MSH|^~\&|ADM|ARH|||201911130833||ADT^A08|4104224|D|2.2|||AL|NE
EVN|A08|201911130833||||
PID|1|FHATVIG0009411|AB00008059|AB8002|ITSTEST^ANIMAL||19890101|F|||123 ABC STREET^^SESAME^BC^99|||||||AB000213/19|9875317907
PV1|1|I|AB-NUR^ABNUR-01^30|EL|||.UNATTACH^Unattach^^^^^^^^^^^XX|||HA||||||||IN|||||||||||||||||||||ARH|||||201905301453|
PV2||W^Ward|
OBX|1|ST|1010.1^WEIGHT^CPT4||50.000||||||F
OBX|2|TX|ADM CURRES^Residing at current add. since (DD/MM/YY)^ADM||19890101||||||F
OBX|3|CE|ADM IDSOUR^SOURCE OF ID^ADM||NONE^None||||||F
OBX|4|CE|ADM MDRO2^Canada in the last 12 months?^ADM||N^NO||||||F
OBX|5|CE|ADM MDRO4^or Bangladesh in the last 12 months?^ADM||N^NO||||||F
OBX|6|CE|ADM MRSA2^correctional/shelter in the last 6 months?^ADM||N^NO||||||F
OBX|7|CE|AcADLWAP01^Wash products/skin protectant used^ADM||2^Protective skin wipes||||||F
OBX|8|CE|AcADLWAT00^Wash type performed^ADM||2^Bedside with basin||||||F
OBX|9|CE|AcCLTYPE00^Clothing type^ADM||1^Hospital gown||||||F
OBX|10|CE|AcDRASST02^Dressing assistance^ADM||1^Unassisted||||||F
OBX|11|CE|AcHAIWAS00^Hair wash performed^ADM||1^With hair cap||||||F
OBX|12|CE|AcMOCAPE00^Mouth care performed^ADM||6^Mouth/Lips moisturized~7^Teeth brushing||||||F
OBX|13|CE|AcMOCARE03^Mouth care assistance^ADM||1^Unassisted||||||F
OBX|14|TX|AcPERSCC00^Personal care comments^ADM||hair brush provided||||||F
OBX|15|TX|AcSHAGIV00^Shave given^ADM||N||||||F
OBX|16|CE|AcWAASST03^Washing assistance^ADM||3^Set-up||||||F
OBX|17|TX|AdADMDAT01^Admission date^ADM||20191113||||||F
OBX|18|CE|AdADMFRO01^Admitted from^ADM||1^Emergency||||||F
OBX|19|TX|AdADMRSN00^Reason for admission^ADM||chest pain||||||F
OBX|20|TX|AdDCBSLP00^Discharge barriers identified by speech language pathologist^ADM||NOT ENOUGH FOOD SUPPLY||||||F
OBX|21|TX|AdDCCOMP00^Discharge plan complete^ADM||N||||||F
OBX|22|TX|AdESTDTD00^Estimated date of discharge^ADM||20190725||||||F
OBX|23|TX|AdESTPTF00^Patient/Family informed of estimated date of discharge^ADM||N||||||F
OBX|24|CE|AdESTREA03^Reason EDD changed^ADM||1^Acuity~8^Waitlisted||||||F
OBX|25|TX|AdFUAPCO04^Services and appointments arranged comments^ADM||MORE FOOD PLEASE||||||F
OBX|26|TX|AdGOALCP00^Goal^ADM||walk with stable gait for more than 100 m||||||F
OBX|27|CE|AdGOALST00^Goal status^ADM||1^In progress||||||F
OBX|28|TX|AdINFOTH02^Information source other^ADM||GUIDE DOG||||||F
OBX|29|TX|AdINPSNT00^Inpatient referral(s) sent to other^ADM||KITCHEN||||||F
OBX|30|CE|AdINPTRF00^Inpatient referral(s) sent to^ADM||10^Dietitian~15^SLP~18^Social worker||||||F
OBX|31|TX|AdINVANR00^1. Intervention to address problem^ADM||PT referral||||||F
OBX|32|TX|AdMRPNAM00^MRP or physician name^ADM||Dr. Marytrain OEDOC||||||F
OBX|33|CE|AdOTPREF00^Outpatient/Community referral(s) sent to^ADM||1^Acquired brain injury~2^Diabetes clinic~6^Dietitian||||||F
OBX|34|TX|AdOTPSNT00^Outpatient/Community referral(s) sent to other^ADM||FOOD BANK||||||F
OBX|35|TX|AdPROBDC00^Problem is a barrier to discharge^ADM||Y||||||F
OBX|36|TX|AdPROBDS00^Problem detail^ADM||L hip - arthritis, walks with stable gait for 100 m only||||||F
OBX|37|CE|AdPROBID20^Problem identified^ADM||13^Mobility||||||F
OBX|38|TX|AdPTFAMY00^Patient/Family goals for discharge^ADM||FAMILY STATES "FEED HER"||||||F
OBX|39|TX|AdSLPCPD00^Problem detail^ADM||cant talk||||||F
OBX|40|TX|AdSLPCPG00^Goal^ADM||learn to talk||||||F
OBX|41|CE|AdSLPCPI00^Problem identified^ADM||13^Expressive language||||||F
OBX|42|TX|AdSLPCPP00^Interventions to address problem^ADM||TOOTHBRUSH||||||F
OBX|43|CE|AdSLPCPS00^Goal status^ADM||1^In progress||||||F
OBX|44|TX|AdSLPCPT00^Goal target date^ADM||20190727||||||F
OBX|45|TX|AdSTRECO01^Reason EDD changed other^ADM||NOT ENOUGH FOOD||||||F
OBX|46|CE|CaCYANOS00^Cyanosis^ADM||1^None||||||F
OBX|47|TX|CaPLDATE00^PIV Insertion date^ADM||20190620||||||F
OBX|48|TX|CmMRPCDA01^MRP or physician communication date^ADM||20191113||||||F
OBX|49|CE|CmMRPCDE01^MRP or physician contact details^ADM||1^Contact made||||||F
OBX|50|CE|CmMRPCME01^MRP or physician communication method^ADM||1^In person||||||F
OBX|51|TX|CmMRPCRE01^MRP or physician communication reason^ADM||notified MRP regarding Yvonne's L hip pain and asked for analgesic orders||||||F
OBX|52|TX|CmMRPCTI01^MRP or physician communication time^ADM||0700||||||F
OBX|53|TX|GuCONLIN00^Control line present^ADM||||||||F
OBX|54|TX|GuUDGLUC00^Urine dipstick glucose^ADM||||||||F
OBX|55|TX|GuUDKT0000^Urine dipstick ketones^ADM||||||||F
OBX|56|TX|GuUDLEUK00^Urine dipstick leukocytes^ADM||||||||F
OBX|57|TX|GuUDNIT000^Urine dipstick nitrites^ADM||||||||F
OBX|58|TX|GuUDPROT00^Urine dipstick protein^ADM||||||||F
OBX|59|TX|GuUR000600^Urine blood^ADM||||||||F
OBX|60|TX|GuUR000700^Urine hemoglobin^ADM||||||||F
OBX|61|TX|GuURPH0000^Urine pH^ADM||||||||F
OBX|62|TX|GuURPREG01^Urine pregnancy test results^ADM||||||||F
OBX|63|TX|HHOTCMST00^Outcome status^ADM||In progress||||||F
OBX|64|CE|HeSW000100^Swallowing concerns identified with solids^ADM||1^No obvious concerns~5^Throat clearing||||||F
OBX|65|CE|HeSW000300^Swallowing concerns identified with fluids^ADM||5^Throat clearing||||||F
OBX|66|CE|HeSW000500^Swallowing concerns identified with oral medications^ADM||1^No obvious concerns||||||F
OBX|67|TX|HeSW000700^Eat at risk order in place^ADM||Y||||||F
OBX|68|CE|HeSW001800^Swallowing concerns intervention^ADM||2^Swallow ax referral||||||F
OBX|69|CE|HeTR000100^Trachea position^ADM||1^Midline||||||F
OBX|70|TX|InBSACTV00^Braden Scale activity^ADM||||||||F
OBX|71|TX|InBSFRSH00^Braden Scale friction and shear^ADM||||||||F
OBX|72|TX|InBSMOBI01^Braden Scale mobility^ADM||||||||F
OBX|73|TX|InBSMOIS00^Braden Scale moisture^ADM||||||||F
OBX|74|TX|InBSNUTR00^Braden Scale nutrition^ADM||||||||F
OBX|75|TX|InBSRISK01^Braden Scale risk level^ADM||||||||F
OBX|76|TX|InBSSCOR00^Braden Skin Risk Assessment Score^ADM||||||||F
OBX|77|TX|InBSSPER00^Braden Scale sensory perception^ADM||||||||F
OBX|78|TX|InEYECAR00^Eye care^ADM||N||||||F
OBX|79|TX|InINDRES00^Dressing dry and intact^ADM||Y||||||F
OBX|80|CE|InISGR0000^infiltration Scale Grade^ADM||1^0||||||F
OBX|81|TX|InPEBIIS00^Abdominal, breast, stump, and pelvic binder in situ^ADM||Y||||||F
OBX|82|CE|InPESIDE00^Peripheral line site description^ADM||1^Satisfactory||||||F
OBX|83|CE|InPOSI0001^Immobilization/positioning device type^ADM||1^Cast||||||F
OBX|84|CE|InSA000600^Skin condition^ADM||2^Open||||||F
OBX|85|CE|InSA001300^Mattress type^ADM||1^Non mechanical therapy||||||F
OBX|86|CE|InSA001700^Additional pressure relief methods^ADM||1^Untuck blankets||||||F
OBX|87|CE|InSKGNTM00^Generalized skin temperature^ADM||1^Hot||||||F
OBX|88|CE|InSKIAPP01^Skin appearance^ADM||1^Normal||||||F
OBX|89|CE|InSKIDES03^Skin description^ADM||2^Flaky~3^Excoriated||||||F
OBX|90|CE|InSKIMOD01^Skin and wound modifier^ADM||2^Right~9^Medial~19^2nd digit||||||F
OBX|91|CE|InSKIMOI02^Skin moisture^ADM||5^Moist||||||F
OBX|92|CE|InSKITEM00^Skin temperature^ADM||2^Warm||||||F
OBX|93|CE|IvFLUSHS01^Flush solution^ADM||1^Normal saline||||||F
OBX|94|CE|IvFLUSHV00^Flush volume^ADM||1^3 mL||||||F
OBX|95|TX|IvINSERT00^Insertion details^ADM||SUCCESSFUL ON FIRST ATTEMPT||||||F
OBX|96|CE|IvLINECA02^Saline lock care^ADM||1^Flush||||||F
OBX|97|CE|IvLOCATM01^Location Modifier^ADM||1^Right||||||F
OBX|98|CE|IvPIVLOC00^Location^ADM||5^Hand PIV||||||F
OBX|99|TX|IvPIVNIC00^PIV insertion time^ADM||1347||||||F
OBX|100|CE|IvPL000700^Initial management^ADM||2^Saline lock||||||F
OBX|101|CE|IvPS000100^Phlebitis scale grade^ADM||1^0||||||F
OBX|102|TX|IvSIZE0000^Size^ADM||20||||||F
OBX|103|TX|MhRIGHT004^Details of visit^ADM||friend by bedside offering to bring patient's favourite food||||||F
OBX|104|CE|MoBDASST08^Assistance required for repositioning in bed^ADM||1^Unassisted||||||F
OBX|105|CE|MoBDASTD00^Mobility in bed assistive devices^ADM||1^Bed rail||||||F
OBX|106|CE|MoPOBDPO01^Bed position^ADM||4^Low fowlers (30-45 deg)||||||F
OBX|107|TX|MsGRPST110^Grip strength trial 1^ADM||5.0||||||F
OBX|108|TX|MsGRPST210^Grip strength trial 2^ADM||10.0||||||F
OBX|109|TX|MsGRPSTA00^Grip strength average^ADM||Incomplete||||||F
OBX|110|CE|MsHANDAX00^Hand assessed^ADM||2^Left||||||F
OBX|111|CE|MsMSFLMM00^Flexion manual muscle testing^ADM||8^2-/5||||||F
OBX|112|CE|MsMSLOCA01^Muscle strength location^ADM||4^Fingers||||||F
OBX|113|CE|MsMSLOCM00^Muscle strength location modifier^ADM||2^Left||||||F
OBX|114|TX|MsROMABE00^Abduction end ROM measurement^ADM||2||||||F
OBX|115|TX|MsROMADE00^Adduction end ROM measurement^ADM||41||||||F
OBX|116|TX|MsROMIRE00^Internal rotation end ROM measurement^ADM||5||||||F
OBX|117|CE|MsROMJAD00^Adduction joint end feel^ADM||2^Bony block||||||F
OBX|118|CE|MsROMJDF00^Dorsiflexion joint end feel^ADM||3^Empty feel||||||F
OBX|119|CE|MsROMJER00^External rotation joint end feel^ADM||3^Empty feel||||||F
OBX|120|CE|MsROMJEX00^Extension joint end feel^ADM||2^Bony block||||||F
OBX|121|CE|MsROMJFL00^Flexion joint end feel^ADM||1^Normal||||||F
OBX|122|CE|MsROMJIR00^Internal rotation joint end feel^ADM||3^Empty feel||||||F
OBX|123|CE|MsROMJPF00^Plantar flexion joint end feel^ADM||3^Empty feel||||||F
OBX|124|CE|MsROMJPR00^Pronation joint end feel^ADM||3^Empty feel||||||F
OBX|125|CE|MsROMJSU00^Supination joint end feel^ADM||3^Empty feel||||||F
OBX|126|CE|MsROMTR000^Range of motion - type of range^ADM||1^Passive||||||F
OBX|127|CE|NmEX007800^Range of motion specific joint^ADM||1^Shoulder||||||F
OBX|128|CE|NmEX007902^Range of motion specific joints side to perform range^ADM||1^Right||||||F
OBX|129|TX|Nu00000200^Oral nutrition amount of meal consumed comments^ADM||LOW APPETITE||||||F
OBX|130|CE|NuBRAMCO01^Breakfast amount consumed^ADM||1^25%||||||F
OBX|131|CE|NuDIAMCO01^Dinner amount consumed^ADM||1^25%||||||F
OBX|132|CE|NuFEEASS01^Feeding assistance^ADM||1^Unassisted||||||F
OBX|133|CE|NuLUAMCO01^Lunch amount consumed^ADM||1^25%||||||F
OBX|134|CE|NuMSTDAP01^Been eating poorly because of a decreased appetite^ADM||2^Yes||||||F
OBX|135|CE|NuMSTLWT02^Have you lost weight recently without trying^ADM||3^Yes||||||F
OBX|136|TX|NuMSTSCR01^Malnutrition Screening Tool score^ADM||3||||||F
OBX|137|CE|NuMSTWTL01^If yes, how much have you lost^ADM||2^6-10 kg (13-22 lbs)||||||F
OBX|138|TX|NuNM000100^Nothing by mouth^ADM||N||||||F
OBX|139|TX|NuONSOOT00^Oral nutrition food source other^ADM||NURSE||||||F
OBX|140|CE|NuONSOUR00^Oral nutrition food source^ADM||1^Hospital~2^Family or friends||||||F
OBX|141|TX|NuONSUPP00^Oral nutrition supplement drink^ADM||BOOST||||||F
OBX|142|CE|NuPPOSBR00^Patient's position during breakfast^ADM||3^Bedside chair||||||F
OBX|143|CE|NuPPOSDI00^Patient's position during dinner^ADM||3^Bedside chair||||||F
OBX|144|CE|NuPPOSLU01^Patient's position during lunch^ADM||3^Bedside chair||||||F
OBX|145|CE|NuSNAMCO01^Snack amount consumed^ADM||4^100%||||||F
OBX|146|TX|OhCLUPDA00^Clinical update provided to^ADM||friend||||||F
OBX|147|CE|OhIN000300^Information source^ADM||7^Friend||||||F
OBX|148|TX|PsCLIFAM01^Clinical update provided^ADM||Y||||||F
OBX|149|CE|ReAUBTHS02^Breath sounds^ADM||4^Fine||||||F
OBX|150|CE|ReAULOCT00^Auscultation location^ADM||7^Left lung||||||F
OBX|151|CE|ReAULOMO00^Auscultation location modifier^ADM||2^Posterior||||||F
OBX|152|TX|ReBCLEAR00^Breath sounds clear throughout^ADM||N||||||F
OBX|153|TX|ReBRESOU00^Breath sounds other^ADM||CLEAR||||||F
OBX|154|CE|ReCGDESC01^Cough description^ADM||2^Congested||||||F
OBX|155|TX|ReCGPROD00^Cough productive^ADM||N||||||F
OBX|156|CE|ReCGSTGH00^Cough strength^ADM||2^Moderate||||||F
OBX|157|TX|ReEMPHYS00^Subcutaneous emphysema^ADM||N||||||F
OBX|158|TX|ReMEDGIV00^Inhalers/Nebulizers given^ADM||Y||||||F
OBX|159|CE|RePHASE000^Phase^ADM||1^Inspiration~2^Expiration||||||F
OBX|160|CE|ReRECHEX01^Chest expansion^ADM||1^Symmetrical||||||F
OBX|161|CE|ReREDISI00^Respiratory distress indicators^ADM||1^Accessory muscle use~2^Audible wheeze~8^Speaks in short sentences||||||F
OBX|162|CE|ReREDPTH00^Respiratory depth^ADM||2^Shallow||||||F
OBX|163|CE|ReRPNM0000^Respiratory pattern^ADM||2^Tachypneic||||||F
OBX|164|CE|ReWRKBRE00^Work of breathing^ADM||3^Moderate||||||F
OBX|165|TX|SpSLEAID00^Sleep aid PRN given^ADM||Y||||||F
OBX|166|TX|TeSLSMRT00^SLP SMART goals^ADM||FEED PATIENT||||||F
OBX|167|CE|VsBPPOST02^Patient position^ADM||3^Sitting||||||F
OBX|168|TX|VsHRADLT01^Heart rate^ADM||55||||||F
OBX|169|CE|VsHRLOCA02^Heart rate location^ADM||1^Radial||||||F
OBX|170|CE|VsHRLOMO00^Pulse location modifier^ADM||1^Right||||||F
OBX|171|CE|VsHRMETH00^Heart rate method used^ADM||1^Palpation||||||F
OBX|172|CE|VsTPSORC03^Temperature source^ADM||2^Oral||||||F
OBX|173|TX|VsTPTEMPO2^Temperature^ADM||39.0||||||F
OBX|174|TX|VsWT000101^Current Weight^ADM||50.000||||||F
OBX|175|CE|VsWT000700^Weight measurement method^ADM||1^Standing scale||||||F
OBX|176|TX|VsWTGRAM00^Weight (Calculated Grams)^ADM||50000.000||||||F
OBX|177|TX|ADM WCB^IS THIS VISIT RELATED TO A WCB CLAIM?^INS||N||||||F
ZFD|.UNATTACH^Unattach^^^^^^^OTH||||.UNATTACH^Unattach^^^^^^^OTH|.UNATTACH^Unattach^^^^^^^OTH|
ZFH|LUMED||||||

