Fill out a hospital admission sheet for Mom with everything they usually ask.
Question
Fill out a hospital admission sheet for Mom with everything they usually ask.
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Supporting records
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| relation | parent |
|---|---|
| first_name | Lorraine |
| middle_name | Mae |
| last_name | Pruitt |
| display_name | Mom |
| date_of_birth | 1945-02-11 |
| gender | Female |
| comments | Hollis before she married. |
| phones | - number: '4235550162' variant: Home - number: '4235550139' variant: Mobile |
| emails | - email: lorraine.pruitt@ridgemail.example variant: Personal |
| addresses | - variant: Home street_address_1: 2217 Larkmoor Lane NW city: Cleveland state: Tennessee postal_code: '37312' |
Whose: Mom (patient)
| created | 2022-12-03 16:30 |
|---|---|
| carrier | medicare |
| patients | - lorraine |
| subscriber_name | LORRAINE M PRUITT |
| identification_number | 4KT7-WL2-MS63 |
| type | Medicare Part A and Part B |
| comments | Part A and Part B both effective 02-01-2010. In her wallet. |
Whose: Mom (patient)
| created | 2022-12-03 16:33 |
|---|---|
| carrier | evermont |
| patients | - lorraine |
| subscriber_name | LORRAINE H PRUITT |
| identification_number | EVG80447162 |
| type | Medicare Supplement Plan G |
| comments | Effective 03-01-2010. |
Whose: Mom (patient)
| created | 2026-01-06 20:05 |
|---|---|
| carrier | silverpine |
| patients | - lorraine |
| subscriber_name | LORRAINE M PRUITT |
| identification_number | SPR40981775 |
| group_number | PDPTN04 |
| type | Medicare Part D drug plan |
| comments | Since 1/1/2026. RxBIN 610742, PCN SPRX. |
Whose: Walt Pruitt (service_provider)
| created | 2022-11-12 19:42 |
|---|---|
| relation | service_provider |
| first_name | Samuel |
| last_name | Tolbert |
| display_name | Dr. Tolbert (Mom's primary) |
| company | Tolbert & Greer Internal Medicine |
| phones | - number: '4235550112' variant: Work |
| addresses | - variant: Work street_address_1: 1180 Paulmont Parkway NW street_address_2: Suite 200 city: Cleveland state: Tennessee postal_code: '37312' |
Whose: Walt Pruitt (service_provider)
| created | 2022-11-12 19:42 |
|---|---|
| relation | service_provider |
| first_name | Nadia |
| last_name | Rahimi |
| display_name | Dr. Rahimi (cardiology) |
| company | Sourwood Heart & Vascular |
| phones | - number: '4235550176' variant: Work |
Whose: Mom (patient)
| created | 2024-08-23 17:50 |
|---|---|
| patient | lorraine |
| medication | Lantus (insulin glargine) |
| dosage | 18 units |
| frequency | once a day at bedtime, 9 pm |
| comments | Dr. Abernathy. 10 units 8/23/2024, 14 units 11/12/2024, 18 since 2/17/2026. |
Whose: Mom (patient)
| created | 2025-03-06 16:05 |
|---|---|
| patient | lorraine |
| medication | Eliquis (apixaban) |
| dosage | 2.5 mg |
| frequency | 1 tablet twice a day, morning and bedtime |
| comments | 2.5 since 3/6/2025, Dr. Rahimi. Never skip, never double up. |
Whose: Mom (patient)
| created | 2025-06-12 19:40 |
|---|---|
| patient | lorraine |
| medication | Donepezil (Aricept) |
| dosage | 10 mg |
| frequency | 1 tablet at bedtime |
| comments | Dr. Mehta. 5 mg from 6/12/2025, 10 since 9/18/2025. |
Whose: Mom (patient)
| created | 2022-12-10 15:27 |
|---|---|
| patient | lorraine |
| medication | Levothyroxine |
| dosage | 75 mcg |
| frequency | 1 tablet every morning on an empty stomach, 30 minutes before breakfast |
Whose: Mom (note_subject)
| about | lorraine |
|---|---|
| date | 2024-11-05 16:20 |
| body | levothyroxine UP - 88 now (olive), was 75 (purple). threw the purple ones out |
Whose: Mom (note_subject)
| about | lorraine |
|---|---|
| date | 2023-02-02 06:10 |
| body | MOM ALLERGIES PENICILLIN - hives. as a girl and again about 1985 SULFA (Bactrim) - rash, lips swelled, 2017 not allergies but tell them: codeine / oxycodone - throws up lisinopril - cough tape tears her skin, ask for paper tape no latex. no foods. |
Whose: Mom (note_subject)
| about | lorraine |
|---|---|
| date | 2023-02-02 06:25 |
| body | Mom surgeries (Betty had the old ones) tonsils - child hysterectomy 1987 gallbladder 1996 right knee replaced 10/16/2018 Voss cataracts - R 2/18/2020, L 3/10/2020 Purcell skin cancer off her nose 9/14/2021 left hip 2/3/2023 Voss no pacemaker, no stents, never smoked |
Whose: Mom (note_subject)
| about | lorraine |
|---|---|
| date | 2023-03-14 21:05 |
| body | For the hospital: I am Mom's HEALTH CARE AGENT. "Appointment of Health Care Age…For the hospital: I am Mom's HEALTH CARE AGENT. "Appointment of Health Care Agent" + advance care plan, signed 3/14/2023, notarized. Russ is the alternate. what she said, near as I can get it: - no machines if she isn't coming back - no feeding tube - yes antibiotics, fluids, oxygen, comfort - CPR: "if it's quick, yes. if I'm already gone, let me go." Evelyn wrote yes for now, ask the doctor again later - at home if there's any way Whitlow has it in her chart. |
Whose: Mom (document_subject)
| folder | folder-mom |
|---|---|
| about | lorraine |
| name | Mom health care agent form 3-14-23 |
| created | 2023-03-14 16:35 |