : "11.4-15.2", "result" : "11.5", "test" : "RDW (%)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2026-09-25T11:52:00", "flag" : "Low", "id" : "olivia-jones-lab-22", "referenceRange" : "140-400", "result" : "98.0", "test" : "Platelet Count (1000/mm3)" }, { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2026-09-25T11:52:00", "flag" : "Normal", "id" : "olivia-jones-lab-23", "referenceRange" : "135-145", "result" : "140", "test" : "Sodium (mEq/L)" }, { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2026-09-25T11:52:00", "flag" : "Normal", "id" : "olivia-jones-lab-24", "referenceRange" : "3.5-5.1", "result" : "4.6", "test" : "Potassium (mEq/L)" }, { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2026-09-25T11:52:00", "flag" : "Normal", "id" : "olivia-jones-lab-25", "referenceRange" : "22-29", "result" : "29", "test" : "CO2 (mEq/L)" }, { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2026-09-25T11:52:00", "flag" : "Normal", "id" : "olivia-jones-lab-26", "referenceRange" : "70-99", "result" : "80", "test" : "Glucose (mg/dL)" }, { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2026-09-25T11:52:00", "flag" : "High", "id" : "olivia-jones-lab-27", "referenceRange" : "6-20", "result" : "32", "test" : "Blood Urea Nitrogen (mg/dL)" }, { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2026-09-25T11:52:00", "flag" : "Normal", "id" : "olivia-jones-lab-28", "referenceRange" : "6.4-8.4", "result" : "7", "test" : "Total Protein (gm/dL)" }, { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2026-09-25T11:52:00", "flag" : "Normal", "id" : "olivia-jones-lab-29", "referenceRange" : "3.5-5.2", "result" : "3.5", "test" : "Albumin (gm/dL)" }, { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2026-09-25T11:52:00", "flag" : "High", "id" : "olivia-jones-lab-30", "referenceRange" : "0-32", "result" : "42", "test" : "AST (U/L)" }, { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2026-09-25T11:52:00", "flag" : "High", "id" : "olivia-jones-lab-31", "referenceRange" : "35-105", "result" : "110", "test" : "Alkaline Phosphate (U/L)" }, { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2026-09-25T11:52:00", "flag" : "High", "id" : "olivia-jones-lab-32", "referenceRange" : "0-33", "result" : "40", "test" : "ALT (U/L)" }, { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2026-09-25T11:52:00", "flag" : "High", "id" : "olivia-jones-lab-33", "referenceRange" : "10:1 - 20:1", "result" : "21:1", "test" : "BUN/Creatinine ratio" }, { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2026-09-25T11:52:00", "flag" : "High", "id" : "olivia-jones-lab-34", "referenceRange" : "250-750", "result" : "800", "test" : "Uric acid" }, { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2026-09-25T11:52:00", "flag" : "Normal", "id" : "olivia-jones-lab-35", "referenceRange" : "9-11mg/dl", "result" : "9", "test" : "Calcium" }, { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2026-09-25T11:52:00", "flag" : "Normal", "id" : "olivia-jones-lab-36", "referenceRange" : "1.5-2.5 mEq/L", "result" : "1.8", "test" : "magnesium" }, { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2026-09-25T11:52:00", "flag" : "Normal", "id" : "olivia-jones-lab-37", "referenceRange" : "50-150mcg/dL", "result" : "65", "test" : "Iron" }, { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2026-09-25T11:52:00", "flag" : "High", "id" : "olivia-jones-lab-38", "referenceRange" : "100-190 unit/L", "result" : "220", "test" : "LDH" }, { "category" : "Lipid Panel", "collectedDateTime" : "2026-09-25T11:52:00", "flag" : "Normal", "id" : "olivia-jones-lab-39", "referenceRange" : "Less than 200", "result" : "180", "test" : "Total Cholesterol (mg/dL)" }, { "category" : "Lipid Panel", "collectedDateTime" : "2026-09-25T11:52:00", "flag" : "High", "id" : "olivia-jones-lab-40", "referenceRange" : "Less than 150", "result" : "180", "test" : "Triglycerides (mg/dL)" }, { "category" : "Other", "collectedDateTime" : "2026-09-25T11:52:00", "flag" : "Normal", "id" : "olivia-jones-lab-41", "referenceRange" : "30-170 unit/L", "result" : "50", "test" : "Amylase" }, { "category" : "Other", "collectedDateTime" : "2026-09-25T11:52:00", "flag" : "Normal", "id" : "olivia-jones-lab-42", "referenceRange" : "280-300mOsm/L", "result" : "300", "test" : "Osmolality" }, { "category" : "Urinalysis", "collectedDateTime" : "2026-09-25T11:52:00", "flag" : "High", "id" : "olivia-jones-lab-43", "referenceRange" : "85-135mL/min", "result" : "154", "test" : "Creatinine Clearance" }, { "category" : "Urinalysis", "collectedDateTime" : "2026-09-25T11:52:00", "flag" : "High", "id" : "olivia-jones-lab-44", "referenceRange" : "0.8 - 2 gram/24 hours", "result" : "2.6g", "test" : "Creatinine" }, { "category" : "Urinalysis", "collectedDateTime" : "2026-09-25T11:52:00", "flag" : "High", "id" : "olivia-jones-lab-45", "referenceRange" : "less than 150mg/24 hours", "result" : "> 450mg", "test" : "Protein" }, { "category" : "Urinalysis", "collectedDateTime" : "2026-09-25T11:52:00", "flag" : "Normal", "id" : "olivia-jones-lab-46", "referenceRange" : "40-250 mEq/24 hour", "result" : "248", "test" : "Sodium" } ], "medications" : [ { "doseRouteFrequency" : "500mL Intravenous Piggyback (IVPB) x1 (1 time only), 1 time only", "drug" : "Lactated Ringer's 500 mL IV bolus", "id" : "olivia-jones-med-35", "nextDue" : "2026-09-25T10:52:00", "notes" : "Source due: 9/25/2026 10:52", "orderedBy" : "Sara Anderson, OB/Gyn Physician", "orderedDateTime" : "2026-09-25T10:52:00", "section" : "Scheduled", "status" : "Active" }, { "doseRouteFrequency" : "4 gram Intravenous Piggyback (IVPB) x1 (1 time only), 1 time only", "drug" : "magnesium sulfate", "id" : "olivia-jones-med-36", "nextDue" : "2026-09-25T09:52:00", "notes" : "Administer 4 gram bolus over 20 minutes Source due: 9/25/2026 09:52", "orderedBy" : "Sara Anderson, OB/Gyn Physician", "orderedDateTime" : "2026-09-25T09:52:00", "section" : "Scheduled", "status" : "Active" }, { "doseRouteFrequency" : "5mg Intravenous (IV) q2min (Every 2 minutes), Every 2 minutes", "drug" : "diazepam", "id" : "olivia-jones-med-37", "notes" : "Diazepam 5mg every 2-3 minutes for convulsions Source due: PRN Do not administer from this unresolved source order. Source repeats 5 mg IV every 2–3 minutes for convulsions without maximum cumulative dose or escalation/monitoring details; clarify rescue-seizure protocol. Do not extrapolate indefinite repeats.", "orderedBy" : "Sara Anderson, OB/Gyn Physician", "orderedDateTime" : "2026-09-25T09:52:00", "section" : "PRN", "status" : "Held — clarification required" }, { "doseRouteFrequency" : "50 ml per hr Intravenous Piggyback (IVPB) cont.", "drug" : "magnesium sulfate", "id" : "olivia-jones-med-38", "nextDue" : "2026-09-25T09:52:00", "notes" : "20 gram in 500mL concentration to be used. Administer 2 gram per hour (50mL/hr) after 4 gram bolus completed. Source due: 9/25/2026 09:52", "orderedBy" : "Sara Anderson, OB/Gyn Physician", "orderedDateTime" : "2026-09-25T09:52:00", "section" : "Scheduled", "status" : "Active" }, { "doseRouteFrequency" : "Intravenous (IV), adjust to keep total IV intake at or below 125 mL/hr", "drug" : "Lactated Ringers", "id" : "olivia-jones-med-39", "lastGiven" : "2026-09-25T10:12:00", "notes" : "Adjust rate so total IV fluids not to exceed 125mL/hr Source due: cont. At magnesium 50 mL/hr, remaining allowance is at most 75 mL/hr, less other concurrent infusions; reconcile bolus order separately.", "orderedBy" : "Sara Anderson, OB/Gyn Physician", "orderedDateTime" : "2026-09-25T09:52:00", "section" : "Scheduled", "status" : "Active" } ], "notes" : [ { "id" : "olivia-jones-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" : "olivia-jones-family-health-history", "summary" : "Family History: Denies knowledge of significant family history", "type" : "Family Health History" }, { "author" : "Tim Kane , Registered Nurse", "dateTime" : "2026-09-25T10:22:00", "id" : "olivia-jones-note-1", "summary" : "Patient to Labor and Delivery unit from physician office due to worsening symptoms related to preeclampsia. Currently taking 200mg Labatolol every day. Patient states taking medication this morning with breakfast. Patient states continued headache, visual changes, weight gain, swelling in hands and feet and epigastric discomfort. Physician orders present in computer. External monitors placed FHT's 135 with moderate variability, no decels observed. Patient educated on plan of care for this admission, questions answered.", "type" : "Nursing - Admission" }, { "id" : "olivia-jones-mar-history-4", "summary" : "9/25/2026 10:12 Maggie Reed, Registered Nurse Yes", "type" : "Medication administration history — Lactated Ringers" }, { "id" : "olivia-jones-section-current-care-providers", "summary" : "Maggie Reed | Registered Nurse\nSara Anderson | OB/Gyn Physician\nTim Kane | Registered Nurse\nTraci Lee | Registered Nurse", "type" : "Current Care Providers" }, { "id" : "olivia-jones-section-relevant-history", "summary" : "Relevant Medical History (Last updated by Tim Kane, Registered Nurse on 9/25/2026 09:52) Help - What Relevant Medical History (Last updated by Tim Kane, Registered Nurse on 9/25/2026 09:52) means / Maternal History / Gravida: 1\nRelevant Medical History (Last updated by Tim Kane, Registered Nurse on 9/25/2026 09:52) Help - What Relevant Medical History (Last updated by Tim Kane, Registered Nurse on 9/25/2026 09:52) means / Maternal History / Number of Term Births: 0\nRelevant Medical History (Last updated by Tim Kane, Registered Nurse on 9/25/2026 09:52) Help - What Relevant Medical History (Last updated by Tim Kane, Registered Nurse on 9/25/2026 09:52) means / Maternal History / Number of Preterm Births: 0\nRelevant Medical History (Last updated by Tim Kane, Registered Nurse on 9/25/2026 09:52) Help - What Relevant Medical History (Last updated by Tim Kane, Registered Nurse on 9/25/2026 09:52) means / Maternal History / Number of Abortions: 0\nRelevant Medical History (Last updated by Tim Kane, Registered Nurse on 9/25/2026 09:52) Help - What Relevant Medical History (Last updated by Tim Kane, Registered Nurse on 9/25/2026 09:52) means / Maternal History / Number of Living Children: 0\nRelevant Medical History (Last updated by Tim Kane, Registered Nurse on 9/25/2026 09:52) Help - What Relevant Medical History (Last updated by Tim Kane, Registered Nurse on 9/25/2026 09:52) means / Maternal History / Hx of Abnormal Ultrasound: No\nSocial History (Last updated by Tim Kane, Registered Nurse on 9/25/2026 09:52) / Prenatal Care / Started Prenatal Care: 4/10/2026\nSocial History (Last updated by Tim Kane, Registered Nurse on 9/25/2026 09:52) / Prenatal Care / Prenatal Preparation: Pregnancy complicated with preeclampsia at 30 weeks; otherwise unremarkable. Father of baby is not involved.\nSocial History (Last updated by Tim Kane, Registered Nurse on 9/25/2026 09:52) / Alcohol Use / Alcohol Consumption During Pregnancy: No\nSocial History (Last updated by Tim Kane, Registered Nurse on 9/25/2026 09:52) / Drug Use / Illicit Drug Use During Pregnancy: No\nPregnancy-Induced Hypertension | | Active", "type" : "Relevant History" }, { "id" : "olivia-jones-section-risks-screenings", "summary" : "Blood Screening / Type: O+\nPrenatal Testing / Prenatal Testing Status: Sickle Cell Anemia\nRisks / Hepatitis B Screening: Negative\nRisks / HIV Status: Negative\nRisks / Syphilis Screening/VDRL (Venereal Disease Research Laboratory), Venereal Disease Research Laboratory: Negative\nRisks / Herpes/Warts Active Lesions: No\nRisks / Gonococcus Screening: Negative\nRisks / Chlamydia Screening: Negative\nRisks / Rubella Immunity: Immune\nRisks / Diabetes: No\nRisks / Genetic Concerns: none\nRisks / Pertinent Maternal Illness: Preeclampsia\nRisks / High Risk Pregnancy: Yes\nWarning Signs / Fetal Movement: Decreased\nWarning Signs / Vaginal Spotting, Bleeding, or Discharge: Present\nWarning Signs / Urination Sensation: Non-painful\nWarning Signs / Vomiting: Not present\nWarning Signs / Abdominal Pain: Absent\nWarning Signs / Contraction Occurrence: Absent\nWarning Signs / Calf Pain: Absent\nWarning Signs / Sudden Weight Gain: Absent\nWarning Signs / Edema: Yes\nWarning Signs / Location: Peripheral edema in extremities\nWarning Signs / Headache with Visual Changes: Present\nWarning Signs / History of Right Upper Quadrant Pain: Present", "type" : "Risks/Screenings" }, { "id" : "olivia-jones-section-contractions-dilation-effacement", "summary" : "Contraction Type | Irregular\nContraction Intensity | Mild\nContraction Frequency (min) | \nContraction Duration (sec) | \nResting Tone | \nBraxton Hicks Contractions | Present\nCervical Dilation (cm) | \nEffacement (%) | 0\nFetal Station | -3\nMembranes Ruptured | \nAmniotic Fluid | ", "type" : "Contractions/Dilation/Effacement" }, { "id" : "olivia-jones-section-intrapartum", "summary" : "Intrapartum Maternal Antibiotic Therapy / Other Medications Given\nRelevant Medical History Help - What Relevant Medical History means / Past Medical History last updated by Tim Kane, Registered Nurse on 9/25/2026 09:52\n24 hour Urine | x1 (1 time only), 1 time only | N/A | 24 hour urine for Total Protein and Creatinine Clearance\n24-hour urine for total protein and creatinine clearance | x1 (1 time only), 1 time only | N/A | N/A\nBedrest with bedside commode | cont. | N/A | N/A\nBedside ultrasound per OB Resident/Certified Nurse-Midwife. Indication: biophysical profile, amniotic fluid index | x1 (1 time only), 1 time only | N/A | N/A\nCall if: Non-reassuring fetal HR | cont. | N/A | N/A\nCall MD with Abnormal Vital Signs | cont. | N/A | Call MD if: SBP > 160 mm Hg or less than 90 mmHg DBP > 110 mm Hg Pulse > 100bpm or less than 50 bpm Oral Temp > 38 degrees Celcius SpO2 < 94%\nCall provider with significant changes including: rupture of membranes, vaginal bleeding, abdominal or epigastric pain. | cont. | N/A | N/A\nContinuous external monitoring (fetal HR and uterine activity) | cont. | N/A | N/A\nDeep Tendon Reflexes | q2h (Every 2 hours), Every 2 hours | N/A | DTR's every two hours while on Magnesium Sulfate\nDeep Tendon Reflexes - Patellar | q1h (Every 1 hour), Every 1 hour | N/A | N/A\ndiazepam (Links to clinical content from Lippincott’s Nursing Advisor), Links to clinical content from Lippincott’s Nursing Advisor | q2min (Every 2 minutes), Every 2 minutes | N/A | Diazepam 5mg every 2-3 minutes for convulsions\nFoley with urometer | cont. | N/A | Place foley after magnesium sulfate initiation or sooner if suspect decrease urine output.\nIncentive spirometry (Links to Lippincott’s Nursing Procedures and Skills), Links to Lippincott’s Nursing Procedures and Skills | x1 (1 time only), 1 time only | N/A | Incentive Spirometry if SpO2 less than 95%.\nInitiate IV Care Protocol as appropriate | x1 (1 time only), 1 time only | N/A | N/A\nInitiate/maintain seizure precautions: Minimize outside stimuli (light, noise, visitors) | cont. | N/A | N/A\nLabs for Preeclampsia | x1 (1 time only), 1 time only | N/A | CBC, Platelets, Uric Acid, AST, LDH BMP, CMP, Coag screen, Hepatic Function\nLactated Ringer's 500 mL IV bolus | x1 (1 time only), 1 time only | N/A | N/A\nLactated Ringers | cont. | 9/25/2026 10:12 | Adjust rate so total IV fluids not to exceed 125mL/hr\nMagnesium Call MD if: | x1 (1 time only), 1 time only | N/A | Call MD if: Systolic Pressure greater than or equal to 160mm Hg Diastolic Pressure greater than or equal to 110mm Hg RR less than 12 breaths/min or greater than 26 breaths/min Urine output less than 30mL/hr with Foley or less than 100mL/hour without foley Absent deep tendon reflexes\nmagnesium sulfate (Links to clinical content from Lippincott’s Nursing Advisor), Links to clinical content from Lippincott’s Nursing Advisor | x1 (1 time only), 1 time only | N/A | Administer 4 gram bolus over 20 minutes\nmagnesium sulfate (Links to clinical content from Lippincott’s Nursing Advisor), Links to clinical content from Lippincott’s Nursing Advisor | cont. | N/A | 20 gram in 500mL concentration to be used. Administer 2 gram per hour (50mL/hr) after 4 gram bolus completed.\nMagnesium sulfate administration, pregnant patient (Links to Lippincott’s Nursing Procedures and Skills), Links to Lippincott’s Nursing Procedures and Skills | x1 (1 time only), 1 time only | N/A | N/A\nMagnesium Sulfate Assessments | q1h (Every 1 hour), Every 1 hour | N/A | Assess for headache and visual changes every hour\nMagnesium Sulfate Assessments | q2h (Every 2 hours), Every 2 hours | N/A | Assess for nausea, vomitting, epigastric pain, upper right quadrant pain every 2 hours\nMagnesium Vital Sign Assessments | cont. | N/A | Temperature every 4 hours Pulse every 15 min during magnesium bolus, then every hour BP every 15 minutes during magnesium bolus, then every hour Resp Rate every 15 minutest during magnesium bolus, then every hour\nNeonatology | x1 (1 time only), 1 time only | N/A | Inform of patient's condition and potential needs if delivery\nNo vaginal exams | cont. | N/A | N/A\nNPO | x1 (1 time only), 1 time only | N/A | N/A\nObtain baseline maternal weight, then daily weights | q24h (Every 24 hours), Every 24 hours | N/A | N/A\nOxygen 10 L/min per rebreather mask for non-reassuring (Category II or III) fetal heart rate: May discontinue oxygen when fetal heart returns to reassuring (Category I) | cont. | N/A | N/A\nPlatelets, Coagulation screen, Comprehensive metabolic panel, Hepatic function panel, ;;SGOT (AST) (liver function test), Uric acid, Fetal fibronectin (fFN), UA on admit for protein and specific gravity | x1 (1 time only), 1 time only | N/A | N/A\nPulse oximetry (Links to Lippincott’s Nursing Procedures and Skills), Links to Lippincott’s Nursing Procedures and Skills | cont. | N/A | N/A\nRespiratory Status for Magnesium Infusion | q2h (Every 2 hours), Every 2 hours | N/A | Assess respiratory status for cough, SOB, and breath sounds every 2 hours\nSocial Services: resource availability | cont. | N/A | N/A\nStrict I&O every shift | cont. | N/A | N/A\nSystem Assessment & Breath Sounds | q4h (Every 4 hours), Every 4 hours | N/A | N/A\nTemp Q 2 hours after rupture of membranes intrapartum or if temp greater than 38° C (100.4° F) orally | cont. | N/A | N/A\nVS: BP Q1 hour x2 then Q4 hours; Temp, HR, RR, Q1 hour, Continuous pulse oximetry | cont. | N/A | N/A\nPregnancy-Induced Hypertension | | Active", "type" : "Intrapartum" }, { "id" : "olivia-jones-section-labor-vital-signs", "summary" : "Maternal Position | Supine\nCervical Dilation (cm) | \nEffacement (%) | 0\nFetal Station | \nMonitor Type | External\nContraction Type | Irregular\nContraction Frequency (min) | \nContraction Duration (sec) | \nContraction Intensity | Mild\nResting Tone | \nContraction Intensity (IUPC) | \nMVU (IUPC) | \nResting Tone (IUPC) | \nMonitor Type | \nFetal Heart Rate (bpm) | 135\nBaseline Rate | Regular\nVariability | Moderate = 6–25 BPM\nAccelerations Presence | Present\nAccelerations Details | Periodic\nDecelerations Presence | Absent\nDecelerations Details | \nInterventions | \nOther Interventions | ", "type" : "Labor Vital Signs" }, { "id" : "olivia-jones-section-delivery", "summary" : "Maternal / Post Birth Maternity History / Gravida: 1\nMaternal / Post Birth Maternity History / Number of Term Births: 0\nMaternal / Post Birth Maternity History / Number of Preterm Birth: 0\nMaternal / Post Birth Maternity History / Number of Abortions: 0\nMaternal / Post Birth Maternity History / Number of Living Children: 0", "type" : "Delivery" }, { "id" : "olivia-jones-clarification-12", "summary" : "Source repeats 5 mg IV every 2–3 minutes for convulsions without maximum cumulative dose or escalation/monitoring details; clarify rescue-seizure protocol. Do not extrapolate indefinite repeats.", "type" : "Chart clarification" }, { "id" : "olivia-jones-clarification-13", "summary" : "Home labetalol frequency conflicts: admission HPI says 200 mg twice daily, nursing note says 200 mg daily. No new active home order inferred. Separate 500 mL LR bolus requires reconciliation with total-fluid restriction and respiratory findings.", "type" : "Chart clarification" } ], "orders" : [ { "author" : "Sara Anderson, OB/Gyn Physician", "category" : "Not specified", "dateTime" : "2026-09-25T10:52:00", "id" : "olivia-jones-order-1", "orderText" : "Bedside ultrasound per OB Resident/Certified Nurse-Midwife. Indication: biophysical profile, amniotic fluid index; x1 (1 time only), 1 time only; Routine; Source due: 9/25/2026 10:52", "status" : "Active" }, { "author" : "Sara Anderson, OB/Gyn Physician", "category" : "Consult", "dateTime" : "2026-09-25T10:52:00", "id" : "olivia-jones-order-2", "orderText" : "Neonatology; x1 (1 time only), 1 time only; Routine; Inform of patient's condition and potential needs if delivery Source due: 9/25/2026 10:52", "status" : "Active" }, { "author" : "Sara Anderson, OB/Gyn Physician", "category" : "Consult", "dateTime" : "2026-09-25T10:52:00", "id" : "olivia-jones-order-3", "orderText" : "Social Services: resource availability; cont.; Routine; Source due: 9/25/2026 10:52", "status" : "Active" }, { "author" : "Sara Anderson, OB/Gyn Physician", "category" : "Dietary", "dateTime" : "2026-09-25T10:52:00", "id" : "olivia-jones-order-4", "orderText" : "NPO; x1 (1 time only), 1 time only; Routine; Source due: 9/25/2026 10:52", "status" : "Active" }, { "author" : "Sara Anderson, OB/Gyn Physician", "category" : "Laboratory", "dateTime" : "2026-09-25T10:52:00", "id" : "olivia-jones-order-5", "orderText" : "Platelets, Coagulation screen, Comprehensive metabolic panel, Hepatic function panel, ;;SGOT (AST) (liver function test), Uric acid, Fetal fibronectin (fFN), UA on admit for protein and specific gravity; x1 (1 time only), 1 time only; Stat; Source due: 9/25/2026 10:52", "status" : "Active" }, { "author" : "Sara Anderson, OB/Gyn Physician", "category" : "Laboratory", "dateTime" : "2026-09-25T09:52:00", "id" : "olivia-jones-order-6", "orderText" : "Labs for Preeclampsia; x1 (1 time only), 1 time only; Stat; CBC, Platelets, Uric Acid, AST, LDH BMP, CMP, Coag screen, Hepatic Function Source due: 9/25/2026 09:52", "status" : "Active" }, { "author" : "Sara Anderson, OB/Gyn Physician", "category" : "Laboratory", "dateTime" : "2026-09-25T09:52:00", "id" : "olivia-jones-order-7", "orderText" : "Labs for Preeclampsia; x1 (1 time only), 1 time only; Stat; CBC, Platelets, Uric Acid, AST, LDH BMP, CMP, Coag screen, Hepatic Function Source due: 9/25/2026 09:52", "status" : "Active" }, { "author" : "Sara Anderson, OB/Gyn Physician", "category" : "Laboratory", "dateTime" : "2026-09-25T09:52:00", "id" : "olivia-jones-order-8", "orderText" : "24 hour Urine; x1 (1 time only), 1 time only; Routine; 24 hour urine for Total Protein and Creatinine Clearance Source due: 9/25/2026 09:52", "status" : "Active" }, { "author" : "Sara Anderson, OB/Gyn Physician", "category" : "Nursing: Activity", "dateTime" : "2026-09-25T10:52:00", "id" : "olivia-jones-order-9", "orderText" : "Bedrest with bedside commode; cont.; Routine; Source due: 9/25/2026 10:52", "status" : "Active" }, { "author" : "Sara Anderson, OB/Gyn Physician", "category" : "Nursing: Activity", "dateTime" : "2026-09-25T10:52:00", "id" : "olivia-jones-order-10", "orderText" : "Initiate/maintain seizure precautions: Minimize outside stimuli (light, noise, visitors); cont.; Routine; Source due: 9/25/2026 10:52", "status" : "Active" }, { "author" : "Sara Anderson, OB/Gyn Physician", "category" : "Nursing: Activity", "dateTime" : "2026-09-25T09:52:00", "id" : "olivia-jones-order-11", "orderText" : "Deep Tendon Reflexes - Patellar; q1h (Every 1 hour), Every 1 hour; Routine; Source due: 9/25/2026 09:52", "status" : "Active" }, { "author" : "Sara Anderson, OB/Gyn Physician", "category" : "Nursing: Activity", "dateTime" : "2026-09-25T09:52:00", "id" : "olivia-jones-order-12", "orderText" : "Incentive spirometry; x1 (1 time only), 1 time only; Routine; Incentive Spirometry if SpO2 less than 95%. Source due: 9/25/2026 09:52", "status" : "Active" }, { "author" : "Sara Anderson, OB/Gyn Physician", "category" : "Nursing: Monitoring", "dateTime" : "2026-09-25T10:52:00", "id" : "olivia-jones-order-13", "orderText" : "Call MD with Abnormal Vital Signs; cont.; Routine; Call MD if: SBP > 160 mm Hg or less than 90 mmHg DBP > 110 mm Hg Pulse > 100bpm or less than 50 bpm Oral Temp > 38 degrees Celcius SpO2 < 94% Source due: 9/25/2026 10:52", "status" : "Active" }, { "author" : "Sara Anderson, OB/Gyn Physician", "category" : "Nursing: Monitoring", "dateTime" : "2026-09-25T10:52:00", "id" : "olivia-jones-order-14", "orderText" : "Call if: Non-reassuring fetal HR; cont.; Routine; Source due: 9/25/2026 10:52", "status" : "Active" }, { "author" : "Sara Anderson, OB/Gyn Physician", "category" : "Nursing: Monitoring", "dateTime" : "2026-09-25T10:52:00", "id" : "olivia-jones-order-15", "orderText" : "Call provider with significant changes including: rupture of membranes, vaginal bleeding, abdominal or epigastric pain.; cont.; Routine; Source due: 9/25/2026 10:52", "status" : "Active" }, { "author" : "Sara Anderson, OB/Gyn Physician", "category" : "Nursing: Monitoring", "dateTime" : "2026-09-25T10:52:00", "id" : "olivia-jones-order-16", "orderText" : "VS: BP Q1 hour x2 then Q4 hours; Temp, HR, RR, Q1 hour, Continuous pulse oximetry; cont.; Routine; Source due: 9/25/2026 10:52", "status" : "Active" }, { "author" : "Sara Anderson, OB/Gyn Physician", "category" : "Nursing: Monitoring", "dateTime" : "2026-09-25T10:52:00", "id" : "olivia-jones-order-17", "orderText" : "Temp Q 2 hours after rupture of membranes intrapartum or if temp greater than 38° C (100.4° F) orally; cont.; Routine; Source due: 9/25/2026 10:52", "status" : "Active" }, { "author" : "Sara Anderson, OB/Gyn Physician", "category" : "Nursing: Monitoring", "dateTime" : "2026-09-25T10:52:00", "id" : "olivia-jones-order-18", "orderText" : "System Assessment & Breath Sounds; q4h (Every 4 hours), Every 4 hours; Routine; Source due: 9/25/2026 10:52", "status" : "Active" }, { "author" : "Sara Anderson, OB/Gyn Physician", "category" : "Nursing: Monitoring", "dateTime" : "2026-09-25T10:52:00", "id" : "olivia-jones-order-19", "orderText" : "Continuous external monitoring (fetal HR and uterine activity); cont.; Routine; Source due: 9/25/2026 10:52", "status" : "Active" }, { "author" : "Sara Anderson, OB/Gyn Physician", "category" : "Nursing: Monitoring", "dateTime" : "2026-09-25T10:52:00", "id" : "olivia-jones-order-20", "orderText" : "Obtain baseline maternal weight, then daily weights; q24h (Every 24 hours), Every 24 hours; Routine; Source due: 9/25/2026 10:52", "status" : "Active" }, { "author" : "Sara Anderson, OB/Gyn Physician", "category" : "Nursing: Monitoring", "dateTime" : "2026-09-25T10:52:00", "id" : "olivia-jones-order-21", "orderText" : "Strict I&O every shift; cont.; Routine; Source due: 9/25/2026 10:52", "status" : "Active" }, { "author" : "Sara Anderson, OB/Gyn Physician", "category" : "Nursing: Monitoring", "dateTime" : "2026-09-25T09:52:00", "id" : "olivia-jones-order-22", "orderText" : "Pulse oximetry; cont.; Routine; Source due: 9/25/2026 09:52", "status" : "Active" }, { "author" : "Sara Anderson, OB/Gyn Physician", "category" : "Nursing: Monitoring", "dateTime" : "2026-09-25T09:52:00", "id" : "olivia-jones-order-23", "orderText" : "Initiate IV Care Protocol as appropriate; x1 (1 time only), 1 time only; Routine; Source due: 9/25/2026 09:52", "status" : "Active" }, { "author" : "Sara Anderson, OB/Gyn Physician", "category" : "Nursing: Monitoring", "dateTime" : "2026-09-25T09:52:00", "id" : "olivia-jones-order-24", "orderText" : "Respiratory Status for Magnesium Infusion; q2h (Every 2 hours), Every 2 hours; Routine; Assess respiratory status for cough, SOB, and breath sounds every 2 hours Source due: 9/25/2026 09:52", "status" : "Active" }, { "author" : "Sara Anderson, OB/Gyn Physician", "category" : "Nursing: Monitoring", "dateTime" : "2026-09-25T09:52:00", "id" : "olivia-jones-order-25", "orderText" : "Deep Tendon Reflexes; q2h (Every 2 hours), Every 2 hours; Routine; DTR's every two hours while on Magnesium Sulfate Source due: 9/25/2026 09:52", "status" : "Active" }, { "author" : "Sara Anderson, OB/Gyn Physician", "category" : "Nursing: Monitoring", "dateTime" : "2026-09-25T09:52:00", "id" : "olivia-jones-order-26", "orderText" : "Magnesium Sulfate Assessments; q1h (Every 1 hour), Every 1 hour; Routine; Assess for headache and visual changes every hour Source due: 9/25/2026 09:52", "status" : "Active" }, { "author" : "Sara Anderson, OB/Gyn Physician", "category" : "Nursing: Monitoring", "dateTime" : "2026-09-25T09:52:00", "id" : "olivia-jones-order-27", "orderText" : "Magnesium sulfate administration, pregnant patient; x1 (1 time only), 1 time only; Routine; Source due: 9/25/2026 09:52", "status" : "Active" }, { "author" : "Sara Anderson, OB/Gyn Physician", "category" : "Nursing: Monitoring", "dateTime" : "2026-09-25T09:52:00", "id" : "olivia-jones-order-28", "orderText" : "Magnesium Sulfate Assessments; q2h (Every 2 hours), Every 2 hours; Routine; Assess for nausea, vomitting, epigastric pain, upper right quadrant pain every 2 hours Source due: 9/25/2026 09:52", "status" : "Active" }, { "author" : "Sara Anderson, OB/Gyn Physician", "category" : "Nursing: Monitoring", "dateTime" : "2026-09-25T09:52:00", "id" : "olivia-jones-order-29", "orderText" : "Magnesium Vital Sign Assessments; cont.; Routine; Temperature every 4 hours Pulse every 15 min during magnesium bolus, then every hour BP every 15 minutes during magnesium bolus, then every hour Resp Rate every 15 minutest during magnesium bolus, then every hour Source due: 9/25/2026 09:52", "status" : "Active" }, { "author" : "Sara Anderson, OB/Gyn Physician", "category" : "Nursing: Monitoring", "dateTime" : "2026-09-25T09:52:00", "id" : "olivia-jones-order-30", "orderText" : "Magnesium Call MD if:; x1 (1 time only), 1 time only; Routine; Call MD if: Systolic Pressure greater than or equal to 160mm Hg Diastolic Pressure greater than or equal to 110mm Hg RR less than 12 breaths/min or greater than 26 breaths/min Urine output less than 30mL/hr with Foley or less than 100mL/hour without foley Absent deep tendon reflexes Source due: 9/25/2026 09:52", "status" : "Active" }, { "author" : "Sara Anderson, OB/Gyn Physician", "category" : "Nursing: Procedure", "dateTime" : "2026-09-25T10:52:00", "id" : "olivia-jones-order-31", "orderText" : "No vaginal exams; cont.; Routine; Source due: 9/25/2026 10:52", "status" : "Active" }, { "author" : "Sara Anderson, OB/Gyn Physician", "category" : "Nursing: Procedure", "dateTime" : "2026-09-25T10:52:00", "id" : "olivia-jones-order-32", "orderText" : "Foley with urometer; cont.; Routine; Place foley after magnesium sulfate initiation or sooner if suspect decrease urine output. Source due: 9/25/2026 10:52", "status" : "Active" }, { "author" : "Sara Anderson, OB/Gyn Physician", "category" : "Nursing: Procedure", "dateTime" : "2026-09-25T10:52:00", "id" : "olivia-jones-order-33", "orderText" : "24-hour urine for total protein and creatinine clearance; x1 (1 time only), 1 time only; Routine; Source due: 9/25/2026 10:52", "status" : "Active" }, { "author" : "Sara Anderson, OB/Gyn Physician", "category" : "Nursing: Procedure", "dateTime" : "2026-09-25T10:52:00", "id" : "olivia-jones-order-34", "orderText" : "Oxygen 10 L/min per rebreather mask for non-reassuring (Category II or III) fetal heart rate: May discontinue oxygen when fetal heart returns to reassuring (Category I); cont.; Routine; Source due: 9/25/2026 10:52", "status" : "Active" }, { "author" : "Sara Anderson, OB/Gyn Physician", "category" : "Pharmacy", "dateTime" : "2026-09-25T10:52:00", "id" : "olivia-jones-order-35", "orderText" : "Lactated Ringer's 500 mL IV bolus; 500mL Intravenous Piggyback (IVPB); x1 (1 time only), 1 time only; Scheduled; Source due: 9/25/2026 10:52", "status" : "Active" }, { "author" : "Sara Anderson, OB/Gyn Physician", "category" : "Pharmacy", "dateTime" : "2026-09-25T09:52:00", "id" : "olivia-jones-order-36", "orderText" : "magnesium sulfate; 4 gram Intravenous Piggyback (IVPB); x1 (1 time only), 1 time only; Scheduled, Stat; Administer 4 gram bolus over 20 minutes Source due: 9/25/2026 09:52", "status" : "Active" }, { "author" : "Sara Anderson, OB/Gyn Physician", "category" : "Pharmacy", "dateTime" : "2026-09-25T09:52:00", "id" : "olivia-jones-order-37", "orderText" : "diazepam; 5mg Intravenous (IV); q2min (Every 2 minutes), Every 2 minutes; PRN; Diazepam 5mg every 2-3 minutes for convulsions Source due: PRN Source repeats 5 mg IV every 2–3 minutes for convulsions without maximum cumulative dose or escalation/monitoring details; clarify rescue-seizure protocol. Do not extrapolate indefinite repeats.", "status" : "Held — clarification required" }, { "author" : "Sara Anderson, OB/Gyn Physician", "category" : "Pharmacy", "dateTime" : "2026-09-25T09:52:00", "id" : "olivia-jones-order-38", "orderText" : "magnesium sulfate; 50 ml per hr Intravenous Piggyback (IVPB); cont.; Cont. Infusion, Stat; 20 gram in 500mL concentration to be used. Administer 2 gram per hour (50mL/hr) after 4 gram bolus completed. Source due: 9/25/2026 09:52", "status" : "Active" }, { "author" : "Sara Anderson, OB/Gyn Physician", "category" : "Pharmacy", "dateTime" : "2026-09-25T09:52:00", "id" : "olivia-jones-order-39", "orderText" : "Lactated Ringers IV: adjust maintenance rate so total IV fluids do not exceed 125 mL/hr. Magnesium infusion contributes 50 mL/hr. Reconcile other infusions and separate bolus order.", "status" : "Active" } ], "overview" : { "height" : "66 in / 167.6 cm", "isolationIndicator" : "Standard", "religion" : "Baptist", "weightKg" : 110.2 }, "vitals" : [ { "bloodPressure" : "162/98", "dateTime" : "2026-09-25T09:52:00", "heartRate" : 98, "id" : "olivia-jones-vital-1", "oxygenDevice" : "Room Air", "respiratoryRate" : 18, "spo2" : "98", "temperature" : "98.2 °F (37 °C), 37 °C Oral" } ] }, "patient" : { "admitDateTime" : "2026-09-25T09:52:00", "admittingDiagnosis" : "Preeclampsia with severe features at 36 weeks gestation", "allergies" : [ ], "attending" : "Sara Anderson, OB/Gyn Physician", "chartDisplayName" : "Jones, Olivia", "codeStatus" : "Full Code", "dob" : "7/6/XX", "history" : { "chiefComplaint" : "Olivia Jones is a 23-year-old African-American female, G1P0 at 36 weeks of gestation. She has been admitted to the labor and delivery unit for assessment and surveillance due to worsening of symptoms. Denies history of diabetes, collagen disease, including Systemic Lupus Erythematosus; denies renal disease or history of hypertensive disease until development of preeclampsia at 30 weeks gestation. Pregnancy has been unremarkable until routine prenatal visit at 30 weeks with elevated blood pressure at 146/92 mm Hg, proteinuria, and developing mild preeclampsia. She has been on bedrest at home until prenatal visit today with increasing symptoms, resulting in admission. At home she has been taking labetalol 200 mg tablets twice a day, last dose this morning at 0900 h. She has gained 3 pounds since prenatal visit one week ago. Protein dip stick is +4, negative ketones, negative glucose, +2 dependent edema, and facial puffiness. Ms. Jones is complaining of a headache that is not resolved with acetaminophen. She presents with nausea and fatigue and complaining of epigastric pain, visual changes, and chest tightness. The fetus is active; however, patient states that it is a bit quieter than normal. There is a possibility of premature rupture of membranes. Will complete Amnisure testing and/or fern and nitrazine as needed to rule out PROM. Plan for IV fluids, labs, and possible magnesium sulfate administration.", "pastMedicalHistory" : [ "Maternal History / Gravida: 1", "Maternal History / Number of Term Births: 0", "Maternal History / Number of Preterm Births: 0", "Maternal History / Number of Abortions: 0", "Maternal History / Number of Living Children: 0", "Maternal History / Hx of Abnormal Ultrasound: No", "General Medical History: Denies prior medical problems", "General Medical History / Notes: Unremarkable medical history. Nonsmoker. Sedentary lifestyle. Denies history of diabetes, collagen disease, including Systemic Lupus Erythematosus; denies renal disease or history of hypertensive disease until development of preeclampsia at 30 weeks gestation. Currently on 200mg Labatolol for preeclampsia.", "Obstetric Medical History / Disease/Condition / Disease/Condition: Pregnancy-Induced Hypertension", "Obstetric Medical History / Active: Active", "Transfusion History / Previous Blood Transfusion?: No", "Transfusion History / Does Patient Know His/Her Blood Type?: Yes", "Transfusion History / Blood Type: O+", "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: No" ], "pastSurgicalHistory" : [ "Previous Surgical Procedures: No prior surgical history" ], "socialHistory" : [ "Age: 23 years", "Home Situation / Patient Living Situation: Home", "Home Situation / Lives With: Other", "Home Situation / Lives With, Other value: Mother", "Education / Highest Grade Completed: High School", "Education / Able to Read?: Yes", "Education / Able to Write?: Yes", "Prenatal Care / Started Prenatal Care Days: 168", "Prenatal Care / Started Prenatal Care Relative To Timing Based On: before student launches assignment", "Prenatal Care / Prenatal Preparation: Pregnancy complicated with preeclampsia at 30 weeks; otherwise unremarkable. Father of baby is not involved.", "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 Consumption During Pregnancy: No", "Alcohol Use / Has Patient Ever Been Diagnosed With or Treated for Alcohol Abuse?: No", "Drug Use / Illicit Drug Use During Pregnancy: No", "Drug Use / Has Patient Ever Been Diagnosed With or Treated for Drug Abuse?: No", "Drug Use / Drug Screening: Negative", "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: Every 2-3 days", "Nutritional Screening / Stool Description: Formed", "Nutritional Screening / Last Bowel Movement Days: 2", "Nutritional Screening / Last Bowel Movement Relative To Timing Based On: before student launches assignment", "Nutritional Screening / Notes: Patient is obese", "Exercise Screening / Exercise Frequency: Rarely", "Exercise Screening / Was Patient Counseled on Exercise?: No", "Mental Health Screening / Does Patient Have Frequent Feelings of Hopelessness/Helplessness?: No", "Mental Health Screening / Does Patient Have Thoughts of Harming Self?: No", "Sexual Activity / Sexually Active?: No", "Sexual Activity / Ever Treated for a Sexually Transmitted Disease?: No", "Other Safety Measures / Seatbelt Use?: Sometimes", "Other Safety Measures / Bicycle/ATV/Motorcycle Helmet Use?: Rarely", "Other Safety Measures / Sun Protection?: Rarely", "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" : "784954", "sex" : "Female", "simulatedFullName" : "Olivia Jones", "unit" : "City Medical Center" }, "setting" : "City Medical Center", "snapshots" : [ { "activityIds" : [ ], "id" : "olivia-jones-current", "notes" : "Captured dated chart history; source relative dates anchored to chart opening. Progressive release not recreated.", "scenarioTime" : "2026-09-25T11:52:00", "sourcePath" : "DocuCare instructor chart: Olivia Jones", "title" : "Captured chart" } ], "subtitle" : "N12 practice record", "tags" : [ "N12", "DocuCare migration" ], "title" : "Olivia Jones" }, "packageId" : "docucare-n12-olivia-jones-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" : "n12-olivia-jones", "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" : "Olivia Jones" } ], "format" : "org.chartslate.case-collection", "id" : "docucare-n12-course-review-v1", "summary" : "Five N12 simulated patient charts in one download. Choose a patient after importing the bundle. Records are available offline after import.", "title" : "N12", "version" : 1 }