MSH|^~\&|ADM|ARH|||202001131219||ADT^A08|4144915|D|2.2|||AL|NE
EVN|A08|202001131219||||
PID|1|FHATVIG0012877||AB8350|EDMTEST^ONE||20011227|F||||||||||AB000892/19|
PV1|1|P|AB.ERZ2|||||||||||||||ER|||||||||||||||||||||ARH|||||201912271110|
PV2|||
OBX|1|ST|1010.1^WEIGHT^CPT4||56.000||||||F
OBX|2|TX|AdNICUA141^Other PIV comments^ADM||Site dry and intact pt is comfortable and has no complaints.||||||F
OBX|3|CE|Ca00000100^Right radial pulse^ADM||5^+3||||||F
OBX|4|CE|Ca00000200^Right ulnar pulse^ADM||5^+3||||||F
OBX|5|CE|Ca00000400^Left radial pulse^ADM||5^+3||||||F
OBX|6|CE|Ca00000500^Left ulnar pulse^ADM||5^+3||||||F
OBX|7|CE|Ca00000700^Right dorsalis pedis pulse^ADM||5^+3||||||F
OBX|8|CE|Ca00000800^Right post tibial pulse^ADM||5^+3||||||F
OBX|9|CE|Ca00000900^Right popliteal pulse^ADM||5^+3||||||F
OBX|10|CE|Ca00001000^Left dorsalis pedis pulse^ADM||5^+3||||||F
OBX|11|CE|Ca00001100^Left post tibial pulse^ADM||5^+3||||||F
OBX|12|CE|Ca00001200^Left popliteal pulse^ADM||5^+3||||||F
OBX|13|CE|Ca00001300^Right femoral pulse^ADM||5^+3||||||F
OBX|14|CE|Ca00001400^Left femoral pulse^ADM||5^+3||||||F
OBX|15|TX|CaBLSRCL00^Source of blood loss^ADM||lesion on right hand||||||F
OBX|16|CE|CaEDEMA000^Edema^ADM||2^Present||||||F
OBX|17|CE|CaHS000200^Heart sounds quality^ADM||3^Loud||||||F
OBX|18|TX|CaHS000300^Heart sounds murmur^ADM||N||||||F
OBX|19|TX|CaHS000500^Heart sounds rub^ADM||N||||||F
OBX|20|TX|CaHS000600^Heart sounds mechanical valve click^ADM||Y||||||F
OBX|21|CE|CaHS000700^Heart sounds audible^ADM||1^S1~3^S2||||||F
OBX|22|TX|CaMSRBLL00^Measured blood loss^ADM||0.00||||||F
OBX|23|CE|CaPARAMR00^Cardiovascular defined parameters^ADM||2^Significant findings||||||F
OBX|24|TX|CaPLNEED00^Peripheral line daily assessment ongoing need reviewed^ADM||Y||||||F
OBX|25|CE|CoNOVECO00^Nonverbal communication^ADM||2^Mouthing words||||||F
OBX|26|TX|EDMCHIEF^Chief Complaint^ADM||NSEIZPOST||||||F
OBX|27|CE|EDMPRIOR^Triage Level^ADM||2^CTAS Level 2||||||F
OBX|28|TX|Gi00000600^Maintaining baseline stool pattern^ADM||N||||||F
OBX|29|CE|GiABPALP02^Abdominal palpation^ADM||4^Firm||||||F
OBX|30|CE|GiABSHAP00^Abdominal shape^ADM||1^Flat||||||F
OBX|31|CE|GiBMINTE01^Bowel movement level of intervention^ADM||2^Disimpaction||||||F
OBX|32|CE|GiBOFLAT00^Bowel flatus present^ADM||1^Absent||||||F
OBX|33|CE|GiBOWELLLQ^Bowel sounds lower left quadrant^ADM||1^Active||||||F
OBX|34|CE|GiBOWELLRQ^Bowel sounds lower right quadrant^ADM||4^Absent||||||F
OBX|35|CE|GiBOWELULQ^Bowel sounds upper left quadrant^ADM||3^Hyperactive||||||F
OBX|36|CE|GiBOWELURQ^Bowel sounds upper right quadrant^ADM||1^Active||||||F
OBX|37|CE|GiBSACTI01^Bowel sounds active in all four quadrants^ADM||2^No||||||F
OBX|38|TX|GiCONSTI00^Patient experiencing constipation^ADM||Y||||||F
OBX|39|TX|GiDIARRH00^Patient experiencing diarrhea^ADM||N||||||F
OBX|40|TX|GiEMAMME00^Emesis amount measured^ADM||250||||||F
OBX|41|TX|GiNAUSVO00^Patient experiencing nausea/vomiting^ADM||Y||||||F
OBX|42|CE|GiPARAMR00^Gastrointestinal defined parameters^ADM||1^Within defined parameters||||||F
OBX|43|TX|GuBDSVA000^Bladder scan volume^ADM||50||||||F
OBX|44|CE|GuBDURSS01^Urinary retention signs and symptoms^ADM||2^Palpable bladder~4^Increased blood pressure~7^Change in voiding pattern~8^Restlessness or agitation~10^Unable to void on sensing||||||F
OBX|45|CE|GuPARAMR00^Genitourinary defined parameters^ADM||1^Within defined parameters||||||F
OBX|46|TX|GuUCINS000^Urinary catheter in situ and patent^ADM||Y||||||F
OBX|47|CE|GuUCRFCU00^Reason for urinary catheter continued use^ADM||1^Unrelieved retention~6^Long term catheter||||||F
OBX|48|TX|GuUCSDU000^Urinary catheter securement device in use^ADM||N||||||F
OBX|49|CE|HeCO000100^Verbal communication^ADM||1^No obvious concerns||||||F
OBX|50|CE|HeTR000100^Trachea position^ADM||3^Deviated right||||||F
OBX|51|CE|Hx00000100^Previously healthy^ADM||1^Yes||||||F
OBX|52|TX|HxSPTCHX01^Pertinent clinical history^ADM||Patient has a history of IBS and other gastro symptoms.  She had febrile~seizures in the past with another flu.||||||F
OBX|53|CE|InBSACTV00^Braden Scale activity^ADM||3^3-Walks occasionally||||||F
OBX|54|CE|InBSFRSH00^Braden Scale friction and shear^ADM||3^3-No apparent problem||||||F
OBX|55|CE|InBSMOBI01^Braden Scale mobility^ADM||3^3-Slightly limited||||||F
OBX|56|CE|InBSMOIS00^Braden Scale moisture^ADM||3^3-Occasionally moist||||||F
OBX|57|CE|InBSNUTR00^Braden Scale nutrition^ADM||2^2-Probably inadequate||||||F
OBX|58|TX|InBSRISK01^Braden Scale risk level^ADM||Low||||||F
OBX|59|TX|InBSSCOR00^Braden Skin Risk Assessment Score^ADM||18||||||F
OBX|60|CE|InBSSPER00^Braden Scale sensory perception^ADM||4^4-No impairment||||||F
OBX|61|CE|InEDEMAS00^Edema severity^ADM||3^+3||||||F
OBX|62|CE|InEDEMLB01^Edema location^ADM||12^Foot||||||F
OBX|63|CE|InEDEMLM00^Edema location modifier^ADM||3^Right||||||F
OBX|64|CE|InEDEMTP00^Edema type^ADM||1^Pitting||||||F
OBX|65|TX|InINDRES00^Dressing dry and intact^ADM||Y||||||F
OBX|66|CE|InISGR0000^infiltration Scale Grade^ADM||2^+1||||||F
OBX|67|CE|InPARAMR00^Integumentary defined parameters^ADM||1^Within defined parameters||||||F
OBX|68|CE|InPESIDE00^Peripheral line site description^ADM||1^Satisfactory||||||F
OBX|69|CE|InSKIAPP01^Skin appearance^ADM||4^Erythema||||||F
OBX|70|CE|InSKIMOI02^Skin moisture^ADM||5^Moist||||||F
OBX|71|CE|InSKITEM00^Skin temperature^ADM||2^Warm||||||F
OBX|72|CE|IvFLUSHS01^Flush solution^ADM||1^Normal saline||||||F
OBX|73|CE|IvFLUSHV00^Flush volume^ADM||2^10 mL||||||F
OBX|74|TX|IvLINCAO00^Line care other^ADM||3mL NS||||||F
OBX|75|CE|IvLINECA02^Saline lock care^ADM||1^Flush||||||F
OBX|76|CE|IvLOCATM01^Location Modifier^ADM||1^Right||||||F
OBX|77|CE|IvPIVLOC00^Location^ADM||5^Hand PIV||||||F
OBX|78|CE|IvPL000700^Initial management^ADM||2^Saline lock||||||F
OBX|79|CE|IvPS000100^Phlebitis scale grade^ADM||1^0||||||F
OBX|80|CE|IvREMOVE00^Removal reason^ADM||1^No longer needed||||||F
OBX|81|TX|IvSIZE0000^Size^ADM||22||||||F
OBX|82|CE|MhAFFECT01^Affect^ADM||11^Sad||||||F
OBX|83|TX|MhESMOOD04^Mood^ADM||aimless||||||F
OBX|84|CE|MhMSEATT01^Attitude^ADM||3^Approachable||||||F
OBX|85|CE|MhPED00100^Behaviour^ADM||8^Restless||||||F
OBX|86|CE|MoPOBDPO01^Bed position^ADM||6^Reverse trendelenburg||||||F
OBX|87|TX|NEURO.PS1^Pain Scale^ADM||7||||||F
OBX|88|CE|NeCATLOC03^5. Altered level of consciousness^ADM||3^Lethargic||||||F
OBX|89|CE|NeCDIFFA02^3. Inattention^ADM||1^Yes||||||F
OBX|90|TX|NeCDIORE01^CAM result^ADM||Delirium Suspected||||||F
OBX|91|CE|NeCEACMS02^1. Acute onset^ADM||1^Yes||||||F
OBX|92|CE|NeCFBDPD02^2. Fluctuating course^ADM||1^Yes||||||F
OBX|93|CE|NeCSPDSI02^4. Disorganized thinking^ADM||1^Yes||||||F
OBX|94|CE|NeGCSEYE03^Glasgow Coma Scale Eye Opening^ADM||1^4- Spontaneous||||||F
OBX|95|CE|NeGCSMOT03^Glasgow Coma Scale Motor Response^ADM||5^5- Localizing||||||F
OBX|96|TX|NeGCSSCR01^GCS score^ADM||13||||||F
OBX|97|CE|NeGCSVER03^Glasgow Coma Scale Verbal Response^ADM||4^4- Confused||||||F
OBX|98|TX|NeGLBLGU00^Glucometer blood glucose^ADM||7.5||||||F
OBX|99|CE|NeLECONS00^Level of consciousness^ADM||3^Stuporous||||||F
OBX|100|CE|NeORIENT01^Oriented to^ADM||3^Place~4^Date/Time~5^Situation||||||F
OBX|101|CE|NePARAMR00^Neurological and cognition defined parameters^ADM||2^Significant findings||||||F
OBX|102|CE|NePOSC0000^POSS score^ADM||3^3 - Frequently drowsy||||||F
OBX|103|CE|NePUEYED01^Eye deviation^ADM||2^Left||||||F
OBX|104|CE|NePURXNL00^Pupil reaction to light^ADM||1^Brisk||||||F
OBX|105|CE|NePUSHPE00^Pupil shape^ADM||1^Round||||||F
OBX|106|CE|NePUSIDE00^Pupil side^ADM||3^Bilateral||||||F
OBX|107|TX|NePUSIZE00^Pupil size^ADM||5||||||F
OBX|108|CE|NeRFCRNL00^Corneal reflex left^ADM||2^Absent||||||F
OBX|109|CE|NeRFCRNR00^Corneal reflex right^ADM||1^Present||||||F
OBX|110|CE|NeRFGAGR00^Gag reflex^ADM||1^Present||||||F
OBX|111|TX|NuOEVDRA01^Output, Cerebrospinal Fluid Amount^ADM||0.00||||||F
OBX|112|TX|NuOGRETU01^Output, Gastric Drainage Amount^ADM||0.00||||||F
OBX|113|TX|NuOSTOOL00^Output - stool^ADM||500.00||||||F
OBX|114|TX|NuOURINE00^Output - urine^ADM||300.00||||||F
OBX|115|TX|OhEDIT0000^Reason for edit^ADM||pt has dementia already so that is their normal baseline so that way there||||||F
OBX|116|CE|PaFREQ0000^Pain frequency^ADM||1^At rest||||||F
OBX|117|CE|PaLOCBDS02^Location^ADM||5^Shoulder||||||F
OBX|118|TX|PaNBCATH00^Catheter distal tip intact with removal^ADM||N||||||F
OBX|119|TX|PaPAGOAL02^Pain goal^ADM||manage pain levels||||||F
OBX|120|CE|PaPALOCM00^Pain location modifier^ADM||2^Right~4^Lower~16^Parietal||||||F
OBX|121|CE|PaPANVBA00^Pain non-verbal behaviours^ADM||5^Decreased activity~9^Moans||||||F
OBX|122|CE|PaPAQUAL01^Pain quality^ADM||10^Numbness||||||F
OBX|123|TX|PaPARADI00^Pain radiating^ADM||Y||||||F
OBX|124|CE|PaPARAMR00^Pain defined parameters^ADM||2^Significant findings||||||F
OBX|125|CE|PaPNMGTT00^Pain management techniques^ADM||1^Medication~5^Positioning||||||F
OBX|126|CE|PsPARAMR00^Psychosocial and mood defined parameters^ADM||1^Within defined parameters||||||F
OBX|127|TX|RESP.RA^On Room Air^ADM||N||||||F
OBX|128|TX|ReAENTRY00^Air entry adequate throughout^ADM||Y||||||F
OBX|129|CE|ReAUAIRE01^Air entry^ADM||4^Diminished||||||F
OBX|130|CE|ReAUBTHS02^Breath sounds^ADM||6^Crackles||||||F
OBX|131|CE|ReAULOCT00^Auscultation location^ADM||2^Right lung||||||F
OBX|132|CE|ReAULOMO00^Auscultation location modifier^ADM||1^Anterior||||||F
OBX|133|TX|ReBCLEAR00^Breath sounds clear throughout^ADM||Y||||||F
OBX|134|CE|ReCGDESC01^Cough description^ADM||2^Congested||||||F
OBX|135|TX|ReCGPROD00^Cough productive^ADM||Y||||||F
OBX|136|CE|ReCGREFL00^Cough reflex^ADM||2^Moderate||||||F
OBX|137|CE|ReCGSTGH00^Cough strength^ADM||2^Moderate||||||F
OBX|138|CE|ReCOLMET01^Secretions collection method^ADM||1^Closed/Inline suction||||||F
OBX|139|TX|ReDISTRE00^Respiratory distress comments^ADM||pt is in respiratory distress||||||F
OBX|140|TX|ReEMPHYS00^Subcutaneous emphysema^ADM||N||||||F
OBX|141|TX|ReFRINOX01^Fraction of inspired oxygen (FiO2)^ADM||0.21||||||F
OBX|142|TX|ReMEDGIV00^Inhalers/Nebulizers given^ADM||N||||||F
OBX|143|CE|ReOXYTHE04^Oxygen therapy delivery method^ADM||13^Venturi mask||||||F
OBX|144|CE|RePARAMR00^Respiratory defined parameters^ADM||2^Significant findings||||||F
OBX|145|TX|RePEEXPR01^Peak expiratory flow rate (pre best of three)^ADM||8||||||F
OBX|146|CE|RePHASE000^Phase^ADM||1^Inspiration||||||F
OBX|147|CE|ReRECHEX01^Chest expansion^ADM||2^Right greater than left||||||F
OBX|148|CE|ReREDISI00^Respiratory distress indicators^ADM||6^Diaphoresis~7^Pursed lip breathing||||||F
OBX|149|CE|ReREDPTH00^Respiratory depth^ADM||2^Shallow||||||F
OBX|150|CE|ReRPNM0000^Respiratory pattern^ADM||1^Normal||||||F
OBX|151|CE|ReSCAMNT00^Secretions amount^ADM||2^Small||||||F
OBX|152|CE|ReSCCOLR00^Secretions colour^ADM||2^White||||||F
OBX|153|CE|ReSCDESC02^Secretions description^ADM||2^Sanguineous/bloody||||||F
OBX|154|CE|ReSE000100^Secretion source^ADM||2^Tracheostomy||||||F
OBX|155|CE|ReSECRET00^Secretions source^ADM||1^Suctioned||||||F
OBX|156|CE|ReWRKBRE00^Work of breathing^ADM||2^Mild||||||F
OBX|157|TX|TR.CC^History of Chief Complaint^ADM||nausea and vomiting x 5 days, unable to eat or drink anything.  Had a seizure~tonight and mom called the ambulance.||||||F
OBX|158|CE|VsBPCFLP01^Blood pressure cuff location^ADM||1^Right arm||||||F
OBX|159|CE|VsBPDEUS00^Device used^ADM||1^Automated cuff||||||F
OBX|160|TX|VsBPDIAO01^Blood pressure diastolic^ADM||56||||||F
OBX|161|TX|VsBPMAPA03^Blood pressure mean arterial pressure^ADM||111||||||F
OBX|162|CE|VsBPPOST02^Patient position^ADM||4^Left side lying||||||F
OBX|163|TX|VsBPSYSO01^Blood pressure systolic^ADM||94||||||F
OBX|164|TX|VsHRADLT01^Heart rate^ADM||110||||||F
OBX|165|CE|VsHRLOCA02^Heart rate location^ADM||1^Radial||||||F
OBX|166|CE|VsHRLOMO00^Pulse location modifier^ADM||1^Right||||||F
OBX|167|CE|VsHRMETH00^Heart rate method used^ADM||3^Pulse Oximetry||||||F
OBX|168|CE|VsHRRHYM02^Pulse rhythm^ADM||2^Irregular||||||F
OBX|169|TX|VsOXDRAD01^Oxygen therapy delivery rate^ADM||100||||||F
OBX|170|TX|VsPEWMAP10^Mean arterial pressure^ADM||45||||||F
OBX|171|TX|VsPOOSAD00^Pulse oximetry oxygen saturation^ADM||98||||||F
OBX|172|CE|VsPRLOMO00^Probe location modifier^ADM||1^Right||||||F
OBX|173|CE|VsPROLOC00^Probe location^ADM||2^Toe||||||F
OBX|174|CE|VsPULSTR00^Pulse strength on palpation^ADM||4^Bounding||||||F
OBX|175|TX|VsRESP0100^Oxygen applied^ADM||Y||||||F
OBX|176|TX|VsRESPAD03^Respiratory rate^ADM||22||||||F
OBX|177|CE|VsTPSORC03^Temperature source^ADM||2^Oral||||||F
OBX|178|TX|VsTPTEMPO2^Temperature^ADM||35.9||||||F
OBX|179|TX|VsWT000101^Current Weight^ADM||1.000||||||F
OBX|180|CE|VsWT000700^Weight measurement method^ADM||3^Wheelchair scale||||||F
OBX|181|TX|VsWTGRAM00^Weight (Calculated Grams)^ADM||1000.000||||||F
ZFH|LUMED|202001131206|2|NSEIZPOST|Seizure,Post-ictal GCS10-13||