Date/ Time	Source	Provider	Clinical Events	Comments
03/28/0000 1312	Outpatient admission assessment p. 5	KLR (Preop RN)		Ms. Client arrived for preop preparation for right shoulder arthroscopy, right shoulder rotator cuff repair and distal clavicle repair.
1316	Preop assessment p. 6	KLR (Preop RN)	Site #1: Hand left Type: Peripheral IV Assessment: New IV insertion	The IV was started by KLR, RN, who documented placement in left hand @1300 for LR 1000cc KVO #20. She documented preop meds given: Versed 2mg IVP and Ancef 1gm IVPB.
1525     1540       1611           1617     1625	PACU Assessment p. 12   PACU Assessment p. 14     PACU Assessment p.15         PACU Assessment p. 20   PACU Assessment p. 22	IH (PACU RN)     IH (PACU RN)       IH (PACU RN)           IH (PACU RN)     IH (PACU RN)	Pt admitted to PACU in stable condition- IV patent   Some nausea. Meds given and tol. well     PACU Medications Administered: Anzemet Dose: 12.5 Qty: 1 Route: IV   IV site: FAL Forearm left: 20 G PATENT   Pt stable and ready for transport to ASU	After surgery, Ms. Client is transported to the PACU department.   The timing of this entry is inconsistent with the documented time of medication administration at 1611. The site is not documented. Recommended IV dose for an adult is 12.5mg. It can be infused as an IV drip if diluted in 50cc of a compatible solution (i.e., NS, D5W) and given over 15 minutes per Anzemet Information sheet and manufacturer’s instructions for use   Ms. Client arrives in ASU at 1628
1625	PACU Standing Orders p. 26	Surgeon	Anzemet 12.5mg IVP PRN for nausea and vomiting	Deviation: Orders signed after administration
1630           1635	Ambulatory Services Unit Notes p. 28       Ambulatory Services Unit Notes p. 28	CFC (ASU RN)           CFC (ASU RN)	PT NOTED TO HAVE HIVES ON LT HAND AND FOREARM ON OTHER AREAS NOTED ON BODY. DR. NOTIFIED AND CHECKED PT   25MG BENADRYL ADM, IV PT DENIES ITCHING Site: Left hand	The record was revised 03/29/000 by CFC (ASU RN). The word “ON” was strike out and changed to “NO”.         This medication should not have been administered in the affected site. No documentation of a new IV site.
1730	Ambulatory Services Unit Notes p. 36	CFC (ASU RN)	NO FURTHER HIVES NOTED PT DENIES ITCHING HIVES SUBSIDING ON RT FOREARM	The record was revised 03/29/000 by CFC (ASU RN). RT was changed to LT.
1752	ASU Recovery Assessment p. 40	CF (ASU RN)	Type: Peripheral IV Site #1: Left hand Assessment: New IV insertion	There is no documentation that the IV was removed prior to discharge.
1755	Surgery/Outpatient Discharge Instructions p. 52	Physician/Dr.	Call doctor if you have any questions or problems such as severe pain, numbness or temp 101 or above	Patient signature is missing indicating that they received a copy of the information