4 - St. Mary's - December 2020 Admission

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RUN DATE: 03/09/21 St. Mary's Healthcare ORDER ENTRY *LIVE* PAGE 1
000310
RUN TIME: 1136 Provider Order Summary
RUN USER: MRMRP
PROVIDER ORDER SUMMARY
St. Mary's Healthcare
PATIENT STATUS: DIS IN ADM/SERVICE DATE: 12/16/20 MR#: M000481032

LOCATION: MARI DISCHARGE DATE: 12/28/20
PATIENT NAME: KUMPEL,CHRIS ACCT#: M0081564346
----ORDER---- PROCEDURE ORDERING PHYSICIAN ORDER #

Date Time
---SERVICE--- ORDER STATUS
Date Time ORDER SOURCE
12/16/20 0711 STOCK Pyxis,Overridedoc 1216-0151

12/16/20 0712 STK DOCPYX CMP
S
RX: 05546370 Start: 12/16/20 0712
Stop:
fentaNYL Inj (Sublimaze Inj) 0.1 MG/2 ML Injectable
Dose: 0 MG
Route: EPIDURAL Direction: .STK-MED Schedule: ONE
Order's Audit Trail of Events

1 12/16/20 0711 PHA ORDER Order ENTER in PHA
2 12/16/20 0711 PHA ORDER Ordering Doctor: Pyxis,Overridedoc
3 12/16/20 0711 PHA ORDER Order Source: SIGNED ORDER
4 12/16/20 0711 STK MED DISCONTINUE in PHA
5 12/16/20 0944 NSJMI order acknowledged
Acknowledged by: NSJMI 12/16/20 0944

S
RX: 05546371 Start: 12/16/20 0712
Stop:
Tranexamic Acid Inj (Cyklokapron Inj) 1,000 MG/10 ML AMPUL
Dose: 0 MG
Route: .ROUTE Direction: .STK-MED Schedule: ONE

PERMANENT MEDICAL RECORD COPY

<Continued>
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RUN USER: MRMRP


Date Time

S
RX: 05546372 Start: 12/16/20 0713
Stop:
Clonidine Hcl (Duraclon) 1,000 MCG/10 ML VIAL
Dose: 0 MCG
Route: EPIDURAL Direction: .STK-MED Schedule: ONE


S
RX: 05546373 Start: 12/16/20 0713
Stop:
methylPREDNISolone Acetate Inj (Depo-Medrol Inj) 80 MG/ 1-ML VIAL
Dose: 0 MG
Route: IJ Direction: .STK-MED Schedule: ONE


<Continued>
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RUN USER: MRMRP


Date Time

S
RX: 05546374 Start: 12/16/20 0713
Stop:
methylPREDNISolone Acetate Inj (Depo-Medrol Inj) 40 MG/ 1-ML VIAL
Dose: 0 MG


S
RX: 05546375 Start: 12/16/20 0713
Stop:
Vancomycin Inj (Vancocin Inj) 1,000 MG VIAL
Dose: 0 MG
Route: TP Direction: .STK-MED Schedule: ONE

5 12/16/20 0725 ACAC order acknowledged
Acknowledged by: ACAC 12/16/20 0725

<Continued>
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RUN USER: MRMRP


Date Time

S
RX: 05546376 Start: 12/16/20 0713
Stop:
Lidocaine 2% Epi 1:100,000 MDV (Xylocaine 2% Epi 1:100,000 MDV) 20 ML VIAL
Dose: 0 ML


S
RX: 05546377 Start: 12/16/20 0713
Stop:
ceFAZolin Inj (Kefzol Inj) 1 GM VIAL
Dose: 0 GM
Route: IVP Direction: .STK-MED Schedule: ONE


<Continued>
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RUN USER: MRMRP


Date Time
12/16/20 0715 SURGICAL LUMBAR SPINE Shen,Jian 1216-0014

12/16/20 SURLS SHEN J CMP POE
VRB
TEMPERATURE:
CAMPUS? MAIN
REASON FOR THIS EXAM: SAME
:;
WHICH SIDE? R
WHICH LEVEL? 2/3,3/4

1 12/16/20 0715 NSJMI Order ENTER in OM
2 12/16/20 0715 NSJMI Ordering Doctor: Shen,Jian
3 12/16/20 0715 NSJMI Order Source: VERBAL READ BACK
4 12/16/20 0716 interface order's status changed from TRANS to LOGGED by RAD
5 12/16/20 0845 MDJIS Signed by Shen,Jian
6 12/16/20 1254 interface order's status changed from LOGGED to IN PRO by RAD
7 12/17/20 0755 interface order's status changed from IN PRO to COMP by RAD
Electronically signed by Shen,Jian on 12/16/20 at 0845

S
RX: 05546385 Start: 12/16/20 0724
Stop:
Povidone-Iodine (Skin and Nasal Antiseptic 5%) 1 EACH KIT
Dose: 0 EACH
Route: NS Direction: .STK-MED Schedule: ONE

5 12/16/20 0725 ACAC order acknowledged
Acknowledged by: ACAC 12/16/20 0725

<Continued>
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RUN USER: MRMRP


Date Time
12/16/20 0748 IV Pyxis,Overridedoc 1216-0173

12/16/20 0749 IV DOCPYX CMP
S
RX: 05546396 Start: 12/16/20 0749 Schedule: ONE
Route: IV Stop:
Clindamycin Inj Volume: 50 ML
Premixed at 900 MG/50 ML (900 MG)
Total Volume: 50 mls
Rate: UD Direction: .STK-MED
Bag Duration: UD
Rx Duration: No Stop Date/Time
Administration Criteria Queries

This medication is part of IV to PO Conversion, allow? Y

5 12/16/20 0751 ACHB order acknowledged
Acknowledged by: ACHB 12/16/20 0751
12/16/20 0757 VISIT LEVEL IV (INTERMEDIATE) Shen,Jian 1216-0003

12/16/20 L4 SHEN J CNC POE
Cancel Date/Time 12/22/20 1446 Cancelled by RAMANI,ASHOK
C
CAMPUS? AC

1 12/16/20 0757 ACDP Order ENTER in OM
2 12/16/20 0757 ACDP Ordering Doctor: Shen,Jian
3 12/16/20 0757 ACDP Order Source: CHARGE ENTRY
4 12/22/20 1446 MDARA Order DC in POM
5 12/22/20 1446 MDARA Ordering Doctor: Ramani, Ashok
6 12/22/20 1446 MDARA Order Source: POM
7 12/22/20 1446 MDARA order cancelled

<Continued>
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Date Time
12/16/20 0757 IV SET-UP OUTPATIENT Shen,Jian 1216-0004

12/16/20 IVO SHEN J CNC POE
C
CAMPUS? AC

1 12/16/20 0757 ACDP Order ENTER in OM
2 12/16/20 0757 ACDP Ordering Doctor: Shen,Jian
3 12/16/20 0757 ACDP Order Source: CHARGE ENTRY

S
RX: 05546409 Start: 12/16/20 0800
Stop:
Propofol Bolus (Diprivan Bolus) 200 MG/20 ML Injectable
Dose: 0 MG


<Continued>
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RUN USER: MRMRP


Date Time

S
RX: 05546410 Start: 12/16/20 0800
Stop:
ROCuronium Inj (Zemuron Inj) 10 MG/ 5-ML VIAL
Dose: 0 MG
Route: IV Direction: .STK-MED Schedule: ONE
Condition Dose/Route/Rate Instruction

1 Initiate at: 8 mcg/kg/min
2 Titrate by: 1 mcg/kg/min every 30 minutes
3 Max rate: 12 mcg/kg/min Contact provider
Treatment Text
Train of Four (TOF)
TOF of 0/4: Hold Infusion;
Check TOF every 30 min until twitches
reappear, then restart and decrease
infusion rate by 1 mcg/kg/min
TOF of 1/4 or 2/4: No change to infusion rate
TOF of 3/4 or 4/4: Increase infusion by 1 mcg/kg/min


S
RX: 05546411 Start: 12/16/20 0802
Stop:
fentaNYL Inj (Sublimaze Inj) 0.1 MG/2 ML Injectable
Dose: 0 MG

<Continued>
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RUN USER: MRMRP


Date Time


S
RX: 05546412 Start: 12/16/20 0802
Stop:
Midazolam Inj (Versed Inj) 2 MG/2 ML Injectable
Dose: 0 MG


S
RX: 05546419 Start: 12/16/20 0813
Stop:
Succinylcholine Inj (Quelicin Inj) 200 MG/10 ML VIAL
Dose: 0 MG


<Continued>
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RUN USER: MRMRP


Date Time

S
RX: 05546426 Start: 12/16/20 0819
Stop:
Remifentanil HCl (Ultiva) 1 MG VIAL
Dose: 0 MG


S
RX: 05546441 Start: 12/16/20 0831
Stop:
Morphine Inj (Morphine Inj) 10 MG/ 1ML SYRINGE
Dose: 0 MG


S
RX: 05546456 Start: 12/16/20 0837
Stop:
Dexamethasone Inj (Decadron Inj) 10 MG/ 1-ML VIAL
Dose: 0 MG

<Continued>
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RUN USER: MRMRP


Date Time


S
RX: 05546473 Start: 12/16/20 0852
Stop:
Phenylephrine Inj (Neo-Synephrine Inj) 10 MG/ Injectable
Dose: 0 MG


S
RX: 05546490 Start: 12/16/20 0859
Stop:
Dose: 0 MG


<Continued>
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RUN USER: MRMRP


Date Time

S
RX: 05546493 Start: 12/16/20 0900
Stop:
ePHEDrine Inj (ePHEDrine Inj) 50 MG/ 1ML AMP
Dose: 0 MG


S
RX: 05546585 Start: 12/16/20 1005
Stop:
Remifentanil HCl (Ultiva) 1 MG VIAL
Dose: 0 MG


<Continued>
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RUN USER: MRMRP


Date Time
12/16/20 1057 XR CHEST ONE VIEW PORTABLE Cirilla, Dennis 1216-0049

12/16/20 1103 CXR1 CIRI D Stat CMP POE
WS
TEMPERATURE:
CAMPUS? MAIN
REASON FOR THIS EXAM: IN OR;DECREASED BREATH SOUNDS
:; L2/3 L3/4 L4/5 LATERAL INTERBODY FUSION ANTERIOR

1 12/16/20 1057 NSGCAS Order ENTER in OM
2 12/16/20 1057 NSGCAS Ordering Doctor: Cirilla, Dennis
3 12/16/20 1057 NSGCAS Order Source: WRITTEN STD -> ESIGN
5 12/16/20 1103 RADREB order service time edited: old value - 1057
6 12/16/20 1103 RADREB order procedure edited:
7 12/16/20 1103 RADREB old value - CXR - XR CHEST XRAY
9 12/16/20 1108 interface order's status changed from IN PRO to LOGGED by RAD
12 12/20/20 0957 MDDCI Signed by Cirilla, Dennis
Electronically signed by Cirilla, Dennis on 12/20/20 at 0957

Amended by : RADREB 12/16/20 1103
Amended by : RADREB 12/16/20 1103

S
RX: 05546630 Start: 12/16/20 1106
Stop:
EPINEPHrine 1 mg/mL 1ml Amp (Adrenalin 1 mg/mL 1ml Amp) 1 MG/ 1ML AMP
Dose: 0 MG


<Continued>
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RUN USER: MRMRP


Date Time

S
RX: 05546632 Start: 12/16/20 1107
Stop:
Dose: 0 MG

5 12/16/20 1229 NSLV order acknowledged
Acknowledged by: NSLV 12/16/20 1229

S
RX: 05546641 Start: 12/16/20 1118
Stop:
Dose: 0 MG


<Continued>
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RUN USER: MRMRP


Date Time
12/16/20 1134 IV Shen,Jian 1216-0396

12/16/20 1135 IV SHEN J CMP POE
VRB
RX: 05546656 Start: 12/16/20 1135 Schedule: SCH
Route: IV Stop:
Renewal Data - Prompt: 48 Period: 30 Renew Stop: 24 Next Period:
EPINEPHrine Drip
Sodium Chloride 0.9% 250ml Volume: 240 ML
EPINEPHrine 0.1 MG/ML 10ML SYR Dose: 1 MG
Rate: TITRATE Direction: DRIP
Infusion Site: CENTRAL
Bag Duration: TITRATE

1 INITIATE DRIP AT: 1 MCG/MIN
2 TITRATE AT: 1 MCG/MIN
3 MAXIMUM DOSE: 10 MCG/MIN
4 GOAL MAP GREATER OR EQUAL TO: 65 mmHg

1 12/16/20 1135 PHAMED Order ENTER in PHA
2 12/16/20 1135 PHAMED Ordering Doctor: Shen,Jian
3 12/16/20 1135 PHAMED Order Source: SIGNED ORDER
4 12/16/20 1135 PHAMED EDIT in PHA
5 12/16/20 1135 PHAMED EDIT
6 12/16/20 1135 PHAMED Edit Dr: Shen,Jian Edit Source: PHARM
7 12/16/20 1135 PHAMED FROM:
8 12/16/20 1135 PHAMED ORDER SOURCE: S - SIGNED ORDER
9 12/16/20 1135 PHAMED RX COMMENTS:
10 12/16/20 1135 PHAMED TO:
11 12/16/20 1135 PHAMED ORDER SOURCE: VRB - VERBAL READ BACK
12 12/16/20 1135 PHAMED RX COMMENTS:
13 12/16/20 1135 PHAMED VERBAL ORDER FROM NURSING
15 12/17/20 0746 RTCJK order viewed from Order Management
16 12/18/20 0833 MDANS Order DC in POM
17 12/18/20 0833 MDANS Ordering Doctor: Santilli,Anthony

<Continued>
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RUN USER: MRMRP


Date Time
18 12/18/20 0833 MDANS Order Source: POM

19 12/18/20 0833 MDANS Order's Rx has been discontinued.
20 12/18/20 0833 MDANS Signed by Santilli,Anthony
21 12/18/20 0849 NSNID order acknowledged
Electronically signed by Santilli,Anthony on 12/18/20 at 0833

Acknowledged by: NSNID 12/18/20 0849

S
RX: 05546660 Start: 12/16/20 1147
Stop:
Dose: 0 MG


S
RX: 05546661 Start: 12/16/20 1148
Stop:
Dose: 0 MG


<Continued>
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RUN USER: MRMRP


Date Time

12/16/20 1148 IV Shen,Jian 1216-0401

12/16/20 1150 IV SHEN J CMP POE
VRB
Route: IV Stop:
Sodium Chloride 0.9% 500ml Volume: 500 ML
Phenylephrine Drip Dose: 30 MG
Infusion Site: C

1 INITIATE INFUSION AT: 100 - 180 MCG/MIN
2 TITRATE BY: 20 MCG/MIN EVERY 2 MINUTES
4 TARGET MAINTENANCE DOSE: 40 - 60 MCG/MIN
5 MAXIMUM DOSE: 180 MCG/MIN

1 12/16/20 1148 PHAMED Order ENTER in PHA
2 12/16/20 1148 PHAMED Ordering Doctor: Shen,Jian
3 12/16/20 1148 PHAMED Order Source: VERBAL READ BACK
5 12/16/20 1622 NURMT order viewed from Order Management
6 12/16/20 1724 NURMT order viewed from Order Management

<Continued>
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RUN USER: MRMRP


Date Time

12/16/20 1155 CBC WITH AUTO DIFF Shen,Jian 1216-1107

12/16/20 1155 CBCD SHEN J Stat CMP
PR

1 12/16/20 1155 NURJHO Order ENTER in OM
2 12/16/20 1155 NURJHO Ordering Doctor: Shen,Jian
3 12/16/20 1155 NURJHO Order Source: PROTOCOL
4 12/16/20 1155 interface cc'd doctors edited in LAB
5 12/16/20 1155 interface order's status changed from TRANS to LOGGED by LAB
6 12/16/20 1156 interface order's status changed from LOGGED to IN PRO by LAB
7 12/16/20 1602 interface order's status changed from IN PRO to COMP by LAB
Amended by : interface 12/16/20 1155
12/16/20 1155 MAG - MAGNESIUM Shen,Jian 1216-1108

12/16/20 1155 MG SHEN J Stat CMP
PR


<Continued>
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Date Time
12/16/20 1155 COMP - COMP METABOLIC PANEL Shen,Jian 1216-1109

12/16/20 1155 COMP SHEN J Stat CMP
PR

6 12/16/20 1155 interface order's specimen number changed from 1216:C00284R to 1216:C0
12/16/20 1155 PHOSPHORUS Shen,Jian 1216-1110

12/16/20 1155 PHOS SHEN J Stat CMP
PR


<Continued>
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Date Time
12/16/20 1155 LACTATE,BLOOD Shen,Jian 1216-1111

12/16/20 1155 LACT SHEN J Stat CMP
PR

8 12/16/20 1235 interface order's status changed from COMP to IN PRO by LAB
12/16/20 1155 TROPONIN I Shen,Jian 1216-1112

12/16/20 1155 TROP SHEN J Stat CMP
PR


<Continued>
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RUN USER: MRMRP


Date Time
12/16/20 1155 PTT - PARTIAL THROMBOPLASTIN Shen,Jian 1216-1113

12/16/20 1155 PTT SHEN J Stat CMP
PR

12/16/20 1155 PT - PROTHROMBIN TIME Shen,Jian 1216-1114

12/16/20 1155 PT SHEN J Stat CMP
PR


<Continued>
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Date Time
12/16/20 1155 ARTERIAL BLOOD GASES Shen,Jian 1216-0015

12/16/20 ABG SHEN J CNC
Cancel Date/Time 12/16/20 1156 Cancelled by NOEL,ROBERT
C

1 12/16/20 1155 RTRN Order ENTER in OE
2 12/16/20 1155 RTRN Ordering Doctor: Shen,Jian
3 12/16/20 1155 RTRN Order Source: CHARGE ENTRY
4 12/16/20 1156 RTRN order's status changed from COMP to CANCEL

12/16/20 ABG SHEN J CMP POE
TRB
7AM-11PM: 2nd Floor: 225-6596 3rd & 4th Floor: 265-6121
11PM - 7AM: 2nd Floor: 530-2687 3rd&4th Floor: 265-6735
ABG to be drawn while pt is on ROOM AIR or OXYGEN?
If on Oxygen, what DELIVERY DEVICE is being used?
If on O2, state liter flow or O2 percentage:
COMMENTS:

1 12/16/20 1157 RTRN Order ENTER in OM
3 12/16/20 1157 RTRN Order Source: TELEPHONE READ BACK
4 12/16/20 1157 RTRN This procedure has reflexed the following order(s)
5 12/16/20 1157 RTRN PUNCTURE ARTERIAL (RT)
6 12/16/20 1424 RTJB order's status changed from TRANS to COMP

<Continued>
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RUN USER: MRMRP


Date Time
12/16/20 1157 PUNCTURE ARTERIAL Shen,Jian 1216-0016

12/16/20 1157 AP SHEN J Stat CMP POE
TRB

1 12/16/20 1157 RTRN Order ENTER in OM
2 12/16/20 1157 RTRN Order from set: REFLEX ARTERIAL PUNCTURE
4 12/16/20 1157 RTRN Order Source: TELEPHONE READ BACK
5 12/16/20 1157 RTRN This Procedure was triggered by :
6 12/16/20 1157 RTRN ARTERIAL BLOOD GASES (RT)
9 01/13/21 1226 MRDMS order viewed

12/16/20 ABG SHEN J CMP
C

1 12/16/20 1235 RTCJK Order ENTER in OM
2 12/16/20 1235 RTCJK Ordering Doctor: Shen,Jian
3 12/16/20 1235 RTCJK Order Source: CHARGE ENTRY
4 12/16/20 1238 RTKW order's status changed from TRANS to COMP

S
RX: 05546710 Start: 12/16/20 1237
Stop:
Dose: 0 MG

<Continued>
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RUN USER: MRMRP


Date Time


DMO
Route: IV Stop:
NORepinephrine Drip Volume: 250 ML
Premixed at 4,000 MCG/250 ML (4,000 MCG)
Bag Duration: UD

1 12/16/20 1254 NURMT Order ENTER in PHA
2 12/16/20 1254 NURMT Ordering Doctor: Pyxis,Overridedoc
3 12/16/20 1254 NURMT Order Source: DISP MACH OVERRIDE
5 12/16/20 1403 NURMT order acknowledged
Acknowledged by: NURMT 12/16/20 1403
12/16/20 1259 INPATIENT Rosefort, Laury 1216-0015

12/16/20 INPATIENT ROSE LA TRN POE
P
SERVICE: ICU ADMITTING PROVIDER: ROSE LA
ADMITTING DIAGNOSIS:
cardiac arrest

1 12/16/20 1259 MDLAR Order ENTER in POM
2 12/16/20 1259 MDLAR Order from set: *STANDARD ADMISSION ORDERS
3 12/16/20 1259 MDLAR Ordering Doctor: Rosefort, Laury

<Continued>
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RUN USER: MRMRP


Date Time
4 12/16/20 1259 MDLAR Order Source: POM

5 12/16/20 1259 MDLAR Signed by Rosefort, Laury
6 12/16/20 1259 MDLAR This procedure has reflexed the following order(s)
7 12/16/20 1259 MDLAR Inpatient Certification Form (CERT)
9 12/17/20 0717 CDIRR order viewed
10 12/18/20 1308 ERMAB order viewed
Electronically signed by Rosefort, Laury on 12/16/20 at 1259

12/16/20 1259 PROBLEM LIST Rosefort, Laury 1216-0001

12/16/20 PROBLIST ROSE LA TRN POE
P
Problem:
Pneumothorax,
Cardiac arrest

12/16/20 1259 Vital Signs, Change Frequency Rosefort, Laury 1216-0053

12/16/20 VSCHFR ROSE LA IPR POE
P
NURSING TEXT: New VS Frequency:
NUR DIRECTIONS: ----START----
DATE TIME DIRECTIONS
1 12/16/20 1956 .[ONCE]


<Continued>
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RUN USER: MRMRP


Date Time

6 12/16/20 1300 interface order's status changed from TRANS to ACTIVE by NUR

12/16/20 1259 UNIT DOSE Rosefort, Laury 1217-0035

12/17/20 1000 UD ROSE LA CMP POE
P
RX: 05546740 Start: 12/17/20 1000
Stop:
Enoxaparin Inj (Lovenox Inj) 40 MG/0.4 ML 0.4ML SYRINGE
Dose: 40 MG
Route: SC Direction: DAILY Schedule: SCH

6 12/16/20 1259 MDLAR VIEWED LAB TEST RESULTS
7 12/16/20 1259 MDLAR Test Group ENOXAPARIN
8 12/16/20 1259 MDLAR LABORATORY
9 12/16/20 1259 MDLAR Date Time Test Result Flag
10 12/16/20 1259 MDLAR 12/16/20 1157 BUN 12
11 12/16/20 1259 MDLAR 12/16/20 1157 CREAT 1.19
12 12/16/20 1259 MDLAR 12/16/20 1157 INR 1.5 H
13 12/16/20 1259 MDLAR WHO recommends the following therapy guideline
14 12/16/20 1259 MDLAR
15 12/16/20 1259 MDLAR Prophylaxis/treatment of:
16 12/16/20 1259 MDLAR Venous Thrombosis, Pulmonary Embolism
17 12/16/20 1259 MDLAR Prevention of systemic embolism from:
18 12/16/20 1259 MDLAR Tissue heart valves
19 12/16/20 1259 MDLAR Acute MI (to prevent systemic embolism)
20 12/16/20 1259 MDLAR Valvular heart disease
21 12/16/20 1259 MDLAR Atrial fibrillation
22 12/16/20 1259 MDLAR Mechanical prosthetic heart valves (high ris

<Continued>
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Date Time
23 12/16/20 1324 PHAMED VERIFIED in PHA

24 12/16/20 1324 PHAMED VIEWED LAB TEST RESULTS in PHA
25 12/16/20 1324 PHAMED VIEWED LAB TEST RESULTS
26 12/16/20 1324 PHAMED Test Group ENOXAPARIN
27 12/16/20 1324 PHAMED LABORATORY
28 12/16/20 1324 PHAMED Date Time Test Result Flag
29 12/16/20 1324 PHAMED 12/16/20 1157 BUN 12
30 12/16/20 1324 PHAMED 12/16/20 1157 CREAT 1.19
31 12/16/20 1324 PHAMED 12/16/20 1157 INR 1.5 H
32 12/16/20 1324 PHAMED WHO recommends the following therapy guideline
33 12/16/20 1324 PHAMED
34 12/16/20 1324 PHAMED Prophylaxis/treatment of:
35 12/16/20 1324 PHAMED Venous Thrombosis, Pulmonary Embolism
36 12/16/20 1324 PHAMED Prevention of systemic embolism from:
37 12/16/20 1324 PHAMED Tissue heart valves
38 12/16/20 1324 PHAMED Acute MI (to prevent systemic embolism)
39 12/16/20 1324 PHAMED Valvular heart disease
40 12/16/20 1324 PHAMED Atrial fibrillation
41 12/16/20 1324 PHAMED Mechanical prosthetic heart valves (high ris


<Continued>
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RUN USER: MRMRP


Date Time
12/16/20 1259 Pneumatic Pressure Device Rosefort, Laury 1216-0054

12/16/20 SCDMS ROSE LA CMP POE
P
NURSING TEXT: *IPCD = Intermittent Pneumatic
Compression Device
1 12/16/20 1254 Q8H EVERY 8 HOURS

8 12/23/20 0950 MDSOL Order DC in POM
9 12/23/20 0950 MDSOL Ordering Doctor: Oliver,Sonyea
10 12/23/20 0950 MDSOL Order Source: POM
11 12/23/20 0950 MDSOL Intervention's Status changed to Comp.
12 12/23/20 0950 MDSOL Signed by Oliver,Sonyea
Electronically signed by Oliver,Sonyea on 12/23/20 at 0950

12/16/20 1259 NURSING VERIFIED Rosefort, Laury 1216-0447

12/16/20 1400 NUR ROSE LA CMP POE
P
RX: 05546741 Start: 12/16/20 1400
Stop:
Sodium Chloride 0.9% 10ml Syr (0.9% Saline 10ML Syringe) 10 ML SYRINGE
Dose: 3 ML
Route: IV Direction: TID Schedule: SCH
Special Instructions: Hold flushes while IV fluids are infusing

<Continued>
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Date Time

7 12/16/20 1325 PHAMED EDIT
8 12/16/20 1325 PHAMED Edit Dr: Rosefort, Laury Edit Source: PHARM
9 12/16/20 1325 PHAMED FROM:
10 12/16/20 1325 PHAMED DISPENSE: 3
11 12/16/20 1325 PHAMED TO:
14 12/16/20 1325 PHAMED VERIFIED
17 12/28/20 1325 DISCHARGE DISCONTINUE in PHA

12/16/20 1259 NOTHING BY MOUTH Rosefort, Laury 1216-0018

12/16/20 L NPO ROSE LA CMP POE
P
* To hold a medication address each individual medication *
COMMENT: AUTH: 167047846

7 12/18/20 1041 System order's status changed from TRANS to COMP
8 12/18/20 1041 System Order Replaced with New Diet


<Continued>
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RUN USER: MRMRP


Date Time
12/16/20 1259 I/O, Strict Rosefort, Laury 1216-0055

12/16/20 IOSTRICT ROSE LA CMP POE
P
1 12/16/20 1442 .[O7,15,23]

11 12/22/20 1446 MDARA Intervention's Status changed to Comp.
12 12/22/20 1446 MDARA Signed by Ramani, Ashok
Electronically signed by Ramani, Ashok on 12/22/20 at 1446

12/16/20 1259 Code Status Rosefort, Laury 1216-0016

12/16/20 1259 CODE ROSE LA CNC POE
P
Code Status: FULL CODE


<Continued>
000339
000340
RUN USER: MRMRP


Date Time

12 12/22/20 1509 NSNID Cancelled order acknowledged

12/16/20 1259 CBC WITH AUTO DIFF Rosefort, Laury 1217-0044

12/17/20 0500 CBCD ROSE LA CMP POE
P
Routine Draw Times - 5am, 6am, 7am, 10am, 1pm 5pm, 9pm, Midnight
CMT to PHLEB:
** CAUTION: If test needs to be drawn at Midnite, enter service time of 0001 **
COMMENTS:



<Continued>
000340
000341
RUN USER: MRMRP


Date Time
12/16/20 1259 COMP - COMP METABOLIC PANEL Rosefort, Laury 1217-0045

12/17/20 0500 COMP ROSE LA CMP POE
P
CMT to PHLEB:
Collection - Timed or Routine? R
COMMENTS:


12/16/20 1259 MAG - MAGNESIUM Rosefort, Laury 1217-0046

12/17/20 0500 MG ROSE LA CMP POE
P
CMT to PHLEB:
FASTING SPECIMEN IS PREFERRED
COMMENTS:


<Continued>
000341
000342
RUN USER: MRMRP


Date Time


12/16/20 1259 UNIT DOSE Rosefort, Laury 1216-0448

12/16/20 1255 UD ROSE LA CMP POE
P
RX: 05546742 Start: 12/16/20 1255
Stop:
Ondansetron Hcl (Zofran Inj) 4 MG/2 ML Injectable
Dose: 4 MG
Route: IVP Direction: Q8H Schedule: PRN
PRN Reason: NAUSEA/VOMITING



<Continued>
000342
000343
RUN USER: MRMRP


Date Time
12/16/20 1259 Inpatient Certification Form Rosefort, Laury 1216-0006

12/16/20 1259 INPT ROSE LA TRN POE
P
I certify my determination for inpatient status is based on on my medical assessment,
after consideration of the patient's risk factors including age, co-morbidities,
presenting symptoms and acuity. I expect this patient will remain in the hospital for
greater than 2 midnights and the services are reasonable and medically necessary to
warrant inpatient care.
Medical Necessity and Plan
**To be completed by admit provider only** SEE PROVIDER'S DOCUMENTATION.
ADMIT CERTIFIED: YES Expected LOS (DAYS): >=2

2 12/16/20 1259 MDLAR Order from set: CERTIFICATION REFLEX
6 12/16/20 1259 MDLAR This Procedure was triggered by :
7 12/16/20 1259 MDLAR INPATIENT (ADT)


<Continued>
000343
000344
RUN USER: MRMRP


Date Time
12/16/20 1259 IV PREMIXED Rosefort, Laury 1216-0449

12/16/20 1300 IVPM ROSE LA CMP POE
P
Route: IVPB Stop:
NORepinephrine Drip Volume: 250 ML
Premixed at 4,000 MCG/250 ML (4,000 MCG)
Infusion Site: C

1 INITIATE AT: 8 MCG/MIN
2 TITRATE BY: 2 MCG/MIN EVERY 3 MINUTES
3 IF RATE 1 MCG/KG/MIN CONTACT PROVIDER
Treatment Text
HYPOTENSION/SHOCK CONTINUOUS IV INFUSION
ADMINISTRATION CRITERIA

6 12/16/20 1326 PHAMED EDIT
8 12/16/20 1326 PHAMED FROM:
10 12/16/20 1326 PHAMED LAST BAG: 1
11 12/16/20 1326 PHAMED TO:
13 12/16/20 1326 PHAMED LAST BAG: 0

<Continued>
000344
000345
RUN USER: MRMRP


Date Time
24 12/17/20 1635 NSNID order viewed from Order Management

12/16/20 1259 IV Rosefort, Laury 1216-0450

12/16/20 1300 IV ROSE LA CMP POE
P
Route: IV Stop:
Lactated Ringers 1000ml Volume: 1,000 ML
Premixed at 1,000 ML (1,000 ML)
Total Volume: 1,000 mls
Rate: 200 ML/HR Direction: DRIP
Infusion Site: P
Bag Duration: 5 HR

2 12/16/20 1259 MDLAR Order from set: IV FLUIDS
8 12/16/20 1326 PHAMED Items Dispensed: 1 Doses Dispensed: 1
9 12/16/20 1326 PHAMED For: 12/16/20 - 1300

<Continued>
000345
000346
RUN USER: MRMRP


Date Time


12/16/20 1310 XR CHEST ONE VIEW PORTABLE Rosefort, Laury 1216-0074

12/16/20 CXR1 ROSE LA Urgent CMP POE
P
TEMPERATURE:
CAMPUS? MAIN
REASON FOR THIS EXAM: cardiac arrest



<Continued>
000346
000347
RUN USER: MRMRP


Date Time
12/16/20 1329 EXPEDITED HIV-AB1-2 Rosefort, Laury 1216-1266

12/16/20 1329 HIVEXP ROSE LA Stat CMP POE
TRB
CMT to PHLEB:
This test may only be ordered for occupational exposure or
prenatal/neonatal patients in need of urgent HIV screening.
COMMENTS:

1 12/16/20 1329 NSTAS Order ENTER in OM
2 12/16/20 1329 NSTAS Ordering Doctor: Rosefort, Laury
3 12/16/20 1329 NSTAS Order Source: TELEPHONE READ BACK

12/16/20 1329 HEPATITIS PROFILE(A,B,BCORE,C) Rosefort, Laury 1216-1267

12/16/20 1329 HEPP ROSE LA Stat CMP POE
TRB
CMT to PHLEB:
This test should only be done once in 1 month. If you get a duplicate order prompt,
or you know the test has been performed within that time, please check with MD.
WHAT COUNTY DOES THE PATIENT LIVE IN? SAR SARATOGA
(County defaults from ADM)
COMMENTS:

1 12/16/20 1329 NSTAS Order ENTER in OM

<Continued>
000347
000348
RUN USER: MRMRP


Date Time
2 12/16/20 1329 NSTAS Ordering Doctor: Rosefort, Laury

3 12/16/20 1329 NSTAS Order Source: TELEPHONE READ BACK

12/16/20 1340 IV Airhienbuwa, Noghama 1216-0476

12/16/20 1340 IV AIRH N CMP POE
P
Route: IV Stop:
Dextrose 5% 1000ml Volume: 1,000 ML
Sodium Bicarb DRIP Dose: 150 MEQ
Rate: 150 MLS/HR Direction: DRIP
Infusion Site: P
Bag Duration: 7 HR 40 MIN

1 RATE:150 MLS PER HOUR

1 12/16/20 1340 MDNOA Order ENTER in POM
2 12/16/20 1340 MDNOA Ordering Doctor: Airhienbuwa, Noghama
3 12/16/20 1340 MDNOA Order Source: POM
4 12/16/20 1340 MDNOA Signed by Airhienbuwa, Noghama
5 12/16/20 1340 MDNOA VIEWED LAB TEST RESULTS
6 12/16/20 1340 MDNOA Test Group BICARB
7 12/16/20 1340 MDNOA LABORATORY
8 12/16/20 1340 MDNOA Date Time Test Result Flag
9 12/16/20 1340 MDNOA 12/16/20 1157 NA 145

<Continued>
000348
000349
RUN USER: MRMRP


Date Time
10 12/16/20 1340 MDNOA 12/16/20 1157 CREAT 1.19

11 12/16/20 1343 NSLMT order acknowledged
12 12/16/20 1346 PHACMO EDIT in PHA
13 12/16/20 1346 PHACMO EDIT
14 12/16/20 1346 PHACMO Edit Dr: Airhienbuwa, Noghama Edit Source: PHARM
15 12/16/20 1346 PHACMO FROM:
16 12/16/20 1346 PHACMO LABEL COMMENTS:
17 12/16/20 1346 PHACMO *
18 12/16/20 1346 PHACMO TO:
19 12/16/20 1346 PHACMO CHARGE TYPE: IV - IV ADMIXTURE
20 12/16/20 1346 PHACMO CHARGE: $280.69
21 12/16/20 1346 PHACMO LABEL COMMENTS:
22 12/16/20 1346 PHACMO
23 12/16/20 1346 PHACMO *
24 12/16/20 1346 PHACMO RATE: 150 MLS/HR
25 12/16/20 1346 PHACMO DURATION: 7 HR 40 MIN
26 12/16/20 1346 PHACMO VERIFIED in PHA
27 12/16/20 1346 PHACMO VERIFIED
28 12/16/20 1346 PHACMO Edit Dr: Airhienbuwa, Noghama Edit Source: PHARM
29 12/16/20 1346 PHACMO Items Dispensed: 1 Doses Dispensed: 1
30 12/16/20 1346 PHACMO For: 12/16/20 - 1340
31 12/16/20 1346 PHACMO VIEWED LAB TEST RESULTS in PHA
32 12/16/20 1346 PHACMO VIEWED LAB TEST RESULTS
33 12/16/20 1346 PHACMO Test Group BICARB
34 12/16/20 1346 PHACMO LABORATORY
35 12/16/20 1346 PHACMO Date Time Test Result Flag
36 12/16/20 1346 PHACMO 12/16/20 1157 NA 145
37 12/16/20 1346 PHACMO 12/16/20 1157 CREAT 1.19
Electronically signed by Airhienbuwa, Noghama on 12/16/20 at 1340

Acknowledged by: NSLMT 12/16/20 1343

<Continued>
000349
000350
RUN USER: MRMRP


Date Time
12/16/20 1342 Respiratory Therapy - Pulse Ox Shen,Jian 1216-0058

12/16/20 1341 OXRT SHEN J CMP POE
1 12/16/20 1341 .PRN

1 12/16/20 1342 RTJB Order ENTER in NUR
2 12/16/20 1342 RTJB Ordering Doctor: Shen,Jian
3 12/16/20 1342 RTJB order originated from NUR.
12/16/20 1342 Respiratory Therapy - Oxygen T Shen,Jian 1216-0059

12/16/20 1341 RTO2 SHEN J IPR POE
NURSING TEXT: COMFORT CARE
1 12/16/20 1341 PRN PRN

9 12/23/20 1817 RTJB Supplemental Text edited:
10 12/23/20 1817 RTJB From:
11 12/23/20 1817 RTJB To:
12 12/23/20 1817 RTJB COMFORT CARE
13 12/23/20 1817 interface order's status changed from IN PRO to ACTIVE by NUR

<Continued>
000350
000351
RUN USER: MRMRP


Date Time

Amended by : RTJB 12/23/20 1817
12/16/20 1342 Respiratory Therapy - Vent Flo Shen,Jian 1216-0060

12/16/20 1342 VENTFS SHEN J IPR

4 12/16/20 1506 RTJB Supplemental Text edited:
5 12/16/20 1506 RTJB From:
6 12/16/20 1506 RTJB To:
7 12/16/20 1506 RTJB PRVC 500 30 60%
8 12/16/20 2144 RTAJM Supplemental Text edited:
9 12/16/20 2144 RTAJM From:
10 12/16/20 2144 RTAJM PRVC 500 30 60%
11 12/16/20 2144 RTAJM To:
12 12/16/20 2144 RTAJM SIMV/PSV X15 550 PSV 12 PEEP 0 60%
14 12/17/20 2324 RTAJM From:
15 12/17/20 2324 RTAJM SIMV/PSV X15 550 PSV 12 PEEP 0 60%
16 12/17/20 2324 RTAJM To:
17 12/17/20 2324 RTAJM SIMV/PC 15 X15 550 PSV 15PEEP 0 60%
19 12/17/20 2324 RTAJM From:
20 12/17/20 2324 RTAJM SIMV/PC 15 X15 550 PSV 15PEEP 0 60%
21 12/17/20 2324 RTAJM To:
22 12/17/20 2324 RTAJM SIMV/PC 15 X15 PSV 15PEEP 0 60%
24 12/17/20 2325 RTAJM From:
26 12/17/20 2325 RTAJM To:
28 12/20/20 1429 interface order's status changed from IN PRO to INACTIVE by NUR
Amended by : RTJB 12/16/20 1506

Amended by : RTAJM 12/16/20 2144

<Continued>
000351
000352
RUN USER: MRMRP


Date Time
12/16/20 1342 Respiratory Tx - Intubation/Ex Shen,Jian 1216-0061

12/16/20 1342 IE SHEN J IPR

12/16/20 1442 MED Rosefort, Laury 1216-0529

12/16/20 1600 MED ROSE LA CMP POE
TRB
RX: 05546846 Start: 12/16/20 1600
Stop:
Ipratropium/Albuterol Svn (Duoneb Svn) 3 ML AMPUL
Dose: 3 ML
Route: INHALED Direction: Q4H Schedule: SCH

2 12/16/20 1442 RTCJK Ordering Doctor: Rosefort, Laury
3 12/16/20 1442 RTCJK Order Source: TELEPHONE READ BACK
4 12/16/20 1442 RTCJK This procedure has reflexed the following order(s)
5 12/16/20 1442 RTCJK SMALL VOLUME NEBULIZER (RT)
7 12/16/20 1507 PHACMO EDIT in PHA
8 12/16/20 1507 PHACMO EDIT
9 12/16/20 1507 PHACMO Edit Dr: Rosefort, Laury Edit Source: PHARM
10 12/16/20 1507 PHACMO FROM:
11 12/16/20 1507 PHACMO START: 12/16/20-1445 STOP: None
12 12/16/20 1507 PHACMO TO:
13 12/16/20 1507 PHACMO START: 12/16/20-1600 STOP: None
15 12/16/20 1507 PHACMO VERIFIED
16 12/16/20 1507 PHACMO Edit Dr: Rosefort, Laury Edit Source: PHARM
17 12/16/20 1513 RTAJM order acknowledged
19 12/21/20 1057 RTCJK DISCONTINUE in PHA

<Continued>
000352
000353
RUN USER: MRMRP


Date Time
20 12/21/20 1057 RTCJK DISCONTINUE

21 12/21/20 1057 RTCJK Edit Dr: Santilli,Anthony Edit Source: TELEP
23 12/21/20 1219 NSGLA order acknowledged

Acknowledged by: RTAJM 12/16/20 1513
Acknowledged by: NSGLA 12/21/20 1219
12/16/20 1442 SMALL VOLUME NEBULIZER Rosefort, Laury 1216-0025

12/16/20 SVN ROSE LA CMP POE
TRB
WHICH DRUG DUONEB - 3mg/0.5mg AMOUNT ORDERED VENT 0.5 ml/ATROV 0.5 mg
FREQUENCY EVERY 4 HOURS
COMMENTS:

2 12/16/20 1442 RTCJK Order from set: RT SVN
3 12/16/20 1442 RTCJK Ordering Doctor: Rosefort, Laury
4 12/16/20 1442 RTCJK Order Source: TELEPHONE READ BACK
5 12/16/20 1442 RTCJK This Procedure was triggered by :
6 12/16/20 1442 RTCJK Duoneb Svn 3 ML INHALED Q4H


<Continued>
000353
000354
RUN USER: MRMRP


Date Time
12/16/20 1452 Respiratory Therapy - SVN & MD Shen,Jian 1216-0079

12/16/20 1452 MEDS SHEN J IPR

1 12/16/20 1452 RTGLS Order ENTER in NUR
2 12/16/20 1452 RTGLS Ordering Doctor: Shen,Jian
3 12/16/20 1452 RTGLS order originated from NUR.
4 12/21/20 1139 RTKW Supplemental Text edited:
5 12/21/20 1139 RTKW From:
6 12/21/20 1139 RTKW DUONEB Q4H
7 12/21/20 1139 RTKW To:
8 12/21/20 1139 RTKW DUONEB Q4H PRN
Amended by : RTKW 12/21/20 1139
12/16/20 1458 CONSULT CARDIOLOGY Rosefort, Laury 1216-0018

12/16/20 CARD ROSE LA TRN POE
P
Reason for consult: cardic arrest
CONSULTING DOCTOR (Dr to be consulted):RUND I PHONE 518-842-7088
Has MD/Service been contacted? Y If yes, who did you speak with?
Patient's DOB: 09/26/51
COMMENTS:



<Continued>
000354
000355
RUN USER: MRMRP


Date Time
12/16/20 1458 CONSULT PULMONOLOGY Rosefort, Laury 1216-0019

12/16/20 1504 PULM ROSE LA TRN POE
P
Reason for consult: cardic arrest
CONSULTING DOCTOR (Dr to be consulted):SANT AN PHONE 518-627-0410
Has MD/Service been contacted? Y If yes, who did you speak with? biancia
Patient's DOB: 09/26/51
COMMENTS:

5 12/16/20 1506 NKH order service time edited: old value -
6 12/16/20 1506 NKH new value - 1504
7 12/16/20 1506 NKH Query: Has MD/Service been contacted?
8 12/16/20 1506 NKH old response - N
9 12/16/20 1506 NKH new response - Y
10 12/16/20 1506 NKH Query: If yes, who did you speak with?
11 12/16/20 1506 NKH old response -
12 12/16/20 1506 NKH new response - biancia
14 12/18/20 1235 NSGBL order viewed

Amended by : NKH 12/16/20 1506
12/16/20 1508 OXYGEN THERAPY Rosefort, Laury 1216-0026

12/16/20 O2 ROSE LA CMP
C

1 12/16/20 1508 RTJB Order ENTER in OE
2 12/16/20 1508 RTJB Ordering Doctor: Rosefort, Laury
3 12/16/20 1508 RTJB Order Source: CHARGE ENTRY

<Continued>
000355
000356
RUN USER: MRMRP


Date Time
12/16/20 1508 OXIMETRY TITRATION Rosefort, Laury 1216-0027

12/16/20 OXT ROSE LA CMP
C

12/16/20 1508 VENTILATOR Rosefort, Laury 1216-0028

12/16/20 VT ROSE LA CMP
C

5 01/13/21 1059 MRDMS order viewed
12/16/20 1508 THERAPIST ASSISTANCE Rosefort, Laury 1216-0002

12/16/20 TA ROSE LA CMP
C

12/16/20 1508 DISPOSABLE BAG/VALVE/MASK Rosefort, Laury 1216-0003

12/16/20 DB ROSE LA CMP
C

<Continued>
000356
000357
RUN USER: MRMRP


Date Time

12/16/20 1518 ARTERIAL BLOOD GASES Rosefort, Laury 1216-0032

12/16/20 ABG ROSE LA CMP POE
TRB
COMMENTS:

1 12/16/20 1518 NURMT Order ENTER in OM
2 12/16/20 1518 NURMT Ordering Doctor: Rosefort, Laury
3 12/16/20 1518 NURMT Order Source: TELEPHONE READ BACK
4 12/16/20 1518 NURMT This procedure has reflexed the following order(s)
5 12/16/20 1518 NURMT PUNCTURE ARTERIAL (RT)

12/16/20 1518 PUNCTURE ARTERIAL Rosefort, Laury 1216-0031

12/16/20 1518 AP ROSE LA Stat CMP POE
TRB

2 12/16/20 1518 NURMT Order from set: REFLEX ARTERIAL PUNCTURE

<Continued>
000357
000358
RUN USER: MRMRP


Date Time
5 12/16/20 1518 NURMT This Procedure was triggered by :

6 12/16/20 1518 NURMT ARTERIAL BLOOD GASES (RT)

12/16/20 1528 TROPONIN I Rosefort, Laury 1216-1441

12/16/20 1528 TROP ROSE LA Stat CMP POE
TRB
CMT to PHLEB:
COMMENTS:



<Continued>
000358
000359
RUN USER: MRMRP


Date Time
12/16/20 1546 US CARDIAC COMP/DOPPLER/CFV Rosefort, Laury 1216-0061

12/16/20 CAR/DOP/CF ROSE LA Urgent CNC POE
Cancel Date/Time 12/16/20 1631 Cancelled by PHILLIPS,KELLY
P
MODE OF TRANSPORTATION? NAP NOT APPLICABLE (Portable)
TEMPERATURE:
CAMPUS? MAIN
REASON FOR THIS EXAM: cardiac arrest
CONSULTING CARDIOLOGIST (if any): Schenectady Cardiology
FOR INSTRUCTIONS - SHIFT F8

5 12/16/20 1546 NURMT OECAMPUS edited: old value - None
6 12/16/20 1546 NURMT new value - MAIN
7 12/16/20 1546 NURMT Query: MODE OF TRANSPORTATION?
8 12/16/20 1546 NURMT old response -
9 12/16/20 1546 NURMT new response - NAP
10 12/16/20 1546 NURMT billing data adjusted in campus edit
11 12/16/20 1546 NURMT order verified/acknowledged
13 12/16/20 1631 interface order's status changed from LOGGED to CANCEL by RAD

Amended by : NURMT 12/16/20 1546

<Continued>
000359
000360
RUN USER: MRMRP


Date Time
12/16/20 1617 ELECTROCARDIOGRAM (EKG) Rund,Ingrid 1216-0036

12/16/20 1630 EKG RUND I RES POE
TRB
***IF ORDERED STAT CALL #6319***
**ALL TESTS AFTER 1600 CALL RT #6304**
STATS/URGENTS call RT at x6304, if after hours below:
After 1600 Mon-Fri, and After 1530 Sat & Sun
Has RT/EKG been contacted? Y If yes, who did you speak with? JEN
REASON FOR VISIT: L2/3 L3/4 L4/5 LATERAL INTERBODY FUSION ANTERIOR
CAMPUS? MAIN

2 12/16/20 1617 NURMT Ordering Doctor: Rund,Ingrid
5 12/16/20 1638 interface order associated with report 20201216-0038
6 12/16/20 1638 interface order's status changed from TRANS to COMP
8 12/17/20 0755 interface order's status changed from COMP to RESULT
10 12/30/20 1152 MRSMM Image Viewed in PCI
11 02/22/21 0812 MDIR Signed by Rund,Ingrid
Electronically signed by Rund,Ingrid on 02/22/21 at 0812


<Continued>
000360
000361
RUN USER: MRMRP


Date Time
12/16/20 1546 US CARDIAC COMP/DOPPLER/CFV Rosefort, Laury 1217-0003

12/17/20 1546 CAR/DOP/CF ROSE LA Stat CMP POE
TRB
TEMPERATURE:
CAMPUS? MAIN
REASON FOR THIS EXAM: POST CARDIAC ARREST
CONSULTING CARDIOLOGIST (if any): Schenectady Cardiology

6 12/16/20 1632 RADKP order service date edited: old value - 12/16/20
10 12/17/20 1102 NSGBL order viewed

Amended by : RADKP 12/16/20 1632

P
COMMENTS:

<Continued>
000361
000362
RUN USER: MRMRP


Date Time

1 12/16/20 1641 RTJB Order ENTER in OM
3 12/16/20 1641 RTJB Order Source: POM
4 12/16/20 1641 RTJB This procedure has reflexed the following order(s)
5 12/16/20 1641 RTJB PUNCTURE ARTERIAL (RT)


P

1 12/16/20 1641 RTJB Order ENTER in OM
2 12/16/20 1641 RTJB Order from set: REFLEX ARTERIAL PUNCTURE
4 12/16/20 1641 RTJB Order Source: POM
5 12/16/20 1641 RTJB This Procedure was triggered by :
6 12/16/20 1641 RTJB ARTERIAL BLOOD GASES (RT)

12/16/20 1642 THERAPIST ASSISTANCE Rosefort, Laury 1216-0005

12/16/20 TA ROSE LA CMP
C


<Continued>
000362
000363
RUN USER: MRMRP


Date Time

DMO
Route: IV Stop:
Dexmedetomidine Bolus Volume: 50 ML
Premixed at 200 MCG/50 ML (200 MCG)
Bag Duration: UD

1 12/16/20 1642 NURMT Order ENTER in PHA
2 12/16/20 1642 NURMT Ordering Doctor: Pyxis,Overridedoc
3 12/16/20 1642 NURMT Order Source: DISP MACH OVERRIDE

P
RX: 05546921 Start: 12/16/20 1705
Stop: 12/16/20 1706
methylPREDNISolone Inj (Solu-MEDROL Inj) 125 MG/2 ML VIAL
Dose: 125 MG
Route: IVP Direction: ONCE Schedule: ONE

6 12/16/20 1706 SCHEDULER DISCONTINUE in PHA

<Continued>
000363
000364
RUN USER: MRMRP


Date Time


P
RX: 05546987 Start: 12/17/20 0100
Stop:
methylPREDNISolone Inj (Solu-MEDROL Inj) 40 MG/ VIAL
Dose: 40 MG
Route: IVP Direction: Q6H Schedule: SCH

6 12/16/20 1751 MDANS Order's Rx has been edited.
8 12/16/20 1751 MDANS EDIT
9 12/16/20 1751 MDANS FROM:
10 12/16/20 1751 MDANS SIG: Q12H
11 12/16/20 1751 MDANS DOSE: 80 MG (2 ML PER DOSE)
12 12/16/20 1751 MDANS START: 12/17/20-0800 STOP: None
13 12/16/20 1751 MDANS CHARGE: $3.90
14 12/16/20 1751 MDANS TO:
15 12/16/20 1751 MDANS SIG: Q6H
16 12/16/20 1751 MDANS DOSE: 40 MG (1 ML PER DOSE)
17 12/16/20 1751 MDANS START: 12/17/20-1755 STOP: None
18 12/16/20 1751 MDANS CHARGE: $1.95
20 12/16/20 1949 PHADYB EDIT in PHA
21 12/16/20 1949 PHADYB EDIT
22 12/16/20 1949 PHADYB Edit Dr: Santilli,Anthony Edit Source: PHARM
23 12/16/20 1949 PHADYB FROM:
24 12/16/20 1949 PHADYB START: 12/17/20-1755 STOP: None

<Continued>
000364
000365
RUN USER: MRMRP


Date Time
25 12/16/20 1949 PHADYB TO:

27 12/16/20 1949 PHADYB VERIFIED in PHA
28 12/16/20 1949 PHADYB VERIFIED
30 12/16/20 1959 NSGBT order acknowledged

Amended by : MDANS 12/16/20 1751
Acknowledged by: NSGBT 12/16/20 1959
12/16/20 1713 RN Hepatitis C Follow Up Rosefort, Laury 1216-0107

12/16/20 1713 HEPC ROSE LA CMP POE
PR
1 12/16/20 1713 .[ONCE]

1 12/16/20 1713 NURMT Order ENTER in NUR
3 12/16/20 1713 NURMT Order Source: PROTOCOL

<Continued>
000365
000366
RUN USER: MRMRP


Date Time
12/16/20 1713 Provider admission notificatio Rosefort, Laury 1216-0108

12/16/20 1713 NUR.ASFUP ROSE LA IPR
PR

5 12/24/20 0043 NSGJP order viewed from Order Management
12/16/20 1713 RN Pneumonia Follow Up Rosefort, Laury 1216-0109

12/16/20 1713 PNEU ROSE LA CMP POE
PR
1 12/16/20 1713 .[ONCE]


12/16/20 1750 LACT SHEN J CMP
L

1 12/16/20 1750 AutoDft Order ENTER in LAB
2 12/16/20 1750 AutoDft Ordering Doctor: Shen,Jian

<Continued>
000366
000367
RUN USER: MRMRP


Date Time
3 12/16/20 1750 AutoDft Order Source: LABORATORY


VRB
COMMENTS:

1 12/16/20 1800 RTAJM Order ENTER in OM
2 12/16/20 1800 RTAJM Ordering Doctor: Rosefort, Laury
3 12/16/20 1800 RTAJM Order Source: VERBAL READ BACK
4 12/16/20 1800 RTAJM This procedure has reflexed the following order(s)
5 12/16/20 1800 RTAJM PUNCTURE ARTERIAL (RT)


VRB

2 12/16/20 1800 RTAJM Order from set: REFLEX ARTERIAL PUNCTURE
3 12/16/20 1800 RTAJM Ordering Doctor: Rosefort, Laury

<Continued>
000367
000368
RUN USER: MRMRP


Date Time
4 12/16/20 1800 RTAJM Order Source: VERBAL READ BACK

5 12/16/20 1800 RTAJM This Procedure was triggered by :
6 12/16/20 1800 RTAJM ARTERIAL BLOOD GASES (RT)

12/16/20 1818 MED Santilli,Anthony 1216-0649

12/16/20 1817 MED SANT AN CMP POE
P
RX: 05546957 Start: 12/16/20 1817
Stop:
Pantoprazole Inj (Protonix Inj) 40 MG VIAL
Dose: 40 MG
Route: IVP Direction: DAILY Schedule: SCH


1 12/16/20 1818 MDANS Order ENTER in POM
12 12/21/20 0802 NSGLA order acknowledged

Acknowledged by: NSGLA 12/21/20 0802

<Continued>
000368
000369
RUN USER: MRMRP


Date Time
12/16/20 1821 BULK Santilli,Anthony 1216-0650

12/16/20 2200 BK SANT AN CMP POE
P
RX: 05546961 Start: 12/16/20 2200
Stop:
Insulin Aspart (NovoLOG Insulin) 100 UNITS/ 10ML VIAL
Dose: 0 UNITS
Route: SC Direction: ACHS Schedule: SCH
Dose Instructions: MODERATE SLIDING SCALE

1 GLUCOSE LEVEL DOSE
2 LESS THAN 70 OR SYMPTOMATIC HYPOGLYCEMIC PROTOCOL
3 70 - 150 0 UNITS
4 151 - 200 3 UNITS
5 201 - 250 6 UNITS
6 251 - 300 9 UNITS
7 301 - 350 12 UNITS
8 351 - 400 15 UNITS
9 > 400 DRAW STAT VENOUS GLUCOSE CALL PYSICIAN WITH RESULTS
Treatment Text
DO NOT ADMINISTER
DOSES GREATER THAN 20 UNITS,
OF RAPID OR SHORT ACTING
INSULIN WITHOUT ORDER ON MAR

2 12/16/20 1821 MDANS Order from set: INSULIN SLIDING SCALE
6 12/16/20 1821 MDANS VIEWED LAB TEST RESULTS
7 12/16/20 1821 MDANS Test Group BGM
8 12/16/20 1821 MDANS LABORATORY
9 12/16/20 1821 MDANS Date Time Test Result Flag
10 12/16/20 1821 MDANS 12/16/20 1157 GLU 273 # H

<Continued>
000369
000370
RUN USER: MRMRP


Date Time

14 12/16/20 1834 PHADYB Items Dispensed: 1 Doses Dispensed: 1
15 12/16/20 1834 PHADYB For: 12/16/20 - 2200
16 12/16/20 1834 PHADYB VIEWED LAB TEST RESULTS in PHA

12/16/20 1821 UNIT DOSE Santilli,Anthony 1216-0651

12/16/20 1820 UD SANT AN CMP POE
P
RX: 05546962 Start: 12/16/20 1820
Stop:
Glucose Fingersticks (Fingersticks - Glucose) 1 PER NURSING
Dose: 1 PER
Route: STICK Direction: PRN Schedule: PRN
PRN Reason: Determination of Glucose

10 12/16/20 1821 MDANS 12/16/20 1157 GLU 273 # H

<Continued>
000370
000371
RUN USER: MRMRP


Date Time

17 12/23/20 0950 MDSOL Order's Rx has been discontinued.


P
RX: 05546963 Start: 12/16/20 1820
Stop:
Glucose 15gm Bottle (Glucose 15gm Bottle) 15 GM/37.5 ML BOTTLE
Dose: 15 GM
Route: PO Direction: PRN Schedule: PRN
PRN Reason: HYPOGLYCEMIA



<Continued>
000371
000372
RUN USER: MRMRP


Date Time

P
RX: 05546964 Start: 12/16/20 1840
Stop:
10% Dextrose 250 ml (Dextrose 10% 250 Ml) 250 ML BAG
Dose: 250 ML
Route: IV Direction: PRN Schedule: PRN
PRN Reason: HYPOGLYCEMIA

8 12/16/20 1835 PHADYB EDIT
10 12/16/20 1835 PHADYB FROM:
11 12/16/20 1835 PHADYB ROUTE: IVP
12 12/16/20 1835 PHADYB DOSE: 50 ML (1 Injectable PER DOSE)
14 12/16/20 1835 PHADYB INVENTORY: MAIN - MAIN
15 12/16/20 1835 PHADYB CHARGE: $22.90
16 12/16/20 1835 PHADYB LABEL COMMENTS:
17 12/16/20 1835 PHADYB BLOOD GLUCOSE LESS THAN 70, OR SYMPTOMATIC
18 12/16/20 1835 PHADYB 1. If able to take PO, give 1 full tube of oral gluco
19 12/16/20 1835 PHADYB gel once (15 grams carbohydrates)
20 12/16/20 1835 PHADYB 2. If unable to take PO, give 50 ml of dextrose 50% I
21 12/16/20 1835 PHADYB once
22 12/16/20 1835 PHADYB 3. If oral glucose has no effect, give 50 ml of dextr
23 12/16/20 1835 PHADYB 50% IV once
24 12/16/20 1835 PHADYB 4. Check FS q15 minutes until greater than 100
25 12/16/20 1835 PHADYB 5. Notify physician
26 12/16/20 1835 PHADYB MED: DEXTSYR - Dextrose 50% Bristoject
27 12/16/20 1835 PHADYB TO:

<Continued>
000372
000373
RUN USER: MRMRP


Date Time
28 12/16/20 1835 PHADYB ROUTE: IV

29 12/16/20 1835 PHADYB DOSE: 250 ML (1 BAG PER DOSE)
31 12/16/20 1835 PHADYB INVENTORY: ICU - ICU
32 12/16/20 1835 PHADYB CHARGE: $18.25
34 12/16/20 1835 PHADYB RATE: 999 ML PER HOUR (15 MINUTE INFUSION)
35 12/16/20 1835 PHADYB
36 12/16/20 1835 PHADYB BLOOD GLUCOSE LESS THAN 70, OR SYMPTOMATIC
37 12/16/20 1835 PHADYB 1. If able to take PO, give 1 full tube of oral
38 12/16/20 1835 PHADYB glucose gel once (15 grams carbohydrates)
39 12/16/20 1835 PHADYB 2. If unable to take PO, give 250 ml of
40 12/16/20 1835 PHADYB dextrose 10% IV once
41 12/16/20 1835 PHADYB 3. If oral glucose has no effect, give 250 ml
42 12/16/20 1835 PHADYB of dextrose 10% IV once
43 12/16/20 1835 PHADYB 4. Check FS q15 minutes until greater than 100
44 12/16/20 1835 PHADYB 5. Notify physician
45 12/16/20 1835 PHADYB MED: DEXT250S77 - Dextrose 10% 250 Ml


<Continued>
000373
000374
RUN USER: MRMRP


Date Time

P
RX: 05546965 Start: 12/16/20 1900
Stop:
Zosyn Inj (Zosyn Inj) 4.5 GM VIAL
Dose: 4.5 GM
Route: IVPB Direction: Q8H Schedule: SCH
Clinical Indication: SEPSIS
Special Instructions: DOSE ADJUSTED PER RENAL DOSING POLICY

7 12/16/20 1838 PHADYB EDIT
9 12/16/20 1838 PHADYB FROM:
10 12/16/20 1838 PHADYB DOSE: 3.375 GM (1 VIAL PER DOSE)
12 12/16/20 1838 PHADYB CHARGE TYPE: INP-UD - INP-DOSE RULE-CHARGE LEFTOVERS
13 12/16/20 1838 PHADYB CHARGE: $12.75
15 12/16/20 1838 PHADYB INFUSE OVER: 4 HOUR
16 12/16/20 1838 PHADYB Premix OR MINIBAG PLUS 100 mL NS OR
17 12/16/20 1838 PHADYB 100 Ml NS (Vialmate) Baxter Bag 2B1302 Only
18 12/16/20 1838 PHADYB SPECIAL INSTRUCTIONS:
19 12/16/20 1838 PHADYB MED: ZOSY3.375 - Zosyn
20 12/16/20 1838 PHADYB TO:
21 12/16/20 1838 PHADYB DOSE: 4.5 GM (1 VIAL PER DOSE)
23 12/16/20 1838 PHADYB CHARGE TYPE: CT - CHARGE TYPE
24 12/16/20 1838 PHADYB CHARGE: $18.95
26 12/16/20 1838 PHADYB INFUSE OVER: 4 HOURS

<Continued>
000374
000375
RUN USER: MRMRP


Date Time
27 12/16/20 1838 PHADYB Premix OR MINIBAG PLUS 100 mL NS OR

28 12/16/20 1838 PHADYB 100 Ml NS (Vialmate) Baxter Bag 2B1302 Only
29 12/16/20 1838 PHADYB SPECIAL INSTRUCTIONS:
30 12/16/20 1838 PHADYB DOSE ADJUSTED PER RENAL DOSING POLICY
31 12/16/20 1838 PHADYB MED: ZOSY4.5I - Zosyn

12/16/20 1832 ARTERIAL BLOOD GASES Santilli,Anthony 1216-0049

12/16/20 2030 ABG SANT AN CMP POE
TRB
COMMENTS:

2 12/16/20 1832 NURMT Ordering Doctor: Santilli,Anthony
4 12/16/20 1832 NURMT This procedure has reflexed the following order(s)
5 12/16/20 1832 NURMT PUNCTURE ARTERIAL (RT)
7 12/16/20 2040 RTAD order's status changed from TRANS to COMP

<Continued>
000375
000376
RUN USER: MRMRP


Date Time

12/16/20 1832 PUNCTURE ARTERIAL Santilli,Anthony 1216-0048

12/16/20 2030 AP SANT AN Stat CMP POE
TRB

2 12/16/20 1832 NURMT Order from set: REFLEX ARTERIAL PUNCTURE
3 12/16/20 1832 NURMT Ordering Doctor: Santilli,Anthony
5 12/16/20 1832 NURMT This Procedure was triggered by :
6 12/16/20 1832 NURMT ARTERIAL BLOOD GASES (RT)


L


<Continued>
000376
000377
RUN USER: MRMRP


Date Time
12/16/20 2119 Restraint Non- Violent Rosefort, Laury 1216-0129

12/16/20 RESTNV ROSE LA IPR POE
P
Restraint Type: Limb (Upper Ext Only)
Elements of Behavior Disoriented or Confusion
1 12/16/20 2119 Q8H EVERY 8 HOURS

6 12/16/20 2126 NURRER order acknowledged
7 12/16/20 2142 NURRER order viewed from Order Management
8 01/07/21 1215 NSSAW order viewed from Order Management

Acknowledged by: NURRER 12/16/20 2126
12/16/20 2152 UNIT DOSE Kolongo, Nsekenene 1216-0736

12/16/20 2200 UD KOLO N CMP POE
TRB
RX: 05547046 Start: 12/16/20 2200
Stop:
Glucose Fingersticks (Fingersticks - Glucose) 1 PER NURSING
Dose: 1 PER
Route: STICK Direction: ACHS Schedule: SCH

1 12/16/20 2152 NURRER Order ENTER in OM
2 12/16/20 2152 NURRER Order from set: INSULIN SLIDING SCALE
3 12/16/20 2152 NURRER Ordering Doctor: Kolongo, Nsekenene
4 12/16/20 2152 NURRER Order Source: TELEPHONE READ BACK
5 12/16/20 2152 NURRER VIEWED LAB TEST RESULTS
6 12/16/20 2152 NURRER Test Group BGM

<Continued>
000377
000378
RUN USER: MRMRP


Date Time
7 12/16/20 2152 NURRER LABORATORY

8 12/16/20 2152 NURRER Date Time Test Result Flag
9 12/16/20 2152 NURRER 12/16/20 1157 GLU 273 # H
19 01/28/21 0713 MDNKO Signed by Kolongo, Nsekenene
Electronically signed by Kolongo, Nsekenene on 01/28/21 at 0713

12/16/20 2209 VENTILATOR SETTING CHANGES Santilli,Anthony 1216-0056

12/16/20 VTCHANGE SANT AN CMP POE
TRB
VENTILATOR SETTING CHANGES
VENTILATOR MODE: SIMV & PSV RESPIRATORY RATE: 15
TIDAL VOLUME (cc): 550 PEEP (cmH2O): 0 FiO2: 60
TITRATE O2 TO SAO2 >: 94 PRESSURE CONTROL (cmH2O): PRESSURE SUPPORT (cmH2O): 12
COMMENTS:

2 12/16/20 2209 RTAJM Ordering Doctor: Santilli,Anthony
3 12/16/20 2209 RTAJM Order Source: TELEPHONE READ BACK
4 12/16/20 2209 RTAJM order's status changed from TRANS to COMP


<Continued>
000378
000379
RUN USER: MRMRP


Date Time
12/16/20 2210 MED Kolongo, Nsekenene 1216-0742

12/16/20 2210 MED KOLO N CMP POE
P
RX: 05547069 Start: 12/16/20 2210
Stop:
Midazolam Hcl (Versed) 5 MG/5 ML VIAL
Dose: 1 MG
Route: IVP Direction: Q2H Schedule: PRN
PRN Reason: AGITATION

1 12/16/20 2210 MDNKO Order ENTER in POM
2 12/16/20 2210 MDNKO Ordering Doctor: Kolongo, Nsekenene
3 12/16/20 2210 MDNKO Order Source: POM
6 12/16/20 2228 PHAMCV VERIFIED in PHA
7 12/17/20 0839 NSNID order viewed from Order Management


<Continued>
000379
000380
RUN USER: MRMRP


Date Time
12/16/20 2223 TROPONIN I Kolongo, Nsekenene 1216-1750

12/16/20 2223 TROP KOLO N Stat CMP POE
TRB
CMT to PHLEB:
COMMENTS:

2 12/16/20 2223 NURRER Ordering Doctor: Kolongo, Nsekenene

12/16/20 2226 ARTERIAL BLOOD GASES Santilli,Anthony 1217-0007

12/17/20 0500 ABG SANT AN CMP POE
TRB
COMMENTS:

2 12/16/20 2226 NURRER Ordering Doctor: Santilli,Anthony
4 12/16/20 2226 NURRER This procedure has reflexed the following order(s)

<Continued>
000380
000381
RUN USER: MRMRP


Date Time
5 12/16/20 2226 NURRER PUNCTURE ARTERIAL (RT)


12/16/20 2226 PUNCTURE ARTERIAL Santilli,Anthony 1217-0008

12/17/20 0500 AP SANT AN CMP POE
TRB

2 12/16/20 2226 NURRER Order from set: REFLEX ARTERIAL PUNCTURE
3 12/16/20 2226 NURRER Ordering Doctor: Santilli,Anthony
5 12/16/20 2226 NURRER This Procedure was triggered by :
6 12/16/20 2226 NURRER ARTERIAL BLOOD GASES (RT)


L


<Continued>
000381
000382
RUN USER: MRMRP


Date Time

L


VRB
RX: 05547135 Start: 12/17/20 0530
Stop: 12/17/20 0531
diphenhydrAMINE Inj (Benadryl Inj) 50 MG/1 ML Injectable
Dose: 25 MG
Route: IVP Direction: NOW Schedule: ONE

1 12/17/20 0531 NSGC Order ENTER in OM
2 12/17/20 0531 NSGC Ordering Doctor: Kolongo, Nsekenene
3 12/17/20 0531 NSGC Order Source: VERBAL READ BACK
4 12/17/20 0531 NSGC order acknowledged

Acknowledged by: NSGC 12/17/20 0531

<Continued>
000382
000383
RUN USER: MRMRP


Date Time

VRB
RX: 05547136 Start: 12/17/20 0530
Stop: 12/17/20 0531
EPINEPHrine (EpiPen) (EpiPen) 0.3 MG/0.3 ML SYRINGE
Dose: 0.3 MG
Route: IM Direction: ONCE Schedule: ONE

1 12/17/20 0531 NSGC Order ENTER in OM
2 12/17/20 0531 NSGC Ordering Doctor: Kolongo, Nsekenene
3 12/17/20 0531 NSGC Order Source: VERBAL READ BACK
6 12/17/20 0545 PHAMCV VERIFIED
7 12/17/20 0545 PHAMCV Items Dispensed: 1 Doses Dispensed: 1
8 12/17/20 0545 PHAMCV For: 12/17/20 - 0530


DMO
RX: 05547128 Start: 12/17/20 0534
Stop:
diphenhydrAMINE Inj (Benadryl Inj) 50 MG/1 ML Injectable
Dose: 0 MG

3 12/17/20 0533 PHA ORDER Order Source: DISP MACH OVERRIDE

<Continued>
000383
000384
RUN USER: MRMRP


Date Time

DMO
RX: 05547141 Start: 12/17/20 0550
Stop:
EPINEPHrine 0.1 MG/ML 10ML SYR (EPINEPHrine 0.1 MG/ML 10ML SYR) 0.1 MG/ 10ML SYRINGE
Dose: 0 MG


DMO
RX: 05547142 Start: 12/17/20 0552
Stop:
EPINEPHrine 0.1 MG/ML 10ML SYR (EPINEPHrine 0.1 MG/ML 10ML SYR) 0.1 MG/ 10ML SYRINGE
Dose: 0 MG


<Continued>
000384
000385
RUN USER: MRMRP


Date Time

L

12/17/20 0745 XR CHEST ONE VIEW PORTABLE Shen,Jian 1217-0012

12/17/20 CXR1 SHEN J Urgent CMP POE
TRB
TEMPERATURE:
CAMPUS? MAIN
REASON FOR THIS EXAM: FOLLOW UP

1 12/17/20 0745 NCH Order ENTER in OM
2 12/17/20 0745 NCH Ordering Doctor: Shen,Jian
3 12/17/20 0745 NCH Order Source: TELEPHONE READ BACK


<Continued>
000385
000386
RUN USER: MRMRP


Date Time

12/17/20 ABG SHEN J CMP POE
TRB
COMMENTS:

4 12/17/20 0747 NCH This procedure has reflexed the following order(s)
5 12/17/20 0747 NCH PUNCTURE ARTERIAL (RT)
8 12/17/20 0909 RTGLS order's status changed from TRANS to COMP

12/17/20 0747 PUNCTURE ARTERIAL Shen,Jian 1217-0010

12/17/20 0747 AP SHEN J Stat CMP POE
TRB

2 12/17/20 0747 NCH Order from set: REFLEX ARTERIAL PUNCTURE
5 12/17/20 0747 NCH This Procedure was triggered by :
6 12/17/20 0747 NCH ARTERIAL BLOOD GASES (RT)
9 12/17/20 0909 RTGLS order's status changed from TRANS to COMP

<Continued>
000386
000387
RUN USER: MRMRP


Date Time

12/17/20 0818 MANUAL DIFFERENTIAL Rosefort, Laury 1217-0200

12/17/20 0630 DIFFM ROSE LA CMP
L

1 12/17/20 0818 LABDMK Order ENTER in LAB
2 12/17/20 0818 LABDMK Ordering Doctor: Rosefort, Laury
3 12/17/20 0818 LABDMK Order Source: LABORATORY

L

12/17/20 1140 CT HEAD WO IV CONTRAST Santilli,Anthony 1217-0007

12/17/20 HWO SANT AN Urgent CMP POE
P
IF CONTRAST TEST, DOES PT HAVE 20-GAUGE IV ABOVE WRIST? NA
REASON FOR THIS EXAM: Cardiac arrest hypoxic injury
:;


<Continued>
000387
000388
RUN USER: MRMRP


Date Time


12/17/20 1142 IV PREMIXED Santilli,Anthony 1217-0255

12/17/20 1145 IVPM SANT AN CMP POE
P
Route: IV Stop:
Sodium Chloride 0.9% 1000ml Volume: 1,000 ML
Premixed at 1,000 ML (1,000 ML)
Rate: 75 ML/HR Direction: DRIP
Infusion Site: P
Bag Duration: 13 HR 20 MIN

6 12/17/20 1150 PHAGS VERIFIED in PHA
7 12/17/20 1150 PHAGS VERIFIED
8 12/17/20 1150 PHAGS Items Dispensed: 1 Doses Dispensed: 1
9 12/17/20 1150 PHAGS For: 12/17/20 - 1145
10 12/18/20 0526 NSYS Order HOLD in OM
11 12/18/20 0526 NSYS Ordering Doctor: Kolongo, Nsekenene
12 12/18/20 0526 NSYS Order Source: VERBAL READ BACK
13 12/18/20 0526 NSYS Rx's Hold/Resume dates edited by KOLO N.
14 12/18/20 0526 NSYS DEACTIVATE
15 12/18/20 0526 NSYS DEACTIVATE: 12/18 0526 REACTIVATE: EVENT:
16 12/18/20 0551 NSYS order acknowledged

<Continued>
000388
000389
RUN USER: MRMRP


Date Time


Amended by : NSYS 12/18/20 0526
Acknowledged by: NSYS 12/18/20 0551

<Continued>
000389
000390
RUN USER: MRMRP


Date Time
12/17/20 1142 BULK Santilli,Anthony 1217-0256

12/17/20 1700 BK SANT AN CMP POE
P
RX: 05547330 Start: 12/17/20 1700
Stop:
Insulin Aspart (NovoLOG Insulin) 100 UNITS/ 10ML VIAL
Dose: 0 UNITS
Route: SC Direction: ACHS Schedule: SCH
Dose Instructions: HIGH SLIDING SCALE

1 GLUCOSE LEVEL DOSE
2 LESS THAN 70 OR SYMPTOMATIC HYPOGLYCEMIC PROTOCOL
3 70 - 150 O UNITS
4 151 - 200 4 UNITS
5 201 - 250 8 UNITS
6 251 - 300 12 UNITS
7 301 - 350 16 UNITS
8 351 - 400 20 UNITS
9 > 400 DRAW STAT VENOUS GLUCOSE CALL PYSICIAN WITH RESULTS
Treatment Text
DO NOT ADMINISTER
DOSES GREATER THAN 20 UNITS,
OF RAPID OR SHORT ACTING
INSULIN WITHOUT ORDER ON MAR

10 12/17/20 1142 MDANS 12/17/20 1107 FINGERSTICK GLU 147 H

<Continued>
000390
000391
RUN USER: MRMRP


Date Time
11 12/17/20 1142 MDANS Heyer, Katrina

12 12/17/20 1142 MDANS 12/17/20 0630 GLU 234 H
14 12/17/20 1150 PHAGS EDIT in PHA
15 12/17/20 1150 PHAGS EDIT
16 12/17/20 1150 PHAGS Edit Dr: Santilli,Anthony Edit Source: PHARM
17 12/17/20 1150 PHAGS FROM:
18 12/17/20 1150 PHAGS DISPENSE: 1
19 12/17/20 1150 PHAGS TO:
20 12/17/20 1150 PHAGS DISPENSE: 0
22 12/17/20 1150 PHAGS VERIFIED
23 12/17/20 1150 PHAGS Edit Dr: Santilli,Anthony Edit Source: PHARM
24 12/17/20 1150 PHAGS VIEWED LAB TEST RESULTS in PHA

12/17/20 1157 ELECTROCARDIOGRAM (EKG) Santilli,Anthony 1217-0010

12/17/20 1144 EKG SANT AN RES POE
P
***IF ORDERED STAT CALL #6319***
**ALL TESTS AFTER 1600 CALL RT #6304**
STATS/URGENTS call RT at x6304, if after hours below:
After 1600 Mon-Fri, and After 1530 Sat & Sun
Has RT/EKG been contacted? Y If yes, who did you speak with? DANIELLE
REASON FOR VISIT: L2/3 L3/4 L4/5 LATERAL INTERBODY FUSION ANTERIOR
CAMPUS? None


<Continued>
000391
000392
RUN USER: MRMRP


Date Time

5 12/17/20 1157 NKH Query: CAMPUS?
7 12/17/20 1157 NKH new response - None
8 12/17/20 1157 NKH Query: Has RT/EKG been contacted?
10 12/17/20 1157 NKH new response - Y
11 12/17/20 1157 NKH Query: If yes, who did you speak with?
13 12/17/20 1157 NKH new response - DANIELLE
14 12/17/20 1157 NKH order verified
15 12/17/20 1203 interface order associated with report 20201217-0007
16 12/17/20 1203 interface order's status changed from TRANS to COMP
18 12/17/20 1412 interface order's status changed from COMP to RESULT
20 12/18/20 0933 CARDRP Image Viewed in PCI
21 12/30/20 1152 MRSMM Image Viewed in PCI

12/17/20 1157 US KIDNEYS BILATERAL Santilli,Anthony 1217-0016

12/17/20 1157 KIDB SANT AN Urgent CMP POE
P
TEMPERATURE:
CAMPUS? MAIN
REASON FOR THIS EXAM: AKI

5 12/17/20 1157 NKH order service time edited: old value -

<Continued>
000392
000393
RUN USER: MRMRP


Date Time
6 12/17/20 1157 NKH new value - 1157

7 12/17/20 1157 NKH OECAMPUS edited: old value - None
8 12/17/20 1157 NKH new value - MAIN
9 12/17/20 1157 NKH billing data adjusted in campus edit
10 12/17/20 1157 NKH order verified

12/17/20 1151 URINALYSIS (Routine) Santilli,Anthony 1217-0512

12/17/20 1645 UA SANT AN CMP POE
P
CMT to PHLEB:
METHOD OF COLLECTION? C CATHETER
COMMENTS:
COLLECTED BY NURSE/MD? Y
HOLD FOR SPECIMEN COLLECTION N

6 12/17/20 1645 NSNID order collected/acknowledged by DINGMAN,NICOLE on 12/17/20 a
7 12/17/20 1645 NSNID order service time edited: old value - 1151

<Continued>
000393
000394
RUN USER: MRMRP


Date Time

Amended by : NSNID 12/17/20 1645
12/17/20 1320 MED Santilli,Anthony 1217-0357

12/17/20 1320 MED SANT AN CMP POE
P
RX: 05547429 Start: 12/17/20 1320
Stop:
Clindamycin Inj (Cleocin Inj) 600 MG/50 ML BAG
Dose: 600 MG
Route: IVPB Direction: Q8H Schedule: SCH
Clinical Indication: SEPSIS


10 12/22/20 1446 MDARA Order's Rx has been discontinued.


<Continued>
000394
000395
RUN USER: MRMRP


Date Time

L

12/17/20 1437 Remove Triple Lumen Catheter Airhienbuwa, Noghama 1217-0020

12/17/20 RTLC AIRH N CNC POE
Cancel Date/Time 12/17/20 1533 Cancelled by interface
P
1 12/17/20 1436 ONCE ONE TIME

6 12/17/20 1532 NSNID order cancel requested
8 12/17/20 1533 interface order's status changed from CANCEL to CANCEL by NUR
9 12/17/20 1533 MDNOA order viewed from Provider Order Management


<Continued>
000395
000396
RUN USER: MRMRP


Date Time
12/17/20 1437 Nurse-Physician Communication Airhienbuwa, Noghama 1217-0055

12/17/20 RNMDCOMM AIRH N CMP POE
P
NURSING TEXT: May use tripple lumen catheter for blood
draws
1 12/17/20 1437 PRN PRN

7 12/26/20 0105 interface order's status changed from COMP to COMP by NUR


L

12/17/20 1730 URINE - Microscopic only Santilli,Anthony 1217-0525

12/17/20 1645 UAM SANT AN CMP
L

<Continued>
000396
000397
RUN USER: MRMRP


Date Time

1 12/17/20 1731 LABMDC Order ENTER in LAB
2 12/17/20 1731 LABMDC Ordering Doctor: Santilli,Anthony
3 12/17/20 1731 LABMDC Order Source: LABORATORY
12/17/20 1816 Restraint Non- Violent Airhienbuwa, Noghama 1217-0092

12/17/20 RESTNV AIRH N CMP POE
P
Restraint Type: Limb (Upper Ext Only)
Elements of Behavior Removal of Medical Device
1 12/17/20 1816 Q8H EVERY 8 HOURS

10 12/22/20 1446 MDARA Intervention's Status changed to Comp.
13 01/07/21 1216 NSSAW order viewed from Order Management


<Continued>
000397
000398
RUN USER: MRMRP


Date Time
12/17/20 1838 CBC WITH AUTO DIFF Airhienbuwa, Noghama 1218-0091

12/18/20 0500 CBCD AIRH N CMP POE
P
CMT to PHLEB:
COMMENTS:


12/17/20 1935 COMP - COMP METABOLIC PANEL Airhienbuwa, Noghama 1218-0092

12/18/20 0500 COMP AIRH N CMP POE
P
CMT to PHLEB:
COMMENTS:

5 12/17/20 1935 NSNID Query: Collection - Timed or Routine?
6 12/17/20 1935 NSNID old response -

<Continued>
000398
000399
RUN USER: MRMRP


Date Time
7 12/17/20 1935 NSNID new response - R

8 12/17/20 1935 NSNID order verified/acknowledged

12/17/20 1838 ARTERIAL BLOOD GASES Airhienbuwa, Noghama 1218-0006

12/18/20 0500 ABG AIRH N CMP POE
P
COMMENTS:

5 12/17/20 1838 MDNOA This procedure has reflexed the following order(s)
6 12/17/20 1838 MDNOA PUNCTURE ARTERIAL (RT)


<Continued>
000399
000400
RUN USER: MRMRP


Date Time
12/17/20 1838 A1C - HEMOGLOBIN A1c Airhienbuwa, Noghama 1218-0093

12/18/20 0500 A1C AIRH N CMP POE
P
CMT to PHLEB:
This test should only be done once in 1 month. If you get a duplicate order prompt,
or you know the test has been performed within that time, please check with MD.
WHAT COUNTY DOES THE PATIENT LIVE IN? SAR SARATOGA
(County defaults from ADM)
COMMENTS:


12/17/20 1838 PUNCTURE ARTERIAL Airhienbuwa, Noghama 1218-0002

12/18/20 0500 AP AIRH N Stat CMP POE
P
COMMENTS:


<Continued>
000400

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000301

PATIENT STATUS: DIS IN ADM/SERVICE DATE: 12/16/20 MR#: M000481032

----ORDER---- PROCEDURE ORDERING PHYSICIAN ORDER #

12/16/20 0711 STOCK Pyxis,Overridedoc 1216-0151

Order's Audit Trail of Events

Acknowledged by: NSJMI 12/16/20 0944

12/16/20 0711 STOCK Pyxis,Overridedoc 1216-0152

Order's Audit Trail of Events

Acknowledged by: NSJMI 12/16/20 0944

PERMANENT MEDICAL RECORD COPY

PATIENT STATUS: DIS IN ADM/SERVICE DATE: 12/16/20 MR#: M000481032

----ORDER---- PROCEDURE ORDERING PHYSICIAN ORDER #

12/16/20 0711 STOCK Pyxis,Overridedoc 1216-0153

Order's Audit Trail of Events

Acknowledged by: NSJMI 12/16/20 0950

12/16/20 0711 STOCK Pyxis,Overridedoc 1216-0154

Order's Audit Trail of Events

Acknowledged by: NSJMI 12/16/20 0948

PERMANENT MEDICAL RECORD COPY

PATIENT STATUS: DIS IN ADM/SERVICE DATE: 12/16/20 MR#: M000481032

----ORDER---- PROCEDURE ORDERING PHYSICIAN ORDER #

12/16/20 0711 STOCK Pyxis,Overridedoc 1216-0155

Order's Audit Trail of Events

Acknowledged by: NSJMI 12/16/20 0949

12/16/20 0711 STOCK Pyxis,Overridedoc 1216-0156

Order's Audit Trail of Events

Acknowledged by: ACAC 12/16/20 0725

PERMANENT MEDICAL RECORD COPY

PATIENT STATUS: DIS IN ADM/SERVICE DATE: 12/16/20 MR#: M000481032

----ORDER---- PROCEDURE ORDERING PHYSICIAN ORDER #

12/16/20 0711 STOCK Pyxis,Overridedoc 1216-0157

Order's Audit Trail of Events

Acknowledged by: NSJMI 12/16/20 0954

12/16/20 0711 STOCK Pyxis,Overridedoc 1216-0158

Order's Audit Trail of Events

Acknowledged by: NSJMI 12/16/20 0945

PERMANENT MEDICAL RECORD COPY

PATIENT STATUS: DIS IN ADM/SERVICE DATE: 12/16/20 MR#: M000481032

----ORDER---- PROCEDURE ORDERING PHYSICIAN ORDER #

12/16/20 0715 SURGICAL LUMBAR SPINE Shen,Jian 1216-0014

Order's Audit Trail of Events

Electronically signed by Shen,Jian on 12/16/20 at 0845

12/16/20 0722 STOCK Pyxis,Overridedoc 1216-0165

Order's Audit Trail of Events

Acknowledged by: ACAC 12/16/20 0725

PERMANENT MEDICAL RECORD COPY

PATIENT STATUS: DIS IN ADM/SERVICE DATE: 12/16/20 MR#: M000481032

----ORDER---- PROCEDURE ORDERING PHYSICIAN ORDER #

12/16/20 0748 IV Pyxis,Overridedoc 1216-0173

Administration Criteria Queries

Order's Audit Trail of Events

Acknowledged by: ACHB 12/16/20 0751

12/16/20 0757 VISIT LEVEL IV (INTERMEDIATE) Shen,Jian 1216-0003

Order's Audit Trail of Events

PERMANENT MEDICAL RECORD COPY

PATIENT STATUS: DIS IN ADM/SERVICE DATE: 12/16/20 MR#: M000481032

----ORDER---- PROCEDURE ORDERING PHYSICIAN ORDER #

12/16/20 0757 IV SET-UP OUTPATIENT Shen,Jian 1216-0004

Order's Audit Trail of Events