Progress Note The New York Times-Books Download

Progress Note The New York Times

2020 | 4 views | 6 Pages | 429.41 KB

Progress Note Printed On Sep 09, 2008 impotence. We recommend that the patient have a s1z1ng of his prostate before proceeding with planning for seed implants. An appointment has been made for prostate sizing and we look forward to seeing the patient at that time. Thank you for referring this nice gentleman with this most unfortunate problem.



Progress Note Printed On Sep 09 2008
impotence We recommend that the patient have a s1z1ng of his prostate before
proceeding with planning for seed implants An appointment has been made for
prostate sizing and we look forward to seeing the patient at that time
Thank you for referring this nice gentleman with this most unfortunate problem
es VASTHI J CHRISTENSEN
Signed 01 04 2005 14 53
es RICHARD WHITTINGTON
Radiation Oncologist
Cosigned 01 04 2005 15 14
01 04 2005 ADDENDUM STATUS COMPLETED
Rev Flippin is a 63yo man recently diagnosed with T2a Gleason 3 3 6 PSA 7 04 Ca
Prostate Metastatic W U not done due to low PSA and Gleason score not
recommended by ACR He has already done extensive reading on prostate cancer
treatment options He has nocturia x2 and no other sx of BOO He has no risk
factors for proctitis PMH HTN no other significant PMH physical findings
as described by Dr Christensen We discussed treatment options including
Surgery brachytherapy and small volume ext beam RT We discussed the bladder
and rectal irritative sx and the risk of proctitis associated with interstitial
and external RT and contraseted that with the risk of incontinence associated
with surgery We explained the risk of impotence is 45 with brachytherapy 60
with surgery and 75 with ext beam RT We answered his questions and he has
decided he wishes to proceed with brachytherapy We have scheduled in him for
treatment planning ultrasound
es RICHARD WHITTINGTON
Radiation Oncologist
Signed 01 04 2005 15 21
LOCAL TITLE NURSE SURGERY CLINIC
STANDARD TITLE NURSING OUTPATIENT E M NOTE
DATE OF NOTE DEC 29 2004 12 58 ENTRY DATE DEC 29 2004 12 58 13
AUTHOR MARTINEZ DAMARIS EXP COSIGNER
URGENCY STATUS COMPLETED
Name FLIPPIN RICARDO CHALMUS
Age 63 Sex MALE
Patient has answered NKA
PATIENT NAME AND ADDRESS Mechanical Imprinting If available VISTA Electronic Medical Documentation
FLIPPIN RICARDO
Printed at PHILADELPHIA PA VAMC
Progress Note Printed On Sep 09 2008
Seeds 79 total
Scrubbed Drs Kao Dorsey
UrologYI cystoscopy Schwab Malkowicz
Needles 20
Planned dose 160 Gy to prostate
Patient was prepped scrubbed and anesthesized without difficulty
Ultrasound probe was introduced and proper positioning verified Needles
preloaded with iodine seeds were then introduced as per plan derived from
most recent sizing US Cytoscopy by Urology performed after implantation
of seeds revealed no seeds in the bladder Followup monitoring by Radiation
Safety also found no seeds lying outside of patient The entire procedure
was completed without difficulty or
complication Anesthesized was reversed and patient taken to the Recovery
Room in satisfactory condition
Gary D Kao MD PhD
lesl GARY D KAO
Signed os 09 200S 11 13
LOCAL TITLE DISCHARGE INSTRUCTIONS
STANDARD TITLE PHYSICIAN EDUCATION DISCHARGE NOTE
DATE OF NOTE MAY 09 200S 10 S8 ENTRY DATE MAY 09 200S 10 S8 21
AUTHOR SCHWAB C WILLIAM EXP COSIGNER
URGENCY STATUS COMPLETED
PHILADELPHIA VETERANS AFFAIRS MEDICAL CENTER
PATIENT DISCHARGE INSTRUCTIONS
FLIPPIN RICARDO C
Date of Admission May 9 200S
Date of Discharge may 10 200S
Type of Discharge Regular Discharge to Home
Discharge Disposition Home
List of all diagnoses treated during this admission
Admitting Diagnosis prostate ca
Principal Diagnosis same
Other Diagnoses HTN
Operative Procedures cystolbrachytherapy
PATIENT NAME AND ADDRESS Mechanical Imprinting if available VISTA Electronic Medical Documentation
FLIPPIN RICARDO
Printed at PHILADELPHIA PA VAMC
FliPPIN RIr ARno fHllMFFF RA I r ON 11I T NOTF ORl141 OOA n n 1 rof
P C RESS tlO II Pllyc l IAN ORDER I li 1 If IIJII j
I t r J I f 1 1
DIAGNOSIS tABS 0 CBC DlfF i J CEA
JCHEM 7 0 HEPATIC FUNCTION
SCAlE 0 10 FILMS 0 CT ABD PELVIS
o Cf CHEST
CHARACTER o PET SCAN
FREQUENCY o COLONOSCOPV
THE OHIO STATE UNIVER Il Y lftJu
11111111111
FlIPPIN RICARDO C
COLON RECTAL SURGERY
PROGRESS NOTES AND ORDERS
P W PTI IIIIIIJIIIII
MC201454 f I04
Progress Note Printed On Sep 09 2008
es Amit Maity MD PhD
Signed 08 13 2008 16 12
08 19 2008 ADDENDUM STATUS COMPLETED
Information pretaining to 1151 claims process and the right to file an
administrative tort claim has been mailed to the veteran POC information for
follow up questions has been provided
es SUSANN M KIRLIN
RISK MANAGER
Signed 08 19 2008 11 39
LOCAL TITLE RADIATION ONCOLOGY TELEPHONE NOTE
STANDARD TITLE RADIATION ONCOLOGY TELEPHONE ENCOUNTER NOTE
DATE OF NOTE JUL 15 2008 16 23 ENTRY DATE JUL 15 2008 16 23 36
AUTHOR MASLOW JOEL EXP COSIGNER
URGENCY STATUS COMPLETED
RADIATION ONCOLOGY TELEPHONE NOTE Has ADDENDA
Mr Flippin was contacted at work to discuss his treatment and potential
complications from this treatment
He was treated in May 2005 and had a D90 calculated as 66 64 Per Mr Flippin he
developed bowel problems and thought that he had radiation proctitis and
presented to the CLarksburg VAMC and was then transferred to Ohio State Univ for
treatment for radation proctitics The long course of treatment resulted in job
loss and he stated he was bed ridden for 6 months
We discussed the fact that his case and others were being reviewed and that we
would request that he come out to Philadelphia once independent review of
treatment options were completed likely in 6 8 weeks or hopefully earlier He
asked whether the seeds from his prostate brachytherapy were causative for his
rectal symptoms and this was stated as posisble and that his case including seed
placement would be discussed at his visit
esl JOEL MASLOW MD
Signed 07 15 2008 16 31
07 23 2008 ADDENDUM STATUS COMPLETED
Information pretaining to 1151 claims process and the right to file an
PATIENT NAME AND ADDRESS Mechanical Imprinting If available VISTA Electronic Medical Documentation
FLIPPIN RICARDO
Printed at PHILADELPHIA PA VAMC
DEPARTMENT OF VETERANS AFFAIRS
VA Medical Center
University and Woodland Avenues
Philadelphia PA 19104
In Reply Refer To
August 15 2008
Richard C Flippin
Charleston WV 25311
Dear Mr Flippin
Recently a letter was sent to notify you that the care you received for prostate cancer at the
Philadelphia VA Medical Center was being reviewed As part of the follow up to assess your
treatment a follow up CT scan was perfonned The results of the CT scan indicate that the
treatment you received did not meet VA s high standard of care You recently were notified by
telephone of this result and this letter is being sent to confinn that conversation We have also
advised your VA primary care physician of this fact and we will send himlher a copy of this
If you have any further questions please call Pamela Devine RN in the Radiation Oncology
Department at 215 to set up a time for your visit
Included in this packet is infonnation regarding the filing of administrative claims and benefits
for which you may be eligible If you have questions about the benefits or claims please call
Sue Kirlin R N Risk Manager at 215 ortoll free at 8 0 0 extension
I apologize for any inconvenience or concerns this may cause regarding the care that you
received at the Philadelphia VA Medical Center
RICHARD S FACHE
Medical Center Director


Related Books

PART I

PART I

THE UNIVERSITY OF THE STATE OF NEW YORK THE STATE EDUCATION DEPA RT M E N T PART I.1 Best Practices: 5 Guiding Principles.....2 NOTE: This document is a work in progress. Parts II and III, in particular, are in need of further development, and we invite the submission of additional learning experiences and local perfor-mance tasks for these sections. Inquiries regarding submission of materials ...

Continue Reading...
Documentation: Case Note Writing - Human Services Ed

Documentation: Case Note Writing - Human Services Ed

Documentation – Case Notes New York State APSE Lake Placid, 2018 4 Case Noting: Documentation: The case note records important details about services provided to the customers. Case notes should record the customer’s participation in activities and his or her progress. Sometimes case notes serve as documentation of factors

Continue Reading...
CONNECTIONS Tip Sheet Progress Notes: Create and Modify

CONNECTIONS Tip Sheet Progress Notes: Create and Modify

Progress Notes fields at the top of the window, the search results grid in the middle, and buttons along the bottom. 3. To create a new note, click on the New Note button (or select from the Options menu). The Progress Notes Detail window displays. 4. To create a note with New Using, select a note from the grid and click on

Continue Reading...
NYC EARLY INTERVENTION PROGRAM Provider Progress Note 3 6 ...

NYC EARLY INTERVENTION PROGRAM Provider Progress Note 3 6 ...

NYC Early Intervention Program Progress Note Instructions 8/2014 Example: IFSP Functional Outcome #1: Ida will be able to pick up small objects, such as raisins or Cheerios, with either hand using her thumb and index figure without resting her arm on the table so that she can begin feeding herself everyday during meal

Continue Reading...
New York State Clinical Records Initiative (NYSCRI)

New York State Clinical Records Initiative (NYSCRI)

Historically, New York State provider agencies/programs have independently developed and used a wide variety of clinical and medical documentation processes. As a result, there are a significant number of different genres/styles of assessments, service plans, and progress notes in current use. The costs associated with developing a standardized ...

Continue Reading...
Regulations and Documentation Templates Guidance

Regulations and Documentation Templates Guidance

Progress Notes : Evaluation and Management (E & M) • Complex Care / Crisis Intervention / Contact Note • Health Monitoring / Injectable Psychotropic Medication Administration / with Monitoring and Education • Pre-Admission / Admission Decision Note • Psychotherapy / Contact: Administration: Treatment Plans • Discharge Summary / Plan – Part A • Patient Safety Plan Template • Rel

Continue Reading...
THE CITY of NEW York Standard Audit Process Guide

THE CITY of NEW York Standard Audit Process Guide

The City of New York Standard Audit Process Guide Table of Contents I. Planning 2 II. Field Work 3 III. Progress Reports 5 IV. Extension Requests 5 V. Preliminary Draft Audit Reports 5 VI. Draft and Final Reports 5 VII. Follow-up 7 VIII. Appendix A – Sample City Agency Audit Announcement Letter, with attached Document List Required for Audit 8 IX. Appendix B – Sample Audit Firm Entrance ...

Continue Reading...
NewYorkCommonCore TaskForceFinalReport - Governor of New York

NewYorkCommonCore TaskForceFinalReport - Governor of New York

Tim Kremer, Executive Director of the New York State School Boards Association Carl Marcellino, Senator and Chair of the Senate Education Committee Cathy Nolan, Assembly Member and Chair of the Assembly Education Committee Sam Radford III, President of the District Parent Coordinating Council of Buffalo Carrie Remis, Rochester Area Parent Randi Weingarten, President of the American Federation ...

Continue Reading...
New York University - NYU

New York University - NYU

New York University in Washington, D.C. and California. 2 Definitions of Tenured/Tenure Track Faculty, Full-Time Continuing Contract Faculty, and Other Faculty, and list of research titles can be found in the Faculty Handbook, Faculty Titles. For purposes of this Policy, Other Faculty includes full-time faculty who are Courant Institute Instructors, Assistant Professor/Faculty Fellows, and ...

Continue Reading...
Clinical Documentation & Recordkeeping - New York State ...

Clinical Documentation & Recordkeeping - New York State ...

The Legal Mandate for Clinical Documentation in New York State The Rules of the New York State Board of Regents defining unprofessional conduct define unprofessional conduct by a health care professional as including, "failing to maintain a record for each patient which accurately reflects the evaluation and treatment of the patient. Unless otherwise provided by law, all patient records must ...

Continue Reading...
CMS Manual System

CMS Manual System

CMS Manual System . Department of Health & Human Services (DHHS) Pub. 100-07 State Operations . Provider Certification . Centers for Medicare & Medicaid Services (CMS) Transmittal 47 . Date: June 5, 2009 . SUBJECT: Revised Appendix A, “Interpretive Guidelines for Hospitals” I. SUMMARY OF CHANGES: The revised issuance of Appendix A dated October 17, 2008, inadvertently omitted language ...

Continue Reading...