MSH|^~\&|ADM|ARH|||201910101224||ADT^A08|4074101|D|2.2|||AL|NE
EVN|A08|201910101224||||
PID|1|FHATVIG0007386|AB00007815|AB7768|PCSTEST^EVELYN||19230116|F|||PORCUPEEK DR^^NEW WESTMINSTER^BC^V5T 0T6|||||||AB000910/18|
PV1|1|I|AB-3CHEAMA^AB3C-C3029^2|UE|||OEDOCN^Oedoc^Nancytrain^^^^MD^^^^^^XX|||ACE||||||||IN|||||||||||||||||||||ARH|||||201901161027|
PV2||W^Ward|CHF
OBX|1|ST|1010.1^WEIGHT^CPT4||55.000||||||F
OBX|2|ST|1010.3^HEIGHT^CPT4||163.0||||||F
OBX|3|CE|ADM CCI1^CCI#1^ADM||AVB^AVB-Agressive/Violent Beh||||||F
OBX|4|CE|ADM CCI2^CCI#2^ADM||ARO^ARO-Antibiotic Resist Org||||||F
OBX|5|TX|ADM CCI3^CCI#3^ADM||||||||F
OBX|6|TX|ADM CCI4^ARO - Antibiotic Resistant Organisms^ADM||||||||F
OBX|7|TX|ADM CCI5^DNA - Do Not Acknowledge^ADM||||||||F
OBX|8|TX|ADM CCI6^AVB - Aggressive/Violent Behaviour^ADM||||||||F
OBX|9|TX|ADM CCI7^MDR - Multiple Drug Resistant Organisms^ADM||||||||F
OBX|10|TX|ADM CCI7a^          **or**^ADM||||||||F
OBX|11|TX|ADM CCICO1^Comments:^ADM||||||||F
OBX|12|TX|ADM CCICO2^:^ADM||||||||F
OBX|13|TX|ADM CCICO3^:^ADM||||||||F
OBX|14|TX|ADM CURRES^Residing at current add. since (DD/MM/YY)^ADM||19940527||||||F
OBX|15|CE|ADM IDSOUR^SOURCE OF ID^ADM||BCSWP^BC Services With Photo||||||F
OBX|16|CE|ADM MDRO2^Canada in the last 12 months?^ADM||N^NO||||||F
OBX|17|CE|ADM MDRO4^or Bangladesh in the last 12 months?^ADM||N^NO||||||F
OBX|18|CE|ADM MRSA2^correctional/shelter in the last 6 months?^ADM||N^NO||||||F
OBX|19|CE|Ac00000500^Clinical update method^ADM||3^In person||||||F
OBX|20|TX|AcEQUPCC02^Equipment recommended for discharge comments^ADM||equipment ordered||||||F
OBX|21|CE|AcFTTYPE00^Footwear type^ADM||3^Shoes||||||F
OBX|22|CE|AcOT000100^Washing location^ADM||1^In bed||||||F
OBX|23|CE|AcOT000200^Washing adaptive aids^ADM||2^Tub transfer bench||||||F
OBX|24|CE|AcOT000400^Washing level of function^ADM||3^Supervision||||||F
OBX|25|CE|AcOT000500^Washing assistance required^ADM||1^1 person||||||F
OBX|26|TX|AcOT000600^Washing comment^ADM||Washing comment||||||F
OBX|27|CE|AcOT000800^Grooming location^ADM||1^In bed||||||F
OBX|28|CE|AcOT000900^Grooming level of function^ADM||5^Moderate assist||||||F
OBX|29|CE|AcOT001000^Grooming assistance required^ADM||1^1 person||||||F
OBX|30|TX|AcOT001100^Grooming comment^ADM||Grooming comment||||||F
OBX|31|CE|AcOT001300^Upper extremity dressing level of function^ADM||3^Supervision||||||F
OBX|32|CE|AcOT001400^Upper extremity dressing assistance required^ADM||1^1 person||||||F
OBX|33|TX|AcOT001500^Upper extremity dressing comment^ADM||Stuff||||||F
OBX|34|CE|AcOT001600^Lower extremity dressing level of function^ADM||7^Total assist||||||F
OBX|35|CE|AcOT001700^Lower extremity dressing adaptive aids^ADM||2^Long handled reacher||||||F
OBX|36|CE|AcOT001900^Lower extremity dressing assistance required^ADM||1^1 person||||||F
OBX|37|CE|AcOT003000^Toileting level of function^ADM||6^Maximal assist||||||F
OBX|38|CE|AcOT003100^Toileting assistance required^ADM||2^2 person||||||F
OBX|39|TX|AcOT003200^Toileting comment^ADM||Sfuff||||||F
OBX|40|TX|AcOT003400^ADL general observations^ADM||General obs||||||F
OBX|41|CE|AcOTSPRT01^Recommended supports for discharge^ADM||1^Washing~2^Dressing||||||F
OBX|42|TX|Ad00002000^Two patient identifiers checked^ADM||Y||||||F
OBX|43|TX|AdADMDAT01^Admission date^ADM||20191010||||||F
OBX|44|CE|AdADMFRO01^Admitted from^ADM||1^Emergency||||||F
OBX|45|TX|AdADMOUT01^Any healthcare encounter outside Canada in last 12 months^ADM||Y||||||F
OBX|46|TX|AdADMSIX00^Admitted to care area in the last 6 months^ADM||N||||||F
OBX|47|TX|AdADMTIM00^Admission time^ADM||1222||||||F
OBX|48|CE|AdAIEQDC00^Equipment recommended for discharge^ADM||17^Grab bars: shower||||||F
OBX|49|CE|AdARRMOD00^Mode of arrival^ADM||1^Stretcher||||||F
OBX|50|CE|AdASEVRD00^As evidenced by^ADM||3^Laboratory value(s)||||||F
OBX|51|TX|AdDCBAHH00^Discharge barriers identified by home health/community nurse^ADM||Further ax by home support case manager required||||||F
OBX|52|TX|AdDCBARD00^Discharge barriers identified by dietitian^ADM||pt currently too weak and lethargic.||||||F
OBX|53|TX|AdDCBNUR00^Discharge barriers identified by nursing^ADM||More formalized supports in community needed||||||F
OBX|54|TX|AdDCCOMP01^Discharge plan complete^ADM||N||||||F
OBX|55|CE|AdDISCHA30^Discharge destination^ADM||1^Home||||||F
OBX|56|TX|AdDRVPLA00^Driving restrictions in place^ADM||Y||||||F
OBX|57|TX|AdDRVRES00^Aware of driving restrictions^ADM||Y||||||F
OBX|58|TX|AdESTDTD00^Estimated date of discharge^ADM||20191002||||||F
OBX|59|CE|AdESTREA03^Reason EDD changed^ADM||1^Acuity||||||F
OBX|60|TX|AdFACINA01^Name of facility^ADM||Support Place||||||F
OBX|61|TX|AdFUAPCO04^Services and appointments arranged comments^ADM||referrals pending||||||F
OBX|62|TX|AdGOALCP00^Goal^ADM||decrease / eliminate ETOH intake||||||F
OBX|63|TX|AdGOALDT00^Goal target date^ADM||20190919||||||F
OBX|64|CE|AdGOALST00^Goal status^ADM||1^In progress||||||F
OBX|65|TX|AdGOCPCL00^Goal^ADM||manage behaviours in hosptial environment||||||F
OBX|66|TX|AdGOCPHH00^Goal^ADM||discharge home with home supports in place||||||F
OBX|67|TX|AdGOCPPT00^Goal^ADM||increase ROM||||||F
OBX|68|TX|AdGOCPRD00^Goal^ADM||Vitamin levels corrected to normal range||||||F
OBX|69|TX|AdGOCPRT00^Goal^ADM||test||||||F
OBX|70|CE|AdGOSTCL00^Goal status^ADM||1^In progress||||||F
OBX|71|CE|AdGOSTHH00^Goal status^ADM||1^In progress||||||F
OBX|72|CE|AdGOSTPT00^Goal status^ADM||1^In progress||||||F
OBX|73|CE|AdGOSTRD00^Goal status^ADM||3^Met||||||F
OBX|74|TX|AdGOTDCL00^Goal target date^ADM||20190930||||||F
OBX|75|TX|AdGOTDHH00^Goal target date^ADM||20190924||||||F
OBX|76|TX|AdGOTDPT00^Goal target date^ADM||20190926||||||F
OBX|77|TX|AdGOTDRD00^Goal target date^ADM||20190918||||||F
OBX|78|TX|AdHCPNPC01^Notification method comment^ADM||spoke to Terry during PT rounds||||||F
OBX|79|TX|AdHXCOND00^History of presenting condition^ADM||hx of presenting condition||||||F
OBX|80|CE|AdINPTRF00^Inpatient referral(s) sent to^ADM||10^Dietitian||||||F
OBX|81|CE|AdINPTRF03^Inpatient referral(s) sent to^ADM||8^SLP||||||F
OBX|82|CE|AdINSM0000^Information source^ADM||1^Patient~3^Family||||||F
OBX|83|TX|AdINVACL00^1. Intervention to address problem^ADM||Remove external stimuli||||||F
OBX|84|TX|AdINVACL01^2. Intervention to address problem^ADM||Communicate strategies with HCPs||||||F
OBX|85|TX|AdINVAHH00^1. Intervention to address problem^ADM||referrals to home supports||||||F
OBX|86|TX|AdINVANR00^1. Intervention to address problem^ADM||referral to ETOH program||||||F
OBX|87|TX|AdINVANR01^2. Intervention to address problem^ADM||referral to social work||||||F
OBX|88|TX|AdINVANR02^3. Intervention to address problem^ADM||CIWA protocol initiated||||||F
OBX|89|TX|AdINVANR03^4. Intervention to address problem^ADM||referral to pharmacist for medication evaluation||||||F
OBX|90|TX|AdINVAPT00^1. Intervention to address problem^ADM||active and passive exercises||||||F
OBX|91|CE|AdINVARD00^Interventions to address problem^ADM||4^Vitamin/Mineral suppl||||||F
OBX|92|TX|AdINVARD10^Interventions to address problem other^ADM||IV vitamins ordered||||||F
OBX|93|CE|AdLITUBE01^Lines/Tubes in situ^ADM||4^PIV~8^Urinary catheter||||||F
OBX|94|CE|AdMRPNMD00^MRP or physician notification method^ADM||1^In person||||||F
OBX|95|TX|AdNAMEBN00^Name band on^ADM||Y||||||F
OBX|96|TX|AdOTCPDE00^Problem details^ADM||difficulty feeding and bathing self||||||F
OBX|97|TX|AdOTCPED00^Equipment in place for discharge^ADM||Y||||||F
OBX|98|TX|AdOTCPEQ00^Sources of equipment recommended for discharge^ADM||patient renting||||||F
OBX|99|TX|AdOTCPGD00^Goal target date^ADM||20190930||||||F
OBX|100|TX|AdOTCPGO00^Goal^ADM||able to complete ADLs independently||||||F
OBX|101|CE|AdOTCPGS00^Goal status^ADM||1^In progress||||||F
OBX|102|CE|AdOTCPID01^Problem identified^ADM||1^Ability to complete ADLs||||||F
OBX|103|TX|AdOTCPIN00^1. Intervention to address problem^ADM||work with pt on feeding self strategies||||||F
OBX|104|TX|AdOTCPIN01^2. Intervention to address problem^ADM||work with pt on bathing self strategies||||||F
OBX|105|TX|AdOTPSNT00^Outpatient/Community referral(s) sent to other^ADM||Loss Support Group||||||F
OBX|106|TX|AdOTRERF00^Reason for referral^ADM||coccyx bed sore||||||F
OBX|107|CE|AdOUTM0000^Outpatient/Community referral(s) sent to^ADM||24^Social Worker||||||F
OBX|108|CE|AdOUTS0100^Outpatient/Community referral(s) sent to^ADM||7^Dietitian||||||F
OBX|109|TX|AdPLACEC00^Lines/Tubes placement confirmed with physician^ADM||Y||||||F
OBX|110|CE|AdPROBCL00^Problem identified^ADM||5^Behaviour||||||F
OBX|111|TX|AdPROBDC00^Problem is a barrier to discharge^ADM||Y||||||F
OBX|112|TX|AdPROBDS00^Problem detail^ADM||chronic excessive ETOH intake||||||F
OBX|113|CE|AdPROBHH01^Problem identified^ADM||2^High care needs||||||F
OBX|114|CE|AdPROBID20^Problem identified^ADM||1^Alcohol/Substance use||||||F
OBX|115|CE|AdPROBPT00^Problem identified^ADM||6^Decreased ROM||||||F
OBX|116|CE|AdPROBRD00^Problem identified^ADM||14^Inadequate energy intake||||||F
OBX|117|CE|AdPROBRT01^Problem identified^ADM||1^Airway clearance||||||F
OBX|118|TX|AdPRODCL01^Problem detail^ADM||ADHD||||||F
OBX|119|TX|AdPRODHH00^Problem detail^ADM||requires support from multiple services||||||F
OBX|120|TX|AdPRODPT00^Problem detail^ADM||restricted motion in left shoulder||||||F
OBX|121|TX|AdPTA06000^Communication impairment prior to admission^ADM||difficulty wording finding x last two months||||||F
OBX|122|CE|AdPTA06700^Diet tolerance prior to admission^ADM||1^No concerns||||||F
OBX|123|TX|AdPTFAMY01^Patient/Family goals for discharge^ADM||return home||||||F
OBX|124|TX|AdRECPDE01^Problem details^ADM||Ineffective coping with loss||||||F
OBX|125|TX|AdRECPGD00^Goal target date^ADM||20190927||||||F
OBX|126|TX|AdRECPGO00^Goal^ADM||Increase effectiveness of coping skills||||||F
OBX|127|CE|AdRECPGS00^Goal status^ADM||1^In progress||||||F
OBX|128|CE|AdRECPID00^Problem identified^ADM||12^Experiencing grief/loss||||||F
OBX|129|TX|AdRECPIN00^1. Intervention to address problem^ADM||Educate on healthy coping skills||||||F
OBX|130|TX|AdRECPIN01^2. Intervention to address problem^ADM||Refer to loss support group in community||||||F
OBX|131|TX|AdRECPIN02^3. Intervention to address problem^ADM||Refer to SW||||||F
OBX|132|CE|AdREPREF00^Report received^ADM||3^By fax||||||F
OBX|133|CE|AdRETORD00^Related to^ADM||12^Organ dysfunction||||||F
OBX|134|TX|AdRETORD10^Related to other^ADM||cancer diagnosis||||||F
OBX|135|TX|AdSLCPIN00^1. Intervention to address problem^ADM||referral to RD||||||F
OBX|136|TX|AdSLCPIN01^2. Intervention to address problem^ADM||education on swallowing assistive techniques||||||F
OBX|137|TX|AdSLCPIN02^3. Intervention to address problem^ADM||recommend feeding assistance with meals||||||F
OBX|138|TX|AdSLPCPD01^Problem detail^ADM||decreased appetite due to difficulties swallowing||||||F
OBX|139|TX|AdSLPCPG00^Goal^ADM||increase intake||||||F
OBX|140|CE|AdSLPCPI01^Problem identified^ADM||11^Reduced oral intake||||||F
OBX|141|CE|AdSLPCPS00^Goal status^ADM||1^In progress||||||F
OBX|142|TX|AdSLPCPT00^Goal target date^ADM||20190930||||||F
OBX|143|CE|AdSLPREF00^SLP referral source^ADM||1^Physician||||||F
OBX|144|TX|AdSTRECO01^Reason EDD changed other^ADM||awaiting home supports||||||F
OBX|145|TX|AdSWCPDE00^Problem detail^ADM||ETOH abuse||||||F
OBX|146|TX|AdSWCPGD00^Goal target date^ADM||20190926||||||F
OBX|147|TX|AdSWCPGO00^Goal^ADM||eliminate ETOH use||||||F
OBX|148|CE|AdSWCPGS00^Goal status^ADM||1^In progress||||||F
OBX|149|CE|AdSWCPID01^Problem identified^ADM||17^Alcohol/Substance use||||||F
OBX|150|TX|AdSWCPIN00^1. Intervention to address problem^ADM||enrolled in program||||||F
OBX|151|CE|CaCYANOS00^Cyanosis^ADM||1^None||||||F
OBX|152|CE|CaPARAMR00^Cardiovascular defined parameters^ADM||1^Within defined parameters||||||F
OBX|153|TX|CaPLDATE00^PIV Insertion date^ADM||20190924||||||F
OBX|154|TX|CmPREVCM01^Previous communication assessment^ADM||none||||||F
OBX|155|TX|CmREPDEF00^Patient or family report of communication difficulty^ADM||pt report on problem||||||F
OBX|156|TX|EnDDRRSP00^Response from designated provider^ADM||Terry to f/u with PCC and doc||||||F
OBX|157|TX|EnITEMCO00^Item(s) of concern^ADM||patient refusing some sessions||||||F
OBX|158|TX|EnITEMRP01^Item(s) of concern reported to (name and designation)^ADM||Terry, PT||||||F
OBX|159|CE|GiPARAMR00^Gastrointestinal defined parameters^ADM||1^Within defined parameters||||||F
OBX|160|TX|GuBDPAT001^Bladder pattern^ADM||||||||F
OBX|161|TX|GuBDVM0002^Voiding method^ADM||||||||F
OBX|162|TX|GuOTDAYC00^Day continence^ADM||Y||||||F
OBX|163|TX|GuOTNGTC00^Night continence^ADM||Y||||||F
OBX|164|CE|GuPARAMR00^Genitourinary defined parameters^ADM||1^Within defined parameters||||||F
OBX|165|TX|GuURCLR000^Urine clarity^ADM||||||||F
OBX|166|TX|GuURCOL002^Urine colour^ADM||||||||F
OBX|167|CE|HeAXPAR001^Assessment participation^ADM||1^No concerns||||||F
OBX|168|TX|HeAXPARC01^Assessment participation comments^ADM||ax part comments||||||F
OBX|169|CE|HeLI000100^Lips colour^ADM||1^Pink||||||F
OBX|170|CE|HeLI000200^Lips appearance^ADM||1^Smooth||||||F
OBX|171|CE|HeOC000100^Oral cavity mucosa colour^ADM||1^Pink||||||F
OBX|172|CE|HeOC000301^Oral cavity mucosa appearance^ADM||1^Moist||||||F
OBX|173|CE|HeOC008000^Oral cavity gums appearance^ADM||1^Satisfactory||||||F
OBX|174|TX|HeORMEXC00^Other oral mechanism exam comments^ADM||oral mech comments||||||F
OBX|175|TX|HeSL000100^Medications relevant to SLP intervention^ADM||Warfarin daily||||||F
OBX|176|TX|HeSL000400^Investigations relevant to Speech-Language Pathologists^ADM||ENT consult||||||F
OBX|177|CE|HeSL001002^Reason for SLP referral^ADM||24^Word finding difficulties||||||F
OBX|178|CE|HeSL010502^Face Motor CN7 appearance^ADM||2^Left facial weakness||||||F
OBX|179|CE|HeSL010701^Jaw Motor CN5 appearance^ADM||3^Deviated to the left||||||F
OBX|180|CE|HeSL010802^Jaw Motor CN5 strength^ADM||1^Within functional limits||||||F
OBX|181|CE|HeSL010902^Jaw Motor CN5 range of motion^ADM||1^Within functional limits||||||F
OBX|182|CE|HeSL011002^Jaw Motor CN5 coordination^ADM||1^Within functional limits||||||F
OBX|183|CE|HeSL011301^Lips Motor CN7 and Sensory CN5 strength^ADM||1^Within functional limits||||||F
OBX|184|CE|HeSL011401^Lips Motor CN7 and Sensory CN5 range of motion^ADM||1^Within functional limits||||||F
OBX|185|CE|HeSL011501^Lips Motor CN7 and Sensory CN5 coordination^ADM||1^Within functional limits||||||F
OBX|186|CE|HeSL011703^Tongue Motor CN12 and Sensory CN5 appearance^ADM||1^Pink and moist||||||F
OBX|187|CE|HeSL011902^Tongue Motor CN12 and Sensory CN5 strength^ADM||1^Within functional limits||||||F
OBX|188|CE|HeSL012002^Tongue Motor CN12 and Sensory CN5 range of motion^ADM||1^Within functional limits||||||F
OBX|189|CE|HeSL012102^Tongue Motor CN12 and Sensory CN5 coordination^ADM||1^Within functional limits||||||F
OBX|190|CE|HeSL012302^Palate Motor CN10 and Sensory CN9 appearance^ADM||1^Symmetrical||||||F
OBX|191|CE|HeSL012402^Palate Motor CN10 and Sensory CN9 elevation^ADM||1^Within functional limits||||||F
OBX|192|CE|HeSL012601^Sensation Sensory CN7 taste^ADM||1^No changes reported||||||F
OBX|193|CE|HeSL012701^Sensation Sensory CN5 face^ADM||1^Within functional limits||||||F
OBX|194|CE|HeSL013100^Oral cavity dentition^ADM||10^Good condition||||||F
OBX|195|CE|HeSL013300^Cough spontaneous^ADM||6^Moderate||||||F
OBX|196|CE|HeSL013500^Cough Motor CN10 voluntary^ADM||6^Moderate||||||F
OBX|197|CE|HeSL013800^Secretions management^ADM||1^No concerns||||||F
OBX|198|CE|HeSL014001^Voice Motor CN10 quality^ADM||1^Within functional limits||||||F
OBX|199|CE|HeSL014201^Voice Motor CN10 breath support^ADM||1^Within functional limits||||||F
OBX|200|TX|HxRESPIR00^Respiratory status^ADM||no issues||||||F
OBX|201|TX|HxSPTCHX01^Pertinent clinical history^ADM||CVA in March 2010 with left sided weakness||||||F
OBX|202|CE|InBSACTV00^Braden Scale activity^ADM||3^3-Walks occasionally||||||F
OBX|203|CE|InBSFRSH00^Braden Scale friction and shear^ADM||2^2-Potential problem||||||F
OBX|204|CE|InBSMOBI01^Braden Scale mobility^ADM||1^1-Completely immobile||||||F
OBX|205|CE|InBSMOIS00^Braden Scale moisture^ADM||1^1-Constantly moist||||||F
OBX|206|CE|InBSNUTR00^Braden Scale nutrition^ADM||2^2-Probably inadequate||||||F
OBX|207|TX|InBSRISK01^Braden Scale risk level^ADM||High||||||F
OBX|208|TX|InBSSCOR00^Braden Skin Risk Assessment Score^ADM||11||||||F
OBX|209|CE|InBSSPER00^Braden Scale sensory perception^ADM||2^2-Very limited||||||F
OBX|210|TX|InINDRES00^Dressing dry and intact^ADM||Y||||||F
OBX|211|CE|InISGR0000^infiltration Scale Grade^ADM||4^+3||||||F
OBX|212|CE|InPARAMR00^Integumentary defined parameters^ADM||2^Significant findings||||||F
OBX|213|CE|InPESIDE00^Peripheral line site description^ADM||1^Satisfactory||||||F
OBX|214|TX|InPRWCMT00^Other pressure ulcer comments^ADM||details of pressure wound||||||F
OBX|215|CE|InPRWOLO00^Pressure wound location^ADM||1^Coccyx||||||F
OBX|216|TX|InSA000200^Skin moisture concerns^ADM||draining serous fluid||||||F
OBX|217|TX|InSA000400^Demonstrates  cognitive ability to direct care^ADM||Y||||||F
OBX|218|CE|InSA000600^Skin condition^ADM||1^Intact||||||F
OBX|219|TX|InSA001100^Turning schedule^ADM||Q2H||||||F
OBX|220|TX|InSA001200^Sitting schedule^ADM||with meals||||||F
OBX|221|CE|InSA001300^Mattress type^ADM||1^Non mechanical therapy||||||F
OBX|222|CE|InSA001500^Heel pressure relief method^ADM||1^Elevated||||||F
OBX|223|CE|InSA001700^Additional pressure relief methods^ADM||1^Untuck blankets||||||F
OBX|224|TX|InSA001900^Additional pressure relief methods comment^ADM||support with pillows||||||F
OBX|225|CE|InSKGNTM00^Generalized skin temperature^ADM||2^Warm||||||F
OBX|226|CE|InSKIAPP01^Skin appearance^ADM||1^Normal||||||F
OBX|227|CE|InSKIDES03^Skin description^ADM||4^Rash||||||F
OBX|228|CE|InSKIMOI02^Skin moisture^ADM||1^Dry||||||F
OBX|229|CE|InSKITEM00^Skin temperature^ADM||2^Warm||||||F
OBX|230|CE|InWOULOC02^Skin or wound location^ADM||29^Generalized||||||F
OBX|231|TX|IoSOLUMA00^Solution^ADM||NS||||||F
OBX|232|TX|IvIN010101^Heparin dose^ADM||125.00||||||F
OBX|233|TX|IvIN010201^Heparin rate^ADM||20.00||||||F
OBX|234|CE|IvLOCATM01^Location Modifier^ADM||1^Right||||||F
OBX|235|CE|IvPHCONC00^Heparin concentration^ADM||1^50 units/mL||||||F
OBX|236|CE|IvPIVLOC00^Location^ADM||5^Hand PIV||||||F
OBX|237|TX|IvPIVNIC00^PIV insertion time^ADM||1344||||||F
OBX|238|CE|IvPL000700^Initial management^ADM||1^Infusion||||||F
OBX|239|CE|IvPS000100^Phlebitis scale grade^ADM||3^+2||||||F
OBX|240|TX|IvRATE0000^Rate^ADM||30.00||||||F
OBX|241|TX|IvREMOTI00^Removal time^ADM||1345||||||F
OBX|242|TX|IvREMOVD00^Removal date^ADM||20190924||||||F
OBX|243|TX|IvSIZE0000^Size^ADM||20||||||F
OBX|244|TX|MhADMIS008^Referred to mental health services^ADM||Y||||||F
OBX|245|CE|MhDISCHA04^MHSU programs/services referred to^ADM||8^ACT~16^Support group||||||F
OBX|246|CE|MhDISCHA09^Location of mental health services referred to^ADM||1^Abbotsford||||||F
OBX|247|TX|MhPLANGC01^Plan G completed by MRP^ADM||Y||||||F
OBX|248|TX|MhPLANGF02^Plan G faxed to appropriate mental health services^ADM||Y||||||F
OBX|249|TX|MhPORTUN01^Oriented to unit and/or provided orientation pamphlet^ADM||Y||||||F
OBX|250|CE|Mo00000501^Ambulation support provided^ADM||2^Supervision||||||F
OBX|251|CE|MoAIDAMB00^Ambulation aid^ADM||2^Cane||||||F
OBX|252|CE|MoAIDBED01^Bed mobility aid^ADM||7^Slider sheet||||||F
OBX|253|CE|MoAIDSTS00^Sit to stand aid^ADM||10^Walker: 4 wheeled||||||F
OBX|254|CE|MoAIDTRA00^Transfer aid^ADM||10^Walker: 4 wheeled||||||F
OBX|255|CE|MoAMBLOC00^Ambulation location^ADM||1^Within room||||||F
OBX|256|TX|MoAOTABR00^Breaks for ambulation assigned^ADM||none||||||F
OBX|257|CE|MoAOTAID00^Aid for ambulation assigned^ADM||2^Cane||||||F
OBX|258|TX|MoAOTAMC00^Ambulation assigned comments^ADM||amb comments||||||F
OBX|259|CE|MoAOTAMF00^Frequency of ambulation assigned^ADM||3^3x/week||||||F
OBX|260|CE|MoAOTAO000^Ambulation outcome^ADM||1^Completed as assigned||||||F
OBX|261|TX|MoAOTATM01^Duration of ambulation assigned^ADM||30||||||F
OBX|262|TX|MoAOTBED00^Bed exercises assigned^ADM||rolling||||||F
OBX|263|CE|MoAOTBEF00^Frequency of bed exercises assigned^ADM||6^Daily||||||F
OBX|264|CE|MoAOTBO000^Bed exercises outcome^ADM||2^Completed in part||||||F
OBX|265|TX|MoAOTCLA01^Therapy classes assigned^ADM||Post stroke - strength training classes 3 x / week||||||F
OBX|266|CE|MoAOTDIS00^Distance of ambulation assigned^ADM||1^5 - 10 m||||||F
OBX|267|TX|MoAOTECL01^Exercise classes assigned^ADM||Leg strengthening x 3 / week||||||F
OBX|268|CE|MoAOTEO000^Exercise class outcome^ADM||3^Patient refused session||||||F
OBX|269|TX|MoAOTEPR00^Exercise programs assigned^ADM||Stairs x 1 / day||||||F
OBX|270|TX|MoAOTLBD00^Lower body dressing assigned^ADM||pants||||||F
OBX|271|CE|MoAOTLBO00^Lower body dressing outcome^ADM||1^Completed as assigned||||||F
OBX|272|CE|MoAOTLDF00^Frequency of lower body dressing assigned^ADM||6^Daily||||||F
OBX|273|CE|MoAOTLOC00^Location of ambulation assigned^ADM||1^Patient room~2^Hallway||||||F
OBX|274|TX|MoAOTOH000^Other tasks assigned^ADM||other tasks comments||||||F
OBX|275|CE|MoAOTOHO00^Other tasks outcome^ADM||1^Completed as assigned||||||F
OBX|276|CE|MoAOTPO000^Exercise program outcome^ADM||2^Completed in part||||||F
OBX|277|TX|MoAOTPRO01^Therapy programs assigned^ADM||Stroke Program x 1 / week||||||F
OBX|278|TX|MoAOTRAC00^Assignment of task comments^ADM||AoT comments||||||F
OBX|279|TX|MoAOTSE000^Seated exercises assigned^ADM||leg raises||||||F
OBX|280|TX|MoAOTSEF00^Frequency of seated exercises assigned^ADM||2 x / day||||||F
OBX|281|CE|MoAOTSEO00^Seated exercises outcome^ADM||3^Patient refused session||||||F
OBX|282|TX|MoAOTST000^Standing exercises assigned^ADM||heel lifts||||||F
OBX|283|TX|MoAOTSTF00^Frequency of standing exercises assigned^ADM||3x / day||||||F
OBX|284|CE|MoAOTSTO00^Standing exercises outcome^ADM||2^Completed in part||||||F
OBX|285|CE|MoAOTTPO00^Therapy program outcome^ADM||2^Completed in part||||||F
OBX|286|CE|MoAOTTR002^Reviewed assignment of task^ADM||1^Assignment of task~3^Mobility recommendations~5^Weight bearing order||||||F
OBX|287|TX|MoAOTUBD00^Upper body dressing assigned^ADM|| ~shirts||||||F
OBX|288|CE|MoAOTUBO00^Upper body dressing outcome^ADM||2^Completed in part||||||F
OBX|289|CE|MoAOTUDF00^Frequency of upper body dressing assigned^ADM||6^Daily||||||F
OBX|290|CE|MoAOTWC000^Wheelchair type assigned^ADM||2^Standard||||||F
OBX|291|TX|MoAOTWCC00^Wheelchair practice assigned comments^ADM||w/c practice||||||F
OBX|292|CE|MoAOTWCF00^Frequency of wheelchair practice assigned^ADM||6^Daily||||||F
OBX|293|CE|MoAOTWM000^Manual wheelchair skills assigned^ADM||4^Foot propel||||||F
OBX|294|CE|MoAOTWO000^Wheelchair practice outcome^ADM||1^Completed as assigned||||||F
OBX|295|CE|MoBCTFTO01^Transfer to^ADM||4^Toilet||||||F
OBX|296|CE|MoBCTTFR01^Transfer from^ADM||2^Chair||||||F
OBX|297|CE|MoBDABIL01^Bed mobility level of ability^ADM||6^Minimal assist||||||F
OBX|298|CE|MoBDASSR01^Bed mobility assistance required^ADM||1^1 person||||||F
OBX|299|TX|MoCHTIME04^Duration of time up in chair^ADM||60||||||F
OBX|300|CE|MoDSABIL00^Dynamic sitting level of ability^ADM||6^Minimal assist||||||F
OBX|301|CE|MoDSASST01^Dynamic sitting assistance required^ADM||2^1 person||||||F
OBX|302|CE|MoEQSTST00^Sit to stand equipment^ADM||2^Ceiling lift||||||F
OBX|303|CE|MoEQUTRA00^Transfer equipment^ADM||8^Mechanical lift||||||F
OBX|304|CE|MoEXERB00^Exercises in bed^ADM||6^Ankle pumping||||||F
OBX|305|TX|MoEXERBC00^Bed exercises completed^ADM||Y||||||F
OBX|306|CE|MoFA000001^Fall prevention strategies^ADM||1^Universal||||||F
OBX|307|CE|MoMOVEDR00^Movement direction^ADM||2^Turning side to side||||||F
OBX|308|CE|MoPOBDPO01^Bed position^ADM||3^Fowlers (45-60 deg)||||||F
OBX|309|TX|MoRASCPL00^RA supervision and communication plan^ADM||daily||||||F
OBX|310|TX|MoRPCMTS00^Repositioning in bed comment^ADM||cueing required||||||F
OBX|311|CE|MoSSASST01^Static sitting assistance required^ADM||2^1 person||||||F
OBX|312|CE|MoSSLEAB00^Static sitting level of ability^ADM||2^Supervision||||||F
OBX|313|CE|MoSTSABI00^Sit to stand level of ability^ADM||4^Total assist||||||F
OBX|314|CE|MoSTSAST01^Sit to stand assistance required^ADM||3^2 person||||||F
OBX|315|CE|MoTRAAST00^Transfer assistance required^ADM||3^2 person||||||F
OBX|316|CE|MoTRABIL00^Transfer level of ability^ADM||3^Moderate assist||||||F
OBX|317|CE|MoTRANSF00^Transfer from^ADM||1^Bed||||||F
OBX|318|CE|MoTRANST02^Transfer to^ADM||2^Chair||||||F
OBX|319|CE|MoTRSUP001^Transfer support provided^ADM||2^Supervision||||||F
OBX|320|TX|MoWBSM0000^Weight bearing order maintained^ADM||Y||||||F
OBX|321|CE|MoWC001800^Shoulder position^ADM||5^Left subluxed||||||F
OBX|322|CE|MoWC002102^Neck position^ADM||1^Neutral||||||F
OBX|323|CE|MoWC002500^Identified risk factors for skin breakdown^ADM||2^Bony prominences~3^Malnutrition||||||F
OBX|324|TX|MoWC002700^Identified risk factors for skin breakdown comment^ADM||nutrition being addressed by RD||||||F
OBX|325|CE|MoWC003801^Type of cushion recommended^ADM||3^High pressure reduction||||||F
OBX|326|CE|MsEM000600^Transportation mode post discharge^ADM||2^Friends||||||F
OBX|327|TX|MsGPC00001^General physical assessment^ADM||bilateral pedal edema||||||F
OBX|328|TX|MsHK001100^Home set-up requirements reviewed^ADM||Y||||||F
OBX|329|CE|MsORTH0003^Supportive orthosis for mobilization^ADM||3^Knee brace||||||F
OBX|330|TX|MsPTSMRT00^PT SMART goals^ADM||PT smart goals||||||F
OBX|331|CE|NeMCACTL00^Activity tolerance^ADM||1^Within functional limits||||||F
OBX|332|CE|NePARAMR00^Neurological and cognition defined parameters^ADM||1^Within defined parameters||||||F
OBX|333|CE|OECODESTAT^MOST Order Designation^ADM||DNR-M3^DNR - M3||||||F
OBX|334|TX|OhAOTTC000^Other task outcome comments^ADM||Will continue to encourage pt to participate||||||F
OBX|335|TX|OhCLUPDA10^Care conference details^ADM||planning||||||F
OBX|336|TX|OhDOWNTI00^Downtime start date^ADM||20191004||||||F
OBX|337|TX|OhDOWNTI10^Downtime start time^ADM||0330||||||F
OBX|338|CE|OhDOWNTI20^Downtime forms completed^ADM||1^Vital signs record~2^Progress notes||||||F
OBX|339|TX|OhDOWNTI30^Downtime end date^ADM||20191004||||||F
OBX|340|TX|OhDOWNTI50^Downtime end time^ADM||0530||||||F
OBX|341|CE|OhIN000300^Information source^ADM||1^Patient~9^Nurse||||||F
OBX|342|TX|OhOTSMRT00^OT SMART goals^ADM|| ~S - OT goal~M - OT goal~A - OT goal~R - OT goal~T - OT goal||||||F
OBX|343|TX|OhPT000300^Exercise tolerance^ADM||SOBOE||||||F
OBX|344|CE|PaPARAMR00^Pain defined parameters^ADM||2^Significant findings||||||F
OBX|345|TX|PsCAREDA00^Date of care conference^ADM||20190920||||||F
OBX|346|TX|PsCAREIN00^Individuals involved in care conference^ADM||Barb and Tom + clinical team||||||F
OBX|347|TX|PsCARETI00^Time of care conference^ADM||0904||||||F
OBX|348|TX|PsCLIFAM01^Clinical update provided^ADM||Y||||||F
OBX|349|TX|PsCOMPRL00^Communication primary language^ADM||English||||||F
OBX|350|CE|PsPARAMR00^Psychosocial and mood defined parameters^ADM||1^Within defined parameters||||||F
OBX|351|TX|PsPATCON00^Patient/Family concerns^ADM||Concerned re: lack of pts progress||||||F
OBX|352|CE|PsSLP07000^Posture entire body^ADM||3^Left leaning||||||F
OBX|353|TX|PsSTAND191^Primary contact person^ADM||Barb||||||F
OBX|354|CE|ReOXYTHE04^Oxygen therapy delivery method^ADM||1^Room air||||||F
OBX|355|CE|RePARAMR00^Respiratory defined parameters^ADM||1^Within defined parameters||||||F
OBX|356|CE|SpCONFOR00^Consent for intervention^ADM||1^Verbal||||||F
OBX|357|CE|SpCONPAT00^Consent received from patient^ADM||1^Verbal||||||F
OBX|358|TX|SpCONRA000^Patient consented to RA session^ADM||Y||||||F
OBX|359|TX|SpCONREA00^Patient consented to assignment of tasks to RA^ADM||Y||||||F
OBX|360|CE|SpCONRIS00^Assessment/Treatment benefits and risks explained to^ADM||1^Patient||||||F
OBX|361|CE|SpCONTYP00^Consent received for^ADM||1^Assessment~2^Treatment plan||||||F
OBX|362|TX|SpUPAICM02^Fall prevention comments^ADM||patient is compliant||||||F
OBX|363|TX|TeEDINTR00^Interpreter utilized^ADM||N||||||F
OBX|364|TX|TeSLPCOM00^SLP Dysphagia SMART goals^ADM||SMART SLP goals||||||F
OBX|365|CE|TeVENDIN00^Mobility equipment - vendor information given to^ADM||1^Patient||||||F
OBX|366|CE|VsBPCFLP01^Blood pressure cuff location^ADM||1^Right arm||||||F
OBX|367|CE|VsBPDEUS00^Device used^ADM||1^Automated cuff||||||F
OBX|368|TX|VsBPDIAO01^Blood pressure diastolic^ADM||96||||||F
OBX|369|CE|VsBPPOST02^Patient position^ADM||1^Right side lying||||||F
OBX|370|TX|VsBPSYSO01^Blood pressure systolic^ADM||145||||||F
OBX|371|TX|VsHRADLT01^Heart rate^ADM||125||||||F
OBX|372|CE|VsHRLOCA02^Heart rate location^ADM||2^Brachial||||||F
OBX|373|CE|VsHRLOMO00^Pulse location modifier^ADM||1^Right||||||F
OBX|374|CE|VsHRMETH00^Heart rate method used^ADM||3^Pulse Oximetry||||||F
OBX|375|CE|VsHRRHYM02^Pulse rhythm^ADM||1^Regular||||||F
OBX|376|TX|VsHTCM0100^Current height^ADM||163.0||||||F
OBX|377|TX|VsOXDRAD01^Oxygen therapy delivery rate^ADM||2||||||F
OBX|378|TX|VsPOOSAD00^Pulse oximetry oxygen saturation^ADM||98||||||F
OBX|379|CE|VsPRLOMO00^Probe location modifier^ADM||1^Right||||||F
OBX|380|CE|VsPROLOC00^Probe location^ADM||1^Finger||||||F
OBX|381|CE|VsPULSTR00^Pulse strength on palpation^ADM||3^Strong||||||F
OBX|382|TX|VsRESPAD03^Respiratory rate^ADM||16||||||F
OBX|383|CE|VsTPSORC03^Temperature source^ADM||2^Oral||||||F
OBX|384|TX|VsTPTEMPO2^Temperature^ADM||37.2||||||F
OBX|385|TX|VsWT000101^Current Weight^ADM||55.000||||||F
OBX|386|CE|VsWT000700^Weight measurement method^ADM||3^Wheelchair scale||||||F
OBX|387|CE|VsWT004900^Height or length source^ADM||3^Stated||||||F
OBX|388|TX|VsWTGRAM00^Weight (Calculated Grams)^ADM||55000.000||||||F
OBX|389|TX|zSEPSISM00^Sepsis screen^ADM||Severe Sepsis Risk||||||F
OBX|390|CE|zSEPSISM01^Sepsis action taken^ADM||1^Physician notified||||||F
OBX|391|TX|zSEPSISM02^Name of provider notified^ADM||TEST||||||F
OBX|392|CE|zSEPSISM15^Infection criteria present^ADM||1^Suspected new infection||||||F
OBX|393|CE|zSEPSISM18^SIRS criteria present^ADM||1^Pulse > 90 bpm~7^WBC > 12.0||||||F
OBX|394|CE|zSEPSISM19^Organ dysfunction criteria present^ADM||2^Creatinine > 2 mg/dl~5^Urine Output <0.5 ml/kg/h||||||F
OBX|395|TX|zSEPSISM43^Risk for sepsis identified^ADM||Y||||||F
OBX|396|TX|ADM WCB^IS THIS VISIT RELATED TO A WCB CLAIM?^INS||N||||||F
AL1|1|DA|F001900388^No Known Allergies|||20190116
ZFD|OEDOCM^Oedoc^Marytrain^^^^MD^50003^DOC|9876 Main Street^^Surrey^BC^V3V 1Z1|||OEDOCN^Oedoc^Nancytrain^^^^MD^50005^DOC|OEDOCN^Oedoc^Nancytrain^^^^MD^50005^DOC|
ZFH|LUMED||||||

