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PATIENT NAE: JOHNSON, Walter E PATIENT NUMBER EDCase014 LOCATION: Emergency Room ED PHYSICIANS Benjamin Baker, MD DATE OF SERVICE 08-31-YYYY DATE OF BIRTH 01-00.YYYY Physician Notes: This man struck his head on some rocks on the bottom of a swimming pool. This caused a laceration in a jagged manner 4 cms long and 1 cm deep, requiring 7 sutures to close. He had a contusion of the left wrist also. X-rays were taken of the wrist, cervical spine and skull and I could see no evidence of fractures. He was cautioned to take it easy, use ice on his head and return to his family physician in 6-8 days for suture removal. Diagnosis: Cerebral concussion: laceration of scalp and forehead. Physician Orders: X-rays, skull, C-spine, and L wrist SIGNATURE OF ED PHYSICIAN Benjamin Baker Benjamin Baker MO DO 05 31.YYYY DT 09.01.YYYY PATIENT NUMBER EDCase014 PATIENT INFORMATION: NAME JOHNSON, Walter ADORES 35 Pinetops Lane cm Alfred STATIO NY ZIP CODE 14802 ADMISSION DATE & THE 08-31-YYYY 1415 DISCHARGE DATE TIME 08-31-YYYY 1510 CONDITION ON DISCHARGE Satisfactory Home Inpatient Admission Transfer to Instruction Sheet Glen THLETIONE 0 AMA ород Code Blue Died 607-5873257 Male 01.00-YYYY GENDER DATE OFW EXPLAIN NURSING DOCUMENTATION: ALL 2 NO OY ROMAIN NKA CINEMATO No Yes 120/72 72 Lacerations, forehead – dove into water and hit bottom. Pain, left wrist. P 16 т CO CONDITION ASAWAMU 4 X 1 cm laceration, forehead, requiring 6 sutures. Left wrist sore and swollen, painful to move. Gail Watson, RN SIGNATURE OF PRAY CARE NUWE сглискую псис