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Flynn, Kevin RECEIVED MAY 3 0 2014 NOTICE OF CLAIM FORM to the City of Saint Paul, M' ,� , '��L��9� Minnesota State Statute 466.05 states that"...every person...who claims damages from any municipality...shall cause to be presented to the governing body of the municipality within 180 days after the alleged loss or injury is discovered a notice stating the time,place,and circumstances thereof,and the amount of compensation or other relief demanded." Please complete this form in its entirety by ciearly typing or printing your answer to each question. If more space is needed,attach additional sheets. Please note that you will not be contacted by telephone to clarify answers,so provide as much information as necessary to explain your claim,and the amount of compensation being requested. You will receive a written acknowledgement once your form is received. The process can take up to ten weeks or longer depending on the nature of your claim. This form must be signed,and boW pages completed. If something dces not apply,write`N/A'. SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK, 15 WEST KELLOGG BLVD,310 CITY HALL, SAINT PAUL,MN 55102 First Name Kevin Middle Initial M Last Name Flynn Company or Business Name N/A Are You an Insurance Company? Yes No ff Yes,Claim Number? Street Address 2�99 Pinehurst Avenue City Saint Paul State MN Zip COde 55116 Daytime Phone( 612 � 360 _4615 Cell Phone(612 �360 4615 Evening Telephone(651 � 291 _ 1892 Date of Accidend Injury or Date Discovered 4/28/2014 Time 8 30 am/pm Please state,in detail,what occurred(happened),and why you aze submitting a claim.Please indicate why or how you feel the City of Saint Paul or its employees are involved and/or responsible for your damages. Piease refer to attached documentation: Attachment A: Explanation of Accident-Resulting in Injury Attachment B:Accident Location Diagram and Photos Attachment C: Medical Report-Fairview Clinic-Highland Park, Ford Parkway Attachment D: Medicai Report-U of M Medical Center Fairview Attachment E: Photos of Injuries Attachment F: Medical Bills Please check the box(es)that most closely represent the reason for completing this form: ❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow ❑ My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow ❑ My vehicle was wrongfully towed and/or ticketed � I was injured on City property ❑ Other type of property damage—please specify ❑ Other type of injury—please specify In order to process your claim vou need to include copies of all apalicable documents. For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of your claim. Documents WILL NOT be returned and become the property of the City. You are encouraged to keep a copy for yourself before submitting your claim form. O Property damage claims to a vehicle:two estimates for the repairs to your vehicle if the damage exceeds $500.00;or the actual bills and/or receipts for the repairs O Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt O Other property damage claims:two repair estimates if the damage exceeds$500.00;or the actual bills and/or receipts for the repairs;detailed list of damaged items '� Injury claims:medical bills,receipts C� Photographs aze always welcome to document and support your claim but will not be retumed. Page 1 of 2—Please complete and return both pages of Claim Form Failure to complete and retum both pages will result in delay in the handling of your claim. All Claims—nlease COmplete this sectiOn Were there witnesses to the incident? Yes No Unlmown (circle) Provide their names,addresses and telephone numbers: Were the police or law enforcement called? Yes No Unlrnown (circle) If yes,what department or agency? Case#or report# Where did the accident or injury take place? Provide street address,cross street,intersection,name of park or facility, closest landmark,etc. Please be as detailed as possible. If necessary,attach a diagram. 2111 Ford Parkway Refer to Attachments A and B Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim to your saUSfaction. I am seeking compensation for medical bills not covered by insurance. $1,062.45 Vehicle Claims—Ulease complete this section liXl dheck box if this section dces not avplv Your Vehicle: Year Make Model License Plate Number State Color Registered Owner Driver of Vehicle Area Damaged City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged Iniurv Claims—please complete this section ❑ check box if this section does not avnlv HoW weTe you injured?Slipped on wooden ramp in rain, feli, struck head on concrete road barrier. See Attachments A, B What part(s)of your body were injured? Head, nose, eye,shin of left leg See Attachment E Have you sought medical treatment? es No Planning to Seek Treatment(circle) When did you receive treatment? 4/28/2014 See Attachments C, D (provide date(s)) Name of Medical Provider(s):Fairview Clinic-Ford Parkwav and U of M Medical Center Fairview Address 4Telephone 612-273-3000 Did you miss work as a result of your injury? Yes No When did you miss work? (provide date(s)) Name of your Employer: N/A Address Telephone �heck here if you are attaching more pages to this claim form. Number of additional pages 20 �._/ By signing this form,you are stating that all information you have provided is true and correct to the best of your knowledge. Unsigned forms will not be processed Submitting a false claim can result in prosecution. Date form was completed 05/28/2014 Print the Name of the Person who Complet this Form� Kevin Flynn Signature of Person Making the Claim: �v" ` Revised February 2011 NOTICE OF CLAIM FORM TO THE CITY OF SAINT PAUL,MN ATTACHMENT A: Explanation of Accident Resulting in Injury i was injured at approximately 8:30 am the morning of Monday,April 28,2014 while walking near the Pieology building currently under construction at the corner of Finn and Ford Parkway, (2111 Ford Parkway). I was walking southbound from Walgreen's along Ford Parkway toward Finn Street.At the transition area for pedestrian access near the bus stop directly adjacent to the construction site, I slipped on the wooden transition ramp from the sidewalk/curb to the roadway and struck the low concrete barrier wall with my head. I suffered multiple abrasions to my forehead, nose and area diredly above my left eye as well as a contusion on my left shin. Attachment 8:See attached diagrams of accident locarion and photos of ramp. I sought medical attention immediately at the Fairview Clinic—Highland Park at 2155 Ford Parkway.The staff there preformed preliminary triage on my injuries and referred me to the ER at the UMMC Fairview Hospital. While at the ER I was examined,my injuries were washed and dressed.The staff there performed a CT scan to determine if other injuries were present. I was released early in the afternoon at approximately 12:53pm Refer to rhe attached medical reports for further information. Attachment C:Medical Information Fairview Clinio-Highland Park, Ford Parkway. Attachment D:Medical lnformation U of M Medical Center Foirview Attachmenr E: See attached Photos 1-4 show inju�ies sustained. After leaving the Fairview Highland Park clinic and before going to the ER, I visited the Pieology construction jobsite and spoke with the construction manager on-site for Broadview Builders-first name"Rocky". After a brief discussion, he essentially told me that my accident and injury wasn't his problem as the sidewalk and road area are the property of the City of St Paul and all of his permits are in order. I believe the wooden transition ramp is unsafe and slippery-especially when wet as it was the morning of 04/28/2014 while it was raining.The ramp surface was constructed of OSB/article board with no anti- slip material applied to its surface. I do not know if this ramp was built by the city or by the construction company for Pieology. I believe the ramp is unsafe and hazardous to others.Subsequently to filing a complaint on the City of Saint Paul website,the ramp has been provided with anti-slip material. Attachmeni 8:See attached diagrams of accident location and phoios of ramp. ; I am seeking compensation for my out of pocket medical expenses not covered by my health insurance plan.This amounts to a total of$1,062.45(one thousand sixty two dollars and forty five cents). Attachment F:Medical Bills Kevin Flynn 2199 Pinehurst Ave. Saint Paul, MN 55116 612-360-4615 � � � � � � • ' • • � • � � • ' � .� +,a,.. �sr .�.�r.* �a.. . ' i � �� .. -� �� _�11 t ..�' , - _ �� .. �C1�1.) ► _ . � r ,,,� - �� t � � � _ i f � # � � � �. , . .. � �� 4�� k,��, � 4 g+ l.OnSl�uC�lOn - xao- . ` $ S�te # Bu� � i � � .,..� � . . �- ' t � - a � r r . � � �� C. . .�.� � .____.__r .�� T,. n _. _ _ � � ., __ ��_ � . . �� ,�x � � � �� : .�� . .�_ .�_ _.F..�.�.,,._.....P�._...-� .._w......._ _......�_. .._..� a r �� _ . � � concrete barrier wall ,� �wooden ramp l _ _. c> a „�. � • • • � • ' � � � Construction � Site � � _ ,d,. ;�,- .�;�-.,.�.. .,� � �. � �... � �,. � ,� .,,�. � ,_, . ,�.. _ _ '�� '� '� � "`�hcr�te barri�r�a11 ;�� -;: � ° � �` , «�:_ � ;� ;� �� .� � _ �,,.� <; _. . � .=,�,�_, � ,� � �wooden ramp . . ATTACHMENT B—CLAIM FORM Photos of Ramp P '; �,: � � P�� d��,� � .... � . �'i"F' �� .� �ry ..� �i.., ;.,r:.< ��i '' I: �� V � ,., �� i. " `�'.C4�� z. .� •;i "� - _ c. }} �.''� •'„�" ..,t v4 �6 ^ X' E• � � N �11 � , � �� _ � � 'ry� �'�4 �'�.�. �_�, � ..f� R �_.n� �'�5 "�, '�`,,. .� _ ,� yB., +�. �'�qY �: ��: =�., �.j_a'. �+ :.'�c, �� :' ffi> rY � � :. :,,�� t.,�,: - = 7�.'^£ #�. y�; ... . .;':�"_.. ,. .. PHOTO A Photo of wooden ramp 04/29/2014—taken from angle of direction of travel on morning following accident PHOTO B Photo of wooden ramp 05/06/2014—after anti-slip material was installed on ramp A-r��t ME�' c ..-`- Flynn, Kevin(MR# 0051000117) M�C/9.lN�RWIPct�o� � �r�� Page 1 of 4 G�l VI-TG �i i �'�'/lN./LP� � r a��w • �atient Inf�rmatisn l � � Patient Name Sex DOB Flynn. Kevin (0051000117) Male 9/20/1961 To Close This Visit Recommended Items , The foilowing vital signs are not recorded: Biood Pressure, Temperature, Weight, Height, Respiration. Encounter Origin� Manuaily Created b;� Corverted from Appointment by ERICKSON, KIMBERLY Eneounter lnformation Provider Department Encaunter# Center , 4/28/2014 9:00 AM Hp RnlTriage Hp Nurse 104225917 HP ', Nurse Only � Reason for Visit Fall walkin Reason for Visit History Vitals -Last Recorded Pulse � 64 Rain information No pain information on file Progress Notes Eleftheri�u. Terri K, RN at 4l28I2014 11:37 AM S;atus Signed _ Kevin Flynn is a 52 year old mate who walks in with fall injury. Was walking on sidewalk near construction site in neighborhood and slipped on a slippery spot and hit head and face on a cement barrier this morning. PRESENTING PROBLEM: Contusion and laceration left frontal area above eye (golfball size) .Left Eyelid laceration. Nose contusion and laceration. Injury from a fall. Walked in. NURSING ASSESSMENT Description/location: See above. Denies LOC. Head injury. OnseUduration: Just happened this morning. Precip. factors: Slippsd on sidewalk where construction was present here on Ford Parkway_ Pt states he is on a medication given by cardiologist post stent so bleeding times may be altered. More prone to bleeding. Associated symtoms: See above Bleeding: yes -from forehead, nose and left eyelid. Also lower left eye area bruised. Deformity/dislocationldiscoloration: yes-golfball size contusion and laceration left forehead , area above left eye. ' Color Motion Sensation: A & O x 3. Denies HA or significant pain at time of visit. I Neurological: no deficits apparent. � �I Pain scale (1-10} not significant Improves/worsens symptoms: i i _ ---- ___- __ ___ ------- __ r------ ` ` Flynn, Kevin (MR#0051000117) Page 2 of 4 . Symptom specific-Treatments: Lacerations covered until he can get to hospital for an � evaluation and will need sutures in various facial locations. Taking medication(s) as prescribed? N/A Taking over the counter medication(s) ?N/A Any medication side effects? No significant side effects and NA Any barriers to taking medication(s) as prescribed? No • Medication(s) improving/managing symptoms? N/A Medication reconciliation completed: No I' �ast related exam/Treatment: 3/10/14 with cardiology. i i NURSING PLAN: Huddle with provider, plan includes sending to ED for eval of injuries. closed � head injury on a "blood thinner" Dr Wegener came in to see pt briefly and he agrees with plan i to go to ED for eval due to the lacerations multiple and on face. Also evaluate if he needs any further f/u in regards to head injury. Increased bleeding risk ciue to medication. ; RECOMMENDED DISPOSITION: To ED, another person to drive-friend arrived to drive pt to i ED. ' Will comply with recommendation: Yes Pt is alert and oriented x 3. Moving all extremities. , Left clinic ambulatory and independently. Accompanied by driver and friend. Plans to go to Ed at UM hospital. If further questions/concems or if symptoms do not improve, worsen or new symptoms develop, call your PCP or Fairview Nurse Advisors as soon as possible. Terri K Eleftheriou, RN Encounter-Level Dacuments: There are no encounter-level documents. Order-�.evel Documents: There are no order-level documents. Diagnoses , Fall with injury - Primary 959.9, E888.9 Facial laceration, initial encounter 873.40 Medication List �This list is accurate as of:4/28/14 9:34 AM. Always use your most recent med list.__ _�j aspirin 81 MG EC tablet ' Take 1 tablet(81 mg) by mouth daily � atorvastatin 40 MG tablet Ccmmon{y known as: �..iPiTOR , Take 1 tablet(40 mg) by mouth daily fish oil-omega-3 fatty acids 1000 MG capsule MULTIVITAL PO nitroglycerin 0.4 MG SL tablet Commonly known as: N�TrtoSZA7 Place 1 tablet(0.4 mg} under the tongue every 5 minutes as needed for chest pain ;`� " Fh�nn, Kevin(MR# 0051000117) Page 3 of 4 i' � prasugrel 10 MG Tabs � Co��mcr;�y known as. E�FiEt�t Take 1 tablet(10 mg) by mouth daily vitamin D 1000 UNITS capsule Medications at Start of Encounter • Medication Disp Refills Start End nitrogiycerin (NITROSTAT}0.4 MG SL 25 tablet 6 3/10/2014 tablet , S�g - Route: Place 1 tablet(0.4 mg) under the tongue every 5 minutes as needed for chest pain-Sublingual Cfass E-Prescribe atorvastatin (LIPITOR)40 MG tablet 90 tablet 3 2/26/2014 5;g - Route Take 1 tablet(40 mg) by mouth daily-Oral �lass E-Prescribe Number of times this order has been changed since signing: 1 Order Audit Trail prasugrel (EFFIENT)10 MG TABS 90 tablet 3 2/26/2014 i Sic - Route: Take 1 tablet(10 mg) by mouth daily-Oral C1ass E-Prescribe Number of times this order has been changed since signing: 1 Order Audit Trail aspirin 81 MG EC tablet 90 tablet 3 2/26/2014 Si� - Route: Take 1 tablet(81 mg) by mouth daily-Oral Class: E-Prescribe Number of times this order has been changed since signing: 1 Order Audit Trail fish oil-omega-3 fatty acids(FISH OIL) 1000 MG capsule ' Si� - Ro::�e Take 1-2 g by mouth daity. -Oral Class Historical Number of times this order has been changed since signing: 3 Order Audit Trail Multiple Vitamins-Minerals (MULTIVITAL PO) ' Sig - RaGte: Take 1 tablet by mouth daily. -Oral Class Historical Number of times this order has been ! changed since signing: 2 Order Audit Trail Cholecalciferol(VITAMIN D) 1000 UNITS capsule Si� - Route: Take 1 capsule by mouth daily. -Oral I C?ass: Historical � Number of times this order has been � changed since signing: 2 � Order Audit Trail Review Complete On: 4/28/2014 By: Kaynes,Tara , Aliergies as of 4l28/2014 B� RN � _ r--- , � � Flynn, Kevin(MR# OOS l 000117) Page 4 of 4 ' No Known Allergies Problem Lis# Date Reviewed: 5/29/2013 ICD-9- CM Priority Ciass Noted- Resolved STEMI(ST elevation myocardial infarction) 410.90 4/28/2013- Present Patient instructions None Encounter Status Closed By: Eleftheriou, Terri K, RN on 4/28/14 at 11:37 AM AEI Flowsheet Temptates (all recorded) Encounter Vitals Vitals Reassessment i I li I i � � � � � May a714�2:13p EcoDEEP ��` `` ' '�� 651-698-0881 p,1 - ° 1'��ql C,PtL t N fi�o RI�I�A'rION �� V � M Mtn�'Prt- �ENT�� .- �a�r✓i�w . � �� j (�b U I l� � �1t3�5'��IN�L`( g� PA� � �'�` (� NlAI1.��SE �� t� � � � '. , � !; :,s . r i. /.I i � e� } f�Princ pacicnc's lega! namc �� 1 Vh� Bird�dare��/� PrcYviotss name • � (ogrra urr mi!}:MR# � ) Phonc numbers{Home)��{• �/. �� (�/ork) (Qchcr) 1. Pleasc release my rccords from: (l�%�io har Jmur rumclr?) 1 Clinic or o1r��nan,il,,ation (iFnoc prinud abovc : � (5� �1 �� .!��Z°j�/1/� Address: �1__�_� V�I/I_UPi �{`�.�e�`�it�•: Scacc- �1l�,��.. Zip eoc�e• ~' Phone• ax: , , f 2. Please release my ceeosds to:(Who nteds_ynur�tcnr�ls.') � �' Pcrson,clinic or orGaniz.tioo (if noi prin�cd ab�v�}: j `�. /� , Address: 1r Ci : ' J�are: � `/_ip codc: � Phone: � Fau: /f�rien.cing records tn yoau;r f sfinuld t e trt:�tla/�c be»utrked"Pcaona!a�id Coirfrclrnti�l':� f] Ycr O No 3• Th.rse ar�the:ewrds I arould like co release: �At!percinenc recocds(extepc 61ms or slides),or chcck all diat appty bdow I I ' (�ischarge sumrnary � Patholo�v re�rrs Q EKG/F.CHO rtpores � � Cau�icalor's discharge surnmary � La�rrports �'Fmrr�rney or utgenr carc repnres � �istory and physical exam �;X-rav!itadiolog}•rrpores C�Psychological ccscs �Consulracion re�o�[s �T'ilms/CDs �Su:d to MD only:Pathotogy slidts/bl�tic�� Ourpacienc clinic notcs t]Operr ive reporcs �`Ocher.�� `��_ '�'` ep�Q�' For condition�r dates of treatmenr. (If 6Gtnk, wc wi/1 rrlrate 1 yrari urorth nf mnst rumt�Yr.ar.ls) Date records are needed v:_ 5 l�(r f_7�� -- . Wil!s�corrlr hr.picied up? p Yer�No 4�' VV�1 �Ltd��f�/T'T' �t. Purpou: ❑ Contirsued ear�hy anothrr provider �+.�.`Insuraner claim iJ Personal usc �Sotial Securiey ciisabiliry• O rlrrorney revicw O Odier S. I understand thc following: • Fxcepr for paycho�herapy nnsea (which are noc indiided in my medic,�l reeord),aIS r�oreis wi11 bc rcleaxed rq che person. clinic or organiraeion named abnve.71iis indudes decails oF rreacmenc for menca{health,chemical depu�dc:ncy,siclde tei3 anemia,genecic wndicions ai�d AIDS/HIV j` if I doni w;�nc che.ce co lie relc�ased, 1�vill placr a Checl:inarl: here: V . 1 do noc want d3e following recnrds rrlcasrd: • If J�h:tnge my r:iinc�, I may wrirc ro chc addrrss in seccion ] to stop chc reiease oF my I'CCasc�S.T�1i5 wtll nOt apply ca recorc3s d�at have alreadY been rettased. � TT�is f�rm rxpitcx qtt�vcar afrcr I sign it,or on (expirncion dacc: �, • "lhcrc ma,y hc a fee for rcl��assns nc�sr rccords. - Once chc rrcords arc releaszd ro thc}xrsan,clinic ar organizarion namcd abo�e, chr clinic o�hospicai rclras�ng my recordc cannot prevent�hem Frvm being sha��ed wirh a rhird parry.Ac chac poinc,rhe recards may no lo��er be prorecred bv state a+id federaE�rivac}•laws. • To be valid,chic form musc he 6lled out eamplctdy and si;nrd.A copy is valid iFit haa not bccn alccrcd. • If�O�oi�n�is fo m,l�vi1)srill hc rr� ed. s rrearmcnc is parc af a research pr�jece. �. � � --��,nfc�� --- �?!�- Da � Sigrr�ure o atieru or nurl�orized p�rro Autharizrd�,errani autlioriey to rign(prbnf reqr.irulj R�atan , ��f�2 unuGlr tn sig�z• C1 Minor i7 Drce.,srd Ocher. ' UNIVERSITY OF MINNESOTA MEDICAL CENTER, FLYNN,KEVIN FAIRVIEW MRN: 0051000117 2450 Riverside Ave DOB: 9/20i1961, Sex: M MPLS, MN 55454 Acct#: 11005329541 Pertinent Info Adm:4/28/2014, D/C:4/28/2014 Admission tnformation Arrival Date/Time: 04/28/2014 9:32 Admit Date/Time: 04/28/2014 9:34 IP Adm. None AM AM Date/Time: Admission Type: Emergency Point of Origin: Emergency Room Admit Category: None Means of Arrival: Walked Primary Service: Emergency Secondary N/A Medicine Service: Transfer Source: None Service Area: Fairview Health Unit: Uu Emergency Services Dept Admit Provider: None Attending Hibino, Seikei, Referring None Provider: MD Provider: Discharqe Information Discharge Date/Time Discharge Disposition Discharge Destination Discharge Provider Unit 04/28/2014 1:03 PM Home Or Self Care Home None Uu Emergency Dept ED Notes ED Notes signed by Kaynes Tara B, RN at 4/28/2014 9:42 AM �Author: Kaynes, Tara B, RN Service: Emergency Medicine Author Registered Nurse Type: Filed: 4/28/2014 9:42 AM Note Time: 4/28/2014 9:40 AM Pt was walking on wood foot walk over a sidewalk at a construction site. Pt slipped and fell landing on I concrete barrier with the left side of his face. No LOC. Denies neck or back pain. Pt walked to highland ! clinic and they applied bandages and refer pt to ER. Pt has left eyebrow laceration and nose laceration. Last tetanus close to 10 years ago per pt. i , i � Electronically Signed by Kaynes, Tara B, RN on 4/28I2014 9:42 AM j ED Provider Notes signed by Hibino Seikei, MD at 4/2812014 3:04 PM Author: Hibino, Seikei, MD Service: (none) Author Physician Type: Filed: 4/28/2014 3:04 PM Note Time: 4/28/2014 9:58 AM � History i Chief Gomplaint ! Patient presents with • Facial Laceration HPI Kevin Flynn is a 52 year old male who presents with facial laceration. Patient was walking home this morning and had to walk over a construction area. He slipped onto a wet wood plank and fell forward, striking his head on a concrete barrier. He had no LOC. He has laceration on left forehead and eyebrow. , He went to an Urgent Care where they put some steri-strips on a nasal laceratian and he was sent here for , further evaluation. He denies changes in his vision. His left eyelid is swollen nearly shut. He denies headache, neck pain, or back pain. He has �ocalized pain over the left side of his forehead. No hearing loss. No chipped or broken teeth. He is unsure of tetanus status. I have reviewed the Medications, Allergies, Past Medical and Surgical History, and Social History in the Epic system. Printed on 5/8/2014 10:37 AM Page 1 ' UNIVERSITY OF MINNESOTA MEDICAL CENTER, FLYNN,KEVIN FAIRVIEW MRN: 0051000117 2450 Riverside Ave DOB: 9/20/1961, Sex: M MPLS, MN 55454 Acct#: 11005329541 Pertinent Info Adm:4/28/2014, D/C:4i28/2014 Past Medical History Diagnosis Date • Asthma exercise induced Past Surgical History Procedure ' Laterality Date • Appendectomy No family histary on file. History Substance Use Topics • Smoking status: Never Smoker • Smokeless tobacco: Not on file • Alcohol Use: Yes Comment:social Current Facility Administered Medications Medication • lidocaine-EPINEPHrine 1 %-1:100,000 injection 30 mL • oxidized cellulose{SUGICEL NU-KNIT)2x3 inch pad Current Outpatient Prescriptions Medication • nitroglycerin (NITROSTAT) 0.4 MG SL tablet • atorvastatin (LIPITOR)40 MG tablet • prasugrel (EFFIENT) 10 MG TABS • aspirin 81 MG EC tablet • fish oil-omega-3 fatty acids(FISH OIL) 1000 MG capsule • Multiple Vitamins-Minerals (MULTIVITAL PO) • Cholecalciferol (VITAMIN D) 1000 UNITS capsule No Known Allergies Review of Systems HENT: Positive for facial swelling. Negative for hearing loss and neck pain. Eyes: Negative for visual disturbance. I Musculoskeletal: Negative for back pain. ; Skin: Positive for wound. Neurological: Negative for headaches. All other systems reviewed and are negative. Physical Exam ` BP: 132I84 mmHg Pulse: 65 Temp: 98.1 °F (36.7 °C) Resp: 16 Printed on 5/8/2014 10:37 AM Page 2 ' UNIVERSITY OF MINNESOTA MEDICAL CENTER, FLYNN,KEVIN FAIRVIEW MRN: 0051000117 2450 Riverside Ave DOB: 9/20/1961, Sex: M MPLS, MN 55454 Acct#: 11005329541 Pertinent Info Adm:4/28/2014, D/C:4/28/2014 Weight: 77.111 kg (170 Ib) Sp02: 100 % Physical Exam Constitutional: He is oriented to person, place, and time. No distress. HENT: Head: Not macrocephalic and not microcephalic. Head is with abrasion and with contusion. Head is without raccoon's eyes, without Battle's sign, without laceration, without right periorbital erythema and without left periorbital erythema. Hair is normal. �,�•� � _ I � � � � � R l " Mouth/Throat: Oropharynx is clear and moist. No oropharyngeal exudate. Eyes: Pupils are equal, round, and reactive to light. No scleral icterus. Neck: Normal range of motion. Neck supple. Cardiovascular: Regular rhythm, normal heart sounds and intact distal pulses. Pulmonary/Chest: Breath sounds normal. No respiratory distress. He exhibits no tenderness. Abdominal: Soft. Bowel sounds are normal. There is no tenderness. Musculoskeletal: He exhibits no edema or tenderness. Cervical back: He exhibits no tenderness. Thoracic back: He exhibits no tenderness. Lumbar back: He exhibits no tendemess. Neurological: He is alert and oriented to person, place, and time. No cranial nerve deficit. Coordination normal. Skin: Skin is warm. No rash noted. He is not diaphoretic. ED Course Procedures CT head, c spine, face-no bleed or fx. Labs Ordered and Resulted from Time of ED Arrival Up to the Time of Departure from the ED - No data to display Assessments 8� Plan (with Medica! Decision Makingj Printed on 5/8/2014 10:37 AM Page 3 ' UNIVERSITY OF MINNESOTA MEDICAL CENTER, FLYNN,KEVIN FAIRVIEW MRN: 0051000117 2450 Riverside Ave DOB: 9/20/1961, Sex: M MPLS, MN 55454 Acct#: 11005329541 Pertinent Info Adm:4/28/2014, D/C:4/28/2014 Fall with facial contusions and abrasions complicated with effient, stopped bleed with surgicel, FU with PMD. I have reviewed the nursing notes. I have reviewed the findings, diagnosis, plan and need for fotlow up with the patient. Discharge Medication List as of 4/28/201412:54 PM Fina!diagnoses; Facial abrasion, initial encounter Fall, initial encounter I, Hannah M Bezek, am serving as a trained medical scribe to document services personally performed by Seikei Hibino, MD, based on the provider's statements to me. I, Seikei Hibino, MD, was physically present and have reviewed and verified the accuracy of this note documented by Hannah M Bezek. 4/28/2014 UMMC, FAIRVIEW, EMERGENCY DEPARTMENT I Hibino, Seikei, MD I 04/28/14 1504 Electronically Signed by Hibino, Seikei, MD on 4/28J2014 3:04 PM ALL RESULTS Resulted: 04/28/14 1135, Result Status: Final Head CT w/o contrast[201874140] result Ordering provider: Hibino, Seikei, MD 04/28/14 1019 Resulted by: Cayci, Zuzan, MD Performed: 04/28/14 1057 -04/28/14 1110 Resulting Lab: RADIOLOGY RESULTS Narrative: Head CT without contrast History: fall/pain, Comparison: none Technique: Axial thin section C7 images of the head were obtained from the base of the skull to the vertex without intravenous contrast and reviewed in brain, subdural, and bone windows. Findings: There is no evidence of intracranial hemorrhage, mass-effect, or midline shift. Gray-white differentiation is intact throughout both cerebral hemispheres. There is no significant cerebral volume loss.The bony calvaria and the bones of the skull Printed on 5/8I2014 10:37 AM Page 4 ' UNIVERSITY OF MINNESOTA MEDICAL CENTER, FLYNN,KEVIN FAfRVIEW MRN: 0051000117 2450 Riverside Ave DOB: 9/20/1961, Sex: M MPLS, MN 55454 Acct#: 11005329541 Pertinent Info Adm:4i28J2014, D/C:4/28/2014 Resulted: 04/28/14 1135, Result Status: Finai Head CT wlo contrast[201874140] result � base appear normal. The visualized portions of the paranasal sinuses and mastoid air cells are unremarkable. There is left periorbital swelling and hematoma. No underlying fracture is noted. There is no abnormality of the retro-bulbar region within the globe. Impression: Impression: Left periorbital swelling and hematoma. Otherwise no acute findings. ZUZAN CAYCI, MD Resulted: 04/28/14 1524, Result Status: Final Cervical spine CT wlo contrast[201874141] result � Ordering provider: Hibino, Seikei, MD 04/28/14 1019 Resulted by: Cayci, Zuzan, MD Hoffman, Benjamin J, DO Performed: 04/28/14 1110-04/28/14 1120 Resulting Lab: RADIOLOGY RESULTS Narrative: Cervical spine CT without contrast 4/28/2014. History: Fall. i Comparison: None. i I Technique: Acquisition of CT images of the cervical spine were obtained without intravenous contrast. Axial, coronal, and sagittal � reconstructions were performed. Images were reviewed in bone and soft tissue windows. Findings: Lateral masses of C1 are normally aligned on C2. Cervical spine alignment is preserved. Mild convex left coronal based curvature f centered at approximately C5-6; straightening of the normal cervical lordosis from C2-C6. Mild disc space narrowing at C5-6 and C6-7; vertebral body heights are preserved. No abnormal prevertebral soft tissue swelling. Multilevel uncinate and endplate spurring, most pronounced posteriorly at C5-6; facet arthropathy is most pronounced bilaterally at C7-T1. � Mild to moderate bilateral foraminal narrowing at C5-6; no significant spinal canal narrowing at any level. No definite abnormality is noted of the visualized paraspinous tissues. Impression: Impression: 1.No acute fracture or subluxation of the cervical spine. 2. Mild multilevel degenerative changes of the spine resulting in mild to moderate bitateral foraminal narrowing at C5-6. I have personally reviewed the Printed on 5/8/2014 10:37 AM Page 5 . ' UNIVERSITY OF MINNESOTA MEDICAL CENTER, FLYNN,KEVIN FAIRVIEW MRN: 0051000117 2450 Riverside Ave DOB: 9/20/1961, Sex: M MPLS, MN 55454 Acct#: 11005329541 Pertinent Info Adm:4/28/2014, DiC:4/28/2014 Resulted: 04128/14 1524, Result Status: Final Cervical spine CT w/o contrast[201874141] result examination and initial interpretation and I agree with the findings. ZUZAN CAYCI, MD Resulted: 04/28l14 1144, Result Status: Final INaxillofacial CT w/o contrast 201874142] result Ordering provider: Hibino, Seikei, MD 04/28/14 1019 Resulted by: Cayci, Zuzan, MD Performed: 04/28/14 1120-04/28/14 1127 Resulting Lab: RADIOLOGY RESULTS Narrative: CT of the Facial Bones without contrast History: fall pain, Comparison: none Technique: Using thin collimation multidetector helical acquisition technique, axial and coronal thin section CT images were reconstructed �i through the facial bones. Images were reviewed in bone and soft tissue � windows. ; Findings: There is left preseptal and periorbital swelling/hematoma. I The globes are normal. Lenses are located. Retro-orbital 'fat are I symmetric and normal. Optic nerves are appear normal on CT. � Extraocular muscles appear within normal limits. � There is no evident fracture of the facial bones. The cribriform plate ', appears intact. Alignment of the facial bones appears normal. ! The visualized portions of the paranasal sinuses are clear. � � I mpression: I mpression: Left preseptal and periorbital � swelling/hematoma. No evidence of fracture or postseptal abnormality. I I ZUZAN CAYCI, MD � __ __ _ __ __ _ _ _._._ __ ___ � __ _. __ � Encounter-Level Documents: There are no encounter-level documents. j Order-Level Documents: � There are no order-level documents. I I Results Head CT w/o contrast(Order 201874140) � � Resulted: 04/28/14 1135, Result Status: Final Head CT w/o contrast[201874140] result Ordermg pro�ider: Hibmo, Seikei, MD 04/28/14 1019 Resulted by: Cayci, Zuzan, MD � Performed: 04/28/14 1057-04/28/14 1110 Resulting Lab: RADIOLOGY RESULTS ' Narrative: Head CT without contrast History: fall/pain, Comparison: none Printed on 5/8/2014 10:37 AM Page 6 UNIVERSITY OF MINNESOTA MEDICAL CENTER, FLYNN,KEVIN FAI RVI EW MRN: 0051000117 2450 Riverside Ave DOB: 9/20/1961, Sex: M MPLS, MN 55454 Orders/Resuits Resulted: 04/28/14 1135, Result Status: Finai Head CT wlo contrast[201874140] _ result Technique: Axial thin section CT images of the head were obtamed from the base of the skull to the vertex without intravenous contrast and reviewed in brain, subdural, and bone windows. Findings: There is no evidence of intracranial hemorrhage, mass-effect, or midline shift. Gray-white differentiation is intact throughout both cerebral hemispheres. There is no significant cerebral volume loss. The bony calvaria and the bones of the skull base appear normal. The visualized portions of the paranasal sinuses and mastoid air cells are unremarkable. There is left periorbital swelling and hematoma. No underlying fracture is noted. There is no abnormality of the retro-bulbar region within the globe. Impress+on: Impression: Left periorbital swelling and hematoma. Otherwise no acute findings. ZUZAN CAYCI, MD Results Cervical spine CT w/o contrast(Order 201874141) Resulted: 04/28/14 1524, Result Status: Final Cervical spine CT w/o contrast[201874141] _ result i Ordering provider: Hibino, Seikei, MD 04/28/14 1019 Resulted by: Cayci, Zuzan, MD , Hoffman, Benjamin J, DO Performed: 04/28/14 1110-04/28/14 1120 Resulting Lab: RADIOLOGY RESULTS � Narrative: Cervical spine CT without contrast 4/28/2014. History: Fall. � Comparison: None. � Technique: Acquisition of CT imayes of the cervical spine were � obtained without intravenous contrast. Axial, coronal, and sagittal ! reconstructions were performed. Images were reviewed in bone and soft I tissue windows. I Findings: Lateral masses of C1 are normally aligned on C2. Cervical spine alignment is preserved. Mild convex left coronal based curvature centered at approximately C5-6; straightening of the normal cervical lordosis from C2-C6. Mild disc space narrowing at C5-6 and C6-7; vertebraf body heights are preserved. No abnormal prevertebral soft tissue swelling. Multilevel uncinate and endplate spurring, most pronounced posteriorly i at C5-6; facet arthropathy is most pronounced bilaterally at C7-T1. ' Mild to moderate bilateral foraminal narrowing at C5-6; no significant spinal canal narrowing at any level. No definite abnormality is noted of the visualized paraspinous tissues. Printed on 5/8/2014 10:37 AM Page 7 � � UNIVERSITY OF MINNESOTA MEDICAL CENTER, FLYNN,KEVIN FAIRVIEW MRN: 0051000117 2450 Riverside Ave DOB: 9/20/1961, Sex: M MPLS, MN 55454 Orders/Results Resulted: 04/28/14 1524, Result Status: Finai Cervical spine CT wlo contrast[201874141] resuit impression: Impression: 1.No acute fracture or subluxation of the cervical spine. 2. Mild multilevel degenerative changes of the spine resulting in mild to moderate bilateral foraminal narrowing at C5-6. I have personally reviewed the examination and initial interpretation and I agree with the findings. ZUZAN CAYCI, MD Results Maxillofacial CT wlo contrast(Order 201874142) Resulted: 04/28/14 1144, Result Status: Final Maxillofacial CT wlo contrast 201874142 result Ordering provider: Hibino, Seikei, MD 04/28/14 1019 Resulted by: Cayci, Zuzan, MD Performed: 04/28/14 1120 -04/28/14 1127 Resulting Lab: RADIOLOGY RESULTS Narrative: CT of the Facial Bones without contrast History: fall pain, Comparison: none Technique: Using thin collimation multidetector helical acquisition technique, axial and coronal thin section CT images were reconstructed through the facial bones. Images were reviewed in bone and soft tissue windaws. Findings: There is left preseptal and periorbital swelling/hematoma. The globes are normal. Lenses are located. Retro-orbital 'fat are symmetric and normal. Optic nerves are appear normal on CT. Extraocular muscles appear within normal limits. There is no evident fracture of the facial bones. The cribriform plate appears intact. Alignment of the facial bones appears normal. The visualized portions of the paranasal sinuses are clear. I m pression: I mpression: Left preseptal and periorbital � swelling/hematoma. No evidence of fracture or postseptal abnormality. ; I ZUZAN CAYCI, MD � % i Page 8 I�I Printed on 5/8/2014 10:37 AM �TACHMEN��IM FORM Photos ��;�3e„� ,, � I „ � �- �� ,� �� i. � � , r�;�.�. - � �.=° ��< _;�3 �-� :�;�..,_ ,�, 5 v .1 � N 01 ,� N \ �`�' O O ., '... � 'z C e� O C � O � � N � N O � � L w �, c m - c c a� y Y Y f0 f0 �"' " O O � O L • � � a • � � a �,;;,�. e � � �g �i� i ,�>' . ��:�_ =;y• ,z��..- � � ��1,. ��;, [,.. _ . �r ��b � .y,' � .� .�. . _ 't'r ' �t� -,�„°.. �. . � � � � rl O � �y N � \ O1 � N N \ � " � � = O � + � O i .: 40 �.�s� � `' C .� �� '� ^; O � - E �=,'� �� E ' � �k � � O � ,'` � � L � � � � � � Y Y fC � a-� �' O � '" O ' • • a � � � � a Explanation of Health Care Benefits —;-- � > BlueCross BlueShieid P A G E o 0 o a o F o 0 o z �.� � of Minnesota ��oo oioi000000a�s• � a An MdeperMmt Mansee ot(he�lue Aoss and�q Ssla�d Aasop�on P.O.Box 64560 THIS IS NOT A BILL Thls Is an explanatlon of the c1a1m processed St.Paul,MN 65164-06� based on your plan benefits in effect when the service was performed. Piesse keep this form for your tax records. Easily find a provider, see your claims, your plan, health programs and wellness info all in one place. Visit the myBlueCross online member center. Sign in at KEVIN FLYNN www.bluecrossmn.com. 2199 PINEHURST AVE ST PAUL MN 55116-1123 ��u��u�u��u��n�� YeartoDateDeductible 1 ,612.88 Contacr For Customer Service-Piease Cati: (651) 662-5001 OR TOLLFREE 1-8D0-531-6676 Patfent ID Group/Poitcy Date Date Claim Number Received Processed XZ2184275 HAMMEL GREEN OER0040HA 05/09/14 05/09/14 4129911633000 Subscrtbe►lMember Name R O X A N N E N E L S O N Patient Name K E V I N F L Y N N �v�d� UNIVERSITY OF MINNESOTA PHYSICIANS Patlent Control Number 0 3 2 0 4 218 0 9 Dates of Service From From From From To 0 4 2 8 14 To To T To ��pt�� LAB/X-RAY Charges 7 3 8.0 0 Provider Responsfbillty Amount 3 7 0.4 0 Ailowed Amount 3 6 7.6 0 Amount Petid By Other Insurance Deductibie Amount 3 6 7.6 0 Copay Amount Colnsurance Amount Pald Amount �atlent Noncover�Amount Amount You Owe 3 6 7.6 0 dotes Id 1 lotes Total Chsrges 1 YOUR PROVIDER IS PARTICIPATING. THE AMOUNT LISTED AS PROVIDER 738.00 RESPONSIBILITY IS NOT YOUR RESPONSIBILITY. REFER TO THE COVERAGE INFORMATION SECTION IN YOUR PLAN DOCUMENTATION. TotalBenefltAmount 0.00 Total Amount Paid by Other Msurance 0.00 �tta,.c h m e.n-f- �• �• � Totai Amount You Owe 367.60 �ee reverse slde for CpmplainUAppeat,Fraud and other Important Information. Explanation of Health Care Beneflts - � BlueCross BlueShield P A G E o 0 o a o F o 0 o a �i�� of Minnesota THIS IS NOT A BILL. 7h�s�s an exp�anat�ori of�t e claQin�roc�s�e�0 0 2 7 0 7 a+a►oena�ddusoenseeo�nmeuwaossaraearosroaie�ssooauon based on your plan beneflts in effect when the service was perfonned. P.O.Box 64660 Please keep thls form for your tax reconds. St.Paul,MN 55184-0680 See reverse side for CompiainUAppeal,Fraud and other important Informatlon. Easily find a provider, see your claims, your plan, health programs and wellness info all in one place. Visit the myBlueCross online member center. Sign in at KEVIN FLYNN www.bluecrossmn.com. 2199 PINEHURST AVE ST PAUL MN 55116-1123 ��ni��u��uu��u��u��u��u�� YeartoDateDeductiWe 2,179.83 Contac�For Customer Servfce-Please Call: (651) 662-5001 OR TOLLFREE 1-800-531-6676 Patient iD Group/Policy Date Date Recelved prp�sg� Claim Number XZ2184275 HAMMEL GREEN OER0040HA 05/12/14 05/12/14 4132905900000 3ubscribeNMember Name R O X A N N E N E L S O N Patlent Name K E V I N F L Y N N Provlder UNIVERSITY OF MINNESOTA MEDICAL CENTER FAIRVIEW Patlent Conuol Number 9 0 0 4 6 414 2 5 0 0 Dates of Servlce From From F From From To 0 4 2$ 14 TO To T To Descrlption M E D I C A L Charges 3 9 8.0 0 Provider Responsiblllty Amount 2 3 . 3 2 Aliowed Amount 3 7 4.6 8 Amount Paid By Other Insurance Deductibie Amount 3 7 4.6 8 �opay Amount Coinsurance Amount Pald Amount Patlent Noncovered Amount Amount You Owe 3 7 4.6 8 Votes Id 1 lotes Total Charges 1 YOUR PROVIDER IS PARTICIPATING. THE AMOUNT LISTED AS PROVIDER 398.00 RESPONSIBILITY IS NOT YOUR RESPONSIBILITY . REFER TO THE COVERAGE INFORMATION SECTION IN YOUR PLAN DOCUMENTATION. TotaleenefitAmount 0.00 Total Amount Patd by Otherinsurance �-f-a.ch�te�t f �: � '2 0 .o0 Total Amount You Owe 374.68 Are you up to date with you�preventive care?Many plans cover preventive services that wlll not result In a cost when you use an In network provlder.Preventive care can include check-ups,screenings.and immunizatlons.For more informatlon,go to: https://www.4luecrossmn.com/Paae/mn/en US/oreventive-cere Explar�ation of Heaitn Care �enetits �. � - BtueCross BlueShieid P A G E o 0 o i o F o 0 0 2 - �.�� of Minnesota ��oo Qiol000�ooa��6 THIS IS NOT A BILL. This Is an explanation ofThe cla m process M I�dant Npnsee otlha dltre Cross�0�ue SMaW AsmdNlon based on your plan benefits In effect when the service wa8 performed. P.O.Box 64660 Please keep tnis form for your tax records. St.Paul,MN 55164-0660 See reverse slde for Complalnt/Appeai,Fraud and other important Informatlon. Easily find a provider, see your claims, your plan, health programs and wellness info all in one place. Visit the myBlueCross online member center. Sign in at KEVIN FLYNN www.bluecrossmn.com. 2199 PINEHURST AVE ST PAUL MN 55116-1123 ��u�� Year to Date Ueductlble 2. 5 0 0.0 0 Contact•For Customer Service-Please Call: (651) 662-5001 OR TOLLFREE 1-800-531-6676 Patlent ID GrouplPoilcy Date �te Claim Number Received Processed XZ2184275 HAMMEL GREEN OER0040HA 05/13/14 05/14/14 4133814388000 Subscrf beNMember Name R O X A N N E N E L S O N Patlent Name K E V I N F L Y N N Provider UNIVERSITY OF MINNESOTA MEDICAL CENTER FAIRVIEW Patient Control Number 110 0 5 3 2 9 5 410 0 Dates of Service From 4 From F From From To 04 28 14 To 04 28 14 To 04 8 14 T To DesGrlption LAB/X-RAY MEDICAL FACILITY Charges 2,464.00 887 .00 79. �0 Provider Responsibillty Amount 1 , 2 3 2 .9 9 4 4 3 . 8 5 3 9. 5 3 Allowed Amount 1 , 2 31 .O 1 4 4 3 .15 3 9.4 7 Amount Pald By Other Insurance Deductible Amount 3 2 0.17 Copay Amount Coinsurance Amount Paid Amount 910.8 4 4 4 3.15 3 9.4 7 Patient Noncovered Amount Amount You Owe 3 2 0 .17 Notes Id Notes Total Charges 3 ,430.00 Totai Benefit Amount 1 , 393 . 46 �� ' • � Total Amount Pald by 11�` f 1 _ �. � Other insurance r-nr�.c,� o. o 0 Total Amount You Owe 320 .17 Are you up to date with your preventive ca►e?Many plans cover preventive servlcea that wiil not result In a cost when you use an in network provider.Preventive care can include check-ups,screenings.and immunizations.For more information,go to: https://www.bluecrossmn.com/Page/mn/en_US/preventive-care