infant ::::8 85concorqiadar, ayesha diagnosis i signs & symptoms accident accident date...

Ultt4ud

"-

Quari(f('d rp 129 Jefferson Davis Bou

O. Box: 1203Natchez, Mississippi 39120Telephone: 601-46-7711

::::8,C'".,."c RESP NSIBLE PARTY & ADDRESS S NUMBER

Gi, BRITT, REBECCA JANEt'. O:: 3 16 WOODLAWN AVENUE

FERRIDAY LA 71334""c., US

EMERGENCY CONTACT NAME

PATIENT EMPLOYER

INFANT

COUNT85CONCORQIA

DATE OF BIRTH

OS/29/2001

428-47-1297RESPONSIBLE PARTY EMPLOYERUNEMP40YED

EMPLOYER PHONE

(999) 999-9999PHONE NUMBER

(318) 757- 2758RELATIONSHIP TO PATIENT

EMERGENCY CONTACT PHONEGUARATOR RE

EMERGENCY CONTACT RELATIONSHIP TO PATIENT

JORDAN LOLA (318) 336- 9746 AUNTCOMMENTS MSP

DY

MED. KEY

Dy I1N

PRIVACY ,ADMIT. BY

LA 7 0 8 2 1GROUP NUMBER GROUP NAME

AUTH Rt ATION

GROUP NUMBER GROUP NAME

AUTHORIZATION

DR. A ENDING I ADMITTING

LAURIEDR. FAMILY PRIMAR ARE

DAR , AYESHADIAGNOSIS I SIGNS & SYMPTOMS ACCIDENT ACCIDENT DATE

PRINCIPAL DIAGNOSIS IThe condition establishe after study to be chieflv responsible for oocasioning the admission of the patient to th HOSPITAL for care.

COMPLICATIONS

COMORBIDITY(IES)

PRINCIPAL PROCEDURE

EXHIBIT "28150000108034

1111!!III!lllIlllrn I1I1I 11/111111111111 111111I1111

ADOO1A UOZ316

I 1111111111!1 111111111111111111111111111 1111111111111111 11111 11m 1111111111 III! 1111 MEDICAL RECORDS COPY

,..:

Case 5:08-cv-00275-KS Document 22-2 Filed 07/31/09 of 25

Utll'itl.c 1" QUIJ/I/jcd ro Coarc.129 Jefferson Davis Bou' vard

O. Box 1203Natchez, Mississippi 391*JTelephone: 601-446-7711

CONDITIONS OF TREATMENT AND ADMISSION

PATIENT'S NAME

ACCOUNT NO.

BRITT r CLOE

2202316ATTENDING PHYSICIAN PATTERSON, LAURIE

DATE & TIME OF ADMISSION 02/21/2002 21: CONSENT TO HOSPITAL CARE AND TREATMENT

I AM PRESENTING MYSELF FOR EMERGENCY SERVICES OR ADMISSION TO THE HOSPITAL AND I VOLUNTARILY CONSENT TO THE RENDERING OF SUCHCARE , INCLUDING DIAGNOSTIC TESTS AND MEDICAL TREATMENT, BY AUTHORIZED AGENTS AND EMPLOYEES OF THE HOSPITAL, AND BY ITS MEDICALSTAFF, OR THEIR DESIGNEES, AS MAY IN THEIR PROFESSIONAL JUDGEMENT BE DEEMED NECESqARY OR BENEFICIAL TO MY WELL BEING.

I ACKNOWLEDGE AND UNDERSTAND THAT MANY OF THE PHYsiCIANS ON THE STAFF OF THIS'HOSPITAl, INCLUDING THE ATTENDING PHYSICIAII(SINAMED ABOVE, AND RADIOLOGISTS, ANESTHESIOLOGISTS. PATHOLOGISTS AND EMERGENCY PHYSICIANS. ARE NOT EMPLOYEES OR AGENTS OF T1EHOSPITAL, BUT RATHER ARE !NDEPENDENT CONTRACTORS WHO HAVE BEEN GRANTED THE PRIVILEGE OF USING THE HOSPITAL FACILITIES FOR. T1ECARE AND TREATMENT OF THEIR PATIENTS. I AGREE TO ACCEPT THEIR CARE EVEN THOUGH THEY ARE NOT EMPLOYED BY THE HOSPIAL .I UNDERSTAND THAT THE EXMINATION AND TREATMENT THAT I RECEIVE ON AN EMERGENCY BASIS IS NOT INTENDED AS A SUBSTITUTION ClR ..REPLACEMENT FOR COMPLETE MEDICAL CARE.

CONSENT TO RELEASE INFORMATION

I HEREBY AUTHORIZE THE HOSPITAL TO DISCLOSE TO INSURANCE COMPANIES, INCLUDING WORKERS COMPENSATION CARRIERS, OR OcHER PARTIeSTHAT MAY BE LIABLE FOR ALL OR PARTDF THE HOSPITAL CHARGES, ALL OR PART OF MY HOSPITAL RECORDS AS MAY BE NECESSARY (INCLUDING ANY;TREA TMENT FOR ALCOHOL OR DRUG ABUSE OR DEPENDENCEI, TO DETERMINE BENEFITS ENTITLEMENT AND PROCESS PAYMENT CLAIMS FOR HEAL"TH -CARE SERVICES PROVIDED. MEDICARE CERTIFICATION RELEASE

I CERTIFY THAT THE INFORMATION GIVEN BY ME IN APPLYING FOR PAYMENT UNDER TH TITLE XVIII AND TiTlE XIX OF THE SOCIAL SECURITY ACT'CORRECT. I AUTHORIZ ANY HOLDER OF MEDICAL OR OTHER INFORMATION ABOUT ME TO RELEASE TO THE SOCIA SECURITY ADMINISTRATION OR ITSINTERMEDIARIES OR CARRIERS ANY INFORMATION NEEDED FOR THIS OR A RELATED MEDICARE CLAIM. I REQUEST THAT PAYMENT OF AUTHORIZEDBENEFITS BE MADE ON MY BEHALF TO THE HOSPITAL OR TO THE pHYSICIA WHO ACCEPTS ASSIGNMENT.

PERSONAL EFFECTS AND VALUABLES

I UNDERSTAND THAT THE HOSPITAL SHALL NOT BE LIABLE FOR THE LOSS OR DAMAGE OF ANY PERSONAL EFFECTS OR VALUABLES (MONEY , JEWELRYGLASSES, DENTURES , DOCUMENTS, CLOTHING, ETC.) UNLESS SUCH ITEMS ARE DEPOSrIED IN THE HOSPITAL SAFE. THE HOSPITAL WILL NOT BE lIABl.EIN EXCESS OF $50 FOR THE LOSS OR DAMAGE OF ANY PERSONAL EFFECTS OR VALUABLES DEPOSITED WITHIN THE HOSPITAL SAFE.

ABOUT YOUR BILL

I UNDERSTAND THAT I WILL RECEIVE A BILL FROM THE HOSPITAL FOR PROVISION OF THE HOSPITAL SERVICES, INCLUDING STAFF AND EQUIPMENT, ANDFOR ANY SUPPLIES OR MEDICINES UTILIZED. I WILL ALSO RECEIVE A BILL FROM ANY PHYSICIAN WHO PROVIDES PROFESSIONAL CARE TO ME. FOREXAMPLE, I MAY RECEIVE A SEPARATE Bill FROM ONE OR MORE OF THE FOLLOWING TYPES OF PHYSICIANS WHO RENDER SERVICES TO ME; MYATTENDING PHYSICIAN OR PERSONAL PHYSICIAN, EMERGENCY ROOM PHYSICIAN , RADIOLOGIST, ANESTHESIOLOGIST, PATHOLOGIST, OR ANY OTHERSPECIALIST.

INSURANCE ASSIGNMENT

I HEREBY ASSIGN TO AND AUTHORIZE THE HOSPITAL AND PHYSICIANS INVOLVED IN CARE DURING THIS PERIOD OF ILLNESS DR TREATMENT(HEREINAFTER ' PHYSICIANS' ), OR THEIR DULY AUTHORIZED ASSIGNS TO TAKE ALL NECESSARY STEPS , WITHOUT LIMITATIONS, TO ENSURE THAT AINSURANCE .BENEFITS OTHERWISE PAYABLE TO ME OR MY ESTATE ARE PAID DIRECTLY TO THE HOSPITAL OR PHYSICIANS. THIS ASSIGNMENT OFINSURANCE BENEFITS INCLUDES BUT IS NOT LIMITED TO BILLING INSURANCE, FILING PETITIONS, FILING SUIT, IN MY NAME OR ON BEHALF OF THEHOSPITAL OR PHYSICIANS, FILING PROOFS OF CLAIM, FILING PROBATE CLAIMS AND FILING GRIEVANCES AND ALL OTHER SIMILAR PROCEDURES, ASMAY BE AMENDED FROM TIME TO TIME WITH THE STATE DEPARTMENT OF INSURANCE- I ALSO AGREE TO PROVIDE AND SIGN ANY OTHER DOCUMENTSTHAT MAYBE REASONABLY NECESSARY TO ACCOMPLISH ANY OF THE OTHER PURPOSES.

STATEMENT OF FINANCIAL RESPONSIBILITY

I UNDERSTAND THAT I AM FINANCIALLY AND LEGALLY RESPONSIBLE FOR CHARGES NOT COVERED IN FULL BY ANY THIRD PARTY. I FURTHER AGREETHAT SHOULD I NOT PAY THE BALANCE WITHIN THIRTY (301 DAYS AFTER THE DATE OF DISCHARGE , MY ACCOUNT WILL BE CONSIDERED DELINQUENT. IAGREE TO PAY COSTS OF COLLECTION, INCLUDING REASONABLE ATTORNEY'S FEES AND COSTS, COLLECTION AGENCY FEES AND COSTS, AI-DINTEREST WHICH SHAll ACCRUE AT THE MAXIMUM RATE ALLOWED BY LAW.

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD , OR DECEIVE ANY INSURANCE COMpANY, OR FILES A STATEMENT OF CLAIMCONTAINING FALSE, INCOMPLETE OR MISLEADING INFORMATION MAY BE SUBJECT TO PROSECUTION UNDER APPLICABLE LAW.

ADVJlNCE DIRECTIVE (FOR ADMISSION TO HOSplTAL ONLYI

IF I AM TO BE ADMITTED TO THE HOSPITAL. I HAVE BEEN GIVEN WRITTEN MATERIALS ABOUT MY RIGHT TO ACCEPT OR REFUSE MEDICAL TREATMENT. IHAVE BEEN INFORMED OF MY RIGHTS TO FORMULATE ADVANCE DIRECTIVES. I UNDERSTAND THAT I AM NOT REQUIRED TO HAVE AN ADVANCEDIRECTIVE IN ORDER TO RECEIVE MEDICAL TREATMENT AT THIS HOSPITAL I UNDERSTAND THAT THE HOSPITAL AND MY CAREGIVERS WILL FOLLOWTHE TERMS OF ANY ADVANCE DIRECTiVE THAT I HAVE EXECUTED TO THE EXTENT PERMITTED BY LAW.

(lNITIAL THE FOLLOWING OPTION THAT APPLIES)

. I HAVE EXECUTED AN ADVANCE DIRECTIVE AND WILL PROVIDE A COPY OF THIS FOR MY MEDICAL RECORD WITHIN A REASONABLE AMOUNT OF TIME.

. I HAVE NOT EXECUTED AN ADVANCE DIRECTIVE AND DO NOT WISH TO DO SO. INIT-INIT. (FOLLOW-UP DONE BY DATE. I WISH TO COMPLETE AN ADVANCE DIRECTIVE DURING THIS HOSPITALIZATION. INIT.

I CERTIFY TH T I H VE READ HAv THE ABOVE CONSENTS AND CERTIFICATIO S AND UNDERSTAND AND AGREE WITH THEM.DATE' Co D Y YEAR GN TURE OF PATIENT 0 LY AUTHORIZED REPRESENTATIVEWITNESS PRINT NAME OF PERSON ABOVE 0028-+AD001B :Z02316 OOOIJ108034

IIIIIIIIIIIIIIIIIIII IIIIIIIIIIIIIIIIII 111111111111111111111111111111111111111111111III1I1I11I11 01111111111111111111111 11! 111/111111 1m III


INITIAL ASSESSMENT FORMPRIORITY: P"uent: BRITT, CLOE

008: 08/29/2001

EDP: Patterson , Laurie

pcp: Dar, Ayesha

AGE:

Natchez Community Hospital

PI#: 220231625WKS ) Sex: F MR#: 0000108034

Worker's Camp:

.,"

Emp. RefeITed:

Critical CareDATE: 02/21/2002

Presentation Time: 21 :40 Triage Time: 21:40 Arrval Mode: PARENT ARMS

Height:

ChiefComplaint:

" Weight 22. !bs. 10. kgs. LMP:

CODE 300

Last Tetanus: Ace By: MOTHER

Vital SiqnsT: . POP: R",9ularR: UnJaboredBP: 000/00002: % RAPain Intensity Scale:

Pain location:

110

BriefAssessment:

PT TO ER VIA PARENTS ARM NOT BREATHING. BLUE COLOR IN FACE, CODE 300 INPROGRESS

NIGHT SWEATS

WEIGHT lOSSANOREXIA

UNK

UNK

UNK

HEMOPTYSISFEVER

UNK

UNK

SuddenOnset:

Pre-HospitalTreatment:

PediatrcAssesment:Past Medica!

History:

Allergies:

NONE

G&D App. for Age - NO , Immunization UTO - NO, Height ft in., Head Cire. - Grade - , with MOTHER

NONE

NKDA

Medicines: ANTIBIOTIC

Sr_"Additona! Not

JLC

00281


"."" .

i'11:1fNatchez Commurnty Dos th.

. .

129 Jeff Davis Blvd. PO Box 1230 Natchez J3 . .(1 'ttt l' MR ; iJ

;.

Name: !T.L. .............m.m...... Age: m .m Sex: () M:. ()J :i 1. - S ,;;0,';' P

;;;-

o:'m'- R

.;;__ --

TI. PROV,

-. :=:, ==:----_ :::

::::: z:-...--.- P""

---

HPI SOURCE: 'lem 0 forioo 0 EMS rse's Notes ReviewedTIING: Began PTA 1 2 5 6 7 8 8-12 12-18 hr, ago; "" ...mm.

....

6):o lrladua Onset uddeD Ornct 0 lntermttyn NatU / tiuous in Nature dy PreSCt 0 Absent

DURTION OF APNEA: 0.0 15 sec. 0 15-20 sec. g) 20 sec.

,._

SIGNS & SYPTOMS DURNG EVJNT)- Ski Color (0 Pink a p

/'-

o Erma usj noci fucl

;-;

O A.c

, .

o n."tcsion ofExtremicies / Iimp J .......m........... Chest WalMovemcnt (lj'None / 0 Acre) ....m.m..

...... '... ...... '...

Assoc. SIGNS & SYPTOMS: OCongcscion Nasal DiscMrgc ( o near; / 0 Yelow 10 Grcen) OStridoc O\ 'hoezing ........o Coug (OJ'on- product Produci sputu) Ofevoc Intae ..........mm.. ..............m.................

...."': . :

CoNTEX: P'eS1ccph, 0 Whie reedi Boy Poiltion: upine OProne _ ,"m..--...,","--,"--

--,","

Q1:G FACTORS: 0 Spontaeous Return of R.splrcions 0 Physical Sciroulus Requied ..

.................. .............. .........--..... .

L""

:' .........:.... --........~~~

ROS

;::

:'1'

02121/200210:12:45

CONST,

EYE:EN!:CV,RESP:

An Other Systems Reviewed And Negative (unkss wattOI Or cickd)f.;' !P:!"-..n--..

..... ......

........... GI:

..... .............

....m.................... ........ PsYCH:

........... ...,... ''''' ''''''.'''''''''' ''''''''......'.

GU: END:.. .&..... 'H'_ U.'_--------- .'r ..nn.--.....- ..un....MS: HEME/LYMH:

---- - -

"'U.n...hu.. n. .......h. n...._. ..nnn"".,.. --...nonn ""0'" "H .'hhu.n ., nnn" .'U.."""..'..SKIN: ALflMMU:

""""""'' ~~~

--..Y\.......

.-......,... .......".. -...- .. -". ''''''''''' ~~~

"'.."C...m........

..-- ..........................

.... NE()D: ..

............................... .....

........... OTR;

.n .............-... n.... ......n.h' T..h.hu.......- ..... U'''''U.. n'h - u. --- -- 'Un..... ..-..u.. ....

."...."'.....'..'."'U".h...n........_.

'_----~~~~~~ ~~~~ ....... ~~~

n -. u...... . ...n . ........ ""UUT'..n.._...n.... n..

PMH BIRTH HISTORY: .. y.e 0 C- Soon PREG. RELATED CaMPL.: ne . U 'l*

.. ,

BIRTH RELATED CaMPL.: oneCmHOOD ILLss: 0 None ' 0 P

~~~

Bkr.

~~~~ ~~~ ...'

z!.jlt;.

::' ''''.''. ''. ''''. """". """". ''. ''. ''''''.::' ''''''''.''''. ''''.~~~~)' ~~~

A;' ES;" KDA".' PCNmt)S'cl".'''.''''''.''''..'n..--

...........................,..--................

f:;:

~~~ ~~~~~~~~~~~ ~~~

Nm"'

...

CICULATION: 0 Carotid p ent 'ucless . "'''....''''.''..c........

...... ....--.................,.....,..

,......'.'''..''''''.....m H.......

..... ................

PSYCHIATRIC: 0 l\ppropciate . a re 0 CombatiV"''''.'.''.''''.'''''.'''''''''''''''..................m..

........ ... ...........,..........=: :=

;::uro

;ya

....?,'."...,

.......................n..............................

.........""""."""

ENT: 0 NOrm Disch ifJm

~~~~--- :-"

CV: ONorm OM

......................

"'''n...... 'REp: . Inpection: ocm 0 Retrctions 0 Iracheal Devation

~~~

w:=7

_. .-~~~

'l5:uP ED RECORD APNEA - PEDIATRICS.l., "-c...

OOt?:'-r


Natchez Community Hospital

!?.

T.!hg!:Q 'h"."."''''''''...'''''''''.''''.''.''''''''''''''''

Medic i~ Makng iscussed With Famil . Id Char Re ue F;.di, ...

......... .... ........ '

DDX: cJP~ Scics Crastrocsophagc Reflux Anemi Ekctl)-tc Disrubace Add/Basc Distuance

,/. ...

\J Hypothenn H,yIf BceathHoIdi ALTE

~~~

Obstrcryc Apnea: Strdor PrematUrity, Abnorm Ajrw)-, Other: (GERD, Rctropha.yagca Abscess)

Centr Apnea: CNS Abnormaties

.. . -' --

1\fucd Apnca: l1fo olt :Jcr busc, TraERFORM bs EssentiaUyra.rm q,nless Noted Below

1 L ::t; 'w.

'''''''' -==.

o URINALYSIS: pH SG Pmrcn G1u \'VCs RBCs Bactri _._..m'_"_"'_"'''-''''-''-'_.'''__h_

....--.

o RSV SWAB: 0 PERTUSSIS

..

CHIA CuTURE "

9 yLUCOSE STICK: ..

'''''''....h.''.''.._._''

0 EI'V d ) LOOD C & S a URI C & s )f

ABG: pH S-7

~~~~ ;'

1'02 5 02 sats ABG INTRETATION: ..

... .... .....:.......................~~~ :=:

o AP & LAT. SOFT TISU OF NECK: 0 Norm

.................................................

ueliinary a Rea RadiolOgist

~~~

:7: 'joN ch:;

see

~~~ ~~~......._... ~~~~~~ :.....

. i

.._ ---- ~~~ ~~~~~~~ ----.. ...... ......--_.... ....__...

T'T...HT'_"'." ................ ....'O.u.n_.nu.... ... .un.- ..... --"'u." -. n----------______nu_---n- -

,,--- . , ....-

"' .....Un..n nu ...00 -........ ....... n...... .. ...... ,,'U, Hhu.n................ ..n..." ..... n .". "u. - ".-

.--~~~~ ~~~~ ~~~ "''' ~~~~~ ..__ ''' ....' '',

"o'''

''''''"-'''' ~~~ ~~~~~~~~

uu''

--___un_n 'OT- .-'.0.... ..0 ...... ...n...- ........ ",.00. .uun._"'''..'.n...- .....n. U""_.

"""

'H" on.n _.--..... .. ..... .un.... .-.....-....... on....... '.. __n_n_______uu....... ..n"".',.,--".,.,. .."..,. h......Tnn ..n. n..... .n."'", .'n... '''.......00.......... .u....n..... 'H.....h.. ..n.. ....... .......... "'00' ,,,,,.., ......... ....n.. ""UhU'''. . Ha"-- . n. --- n. .UT"'" ....... n..n.".. n. ........ ....... .u,...... ........ ......

"r--

""''-"''. ''' ''.'''''

'''''-U''_

-._ ~~~~~ ~~~~~~ ~~~ ~~~ ~~~ ~~~ ""'''' .''"'. ~~~~ "'-' --''' ''.'''

...Hd.. .nn.... "'n. .....-....... n.". ......... "'u" .'U'." .......... .''' U_nn n . .n_.n- ...._n ..................... ..n ...... ........ n...'. ....... ......... n.....,... ".h.. orn. .......... .....nn...nu.............. n....... .......

-..

.. n.... ....00. .H""+'T".' " .n '''"." ... n. ..... ... .00.. ,.,.., '.. n... ...... n. ...... ....... .... ..

.. .----. - -

'" - .n"'" '..nU' hn... n.....,.. ........ ....... "'''Hnn. h... .nn. ,.,...... ........ ...00.,

- ---..-..'' ~~~ ~~~~ ~~~~~ ~~~~

''-H-'

... ~~~ ~~~ -'''' ~~~.....y,'"".... .._ ~~~ ~~~~~

.... ... ".".U'.'.. -- __n. -

. -"---

'T"' 'U""." n. ".....n" "" ...... ....00 ..

..........

.........., '0000'.."'''''''.'''''' ... d.... .... ... ................................ """h_

...' -----. -..- ..- ....

.. .00...." .'...n... .. ."".H.u_ . h' "T". ---. n.n.. -........ ..."... ....... ........

""'."

'."'H"" +"T.""" ...... ... .n.... "'.'..Un'.',."". n ..00..... ..... '.'U'." ."".H -..

- _

,nn ........ n....... ................ ........ ...00., u.".... ........ ......

~~~ ~~~~~~ -'-'-

Impression(s)

Disposi . n 0 AM 0 LWfDISCHARGE: OAlone 0 With Famy

PRECRPTONS: ...00.00 ....... u.....+o '.""h,, ".n. .nn..... .........00. ....u.. ..... .... ""...00.... UH'" u. .n h. .... . n.. nH" ..... .......... 00

...... ". .". -

...' - ---.- n---

...-

u........ .n

'" - - -

un.... u ...nDISCHAGE INSTRUCTIONS:

'.'..

........,..nU"++ .n........ nr... .....00..",...,.,.,,,.,,,,,. .,.p".

, ......

.".'.hn ....... ........-...... ....u.. ....... .u._

._- .------ - ...-

.u...-- -- _--__n- __n

,. .......

FOLLW-UP: 0 Fam.y Physici a pediatrcian a Tomorrow 0 1-2 Days a 3-5 Days 0 7-10 Days a proADMIT 0 Obscryarinn Unit a Floor 0 lclc

;;-"

51cu-- o C)

''''-

'TRASFER To:

ACCPTNGPHYfClA: DR.

-... --.... - -------. ------

....un..... ........... ....... ...... -"."H'.",

'''

.n..

, ....

.. u_.

+..

...un... ......

--."."00'" 00'00.--"''''00'' _n

__.

o Unstable

- -

,.u- .. n...n 00 .,...u - ...n. .

-....... ..... --.....

PAl ARP: n..,.. ........ ...nnn............ U.....n.. ....... H.."... or...... PHYSICIA' S SIGNATURE

ED RECORD APNEA - PEDIATRICSTHOSw" tlt..-2n....;_c.'P.

(/i"tj"

:;-

I - -

. 'Case 5:08-cv-00275-KS Document 22-2 Filed 07/31/09 of 25

ORDER PROCEDURE FORMCARDIOVASCULAR EMERGL :;IES

Date In: 2/21102

Natchez Community HospitalName: BRITT, CLOE Pt#: 2202316Age: 25WKS DOB: 08/29/2001 Sex: F MR#: 0000108034EDP:Pattersofl, Laurie PCP: Dar, Ayesha

'.C

Order Time laboratory( CBC)rBMP )

!P/PTTMagnesiumCardiac Pfofile

Order Sent

CMP

Radiology( CXR)(PAIT - Portble) A 'v

CardiopulmonaryEKG

Physical Therapy - E\I & Tx

,..

;:J A r '

,,

Y)/\

.-

K-l

\. .

LJ IV

o KVO Device

lR. 24\PtCN LIlt:: --\ a J.0'Vb\ kwrl.v O'rlAiD

't NIBP Monitor Internal Pacer (Temporary) \. 0 Arterial Line Place ent )\.fPUlse Oximetr 0 Central line Placement 0 NGT Inserton

.. ? .

l.UL1

o Thrombolytic Therapy (Thrombolytc Flow Sheet) 0 CVP Monitong J\l-e"\CV\

NIt:7 r' fu. /2

JU . Atr'A

--

tY '" l.

.:

vt

o Carotid Massage

o Cardioversion

CPR

IS Endotrcleallntubation

Initials/Signature:

I Initials/Signature: 0i

tials/Signature:

Ph\ 11: a rU- -/ /t r' .If--/ ./(l, /1411." 2 0L/

PAIARNP:


Name: BRITT, CLOf.Age: 25WKS 00B:08/29/2001EOP:Patterson , Laurie

Natchez Community HospitalPt#: 2202316

Sex: F MR#:000010B034PCP; Dar, Ayesha

EMr:RGENCY DEPARTMENTCHEST PAIN NURSING ASSE.. MENT

Caregiver: D Self mily member 0 Signifcant Other D Group homeEmployment 0 Full time 0 Part time 0 UnemployedActivity level: oAmbulates independently oRequires assistance .ambulat()ry

DPerforms ADL's independently uires assistance with ADL'Environment steps 0 Few steps 0 "'ny stepsNutrtional status: ormar 0 Cachetic 0 Obese

Religious preference:

Cullural preference: Highest grade completed:

Read: o oYes Write: o DYesLearning Barrers: OTDD phone 6 Interpreter oNo

o Other:

bYes

Onset: Date: Time: Duration:Onset;: 24 hrs. medical attention was sought? 0 No

Radiation Ii, \. 0 to r Y\0. Quality IJ.)J U'\

D Substema'I"- '(ci 0 Presu/'e I Heavy '- o';ndigeStio Epigasbic 0 0 Burning 0 Ind 'bableo Left Chest . UE D Sharp Stabbing o Right Chest Shoulder o Costant 0 Crushingo Neck Jaw Dlntennittnt 0

Status at onseto Resto ExertonOAwakened from sleep

DYes. Date:

Relief Measures

RestFooNTG SL

Yes No

Associated signs andsymptoms o Dyspnea

o Diaphoresis

Chest discomfort with

PMH from triage: NONE

DHigh CholesterolDPeripheral Vascular DiseaseD Previous cardiac arrestD MI Date:

o Pacemakero Family HistoryOSmoker: PPO Yrso Other

Date

Heart Sound 0J JS Palpation DWNL DCli fRub "' t";"M

r;r,,U,"

o Murmur DRub \.'/V\lt I \ s: Carotid Femora!

D Muffed D Other: Brachial

..

Popliteal

Cap Refil: 000 2 sec. (Normal)i:: 2 sec. (DelaYBd) Radial Dorsalis pedi

Edema: 0 No es Loca S=Strong W=Weak D=Doppler A=Absentf/ - . Degree: D 1 + 02+ 03+

Cardiac Rhytm: ONS Sinus Bradycardia DSinus Tachycardia OSVT oOther:Apical Pulse: Sp02: 0 Room Air

Abdomen:

)1S0ft o DistendedD Firm oNon-Tendero Rigid oTender

o Rebound Tendernesso Other:


EMERGENCY DEPARTMENTONGOING NURSING ASSE !TENT Name:BRITT, CLO

Age: 25WKS ooB:08/29/2001EDP:Patterson , Laurie

Natchez Community HospitalPt#: 2202316

Sex: F MR#: 000010B034PCP: Dar, AyeshaDate: 2/21/02

Jlrwy Clearance , IneffectiveAnxietyBrealhing Pattems, Ineffective

KCardiac Output, DecrBasedComfort, Alteration inOther

Communication Impaire

Coping, IneffectveFluid Volume , Alteration in

as Exchange , Impaired-- Hypertermis (FevB

Infection, Potentialinjury, Potential

KnO'edge Deficitobilty Impaired

Non-ComplianceOther

Self Care Deficit-Skin Integrity Impairment

hought Processes , Impaired .

Thought Procees, Alteration . inTissue Perfsion , Alteration if!

NotMet Met lot

NotMet Met lot

o FB REMOVALo BLEEDING CONTROLo PAIN CONTROLo ALEVIATE

o FEVER CONTROLo DECREASE ANXIET

SAFET IN THE ED

o IMMOBILIZATION PROPER ALIGNMENo DECREASE PREVENT SWELLING

f!MANTAIN STABLE HOMEOSTASISo MANTAIN SKIN TISSUE INTEGRITY

o PREENT FURTHER INJURYMAINTAIN IMPROVE CIRCULATION

o INFECTION CONTROL

o IMPROVEMENT OF BRETHINGo STABilIZ PATIENT IN DISTRESS

o meet ENVIRONMENTAL NEEDSjj met PSYCHOSOCIA NEEDSo met SELF CARE AB (LIT NEEDSo met EDUCATIONAL NEEDS

Int: N = documentation in nurs note,., othr 'coe,.' per HD$pitl Pojicy.

124 117 / 74)134 61 / 44)

XX / XX (XX)114 89 / 65)136 81 / 58)154 89 / 57)

100 114 /

2,ae

DVerbalizBd understanding

o Admit - Room #: to Dr.

o Left without treatment 0 Left AMA

eport called at and given to

D/C Condition: Dlmproved DStable DSeriOU EXPired

Pain: Severity Scale: Dlmproved D nged DWorse

Time: W- Nurse:

, "' f'


N63D1

t:ach entry requires date, time, signature and tile

Date Time Interdisciplinary Patient Notes

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Interdisciplinary Patient Notes

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N6301

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Date Time Interdisciplinary Patient Notes

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N6301

002825


Natchez Community Hospital129 Jeff Davi Blvd. PO Box 1230 Natchez MS 39120/601445-6700MRN

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THOSNGW" H41f1__'::t.._ ED RECORD BLAK ADDENDUM

002826


PROGRESS NOTESDate / TIme

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129 IcffDavisBlvd. PO Box. 1230 Natchez M:tjp:nOJaO.APIC

02/21(2002MR ._m

Age.

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Name: . rf!!.. tI!:QI:L..

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02/22/20027:01:17

LOCATION: o FIoOt o lCU "',".....n_' ......._.......n.."'."."'.'"' '''''''""'.""'."""'U'-'.O"'--

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Ciculolion: 0 C2Itid Pue Prsent 0 Puscless n__n_

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INIIA TELEMETRY:

a Bracadia. a v Fib

PHYl INTERVENTlONS: tuba.lion CPR 0 cn PIo.ment 0 Dejibra.tion

jyaso-Active Drips (0 I)pamne, a Dobu..ne, phr, Other: A..

ystole o PEA o Pusele.. vr o Nanw-CornlexTa.chy ardia. o "Wde-plex Tachycardia.

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SECONOARY AsSESMESKI: 0 Normal otie

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Id 0 Di"phoretic

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REsp: 0 Norm

.3 Unequa Breath Sounds 0 Craddes 0 Wheeze o Resira.tions ...............m...................................

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GI: 0 N"rmal Joteuded 0 Puatile Mas.MS (includes neck & back): a Nonn 0 JV IJ;;;;.

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HEME/LYMPH: 0 Nonn 0 Ede"" .

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NEURO: a Normal COMA 0 GCS:

ADDI'IONAL INTERVENTIONS/RESULTS:

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CA DISCUSSED WITH: MD 0 OthePA/ARP: ."''''''.''.

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THOSENGUP ED RECORD HospITAL CODE:D(" .I!nbI.I'1I:"..,... G"""k-..

002829


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129 Jeff Davis Blvd. PO Box 1230 Natchez MS 3PI2P/601-64S:6'100L .( 14

MR "m_ '''m_mm__... __mmm ?a!291200r I2112002Name: .- rII, 9.Ij!:Q.

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02122/2002 7:00:20 AM

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CONSENTo Written Consent 00 Chart

o Verbal Consent Obtaedoos nt Unobtainable Due To Patient Condition

PRE ENATION6.0% NRB 0 None C-W

PRE-MEDICATIONDefasiculating Meds: 0 Norcuron 0 Pavulon Other: ......... ........... Dose: Other Meds: 0 Udocaine 0 Atrpine 0 Esmolol Other. ..

.........

m... .....

..... -..

o Thiopental (pentothal"T 0 Fentanyl (Sublim.azenl 0 Midazo1all (VersedT

o Ketamine (Ketaar1l 0 Propofol (DiprivanTI 0 Etomidate (AmidateTM

Other. Dose:.. n" n ".",,".n. ........ o.....no" ...... ..0... ...nno" ..... -... un - - -.. n.. n. ..._h........ .......0.. .n.. n............. u n.... q.

PARYDe 0 Succinylcholine

INTBAT.I9. A ET Tube was insered. 0 Oraly 0 Nasally

S. 0 0 First Attempt rThidAttempt 0 'fhirdAttempt

Other:

Ifunsuc

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Sellck Maneuver was done throughout paralysis: 0 Y ON . fThere was symmetrc chest rise and BBS post : 0 Y ON

indicator used for commnation: 0 N Results: 0 (+) CO. RetU Other. __ .....m

Other. Dose:.. n....._.. ................. ...... ......... ".U .....4........... ....... .....n. n...n" un.... "H" 'H h..d--un...........

Pulse Oxietr post-intubation was

The ET Tube was taped at em at the lips

Post-intubation CX conftrDled good tube location: o YOther.

"..............,.. ..........~~~ ... ~~~ ..........--...' """","""'''''''''''

The patient tolerated the procedure: DWel o Adequately o Poorly

COMPLICATIONS: one o Dental TrauDla o Aspiration o Esophageal Placement

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002830


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DATE TIME:02/21/02 22:25: 58Reagent Sensor OFF

Seguence # 1"'

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PHYSICIANDATE OF SIR H

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WBC 12. H 10 3/uL RSCNE% 15. L % r+GB 10.LY% 76. H % HCT 29.MO% MCV 88.EO% NCH 3D.BA% MCHC 35.

1.8 3/uL RDW 11.33/uL

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Sl astsVar; ant Lymphs

SUSPECT FLAGS:

Neutropen; a %Lymphocytosi s %

- -

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DEFINITIVE FLAGS:Anemia

NO RANGES MicrosicWB Diff

41: m:a MB b:8= 16 = 1

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NATCHEZ COMMUNITY HOSPITAL129 JEFF DAVI S BLVD.

NATCHEZ, MS 39120

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PATIENT NAME: BRITT CHLOEHOSPITAL #:AGE: SE X:

PHYSICIAN: PATTERSON#

COLLECTED DATE/TINE:COLLECTED BY: EW

2/21/02 2230

ROOM: ER

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PRIORITY: ROUTINEMi sc;

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-------------- ~~~--------- ---- ------------ -------- ----

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GLUCOSE mg/dL 75. 110.UREA NITROGEN g/dL 9. 20.CREATININE mg/dL . 8 1. 5SODIUM mmol/L 137. i45.POTASSIUM mmol/L 3.& 5.CHLORIDE 101. mmol/L 98. 107.CARBON DIOXIDE LO 11. mmol/L 22. 30.BUN/CREATININE 19.3 7. 0 25.CALCIUM HI 10. & mg/dL 10.

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AM/PM

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