MSH|^~\&|ITS|SMH|||202001140508||ORU^R01|4145391|D|2.3|||AL|NE PID|1|FHATVIG0013014|SM00047233|SM47012|SMITHSON^LUMED||19711110|F||||||||||SM003928/19|9923981723 PV1|1|I ORC||5143.002SMH OBR|1|SW5143.002SMH||SW^REF^Social Work Referral^N/A^Social Work Intervention Record||202001130000|202001131530|202001131534||||||||||||SW|FH-INTVN||||S|||||| OBX|1|TX||| \H\NAME\N\: SMITHSON,LUMED OBX|2|TX||| \H\ACCT#\N\: SM003928/19 \H\UNIT#\N\: SM00047233 OBX|3|TX||| \H\ADM DT\N\: 13/01/20 \H\PHN\N\: 9923981723 OBX|4|TX|||\H\Social Work\N\ \H\LOC\N\: SM-N42 \H\RM/B\N\: SMN42-019-B OBX|5|TX|||\H\Intervention Report\N\ \H\DOB\N\: 10/11/1971 \H\A/S\N\: 48 F OBX|6|TX||| \H\REG CAT\N\: S.ACU OBX|7|TX||| \H\ATT DR\N\: Test Provider,IM/IT Use Only OBX|8|TX||| \H\FAM DR\N\: Test Provider,IM/IT Use Only OBX|9|TX|||\ZU\ \N\ OBX|10|TX|||\H\TESTING SWITCHED PT. THE HEADER WILL NOT UPDATE WITH NEW INFO FROM SWITCHED TO PERSON. THIS IS WORKING AS DESIGNED. OBX|11|TX|||\ZHU\ OBX|12|TX|||SOCIAL WORK INTERVENTION REPORT OBX|13|TX|||\N\ OBX|14|TX|||\H\PURPOSE OF SOCIAL WORK INVOLVEMENT OBX|15|TX|||\N\ OBX|16|TX||| OBX|17|TX|||\H\CURRENT SITUATION OBX|18|TX|||\N\ OBX|19|TX||| OBX|20|TX|||\H\PATIENT/CLIENT/FAMILY PERSPECTIVE OBX|21|TX|||\N\ OBX|22|TX||| OBX|23|TX|||\H\THERAPEUTIC INTERVENTION OBX|24|TX|||\N\ OBX|25|TX||| OBX|26|TX|||\H\CLINICAL IMPRESSIONS AND SOCIAL WORK DIAGNOSIS OBX|27|TX|||\N\ OBX|28|TX||| OBX|29|TX|||\H\PLAN OBX|30|TX|||\N\ OBX|31|TX||| OBX|32|TX|||\H\OUTCOME OBX|33|TX|||\N\ OBX|34|TX||| OBX|35|TX||| OBX|36|TX|||\H\Rene Campbell, - Social Worker OBX|37|TX|||\N\Surrey Memorial Hospital Social Work OBX|38|TX|||Date/Time: \ZU\13/01/20\N\ \ZU\1534  MSH|^~\&|ITS|ARH|||202001140508||ORU^R01|4145568|D|2.3|||AL|NE PID|1|FHATVIG0009359|AB00008058|AB8001|PANFIVES^MELLOWING^SUNSHINE||19930719|M||||||||||AB000212/19|9875370662 PV1|1|O OBR|1|||||201910221052|20191022|201910221052||||||||||||CS|CR-TMNT||||D|||||| OBX|1|TX||| \H\NAME\N\: PANFIVES,MELLOWING SUNSHINE OBX|2|TX||| \H\ACCT#\N\: AB000212/19 \H\UNIT#\N\: AB00008058 OBX|3|TX||| \H\ADM DT\N\: 30/05/19 \H\PHN\N\: 9875370662 OBX|4|TX|||\H\Cardiac Services\N\ \H\LOC\N\: AB.AUD \H\RM/B\N\: OBX|5|TX|||\H\Cardiac Rehab Clinic Team Note\N\ \H\DOB\N\: 19/07/1993 \H\A/S\N\: 25 M OBX|6|TX||| \H\REG CAT\N\: AB.CLI OBX|7|TX||| \H\ATT DR\N\: GENP,TEST A OBX|8|TX||| \H\FAM DR\N\: DOC,TEST A OBX|9|TX|||\ZU\ \N\ OBX|10|TX|||\ZHU\ CARDIAC REHAB CLINIC OBX|11|TX|||\H\ OBX|12|TX|||Date\N\: 22/10/19 OBX|13|TX||| OBX|14|TX|||Cardiologist: Crystal O'Hern OBX|15|TX||| OBX|16|TX|||We saw [*g CSSALUTN] MELLOWING SUNSHINE PANFIVES in our cardiac rehab clinic. OBX|17|TX||| OBX|18|TX|||\ZHU\CARDIAC HISTORY OBX|19|TX|||\N\Prevention level: [*g CS CARDHX] OBX|20|TX|||Devices: [*g CS CDEVICE] OBX|21|TX|||NYHA Level: [*g CS NYHA] EF%: [*] EF Date: [*] Type: [*] OBX|22|TX|||[*] OBX|23|TX||| OBX|24|TX|||\ZHU\CARDIAC RISK FACTORS OBX|25|TX|||\N\1. Hypertension: [*g CS YESNO] OBX|26|TX||| # years: [*] OBX|27|TX||| Controlled: [*] OBX|28|TX||| Home monitoring: [*] OBX|29|TX||| Na restrictions: [*] OBX|30|TX|||2. Hyperlipidemia: [*g CS YESNO] OBX|31|TX|||3. Diabetes Mellitus: [*g CS YESNO] OBX|32|TX||| OBX|33|TX||| 3 OBX|34|TX||| OBX|35|TX|||Type 1: [*] Type 2: [*] OBX|36|TX||| OBX|37|TX|||# years with Diabetes [*] Diet [*] OBX|38|TX||| OBX|39|TX|||Oral Meds: [*] Neuropathy [*] OBX|40|TX||| OBX|41|TX|||Attended DEC: [*] Year training attended: [*] OBX|42|TX||| OBX|43|TX|||Foot Care daily: [*] Annual Eye Exam [*] OBX|44|TX||| OBX|45|TX|||Home Monitoring [*] OBX|46|TX||| OBX|47|TX||| OBX|48|TX|||4. Smoking: [*g CS YESNO] OBX|49|TX||| # cig/day: [*] # years smoked: [*] Willing to quit: [*g CS YESNO] OBX|50|TX||| If yes, date Quitnow line faxed: [*] OBX|51|TX||| Education pamphlet given: [*g CS YESNO] OBX|52|TX||| Pharmacotherapy: [*] OBX|53|TX|||5. Family History: [*] OBX|54|TX|||6. Ethnicity: [*] OBX|55|TX||| OBX|56|TX|||\ZHU\CARDIAC REVIEW OF SYMPTOMS OBX|57|TX|||\N\1. Chest pain: [*] OBX|58|TX|||2. Shortness of breath: [*] OBX|59|TX|||3. Orthopnea: [*] OBX|60|TX|||4. PND: [*] OBX|61|TX|||5. Palpitations: [*] OBX|62|TX|||6. Syncope: [*] OBX|63|TX|||7. OSA/Snoring: [*] OBX|64|TX|||8. Fatigue: [*] OBX|65|TX||| OBX|66|TX|||\ZHU\PAST MEDICAL HISTORY OBX|67|TX|||\N\[*] OBX|68|TX||| OBX|69|TX|||\ZHU\PAST SURGICAL HISTORY OBX|70|TX|||\N\[*] OBX|71|TX||| OBX|72|TX|||\ZHU\ALLERGIES OBX|73|TX|||\N\[*] OBX|74|TX||| OBX|75|TX|||\ZHU\MEDICATION OBX|76|TX|||\N\Client medication review completed via Best Possible Medication History Process (BPMH): [*] OBX|77|TX|||Flu Vaccine: [*g CS YUN] Pneumococcal Vaccine: [*g CS YUN] OBX|78|TX||| OBX|79|TX|||\ZHU\SOCIAL HISTORY OBX|80|TX|||\N\1. Marital Status: [*g CS MARITST] OBX|81|TX|||2. Children: [*] OBX|82|TX|||3. Occupation: [*] Current Work Status: [*g CS CWORKST] OBX|83|TX|||4. Alcohol: [*] OBX|84|TX||| Frequency: [*] Amount: [*] Assess dependency: [*] OBX|85|TX|||5. Recreational drugs: [*] OBX|86|TX|||6. Language: [*] OBX|87|TX||| OBX|88|TX|||\ZHU\PHYSICAL EXAM OBX|89|TX|||\N\Blood Pressure Sitting: [*] OBX|90|TX|||Blood Pressure Standing: [*] OBX|91|TX|||Heart Rate: [*] OBX|92|TX|||Height (cm): [*] \ZI\(moved location) OBX|93|TX|||\N\Weight (kg): [*] OBX|94|TX|||Recent Weight Changes: [*] OBX|95|TX|||BMI: [*] OBX|96|TX|||Waist (cm): [*] OBX|97|TX|||Head/Neck: [*] OBX|98|TX|||Lungs: [*] OBX|99|TX|||Heart: [*] OBX|100|TX|||Edema: [*] OBX|101|TX|||Incisions: [*] OBX|102|TX||| OBX|103|TX|||\ZHU\LABORATORY INVESTIGATIONS OBX|104|TX|||\N\ OBX|105|TX||| 3 OBX|106|TX||| OBX|107|TX|||Date: [*] Date: [*] Date: [*] OBX|108|TX||| OBX|109|TX|||Total Cholesterol: Na: Fasting Glucose: OBX|110|TX||| OBX|111|TX|||\H\Triglycerides: \N\K: HbA1C: OBX|112|TX||| OBX|113|TX|||HDL: Creatinine: OBX|114|TX||| OBX|115|TX|||LDL: GFR: Date: [*] OBX|116|TX||| OBX|117|TX|||Non-HDL Urea: Alkaline phos.: OBX|118|TX||| OBX|119|TX||| GGT: OBX|120|TX||| OBX|121|TX||| Date [*] ALT: OBX|122|TX||| OBX|123|TX||| TSH: AST: OBX|124|TX||| OBX|125|TX||| BNP: OBX|126|TX||| OBX|127|TX||| OBX|128|TX|||\ZHU\PSYCHOLOGICAL ASSESSMENT OBX|129|TX|||\N\ OBX|130|TX||| 3 OBX|131|TX||| OBX|132|TX|||Psychosocial Symptom Score (0-9) OBX|133|TX||| OBX|134|TX|||Depression: [*] OBX|135|TX||| OBX|136|TX|||Anxiety: OBX|137|TX||| OBX|138|TX|||Stress: OBX|139|TX||| OBX|140|TX|||Anger: OBX|141|TX||| OBX|142|TX|||Social Support: OBX|143|TX||| OBX|144|TX|||\H\ OBX|145|TX|||\N\ OBX|146|TX|||\ZHU\CURRENT PHYSICAL ACTIVITY LEVEL OBX|147|TX|||\H\1. Current Exercise (FITT): (\ZHI\Move from #10 to #1) OBX|148|TX||| \H\F: \N\[*] OBX|149|TX|||\H\ I: \N\[*] OBX|150|TX|||\H\ T: \N\[*] OBX|151|TX|||\H\ T: \N\[*] OBX|152|TX|||2. Number of stairs able to perform: [*] OBX|153|TX|||3. Activities of daily living: [*] OBX|154|TX|||4. Exercise related angina: [*] OBX|155|TX|||5. Relieved by: [*] OBX|156|TX|||6. Shortness of breath in relation to exercise: [*] OBX|157|TX|||7. Musculoskeletal limitations: [*] OBX|158|TX|||8. Balance issues: [*] OBX|159|TX|||9. Falls in past 6 months: [*] OBX|160|TX||| OBX|161|TX|||\ZHU\STERNAL HEALING OBX|162|TX|||\N\Restrictions on ROM: [*] OBX|163|TX|||Symptoms in relation to sternal healing: [*g CS STERNAL] OBX|164|TX|||Sternal Precautions off: [*] OBX|165|TX|||Comments: [*] OBX|166|TX||| OBX|167|TX|||\ZHU\PPM/ICD HEALING OBX|168|TX|||\N\Restrictions on ROM: [*] OBX|169|TX|||Symptoms in relation to healing: [*g CS STERNAL] OBX|170|TX|||Precautions off: [*] OBX|171|TX|||Comments: [*] OBX|172|TX||| OBX|173|TX|||\ZHU\STRESS TEST RESULTS OBX|174|TX|||\N\1. Date performed: [*] OBX|175|TX||| OBX|176|TX||| 3 OBX|177|TX||| OBX|178|TX|||Protocol: [*] Delete column Time: [*] OBX|179|TX||| OBX|180|TX|||Stage: * METS: OBX|181|TX||| OBX|182|TX|||HR Range: * BP Range: OBX|183|TX||| OBX|184|TX|||ST Changes: * Chest Pain: OBX|185|TX||| OBX|186|TX|||Arrhythmias: * OBX|187|TX||| OBX|188|TX||| OBX|189|TX|||2. Reason for stopping: [*] OBX|190|TX|||3. Medication taken on day of test: [*] OBX|191|TX|||4. Result: [*] OBX|192|TX|||5. Target heart rate (Karvonen Formula): [*] OBX|193|TX|||\H\6. Target METs: [*] OBX|194|TX|||7. Comments: [*] OBX|195|TX|||\N\ OBX|196|TX|||\ZHU\SMART GOAL SETTING OBX|197|TX|||\N\[*] OBX|198|TX|||Confidence in achieving the goal: ([*g CS CONGOAL]/10) OBX|199|TX||| OBX|200|TX|||\ZHU\RECOMMENDED EXERCISE PLAN PRIOR TO STARTING CARDIAC REHAB PROGRAM OBX|201|TX|||\N\1. Frequency: [*] OBX|202|TX|||2. Intensity: [*] OBX|203|TX|||3. Type: [*] OBX|204|TX|||4. Duration: [*] OBX|205|TX||| OBX|206|TX|||* Highlighted importance and guidelines of warm up and cool down OBX|207|TX|||* Discussed the use of rating of perceived exertion scale and the talk test to monitor intensity of exercise (Light warm up and cool down at RPE 2, Moderate to Heavy peak exercise at RPE 3-5). OBX|208|TX|||* Reviewed and discussed the use of stress test results as a guide to monitor exercise intensity. OBX|209|TX|||* Client encouraged to be aware of signs and symptoms of over-exertion, shortness of breath, chest discomfort, and low blood glucose levels. OBX|210|TX|||* Client to follow recommended exercise plan while waiting to start the cardiac rehab classes. OBX|211|TX|||* Client encouraged to follow sternal precautions, which were reviewed during intake. OBX|212|TX||| OBX|213|TX|||Comments: [*] OBX|214|TX||| OBX|215|TX|||\ZHU\CLINICAL PLAN/DISCUSSION OBX|216|TX|||\N\1. The client has been recommended for the Education Self-Management Support Program within Cardiac Rehab. OBX|217|TX|||2. The client has completed ____ of the 5 education classes offered through Cardiac Rehab, prevention literature has been provided. OBX|218|TX|||3. The client has been risk stratified _ as per Dr. _. Client will enroll in the _. OBX|219|TX||| OBX|220|TX||| OBX|221|TX|||\H\Cardiac Nurse\N\: Crystal O'Hern OBX|222|TX|||\H\Cardiac Exercise Specialist\N\: OBX|223|TX|||\H\Signed Date/Time\N\:  MSH|^~\&|ITS|ARH|||202001140508||ORU^R01|4145569|D|2.3|||AL|NE PID|1|FHATVIG0004262|AB00007400|AB7442|TEST^STRAW||19851010|F||||||||||AB000584/19|9876015046 PV1|1|O OBR|1|||||202001060923|20200106|202001060923||||||||||||CS|CM-ESPN||||D|||||| OBX|1|TX||| \H\NAME\N\: TEST,STRAW OBX|2|TX||| \H\ACCT#\N\: AB000584/19 \H\UNIT#\N\: AB00007400 OBX|3|TX||| \H\ADM DT\N\: 24/10/19 \H\PHN\N\: 9876015046 OBX|4|TX|||\H\Cardiac Services\N\ \H\LOC\N\: AB.AUD \H\RM/B\N\: OBX|5|TX|||\H\Exercise Specialist Prog Note\N\ \H\DOB\N\: 10/10/1985 \H\A/S\N\: 34 F OBX|6|TX||| \H\REG CAT\N\: AB.RCR OBX|7|TX||| \H\ATT DR\N\: GENP,TEST A OBX|8|TX||| \H\FAM DR\N\: CWS,TEST A OBX|9|TX|||\ZU\ \N\ OBX|10|TX|||\ZHU\ CARDIAC REHAB CLINIC OBX|11|TX|||\H\ OBX|12|TX|||Date\N\: 06/01/20 OBX|13|TX|||\H\ OBX|14|TX|||The client profile has been reviewed by \N\Crystal O'Hern OBX|15|TX||| OBX|16|TX|||\H\The initial Cardiac Rehab Assessment for \N\__patient name (auto insert?)___ \H\was on ___\N\Date[*]\H\___. A follow-up phone consult was conducted as part of the Home-Based Exercise Program. OBX|17|TX||| OBX|18|TX|||\ZHU\Current FITT: OBX|19|TX|||\H\F: \N\[*] OBX|20|TX|||\H\I: \N\[*] OBX|21|TX|||\H\T: \N\[*] OBX|22|TX|||\H\T: \N\[*] OBX|23|TX|||\H\ OBX|24|TX|||\ZHU\Client Comments/ Concerns: OBX|25|TX|||\N\[*] OBX|26|TX|||\ZHU\ OBX|27|TX|||Recommendations: OBX|28|TX|||\N\[*] OBX|29|TX||| OBX|30|TX|||\H\Client is aware he/she can contact us with any questions or concerns related to exercise prescription. OBX|31|TX||| OBX|32|TX|||Crystal O'Hern OBX|33|TX|||\N\Cardiac Services, Exercise Specialist  MSH|^~\&|ITS|SMH|||202001140510||ORU^R01|4145575|D|2.3|||AL|NE PID|1|FHATVIG0013014|SM00047233|SM47012|SMITHSON^LUMED||19711110|F||||||||||SM003928/19|9923981723 PV1|1|I ORC||5143.001SMH OBR|1|PT5143.001SMH||PT^IPREF^PT Inpatient Referral^N/A^Physical Therapy Assessment Report||202001130000|202001131530|202001131532||||||||||||PT|FH-KNEESX||||S|||||| OBX|1|TX||| \H\NAME\N\: SMITHSON,LUMED OBX|2|TX||| \H\ACCT#\N\: SM003928/19 \H\UNIT#\N\: SM00047233 OBX|3|TX||| \H\ADM DT\N\: 13/01/20 \H\PHN\N\: 9923981723 OBX|4|TX|||\H\Physical Therapy\N\ \H\LOC\N\: SM-N42 \H\RM/B\N\: SMN42-019-B OBX|5|TX|||\H\Knee Surgery Assessment\N\ \H\DOB\N\: 10/11/1971 \H\A/S\N\: 48 F OBX|6|TX||| \H\REG CAT\N\: S.ACU OBX|7|TX||| \H\ATT DR\N\: Test Provider,IM/IT Use Only OBX|8|TX||| \H\FAM DR\N\: Test Provider,IM/IT Use Only OBX|9|TX|||\ZU\ \N\ OBX|10|TX|||\H\TEST SWITCH - HEADER WILL NOT UPDATE WITH NEW INFO SUCH AS ACCT/UNIT NUMBER. THIS IS WORKING AS DESIGNED OBX|11|TX||| OBX|12|TX||| OBX|13|TX||| OBX|14|TX||| KNEE SURGERY ASSESSMENT OBX|15|TX||| OUTPATIENT PHYSIOTHERAPY DEPARTMENT OBX|16|TX|||\N\ OBX|17|TX|||\ZHU\Physiotherapy Database OBX|18|TX|||\N\ OBX|19|TX|||\H\Present History \N\(Sx Type, Date, WB status, Surgeon) OBX|20|TX|||TEST OBX|21|TX||| OBX|22|TX|||\H\Past Medical History OBX|23|TX|||\N\[*] OBX|24|TX||| OBX|25|TX|||\H\Patient Profile/Social History OBX|26|TX|||\N\ OBX|27|TX||| OBX|28|TX|||\H\Medications OBX|29|TX|||\N\ OBX|30|TX||| OBX|31|TX|||\H\X-rays and Special Test Results OBX|32|TX|||\N\ OBX|33|TX||| OBX|34|TX|||\ZHU\Initial Assessment OBX|35|TX|||\N\ OBX|36|TX|||\H\Pain\N\ (numeric rating pain scale (0-10), nature, duration, location, aggravates, eases, intensity) OBX|37|TX||| OBX|38|TX||| OBX|39|TX||| OBX|40|TX|||\H\Sensation OBX|41|TX|||\N\Hot OBX|42|TX|||Sharp OBX|43|TX||| OBX|44|TX||| OBX|45|TX|||\H\Observation\N\ (colour, deformity, scars, atrophy, stitches in situ, swelling) OBX|46|TX||| OBX|47|TX||| OBX|48|TX|||\H\ROM/Strength OBX|49|TX|||\N\ 3 OBX|50|TX||| OBX|51|TX||| AROM AROM PROM PROM End Feel End Feel Strength Strength OBX|52|TX||| OBX|53|TX||| Left Right Left Right Left Right Left Right OBX|54|TX||| OBX|55|TX||| Flexion OBX|56|TX||| OBX|57|TX||| Extension OBX|58|TX||| OBX|59|TX||| Quad Lag XXXX XXXX XXXX XXXX XXXX XXXX OBX|60|TX||| OBX|61|TX||| OBX|62|TX|||\H\Functional Enquiry Mobility, Ambulation and Transfers\N\ (Distance, Aids, WB status, Gait, Footwear) OBX|63|TX||| OBX|64|TX||| OBX|65|TX|||\H\Stairs OBX|66|TX|||\N\ OBX|67|TX||| OBX|68|TX|||\H\Other OBX|69|TX|||\N\ OBX|70|TX||| OBX|71|TX|||\H\Outcome Measures\N\ (LEFS, 10 m walk test) OBX|72|TX||| OBX|73|TX||| OBX|74|TX|||\H\Problem List OBX|75|TX|||\N\Decreased ROM in right/left knee OBX|76|TX|||Decreased strength in right/left knee OBX|77|TX|||Potential scar adhesion OBX|78|TX|||Decreased ambulation/altered gait pattern OBX|79|TX|||Decreased balance reactions OBX|80|TX|||Decreased knowledge precautions TKA OBX|81|TX|||Decreased stair climbing ability OBX|82|TX|||Pain, swelling OBX|83|TX|||Discharge planning OBX|84|TX||| OBX|85|TX|||\H\Treatment Plan OBX|86|TX|||\N\AAROM/AROM for right/left knee OBX|87|TX|||TKA treatment guidelines right/left, Home exercise program (HEP) OBX|88|TX|||Scar massage, education OBX|89|TX|||Gait training OBX|90|TX|||Balance/proprioception exercises OBX|91|TX|||Reinforce precautions, WB status OBX|92|TX|||Stair climb practice OBX|93|TX|||Ice, elevation, modalities OBX|94|TX|||HEP, community resources, Theraband OBX|95|TX||| OBX|96|TX|||\H\Treatment Given OBX|97|TX|||\N\ OBX|98|TX||| OBX|99|TX|||\H\Response/Analysis OBX|100|TX|||\N\ OBX|101|TX||| OBX|102|TX|||\H\Plan OBX|103|TX|||\N\ OBX|104|TX||| OBX|105|TX|||\H\Goals OBX|106|TX|||\N\ OBX|107|TX||| OBX|108|TX|||Assessment and treatment procedures explained to patient. OBX|109|TX|||Patient consent received. OBX|110|TX|||Expected length of stay: OBX|111|TX||| OBX|112|TX|||\H\Rene Campbell, Physical Therapist OBX|113|TX|||\N\Date/Time: \ZU\13/01/20\N\ \ZU\1532