Trivent Legal



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|MEDICAL CHRONOLOGY - INSTRUCTIONS TO FOLLOW |

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|General Instructions: |

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|Brief Summary/Flow of Events: |

|In the beginning of the chronology, a Brief Summary/Flow of Events outlining the significant medical events is provided which will give a general picture of the |

|focus points in the case |

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|Patient History: |

|Details related to the patient’s past history (medical, surgical, social and family history) present in the medical records |

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|Detailed Medical Chronology: |

|Information captured “as it is” in the medical records without alteration of the meaning. Type of information capture (all details/zoom-out model and relevant |

|details/zoom-in model) is as per the demands of the case which will be elaborated under the ‘Specific Instructions’ |

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|Reviewer’s Comments: |

|Comments on contradicting information and misinterpretations in the medical records, illegible handwritten notes, missing records, clarifications needed etc. are |

|given in italics and red font color and will appear as * Reviewer’s Comment |

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|Illegible Dates: Illegible and missing dates are presented as “00/00/0000”(mm/dd/yyyy format) |

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|Illegible Notes: Illegible handwritten notes are left as a blank space “_____” with a note as “Illegible Notes” in the heading of the particular |

|consultation/report. |

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|Specific Instructions: |

|Chronology focuses on Ms. Doe’ admission to Brentwood nursing home, wound care for burn wounds to right anterior leg and fall in the nursing home on 06/05/YYYY |

|requiring internal fixation and subsequent management of same. |

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|There is no pressure sore noted during the nursing home stay. The wound care given was for burn wounds in the right leg. |

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|If the provider’s name or signature is not decipherable, then the snapshot of the same is taken. |

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|Records which are not significant to the case are not captured in detail. They can be elaborated if needed. |

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|In records given cumulatively, the PDF reference numbers are given in brown font within the Occurrence column for ease of reference. |

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|There are lots of illegible hand- written notes and we have tried our best to decipher them. |

|Missing Medical Records Table: |

|What Records are Needed |

|Hospital/Medical Provider |

|Date/Time Period |

|Why we need the records/bills? |

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|Fall risk assessment, plan of care, physicians orders |

|X - Health Care System |

|05/31/YYYY-06/05/YYYY |

|To substantiate the nursing care rendered |

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Brief Summary/Flow of Events

05/31/YYYY-06/05/YYYY: X - Health Care System

05/31/YYYY – Admitted to nursing home for medical care of non healing burn wounds, frequent fall at home and for physical and occupational therapy

[pic]

06/01/YYYY-06/03/YYYY: Dementia, unsteady gait - required limited assistance and one person assist to activities of daily living – Chronic radiation burns to right lower and upper anterior leg – managed with wound care

[pic]

06/05/YYYY: @ 0230 hrs – Stated she was going to toilet and fell - Found on floor between bed and wheel chair – Pain to left knee – ordered X-rays

X-ray revealed supracondylar fracture of the distal femur – @1245 hrs ordered to be transferred to x - hospital

[pic]

06/05/YYYY-06/08/YYYY: X - Medical Center

Admitted to hospital - Diagnosed with distal left femur comminuted fracture – Underwent Open Reduction and Internal Fixation (ORIF) of left distal femur fracture on 06/06/YYYY – Diagnosed with urinary tract infection – Managed with antibiotics – Condition improved – Discharged to nursing home on 06/08/YYYY for further rehab care.

[pic]

06/08/YYYY-08/31/YYYY: X - Health Care System

Readmitted to nursing home for rehab and wound care – Underwent continued physical therapy, occupational therapy and wound care – Burn wounds in the right leg improved overall – Discharged home on 08/31/YYYY

Patient History

Past Medical History: Hypertension, hypothyroid, dementia, chronic right lower leg wound post burn, fell at home on 05/18/YYYY, osteoarthrosis.

Surgical History: Unremarkable.

Family History: Non contributory.

Social History: Lives with her family, denies alcohol, illicit drugs or smoking.

Allergy: No known drug allergies.

Detailed Chronology

|DATE | |OCCURRENCE/TREATMENT |PDF REF |

|ABC Facility |

|05/31/YYYY |Provider’s name/Signature |Nursing admission assessment: |237-242, |

| | |Vitals: Temperature 97.9, pulse 70, respiration 18, Blood Pressure (BP) 118/70 mmHg. |435 |

| | | | |

| | |Physical evaluation: | |

| | |Neurological/cognition: Can recall current season, staff names/faces, and she is in a nursing home. Makes | |

| | |independent decisions. | |

| | |Hearing/communication: Adequate. Clear speech, makes self understood. Understands clear comprehensions, vision | |

| | |adequate, pupils equal, wears glasses. | |

| | | | |

| | |Musculoskeletal: Mode of locomotion – Wheelchair. No functional limitation in Range of Motion (ROM) in upper and| |

| | |lower extremity. | |

| | |Prior falls: Fell in the last 30 days. | |

| | |Balance (If not steady, complete fall risk evaluation): Not steady, only able to stabilize with human | |

| | |assistance. | |

| | |*Reviewer’s comment: The fall risk evaluation is not available for review. | |

| | | | |

| | |Device and restraints: Half rails used. | |

| | | | |

| | |Gastrointestinal: Dentures used. Bowel and urinary continence: Always continent. | |

| | |Pain evaluation: Has no pain. Pain scale 0. | |

| | |Skin condition: Dry, warm. Wounds: NA. | |

| | |Braden score: 18. | |

| | | | |

| | |Notes: Received patient from home alert and oriented to time, place and person, uses Wheel Chair (W/C) denies | |

| | |discomfort, lung sounds clear, abdomen soft and non-distended. Bowel sounds active, bilateral pedal pulses | |

| | |present, capillary refills less than 3 seconds. Diet and wound care notified. | |

| | |*Reviewer’s comment: The physician’s orders, plan of care and fall risk assessment are not available for the | |

| | |nursing home stay from 05/31/YYYY-06/05/YYYY. | |

|05/31/YYYY |Provider’s name/Signature |Physician admission notes: (Illegible notes) |202 |

| | |Complaints of non healing wounds, here for Physical Therapy (PT), Occupational Therapy (OT) and medical care. | |

| | | | |

| | |Physical exam: | |

| | |Status: Functional limitations – Walker and wheelchair. Decubitus – No ___. | |

| | |Behaviors/mood: Calm. | |

| | |Review of system: Leg edema, leg vascular ulcer. | |

| | | | |

| | |Primary diagnosis: Weakness. Mechanical falls. Right lower extremities non-healing wound. Denture. Hypertension.| |

| | |Hyper parathyroid. | |

| | | | |

| | |Prognosis: Fair. | |

| | |Projected discharge: Within 30 days. | |

|05/31/YYYY |Provider’s name/Signature |Daily nursing notes: |431-432 |

| | |Patient alert. | |

| | |Physical functioning: Limited assistance and one person assist in bed mobility, transfers, locomotion and toilet| |

| | |use. Independent in eating. | |

| | | | |

| | |Snapshot of physical function. | |

| | |[pic] | |

| | | | |

| | |Patient in W/C at nurse station, no distress noted, will monitor. | |

|06/01/YYYY |Provider’s name/Signature |Nursing notes – Skin assessment: |437 |

| | |Skin assessment completed. Patient has radiation burn to right lower anterior leg A - 3 x3 x 0.5, B - 3x 2 x | |

| | |0.5, right upper anterior leg 2 x 1.5, 80% red tissue 20% yellow slough to wounds. With serosanguineous | |

| | |drainage. MD aware of wounds. | |

| | | | |

| | |Spoke with daughter Sylvia aware of wounds and treatment. Stated “Same from radiation burn unable to heal” | |

| | |explained Plan of Action (POA). Wound MD will follow, if any changes will notify POA. | |

|06/01/YYYY |Provider’s name/Signature |Nursing daily progress notes: |429-430 |

| | |Gait unsteady. Physical functioning: Supervision in bed mobility. Limited assistance in transfer and toilet use.| |

| | |Independent in eating and locomotion. | |

| | | | |

| | |Patient with dressing to wound to Right Lower Extremity (RLE), voiced no pain or discomfort. Seen by MD with no | |

| | |new orders. | |

|06/02/YYYY |Provider’s name/Signature |Nursing daily progress notes: |427-428 |

| | |Physical functioning: Independent in bed mobility, eating. Limited assistance and one person assist with | |

| | |transfer, toilet use and locomotion. | |

| | | | |

| | |Remains in stable condition, medications given, and dressing in place to tight lower extremity. Patient | |

| | |repositioned every 2 hours and safety precautions maintained. | |

|06/02/YYYY |Provider’s name/Signature |Physical therapy plan of care: |487-488 |

| | |Reason for referral: Functional decline. Patient presents to therapy with a decline in functional abilities due | |

| | |to fall and diarrhea. Family has noticed a decrease in mobility, resulting in decreased safety and an increased | |

| | |need for assistance. Patient requires skilled therapy in order to improve safety and function. | |

| | | | |

| | |Therapy necessity: Muscle weakness; Difficulty ambulating. | |

| | |Medical history related to diagnosis/condition: She was admitted to the facility from Trinity Hospital with | |

| | |diagnosis of fall and diarrhea (per family, she was lactose intolerant and she ate a lot of ice cream at home). | |

| | | | |

| | |Prior residence and living arrangement: Per daughter she lives with daughter in a 2-flat apartment building (2nd| |

| | |floor) with 22 stairs to enter. Assistance (A) with Activities of Daily Living (ADLs); has 24 hr Supervision | |

| | |(S), ambulatory with Rolling Walker (RW) but mostly stays in a W/C. Had HHPT 2x/week (Discharged 2wks ago). | |

| | |Patient able to feed self. | |

| | | | |

| | |Precautions: Full code; Falls. | |

| | |Discharge plans: Discharge to home with patient continuing therapy with Home Health and 24 hr care. | |

| | | | |

| | |Initial assessment: | |

| | |Functional deficits | |

| | |Prior level | |

| | |Current level | |

| | |anticipated | |

| | | | |

| | |Bed mobility, rolling to side | |

| | |Modified independent | |

| | |Modified independent | |

| | |Modified independent | |

| | | | |

| | |Bed mobility, supine sit | |

| | |Modified independent | |

| | |Modified independent | |

| | |Modified independent | |

| | | | |

| | |Gait, distance | |

| | |30 feet | |

| | |20 feet | |

| | |100 feet | |

| | | | |

| | |Gait assistive device | |

| | |Front wheeled walker | |

| | |Front wheeled walker | |

| | |Front wheeled walker | |

| | | | |

| | |Gait, level surface | |

| | |Stand by assist (supervision) | |

| | |Minimum assist (25% assist) | |

| | |Stand by assist (supervision) | |

| | | | |

| | |Transfers, sit-stand | |

| | |Minimum assist (25% assist) | |

| | |Stand by assist (supervision) | |

| | |Stand by assist (supervision) | |

| | | | |

| | | | |

| | |Underlying impairments: | |

| | |Cognition, orientation – Oriented to person x 1 | |

| | |Cognition, safety awareness – Moderately impaired. | |

| | | | |

| | |Dressings intact on right lower leg, denies any pain. Bilateral Lower Extremity (LE) Active Range of Motion | |

| | |(AROM) and sensation is within normal limits/intact therefore splints not recommended at this time. Bilateral LE| |

| | |strength is grossly graded 3+/5. | |

| | | | |

| | |Treatment diagnosis: Muscle weakness, difficulty in walking. | |

| | | | |

| | |Rehab potential: Good due to patient is alert, oriented x 1, cooperative, and motivated. She is able to follow | |

| | |simple commands with increased cuing given for complex commands. | |

| | |Requires skilled services to focus on: PT evaluation, therapeutic exercise, neuromuscular reeducation, gait | |

| | |training, group therapy, and therapeutic activities. | |

| | | | |

| | |Frequency/Duration: 6 times a week for 12 weeks. | |

|06/03/YYYY |Provider’s name/Signature |Nursing daily notes: |425-426 |

| | |Physical functioning: Limited assistance and one person assist in bed mobility, transfers, locomotion and toilet| |

| | |use. Independent in eating. | |

| | | | |

| | |Requires limited assist to ADLs. Continent of bowel and bladder. No complaints or distress. | |

|06/04/YYYY |Provider’s name/Signature |Social service initial note: |193-194 |

| | |Patient is aware of need for RW. Patient is stable to make her needs known, wears glasses. She is alert and | |

| | |oriented x 2. She displays short term memory impairments. She has history of dementia and has difficulty making | |

| | |appropriate decisions. Resident is involved in PT/OT. | |

| | | | |

| | |Current status: Patient admitted due to fall and diarrhea, she has history of dementia. | |

| | |Family status: She has supportive daughter and granddaughter whom she lives with. She also has a grandson. | |

| | | | |

| | |Discharge plan: She will return home with her daughter and granddaughter, she has 4-5 stairs to access and 10-12| |

| | |stairs to second floor apartment. | |

|06/04/YYYY |Provider’s name/Signature |Daily nursing notes: (Illegible notes) |423-424 |

| | |Physical functioning: Supervision and set-up help only in transfer, toilet use. Independent in bed mobility, | |

| | |locomotion, and eating. | |

| | |[pic] | |

| | | | |

| | |Comment - Evening shift: Up in wheel chair, alert, no distress noted, denies any pain. Continent of bowel and | |

| | |bladder will continue to monitor, call light in reach, safety maintained. | |

| | | | |

| | |Comment – Night shift: Wake early part of night, up in wheel chair, alert and oriented x 2, verbally responsive,| |

| | |voiced no complaints, ___ assisted to bed, toilet/__, slept rest of the night, call light within easy reach. | |

| | | | |

| | |0230 hrs: Patient found on floor between bed and wheel chair, stated I was going to the toilet and fell, body | |

| | |check done, no apparent injury, complaints of pain to left knee. Dr. XXX notified, X-ray of left knee ordered. | |

|06/05/YYYY |Provider’s name/Signature |Wound assessment: (Illegible notes) |446-448 |

| | |Seen exclusively for wound care. | |

| | | | |

| | |Wound # 1: Right anterior leg – 2 x 1.5. 76-100% granulation. | |

| | |Wound # 2: Anterior right lower anterior leg – 3 x 3 x 0.5. 76-100% granulation. | |

| | |Wound # 3: __ 3 x x2 x 0.5. 76-100% granulation. | |

| | | | |

| | |Adverse factor affecting wound: Impaired circulation, nutrition/weight low, contracture, anemia, inflammatory | |

| | |disorder, depression/dementia and incontinence of stool/urine. | |

| | | | |

| | |Wound management: We need to debride enzymatically right anterior leg, follow and support nutrition and | |

| | |hydration, avoid ___. | |

|06/05/YYYY |Provider’s name/Signature |Daily nursing notes: (Illegible notes) |419-422 |

| | |Physical functioning: Extensive assistance in transfer and toilet use, limited assistance in bed mobility and | |

| | |locomotion, supervision in eating. | |

| | |Patient up in the wheel chair spoke to family in the morning about patient on the floor and of X-ray to be done | |

| | |to left knee. | |

| | | | |

| | |1045 hrs: Tylenol 650 mg given at 8am with good result. X-ray done to left knee results pending. | |

| | |X-ray results received at 1200 hrs, MD on page awaiting return call. MD returned call at 1245 hrs, informed of | |

| | |X-ray results, new order received, call placed to XX Ambulance. | |

| | | | |

| | |1300 hrs: Patient remained in stable condition, last dose of Tylenol 650 mg given at 12 noon. | |

| | | | |

| | |1350 hrs: XX Ambulance here for patient report given to Jamie at X - hospital, message left for Sylvia X to | |

| | |return call. | |

| | | | |

| | |1410 hrs: Spoke with Sylvia informed her of transfer to ZZ ER. Received call from Sylvia X who asked me if ZZ | |

| | |would be able to tell if fracture new or old and that patient fell twice on Friday at home and her ___ family | |

| | |member didn’t inform her, I told her I wasn’t sure if ZZ would be able to tell. | |

|06/05/YYYY |Provider’s name/Signature |X-ray left knee: |235 |

| | | | |

| | |Findings: Examination reveals some demineralization and degenerative arthritic changes with oblique | |

| | |supracondylar fracture of the distal femur with slight overriding of the fracture fragments and no significant | |

| | |displacement. | |

|06/05/YYYY |Provider’s name/Signature |Physical therapy discharge: |485-486 |

| | |No of skilled services: 2 since last report. | |

| | | | |

| | |Analysis of functional outcome / clinical impression: The patient did not make significant progress toward goals| |

| | |due to unexpected facility discharge due to a fall with fracture. She was starting to make progress when she had| |

| | |a fall. | |

| | | | |

| | |Skilled services provided since last report: Therapeutic activities; therapeutic exercises; neuromuscular | |

| | |reeducation; gait training. | |

| | | | |

| | |Discharge plans: She was discharged to the hospital status post fall with recommendations of PT eval and treat | |

| | |once medically stable. | |

| |

|06/05/YYYY |Provider’s name/Signature |EMS report: |89-90 |

| | |Patient complaints of fractured left knee. | |

| | |Patient transported to X - hospital. | |

|06/05/YYYY |Provider’s name/Signature |ER visit for femur fracture: |91-106 |

| | |Triage: (Ref -103) | |

| | |Patient brought here from nursing home status post mechanical fall. Patient alert and oriented x 2. Per medics | |

| | |she has possible left knee or left distal femur fracture. | |

| | | | |

| | |Vitals: Temperature 97.9 °, pulse 67, RR 18, BP 180/104. | |

| | | | |

| | |Physician record: (Ref -94-95 ) | |

| | |Patient sent to ED from Brentwood after fall. She says she was leaving her garage and was pushed over by the | |

| | |door, but is not a reliable historian (dementia). No other complaints. Says she was in good health prior. | |

| | | | |

| | |Examination: Alert, mild distress. Neck: No tenderness, C-collar removed, patient able to move head without | |

| | |pain. | |

| | |Musculoskeletal: Tender to palpation lower left thigh. Unable to lift leg off bed. Pain with attempt to flex | |

| | |knee, able to wiggle toes. Sensation intact distally, pulse 1 + Dorsalis Pedis (DP) bilaterally. | |

| | |Neurological: Normal sensory, motor and speech observed. | |

| | | | |

| | |Medical decision making: X-ray report from Brentwood described distal femur fracture, will repeat X-ray here, | |

| | |start Pre-operative labs. | |

|06/05/YYYY |Provider’s name/Signature |Height and weight: |37 |

| | |Weight 51.5 kg, height 152.5. BMI 22.1 kg/m2. | |

|06/05/YYYY |Provider’s name/Signature |EKG: |85-87 |

| | |Normal sinus rhythm, with sinus arrhythmia, possible left atrial enlargement, left ventricular hypertrophy. | |

| | |Abnormal ECG. | |

|06/05/YYYY |Provider’s name/Signature |Orthopedic consultation for left knee pain: |120 |

| | |A 96-year-old female sent from nursing home after a slip and fall landing on her left leg with outpatient, X-ray| |

| | |showing left femur fracture, supracondylar. Patient denies numbness weakness or tingling in the left lower | |

| | |extremity, she denies hip or ankle pain, does complain of pain with range of motion or palpation of the left | |

| | |distal femur knee. Patient is demented unable to give detailed history. She states she typically is able to | |

| | |ambulate at the nursing home either with a walker or slowly on her own. She was not using her walker when she | |

| | |fell. Denies head injury or any other complaints. | |

| | | | |

| | |Physical examination: Vital signs stable. | |

| | |General: No acute distress, well-appearing. Non-labored Respirations, distal extremities well perfused, warm, | |

| | |cap refill less than 2 seconds, distal pulses 2+ and PT, DP and radial areas. | |

| | |Muscle skeletal: Left lower extremity: Tenderness to palpation over the left anterior distal femur, pain with | |

| | |range of motion of the left knee. Compartment is soft and thigh and calf. Sensation intact distally. Full range | |

| | |of motion at the ankle and foot. No hip pain with palpation or range of motion. | |

| | | | |

| | |Assessment: 96-year-old female left distal femur fracture after a slip and fall at the nursing home. | |

| | | | |

| | |Plan: X-rays left femur, knee, and hip. Long-leg splint to the left leg after X-rays. Non-weightbearing left | |

| | |lower extremity. Pain control. Admit to primary care physician. Will discuss with attending. | |

|06/05/YYYY |Provider’s name/Signature |X-ray chest: Unremarkable. |171 |

|06/05/YYYY |Provider’s name/Signature |X-ray femur: |171 |

| | |Views of the left femur show comminuted fracture in the distal end of the femur. The right hip shows | |

| | |degenerative arthritic changes. There are tiny metallic opacities in the area of the hip. | |

| | | | |

| | |Impression: Comminuted fracture distal left femur as described. | |

|06/06/YYYY |Provider’s name/Signature |Admission for left femur fracture: |126-128 |

| | |She was sent from Brentwood x Center after a trip and fall. The patient was complaining of pain. Mobile X-ray | |

| | |was performed and showed distal femur comminuted fracture. The patient was sent to ER where she was evaluated | |

| | |and admitted. Ortho was on consult. This morning, the patient is denying any new symptoms. The patient is very | |

| | |demented. I am unable to get any information. | |

| | | | |

| | |Medications: Adderall, Tramadol, Ibuprofen, Collagenase topical application to the wound. | |

| | | | |

| | |Examination: Extremities: No pitting edema. Pulses are positive bilaterally. There is right knee deformity, | |

| | |possible old fracture and left knee tenderness, on immobilizer. | |

| | | | |

| | |Laboratory data: Sodium 141, potassium 4.2, chloride 107, CO2 of 25, Blood Urea Nitrogen (BUN) 37, creatinine | |

| | |0.88, glucose 119. White Blood Cells (WBC) 13.0, hemoglobin 13.1, hematocrit 39.8, platelets 239. UA showed a | |

| | |large leukocyte. Chest X-ray negative, and femur shows comminuted fracture, distal femur. | |

| | | | |

| | |Assessment: | |

| | |1. Left distal femur fracture. | |

| | |2. Mechanical fall. | |

| | |3. Dementia. | |

| | |4. Hyperparathyroidism. | |

| | |5. Hypertension. | |

| | |6. Urinary tract infection. | |

| | | | |

| | |Plan: Admitted. Ortho on consult. She will be taken to OR for ORIF. She is medically cleared for surgery. | |

|06/06/YYYY |Provider’s name/Signature |Wound care notes: |164 |

| | |Patient’s labs; WBC 13, platelet 239. Patient with 3 full thickness ulcers on the Right Lower Extremity (RLE) | |

| | |secondary to a burn in Jan. YYYY. The proximal wound measures 1.5cm x 1cm x 0.1cm. Wound bed is 100% yellow | |

| | |moist slough. Peri-wound intact. No drainage. No clinical signs of infection. | |

| | | | |

| | |The RLE medial ulcer measures 3.4cm x 2.4cm x 0.2cm. Wound bed is 75% red granular tissue with multiple spots of| |

| | |yellow moist slough. Small amount of yellow non-purulent drainage present. Peri-wound skin intact. No clinical | |

| | |signs of infection. | |

| | | | |

| | |RLE distal ulcer measures 3cm x 1.6cm x 0.2cm. Wound bed is 75% red granular tissue with several spots of yellow| |

| | |moist slough. Small amount of yellow nonpurulent drainage present. Peri-wound skin intact. No clinical signs of | |

| | |infection. | |

| | | | |

| | |Recommendations: Continue daily application of Santyl ointment and saline moist gauze to RLE wounds. Patient to | |

| | |turn every 2hrs as tolerated and elevate heels. Patient’s RN informed. Patient to have surgery tomorrow. Will | |

| | |continue to follow. | |

|06/06/YYYY |Provider’s name/Signature |Orthopedic consultation for left femur fracture: |121-124 |

| | |Patient is doing overall very well for herself at the age of 96, but she does have advanced dementia, but she is| |

| | |overall mobilizing very well with the use of a walker. She was at rehab secondary to the wound care, and she | |

| | |suffered a fall. The patient, at this point in time, after suffering a fall has been diagnosed with a left | |

| | |distal femur fracture on radiographic evaluation. At this point in time, because of her mobilization in order to| |

| | |keep the patient overall mobilized, we will get the patient set up for surgical intervention for stabilization | |

| | |of the left femur fracture. The inherent risks and benefits of surgical intervention were fully explained to the| |

| | |daughter as well as the grandson on the phone this morning, call in their home number. The patient at this point| |

| | |in time is currently being treated for a UTI. The patient has been treated, placed on Rocephin. | |

| | | | |

| | |Examination: She has had underlying baseline confusion, but she is doing overall well. Overall, grossly large | |

| | |intact to her upper extremities. She does have dressings in place to her right leg from the underlying chronic | |

| | |wound, but she has no complaints pain to the right leg. She has no complaints of pain, range motion to the right| |

| | |hip, knee, or foot ankle region. On examination of the left lower extremity, she has no pain on range of motion | |

| | |of the left hip or of the foot and ankle region. She is markedly tender around the knee area. The patient’s | |

| | |calves and thighs are soft. She is nontender bilaterally. | |

| | |Her plain X-rays were reviewed, demonstrated displaced supracondylar femur fracture, extra-articular. | |

| | | | |

| | |Assessment: Displaced left femur fracture. | |

| | | | |

| | |Plan: The patient, at this point, will benefit stabilization of the again distal femur. We will take the patient| |

| | |down for surgical intervention and stabilization. | |

|06/06/YYYY |Provider’s name/Signature |Operative report for ORIF of left distal femur fracture: |128-131 |

| | | | |

| | |Pre and post operative diagnosis: Left distal femoral fracture, extra-articular. | |

| | | | |

| | |Procedure performed: Open reduction, internal fixation of left distal femur fracture. | |

| | | | |

| | |Components implanted: Zimmer locking plate series of proximal as well as distal locking screws. | |

| | | | |

| | |Patient’s disposition is stable to post op anesthesia recovery unit. | |

|06/06/YYYY |Provider’s name/Signature |X-ray femur: |171-172 |

| | |Indication: Postoperative images. | |

| | | | |

| | |Findings: A metallic plate is seen extending along the lateral aspect of the mid to distal left femur anchored | |

| | |by multiple screws proximally and distally with a plate extending across the comminuted fracture of the distal | |

| | |femur which is held in satisfactory position and alignment. | |

|06/07/YYYY |Provider’s name/Signature |Physical therapy notes: PT attempted evaluation, but as per RN Laura patient’s daughter was refusing therapy at |119, 117 |

| | |this time. | |

|06/07/YYYY-06/08/YY|Provider’s name/Signature |Cumulative progress notes: |132-134 |

|YY | |Dressings to lower left extremity clean/dry, CSM intact to LLE. Anticipate evaluation with PT; non weight | |

| | |bearing. Anticipate discharge to sub acute rehab, follow-up with X-ray in 10-12 days. | |

|06/08/YYYY |Provider’s name/Signature |Urine culture: |170 |

| | |Collected date: 06/05/YYYY. | |

| | |Result: Greater than 100, 00 CFU/ml Proteus Mirabilis, Extended Spectrum Beta Lactamase (ESBL) producer note – | |

| | |Implement contact precautions as soon as possible per infection prevention policy. | |

|06/08/YYYY |Provider’s name/Signature |Discharge summary: |125- |

| | |Discharge diagnoses: 1. Left distal femoral fracture, status post open reduction internal fixation. 2. | |

| | |Mechanical fall. 3. Dementia. 4. Hyperparathyroidism. 5. Hypertension. 6. Urinary tract infection. | |

| | | | |

| | |Hospital course: This patient was at the nursing home for subacute rehab. Patient was at the nursing home for | |

| | |physical therapy, slipped, fell, and broke her left distal femur, sent to the hospital, Ortho was put on | |

| | |consult. The patient was taken to OR and ORIF of the left leg was performed. The patient did well. The patient | |

| | |is going back for more physical therapy in stable condition with medication, see medication reconciliation. | |

| | |Discharge plan was explained to the patient and the family, who expressed understanding. | |

|06/05/YYYY – |Provider’s name/Signature |Other related records: | |

|06/08/YYYY | |Nursing Notes/Records, plan of care, assessment, sleep study, Medication Reconciliation Record, flow sheet, labs| |

| | | | |

| | |*Reviewer’s comment: These records are reviewed and contain no significant information relevant to the case; | |

| | |hence not elaborated. | |

| | | | |

| | |PDF Ref: 1-76, 107-118, 174-176, 137-139, 141-163, 165-170 | |

| |

|06/08/YYYY |Provider’s name/Signature |Nursing readmission assessment: |243-248, |

| | |Vitals: Temperature 97.8, pulse 76, respiration 20, Blood Pressure (BP) 116/60 mmHg. |433 |

| | |Active diagnosis in the last seven days: Dementia. | |

| | |Specific barriers to learning: Physical, age related issues. | |

| | | | |

| | |Physical evaluation: | |

| | |Neurological/cognition: Can recall staff names/faces, and she is in a nursing home. Decision making: Moderately | |

| | |impaired. | |

| | |Hearing/communication: Adequate. Clear speech, makes self understood. Understands clear comprehensions, vision | |

| | |adequate, pupils equal, wears glasses. | |

| | | | |

| | |Musculoskeletal: Mode of locomotion – Wheelchair. | |

| | |Functional limitations in ROM: Right (It should be left) leg surgery. | |

| | |Prior falls: Fell in the past 31-180 days. | |

| | |Balance (If not steady, complete fall risk evaluation): Not steady, only able to stabilize with human | |

| | |assistance. | |

| | |*Reviewer’s comment: Fall risk evaluation is not available for review. | |

| | |Device and restraints: Bed rails, half rails used. | |

| | | | |

| | |Gastrointestinal: Weight: 130 lbs. Appetite fair. | |

| | |Bowel continence: Occasionally incontinent. | |

| | |Urinary: Always continent, pain with urination. | |

| | | | |

| | |Pain evaluation: Occasional pain, received as needed pain medications. Pain score 6/10. | |

| | |Skin condition: Wounds, staples –leg 44 staple. | |

| | |Braden score: 16 | |

|06/08/YYYY |Provider’s name/Signature |Physician orders: |218-225 |

| | |Isolation for ESBL urine. | |

| | |Splint site: Left leg. | |

| | |Assess for pain every shift. | |

| | |May utilize tabs alarm and or low bed as fall precaution, may utilize side rails to promote bed mobility. | |

| | |PT/OT service: Evaluate and treat. Full weight bearing as tolerated. | |

| | |Skin assessment: Biweekly on Mondays and Thursdays. | |

| | | | |

| | |Medication order: Cipro 500 mg 1 tab per oral every 12 hrs for 5 days. Santyl topical | |

|06/08/YYYY |Provider’s name/Signature |Nurse daily notes: (Illegible notes) |417-418 |

| | |Skin concerns: Bilateral lower extremity abnormal skin color and turgor. | |

| | |Physical functioning: Extensive assistance and 1 person physical assist – Bed mobility, transfer, locomotion, | |

| | |toilet use. Independent with eating. | |

| | | | |

| | |Comments: Readmission from X - hospital via ambulance, alert, color fair, skin warm and dry to touch, breath | |

| | |sound clear, radial and brachial pulses fair, abdomen soft to touch, right leg multiple ___ skin, left leg | |

| | |surgical site, 44 staple, pedal pulse fair. Dr. XXX notified, order received. | |

| | | | |

| | |Night shift: Patient attempt to get out, redirected several times. Denies pain. Noted with dressing to left hip | |

| | |and bilateral legs with immobilizer to left leg. | |

| | |1240 hrs: Patient with 4 attempts to get up. Stating she has to get up, assisted to W/C. | |

|06/09/YYYY |Provider’s name/Signature |Physical therapy plan of care: |481-482 |

| | |Patient status post ORIF presented with decline in functional mobility status requiring skilled PT to maximize | |

| | |functional mobility independence. | |

| | | | |

| | |Medical history related to diagnosis/condition: She is re-admitted due to fall injury. Left distal femur | |

| | |fracture, femur rodding. Intramedullary Retrograde by Dr. Daniel XXXX. She burned her right LE on radiator, 2nd | |

| | |degree burn to right lower leg, hypertension, osteoarthritis, colon surgery and right toe surgery. | |

| | | | |

| | |Initial assessment: | |

| | |Functional deficits | |

| | |Prior level | |

| | |Current level | |

| | |anticipated | |

| | | | |

| | |Bed mobility, supine sit, sit-supine | |

| | |Modified independent | |

| | |Moderate assist (50% assist) | |

| | |Modified independent | |

| | | | |

| | |Gait, distance | |

| | |30 feet | |

| | |unable | |

| | |50 feet | |

| | | | |

| | |Gait assistive device | |

| | |Front wheeled walker | |

| | |None | |

| | |Front wheeled walker | |

| | | | |

| | |Gait, level surface | |

| | |Stand by assist (supervision) | |

| | |Total assist (100% assist) | |

| | |Stand by assist (supervision) | |

| | | | |

| | |Transfers, bed/chair | |

| | |Stand by assist (supervision) | |

| | |Max assist (75%) | |

| | |Stand by assist (supervision) | |

| | | | |

| | |Transfers, sit-stand, stand-sit. | |

| | |Stand by assist (supervision) | |

| | |Total assist (100% assist) | |

| | |Stand by assist (supervision) | |

| | | | |

| | |Wound dressing dry and intact around right lower leg as well as wound dressing on the surgery site on the left | |

| | |knee and distal femur with noted minimal swelling. She reports an unrated pain on the LLE upon movement. LLE ROM| |

| | |and manual muscle testing is not tested except for left ankle within normal limits and with muscle strength 3+/5| |

| | |on the ankle. | |

| | | | |

| | |Rehab potential: Good due to: Able to follow 2 step directions. Demonstrated higher functional level compared to| |

| | |current condition. | |

| | | | |

| | |Requires skilled services to focus on: PT evaluation, therapeutic exercise, neuromuscular reeducation, gait | |

| | |training, group therapy, and therapeutic activities. | |

| | |Frequency/Duration: 5 times a week for 12 weeks | |

|06/09/YYYY |Provider’s name/Signature |Readmission skin assessment: |437 |

| | |Noted right upper extremity bruises, abdominal bruises, left lateral thigh surgical incision, well approximated | |

| | |with 40 intact staples. Left heel blanchable redness. | |

| | | | |

| | |Right leg burns. Right upper anterior leg burns approximately 1.5 x 1, 85 % red tissue, 15 % yellow slough, | |

| | |scattered. Right lower anterior leg burns approximately A – 3 x 2.5x0.4, B – 3 x 1.6 x 0.4, 85% red tissue 15% | |

| | |scattered yellow slough. MD aware. | |

| | | | |

| | |1000 hrs: Message left on Sylvia’s voice mail concerning right leg wounds. | |

|06/09/YYYY-06/12/YY|Provider’s name/Signature |Cumulative daily nursing notes: (Illegible notes) |409-416 |

|YY | |06/09/YYYY: Alert and oriented x 2, confusion at times. Dressing to left femur, immobilizer intact. Tramadol 150| |

| | |mg given for pain 8/10, ___ with verbal moaning. Antibiotics Cipro per oral x 5 days every 12 hrs. Decreased | |

| | |balance, ___ alarms related to high fall risk. Contact isolation related to positive ESBL urine. (Ref -416 ) | |

| | | | |

| | |06/12/YYYY: Spoke with POA Sylvia X about leg wounds. (Ref -437 ) | |

|06/12/YYYY |Provider’s name/Signature |Physician progress notes: |216 |

| | |Patient was seen and examined, feels ok. | |

| | | | |

| | |Assessment and plan: Generalized weakness. Status post ORIF. Continue mediations, PT, OT, fall precautions. | |

|06/09/YYYY-06/13/YY|Provider’s name/Signature |Medication Reconciliation Record: |526 |

|YY | |Cipro 500 mg 1 tab every 12 hrs given from 9th June to 13th June. | |

|06/13/YYYY-06/19/YY|Provider’s name/Signature |Cumulative daily nursing notes: (Illegible notes) |395-408, |

|YY | |06/15/YYYY: Skin: Bruise left ischium. |437 |

| | |Patient was a transfer from joint unit. Patient received in __ with complaints of left leg, given Tramadol, left| |

| | |leg brace intact. (Ref -404). | |

| | | | |

| | |06/16/YYYY: Has intermittent pain, left ischium bruise noted. (Ref -402 ) | |

| | | | |

| | |06/19/YYYY: No complaints. Urine specimen collected and ready for pick up. (Ref -396 ) | |

| | |Wound assessed by _________ no new orders. (Ref -437 ) | |

|06/19/YYYY |Provider’s name/Signature |Weekly wound management notes: (Illegible notes) |449-451 |

| | |Wound # 1: Right leg ___ulcer – 3 x 3 x 0.4; 3 x 1.5 x 0.4. 76-100% granulation. | |

| | | | |

| | |There is less sludge on the shin compared to previous. No infection, minimal maceration, no erythema, will use | |

| | |enzymatic ___. | |

|06/20/YYYY |Provider’s name/Signature |Occupational therapy progress notes: |517-518 |

| | |Start of care: 06/09/YYYY. | |

| | |Functional deficits: ADL self care, functional transfers, toilet, ADL self care, upper body dressing, lower body| |

| | |dressing, grooming, bathing. | |

| | |Anticipated level: Stand by assist (supervision). | |

| | | | |

| | |Patient continues to require skilled OT services to focus on: Therapeutic exercise, neuromuscular reeducation, | |

| | |therapeutic activities, cognitive Skills development, self care/home management training. | |

| | |Analysis of functional outcome / clinical impression: Increase in lower body ADLs with use of adaptive | |

| | |equipment. | |

| | |Skilled services provided since last report: Compensatory strategy/Adaptive Equipment Training With ADLs. | |

| | | | |

| | |Impact on burden of care / daily life: Complicating factors, including decreased mobility, balance, and muscle | |

| | |strength prevent the patient from achieving all established goals. | |

| | |Updates to treatment approach: Continue with OT plan of care for increased ADLs. | |

| | |Precautions: Full code; Falls, NWB on the LLE, LLE immobilizer, ESBL Urine. | |

| | | | |

| | |Prognosis: Good due to cooperation. | |

| | |*Reviewer’s comment: The initial OT evaluation is not available for review. Only the OT progress notes and | |

| | |discharge summary is available for review. | |

|06/20/YYYY-06/26/YY|Provider’s name/Signature |Cumulative daily nursing notes: |379-394, |

|YY | |06/20/YYYY: Complaints of pain to left leg, medicated with Tramadol. (Ref -394 ) |229-231, |

| | | |195, 228 |

| | |06/21/YYYY: Received VM from patient’s daughter requesting status of cultures. Contacted lab and received | |

| | |results to date. ESBL negative x 1 with 2 week culture pending but due Sunday evening. Informed no growth of 2nd| |

| | |culture so far. (Ref -391) | |

| | |Out to MD appointment for surgeon follow-up related to LLE for staple removal. Patient returned to facility with| |

| | |orders from Surgeon to remain non weight bearing to LLE. (Ref -390) | |

| | | | |

| | |Labs: Urine culture: Mixed urogenital flora, not indicative of infection. (Ref -229, 231) | |

| | | | |

| | |06/25/YYYY: Labs: Urinalysis (collected date 06/21/YYYY) – Cloudy, small leucocytes. Microscopic – Many | |

| | |bacteria, few yeast. (Ref -228 ) | |

| | |Urine culture: Mixed urogenital flora, not indicative of infection. | |

| | | | |

| | |06/25/YYYY: Room change – Off isolation. (Ref -195 ) | |

|06/26/YYYY |Provider’s name/Signature |Weekly wound management notes: |478-480 |

| | | | |

| | |Site | |

| | |Size | |

| | |Granulation | |

| | | | |

| | |Right lower anterior leg A | |

| | |3 x 3 x 0.2. | |

| | |76-100% granulation. | |

| | | | |

| | |B | |

| | | | |

| | |76-100% granulation | |

| | | | |

| | |Right upper anterior leg. | |

| | |1.6 x 1 | |

| | |76-100% granulation | |

| | | | |

| | | | |

| | |Despite advance age and non compliance the wound have less slough but some areas are deeper due to debridement, | |

| | |protect peri-wound area, avoid trauma, try to decrease full frequency. | |

|06/22/YYYY-06/30/YY|Provider’s name/Signature |Physician progress notes: |212, 214 |

|YY | |Was seen and evaluated, feels ok. | |

| | |Continue medications, PT, OT. Follow-up with Ortho. Fall precautions. | |

|06/30/YYYY |Provider’s name/Signature |Physician order: |222 |

| | |Right lower anterior leg cleanse apply foam and Kerlix daily as needed. | |

|06/27/YYYY-07/03/YY|Provider’s name/Signature |Cumulative daily nursing notes: |365-378, |

|YY | |07/02/YYYY: Patient fit with new ROM hinged knee brace. The brace feels much better and she was pleased with the|210 |

| | |fit. (Ref -201 ) | |

| | | | |

| | |07/03/YYYY: Patient up at side of bed restless throughout the night, no distress noted. Immobilizer to left leg | |

| | |in place. ADLs rendered by staff x 1 person assist. (Ref -366 ) | |

|07/03/YYYY |Provider’s name/Signature |Weekly wound management notes: |475-477 |

| | |Overall improving site, no signs of infection. The wounds are shrinking, will continue to monitor. | |

|07/04/YYYY-07/10/YY|Provider’s name/Signature |Cumulative daily nursing notes: (Illegible notes) |350-364 |

|YY | |07/07/YYYY: Complaints of increased diarrhea that stated this morning, she stated that it was caused by ___ that| |

| | |she may have taken. Refused need for the afternoon states she was to make sure her stomach settles first. (Ref | |

| | |-358 ) | |

|07/10/YYYY |Provider’s name/Signature |Weekly wound management notes: (Illegible notes) |472-474 |

| | |Site | |

| | |Size | |

| | |Granulation | |

| | | | |

| | |Right upper anterior leg | |

| | |Healed | |

| | |76-100% granulation. | |

| | | | |

| | |Right lower anterior leg A | |

| | |2 x 2 | |

| | |76-100% granulation | |

| | | | |

| | |B | |

| | |2 x 1 | |

| | |76-100% granulation | |

| | | | |

| | | | |

| | |The wounds are shrinking in size. No signs of infection or maceration. Will ___ drainage, protect peri-wound | |

| | |area. | |

|07/11/YYYY-07/17/YY|Provider’s name/Signature |Cumulative daily nursing notes: |337-350 |

|YY | |Left leg immobilizer in place, no distress noted. Continent of bowel and bladder. No complaints. | |

|07/17/YYYY |Provider’s name/Signature |Weekly wound management notes: |469-471 |

| | |Site | |

| | |Size | |

| | |Granulation | |

| | | | |

| | |Right lower anterior leg A | |

| | |1.9 x 1.8 | |

| | |76-100% granulation. | |

| | | | |

| | |B | |

| | |1.5 x 1 | |

| | |76-100% granulation | |

| | | | |

| | | | |

| | |No recent trauma. The edges of the wounds are healthy. No peri-wound erythema or maceration. | |

|07/17/YYYY-07/24/YY|Provider’s name/Signature |Cumulative daily nursing notes: |325-336 |

|YY | |Left leg immobilizer in place, no distress noted. Continent of bowel and bladder. No complaints. | |

|07/24/YYYY |Provider’s name/Signature |Physician orders: Apply left leg immobilizer at all times, except for hygiene and skin inspection. |223 |

|07/24/YYYY |Provider’s name/Signature |Weekly wound management notes: |466-468 |

| | |Site | |

| | |Size | |

| | |Granulation | |

| | | | |

| | |Right lower anterior leg A | |

| | |1.5 x 1.5 | |

| | |76-100% granulation. | |

| | | | |

| | |B | |

| | |1.5 x 1 | |

| | | | |

| | | | |

| | | | |

| | |More granulation tissue. No signs of infection, avoid trauma. | |

|07/24/YYYY-07/31/YY|Provider’s name/Signature |Cumulative daily nursing notes: |309-324 |

|YY | |Patient alert and oriented with periods of confusion. Denies any pain or discomfort, immobilizer on to left leg.| |

| | |Remains in stable condition. | |

|07/31/YYYY |Provider’s name/Signature |Weekly wound management notes: |463-465 |

| | |Site | |

| | |Size | |

| | |Granulation | |

| | | | |

| | |Right lower anterior leg A | |

| | |1.5 x 1.5 | |

| | |76-100% granulation. | |

| | | | |

| | | | |

| | |The edges of the wounds are well or the bases of the wounds are well demarcated. | |

|08/01/YYYY-08/16/YY|Provider’s name/Signature |Cumulative daily nursing notes: |277-308 |

|YY | |Non productive cough and sore throat from 08/05/YYYY – 08/07/YYYY, medicated with Robitussin 10 ml with good | |

| | |results. | |

|08/03/YYYY-08/17/YY|Provider’s name/Signature |Physician progress notes: |204, 206, |

|YY | |Was seen and evaluated, feels ok. |207 |

| | |Continue medications, PT, OT. Follow-up with Ortho. Fall precautions. | |

|08/16/YYYY |Provider’s name/Signature |Occupational therapy discharge: |515-516 |

| | |Start of care: 06/09/YYYY. End of care: 08/16/YYYY. | |

| | | | |

| | |Analysis of functional outcomes/clinical impression: The patient did not make significant progress towards goal.| |

| | | | |

| | |Skilled services provided since last report: Compensatory strategy training with ADLs. | |

| | |Patient / caregiver training: Safety training with transfers with use of DME. | |

| | |Impact on burden of care / daily life: Complicating factors, including weakness, decreased endurance and balance| |

| | |prevent the patient from achieving all established goals. | |

| | |Precautions: Full code; Falls, NWB on the LLE, LLE immobilizer, ESBL Urine. | |

| | | | |

| | |Discharge plans: Patient will remain at Brentwood. Discharge from skilled OT to routine restorative program for | |

| | |BUE AROM exercises 10 x l set, all joints as tolerated by patient, 6 x / week for 4 weeks. | |

|08/17/YYYY-08/30/YY|Provider’s name/Signature |Cumulative daily nursing notes: |251-276 |

|YY | |Alert and verbal with periods of confusion noted. No complaints of pain. Brace in place to LLE. Dressings placed| |

| | |to wound RLE. | |

|08/07/YYYY – |Provider’s name/Signature |Cumulative weekly wound management notes: |452-462 |

|08/28/YYYY | |Site | |

| | |Size | |

| | |Granulation | |

| | | | |

| | |Right lower anterior leg A | |

| | |1 x 1 | |

| | |76-100% granulation. | |

| | | | |

| | |B | |

| | |0.5 x 0.5 | |

| | |76-100% granulation. | |

| | | | |

| | | | |

| | |Wounds improving overall. No signs of infection. The wounds are shrinking. Avoid trauma, follow and support | |

| | |nutrition and hydration. | |

|08/30/YYYY |Provider’s name/Signature |Nurse notes: Wound care |438 |

| | |3 day supply of treatments given to patient with dressing change instructions for home. | |

|08/31/YYYY |Provider’s name/Signature |Nursing discharge note: |249-250 |

| | |Alert, verbal, no complaints, up in wheel chair, ate well, no distress noted. Discharge instructions given to | |

| | |patient with her understanding along with supply of medications and instructions and belongings taken with. | |

| | |Ambulance her at 2 pm and patient discharged to home. | |

|06/01/YYYY-08/31/YY|Provider’s name/Signature |Flow sheet-Wound treatment |439-445 |

|YY | | | |

| | |*Reviewer's comments: The significant details have already been elaborated in the chronology; hence this record| |

| | |is not summarized. Can be included if required. | |

|06/08/YYYY – |Provider’s name/Signature |Other related records: | |

|08/31/YYYY | |Patient's Information, medical bills, orders, OT progress notes. | |

| | | | |

| | |*Reviewer’s comment: These records are reviewed and contain no significant information relevant to the case; | |

| | |hence not elaborated. | |

| | | | |

| | |PDF Ref: 190-192, 226-227, 177-189, 218-225, 196-201, 437-438, 520-532, 483-484, 489-492, 495-496, 498-519 | |

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