Raymond S Campo v. Dialysis Clinic, Inc. et al, 034136/2016, 161 (N.Y. Sup. Ct., Rockland County Jul. 15, 2019) (2024)

`FILED: ROCKLAND COUNTY CLERK 07/12/2019 05:16 PMFILED: ROCKLAND COUNTY CLERK 07/15/2019 02:48 PM
`
`NYSCEF DOC. NO. 104NYSCEF DOC. NO. 161
`
`
`
`INDEX NO. 034136/2016INDEX NO. 034136/2016
`
`
`
`RECEIVED NYSCEF: 07/12/2019RECEIVED NYSCEF: 07/15/2019
`
`2
`
`()H
`
`rds
`
`A
`
`

`
`FILED: ROCKLAND COUNTY CLERK 07/12/2019 05:16 PMFILED: ROCKLAND COUNTY CLERK 07/15/2019 02:48 PM
`
`NYSCEF DOC. NO. 104NYSCEF DOC. NO. 161
`
`
`
`INDEX NO. 034136/2016INDEX NO. 034136/2016
`
`
`
`RECEIVED NYSCEF: 07/12/2019RECEIVED NYSCEF: 07/15/2019
`
`CIOX Health
`P.O. Box 1812
`GA 30023-1812
`Alpharetta,
`Fed Tax ID 58 - 2659941
`367 - 1500
`(800)
`
`to·
`
`Ship
`
`Siuh Risk Mgmt
`Siuh Risk Mgmt
`475 SEAVIEW
`AVE
`STATEN
`ISLAND,
`
`NY 10305-3436
`
`Records
`
`from:
`
`UNIVERSITY
`ISLAND
`STATEN
`475 SEAVIEW
`AVE
`STATEN
`ISLAND,
`
`NY 10305-3436
`
`NORTH
`
`12/19/2016
`
`Request
`
`ID #
`
`0207068365
`
`Requested
`Patient
`
`DOB:
`
`By:
`
`SIUH RISK MGMT
`
`Name:
`
`CAMPO
`
`RAYMOND
`
`956
`
`Health
`CIOX
`We ensure
`healthcare
`
`provider
`largest
`is the
`exchange
`the
`compliant
`facilities
`nationwide.
`
`re!eese
`of
`of protected
`
`of
`
`information(ROl)
`health
`information
`
`services
`for
`over
`
`technology.
`
`and
`18,000
`
`

`
`FILED: ROCKLAND COUNTY CLERK 07/12/2019 05:16 PMFILED: ROCKLAND COUNTY CLERK 07/15/2019 02:48 PM
`
`NYSCEF DOC. NO. 104NYSCEF DOC. NO. 161
`
`
`
`INDEX NO. 034136/2016INDEX NO. 034136/2016
`
`
`
`RECEIVED NYSCEF: 07/12/2019RECEIVED NYSCEF: 07/15/2019
`
`Risk Management
`200 Community
`Drive
`Great Neck, New York 11021
`Tel
`(516) 465 8863
`Fax (516)
`465 8042
`
`Katherine
`Jeannanne
`Melissa
`
`Olivo-
`
`Restivo
`
`Guarino,
`
`IP Medical
`- Pathology,
`Tari Deliberti
`
`kolivo@northwell.edu
`Records,
`JGarito@northwell.edu
`- Billing,
`MGuarino@northwell.edu:
`
`Angela
`
`Perretta
`
`- Radiology,
`
`Aperretta@northwellsee-d_u
`
`Florence
`
`Vargas,
`
`Claims
`
`Coordinator-
`
`Risk Management
`
`November
`
`15, 2016
`
`Secure
`
`Records
`
`(lawsuit)
`
`Northwell
`Health~
`
`TO:
`
`Tdeliberti@northwell.edu
`
`FROM:
`
`DATE:
`
`SUBJECT:
`
`PATIENT:
`
`MED REC NO:
`
`DATE
`
`OF BIRTH:
`
`V/gIL
`
`Td
`
`ADM DATES:
`
`Please
`
`secure
`
`the medical
`records
`but not
`limited
`
`pathology,
`including
`sponges/instrüñicnts,
`please
`contact
`
`etc.)
`relating
`Risk Management.
`
`†Ï¾891L392701f61n
`
`and all
`shadies,
`to all
`slides,
`to the above
`
`reports,
`blocks,
`named
`
`fetal monitoring
`strips,
`and foreign
`bodies
`(i.e.,
`patient.
`If
`there
`is any doubt
`
`records
`films,
`billing
`retained
`hardware,
`as to what must
`
`and all
`
`be secured,
`
`No
`
`copies
`
`of
`
`this
`
`file
`
`should
`
`be released
`
`without
`
`authorization
`
`from Risk Management.
`
`***Please
`
`make
`
`two CERTIFIED
`
`Electronic
`
`copies,
`
`send
`
`one to PRI
`
`and one copy
`
`to our attorney.***
`
`***Email
`
`addresses
`
`are strictly
`
`for
`
`the nuroose
`
`of emailing
`
`passwords
`
`for
`
`the electronic
`
`rp_cards***
`
`Physicians'
`
`Reciprocal
`Insurers
`1800 Northem
`Boulevard
`NY 11576
`Roslyn,
`Joan Rudolph-
`i.rudoh‡^medmal.com
`InBox-
`neithwell@medmal.com
`
`Attention:
`General
`
`& Slattery
`Benvenuto
`Santangelo,
`1800 Northern
`Boulevard
`NY 11576
`Roslyn,
`Mark
`Attention:
`Salsberg,
`
`Esq.
`
`

`
`FILED: ROCKLAND COUNTY CLERK 07/12/2019 05:16 PMFILED: ROCKLAND COUNTY CLERK 07/15/2019 02:48 PM
`
`NYSCEF DOC. NO. 104NYSCEF DOC. NO. 161
`
`
`
`INDEX NO. 034136/2016INDEX NO. 034136/2016
`
`
`
`RECEIVED NYSCEF: 07/12/2019RECEIVED NYSCEF: 07/15/2019
`
`neums B
`
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`nasm.
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`Consent
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`To Operative
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`Invasive
`
`/ Diagn
`
`tic Procedures,
`
`Anesthesla
`
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`
`1
`
`I authorize Dr.
`
`Permission.
`or assistents
`facility to perform I
`this heâ‰äis
`at
`'
`(procedures to be written both in m
`
`following op ration(s) and/o
`terminology and in terms
`
`and bis/her associates
`and possible residents
`and/or course of treemed(s):
`p•~•eders(s),
`dagnostic
`the patient can understand).
`
`rocedure(s) as may be purposeful
`identity will remain
`patient's)
`
`televising or o er metho s of visually recording
`including such ah±g'±ph...g.
`videotaping.
`of medical knowledge andfor édücâticia, with the understanding that my
`for the adence'aªnt
`anonymous.
`Dr.
`risks, benefite and alternatives.
`of procedure(s),
`Explanation
`and has also informed me of expected benefits
`has fully explained to me the nature and purpose of the operation(s)/procedure(s)
`and the risks that may arise, as well as possible attemative
`(from known causes), attendant discomforts
`and complications
`I have been given an ojipGrkn".y to
`including no treatment.
`to the proposed procedure(s).
`treatment
`methods of diagnosis and/or
`ask questions, and all my questions have been enswered fully and seliefactorlly.
`(as may be considered necessary) and the type, will be
`I understand that attesthetics, sedatives or analgesics
`Anesthesta.
`team or other practitioner
`(with
`explained to me along with the risks, benefits and attematives by a representative of the an=:thaeh
`services at this healthcare facility prior to the surgery.
`providing sedation/anesthesia
`appropriate competencies)
`I recognize that there are always
`to the administration of blood or blood products as may be considered necessary.
`) further consent
`risks to health associated with the administration of blood or blood pmducts and such risks have been fully explained to me.
`I refuse transfusion of packed red cells, platelets, plasma or while blood cells even if such refusal will
`Refusal of Blood Products.
`in my death.
`result
`Time:
`Date:
`signature:
`**Pstient's
`for medical, scientific or
`Any organ and/or tissue surgically removed may be examined and retained by the Hospital
`S. Specimens.
`ucational purposes and such organ endfor tissue may be disposed of in accordance with customary practices and apjjlicable State
`and regü:âilsiiã. Post pathology gross examination and sl× weeks afler final diagnosis. organ andfor tissue may be transported
`training and scientific research purposes or otheswise
`hore-LlJ Schoci of NIedicine to be used for medical student
`ofstra No
`di
`rlat
`d of.
`I confirm that I have read this form, fully understand Its contents. and that all the blank spaces above
`a form.
`n
`to my signing.I understand that no ;=rms
`or assurances have been made to me conceming the
`ted prior
`from the pracâdate(s) described above
`
`L
`
`3.
`
`4,
`
`5.
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`.
`
`ap
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`Z
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`Re tive/ uardian'
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`(Signature)
`
`I
`
`rm
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`t Name
`
`Aelationshlp if other than patlant
`
`ele
`
`ni
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`Inte
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`eter's ID #
`
`Date / Tirne
`
`·'
`
`Witn'ess to signatdre (Signaturd)
`ime
`Dete
`Print Witness Name
`' Thesignatureof the patientmustbe obtainedunlessthe patientIs an unemancipaledminorundertheage o118or is otherwiseIncapableof signing.
`Responsible
`Practitioners
`I have explained the nature, purpose. benefits, C--;:kéuna
`Certification.
`I certify that
`from. risks of,
`attematives (including no !reatment and attendant
`IIkelihood of achieving goals of care and potential problems that might occur
`risks).
`to the proposed procedureloperation,
`have offered to answer any questions and have fully answered all such
`during recuperation,
`( believe that
`questions.
`I certify that the
`the patient'sgent/rciaWe/guardian
`I have explained and answered.
`fully understands what
`procedure described in the permission section of this form is accurate.
`In the event that I was not present when the patient signed this
`the informed consent process took place. 1 remain responsible for having
`the form Is only documentation that
`I understand that
`form,
`I cert
`obtained the consent
`that outside pathology slides have been reviewed by the Hospital's
`he patient.
`If applicable,
`Pathology Departm
`
`.
`
`Responsible Practitioner's
`
`n
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`
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`im
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`rint espons ble Practit oner's
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`"Pagentsrefusingtfood pnxiumsmustsignei
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`A COPY
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`
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`lipdpoodAndaloodProducts'ImmaVO003.
`16
`
`

`
`FILED: ROCKLAND COUNTY CLERK 07/12/2019 05:16 PMFILED: ROCKLAND COUNTY CLERK 07/15/2019 02:48 PM
`
`NYSCEF DOC. NO. 104NYSCEF DOC. NO. 161
`
`
`
`INDEX NO. 034136/2016INDEX NO. 034136/2016
`
`
`
`RECEIVED NYSCEF: 07/12/2019RECEIVED NYSCEF: 07/15/2019
`
`.
`
`.
`
`island
`Staten
`Ull
`University
`UU Northwell
`Health-
`North Shore-LuHealth Systemis now Northwell Health
`
`Hospital
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`KIRoYCHEVA, MILITEA
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`Consent
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`For
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`Anesthesia
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`services at
`to provide anestheds
`care team, all of whom are credentialed
`I hereby authorize the anesthesla
`Permission.
`during the
`and supportive measures may become
`to administer whatever âüésthesia
`necessary
`this healthcare
`facility,
`I also
`of an enesthss!dag!±
`and recovery within their scope of pra ctice under
`the supervision
`course of my procedure
`as part of
`the supervision
`of an a.aesthê5!0ft-jd
`In my care under
`residents may assist
`that students and/or
`understand
`training.
`their
`
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`t understand
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`and suppcidve
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`o the
`I consent
`or whomever he/she may designate.
`S.C,
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`
`and treatments which become necessary during the course of iny procedure and recovery.
`(if applicable)
`refuse the following treat,nents
`I specifically
`
`as well as any other procedure
`
`. .
`
`2.
`
`3.
`
`4.
`
`Team has fully
`from the Anesthesia
`ves, A representative
`and aft
`risks, benefits
`of procedure(s),
`Explanation
`that
`risks and discomforts
`explained the purpose, nature and benefits of the proposed anesthesia
`treatment
`compilcations,
`I have been given an
`anesthesia
`to the proposed
`treatment.
`are reasonable
`if any,
`the e!temet!ves,
`iciassaabic,
`and;
`have been answered to my satisfaction.
`that all forms of
`and all of my questions
`I understand
`to ask questions,
`opportunity
`or promises
`treatment
`I have received no guarar.têas
`and medical
`risks and I acknowledge
`that
`involves
`anesthesla
`the results of my anesthesia,
`procedure or treatment
`concerning
`(when applicable)
`Serial Procedures.
`
`Cone
`
`n
`
`I conse
`
`es of the same proced ure over a period of time:___f_.....,J-
`Date
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`to ..__.}_..._/_
`Date
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`.
`
`U
`above
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`ndl
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`this
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`confirm that
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`I have read this form,
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`Its contents,
`
`that all the blank spaces
`
`Patient/Age
`
`/Guardian'
`
`(Mgnature)
`
`Date / TIF
`
`Prin Name
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`Re
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`
`f of
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`r than pat ent
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`Telepho
`O
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`erpreter's ID #
`
`Date / Time
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`Sig
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`interpreter
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`
`Date / Ti e
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`Print
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`
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`obtalpedunlessthe patientis an unemancipatedrninorondertheageof 18or is commise Incapapleof signing.
`
`risks
`I have expiâiiled the nature, purpose, benefits, complications
`I certify that
`Cer"Meetion.
`Practitioner's
`Responsible
`from,
`goals of care and potential
`no treatment
`of achieving
`likelihood
`problems
`and attendant
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`risks),
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`to the proposed
`have offered to answer any questions
`and have fully
`might occur during recuperation,
`procedure/operation,
`all such questions.
`I have explained
`fully understands what
`and
`I believe that
`the ps:ba'/sger.t½!ive/guardian
`answered
`answered.
`the procedure described
`I certify that
`in the permiseicn
`section of
`this form is accurate.
`I was not
`In the event
`that
`I understand that
`present when the patient
`the informed consent process
`the form is only d.ccüñi5ñ:6t100 that
`n
`this form,
`from the patient.
`ain re
`for having obtained th
`consent
`took place.
`I
`
`a
`
`Responsible Practitioners Signature
`
`[thie / me
`
`Print Responsible Practitioner's NamePRINTED
`DATE
`
`voozetww141'·$
`
`THIS
`
`IS
`
`KOLIVO
`2016
`
`BY:
`12/19/
`A COPY
`
`contact
`
`information
`
`..
`
`

`
`FILED: ROCKLAND COUNTY CLERK 07/12/2019 05:16 PMFILED: ROCKLAND COUNTY CLERK 07/15/2019 02:48 PM
`
`NYSCEF DOC. NO. 104NYSCEF DOC. NO. 161
`
`
`
`INDEX NO. 034136/2016INDEX NO. 034136/2016
`
`
`
`RECEIVED NYSCEF: 07/12/2019RECEIVED NYSCEF: 07/15/2019
`
`NoŸ
`
`Shored)
`
`Staten
`
`island
`
`UniversityHospital
`
`intravenous
`
`Contrast
`
`Information
`
`CAMPO, RAYMoND
`
`KIROYCitEVA, MILIT2A
`
`l|IllilH
`S..-
`
`illiligil
`
`M
`
`o59Y H
`1956
`
`DOB:
`
`contrast agent (''X-ray dye") that contains iodine.The purpose
`Ybur imaging procedure Involves the ad,-.i:::ctration of an !dsæñca
`of this dye is to provide the radiolog|st with a rnore detailed picture that will he)p in interpreting your examination.
`r-M"-ray dye is admidat::·ed by Infection through a arnall needle placed into your veirt. During the adrr/d-:tratiGii
`Intravenous cc
`your body. Some people report a metafife taste in their mouth. Both feelings
`you may experience a feeling of warmth theegheet
`are normal and temporary,
`safe. However, as with any medication or
`cens!deed
`The intravenous contrast has been in use for many years and is generally
`Mild s[de effects such as
`a very small number of patients may experience side effects related to its adrres95,,s.
`pharmaceutic:!,
`transient hives, skin blotching or wheering have beert noted in (eas than 1% of patients, More serious aftergic meet!c:::,
`Including
`life-threatening events, have been reported in -:pp-:::!-:dely
`1 in 10,00D cases.
`major drops in blood pressure and p±r.tis."y
`Do vou have:
`ClR
`Cla
`Yes
`Asthma
`
`Ño
`
`Yes
`
`No
`
`No
`No
`
`Are you ourrently wheezing?
`Have you ever been intubated for asthma
`exacerbation?
`Do you take blood pressure medications?
`Do you have one kidney or kidney disease?
`Yes
`Do you have diabetes?
`Te's
`Are you 80 years of age or older?
`Do vou take a lyletformln cont nina medlcatlan?
`Yes
`Ackplus Met, Acttplus Met XR,Awndamet, Fortarret, Guo3phage,
`Gucophage XR, Glucovance,GIwnetza, invokamet,Janumet,Jarunet
`XR,Jersadur,¾ Kazeno,KontliglyzeXR Metaglip,Metforrrirt
`Randimet. Riemet
`if I.es_; Notification
`
`to Hold Medication
`
`48 hours
`Form
`
`Chart Note
`
`Have you ever had a CT scan or 1VP with
`Yes
`injected into a vesn?
`contrast
`]Lag, have ou had any of the following as a result?:
`Yes
`*Facial Swelling
`Yes
`Throat Mahtness or hoarseness
`Sudden drop in blood pressure
`Yes
`
`ness of breath/wheezing
`*Falnting or collapse
`(please specity):
`*Other
`
`Yes
`Yes
`
`No
`
`o
`No
`No
`
`No
`No
`
`If you have any severe allergies or anaphyl
`medication. please iist them:
`
`'s
`
`any food or
`
`prescribed
`Has your physician
`for you to take In preparation
`
`any medication
`for this exam?
`
`Yes
`
`No
`
`If Yes. please fist medications below:
`
`yo
`
`have a
`
`quost!o
`
`-----
`
`--
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`-
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`Are you:
`On dialysis?
`Pregnant?
`(Breast
`feeding does not need 10be discontinued)
`e, please Inform a staff member who w[H have a physlolan
`speak to you.
`
`Yes
`Yes
`
`Patier
`
`.ge
`
`.c
`
`Guardlan'
`
`(Signature)
`
`Date / Time
`
`Print Name
`
`Relationship if other than patient
`
`Tefephonic interpreter's lD #
`OR
`
`Signature: tr,ts: eter
`
`Dafe / Time
`
`Date / Time
`
`Print: Mterp-ctafs Name and Relationship to Patient
`
`Witness to sign u
`
`nature)
`
`Oate / Time
`
`Print Witness Name
`
`Print Technologist Narne
`Date / Time
`Technologist (Sig
`re)
`' ThesignatureDIthe pa1ien|rnusrbe obtainedUntSSSthe patientIs an unemancipatedEninorundertheageof 18or is otherwiseincilpableof signng
`Contrast UtE!::d!en
`Type of Contrast
`
`Brand Name
`
`Concentration
`
`IV injection performed via:
`Existing IV
`New IV started
`Creatin1ne fevel:
`
`I
`
`tn]acted =
`
`Discarded =
`
`mL
`
`mL
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`onn-
`Radiology a
`VDP10219/3D/14|
`
`rfortning inje
`
`NTE
`natur
`
`| d(OLIVO
`u
`
`P nt Narn
`
`THIS
`
`IS
`
`A COPY
`
`

`
`FILED: ROCKLAND COUNTY CLERK 07/12/2019 05:16 PMFILED: ROCKLAND COUNTY CLERK 07/15/2019 02:48 PM
`
`NYSCEF DOC. NO. 104NYSCEF DOC. NO. 161
`RUN DATE:
`06/14/16
`RUN TIME:
`"0613
`
`
`
`INDEX NO. 034136/2016INDEX NO. 034136/2016
`
`NEW YORK
`
`10305
`
`
`RECEIVED NYSCEF: 07/12/2019RECEIVED NYSCEF: 07/15/2019
`HOSPITAL
`PAG
`REPORT
`ISLANDr
`
`ISLAND
`FINAL
`PLAZA,
`
`UNIVERSITY
`SPECIMEN
`STATEN
`
`STATEN
`
`CAMPO,RAYMOND
`-----...----------------------___--__--
`Specimen:
`16:C1780
`
`ONE
`
`EDGEWATER
`
`59/M
`
`<REG
`
`CLI
`
`Received:
`Collected:
`Subm
`
`Doc:
`
`(
`
`06/09>
`--------...-_
`20160609-1551
`20160609-
`AHMAD,NOOR
`
`MD
`
`___ _._ __ _
`Status:
`Type:
`Sp
`
`JZ
`
`KIROYCHEVA,MILITZA
`-------
`_..._ _...--.-------....__.
`Req#:
`
`SOUT
`CYTOLOGY
`
`MD
`
`2420.
`
`CLINICAL
`
`HISTORY
`OTHER
`
`CYTOLOGY:
`PERTINENT
`
`HISTORY:
`
`Left
`
`paraspinal
`
`soft
`
`tissue
`
`mass
`
`SURGICAL
`CT-guided
`
`PROCEDURE:
`needle
`
`core
`
`biopsy
`
`SPECIMEN:
`Left
`
`paraspinal
`
`soft
`
`tissue
`
`mass
`
`CYTOLOGY
`
`GROSS
`
`DESCRIPTION1
`
`Received
`patient's
`
`Specimen
`Staten
`Staten
`
`are
`name
`
`two
`
`Diff-Quik
`date
`
`and
`
`stained
`birth(
`
`of
`
`slides.
`DOB)
`
`.
`
`All
`
`slides
`
`are
`
`labeled
`
`with
`
`was
`Island
`Island,
`
`received
`University
`New
`
`York
`
`and
`
`underwent
`Hospital,
`10309.
`
`gross
`375
`
`examination
`Seguine
`Avenue,
`
`at
`
`vk
`
`Dictated
`
`by:
`
`ASSESSMENT
`
`OF
`
`ADEQUACY:
`
`On-site
`
`adequacy
`
`assessment
`
`performed
`
`by
`
`Dr.
`
`Tong.
`
`-
`
`INADEQUATE:
`diagnosis.
`
`scant
`
`fibroadipose
`
`tissue;
`
`insufficient
`
`for
`
`*
`
`CYTOLOGY
`
`FINAL
`
`DIAGNOSIS
`
`+:
`
`LEFT
`
`PARASPINAL
`
`SOFT
`
`TISSUE
`
`MASS,
`
`CT-GUIDED
`
`NEEDLE
`
`BIOPSY
`
`(TOUCH
`
`PREP):
`
`-
`
`-
`
`SCANT
`
`FIBROADIPOSE
`
`TISSUE;
`
`INSUFFICIENT
`
`FOR
`
`SPECIFIC
`
`DIAGNOSIS.
`
`ALSO
`
`SE

Raymond S Campo v. Dialysis Clinic, Inc. et al, 034136/2016, 161 (N.Y. Sup. Ct., Rockland County Jul. 15, 2019) (2024)

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References

Raymond S Campo v. Dialysis Clinic, Inc. et al, 034136/2016, 161 (N.Y. Sup. Ct., Rockland County Jul. 15, 2019) (2024)

We are redirecting youto a mobile optimized page.

References

We are redirecting you
to a mobile optimized page.