MSH|^~\&|ADM|MSA|||201912031421||ADT^A08|4122690|D|2.2|||AL|NE
EVN|A08|201912031421||||
PID|1|FHATVIG0012693|AB00008382|AB8299|PCSTEST^MIMIKYU||19551203|M|||456 MAIN ST^^REGINA^SK^S7H 3j9|||||||MS000004/19|
PV1|1|I|MS-WP1W^MSWP1W-43^1|EL|||SEUSST^SEUSS *TEST^THEODORE^*TEST* G^^^^^^^^^XX|||RH-GEN||||||||IN|||||||||||||||||||||MSA|||||201912030901|
PV2||P^Private - Non-Solicited|
OBX|1|ST|1010.1^WEIGHT^CPT4||83.000||||||F
OBX|2|ST|1010.3^HEIGHT^CPT4||178.0||||||F
OBX|3|TX|ADM CURRES^Residing at current add. since (DD/MM/YY)^ADM||20170616||||||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|Ac00000900^Mouth care support provided^ADM||8^Independent||||||F
OBX|8|CE|Ac00001000^Grooming support provided^ADM||8^Independent||||||F
OBX|9|CE|Ac00001100^Toileting hygiene ability^ADM||8^Independent||||||F
OBX|10|CE|Ac00001900^Community supports utilized prior to hospitalization^ADM||3^Private home support||||||F
OBX|11|TX|Ac00002100^Community supports utilized comments^ADM||private support 1/week for supervised bathing||||||F
OBX|12|CE|Ac00002500^Equipment/Aids used prior to hospitalization^ADM||8^Cane||||||F
OBX|13|TX|Ac00003800^IADL support required prior to hospitalization^ADM||takes medication independently at home||||||F
OBX|14|TX|Ac00005100^Equipment/Aids used comments^ADM||occasionally||||||F
OBX|15|CE|AcHEHT0M00^Home environment - housing type^ADM||1^House||||||F
OBX|16|CE|AcTOASST02^Toileting assistance^ADM||3^1 person assist||||||F
OBX|17|TX|Ad00002900^Personal aids present^ADM||Y||||||F
OBX|18|TX|Ad00003000^Communication difficulties^ADM||N||||||F
OBX|19|TX|AdAC000100^Accompanied by other^ADM||EHS||||||F
OBX|20|TX|AdADMDAT01^Admission date^ADM||20191203||||||F
OBX|21|CE|AdADMFRO01^Admitted from^ADM||4^Other site||||||F
OBX|22|TX|AdADMRSN00^Reason for admission^ADM||left hip arthroplasty 1 month ago - rehab||||||F
OBX|23|TX|AdADMTIM00^Admission time^ADM||1000||||||F
OBX|24|TX|AdADMTRA00^Name of other unit/site^ADM||LMH||||||F
OBX|25|TX|AdALLERR00^Allergies reviewed^ADM||Y||||||F
OBX|26|CE|AdARRMOD00^Mode of arrival^ADM||1^Stretcher||||||F
OBX|27|TX|AdCRSTAT00^Current problem status^ADM||refusing hip protectors||||||F
OBX|28|TX|AdGOALCP00^Goal^ADM||universal falls in placew||||||F
OBX|29|TX|AdGOALDT00^Goal target date^ADM||20191207||||||F
OBX|30|CE|AdGOALST00^Goal status^ADM||1^In progress||||||F
OBX|31|TX|AdHXCOND00^History of presenting condition^ADM||fell at home, left hip arthroplasty 1 month ago||||||F
OBX|32|TX|AdINVANR00^1. Intervention to address problem^ADM||bed alarm when in bed||||||F
OBX|33|TX|AdINVANR01^2. Intervention to address problem^ADM||hip protectors - pt refusing even after education||||||F
OBX|34|TX|AdINVANR02^3. Intervention to address problem^ADM||universal falls precautions||||||F
OBX|35|TX|AdINVANR03^4. Intervention to address problem^ADM||constant reminder to call for assistance||||||F
OBX|36|TX|AdNEWBO330^Skin comments^ADM||cream applied||||||F
OBX|37|TX|AdPRLANG00^Primary language spoken^ADM||English||||||F
OBX|38|TX|AdPROBDC00^Problem is a barrier to discharge^ADM||N||||||F
OBX|39|TX|AdPROBDS00^Problem detail^ADM||history of falls at home||||||F
OBX|40|CE|AdPROBID20^Problem identified^ADM||29^Risk: falls||||||F
OBX|41|CE|AdPTA05600^Diet type prior to admission^ADM||1^General||||||F
OBX|42|TX|AdPTA14000^Sleep pattern prior to admission^ADM||Difficulty falling asleep since hip fracture, related to spasms in left~hip and thigh||||||F
OBX|43|CE|AdREPREF00^Report received^ADM||2^By telephone||||||F
OBX|44|CE|Ca00000700^Right dorsalis pedis pulse^ADM||5^+3||||||F
OBX|45|CE|Ca00001000^Left dorsalis pedis pulse^ADM||5^+3||||||F
OBX|46|CE|Ca00001900^Cardiovascular assessment^ADM||2^Significant findings||||||F
OBX|47|TX|Ca00002100^Circulation satisfactory^ADM||Y||||||F
OBX|48|CE|CaEDEMA000^Edema^ADM||2^Present||||||F
OBX|49|TX|CmMRPAWR01^MRP or physician aware^ADM||Y||||||F
OBX|50|CE|CmMRPCME01^MRP or physician communication method^ADM||2^By phone||||||F
OBX|51|TX|CmMRPCOC01^MRP or physician communication outcome^ADM||orders received for STAT xray and non-weight bearing||||||F
OBX|52|TX|Ec00000000^History of diabetes^ADM||N||||||F
OBX|53|TX|Gi00001400^Gastrointestinal pre-hospital baseline^ADM||GI pre hospital||||||F
OBX|54|CE|Gi00001500^Gastrointestinal assessment^ADM||1^Within defined parameters||||||F
OBX|55|TX|Gi00001600^Genitourinary pre-hospital baseline^ADM||long standing issues with frequency and urgency to void||||||F
OBX|56|CE|Gi00001700^Genitourinary assessment^ADM||3^At pre-hospital baseline||||||F
OBX|57|CE|Gi00001900^Care plan^ADM||1^Initiated||||||F
OBX|58|CE|GiBMAMT201^Bowel movement amount^ADM||2^Medium (240 mL)||||||F
OBX|59|TX|GiBMINCO00^Bowel movement incontinence^ADM||N||||||F
OBX|60|TX|GiBO000301^Last bowel movement date as reported by patient^ADM||20191203||||||F
OBX|61|CE|GiBS000100^Bowel sounds frequency^ADM||1^Active||||||F
OBX|62|TX|GiBSST0001^Bristol Chart stool consistency^ADM||4||||||F
OBX|63|TX|GiFART0001^Flatus^ADM||Y||||||F
OBX|64|TX|GuBDINCO00^Bladder incontinence^ADM||N||||||F
OBX|65|TX|Hx486PRO00^Pre-admission screening questionnaire provided^ADM||N||||||F
OBX|66|TX|HxSPTCHX01^Pertinent clinical history^ADM||CBA 12 years ago, HTN, CHF||||||F
OBX|67|TX|In00000600^Skin pre-hospital baseline^ADM||skin pre-hospital baseline||||||F
OBX|68|CE|In00001000^Skin description^ADM||1^Flaky||||||F
OBX|69|TX|In00001100^Wound dressing change details^ADM||cleassed with NS and barrier cream applied.||||||F
OBX|70|CE|InBSACTV00^Braden Scale activity^ADM||3^3-Walks occasionally||||||F
OBX|71|CE|InBSFRSH00^Braden Scale friction and shear^ADM||2^2-Potential problem||||||F
OBX|72|CE|InBSMOBI01^Braden Scale mobility^ADM||3^3-Slightly limited||||||F
OBX|73|CE|InBSMOIS00^Braden Scale moisture^ADM||3^3-Occasionally moist||||||F
OBX|74|CE|InBSNUTR00^Braden Scale nutrition^ADM||3^3-Adequate||||||F
OBX|75|TX|InBSRISK01^Braden Scale risk level^ADM||Low||||||F
OBX|76|TX|InBSSCOR00^Braden Skin Risk Assessment Score^ADM||17||||||F
OBX|77|CE|InBSSPER00^Braden Scale sensory perception^ADM||3^3-Slightly limited||||||F
OBX|78|CE|InEDEMLB01^Edema location^ADM||12^Foot||||||F
OBX|79|CE|InEDEMLM00^Edema location modifier^ADM||2^Left||||||F
OBX|80|CE|InEDEMTP00^Edema type^ADM||2^Non-pitting||||||F
OBX|81|CE|InSKIMOD01^Skin and wound modifier^ADM||1^Left~4^Lower||||||F
OBX|82|CE|InWNDLOC02^Wound location^ADM||31^Buttock||||||F
OBX|83|CE|InWNDMOD00^Wound location modifier^ADM||1^Right||||||F
OBX|84|CE|InWNDTYM00^Wound type^ADM||4^Skin tear||||||F
OBX|85|CE|InWOULOC02^Skin or wound location^ADM||17^Leg||||||F
OBX|86|TX|MhALERTE00^Alert criteria met^ADM||N||||||F
OBX|87|CE|MhEYETYP02^Type of eyewear^ADM||1^Glasses||||||F
OBX|88|CE|MhINFOSC00^Information source^ADM||1^Patient~9^Health record review||||||F
OBX|89|TX|MhMRSAMD00^MRSA/MDRO swabs collected^ADM||Y||||||F
OBX|90|CE|MhPBDEND01^Disposition of dentures^ADM||1^None present||||||F
OBX|91|CE|MhPBGLAD01^Disposition of eyewear^ADM||3^Kept/Sent with patient||||||F
OBX|92|TX|MhPBOAID02^Other personal aids^ADM||cane||||||F
OBX|93|TX|MhPERAID01^Personal aids present^ADM||Y||||||F
OBX|94|CE|Mo00000200^Transfer support provided for bed to chair transfer^ADM||6^1 person assist||||||F
OBX|95|CE|Mo00000300^Transfer support provided for chair to bed transfer^ADM||6^1 person assist||||||F
OBX|96|CE|Mo00000400^Transfer support provided for toilet transfer^ADM||6^1 person assist||||||F
OBX|97|CE|Mo00000500^Ambulation support provided^ADM||6^1 person assist||||||F
OBX|98|CE|Mo00000600^Upper body dressing support provided^ADM||8^Independent||||||F
OBX|99|CE|Mo00000800^Lower body dressing support provided^ADM||6^1 person assist||||||F
OBX|100|CE|Mo00001400^Falls safety equipment set up on admission^ADM||1^Bed alarm||||||F
OBX|101|TX|Mo00002100^Falls in hospital^ADM||N||||||F
OBX|102|TX|Mo00002300^Independent with mobility and ADLs prior to hospitalization^ADM||Y||||||F
OBX|103|CE|MoAIDAMB01^Ambulation aid^ADM||10^Walker: 2 wheeled||||||F
OBX|104|CE|MoFA000001^Fall prevention strategies^ADM||1^Universal~10^Hip protectors||||||F
OBX|105|TX|Ne00005000^Neurological pre-hospital baseline^ADM||neurological pre-hospital baseline||||||F
OBX|106|CE|Ne00005100^Neurological assessment^ADM||1^Within defined parameters||||||F
OBX|107|TX|Ne00005500^Pain reported^ADM||N||||||F
OBX|108|TX|Ne00005600^Orientation checks complete^ADM||Y||||||F
OBX|109|TX|Ne00005800^History of seizure^ADM||N||||||F
OBX|110|CE|NeCATLOC03^5. Altered level of consciousness^ADM||1^Alert||||||F
OBX|111|CE|NeCDIFFA02^3. Inattention^ADM||2^No||||||F
OBX|112|TX|NeCDIORE01^CAM result^ADM||Delirium not suspected||||||F
OBX|113|CE|NeCEACMS02^1. Acute onset^ADM||2^No||||||F
OBX|114|CE|NeCFBDPD02^2. Fluctuating course^ADM||2^No||||||F
OBX|115|CE|NeCSPDSI02^4. Disorganized thinking^ADM||2^No||||||F
OBX|116|TX|NeGLBLGU00^Glucometer blood glucose^ADM||5.2||||||F
OBX|117|CE|NeLECONS00^Level of consciousness^ADM||1^Alert||||||F
OBX|118|CE|NeLECONS01^Level of consciousness^ADM||1^Alert||||||F
OBX|119|CE|NeORIENT01^Oriented to^ADM||1^All domains||||||F
OBX|120|CE|NePURXNL00^Pupil reaction to light^ADM||1^Brisk||||||F
OBX|121|CE|NePUSIDE00^Pupil side^ADM||3^Bilateral||||||F
OBX|122|TX|NePUSIZE00^Pupil size^ADM||2||||||F
OBX|123|TX|Nu00000900^Have you lost wt in the past 6 mo without trying to lose wt?^ADM||N||||||F
OBX|124|TX|Nu00001000^Have you been eating less than usual for more than a week?^ADM||N||||||F
OBX|125|CE|NuCMSTHR00^Canadian malnutrition screening tool high nutritional risk^ADM||2^No||||||F
OBX|126|CE|OEISO^Infection Control:^ADM||S^Standard/Routine||||||F
OBX|127|CE|Oh00000801^Care plan^ADM||1^Initiated||||||F
OBX|128|TX|Oh00000900^Patient stated rehab goals^ADM||independent with all ADLs, Ambulation and stair management||||||F
OBX|129|TX|Oh00001000^Reported bedtime^ADM||0000||||||F
OBX|130|TX|Oh00001100^Reported wake time^ADM||0800||||||F
OBX|131|TX|Oh00001200^Number naps during day^ADM||1||||||F
OBX|132|CE|OhIN000300^Information source^ADM||1^Patient||||||F
OBX|133|TX|OhMOSTST00^MOST status reviewed^ADM||Y||||||F
OBX|134|TX|Pa00000000^Pain pre-hospital baseline^ADM||pain prehospital baseline||||||F
OBX|135|CE|Pa00000100^Pain assessment^ADM||3^Pain present||||||F
OBX|136|CE|PaLOCBDS02^Location^ADM||21^Hip||||||F
OBX|137|CE|PaPALOCM00^Pain location modifier^ADM||1^Left||||||F
OBX|138|CE|PaPASCL000^Pain scale used^ADM||1^Numeric||||||F
OBX|139|TX|PaPASCRE01^Pain score^ADM||8.00||||||F
OBX|140|TX|PaPATEXP00^Patient experiencing pain^ADM||Y||||||F
OBX|141|CE|PaPNMGTT00^Pain management techniques^ADM||1^Medication||||||F
OBX|142|TX|PsCLB00000^Communication language barrier^ADM||N||||||F
OBX|143|CE|PsFIMS0002^Marital status^ADM||1^Single||||||F
OBX|144|CE|Re00000100^Respiratory assessment^ADM||2^Significant findings||||||F
OBX|145|TX|Re00000200^Airway stable^ADM||Y||||||F
OBX|146|TX|Re00000300^Breathing easy^ADM||Y||||||F
OBX|147|CE|ReAUBTHS02^Breath sounds^ADM||6^Crackles||||||F
OBX|148|CE|ReAULOCT00^Auscultation location^ADM||2^Right lung||||||F
OBX|149|CE|ReOXYTHE04^Oxygen therapy delivery method^ADM||1^Room air||||||F
OBX|150|CE|ReREDPTH00^Respiratory depth^ADM||1^Normal||||||F
OBX|151|CE|ReRPNM0000^Respiratory pattern^ADM||1^Normal||||||F
OBX|152|TX|SpFALWIT00^Fall witnessed^ADM||Y||||||F
OBX|153|CE|SpFASETF01^Fall safety equipment in use at time of fall^ADM||1^Hip protectors||||||F
OBX|154|TX|SpHENEIN00^Concerns re: possible head and/or neck injury^ADM||N||||||F
OBX|155|TX|SpINJFAL00^Other injuries sustained in fall^ADM||N||||||F
OBX|156|TX|SpORNEIN00^Concerns re: orthopedic/neurovascular injury^ADM||Y||||||F
OBX|157|TX|SpPFPANC01^On anticoagulant therapy^ADM||Y||||||F
OBX|158|TX|SpTIMEFD00^Time fall discovered/occurred^ADM||0850||||||F
OBX|159|TX|SpUPAICM01^Fall prevention comments^ADM||refusing||||||F
OBX|160|CE|TeEDOUTM00^Learning outcome^ADM||1^Shows understanding~3^Reinforcement needed||||||F
OBX|161|CE|TeEDPRVD00^Education provided to^ADM||1^Patient||||||F
OBX|162|TX|TeEDTOPC00^Topics of education^ADM||hip protectors reason for use||||||F
OBX|163|TX|TeEDUCOM00^Education comment^ADM||refuses to wear||||||F
OBX|164|TX|VsBPDIAO01^Blood pressure diastolic^ADM||85||||||F
OBX|165|TX|VsBPSYSO01^Blood pressure systolic^ADM||140||||||F
OBX|166|TX|VsHRADLT01^Heart rate^ADM||65||||||F
OBX|167|CE|VsHRLOCA02^Heart rate location^ADM||1^Radial||||||F
OBX|168|CE|VsHRLOMO00^Pulse location modifier^ADM||1^Right||||||F
OBX|169|CE|VsHRMETH00^Heart rate method used^ADM||1^Palpation||||||F
OBX|170|TX|VsHTCM0100^Current height^ADM||178.0||||||F
OBX|171|TX|VsPOOSAD00^Pulse oximetry oxygen saturation^ADM||93||||||F
OBX|172|TX|VsRESPAD03^Respiratory rate^ADM||20||||||F
OBX|173|CE|VsTPSORC03^Temperature source^ADM||2^Oral||||||F
OBX|174|TX|VsTPTEMPO2^Temperature^ADM||36.8||||||F
OBX|175|TX|VsWT000101^Current Weight^ADM||83.000||||||F
OBX|176|CE|VsWT000700^Weight measurement method^ADM||2^Bed scale||||||F
OBX|177|CE|VsWT004900^Height or length source^ADM||3^Stated||||||F
OBX|178|TX|VsWTGRAM00^Weight (Calculated Grams)^ADM||83000.000||||||F
OBX|179|TX|ADM WCB^IS THIS VISIT RELATED TO A WCB CLAIM?^INS||N||||||F
ZFD|SEUSST^SEUSS *TEST^THEODORE^*TEST* G^^^^12^DOC|123 ROAD^^SURREY^BC^V2V 0A0|||SEUSST^SEUSS *TEST^THEODORE^*TEST* G^^^^12^DOC|SEUSST^SEUSS *TEST^THEODORE^*TEST* G^^^^12^DOC|
ZFH|LUMED||||||

