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PATIENT: Peterson, Wallace DOB: 06/06/1954 AGE: 69 GENDER: MALE

MRN: 7214732 HOSPITAL FLOOR: Med-Surg ROOM: 327 HCP: Lois Myer, MD

CODE STATUS: FULL CODE ISOLATION: Standard ALERTS: None

DRUG ALLERGIES: NKDA ENVIRONMENTAL ALLERGIES: NKA FOOD ALLERGIES: NKA

DIET: Sodium-Controlled HEIGHT: 5’ 7” WEIGHT: 131 lbs. BMI: 20.5

PATIENT CHART TABS

➢ SCENARIO SUMMARY

➢ PROVIDER CHARTS: PROVIDER ORDERS

➢ PROVIDER CHARTS: HISTORY & PHYSICAL

➢ PROVIDER CHARTS: PROGRESS NOTES

➢ PROVIDER CHARTS: CONSULTATION REPORTS

➢ PATIENT CHARTING: ADMISSION HISTORY

➢ PATIENT CHARTING: SYSTEM ASSESSMENTS

➢ PATIENT CHARTING: IV’s

➢ VITAL SIGNS: VITAL SIGNS

➢ VITAL SIGNS: INTAKE/OUTPUT

➢ VITAL SIGNS: BLOOD GLUCOSE

➢ VITAL SIGNS: HEIGHT & WEIGHT

➢ ORDER ENTRY – PHARMACY

➢ ORDER RESULTS

➢ PATIENT CARD

➢ MEDICATION ADMINISTRATION RECORD

➢ OTHER DEPARTMENTS: AMBULATORY & EMERGENCY

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SCENARIO SUMMARY

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PROVIDER CHARTS: PROVIDER ORDERS

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PROVIDER CHARTS: HISTORY & PHYSICAL

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PROVIDER CHARTS: PROGRESS NOTES

PROVIDER CHARTS: CONSULTATION REPORTS

PATIENT CHARTING: ADMISSION HISTORY

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PATIENT CHARTING: ADMISSION HISTORY CONTINUED…

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PATIENT CHARTING: ADMISSION HISTORY CONTINUED…

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PATIENT CHARTING: ADMISSION HISTORY CONTINUED…

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PATIENT CHARTING: ADMISSION HISTORY CONTINUED…

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PATIENT CHARTING: ADMISSION HISTORY CONTINUED…

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PATIENT CHARTING: ADMISSION HISTORY CONTINUED…

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PATIENT CHARTING: ADMISSION HISTORY CONTINUED…

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PATIENT CHARTING: ADMISSION HISTORY CONTINUED…

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PATIENT CHARTING: ADMISSION HISTORY CONTINUED…

PATIENT CHARTING: SYSTEM ASSESSMENTS

SYSTEM ASSESSMENTS INTERVENTIONS

BASIC NURSING CARE

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PATIENT CHARTING: SYSTEM ASSESSMENTS PATIENT CHARTING SUMMARIES

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PATIENT CHARTING: SYSTEM ASSESSMENTS PATIENT CHARTING SUMMARIES CONTINUED..

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PATIENT CHARTING: IV’s

VITAL SIGNS: VITAL SIGNS

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VITAL SIGNS: INTAKE/OUTPUT

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VITAL SIGNS: HEIGHT/WEIGHT

VITAL SIGNS: BLOOD GLUCOSE

ORDER ENTRY – PHARMACY

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ORDER RESULTS

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PATIENT CARD

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MEDICATION ADMINISTRATION RECORD

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OTHER DEPARTMENTS: AMBULATORY & EMERGENCY OB TRIAGE NOTES

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STUEDENT RESOURCES:

Centers for Disease Control and Prevention (CDC)

The CDC is the central authority for Health Care information. From this site, the user may explore national standards, find specialized patient teaching, and follow emergency trends of health and disease in the United States.

http://www.cdc.gov

CDC: Vaccines & Immunizations

This dedicated CDC site focuses on immunization standards and infection control trends. Stay up to date with the current standards by monitoring this site.

http://www.cdc.gov/vaccines/

Quality and Safety Education for Nurses (QSEN)

QSEN is a comprehensive resource for quality and safety education for nurses. From this site, the reader can find detailed information about the knowledge, skills and attitudes nurses need related to patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics.

http://www.qsen.org/

The Joint Commission

The Joint Commission is the gatekeeper for hospital accreditation. This organization monitors hospital quality, establishes monitoring and accreditation standards, and serves as the institutional watch dog on behalf of the public. This important website lists patient care standards and monitoring trends.

http://www.jointcommission.org/

Agency for Healthcare Research and Quality (AHRQ)

This extremely rich and valuable interdisciplinary site is sponsored by the U.S. Department of Health and Human Services. The site serves as the National Guideline Clearinghouse for a wide variety of health care problems and diseases.

http://www.guideline.gov/

Institute of Health Care Improvement

The institute of Health Care Improvement is a nonprofit organization dedicated to providing safe and effective healthcare to patients. The Programs and Topics sections of this website offer valuable information about best practices and national practice standards.

http://www.ihi.org/ihi/programs

Institute for Safe Medication Practices (ISMP)

ISMP is a nonprofit organization dedicated to educating the healthcare community and consumers about safe medication practice. This site is an excellent resource for information related to medication standards, education, and monitoring.

http://www.ismp.org/

Institute of Medicine (IOM)

The IOM is part of the National Academies. The purpose of this organization is to advise the nation as how to improve health. The IOM may address clinical issues such as the safety of medication administration in addition to advising the nation as to the health and direction of a specific discipline such as nursing.

http://www.iom.edu/

MedlinePlus MedlinePlus, sponsored by the National Institute of Health, provides information regarding various health topics, drugs and supplements, and related information.

http://www.nlm.nih.gov/medlineplus/

Medline and PubMed

Medline and PubMed is The National Library of Medicine’s database covering the fields of nursing, medicine, and a variety of other clinical and preclinical services.

http://www.nlm.nih.gov/databases/da tabases_medline.html

NANDA International

NANDA International is an organization dedicated to the support of an international community of nurses equipped with a common language of nursing diagnoses to further patient care. Access a global network of nurses from this site and take part in the evolution of nursing diagnoses and care planning.

Home

Canadian Nurses Association (CNA)

Canadian Nurses Association (CNA) is the national voice of registered nurses in Canada. CNA works to improve health outcomes and strengthen the publicly funded, not-for-profit health system. The site contains valuable information about becoming a registered nurse, professional development, current issues, and the benefits of joining CNA.

http://www.cna-aiic.ca/en

American Nurses Association (ANA)

The American Nurses Association (ANA) is the premier organization representing the interests of the nation’s 4 million registered nurses. ANA is at the forefront of improving the quality of health care for all. Founded in 1896, and with members in all 50 states and U.S. territories, ANA is the strongest voice for the profession. ANA exists to advance the nursing profession by fostering high standards of nursing practice, promoting a safe and ethical work environment, bolstering the health and wellness of nurses, and advocating on health care issues that affect nurses and the public.

https://www.nursingworld.org