N 1 3801 172 Y 서울성모사용 * 이 기록은 검사결과 등의 추후 판독에 따라 진단명 및 내용이 변경될 수 있습니다. *고열, 심한 통증, 출혈 등의 응급상황 발생시에는 의료기관 방문 및 문의하시기 바랍니다. - 2 19000101 99991231 174 Y 퇴원교육-환자보관용 *고열, 심한 통증, 출혈 등의 응급상황 발생시에는 의료기관 방문 및 문의하시기 바랍니다. *퇴원 후 일부검사(ex:배양검사, 추가면역검사 등)에 대해 추가 비용이 발생할 수 있습니다. - 1 19000101 99991231 R4 1300014087 공통 퇴원간호계획 서식코드 01 1 19000101 99991231 R4 0000002453 소아 퇴원간호계획 서식코드 02 2 19000101 99991231 R4 0000002455 정신과 퇴원간호계획 서식코드 03 3 19000101 99991231 R4 0000002457 BMT 퇴원간호계획 서식코드 04 4 19000101 99991231 R4 1300014129 산모 퇴원간호계획 서식코드 05 5 19000101 99991231 R4 1300014128 신생아 퇴원간호계획 서식코드 06 6 19000101 99991231 T40 3050404000 2217 52병동 0000000000 1 19000101 99991231 T40 3050406000 2237 62병동 0000000000 2 19000101 99991231 T40 3050408000 2257 72병동 0000000000 3 19000101 99991231 T40 3050410000 2277 82병동 0000000000 4 19000101 99991231 T40 3050412000 2297 92병동 0000000000 5 19000101 99991231 T40 3050305000 2317 33병동 0000000001 11 19000101 99991231 T40 3050310000 2337 43병동 0000000001 12 19000101 99991231 T40 3050311000 2357 53병동 0000000001 13 19000101 99991231 T40 3050312000 2377 63병동 0000000001 14 19000101 99991231 T40 3050313000 2397 73병동 0000000001 15 19000101 99991231 T40 2280200000 2100 응급실 0000000002 21 19000101 99991231 T40 2364601000 3501 집중치료실1 0000000002 22 19000101 99991231 T40 2343602000 3501 집중치료실2 0000000002 23 19000101 99991231 Y N 1877402 20140711 1 6 032 M Y N N 1912 99991231 - - - A R 11 00 - 2112800000 13154 12088 Y 3050314000 45병동 4552 G0110 G01 - - N N N - - N 00000000 - Y 20140725155553 12088 이수정 20140724155552694 - N - - - A - - - 11289 G0110 G01 - - - - 정명진 정명진 정명진 정명진 M 13 3 - N I E Y I N E 2 2112500000 20140712201300 20140712 2013 10333 - N 010316 11 20010316 20140711 1912 최봉석 소아알레르기호흡기 Y 000 DSCHREC 0 Y 20140712 2014 - - - 010316 3777218 B 일괄선택위임 010-7312-5946 054-873-5945 Y 1877402 정명진 M/13y7m 건강보험 PEDAP 최봉석 이수정[87166 Stupor 유 무 Hopeless 유모차/휠체어 타병원 무 안정 일반식 제한없음 원함 유방관리 방법 유( ) 유 유 Foley catheter 수령 혼합수유 02 053) 200 - 상 완전 모유수유 20141031 1023 ENR 20140725 EⓐR 201407301104 (수) 2112800000 소아알레르기호흡기 2880000000 어린이병원외래센터 - 13154 최봉석 20140725121627814 - 201408281330 (목) 2112500000 소아청소년신경 2990000000 발달재활센터 - 99001 권순학 20140626141131442 (+) 201501061424 (화) 2112300000 소아청소년내분비 2880000000 어린이병원외래센터 - 93268 고철우 20140508130405559 (+) 퇴원후외래 2112800000 G2101-3G 영상 20140725 412842888 DOTS 960 mg 2 tab 2 7 480 mg 1 tab 412842889 DOCOMTH 62.5 mcg 1 tab 1 7 62.5 mcg 1 tab 412842890 DORIVOT 0.25 mg 0.5 tab 1 7 0.25 mg 0.5 tab 412842891 DORAMNO 3 pack 3 포 3 7 1 pack 1 포 412842892 DODENOL 900 mg 3 tab 3 7 300 mg 1 tab 412842893 DOCURAA 80 mg 1.066 tab 2 7 40 mg 0.533 tab 412842894 DEVENTO 20 ml 1 btl 1 1 20 ml 1 btl 412842895 DEPULMR 3 mg 6 amp 1 7 3 mg 6 amp 412842897 DEMUCOM 1600 mg 2 vial 1 7 1600 mg 2 vial 입원예정으로 발급된 입원장이 없습니다. ENR EⓐR 칠곡경북대학교병원 간호부 칠곡경북대학교병원 정보통신파트 간호 개인HIS개발 개인HIS개발[칠곡 교육DB] 20141031090611153 줄삭제 fDelCurRow '172','174','178','T40','U31','R4' 20141031 20141031 1023 201410311023 ENR EⓐR 20140725 03 03 03 03 01 02 01 <dschcareeduc> <actscop>03</actscop> <dietcd>02</dietcd> <dietnm/> <bathcd>01</bathcd> <lacmthdyn>01</lacmthdyn> <lacmthdnm/> <healmngtcd>2</healmngtcd> <mngtaftdschyn>02</mngtaftdschyn> <mngtaftdschcd/> <dschseqeducyn>01</dschseqeducyn> <dschmeditmedguidyn>01</dschmeditmedguidyn> <dschcatestatcd>2</dschcatestatcd> <spcffact/> <brthcrtfctyn>01</brthcrtfctyn> <lacmthdcd>03</lacmthdcd> <dschcareeducinclyn/> <dschcatestatyn>02</dschcatestatyn> <bathnm/> <brthcrtfctnm/> <mngtaftdschnm/> <treatdiet/> <healmngtnm/> <healmngtsymp/> <dschcateoxy/> <dschcatestatnm/> </dschcareeduc> <etcfact> <tel>053) 200 - </tel> <eductrgt/> <educunstdgrde>01</educunstdgrde> <dschlactype>01</dschlactype> </etcfact> 05 1877402 20140711 2112800000 032 N C 20140711 1 Y 02 I 0000001583 13154 <SignData> <PatientInfo name="환자정보"> <pid name="환자번호">1877402</pid> <pname name="환자이름">정명진</pname> <age name="나이성별">M/13y7m</age> <insukind name="보험유형">건강보험</insukind> <orddept name="진료과">PEDAP</orddept> <apntdr name="지정의">최봉석</apntdr> <attndr name="주치의">이수정[87166</attndr> </PatientInfo> <SignInfo name="인증정보"> <dschcareinfo> <dschcareinfo> <cscsstatcd>Stupor</cscsstatcd> <proceracomp>유</proceracomp> <dracomp>무</dracomp> <dschtypecds>Hopeless</dschtypecds> <dschmthdcd>유모차/휠체어</dschmthdcd> <dschgoplaccd>타병원</dschgoplaccd> <antibioallgyn>무</antibioallgyn> <dschcareeducinfo> <dschcareeduc> <actscop>안정</actscop> <dietcd>일반식</dietcd> <bathcd>제한없음</bathcd> <lacmthdyn>원함</lacmthdyn> <healmngtcd>유방관리 방법</healmngtcd> <mngtaftdschyn>유( )</mngtaftdschyn> <dschseqeducyn>유</dschseqeducyn> <dschmeditmedguidyn>유</dschmeditmedguidyn> <dschcatestatcd>Foley catheter</dschcatestatcd> <brthcrtfctyn>수령</brthcrtfctyn> <lacmthdcd>혼합수유</lacmthdcd> <dschcatestatyn>02</dschcatestatyn> </dschcareeduc> </dschcareeducinfo> <etcfactinfo> <etcfact> <tel>053) 200 - </tel> <educunstdgrde>상</educunstdgrde> <dschlactype>완전 모유수유</dschlactype> </etcfact> </etcfactinfo> <recdd>20141031</recdd> <rectm>1023</rectm> <recuserid>ENR</recuserid> <dschdd>20140725</dschdd> <recusernm>EⓐR</recusernm> </dschcareinfo> <rsrvinfo> <ordrsrvinfo> <rsrvdt>201407301104</rsrvdt> <rsrvday>(수)</rsrvday> <orddeptcd>2112800000</orddeptcd> <orddeptnm>소아알레르기호흡기</orddeptnm> <centcd>2880000000</centcd> <centnm>어린이병원외래센터</centnm> <subdeptcd>-</subdeptcd> <orddrid>13154</orddrid> <orddrnm>최봉석</orddrnm> <fstrgstdt>20140725121627814</fstrgstdt> <rcptamt>-</rcptamt> </ordrsrvinfo> <ordrsrvinfo> <rsrvdt>201408281330</rsrvdt> <rsrvday>(목)</rsrvday> <orddeptcd>2112500000</orddeptcd> <orddeptnm>소아청소년신경</orddeptnm> <centcd>2990000000</centcd> <centnm>발달재활센터</centnm> <subdeptcd>-</subdeptcd> <orddrid>99001</orddrid> <orddrnm>권순학</orddrnm> <fstrgstdt>20140626141131442</fstrgstdt> <rcptamt>(+)</rcptamt> </ordrsrvinfo> <ordrsrvinfo> <rsrvdt>201501061424</rsrvdt> <rsrvday>(화)</rsrvday> <orddeptcd>2112300000</orddeptcd> <orddeptnm>소아청소년내분비</orddeptnm> <centcd>2880000000</centcd> <centnm>어린이병원외래센터</centnm> <subdeptcd>-</subdeptcd> <orddrid>93268</orddrid> <orddrnm>고철우</orddrnm> <fstrgstdt>20140508130405559</fstrgstdt> <rcptamt>(+)</rcptamt> </ordrsrvinfo> <testrsrvinfo> <prcpkindnm>퇴원후외래</prcpkindnm> <testnm> <![CDATA[Chest AP]]> </testnm> <testplacnm> <![CDATA[2동 1층 영상의학센터 접수실 ]]> </testplacnm> <orddeptcd>2112800000</orddeptcd> <calcscorcd>G2101-3G</calcscorcd> <prcpclsnm>영상</prcpclsnm> <prcphopedd>20140725</prcphopedd> </testrsrvinfo> <dschdrugfactinfo> <prcpno>412842888</prcpno> <drugcd>DOTS</drugcd> <drugnm> <![CDATA[Septrin tab 480mg[powder] ]]> </drugnm> <vol>960</vol> <prcpvolunit>mg</prcpvolunit> <direc> <![CDATA[아침,저녁 식후30분]]> </direc> <qty>2</qty> <prcpqtyunit>tab</prcpqtyunit> <prcptims>2</prcptims> <prcpdayno>7</prcpdayno> <caucnts> <![CDATA[-]]> </caucnts> <drprcpetc7>480</drprcpetc7> <prcpvolunitflag>mg</prcpvolunitflag> <drprcpetc8>1</drprcpetc8> <prcpqtyunitflag>tab</prcpqtyunitflag> </dschdrugfactinfo> <dschdrugfactinfo> <prcpno>412842889</prcpno> <drugcd>DOCOMTH</drugcd> <drugnm> <![CDATA[Comthyroid[powder] ]]> </drugnm> <vol>62.5</vol> <prcpvolunit>mcg</prcpvolunit> <direc> <![CDATA[취침전]]> </direc> <qty>1</qty> <prcpqtyunit>tab</prcpqtyunit> <prcptims>1</prcptims> <prcpdayno>7</prcpdayno> <caucnts> <![CDATA[-]]> </caucnts> <drprcpetc7>62.5</drprcpetc7> <prcpvolunitflag>mcg</prcpvolunitflag> <drprcpetc8>1</drprcpetc8> <prcpqtyunitflag>tab</prcpqtyunitflag> </dschdrugfactinfo> <dschdrugfactinfo> <prcpno>412842890</prcpno> <drugcd>DORIVOT</drugcd> <drugnm> <![CDATA[Rivotril 0.5mg [powder] ]]> </drugnm> <vol>0.25</vol> <prcpvolunit>mg</prcpvolunit> <direc> <![CDATA[취침전]]> </direc> <qty>0.5</qty> <prcpqtyunit>tab</prcpqtyunit> <prcptims>1</prcptims> <prcpdayno>7</prcpdayno> <caucnts> <![CDATA[-]]> </caucnts> <drprcpetc7>0.25</drprcpetc7> <prcpvolunitflag>mg</prcpvolunitflag> <drprcpetc8>0.5</drprcpetc8> <prcpqtyunitflag>tab</prcpqtyunitflag> </dschdrugfactinfo> <dschdrugfactinfo> <prcpno>412842891</prcpno> <drugcd>DORAMNO</drugcd> <drugnm> <![CDATA[Ramnos]]> </drugnm> <vol>3</vol> <prcpvolunit>pack</prcpvolunit> <direc> <![CDATA[아침,점심,저녁 식후30분]]> </direc> <qty>3</qty> <prcpqtyunit>포</prcpqtyunit> <prcptims>3</prcptims> <prcpdayno>7</prcpdayno> <caucnts> <![CDATA[-]]> </caucnts> <drprcpetc7>1</drprcpetc7> <prcpvolunitflag>pack</prcpvolunitflag> <drprcpetc8>1</drprcpetc8> <prcpqtyunitflag>포</prcpqtyunitflag> </dschdrugfactinfo> <dschdrugfactinfo> <prcpno>412842892</prcpno> <drugcd>DODENOL</drugcd> <drugnm> <![CDATA[Denol[powder] ]]> </drugnm> <vol>900</vol> <prcpvolunit>mg</prcpvolunit> <direc> <![CDATA[아,점,저 식전1시간]]> </direc> <qty>3</qty> <prcpqtyunit>tab</prcpqtyunit> <prcptims>3</prcptims> <prcpdayno>7</prcpdayno> <caucnts> <![CDATA[-]]> </caucnts> <drprcpetc7>300</drprcpetc7> <prcpvolunitflag>mg</prcpvolunitflag> <drprcpetc8>1</drprcpetc8> <prcpqtyunitflag>tab</prcpqtyunitflag> </dschdrugfactinfo> <dschdrugfactinfo> <prcpno>412842893</prcpno> <drugcd>DOCURAA</drugcd> <drugnm> <![CDATA[Jeidin 75mg[powder] ]]> </drugnm> <vol>80</vol> <prcpvolunit>mg</prcpvolunit> <direc> <![CDATA[아침,저녁 식후30분]]> </direc> <qty>1.066</qty> <prcpqtyunit>tab</prcpqtyunit> <prcptims>2</prcptims> <prcpdayno>7</prcpdayno> <caucnts> <![CDATA[-]]> </caucnts> <drprcpetc7>40</drprcpetc7> <prcpvolunitflag>mg</prcpvolunitflag> <drprcpetc8>0.533</drprcpetc8> <prcpqtyunitflag>tab</prcpqtyunitflag> </dschdrugfactinfo> <dschdrugfactinfo> <prcpno>412842894</prcpno> <drugcd>DEVENTO</drugcd> <drugnm> <![CDATA[Ventolin]]> </drugnm> <vol>20</vol> <prcpvolunit>ml</prcpvolunit> <direc> <![CDATA[의사지시대로 흡입]]> </direc> <qty>1</qty> <prcpqtyunit>btl</prcpqtyunit> <prcptims>1</prcptims> <prcpdayno>1</prcpdayno> <caucnts> <![CDATA[-]]> </caucnts> <drprcpetc7>20</drprcpetc7> <prcpvolunitflag>ml</prcpvolunitflag> <drprcpetc8>1</drprcpetc8> <prcpqtyunitflag>btl</prcpqtyunitflag> </dschdrugfactinfo> <dschdrugfactinfo> <prcpno>412842895</prcpno> <drugcd>DEPULMR</drugcd> <drugnm> <![CDATA[Pulmican Respule]]> </drugnm> <vol>3</vol> <prcpvolunit>mg</prcpvolunit> <direc> <![CDATA[의사지시대로 흡입]]> </direc> <qty>6</qty> <prcpqtyunit>amp</prcpqtyunit> <prcptims>1</prcptims> <prcpdayno>7</prcpdayno> <caucnts> <![CDATA[-]]> </caucnts> <drprcpetc7>3</drprcpetc7> <prcpvolunitflag>mg</prcpvolunitflag> <drprcpetc8>6</drprcpetc8> <prcpqtyunitflag>amp</prcpqtyunitflag> </dschdrugfactinfo> <dschdrugfactinfo> <prcpno>412842897</prcpno> <drugcd>DEMUCOM</drugcd> <drugnm> <![CDATA[Mucomyst ]]> </drugnm> <vol>1600</vol> <prcpvolunit>mg</prcpvolunit> <direc> <![CDATA[의사지시대로 사용]]> </direc> <qty>2</qty> <prcpqtyunit>vial</prcpqtyunit> <prcptims>1</prcptims> <prcpdayno>7</prcpdayno> <caucnts> <![CDATA[-]]> </caucnts> <drprcpetc7>1600</drprcpetc7> <prcpvolunitflag>mg</prcpvolunitflag> <drprcpetc8>2</drprcpetc8> <prcpqtyunitflag>vial</prcpqtyunitflag> </dschdrugfactinfo> <inrsrvinfo> <inreq>입원예정으로 발급된 입원장이 없습니다.</inreq> </inrsrvinfo> </rsrvinfo> </dschcareinfo> </SignInfo> <SessionInfo name="Session정보"> <userid name="사용자번호">ENR</userid> <usernm name="사용자이름">EⓐR</usernm> <posinstnm name="소속기관명">칠곡경북대학교병원</posinstnm> <posdeptnm name="소속부서명">간호부</posdeptnm> <dutplceinstnm name="근무지기관명">칠곡경북대학교병원</dutplceinstnm> <dutplcenm name="근무지부서명">정보통신파트</dutplcenm> <jobkindnm name="직종명">간호</jobkindnm> <systemnm name="시스템명칭">개인HIS개발</systemnm> <systeminstnm name="시스템소속기관명">개인HIS개발[칠곡 교육DB]</systeminstnm> <logindt name="로그인시간">20141031090611153</logindt> </SessionInfo> </SignData> MIItowIBADEPMA0GCWCGSAFlAwQCAQUAMIImRwYJKoZIhvcNAQcBoIImOASCJjQ8 U2lnbkRhdGE+DQoJPFBhdGllbnRJbmZvIG5hbWU9IsivwNrBpLq4Ij4NCgkJPHBp ZCBuYW1lPSLIr8DaufjIoyI+MTg3NzQwMjwvcGlkPg0KCQk8cG5hbWUgbmFtZT0i yK/A2sDMuKciPsGkuO3B+DwvcG5hbWU+DQoJCTxhZ2UgbmFtZT0is6rAzLy6urAi Pk0vMTN5N208L2FnZT4NCgkJPGluc3VraW5kIG5hbWU9Irq4x+jAr8f8Ij6wx7Ct 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053) 200 - 2014103150050 EⓐR http://his999dev.knu.ac.kr:8088/himed/webapps/com/commonweb/images/biglogo032.jpg 20141031 102333 PEDAP N 입원예정으로 발급된 입원장이 없습니다. 4552 201407301104 (수) 2112800000 소아알레르기호흡기 2880000000 어린이병원외래센터 - 13154 최봉석 20140725121627814 - 201408281330 (목) 2112500000 소아청소년신경 2990000000 발달재활센터 - 99001 권순학 20140626141131442 (+) 201501061424 (화) 2112300000 소아청소년내분비 2880000000 어린이병원외래센터 - 93268 고철우 20140508130405559 (+) 퇴원후외래 2112800000 G2101-3G 영상 20140725 퇴원후외래 2112800000 G2101-2G 기능 20140726 412842888 DOTS 960 mg 2 tab 2 7 480 mg 1 tab 412842889 DOCOMTH 62.5 mcg 1 tab 1 7 62.5 mcg 1 tab 412842890 DORIVOT 0.25 mg 0.5 tab 1 7 0.25 mg 0.5 tab 412842891 DORAMNO 3 pack 3 포 3 7 1 pack 1 포 412842892 DODENOL 900 mg 3 tab 3 7 300 mg 1 tab 412842893 DOCURAA 80 mg 1.066 tab 2 7 40 mg 0.533 tab 412842894 DEVENTO 20 ml 1 btl 1 1 20 ml 1 btl 412842895 DEPULMR 3 mg 6 amp 1 7 3 mg 6 amp 412842897 DEMUCOM 1600 mg 2 vial 1 7 1600 mg 2 vial cefo+vanco vanco inj후 allergy Rx 양상 보여 vanco ->teico change 하였으며, 이후 PEG site culture 에서 S.aureus heavy growth확인 되어 merop 추가 하였으며, anti med 중 sx 호전 되어 p.o septrin change 후에도 fever 호전 되어 D/C. ]]> 1. pulmonary aspiration pneumonia 고려하여 i.v cefotaxime + unasyn med 중임. sputurm culture: S.aureus heavy growth 확인됨.(7.11) 금일 anti change 함.cefo+unasyn -> cefo+vanco vanco inj후 allergy Rx 양상 보여 vanco ->teico change 하였으며, 이후 PEG site culture 에서 S.aureus heavy growth확인 되어 merop 추가 하였으며, anti med 중 sx 호전 되어 p.o septrin change 후에도 fever 호전 되어 D/C. ■Lab CBC Hb : 9.7 g/dL, Hct :29 ％, WBC : 11200 /㎕( 77 / 15 ), Plt : 209 K /㎕ ESR/CRP :28/0.02 U/A P: -, OB: - , RBC: 0-2, WBC: 3-5, K: - Na/K : 135 / 4.1 mmol/L BUN/Cr : 7.5 / 0.4 mg/dL Ca/P: 9.0 /2.9 mg/dL AST/ALT: 127 / 98 U/L Blood gas analysis : V PH :7.43 ,PCO2 : 52 ,HCO3 :34 ,BD :9.7 ■Radiologic findings Chest PA: Rt. perihilar consolidation, CTR: 58% D/C & OPD f/u * 이 기록은 검사결과 등의 추후 판독에 따라 진단명 및 내용이 변경될 수 있습니다. *고열, 심한 통증, 출혈 등의 응급상황 발생시에는 의료기관 방문 및 문의하시기 바랍니다. *고열, 심한 통증, 출혈 등의 응급상황 발생시에는 의료기관 방문 및 문의하시기 바랍니다. *퇴원 후 일부검사(ex:배양검사, 추가면역검사 등)에 대해 추가 비용이 발생할 수 있습니다. 1877402 20140711 1 2112800000 032 20140725 05 1300014129 20140711 info true 1414718587714 1414715378964 11100000 MG00320000|MA00000011|분만간호(ENR) MI00320079 산모퇴원간호계획 info ENR http://his999dev.knu.ac.kr:8088/himed/webapps/com/commonweb/images/error_logo032.gif RPMNN00500 RPMNN00500 XMLSTR true true true 2 Y 450 Y 010316 3777218 소아알레르기호흡기 PEDAP 2014103150050 1300014129 20140311110444 1 cefo+vanco vanco inj후 allergy Rx 양상 보여 vanco ->teico change 하였으며, 이후 PEG site culture 에서 S.aureus heavy growth확인 되어 merop 추가 하였으며, anti med 중 sx 호전 되어 p.o septrin change 후에도 fever 호전 되어 D/C. ]]>
20140725 03 03 03 03 01 02 01 03 02 01 01 2 02 01 01 2 01 03 02 053) 200 - 01 01 05 20141031 1023 ENR 20140725 1400000037807849 201407301104 (수) 2112800000 소아알레르기호흡기 2880000000 어린이병원외래센터 - 13154 최봉석 20140725121627814 - 201408281330 (목) 2112500000 소아청소년신경 2990000000 발달재활센터 - 99001 권순학 20140626141131442 (+) 201501061424 (화) 2112300000 소아청소년내분비 2880000000 어린이병원외래센터 - 93268 고철우 20140508130405559 (+) 퇴원후외래 2112800000 G2101-3G 영상 20140725 412842888 DOTS 960 mg 2 tab 2 7 480 mg 1 tab 412842889 DOCOMTH 62.5 mcg 1 tab 1 7 62.5 mcg 1 tab 412842890 DORIVOT 0.25 mg 0.5 tab 1 7 0.25 mg 0.5 tab 412842891 DORAMNO 3 pack 3 포 3 7 1 pack 1 포 412842892 DODENOL 900 mg 3 tab 3 7 300 mg 1 tab 412842893 DOCURAA 80 mg 1.066 tab 2 7 40 mg 0.533 tab 412842894 DEVENTO 20 ml 1 btl 1 1 20 ml 1 btl 412842895 DEPULMR 3 mg 6 amp 1 7 3 mg 6 amp 412842897 DEMUCOM 1600 mg 2 vial 1 7 1600 mg 2 vial 입원예정으로 발급된 입원장이 없습니다.
Y