Admission Info Jett Munsor DOB 01/01/ 2003
Admission History
| Admit Date | Discharge Date | Location | Reason for Visit | |||
| yester day | unknown | TRU simulation hospital | MVI – stabilization, mobility, pain management | |||
Health History
| Source of Information | Patient | |||||||
| Reason for Visit | MVI | |||||||
| Health History | depression x 9 months | |||||||
| Height | 180 cm | Weight | 79 kg | |||||
| Allergies | Reaction type: | NKA | Severity: | |||||
| Language Spoken | English / French | Reading/Writing | yes. Completed grade 12 | |||||
| Family History | unremarkable | |||||||
| Previous Illnesses | none | |||||||
| ARO Screening | complete | MRSA: | — | CPO: | — | Close contact with someone positive: | no | |
| Isolation Precautions | Type: | routine | ||||||
| Surgical History | none | |||||||
| Wounds | abrasions left side of scalp, left knee. Fractures left patella, clavicle | |||||||
| Aggressive Behavior Screening | History of Violence: | none | Physically violent: | no | Verbally Aggressive: | no | AGG FORM | |
| Dietary History | Diet Type: | general | Consistency: | regular | ||||
| Substance Use | Type: | states alcohol social | Last Used: | 2 weeks ago | ||||
| Substance Use | Type: | cannabis | Last Used: | 5 days ago | ||||
| Housing | lives with mother and sister | Barriers: | none known | Community Support: | none | |||
| Current Medications | Drug | Dose | Route | Freq | Comments | |||
| Fluoxetine | 15 mg | PO | BID | |||||
Pre Hospital Level of Functioning Summary
| Pain Management: | Independent | — | Comments: | does not have pain typically | ||||
| Medication Management: | Independent | Y | Comments: | |||||
| Cognitive Functioning: | Independent | Y | Comments: | |||||
| Psychosocial: | Independent | Y | Comments: | lives with mother & sister | ||||
| Nutrition/Swallowing: | Independent | Y | Comments: | |||||
| Bowel/Bladder Management: | Independent | Y | Comments: | |||||
| Functional Mobility: | Independent | — | Comments: | typically independent | ||||
| Discharge Considerations: consider mobility, pain management, supports at home | ||||||||
| Patient/Family Goals: | to get home asap | Date: yesterday | ||||||
Plan of Care
| SMART GOAL: | independent with ADLS prior to discharge | |||||||
| Interventions: | refer to physio | |||||||
| Plan: | TBA | |||||||
| Provider: | ||||||||
| Day: | ||||||||
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