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CorrecUonal Health Ser~ces

JORDAN, GIGINYSID: o6836766Q BookCasc: 7011000006

Facility Code: RMSC Hol;sing Area: 8A50 Y old Female, DOB: 12/o2/196o

CENTRAL PARK ~EST, 818, MANHAUFEN, NY-loo23Home: ooo-ooo-oooo

Insurance: Self Pay

O3/28/2Oll Jesika Asaro

Current MedicationsAspirin EC Tablet Delayed Release 8~ MG ~tab Daily, stop date o4/2o/2o~Lamotrigine Tablet a5 MG ~ tab At Bedtime+2 tab QAM, stop date o3/3o/2ox~Benadryl Capsule 25 MG 1 cap At Bedtime,stop date 03/3o/20~1Montelukast Sodium Tablet lO mg ~ tabDaily, stop date o4/ao/2o1~Qvar Aerosol Solution 40 MCG/ACT iiinhalations bid po Every m Hours, stop dateo5/23/~o~A]buterol Sulfate HFA Aerosol Solution lO8(9o Base~ MCG/ACT 2 puffs Every 6 Hours-Refill/RenewalMultivitamins Tablet app ~ tab Daily, stopdate o5/2o/2o11Ibuprofen Tablet 4oo MG I tab Every. 8Hours/prn, stop date o3/28/2oIiOmeprazole Capsule Delayed Release 20 mg Icap Daily, stop date 04/22/2011Calcium Carbonate Tablet ~25o MG I tabEvery m Hours, stop date O5/22/2011Co]ace Capsule Ioo mg I cap Every 12 Hours,stop date 05/22/2011

Past Medical HistoryChickenpoxPSYCHOSIS NOSAnxiety disorder NOSAdjustment disorder with mixed emotionalfeatures

AllergiesCipro: hives: Allergy

Reason for Appointment1. MH Clinicians Progress Note

History of Present IllnessSUBJECTIVE:

Subjective = Patient states, " Im busy busy busy," and contines tooffer no complaints at this time, indicating adequate sleep,socialization, appetite, use of free time, active involvement in variouslegal circumstances, and compliance with medications with goodeffect.

ExaminationOBJECTIVE:

Objective: = Pt scheduled this date for FU. Pt sitting calmly andappropriately for interview.MENTAL STATUS:

Appearance: = Chronological Age,Normal Weight,WellGroomed,Well Dressed. Mood: = Euthymic (Normal Range). Affect: =Appropriate,Full Range. Impulse control: = Adequate. Thoughtprocess: = Spontaneous,Organized,Relevant,Goal Directed. Perceptualdisturbance: = No Perceptual Distortions. Suicidal: = No SuicidalThoughts. Homicidal: = No Homicidal Thoughts. Insight: = SlightAwareness of Illness,Aware Accepts Treatment. Judgment: =Adequate.RISK ASSESSMENT:

Risk Assessment Does patient have suicidal/homicidal thoughts:No, Does patient have suicidal/homicidal intent: No, Does patient havea suicidal/homicidal plan: No, Is the patient imminently suicidal(consider hospitalization): No, Is the patient potentially suicidal?(Consider Mental Observation Housing) Yes, If so, what factors mayprecipitate an attempt:, What precautions are being taken to minimizerisk: Pt seen more frequently, housed in PC w/peers and officerspresent at all times. Pt compliant w/medications/therapyrecommendations., Some risk factors for suicide: Crime committed isshocking,Held position of respect,Previous suicide attempt,Shame andguilt,No feelings inside,Significant loss, Protective Factors: CopingSkills,Values / Prohibitions,Good past response to stress,Capacity forreality testing,Hope for future,Engagement with treatment,.

AssessmentsAxis I: Mood Disorder NOS.

Patient: JORDAN, GIGI DOB: Iz/o~/,96o Progress Note: Jesika AsaroNote generated by eGIinicalWorks EMR/F~M Software (www.eGIinica/Works com)

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Axis II: Diagnosis DefenedAxis III: Asthma NOSAxis IV: IncarcerationAxis V: 60ASSESSMENT:Pt continues to present as stable, alert, Ox3 withnormal psychomotor activity, good eye contact and speechunremarkable. Pt presents as well-related, cooperative, pleasant,and engaged.

Disposition: GP with MH follow up-Clinician/Psychiatrist

Electronically signed by Jesika Asaro on o3/28/2011 at 10:o9A~I EDT

Sign offstatus: Completed

Rose M0 Singer Center~9-~9 Hazen Street

East Ehnhurst, NY i 137oTel:Fax:

Patient: JORDAN, GIGI DOB: 1"2/o2/196o Progress Note: Jesika Asaro

Note generated by eClinicalWorl~s EMR/PM Software (www. eClinicatWorks.com)

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Correctional Health Settees

JORDAN, GIGINYSID: o6836706Q BookCasc: 7o ! iooooo6

Facility Code: RMSC Housing Area: 8A5o Y old Female, DOB: t2/o2/~96o

CENTRAL PARK ~rEST, 8~8, MANHATI~EN, NY-loo23Home: ooo-ooo-oooo

Insurance: Self Pay

03/22/2Oll Harold Charles, PA

Current MedicationsAspirin EC Tablet Delayed Release 8~ MG ~tab Dally, stop date o4/2o!~o~1Co]ace Capsule too mg ~ cap EyeD 12 Hours,stop date o3/27/2o~Calcium Carbonate Tablet ~5o MG 1 tabEvery 12 Hours, stop date o3/~7/~oHLamotrigine Tablet ~5 MG ~ tab At Bedtime+a tab QAM, stop date o3/3o/2o~Benadryl Capsule 25 MG ~ cap At Bedtime,stop date o3/3o/2m~Clonazepam Tablet o.5 MG ~ tab Twice a Day,stop date o3/~/~o~Montelukast Sodium Tablet ~o mg ~ tabDaily, stop date o4/2o/2o1~Qvar Aerosol Solution 40 MCG/ACT iiinhalations bid po Every 1~ Hours, stop dateO5/23/2OllA!buterol Sulfate HFA Aerosol Solution zo8(9o Base) MCG/ACT 2 puffs Every 6 Hours-Refill/RenewalMultivitamins Tablet app ~ tab Daily, stopdate 05/20/20~

Past Medical HistoryChickenpoxPSYCHOSIS NOSAnxiety disorder NOSAdjustment disorder with mixed emotionalfeatures

AllergiesCipro: hives: Allergy

Reason for Appointmentz. Medication follow-up~. " I am fine with my reeds". Pt. here for Klonopin renewal--- nocomplaints.

History of Present IllnessTEMPLATES:

Psychiatry - Medication Reevaluation.SUBJECTIVE:

Subjective = Pt coping well.,

ExaminationOBJECTIVE:

Objective: =, Pt appears to be functioning well on the unit.MENTAL STATUS:

Appearance: =, well groomed, Pt Alert & O x 3. Behavior: =Cooperative,Accessible,Good Eye Contact. Mood: = Euthymic (NormalRange). Affect: = Appropriate. Impulse control: -- Adequate. Thoughtprocess: = Spontaneous,Organized. Thought content: = Normal.Perceptual disturbance: = No Perceptual Distortions. Suicidal: = NoSuicidal Thoughts. Homicidal: = No Homicidal Thoughts. Insight: =Aware Accepts Treatment. Judgment: =, fair.MEDICATION SIDE EFFECT:

Medication Side Effect Medication Side Effect: No,.PATIENT EDUCATION - SIDE EFFECTS:

Patient education - side effects -Patient education provided on sideeffects of proposed medication: Yes,.MEDICATION COMPLIANCE:

Medication Compliance =, good 67 %..CHANGE IN MEDICATION:

Change in Medication Change in medication regimen: None,.

Assessments~. Mood disorder NOS - 296.90 (Primary)

Treatmentx. Mood disorder NOSRefill Clonazepam Tablet, o.5 MG, ~ tab, Orally, bid, 5 days, ~o, Refillso

2. Others

Patient: ,JORDAN, GIGI DOB: nz/o2/19()o Progress Note: Harold Charles. PANote generated lay eCiinicalWorks EMR/PM Software (www.eOlinicalWork$. corn)

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Stop Clonazepam Tablet, 0.5 MG, 1 tab, Orally, Twice a Day, 5 days,

Follow Up5 days.

Disposition: GP with MH follow up-Clinician/PsychiatristNotes: Pt. seen and reed renewed.

Electronically signed by Harold Charles PA on o3/22/2Oll at05:36 PM EDT

Sign offstatus: Completed

Rose M. Singer Center19-19 Hazen Street

East Ehnhurst, NY t137oTel:Fax:

Patient: JORDAN, GIG1 DOB: 12/o2/196o Progress Note: Harold Charles, PA o3/22/2o! I

Note genera ted by eC#nicalWorks EMR/PM So~va re (www. e CtinlcatWorks. corn)

http://l 0.131.61.134: 8080imobiledoc/jsp/catalog/xml/printChartOptions.j sp?encounterlD=... 3/29/2011

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JORDAN, GIGINYSID: o6836766Q BookCase: 70!iOOOOO6

Facility Code: RMSC Housing Area: 8A5o Y old Female, DOB: 12/O2/1960

t CENTRAL PARK VvEST, 818, MANHAI~EN, NY-too23Home: ooo-ooo-oooo

lnsllrallee: Self Pay

O3/17/2Oll Barbara O Connell, MD

Current MedicationsAspirin EC Tablet Delayed Release 81 MGtab Daily, stop date o4/~0/~o~Monte]ukast Sodium Tablet ~o mg I tabDaily, stop date o4/20/2011Colaee Capsule mo nag I rap Every ~ 2 Hours,stop date 03/aT/aOnCalcium Carbonate Tablet 1250 MG i tabEvery ~ Hours, stop dateQvar Aerosol Solution 40 MCG/ACT iiinhalations bid po Every ~2 Hours, stop date05/23/2011Lamotrigine Tablet 95 MG ~ tab At Bedtime+2 tab QAM, stop date 03/3o/2o]~Benadryl Capsule 25 MG ~ cap At Bedtime,stop date 03/30/20H

Past Medical HistoryChickenpoxPSYCHOSIS NOSAnxiety disorder NOSAdjustment disorder with mixed emotionalfeatures

AllergiesCipm: hives: Allergy

Reason for Appointment1. Medication follow-up

History of Present IllnessTEMPLATES:

Psychiatry - Medication Reevaluation.SUBJECTIVE:

Subjective = Says she feels calm and her mood is stable on themedication program. She is here for medication renewal.,

ExaminationOBJECTWE:

Objective: =.MENTAL STATUS:

Appearance: = Chronological Age,Normal Weight. Behavior: =Cooperative,Relates Well,Accessible,Good Eye Contact. Mood: =Euthymic (Normal Range). Affect: = Appropriate. Impulse control: =Adequate. Thought process: = Spontaneous. Thought content: =Normal. Perceptual disturbance: = No Perceptual Distortions.Suicidal: = No Suicidal Thoughts. Homicidal: = No HomicidalThoughts. Insight: = Aware Accepts Treatment. Judgment: =Adequate.MEDICATION SIDE EFFECT:

Medication Side Effect Medication Side Effect: No,.PATIENT EDUCATION - SIDE EFFECTS:

Patient education - side effects -Patient education provided on sideeffects of proposed medication: Yes,.MEDICATION COMPLIANCE:

Medication Compliance =.CHANGE IN MEDICATION:

Change in Medication.

AssessmentsL Mood disorder NOS - 296.90

Treatment~. Mood disorder NOSRefill Clonazepam Tablet, 0.5 MG, ~ tab, Orally, Twice a Day, 5 days

Disposition: GP