<results version='1.05' timeZone='-0500' >
<documents total='3' >
<document>
<category value='PN' />
<clinicians>
<clinician code='520647004' name='MCCARTHY,MOIRA C' role='A' service='OIFO BAYPINES TEST LAB ' />
<clinician code='520647004' name='MCCARTHY,MOIRA C' role='S' dateTime='3150708.145203' signature='MOIRA C MCCARTHY ' service='OIFO BAYPINES TEST LAB ' />
</clinicians>
<content xml:space='preserve'>
 LOCAL TITLE: NURSING ONCOLOGY NOTE                              
STANDARD TITLE: RN INTAKE AND OUTPUT NOTE                       
DATE OF NOTE: JUL 08, 2015@13:46     ENTRY DATE: JUL 08, 2015@13:46:41      
      AUTHOR: MCCARTHY,MOIRA C     EXP COSIGNER:                           
     URGENCY:                            STATUS: COMPLETED                     

Diagnosis:
Ordering Physician:
 
Note Dated: JUL 08, 2015 13:46
Visit:  06/18/15 15:17
Vitals Signs:
Temperature:  55 F [12.8 C] (01/16/2015 11:51)
B/P:  55/ (01/16/2015 11:51)
Pulse:  55 (01/16/2015 11:51)
Weight:  123 lb [55.9 kg] (01/16/2015 11:51)
Height:  66 in [167.6 cm] (01/16/2015 11:51)
 
Pulse/Oximetry:
 
Subjective:
Patient&apos;s description of being:
 
Pain (Scale 0-10) ________.  (1=least  - 10=worst)
___Well controlled with medication
___Uncontrolled - Comments:
 
Fatigue:  None____  Mild____  Moderate____  Severe____
 
Appetite:
___Normal
___Eating approximately 3/4 normal amount
___Eating approximately 1/2 normal amount
___Eating approximately 1/4 normal amount
___Eating more than normal
 
Side effects noted after last Rx (Mark only noted side effects and make comment)
___Nausea:
___Vomiting:
___Constipation:
___Diarrhea:
___Stomatitis:
___Fever/Infections:
___Peripheral Neuropathy:
___General Malaise:
___Phlebitis:
___Edema:
___SOB:
___Other:
 
Objective:
Lab Values:
___WBC checked and within acceptable limits.
Hematocrit: 
Creatinine:
Magnesium:
Potassium:
Other:
___adequate     ___cc Pre Cisplatin Rx          ___cc Post Cisplatin Rx
 
Comments:
 
Antiemetics and Premeds:
 
Current Medications:
 
Method:  (all bolus drugs slow, IV push through side arm of fast flowing
IV unless noted otherwise)
 
Cycle___        Day___
 
Drugs           Dosage
 
 
Reactions, Problems:
 
Additional Comments:
 
Any Change in Support System
 
Education:
 
___Given or has received printed materials relevant to cancer diagnosis
and treatment. 
Comments:
 
___Viewed or has viewed video relevant to cancer diagnosis and treatment.
Comments:
 
___Rationale, schedule, treatment side effects and management discussed.
Comments:
 
___Able to verbalized side effects and management of treatment side effects. 
Comments:
 
Plan:
 
Performance Status:
Grade 0  _____  Fully active:  able to carry on all pre-disease activities
                without restriction.
 
Grade 1  _____  Restricted in physically strenuous activity but ambulatory
                and able to carry out work of a light or sedentary nature,
                e.g., light housework, office work.
 
Grade 2  _____  Ambulatory and capable of all self-care but unable to
                carry any work activities.  *Up and about more than 50% of
                working hours.
 
Grade 3  _____  Capable of only limited self-care:  confined to bed or
                chair more than 50% of waking hours.
 
Grade 4  _____  Completely disabled.  Cannot carry on any self-care.
                Totally confined to bed or chair.
 
Comments:
 
Venous Assess
Peripheral
1.  IV site:  Hand  L____    R____  Forearm  L____  R____
    Other:
2.  Catheter type:  Angio:  #18___   #20___   #22___   #24___
    Other:
3.  Blood return:  before___    during___       after___
    Comment:
4.  ___There is 0 redness, swelling or c/o discomfort at site.
    Comments:
 
CVA:
1.  Groshong ___  Cook ___  PICC ___  Port ___
___Able to withdraw blood:
___Flushes without difficulty:
___Exit site normal:
___Line care given:
Comments:
 
Hydration:
1.  Prehydration
2.  Post hydration
3.  Flush with Normal Saline ___mls
4.  Comments
 
/es/ MOIRA C MCCARTHY

Signed: 07/08/2015 14:52
</content>
<documentClass value='PROGRESS NOTES' />
<encounter value='2205644' />
<facility code='442' name='CHEYENNE VAMC' />
<id value='1804649' />
<localTitle value='NURSING ONCOLOGY NOTE' />
<nationalTitle name='RN INTAKE AND OUTPUT NOTE' />
<nationalTitleRole name='REGISTERED NURSE' />
<nationalTitleService name='INTAKE AND OUTPUT' />
<nationalTitleType name='NOTE' />
<referenceDateTime value='3150708.1346' />
<status value='completed' />
<type value='PN' />
</document>
<document>
<category value='D' />
<clinicians>
<clinician code='520646951' name='FORREST,ZACHARY H' role='A' taxonomyCode='203BS0130Y' providerType='Physicians (M.D. and D.O.)' classification='Physician/Osteopath' specialization='Surgery, Otorhinolaryngology &amp; Facial Plastic Surgery' service='OIFO BAYPINES TEST LAB ' />
<clinician code='520646951' name='FORREST,ZACHARY H' role='S' dateTime='3150115.11251' signature='ZACHARY H FORREST physician tester' taxonomyCode='203BS0130Y' providerType='Physicians (M.D. and D.O.)' classification='Physician/Osteopath' specialization='Surgery, Otorhinolaryngology &amp; Facial Plastic Surgery' service='OIFO BAYPINES TEST LAB ' />
</clinicians>
<content xml:space='preserve'>
 LOCAL TITLE: ADVANCE DIRECTIVE
STANDARD TITLE: ADVANCE DIRECTIVE
DATE OF NOTE: JAN 15, 2015@11:11     ENTRY DATE: JAN 15, 2015@11:11:29
      AUTHOR: FORREST,ZACHARY H    EXP COSIGNER:
     URGENCY:                            STATUS: COMPLETED

Testing C-CDA

/es/ ZACHARY FORREST
physician tester
Signed: 01/15/2015 11:12
</content>
<documentClass value='PROGRESS NOTES' />
<encounter value='2205186' />
<facility code='442' name='CHEYENNE VAMC' />
<id value='1804110' />
<localTitle value='ADVANCE DIRECTIVE' />
<nationalTitle name='ADVANCE DIRECTIVE' />
<nationalTitleType name='ADVANCE DIRECTIVE' />
<referenceDateTime value='3150115.1111' />
<status value='completed' />
<type value='D' />
</document>
<document>
<category value='PN' />
<clinicians>
<clinician code='520646951' name='FORREST,ZACHARY' role='A' taxonomyCode='203BS0130Y' providerType='Physicians (M.D. and D.O.)' classification='Physician/Osteopath' specialization='Surgery, Otorhinolaryngology &amp; Facial Plastic Surgery' service='OIFO BAYPINES TEST LAB ' />
<clinician code='520646951' name='FORREST,ZACHARY' role='S' dateTime='3150617.1455' signature='ZACHARY FORREST physician tester' taxonomyCode='203BS0130Y' providerType='Physicians (M.D. and D.O.)' classification='Physician/Osteopath' specialization='Surgery, Otorhinolaryngology &amp; Facial Plastic Surgery' service='OIFO BAYPINES TEST LAB ' />
</clinicians>
<content xml:space='preserve'>
 LOCAL TITLE: PM&amp;R FIM NOTE                                      
STANDARD TITLE: PHYSICAL MEDICINE REHAB DIAGNOSTIC STUDY REPORT 
DATE OF NOTE: JUN 17, 2015@14:54     ENTRY DATE: JUN 17, 2015@14:54:57      
      AUTHOR: FORREST,ZACHARY      EXP COSIGNER:                           
     URGENCY:                            STATUS: COMPLETED                     

Rehab Bed Unit Admission: 6/17/2015
Admission Class: 1-Initial Rehabilitation
Discharge Date:  6/17/2015

DIAGNOSIS
      Impairment Group: 2.1 Brain Dysfunction, Non-Traumatic         
                                             
         Date of Onset: 6/17/2015

FUNCTIONAL INDEPENDENCE MEASURE (FIM)
                                                             GOALS
 Self-Care                                                             
  Eating                                                           7 
  Grooming                                                         7   
  Bathing                                                          7  
  Dressing-Upper Body                                              7       
  Dressing-Lower Body                                              7       
  Toileting                                                        7    
 Sphincter Control                                                         
  Bladder Management                                               7       
  Bowel Management                                                 7       
 Mobility                                                             
  Bed, Chair, Wheelchair                                           7       
  Toilet                                                           7 
  Tub, Shower                                                      7      
 Locomotion                                                             
  Walk/Wheelchair                                             both 7       
  Stairs                                                           7 
Motor Subtotal Score:                                              91      
 Communication                                                             
  Comprehension                                               both 7       
  Expression                                                  both 7       
 Social Cognition                                                          
  Social Interaction                                               7       
  Problem Solving                                                  7       
  Memory                                                           7 
 Cognitive Subtotal Score:                                         35      
Total Motor and
      Cognitive Score:                                             126     
 
* FIM MEASUREMENT DEFINITIONS
     NO HELPER
       7.  Complete Independence (Timely, Safely)
       6.  Modified Independence (Device)
     HELPER (Modified Dependence)
       5.  Supervision
       4.  Minimal Assistance (Subject = 75% +)
       3.  Moderate Assistance (Subject = 50% +)
     HELPER (Complete Dependence)
       2.  Maximal Assistance (Subject = 25% +)
       1.  Total Assistance (Subject = 0% +)
 
ADDITIONAL INFORMATION:
  Testing CCDA
 
/es/ ZACHARY FORREST
physician tester
Signed: 06/17/2015 14:55
</content>
<documentClass value='PROGRESS NOTES' />
<encounter value='2205639' />
<facility code='442' name='CHEYENNE VAMC' />
<id value='1804644' />
<localTitle value='PM&amp;R FIM NOTE' />
<nationalTitle name='PHYSICAL MEDICINE REHAB DIAGNOSTIC STUDY REPORT' />
<nationalTitleService name='DIAGNOSTIC STUDY' />
<nationalTitleSubject name='PHYSICAL MEDICINE &amp; REHABILITATION' />
<nationalTitleType name='REPORT' />
<referenceDateTime value='3150617.1454' />
<status value='completed' />
<type value='PN' />
</document>
</documents>
</results>