23h 45min, aug 29, 2014 y - MEDICAL NOTES
Amber Heard
Nurse Erin
Description:
The unpublished Medical Progress Notes appeared on screen during the televised trial - the text is taken from the screen grabs as the Medical Notes were not published or leaked to the public.
[FIRST TWO PARAGRAPHS REDACTED]
2345 Client, RN, and Debbie, RN went to dinner together. Ct demonstrates good appetite. Drinks 2-3 glasses red wine, No water consumes as ct "prefers only bottled water." RN encouraged ct to adequately hydrate upon returning to hotel where bottled water is available. Ct agrees to do so and verbalizes understanding for necessity of adequate hydration especially due to dehydrating effects of wine and also medication regimen. RN also educates client that alcohol intake can effect prescribed medication, including new medication Latuda. Ct states she understands but continued to consume wine. Ct discussed individual and couples therapy with RN and states she "looks forward to it." 1:1 emotional support and positive reinforcement given. Ct verbalizes feelings of confusion as she feels fiancé would like her to decrease/eliminate acting career and stay at home. Ct wishes to continue working and expresses feelings of fulfilment from career. Ct will have individual therapy session with Dr. Cowan tomorrow at 1800, and RN encouraged her to discuss feelings with him. RN discussed Neurontin with ct per prior request. RN educated ct on necessity of steady blood level of medication for maximum effectiveness, along with ct's typical wake/sleep schedule. Plan was determined to administer Neurontin q 6-8hr. Ct will take Neurontin 100mg an hour after waking, then Neurontin 100mg 6-8 hr after first dose, then Neurontin 300mg at bedtime. Ct verbalizes understanding and is agreeable to this plan. RN offers to notify ct at administration times to assist in establishing medication schedule, but ct declines stating, "it's ok, I will remember." Dr. Kipper is made aware of Neurontin dosing administration change. Ct appeared to enjoy socializing with both nurses during evening. Ct's mood has remained stable throughout day. She responds well to positive reinforcement along with distraction and relaxation techniques. Ct verbalizes desire to increase exercise and to specifically start yoga. RN will continue to encourage ct to achieve this goal. RN offered to provide ct with three day's worth of medication in case she would like privacy during the weekend. Ct declined and took only the pill box for tomorrow. Ct states, "it's ok, you are nearby and I'd like to see you anyway." Ct has bedtime medication with her and has retired to room.
SOURCE: US VA Court Documents: - US VA AMBER EXHIBIT 1052 - Boerum - nursing notes, 7/31/14-8/24/14 - US VA AMBER EXHIBIT 1053 - Boerum - nursing notes, 8/27/14 - 5/11/16 - US VA AMBER EXHIBIT 1054 - Boerum - nursing notes, 8127/14 - 8/29/14 - US VA AMBER EXHIBIT 1055 - Boerum - nursing notes, 4/7/16 6/28/16 - US VA AMBER EXHIBIT 1056 - Boerum - nursing notes, 9/1/14 - 10/31/14
