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Psych Eval History & Physical Discharge Summary Chemistries CBC CXR UA MRI
Living Will / Medical Treatment Plan EKG Graphic Chart Nursing Admission Assessment
Physician's Orders Progress Notes Nursing Staff Notes Medication Administration Record
Phone Intake Data Overnight Oximetry
COLORS: RED - PAIN ORANGE - AGITATION GREEN - TERMINAL
| 1/10/96
MD |
Patient seen and examined. Psychiatric evaluation dictated. Diagnosis: Psychosis, not otherwise specified. Plan: increase Risperdol, continue Buspar, use Haldol intramuscularly if patient unwilling to take Risperdol. Possible Depakote. Robert Weitzel, M.D. | |
| 1/11/96
MD |
Patient generally unresponsive to questions, lies in bed whimpering, groaning. Initially elevated temperature, now afebrile. White blood cell count within normal limits, sodium increased a little, glucose mildly elevated. Assessment - psychosis not otherwise specified. Plan - continue current care. Robert Weitzel, M.D. | |
| 1/11/96
Social Services/IT |
Individual session - attempted to engage patient in conversation, but patient was sleeping and unresponsive. I will attempt to engage him at a later time. S. Bennion, LCSW | |
| 1/11/96
O.T |
Occupational therapy will place patient on therapeutic hold today because of agitation and inability to participate in tasks. Occupational therapy will attempt assessment tomorrow. ? | |
| 1/12/96
Dietary |
Assessment completed. See assessment. Patient not eating presently. Will follow closely to see if appetite improves or if tube feeding will be necessary. (No signature). | |
| 1/12/96
MD |
Remains quite demented. Combative, mumbles incoherently, cries out. Will not take any medications. Vital signs stable, afebrile. Assessment - psychosis not otherwise specified. Plan - continue current care, increase Haldol. Robert Weitzel, M.D. | |
| 1/12/96
Social Services/FT |
Late entry for 1/11/96. Phone conversation with patient's wife. Gathered information for psychosocial assessment and discussed treatment plans. (continued, S. Bennion) | |
| 1/12/96
Social Services/FT |
(continued) Patient's wife expressed how difficult it is to be so far away from him but also admitted that it is a relief to know he's in good hands. Encouraged her to use his hospitalization time for respite. We will try to set up a family session on a Thursday or Friday in the near future. S. Bennion, LCSW | ||
| 1/12/96
IT |
Individual session - patient was sleeping again this evening so I was unable to talk to him. I will visit him again next week to attempt to engage him. S. Bennion, LCSW | ||
| 1/13/96
MD |
Patient remains incoherent, unresponsive,
crying, needs restraint. Magnetic Resonance Imaging shows left occipital
infarction. Urinalysis is pyuric. Glucose level at 40 by Accuchex at 6:00 a.m. He is afebrile, vital signs stable. Chem 7 at 6:10 a.m. reveals glucose
of 226, sodium elevated at 148. Potassium adequate. Assessment - cerebral
vascular accident. Urinary tract infection. Dehydration. Appears to be
quite uncomfortable. Insulin dependent diabetes mellitus, mycoses fungoides.
Plan - will attempt to call wife, work out a plan with her. Robert Weitzel,
M.D.
Addendum- spoke with wife extensively- she feels strongly that no extraordinary measures should be taken to prolong Ennis' life, given the cerebral vascular accident found on MRI. She requests we discontinue IV and give comfort care, let him expire naturally. (continued) Robert Weitzel, M.D. |
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| 1/13/96
MD |
(continued) Assessment - Cerebral vascular accident,etc. Plan - discontinue IV, decrease insulin, discontinue oral medications. Morphine sulfate 10 mg every 3 hours intramuscularly, Ativan 0.5 mg every 3 hours intramuscularly, Haldol as needed. Robert Weitzel, M.D. | |
| 1/3/96
Social Services |
Met with family for 1 2 hours. They asked me to call the mortuary in Delta, Utah. I contacted Nichol's Mortuary and they will come within 2 2 to 3 hours of being notified. Family very supportive of measures being taken. They are especially glad that the patient is close by in Davis county so that they don't have to travel to Logan. Attempted to notify Dr. Dienhart and as of 10:10 a.m. he has not answered the page. Will try at home in order to notify of patient's condition and MRI results. Please notify me if any further problems arise. Todd Chambers, LCSW | |
| 1/14/96
Nursing |
Weekly RN Advocate note - Please
see Dr. Weitzel's note above regarding MRI results. The patient=s
care plan has been amended to reflect death and dying issues. Patient=s
goal is to experience a peaceful death free of discomfort. Morphine sulfate
and Ativan intramuscularly are being provided every 3 hours around the
clock to assure patient=s comfort.
Please see new care plan for other issues and interventions being addressed.
L. Wilson, RN, MSW
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| 1/14/96
MD |
Cheyne-Stokes respirations, deep chest rales, had been quiet most of night, but appeared agitated this morning - was given extra Morphine sulfate. Slightly febrile. Blood pressure is down. Assessment - close to death. Plan - continue comfort care. Robert Weitzel, M.D. | |
| 1/15/96
MD |
Died this last morning secondary to respiratory arrest, family with him, grief work done. Body released to mortuary. Robert Weitzel, M.D. | |
| 1/15/96
OT |
Occupational therapy discharge note: Due to patient condition, occupational therapy was unable to assist patient and no therapy was administered. J.V...? COTA | |
Psych Eval History & Physical Discharge Summary
Living Will / Medical Treatment Plan