Question: PATIENT NAME: TAYLOR, Lonnie W PATIENT NUMBER EDCase005 LOCATION: Emergency Room ED PHYSICIAN: Jon W. Beeson, M.D. DATE OF SERVICE: 02-08-YYYY DATE OF BIRTH 04-01-YYYY Physician Notes: Gen – Middle-aged Wm Head – NC/AT EENT – Nl. R Shoulder — Pain On Abduction Of Arm E Deformity Over Mid-shaft R Clavicle Tenderness To Palpation On R Post Ribs Lungs- …

PATIENT NAME: TAYLOR, Lonnie W PATIENT NUMBER EDCase005 LOCATION: Emergency Room ED PHYSICIAN: Jon W. Beeson, M.D. DATE OF SERVICE: 02-08-YYYY DATE OF BIRTH 04-01-YYYY Physician Notes: Gen – middle-aged wm head – NC/AT EENT – nl. R shoulder — pain on abduction of arm e deformity over mid-shaft R clavicle tenderness to palpation on R post ribs Lungs- clear X-ray R clavicle → Rx Tylend #3,94h PRN Disp #30 Copy of film to accompany patient to Clavicle brace sling Diagnosis: fx R clavicle contusion of ribs R Physician Orders: Xray R shoulder R davicle, R ribs Discharge instruction Brace sling Fdfar-up with family MD in 1 wk SIGNATURE OF ED PHYSICIAN Jan W. Beeson aloud Draw Hig CARE ELDRA Global Care Medical Center 100 Main St, Alfred NY 14802 (607)555-1234 EMERGENCY DEPARTMENT RECORD “ECA CENTE PATIENT INFORMATION: NAME: TAYLOR, Lonnie W ADDRESS: 6278 Mission Road Chry: Henrietta STATE: NY ZIP CODE: 14467 PATIENT NUMBER EDCase005 ADMISSION DATE & TIME: 02-08-YYYY 1210 DISCHARGE DATETIME: 02-08-YYYY 1330 CONDITION ON DISCHARGE Satisfactory Home Inpatient Admission Transfer to en Instruction Sheet Given ОАМА TELEPHONE: 585-334-8567 DOA GENDER: Male Code Blue Died DATE OF BIRTH 04-01-YYYY NURSING DOCUMENTATION: ALLERGIESE ONO Yes CURLINE MEDICATIONS: No Yes EXPLAIN EXPLAIN 180/110 P 72 R 20 TI 988 Сс Complains severe pain on movement HIPE CONDITION Snowmobiling (flew off tanding on Rt ribs, shoulder) ASSESSMENT: SIGNATURE OF PUIMARY CARE NURSER Donna A Smith RN ICD COEN CET/HCPCS LIVE ICOON NAME ADDRESS: TAYLOR, Lonnie W 6278 Mission Road Henrietta Chry: STATE: NY ZIP CODE 14467 PATIENT NUMBER EDCase005 ADMISSION DATETIME 02-08-YYYY 1210 DISCHARGE DATE & THE 02-08-YYYY 1330 CONDITION ON DISCHARGE: Satisfactory Home Inpatient Admission Transfer to: Instruction Sheet Given Ο AMA TELEPHONE: 585-334-8567 DOA GENDER: Male Code Blue DATE OF BIRTH 04-01-YYYY Died NURSING DOCUMENTATION: ALLERGIES: NO Yes CURRENT MEDICATIONS: No Yes EXPLAIN EXPLAIN BP: 72 R: 20 T: 988 180/110 P: Complains severe pain on movement CC: HPI: CONDITION: Snowmobiling – (flew off landing on Rt ribs, shoulder) ASSESSMENT: SIGNATURE OF PRIMARY CARE NURSE: Donna A Smith, RN ICD CODES: CPT/HCPCS LIVE. I CODES: CVO