CONTACTS 

SUBJECTS
Endoscopy Colonoscopy Test Follow Up Complications None Reported Med

2803 -
2803 -    ..
2804 - Summary/Objective
2805 -
280501 - Follow up ref SDS 49 0000. ref SDS 48 0000.
280502 -
280503 -
280505 -  ..
2806 -
2807 -
2808 - Progress
2809 -
280901 - Background on endoscopy and colonoscopy tests reported on 100305 1000.
280902 - ref SDS 49 5R5H
280904 -  ..
280905 - Marcia works for the surgery department at the VA in Martinez.
280907 -  ..
280908 - Marcia asked if any of complications have occurred from GI procedures
280909 - performed at the VA on 090305, and listed in the doucment received
280910 - from Kay. ref SDS 49 7U4I
280912 -  ..
280913 - Advised that no complications have occurred.
280915 -  ..
280916 - Marcia asked about quality of service received from Doctor Lee and
280917 - the GI team?
280919 -  ..
280920 - Strongly commended excellent medical services provided by Doctor Lee
280921 - and his team, as related to Doctor Lee on 100305 1000. ref SDS 49 E18F
280922 -
280923 -          [...below, on 100308 1411 Marcia's Progress Notes report
280924 -          patient satisfied with medical services. ref SDS 0 IM3J
280926 -  ..
280927 - Marcia explained that Doctor Lee prescribed medication to treat acid
280928 - burn, found during endoscopy test on 100305 1000. ref SDS 49 PR6P; she
280929 - asked if medication has been received from the VA?
280931 -  ..
280932 - Advised Marcia that no medication has been received from the VA.
280934 -  ..
280935 - Asked for explanation of medication?
280937 -  ..
280938 - Marcia advised that the form issued by the VA on 100305 prescribes
280939 - medication and instructions for daily use.
280940 -
280941 -            Omeprazole 20 mg 90 capsules
280942 -            Take one capsule daily 15 minutes before 1st meal to
280943 -            relieve severe acid reflux and esophageal narrowing.
280945 -  ..
280946 - Advised Marcia that there is illegible handwriting on the GI Discharge
280947 - form, and cannot find instructions on use, reported on 100305 1000.
280948 - ref SDS 49 HC7K
280950 -  ..
280951 - Marcia feels that delay ordering medication may be related to
280952 - illebible handwriting on the Discharge form.  This aligns with
280953 - national reporting that illegible handwriting cause a lot of mistakes
280954 - in healthe care, shown in the record on 990912, ref SDS 2 0960
280955 - Marcia will investigate and take appropriate action to order
280956 - prescribed medication with Omeprazole 20 mg 90 capsules, per above.
280957 - ref SDS 0 CH48
280958 -
280959 -        [On 100317 1213 letter to VA reports Omeprazole medication was
280960 -        received from the VA and started treating esophagitis from acid
280961 -        reflux. ref SDS 51 PU3W
280963 -         ..
280964 -        [On 100810 1530 Doctor Lee asked why meeting to perform follow
280965 -        up EGD was delayed more than 2 months, ref SDS 53 M18F, planned
280966 -        in the meeting today, per above, ref SDS 49 HB86, and was
280967 -        advised there were no instructions on taking Omeprazole, and
280968 -        Marcia reported on 100308, ref SDS 0 NB7H, that illegible
280969 -        handwriting in Discharge papers, noted below, ref SDS 49 HC7K,
280970 -        delayed the VA ordering medication. ref SDS 53 M18K
280972 -         ..
280973 -        [On 100827 0738 medical chart presents "Findings" plus
280974 -        Impressions and Recommendations missing from medical chart for
280975 -        work today on 100305, for treament with Omeprazole 40 mg,
280976 -        ref SDS 54 MZ8J, and which doubled dose prescribed today on
280977 -        100305, though not listed in the medical chart, nor presented
280978 -        by the medical team after the procedure, per above, ref SDS 49
280979 -        HB86; later Marcia called and reported the doctor prescribed
280980 -        Omeprazole 20 mg per day, which turned out to be illegible
280981 -        handwriting in the discharge document, per above, ref SDS 49
280982 -        HC7K, as explained by Marcia on 100308 1411. ref SDS 0 CH3O
280984 -         ..
280985 -        [On 100827 0738 VA medical chart for follow up EGD test
280986 -        reports use of prescribed medication with Omeprazole was
280987 -        inconsistent, ref SDS 54 JE7X, and again in "Impression"
280988 -        section, ref SDS 54 JE9J, - clarification note appended on
280989 -        not getting instructions to use Omeprazole, and illegible
280990 -        handwriting was vague in Discharge documents. ref SDS 54
280991 -        JE7X
280993 -         ..
280994 -        [On 101210 0930 Doctor Lee prescribes doubling dose again
280995 -        to Omeprazole 80 mg per day after EGD and dilation found
280996 -        continuing esophagael sphincter severely restricts
280997 -        swallowing, ref SDS 56 ZN4M, and shown in medical chart
280998 -        Recommendations. ref SDS 56 XT5N
281000 -  ..
281001 - Marcia explained that the doctor's prescription for medication to
281002 - resolve acid burn, and instructions for use are reported in VA
281003 - Progress Notes for the Endoscopy procedure on 100305.  Marcia also
281004 - noted that instructions for medication will be printed on the
281005 - medication container.
281006 -
281007 -        [On 100312 1200 received Progress Notes for Endoscopy test
281008 -        performed on 100305, ref SDS 50 EY4F, "acid burn" and
281009 -        medication prescription are not reported in Progress Notes for
281010 -        Endoscopy on 100305 1000. ref SDS 49 Y65V
281012 -  ..
281013 - Related discussion with Doctor Lee on 100305, reviewing objectives to
281014 - support the doctor/patient partnership for case management.  Working
281015 - intelligently requires getting detailed findings in a computer file
281016 - that can be linked into a web of intelligence "connecting the dots" of
281017 - cause and effect that leverages the power of knowledge to control the
281018 - future.  At that time on 100305 discussed getting a letter with a copy
281019 - to Doctor Stewart at the VA Medical Center in San Francisco,
281020 - ref SDS 49 HB4K, and transmitting Doctor Lee's findings on "acid burn"
281021 - to the "flap" which Doctor Stewart surgically constructed on 091216,
281022 - 091216 0600. ref SDS 31 KE9U
281024 -  ..
281025 - Marcia advised that the the VA will not electronically transmit the
281026 - computer file on patient medical records for efficient case managment.
281027 - Patient can get the doctor's report from the VA Release of Information
281028 - (ROI) Department.  She expects that pathology for the biopsies will
281029 - take a week or so to be available.
281031 -  ..
281032 - Getting in the car to drive 20 miles, standing in line, having VA
281033 - staff find the computer file, send the file to a printer, buying paper
281034 - logistics handling paper, getting back in the car, driving another 20
281035 - miles, typing contents on the paper into another computer eviscerate
281036 - efficiencies required for containing medical costs.
281037 -
281038 -        [On 100312 1119 VA transmittal letter explains patient medical
281039 -        records are confidential to protect patient identify theft,
281040 -        avoid patient embarrassment, and enhance patient convenience.
281041 -        ref SDS 50 SQ9J
281043 -         ..
281044 -        [On 100317 1213 letter to VA commends excellent medical
281045 -        services, and confirms understandings that medical tests on
281046 -        100305 made findings of no cancer, and that acid burn has
281047 -        occurred only on the flap constructed by Doctor Stewart to
281048 -        protect the modified esophgeal sphincter valve from causing
281049 -        acid reflux. ref SDS 51 PT6W
281051 -         ..
281052 -        [On 100331 1448 VA letter seems to expand understandings from
281053 -        meeting on 100305, ref SDS 49 PR6P, and presented in feedback
281054 -        letter to the VA on 100317 1213. ref SDS 51 PT6W, to relate
281055 -        test findings of general reflux esophagitis, rather than or in
281056 -        addition to mere "acid burn" on the flap for the esophageal
281057 -        sphincter valve. ref SDS 52 YW5S
281059 -         ..
281060 -        [On 100912 1127 received Doctor Lee's letter confirming
281061 -        findings from test on 100827, and setting out follow up work
281062 -        plan. ref SDS 55 1W5I
281063 -
281064 -
281065 -
2811 -

SUBJECTS
Progress Notes Telecon Follow Up Endoscopy Colonoscopy Test Post-pro

4503 -
4504 - 1320
450501 -  ..
450502 - Progress Notes
450503 - GI Post Procedure Phone Call
450504 -
450505 - This record was received in a printed document by getting in the car
450506 - and driving 20 miles to the VA in Martinez, CA, getting excellent
450507 - service from a staff person, and then driving 20 miles home; and then
450508 - spending an hour typing up the record that was already typed by
450509 - excellent VA staff...
450511 -         ..
450512 -    1.  Printed March 12, 2010
450514 -         ..
450515 -    2.  Local Title:  GI Post Procedure Phone Call
450516 -
450517 -        Standard Title:  Gastroenterology Telephone Encounter Note
450518 -        Date of Note............................. 2010 MAR 08 1320
450519 -        Entry Date............................... 2010 MAR 08 132042
450520 -        Author
450524 -         ..
450525 -        EXP Cosigner.............................
450526 -        Urgency..................................
450527 -        Status................................... Completed
450529 -         ..
450530 -    3.  Patient's Name
450534 -         ..
450535 -    4.  Phone Numer
450539 -         ..
450540 -    5.  Procedure................................ EGC/Colonoscopy
450541 -        Procedure Date........................... 2010 MAR 05
450542 -        MD.......................................
450543 -
450544 -                Lee Randall
450546 -         ..
450547 -    6.  Spoke With............................... patient
450548 -        Date & Time.............................. 2010 MAR 08 1321
450550 -         ..
450551 -    7.  Comment
450552 -
450553 -        Pt is doing well (hiked 5 miles on Sat and 3 miles on Sun) post
450554 -        procedure.  Written discharge instructions were reviewed with
450555 -        the patient at this time and clarifications offered.
450557 -         ..
450558 -        Pt denies any of the six listed below. ref SDS 0 QQ6K
450560 -         ..
450561 -        However, patient strongly wants Doctor Lee to write him a
450562 -        personal letter detailing the exam findings and his rationale
450563 -        for his treatment and fu plan.  I referred pt to his GI
450564 -        discharge instruction sheet (which we reviewed in detail), to
450565 -        Release of Records for the EGD procedural report (pending), and
450566 -        told him that I would alert Doctor Lee to this note.  This, to,
450567 -        did not seem to totally satisfy him.
450569 -  ..
450570 - Marcia deserves an apology from the patient for emotional duress
450571 - evident in her Progress Notes comment. ref SDS 0 ES50
450573 -  ..
450574 - For some reason, Marcia does not report in the Progress Notes that
450575 - medication prescription to treat "acid burn" on the "flap" surgically
450576 - constructed by Doctor Stewart is not evident in GI Discharge
450577 - documentation received on 100305, as discussed above. ref SDS 0 CH3O
450578 -
450579 -        [On 100312 1119 VA transmittal letter explains patient medical
450580 -        records are confidential to protect patient from identity
450581 -        theft, avoid patient embarrassment, and enhance patient
450582 -        convenience. ref SDS 50 SQ9J
450584 -         ..
450585 -        [On 100312 1200 received Progress Notes for Endoscopy test
450586 -        performed on 100305, ref SDS 50 EY4F, "acid burn" and
450587 -        medication prescription are not reported in Progress Notes for
450588 -        Endoscopy on 100305 1000. ref SDS 49 Y65V
450590 -         ..
450591 -        [On 100317 1213 letter to VA commends excellent medical
450592 -        services, and confirms understandings that medical tests on
450593 -        100305 made findings of no cancer, and that acid burn has
450594 -        occurred only on the flap constructed by Doctor Stewart to
450595 -        protect the modified esophgeal sphincter valve from causing
450596 -        acid reflux. ref SDS 51 PT6W
450598 -         ..
450599 -        [On 100331 1448 VA letter seems to expand understandings from
450600 -        meeting on 100305, ref SDS 49 PR6P, and presented in feedback
450601 -        letter to the VA on 100317 1213. ref SDS 51 PT6W, to relate
450602 -        test findings of general reflux esophagitis, rather than or in
450603 -        addition to mere "acid burn" on the flap for the esophageal
450604 -        sphincter valve. ref SDS 52 YW5S
450606 -  ..
450607 - Patient requested in the call from Marcia transmission of VA computer
450608 - file for efficient case management, per above, ref SDS 0 ES5O, and
450609 - citing discussion with Doctor Lee on 100305 1000. ref SDS 49 HB4K
450611 -  ..
450612 - VA Progress Notes from Marcia continue...
450613 -
450614 -        Furthermore, patient wanted his GI team in the SFVA to be
450615 -        alerted to Doctor Lee's report in CPRS.  He is aware that the
450616 -        inforation will be avaliable to them as soon as ti is in CPRS,
450617 -        but this, too, was not totally satisfactory to him.
450619 -  ..
450620 - Discussed this with Doctor Lee on 100305 1000. ref SDS 49 HB4K
450622 -  ..
450623 - Actually, the record should go to Doctor Stewart in the General
450624 - Surgery Department at the VA Medical Center in San Francisco, who
450625 - performed Heller Myotomy surgery to resolve achalasia, and who
450626 - surgically constructed the "flap", which is evidently now at risk from
450627 - "acid burn," reported by Doctor Lee's findings during the test on
450628 - 100305 1000. ref SDS 49 PR6P  In this case the GI team at VA Medical
450629 - Center in San Francisco was not involved in the procedure, except for
450630 - signing off on performing a surgery solution, rather than pneumatic
450631 - dilation, originally planned by Doctor Lee.
450633 -         ..
450634 -        [On 100317 1213 letter to VA commends excellent medical
450635 -        services, and confirms understandings that medical tests on
450636 -        100305 made findings of no cancer, and that acid burn has
450637 -        occurred only on the flap constructed by Doctor Stewart to
450638 -        protect the modified esophgeal sphincter valve from causing
450639 -        acid reflux. ref SDS 51 PT6W
450641 -         ..
450642 -        [On 100331 1448 VA letter seems to expand understandings from
450643 -        meeting on 100305, ref SDS 49 PR6P, and presented in feedback
450644 -        letter to the VA on 100317 1213. ref SDS 51 PT6W, to relate
450645 -        test findings of general reflux esophagitis, rather than or in
450646 -        addition to mere "acid burn" on the flap for the esophageal
450647 -        sphincter valve. ref SDS 52 YW5S
450649 -  ..
450650 - VA Progress Notes from Marcia continue...
450651 -
450652 -    8.  Did you experience any of the following:
450653 -
450654 -        1.  No fever chills.
450656 -             ..
450657 -        2.  No redness, soreness, swelling or bruising of IV.
450658 -            Thoracentesis or Paracentesis puncture site.
450660 -             ..
450661 -        3.  No loss of consciousness.
450663 -             ..
450664 -        4.  No Bleeding (in stool, emesis, sputum, or at PEG tube
450665 -            site).
450667 -             ..
450668 -        5.  No severe abdominal pain.
450670 -             ..
450671 -        6.  No nausea / vomitting.
450673 -             ..
450674 -        7.  No difficulty swallowing.
450676 -             ..
450677 -        8.  No sore throat.
450679 -             ..
450680 -        9.  No chest pain or chest tightness.
450682 -             ..
450683 -       10.  No hoarseness.
450685 -             ..
450686 -       11.  No lung pain.
450688 -             ..
450689 -       12.  N/A severe peri rectal pain.
450691 -             ..
450692 -       13.  N/A urniary retention post hemorrhoid banding.
450694 -         ..
450695 -    9.  Were you satisfied with your experience?
450696 -
450697 -        Yes.
450699 -  ..
450700 - This understates the record commending the VA, per above, ref SDS 0
450701 - V55H, and as shown in patient history meeting with Jennifer and Kim
450702 - for pre-procedure preparation on 100305 1000, ref SDS 49 GO6G, and
450703 - meeting with Doctor Lee for post-procedure de-briefing. 100305 1000,
450704 - ref SDS 49 E18F
450705 -
450706 -        [On 100317 1213 letter to VA commends excellent medical
450707 -        services, and confirms understandings that medical tests on
450708 -        100305 made findings of no cancer, and that acid burn has
450709 -        occurred only on the flap constructed by Doctor Stewart to
450710 -        protect the modified esophgeal sphincter valve from causing
450711 -        acid reflux. ref SDS 51 PT6W
450713 -  ..
450714 - VA Progress Notes from Marcia continue...
450715 -
450716 -   10.  Is there anything we could have done better?
450718 -         ..
450719 -        Yes.  See Comments/Instructions: via additional signature mode.
450720 -        ref SDS 0 ES50
450721 -
450722 -            [On 100331 1448 VA letter seems to expand understandings
450723 -            from meeting on 100305, ref SDS 49 PR6P, and presented in
450724 -            feedback letter to the VA on 100317 1213. ref SDS 51 PT6W,
450725 -            to relate test findings of general reflux esophagitis,
450726 -            rather than or in addition to mere "acid burn" on the flap
450727 -            for the esophageal sphincter valve. ref SDS 52 YW5S
450729 -         ..
450731 -        Nursing Service
450732 -        Signed:  2010 MAR 08 1353
450734 -         ..
450735 -        Receipt Acknowledge By:
450736 -        * Awaiting Signature *
450737 -
450740 -
450741 -
450742 -
450743 -
450744 -
450745 -
450746 -
450747 -
450748 -
4508 -