| Documentation | Contact | Effective Date | Comments |
|---|---|---|---|
| Living Will | Obtain from her Husband | 1994 | Copy on file |
| Power of Attorney | Obtain from her Husband | 1994 | |
| Healthcare Proxy | Obtain from her Husband | 1994 | |
| Organ Donor | Massachusetts Registry of Motor Vehicles | 1/27/2004 | Registered Organ Donor |
| Family Member | Problem | Cause of Death? |
|---|---|---|
| Father | Alcoholism | No |
| Father | Liver Cancer | Yes |
| Social History | Comments | Date Range |
|---|---|---|
| Smoking | 1/2 pack per day | ? - 1996 |
| Alcohol Use | 1-2 drinks per week |
| Problem | Date | Status | Comments |
|---|---|---|---|
| Cholecystitis | 9/28/2002 - 6/2003 | Resolved | Surgery postponed until after delivery |
| Pregnancy | 7/2001 - 4/22/2002 | Resolved | Prior history of miscarraige |
| Ankle Sprain | 3/28/2005 | Current | Slipped on ice and fell |
| Allergen | Reaction | Comments |
|---|---|---|
| Penicillin | Hives | Amoxicillin is OK |
| Medication | Prescription or Dose | Dates of Use |
|---|---|---|
| Indomethacin | 50mg bid with food | 12/10/2003 - present |
| Acetaminophen with codeine | #3 1-2 tablets for pain as needed | 03/28/2005 |
| Procedure | Date |
|---|---|
| Laparoscopic Cholecystectomy | 9/28/2002 |
| Cesarian Section | 3/22/2002 |
| Date | Provider | Description |
|---|---|---|
| 3/28/2005 | Community Hospital | ED Visit for Ankle Sprain |
| 9/28/2002 | City Hospital | Gall Bladder Surgery |
| 3/21/2002 | Community Hospital | Labor and Delivery |
| 10/28/2001 | Community Hospital | ED Visit for Acute Cholecystitis |
| Date | Height | Weight | Temperature | BP | Pulse | Respiration | O2 |
|---|---|---|---|---|---|---|---|
| 3/28/2005 | 5'9" | 215 lbs. | 98.7 °F | 120/80 | 68 | 16 | 99% |
| Study | Summary | Date of Study |
|---|---|---|
| X-Ray Study - Left Ankle | No Fracture | 3/28/2005 |