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LGH Medical File From 302 by Detective Bearinger of Lancaster City Police of July 10, 2015un

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LGH Medical File From 302 by Detective Bearinger of Lancaster City Police of July 10, 2015un
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LANCASTER GENERAL HOSPITAL Health Information Management 555 North Duke Street Lancaster PA 17604-3555 ED Record CATERBONE,STANLEY J MRN: 0542297 DOB: 7/15/1958, Sex: M Adm: 7/10/2015, D/C: 7/11/2015 Patient Demographics ED Arrival Information Expected Arrival Acuity Means of Arrival Escorted By Service Admission Type - 7/10/2015 17:46 2=Emergent Police - Emergency Medicine Emergency Arrival Complaint psych eval Chief Complaint Psych Evaluation [160478] Diagnosis Acute psychosis ED Events Date/Time Event User Comments 07/10/15 1746 Patient arrived in ED RODRIGUEZ-SOTO, MELISSA 07/10/15 1747 RODRIGUEZ-SOTO, MELISSA 07/10/15 1747 RODRIGUEZ-SOTO, MELISSA 07/10/15 1747 Patient roomed in ED RODRIGUEZ-SOTO, MELISSA To room 15BHE 07/10/15 1747 Assign Nurse HUEHNERGARTH, GRETCHEN A Huehnergarth, Gretchen A, RN assigned as Registered Nurse 07/10/15 1748 Assign Attending HUEHNERGARTH, GRETCHEN A McIntyre, Daniel, MD assigned as Attending 07/10/15 1748 Assign Doctor/Pt. eval begins HUEHNERGARTH, GRETCHEN A 07/10/15 1749 Triage Started HUEHNERGARTH, GRETCHEN A 07/10/15 1749 XR Ordered MCINTYRE MD, DANIEL P XR SHOULDER RIGHT MIN 2 VW 07/10/15 1749 Imaging Exam Ordered MCINTYRE MD, DANIEL P Printed on 7/28/2015 11:44 AM Page 1 CATERBONE,STANLEY ENGLISH Emergency Contact 1 Refused Name Patient ID SSN Address Phone EMail Employer 1250 FREMONT STREET LANCASTER PA 17603- 9543 717-826-5354 (H) 717-669-2163 (M) Sex Birth Date County Race LANCASTER White Caterbone, Stanley J 0542297 xxx-xx-0959 Reg Status PCP Verified Sullivan, Brian P, MD717-291-5991 Male 07/15/58 (57 yrs) Marital Status Religion Alias Language Single -
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  • LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record

    CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015

    Patient Demographics

    ED Arrival Information

    Expected Arrival AcuityMeans ofArrival Escorted By Service

    AdmissionType

    - 7/10/201517:46

    2=Emergent Police - EmergencyMedicine

    Emergency

    Arrival Complaintpsych eval

    Chief ComplaintPsych Evaluation [160478]

    DiagnosisAcute psychosis

    ED EventsDate/Time Event User Comments07/10/15 1746 Patient arrived in ED RODRIGUEZ-SOTO,

    MELISSA07/10/15 1747 RODRIGUEZ-SOTO,

    MELISSA07/10/15 1747 RODRIGUEZ-SOTO,

    MELISSA07/10/15 1747 Patient roomed in ED RODRIGUEZ-SOTO,

    MELISSATo room 15BHE

    07/10/15 1747 Assign Nurse HUEHNERGARTH,GRETCHEN A

    Huehnergarth, Gretchen A, RN assigned asRegistered Nurse

    07/10/15 1748 Assign Attending HUEHNERGARTH,GRETCHEN A

    McIntyre, Daniel, MD assigned as Attending

    07/10/15 1748 Assign Doctor/Pt. evalbegins

    HUEHNERGARTH,GRETCHEN A

    07/10/15 1749 Triage Started HUEHNERGARTH,GRETCHEN A

    07/10/15 1749 XR Ordered MCINTYRE MD, DANIEL P XR SHOULDER RIGHT MIN 2 VW07/10/15 1749 Imaging Exam

    OrderedMCINTYRE MD, DANIEL P

    Printed on 7/28/2015 11:44 AM Page 1

    CATERBONE,STANLEY ENGLISH

    Emergency Contact 1Refused

    Name Patient ID SSN

    Address Phone EMail Employer1250 FREMONT STREETLANCASTER PA 17603-9543

    717-826-5354 (H)717-669-2163 (M)

    Sex Birth Date

    County RaceLANCASTER White

    Caterbone, Stanley J 0542297 xxx-xx-0959

    Reg Status PCPVerified Sullivan, Brian P, MD717-291-5991

    Male 07/15/58 (57 yrs)

    Marital Status Religion Alias LanguageSingle -

  • LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record

    CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015

    ED EventsDate/Time Event User Comments07/10/15 1750 Vitals Assessment HUEHNERGARTH,

    GRETCHEN A07/10/15 1801 Charting Complete MCINTYRE MD, DANIEL P07/10/15 1801 Transfer Disposition

    SelectedMCINTYRE MD, DANIEL P ED Disposition set to Transfer

    07/10/15 1801 Disposition Selected MCINTYRE MD, DANIEL P07/10/15 1824 Registration

    CompletedGROFF, BARBARA A

    07/10/15 1829 Xray Final Result INTERFACE, INCOMINGRAD RESULTS

    (Final result) XR SHOULDER RIGHT MIN 2VW

    07/10/15 1938 Lab Ordered HUEHNERGARTH,GRETCHEN A

    CBC, POCT URINE PREGNANCY

    07/10/15 1946 Admit DispositionSelected

    ECHEVARRIA, MARIAN ER

    ED Disposition set to Admit

    07/10/15 1946 Disposition Selected ECHEVARRIA, MARIAN ER

    07/10/15 1946 Transfer DispositionSelected

    ECHEVARRIA, MARIAN ER

    ED Disposition set to Transfer

    07/10/15 1946 Disposition Selected ECHEVARRIA, MARIAN ER

    07/10/15 2010 Lab Resulted INTERFACE, INCOMINGLAB RESULTS

    (Final result) CBC

    07/10/15 2034 Lab Resulted INTERFACE, INCOMINGLAB RESULTS

    (Final result) BASIC METABOLIC PANEL(BMP)

    07/10/15 2323 Assign Nurse YARNISH, THERESA M Yarnish, Theresa M, RN assigned asRegistered Nurse

    07/10/15 2323 Remove Nurse YARNISH, THERESA M Huehnergarth, Gretchen A, RN removed asRegistered Nurse

    07/10/15 2333 Triage Completed YARNISH, THERESA M07/11/15 0000 ED Census07/11/15 0040 Patient discharged YARNISH, THERESA M07/11/15 0040 Patient departed from

    EDYARNISH, THERESA M

    07/11/15 0114 YARNISH, THERESA M07/11/15 0114 YARNISH, THERESA M07/11/15 0114 YARNISH, THERESA M07/11/15 0114 YARNISH, THERESA M07/11/15 0119 Charting Complete YARNISH, THERESA M07/21/15 1520 Charting Complete HUEHNERGARTH,

    GRETCHEN A07/10/15 1810 Imaging Exam Started MESKEY, ELIZABETH M XR SHOULDER RIGHT MIN 2 VW07/10/15 1812 Imaging Exam Ended MESKEY, ELIZABETH M XR SHOULDER RIGHT MIN 2 VW

    ED Treatment TeamProvider Role From To Phone PagerMcIntyre, Daniel, MD Attending Provider 07/10/15 1748 07/11/15 0040 717-544-4978Huehnergarth,Gretchen A, RN

    Registered Nurse 07/10/15 1747 07/10/15 2323

    Yarnish, Theresa M,RN

    Registered Nurse 07/10/15 2323 --

    Printed on 7/28/2015 11:44 AM Page 2

  • LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record

    CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015

    Discharge OrdersNone

    Printed on 7/28/2015 11:44 AM Page 3

  • LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record

    CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015

    ED Notes

    ED Notes by Huehnergarth, Gretchen A, RN at 7/10/2015 5:49 PM Version 1 of 1Author: Huehnergarth, Gretchen A,RN

    Service: (none) Author Type: Registered Nurse

    Filed: 7/10/2015 5:50 PM Note Time: 7/10/2015 5:49 PM Status: SignedEditor: Huehnergarth, Gretchen A, RN (Registered Nurse)

    Patient on 302 for psychosis and paranoia directed at a Lancaster Detective

    Signed by Huehnergarth, Gretchen A, RN on 7/10/2015 5:50 PM

    ED Provider Notes by McIntyre, Daniel, MD at 7/10/2015 5:58 PM Version 1 of 1Author: McIntyre, Daniel, MD Service: Emergency Medicine Author Type: PhysicianFiled: 7/10/2015 6:01 PM Note Time: 7/10/2015 5:58 PM Status: SignedEditor: McIntyre, Daniel, MD (Physician)

    HISTORY:

    Chief ComplaintPatient presents with

    Psych Evaluation

    HPI56-year-old male with a long psychiatric history presents to the emergency room in police custody on a 302petition. Apparently the patient has been contacting a detective and making threats of packing into policecomputers. The patient has been off of his medication for some time. The patient appears paranoid. He iscomplaining of right shoulder pain. He states that he was arrested while cutting his lawn today. He thinks thathis right arm was twisted in his shoulders been uncomfortable since. The patient denied any other injuries. Hedenies any homicidal or suicidal thoughts. No past medical history on file.

    No past surgical history on file.

    No family history on file.Not significantSocial HistorySubstance Use Topics

    Smoking status: Current Every Day Smoker -- 1.00 packs/dayTypes: CigarettesSmokeless tobacco: Not on fileAlcohol Use: Yes

    Continues to smoke dailyProblem List

    DiagnosisParanoid Schizophrenia

    Printed on 7/28/2015 11:44 AM Page 4

  • LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record

    CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015

    ED Notes (continued)

    Review of SystemsI have reviewed and agree with the nursing notes as well as the social history.

    Review of Systems both pertinent positive and negative findings of the review of systems, has beenthoroughly documented in the HPI (above in the chart) and all other systems are negative.

    PHYSICAL EXAM:Vital SignsTemperaturePulse/Heart RateRespirationBP 132/74 mmHg (07/10/15 1750)MAP 93 MM HG (07/10/15 1750)SpO2O2 DeviceO2 Therapy Flow

    Physical ExamConstitutional: He is oriented to person, place, and time. He appears well-developed and well-nourished. Nodistress.HENT:Head: Normocephalic and atraumatic.Eyes: Conjunctivae are normal. Pupils are equal, round, and reactive to light.Neck: Normal range of motion. Neck supple.Cardiovascular: Normal rate, regular rhythm and normal heart sounds.Pulmonary/Chest: Effort normal and breath sounds normal. No respiratory distress. He has no wheezes.Abdominal: Soft. There is no tenderness.Musculoskeletal: Normal range of motion. He exhibits no edema.Neurological: He is alert and oriented to person, place, and time. No cranial nerve deficit. He exhibits normalmuscle tone.Skin: Skin is warm and dry. He is not diaphoretic.Psychiatric: His mood appears anxious. His speech is rapid and/or pressured. Thought content is paranoid anddelusional. He expresses no homicidal and no suicidal ideation.

    EKG RHYTHM:

    EKG INTERPRETATION:

    OXYGEN SATURATION INTERPRETATION:

    Printed on 7/28/2015 11:44 AM Page 5

  • LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record

    CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015

    ED Notes (continued)

    LAB INTERPRETATION:

    RADIOLOGY INTERPRETATION:

    ED COURSE:Procedures

    MDMPatient has been evaluated by myself and the mental health liason. Mental health liason has discussed thecase with the psychiatrist on call. We feel patient would benefit from inpatient psychiatric admission. Mentalhealth liason is arranging transfer to an inpatient bed.

    The patients condition at the time of Disposition is Unchanged.

    McIntyre, Daniel, MD07/10/15 1801

    Signed by McIntyre, Daniel, MD on 7/10/2015 6:01 PM

    ED Notes by Huehnergarth, Gretchen A, RN at 7/10/2015 8:31 PM Version 1 of 1Author: Huehnergarth, Gretchen A,RN

    Service: (none) Author Type: Registered Nurse

    Filed: 7/10/2015 8:31 PM Note Time: 7/10/2015 8:31 PM Status: SignedEditor: Huehnergarth, Gretchen A, RN (Registered Nurse)

    Patient medical history and current status reviewed. Active medical problems: stable

    Signed by Huehnergarth, Gretchen A, RN on 7/10/2015 8:31 PM

    ED Notes by Huehnergarth, Gretchen A, RN at 7/10/2015 8:32 PM Version 2 of 2Author: Huehnergarth, Gretchen A,RN

    Service: (none) Author Type: Registered Nurse

    Filed: 7/10/2015 10:05 PM Note Time: 7/10/2015 8:32 PM Status: AddendumEditor: Huehnergarth, Gretchen A, RN (Registered Nurse)Related Notes: Original Note by Huehnergarth, Gretchen A, RN (Registered Nurse) filed at 7/10/2015 8:52 PM

    Arrival Status:Police on 302 petitioned by Lancaster Detective

    Chief Complaint:Patient was sending paranoid and harrassing emails to local detective(enclosed copies in 302)Printed on 7/28/2015 11:44 AM Page 6

  • LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record

    CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015

    ED Notes (continued)

    History of Present Illness:Patient denies he is suicidal or homicidal or psychotic. He denies he is paranoid and is invested inaseries of paranoid delusions regarding the government and FBIPatients petitioner is a local Detective who states that patient has sent him over 100 emails since midJune 2015, and to other police. He states the emails are more antagonistic One of them stating "Whyare you trying to kill me" the petitioner states that patients behavior is becoming alarming and that hefears patient will reach the paranoid state of 2010 when he stated cops should be beaten and killedTo this writers knowledge patient has never been violentPatient told this writer a lengthy statement of his making a legal petition in the case of MichelleLambert (convicted Lancaster murderer from 1990's), patient states he met with the attorney generalrecently about this case and that he also drove to the office of Mike Sturla in Harrisburg.Patient became very paranoid of nurse and said she had purposely given him a cold room, that shewas a liar. He stated he would sue the hospital "back to the courts" and demanded this writer writedown the number of the court case he had against LGH from the past.Patient believes the police and FBI are hacking his computerPatient lives with his brother and doesn't drink alcohol or use drugsHe denies he has been hospitalized since 2010 at Fairmount. He is requesting to return to Fairmount

    General Appearance and Behavior:Appearance/Behavior: AgitatedEye Contact: GoodAppetite: no change from normalSleep: no change

    Thought Processing and Cognitive Evaluation:Orientation: Time, Place, Person, Name and SituationAttention & Concentration: WNLMood: HostileAffect: AppropriateSpeech: Rate: normal Volume: normal Coherence: goodThought Process: Logical:noThought Association: Tangential

    Abnormal Thought Content:Suicidal thoughts: noHomicidal thoughts: noHallucinations: noDelusions: yes

    Printed on 7/28/2015 11:44 AM Page 7

  • LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record

    CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015

    ED Notes (continued)

    Insight: poorJudgment: poor

    Substance Use:Alcohol use: no Type: Amount/Frequency: Last use: History of withdrawal symptoms:

    Use of other substances: no Type/Route: Amount/Frequency: Last use: History of withdrawal symptoms:

    History of Treatment for Substance Use: no

    Past Psychiatric History and Current Treatment:Inpatient history: yesOutpatient services: no Psychiatrist: Therapist: Case Management: Other Services:Medication and treatment compliance: n/aHistory of Suicide Attempts: noFamily history of suicide: noActs of Self Harm: noActs of Violence: no

    Social, Family and Developmental History:Current relationships/support system: brotherLiving situation: with brotherEducation:Employment: noLegal history and current charges, probation/parole: noCustody status/Child Service Involvement: noAbuse/Trauma: no

    Printed on 7/28/2015 11:44 AM Page 8

  • LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record

    CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015

    ED Notes (continued)

    Functional Status:Independent for ambulation: yesIndependent in performing ADLs: yesSpecial equipment/environmental needs: noLanguage and Cultural Needs: no

    Clinical Impression:psychosis

    Plan for Disposition:Commitment Status: 302Physician recommendation: admit Psychiatrist is okay with patient request to transfer to Fairmount

    Signed by Huehnergarth, Gretchen A, RN on 7/10/2015 10:05 PM

    ED Notes by Huehnergarth, Gretchen A, RN at 7/10/2015 8:32 PM Version 1 of 2Author: Huehnergarth, Gretchen A,RN

    Service: (none) Author Type: Registered Nurse

    Filed: 7/10/2015 8:52 PM Note Time: 7/10/2015 8:32 PM Status: SignedEditor: Huehnergarth, Gretchen A, RN (Registered Nurse)Related Notes: Addendum by Huehnergarth, Gretchen A, RN (Registered Nurse) filed at 7/10/2015 10:05 PM

    Arrival Status:Police on 302 petitioned by Lancaster Detective

    Chief Complaint:Patient was sending paranoid and harrassing emails to local detective(enclosed copies in 302)

    History of Present Illness:Patient denies he is suicidal or homicidal or psychotic. He denies he is paranoid and is invested inaseries of paranoid delusions regarding the government and FBIPatients petitioner is a local Detective who states that patient has sent him over 100 emails since midJune 2015, and to other police. He states the emails are more antagonistic One of them stating "Whyare you trying to kill me" the petitioner states that patients behavior is becoming alarming and that hefears patient will reach the paranoid state of 201 when he stateded cops should be beaten and killedTo this writers knowledge patient has never been violentPatient told this writer a lengthy statement of his making a legal petition in the case of MichelleLambert (convicted Lancaster murderer from 1990's), patient states he met with the attorney generalrecently about this case and that he also drove to the office of Mike Sturla in Harrisburg.Patient became very paranoid of nurse and said she had purposely given him a cold room, that shewas a liar. He stated he would sue the hospital "back to the courts" and demanded this writer writedown the number of the court case he had against LGH from the past.

    Printed on 7/28/2015 11:44 AM Page 9

  • LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record

    CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015

    ED Notes (continued)

    Patient believes the police and FBI are hacking his computerPatient lives with his brother and doesn't drink alcohol or use drugsHe denies he has been hospitalized since 2010 at Fairmount. He is requesting to return to Fairmount

    General Appearance and Behavior:Appearance/Behavior: AgitatedEye Contact: GoodAppetite: no change from normalSleep: no change

    Thought Processing and Cognitive Evaluation:Orientation: Time, Place, Person, Name and SituationAttention & Concentration: WNLMood: HostileAffect: AppropriateSpeech: Rate: normal Volume: normal Coherence: goodThought Process: Logical:noThought Association: Tangential

    Abnormal Thought Content:Suicidal thoughts: noHomicidal thoughts: noHallucinations: noDelusions: yes

    Insight: poorJudgment: poor

    Substance Use:Alcohol use: no Type: Amount/Frequency: Last use: History of withdrawal symptoms:

    Use of other substances: no Type/Route: Amount/Frequency: Last use:

    Printed on 7/28/2015 11:44 AM Page 10

  • LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record

    CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015

    ED Notes (continued)

    History of withdrawal symptoms:

    History of Treatment for Substance Use: no

    Past Psychiatric History and Current Treatment:Inpatient history: yesOutpatient services: no Psychiatrist: Therapist: Case Management: Other Services:Medication and treatment compliance: n/aHistory of Suicide Attempts: noFamily history of suicide: noActs of Self Harm: noActs of Violence: no

    Social, Family and Developmental History:Current relationships/support system: brotherLiving situation: with brotherEducation:Employment: noLegal history and current charges, probation/parole: noCustody status/Child Service Involvement: noAbuse/Trauma: no

    Functional Status:Independent for ambulation: yesIndependent in performing ADLs: yesSpecial equipment/environmental needs: noLanguage and Cultural Needs: no

    Clinical Impression:psychosis

    Plan for Disposition:Commitment Status: 302Physician recommendation: admit Psychiatrist is okay with patient request to transfer to Fairmount

    Signed by Huehnergarth, Gretchen A, RN on 7/10/2015 8:52 PM

    ED Notes by Huehnergarth, Gretchen A, RN at 7/10/2015 10:26 PM Version 1 of 1

    Printed on 7/28/2015 11:44 AM Page 11

  • LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record

    CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015

    ED Notes (continued)

    ED Notes by Huehnergarth, Gretchen A, RN at 7/10/2015 10:26 PM Version 1 of 1Author: Huehnergarth, Gretchen A,RN

    Service: (none) Author Type: Registered Nurse

    Filed: 7/10/2015 10:28 PM Note Time: 7/10/2015 10:26 PM Status: SignedEditor: Huehnergarth, Gretchen A, RN (Registered Nurse)

    Insurance

    Insurance Company :humanaMH Managed by : lifesyncPhone Number :8665500027Staff talked with :heather HAuthorization # :noneDates Authorized :7/10-7/13 review 7/13Other Information :

    Signed by Huehnergarth, Gretchen A, RN on 7/10/2015 10:28 PM

    ED Notes by Huehnergarth, Gretchen A, RN at 7/10/2015 10:33 PM Version 1 of 1Author: Huehnergarth, Gretchen A,RN

    Service: (none) Author Type: Registered Nurse

    Filed: 7/10/2015 10:33 PM Note Time: 7/10/2015 10:33 PM Status: SignedEditor: Huehnergarth, Gretchen A, RN (Registered Nurse)

    Patient requested and was given copy of 302

    Signed by Huehnergarth, Gretchen A, RN on 7/10/2015 10:33 PM

    ED Notes by Huehnergarth, Gretchen A, RN at 7/10/2015 10:37 PM Version 1 of 1Author: Huehnergarth, Gretchen A,RN

    Service: (none) Author Type: Registered Nurse

    Filed: 7/10/2015 10:37 PM Note Time: 7/10/2015 10:37 PM Status: SignedEditor: Huehnergarth, Gretchen A, RN (Registered Nurse)

    Patient declined any anxiolytic or antipsychotic

    Signed by Huehnergarth, Gretchen A, RN on 7/10/2015 10:37 PM

    ED Orders

    Start Status Ordering Provider07/10/15

    1939Final result MCINTYRE, DANIEL

    07/10/151939

    Final result MCINTYRE, DANIEL

    Printed on 7/28/2015 11:44 AM Page 12

    Toxic Screen, Urine, No Confirmation ONE TIME

    Alcohol, Serum ONE TIME

  • LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record

    CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015

    ED Orders

    Start Status Ordering Provider07/10/15

    1939Final result MCINTYRE, DANIEL

    07/10/151939

    Final result MCINTYRE, DANIEL

    07/10/151830

    Last MAR action:Given - byHUEHNERGARTH,GRETCHEN A on07/10/15 at 1954

    MCINTYRE, DANIEL

    07/10/151750

    Final result MCINTYRE, DANIEL

    Lab Results (07/10/15 - 07/10/15)

    CBC (For Transfers Only) [110835910] (Abnormal)Resulted: 07/10/15 2010, Result Status: Final

    resultOrdering provider: McIntyre, Daniel, MD 07/10/15 1938 Resulting Lab: LANCASTER GENERAL

    LABORATORY

    Basic Metabolic Panel (BMP) (For Transfers Only) [110835909](Abnormal)

    Resulted: 07/10/15 2034, Result Status: Finalresult

    Ordering provider: McIntyre, Daniel, MD 07/10/15 1938 Resulting Lab: LANCASTER GENERALLABORATORY

    Printed on 7/28/2015 11:44 AM Page 13

    07/10/15 1948Comment: For Transfers Only.

    XR SHOULDER RIGHT MIN 2 VW ONE TIME

    Components

    Value Ref Range Flag Comment LabWBC Count 11.4 4.8 - 10.8 K H - LG

    LABRBC Count 5.12 4.60 - 6.20 M - LG

    LABHgb 14.7 14.0 - 18.0 g/dL - LG

    LABHct 42.5 42.0 - 52.0 % - LG

    LABMCV 83.0 80.0 - 100.0 fL - LG

    LABMCH 28.7 27.0 - 33.0 pg - LG

    LABMCHC 34.6 32.0 - 36.0 % - LG

    LABPlatelet Count 203 150 - 450 K - LG

    LABRDW 14.4 12.2 - 14.6 % - LG

    LAB

    Basic Metabolic Panel (BMP) (For Transfers Only)ONE TIME

    CBC (For Transfers Only) ONE TIME

    ibuprofen (ADVIL,MOTRIN) tablet 600 mg ONCE

    Comments: For Transfers Only.

    Comments: For Transfers Only.

    Specimen Collection

    Specimen CollectionType Source Collected On

    07/10/15 1948

    Type Source Collected On

  • LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record

    CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015

    Lab Results (07/10/15 - 07/10/15) (continued)

    Basic Metabolic Panel (BMP) (For Transfers Only) [110835909](Abnormal)

    Resulted: 07/10/15 2034, Result Status: Finalresult

    Alcohol, Serum [110835908]Resulted: 07/10/15 2037, Result Status: Final

    resultOrdering provider: McIntyre, Daniel, MD 07/10/15 1938 Resulting Lab: LANCASTER GENERAL

    LABORATORY

    Printed on 7/28/2015 11:44 AM Page 14

    16 8 - 22 mg/dL - LGLAB

    Sodium 137 135 - 145mmol/L

    - LGLAB

    Potassium 4.1 3.4 - 5.3 mmol/L - LGLAB

    Chloride 105 98 - 107 mmol/L - LGLAB

    CO2 Venous 28.0 21.0 - 31.0mmol/L

    - LGLAB

    Anion Gap 4 5 - 15 mmol/L L - LGLAB

    Creatinine 0.8 0.7 - 1.2 mg/dL - LGLAB

    BUN/CreatinineRatio

    20 10 - 20 Ratio - LGLAB

    OsmolalityCalculation(serum)

    275 275 - 300mOsm/Kg

    - LGLAB

    Calcium 9.7 8.6 - 10.3 mg/dL - LGLAB

    GFR >60 mL/min/1.73sqm

    LGLAB

    Comment: Notes for GFR:1. Multiply result by 1.21 if patient is black/African American.2. Chronic kidney disease:

  • LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record

    CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015

    Lab Results (07/10/15 - 07/10/15) (continued)

    Alcohol, Serum [110835908]Resulted: 07/10/15 2037, Result Status: Final

    result

    Toxic Screen, Urine, No Confirmation [110835906]Resulted: 07/10/15 2301, Result Status: Final

    resultOrdering provider: McIntyre, Daniel, MD 07/10/15 1938 Resulting Lab: LANCASTER GENERAL

    LABORATORY

    Printed on 7/28/2015 11:44 AM Page 15

    Collected On07/10/15 2149

    Components

    Value Ref Range Flag Comment LabUrineAmphetamineScreen

    NONE DETECTED None Detected - LGLAB

    Urine BarbiturateScreen

    NONE DETECTED None Detected - LGLAB

    UrineBenzodiazepineScreen

    NONE DETECTED None Detected - LGLAB

    Urine CocaineMetabolite Screen

    NONE DETECTED None Detected - LGLAB

    Urine MarijuanaScreen

    NONE DETECTED None Detected - LGLAB

    Urine OpiateScreen

    See Below None Detected LGLAB

    Comment: NONE DETECTED -Hydrocodone and Methadone are not routinelydetected by the LGH Urine Toxic Screen. These drugsmust be ordered specifically.

    UR OxycodoneScreen

    NONE DETECTED None Detected - LGLAB

    UrinePCP(Phencyclidine) Screen

    NONE DETECTED None Detected LGLAB

    Comment: Unconfirmed screening results MUST NOT be used fornon-medical purposes: (eg. employment testing, legal testing) CUT OFF CONCENTRATION FOR POSITIVE RESULTS: Amphetamines = 1000 ng/mL Barbiturates = 200 ng/mL Benzodiazepine = 200 ng/mL Cocaine = 300 ng/mL Opiates = 300 ng/mL Oxycodone = 100 ng/mL Phencyclidine = 25 ng/mL THC = 50 ng/mL

    Concentrations above 400 mg/dL may be fatal.

    Specimen CollectionType Source

  • LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record

    CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015

    Lab Results (07/10/15 - 07/10/15) (continued)

    Toxic Screen, Urine, No Confirmation [110835906]Resulted: 07/10/15 2301, Result Status: Final

    result

    Testing Performed ByLab - Abbreviation Name Director Address Valid Date Range6 - LG LAB LANCASTER

    GENERALLABORATORY

    Bruce King, M.D.,Director

    555 N. Duke St.Lancaster PA 17602-2250

    10/10/13 1035 - Present

    Radiology Results (07/10/15 - 07/10/15)

    XR SHOULDER RIGHT MIN 2 VW [110832753]Resulted: 07/10/15 1825, Result Status: Final

    resultOrdering provider: McIntyre, Daniel, MD 07/10/15 1749 Resulted by: Smigocki, Gene C, MDPerformed: 07/10/15 1810 - 07/10/15 1810 Resulting Lab: LANCASTER GENERAL RADIOLOGYNarrative: Two-view right shoulder

    History: Pain following injury

    Comparison: None

    Technique: Internal and external views were obtained

    Findings:

    No osseous abnormality is present. Minor degenerative changes are present in theacromioclavicular joint. Joint spaces and soft tissues are otherwise normal.

    Impression:

    No evidence of fracture

    Dictating Workstation: HMINWKS2

    Testing Performed ByLab - Abbreviation Name Director Address Valid Date Range7 - LG RADIOLOGY LANCASTER

    GENERALRADIOLOGY

    RobertLatshaw,MD

    555 N. Duke St.Lancaster PA 17604-3555

    08/08/12 1438 - Present

    EKG ResultsNone

    All Administrations of ibuprofen (ADVIL,MOTRIN) tablet 600 mg

    User(s)ActionTime

    RecordedTime

    Dose/Rate Route Site Comment Action

    Reason

    Huehnergarth,Gretchen A, RN

    07/10/151954

    07/10/151955

    600 mg Oral Given

    Printed on 7/28/2015 11:44 AM Page 16

    Specimen CollectionType Source Collected On

    07/10/15 1810

  • LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record

    CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015

    All Administrations of ibuprofen (ADVIL,MOTRIN) tablet 600 mg

    ED Current OP MedicationsMedication Sig Dispense Start Date End Date Doc. ProviderNAPROXEN 500 MG ORAL TABS 1 TABLET

    TWICE DAILYas needed forpain

    60 9/23/2009 Sullivan, Brian P,MD

    VICODIN ES 7.5-750 MG ORALTABS

    1/2 to 1 tabletevery 6 hoursas needed forpain

    30 tablet 5/10/2010 Sullivan, Brian P,MD

    Medications not reviewed this encounter

    Medication Comments** No Medication Comments Found **

    Allergies (verified on: 05/25/10)Agent Severity CommentsNO KNOWN ALLERGIES

    Follow-up InformationNone

    Vitals from to

    Date and Time BPPosition Pulse Resp Temp

    Tempsrc SpO2

    OxygenTherapyFlow(L/min)

    Weight

    Doppler/Fetoscope Rate

    POCTCarboxyhemoglobin

    Who

    07/10/15 1750 132/74mmHg

    -- 82 20 98 F(36.7C)

    Oral -- -- -- -- -- GAH

    Flowsheets (all recorded)

    Printed on 7/28/2015 11:44 AM Page 17

    AmbulanceArrived

    Yes -TMYARNIS

    Transfer Charting - Sat July 11, 2015

    Transfer Checklist - Sat July 11, 2015

    0043Transfer ChecklistReport toTransfer Team

    Yes -TMYARNIS

    0043Transport Request

  • LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record

    CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015

    Flowsheets (all recorded)

    Printed on 7/28/2015 11:44 AM Page 18

    MAR MINI-FLOWSHEET DATA - Fri July 10, 2015

    Custom Formula Data - Fri July 10, 2015

    1750OTHERMean ArterialPressure

    93 MM HG -GAHUEHNE

    1954 1817

    Triage Plan - Fri July 10, 2015

    2333Triage Acuity CalculatorIsRESUSCITATION required?

    No -TMYARNIS

    Is this anEMERGENT(High Risk,Altered LOC,Severe Pain)situation?

    Yes (2) -TMYARNIS

    Patient Acuity 2 -TMYARNISED Destination Behavioral Health

    -TMYARNIS

    Vital Signs - Fri July 10, 2015

    1954 1817 1750Vital SignsBP 132/74 mmHg -

    GAHUEHNE

    Pulse 82 -GAHUEHNEResp 20 -GAHUEHNETemp 98 F (36.7 C) -

    GAHUEHNE

    Temp src Oral -GAHUEHNEPainAssessment

    0-10 -GAHUEHNE

    Number Scale*Pain Rating 4 -GAHUEHNE 7 -GAHUEHNE*Pain Location shoulder -

    GAHUEHNE

    PainDescription -Quality

    aching -GAHUEHNE

    *Factors thatAggravate Pain

    activity -GAHUEHNE

    *Factors thatRelieve Pain

    repositioning -GAHUEHNE

    Number Scale

    Transfer Charting - Fri July 10, 2015

    2216

    *Pain Rating 4 -GAHUEHNE 7 -GAHUEHNE

  • LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record

    CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015

    Printed on 7/28/2015 11:44 AM Page 19

    ETA ofAmbulance

    2330 -GAHUEHNE

    AmbulanceArrived

    Yes -GAHUEHNE

    Transfer Mode Gurney -GAHUEHNE

    Type ofTransfer

    BLS/ALS/CCTAmbulance -GAHUEHNE

    AccompaniedBy

    EMS Personnel -GAHUEHNE

    Transport Request

    Transfer Checklist - Fri July 10, 2015

    2216Transfer ChecklistReason forTransfer

    Patient Request -GAHUEHNE

    AcceptingHospital

    fairmount -GAHUEHNE

    AcceptingPhysician

    bridget bautista -GAHUEHNE

    SendingPhysician

    mcintyre -GAHUEHNE

    Report toTransfer Team

    Yes -GAHUEHNE

    Report toReceivingFacility

    Yes -GAHUEHNE

    Spoke with tyree -GAHUEHNETransferConsentSigned

    Yes -GAHUEHNE

    Copy ofRecords and DIObtained

    Yes -GAHUEHNE

    Faxed Recordsto ReceivingFacility

    Yes -GAHUEHNE

    DispatcherCalled

    Yes -GAHUEHNE

    Travel Screening - Fri July 10, 2015

    1824Travel ScreeningHas the patienttraveled toAfrica OR hadcontact withsomeone whohas traveled toAfrica in thelast 21 days?

    No -BG017

    Name ofDispatcher

    jaimie -GAHUEHNE

  • LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record

    CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015

    ED After Visit Summary

    Diagnoses this visitYour diagnosis was ACUTE PSYCHOSIS.

    You were seen byYou were seen by McIntyre, Daniel, MD.

    ED PrescriptionsNone

    Orders Completed During Your ED Visit

    Start Status Ordering Provider07/10/15

    1939Final result MCINTYRE, DANIEL

    07/10/151939

    Final result MCINTYRE, DANIEL

    07/10/151939

    Final result MCINTYRE, DANIEL

    07/10/151939

    Final result MCINTYRE, DANIEL

    07/10/151830

    Last MAR action:Given

    MCINTYRE, DANIEL

    07/10/151750

    Final result MCINTYRE, DANIEL

    Suture Information from toNone

    Printed on 7/28/2015 11:44 AM Page 20

    Automaticrestart vitalstimer

    YES -GAHUEHNE

    Arrival Documentation - Fri July 10, 2015

    User Key(r) = User Recd, (t) = User Taken, (c) = User

    Cosigned

    Toxic Screen, Urine, No Confirmation ONE TIME

    User ID Name Effective DatesBG017

    Alcohol, Serum ONE TIME

    Groff, Barbara A -GAHUEHNE Huehnergarth, Gretchen A, RN 03/23/11 -

    Basic Metabolic Panel (BMP) (For Transfers Only)ONE TIME

    TMYARNIS Yarnish, Theresa M, RN 03/23/11 -

    CBC (For Transfers Only) ONE TIME

    1749

    ibuprofen (ADVIL,MOTRIN) tablet 600 mg ONCE

    Triage StartTriage Start

    XR SHOULDER RIGHT MIN 2 VW ONE TIME

    Start -GAHUEHNEPrehospital TreatmentPrehospitalTreatment

    No -GAHUEHNE

    Vitals Reassessment - Fri July 10, 2015

    1750Vitals Assessment

  • LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record

    CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015

    ED After Visit Summary (continued)

    Information regarding the care you received at theLancaster General Hospital Emergency Department

    You may receive a survey about your emergency department visit.Our goal is for our patients to receive very good care during their ED visit.Please take a moment to complete a survey if you receive one so we may continue to improve.

    The examination and treatment you have received in the Emergency Department have been rendered on anemergency basis only, and are not intended to be a substitute for or an effort to provide complete medicalcare. Your primary care physician may request a copy of your records and all test results. It is important thatyou let him/her check you again, and that you report any new or remaining problems.

    XRAYS/EKGSThe interpretation of EKG'S and/or x-rays at the time of the emergency visit may only be a preliminary report.You will be notified by telephone if there is a change in the interpretation when the tests are reviewed by thecardiologist and/or radiologist.

    MEDICATIONS/PRESCRIPTIONSTake all medication as prescribed by the physician.

    FAMILY PHYSICIAN If you are being referred to your own Primary Care Physician for follow up and do not have one, please callthe Physician Referral Line at 1-888-LGH-INFO (1-888-544-4636) and you will be assisted in locating aPrimary Care Physician.

    REFERRAL TO SPECIALISTIf you are being referred to any doctor/specialist other than your own Primary Care Physician: Please contactyour doctor for a referral and any paperwork or referral forms that may be required. If you have anyquestions about whether you need such forms, contact your insurance company or doctor's office as soon aspossible.

    The staff of the Lancaster General Hospital Emergency Department and Trauma Services strives to ensurequality care and customer service during your visit.Your Current Condition does not require hospitalization. Your condition can, however, change. If there areany concerns regarding your condition, you may return to the Emergency Department or contact yourPrimary Physician.

    The Emergency Physicians of Lancaster Emergency Associates (LEA) are the exclusive providers ofEmergency Medical care at Lancaster General Hospital. We appreciate any comments or feedback you mayhave on your experience with us in the Emergency Department and invite you to visit us atwww.LancasterEmergencyAssociates.com

    We constantly are looking for ways to improve your Emergency Department Experience.If you have any suggestions or concerns, please let us know.

    Printed on 7/28/2015 11:44 AM Page 21

  • LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record

    CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015

    ED After Visit Summary (continued)

    You may call any of the following ED Management Team:Jolyne Barnett, RN ED Nurse Manager 717 544-5125Penne Marino, RN, Days Assistant Nurse Manager 717 544-4582Amy Sechrist, RN Evenings Assistant Nurse Manager 717 544-7055Lisa Williams, RN Nights Assistant Nurse Manager 717 544-1776

    Lancaster General Hospital Convenience Pharmacy 717 544-5929Hours of Operation: Monday through Friday 7am- 6pmSaturday 9am- 3pmSunday Closed

    Procedures and tests performed during your visitAlcohol, SerumBasic Metabolic Panel (BMP) (For Transfers Only)CBC (For Transfers Only)Toxic Screen, Urine, No ConfirmationXR SHOULDER RIGHT MIN 2 VW

    Scanned Information

    Encounter-Level Documents - 07/10/2015:

    Scan on 7/11/2015 8:21 PM (below)

    Printed on 7/28/2015 11:44 AM Page 22

  • LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record

    CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015

    Scanned Information (continued)

    Scan on 7/11/2015 5:38 PM (below)

    Printed on 7/28/2015 11:44 AM Page 23

  • LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record

    CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015

    Scanned Information (continued)

    Order-Level Documents:There are no order-level documents.

    Code Documentation

    No data selected in time range

    Printed on 7/28/2015 11:44 AM Page 24

  • LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record

    CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015

    Scanned Information (continued)

    Sedation Documentation

    No data selected in time range

    Hospital Encounter on 7/10/2015ED Arrival InformationChief ComplaintTreatment TeamDischarge OrdersED Notes by Huehnergarth, Gretchen A, RN at 7/10/2015 5:49 PMED Provider Notes by McIntyre, Daniel, MD at 7/10/2015 5:58 PMED Notes by Huehnergarth, Gretchen A, RN at 7/10/2015 8:31 PMED Notes by Huehnergarth, Gretchen A, RN at 7/10/2015 8:32 PMVersion 1

    ED Notes by Huehnergarth, Gretchen A, RN at 7/10/2015 10:26 PMED Notes by Huehnergarth, Gretchen A, RN at 7/10/2015 10:33 PMED Notes by Huehnergarth, Gretchen A, RN at 7/10/2015 10:37 PMCBC (For Transfers Only) - Final resultBasic Metabolic Panel (BMP) (For Transfers Only) - Final resultAlcohol, Serum - Final resultToxic Screen, Urine, No Confirmation - Final resultXR SHOULDER RIGHT MIN 2 VW - Final resultAllergiesFollow-up InformationAll Flowsheets07/11/15Transfer ChartingTransfer Checklist

    07/10/15MAR MINI-FLOWSHEET DATACustom Formula DataTriage PlanVital SignsTransfer ChartingTransfer ChecklistTravel ScreeningArrival DocumentationVitals Reassessment

    User Key

    PrescriptionsEncounter-Level Documents:Scan on 7/11/2015 8:21 PMScan on 7/11/2015 5:38 PM

    Order-Level Documents:


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