Pediatric Admission Profile
Page 1
Timothy W_
Date: 12/20/95
Valuables
Hearing Aid: N/A
Clothing: Sent Home
Other: N/A
Other: N/A
I fully understand that HUMC (REDACTED - because location is wrong OOG) is not responsible for any personal property brought in or retained at the bedside at any time. I fully understand that HUMC 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:
Allergies:
Medications: Amoxicillin, codeine
Explain reaction: Hives
Medications: N/A
Able to swallow pills? Yes
Page 2:
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
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:
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:
Section VIII - Elimination
Toilet Trained (Redacted): Yes
History of Diarrhea (Redacted): No
History of Constipation: (Redacted)
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: Redacted
Relationship: Mother
Admitted From: Home
Admitted via: Ambulatory
Orientation to Nursing Unit: [All listed are checked off.]
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 (Not checked)
No toys or objects to create sparks or friction if in croup tent (not checkted)
Bed/crib must be kept in lowest position at all times (Not checked)
Immunizations Current? Yes
Chief Complaint: Headaches, insomnia, (REDACTED)
Disposition of Valuables (REDACTED)
Caldwell County Hospital (REDACTED, but probably for consistency's sake since the location isn't right.) 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.
Patient/Family Signature:
Witness Signature:
Date: 12/20/95
Time: 12:01 P.M.
Valuables picked up by: Janet W.
Witness: (Cant read)
Date/Time: 12/20/95 12:01 P.M.
Health Profile: Other, 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 (Someone can't read directions…)
Page 2:
Medical History and Previous Surgery:
Ever had a blood transfusion? No
Social/Environmental Assessment: (Only checked items shown)
1. Patient lives: With family
2. Habits: Tobacco
Member of household uses tobacco (Note: It is listed such that Tim himself does not use tobacco at this age, but rather, a member of his family does.)
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? No (Originally Yes)
Are you afraid of anyone? No (Originally Yes)
Have you ever been physically, sexually, or emotionally abused? No
Within the past year, have you ever been hit, slapped, kicked, or otherwise physically hurt? No (REDACTED)
Have you ever been touched in a manner that makes you feel uncomfortable? No (REDACTED)
Evidence of neglect by self? No
Evidence of neglect by caretakers? No
Evidence of abuse by self or others? No
Skin:
Color Impairment: None
Temperature: Warm
Turgor: Good
Page 3:
Oral/Denatal/Nasal
Teeth Condition: Good
Gums: Pink,
Nose: No problems
Hygiene
Bathing: Partial Assist
Condition on arrival: Good
Oral Hygience: Self
Hair Condition: Good
Neuro Status
Conscious
Oriented To: Person, Place (Time is left unchecked)
Weakness/Paralysis: None
Range of Motion: Independent
Pupils/Eyes
Pupils: Equal
Eyes:
Vision (All listed here checked)
Adequate
Glasses/Contacts: With Patient
Speech/Sqallowing
Speech: Clear
Swallows: Without Difficulty
Hearing/Ears
Hearing: Adequate
Mobility
Independent
Respiratory/Cardiovascular
Respiratory Problems:
Cough
Cardiovascular Problems: None
Page 4:
Frequency of BM (REDACTED): Daily
Abdomen: Soft
Urinary Status:
Problems: None
GU (REDACTED)
Comfort/Rest/Sleep
Sleep
Unable to fall asleep easily
Avg # Hrs Slept Each Night: 4 #Pillows used: 2
Sleeps with Night Light On
Comfort/Pain
Is the patient currently having pain or admitted a pain related diagnosis? Yes
RATING ON PAIN SCALE: 6
Location: Head
Duration: 2-4 Hrs
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
Social
Engages in group activities with same sex peers (UNCHECKED)
Cognitive
Wide Range of Vocabulary
Learns to read
Learning math skills
Begins collections (Hobbies) (UNCHECKED)
Physical
Exhibits physical endurance (plays sports, games) increased time motor ability (writing, painting drawing) (UNCHECKED)
Discharge Needs
Transportation
Plan of Care Reviewed With:
Family
Other Notes: Ran away from home 2 _(REDACTED)_ 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 (underlined), postural hypotension - 20
Total: 40 (High Risk)
OOG there is another page on the blank version of this form (see sources), but Jay states that it isn't there. Given the nature of the information shown in the blank document, however, this is most likely unimportant.
Delayed Therapy Communication Form
Person Documenting Delay: REDACTED
Routine: REDACTED
Stat: REDACTED
Person Responding to Delay: REDACTED
Date: 7/8/02 Time (Military Time): 15:10
Name of Procedure: Monthly Session
Date Ordered: REDACTED
Tracking Codes
Patient/Family Variance Codes
P4 - Patient/Family Uncooperative
Delay Description: REDACTED
Intervention: REDACTED
*Intervention: REDACTED
Brief Operative Progress Note
An Operator symbol is on the top right of the page.
Date: 1/10/(REDACTED)
To be conducted by: Dr. (REDACTED)
Anaesthesia: General (A note next to the checkbox is redacted)
Wound: Clean
Procedure: (Wound prep, incision, Findings, pathology, closure, etc.)
A description may be present, but the entirety of the dedicated space is redacted, as is the remainder of the document. See PDF for more details on redacted info.
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)
HOPELESSNESS
[Helplessness left unchecked, interestingly]
ANHEDONIA
ANGER/RAGE
CURRENT MORBID THOUGHTS: Frequently (1)
Section III.
RN's SUBJECTIVE APPRAISAL OF PATIENT'S RELIABILITY
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): [Unreadable]
Date: 7/8/02
Time: 8:45