Mrs.

Jenny
D0B: 16/7/1940
Room:504
Progress Notes Allergies: Nuts

Dr. M. Roberts
Signature and
Designation
DATE TIME
13/09/19 9:15 Resident admitted to home from Progress Hospital at 9:15 am by paramedics. M. Krosher, RN

Resident’s vitals were taken T; 37.6, P: 86, R: 18, BP: 130/67, SaO2 98 % on RA.
Resident’s pain is 4/10. Resident received pain medication at 8:30 am. Head to
toe assessment completed with assistance of the PCA. Resident has a stage
2 pressure ulcer on coccyx. Treatment has been initiated in hospital. Dr.
Roberts have approved all medications from hospital. Resident is resting supine
in a semi fowler’s position; bed was placed in the lowest position with call bell
within resident’s reach. ______________________________________________
13/09/19 13:05 Resident ate in her room with her friend Irene. Resident completed meal and M. Krosher, RN
received pain medication as per doctor’s order. Resident’s pain is 6/10 prior to
receiving scheduled pain medication will check in 30 minutes to evaluate its
effectiveness. _____________________________________________________
13/09/19 14:55 Before commencing Tx at 14:00, Tx to coccyx pain was 4/10. Tx to coccyx M. Krosher, RN
completed with the following noted: medium amount of serosanguinous
drainage noted on non-adhesive dressing. The wound is 30 mm width by 50 mm
length. This information was written in the physician book. After Tx resident
positioned on the Rt Lateral side. Resident informed that part of the Tx is to
continue to reposition her every 2 hours. Breakthrough medication of0.5 mg
morphine PO given for pain 6/10 after dressing was completed at 14:30.
Resident’s bed was placed in the lowest position with call bell positioned within
resident’s reach. __________________________________________________