STUDENT NAME DATE EMERGENCY DEPARTMENT RECORD Global Care Medical Center 100 Main St, Alfred NY 14802 (607) 555-1234 P ATIENT INFORMATION : N AME : JORDAN, Mary S. P ATIENT N UMBER: EDCase023 ADDRESS: 40 S. Main Street ADMISSION D ATE & TIME : 05-16-YYYY 1315 CITY : Pittsford D ISCHARGE D ATE & TIME : 05-16-YYYY 1400 STATE : NY CONDITION ON D ISCHARGE : ZIP CODE : 14534 R Satisfactory AMA TELEPHONE: 585-264-0123 Home DOA G ENDER: Female Inpatient Admission Code Blue D ATE OF BIRTH : 05-13-YYYY Transfer to: Died R Instruction Sheet Given NURSING DOCUMENTATION : ALLERGIES: EXPLAIN: Penicillin, bee stings CURRENT M EDICATIONS : R No Yes EXPLAIN: None BP: R: No 140/70 RYes P: 112 20 T: 99.2 CC: Right wrist pain. HPI: Motorcycle acc inj to rt wrist - left ribs - left knee. CONDITION : Abrasion L knee, pain R forearm and L ribs. ASSESSMENT: SIGNATURE OF P RIMARY CARE N URSE: ICD CODES: CPT/HCPCS LEVEL II CODES : Marilyn Hillman, RN EMERGENCY DEPARTMENT PHYSICIAN DOCUMENTATION Global Care Medical Center 100 Main St, Alfred NY 14802 (607) 555-1234 P ATIENT N AME : JORDAN, Mary S. P ATIENT N UMBER: EDCase023 L OCATION : Emergency Room ED P HYSICIAN: Preston Treeline, M.D. D ATE OF SERVICE : 05-16-YYYY D ATE OF BIRTH 05-13-YYYY Physician Notes: This 16-year-old girl had been thrown from a motorcycle earlier today and sustained an injury to her forearm. She was seen by the ER physician and noted to have a nondisplaced fracture of the junction of the mid and distal one-third of the ulna and was referred to me for definitive treatment. Distal neurovasculature was intact to the hand. There was minimal swelling. She had an abrasion on the left knee and complained of some discomfort over the point of the left ribs anteriorly. There was small contused area on the abdominal wall. There was no localizing tenderness to palpation. Bowel sounds were normal. She had no flank tenderness. She was taken to the fracture room where a well-padded, long arm plaster cast was applied in the usual position. Discussed with her that many times healing is prolonged with fractures of the ulna, but recommended return to see me in 7-10 days for follow-up. She was given prescription for Empirin Compound #3 p.o. q. 4 hours p.r.n. for pain, #25 x 2, and p.r.n. if any further problems develop. Other treatment for abrasions per ER physician. Dr. Corey to see. Diagnosis: Fracture of the right ulna, treated without reduction. Physician Orders: X-rays, R Forearm, L knee and L ribs Discharge instructions: Refer Dr. Corey SIGNATURE OF ED P HYSICIAN Preston Treeline DD: 05-16-YYYY Preston Treeline, M.D. DT: 05-17-YYYY Global Care Medical Center PHYSICIAN'S OFFICE ENCOUNTER FORM 100 Main St, Alfred NY 14802 (607) 555-1234 EIN: 12-345678 MCD PIN: GCMC1234 BCBS PIN: GC2222 MEDICARE UPIN: GC1111 BCBS GRP : 1234-P P ATIENT INFORMATION : N AME : BRONTE, Betty P ATIENT N UMBER: POCase005 ADDRESS: 77 Sunset Blvd. ADMISSION D ATE & TIME : 09-02-YYYY CITY : Hornell P RIMARY INSURANCE P LAN : BCBS of WNY STATE : NY P RIMARY INSURANCE P LAN ID #: 291837241 ZIP CODE : 14843 TELEPHONE: 607-324-1290 G ENDER: Female D ATE OF BIRTH : 04-17-1970 SECONDARY INSURANCE P LAN : SECONDARY INSURANCE P LAN ID #: OCCUPATION : Reporter N AME OF E MPLOYER: Evening Tribune DIAGNOSIS INFORMATION Diagnosis Code Diagnosis 1. 5. 2. 6. 3. 7. 4. 8. Code PROCEDURE INFORMATION Description of Procedure or Service 1. 2. 3. 4. 5. SPECIAL NOTES: Date Code Charge Global Care Medical Center PHYSICIAN OFFICE RECORD 100 Main St, Alfred NY 14802 (607) 555-1234 P ATIENT N AME : BRONTE, Betty P ATIENT N UMBER: POCase005 D ATE OF SERVICE : 09-02-YYYY D ATE OF BIRTH 04-17-1970 NURSING DOCUMENTATION : M EDICATIONS ALLERGIES/R EACTIONS: None CURRENT M EDICATIONS : BP: 140/100 P: CC: Tiredness PMH: Depression R: 94 T: WT: 300 OVS: N OTES: SIGNATURE OF P RIMARY CARE N URSE: Jeanette Allen, R.N . P HYSICIAN DOCUMENTATION : Notes: Mrs. Bronte is appearing more spirited and less troubled by feelings of depression. She states that things are not so gloomy. She seems upbeat about her life. She had recently graduated and had obtained an associate's degree and wishes to go on further with her education. She is trying to work on getting her husband more involved in their life. She still manifests tearfulness at times, but she is more focused on her needs at this time, which is healthy. She sees the marriage as something to continue to work on despite her own ambitions. The meds are very helpful to her and she is feeling less depressed. She complains of tiredness today, and I have recommended her to cut back on the dosage which she is in agreement with. She is also seeing Tammy Titus for psychotherapy which is very helpful. She is going through her menopause and being inactive sexually, she does not worry about getting pregnant, in view of taking meds. She is alert, o riented x 3, no abnormalities of thought content or thought process. She states that she has never had any suicidal thoughts. RTC in 2 months. SIGNATURE OF P ROVIDER: DD: 09-02-YYYY DT: 09-04-YYYY Raymond E. Massey, M.D. Raymond E. Massey, M.D. Global Care Medical Center PHYSICIAN'S OFFICE ENCOUNTER FORM 100 Main St, Alfred NY 14802 (607) 555-1234 EIN: 12-345678 MCD PIN: GCMC1234 BCBS PIN: GC2222 MEDICARE UPIN: GC1111 BCBS GRP : 1234-P P ATIENT INFORMATION : N AME : HALL, Harry P ATIENT N UMBER: POCase006 ADDRESS: 999 Appian Way ADMISSION D ATE & TIME : 08-16-YYYY CITY : Hornell P RIMARY INSURANCE P LAN : Medicare STATE : NY P RIMARY INSURANCE P LAN ID #: 444569090A ZIP CODE : 14843 SECONDARY INSURANCE P LAN : United Health Medigap TELEPHONE: 607-324-1110 SECONDARY INSURANCE P LAN ID #: 444569090 G ENDER: Male OCCUPATION : Retired D ATE OF BIRTH : 01-21-1932 N AME OF E MPLOYER: DIAGNOSIS INFORMATION Diagnosis Code Diagnosis 1. 5. 2. 6. 3. 7. 4. 8. Code PROCEDURE INFORMATION Description of Procedure or Service 1. 2. 3. 4. 5. SPECIAL NOTES: Date Code Charge Global Care Medical Center PHYSICIAN OFFICE RECORD 100 Main St, Alfred NY 14802 (607) 555-1234 P ATIENT N AME : HALL, Harry P ATIENT N UMBER: POCase006 D ATE OF SERVICE : 08-16-YYYY D ATE OF BIRTH 01-21-1932 NURSING DOCUMENTATION : M EDICATIONS ALLERGIES/R EACTIONS: CURRENT M EDICATIONS : BP: 122/70 CC: Feels tired all the time and no energy. PMH: Hyperlipidemia, coronary artery disease, cerebrovascular disease, esophageal reflux, and anxiety with depression. Patient says he is feeling tired all the time and no energy. N OTES: P: None Cimetidine, Fluoxetine R: 60 SIGNATURE OF P RIMARY CARE N URSE: 18 T: WT: 183 HEENT: Within Normal Limits Jeanette Allen, R.N . P HYSICIAN DOCUMENTATION : Notes: Mr. Hall has the following problems: Hyperlipidemia, coronary artery disease, cerebrovascular disease, esophageal reflex, and anxiety with depression. HPI: Mr. Hall is an 80-year-old white male who was last seen in June of this year by Dr. Hank Himmel for the above problems. At that time the patient was placed on Cimetidine twice a day and Fluoxetine 10 mg a day by Dr. Carl Custer for psychiatry. The patient had been followed up in the past by a private M.D. in Fairport. However, he no longer sees him and is using us now as his primary care providers. There are no labs done on this patient as of yet. He comes in today without any new complaints, except for his original complaint of feeling tired all of the time and no energy. PE: Today on examination the patient was 57 inches tall, weighed 184 lbs. Blood pressure: 122/70. Pulse: 60 per minute. Respiration: 18 per minute. HEENT: Basically within normal limits. He wears glasses for visual acuity. He has hearing aids bilaterally. NECK: Supple. Trachea is midline. Thyroid not palpable. LUNGS: Clear to A&P. HEART: sounds were regular without murmur or ectopic beat noted. ABDOMEN: slightly obese. It was nontender. There was no gross organomegaly noted. His bowel sounds were normal. EXTREMITIES: The lower extremities were present. He had good circulation with some very mild edema around the ankles. ASSESSMENT: As stated above in the problem list. PLAN: I would like to see this patient back in three months time. Before leaving today he will be referred and taken to psychiatry where he can have a new appointment set up and have his medications renewed. He will have labs requested in the next two to three weeks. We will check his chemistries, as well as hemogram. I also want to get fecults times three. I will see him in three months. He will continue his medications of Cimetidine 400 mg. However, he will take just once a day at nighttime. He is also taking Lovastatin for his hyperlipidemia 40 mg a day. He has used blocks under the head of his bed which has relieved his nighttime heartburn. I would advise him to continue doing this, as well as taking the Cimetidine at bedtime. He is being referred as stated to psychiatry for follow up, and I will see him in three months. SIGNATURE OF P ROVIDER: DD: 08-16-YYYY DT: 08-18-YYYY Raymond E. Massey, M.D. Raymond E. Massey, M.D. Global Care Medical Center PHYSICIAN'S OFFICE ENCOUNTER FORM 100 Main St, Alfred NY 14802 (607) 555-1234 EIN: 12-345678 MCD PIN: GCMC1234 BCBS PIN: GC2222 MEDICARE UPIN: GC1111 BCBS GRP : 1234-P P ATIENT INFORMATION : N AME : TRUMAN, Leonard P ATIENT N UMBER: POCase008 ADDRESS: 78909 Holmes Road ADMISSION D ATE & TIME : 08-17-YYYY CITY : Hornell P RIMARY INSURANCE P LAN : Medicare STATE : NY P RIMARY INSURANCE P LAN ID #: 020443413A ZIP CODE : 14843 SECONDARY INSURANCE P LAN : Medicare TELEPHONE: 607-324-3333 SECONDARY INSURANCE P LAN ID #: UHI Medigap G ENDER: Male OCCUPATION : Retired D ATE OF BIRTH : 06-20-1925 N AME OF E MPLOYER: DIAGNOSIS INFORMATION Diagnosis Code Diagnosis 1. 5. 2. 6. 3. 7. 4. 8. Code PROCEDURE INFORMATION Description of Procedure or Service 1. 2. 3. 4. 5. SPECIAL NOTES: Date Code Charge Global Care Medical Center PHYSICIAN OFFICE RECORD 100 Main St, Alfred NY 14802 (607) 555-1234 P ATIENT N AME : TRUMAN, Leonard P ATIENT N UMBER: POCase008 D ATE OF SERVICE : 08-17-YYYY D ATE OF BIRTH 06-20-1925 NURSING DOCUMENTATION : M EDICATIONS ALLERGIES/R EACTIONS: CURRENT M EDICATIONS : BP: None amitriptyline P: R: T: LMP: OVS: CC: PMH: N OTES: SIGNATURE OF P RIMARY CARE N URSE: Karla Herrslip P HYSICIAN DOCUMENTATION : Notes: S: Some improvement in paresthesias since amitriptyline started, though he is using it only sporadically. O: As per previous visit, most notable findings being moderate distal weakness RLE, antalgic gait, diminished AJs, impaired vibratory sensation below knees, and low stocking sensory impairment. A: Distal sensorimotor neuropathy, symptomatic response to amitriptyline. P: Suggested he take amitriptyline qhs as originally prescribed; reassess in 4 months. SIGNATURE OF P ROVIDER: Phyllis A. Neumann, M.D. DD: 08-17-YYYY Phyllis A. Neumann, M.D. DT: 08-20-YYYY Global Care Medical Center PHYSICIAN'S OFFICE ENCOUNTER FORM 100 Main St, Alfred NY 14802 (607) 555-1234 EIN: 12-345678 MCD PIN: GCMC1234 BCBS PIN: GC2222 MEDICARE UPIN: GC1111 BCBS GRP : 1234-P P ATIENT INFORMATION : N AME : MOHR, Lee P ATIENT N UMBER: POCase024 ADDRESS: 157 Grossman Avenue ADMISSION D ATE & TIME : 08-17-YYYY CITY : Olean P RIMARY INSURANCE P LAN : BCBS of WNY STATE : NY P RIMARY INSURANCE P LAN ID #: 097041380 ZIP CODE : 14760 TELEPHONE: 585-372-7368 G ENDER: Male D ATE OF BIRTH : 04-24-1947 SECONDARY INSURANCE P LAN : SECONDARY INSURANCE P LAN ID #: OCCUPATION : Instructor N AME OF E MPLOYER: Jamestown College DIAGNOSIS INFORMATION Diagnosis Code Diagnosis 1. 5. 2. 6. 3. 7. 4. 8. Code PROCEDURE INFORMATION Description of Procedure or Service 1. 2. 3. 4. 5. SPECIAL NOTES: Date Code Charge Global Care Medical Center PHYSICIAN OFFICE RECORD 100 Main St, Alfred NY 14802 (607) 555-1234 P ATIENT N AME : MOHR, Lee P ATIENT N UMBER: POCase024 D ATE OF SERVICE : 08-17-YYYY D ATE OF BIRTH 04-24-1947 NURSING DOCUMENTATION : M EDICATIONS ALLERGIES/R EACTIONS: CURRENT M EDICATIONS : P: None Warfarin, diltiazem, simvastatin, famotidine, and nitrogycerine. BP: 118/72 R: CC: The patient has no acute problems or complaints today. PMH: Coronary artery disease with cardiac dysrhythmia, cerebrovascular disease, hyperluipidemia, and speech impediment secondary to the CVA. Anterior wall MI with both ventricular and atrial fibrillation as well as congestive heart failure and chronic ischemic heart disease N OTES: Patient is upset today over care he states he never received approximately 3 weeks ago. Patient calmed down enough to see Ruben Blades, P.A. and is happy to be seen by him today he stated. 76 SIGNATURE OF P RIMARY CARE N URSE: 18 T: WT 212 HT 70\" Mary Kay Place, R.N. P HYSICIAN DOCUMENTATION : Notes: Mr. Mohr is a 49-year-old white male who has the following problems: Coronary artery disease with cardiac dysrhythmia, cerebrovascular disease, hyperlipidemia and speech impediment secondary to the CVA. He has a history of anterior wall MI with both ventricular and atrial fibrillation as well as congestive heart failure and chronic ischemic heart disease. Presently, the patient has no acute problems or no acute complaints. Today, his weight is 212 pounds. He stands 70 inches tall. His blood pressure is 118/72, pulse 76, respirations 18. The PE shows him to have a normal HEENT except for some speech impediments due to the CVA. He can speak clearly, but he must speak slowly. His thought pattern to get his words out sometimes takes a little effort, but he does remarkably well. He has a full beard. His lungs are clear to A&P. The heart sounds are regular with a grade 2/6 systolic murmur. The abdomen was obese, no gross organomegaly noted. Bowel sounds were normal. He has a small abdominal hernia along the ventral line at the umbilicus and just above the umbilicus. Lower extremities have good peripheral sensation, good warmth, adequate circulation and there was no evidence of any edema. As stated the patient has no acute medical problems. His medications continue to be Warfarin which he takes 10 mg on Tuesdays, Thursdays and Saturdays and 5mg on Mondays, Wednesdays, Fridays and Sundays. He is also on 30 mg of diltiazem three times a day, simvastatin 20 mg after supper and famotidine 20 mg twice a day. He also has p.r.n. nitroglycerine subinguinally if he needs it for any chest discomfort or perceived symptoms. As stated, the patient is doing well. He plans to go bear hunting in another couple of weeks in the North country of New York. There were no acute findings. Continue present treatment plan. He is to be followed up in three months at which time we will also get fasting labs. SIGNATURE OF P HYSICIAN: DD: 08-17-YYYY DT: 08-20-YYYY H.W. Pocket, M.D. H.W. Pocket, M.D