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The CBC was collected on 9 22, received on 9 22, and reported on 9 29. The physician initialed it on 10 Assessment: Ordering a stat blood count, but not getting the results for ten days is not an adequate system for evaluating acute abdominal pain. Patient 6. On 10 06, a nurse saw this 20-year-old parole violator upon arrival. His vital signs were: pulse 44 beats minute and irregular, BP 137 65 mm hg, respirations 18 minute and Temp 98.4. A physician saw him the same day at 1237, but did not take a cardiac history. He documented that the youth had a history of alcohol use the preceding night, and a history of cocaine and methamphetamine use, but did not document the date of his most recent use. The physician noted that his heart rate was 45-50 beats minute and irregular. His assessment was bradyarrhythmia and probable hangover from alcohol overdose. He sent him to the OHU for observation and an EKG. The orders did not include vital signs. The youth arrived at the OHU at 1300. The nurse repeated the vital signs that were essentially unchanged. The nurse documented that the OHU physician saw the patient but he did not write a note. He wrote no further orders. At 1438, the nurse measured the patient's vital signs, which were markedly changed Pulse 115 beats minute and BP 134 77 mm hg ; 1452, an EKG showed the patient's heart rate was 78 beats minute with sinus arrhythmia with frequent PVCs. The physician saw the patient the next day at 0825 and did not evaluate the patient's vital signs. He ordered a chest x-ray, CBC, and cardiology consult, and discharged the patient to the dorm. A part-time physician who happened to be a cardiologist but not practicing in that capacity at the facility ; saw the patient on 10 26 and determined that he had benign PVCs arising from right ventricle and reassured the patient, recommended avoiding alcohol use, a light potassium diet, and no physical limitation. His chest x-ray, CBC, serum chemistry, electrolytes, liver panel, and drug screen were all normal. Assessment: Alcohol withdrawal is a concern for youth who may enter directly off the street. The physician noted that the youth had been drinking the previous night, but did not obtain a history related to the amount or extent of his alcohol consumption. Furthermore, the facility did not have an appropriate protocol for monitoring youth at risk for alcohol withdrawal. The patient's vital signs were not closely monitored. The on-site physician happened to be a cardiologist but was not acting in a consultant capacity; however, his evaluation was performed in lieu of a requested cardiology consultation. This was not clear in the health record documentation. Health Records New health record forms have not been implemented. The Problem List was often not completed and filed where it could be readily seen when the medical record was opened. In addition, information, such as normal physical examinations, the preparation of parole meds, and eyeglasses was sometimes documented on the Problem List. Such information does not belong there and makes the list less functional. Information in the medical records was often not filed chronologically. Some forms and other papers were filed in different sections of the medical records in the different facilities. For.

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