Admission Information Suzanne Gordon DOB 09/27/1988

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Admission History

Admit DateDischarge DateLocationReason for Visit

Health History

Source of InformationClient
Reason for VisitCaesarean
Health HistoryGestational Diabetes
Height170cmWeight150lbs
AllergiesReaction type:Severity:
Language SpokenEnglishReading/WritingEnglish
Family History
Previous IllnessesDepession and Anxiety
ARO ScreeningCompleteMRSA:NegativeCPO:NegativeClose contact with someone positive:No
Isolation PrecautionsType:
Surgical History
Wounds
Aggressive Behavior ScreeningHistory of Violence:NoPhysically violent:NoVerbally Aggressive:NoAGG FORMNo
Dietary HistoryDiabetic DietDiet Type:RegularConsistency:Regular
Substance UseType:NONELast Used:
Substance UseType:Last Used:
HousingHomeBarriers:Community Support:Supportive family

Pre Admission Health Assessment

HEENT (head, eyes, ears, nose, throat): no concerns
Integument: Denies rashes or wounds
Respiratory: Work of breathing easy. Chest clear. Equal air entry bilaterally. Denies cough. Denies smoking. RR 12 SpO2 97% room air. History of Asthma
Cardiovascular: Heart rate: 78 regular BP: 134/86 . Brisk cap refill all extremities. Denies cardiovascular health issues
Gastrointestinal: BSX4, denies nausea or vomiting
Genitourinary: Frequent urination currently, amber in color
Musculoskeletal: No concerns
Neurologic: Alert and oriented x 3. Denies headaches.
Endocrine: Gestational Diabetes
Lymphatic: denies lymphatic health issues
Pain: Acetaminophen for headaches and back aches, currently experiencing soreness to back, dull ongoing, 4/10, does not radiate.
Cognitive: Feels anxious in final weeks of pregnancy
Phycological: History of anxiety and depression
Assessment completed by: TG Litt RN Date: Pre C/S

Pre Hospital Level of Functioning Summary

Pain Management:IndependentYesComments:No issues
Medication Management:IndependentYesComments:
Cognitive Functioning:IndependentYesComments:
Psychosocial:IndependentYesComments:
Nutrition/Swallowing:IndependentYesComments:
Bowel/Bladder Management:IndependentYesComments:
Functional Mobility:IndependentYesComments:
Discharge Considerations
Patient/Family Goals:Date:
Patient/Family Goals:Date:

Plan of Care

SMART GOAL:
Interventions:
Plan:
Provider:
Day:
Time:

Patient Demographics

Last Name:First Name:Middle Name:Age:DOB:Sex:Marital Status:Ethnicity:Religion:
GordonSuzanne3609/27/1988FM
Address:StreetApt. #CityProvincePostal CodeMRP
3000 Plain StKamloopsBCV2BC27Liz Abre
Home Phone:240-333-0909Cell Phone:250-379-9990
Guarantor/Legal Guardian of Minor (If different from patient)
Last Name:First Name:Middle Name:Age:DOB:Sex:Relation:
Address:StreetApt. #CityProvince:Postal Code
Home PhoneCell Phone
Employer Information
Name
AddressStreetSuite #CityProvince:Postal Code
Primary Insurance Information
Name of Insurance Company:MedicarePhone:
Policy #903444456yes
Group name:Bluelight
Group Number:0011
Insured:Last:First:MI:
Sex:Relation:DOB:
Emergency Contact
Name:Ben GordonRelationship:Partner
Address:3000 Plain StCity:Kamloops
Phone:240-333-0909Province:BCPostal:V2BC27
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Patient Care Suzanne Gordon DOB 09/27/1988

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Wound Type/Etiology (if known)Pressure ☐            Venous ☐               Arterial ☐                Diabetic ☐               Surgical 2°Intent ☐             Skin Tear ☐            Other ☐ If Pressure Ulcer, chart stage: Stage 1_________        Stage 2_________            Stage3_________         Stage 4_________                                       Stage X(unstageable)_________                   Stage SDTI (Suspected Deep Tissue Injury)_________                                                                                                                                                                                                                   MARK LOCATION OF WOUND/ULCER WITH AN ARROW OR AN ”X” Legend: X or Blank Space = Not Applicable (as per agency)    …

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