Medical Documents

██████████ University Medical Center

Pediatric Admission Profile

Page 1

Timothy W█████

Date: 12/20/95

Eyeglasses: Remains at Bedside
Hearing Aid: N/A
Clothing: Sent Home
Other: N/A
Other: N/A
I fully understand that ████ is not responsible for any personal property brought in or retained at the bedside at any time. I fully understand that ████ provides a safe for my valuables should I wish to place them there for the hospital stay.

Section I
Source of Information: Janet W█████
Relationship: Mother
Reason for Admission/Chief Complaint: insomnia, headaches, possible disorder

Medications: Amoxicillin, codeine
Explain reaction: Hives

Medications: N/A

Able to swallow pills? Yes

Page 2:

Timothy W█████

Section II - Health History
Source of Information Section II-XII: Janet W█████
Relationship: Mother
Actual Weight: 21 kg
Actual Height/Length: 107 cm

Advance Directive: Less than 18 years old, N/A
Transferred From/Admitted From: Home

Work #: █████████████
Home #: █████████████

Recent Infections or Exposures: Denies

Immunizations Up-To-Date: Yes
Outpatient Services: Not Applicable
Vascular Access: Not Applicable
Blood/Blood Component Transfusion History: Not Applicable

Section III: Psychosocial History
Tobacco: No
Has patient or someone in your house smoked in the last year? Yes
If yes, would you like: Patient/Family refused
Alcohol: No
Illicit Drug Use: No
Cultural needs/considerations affecting hospitalization/plan of care: Denies

[There is no Section IV]

Page 3:

Patient Name: Timothy W█████

Section V - Growth and Development
Prior to admission able to complete ADL: Yes

Section VI - Activity/Safety
Seizure precautions: anticonvulsant

Morse Fall Scale
History of Falls: Yes 25
Secondary Diagnosis: No 0
Ambulatory Aid: None/Bedrest/Wheelchair/Nurse 0
IV/Saline Lock: No 0
Gait Transferring: Normal/Bedrest/Immobile
Mental Status: Oriented to Own Ability 0
Total: Moderate Risk 25-20

Page 4:

Patient Name: Timothy W█████

Section VIII - Elimination
██████████████: Yes
███████████████████: No

Section IX - Cognitive/Sensory Perception
Vision: Glasses
Hearing: No difficulty reported
Speech: Appropriate for age

Section X - Pain History Assessment
Do you have pain now? Yes
How does your child express pain? Screaming
Pain Scale: 0-10
Pain intensity/Score: 6
Describe: Headaches (frequent)

Section XI - Teaching
Readiness to Learn: Yes
Preferred Learning Style: Visual
Potential Barriers to Learning: Emotional
Learning Needs: Medications

Section XII - Initial Discharge Assessment:
Previous Home Care Services: No
Who does child live with? Mother
Who will care for the child at home? Mother
Based on obtained child patient information and nursing assessment - referral related to discharge needs made to: Case Management

Pediatric Admission Assessment

Page 1:


Date: 12/20/95
Time: 11:45 A.M.

Person to Notify in Case of Emergency:
Name: Janet W█████
Phone: █████████████
Relationship: Mother

Admitted From: Home (✓)
Admitted via: Ambulatory (✓)

Orientation to Nursing Unit:
Nurse Call System (✓)
Crib/Side Rails (✓)
Bathroom (✓)
Phone (✓)
No Smoking (✓)
No leaving children unattended (✓)
Bed Controls (✓)
ID Bracelet (✓)
TV Controls ( )
Visiting Hours (✓)
Patient Information (✓)

Cribs must have rails up at all times when occupied ( )
No toys or objects to create sparks or friction if in croup tent ( )
Bed/crib must be kept in lowest position at all times ( )

Immunizations Current? Yes

Chief Complaint: Headaches, insomnia, █████████████

█████████████████████████ will not assume responsibility for lost or damaged valuables, clothing, or personal items kept in the patient's possession. Valuables should be taken home or secured by the hospital.
Valuables taken home (✓)
Patient/Family Signature
Witness Signature
Date: 12/20/95
Time: 12:01 P.M.

Valuables picked up by: Janet W█████
Date/Time: 12/20/95 12:01 P.M.

Health Profile: Other (X), Janet W█████

Have you been hospitalized at our facility in the past 7 days? No
If yes, has there been any changes in your status since last admission? No

Page 2:

Medical History and Previous Surgery:
Ever had a blood transfusion? No (✓)

Social/Environmental Assessment:
1. Patient lives: With family (✓)

2. Habits: Tobacco
Member of household uses tobacco (✓)

3. Education: Last grade in school attended: 2
Can read? Yes (✓)
Can write? Yes (✓)
Is Home Health involved in your Care? No (✓)

5. Assistance required for Care
Toileting: Goes to bathroom alone (✓), Independent (✓)
Medication: Taken best as: Liquid (✓)
Who else besides parents might be staying with child? N/A
Emotional Support: Has your family had any recent changes in your life? (moved, divorce, birth, death, new job, etc.): No (✓)

6. Abuse/Neglect/Exploitation Screen
Do you feel safe in your home? Yes (█) No (✓)
Are you afraid of anyone? Yes (█) No (✓)
█████████████████████████████████████████████████████████████ No (✓)
Within the past year, have you ever been hit, slapped, kicked, or otherwise physically hurt? No (✓)
█████████████████████████████████████████████████████████████████████████ No (✓)
Evidence of neglect by self? No (✓)
Evidence of neglect by caretakers? No (✓)
Evidence of abuse by self or others? No (✓)

Color Impairment: None (✓)
Temperature: Warm (✓)
Turgor: Good (✓)

Page 3:

Teeth Condition: Good (✓)
Gums: Pink (✓)
Nose: No problems (✓)

Bathing: Partial Assist (✓)
Condition on arrival: Good
Oral Hygiene: Self (✓)
Hair Condition: Good

Neuro Status
Conscious (✓)
Oriented To: Person (✓), Place (✓)
Weakness/Paralysis: None (✓)
Range of Motion: Independent (✓)

Pupils: Equal (✓)
Eyes: ( )

Adequate (✓)
Glasses/Contacts: With Patient (✓)

Speech: Clear (✓)
Swallows: Without Difficulty (✓)

Hearing: Adequate (✓)

Independent (✓)

Respiratory Problems: Cough (✓)
Aids to Respiration: None (✓)
Cardiovascular Problems: None (✓)

Page 4:



Unable to fall asleep easily (✓)
Avg # Hrs Slept Each Night: 4 #Pillows used: 2
Sleeps with Night Light On (✓)

Is the patient currently having pain or admitted a pain related diagnosis? Yes (✓)
Location: Head
Duration: 2-4 Hrs
Type: Chronic (✓), Dull (✓)
Relieved by: Rest (✓)
Aggravated by: Talking
Do you have any personal, cultural, spiritual, and/or ethnic beliefs that may affect the way your pain is treated? No (✓)

Page 5:

Psychological Status
Body Image/Self Concept Problems: Signs/Symptoms of Depression (✓)
Spiritual Needs: No Requests (✓) Minister, etc. be notified: No (✓)
Observation of Patient Behavior/Interaction: Cooperative (✓), Restless (✓)

Developmental/Other Needs Assessment

School Age Child, 6-12 Years

Engages in group activities with same sex peers ( )

Wide Range of Vocabulary (✓)
Learns to read (✓)
Learning math skills (✓)
Begins collections (Hobbies) ( )

Exhibits physical endurance (plays sports, games) increased time motor ability (writing, painting drawing) ( )

Discharge Needs
Transportation (✓)

Plan of Care Reviewed With:
Family (✓)

Other Notes: Ran away from home 2 █████ ago. Found at Rosswood Park.


Page 6:

Is this child's condition affected by the family? No (✓)

Is the family affected by this child's hospitalization? No (✓)

Fall Risk Assessment
Confused, disoriented, hallucinating, combative - 20 (✓)
Hx of syncope, seizures, postural hypotension - 20 (✓)
Total: 40 (High Risk)

Delayed Therapy Communication Form

Person Documenting Delay: ███████████████
Routine: ████████████
Stat: ████████████
Person Responding to Delay: ████████████
Date: 7/8/02 Time (Military Time): 15:10
Name of Procedure: Monthly Session
Date Ordered: █████████

Tracking Codes
Patient/Family Variance Codes: P4 - Patient/Family Uncooperative

Delay Description: ████████████
Intervention: ████████████
*Intervention: ████████████

Brief Operative Progress Note

Date: 1/10/████
To be dictated by: Dr. █████████

Operation: ██████████████████

Surgeon: ██████████

1st Asst.:█████████████

Pre-Op Diagnosis: ████████████████

Post-Op Diagnosis: ██████████████████

Anesthesia: General (X) █████████

Blood Loss: ██████████

Blood Replacement: ████████

IV Fluids: ██████████████████

Drains and Packing: ██████████████████

Wound: Clean (X) █████████

Complications: ██████████████████

Procedure: (Wound prep, incision, Findings, pathology, closure, etc.)


Suicide/Self-Harm Assessment Tool

█████████████ █████████████
█████████████ █████████████
█████████████ █████████████

High Risk - 2 Points
Moderate Risk - 1 Point
No Precautions - 0 Points

Question I.
Is the CURRENT ADMISSION precipitated by a SUICIDE ATTEMPT? No (1 point)

Section II.
CONTRACT FOR SAFETY: Unwilling to contract -OR- Unable to contract because of impaired reality testing (hallucinations, delusions, dementia, delirium, disassociation) (2 points)

SUICIDE PLAN: Has plan with actual or potential access to planned method (2 points)

PLAN LETHALITY: Highly lethal plan (gun, hanging, jumping, carbon monoxide) (2 points)

ELOPEMENT RISK: Low elopement risk (1 point)

SUICIDAL IDEATION: Constant suicidal thoughts (2 points)

ATTEMPT HISTORY: No previous attempts (0 points)

SYMPTOMS: 3-4 symptoms present (1 point)


Section III.
Replies Not Trustworthy = 4 points
Replies Questionable = 3 points
Replies Trustworthy = 0 points

Pt. Replies questionably, trustworthy; at least one nonverbal cue (3 points)

Total Score: 14 (10 or more = High-risk Precautions (1:1))

Assessed by (RN)

Date: 7/8/02

Time: 8:45

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