Question: SBAR Situation: Room Number: Age: Patient’s Name: Sex: Medical Diagnosis: Background: History: Allergies: Attending MD: Consults: Assessment: Current Vital Signs: Охус Heart Rhythm: Rate: Skin: IV Sites Change Date: Lung Sounds: IV Site १४ READ ONLY – This Is An Older File Format. To Ma… > Consults: Issessment: Current Vital Signs: Heart Rhythm: …

SBAR Situation: Room Number: Age: Patient’s Name: Sex: Medical Diagnosis: Background: History: Allergies: Attending MD: Consults: Assessment: Current Vital Signs: Охус Heart Rhythm: rate: Skin: IV sites Change Date: Lung sounds: IV site १४ READ ONLY – This is an older file format. To ma… > Consults: Issessment: Current Vital Signs: Heart Rhythm: Lung sounds: Oxygen rate: Skin: IV sites: IV sites Change Date: Dressings: Last BM: Foley: Activity: Diet: Drains: Fall Risk: II Recommendation: Current Labs: Pending Labs: og Activity: Diet: Drains: Fall Risk: Recommendation: Current Labs: Pending Labs: Awaiting Procedures: Nursing Concerns/Interventions: Current Medication(s) & Use: ANXIETY DISORDER MENTAL HEALTH Flow Sheet – Sex: Female Patient: Alicia Corny DOB: 06/11/1988 Admit: 02/14/ 2019 – Age: 25 – Ht: 165.1 cm (65 inches) – Wt: 63,6 kg (140 lbs) Allergy: No known allergies MRN: 815556 Physician: Karen Dolphin Date/Time Orders Progress Notes 02/14/XX 0745 Admit to the mental health unit: Observation 02/14/XX 0745 Rule out cardiac etiology for chest pain. 02/14/XX 0745 Vital signs with oxygen saturations every 4 hr and PRN 02/14/XX 0745 Diet: As tolerated 02/14/XX 0745 Activity: As tolerated 02/14/XX 0745 Paroxetine (Paxil) 40 mg PO daily 02/14/XX 0745 Ibuprofen (Motrin) 600 mg PO every 6 hr PRN mild pain MOM 30 ml PO daily PRN constipation Diphenhydramine (Benadryl) 50 mg PO at 02/14/XX 0745 02/14/XX 0745 bedtime RDM oloon difficult Date/Time Orders 02/14/XX 0745 Admit to the mental health unit: Observation Progress Notes 02/14/XX 0745 Rule out cardiac etiology for chest pain. 02/14/XX 0745 Vital signs with oxygen saturations every 4 hr and PRN 02/14/XX 0745 Diet: As tolerated 02/14/XX 0745 Activity: As tolerated 02/14/XX 0745 Paroxetine (Paxil) 40 mg PO daily 02/14/XX 0745 02/14/XX 0745 Ibuprofen (Motrin) 600 mg PO every 6 hr PRN mild pain MOM 30 ML PO daily PRN constipation Diphenhydramine (Benadryl) 50 mg PO at bedtime PRN sleep difficulty Ortho Tri-Cyclen 1 tablet PO daily B. Fisher, MD (7007) Electronic signature 02/14/XX 0745 02/14/XX 0745 02/14/XX 0745 02/14/XX 0745 02/14/XX 0745 Ibuprofen (Motrin) 600 mg PO every 6 hr PRN mild pain MOM 30 ML PO daily PRN constipation Diphenhydramine (Benadryl) 50 mg PO at bedtime PRN sleep difficulty Ortho Tri-Cyclen 1 tablet PO daily B. Fisher, MD (7007) Electronic signature 02/14/XX 0745 02/14/XX 0745 02/14/XX 0745 02/14/XX 0745 02/14/XX 0745 Ibuprofen (Motrin) 600 mg PO every 6 hr PRN mild pain MOM 30 ml PO daily PRN constipation Diphenhydramine (Benadryl) 50 mg PO at bedtime PRN sleep difficulty Ortho Tri-Cyclen 1 tablet PO daily B. Fisher, MD (7007) Electronic signature 02/14/XX 0745 02/14/XX 0745 02/14/XX 0745 Orders and Progress Notes Ibuprofen (Motrin) 600 mg PO every 6 hr 02/14/XX 0745 PRN mild pain 02/14/XX 0745 MOM 30 ml PO daily PRN constipation Diphenhydramine (Benadryl) 50 mg PO at 02/14/XX 0745 bedtime PRN sleep difficulty 02/14/XX 0745 Ortho Tri-Cyclen 1 tablet PO daily 02/14/XX 0745 B. Fisher, MD (7007) Electronic signature Date/Time 02/14/XX 0745 02/14/XX 0745 Orders Progress Notes Admit to the mental health unit: Observation 02/14/XX 0745 Vital signs with oxygen saturations every 4 hr Rule out cardiac etiology for chest pain. and PRN Diet: As tolerated Activity: As tolerated Paroxetine (Paxil) 40 mg PO daily 02/14/XX 0745 02/14/XX 0745 02/14/XX 0745 HISTORY AND PHYSICAL Mode of arrival Private vehicle Admission status Voluntary Accompanied by N/A Information provided by Client Present concern Client presents to the emergency department with reports of chest pain, headache and shortness of breath History of present illness New onset of chest pain History of prior psychiatric treatment Generalized anxiety disorder Previous illness/surgery NA Medications Paroxetine (Paxil) 20 mg PO daily, reports not having taken for approximately 2 weeks; Ortho Tri-Cyclen 1 tablet PO daily Diagnostics/Labs Completed in the emergency department, ECG -noncontributary Social/Cultural College student Spiritual Not able to discuss at this time HISTORY AND PHYSICAL Spiritual Not able to discuss at this time Sleep habits Reports poor, awakens frequently at night Nausea/Vomiting Denies Physical Vital signs Blood pressure: 148/76, heart rate: 115, respiratory rate: 32, temperature 37.0° C (98.6° F), oxygen saturation: 96% Neurosensory Oriented to time, person, and place Head and neck No redness, edema, visible abnormalities, report of occipital lobe headache and pain of 2/10 Cardiac and peripheral vascular Heart rate and rhythm regular, no murmurs, pulses +2 equal bilaterally, report of chest pain of 2/10 over mid to lower sternum Respiratory Respirations shallow and labored, lung sounds clear bilaterally to auscultation Gastrointestinal Abdomen soft, nontender, bowel sounds present in all 4 quadrants Musculoskeletal Gait steady, denies pain Skin Pink, warm, diaphoretic General appearance Appropriate, clean appearance 9 MEDICATION ADMINISTRATION RECORD Order Date Stop Date Scheduled Medications 0700-1900 1900-0700 02/14/XX Paroxetine (Paxil ) 20 mg PO daily Ortho Tri-Cyclen 1 tablet PO daily 02/14/XX HISTORY AND PHYSICAL Spiritual Not able to discuss at this time Sleep habits Reports poor, awakens frequently at night Nausea/Vomiting Denies Physical Vital signs Blood pressure: 148/76, heart rate: 115, respiratory rate: 32, temperature 37.0°C (98.6°F), oxygen saturation: 96% Neurosensory Oriented to time, person, and place Head and neck No redness, edema, visible abnormalities, report of occipital lobe headache and pain of 2/10 Cardiac and peripheral vascular Heart rate and rhythm regular, no murmurs, pulses +2 equal bilaterally, report of chest pain of 2/10 over mid to lower sternum Respiratory Respirations shallow and labored, lung sounds clear bilaterally to auscultation Gastrointestinal Abdomen soft, nontender, bowel sounds present in all 4 quadrants Musculoskeletal Gait steady, denies pain Skin Pink, warm, diaphoretic General appearance Appropriate, clean appearance 9 MEDICATION ADMINISTRATION RECORD Order Date Stop Date Scheduled Medications 0700-1900 1900-0700 02/14/XX Paroxetine (Paxil ) 20 mg PO daily Ortho Tri-Cyclen 1 tablet PO daily 02/14/XX 10 MEDICATION ADMINISTRATION RECORD PRN Medications 02/14/XX 02/14/XX Ibuprofen (Motrin) 600 mg PO every 6 hr PRN mild pain MOM 30 ml PO daily PRN constipation Diphenhydramine (Benadryl) 50 mg PO at bedtime PRN sleep difficulty 02/14/XX IV Therapy Electronic Signature Date Name 11