Sample
Brief Summary of Medical Records for Mrs. A. J.

Mrs. A.J. is an 86-year old female that was admitted to General Hospital on 6/19/96, with 3 vertebral compression fractures, after a fall at home in her bathroom.

She had a previous history of compression fractures, osteoporosis and degenerative arthritis.

Admission was primarily for parental (intravenous) medication by use of a patient controlled anesthesia pump (PCA pump). She was admitted to a medical-surgical unit and remained there throughout her hospitalization.

On 6/24/96, she was changed from an acute status to a swing bed status, decreasing the level of care required to that of a skilled nursing facility. The term “swing bed” refers to those rural hospitals, which can be dually licensed as acute and nursing home beds.

Early in the morning of 6/27/96, Mrs. A.J. while attempting to get to the bathroom, fell and fractured her left femoral neck (hip). There is some discrepancy in the records as to the exact mechanism of injury. There are several mentions of her climbing over the bedrails versus the patient's statement in the emergency room the morning of the event, stating she fell while walking. There are also minor discrepancies as to where she was found: in her room versus in the hallway. Significant positive risk factors for falls in this client, using the Center for Disease Control (CDC) and Prevention criteria include:

History of a recent fall

Low bone mineral density

Cognitive deficit (loss of judgment)

Osteoarthritis

The medical risk factors for falls with this client may include: blood pressure fluctuation, use of PCA pump, sedative effect of Demerol given via PCA pump, combined use of narcotic analgesics with benzodiazepines (Librium) and need for assistive device (front wheeled walker).