Performing Lab Sites

[634] SACRAMENTO VA MEDICAL CENTER [CLIA# 05D0988241]

 10535 HOSPITAL WAY MATHER, CA 95655-4200

SCL1 - PSA

Collection DT Spec Lab PSA

07/25/2019 10:35 SERUM [634] 1.04

08/06/2015 13:38 SERUM [634] 0.79

07/16/2014 11:17 SERUM [634] 0.68

05/13/2010 11:26 SERUM [634] 0.69

Performing Lab Sites

[634] SACRAMENTO VA MEDICAL CENTER [CLIA# 05D0988241]

 10535 HOSPITAL WAY MATHER, CA 95655-4200

SCLU - TSH

Collection DT Spec Lab Tsh

08/20/2020 10:35 SERUM [634] 3.51

07/25/2019 10:35 SERUM [634] 2.64

Performing Lab Sites

[634] SACRAMENTO VA MEDICAL CENTER [CLIA# 05D0988241]

 10535 HOSPITAL WAY MATHER, CA 95655-4200

A/p:

1. L knee pain s/p 3 surgeries, pain is now worsening, pt is SC for this. 

-update xray, then refer to ortho for further eval/treamtmentn as ongoing issue 

for years and worsening

-NSAID PRN, use sparingly to avoid HTN

-diclofenac gel PRN

-will bring FMLA paperwork to appt with RNCM to fill out

2. Cough: likely PND, encourage hydration and flonase PRN

3. Cramp in extremities: likely related to dehydration, also a pilot

-encourage water hydration, pt agrees with plan

-check CMP

4. L cataract: will f/u with eye clnic

5. Elevated BP w/o HTN: advise to rest 10-15 min before checking BP, and will 

make log this week. F/u with RNCM in 1 week f2f for repeat BP check and will 

eval if HTN med needed. 

-foods to avoid discussed, as well as use NSAID sparingly

-likely stress induced

HCM:

Colon Ca screening: last Cscope done 2011 and wnl, will order FIT test now

Labs pending

Immunizations: refused flu and covid booster

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APPENDIX 656

5. Elevated BP w/o HTN: advise to rest 10-15 min before checking BP, and will

make log this week. F/u with RNCM in 1 week f2f for repeat BP check and will 

eval if HTN med needed. 

-foods to avoid discussed, as well as use NSAID sparingly

-likely stress induced

Case 4:22-cv-00343-Y Document 239-16 Filed 04/26/24 Page 1 of 46 PageID 7335
will make f2f with RN CM for BP check and drop off paperwork. 

Telephone time 20 min

Clinical Reminders:

 Alcohol Use Screen (AUDIT-C):

 Alcohol Screen:

 SCREEN FOR ALCOHOL (AUDIT-C)

 An alcohol screening test (AUDIT-C) was negative (score=2).

 1. How often did you have a drink containing alcohol in the past 

 year?

 Two to four times a month

 2. How many drinks containing al

cohol did you have on a typical 

 day when you were drinking in the past year?

 One or two drinks

 3. How often did you have six or more drinks on one occasion in 

 the past year?

 Never

 Tobacco Use Screening:

 The patient has never used tobacco.

 Medication Reconciliation:

 Med Rec performed with patient/caregiver:

 -Home meds compared with CPRS meds

 -Medication allergies (local and remote) reviewed

 -Discrepancies, if any, discussed with patient/caregiver

 -Changes, if any, addressed in "Plan" section of visit note and

 reflected in CPRS medication list

 -Patient/caregiver provided with an updated medication list (or

 written instructions provided for minor med changes)

 -Education provided regarding managing personal medication

 information, including carrying an updated med list at all times

 Colonoscopy GAP Reminder:

 Recommendations are needed in the clinical reminder system following the

 patient's most recent colorectal cancer screening/surveillance test

 (Colonoscopy, Sigmoidoscopy or CT Colonography)

 Screening is due now. A FOBT/FIT (Fecal Immunochemical Testing) has been 

 ordered and average risk CRC screening set to annual screening. See order 

 tab for order details.

/es/ Kamalpreet Dulai, MD

Physician, Primary Care

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APPENDIX 657

Case 4:22-cv-00343-Y Document 239-16 Filed 04/26/24 Page 2 of 46 PageID 7336
Signed: 12/02/2021 11:05

12/02/2021 ADDENDUM STATUS: COMPLETED

MSA, Please make f2f with RN CM next week. 

RNCM, pt will be dropping off FMLA paperwork, he will also need his BP checked. 

I have ordered labs for him to complete that day. thanks. 

/es/ Kamalpreet Dulai, MD

Physician, Primary Care

Signed: 12/02/2021 11:07

Receipt Acknowledged By:

12/09/2021 13:17 /es/ Shearon Jones, RN

 Nursing Service, Case Manager, Primary Care

12/08/2021 14:15 /es/ MONICA MARIE MASER

12/06/2021 ADDENDUM STATUS: COMPLETED

msa cld # left mssg for pt-to call 8003 to schedule appt for this 

week with the RN care manager-

/es/ MONICA MARIE MASER

Signed: 12/06/2021 15:57

12/09/2021 ADDENDUM STATUS: COMPLETED

Please let pt know B12 very low, i mailed out B12 500mcg dialy. 

Vitamin D very low, i mailed out 4000iu daily x 1 month, then 2000 iu daily 

thereafter.

A1c in PreDm range, continue with low glycemic foods

LDL not at goal, rec we watch diet, if he needs diet consult, we can place and 

reassess in 6months and if still elevated, rec statin therapy. 

/es/ Kamalpreet Dulai, MD

Physician, Primary Care

Signed: 12/09/2021 09:14

Receipt Acknowledged By:

12/09/2021 13:18 /es/ Shearon Jones, RN

 Nursing Service, Case Manager, Primary Care

12/09/2021 ADDENDUM STATUS: COMPLETED

FMLA paperwork completed and handed to RNCM. 

/es/ Kamalpreet Dulai, MD

Physician, Primary Care

Signed: 12/09/2021 10:19

Receipt Acknowledged By:

12/09/2021 13:18 /es/ Shearon Jones, RN

 Nursing Service, Case Manager, Primary Care

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APPENDIX 658

Case 4:22-cv-00343-Y Document 239-16 Filed 04/26/24 Page 3 of 46 PageID 7337
Date/Time: 02 Dec 2021 @ 0950

Note Title: TCP Telephone Care Staff Note

Location: No CA Healthcare Sys-Martinez

Signed By: BELANTES,GREG CASTRO

Co-signed By: BELANTES,GREG CASTRO

Date/Time Signed: 02 Dec 2021 @ 0954

Note

 LOCAL TITLE: TCP Telephone Care Staff Note

STANDARD TITLE: NURSING TELEPHONE ENCOUNTER NOTE

DATE OF NOTE: DEC 02, 2021@09:50:06 ENTRY DATE: DEC 02, 2021@09:54:05

 AUTHOR: BELANTES,GREG CASTR EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

**PATIENT called in for ROSS,ROBERT ALLEN (387725153) Phone: 9162842402.

Type of call: CALL BACK.

Contact Phone Number: 9162842402

Patient's Email Address: 1RROSS@COMCAST.NET

The following identifiers were used to verify this patient: DOB. SSN.

Caller Area: MCCLELLAN

Comments:

Pt has family leave paperwork that he needs signed by PCP. Pt wants to know if 

possible he can send it to PCP via email. Pt has TAP 120221 @ 10:30.

Pt can be reached: 916.284.2402.

Chief Complaint: Not applicable to call.

Caller Response: *OTHER

Author: BELANTES,GREG CASTRO

Class Code: Other specified counseling.

Evaluation/Management Code: HC PRO PHONE CALL 5-10 MIN (98966).

Starting at: 12/02/2021 @ 9:50:06 AM

Ending at: 12/02/2021 @ 9:52:27 AM

Length: 2 minutes.

/es/ GREG CASTRO BELANTES

Medical Support Assistant

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APPENDIX 659

Case 4:22-cv-00343-Y Document 239-16 Filed 04/26/24 Page 4 of 46 PageID 7338
Signed: 12/02/2021 09:54

Receipt Acknowledged By:

12/02/2021 10:34 /es/ Kamalpreet Dulai, MD

 Physician, Primary Care

12/03/2021 14:55 /es/ Shearon Jones, RN

 Nursing Service, Case Manager, Primary Care

Date/Time: 24 Sep 2021 @ 1330

Note Title: Report of Contact

Location: No CA Healthcare Sys-Martinez

Signed By: GREEN,ALMITA CAREN

Co-signed By: GREEN,ALMITA CAREN

Date/Time Signed: 24 Sep 2021 @ 1332

Note

 LOCAL TITLE: Report of Contact

STANDARD TITLE: ADMINISTRATIVE NOTE

DATE OF NOTE: SEP 24, 2021@13:30 ENTRY DATE: SEP 24, 2021@13:30:37

 AUTHOR: GREEN,ALMITA CAREN EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

Called pt. and lvm to call central appt. number and sched. appt. with PCP. 

/es/ ALMITA CAREN GREEN

ADVANCED MSA

Signed: 09/24/2021 13:32

Date/Time: 24 Sep 2021 @ 1001

Note Title: Care Management Nursing Note

Location: No CA Healthcare Sys-Martinez

Signed By: JONES,SHEARON

Co-signed By: JONES,SHEARON

Date/Time Signed: 24 Sep 2021 @ 1006

Note

 LOCAL TITLE: Care Management Nursing Note

STANDARD TITLE: CARE MANAGEMENT NURSING NOTE

DATE OF NOTE: SEP 24, 2021@10:01 ENTRY DATE: SEP 24, 2021@10:01:41

 AUTHOR: JONES,SHEARON EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

Called patient and he was identified using 2/3 patient identifiers (full name, 

full soc sec number, birth date).

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APPENDIX 660

Case 4:22-cv-00343-Y Document 239-16 Filed 04/26/24 Page 5 of 46 PageID 7339
COVID-19 Telephone Follow-Up

Patient notified of negative COVID-19 test result.

 Recommendations:

 - Minimize contact with others until 24 hours

 after symptoms resolve.

 Steps to prevent the spread of COVID-19:

 - Stay at home except to get medical care that cannot be provided

 by a telephone or video visit.

 - Get rest and stay hydrated.

 - Call ahead before visiting your doctor.

 - Wear a facemask if you are around others.

 - Cover your coughs and sneezes.

 - Clean your hands often.

 - Keep a six-foot distance from others in your home, ideally in a

 separate room. Isolate in a private room, if available.

 - Avoid sharing household items.

 - Disinfect high touch surfaces daily, ideally with a product

 that kills cold and flu viruses.

/es/ Shearon Jones, RN

Nursing Service, Case Manager, Primary Care

Signed: 09/24/2021 10:06

Receipt Acknowledged By:

09/24/2021 10:58 /es/ Kamalpreet Dulai, MD

 Physician, Primary Care

Date/Time: 24 Sep 2021 @ 0944

Note Title: TCP Telephone Care Staff Note

Location: No CA Healthcare Sys-Martinez

Signed By: ROUNDTREE,CARLA NICOLE

Co-signed By: ROUNDTREE,CARLA NICOLE

Date/Time Signed: 24 Sep 2021 @ 0945

Note

 LOCAL TITLE: TCP Telephone Care Staff Note

STANDARD TITLE: NURSING TELEPHONE ENCOUNTER NOTE

DATE OF NOTE: SEP 24, 2021@09:44:45 ENTRY DATE: SEP 24, 2021@09:45:32

 AUTHOR: ROUNDTREE,CARLA NIC EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

 *** TCP Telephone Care Staff Note Has ADDENDA ***

**PATIENT called in for ROSS,ROBERT ALLEN (387725153) Phone: 9162842402.

Contact Phone Number: 9162842402

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APPENDIX 661

Case 4:22-cv-00343-Y Document 239-16 Filed 04/26/24 Page 6 of 46 PageID 7340
Caller Area: MCCLELLAN

Caller Response: *OTHER

Type of call: CALL BACK.

The following identifiers were used to verify this patient: DOB. SSN.

Class Code: Other specified counseling.

Chief Complaint: Not applicable to call.

Comments:

pt called he would like to speak with you he can be reached ( Thank 

you-cr

Author: ROUNDTREE,CARLA NICOLE

Evaluation/Management Code: HC PRO PHONE CALL 5-10 MIN (98966).

Starting at: 09/24/2021 @ 9:44:45 AM

Ending at: 09/24/2021 @ 9:45:12 AM

Length: 0 minutes.

Patient's Email Address: 1RROSS@COMCAST.NET

/es/ ROUNDTREE,CARLA NICOLE 

Signed: 09/24/2021 09:45

Receipt Acknowledged By:

09/24/2021 09:56 /es/ Kamalpreet Dulai, MD

 Physician, Primary Care

09/24/2021 10:40 /es/ Shearon Jones, RN

 Nursing Service, Case Manager, Primary Care

09/24/2021 ADDENDUM STATUS: COMPLETED

please follow up, thanks. 

/es/ Kamalpreet Dulai, MD

Physician, Primary Care

Signed: 09/24/2021 09:56

Receipt Acknowledged By:

09/24/2021 10:41 /es/ Shearon Jones, RN

 Nursing Service, Case Manager, Primary Care

Date/Time: 24 Sep 2021 @ 0802

Note Title: Care Management Nursing Note

Location: No CA Healthcare Sys-Martinez

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APPENDIX 662

Case 4:22-cv-00343-Y Document 239-16 Filed 04/26/24 Page 7 of 46 PageID 7341
Signed By: JONES,SHEARON

Co-signed By: JONES,SHEARON

Date/Time Signed: 24 Sep 2021 @ 0803

Note

 LOCAL TITLE: Care Management Nursing Note

STANDARD TITLE: CARE MANAGEMENT NURSING NOTE

DATE OF NOTE: SEP 24, 2021@08:02 ENTRY DATE: SEP 24, 2021@08:03:02

 AUTHOR: JONES,SHEARON EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

COVID-19 Telephone Follow-Up

Unable to reach patient. Left message to call back.

/es/ Shearon Jones, RN

Nursing Service, Case Manager, Primary Care

Signed: 09/24/2021 08:03

Date/Time: 23 Sep 2021 @ 1031

Note Title: Screening Covid

Location: No CA Healthcare Sys-Martinez

Signed By: YARMOLA,ULYANA

Co-signed By: YARMOLA,ULYANA

Date/Time Signed: 23 Sep 2021 @ 1033

Note

 LOCAL TITLE: Screening Covid

STANDARD TITLE: INFECTIOUS DISEASE RISK ASSESSMENT SCREENING NOT

DATE OF NOTE: SEP 23, 2021@10:31 ENTRY DATE: SEP 23, 2021@10:31:42

 AUTHOR: YARMOLA,ULYANA EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

 *** Screening Covid Has ADDENDA ***

Coronavirus Disease 2019 (COVID-19) Screen

The patient was asked if in the last 14 days they have had new onset of any 

COVID-19 symptoms. They report the following:

 Cough

 Sore throat

The patient reports close exposure (within 6 feet for more than 15 minutes) to 

someone with a febrile/respiratory illness within the last 14 days.

Result:

 Patient has a positive symptom or exposure and requires further evaluation.

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APPENDIX 663

Case 4:22-cv-00343-Y Document 239-16 Filed 04/26/24 Page 8 of 46 PageID 7342
COVID-19 Swab Testing

Swab completed for Covid-19

 CDC Person Under Investigation (PUI) form completed and to lab w/specimen

 Symptoms: cough, sore throat

Plan: Discharged Home for Self-Quarantine, Post Swab Instructions Reviewed,

Home Care Instructions Reviewed

Veteran/caregiver verbalized an understanding of/agreed with the plan of care.

Veteran/caregiver instructed to call VetsCONNECT or the PACT care manager for

any future routine issues/concerns. Veteran/caregiver advised to call 911 for

any potentially life threatening problems/conditions.

/es/ Ulyana Yarmola,RN, BSN

Nurse, COVID Vacc/Swab, PACT/SAC

Signed: 09/23/2021 10:33

09/24/2021 ADDENDUM STATUS: COMPLETED

Please let pt know covid test is negative. 

/es/ Kamalpreet Dulai, MD

Physician, Primary Care

Signed: 09/24/2021 07:57

Receipt Acknowledged By:

09/24/2021 10:40 /es/ Shearon Jones, RN

 Nursing Service, Case Manager, Primary Care

Date/Time: 23 Sep 2021 @ 0950

Note Title: Medical Clerk Note

Location: No CA Healthcare Sys-Martinez

Signed By: GREEN,ALMITA CAREN

Co-signed By: GREEN,ALMITA CAREN

Date/Time Signed: 23 Sep 2021 @ 0951

Note

 LOCAL TITLE: Medical Clerk Note

STANDARD TITLE: COMMUNICATION NOTE

DATE OF NOTE: SEP 23, 2021@09:50 ENTRY DATE: SEP 23, 2021@09:50:32

 AUTHOR: GREEN,ALMITA CAREN EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

Walk in visit

 MSA Same Day Care: Unscheduled Visit

 From: Walk-In

 Visit

 Reason: Health Concern pid 09.23.2021, COVID test, PUI, cough & sore 

throat

 Disposition

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APPENDIX 664

Case 4:22-cv-00343-Y Document 239-16 Filed 04/26/24 Page 9 of 46 PageID 7343
 To: Nurse

/es/ ALMITA CAREN GREEN

ADVANCED MSA

Signed: 09/23/2021 09:51

Date/Time: 22 Sep 2021 @ 1625

Note Title: TCP Telephone Care Staff Note

Location: No CA Healthcare Sys-Martinez

Signed By: LEITNAKER,KAREN MARIE

Co-signed By: LEITNAKER,KAREN MARIE

Date/Time Signed: 22 Sep 2021 @ 1645

Note

 LOCAL TITLE: TCP Telephone Care Staff Note

STANDARD TITLE: NURSING TELEPHONE ENCOUNTER NOTE

DATE OF NOTE: SEP 22, 2021@16:25:54 ENTRY DATE: SEP 22, 2021@16:45:35

 AUTHOR: LEITNAKER,KAREN MAR EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

**PATIENT called in for ROSS,ROBERT ALLEN (387725153) Phone: 9162842402.

Contact Phone Number: 9162842402

Caller Area: MCCLELLAN

Caller Response: *OTHER

Type of call: SYMPTOM.

The following identifiers were used to verify this patient: DOB. SSN. Other: 

full name.

Class Code: Other specified counseling.

Chief Complaint: Not applicable to call.

Comments:

MSA/Clerk comments: Pt reports lethargy, congestion, runny nose, productive 

cough x1 week. Best 

number:

Nurse Notes:

Clinical Contact/Call Center COVID 19 SCREEN UPDATE_2_0_200, April 2021 Screen 

version 7.1

Record the patient's responses to the following questions: (check all that 

apply, or None at the end)

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APPENDIX 665

Case 4:22-cv-00343-Y Document 239-16 Filed 04/26/24 Page 10 of 46 PageID 7344
In the last 14 days have you had new onset of any of the following symptoms?

 a. Chills:

 () Yes

 (X) No

 Comment(s):

 b. Cough:

 (X) Yes

 () No

 Comment(s):

 c. Diarrhea:

 () Yes

 (X) No

 Comment(s):

 d. Fatigue:

 (X) Yes

 () No

 Comment(s):

 e. Fever:

 () Yes

 (X) No

 Comment(s):

 f. Headache:

 (X) Yes

 () No

 Comment(s):

 g. Loss of taste or smell:

 () Yes

 (X) No

 Comment(s):

 h. Muscle pain (Myalgias):

 (X) Yes

 () No

 Comment(s):

 i. Nausea:

 () Yes

 (X) No

 Comment(s):

 j. Runny nose (Rhinorrhea):

 (X) Yes

 () No

 Comment(s):

 k. Shortness of breath (Dyspnea):

 (X) Yes

 () No

 Comment(s):

 l. Sore throat:

 (X) Yes

 () No

 Comment(s):

 m. Vomiting:

 () Yes

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APPENDIX 666

Case 4:22-cv-00343-Y Document 239-16 Filed 04/26/24 Page 11 of 46 PageID 7345
 (X) No

 Comment(s):

 No Symptoms ()

Within the last 14 days, have you had:

 Close exposure (within 6 feet for more than 15 minutes) to someone with a 

febrile/respiratory illness

 () Yes 

 Comment(s):

 Close exposure (within 6 feet for more than 15 minutes) to someone with 

known or suspected case of COVID-19

 () Yes

 Comment(s):

 No known exposure (X)

Veteran declined triage, requested COVID test d/t cold/flu like symptoms. 

Denied respiratory distress and chest pain. Covid screen performed and Veteran 

is a PUI, Covid swab ordered per protocol. Veteran agrees to report to 

McClellan VA Clinic to get a Covid Test. Provided education, home care and 

warning signs. Advised to call Vets Connect 1-800-382-8387 if symptoms worsen 

or for any additional questions or concerns. Veteran verbalized understanding.

Will forward note to Provider/PACT.

Any symptom or exposure equal to positive screen:

 Patient has a POSITIVE symptom or exposure and requires further evaluation

 Nurse/Provider/Other notified (X) Yes

 Comments(s):

 Screen is negative ()

 ************

Patient is waiting on COVID-19 test results:

 () Yes

 (X) No

 Comment(s):

Patient reports prior COVID-19 Diagnosis:

 () Yes

 (X) No

 Comment(s):

Author: LEITNAKER,KAREN MARIE

Evaluation/Management Code: HC PRO PHONE CALL 11-20 MIN (98967).

Original call started at: SEP 22, 2021 @ 16:21 (Call was suspended)

- GLATT,MARY E SEP 22, 2021@16:21:58 - SEP 22, 2021@16:24:46

Ending at: 09/22/2021 @ 4:38:30 PM

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APPENDIX 667

Case 4:22-cv-00343-Y Document 239-16 Filed 04/26/24 Page 12 of 46 PageID 7346
Length: 15 minutes. (Call was suspended. This call length is the total amount 

of time spent "active" in Telecare Record Manager.)

Patient's Email Address: 1RROSS@COMCAST.NET

/es/ Karen Marie Leitnaker, RN

Telephone Advice Nurse

Signed: 09/22/2021 16:45

Receipt Acknowledged By:

09/23/2021 08:05 /es/ Kamalpreet Dulai, MD

 Physician, Primary Care

Date/Time: 15 Jun 2021 @ 0935

Note Title: Medical Clerk Note

Location: No CA Healthcare Sys-Martinez

Signed By: DHILLON,RAVNEET KAUR

Co-signed By: DHILLON,RAVNEET KAUR

Date/Time Signed: 15 Jun 2021 @ 0937

Note

 LOCAL TITLE: Medical Clerk Note

STANDARD TITLE: COMMUNICATION NOTE

DATE OF NOTE: JUN 15, 2021@09:35 ENTRY DATE: JUN 15, 2021@09:35:53

 AUTHOR: DHILLON,RAVNEET KAU EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

Documenting COVID Vaccine information from CAIR2 database

Moderna COVID-19 Vaccine given previously

Patient received a prior dose of the Moderna COVID-19 Vaccine.

 Date: February 27, 2021

 Location: EL DORADO PUBLIC HEALTH DEPARTMENT PLACERVILLE

Patient received a prior dose of the Moderna COVID-19 Vaccine.

 Date: March 27, 2021

 Location: El Dorado County Emergency Medical Services Agency

/es/ RAVNEET KAUR DHILLON

Advanced Medical Support Assistant 

Signed: 06/15/2021 09:37

Date/Time: 29 Apr 2021 @ 1119

Note Title: Primary Care Telephone Note

Location: No CA Healthcare Sys-Martinez

Signed By: DULAI,KAMALPREET

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APPENDIX 668

Case 4:22-cv-00343-Y Document 239-16 Filed 04/26/24 Page 13 of 46 PageID 7347
Co-signed By: DULAI,KAMALPREET

Date/Time Signed: 29 Apr 2021 @ 1120

Note

 LOCAL TITLE: Primary Care Telephone Note

STANDARD TITLE: PRIMARY CARE TELEPHONE ENCOUNTER NOTE

DATE OF NOTE: APR 29, 2021@11:19 ENTRY DATE: APR 29, 2021@11:19:37

 AUTHOR: DULAI,KAMALPREET EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

COVID-19 Telephone Follow-Up

Patient notified of negative COVID-19 test result.

 Recommendations:

 - Minimize contact with others until 24 hours

 after symptoms resolve.

 Steps to prevent the spread of COVID-19:

 - Stay at home except to get medical care that cannot be provided

 by a telephone or video visit.

 - Get rest and stay hydrated.

 - Call ahead before visiting your doctor.

 - Wear a facemask if you are around others.

 - Cover your coughs and sneezes.

 - Clean your hands often.

 - Keep a six-foot distance from others in your home, ideally in a

 separate room. Isolate in a private room, if available.

 - Avoid sharing household items.

 - Disinfect high touch surfaces daily, ideally with a product

 that kills cold and flu viruses.

Work letter written to return to work with no restrictions. 

/es/ Kamalpreet Dulai, MD

Physician, Primary Care

Signed: 04/29/2021 11:20

Date/Time: 28 Apr 2021 @ 1000

Note Title: Screening Covid

Location: No CA Healthcare Sys-Martinez

Signed By: INTAGLIATA,MARGARET JOAN

Co-signed By: INTAGLIATA,MARGARET JOAN

Date/Time Signed: 28 Apr 2021 @ 1003

Note

 LOCAL TITLE: Screening Covid

STANDARD TITLE: INFECTIOUS DISEASE RISK ASSESSMENT SCREENING NOT

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APPENDIX 669

Case 4:22-cv-00343-Y Document 239-16 Filed 04/26/24 Page 14 of 46 PageID 7348
DATE OF NOTE: APR 28, 2021@10:00 ENTRY DATE: APR 28, 2021@10:00:38

 AUTHOR: INTAGLIATA,MARGARET EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

Coronavirus Disease 2019 (COVID-19) Screen

The patient was asked if in the last 14 days they have had new onset of any 

COVID-19 symptoms. They report the following:

 No symptoms

The patient reports close exposure (within 6 feet for more than 15 minutes) to 

someone with known or suspected case of COVID-19 in the last 14 days.

Result:

 Patient has a positive symptom or exposure and requires further evaluation.

COVID-19 Secondary Screening

Temperature

 96.8 F (36 C)

Pulse

 69

Pulse Oximetry 98 Room Air

The patient has the following previously known conditions which may mimic

COVID-19 symptoms:

None

Plan:

Home Care Instructions Reviewed, Report to testing center for swabbing

swabbed for Covid -19 positive exposure. Veteran is asymptomatic

Veteran/caregiver verbalized an understanding of/agreed with the plan of care.

Veteran/caregiver instructed to call VetsCONNECT or the PACT care manager for

any future routine issues/concerns. Veteran/caregiver advised to call 911 for

any potentially life threatening problems/conditions.

/es/ MARGARET JOAN INTAGLIATA

Nursing Service, Diabetes Educator, Primary Care

Signed: 04/28/2021 10:03

Receipt Acknowledged By:

04/28/2021 10:24 /es/ Kamalpreet Dulai, MD

 Physician, Primary Care

04/28/2021 15:00 /es/ Shearon Jones, RN

 Nursing Service, Case Manager, Primary Care

Date/Time: 28 Apr 2021 @ 0936

Note Title: Medical Clerk Note

Location: No CA Healthcare Sys-Martinez

Signed By: HELFRICK,MARY LIN

Co-signed By: HELFRICK,MARY LIN

Date/Time Signed: 28 Apr 2021 @ 0938

Note

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APPENDIX 670

Case 4:22-cv-00343-Y Document 239-16 Filed 04/26/24 Page 15 of 46 PageID 7349
 LOCAL TITLE: Medical Clerk Note

STANDARD TITLE: COMMUNICATION NOTE

DATE OF NOTE: APR 28, 2021@09:36 ENTRY DATE: APR 28, 2021@09:36:57

 AUTHOR: HELFRICK,MARY LIN EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

Walk in visit

 MSA Same Day Care: Unscheduled Visit

 From: Walk-In

 Visit

 Reason: Health Concern pt had direct contact w/positive person 04/21

 Disposition

 To: Nurse

/es/ MARY LIN HELFRICK

Signed: 04/28/2021 09:38

Date/Time: 23 Apr 2021 @ 1546

Note Title: Primary Care Telephone Note

Location: No CA Healthcare Sys-Martinez

Signed By: DULAI,KAMALPREET

Co-signed By: DULAI,KAMALPREET

Date/Time Signed: 23 Apr 2021 @ 1555

Note

 LOCAL TITLE: Primary Care Telephone Note

STANDARD TITLE: PRIMARY CARE TELEPHONE ENCOUNTER NOTE

DATE OF NOTE: APR 23, 2021@15:46 ENTRY DATE: APR 23, 2021@15:46:56

 AUTHOR: DULAI,KAMALPREET EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

Pt called for TAP today. Pt states his daughter has to quarantine until 5/1 due 

to COVID+ contact at school, therefore he and the rest of the family will also 

quarantine. He denies any symptoms, neither does the family. No SOB, fevers, ab 

pain, diarrhea, loss of taste/smell, fatigue, body aches. He would like to get 

testing done on 4/26 and if neg, safely go back to work. He works for the 

airlines.

He also has pain in thumb, states he picked at a hang nail. Now is red and 

swollen on side, no pus. Has been bleeding as well. 

A/P:

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APPENDIX 671

Case 4:22-cv-00343-Y Document 239-16 Filed 04/26/24 Page 16 of 46 PageID 7350
1. PUI: asymptomatic, however COVID + contact by daughter at school, who was 

asked to quarantine,therefore whole family is going to quarantine until 5/1.

-work letter given to quarantine until 5/1, however will test on 4/26 and if 

negative, can safely go to work. 

2. Paronychia: likely from hangnail. 

-warm water soaks, slow massage, and use OTC bacitracin x 1 week. If not 

improving, may need oral antibiotics. Pt agrees with plan. 

Telephone time 15 minutes 

Clinical Reminders:

 Medication Reconciliation:

 Med Rec performed with patient/caregiver:

 -Home meds compared with CPRS meds

 -Medication allergies (local and remote) reviewed

 -Discrepancies, if any, discussed with patient/caregiver

 -Changes, if any, addressed in "Plan" section of visit note and

 reflected in CPRS medication list

 -Patient/caregiver provided with an updated medication list (or

 written instructions provided for minor med changes)

 -Education provided regarding managing personal medication

 information, including carrying an updated med list at all times

/es/ Kamalpreet Dulai, MD

Physician, Primary Care

Signed: 04/23/2021 15:55

Date/Time: 23 Apr 2021 @ 1011

Note Title: Medical Clerk Note

Location: No CA Healthcare Sys-Martinez

Signed By: O'NEIL-DOMINGUEZ,KIARA

Co-signed By: O'NEIL-DOMINGUEZ,KIARA

Date/Time Signed: 23 Apr 2021 @ 1019

Note

 LOCAL TITLE: Medical Clerk Note

STANDARD TITLE: COMMUNICATION NOTE

DATE OF NOTE: APR 23, 2021@10:11 ENTRY DATE: APR 23, 2021@10:11:41

 AUTHOR: O'NEIL-DOMINGUEZ,KI EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

Walk in visit

 MSA Same Day Care: Unscheduled Visit

 From: Walk-In

 Visit

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APPENDIX 672

Case 4:22-cv-00343-Y Document 239-16 Filed 04/26/24 Page 17 of 46 PageID 7351
 Reason: Health Concern// right thumb sidewall bleeding "something stuck 

in

 there"

 Disposition

 To: Other

/es/ O'NEIL-DOMINGUEZ,KIARA 

Signed: 04/23/2021 10:19

Date/Time: 22 Apr 2021 @ 0956

Note Title: TCP Telephone Care Staff Note

Location: No CA Healthcare Sys-Martinez

Signed By: HOLLOW,NYX ALIXANDIR

Co-signed By: HOLLOW,NYX ALIXANDIR

Date/Time Signed: 22 Apr 2021 @ 1002

Note

 LOCAL TITLE: TCP Telephone Care Staff Note

STANDARD TITLE: NURSING TELEPHONE ENCOUNTER NOTE

DATE OF NOTE: APR 22, 2021@09:56:11 ENTRY DATE: APR 22, 2021@10:02:39

 AUTHOR: HOLLOW,NYX ALIXANDI EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

 *** TCP Telephone Care Staff Note Has ADDENDA ***

**PATIENT called in for ROSS,ROBERT ALLEN (387725153) Phone: 9162842402.

Contact Phone Number: 9162842402

Caller Area: MCCLELLAN

Caller Response: MESSAGE LEFT

Type of call: CALL BACK.

The following identifiers were used to verify this patient: DOB. SSN.

Class Code: Other specified counseling.

Chief Complaint: Not applicable to call.

Comments:

Pt called requesting letter excusing him from work due to having to quarantine 

after his daughter was exposed to COVID-19. Pt states he needs to have letter 

by 04/23/2021. Pt requesting call back today 04/22/2021 if possible to confirm 

that he will be able to get letter.

Pt scheduled for TAP with PCP 04/23/2021 @1530 to discuss additional 

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APPENDIX 673

Case 4:22-cv-00343-Y Document 239-16 Filed 04/26/24 Page 18 of 46 PageID 7352
information. Best number: 

Author: GLATT,MARY E

Evaluation/Management Code: HC PRO PHONE CALL 5-10 MIN (98966).

Starting at: 4/22/2021 @ 9:56:11 AM

Ending at: 4/22/2021 @ 10:02:05 AM

Length: 5 minutes.

Patient's Email Address: 1RROSS@COMCAST.NET

/es/ MARY E GLATT

Signed: 04/22/2021 10:02

Receipt Acknowledged By:

04/22/2021 10:32 /es/ Kamalpreet Dulai, MD

 Physician, Primary Care

04/22/2021 10:07 /es/ James B. Painter, RN

 RN Case Manager, Primary Care Clinic

 for SHEARON JONES

05/06/2021 12:12 /es/ Rima Oleynik, LVN

 Licensed Vocational Nurse, Primary Care

04/22/2021 ADDENDUM STATUS: COMPLETED

RN CM, ok to write letter for quarantine, please follwo up with patient on dates 

needed. Thanks. 

/es/ Kamalpreet Dulai, MD

Physician, Primary Care

Signed: 04/22/2021 10:32

Receipt Acknowledged By:

04/22/2021 14:10 /es/ James B. Painter, RN

 RN Case Manager, Primary Care Clinic

Date/Time: 14 Oct 2020 @ 0826

Note Title: Care Management Nursing Note

Location: No CA Healthcare Sys-Martinez

Signed By: JONES,SHEARON

Co-signed By: JONES,SHEARON

Date/Time Signed: 14 Oct 2020 @ 0834

Note

 LOCAL TITLE: Care Management Nursing Note

STANDARD TITLE: CARE MANAGEMENT NURSING NOTE

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APPENDIX 674

Case 4:22-cv-00343-Y Document 239-16 Filed 04/26/24 Page 19 of 46 PageID 7353
DATE OF NOTE: OCT 14, 2020@08:26 ENTRY DATE: OCT 14, 2020@08:26:49

 AUTHOR: JONES,SHEARON EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

Called patient and he was identified using 2/3 patient identifiers (full name, 

full soc sec number, birth date).

COVID-19 Telephone Follow-Up

Patient notified of negative COVID-19 test result.

 Recommendations:

 - Minimize contact with others until 24 hours

 after symptoms resolve.

 Steps to prevent the spread of COVID-19:

 - Stay at home except to get medical care that cannot be provided

 by a telephone or video visit.

 - Get rest and stay hydrated.

 - Call ahead before visiting your doctor.

 - Wear a facemask if you are around others.

 - Cover your coughs and sneezes.

 - Clean your hands often.

 - Keep a six-foot distance from others in your home, ideally in a

 separate room. Isolate in a private room, if available.

 - Avoid sharing household items.

 - Disinfect high touch surfaces daily, ideally with a product

 that kills cold and flu viruses.

Patient requests copy of COVID-19 test result for employer.

/es/ Shearon Jones, RN

Nursing Service, Case Manager, Primary Care

Signed: 10/14/2020 08:34

Receipt Acknowledged By:

10/14/2020 10:15 /es/ Eleanor Bucaycay, MD

 Physician, Primary Care

Date/Time: 09 Oct 2020 @ 1524

Note Title: TCP Telephone Care Staff Note

Location: No CA Healthcare Sys-Martinez

Signed By: KRUPA,SARAH MARIE

Co-signed By: KRUPA,SARAH MARIE

Date/Time Signed: 09 Oct 2020 @ 1529

Note

 LOCAL TITLE: TCP Telephone Care Staff Note

STANDARD TITLE: NURSING TELEPHONE ENCOUNTER NOTE

DATE OF NOTE: OCT 09, 2020@15:24:26 ENTRY DATE: OCT 09, 2020@15:29:59

 AUTHOR: KRUPA,SARAH MARIE EXP COSIGNER:

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APPENDIX 675

Case 4:22-cv-00343-Y Document 239-16 Filed 04/26/24 Page 20 of 46 PageID 7354
 URGENCY: STATUS: COMPLETED

 *** TCP Telephone Care Staff Note Has ADDENDA ***

**PATIENT called in for ROSS,ROBERT ALLEN (387725153) Phone: 9162842402.

Contact Phone Number: 9162842402

Caller Area: MCCLELLAN

Caller Response: MESSAGE LEFT

Type of call: CALL BACK.

The following identifiers were used to verify this patient: DOB.

Class Code: Other specified counseling.

Chief Complaint: Not applicable to call.

Comments:

--Pt is requesting results for "COVID19 test"

Please email results so Pt may go back to work.

Please contact Pt.

Author: KRUPA,SARAH MARIE

Evaluation/Management Code: HC PRO PHONE CALL 5-10 MIN (98966).

Starting at: 10/09/2020 @ 3:24:26 PM

Ending at: 10/09/2020 @ 3:29:11 PM

Length: 4 minutes.

Patient's Email Address: 1RROSS@COMCAST.NET

/es/ SARAH MARIE KRUPA

Medical Support Assistant

Signed: 10/09/2020 15:29

Receipt Acknowledged By:

10/23/2020 15:31 /es/ Eleanor Bucaycay, MD

 Physician, Primary Care

10/14/2020 08:45 /es/ Shearon Jones, RN

 Nursing Service, Case Manager, Primary Care

10/13/2020 ADDENDUM STATUS: COMPLETED

Unable to reach patient. Left voicemail message asking that telephone call be 

returned.

/es/ Shearon Jones, RN

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APPENDIX 676

Case 4:22-cv-00343-Y Document 239-16 Filed 04/26/24 Page 21 of 46 PageID 7355
Nursing Service, Case Manager, Primary Care

Signed: 10/13/2020 10:35

Date/Time: 06 Oct 2020 @ 1438

Note Title: TCP Telephone Care Staff Note

Location: No CA Healthcare Sys-Martinez

Signed By: TKACHOVA,ANNA

Co-signed By: TKACHOVA,ANNA

Date/Time Signed: 06 Oct 2020 @ 1443

Note

 LOCAL TITLE: TCP Telephone Care Staff Note

STANDARD TITLE: NURSING TELEPHONE ENCOUNTER NOTE

DATE OF NOTE: OCT 06, 2020@14:38:48 ENTRY DATE: OCT 06, 2020@14:43:53

 AUTHOR: TKACHOVA,ANNA EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

**PATIENT called in for ROSS,ROBERT ALLEN (387725153) Phone: 9162842402.

Contact Phone Number: 9162842402

Caller Area: MCCLELLAN

Caller Response: *OTHER

Type of call: INFORMATION.

The following identifiers were used to verify this patient: DOB. SSN.

Class Code: Other specified counseling.

Chief Complaint: Not applicable to call.

Comments:

pts job requires him to have paper work, proof that he had covid19 test done 

today 10.06.20 in order to take him off a flight on 10.08.20

you can email it to 1RROSS@COMCAST.NET

or please contact pt as soon as possible 

thank you -AT

Author: TKACHOVA,ANNA

Evaluation/Management Code: HC PRO PHONE CALL 5-10 MIN (98966).

Starting at: 10/06/2020 @ 2:38:48 PM

Ending at: 10/06/2020 @ 2:43:34 PM

Length: 4 minutes.

Patient's Email Address: 1RROSS@COMCAST.NET

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APPENDIX 677

Case 4:22-cv-00343-Y Document 239-16 Filed 04/26/24 Page 22 of 46 PageID 7356
/es/ ANNA TKACHOVA

Signed: 10/06/2020 14:43

Receipt Acknowledged By:

12/09/2020 16:02 /es/ Eleanor Bucaycay, MD

 Physician, Primary Care

10/08/2020 11:39 /es/ Shearon Jones, RN

 Nursing Service, Case Manager, Primary Care

10/06/2020 16:09 /es/ KELLEY DAWN STEELE-SMITH

 AMSA

Date/Time: 06 Oct 2020 @ 1221

Note Title: Injections, Immunizations, Skin Tests

Location: No CA Healthcare Sys-Martinez

Signed By: KRAFT,ERIC EDWARD

Co-signed By: KRAFT,ERIC EDWARD

Date/Time Signed: 06 Oct 2020 @ 1223

Note

 LOCAL TITLE: Injections, Immunizations, Skin Tests

STANDARD TITLE: IMMUNIZATION NOTE

DATE OF NOTE: OCT 06, 2020@12:21 ENTRY DATE: OCT 06, 2020@12:21:36

 AUTHOR: KRAFT,ERIC EDWARD EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

The patient was given the influenza VIS which lists the benefits and side

effects of the vaccine and which reviews the risks of not receiving the flu

vaccine. The VIS was reviewed with the patient and they were given an

opportunity to ask questions. The patient was provided education on how to

decrease the risk of influenza infection including social distancing and use of

good hand hygiene. The patient denied any prior severe reaction to the flu

vaccine or its components. The patient gave verbal consent to receive the

vaccine.

The seasonal influenza vaccine VIS given to the patient:

 VIS version date Aug 15,2019.

 The patient received seasonal influenza vaccine today - Influenza,

 Quadrivalent preservative free (Fluarix) 0.5 ml IM today in Left Deltoid.

 Manufacturer: GlaxoSmithKline

 Lot # and Expiration Date: Fluarix; Lot# 9S4K5; Expires: 6/30/21

 Administered by protocol/policy

 Complications: None

 Influenza vaccine administered by: Jiminez, Justin LVN

 Credentials: LPN

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APPENDIX 678

Case 4:22-cv-00343-Y Document 239-16 Filed 04/26/24 Page 23 of 46 PageID 7357
/es/ Eric Kraft, LVN 

Primary Care

Signed: 10/06/2020 12:23

Date/Time: 06 Oct 2020 @ 1030

Note Title: Medical Clerk Note

Location: No CA Healthcare Sys-Martinez

Signed By: SHEKHAR,RONIKA DEVI

Co-signed By: SHEKHAR,RONIKA DEVI

Date/Time Signed: 06 Oct 2020 @ 1031

Note

 LOCAL TITLE: Medical Clerk Note

STANDARD TITLE: COMMUNICATION NOTE

DATE OF NOTE: OCT 06, 2020@10:30 ENTRY DATE: OCT 06, 2020@10:30:42

 AUTHOR: SHEKHAR,RONIKA DEVI EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

Walk in visit

 MSA Same Day Care: Unscheduled Visit

 From: Walk-In

 Visit

 Reason: Health Concern on demand

 Disposition

 To: Nurse

/es/ RONIKS SHEKHAR SHEKHAR

medical support assistan 

Signed: 10/06/2020 10:31

Date/Time: 06 Oct 2020 @ 0833

Note Title: TCP Telephone Care Staff Note

Location: No CA Healthcare Sys-Martinez

Signed By: DIANGELO,AMELIA DARAY

Co-signed By: DIANGELO,AMELIA DARAY

Date/Time Signed: 06 Oct 2020 @ 0835

Note

 LOCAL TITLE: TCP Telephone Care Staff Note

STANDARD TITLE: NURSING TELEPHONE ENCOUNTER NOTE

DATE OF NOTE: OCT 06, 2020@08:33:39 ENTRY DATE: OCT 06, 2020@08:35:22

 AUTHOR: DIANGELO,AMELIA DAR EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

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APPENDIX 679

Case 4:22-cv-00343-Y Document 239-16 Filed 04/26/24 Page 24 of 46 PageID 7358
**PATIENT called in for ROSS,ROBERT ALLEN (387725153) Phone: 9162842402.

Contact Phone Number: 9162842402

Caller Area: MCCLELLAN

Caller Response: *OTHER

Type of call: SYMPTOM.

The following identifiers were used to verify this patient: DOB. SSN.

Class Code: Other specified counseling.

Chief Complaint: Not applicable to call.

Comments:

Vet was covis tested 9/15 but said that his daughter has come down with SX of 

covid and they are waiting on her results to come back.. He doesn't have any 

SX

but said that he wants ti come into NSAC to have another test done this am. Vet 

can be reached at 916 284 2402

Author: DIANGELO,AMELIA DARAY

Evaluation/Management Code: HC PRO PHONE CALL 5-10 MIN (98966).

Starting at: 10/06/2020 @ 8:33:39 AM

Ending at: 10/06/2020 @ 8:35:16 AM

Length: 1 minutes.

Patient's Email Address: 1RROSS@COMCAST.NET

/es/ Amelia Darya Diangelo

Martinez Call Center (MSA)

Signed: 10/06/2020 08:35

Receipt Acknowledged By:

10/20/2020 14:59 /es/ Eleanor Bucaycay, MD

 Physician, Primary Care

10/06/2020 10:19 /es/ Shearon Jones, RN

 Nursing Service, Case Manager, Primary Care

Date/Time: 17 Sep 2020 @ 1404

Note Title: Nursing Note

Location: No CA Healthcare Sys-Martinez

Signed By: OLEYNIK,RIMA

Co-signed By: OLEYNIK,RIMA

Date/Time Signed: 17 Sep 2020 @ 1409

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APPENDIX 680

Case 4:22-cv-00343-Y Document 239-16 Filed 04/26/24 Page 25 of 46 PageID 7359
Note

 LOCAL TITLE: Nursing Note

STANDARD TITLE: NURSING NOTE

DATE OF NOTE: SEP 17, 2020@14:04 ENTRY DATE: SEP 17, 2020@14:04:44

 AUTHOR: OLEYNIK,RIMA EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

Pt identified by their DOB, first and last name.

COVID-19 Telephone Follow-Up

Patient notified of negative COVID-19 test result.

 Recommendations:

 - Minimize contact with others until 24 hours

 after symptoms resolve.

 Steps to prevent the spread of COVID-19:

 - Stay at home except to get medical care that cannot be provided

 by a telephone or video visit.

 - Get rest and stay hydrated.

 - Call ahead before visiting your doctor.

 - Wear a facemask if you are around others.

 - Cover your coughs and sneezes.

 - Clean your hands often.

 - Keep a six-foot distance from others in your home, ideally in a

 separate room. Isolate in a private room, if available.

 - Avoid sharing household items.

 - Disinfect high touch surfaces daily, ideally with a product

 that kills cold and flu viruses.

/es/ Rima Oleynik, LVN

Licensed Vocational Nurse, Primary Care

Signed: 09/17/2020 14:09

Date/Time: 17 Sep 2020 @ 0838

Note Title: Primary Care Interim Note

Location: No CA Healthcare Sys-Martinez

Signed By: BUCAYCAY,ELEANOR

Co-signed By: BUCAYCAY,ELEANOR

Date/Time Signed: 12 Jan 2021 @ 0805

Note

 LOCAL TITLE: Primary Care Interim Note

STANDARD TITLE: PRIMARY CARE NOTE

DATE OF NOTE: SEP 17, 2020@08:38 ENTRY DATE: SEP 30, 2020@08:38:36

 AUTHOR: BUCAYCAY,ELEANOR EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

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APPENDIX 681

Case 4:22-cv-00343-Y Document 239-16 Filed 04/26/24 Page 26 of 46 PageID 7360
Here today for ffup. He has the chronic cough, Not on any meds. Allergy to 

dairy

is the only allergy he is aware of.

He has nasl/sinus issues. Was never seen by ENT. Nonsmoker.Denies any GERD 

issues.

Computerized Problem List is the source for the following:

1. Knee pain 08/26/20 

BUCAYCAY,ELEANO

2. Depressive episode 08/31/15 WEBER,DIANE 

ELL

3. General Anxiety 08/31/15 WEBER,DIANE 

ELL

4. Varicose veins of lower extremity (SNOMED CT 08/04/14 TAYLOR,JEFFERY

72866009)

5. Impaired Fasting Glucose (ICD-9-CM 790.21) 04/24/13 

DOCTOR,FEDERICO

6. GERD * (ICD-9-CM 530.81) 04/24/13 

DOCTOR,FEDERICO

7. DJD, Knee/Lower Leg 03/04/13 TAYLOR,JEFFERY

8. CMP INT ORT DEV/GFT NOS 03/04/13 TAYLOR,JEFFERY

9. Low Back Pain * (ICD-9-CM 724.2) 08/09/12 

DOCTOR,FEDERICO

10. Hearing loss * (ICD-9-CM 389.9) 05/24/10 

DOCTOR,FEDERICO

11. Hyperlipidemia 06/30/08 WOO,JOSEPH C

12. Pain in joint involving lower leg (ICD-9-CM 06/27/08 WOO,JOSEPH C

719.46)

13. Tear of lateral cartilage or meniscus of knee, 06/27/08 WOO,JOSEPH C

current (ICD-9-CM 836.1)

Active Outpatient Medications (excluding Supplies):

 Active Outpatient Medications Status

=========================================================================

1) IBUPROFEN 800MG TAB TAKE ONE TABLET BY MOUTH THREE ACTIVE

 TIMES A DAY - FOR PAIN OR INFLAMMATION.

Vitals - most recent BMI: 25.4

 Height: 68 in [172.7 cm] (07/26/2019 13:37)

 Weight: 167 lb [75.9 kg] (09/15/2020 12:27)

 Temp: 98.1 F [36.7 C] (09/15/2020 12:27)

 Pulse: 66 (09/15/2020 12:27)

 Resp: 16 (09/15/2020 12:27)

 BP: 128/74 (09/15/2020 12:27)

 O2 Sat: No data available for PULSE OXIMETRY

Gen: obese, nad, normal gai, no AD

Neck: no jvd, nomasses. no LN palpated

Heart:rrr, n0o m

Lungs:clear to a, no crackles or wheezes

Abd: soft, no masses, no tendernwes

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APPENDIX 682

Case 4:22-cv-00343-Y Document 239-16 Filed 04/26/24 Page 27 of 46 PageID 7361
EXt: no edema: 

Collection DT Spec WBC HGB HCT MCV MCHC PLT

08/20/2020 10:35 BLOOD 5.1 15.7 46.7 89.0 33.6 307

07/25/2019 10:35 BLOOD 4.7 L 16.1 47.0 88.7 34.3 332

Collection DT Spec GLUCOSE BUN CREAT NA K CL CO2

08/20/2020 10:35PLASMA 117 19 1.10 134 L 4.1 99 24

07/26/2019 14:54PLASMA 100 21 1.03 132 L 4.6 99 26

Collection DT Spec GLUCOSE BUN CREAT NA K CL CO2

08/20/2020 10:35PLASMA 117 19 1.10 134 L 4.1 99 24

07/26/2019 14:54PLASMA 100 21 1.03 132 L 4.6 99 26

A/P:

/es/ Eleanor Bucaycay, MD

Physician, Primary Care

Signed: 01/12/2021 08:05

Date/Time: 15 Sep 2020 @ 1435

Note Title: Screening Covid

Location: No CA Healthcare Sys-Martinez

Signed By: SUBA,LETICIA P

Co-signed By: SUBA,LETICIA P

Date/Time Signed: 15 Sep 2020 @ 1438

Note

 LOCAL TITLE: Screening Covid

STANDARD TITLE: INFECTIOUS DISEASE RISK ASSESSMENT SCREENING NOT

DATE OF NOTE: SEP 15, 2020@14:35 ENTRY DATE: SEP 15, 2020@14:35:19

 AUTHOR: SUBA,LETICIA P EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

Coronavirus Disease 2019 (COVID-19) Screen

The patient reports no COVID-19 diagnosis.

 The patient reports not waiting for the results of a COVID-19 lab test.

 The patient reports no fever.

 The patient reports no new or worsening cough or shortness of breath.

 The patient reports no cold or flu-like symptoms.

 The patient reports no new onset of diarrhea, nausea or vomiting.

 The patient reports no new onset of headache, loss of taste or loss of 

smell.

 The patient reports no exposure to someone with COVID-19 within the past 2 

 weeks.

Result:

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APPENDIX 683

Case 4:22-cv-00343-Y Document 239-16 Filed 04/26/24 Page 28 of 46 PageID 7362
 Screen is negative.

COVID-19 Swab Testing

Swab completed for Covid-19

 Pre-op /other: vet works as a flight crew, needing COVID-19 test for his 

work. Swabbed by Peggy,RN 

Plan: Post Swab Instructions Reviewed, Home Care Instructions Reviewed

Veteran/caregiver verbalized an understanding of/agreed with the plan of care.

Veteran/caregiver instructed to call VetsCONNECT or the PACT care manager for

any future routine issues/concerns. Veteran/caregiver advised to call 911 for

any potentially life threatening problems/conditions.

/es/ Leticia P. Suba,RN,BSN

Nursing Service

Signed: 09/15/2020 14:38

Receipt Acknowledged By:

12/31/2020 13:30 /es/ Eleanor Bucaycay, MD

 Physician, Primary Care

09/16/2020 09:23 /es/ Shearon Jones, RN

 Nursing Service, Case Manager, Primary Care

Date/Time: 15 Sep 2020 @ 1338

Note Title: Medical Clerk Note

Location: No CA Healthcare Sys-Martinez

Signed By: SHEKHAR,RONIKA DEVI

Co-signed By: SHEKHAR,RONIKA DEVI

Date/Time Signed: 15 Sep 2020 @ 1339

Note

 LOCAL TITLE: Medical Clerk Note

STANDARD TITLE: COMMUNICATION NOTE

DATE OF NOTE: SEP 15, 2020@13:38 ENTRY DATE: SEP 15, 2020@13:39:10

 AUTHOR: SHEKHAR,RONIKA DEVI EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

Walk in visit

 MSA Same Day Care: Unscheduled Visit

 From: Walk-In

 Visit

 Reason: Health Concern PUI

 Disposition

 To: Nurse PEGGY CM

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APPENDIX 684

Case 4:22-cv-00343-Y Document 239-16 Filed 04/26/24 Page 29 of 46 PageID 7363
/es/ RONIKS SHEKHAR SHEKHAR

medical support assistan 

Signed: 09/15/2020 13:39

Date/Time: 15 Sep 2020 @ 1223

Note Title: Preventive Health Screen 11514

Location: No CA Healthcare Sys-Martinez

Signed By: OLEYNIK,RIMA

Co-signed By: OLEYNIK,RIMA

Date/Time Signed: 15 Sep 2020 @ 1245

Note

 LOCAL TITLE: Preventive Health Screen 11514

STANDARD TITLE: PREVENTIVE MEDICINE RISK ASSESSMENT SCREENING NO

DATE OF NOTE: SEP 15, 2020@12:23 ENTRY DATE: SEP 15, 2020@12:23:36

 AUTHOR: OLEYNIK,RIMA EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

Clinical Reminders:

 Tobacco Use Screening:

 The patient has never used tobacco.

 Alcohol Use Screen (AUDIT-C):

 Alcohol Screen:

 SCREEN FOR ALCOHOL (AUDIT-C)

 An alcohol screening test (AUDIT-C) was negative (score=2).

 1. How often did you have a drink containing alcohol in the past 

 year?

 Two to four times a month

 2. How many drinks containing alcohol did you have on a typical 

 day when you were drinking in the past year?

 1 or 2

 3. How often did you have six or more drinks on one occasion in 

 the past year?

 Never

 Patient had a negative AUDC score and does not require a follow-up

 Homelessness/Food Insecurity Screen:

 In the past 2 months, have you been living in stable housing that you 

 own, rent, or stay in as part of a household? Yes - Living in stable 

 housing.

 Are you worried or concerned that in the next 2 months you may NOT have

 stable housing that you own, rent, or stay in as part of a household?

 No - Not worried about housing near future

 In the past three months did you ever run out of food and you were not

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APPENDIX 685

Date/Time Signed: 15 Sep 2020 @ 1245

Case 4:22-cv-00343-Y Document 239-16 Filed 04/26/24 Page 30 of 46 PageID 7364
 able to access more food or have the money to buy more food?

 No - No Food shortage

 Depression Screening:

 PHQ-2+I9

 Depression Screening Score: 2

 The score on this administration is 2, which indicates a

 negative screen on the Depression Scale over the past two weeks.

 Suicide Screening Score: 0

 The results of this administration indicates a NEGATIVE

 primary screen for Risk of Suicide over the last 2 weeks.

 Over the past two weeks, how often have you been bothered by the 

 following problems?

1. Little interest or pleasure in doing things

Several days

2. Feeling down, depressed, or hopeless

Several days

3. Thoughts that you would be better off dead or of hurting

yourself in some way

Not at all

 Emotional Health Screening:

 The Veteran states they have worry or stress in their life.

 Source of concerns:

ǁŽƌŬƌĞůĂƚĞĚstress

 Acknowledged Veterans concerns about their emotional health.

 stress. 

 Vitals:

 Most recent VS: Wt. 167 lb [75.9 kg] (09/15/2020 12:27)

BP 128/74 (09/15/2020 12:27)

HR 66 (09/15/2020 12:27)

Temp 98.1 F [36.7 C] (09/15/2020 12:27)

BMI 25.4

 Nutrition Screening:

 Most recent measurements:

 Measurement DT WEIGHT

LB(KG)[BMI]

 09/15/2020 12:27 167(75.75)[25]

 07/26/2019 13:37 165(74.84)[25]

 08/17/2015 11:24 164(74.39)[25]

 07/18/2014 13:34 162(73.48)[25]

 Ht. 68 in [172.7 cm] (07/26/2019 13:37)

 BMI 25.4

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APPENDIX 686

 Emotional Health Screening:

 The Veteran states they have worry or stress in their life.

 Source of concerns:

ǁŽƌŬƌĞůĂƚĞĚ stress

 Acknowledged Veterans concerns about their emotional health.

stress. 

Case 4:22-cv-00343-Y Document 239-16 Filed 04/26/24 Page 31 of 46 PageID 7365
/es/ Rima Oleynik, LVN

Licensed Vocational Nurse, Primary Care

Signed: 09/15/2020 12:45

Date/Time: 26 Aug 2020 @ 1016

Note Title: Primary Care Note

Location: No CA Healthcare Sys-Martinez

Signed By: BUCAYCAY,ELEANOR

Co-signed By: BUCAYCAY,ELEANOR

Date/Time Signed: 26 Aug 2020 @ 1025

Note

 LOCAL TITLE: Primary Care Note

STANDARD TITLE: PRIMARY CARE NOTE

DATE OF NOTE: AUG 26, 2020@10:16 ENTRY DATE: AUG 26, 2020@10:16:27

 AUTHOR: BUCAYCAY,ELEANOR EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

I have never seen the patient in the past. Last seen by Dr. Wilson.

He has 3 things he wants to be checked. Has chronic knee pain: woresning dur to 

the pain

FMLA papres to be completed.

He has an exposure to COVID as he works in th eplanes and was in Hongkong in 

Dec.

In Jan Had been sick but recovered fast.

A/P:

1.Knee pain: xryas oredered. Consider Orthho

2. COVID exposure: antibody toest requested

3. FMLA to be addressed

/es/ Eleanor Bucaycay, MD

Physician, Primary Care

Signed: 08/26/2020 10:25

Date/Time: 13 Aug 2020 @ 1132

Note Title: Patient Appointment Reminder Letter

Location: No CA Healthcare Sys-Martinez

Signed By: STEELE-SMITH,KELLEY DAWN

Co-signed By: STEELE-SMITH,KELLEY DAWN

Date/Time Signed: 13 Aug 2020 @ 1133

Note

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APPENDIX 687

Signed: 09/15/2020 12:45

Case 4:22-cv-00343-Y Document 239-16 Filed 04/26/24 Page 32 of 46 PageID 7366
 LOCAL TITLE: Patient Appointment Reminder Letter

STANDARD TITLE: PRIMARY CARE LETTERS

DATE OF NOTE: AUG 13, 2020@11:32 ENTRY DATE: AUG 13, 2020@11:32:16

 AUTHOR: STEELE-SMITH,KELLEY EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

 Department Of Veterans 

Affairs

 VA Northern California Health Care System 

(VANCHCS)

CLINIC ADDRESS:

 5342 Dudley Blvd., McClellan, CA 95652

AUG 13, 2020

 ROBERT ALLEN ROSS

 Dear Mr. ROSS:

 You have scheduled a VA Video Connect visit with your health care provider:

 08/25/2020 @ 2:00 Nsac VVC Pact Green

On the day of your VVC appointment with your PCP, Eleanor Bucaycay MD 

 Visit the website. 

 Go to the VA Video Connect page on the VA App Store website at 

mobile.va.gov/ app/va-video-connect. 

 Get set up. 

 For Apple mobile devices (iPhone, iPad, or iPod Touch): Search for 

and download the "VA Video Connect" app from the Apple App Store 

 Test your device. 

 Open an internet browser and go to mobile.va.gov/app/va-videoconnect. Once on the page, select "visit the VA Video Connect test 

site" to 

make sure your device's camera and microphone are fully functioning. 

 If you would like to practice using the app before your appointment, 

ask your VA care team for a practice session. 

 Join your visit. 

 A few minutes before your video visit, find the appointment email 

from "donotreply@mobilehealth.va.gov" and select the appointment link 

to join 

your session. In some cases, you will be directed to a virtual waiting room 

before your session begins. 

Having technical difficulty? Contact the National Telehealth Technology Help 

Desk.

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APPENDIX 688

Case 4:22-cv-00343-Y Document 239-16 Filed 04/26/24 Page 33 of 46 PageID 7367
 Call 866-651-3180 or 703-234-4483, Monday through Saturday, 7 a.m. ? 

11 p.m. Eastern time

Thank you for the opportunity to serve you. 

 Sincerely,

Primary Care Clinic

Northern California Health Care System

Department of Veterans Affairs

Bldg.98

5342 Dudley Blvd.

McClellan Park, CA 95652-1074

 Thank you for the opportunity to serve you 

 Sincerely,

 /es/ KELLEY DAWN STEELE-SMITH

 ASA

Patient Record Number 7366310

Date/Time: 15 Jul 2020 @ 0948

Note Title: Medical Clerk Note

Location: No CA Healthcare Sys-Martinez

Signed By: STEELE-SMITH,KELLEY DAWN

Co-signed By: STEELE-SMITH,KELLEY DAWN

Date/Time Signed: 15 Jul 2020 @ 0950

Note

 LOCAL TITLE: Medical Clerk Note

STANDARD TITLE: COMMUNICATION NOTE

DATE OF NOTE: JUL 15, 2020@09:48 ENTRY DATE: JUL 15, 2020@09:48:52

 AUTHOR: STEELE-SMITH,KELLEY EXP COSIGNER:

 URGENCY: STATUS: COMPLETED

Phone Call

WHO IS CALLING: Patient 

REASON FOR CALL:pt called to reschedule his appointment to August needs to

have blood work added. Per pt don't need to call him back 

TIME PATIENT WILL BE HOME FOR RETURN CALL: Jul 15,2020@15:00 

MESSAGE MAY BE LEFT WITH: Patient 

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APPENDIX 689

Case 4:22-cv-00343-Y Document 239-16 Filed 04/26/24 Page 34 of 46 PageID 7368
CALLER'S MOOD: Calm 

DISPOSITION: Note forwarded to RN 

ADDRESS:

AGE: 60 y.o. 

PCP:

FUTURE APPOINTMENT(S): 

MAS CLINIC VISITS FUTURE

08/25/2020 14:00 NSAC PACT GREEN 

Letter Reminders

RECALL DATE CLINIC

No data available

/es/ KELLEY DAWN STEELE-SMITH

MSA

Signed: 07/15/2020 09:50

Receipt Acknowledged By:

07/15/2020 10:36 /es/ Shearon Jones, RN

 Nursing Service, Case Manager, Primary Care

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APPENDIX 690

Case 4:22-cv-00343-Y Document 239-16 Filed 04/26/24 Page 35 of 46 PageID 7369
Self Reported Medical Events

Source: Self-Entered

No information was available that matched your selection.

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APPENDIX 691

Case 4:22-cv-00343-Y Document 239-16 Filed 04/26/24 Page 36 of 46 PageID 7370
VA Immunizations/Vaccinations

Source: VA

Last Updated:

Your VA immunizations/vaccinations list may not be complete. If you have questions about your 

vaccinations, contact your VA health care team.

This section shows your five most recent vaccination records.

Sorted By: Date Received (Descending)

Immunization Date Received

COVID-19 (MODERNA), MRNA, LNP-S, PF, 100 MCG/0.5ML DOSE 

OR 50 MCG/0.25ML DOSE

27 Mar 2021 @ 1200

COVID-19 (MODERNA), MRNA, LNP-S, PF, 100 MCG/0.5ML DOSE 

OR 50 MCG/0.25ML DOSE

27 Feb 2021 @ 1200

INFLUENZA, INJECTABLE, QUADRIVALENT, PRESERVATIVE FREE 06 Oct 2020 @ 1040

TDAP 26 Jul 2019 @ 1330

TD(ADULT) UNSPECIFIED FORMULATION --

This section shows all the vaccinations listed in your official VA health record, grouped by vaccination.

Sorted By: Immunization Name, then Date (Descending)

Immunization: COVID-19 (MODERNA), MRNA, 

LNP-S, PF, 100 MCG/0.5ML DOSE 

OR 50 MCG/0.25ML DOSE

Date Received: 27 Mar 2021 @ 

1200

Location: NORTHERN CALIFORNIA HCS

Reaction:* None Reported

Comments: --

Immunization: COVID-19 (MODERNA), MRNA, 

LNP-S, PF, 100 MCG/0.5ML DOSE 

OR 50 MCG/0.25ML DOSE

Date Received: 27 Feb 2021 @ 

1200

Location: NORTHERN CALIFORNIA HCS

Reaction:* None Reported

Comments: --

Immunization: INFLUENZA, INJECTABLE, 

QUADRIVALENT, PRESERVATIVE 

FREE

Date Received: 06 Oct 2020 @ 

1040

Location: ZZNSAC PACT IMMUNIZATION

Reaction:* None Reported

Comments: --

Immunization: TD(ADULT) UNSPECIFIED 

FORMULATION

Date Received: --

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APPENDIX 692

Case 4:22-cv-00343-Y Document 239-16 Filed 04/26/24 Page 37 of 46 PageID 7371
Location: NORTHERN CALIFORNIA HCS

Reaction:* None Reported

Comments: --

Immunization: TDAP Date Received: 26 Jul 2019 @ 

1330

Location: NSAC PACT GREEN

Reaction:* None Reported

Comments: --

Reaction Key: * = Check your VA Allergies and Adverse Reactions record as well as your Self-Reported 

Allergies in My HealtheVet. This may show an adverse reaction to a vaccination you received. If you 

have questions about your vaccinations, contact your VA health care team.

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APPENDIX 693

Case 4:22-cv-00343-Y Document 239-16 Filed 04/26/24 Page 38 of 46 PageID 7372
Self Reported Immunizations

Source: Self-Entered

No information was available that matched your selection.

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APPENDIX 694

Case 4:22-cv-00343-Y Document 239-16 Filed 04/26/24 Page 39 of 46 PageID 7373
VA Laboratory Results

Source: VA

Last Updated: 31 Dec 2023 @ 1453

Sorted By: Date Specimen Collected (Descending) then Time Specimen Collected

VA test results are generally available to you 36 hours after the results are finalized. COVID-19 test 

results are available to you immediately after the results are finalized. When you review your test results, 

please remember that not all test results outside the reference range are clinically significant. You may be 

seeing a test result before your provider. Your provider will be reviewing your test results and may 

contact you with additional information. If you have questions, please call or message your provider or 

team.

If you would like to talk to a mental health provider, please call your local facility for same day services 

(Same-Day Healthcare Services Search - VA Access to Care) . If you are in crisis, please contact the 

Veterans Crisis Line for confidential intervention and support 24 hours a day, seven days a week, 365 

days a year at 988 and Press 1, chat online at , or send a message to 838255. VeteransCrisisLine.net/Chat

Lab Test: Drug Screen Basic

Lab Type: Chemistry/Hematology Ordering

Provider:

DOMA, ANAMIKA

Specimen: Urine (substance) Ordering

Location:

SACRAMENTO VA 

MEDICAL CENTER

Date/Time Collected: 22 Sep 2023 @ 1125 Collected

Location:

SACRAMENTO VA 

MEDICAL CENTER

Test Name Result Units Reference Range Status Performing 

Location

AMPHETAMINES NEG -- (NEG 

(Cutoff=1000ng

/mL))

Final SACRAMENTO VA 

MEDICAL CENTER 

10535 HOSPITAL 

WAY , MATHER, 

CA 95655-4200

Interpretation: Highlights:

A. Enzyme-Multiplied Immunoassay is typically the first test used to

screen for drugs

B. Confirmatory testing is required / considered when:

1) Negative for prescribed opioid -immunoassay less/not sensitive for

semisynthetic and synthetic opioids

2) Negative for prescribed benzodiazepines - immunoassay less sensitive

to clonazepam, lorazepam, and alprazolam

3) Positive for prescription drugs not prescribed (benzodiazepines,

opioids, stimulants.)

4) Positive for illicit drugs (methamphetamine, cocaine, etc)

- amphetamines are highly cross-reactive

Positive screening results are unconfirmed and should not be used for

non-medical purposes.

Specimens for drugs of abuse are kept for 30 days if further

testing/confirmation is required.

COCAINE NEG -- (NEG 

(Cutoff=300ng

Final SACRAMENTO VA 

MEDICAL CENTER 

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APPENDIX 695

Case 4:22-cv-00343-Y Document 239-16 Filed 04/26/24 Page 40 of 46 PageID 7374
/mL)) 10535 HOSPITAL 

WAY , MATHER, 

CA 95655-4200

CANNABINOIDS NEG -- (NEG (Cutoff=50ng

/mL))

Final SACRAMENTO VA 

MEDICAL CENTER 

10535 HOSPITAL 

WAY , MATHER, 

CA 95655-4200

OPIATES NEG -- (NEG 

(Cutoff=300ng

/mL))

Final SACRAMENTO VA 

MEDICAL CENTER 

10535 HOSPITAL 

WAY , MATHER, 

CA 95655-4200

Creatinine, Urine 41.8 mg/dl (27-300) Final SACRAMENTO VA 

MEDICAL CENTER 

10535 HOSPITAL 

WAY , MATHER, 

CA 95655-4200

OXYCODONE NEG -- (NEG (Cutoff=300 

ng/mL))

Final SACRAMENTO VA 

MEDICAL CENTER 

10535 HOSPITAL 

WAY , MATHER, 

CA 95655-4200

Comments: --

Performing Location Name/Address:

SACRAMENTO VA MEDICAL CENTER 10535 HOSPITAL WAY , MATHER, CA 95655-4200

Lab Test: Gen Chem Specimen

Lab Type: Chemistry/Hematology Ordering

Provider:

DOMA, ANAMIKA

Specimen: Urine (substance) Ordering

Location:

SACRAMENTO VA 

MEDICAL CENTER

Date/Time Collected: 22 Sep 2023 @ 1125 Collected

Location:

SACRAMENTO VA 

MEDICAL CENTER

Test Name Result Units Reference Range Status Performing 

Location

APPEARANCE Clear -- Final SACRAMENTO VA 

MEDICAL CENTER 

10535 HOSPITAL 

WAY , MATHER, 

CA 95655-4200

URINE COLOR COLORLESS -- Final SACRAMENTO VA 

MEDICAL CENTER 

10535 HOSPITAL 

WAY , MATHER, 

CA 95655-4200

SPECIFIC GRAVITY 1.009 -- (1.003-1.035) Final SACRAMENTO VA 

MEDICAL CENTER 

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APPENDIX 696

Case 4:22-cv-00343-Y Document 239-16 Filed 04/26/24 Page 41 of 46 PageID 7375
10535 HOSPITAL 

WAY , MATHER, 

CA 95655-4200

UR.

UROBILINOGEN

Negative mg/dL (0.2-1.0) Final SACRAMENTO VA 

MEDICAL CENTER 

10535 HOSPITAL 

WAY , MATHER, 

CA 95655-4200

URINE BLOOD Negative -- (NEG) Final SACRAMENTO VA 

MEDICAL CENTER 

10535 HOSPITAL 

WAY , MATHER, 

CA 95655-4200

URINE BILIRUBIN Negative -- (NEG) Final SACRAMENTO VA 

MEDICAL CENTER 

10535 HOSPITAL 

WAY , MATHER, 

CA 95655-4200

URINE KETONES Negative mg/dL (NEG) Final SACRAMENTO VA 

MEDICAL CENTER 

10535 HOSPITAL 

WAY , MATHER, 

CA 95655-4200

URINE GLUCOSE Negative mg/dL (NEG) Final SACRAMENTO VA 

MEDICAL CENTER 

10535 HOSPITAL 

WAY , MATHER, 

CA 95655-4200

URINE PROTEIN Negative mg/dL (NEGTRACE) Final SACRAMENTO VA 

MEDICAL CENTER 

10535 HOSPITAL 

WAY , MATHER, 

CA 95655-4200

URINE PH 6.5 -- (5.0-8.0) Final SACRAMENTO VA 

MEDICAL CENTER 

10535 HOSPITAL 

WAY , MATHER, 

CA 95655-4200

URINE NITRITE Negative -- (NEG) Final SACRAMENTO VA 

MEDICAL CENTER 

10535 HOSPITAL 

WAY , MATHER, 

CA 95655-4200

LEUKOCYTE

ESTERASE

Negative Leu/uL (NEG) Final SACRAMENTO VA 

MEDICAL CENTER 

10535 HOSPITAL 

WAY , MATHER, 

CA 95655-4200

Interpretation: Reflex cultures are not performed on Urinalysis orders for future

collection. If a culture is needed on this specimen, the laboratory must

be notified within 48 hours of collection.

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APPENDIX 697

Case 4:22-cv-00343-Y Document 239-16 Filed 04/26/24 Page 42 of 46 PageID 7376
Mather lab: 916-366-5373

Martinez lab: 916-372-2961

Redding lab: 530-226-7595

Oakland lab: 510-267-7532

Chico lab: 530-879-5024

Comments: Reagent strip does not indicate a microscopic exam.

Performing Location Name/Address:

SACRAMENTO VA MEDICAL CENTER 10535 HOSPITAL WAY , MATHER, CA 95655-4200

Lab Test: Troponin I POC

Lab Type: Chemistry/Hematology Ordering

Provider:

DOMA, ANAMIKA

Specimen: Blood (substance) Ordering

Location:

SACRAMENTO VA 

MEDICAL CENTER

Date/Time Collected: 22 Sep 2023 @ 0955 Collected

Location:

SACRAMENTO VA 

MEDICAL CENTER

Test Name Result Units Reference 

Range

Status Performing 

Location

TROPONIN-I (iSTAT)0.01 ng/mL (<0.04) Final SACRAMENTO VA 

MEDICAL CENTER 

10535 HOSPITAL 

WAY , MATHER, CA 

95655-4200

Interpretation: SEND CRITICAL SAMPLES TO MAIN LABORATORY FOR CONFIRMATION

Comments: Operator ID Britts Kelley

Meter ID 379956

Performing Location Name/Address:

SACRAMENTO VA MEDICAL CENTER 10535 HOSPITAL WAY , MATHER, CA 95655-4200

Lab Test: D Dimer Quant~ACL 3000

Lab Type: Chemistry/Hematology Ordering

Provider:

DOMA, ANAMIKA

Specimen: Plasma (substance) Ordering

Location:

SACRAMENTO VA 

MEDICAL CENTER

Date/Time Collected: 22 Sep 2023 @ 0955 Collected

Location:

SACRAMENTO VA 

MEDICAL CENTER

Test Name Result Units Reference 

Range

Status Performing 

Location

D-DIMER 289 ng/mL FEU (0-500) Final SACRAMENTO VA 

MEDICAL CENTER 

10535 HOSPITAL 

WAY , MATHER, CA 

95655-4200

Interpretation: Reference range for this assay (D-DIMER) changed 06/18/2018

Previous reference range: 6-450 ng/ml FEU.

FEU=Fibrinogen Equivalent Units

In the appropriate clinical setting a d-dimer level in the

reference range largely rules out active intravascular thrombosis

with a probability of >90%. Results of D-Dimer testing should be

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APPENDIX 698

Case 4:22-cv-00343-Y Document 239-16 Filed 04/26/24 Page 43 of 46 PageID 7377
interpreted in conjunction with the patient's history and clinical

presentation. Clinical diagnosis should not be based only on

D-Dimer test results for exclusion of VTE (DTE or PE).

Comments: --

Performing Location Name/Address:

SACRAMENTO VA MEDICAL CENTER 10535 HOSPITAL WAY , MATHER, CA 95655-4200

Lab Test: Hemogram V~SYSMEX XE-2100

Lab Type: Chemistry/Hematology Ordering

Provider:

DOMA, ANAMIKA

Specimen: Blood (substance) Ordering

Location:

SACRAMENTO VA 

MEDICAL CENTER

Date/Time Collected: 22 Sep 2023 @ 0955 Collected

Location:

SACRAMENTO VA 

MEDICAL CENTER

Test Name Result Units Reference Range Status Performing Location

WBC 9.1 K/cmm (4.8-10.8) Final SACRAMENTO VA 

MEDICAL CENTER 

10535 HOSPITAL 

WAY , MATHER, CA 

95655-4200

RBC 4.97 M/cmm (4.7-6.1) Final SACRAMENTO VA 

MEDICAL CENTER 

10535 HOSPITAL 

WAY , MATHER, CA 

95655-4200

HGB 15.2 g/dL (14-18) Final SACRAMENTO VA 

MEDICAL CENTER 

10535 HOSPITAL 

WAY , MATHER, CA 

95655-4200

HCT 44.8 % (42-52) Final SACRAMENTO VA 

MEDICAL CENTER 

10535 HOSPITAL 

WAY , MATHER, CA 

95655-4200

MCV 90.1 fL (80-99) Final SACRAMENTO VA 

MEDICAL CENTER 

10535 HOSPITAL 

WAY , MATHER, CA 

95655-4200

MCH 30.6 uug (27-34) Final SACRAMENTO VA 

MEDICAL CENTER 

10535 HOSPITAL 

WAY , MATHER, CA 

95655-4200

MCHC 33.9 gm/dL (31.8-35.3) Final SACRAMENTO VA 

MEDICAL CENTER 

10535 HOSPITAL 

WAY , MATHER, CA 

95655-4200

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APPENDIX 699

Case 4:22-cv-00343-Y Document 239-16 Filed 04/26/24 Page 44 of 46 PageID 7378
PLT 323 K/cmm (130-400) Final SACRAMENTO VA 

MEDICAL CENTER 

10535 HOSPITAL 

WAY , MATHER, CA 

95655-4200

MPV 9.5 fL (9.1-12.5) Final SACRAMENTO VA 

MEDICAL CENTER 

10535 HOSPITAL 

WAY , MATHER, CA 

95655-4200

LYMPH % 16.5 Low % (20-51) Final SACRAMENTO VA 

MEDICAL CENTER 

10535 HOSPITAL 

WAY , MATHER, CA 

95655-4200

LYMPH # 1.5 K/cmm (1.2-3.4) Final SACRAMENTO VA 

MEDICAL CENTER 

10535 HOSPITAL 

WAY , MATHER, CA 

95655-4200

MONO % 7.6 % (2.0-13.0) Final SACRAMENTO VA 

MEDICAL CENTER 

10535 HOSPITAL 

WAY , MATHER, CA 

95655-4200

MONO # 0.7 K/cmm (0.2-1.2) Final SACRAMENTO VA 

MEDICAL CENTER 

10535 HOSPITAL 

WAY , MATHER, CA 

95655-4200

EOS % 0.9 % (0.5-7.0) Final SACRAMENTO VA 

MEDICAL CENTER 

10535 HOSPITAL 

WAY , MATHER, CA 

95655-4200

EOS # 0.1 K/cmm (0.1-0.5) Final SACRAMENTO VA 

MEDICAL CENTER 

10535 HOSPITAL 

WAY , MATHER, CA 

95655-4200

BASO % 0.4 % (0-2.0) Final SACRAMENTO VA 

MEDICAL CENTER 

10535 HOSPITAL 

WAY , MATHER, CA 

95655-4200

NEUT # 6.7 K/cmm (1.5-7.9) Final SACRAMENTO VA 

MEDICAL CENTER 

10535 HOSPITAL 

WAY , MATHER, CA 

95655-4200

NEUT % 74.3 % (40-80) Final SACRAMENTO VA 

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APPENDIX 700

Case 4:22-cv-00343-Y Document 239-16 Filed 04/26/24 Page 45 of 46 PageID 7379
MEDICAL CENTER 

10535 HOSPITAL 

WAY , MATHER, CA 

95655-4200

BASO # 0.0 K/cmm (0.0-0.2) Final SACRAMENTO VA 

MEDICAL CENTER 

10535 HOSPITAL 

WAY , MATHER, CA 

95655-4200

IG # 0.0 K/cmm (<0.4) Final SACRAMENTO VA 

MEDICAL CENTER 

10535 HOSPITAL 

WAY , MATHER, CA 

95655-4200

IG % 0.3 % (<4.9) Final SACRAMENTO VA 

MEDICAL CENTER 

10535 HOSPITAL 

WAY , MATHER, CA 

95655-4200

RDW-SD 42.9 fL (35.1-43.9) Final SACRAMENTO VA 

MEDICAL CENTER 

10535 HOSPITAL 

WAY , MATHER, CA 

95655-4200

Comments: --

Performing Location Name/Address:

SACRAMENTO VA MEDICAL CENTER 10535 HOSPITAL WAY , MATHER, CA 95655-4200

Lab Test: Ethanol

Lab Type: Chemistry/Hematology Ordering

Provider:

DOMA, ANAMIKA

Specimen: Serum (substance) Ordering

Location:

SACRAMENTO VA 

MEDICAL CENTER

Date/Time Collected: 22 Sep 2023 @ 0955 Collected

Location:

SACRAMENTO VA 

MEDICAL CENTER

Test Name Result Units Reference 

Range

Status Performing 

Location

ALCOHOL (BLOOD) <5 mg/dL (<5) Final SACRAMENTO VA 

MEDICAL CENTER 

10535 HOSPITAL 

WAY , MATHER, CA 

95655-4200

Interpretation: NORMAL: <5 = NONE DETECTED. LEGAL INTOXICATION: 80 mg/dl or 0.08%.

Comments: --

Performing Location Name/Address:

SACRAMENTO VA MEDICAL CENTER 10535 HOSPITAL WAY , MATHER, CA 95655-4200

Lab Test: Hepatic Function Panel

Lab Type: Chemistry/Hematology Ordering DOMA, ANAMIKA

526652%(57$//(1

'DWHRI%LUWK Page 242 of 337

APPENDIX 701

Case 4:22-cv-00343-Y Document 239-16 Filed 04/26/24 Page 46 of 46 PageID 7380