jGHELE DOAN GIA Fac: Hunbor River Hospital Zoe:Wilson Emergency Bea:- 33M 20/11/1986 Med Rec Wum:H001446022 viste:28090855/20 institution? G7 Has Known of High Risk for WPSA/VRE/ESBL Wo YORE Query TextsIf Yes, initiate contact Precautions Known TE/Syrptoms: Cough, Blood in Wo Sputun, Weight Loss, Wight Sweats? Query TexteTf Yes, initiate Airborne precautions and notify TRAC New/Worse Diarrhea Symptons Last 7 Days? Wo Quecy TextsIf Yes, intiate Contact precautions Erecautions Rtn-Noadd"1 ‘Query Text+all patients at HRE will be eared for according to Health Canada and PIDAQ Routine Practices. IPAC should be consulted regarding all patients on Additional Precautions, ALl etatt perform Hand Hygiene as per HRM guidelines. Healtn Care Partners EMS Trip Nurbor 3071 led Triage Peassessnent2 Bearer Zi/TL/T8 Zoras Discharge systen (Rec: 21/11/19 20:45 System 1ERCEOE4) led tedioal Dizectives Stat Qi/TL/IS 20s leq: wonce Status: Discharge lecotocal: | SAFE.IPACE created Systen (Rec: 21/11/19 20:49 System 1ERCEOE4) |fciage Assessuent,AdUIt (eCTAS downtime] ‘Start; Zi/Ti/78 20:43 lrcea: .once Status: Discharge lecotocol: SAPE.IPACE Created Systen (Rec: 21/11/19 20:45 System 1ERCEOE4) jiacharge ‘Startr 1/TL/1S 20749 lrceq: .once Status: Discharge lerotaco! Created system (Rec: 21/11/19 20:49 system 1ERCPOB4) [ED to Unft-Corrected Transter Date/Time ‘Start; Gi/TL/18 Fores leceas Status: Discharge lezotocal: Created System (Rec: 21/11/19 20:49 System 1ERCEOEA) lai7a3/19 20:57 [aCTAS Report Start: 21/11/19 20:58 lrceq: wonce Statuet Disenarge ‘SAFE.IPRCE AVIGBATO (Roc: 21/11/19 20:58 BKG DARMON HUB-BG2) vent (eCTAS) eCTAS Triage Modifiers ‘Texperature (36 -37.5 C) ata Texperature Source ‘Tympanic Pulse Rate (60-100 beate/niin) 78 pulse rhythm Regular Respiratory Rate (12-20 breaths/min) 18 ‘Continued en Page 2 ‘These forms are part of the Legal Medical Record.jGHELE DOAN GIA Fac: Hunbor River Hospital Zoe:Wilson Emergency Bea:- 33 M 20/11/1986 Med Rec Wum:H00L446022 viste:28090855/20 Elood Pressure (S0/@0-100/30 mm Ha) 15/81 Oxygen Saturation (@) (95-100) 98 Cxygen Saturation source Room Aly ‘Triage Numeric Pain Rating 0 Glascow Coma Scale Score 15 ‘Triage Elood Glucose Monitor Reading (7.3 mmpl per litre) SOTAS Triage Modifiers Used Suicidal Tdestion No Plan ( Depression / Suicidal / Deliberate Self Harml eCTAS Triage Summary Stated Complaint SUICIDAL THOUGHTS/ ANXIETY ENS care 737.0 B86 Ra Bp-ilt/64 02-878 B/A cHG-7.3 Subjective Assocement Pationt presents to HR with EMS from home, history of anxiety and depression. Pationt states TeeLing nore depressed, isolating self. Fatient also has auditory hallucinations. Haz been to CAME. On psych meds and compliant. objective Assessment anxious at triage MeWlesl History depression. anxiety l2ijiay1s 20:58 [Physician Communication Start: 21/11/18 20:58 Jrcea: PRI Status: Discharge lecotocol Created systen (Rec: 21/11/19 20:58 aystem KUB-862) fransfer, Thternal/Bxternal ‘Start: 2I/TL/15 20:58 Jrcea:-PRY Status: Discharge lerotaco! Created System (Rec: 21/11/19 20:58 system _KUB~8c2) [fseatnent/ Procedure ‘Start; Gi/IL/15 Boise Jecea: .PRY Status: Discharge lecotocal: Created System (Rec: 21/11/19 20:58 System KUB-E62) [Specimen Collection Documentation ‘Starty eI/TL/19 20vSe lrceq: .PR Status: Discharge Jpsotcce! Created system (Rec: 21/11/19 20:58 system _KUB~8C2) [Health Teaching, General ‘Start; Zi/Ii/18 20:Se lecea: .PRN Status: Discharge Jeroteca! Created System (Rec: 21/11/19 20:58 System KUB~862) issesenent, Secondary - Adult2 ‘Stare: Qi/IL/IS DOSE lrceq: .once Status: Discharge lproraecl: SAPE.1PACE Created systen (Rec: 21/11/19 20:58 system HuB-8G2) Continued on Page 4 ‘These forms are pact of the Legal Medical Record.jGHELE DOAN GIA Fac: Hunbor River Hospital Zoe:Wilson Emergency 33M 20/11/1986 Med Rec Wum:H00144 6022 vaste: 8090855/20 [Discharge Plan/ Instructions 1 Bearer ZI/TI/18 20:58 Status: Dlecharge Created Systen (Rec: 21/11/19 20:58 System KUB-862) |fmecgency Transfer Report ‘Start: 2i/Ti/18 20:58 lrceq: | wonce Status: Discharge Jecotocat Created System (Ree: 21/11/19 20:58 aystem HuB-862) [Psychosocial/Nental Fealth ‘Start; ZI/IL/18 208 Jrea: Every 4 hours and PRN Status: Discharge lecctocol Created System (Rec: 21/11/19 20:58 System _KUB-862) |Fital signs and oaygenation ‘Start: Gi/TL/IS 0:56 |rext: *After 48 hours then OSH and PRN Status: Discharge Jrceq: .oaK and PRI lecotocal: Created System (Rec: 21/11/19 20:58 System KUB-E2) issesenent, Paint ‘Starer PIsTI/19 20:Se Jecoa: .04K AND DAN Statue: Diecharge lezctocais Created Systan (Rec: 21/11/19 20:58 system KUB~262) lintaxe and Gutput ‘Stare Zi/Ii/18 Z0se Oak Statue: Cisenarge System (Rec: 21/11/19 20:58 System _KUB~8G2) ]InR-Nesication Titration ‘Start; ZI/TL/I8 20:88 Statue: Dlecharge Created systen (Ree: 21/11/19 20:58 system HuB-sG2) lcorporate Patient safety check ‘Start 2i/Ti/18 20758 frext: ALL patients at HRH will be cared for according to Statue: Discharge Jiealth canada and PIDAC Routine Practices. TPAC should be [consulted regarding all patients on Additional Precautions ALL staff perform Hand Hygiene as per WRK guideline. Jeceas lrcotocol: SAFE.IPACE Created systen (Rec: 21/11/19 20:58 system _HuB-862) |fital signs/ventilation wont tor ‘Start Qi/TL/I8 20:56 Jrcea: Status: Discharge Jprotece! Created System (Rec: 21/11/19 20:58 system _KUB-E62) issescnent, Pressure Injury Risk ‘Start, Di/ii/10 20iSe leceq: .4GH AND PRN Status: Discharge lcctocal: INT.cu.P Created System (Rec: 21/11/19 20:58 System KUB-862) led Triage Wental Health checklist ‘Starter Di/TL/18 20Se lrceq: .once Status: Discharge |protece! Created system (Rec: 21/11/19 20:58 system _KUB-2G2) |S15/030 and Constant Observation ‘Start; Zi/IL/18 20:88 |rext: ***please refer to the attached policy for specific status: Discharge luctaiier** lrraq: Pea lecotocal: cm.oasgerc Continued on Page = ‘These forms are pact of the Legal Medical Record.jGHELE DOAN GIA Fac: Hunbor River Hospital 33M 20/11/1986 Loe:Wileon smergonoy Med Rec Wum:H001046022 viste:28090855/20 [Psychosocial/Nental Health |rceq: sEvery 4 hours and PRN lerotaco! Document ANNAANDR (Rec: 21/11/19 2 ED Assessment, Psychosocial Patient Presentation Fatient Presentation Problem known History of VLolence (verbal and/or physical) eroplen Cognitive Level of Consciousness Patient Behaviour Columbia Suicide Seale Protocol: PSY.COLSSR Please ask questions as written 1. Have you wished you were dead or wished you could go to sleep and not pake up 2. Have you actually hed any thoughts of killing yoursel! Query Text:If anewer to both #1 and #2 is ‘No’ then go to question #6 . lave you been thinking about how you might kill yourself Mental Health Act Mental Health Act Form Physics] Appearance Body Build MG agseccment Mood Desoription Indicators of ansLety Substance abuse Type Created System (Ree! 21/1/19 20:58 System KUB=EG2) JectAs Report ‘Stat: 2i/1L/19 20:88 lrcea: .once Status: Discharge lecctocal: SArE.IPACE Created RG DABMOW (Rect 21/11/19 20:58 BKG DARMON HUB-RG2) lau/aa/1s 22:11 Start: 21/11/19 20:58 Status: Discharge (0. ANNAANDR W1ERACYECOS) Er. pacing the room,ansious, restless, says that he's seen psychiatrist today, but feels that no one can help him, takes his med.s regularly, but feels they are not helping. Dencies suicidal/honocidal ‘thoughts. Wo Mental Health awake alert appropriate Wo Wo Ye Medium calm Depressed Anzious Facing § Restlessness Wone la27aa/t9 01:54 [reiage Assesenent lrraq: once lecotocal: sarE.IPACE Start: 21/11/18 20:49 Status: Gsenarge Continued on Page © ‘These forms are pact of the Legal Medical Record.jGHELE DOAN GIA Fac: Hunbor River Hospital Loe:Wileon smergonoy 33 M 20/11/1986 Med Rec Wum:H00L446022 viste:28090855/20 Hit Status BMG OAENON (Rect 22/11/18 0irs4 GXG DAEMON HUB-EGIa) Active=>Dlecharge [aD Triage Reassessnent2 Stare, S/TLIS Boas Jrceq: Status: Discharge lerotacol: Bit Status BKG DAEMON (Rec: 22/11/19 01:54 8KG DAEMON ¥HUB-RGIa) Actives:Discharge lad Medical Dicectiver Beart; S/TL/T9 20249 sonce Status: Discharge SAFE.TPACE BALL Status BMG DAEMON (Rec: 22/11/19 01:54 BHG DAEMON ¥HUB-BGIa) Active--Discharge [Felage Assessnent, Adult (eCTAS dowtine) Beare CA/TL/TS 00a lrceq: .once Status: Discharge lecotocal: SArE.zPAce Ait Status BMG DAEMON (Rec: 22/11/19 01:54 BKG DAEMON ¥HUB-BG1a) Aotive->Diseharge [pischarae Beart, PITTS 20a lrcoq: .once Statue: Diecharge lrzctocai: Ait Status BKG DAEMON (Rec: 22/11/19 01:54 &KG DAEMON ¥UB~EG1a) Active=>Disenarge Jed to Unit-Corrected Teanster Date/Time Bearer Zi/TL/T8 Zoras Status: Discharge BKG DAEMON (Rec: 22/11/19 1:54 SKG DAEMON ¥HUB-EG2a) Active=>DLeeharge lenysician conmunication Start, isi 20:58 RK Status: Slscharge Bit Status BKG DAEMON (Rec: 22/11/19 01:54 BKG DARMON ¥HUB-EGIa) ActLve=pDlscharge |feanster, Thternal/txternal Beart; Fi/TL/19 20:58 CBRN Status: Discharge Ait Status BG DAEMON (Rec: 22/11/19 01:54 BKG DARMON ¥HUB-EGIa) Active=>Diecharge [Tesatnent/ Procedure Bearer Oi/TL/I8 20Se Status: Discharge Ait Status BMG DAEMON (Rec: 22/11/19 01:54 BMG DAEMON HuB-BG1a) Aotive-sDischarge [Specinen Collection Docurentation Bearer PITTS 20:Se lrceq: .PR Status: Discharge Jpzctcce! Ait Status BKG DAEMON (Rec: 22/11/19 01:54 BKC DAEMON ¥HUB-BGIa) Agtive=>Disenarge jealth Teaching, General Beart, CISTL/TS 20:Se Jrcea: .PRW Status: Discharge lecctocar: BAit Status BKG DAEMON (Rec: 22/11/19 01:54 BKC DASMON HUE-BGIa) active=>Disenarge lissessnent, Secondary = Adult? lreeq: .once Start, 2i/ii/18 20:58 Status: Discharge Continued on Page 7 ‘These forms are pact of the Legal Medical Record.jGHELE DOAN GIA Fac: Hunbor River Hospital Zoe:Wilson Emergency 33M 20/11/1986 Med Rec Wum:H001446022 viste:28090855/20 lecotocal: sare. PACE BAit Status BMG DAEMON (Rec: 22/11/19 01:54 BXG DASMON MuB~BG1a) Active=>Dlecharge [Discharge Plan/ Instructions Wi Start: Zi/T1/18 20:58 Jrceas Status: Discharge Jecotocat BALt Status BMG DAEMON (Rec: 22/11/19 01:54 KG DAEMON ¥HUB-EGIa) Active=sDischarge faneraency Transfer Report Stare; ZI/TL/15 FOSS lrea: .once Status: Discharge lecotocal: Ait Status BMG DAEMON (Rect 22/11/19 01:54 BXG DASMON HUB-BGIa) Active=>Discharge |Esychosocial/Nental Health Bearer Qi/TL/I8 20Se lceq: .Every 4 hours and PRN Status: Discharge lecotocal: Ait Status BKG DAEMON (Rec: 22/11/19 01:54 BXG DAEMON HUB-EGIa) Active->Discharge tal Signs and oxygenation Beart, CISTI/1S 2OSe rents *Agter 4¢ houre then Q8H and PRN Statuer Discharge -QtH and PRN Ait Status EKG DAEMON (Rec: 22/11/19 01:54 &KG DARMON ¥HUE-EGIa) Active=>Discharge issessnent, Paint Start, ZA/TL/18 Ose Jrceq: .o0K AND PRN Status: Discharge Jerotaca! BAit Status BKG DAEMON (Rec: 22/11/19 01:54 BKG DAEMON ¥HUB-BGIa) aotives>nischarge lintake ana curput Start, 2i/Ti/i8 20758 Jrceq: .cae Status: Discharge lecotacol: Ait Status BMG DABMON (Rec: 22/11/19 01:54 BKG DARMON un-no1a) Active->Discharge AR-Nedication Titration Seartr PI/TLIS 20258 Status: Discharge BALt Status BMG DAEMON (Rec: 22/11/19 01:54 BKG DAEMON ¥UB-BS1a) Active->Discharge |Sorporate Patient Safety Check Bearer ITL/TY 20:e lrexts All patients at HRH will be cared for according to Statue: Discharge Jiealth canada and PIDAC Routine Practices. IPAC chould be lconsulted regarding all patients on Additional Precautions All staff perform Hand Hygiene as per HAH guideline. leceqs lrrotocol: sarE.1pace BAit Status BKG DAEMON (Rec: 22/11/19 01:54 &KG DASMON ¥HUB-EGIa) Active=>Discharge |"ital signs/ventilstion wonltor Start PI/TL/IS BOSE Jecca: Status: Discharge Jproteca! BALt Status BKG DAEMON (Rec: 22/11/19 01:54 8KG DAEMON ¥HUB-EGIa) Aotivessnisenarge lassessnent, Pressure Thjury Risk Stare, Sa/ii/i9 20058 Continued on Page © ‘These forms are pact of the Legal Medical Record.age: 3 jGHELE DOAN GIA Fac: Hunbor River Hospital Loe:Wileon smergonoy Bea:- 33 M 20/11/1986 Med Rec Wum:H001046022 vistt:E8090855/20 Freq: .QU8H AND EEN Status? Discharge lerotecol: aNT.eU.e BAlt Statue BAG DAEMON (Rec: 22/11/19 01:54 BKG DAEMON HUB-BG14) Active: sDischarge lkD Triage Mental Health checkIIst Bearer PVTI/Ts 2Se Freq: Once Status: Discharge lprotacat BALt Status ENG DARMON (Ree: 22/11/19 01:54 BNG DAEMON HUB-nG14) Active=>Discharge |0157030 and Constant observation Starter I/TI/15 20:56 Jrext: **Please refer to the attached policy for specific Status: Discharge eetailet™* lrreq: PR lprotecol! om.oesorte Bait Status EKG DAEMON (J sctive=>Diseharge + 22/11/19 01:54 GKG DAEMON ¥UB-EGIa) SCIRS Report Beart, F/TL/18 20iSe ‘once Statue: Diecharge ‘SAFE.1PACE Edit Status BAG DAEMON (Re bisenarge 22/11/19 01:54 BKG DARMON HUB-EGIa) Pal jent Notes: [21/11/19 22:42 Emergency Department Note by Andric,Anna IResponse:Pt, requested sendwich and juice, stated that he hasn't had anything to eat today, no sendwich lavailable, pt. given juice and cookies, but he didn’t like the option, stated that he will go to Tim Hortons to [buy something. linitialized on 21/11/19 22:42 - END OF NOTE [22/11/19 00:15 Emergency Department Note by Andric,Anna Data: IResponse:Pt. has left the building, as, per security who reviewed the video of the pt.’s leaving the ldepartment and heading toward the Willson/Keel Intersection. Dr. Gibbons wants the pt. brought back, lrequested form 9. Police called and promised to try and locate the pt. if, successful, they will Bring him back Ito ER. [initialized on 22/11/19 00:15 - END OF NOTE User Key Continued on Bage 5 ‘hese forms are part of the Legal Medical Record.age: > jGHELE DOAN GIA Fac: Hunbor River Hospital Loe:Wileon smergonoy Bea:- 33 M 20/11/1986 Med Rec Wum:H00104H022 vaste: ER090855/20 User Key = continued Monogram | Mnemonic | Name ‘Gredentials | Provider Type ANNAANDR | Andiric,Anna RN. Registered Nurse ‘AVIGBATO | Batoon Avigall | RN Registered Nurse BKG DAEMON | BKG DAEMON,MT Erinted on Sa/Ii/is 19:36 These forms are part of the Legal Medical Recordfx Records (HIM Archive) |wGRT, DOAN GTA Fac: thunber River Hospital 33 M 20/11/1986 Loc:Wilson Smergency Med Rec Wum:1i00144 6022 Bea Wisdt:E8090855/20 Reg Date:21/11/15, ‘Attending: Reason SUICIDAL THOUGHTS/ANKIETY ED Activity hast Mame: NGHTEM Status: Final Discharge lPiret Nane+ DOAN ‘Triage Levelt 3 CIAS URGENT fuiaare: era Condition: lpirthdate: 20/11/1986 Arrival Date/Time: 21/11/19 20:48 lage: 33 Arrival Moce: Bis Ise " ‘Triaged At: 2i/1a/19 20:49 hanguage: Toglish Tine Seen by Providers 21/11/19 23:01 [stated Conplaintr lender compiaint SUICTORL THOUGHTS /ANKIBTY Depression/Suicidal/Deliberate Selfkarm IED Lecation Sab-Reute Jaros [station: [azour’ leD Proviaert EDM-DR, DR IED Midlevel Provider: leD aur primary Care Provider Status Phase Detm/Value User/Action: Final Discharge 22AA/1 17:24:25 | Muscat, Colleen Ed Provider EDM-DR Edit MD Seen 24/11/19 23:07:19 | Gibbons,Paul Ed Provider Dr. Paul Gibbons (Gomez) Edit REG. Ragistered 24/11/19 24:00:02 | Turner, Kerry Ed Provider EDM-DR Ney TRIAGED 2i/11/19 20:58:59 | BKG DAEMON, MT ‘Chief Complaint Depression/Suicidal/Deliberate Selftiarm | _New RECEIVED. 21/11/19 20:48:56 | Batoon Avigall ‘Stated Complaint SUICIDAL THOUGHTS/ANXIETY Nevr [22/11/19 00:15 Emergency Department Note by Andric,Anna Data: Action: IResponse:Pt. has left the building, as, per security who reviewed the video of the pt.’ leaving the \department and heading toward the Willson/Keel intersection. Dr. Gibbons wants the pt. brought back, lrequested form 9. Police called and promised to try and locate the pt. if, successful, they will bring him back Ito ER. In ized on 22/11/19 00:15 - END OF NOTE Continued on Bage 2 This forms a part of the patient's madical record.age: jGHELE DOAN GIA Fac: Hunbor River Hospital Loe:Wileon smergonoy Bea:- 33 M 20/11/1986 Med Rec Wum:H001046022 viste:28090855/20 [21/11/19 22:42 Emergency Department Note by Andric,Anna Data: Action: IResponse:Pt. requested sendwich and juice, stated that he hasn't had anything to eat today, no sendwich lavailable, pt. alven juice and cookies, but he didn’t like the option, stated that he will go to Tim Hortons to [buy something, linitiaized on 21/11/19 22:42 - END OF NOTE ‘Archived EDM Records lpiaa/19 20:58 lrnergency Transfer Report Start: 21/11/19 20:58 Freq: once Statue: Diecnarge lprotacor? created systen (Rec: 21/11/19 20:58 system _HuB-862) la2/aa/1s 01:58 [Pnergency Transfer Report Start: 21/11/18 20:58 Freq: once Statue: Dlecharge lprotacort Edit Status EKG DAEMON (Rec: active=>Disenarge 2/11/19 01:54 EKG DAEMON UB-BG14) Patient Notes [22/11/19 00:15 Emergency Department Note by Andric,Anna Data: Action: IResponse:Pt. has left the building, as, per security who reviewed the video of the pt.’s leaving the ldepartment and heading toward the Willson/Keel intersection. Dr. Gibbons wants the pt. brought back, lrequested form 9. Police called and promised to try and locate the pt. if, successful, they will bring him back to ER. linitialized on 22/11/19 00:15 - END OF NOTE [21/11/19 22:42 Emergency Department Note by Andric,Anna IResponse:Pt. requested sendwich and juice, stated that he hasn't had anything to eat today, no sendwich lavailable, pt. given juice and cookies, but he didn't like the option, stated that he will go to Tim Hortons to lbuy something. Hinitiaized on 21/11/19 22:42 - END OF NOTE Continued on Bage 3 This forms a part of the patient's madical record.age: 3 jGHELE DOAN GIA Fac: Hunbor River Hospital Loe:Wileon smergonoy Bea:- 33 M 20/11/1986 Med Rec Wum:H00104H022 vaste: ER090855/20 Patient Notes - Continued VITAL SIGNS Temp _| Pulse | Resp | BP Pulse Ox 2ayis/i9 20:57 | 37,0C| 78 | 18 | 115/81 | 98 Glincal Data lecseautione Ren-WaAdd" 1 looes patient have oxygen or Iv? Mode of Transportation inpatient for discharge within 24 hours? fieignt feign lbody Mace Index (BMI) Jkeason tor VIP: [specific interventions to he provided primary olagnocis: [secondary Diagnosis lece-op lbate ot surgery: [surgical Procedure: hoeation |sx> Rotuen Date/Tine lex Retuen Mins lconaition lcondition corment |iisitore Aliowed visit Reason SUICIDAL THoUGHTS/amtETY luanquace English fold tray Date Joa tray tine Release Tray Date lRelesce Tray Tins lrood Likes |zood Dlelike: [______ER Clinical Assessments lpijat/19 70:49 Continued on Page @ This forms a part of the patient's madical record.jGHELE DOAN GIA Fac: Hunbor River Hospital Zoe:Wilson Emergency 33 M 20/11/1986 Med Rec Wum:H001446022 vaste: ER090855/20 [isiage Assessment Stare, Zi/TL/i8 20:43 lrceq: | -once Status: Discharge ‘SAFE.TERCE Created Systen (Rec: 21/11/19 20:49 System 1ERCEOR4) [Fciage Assessient ‘Start 2i/Ti/18 20749 lrceq: | wonce Status: Discharge lecotocal: SAFE.IPACe Document —AVIGBATO. (Rec: 21/11/19 20:50 AVIGBATO 1BRCPORA) Triage Assessment TRI Screen-Won-Outbreak conditions Do you have 2 nen /worse cough or Wo shortness of breath in the past 7 days? Query TexteIf yes,patient to wear procedure mask/clean hands Are you feeling feverish, or have you Wo had shakes or chills in the past 24 house? Query TexteI£ Yes to first and second question, initiate Droplet/Contact precautions Have you traveled within the last 20 we ays? Tf yes, where? ‘query Textsclick Protocol to Health0anads link to view affected countries. If patient visited any of the affected countries in last 30 days, initiate Droplet/contact/alrborne Precautions and page TPAC Have you had contact with a sick person Wo who has traveled to affected area? Tf yes, where? Have you been overnight at hospital in Yes the last 12 months Are you a resident of a long term care Wo institution? (1/M Has Known or High Risk for WRSA/VRE/ESDL Wo YORE Query TextsIf Yes, initiate contact precautions Known TE/Syxptoms: Cough, Blood in Wo Sputun, Weight Loss, Might Sweate? Query Textelf Yes, initiate Airborne Precautions and notify IPAC New/Worse Diarrhea Symptons Last 7 Days? Wo Quory ToxtrIf Yes, intiate contact precautions Precautions Rtn-Noadd"1 ‘Query Text+all patients at HRH will be Gared for according to Health Canada and PIDAC Routine Practices. IpAC should he consulted regarding all patlents on Additional Precautions. All staff Per Gorm Hand Hygiene as per HRH ‘Continued on Page = This forms a part of the patient's medical record.jGHELE DOAN GIA Fac: Hunbor River Hospital Zoe:Wilson Emergency Bea:- 33M 20/11/1986 Med Rec Wum:H001446022 viste:28090855/20 guidelines. Health Care Partners EMS Trip Nurber 307, Rolice Badge and Division # Nental Health Mobile Crisis Intervention Teams (XCIT) Additional Assessment, Fatient Demonstrates Agitated/Aggressive Behaviour Query TextsTf patient devonstrates agitated/agyressive behavior, select Rehavicr Risk-Alert” to display an alert on EDM Teacker immunization status Medical Directives “ay selecting one or more of the following medical dicective(s|, Tan initiating the medical directive(s) fer the patient which will be entered by clerical** Laboratory Teste, BCC and Medical Imaging led Triage Reassessnentz Bearer Ai/Ti/18 Zora lecoa: Status: Disenarge Jecctocai: Created system (Rec: 21/11/19 20:49 system _1sRCzOE4) led Medical Directives ‘Start; Zi/ii/i8 Zoras rence Status: Discharge SAFE.1PRCE Created systen (Rec: 21/11/19 20:49 System _1ERCEOEA) |Felage ascessuent,aduit (ecTAS downtine) Start 2i/fi/18 20749 lrceq: conse Status: Discnarge lcotocal: SAFE.IPACE Created systen (Rec: 21/11/19 20:49 system _1ERCEOE4) |bischacge Start; Qi/T1/19 20:49 once Status: Discharge Systen (Rec: 21/11/19 20:49 System _1ERCEOE4) fad to Unlt-corrected Transfer Date/Tine ‘Starer 2i/Ti/15 20749 Status: Discharge Created System (Rec: 21/11/19 20:49 System 1ERCPOEA) lp1/ai/19 20:57 [eCTAS Report Start: 21/11/19 20:58 lrceq: .once Status: Discharge lrcctocal: SAFE.IPACE Document —AVIGEATO. (Rec! 21/11/19 20958 BKG DAEMON HUB-BG2) Triage Assessment (6cTAS) eOTAS Triage Modifiers ‘Temperature (36 C-37.5 ©) 37.0 ¢ Temperature Source ‘Tympanic Pulse Rate (60-100) cr pulse Location Pulse Roytnm Regular Respiratary Rate (12-20) ae Elood Pressure (90/60=140/90) ais/at Continued on Page © This forms a part of the patient's madical record.jGHELE DOAN GIA Fac: Hunbor River Hospital 33 M 20/11/1986 Med Rec Wum:H001046022 Loe:Wileon smergonoy viste:28090855/20 Oxygen Saturation (1 Oxygen Saturation Source Cxygen Saturation Method ‘Triage Numeric Pain Rating Fain Location Pain Chronicity Glascow Coma Scale Score Capillary Refill nmol per litre) eight eCTAS Triage Modifiers Used eCTAS Triage Summary Stated Complaint EMS Care Subjective Assessment Objective Assessment Medical Directive Applied ‘Treatment and Interventions Medical History Medications TAS Score overridden Reason for Override Additional Data (eC7AS) Patient presented as unknown Eriority in queue Care Instructions T5100), 3 Room Aly 0 a5 ‘Triage Blood Glucose Monitor Reading (743 Suicidal Tdeation No Plan ( Depression / Suicidal / Deliberate Self Sarm| SUICIDAL THOUGHTS/ANKIETY 137.0 B86 Ra sp-ilt/et 02-978 B/A cHG-1.3 Patient presents to ER with ENS from home, history of ansiety and depression. Patient states feeling more depressed, Isolating self. Patient also has auditory hallucinations. Has been to (CAME. On psyen meds and compliant. anxious at triage depression. anxiety lai7aay19 20:58 fehysician Conmunication Start: 21/11/19 20:58 leceq: .2RW Statuet Disenarge Jprotece! Created System (Rec: 21/Li/19 20:58 System _KUB~262) |feanster, Internal/external Start: GI/IL/IS 20Se Jrcea: -PRW Status: Discharge lecctocai: Created system (Rec: 21/11/19 20:58 system _HUB~862) [Feeatnent/ Procedure: ‘Start, Zi/Ti/i8 20vse lrraq: Pea Status: Gsenarge lecctocat: Continued on Page 7 This forms a part of the patient's madical record.jGHELE DOAN GIA Fac: Hunbor River Hospital Zoe:Wilson Emergency 33M 20/11/1986 Med Rec Wum:H00L44 6022 viste:28090855/20 Created Systen (Ree! 21/1/19 20:58 System KUB=EG2) [Specimen Collection Docurentation ‘Stat: 2i/1L/19 20:88 Jrcea: .PRW Status: Discharge Jecotscat Created systen (Rec: 21/11/19 20:58 system _HUB-862) lieaith Teaching, General ‘Start; 2i/T1/18 20:58 Jrceq: .PaN Status: Discharge lecotocol Created Systen (Rec: 21/11/19 20:58 aystem KUB-862) Assessment, Secondary - Adult? ‘Starter CI/TL/15 20:56 leceq: © .once Status: Discharge ‘SAFE.TPRCE Created Syste (Rec: 21/11/19 20:50 system _nus~262) [Bischarge Plan/ Instructions 1at ‘Start Si/TL/I8 20:58 Jrcea: Status: Discharge lecotocal: Created System (Rec: 21/11/19 20:58 System KUB-E62) |anecgency Transter Report ‘Starer PIsTI/19 20:Se lrcoq: .once Statue: Diecharge lezctocais Created Systan (Rec: 21/11/19 20:58 system KUB~262) lesyenosoctal/Nental Health ‘Stare Zi/Ii/18 Z0se leceq: .Every 4 noure and PRN Statue: Cisenarge lecotoce! Created System (Rec: 21/11/19 20:58 System _KUB~262) |fital Signs and oxygenation ‘Start; ZI/TL/I8 20:88 |rext: *After 48 houre then Q8H and PRY Status: Discharge Jreeq: .ouK and PRN lecotocot: Created Systen (Rec: 21/11/19 20:58 system KUB~862) issessnent, Paint ‘Start: Zi/Ti/18 20:58 lrcea: .o8i ano PRN Status: Discharge lecotocol } Created systen (Rec: 21/11/19 20:58 aystem KUB-862) intake and Output ‘Start: 2I/TL/15 20:58 Jrceq: .oae Status: Discharge lerotaco! Created System (Rec: 21/11/19 20:58 system _KUB~8c2) ]IAR-Nesication Titration ‘Start; Gi/IL/15 Boise leceas Status: Discharge lezotocal: Created System (Rec: 21/11/19 20:58 System KUB-862) |Coxporate Patient Safety check ‘Starty eI/TL/19 20vSe frets ALL patients at HRH will be cared for according to Statue: Discharge |seath canada and PIUAC Routine Practices. IPAC chould be leonsulted cogarding all patients on Additional Precautions All staff perform Hand Hygiene as per HRH guideline. leceas lecotecol: sare. IPACE Created System (Rec: 21/11/19 20:58 System KUB~862) |"ital signs/Ventilation wonitor ‘Startr CI/IL/18 20Se Jecoa: Status: Discharge lpraraccls Created systen (Rec: 21/11/19 20:58 system HuB-8G2) Continued on Page & This forms a part of the patient's medical record.jGHELE DOAN GIA Fac: Hunbor River Hospital 33M 20/11/1986 Loe:Wileon smergonoy Med Rec um: H0 01446022 vaste: 8090855/20 RW oM.onsorte fissessnent, Pressure Injury Rise Bearer ZI/TI/18 20:58 lrreq: 48H AND PRN Status: Discharge lecotocol? ir.eu.e Created Systen (Rec: 21/11/19 20:58 system KUB-862) |fD Triage wental wealth checklist ‘Start: 2i/Ti/18 20:58 lrceq: .once Status: Discharge Jecotocat Created Systen (Ree: 21/11/19 20:58 aystem HuB-862) \o157030 and Constant Observation ‘Start; ZI/IL/18 208 |Texts ***Please refer to the attached policy for specific Status: Discharge [ictailote Created system (Rec: 21/11/19 20:58 system _KUB~8c2) JECTAS Report ‘Start; Gi/IL/18 Boise Once Status: Discharge ‘SAFE.IPRCE Created BMG DAEMON (Recs 21/11/19 20:58 _BXG DARMON wUB-BG2) laijaa/19 22:13 pyehosocial/Mental Health leceq: .Every 4 noure and PRN Jproteco! Document ANWARNDR (Rec: 21/11/19 22:20 ED Assessment, Psychosocial Patient Presentation Patient Presentation Problem Known History of Violence (verbal and/or physical) Fatient Demonstrates Agitated/aggressive Behaviour Query TextsIf patient demonstrates agitsted/aqgressive behavior, select " Behavicr Riak-Alert™ to display an alert on EDM Teacker Problen Violence Risk Interventions Comment, cognitive Level of Consciousness Comment Fatient Behaviour Comment OrLentation Harm to Self Have you ever hurt yourself to cope with Start: 21/11/19 20:58 Status: Disenarge ANNARNDR MIERACYECO3) Br. pacing the roomyanzious, restless, says that he's seen psychiatrist today, but reels that ne one can help him, takes nis med.s regulary, but feels they are not helping. Deneles suicidal/honocidal thoughts. Wo Mental Health awake Alert, Appropriate Continued on Page © This forms a part of the patient's medical record.jGHELE DOAN GIA Fac: Hunbor River Hospital Zoe:Wilson Emergency 33. M 20/11/1986 Med Rec Wum:H001446022 viste:28090855/20 ‘your lite/feelings If yes, please describe columbia Suicide Seale Protacal: PSY.COLSSR Please ask questions as written 1. Have you wished you were dead or Wo ‘wished you could go to sleep and not wake up 2, Have you actually had any thoughts of Wo killing yourself Query TexteT£ answer to both #1 and #2 is to! then go to question #5 3. Mave you been thinking about how you wo might kill yourself + lave you had these thoughts and had fome intention of acting on then 5. Have you started to work out or worked out the detaile of how to kill youresle Sa. De you intend to carry out this plan 6. Have you evar done anything, startes to do anything, or prepared to do anthing to end your lite Sa. How long ago aid you do any of these Mental Healtn act Mental Health act Form Wo Form Number Patient On Form 1 Query TexteTf patient £2 on Mental Health Form 1, select "Fi - Form 1 Alert " to display on &DM Tracker Arrived to ED ona Form Restraint Query TextiI£ yes complete restraint Eecord q2h prn Physical Appearance Body Butld Medium comment Distinct Features MG assessment Mood Description calm Depressed Anzious Conant Indicators of Aniety Pacing & Restlessnese comment Indicators of Psychosis ‘Comment Additional indicatere Degree of insight/judgement into his/her ental health> comment Substance abuse Type one Description of substance use Gantinued on Page 10 This forms a part of the patient's madical record.jGHELE DOAN GIA Fac: Hunbor River Hospital 33 M 20/11/1986 Loe:Wileon smergonoy Med Rec Wum:H001046022 viste:28090855/20 Date Of Last Use CIWA order set initiated Soclal Information Previous/Current Involvement With Children's aid society Social Worker referral required Reason for SW referral Comment: GEM referral required Reason for Geriatric Bueraency Management Referral> specif ‘Conment Crisis referral required Reason lp27aa/as 01:54 ige Assesstiont ‘SAFE.1PACE Start: 21/11/19 20 Statue: Diecharge 49 This forms a part of the patient's medical record. Ait Status BKG DAEMON (Rect 22/11/19 01:54 KG DASMON ¥HUB-EGIa) Aotive-sDizenarge led Triage Reassossnentz Stare, i/Ti/is Zoas Statue: Cisenarge BHit Status BKG DAEMON (Rec: 22/11/19 01:54 &KG DAEMON ¥HUB-EGIa) dotive->Disenarge lad Wedioal Divectives Bearer QA/TL/IS Bas leq: wonce Status: Discharge lrcotocal: | SAFE.IPACE BALL Status BAG DAEMON (Rec: 22/11/19 01:54 8KG DARMON ¥HUB-RGIa) Actives>Diseharge [Felage Assessment, AduIE (eCTAS downtime} Start, CVTL/T9 20789 lrcea: wonce Status: Discharge Jprotocol: SAFE.IPACE BAit Status BKG DAEMON (Rec: 22/11/19 01:54 BKG DAEMON HVB-G1a) Actives;Diseharge |Pischarge Bearer Gi/TL/15 20749 lrceq: .once Status: Discharge Jpcotacat Edit Status BKG DAEMON (Rec: 22/11/19 01:54 BKG DAEMON HUB-BG2a) Active->Discharge JED to Unit-Corrected Transfer Date/Time Start, G/TL/TO Boao leceas Status: Discharge lrectocars Ait Status BMG DAEMON (Rec: 22/11/19 01:54 KG DAEMON HUB-EGIa) Active=>Dicenarae leaysician Communication Stare, A/T/18 20se Jecea: .PRN Status: Discharge Jerotacal Ait Status BKG DAEMON (Rec: 22/11/19 01:54 SKG DAEMON ¥HUB-BGIa) Active=>Diseharge [Fenster titernal/external Start, A/Ti/is ose lrraq: “Pra Status: Gsenarge lecctocat: Continued on Page 1jGHELE DOAN GIA Fac: Hunbor River Hospital Loe:Wileon smergonoy Aotive=snisenarge 33 M 20/11/1986 Med Rec Wum:H00L446022 viste:28090855/20 Hit Status BMG OAENON (Rect 22/11/18 0irs4 GXG DAEMON HUB-EGIa) Active=>Dlecharge [Feeatment/ Procedure Start: Bi/HL/Is 2086 Status: Discharge 1 22/11/19 01:54 BKG DAEMON ¥HUB-BGIa) Actives>Discharge [Specimen Collection Docurentation Beart; Si/TL/19 20:56 Jecea: «PRY Status: Discharge Jprotaco! Ait Status BG DAEMON (Rec: 22/11/19 01:54 BKG DAEMON ¥HUB-BGIa) Active->Discnarge liealth Teaching, ceneral Bearer Gi/TL/IS BOSE Jrceq: .PRW Status: Discharge Jpcotaca! BAit Status BMG DAEMON (Rec: 22/11/19 01:54 BKG DAEMON ¥HUB-BG1a) hotive->Discharge issesenent, Secondary — Adult Bearer PITTS 20rSe lrcoa: .once Statue: Diecharge lecctocal: sar. IPACE BAit Status EKG DAEMON (Rec: 22/11/19 01:54 KG DAEMON ¥UB~EG1a) Active=Disenarge [Discharge Plan/ Instructions 1 Sesrt, Zi/TL/18 2075s Status: Discharge BKG DAEMON (Rec: 22/11/19 1:54 SKG DAEMON ¥HUB-EG2a) Active=>DLeeharge lanergency Transfer Report Start, isi 20:58 ‘once Status: Slscharge Bit Status BKG DAEMON (Rec: 22/11/19 01:54 BKG DARMON ¥HUB-EGIa) ActLve=pDlscharge |Esyeho=ocial/Mental Health Beart; Fi/TL/19 20:58 Jcea: Every 4 hours and PRN Status: Discharge lprotocol: Ait Status BG DAEMON (Rec: 22/11/19 01:54 BKG DARMON ¥HUB-EGIa) Active=>Diecharge |Ftal Signs and ouygenatlon Bearer Oi/TL/I8 20Se frext: ‘After 48 hours then QBH and PRY Status: Discharge lecea: .04K and PR lecotocal: Ait Status BKG DAEMON (Rect 22/11/19 01:54 BKG DARMON HUB-BGIa) Active--Discharge iscecenent, Paint Beart, FI/Ti/18 Oise leceq? .o4K AND PRI Statuet Disenarge BAit Status BKG DAEMON (Rec: 22/11/19 01:54 &KG DASMON ¥HUB-EGIa) Active=Discharge liatake and output Start PI/TL/IS BOSE Jrcea: .oue Status: Discharge Jproteca! BALt Status BKG DAEMON (Rec: 22/11/19 01:54 8KG DAEMON ¥HUB-EGIa) liAR-Nedication Ticration Stare, Sa/ii/i9 20058 font inued ‘on Page 12 This forms a part of the patient's madical record.jGHELE DOAN GIA Fac: Hunbor River Hospital Zoe:Wilson Emergency Bea:- 33M 20/11/1986 Med Rec Wum:H001446022 vistt:E8090855/20 lFrea: Status? Discharge lerotocol: BALL Status BAG DAEMON (Rec: 22/11/19 01:54 BXG DAEMON ¥HvE-BG1a) ActivessDischarge lcorporate Patient Safety check Start, 2i/Ti/18 20:58 jrext: ALL patients at HRH will be cared for according to Statue: Discharge fieaith canada and PIDAC Routine Practices. IPAC should be [consulted regarding ell patients on Additional Precautions ALL staff perform Hand Aygiene as per WRK guideline. Jered: lecotocal: SAPE.IPACE Ait Status BXG DAEMON (Rect 22/11/19 01:54 BXG DASMON ¥HUB-BGIa) Active=>Discharge [ital Signs/ventilation wonitor Bearer Qi/TL/I8 20Se Jrcea: Status: Discharge lecotocal: Ait Status BKG DAEMON (Rec: 22/11/19 01:54 BXG DAEMON HUB-EGIa) Active->Discharge Piscccnent, Procure Injury Risk Beart, CISTI/1S 2OSe .Q4gH AND PRN Statuer Discharge INP.2U.E Bait Status BKG DAEMON (Rec: 22/11/19 01:54 BKC DASMON ¥HUB-BGIa) Active-sDisenarge [ED Triage mental Health checklist Stare, CI/IL/IS 205s lrceq: .once Status: Discharge lecotocai: BALL Status BKG DAEMON (Rec: 22/11/19 01:54 BKG DAEMON ¥HvB-BG1a) Active=>Disenarge |g157930 and constant cbservation Start: 2i/ii/78 20:58 |rext: ***Piease refer to the attached policy for speciric status: Discharge fictaiiets+ Jrcea: PRI Jecotocol: cf.onsorrc Ait Status BKG DAEMON (Rect 22/11/19 01:54 BKG DAEMON HVB-RG1a) Active->Discharge |SCIAS Report Start, AI/T/Is Zoe lrceq: wonce Status: Discharge lecotocol: SarE.IPACE Ait Status EKG DAEMON (Rec: 22/11/19 01:54 KG DAEMON ¥UB-EGIa) Active->Discharge Discharge Documentation lad Peoviderr EDN-DR, OR |seatust Final Discharge [time Scen by Provider: 2/11/19 2: lconaition: [eiaged Ate eayayy/is 20:49 7 lanergency Discharge Date/Tiner 21/11/19 23740 Jemergency Discharge Disposition: ER Triaged, Registered, LWaS lclinical trpression lamcegency Discharge Comment: lbisenarge intervention Tast tone Jotseharge Gantinued on Page 12 This forms a part of the patient's madical record.Page: jGHELE DOAN GIA Fac: Hunbor River Hospital Loe:Wileon smergonoy Bea:- 33 M 20/11/1986 Med Rec Num:H0 01048022 vaste: ER090855/20 Discharge Decueotation = continued le te Unit-corrected Transfer Date/Time lnstractione |scand-Alone rorns: prescriptions: visit Report = Forme = Retercale User Key Monogram | Mnemonic | Name ‘Credentials | Provider Type ANNAANDR | Andirie,Anna RN. Registered Nurse AVIGBATO | Batoon Avigall | RN Registered Nurse BKG DAEMON | BKG DAEMON,MT. Printed on 22/11/19 19:36 This forme a part of the patient's nedi al record.Ds Dseahaege Summary! Aeahive date: 25/21/19 0712 Fac: thunber River Hospital Zoo:Wilson Emergency Bea:~ 33 M 20/11/1986 Med Rec Wum:H001446022 Wisdt:E8090855/20 ‘Attending: Reason :SUICIDAL THOUGHTS/ANXIETY Reg Date:21/11/15, Discharge Documentation lp Provider: EDW=DR, DR |scatues Pinal Discharge lime Seen by Provider: 22/11/19 23:07 Jcondition: [reiaged ats zayayyi9 20:49 |anecgency Discharge Date/Tiner — ZI/TL/19 23:40 lamergency Discharge Disposition: ER Triaged, Registered, LWBS lcliniesl Tnpression lameraency Discharge Comment: |Sischarge Intervention Tast Dene Jpischarge lab ta Unit-Corvected Transfer Date/Time [instructions |stana-alone Forms: lPrescriptions: issit Report = Form = Referrals Printed on 28/1i/i8 O7-12 this document is part of the patient's medical ceeHOGER RIVER HOSPITAL. (SRT 10/11/19 _| 17:55 001446022 Noureor [2o/3/198 _—— onan, am 1a fe sn * —_ ferazssazr—ie |" [aie Yereassza7e ‘x : ae a ? fess Spear aS fxzsosparon one = 36.9 87 20 10/74 oe . sees FT) RODE PRAT ] [Seo nan a I Forni Teitiate a [ennaena ana Mng a a fates [a aE ae : eae ote | AL pum a [71 pein or cars werden 4 Ea rone_| _srotenn once = a 5 (la pew maaan armcesme = Mex a art [wen ia nad a ee [Te en (0