Shafer KRUEGER LAW FIRM '
Roselawn Village Office Building r ATTORNEYS AT LAW
i9i2 Lexington Avenue North, Suite 300 '��'`" -
Roseville,Minnesota 551i3 John A.Krueger�
Office(65�)628-0800 �i� 1 Y �L�.�1�� LindseyA.Carpenter
Facsimile(65i)628-01�� John A.Kindseth
R E C E I V E D Edward W.�S�h
Cole J.Dixon
Jessica A.Stachnik
JUL 19 2013 MaiNengMoua
*Also licensed in Wisconsin
July 17, Zo�3 CITY CLERK
St. Paul City Clerk
15 W. Kellogg Blvd
310 City Hall
Saint Paul, MN 55102
RE: Our Client: Karen Shafer
Your Insured: St.Paul PD
Our File Number: 210072
Date of Accident: 7/6/2013
Dear St. Paul City Clerk:
Enclosed please find Karen Shafer's Notice of Claim Form and supporting documents. Please be advised
that we have been retained by Karen Shafer for personal injuries she sustained as a result of a dog bite
accident on July 6, 2013, in which a K-9 unit dog from the St. Paul Police Department attacked her. Our
records show that City of St. Paul has liability insurance covering this incident. All future contact and
correspondence should be directed to this office for further handling of this matter.
Please provide us with the following information:
1. The policy limits and coverages for your insured, including any umbrella coverage;
2. A copy of the police report(if available);
3. Any recorded statements taken;
4. Color copies of any photographs showing damage to the vehicle(s) involved.
Please note that pursuant to Minn. Stat. § 72A.201 Subd. 11 Disclosure Mandatory. "An insurer must
disclose the coverage and limits of an insurance policv within 30 days after the information is requested in
writin�v a claimant." �
i
If you have any questions or concerns, please call me.
Sincerely,
KRUEGER LAW FIRM
C
Cole J. Dixon '
Attorney at Law
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota Sta[e Statute 466.05 states that "...every person...who claims damages from any municipaliry...shall cause to be presented to[he
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 clearly 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 both pages completed. If something does 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 f—/t �� � Middle Initial � Last Name ��� �� V'C
Company or Business Name �-
Are You an Insurance Company? Yes/�If Yes, Claim Number?
Street Address �y Z- VG�v� J�.t rC � �v e •
City �"� • ���.�. � State � /�/ Zip Code ��(� �7
Daytime Phone( SI)Z� - �lJ►6 Cell Phone( ) - Evening Telephone( ) -
Date of Accidend Injury or Date Discovered � � � - ( � Time �2�4� �/pm
Please state, in detail, what occurred(happened),and why you are 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 dama es.
._ �� k a r d a7 14 Z V., � �u r<<.► . S� . � �
r G L A i 1� � �� w � �� � '^� �
t�JaS at �.� ; .✓ 1�L : G 1.� [ �+�"
°� a w�L '� a r .r Q G �
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✓ � Ot i : 1 f
1n i i�- V Q �C a[SL ( � T� S H 1 1.�1 U�t��✓L�.
i�t d �ct,�" a -1-0 � S: G�+ '� vl Vc� d o o -
Please check the box(es)that most closely represent the�'eason for completing this�m:
❑ 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 ' �7
�Other type of injury-please specify Mvt ��-�� e4 i �T�t i/iG f� I.�ok�n S =�s�►'�L�^�S
� TC�A t-
In order to process your claim You need to include copies of all applicable 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. i
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
• Photographs are always welcome to document and support your claim but will not be returned.
Page 1 of 2-Please complete and return both pages of Claim Form
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims-ulease comnlete this section
Were there witnesses to the incident? es No Unknown ircle) `
Provide their names, addresses and telephone numbers: O���Gt� ov� �� = ��� �-'.f/�t,� L'`S �'�'"''��
- S Z - - 26 �e 'a+�.► S' - 37
Were the police or law enforcement called? n Ye No Unknown (circle)
If yes, what department or agency? S-� • V�ac w� �� Case#or report# �3 -- t 39 T.�D
Where did the accident or injury take place? Provide street address,cross street, intersection, name of park or facility,
closest]andmark,etc. Please be as detailed a possible. If necessary, at ch a diagram.
/VI,,, L�a�k .�a v�o�- -� �t z � .,.� L��,.��� �c7�i_,P�..... ,�.t�
Please indicate the amount you are seeking in compensation or what you would like the City to do t resolve t �s claim
to your satisfaction. -�- � i ti �.4 ` ./til i �� S
a � a C' — G
Vehicle Claims-please complete this section _I,�q check box if this section does not applx
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
In'ur Claims- lease com lete this section ❑ heck box if this section does ot a 1
How were you injured? - �c C
a M � Os
What part(s)of your body were injured�
r ar
Have you sought medical treatment? Yes No Plannin to Seek Tre t ent(circle)
When did you receive treatment? ���o-l ' - �?- � ` o tr �u�c- �'Q7(provide date(s)) /l
Name of Medical Provider(s): 03 ' 1� S �` �. ��• � � ���'D�'n�
Address � Telephone
Did you miss work as a result of your injury? es No
When did you miss work? i ,e 1� �: .�. o� 7-6 � � (provide date(s))
Name of your Em loyer: ' .. D � �i S ✓ a f
Address �• �a cl- TelephoneG�1- 25s/- 3''tS''6
Gsi - 7�o _ Kz �
�Check here if you are attaching more pages to this claim form. Number of additional pages
By signing this form,you are stating that all information you have provided is true and correct to the best
of your k►zowledge. Unsigned forms will not be processed.
Submitting a false claim can result in prosecution. Date form was completed �� � �� r3
Print the Name of the Person who Completed his Form: D l e- �� X 0✓l
Signature of Person Making the Clai . '
Revised February 2011
�� c�� l t �� �� �� � �"
c.: : i . IC� i �; �
���otn��s� R��� :�t���t ����,�C
980 Rice Street
St. Paul, MN 55117
P�ar�e: (651) 326-9020
APPOINTMENT QATE: APPOINTMENT TIME:
Patient: KAREN SHAFER MRN: 604430 Sex: F
742 VAN BUREN AVE DOB: 01-Ju1-1968
ST PAUL, MN 55104 Insurance: SELF PAY
Home: (651) 216-8016 Guarantor: SHAFER, KAREN - [Self]
Work: (651) 216-8016 Encounter Date: 15-Ju1-2013
PCP: Charlene Ulstad-Warkentien Ordering Provider: Charlene Ulstad-Warkentien, M.D.
»Orthop�dic� Referral Order # TW262570229
Diaqnosis
Contusion With Intact Skin Surface Of The Left Arm 923.03
Date Ordered Ordering Provider
15-Ju1-2013 Charlene Ulstad-Warkentien
To Be Done Date Priority
15 Jul 2013 Routine
Performing Location Comment:
patient was attacked by police dog with multiple lacerations; had swelling/deformity right middle finger and significant
swelling and tenderness over left biceps
maplewood summit hand
Additional Information
Will Patient Schedule No �
Group Referred To Summit Ortho 651-968-5201 '
__ _
Clinician Referred To downtown-dr holmes jillian �
Is Insurance Referral Needed No
Was Referral Redirected by Specialty Scheduler No ;
Educated on Referral Process Yes
Is Referral Out of Network No
:
Appointment Scheduled for '`16Ju12013 08:30AM°'
ORDERING PROVIDEF Charlene Ulstad-Warkentien M.I�
Electronic Signature: �
Order Requisition Page 1 of 1
S}��aie�r; k��i;�e�, I� (1vIR;,` 9017�2%9j Encoiu�ter Date: 07/07/201�
Emergency Dep�rtment
Return to Work Note
Pa�ient Narn�: Karen f< Shai2r
Date ofi Bit�h: l/1/1958
Date af Evaluation: 7%I/2013
Returr to wiork in thr�e day�.
Follo+,v up needed with: Primary clinic/physician onlin 7-10 days fo�suture removal.
Maria N Betgstrand, MED STDNT 7/7/2013 5:34 AM
Electronically Signed
i
I
i
;
Shaftr. Karen I� (�1� = �)017�?79) Yi-inted bti Holl�����a��. it�le _� (=�11 ti] at 7;'7�1; >:�7 _'�'�'I
� � �. ����P�i�`�
� t��d`t'H�r�;������
f�octors Profe�sional �Icig Clinic
280 Smith /�ve P�
Suite 500
5t. Paul, MN, 55'102
(651) 968-5200
Patie��t lnformatia�: Shafer, Karen K�.
DOB: 07/01/1968 Gender. F
Karen Shafer
742 Van Buren Ave
St PauI,MN 551Q4
(H) (651) 216-8016
Encounter Date: 07/16/2013 9:OOAM
MRN: 423473
Diagnosis Summary
1. Dog Bite E906.0
Message
Karen Shafer unable to�^rork at a!I from 07/16/2013 through 07/23I2013. Employee's v.�ork restrictions apply to next
scheduled appointment.
TREATMENl PLAN/RECOP�IMENDATIONS:
Signatures
Electronically signed by : Bethany J Curtis, ; Jul 16 2013 8:54AM (Author)
"`*Re-disclosure not permitted without the express written permission of the patient"'
Printed By: 430 1 of 1 7/16/13 8 54 48 AM
;�11at�er, l�aren 1f (��1K # )Ul�/�Z"/y) UUH: 7/1/]>6� Yage ] of 7
a::3"i�€;:�ta�6x;'.\� �_��;�'<aa'ig�'i�f'ii �.�''a!lCil:�'tai'}/ �.C��CtYC
k'�'? t�'t"�t,�[���i' i��(�i�S
-----____------------�,_��_—°------------------ --------- ---------------°------°—
EC� I�rcvider Notes �ig��ed by Ht�ilo�nlay, N:yle A at 717i20i3 7:2� H��/I �
,,.s ,___ Holloway, Kyle A `>�.: �._.�_ (none)�._._- -- r a;���,� � RESIDENT �-_._.______.__
'til-�
`�i��{i� 7/7I2013 7:29 AM ��;�,���; 7/7/2013 1:49 AM
�i'.:rl-:
Regions Flospifal
Emergen�y Qepartment !lisit Note
Chief Complaint: ANIMAL BITE--DOG--ED
History c�f Present Illness E
HPI
Karen K Shafer is a 45 yr old female who presents to the ED after being bitten by a police canine. She
was at her house celebrating her birthday outside when a police canine who was chasing another person
came at her and bit her multiple times. She has several bites to the left upper arm, one large wound to the
left lateral/posterior thigh and two wounds to the right middle finger. She denies any numbness or tingling
and has full movement of all extremities. Her tetanus was updated last month. She is nauseous but
denies any other complaints.
Medicatians:
None
Allergies: Review of patienYs allergies indicates no known allergies.
Medical History:
No pertinent history.
Surgical History:
No pertinent history.
�.�;F=.,_ ,
-r�-..tv;}
`��.��J�/'�1�vf: lJ >�: %i}�)ii�� . . . .. . j., � � . .. �
• Smoking status: Current Some Day Smoker 'I
• Smokeless tobacco: Not on file ,
Comment:social smoker, plans to quit with the Electronic cigarette j
• Alcohol Use: Not on file
Review of Systems i
Gastrointestinal: Positive for n�usea. Negative for vomiting. �,
Skin:
Multiple bites to left upper arm, left posterior thigh and right middle finger.
All other systems reviewed and are negative. �
Physica[Exam � '
Vital signs: BP 121/72 � Pulse 94 � Temp(Src) 97.8 °F (36.6 °C) (Oral) � Resp 16 � Sp02 96%
Phvsical Exam
Nursing note and vitals reviewed.
Constitutional: She is oriented to person, place, and time. She appears well-developed and well-
nourished.
Shafer-, Karen K (MR # 90175279) Printed by ( �096) at 7/1�/13 11:32 AM
>naler, I�arcn Y� (1��1K�1 �JU1 /JG/y) 11U1i: //1/1�16� 1'age� 2 of�7
F-IEN7:
Nead: Normocephalic and atraumatic.
Eyes: Conjunciivae are normai.
Nec�: Normal range of motion.
Pulmonary/Chest: Effort normal and breath sounds normal.
Abdominai: Soft.
Musculoskeletal: Normal range of motion.
Neurological: She is alert and oriented to person, place, and time.
5/5 strength of left arm, ieft leg and right middle finger, sensation intact throughout.
Skin: Skin is warm ��nd dry.
4 deep lacerations between 0.5-1 cm with adipose tissue exposed to the left upper arm extending
anteriorly to medially.
3 cm laceration with tissue avulsion to the 1eft lateral posterior thigh with surrounding edema. 0.5 cm
laceration at the PIP joint on the right middle finger, 2 cm laceration on the lateral aspect of the proximal
right middle finger, superficial scrape down the length of the volar surface of the right middle finger.
Imaging:
XR R Hand (3 views): No evidence of acute bony injury. Reading per radiology.
Medical L�ecision Making & ED Course ; ,;
_ _ _.--._ _ _.
45 year old male with multiple wounds after being bitten by a police canine at her home tonight. She was
given IV morphine for pain control. X-rays were obtained of her right hand and were negative. She
became nauseous and vomited and was given IV Zofran. Wounds were anesthetized, irrigated and
loosely closed with sutures. Her tetanus was up to date. She was given prescriptions for Augmentin,
Percocet and Zofran and instructed to see her PCP in 7-10 days. Signs/symptoms of wound infection
were discussed with her and she will be seen earlier if she develops these.
Please see associated EPIC note for wound closure details.
Diagnosis & Disposition : ; :
Diagnosis: _ . _ _ _
Multiple dog bites
Dispo: Discharge to home with prescriptions for Augmentin, Percocet, and Zofran
This document serves as a record of services personally performed by Resident Preceptor: Kyle I�
Holloway. It was created on his/her behalf by Kyle A Holloway, MD, a medical scribe. The creation of this
record is based on the scribe's personal observations and the provider's statements to them. The
document has been checked and approved by the provider. ��
�
ED Note� signed by Hernandez, Bradley S at 7/7/2013 5:26 AM
���_��;���?_ Hernandez, Bradley Serv:e�: Emergency ����.���i HP PHYSICIAN
S Department -I-,;;�„ ;
r .;,- 7/7/2013 5:26 AM ��Jc�t�= 7/7/2013 4:16 AM
i�ir„�� �
� _;_:.._ - Original Note by Hernandez, Bradley S filed at 7/7/2013 4:17 AM
3,_ �
f���i___��.
Regions Hospital
Emergency Department Attending Supervision Note
I performed the key elements of history and exam, and agree with resident's findings and plan of care as
discussed with Dr. Kyle Holloway.
I have reviewed and agreed with the PMH, FH, SOC, ROS.
Please see today's note by resident physician.
Assessment:
Shafer, Karen K (MR # 90175279) Printed by ( 5096) at 7/15/13 11:32 AM
�naler, haren n (1v1K�r� �1U1�/JL/�) llUli: 7/1/1�)bb Pa�e 3 of7
Dog bite to right hand, lefi thiyh and left arm
!'lae�t:
Wound repair
Xray
Antibiotics
Home
i �vas present for key portion of��altiple Wound Repair X � by medical student.
Author: Bradley Hernandez, MD
Patient Vitals for the past 24 hrs:
BP Temp Temp src Pulse Resp Sp02
07/07/13 121/72 mmHg - - 84 16 98 %
0215
07/07/13 110/53 mmHg 97.8 °F (36.6 °C) Oral 90 20 99 %
0121
i:.?rr�l��u "4�.�, C,"1:��,� xi�:��:;;iz C�!;t�i.��tifi �iG+�j�i:i�� f'li C?,!iif:!.i ft�i?T � 71 t.-
,
jii�' ;-t,P.1P���� ;'�ty�f��'; ;�`;
Narrative:
X-RAY HAND 3 VIEWS RIGHT Jul 07, 2013 02:34:35 AM
INDICATION: Dog bite to the middle finger.
COMPARlSON: None.
FINDINGS: No acute fracture or dislocation. The joint spaces are
well-maintained. No obviocis foreign body deposition.
CONCLUSION: No evidence of acute bony injury.
Previous Versions
7/7/2013 4:16 AM ED Not2s siqned bV Hernandez Bradlev S
AI! Other Provider Notes
%=,C�t^cr Typ� Autnvr Filed
REGISTERED NURSE Costello, Jessica R 07/07/13 0605
REGISTERED NURSE Costello, Jessica R 07i07/13 0545
REGISTERED NURSE Costello, Jessica R 07/07/13 0403
REGISTERED NURSE Costello, Jessica R 07/07/13 0321
REGISTERED NURSE Strong, Sarah O 07/07/13 0311
REGISTERED NURSE Strong, Sarah O 07/07/13 0249
REGISTERED NURSE Strong, Sarah O 07J07/13 0130
Transcribed Documents (for visits prior to May 1, 2004j '
ED Comprehensive Report
F lows h eets
Flowsheet Data
Shafer, Karen K (MR# 90175279) Printed by ( 5096) at 711�/13 11:32 AM
,>!laici-, ��arcn a� �lvi�t r ��ui i��i��� 1�Ut5: l/1/1yt�� }'age 4 oi 7
�_.�ia;£'�1:;R'C��' �i:�=�E�a'E,s;;S:l�`9"s�b
�j:.f9��aTa�4E�: �i��3!{��vL�{.)��v
i ake �ugmentir� for ,►°a e�ays as pre�crib�d. U�� ��fra� fior �au�ea, Per�oce€for ��in.
�utur� rernoval in 7-'10 days.
!�you dev�fo� �igns of wound infecfion including increased pain, rednes� aroi�rzd
the �rou�d �r fever please b� �va�ua�tet�.
Take zofran 4mg tablets as needed for nausea and vomiting. You can fiake '�-2
�ablets every 4 hour�.
Take percocet as needed for pain. One or two tablets every 4-6 hours. No driving
while taking percocet. Do not take additional tylenol while taking percocet.
You have 3 prescriptions waiting for you at the Regions Hospital Emergency
Department pharmacy. This is located in the waiting room of the Emergency
Department.
Take your antibiotics to completion.
Wound Care: Af�er Your �lisit
Your Care Instructions
Taking good care of your wound at home will help it heal quickly and reduce your chance of
infection.
The doctor has checked you carefully, but problems can develop later. If you notice any
problems or new symptoms, get medical treatment right away.
Follow-up care is a key part of your treatment and safety. Be sure to make and go to all
appointrnents, and call your doctor if you are having problems. It's also a good idea to know
your test results and keep a list of the medicines you take.
How can you care for yourself at home?
. Clean the area with soap and water 2 times a day unless your doctor gives you
different instructions. Don't use hydrogen peroxide or alcohol, which can slow healing.
o You may cover the wound with a'thin layer of antibiotic ointment, such as
bacitracin, and a nonstick banda e.
o Apply more ointment and replac�the bandage as needed. �
. Take pain medicines exactly as directed. Some pain is normal with a wound, but do ,
not ignore pain that is getting worse instead of better. You could have an infection. !
o If the doctor gave you a prescription medicine for pain, take it as prescribed. ',
o If you are not taking a prescription pain medicine, ask your doctor if you can take i,
an over-the-counter medicine. I
. Your doctor may have closed your wound with stitches (sutures), staples, or skin glue. I
o If you have stitches, your doctor may remove them after several days to 2 weeks.
Or you may have stitches that dissolve on their own.
o If you have staples, your doctor may remove them after 7 to 10 days.
o If your wound was closed with skin glue, the glue will wear off in a few days to 2
weeks.
Shafer, Karen K (MR # 90175279) Printed by ( 5096) at 7/15/1� 11:32 AM
�>ll�i1C1�; riQi'C'�il Yz �lVl[�+t JU1. /JL/)) 1JVts: //1/1)b25 1'c`lbE � Of �/
��Iti�� �E-o�c�ld y��a c�ll �o�• hel�?
�a{i ypur c�acto�- no� or seek immediate medic�l c;are if:
m You have signs of infection, such as:
o Increased pain, swelling, warmth, or redness near the wound.
o Red streaks leading from the Urour�d.
o Pus draining from the wound.
o A fever.
� You bleed so much fram your incision z�at you �oak one or more bandages over 2 to 4
hours.
1,Natch closely for changes in your health, and be sure to contact your doctor if:
Q The wound is not getting better each day.
Where can you learn more?
Go to healthpartners.com/healthlibrary and enter M973 in the search
box.
Last Revised: April 23, 2012
O 2006-2013 Healthwise, Incorporated.
'�
Shafer, Karen K (MR# 90175279} Printed by ( 5096) at 7/15/13 11:32 AM
,�iinivi, i��rcii i�. �n�ia� ;, iv i i��i y� livts: ��1�1�bti Yage � 01 �/
�mergency Department
Returr�to Work Note
�atient i�ar7e: f:aren K Shaier
p�ie o� �irfh: 7/1/1958
�ate �f�valuation: 7/7/2013
Return to work in three days.
Follow up needed with: Primary clinic/physician on/in 7-10 days for suture removal.
Maria N Bergstrand, MED STDNT 7/7/2013 5:34 AM
Electronically Signed
Shafer, Karen K (MR# 90175279)Printed by ( 5096) at 7/15/13 11:32 AM
r�un�ci, n���t.ii » ����i�� +; ��i i_��i�� ����ts: ii�i���ts YZge �/ of "/
Shafer, Karen K (MR# 90175279) Printed by ( 5096) at 7/15/13 11:32 AM
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7/7/2013 2:50 AM
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�__� �_�__�____._�___._.__._ �._.-- -----�--.__.____�_�__.v_ __�._.__._�___�.._.__.___
LEE, DAVID A[22639]
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►�etail;:t1 �x�in �:epos�
XR NAND 3VVVS RT (Order�173948168) on 7!7/2013 - Detailed Exam ftepork Information � �
Result Fiis�t�r},
XR HA�dD 3V�iVS (�T (Ord2r�`;7���816°j on 7/r'l13 - Order P,esul� !-fstary Report. -----�--��---�._�
Patient I D 90175279
RQI #: 173947870
Result Report for Printing
MyChart Status This result is not viewable by the patient.
I nactive
ReSUItS �R HAND 3:VIEWS RIGHT[IMG1316] {Order# 173948168)
Patient Information
Pa.ient N�m� ` �e;� �'�v8 �Age,
Shafer, Karen K (90175279) Female 7/1/1968 (45 yr)
Patient Demographics
J-°tr C.ii":?S� } �,v^i?t2Cf i'vUfTt�".`;;rj �
742 VAN BUREN AVE 651-216-8016 (Home Phone)
SAINT PAUL MN 55104-1662 000-000-0000 (Work Phone)
651-646-0018 (Mobile)
Patient ID 90175279
Order Information �'
DatG and Tirr�e ! Depar�w��nt
7/7/2013 1:59 AM RH Emergency Dept
Shafer. Karen K (MR# 9017�279) Printed by ( 5096) at 7/15/13 11:32 AM
...�....� , �.�,.,..,,.� �> �� u.. „ i.,,. i„�..,i .� ��..��. �� �� ,.ivv i ub� ,_ w. ...
, .'i --.�. � , tc�{�(i:[ ;.� .��',;i .'1 "•.'�L�1 .t . ,. -_Y�`ti:�r .
f�ollov✓�y, f<yle A(�11115) Holloway, Kyle A, MD (41115) Hernandez, Bradley S, MD
(21993)
�+�:;,
. :-
Unassigned, Provider(9999999)
F'rovir��r Pager Infio
.'F-'_� . �...<-lL,. �
STAT� Ancillary
Performed
�i�e�#ian� (io�c{ Uecision Su���c�rk�vhere appli��ble)
�T,.E.:[�i�F�r.l � � � r's�1SE'l�:s1 � �li !fi::;i; �� _ —
Desired Date/Time Today
Clinical Presentation (for radiologist) dog bite to middle
finger
Clinical History (signs, symptoms, TRAUMA
indications)(billing)
PAIN
Test prep required No
Urigit�al �rder
' ti�:,� � C)r� �� .i�re;x:� ��;_
Sun_Ju1 7, 2U13 i:5� AM Holloway, Kyle A
Scheduling ins�r��ctions
PREP ItJ;�TRDr I�IOtdS �—_� _�_ _,._._.._.T-- --------.�,___._...___._._._
'i10 p:_ep neec3:-,;i.
Cr�.a�i��i�;:: (L�;�fi ?_ re:ults itt 375 c�ay�j
None __.__,.____ �_ __ �_______�—__�—__-------------__�_.�__.
�lppoinYments for t�is Order
7/7/2013 2:30 A�rt - 15 min 1, Rc Xr(Resource) Rc Radiology Gd
yyY Electronic orders are electronically signed by the ordering �rovider.YYY
Encounter
View Encounter
Radport DSN
173948168
Shafer. Karen K (MR � 90175279) Printed by ( 5096) at 7/1�/13 11:32 AM
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