Preview
FILED: BRONX COUNTY CLERK 02/24/2022 02:17 PM INDEX NO. 21169/2011E
NYSCEF DOC. NO. 283 RECEIVED NYSCEF: 02/24/2022
MONTEFIORE Moses Emergency Department Patient: PHILLlPS, Kelley
, •111 East 210th Street Triage Date: June 3, 2010
. Bronx, NY 10467 1978-
DOB: April 24, Sex: Female
Med Rec#: 03088163 Age: 32 yr
Account#: 211470760
Nursing Notes - Triage
Pre-Hospital Care Initial VS
IV: Site:
MEDS: Time:
Triage Time:
Oxygen @ T:
Trlage Levels Backboard: C-Collar:
O 1 T Dmss;ñg/Splints: P:
O 2 O FUFT
O 3 O POS Fall Screen Needed O Yes o R:
4 . Special ConsiderationslBarrier/ o Learning:
5 O Commun:caticas: O Language O Hearing O Speech BP:
Protece!e O.Interpreter D Deaf Talk
O CEUs O Abuse/Neglect/Exploitation Screen: O Pos ç bleg Pulse ox On O O2 A
OESepsis O Social Services to be Notified: O Yes O No
O Stroke O Communicable Disease Screen: O Pos 13fleg Peak Flow:
O Isolation O Yes O No Type:
O Suicidal O Hornicidal O CO Initiated Time: Best P.F.:
Have you ever tried-to end your life before? O Y O N
Do you feel that way now? O Y O N
-
Chief Complaint: f- |€s).£ ÂfaMje- pygurt
q g Af§e...t f - ff r (d
(ÂÞf
Assessment:
RN Signature: Endorsed To:
Past MedlSurg Hx: g( LMP:
DPT:
Current Medications:
ACCT: 21 1470760
PHILLIPS. K9lley
Ins:24Apr78 REG:n6/tEt/poin 3:41PM -
RELIG:MT
. APT:24R
: 450 WAYNE AVENUE BRONX
SF×:F AGE:3P M3:F
NY 10467 TFI : (321 }298-0044
E3 teen . REL:M
EC: PHILLtPS.
ADDR:
TEL: (3211759-3523
SPOUSE:
-NOK: PHILLIPS. Eileen - Allergies:
FLAG: NONE
PCP:TORRES. CARLOS
1575 BLONDELL AVE STE 200 BRONX
NON MMC: Allergy Band: O Yes
NY 10467 TEL: (866)633-8255
Limb Alert: O Yes
PAT D00:04/24/ 1978 Mn# : 030881 63
N/A
ACC: Auto Accident /No Fault Ins
ain Scale:
ARRIVED:0ther
9999999999999999 - /Used Scale:
PRI CARR: F00
SEC CARR:
- O Wong-Baker ,
TER CARR:
ACCID PLACE:ba.inbridge 211 street O Descriptive
• ACCID D/T:06/03/2010 10:30am O Non-Verbal
1 EMP:MONTEFl0RE MEDICAL CTR (See Patient Record)
Piinted6/3/2010 at 15:49-Page 1 of 2
g g||g|gg t||ggg|||||gg|||gg||||
Nursing Notes - Triage / Assessment Lynx Medical Systems, Inc copyright 2006 PHILLIPS, Kelley (17 -40 yr F) Minor MVC
FILED: BRONX COUNTY CLERK 02/24/2022 02:17 PM INDEX NO. 21169/2011E
NYSCEF DOC. NO. 283 RECEIVED NYSCEF: 02/24/2022
MONTEFiORE Moses Emsrgsriiry Department Patient: PHILLIPS, Kelley
111 East 210th Street Triage Date: June 3', 2010
B
DOB: April 24, 1978 Sex: Fernale
nx,0 731
Med Rec#: 03088163 Age: 32 yr
Account#: 211470760
otWED
iÜÏril N
__ _ _
As t s s n D
--.... .._
e
.. -.-- ------..... __--
PAIN ASSESSMENT / COMFORT
Have you had pain in the past week? O Yes O No
Do you currently have pain? O Yes O No
A Des:dp± a Pain Intensity Scale A Scale Using Facial Expressions (Wong-Baker Scale Faces)
I I
No Mild Mederate Severe VerySevere Worse PaIn 0 2 4 6 8 10
Paln Pain Pain Pain Pain Possible No Hurts A Hurts A Hurts HudsA HurtsWorse
Hurt Littleeit Little More EvenMore Whole1.ot
DATE / TIME INITIALS PAIN LEVEL INTERVENTION RESPONSE
Satisfied Nat Satisfied
Non Veibal Patients
is present(check allthat apph0:
If apatientis unabletecornrnunicatepain is assurnedto becurrentif ary of 1hefellouving
O UsuallyPainfulDisease O PainfulProcedure
Patientedilbits behaulorsIndlestium
of painsuch m:
O Freveningforirricing,_ O ArociousArritable O SadfFearfulMfithdraven O CryingfMeaning
O PalnedEnression D Resiless/AgitmadlScr
eming O Mraid To MwefRigid O JurnpsWhen Touched
O No1ndloationOf PainPresent
DATE / TIME INITIALS INTERVENTION
Printed6/32010 st 15:49 - Page 2 of 2
Nursing Notes - Triage / Assessrnent Lynx Medical Systems, inc copyright 2006 PHILLIPS. Kelley (17 - 40 yr F) Minor MVC
FILED: BRONX COUNTY CLERK 02/24/2022 02:17 PM INDEX NO. 21169/2011E
NYSCEF DOC. NO. 283 RECEIVED NYSCEF: 02/24/2022
MONTEFlOREMoses Emerg=cy Department Patient: PHILLIPS, Kelley
, 111 East 210th Street Triage Date: June 3, 2010
DOB: April 24, 1978 Sex: Female
71 .9 0 5731
Med Rec#: 03088163 Age: 32 yr
Account#: 211470760
Nursing ED Assessment Form
Date: Time:
Advance Directives: O None O DNR O DNI O Health Proxy
Precautions: O Fall O Seizure
Social History: O Non-Smoker O Smoker/ppd:_ O Drugs _ __
O ETOH/amount per day: Last Drink:
Initial G|ücameter (Reference Range 70-115 mg/dL): Urine Hcg:
Spiritual / Cultural Needs: !deñt™ad O Yes O No Addressed O Yes O No
Crisis lataivsation: O Yes O No Type:
tespiratory Cardiovascular Neurological A½±!
Airway: O Rhythm O Alert O Oriented O.Soft O Distended O Firm
O Patent O Obstructed O Pacer O IACD O Confused O Verbal EtTender O Nontender
O Trach O Cap Relil: O <4 sec Ot>4 sec O Lethargic O Unresponsive EEGuarding
O JVD OtY O N O Combative O:Bowel Sounds
Respirations·
O Edema O Y O N O Dizziness O present O absent
O Rate Integumentary Speech: O Nausea O Vomiting
O Labored Color: O Slurred O Clear OiDiarrhea O Lactation
O Accessory Muscle Use O WNL O Pale O Flushed O Aphasic O LMP O Menopausal
_
O Nasal Flaring O Mottled O Cyanotic PERLA O Y O N O Gravida O Para_ |
O Jaundice O Facial Droop O Discharge
•
O Bleeding
Breath Sounds: Temperature: O Weakness O R O L O Pad Count
* Clear O R O L O Warm O Cool O Hot O Paralysis O R O L O Dysuria O Frequency
Diminished O R O L O Dry O Diaphoretic Mobility: OtincontinenceO Last Void:
Absent O R O L Skin Integrity: O Mows All Extremities Safety\Universal Precautions:
Wheezing O R O L O Intact O Y O N Gait: O Steady O Unsteady O Bed in Low Position
; Rhonchi O R O L Describe O Unable to Ambulate O Bed in Prominent Area
Crackles-
O R O L O Injury O Side Rails Up x2
Cough: O Rash O Y O N· O Assist devicehype: O Call Bell
O Non Productive O Bruising O Y O N O Deformity O Family at Bedside
) O Productive O Pressure UIcer O Pulses O Restraint Type:
Color: lLocation: RUE RLE (see flow sheet)
Stage: LUE LLE O ice!cticñ
BarriersTo Learnin O No Barriers O Physical Socialj O Nursing Home Resident
J O Cognitive O Primary Language O Lives with Family O Y O N O Lives Alone O Y O N
O Urdente English O Social Service Notified O Has help @ home
Date/Tlrne Print Name / Title Signatitre Initials
Printed 6/3/2010 at 15:49- Page 1 of 2
Nursing Notes - Flow Sheet Lynx Medical Systems, inc copyright PHILL1PS, Kelley (17-40yr F) Minor MVC
FILED: BRONX COUNTY CLERK 02/24/2022 02:17 PM INDEX NO. 21169/2011E
NYSCEF DOC. NO. 283 RECEIVED NYSCEF: 02/24/2022
MONTEFIORE Moses Emergency Depc-tment Patient: PHILLIPS, Kelley
111 East 210th Street Triage Date: June 3, 2010
Bronx NY 10467
DOB: April 24, 1978 Sex: Female
Med Rec#: 03088163 Age: 32 yr
Account#: 211470760
Procedures (Check only if Applicab e)
.x Mr
O O2 @ hia Spo2 O Venipundure Performed
O ECG ×3 Enzyrnes x 3 Tme Due: O Labs Sent @ o'dodt
_
Tme Due: O Normal Saline Lock Site
Trne Due: O Foler Size: Arnount: cc
Blood Cultures Set #1 Mual Eme Drawn: O U/A C&S Tirne
Sd F2 Mual Eme Drawn: O X-Ray O Chest O MRI O Cr Type:
FALL RISK:
If 22 factors, hx fat(s) in the last 3 mos, fear of falling, a < 2 factors but cinicany judges At Rsk: Implement htervertions/activity.
Check all appropriate boxes.
O Muscle Weakness
O Hx Fall(s) in last 3 mos
O Gait/balance defidt(s)
O Arthritis
O Uses· O Cane O Waker O Whedchair
I O Visual defidt(s): lega y blind, cataract(s), multifocal glasses, no glasses of contads
O Expresses fear of faling
O Impaired AD4s)
O Spedfic Medication (antidepressant, beracdamepine, neuroleptic non-mioticglaucoma med, sedative, hypnotic, > 1 psychotropic agent)
O Cognitive impailment or does not call for help
O Depression
O Age > 65 Years
O Fag Risk O Yes O No Fall Precaution Iriplemented O Yes
UaW IIme Notes
Printed 6/3/2010 at 15:49 - Page 2of 2
Nursing Notes - Flow Sheet Lynx Medical Systems, inc copyright 5 PHILLIPS, Kelley (17 - 40 yr F) Minor MVC
FILED: BRONX COUNTY CLERK 02/24/2022 02:17 PM INDEX NO. 21169/2011E
NYSCEF DOC. NO. 283 RECEIVED NYSCEF: 02/24/2022
MONTEFIOREMoses Emergency Department Patient: PHILLIPS, Kelley
11.1 East 210th Street Triage Date: June 3, 2010
Bronx, NY 10467
DOB: April 24, 1978 Sex: Female
Med Rec#: 03088163 Age: 32 yr
Ilu I IIll g I I I 11 IIIII Account#: 211470760
4ursing Notes -- Vital Signs Page 1
VITA L S IG NS
Date/Tim T P R BP Pulse ox a n 0-10 Initial
Date/lima Print Hame / Title Signature Initials
OLUCOMElkit - Reference range M•116 mgidL..
Date/Tim e Glucose Comments Initial
IIIIIIIIIIIIIIll IIIIIIIIIllIII IlllIIIllIIIIll Ill Ill IIII #lllllli lKIII Pñnted 6/3/2010 at 15:49- Page 1 of 2
FILED: BRONX COUNTY CLERK 02/24/2022 02:17 PM INDEX NO. 21169/2011E
NYSCEF DOC. NO. 283 RECEIVED NYSCEF: 02/24/2022
MONTEFlORE Moses Emergency Department Patient: PHILLIPS, Kelley
111 East 210th Street Triage Date: June 3; 2010.
Bronx, NY 10467
DOB: April 24, 1978 Sex: Female
Med Rec#: 03088163 Age: 32 yr
II II III Ill II I s lu Account#: 211470760
otes Aow S 2
Time IV # Ste Solution/Additive Amount Rate Site Assessment Initials Time Amou
I---
I I
Date/Time Print Name / Title Signmera Initials
. ____
ntake and I ulput
Irput butput
Time PO IV NC/GT ima Urine N/0 Emesis Other
T OT AL S T OTA L S
Printed 6/3/2010 at 15:49 - Page 2 of 2
Nursing Notes - Flow Sheet Lynx Medical Systems, Inc copyright å PHILLIPS, Kepey (17 - 40 yr F) Minor MVC
FILED: BRONX COUNTY CLERK 02/24/2022 02:17 PM INDEX NO. 21169/2011E
NYSCEF DOC. NO. 283 RECEIVED NYSCEF: 02/24/2022
ED Physician Notes Chart by exception. Circle positive responses - findings. A backslash ( \ ) indicates a portinent negative.
MONTERORE . Moses Emergency Department Patient: PHILUPS, Kelley
111 East 210th Street Triage Date: June 3, 2010
DOB: April 24, 1978 Sex: Female
71 .920 5731
Age: 32 yr
•
M Re : 03088163
g
I Ell III I I IlullllEl cc nt# 211470760
Chief Complaint 1. Minor MVC
Basic Mfor=ye- In Provider: name / Time seen:
. ..- .. ..... _ - .. . H : Pt / _ use/_S.O./ Father/ Mot r 4 / Other // Amb: BLSALS //_Police
Vital signs: Pernursenotes/ WNL/ T P R BP SaO2 %/
Medications: Per nursenotes/ None/ Perlist / Reconciled/
. .. ... .. . . .. ..... . .. . . .. ...... .... ... ..... . . ..... ............ .. ...
. .Allergies-intolerances: Per nursingnotes- substancesreactions/ NKDA/ .. ....... ... .. .. .... . . . ........ .... ..... ..
.
.Meastaa!:?Ghx•
notesf LMP / G _
P _..__ SAb ___ TAb __ / Preg N Y unknown/
Historylimitation: Clinicalcondition/ Physicalimpairmen,t
/ ognitiveimpo / Languagebarrier/
History of Present III as
Durationmmina
(ms) Occurrence: s hrs days s mos PTA/ Date Time
(ms) Painonset: Immediate/ / .. .. .
(ms) Paincourse: Resolved/ Decreasing/ Constant/ / Episodic/ WaxIng & waning/
Location . . .. ... . ... ... .. . . . . .... .. . . - .
(ms) Pain: None/ Head/ Neck/ Chest/ Bac Abdomen/ R_L_Arm / R._ Hand/ R_L_Leg / R_L_Foot /
(hem) Bleeding: Head/ Neck/ Chest/ Back/ Abdomen/ R_L_Arm / R_L_Hand / R_L_Leg / R_L_,__Foot /
(int) Lacs: None Head/ Neck/ Chest/ Back/ Abdomen/ R_L_Arm / R_L Hand/ R L Leg/ R_L_Foot /
. . . Qua
(neu) Headache: Mild/ Mod/ Sev/
•
(ms) Otherpain: Min/ Mod/ Sev/
(hem) Bleeding: Min/ Mod/ Sev/
(ms) a t Backboard/ C-collar/ Oxygen/ IV fluid/ NabotÑÎs/ Intu t
.. . .. .. .. . . . ...... . .. . .............. . .... ..... ........
(ms) Description Speed niph/ Rollover/ Impact:R L front ear / Broken:st..wheel w shield
(ms) PatientlocationInvehicle a Mid L front back/
(ms) Restraints: N I.apbelt r he / Deployedair bag /
(con) Substanceingestion: spected/ / Cocaine/ Amphetamines
(ms) Priorinjuries: None/ As above/ Describe/ . ..
(ms) Accidentlocalion: / Farm/ Hwy/ Home/ Industrial/ Institution/ Mine/ Public bldg/ Quarry/ Recreational/ Residential/ Street/
AssocSians& Surnos
(con) Lossof consciousness: nsure/ Dazed/ Momentarily/ / _ secs mins / Still unconscious/
(con) Const(other): hills/ Malaise/ Genweakness/ DecreasedLOC/
(cv) CV (other): Ipliations/ Tachycardia/ Syncope/ . . . . . . .
(res) Resp: . . ... . ... . . ... atrast / SOBc exercise/ Orthopnea/ Cough/ Wheezing/ Stridor/
(gi) GI (other): Nausea/ PoorPOIntake:sollds IIqukIs/ Vomiting/ Hematemesis/ Diarrhea/
Constipa6on / Hematochezia/ Melena/ .... . .... . . . . ... . . . ...
(neu) Neuro: Confusion/ R_L_Hearimposs / R_L_Vision loss / Diplopia/
(neu) t Abnl: speechmotor sensationbalance/ Seizure/
Review of Systems HPI for- ConstCV RespGI MS SkinNeuroHeme
Eye· Pain/ Eyelidinflammation/ Conjunctivali±mb±n / Visionchange/
(eye)
(ent) ENT: / R_L_Ear pain disch/ Nose·congestiondisch bleed/ Mouth-pain swelling/ Throat pain swelling hoarse/
(gu) GU: / Dysurla/ Hematurla/ Vag discharge/ Abnl menses/ R..___L_pelvic
pain/ Urine: decr incr/
(hem) Heme/Lýmph: / Lymphadenopathy / Easybruising/ Prolongedbleeding/ Anemia/
Othersignificant· systemsotherwiseneg /
Past Medical History HPl/ Seedctation/ See medrecorddated
• Med: / CADHTNAnginaA.Fib MI CHFMur/ Asthma/ GEROf CA / CRF/ Highchal/ Hypothyroid/ DM: type...1type_2/
Fx(s)/ RA/ OA/ Gout/ Osteoporosis/ . . . . .. .... .....
IllillllllKIllllllllKIllKlll0Ill0ll|lllIIIIIIIEllIlll1011011IKI111101111IIIIIHII|lll
ED Physician NoteS copyrightLYNXMedicalSystems,Inc2001 N9
-
PHILLIPS, Kelley (17 - 40 yr F) Minor MVC
•
FILED: BRONX COUNTY CLERK 02/24/2022 02:17 PM INDEX NO. 21169/2011E
NYSCEF DOC. NO. 283 RECEIVED NYSCEF: 02/24/2022
ED Physician Notes Chart by âxcâpt:GG. Circle positive r=p-s - findings. A backslash ( \ ) indicates a pertinent negative.
MONTEFIORE Moses Emergency Depedment Patient: PHILLIPS, Kelley
111 East 210th Street Triage Date: June 3, 2010
DOB: April 24, 1978 Sex: Female
'O 73
Med Rec#: 03088163 Age: 32 y
IIE IIIIII II lulill Account#: 211470760
Surg significant/ PTCA/ Stent/ CABGx _..,_/ Appy/ Chole/ Hyster/ Oophorectomy/
Neck surg/ Backsurg/
. . . . .. . . . ..
Social History
Socialconcems: / Neglect/ Abuse/ Livingsituation/
Habits: / ETOH: occ reg amt per day wk / Tobacco: occ reg _ ppdx _ yrs /
Marijuana/ Cocaine/ Heroin( Amphetamines/
Examination Umind condh /
(con) Generat NAD/ d / Moddistress/ Sewdstress/
(Int) Skin: WNL / undice/ Cyanotic/ Molged/ Disphoretic/ Ashen/ Tenting/
(an0 . ac aiaw: WNL / R_L_Zygome deformity/ R__L__Marldible deformity/ Abnl bite/ Midfaceinstability/
..... ... .calp: WNL / R / L / OccIpital/ Parietat/ Temporal/ Frontal/ Erythema/ Bruises/ Swelling/ Tenderness/
(eye) Eyee
(eye)
(enQ
AbnIpupit L
WNL PERRL/ AbniEOM/ R_L_tid: abrasion lac/ R_L_Conjunctivac bleed lac/ R_L_Comeat abrasion FB/
L_ / R I Globelac(s) / R_LPaptisdems /
R_.. Ext.ear: abrast lac(s)/ RATM perforation/ R,L,Nesel: abras. lac(s)/
(enQ R,,Â,,,Neds: blood lac(s)/ R_LMouth Inc(s)/ Tooth#_: loose fx avulsion/ Absentgag /
(ms) Necle N Supple/ Tendemess:spinous..jnocessparaspinal/ Enlargedthyroid/ Stilfness/ PainfulROM/
(ms) Deformity/ kninobilization/
Ons) Chestwall: / R / L / Ant/ Lateral/ Post/ Superior/ Mid/ Inferior/ Tendemess12 3 4 + / SOemphysema/
(ci Heart: rate& shythm/ Gradycardis/ Tachycardle/ ,Extrabeats/ Irregular/ S3/ S4/
(ct Systmu 8 at , radw ( Dias mur /Oat .red to
W
_
Des) Lunpe WN Clear/ Okninished_ ( Rhoncht insp axp / courseIIne hisp exp_______/ . . .
(res) Wheezes: Insp exp ___...._1 Sbidor insp exp / Pleuralrub: Insp exp /
(gS AtNt L / Obeselimilingexam/ Soft/ Scais / Distended/ Abngbowelsounds / Tendemess_,,,_ /
(gi) Guarding / Rebound / Enlarged liver spleen cm / Mass / Bruit
(ms) Back: L / R / L / Thomcic/ Lumber/ MitEne/ Parespinous/ CVA/ Abrosion/ Tendemess/
$"8)...Extrem es: R / L/ Hand/ Arm/ Foot/ Anide/ i.owerleg / Thigh / Tender/ Swelling/ Delormity/ Edoma__+ /
$mu) Neuro: Alert/ O x _
/ DecrLOC/ Cognitivedysfuncdon/ Atmi CNSII.XN/ Aphasis- Dyserthda/
Motordeficit/ Sensorydeficit/ Abnicerebellartests/ Abnt gait /
(psy) Psych: Appropriate/ Flats Depressed/ ArudoustAgitated/ U / Combative/
Pn blen Ares
Erythema
Abraslan
Tendemess:1
Lac #t: length _cm, Depth: partial MI
. . . Lac #2 length,_.,,,,,cm,depth: partial MI
"
IllIllillilllIIIlllilllIllIIIIIIIIllIIIlllIlillllllIllllIllIIIIIIIIIllIlllIIIllIIIIIll --- ".
ED Physician Notes copyrightLYNXMedicalSystems./nc2001 N9 PHILLIPS, Kelley (17 - 40 yr F) Minor MVC
_.
FILED: BRONX COUNTY CLERK 02/24/2022 02:17 PM INDEX NO. 21169/2011E
NYSCEF DOC. NO. 283 RECEIVED NYSCEF: 02/24/2022
MONTEFIORE Moses Enm.uv••.y Departraent Patient: PHILLIPS, Kelley
, -111 East 210th Street Triage Date: June 3, 2010
B n9x,
DOB: April 24, 1978 Sex: Female
N5731
Med Rec#: 03088163 Age: 32 yr
I I II I I IIAlills Account#: 211470760
A"-anding Note Attending Name:
Resident Supervision Note: | NP/PA Conse!tt-ien-Supervision
I havg participated patient's care as diecked: I have had face to face E/M as noted:
[A Physical presence during key portions of the E/M service. [ ] Hx
Perfolfally performed a history, entm, and MDM.
__ se discussion with resident. [ ] PE:
I agree with the resident evaluation with corrections
and nMitions as noted MDM- Pt. Counseing:
| ]
IDX·
Physician: IDX·_ Physidan: __
Attending linkage notellmpression/Plan
[ ] Meds/Aiiergies/inmunizations verified with patient
Medical Decision Making
I am [ ] Admitting ( ] Discharging [ ] Transferring
this patient bacasr:6:
Procedures
[ ] 1 personally pcfcëM the
[ ) I was physicaly present during the entire:
[ ] I was personally present during the critical / key portion of the:
‡GN IS:
1 2 . 3
[-
A*==d-fP AINP signatu : IDX#: Date/Timr __
•
o a
IllM Illl#111111|1118111111H11111111lIll Ililill II IllHi I IlllIIlll 111111
Attending Note / Procedures Lynx Medical Systems, Inc copyright 2006 PHILL1PS, Kelley (17 - 40 yr F) Minor MVC
FILED: BRONX COUNTY CLERK 02/24/2022 02:17 PM INDEX NO. 21169/2011E
NYSCEF DOC. NO. 283
Preview
FILED: BRONX COUNTY CLERK 02/24/2022 02:17 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 283 RECEIVED NYSCEF: 02/24/2022 MONTEFIORE Moses Emergency Department Patient: PHILLlPS, Kelley , •111 East 210th Street Triage Date: June 3, 2010 . Bronx, NY 10467 1978- DOB: April 24, Sex: Female Med Rec#: 03088163 Age: 32 yr Account#: 211470760 Nursing Notes - Triage Pre-Hospital Care Initial VS IV: Site: MEDS: Time: Triage Time: Oxygen @ T: Trlage Levels Backboard: C-Collar: O 1 T Dmss;ñg/Splints: P: O 2 O FUFT O 3 O POS Fall Screen Needed O Yes o R: 4 . Special ConsiderationslBarrier/ o Learning: 5 O Commun:caticas: O Language O Hearing O Speech BP: Protece!e O.Interpreter D Deaf Talk O CEUs O Abuse/Neglect/Exploitation Screen: O Pos ç bleg Pulse ox On O O2 A OESepsis O Social Services to be Notified: O Yes O No O Stroke O Communicable Disease Screen: O Pos 13fleg Peak Flow: O Isolation O Yes O No Type: O Suicidal O Hornicidal O CO Initiated Time: Best P.F.: Have you ever tried-to end your life before? O Y O N Do you feel that way now? O Y O N - Chief Complaint: f- |€s).£ ÂfaMje- pygurt q g Af§e...t f - ff r (d (ÂÞf Assessment: RN Signature: Endorsed To: Past MedlSurg Hx: g( LMP: DPT: Current Medications: ACCT: 21 1470760 PHILLIPS. K9lley Ins:24Apr78 REG:n6/tEt/poin 3:41PM - RELIG:MT . APT:24R : 450 WAYNE AVENUE BRONX SF×:F AGE:3P M3:F NY 10467 TFI : (321 }298-0044 E3 teen . REL:M EC: PHILLtPS. ADDR: TEL: (3211759-3523 SPOUSE: -NOK: PHILLIPS. Eileen - Allergies: FLAG: NONE PCP:TORRES. CARLOS 1575 BLONDELL AVE STE 200 BRONX NON MMC: Allergy Band: O Yes NY 10467 TEL: (866)633-8255 Limb Alert: O Yes PAT D00:04/24/ 1978 Mn# : 030881 63 N/A ACC: Auto Accident /No Fault Ins ain Scale: ARRIVED:0ther 9999999999999999 - /Used Scale: PRI CARR: F00 SEC CARR: - O Wong-Baker , TER CARR: ACCID PLACE:ba.inbridge 211 street O Descriptive • ACCID D/T:06/03/2010 10:30am O Non-Verbal 1 EMP:MONTEFl0RE MEDICAL CTR (See Patient Record) Piinted6/3/2010 at 15:49-Page 1 of 2 g g||g|gg t||ggg|||||gg|||gg|||| Nursing Notes - Triage / Assessment Lynx Medical Systems, Inc copyright 2006 PHILLIPS, Kelley (17 -40 yr F) Minor MVC FILED: BRONX COUNTY CLERK 02/24/2022 02:17 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 283 RECEIVED NYSCEF: 02/24/2022 MONTEFiORE Moses Emsrgsriiry Department Patient: PHILLIPS, Kelley 111 East 210th Street Triage Date: June 3', 2010 B DOB: April 24, 1978 Sex: Fernale nx,0 731 Med Rec#: 03088163 Age: 32 yr Account#: 211470760 otWED iÜÏril N __ _ _ As t s s n D --.... .._ e .. -.-- ------..... __-- PAIN ASSESSMENT / COMFORT Have you had pain in the past week? O Yes O No Do you currently have pain? O Yes O No A Des:dp± a Pain Intensity Scale A Scale Using Facial Expressions (Wong-Baker Scale Faces) I I No Mild Mederate Severe VerySevere Worse PaIn 0 2 4 6 8 10 Paln Pain Pain Pain Pain Possible No Hurts A Hurts A Hurts HudsA HurtsWorse Hurt Littleeit Little More EvenMore Whole1.ot DATE / TIME INITIALS PAIN LEVEL INTERVENTION RESPONSE Satisfied Nat Satisfied Non Veibal Patients is present(check allthat apph0: If apatientis unabletecornrnunicatepain is assurnedto becurrentif ary of 1hefellouving O UsuallyPainfulDisease O PainfulProcedure Patientedilbits behaulorsIndlestium of painsuch m: O Freveningforirricing,_ O ArociousArritable O SadfFearfulMfithdraven O CryingfMeaning O PalnedEnression D Resiless/AgitmadlScr eming O Mraid To MwefRigid O JurnpsWhen Touched O No1ndloationOf PainPresent DATE / TIME INITIALS INTERVENTION Printed6/32010 st 15:49 - Page 2 of 2 Nursing Notes - Triage / Assessrnent Lynx Medical Systems, inc copyright 2006 PHILLIPS. Kelley (17 - 40 yr F) Minor MVC FILED: BRONX COUNTY CLERK 02/24/2022 02:17 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 283 RECEIVED NYSCEF: 02/24/2022 MONTEFlOREMoses Emerg=cy Department Patient: PHILLIPS, Kelley , 111 East 210th Street Triage Date: June 3, 2010 DOB: April 24, 1978 Sex: Female 71 .9 0 5731 Med Rec#: 03088163 Age: 32 yr Account#: 211470760 Nursing ED Assessment Form Date: Time: Advance Directives: O None O DNR O DNI O Health Proxy Precautions: O Fall O Seizure Social History: O Non-Smoker O Smoker/ppd:_ O Drugs _ __ O ETOH/amount per day: Last Drink: Initial G|ücameter (Reference Range 70-115 mg/dL): Urine Hcg: Spiritual / Cultural Needs: !deñt™ad O Yes O No Addressed O Yes O No Crisis lataivsation: O Yes O No Type: tespiratory Cardiovascular Neurological A½±! Airway: O Rhythm O Alert O Oriented O.Soft O Distended O Firm O Patent O Obstructed O Pacer O IACD O Confused O Verbal EtTender O Nontender O Trach O Cap Relil: O <4 sec Ot>4 sec O Lethargic O Unresponsive EEGuarding O JVD OtY O N O Combative O:Bowel Sounds Respirations· O Edema O Y O N O Dizziness O present O absent O Rate Integumentary Speech: O Nausea O Vomiting O Labored Color: O Slurred O Clear OiDiarrhea O Lactation O Accessory Muscle Use O WNL O Pale O Flushed O Aphasic O LMP O Menopausal _ O Nasal Flaring O Mottled O Cyanotic PERLA O Y O N O Gravida O Para_ | O Jaundice O Facial Droop O Discharge • O Bleeding Breath Sounds: Temperature: O Weakness O R O L O Pad Count * Clear O R O L O Warm O Cool O Hot O Paralysis O R O L O Dysuria O Frequency Diminished O R O L O Dry O Diaphoretic Mobility: OtincontinenceO Last Void: Absent O R O L Skin Integrity: O Mows All Extremities Safety\Universal Precautions: Wheezing O R O L O Intact O Y O N Gait: O Steady O Unsteady O Bed in Low Position ; Rhonchi O R O L Describe O Unable to Ambulate O Bed in Prominent Area Crackles- O R O L O Injury O Side Rails Up x2 Cough: O Rash O Y O N· O Assist devicehype: O Call Bell O Non Productive O Bruising O Y O N O Deformity O Family at Bedside ) O Productive O Pressure UIcer O Pulses O Restraint Type: Color: lLocation: RUE RLE (see flow sheet) Stage: LUE LLE O ice!cticñ BarriersTo Learnin O No Barriers O Physical Socialj O Nursing Home Resident J O Cognitive O Primary Language O Lives with Family O Y O N O Lives Alone O Y O N O Urdente English O Social Service Notified O Has help @ home Date/Tlrne Print Name / Title Signatitre Initials Printed 6/3/2010 at 15:49- Page 1 of 2 Nursing Notes - Flow Sheet Lynx Medical Systems, inc copyright PHILL1PS, Kelley (17-40yr F) Minor MVC FILED: BRONX COUNTY CLERK 02/24/2022 02:17 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 283 RECEIVED NYSCEF: 02/24/2022 MONTEFIORE Moses Emergency Depc-tment Patient: PHILLIPS, Kelley 111 East 210th Street Triage Date: June 3, 2010 Bronx NY 10467 DOB: April 24, 1978 Sex: Female Med Rec#: 03088163 Age: 32 yr Account#: 211470760 Procedures (Check only if Applicab e) .x Mr O O2 @ hia Spo2 O Venipundure Performed O ECG ×3 Enzyrnes x 3 Tme Due: O Labs Sent @ o'dodt _ Tme Due: O Normal Saline Lock Site Trne Due: O Foler Size: Arnount: cc Blood Cultures Set #1 Mual Eme Drawn: O U/A C&S Tirne Sd F2 Mual Eme Drawn: O X-Ray O Chest O MRI O Cr Type: FALL RISK: If 22 factors, hx fat(s) in the last 3 mos, fear of falling, a < 2 factors but cinicany judges At Rsk: Implement htervertions/activity. Check all appropriate boxes. O Muscle Weakness O Hx Fall(s) in last 3 mos O Gait/balance defidt(s) O Arthritis O Uses· O Cane O Waker O Whedchair I O Visual defidt(s): lega y blind, cataract(s), multifocal glasses, no glasses of contads O Expresses fear of faling O Impaired AD4s) O Spedfic Medication (antidepressant, beracdamepine, neuroleptic non-mioticglaucoma med, sedative, hypnotic, > 1 psychotropic agent) O Cognitive impailment or does not call for help O Depression O Age > 65 Years O Fag Risk O Yes O No Fall Precaution Iriplemented O Yes UaW IIme Notes Printed 6/3/2010 at 15:49 - Page 2of 2 Nursing Notes - Flow Sheet Lynx Medical Systems, inc copyright 5 PHILLIPS, Kelley (17 - 40 yr F) Minor MVC FILED: BRONX COUNTY CLERK 02/24/2022 02:17 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 283 RECEIVED NYSCEF: 02/24/2022 MONTEFIOREMoses Emergency Department Patient: PHILLIPS, Kelley 11.1 East 210th Street Triage Date: June 3, 2010 Bronx, NY 10467 DOB: April 24, 1978 Sex: Female Med Rec#: 03088163 Age: 32 yr Ilu I IIll g I I I 11 IIIII Account#: 211470760 4ursing Notes -- Vital Signs Page 1 VITA L S IG NS Date/Tim T P R BP Pulse ox a n 0-10 Initial Date/lima Print Hame / Title Signature Initials OLUCOMElkit - Reference range M•116 mgidL.. Date/Tim e Glucose Comments Initial IIIIIIIIIIIIIIll IIIIIIIIIllIII IlllIIIllIIIIll Ill Ill IIII #lllllli lKIII Pñnted 6/3/2010 at 15:49- Page 1 of 2 FILED: BRONX COUNTY CLERK 02/24/2022 02:17 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 283 RECEIVED NYSCEF: 02/24/2022 MONTEFlORE Moses Emergency Department Patient: PHILLIPS, Kelley 111 East 210th Street Triage Date: June 3; 2010. Bronx, NY 10467 DOB: April 24, 1978 Sex: Female Med Rec#: 03088163 Age: 32 yr II II III Ill II I s lu Account#: 211470760 otes Aow S 2 Time IV # Ste Solution/Additive Amount Rate Site Assessment Initials Time Amou I--- I I Date/Time Print Name / Title Signmera Initials . ____ ntake and I ulput Irput butput Time PO IV NC/GT ima Urine N/0 Emesis Other T OT AL S T OTA L S Printed 6/3/2010 at 15:49 - Page 2 of 2 Nursing Notes - Flow Sheet Lynx Medical Systems, Inc copyright å PHILLIPS, Kepey (17 - 40 yr F) Minor MVC FILED: BRONX COUNTY CLERK 02/24/2022 02:17 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 283 RECEIVED NYSCEF: 02/24/2022 ED Physician Notes Chart by exception. Circle positive responses - findings. A backslash ( \ ) indicates a portinent negative. MONTERORE . Moses Emergency Department Patient: PHILUPS, Kelley 111 East 210th Street Triage Date: June 3, 2010 DOB: April 24, 1978 Sex: Female 71 .920 5731 Age: 32 yr • M Re : 03088163 g I Ell III I I IlullllEl cc nt# 211470760 Chief Complaint 1. Minor MVC Basic Mfor=ye- In Provider: name / Time seen: . ..- .. ..... _ - .. . H : Pt / _ use/_S.O./ Father/ Mot r 4 / Other // Amb: BLSALS //_Police Vital signs: Pernursenotes/ WNL/ T P R BP SaO2 %/ Medications: Per nursenotes/ None/ Perlist / Reconciled/ . .. ... .. . . .. ..... . .. . . .. ...... .... ... ..... . . ..... ............ .. ... . .Allergies-intolerances: Per nursingnotes- substancesreactions/ NKDA/ .. ....... ... .. .. .... . . . ........ .... ..... .. . .Meastaa!:?Ghx• notesf LMP / G _ P _..__ SAb ___ TAb __ / Preg N Y unknown/ Historylimitation: Clinicalcondition/ Physicalimpairmen,t / ognitiveimpo / Languagebarrier/ History of Present III as Durationmmina (ms) Occurrence: s hrs days s mos PTA/ Date Time (ms) Painonset: Immediate/ / .. .. . (ms) Paincourse: Resolved/ Decreasing/ Constant/ / Episodic/ WaxIng & waning/ Location . . .. ... . ... ... .. . . . . .... .. . . - . (ms) Pain: None/ Head/ Neck/ Chest/ Bac Abdomen/ R_L_Arm / R._ Hand/ R_L_Leg / R_L_Foot / (hem) Bleeding: Head/ Neck/ Chest/ Back/ Abdomen/ R_L_Arm / R_L_Hand / R_L_Leg / R_L_,__Foot / (int) Lacs: None Head/ Neck/ Chest/ Back/ Abdomen/ R_L_Arm / R_L Hand/ R L Leg/ R_L_Foot / . . . Qua (neu) Headache: Mild/ Mod/ Sev/ • (ms) Otherpain: Min/ Mod/ Sev/ (hem) Bleeding: Min/ Mod/ Sev/ (ms) a t Backboard/ C-collar/ Oxygen/ IV fluid/ NabotÑÎs/ Intu t .. . .. .. .. . . . ...... . .. . .............. . .... ..... ........ (ms) Description Speed niph/ Rollover/ Impact:R L front ear / Broken:st..wheel w shield (ms) PatientlocationInvehicle a Mid L front back/ (ms) Restraints: N I.apbelt r he / Deployedair bag / (con) Substanceingestion: spected/ / Cocaine/ Amphetamines (ms) Priorinjuries: None/ As above/ Describe/ . .. (ms) Accidentlocalion: / Farm/ Hwy/ Home/ Industrial/ Institution/ Mine/ Public bldg/ Quarry/ Recreational/ Residential/ Street/ AssocSians& Surnos (con) Lossof consciousness: nsure/ Dazed/ Momentarily/ / _ secs mins / Still unconscious/ (con) Const(other): hills/ Malaise/ Genweakness/ DecreasedLOC/ (cv) CV (other): Ipliations/ Tachycardia/ Syncope/ . . . . . . . (res) Resp: . . ... . ... . . ... atrast / SOBc exercise/ Orthopnea/ Cough/ Wheezing/ Stridor/ (gi) GI (other): Nausea/ PoorPOIntake:sollds IIqukIs/ Vomiting/ Hematemesis/ Diarrhea/ Constipa6on / Hematochezia/ Melena/ .... . .... . . . . ... . . . ... (neu) Neuro: Confusion/ R_L_Hearimposs / R_L_Vision loss / Diplopia/ (neu) t Abnl: speechmotor sensationbalance/ Seizure/ Review of Systems HPI for- ConstCV RespGI MS SkinNeuroHeme Eye· Pain/ Eyelidinflammation/ Conjunctivali±mb±n / Visionchange/ (eye) (ent) ENT: / R_L_Ear pain disch/ Nose·congestiondisch bleed/ Mouth-pain swelling/ Throat pain swelling hoarse/ (gu) GU: / Dysurla/ Hematurla/ Vag discharge/ Abnl menses/ R..___L_pelvic pain/ Urine: decr incr/ (hem) Heme/Lýmph: / Lymphadenopathy / Easybruising/ Prolongedbleeding/ Anemia/ Othersignificant· systemsotherwiseneg / Past Medical History HPl/ Seedctation/ See medrecorddated • Med: / CADHTNAnginaA.Fib MI CHFMur/ Asthma/ GEROf CA / CRF/ Highchal/ Hypothyroid/ DM: type...1type_2/ Fx(s)/ RA/ OA/ Gout/ Osteoporosis/ . . . . .. .... ..... IllillllllKIllllllllKIllKlll0Ill0ll|lllIIIIIIIEllIlll1011011IKI111101111IIIIIHII|lll ED Physician NoteS copyrightLYNXMedicalSystems,Inc2001 N9 - PHILLIPS, Kelley (17 - 40 yr F) Minor MVC • FILED: BRONX COUNTY CLERK 02/24/2022 02:17 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 283 RECEIVED NYSCEF: 02/24/2022 ED Physician Notes Chart by âxcâpt:GG. Circle positive r=p-s - findings. A backslash ( \ ) indicates a pertinent negative. MONTEFIORE Moses Emergency Depedment Patient: PHILLIPS, Kelley 111 East 210th Street Triage Date: June 3, 2010 DOB: April 24, 1978 Sex: Female 'O 73 Med Rec#: 03088163 Age: 32 y IIE IIIIII II lulill Account#: 211470760 Surg significant/ PTCA/ Stent/ CABGx _..,_/ Appy/ Chole/ Hyster/ Oophorectomy/ Neck surg/ Backsurg/ . . . . .. . . . .. Social History Socialconcems: / Neglect/ Abuse/ Livingsituation/ Habits: / ETOH: occ reg amt per day wk / Tobacco: occ reg _ ppdx _ yrs / Marijuana/ Cocaine/ Heroin( Amphetamines/ Examination Umind condh / (con) Generat NAD/ d / Moddistress/ Sewdstress/ (Int) Skin: WNL / undice/ Cyanotic/ Molged/ Disphoretic/ Ashen/ Tenting/ (an0 . ac aiaw: WNL / R_L_Zygome deformity/ R__L__Marldible deformity/ Abnl bite/ Midfaceinstability/ ..... ... .calp: WNL / R / L / OccIpital/ Parietat/ Temporal/ Frontal/ Erythema/ Bruises/ Swelling/ Tenderness/ (eye) Eyee (eye) (enQ AbnIpupit L WNL PERRL/ AbniEOM/ R_L_tid: abrasion lac/ R_L_Conjunctivac bleed lac/ R_L_Comeat abrasion FB/ L_ / R I Globelac(s) / R_LPaptisdems / R_.. Ext.ear: abrast lac(s)/ RATM perforation/ R,L,Nesel: abras. lac(s)/ (enQ R,,Â,,,Neds: blood lac(s)/ R_LMouth Inc(s)/ Tooth#_: loose fx avulsion/ Absentgag / (ms) Necle N Supple/ Tendemess:spinous..jnocessparaspinal/ Enlargedthyroid/ Stilfness/ PainfulROM/ (ms) Deformity/ kninobilization/ Ons) Chestwall: / R / L / Ant/ Lateral/ Post/ Superior/ Mid/ Inferior/ Tendemess12 3 4 + / SOemphysema/ (ci Heart: rate& shythm/ Gradycardis/ Tachycardle/ ,Extrabeats/ Irregular/ S3/ S4/ (ct Systmu 8 at , radw ( Dias mur /Oat .red to W _ Des) Lunpe WN Clear/ Okninished_ ( Rhoncht insp axp / courseIIne hisp exp_______/ . . . (res) Wheezes: Insp exp ___...._1 Sbidor insp exp / Pleuralrub: Insp exp / (gS AtNt L / Obeselimilingexam/ Soft/ Scais / Distended/ Abngbowelsounds / Tendemess_,,,_ / (gi) Guarding / Rebound / Enlarged liver spleen cm / Mass / Bruit (ms) Back: L / R / L / Thomcic/ Lumber/ MitEne/ Parespinous/ CVA/ Abrosion/ Tendemess/ $"8)...Extrem es: R / L/ Hand/ Arm/ Foot/ Anide/ i.owerleg / Thigh / Tender/ Swelling/ Delormity/ Edoma__+ / $mu) Neuro: Alert/ O x _ / DecrLOC/ Cognitivedysfuncdon/ Atmi CNSII.XN/ Aphasis- Dyserthda/ Motordeficit/ Sensorydeficit/ Abnicerebellartests/ Abnt gait / (psy) Psych: Appropriate/ Flats Depressed/ ArudoustAgitated/ U / Combative/ Pn blen Ares Erythema Abraslan Tendemess:1 Lac #t: length _cm, Depth: partial MI . . . Lac #2 length,_.,,,,,cm,depth: partial MI " IllIllillilllIIIlllilllIllIIIIIIIIllIIIlllIlillllllIllllIllIIIIIIIIIllIlllIIIllIIIIIll --- ". ED Physician Notes copyrightLYNXMedicalSystems./nc2001 N9 PHILLIPS, Kelley (17 - 40 yr F) Minor MVC _. FILED: BRONX COUNTY CLERK 02/24/2022 02:17 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 283 RECEIVED NYSCEF: 02/24/2022 MONTEFIORE Moses Enm.uv••.y Departraent Patient: PHILLIPS, Kelley , -111 East 210th Street Triage Date: June 3, 2010 B n9x, DOB: April 24, 1978 Sex: Female N5731 Med Rec#: 03088163 Age: 32 yr I I II I I IIAlills Account#: 211470760 A"-anding Note Attending Name: Resident Supervision Note: | NP/PA Conse!tt-ien-Supervision I havg participated patient's care as diecked: I have had face to face E/M as noted: [A Physical presence during key portions of the E/M service. [ ] Hx Perfolfally performed a history, entm, and MDM. __ se discussion with resident. [ ] PE: I agree with the resident evaluation with corrections and nMitions as noted MDM- Pt. Counseing: | ] IDX· Physician: IDX·_ Physidan: __ Attending linkage notellmpression/Plan [ ] Meds/Aiiergies/inmunizations verified with patient Medical Decision Making I am [ ] Admitting ( ] Discharging [ ] Transferring this patient bacasr:6: Procedures [ ] 1 personally pcfcëM the [ ) I was physicaly present during the entire: [ ] I was personally present during the critical / key portion of the: ‡GN IS: 1 2 . 3 [- A*==d-fP AINP signatu : IDX#: Date/Timr __ • o a IllM Illl#111111|1118111111H11111111lIll Ililill II IllHi I IlllIIlll 111111 Attending Note / Procedures Lynx Medical Systems, Inc copyright 2006 PHILL1PS, Kelley (17 - 40 yr F) Minor MVC FILED: BRONX COUNTY CLERK 02/24/2022 02:17 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 283