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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
BRAZEAL, HAROLD.pdf (PDF, 97.94 MB)
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