Preview
FILED: BRONX COUNTY CLERK 02/24/2022 02:17 PM INDEX NO. 21169/2011E
NYSCEF DOC. NO. 284 RECEIVED NYSCEF: 02/24/2022
SUMMARY SHEET
MEDREC#:03088163 MONTE FIORE MEDIC AL CENTER
ACCTNO:212787303 MMCMOSESDIVISION
INPATIENT
IIIIIIIIll
ADM DT & TIME: 06/30/2010 9:08pm ADM STATUS: Emergency DIS DT & TIME: 2:31pm 07/01/2010
UNIT: K5 RM #: K534-A READM: N ADV DIR:
PATIENT NAME:PHILCIPS, Kelley . SSN #: SEX:F MS:S
C/0: DOB: 04/24/1978 AGE: 32 REL: MT
ADDR: 3450 WAYNE AVENUE 24R MOTHER'S MAIDEN NAME:
CITY: BRONX ST: NY ZIP: 10467 BIRTH PLACE:
PHONE BUS: HOME: (321)298-0044 PCP: TORRES, CARLOS
RHIO CONSENT: PCP PHONE: 633- 8255
(866)
SPOUSE NAME & EMPLOYER NEXT OF KIN EMERGENCY
PHILLIPS, Eileen . MALLIS. Melinda .
FL M 0
(321)759-3523 (917)923-4133
SERVICE: MPA ADM SOURCE: EMERGENCY DEPARTMENT PREVIOUS HOSPITAL ADMISSION
ATTEND MD: GANDHI. SONIYA G/P/S: H DATE FROM: TO:
ADMIT MD: FERNANDES. DAVID HOSP NAME:
ADMITiDIAG: PAIN CONTROL ADDR:
PATIENT OCCUPATION: RESIDENT PRIM INSUR: F00 999999999999999 -
EMPLOYER: MONTEFIORE MEDICAL C SEC INSUR: -
ADDR: 111 E. 210JiH STREET TER INSUR: -
CITY: BRONX ST: NY ZIP: 10467 PHONE:
DISCHARGE DISPOSITION:
REGULAR - AMA TRANSFERRED -- WHERE?
EXPIRED AUTOP5Y? YES NO ME CASt? n.S NU
Printed On: 07/01/2010 9:36pm
FILED: BRONX COUNTY CLERK 02/24/2022 02:17 PM INDEX NO. 21169/2011E
NYSCEF DOC. NO. 284 RECEIVED NYSCEF: 02/24/2022
• DisSuM-
PHILLIPS.
,FAC C MOSES DIV
MONTEFlORE MEDICAL CENTER DISCHARGESUMMARY ISION .
ADMISSION DATE:0h PO DIScHARGE DATE: DOB: 04/ 2 97
BRIEFHISTORY/ REASONFORADMISSION 0/ 2010
[ :08p
PERTINENTPHYSICALEXAMINATION
FINDINGS
PERTINENT
LABORATORY, FINOlNGS
X-RAYANDPATHOLOGICAL
C
COURSEANDTHERAPY
HOSPITAL
A
.
R
G
DIAGNOSES
1. 4.
2. 5.
AND/ ORPROCEDURES
PERATIONS (INCLUDEDATES)
2. 4.
OFACTIVITY O NONE
UMITATIONS DET
CONDITIONONDisGhaRGE(MUSTBERELATEDTOREASONFORADMISSION) M
UnderstoodDischargeInstructionsO Yes O No C mments
PLANSFORFUTURECARE
O Transfer To:
NAMEOF INSTITUTION
Follow up Appointments:
Date/Time MDName Specialty Location/Phone
2)'l /''-
f
T•'l5®__ )_0. _ow'CX-
59
o . ov o 95 Ens3r b.eal R
The Home Discharge IssenemnanList that is attached to this form must be completed nd Ives to the tient soon discharge trom.the hospital.
PHYSICIANPRINTEDNA "PJeTIALS TRAINI LEVEL PHYSICI SIGNATURE/CREDENTIALS DATEmME
MD2942ME(12/09) Page1of2
WHITE - CHART COPY YELLOW - PATIENT/FACtLITY PINK - PROVIDER
FILED: BRONX COUNTY CLERK 02/24/2022 02:17 PM INDEX NO. 21169/2011E
NYSCEF DOC. NO. 284 RECEIVED NYSCEF: 02/24/2022
MONTEFlOliE MEDICAL CENTER
HOME DISCHARGE MEDICATION LIST 'THIS IS NOT A PRESCRIPTION. L E
Im#O3088163 K
DOB; 04 /24 / 19
V iS:06/ 30/2010
ACCT: 21 278730
MEDICATION NAME STRENGTH NUMBER HOW OFTEN MEDICATION
ROUTE DURATION
Brand Name of tabs,caps, of tabs.caps, When? W.E W
GenericName(also known as) P.uffs,drops, puffs, drops, (i.e., twIcea day, AJUSTES DE LDS med
mlections? medication? Stop date?
Inlections? breakfastand dinner)
MEDICAMENTOS
CHANGED
NOMBRE DEL
MEDICAMENTO
d a et s.
cápsulas,
d t beus
capsulas,
FRECUENCIA
·
Cudndo?
a me n
SAME NEW
DOSE M
inhataciones, inhalaciones, (es decir,dos vecesal ¿Pa
NombrecomernialNombre medicaclón? debedejarde DOSIS
go as, gotas, MISMD NUEVO
generico(tamblin conocido como) inyecciones Inyecciones tomarla? gaggggg,
med
Discontinue (1.e., stop taking these medications):
Discontinúa (Para de tomar estos medicamentos):
This Medication List Is to be ccmplstad using Patient Friendly Language
=
LEGEND: O Oral, Inh = =
Inhalation, inj Injection, Top = Topical, SC = Subcutaneous, IV = Intravenous Please see patient instructions
DESCRIPCtÓN: O = Oral, inh = Inhalación, lr = Inyección, Top = Tópico, SC = Subcutdneo, IV = Intravenoso Vea por favor las instrucciones
MOlPA/NP Completing Form Pa
Print Name Signature/Credentials Datemme Print Name
MO3642ME
(12/o9)
FILED: BRONX COUNTY CLERK 02/24/2022 02:17 PM INDEX NO. 21169/2011E
NYSCEF DOC. NO. 284 RECEIVED NYSCEF: 02/24/2022
PHILLIPS, KELLEY .
FAC:MMC MOSEs DIVisION
MR#03088163 K5 K534-A
DOB'
04/24/1978 F
VIS:06/30/ 2010 9:08p
ACCT: 21 2787303
Patient Instructions: (THIS IS NOT A PRESCRIPTION)
• Take all your medications as prescribed.
• a list of your medications with you, and this list to each physiciañ visit.
Keep bring
a Contact your physiciañ before medications you have at home and not on this list.
taking any
• Contact your physician before over-the-counter med!cations or herbal medicaticñs.
taking any
• Contact your physician if you have questions about your medications.
any
Instrucciones para el paciente: (ESTO NO ES UNA RECETA)
• Tome todos ios medicamentos como se indica.
• Conserve una lista de los medicamêñtas con:usted y IIévela a cada visita al médico.
• Comuniquese con su médico antes de tomar cualquier medicamento que tenga en su casa
que no esté en la lista.
• Comuñ!qüêss con su médico antes de .tomar cualquier medicamento de venta libre o
medicamentos a base de hierbas.
a Comuniquese con su médico si tiene alguna pregunta sobre sus medicamentos.
FILED: BRONX COUNTY CLERK 02/24/2022 02:17 PM INDEX NO. 21169/2011E
NYSCEF DOC. NO. 284 RECEIVED NYSCEF: 02/24/2022
OSES O VI S Î
ON
K5 DOS K534-A
MONTEFlORE MEDICAL CENTER ' · 04/24/1978 F
vys
2010 9: 08p
DISCHARGE P I UCTIONS ACCT
Admission Date: / D FEI 278730s .
. Discharge Date:
Discharge to: Allergies:
Surgical Procedure: tf ADDRESsuunew
.. / 24
t ns BP T: P: $4 R: Wei
P Re A ble: O o
Mental Status:
Environment:
Awake & Alert ED es O No
Needs Adjustment: O Yes No
nted to: Person:
Describe:
O No Place: d O No Time: ffYes O No
II. ABILITY TO PERFORM ACTIVITIES OF DAILY LIVING (ADL)
ADL Self Assisted (!ne!ud!ng Devices) Dependent Restrictions
Transf er
Dressing
Ambu!eting cane crutches walker w/c other _..
Feeding
Bathing
Toileting
Position Chance
• Gait steadv· I-ly s FI No Bedfast: Q Yes O No Chairfast Q Yes Q No
Ill. DIET INSTRUCTIONS:
IV, DISCHARGE MEDICATION O None
Home discharge medication list completed by / ANP ElÝes O No
Patient instructed to bring current list of med tions during
Action & Side Eff'ects of Medication Were Reviewsd? Yes O No provider visits/future hospitalizations: es O No
Specialized Treatments Frequency
V. PLANS FOR FUTURE CARE O Transfer To: ____
NAMEOFINSTITUTION
Follow ^P'==nts:
VI. WOUND/SKIN INTACT? O No If No, is it pressure-related O Yes O No
• If Pressure Related: Identify site and stage
Site Stage Site Stage Site Stage Site Stage
Non-Pressure Related: Describe condition of skin
VII. LIST SIGNS/SYMPTOMS WHEN TO SEEK MEDICAL ASM.RTANCE (Tailor to specific diagnosis I.e. CHF)
your Doctor / Retum to Hospital if the following symptoms occur:
r O Unusual n O Redn rainaga,‡wailing at the wound site O Vomiting O Nausea O Diarrhea
natipation Chest Pain culty Breathing O Leg/Ankle Swelling d Caif eain
. O Other
Monitor weight: Notify MD if the following occurs O Gain/Loss of 31bs
O Other
Vill.PROPERTY/CLOTHING RETURNED TO: QFatient O Family O N/A
IX. LIST UNRESOLVED PROBLEMS/NEEDS AND INDICATE L ADDITIONAL COMMENTS/EDUCATIONAL
PLAN OF CARE TO BE FOLLOWED POST-DISCHARGE INSTRUCTIONS:
* Include Unacceptable Pain Relief f If you have heart failure, check your weight daily and report changes
Problem/Need Plan of Care Post-Discharge
#1 help quitting call the NYS Srnokers Quit Line at 1-866-NY-QUITS or
1-866-697-8487.
When you feel you can't go on call 1-800-273-TALK
#3 (1-800-273-8255) SUICIDE HOTLINE
I'HIS DIS GEPLANHAS BEENREVIEWEDAND I HAVERECElVED
A COPY.
Signature of Patient / Repn=,antative / Releuenehip RN Signat re Time
(06/08) ·
MMC-NR7959ME White - Chart Copy Yellow - Patient Copy Pink - Nursing Home Side 1 of 2
FILED: BRONX COUNTY CLERK 02/24/2022 02:17 PM INDEX NO. 21169/2011E
NYSCEF DOC. NO. 284 RECEIVED NYSCEF: 02/24/2022
Procedure:
• Upon discharge, unit secretaries and-admitting clerks must verify whethsr patient is going home with or without Home
Care services, .whethar the patient expired or to what type of facility the patient was discharged.
• There are several options in Carecast to denote discharge disposition. See listing and definitions below.
• Disposition codes must accurately reflect the actual patient disposition when discharged.
• if the patient Discharge Disposition iñciudss a + code, the name of the facility which is taking responsibility for the patient
must be further specified by clicking on the appropriate name in the drop down menu. This information must be obtained
frorn "either discussion with the nurse, social worker and/or documentation in the discharge summary in the medical
Irecord.
• This iñfürrñation is isquired regardless of which department discharges the patient in Carecast.
Code Structure
01 Discharged to home or self ccare (routine disubarge)
02 Discharg-d½nsferred to a short-term general hospital for inpatient care.
. .....
03 Discharged/transferred to SNF with Medicare certification in anticipstion of covered skilled care (sifacttwé 2/23/05).
See Code 61 below.
04 DischargedMnsferred to an Intermediate Care Facility (ICF)
06 DiscusrgêdMnsferred to home under care of organized home health service organization in anucipatcñ of
covered skills care (effective 2/23/05).
07 Left against medical advice or disccatiñüsd care
20 Expired (or did not recover - Rê;ig;óüs Non Medical Health Care Patient)
__
30 Still patient or expected to retum for outpatient services
41 Expired in a medical facility, such as a hospital, SNF, ICF or freestanding hospice (Hospice claims only)
. ,43. Discharged/transferred to a federal
health care facility. (effective 10/143) .
Usage note: Dischargesand transfers to a sw-,...n-ñt operated health care facility such as a Depadment of
Defense-hospital, a Veteran's Ad= ictaion (VA) hospital or VA hospital or a VAnursing facility. To be used
whenever the dese::éhn at discharge is a federal health care facility, whether the patient lives there or not.
50 Discharged/transferred to Hospice - home
_ _. . __ __ _
51 Discharged/transferred to Hospice - medical
facility
62 Discharged.hn ed to aninpatient rehabilitation facility including distinct part units of a hospital
..
65 Dishsigêd/hanefer-ed to a psychiatric hospital or psychiatric distinct part unit of a hospital
70 Dischargê/transfer to another type of health care institution not defined elsewhere in the code list. (effective 4/1/08)
RN Signature:
PHILLIPS, KELLEY .
FAC: MMC MOSES DIVISIoN
MR#O3088163 KS K534·.A
DOB: 04/24/1978 F
VIS:06/30/2010 9:08p
ACCT: 212787303
,
MMC-NR7959ME
(O6/08) Side 2 of 2
FILED: BRONX COUNTY CLERK 02/24/2022 02:17 PM INDEX NO. 21169/2011E
NYSCEF DOC. NO. 284 RECEIVED NYSCEF: 02/24/2022
.
'SUCAREe ED Summary
Hospital : Mos es Emergency Department Patient: PHILLIPS , Ke lley
Address: 111 East 210th street Age: 32 yr Sex: F
Bronx, NY 10467 VisitDate: 06/30/2010 21:08
Phone: 718 . 92 O . 5731 MedRec: 03 O8 8163
Account: 212787303
Primary Diagnosis
• Acute Pain
Other Diagnoses
• Muscuicske|õtal: genem!!zed body pain
Conditions
• Blood Presure: Elevated, Value: 152/97
a CBC: Hgb: Value: 10.8
• None
Risk Considerations
• Notes:32yo F w/ diffuse body pain, sp MVA accident weeks ago. Pt given pain meds in ED, no avail. Plain views
neg. May have psych component
Vitals AVSS
Plain films neg.
a Trõâtmsñt Risks: Significantly symptomatic after ED treatrñõiit squMng further tr::t-ent, Persistent sympªces:
generalized body pain
Morbidity / Mortality
• Moderate - High: Condit!en with signiflusht scit-|dity or pciéü1isi morbidity >= 24hrs of eva:üâtion or
-aq±!ng
treatment
• Additional Süpporting Documaritation: intractable pain
Plan of Care
a Further Radiology Disgñéstic Testing: c spine, t spine, LS spine
• Intent - Estimated Duration: >= 24 brs
• Medication: IV Ana|gssic: morphine
a Physiologic Monitoring
Initial Assessment
Phys ician Signature (s)
Page 1 of 2 CreatedOn 07/01/2010 03:26AM
THESE ALGORITHMS/GUDELNESARETO BE USED TO AID DOCUMENTATIONONLY. THEYARE NOTTO BE USEDTO DETERMINE DISPOSITION
FILED: BRONX COUNTY CLERK 02/24/2022 02:17 PM INDEX NO. 21169/2011E
NYSCEF DOC. NO. 284 RECEIVED NYSCEF: 02/24/2022
'SUCARE. ED Summary
Hospital: Moses Emergency Department Patient: PHILLIPS, Kelley
Address: 111 East 210th street . Age: 32 yr Sex: F
Bronx, NY 10467 VisitDate: 06/30/2010 21:08
Phone: 718.920.5731 MedRec: 03088163
Account: 212787303
I have reviewed this document and attest that these conditions are present.
Izzo, Albert
Attending Physician Date/Time
Progress Notes
Discharged:
Hospitalist Signature: Date/Time:
Page2of2 CreatedOn07/01/2010 03:26 AM
THESEALGORITHMS/GUDELNESARETOBE USEDTO AID DOCUMENTATIONONLY.THEY ARE NOT TO BE USEDTO DETERMINEDISPOSITION
FILED: BRONX COUNTY CLERK 02/24/2022 02:17 PM INDEX NO. 21169/2011E
NYSCEF DOC. NO. 284 RECEIVED NYSCEF: 02/24/2022
SUCARE* ED Summary
• Hospital:
Address:
Moses
111
Emergency
East 210th
Department
street
Patient : PHILLIPS,
Age : 3 2 yr
Kelley
Sex: F
Bronx, NY 10467 VisitDate: 06/30/2010 21:08
Phone : 718 . 920 . 5731 MedRec: 03 0 8 8163
Account : 212 78 7303
Primary Diagnosis
e Acute Pain
Other Diagnoses
• Museu!eskelete!: generalized body pain
Conditions
a Blood Presure: EJevated, Value: 152/97
• CBC: Hgb: Value: 10.8
e None
•
Risk Considerations
• Notes: 32yo F w/diffuse body pain, sp MVA accident weeks ago. Pt given pain meds in ED, no avail Plain views
neg. May have psych component
Vitals AVSS:
Plain films neg.
• Tretmen.t Risks: Significâñtly s;=pic--stc after ED tisatmêñt requiring further 'J::tmor.:, Persistent sy-ptoms
generalized body pain
Morbidity / Mortality
•·Moderate - High: Condition with significant merbidity or pGisatiâ| morbidity requiring >= 24hrs of êvaiüatiü¯ or
treatment
• Additional Supporting Docum:-.t:±!:ñ: irdeet-b'e pain
Plan of Care
• Further Radiology Disgñõstic Testing: c spine, t spine, LS spine
• Intent - Estimated Duration: >= 24 brs
• Medication: IV Analgesic: morphine
• Physiologic Monitoring
Initial Assessment
Physician Signature (s)
Page 1 of 2 CreatedOn 07/01/201003:26AM
THESE ALGORITHMS/GUDELNESARE TO BE USED TO AID DOCUMENTATIONONLY. THEY ARE NOT TO BE USEDTO DETERMINEDISPOSITION
FILED: BRONX COUNTY CLERK 02/24/2022 02:17 PM INDEX NO. 21169/2011E
NYSCEF DOC. NO. 284 RECEIVED NYSCEF: 02/24/2022
.
"SUCARE* ED Swan
Hospital: Moses Emergency Departtpent Patient: EHILLIPS, Kelley
Address: 111 East 210th street Age: 32 yr Sex: F
Bron.x , NY 10467 VisitDate: 66/30/2010 21:08
Phone: 718.920 . 5731 MedRec: 03088163
ACCount: 2127S7303
I have revi d this document and attest that these conditionis are present.
12 EO, S EC
Atters g Physician Date/Time
Progress Notes
Discharged: _, , ,
Hospitalist Signature: Date/Time:
9
Page 2 of 2 Createc On 07/01/201003:26 AM
THESE ALGORITHMS/GtJDELNESARE TO BE USEDTOAID DOCJMENTADON ONLY THEY ARE NOTTOBE USED TO DETERMiNEDISPOSITION
FILED: BRONX COUNTY CLERK 02/24/2022 02:17 PM INDEX NO. 21169/2011E
NYSCEF DOC. NO. 284 RECEIVED NYSCEF: 02/24/2022
NTEFlORE Moses Emergency Department Patient: PHILLlPS, Kelley
111 East 210th Street Triage Date: June 2010
30,
DOB: April 24, 1978 Sex: Female
20 731
Med Rec#: 03088163 Age: 32 yr
Account#: 212787303
uni t - Triage
Pro-Hospital Care Initial VS
\, IV: Site:
MEDS: Time:
Oxygen @ T:
Triage Lev Backboard: C-Collar:
O 1 FT Dressing/Sp!!nts: P:
O 2 FUFT
3 O POS Fall Screen Needed O Yes o R:
4 Special Considerations\Barrie Learning:
O 5 O Communications: O Language Hearing O Speech BP:
Prctoco!= O interpreter O Deaf Talk
O CEU O Abuse/Neglect/Exp!citet!en Screen: O Pos Neg Pulse ox On O O2 .RA
-
O Sepsis O Social Services to be Notified: O Yes O No
O Stroke O: Communicable Disease Screen: O Pos eg Peak Flow:
O Isolation O Yes O No Type:
O Suicidal O Homicidal O CO Initiated Tune: Best P.F.:
Ham you ever tried to end your life before? OtY O N
D ot|feel that way now? pY C N , f
Chief Com laint: .
Assessment:
RN Signature: Endorsed To:
Past Med/Surg Hx: ILMP:
DPT:
,AA I
Current Medications:
ACCT: 212787303
PH1LLIPS. Kelley .
RF1 IG:MT DOB:24Apr78 HEG:06/30/2010 9:08PM
CARE OF: APT:24R
ADDR:3450 WAYNE AVENUE BRONX U
I.1 . 1 d
Preview
FILED: BRONX COUNTY CLERK 02/24/2022 02:17 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 284 RECEIVED NYSCEF: 02/24/2022 SUMMARY SHEET MEDREC#:03088163 MONTE FIORE MEDIC AL CENTER ACCTNO:212787303 MMCMOSESDIVISION INPATIENT IIIIIIIIll ADM DT & TIME: 06/30/2010 9:08pm ADM STATUS: Emergency DIS DT & TIME: 2:31pm 07/01/2010 UNIT: K5 RM #: K534-A READM: N ADV DIR: PATIENT NAME:PHILCIPS, Kelley . SSN #: SEX:F MS:S C/0: DOB: 04/24/1978 AGE: 32 REL: MT ADDR: 3450 WAYNE AVENUE 24R MOTHER'S MAIDEN NAME: CITY: BRONX ST: NY ZIP: 10467 BIRTH PLACE: PHONE BUS: HOME: (321)298-0044 PCP: TORRES, CARLOS RHIO CONSENT: PCP PHONE: 633- 8255 (866) SPOUSE NAME & EMPLOYER NEXT OF KIN EMERGENCY PHILLIPS, Eileen . MALLIS. Melinda . FL M 0 (321)759-3523 (917)923-4133 SERVICE: MPA ADM SOURCE: EMERGENCY DEPARTMENT PREVIOUS HOSPITAL ADMISSION ATTEND MD: GANDHI. SONIYA G/P/S: H DATE FROM: TO: ADMIT MD: FERNANDES. DAVID HOSP NAME: ADMITiDIAG: PAIN CONTROL ADDR: PATIENT OCCUPATION: RESIDENT PRIM INSUR: F00 999999999999999 - EMPLOYER: MONTEFIORE MEDICAL C SEC INSUR: - ADDR: 111 E. 210JiH STREET TER INSUR: - CITY: BRONX ST: NY ZIP: 10467 PHONE: DISCHARGE DISPOSITION: REGULAR - AMA TRANSFERRED -- WHERE? EXPIRED AUTOP5Y? YES NO ME CASt? n.S NU Printed On: 07/01/2010 9:36pm FILED: BRONX COUNTY CLERK 02/24/2022 02:17 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 284 RECEIVED NYSCEF: 02/24/2022 • DisSuM- PHILLIPS. ,FAC C MOSES DIV MONTEFlORE MEDICAL CENTER DISCHARGESUMMARY ISION . ADMISSION DATE:0h PO DIScHARGE DATE: DOB: 04/ 2 97 BRIEFHISTORY/ REASONFORADMISSION 0/ 2010 [ :08p PERTINENTPHYSICALEXAMINATION FINDINGS PERTINENT LABORATORY, FINOlNGS X-RAYANDPATHOLOGICAL C COURSEANDTHERAPY HOSPITAL A . R G DIAGNOSES 1. 4. 2. 5. AND/ ORPROCEDURES PERATIONS (INCLUDEDATES) 2. 4. OFACTIVITY O NONE UMITATIONS DET CONDITIONONDisGhaRGE(MUSTBERELATEDTOREASONFORADMISSION) M UnderstoodDischargeInstructionsO Yes O No C mments PLANSFORFUTURECARE O Transfer To: NAMEOF INSTITUTION Follow up Appointments: Date/Time MDName Specialty Location/Phone 2)'l /''- f T•'l5®__ )_0. _ow'CX- 59 o . ov o 95 Ens3r b.eal R The Home Discharge IssenemnanList that is attached to this form must be completed nd Ives to the tient soon discharge trom.the hospital. PHYSICIANPRINTEDNA "PJeTIALS TRAINI LEVEL PHYSICI SIGNATURE/CREDENTIALS DATEmME MD2942ME(12/09) Page1of2 WHITE - CHART COPY YELLOW - PATIENT/FACtLITY PINK - PROVIDER FILED: BRONX COUNTY CLERK 02/24/2022 02:17 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 284 RECEIVED NYSCEF: 02/24/2022 MONTEFlOliE MEDICAL CENTER HOME DISCHARGE MEDICATION LIST 'THIS IS NOT A PRESCRIPTION. L E Im#O3088163 K DOB; 04 /24 / 19 V iS:06/ 30/2010 ACCT: 21 278730 MEDICATION NAME STRENGTH NUMBER HOW OFTEN MEDICATION ROUTE DURATION Brand Name of tabs,caps, of tabs.caps, When? W.E W GenericName(also known as) P.uffs,drops, puffs, drops, (i.e., twIcea day, AJUSTES DE LDS med mlections? medication? Stop date? Inlections? breakfastand dinner) MEDICAMENTOS CHANGED NOMBRE DEL MEDICAMENTO d a et s. cápsulas, d t beus capsulas, FRECUENCIA · Cudndo? a me n SAME NEW DOSE M inhataciones, inhalaciones, (es decir,dos vecesal ¿Pa NombrecomernialNombre medicaclón? debedejarde DOSIS go as, gotas, MISMD NUEVO generico(tamblin conocido como) inyecciones Inyecciones tomarla? gaggggg, med Discontinue (1.e., stop taking these medications): Discontinúa (Para de tomar estos medicamentos): This Medication List Is to be ccmplstad using Patient Friendly Language = LEGEND: O Oral, Inh = = Inhalation, inj Injection, Top = Topical, SC = Subcutaneous, IV = Intravenous Please see patient instructions DESCRIPCtÓN: O = Oral, inh = Inhalación, lr = Inyección, Top = Tópico, SC = Subcutdneo, IV = Intravenoso Vea por favor las instrucciones MOlPA/NP Completing Form Pa Print Name Signature/Credentials Datemme Print Name MO3642ME (12/o9) FILED: BRONX COUNTY CLERK 02/24/2022 02:17 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 284 RECEIVED NYSCEF: 02/24/2022 PHILLIPS, KELLEY . FAC:MMC MOSEs DIVisION MR#03088163 K5 K534-A DOB' 04/24/1978 F VIS:06/30/ 2010 9:08p ACCT: 21 2787303 Patient Instructions: (THIS IS NOT A PRESCRIPTION) • Take all your medications as prescribed. • a list of your medications with you, and this list to each physiciañ visit. Keep bring a Contact your physiciañ before medications you have at home and not on this list. taking any • Contact your physician before over-the-counter med!cations or herbal medicaticñs. taking any • Contact your physician if you have questions about your medications. any Instrucciones para el paciente: (ESTO NO ES UNA RECETA) • Tome todos ios medicamentos como se indica. • Conserve una lista de los medicamêñtas con:usted y IIévela a cada visita al médico. • Comuniquese con su médico antes de tomar cualquier medicamento que tenga en su casa que no esté en la lista. • Comuñ!qüêss con su médico antes de .tomar cualquier medicamento de venta libre o medicamentos a base de hierbas. a Comuniquese con su médico si tiene alguna pregunta sobre sus medicamentos. FILED: BRONX COUNTY CLERK 02/24/2022 02:17 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 284 RECEIVED NYSCEF: 02/24/2022 OSES O VI S Î ON K5 DOS K534-A MONTEFlORE MEDICAL CENTER ' · 04/24/1978 F vys 2010 9: 08p DISCHARGE P I UCTIONS ACCT Admission Date: / D FEI 278730s . . Discharge Date: Discharge to: Allergies: Surgical Procedure: tf ADDRESsuunew .. / 24 t ns BP T: P: $4 R: Wei P Re A ble: O o Mental Status: Environment: Awake & Alert ED es O No Needs Adjustment: O Yes No nted to: Person: Describe: O No Place: d O No Time: ffYes O No II. ABILITY TO PERFORM ACTIVITIES OF DAILY LIVING (ADL) ADL Self Assisted (!ne!ud!ng Devices) Dependent Restrictions Transf er Dressing Ambu!eting cane crutches walker w/c other _.. Feeding Bathing Toileting Position Chance • Gait steadv· I-ly s FI No Bedfast: Q Yes O No Chairfast Q Yes Q No Ill. DIET INSTRUCTIONS: IV, DISCHARGE MEDICATION O None Home discharge medication list completed by / ANP ElÝes O No Patient instructed to bring current list of med tions during Action & Side Eff'ects of Medication Were Reviewsd? Yes O No provider visits/future hospitalizations: es O No Specialized Treatments Frequency V. PLANS FOR FUTURE CARE O Transfer To: ____ NAMEOFINSTITUTION Follow ^P'==nts: VI. WOUND/SKIN INTACT? O No If No, is it pressure-related O Yes O No • If Pressure Related: Identify site and stage Site Stage Site Stage Site Stage Site Stage Non-Pressure Related: Describe condition of skin VII. LIST SIGNS/SYMPTOMS WHEN TO SEEK MEDICAL ASM.RTANCE (Tailor to specific diagnosis I.e. CHF) your Doctor / Retum to Hospital if the following symptoms occur: r O Unusual n O Redn rainaga,‡wailing at the wound site O Vomiting O Nausea O Diarrhea natipation Chest Pain culty Breathing O Leg/Ankle Swelling d Caif eain . O Other Monitor weight: Notify MD if the following occurs O Gain/Loss of 31bs O Other Vill.PROPERTY/CLOTHING RETURNED TO: QFatient O Family O N/A IX. LIST UNRESOLVED PROBLEMS/NEEDS AND INDICATE L ADDITIONAL COMMENTS/EDUCATIONAL PLAN OF CARE TO BE FOLLOWED POST-DISCHARGE INSTRUCTIONS: * Include Unacceptable Pain Relief f If you have heart failure, check your weight daily and report changes Problem/Need Plan of Care Post-Discharge #1 help quitting call the NYS Srnokers Quit Line at 1-866-NY-QUITS or 1-866-697-8487. When you feel you can't go on call 1-800-273-TALK #3 (1-800-273-8255) SUICIDE HOTLINE I'HIS DIS GEPLANHAS BEENREVIEWEDAND I HAVERECElVED A COPY. Signature of Patient / Repn=,antative / Releuenehip RN Signat re Time (06/08) · MMC-NR7959ME White - Chart Copy Yellow - Patient Copy Pink - Nursing Home Side 1 of 2 FILED: BRONX COUNTY CLERK 02/24/2022 02:17 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 284 RECEIVED NYSCEF: 02/24/2022 Procedure: • Upon discharge, unit secretaries and-admitting clerks must verify whethsr patient is going home with or without Home Care services, .whethar the patient expired or to what type of facility the patient was discharged. • There are several options in Carecast to denote discharge disposition. See listing and definitions below. • Disposition codes must accurately reflect the actual patient disposition when discharged. • if the patient Discharge Disposition iñciudss a + code, the name of the facility which is taking responsibility for the patient must be further specified by clicking on the appropriate name in the drop down menu. This information must be obtained frorn "either discussion with the nurse, social worker and/or documentation in the discharge summary in the medical Irecord. • This iñfürrñation is isquired regardless of which department discharges the patient in Carecast. Code Structure 01 Discharged to home or self ccare (routine disubarge) 02 Discharg-d½nsferred to a short-term general hospital for inpatient care. . ..... 03 Discharged/transferred to SNF with Medicare certification in anticipstion of covered skilled care (sifacttwé 2/23/05). See Code 61 below. 04 DischargedMnsferred to an Intermediate Care Facility (ICF) 06 DiscusrgêdMnsferred to home under care of organized home health service organization in anucipatcñ of covered skills care (effective 2/23/05). 07 Left against medical advice or disccatiñüsd care 20 Expired (or did not recover - Rê;ig;óüs Non Medical Health Care Patient) __ 30 Still patient or expected to retum for outpatient services 41 Expired in a medical facility, such as a hospital, SNF, ICF or freestanding hospice (Hospice claims only) . ,43. Discharged/transferred to a federal health care facility. (effective 10/143) . Usage note: Dischargesand transfers to a sw-,...n-ñt operated health care facility such as a Depadment of Defense-hospital, a Veteran's Ad= ictaion (VA) hospital or VA hospital or a VAnursing facility. To be used whenever the dese::éhn at discharge is a federal health care facility, whether the patient lives there or not. 50 Discharged/transferred to Hospice - home _ _. . __ __ _ 51 Discharged/transferred to Hospice - medical facility 62 Discharged.hn ed to aninpatient rehabilitation facility including distinct part units of a hospital .. 65 Dishsigêd/hanefer-ed to a psychiatric hospital or psychiatric distinct part unit of a hospital 70 Dischargê/transfer to another type of health care institution not defined elsewhere in the code list. (effective 4/1/08) RN Signature: PHILLIPS, KELLEY . FAC: MMC MOSES DIVISIoN MR#O3088163 KS K534·.A DOB: 04/24/1978 F VIS:06/30/2010 9:08p ACCT: 212787303 , MMC-NR7959ME (O6/08) Side 2 of 2 FILED: BRONX COUNTY CLERK 02/24/2022 02:17 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 284 RECEIVED NYSCEF: 02/24/2022 . 'SUCAREe ED Summary Hospital : Mos es Emergency Department Patient: PHILLIPS , Ke lley Address: 111 East 210th street Age: 32 yr Sex: F Bronx, NY 10467 VisitDate: 06/30/2010 21:08 Phone: 718 . 92 O . 5731 MedRec: 03 O8 8163 Account: 212787303 Primary Diagnosis • Acute Pain Other Diagnoses • Muscuicske|õtal: genem!!zed body pain Conditions • Blood Presure: Elevated, Value: 152/97 a CBC: Hgb: Value: 10.8 • None Risk Considerations • Notes:32yo F w/ diffuse body pain, sp MVA accident weeks ago. Pt given pain meds in ED, no avail. Plain views neg. May have psych component Vitals AVSS Plain films neg. a Trõâtmsñt Risks: Significantly symptomatic after ED treatrñõiit squMng further tr::t-ent, Persistent sympªces: generalized body pain Morbidity / Mortality • Moderate - High: Condit!en with signiflusht scit-|dity or pciéü1isi morbidity >= 24hrs of eva:üâtion or -aq±!ng treatment • Additional Süpporting Documaritation: intractable pain Plan of Care a Further Radiology Disgñéstic Testing: c spine, t spine, LS spine • Intent - Estimated Duration: >= 24 brs • Medication: IV Ana|gssic: morphine a Physiologic Monitoring Initial Assessment Phys ician Signature (s) Page 1 of 2 CreatedOn 07/01/2010 03:26AM THESE ALGORITHMS/GUDELNESARETO BE USED TO AID DOCUMENTATIONONLY. THEYARE NOTTO BE USEDTO DETERMINE DISPOSITION FILED: BRONX COUNTY CLERK 02/24/2022 02:17 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 284 RECEIVED NYSCEF: 02/24/2022 'SUCARE. ED Summary Hospital: Moses Emergency Department Patient: PHILLIPS, Kelley Address: 111 East 210th street . Age: 32 yr Sex: F Bronx, NY 10467 VisitDate: 06/30/2010 21:08 Phone: 718.920.5731 MedRec: 03088163 Account: 212787303 I have reviewed this document and attest that these conditions are present. Izzo, Albert Attending Physician Date/Time Progress Notes Discharged: Hospitalist Signature: Date/Time: Page2of2 CreatedOn07/01/2010 03:26 AM THESEALGORITHMS/GUDELNESARETOBE USEDTO AID DOCUMENTATIONONLY.THEY ARE NOT TO BE USEDTO DETERMINEDISPOSITION FILED: BRONX COUNTY CLERK 02/24/2022 02:17 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 284 RECEIVED NYSCEF: 02/24/2022 SUCARE* ED Summary • Hospital: Address: Moses 111 Emergency East 210th Department street Patient : PHILLIPS, Age : 3 2 yr Kelley Sex: F Bronx, NY 10467 VisitDate: 06/30/2010 21:08 Phone : 718 . 920 . 5731 MedRec: 03 0 8 8163 Account : 212 78 7303 Primary Diagnosis e Acute Pain Other Diagnoses • Museu!eskelete!: generalized body pain Conditions a Blood Presure: EJevated, Value: 152/97 • CBC: Hgb: Value: 10.8 e None • Risk Considerations • Notes: 32yo F w/diffuse body pain, sp MVA accident weeks ago. Pt given pain meds in ED, no avail Plain views neg. May have psych component Vitals AVSS: Plain films neg. • Tretmen.t Risks: Significâñtly s;=pic--stc after ED tisatmêñt requiring further 'J::tmor.:, Persistent sy-ptoms generalized body pain Morbidity / Mortality •·Moderate - High: Condition with significant merbidity or pGisatiâ| morbidity requiring >= 24hrs of êvaiüatiü¯ or treatment • Additional Supporting Docum:-.t:±!:ñ: irdeet-b'e pain Plan of Care • Further Radiology Disgñõstic Testing: c spine, t spine, LS spine • Intent - Estimated Duration: >= 24 brs • Medication: IV Analgesic: morphine • Physiologic Monitoring Initial Assessment Physician Signature (s) Page 1 of 2 CreatedOn 07/01/201003:26AM THESE ALGORITHMS/GUDELNESARE TO BE USED TO AID DOCUMENTATIONONLY. THEY ARE NOT TO BE USEDTO DETERMINEDISPOSITION FILED: BRONX COUNTY CLERK 02/24/2022 02:17 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 284 RECEIVED NYSCEF: 02/24/2022 . "SUCARE* ED Swan Hospital: Moses Emergency Departtpent Patient: EHILLIPS, Kelley Address: 111 East 210th street Age: 32 yr Sex: F Bron.x , NY 10467 VisitDate: 66/30/2010 21:08 Phone: 718.920 . 5731 MedRec: 03088163 ACCount: 2127S7303 I have revi d this document and attest that these conditionis are present. 12 EO, S EC Atters g Physician Date/Time Progress Notes Discharged: _, , , Hospitalist Signature: Date/Time: 9 Page 2 of 2 Createc On 07/01/201003:26 AM THESE ALGORITHMS/GtJDELNESARE TO BE USEDTOAID DOCJMENTADON ONLY THEY ARE NOTTOBE USED TO DETERMiNEDISPOSITION FILED: BRONX COUNTY CLERK 02/24/2022 02:17 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 284 RECEIVED NYSCEF: 02/24/2022 NTEFlORE Moses Emergency Department Patient: PHILLlPS, Kelley 111 East 210th Street Triage Date: June 2010 30, DOB: April 24, 1978 Sex: Female 20 731 Med Rec#: 03088163 Age: 32 yr Account#: 212787303 uni t - Triage Pro-Hospital Care Initial VS \, IV: Site: MEDS: Time: Oxygen @ T: Triage Lev Backboard: C-Collar: O 1 FT Dressing/Sp!!nts: P: O 2 FUFT 3 O POS Fall Screen Needed O Yes o R: 4 Special Considerations\Barrie Learning: O 5 O Communications: O Language Hearing O Speech BP: Prctoco!= O interpreter O Deaf Talk O CEU O Abuse/Neglect/Exp!citet!en Screen: O Pos Neg Pulse ox On O O2 .RA - O Sepsis O Social Services to be Notified: O Yes O No O Stroke O: Communicable Disease Screen: O Pos eg Peak Flow: O Isolation O Yes O No Type: O Suicidal O Homicidal O CO Initiated Tune: Best P.F.: Ham you ever tried to end your life before? OtY O N D ot|feel that way now? pY C N , f Chief Com laint: . Assessment: RN Signature: Endorsed To: Past Med/Surg Hx: ILMP: DPT: ,AA I Current Medications: ACCT: 212787303 PH1LLIPS. Kelley . RF1 IG:MT DOB:24Apr78 HEG:06/30/2010 9:08PM CARE OF: APT:24R ADDR:3450 WAYNE AVENUE BRONX U I.1 . 1 d