Age: 79.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Acute kidney injury, Bladder catheterisation, COVID-19, Haematuria, SARS-CoV-2 test positive
Clinical narrative: Length of Stay:          Hospital Day(s): 3      CURRENT MEDICAL STATUS AND PLAN OF CARE Level of Care  | Level of Service LEVEL OF CARE: Levelofcare: Telemetry CLASS: Observation Diagnosis   NONTRAUMATIC ACUTE KIDNEY INJURY   Status Post  ()    Discussed with Chart review/HBS Current Treatment Plan/ Plan of Care   Per HBS note dated 8/23/23: Hematuria from foley insertion..   Plan: IVF. Flomax. Discharge with foley when Hematuria becomes more clear.    MSW referral initiated No Palliative Care referral initiated No    Additional Comments 8/23/23 Met with patient at bedside, patient called wife and placed on speaker for conference call regarding discharge plan/disposition, spoke to patient/wife.   COVID de-isolation 8/30/23 per HBS    Addendum: RN approval by leadership. Called patient/wife, ok per patient, regarding  RN, patient/wife agreeable to RN and understand to call  if do not hear from staff in 1-2 days to schedule RN home visits. Patient/wife made aware, understand and agreeable patient will not receive daily HH RN visits., HH RN ordered and informed HBS to co-sign RN  8/23/2023 3:54 PM    Hand off given to ER PCC to follow up on discharge plan/disposition    DISCHARGE PLAN IM Reissue N/A Preferences Discussed Yes  Anticipated DC Dispo Home with Family, awaiting approval from COC leadership to otder HH RN d/t COVID  Transportation at DC Family/Private Vehicle: wife  DME Needs for DC None anticipated  Teaching/ Learning Needs Foley teaching/foley care Risk for readmission LOW    PCC to Follow Medical readiness FU with COC leadership regarding approval to order HH RN  Emerging discharge needs   Addendum: Hand-off given to ER PCC to follow up on discharge plan/disposition    RN  8/23/2023 4:08 PM        08/22/2023   COC note: Spoke with son at bedside, stated that he's not ready to take patient home because of fears regarding COVID, pt's stents, AKI, unable to learn foley teaching. Printed out lab results for son to understand and to show his mom. Foley teaching by kiosk started with patient who is AOx4. Asked primary RN to print out for wife to read. Recup nurse was present and said she will see patient to confirm proper education. Blood was found in foley back with clots. Primary RN sent photo to on-call, discharged cancelled for tonight. Son was notified by primary RN, family made aware a DC tomorrow is likely. COC notified.    RN  8/22/2023 7:27 PM      Medical Center COORDINATION OF CARE    Length of Stay:          Hospital Day(s): 3      CURRENT MEDICAL STATUS AND PLAN OF CARE Level of Care  | Level of Service LEVEL OF CARE: Levelofcare: Med-surg CLASS: Observation Diagnosis   NONTRAUMATIC ACUTE KIDNEY INJURY     Discussed with Patient, Bedside RN: and chart review.  Current Treatment Plan/ Plan of Care   - Plan to remove foley and voiding trial today.  - Conditional order to discharge if pt able to void post foley removal.  - Continue flomax.     MSW referral initiated No Palliative Care referral initiated No    Additional Comments Addendum: 08/22/2023: - Notified by bedside RN,  that pt had PVR 850.  - Dr aware, foley replaced and plan to f/u with Urology outpatient.  - Foley teaching ordered to be done prior to discharge.  - PCC requested to contact CSN for foley teaching to be done prior to discharge.  - Also notified by RN, earlier that pt's wife, unwilling to take patient home when he is COVID (+).Wife to speak with her son when he comes home at 1800 and will call RN back.  - PCC has attempted to call wife a few times, but no answer and VM not set up. Will continue to try and contact pt's wife.    RN  8/22/2023 3:38 PM   Addendum: 08/22/2023 - Spoke w/ pt's Wife, regarding concerns about taking pt home being COVID (+). Wife also expressed concerns about pt going home with foley in place.  - PCC has explained to wife that pt has received IV tx for COVID and respiratory status is stable as pt is not requiring oxygen at this time. Also informed wife that pt will be receiving foley teaching prior to discharge. PCC has offered wife to be at bedside at time of foley teaching so that she may feel comfortable with pt going home w/ foley.  Wife insistent that she would like her Son, to be informed about discharge home and that he will be at her home by 1800 tonight. PCC has offered to update son regarding pt's discharge, but wifea declines at this time and prefers that her son be present at her home to listen to pt's discharge plan.  - PCC has informed wife, that pt may incur charge for hospital stay as pt is medically cleared for discharge today. wife is aware of this but again would like Son, present for discharge plan.  - F/u with bedside RN, regarding foley teaching. No teaching done at this time. RN to follow up.  - PCC has also left VM for recup RN regarding foley teaching needed for pt prior to discharge.  - Updated ED PCC regarding BTD. PCC to f/u.     RN  8/22/2023 4:49 PM        DISCHARGE PLAN IM Reissue OBS Preferences Discussed yes Anticipated DC Dispo Home with Family Transportation at DC Family/Private Vehicle: Spouse,  DME Needs for DC Anticipate none.  Teaching/ Learning Needs TBD Addendum: 08/22/2023 Will need foley teaching prior to discharge.  Risk for readmission LOW    PCC to Follow - Emerging medical needs.    RN  8/22/2023 10:15 AM          Discharge Planning / Admission Assessment Form       Patient Name MRN DOB AGE SEX 82 Y male    Patient Location Home Address Phone B/B-01  Telephone Information: Home Phone  Work Phone  Mobile     Code status Marital status Durable Power of Attorney on file Data unavailable Married      Advance Directives Admission Date Admission Type No 8/20/2023 Emergency    Re-Admission Admission Method Admission Diagnosis YES Car      Problem List Active Multidisciplinary Problems Mental Status Patient Active Problem List:    HTN (HYPERTENSION)   HX OF LACUNAR STROKE   ANEMIA   ATHEROSCLEROSIS OF AORTA   LUMBAR SPONDYLOSIS   HEART MURMUR   LUMBAR DISC DEGENERATION   SPINAL STENOSIS OF LUMBAR SPINE   SPINAL STENOSIS OF LUMBAR SPINE W NEUROGENIC CLAUDICATION   ROUTINE ADULT HEALTH CHECK UP EXAM   VERTIGO   LEFT ILIAC ARTERY ANEURYSM   HX OF DECOMPRESSIVE LUMBAR LAMINECTOMY   INFECTED RIGHT OLECRANON BURSA   ELEVATED TROPONIN I   ACUTE NON ST ELEVATION MI   CAD WO ANGINA, PRESENCE OF STENT   DYSLIPIDEMIA   CONSTIPATION   No multi-disciplinary problems found     alert and oriented   Living Arrangements    Lives at home Dwelling Type Potential Physical Barriers at home family Single Level        Assistive Devices Present Existing DME Visual Impairment     cane  Visual Impairment: GLASSES glasses    Support Systems Patient's Prior Level of Function PCC Consulted Family Ambulatory, Independent and Assistive Devices Recent discharge from SF for NSTEMI, s/p PCI      Anticipated Journey Home Partner (name and number) Wife  Anticipated Transportation Mode Family/Friend Vehicle Assessment / Comments / Concerns / Teaching pls evaluate for discharge needs Anticipated Discharge Plan Home          Note Details  Author  (R.N.) File Time 8/23/2023  4:08 PM Author Type REGISTERED NURSE Status Addendum Last Editor (R.N.) Specialty GENERAL, OTHER Hospital Acct #  Admit Date 8/20/2023  ED to Hosp-Admission (Discharged) on 8/20/2023  ED to Hosp-Admission (Discharged) on 8/20/2023   Revision History   Detailed Report  Note shared with patient Care Timeline  08/20   Admitted from ED (Observation) 1904 08/23   Discharged 1930