Preview
FILED: NEW YORK COUNTY CLERK 06/02/2021 12:33 PM INDEX NO. 805302/2015
NYSCEF DOC. NO. 147 RECEIVED NYSCEF: 06/02/2021
Exhibit B4
FILED: NEW YORK COUNTY CLERK 06/02/2021
05/29/2020 12:33
04:59 PM INDEX NO. 805302/2015
NYSCEF DOC. NO. 147
112 RECEIVED NYSCEF: 06/02/2021
05/29/2020
···1111RN ,·1129.0550·· HOFFMAN, SHELL YANN NY:Pres1>yteria11 Weill
• Visit: 000414138 983 Gender: Female • Cornell
•.. Age: ..38y • Location: GO?S-7244-A
SEDATION SCALE
Sedation Scale - m-POSS : 0 =Awake/No Sedation
PAIN ASSESSMENT
Pain Assessment Patient Self-Report: Numeric 0-10 scale
Pain Assessment Pain Scale : 2
Pain Assessment Location of pain : abdominal incision
Pain Assessment Description of pain : Dull
Pain Assessment Effect on physical activity : No effect
Row Comment : If new or uncontrolled pain, complete the Comprehensive Pain Assessment
COMPREHENSIVE PAIN ASSESSMENT
Comprehensive Pain Assessment Onset of Pain : Gradual
Comprehensive Pain Assessment Duration of Pain : Intermittent
Comprehensive Pain Assessment Pattern: The patient describes the pain as happening in the:
The patient reports there is no pattern
Comprehensive Pain Assessment Cause/Triggers: The patient reports that the pain increases
with : Not applicable
Comprehensive Pain Assessment Relief Measures: The patient reports that there is
relief/decrease in pain with : The patient reports that nothing relieves the pain
Comprehensive Pain Assessment Function: Due to pain, the patient reports change in : Not
applicable
PAIN INTERVENTIONS
Pain Interventions Pharmacologic : Oxycodone
Pain Interventions Non-Pharmacologic: Decreased environmental stimulation (decrease light,
noise), Positioned, provided boundaries and decreased handling., Relaxation, distraction, music,
television.
Pain Interventions PatienVFamily Education : Complete Shift Assessment or Pt ED-Nursing
Flowsheet
****************************************************************************************************
6) OB Shift Assessment [Authored: 18-Sep-2014 15:00]- for Visit: 000414138 983, Severino
Wynn, Danika (Per Diem Rn), Complete, Entered, Signed in Full, General
Skin -Skin Impair. Site & Loe.: Use Modify Row Label
Skin Color : Skin color is normal.
Skin Integrity : Skin intact, no breakdown
Skin Impairment Surgical Incision : Appearance clean, Wound healing
Assessment
Breasts : Breasts are soft, Breasts are non-tender
Perineum : Intact
670
FILED: NEW YORK COUNTY CLERK 06/02/2021
05/29/2020 12:33
04:59 PM INDEX NO. 805302/2015
NYSCEF DOC. NO. 147
112 RECEIVED NYSCEF: 06/02/2021
05/29/2020
···1111RN ,·1129.0550·· HOFFMAN,SHELLYANN NY-Presbyterian Weill
• Visit: 000414138 983 Gender: Female • Cornell
•__ Age: __38y( Location: GO?S-7244-A
Lochia : NIA
Homan's Sign : Absent
Sequential Compression Sleeves : Off
****************************************************************************************************
OB PACU Flowsheet [Authored: 18-Sep-2014 15:00]- for Visit: 000414138 983, Severino
Wynn, Danika (Per Diem Rn), Complete, Entered, Signed in Full, General
MATERNAL ASSESSMENT
Sequential Compression Sleeves : Off
****************************************************************************************************
5) Treatment Flowsheet [Authored: 18-Sep-2014 15:00]- for Visit: 000414138 983, Severino
Wynn, Danika (Per Diem Rn), Complete, Entered, Signed in Full, General
CARES
Sequential Compression Sleeves : Off
****************************************************************************************************
OB Recovery Room Flowsheet (Vag. Del.) [Authored: 18-Sep-2014 15:00]- for Visit:
000414138 983, Severino Wynn, Danika (Per Diem Rn), Complete, Entered, Signed in Full,
General
MATERNAL ASSESSMENT
Sequential Compression Sleeves : Off
****************************************************************************************************
1) Vitalsign Flowsheet [Authored: 18-Sep-2014 15:19]- for Visit: 000414138 983, Severino
Wynn, Danika (Per Diem Rn), Complete, Entered, Signed in Full, General
WEIGHT
Current Weight (kg) Current Weight (kg) kg : 88.45 kg
Height (cm) cm : 165.1 cm
BMl_(MetricCalculation)_kg/m2_:_32.4_kg/m2 __ _
Flequested by (3r9ce, fv1ighc1elJfv1ed Flcds), 2];C)c1;2Q15Q9 45 page 7Df26
671
FILED: NEW YORK COUNTY CLERK 06/02/2021
05/29/2020 12:33
04:59 PM INDEX NO. 805302/2015
NYSCEF DOC. NO. 147
112 RECEIVED NYSCEF: 06/02/2021
05/29/2020
···1111RN ,·1129.0550·· HOFFMAN,SHELLYANN NY-Presbyterian Weill
• Visit: 000414138 983 Gender: Female • Cornell
•.. Age: ..38y Location: GO?S-7244-A
****************************************************************************************************
Vital Signs (ICU) - Physicians Only [Authored: 18-Sep-2014 15:19]- for Visit: 000414138
983, Severino Wynn, Danika (Per Diem Rn), Complete, Entered, Signed in Full, General
WEIGHT
Current Weight (kg) kg : 88.45 kg
Height (cm) cm : 165.1 cm
****************************************************************************************************
1) Vital Signs Flowsheet (OB) [Authored: 18-Sep-2014 15:19]- for Visit: 000414138 983,
Severino Wynn, Danika (Per Diem Rn), Complete, Entered, Signed in Full, General
WEIGHT
Current Weight (kg) kg : 88.45 kg
Height (cm) cm : 165.1 cm
BMI (Metric Calculation) kg/m2: 32.4 kg/m2
****************************************************************************************************
Vital Signs - Physicians Only [Authored: 18-Sep-2014 15:19]- for Visit: 000414138 983,
Severino Wynn, Danika (Per Diem Rn), Complete, Entered, Signed in Full, General
WEIGHT
Current Weight (kg) kg : 88.45 kg
****************************************************************************************************
1) Vital Signs Flowsheet (OB) [Authored: 18-Sep-2014 15:30]- for Visit: 000414138 983,
Severino Wynn, Danika (Per Diem Rn), Complete, Entered, Signed in Full, General
PAIN REASSESSMENT/PT RESPONSE WITHIN ONE HOUR
Pain Re-Assessment/Patient Response within 1 Hour Side Effect of Interventions : None
Pain Re-Assessment/Patient Response within 1 Hour Pain Rating Scale : Numeric 0-10 scale
Pain Re-Assessment/Patient Response within 1 Hour Patient Response : Yes, no further actions
needed
Flequested by (3r9ce, fv1ighc1elJfv1ed Flcds), 2];C)c1;2Q15Q9 45 page 8pf26
672
FILED: NEW YORK COUNTY CLERK 06/02/2021
05/29/2020 12:33
04:59 PM INDEX NO. 805302/2015
NYSCEF DOC. NO. 147
112 RECEIVED NYSCEF: 06/02/2021
05/29/2020
···1111RN ,·1129.0550·· HOFFMAN, SHELL YANN NY:Pres1>yteria11 Weill
• Visit: 000414138 983 Gender: Female • Cornell
•.. Age: ..38y • Location: GO?S-7244-A
Pain Re-Assessment/Patient Response within 1 Hour Pain Scale : 0
****************************************************************************************************
.,
/j 1) Vitalsign Flowsheet [Authored: 18-Sep-2014 18:00]- for Visit: 000414138 983, Liboro,
Roy A (Nurse), Complete, Revised, Signed in Full, General
PATIENT LOCATION
Location : F 10 PACU
WEIGHT
Current Weight (kg) Current Weight (kg) kg : 88 kg
Height (cm) cm : 165 cm
BMI (Metric Calculation) kg/m2: 32.3 kg/m2
BMI percentile BMI % : N/A
TEMPERATURE
Temperature Temperature (C) degrees C : 37 degrees C
Temperature Temperature Source: Temporal
HEART RATE
Heart Rate : 95
RESP
Respiratory Rate, Patient (bpm) Respiratory Rate, Patient (bpm): 16
Oxygen Flow Oxygen Flow (Lpm) : 0
Sp02 (Pulse Ox) Sp02 (Pulse Ox) (%) : 96
NONINVASIVE BLOOD PRESSURE
Noninvasive BP NIBP Systolic: 168
Noninvasive BP NIBP Diastolic : 97
Noninvasive BP NIBP Mean: 120 mm Hg
PAIN ASSESSMENT
Pain Assessment Patient Self-Report: Numeric 0-10 scale
Pain Assessment Pain Scale : 0
ACTIVITY/POSITIONING
Activity : Bed rest
Positioning : HOB 30 degrees
MISCELLANEOUS
673
FILED: NEW YORK COUNTY CLERK 06/02/2021
05/29/2020 12:33
04:59 PM INDEX NO. 805302/2015
NYSCEF DOC. NO. 147
112 RECEIVED NYSCEF: 06/02/2021
05/29/2020
···1111RN ,·1129.0550·· HOFFMAN,SHELLYANN NY-Presbyterian Weill
• Visit: 000414138 983 Gender: Female • Cornell
•.. Age: ..38y Location: GO?S-7244-A
PACU IV site check : Site WNL
Level of Consciousness : LOC3
****************************************************************************************************
p:') 5) Treatment Flowsheet [Authored: 18-Sep-2014 18:00]- for Visit: 000414138 983,
Liboro, Roy A (Nurse), Complete, Revised, Signed in Full, General
SAFETY
Ambu Bag/Mask Present : Yes
Call Device in place : Done
Siderails Up : up X 2
Monitor Alarms On : Done
ID band present and correct : Yes
Allergy band present and correct : No Allergies
ACTIVITY/POSITIONING
Activity : Bed rest
Positioning : HOB 30 degrees
****************************************************************************************************
1) Vital Signs Flowsheet (OB) [Authored: 18-Sep-2014 18:00]- for Visit: 000414138 983,
Liboro, Roy A (Nurse), Complete, Entered, Signed in Full, General
ACTIVITY/POSITIONING
Activity : Bed rest
Positioning : HOB 30 degrees
****************************************************************************************************
2) l&O Flowsheet [Authored: 18-Sep-2014 18:00]- for Visit: 000414138 983, Liboro, Roy A
(Nurse), Complete, Entered, Signed in Full, General
INTAKE
CRYSTALLOID
Lactated Ringers ml ln:1000 ml
Comment: given in the OR
674
FILED: NEW YORK COUNTY CLERK 06/02/2021
05/29/2020 12:33
04:59 PM INDEX NO. 805302/2015
NYSCEF DOC. NO. 147
112 RECEIVED NYSCEF: 06/02/2021
05/29/2020
···1111RN ,·1129.0550·· HOFFMAN, SHELL YANN NY:Pres1>yteria11 Weill
• Visit: 000414138 983 Gender: Female • Cornell
•.. Age: ..38y • Location: GO?S-7244-A
****************************************************************************************************
7) Patient Education [Authored: 18-Sep-2014 18:00]- for Visit: 000414138 983, Liboro, Roy
A (Nurse), Complete, Entered, Signed in Full, General
Patient Education - Nursing
Learner Learner : Patient
Barriers Barriers To Learning : No Barriers/Ready to learn
Topics Discussed: Patient Safety . Admission Education : *Orientation to Hospital Setting. *Use
of Patient ID Band. Surgical procedure. Anesthetic
Topics Discussed: Patient Safety Falls Prevention : Orientation to immediate surroundings. Use
of call bell and importance of calling for assistance. Safe use of equipment (IV pole, rolling
furniture etc.). Medications and potential side effects
****************************************************************************************************
6) OB Shift Assessment [Authored: 18-Sep-2014 18:00]- for Visit: 000414138 983, Liboro,
Roy A (Nurse), Complete, Entered, Signed in Full, General
Patient Education--Nursing
Learner Learner : Patient
Barriers Barriers To Learning : No Barriers/Ready to learn
Topics Discussed: Patient Safety . Admission Education : *Orientation to Hospital Setting. *Use
of Patient ID Band. Surgical procedure. Anesthetic
Topics Discussed: Patient Safety Falls Prevention : Orientation to immediate surroundings. Use
of call bell and importance of calling for assistance. Safe use of equipment (IV pole, rolling
furniture etc.). Medications and potential side effects
****************************************************************************************************
Interdisciplinary Plan of Care [Authored: 18-Sep-2014 18:00]- for Visit: 000414138 983,
Liboro, Roy A (Nurse), Complete, Entered, Signed in Full, General
Nursing Plan of Care
Plan Of Care : Recovery for Anesthesia Diagnosis/Problem(s) :Recovery from Anesthesia :
Altered Respiratory Pattern related to Anesthesia, 2nd sedation
Plan Of Care : Recovery for Anesthesia Measurable Goal : Established optimal respiratory status
Return to pre-anesthesia state
Plan Of Care : Recovery for Anesthesia Goal Met: In Progress
Plan of Care : Surgery Diagnosis/Problem(s) : Surgery : Alteration in comfort related to Surgery
Plan of Care : Surgery Measurable Goal : Manage, diminish and control pain Control nausea
Plan of Care : Surgery Goal Met: In Progress
Flequested by (3r9ce, fv1ighc1elJfv1ed Flcds), 2];C)c1;2Q15Q9 45 page 11 gf26
675
FILED: NEW YORK COUNTY CLERK 06/02/2021
05/29/2020 12:33
04:59 PM INDEX NO. 805302/2015
NYSCEF DOC. NO. 147
112 RECEIVED NYSCEF: 06/02/2021
05/29/2020
···1111RN ,·1129.0550·· HOFFMAN,SHELLYANN NY-Presbyterian Weill
• Visit: 000414138 983 Gender: Female • Cornell
•.. Age: ..38y Location: GO?S-7244-A
Plan of Care : Consciousness Diagnosis/Problem(s) : Consciousness : Alteration in
Consciousness
Plan of Care : Consciousness Measurable Goal : Return to pre-op level of consciousness
Plan of Care : Consciousness Goal Met: In Progress
****************************************************************************************************
;,<"! 1) Vitalsign
Flowsheet [Authored: 18-Sep-2014 18:15]- for Visit: 000414138 983, Liboro,
Roy A (Nurse), Complete, Revised, Signed in Full, General
HEART RATE
Heart Rate : 90
RESP
Respiratory Rate, Patient (bpm) Respiratory Rate, Patient (bpm): 15
Oxygen Flow Oxygen Flow (Lpm) : 0
Sp02 (Pulse Ox) Sp02 (Pulse Ox) (%) : 97
NONINVASIVE BLOOD PRESSURE
Noninvasive BP NIBP Systolic: 171
Noninvasive BP NIBP Diastolic : 93
PAIN ASSESSMENT
Pain Assessment Patient Self-Report: Numeric 0-10 scale
Pain Assessment Pain Scale : 0
ACTIVITY/POSITIONING
Activity : Bed rest
Positioning : HOB 30 degrees
****************************************************************************************************
5) Treatment Flowsheet [Authored: 18-Sep-2014 18:15]- for Visit: 000414138 983, Liboro,
Roy A (Nurse), Complete, Entered, Signed in Full, General
ACTIVITY/POSITIONING
Activity : Bed rest
Positioning : HOB 30 degrees
****************************************************************************************************
676
FILED: NEW YORK COUNTY CLERK 06/02/2021
05/29/2020 12:33
04:59 PM INDEX NO. 805302/2015
NYSCEF DOC. NO. 147
112 RECEIVED NYSCEF: 06/02/2021
05/29/2020
···1111RN ,·1129.0550·· HOFFMAN, SHELL YANN NY:Pres1>yteria11 Weill
• Visit: 000414138 983 Gender: Female • Cornell
•.. Age: ..38y • Location: GO?S-7244-A
1) Vital Signs Flowsheet (OB) [Authored: 18-Sep-2014 18:15]- for Visit: 000414138 983,
Liboro, Roy A (Nurse), Complete, Entered, Signed in Full, General
ACTIVITY/POSITIONING
Activity : Bed rest
Positioning : HOB 30 degrees
****************************************************************************************************
1) Vitalsign Flowsheet [Authored: 18-Sep-2014 18:30]- for Visit: 000414138 983, Liboro,
Roy A (Nurse), Complete, Entered, Signed in Full, General
HEART RATE
Heart Rate : 94
RESP
Respiratory Rate, Patient (bpm) Respiratory Rate, Patient (bpm): 18
Oxygen Flow Oxygen Flow (Lpm) : 0
Sp02 (Pulse Ox) Sp02 (Pulse Ox) (%) : 97
NONINVASIVE BLOOD PRESSURE
Noninvasive BP NIBP Systolic: 163
Noninvasive BP NIBP Diastolic : 95
Noninvasive BP NIBP Mean: 117 mm Hg
PAIN ASSESSMENT
Pain Assessment Patient Self-Report: Numeric 0-10 scale
Pain Assessment Pain Scale : 0
ACTIVITY/POSITIONING
Activity : Bed rest
Positioning : HOB 30 degrees
****************************************************************************************************
5) Treatment Flowsheet [Authored: 18-Sep-2014 18:30]- for Visit: 000414138 983, Liboro,
Roy A (Nurse), Complete, Entered, Signed in Full, General
ACTIVITY/POSITIONING
677
FILED: NEW YORK COUNTY CLERK 06/02/2021
05/29/2020 12:33
04:59 PM INDEX NO. 805302/2015
NYSCEF DOC. NO. 147
112 RECEIVED NYSCEF: 06/02/2021
05/29/2020
···1111RN ,·1129.0550·· HOFFMAN, SHELL YANN NY:Pres1>yteria11 Weill
• Visit: 000414138 983 Gender: Female • Cornell
•.. Age: ..38y • Location: GO?S-7244-A
Activity : Bed rest
Positioning : HOB 30 degrees
****************************************************************************************************
p:') 1) Vital Signs Flowsheet (OB) [Authored: 18-Sep-2014 18:30]- for Visit: 000414138 983,
Liboro, Roy A (Nurse); Hipp, Susana (Nurses Aide), Complete, Revised, Signed in Full, General
TEMPERATURE
Temperature Temperature (C) degrees C : 36.8 degrees C
Temperature Temperature Source : Oral
HEART RATE
Heart Rate : 93
RESP
Respiratory Rate, Patient (bpm) Respiratory Rate, Patient (bpm): 18
Sp02 (Pulse Ox) Sp02 (Pulse Ox) (%) : 97
NONINVASIVE BLOOD PRESSURE
Noninvasive BP NIBP Systolic: 113
Noninvasive BP NIBP Diastolic : 84
Noninvasive BP NIBP Mean : 93 mm Hg
ACTIVITY/POSITIONING
Activity : Bed rest
Positioning : HOB 30 degrees
****************************************************************************************************
,,
/j 2) l&O Flowsheet - (Shift) [Authored: 18-Sep-2014 19:00]- for Visit: 000414138 983,
Severino Wynn, Danika (Per Diem Rn); Liboro, Roy A (Nurse); Mohammed, Rachel (Nurse),
Complete, Revised, Signed in Full, General
INTAKE
CRYSTALLOID
Lactated Ringers ml ln:1125 ml
OUTPUT
678
FILED: NEW YORK COUNTY CLERK 06/02/2021
05/29/2020 12:33
04:59 PM INDEX NO. 805302/2015
NYSCEF DOC. NO. 147
112 RECEIVED NYSCEF: 06/02/2021
05/29/2020
···1111RN ,·1129.0550·· HOFFMAN, SHELL YANN NY:Pres1>yteria11 Weill
• Visit: 000414138 983 Gender: Female • Cornell
•.. Age: ..38y • Location: GO?S-7244-A
URINE
Indwelling Urinary Catheter ml Out:1525 ml
****************************************************************************************************
,,J 2) l&O Flowsheet[Authored: 18-Sep-2014 19:00]- for Visit: 000414138 983, Liboro, Roy
A (Nurse); Mohammed, Rachel (Nurse), Complete, Revised, Signed in Full, General
INTAKE
CRYSTALLOID
Lactated Ringers ml ln:125 ml
OUTPUT
URINE
Indwelling Urinary Catheter ml Out:400 ml
****************************************************************************************************
7) Patient Education [Authored: 18-Sep-2014 19:00]- for Visit: 000414138 983, Mohammed,
Rachel (Nurse), Complete, Entered, Signed in Full, General
Patient Education - Nursing
Learner Learner : Patient
Barriers Barriers To Learning : No Barriers/Ready to learn
Topics Discussed: Patient Safety . Admission Education : *Orientation to Hospital Setting. *Use
of Patient ID Band. *Reinforce Use of Patient I Visitor Guide. *How to Communicate Concerns
About Patient Safety Issues. *Reporting Concerns about a Change in Condition I RRT. *Hand
and Respiratory Hygiene. *How to notify staff (call bell, verbal cues, speaking up). Preventing
Surgical Site Infections. Wound/Skin Care
Topics Discussed: Patient Safety Falls Prevention : Orientation to immediate surroundings. Use
of call bell and importance of calling for assistance. Use of non-skid footwear. Use of siderails.
Keep floor clean and dry, and free of barriers. Keep bed/stretcher in lowest postion. Safe room
lighting. Safe use of equipment (IV pole, rolling furniture etc.). Medications and potential side
effects
Topics Discussed: Disease Process OB Ante/lntra/Postpartum/Perioperative and Newborn :
Breast & nipple care. Perinea I hygiene (mother). Sequential Compression Sleeves
Topics Discussed: Medications Medications : Analgesics. Cardiovascular
Topics Discussed: Medications Administration Methods : Method of administration (specify
Flequested by (3r9ce, fv1ighc1elJfv1ed Flcds), 2];C)c1;2Q15Q9 45 page 15pf26
679
FILED: NEW YORK COUNTY CLERK 06/02/2021
05/29/2020 12:33
04:59 PM INDEX NO. 805302/2015
NYSCEF DOC. NO. 147
112 RECEIVED NYSCEF: 06/02/2021
05/29/2020
···1111RN ,·1129.0550·· HOFFMAN, SHELL YANN NY:Pres1>yteria11 Weill
• Visit: 000414138 983 Gender: Female • Cornell
•.. Age: ..38y • Location: GO?S-7244-A
below). po
Topics Discussed: Medications Medication Safety: Allergies. Purpose. Side effects. Signs and
symptoms to report
Topics Discussed: Pain Management Pain Management: Opioid use and low risk of addiction.
Pain -type,onset,location,duration,radiation,quality. Pain Med-type, purpose.side effects.report
S&S,interactions. Reporting pain to providers. Reporting relief acceptability. Right of the patient
to receive good pain management Use of the pain scale
Topics Discussed: Nutrition Diet Instructions : regular diet
Methods/Resource Used : Demonstration. Verbal Discussion
Evaluation : Able to repeat I verbalize key points (Teach back)
****************************************************************************************************
6) OB Shift Assessment [Authored: 18-Sep-2014 19:00]- for Visit: 000414138 983,
Mohammed, Rachel (Nurse), Complete, Entered, Signed in Full, General
Patient Education--Nursing
Learner Learner : Patient
Barriers Barriers To Learning : No Barriers/Ready to learn
Topics Discussed: Patient Safety . Admission Education : *Orientation to Hospital Setting. *Use
of Patient ID Band. *Reinforce Use of Patient I Visitor Guide. *How to Communicate Concerns
About Patient Safety Issues. *Reporting Concerns about a Change in Condition I RRT. *Hand
and Respiratory Hygiene. *How to notify staff (call bell, verbal cues, speaking up). Preventing
Surgical Site Infections. Wound/Skin Care
Topics Discussed: Patient Safety Falls Prevention : Orientation to immediate surroundings. Use
of call bell and importance of calling for assistance. Use of non-skid footwear. Use of siderails.
Keep floor clean and dry, and free of barriers. Keep bed/stretcher in lowest postion. Safe room
lighting. Safe use of equipment (IV pole, rolling furniture etc.). Medications and potential side
effects
Topics Discussed: Disease Process OB Ante/lntra/Postpartum/Perioperative and Newborn :
Breast & nipple care. Perinea I hygiene (mother). Sequential Compression Sleeves
Topics Discussed: Medications Medications : Analgesics. Cardiovascular
Topics Discussed: Medications Administration Methods : Method of administration (specify
below). po
Topics Discussed: Medications Medication Safety: Allergies. Purpose. Side effects. Signs and
symptoms to report
Topics Discussed: Pain Management Pain Management: Opioid use and low risk of addiction.
Pain -type,onset,location,duration,radiation,quality. Pain Med-type, purpose.side effects.report
S&S,interactions. Reporting pain to providers. Reporting relief acceptability. Right of the patient
to receive good pain management Use of the pain scale
Topics Discussed: Nutrition Diet Instructions : regular diet
Methods/Resource Used : Demonstration. Verbal Discussion
Evaluation : Able to repeat I verbalize key points (Teach back)
****************************************************************************************************
1::] 2) l&O Flowsheet [Authored: 18-Sep-2014 20:00]- for Visit: 000414138 983, Osei-Bobie,
Antoinette (Nurse), Complete, Revised, Signed in Full, General
Flequested by (3r9ce, fv1ighc1elJfv1ed Flcds), 2];C)ct;2Q15Q9 45 page 16pf26
680
FILED: NEW YORK COUNTY CLERK 06/02/2021
05/29/2020 12:33
04:59 PM INDEX NO. 805302/2015
NYSCEF DOC. NO. 147
112 RECEIVED NYSCEF: 06/02/2021
05/29/2020
···1111RN ,·1129.0550·· HOFFMAN, SHELL YANN NY:Pres1>yteria11 Weill
• Visit: 000414138 983 Gender: Female • Cornell
•.. Age: ..38y • Location: GO?S-7244-A
INTAKE
CRYSTALLOID
Lactated Ringers ml ln:125 ml
OUTPUT
URINE
Indwelling Urinary Catheter ml Out:550 ml
****************************************************************************************************
2) l&O Flowsheet [Authored: 18-Sep-2014 21 :00]- for Visit: 000414138 983, Osei-Bobie,
Antoinette (Nurse), Complete, Entered, Signed in Full, General
INTAKE
CRYSTALLOID
Lactated Ringers ml ln:125 ml
****************************************************************************************************
;,<"! 5) Treatment Flowsheet [Authored: 18-Sep-2014 21:20]-for Visit: 000414138 983,
Osei-Bobie, Antoinette (Nurse); Tan, Susan R (Nurse), Complete, Revised, Signed in Full,
General
SAFETY
Ambu Bag/Mask Present : Yes
Call Device in place : Done
Siderails Up : up X 2
Monitor Alarms On : Done
ID band present and correct : Yes
Allergy band present and correct : Yes
CARES
Bath : Self
Oral Care : Self
Sequential Compression Sleeves : On
Flequested by (3r9ce, fv1ighc1elJfv1ed Flcds), 2];C)ct;2Q15Q9 45 page 17gf26
681
FILED: NEW YORK COUNTY CLERK 06/02/2021
05/29/2020 12:33
04:59 PM INDEX NO. 805302/2015
NYSCEF DOC. NO. 147
112 RECEIVED NYSCEF: 06/02/2021
05/29/2020
···1111RN ,·1129.0550·· HOFFMAN, SHELL YANN NY:Pres1>yteria11 Weill
• Visit: 000414138 983 Gender: Female • Cornell
•.. Age: ..38y • Location: GO?S-7244-A
Feeds: Self
ACTIVITY/POSITIONING
Activity : Bed rest with bathroom privileges
Positioning : Able to self-position
PIV's
PIV Insertion Date: 09/18/14
PIV Insertion Date: 09/18/14
Site:left hand/20g
Row Comment: 9-14-14
PIV Insertion Date: 09/18/14
Site:right forearm/22 gauge
Row Comment: 9/12/14
Type : IV cath
Size : 20 gauge
Site : Antecubital R
Site : Antecubital R
Site: right AC/G-20
Row Comment: 9-18-14
IV Action : IV start
Infiltration Scale: Grade O
Phlebitis Scale : Grade 0: no symptoms
Patient's tolerance : Patient tolerated well.
Patient teaching : Instructed patient/family to report any swelling, redness, leakage, pain or
discomfort on or above the IV site.
PIV Insertion Date: 9-18-14
Type : Saline Lock
Size : 20 gauge
Site : Antecubital R
Site: right AC/G-20
Row Comment: 9-18-14
IV Action : IV start
Infiltration Scale: Grade O
Phlebitis Scale : Grade O
Patient's tolerance : Patient tolerated well.
Patient teaching : Instructed patient/family to report any swelling, redness, leakage, pain or
discomfort on or above the IV site.
Number of attempts : Able to insert on first attempt
****************************************************************************************************
OB PACU Flowsheet [Authored: 18-Sep-2014 21 :20]- for Visit: 000414138 983, Osei-Bobie,
Antoinette (Nurse), Complete, Entered, Signed in Full, General
MATERNAL ASSESSMENT
Sequential Compression Sleeves : On
682
FILED: NEW YORK COUNTY CLERK 06/02/2021
05/29/2020 12:33
04:59 PM INDEX NO. 805302/2015
NYSCEF DOC. NO. 147
112 RECEIVED NYSCEF: 06/02/2021
05/29/2020
···1111RN ,·1129.0550·· HOFFMAN, SHELL YANN NY:Pres1>yteria11 Weill
• Visit: 000414138 983 Gender: Female • Cornell
•.. Age: ..38y • Location: GO?S-7244-A
****************************************************************************************************
t::! 6) OB Shift Assessment [Authored: 18-Sep-2014 21 :20]- for Visit: 000414138 983,
Osei-Bobie, Antoinette (Nurse), Complete, Revised, Signed in Full, General
OB Fall Risk (Complete all items)
Meds: Taking 1 or more sedatives : No
Impaired mobility; unsteady gait : No
Orthostatic Changes relative to excessive blood loss : No
Use of Medications that alter equilibrium (Le magnesium sulfate) : No
Total Assessment (if one or more of the above risk factors are identified, the obstetric patient is at
high risk for falls) : Nursing to implement appropriate safety measures.
Fall Prevention Safety Measures
Fall Prevention Safety Measures : Provided the approved patient education resource on safety.
Reviewed with patient/family their shared responsibility in fall prevention: Orientation to
immediate surroundings Use of call bell and importance of calling for assistance Call bell,
telephone, and night stand within reach Use of non-skid socks/shoes Keep floor dry and free of
barriers Keep bed in lowest position possible with wheels locked Keep 2 upper side rails in
raised position Reviewed Medications and potential side effects Use of room lighting; use
nightlight on bed Use of equipment (e.g., IV pole, pump) and cords in safe positions
Patient Education--Nursing
Learner Learner : Patient
Barriers Barriers To Learning : No Barriers/Ready to learn
Topics Discussed: Patient Safety . Admission Education : *Orientation to Hospital Setting. *Use
of Patient ID Band. *Reinforce Use of Patient I Visitor Guide. *How to Communicate Concerns
About Patient Safety Issues. *Reporting Concerns about a Change in Condition I RRT. *Hand
and Respiratory Hygiene. *How to notify staff (call bell, verbal cues, speaking up). *Preventing
Falls and Injuries. *Immunization Review
Topics Discussed: Patient Safety Falls Prevention : Orientation to immediate surroundings. Use
of call bell and importance of calling for assistance. Use of non-skid footwear. Use of siderails.
Keep floor clean and dry, and free of barriers. Keep bed/stretcher in lowest postion. Safe room
lighting. Safe use of equipment (IV pole, rolling furniture etc.). Medications and potential side
effects
Topics Discussed: Patient Safety Isolation : Standard precautions
Topics Discussed: Patient Safety Infection control : Hand hygiene
Topics Discussed: Disease Process OB Ante/lntra/Postpartum/Perioperative and Newborn :
Cesarean section. Coughing & deep breathing. Rpt Mom S/S:bleeding, fever, unusual discharge
pain, depress. Temperature taking. Wound care for cesarean section patients
Topics Discussed: Medications Medications : Analgesics
Topics Discussed: Medications Administration Methods : Method of administration (specify
below)
Topics Discussed: Medications Medication Safety: Adherence. Purpose
Topics Discussed: Medications Self Administration of Medicine: Medication name, type and
reason for use. How to admin meds including process, Time, Freq., RTE & Dose. Anticipated
actions & potential side effects of med ad min. Monitoring the effects of the medication
Topics Discussed: Pain Management Pain Management: Managing pain at home.
Flequested by (3r9ce, fv1ighc1elJfv1ed Flcds), 2];C)ct;2Q15Q9 45 page 19pf26
683
FILED: NEW YORK COUNTY CLERK 06/02/2021
05/29/2020 12:33
04:59 PM INDEX NO. 805302/2015
NYSCEF DOC. NO. 147
112 RECEIVED NYSCEF: 06/02/2021
05/29/2020
···1111RN ,·1129.0550·· HOFFMAN, SHELL YANN NY:Pres1>yteria11 Weill
• Visit: 000414138 983 Gender: Female • Cornell
•.. Age: ..38y • Location: GO?S-7244-A
Non-pharmogologic pain relief interventions. Opioid use and low risk of addiction. Pain -
type.onset, location,duration,radiation,quality. Pain Med-type, purpose.side effects, report
S&S,interactions. Reporting pain to providers. Reporting relief acceptability. Right of the patient
to receive good pain management Use of the pain scale
Topics Discussed: Nutrition Diet Instructions : Keep well hydrated
Topics Discussed: Treatment/Dev/Equip/Procedures Procedures: CAT Scan. IV Therapy.
Sequential compression sleeves
Topics Discussed: Treatment/Dev/Equip/Procedures Post operative I Procedure care : Incision I
Operative site care, Dressing care, Dressing change, Expected discharge or bleeding amount to
Operative I Procedure site, Indwelling Urinary Catheter I Drain care
Topics Discussed: Treatment/Dev/Equip/Procedures Device/Equipment Use: Indwelling urinary
catheter. Pulse Oximetry. Vital Sign Monitoring
. Non-Behavioral Health : ADL/self care techniques
Methods/Resource Used : Demonstration. Verbal Discussion
Evaluation : Able to repeat I verbalize key points (Teach back)
Neuro/Muscoloskeletal
LOC/Responsiveness : Alert and Oriented x3
Respiratory
Rhythm & Character : Resp rhythm regular
Cough : No cough noted
Cardiovascular
Skin Vitals : Skin warm
Gastrointestinal
Bowel Sounds : Bowel sounds normal
Abdomen : non-distended, non-tender, soft
Bowel Movement : No stool
Urine
Indication for indwelling urinary catheter? : Indication Confirmed., Catheter and tubing free of
kinking, Collection bag maintained below the bladder, Sterility of system maintained
Urine : Clear urine, Yellow colored urine
BRAD SCAL *Braden Scale (Copyright)
Sensory Perception : 4 No impairment: Responds to verbal commands. Has no sensory deficit,
which would limit ability to feel or voice pain or discomfort.
Row Comment : Ability to respond meaningfully to pressure-related discomfort
Moisture : 4 Rarely moist: Skin is usually dry; linen requires changing only at routine intervals.
Row Comment : Degree to which skin is exposed to moisture
Activity : 2 Chairfast: Ability to walk severely limited or nonexistent Cannot bear own weight
and/or must be assisted into chair or wheelchair.
Row Comment : Degree of physical activity
Mobility : 3 Slightly limited: Make frequent though slight changes in body or extremity position
independently.
Row Comment : Ability to change and control body position
Flequested by (3r9ce, fv1ighc1elJfv1ed Flcds), 2];C)c1;2Q15Q9 45 page 2Qgj26
684
FILED: NEW YORK COUNTY CLERK 06/02/2021
05/29/2020 12:33
04:59 PM INDEX NO. 805302/2015
NYSCEF DOC. NO. 147
112 RECEIVED NYSCEF: 06/02/2021
05/29/2020
···1111RN ,·1129.0550·· HOFFMAN, SHELL YANN NY:Pres1>yteria11 Weill
• Visit: 000414138 983 Gender: Female • Cornell
•.. Age: ..38y • Location: GO?S-7244-A
Nutrition : 3 Adequate: Eats over half of most meals. Eats a total of 4 servings of protein
(meat.dairy products) each day. Occasionally will refuse a meal, but will usually take a
supplement if offered, O
Preview
FILED: NEW YORK COUNTY CLERK 06/02/2021 12:33 PM INDEX NO. 805302/2015 NYSCEF DOC. NO. 147 RECEIVED NYSCEF: 06/02/2021 Exhibit B4 FILED: NEW YORK COUNTY CLERK 06/02/2021 05/29/2020 12:33 04:59 PM INDEX NO. 805302/2015 NYSCEF DOC. NO. 147 112 RECEIVED NYSCEF: 06/02/2021 05/29/2020 ···1111RN ,·1129.0550·· HOFFMAN, SHELL YANN NY:Pres1>yteria11 Weill • Visit: 000414138 983 Gender: Female • Cornell •.. Age: ..38y • Location: GO?S-7244-A SEDATION SCALE Sedation Scale - m-POSS : 0 =Awake/No Sedation PAIN ASSESSMENT Pain Assessment Patient Self-Report: Numeric 0-10 scale Pain Assessment Pain Scale : 2 Pain Assessment Location of pain : abdominal incision Pain Assessment Description of pain : Dull Pain Assessment Effect on physical activity : No effect Row Comment : If new or uncontrolled pain, complete the Comprehensive Pain Assessment COMPREHENSIVE PAIN ASSESSMENT Comprehensive Pain Assessment Onset of Pain : Gradual Comprehensive Pain Assessment Duration of Pain : Intermittent Comprehensive Pain Assessment Pattern: The patient describes the pain as happening in the: The patient reports there is no pattern Comprehensive Pain Assessment Cause/Triggers: The patient reports that the pain increases with : Not applicable Comprehensive Pain Assessment Relief Measures: The patient reports that there is relief/decrease in pain with : The patient reports that nothing relieves the pain Comprehensive Pain Assessment Function: Due to pain, the patient reports change in : Not applicable PAIN INTERVENTIONS Pain Interventions Pharmacologic : Oxycodone Pain Interventions Non-Pharmacologic: Decreased environmental stimulation (decrease light, noise), Positioned, provided boundaries and decreased handling., Relaxation, distraction, music, television. Pain Interventions PatienVFamily Education : Complete Shift Assessment or Pt ED-Nursing Flowsheet **************************************************************************************************** 6) OB Shift Assessment [Authored: 18-Sep-2014 15:00]- for Visit: 000414138 983, Severino Wynn, Danika (Per Diem Rn), Complete, Entered, Signed in Full, General Skin -Skin Impair. Site & Loe.: Use Modify Row Label Skin Color : Skin color is normal. Skin Integrity : Skin intact, no breakdown Skin Impairment Surgical Incision : Appearance clean, Wound healing Assessment Breasts : Breasts are soft, Breasts are non-tender Perineum : Intact 670 FILED: NEW YORK COUNTY CLERK 06/02/2021 05/29/2020 12:33 04:59 PM INDEX NO. 805302/2015 NYSCEF DOC. NO. 147 112 RECEIVED NYSCEF: 06/02/2021 05/29/2020 ···1111RN ,·1129.0550·· HOFFMAN,SHELLYANN NY-Presbyterian Weill • Visit: 000414138 983 Gender: Female • Cornell •__ Age: __38y( Location: GO?S-7244-A Lochia : NIA Homan's Sign : Absent Sequential Compression Sleeves : Off **************************************************************************************************** OB PACU Flowsheet [Authored: 18-Sep-2014 15:00]- for Visit: 000414138 983, Severino Wynn, Danika (Per Diem Rn), Complete, Entered, Signed in Full, General MATERNAL ASSESSMENT Sequential Compression Sleeves : Off **************************************************************************************************** 5) Treatment Flowsheet [Authored: 18-Sep-2014 15:00]- for Visit: 000414138 983, Severino Wynn, Danika (Per Diem Rn), Complete, Entered, Signed in Full, General CARES Sequential Compression Sleeves : Off **************************************************************************************************** OB Recovery Room Flowsheet (Vag. Del.) [Authored: 18-Sep-2014 15:00]- for Visit: 000414138 983, Severino Wynn, Danika (Per Diem Rn), Complete, Entered, Signed in Full, General MATERNAL ASSESSMENT Sequential Compression Sleeves : Off **************************************************************************************************** 1) Vitalsign Flowsheet [Authored: 18-Sep-2014 15:19]- for Visit: 000414138 983, Severino Wynn, Danika (Per Diem Rn), Complete, Entered, Signed in Full, General WEIGHT Current Weight (kg) Current Weight (kg) kg : 88.45 kg Height (cm) cm : 165.1 cm BMl_(MetricCalculation)_kg/m2_:_32.4_kg/m2 __ _ Flequested by (3r9ce, fv1ighc1elJfv1ed Flcds), 2];C)c1;2Q15Q9 45 page 7Df26 671 FILED: NEW YORK COUNTY CLERK 06/02/2021 05/29/2020 12:33 04:59 PM INDEX NO. 805302/2015 NYSCEF DOC. NO. 147 112 RECEIVED NYSCEF: 06/02/2021 05/29/2020 ···1111RN ,·1129.0550·· HOFFMAN,SHELLYANN NY-Presbyterian Weill • Visit: 000414138 983 Gender: Female • Cornell •.. Age: ..38y Location: GO?S-7244-A **************************************************************************************************** Vital Signs (ICU) - Physicians Only [Authored: 18-Sep-2014 15:19]- for Visit: 000414138 983, Severino Wynn, Danika (Per Diem Rn), Complete, Entered, Signed in Full, General WEIGHT Current Weight (kg) kg : 88.45 kg Height (cm) cm : 165.1 cm **************************************************************************************************** 1) Vital Signs Flowsheet (OB) [Authored: 18-Sep-2014 15:19]- for Visit: 000414138 983, Severino Wynn, Danika (Per Diem Rn), Complete, Entered, Signed in Full, General WEIGHT Current Weight (kg) kg : 88.45 kg Height (cm) cm : 165.1 cm BMI (Metric Calculation) kg/m2: 32.4 kg/m2 **************************************************************************************************** Vital Signs - Physicians Only [Authored: 18-Sep-2014 15:19]- for Visit: 000414138 983, Severino Wynn, Danika (Per Diem Rn), Complete, Entered, Signed in Full, General WEIGHT Current Weight (kg) kg : 88.45 kg **************************************************************************************************** 1) Vital Signs Flowsheet (OB) [Authored: 18-Sep-2014 15:30]- for Visit: 000414138 983, Severino Wynn, Danika (Per Diem Rn), Complete, Entered, Signed in Full, General PAIN REASSESSMENT/PT RESPONSE WITHIN ONE HOUR Pain Re-Assessment/Patient Response within 1 Hour Side Effect of Interventions : None Pain Re-Assessment/Patient Response within 1 Hour Pain Rating Scale : Numeric 0-10 scale Pain Re-Assessment/Patient Response within 1 Hour Patient Response : Yes, no further actions needed Flequested by (3r9ce, fv1ighc1elJfv1ed Flcds), 2];C)c1;2Q15Q9 45 page 8pf26 672 FILED: NEW YORK COUNTY CLERK 06/02/2021 05/29/2020 12:33 04:59 PM INDEX NO. 805302/2015 NYSCEF DOC. NO. 147 112 RECEIVED NYSCEF: 06/02/2021 05/29/2020 ···1111RN ,·1129.0550·· HOFFMAN, SHELL YANN NY:Pres1>yteria11 Weill • Visit: 000414138 983 Gender: Female • Cornell •.. Age: ..38y • Location: GO?S-7244-A Pain Re-Assessment/Patient Response within 1 Hour Pain Scale : 0 **************************************************************************************************** ., /j 1) Vitalsign Flowsheet [Authored: 18-Sep-2014 18:00]- for Visit: 000414138 983, Liboro, Roy A (Nurse), Complete, Revised, Signed in Full, General PATIENT LOCATION Location : F 10 PACU WEIGHT Current Weight (kg) Current Weight (kg) kg : 88 kg Height (cm) cm : 165 cm BMI (Metric Calculation) kg/m2: 32.3 kg/m2 BMI percentile BMI % : N/A TEMPERATURE Temperature Temperature (C) degrees C : 37 degrees C Temperature Temperature Source: Temporal HEART RATE Heart Rate : 95 RESP Respiratory Rate, Patient (bpm) Respiratory Rate, Patient (bpm): 16 Oxygen Flow Oxygen Flow (Lpm) : 0 Sp02 (Pulse Ox) Sp02 (Pulse Ox) (%) : 96 NONINVASIVE BLOOD PRESSURE Noninvasive BP NIBP Systolic: 168 Noninvasive BP NIBP Diastolic : 97 Noninvasive BP NIBP Mean: 120 mm Hg PAIN ASSESSMENT Pain Assessment Patient Self-Report: Numeric 0-10 scale Pain Assessment Pain Scale : 0 ACTIVITY/POSITIONING Activity : Bed rest Positioning : HOB 30 degrees MISCELLANEOUS 673 FILED: NEW YORK COUNTY CLERK 06/02/2021 05/29/2020 12:33 04:59 PM INDEX NO. 805302/2015 NYSCEF DOC. NO. 147 112 RECEIVED NYSCEF: 06/02/2021 05/29/2020 ···1111RN ,·1129.0550·· HOFFMAN,SHELLYANN NY-Presbyterian Weill • Visit: 000414138 983 Gender: Female • Cornell •.. Age: ..38y Location: GO?S-7244-A PACU IV site check : Site WNL Level of Consciousness : LOC3 **************************************************************************************************** p:') 5) Treatment Flowsheet [Authored: 18-Sep-2014 18:00]- for Visit: 000414138 983, Liboro, Roy A (Nurse), Complete, Revised, Signed in Full, General SAFETY Ambu Bag/Mask Present : Yes Call Device in place : Done Siderails Up : up X 2 Monitor Alarms On : Done ID band present and correct : Yes Allergy band present and correct : No Allergies ACTIVITY/POSITIONING Activity : Bed rest Positioning : HOB 30 degrees **************************************************************************************************** 1) Vital Signs Flowsheet (OB) [Authored: 18-Sep-2014 18:00]- for Visit: 000414138 983, Liboro, Roy A (Nurse), Complete, Entered, Signed in Full, General ACTIVITY/POSITIONING Activity : Bed rest Positioning : HOB 30 degrees **************************************************************************************************** 2) l&O Flowsheet [Authored: 18-Sep-2014 18:00]- for Visit: 000414138 983, Liboro, Roy A (Nurse), Complete, Entered, Signed in Full, General INTAKE CRYSTALLOID Lactated Ringers ml ln:1000 ml Comment: given in the OR 674 FILED: NEW YORK COUNTY CLERK 06/02/2021 05/29/2020 12:33 04:59 PM INDEX NO. 805302/2015 NYSCEF DOC. NO. 147 112 RECEIVED NYSCEF: 06/02/2021 05/29/2020 ···1111RN ,·1129.0550·· HOFFMAN, SHELL YANN NY:Pres1>yteria11 Weill • Visit: 000414138 983 Gender: Female • Cornell •.. Age: ..38y • Location: GO?S-7244-A **************************************************************************************************** 7) Patient Education [Authored: 18-Sep-2014 18:00]- for Visit: 000414138 983, Liboro, Roy A (Nurse), Complete, Entered, Signed in Full, General Patient Education - Nursing Learner Learner : Patient Barriers Barriers To Learning : No Barriers/Ready to learn Topics Discussed: Patient Safety . Admission Education : *Orientation to Hospital Setting. *Use of Patient ID Band. Surgical procedure. Anesthetic Topics Discussed: Patient Safety Falls Prevention : Orientation to immediate surroundings. Use of call bell and importance of calling for assistance. Safe use of equipment (IV pole, rolling furniture etc.). Medications and potential side effects **************************************************************************************************** 6) OB Shift Assessment [Authored: 18-Sep-2014 18:00]- for Visit: 000414138 983, Liboro, Roy A (Nurse), Complete, Entered, Signed in Full, General Patient Education--Nursing Learner Learner : Patient Barriers Barriers To Learning : No Barriers/Ready to learn Topics Discussed: Patient Safety . Admission Education : *Orientation to Hospital Setting. *Use of Patient ID Band. Surgical procedure. Anesthetic Topics Discussed: Patient Safety Falls Prevention : Orientation to immediate surroundings. Use of call bell and importance of calling for assistance. Safe use of equipment (IV pole, rolling furniture etc.). Medications and potential side effects **************************************************************************************************** Interdisciplinary Plan of Care [Authored: 18-Sep-2014 18:00]- for Visit: 000414138 983, Liboro, Roy A (Nurse), Complete, Entered, Signed in Full, General Nursing Plan of Care Plan Of Care : Recovery for Anesthesia Diagnosis/Problem(s) :Recovery from Anesthesia : Altered Respiratory Pattern related to Anesthesia, 2nd sedation Plan Of Care : Recovery for Anesthesia Measurable Goal : Established optimal respiratory status Return to pre-anesthesia state Plan Of Care : Recovery for Anesthesia Goal Met: In Progress Plan of Care : Surgery Diagnosis/Problem(s) : Surgery : Alteration in comfort related to Surgery Plan of Care : Surgery Measurable Goal : Manage, diminish and control pain Control nausea Plan of Care : Surgery Goal Met: In Progress Flequested by (3r9ce, fv1ighc1elJfv1ed Flcds), 2];C)c1;2Q15Q9 45 page 11 gf26 675 FILED: NEW YORK COUNTY CLERK 06/02/2021 05/29/2020 12:33 04:59 PM INDEX NO. 805302/2015 NYSCEF DOC. NO. 147 112 RECEIVED NYSCEF: 06/02/2021 05/29/2020 ···1111RN ,·1129.0550·· HOFFMAN,SHELLYANN NY-Presbyterian Weill • Visit: 000414138 983 Gender: Female • Cornell •.. Age: ..38y Location: GO?S-7244-A Plan of Care : Consciousness Diagnosis/Problem(s) : Consciousness : Alteration in Consciousness Plan of Care : Consciousness Measurable Goal : Return to pre-op level of consciousness Plan of Care : Consciousness Goal Met: In Progress **************************************************************************************************** ;,<"! 1) Vitalsign Flowsheet [Authored: 18-Sep-2014 18:15]- for Visit: 000414138 983, Liboro, Roy A (Nurse), Complete, Revised, Signed in Full, General HEART RATE Heart Rate : 90 RESP Respiratory Rate, Patient (bpm) Respiratory Rate, Patient (bpm): 15 Oxygen Flow Oxygen Flow (Lpm) : 0 Sp02 (Pulse Ox) Sp02 (Pulse Ox) (%) : 97 NONINVASIVE BLOOD PRESSURE Noninvasive BP NIBP Systolic: 171 Noninvasive BP NIBP Diastolic : 93 PAIN ASSESSMENT Pain Assessment Patient Self-Report: Numeric 0-10 scale Pain Assessment Pain Scale : 0 ACTIVITY/POSITIONING Activity : Bed rest Positioning : HOB 30 degrees **************************************************************************************************** 5) Treatment Flowsheet [Authored: 18-Sep-2014 18:15]- for Visit: 000414138 983, Liboro, Roy A (Nurse), Complete, Entered, Signed in Full, General ACTIVITY/POSITIONING Activity : Bed rest Positioning : HOB 30 degrees **************************************************************************************************** 676 FILED: NEW YORK COUNTY CLERK 06/02/2021 05/29/2020 12:33 04:59 PM INDEX NO. 805302/2015 NYSCEF DOC. NO. 147 112 RECEIVED NYSCEF: 06/02/2021 05/29/2020 ···1111RN ,·1129.0550·· HOFFMAN, SHELL YANN NY:Pres1>yteria11 Weill • Visit: 000414138 983 Gender: Female • Cornell •.. Age: ..38y • Location: GO?S-7244-A 1) Vital Signs Flowsheet (OB) [Authored: 18-Sep-2014 18:15]- for Visit: 000414138 983, Liboro, Roy A (Nurse), Complete, Entered, Signed in Full, General ACTIVITY/POSITIONING Activity : Bed rest Positioning : HOB 30 degrees **************************************************************************************************** 1) Vitalsign Flowsheet [Authored: 18-Sep-2014 18:30]- for Visit: 000414138 983, Liboro, Roy A (Nurse), Complete, Entered, Signed in Full, General HEART RATE Heart Rate : 94 RESP Respiratory Rate, Patient (bpm) Respiratory Rate, Patient (bpm): 18 Oxygen Flow Oxygen Flow (Lpm) : 0 Sp02 (Pulse Ox) Sp02 (Pulse Ox) (%) : 97 NONINVASIVE BLOOD PRESSURE Noninvasive BP NIBP Systolic: 163 Noninvasive BP NIBP Diastolic : 95 Noninvasive BP NIBP Mean: 117 mm Hg PAIN ASSESSMENT Pain Assessment Patient Self-Report: Numeric 0-10 scale Pain Assessment Pain Scale : 0 ACTIVITY/POSITIONING Activity : Bed rest Positioning : HOB 30 degrees **************************************************************************************************** 5) Treatment Flowsheet [Authored: 18-Sep-2014 18:30]- for Visit: 000414138 983, Liboro, Roy A (Nurse), Complete, Entered, Signed in Full, General ACTIVITY/POSITIONING 677 FILED: NEW YORK COUNTY CLERK 06/02/2021 05/29/2020 12:33 04:59 PM INDEX NO. 805302/2015 NYSCEF DOC. NO. 147 112 RECEIVED NYSCEF: 06/02/2021 05/29/2020 ···1111RN ,·1129.0550·· HOFFMAN, SHELL YANN NY:Pres1>yteria11 Weill • Visit: 000414138 983 Gender: Female • Cornell •.. Age: ..38y • Location: GO?S-7244-A Activity : Bed rest Positioning : HOB 30 degrees **************************************************************************************************** p:') 1) Vital Signs Flowsheet (OB) [Authored: 18-Sep-2014 18:30]- for Visit: 000414138 983, Liboro, Roy A (Nurse); Hipp, Susana (Nurses Aide), Complete, Revised, Signed in Full, General TEMPERATURE Temperature Temperature (C) degrees C : 36.8 degrees C Temperature Temperature Source : Oral HEART RATE Heart Rate : 93 RESP Respiratory Rate, Patient (bpm) Respiratory Rate, Patient (bpm): 18 Sp02 (Pulse Ox) Sp02 (Pulse Ox) (%) : 97 NONINVASIVE BLOOD PRESSURE Noninvasive BP NIBP Systolic: 113 Noninvasive BP NIBP Diastolic : 84 Noninvasive BP NIBP Mean : 93 mm Hg ACTIVITY/POSITIONING Activity : Bed rest Positioning : HOB 30 degrees **************************************************************************************************** ,, /j 2) l&O Flowsheet - (Shift) [Authored: 18-Sep-2014 19:00]- for Visit: 000414138 983, Severino Wynn, Danika (Per Diem Rn); Liboro, Roy A (Nurse); Mohammed, Rachel (Nurse), Complete, Revised, Signed in Full, General INTAKE CRYSTALLOID Lactated Ringers ml ln:1125 ml OUTPUT 678 FILED: NEW YORK COUNTY CLERK 06/02/2021 05/29/2020 12:33 04:59 PM INDEX NO. 805302/2015 NYSCEF DOC. NO. 147 112 RECEIVED NYSCEF: 06/02/2021 05/29/2020 ···1111RN ,·1129.0550·· HOFFMAN, SHELL YANN NY:Pres1>yteria11 Weill • Visit: 000414138 983 Gender: Female • Cornell •.. Age: ..38y • Location: GO?S-7244-A URINE Indwelling Urinary Catheter ml Out:1525 ml **************************************************************************************************** ,,J 2) l&O Flowsheet[Authored: 18-Sep-2014 19:00]- for Visit: 000414138 983, Liboro, Roy A (Nurse); Mohammed, Rachel (Nurse), Complete, Revised, Signed in Full, General INTAKE CRYSTALLOID Lactated Ringers ml ln:125 ml OUTPUT URINE Indwelling Urinary Catheter ml Out:400 ml **************************************************************************************************** 7) Patient Education [Authored: 18-Sep-2014 19:00]- for Visit: 000414138 983, Mohammed, Rachel (Nurse), Complete, Entered, Signed in Full, General Patient Education - Nursing Learner Learner : Patient Barriers Barriers To Learning : No Barriers/Ready to learn Topics Discussed: Patient Safety . Admission Education : *Orientation to Hospital Setting. *Use of Patient ID Band. *Reinforce Use of Patient I Visitor Guide. *How to Communicate Concerns About Patient Safety Issues. *Reporting Concerns about a Change in Condition I RRT. *Hand and Respiratory Hygiene. *How to notify staff (call bell, verbal cues, speaking up). Preventing Surgical Site Infections. Wound/Skin Care Topics Discussed: Patient Safety Falls Prevention : Orientation to immediate surroundings. Use of call bell and importance of calling for assistance. Use of non-skid footwear. Use of siderails. Keep floor clean and dry, and free of barriers. Keep bed/stretcher in lowest postion. Safe room lighting. Safe use of equipment (IV pole, rolling furniture etc.). Medications and potential side effects Topics Discussed: Disease Process OB Ante/lntra/Postpartum/Perioperative and Newborn : Breast & nipple care. Perinea I hygiene (mother). Sequential Compression Sleeves Topics Discussed: Medications Medications : Analgesics. Cardiovascular Topics Discussed: Medications Administration Methods : Method of administration (specify Flequested by (3r9ce, fv1ighc1elJfv1ed Flcds), 2];C)c1;2Q15Q9 45 page 15pf26 679 FILED: NEW YORK COUNTY CLERK 06/02/2021 05/29/2020 12:33 04:59 PM INDEX NO. 805302/2015 NYSCEF DOC. NO. 147 112 RECEIVED NYSCEF: 06/02/2021 05/29/2020 ···1111RN ,·1129.0550·· HOFFMAN, SHELL YANN NY:Pres1>yteria11 Weill • Visit: 000414138 983 Gender: Female • Cornell •.. Age: ..38y • Location: GO?S-7244-A below). po Topics Discussed: Medications Medication Safety: Allergies. Purpose. Side effects. Signs and symptoms to report Topics Discussed: Pain Management Pain Management: Opioid use and low risk of addiction. Pain -type,onset,location,duration,radiation,quality. Pain Med-type, purpose.side effects.report S&S,interactions. Reporting pain to providers. Reporting relief acceptability. Right of the patient to receive good pain management Use of the pain scale Topics Discussed: Nutrition Diet Instructions : regular diet Methods/Resource Used : Demonstration. Verbal Discussion Evaluation : Able to repeat I verbalize key points (Teach back) **************************************************************************************************** 6) OB Shift Assessment [Authored: 18-Sep-2014 19:00]- for Visit: 000414138 983, Mohammed, Rachel (Nurse), Complete, Entered, Signed in Full, General Patient Education--Nursing Learner Learner : Patient Barriers Barriers To Learning : No Barriers/Ready to learn Topics Discussed: Patient Safety . Admission Education : *Orientation to Hospital Setting. *Use of Patient ID Band. *Reinforce Use of Patient I Visitor Guide. *How to Communicate Concerns About Patient Safety Issues. *Reporting Concerns about a Change in Condition I RRT. *Hand and Respiratory Hygiene. *How to notify staff (call bell, verbal cues, speaking up). Preventing Surgical Site Infections. Wound/Skin Care Topics Discussed: Patient Safety Falls Prevention : Orientation to immediate surroundings. Use of call bell and importance of calling for assistance. Use of non-skid footwear. Use of siderails. Keep floor clean and dry, and free of barriers. Keep bed/stretcher in lowest postion. Safe room lighting. Safe use of equipment (IV pole, rolling furniture etc.). Medications and potential side effects Topics Discussed: Disease Process OB Ante/lntra/Postpartum/Perioperative and Newborn : Breast & nipple care. Perinea I hygiene (mother). Sequential Compression Sleeves Topics Discussed: Medications Medications : Analgesics. Cardiovascular Topics Discussed: Medications Administration Methods : Method of administration (specify below). po Topics Discussed: Medications Medication Safety: Allergies. Purpose. Side effects. Signs and symptoms to report Topics Discussed: Pain Management Pain Management: Opioid use and low risk of addiction. Pain -type,onset,location,duration,radiation,quality. Pain Med-type, purpose.side effects.report S&S,interactions. Reporting pain to providers. Reporting relief acceptability. Right of the patient to receive good pain management Use of the pain scale Topics Discussed: Nutrition Diet Instructions : regular diet Methods/Resource Used : Demonstration. Verbal Discussion Evaluation : Able to repeat I verbalize key points (Teach back) **************************************************************************************************** 1::] 2) l&O Flowsheet [Authored: 18-Sep-2014 20:00]- for Visit: 000414138 983, Osei-Bobie, Antoinette (Nurse), Complete, Revised, Signed in Full, General Flequested by (3r9ce, fv1ighc1elJfv1ed Flcds), 2];C)ct;2Q15Q9 45 page 16pf26 680 FILED: NEW YORK COUNTY CLERK 06/02/2021 05/29/2020 12:33 04:59 PM INDEX NO. 805302/2015 NYSCEF DOC. NO. 147 112 RECEIVED NYSCEF: 06/02/2021 05/29/2020 ···1111RN ,·1129.0550·· HOFFMAN, SHELL YANN NY:Pres1>yteria11 Weill • Visit: 000414138 983 Gender: Female • Cornell •.. Age: ..38y • Location: GO?S-7244-A INTAKE CRYSTALLOID Lactated Ringers ml ln:125 ml OUTPUT URINE Indwelling Urinary Catheter ml Out:550 ml **************************************************************************************************** 2) l&O Flowsheet [Authored: 18-Sep-2014 21 :00]- for Visit: 000414138 983, Osei-Bobie, Antoinette (Nurse), Complete, Entered, Signed in Full, General INTAKE CRYSTALLOID Lactated Ringers ml ln:125 ml **************************************************************************************************** ;,<"! 5) Treatment Flowsheet [Authored: 18-Sep-2014 21:20]-for Visit: 000414138 983, Osei-Bobie, Antoinette (Nurse); Tan, Susan R (Nurse), Complete, Revised, Signed in Full, General SAFETY Ambu Bag/Mask Present : Yes Call Device in place : Done Siderails Up : up X 2 Monitor Alarms On : Done ID band present and correct : Yes Allergy band present and correct : Yes CARES Bath : Self Oral Care : Self Sequential Compression Sleeves : On Flequested by (3r9ce, fv1ighc1elJfv1ed Flcds), 2];C)ct;2Q15Q9 45 page 17gf26 681 FILED: NEW YORK COUNTY CLERK 06/02/2021 05/29/2020 12:33 04:59 PM INDEX NO. 805302/2015 NYSCEF DOC. NO. 147 112 RECEIVED NYSCEF: 06/02/2021 05/29/2020 ···1111RN ,·1129.0550·· HOFFMAN, SHELL YANN NY:Pres1>yteria11 Weill • Visit: 000414138 983 Gender: Female • Cornell •.. Age: ..38y • Location: GO?S-7244-A Feeds: Self ACTIVITY/POSITIONING Activity : Bed rest with bathroom privileges Positioning : Able to self-position PIV's PIV Insertion Date: 09/18/14 PIV Insertion Date: 09/18/14 Site:left hand/20g Row Comment: 9-14-14 PIV Insertion Date: 09/18/14 Site:right forearm/22 gauge Row Comment: 9/12/14 Type : IV cath Size : 20 gauge Site : Antecubital R Site : Antecubital R Site: right AC/G-20 Row Comment: 9-18-14 IV Action : IV start Infiltration Scale: Grade O Phlebitis Scale : Grade 0: no symptoms Patient's tolerance : Patient tolerated well. Patient teaching : Instructed patient/family to report any swelling, redness, leakage, pain or discomfort on or above the IV site. PIV Insertion Date: 9-18-14 Type : Saline Lock Size : 20 gauge Site : Antecubital R Site: right AC/G-20 Row Comment: 9-18-14 IV Action : IV start Infiltration Scale: Grade O Phlebitis Scale : Grade O Patient's tolerance : Patient tolerated well. Patient teaching : Instructed patient/family to report any swelling, redness, leakage, pain or discomfort on or above the IV site. Number of attempts : Able to insert on first attempt **************************************************************************************************** OB PACU Flowsheet [Authored: 18-Sep-2014 21 :20]- for Visit: 000414138 983, Osei-Bobie, Antoinette (Nurse), Complete, Entered, Signed in Full, General MATERNAL ASSESSMENT Sequential Compression Sleeves : On 682 FILED: NEW YORK COUNTY CLERK 06/02/2021 05/29/2020 12:33 04:59 PM INDEX NO. 805302/2015 NYSCEF DOC. NO. 147 112 RECEIVED NYSCEF: 06/02/2021 05/29/2020 ···1111RN ,·1129.0550·· HOFFMAN, SHELL YANN NY:Pres1>yteria11 Weill • Visit: 000414138 983 Gender: Female • Cornell •.. Age: ..38y • Location: GO?S-7244-A **************************************************************************************************** t::! 6) OB Shift Assessment [Authored: 18-Sep-2014 21 :20]- for Visit: 000414138 983, Osei-Bobie, Antoinette (Nurse), Complete, Revised, Signed in Full, General OB Fall Risk (Complete all items) Meds: Taking 1 or more sedatives : No Impaired mobility; unsteady gait : No Orthostatic Changes relative to excessive blood loss : No Use of Medications that alter equilibrium (Le magnesium sulfate) : No Total Assessment (if one or more of the above risk factors are identified, the obstetric patient is at high risk for falls) : Nursing to implement appropriate safety measures. Fall Prevention Safety Measures Fall Prevention Safety Measures : Provided the approved patient education resource on safety. Reviewed with patient/family their shared responsibility in fall prevention: Orientation to immediate surroundings Use of call bell and importance of calling for assistance Call bell, telephone, and night stand within reach Use of non-skid socks/shoes Keep floor dry and free of barriers Keep bed in lowest position possible with wheels locked Keep 2 upper side rails in raised position Reviewed Medications and potential side effects Use of room lighting; use nightlight on bed Use of equipment (e.g., IV pole, pump) and cords in safe positions Patient Education--Nursing Learner Learner : Patient Barriers Barriers To Learning : No Barriers/Ready to learn Topics Discussed: Patient Safety . Admission Education : *Orientation to Hospital Setting. *Use of Patient ID Band. *Reinforce Use of Patient I Visitor Guide. *How to Communicate Concerns About Patient Safety Issues. *Reporting Concerns about a Change in Condition I RRT. *Hand and Respiratory Hygiene. *How to notify staff (call bell, verbal cues, speaking up). *Preventing Falls and Injuries. *Immunization Review Topics Discussed: Patient Safety Falls Prevention : Orientation to immediate surroundings. Use of call bell and importance of calling for assistance. Use of non-skid footwear. Use of siderails. Keep floor clean and dry, and free of barriers. Keep bed/stretcher in lowest postion. Safe room lighting. Safe use of equipment (IV pole, rolling furniture etc.). Medications and potential side effects Topics Discussed: Patient Safety Isolation : Standard precautions Topics Discussed: Patient Safety Infection control : Hand hygiene Topics Discussed: Disease Process OB Ante/lntra/Postpartum/Perioperative and Newborn : Cesarean section. Coughing & deep breathing. Rpt Mom S/S:bleeding, fever, unusual discharge pain, depress. Temperature taking. Wound care for cesarean section patients Topics Discussed: Medications Medications : Analgesics Topics Discussed: Medications Administration Methods : Method of administration (specify below) Topics Discussed: Medications Medication Safety: Adherence. Purpose Topics Discussed: Medications Self Administration of Medicine: Medication name, type and reason for use. How to admin meds including process, Time, Freq., RTE & Dose. Anticipated actions & potential side effects of med ad min. Monitoring the effects of the medication Topics Discussed: Pain Management Pain Management: Managing pain at home. Flequested by (3r9ce, fv1ighc1elJfv1ed Flcds), 2];C)ct;2Q15Q9 45 page 19pf26 683 FILED: NEW YORK COUNTY CLERK 06/02/2021 05/29/2020 12:33 04:59 PM INDEX NO. 805302/2015 NYSCEF DOC. NO. 147 112 RECEIVED NYSCEF: 06/02/2021 05/29/2020 ···1111RN ,·1129.0550·· HOFFMAN, SHELL YANN NY:Pres1>yteria11 Weill • Visit: 000414138 983 Gender: Female • Cornell •.. Age: ..38y • Location: GO?S-7244-A Non-pharmogologic pain relief interventions. Opioid use and low risk of addiction. Pain - type.onset, location,duration,radiation,quality. Pain Med-type, purpose.side effects, report S&S,interactions. Reporting pain to providers. Reporting relief acceptability. Right of the patient to receive good pain management Use of the pain scale Topics Discussed: Nutrition Diet Instructions : Keep well hydrated Topics Discussed: Treatment/Dev/Equip/Procedures Procedures: CAT Scan. IV Therapy. Sequential compression sleeves Topics Discussed: Treatment/Dev/Equip/Procedures Post operative I Procedure care : Incision I Operative site care, Dressing care, Dressing change, Expected discharge or bleeding amount to Operative I Procedure site, Indwelling Urinary Catheter I Drain care Topics Discussed: Treatment/Dev/Equip/Procedures Device/Equipment Use: Indwelling urinary catheter. Pulse Oximetry. Vital Sign Monitoring . Non-Behavioral Health : ADL/self care techniques Methods/Resource Used : Demonstration. Verbal Discussion Evaluation : Able to repeat I verbalize key points (Teach back) Neuro/Muscoloskeletal LOC/Responsiveness : Alert and Oriented x3 Respiratory Rhythm & Character : Resp rhythm regular Cough : No cough noted Cardiovascular Skin Vitals : Skin warm Gastrointestinal Bowel Sounds : Bowel sounds normal Abdomen : non-distended, non-tender, soft Bowel Movement : No stool Urine Indication for indwelling urinary catheter? : Indication Confirmed., Catheter and tubing free of kinking, Collection bag maintained below the bladder, Sterility of system maintained Urine : Clear urine, Yellow colored urine BRAD SCAL *Braden Scale (Copyright) Sensory Perception : 4 No impairment: Responds to verbal commands. Has no sensory deficit, which would limit ability to feel or voice pain or discomfort. Row Comment : Ability to respond meaningfully to pressure-related discomfort Moisture : 4 Rarely moist: Skin is usually dry; linen requires changing only at routine intervals. Row Comment : Degree to which skin is exposed to moisture Activity : 2 Chairfast: Ability to walk severely limited or nonexistent Cannot bear own weight and/or must be assisted into chair or wheelchair. Row Comment : Degree of physical activity Mobility : 3 Slightly limited: Make frequent though slight changes in body or extremity position independently. Row Comment : Ability to change and control body position Flequested by (3r9ce, fv1ighc1elJfv1ed Flcds), 2];C)c1;2Q15Q9 45 page 2Qgj26 684 FILED: NEW YORK COUNTY CLERK 06/02/2021 05/29/2020 12:33 04:59 PM INDEX NO. 805302/2015 NYSCEF DOC. NO. 147 112 RECEIVED NYSCEF: 06/02/2021 05/29/2020 ···1111RN ,·1129.0550·· HOFFMAN, SHELL YANN NY:Pres1>yteria11 Weill • Visit: 000414138 983 Gender: Female • Cornell •.. Age: ..38y • Location: GO?S-7244-A Nutrition : 3 Adequate: Eats over half of most meals. Eats a total of 4 servings of protein (meat.dairy products) each day. Occasionally will refuse a meal, but will usually take a supplement if offered, O