Homelessness Documentation – CA SB 1152

DC, MDM

I have provided a medical screening examination and evaluation.

The patient is clinically stable for discharge. I have communicated post-discharge medical needs to the patient and the patient has been provided with or offered the following:

Meal
Weather appropriate clothing
Prescription or adequate supply of medication from hospital outpatient pharmacy
Referral to outpatient clinic for infectious disease screening
Vaccines appropriate to the patient’s presenting medical condition

Transportation has been arranged to patient’s post discharge destination.

Viral URI – Discharge

MDM

This *** patient presents with symptoms suspicious for likely viral upper respiratory infection. Differential includes bacterial pneumonia, sinusitis, allergic rhinitis, ***. Do not suspect underlying cardiopulmonary process. I considered, but think unlikely, dangerous causes of this patient’s symptoms to include ACS, CHF or COPD exacerbations, pneumonia, pneumothorax. Patient is nontoxic appearing and not in need of emergent medical intervention.

Plan: reassurance, reassessment, over the counter medications, discharge with PCP followup

CHF Exacerbation – Admit

Uncategorized

This patient presents with signs and symptoms consistent with an acute exacerbation of chronic CHF, likely due to ***. Differential diagnosis includes alternate cardiopulmonary causes such as ischemia, PE, pneumothorax, and pneumonia, as well as other causes of dyspnea such as asthma/RAD, COPD, flash pulmonary edema, dysrhythmia but these are less likely. Patient is generally hemodynamically stable.

Plan: labs, EKG, CXR, troponin, intravenous diuresis, and electrolyte repletion. Will require admission for IV diuretics and medical optimization.

Capacity Assessment

MDM

YES:

Capacity Assessment: In my medical opinion, this patient has capacity to make medical decisions. The patient has the ability to communicate their choice to me and others, understands the information relevant to this decision, appreciates the situation itself and the consequences inherent to their choice, and can logically explain their rationale for their decision.

NO:

In my medical opinion, this patient does NOT have capacity to make a medical decision regarding ***, because
a. The patient is unable to communicate a choice.
b. The patient is unable to understand the relevant information
c. The patient is unable to appreciate a situation and its consequences
d. The patient is unable to reason rationally.

AMA Documentation

MDM

This patient has elected to leave against medical advice. In my opinion, the patient has capacity to leave AMA. The patient is clinically sober, free from distracting injury, appears to have intact insight and judgment and reason, and in my opinion has capacity to make decisions. I explained to the patient that his symptoms may represent *** and the patient verbalized understanding of my concerns.

I had a discussion with the patient about their workup and results, and that they may still have *** despite ***. I informed the patient that the next step in diagnosis and treatment would be ***, and they verbalized understanding of this as well. I explained the risks of leaving without further workup or treatment, which included reasonably foreseeable complications such as death, serious injury, permanent disability, and ***. I also offered alternatives to departing AMA such as assigning the patient a different provider or an alternate workup pathway.

The patient is refusing any further care, specifically ***, and is leaving against medical advice. I am unable to convince the patient to stay. I have asked them to return as soon as possible to complete their evaluation, and also explained that they were welcome to return to the ER for further evaluation whenever they choose. I have asked the patient to follow up with their primary doctor as soon as possible. I have answered all their questions. Patient signed***did not sign AMA paperwork.

DC Inst – Wrist Pain

DC

You have been evaluated in the Emergency Department today for wrist pain after a fall. Your evaluation, including physical exam and x-ray, has revealed that you have a fracture of your _______ // no evidence of any acute fractures or dislocations.

You can alternate Tylenol and Motrin every 4-6 hours to help control your pain as directed on the package. Please also rest, ice, and elevate your arm to control pain and inflammation.

Please follow up with your primary care physician within two days. If your pain persists in 7- 10 days please have repeat x-ray. // Please follow up with an orthopedic surgeon within 1 week.

Return to the Emergency Department if you experience worsening or uncontrolled pain, numbness or weakness to your hand, color change to your hand, or any other concerning symptoms.

Thank you for choosing us for your care.

DC Inst – Vomiting

DC

You have been evaluated in the Emergency Department today for your nausea and vomiting. Your evaluation suggests that your symptoms are most likely to do a viral infection which will improve on its own with rest and fluids.

Please follow up with your primary care physician within two days.

Remember to drink plenty of fluids at home.

Return to the Emergency Department if you experience worsening or uncontrolled pain, inability to tolerate fluids by mouth, difficulty breathing, fevers 100.4°F or greater, recurrent vomiting, or any other concerning symptoms.

Thank you for choosing for your care.

DC Inst – Vasovagal Syncope

DC

You have been evaluated in the Emergency Department today for your syncopal episode. Your evaluation did not show evidence of medical conditions requiring emergent intervention at this time, however we recommend you follow up with your primary care provider for further testing as an outpatient.

Please follow up with your primary care doctor in 2-3 days.

Return to the ER immediately for worsening or uncontrolled symptoms, headache, chest pain, shortness of breath, persistent vomiting, vision changes, recurrent fainting, or for any other concerning symptoms.

Thank you for choosing us for your care.

DC Inst – Vaginal Bleeding

DC

You have been evaluated in the UCLA Emergency Department today for your vaginal bleeding. Your evaluation suggests that your symptoms are due to ***. Your ultrasound showed ***.

Please follow up with your primary care physician within two days.

***Please follow up with your OB/Gyn within 2 days.

Return to the Emergency Department if you experience worsening or uncontrolled bleeding, shortness of breath, feeling lightheaded, chest tightness, abdominal cramping, severe abdominal pain, fevers,vomiting, or for any other concerning symptoms.

Thank you for choosing us for your care.