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Created By Pear| EMR- PH0512 CMCP
Schema: TDCJ
EMR Medication Print Pass
Act/'ve Medications From 08/05/2015 to 08/06/2015
LEw/s (GL)
A.l_-.L-LB§].ESL
BENZOD|AZEP|NES | BUTYROPHENONES
/_
Report Date/Time; 8/05/2015 11;16A|Vl
H/S
PAT|ENT: BR|GGS, DEREK MRN:1666858 DOB:10/20/1980 HOUS|NG: HML 16
D|PHENHYDRAM|NE 50MG _CAPSULE
2 CAPS OR``AL E\/ERY EVEN|NG FOR 30 DAYS.
RX DATE: 08/05/2015 11:06 A|V|
ORDER|NG FAC|L|TYZ LEW|S (GL)
ORDER|NG_PROV|DERI DAN|EL, V|V| S M.D.
MED|CAT|ON STATUS: ACT|VE
RUN START DATE: 08/05/2015 11:05 A|V|
RxlD;19619052
REF|LLS; 0 / 11
RuN END DATE;09/04/201511;05 AM
ExPlRATlON DATE; 07/30/2016 11;05 AM
ENTRY USER; DAN|EL, V|V| S M.D.
D|VALPR EX SOD OOMG EC TABLET
5 TABS ORAL EVERY EVEN|NG FOR 30 DAYS.
RX DATE; 08/05/2015 11:06 /~\|V|
ORDER|NG FAC|L\TYZ LEW|S (GL) '
ORDER|NG PROV|DERZ DAN|EL, V|V| S M.D.
MED|CAT|ON STATUS; ACT|VE
RUN START DATEI 08/05/2015 11:05 AN|
Rx ID: 19619063
REF|LLS. O / 11
RUN END DATE. 09/04/2015 11. 05 AM
EXP|RAT|ON DATE: 07/30/2016 11.05 AM
ENTRY USER: DANIEL, V|V| S M,D``
hydroCHLORO*,hiazige 25|\¢‘|3 TAB
1 TABS ORAL DA|LY FOR 30 DAYS.
RX DATE: 04/14/2015 02:43 PM
ORDER|NG FAC|L|TY: LEW|S (GL)
ORDER|NG PROV|DER; DONOHUE, THOMAS A M.D.
N|ED|CAT|ON STATUS; ACT|VE
RUN START DATEI 07/13/2015 02:43 PM
Rx |DZ 19061262
REF|LLSZ 3 / 11
RUN END DATE: 08/12/2015 02:43 PM
EXP|RAT|ON DATEI 04/08/2016 02.'43 PM
ENTRY USER: DONOHUE, THON|AS A M.D.
_S_ERTRAL|NE 1QOMG TABLET
1 TABS ORAL EVERY EVEN|NG FOR 30 DAYS.
RX DATE: 08/05/2015 11:06 AM
ORDER|NG FAC|L|TY: LEW|S (GL)
ORDER|NG PROV|DER; DAN|EL, V|V| S M.D.
N|ED|CAT|ON STATUS: ACTIVE
RUN START DATE: 08/05/2015 _11:06 AM
RX |D; 19619075
REF|LLS: 0 / 11
RUN END DATE; 09/04/2015 11:06 AM
EXP|RAT|ON DATE: 07/30/2016 11:06 AM
ENTRY USER; DAN|EL, V|V| S |V|.D.
TRIFLU PERAZ|NE1 MG TABLET_
3 TABS ORAL EVERY EVEN|NG FOR 30 DAYS.
RX DATE: 08/05/2015 11:06 AM
ORDER|NG FAC|L|TY; LEW|S (GL)
ORDER|NG PROV|DER; DAN|EL, V|V| S M.D.
|\/|ED|CAT|ON STATUS: ACT|VE
RUN START DATE: 08/05/2015 11:06 AM
Rx 113_; 19619072
REF|LL``S; 0 / 11
RUN END DATE; 09/04/2015 11:06 AM
EXPIRATlON DATE; 07/30/2016 11:06 AM
ENTRY USER: DAN|EL, V|V| S |V|.D.
TOTAL FOR BR|GGS, DEREK
Page 1 of 2
OFFICE USE ONLY
Texas Department of 1Criminal Ju``stice crievahce'#=
» UGl Recd Date:
STEP 2 OFFENDER
. HQ Recd Date:
, GRIEVANCE FORM Date met
Offender Name° MR D@_YQY\\Q“'W _ TDCJ #§;Q§Q§Q&E)& Gri'evance Codc':
Unit: i:``§ 3b L&)N° , § Ho_using Assignment:
, Investigator lD¢l:
Unit where incident occurred: ij 1\\ \.\~Q~I\'r\\° \ C; , Extension Dat¢;
You must attach the completed Step 1 Grievance that has been signed by the Warden for your Step 2 appeal to be
accepted You may not appeal to Step 2 with a Step 1 that has been returned unprocessed. ``
Give reason for appeal (Be Specific). I am dissatisfied with the )``"esponse at Step l because...
106;6@_ m\')s@\eq»\jl,c>".
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(OVER)
, APR 0 7 2015 ~AppendixG
el\`` 0\\\1 1\()&\‘\* §i°\\’ Ct@‘§' :< \\)‘5:1’ G\O‘\‘ 0‘§5``§\ "\\.Af)' //``l +l£l(é 1 /'/_P l:``zl//ri:»/``n 7)’($‘ P‘U``FP)’
'l'_ Af Il¢ l 'lr|/ ~ ,._' p\g r-``/_q," ``1*1-``\ o.~t.. ¢ j"_ .``1116,
`` `` 1 1 4 _ 0 , ' . f
l¢l"l_§__.l f \1’__ ,»_|._l ..»_ 1 l_l . ll-’¢‘;.'m/l ll *1_.,‘ ' .- 60 '~) f _
`` .. n " ~ _ .. . . b ‘ \ /,-
'_°‘ '_ ,1' g 1‘,`` " 1 § \- 00»\\ \\\~ :'\ \`` 1"`` wu
Offender Signature:' _1 Q)'©L``:)``,MM. Date: _``7)"`` ?)1' 15
Grievance Response: 7 f _ 656
41
Signature Authority: . § ' 4 » Date:
Retnrned because: *Re_submit this form when cbrr``ections are made. l ' ' ()FFICE USE ONLY
`` '~ ``. ~ "_ ' , . lnitial Submission ' _'CGO Initials:
i:l 1. Grievable time perind has expii‘ed. v Dare'UGlRecd:
l:l' 2. lllegible/Incomprehensible.* v " , x y , DateCGORecdi
m 3. Origin-als not submitted. *- v _ . .:::'"'t. `` v (check one) ____SCr€€ned lmproperly Submitted
m 0 o ``kt 4 ’ » . `` ' _ Comments:
4. Inapproprlate/Excessive attachments. ~. _ 1 . . DateRetun-ledtooffender:
m 5.~ Malicious use of vulgar, indecent, or physically threatening language. ZM§IAL)_HM `` ' CGO lnifials=
Date UGI Recd:
|:l 6. lnappropriate.* ' ' -
. `` § "`` _ Date CGO Recd'.
6 l » w b (chec``k one)_ Scr``eened ___lmproperly Submitted
`` \
-64. ,, Comments: '
CGO Staff Signatilre: v Date Retumed to Offender:
'_», l `` §L" Submission `` CGO Initials:
f . 6 Date UGI Recd: f y '
' l Date CGO Recd:
(checkone)`` Scr€ened lmproperly Submitted '
Comments:v
Date Retumed to Oft``endei': _ v
l-lZB.Back-(Revised ‘111¢2_01(\)) _. 6,. Appendix G
xii :‘ g ;_' l
L ulmt,) unr 4 LA\``._ 4. L-r_.. . ..
Inter~Oft'r``cr. communication
Adrninistrative Review and Rislc Management'
Offender Grievance /SI_:(§\
TO: VQN\,LM \_% ©f\onYC-J
TDCJ# \\_p\\i)\§>%<§?\
UNIT; f_``~_-;L
FROM: Central Grievance Office SUBJECT: lmpronerlv Submitted Grievance
reviewed and a response is indicated below. Contact the warden, major,
Your documents received in this office have been
deem as an eniergency.’lf you need additional information or
chief of classification or a security officer for issues you
assistanc you may contact the Unit Grievance Investigator at your unit.'
l recessed without the corresponding original, answered Step 1 grievance 'I'he
original, answered:``-S"tep'?l_ must be attached to the Step 2 at the time of submission to your Unit Grievance
Investigator.__ LBe advised; it is not permissible to mail your grievances to offices outside of your unit for
_ _ prrgc¢ss_i;ig_;,; All"f``gr``ievya__ri§:"es are to be submitted to~your Unit Grievance Investigator. Submitting your grievances
,» 12 , mcgn€ctly§may.rg§glt§m your grievable time to expire. ~ ``
k'“ l:l l "~l``hé'se``iss``iies``€have;.been reviewed at both steps of the grievance procedure No other administrative remedies are
ou regarding the issue. Further action by this office is not warranted
tied with the response you receive from a Step 1 investigation, you have the option of appealing
the Step 1 form. Policy requires that all grievances be submitted
This Step 2 appeal:§``:annot be p
available``to' y
I:l If you are not satis
to Step 2 within 15 days .of the signature date on
through your Unit Grievance Investigato r. b
tep 2 appeal on a Step "i' grievance that was screened using one of the screening criteria, and
retumed to you unprocessed. You``had the_ option of correcting the screened grievance and resubmitting to the unit
grievance investigator within 15 days fi'om,the-date_of the returned grievance If you feel that your Step 1 grievance
inita new Step 1 grievance to the Unit Grievanoe Investigator.
E%,been screened in error, you may sub
Policy requires that'all grievances be submitted tli;r(fzngh your Unit Grievance Investigato``r within 15 days of the
sible to mail yoiiF' grievances directly to the Central Grievance OHice.' Submitting
applicable date. It is not permis
_ your grievances incorrectly may result in your grievable time to expire.
[:l ' 'I``his Step 2 appeal is»being returned to you without action; however, the unprocessed Step 1 grievance is under
review. _ _ . ' ' l z -. '
I:l This issue is currently being addressed and is under review at Step 2.
`` l:l You may not submit a S
. lfyou are not satisfied with the
`` l:] This issue is currently being addressed in grievance # - ' . _
Step 1 response, at that time you may appeal the Step 1 decision by Eling a Step 2 (I-128) through your Unit
Grievance Investigator Within 15 days of the applicable date.
\
ll/7/l4/20 l4
