9 CH WILSON, DARREN 3f9f2014 TlFace BfoZUl4 2:59:55 PM BIBIZDIQ 3:00:44 PM -05:00 ED Enc Start Date Time Pt Location LDC Clin PAT Enc Type ACUTE ERD OP Adm Dx Code Desc rintectious Visitor Restriction Disease ALLEGED ASSAULT Confidential Reason Adm Type Adm Source Last Enc Date 45,! Emergency Non-Health Care Fee #529 {Birth Date Rape Maiden Name Tim? i. 28Y White Eounty [Birth Place Health Care ProiililiI SIS Patient leing Will Status Patient Name Address. Phone Employer Name. Address, Phone Emplm Ste WILSON, DARREN FERGUSON POLICE Cell: Guarantor Name, Pt Rel, Address. Phone Guarantor Empr, Address, Phone Emplm Ste Self FERGUSON POLICE Phone: lErnergency Contact 1 Emergency Contact 2 Phone 1: Phone 2: Insurance 1 Namer Address1 Phone Policy Number Group Number Subscriber DOB FERGUSON POLICE ReferraliAutthzatIon it DEPARTMENT Subscriber Employer Eff. Date Pie-Cert. Phone insurance 2 Name, Address, Phone Policy Number Group Number Subscriber DOB ReferrelIAuthorizatIon if Subscriber Employer . . . ven?cd? Eff Date Pre- ert Phone Insurance 3 Name. Address, Phone Policy Number Group Number Subscriber DOB ReferrgyAuthorizatlon it Subscriber Employer veri?ed? Eff. Date Pre-Cert. Phone linsurance 4 Name, Address. Phone Policy Number Group Number Subscriber DOB ReferraliAulhorigtlon Subscriber Employer veri?ed? Eff. Date Pro-Cert. Phone Primary Physician Admitting Physician. ID Dhuelninn. In MISCELLANEOUS, NOTINFILE Incident Date Incident Type Inc StIProv Incident Description 1' Location 081119;? 14 Onset 081?091'14 0th Acc M0 ASSAULTED BY SUSPECT FERG POLICE DEPT Patient Notification Category 1 Patient Noti?cation I Start Date I End Date Printed: DBIDleli?i-Il 14:58 User: PRINTED BY: DATE: 8fl3f2?l4 Page 1 OF 1 Heal?lCare St Louis, MO 63136 OPIED Abstract Summary Patient Name Sex Birth Date lPage MR Number Account Number WILSON, DARREN Male 28 Admit Date Discharge Date LOS Billing Category Disposition 08I09I14 02:20 PM 04:12 PM 1 WORK COMP 01-DISCHARGE TO HOME (ROUTINE) Attendino Physician Coder Patient Type 95909 Otherlu spec 78492 Jaw pain ?new E975 Injury due to teal intervention by spe E8499 injury or poisoning occurring atlln unspeci?ed place E0000 Civilian activity done for income or pay A otal Weight Total CMS Reimbursement Bill Type I Claim Type Claim Disposition Condition Code MR number: Account number: Patient name: WILSON. DARREN Admit date: 08.09114 02:20 PM Discharge date: 08109014 04:12 PM Date printed: 8I12l2014 Page 1 cl"! PRINTED BY: DATE: 8/13/2014 I Page 1 of 11 NORTHWEST HEALTHCARE a part of Christian Hospital - Florissant, MO 63031 Patient: DARREN WILSON DOB: MR AgeIGender:28y DDS: 8I9I2014 14:20 Acct Private Phys: MISCELLANEOUS, NOTINFILE ED Phys: CHIEF COMPLAINT: Enc. Type: ACUITY: Alieged assault Initial 3 - ESI Physicians caring for patient: VITAL SIGNS lnitiaIsIDateITime TemplF) Rt. Pulse Resp Diast P00. 02 Sat 02 Supp PAIN 97Vital Signs Alert: Check Vital Signs . PA 0:0:2014 14:43:- TRIAGE Medical Screening Exam Initiated 00:00:14 14:20 Patient arrived for evaluationzApproximately Saturday. August 9, 2014 14:28 The patient is alert and oriented 3 0:0:2014 14:20:- lnitial VS Deferred Patient to: Room in ER LCC 81'01'2014 14:29> MEDICAL SCREENING CONTINUED The patient is called to the medical screening area. 00:00:14140: History Provided By: Patient 4 NJH3 0:0:2014 14:31:- BJC 24-? Occupational Med notified. 00:00:1414:37 Fall Risk Assessment: Not at Risk. 00:00:14 14:30 The skin is pink. dry and warm 14:30:- Patient denies physical or emotional abuse. 00:00:14 14:30 Suicide Risk Assessment: 00:00:14 14:30 The patient is not expressing thoughts of harming self or others. 4140113 00:00:14 14:30 Printed By rm 0::2:20:4 2:103 PM Medioat Chart with Audits PRINTED BY: DATE: 8fl3f2014 i a Page 2 of 1] NORTHWEST HEALTHCARE a part of Christian Hospital - Florissant, MO 63031 Patient: DARREN WILSON DOB: MR AgeiGender:28y DDS: $912014 14:20 Acct Private Phys: MISCELLANEOUS, NOTINFILE ED Phys: The patient states no attempted suicide in the last 14 days. 031991141439 Patient denies being treated for mental andior emotionai problems. 441-13 03109114 14:39 The patient denies history of Diabetes. 93199114 14:39 The developmental level is appropriate for this young adult. 031991141439 Medical Screening Exam Completed 0310911414:39 Further evaiuation needed to assess if an emergency medicai condition exists. 0310911414:39 ABUSE SCREENING Patient denies physical or emotional abuse. 93199114 14:39 Patient states that hefshe is not a victim of violence. 4141113 9319911414:39 Suicide Screening Suicide Risk Assessment: 03199114 14:39 The patient is not expressing thoughts of harming self or others. 0319911414:39 The patient states no attempted suicide in the last 14 days. 9319911414:39 Patient denies being treated for mental andr'or emotional problems. ?41411-13 93199114 14:39 ALLERGIES Patient allergies: No known allergies. ?4 111113 31912014 14:31? HOME MEDICATIONS Patient not currently taking any medications. 199113 31912914 14:99:? SEPSIS SCREENING Temp is not less then 96.8F or greater than 101 F. 03199114 14:37 Heart rate is not greater or equal to 90 bpm. 931991141431 Resp rate is not greater than 201mm. 991143 031991141431 WA at this time 4141113 03199114 14:31 PAST HISTORY The patient's pertinent past medical history is as follows: NJH3 3191291414:33> The patient's pertinent past surgical history is as follows: 141143 31912914113333 At the time of this signature, i have reviewed and agree with documented Past History. 9319911414:52> No significant social history. 031091141452 Smoking Status: Unknown if ever smoked 4- NJH3 31?912014 14:39> At the time of this signature, I have reviewed and agree with documented Past History. 0319911414:52> At the time of this signature, I have reviewed and agree with documented Past History. 931091141452:- Prl?nred' By on 8172120151 2:01? PM Medical Chart with Audits PRINTED BY: DATE: 81?13f2014 . Page 3 of ii NORTHWEST HEALTHCARE a part of Christian Hospital - Florissant, MO 63031 Patient: DARREN WILSON DOB: MR AgeiGender':23y DOS: 8i'9i2014 14:20 Acct Private Phys: MISCELLANEOUS, NOTINFILE ED Phys: FLOWSH EETS Medication Administration NAPROSYN ORAL 500mgs PO 15:13 GivenDose given 500 mg . Route: 81912014 15:16 NJHS 8i9i2014 15:16 Glasgow NJH3 8i9i'2014 14:39 4-Eye opening spontaneously; 5-0riented Converses; 6-Obeys 15 Printed By an 8112129? PM Medical Chart with Audits PRINTED BY: DATE: ens/2014 Page 40f11 NORTHWEST HEALTHCARE a part of Christian Hospital - Florissant, MO 63031 Patient: DARREN WILSON DOB: MR DDS: 8I912014 14:20 Acct Private Phys: MISCELLANEOUS, NOTINFILE ED Phys: Nursing Pain ?ew sheet . . . ain index . . eneral peci?c . . eneral Epeci?c T'me Ell i?escr'ptm" ?cation Eacation i?ad'atm Eadiation adiation 2014 . NJH3 ?gga 5/10 Aching [9/2014 E439 *3/10 l9/2014 E5342 *3/10 {9/2014 F5943 F110 Primed By rm 8/32/201?4 2:08 PM Medical Chart with Audits PRINTED BY DATE 8/13/2014 . Page 5 of 1] NORTHWEST HEALTHCARE a part of Christian Hospital - Florissant, MO 63031 Patient: DARREN WILSON DOB: MR AgeIGender:28y DOS: 8I9i2014 14:20 Acct Private Phys: MISCELLANEOUS, NOTINFILE ED Phys: NURSING NOTES 081094?14 14:39 Side rails up Entered: 8.4312014141393- 08i'09f 14 14:39 Side rails up.: X1 Entered: 08i'09i'14 14:39 Call light within reach. Entered: <14st 31912014 14:3o> 14 14:39 The patient care is assumed at this time. Entered: 14:39: osrosr 14 14:39 Initial assessment Entered: atorzoi4 14:39> 08.139114 initial assessmenttPatient complains of or exhibits signs of painfdiscomfort at this time. Entered: euro 1439 3:912014 14:39:. career 14 Initial assessmentPatient is alert, active and moves all extremities equally with good tone. Denies 14:40 any numbness or tingling throughout body. Entered: ai9r2ot414:4o> 08409.I 14 initial assessment:Respirations are even and unlabored. Lung sounds are clear to auscultation in all 14:40 lung fields. Trachea is midline. Entered: sis-12014 14:4o> career 14 Initial assessment:Patient denies chest pain. Pulse is strong and regular. Entered: stor201414:4o> 14:40 OBJOQI 14 Initial assessmentAbdomen is soft, non-tender and with normal bowel sounds noted in all 14:40 quadrants. Patient denies any difficulty with elimination. Entered: 14:4o> OBIDQIM 14:42Nursing Assessment Note: 08-09-2014 14:42>Pt to ED with complaint of bilateral jaw pain. Pt states he is a police of?cer and was struck twice in the face by a suspect. Pt denies LOC and NN. Pt denies difficulty moving jaw. No obvious deformity noted. 08f09i'14 15:16 MAR Reviewed Entered: Bf9f2014 15:16> HISTORY OF PRESENT ILLNESS . HPI text: Pt presents with cic bilateral law pain, after being punched in face while attempting to detain suspect. He was also scratched in neck. He denies any other injuries. He denies LOC, headache, ear pain, nose or pain, dif?culty opening or closing mouth, difficulty swallowing or breathing. He has full TMJ ROM. He denies prior treatment for pain. He is up to date with tetanus. 03:09:14 14:52> REVIEW OF SYSTEMS Patient Denies: Headache, fever, chills, abdominal pain. nausea, vomiting, chest pain and shortness of breath JXH1 8i9i2014 14:52:? As documented in HPI, all other systems are negative. ostosr14 14:52 Printed By an 8f1?2t?2l'H4 2:03 PM Medical Chart with Audits PRINTED BY: DATE: 8f13f2014 . . Page 5 oft] NORTHWEST HEALTHCARE a part of Christian Hospital - Florissant, MO 63031 Patient: DARREN WILSON DOB: MR AgelGender:28v DDS: BIQIZOM 14:20 - Acct Private Phys: MISCELLANEOUS, NOTINFILE ED Phys: EXAM CONSTITUTIONAL: Well-appearing; well-nourished; in no apparent distress HEAD: Norrnocephallc; atraumatio EYES: EOM intact; conjunctiva and solera are clear bilaterally; no palpable pain, swelling, ecohymosis or deformity to bilateral orbital bones ENT: TM's and canals normal; no rhinorrhea, no obvious nasal injury, no epistaxis; normal pharynx with no tonsiilar hypertrophy; mucous membranes pinkfmoist, no erythema, no exudate; right mid mandible and mid maxillary region with mild palpable pain; no swelling. deformity or crepitus, mild developing to area, no palpable pain to bilateral TMJ and full ROM to minimal palpable pain to left mid maxillary region without associated deformity or crepitus; no obvious dental injury NECK: Supple; non?tender; no cervicat EXT: Normal ROM in all four extremities; non-tender to palpation; distal pulses are normal, no edema. SKIN: Normal for age and race; warm; dry; good turgor; few faint super?cial abrasion to posterior neck at hairline, no bleeding, no laceration; no NEURO: Alert, moves all extremities equally, follows commands without difficulty. osro9n414:56> ORDERS Medicine ORAL 500mgs PO sreizom 15:13> Radiology X-Rav Diagnostic Procedures XR Mandible Routine 4 Views Trauma [Reference: 3503433} Bl0l2014 14:49> RESULTS Radiology X?Ray Diagnostic Procedures XR Mandible Routine 4 Views Trauma Result 811 01201 4 01 :04 3110:2014 01:04> Result completed: 8i9l2014 to:uz X?Ray Diagnostic Procedures XR Mandible Routine 4 views Trauma DATE OF EXAM: Aug 9 2014 Acc#: - KR Mandible Routine 4 Views DIAGNOSIS: ALLEGED ASSAULT CLINICAL HISTORY: Trauma_Trauma Printed By an 2:08 PM Medical Chart with Audits PRINTED BY: DATE: 8/13/2014 . I Page 7 of NORTHWEST HEALTHCARE a part of Christian Hospital - Florissant, MO 63031 Patient: DARREN WILSON DOB: MR AgeIGender:28v DDS: 81919014 14:20 Acct Private Phys: MISCELLANEOUS, NOTINFILE ED Phys: RESULT: RIGHT MANDIBLE: HISTORY: Punch to right side of jaw. Four views. The mandible appears intact without fracture or dislocation. IMPRESSION: UNREMARKABLE STUDY. TRANSCRIPTIDNIST: TR6 TRANSCRIBE DATEITIME: Aug 9 2014 10:18? RADIOLOGIST: READ ON: Aug 9 2014 ORDERING DR: THIS DOCUMENT HAS BEEN ELECTRONICALLY SIGNED BY: . ON: Aug 10 2014 Reviewed By: 811012014 14:41 Result 8f101'2014 01 :02 ii10I2014 01:02:? Result completed: 8f9f2014 1ozuz x-Ray Diagnostic Procedures KR Mandible Routine 4 Views Trauma DATE OF EXAM: Aug 9 2014 Aoc#: WDX 0077 XR Mandible Routine 4 Views DIAGNOSIS: ALLEGED ASSAULT CLINICAL HISTORY: Trauma_Trauma RESULT: RIGHT MANDIBLE: HISTORY: Punch to right side of jaw. Four views. The mandible appears intact without fracture or dislocation. IMPRESSION: UNREMARKABLE STUDY. Primed By rm 8112,0014 2:08 PM Medical Chart with Audits PRINTED BY: DATE: 8/l3f2014 Page 80ft] NORTHWEST HEALTHCARE a part of Christian Hospital - Florissant, MO 63031 Patient: DARREN WILSON DOB: MR AgeiGender:28y DOS: 81912014 14:20 Acct Private Phys: MISCELLANEOUS, NOTINFILE ED Phys: TRANSCRIPTIDNIST: TRE TRANSCRIBE DATEJTTME: 9 2014 RADIOLOGIST: M.D. READ 0N: Aug 9 2014 ORDERING DR: P.A. THIS DOCUMENT HAS BEEN ELECTRONICALLY SIGNED BY: ON: Reviewed By: 8i10i2014 14:41 Result 8i9i2014 22: 1 8 Result completed: 81'912014 15:02 x-Ray Diagnostic Procedures KR Mandible Routine 4 Views Trauma 81912014 22:18:- DATE OF EXAM: Aug 9 201a Acct: WDX 0077 KR Mandible Routine 4 Views DIAGNOSIS: ALLEGED ASSAULT CLINICAL HISTORY: Trauma_Traume RESULT: RIGHT MANDIBLE: Four views. HISTORY: Punch to right side of jaw. The mandible appears intact without fracture or dislocation. IMPRESSION: UNREMARKABLE STUDY. TRANSCRIPTIONIST: TRE TRANSCRIBE DATEITIME: Auq RADIOLOGIST: ORDERING DR: 9 2014 10:18? READ ON: Aug 9 2014 THIS DOCUMENT HAS BEEN ELECTRONICALLY SIGNED BY: ON: Printed By rm 2.113 PM Medical Chart with Audits PRINTED BY: DATE: 8f13/2014 I I Page 9 of ii NORTHWEST HEALTHCARE a part of Christian Hospital - Florissant, MO 63031 Patient: DARREN WILSON DOB: MR AgelGender:28v DDS: 8I9I2014 14:20 Acct Private Phys: MISCELLANEOUS, NOTINFILE ED Phys: Reviewed By: 8i10f20?l4 14:41 Result 8i9i2014 15:34 Result completed: 81?91'201 4 152344 No fracture or dislocation Reviewed By: BIQIZOM 17:28 DIAGNOSIS Contusion of mandibular joint area . PA 3rsr2314 15:35> Assault by other bodily force 3r912014 15:35:? OBIDQIM 15:35> Departure Time Physician I agree with and have signed off on all verbal orders and protocol orders. 33r35r1415:s4 Sepsis Screening Not Required oarcsr1415:34 Does not meet criteria for critical care 4 05r33r1415:34 Pt was not intu bated Jsrosr14 15:34 5 Physician interpretation of cardiac monitoring not applicable for this patient. Documentation has been completed. isrosr1415:35 have reviewed all of the nursing and ancillary staff documentation isrosr1415:35 Discharge from ED: The patient is discharged to home . Patient's condition is satisfactory . Discharge occured after medical screening and evaluation. . The patient is to follow-up with Contact your supervisor at work on the next business day for information on where to get further treatment of your medical problem. If your supevisor has not been contacted by 11AM, have himl'her call BJC Occupational Medicine at . in the next 1-2 day(s) as needed . Purpose of referral: for re-evaiuation and further treatment sr3r231415:35> R): osrosr14 15:35 Ready ror discharge. osrosr14 15:35 Nursing Nursing Diagnosis: Comfort, alteration in arsrzo14 15:42> IV Flow Sheet is: Not Applicable i3r09r14 15:42 Departure Type: Discharged Admissron orders are not applicable. Patient home . The patient ambulated to private vehicle . Instructions given to: Patient . Rx: Prescription reviewed with patient or representative. Understanding verbalized. . Discharge form signed. Patient can explain discharge instructions in their own words. Time: 1543 Printed By an 2:03 PM Medical Chart with Audits PRINTED BY: DATE: 8f13/2014 1 Page 10 of 11 NORTHWEST HEALTHCARE a part of Christian Hospital - Florissant, MO 63031 Patient: DARREN WILSON DOB: MR it: AgeiGender:28v DDS: 81912014 14:20 Acct Private Phys: MISCELLANEOUS, NOTINFILE ED Phys: was snrzom 15:43:? Saturday, August 9. 2014 15:43 osrosr14 15:44 All orders have been reviewed and addressed by me. 0810911415:44> A nutritional information sheet was provided to the patient. 98109l1415:44> I have signed my chart off after review. 15:44 AFTER CARE INSTRUCTIONS DC-123 Professional enema 15:36? Prescriptions 500mg; Twenty Take one by mouth twice daily as needed for pain, with food sreizom 15:35:? Collaborating physician: 819120141535:- SCANS Bed Assignments: 81912014 14:21 ECP25 LCC 81912014 14:24 Status Activity: Awaiting triage 81912014 14:20 assumes care of this patient. 81912014 14:28 Provider contact 81912014 14:28 Nurse assio'nedi 81912014 14:31 Released 81912014 15:12 Acu H'quity: _Unassigned 81912014 14:21 3 - 1531 LOG 8.4912014 14:29 Chart Documented By: Release Informatlon: Patient released 81912014 16:12 Released by Transfers: Patient care transferred from This chart has been electronically signed by the receiving Physician accepted the transfer. 81912014 14:28 Signatu res: Chart electronically signed by. 81912014 15:37 Chart electronically signed by. 91912014 19:04 Printed By on 5141212014 2:08 PM Medical Chart with Audits PRINTED BY: DATE: 8f13f2014 I . Page 11 of 11 NORTHWEST a part of Christian Hospital - Fiorissant, MO 63031 Patient: DARREN WILSON DOB: MR AgeIGender:28y DDS: 8192014 14:20 Acct Private Phys: MISCELLANEOUS, NOTINFILE ED Phys: Primed By an 3:72:90} 4 2:03 PM Medical Chart with Audits PRINTED BY: DATE: 8113;2014 c: we at Healtl?iCare Elia lr.1l:ht .trr Patient: WILSON, DARREN MRii: Acct DOB: Northwest Healthcare a part of Christian Hospital 1225 Graham Road Florissant . M0 6303] General Emergency Department Discharge Instructions The exam and treatment you received in the Emergency Department were for an urgent problem and are not intended as complete care. It is important that you follow up with a doctor, nurse practitioner, or physician?s assistant for ongoing care. If your become worse or you do not improve as expected and you are unable to reach your usual health care provider, you should return to the Emergency Department. We are available 24 hours a day. You were treated in the Emergency Department by: What to do: I Follow the instructions on the additional sheets you were given: - Please call as soon as possible to make an appointment for follow-up care: Discharge from ED: The patient is discharged to home . Patient's condition is satisfactory . Discharge occured after medical screening and evaluation. . The patient is to follow-up with Contact your supervisor at work on the next business day for information on where to get ?thher treatment of your medical problem. If your supevisor has not been contacted by 11AM, have hinr?her call BJC Occupational Medicine at . in the next 1-2 day(s) as needed . Purpose of referral: for re?evaluation and further treatment - Take this sheet with you when you go to your follow-up visit. - If you have any problem arranging the follow-up visit, contact the Emergency Department immediately. in Take all medications as directed. Your diagnosis is Contusion of mandibular joint area (ED) Assault by other bodily force (ED) Diagnosis instructions: Facial Contusion Facial Contusion You have been diagnosed with a facial contusion. it? 9r2143PRINTED BY: entrailng 8/13f2014 Haitian i lmmu m1. Patient: WILSON, DARREN Acct DOB: Contusion is the medical term for a bruise. A faciai contusion can be caused by a fall or by being struck in the face. The skin, muscles and other soft tissues of the face may become swollen and painfui. You may have other injuries, like cuts or scrapes. The bones under your face might be bruised. The doctor does not believe you have injured essential organs, like your eyes, brain or spine. Apply ice to the face to help with pain and swelling. Place some ice cubes In a re-sealable plastic bag (like Ziploc). Add some water. Seal the bag. Put a thin washcloth between the bag and the skin. Apply the ice bag for at least 20 minutes. Do this at least 4 times per day. It?s okay to apply ice longer or more often. NEVER APPLY ICE DIRECTLY TO THE SKIN. Always keep a washcloth between the ice pack and your body. Swelling may increase overnight when your head is down and gravity causes ?uids to pool in your face. This should improve within a few hours after you are awake with your head up. Try sleeping with extra pillows to keep your head high. Use Acetaminophen (Tylenol) or Ibuprofen (Advil or Motrin) to decrease pain and inflammation. The physician will decide if you need a prescription medication. If your nose bleeds, pinch it closed for 15 minutes. If that does not stop the bleeding, then return here or to the closest Emergency Department. If you have a cut that requires stitches, then you will receive additional wound care instructions. One concern after a facial injury is the possibility of other injuries to the head or neck. The doctor has determined that you do not have any other serious injuries and that it is safe for you to go home. If you develop of a head or neck injury, return immediately to the nearest Emergency Department. YOU SHOULD SEEK MEDICAL ATTENTION IMMEDIATELY, EITHER HERE OR AT THE NEAREST EMERGENCY DEPARTMENT, IF ANY OF THE OCCURS: - Your headaches are severe or become worse. You vomit repeatedly. - You are lethargic or difficult to awaken or you feet confused or seem intoxicated (drunk). - You have trouble with coordination or balance, feel dizzy, pass out, or have difficulty speaking or slurred speech. - Your vision changes or your pupils are unequal in sizePRINTED BY: 3/1312014 orthwest i?lealthcare Iii-AIth .313 Inn-m: .l'r Patient: WILSON, DARREN Acct DOB: Studies done in the Emergency Department: Radiology Information: X-Ray Diagnostic Procedures XR Mandible Routine 4 Views Trauma The emergency physician provided an on-the-spot interpretation of your x?rays andfor EKG if done). A specialist will do a ?nal interpretation of these tests. if a change in your diagnosis or treatment is needed, we will contact you. It is critical that we have a current phone number for you. Additional information or instructions: I) :s 3 ate? ?me f9? PRINTED er: 8/ 1319014 I I Meal-gm I vie-cm Patient: DARREN Acct DOB: Medication THIS IS A LIST OF THE MEDICATIONS THAT YOU WERE ON: - Patient not currently taking any medications. THESE ARE THE MEDICATIONS YOU WERE GIVEN THE EMERGENCY ROOM: . NAPROSYN ORAL 500mgs PO THESE ARE THE PRESCRIPTIONS THAT YOU WERE GIVEN TODAY: - New: Naprosyn 500mg; Twenty Take one by mouth twice daily as needed for pain, with food a New: ;Coiiaborating physician: 15f Side (?eets develop, such as a rash, difficulty breathing. or a severe upset stomach, stop the medication and can?! your doctor or the Emergency Department. 1, WILSON, DARREN D, understand the instructions and will arrange for follow-up care. Patient Signature Representative Signature Staff Signature DateiTime: 8i9i?20143z36 PM 5e 4 Pa PRINTED BY: DATE 8f13f2014 I I ?Silan Imam . mm Patient: WILSON, DARREN Acct DOB: . . . 5 DatefTIme. 8f9f20143 .36 PM PRINTED BYI I ?Stan [hith I In-ufrn: Patient: WILSDN- DARREN Acct DOB: 1, WILSON, DARREN D, understand the instructions and will arrange for follow-up care. Patient Signature Representative Signature Staff Signature DateiTime: Si9i20143:36 PM ge 6 PRINTED BY: DATE3 8 13 x2 01 4 . .10 mama '5 mm .mltl'lfmr. Patient: MLSON. DARREN Acct DOB: I, WILSON, DARREN D, underst the instructions and will arrange for follow-up care. Patient Signature. Representative Signatwc Staff Signat DateJ'Time: 81912014356 PM Paga 6 PRINTED BY: DATE: 8/13/2014 WILSON, FaciTity: CHN Patient Name: WILSON, DARREN DOB: Sex: Account Number: Medica1 Record Number: Accession Number: Date of Service: 08/09/2014 Ordering Physician: DATE OF EXAM: Aug 9 2014 Acc#: WDX 0077 - XR Mandib1e Routine 4 Views DIAGNOSIS: ALLEGED ASSAULT CLINICAL HISTORY: Trauma_Trauma RESULT: RIGHT MANDIBLE: Four views. HISTORY: Punch to right side of jaw. The mandib1e appears intact without fracture or dis1ocation. IMPRESSION: UNREMARKABLE STUDY. TRANSCRIPTIONIST: TRG TRANSCRIBE AUG 9 2014 RADIOLOGIST: READ on: Aug 9 2014 ORDERING DR: THIS DOCUMENT HAS BEEN ELECTRONICALLY SIGNED BY: ON: Aug 10 2014 Patient Name: WILSON, DARREN Account Number: PRINTED BY: DATE: 8f13/2014 CH DARREN CONSENT Br'iifZEIl-t 2:50:44 PM ?o5:uu .. . .. I ?3 E?i?hii?i? 3 'r - ZIVM narnarxore PATIENT mammaran- - . Christian Hosp at I I HOSPITAL CARE and TREAT CONSENT ADMISSION INFORMATION AND FIN RESPONSIBILITY 1. CONSENT TO TREATMENT. i request and consent for Christian 5 'al including its nursingI ancillary-medical and house etch and students; and the esoteric) and th 'oviders (including their assistants) to provide the medicai care, treatment, supplies, tests. procedures and or I ted services (such as pathology. radiology, anesthesia} considered necessary and ordered by my doctortsconsenting. I have not relied on any statement as to the outcome of my care and treatment. I furthe no a . land and give consent to the Hospital. as part of my treatment, to take pictures. video andlor electronic imag rposes related to my care and for use in medical educationitreining or internal quality purposes. I further and retain that the Hospital and other authorized personnel may examine. use, store andlor dispose of any bones, orga s, as, liuids otparls removed from my body, except for authorized organ donation andior transplantation. In the av tt, at. staff assisting in my care and treatment ls exposed (or may have been exposed) to any of my blood andlor ily i that can transmit disease, the Hospth will perform limited testing to detennine the presence, ii any, of blood born di apes such astepaiitisA, B. and and HIV in the interest of the staii member's health. 2. RELEASE OF INFORMATION: ioonsent tothe Hospital's use. etc pictures. andior other Images). either electronically or otherwise, are treelrnent as penniltsd by law. Further. I direct and authorize the Hospi ycioctors (includlng anesthesia. radiology and pathology providers) and other BJO HealthCare af?liated providers (su rursing homeliong-tenn or home care services) to reIease. electronically or otherwise, any medicai andior billing info ail: concerning my care, inciuding copies of my medll records, asiollows. to: I . a. the providers invoivsd or who may be involved in my care at the or after hospitalization, including residential or long-ism: care facility or home heatth agency; . i b. the company or other person that will the Hospital, my doctors or on behalf of the Hospital; 5 i ia is release of my medical records (inciuding 'ved by the Hospital for my care and c. any govemrnentel or other entity as required by iaw for purpes of. rting, including applicable registries. or for purposes of determining eligibility in govemme -s cred bene?t programs; d. other providers and hospitals who have been invoivsd in my ca folIthJem to assess or evaluate health or other services, Including products. provided to me, for purposes of Ineil quality reviews. compliance, case management or accreditation surveys; or a! at the supplier of any blood or blood products which may be adml steredto me for the purposes of queiity conth and recipient monitoring. i s. loertiiy that I have provi ed information in applying for bene?ts and payments to be made under Medicare (Title of the Social Seouri A authorize the release of my medical orciher inionnattcn to the Medicare Program, Intending intermediaries or card rs. as coming this .or a related ciaim. request and assign payment of bene?ts to be made on my behalf to the Hospi I for Moss and to my doctor(s) furnishing their services. i understand that i am responsible for the Perth and Part Is for each year andlor visit. the remaining coinsurance and any other non-covered charges. (continuum page, THIS IS A PART i om: mono Paget of: TAB: CONSENT PRINTED BY: - I . Page 1 2 a CH WILSON, DARREN ECPII 8f9f2014 CONSENT 3.3919014 2:50:lisp-a \Ie Christian Hospital (continued from page 1} HOSPITAL CARE and TREATMENT CONSENT, ADMISSION INFORMATION AND FINANCIAL RESPONSIBILITY 4. PAYMENT FOR HOSPITAL AND PHYSICIAN SERVICES: I understand that both the Hospital and dootoris) who provide services to me will request payment for their services. Further. I understand that the doctors are often not Hospital employees and maysend me a separate bill for their services. this understanding. i agree to pay all amounts due for the services that i receive from the Hospital and the doctoris). I will also assist, as needed' the Hospital and the doctoris) in obtaining payment for the health cats services that I receive. I understand that the Hospital will provide me with information and assistance on how to obtain ?nancial assistance if needed. Further. I understand that - many of the services that I receive are ordered by doctor(s) and that my ?nal bill will not be detennlned until after I am discharged from the Hospital; and - that the ?nal amount that i may be obligated to pay is based on my health bene?ts de?ned in my insurance coverage, including Medicare. Medicaid or, it! have no insurance coverage, by the Hospital's policies. 5. ASSIGNMENT OF AND ASSISTANCE WITH INSURANCE BENEFITS: I hereby assign and direct payment to the Hospital of insurance or other bene?ts payable under my insurance or bene?t plan for its services and also to my doctorts) (or other providers) for their services. If requested by the Hospital or others. i will provide information or other assistance to my insuranoefbene?t plan. the Hpital or doctorts) for authorizations. referrals andlor ore-certi?cations required by insurance or other bene?t plans. I understand that I may be responsible to pay the Hospilal andior doctor(s) for the services provided it have not followed the directions or requirements of my insuranceibenefit plan. i understand that I am ?nancially responsible tor charges not covered by this assignment. 6. PERSONAL VALUABLES: Hospital security may accept items, such as money, valubles or other personal effects for safekeeping. It I choose not to deposit items with Hospital security. I understand that the Hospital will not have any responsibility for the loss of these home. 7. NOTICE OF VISITATION POLICY: acknowledge receipt of information on the right to designate visitors while at the Hospital as well as the information on visiting hours. patient safety and clinical conditions that may affect visitation. 8. NOTICE OF PRIVACY PRACTICES - ACKNOMEDGMENT OF RECEIPT I have received or have been provided the opportunity to receive a copy of the I?Notice of Privacy Practices? that explains when, utters and why my con?dential health infomration may be used or shared. legu'? pa?e' 'nt I acknowledge that the Hospital. doctoris), nurses. and other Hospital staff may use and share my health or Person Authorized infonnalion with others in order to treat me. in order to arrange for payment of my bill, and for issues that. To Sign For Patient concern Hospital operations and as otherwise described in tire Hospital?s Notice of Privacy Practices. at I have read the above Intonna?on and request and consent to treatment and authorize of the patient]. um 67/? 1 films ?1 I ?ner-rm In Patient for'hther vdfo niav stun on behalf otthe patient} THIS IS A PERMANENT PART or Page 2 Of 2 TAB: CONSENT PRINTED BY: . Pm 2 OF 2 DATE. 81?131?2014