12 h, sep 4, 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The unpublished Medical Progress Notes appeared on screen during the televised trial - the text is taken from the screen grabs as the Medical Notes were not published or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.

Ct awake at 0900. Reports sleeping soundly from 0300 to 0900. Woke without difficulty this morning. Denies lethargy, fatigue, or "grogginess." Dr. Kipper notified of dosage reduction effectiveness. RN confirmed with ct that she will continue Neurontin 400mg two hours prior to bedtime, as dose was effective. Ct spent day participating in online college course, attending a meeting, and studying. Ct self-administered all medications at proper times without prompting. Ct, RN out for shopping with ct's assistant and Debbie, RN this evening per ct's request. Ct ate dinner with RN at 2100 at restaurant. Ct became frustrated with wait staff over miscommunication; ct calmly repeated herself to staff to resolve issue. Ct expressed frustration after conflict to RN. RN reflected change in coping mechanisms as ct's previous coping skills involved impulsive anger and yelling. Ct able to acknowledge ability to process conflict and expressed pride in healthy conflict resolution. Ct had small piece fish and salad at home at 2330. RN discussed eating small, frequent meals throughout the day with ct as she tends to have limited amount of food during daytime and consumes most of her daily calories 1-3 hours prior to bedtime. Ct is social, affect and mood appropriate. States minimal anxiety. Ct expresses appreciation of RN's presence and assistance, and reports that she "is feeling great" with her current medication regimen. Positive reinforcement given. Manual BP 96/50 left arm while sitting, P 78. RN has created chart of VS for ct so she is able to determine baseline VS. Ct expresses much interest in well-being. Ct plans to fly to [..New York in a day or two?]


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

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