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Data Collection Worksheet.doc - Data Collection Sheet...

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Data Collection SheetStudent Name:Data Source (Circle):PatientFriendRelativeE-ChartADMISSION INFORMATIONDate of Care:4/28/22Client InitialsRoom #AN3617Age/DOB:75 years-old4/11/1947Advance Directives(Living Will,POA, DNR): None recordedCode Status:FULL CODE BLUESex/Race:FemaleAdmit Date: 4/26/22Admitting MD: Moore,Jessica PAReason for Hospitalization:Chest pain on left sideMedical Diagnoses: (present & past diagnoses, physician’s H/P, EDReport, nursing admission assessment):Chest pain, Hypertension, Influenza A, Breast screening, Hip Pain,Lightheaded, Memory Change, Night Sweats, Osteoarthritis, Rheumatoiddisease, Urinary incontinence.Surgical Procedures & History:NoneAllergies:Meds, Foods, EnvironmentalCodeine, TomatoesWound(s):N/ADressings & Wound Care Orders:N/ADrain(s) Type & Location:N/AHeight:166.37cmMeds:Take Whole, Crushed inApplesauce/puddingWeight:64.8kgRisk for Skin Breakdown (Braden Score):21Precautions (specify):Contact/Droplet/AirborneBMI: 22.04Fall Risk (Morse Score):60Activity Order:Eating, Lying in bedNUTRITION & FLUID BALANCE (Circle or Write in as Appropriate)IV site: Location & type: PICC, saline lock, peripheral,Midline, other Central line:

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Intravenous therapy

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