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Inpatient Care & Hospital Admission Record

James Morrison

Critical (ICU) ICU-1 / Bed B1
#IPD-0001 MRN: #PAT-88392 Dr. Robert Chen, MD Nurse Alba, RN Length of Stay: 6 Days
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Continuous ICU Telemetry Monitoring Bedside Monitor Channel #04 Active
ECG Heart Rate

84 bpm

Sinus Rhythm
Arterial BP

118/76 mmHg

MAP: 90 mmHg
Pulse Oximetry

99% SpO2

Nasal Cannula 2L
Core Temp

98.8 °F

Normothermic
GCS Score

15/15 GCS

Alert & Oriented
24h Fluid Balance

+300 mL

In: 2400 / Out: 2100
Ward

ICU Ward

Room ICU-1 · Bed B1

Stay Length

6 Days

Admitted 6 Days Ago

Primary Nurse

Nurse Alba

ICU Shift Leader

Care Status
Active Inpatient

Under ICU Protocol

Consultant Daily Ward Round & Care Plan

Chief Attending Review by Dr. Robert Chen, MD

ICU Round #DAY-06

Clinical Assessment & Progress:

58-year-old male admitted 6 days ago for acute cardiac decompensation. Patient remains hemodynamically stable on low-dose inotropic support. Telemetry shows sinus rhythm at 84 bpm without ventricular ectopy. Lungs show bilateral basilar crackles, improved from admission.

Diagnostic Imaging & Lab Summary:

• Bedside Echocardiogram: LVEF 42%, mild mitral regurgitation.
• Electrolytes: Serum Potassium 4.2 mEq/L, Sodium 138 mEq/L, Serum Creatinine 1.1 mg/dL.
• BNP: 420 pg/mL (trending down from 1,200 pg/mL on Day 01).

Plan of Care for Next 24 Hours:

1. Wean IV Furosemide drip to oral Torsemide 20mg twice daily.
2. Continue oxygen via nasal cannula at 2L/min to maintain SpO2 > 95%.
3. Evaluate for transfer from ICU Bed B1 to Step-Down Cardiac Telemetry Ward tomorrow morning if hemodynamics remain stable.
4. Low sodium (2g/day) cardiac diet protocol.

Inpatient Medication Administration Record (MAR)

Scheduled IV & Oral inpatient administrations

Drug & Route Dosage Frequency Nurse Sign-off Status
Furosemide (Lasix) IV 40 mg (IV Push) Q12H (08:00 & 20:00) Nurse Alba, RN (08:05 AM) GIVEN
Metoprolol Succinate 25 mg (Oral Tab) Once Daily (09:00 AM) Nurse Alba, RN (09:02 AM) GIVEN
Enoxaparin (Lovenox) SC 40 mg (SubQ Syringe) Once Daily (20:00 PM) Scheduled 20:00 PM DUE LATER

Inpatient Admission Journey Timeline

Sequential record of hospital stay events

Emergency Admission

6 Days Ago

Admitted via ER with acute dyspnea and pulmonary congestion

ICU Bed Allocation (ICU-1 / Bed B1)

6 Days Ago

Transferred to ICU under telemetry channel #04

Active Treatment & Inotrope Weaning

Day 06 Active

Consultant rounds by Dr. Robert Chen • Preparing for step-down

Discharge Planning & Clearance

Target Day 08

Post-discharge medication reconciliation and outpatient follow-up

Attending Consultant

Dr. Robert Chen, MD

Head of Cardiology & Critical Care

Primary Nurse: Nurse Alba, RN
ICU Nursing Station: Ext. 4401

Bed & Placement Context

WardICU Ward
RoomICU-1
Bed NumberBed B1
TelemetryChannel #04
Insurance$25,000 Approved

Inpatient Actions

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