Electronic Health Record: Name: Password

ELECTRONIC HEALTH R
Name: ARIAN MAY MA
Password: BSN 2-F
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LTH RECORD
RIAN MAY MARCOS
BSN 2-F
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Patients
Patient
atients
Patient
ELECTRONIC HEAL
Bianca Summer Jimenez
First Name Bianca Summer Last Name
Birthday: 01-Jan-96 Age:
Marital Status:
Home Phone: N/A

Profile
Cell Phone: 0909-762-5218
Patient's History
Email Address: N/A
History of Present illness
Spouses Name: John Lee Jimenez
Past Medical History
Emergency Contact:
Family History
Last Name: Jimenez
13 Areas of Assessment
Relationship: Husband
TPR Graphic Record
Home Phone: N/A
Medication and Treatment Record
Data Furnished by: Address of Inform
Physician’s Order
John Lee Jimenez Balili Km3, La Trinida
Nurse’s Notes
Admission Diagnosis:
Home
Principal Diagnosis:
Log Out
Other Diagnosis:
Principal Operation Procedure:
Other Operation(s) Procedure(s):
Accident / Injuries / Poisoning (E CODE)

Place of Occurrence:
Disposition:
Discharged DAMA
Transferred Absconded
C HEALTH RECORD
Date of Admission
28-Feb-21
Pt. Number #01
Last Name Jimenez Middle Name Ferrer
Age: 25 Sex:
Address: Balili Km3, La Trinidad, Benguet
City: La Trinidad
Zip: 2601
Country: Philippines
e Jimenez Children: N/A
First Name: John Middle Name: Lee
band Email Address: Jlee@gmail.com
Cell Phone: 0909-020-2711
Address of Informant: Relation to patient:

Balili Km3, La Trinidad, Benguet Husband
Abdominal pain
Labor pain
Home
RESULTS:
Recovered Died Autopsy
Improved <48 hours No Autopsy
Unimproved >48 hours
Electronic Hea
Previous Care for Same Condition:
Have you seen other doctors FOR THIS CONDITION?
Type of Treatment
Previous Chiropractic Care:

Profile
Doctor's Name:
Patient's History
Current Medication (s): List ANY/ALL
Medication Dosage
Family History
TPR Graphic Record

Alcohol:
Physician’s Order
Diet (please mark all that apply):
Nurse’s Notes
Education (please mark the highest level complicated):
Home
Log Out
Drug :
Tobacco :
Occupation: Teacher
Marital Status: Married
Ins
Who is Responsible for your Bills?
Personal Health Insurance Carrier: Insular Life Philip
Policy Holder's Name: Bianca Summer Jim
Policy Holder's Date of Birth: 01-Jan-96

onic Health Record
Date of Admission
28-Feb-21
Pt. Number #01
If yes, Who?
Was the treatment beneficial in resolving conditon
Location: Date:
cation (s): List ANY/ALL medications you are CURRENTLY taking. Be Specific.
For What Condition? How long have you been taking this?
Social History:
Sexual History
Travel History
Exposure
Insurance Information:
Insular Life Philippines Health ID Card : 0123-4567-8910
Bianca Summer Jimenez Group No : __________________________________
01-Jan-96 Primary Care Physician : _______________________

01
his?
567-8910
__________________
_________________
Electronic He
Review of Systems
HEENT
A. EYES YES NO
Blurred vision
Change of Vision
Double vision
Profile
Dryness
Flashing spots
Patient's History
Loss of vision
Pain
Redness

B. EARS YES NO
Hearing aids
Family History
Loss of hearing
Ringing in ears
C. NOSE/ MOUTH/ THROAT YES NO
TPR Graphic Record
Acid/ bitter taste
Bleeding gums
Dry sinuses
Hoarseness
Physician’s Order
Loss of smell
Mouth sores
Nurse’s Notes
Nose bleeds
Sinusitis
Home
Sore tongue
Trouble swallowing
Log Out
CARDIOVASCULAR YES NO
Chest pain
Cramping legs
Heart murmurs
Heart Palpitation
High blood pressure
Swelling in arms
Swelling in legs
Varicose veins
RESPIRATORY YES NO
Asthma
Bronchitis
Chest pain with breathing
Chronic dry cough
Cough with mucus
Coughing up blood
Dyspnea
Emphysema
Night sweats
Pulmonary edema
Pneumonia
Produces sputum
Shortness of breath
Smoker
Tuberculosis
Wheezing
HEMATOLOGY/LYMPHATICS YES NO
Anemia
Easily bleed
Easily clot
OTHER SYMPTOMS YES NO

Weight gain/loss
Fever/ Chills
Night Sweats
Body Malaise
Anorexia
Pain
Pruritis
Rashes
Cyanosis
History head trauma
Headache
Diziness
Loss of Consciousness
Seizure
Visual Dysfunction
Diffculty of Hearing
Tinnitus
Epistaxis
Hoarseness
Nausea/ Vomiting
Hematemesis
Obs
M I
G P
LMP Feb. 28, 2021
Jaundice CLAD
Cyanosis TPWC
Pallor Anterior Neck Mass
Rash JVP
Skin Turgor Assymetric CWE
Warm to touch Lagging
Pink Sclera Retraction
Pale Sclera Hyper resonant
Nasal Discharge Equal Tactile
Ear Discharge Vocal Fremitus
Tragal Tenderness Bronchovesicular breath sound
NURSE ON DUTY:
Arian May Marcos
onic Health Record
Date of Admission
28-Feb-21 Pt. Number
GASTROINTESTINAL (GI) YES NO INTEGUMENTARY/ BREASTS

Nausea Change in skin
Belching Alopecia
Blood in stool Breast lumps
Constipation Breast pain
Diarrhea Change in hair
Excessive gas Change in moles
Heartburn Change in nails
Hemorrhoids Color change of feet with cold
Regurgitation/ Wet burp Color change of hands with cold
Vomiting blood Easy bruising
Yellow skin Hair loss
Hives
GASTROURINARY (GU) YES NO Nipple discharge
Blood in urine Nodules/bumps
Cloudy urine Papules
Frequent urination at night Persistent sores
Incontinence Sensitive to sun
Kidney stones Skin reddness
Pain when urinating Skin tightness
Rash in genitals Tumor
Sexual problems
Sexually transmitted diseases NEUROLOGIC
Trouble urinating Balance problems
Urgency Chronic headache
Dizziness
WOMEN ONLY YES NO Memory loss
Abnormal period Numbness (feet)
Pregnant Numbness (hands)
Tubal ligation Tingling (feet)
Vaginal discharge Tingling (hands)
Unconsciousness
MEN ONLY YES NO
Circumcized ENDOCRINE
Painful ejaculations Decreased sex drive
Penile discharge Increased thirst
Poor urinary stream Sensitive to cold
Vasectomy Sensitive to heat
MUSCULOSKELETAL YES NO ALLERGY
Back pain Environmental allergies
Fractures Flower (pollen) allergies
Joint pain Food allergies
Joint replacement Insect allergies
Joint swelling Latex allergies
Kyphosis Medication allergies
Lordosis Rhinitis
Muscle cramps Seasonal allergies
Neck pain
Scoliosis PSYCHIATRIC
Weak muscles Agitated
Anxiety
IMMUNIZATION YES NO Delusion
Hepatitis Date: ________ Depression
HPV Date: ________ Hallucination
Influenza Date: ________ History of abuse
MMR Date: ________ Illusion
Pneumonia Date: ________ Obsessive/compulsive habits
Polio Date: ________ Problems concentrating
Tetanus Date: ________ Suicidal ideation
OTHER SYMPTOMS YES NO OTHER SYMPTOMS

Colds Dysuria
Difficulty of Breathing Urinary fequency
Cough Flank pain
Hemoptysis Polyuria
Chest Pain Ologurial/ Anuria
Chest Discomfort Nocturia
Palpitations Hematuria
Orthopnea Urgency
PND Hesitancy
Easy Fatiguability Dribbling
Exertional dyspnea Urinary Incontinence
Edema Pelvic/ Inguinal pain
Calauditions Vaginal/ Penile Discharge
Dysphagia Menorrhagia
Heartburn Amenorrhea
Abdominal Pain Joint pain/ stiffness
Abdominal Enlargement Joint Swelling
Early Satiefy Muscle cramps
Diarrhea Easy Bruisability
Constipation
Others::
Melena/ Hematochizia
Obstetric & Menstrual History

D A S
PMP
Contraception:
Physical Examination
CLAD Crackles Rebound CN I
TPWC Wheezing Tenderness CN II
Anterior Neck Mass Rhonchi Guarding CN III
JVP Heaves/ thrills Roving's sign CN IV
Assymetric CWE PMII Obturator sign CN V
Lagging Murmur Psoas sign CN VI
Retraction Heart Sound Heel jarring sign CN VII
Hyper resonant Heart Rate Cough sign CN VIII
Equal Tactile Tympany Splenomegaly CN IX
Vocal Fremitus Soft/ rigid CN X
onchovesicular breath sound Direct CN XI
CN XII
Y: PATIENT'S NAME:
os Bianca Summer Jimenez
#01
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
nez
Electronic Healt
Childhood Illness (es): LIST all health conditions. CHECK all past condition
Profile
Patient's History
Adult Illness (es): LIST all health conditions. CHECK all past conditions.
Family History
TPR Graphic Record
Physician’s Order
Doctor: Are Child/Adult Illnesses listed contributory to the CURRENT Cond
Nurse’s Notes
Surgery (ies): LIST all the Surgery Procedures. Write the DATE of the Proce
Home
Log Out
Injury (ies): Mark or List Injuries. Write the DATE of the Injury immediatel
nic Health Record
Date of Admission
28-Feb-21 Pt. Number #01
. CHECK all past conditions.
ECK all past conditions.
ory to the CURRENT Condition?
Write the DATE of the Procedure immediately afterward.
TE of the Injury immediately afterward.

Electronic Healt
Family History: Mark all that apply below. List any specific conditions
General Family
Father
Mother
Paternal Grandfather
Paternal Grandmother
Profile
Maternal Grandfather
Maternal Grandmother
Patient's History
Son (s)
Daughter (s)
Brother (s)
Sister (s)
Family History
TPR Graphic Record
Physician’s Order
Nurse’s Notes
Home
Log Out
nic Health Record
Date of Admission
28-Feb-21
Pt. Number #01
st any specific conditions past or present after has/had.
Hypertension
Hypertension
Electronic Health R
Date of Admission
Bianca Summer Jimenez 28-Feb-21
I. PSYCHOLOGICAL STATUS
The patient is a 25-year-old female. She is married and presently residing with her
an elementary teacher. The patient and her family are Roman Catholic and have
Watching the television, eating and singing is her way in spending her leisure time
is classified under Intimacy vs. Isolation. She values her relationship with her hus
loving relationsh
Profile
II. MENTAL & EMOTIONAL STATUS
Patient's History
History of Present illness Mrs. Jimenez is having a hard time to cope up with her current situation because o
yet perform her duty on how to position the baby properly when giving breastfeedi
Past Medical History when the health worker is obta
Family History
III. ENVIRONMETAL STATUS
The patient is oriented that she is in the hospital and has no sensory deficits. Sh
TPR Graphic Record procedures she is taking. Bed rails are available for the patient together with disin
She has intravenous access on her right arm for her IVF that may limit her mob
Medication and Treatment Record unnecessary noise was noted. The floor is well-main
Physician’s Order
IV. SENSORY STATUS
Nurse’s Notes During the assessment, she can also distinguish voice using the whisper test even
auditory device noted being us
Home
The patient's nose is symmetrical, proportionate and no lesions were seen. She ha
distinguish the smell of familiar o
Log Out
The patient verbalized that she has a good sense of taste. The patient is able to d
description of the food she
V. MOTOR STATUS
Motor strength is assessed. Post-operatively, the patient was instructed to remain fl

was encouraged. Her movements are limited since she has undergone an operat
carefully as of the moment. No prosthetic device was noted present with the patie
verbalized that she needs assistance whenever she ne
VI. NUTRITIONAL STATUS
The patient's food is being served in the hospital. Her appetite is good and usually
on a diet as tolerated except for dark-colored foods with a Good Appetite. Teeth ar
color. Her nails were delicate and well-trimmed. There is no culture or religious di
and medications as
The patient's food is being served in the hospital. Her appetite is good and usually
on a diet as tolerated except for dark-colored foods with a Good Appetite. Teeth ar
color. Her nails were delicate and well-trimmed. There is no culture or religious di
and medications as
VII. ELIMINATION STATUS
She goes to the comfort room with no assistance and patient urination is estimated
pain was reported to be felt during ur
VIII. FLUID & ELECTORLYTE STATUS
The patient consumes 8 – 12 glasses of water normally. She urinates frequently

yellow. She has moist lips, pink and moist buccal mucosa and the tongue is pinki
pinkish. Nail beds are good, no
IX. CIRCULATORY STATUS
During initial vital signs taking, the Patient has a pulse rate of 75 beats per minute
She has a capillary refill of 1-2 seconds. Membranes are pallo
X. RESPIRATORY STATUS
She has a respiratory rate of 17 breaths per minute. No use of accessory mus
symmetrically expands with each respi
XI. TEMPERATURE STATUS
The Patient verbalized feeling of warmth and cold. Her temperature is 36.5 C,
ventilated. The Patient is using the blanket provided by the hospital and weari
XII. INTEGUMENTARY STATUS
Patient’s skin is brown in color, warm, and moist. There are no scars, pallor, and j
upper and lower extremities. Her nails are yellow in color, and appears to
Patient’s skin is brown in color, warm, and moist. There are no scars, pallor, and j
upper and lower extremities. Her nails are yellow in color, and appears to
XIII.COMFORT & REST STATUS
The Patient usually sleep 6-8 hours at night, she stated that sometimes her sleep
husband and sister are helping by taking care of the ba
Health Record
Date of Admission
28-Feb-21
Pt. Number #01
nd presently residing with her husband and child at Blili Km3, La Trinidad, Benguet. She works as
are Roman Catholic and have no practices or beliefs which might affect to providing health care.
y in spending her leisure time. Based on Erickson’s psychosocial theory, the patient a young adult
s her relationship with her husband. They have been married for 2 years already and have a good
loving relationship.
er current situation because of the pain she’s going through and in a view of the fact that she can’t
perly when giving breastfeeding. Also, she’s irritable and shows facial grimace during ambulation
when the health worker is obtaining vital signs.
nd has no sensory deficits. She is also knowledgeable about her condition and knows about the
the patient together with disinfectants. Drinking water and food are located in her bedside table.
r IVF that may limit her mobility. Patient is in a private room with good ventilation and and no
noted. The floor is well-maintained, and no scatter rugs were seen.
ce using the whisper test even from a distance of 2-3 feet. No corrective auditory deficits and no
uditory device noted being used by the patient.
c. Olfactory Status
d no lesions were seen. She has an intact sense of smell. No epistaxis was noted. She was able to
inguish the smell of familiar odor such as food.
d. Gustatory Status
taste. The patient is able to distinguish sweet, sour, salty and bitter foods as evidenced by proper
description of the food she was taking in.
nt was instructed to remain flat on the bed for a few hours after surgery, and then early ambulation
e she has undergone an operation. The patient can move and can move all her joints slowly and
as noted present with the patient, and all her extremities are intact and with proper symmetry. She
ds assistance whenever she needs something.
r appetite is good and usually depends on the food being served. During the hospitalization, she is
with a Good Appetite. Teeth are without dental caries. Her skin is smooth and with a pinkish white
re is no culture or religious dietary restriction reported by the patient. She can swallow in her food
and medications as well.
patient urination is estimated to be 2-3 times per shift. Urine is clear and dark yellow urine and no
as reported to be felt during urination and defecation.
mally. She urinates frequently from four to ten times a day. The color of her urine is transparent
mucosa and the tongue is pinkish in color. Skin turgor is good and the nails generally appear to be
nkish. Nail beds are good, no signs of clubbing.
se rate of 75 beats per minute and blood pressure of 120/85 mmHg while in semi fowler position.
seconds. Membranes are pallor which may suggest poor perfusion or anemia.
ute. No use of accessory muscles was noted There is no abnormal breath sounds. Chest wall
cally expands with each respiration and no retractions.
d. Her temperature is 36.5 C, per axillary upon initial vital signs taken. The ward is adequately
ded by the hospital and wearing clothes made of cotton not greatly affecting her temperature.
here are no scars, pallor, and jaundice. Edema and dermatoses is present in her face and also in her
llow in color, and appears to be clean and short. Black smooth dry hair, no lice and nits.
ted that sometimes her sleep is interrupted because of the discomfort due to her episiotomy. Her
lping by taking care of the baby while the patient take her rest period.
Electronic He
Family Name Jimenez First Name
Date 28-Feb-21
Date in Hospital 2/28/2021
Day of PO or PP 28-Feb-21
A.M P.M A.M P.M
HOUR
7:40 MB
Profile T 106
Patient's History E 105
History of Present illness M 104

P 103
Family History
E 102
R 101
TPR Graphic Record

A 100

T 99
Physician’s Order
U 98
R
Nurse’s Notes 97
E
Home 96
Log Out C 150
A 140
R
130
D
I 120
A
110
C
100
R 90
A
T
E
C
R 90
A
T 80
E 70
60
R
E 50
S
P 40
I
R
A 30
T
I 20
O
N 10
Blood Pressure 120/85 mmGH
Fluid Intake 6 glasses
Urine 3
Defecation 1
Weight 50 kg
Vital
DATE Date: (February/ 28/ 2021)
SHIFT: AM PM NIGHT PRN
TIME TAKEN: 7:40
BP 120/85
TEMP (Degrees Celsius) 36.5
TEMP ROUTE (Oral,
AX
Axillary, PR, Forehead Scan)
PR 75
RR 17
O2 SAT 95%
Pain Scale:
ronic Health Record
Date of Admission
First Name Bianca Summer Room No. #501-P Patient No. #01
A.M P.M A.M P.M A.M P.M A.M P.M A.M P.M
Vital Signs Summary
Date: (MM/ DD/ YY) Date: (MM/ DD/ YY) Date: (MM/ DD/ YY)
AM PM NIGHT PRN AM PM NIGHT PRN AM PM
#01
#01
A.M P.M
Date: (MM/ DD/ YY)
NIGHT PRN
Electronic Healt
MEDICATION/ DOSE/ FREQUENCY DATE AM
Feb. 08:00/MB
28
Pitocin: 0.5-1 mUnit/min IV
2021

Feb. 08:00/MB
Profile
28
Pethidine: IV 25-100mg 4 hourly
2021
Patient's History
Feb. 08:00/MB
Butarphanol: 1mg IV or 2 mg IM
28
every 3 to 4 hours. 2021
Family History
Feb.
28
2021
TPR Graphic Record
Feb.
28
Physician’s Order
2021
Nurse’s Notes
Feb.
Home
28
2021
Log Out
Feb.
28
2021

Feb.
28
2021
Feb.
28
2021

Feb.
28
2021
nic Health Record
Date of Admission
PM NIGHT AM PM NIGHT AM PM NIGHT
DATE DATE
DATE DATE
DATE DATE
DATE DATE
DATE DATE
DATE DATE
DATE DATE
DATE DATE
DATE DATE
DATE DATE
Electronic Health
Date, Time and Progress Note Physician's Order / Name & S
28-Feb-21 1. Pitocin: 0.5-1 mUnit/min IV
2.Pethidine: IV 25-100mg 4 hourly
3. Butarphanol: 1mg IV or 2 mg IM eve

Profile
Patient's History
Family History
TPR Graphic Record
Physician’s Order
Nurse’s Notes
Dr. Z
Home
(08:00 AM/MB)
Log Out
c Health Record
Date of Admission
ysician's Order / Name & Signature of Physician (Time Noted by the Nurse) Remarks
0.5-1 mUnit/min IV
e: IV 25-100mg 4 hourly
hanol: 1mg IV or 2 mg IM every 3 to 4 hours.
M/MB)
Electronic Health R
Date of Admission
Chevy Rolet Sparks 28-Feb-21
Date & Time Focus Data

28-Feb-21 Abdominal Pain D: "Sobrang sakit na po hind
9:00 AM looks uncomfortable, grima
A. Monitor vital signs and as
duration, provide and encour
techniques, provide comfort
of comfort, encourage verba
Profile
28-Feb-21 R: Patient pain was relieved
9:00 PM
Patient's History

Arian May Marcos
Registered Nurse
Family History
TPR Graphic Record
Physician’s Order
Nurse’s Notes
Home
Log Out
Health Record
Date of Admission
Data Action Response
D: "Sobrang sakit na po hindi ko na kaya" verbalized by the patient. The patient-
looks uncomfortable, grimacing of face, irritable , and restlessness.
A. Monitor vital signs and assessed pain, noting location, intensity (Scale 0-10)-----
duration, provide and encourage deep breathing exercises and relaxation--------
techniques, provide comfort measures such as back rubs, and helping position---
of comfort, encourage verbalization of pain, and reviewed ways to lessen pain.
R: Patient pain was relieved and controlled.Pain rating: 2/10
Arian May Marcos

Registered Nurse

Electronic Health Record: Name: Password

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ELECTRONIC HEALTH R

Name: ARIAN MAY MA

Password: BSN 2-F

Birthday: 01-Jan-96 Age:

Home Phone: N/A

Principal Operation Procedure:

Other Operation(s) Procedure(s):

Accident / Injuries / Poisoning (E CODE)

Address: Balili Km3, La Trinidad, Benguet

e Jimenez Children: N/A

First Name: John Middle Name: Lee

band Email Address: Jlee@gmail.com

Cell Phone: 0909-020-2711

Address of Informant: Relation to patient:

Have you seen other doctors FOR THIS CONDITION?

Previous Chiropractic Care:

TPR Graphic Record

Medication and Treatment Record

Personal Health Insurance Carrier: Insular Life Philip

Policy Holder's Name: Bianca Summer Jim

Policy Holder's Date of Birth: 01-Jan-96

Was the treatment beneficial in resolving conditon

Bianca Summer Jimenez Group No : __________________________________

01-Jan-96 Primary Care Physician : _______________________

Past Medical History

OTHER SYMPTOMS YES NO

GASTROINTESTINAL (GI) YES NO INTEGUMENTARY/ BREASTS

OTHER SYMPTOMS YES NO OTHER SYMPTOMS

Obstetric & Menstrual History

Past Medical History

TPR Graphic Record

Medication and Treatment Record

ECK all past conditions.

ory to the CURRENT Condition?

Write the DATE of the Procedure immediately afterward.

TE of the Injury immediately afterward.

TPR Graphic Record

Medication and Treatment Record

Motor strength is assessed. Post-operatively, the patient was instructed to remain fl

VI. NUTRITIONAL STATUS

VII. ELIMINATION STATUS

VIII. FLUID & ELECTORLYTE STATUS

The patient consumes 8 – 12 glasses of water normally. She urinates frequently

IX. CIRCULATORY STATUS

XI. TEMPERATURE STATUS

XII. INTEGUMENTARY STATUS

XIII.COMFORT & REST STATUS

Patient's History E 105

History of Present illness M 104

Past Medical History

TPR Graphic Record

Medication and Treatment Record

Log Out C 150

MEDICATION/ DOSE/ FREQUENCY DATE AM

MEDICATION/ DOSE/ FREQUENCY DATE AM

MEDICATION/ DOSE/ FREQUENCY DATE AM

PM NIGHT AM PM NIGHT AM PM NIGHT

PM NIGHT AM PM NIGHT AM PM NIGHT

PM NIGHT AM PM NIGHT AM PM NIGHT

PM NIGHT AM PM NIGHT AM PM NIGHT

PM NIGHT AM PM NIGHT AM PM NIGHT

PM NIGHT AM PM NIGHT AM PM NIGHT