Pt. name:  Carson, Sarah                         Admitting Physician:   Dr. Cane        
Age:
65                                            DOB:1/20/1948                               Bed: 244
Admitting diagnosis:
Non-small cell carcinoma, right lung, recurrent
Pt. ID # 542768
                                                Med Rec #:  78543
Wt. lbs: 114.8   kg: 52.2                 Ht.: 64 cm                                 Race: Hispanic
Major Support:
 Husband, Daughter                                                                      Religion:
Catholic

Immunizations: current
Allergies:
NKDA

 

Nursing Map of Care
Complete Patient Assessment

Current MAR

Medication History:

 

Order #
Med/dose
Route/schedule
Reason
Date started
#1
2 mg SL q4h
pain and/or dyspnea
08/15/2013
#2
1 mg SL Q1h prn
breakthrough pain and/or dyspnea
08/15/2013
#3
200 mg po qHS
Prevention of constipation
8/15/2013
#4
2 drops SL Q4hrs prn
increased secretions/pharyngeal rales
8/15/2013
#5
2 puffs QID prn
shortness of breath
8/15/2013
#6
0.5 mg TID prn
anxiety/shortness of breath
#7
10 mg suppository prn
constipation
#8        
#9
#10
#11

#12

 

 

 

 
         
         
         
         
         
         
         

 

AC EMR