CONTACTS 

SUBJECTS
Default Null Subject Account for Blank Record

0403 -
0403 -    ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 29 0000. ref SDS 28 0000.
040502 -
040503 -
040504 -
040505 -
040506 -
040508 -  ..
0406 -
0407 -
0408 - Background
0409 -
040901 - On 091103 Paula reported the VA has scheduled a meeting today with
040902 - Doctor Stewart for planning Heller Myotomy surgery to correct
040903 - achalasia problem. ref SDS 17 PS60  On 091104 0718 Medical Chart
040904 - discharge guidance lists meeting with Doctor Stewart 091117 1300,
040905 - which conflicts with patient history today. ref SDS 18 Q03J  On 091119
040906 - 1000 Erick confirmed visit with Doctor Stewart on 091208, and is
040907 - reviewing date of surgery scheduled for 091217. ref SDS 20 935H
040909 -  ..
040910 - On 091208 Doctor Stewart advanced the schedule for surgery one day to
040911 - 091216. ref SDS 22 6E41
040913 -  ..
040914 - On 091216 0600 meeting Doctor Stewart for Heller Myotomy surgery to
040915 - correct achalasia; check in at ASU. ref SDS 26 PP8W
040917 -  ..
040918 - On 091217 0600 meeting with Joe and Jon on recovring from Heller
040919 - Myotomy surgery; report of complication during surgery on 091216,
040920 - which was repaired, with plan for test to evaluate recovery. reported
040921 - on 091217 0600, ref SDS 27 0042  Doctor Stewart visited and expects
040922 - can start eating after favorable test. ref SDS 27 027A
040924 -  ..
040925 - On 091218 0600 xray with gastrogafin to evaluate repair for
040926 - complicaiton during Heller Myotomoy surgery Wednesday, ref SDS 28 PP8W,
040928 -  ..
040929 - On 091219 0600 doctor plans discharge tomorrow after evaluating
040930 - progress eating solid food today. ref SDS 29 PP5V  Since now eating
040931 - solid food, switched to oral pill medication to replace IV injections;
040932 - this relieved pain that has been increasing using IV catheters set on
040933 - Wednesday, ref SDS 29 PQPX, and also eliminated need to replace IV
040934 - catheters per TCU protocol. ref SDS 29 7Q55  Doctors prescribed hiking
040935 - to recover from Heller Myotomy surgery resolving achalasia.
040936 - ref SDS 29 7Q6P   Doctor Ratcliff and Neil visit and discussing doing a
040937 - small business trial to apply SDS technology for upgrading VA and UCSF
040938 - case management. ref SDS 29 0M6S  Nurse advises that patient approved
040939 - for moving to a ward for non-critical care, as a predicate to
040940 - discharge, but since there are no rooms available, patient will remain
040941 - in TCU untill a room is available. ref SDS 29 0M8S
040943 -  ..
040944 - On 091220 0527 discharge approved from hospital today. ref SDS 0 PP8W
040945 - Left the hospital about 1220. ref SDS 0 HB5O
040946 -
040947 -
040949 -  ..
0410 -
0411 -
0412 - Progess
0413 -
041301 - Saide visits to take vitals and blood sugar.
041302 -
041303 - She says everything still looks good for strong recovery from surgery
041304 - on 091216.
041306 -  ..
041307 - There was no blood draw this morning.
041309 -  ..
041310 - Saide delivered pill that to be taken before breakfast that aids
041311 - digestion.
041313 -  ..
041314 - Went for a hike and checked weight................. 167
041316 -  ..
041317 - This is a good start toward goal of 155, having come down from about
041318 - 200 # since last March, and from 180 since September.
041319 -
041320 -            [On 100721 0800 weight gain from reduced exercise and
041321 -            increased digestion with resolution of achalasia.
041322 -            ref SDS 31 RP6I
041323 -
041324 -
041325 -
041327 -  ..
0414 -
0415 -
0416 - 0800
0417 -
041701 - Shift change.  Elizabeth replaces Saide.
041702 -
041704 -  ..
0418 -
0419 -
0420 - 0809
0421 -
042101 - Two-person medical team arrives, both women.  One the women assisted
042102 - Steve yesterday.  Steve evidently went off shift after having the
042103 - night on-call duty.
042105 -  ..
042106 - The woman said that discharge is approved for today since eating seems
042107 - to be going well from the test yesterday, reported on, ref SDS 29 YP3J
042109 -  ..
042110 - There will be a follow up meeting for progress review in 2 weeks.
042111 -
042112 -        [On 091221 1532 Isaani called and scheduled meeting with Doctor
042113 -        Steward on 100105 1400. ref SDS 30 PP8W
042115 -  ..
042116 - Discussed getting a ride home today to Concord, so that Millie does
042117 - not have to drive to San Francisco after getting chemotherapy to
042118 - recover from 9th relapse of stage IV cancer.
042120 -  ..
042121 - One of the doctors said they would investigate, and noted that getting
042122 - transportation for customers on the weekend is difficult.
042123 -
042124 -        [...below nurse, Elizabeth, reports that VA cannot provide
042125 -        assistance with travel to get home today. ref SDS 0 HA6G
042126 -
042127 -
042129 -  ..
0422 -
0423 -
0424 - 0810
0425 -
042501 - Breakfast arrives.
042502 -
042503 - Got one can of Ensure.
042505 -  ..
042506 - Ate most of cream of wheat.
042508 -  ..
042509 - Ate some of the scrambled eggs and a few bites of toast.
042511 -  ..
042512 - There was no juice.
042513 -
042514 -
042516 -  ..
0426 -
0427 -
0428 - 0843
0429 -
042901 - Elizabeth visited.
042902 -
042903 - Received pill for simvastatin and half of a pill for Melotrolo the
042904 - controls blood pressure.
042906 -  ..
042907 - Elizabeth will deliver discharge instructions.
042909 -  ..
042910 - She said that VA cannot provide transportation assistance for
042911 - customers released from the hospital on the weekend, following up
042912 - discussion with the doctors this morning, per above. ref SDS 0 U66O
042913 -
042915 -  ..
0430 -
0431 -
0432 - 0857
0433 -
043301 - Called Millie.
043302 -
043303 - She does not sound good, but is pleased that discharge will be today.
043305 -  ..
043306 - Discuss taking a cab to BART and then getting home via BART.  Millie
043307 - reminds that she took the walut on Wednesday, so there is no cash to
043308 - finance the trip.
043310 -  ..
043311 - Millie decides to come to San Francisco and drive home together.
043312 -
043313 -
043315 -  ..
0434 -
0435 -
0436 - 1042
0437 -
043701 - Elizabeth delivers printed medical chart with discharge guidance.
043702 -
043703 - She said that medicaitons have been ordred from the pharmacy, and they
043704 - estimate the order will be delivered about noon.  Elizabeth to tell
043705 - Millie to arrive about 1300 to allow another hour for getting
043706 - medications from the pharmacy.
043707 -
043709 -  ..
0438 -
0439 -
0440 - 1113
0441 -
044101 - Medications delivered from pharmacy.
044102 -
044103 - Thanked the attendant for timely delivery.
044104 -
044106 -  ..
0442 -
0443 -
0444 - 1120
0445 -
044501 - Called Millie.
044502 -
044503 - Advised that we can leave as soon as she arrives, since everything is
044504 - now done.
044506 -  ..
044507 - Mil said she is all set, and will leave in 5 minutes.
044508 -
044510 -  ..
0446 -
0447 -
0448 - 1134
0449 -
044901 - Received call from one of the two doctors who met this morning and
044902 - notified that discharge is approved.  The doctor said they have been
044903 - successful making arrangements for transportation to Concord.
044905 -  ..
044906 - Explained that Millie has already left based on Elizabeth's report
044907 - that she was told the VA could not make provide patient transportation
044908 - today, per above. ref SDS 0 QB6H
044910 -  ..
044911 - The doctor said she didn't talk any of the nurses, because she just
044912 - found out that transportation is available.
044914 -  ..
044915 - Thanked her for extra effort, and commended everyone at the VA for
044916 - excellent work.
044917 -
044919 -  ..
0450 -
0451 -
0452 - 1137
0453 -
045301 - Called for Millie and got answering machine, so she has already left.
045302 -
045303 - Dressed for travel, and put the computer in the case ready to go.
045304 -
045305 -
045306 -
045308 -  ..
0454 -
0455 -
0456 - 1220
0457 -
045701 - Millie arrives.
045702 -
045703 - She made good time, because traffic is light this morning.
045705 -  ..
045706 - Visited with Scott in the nurses control center.
045708 -  ..
045709 - Asked to borrow a wheelchair to take the computer and keyboard to the
045710 - car, since this exceeds sternum precautions on lifting.
045712 -  ..
045713 - Scott asked a nurses aide to take the computer down to the parking
045714 - lot.
045716 -  ..
045717 - Thanked Scott for wonderful experience getting care at the VA since
045718 - Wednesday.
045719 -
045720 -
045722 -  ..
0458 -
0459 -
0460 - 1400
0461 -
046101 - Medical Record Discharge Instructions Medications Follow Up Meetings
046102 -
046103 - Follow up ref SDS 18 UM4K.
046104 -
046105 - Reviewed discharge guidance in medical chart received from VA this
046106 - morning, per above. ref SDS 0 PQPX
046108 -  ..
046109 - Similar format to discharge instructions on 091104 following heart
046110 - surgery. ref SDS 18 UM4K
046111 -
046112 -    Medical Record                       Progress Notes
046113 -
046114 -    1.  Note dated:  091220 1029
046116 -         ..
046117 -    2.  Local title:  Discharge Instructions Note
046119 -         ..
046120 -    3.  Standard Title:  Physician Discharge Note
046122 -         ..
046123 -    4.  Admitted:  091216 0734    3B(3)TCUS
046125 -         ..
046126 -    5.  Discharge Medications:
046127 -
046128 -        Patient is being discharged to home.
046130 -         ..
046131 -        Patient:  with these discharge instructions, you will receive
046132 -        a printout of the medicatoins from the San Francisco VA
046133 -        Medical Center which you should take afer discharge.
046135 -         ..
046136 -        Ask your doctor, nurse, or pharmacist if you have any questions
046137 -        about your medication.
046139 -         ..
046140 -        You should do the following with medications that your already
046141 -        have at thome that are not on the listr from San Francisco.
046143 -         ..
046144 -        [Printed list of medications...]
046146 -         ..
046147 -        Location:  MTZ ANC Pharmacotherapy (new) 091117
046149 -         ..
046150 -        Printed 091116 2359
046152 -         ..
046153 -        Confidential medication reconciliation summary
046155 -         ..
046158 -         ..
046159 -        MRP - Unified Activ Pharm
046161 -         ..
046162 -        Alphabetized list of outpatient Rx's, inpatient orders, remote
046163 -        and non-VA meda
046165 -         ..
046166 -        Legend:  OPT = VA issued outpatient prescription.
046167 -                 INP = VA issued inpatient order
046169 -         ..
046170 -        Non-VA Meda Last Documented On:  ** data not found **
046171 -
046172 -        1.  Aspirin................................. 325 MG
046173 -
046174 -            Take one tablet every day
046176 -             ..
046177 -            Last filled:  091104 (active at San Francisco VAMC)
046179 -             ..
046180 -            Rx (prescription) expiration........ 101031
046181 -            Days supply......................... 90
046182 -            Refills............................. 3
046184 -             ..
046185 -        2.  Hydrocodone 5/Acetaminophen............. 500 MG
046186 -            (Vicadin)
046188 -             ..
046189 -            Take 1 - 2 tablets every 6 hours as needed for pain
046191 -             ..
046192 -            Last filled:  091220 (active at San Francisco VAMC)
046194 -             ..
046195 -            Rx (prescription) expiration........ 100119
046196 -            Days supply......................... ?
046197 -            Refills............................. 0
046199 -  ..
046200 - On 091218 0541 report that surgical pain has been resolved by hiking,
046201 - so ended medication in the hospital. ref SDS 28 PP8W
046203 -  ..
046204 - Medical chart medication listing continues...
046205 -
046206 -        3.  Metoprolol Tartrate..................... 25 MG
046207 -
046208 -            Take one half tablet twice per day.
046210 -             ..
046211 -            Last filled:  091104 (active at San Francisco VAMC)
046213 -             ..
046214 -            Rx (prescription) expiration........ 100128
046215 -            Days supply......................... 90
046216 -            Refills............................. 0
046218 -             ..
046219 -        4.  Omeprazole.............................. 20 MG capsules
046220 -
046221 -            Take one capsule every morning before breakfast
046223 -             ..
046224 -            Last filled:  091220 (active at San Francisco VAMC)
046226 -             ..
046227 -            Rx (prescription) expiration........ 100119
046228 -            Days supply......................... 30
046229 -            Refills............................. 0
046231 -             ..
046232 -        5.  Simvastatin............................. 20 MG
046233 -
046234 -            Take one tablet every day for cholesterol.
046236 -             ..
046237 -            Last filled:  091104 (active at San Francisco VAMC)
046239 -             ..
046240 -            Rx (prescription) expiration........ 101031
046241 -            Days supply......................... 90
046242 -            Refills............................. 3
046244 -             ..
046245 -        6.  Simvastatin............................. 40 MG
046246 -
046247 -            Take one-half tablet every day for cholesterol.
046249 -             ..
046250 -            Use pill cutter; do not take with grapefruit juice.
046252 -             ..
046253 -            Last released:  091005 (active at San Francisco VAMC)
046255 -             ..
046256 -            Rx (prescription) expiration........ 100815
046257 -            Days supply......................... 30
046258 -            Refills............................. 5
046260 -         ..
046261 -    6.  Inpatient attending:  Doctor Stewart.
046263 -         ..
046264 -    7.  Discharge date/time
046265 -
046266 -        Anticipated discharge date/time...
046267 -
046268 -            091220 1200
046270 -         ..
046271 -        Comments:  [none]
046273 -         ..
046274 -    8.  Discharge diagnoses:
046275 -
046276 -            Primary diagnosis............. achalasia
046277 -            Secondary Diagnosos...........
046279 -         ..
046280 -    9.  Discharge condition:  good
046282 -         ..
046283 -   10.  Discharge disposition:  home
046285 -         ..
046286 -   11.  Discharge activity:  no restrictions
046288 -         ..
046289 -   12.  Discharge transportation:  self
046291 -         ..
046292 -   13.  Discharge diet:
046293 -
046294 -        Current Diet:  MECH SOFT
046296 -         ..
046297 -        Restrictions:
046298 -
046299 -            Eat soft/liquid foods.  Advance your diet slowly
046301 -             ..
046302 -            Your last calculated Body Mass Index (BMI) is 28.1
046303 -            (Overweight).  Patients with a BMI less than <18.5 should
046304 -            contact our nutrition clinic at 415 221 4810 ext 2895 for
046305 -            nutrition services.  Patients with a BMI over 30 should
046306 -            speak with their primary care provider about weight loss.
046307 -            Your last serum albumin (blood test reflective of yor
046308 -            prtein stores) is....
046309 -
046310 -                091216  Albumin    3.80  gm/dL        3.3 - 5.2  Plasma
046312 -             ..
046313 -            Patients with a serum albumin less than 2.8 gm/dL should
046314 -            contact our nutrition clinic at 415 221 4810 ext 3354 for
046315 -            nutrition services.
046317 -         ..
046318 -   14.  Discharge smoking instructions.
046319 -
046320 -        Don't smoke.  If you need help quitting smoking, talk to your
046321 -        Primary Care Provider or call the Smoking Cessation Hotline at
046322 -        415 379 5566 or call Bloria Wilcher at the Smoking Cessatoin
046323 -        Clinic 415 750 2050.
046325 -         ..
046326 -   15.  Discharge nursing instructions.
046327 -
046328 -        Nursing instructions regarding patient teaching or other
046329 -        specifics:  none.
046331 -         ..
046332 -   16.  Discharge wound instructions.
046333 -
046334 -        Wound care as follows:  none.
046336 -         ..
046337 -   17.  Special discharge instructions.
046339 -         ..
046340 -   18.  Discharge Follow-up.
046341 -
046342 -        Follow up is important after discharge.  Refer to the attached
046343 -        list for future meetings with the medical team. ref SDS 0 9T6O
046345 -         ..
046346 -        If you do nothave a future appointment scheduled after
046347 -        discharge and you are not contacted within 4 days with an
046348 -        appointment, please call the following clinic(s) and ask to
046349 -        schedule your post discharge follow up appointment(s).
046350 -
046351 -            Clinic 1:  General Surgery:  call 415 379 5672
046353 -         ..
046354 -   19.  Discharge call information.
046355 -
046356 -        For more information or if your symptoms worsen call Telephone
046357 -        Care...
046358 -
046359 -                    800 733 0502
046361 -         ..
046362 -        Other numbers...
046363 -
046364 -        a.  Call to make an appointment to see Doctor Stewart in
046365 -            clinic in 2 weeks.
046366 -
046367 -        b.  Prescription Refills............ 415 750 2233 or
046368 -                                             800 847 3202
046370 -             ..
046371 -            Prescription number and number of refills are listed on
046372 -            the prescription lable.
046374 -             ..
046375 -        c.  Link to your health care by signing up for Myhealthevet at
046376 -
046377 -                http://www.myhealth.va.gov
046378 -
046379 -            ...to manage your VA prescription refills, personal health
046380 -            journals and more.  Contact the Myhealthevet POC at...
046381 -
046382 -                415 221 4810 ext 3834
046384 -             ..
046385 -        d.  If there are no refills for the medication:  please contact
046386 -            your provider if you need new prescriptions.
046388 -             ..
046389 -        e.  If you wish to have a copy of your discharge summary sent
046390 -            to a provider not at the San Francisco VA Medical Center,
046391 -            please contact Release of information at 415 750 6607 or
046392 -            stop by room 176 in building 2 of the Medical Center.
046394 -         ..
046395 -   20.  A copy of these instructions was given to the patient at
046396 -        discharge.
046398 -         ..
046399 -   21.  Signed by:
046400 -
046401 -        Amanda Sammann, MD MPH
046402 -        R1, Surgical Service UC # 72144
046403 -        091220 1033
046405 -         ..
046406 -   22.  Future Clinic Meetings
046407 -
046408 -        091117 1340    Surgery General New   Doctor Lygia Stewart    415 750 6922     Building 200 Ground Floor Module 2
046410 -  ..
046411 - This meeting has no support in the record.  Paula advised that 2
046412 - meetings are scheduled with Doctor Stewart, initially on 091208, and
046413 - then surgery to correct achalasia problem on 091217, reported on
046414 - 091103 0347. ref SDS 18 PS60
046415 -
046416 -            [On 091119 1000 Erick confirmed visit with Doctor Stewart
046417 -            on 091208, and is reviewing date of surgery scheduled for
046418 -            091217. ref SDS 21 935H
046420 -  ..
046421 - Medical chart continues...
046422 -
046423 -        091119 1000    Cardiothoracic        Doctor Neil Cambronero  415 750 6922     Building 200 Ground Floor Module 1
046424 -
046425 -            [On 091117 1317 Ramon called - requested that Ramon call
046426 -            the VA in Martinez to coordinate labs and tests performed
046427 -            at VA in Martinez needed for meeting with Neil in San
046428 -            Francisco to review progress recovering from heart surgery.
046429 -            ref SDS 19 QF7O
046431 -             ..
046432 -            [On 091117 1500 meeting at VA in Martinez; Ramon called and
046433 -            coordinated getting tests for meeting with Neil on 091119
046434 -            in San Francisco to review progress recovering from heart
046435 -            surgery. ref SDS 20 TC4I
046436 -
046437 -
046438 -
046440 -  ..
0465 -
0466 -
0467 - 1734
0468 -
046801 - Evon arrives to make arrangements for the ride home.
046802 -
046803 - She has 2 other customers who are currently getting treatment.
046804 -
046805 -
046806 -
046807 -
046808 -
046809 -
0469 -