Account [NEY MeN Registration Date 34 May 2014 02:01 Name LIM CHIN SHENGLIN JINGSHENG ‘Sex/Date of BirtRace Mald NIE 1972/Chinese atient's gat is Impaired tient’s mental status is Orientated towards own ability all Risk Assessment Score: 75 tate Fall Risk’ Alert Coloured wrist band on patient Post Falling Tree ‘Fall Precaution” signage on trolley Inform all other team members of the patient fall risk sess environment safely - lighting, spills: Lower beartroliey to lowest position 52 Page 3 of ¢ -xplain to patient and family members of the fall risk and engage them in all aspects of the fll prevention program 1608 (09 Jun 2014Account MRN Registration Date 31 May 2014 02:01, Name LIM CHIN SHENGLIN JINGSHENG Sex/Daie of Birth/Race ——MaleNINB 1972/Chineso Teach and shaw patient use of call Ball To request for assistance (obs wd) ‘plain and instruct CRIB as ordered. Locate patient near nurses’ station for increased surveillance or allow one family caregiver to stay with patient, ifnecessary (Recorded by SSN III Louisa on 31 May 2014 02:10] primary nurse: conscious and alert Nil IV plug inserted Not accompained by relatives. Recorded by SSN [jij Sophia on 31 May 2014 03:17] Plan of Management XR - neck and facial bones analgesia MC [Recorded by Dr Neo Xiu Min Shermyn on 31 May 2014 02:44] Medical Status Emergency Trauma Type of Accident Main Diaanosis Primary diagnosis 820 Contusion Of Face Scalp And Neck [Recorded by Dr Neo Xiu Min Shermyn on 31 May 2014 03:28) Disposition Treated and Discharged on 31 May 2014 03:28 by Dr Neo Xiu Min Shermyn, Patient's condition on discharge was Well Medical Certificate MC Number waass286 Date Issued 31 May 2014 3:28 Issued By Dr Neo Xiu Min Shermyn MC Issued from 31 May 2014 to jun 2014 for Sdays Medical Leave: Outpatient leave: Advice/Education Given Issued Date Given By AdvicelEducation Given to Relationship 31 May 2014 3:2€ Dr Neo Xiu Min Shermyn See Doctor if unwell patient Prescription (CPOE) OrderName Dosage Frequency Duration _ Prescribed By Time Prescribed ANArex Tablet [Paracetamol 2 tablet TDs weeks Shermyn Neo Xiumin 3:11:00 ‘450mg, Orphenadrine 35mg} PRN Pain Ketoprofen 2.5% Gel 4 pplication 8D ‘Sheemyn Neo Xiumin 3:11:00 PRN: Pain Doctor List Primary Provider Dr Neo Xiu Min Shermy / |Supervising Senior Provider OD Aner i XX XKAAKAAKA AXA KKXXHK XK K KKK IHN, End of Page Page 4 or4 oadun 2014 16:09] (Py TARE gen ‘Om Be