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HomeMy WebLinkAbout2017CV884 - Chayce Anderson V. Fcps Officer Jason Shutters - 133J - Exhibit 10EXHIBIT 10 Case 1:17-cv-00884-CMA-STV Document 133-10 Filed 07/26/19 USDC Colorado Page 1 of 24 PVH EMERGENCY Anderson, Chayce A MRN: , DOB: , Sex: M Adm: 8/28/2015, D/C: 8/29/2015 Patient Information Patient Information Name: ANDERSON,CHAYCE A SSN: Baby band #: Alias: Religion: Lutheran DOB: Age: 26y Legal Sex: M Gender Identity: Sex Assigned at Birth: Marital: Single Ethnic group : Non- Hispan ic Address: City: State: Zip: Phone: Guarantor Information Name: ANDERSON,CHAYCE A SSN: Address: City: State: Zip: Phone: Employer: Address: City: State: Zip: Phone: Guar DOB: 03/11/92 Insurance Information COLORADO MEDICAID/MEDICAID COLORADO HEALTH FIRST Phone: 844-235-2387 Subscriber: Anderson, Chayce A Subscriber#: Group#: Precert#: Patient Employment Employer: Address: City: State: Zip: Phone: Occupation: Employee?: No Emergency Contact Information Name: Relationship: Father Address: City: State: Zip: Phone: Business phone: Admission/Discharge Information Admission Information Unit/Bed: PVH EMERGENCY/16 Service: EMERGENCY MEDICINE Admitting provider: Phone: Attending provider: Phone: PCP: Asked, Nopcp Phone: Admission dx: Patient class: Emergency Admission type: ER Discharge Information Discharge Date/Time Discharge Disposition Discharge Destination Discharge Provider Unit 08/29/2015 0012 Home Or Self Care None None UCHealth Emergency Care - Poudre Valley Hospital Account: MRN: Current HOV: None Current admission: 08/28/15 2349 Previous HOV: 09/19/13 2120 Previous admission: 09/19/13 1849 Previous discharge: 09/19/13 1919 Final Diagnoses (ICD-9-CM) Code Description POA CC HAC Affects DRG 782.0 [Principal] Disturbance of skin sensation Events PVH EMERGENCY Anderson, Chayce A MRN: DOB: , Sex: M Adm: 8/28/2015, D/C: 8/29/2015 Events (continued) Allergies Allergies as of 8/29/2015 Fully Reviewed On: 8/28/2015 By: Lindeken, Kimberly L No Known Allergies Immunizations Patient History Medical as of 8/29/2015 Past Medical History: None Surgical as of 8/29/2015 None Family as of 8/29/2015 None Family Status as of 8/29/2015 None Activities of Daily Living as of 8/29/2015 None Social Documentation as of 8/29/2015 None Occupational as of 8/29/2015 None Socioeconomic as of 8/29/2015 Printed by 79672 at 3/4/19 4:12 PM Page 2 Unit: UCHealth Emergency Care - Poudre Valley Hospital Room: 16 Bed: 16 Patient class: Emergency Service: EMERGENCY MEDICINE Unit: UCHealth Emergency Care - Poudre Valley Hospital ED Roomed at 8/28/2015 2349 Unit: UCHealth Emergency Care - Poudre Valley Hospital Room: 16 Bed: 16 Patient History Patient class: Emergency Service: EMERGENCY MEDICINE Discharge at 8/29/2015 0012 Unit: UCHealth Emergency Care - Poudre Valley Hospital Room: 16 Bed: 16 Patient class: Emergency Service: EMERGENCY MEDICINE Admission at 8/28/2015 2349 Discharge at 8/29/2015 0012 Unit: UCHealth Emergency Care - Poudre Valley Hospital Room: 16 Bed: 16 Patient class: Emergency Service: EMERGENCY MEDICINE Anderson 0014 REDACTED REDACTED Case 1:17-cv-00884-CMA-STV Document 133-10 Filed 07/26/19 USDC Colorado Page 3 of 24 PVH EMERGENCY Anderson, Chayce A MRN: , DOB: , Sex: M Adm: 8/28/2015, D/C: 8/29/2015 Socioeconomic as of 8/29/2015 (continued) Marital Status Spouse Name Number of Children Years Education Education Level Preferred Language Ethnicity Race Source Single — — — — English Non-Hispanic White or Caucasian — Financial Resource Strain Food Insecurity: Worry Food Insecurity: Inability Transportation Needs: Medical Transportation Needs: Non- medical — — — — — Birth as of 8/29/2015 None Problem List Problem List None ED Records ED Arrival Information Expected Arrival Acuity Means of Arrival Escorted By Service Admission Type - 8/28/2015 23:48 4=Less Urgent Amb- Northern Colorado Rural EMS Self EMERGENCY MEDICINE Emergency Arrival Complaint amb ED Disposition ED Disposition Condition Comment Discharge ED Notes ED Notes by Lindeken, Kimberly L at 8/29/2015 12:11 AM Author: Lindeken, Kimberly L Service: — Author Type: Registered Nurse Filed: 8/29/2015 12:12 AM Date of Service: 8/29/2015 12:11 AM Status: Signed Editor: Lindeken, Kimberly L Patient provided ACI's, refusing to sign ACI's. Police at bedside. Electronically signed by Lindeken, Kimberly L on 8/29/2015 12:12 AM ED Provider Notes by Carnahan, Erin, PAC at 8/28/2015 11:55 PM Author: Carnahan, Erin, PAC Service: — Author Type: Physician Assistant Filed: 8/29/2015 12:02 AM Date of Service: 8/28/2015 11:55 PM Status: Signed Editor: Carnahan, Erin, PAC (Physician Assistant) Cosigner: Hallahan, Tara A, DO at 8/29/2015 2:28 AM Clinical Impression 1. Medical clearance for incarceration 2. Paresthesia ED Course/Discussion/Disposition Differential: 1. Wrist numbness 2. Wrist trauma 3. Medical clearance for incarceration Printed by 79672 at 3/4/19 4:12 PM Page 3 PVH EMERGENCY Anderson, Chayce A MRN: , DOB: Sex: M Adm: 8/28/2015, D/C: 8/29/2015 ED Notes (continued) ED Provider Notes by Carnahan, Erin, PAC at 8/28/2015 11:55 PM (continued) 4. malingering Discussion: On physical examination the patient's wrists have no evidence of trauma visually. There is no swelling no erythema, no laceration, no abrasion. He does have good radial pulses noted bilaterally. Good capillary refill is noted less than 3 seconds. He does have full range of motion in the distal appendages. Patient was shaking initially but after talking to him and getting his mind off of controlling his shaking his shaking stopped which I did address. Patient was brought in for medical clearance for incarceration, there is no evidence of trauma noted. He is neurologically intact and has good deep tendon reflexes in the upper extremities. At this time the patient is afebrile at 98.8, pulse 70, respirations 16, blood pressure 133/79, pulse ox at 96% on room air. No complications or visible therefore the patient will be discharged medically for incarceration. DECISION TO ADMIT None History Chief Complaint Patient presents with •Wrist Pain this patient is a 23-year-old male that was brought in by the Police Department for bilateral wrist numbness after patient had handcuffs put on. States this happened approximately one hour ago. Patient states the handcuffs hurt and then his wrist went numb and at this time he is having no pain just numbness. He denies any trauma to his wrist, denies any previous history of wrist pain or numbness. The patient states his hands are shaking as well and is worried that he has severe nerve damage. He denies any other complications or trauma. No other complications noted. The patient was brought in for medical clearance for incarceration. Patient is a 23 y.o. male presenting with wrist pain. The history is provided by the patient. Upper Extremity Injury/Pain: Incident occurred: Less than 1 hour ago Incident location: In the street Injury mechanism: No injury mechanism Pain location: Left wrist and right wrist Associated symptoms include: numbness. Pertinent negatives includes no fever. History reviewed. No pertinent past medical history. Prior to Admission medications Not on File Allergies as of 08/28/2015 •(No Known Allergies) History reviewed. No pertinent past surgical history. History Substance Use Topics •Smoking status: Current Every Day Smoker •Smokeless tobacco: Not on file Comment: uses e cigarettes, prior tobacco use, non since 8/2013 •Alcohol Use: No History Drug Use No Printed by 79672 at 3/4/19 4:12 PM Page 4 Anderson 0016 REDACTED REDACTED Case 1:17-cv-00884-CMA-STV Document 133-10 Filed 07/26/19 USDC Colorado Page 5 of 24 PVH EMERGENCY Anderson, Chayce A MRN: , DOB: , Sex: M Adm: 8/28/2015, D/C: 8/29/2015 ED Notes (continued) ED Provider Notes by Carnahan, Erin, PAC at 8/28/2015 11:55 PM (continued) History reviewed. No pertinent family history. Review of Systems Constitutional: Negative for fever, activity change, appetite change and fatigue. HENT: Negative for congestion, drooling, rhinorrhea, sinus pressure, sneezing, sore throat and voice change. Eyes: Negative for pain, discharge, redness and itching. Respiratory: Negative for apnea, cough, choking, chest tightness and shortness of breath. Cardiovascular: Negative for chest pain. Gastrointestinal: Negative for nausea, vomiting, abdominal pain, diarrhea, constipation and abdominal distention. Genitourinary: Negative for dysuria, frequency, hematuria, flank pain, decreased urine volume and difficulty urinating. Musculoskeletal: Negative for myalgias, back pain, joint swelling, arthralgias, gait problem, neck pain and neck stiffness. Skin: Negative for color change, pallor, rash and wound. Neurological: Positive for numbness. Negative for dizziness, seizures, syncope and weakness. Hematological: Negative for adenopathy. Psychiatric/Behavioral: Negative for agitation. Blood pressure 133/79, pulse 70, temperature 37.1 °C (98.8 °F), temperature source Oral, resp. rate 16, height 1.778 m (5' 10"), weight 68.04 kg (150 lb), SpO2 96 %. Physical Exam Constitutional: He is oriented to person, place, and time. He appears well-developed and well-nourished. He is not intubated. HENT: Head: Normocephalic and atraumatic. Eyes: Conjunctivae and EOM are normal. Pupils are equal, round, and reactive to light. Right eye exhibits no discharge. Left eye exhibits no discharge. No scleral icterus. Neck: Normal range of motion. Cardiovascular: Normal rate, regular rhythm, normal heart sounds and normal pulses. Pulmonary/Chest: Effort normal and breath sounds normal. No accessory muscle usage. No apnea, no tachypnea and no bradypnea. He is not intubated. No respiratory distress. He has no decreased breath sounds. He has no wheezes. He has no rhonchi. He has no rales. He exhibits no tenderness. Abdominal: Soft. Normal appearance. He exhibits no shifting dullness, no distension, no pulsatile liver, no fluid wave, no abdominal bruit, no ascites, no pulsatile midline mass and no mass. There is no tenderness. There is no rebound and no guarding. Musculoskeletal: Normal range of motion. He exhibits no edema or tenderness. Right wrist: Normal. He exhibits normal range of motion, no tenderness, no bony tenderness, no swelling, no effusion, no crepitus, no deformity and no laceration. Left wrist: Normal. He exhibits normal range of motion, no tenderness, no bony tenderness, no swelling, no effusion, no crepitus, no deformity and no laceration. Neurological: He is alert and oriented to person, place, and time. He has normal strength and normal reflexes. He is not disoriented. He displays no atrophy, no tremor and normal reflexes. No cranial nerve deficit or sensory deficit. He exhibits normal muscle tone. He displays a negative Romberg sign. He displays no seizure activity. Coordination normal. He displays no Babinski's sign on the right side. He displays no Babinski's sign on the left side. Skin: Skin is warm. He is not diaphoretic. Psychiatric: He has a normal mood and affect. Nursing note and vitals reviewed. Objective data reviewed: Epic records reviewed and Other Pertinent Findings: Encounter Meds None Printed by 79672 at 3/4/19 4:12 PM Page 5 Anderson 0017 REDACTED REDACTED Case 1:17-cv-00884-CMA-STV Document 133-10 Filed 07/26/19 USDC Colorado Page 6 of 24 PVH EMERGENCY Anderson, Chayce A MRN: , DOB: , Sex: M Adm: 8/28/2015, D/C: 8/29/2015 ED Notes (continued) ED Provider Notes by Carnahan, Erin, PAC at 8/28/2015 11:55 PM (continued) Discharge Orders None Consult Orders None Procedures Erin Carnahan 12:02 AM Carnahan, Erin, PAC 08/29/15 0002 Electronically signed by Carnahan, Erin, PAC on 8/29/2015 12:02 AM Electronically signed by Hallahan, Tara A, DO on 8/29/2015 2:28 AM ED Notes by Lindeken, Kimberly L at 8/28/2015 11:51 PM Author: Lindeken, Kimberly L Service: — Author Type: Registered Nurse Filed: 8/28/2015 11:52 PM Date of Service: 8/28/2015 11:51 PM Status: Signed Editor: Lindeken, Kimberly L BIBA in police custody for bilateral wrist pain and left shoulder pain. Pt admits to drinking 1 shot of alcohol. Pt states that he "has extreme nerve damage". Respirations even and unlabored at triage, skin pwd, nad. Electronically signed by Lindeken, Kimberly L on 8/28/2015 11:52 PM ED Notes by Van Leeuwen, Jason K, RN at 8/28/2015 11:49 PM Author: Van Leeuwen, Jason K, RN Service: — Author Type: Registered Nurse Filed: 8/28/2015 11:49 PM Date of Service: 8/28/2015 11:49 PM Status: Signed Editor: Van Leeuwen, Jason K, RN (Registered Nurse) Bed: 16 Expected date: Expected time: Means of arrival: Comments: Wrist pain (in custody) Electronically signed by Van Leeuwen, Jason K, RN on 8/28/2015 11:49 PM Encounter Notes Discharge Summaries No notes of this type exist for this encounter. History and Physical Notes No notes of this type exist for this encounter. Consult Notes No notes of this type exist for this encounter. Procedure Notes No notes of this type exist for this encounter. Printed by 79672 at 3/4/19 4:12 PM Page 6 Anderson 0018 REDACTED REDACTED Case 1:17-cv-00884-CMA-STV Document 133-10 Filed 07/26/19 USDC Colorado Page 7 of 24 PVH EMERGENCY Anderson, Chayce A MRN: , DOB: , Sex: M Adm: 8/28/2015, D/C: 8/29/2015 Interim Summaries No notes of this type exist for this encounter. Progress Notes No notes of this type exist for this encounter. Plan of Care Notes No notes of this type exist for this encounter. Other Notes No notes of this type exist for this encounter. Coding Query OP Reports Operative Notes No notes of this type exist for this encounter. Surgery Report Anesthesia Other Anesthesia Notes No notes of this type exist for this encounter. Orders All Orders No orders found Clinical Lab Results Lab Results No Lab Results Radiology Results Radiology Results No Radiology Results Found ECG/EMG Results ECG/EMG Results No ECG/EMG Results GI Results GI Results No GI Results Found Cardiac Results Cardiac Results No Cardiac Results Pathology Results Medications All Meds and Administrations (No medication admins scheduled or recorded for this encounter) Care Plan Patient Education Education Printed by 79672 at 3/4/19 4:12 PM Page 7 No education to display Anderson 0019 REDACTED REDACTED Case 1:17-cv-00884-CMA-STV Document 133-10 Filed 07/26/19 USDC Colorado Page 8 of 24 PVH EMERGENCY Anderson, Chayce A MRN: , DOB: , Sex: M Adm: 8/28/2015, D/C: 8/29/2015 Education (continued) Discharge Instructions Discharge Instructions Anderson, Chayce A (MR # 3125710) Date Status User User Type Discharge Note 08/29/15 0002 Pended Carnahan, Erin, PAC Physician Assistant Original Note: Paresthesia WHAT YOU SHOULD KNOW: Paresthesia is numbness and tingling. It can happen in any part of your body, but usually occurs in your legs, feet, arms, or hands. There are a large number of conditions that can cause paresthesia. It affects the nerves that provide sensation and happens when there are changes in nerves or nerve pathways. These changes can be temporary, such as if you take certain medicines or you are not getting enough vitamin B. Paresthesia can become permanent when there is nerve damage. Conditions that may cause nerve damage include diabetes, carpel tunnel syndrome, stroke, and multiple sclerosis. The exact cause of your paresthesia may be unknown. INSTRUCTIONS: Medicines: Ask for more information about medicines you may need to treat the condition causing your paresthesias. · NSAIDs help decrease swelling and pain or fever. This medicine is available with or without a doctor's order. NSAIDs can cause stomach bleeding or kidney problems in certain people. If you take blood thinner medicine, always ask your healthcare provider if NSAIDs are safe for you. Always read the medicine label and follow directions. · Take your medicine as directed. Call your healthcare provider if you think your medicine is not helping or if you have side effects. Tell him if you are allergic to any medicine. Keep a list of the medicines, vitamins, and herbs you take. Include the amounts, and when and why you take them. Bring the list or the pill bottles to follow-up visits. Carry your medicine list with you in case of an emergency. Follow up with your primary healthcare provider or neurologist as directed: Write down your questions so you remember to ask them during your visits. Contact your primary healthcare provider or neurologist if: · Your symptoms do not improve. · You have symptoms in more than one part of your body. · You have questions about your condition or care. Return to the emergency department if: · You have any of the following signs of a stroke: ¨ Numbness or drooping on one side of your face ¨ Weakness in an arm or leg Printed by 79672 at 3/4/19 4:12 PM Page 8 Anderson 0020 REDACTED REDACTED Case 1:17-cv-00884-CMA-STV Document 133-10 Filed 07/26/19 USDC Colorado Page 9 of 24 PVH EMERGENCY Anderson, Chayce A MRN: , DOB: , Sex: M Adm: 8/28/2015, D/C: 8/29/2015 ¨ Confusion or difficulty speaking ¨ Dizziness, a severe headache, or vision loss · You are not able to control your urine or bowel movements. · You have severe pain along with numbness and tingling. · Your legs suddenly become cold. You have trouble moving your legs, and they ache. · You have increased weakness in a part of your body. · You have uncontrolled movements, or you have a seizure. © 2014 Truven Health Analytics Inc. Information is for End User's use only and may not be sold, redistributed or otherwise used for commercial purposes. All illustrations and images included in CareNotes® are the copyrighted property of A.D.A.M., Inc. or Truven Health Analytics. The above information is an educational aid only. It is not intended as medical advice for individual conditions or treatments. Talk to your doctor, nurse or pharmacist before following any medical regimen to see if it is safe and effective for you. Discharge Placement Information Discharge Destination No service coordination in this encounter. Durable Med Equipment No service coordination in this encounter. Dialysis / Infusion No service coordination in this encounter. Home Health Services No service coordination in this encounter. Community Resources No service coordination in this encounter. Obstetrics OB Notes No notes of this type exist for this encounter. Flowsheets Printed by 79672 at 3/4/19 4:12 PM Page 9 Anderson 0021 REDACTED REDACTED Case 1:17-cv-00884-CMA-STV Document 133-10 Filed 07/26/19 USDC Colorado Page 10 of 24 PVH EMERGENCY Anderson, Chayce A MRN: DOB: , Sex: M Adm: 8/28/2015, D/C: 8/29/2015 Flowsheets (all recorded) Abuse Indicators Row Name 08/28/15 2356 Screening Safe in Home Did not ask -KL Safe in Relationship Did not ask -KL Are you in immediate danger? Did not ask -KL Anthropometrics Row Name 08/28/15 2352 Anthropometrics Weight Change 0 -KL Arrival Documentation Row Name 08/28/15 2351 Triage Call Triage Call Call 1x -KL Triage Start Triage Start Start -KL Prehospital Treatment Prehospital Treatment Yes -KL Pre-arrival Vitals BP 146/78 -KL Pulse 100 -KL Care Handoff Row Name 08/29/15 0012 Care Handoff Report Given to Given to other (Comment) -KL Complete Intake Row Name 08/28/15 2356 Complete Intake Intake Complete? Yes -KL Custom Formula Data Row Name 08/28/15 2352 Height and Weight BSA (Calculated - sq m) 1.83 sq meters -KL OTHER BMI (Calculated) 21.6 -KL Weight gain/loss (kg) 68.04 kg -KL IBW (lb) - Calculated 160 lb -KL Today's Excess Weight (lbs) -10 -KL IBW/kg (Calculated) 73 kg -KL % Weight Change Since Birth 0 % -KL IBW/kg (Calculated) 73 kg -KL Current BSA 1.83 -KL Weight gain/loss 68040 gms -KL Low: Female Calculated Energy for BMI < 25 2041.2 -KL PVH EMERGENCY Anderson, Chayce A MRN: DOB: , Sex: M Adm: 8/28/2015, D/C: 8/29/2015 Flowsheets (all recorded) (continued) Custom Formula Data (continued) Row Name 08/28/15 2352 BMI < 25 Low: Male Calculated Energy for BMI < 27 2041.2 -KL High: Male Calculated Energy for BMI <27 84 -KL Male: BMI > 27 1681.65 -KL Female: BMI > 25 1515.65 -KL Weight gain/loss (kg) 68.04 kg -KL Grams Protein Needed (calculated) 68.04 -KL Weight/Height Bariatric Measurements Ideal Body Weight 150 lb -KL Ideal Body Weight 160 lb -KL Departure Vitals Row Name 08/29/15 0011 Departure Condition Patient Teaching Discharge instructions reviewed -KL Departure Mode In police custody -KL Neuro Assessment Row Name 08/28/15 2356 LOC Loss of Consciousness No -KL Posturing Posturing Type None -KL Glasgow Coma Scale Eye Opening 4 -KL Best Verbal Response 5 -KL Best Motor Response 6 -KL Glasgow Coma Scale Score 15 -KL Motor / Strength Extremity Numbness Left Arm -KL Pre-Arrival IV Access Row Name 08/28/15 2351 Pre-Hospital IV Access Pre-hospital IV placed? No -KL Previous Hospital Admission Row Name 08/28/15 2355 Previous Admission Have you been admitted to a hospital in the last 30 days? No -KL Sepsis Screening Row Name 08/28/15 2355 PVH EMERGENCY Anderson, Chayce A MRN: DOB: , Sex: M Adm: 8/28/2015, D/C: 8/29/2015 Flowsheets (all recorded) (continued) Sepsis Screening (continued) Row Name 08/28/15 2355 cellulitus, post- operative, line/catheter, or immunocompromised. Does the patient have new mental status changes? No -KL Travel & Exposure Screen Row Name 08/28/15 2348 Ebola Screening In the last 21 days, have you traveled to Guinea or Sierra Leone (for newborns has mother traveled to these regions)? No -MT In the last 21 days, have you been near any person with Ebola (for newborns has the mother been near any person with Ebola)? No -MT Triage Plan Row Name 08/28/15 2355 ESI ESI 4 -KL UCH ED FALL RISK ASSESSMENT TOOL. Row Name 08/28/15 2356 Fall Risk Assessment Tool History of Falling in Last 3 Months, Including Since Admission 1 -KL Is patient confused or disoriented? 0 -KL Is patient intoxicated or sedated? 0 -KL Does patient have an impaired gait? 1 -KL Does patient use a mobility assistance device? 0 -KL Is patient experiencing altered elimination? 1 -KL Fall Risk Score 3 -KL PVH EMERGENCY Anderson, Chayce A MRN: DOB: Sex: M Adm: 8/28/2015, D/C: 8/29/2015 Flowsheets (all recorded) (continued) Vital Signs (continued) Row Name 08/28/15 2352 Patient Position Sitting -KL Pulse 70 -KL Resp 16 -KL Temp 37.1 °C (98.8 °F) -KL Temp src Oral -KL Oxygen Therapy SpO2 96 % -KL SpO2- Pt at Rest or with Activity Rest -KL O2 Status RA -KL Pain Management ("Yes" or "No" fufills this red clock) Patient in Pain? No -KL Patient reporting pain Self-reporting or Non- reporting Self-reporting -KL Sedation Scale Moline-Roberts Sedation Scale 1-alert -KL RASS Sedation Scale 0 -KL Height and Weight Height 1.778 m (5' 10") -KL Height Method Stated -KL Weight 68 kg (150 lb) -KL Weight Method Stated -KL User Key (r) = Recorded By, (t) = Taken By, (c) = Cosigned By Initials Name KL Lindeken, Kimberly L MT Taggart, Molly R Letters Scanned Images Encounter-Level Documents: There are no encounter-level documents. Order-Level Documents: There are no order-level documents. Scanned Images Document on 9/1/2015 12:57 PM by Interface, Attendingdrone, MD (below) Printed by 79672 at 3/4/19 4:12 PM Page 13 Anderson 0025 REDACTED REDACTED Case 1:17-cv-00884-CMA-STV Document 133-10 Filed 07/26/19 USDC Colorado Page 14 of 24 PVH EMERGENCY Anderson, Chayce A MRN: DOB: Sex: M Adm: 8/28/2015, D/C: 8/29/2015 Printed by 79672 at 3/4/19 4:12 PM Page 14 Anderson 0026 REDACTED REDACTED R E D A C T E D REDACTED REDACTED REDACTED Case 1:17-cv-00884-CMA-STV Document 133-10 Filed 07/26/19 USDC Colorado Page 15 of 24 PVH EMERGENCY Anderson, Chayce A MRN: , DOB: Sex: M Adm: 8/28/2015, D/C: 8/29/2015 Printed by 79672 at 3/4/19 4:12 PM Page 15 Anderson 0027 REDACTED REDACTED REDACTED Case 1:17-cv-00884-CMA-STV Document 133-10 Filed 07/26/19 USDC Colorado Page 16 of 24 PVH EMERGENCY Anderson, Chayce A MRN: DOB: Sex: M Adm: 8/28/2015, D/C: 8/29/2015 Printed by 79672 at 3/4/19 4:12 PM Page 16 Anderson 0028 REDACTED REDACTED REDACTED Case 1:17-cv-00884-CMA-STV Document 133-10 Filed 07/26/19 USDC Colorado Page 17 of 24 PVH EMERGENCY Anderson, Chayce A MRN: DOB: Sex: M Adm: 8/28/2015, D/C: 8/29/2015 Printed by 79672 at 3/4/19 4:12 PM Page 17 Anderson 0029 REDACTED REDACTED REDACTED Case 1:17-cv-00884-CMA-STV Document 133-10 Filed 07/26/19 USDC Colorado Page 18 of 24 PVH EMERGENCY Anderson, Chayce A MRN: DOB: Sex: M Adm: 8/28/2015, D/C: 8/29/2015 Scanned Images Printed by 79672 at 3/4/19 4:12 PM Page 18 Anderson 0030 REDACTED REDACTED REDACTED Case 1:17-cv-00884-CMA-STV Document 133-10 Filed 07/26/19 USDC Colorado Page 19 of 24 PVH EMERGENCY Anderson, Chayce A MRN: DOB: Sex: M Adm: 8/28/2015, D/C: 8/29/2015 Document on 9/1/2015 12:58 PM by Interface, Attendingdrone, MD (below) Printed by 79672 at 3/4/19 4:12 PM Page 19 Anderson 0031 REDACTED REDACTED REDACTED REDACTED Case 1:17-cv-00884-CMA-STV Document 133-10 Filed 07/26/19 USDC Colorado Page 20 of 24 PVH EMERGENCY Anderson, Chayce A MRN: DOB: Sex: M Adm: 8/28/2015, D/C: 8/29/2015 Printed by 79672 at 3/4/19 4:12 PM Page 20 Anderson 0032 REDACTED REDACTED REDACTED Case 1:17-cv-00884-CMA-STV Document 133-10 Filed 07/26/19 USDC Colorado Page 21 of 24 PVH EMERGENCY Anderson, Chayce A MRN: DOB: Sex: M Adm: 8/28/2015, D/C: 8/29/2015 Printed by 79672 at 3/4/19 4:12 PM Page 21 Anderson 0033 REDACTED REDACTED REDACTED Case 1:17-cv-00884-CMA-STV Document 133-10 Filed 07/26/19 USDC Colorado Page 22 of 24 PVH EMERGENCY Anderson, Chayce A MRN: DOB: Sex: M Adm: 8/28/2015, D/C: 8/29/2015 Printed by 79672 at 3/4/19 4:12 PM Page 22 Anderson 0034 REDACTED REDACTED REDACTED Case 1:17-cv-00884-CMA-STV Document 133-10 Filed 07/26/19 USDC Colorado Page 23 of 24 PVH EMERGENCY Anderson, Chayce A MRN: DOB: Sex: M Adm: 8/28/2015, D/C: 8/29/2015 END OF REPORT Printed by 79672 at 3/4/19 4:12 PM Page 23 Anderson 0035 REDACTED REDACTED REDACTED Case 1:17-cv-00884-CMA-STV Document 133-10 Filed 07/26/19 USDC Colorado Page 24 of 24 Fall Interventions Moderate and High Risk >/= to 3 Bed in low position;Assistance with toileting;Call light within reach;Move into view of nurses station -KL Fall Risk Education Completed Yes -KL Vital Signs Row Name 08/28/15 2352 Vital Signs BP 133/79 -KL MAP (mmHg) 90 -KL Printed by 79672 at 3/4/19 4:12 PM Page 12 Anderson 0024 REDACTED REDACTED Case 1:17-cv-00884-CMA-STV Document 133-10 Filed 07/26/19 USDC Colorado Page 13 of 24 Sepsis Screening Does patient have risk factors, signs or symptoms of infection? ie: pneumonia, urinary, No -KL Printed by 79672 at 3/4/19 4:12 PM Page 11 Anderson 0023 REDACTED REDACTED Case 1:17-cv-00884-CMA-STV Document 133-10 Filed 07/26/19 USDC Colorado Page 12 of 24 High: Female Calculated Energy for 84 -KL Printed by 79672 at 3/4/19 4:12 PM Page 10 Anderson 0022 REDACTED REDACTED Case 1:17-cv-00884-CMA-STV Document 133-10 Filed 07/26/19 USDC Colorado Page 11 of 24 Anderson 0015 REDACTED REDACTED Case 1:17-cv-00884-CMA-STV Document 133-10 Filed 07/26/19 USDC Colorado Page 4 of 24 Printed by 79672 at 3/4/19 4:12 PM Page 1 ED Arrival at 8/28/2015 2348 Anderson 0013 REDACTED REDACTED REDACT ED REDACTED REDACTED RE DA CT ED REDA CTED REDACTED REDACTED REDACTED REDACTED RE DA CT ED REDA CTED REDACTED REDACTED REDACTE D REDACTED REDACTED REDACTED RE DA CT ED REDA CTED REDACTED REDACTED REDACT ED Case 1:17-cv-00884-CMA-STV Document 133-10 Filed 07/26/19 USDC Colorado Page 2 of 24