Routine Postpartum Care in Ward Labour Progress Note CARDIOLOGY BARU KARDIOLOGI Medication Chart ICU Chart BHT Billing Form hourly Urine output > 0.5ml/kg/hr Clinical Frailty Scale Total GSC_2 Total GSC_1 Obstructed Airway_15489 Terminally Ill Very Severely Frail Vulnerable Severely Frail Moderately Frail Managing Well Very Fit Mildly Frail Not Intubated Not Intubated Method Uneven Oxygen Suction; Secretion Cough Reflex RBC Albumin 4.5% Albumin 50% Cool -3 - Deep Sedation 3 - Flexion in Response to Pain -4 - Unarousable 3 - Inappropriate Words 3 - Respond to Verbal 2 - Respond to Pain Hematuria Scale_15475 2 - Extension Response to Pain -3 - Moderate Sedation 5 - Orientated 4 - Spontaneous Eye Opening T1 - Generally Unresponsive 2 - Incomprehensive Sound 1 - Restless -2 - Light Sedation 4 - Withdraws in Pain Infusion 1 - No Response -1 - Drowsy -5 - Unarousable Sedation 0 - Alert and Calm 4 - Confused Conversation T3 - Questionable Ability to Talk 0 - No response -4 - Deep Sedation Diaper 5 - Purposely movement to pain 6 - Obey movement commands Subcutaneous T5 - Seems able to Talk 4 - Combative 3 - Very Agitated 2 - Agitated Cardiac Arrhythmia Obstructed Airway Preoperative Postoperative Planned Postoperative Unplanned Medicine Child Classification B Child Classification C Child Classification A Type 1 RVD CVA ESRF PTB IDH Subspecialities Subspecialities_15319 DOTAREM 0.5 MMOL/ML E-Z-Paque OMNIQUE 300mg VISIPAQUE 320MG ULTRAVIST 370mg E-Z- HD OMNIQUE 350mg GADOVIST 1.0 MMOL/ML GASTROGRAFFIN 76% ULTRAVIST 300mg R CONTRAINDICATION FOR PREGNANCY PATIENT KEEN FOR PREGNANCY DESPITE MEDICAL ADVICE Employed_15284 Argon Plasma Coagulation (ACP) Unemployed_7991 CHEST PAIN TESTING IMMUNOLOGY SLE PRESENTATION DIABETICS EDUCATIONS MEDICATION COUNSELLING DIABETIC EDUCATIONS 1st trimester T Sign 100 mls 50 mls 80 mls <100mls ≥500mls 120 mls 1000mls - 500mls MR IV Contrast Media Water Soluble Non Ionic IV Analysis_3265 Volume_6214 OCT ULTRAVIST 370 Corticosteroid Year of Onset_8070 Upper Segment GA Spiral Buttonhole Injury Minor Major Non-cardiac Stable Angina Cardiovascular Non-cardiovascular HEALTH FACILITY NAME Intubated Detail <8 weeks size Progesterone - releasing IUS Calendar Method Crowning Organ Involved Pulmonary and Extra Pulmonary Freetext_2533 Thoracic Malignancy Assessment Zonular Dehiscence Central Corneal Oedema Vitreous Loss Posterior Capsule Rupture Total No. of Samples_13807 Subterior Loss of Weight (LOW) Early onset (<= 72 hours of life) Later onset (>= 72 hours of life) Item Transmission Yes_6330 Date Change Date ART Started 3cm 2cm 1cm Antiretrovirals Muscle Strength Grade Accessory Movement Active Range Passive Range Medication Counseling Foot Care Education Dietary Counselling gram stain -ve/+ve PD Cell count. WBC + Percentage of Polymorph Torn GOV/PRIVATE HOSPITAL/CLINIC Retina Table Frequency Doubling Technique Humphrey Visual Field Octopus FBAO Removal Advanced Airway Difficult Rapid Soft non tender Singleton /cephalic Head per abdomen Uterus size Estimated fetal weight Distressed Comfortable Verbal Response Pain Response No Reaction Acute Bleed Type of Malignancy method_3662 Pelvic Pain Known Other abnormalities, specify beats/min Dysmorphic, specify Advanced Maternal Age Undescended, specify hours of life Umbilical Artery 2 Arteries Single Artery Speech Therapy Fine Tuning of Tinnitus Device No Patient at Scene Behaviour Experiment Dysfunctional Thought Record Transported by Other Responder Treated as Outpatient and Discharged Educational Counselling Group Therapy / Session Cognitive Reconstructuring Patient Refusal Dry Run Transported by Relative / Own Transport / Public Prank Call Advise Own Transport Diari Harian Sound Therapy + Hearing Aid Psyco Education Hot Cross Bun Directive Counselling Relaxation Excersise HRPB Healthcare Facility Transport to Hospital Termination of Resuscitation Termination of Resuscitation (TOR) Narrow complex PEA Wide Complex PEA Collection of Forensic Samples Shockable Non Shockable Shockable_13593 CPR Device OPA NPA C-spine protection MCI MERS 999 Interfacility Zeamays to Maize Select all Electroacoustic features Which ear is louder : out of Hypernasility 4 - Mild Insulin Regimen GLP1-RA_method GLP1-RA Abnormal Bleeding Potential Acuity Meter Colour Vision Testing Photostress Recovery Test Dark Adaptometry Glare Testing Electrodiagnostic Testing B-Scan Feeling of a foreign substance or "lump" in the throat Low Pitched High Pitched Non-Pulsatile Tinnitus Assessment Duration of Hearing Deprivation Duration of Hearing Impairment Living Related Living Unrelated Para_4254 No Contraindication Analysis_Swallowing Analysis_Clinical_Voice Analysis_Apraxia Analysis_Adult_Language Analysis_Paediatrics_Feeding Analysis_Aural_Rehab Analysis_AAC Analysis_Resonance Analysis_Fluency Analysis_Childhood_Apraxia Analysis_Speech_Sounds Analysis_Dysarthia Analysis_OME Analysis_Language_of_School Analysis_Paediatrics_Language Transfer-in : Never on treatment Transfer-in : Previous ART Transfer-in : On ART Nurse Maternity OT Postnatal Ward, specify Criminal Charges_1645 Date of CPC_1746 Date of Completion Multibacillary (MB) Paucibacillary (PB) ACR/EULAR_6703 Monofilamen If Foreign Specify Neville Barnes forceps Fire & Rescue APM Non Government Organisation MOH Self driven Air transport Bystander's private vehicle Water transport Travel not elsewhere classified Work Related Construction Area Industrial Area Sports / Recreational Area Jungle / Forest / Waterfall / Nature Walks River / Sea / Lake Highway / Freeway / Roads Residential Area Commercial / Mall School / Child Center Farm / Agricultural Area Work Office Area Center of Higher Education Country Side / Village Mechanical Related Shop / Service Centers Pyrotechnics / Fire works Military Improvised Explosive Devise IED) Industrial Tools / machine Agriculture tools /machine Vehicle machinary Gun Shot Wound (GSW) Knife or equivalent (ie. parang / machete) Choking / Hanging Blast Chemicals Combined blunt and penetrating Penetrating MCI / MCE Bites / Stings Vehicular Crash Environmental Industrial Injuries Pedestrian Injury CBRN Exposure Respiratory symptoms ENT symptoms Altered mental state Abdominal Symptoms Generalized Weakness Visual disturbances GI Symptoms / Skin rashes *Risk indicators that are marked with an asterisk are of greater concern for delayed onset hearing loss - refer even if pass screening. Neonatal Encephalopathy Parental concern * Mechanical ventilation > 5 days Hyperbilirubinemia (> 340 micromol/L or required exchange transfusion) * In utero infections (TORCHES) * NICU stay > 48 hours Family history * Bacterial Meningitis * Ototoxic medication Associated Syndrome * Very Low Birth Weight (<1500gm) Cardio Echo 4 Cardio Echo 3 Cardio Echo 2 Cardio Echo 1 Encephalocoele Sexual Transmited Disease Fraud Dealing Crime involving violence Property Crime How many times?_13441 Benzodiazapine & other sedative Naltraxone Suboxone Methadone Type of substance_13436 Substance User Disorder L Slit Lamp 6 cm 5 cm 4 cm From Last office completed at Asystole ROSC Time of First Defibrillation_13416 Cardioversion Left Bundle Branch Block ST depression >= 0.5 mm ST elevation >= 2.5 mm ST elevation >= 2 mm ST elevation >= 1.5 mm ST elevation >= 1 mm ST elevation >= 0.5 mm Time of ECG_13413 Table Pack Years (24-hour time format) Palliative Intent As Above Normal_ Investigation of Maternal Death Depot and Dosage Number of years smoked_13307 ETD TRIAGE CATEGORY ETD ASSIGN ZONE Hydrocephalus: Emotional disturbance of parents Exomphalus: Potential infection Hydrocephalus: Potential of increasing intracranial pressure Hydrocephalus: Potential pressure injury over the head Hydrocephalus: Altered comfort Hypothermia Polypoid >=10 Surat Perakuan Masalah Pendengaran HBV positive machine HCV positive machine Unknown machine Negative machine HIV positive machine Gentle HD SLED-F Sequential Ultrafiltration Plasma Exchange DFPP SLED Immunoadsorption PD Fluid Primasol® Duosol® mls/hour HCV positive HBV positive mls/kg/hour CVVHD CVVHDF CVVH SCUF Citrate Heparine ESA IV meds Blood/Blood products degC Normal temperature No of use_13327 unit/hour Unit Reuse Single use High Flux Intermediate Flux Low Flux m2 Haemodiafiltration Conventional HD unit/L Cycles Stab Tenckhoff Do not proceed for further vaginal examination Bismuth Classification_ Strasburg Classification Number of cigarettes smoked per day_13306 Ex-Smoker/Vape (Stopped More Than 6 Months) Morse Fall Scale Community Psychiatry Referral Letter General Analgesia Medication From Home_4629 High Aspiration Baseline Result Type of Radiation_13265 Specify Place_12938 Effect_13244 Duration_13244 g/d kcal/day OM Drug Induced Occuptional Related - For Occuptional Related Autoimmune Bacteria Multidisciplinary team (MDT) Dietetic Ward Round Kumpulan/ Kelas Pendidikan Pemakanan Individu Food Intake PSP Chart Modified MDT_7341 WHO regime_8061 SHIM/IIEF-5 Chart I-PSS Chart >=4 mg Weekly Dose(mg)_3186 Current Dose_3186 Radiology form available Change in patient health status compared to pre procedural sedation medical assessment; specialist notified No change in patient health status compared to pre procedural sedation medical assessment Specify_16396 Pre-Procedural Sedation Assessment by Doctor Pre-Sedation Assessment by Doctor Others, specify_7454 Year diagnosed_6325 LITRE CARDIOVASCULAR TECHNICIAN REFERRAL SOURCE Comments_751 Biologics Duration and Location_1329 Operative Procedure Homemaker/Housewife Service (Waiter, Maid, Barber, Security, Guard) Clerical/Sales Military/Police/Fireman Agricultural/Fishery/Forestry Professional/Technical/Managerial PHARMACOLOGICAL TREATMENT AT NOTIFICATION comments_183 Voice is persistently abnormal. Patient may not be able to use voice to communicate. Voice usage in these activities is usually limited to low vocal demand activities, but consistently limited in high vocal demand activities. Patient able to participate in social activities requiring voice. Voice occasionally functional for communication but is consistently distracting to the listener. There is some situational variation. Patient able to participate in social activities requiring voice. Voice occasionally sounds normal and is usually distracting to the listener. Voice usage in these activities is rarely limited in low vocal demand activities, but occasionally limited in activities with high vocal demand. Patient able to participate in social activities requiring low or high vocal demands which is not limited by his/her voice. Voice consistently sounds normal and does not call attention to itself. Testicular maldescent Method Prolactin_13125 Testoserone_13124 FSH_13123 Detrusor Under Activity Detrusor Sphincter Dyssynergia (DSD) Outlet Obstruction Voiding Difficulty Increased Bladder Sensation Mixed DO and USI Detrusor Overactivity (DO) Urodynamically Stress Incontinence (USI) Name of Staff Who Ended Observation DESIGNATIONS Date of Last Pap Smear_13115 D&C Position of Vertex 2 Soft Response Team Vital Sign Samples for Baseline UPT and STI Reference Samples for DNA analyses Sampling for alcohol and toxicology analyses Collection of samples from the internal anus Collection of samples from the external anus Collection of samples from the vagina Swabs from vulva Swabs from the penis Collect 3 swabs from oral cavity Collection of foreign materials and / or swabs from the body ;_18683 NATIONS Bowel Sound Previous Complication Word Count (every 3 months) 3months_19051 Reason__4823 Own Account Worker Employee Disabled/Permanently Sick NORL Registry Follow Up Receptive Language Skills Word Count (every 3 months) 3months_13048 Borang Harta Benda Pesakit PROLACTIN_13008 TESTOSERONE_13007 FSH_13006 Apnea apart from feeding Apnea with feeding Symbol SFA Result Comments_12997 Comments_12996 Comments_12995 Distribution Of Sensory Deficits Distal (Glove Stocking): Dermatome: Sensory Level: Cranial Nerves (Other Signs) Status Admission required (term infant <44 weeks post conceptional age, ex- premature infant < 50 weeks post conceptional age; or children on apnea therapy, and or on home oxygen regardless of age) Calendar Untreated Partially Treated Dilution STATES Varicocele Method DOCTORS Specify duration Cleft soft palate Bilateral cleft lip & palate Cleft lip alveolus only Unilateral left cleft lip & palate Unilateral right cleft lip & palate Estimated Delivery Date (If <37 Weeks) Decreased movement Asymmetrical Movement cm below left costal margin cm below right costal margin at mid clavicular line b/min Word Count (every 6 months) 36months Word Count (every 6 months) 30months Management Word Count (every 3 months) 12months Word Count (every 3 months) 9months Word Count (every 3 months) 6 months Word Count (every 3 months) 3months Elective Routine Pharmo-invasive PCI RELIGION Date of CI Approval CI Candidacy Checklist Oxygen (L/min) Location_719 UNIT HOSPITAL Location_3453 Basilic Sterilization Injection Safe Period ml/15mins Trigger for Refraction Findings within 6 to 12 weeks Post Op Not Applicable / Not Available Aided and + 3.00 °C °C_12834 ≥4 Delivery Details Method UNHS Method Cord Blood Gas Method Myocardial Perfusion Imaging Exercise Stress Test Stress Test Lung function test 24 hours AMBP Chromium EDTA/DMSA DTPA Provide gentle forward pressure on lower jaw if small chin or wide jaw excursion to ensure tongue stripping. Burp infant based on behavioral cues, not on time or volume completed. Poide gentle unilateral support to improve intraoral pressure. Use teat other than standard for specific purposes, i.e. nipple shield, slow flow, Haberman. Tip bottle downwards/break sela at breast to remove or decrease the flow of liquid to facilitate SSB pattern. History of Crime History of impulsivity and aggressive behaviour Ultrasound Compression Estimated years_2263 Voice Problem Caused By Other Neurological Disorder (Myasthenia Gravis,Amyotropic Lateral Scelorosis Year of Diagnosis_8069 Frequency_2535 Single word - alphabet based No radiotherapy indicated. The following treatment is advised. Patient needs further assessment at the Institut. Kindly advise patient to be examined at the Institute (Radiotherapy Clinic) on Patient needs a course of chemotherapy followed by radical radiotherapy. The following is advise Year_6324 SLT Swallowing Note SLT Adult Aural Rehabilitation Note SLT Clinical Voice Note SLT BDAE (Adapted) Note SLT Adult Language Disorder Note SLT Case History Note Interjection / Fillers SLT Kinesiology And Alternative Approach Note SLT Neuromuscular Electrical Stimulation Procedure Note SLT Videofluoroscopy Swallowing Study (VFSS) Note SLT Fiberoptic Endoscopic Evaluation Of Swallowing (FEES) Note SLT Speech Auditory Assessment Note SLT Pragmatic Language Note SLT Language Of School Aged Children(7-18 years old) Note SLT Pediatrics Language Development Note SLT Pediatrics Feeding Note SLT Paediatric Aural Rehabilitation Note SLT Speech Sounds Note SLT Alternative & Augmentative Communication (AAC) Note SLT Alternative & Augmentative SLT Resonance Note SLT Fluency Note SLT Childhood Apraxia of Speech Note SLT Dysarthria Note SLT Speech Apraxia Note SLT Oral Motor Note SLT Cognitive Communication Note SLT Pediatrics Communication Screening Note SLT Case History Feeding Note Problem List More than 2 days First 2 days +++ ++ + Vault /Vagina Pattern Standard Deviation (PSD) Mean Deviation (MD) Visual Field Index (VFI) Glaucoma Hemifield Test (GHT) Reliability No of cigarrete smoked daily No of cigarretes smoked daily_7389 RACE Pad Chart Contraction Chart Hourly for 4 hours then 4 hourly Antibiotic IV Drip Nil By Mouth Till Review Observation Hourly for 4 hours then 4 hourly Rest in Bed Mortuary Nursery Admitted To NICU RM3000-RM4499 For HCT:
Male age ≤ 60: HCT > 46
Male age > 60: HCT > 42
Female all ages: HCT > 40 Findings_2451 PRIVATE HOSPITAL/CLINIC GOVERNMENT HOSPITAL/CLINIC History Of Presenting Complaints Chronic Obstructive Pulmonary Disease(COAD) Weight Exam Surgical Procedure No anaesthesia Non Surgical Procedure LOCATIONS Non Small Cell Lung Cancer Out of Lab Date_1724 600 mg Others,Specify_12691 Percutaneuos entry site Minor (Non CNS bleeding with 3-5g/dL Hb drop) /_6890 Name Of centre_12711 6-24 hrs >= 1200 mg Counseling / Consultation Only Days_1790 Ticlopidine Date of Discharge_1750 micromol/L First load dose In Lab Regimes & Dates_7687 /_10114 300 mg >24 hrs - 72 hrs <6 hrs 75 mg Minimal (Non CNS bleeding, non overt bleeding , ≤ 3g/dL Hb drop) Major (Any intracranial bleed or other bleeding ≥ 5d/dl Hb drop Dissection Retroperitoneal Statin Clopidrogel Bleeding Site : >72 hrs Date Start_6808 Neurological ACE inhibitor Beta blocker Echo No Caesarean Section Total Score_5797 Specify_7337 Mod No Age Related Macular Degeneration(ARMD) Assisted Vaginal Delivery (VD) Tape No Specify_6890 Specify_7895 Retinopathy of Prematurity(ROP) Non Small Cell Lung Cancer_7912 Stages Curb 65 Score_7540 Clinic staff, how to contact clinic, clinic working hours EDUCATION LEVEL CARDIOLOGIST MICROSCOPIST BNO Malaena Stool Watery Stool Hard Stool Loose Stool Normal Stool NPU Tea-coloured Urine Concentrated Urine Cloudy Urine Blood Stained Urine Clear Urine Serous / Yellowish Vacuum Drain Chest Drain Abdominal Drain CSF Undigested Food Coffee-Ground Greenish Milkcurd Yellowish Cracked Nipple Engorgement Breast Fullness Sucking Cleave to the Nipple Incorrect Positioning Poor Sucking Well Tolerated Added Polycose Added MCT Added HMF EBM Special Formula, specify Preterm Formula Term Formula Gastrotomy Feeding Continuous Feeding Syringe Feeding Ryles Tube Cup Feeding Fresh Frozen Plasma Whole blood 2 gm Potassium Chloride 1 1/2 gm Potassium Chloride 1 gm Potassium Chloride 1/2 gm Potassium Chloride Additive Dextrose 10% Albumin Gelafundin Hartman Normal Saline with Dextrose 5% 1 / 2 Normal Saline with Dextrose 10% 1 / 5 Normal Saline with Dextrose 10% 1 / 2 Normal Saline with Dextrose 5% 1 / 5 Normal Saline with Dextrose 5% Normal Saline 0.9% IVD 1 IVD 2 IVD 3 Intercostal Chest Drain Intercostal Drainage of Chest Pacemaker - Temporary - Foreigner Mantoux Test - Foreigner Bone Marrow Aspiration and Trephine Mantoux Test Pleurocentesis Bone Marrow Aspiration (BMA) Peritoneal Tap Lumbar Puncture Temporary Pacemaker Botulinum Toxin Therapy Central Method Cranial Nerves 1 Lain-lain, terangkan Terapi Carakerja Fisioterapi Penukaran Catether Penukaran Ryle's Tube Cucian Luka (dressing) Ubatan / Suntikan Nursing Care Hearing Assessment Assessment Otology Assessment Patient's Performance Base of Tongue Method Retropalatal area Upper Airway Method Phonemes Doppler Sleep Apnea Questionnaire Survey Method Tonsil Grading Tonsil Red Flags For Paediatrics Communication Skill Oral Cavity & Oropharynx Visual Assessment No of symbols sequence Baby Record Complication Of Pregnancy Delivery Vocal Cords / Folds Posterior Comissure Arytenoids Ventricular Fold (False Vocal Cords) Head And Neck Interarytenoid Area Anterior Comissure Aryepiglottic Fold ; Eye Examination Diet Consistency Degree Of Hearing Impairment Hearing Assessment RADIOLOGIST Profound impairment - Patient presents no attempt to clear aspirate Severe impairment - Patient presents no cough response to aspiration. There may be some change in respiratory pattern to acknowledge aspiration Moderate impairment - Patient presents cough response upon aspiration but it is not consistently effective to clear aspiration Mild impairment - Patient presents prompt cough response, that clears penetration/aspiration No significant impairment - Patient presents strong, productive volitional cough Fatigue After Time Indicator Age Range Gestation At Delivery Otology Examination Data Analysis Voice Enviromental sound Noise Maker ha/Ci Function Assessment Measures If no, please specify why_2979 If yes, please specify why_2990 Intelligibility Articulation Oromotor Movement Speech Behaviour Stimulus 2 1 hour post - swallow Immediate post - swallow 30 minutes post - swallow 15 minutes post - swallow Dentition Stimulus Oral Apraxia (B) Limb Apraxia (A) Markah Pencapaian 2 Markah Pencapaian 3-Syllable Bisyllabic Monosyllabic Pencapaian Level of support Quality problem Translocation Pitch problem Visual Processing 1 Method Articulation errors No of symbol sequence Deaf speech Loudness problem Passage Reading Method Sentence Reading Method Word Reading Method Calculation Method Organizational Thinking Method Long-term Memory Method Inferencing Method Idioms Method Logic Method Problem Solving Method Auditory Processing & Comprehension Method Short-term Memory Method Working Memory Method Tracheostomy mask Orientation & Awareness Method Non-ambulant Protrusion Problem/Adverse Incident Report Extubated Amount Effectiveness Kualitatif Method Indication For Study Surgical Outcome Pemarkahan Method Poor Control Mengenal Perkataan Method Haiwan Perbuatan Objek Kebolehan Mengeja Method Penulisan Mekanikal Pemahaman Pembacaan Method Membaca Ayat dan Memahami Ayat Yang Dibaca Method 2 Membaca Ayat dan Memahami Ayat Yang Dibaca Method 1 Membaca perkataan asas Memadankan Nombor Method 2 Memadankan Nombor Method 1 Memadankan Huruf Dan Skrip Method Penamaan Konfrontasi Method Penamaan Berespon Method Pengulangan Method Susunan Automatik Method For Suspected Ovarian Cancer Patients Description_1847 Memahami Petikan 2 Method Biopsy (For cervical cancer / vaginal / vulvar cancer) Menjawab Soalan Ya / Tidak Method Memahami Petikan 1 Method Pipelle / Hysteroscopy DD&C (For Uterine Cancer) Intra Op Details Pap Smear