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MERCY HOSPITAL NORTHWEST
ARKANSAS
2710 Rife Medical Lane
Rogers, AR 72758-1452

BRAZEAL,HAROLD E
MRN: E1501688231
DOB: 8/23/1936, Sex: M
Adm:5/15/2008, D/C:5/15/2008

Patient Demographics
Patient Name
Brazeal, Harold E

Sex
Male

DOB
8/23/1936

Address
13743 ROUTE E
PINEVILLE MO 64856

Phone
417-435-2344 (Home)
417-540-2556 (Mobile)

Patient Ethnicity & Race
Ethnic Group
Non-Hispanic

Patient Race
Caucasian

Admission Information
Arrival Date/Time:
Admission Type:
Means of Arrival:
Transfer Source:

05/15/2008 12:03 PM
Emergency
Car
None

Admit Date/Time:
Point of Origin:
Primary Service:
Service Area:

Admit Provider:

Menchetti, Leslie, NP

Attending Provider:

05/15/2008 12:08 PM
Emergency Room
Ed
Mercy Health Northwest
Arkansas Communities
Menchetti, Leslie, NP

IP Adm. Date/Time:
Admit Category:
Secondary Service:
Unit:
Referring Provider:

None
No - Copay
None
Rogr Emergency
Department
None

Discharge Information
Discharge Date/Time
05/15/2008 1:37 PM

Discharge Disposition
Home Or Self Care

Discharge Destination
Home

Discharge Provider
None

Unit
Rogr Emergency
Department

Diagnosis Information
Primary Visit Diagnosis:
Principal Problem:
Visit Diagnoses
Laceration of finger

None found
None found
Problem List
None found

ADT Coded Diagnoses
None found

ADT Free Text Diagnoses
None found

Contact Information
Name
BRAZEAL,ANNA L
PANKAU,SARAH
BRAZEAL,GEORGE L

Relation
Spouse
Daughter
Brother

Home
417-435-2344
417-435-2664
417-435-2521

Work

Mobile
417-540-2556
417-825-9091

Administrative Information
Administrative Information
Encounter Classification(s)
None

Referring Provider
None

Visit Indicator
None

Advance Directives
Advance Directives
On File? No

Power of Attorney
On File? Yes
Date Asked: 1/3/2013

Events
Date/Time
05/15/08 1203

Event
Patient arrived in ED

Pt Class

05/15/08 1208

Patient roomed in ED

Emergency

05/15/08 1337

Patient discharged

Emergency

Unit
ROGR EMERGENCY
DEPARTMENT
ROGR EMERGENCY
DEPARTMENT
ROGR EMERGENCY
DEPARTMENT

Room/Bed

Service

15/15

ED

15/15

ED

Hospital Account
Name
Brazeal, Harold E

Acct ID
81081360196

Class
Emergency

Status
Billed

Primary Coverage
HUMANA - HUMANA
GOLD CHOICE MCR

Relation to Pt

Service Area
MHSA

Active?
Yes

Acct Type
Personal/Family

Guarantor Account (for Hospital Account #81081360196)
Name
Brazeal, Harold E
Address
13743 ROUTE E

Phone
417-435-2344(H)

ROGR HEALTH INFORMATION
2710 Rife Medical Lane

BRAZEAL,HAROLD E
MRN: E1501688231
Printed by 4990 at 12/2/13 12:13 PM

MERCY HOSPITAL NORTHWEST
ARKANSAS
2710 Rife Medical Lane
Rogers, AR 72758-1452

BRAZEAL,HAROLD E
MRN: E1501688231
DOB: 8/23/1936, Sex: M
Adm:5/15/2008, D/C:5/15/2008

Administrative Information (continued)
Guarantor Account (for Hospital Account #81081360196) (continued)
Address
PINEVILLE, MO 64856
Emp Name
RETIRED
Emp Address

Phone
Emp Status
Retired
Emp Phone

Occupation

Coverage Information (for Hospital Account #81081360196)
F/O Payor/Plan
HUMANA/HUMANA GOLD CHOICE MCR
Subscriber
Brazeal, Harold E
Grp #
80840
Address
PO BOX 14601
LEXINGTON, KY 40512-4601
Policy Number
H58599885
Subscriber Emp
RETIRED

Precert #
Relation to Pt
Self

Subscriber #
H58599885

Phone

Status
Emp Phone

Effective Date
Emp Address

Insurance as of5/15/2008
Payor
HUMANA

Plan
HUMANA GOLD CHOICE MCR
[4227]

Group
80840

Member
H58599885

Effective Dates
5/14/2008 - 12/31/2008

Subscriber: BRAZEAL,HAROLD E [H58599885]
Guarantor : BRAZEAL,HAROLD E

Patient Employment
Employment Status
Retired

Employer
RETIRED

Problem List
Problem List as of 5/15/2008

Never Reviewed
Priority

Other Postprocedural Status

Other and Unspecified Hyperlipidemia

Unspecified Essential Hypertension

Unspecified Hemorrhoids without Mention of
Complication
Diverticulosis of Small Intestine (without Mention
of Hemorrhage)
Diverticulosis of Colon (without Mention of
Hemorrhage)
Diverticulitis of Colon (without Mention of
Hemorrhage)
Hemorrhage of Rectum and Anus

Class

Noted - Resolved
11/15/2007 - Present

Last Modified
11/15/2007 by Interface, Som Aok Conv
Problem List
Entered by Interface, Som Aok Conv Problem List
11/15/2007 - Present
11/15/2007 by Interface, Som Aok Conv
Problem List
Entered by Interface, Som Aok Conv Problem List
11/15/2007 - Present
11/15/2007 by Interface, Som Aok Conv
Problem List
Entered by Interface, Som Aok Conv Problem List
11/15/2007 - Present
11/15/2007 by Interface, Som Aok Conv
Problem List
Entered by Interface, Som Aok Conv Problem List
11/15/2007 - Present
11/15/2007 by Interface, Som Aok Conv
Problem List
Entered by Interface, Som Aok Conv Problem List
11/15/2007 - Present
11/15/2007 by Interface, Som Aok Conv
Problem List
Entered by Interface, Som Aok Conv Problem List
11/15/2007 - Present
11/15/2007 by Interface, Som Aok Conv
Problem List
Entered by Interface, Som Aok Conv Problem List
11/15/2007 - Present
11/15/2007 by Interface, Som Aok Conv
Problem List
Entered by Interface, Som Aok Conv Problem List

ROGR HEALTH INFORMATION
2710 Rife Medical Lane

BRAZEAL,HAROLD E
MRN: E1501688231
Printed by 4990 at 12/2/13 12:13 PM

MERCY HOSPITAL NORTHWEST
ARKANSAS
2710 Rife Medical Lane
Rogers, AR 72758-1452

BRAZEAL,HAROLD E
MRN: E1501688231
DOB: 8/23/1936, Sex: M
Adm:5/15/2008, D/C:5/15/2008

Problem List (continued)
Problem List as of 5/15/2008 (continued)

Never Reviewed
Priority

Class

Noted - Resolved
11/15/2007 - Present

Last Modified
11/15/2007 by Interface, Som Aok Conv
Problem List
Entered by Interface, Som Aok Conv Problem List
11/15/2007 - Present
11/15/2007 by Interface, Som Aok Conv
Problem List
Entered by Interface, Som Aok Conv Problem List
11/15/2007 - Present
11/15/2007 by Interface, Som Aok Conv
Problem List
Entered by Interface, Som Aok Conv Problem List

Allergic Urticaria

Polymyalgia Rheumatica

Unspecified Disorders of Bursae and Tendons in
Shoulder Region

Past Surgical History
Surgical
as of 5/15/2008 PR EXPLORATORY OF ABDOMEN [49000]

Laterality

Date

Comments

Past Medical History
Medical
as of 5/15/2008 Unspecified essential hypertension

Date

Comments

Source
Provider

Past Surgical History
Surgical
as of 5/15/2008 PR EXPLORATORY OF ABDOMEN

Laterality

Date

Comments

PR TOTAL HIP ARTHROPLASTY [27130]
Social & Medical History

PR TOTAL HIP ARTHROPLASTY

Family
**None**
as of 5/15/2008
Family Status
**None**
as of 5/15/2008
Tobacco Use Smoking Status Source
as of
5/15/2008

Never Smoker

Types

Provider

Packs/day Years
Used
0.0

Comments

0.0

Smoking Smoking Smokeles Smokeles
Start Date Quit Date s Tobacco s Tobacco
Status
Quit Date
Unknown

Alcohol Use
Alcohol Use
as of 5/15/2008 No

Source
Provider

Drinks/Week

Alcohol/Wk

Drug Use
Drug Use
as of 5/15/2008 Yes

Source
Provider

Types
Prescription Drugs

Frequency
0.00

Comments

Sexual Activity Sexually Active
as of 5/15/2008 Not Currently

Source
Provider

Birth Control
None

Partners
Female

Comments

ADL Question
Social ADL
as of 5/15/2008 **None**

Social Doc

Response

Comments

Comments

Source

**None**
ROGR HEALTH INFORMATION
2710 Rife Medical Lane

BRAZEAL,HAROLD E
MRN: E1501688231
Printed by 4990 at 12/2/13 12:13 PM

MERCY HOSPITAL NORTHWEST
ARKANSAS
2710 Rife Medical Lane
Rogers, AR 72758-1452

BRAZEAL,HAROLD E
MRN: E1501688231
DOB: 8/23/1936, Sex: M
Adm:5/15/2008, D/C:5/15/2008

as of 5/15/2008
Occupational
**None**
as of 5/15/2008
Socioeconomic Marital Status
as of 5/15/2008 Married

Spouse Name

Num of Children

Language

Ethnicity

Race

English

Non-Hispanic

Caucasian

Years Education

Source

Family History

Family
**None**
as of 5/15/2008
Family Status
**None**
as of 5/15/2008
Prior to Admission Meds
Reviewed by Breen, Covette K, LPN (License Practical Nurse) on 05/15/08 at 1218
Medication
Taking?
Sig
ACTONEL PO
Yes
Take 1 Tab by mouth daily.
aspirin (BAYER) 81 mg Oral Tab
Yes
Take 1 Tab by mouth daily.

Documenting Provider
Emergency, Nurse, RN
Emergency, Nurse, RN

Status
Active
Active

Last Dose

Allergies
Allergies as of 5/15/2008

Reviewed on: 5/15/2008

No Known Allergies

Immunizations
Immunizations as of 5/15/2008

Never Reviewed

Name
Influenza

Date
11/1/2006

Influenza

10/19/2005

Influenza

10/6/2004

Influenza

10/29/2003

Influenza

10/23/2002

Influenza

10/23/2001

Influenza

10/19/1999

Influenza

10/27/1998

Influenza

10/21/1997

Influenza

10/22/1996

Influenza

11/7/1995

Influenza

10/21/1994

Influenza

10/25/1993

PNEUMOCOCCAL 23-VALENT

11/26/2002

Dose
NO DOSE ON
FILE
NO DOSE ON
FILE
NO DOSE ON
FILE
NO DOSE ON
FILE
NO DOSE ON
FILE
NO DOSE ON
FILE
NO DOSE ON
FILE
NO DOSE ON
FILE
NO DOSE ON
FILE
NO DOSE ON
FILE
NO DOSE ON
FILE
NO DOSE ON
FILE
NO DOSE ON
FILE
NO DOSE ON

ROGR HEALTH INFORMATION
2710 Rife Medical Lane

VIS Date

Route

BRAZEAL,HAROLD E
MRN: E1501688231
Printed by 4990 at 12/2/13 12:13 PM

MERCY HOSPITAL NORTHWEST
ARKANSAS
2710 Rife Medical Lane
Rogers, AR 72758-1452

BRAZEAL,HAROLD E
MRN: E1501688231
DOB: 8/23/1936, Sex: M
Adm:5/15/2008, D/C:5/15/2008

Immunizations (continued)
Immunizations as of 5/15/2008 (continued)

Never Reviewed

Name

Date

Td
Site: Right Arm
Given By: Castor, Jessica, RN

5/15/2008

Dose
FILE
0.5 mL

ROGR HEALTH INFORMATION
2710 Rife Medical Lane

VIS Date

Route
Intramuscular

BRAZEAL,HAROLD E
MRN: E1501688231
Printed by 4990 at 12/2/13 12:13 PM

MERCY HOSPITAL NORTHWEST
ARKANSAS
2710 Rife Medical Lane
Rogers, AR 72758-1452

BRAZEAL,HAROLD E
MRN: E1501688231
DOB: 8/23/1936, Sex: M
Adm:5/15/2008, D/C:5/15/2008

ER Records
ED Arrival Information
Expected
-

Arrival
5/15/2008 12:03

Acuity
ESI 4

Means of Arrival
Car (AUTOMOBILE)

Escorted By
Family Member

Service
ED

Admission Type
Emergency

Arrival Complaint
LEFT HAND LACERATION

ED Final Diagnosis
None

ED Disposition
Discharge

ED Provider Notes
ED Provider Notes signed by Menchetti, Leslie, NP at 5/15/2008 10:13 PM
Author:
Menchetti, Leslie, NP
Service:
ED
Filed:
5/15/2008 10:13 PM
Note Time:
5/15/2008 12:31 PM

Author Type:
Cosigner:

Nurse Practitioner
Karas, Robert at 5/18/2008 1:30 PM

HISTORY OF PRESENT ILLNESS
Harold E Brazeal, a 71 y.o. male presents to the ED with a Chief Complaint of Hand Laceration
The history is provided by the patient. The incident occurred less than 1 hour ago. The laceration is located on the left
hand. Size: 2,3,4th fingers with 1-3cm lacerations. Injury Mechanism: circular saw. The pain is at a severity of 1/10. He
reports no foreign bodies present. His tetanus status is out of date.

REVIEW OF SYSTEMS
Review of Systems
Skin:
2,3,4th left fingers with lacerations
All other systems reviewed and are negative.

MEDICAL DECISION MAKING AND PLAN OF CARE
The following areas were reviewed/utilized in the MDM/Plan of care for this patient:
Past Medical History
Diagnosis

Date

•Unspecified Essential Hypertension

Past Surgical History
Procedure

Date

•Pr exploratory of abdomen
•Pr total hip arthroplasty

History
Alcohol Use
History
Drug Use

•Yes
•Special:

Prescription Drugs

History

ROGR HEALTH INFORMATION
2710 Rife Medical Lane

BRAZEAL,HAROLD E
MRN: E1501688231
Printed by 4990 at 12/2/13 12:13 PM

MERCY HOSPITAL NORTHWEST
ARKANSAS
2710 Rife Medical Lane
Rogers, AR 72758-1452

BRAZEAL,HAROLD E
MRN: E1501688231
DOB: 8/23/1936, Sex: M
Adm:5/15/2008, D/C:5/15/2008

ER Records (continued)
ED Provider Notes (continued)

Tobacco Use

Never

No family history on file.
History
Sexual Activity

•Sexually Active:
•Birth Control/ Protection:

Not Currently -- Female partner(s)
None

ALLERGIES: Review of patient's allergies indicates no known allergies.

PHYSICAL EXAM
BP 146/77 | Pulse 60 | Temp (Src) 96.9 °F (36.1 °C) (Temporal) | Resp 16 | Ht 5' 9" (1.753 m) | Wt 89.359 kg |
SpO2 96%
Physical Exam
Nursing note and vitals reviewed.
Constitutional: He is oriented. He appears well-developed and well-nourished.
HENT:
Head: Normocephalic and atraumatic.
Eyes: Conjunctivae and extraocular motions are normal. Pupils are equal, round, and reactive to light.
Neck: Normal range of motion. Neck supple.
Musculoskeletal:

Hands:
Neurological: He is alert and oriented.
Skin: Skin is warm and dry. Laceration noted.

Laceration Repair Procedure Note: #1
Location: hand: left, 3rd finger
ROGR HEALTH INFORMATION
2710 Rife Medical Lane

BRAZEAL,HAROLD E
MRN: E1501688231
Printed by 4990 at 12/2/13 12:13 PM

MERCY HOSPITAL NORTHWEST
ARKANSAS
2710 Rife Medical Lane
Rogers, AR 72758-1452

BRAZEAL,HAROLD E
MRN: E1501688231
DOB: 8/23/1936, Sex: M
Adm:5/15/2008, D/C:5/15/2008

ER Records (continued)
ED Provider Notes (continued)

Length: 3 cm
Shape: flap
Depth: through dermis
The wound area was anesthetized with Lidocaine 1% without epinephrine without added sodium bicarbonate.
The wound area was cleansed with chlorhexidine gluconate, irrigated with sterile saline and draped in a sterile
fashion.
The wound was explored with the following results: No foreign bodies found, No tendon laceration seen.
Wound edges revised/debrided: yes, debrided and wound margins revised.
The wound was repaired with 4-0 Nylon; 6 sutures were used. Suture technique used was interrupted.
Tetanus status: more than 10 years ago
Laceration Repair Procedure Note:#2
Location: 3rd finger left
Length: 1 cm
Shape: linear
Depth:
clean appearing
through dermis
The wound area was anesthetized with Lidocaine 1% without epinephrine without added sodium bicarbonate.
The wound area was cleansed with chlorhexidine gluconate, irrigated with sterile saline and draped in a sterile
fashion.
The wound was explored with the following results: No foreign bodies found, No tendon laceration seen.
Wound edges revised/debrided: yes
The wound was repaired with 4-0 Nylon; 2 sutures were used. Suture technique used was interrupted.
Tetanus status: more than 5 years ago
Laceration Repair Procedure Note:#3
Location: left 4th finger
Length: 1.5 cm
Shape: linear
Depth:
clean appearing
through dermis
The wound area was anesthetized with Lidocaine 1% without epinephrine without added sodium bicarbonate.
The wound area was cleansed with chlorhexidine gluconate, irrigated with sterile saline and draped in a sterile
fashion.
The wound was explored with the following results: No foreign bodies found, No tendon laceration seen.
Wound edges revised/debrided: yes
The wound was repaired with 4-0 Nylon; 3 sutures were used. Suture technique used was interrupted.
Tetanus status: more than 5 years ago

ROGR HEALTH INFORMATION
2710 Rife Medical Lane

BRAZEAL,HAROLD E
MRN: E1501688231
Printed by 4990 at 12/2/13 12:13 PM

MERCY HOSPITAL NORTHWEST
ARKANSAS
2710 Rife Medical Lane
Rogers, AR 72758-1452

BRAZEAL,HAROLD E
MRN: E1501688231
DOB: 8/23/1936, Sex: M
Adm:5/15/2008, D/C:5/15/2008

ER Records (continued)
ED Provider Notes (continued)

CLINICAL IMPRESSION
Encounter Diagnoses
Code
Name

•883.0J

Primary?

Qualifier

Laceration of Finger

CASE DISCUSSED

PATIENT COUNSELING
Diagnostics reviewed and questions answered. Diagnosis, treatment options and plan of care discussed with
understanding verbalized.
DISPOSITION, EDUCATION AND MEDICATION RECONCILIATION:
See After Visit Summary.

Other ED Notes
ED Notes signed by Cordasco, Jeffrey E, RN at 5/15/2008 12:07 PM
Author:
Cordasco, Jeffrey E, RN
Service:
Filed:
5/15/2008 12:07 PM
Note Time:

ED
5/15/2008 12:06 PM

Author Type:

Registered Nurse

Author Type:

License Practical Nurse

Pt c/o lac to left 2nd,3rd, and 4th digits.
Electronically signed by Cordasco, Jeffrey E, RN at 5/15/2008 12:07 PM
ED Notes signed by Breen, Covette K, LPN at 5/15/2008 12:21 PM
Author:
Breen, Covette K, LPN
Service:
Filed:
5/15/2008 12:21 PM
Note Time:

ED
5/15/2008 12:19 PM

71 yr old female c/o lac to 2, 3, and 4th fingers after using saw at home. Needs td. Bleeding under
control at this time.
Electronically signed by Breen, Covette K, LPN at 5/15/2008 12:21 PM
ED Notes signed by Breen, Covette K, LPN at 5/15/2008 12:27 PM
Author:
Breen, Covette K, LPN
Service:
Filed:
5/15/2008 12:27 PM
Note Time:

ED
5/15/2008 12:25 PM

Author Type:

License Practical Nurse

Pt soaking injured fingers in hibclens and nacl. Bleeding under control at this time.
Electronically signed by Breen, Covette K, LPN at 5/15/2008 12:27 PM

ROGR HEALTH INFORMATION
2710 Rife Medical Lane

BRAZEAL,HAROLD E
MRN: E1501688231
Printed by 4990 at 12/2/13 12:13 PM

MERCY HOSPITAL NORTHWEST
ARKANSAS
2710 Rife Medical Lane
Rogers, AR 72758-1452

BRAZEAL,HAROLD E
MRN: E1501688231
DOB: 8/23/1936, Sex: M
Adm:5/15/2008, D/C:5/15/2008

ER Records (continued)
Other ED Notes (continued)
ED Notes filed by Aok Scanning, Amb Physician at 5/16/2008 7:55 AM
Author:
Aok Scanning, Amb Physician
Service:
(none)
Filed:
5/16/2008 7:55 AM
Note Time:
5/16/2008 12:00 AM
Trans Status:
Available
Dictation Time:
Trans Time:

Author Type:
Trans ID:

(none)
PRDAOK/CLINICAL/242922

Trans Doc
Type:

ED Report

Scan on 5/16/2008 12:00 AM (below)

ROGR HEALTH INFORMATION
2710 Rife Medical Lane

BRAZEAL,HAROLD E
MRN: E1501688231
Printed by 4990 at 12/2/13 12:13 PM

MERCY HOSPITAL NORTHWEST
ARKANSAS
2710 Rife Medical Lane
Rogers, AR 72758-1452

BRAZEAL,HAROLD E
MRN: E1501688231
DOB: 8/23/1936, Sex: M
Adm:5/15/2008, D/C:5/15/2008

ER Records (continued)
Other ED Notes (continued)

ROGR HEALTH INFORMATION
2710 Rife Medical Lane

BRAZEAL,HAROLD E
MRN: E1501688231
Printed by 4990 at 12/2/13 12:13 PM

MERCY HOSPITAL NORTHWEST
ARKANSAS
2710 Rife Medical Lane
Rogers, AR 72758-1452

BRAZEAL,HAROLD E
MRN: E1501688231
DOB: 8/23/1936, Sex: M
Adm:5/15/2008, D/C:5/15/2008

Non-Physician Notes
ED Notes filed by Aok Scanning, Amb Physician at 5/16/2008 7:55 AM
Author:
Aok Scanning, Amb Physician
Service:
(none)
Filed:
5/16/2008 7:55 AM
Note Time:
5/16/2008 12:00 AM
Trans Status:
Available
Dictation Time:
Trans Time:

Author Type:
Trans ID:

(none)
PRDAOK/CLINICAL/242922

Trans Doc
Type:

ED Report

Scan on 5/16/2008 12:00 AM (below)

Scanned Form filed by Aok Scanning, Amb Physician at 5/16/2008 3:19 PM

ROGR HEALTH INFORMATION
2710 Rife Medical Lane

BRAZEAL,HAROLD E
MRN: E1501688231
Printed by 4990 at 12/2/13 12:13 PM

MERCY HOSPITAL NORTHWEST
ARKANSAS
2710 Rife Medical Lane
Rogers, AR 72758-1452

BRAZEAL,HAROLD E
MRN: E1501688231
DOB: 8/23/1936, Sex: M
Adm:5/15/2008, D/C:5/15/2008

Non-Physician Notes (continued)
Author:
Filed:
Trans Status:
Dictation Time:

Aok Scanning, Amb Physician
5/16/2008 3:19 PM
Available

Service:
Note Time:

(none)
5/16/2008 12:00 AM

Trans Time:

Author Type:
Trans ID:

(none)
PRDAOK/CLINICAL/245224

Trans Doc
Type:

Non Clinical Miscellaneous

Scan on 5/16/2008 12:00 AM (below)

Nursing Notes
ED Notes signed by Cordasco, Jeffrey E, RN at 5/15/2008 12:07 PM

ROGR HEALTH INFORMATION
2710 Rife Medical Lane

BRAZEAL,HAROLD E
MRN: E1501688231
Printed by 4990 at 12/2/13 12:13 PM

MERCY HOSPITAL NORTHWEST
ARKANSAS
2710 Rife Medical Lane
Rogers, AR 72758-1452

BRAZEAL,HAROLD E
MRN: E1501688231
DOB: 8/23/1936, Sex: M
Adm:5/15/2008, D/C:5/15/2008

Nursing Notes (continued)
Author:
Filed:

Cordasco, Jeffrey E, RN
5/15/2008 12:07 PM

Service:
Note Time:

ED
5/15/2008 12:06 PM

Author Type:

Registered Nurse

Author Type:

License Practical Nurse

Pt c/o lac to left 2nd,3rd, and 4th digits.
Electronically signed by Cordasco, Jeffrey E, RN at 5/15/2008 12:07 PM
ED Notes signed by Breen, Covette K, LPN at 5/15/2008 12:21 PM
Author:
Breen, Covette K, LPN
Service:
Filed:
5/15/2008 12:21 PM
Note Time:

ED
5/15/2008 12:19 PM

71 yr old female c/o lac to 2, 3, and 4th fingers after using saw at home. Needs td. Bleeding under
control at this time.
Electronically signed by Breen, Covette K, LPN at 5/15/2008 12:21 PM
ED Notes signed by Breen, Covette K, LPN at 5/15/2008 12:27 PM
Author:
Breen, Covette K, LPN
Service:
Filed:
5/15/2008 12:27 PM
Note Time:

ED
5/15/2008 12:25 PM

Author Type:

License Practical Nurse

Pt soaking injured fingers in hibclens and nacl. Bleeding under control at this time.
Electronically signed by Breen, Covette K, LPN at 5/15/2008 12:27 PM
ED Provider Notes signed by Menchetti, Leslie, NP at 5/15/2008 10:13 PM
Author:
Menchetti, Leslie, NP
Service:
ED
Filed:
5/15/2008 10:13 PM
Note Time:
5/15/2008 12:31 PM

Author Type:
Cosigner:

Nurse Practitioner
Karas, Robert at 5/18/2008 1:30 PM

HISTORY OF PRESENT ILLNESS
Harold E Brazeal, a 71 y.o. male presents to the ED with a Chief Complaint of Hand Laceration
The history is provided by the patient. The incident occurred less than 1 hour ago. The laceration is located on the left
hand. Size: 2,3,4th fingers with 1-3cm lacerations. Injury Mechanism: circular saw. The pain is at a severity of 1/10. He
reports no foreign bodies present. His tetanus status is out of date.

REVIEW OF SYSTEMS
Review of Systems
Skin:
2,3,4th left fingers with lacerations
All other systems reviewed and are negative.

MEDICAL DECISION MAKING AND PLAN OF CARE
The following areas were reviewed/utilized in the MDM/Plan of care for this patient:
Past Medical History
Diagnosis

Date

•Unspecified Essential Hypertension

Past Surgical History
Procedure

Date

•Pr exploratory of abdomen
•Pr total hip arthroplasty
ROGR HEALTH INFORMATION
2710 Rife Medical Lane

BRAZEAL,HAROLD E
MRN: E1501688231
Printed by 4990 at 12/2/13 12:13 PM

MERCY HOSPITAL NORTHWEST
ARKANSAS
2710 Rife Medical Lane
Rogers, AR 72758-1452

BRAZEAL,HAROLD E
MRN: E1501688231
DOB: 8/23/1936, Sex: M
Adm:5/15/2008, D/C:5/15/2008

Nursing Notes (continued)

History
Alcohol Use
History
Drug Use

•Yes
•Special:

Prescription Drugs

History
Tobacco Use

Never

No family history on file.
History
Sexual Activity

•Sexually Active:
•Birth Control/ Protection:

Not Currently -- Female partner(s)
None

ALLERGIES: Review of patient's allergies indicates no known allergies.

PHYSICAL EXAM
BP 146/77 | Pulse 60 | Temp (Src) 96.9 °F (36.1 °C) (Temporal) | Resp 16 | Ht 5' 9" (1.753 m) | Wt 89.359 kg |
SpO2 96%
Physical Exam
Nursing note and vitals reviewed.
Constitutional: He is oriented. He appears well-developed and well-nourished.
HENT:
Head: Normocephalic and atraumatic.
Eyes: Conjunctivae and extraocular motions are normal. Pupils are equal, round, and reactive to light.
Neck: Normal range of motion. Neck supple.
Musculoskeletal:

ROGR HEALTH INFORMATION
2710 Rife Medical Lane

BRAZEAL,HAROLD E
MRN: E1501688231
Printed by 4990 at 12/2/13 12:13 PM

MERCY HOSPITAL NORTHWEST
ARKANSAS
2710 Rife Medical Lane
Rogers, AR 72758-1452

BRAZEAL,HAROLD E
MRN: E1501688231
DOB: 8/23/1936, Sex: M
Adm:5/15/2008, D/C:5/15/2008

Nursing Notes (continued)

Hands:
Neurological: He is alert and oriented.
Skin: Skin is warm and dry. Laceration noted.

Laceration Repair Procedure Note: #1
Location: hand: left, 3rd finger
Length: 3 cm
Shape: flap
Depth: through dermis
The wound area was anesthetized with Lidocaine 1% without epinephrine without added sodium bicarbonate.
The wound area was cleansed with chlorhexidine gluconate, irrigated with sterile saline and draped in a sterile
fashion.
The wound was explored with the following results: No foreign bodies found, No tendon laceration seen.
Wound edges revised/debrided: yes, debrided and wound margins revised.
The wound was repaired with 4-0 Nylon; 6 sutures were used. Suture technique used was interrupted.
Tetanus status: more than 10 years ago
Laceration Repair Procedure Note:#2
Location: 3rd finger left
Length: 1 cm
Shape: linear
Depth:
clean appearing
through dermis
The wound area was anesthetized with Lidocaine 1% without epinephrine without added sodium bicarbonate.
The wound area was cleansed with chlorhexidine gluconate, irrigated with sterile saline and draped in a sterile
fashion.
The wound was explored with the following results: No foreign bodies found, No tendon laceration seen.
Wound edges revised/debrided: yes
The wound was repaired with 4-0 Nylon; 2 sutures were used. Suture technique used was interrupted.
ROGR HEALTH INFORMATION
2710 Rife Medical Lane

BRAZEAL,HAROLD E
MRN: E1501688231
Printed by 4990 at 12/2/13 12:13 PM

MERCY HOSPITAL NORTHWEST
ARKANSAS
2710 Rife Medical Lane
Rogers, AR 72758-1452

BRAZEAL,HAROLD E
MRN: E1501688231
DOB: 8/23/1936, Sex: M
Adm:5/15/2008, D/C:5/15/2008

Nursing Notes (continued)

Tetanus status: more than 5 years ago
Laceration Repair Procedure Note:#3
Location: left 4th finger
Length: 1.5 cm
Shape: linear
Depth:
clean appearing
through dermis
The wound area was anesthetized with Lidocaine 1% without epinephrine without added sodium bicarbonate.
The wound area was cleansed with chlorhexidine gluconate, irrigated with sterile saline and draped in a sterile
fashion.
The wound was explored with the following results: No foreign bodies found, No tendon laceration seen.
Wound edges revised/debrided: yes
The wound was repaired with 4-0 Nylon; 3 sutures were used. Suture technique used was interrupted.
Tetanus status: more than 5 years ago

CLINICAL IMPRESSION
Encounter Diagnoses
Code
Name

•883.0J

Primary?

Qualifier

Laceration of Finger

CASE DISCUSSED

PATIENT COUNSELING
Diagnostics reviewed and questions answered. Diagnosis, treatment options and plan of care discussed with
understanding verbalized.
DISPOSITION, EDUCATION AND MEDICATION RECONCILIATION:
See After Visit Summary.

Electronically signed by Menchetti, Leslie, NP at 5/15/2008 10:13 PM
Electronically signed by Karas, Robert at 5/18/2008 1:30 PM

ROGR HEALTH INFORMATION
2710 Rife Medical Lane

BRAZEAL,HAROLD E
MRN: E1501688231
Printed by 4990 at 12/2/13 12:13 PM

MERCY HOSPITAL NORTHWEST
ARKANSAS
2710 Rife Medical Lane
Rogers, AR 72758-1452

BRAZEAL,HAROLD E
MRN: E1501688231
DOB: 8/23/1936, Sex: M
Adm:5/15/2008, D/C:5/15/2008

Discharge Instructions
Date
05/15/08 1340
Note:

Status
Pended

User
Menchetti, Leslie, NP

User Type
Nurse Practitioner

Brazeal, Harold E (MR # E1501688231)
Discharge Note
Original

Return to ER in 10 days to have 6/2/3 sutures removed. Gently wash area with soap and water 2
times a day and apply antibiotic ointment. Return to ER if any signs of infection, increased swelling,
pain, fever or drainage.

Cardiac Cath Results
Cardiology Orders and Results
No orders and results found

Clinical Lab Results
Lab Orders and Results
No orders and results found

Radiology Reports
Radiology All Orders and Results
No orders and results found

All Other Orders and Results (05/15/08 - 05/15/08)
tetanus-diphtheria toxoids (TD) injection 0.5 mL [6689604]
Ordering user:
Authorized by:
Frequency:
Electronically signed
by:
Acknowledged:

Menchetti, Leslie, NP 05/15/08 1234
Menchetti, Leslie, NP
STAT ONCE 05/15/08 1245 - 1 Occurrences
Menchetti, Leslie, NP 05/15/08 1234

Completed
Ordering provider:
Ordering mode:

Menchetti, Leslie, NP
Standard

Menchetti, Leslie, NP 05/15/08 1338
Standard
Pain
may take 2 if needed
Menchetti, Leslie, NP 05/15/08 1338

Authorized by:
Frequency:

Menchetti, Leslie, NP
ROUTINE q 4 hour PRN 05/15/08 - 11/13/08

Menchetti, Leslie, NP 11/13/08 1400

Acknowledged:

Breen, Covette K, LPN 05/15/08 1348 for Placing Order

Ordering provider:
Ordering mode:

Menchetti, Leslie, NP
Standard

Breen, Covette K, LPN 05/15/08 1240 for Placing Order

hydrocodone-acetaminophen (VICODIN) 5-500 mg Oral Tab [6690479]
Ordering user:
Ordering mode:
PRN Reasons:
PRN Comment:
Electronically signed
by:
Discontinued by:

Discontinued

DISCHARGE PATIENT [6690480]
Ordering user:
Authorized by:
Electronically signed
by:
Discontinued by:

Discontinued

Menchetti, Leslie, NP 05/15/08 1338
Menchetti, Leslie, NP
Menchetti, Leslie, NP 05/15/08 1338
Provider, Discharge Patient 05/15/08 1612 [Patient
Discharge]

ROGR HEALTH INFORMATION
2710 Rife Medical Lane

BRAZEAL,HAROLD E
MRN: E1501688231
Printed by 4990 at 12/2/13 12:13 PM

MERCY HOSPITAL NORTHWEST
ARKANSAS
2710 Rife Medical Lane
Rogers, AR 72758-1452

BRAZEAL,HAROLD E
MRN: E1501688231
DOB: 8/23/1936, Sex: M
Adm:5/15/2008, D/C:5/15/2008

Surgical Information
All Meds and Administrations
tetanus-diphtheria toxoids (TD) injection 0.5 mL [6689604]
Ordering Provider: Menchetti, Leslie, NP
Ordered On: 05/15/08 1234
Dose (Remaining/Total): 0.5 mL (0/1)
Route: IM
Admin Instructions:
Administration
05/15/08 1245

Status
Given

Dose
0.5 mL

Status: Completed (Past End Date/Time)
Starts/Ends: 05/15/08 1245 - 05/15/08 1343
Frequency: ONE TIME ONLY
Rate/Duration: - / Comments:
Route
IM

ROGR HEALTH INFORMATION
2710 Rife Medical Lane

Site
Arm, Right Upper

Given By
Castor, Jessica, RN

BRAZEAL,HAROLD E
MRN: E1501688231
Printed by 4990 at 12/2/13 12:13 PM

MERCY HOSPITAL NORTHWEST
ARKANSAS
2710 Rife Medical Lane
Rogers, AR 72758-1452

BRAZEAL,HAROLD E
MRN: E1501688231
DOB: 8/23/1936, Sex: M
Adm:5/15/2008, D/C:5/15/2008

Multi-Disciplinary Problems (Active)

Care Plan
There are no active problems.

Multi-Disciplinary Problems (Resolved)
There are no resolved problems.

Patient Education
Patient Education
None

ROGR HEALTH INFORMATION
2710 Rife Medical Lane

BRAZEAL,HAROLD E
MRN: E1501688231
Printed by 4990 at 12/2/13 12:13 PM

MERCY HOSPITAL NORTHWEST
ARKANSAS
2710 Rife Medical Lane
Rogers, AR 72758-1452

BRAZEAL,HAROLD E
MRN: E1501688231
DOB: 8/23/1936, Sex: M
Adm:5/15/2008, D/C:5/15/2008

Flowsheets
Flowsheet (all recorded)
Acuity
05/15/08 1205
Triage Acuity
ESI
Acuity
To:

05/15/08 1207
4 Less Urg -JC

4 Less Urg -JC
Triage Room -JC

Screening Questions
05/15/08 1218
Immunization History
Immunizations
Up to date -CB
Adult Suicide Risk Assessment (Ages 19 and older)
Does the patient have No -CB
any thoughts of
harming him/herself or
anyone else?
Nutritional Assessment
Significant Weight
None -CB
Changes
Domestic Concerns
Concerns
None -CB
Functional Assessment
Living Arrangements
F -CB
Current Living
1 -CB
Situation
Ambulation
Independent -CB
Transferring
Independent -CB
Toileting
Independent -CB
Fall Risk Assessment (every shift)( for 18 yrs. and older)
History of Fall
0 -CB
Polypharmacy
0 -CB
Central Nervous
0 -CB
System/Psychotropic
Medication
Cardiovascular
3 -CB
Medication
Age Greater Than 65
2 -CB
Years
Altered Elimination
0 -CB
Cognitive Deficit
0 -CB
Sensory Deficit
0 -CB
Dizziness/Vertigo
0 -CB
Depression
0 -CB
Mobility
0 -CB
Deficit/Weakness
Sex
1 -CB
Fall Risk Score
6 -CB

Screening Questions
05/15/08 1205
05/15/08 1218
Adult Suicide Risk Assessment (Ages 19 and older)
Does the patient have No -JC
No -CB
any thoughts of
harming him/herself or
anyone else?
Armband
Armband, In
Identification -JC
Place/Activated
Domestic Concerns
Concerns
None -CB

ROGR HEALTH INFORMATION
2710 Rife Medical Lane

BRAZEAL,HAROLD E
MRN: E1501688231
Printed by 4990 at 12/2/13 12:13 PM

MERCY HOSPITAL NORTHWEST
ARKANSAS
2710 Rife Medical Lane
Rogers, AR 72758-1452

BRAZEAL,HAROLD E
MRN: E1501688231
DOB: 8/23/1936, Sex: M
Adm:5/15/2008, D/C:5/15/2008

Simple Vitals
05/15/08 1212
Vitals
Temp
96.9 °F (36.1 °C) -AW
Temp src
Temporal -AW
Pulse
60 -AW
BP
146/77 mmHg -AW
Resp
16 -AW
SpO2
96 % -AW
O2 Therapy
Room air -AW
Height and Weight
Height
5' 9" (1.753 m) -AW
Height Method
Stated -AW
Weight
197 lb (89.359 kg) -AW
Weight Method
Stated -AW
BSA (Calculated)
2.09 -AW
BMI (Calculated)
29.15 -AW
IBW/kg (Calculated)
66.2 kg -AW
Female
IBW/kg (Calculated)
70.7 kg -AW
Male
Pain
Location
fingers -AW
Pain Rating at
0 -AW
Rest (Numeric)
Spiritual Cultural Ethical
05/15/08 1219
Ethics Assessment
Patient/Family Has N -CB
Questions About
Goals of Treatment
or Treatment
Decisions
Triage Plan
05/15/08 1207
Emergency Severity Index
Immediate life saving
0 -JC
interventions needed?
Is this a high risk
0 -JC
situation?
Number of resources
4 -JC
used?
Are vital signs
3 -JC
abnormal?
Triage Plan
ED Destination
Non-Acute Care -JC
ESI
4 Less Urg -JC

User Key
Initials
CB
JC
AW

Name
Breen, Covette K, LPN
Cordasco, Jeffrey E, RN
Wallace, Amy J., RCP

ROGR HEALTH INFORMATION
2710 Rife Medical Lane

(r) = User Recd, (t) = User Taken, (c) = User Cosigned
Effective Dates
02/01/08 - 09/10/08
02/01/08 - 09/10/08
02/01/08 - 09/10/08

BRAZEAL,HAROLD E
MRN: E1501688231
Printed by 4990 at 12/2/13 12:13 PM

MERCY HOSPITAL NORTHWEST
ARKANSAS
2710 Rife Medical Lane
Rogers, AR 72758-1452

BRAZEAL,HAROLD E
MRN: E1501688231
DOB: 8/23/1936, Sex: M
Adm:5/15/2008, D/C:5/15/2008

Encounter-Level Documents - 5/15/08:
Scan on 5/16/2008 12:00 AM (below)

End of Encounter

ROGR HEALTH INFORMATION
2710 Rife Medical Lane

BRAZEAL,HAROLD E
MRN: E1501688231
Printed by 4990 at 12/2/13 12:13 PM

MERCY HOSPITAL NORTHWEST
ARKANSAS
2710 Rife Medical Lane
Rogers, AR 72758-1452

BRAZEAL,HAROLD E
MRN: E1501688231
DOB: 8/23/1936, Sex: M
Adm:5/15/2008, D/C:5/15/2008

ROGR HEALTH INFORMATION
2710 Rife Medical Lane

BRAZEAL,HAROLD E
MRN: E1501688231
Printed by 4990 at 12/2/13 12:13 PM

MERCY HOSPITAL NORTHWEST
ARKANSAS
2710 Rife Medical Lane
Rogers, AR 72758-1452

BRAZEAL,HAROLD E
MRN: E1501688231
DOB: 8/23/1936, Sex: M
Adm:5/27/2008, D/C:5/27/2008

Patient Demographics
Patient Name
Brazeal, Harold E

Sex
Male

DOB
8/23/1936

Address
13743 ROUTE E
PINEVILLE MO 64856

Phone
417-435-2344 (Home)
417-540-2556 (Mobile)

Patient Ethnicity & Race
Ethnic Group
Non-Hispanic

Patient Race
Caucasian

Admission Information
Arrival Date/Time:
Admission Type:
Means of Arrival:
Transfer Source:

05/27/2008 11:00 AM
Emergency
Car
None

Admit Date/Time:
Point of Origin:
Primary Service:
Service Area:

Admit Provider:

None

Attending Provider:

05/27/2008 11:09 AM
Emergency Room
Ed
Mercy Health Northwest
Arkansas Communities
None

IP Adm. Date/Time:
Admit Category:
Secondary Service:
Unit:
Referring Provider:

None
No - Copay
None
Rogr Emergency
Department
None

Discharge Information
Discharge Date/Time
05/27/2008 11:10 AM

Discharge Disposition
Home Or Self Care

Discharge Destination
None

Discharge Provider
None

Unit
Rogr Emergency
Department

Diagnosis Information
Primary Visit Diagnosis:
Principal Problem:
Visit Diagnoses
None found

None found
None found
Problem List
None found

ADT Coded Diagnoses
None found

ADT Free Text Diagnoses
None found

Contact Information
Name
BRAZEAL,ANNA L
PANKAU,SARAH
BRAZEAL,GEORGE L

Relation
Spouse
Daughter
Brother

Home
417-435-2344
417-435-2664
417-435-2521

Work

Mobile
417-540-2556
417-825-9091

Administrative Information
Administrative Information
Encounter Classification(s)
None

Referring Provider
None

Visit Indicator
None

Advance Directives
Advance Directives
On File? No

Power of Attorney
On File? Yes
Date Asked: 1/3/2013

Events
Date/Time
05/27/08 1100

Event
Patient arrived in ED

Pt Class

05/27/08 1109

Patient roomed in ED

Emergency

05/27/08 1110

Patient discharged

Emergency

Unit
ROGR EMERGENCY
DEPARTMENT
ROGR EMERGENCY
DEPARTMENT
ROGR EMERGENCY
DEPARTMENT

Room/Bed

Service

TRIAGE A/TG A

ED

TRIAGE A/TG A

ED

Hospital Account
Name
Brazeal, Harold E

Acct ID
81081480199

Class
Emergency

Status
Closed

Primary Coverage
HUMANA - HUMANA
GOLD CHOICE MCR

Relation to Pt

Service Area
MHSA

Active?
Yes

Acct Type
Personal/Family

Guarantor Account (for Hospital Account #81081480199)
Name
Brazeal, Harold E
Address

Phone

ROGR HEALTH INFORMATION
2710 Rife Medical Lane

BRAZEAL,HAROLD E
MRN: E1501688231
Printed by 4990 at 12/2/13 12:13 PM

MERCY HOSPITAL NORTHWEST
ARKANSAS
2710 Rife Medical Lane
Rogers, AR 72758-1452

BRAZEAL,HAROLD E
MRN: E1501688231
DOB: 8/23/1936, Sex: M
Adm:5/27/2008, D/C:5/27/2008

Administrative Information (continued)
Guarantor Account (for Hospital Account #81081480199) (continued)
Address
13743 ROUTE E
PINEVILLE, MO 64856
Emp Name
RETIRED
Emp Address

Phone
417-435-2344(H)
Emp Status
Retired
Emp Phone

Occupation

Coverage Information (for Hospital Account #81081480199)
F/O Payor/Plan
HUMANA/HUMANA GOLD CHOICE MCR
Subscriber
Brazeal, Harold E
Grp #
80840
Address
PO BOX 14601
LEXINGTON, KY 40512-4601
Policy Number
H58599885
Subscriber Emp
RETIRED

Precert #
Relation to Pt
Self

Subscriber #
H58599885

Phone

Status
Emp Phone

Effective Date
Emp Address

Insurance as of5/27/2008
Payor
HUMANA

Plan
HUMANA GOLD CHOICE MCR
[4227]

Group
80840

Member
H58599885

Effective Dates
5/14/2008 - 12/31/2008

Subscriber: BRAZEAL,HAROLD E [H58599885]
Guarantor : BRAZEAL,HAROLD E

Patient Employment
Employment Status
Retired

Employer
RETIRED

Problem List
Problem List as of 5/27/2008

Never Reviewed
Priority

Other Postprocedural Status

Other and Unspecified Hyperlipidemia

Unspecified Essential Hypertension

Unspecified Hemorrhoids without Mention of
Complication
Diverticulosis of Small Intestine (without Mention
of Hemorrhage)
Diverticulosis of Colon (without Mention of
Hemorrhage)
Diverticulitis of Colon (without Mention of
Hemorrhage)
Hemorrhage of Rectum and Anus

Class

Noted - Resolved
11/15/2007 - Present

Last Modified
11/15/2007 by Interface, Som Aok Conv
Problem List
Entered by Interface, Som Aok Conv Problem List
11/15/2007 - Present
11/15/2007 by Interface, Som Aok Conv
Problem List
Entered by Interface, Som Aok Conv Problem List
11/15/2007 - Present
11/15/2007 by Interface, Som Aok Conv
Problem List
Entered by Interface, Som Aok Conv Problem List
11/15/2007 - Present
11/15/2007 by Interface, Som Aok Conv
Problem List
Entered by Interface, Som Aok Conv Problem List
11/15/2007 - Present
11/15/2007 by Interface, Som Aok Conv
Problem List
Entered by Interface, Som Aok Conv Problem List
11/15/2007 - Present
11/15/2007 by Interface, Som Aok Conv
Problem List
Entered by Interface, Som Aok Conv Problem List
11/15/2007 - Present
11/15/2007 by Interface, Som Aok Conv
Problem List
Entered by Interface, Som Aok Conv Problem List
11/15/2007 - Present
11/15/2007 by Interface, Som Aok Conv
Problem List

ROGR HEALTH INFORMATION
2710 Rife Medical Lane

BRAZEAL,HAROLD E
MRN: E1501688231
Printed by 4990 at 12/2/13 12:13 PM

MERCY HOSPITAL NORTHWEST
ARKANSAS
2710 Rife Medical Lane
Rogers, AR 72758-1452

BRAZEAL,HAROLD E
MRN: E1501688231
DOB: 8/23/1936, Sex: M
Adm:5/27/2008, D/C:5/27/2008

Problem List (continued)
Problem List as of 5/27/2008 (continued)

Never Reviewed
Priority

Class

Noted - Resolved
Last Modified
Entered by Interface, Som Aok Conv Problem List
11/15/2007 - Present
11/15/2007 by Interface, Som Aok Conv
Problem List
Entered by Interface, Som Aok Conv Problem List
11/15/2007 - Present
11/15/2007 by Interface, Som Aok Conv
Problem List
Entered by Interface, Som Aok Conv Problem List
11/15/2007 - Present
11/15/2007 by Interface, Som Aok Conv
Problem List
Entered by Interface, Som Aok Conv Problem List

Allergic Urticaria

Polymyalgia Rheumatica

Unspecified Disorders of Bursae and Tendons in
Shoulder Region

Past Surgical History
Surgical
as of 5/27/2008 PR EXPLORATORY OF ABDOMEN [49000]

Laterality

Date

Comments

Past Medical History
Medical
as of 5/27/2008 Unspecified essential hypertension

Date

Comments

Source
Provider

Past Surgical History
Surgical
as of 5/27/2008 PR EXPLORATORY OF ABDOMEN

Laterality

Date

Comments

PR TOTAL HIP ARTHROPLASTY [27130]
Social & Medical History

PR TOTAL HIP ARTHROPLASTY

Family
**None**
as of 5/27/2008
Family Status
**None**
as of 5/27/2008
Tobacco Use Smoking Status Source
as of
5/27/2008

Never Smoker

Types

Provider

Packs/day Years
Used
0.0

Comments

0.0

Smoking Smoking Smokeles Smokeles
Start Date Quit Date s Tobacco s Tobacco
Status
Quit Date
Unknown

Alcohol Use
Alcohol Use
as of 5/27/2008 No

Source
Provider

Drinks/Week

Alcohol/Wk

Drug Use
Drug Use
as of 5/27/2008 Yes

Source
Provider

Types
Prescription Drugs

Frequency
0.00

Comments

Sexual Activity Sexually Active
as of 5/27/2008 Not Currently

Source
Provider

Birth Control
None

Partners
Female

Comments

ADL Question
Social ADL
as of 5/27/2008 **None**

Social Doc

Response

Comments

Comments

Source

**None**
ROGR HEALTH INFORMATION
2710 Rife Medical Lane

BRAZEAL,HAROLD E
MRN: E1501688231
Printed by 4990 at 12/2/13 12:13 PM

MERCY HOSPITAL NORTHWEST
ARKANSAS
2710 Rife Medical Lane
Rogers, AR 72758-1452

BRAZEAL,HAROLD E
MRN: E1501688231
DOB: 8/23/1936, Sex: M
Adm:5/27/2008, D/C:5/27/2008

as of 5/27/2008
Occupational
**None**
as of 5/27/2008
Socioeconomic Marital Status
as of 5/27/2008 Married

Spouse Name

Num of Children

Language

Ethnicity

Race

English

Non-Hispanic

Caucasian

Years Education

Source

Family History

Family
**None**
as of 5/27/2008
Family Status
**None**
as of 5/27/2008
Prior to Admission Meds
**Prior to Admission medications have not yet been reviewed for this encounter**

Allergies
Allergies as of 5/27/2008

Reviewed on: 5/15/2008

No Known Allergies

Immunizations
Immunizations as of 5/27/2008

Never Reviewed

Name
Influenza

Date
11/1/2006

Influenza

10/19/2005

Influenza

10/6/2004

Influenza

10/29/2003

Influenza

10/23/2002

Influenza

10/23/2001

Influenza

10/19/1999

Influenza

10/27/1998

Influenza

10/21/1997

Influenza

10/22/1996

Influenza

11/7/1995

Influenza

10/21/1994

Influenza

10/25/1993

PNEUMOCOCCAL 23-VALENT

11/26/2002

Td
Site: Right Arm
Given By: Castor, Jessica, RN

5/15/2008

Dose
NO DOSE ON
FILE
NO DOSE ON
FILE
NO DOSE ON
FILE
NO DOSE ON
FILE
NO DOSE ON
FILE
NO DOSE ON
FILE
NO DOSE ON
FILE
NO DOSE ON
FILE
NO DOSE ON
FILE
NO DOSE ON
FILE
NO DOSE ON
FILE
NO DOSE ON
FILE
NO DOSE ON
FILE
NO DOSE ON
FILE
0.5 mL

ROGR HEALTH INFORMATION
2710 Rife Medical Lane

VIS Date

Route

Intramuscular

BRAZEAL,HAROLD E
MRN: E1501688231
Printed by 4990 at 12/2/13 12:13 PM

MERCY HOSPITAL NORTHWEST
ARKANSAS
2710 Rife Medical Lane
Rogers, AR 72758-1452

BRAZEAL,HAROLD E
MRN: E1501688231
DOB: 8/23/1936, Sex: M
Adm:5/27/2008, D/C:5/27/2008

Immunizations (continued)

ROGR HEALTH INFORMATION
2710 Rife Medical Lane

BRAZEAL,HAROLD E
MRN: E1501688231
Printed by 4990 at 12/2/13 12:13 PM

MERCY HOSPITAL NORTHWEST
ARKANSAS
2710 Rife Medical Lane
Rogers, AR 72758-1452

BRAZEAL,HAROLD E
MRN: E1501688231
DOB: 8/23/1936, Sex: M
Adm:5/27/2008, D/C:5/27/2008

ER Records
ED Arrival Information
Expected
-

Arrival
5/27/2008 11:00

Acuity
ESI 5

Means of Arrival
Car (AUTOMOBILE)

Escorted By
Self

Service
ED

Admission Type
Emergency

Arrival Complaint
STICHES OUT

ED Final Diagnosis
None

ED Disposition
None

Other ED Notes
ED Notes signed by Dickerson, Kathleen S, RN at 5/27/2008 11:07 AM
Author:
Dickerson, Kathleen S, RN
Service:
ED
Filed:
5/27/2008 11:07 AM
Note Time:
5/27/2008 11:06 AM

Author Type:

Registered Nurse

Here for suture removal. Removed fromthird and fourth finger without difficulty. Steristrips applied,
instructed on further care given
Electronically signed by Dickerson, Kathleen S, RN at 5/27/2008 11:07 AM

ROGR HEALTH INFORMATION
2710 Rife Medical Lane

BRAZEAL,HAROLD E
MRN: E1501688231
Printed by 4990 at 12/2/13 12:13 PM

MERCY HOSPITAL NORTHWEST
ARKANSAS
2710 Rife Medical Lane
Rogers, AR 72758-1452

BRAZEAL,HAROLD E
MRN: E1501688231
DOB: 8/23/1936, Sex: M
Adm:5/27/2008, D/C:5/27/2008

Nursing Notes
ED Notes signed by Dickerson, Kathleen S, RN at 5/27/2008 11:07 AM
Author:
Dickerson, Kathleen S, RN
Service:
ED
Filed:
5/27/2008 11:07 AM
Note Time:
5/27/2008 11:06 AM

Author Type:

Registered Nurse

Here for suture removal. Removed fromthird and fourth finger without difficulty. Steristrips applied,
instructed on further care given
Electronically signed by Dickerson, Kathleen S, RN at 5/27/2008 11:07 AM

ROGR HEALTH INFORMATION
2710 Rife Medical Lane

BRAZEAL,HAROLD E
MRN: E1501688231
Printed by 4990 at 12/2/13 12:13 PM

MERCY HOSPITAL NORTHWEST
ARKANSAS
2710 Rife Medical Lane
Rogers, AR 72758-1452
Discharge Instructions

BRAZEAL,HAROLD E
MRN: E1501688231
DOB: 8/23/1936, Sex: M
Adm:5/27/2008, D/C:5/27/2008
Brazeal, Harold E (MR # E1501688231)

None

Cardiac Cath Results
Cardiology Orders and Results
No orders and results found

Clinical Lab Results
Lab Orders and Results
No orders and results found

Radiology Reports
Radiology All Orders and Results
No orders and results found

All Other Results
All Other Orders and Results
No orders and results found

ROGR HEALTH INFORMATION
2710 Rife Medical Lane

BRAZEAL,HAROLD E
MRN: E1501688231
Printed by 4990 at 12/2/13 12:13 PM

MERCY HOSPITAL NORTHWEST
ARKANSAS
2710 Rife Medical Lane
Rogers, AR 72758-1452

BRAZEAL,HAROLD E
MRN: E1501688231
DOB: 8/23/1936, Sex: M
Adm:5/27/2008, D/C:5/27/2008

Surgical Information
All Meds and Administrations
(There are no med orders for this encounter)

ROGR HEALTH INFORMATION
2710 Rife Medical Lane

BRAZEAL,HAROLD E
MRN: E1501688231
Printed by 4990 at 12/2/13 12:13 PM

MERCY HOSPITAL NORTHWEST
ARKANSAS
2710 Rife Medical Lane
Rogers, AR 72758-1452

BRAZEAL,HAROLD E
MRN: E1501688231
DOB: 8/23/1936, Sex: M
Adm:5/27/2008, D/C:5/27/2008

Multi-Disciplinary Problems (Active)

Care Plan
There are no active problems.

Multi-Disciplinary Problems (Resolved)
There are no resolved problems.

Patient Education
Patient Education
None

ROGR HEALTH INFORMATION
2710 Rife Medical Lane

BRAZEAL,HAROLD E
MRN: E1501688231
Printed by 4990 at 12/2/13 12:13 PM

MERCY HOSPITAL NORTHWEST
ARKANSAS
2710 Rife Medical Lane
Rogers, AR 72758-1452

BRAZEAL,HAROLD E
MRN: E1501688231
DOB: 8/23/1936, Sex: M
Adm:5/27/2008, D/C:5/27/2008

Flowsheets
Flowsheet (all recorded)
Acuity
05/27/08 1106
Triage Acuity
ESI
Acuity
To:

05/27/08 1107
5 NON urg -KD

5 NON urg -KD
Triage Room -KD

Simple Vitals
05/27/08 1105
Vitals
Temp
Pulse
BP
Resp
SpO2
Pain
Presence of Pain

98 °F (36.7 °C) -KD
56 -KD
151/84 mmHg -KD
12 -KD
98 % -KD
Denies
pain/discomfort -KD

Triage Plan
05/27/08 1107
Triage Plan
ESI

User Key
Initials
KD

5 NON urg -KD

Name
Dickerson, Kathleen S, RN

ROGR HEALTH INFORMATION
2710 Rife Medical Lane

(r) = User Recd, (t) = User Taken, (c) = User Cosigned
Effective Dates
02/01/08 - 09/10/08

BRAZEAL,HAROLD E
MRN: E1501688231
Printed by 4990 at 12/2/13 12:13 PM

MERCY HOSPITAL NORTHWEST
ARKANSAS
2710 Rife Medical Lane
Rogers, AR 72758-1452

BRAZEAL,HAROLD E
MRN: E1501688231
DOB: 8/23/1936, Sex: M
Adm:5/27/2008, D/C:5/27/2008

End of Encounter

ROGR HEALTH INFORMATION
2710 Rife Medical Lane

BRAZEAL,HAROLD E
MRN: E1501688231
Printed by 4990 at 12/2/13 12:13 PM

MERCY HOSPITAL NORTHWEST
ARKANSAS
2710 Rife Medical Lane
Rogers, AR 72758-1452

BRAZEAL,HAROLD E
MRN: E1501688231
DOB: 8/23/1936, Sex: M
Adm:5/27/2008, D/C:5/27/2008

ROGR HEALTH INFORMATION
2710 Rife Medical Lane

BRAZEAL,HAROLD E
MRN: E1501688231
Printed by 4990 at 12/2/13 12:13 PM

MERCY HOSPITAL NORTHWEST
ARKANSAS
2710 Rife Medical Lane
Rogers, AR 72758-1452

BRAZEAL,HAROLD E
MRN: E1501688231
DOB: 8/23/1936, Sex: M
Adm:11/13/2008, D/C:11/13/2008

Patient Demographics
Patient Name
Brazeal, Harold E

Sex
Male

DOB
8/23/1936

Address
13743 ROUTE E
PINEVILLE MO 64856

Phone
417-435-2344 (Home)
417-540-2556 (Mobile)

Patient Ethnicity & Race
Ethnic Group
Non-Hispanic

Patient Race
Caucasian

Admission Information
Arrival Date/Time:
Admission Type:
Means of Arrival:
Transfer Source:

11/13/2008 11:47 AM
Emergency
Ambulance
None

Admit Date/Time:
Point of Origin:
Primary Service:
Service Area:

Admit Provider:

None

Attending Provider:

11/13/2008 11:49 AM
Emergency Room
Ed
Mercy Health Northwest
Arkansas Communities
Menchetti, Leslie, NP

IP Adm. Date/Time:
Admit Category:
Secondary Service:
Unit:
Referring Provider:

None
No - Copay
None
Rogr Emergency
Department
None

Discharge Information
Discharge Date/Time
11/13/2008 1:58 PM

Discharge Disposition
Home Or Self Care

Discharge Destination
Home

Discharge Provider
None

Unit
Rogr Emergency
Department

Diagnosis Information
Primary Visit Diagnosis:
Principal Problem:
Visit Diagnoses
Sprain of thoracic region
Contusion of hand

None found
None found
Problem List
None found

ADT Coded Diagnoses
None found

ADT Free Text Diagnoses
None found

Contact Information
Name
BRAZEAL,ANNA L
PANKAU,SARAH
BRAZEAL,GEORGE L

Relation
Spouse
Daughter
Brother

Home
417-435-2344
417-435-2664
417-435-2521

Work

Mobile
417-540-2556
417-825-9091

Administrative Information
Administrative Information
Encounter Classification(s)
None

Referring Provider
None

Visit Indicator
None

Advance Directives
Advance Directives
On File? No

Power of Attorney
On File? Yes
Date Asked: 1/3/2013

Events
Date/Time
11/13/08 1147

Event
Patient arrived in ED

Pt Class

11/13/08 1149

Patient roomed in ED

Emergency

11/13/08 1205

Patient transferred

Emergency

11/13/08 1358

Patient discharged

Emergency

Unit
ROGR EMERGENCY
DEPARTMENT
ROGR EMERGENCY
DEPARTMENT
ROGR EMERGENCY
DEPARTMENT
ROGR EMERGENCY
DEPARTMENT

Room/Bed

Service

PEDIATRIC
TRAUMA/TR PED
17/17

ED

17/17

ED

ED

Hospital Account
Name
Brazeal, Harold E

Acct ID
81083180201

Class
Emergency

Status
Closed

Primary Coverage
HUMANA - HUMANA
GOLD CHOICE MCR

Guarantor Account (for Hospital Account #81083180201)

ROGR HEALTH INFORMATION
2710 Rife Medical Lane

BRAZEAL,HAROLD E
MRN: E1501688231
Printed by 4990 at 12/2/13 12:13 PM

MERCY HOSPITAL NORTHWEST
ARKANSAS
2710 Rife Medical Lane
Rogers, AR 72758-1452

BRAZEAL,HAROLD E
MRN: E1501688231
DOB: 8/23/1936, Sex: M
Adm:11/13/2008, D/C:11/13/2008

Administrative Information (continued)
Guarantor Account (for Hospital Account #81083180201) (continued)
Name
Brazeal, Harold E
Address
13743 ROUTE E
PINEVILLE, MO 64856
Emp Name
RETIRED
Emp Address

Relation to Pt

Service Area
MHSA

Active?
Yes

Acct Type
Personal/Family

Phone
417-435-2344(H)
Emp Status
Retired
Emp Phone

Occupation

Coverage Information (for Hospital Account #81083180201)
F/O Payor/Plan
HUMANA/HUMANA GOLD CHOICE MCR
Subscriber
Brazeal, Harold E
Grp #
80840
Address
PO BOX 14601
LEXINGTON, KY 40512-4601
Policy Number
H58599885
Subscriber Emp
RETIRED

Precert #
Relation to Pt
Self

Subscriber #
H58599885

Phone

Status
Emp Phone

Effective Date
Emp Address

Insurance as of11/13/2008
Payor
HUMANA

Plan
HUMANA GOLD CHOICE MCR
[4227]

Group
80840

Member
H58599885

Effective Dates
5/14/2008 - 12/31/2008

Subscriber: BRAZEAL,HAROLD E [H58599885]
Guarantor : BRAZEAL,HAROLD E

Patient Employment
Employment Status
Retired

Employer
RETIRED

Problem List
Problem List as of 11/13/2008

Never Reviewed
Priority

Other Postprocedural Status

Other and Unspecified Hyperlipidemia

Unspecified Essential Hypertension

Unspecified Hemorrhoids without Mention of
Complication
Diverticulosis of Small Intestine (without Mention
of Hemorrhage)
Diverticulosis of Colon (without Mention of
Hemorrhage)
Diverticulitis of Colon (without Mention of
Hemorrhage)

Class

Noted - Resolved
11/15/2007 - Present

Last Modified
11/15/2007 by Interface, Som Aok Conv
Problem List
Entered by Interface, Som Aok Conv Problem List
11/15/2007 - Present
11/15/2007 by Interface, Som Aok Conv
Problem List
Entered by Interface, Som Aok Conv Problem List
11/15/2007 - Present
11/15/2007 by Interface, Som Aok Conv
Problem List
Entered by Interface, Som Aok Conv Problem List
11/15/2007 - Present
11/15/2007 by Interface, Som Aok Conv
Problem List
Entered by Interface, Som Aok Conv Problem List
11/15/2007 - Present
11/15/2007 by Interface, Som Aok Conv
Problem List
Entered by Interface, Som Aok Conv Problem List
11/15/2007 - Present
11/15/2007 by Interface, Som Aok Conv
Problem List
Entered by Interface, Som Aok Conv Problem List
11/15/2007 - Present
11/15/2007 by Interface, Som Aok Conv
Problem List
Entered by Interface, Som Aok Conv Problem List

ROGR HEALTH INFORMATION
2710 Rife Medical Lane

BRAZEAL,HAROLD E
MRN: E1501688231
Printed by 4990 at 12/2/13 12:13 PM

MERCY HOSPITAL NORTHWEST
ARKANSAS
2710 Rife Medical Lane
Rogers, AR 72758-1452

BRAZEAL,HAROLD E
MRN: E1501688231
DOB: 8/23/1936, Sex: M
Adm:11/13/2008, D/C:11/13/2008

Problem List (continued)
Problem List as of 11/13/2008 (continued)

Never Reviewed
Priority

Class

Noted - Resolved
11/15/2007 - Present

Last Modified
11/15/2007 by Interface, Som Aok Conv
Problem List
Entered by Interface, Som Aok Conv Problem List
11/15/2007 - Present
11/15/2007 by Interface, Som Aok Conv
Problem List
Entered by Interface, Som Aok Conv Problem List
11/15/2007 - Present
11/15/2007 by Interface, Som Aok Conv
Problem List
Entered by Interface, Som Aok Conv Problem List
11/15/2007 - Present
11/15/2007 by Interface, Som Aok Conv
Problem List
Entered by Interface, Som Aok Conv Problem List

Hemorrhage of Rectum and Anus

Allergic Urticaria

Polymyalgia Rheumatica

Unspecified Disorders of Bursae and Tendons in
Shoulder Region

Past Surgical History
Surgical
as of 11/13/2008 HX COLECTOMY [SHX59]

Laterality

Date

Comments

Past Medical History
Medical
as of 11/13/2008 Unspecified essential hypertension

Date

Comments

Source
Provider

Past Surgical History
Surgical
as of 11/13/2008 HX COLECTOMY

Laterality

Date

Comments

PR TOTAL HIP ARTHROPLASTY [27130]
Social & Medical History

PR TOTAL HIP ARTHROPLASTY

Family
**None**
as of 11/13/2008
Family Status
**None**
as of 11/13/2008
Tobacco Use Smoking Status Source
as of
11/13/2008

Never Smoker

Types

Provider

Packs/day Years
Used
0.0

Comments

0.0

Smoking Smoking Smokeles Smokeles
Start Date Quit Date s Tobacco s Tobacco
Status
Quit Date
Unknown

Alcohol Use
Alcohol Use
as of 11/13/2008 No

Source
Provider

Drinks/Week

Alcohol/Wk

Drug Use
Drug Use
as of 11/13/2008 Yes

Source
Provider

Types
Prescription Drugs

Frequency
0.00

Comments

Sexual Activity Sexually Active
as of 11/13/2008 Not Currently

Source
Provider

Birth Control
None

Partners
Female

Comments

ADL Question
Social ADL
as of 11/13/2008 **None**

Response

Comments

Comments

ROGR HEALTH INFORMATION
2710 Rife Medical Lane

Source

BRAZEAL,HAROLD E
MRN: E1501688231
Printed by 4990 at 12/2/13 12:13 PM

MERCY HOSPITAL NORTHWEST
ARKANSAS
2710 Rife Medical Lane
Rogers, AR 72758-1452

BRAZEAL,HAROLD E
MRN: E1501688231
DOB: 8/23/1936, Sex: M
Adm:11/13/2008, D/C:11/13/2008

Social Doc
**None**
as of 11/13/2008
Occupational
**None**
as of 11/13/2008
Socioeconomic Marital Status
as of 11/13/2008 Married

Spouse Name

Num of Children

Language

Ethnicity

Race

English

Non-Hispanic

Caucasian

Years Education

Source

Family History

Family
**None**
as of 11/13/2008
Family Status
**None**
as of 11/13/2008
Prior to Admission Meds
Reviewed by Breen, Covette K, LPN (License Practical Nurse) on 11/13/08 at 1212
Medication
Taking?
Sig
ACTONEL PO
No
Take 1 Tab by mouth daily.
aspirin (BAYER) 81 mg Oral Tab
Yes
Take 1 Tab by mouth daily.
hydrocodone-acetaminophen
No
Take 1 Tab by mouth every 4 hours as
(VICODIN) 5-500 mg Oral Tab
needed for Pain. may take 2 if needed
triamterene-hydrochlorothiazide
(DYAZIDE) 37.5-25 mg Oral Cap
atenolol (TENORMIN) 25 mg Oral
Tab

Yes
Yes

Take 1 Cap by mouth daily early
morning.
Take 1 Tab by mouth daily.

Reviewed by Roberts, Calley L, RN (Registered Nurse) on 11/13/08 at 1203
Medication
Taking?
Sig
ACTONEL PO
No
Take 1 Tab by mouth daily.
aspirin (BAYER) 81 mg Oral Tab
Yes
Take 1 Tab by mouth daily.
hydrocodone-acetaminophen
No
Take 1 Tab by mouth every 4 hours as
(VICODIN) 5-500 mg Oral Tab
needed for Pain. may take 2 if needed
triamterene-hydrochlorothiazide
Yes
Take 1 Cap by mouth daily early
(DYAZIDE) 37.5-25 mg Oral Cap
morning.
atenolol (TENORMIN) 25 mg Oral
Yes
Take 1 Tab by mouth daily.
Tab

Documenting Provider
Emergency, Nurse, RN
Emergency, Nurse, RN
Menchetti, Leslie, NP

Last Dose

Neaville, Gary A, MD

Status
Active
Active
Flag for
Provider
Review
Active

Neaville, Gary A, MD

Active

11/13/2008

Documenting Provider
Emergency, Nurse, RN
Emergency, Nurse, RN
Menchetti, Leslie, NP

Status
Active
Active
Active

Last Dose

Neaville, Gary A, MD

Active

11/13/2008

Neaville, Gary A, MD

Active

11/13/2008

11/13/2008

11/13/2008

11/13/2008

Allergies
Allergies as of 11/13/2008

Reviewed on: 11/13/2008

No Known Allergies

Immunizations
Immunizations as of 11/13/2008
Name
Influenza
Site: Left Deltoid
Given By: Capps, Emily
Influenza

Date
10/20/2008

Dose
0.5 ml

11/1/2006

Influenza

10/19/2005

NO DOSE ON
FILE
NO DOSE ON

ROGR HEALTH INFORMATION
2710 Rife Medical Lane

VIS Date
7/24/2008

Never Reviewed
Route
Intramuscular

BRAZEAL,HAROLD E
MRN: E1501688231
Printed by 4990 at 12/2/13 12:13 PM

MERCY HOSPITAL NORTHWEST
ARKANSAS
2710 Rife Medical Lane
Rogers, AR 72758-1452

BRAZEAL,HAROLD E
MRN: E1501688231
DOB: 8/23/1936, Sex: M
Adm:11/13/2008, D/C:11/13/2008

Immunizations (continued)
Immunizations as of 11/13/2008 (continued)

Never Reviewed

Name

Date

Influenza

10/6/2004

Influenza

10/29/2003

Influenza

10/23/2002

Influenza

10/23/2001

Influenza

10/19/1999

Influenza

10/27/1998

Influenza

10/21/1997

Influenza

10/22/1996

Influenza

11/7/1995

Influenza

10/21/1994

Influenza

10/25/1993

PNEUMOCOCCAL 23-VALENT

11/26/2002

Td
Site: Right Arm
Given By: Castor, Jessica, RN

5/15/2008

Dose
FILE
NO DOSE ON
FILE
NO DOSE ON
FILE
NO DOSE ON
FILE
NO DOSE ON
FILE
NO DOSE ON
FILE
NO DOSE ON
FILE
NO DOSE ON
FILE
NO DOSE ON
FILE
NO DOSE ON
FILE
NO DOSE ON
FILE
NO DOSE ON
FILE
NO DOSE ON
FILE
0.5 mL

ROGR HEALTH INFORMATION
2710 Rife Medical Lane

VIS Date

Route

Intramuscular

BRAZEAL,HAROLD E
MRN: E1501688231
Printed by 4990 at 12/2/13 12:13 PM

MERCY HOSPITAL NORTHWEST
ARKANSAS
2710 Rife Medical Lane
Rogers, AR 72758-1452

BRAZEAL,HAROLD E
MRN: E1501688231
DOB: 8/23/1936, Sex: M
Adm:11/13/2008, D/C:11/13/2008

ER Records
ED Arrival Information
Expected
-

Arrival
11/13/2008 11:47

Acuity
ESI 4

Means of Arrival
Ambulance

Escorted By
Self

Service
ED

Admission Type
Emergency

Arrival Complaint
mva

ED Final Diagnosis
Diagnosis
Thoracic Sprain and Strain

Comment

Added By
Menchetti, Leslie, NP

Contusion of Hand

Menchetti, Leslie, NP

Time Added
11/13/2008
1:57 PM
11/13/2008
1:57 PM

Team Role
Nurse Practitioner

Provider Specialty
Emergency Medicine

Nurse Practitioner

Emergency Medicine

ED Disposition
Discharge

ED Provider Notes
ED Provider Notes signed by Clark, Teresa, MD at 3/29/2009 3:44 PM
Author:
Clark, Teresa, MD
Service:
ED
Filed:
3/29/2009 3:44 PM
Note Time:
11/13/2008 12:24 PM
Related Notes:
Original Note by Menchetti, Leslie, NP filed at 11/13/2008 2:03 PM

Author Type:

Physician

HISTORY OF PRESENT ILLNESS
Harold E Brazeal, a 72 y.o. male presents to the ED with a Chief Complaint of Motor Vehicle Crash

Patient is a 72 y.o. male presenting with MVA. The history is provided by the patient.
Motor Vehicle Crash
The accident occurred less than 1 hour ago. The means of arrival was walk-in. At the time of the accident, he
was located in the driver's seat. He was restrained by a shoulder strap, a lap belt and an airbag. The pain is
present in the upper back, right hand and left hand. The pain is at a severity of 5/10. The pain has been
constant since the accident. It was a front-end accident. The accident occurred while the vehicle was traveling
at a low speed. The vehicle's windshield was cracked after the accident. The vehicle's steering column was
intact after the accident. He was not thrown from the vehicle. The vehicle was not overturned. The airbag was
deployed. He reports no foreign bodies present. He was found conscious by EMS personnel.

REVIEW OF SYSTEMS
Review of Systems
Musculoskeletal: Positive for back pain and joint pain.
All other systems reviewed and are negative.

PAST MEDICAL HISTORY REVIEWED
Past Medical History
Diagnosis

Date

•Unspecified Essential Hypertension

Past Surgical History
Procedure

Date

•Hx colectomy
•Pr total hip arthroplasty
ROGR HEALTH INFORMATION
2710 Rife Medical Lane

BRAZEAL,HAROLD E
MRN: E1501688231
Printed by 4990 at 12/2/13 12:13 PM

MERCY HOSPITAL NORTHWEST
ARKANSAS
2710 Rife Medical Lane
Rogers, AR 72758-1452

BRAZEAL,HAROLD E
MRN: E1501688231
DOB: 8/23/1936, Sex: M
Adm:11/13/2008, D/C:11/13/2008

ER Records (continued)
ED Provider Notes (continued)

No family history on file.
History
Social History Main Topics

•Tobacco Use:
•Alcohol Use:
•Drug Use:

Never
No
Yes
Prescription Drugs
Not Currently -- Female partner(s)
None

Special:
•Sexually Active:

Birth Control/ Protection:

ALLERGIES
Review of patient's allergies indicates no known allergies.
HOME MEDICATIONS
•ibuprofen (MOTRIN) 800 mg Oral Tab

Take 1 Tab by mouth every 8 hours. Take with
food
•methocarbamol (ROBAXIN) 500 mg Oral Tab
Take 1 Tab by mouth 4 times daily.
•HYDROCODONE BIT/ACETAMINOPHEN
Take 1 Tab by mouth every 4 hours as needed for
(HYDROCODONE-ACETAMINOPHEN) 5-500 mg Pain. may take 2 if needed
Oral Tab
•atenolol (TENORMIN) 25 mg Oral Tab
Take 1 Tab by mouth daily.
•triamterene-hydrochlorothiazide (DYAZIDE) 37.5- Take 1 Cap by mouth daily early morning.
25 mg Oral Cap
•aspirin (BAYER) 81 mg Oral Tab
Take 1 Tab by mouth daily.
•ACTONEL PO
Take 1 Tab by mouth daily.
•DISCONTD: hydrocodone-acetaminophen
Take 1 Tab by mouth every 4 hours as needed for
(VICODIN) 5-500 mg Oral Tab
Pain. may take 2 if needed

PHYSICAL EXAM
Initial Vitals
BP
11/13/08 1158
156/96 mmHg
Pulse

11/13/08 1158

63

Resp

11/13/08 1158

16

Temp

--

Temp src

-ROGR HEALTH INFORMATION
2710 Rife Medical Lane

BRAZEAL,HAROLD E
MRN: E1501688231
Printed by 4990 at 12/2/13 12:13 PM

MERCY HOSPITAL NORTHWEST
ARKANSAS
2710 Rife Medical Lane
Rogers, AR 72758-1452

BRAZEAL,HAROLD E
MRN: E1501688231
DOB: 8/23/1936, Sex: M
Adm:11/13/2008, D/C:11/13/2008

ER Records (continued)
ED Provider Notes (continued)

SpO2

11/13/08 1158

98 %

BP 156/96 | Pulse 63 | Resp 16 | SpO2 98%
Physical Exam
Nursing note and vitals reviewed.
Constitutional: He is oriented. He appears well-developed and well-nourished. No distress.
HENT:
Head: Normocephalic and atraumatic.
Right Ear: External ear normal.
Left Ear: External ear normal.
Mouth/Throat: Oropharynx is clear and moist.
Eyes: Conjunctivae and extraocular motions are normal. Pupils are equal, round, and reactive to light.
Neck: Normal range of motion. Neck supple.
Cardiovascular: Normal rate, regular rhythm and normal heart sounds.
Pulmonary/Chest: Effort normal and breath sounds normal.
Abdominal: Soft. No tenderness.
Musculoskeletal: He exhibits edema and tenderness.
Thoracic back: He exhibits decreased range of motion, tenderness, pain and spasm. He exhibits no bony
tenderness.
Back:

Right hand: He exhibits tenderness and swelling.

ROGR HEALTH INFORMATION
2710 Rife Medical Lane

BRAZEAL,HAROLD E
MRN: E1501688231
Printed by 4990 at 12/2/13 12:13 PM

MERCY HOSPITAL NORTHWEST
ARKANSAS
2710 Rife Medical Lane
Rogers, AR 72758-1452

BRAZEAL,HAROLD E
MRN: E1501688231
DOB: 8/23/1936, Sex: M
Adm:11/13/2008, D/C:11/13/2008

ER Records (continued)
ED Provider Notes (continued)

Hands:
Neurological: He is alert and oriented. No cranial nerve deficit. Coordination normal.
Skin: Skin is warm and dry.
Psychiatric: He has a normal mood and affect. His behavior is normal. Judgment and thought content normal.
Past medical and surgical history, social history, family history, nurses notes, VS, medications and allergies
were reviewed.
MDM Coding
Reviewed: nursing note and vitals
Interpretation: x-ray

DIAGNOSTICS
RADIOLOGY:
XR THORACIC SPINE 3 VW
ED Interpretation:

No acute abnormalities

XR HAND 3+ VW RIGHT
ED Interpretation:

No fracture noted.

MEDICAL DECISION MAKING AND PLAN OF CARE
See discharge instructions.
CLINICAL IMPRESSION
Encounter Diagnoses
Code

•847.1
•923.20A

Name

Primary?

Qualifier

Thoracic Sprain and Strain
Contusion of Hand

ROGR HEALTH INFORMATION
2710 Rife Medical Lane

BRAZEAL,HAROLD E
MRN: E1501688231
Printed by 4990 at 12/2/13 12:13 PM

MERCY HOSPITAL NORTHWEST
ARKANSAS
2710 Rife Medical Lane
Rogers, AR 72758-1452

BRAZEAL,HAROLD E
MRN: E1501688231
DOB: 8/23/1936, Sex: M
Adm:11/13/2008, D/C:11/13/2008

ER Records (continued)
ED Provider Notes (continued)

This physician not consulted on this pt. T. Clark, MD.
PATIENT COUNSELING
Diagnostics reviewed and questions answered. Diagnosis, treatment options and plan of care discussed with
understanding verbalized.
DISPOSITION, EDUCATION AND MEDICATION RECONCILIATION
Medications reconciled. See after visit summary for patient education on discharged patients.

Other ED Notes
ED Notes signed by Roberts, Calley L, RN at 11/13/2008 12:01 PM
Author:
Roberts, Calley L, RN
Service:
Filed:
11/13/2008 12:01 PM
Note Time:

ED
11/13/2008 11:59 AM

Author Type:

Registered Nurse

Mva. Client was driving. A and O x3. Pain to left thumb with small abrasion. Right 4th finger
bruising. C/o slight pain to base of neck going down back. Described pain as "whiplash".
Electronically signed by Roberts, Calley L, RN at 11/13/2008 12:01 PM
ED Notes signed by Breen, Covette K, LPN at 11/13/2008 12:14 PM
Author:
Breen, Covette K, LPN
Service:
Filed:
11/13/2008 12:14 PM
Note Time:

ED
11/13/2008 12:13 PM

Author Type:

License Practical Nurse

72 yr old male c/o bruising on right hand, left palm and neck pain after MVA this morning. Pt. Was
wearing seat belt and air bag deployed.
Electronically signed by Breen, Covette K, LPN at 11/13/2008 12:14 PM
ED Notes filed by Aok Scanning, Amb Physician at 11/14/2008 8:28 AM
Author:
Aok Scanning, Amb Physician
Service:
(none)
Filed:
11/14/2008 8:28 AM
Note Time:
11/14/2008 8:21 AM
Trans Status:
Available
Dictation Time:
Trans Time:

Author Type:
Trans ID:

(none)
PRDAOK/CLINICAL/101191054

Trans Doc
Type:

ED Report

Scan on 11/14/2008 8:21 AM (below)

ROGR HEALTH INFORMATION
2710 Rife Medical Lane

BRAZEAL,HAROLD E
MRN: E1501688231
Printed by 4990 at 12/2/13 12:13 PM

MERCY HOSPITAL NORTHWEST
ARKANSAS
2710 Rife Medical Lane
Rogers, AR 72758-1452

BRAZEAL,HAROLD E
MRN: E1501688231
DOB: 8/23/1936, Sex: M
Adm:11/13/2008, D/C:11/13/2008

ER Records (continued)
Other ED Notes (continued)

ROGR HEALTH INFORMATION
2710 Rife Medical Lane

BRAZEAL,HAROLD E
MRN: E1501688231
Printed by 4990 at 12/2/13 12:13 PM

MERCY HOSPITAL NORTHWEST
ARKANSAS
2710 Rife Medical Lane
Rogers, AR 72758-1452

BRAZEAL,HAROLD E
MRN: E1501688231
DOB: 8/23/1936, Sex: M
Adm:11/13/2008, D/C:11/13/2008

Non-Physician Notes
ED Notes filed by Aok Scanning, Amb Physician at 11/14/2008 8:28 AM
Author:
Aok Scanning, Amb Physician
Service:
(none)
Filed:
11/14/2008 8:28 AM
Note Time:
11/14/2008 8:21 AM
Trans Status:
Available
Dictation Time:
Trans Time:

Author Type:
Trans ID:

(none)
PRDAOK/CLINICAL/101191054

Trans Doc
Type:

ED Report

Scan on 11/14/2008 8:21 AM (below)

ROGR HEALTH INFORMATION
2710 Rife Medical Lane

BRAZEAL,HAROLD E
MRN: E1501688231
Printed by 4990 at 12/2/13 12:13 PM

MERCY HOSPITAL NORTHWEST
ARKANSAS
2710 Rife Medical Lane
Rogers, AR 72758-1452

BRAZEAL,HAROLD E
MRN: E1501688231
DOB: 8/23/1936, Sex: M
Adm:11/13/2008, D/C:11/13/2008

Non-Physician Notes (continued)

Nursing Notes
ED Notes signed by Roberts, Calley L, RN at 11/13/2008 12:01 PM
Author:
Roberts, Calley L, RN
Service:
Filed:
11/13/2008 12:01 PM
Note Time:

ED
11/13/2008 11:59 AM

Author Type:

Registered Nurse

Mva. Client was driving. A and O x3. Pain to left thumb with small abrasion. Right 4th finger
bruising. C/o slight pain to base of neck going down back. Described pain as "whiplash".
Electronically signed by Roberts, Calley L, RN at 11/13/2008 12:01 PM
ED Notes signed by Breen, Covette K, LPN at 11/13/2008 12:14 PM
Author:
Breen, Covette K, LPN
Service:
Filed:
11/13/2008 12:14 PM
Note Time:

ED
11/13/2008 12:13 PM

Author Type:

License Practical Nurse

72 yr old male c/o bruising on right hand, left palm and neck pain after MVA this morning. Pt. Was
wearing seat belt and air bag deployed.
Electronically signed by Breen, Covette K, LPN at 11/13/2008 12:14 PM

ROGR HEALTH INFORMATION
2710 Rife Medical Lane

BRAZEAL,HAROLD E
MRN: E1501688231
Printed by 4990 at 12/2/13 12:13 PM


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