MSH|^~\&|ADM|ARH|||201911151254||ADT^A08|4106479|D|2.2|||AL|NE
EVN|A08|201911151254||||
PID|1|FHATVIG0012080|AB00008298|AB8205|PCSTEST^REPORT1||19631021|F|||123 Arbutus Way^^Victoria^BC^V6H 9I0|||||||AB000580/19|
PV1|1|I|AB-2BAKER^AB2B-FLO^E|UE|||ZTEST^Test Provider^IM/IT^Use Only^^^^^^^^^XX|||MEDS||||||||IN|||||||||||||||||||||ARH|||||201910211147|
PV2||W^Ward|
OBX|1|ST|1010.1^WEIGHT^CPT4||75.000||||||F
OBX|2|ST|1010.3^HEIGHT^CPT4||170.2||||||F
OBX|3|TX|ADM CURRES^Residing at current add. since (DD/MM/YY)^ADM||20190723||||||F
OBX|4|CE|ADM IDSOUR^SOURCE OF ID^ADM||BCC^BC CareCard (No Photo ID)||||||F
OBX|5|CE|ADM MDRO2^Canada in the last 12 months?^ADM||N^NO||||||F
OBX|6|CE|ADM MDRO4^or Bangladesh in the last 12 months?^ADM||N^NO||||||F
OBX|7|CE|ADM MRSA2^correctional/shelter in the last 6 months?^ADM||N^NO||||||F
OBX|8|TX|Ac00000000^Specialty skin product used^ADM||N||||||F
OBX|9|TX|Ac00000100^Hair washed^ADM||Y||||||F
OBX|10|TX|Ac00000800^Bathing support comment^ADM||bathing comments||||||F
OBX|11|CE|Ac00001000^Grooming support provided^ADM||3^Set-up||||||F
OBX|12|CE|Ac00001200^Oral care support provided^ADM||5^Total||||||F
OBX|13|CE|Ac00001300^Dressing support provided^ADM||7^2 person assist||||||F
OBX|14|CE|Ac00001400^Bed mobility support provided^ADM||8^Independent||||||F
OBX|15|CE|Ac00005400^Aids in use^ADM||2^Dentures||||||F
OBX|16|TX|Ac00005500^Aids in use other^ADM||aids in use other||||||F
OBX|17|CE|Ac00005600^Aids removed^ADM||1^Glasses||||||F
OBX|18|TX|Ac00005700^Aids removed other^ADM||aids removed other||||||F
OBX|19|TX|Ac00005800^Assistance given^ADM||N||||||F
OBX|20|TX|Ac00005900^Aids comments^ADM||aids comments||||||F
OBX|21|CE|Ac00006000^Bathing support provided^ADM||7^2 person assist||||||F
OBX|22|TX|Ac00006100^Specialty skin product used^ADM||N||||||F
OBX|23|TX|AcADLCOM00^Activities of Daily Living Comments^ADM||other adl comments||||||F
OBX|24|CE|AcADLWAT01^Wash type performed^ADM||1^Full bed bath||||||F
OBX|25|CE|AcCLTYPE00^Clothing type^ADM||2^Hospital pajamas||||||F
OBX|26|CE|AcEYECAR00^Eye care^ADM||2^Saline||||||F
OBX|27|CE|AcFTTYPE00^Footwear type^ADM||1^Non slip socks||||||F
OBX|28|CE|AcHAIWAS00^Hair wash performed^ADM||1^With hair cap||||||F
OBX|29|TX|AcHMRF0001^Falls since admission^ADM||N||||||F
OBX|30|TX|AcHYGIEN00^Hygiene/Dependent patient comments^ADM||other hygiene comments||||||F
OBX|31|CE|AcMOCAPE01^Mouth care performed^ADM||7^Teeth brushing||||||F
OBX|32|TX|AcMOUCAO00^Mouth care performed other^ADM||other oral care||||||F
OBX|33|CE|AcPER00001^Personal care provided by^ADM||1^Nurse||||||F
OBX|34|TX|AcPER00100^Personal care provided by other^ADM||ggrandmother||||||F
OBX|35|TX|AcPERSCC00^Personal care comments^ADM||other personal care comments||||||F
OBX|36|CE|AcPRUSED00^Physical restraint used^ADM||1^Soft Velcro||||||F
OBX|37|TX|AcPRUSEO00^Physical restraint used other^ADM||restraint other||||||F
OBX|38|TX|AcSHAGIV00^Shave given^ADM||Y||||||F
OBX|39|TX|AdADMRSN00^Reason for admission^ADM||Bowel Obstruction||||||F
OBX|40|TX|AdALLERR00^Allergies reviewed^ADM||Y||||||F
OBX|41|CE|AdASEVRD00^As evidenced by^ADM||13^Chronic disease/condition||||||F
OBX|42|CE|AdDISCHA30^Discharge destination^ADM||2^Acute care facility||||||F
OBX|43|TX|AdESTDTD00^Estimated date of discharge^ADM||20191021||||||F
OBX|44|CE|AdESTREA03^Reason EDD changed^ADM||1^Acuity~4^Pending lab/consults||||||F
OBX|45|TX|AdFACINA01^Name of facility^ADM||Maple House||||||F
OBX|46|TX|AdGOCPRD00^Goal^ADM||opp||||||F
OBX|47|CE|AdGOSTRD00^Goal status^ADM||1^In progress||||||F
OBX|48|TX|AdGOTDRD00^Goal target date^ADM||20191122||||||F
OBX|49|TX|AdHXCOND00^History of presenting condition^ADM||Two day history of abdominal pain, nausea and vomiting.||||||F
OBX|50|CE|AdINVARD00^Interventions to address problem^ADM||1^Meals and snacks~4^Vitamin/Mineral suppl||||||F
OBX|51|CE|AdPROBRD00^Problem identified^ADM||35^Inadequate protein-E||||||F
OBX|52|CE|AdRETORD00^Related to^ADM||2^Inadequate energy intake||||||F
OBX|53|TX|AdSTRECO01^Reason EDD changed other^ADM||EDD changed other||||||F
OBX|54|TX|CaCAMODA00^Date cardiac monitoring initiated^ADM||20191007||||||F
OBX|55|TX|CaCAMODD00^Date cardiac monitoring discontinued^ADM||20191114||||||F
OBX|56|TX|EnPA000100^Palliative Performance Scale^ADM||75||||||F
OBX|57|TX|GiBO000301^Last bowel movement date as reported by patient^ADM||20191113||||||F
OBX|58|TX|GuUCID0000^Urinary catheter insertion date^ADM||20191112||||||F
OBX|59|TX|GuUCRDT000^Urinary catheter removal date^ADM||20191114||||||F
OBX|60|TX|He00002400^Oral care comments^ADM||comments||||||F
OBX|61|TX|HxSPTCHX01^Pertinent clinical history^ADM||History of constipation. Diabetes Type 2||||||F
OBX|62|CE|HxWHX00002^Weight change prior to admission weight history^ADM||1^Stable||||||F
OBX|63|TX|InEYECAR00^Eye care^ADM||N||||||F
OBX|64|TX|InWDRDRY00^Wound dressing dry and intact^ADM||Y||||||F
OBX|65|CE|InWNDLOC02^Wound location^ADM||2^Arm||||||F
OBX|66|CE|InWNDMOD00^Wound location modifier^ADM||1^Right||||||F
OBX|67|CE|InWNDTYM00^Wound type^ADM||2^Arterial||||||F
OBX|68|CE|MhREST0001^Reason for restraint use^ADM||2^Harm to others||||||F
OBX|69|TX|MhREST0002^Reason for restraint use other^ADM||reason for use||||||F
OBX|70|TX|MhRESTEV01^Evaluation for continued restraint use assessed/reassessed^ADM||N||||||F
OBX|71|CE|Mo00000500^Ambulation support provided^ADM||2^Supervision||||||F
OBX|72|TX|Mo00002600^Bed mobility comment^ADM||bed mobility comments||||||F
OBX|73|CE|MoAIDAMB01^Ambulation aid^ADM||10^Walker: 2 wheeled||||||F
OBX|74|CE|MoAIDTRA01^Transfer aid^ADM||10^Walker: 2 wheeled||||||F
OBX|75|CE|MoAMBLOC00^Ambulation location^ADM||1^Within room||||||F
OBX|76|TX|MoBDACMT00^Mobility in bed assistance required comment^ADM||bed mobility comments||||||F
OBX|77|CE|MoBDASTD00^Mobility in bed assistive devices^ADM||1^Bed rail||||||F
OBX|78|CE|MoBDIN0000^In bed mobilization^ADM||1^Positioned in bed||||||F
OBX|79|CE|MoEQUITR01^Transfer equipment^ADM||2^No equipment used||||||F
OBX|80|TX|MoEXCPRE00^Exercises prescribed^ADM||Exercises prescribed||||||F
OBX|81|CE|MoFA000001^Fall prevention strategies^ADM||1^Universal||||||F
OBX|82|CE|MoMOTYPT00^Mobility type^ADM||4^Toilet transfer||||||F
OBX|83|TX|MoPHYSIO00^Physiotherapy treatment^ADM||PT treatment||||||F
OBX|84|CE|MoPOBDPO01^Bed position^ADM||4^Low fowlers (30-45 deg)||||||F
OBX|85|CE|MoPOSRBM00^Positioning side rails bottom^ADM||2^Both up||||||F
OBX|86|CE|MoPOSRTP00^Positioning side rails top^ADM||1^1 side up||||||F
OBX|87|TX|MoPTPLAN00^PT plan^ADM||PT plan||||||F
OBX|88|CE|MoRECAID02^Recommended aid^ADM||1^No aid recommended||||||F
OBX|89|CE|MoRECEQP02^Recommended equipment^ADM||1^No equipment recommended||||||F
OBX|90|CE|MoRECTEC00^Recommended mobility technique^ADM||2^To left side||||||F
OBX|91|CE|MoSUPPPT01^Recommended support provided^ADM||2^Supervision||||||F
OBX|92|CE|MoTRANSF00^Transfer from^ADM||1^Bed||||||F
OBX|93|CE|MoTRANST02^Transfer to^ADM||2^Chair||||||F
OBX|94|CE|MoTRSEMR00^Transfer support provided^ADM||6^1 person assist||||||F
OBX|95|CE|MoTRSUP002^Transfer support provided^ADM||2^Supervision||||||F
OBX|96|CE|Ms00000800^Type^ADM||3^Serial||||||F
OBX|97|CE|Ms00001400^Type^ADM||2^Brace||||||F
OBX|98|TX|Ms00001500^Type details^ADM||aspen||||||F
OBX|99|TX|Ms00001600^Location Modifier^ADM||neck||||||F
OBX|100|TX|Ms00001700^Location^ADM||neck||||||F
OBX|101|CE|Ms00001800^Splint/Brace status^ADM||1^On||||||F
OBX|102|TX|Ms00001900^Splint/Brace comments^ADM||checked position||||||F
OBX|103|TX|Ms00002000^Skin satisfactory^ADM||Y||||||F
OBX|104|TX|MsPTSMRT00^PT SMART goals^ADM||PT smart goals||||||F
OBX|105|TX|NmEX010000^Home exercise program^ADM||home exercise program||||||F
OBX|106|TX|NuAPWECH01^Percent weight loss^ADM||1.3||||||F
OBX|107|CE|NuAPWELO01^Dietitian weight loss assessment^ADM||1^Non-significant loss||||||F
OBX|108|CE|NuCNFEED00^Current nutrition status refeeding concern^ADM||1^No risk||||||F
OBX|109|CE|NuCNMETH00^Nutrition status assessment method^ADM||1^Subjective Global Ax||||||F
OBX|110|TX|NuDPMEHX00^Clinical history relevant to dietitian plan^ADM||L MCA stroke HTN, Diabetes||||||F
OBX|111|TX|NuDPTEST01^Lab/Test/Procedure results relevant to dietitian plan^ADM||hyponatremia||||||F
OBX|112|CE|NuDRREAS05^Reason for dietitian assessment^ADM||4^Enteral nutrition||||||F
OBX|113|TX|NuENPNNU00^Enteral/Parenteral details^ADM||feeds as per RD||||||F
OBX|114|TX|NuFADIHX00^Diet history relevant to dietitian plan^ADM||eating well prior to admission||||||F
OBX|115|CE|NuFKLEVE00^Food and nutrition knowledge level^ADM||2^Basic||||||F
OBX|116|CE|NuKNOW0001^Knowledge assessment of^ADM||1^Patient~3^Family||||||F
OBX|117|CE|NuNIADEQ00^Nutrient intake adequacy^ADM||2^Inadequate||||||F
OBX|118|CE|NuONBARR01^Barriers to eating^ADM||22^NPO||||||F
OBX|119|TX|NuONINTA00^Oral nutrition current food intake^ADM||NPO x 2 days||||||F
OBX|120|TX|NuONORDI01^Oral diet type^ADM||NPO||||||F
OBX|121|TX|NuSGA00100^SGA weight change - overall loss in past 6 months^ADM||1.000||||||F
OBX|122|CE|NuSGA01800^SGA rating^ADM||1^A= Well nourished||||||F
OBX|123|TX|NuTEEDCO00^Nutrition education content (specify)^ADM||nasogastric tube||||||F
OBX|124|CE|NuWTCH0000^Weight change calculation based on^ADM||1^Usual/Previous weight||||||F
OBX|125|TX|OEDIAG^Diagnosis:^ADM||Testing Diagnosis||||||F
OBX|126|CE|OEISO^Infection Control:^ADM||D^Droplet||||||F
OBX|127|CE|OhIN000300^Information source^ADM||1^Patient~2^Health record review||||||F
OBX|128|TX|OhPT000101^Treatment analysis^ADM||analysis from UAP PT||||||F
OBX|129|TX|OhPT000201^Patient's concerns^ADM||patients subjective report from UAP PT||||||F
OBX|130|TX|OhPTSTUP00^Patient status update^ADM||patient status update from UAP PT||||||F
OBX|131|TX|OtPDABTR00^Appointments, booking and transportation ? ? ^ADM||Booked for cath Nov 5~1100 at RCH||||||F
OBX|132|TX|OtPDCAR00^Consults and referrals^ADM||Cardiac consult||||||F
OBX|133|TX|OtPDGLUC00^Glucometer frequency^ADM||Gluc Q6H||||||F
OBX|134|TX|OtPDPCCN00^PCC notes^ADM||Testing PCC Notes~Line 2~Line 3~Line 4||||||F
OBX|135|TX|OtPDSPDO00^Surgery/Procedure 1 date^ADM||20191016||||||F
OBX|136|TX|OtPDSPDT00^Surgery/Procedure 2 date^ADM||20191021||||||F
OBX|137|TX|OtPDSPON00^Surgery/Procedure 1^ADM||Bowel resection||||||F
OBX|138|TX|OtPDSPTW00^Surgery/Procedure 2^ADM||Trach||||||F
OBX|139|TX|OtPDSSUM00^Shift summary^ADM||Testing Shift summary~Line 2~Line 3~Line 4||||||F
OBX|140|TX|OtPDVSIG00^Vital signs frequency^ADM||VS Q4H||||||F
OBX|141|TX|OtPDWEIG00^Weight frequency^ADM||Weight OD||||||F
OBX|142|TX|OtRPOSBD00^Recommendations for positioning in bed^ADM||bed possitioning recommendations||||||F
OBX|143|TX|OtRSEATG00^Recommendations for seating^ADM||recommendations for seating||||||F
OBX|144|CE|OtRSITTL00^Recommendation for sitting tolerance^ADM||2^1 hour||||||F
OBX|145|TX|OtSGBMGM00^Recommendations for behavioural management^ADM||recommendations for behaviour management||||||F
OBX|146|TX|PdDGFQ0000^Dressing change frequency^ADM||Dressing change BID||||||F
OBX|147|TX|PdOIOUTP01^Intake/Output^ADM||||||||F
OBX|148|TX|PdTUBDRN00^Tubes/Drains/Lines^ADM||testing tubes lines and drains||||||F
OBX|149|CE|ReCOLMET01^Secretions collection method^ADM||2^Open catheter||||||F
OBX|150|TX|ReDIFFAW01^Difficult airway^ADM||Y||||||F
OBX|151|CE|ReOXYTHE04^Oxygen therapy delivery method^ADM||5^Nasal cannula||||||F
OBX|152|CE|ReSCAMNT00^Secretions amount^ADM||2^Small||||||F
OBX|153|CE|ReSCCOLR00^Secretions colour^ADM||1^Clear||||||F
OBX|154|CE|ReSCDESC02^Secretions description^ADM||1^Mucoid||||||F
OBX|155|CE|ReSE000100^Secretion source^ADM||1^Endotracheal||||||F
OBX|156|TX|ReSECCOM00^Secretions comments^ADM||comments||||||F
OBX|157|TX|ReSECMET00^Secretions collection method other^ADM||secretion collection method other||||||F
OBX|158|TX|SpCARPOS00^Recommendations for car seat/positioning^ADM||recommendations for care/seat positioning||||||F
OBX|159|CE|SpCONPAT00^Consent received from patient^ADM||1^Verbal||||||F
OBX|160|CE|SpCONRIS00^Assessment/Treatment benefits and risks explained to^ADM||1^Patient||||||F
OBX|161|CE|SpCONTYP00^Consent received for^ADM||1^Assessment~2^Treatment plan||||||F
OBX|162|TX|SpOSPATT01^Observed sleep pattern^ADM||sleep pattern||||||F
OBX|163|TX|SpPRLOTH00^Physical restraint location other^ADM||restraint location other||||||F
OBX|164|CE|SpPRSCHE00^Physical restraint safety checks^ADM||4^Body in alignment||||||F
OBX|165|TX|SpPRSCOT00^Physical restraint safety checks other^ADM||restraint safety checks other||||||F
OBX|166|TX|SpREPSLE00^Reported sleep pattern^ADM||not applicable||||||F
OBX|167|TX|SpREST0001^Family informed of need for restraint measures^ADM||Y||||||F
OBX|168|CE|SpRESTRA00^Physical restraint location^ADM||2^Left wrist||||||F
OBX|169|TX|SpSLEAID00^Sleep aid PRN given^ADM||N||||||F
OBX|170|TX|TeEDNAME00^Name of person if other than patient^ADM||Nicole||||||F
OBX|171|CE|VsBPPOST02^Patient position^ADM||2^Supine||||||F
OBX|172|TX|VsHTCM0100^Current height^ADM||170.2||||||F
OBX|173|TX|VsOXDRAD01^Oxygen therapy delivery rate^ADM||5||||||F
OBX|174|TX|VsSOXYGE00^Oxygen saturation (O2) goal^ADM||Sat>92%||||||F
OBX|175|CE|VsWGCBMI01^Weight used to calculate body mass index^ADM||1^Current weight||||||F
OBX|176|TX|VsWT000101^Current Weight^ADM||74.000||||||F
OBX|177|CE|VsWT000400^Current weight source^ADM||1^Measured||||||F
OBX|178|TX|VsWT002701^Usual/Previous weight^ADM||75.000||||||F
OBX|179|CE|VsWT004900^Height or length source^ADM||1^Measured (head-to-toe)||||||F
OBX|180|TX|VsWT005300^Body mass index^ADM||25.6||||||F
OBX|181|TX|VsWTGRAM00^Weight (Calculated Grams)^ADM||74000.000||||||F
AL1|1|DA|F006001545^morphine|MI|Hives/Urticaria       *AL|20191021
ZFD|ZTEST^Test Provider^IM/IT^Use Only^^^^500001^DOC||||ZTEST^Test Provider^IM/IT^Use Only^^^^500001^DOC|ZTEST^Test Provider^IM/IT^Use Only^^^^500001^DOC|
ZFH|LUMED||||||

