{ "audience" : "student", "createdAt" : "2026-09-22T21:10:40Z", "entries" : [ { "envelope" : { "appName" : "ChartSlate", "audience" : "student", "createdAt" : "2026-09-22T19:04:02.769031+00:00", "exportVersion" : "1", "kind" : "casePackage", "package" : { "case" : { "activities" : [ ], "id" : "docucare-n21-andrew-davis", "learningLevel" : "N21", "panels" : { "assessments" : [ { "author" : "Petra Popovich, Registered Nurse", "dateTime" : "2022-10-05T21:00:00", "id" : "ad-assessment-1", "label" : "Neurological", "summary" : "Quick orientation: Person, Time, Place, Situation. Both-eye reaction: Round, Brisk, Accommodation. Behavioral/emotional: Cooperative. GCS 15: Eye opening Spontaneously; Motor response Obeys Verbal Command; Verbal response Oriented X 3. Additional neurological tabs not yet captured." }, { "author" : "Petra Popovich, Registered Nurse", "dateTime" : "2022-10-05T21:00:00", "id" : "ad-assessment-2", "label" : "Cardiac", "summary" : "Heart tones: S1, S2. Pulses: +2 in All. Edema: Absent. Capillary refill: <3 sec in All. Skin: Appropriate for ethnicity, Warm, Dry." }, { "author" : "Petra Popovich, Registered Nurse", "dateTime" : "2022-10-05T21:00:00", "id" : "ad-assessment-3", "label" : "Gastrointestinal", "summary" : "Abdominal description: Non-tender. GI symptoms: None. Bowel sounds: Present. Other blank fields have not been converted to normal findings." }, { "author" : "Petra Popovich, Registered Nurse", "dateTime" : "2022-10-05T21:00:00", "id" : "ad-assessment-4", "label" : "Genitourinary", "summary" : "Urinary symptoms: None. Other unfilled selections have not been converted to normal findings." }, { "author" : "Petra Popovich, Registered Nurse", "dateTime" : "2022-10-05T21:00:00", "id" : "ad-assessment-5", "label" : "Respiratory", "summary" : "Sputum color: None. Sputum amount: None. Breath sounds: Clear in RUL, RML, RLL, LUL, and LLL. Respirations: Regular. Respiratory therapy tabs (ABG, Aerosol Therapy, Airway Clearance, Lung Expansion, Mechanical Ventilation, Noninvasive Ventilation, Percussion, Pt. Education) contain no populated findings." }, { "author" : "Petra Popovich, Registered Nurse", "dateTime" : "2022-10-05T21:00:00", "id" : "ad-assessment-6", "label" : "Mental Health — CIWA-Ar", "summary" : "CIWA-Ar score = 1 Nausea/Vomitting: 0 Tremors: 0 Paroxysmal Sweats: 0 Anxiety: 1 Agitation: 0 Tactile Disturbances: 0 Auditory Disturbances: 0 VIsual Disturbances: 0 Headache, Fullness in Head: 0 Orientation: 0" }, { "author" : "Petra Popovich, Registered Nurse", "dateTime" : "2022-10-06T01:00:00", "id" : "ad-assessment-7", "label" : "Mental Health — CIWA-Ar", "summary" : "CIWA-Ar Score 3 Nausea/Vomitting: 0 Tremors: 1 Paroxysmal Sweats: 0 Anxiety: 1 Agitation: 0 Tactile Disturbances: 0 Auditory Disturbances: 0 VIsual Disturbances: 0 Headache, Fullness in Head: 1 Orientation: 0" }, { "author" : "Petra Popovich, Registered Nurse", "dateTime" : "2022-10-06T05:00:00", "id" : "ad-assessment-8", "label" : "Mental Health — CIWA-Ar", "summary" : "CIWA-Ar Score 5 Nausea/Vomitting: 0 Tremors: 1 Paroxysmal Sweats: 0 Anxiety: 1 Agitation: 1 Tactile Disturbances: 0 Auditory Disturbances: 0 VIsual Disturbances: 0 Headache, Fullness in Head: 2 Orientation: 0" }, { "author" : "Petra Popovich, Registered Nurse", "dateTime" : "2022-10-06T09:00:00", "id" : "ad-assessment-9", "label" : "Mental Health — CIWA-Ar", "summary" : "Clinical Institue Withdrawal Assessment (CIWA-AR) = 9 Nausea/Vomitting: 1 Tremors: 1 Paroxysmal Sweats: 0 Anxiety: 2 Agitation: 2 Tactile Disturbances: 0 Auditory Disturbances: 0 VIsual Disturbances: 0 Headache, Fullness in Head: 3 Orientation: 0" }, { "author" : "Petra Popovich, Registered Nurse", "dateTime" : "2022-10-05T21:00:00", "id" : "ad-assessment-10", "label" : "Musculoskeletal", "summary" : "Musculoskeletal symptoms: None. Other unfilled selections have not been converted to normal findings." }, { "author" : "Petra Popovich, Registered Nurse", "dateTime" : "2022-10-05T21:00:00", "id" : "ad-assessment-11", "label" : "Pain Scale", "summary" : "Pain location: none. Pain rating: 0 - No Pain. Pain scale name not documented." }, { "author" : "Petra Popovich, Registered Nurse", "dateTime" : "2022-10-05T21:00:00", "id" : "ad-assessment-12", "label" : "Clean/Dry/Intact Skin Assessment", "summary" : "I have assessed this patient’s integumentary system and his/her skin is clean, dry, and intact." } ], "labs" : [ { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2022-10-05T23:00:00", "flag" : "Normal", "id" : "ad-lab-1", "referenceRange" : "135-145 mEq/L", "result" : "138", "test" : "Sodium (mEq/L)" }, { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2022-10-05T23:00:00", "flag" : "Normal", "id" : "ad-lab-2", "referenceRange" : "3.5-5.0 mEq/L", "result" : "3.5", "test" : "Potassium (mEq/L)" }, { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2022-10-05T23:00:00", "flag" : "Normal", "id" : "ad-lab-3", "referenceRange" : "100 - 108 mEq/L", "result" : "100", "test" : "Chloride (mEq/L)" }, { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2022-10-05T23:00:00", "flag" : "Normal", "id" : "ad-lab-4", "referenceRange" : "70-110 mg/dL", "result" : "88", "test" : "Glucose (mg/dL)" }, { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2022-10-05T23:00:00", "flag" : "Normal", "id" : "ad-lab-5", "referenceRange" : "8 - 20 mg/dL", "result" : "20", "test" : "Blood Urea Nitrogen (mg/dL)" }, { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2022-10-05T23:00:00", "flag" : "Normal", "id" : "ad-lab-6", "referenceRange" : "0.6 - 1.2", "result" : "0.8", "test" : "Creatinine (mg/dL)" }, { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2022-10-05T23:00:00", "flag" : "Normal", "id" : "ad-lab-7", "referenceRange" : "8.5 - 10.5 mg/dL", "result" : "10", "test" : "Calcium (mg/dL)" }, { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2022-10-05T23:00:00", "flag" : "Normal", "id" : "ad-lab-8", "referenceRange" : "6.0 - 8.3 g/dL", "result" : "6.8", "test" : "Total Protein (gm/dL)" }, { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2022-10-05T23:00:00", "flag" : "Low", "id" : "ad-lab-9", "referenceRange" : "3.4-5.4 g/dL", "result" : "3.1 g/dL", "test" : "Albumin (gm/dL)" }, { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2022-10-05T23:00:00", "flag" : "High", "id" : "ad-lab-10", "referenceRange" : "0.3-1.0 mg/dL", "result" : "1.1", "test" : "Total Bilirubin (mg/dL)" }, { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2022-10-05T23:00:00", "flag" : "High", "id" : "ad-lab-11", "referenceRange" : "14-20 U/L", "result" : "44 U/L", "test" : "AST (U/L)" }, { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2022-10-05T23:00:00", "flag" : "High", "id" : "ad-lab-12", "referenceRange" : "25-100 U/L", "result" : "125 units/L", "test" : "Alkaline Phosphate (U/L)" }, { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2022-10-05T23:00:00", "flag" : "Normal", "id" : "ad-lab-13", "referenceRange" : "10-40 U/L", "result" : "40", "test" : "ALT (U/L)" }, { "category" : "Complete Metabolic Panel", "collectedDateTime" : "2022-10-05T23:00:00", "flag" : "Normal", "id" : "ad-lab-14", "referenceRange" : "19-25", "result" : "22", "test" : "HCO3" }, { "category" : "Ethanol Level", "collectedDateTime" : "2022-10-05T23:00:00", "flag" : "High", "id" : "ad-lab-15", "referenceRange" : "<10mg/dL", "result" : "50 mg/dL", "test" : "Ethanol" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2022-10-05T23:00:00", "flag" : "Normal", "id" : "ad-lab-16", "referenceRange" : "4.5 - 10.5 X 109", "result" : "8", "test" : "WBC (10 x 3/uL)" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2022-10-05T23:00:00", "flag" : "Normal", "id" : "ad-lab-17", "referenceRange" : "14 -17 g/dL", "result" : "14", "test" : "Hbg" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2022-10-05T23:00:00", "flag" : "Normal", "id" : "ad-lab-18", "referenceRange" : "42 - 52%", "result" : "42", "test" : "HCT" }, { "category" : "Complete Blood Count without differential", "collectedDateTime" : "2022-10-05T23:00:00", "flag" : "Normal", "id" : "ad-lab-19", "referenceRange" : "150 - 400 X 109", "result" : "243", "test" : "PLT" }, { "category" : "Magnesium Level", "collectedDateTime" : "2022-10-05T23:00:00", "flag" : "Normal", "id" : "ad-lab-20", "referenceRange" : "1.8 - 2.6 mg/dL", "result" : "1.8", "test" : "Magnesium" }, { "category" : "Vitamin B12 level", "collectedDateTime" : "2022-10-05T23:00:00", "flag" : "Normal", "id" : "ad-lab-21", "referenceRange" : "280-1500 pg/mL", "result" : "321", "test" : "Vitamin B12" }, { "category" : "Folate Level", "collectedDateTime" : "2022-10-05T23:00:00", "flag" : "Normal", "id" : "ad-lab-22", "referenceRange" : "6.8-29.5 ng/mL", "result" : "16", "test" : "Folate level" }, { "category" : "Phosphate", "collectedDateTime" : "2022-10-05T23:00:00", "flag" : "Normal", "id" : "ad-lab-23", "referenceRange" : "2.7-4.5 mg/dL", "result" : "3.1", "test" : "Phosphate" }, { "category" : "Urine Toxicology", "collectedDateTime" : "2022-10-05T23:00:00", "flag" : "Normal", "id" : "ad-lab-24", "result" : "neg", "test" : "Urine Toxicology" } ], "medications" : [ { "administrationBy" : "Petra Popovich, Registered Nurse", "doseRouteFrequency" : "100 mg Oral (PO); q24h; Scheduled", "drug" : "Thiamine", "id" : "ad-med-1", "lastGiven" : "2022-10-05T23:00:00", "nextDue" : "2022-10-06T23:00:00", "notes" : "Start Date/Time: 10/05/2022 at 21:00. Stop Date/Time: 10/19/2022 at 21:00. Administration history: 10/5/2022 23:00; administered by Petra Popovich, Registered Nurse; Administered: Yes; notes blank. Scheduled daily at 23:00.", "orderedBy" : "C. Walsh, Admitting Physician", "orderedDateTime" : "2022-10-05T21:00:00", "section" : "Scheduled", "status" : "Active" }, { "administrationBy" : "Petra Popovich, Registered Nurse", "doseRouteFrequency" : "1 Oral (PO); q24h; Scheduled", "drug" : "Multivitamin with minerals", "id" : "ad-med-2", "lastGiven" : "2022-10-05T23:00:00", "nextDue" : "2022-10-06T23:00:00", "notes" : "Start Date/Time: 10/05/2022 at 21:00. Stop Date/Time: 10/19/2022 at 21:00. Administration history: 10/5/2022 23:00; administered by Petra Popovich, Registered Nurse; Administered: Yes; notes blank. Scheduled daily at 23:00.", "orderedBy" : "C. Walsh, Admitting Physician", "orderedDateTime" : "2022-10-05T21:00:00", "section" : "Scheduled", "status" : "Active" }, { "administrationBy" : "Petra Popovich, Registered Nurse", "doseRouteFrequency" : "2000mcg Oral (PO); q24h; Scheduled", "drug" : "Vitamin B 12", "id" : "ad-med-3", "lastGiven" : "2022-10-05T23:00:00", "nextDue" : "2022-10-06T23:00:00", "notes" : "Start Date/Time: 10/05/2022 at 21:00. Stop Date/Time: 10/19/2022 at 21:00. Administration history: 10/5/2022 23:00; administered by Petra Popovich, Registered Nurse; Administered: Yes; notes blank. Scheduled daily at 23:00.", "orderedBy" : "C. Walsh, Admitting Physician", "orderedDateTime" : "2022-10-05T21:00:00", "section" : "Scheduled", "status" : "Active" }, { "doseRouteFrequency" : "2 mg Intravenous (IV); q2h; PRN", "drug" : "LORazepam", "id" : "ad-med-4", "notes" : "Start Date/Time: 10/05/2022 at 21:00. Stop Date/Time: 10/19/2022 at 21:00. Give for a CIWA-Ar score of 8 or greater. Hold for excessive sedation or a respiratory rate less than 12 breaths/min.", "orderedBy" : "C. Walsh, Admitting Physician", "orderedDateTime" : "2022-10-05T21:00:00", "section" : "PRN", "status" : "Active" }, { "doseRouteFrequency" : "325mg - 650mg Oral (PO); q6h; PRN", "drug" : "acetaminophen", "id" : "ad-med-5", "notes" : "Start Date/Time: 10/05/2022 at 21:00. Stop Date/Time: 10/19/2022 at 21:00. Acetaminophen 325mg tab, 1-2 tablets for pain or fever every 6 hours; not to exceed 1500mg/day", "orderedBy" : "C. Walsh, Admitting Physician", "orderedDateTime" : "2022-10-05T21:00:00", "section" : "PRN", "status" : "Active" } ], "notes" : [ { "author" : "C. Walsh, Admitting Physician", "dateTime" : "2022-10-05T21:00:00", "id" : "ad-note-1", "summary" : "Andrew Davis was admitted to unit and oriented to room and unit procedures. CIWA score was 1. Mental status exam: Patient is oriented x 4. Appearance and affect are calm. Speech is regular rate, rhythm and volume with clear language, and patient maintains eye contact. His thought processes are logical, and goal directed with questions asked. He describes his mood as “tired and disgusted with myself.” No motor deficits or tremors are noted. He denies any suicidal ideation and has good judgment and reasoning skills with good insight. /Carol Walsh, MD", "type" : "Physician Notes" }, { "author" : "Petra Popovich, Registered Nurse", "dateTime" : "2022-10-06T01:00:00", "id" : "ad-note-2", "summary" : "No change in behavior. Attended Alcoholics Anonymous meeting for 20-30 minutes. CIWA score 3.", "type" : "Nursing - Event" }, { "author" : "Marion Cummings, Registered Nurse", "dateTime" : "2022-10-06T05:00:00", "id" : "ad-note-3", "summary" : "Unable to sleep; behavior otherwise appropriate. CIWA score 5. Offered acetaminophen for headache, pt declined.", "type" : "Nursing - Shift" }, { "author" : "Marion Cummings, Registered Nurse", "dateTime" : "2022-10-06T09:00:00", "id" : "ad-note-4", "summary" : "Slept very little. Becoming more anxious. CIWA score 9.", "type" : "Nursing - Shift" }, { "author" : "Marion Cummings, Registered Nurse", "dateTime" : "2022-10-06T11:00:00", "id" : "ad-note-5", "summary" : "Still restless and complaining of headache. Blood for morning labs drawn.", "type" : "Nursing - Shift" }, { "author" : "Simulation history reconciliation from source documentation", "dateTime" : "2022-10-05T21:00:00", "id" : "ad-note-6", "summary" : "Andrew Davis is a 56-year-old male voluntarily admitted yesterday to the alcohol rehab program for alcohol detox. Andrew, a local school board member, showed up to a public school board meeting intoxicated, started making racial and ethnic slurs, resulting in his removal from the meeting by security. His partner refuses to allow him to return home until he checks himself into a detox program. He reports alcohol use for approximately 20 years, with escalation over the past decade and further increase over the last five years. He has consumed approximately one pint of vodka daily for the past two years. This is his first admission for alcohol withdrawal.", "type" : "Imported admission history" }, { "author" : "Simulation history reconciliation from source documentation", "dateTime" : "2022-10-05T21:00:00", "id" : "ad-note-7", "summary" : "Alcohol Use: He reports alcohol use for approximately 20 years, with escalation over the past decade and further increase over the last five years. He has consumed approximately one pint of vodka daily for the past two years. Vodka is his drink of choice. He hides his alcohol use from his family. He has no previous detox or rehab stays. He had one blackout that he can recall a year ago, when he woke up at home alone. He denies any history of seizures or hallucinations. He tried to stop drinking on his own at his partner’s insistence 5 years ago but became “jittery” after 2 days and resumed drinking. Notes: Family history is significant for alcohol use with his mother; however, she was never in treatment, but patient remembers that she used alcohol frequently and it was a source of friction in the family. Notes: He has three children: Aged 25, 21 and 17 years old He reports a strained relationship with his two youngest. His oldest is still supportive and accompanied Mr. Davis to the clinic yesterday. His partner asked him to move out of their house following the incident at the school board meeting. She has threatened to divorce him several times in the past secondary to behaviors associated with drinking.", "type" : "Imported social history" }, { "author" : "Simulation history reconciliation from source documentation", "dateTime" : "2022-10-05T21:00:00", "id" : "ad-note-8", "summary" : "Patient reports frequent maternal alcohol use associated with family conflict; mother was never in treatment. Other maternal medical history and other significant family history are not documented.", "type" : "Imported family health history" }, { "dateTime" : "2020-10-15T21:00:00", "id" : "ad-note-9", "summary" : "Diagnosis: Fracture (arm or leg). Location: Humerus. Notes: Open reduction internal fixation of humerus fracture after fall. Admission: 10/15/2020 21:00. Discharge: 10/16/2020 21:00.", "type" : "Imported previous visit" }, { "id" : "ad-note-10", "summary" : "Current care providers: C. Walsh (Admitting Physician); Marion Cummings, Petra Popovich, Robert Bell, Sally Lewis (Registered Nurses).", "type" : "Imported care team" }, { "id" : "ad-note-11", "summary" : "DocuCare displays no data for Allergies, Immunizations, Plan of Care, Patient Teaching, Intake/Output, Other Diagnostics, Forms, and Home Medication History. No allergy status is inferred from the empty allergy table.", "type" : "Source documentation status" } ], "orders" : [ { "author" : "C. Walsh, Admitting Physician", "category" : "Dietary", "dateTime" : "2022-10-05T21:00:00", "id" : "ad-order-1", "orderText" : "Regular diet. Timing: Routine. Frequency: cont..", "status" : "Active" }, { "author" : "C. Walsh, Admitting Physician", "category" : "Laboratory", "dateTime" : "2022-10-05T21:00:00", "id" : "ad-order-2", "orderText" : "Comprehensive Metabolic Panel (CMP). Timing: Routine. Frequency: x1. on admission and daily in am x 3 days", "status" : "Active" }, { "author" : "C. Walsh, Admitting Physician", "category" : "Laboratory", "dateTime" : "2022-10-05T21:00:00", "id" : "ad-order-3", "orderText" : "Complete Blood Count. Timing: Routine. Frequency: x1. on admission", "status" : "Discontinued" }, { "author" : "C. Walsh, Admitting Physician", "category" : "Laboratory", "dateTime" : "2022-10-05T21:00:00", "id" : "ad-order-4", "orderText" : "Magnesium and Phospate Levels. Timing: Routine. Frequency: x1. on admission", "status" : "Discontinued" }, { "author" : "C. Walsh, Admitting Physician", "category" : "Laboratory", "dateTime" : "2022-10-05T21:00:00", "id" : "ad-order-5", "orderText" : "Vitamin B12 and Folate Levels. Timing: Routine. Frequency: x1. on admission", "status" : "Discontinued" }, { "author" : "C. Walsh, Admitting Physician", "category" : "Laboratory", "dateTime" : "2022-10-05T21:00:00", "id" : "ad-order-6", "orderText" : "Urine Toxocology Screen. Timing: Routine. Frequency: x1. on admission", "status" : "Discontinued" }, { "author" : "C. Walsh, Admitting Physician", "category" : "Laboratory", "dateTime" : "2022-10-05T21:00:00", "id" : "ad-order-7", "orderText" : "Ethanol Level. Timing: Routine. Frequency: x1. on admission", "status" : "Discontinued" }, { "author" : "C. Walsh, Admitting Physician", "category" : "Laboratory", "dateTime" : "2022-10-05T21:00:00", "id" : "ad-order-8", "orderText" : "Venipuncture. Timing: Routine. Frequency: q24h x3. Labs in the Morning (Daily X 3) CMP Mg Phos", "status" : "Active" }, { "author" : "C. Walsh, Admitting Physician", "category" : "Nursing", "dateTime" : "2022-10-05T21:00:00", "id" : "ad-order-9", "orderText" : "Admission. Timing: Routine. Frequency: x1. Admit to Detox Unit", "status" : "Active" }, { "author" : "Simulation adaptation of C. Walsh source order", "category" : "Nursing", "dateTime" : "2022-10-05T21:00:00", "id" : "ad-order-10", "orderText" : "Alcohol withdrawal management. Timing: Routine. Frequency: cont.. Vital signs and CIWA-Ar score on admission If the initial CIWA-Ar score is less than 10, continue assessment every 4 hours for 72 hours. If the initial CIWA-Ar score is 10 or greater, continue assessment and vital signs every hour for 8 hours and then, if stable, every 2 hours for 8 hours and then, if stable, every 4 hours thereafter until discharge. If the CIWA-Ar score is less than 8 for 72 hours, discontinue the assessment. If the CIWA-Ar score is 8 or greater, administer LORazepam 2 mg IV every 2 hours as needed per the medication order. Hold for excessive sedation or respiratory rate less than 12 breaths/min. Monitor for sedation and respiratory depression and reassess symptoms after medication. The medication trigger is separate from the intensified assessment threshold of 10. Call the provider for a CIWA-Ar score above 35.", "status" : "Active" }, { "author" : "C. Walsh, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2022-10-05T21:00:00", "id" : "ad-order-11", "orderText" : "Thiamine: 100 mg Oral (PO); q24h; Scheduled. Start Date/Time: 10/05/2022 at 21:00. Stop Date/Time: 10/19/2022 at 21:00. Administration history: 10/5/2022 23:00; administered by Petra Popovich, Registered Nurse; Administered: Yes; notes blank. Scheduled daily at 23:00.", "status" : "Active" }, { "author" : "C. Walsh, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2022-10-05T21:00:00", "id" : "ad-order-12", "orderText" : "Multivitamin with minerals: 1 Oral (PO); q24h; Scheduled. Start Date/Time: 10/05/2022 at 21:00. Stop Date/Time: 10/19/2022 at 21:00. Administration history: 10/5/2022 23:00; administered by Petra Popovich, Registered Nurse; Administered: Yes; notes blank. Scheduled daily at 23:00.", "status" : "Active" }, { "author" : "C. Walsh, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2022-10-05T21:00:00", "id" : "ad-order-13", "orderText" : "Vitamin B 12: 2000mcg Oral (PO); q24h; Scheduled. Start Date/Time: 10/05/2022 at 21:00. Stop Date/Time: 10/19/2022 at 21:00. Administration history: 10/5/2022 23:00; administered by Petra Popovich, Registered Nurse; Administered: Yes; notes blank. Scheduled daily at 23:00.", "status" : "Active" }, { "author" : "C. Walsh, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2022-10-05T21:00:00", "id" : "ad-order-14", "orderText" : "LORazepam: 2 mg Intravenous (IV); q2h; PRN. Start Date/Time: 10/05/2022 at 21:00. Stop Date/Time: 10/19/2022 at 21:00. Give for a CIWA-Ar score of 8 or greater. Hold for excessive sedation or a respiratory rate less than 12 breaths/min.", "status" : "Active" }, { "author" : "C. Walsh, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2022-10-05T21:00:00", "id" : "ad-order-15", "orderText" : "acetaminophen: 325mg - 650mg Oral (PO); q6h; PRN. Start Date/Time: 10/05/2022 at 21:00. Stop Date/Time: 10/19/2022 at 21:00. Acetaminophen 325mg tab, 1-2 tablets for pain or fever every 6 hours; not to exceed 1500mg/day", "status" : "Active" } ], "overview" : { "emergencyContact" : "Julie Davis", "height" : "72 in / 182.9 cm", "isolationIndicator" : "Standard", "religion" : "Christian", "weightKg" : 81.6 }, "vitals" : [ { "bloodPressure" : "134/72", "dateTime" : "2022-10-05T21:00:00", "heartRate" : 84, "id" : "ad-vital-1", "respiratoryRate" : 18, "snapshotId" : "ad-current", "spo2" : "98%", "temperature" : "98.6 °F (oral)" }, { "bloodPressure" : "138/75", "dateTime" : "2022-10-06T01:00:00", "heartRate" : 88, "id" : "ad-vital-2", "respiratoryRate" : 18, "snapshotId" : "ad-current", "spo2" : "99%", "temperature" : "98.7 °F (oral)" }, { "bloodPressure" : "148/84", "dateTime" : "2022-10-06T05:00:00", "heartRate" : 90, "id" : "ad-vital-3", "respiratoryRate" : 18, "snapshotId" : "ad-current", "spo2" : "99%", "temperature" : "98.7 °F (oral)" }, { "bloodPressure" : "154/90", "dateTime" : "2022-10-06T09:00:00", "heartRate" : 94, "id" : "ad-vital-4", "oxygenDevice" : "Room Air", "respiratoryRate" : 20, "snapshotId" : "ad-current", "spo2" : "98%", "temperature" : "98.6 °F (oral)" } ] }, "patient" : { "admitDateTime" : "2022-10-05T21:00:00", "admittingDiagnosis" : "Alcohol Withdrawal", "attending" : "C. Walsh, Admitting Physician", "chartDisplayName" : "Davis, Andrew", "codeStatus" : "Full Code", "dob" : "8/11/XX", "history" : { "chiefComplaint" : "Alcohol withdrawal", "hpiSummary" : "Andrew Davis is a 56-year-old male voluntarily admitted yesterday to the alcohol rehab program for alcohol detox. Andrew, a local school board member, showed up to a public school board meeting intoxicated, started making racial and ethnic slurs, resulting in his removal from the meeting by security. His partner refuses to allow him to return home until he checks himself into a detox program. He reports alcohol use for approximately 20 years, with escalation over the past decade and further increase over the last five years. He has consumed approximately one pint of vodka daily for the past two years. This is his first admission for alcohol withdrawal.", "pastMedicalHistory" : [ "Denies prior medical problems (source checkbox).", "No previous blood transfusion.", "No history of chronic pain." ], "pastSurgicalHistory" : [ "Open reduction internal fixation surgery to repair a humerus fracture after a fall 2 years ago" ], "socialHistory" : [ "Age documented separately as 56 years; birth year intentionally displayed as XX.", "Marital status: Married. Partner/next of kin: Julie Davis. Contact information not documented.", "Primary language: English. Occupation: Pastor. Religion: Christian. Race: White. Ethnicity: Unknown (individual not reporting ethnicity).", "Patient living situation: Unclear (wife asked him to leave home). Lives with partner, but partner refuses to allow him to return home until he receives treatment.", "Highest grade completed: College. Able to read: Yes. Able to write: Yes.", "Cigarettes: Nonsmoker. Alcohol status: Current user. Drinks/week: 7 or more. Prior alcohol abuse diagnosis/treatment: Unknown. Illicit drug use: Nonuser.", "Feels safe at home and in current environment. Denies being hurt emotionally, physically, or sexually. Score of 0 on Broset Violence Risk Screening.", "Frequent feelings of hopelessness/helplessness: Yes. Psychiatric consult ordered: Yes. Sexually active: Yes.", "Alcohol Use: He reports alcohol use for approximately 20 years, with escalation over the past decade and further increase over the last five years. He has consumed approximately one pint of vodka daily for the past two years. Vodka is his drink of choice. He hides his alcohol use from his family. He has no previous detox or rehab stays. He had one blackout that he can recall a year ago, when he woke up at home alone. He denies any history of seizures or hallucinations. He tried to stop drinking on his own at his partner’s insistence 5 years ago but became “jittery” after 2 days and resumed drinking. Notes: Family history is significant for alcohol use with his mother; however, she was never in treatment, but patient remembers that she used alcohol frequently and it was a source of friction in the family. Notes: He has three children: Aged 25, 21 and 17 years old He reports a strained relationship with his two youngest. His oldest is still supportive and accompanied Mr. Davis to the clinic yesterday. His partner asked him to move out of their house following the incident at the school board meeting. She has threatened to divorce him several times in the past secondary to behaviors associated with drinking." ] }, "mrn" : "213546879", "sex" : "Male", "simulatedFullName" : "Andrew Davis", "unit" : "Inpatient alcohol rehabilitation unit" }, "setting" : "Inpatient alcohol rehabilitation unit", "snapshots" : [ { "activityIds" : [ ], "id" : "ad-current", "notes" : "Single adapted chart state. No progressive-release timing is enforced.", "scenarioTime" : "2022-10-06T13:00:00", "sourcePath" : "DocuCare visible case 68080", "title" : "Reconciled chart at 10/6/2022 13:00" } ], "subtitle" : "N21 practice record", "tags" : [ "N21", "DocuCare migration" ], "title" : "Andrew Davis" }, "packageId" : "docucare-n21-andrew-davis-review-v2", "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 — partial capture with authorized simulation corrections" }, "workingNames" : [ "ChartSlate" ] } }, "id" : "n21-andrew-davis", "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" : "Andrew Davis" }, { "envelope" : { "appName" : "ChartSlate", "audience" : "student", "createdAt" : "2026-09-22T21:10:32.768033+00:00", "exportVersion" : "1", "kind" : "casePackage", "package" : { "case" : { "activities" : [ ], "id" : "docucare-n21-tony-wallace", "learningLevel" : "N21", "panels" : { "assessments" : [ { "author" : "K Chambers, Registered Nurse", "dateTime" : "2022-02-07T14:00:00", "id" : "tony-wallace-assessment-1", "label" : "HEENT", "summary" : "Head symmetric; no recent trauma; hair fine; ears not assessed; nose symmetrical; oral mucosa normal. Eye movement symmetrical and intact bilaterally." }, { "author" : "K Chambers, Registered Nurse", "dateTime" : "2022-02-07T14:00:00", "id" : "tony-wallace-assessment-2", "label" : "Neurological", "summary" : "Oriented to person, time, place, situation. Pupils 3 mm bilaterally, round, brisk, accommodation. Hearing intact. All four extremities move spontaneously. Calm and cooperative. Secondary neurological scale tabs unverified." }, { "author" : "K Chambers, Registered Nurse", "dateTime" : "2022-02-07T14:00:00", "id" : "tony-wallace-assessment-3", "label" : "Cardiovascular", "summary" : "S1/S2 regular; pulses +2 all; edema absent; capillary refill <3 seconds all. Skin appropriate for ethnicity, dry, intact, ashen (both color selections checked)." }, { "author" : "K Chambers, Registered Nurse", "dateTime" : "2022-02-07T14:00:00", "id" : "tony-wallace-assessment-4", "label" : "Respiratory", "summary" : "All five lung lobes clear. RUL anterior/posterior selected. Regular respirations; respiratory symptoms none; sputum color none. Oxygen delivery selector unfilled; no oxygen flow inferred. Respiratory therapy subtabs unverified." }, { "author" : "K Chambers, Registered Nurse", "dateTime" : "2022-02-07T14:00:00", "id" : "tony-wallace-assessment-5", "label" : "Skin", "summary" : "Skin assessed as clean, dry, and intact." }, { "author" : "K Chambers, Registered Nurse", "dateTime" : "2022-02-08T13:00:00", "id" : "tony-wallace-assessment-6", "label" : "HEENT", "summary" : "Head symmetric; no recent trauma; hair fine; ears not assessed; nose symmetrical; oral mucosa normal. Sclera normal/clear bilaterally." }, { "author" : "K Chambers, Registered Nurse", "dateTime" : "2022-02-08T13:00:00", "id" : "tony-wallace-assessment-7", "label" : "Neurological", "summary" : "Oriented to person, time, place, situation. Pupils 4 mm bilaterally, round, brisk, accommodation. Hearing intact. All four extremities move spontaneously. Calm and cooperative. Secondary neurological scale tabs unverified." }, { "author" : "K Chambers, Registered Nurse", "dateTime" : "2022-02-08T13:00:00", "id" : "tony-wallace-assessment-8", "label" : "Cardiovascular", "summary" : "S1/S2 regular; pulses +2 all; edema absent; capillary refill <3 seconds all. Skin appropriate for ethnicity, dry, intact, ashen (both color selections checked)." }, { "author" : "K Chambers, Registered Nurse", "dateTime" : "2022-02-08T13:00:00", "id" : "tony-wallace-assessment-9", "label" : "Respiratory", "summary" : "RUL, RML, RLL, LUL clear; LLL crackles and diminished. All lobes anterior/posterior selected. Regular respirations; symptoms none; sputum color none. Oxygen delivery selector unfilled; no oxygen flow inferred. Respiratory therapy subtabs unverified." }, { "author" : "K Chambers, Registered Nurse", "dateTime" : "2022-02-08T13:00:00", "id" : "tony-wallace-assessment-10", "label" : "Skin", "summary" : "Skin assessed as clean, dry, and intact." }, { "author" : "K Chambers, Registered Nurse", "dateTime" : "2022-02-09T13:00:00", "id" : "tony-wallace-assessment-11", "label" : "HEENT", "summary" : "Head symmetric; no recent trauma; hair fine; ears not assessed; nose symmetrical; oral mucosa normal." }, { "author" : "K Chambers, Registered Nurse", "dateTime" : "2022-02-09T13:00:00", "id" : "tony-wallace-assessment-12", "label" : "Neurological", "summary" : "Oriented to person, time, place, situation. Pupils 3 mm bilaterally, round, brisk, accommodation. Hearing intact. All four extremities move spontaneously. Calm and cooperative. Secondary neurological scale tabs unverified." }, { "author" : "K Chambers, Registered Nurse", "dateTime" : "2022-02-09T13:00:00", "id" : "tony-wallace-assessment-13", "label" : "Cardiovascular", "summary" : "S1/S2 regular; pulses +2 all; edema absent; capillary refill <3 seconds all. Skin appropriate for ethnicity, warm, dry, intact." }, { "author" : "K Chambers, Registered Nurse", "dateTime" : "2022-02-09T13:00:00", "id" : "tony-wallace-assessment-14", "label" : "Respiratory", "summary" : "Cough; labored respirations. RUL, RML, LUL clear; RLL diminished; LLL crackles and diminished. All lobes anterior/posterior selected. Oxygen delivery selector unfilled; no oxygen flow inferred. Respiratory therapy subtabs unverified." }, { "author" : "K Chambers, Registered Nurse", "dateTime" : "2022-02-09T13:00:00", "id" : "tony-wallace-assessment-15", "label" : "Skin", "summary" : "Skin assessed as clean, dry, and intact." }, { "author" : "K Chambers, Registered Nurse", "dateTime" : "2022-02-07T14:00:00", "id" : "tony-wallace-assessment-16", "label" : "Pain", "summary" : "Arms and legs. Constant, chronic, onset at admission; goal 3; rating 10/unbearable. Movement and breathing aggravate; medication and ice alleviate. Aching, throbbing, stabbing. Scale name unfilled." }, { "dateTime" : "2022-02-09T13:00:00", "id" : "tony-wallace-assessment-17", "label" : "Pain", "summary" : "Arms, legs, and chest. Constant, chronic, onset at admission; goal 3; numerical rating 9. Movement and coughing aggravate; medication alleviates. Aching, throbbing, sore. Documented-by field unselected." }, { "dateTime" : "2022-02-07T13:00:00", "id" : "tony-wallace-assessment-18", "label" : "Vascular access", "summary" : "Right forearm peripheral IV, 18 ga, inserted on admission; transparent dressing. Site clean/dry/intact without IV-related complications. Good blood return, flushes easily. Documented-by field unselected." } ], "intakeOutput" : { "documentedIntakeTotalMl" : 2520, "documentedNetMl" : 970, "documentedOutputTotalMl" : 1550, "intakeEntries" : [ { "amountMl" : 960, "id" : "io-in-0", "time" : "2022-02-09T05:00:00", "type" : "IVPB & IV Push" }, { "amountMl" : 600, "id" : "io-in-1", "time" : "2022-02-09T05:00:00", "type" : "Oral" }, { "amountMl" : 960, "id" : "io-in-2", "time" : "2022-02-09T12:00:00", "type" : "IVPB & IV Push" } ], "outputEntries" : [ { "amountMl" : 750, "id" : "io-out-0", "time" : "2022-02-09T05:00:00", "type" : "Urine" }, { "amountMl" : 600, "id" : "io-out-1", "time" : "2022-02-09T12:00:00", "type" : "Urine" }, { "amountMl" : 200, "id" : "io-out-2", "time" : "2022-02-09T12:00:00", "type" : "Emesis" } ] }, "labs" : [ { "category" : "Complete Blood Count with differential", "collectedDateTime" : "2022-02-09T12:00:00", "flag" : "High", "id" : "tony-wallace-lab-1", "referenceRange" : "4,500 - 11,000/mm3", "result" : "32.1", "test" : "WBCs" }, { "category" : "Complete Blood Count with differential", "collectedDateTime" : "2022-02-09T12:00:00", "flag" : "Normal", "id" : "tony-wallace-lab-2", "referenceRange" : "140 - 400 X 103 mm3", "result" : "231", "test" : "Platelets" }, { "category" : "Complete Blood Count with differential", "collectedDateTime" : "2022-02-09T12:00:00", "flag" : "Low", "id" : "tony-wallace-lab-3", "referenceRange" : "37-49%", "result" : "26.4%", "test" : "Hematocrit" }, { "category" : "Complete Blood Count with differential", "collectedDateTime" : "2022-02-09T12:00:00", "flag" : "Low", "id" : "tony-wallace-lab-4", "referenceRange" : "13.0-18.0 g/100 ml", "result" : "9.4", "test" : "Hemoglobin" }, { "category" : "Complete Blood Count with differential", "collectedDateTime" : "2022-02-09T12:00:00", "flag" : "Normal", "id" : "tony-wallace-lab-5", "referenceRange" : "50%-60%", "result" : "57%", "test" : "Segs" }, { "category" : "Complete Blood Count with differential", "collectedDateTime" : "2022-02-09T12:00:00", "flag" : "High", "id" : "tony-wallace-lab-6", "referenceRange" : "0%-5%", "result" : "32%", "test" : "Bands" }, { "category" : "Complete Blood Count with differential", "collectedDateTime" : "2022-02-09T12:00:00", "flag" : "Low", "id" : "tony-wallace-lab-7", "referenceRange" : "25%-35%", "result" : "7%", "test" : "Lymphs" }, { "category" : "Complete Blood Count with differential", "collectedDateTime" : "2022-02-09T12:00:00", "flag" : "Normal", "id" : "tony-wallace-lab-8", "referenceRange" : "2%-6%", "result" : "3%", "test" : "Monocytes" }, { "category" : "Complete Blood Count with differential", "collectedDateTime" : "2022-02-09T12:00:00", "flag" : "Normal", "id" : "tony-wallace-lab-9", "result" : "1%", "test" : "nRBC" }, { "category" : "Complete Blood Count with differential", "collectedDateTime" : "2022-02-09T12:00:00", "flag" : "High", "id" : "tony-wallace-lab-10", "referenceRange" : "0.5 - 1.5%", "result" : "3.2%", "test" : "Reticulocyte" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2022-02-09T12:00:00", "flag" : "Normal", "id" : "tony-wallace-lab-11", "referenceRange" : "135 - 145 mEq/L", "result" : "138", "test" : "Na" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2022-02-09T12:00:00", "flag" : "Normal", "id" : "tony-wallace-lab-12", "referenceRange" : "3.5 - 5 mEq/L", "result" : "3.8", "test" : "K" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2022-02-09T12:00:00", "flag" : "Normal", "id" : "tony-wallace-lab-13", "referenceRange" : "100 - 108 mEq/L", "result" : "107", "test" : "CL" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2022-02-09T12:00:00", "flag" : "Normal", "id" : "tony-wallace-lab-14", "referenceRange" : "8 - 25 mg/dL", "result" : "8", "test" : "BUN" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2022-02-09T12:00:00", "flag" : "Normal", "id" : "tony-wallace-lab-15", "referenceRange" : "0.6 - 1.5 mg/dL", "result" : "0.7", "test" : "Creatinine" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2022-02-09T12:00:00", "flag" : "Normal", "id" : "tony-wallace-lab-16", "referenceRange" : "8.5 - 10.5 mg/dL", "result" : "8.5", "test" : "Calcium" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2022-02-09T12:00:00", "flag" : "Normal", "id" : "tony-wallace-lab-17", "referenceRange" : "70 -110 mg/dL", "result" : "92", "test" : "Glucose" }, { "category" : "Basic Metabolic Panel", "collectedDateTime" : "2022-02-09T12:00:00", "flag" : "Normal", "id" : "tony-wallace-lab-18", "referenceRange" : "24 - 30 mEq/L", "result" : "26", "test" : "CO2" }, { "category" : "Bilirubin", "collectedDateTime" : "2022-02-09T12:00:00", "flag" : "High", "id" : "tony-wallace-lab-19", "referenceRange" : "0.3 - 1.0 mg/dL", "result" : "3.2", "test" : "Bilirubin Total" }, { "category" : "Arterial Blood Gas — FiO2 100%", "collectedDateTime" : "2022-02-09T13:30:00", "flag" : "High", "id" : "tony-wallace-lab-20", "referenceRange" : "7.35 - 7.45", "result" : "7.5", "test" : "pH" }, { "category" : "Arterial Blood Gas — FiO2 100%", "collectedDateTime" : "2022-02-09T13:30:00", "flag" : "Low", "id" : "tony-wallace-lab-21", "referenceRange" : "35 - 45 mmHg", "result" : "32", "test" : "PaCO2" }, { "category" : "Arterial Blood Gas — FiO2 100%", "collectedDateTime" : "2022-02-09T13:30:00", "flag" : "Low", "id" : "tony-wallace-lab-22", "referenceRange" : "75 - 100 mmHg", "result" : "65", "test" : "PaO2" }, { "category" : "Arterial Blood Gas — FiO2 100%", "collectedDateTime" : "2022-02-09T13:30:00", "flag" : "Low", "id" : "tony-wallace-lab-23", "referenceRange" : "22 -28 mEq/L", "result" : "20", "test" : "HCO3" }, { "category" : "Arterial Blood Gas — FiO2 100%", "collectedDateTime" : "2022-02-09T13:30:00", "flag" : "Low", "id" : "tony-wallace-lab-24", "referenceRange" : "> 94%", "result" : "90", "test" : "SpO2" } ], "medications" : [ { "administrationBy" : "K Chambers, Registered Nurse", "doseRouteFrequency" : "2 gram IVPB q12h", "drug" : "Ceftriaxone (Rocephin)", "id" : "tw-med-1", "lastGiven" : "2022-02-09T02:00:00", "nextDue" : "2022-02-09T14:00:00", "notes" : "Source order stop: 2022-02-21T14:00:00. Administration history: 2022-02-07T14:00:00 — K Chambers, Registered Nurse; Administered Yes; 2022-02-08T02:00:00 — K Chambers, Registered Nurse; Administered Yes; 2022-02-08T14:00:00 — K Chambers, Registered Nurse; Administered Yes; 2022-02-09T02:00:00 — K Chambers, Registered Nurse; Administered Yes", "orderedBy" : "Dr. Jill Herrick, Admitting Physician", "orderedDateTime" : "2022-02-07T14:00:00", "section" : "Scheduled", "status" : "Active" }, { "administrationBy" : "K Chambers, Registered Nurse", "doseRouteFrequency" : "1 mg PO q24h", "drug" : "Folic Acid (vitamin B9)", "id" : "tw-med-2", "lastGiven" : "2022-02-08T14:00:00", "nextDue" : "2022-02-09T14:00:00", "notes" : "Source order stop: 2022-02-21T14:00:00. Administration history: 2022-02-07T14:00:00 — K Chambers, Registered Nurse; Administered Yes; 2022-02-08T13:30:00 — Janice Abbe, Registered Nurse; Administered Yes; 2022-02-08T14:00:00 — K Chambers, Registered Nurse; Administered Yes", "orderedBy" : "Dr. Jill Herrick, Admitting Physician", "orderedDateTime" : "2022-02-07T14:00:00", "section" : "Scheduled", "status" : "Active" }, { "administrationBy" : "Janice Abbe, Registered Nurse", "doseRouteFrequency" : "80 mg PO q12h", "drug" : "Oxycodone (Oxycontin)", "id" : "tw-med-3", "lastGiven" : "2022-02-09T01:30:00", "nextDue" : "2022-02-09T13:30:00", "notes" : "Source order stop: 2022-02-21T14:00:00. Administration history: 2022-02-09T01:30:00 — Janice Abbe, Registered Nurse; Administered Yes", "orderedBy" : "Dr. Jill Herrick, Admitting Physician", "orderedDateTime" : "2022-02-07T14:00:00", "section" : "Scheduled", "status" : "Active" }, { "administrationBy" : "K Chambers, Registered Nurse", "doseRouteFrequency" : "1000 mg PO q24h", "drug" : "Hydroxyurea (Droxia)", "id" : "tw-med-4", "lastGiven" : "2022-02-08T14:00:00", "nextDue" : "2022-02-09T14:00:00", "notes" : "Source order stop: 2022-02-21T14:00:00. Administration history: 2022-02-07T14:00:00 — K Chambers, Registered Nurse; Administered Yes; 2022-02-08T13:30:00 — Dr. Jim Herrick, Primary Care Provider; Administered Yes; 2022-02-08T14:00:00 — K Chambers, Registered Nurse; Administered Yes", "orderedBy" : "Dr. Jill Herrick, Admitting Physician", "orderedDateTime" : "2022-02-07T14:00:00", "section" : "Scheduled", "status" : "Active" }, { "administrationBy" : "K Chambers, Registered Nurse", "doseRouteFrequency" : "2 tabs PO q12h", "drug" : "Senna/docusate (Senokot-S)", "id" : "tw-med-5", "lastGiven" : "2022-02-08T23:00:00", "nextDue" : "2022-02-09T11:00:00", "notes" : "Hold for loose stools. Source order stop: 2022-02-21T14:00:00. Administration history: 2022-02-07T14:00:00 — K Chambers, Registered Nurse; Administered Yes; 2022-02-07T23:00:00 — K Chambers, Registered Nurse; Administered Yes; 2022-02-08T14:00:00 — K Chambers, Registered Nurse; Administered Yes; 2022-02-08T23:00:00 — K Chambers, Registered Nurse; Administered Yes", "orderedBy" : "Dr. Jill Herrick, Admitting Physician", "orderedDateTime" : "2022-02-07T14:00:00", "section" : "Scheduled", "status" : "Active" }, { "administrationBy" : "K Chambers, Registered Nurse", "doseRouteFrequency" : "40 mg SC q24h", "drug" : "Enoxaparin Sodium (Lovenox)", "id" : "tw-med-6", "lastGiven" : "2022-02-08T22:00:00", "nextDue" : "2022-02-09T22:00:00", "notes" : "Source order stop: 2022-02-21T22:00:00. Administration history: 2022-02-07T22:00:00 — A Marion, Registered Nurse; Administered Yes; 2022-02-08T22:00:00 — K Chambers, Registered Nurse; Administered Yes", "orderedBy" : "Dr. Jill Herrick, Admitting Physician", "orderedDateTime" : "2022-02-07T22:00:00", "section" : "Scheduled", "status" : "Active" }, { "administrationBy" : "A Marion, Registered Nurse", "doseRouteFrequency" : "30 mg IV q6h x4", "drug" : "Ketorolac (Toradol)", "id" : "tw-med-7", "lastGiven" : "2022-02-08T11:00:00", "notes" : "Source order stop: 2022-02-21T13:00:00. Administration history: 2022-02-07T17:00:00 — K Chambers, Registered Nurse; Administered Yes; 2022-02-07T23:00:00 — K Chambers, Registered Nurse; Administered Yes; 2022-02-08T05:00:00 — A Marion, Registered Nurse; Administered Yes; 2022-02-08T11:00:00 — A Marion, Registered Nurse; Administered Yes", "orderedBy" : "Dr. Jill Herrick, Admitting Physician", "orderedDateTime" : "2022-02-07T13:00:00", "section" : "Discontinued", "status" : "Discontinued" }, { "doseRouteFrequency" : "1 application topical q12h", "drug" : "Lidex 0.05% and moisterizer with menthol lotion", "id" : "tw-med-8", "nextDue" : "2022-02-07T13:00:00", "notes" : "Apply to skin BID and as needed itching/dryness. Source order stop: 2022-02-21T13:00:00. Administration history table: no data.", "orderedBy" : "Dr. Jill Herrick, Admitting Physician", "orderedDateTime" : "2022-02-07T13:00:00", "section" : "Scheduled", "status" : "Active" }, { "administrationBy" : "A Marion, Registered Nurse", "doseRouteFrequency" : "30 mg IV q6h PRN", "drug" : "ketorolac tromethamine (oral, nasal, injection)", "id" : "tw-med-9", "lastGiven" : "2022-02-09T12:00:00", "notes" : "To begin after ketorolac 30 mg IV q6h x4 doses. Source order stop: 2022-02-21T13:00:00. Administration history: 2022-02-08T18:00:00 — K Chambers, Registered Nurse; Administered Yes; 2022-02-09T00:00:00 — K Chambers, Registered Nurse; Administered Yes; 2022-02-09T05:30:00 — A Marion, Registered Nurse; Administered Yes; 2022-02-09T12:00:00 — A Marion, Registered Nurse; Administered Yes", "orderedBy" : "Dr. Jill Herrick, Admitting Physician", "orderedDateTime" : "2022-02-07T13:00:00", "section" : "PRN", "status" : "Active" }, { "administrationBy" : "K Chambers, Registered Nurse", "doseRouteFrequency" : "4 mg IV q6h PRN", "drug" : "ondansetron", "id" : "tw-med-10", "lastGiven" : "2022-02-07T13:00:00", "notes" : "For nausea and vomiting. Source order stop: 2022-02-21T13:00:00. Administration history: 2022-02-07T13:00:00 — K Chambers, Registered Nurse; Administered Yes", "orderedBy" : "Dr. Jill Herrick, Admitting Physician", "orderedDateTime" : "2022-02-07T13:00:00", "section" : "PRN", "status" : "Active" }, { "administrationBy" : "A Marion, Registered Nurse", "doseRouteFrequency" : "650 mg PO q6h PRN", "drug" : "acetaminophen", "id" : "tw-med-11", "lastGiven" : "2022-02-09T04:00:00", "notes" : "For temperature greater than 100 F. Source order stop: 2022-02-21T13:00:00. Administration history: 2022-02-07T13:00:00 — K Chambers, Registered Nurse; Administered Yes; 2022-02-08T14:00:00 — K Chambers, Registered Nurse; Administered Yes; 2022-02-09T04:00:00 — A Marion, Registered Nurse; Administered Yes", "orderedBy" : "Dr. Jill Herrick, Admitting Physician", "orderedDateTime" : "2022-02-07T13:00:00", "section" : "PRN", "status" : "Active" }, { "doseRouteFrequency" : "PCA IV: demand only 2 mg q10min PRN; 4-hour lockout 48 mg", "drug" : "morphine sulfate", "id" : "tw-med-12", "notes" : "RN-to-RN check at shift change and every dosage, medication, rate or bag change. Source order stop: 2022-02-21T13:00:00. Administration history: 2022-02-08T01:00:00 — A Marion, Registered Nurse; Administered Yes; PCA RN to RN check MA/KC; 2022-02-08T13:00:00 — K Chambers, Registered Nurse; Administered Yes; RN-toRN check by AM/KC; 2022-02-09T01:00:00 — A Marion, Registered Nurse; Administered Yes; RN to RN shift check KC/AM", "orderedBy" : "Dr. Jill Herrick, Admitting Physician", "orderedDateTime" : "2022-02-07T13:00:00", "section" : "PRN", "status" : "Active" }, { "administrationBy" : "A Marion, Registered Nurse", "doseRouteFrequency" : "120 mL/hr IV continuous; concentration not documented", "drug" : "sodium chloride", "id" : "tw-med-13", "lastGiven" : "2022-02-09T13:00:00", "notes" : "Source order stop: 2022-02-21T13:00:00. Administration history: 2022-02-07T13:00:00 — K Chambers, Registered Nurse; Administered Yes; 2022-02-07T21:00:00 — K Chambers, Registered Nurse; Administered Yes; 2022-02-08T05:00:00 — A Marion, Registered Nurse; Administered Yes; 2022-02-08T13:00:00 — A Marion, Registered Nurse; Administered Yes; 2022-02-08T21:00:00 — K Chambers, Registered Nurse; Administered Yes; 2022-02-09T05:00:00 — A Marion, Registered Nurse; Administered Yes; 2022-02-09T13:00:00 — A Marion, Registered Nurse; Administered Yes", "orderedBy" : "Dr. Jill Herrick, Admitting Physician", "orderedDateTime" : "2022-02-07T13:00:00", "section" : "Cont. Infusion", "status" : "Active" } ], "notes" : [ { "author" : "K Chambers, Registered Nurse", "dateTime" : "2022-02-07T13:00:00", "id" : "tony-wallace-note-1", "summary" : "Additional diagnoses: Pneumonia; Coronavirus disease 2019 (COVID-19). Full Code; signed advance directive checkbox unselected.", "type" : "Encounter diagnoses" }, { "dateTime" : "2022-01-08T13:00:00", "id" : "tony-wallace-note-2", "summary" : "Medical Floor: sickle cell anemia; vaso-occlusive crisis and acute pain management. Discharged 1/12/2022 13:00.", "type" : "Previous visit" }, { "id" : "tony-wallace-note-3", "summary" : "Dr. Jill Herrick (admitting physician); K Chambers and A Marion (registered nurses).", "type" : "Care team" }, { "author" : "Dr. Jill Herrick, Admitting Physician", "dateTime" : "2022-02-07T14:00:00", "id" : "tony-wallace-note-4", "summary" : "Client has a history of SS sickle cell disease, recurrent vaso-occlusive crises (VOC) and acute chest syndrome. His las hospitalization was 1 month ago for VOC and acute pain management. He requires hospitalization approximately 3-4 times a year for these painful vaso-occlusive episodes. He has been on hydroxyurea for 6 months. Client presents today with signs and symptoms of VOC, including acute onset of left arm and leg pain. Client is a febrile. Plan for admission to medical unit, initiate IV fluids, and pain medications to manage VOC.", "type" : "Physician Notes" }, { "author" : "Dr. Jill Herrick, Admitting Physician", "dateTime" : "2022-02-09T13:00:00", "id" : "tony-wallace-note-5", "summary" : "Progress Note Client presented to the emergency department two days ago with signs and symptoms of VOC, including acute onset of left arm and leg pain. He was admitted to the medical surgical unit for pain management and monitoring. Yesterday morning he presented with increased pain in his arms and legs which was not relieved with oral pain management. Additionally, the client reported new onset sore throat and cough. He was found to be febrile with a temperature of 38.8C. He was tested for SARS-CoV-2 via rapid PCR nasal swab and was found to be positive. He received the initial covid-19 vaccination series, but has not received a booster dose.. A chest xray was completed and it showed infiltrates in lower left lobe. In addition to COVID-19, he has pneumonia and will be started on IV antibiotic therapy.", "type" : "Physician Notes" }, { "author" : "K Chambers, Registered Nurse", "dateTime" : "2022-02-09T13:30:00", "id" : "tony-wallace-note-6", "summary" : "Situation: Tony Wallace is a 24-year-old male with known sickle cell disease (Hb SS) who was admitted 2 days ago with a vascular-occlusion crisis and acute pain. Yesterday, he developed a fever. He was found to be positive for COVID-19 and was placed under infection precautions. Background: The patient has a history of recurrent episodes of vaso-occlusive crisis (VOC) and acute chest syndrome requiring acute hospital admissions; his last admission was 1 month ago. He requires hospitalization 3-4 times per year. Assessment: The patient is alert and oriented X 4. He reports pain of 9-10/10 in his left arm and left leg. His pain is managed with scheduled oxycodone and PCA demand-only morphine 2 mg PRN every 10 minutes with a 4-hour lockout of 48 mg and ketorolac IV for breakthrough pain. After breakthrough pain medication administration, his pain decreases to a 6-7/10. His vital signs are monitored every 6 hours; his last set at 0100 was BP 120/74, HR 90, SpO2 92% on 2 L O2 nasal cannula, RR 18, and temp 37.6°C (99.68°F). He was febrile last night at around 2200 hours and responded to acetaminophen 650 mg PO. His lungs are diminished in the left lower lobes with scattered rhonchi that clear with cough. As of this morning, the patient reported shortness of breath when he ambulated to the bathroom. I encouraged him to use his incentive spirometer, but he reported he was in too much pain. Recommendation: The patient received his breakthrough pain medication, ketorolac IV, 1 hour ago. He is due for his 0800 medications soon. We will need to review his PCA settings before I leave. The patient care technician is getting his AM vitals right now.", "type" : "Nursing - Shift" }, { "dateTime" : "2022-02-07T14:00:00", "id" : "tony-wallace-note-7", "summary" : "Priority 1: Acute pain. Physiological, Actual, Open. Comments empty; documented-by field unselected.", "type" : "Plan of care" }, { "dateTime" : "2022-02-09T12:00:00", "id" : "tony-wallace-note-8", "summary" : "2/9/2022: 05:00 IVPB/IV Push 960 mL and oral 600 mL; urine 750 mL. 11:00 urine count 2 (no volume documented). 12:00 IVPB/IV Push 960 mL; urine 600 mL; emesis 200 mL. Source totals: intake 2520 mL, output 1550 mL, balance +970 mL. Fluid categories retained as documented.", "type" : "Intake/output summary" }, { "id" : "tony-wallace-allergy-source", "summary" : "No known medication, food, or environmental allergies (documented 2/7/2022 13:00 by K Chambers).", "type" : "Allergy documentation" } ], "orders" : [ { "author" : "Dr. Jill Herrick, Admitting Physician", "category" : "Medical Floor", "dateTime" : "2022-02-07T14:00:00", "id" : "tw-med-order-1", "orderText" : "Ceftriaxone (Rocephin): 2 gram IVPB q12h. Source order stop: 2022-02-21T14:00:00. ", "status" : "Active" }, { "author" : "Dr. Jill Herrick, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2022-02-07T14:00:00", "id" : "tw-med-order-2", "orderText" : "Folic Acid (vitamin B9): 1 mg PO q24h. Source order stop: 2022-02-21T14:00:00. ", "status" : "Active" }, { "author" : "Dr. Jill Herrick, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2022-02-07T14:00:00", "id" : "tw-med-order-3", "orderText" : "Oxycodone (Oxycontin): 80 mg PO q12h. Source order stop: 2022-02-21T14:00:00. ", "status" : "Active" }, { "author" : "Dr. Jill Herrick, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2022-02-07T14:00:00", "id" : "tw-med-order-4", "orderText" : "Hydroxyurea (Droxia): 1000 mg PO q24h. Source order stop: 2022-02-21T14:00:00. ", "status" : "Active" }, { "author" : "Dr. Jill Herrick, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2022-02-07T14:00:00", "id" : "tw-med-order-5", "orderText" : "Senna/docusate (Senokot-S): 2 tabs PO q12h. Hold for loose stools. Source order stop: 2022-02-21T14:00:00. ", "status" : "Active" }, { "author" : "Dr. Jill Herrick, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2022-02-07T22:00:00", "id" : "tw-med-order-6", "orderText" : "Enoxaparin Sodium (Lovenox): 40 mg SC q24h. Source order stop: 2022-02-21T22:00:00. ", "status" : "Active" }, { "author" : "Dr. Jill Herrick, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2022-02-07T13:00:00", "id" : "tw-med-order-7", "orderText" : "Ketorolac (Toradol): 30 mg IV q6h x4. Source order stop: 2022-02-21T13:00:00. ", "status" : "Discontinued" }, { "author" : "Dr. Jill Herrick, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2022-02-07T13:00:00", "id" : "tw-med-order-8", "orderText" : "Lidex 0.05% and moisterizer with menthol lotion: 1 application topical q12h. Apply to skin BID and as needed itching/dryness. Source order stop: 2022-02-21T13:00:00. ", "status" : "Active" }, { "author" : "Dr. Jill Herrick, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2022-02-07T13:00:00", "id" : "tw-med-order-9", "orderText" : "ketorolac tromethamine (oral, nasal, injection): 30 mg IV q6h PRN. To begin after ketorolac 30 mg IV q6h x4 doses. Source order stop: 2022-02-21T13:00:00. ", "status" : "Active" }, { "author" : "Dr. Jill Herrick, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2022-02-07T13:00:00", "id" : "tw-med-order-10", "orderText" : "ondansetron: 4 mg IV q6h PRN. For nausea and vomiting. Source order stop: 2022-02-21T13:00:00. ", "status" : "Active" }, { "author" : "Dr. Jill Herrick, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2022-02-07T13:00:00", "id" : "tw-med-order-11", "orderText" : "acetaminophen: 650 mg PO q6h PRN. For temperature greater than 100 F. Source order stop: 2022-02-21T13:00:00. ", "status" : "Active" }, { "author" : "Dr. Jill Herrick, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2022-02-07T13:00:00", "id" : "tw-med-order-12", "orderText" : "morphine sulfate: PCA IV: demand only 2 mg q10min PRN; 4-hour lockout 48 mg. RN-to-RN check at shift change and every dosage, medication, rate or bag change. Source order stop: 2022-02-21T13:00:00. ", "status" : "Active" }, { "author" : "Dr. Jill Herrick, Admitting Physician", "category" : "Pharmacy", "dateTime" : "2022-02-07T13:00:00", "id" : "tw-med-order-13", "orderText" : "sodium chloride: 120 mL/hr IV continuous; concentration not documented. Source order stop: 2022-02-21T13:00:00. ", "status" : "Active" }, { "author" : "Dr. Jill Herrick, Admitting Physician", "category" : "Monitoring", "dateTime" : "2022-02-07T13:00:00", "id" : "tw-order-1", "orderText" : "End-tidal carbon dioxide monitoring. With PCA pump; continuous. Timing: Routine.", "status" : "Active" }, { "author" : "Dr. Jill Herrick, Admitting Physician", "category" : "Consult", "dateTime" : "2022-02-09T13:30:00", "id" : "tw-order-2", "orderText" : "ICU Consult for evaluation. Once. Timing: Routine.", "status" : "Active" }, { "author" : "Dr. Jill Herrick, Admitting Physician", "category" : "Dietary", "dateTime" : "2022-02-07T13:00:00", "id" : "tw-order-3", "orderText" : "Regular Diet. Continuous. Timing: Routine.", "status" : "Superseded" }, { "author" : "Dr. Jill Herrick, Admitting Physician", "category" : "Dietary", "dateTime" : "2022-02-09T13:30:00", "id" : "tw-order-4", "orderText" : "NPO except for meds. Once. Timing: Routine.", "status" : "Active" }, { "author" : "Dr. Jill Herrick, Admitting Physician", "category" : "Laboratory", "dateTime" : "2022-02-07T13:00:00", "id" : "tw-order-5", "orderText" : "Venipuncture. Once on admission: reticulocyte count, CBC with differential, CMP. Timing: Routine.", "status" : "Active" }, { "author" : "Dr. Jill Herrick, Admitting Physician", "category" : "Laboratory", "dateTime" : "2022-02-07T13:00:00", "id" : "tw-order-6", "orderText" : "Venipuncture. q24h: CBC with differential, BMP. Timing: Routine.", "status" : "Active" }, { "author" : "Dr. Jill Herrick, Admitting Physician", "category" : "Laboratory", "dateTime" : "2022-02-09T13:30:00", "id" : "tw-order-7", "orderText" : "Arterial puncture for blood gas analysis. ABG STAT, once. Timing: Stat.", "status" : "Active" }, { "author" : "Dr. Jill Herrick, Admitting Physician", "category" : "Laboratory", "dateTime" : "2022-02-09T13:30:00", "id" : "tw-order-8", "orderText" : "Blood and blood product transfusion. Type and crossmatch for 2 units packed red blood cells; once. No transfusion administration documented in this order. Timing: Routine.", "status" : "Active" }, { "author" : "Dr. Jill Herrick, Admitting Physician", "category" : "Nursing", "dateTime" : "2022-02-07T13:00:00", "id" : "tw-order-9", "orderText" : "Admit to Medical Unit. Condition stable; continuous. Timing: Routine.", "status" : "Active" }, { "author" : "Dr. Jill Herrick, Admitting Physician", "category" : "Nursing", "dateTime" : "2022-02-07T13:00:00", "id" : "tw-order-10", "orderText" : "Incentive spirometry. q1h x10 while awake. Timing: Routine.", "status" : "Active" }, { "author" : "Dr. Jill Herrick, Admitting Physician", "category" : "Nursing", "dateTime" : "2022-02-09T13:30:00", "id" : "tw-order-11", "orderText" : "Transfer to ICU. Once; transfer to ICU. Timing: Stat.", "status" : "Active" }, { "author" : "Dr. Jill Herrick, Admitting Physician", "category" : "Nursing", "dateTime" : "2022-02-07T13:00:00", "id" : "tw-order-12", "orderText" : "Communication. PCA RN-to-RN checks at shift change and with every dosage, medication, rate, or bag change. Timing: Routine.", "status" : "Active" }, { "author" : "Dr. Jill Herrick, Admitting Physician", "category" : "Nursing", "dateTime" : "2022-02-09T13:30:00", "id" : "tw-order-13", "orderText" : "Communication: Administer PRN Acetaminophen. 650 mg PO once for temperature >100.5 F or 38 C. Timing: Routine.", "status" : "Active" }, { "author" : "Dr. Jill Herrick, Admitting Physician", "category" : "Nursing", "dateTime" : "2022-02-09T13:30:00", "id" : "tw-order-14", "orderText" : "12-lead electrocardiogram. Once, STAT. Timing: Stat.", "status" : "Active" }, { "author" : "Dr. Jill Herrick, Admitting Physician", "category" : "Nursing: Activity", "dateTime" : "2022-02-07T13:00:00", "id" : "tw-order-15", "orderText" : "Oxygen administration. Continuous; maintain SpO2 greater than 92%. Timing: Stat.", "status" : "Active" }, { "author" : "Dr. Jill Herrick, Admitting Physician", "category" : "Nursing: Activity", "dateTime" : "2022-02-07T13:00:00", "id" : "tw-order-16", "orderText" : "Activity. As tolerated; continuous. Timing: Routine.", "status" : "Active" }, { "author" : "Dr. Jill Herrick, Admitting Physician", "category" : "Nursing: Activity", "dateTime" : "2022-02-07T13:00:00", "id" : "tw-order-17", "orderText" : "Intake and output assessment. q6h; every shift. Timing: Routine.", "status" : "Active" }, { "author" : "Dr. Jill Herrick, Admitting Physician", "category" : "Nursing: Activity", "dateTime" : "2022-02-09T13:30:00", "id" : "tw-order-18", "orderText" : "Oxygen administration. NRB 100% FiO2; continuous. Timing: Routine.", "status" : "Active" }, { "author" : "Dr. Jill Herrick, Admitting Physician", "category" : "Nursing: Activity", "dateTime" : "2022-02-09T13:30:00", "id" : "tw-order-19", "orderText" : "Communication: Give scheduled oral pain medication. Once. Timing: Routine.", "status" : "Active" }, { "author" : "Dr. Jill Herrick, Admitting Physician", "category" : "Nursing: Activity", "dateTime" : "2022-02-09T13:30:00", "id" : "tw-order-20", "orderText" : "Vital Signs. q1h. Timing: Routine.", "status" : "Active" }, { "author" : "Dr. Jill Herrick, Admitting Physician", "category" : "Nursing: Activity", "dateTime" : "2022-02-09T13:30:00", "id" : "tw-order-21", "orderText" : "Droplet precautions. Continuous. Timing: Routine.", "status" : "Active" }, { "author" : "Dr. Jill Herrick, Admitting Physician", "category" : "Nursing: Activity", "dateTime" : "2022-02-09T13:30:00", "id" : "tw-order-22", "orderText" : "Contact precautions. Continuous. Timing: Routine.", "status" : "Active" }, { "author" : "Dr. Jill Herrick, Admitting Physician", "category" : "Nursing: Activity", "dateTime" : "2022-02-07T13:00:00", "id" : "tw-order-23", "orderText" : "Infection precautions for SARS-CoV-2. Continuous. Timing: Routine.", "status" : "Active" }, { "author" : "Dr. Jill Herrick, Admitting Physician", "category" : "Nursing: Monitoring", "dateTime" : "2022-02-07T13:00:00", "id" : "tw-order-24", "orderText" : "Vital Signs. q4h. Timing: Routine.", "status" : "Superseded" }, { "author" : "Dr. Jill Herrick, Admitting Physician", "category" : "Nursing: Monitoring", "dateTime" : "2022-02-07T13:00:00", "id" : "tw-order-25", "orderText" : "Pulse oximetry. Continuous. Timing: Routine.", "status" : "Active" }, { "author" : "Dr. Jill Herrick, Admitting Physician", "category" : "Radiology", "dateTime" : "2022-02-09T13:30:00", "id" : "tw-order-26", "orderText" : "Portable Chest X-ray. Once, STAT. Timing: Stat.", "status" : "Active" } ], "overview" : { "emergencyContact" : "Andrea Wallace (mother)", "height" : "70 in / 177.8 cm", "isolationIndicator" : "Airborne", "religion" : "Methodist", "weightKg" : 65.8 }, "vitals" : [ { "bloodPressure" : "112/74", "dateTime" : "2022-02-09T04:00:00", "heartRate" : 98, "id" : "tw-vital-04:00", "oxygenDevice" : "Room Air", "respiratoryRate" : 22, "spo2" : "94%", "temperature" : "100.4 °F oral" }, { "bloodPressure" : "110/70", "dateTime" : "2022-02-09T13:00:00", "heartRate" : 115, "id" : "tw-vital-13:00", "oxygenDevice" : "Room Air", "respiratoryRate" : 26, "spo2" : "90%", "temperature" : "100.5 °F oral" }, { "dateTime" : "2022-02-09T13:30:00", "id" : "tw-vital-13:30", "temperature" : "101.1 °F oral" } ] }, "patient" : { "admitDateTime" : "2022-02-07T13:00:00", "admittingDiagnosis" : "Anemia (sickle cell)", "allergies" : [ ], "attending" : "Dr. Jill Herrick, Admitting Physician", "chartDisplayName" : "Wallace, Tony R", "codeStatus" : "Full Code", "dob" : "9/7/XX", "history" : { "chiefComplaint" : "My left arm and leg are killing me. I can't control the pain at home. Please help me", "pastMedicalHistory" : [ "Hb SS sickle cell disease; recurrent vaso-occlusive crises and acute chest syndrome." ], "pastSurgicalHistory" : [ "No prior surgical history." ], "socialHistory" : [ "Age 24; birth year intentionally masked. Never married. Lives alone at home. College education; can read and write.", "Nonsmoker, no smokeless tobacco or other nicotine use; nondrinker; no illicit drug use.", "Black or African American; not Hispanic or Latino. Methodist. Surgical technician at County Hospital.", "Source simulated address: 56 Jenkins Way, Clymer, Indiana, 21XXX; source masked SSN 21X-XX-XXXX.", "Mother/next of kin and emergency contact: Andrea Wallace; contact number not documented. Primary language not documented." ] }, "mrn" : "PCS90700", "sex" : "Male", "simulatedFullName" : "Tony Ray Wallace", "unit" : "Holy Cross Hospital — Medical Unit, Room 204 Bed B" }, "setting" : "Holy Cross Hospital — Medical Unit, Room 204 Bed B", "snapshots" : [ { "activityIds" : [ ], "id" : "tony-wallace-current", "notes" : "One captured chart state; all dated records are visible. Progressive-release behavior is not recreated.", "scenarioTime" : "2022-02-09T13:30:00", "sourcePath" : "DocuCare instructor chart: Nur 21: Tony Wallace", "title" : "Captured chart" } ], "subtitle" : "N21 practice record", "tags" : [ "N21", "DocuCare migration" ], "title" : "Tony Wallace" }, "packageId" : "docucare-n21-tony-wallace-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" : "n21-tony-wallace", "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" : "Tony Ray Wallace" }, { "envelope" : { "appName" : "ChartSlate", "audience" : "student", "createdAt" : "2026-09-22T21:10:32.768033+00:00", "exportVersion" : "1", "kind" : "casePackage", "package" : { "case" : { "activities" : [ ], "id" : "docucare-n21-maria-gonzales", "learningLevel" : "N21", "panels" : { "assessments" : [ { "author" : "K Chambers, Registered Nurse", "dateTime" : "2022-07-06T15:00:00", "id" : "maria-gonzales-assessment-1", "label" : "Neurological", "summary" : "Oriented person/time/place/situation; hearing intact; agitated. All extremities move spontaneously. Pupils not selected. Secondary scales unverified." }, { "author" : "K Chambers, Registered Nurse", "dateTime" : "2022-07-06T15:00:00", "id" : "maria-gonzales-assessment-2", "label" : "Cardiovascular", "summary" : "S1/S2 regular; pulses +2 all; no edema; capillary refill <3 seconds all. Skin warm, dry, intact." }, { "author" : "K Chambers, Registered Nurse", "dateTime" : "2022-07-06T15:00:00", "id" : "maria-gonzales-assessment-3", "label" : "Gastrointestinal", "summary" : "Distended, round, tender abdomen; vomiting bilious emesis and nausea; last BM source admission time. Hypoactive bowel sounds; NPO. GI secondary tabs unverified." }, { "author" : "K Chambers, Registered Nurse", "dateTime" : "2022-07-06T15:00:00", "id" : "maria-gonzales-assessment-4", "label" : "Genitourinary", "summary" : "No urinary symptoms; yellow concentrated urine; voiding without difficulty. No catheter type or size selected." }, { "author" : "K Chambers, Registered Nurse", "dateTime" : "2022-07-06T15:00:00", "id" : "maria-gonzales-assessment-5", "label" : "Respiratory", "summary" : "No symptoms or sputum; regular respirations; default RUL tab clear. Other lobes and therapy subtabs unverified; no oxygen device selected." }, { "author" : "K Chambers, Registered Nurse", "dateTime" : "2022-07-06T15:00:00", "id" : "maria-gonzales-assessment-6", "label" : "Musculoskeletal", "summary" : "Weakness; movement against resistance but less than normal all extremities; unsteady gait; devices none." }, { "author" : "B Conroy, Registered Nurse", "dateTime" : "2022-07-07T00:00:00", "id" : "maria-gonzales-assessment-7", "label" : "Neurological", "summary" : "Disoriented, drowsy at times; aware of person/place; disoriented to time but easily reoriented; confused and agitated. All extremities move spontaneously. Pupils not selected. Secondary scales unverified." }, { "author" : "B Conroy, Registered Nurse", "dateTime" : "2022-07-07T00:00:00", "id" : "maria-gonzales-assessment-8", "label" : "Cardiovascular", "summary" : "S1/S2 regular; pulses +2 all; no edema; capillary refill <3 seconds all. Skin appropriate for ethnicity and intact." }, { "author" : "B Conroy, Registered Nurse", "dateTime" : "2022-07-07T00:00:00", "id" : "maria-gonzales-assessment-9", "label" : "Gastrointestinal", "summary" : "Distended, tender abdomen; nausea; last BM 7/6 18:00. Hypoactive bowel sounds; NPO. GI secondary tabs unverified." }, { "author" : "B Conroy, Registered Nurse", "dateTime" : "2022-07-07T00:00:00", "id" : "maria-gonzales-assessment-10", "label" : "Genitourinary", "summary" : "No urinary symptoms; amber concentrated urine; voiding without difficulty. No catheter type or size selected." }, { "author" : "B Conroy, Registered Nurse", "dateTime" : "2022-07-07T00:00:00", "id" : "maria-gonzales-assessment-11", "label" : "Respiratory", "summary" : "No symptoms or sputum; regular respirations; default RUL tab clear. Other lobes and therapy subtabs unverified; no oxygen device selected." }, { "author" : "B Conroy, Registered Nurse", "dateTime" : "2022-07-07T00:00:00", "id" : "maria-gonzales-assessment-12", "label" : "Musculoskeletal", "summary" : "Weakness; movement against resistance but less than normal all extremities; devices none." }, { "author" : "B Conroy, Registered Nurse", "dateTime" : "2022-07-06T14:00:00", "id" : "maria-gonzales-assessment-13", "label" : "Pain", "summary" : "Abdominal pain 8/10, radiating; sharp, penetrating and radiating to mid back. Onset admission time." }, { "author" : "B Conroy, Registered Nurse", "dateTime" : "2022-07-06T16:00:00", "id" : "maria-gonzales-assessment-14", "label" : "Skin", "summary" : "Clean, dry, intact." }, { "author" : "B Conroy, Registered Nurse", "dateTime" : "2022-07-07T14:00:00", "id" : "maria-gonzales-assessment-15", "label" : "Skin", "summary" : "Clean, dry, intact." }, { "author" : "K Chambers, Registered Nurse", "dateTime" : "2022-07-06T16:00:00", "id" : "maria-gonzales-assessment-16", "label" : "Vascular access", "summary" : "Right forearm 18 gauge peripheral IV, inserted admission day; CDI without signs of IV-related complications; transparent dressing; good blood return, flushes easily." } ], "intakeOutput" : { "documentedIntakeTotalMl" : 4000, "documentedNetMl" : 2350, "documentedOutputTotalMl" : 1650, "intakeEntries" : [ { "amountMl" : 2000, "id" : "io-in-0", "time" : "2022-07-07T16:00:00", "type" : "IVPB & IV Push" }, { "amountMl" : 2000, "id" : "io-in-1", "time" : "2022-07-07T20:00:00", "type" : "IVPB & IV Push" } ], "outputEntries" : [ { "amountMl" : 450, "id" : "io-out-0", "time" : "2022-07-07T16:00:00", "type" : "Urine" }, { "amountMl" : 200, "id" : "io-out-1", "time" : "2022-07-07T16:00:00", "type" : "NG/OG/G tube" }, { "amountMl" : 800, "id" : "io-out-2", "time" : "2022-07-07T20:00:00", "type" : "Urine" }, { "amountMl" : 200, "id" : "io-out-3", "time" : "2022-07-07T20:00:00", "type" : "NG/OG/G tube" } ] }, "labs" : [ { "category" : "POC blood glucose", "collectedDateTime" : "2022-07-07T17:00:00", "id" : "maria-gonzales-lab-1", "result" : "184 mg/dL", "test" : "Glucose" }, { "category" : "POC blood glucose", "collectedDateTime" : "2022-07-07T20:00:00", "id" : "maria-gonzales-lab-2", "result" : "198 mg/dL", "test" : "Glucose" }, { "category" : "CBC", "collectedDateTime" : "2022-07-07T11:00:00", "flag" : "Low", "id" : "maria-gonzales-lab-3", "referenceRange" : "37–49%", "result" : "30", "test" : "Hct" }, { "category" : "CBC", "collectedDateTime" : "2022-07-07T11:00:00", "flag" : "Low", "id" : "maria-gonzales-lab-4", "referenceRange" : "12–18 g/100mL", "result" : "11", "test" : "Hgb" }, { "category" : "CBC", "collectedDateTime" : "2022-07-07T11:00:00", "flag" : "Normal", "id" : "maria-gonzales-lab-5", "referenceRange" : "4.5–11/mm3", "result" : "10.9", "test" : "WBCs" }, { "category" : "CBC", "collectedDateTime" : "2022-07-07T11:00:00", "flag" : "Normal", "id" : "maria-gonzales-lab-6", "referenceRange" : "150–400 × 10³ mm3", "result" : "250,000", "test" : "Platelets" }, { "category" : "CMP", "collectedDateTime" : "2022-07-07T11:00:00", "flag" : "Normal", "id" : "maria-gonzales-lab-7", "referenceRange" : "135–145 mEq/L", "result" : "144", "test" : "Na" }, { "category" : "CMP", "collectedDateTime" : "2022-07-07T11:00:00", "flag" : "Normal", "id" : "maria-gonzales-lab-8", "referenceRange" : "3.5–5 mEq/L", "result" : "3.8", "test" : "K" }, { "category" : "CMP", "collectedDateTime" : "2022-07-07T11:00:00", "flag" : "Low", "id" : "maria-gonzales-lab-9", "referenceRange" : "1.5–2 mEq/L", "result" : "1.3", "test" : "Magnesium" }, { "category" : "CMP", "collectedDateTime" : "2022-07-07T11:00:00", "flag" : "Normal", "id" : "maria-gonzales-lab-10", "referenceRange" : "100–108 mEq/L", "result" : "105", "test" : "Cl" }, { "category" : "CMP", "collectedDateTime" : "2022-07-07T11:00:00", "flag" : "Normal", "id" : "maria-gonzales-lab-11", "referenceRange" : "8.5–10.5 mg/dL", "result" : "8.5", "test" : "Calcium" }, { "category" : "CMP", "collectedDateTime" : "2022-07-07T11:00:00", "flag" : "Normal", "id" : "maria-gonzales-lab-12", "referenceRange" : "24–30 mEq/L", "result" : "27", "test" : "CO2" }, { "category" : "CMP", "collectedDateTime" : "2022-07-07T11:00:00", "flag" : "High", "id" : "maria-gonzales-lab-13", "referenceRange" : "70–110 mg/dL", "result" : "160", "test" : "Glucose" }, { "category" : "CMP", "collectedDateTime" : "2022-07-07T11:00:00", "flag" : "Normal", "id" : "maria-gonzales-lab-14", "referenceRange" : "8–25 mg/dL", "result" : "20", "test" : "BUN" }, { "category" : "CMP", "collectedDateTime" : "2022-07-07T11:00:00", "flag" : "Normal", "id" : "maria-gonzales-lab-15", "referenceRange" : "0.6–1.5 mg/dL", "result" : "1.0", "test" : "Creatinine" }, { "category" : "CMP", "collectedDateTime" : "2022-07-07T11:00:00", "flag" : "High", "id" : "maria-gonzales-lab-16", "referenceRange" : "10–35 U/L", "result" : "160", "test" : "ALT" }, { "category" : "CMP", "collectedDateTime" : "2022-07-07T11:00:00", "flag" : "High", "id" : "maria-gonzales-lab-17", "referenceRange" : "14–20 U/L", "result" : "220", "test" : "AST" }, { "category" : "CMP", "collectedDateTime" : "2022-07-07T11:00:00", "flag" : "High", "id" : "maria-gonzales-lab-18", "referenceRange" : "25–125 U/L", "result" : "550", "test" : "Amylase" }, { "category" : "CMP", "collectedDateTime" : "2022-07-07T11:00:00", "flag" : "High", "id" : "maria-gonzales-lab-19", "referenceRange" : "<200 mg/dL", "result" : "242", "test" : "Cholesterol" }, { "category" : "CMP", "collectedDateTime" : "2022-07-07T11:00:00", "flag" : "High", "id" : "maria-gonzales-lab-20", "referenceRange" : "<100 / <40", "result" : "190/51", "test" : "LDL/HDL" }, { "category" : "CMP", "collectedDateTime" : "2022-07-07T11:00:00", "flag" : "Normal", "id" : "maria-gonzales-lab-21", "referenceRange" : "10–150 mg/dL", "result" : "130", "test" : "Triglycerides" }, { "category" : "CMP", "collectedDateTime" : "2022-07-07T11:00:00", "flag" : "High", "id" : "maria-gonzales-lab-22", "referenceRange" : "0.3–1.0 mg/dL", "result" : "3.5", "test" : "Bilirubin total" }, { "category" : "CMP", "collectedDateTime" : "2022-07-07T11:00:00", "flag" : "High", "id" : "maria-gonzales-lab-23", "referenceRange" : "0–0.2 mg/dL", "result" : "2.8/0.7", "test" : "Bilirubin D/I" }, { "category" : "CMP", "collectedDateTime" : "2022-07-07T11:00:00", "flag" : "High", "id" : "maria-gonzales-lab-24", "referenceRange" : "10–140 U/L", "result" : "879", "test" : "Lipase" }, { "category" : "ABGs — FiO2 40% face mask", "collectedDateTime" : "2022-07-07T11:00:00", "flag" : "Low", "id" : "maria-gonzales-lab-25", "referenceRange" : "7.35–7.45", "result" : "7.27", "test" : "pH" }, { "category" : "ABGs — FiO2 40% face mask", "collectedDateTime" : "2022-07-07T11:00:00", "flag" : "Low", "id" : "maria-gonzales-lab-26", "referenceRange" : "75–100 mmHg", "result" : "74", "test" : "PO2" }, { "category" : "ABGs — FiO2 40% face mask", "collectedDateTime" : "2022-07-07T11:00:00", "flag" : "Normal", "id" : "maria-gonzales-lab-27", "referenceRange" : "35–45 mmHg", "result" : "45", "test" : "PCO2" }, { "category" : "ABGs — FiO2 40% face mask", "collectedDateTime" : "2022-07-07T11:00:00", "flag" : "Low", "id" : "maria-gonzales-lab-28", "referenceRange" : "22–28 mEq/L", "result" : "21", "test" : "HCO3" }, { "category" : "ABGs — FiO2 40% face mask", "collectedDateTime" : "2022-07-07T11:00:00", "flag" : "Low", "id" : "maria-gonzales-lab-29", "referenceRange" : ">94%", "result" : "92%", "test" : "Oxygen saturation" }, { "category" : "Coagulation studies", "collectedDateTime" : "2022-07-07T11:00:00", "flag" : "Normal", "id" : "maria-gonzales-lab-30", "referenceRange" : "11.2–13.2 (±2 seconds)", "result" : "12 seconds", "test" : "PT" }, { "category" : "Coagulation studies", "collectedDateTime" : "2022-07-07T11:00:00", "flag" : "High", "id" : "maria-gonzales-lab-31", "referenceRange" : "22.1–34.1 seconds activated", "result" : "40 seconds", "test" : "PTT" }, { "category" : "Coagulation studies", "collectedDateTime" : "2022-07-07T11:00:00", "flag" : "Low", "id" : "maria-gonzales-lab-32", "referenceRange" : "2.0–3.0", "result" : "1.1", "test" : "INR" }, { "category" : "CMP", "collectedDateTime" : "2022-07-08T00:00:00", "flag" : "Normal", "id" : "maria-gonzales-lab-33", "referenceRange" : "135–145 mEq/L", "result" : "143", "test" : "Na" }, { "category" : "CMP", "collectedDateTime" : "2022-07-08T00:00:00", "flag" : "Normal", "id" : "maria-gonzales-lab-34", "referenceRange" : "3.5–5 mEq/L", "result" : "3.7", "test" : "K" }, { "category" : "CMP", "collectedDateTime" : "2022-07-08T00:00:00", "flag" : "Normal", "id" : "maria-gonzales-lab-35", "referenceRange" : "100–108 mEq/L", "result" : "105", "test" : "Cl" }, { "category" : "CMP", "collectedDateTime" : "2022-07-08T00:00:00", "flag" : "Normal", "id" : "maria-gonzales-lab-36", "referenceRange" : "24–30 mEq/L", "result" : "26", "test" : "CO2" }, { "category" : "CMP", "collectedDateTime" : "2022-07-08T00:00:00", "flag" : "High", "id" : "maria-gonzales-lab-37", "referenceRange" : "70–110 mg/dL", "result" : "420", "test" : "Glucose" }, { "category" : "CMP", "collectedDateTime" : "2022-07-08T00:00:00", "flag" : "Normal", "id" : "maria-gonzales-lab-38", "referenceRange" : "8–25 mg/dL", "result" : "21", "test" : "BUN" }, { "category" : "CMP", "collectedDateTime" : "2022-07-08T00:00:00", "flag" : "Normal", "id" : "maria-gonzales-lab-39", "referenceRange" : "0.6–1.5 mg/dL", "result" : "1.1", "test" : "Creatinine" }, { "category" : "CMP", "collectedDateTime" : "2022-07-08T00:00:00", "flag" : "Low", "id" : "maria-gonzales-lab-40", "referenceRange" : "8.5–10.5 mg/dL", "result" : "8.4", "test" : "Calcium" }, { "category" : "CMP", "collectedDateTime" : "2022-07-08T00:00:00", "flag" : "High", "id" : "maria-gonzales-lab-41", "referenceRange" : "0.3–1 mg/dL", "result" : "3.5", "test" : "Bilirubin total" }, { "category" : "CMP", "collectedDateTime" : "2022-07-08T00:00:00", "flag" : "High", "id" : "maria-gonzales-lab-42", "referenceRange" : "14–20 U/L", "result" : "220", "test" : "AST" }, { "category" : "CMP", "collectedDateTime" : "2022-07-08T00:00:00", "flag" : "High", "id" : "maria-gonzales-lab-43", "referenceRange" : "10–35 U/L", "result" : "160", "test" : "ALT" }, { "category" : "CMP", "collectedDateTime" : "2022-07-08T00:00:00", "flag" : "High", "id" : "maria-gonzales-lab-44", "referenceRange" : "0–0.2 mg/dL", "result" : "2.8/0.7", "test" : "Bilirubin D/I" }, { "category" : "CMP", "collectedDateTime" : "2022-07-08T00:00:00", "flag" : "High", "id" : "maria-gonzales-lab-45", "referenceRange" : "25–125 U/L", "result" : "600", "test" : "Amylase" }, { "category" : "CMP", "collectedDateTime" : "2022-07-08T00:00:00", "flag" : "High", "id" : "maria-gonzales-lab-46", "referenceRange" : "10–140 U/L", "result" : "950", "test" : "Lipase" }, { "category" : "CMP", "collectedDateTime" : "2022-07-08T00:00:00", "flag" : "Normal", "id" : "maria-gonzales-lab-47", "referenceRange" : "1.5–2 mEq/L", "result" : "1.5", "test" : "Magnesium" }, { "category" : "CBC", "collectedDateTime" : "2022-07-08T00:00:00", "flag" : "High", "id" : "maria-gonzales-lab-48", "referenceRange" : "4.5–11.0/mm3", "result" : "14.5", "test" : "WBC (10 x 3/uL)" }, { "category" : "CBC", "collectedDateTime" : "2022-07-08T00:00:00", "flag" : "Low", "id" : "maria-gonzales-lab-49", "referenceRange" : "13–18 g/100mL", "result" : "9", "test" : "Hemoglobin" }, { "category" : "CBC", "collectedDateTime" : "2022-07-08T00:00:00", "flag" : "Low", "id" : "maria-gonzales-lab-50", "referenceRange" : "37–49%", "result" : "28%", "test" : "Hematocrit" }, { "category" : "CBC", "collectedDateTime" : "2022-07-08T00:00:00", "flag" : "Normal", "id" : "maria-gonzales-lab-51", "referenceRange" : "140–400 × 10³ mm3", "result" : "250", "test" : "Platelets (1000/mm3)" } ], "medications" : [ { "administrationBy" : "B Conroy, Registered Nurse", "doseRouteFrequency" : "20 mg IV q24h", "drug" : "Esomeprazole (Nexium)", "id" : "mg-med-1", "lastGiven" : "2022-07-07T11:00:00", "nextDue" : "2022-07-08T11:00:00", "notes" : "Stat Source order stop: 2022-07-20T23:00:00. Administration history: 2022-07-06T14:00:00 — K Chambers, Registered Nurse; administered Yes; 2022-07-07T11:00:00 — B Conroy, Registered Nurse; administered Yes", "orderedBy" : "Dr. Meyer, Primary Care Provider", "orderedDateTime" : "2022-07-06T23:00:00", "section" : "Scheduled", "status" : "Active" }, { "administrationBy" : "K Chambers, Registered Nurse", "doseRouteFrequency" : "1 gram IVPB once", "drug" : "ceftriaxone sodium", "id" : "mg-med-2", "lastGiven" : "2022-07-06T15:00:00", "notes" : "Ceftriaxone 1 gram IVPB x1 now. Source order stop: 2022-07-20T23:00:00. Administration history: 2022-07-06T15:00:00 — K Chambers, Registered Nurse; administered Yes", "orderedBy" : "Dr. Meyer, Primary Care Provider", "orderedDateTime" : "2022-07-06T23:00:00", "section" : "Discontinued", "status" : "Discontinued" }, { "doseRouteFrequency" : "Sliding scale SC once", "drug" : "insulin (regular)", "id" : "mg-med-3", "nextDue" : "2022-07-08T00:00:00", "notes" : "For glucose >180 mg/dL: 181–230: 3 units; 231–280: 6 units; 281–320: 9 units; >320: 12 units and call provider. Source order stop: 2022-07-22T00:00:00. Administration table: no data. Overlapping insulin orders: clarify intended single regimen before administration; do not add the now dose to the scale.", "orderedBy" : "Dr. Meyer, Primary Care Provider", "orderedDateTime" : "2022-07-08T00:00:00", "section" : "Scheduled", "status" : "Active" }, { "doseRouteFrequency" : "500 mg IVPB q24h x3", "drug" : "Imipenem", "id" : "mg-med-4", "nextDue" : "2022-07-08T00:00:00", "notes" : "Administer first dose after blood cultures. Source order stop: 2022-07-22T00:00:00. Administration table: no data. Formulation and q24h x3 frequency require clarification; source retained.", "orderedBy" : "Dr. Meyer, Primary Care Provider", "orderedDateTime" : "2022-07-08T00:00:00", "section" : "Scheduled", "status" : "Active" }, { "doseRouteFrequency" : "650 mg rectal once", "drug" : "acetaminophen", "id" : "mg-med-5", "nextDue" : "2022-07-08T00:00:00", "notes" : " Source order stop: 2022-07-22T00:00:00. Administration table: no data.", "orderedBy" : "Dr. Meyer, Primary Care Provider", "orderedDateTime" : "2022-07-08T00:00:00", "section" : "Scheduled", "status" : "Active" }, { "administrationBy" : "B Conroy, Registered Nurse", "doseRouteFrequency" : "4 mg IV q6h PRN", "drug" : "ondansetron", "id" : "mg-med-6", "lastGiven" : "2022-07-07T17:00:00", "notes" : "PRN nausea. Source order stop: 2022-07-20T23:00:00. Administration history: 2022-07-07T00:00:00 — K Chambers, Registered Nurse; administered Yes; 2022-07-07T17:00:00 — B Conroy, Registered Nurse; administered Yes", "orderedBy" : "Dr. Meyer, Primary Care Provider", "orderedDateTime" : "2022-07-06T23:00:00", "section" : "PRN", "status" : "Active" }, { "doseRouteFrequency" : "12 units SC once", "drug" : "Regular Insulin", "id" : "mg-med-7", "notes" : "12 units Regular insulin subcutaneous x1 now, recheck glucose in 15 minutes. Source order stop: 2022-07-22T00:00:00. Administration table: no data. Overlapping insulin orders: clarify intended single regimen before administration; do not add the now dose to the scale.", "orderedBy" : "Dr. Meyer, Primary Care Provider", "orderedDateTime" : "2022-07-08T00:00:00", "section" : "PRN", "status" : "Active" }, { "administrationBy" : "B Conroy, Registered Nurse", "doseRouteFrequency" : "2 mg IV q2h PRN", "drug" : "morphine sulfate", "id" : "mg-med-8", "lastGiven" : "2022-07-07T23:00:00", "notes" : "PRN pain. Source order stop: 2022-07-20T23:00:00. Administration history: 2022-07-06T14:00:00 — K Chambers, Registered Nurse; administered Yes; 2022-07-06T18:00:00 — K Chambers, Registered Nurse; administered Yes; 2022-07-07T00:00:00 — K Chambers, Registered Nurse; administered Yes; 2022-07-07T13:00:00 — B Conroy, Registered Nurse; administered Yes; 2022-07-07T17:00:00 — B Conroy, Registered Nurse; administered Yes; 2022-07-07T23:00:00 — B Conroy, Registered Nurse; administered Yes", "orderedBy" : "Dr. Meyer, Primary Care Provider", "orderedDateTime" : "2022-07-06T23:00:00", "section" : "PRN", "status" : "Active" }, { "doseRouteFrequency" : "D50W 25 mL IV push, may repeat once", "drug" : "dextrose", "id" : "mg-med-9", "notes" : "For glucose <60 mg/dL, give 25 mL D50W IV push. Recheck in 15 minutes; if <70 mg/dL repeat once. Source order stop: 2022-07-22T00:00:00. Administration table: no data.", "orderedBy" : "Dr. Meyer, Primary Care Provider", "orderedDateTime" : "2022-07-08T00:00:00", "section" : "PRN", "status" : "Active" }, { "administrationBy" : "K Chambers, Registered Nurse", "doseRouteFrequency" : "500 mL/hr IV continuous", "drug" : "Lactated Ringers", "id" : "mg-med-10", "lastGiven" : "2022-07-06T23:00:00", "notes" : " Source order stop: 2022-07-20T23:00:00. Administration history: 2022-07-06T23:00:00 — K Chambers, Registered Nurse; administered Yes Discontinued at 2022-07-08T00:00:00 per explicit discontinuation order.", "orderedBy" : "Dr. Meyer, Primary Care Provider", "orderedDateTime" : "2022-07-06T23:00:00", "section" : "Cont. Infusion", "status" : "Discontinued" }, { "doseRouteFrequency" : "200 mL/hr IV continuous", "drug" : "Lactated Ringers", "id" : "mg-med-11", "nextDue" : "2022-07-08T00:00:00", "notes" : " Source order stop: 2022-07-22T00:00:00. Administration table: no data.", "orderedBy" : "Dr. Meyer, Primary Care Provider", "orderedDateTime" : "2022-07-08T00:00:00", "section" : "Cont. Infusion", "status" : "Active" } ], "notes" : [ { "author" : "K Chambers, Registered Nurse", "dateTime" : "2022-07-06T14:00:00", "id" : "maria-gonzales-note-1", "summary" : "Additional diagnosis: Hyperlipidemia. Standard precautions, Full Code. Admitted 1 day 10 hours before launch. Height 60 inches, weight 205 lb (93 kg).", "type" : "Encounter" }, { "author" : "Dr. Meyer, Primary Care Provider", "dateTime" : "2022-07-06T14:00:00", "id" : "maria-gonzales-note-2", "summary" : "Admission: Mrs. Gonzales presents to the emergency department with nausea and vomiting; persistent, severe upper abdominal pain described as sharp, penetrating, and radiating to her mid back. Over the last month she has experienced intermittent, upper abdominal discomfort when eating a fatty meal. Past Medical History: Mrs. Gonzales has a history of hyperlipidemia and class III obesity (BMI 40). She has a history of smoking but quit 20 years ago and drinks alcohol on social occasions. Plan: 1. Abdominal Ultrasound 2. IV Fluids 3. Antiemetics 4. Pain Management 5. Labs - CMP, CBC, ABG, Coags, Amylase, Lipase 6. Possible admission based on labs and ultrasound findings", "type" : "Physician Notes" }, { "author" : "K Chambers, Registered Nurse", "dateTime" : "2022-07-07T14:00:00", "id" : "maria-gonzales-note-3", "summary" : "Situation: Maria Gonzales is a 56-year-old female who arrived at the emergency department (ED) yesterday with abdominal pain. After an abdominal ultrasound, she was diagnosed with choledocholithiasis. Her labs also indicated signs of acute pancreatitis with an elevated lipase and amylase. Background: The patient has a history of hyperlipidemia and class III obesity (BMI 40). She has a history of smoking but quit 20 years ago and drinks alcohol on social occasions. She takes simvastatin daily. Assessment: The patient is drowsy at times, slightly agitated, and oriented to person and place; she is disoriented to time but easily reoriented. She is receiving morphine 2 mg IVP PRN for pain and was last medicated an hour ago. She has a nasogastric tube (NGT) that was placed for intractable vomiting and abdominal distention. The NGT is attached to low intermittent wall suction and has drained 400 mL in the last 8 hours. The NGT drainage is light brown, mucousy. The patient was started on point of care (POC) blood glucose checks Q6 hours at 0600 this morning. Her last POC glucose was 198; call the provider if glucose is > 200. Recommendation: Continue to monitor the patient’s point of care glucose checks. Labs results will be available any minute. Continue to monitor vital signs every 4 hours and as needed.", "type" : "Nursing - Shift" }, { "dateTime" : "2022-07-07T20:00:00", "id" : "maria-gonzales-note-4", "summary" : "7/7: 16:00 intake IVPB/IV Push 2000 mL, urine 450 mL, NG/OG/G tube 200 mL. 20:00 intake IVPB/IV Push 2000 mL, urine 800 mL, NG/OG/G tube 200 mL. Totals: 4000 mL in, 1650 mL out, +2350 mL. Categories retained as charted.", "type" : "Intake/output summary" }, { "id" : "maria-gonzales-allergy-source", "summary" : "Aspirin — urticaria; Betadine — contact dermatitis (documented 7/6/2022 14:10).", "type" : "Allergy documentation" } ], "orders" : [ { "author" : "Dr. Meyer, Primary Care Provider", "category" : "Pharmacy", "dateTime" : "2022-07-06T23:00:00", "id" : "mg-med-order-1", "orderText" : "Esomeprazole (Nexium): 20 mg IV q24h. Stat", "status" : "Active" }, { "author" : "Dr. Meyer, Primary Care Provider", "category" : "Pharmacy", "dateTime" : "2022-07-06T23:00:00", "id" : "mg-med-order-2", "orderText" : "ceftriaxone sodium: 1 gram IVPB once. Ceftriaxone 1 gram IVPB x1 now.", "status" : "Discontinued" }, { "author" : "Dr. Meyer, Primary Care Provider", "category" : "Pharmacy", "dateTime" : "2022-07-08T00:00:00", "id" : "mg-med-order-3", "orderText" : "insulin (regular): Sliding scale SC once. For glucose >180 mg/dL: 181–230: 3 units; 231–280: 6 units; 281–320: 9 units; >320: 12 units and call provider.", "status" : "Active" }, { "author" : "Dr. Meyer, Primary Care Provider", "category" : "Pharmacy", "dateTime" : "2022-07-08T00:00:00", "id" : "mg-med-order-4", "orderText" : "Imipenem: 500 mg IVPB q24h x3. Administer first dose after blood cultures.", "status" : "Active" }, { "author" : "Dr. Meyer, Primary Care Provider", "category" : "Pharmacy", "dateTime" : "2022-07-08T00:00:00", "id" : "mg-med-order-5", "orderText" : "acetaminophen: 650 mg rectal once. ", "status" : "Active" }, { "author" : "Dr. Meyer, Primary Care Provider", "category" : "Pharmacy", "dateTime" : "2022-07-06T23:00:00", "id" : "mg-med-order-6", "orderText" : "ondansetron: 4 mg IV q6h PRN. PRN nausea.", "status" : "Active" }, { "author" : "Dr. Meyer, Primary Care Provider", "category" : "Pharmacy", "dateTime" : "2022-07-08T00:00:00", "id" : "mg-med-order-7", "orderText" : "Regular Insulin: 12 units SC once. 12 units Regular insulin subcutaneous x1 now, recheck glucose in 15 minutes.", "status" : "Active" }, { "author" : "Dr. Meyer, Primary Care Provider", "category" : "Pharmacy", "dateTime" : "2022-07-06T23:00:00", "id" : "mg-med-order-8", "orderText" : "morphine sulfate: 2 mg IV q2h PRN. PRN pain.", "status" : "Active" }, { "author" : "Dr. Meyer, Primary Care Provider", "category" : "Pharmacy", "dateTime" : "2022-07-08T00:00:00", "id" : "mg-med-order-9", "orderText" : "dextrose: D50W 25 mL IV push, may repeat once. For glucose <60 mg/dL, give 25 mL D50W IV push. Recheck in 15 minutes; if <70 mg/dL repeat once.", "status" : "Active" }, { "author" : "Dr. Meyer, Primary Care Provider", "category" : "Pharmacy", "dateTime" : "2022-07-06T23:00:00", "id" : "mg-med-order-10", "orderText" : "Lactated Ringers: 500 mL/hr IV continuous. ", "status" : "Discontinued" }, { "author" : "Dr. Meyer, Primary Care Provider", "category" : "Pharmacy", "dateTime" : "2022-07-08T00:00:00", "id" : "mg-med-order-11", "orderText" : "Lactated Ringers: 200 mL/hr IV continuous. ", "status" : "Active" }, { "author" : "Dr. Meyer, Primary Care Provider", "category" : "Dietary", "dateTime" : "2022-07-07T11:00:00", "id" : "mg-order-1", "orderText" : "Diet: Continue strict NPO. Continuous.", "status" : "Active" }, { "author" : "Dr. Meyer, Primary Care Provider", "category" : "Laboratory", "dateTime" : "2022-07-06T23:00:00", "id" : "mg-order-2", "orderText" : "Venipuncture. Source frequency q12h x1; notes daily labs every 12 hours 0600/1800: BMP, CBC, calcium, magnesium, amylase, lipase.", "status" : "Active" }, { "author" : "Dr. Meyer, Primary Care Provider", "category" : "Laboratory", "dateTime" : "2022-07-08T00:00:00", "id" : "mg-order-3", "orderText" : "Blood culture sample collection. Peripheral blood culture x2 STAT.", "status" : "Active" }, { "author" : "Dr. Meyer, Primary Care Provider", "category" : "Nursing", "dateTime" : "2022-07-06T23:00:00", "id" : "mg-order-4", "orderText" : "Unit for admission. Intermediate Care Unit. Continuous.", "status" : "Active" }, { "author" : "Dr. Meyer, Primary Care Provider", "category" : "Nursing", "dateTime" : "2022-07-06T23:00:00", "id" : "mg-order-5", "orderText" : "Condition. Guarded. Continuous.", "status" : "Active" }, { "author" : "Dr. Meyer, Primary Care Provider", "category" : "Nursing", "dateTime" : "2022-07-06T23:00:00", "id" : "mg-order-6", "orderText" : "Code management. Full Code. Continuous.", "status" : "Active" }, { "author" : "Dr. Meyer, Primary Care Provider", "category" : "Nursing: Activity", "dateTime" : "2022-07-06T23:00:00", "id" : "mg-order-7", "orderText" : "Incentive spirometry. Hourly.", "status" : "Active" }, { "author" : "Dr. Meyer, Primary Care Provider", "category" : "Nursing: Activity", "dateTime" : "2022-07-06T23:00:00", "id" : "mg-order-8", "orderText" : "Oxygen administration. Face mask 40% FiO2. Continuous.", "status" : "Active" }, { "author" : "Dr. Meyer, Primary Care Provider", "category" : "Nursing: Activity", "dateTime" : "2022-07-06T23:00:00", "id" : "mg-order-9", "orderText" : "Activity. Bedrest. Continuous.", "status" : "Active" }, { "author" : "Dr. Meyer, Primary Care Provider", "category" : "Nursing: Activity", "dateTime" : "2022-07-06T23:00:00", "id" : "mg-order-10", "orderText" : "SBAR communication. Call provider if serum glucose >200 mg/dL.", "status" : "Active" }, { "author" : "Dr. Meyer, Primary Care Provider", "category" : "Nursing: Monitoring", "dateTime" : "2022-07-06T23:00:00", "id" : "mg-order-11", "orderText" : "Vital Signs. Every 4 hours.", "status" : "Active" }, { "author" : "Dr. Meyer, Primary Care Provider", "category" : "Nursing: Monitoring", "dateTime" : "2022-07-07T11:00:00", "id" : "mg-order-12", "orderText" : "Blood glucose monitoring. Every 6 hours; Stat.", "status" : "Active" }, { "author" : "Dr. Meyer, Primary Care Provider", "category" : "Nursing: Monitoring", "dateTime" : "2022-07-06T23:00:00", "id" : "mg-order-13", "orderText" : "Cardiac monitoring. Continuous telemetry.", "status" : "Active" }, { "author" : "Dr. Meyer, Primary Care Provider", "category" : "Nursing: Monitoring", "dateTime" : "2022-07-06T23:00:00", "id" : "mg-order-14", "orderText" : "Pulse oximetry. Continuous.", "status" : "Active" }, { "author" : "Dr. Meyer, Primary Care Provider", "category" : "Nursing: Monitoring", "dateTime" : "2022-07-06T23:00:00", "id" : "mg-order-15", "orderText" : "12-lead ECG. Once.", "status" : "Active" }, { "author" : "Dr. Meyer, Primary Care Provider", "category" : "Nursing: Monitoring", "dateTime" : "2022-07-06T23:00:00", "id" : "mg-order-16", "orderText" : "Keep SpO2 greater than 95%. Continuous.", "status" : "Active" }, { "author" : "Dr. Meyer, Primary Care Provider", "category" : "PCU", "dateTime" : "2022-07-06T23:00:00", "id" : "mg-order-17", "orderText" : "Intake/output. Every 4 hours.", "status" : "Active" }, { "author" : "Dr. Meyer, Primary Care Provider", "category" : "PCU", "dateTime" : "2022-07-06T23:00:00", "id" : "mg-order-18", "orderText" : "Diet: NPO. Strict NPO continuous.", "status" : "Active" }, { "author" : "Dr. Meyer, Primary Care Provider", "category" : "Pharmacy", "dateTime" : "2022-07-08T00:00:00", "id" : "mg-order-19", "orderText" : "Discontinue LR 500 mL/hr. Once.", "status" : "Active" }, { "author" : "Dr. Meyer, Primary Care Provider", "category" : "Radiology", "dateTime" : "2022-07-07T11:00:00", "id" : "mg-order-20", "orderText" : "ERCP scheduled for tomorrow. Once.", "status" : "Active" }, { "author" : "Dr. Meyer, Primary Care Provider", "category" : "Respiratory", "dateTime" : "2022-07-07T11:00:00", "id" : "mg-order-21", "orderText" : "ABG Stat. Once.", "status" : "Active" } ], "overview" : { "emergencyContact" : "Antonio Gonzalez (spouse)", "height" : "60 in / 152.4 cm", "isolationIndicator" : "Standard", "religion" : "Catholic", "weightKg" : 93 }, "vitals" : [ { "bloodPressure" : "136/78", "dateTime" : "2022-07-07T11:00:00", "heartRate" : 116, "id" : "mg-vital-11:00", "oxygenDevice" : "Simple Face Mask", "respiratoryRate" : 24, "spo2" : "95%", "temperature" : "99.3 °F oral" }, { "bloodPressure" : "110/70", "dateTime" : "2022-07-07T15:00:00", "heartRate" : 98, "id" : "mg-vital-15:00", "oxygenDevice" : "Simple Face Mask", "respiratoryRate" : 20, "spo2" : "95%", "temperature" : "98.9 °F oral" }, { "bloodPressure" : "118/68", "dateTime" : "2022-07-07T19:00:00", "heartRate" : 110, "id" : "mg-vital-19:00", "oxygenDevice" : "Simple Face Mask", "respiratoryRate" : 22, "spo2" : "95%", "temperature" : "100.7 °F oral" } ] }, "patient" : { "admitDateTime" : "2022-07-06T14:00:00", "admittingDiagnosis" : "Pancreatitis", "allergies" : [ { "id" : "allergy-1c998002a5825354", "reaction" : "Urticaria", "severity" : "Not documented", "substance" : "Aspirin" }, { "id" : "allergy-2cd12be5fc49b445", "reaction" : "Contact dermatitis", "severity" : "Not documented", "substance" : "Betadine" } ], "attending" : "Dr. Meyer, Primary Care Provider", "chartDisplayName" : "Gonzales, Maria C", "codeStatus" : "Full Code", "dob" : "6/24/XX", "history" : { "chiefComplaint" : "My stomach and belly hurts so much. The pain is so sharp that it feels like it is going through me. I can feel it all the way to my back. The pain has made me throw up and I am very nauseous. Sometimes after a fatty meal I have stomach pain, but not as bad as what I am feeling right now.", "pastMedicalHistory" : [ "Obesity, class III (source BMI 40)", "Hyperlipidemia" ], "pastSurgicalHistory" : [ "No prior surgical history" ], "socialHistory" : [ "Age 56; birth year masked. Married; lives at home with spouse Antonio Gonzalez; two adult children. Can read and write. English primary language. Catholic. Hispanic or Latino; race Other selected without description. Sales manager at retail store.", "Former smoker, quit 20 years ago; no smokeless tobacco; other nicotine former smoker with no dates. Alcohol current user, 1–3 drinks/week, social occasions. Illicit drug nonuser.", "Source simulated address: 400 Oak Street, Saltsburg, Maine, 15XXX; masked SSN 189-XX-XXX." ] }, "mrn" : "PCS62400", "sex" : "Female", "simulatedFullName" : "Maria Consuela Gonzales", "unit" : "Holy Cross Hospital — Intermediate Care Unit, Room 206 Bed A" }, "setting" : "Holy Cross Hospital — Intermediate Care Unit, Room 206 Bed A", "snapshots" : [ { "activityIds" : [ ], "id" : "maria-gonzales-current", "notes" : "One captured chart state; all dated records are visible. Progressive-release behavior is not recreated.", "scenarioTime" : "2022-07-08T00:00:00", "sourcePath" : "DocuCare instructor chart: Nur 21: Maria Gonzales", "title" : "Captured chart" } ], "subtitle" : "N21 practice record", "tags" : [ "N21", "DocuCare migration" ], "title" : "Maria Gonzales" }, "packageId" : "docucare-n21-maria-gonzales-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" : "n21-maria-gonzales", "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" : "Maria Consuela Gonzales" }, { "envelope" : { "appName" : "ChartSlate", "audience" : "student", "createdAt" : "2026-09-22T21:10:32.768033+00:00", "exportVersion" : "1", "kind" : "casePackage", "package" : { "case" : { "activities" : [ ], "id" : "docucare-n21-colin-hawkins", "learningLevel" : "N21", "panels" : { "assessments" : [ { "author" : "Becky Masson, Registered Nurse", "dateTime" : "2026-09-22T13:07:00", "id" : "colin-hawkins-assessment-1", "label" : "Neurological", "summary" : "Oriented person/time/place/situation; pupils both 4 mm and brisk; calm, cooperative. GCS components: eyes open spontaneously, obeys verbal command, oriented x3." }, { "author" : "Becky Masson, Registered Nurse", "dateTime" : "2026-09-22T13:07:00", "id" : "colin-hawkins-assessment-2", "label" : "Cardiovascular", "summary" : "S1/S2 regular; all pulses +3; no edema; all capillary refill <3 sec. Skin appropriate for ethnicity, warm, intact, diaphoretic. Cardiac monitor first-degree heart block, HR 55. Arterial line pressure 116/55; no signs of infection, dressing CDI." }, { "author" : "Becky Masson, Registered Nurse", "dateTime" : "2026-09-22T13:07:00", "id" : "colin-hawkins-assessment-3", "label" : "GI", "summary" : "Flat, soft abdomen; nausea, bowel sounds present; diet tolerance Good. Last BM form points to admission (conflicts with social history two days before launch)." }, { "author" : "Becky Masson, Registered Nurse", "dateTime" : "2026-09-22T13:07:00", "id" : "colin-hawkins-assessment-4", "label" : "GU", "summary" : "No urinary symptoms; urine yellow and clear; catheter type/size unfilled." }, { "author" : "Becky Masson, Registered Nurse", "dateTime" : "2026-09-22T13:07:00", "id" : "colin-hawkins-assessment-5", "label" : "Respiratory", "summary" : "Nasal cannula 3 L/min. Shortness of breath and None both selected under respiratory symptoms; no sputum; regular respirations; default RUL tab clear. Other lung lobes unverified." }, { "author" : "Becky Masson, Registered Nurse", "dateTime" : "2026-09-22T13:07:00", "id" : "colin-hawkins-assessment-6", "label" : "Mental health", "summary" : "Stressors: condition, hospitalization and diagnosis. Coping well. No tool or score supplied." }, { "author" : "Becky Masson, Registered Nurse", "dateTime" : "2026-09-22T13:07:00", "id" : "colin-hawkins-assessment-7", "label" : "Musculoskeletal", "summary" : "No symptoms selected; normal strength all extremities; independent." }, { "author" : "Becky Masson, Registered Nurse", "dateTime" : "2026-09-22T13:07:00", "id" : "colin-hawkins-assessment-8", "label" : "Skin", "summary" : "Clean/dry/intact checkbox unselected; notes blank. Presence of this assessment entry is not a normal skin finding." }, { "author" : "Becky Masson, Registered Nurse", "dateTime" : "2026-09-22T13:07:00", "id" : "colin-hawkins-assessment-9", "label" : "Vascular access — left hand", "summary" : "Peripheral IV, size 20, inserted admission day; no signs of infection; dressing CDI. Normal saline 30 mL/hr to keep vein open." }, { "author" : "Becky Masson, Registered Nurse", "dateTime" : "2026-09-22T13:07:00", "id" : "colin-hawkins-assessment-10", "label" : "Vascular access — right forearm", "summary" : "Peripheral IV, size 20, inserted admission day; no signs of infection; dressing CDI. Saline locked." } ], "labs" : [ { "category" : "Chemistry/Hematology — units and reference ranges absent in source", "collectedDateTime" : "2026-09-22T12:47:00", "flag" : "Normal", "id" : "colin-hawkins-lab-1", "result" : "20", "test" : "ALT" }, { "category" : "Chemistry/Hematology — units and reference ranges absent in source", "collectedDateTime" : "2026-09-22T12:47:00", "flag" : "Normal", "id" : "colin-hawkins-lab-2", "result" : "28", "test" : "AST" }, { "category" : "Chemistry/Hematology — units and reference ranges absent in source", "collectedDateTime" : "2026-09-22T12:47:00", "flag" : "Normal", "id" : "colin-hawkins-lab-3", "result" : "7.1", "test" : "BUN" }, { "category" : "Chemistry/Hematology — units and reference ranges absent in source", "collectedDateTime" : "2026-09-22T12:47:00", "flag" : "Normal", "id" : "colin-hawkins-lab-4", "result" : "101", "test" : "Chloride" }, { "category" : "Chemistry/Hematology — units and reference ranges absent in source", "collectedDateTime" : "2026-09-22T12:47:00", "flag" : "High", "id" : "colin-hawkins-lab-5", "result" : "5.8", "test" : "Cholesterol" }, { "category" : "Chemistry/Hematology — units and reference ranges absent in source", "collectedDateTime" : "2026-09-22T12:47:00", "flag" : "Normal", "id" : "colin-hawkins-lab-6", "result" : "70", "test" : "Glucose" }, { "category" : "Chemistry/Hematology — units and reference ranges absent in source", "collectedDateTime" : "2026-09-22T12:47:00", "flag" : "Normal", "id" : "colin-hawkins-lab-7", "result" : "48", "test" : "Hematocrit" }, { "category" : "Chemistry/Hematology — units and reference ranges absent in source", "collectedDateTime" : "2026-09-22T12:47:00", "flag" : "Normal", "id" : "colin-hawkins-lab-8", "result" : "4.2", "test" : "HDL cholesterol" }, { "category" : "Chemistry/Hematology — units and reference ranges absent in source", "collectedDateTime" : "2026-09-22T12:47:00", "flag" : "Normal", "id" : "colin-hawkins-lab-9", "result" : "16.0", "test" : "Hemoglobin" }, { "category" : "Chemistry/Hematology — units and reference ranges absent in source", "collectedDateTime" : "2026-09-22T12:47:00", "flag" : "Normal", "id" : "colin-hawkins-lab-10", "result" : "1.0", "test" : "INR" }, { "category" : "Chemistry/Hematology — units and reference ranges absent in source", "collectedDateTime" : "2026-09-22T12:47:00", "flag" : "Normal", "id" : "colin-hawkins-lab-11", "result" : "1.26", "test" : "LDL cholesterol" }, { "category" : "Chemistry/Hematology — units and reference ranges absent in source", "collectedDateTime" : "2026-09-22T12:47:00", "flag" : "Normal", "id" : "colin-hawkins-lab-12", "result" : "225", "test" : "Platelets" }, { "category" : "Chemistry/Hematology — units and reference ranges absent in source", "collectedDateTime" : "2026-09-22T12:47:00", "flag" : "Normal", "id" : "colin-hawkins-lab-13", "result" : "4.1", "test" : "Potassium" }, { "category" : "Chemistry/Hematology — units and reference ranges absent in source", "collectedDateTime" : "2026-09-22T12:47:00", "flag" : "Normal", "id" : "colin-hawkins-lab-14", "result" : "12", "test" : "PT" }, { "category" : "Chemistry/Hematology — units and reference ranges absent in source", "collectedDateTime" : "2026-09-22T12:47:00", "flag" : "Normal", "id" : "colin-hawkins-lab-15", "result" : "5.0", "test" : "RBC" }, { "category" : "Chemistry/Hematology — units and reference ranges absent in source", "collectedDateTime" : "2026-09-22T12:47:00", "flag" : "Normal", "id" : "colin-hawkins-lab-16", "result" : "135", "test" : "Sodium" }, { "category" : "Chemistry/Hematology — units and reference ranges absent in source", "collectedDateTime" : "2026-09-22T12:47:00", "flag" : "High", "id" : "colin-hawkins-lab-17", "result" : "4.5", "test" : "Troponin 1" }, { "category" : "Chemistry/Hematology — units and reference ranges absent in source", "collectedDateTime" : "2026-09-22T12:47:00", "flag" : "Normal", "id" : "colin-hawkins-lab-18", "result" : "5.5", "test" : "WBC" } ], "medications" : [ { "doseRouteFrequency" : "80 mg PO q24h", "drug" : "aspirin", "id" : "ch-med-1", "notes" : " Pending source order; no administration record displayed.", "orderedBy" : "Howard Swan, Admitting", "orderedDateTime" : "2026-09-22T13:07:00", "section" : "Scheduled", "status" : "Pending" }, { "doseRouteFrequency" : "50 mg PO q24h", "drug" : "metoprolol succinate", "id" : "ch-med-2", "notes" : " Pending source order; no administration record displayed.", "orderedBy" : "Howard Swan, Admitting", "orderedDateTime" : "2026-09-22T13:07:00", "section" : "Scheduled", "status" : "Pending" }, { "doseRouteFrequency" : "20 mg PO q24h", "drug" : "atorvastatin calcium", "id" : "ch-med-3", "notes" : " Pending source order; no administration record displayed.", "orderedBy" : "Howard Swan, Admitting", "orderedDateTime" : "2026-09-22T13:07:00", "section" : "Scheduled", "status" : "Pending" }, { "doseRouteFrequency" : "12 units/kg/hr IV continuous", "drug" : "Heparin Drip", "id" : "ch-med-4", "nextDue" : "2026-09-22T13:07:00", "notes" : "Stat. Bolus 60 units/kg IV then infusion 12 units/kg/hr. Titrate to aPTT 1.5–2 times normal; check aPTT 6 hours after start and after each rate change. Source stop 10/6/2026 13:07. No administration data.", "orderedBy" : "Howard Swan, Admitting", "orderedDateTime" : "2026-09-22T13:07:00", "section" : "Scheduled", "status" : "Active" }, { "doseRouteFrequency" : "2–4 mg IV q1h PRN", "drug" : "morphine sulfate", "id" : "ch-med-5", "notes" : "As needed for pain. Pending source order; no administration record displayed.", "orderedBy" : "Howard Swan, Admitting", "orderedDateTime" : "2026-09-22T13:07:00", "section" : "PRN", "status" : "Pending" }, { "doseRouteFrequency" : "5 mcg/kg/min IV continuous PRN", "drug" : "Dopamine hydrochloride", "id" : "ch-med-6", "notes" : "Dopamine 200 mg in 250 mL normal saline. Titrate to maintain systolic BP >90 mmHg. Pending source order; no administration record displayed.", "orderedBy" : "Howard Swan, Admitting", "orderedDateTime" : "2026-09-22T13:07:00", "section" : "PRN", "status" : "Pending" }, { "doseRouteFrequency" : "20 mcg/min IV continuous PRN", "drug" : "nitroglycerin IV", "id" : "ch-med-7", "notes" : "Nitroglycerin 100 mg in 250 mL normal saline. Start 20 mcg/min; maximum 200 mcg/min. Titrate as needed to relieve chest pain. Pending source order; no administration record displayed.", "orderedBy" : "Howard Swan, Admitting", "orderedDateTime" : "2026-09-22T13:07:00", "section" : "PRN", "status" : "Pending" }, { "doseRouteFrequency" : "0.4 mg SL q5min x3 PRN", "drug" : "nitroglycerin SL", "id" : "ch-med-8", "notes" : "One spray every 5 minutes for chest pain, maximum three doses. Pending source order; no administration record displayed.", "orderedBy" : "Howard Swan, Admitting", "orderedDateTime" : "2026-09-22T13:07:00", "section" : "PRN", "status" : "Pending" } ], "notes" : [ { "author" : "Becky Masson, Registered Nurse", "dateTime" : "2026-09-22T12:47:00", "id" : "colin-hawkins-note-1", "summary" : "Colin A. Hawkins, a 59-year-old male, just arrived to the ED via private vehicle with his wife. He reports substernal chest pressure radiating to his left arm for the past 90 minutes, associated with shortness of breath and diaphoresis. History of hypertension and hyperlipidemia. EKG shows ST depression in anterior leads. Initial troponin is elevated. Patient is in gown and connected to the cardiac monitor in ED bed. MD at bedside.", "type" : "Nursing - Admission" }, { "author" : "Howard Swan, Admitting", "dateTime" : "2026-09-22T12:47:00", "id" : "colin-hawkins-note-2", "summary" : "Admission narrative mentions lisinopril, atorvastatin and insulin with inconsistent adherence; doses unspecified. Home medication history table is empty. These were not invented as inpatient medication orders.", "type" : "Home medications — narrative only" }, { "author" : "Howard Swan, Admitting", "dateTime" : "2026-09-22T13:07:00", "id" : "colin-hawkins-note-3", "summary" : "Priority 1: Acute pain, Open. Category/type unselected; comments blank.", "type" : "Care plan" }, { "id" : "colin-hawkins-allergy-source", "summary" : "Cats (environmental) — runny eyes and nose. Medication allergy status not documented.", "type" : "Allergy documentation" } ], "orders" : [ { "author" : "Howard Swan, Admitting", "category" : "Medicine", "dateTime" : "2026-09-22T13:07:00", "id" : "ch-med-order-1", "orderText" : "aspirin: 80 mg PO q24h. ", "status" : "Pending" }, { "author" : "Howard Swan, Admitting", "category" : "Medicine", "dateTime" : "2026-09-22T13:07:00", "id" : "ch-med-order-2", "orderText" : "metoprolol succinate: 50 mg PO q24h. ", "status" : "Pending" }, { "author" : "Howard Swan, Admitting", "category" : "Medicine", "dateTime" : "2026-09-22T13:07:00", "id" : "ch-med-order-3", "orderText" : "atorvastatin calcium: 20 mg PO q24h. ", "status" : "Pending" }, { "author" : "Howard Swan, Admitting", "category" : "Medicine", "dateTime" : "2026-09-22T13:07:00", "id" : "ch-med-order-4", "orderText" : "Heparin Drip: 12 units/kg/hr IV continuous. Stat. Bolus 60 units/kg IV then infusion 12 units/kg/hr. Titrate to aPTT 1.5–2 times normal; check aPTT 6 hours after start and after each rate change. Source stop 10/6/2026 13:07. No administration data.", "status" : "Active" }, { "author" : "Howard Swan, Admitting", "category" : "Medicine", "dateTime" : "2026-09-22T13:07:00", "id" : "ch-med-order-5", "orderText" : "morphine sulfate: 2–4 mg IV q1h PRN. As needed for pain.", "status" : "Pending" }, { "author" : "Howard Swan, Admitting", "category" : "Medicine", "dateTime" : "2026-09-22T13:07:00", "id" : "ch-med-order-6", "orderText" : "Dopamine hydrochloride: 5 mcg/kg/min IV continuous PRN. Dopamine 200 mg in 250 mL normal saline. Titrate to maintain systolic BP >90 mmHg.", "status" : "Pending" }, { "author" : "Howard Swan, Admitting", "category" : "Medicine", "dateTime" : "2026-09-22T13:07:00", "id" : "ch-med-order-7", "orderText" : "nitroglycerin IV: 20 mcg/min IV continuous PRN. Nitroglycerin 100 mg in 250 mL normal saline. Start 20 mcg/min; maximum 200 mcg/min. Titrate as needed to relieve chest pain.", "status" : "Pending" }, { "author" : "Howard Swan, Admitting", "category" : "Medicine", "dateTime" : "2026-09-22T13:07:00", "id" : "ch-med-order-8", "orderText" : "nitroglycerin SL: 0.4 mg SL q5min x3 PRN. One spray every 5 minutes for chest pain, maximum three doses.", "status" : "Pending" }, { "author" : "Howard Swan, Admitting", "category" : "Intensive Care Unit", "dateTime" : "2026-09-22T13:02:00", "id" : "ch-order-1", "orderText" : "Vital signs assessment. q15min until stable, then q1h. Source frequency q1h.", "status" : "Pending" }, { "author" : "Howard Swan, Admitting", "category" : "Intensive Care Unit", "dateTime" : "2026-09-22T13:07:00", "id" : "ch-order-2", "orderText" : "Activity level. Bedrest with head of bed 30 degrees (source phrase: supine at 30 degrees). Continuous.", "status" : "Pending" }, { "author" : "Howard Swan, Admitting", "category" : "Intensive Care Unit", "dateTime" : "2026-09-22T13:07:00", "id" : "ch-order-3", "orderText" : "Cardiac monitoring. STAT, continuous.", "status" : "Pending" }, { "author" : "Howard Swan, Admitting", "category" : "Intensive Care Unit", "dateTime" : "2026-09-22T13:07:00", "id" : "ch-order-4", "orderText" : "Diet. Low sodium, low cholesterol. Continuous.", "status" : "Pending" }, { "author" : "Howard Swan, Admitting", "category" : "Intensive Care Unit", "dateTime" : "2026-09-22T13:07:00", "id" : "ch-order-5", "orderText" : "IV catheter insertion. Start normal saline to keep vein open. Continuous.", "status" : "Pending" }, { "author" : "Howard Swan, Admitting", "category" : "Intensive Care Unit", "dateTime" : "2026-09-22T13:07:00", "id" : "ch-order-6", "orderText" : "Arterial pressure monitoring. Left radial. Continuous.", "status" : "Pending" }, { "author" : "Howard Swan, Admitting", "category" : "Intensive Care Unit", "dateTime" : "2026-09-22T13:07:00", "id" : "ch-order-7", "orderText" : "12-lead ECG. STAT now and every 24 hours.", "status" : "Pending" }, { "author" : "Howard Swan, Admitting", "category" : "Intensive Care Unit", "dateTime" : "2026-09-22T13:07:00", "id" : "ch-order-8", "orderText" : "Venipuncture. CBC, chemistry, electrolytes, glucose, urea, creatinine q24h.", "status" : "Pending" }, { "author" : "Howard Swan, Admitting", "category" : "Laboratory", "dateTime" : "2026-09-22T13:07:00", "id" : "ch-order-9", "orderText" : "Venipuncture. Troponin every 3 hours x3.", "status" : "Pending" }, { "author" : "Howard Swan, Admitting", "category" : "Laboratory", "dateTime" : "2026-09-22T13:07:00", "id" : "ch-order-10", "orderText" : "Venipuncture. Coagulation studies PT/PTT once.", "status" : "Pending" }, { "author" : "Howard Swan, Admitting", "category" : "Radiology", "dateTime" : "2026-09-22T13:07:00", "id" : "ch-order-11", "orderText" : "Chest X-ray. Once.", "status" : "Pending" } ], "overview" : { "height" : "72 in / 182.9 cm", "isolationIndicator" : "Standard", "religion" : "Christian", "weightKg" : 113.4 }, "vitals" : [ { "bloodPressure" : "115/55", "dateTime" : "2026-09-22T12:47:00", "heartRate" : 55, "id" : "ch-vital-1", "oxygenDevice" : "Nasal Cannula", "respiratoryRate" : 22, "spo2" : "99%", "temperature" : "98.8 °F oral" } ] }, "patient" : { "admitDateTime" : "2026-09-22T12:47:00", "admittingDiagnosis" : "Myocardial infarction", "allergies" : [ { "id" : "allergy-7f2cb559321ddf0c", "reaction" : "Runny eyes and nose", "severity" : "Not documented", "substance" : "Cats" } ], "attending" : "Howard Swan, Admitting", "chartDisplayName" : "Hawkins, Colin A", "codeStatus" : "Full Code", "dob" : "7/19/XX", "history" : { "chiefComplaint" : "59-year-old male with a history of previous myocardial infarction, insulin-dependent type 2 diabetes mellitus, and smokes 2 packs per day presents to the ED with substernal chest pressure radiating to his left arm and jaw for the past 90 minutes. The pain started while watching television at home and is associated with shortness of breath and diaphoresis. He rates the pain 8/10 and states it is similar to his previous MI. He has been taking his home medications irregularly (lisinopril and atorvastatin) and admits to poor compliance with his insulin regimen. No vomiting, no recent trauma. Wife is at bedside and confirms the history. No other acute symptoms reported.", "pastMedicalHistory" : [ "Prior myocardial infarction and hyperlipidemia (admission narrative)", "Hypertension; type 2 diabetes mellitus; obesity; cellulitis (active/resolved not selected)", "Chronic pain in back and knees; takes pain medication, agent unspecified. No prior transfusions; does not know blood type." ], "pastSurgicalHistory" : [ "No prior surgical history." ], "socialHistory" : [ "Age 59 per demographics and admission notes (case-list description says 51); married; lives at home. White, not Hispanic or Latino; Christian. Construction worker at American Construction.", "Current cigarette smoker 2 packs/day for 36 years; no smokeless tobacco. Alcohol 4–7 drinks/week; no history of diagnosed/treated alcohol abuse; no illicit drug use.", "Feels safe at home and current environment; denies emotional/physical/sexual harm. No unintentional weight loss or decreased appetite. Type 2 diabetes; consult status unknown. Stools formed every 2–3 days; last bowel movement two days before launch. Rare exercise, golf.", "Source simulated address: 112 Sussex Drive, Madison, Wisconsin 53562. Primary language and next-of-kin contact unfilled." ] }, "mrn" : "778543", "sex" : "Male", "simulatedFullName" : "Colin Andrew Hawkins", "unit" : "Happy Hospital — Room 2 Bed 1" }, "setting" : "Happy Hospital — Room 2 Bed 1", "snapshots" : [ { "activityIds" : [ ], "id" : "colin-hawkins-current", "notes" : "One captured chart state; all dated records are visible. Progressive-release behavior is not recreated.", "scenarioTime" : "2026-09-22T13:47:00", "sourcePath" : "DocuCare instructor chart: Nur 21: Colin Hawkins", "title" : "Captured chart" } ], "subtitle" : "N21 practice record", "tags" : [ "N21", "DocuCare migration" ], "title" : "Colin Hawkins" }, "packageId" : "docucare-n21-colin-hawkins-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" : "n21-colin-hawkins", "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" : "Colin Andrew Hawkins" }, { "envelope" : { "appName" : "ChartSlate", "audience" : "student", "createdAt" : "2026-09-22T21:10:32.768033+00:00", "exportVersion" : "1", "kind" : "casePackage", "package" : { "case" : { "activities" : [ ], "id" : "docucare-n21-william-edwards", "learningLevel" : "N21", "panels" : { "assessments" : [ { "author" : "Patti Picksdale, Registered Nurse", "dateTime" : "2026-09-21T14:40:00", "id" : "william-edwards-assessment-1", "label" : "HEENT", "summary" : "Head symmetric, no recent trauma; hair fine. Hearing intact bilaterally; sclera normal/clear bilaterally; right eye lid lag. Nose symmetrical, obstruction absent, septum intact. Teeth present; oral mucosa and pharynx normal; lymph nodes non-tender." }, { "author" : "Patti Picksdale, Registered Nurse", "dateTime" : "2026-09-21T14:40:00", "id" : "william-edwards-assessment-2", "label" : "Neurological", "summary" : "Oriented person/time/place/situation; left pupil 3 mm brisk, right pupil 3 mm sluggish; hearing intact; left upper/lower extremities move upon request; weak right upper/lower movement upon request. Cooperative. Secondary scales unverified." }, { "author" : "Patti Picksdale, Registered Nurse", "dateTime" : "2026-09-21T14:40:00", "id" : "william-edwards-assessment-3", "label" : "Cardiovascular", "summary" : "S1/S2; all pulses +2; no edema; capillary refill <3 sec all; skin warm, dry, intact." }, { "author" : "Patti Picksdale, Registered Nurse", "dateTime" : "2026-09-21T14:40:00", "id" : "william-edwards-assessment-4", "label" : "GI", "summary" : "soft, nontender abdomen; no symptoms, bowel sounds present. Diet tolerance Other: risk for aspiration. Stool soft and brown; last BM source field admission +1 day (future relative to this assessment)." }, { "author" : "Patti Picksdale, Registered Nurse", "dateTime" : "2026-09-21T14:40:00", "id" : "william-edwards-assessment-5", "label" : "GU", "summary" : "No urinary symptoms; yellow clear urine; voiding without difficulty; no catheter type/size specified." }, { "author" : "Patti Picksdale, Registered Nurse", "dateTime" : "2026-09-21T14:40:00", "id" : "william-edwards-assessment-6", "label" : "Respiratory", "summary" : "No symptoms, sputum color None and consistency None; regular respirations; default RUL tab clear. Other lobes and respiratory-therapy subtabs unverified." }, { "author" : "Patti Picksdale, Registered Nurse", "dateTime" : "2026-09-21T14:40:00", "id" : "william-edwards-assessment-7", "label" : "Musculoskeletal", "summary" : "Symptoms None selected; normal left upper/lower strength and active ROM; right upper/lower movement against gravity but not resistance, passive ROM; unsteady gait." }, { "author" : "Patti Picksdale, Registered Nurse", "dateTime" : "2026-09-21T14:40:00", "id" : "william-edwards-assessment-8", "label" : "Pain", "summary" : "No pain, 0/10; onset form admission time." }, { "author" : "Jason Speck, Registered Nurse", "dateTime" : "2026-09-22T01:40:00", "id" : "william-edwards-assessment-9", "label" : "Neurological", "summary" : "Oriented person/time/place/situation; left pupil 3 mm brisk, right pupil 3 mm sluggish; hearing intact; left upper/lower extremities move upon request; weak right upper/lower movement upon request. Cooperative; calm. Secondary scales unverified." }, { "author" : "Jason Speck, Registered Nurse", "dateTime" : "2026-09-22T01:40:00", "id" : "william-edwards-assessment-10", "label" : "Cardiovascular", "summary" : "S1/S2; all pulses +2; no edema; capillary refill <3 sec all; skin warm, dry, intact." }, { "author" : "Jason Speck, Registered Nurse", "dateTime" : "2026-09-22T01:40:00", "id" : "william-edwards-assessment-11", "label" : "GI", "summary" : "Flat, soft, nontender abdomen; no symptoms, bowel sounds present. Diet tolerance Other: risk for aspiration. Last BM source field admission time." }, { "author" : "Jason Speck, Registered Nurse", "dateTime" : "2026-09-22T01:40:00", "id" : "william-edwards-assessment-12", "label" : "GU", "summary" : "No urinary symptoms; yellow clear urine; voiding without difficulty; no catheter type/size specified." }, { "author" : "Jason Speck, Registered Nurse", "dateTime" : "2026-09-22T01:40:00", "id" : "william-edwards-assessment-13", "label" : "Respiratory", "summary" : "No symptoms, sputum color None and consistency None; regular respirations; default RUL tab clear. Other lobes and respiratory-therapy subtabs unverified." }, { "author" : "Jason Speck, Registered Nurse", "dateTime" : "2026-09-22T01:40:00", "id" : "william-edwards-assessment-14", "label" : "Musculoskeletal", "summary" : "Symptoms None selected; normal left upper/lower strength and active ROM; right upper/lower movement against gravity but not resistance, passive ROM; unsteady gait." }, { "author" : "Jason Speck, Registered Nurse", "dateTime" : "2026-09-22T01:40:00", "id" : "william-edwards-assessment-15", "label" : "Pain", "summary" : "No pain, 0/10; onset form admission time." }, { "author" : "Patti Picksdale, Registered Nurse", "dateTime" : "2026-09-22T13:55:00", "id" : "william-edwards-assessment-16", "label" : "Respiratory", "summary" : "Tan, tenacious sputum; cough, shortness of breath, accessory muscle use; irregular, labored, retracting respirations. RUL/LUL clear; RML both clear and coarse selected; RLL/LLL coarse. No oxygen device/flow selected. Source summary row incorrectly dates this at admission; detail explicitly uses simulation launch time." }, { "author" : "Patti Picksdale, Registered Nurse", "dateTime" : "2026-09-21T14:40:00", "id" : "william-edwards-assessment-17", "label" : "Skin", "summary" : "Clean, dry and intact checkbox selected." }, { "author" : "Patti Picksdale, Registered Nurse", "dateTime" : "2026-09-21T13:40:00", "id" : "william-edwards-assessment-18", "label" : "Vascular access", "summary" : "Right forearm 18 gauge peripheral IV; inserted admission day; CDI, no signs of IV-related complications; transparent dressing; good blood return and flushes easily." } ], "imaging" : [ { "bodyPart" : "Chest", "dateTime" : "2026-09-21T14:10:00", "id" : "we-imaging-1", "impression" : "Normal Chest X ray. No active disease", "modality" : "X-ray", "reportText" : "Source report field blank. Linked source image not yet migrated.", "source" : "DocuCare visible diagnostic report", "title" : "Chest X-Ray" } ], "labs" : [ { "category" : "Complete metabolic panel", "collectedDateTime" : "2026-09-22T13:55:00", "flag" : "Normal", "id" : "william-edwards-lab-1", "referenceRange" : "137–147 mmol/L", "result" : "138", "test" : "Na" }, { "category" : "Complete metabolic panel", "collectedDateTime" : "2026-09-22T13:55:00", "flag" : "Normal", "id" : "william-edwards-lab-2", "referenceRange" : "3.4–5.3 mmol/L", "result" : "3.5", "test" : "K" }, { "category" : "Complete metabolic panel", "collectedDateTime" : "2026-09-22T13:55:00", "flag" : "Normal", "id" : "william-edwards-lab-3", "referenceRange" : "99–108 mmol/L", "result" : "107", "test" : "Cl" }, { "category" : "Complete metabolic panel", "collectedDateTime" : "2026-09-22T13:55:00", "flag" : "Normal", "id" : "william-edwards-lab-4", "referenceRange" : "22–29 mg/L", "result" : "25", "test" : "CO2" }, { "category" : "Complete metabolic panel", "collectedDateTime" : "2026-09-22T13:55:00", "flag" : "Normal", "id" : "william-edwards-lab-5", "referenceRange" : "60–99 mg/dL", "result" : "81", "test" : "Glucose" }, { "category" : "Complete metabolic panel", "collectedDateTime" : "2026-09-22T13:55:00", "flag" : "Normal", "id" : "william-edwards-lab-6", "referenceRange" : "8–21 mg/dL", "result" : "17", "test" : "BUN" }, { "category" : "Complete metabolic panel", "collectedDateTime" : "2026-09-22T13:55:00", "flag" : "Normal", "id" : "william-edwards-lab-7", "referenceRange" : "0.75–1.2 mg/dL", "result" : "1.0", "test" : "Creatinine" }, { "category" : "CBC", "collectedDateTime" : "2026-09-22T13:55:00", "flag" : "Normal", "id" : "william-edwards-lab-8", "referenceRange" : "4.0–9.0", "result" : "9.0", "test" : "WBC (10x3/uL)" }, { "category" : "CBC", "collectedDateTime" : "2026-09-22T13:55:00", "flag" : "Normal", "id" : "william-edwards-lab-9", "referenceRange" : "3.90–4.98", "result" : "4.6", "test" : "RBC (mill/cumm)" }, { "category" : "CBC", "collectedDateTime" : "2026-09-22T13:55:00", "flag" : "Normal", "id" : "william-edwards-lab-10", "referenceRange" : "12.0–15.5", "result" : "14.3", "test" : "Hemoglobin (g/dL)" }, { "category" : "CBC", "collectedDateTime" : "2026-09-22T13:55:00", "flag" : "Normal", "id" : "william-edwards-lab-11", "referenceRange" : "35–45", "result" : "42.2%", "test" : "Hematocrit" }, { "category" : "CBC", "collectedDateTime" : "2026-09-22T13:55:00", "flag" : "Normal", "id" : "william-edwards-lab-12", "referenceRange" : "140–400 1000/mm3", "result" : "208", "test" : "Platelets (1000/mm3)" }, { "category" : "CBC", "collectedDateTime" : "2026-09-22T13:55:00", "flag" : "Normal", "id" : "william-edwards-lab-13", "referenceRange" : "6.0–11.1 fL", "result" : "10", "test" : "Mean platelet volume (fL)" }, { "category" : "Lipid panel", "collectedDateTime" : "2026-09-22T13:55:00", "flag" : "High", "id" : "william-edwards-lab-14", "referenceRange" : "<200", "result" : "210", "test" : "Total cholesterol (mg/dL)" }, { "category" : "Lipid panel", "collectedDateTime" : "2026-09-22T13:55:00", "flag" : "High", "id" : "william-edwards-lab-15", "referenceRange" : "<150", "result" : "165", "test" : "Triglycerides (mg/dL)" }, { "category" : "Lipid panel", "collectedDateTime" : "2026-09-22T13:55:00", "flag" : "Low", "id" : "william-edwards-lab-16", "referenceRange" : ">40", "result" : "35", "test" : "HDL cholesterol (mg/dL)" }, { "category" : "Lipid panel", "collectedDateTime" : "2026-09-22T13:55:00", "flag" : "High", "id" : "william-edwards-lab-17", "referenceRange" : "<100", "result" : "110", "test" : "LDL cholesterol" }, { "category" : "HbA1c", "collectedDateTime" : "2026-09-22T13:55:00", "flag" : "High", "id" : "william-edwards-lab-18", "referenceRange" : "0.0–6.4%", "result" : "7.0%", "test" : "Glycohemoglobin" } ], "medications" : [ { "doseRouteFrequency" : "500 mg PO q12h", "drug" : "Metformin (Glucophage)", "id" : "we-med-1", "nextDue" : "2026-09-21T14:10:00", "notes" : " Source stop 10/5/2026 14:10. Administration table empty. NPO pending dysphagia screen applies to this oral order. NPO pending documented dysphagia screen; do not administer oral medication until swallowing clearance.", "orderedBy" : "Dr. Taylor Amin, Admitting", "orderedDateTime" : "2026-09-21T14:10:00", "section" : "Scheduled", "status" : "Active" }, { "doseRouteFrequency" : "5 mg PO q24h", "drug" : "Glipizide (Glucotrol)", "id" : "we-med-2", "nextDue" : "2026-09-21T14:10:00", "notes" : " Source stop 10/5/2026 14:10. Administration table empty. NPO pending dysphagia screen applies to this oral order. NPO pending documented dysphagia screen; do not administer oral medication until swallowing clearance.", "orderedBy" : "Dr. Taylor Amin, Admitting", "orderedDateTime" : "2026-09-21T14:10:00", "section" : "Scheduled", "status" : "Active" }, { "doseRouteFrequency" : "25 mg PO q24h", "drug" : "Hydrochlorothiazide (HCTZ)", "id" : "we-med-3", "nextDue" : "2026-09-21T14:10:00", "notes" : " Source stop 10/5/2026 14:10. Administration table empty. NPO pending dysphagia screen applies to this oral order. NPO pending documented dysphagia screen; do not administer oral medication until swallowing clearance.", "orderedBy" : "Dr. Taylor Amin, Admitting", "orderedDateTime" : "2026-09-21T14:10:00", "section" : "Scheduled", "status" : "Active" }, { "doseRouteFrequency" : "10 mg PO q24h", "drug" : "Lisinopril (Prinivil)", "id" : "we-med-4", "nextDue" : "2026-09-21T14:10:00", "notes" : " Source stop 10/5/2026 14:10. Administration history not verified; no last-given time inferred. NPO pending dysphagia screen applies to this oral order. NPO pending documented dysphagia screen; do not administer oral medication until swallowing clearance.", "orderedBy" : "Dr. Taylor Amin, Admitting", "orderedDateTime" : "2026-09-21T14:10:00", "section" : "Scheduled", "status" : "Active" }, { "doseRouteFrequency" : "20 mg PO q24h", "drug" : "Simvastatin (Zocor)", "id" : "we-med-5", "nextDue" : "2026-09-22T21:00:00", "notes" : "Give at bedtime. Source stop 10/5/2026 14:10. Administration history not verified; no last-given time inferred. NPO pending dysphagia screen applies to this oral order. Draft administration time 21:00 chosen for bedtime; faculty scheduling assumption. NPO pending documented dysphagia screen; do not administer oral medication until swallowing clearance.", "orderedBy" : "Dr. Taylor Amin, Admitting", "orderedDateTime" : "2026-09-21T14:10:00", "section" : "Scheduled", "status" : "Active" }, { "doseRouteFrequency" : "300 mg PR q24h", "drug" : "Aspirin (ASA)", "id" : "we-med-6", "nextDue" : "2026-09-21T14:10:00", "notes" : " Source stop 10/5/2026 14:10. Administration history not verified; no last-given time inferred.", "orderedBy" : "Dr. Taylor Amin, Admitting", "orderedDateTime" : "2026-09-21T14:10:00", "section" : "Scheduled", "status" : "Active" }, { "doseRouteFrequency" : "40 mg SC; frequency not specified", "drug" : "Enoxaparin (Lovenox)", "id" : "we-med-7", "nextDue" : "2026-09-21T14:10:00", "notes" : "Source frequency N/A; requires clarification. Source stop 10/5/2026 14:10. Administration history not verified; no last-given time inferred. Frequency missing in source. Clarify before administration.", "orderedBy" : "Dr. Taylor Amin, Admitting", "orderedDateTime" : "2026-09-21T14:10:00", "section" : "Scheduled", "status" : "Active" }, { "doseRouteFrequency" : "75 mL/hr IV continuous", "drug" : "Normal Saline", "id" : "we-med-8", "nextDue" : "2026-09-21T14:10:00", "notes" : "0.9% sodium chloride per admission note. Source stop 10/5/2026 14:10. Administration history not verified; no last-given time inferred.", "orderedBy" : "Dr. Taylor Amin, Admitting", "orderedDateTime" : "2026-09-21T14:10:00", "section" : "Cont. Infusion", "status" : "Active" } ], "notes" : [ { "author" : "Patti Picksdale, Registered Nurse", "dateTime" : "2026-09-21T13:40:00", "id" : "william-edwards-note-1", "summary" : "Mr. Edwards is a 65-year-old male who presented to the emergency department after waking up yesterday a.m. with right-sided weakness and presumed ischemic stroke. He is paretic on the right side with strength in upper and lower extremity rated as 3 out of 5. He has right-sided facial weakness and garbled speech. A peripheral IV with 0.9% sodium chloride infusing at 75 mL/hour is running. He has no medications and is on no oral intake (NPO). Mr. Edwards is awaiting admission to the stroke unit once a bed is available. The family has just arrived.", "type" : "Nursing - Admission" }, { "author" : "Dr. Taylor Amin, Admitting", "dateTime" : "2026-09-21T13:40:00", "id" : "william-edwards-note-2", "summary" : "Pharmacy Note: Home Medications Metformin, Glucotrol, Hydrochlorothiazide, Lisinopril, Simvastatin", "type" : "Pharmacy Notes" }, { "author" : "Dr. Taylor Amin, Admitting", "dateTime" : "2026-09-21T13:40:00", "id" : "william-edwards-note-3", "summary" : "Mr. Edwards has been diagnosed and treated by his own physician over the past years for high blood pressure, coronary heart disease and non-compliant diabetes (NIDDM). He still smokes 1 pack of cigarettes per day even though he has been told to quit. He is left-handed. He is a newly retired police officer and he enjoys boating. Mr. Edwards woke up with right-sided weakness and facial droop yesterday morning. After much persuasion his wife was able to get him to come to the hospital.", "type" : "Emergency Room Physician" }, { "author" : "Radiology", "dateTime" : "2026-09-21T14:10:00", "id" : "william-edwards-note-4", "summary" : "Normal Chest X ray. No active disease. Report field blank; source has a linked image, not yet migrated.", "type" : "Chest X-Ray" }, { "id" : "william-edwards-allergy-source", "summary" : "Codeine — rash (documented at admission).", "type" : "Allergy documentation" } ], "orders" : [ { "author" : "Dr. Taylor Amin, Admitting", "category" : "Pharmacy", "dateTime" : "2026-09-21T14:10:00", "id" : "we-med-order-1", "orderText" : "Metformin (Glucophage): 500 mg PO q12h. NPO pending dysphagia screen applies to oral administration.", "status" : "Active" }, { "author" : "Dr. Taylor Amin, Admitting", "category" : "Pharmacy", "dateTime" : "2026-09-21T14:10:00", "id" : "we-med-order-2", "orderText" : "Glipizide (Glucotrol): 5 mg PO q24h. NPO pending dysphagia screen applies to oral administration.", "status" : "Active" }, { "author" : "Dr. Taylor Amin, Admitting", "category" : "Pharmacy", "dateTime" : "2026-09-21T14:10:00", "id" : "we-med-order-3", "orderText" : "Hydrochlorothiazide (HCTZ): 25 mg PO q24h. NPO pending dysphagia screen applies to oral administration.", "status" : "Active" }, { "author" : "Dr. Taylor Amin, Admitting", "category" : "Pharmacy", "dateTime" : "2026-09-21T14:10:00", "id" : "we-med-order-4", "orderText" : "Lisinopril (Prinivil): 10 mg PO q24h. NPO pending dysphagia screen applies to oral administration.", "status" : "Active" }, { "author" : "Dr. Taylor Amin, Admitting", "category" : "Pharmacy", "dateTime" : "2026-09-21T14:10:00", "id" : "we-med-order-5", "orderText" : "Simvastatin (Zocor): 20 mg PO q24h. Give at bedtime. NPO pending dysphagia screen applies to oral administration.", "status" : "Active" }, { "author" : "Dr. Taylor Amin, Admitting", "category" : "Pharmacy", "dateTime" : "2026-09-21T14:10:00", "id" : "we-med-order-6", "orderText" : "Aspirin (ASA): 300 mg PR q24h. ", "status" : "Active" }, { "author" : "Dr. Taylor Amin, Admitting", "category" : "Pharmacy", "dateTime" : "2026-09-21T14:10:00", "id" : "we-med-order-7", "orderText" : "Enoxaparin (Lovenox): 40 mg SC; frequency not specified. Source frequency N/A; requires clarification.", "status" : "Active" }, { "author" : "Dr. Taylor Amin, Admitting", "category" : "Pharmacy", "dateTime" : "2026-09-21T14:10:00", "id" : "we-med-order-8", "orderText" : "Normal Saline: 75 mL/hr IV continuous. 0.9% sodium chloride per admission note.", "status" : "Active" }, { "author" : "Dr. Taylor Amin, Admitting", "category" : "", "dateTime" : "2026-09-21T13:40:00", "id" : "we-order-1", "orderText" : "Neurologic assessment. q4h.", "status" : "Active" }, { "author" : "Dr. Taylor Amin, Admitting", "category" : "", "dateTime" : "2026-09-21T13:40:00", "id" : "we-order-2", "orderText" : "NIHSS. q4h; notify if score changes >3.", "status" : "Active" }, { "author" : "Dr. Taylor Amin, Admitting", "category" : "Lab", "dateTime" : "2026-09-21T14:10:00", "id" : "we-order-3", "orderText" : "Venipuncture. Fasting lipid profile and HbA1c in AM; STAT once.", "status" : "Active" }, { "author" : "Dr. Taylor Amin, Admitting", "category" : "Lab", "dateTime" : "2026-09-21T14:10:00", "id" : "we-order-4", "orderText" : "Venipuncture. CMP and CBC every AM; STAT q24h.", "status" : "Active" }, { "author" : "Dr. Taylor Amin, Admitting", "category" : "Nursing", "dateTime" : "2026-09-21T14:10:00", "id" : "we-order-5", "orderText" : "Fingerstick blood glucose. Before meals and three hours after supper; source frequency continuous, STAT.", "status" : "Active" }, { "author" : "Dr. Taylor Amin, Admitting", "category" : "Stroke Unit", "dateTime" : "2026-09-21T14:10:00", "id" : "we-order-6", "orderText" : "NPO until dysphagia screen completed. STAT once.", "status" : "Active" }, { "author" : "Dr. Taylor Amin, Admitting", "category" : "Stroke Unit", "dateTime" : "2026-09-21T14:10:00", "id" : "we-order-7", "orderText" : "Oxygen. Nasal cannula titrated to keep SpO2 >92%; STAT once.", "status" : "Active" }, { "author" : "Dr. Taylor Amin, Admitting", "category" : "Stroke Unit", "dateTime" : "2026-09-21T14:10:00", "id" : "we-order-8", "orderText" : "Admit to Stroke Unit. Condition stable; STAT once.", "status" : "Active" }, { "author" : "Dr. Taylor Amin, Admitting", "category" : "Stroke Unit", "dateTime" : "2026-09-21T14:10:00", "id" : "we-order-9", "orderText" : "Vital Signs with SpO2. q4h; STAT.", "status" : "Active" }, { "author" : "Dr. Taylor Amin, Admitting", "category" : "Stroke Unit", "dateTime" : "2026-09-21T14:10:00", "id" : "we-order-10", "orderText" : "Neurologic assessment. q4h; STAT.", "status" : "Active" }, { "author" : "Dr. Taylor Amin, Admitting", "category" : "Stroke Unit", "dateTime" : "2026-09-21T14:10:00", "id" : "we-order-11", "orderText" : "Oronasopharyngeal suction. PRN; source frequency once, STAT.", "status" : "Active" }, { "author" : "Dr. Taylor Amin, Admitting", "category" : "Stroke Unit", "dateTime" : "2026-09-21T14:10:00", "id" : "we-order-12", "orderText" : "OOB to chair. 3 times/day (source q8h); no lifting or pulling on paretic side. STAT.", "status" : "Active" }, { "author" : "Dr. Taylor Amin, Admitting", "category" : "Stroke Unit", "dateTime" : "2026-09-21T14:10:00", "id" : "we-order-13", "orderText" : "Compression stockings. Continuous; STAT.", "status" : "Active" }, { "author" : "Dr. Taylor Amin, Admitting", "category" : "Stroke Unit", "dateTime" : "2026-09-21T14:10:00", "id" : "we-order-14", "orderText" : "Intake/output. q12h; STAT.", "status" : "Active" }, { "author" : "Dr. Taylor Amin, Admitting", "category" : "Stroke Unit", "dateTime" : "2026-09-21T14:10:00", "id" : "we-order-15", "orderText" : "Dysphagia screening by RN. Impaired swallowing and aspiration precautions; once, STAT.", "status" : "Active" }, { "author" : "Dr. Taylor Amin, Admitting", "category" : "Stroke Unit", "dateTime" : "2026-09-21T14:10:00", "id" : "we-order-16", "orderText" : "Stroke education. Provide to family members; once, STAT.", "status" : "Active" } ], "overview" : { "height" : "73 in / 185.4 cm", "isolationIndicator" : "Standard", "religion" : "Christian", "weightKg" : 93 }, "vitals" : [ { "bloodPressure" : "130/85", "dateTime" : "2026-09-21T13:55:00", "heartRate" : 84, "id" : "we-vital-1", "oxygenDevice" : "Room Air", "respiratoryRate" : 18, "spo2" : "96%", "temperature" : "99.2 °F Oral" }, { "bloodPressure" : "128/80", "dateTime" : "2026-09-21T17:40:00", "heartRate" : 82, "id" : "we-vital-2", "oxygenDevice" : "Room Air", "respiratoryRate" : 18, "spo2" : "96%", "temperature" : "98.2 °F Oral" }, { "bloodPressure" : "130/78", "dateTime" : "2026-09-22T01:40:00", "heartRate" : 82, "id" : "we-vital-3", "oxygenDevice" : "Room Air", "respiratoryRate" : 20, "spo2" : "95%", "temperature" : "98.9 °F Oral" }, { "bloodPressure" : "130/80", "dateTime" : "2026-09-22T13:55:00", "heartRate" : 98, "id" : "we-vital-4", "respiratoryRate" : 28, "spo2" : "90%", "temperature" : "100.4 °F Tympanic" } ] }, "patient" : { "admitDateTime" : "2026-09-21T13:40:00", "admittingDiagnosis" : "Ischemic Stroke", "allergies" : [ { "id" : "allergy-bc53f18f69b4501f", "reaction" : "Rash", "severity" : "Not documented", "substance" : "Codeine" } ], "attending" : "Dr. Taylor Amin, Admitting", "chartDisplayName" : "Edwards, William D", "codeStatus" : "Full Code", "dob" : "5/18/XX", "history" : { "chiefComplaint" : "Right-sided weakness and facial droop on waking the morning before presentation; wife persuaded him to attend hospital.", "pastMedicalHistory" : [ "Hypertension; coronary artery disease", "Type 2 diabetes mellitus (simulation reconciliation from physician NIDDM narrative and home oral agents; source structured fields said type 1)." ], "pastSurgicalHistory" : [ ], "socialHistory" : [ "Age 65, married, Christian, not Hispanic or Latino. Newly retired police officer; enjoys boating. Left-handed.", "Current cigarette smoker, 1 pack/day; duration unfilled. Other social screening fields unfilled.", "Source simulated address: 15 Berry Lane, Indiana, Pennsylvania 15XXX. Primary language, race, next-of-kin contact unfilled." ] }, "mrn" : "PCS51800", "sex" : "Male", "simulatedFullName" : "William Daniel Edwards", "unit" : "St. Joseph's — Room 2 Bed A; awaiting stroke unit" }, "setting" : "St. Joseph's — Room 2 Bed A; awaiting stroke unit", "snapshots" : [ { "activityIds" : [ ], "id" : "william-edwards-current", "notes" : "One captured chart state; all dated records are visible. Progressive-release behavior is not recreated.", "scenarioTime" : "2026-09-22T13:55:00", "sourcePath" : "DocuCare instructor chart: Nur 21: William Edwards", "title" : "Captured chart" } ], "subtitle" : "N21 practice record", "tags" : [ "N21", "DocuCare migration" ], "title" : "William Edwards" }, "packageId" : "docucare-n21-william-edwards-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" : "n21-william-edwards", "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" : "William Daniel Edwards" } ], "format" : "org.chartslate.case-collection", "id" : "docucare-n21-course-review-v1", "summary" : "Five N21 simulated patient charts in one download. Choose a patient after importing the bundle. Records are available offline after import.", "title" : "N21", "version" : 1 }