Document
Facility
Patient Name
DOB
SEX
NOTES
Photos or/and Videos
DOS
*
Room #
*
Type of Care
*
SKILLED
LTC
PRIVATE
HOSPICE
NA
STATUS
FOLLOW UP
NEW
Time of Service
DX
DX-1
DX-2
Census Team Notes/Comments
*
Meropenem 03/17-03/23 & Doxycycline 03/18-03/23
Chief Complaint (CC)
Right ear pain and itching. Monitor Meropenem 03/17 to 03/23 and Doxycycline 03/18 to 03/23
Subjetive
HPI
Rivera Viera Noel is a 52cy/o male patient with PMH of Acute respiratory failure with hypoxia, Tracheostomy status, Dependence on respirator [ventilator] status, Pneumonia, unspecified organism, Acute pulmonary edema, Pleural effusion, not elsewhere classified Heart failure, unspecified, Down syndrome, Type 2 diabetes mellitus without complications, Hypothyroidism, Anemia. The patient will be evaluated today for medical needs to avoid future complications. Today, the patient was lying in a hospital bed and followed simple commands. He had decreased respiratory sounds in both lung bases, and no accessory muscle was noted. The patient's right ear was improved, and cleaning with NS was applied. The patient was in discomfort. Continue with Meropenem 1 g iv q12 hour for 7 days and Doxycycline 100 mg po bid for 7 days. The patient heart rate was regular, S1 and S2 noted. No edema was present. capillary refill less than 2 sec. radial pulse 2+ bilateral. The RN cleaned the patient's right ear, and a dressing was applied to prevent more episodes of scratching.
Allergies
*
Penicillin and cephalosporins
Epidemiology
n/a
Current Medications
*
Meropenem 1 g iv q12 hours for 7 days and Doxycycline 100 mg po for 7 days Starting: 03/17/25 Ending: 03/23/25
Objetive
Vital Signs
BP (mm Hg)
HR (bmp)
RR (breaths/min)
Q2 SAT (%, Room air)
T (°F)
General Appearance
*
n/a
HEENT
Eyes
n/a
Ears
n/a
Nose
n/a
Throat
n/a
Cardiovascular
n/a
Respiratory
n/a
Gastrointestinal
n/a
Skin
n/a
Musculoskeletal
n/a
Neurological
n/a
Lymphatic
n/a
Microbiology Data
n/a
Antimicrobial Therapy
n/a
Diagnostic test or pertinent labs
n/a
ASSESSMENT
ICD-10 Diagnosis
PLAN
Antibiotics
Meropenem 1 g iv q12 hours for 7 days and Doxycycline 100 mg po for 7 days Starting: 03/17/25 at 06:00 AM Ending: 03/23/25
Monitor signs of sepsis fever or change in mental status
n/a
ID team will be available if there is deterioration of the clinical condition
n/a
Vaccines
n/a
I reviewed the hospital discharge summary, consultants’ notes, relevant labs, medications, and images.
n/a
Risk of Complications and/or Morbidity or Mortality
n/a
Other recommendations
Careful airway management, infection control, and respiratory support. Ensure proper tracheostomy care by regularly suctioning secretions, maintaining humidification to prevent mucus plugging, and monitoring for signs of respiratory distress or worsening infection. Education was given about the importance of oral care to prevent infection and continue with the antibiotic treatment. Education was given to RN to assess for pain to be able to minimize patient discomfort and administer PRN pain medication. Continue round to evaluate patient condition.
PROVIDER’s Eduviges M Puentes, ARNP
Case discussed with Dr. Leopoldo Cordova
Ferrer Pulmonary Institute
CPT code (s)
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