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Description

Medical Records Participant:

Taylor N Evans

Birth Date:

07/02/1990

Clinical services provided and/or recorded by Driscoll Children's Hospital System - Employee Health Services, 3533 S Alameda St, Corpus Christi, TX 78411 (361) 694-5000 Record/Results Printed: 02/14/2020 02:53:10 PM

HEPATITIS B IMMUNIZATION RECORD Description / Result

10/23/2017 10:15

Reason for this visit:

NEW TO THIS ORGANIZATION NEW TO THIS ORGANIZATION NEW TO THIS ORGANIZATION

04/21/2017 14:35

10/21/2016 14:54

Education: Vaccine Information Statement (VIS) given?

YES

YES

YES

Dose administered this visit (or latest dose from prior documentation): Immunity status:

THIRD DOSE

SECOND DOSE

FIRST DOSE

IMMUNE

UNKNOWN

NOT IMMUNE

Date vaccine administered:

10/23/2017

04/21/2017

10/21/2016

Hepatitis B vaccination performed by:

EHS AS PART OF THIS ENCOUNTER

EHS AS PART OF THIS ENCOUNTER

EHS AS PART OF THIS ENCOUNTER

Signed by:

Jennifer Cole RN

Jennifer Coronado CMA

Julia Reyes DNP RN CPNPAC

Date signed:

10/23/2017

04/21/2017

10/21/2016

09/25/2017

11/18/2016

Administration site:

RIGHT DELTOID

RIGHT DELTOID

LEFT DELTOID

Administered by:

Jennifer Cole RN

Jennifer Coronado CMA

Julia Reyes DNP RN CPNPAC

Time vaccine administered:

10:26

14:36

Date of next vaccination (if required):

CPT 4 Code

90746

90746

90746

CVX Code

43

43

43

Dose Administered

1.0 mL

1.0 mL

1.0 mL

Dose Form

1.0 mL

1.0 mL

1.0 mL

Expiration Date

02/12/2020

03/13/2019

03/06/2019

Lot Number

53P39

EB993

Z25GH

Manufacturer

GSK

GSK

GSK

Presentation

Pre-filled syringe (single dose)

Pre-filled syringe (single dose)

Pre-filled syringe (single dose)

This Electronic Health Record was generated by the ReadySet Employee Health System. This Electronic Health Record contains personal health information and is intended for authorized healthcare personnel only. Contact Driscoll Children's Hospital System - Employee Health Services for more information. Page 1 of 18

Participant:

Taylor N Evans

Birth Date:

07/02/1990

Clinical services provided and/or recorded by Driscoll Children's Hospital System - Employee Health Services, 3533 S Alameda St, Corpus Christi, TX 78411 (361) 694-5000 Record/Results Printed: 02/14/2020 02:53:10 PM

HEPATITIS B IMMUNIZATION RECORD Description / Result

10/23/2017 10:15

04/21/2017 14:35

10/21/2016 14:54

Product ID

20171

20171

20171

Product Name

Engerix-B

Engerix-B

Engerix-B

Route

Intramuscular

Intramuscular

Intramuscular

VIS Date

07/20/2016

07/20/2016

07/20/2016

This Electronic Health Record was generated by the ReadySet Employee Health System. This Electronic Health Record contains personal health information and is intended for authorized healthcare personnel only. Contact Driscoll Children's Hospital System - Employee Health Services for more information. Page 2 of 18

Participant:

Taylor N Evans

Birth Date:

07/02/1990

Clinical services provided and/or recorded by Driscoll Children's Hospital System - Employee Health Services, 3533 S Alameda St, Corpus Christi, TX 78411 (361) 694-5000 Record/Results Printed: 02/14/2020 02:53:10 PM

HEPATITIS B TITER RECORD Description / Result

08/24/2015 13:30

Hepatitis B titer performed by:

EHS AS PART OF THIS ENCOUNTER

Result of hepatitis B virus surface antibody:

NEGATIVE

Immunity status:

NOT IMMUNE

Date and time of specimen collection:

08/24/2015

Date and time of hepatitis B virus surface antibody:

08/24/2015

Date and time hepatitis B virus surface antibody results received:

08/26/2015

Reviewed by:

Jennifer Coronado, CMA

Date reviewed:

08/26/2015

This Electronic Health Record was generated by the ReadySet Employee Health System. This Electronic Health Record contains personal health information and is intended for authorized healthcare personnel only. Contact Driscoll Children's Hospital System - Employee Health Services for more information. Page 3 of 18

Participant:

Taylor N Evans

Birth Date:

07/02/1990

Clinical services provided and/or recorded by Driscoll Children's Hospital System - Employee Health Services, 3533 S Alameda St, Corpus Christi, TX 78411 (361) 694-5000 Record/Results Printed: 02/14/2020 02:53:10 PM

IGRA Description / Result

08/24/2015 13:30

IGRA performed by:

EHS AS PART OF THIS ENCOUNTER

Reason for test:

FIRST TEST (PREPLACEMENT)

Date results received:

08/31/2015

Reviewed by:

J. Reyes

Type of test:

T-SPOT

Date reviewed:

08/31/2015

Date of specimen collection:

08/24/2015

Result:

NEGATIVE

This Electronic Health Record was generated by the ReadySet Employee Health System. This Electronic Health Record contains personal health information and is intended for authorized healthcare personnel only. Contact Driscoll Children's Hospital System - Employee Health Services for more information. Page 4 of 18

Participant:

Taylor N Evans

Birth Date:

07/02/1990

Clinical services provided and/or recorded by Driscoll Children's Hospital System - Employee Health Services, 3533 S Alameda St, Corpus Christi, TX 78411 (361) 694-5000 Record/Results Printed: 02/14/2020 02:53:10 PM

INFLUENZA LABS Description / Result

01/24/2018 12:16

Accession number:

RQ41

Date and time of specimen collection:

01/24/2018 16:02

Rapid influenza test: Specimen source

NASOPHARYNGEAL

Rapid influenza test: Comments

Negative

Reviewed by:

Jennifer Coronado, CMA

Date reviewed:

01/29/2018

This Electronic Health Record was generated by the ReadySet Employee Health System. This Electronic Health Record contains personal health information and is intended for authorized healthcare personnel only. Contact Driscoll Children's Hospital System - Employee Health Services for more information. Page 5 of 18

Participant:

Taylor N Evans

Birth Date:

07/02/1990

Clinical services provided and/or recorded by Driscoll Children's Hospital System - Employee Health Services, 3533 S Alameda St, Corpus Christi, TX 78411 (361) 694-5000 Record/Results Printed: 02/14/2020 02:53:10 PM

MEASLES (RUBEOLA) TITER RECORD Description / Result

08/24/2015 13:30

Measles (rubeola) titer performed by: Result of measles IgG:

EHS AS PART OF THIS ENCOUNTER POSITIVE

Immunity status:

IMMUNE

Date and time of specimen collection:

08/24/2015

Date and time of measles IgG:

08/24/2015

Date and time measles IgG results received:

08/26/2015

Reviewed by:

Jennifer Coronado, CMA

Date reviewed:

08/26/2015

This Electronic Health Record was generated by the ReadySet Employee Health System. This Electronic Health Record contains personal health information and is intended for authorized healthcare personnel only. Contact Driscoll Children's Hospital System - Employee Health Services for more information. Page 6 of 18

Participant:

Taylor N Evans

Birth Date:

07/02/1990

Clinical services provided and/or recorded by Driscoll Children's Hospital System - Employee Health Services, 3533 S Alameda St, Corpus Christi, TX 78411 (361) 694-5000 Record/Results Printed: 02/14/2020 02:53:10 PM

MEASLES, MUMPS, AND RUBELLA (MMR) IMMUNIZATION RECORD Description / Result

02/12/2020 15:00

Reason for this visit:

NEW TO THIS ORGANIZATION OTHER REASON

01/07/2020 14:15

Education: Vaccine Information Statement (VIS) given?

YES

YES

Dose administered this visit (or latest dose from prior documentation):

SECOND DOSE

FIRST DOSE

Immunity status:

IMMUNE

NOT IMMUNE

Date vaccine administered:

02/12/2020

01/07/2020

MMR vaccination performed by:

EHS AS PART OF THIS ENCOUNTER

EHS AS PART OF THIS ENCOUNTER

Signed by:

Jennifer Cole RN

Schamica Rector

Date signed:

02/12/2020

01/07/2020

Administration site:

LEFT ARM

LEFT ARM

Administered by:

Jennifer Cole RN

Schamica Rector

Time vaccine administered:

15:00

14:16

CPT 4 Code

90707

90707

CVX Code

03

03

Dose Administered

0.5 mL

0.5 mL

Dose Form

0.5 mL

0.5 mL

Expiration Date

05/23/2021

05/23/2021

Lot Number

SO15961

SO15962

Date of next vaccination (if required):

02/10/2020

Manufacturer

Merck

Merck

Presentation

Single Dose Vial

Single Dose Vial

Product ID

31252

31252

Product Name

MMR-II

MMR-II

Route

Subcutaneous

Subcutaneous

VIS Date

08/15/2019

08/15/2019

This Electronic Health Record was generated by the ReadySet Employee Health System. This Electronic Health Record contains personal health information and is intended for authorized healthcare personnel only. Contact Driscoll Children's Hospital System - Employee Health Services for more information. Page 7 of 18

Participant:

Taylor N Evans

Birth Date:

07/02/1990

Clinical services provided and/or recorded by Driscoll Children's Hospital System - Employee Health Services, 3533 S Alameda St, Corpus Christi, TX 78411 (361) 694-5000 Record/Results Printed: 02/14/2020 02:53:10 PM

MUMPS TITER RECORD Description / Result

01/06/2020 11:14

Mumps titer performed by:

EHS AS PART OF THIS ENCOUNTER

Result of mumps IgG:

NEGATIVE

Immunity status:

NOT IMMUNE

Mumps IgG reference range:

Negative

Date and time of specimen collection:

01/06/2020 11:19

Date and time of mumps IgG:

01/06/2020 11:19

Reviewed by:

Schamica Rector

Date reviewed

01/07/2020

This Electronic Health Record was generated by the ReadySet Employee Health System. This Electronic Health Record contains personal health information and is intended for authorized healthcare personnel only. Contact Driscoll Children's Hospital System - Employee Health Services for more information. Page 8 of 18

Participant:

Taylor N Evans

Birth Date:

07/02/1990

Clinical services provided and/or recorded by Driscoll Children's Hospital System - Employee Health Services, 3533 S Alameda St, Corpus Christi, TX 78411 (361) 694-5000 Record/Results Printed: 02/14/2020 02:53:10 PM

RESPIRATOR FIT TESTING Description / Result

02/06/2020 12:14

01/25/2018 00:00

N95: Overall fit test result

PASS

PASS

N95: Make, model, and size

3M 1870 ONE SIZE N95

3M 1870 ONE SIZE N95

Respirator fit testing follow-up date:

01/30/2021

01/30/2019

Education provided:

YES

YES

N95 respirator versus surgical mask

N95 RESPIRATOR VERSUS SURGICAL MASK

Respirator limitations

RESPIRATOR LIMITATIONS

Inspecting respirator condition

INSPECTING RESPIRATOR CONDITION

Re-use

RE-USE

Donning and Doffing respirator and other PPE

DONNING AND DOFFING RESPIRATOR AND OTHER PPE

Where to obtain replacement respirators

WHERE TO OBTAIN REPLACEMENT RESPIRATORS

Location of respirator protection program

LOCATION OF RESPIRATOR PROTECTION PROGRAM

Performed by:

Julia Reyes DNP, RN

Julia Reyes DNP RN CPNPAC

Date of fit test:

01/31/2020

01/31/2018

Date reviewed:

02/06/2020

N95: Expiration date

01/30/2021

01/30/2019

Glasses

GLASSES

Has the health care worker had anything to eat, drink (other NO than water), or have they smoked or chewed gum in the past 15 minutes?

NO

N95

N95

N95

Positive pressure fit check:

PASS

PASS

Negative pressure fit check:

PASS

PASS

Agent used for qualitative (sensitivity) fit testing:

SACCHARIN

SACCHARIN

Qualitative normal breathing (beginning of test):

PASS

This Electronic Health Record was generated by the ReadySet Employee Health System. This Electronic Health Record contains personal health information and is intended for authorized healthcare personnel only. Contact Driscoll Children's Hospital System - Employee Health Services for more information. Page 9 of 18

Participant:

Taylor N Evans

Birth Date:

07/02/1990

Clinical services provided and/or recorded by Driscoll Children's Hospital System - Employee Health Services, 3533 S Alameda St, Corpus Christi, TX 78411 (361) 694-5000 Record/Results Printed: 02/14/2020 02:53:10 PM

RESPIRATOR FIT TESTING Description / Result

02/06/2020 12:14

Qualitative deep breathing:

PASS

Qualitative turning head side to side:

PASS

Qualitative nodding head up and down:

PASS

Qualitative count or talk out loud slowly:

PASS

Qualitative grimace (smile or frown):

PASS

Qualitative bending forward and touch toes:

PASS

Has medical clearance been completed?

YES

Qualitative normal breathing (end of test):

PASS

01/25/2018 00:00

YES

Qualitative number of squeezes:

10

10

Qualitative: Amount of time

15

20

This Electronic Health Record was generated by the ReadySet Employee Health System. This Electronic Health Record contains personal health information and is intended for authorized healthcare personnel only. Contact Driscoll Children's Hospital System - Employee Health Services for more information. Page 10 of 18

Participant:

Taylor N Evans

Birth Date:

07/02/1990

Clinical services provided and/or recorded by Driscoll Children's Hospital System - Employee Health Services, 3533 S Alameda St, Corpus Christi, TX 78411 (361) 694-5000 Record/Results Printed: 02/14/2020 02:53:10 PM

RESPIRATOR USER MEDICAL CLEARANCE Description / Result

01/22/2020 15:44

Reason for evaluation:

ROUTINE (ANNUAL)

N95 respirator recommendations:

CLEARED FOR RESPIRATOR USE

CAPR recommendations:

CLEARED FOR RESPIRATOR USE

I have reviewed the health care worker's Respirator questionnaire and made the following determination:

Respirator clearance expiration date:

PASS BASED ON QUESTIONNAIRE. MEDICALLY SUITABLE FOR RESPIRATOR USE WITH NO RESTRICTIONS. 01/30/2021

Reviewed by:

Julia Reyes DNP, RN

Filter-mask non-cartridge (N, R, or P disposable) (N95)

FILTER-MASK NONCARTRIDGE (N, R, OR P DISPOSABLE) (N95)

Date reviewed:

01/22/2020

Schedule next routine medical clearance

SCHEDULE NEXT ROUTINE MEDICAL CLEARANCE

Next evaluation date:

1 YEAR

This Electronic Health Record was generated by the ReadySet Employee Health System. This Electronic Health Record contains personal health information and is intended for authorized healthcare personnel only. Contact Driscoll Children's Hospital System - Employee Health Services for more information. Page 11 of 18

Participant:

Taylor N Evans

Birth Date:

07/02/1990

Clinical services provided and/or recorded by Driscoll Children's Hospital System - Employee Health Services, 3533 S Alameda St, Corpus Christi, TX 78411 (361) 694-5000 Record/Results Printed: 02/14/2020 02:53:10 PM

RUBELLA TITER RECORD Description / Result

08/24/2015 13:30

Result of rubella IgG:

POSITIVE

Immunity status:

IMMUNE

Rubella titer performed by:

EHS AS PART OF THIS ENCOUNTER

Date and time of specimen collection:

08/24/2015

Date and time of rubella IgG:

08/24/2015

Date and time rubella IgG results received:

08/26/2015

Reviewed by:

Jennifer Coronado, CMA

Date reviewed:

08/26/2015

This Electronic Health Record was generated by the ReadySet Employee Health System. This Electronic Health Record contains personal health information and is intended for authorized healthcare personnel only. Contact Driscoll Children's Hospital System - Employee Health Services for more information. Page 12 of 18

Participant:

Taylor N Evans

Birth Date:

07/02/1990

Clinical services provided and/or recorded by Driscoll Children's Hospital System - Employee Health Services, 3533 S Alameda St, C...