J18.9
99309
Monitor Levofloxacin. Monitor for unspecific organisms.
The patient's lungs are clear on auscultation, and heart S1 and S2 are present—the last bowel movement was 03/15/25. The skin is intact. No pain, nausea/ vomiting, or SOB were reported. No edema was present. The patient was sitting in his wheelchair. The patient is alert time 4. The patient's abdomen is soft and not distended. No edema present, and the skin is intact. The patient reported poor appetite. The patient reported, " I don't like the food they give me." Education was provided about the importance of eating and taking good intake.
No known allergies
Levofloxacin tablet; 500 mg; amt: 1 tab; oral Special Instructions: levofloxacin tab 500 mg (1 tab QD) X 7 days .Dx: Pneumonia Once A Day. Begin: 03/15/2025 - 03/21/2025 End: 03/21/2025
J18.9 Pneumonia, unspecified organism
Levofloxacin tablet; 500 mg; amt: 1 tab; oral Special Instructions: levofloxacin tab 500 mg (1 tab QD) X 7 days .Dx: Pneumonia Once A Day. Begin: 03/15/2025 - 03/21/2025 End: 03/21/2025
Diet: LCS/NAS, Mechanical Soft. Oral care, ambulation with assistance, good nutrition, and complete the antibiotic.
99309
YES
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