Part 86, page 55

Transcript

The scan is the source; the transcript is machine-generated from it.

NORTHERN VIRGINIA DOCTORS HOSPITAL No. 2799 EMERGENCY ROOM RECORD 1 7089 S.S. or H.I.S. No.: [redacted] 4 / 3248

Last Name: [redacted] First Name: [redacted] Middle Name: Home Phone: [redacted] Admission Date: [redacted] A.M./P.M. 7-10-72 Hosp No. Address: [redacted] City: State: Age: [redacted] Date of Birth: [redacted] Sex: [redacted] M F Civil Status: M S W D Sep. Religion: Employer: [redacted] Address: [redacted] Compensation: Yes ☐ No ☐ Rel: [redacted] No: [redacted] Group No.: [redacted] Contract No.: [redacted] [redacted] Family Member ☐ Other hospitalization insurance: [redacted] Name: Address: Cert or Policy No. Group No Dependents ☐ Comprehensive ☐ Effective Date Family Doctor: [redacted] Notified: Yes/No ☐ Brought By: Self ☐ Police ☐ Fire ☐ Relative ☐ Other ☐ Type of Service: XR ☐ PH ☐ PT ☐ Lab ☐ Other ☐

Authorizations on Reverse Side Must be Signed by Patient or Authorized Person

EMERGENCY ROOM CHARGES OTHER SERVICES RENDERED Does Not Include Fee of Attending Physician ITEM CHARGE ITEM CHARGE Emergency Room ✓ Sutures X-ray _________ ☐ Anesthetic Tetanus Antitoxin Laboratory _____ ☐ Central Supply Cast Physical Therapy ☐ Dressings E.D.U. EKG ____________ ☐ Drugs ☐ Oxygen ☐

[handwritten: illegible] [handwritten: [guess: sthorned]] BRIEF HISTORY

If accident state where, when and how injured; If illness describe ___ [handwritten entry - largely illegible, multiple lines] NOTIFIED Relatives ☐ Coroner ☐ Police ☐ By Whom. Nurse's Signature: Officer's Signature: Badge: District: Time: AM/PM R.N. b6

PHYSICIAN'S REPORT b7C CONDITION ON ADMISSION Good ☐ Fair ☐ Poor ☐ Shock ☐ Hemorrhage ☐ Coma ☐ Temp. [guess: 196] Oral Rectal [guess: pulse] [guess: R] BP /10 Treatment: Tetanus Toxoid _________ cc. Tetanus Antitoxin Test _________ Tetanus Antitoxin _________ units

Diagnosis: [handwritten: Thrombophlebitis]

Disposition of Case: [handwritten: [guess: released/left]] Referred to Dr. _________ Date: 7/11/23 [guess: P.A.] b6 b7C INSTRUCTIONS TO PATIENT: ___________

(Date) 7/10/72 (Patient's Signature)

PATIENTS OFFICE NVDH #105