Pt. name:  Dale Mayman                        Admitting Physician:   Dr. S Phillips       
Age:
51                                           DOB: 11/13/xx                             Bed: ER Bed 2
Admitting diagnosis:
Confusion bleeding gums
Pt. ID # 542768
                                                Med Rec #:  78543
Wt. lbs: 172  kg: 78                 Ht.: 71 inches                                 Race:Caucasian
Major Support:
 Wife                                                                      Religion:
Not stated

Immunizations: current
Allergies:
Ace inhibitors (angioedema)

 

Nursing Map of Care
Complete Patient Assessment

Current MAR

Medication History:

 

Order #
Med/dose
Route/schedule
Reason
Date started
#1
100 mg PO Daily
diuretic
 
#2
40 mg PO Daily
diuretic
#3
Inderal (hold if HR<60, SBP < 100)
10 mg PO BID
Blood Pressure
#4
1 tab PO Daily
Muti-vitamin
 
#5
30 mL PO Daily
elevated ammonia levels
#6
1 gram IVPB Q 12 hrs
antibiotic
#7
3.375 mg IVPB Q 6 hrs
antibiotic
#8        
#9
#10
#11

#12

 

 

 

 
         
         
         
         
         
         
         

 

AC EMR