Progress Notes ALEXIS ,AARON (b) (6) May 09, *** WORK COPY ONLY *** Facility Date/Time 1979 (34) Printed: Sep 17, 2013 11: 13 Type of Note Author WASHINGTON 08/28/2013 17:31 Note Text < EMERGENCY (b) (6) « Interdisciplinary Note » LOCATION: EMERGENCY DEPARTMENTVISIT DATE: AUG 28, 2013@17:30 LOCAL TITLE: EMERGENCY DEPARTMENT 10-10M INTAKE NOTE STANDARD TITLE: EMERGENCY DEPT TRIAGE NOTE DATE OF NOTE: AUG 28, 2013@17:31 ENTRY DATE: AUG 28, 2013@17:31:49 AUTHOR: (b) (6) EXP COSIGNER: URGENCY: STATUS: COMPLETED Date Age: Sex: Mode and time of arrival: Aug 28,2013@17:31 34 MALE of arrival: ambulatory Patient's complaint (in patient's own words): Sleep apnea Patient's Phone Number: Homeless: No Allergies: No Allergy Assessment (Pls. see CPRS Vital Signs section for VS, height and weight). /es/ (b) (6) ADMIN OFFICER of the DAY Signed: 08/28/2013 17:32 « Interdisciplinary Note - Cont. » LOCAL TITLE: EMERGENCY DEPARTMENT RN TRIAGE NOTE STANDARD TITLE: NURSING EMERGENCY DEPT TRIAGE NOTE DATE OF NOTE: AUG 28, 2013@18:56 STATUS: COMPLETED RN TRIAGE NOTE: Triage Date/Time: Aug 28,2013 @ 18:50 hrs; Sex:MALE Age:34 years old Chief complaint (include date of onset): Patient presents to ER with c/o awakening each morning about 4:00 am like clockwork and he cannot figure out why this is happening. « Interdisciplinary Note » LOCATION; EMERGENCY DEPARTMENTVISIT DATE; AUG 28, 2013@17;30 LOCAL TITLE; EMERGENCY DEPARTMENT 10-10M INTAKE NOTE STANDARD TITLE; EMERGENCY DEPT TRIAGE NOTE DATE OF NOTE; AUG 28, 2013@17;31 ENTRY DATE; AUG 28, 2013@17;31;49 AUTHOR; (b) (6) EXP COSIGNER; STATUS; COMPLETED URGENCY; Date Age; Sex; Mode and time of arrival: Aug 28,2013@17:31 34 MALE of arrival: ambulatory Patient's complaint (in patient's own words): Sleep apnea Patient's Phone Number: Homeless: No Allergies: No Allergy Assessment (PIs. see CPRS Vital Signs section for VS, height and weight). /es/ (b) (6) ADMIN OFFICER of the DAY Signed; 08/28/2013 17;32 « Interdisciplinary Note - Cant. » LOCAL TITLE; EMERGENCY DEPARTMENT RN TRIAGE NOTE STANDARD TITLE; NURSING EMERGENCY DEPT TRIAGE NOTE DATE OF NOTE; AUG 28, 2013@18;56 STATUS; COMPLETED RN TRIAGE NOTE; Triage Date/Time; Aug 28,2013 @ 18;50 hrs; Sex;MALE Age;34 years old Chief complaint (include date of onset): Patient presents to ER with c/o awakening each morning about 4:00 am like clockwork and he cannot figure out why this is happening. Mode of arrival:Ambulatory Pain:O (08/28/2013 18:54) Pulse Ox:8/28/13 @ 1854 PULSE OXIMETRY: 100 EXAM (requires 6-11 elements) General: NAD, alert and o.-riented x 3 HENT: normocephalic, atraumatic, normal external ear canal Eyes: eoroi, perrla, no conjunctival injection, no scleral icterus. Neck: supple, no meningismus, no ttp Cardiac: RRR, no rn/gir, Respiratory: lungs eTAB, Abdomen: soft, + BS, no ttp. Extremities: FROM,no edema, no calf pain Skin: warm, well perfused. no rash, vesicles, petechiae, purpura. Neura: no gross deficits. Treatment and Plan: will die horne on short course of trazodone and encourage pcp follow up with oragne clinic Consultant called at: Consultant arrived in Emergency Department at: Follow-up/Referral: Medication Reconciliation: DISCHARGE INFORMATION: Patient's condition: stable Date and time of disposition: Aug 28,2013@19:35 Patient transferred/discharged to (pIs. specify) /es/ (b) (6) PHYSICIAN ASSISTANT (FB) Signed: 08/28/2013 19:52 /es/ (b) (6) , MD ATTENDING PHYSICIAN (FB) Cosigned: 08/28/2013 20:37 08/28/2013 ADDENDUM STATUS: COMPLETED I was present for evaluation and treatment and agree c above note. Pt presents requesting medication refill of trazodone for insomnia, currently taking same. No new c/o. Unremarkable PE. care flu for further mgrnt. /e8/ (b) (6) , MD ATTENDING PHYSICIAN (FE) Signed: 08/28/2013 20:38 Short course prescribed c plan for outpt primary Progress Notes ALEXIS,AARON *** (b) (6) WORK COPY ONLY Facility May 09, *** Date/Time 1979 (34) Printed: Sep 17, 2013 11:13 Type of Note Author PROVIDENCE 08/23/2013 17:37 ER BRIEF/PHY (b) (6) Note Text LOCAL TITLE: ER BRIEF/PHYSICIAN (INPARENT) STANDARD TITLE: EMERGENCY DEPT TRIAGE NOTE DATE OF NOTE: AUG 23, 2013@17:37 ENTRY DATE: AUG 23, 2013@17:37:13 AUTHOR: (b) (6) EXP COSIGNER: URGENCY: STATUS: COMPLETED ALEXIS,AARON Aug 23,2013@17:37 Chief Complaint: insomnia Brief focused history: 34 yrs old man presents with inability to go to sleep for more then 2-3 hrs for about 3 weeks. He just cannot say asleep. He would wake up with around 1 or 2 am, after 2-3 hours of sleep, startling and cannot go back to sleep. Denies drugs, cocaine, heroin, caffeine product, depression, anxiety, chest pain, sob, nightmares. He denies taking nap during the day. Denies 81 or HI. He works in the defense department, no problem there. Brief physical examination: Lungs: CTA Heart: RRR Abd: normal Ext: normal Psy: normal Most recent Vitals HT: WT: T: 98.9 F [37.2 C] (08/23/2013 17:32) P: 72 (08/23/2013 17:32) R: 16 (08/23/2013 17:32) BP: 123/81 (08/23/2013 17: 32) Progress Notes ALEXIS,AARON (b) (6) May 09, 1979 (34) "k** WORK COpy ONLY *** Facility Date/Time Printed: Sep 17, 2013 11:13 Type of Note Author 1010M NURSIN (b) (6) PROVIDENCE 08/23/2013 17:39 Note Text LOCAL TITLE: 1010M NURSING INTAKE/EMERGENCY ROOM (IN CHILD) (T) STANDARD TITLE: NURSING EMERGENCY DEPT TRIAGE NOTE DATE OF NOTE: AUG 23, 2013@17:39 ENTRY DATE: AUG 23, 2013@17:39:47 AUTHOR: (b) (6) EXP COSIGNER: STATUS: COMPLETED URGENCY: ED NURSING NOTE ******************************************************************************** WANDERING PATIENT SCREENING (MANDATORY SCREEN) ******************************************************************************** 1) At the time of this assessment, the patient appears to lack the cognitive ability to make relevant decisions, had/has a cognitive disorder diagnosis, and has independent mobility? No 2) Does the patient have a known history of elopement and appear to have independent mobility? No 3) Does the patient have a court appointed legal guardian and appear to have independent mobility? No IF YES TO ANY OF ABOVE, IMPLEMENT WANDER GUARD 4) Was a Wander Guard applied? NA If no specify: ******************************************************************************** THERAPEUTIC INTERVENTIONS AND OR PROCEDURES: ******************************************************************************** 5:00pm pt placed in bed # 2 pt denies any illicit drugs or alcohol denies si or hi feels safe where he is staying denies depression nkda 5:10pm 6:00pm er md at bedside pt discharged at this time with his script for trazodone pt to flu with his pcp once he gets home in Texas- going home tomorrow Community Acquired Pneumonia: No If yes blood cultures obtained prior to first dose of Antibiotic? Time ~t 1 Blood Culture Drawn Time # 2 Blood Culture Drawn Time Antibiotic given: Infusion time for # 1 antibiotic Infusion time for # 2 antibiotic Acute MI/Acute Coronary Syndrome: No If yes EKG within 10 minutes of Arrival? Time EKG obtained: Troponin drawn within 15 minutes of arrival? ASA given within 10 minutes of arrival? IV LINES: n/a *IV site location(s): *IV site appearance(s): *Date of IV insertion: *Date IV site/catheter needs to be changed: *IV site issue(s) identified: *If yes,select IV issue(s) identified: Pain Redness Edema Other: *If IV issue(s) identified! specifyaction(s)taken: Replaced line If replaced specify date of insertion If replaced specify date of anticipated needed change Discontinued line If line discontinued was catheter intact? Other