⚕Case Management: Inpatient DocumentationNorthline Health System: New York Daniel
DEPARTMENTS
NL-NYC Emergency Department
PATIENT NAME
Patients
▤ Inputs
DATE OF SERVICE
Tue, Jan 16, 2024
AUTHOR Daniel Westphal
DIAGNOSIS CHF - Inpatient
Objective Criteria
◎Tachypnea
◎Hemodynamic Instability
◔ Selected Notes
✎ H&P
Author · Dr. John Smith
✎ Concurrent Review Draft
Searching ◎ Objective Criteria
Thought: First, I need to find the Objective Criteria objects linked to the given Objective Id. Then, I will query the notes using the provided note ids. Tool Name: Object Type Tool. Input: OBJECT_TYPE ObjectiveCriteria FILTER objectiveId == ‘575f9d7c-7761-48a6-a263-11b5daf78c17’
◎ Tachypnea
◎ Hemodynamic Instability
Searching ✎ Notes
Thought: I made a mistake in the syntax for filtering note ids. I will correct it and try again. Tool Name: Object Type Tool. Input: OBJECT_TYPE Note FILTER noteId == ‘01496b6d-eeef-4ec0-9082-d109c19a0128’ or noteId == ‘8’
✎ H&P
⧖ Output: UR
1.Persistent fever: The patient's fever has decreased but is still present (Tmax: 100.2°F), indicating a potential ongoing infection.
2.Oxygen saturation: The patient's O2 saturation is maintained above 94% on room air. However, there is still a requirement for close monitoring and potential supplemental oxygen therapy.
3.Inability to tolerate oral medications: The patient remains on IV antibiotic therapy (Ceftriaxone 1g daily and Azithromycin 500mg daily) due to difficulty in tolerating oral medications.
4.Intravenous fluid therapy: The patient requires ongoing IV fluid therapy for rehydration, as oral intake is still insufficient.
5.The patient's respiratory rate remains elevated at 28 breaths/min, indicating tachypnea and requiring close monitoring.
6.The patient's blood pressure is unstable, fluctuating between 90/60 mmHg and 160/100 mmHg, demonstrating hemodynamic instability and necessitating ongoing medical intervention.