ROSE emr

Elmer Crawford
92-year-old Caucasian Male

1933-11-29

Allergies:	Penicillin
Code Status:	Full Code

Note	Authors	Written
Progress Note - Physician	Brandon Stoneman, RN	1991-11-22 15:00
Progress Note - Physician	Brandon Stoneman, RN	1991-11-22 13:30
Progress Note - Physician	Brandon Stoneman, RN	1991-11-22 03:00
Progress Note - Physician	Brandon Stoneman, RN	1991-11-22 03:00
Progress Note - Physician	Courtney Hall, PT	1991-11-22 00:00
Nursing - Progress Note	Karen Pontiff, RN	1991-11-22 00:00
Cardiology - Consult	Susie Piper, RN	1991-11-22 00:00
Nursing - Progress Note	Bryan J. Donald, PharmD	1991-11-21 23:30
Nursing - Progress Note	Brandon Stoneman, RN	1991-11-21 23:30
Nursing - Progress Note	Brandon Stoneman, RN	1991-11-21 15:30
Nursing - Progress Note	Brandon Stoneman, RN	1991-11-21 01:30
Cardiology - Consult	Courtney Hall, PT	1991-11-21 00:00
Progress Note - Physician	Donna Salestrip, PT	1991-11-21 00:00
Nursing - Progress Note	Karen Pontiff, RN	1991-11-21 00:00
Progress Note - Physician	Courtney Hall, PT	1991-11-20 00:00
Progress Note - Physician	Steph Howell, PT	1991-11-20 00:00
Cardiac - Progress Note	Willey Bestman, MD	1991-11-20 00:00
Nursing - Progress Note	Cathy McRay, RN	1991-11-19 23:30
Cardiology - Consult	Cathy McRay, RN	1991-11-19 23:00
Nursing - Progress Note	Cathy McRay, RN	1991-11-19 15:30
Cardiology - Consult	Cathy McRay, RN	1991-11-19 07:30
Progress Note - Physician	James Barry, MD	1991-11-19 00:00
Progress Note - Physician	Courtney Hall, PT	1991-11-19 00:00
Progress Note - Physician	JC Haddock, PT	1991-11-19 00:00
Nursing - Progress Note	Cathy McRay, RN	1991-11-18 22:30
Cardiology - Consult	Jerome Ruskin, MD	1991-11-18 18:30
Cardiology - Consult	Jerome Ruskin, MD	1991-11-18 18:30
Progress Note - Physician	Bryan J. Donald, PharmD	1991-11-18 18:00
Progress Note - Physician	James Barry, MD	1991-11-18 14:15
Cardiology - Consult	Mark Shogry, MD	1991-11-18 14:00
Progress Note - Physician	Mitch Ray, MD	1991-11-18 13:30
Nursing - Progress Note	Chris Tadwell, RN	1991-11-18 07:30
Progress Note - Physician	James Barry, MD	1991-11-18 00:00
Progress Notes - Physician	James Barry, MD	1991-11-18 00:00
Progress Notes - Physician	James Barry, MD	1991-11-17 00:00
Nursing - Progress Note	Chris Tadwell, RN	1991-11-16 23:30
Progress Note - Physician	James Barry, MD	1991-11-16 00:00
Progress Note - Physician	Willey Bestman, MD	1991-11-16 00:00
Cardiology - Consult	JC Haddock, PT	1991-11-16 00:00
Progress Note - Physician	JC Haddock, PT	1991-11-16 00:00
Progress Note - Physician	Courtney Hall, PT	1991-11-15 00:00
Progress Note - Physician	James Barry, MD	1991-11-15 00:00
Nursing - Progress Note	Karen Pontiff, RN	1991-11-15 00:00
Progress Note - Physician	JC Haddock, PT	1991-11-15 00:00
Dietitian - Progress Notes	Andrew Shamp, MPH, RD	1991-11-14 10:30
Progress Note - Physician	Courtney Hall, PT	1991-11-14 00:00
Pharmacy - Progress Notes	Rick McKinner, RPh	1991-11-14 00:00
Nursing - Progress Note	Susie Piper, RN	1991-11-14 00:00
Progress Note - Physician	JC Haddock, PT	1991-11-14 00:00
Cardiology - Consult	Willey Bestman, MD	1991-11-13 00:00
Progress Note - Physician	James Barry, MD	1991-11-13 00:00
Cardiology - Consult	Karen Pontiff, RN	1991-11-12 00:00
Progress Note - Physician	Courtney Hall, PT	1991-11-12 00:00
Pharmacy - Progress Notes	Jim Donovan, RPh	1991-11-11 02:00
Progress Notes - Physician	Bryan J. Donald, PharmD	1991-11-11 00:00
Progress Note - Physician	James Barry, MD	1991-11-10 00:00
Cardiology - Consult	Andrew Shamp, MPH, RD	1991-11-09 01:29
Progress Note - Physician	James Barry, MD	1991-11-09 00:00
Progress Note - Physician	Willey Bestman, MD	1991-11-09 00:00
Cardiology - Consult	Willey Bestman, MD	1991-11-08 00:00
Pharmacy - Progress Notes	Andrea Angel, RPh	1991-11-07 01:00
Progress Note - Physician	Willey Bestman, MD	1991-11-07 00:00
Nursing - Progress Note	Karen Pontiff, RN	1991-11-07 00:00
Progress Note - Physician	James Barry, MD	1991-11-07 00:00
Progress Note - Physician	James Barry, MD	1991-11-06 00:00
Progress Note - Physician	JC Haddock, PT	1991-11-06 00:00
Dietitian - Progress Notes	Andrew Shamp, MPH, RD	1991-11-05 02:00
Progress Note - Physician	Stephen Blankenship, PT	1991-11-05 00:00
Progress Note - Physician	Willey Bestman, MD	1991-11-05 00:00
Pharmacy - Progress Notes	Andrea Angel, RPh	1991-11-04 02:15
Progress Note - Physician	Jacob Chladdocb, PT	1991-11-04 00:00
Nursing - Progress Note	Karen Pontiff, RN	1991-11-04 00:00
Nursing - Progress Note	Karen Pontiff, RN	1991-11-04 00:00
Cardiac - Progress Note	James Barry, MD	1991-11-03 00:00
Pharmacy - Progress Notes	Jim Donovan, RPh	1991-11-02 12:30
Progress Note - Physician	James Barry, MD	1991-11-02 00:00
Progress Note - Physician	James Barry, MD	1991-11-01 00:00
Pharmacy - Progress Notes	Jim Donovan, RPh	1991-11-01 00:00
Progress Note - Physician	James Barry, MD	1991-11-01 00:00
Cardiac - Progress Note	Spencer Tilley, MD	1991-11-01 00:00
Nursing - Progress Note	Karen Pontiff, RN	1991-11-01 00:00
Progress Note - Physician	Karen Pontiff, RN	1991-11-01 00:00
Progress Note - Physician	James Barry, MD	1991-10-31 00:00
Cardiac - Progress Note	Karen Pontiff, RN	1991-10-31 00:00
Progress Note - Physician	James Barry, MD	1991-10-30 00:00
Cardiac - Progress Note	Spencer Tilley, MD	1991-10-30 00:00
Progress Note - Physician	James Barry, MD	1991-10-29 00:00
Progress Note - Physician	James Barry, MD	1991-10-29 00:00
Pharmacy - Progress Notes	Robert Alhebert, PharmD	1991-10-29 00:00
Dietitian - Progress Notes	Andrew Shamp, MPH, RD	1991-10-29 00:00
Cardiac - Progress Note	Spencer Tilley, MD	1991-10-28 05:25
Pharmacy - Progress Notes	Jim Donovan, RPh	1991-10-28 04:00
Progress Note - Physician	James Barry, MD	1991-10-27 00:00
Nursing - Progress Note	Sandra Roach, RN	1991-10-26 00:00
Pharmacy - Progress Notes	Robert Alhebert, PharmD	1991-10-26 00:00
Pharmacy - Progress Notes	Robert Alhebert, PharmD	1991-10-25 12:30
Dietitian - Progress Notes	Andrew Shamp, MPH, RD	1991-10-25 10:10
Pharmacy - Progress Notes	Robert Alhebert, PharmD	1991-10-25 01:00
Progress Note - Physician	James Barry, MD	1991-10-25 00:00
Pharmacy - Progress Notes	Robert Alhebert, PharmD	1991-10-25 00:00
Pharmacy - Progress Notes	Robert Alhebert, PharmD	1991-10-25 00:00
Cardiac - Progress Note	Spencer Tilley, MD	1991-10-25 00:00
Progress Note - Physician	Jacob Chladdocb, PT	1991-10-25 00:00
Progress Note - Physician	Stephen Blankenship, PT	1991-10-24 00:00
Pharmacy - Progress Notes	Robert Alhebert, PharmD	1991-10-24 00:00
Pharmacy - Progress Notes	Robert Alhebert, PharmD	1991-10-24 00:00
Progress Note - Physician	James Barry, MD	1991-10-23 00:00
Cardiac - Progress Note	Spencer Tilley, MD	1991-10-23 00:00
Progress Note - Physician	Maigie Macy, PT	1991-10-23 00:00
Pharmacy - Progress Notes	Robert Alhebert, PharmD	1991-10-23 00:00
Progress Note - Physician	Chris Young, MD	1991-10-23 00:00
Dietitian - Progress Notes	Andrew Shamp, MPH, RD	1991-10-22 12:30
Progress Note - Physician	James Barry, MD	1991-10-22 00:00
Cardiology - Consult	Spencer Tilley, MD	1991-10-22 00:00
Pharmacy - Progress Notes	Robert Alhebert, PharmD	1991-10-22 00:00
Progress Note - Physician	James Barry, MD	1991-10-21 00:00
Progress Note - Physician	Jacob Chladdocb, PT	1991-10-21 00:00
Cardiology - Consult	Spencer Tilley, MD	1991-10-21 00:00
Cardiology - Consult	Spencer Tilley, MD	1991-10-20 12:00
Progress Note - Physician	James Barry, MD	1991-10-19 00:00
Cardiology - Consult	Spencer Tilley, MD	1991-10-19 00:00
Progress Note - Physician	Stephen Blankenship, PT	1991-10-19 00:00
Cardiology - Consult	Mark Shogry, MD	1991-10-18 14:00
Cardiology - Consult	Spencer Tilley, MD	1991-10-18 12:30
Pharmacy - Progress Notes	Donna Brooks, RPh	1991-10-18 07:15
Nursing - Progress Note	Sandra Roach, RN	1991-10-18 05:19
Surgery - Consult	Donna Brooks, RPh	1991-10-18 03:15
Progress Note - Physician	Courtney Hall, PT	1991-10-18 00:00
Pharmacy - Progress Notes	Donna Brooks, RPh	1991-10-18 00:00
Hydrotherapy - Consult	Courtney Hall, PT	1991-10-17 15:00
Radiology - Consult	Arthur F. Kriner, MD	1991-10-17 14:00
Dietitian - Progress Notes	Andrew Shamp, MPH, RD	1991-10-17 12:30
Pharmacy - Progress Notes	Tim Saishardl, RPh	1991-10-17 09:05
Pharmacy - Progress Notes	Donna Brooks, RPh	1991-10-17 00:00
Progress Note - Physician	Courtney Hall, PT	1991-10-17 00:00
Cardiology - Consult	James Barry, MD	1991-10-16 16:00
Pharmacy - Progress Notes	Tim Saishardl, RPh	1991-10-16 12:00
Progress Note - Physician	James Barry, MD	1991-10-16 00:00
Progress Note - Physician	Courtney Hall, PT	1991-10-16 00:00
Progress Note - Physician	James Barry, MD	1991-10-16 00:00
Medication Counseling - Pharmacy Note	Tim Saishardl, RPh	1991-10-15 12:15
Cardiology - Consult	Spencer Tilley, MD	1991-10-15 07:30
Progress Notes - Physician	James Barry, MD	1991-10-15 00:00
Radiology - Consult	Chuck Clark, MD	1991-10-14 12:00
Radiology - Consult	Chuck Clark, MD	1991-10-14 10:30
Surgery - Consult	William Tilley, MD	1991-10-14 05:00
Progress Notes - Physician	Sandra Roach, RN	1991-10-14 00:00
Progress Notes - Physician	April M. Stelly, PhIntern James Barry, MD	1991-10-14 00:00
Cardiology - Consult	Spencer Tilley, MD	1991-10-14 00:00
Cardiology - Consult	Spencer Tilley, MD	1991-10-14 00:00
Attending Physician - History and Physical Exam	James Barry, MD	1991-10-13 04:00

Note from Courtney Hall, PT at 1991-10-17 15:00

Diagnosis: non-healing ulcer, right lat. mal.

Age:75 Sex: M Admitted: 10/13/91 Date of onset: 4 mos.

PMH: DM partieal right foot amp ’85 2° PVD; COPD, cig use

Subjective: “I feel sick.”

Objective: wound over right lat. malleolus and covered without thick eschar throughout (3.4cm by 2.4cm)

Treatment:

· Type of Whirlpool: highboy on stretcher
· Additive: hibiclins
· Debriddement: mechanical
· Dressing: betadine-soaked gauze, dry gauze and herlix

Mechanism of injury: non-healing ulcer

Depth/diameter: as above

Eschar diameter: this eschar covers wound

Odor/drainage: mild odor (drainage (wound covered in opsite)

Edema/circulatory status: decrease circulation peripherally, min erythemia/edema

Mental Status: A+0 x 3

Mobility: via stretcher to up

Assessment:

· Tolerance: Pt did not tol Rx- Rx terminated 10 min 2°
· Anticipated problems: slow healing
· Goals: 1. Prevent infection 2. Cleanse to level of no eschar present 3. 25% closure
· Rehab potential: fair ELS: 3 weeks

Plan: Cont WP as above qd 6d/wk to pt tolerance.

Courtney Hall
Pysical Therapist

Signed by Courtney Hall, PT at 1991-10-17 15:00