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Home My WebLink About00-02060 -- " , -<- METZGER, WICKERSHAM, KNAUSS & ERB, P.C. P.O. BOX 5300 HARRISBURG, PA 17110-0300 717/238-8187 TAX I.D. 23-2871395 October 25, 2000 Billed through 10/25/00 Bill number 000092-00116-006 CDV Megan N. Myers 6720 Rice Road Shippensburg, PA 17257 M. N. MYERS v. Sheaffer MEGAN N. MYERS v. Gary Sheaffer and Osborne Printing Company FOR PROFESSIONAL SERVICES RENDERED 07/12/99 CDV Phone conference with potential motor vehicle client. .10 hrs 07/23/99 CDV Initial meeting at client's Shippensburg residence with six clients. .70 hrs 07/26/99 CDV Open file for six clients, draft letter to clients, draft letter to Penn National, draft letter to Erie, draft memo to Associate. Phone conference with clients' bank. Phone call to clients. .30 hrs 07/27/99 CDV Review open file, phone call to and from client regarding property damage. .20 hrs 07/29/99 CDV Review photographs and draft memo to Associate. .10 hrs 08/02/99 CDV Check on statute of limitations, review additional photographs, review medical bills and instructions on payment for medical bills. .30 hrs 08/02/99 SCS Telecon to Tpr Myers re: movement of defendant's vehicle; left message; telecon to plaintiff re: same; left message; telecon to witness, Cecilia Hinebaugh re: interview; letter to witness re: same; telecon from Myers re: movement of defendant's vehicle. .30 hrs 08/03/99 CDV Phone call from client, phone call to first party benefit carrier and return phone call to client regarding income loss payments: .10 hrs ,"',' _A, ~ "''' l#-_. 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr P!.A,N""FF S EXrHBIT ., I J..fH ...- Megan N. Myers Bill number 08/03/99 SCS 08/04/99 CDV 08/04/99 SCS 08/05/99 SCS 08/06/99 CDV 08/10/99 CDV 08/12/99 CDV 08/13/99 CDV 08/13/99 SCS 08/16/99 SCS 08/17/99 SCS 08/21/99 CDV 08/24/99 CDV 09/02/99 CDV 09/03/99 CDV 09/03/99 CDV 09/07/99 CDV '<< 000092-00116-006 CDV Telecons (2) to Veronica Harteis, Claim Adjuster, at Penn National re: location of defendant's car; telecon to investigating officer re: same; proofed and amended witness fee. .20 hrs Investigation of vehicle damage. .10 hrs Telecon from Veronica Harteis re: location of defndant's vehicle; telecon to Central Penn Sales re: status of defendant's vehicle. .10 hrs Telecon to salvage yard; telecon to Penn National Insurance re: request for pictures; travel to and from salvage yard; picture taking at salvage yard. .30 hrs Review medical bills and notes from clients and instructions on medical bills and notes. .10 hrs .10 hrs .10 hrs miscellaneous issues. .10 hrs Conference call with CDV and Wendell Myers; telecon to insurance rep, Jeffrey Coy re: title; telecon from Barbara at Coy's office re: title; telecon to pennDot re: title; telecon to Wendell Myers re: title. .20 hrs Telecon to Wendell Myers re: title receipt; telecon to Legislative liaison at PennDot, Bill Yocum, re: procuring duplicate title; determined to whom title would have been sent, Myers or lienholder; received fax from Bill Yocum which included the requisite form for getting duplicate title and completion of forms. .20 hrs Telecon to Orrstown Bank re: title; telecon to Orrstown Bank re: lien; telecon to Sauder Chevrolet re: title and lien; 'telecon from Wendell Myers re: informing title was received. .20 hrs Miscellaneous file matters. Review photographs. Automobile title issues and Review memorandum regarding title. .10 hrs Medical update with Donna Myers. .10 hrs Review first party benefit materials. .10 hrs Draft letter to Myers' family and Mr. Helm regarding additional discovery materials. .10 hrs Review documents and photographs from clients. .10 hrs Review medical records from Carlisle Hospital. .30 hrs ~-,,:~! PAGE 2 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr >"~ ~. Megan N. Myers Bill number 09/08/99 CDV 09/14/99 SCS 09/16/99 CDV 09/20/99 CDV 09/25/99 CDV 09/27/99 CDV 10/06/99 CDV 10/20/99 CDV 10/22/99 CDV 11/09/99 CDV 11/11/99 CDV 11/13/99 CDV 11/15/99 CDV 11/16/99 CDV 12/06/99 CDV 12/06/99 SG 12/09/99 CDV 12/09/99 SG 12/10/99 CDV 12/17/99 CDV 12/19/99 CDV 12/20/99 CDV . 000092-00116-006 CDV Conference with client on medical treatments update for all injured parties. .20 hrs Drafted letter to witness Cecila Hinebaugh. .10 hrs follow up on .10 hrs .10 hrs review FedEx .10 hrs Penn National and .30 hrs .10 hrs scene with .10 hrs and memo on photographs. .10 hrs Follow up on demand package. .10 hrs Follow up on photographs of scarring including conference with JLH. .10 hrs Begin draft of demand package and assemble exhibits. .50 hrs Complete demand letter and assemble exhibits. .70 hrs Phone conference with photographer and photography scheduling. .10 hrs phone conference with Wendell Myers and scheduling of settlement authority meeting. .10 hrs Assemble documents for demand package and phone call to client regarding 12/10/99 appointment with CDV. 1.00 hrs Review and revise demand package and prepare for client meeting. .60 hrs Phone call with photographer regarding proofs; letters to medical providers and updated medical billing summary for assembly of demand package. .40 hrs Review note regarding Erie Insurance records, meeting with clients at Shippensburg office, meeting with photographer at Shippensburg office, phone call to Penn National Insurance, review and review demand package and draft letter to clients on settlement authority. 1.00 hrs Review photographs and instructions on demand package. .10 hrs Review and make revisions to demand letter and package. .30 hrs Miscellaneous matters relating to demand package. .10 hrs Review police accident report and photographs (one-sixth time). Process medical bills. Phone call from Penn National, regarding watch. Extensive phone conference with treatment update. Medical investigation. Review photographs of accident Associate. Review photographs "-- ilf~fi PAGE 3 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 55 /hr 150 /hr 55 /hr 150 /hr 150 /hr 150 /hr 150 /hr Megan N. Myers Bill number 12/20/99 SG 12/21/99 CDV 12/22/99 CDV 01/04/00 CDV 02/02/00 CDV 02/07/00 CDV 02/08/00 CDV 02/19/00 CDV 02/21/00 CDV 03/01/00 CDV 03/03/00 CDV 03/06/00 CDV 03/08/00 CDV 03/09/00 CDV 03/11/00 CDV 03/13/00 CDV 03/17/00 MLS 03/17/00 CDV 03/17/00 CDV 03/17/00 CDV 03/17/00 CDV 03/18/00 CDV 000092-00116-006 CDV Finish putting together demand package and exhibits. .30 hrs Final review and revisions to demand letter and package, phone call from client regarding medical bills. .60 hrs Regarding photographs. .10 hrs Phone call to and from Penn National to discuss demand package. .10 hrs Conference with client (Wendell Myers) . .10 hrs Phone call from Penn National regarding demand. .10 hrs Review letter from Penn National. .10 hrs Review phone message from Penn National on settlement. .10 hrs Phone call from client regarding settlement status. .10 hrs Follow up with Penn National on demand package. .10 hrs Phone conference with Penn National on settlement offers, phone conference with Wendell Myers, Sr. on settlement offers and intra-office conferences regarding settlement offers. .30 hrs Draft detailed response letter to Penn National's offer including calculation of percentages and supplement with other case information. .70 hrs Review settlement offer letter from Penn National. .10 hrs Phone conference with Penn National, phone conference with Wendell Myers, Sr. and draft letter to Penn National with counter-demand. .30 hrs Review and revise reduced demand letter. .10 hrs Review Penn National's letter. .10 hrs Phone call to Corporate Bureau and memo to file. .10 hrs Phone conference with Penn National and phone conference with client. .50 hrs Perform research in preparation of drafting Complaint. .50 hrs Review research memo from Associate on defendant investigation. .10 hrs Draft letter to Penn National for Complaint. .10 hrs Draft Civil Complaint, draft letter to Prothonotary, instructions on forwarding and service and revise letter to Penn National. .60 hrs PAGE 4 55 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr Megan N. Myers Bill number 03/18/00 CDV 03/20/00 CDV 03/22/00 CDV 03/24/00 CDV 03/27/00 CDV 03/28/00 CDV 03/30/00 CDV 03/31/00 CDV 04/03/00 CDV 04/05/00 CDV 04/11/00 CDV 04/19/00 CDV 04/27/00 CDV 04/28/00 CDV 05/01/00 CDV 05/02/00 SCC 05/03/00 CDV 05/09/00 CDV 05/09/00 CDV " 000092-00116-006 CDV Draft Request for Production of Documents and Interrogatories directed to each Defendant. .60 hrs Phone call to Penn National regarding policy limits and final offers. .10 hrs Phone conference with client. .10 hrs Phone calls to and from Penn National and meeting to discuss case. .10 hrs Review and revise Complaint. .50 hrs Review correspondence from Penn National on settlement offers. .10 hrs Review, revise and prepare Complaint for clients' verification. .10 hrs Review Complaint with client at Shippensburg office and have clients verify Complaint. .70 hrs Final review of discovery requests and forwarding of requests with Complaint for filing. .60 hrs Review return documents from Prothonotary. .10 hrs Review Defendants' counsel's Entry of Appearance, two letters and draft letter to defense counsel on extension. .10 hrs Review of Sheriffs returns of service, calculate due dates for Answer and discovery. .10 hrs Review letter from defense counsel regarding bankruptcy filing and meeting with Associate to discuss bankruptcy motion. .10 hrs Review bankruptcy filing documents on Osborn, conference with Associate regarding bankruptcy and draft letter to client. .10 hrs Review Defendants' discovery requests including Interrogatories, Request for production, letter from defense counsel, conference with Associate regarding discovery matters, review proposed bankruptcy filings, conference with Associate regarding Motion and proposed Order on bankruptcy filings. .20 hrs Drafted Proof of Claim regarding Osborn printing Company. .30 hrs Phone conference with Wendell Myers regarding bankruptcy. .10 hrs Review subpoenaed documents from defense counsel. .10 hrs Review and revise Proofs of Claim and Motion. .20 hrs "~--'~b"'; PAGE 5 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr Megan N. Myers Bill number 000092-00116-006 CDV 05/09/00 ERG Conference with Steve Courtney regarding filing Petition to lift stay of bankruptcy. 05/10/00 CDV 05/10/00 CDV 05/12/00 CDV 05/13/00 CDV 05/15/00 CDV 05/15/00 FJL 05/15/00 FJL 05/17/00 CDV 05/18/00 CDV 05/18/00 FJL OS/22/00 CDV OS/22/00 FJL OS/23/00 CDV OS/23/00 FJL OS/24/00 CDV OS/24/00 FJL OS/25/00 CDV .30 hrs Final review of bankruptcy motion and bankruptcy filings. .10 hrs Draft letter to client regarding bankruptcy filings, draft letter to defense counsel on bankruptcy filings, draft letter to bankruptcy debtor counsel. .20 hrs Review Bankruptcy Order, draft letter to debtor counsel, draft letter to clients, draft letter to defense counsel, phone call from debtor counsel and review, revise Proofs of Claim. .50 hrs Review amended Proofs of Claim. .10 hrs Review letter from bankruptcy counsel and handle bankruptcy matters. .10 hrs Draft Interrogatory Answers directed to Plaintiffs. 1.00 hrs Draft document request answers directed to Plaintiffs. .50 hrs Phone conference with Wendell Myers on bankruptcy and other issues. .10 hrs Review new case on punitive damages. .10 hrs Edit discovery responses for Megan. .50 hrs Review responses to discovery requests including Request for Production of Documents and Interrogatories, letter from defense counsel, issue subpoena and deposition instructions. .80 hrs Review, edit and finalize Interrogatories. .40 hrs Draft letter to defense counsel regarding Answer to Complaint and discuss discovery responses. .10 hrs Review and edit all information for discovery. .30 hrs Review, revise and supplement discovery responses, draft letter to defense counsel forwarding discovery responses. .60 hrs Travel to and from Shippensburg, meet with clients to review all discovery information and to secure signed Verification forms. .60 hrs Review and forward discovery responses. .20 hrs ""i PAGE 6 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr ~ ~ Megan N. Myers Bill number 05/30/00 CDV 06/02/00 CDV 06/0S/00 CDV 06/13/00 CDV 06/14/00 CDV 06/19/00 CDV 06/26/00 CDV 06/27/00 CDV 07/05/00 CDV 07/06/00 CDV 07/17/00 CDV 07/26/00 CDV OS/02/00 CDV OS/04/00 CDV OS/OS/OO CDV OS/09/00 CDV OS/14/00 CDV . . , 000092-00116-006 CDV Phone call from defense counsel regarding Answer to Complaint. .10 hrs Review letter from defense counsel, review Answer with New Matter, draft Reply to New Matter, draft letter to Prothonotary and draft letter to defense counsel. .40 hrs Phone conference with Wendell Myers regarding Answer with New Matter and discovery. .10 hrs Review subpoenas, deposition notices, letters. .20 hrs Review bankruptcy filings. .10 hrs Review recorded statement from Gary Sheaffer with correspondence from defense counsel. .10 hrs Review Defendants' supplementary documents to discovery responses, review documents subpoenaed from Penn National, draft letter to defense counsel and review bankruptcy documents. .30 hrs Review bankruptcy documents, review letter from defense counsel and review and revise subpoena documents. .10 hrs Phone call from court reporter, phone call to clients, review deposition notices for depositions and medical records from Carlisle Hospi talon Gary Sheaf f er . . 20 hrs pre-deposition meeting with clients and depositions of each client at Shippensburg, depositions of Schlein and Sheaffer, including travel time. 1. 50 hrs Review letter from defense counsel, draft letter to defense counsel on mediator and perform research to select mediator. .20 hrs Extended phone conference with defense counsel regarding mediation. .10 hrs Matters regarding mediation and mediation scheduling including phone conference with defense counsel. .20 hrs Phone call from defense counsel regarding mediation and draft letter to Judge Murphy on settlement offers and demands. .10 hrs Review copy of first party file and instructions on mediation. .30 hrs Review documents from mediator including agreement to mediate. .10 hrs Review letter from defense counsel regarding mediation. .10 hrs - ~'''''I I , i , PAGE 7 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr - Megan N. Myers Bill number 08/16/00 CDV 08/18/00 CDV 08/18/00 SG 08/28/00 CDV 08/29/00 CDV 08/30/00 CDV 08/31/00 CDV 09/01/00 CDV 09/06/00 CDV 09/07/00 CDV 09/13/00 CDV 09/26/00 CDV 09/27/00 CDV 09/29/00 CDV 10/03/00 CDV ~' . 000092-00116-006 CDV Review deposition transcripts. .30 hrs Review bankruptcy motion and fax on mediation. .10 hrs Prepare letter to clients for CDV review and signature. .10 hrs Mediation preparation including review of defense mediation memo. .40 hrs Attend mediation, attend conference with structured settlement representative and draft letter to defense counsel. 1.30 hrs Phone conference with Wendell Myers and two phone conferences with structured settlement expert and review faxed documents including proposed Settlement Agreement from structured settlement expert. .30 hrs Review settlement documents, review and revise Settlement Agreement and matters regarding structured settlement. .40 hrs Two phone calls with Structured Settlement expert. .20 hrs Review birth certificates, review invoice from mediator, draft letter to client regarding mediation invoice, draft letter to Structured Settlement regarding birth certificates, review and revise letter to defense counsel, review and revise proposed Settlement Agreement and Release. .50 hrs Review UQA and phone call to Structured Settlement, draft letter to client UQA. . 10 hrs Review note and signed Agreement from client, draft letter to Penn National forwarding signed Agreement, draft petition for Approval of Minor Compromise Settlement hearing with three proposed Orders and three letters. .50 hrs Phone conference with defense counsel and instructions regarding forwarding of Release for review. . 10 hrs Additions to both adult and minor releases, phone call to structured settlement consultant and email notes to defense counsel regarding releases. .80 hrs Review two emails regarding Releases, review and revise Petition for Approval of Minor Settlements. .30 hrs Travel to and from Shippensburg office to review and sign Settlement Agreement and petition for Approval, forward ReI-ease and petition for service and filing. .70 hrs ,~-- .-1 -- =~ _ u .~",",,;-' PAGE 8 150 /hr 150 /hr 55 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 10/11/00 CDV Minor Compromise hearing and follow up on settlement checks. .10 hrs 10/12/00 CDV Review Order from Court on Minor Settlement hearing, draft letter to clients, draft letter to counsel, draft research memo and instructions on securing fee records. .20 hrs Review research results from Associate on the minor settlements. .10 hrs Review bankruptcy documents. .10 hrs Phone conference with Jeff Gross regarding structured settlements. .10 hrs Hearing preparation. .10 hrs Settlement calculations. .20 hrs Hearing preparation. .50 hrs Attend settlement hearing. 1.00 hrs ~. . Megan N. Myers Bill number 10/12/00 CDV 10/18/00 CDV 10/18/00 CDV 10/18/00 CDV 10/20/00 CDV 10/24/00 CDV 10/25/00 CDV BILLING SUMMARY '<<, ~ ii..a<'i~'. ' PAGE 9 000092-00116-006 CDV 150 /hr Total fees for this matter 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 5,769.00 $ STEVEN C. COURTNEY (SCC) CLARK DeVERE (CDV) E. RALPH GODFREY (ERG) STEPHANIE A. GRATKOWSKI (SG) FRANCIS J. LAFFERTY (FJL) STEVEN C. SKOFF (SCS) MELISSA L. STICKEL (MLS) .30 hrs 45.00 32.20 hrs 4,830.00 .30 hrs 45.00 1. 80 hrs 99.00 3.30 hrs 495.00 1. 60 hrs 240.00 .10 hrs 15.00 ------------ 39.60 hrs 5,769.00 ------------ $ 5,769.00 TOTAL FEES TOTAL CHARGES FOR THIS BILL ~-'=--~ .~. . .' ~ ~. ' METZGER, WICKERSHAM, KNAUSS & ERE, P.C. P.O. BOX 5300 HARRISBURG, PA 17110-0300 717/238-8187 TAX I.D. 23-2871395 October 25, 2000 Billed through 10/25/00 Bill number 000092-00115-006 CDV Shannon B. Myers 6720 Rice Road Shippensburg, PA 17257 S. B. MYERS v. Sheaffer SHANNON B. MYERS v. Gary Sheaffer and Osborne Printing Company FOR PROFESSIONAL SERVICES RENDERED 07/12/99 CDV Phone conference with potential motor vehicle client. .10 hrs 07/23/99 CDV Initial meeting at client's Shippensburg residence with six clients. .70 hrs 07/26/99 CDV Open file for six clients, draft letter to clients, draft letter to Penn National, draft letter to Erie, draft memo to Associate. Phone conference with clients' bank. Phone call to clients. .30 hrs 07/27/99 CDV Review open file, phone call to and from client regarding property damage. .20 hrs 07/29/99 CDV Review photographs and draft memo to Associate. .10 hrs 08/02/99 CDV Check on statute of limitations, review additional photographs, review medical bills and instructions on payment for medical bills. .30 hrs 08/02/99 SCS Telecon to Tpr. Myers re: movement of defendant's vehicle; left message; telecon to plaintiff re: same; left message; telecon to witness, Cecilia Hinebaugh, re: interview; letter to witness re: same; telecon from Myers re: movement of defendant's vehicle. .30 hrs 08/03/99 CDV Phone call from client, phone call to first party benefit carrier and return phone call to client regarding income loss payments. .10 hrs " c"" tllllhlmfu,",_,.-' 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr - Shannon B. Myers Bill number 000092-00115-006 CDV 08/03/99 SCS Telecons (2) to Veronica Harteis, Claim Adjuster, Penn National re: location of defendant's car; telecon to investigating officer re: same; proofed and amended witness letter. .20 hrs Telecons (2) to Veronica Harteis, Claim Adjuster at Penn National re: location of defendant's car; telecon to investigating officer re: same; proofed and amended witness letter. .20 hrs Investigation of vehicle damage. .10 hrs Telecon from Veronica Harteis re: location of defndant's vehicle; telecon to Central Penn Sales re: status of defendant's vehicle. .10 hrs Telecon to salvage yard; telecon to Penn National Insurance re: request for pictures; travel to and from salvage yard; picture taking at salvage yard. .30 hrs Review medical bills and notes from clients and instructions on medical bills and notes. . 10 hrs .10 hrs . 10 hrs miscellaneous issues. .10 hrs Conference call with CDV and Wendell Myers; telecon to insurance rep, Jeffrey Coy re: title; telecon from Barbara at Coy's office re: title; telecon to PennDot re: title; telecon to Wendell Myers re: title. .20 hrs Telecon to Wendell Myers re: title receipt; telecon to Legislative liaison at PennDot, Bill Yocum, re: procuring duplicate title; determined to whom title would have been sent, Myers or lienholder; received fax from Bill Yocum which included the requisite form for getting duplicate title and completion of forms. .20 hrs Telecon to Orrstown Bank re: title; telecon to Orrstown Bank re: lien; telecon to Sauder Chevrolet re: title and lien; telecon from Wendell Myers re: informing title was received. .20 hrs 08/03/99 SCS 08/04/99 CDV 08/04/99 SCS 08/05/99 SCS 08/06/99 CDV 08/10/99 CDV 08/12/99 CDV 08/13/99 CDV 08/13/99 SCS 08/16/99 SCS 08/17/99 SCS 08/21/99 CDV 08/24/99 CDV 09/02/99 CDV Miscellaneous file matters. Review photographs. Automobile title issues and Review memorandum regarding title. Medical update with Donna Myers. Review first party benefit materials. .10 .10 hrs hrs .10 hrs , """'I PAGE 2 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr ~'~ ' Shannon B. Myers Bill number 000092-00115-006 CDV 09/03/99 CDV 09/03/99 CDV 09/07/99 CDV 09/08/99 CDV 09/14/99 SCS 09/16/99 CDV 09/20/99 CDV 09/25/99 CDV 09/27/99 CDV 10/06/99 CDV 10/20/99 CDV 10/22/99 CDV 11/09/99 CDV 11/11/99 CDV 11/13/99 CDV 11/15/99 CDV 11/16/99 CDV 12/06/99 CDV 12/06/99 SG 12/09/99 CDV 12/09/99 SG 12/10/99 CDV Draft letter to Myers' family and Mr. Helm regarding additional discovery materials. .10 hrs Review documents and photographs from clients. .10 hrs Review medical records from Carlisle Hospital. .30 hrs Conference with client on medical treatments update for all injured parties. .20 hrs Drafted letter to witness Cecila Hinebaugh. .10 hrs follow up on .10 hrs .10 hrs review FedEx .10 hrs Penn National and .30 hrs .10 hrs scene with .10 hrs and memo on photographs. .10 hrs Follow up on demand package. .10 hrs Follow up on photographs of scarring including conference with JLH. .10 hrs Begin draft of demand package and assemble exhibits. .50 hrs Complete demand letter and assemble exhibits. .70 hrs Phone conference with photographer and photography scheduling. .10 hrs Phone conference with Wendell Myers and scheduling of settlement authority meeting. .10 hrs Assemble documents for demand package and phone call to client regarding 12/10/99 appointment with CDV. 1.00 hrs Review and revise demand package and prepare for client meeting. .60 hrs Phone call with photographer regarding proofs; letters to medical providers and updated medical billing summary for assembly of demand package. .40 hrs Review note regarding Erie Insurance records, meeting with clients at Shippensburg office, meeting with photographer at Shippensburg office, phone call to Penn Nati~nal Insurance, revie~ and review demand package and draft letter to cl~ents on settlement authority. 1.00 hrs Review police accident report and photographs (one-sixth time) . Process medical bills. Phone call from Penn National, regarding watch. Extensive phone conference with treatment update. Medical investigation. Review photographs of accident Associate. ' Review photographs _,,'~\\i;!;m~_,. PAGE 3 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 55 /hr 150 /hr 55 /hr 150 /hr Shannon B. Myers Bill number 000092-00115-006 CDV 12/14/99 SG 12/17/99 CDV 12/19/99 CDV 12/20/99 CDV 12/20/99 SG 12/21/99 CDV 12/22/99 CDV 01/04/00 CDV 02/02/00 CDV 02/07/00 CDV 02/08/00 CDV. 02/19/00 CDV 02/21/00 CDV 03/01/00 CDV 03/03/00 CDV 03/06/00 CDV 03/08/00 CDV 03/09/00 CDV 03/n/00 CDV 03/13/00 CDV 03/17/00 MLS 03/17/00 CDV Phone call with ambulance bill. Review photographs and instructions package. Review and make revisions to demand package. Miscellaneous matters relating provider regarding .10 hrs on demand .10 hrs letter and .30 hrs to demand package. .10 hrs Finish putting together demand package and exhibits. .30 hrs Final review and revisions to demand letter and package, phone call from client regarding medical bills. .60 hrs Regarding photographs. .10 hrs Phone call to and from Penn National to discuss demand package. .10 hrs Conference with client (Wendell Myers). .10 hrs Phone call from Penn National regarding demand. .10 hrs Review letter from Penn National. .10 hrs Review phone message from Penn National on settlement. .10 hrs Phone call from client regarding settlement status. . 10 hrs Follow up with Penn National on demand package. .10 hrs Phone conference with Penn National on settlement offers, phone conference with Wendell Myers, Sr. on settlement offers and intra-office conferences regarding settlement offers. .30 hrs Draft detailed response letter to Penn National's offer including calculation of percentages and supplement with other case information. .70 hrs Review settlement offer letter from Penn National. .10 hrs Phone conference with Penn National, phone conference with Wendell Myers, Sr. and draft letter to Penn National with counter-demand. .30 hrs Review and revise reduced demand letter. .10 hrs Review Penn National's letter. .10 hrs Phone call to Corporate Bureau and memo to file. . 10 hrs Phone conference with Penn National and phone conference with client. .50 hrs . ",..,.~L'l~,II' , PAGE 4 55 /hr 150 /hr 150 /hr 150 /hr 55 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr . -> , Shannon B. Myers Bill number 000092-00115-006 COV 03/17/00 CDV 03/17/00 CDV 03/17/00 CDV 03/18/00 COV 03/18/00 CDV 03/20/00 CDV 03/22/00 COV 03/24/00 COV 03/27/00 CDV 03/28/00 CDV 03/30/00 COV 03/31/00 CDV 03/31/00 CDV 04/03/00 CDV 04/05/00 CDV 04/11/00 COV 04/19/00 CDV 04/27/00 COV 04/28/00 COV 05/01/00 CDV Perform research in preparation Complaint. Review research memo investigation. Draft letter to Penn of drafting .50 hrs from Associate on defendant .10 hrs National for Complaint. .10 hrs Draft Civil Complaint, draft letter to Prothonotary, instructions on forwarding and service and revise letter to Penn National. .60 hrs Draft Request for production of Documents and Interrogatories directed to each Defendant. .60 hrs Phone call to Penn National regarding policy limits and final offers. .10 hrs Phone conference with client. .10 hrs phone calls to and from Penn National and meeting to discuss case. .10 hrs Review and revise Complaint. .50 hrs Review correspondence from Penn National on settlement offers. .10 hrs Review, revise and prepare Complaint for clients' verification. .10 hrs Review Complaint with client at Shippensburg office and have clients verify Complaint. .70 hrs Review Complaint with client at Shippensburg office and have clients verify Complaint. .70 hrs Final review of discovery requests and forwarding of requests with Complaint for filing. .60 hrs Review return documents from Prothonotary. .10 hrs Review Defendants' counsel's Entry of Appearance, two letters and draft letter to defense counsel on extension. .10 hrs Review of Sheriffs returns of service, calculate due dates for Answer and discovery. .10 hrs Review letter from defense counsel regarding bankruptcy filing and meeting with Associate to discuss bankruptcy motion. .10 hrs Review bankruptcy filing documents on Osborn, conference with Associate regarding bankruptcy and draft letter to client. .10 hrs Review Defendants' discovery requests including Interrogatories, Request for Production, letter from defense counsel, conference with Associate regarding discovery matters, review proposed bankruptcy filings, conference with Associate regarding Motion and proposed Order on bankruptcy filings. .20 hrs ill .a;,jj"",,i,.,,-"!:~ PAGE 5 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr ~ 0 ,_",~' Shannon B. Myers Bill number 000092-00115-006 CDV 05/02/00 SCC 05/03/00 CDV 05/09/00 CDV 05/09/00 CDV 05/10/00 CDV 05/10/00 CDV 05/12/00 CDV 05/13/00 CDV 05/15/00 CDV 05/15/00 FJL 05/15/00 FJL 05/17/00 CDV 05/17/00 FJL 05/18/00 CDV OS/22/00 CDV OS/22/00 FJL OS/23/00 CDV OS/23/00 FJL OS/24/00 CDV OS/24/00 FJL Drafted Proof of Company. Phone conference bankruptcy. Review subpoenaed Claim regarding Osborn Printing .30 hrs with Wendell Myers regarding .10 hrs documents from defense counsel. .10 hrs Review and revise Proofs of Claim and Motion. .20 hrs Final review of bankruptcy motion and bankruptcy filings. .10 hrs Draft letter to client regarding bankruptcy filings, draft letter to defense counsel on bankruptcy filings, draft letter to bankruptcy debtor counsel. .20 hrs Review Bankruptcy Order, draft letter to debtor counsel, draft letter to clients, draft letter to defense counsel, phone call from debtor counsel and review, revise Proofs of Claim. .50 hrs Review amended Proofs of Claim. .10 hrs Review letter from bankruptcy counsel and handle bankruptcy matters. .10 hrs Draft Interrogatory Answers to directed to Shannon Myers. 1.00 hrs Draft document request directed to Shannon Myers. .50 hrs Phone conference with Wendell Myers on bankruptcy and other issues. .10 hrs Review, edit and finalize Interrogatories. .50 hrs Review new case on punitive damages. .10 hrs Review responses to discovery requests including Request for Production of Documents and Interrogatories, letter from defense counsel, issue subpoena and deposition instructions. .80 hrs Review, edit and finalize Interrogatories. .40 hrs Draft letter to defense counsel regarding Answer to Complaint and discuss discovery responses with Associate. .10 hrs Review and edit all information for discovery. .30 hrs Review, revise and supplement discovery responses, draft letter to defense counsel forwarding discovery responses. .60 hrs Travel to and from Shippensburg, meet with clients to review all discovery information and to secure signed Verification forms. .60 hrs -"~;lli:""d PAGE 6 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr Shannon B. Myers Bill number 000092-00115-006 CDV OS/25/00 CDV 05/30/00 CDV 06/02/00 CDV 06/08/00 CDV 06/13/00 CDV 06/14/00 CDV 06/19/00 CDV 06/26/00 CDV 06/27/00 CDV 07/05/00 CDV 07/06/00 CDV 07/17/00 CDV 07/26/00 CDV 08/02/00 CDV 08/04/00 CDV 08/08/00 CDV 08/09/00 CDV Review and forward discovery responses. .20 hrs Phone call from defense counsel regarding Answer to Complaint. .10 hrs Review letter from defense counsel, review Answer with New Matter, draft Reply to New Matter, draft letter to Prothonotary and draft letter to defense counsel. .40 hrs Phone conference with Wendell Myers regarding Answer with New Matter and discovery. .10 hrs Review subpoenas, deposition notices, letters. .20 hrs Review bankruptcy filings. .10 hrs Review recorded statement from Gary Sheaffer with correspondence from defense counsel. .10 hrs Review Defendants' supplementary documents to discovery responses, review documents subpoenaed from Penn National, draft letter to defense counsel and review bankruptcy documents. .30 hrs Review bankruptcy documents, review letter from defense counsel and review and revise subpoena documents. . 10 hrs Phone call from court reporter, phone call to clients, review deposition notices for depositions and medical records from Carlisle Hospital on Gary Sheaffer. .20 hrs Pre-deposition meeting with clients and depositions of each client at Shippensburg, depositions of Schlein and Sheaffer, including travel time. 1.50 hrs Review letter from defense counsel, draft letter to defense counsel on mediator and perform research to select mediator. .20 hrs Extended phone conference with defense counsel regarding mediation. .10 hrs Matters regarding mediation and mediation scheduling including phone conference with defense counsel. .20 hrs Phone call from defense counsel regarding mediation and draft letter to Judge Murphy on settlement offers and demands. .10 hrs Review copy of first party file and instructions on mediation. .30 hrs Review documents from mediator including agreement to mediate. .10 hrs PAGE 7 ~,,:<r"';_i I I !I 'I i II :1 I ,I 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr ._,,-~~ "" - Shannon B. Myers Bill number 000092-00115-006 CDV 08/14/00 CDV 08/16/00 CDV 08/18/00 CDV 08/18/00 SG 08/28/00 CDV 08/29/00 CDV 08/30/00 CDV 08/31/00 CDV 09/01/00 CDV 09/06/00 CDV 09/07/00 CDV 09/13/00 CDV 09/26/00 CDV 09/27/00 CDV 09/29/00 CDV 10/03/00 CDV Review letter from defense mediation. Review deposition Review bankruptcy counsel regarding .10 hrs .30 hrs mediation. .10 hrs Prepare letter to clients for CDV review and signature. .10 hrs Mediation preparation including review of defense mediation memo. .40 hrs Attend mediation, attend conference with structured settlement representative and draft letter to defense counsel. 1.30 hrs Phone conference with Wendell Myers and two phone conferences with structured settlement expert and review faxed documents including proposed Settlement Agreement from structured settlement expert. .30 hrs Review settlement documents, review and revise Settlement Agreement and matters regarding structured settlement. .40 hrs Two phone calls with Structured Settlement expert. .20 hrs Review birth certificates, review invoice from mediator, draft letter to client regarding mediation invoice, draft letter to Structured Settlement regarding birth certificates, review and revise letter to defense counsel, review and revise proposed Settlement Agreement and Release. .50 hrs Review UQA and phone call to Structured Settlement, draft letter to client UQA. .10 hrs Review note and signed Agreement from client, draft letter to Penn National forwarding signed Agreement, draft Petition for Approval of Minor Compromise Settlement hearing with three proposed Orders and three letters. .50 hrs Phone conference with defense counsel and instructions regarding forwarding of Release for review. .10 hrs Additions to both adult and minor releases, phone call to structured settlement consultant and email notes to defense counsel regarding releases. .80 hrs Review two emails regarding Releases, review and revise Petition for Approval of Minor Settlements. .30 hrs Travel to and fromShippensburg office to review and sign Settlement Agreement and petition for Approval, forward Release and Petition for service and filing. .70 hrs transcripts. motion and fax on ~::,~,...""..,~..., PAGE 8 150 /hr 150 /hr 150 /hr 55 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr "'- Shannon B. Myers Bill number 000092-00115-006 CDV 10/11/00 CDV Minor Compromise hearing and follow up on settlement checks. .10 hrs 10/12/00 CDV Review Order from Court on Minor Settlement hearing, draft letter to clients, draft letter to counsel, draft research memo and instructions on securing fee records. .20 hrs Review research results from Associate on the minor settlements. .10 hrs Review bankruptcy documents. .10 hrs Phone conference with Jeff Gross regarding structured settlements. .10 hrs Hearing preparation. .10 hrs Settlement calculations. .20 hrs Hearing preparation. .50 hrs Attend settlement hearing. 1.00 hrs 10/12/00 CDV 10/18/00 CDV 10/18/00 CDV 10/18/00 CDV 10/20/00 CDV 10/24/00 CDV 10/25/00 CDV BILLING SUMMARY .30 hrs 45.00 32.90 hrs 4,935.00 1. 90 hrs 104.50 3.30 hrs 495.00 1. 80 hrs 270.00 .10 hrs 15.00 ------------ 40.30 hrs 5,864.50 ------------ $ 5,864.50 Total fees for this matter $ STEVEN C. COURTNEY (SCC) CLARK DeVERE (CDV) STEPHANIE A. GRATKOWSKI (SG) FRANCIS J. LAFFERTY (FJL) STEVEN C. SKOFF (SCS) MELISSA L. STICKEL (MLS) TOTAL FEES TOTAL CHARGES FOR THIS BILL PAGE 9 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 5,864.50 '"-~~L", " u .., 1'1 ~ " :11 ~, I, '! "1 "I :~ ~l ti ," ,I 1,1 :'1 !'j " i.'1 1',1 I 'I fj I' ~1 j'l Ii "I I' I S . " ,-" , METZGER, WICKERSHAM, KNAUSS & ERB, P.C. P.O. BOX 5300 HARRISBURG, PA 17110-0300 .717/238-8187 TAX I.D. 23-2871395 October 25, 2000 Billed through 10/25/00 Bill number 000092-00114-007 COV Wendell K. Myers, Jr. 6720 Rice Road Shippensburg, PA 17257 W. K. MYERS, JR. v. Sheaffer WENDELL K. MYERS, JR. v. Gary Sheaffer and Osborne printing Co. FOR PROFESSIONAL SERVICES RENDERED 07/12/99 COV 07/23/99 CDV 07/26/99 CDV 07/27/99 COV 07/29/99 COV 08/02/99 CDV 08/02/99 SCS 08/03/99 CDV Phone conference with potential motor vehicle client. .10 hrs Initial meeting at client's Shippensburg residence with six clients. .70 hrs Open file for six clients, draft letter to clients, draft letter to Penn National, draft letter to Erie, draft memo to Associate. Phone conference with clients' bank. Phone call to clients. .30 hrs Review open file, phone call to and from client regarding property damage. .20 hrs Review photographs and draft memo to Associate. . 10 hrs Check on statute of limitations, review additional photographs, review medical bills and instructions on payment for medical bills. .30 hrs Telecon to Tpr. Myers re: movement of defendant's vehicle; left message; telecon to plaintiff re: same; left message; telecon to witness, Cecilia Hinebaugh re: interview; letter to witness, re: same; telecon from Myers re: movement of defendant's vehicle. .30 hrs Phone call from client, phone call to first party benefit carrier and return phone call to client regarding income loss payments. .10 hrs ............" ~~' '''''W!_'ili~I$;';(,', 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr ~ ~~ ~. ""~ " --" -. - Wendell K. Myers, Jr. Bill number 000092-00114-007 CDV 08/03/99 SCS Telecons (2) to Veronica Harteis, Claim Adjuster, at Penn National re: location of defendant's car; telecon to investigating officer re: same; proOfed and amended witness letter. .20 hrs Investigation of vehicle damage. .10 hrs Telecon from Veronica Harteis re: location of defndant's vehicle; telecon to Central Penn Sales re: status of defendant's vehicle. .10 hrs Telecon to salvage yard; telecon to Penn National Insurance re: request for pictures; travel to and from salvage yard; picture taking at salvage yard. .30 hrs Review medical bills and notes from clients and instructions on medical bills and notes. .10 hrs Miscellaneous file matters. .10 hrs Review photographs. .10 hrs Automobile title issues and miscellaneous issues. .10 hrs Conference call with CDV and Wendell Myers; telecon to insurance rep, Jeffrey Coy re: title; telecon from Barbara at Coy's office re: title; telecon to PennDot re: title; telecon to Wendell Myers re: title. .20 hrs Telecon to Wendell Myers re: title receipt; telecon to Legislative liaison at PennDot, Bill Yocum, re: procuring duplicate title; determined to whom title would have been sent, Myers or lienholder; received fax from Bill Yocum which included the requisite form for getting duplicate title and completion of forms. .20 hrs Telecon to Orrstown Bank re: title; telecon to Orrstown Bank re: lien; telecon to Sauder Chevrolet re: title and lien; telecon from Wendell Myers re: informing title was received. .20 hrs 08/04/99 CDV 08/04/99 SCS 08/05/99 SCS 08/06/99 CDV 08/10/99 CDV 08/12/99 CDV 08/13/99 CDV 08/13/99 SCS 08/16/99 ses 08/17/99 SCS 08/21/99 CDV Review memorandum regarding title. 08/24/99 CDV 09/02/99 CDV .10 .10 hrs hrs Medical update with bonna Myers. Review first party benefit materials. .10 hrs 09/03/99 CDV Draft letter to Myers' family and Mr. Helm regarding additional discovery materials. .10 hrs 09/03/99 CDV Review documents and photographs from clients. .10 hrs """'_Nk<l<;I",i,-, PAGE 2 150 /hr 150 /hr 150 /hr 150 /hr I" ! 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr ~< - ~ , , Wendell K. Myers, Jr. Bill number 000092-00114-007 CDV 09/07/99 CDV 09/08/99 CDV 09/10/99 CDV 09/14/99 ses 09/16/99 CDV 09/20/99 CDV 09/25/99 CDV 09/27/99 CDV 10/06/99 CDV 10/20/99 CDV 10/20/99 FJL 10/22/99 CDv 11/09/99 CDv 11/11/99 CDV 11/13/99 CDV 11/15/99 CDv 11/16/99 CDV 11/17/99 CDV 12/06/99 CDV 12/06/99 SG 12/09/99 CDv 12/09/99 SG 12/10/99 CDv Review medical records from Carlisle Hospital. .30 hrs Conference with client on medical treatments update for all injured parties. .20 hrs Review medical records from Dr. Baker. .20 hrs Drafted letter to witness Cecila Hinebaugh. .10 hrs Review police accident report and follow up on photographs (one-sixth of time). .10 hrs Process medical bills. .10 hrs Phone call from Penn National, review FedEx regarding watch. .10 hrs Extensive phone conference with Penn National and treatment update. .30 hrs Medical investigation. .10 hrs Review photographs of accident with Associate. .10 hrs Drive to location of accident; photograph scene; review accident scene; have pictures developed; memo to CDV regarding same. 3 . 80 hrs Review photographs and memo on photographs. .10 hrs Follow up on demand package. .10 hrs Follow up on photographs of scarring including conference with JLH. .10 hrs Begin draft of demand package and assemble exhibits. .50 hrs Complete demand letter and assemble exhibits. .70 hrs Phone conference with photographer and photography scheduling. .10 hrs Review and revise photography letters and scheduling of photography session. .10 hrs Phone conference with wendell Myers and scheduling of settlement authority meeting. .10 hrs Assemble documents for demand package and phone call to client regarding 12/10/99 appointment with CDV. 1.00 hrs Review and revise demand package and prepare for client meeting. .60 hrs Phone call with photographer regarding proofs; letters to medical providers and updated medical billing summary for assembly of demand package. .40 hrs Review note regarding Erie Insurance records, meeting with clients at Shippensburg office, meeting with photographer at Shippensburg office, phone call to Penn National Insurance, review and review demand package and draft letter to clients on settlement authority. 1.00 hrs , H~~ W"J""".lm,,"" PAGE 3 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 55 /hr 150 /hr 55 /hr 150 /hr -~ ,. ~ Wendell K. Myers, Jr. Bill number 000092-00114-007 CDV 12/14/99 CDV 12/17/99 CDV 12/19/99 CDV 12/20/99 CDV 12/20/99 SG 12/21/99 CDV 12/22/99 CDV 01/04/00 CDV 02/02/00 CDV 02/07/00 CDV 02/08/00 CDV 02/19/00 CDV 02/21/00 CDV 03/01/00 CDV 03/03/00 CDV 03/06/00 CDV 03/08/00 CDV 03/09/00 CDV 03/11/00 CDV 03/13/00 CDV 03/17/00 MLS 03/17/00 CDV 03/17/00 CDV Review medical record. Review photographs and instructions package. Review and make revisions to demand package. Miscellaneous matters relating .10 hrs on demand . 10 hrs letter and .30 hrs to demand package. .10 hrs Finish putting together demand package and exhibits. .30 hrs Final review and revisions to demand letter and package, phone call from client regarding medical bills. .60 hrs Regarding photographs. .10 hrs Phone call to and from Penn National to discuss demand package. .10 hrs Conference with client (Wendell Myers). . 10 hrs Phone call from Penn National regarding demand. .10 hrs Review letter from Penn National. .10 hrs Review phone message from Penn National on settlement. .10 hrs Phone call from client regarding settlement status. .10 hrs Follow up with Penn National on demand package. .10 hrs Phone conference with Penn National on settlement offers, phone conference with Wendell Myers, Sr. on settlement offers and intra-office conferences regarding settlement offers. .30 hrs Draft detailed response letter to Penn National's offer including calculation of percentages and supplement with other case information. .70 hrs Review settlement offer letter from Penn National. .10 hrs Phone conference with Penn National, phone conference with wendell Myers, Sr. and draft letter to Penn National with counter-demand. .30 hrs Review and revise reduced demand letter. . 10 hrs Review Penn National's letter. .10 hrs Phone call to Corporate Bureau and memo to file. . 10 hrs Phone conference with Penn National and phone conference with client. .50 hrs Perform research in preparation of drafting Complaint. ' . 50 hrs .~-'-". PAGE 4 150 /hr 150 /hr 150 /hr 150 /hr 55 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr Wendell K. Myers, Jr. Bill number 000092-00114-007 CDV 03/17/00 CDV 03/17/00 CDV 03/18/00 CDV 03/18/00 CDV 03/20/00 CDV 03/22/00 CDV 03/24/00 CDV 03/27/00 CDV 03/28/00 CDV 03/29/00 CDV 03/30/00 CDV 03/31/00 CDV 04/03/00 CDV 04/05/00 CDV 04/11/00 CDV 04/19/00 CDV 04/27/00 CDV 04/28/00 CDV 05/01/00 CDV Review research investigation. Draft letter to memo from Associate on defendant .10 hrs Penn National for Complaint. .10 hrs Draft Civil Complaint, draft letter to Prothonotary, instructions on forwarding and service and revise letter to Penn National. .60 hrs Draft Request for Production of Documents and Interrogatories directed to each Defendant. .60 hrs Phone call to Penn National regarding policy limits and final offers. .10 hrs Phone conference with client. .10 hrs Phone calls to and from Penn National and meeting to discuss case. .10 hrs Review and revise Complaint. .50 hrs Review correspondence from Penn National on settlement offers. .10 hrs Review verdict information. .20 hrs Review, revise and prepare Complaint for clients' verification. .10 hrs Review Complaint with client at Shippensburg office and have clients verify Complaint. .70 hrs Final review of discovery requests and forwarding of requests with Complaint for filing. .60 hrs Review return documents from prothonotary. .10 hrs Review Defendants' counsel's Entry of Appearance, two letters and draft letter to defense counsel on extension. .10 hrs Review of Sheriffs returns of service, calculate due dates for Answer and discovery. .10 hrs Review letter from defense counsel regarding bankruptcy filing and meeting with Associate to discuss bankruptcy motion. .10 hrs Review bankruptcy filing documents on Osborn, conference with Associate regarding bankruptcy and draft letter to client. .10 hrs Review Defendants' discovery requests including Interrogatories, Request for production, letter from defense counsel, conference with Associate regarding discovery matters, review proposed bankruptcy filings, conference with Associate regarding Motion and proposed Order on bankruptcy filings. .20 hrs ~_~."Co PAGE 5 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr Wendell K. Myers, Jr. Bill number 000092-00114-007 CDV 05/02/00 SCC 05/03/00 CDV 05/09/00 CDV 05/09/00 CDV 05/10/00 CDV 05/10/00 CDV 05/12/00 CDV 05/13/00 CDV 05/15/00 CDV 05/15/00 FJL 05/15/00 FJL 05/17/00 CDV 05/18/00 CDV 05/18/00 FJL OS/22/00 CDV OS/22/00 FJL OS/23/00 CDV OS/23/00 FJL OS/24/00 CDV OS/24/00 FJL Drafted Proof of Company. Phone conference bankruptcy. Review subpoenaed Claim regarding Osborn Printing .30 hrs with Wendell Myers regarding .10 hrs documents from defense counsel. .10 hrs Review and revise Proofs of Claim and Motion. .20 hrs Final review of bankruptcy motion and bankruptcy filings. .10 hrs Draft letter to client regarding bankruptcy filings, draft letter to defense counsel on bankruptcy filings, draft letter to bankruptcy debtor counsel. .20 hrs Review Bankruptcy Order, draft letter to debtor counael, draft letter to clients, draft letter to defense counsel, phone call from debtor counsel and review, revise Proofs of Claim. .50 hrs Review amended Proofs of Claim. .10 hrs Review letter from bankruptcy counsel and handle bankruptcy matters. .10 hrs Draft Interrogatory Answers directed to Wendell, Jr. 1.00 hrs Draft document request directed to wendell, Jr. .50 hrs Phone conference with Wendell Myers on bankruptcy and other issues. .10 hrs Review new case on punitive damages. .10 hrs Edit discovery responses for Wendell, Jr. .50 hrs Review responses to discovery requests including Request for Production of Documents and Interrogatories, letter from defense counsel, issue subpoena and deposition instructions. .80 hrs Review, edit and finalize Interrogatories. .40 hrs Draft letter to defense counsel regarding Answer to Complaint and discuss discovery responses with Associate. .10 hrs Review and edit all information for discovery. .30 hrs Review, revise and supplement discovery responses, draft letter to defense counsel forwarding discovery responses. .60 hrs Travel to and from Shippensburgi meet with clients to review all discovery information and to secure signed Verification forms. .60 hrs >~, PAGE 6 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr ~-~...- '" ~ '~" . ~" " ,.-~, ~ "~~_11<U,._","!;,--_ Wendell K. Myers, Jr. Bill number 000092-00114-007 CDV OS/25/00 CDV 05/30/00 CDV 06/02/00 CDV 06/08/00 CDV 06/13/00 CDV 06/14/00 CDV 06/19/00 CDV 06/26/00 CDV 06/27/00 CDV 07/05/00 CDV 07/06/00 CDV 07/17/00 CDV 07/26/00 CDV 08/02/00 CDV 08/04/00 CDV 08/08/00 CDV 08/09/00 CDV PAGE 7 Review and forward discovery responses. .20 hrs Phone call from defense counsel regarding Answer to Complaint. .10 hrs Review letter from defense counsel, review Answer with New Matter, draft Reply to New Matter, draft letter to Prothonotary and draft letter to defense counsel. .40 hrs Phone conference with Wendell Myers regarding Answer with New Matter and discovery. .10 hrs Review subpoenas, deposition notices, letters. .20 hrs Review bankruptcy filings. .10 hrs Review recorded statement from Gary Sheaffer with correspondence from defense counsel. .10 hrs Review Defendants' supplementary documents to discovery responses, review documents subpoenaed from Penn National, draft letter to defense counsel and review bankruptcy documents. .30 hrs Review bankruptcy documents, review letter from defense counsel and review and revise subpoena documents. .10 hrs Phone call from court reporter, phone call to clients, review deposition notices for depositions and medical records from Carlisle Hospital on Gary Sheaffer. .20 hrs pre-deposition meeting with clients and depositions of each client at Shippensburg, depositions of Schlein and Sheaffer, including travel time. 1.50 hrs Review letter from defense counsel, draft letter to defense counsel on mediator and perform research to select mediator. .20 hrs Extended phone conference with defense counsel regarding mediation. .10 hrs Matters regarding mediation and mediation scheduling including phone conference with defense counsel. .20 hrs Phone call from defense counsel regarding mediation and draft letter to Judge Murphy on settlement offers and demands. .10 hrs Review copy of first party file and instructions on mediation. .30 hrs Review documents from mediator including agreement to mediate. .10 hrs 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr Wendell K. Myers, Jr. Bill number 000092-00114-007 CDV 08/14/00 CDV 08/16/00 CDV 08/18/00 CDV 08/18/00 SG 08/28/00 CDV 08/29/00 CDV 08/30/00 CDV 08/31/00 CDV 09/01/00 CDV 09/06/00 CDV 09/07/00 CDV 09/13/00 CDV 09/26/00 CDV 09/27/00 CDV 09/29/00 CDV 10/03/00 CDV Review letter from defense counsel regarding mediation. .10 hrs Review deposition transcripts. .30 hrs Review bankruptcy motion and fax on mediation. .10 hrs prepare letter to clients for CDV review and signature. .10 hrs Mediation preparation including review of defense mediation memo. .40 hrs Attend mediation, attend conference with structured settlement representative and draft letter to defense counsel. 1.30 hrs Phone conference with Wendell Myers and two phone conferences with structured settlement expert and review faxed documents including proposed Settlement Agreement from structured settlement expert. .30 hrs Review settlement documents, review and revise Settlement Agreement and matters regarding structured settlement. .40 hrs Two phone calls with Structured Settlement expert. .20 hrs Review birth certificates, review invoice from mediator, draft letter to client regarding mediation invoice, draft letter to Structured Settlement regarding birth certificates, review and revise letter to defense counsel, review and revise proposed Settlement Agreement and Release. .50 hrs Review UQA and phone call to Structured Settlement, draft letter to client UQA. .10 hrs Review note and signed Agreement from client, draft letter to Penn National forwarding signed Agreement, draft Petition for Approval of Minor Compromise Settlement hearing with three proposed Orders and three letters. .50 hrs Phone conference with defense counsel and instructions regarding forwarding of Release for review. .10 hrs Additions to both adult and minor releases, phone call to structured settlement consultant and email notes to defense counsel regarding releases. .80 hrs Review two emails regarding Releases, review and revise Petition for Approval of Minor Settlements. .30 hrs Travel to and from Shippensburg office to review and sign Settlement Agreement and petition for Approval, forward Release and Petition for service and filing. .70 hrs Ili>>-~",~;-" PAGE 8 150 /hr 150 /hr 150 /hr 55 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr . , ,. , . Wendell K. Myers, Jr. Bill number 000092-00114-007 CDV 10/11/00 CDV Minor Compromise hearing and follow up on settlement checks. .10 hrs 10/12/00 CDV Review Order from Court on Minor Settlement hearing, draft letter to clients, draft letter to counsel, draft research memo and instructions on securing fee records. .20 hrs Review research results from Associate on the minor settlements. .10 hrs Review bankruptcy documents. .10 hrs Phone conference with Jeff Gross regarding structured settlements. .10 hrs Hearing preparation. .10 hrs Settlement calculations. .20 hrs Hearing preparation. .50 hrs Attend settlement hearing. 1.00 hrs 10/12/00 CDV 10/18/00 CDV 10/18/00 CDV 10/18/00 CDV 10/20/00 CDV 10/24/00 CDV 10/25/00 CDV BILLING SUMMARY .30 hrs 45.00 32.80 hrs 4,920.00 1. 80 hrs 99.00 7.10 hrs 1,065.00 1. 60 hrs 240.00 .10 hrs 15.00 ------------ 43.70 hrs 6,384.00 ------------ $ 6,384.00 Total fees for this matter $ STEVEN C. COURTNEY (SCC) CLARK DeVERE (CDV) STEPHANIE A. GRATKOWSKI (SG) FRANCIS J. LAFFERTY (FJL) STEVEN C. SKOFF (SCS) MELISSA L. STICKEL (MLS) TOTAL FEES TOTAL CHARGES FOR THIS BILL '" ~- ~ . ~il:l!.",&.,!.i,.a"""kw PAGE 9 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 150 /hr 6,384.00 _ A_" ." "..""l:( r;".." "" r-" ''If;l',.:\} ~: 'i;,: ':.:~ ..; "'- '..I ,,,'.~ WENDEll. K. ~,lYERS., HI... MEGAN "i, ~jYERS AND SH.ANNON B. MYERS, minors, by WENDELL K. MYERS and IlONNA J.lvIYERS, lhe:ir parents ami natural guardians and WENDELL. K, MYERS.. DONNA.I. IvlYERS and ERNEST F. HE!M, inthc'ir own right. Plaintiffs IN THE ('(lURI' OF COMtvlON PLL\S OF ClfJ\lBERLAND C€JUNTV. PENNSYI.VANJA CIVIL ACT!ON . L!\ W NO. 2000-206(J t ,~. " ~', GARY E, SIIE,\FFER and OSBC}RN PRINTING CO.. D~ Ccndants JURY I'R1AL !lEM;\NDED QR])E.~ Upon cOl1silkralion of the: l'cliiion t,lt' Approval of Minor Plaintiff,;' Compromised Scltlern<'nts, a hearing is schedukd 1'11' lhl'~~' of .t2.fk,i4itflf. 20()(), at i :,JOA.m, in Courtroom No, r bdi.m': Judgc~"" J".., ~~ c.---e f,P~ hs--/~~I' .~~ -_ j t~ de"t;;".:R ~-I'.:;::e <:-J ~r:;::4- ~-~ ~ A rCft 0.. t"~ ~---, BY 1"1 IE COUJ~t';-~, ~/\ ~~ .....r;;t;;:;A~E::t:: u,' d"';' .-T.... ./ ()~lldtJ() 1.l':'td, J L. Nfllf" Cd""t1St.. ,x: Clark DeYc,rc, Esquire - cOllnsell,\f' Plaintiffs Stephen E. Gcdllldig, Esquirc - counsd I~Jr Del"J1dants ,.'"1 Lop.~9-P -fi -\ C,\:~L(L 10 ,if ~O() "I I RX.3 nOd.'IIi,'.>it Ii i8:in';'5.l ~\DiiiUi&llil. liillliliiilli"~'4I'~~llIIiII~1_~~ill1I,@!ilI!i\!H"~t;;ail~;a<iii,<J. '"'t-Nli1^SNN3d v\\ ~ il .' . .r"' ,.....,,...'L'\I(V'i. ~ \~ \r.rn (1\:'" k\-:\":,n. pJ [\J...l\j\ \\..\.,) "',, .- ~ \ .r !..lei D .V 1\.. l'lOno j.v '..t )\'d\!l(~B(~'~:~,):G:j~\\':':\ :\0 :1. -. ~ "" .. 1 ~'\1' "...oilo......~~ .. . , WENDELL K. MYERS, JR., MEGAN N. MYERS AND SHANNON B. MYERS, minors, by WENDELL K. MYERS and DONNA J. MYERS, their parents and natural guardians and WENDELL K. MYERS, DONNA J. MYERS and ERNEST F. HELM, in their own right, Plaintiffs IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW NO. 2000-2060 vs. GARY E. SHEAFFER and OSBORN PRINTING CO., Defendants JURY TRIAL DEMANDED PETITION FOR APPROVAL OF MINOR PLAINTIFFS' COMPROMISED SETTLEMENTS Pursuant to Pa.R.C.P. No, 2039, Plaintiffs Wendell Myers and Donna Myers, as parents and natural guardians of Wendell Myers, Jr., Megan Myers and Shannon Myers, file this Petition for Court Approval of Minor Plaintiffs' Compromised Settlements and in support thereof aver the following: 1. Plaintiffs Wendell K. and Donna J. Myers, husband and wife, are adult individuals residing at 6720 Rice Road, Shippensburg, Franklin County, Pennsylvania. 2. Plaintiffs Wendell K. and Donna J. Myers, are the parents and natural guardians of minor Plaintiff Wendell K. Myers, Jr. who resides with them and who is 16 years old, having been born on September 24,1984. 3. Plaintiffs Wendell K. and Donna J. Myers, are the parents and natural guardians of minor Plaintiff Megan N. Myers who resides with them and who is 10 years old, having been born on February 23, 1990. Document #: 185095.1 - " ~, . , 4. Plaintiffs Wendell K. and Donna J. Myers, are the parents and natural guardians of minor Plaintiff Shannon B. Myers who resides with them and who is 6 years old, having been born on May 17, 1994. 5. The minor Plaintiffs have selected Plaintiffs Wendell K. and Donna 1. Myers, the Petitioners, as their parents and natural guardians, to represent their interest in this Petition. 6. Defendant Gary E. Sheaffer is an adult individual residing at 104 Carlisle Street, Apartment 1, Gettysburg, Adams County, Pennsylvania. 7. Defendant Osborn Printing Company is a Pennsylvania corporation with a principal place of business at 3055 Biglerville Road, Biglerville, Adams County, Pennsylvania. 8. On July 8, 1999, Plaintiffs were involved in a motor vehicle accident at the intersection of State Route 174 and 233 in Penn Township, Cumberland County, Pennsylvania. 9. At the time of the aforesaid accident, Plaintiff Wendell K. Myers was operating his vehicle with the remaining Plaintiffs as passengers in the vehicle. 10. At the time of the aforesaid accident, Defendant Gary Sheaffer was operating his employer's vehicle with the permission of his employer Defendant Osborn Printing Company and within the scope of his employment with Defendant Osborn Printing Company. A true and correct copy of the police accident report for the aforesaid accident is attached hereto as Exhibit "A" and incorporated herein by reference. 11. As a result of the aforesaid accident, all Plaintiffs were taken to the hospital and sustained injuries. 12. Since the accident, all minor Plaintiffs have made a good recovery and are no longer treating with any medical providers. A true and correct copy of the medical records for minor Plaintiff Wendell Myers, Jr. are attached hereto as Exhibit "B" and incorporated by -2- Document #: 185095.1 . ~" '= " ~. ~ . , . reference. The medical records for minor Plaintiff Megan N. Myers are attached hereto as Exhibit "C" and incorporated by reference. The medical records for minor Plaintiff Shannon B. Myers are attached hereto as Exhibit "D" and incorporated by reference. 13. The minor Plaintiffs have no out-of-pocket expenses and there are no liens or rights of recovery related to the accident and the medical bills have been paid by automobile insurance. 14. On August 29, 2000, the parties met for a mediation conducted by the Honorable David W. Murphy. 15. As a result of the aforesaid mediation, the parties agreed to a global settlement of Three Hundred and Eighty Thousand Dollars ($380,000.00) with the Plaintiffs receiving the following sums of money: (a) Wendell Myers, Sr. $100,000.00* (b) Donna Myers - $100,000.00*; (c) Ernest Helm - $100,000.00*; (d) Wendell Myers, Jr.- $ 50,000.00; (e) Megan N. Myers- $ 15,000.00; and (f) Shannon Myers - $ 15,000.00 * The adults sustained significant injuries in the accident; 16. The Plaintiffs after consultation with their counsel and the structured settlement representative, determined that the best interests of the minors would be served by counsel taking the 25% fee from the total amount going to the minors of Eighty Thousand Dollars ($80,000.00) and then distributing the sums of Forty Thousand Dollars ($40,000.00) to Wendell Myers, Jr., - 3 - Document #: 185095.1 " l...liW"jl ~ -, , . , . Ten Thousand Dollars ($10,000.00) to Megan Myers, and Ten Thousand Dollars ($10,000.00) to Shannon Myers to be placed in a structured settlement account in accordance with the documents attached hereto as Exhibit "E" and incorporated herein by reference. 17. The assignor for the structured settlement would be the liability insurer for Defendants, Penn National Insurance Company, the assignee would be AEGON Assignment Corporation and the annuity issuer would be Monumental Life Insurance Company. I have attached hereto as Exhibit "F" a document regarding the fmancial strength of the assignee and annuity issuer provided to me by the structured settlement specialist Jeffrey Gross. 18. The structured settlement accounts are designed so that all three minors will have set sums of money when they turn 18, 19, 20 and 21 to finance their future higher education. 19. The adult Plaintiffs have agreed to deduct all case expenses from their settlement so that costs and expenses do not need to be deducted from the sums given to the minor Plaintiffs. 20. In light of the limited injuries sustained by the minor Plaintiffs and the nature of the structured settlements, the minor Plaintiffs' best interests would be served by approval of these settlements and Petitioners respectfully request that this Honorable Court approve the settlement of the claims in the foregoing amounts. 21. Counsel was retained by the Petitioners to represent the minor Plaintiffs on a contingent fee basis of 25% of gross recovery, which fee is fair and reasonable for the time and effort expended on behalf of the minor Plaintiffs which included filing of the civil action, the taking of depositions and the attendance at mediation. A copy of the Fee Agreement is attached hereto as Exhibit "G" and incorporated herein by reference. -4- Document #: 185095.1 . , 22. The Petitioners respectfully request that this Honorable Court approve of the compromised settlements of the minor claims in the gross amounts of Fifty Thousand Dollars ($50,000.00) for Wendell Myers, Jr., Fifteen Thousand Dollars ($15,000.00) for Megan Myers, and Fifteen Thousand Dollars ($15,000.00) for Shannon Myers out of which Petitioners will receive directly for the benefit of minor Plaintiff Wendell Myers, Jr., Twenty-Five Hundred Dollars ($2,500.00) to be used for a computer expense; counsel will receive the Twenty Thousand Dollars ($20,000.00) out of the lump sum of the three minor settlements and the remainder will go into structured settlements in accordance with the documents attached hereto as Exhibit "E" and incorporated herein by reference. 23. The Petitioners request for the balance to go into the structured settlement accounts is in accordance with Pa.R.C.P. No. 2039 and in particular 2039(b )(3). 24. Upon approval, the Petitioners will also sign the Settlement Agreement and Release, a copy of which is attached hereto as Exhibit "H" and incorporated herein by reference. 25. Upon approval of the minor compromised settlements, the Petitioners also desire to discontinue this action filed against Defendants upon receipt of the lump sum to be paid on behalf of Wendell Myers, Jr. and the transfer of the funds to the structured settlement accounts as set forth herein. 26. The Defendants concur with the filing of this Petition and also seek approval of the minor compromised settlements under the terms set forth above. WHEREFORE, the Petitioners respectfully request that this Honorable Court approve of the minor Plaintiffs' compromised settlements and enter an Order distributing the funds as follows: - 5- Document#:18509~1 --~ . . , (1) To be paid to Wendell Myers, Sr. and Donna Myers, who are appointed guardians of Wendell Myers, Jr., the sum of Twenty-Five Hundred Dollars ($2,500.00) for the immediate benefit of Wendell Myers, Jr.; (2) To be paid to Metzger, Wickersham, P.C. for counsel fees for all three minor Plaintiffs - Twenty Thousand Dollars ($20,000.00); (3) To paid to Metzger, Wickersham, P.C. for expenses - $0.00; and (4) The balance: Wendell Myers, Jr. - Forty Thousand Dollars ($40,000.00); Megan Myers - Ten Thousand Dollars ($10,000.00); and Shannon Myers - Ten Thousand Dollars ($10,000.00), as agreed by the parties and guardians, to be placed in a structured settlement pursuant to the Uniform Qualified Assignment and Release attached to the Petition with assignor as Penn National Insurance Company, the assignee AEGON Assignment Corporation and the annuity issuer as Monumental Life Insurance Company. METZGER, WICKERSHAM, KNAUSS & ERB, P.C. By: C~'f'~J~ Clark DeVere, Esquire Attorney LD. No. 68768 3211 North Front Street P.O. Box 5300 Harrisburg, PA 17110-0300 (717) 238-8187 Attorney for Plaintiffs Dated: 10/3/00 -6- Document #: 185095.1 ~~"",~i!'~"' ,. " -~ .-.,." ~~ ~ ~~, . , , - ",.\ ~. COMMONWEALTH ~F PENNSYLVANIA POUCE ACCIDfENT REPORT @ nrPORTAOlf ~ oo!~. RfPORTARlEr"."1 PENNOOTUSE ONlY "ACCI~t;,LOCA'f!ON"'.ii1J'~, .'.', ~', 20. cOlJlNTY CODE 'Z ____._.._..U~~~t;> , 2'MU.~~~1TY PE>1oWTwp..cooe.'7-\C>. ,PRINCIPAL ROADWAY INFORMATION 22: ~~ir':"";$RIJ.7+.(W'lI1.NlfL 8o:no,,,<.Bp~.... 13. ~~D +5"" '~'I~-::fWAV 0 r25.l~~:" I ~ _____.._ .._n_m... .. __ __ __ .._ ____.____.___._.._., __ L .._._..____ ._"._.._______. .,__ INTERSECTING ROAD: 16~.wiT~S~r:Z33-- m . . ... 21,SPE~D 55 128"TVI'E' ... .1~jACC'ESS ""._- l.lMrr. _ .,. _.___L~~~~A!_u_~l-- CONTROL , IF NOT AT INTERSECTION: 3O.-cRqssSTRE-efoR------.-.--- 3T~!~*~~E~-.E-;-T32. ~:ci~~---"'-"- ---;~'.-----" MI. 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IICC · [T3JCARGO OOOY tYPE 1(76-:iHAiARObUs , . MATERIALS 'I:;VNR (~~~.;~.......;;)~~.-. r;:RElEASE'OF.HAZMAT 75. NO. OF 76.HAZARDOUS ! _ ___ ~..~::L~J;L ~D AXLE~._ __ MATERIAl,.S PAGE: _ -l.-- . . jPuc.......... ._.m -.~. ..... .--u.-CVWR ..-.----,..- --- 77.RELEASEOfHAzMAT ,VONOUNl(O .'..""c.or - BHSTE 339478-;- iFMHI,jMJ!i~,&!J," _"-c..""",,.,.,' -,~~-"' ,,",~,..~ . . ...__.__..__. __ 000244 ---------. N~v,u.CAMe.UIA~L. C I ____n_ flj PF.SPONOING EMS AGENCY . 19. MEDICAl FACUTY 80. pEOPLE INFORMATION _~ _.8: !=:__J!.. !.__ F G NAME_~_.__,___._______.. ADDRESS ~...}~ ~$ ~ tTf. 6~:~~~~~.__ ...---- '2 3 F31-~. 1 J.. _~...t!.".';;5",.~':(~..__~\>.....C..Jl,OO~Lh~ O"..~ ~. 1- M l'+.~ to' W&"Q~!-l-__\C ,,^'(i\l&. "':..._':__,,__~ 2.. tf 5'1.1_ ~ .s,."..~I..4,'iL.,,^,'i,,-l1,~_ " " I' " ZlbMtS'2..20 '3". " ,. " .. DIAGRAM 'yJAIiJI1T &"l'roM+ P-I'I'l!o".5",,\c~ .J INcioENTli:.-----.-...---- CCIDENT DATE: H 2- I I I , ... D!.. 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CENTER FOR HIGHWAYSA,FETY ~""'id~;",,""__'!~i-. , ~. t u '",, ,;~ f ~j' .. ~-~,~. , ,'*""....~v __ v - "' -l 1iIIiIiI~.'~~ "" -,"._, ~ ~~ _B>'J~.g.""'-'~,J","'-" (.j() AHEA TOClYEAlAYSHEETS AEl'ORTAIU 1i!3 """""PORTAIU 0 P9H)QTUSECK.'1 ~ \-\.2.- \07~'3~S 1~~NT"7/ocglqq ~ ~I IW:Al 1.\ " RSON WORMAllON. USE OVERlAY' 25HEET FORCOOES BCD E F G NAME ADDRESS H I J K L .. (J1.~AR~TrvE~ (~ (f"o~'\ \N\"T"'&'>\t~ 'N~\Z",\ fo" ..~ -n..," . :A.f! PizOV/~~ : 'WlI.rTTj", '<...fA.-(~UEAln 76 -rillS Ot:J::"U:P ,.,....,^.\ "n.~ A........."'<...-.J.~ 'T... :.,.U~S : 0"';'. ~:-1A'" ,..;" _r ~ ~Hb.<LJ.4 <go. : : , . U"kT"" .. .Ar....... ........ . ......... c:..,..,.,... a... t. -:se....o;)'~ J. 1...r Ie CD: . :';;;"'. . , tN,'r "-z- Qh..... -n,... Sc.oJC P"......"'..t2.'..: ~ O\..i",c:.: : WAS 8'1': : : , C;-d\lM s.P'-OO\S" W/>o..';. "-'A,..e",.... t'""'\ '"I'nl2. ~"L A"';" C>S'<!.6~"" '-----;::>, , , (,.,WN",6 0(. ""'1 · I. "\ : . t 1'-;.....,;..'; : : : . : : , , . "-~f' _.".';"~ c,cn<!:~.,.+~~O Fi. ro ...~I,..''1 .- :fAlL ~ \ (~:~I.~/<.. ~ ) : : : : : : : : : . , : : : : : :c :--., , , .... : : , : . : . , : ~"" ~ESCAIBEVIOLATKJNS 00. SECTION NUMBEAS (OIIt Y IF CHARGED I TC" NTC UNIT 1 Il Il ~ (] (] . 91. J'ROBABlE 92,)TYPE VESULTS DN;lTES~ ~ ~5ULTS D hDTEST 94.lfNESTlGATION USE f-' TEST o REFUSE USE o F6\JSE eot.I'lE1E ? UNITt 0.__% 0 UNK UNIT2 0.__% 0 UNK YES -a1'"" 0 ~~ @ 000246 COMMONWEAL TH OF PENNSYLVANIA PAR CONTINUATION SHEET M-45C(1192) PAG"'~ CENTERFOA HIGHWAVSA,FETY .>..""..<...,,__',,..;I'_~l"".'-' " ~--......--- .~.~ ~- - ~. . '_~"-;"-'..e. ",~._,_.'-~C~'_'"""""'=l ~"_,I", ,- - ~" ""'liDl!ILJ~il~,~-idL@l:1~ I"~\E -Mona- . . Undet SectIon.toc of the ". Crimes Code. UmwomF.1sHication toAuthorltiu.. petSOftCCMnftllilsa ",isdtmeNtOrofthll thirddegree If... ....ltes. _,..............._...__1>0110..10..._. ,.. VICTl....."'ISS ""'-'fUll: ",_",'d,"",'lUi;o;;1 ~ ~ ~. " I ~""" "",""" IYVl ~-~q Chts6vKf sf. &.KACI; SR 174- '.OIflCP"S......lISIGWA1"UfII.t,AOGI1iKl: ~ .\:::>..~\i)~. ..stAnMI"': '.'.- - " ."ona- U__.104of....'''Crim..CocIo.U.._'.__...,,__.__...__of....'''''''dogtoelf......k... written ',Ise state....nt wNch he do4tt not be"'" to bit true. t& VICf1M'MTJiI(SJstGlMnMI: ".,"-.~',;I ,.,,,_.' -' .~. '''''''''iIl/Ii _=T ~~'''''.~'Kj. ~~~" ~ .~ .--. ~ .~... 0002 ",'.'F.."l,7/f Clfn:fo(m;'f.,!-ill.i~(1!,,:1. ".' ftHIlSYl.VAMUTAn;oua WR1',.,: ." '. . . VICTIMIWITNESS~ATEMENTFORM;:'. .. '.~ .....-...-....,.-..-....- ._........,.....-,..~ "'- . s,~_o~ .J1- . ,...::i(~.-..'i.:~i:::'~t..~?~.:m.j;l~~ a.~.'?'_~ (ii: ,C .".....\.- . .,' fI1"~ s W/fd '<.~< I '7o.:f-s S~ '2.'3 ,.., .....,o~. U\.(c~'", t.STAnMlNT: (;l &!c. #' lL- /b vcc:/pst::cT,o /VI(, ref S7b r e:>r l/;( ;U . .~. , I ".1 f ':~l' . ,.~~;\'~.:,~.~L~-(;;.::~..l. l\;'~l~l nirin';J- " J..r .;~tj().j 'l':Jd~)" _.',1 "j' . '...nf;:~i.!(:Hl1rfH:)h "41- ,,-, 'l\iJ".t\"FH1'!iQ .NOTICI. Under S~ion ..teM of the P,. Crimes Code, Unsworn f,hifkltion toAuIhorilles.' person commits. lIIiscIemdnor of the third degree If hi' ",.lreta wrmen faka'U'tlMnt whic.hht-doetnot bdevetobetrve. ,.. vtC1lMNI'tTNI'" VGNAru..: CARLISLE HOSPITAL ~- ~ " "~ - - -, ~ ~,- M~_ ~ ' ~ CarliSle Hospital ~! and Health Services 2il6P.rkerStreet Carl~le.PAI7013.0310 (717)249.1212 OUTPATIENT RECORO SHIPPENSBlJRG, PA 17257 PA "F" OATftTIlAE 07/09/99 19:30 NAI.lElAOOREBMHOfomAtlet$fXIRACfllA.9. MYERS JR, WENDELL K. 6720 RICE RD PATIENTIOTHEAEMPLOVEA 14Y M W S 09/24/94 000-00-0000 NII.MF'ArmnP.'lSIPHnt-IFI11Ft A 110NI0 0 IlI!lOC-SI'C.NO .J ,- GUARANTORS EMPLOYER MYERS SR, WENDELL K. 6720 RICE RD HOFFMAN MILLS 164-60-3353 SHIPPENSBURG, PA SHIPPENSBlJRG. PA 17257 NAt.lE/ADOIlESSIPHONE.nELATIONiSOC.SEC.NO. EMERGENCY NOTIFY MYERS, DONNA J. (717)532-7970 19 WENDELL K. 03 FX L CLAVICLE MULTIPLE COMPLEX LAC SIP MVA f JlftrrnlfLl' 3 TO 5 RNS tlos .,;/:J tft:J,D ATTENDING FAMILY SEDLACK, JEFFREY 0 MD FALVO, THOMAS C. D.O. 095 CUMB SOUTHAMPTON TWP DEPARTMENT ISO? N '. .' ~. ""'" ~ '~ " .~ " ,', ~ . o P L H rr R S JR. 11/ EN DEL tIt\ Carlisle Hospital 071 O'~ Iqq b 72 0 R I C [ R 3 ~, and Health Services 011?4/~4 $HIPPlNSBURr.. PA S I :J LICK. J [ F FREY 0 H 0 CONSE10'411'O [HOSPITAL ADM I' 0 0 S F 18 0 8 3 2lf q l ICAL TREA'P" 'Name of Attending Physician (s : S<t'f / C't Al T~ p{G Date of lIdmisaioll: / Time: (AM)_(PM)_ 1. acting on behalf of) e or Authorized Representative , suffering from a condition requiring hospital care, hereby ame or Patle consent to rendering of such care, which may include routine diagnostic procedures and such medical treatment as the named attending physician(s) or other of the hospital's medical staff consider to be necessary. 2. I understand that the practice of medicine and surgery is not an exact science and that diagnosis and treatment may involve risks of injury, or even death. I acknowledge that no guarantees have been made to me as to the result of examination or treatment during this hospitalization. 3. I understand that: (A) It is customary, absent emergency or extraordinary circumstances, that no substantial procedures are performed upon a patient unless and until he or she has had an opportunity to discuss them with the physician or other health professional to the patient's satisfaction; (B) Each patient has the right to consent, or to refuse consent, to any proposed procedure or therapeutic course; and (C) No patient will be involved in any research or experimental procedure without his or her f~~l knowledge and consent. 4. I understand that many of the physicians on the staff of this hospital, including the att~nding physician(s) named above, are not employees or agents of the hospital but, rather, are independent contractors who have been granted the privilege of using its facilities for the care and treatment of their patients. Further, I realize that among those who attend patients at this hospital are medical, nursing, and other health care personnel in training who, unless requested otherwise, may be present during patient care as a part of their education. still or motion pictures and closed circuit television monitoring of patient care also may be used for educational purposes or for documentation of the clinical course unless a patient expressly requests otherwise. 5. I release CARLISLE HOSPITAL from all responsibility for all articles which I am retaining or will have with me during my stay at the hospital. I understand this includes clothing, bridgework, false teeth, eyeglasses, jewelry, money, radio, razor or any other item kept in my possession. I understand I may deposit valuables in a safe provided by the hospital; only if this is done will the hospital assume any responsibility for the safekeeping. 6. I hereby acknowledge that I have received written information on the topics of Patient Rights and Advance Directives. Date of Signature: ~-~ .~~ {SIQNATURE OF PATIENT} {SIGNATURE OF WJ:TNESS} .' (If patient is unable to consent or is a minor, complete the following:) Patient [is a minor ____ years of age] [is unable ,to consent because] : ~ /A/"'j f{1(\0T'I\ zY SIGNATURE OF WITNESS AD 0315 (10/91) INSURANCE CO,: Carlisle Hospital and Health Se 'ces ~~ 1. LI.h ." S JR, wENDEll K. ir"JA' q R ICE R D 1/24/"4 SHIPPENSBURG, PA " ACK JEffREY D MD 241> P iOS8i80 832~9l PATIENT'S NAME: ;'1 Statement to Permit the Release of Medical Information and Pavment of Medicare and / or Other Health Insurance Benefits and / or Phvsician. I authorize Carlisle Hospital as the holder of medical infonnation pertaining to me to release the necessary and appropriate medical information to the fiscal intermediary of the Social Security Administration and/or to my primary or supplemental health insurance company or its designated review agency for payment for services rendered. I authorize the Carlisle Hospital's and/or the physician's billing agent to submit a claim to Medicare or other health insurance on my behalf, or to request, on a one time only basis, from the Social Security Administration, such information necessary to complete the claim submission process. I am the individual to whom the information/record pertains, or am authorized to consent, on behalf of the individual, to the release of tile information/record. I understand that any false statement or representation knowingly and wilfully made or caused to be made for use in determining rights to Medicare benefits Or payments may be punishable by a fine of not more than $10,000.00 or one year in prison, or both. I request that payment of authorized benefits be made on my behalf. I assign the payment of inpatient or outpatient hospital benefits to Carlisle Hospital for those services provided by Carlisle Hospital and/or I assign the benefit payable for physician services to the physician. I certify that the information given by me in applying for payment of services under Title XVIII of the Social Security Act or for any/all other health insurance is correct. \.1".", Patient'. Signature r Responsl Ie z Insured Person's Signature (If different from patient Ot If patient Is a minor.) Date .' Reason patient could not sign. /V) ,'(\/ 01. . (' f/L.... ~ Witness WhKe Copy. HeBllhcB,e Billing Canary Copy & Medical Records! Ancillary Departments AD 1825 (5/99) / " Dill!: Activity: Dressing/Personal Care Instructions: r Y-I-? P' . 2~~. c. ".'>'- (.... Follow-up appointment with Physician: Other rollPw.uP' appointments: ( . "S\ ro.. \\~ -- r a r ( I " Supplie$.sent with patient: ;1. ,.y ~A-/- au..- IS I h ~()O( r c /~ o Home Health Nurses Redwood Home Health Services - 245-5600 o Other egeney SERVICES: 0 Skilled nursing 0 Home health aide 0 P.T, OO,T. OS.T. MEDICATIONS: ILlST BELOw) NAME DOSAGE INSTRUCTIONS i'HIt! f .'l,;VO b'l3.:.;;'l :', I cO:3 , ,j',! l;:' ,.;:"j (.~r _.jllll" ~ ;,1 J.;'. ') 'II <:;D ..-,. ) . q,r."v "/l~I/'(' .:.. " Co '..' .-" " 1 I have received and understand the Instructions on my medications and on food/drug Interactions for these medications. this Information Is provided for educational purposes. Any recommendations from my physician will supercede this Information. ( PatlentorResponsiblePariySlgnature: \L_uI1/vI ,) flY,,) Date: ?cf.f9 ~~4>,4- Carlisle Hospital and Health Services RN Signature: Physician Signature: ~ Patient Identification ." 248 PARKER ST., P.O. BOX 310 CARLISLE, PA. 1701:HJ310 ,'" "y[P,S .'~. "1~[lElL k. l/f'/11 ~7l0 RICE "3 . \"" '4/~4 S-IPPENSPUcr. PA ',t'l..CK. JlffREY 0 "~. 246 005BIPO 832~91 p DISCHARGE INSTRUCTIONS MR 0410 (03197) t. 'P",! oil.., . MEDICAl. RECORDS v Date of Surgery/Procedure 'I\dmiSSion/Preop Diagnosis 0') ct..:) ~f\J)o ...J.\ ev.,h:.- 'CC/H~I I'! ,p. IN ,? \ ;; ~ r>->; "'. ~~ .' my/> ~...~\.. f""'\' Le lr (~ ~ e:- ~I...o 1""" ---~ '''t;. fJ )~Jv- .,) 'i'\.... r- .Past Significant Surgery or Illnesses uk. \:\...~ ~ L ~-" ROS 'Allergies }.Aw, *Meds --...l,-~ '~........... I"'vJ"cv.-. FH >sn ~k. ~ lIMr ==..a====._.D===.......=~==.=~_=============================_========._.====================== BP P R Temp *General Condition Wt. other >Mental Status ~ 'Heart ~ j, <. , . Lungs ~ ^~ .w.J r-- \ ~c ~ .f.A..:Jl'"" <; c..- t. ..., @ 'c9....J .c;.. -'- f........-lL.. Mo "- Gv-~~ M> <\.1>-- ~...."'\:... c:'^---- A ~ A~ y..v.&s, . 1-" No r;l..:..Ji ~ 'Planned Treatment/Procedure (C) d)......S> ~ I /"JI, p ......A.. (..;:L r-~'~ n........... (/0 v-u. I i Physician's Signature Date 'CONDITION AT TIME OF PROCEDURB/TREATMBNT o llNCHlINGED DATE INITIALS 'Co~lete all starred ALL patients. Complete all other lines pertinent to patients planned procedure or medical condition. AMBULATORY CARE RECORD (2: D~p(. :.. \...J ~..... &...v.. ~ ,;, ,"...:, J<. (Y)J-lM) ~ Carlisle Hospital ~, and Health SeIVices FOOt HYfRS JR. w[NDELl K. ~ 07/0A/Qq 6720 RICE RO oQ/24/A4 SH(pPE~SaURG. PA Sf JlICK, JEHRfY 0 HO 246 P 0058180 832~ql NO 01.0Ft fl/9G) ~~ -- ,- ~- PO~TOPERATIVE NOTE: ~Postoperative Diagnosis *P~ocedure 'SUrgeon/Assistants Complication · Specimens EBL Drains/lmplants Disposition: Uate ~nYS1C1an's ~1gnature ...~.........a~=.==.._..=======..._.==================~==========================.============= PROGRIlSS NOTES i: , " " :! ~ 'I I II II II I I I , I I I ! .' .' ODE'; k. I .7/~./qq &'20 RIEE RO : 'Q/?4/"4 SkIPPENSeUJG. Pl p Q'lHK J[fFREYOMO ("'1241, v OOS8 lFO 8321h ~ Carlisle Hospital ~, and Health Services AMBULATORY CARE RECORD A.... 1 ') NO 0106 (1/96) " .- , ".' '-1 MYERS JR., WENDELL K. 304-D 07/09/1999 MR# 832497 DATE: PERFORMED BY: 07/08/1999 John P. Stratis, M.D. PREOPERATIVE DIAGNOSES: Complex laceration of the right forearm and left face status-post motor vehicle accident. POSTOPERATIVE DIAGNOSES: Complex laceration of the right forearm and left face status~post motor vehicle accident. PROCEDURE: Repair. ANESTHESIA: 1% Xylocaine with epinephrine. INDICATIONS FOR PROCEDURE: A 14-year-old white male who was involved in a motor vehicle accident. He was an unrestrained passenger, He sustained complex lacerations of the right forearm and left face. These involved multiple lacerations with nonvia- ble tissue and shards of glass within the wounds. The plan is for repair. The procedure is as follows. \??J9 Both areas were first cleaned with saline solution and then in- jected with local anesthetic. They were then cleaned with Beta- dine solution and saline. The wounds were all examined. There were multiple wounds, totaling about 10 to 12 cm on the forearm and only 3 cm on the face. Nonviable tissues were excised using scissors and forceps. Each wound was probed, and glass was re- moved when found. Some protruding fat was also debrided from one of the wounds. The forearm wounds were then closed with inter- rupted and running 5-0Prolene suture. This was dressed with Adaptic and dry gauze and Kling. After the facial lacerations were debrided, they were closed with interrupted 6-0 nylon su- ture. This was dressed with bacitracin ointment. The patient tolerated the procedure well. He is being admitted for observa- tion under Dr. Sedlack's service. JPS/kw D: 07/08/1999 - 06:40 pm T: 07/09/1999 c John P. Stratis, M.D. John ~ M.D. MYERS JR., WENDELL K. 304-0 MR# 832497 07/08/1999 09/24/1984 John P. Stratis, M.D. Page 1 of 1 ORIGINAL CARLISLE HOSPITAL PROCEDURE NOTE <-- ~. ~ ~~ ~ Carlisle Hospital ~, and Health Services 2016 rarhr Slreet . Carlisle, rA 17013.0310 . 717-245-5500 REG.OATEmME OP. 07/0B/99 15:39 NAME I AOOAESS f PHONE I AGE I SEX I RACE 'M.B. K. PA 17257 NAIIIE / ADDRESS I PHONE I RELATION I D,O.B. I sac-SEC.NO. MVERS SR, MENDELL K. 6720 RICE RO PA 17257 NAME f AODRESS I PHONE I RELATION / SOC.SEC.NO. EMERGENCY NOTlFY .<.L::l .. _n' PA ( 717>532-7970 14V M N S 09/24/94 000-00-0000 PATlENT/OTHEAEMPLOYEfl GUARANTOR'S EMPLOYER 164-60-3353 HOFFMAN MILLS SHIPPENSBURG, PA MENDELL K. 03 MVA ALVO, THOMAS C. 0.0; BRIEF VISI r 28700 CLASS I VISIT 26710 CLASS II VISIT 26720 CLASS III VISIT 26730 CLASS IV VISIT 26740 CLASS V VISIT 26750 CONVENIENT CARE I 27020 CONVENIENT CARE II 27025 MINOR SUTURE EDSOl MEDIUM SUTURE EDS 02 MAJOR SUTURE EDS 03 INTUBATION EDS 04 IV SET UP EDS 08 CARDIAC MONITOR EDSll PELVIC EXAM EDS14 NITRO SET.UP EDS 16 CAST, SCOTCH SHORT ARM 26031 CAST, SCOTCH LONG ARM 26032 CAST, SCOTCH SHORT lEG 26033 CAST, SCOTCH lONG lEG 29034 CAST ROLL, PLASTER 26075 B/P MONITOR 26037 PACER PADS 79064 GASTROIHEMO SUDE 26060 KIDDE TOURNIQUET 26048 OCl PER FOOT 79670 F.S,B,S, 60081 TUBE GAUZE PER FOOT 26074 ED STAT ESTAT PULSE OX POXED EXTENDED CHARGE I 26760 EXTENDED CHARGE II 26770 ~-------------- --------------, , , , I I I I I I I I I I I I I , , ,------------------------------~ ,~--- --- ----....- --------------', , I I I I I I I I , I , , I , " ,------------------------------~ ISOLATION ALERT N ALL ADDITIONAL (jHAIIC~s"''','".'" "" ,~-------- --------', , , I I I I , I , I , I I I , , ,-------------------, ,----- ----, , , I , I I I I I I I I I I , , ,-------------------, ,~-------- --------', , , I I I I I I I : I I , , ,-------------------, ,-------------------', , , I I I I I I I I I I I I , , ,-------------------, ,---- --------', , I I I I I I I , I I I I I , , ,-------------------, ,---------- -----.... , ' I I I I I I I : : I , ) ,-------------------- ,---------- ---------, , \ I I I I I : : I I I , } ,-------------------- ~--------- ---------, , \ , , I , , I I I I I : I \,--------------------} ,---------- I I I I I I I , ,------- ---------, \ I , I I I I , ----------_...' ...--------- ------- -, , , , I I I I I I I I I : I \ } ,-------------------- ,--------- ---------, ,---------- ---------...., I 1: ' I I, I I I, I I II I I II I I II I \ 1 , ) ,-------------------, ,-------------------... ER-Q508 (REV, 8!96) "~~ ., .......~~. " ,-,,-, -o;j-i MYERS JR., WENDELL K. MR #832497 07/08/1999 ER to 304-D CHIEF COMPLAINT: Multiple complex lacerations, right forearm and left face after motor vehicle accident. HISTORY OF PRESENT ILLNESS: This is a 14-year-old white male who was an unrestrained passenger in a Suburban, which his father was driving, when it was involved in a motor vehicle accident. The patient was brought to the emergency room and was evaluated by Dr. Sedlack who noted complex lacerations to the right forearm and left face, and he called me to evaluate and treat the pa- tient. PAST MEDICAL HISTORY: Significant for no known allergies. The patient has had previous lacerations and repair. He takes no medications. EXAMINATION: The patient is awake and alert. He has obvious lacerations of the left cheek and temple area and lacerations of the right forearm. These are multiple with areas of devitalized skin and subcutaneous tissues and foreign body, glass. The PLAN is for debridement of these tissues and repair. The patient will be admitted to Dr. Sedlack's service for observa- tion. JPS/kw D: 07/08/1999 - 06:42 pm T: 07/09/1999 c John P. Stratis, M.D. John 2:2, M.D. " Page 1 of 1 ORIGINAL CARLISLE HOSPITAL EMERGENCY ROOM RECORD ---,- -10. 5J~',-r NAME I 'MYERS JR, WENDELL MRNI 832497 DOS: ,/' ADMIT 07/08/1999 . TIME SEEN: CHIEF COMPLAINT: 1539 MOTOR-VEHICLE COLLISION. HPI, The patient is a 14-year-old Caucasian male who was the unrestrained backseat passenger in a motor-vehicle collision in which there were multiple casualties and several people were flown to the local trauma center. He was brought here via ambulance complaining of multiple abrasions and pain in his left shoulder. He has had no neck pain, back pain, loss of consciousness, alteration of consciousness, nausea, chest pain or abdominal pain. He has no sbortness of breath. He has no paresthesias or weakness in his extremities. PMH: IMMUNIZATIONS, The patient has no significant illnesses. The patient's tetanus status is unknown. ROS: See above; otherwise unremarkable. PHYSICAL EXAMINATION: GENERAL: This is a well-nourished, well-hydrated Caucasian male. The patient is alert with a clear sensorium. The ~atient's airway is stable. He has no dysphonia. He has no respiratory dlfficulty. VITAL SIGNS: Blood pressure 142/64, respirations 20, pulse 80, temperature 35.2. SKIN: The patient has multiple deep and superficial abrasions and multiple lacerations from windshield glass. HEENT: There is no cephalohematoma. The pupils are equal and reactive at 5 mm. NEUROLOGIC: Cranial nerves II through XII are intact. lIis sensorium is clear. The motor and sensory examination is symmetrical with all of his motor and sensory function checked bilaterally. CHEST: The chest wall is nontender. His distal clavicle on the left, however, is exquisitely tender. LUNGS: Clear. HEART: Regular rate and rhythm without murmur. ABDOMEN: Soft and nontender. There is no rebound, guarding or rigidity. EXTREMITIES: There is no clubbing, cyanosis, or edema. There are no deformities. Again, he has a large amount of red rash on his arms. IMPRESSION: Rule out clavicular fracture. LABS/X-RAY: The patient had a negative di~stick urine. An x-ray of the neck was obtalned, which was cleared by me. He was then removed from the backboard and collar. He was sent over to the radiology department for further films. The complete C- spine series showed no eVldence of fracture. The clavicular series showed a non-opposed fracture of the distal clavicle with apparent acromioclavicular separation. The chest x-ray showed no evidence of pneumothorax or hemothorax. The heart size was normal. There were no broken ribs. ED COURSE, The patient was given 5 mg of morphine for pain. The patient's wounds were scrubbed and seen by Dr. Sedlack of our trauma team. He was the emergency department, by Dr. Stratis, our dressed. The patient was then seen, before leaving plastic surgeon. " CONTINUED CARLISLE HOSPITAL EMERGENCY DEPARTMENT RECORD - ~~ ~ NAME: MYERS JR, WENDELL Page 2 FINAL DIAGNOSIS: PLAN: THOMAS D 2248 EST T 2253 EST/425/02451 ~ ~ J ~ ~ - ~-. ~,~.-~. " '\" ~" MRN: 832497 DOS: 07/08/1999 1. MOTOR-VEHICLE COLLISION - PASSENGER. 2. LEFT CLAVICULAR FRACTURE. 3. MULTIPLE DEEP ABRASIONS AND WINDSHIELD GLASS WOUNDS. Improved. The patient was admitted to the hospital for observation. 07/08/1999 07/08/1999 CARLISLE HOSPITAL EMERGENCY,DEPARTMENT RECORD COr.vENIENT CARE/~MERG~~CY RE:lt2:0N MEDICINES: f c SEE T1~3 HISTORY nos: PMII: "'I: ~ - ~ \ PHYSICAL EXAM AEASONFORVlSll),) MVA f (1 E-f~r"f:~'T~~' I}!,';' TIME I/)~ I I\n~:;~ ?/r-tz- PRESCflIPTIONS GIVEN NONE 0 ~SPOSrrlON o 0 HOME ADMIT 'c~ t,.\i;, ~'-N. O,I"Q "'XC'llb e-vJ-- ".'rm MYERS MENDELL K. DISPOSITION FROM '"' ~gn~I@D;lc ~C.O.<.LV PATlEHI' NUMBER PA11ENT NAME 0058180 7/08/99 15:38 ,1198) - ~- ,.~~ ,.~ _'c = " I "\ ,~: '~;~O'lqq :;~~\ ~/ ~}~OI;i\6\ n 1/ .' 4 I .' 4 S" I P Pl N S H R ~ l'P I . ISAO~~PifW:RI[Y 83?'f'il Z4t r \!f.({l n (\ C l \, Y\ \ "t c (' ':> PATIENT IDENTIFICATION ~ Carlisle Hospital and Health Services 246 PARKER STREET" P,O, BOX 310 CARLISLE, PA.17013-0310 PHYSICIAN'S ORDERS DATE ORDERED ORDERS NOTED BY \ t:..\cv.. \P~VL '\t\..~ \t.v::> ^... "T (JWJ-:, , +M~. - \ {.I.LA. '-\lit, ----- 0 'v:~,I.!.J:'b~'fd'>;J,,-. '-IA, ,\'(~\),f.>(.. pYbi'\lt (I1L9-- ~---+ ~"h~ 1 ~b!. A\of<\l.~l, (5) "CO ~'Lc...'i:,f'N: <\'<'.0 ~ C.Co"VL~ c.0'"--\. "\~Il::,l 'kfl-o. l;:.l.lI\oJ .74? /3y<J.. (.~.J:, " NO 1815 112192) WHEN THE NUMBER "4" COPY HAS BEEN REMOVED, REPLACE: WITH ANOTHER IMPRINTED FORM. Ut/\lll f,~ II'\" . ~iIIiI - .IL ~o ,. 'r,. = TROATMENT IN PROGRESS ON ARRIVAL: DRUGS: D CPR Down Time min. D Monilor. Rhythm Rate D Airway - 0 Oral 0 Nasal - Size o Oxygen. 0 Mask, ~. LJMin D Airway, Endotracheal - Size )i1 Spinal Immobilization, I CAr C'..IO I ~B 0 Airway, NAsolracheal - Size __._.__ o Mast Vital Signs: 0 IV'. Solution Site Size o Pressure Dressing 0 Other pox. Saline Lock Site Siz~ Pupil Sizes: VIsual Activity: extremities: DN/A Pupils: ONIA ,. ,. 00 o Laceration ---~- ------ Right - Size 5. OS o Deformity Reaelion 2. ONIA o Abrasion Left . Size 3. .. o With Glasses o MAE Reaction o Without Glasses - INITIAL NURSING REVIEW: TIME: .I.,Cle LMP: POX: REASON FOR VISIT: '.'V(,.RAUMA PAST MEDICAL HISTO~ o MEDICAL 0 PSYCHOSOCIALJEMOTIONAL Weight: ~r,IAtn. Nu..f 1 ~)S:hOlLl(It.,( pc:, n ' BL.oc... . OBJECTIVE: PATIENT PROBLEM: Nursing Diagnosis _ Coping. Ineffective _ Mobility, Impaired PlAN OF CARE: _ Airway Clearance. Ineffective Fluid Volume, Alterations in; _ Noncompliance <Ei Maintain Patient Airway _ Anxiety = Gas Exchange, Impaired Self Care Deficit tf:"Kor Cardiovascular Status Breathing Patlerns. Ineffective _ Hyperthermia (Fever) ~ Skin Integrity, Impaired IV 0 BP Monitor - Cardiac Output. Decreased _ Infeclion, Potential _ Thought Process. All. in: ~ EKG 0 Cardiac Monitor - Comfort. Alterations in: _Injury, Potential _ Tissue Perfusion, Alt. in: Safety Measures - Communication Impaired Knowledge, Deficit Other ( 0 Restraints 0 Suicide Precautions o Seizure Precautions OUTCOME/GOAL: Expected by DiSCharge: o Side Rails Up J: D pomfort Measures NURSE'S SIGNATURE Brain Control Position for Comfort ' \. J NONE ,." flOOR " Prepare for Exam WtVlOo..l \ "" Explain Procedures my en Clothing Emotional Support Patient Teaching ,I 01 ct~ ' . Discharge Instructions ~~lher Jewelry Other '. Yf p 5 JP, ~[HO[LL K. J ~ Carlisle Hospital .' l'! t7 ?C R I C r RO Other: and Health Services , I ~ 4 ~"I PP[HSRURG, PA Copyright 1992 , . ~ . J[HRfY 0 NJ 246 ,. NURSE'S NURSING DOCUMENTATION En;":,~J. PO 832 <1 I SlG: EMERGENCY DEPARTMENT If 1 ~ ~ ~ "~ ~...-.....--. 1~1>~ .:.....,.. ~~-, ~ .- ~, " " ."" ',tik IV FLUIDS TYPE/AMT SITE SIZE TIME RATE . 'R~ ATTEMPTS MEDICATIONS ,.,L fiR 1'if1Jt. IS-liS f f--'" ~ Med, -D"'l" Route Time Slgnatufe !K '" )l'lJ7l II.., .)/t'\ p.{ ( (" A/7 ./ - / k'/Jt'. ~ . 7rl7YT ./.( , f, :..I.A~ '<'"( I /ii1_ ~ "" - ,(j< "~ I ;'lJ_V'j" J ~ -- '<:-/OrJ fl. ~...ll--'. 0 IV D/C'd with catheter intact f.J1t7,~ {',f / u , , A d '" ~- TREATMENT I PAOCEDUAE TIMES IV TOTAL t"- .., v"7 -'oJ AFo'f.b~alion to, () o Transferred to: o AESP,TAEATMENT IIMF _...__... IIMF TIME TIME o AIRWAV. TVPE TIME _ SIZE o NASOGASlAlC TUBE SIZE _ TIME SITE AMT IN AMT OUT = NOTIFICATION OF: TOTAL TOTAL TOTAL 0 Hospital Social Worker o FOLEY SIZE 0 Family o Police TIME COLOR _ INTAKE: 0 Crisis I~t,:~:ntion o 02 @ VIA TOTAL OUTPUT: 0 NursingF'2me - VITAL SIGNS. 0 ON Bp MQNITOR I TIMES: EKG ...lYi ~ LAB UA ABG 0 PULSE OX TIme BP P A NOTES: & ~ ,( V <:. \oJ. 1/10 ('.+., \ rl,u. r / II fC,'{, //"lA~" 0,..,. ..._ L~, nTT"'A.J (/Z) (AA()S> Iv ISl./O C 1/6 f), !'..ecAlcA.lc. ~ ~\~, ,~,,}. ~. nl. m.o-:rl/JL.. It--.:> -" ku &" L-7, P cJl.-\- .{".'I~'-'\ \.- ,,-' r I ""'-" ,,_ (, _U I, "5111 V -::::}V /1) LJ .J .A'1.1 ./ A7T ./7/ r-vL /,( ~.... ....,..,.", A.--,., L/ ./ A/II ~- . V//11 V r(Ve. J~ ~VJ /,~""r...",~f" -#/,.::y~~ I J/ /j;..-.v. ~- ~/-:y/ v-J rf1 Cft'lc,- rl--/ '"' f;7 / ':': - '.u/1 1..Ii /t;;L , /J /f7/lft'~ n/..-/f. U 4\J -: ~/ pr~ /./../Yi /~-=. n~ tJ-., /-d/A)O 7'"" /}1 ,VI& ./. /.. ~ ....... A. A'7i'77 ~ V", A/1 .A1 ~ //. ... "A / hl'<'j 7# ..J'H?.' "lr'I/ f//J "I. Td' .?A t!JrJ/ /A A.A'1A.'" / ,; I L~ J _ If J / ~?r,,,.)d/YYI,,- TT/.A'~ ~.d1,,~n //A. '0 C /}'/l'J.L/~ . _T k '''AI ')<.... /"-..Br ~b..o /[t.'171 ~ L1 /.7.(/1 /./.h-! ~a. /99- 'J/ (:/77 I-CJ, ue ~ II =EVALUATIONANDDISCHARGEN~ (/fi.ijkJ- rJ!?1l/ ~ 'rL, .. rt1'j J I() 'E' H _ .rJ'!~A 1J!14if 0 d <./ /"'.~~ / .-;/1TT:H1'....,...,( nfiJ - V_A /],(j .#7 :// A /Yl';; hi ./.;; ~ ~ L ~')/ p "I... ~ / o PATIENTIFAMllYVERBAUZEDUNDERSTANDINGOFDISCHARG~STAUCTIONS: 155'9 - /G,...3 7 s;ilf'mo ..~/ DISPOSmON: DISCHARGE: 0 W~riTeN INS/RUCTIONS GIVEN-r: 0/ o Admitted 10: ~tter 0 Self 0 Computer L. }{ r/...I~ /11 1 I) [] Carried '):s.:samily 0 Prescription J/ D Ambulatory 0 Friend A/1~r'AA'''' [] Ambulatory with Assistance 0 Police .. 0 Ot~er ' h /' //'1 ~ . ~ .0 Wheelchair 0 Valuables /' ~.AI,,- D Ambulance 1/;rballnS{tructions by MD ~ 11'./ ~ . _. .... D Monitored Lilter A r /i /7:ii,.,.. .yn 111 A:"'" D Other /' ~ ,~I1t, ~ ~ d Y;'/(';:/"Y ,..m.._' LtJe< d at> Q }JJ..,-,,,, / ~~..t',.t ~ ~ '-. '~iI/f:; /r;;jd~A PO Urine other o Family Doctor o Coroner o Consultant o Other ,f ( i : t , /.x ~ o Morgue ",' , " ,~ NONE 0 UNKNOWN 0 "I II , 1 , 'I " , ~ I !I 1\ I' Ii ~I II II <- 'I 1 I :1 II i1 i 'I !I t " OPL 'ERS JR, WE, L K. , C 71 0 R / q q, 0 I 2 0 RICE R 0 ~ Carlisle ltospital OQn4/P4SHIPPENSBURG PA dH IhS . Sf ;jlACK. JEFFREY 0 HO' Z pan eat el'Vlces 005818 0 ~"GF'r'CY DEP RTMENT NURSING NOTES lAST TETANUS BOOSTER N/AO NAME A l CURRENT MEDICATIONS: ,. Abrasion 2. Laceration 3. Puncture 4. Fracture 5. Dislocation 6. Sprain/Strain 7. First-Degree Burn 8. Second-Degree BlIrn 9. Third-Degree Burri 10. Pal" 11. Contusion 12. Weakness 13. Decreased Sensation 14. Absent Sensation 15. Edema 16. Decreased Pulse 17. Absent Pulse 18. Parl;llysls '9, :to, INTAKE: /, ,...) --/'; ,- , " " , ; ;, ' . ~ OUTPUT, ; j TEMP: ORAL 0 RECTAL 0 u ~r -- FORM NO. 1414 17/89) 1_ ., ~o~ , - ~"" '" '. " . , - TIME 81P PULSE AESP. COMMENTS/NOTES/PROCEDURES . . ~1!060'~ . . ~" ~~_._~ ~ , .~ , , cl VlTALSWI'I<; PRti~ ;nme: ned Number: Cnre Unll: MYRRS,. 3A EIt ALL Datel'J .. Time Printed: Page: 8.111] 1999 19:41 lof 1 8-Jol 8-Jul 8-Jol 8-Jul 8--Jul 8-Jul 8-Jul 8-Jul 8--Jul 8--Jol 8--Jul 8--Jul ]5:37 15:42 . ]5:47 15:52 15:57 16:07 16:12 16:17 16:22 16:27 16:32 16:37 NIIP-S IIIl11l1g 141 154 146 140 145 143 148 149 146 143 122 141 NBP-D mmH. 73 61 66 69 71 80 58 63 74 80 75 82 NBP-M ImnH. 104 89 Il3 97 94 104 108 100 95 99 88 112 NBP-R hnm 87 90 90 73 83 74 74 69 87 80 86 77 HR hPIII 94 78 74 72 84 72 74 66 78 80 74 pve #/mill 0 0 0 0 0 0 0 0 0 0 0 ST-I 11I11I 0.1 0.1 0.2 0.2 0,2 0.1 0,1 0.0 0.0 0.1 0.2 ST-lI mm 1-0.3 0,0 0.3 0.3 0.1 0.0 0.3 0.3 0.0 O.t 0.4 ST-1l1 111m 0.4 0.3 0,0 0.0 OJ 0,0 0.1 0.1 0.0 0.0 0.3 ST VI mm 0.5 0.5 0,3 0,2 0.3 0.3 0.1 0,1 0.1 0.3 0.0 ST A VR 11Im 0.1 0,0 0.3 0.3 0,2 0.1 0.2 1-0.2 0.0 1-0.1 Ln.3 ST AVL mm 0.2 0.1 0,1 0.0 0.1 0.0 0,1 1-0.1 0.0 0.0 HJ.1 ST-AvF nUll 0.4 0,2 0.1 0.1 0.0 0.0 0.1 0.1 0.0 0.0 0.3 SP02 % 96 99 99 98 99 100 97 96 99 99 99 94 SP02 R hnlll 94 94 80 74 72 82 74 80 66 80 82 78 --- " M~rqllelleMet1lclllSyslel1lS ~ . -, -'~ ~= fli, Pennsylvania EMS Report ~~- 7-~ < 0)/, 1/ 'V\L< Service Name Service No. I Incident No. I Dale Carlisle Community Ambulance 2100244 9902705 07-08.1999 Incident Location MCD I Receiving Facility RT 233 AND RT 174 21922 Carlisle Hospital Patient Name Phone No. Age I Date ofBlrth I Soda! See, No, I Sox P WENDELL MYERS (717) 532-7970 14 09/24/84 .. M a t Slll~ct Addrcss Crew Times i 6720 RICE RD A#I Bretzman, Gary E 002259 Dispatch 14:36 e City State Zip A#2 Weer, Jeff E 144538 Enroute 14:36 n t S1I1PPENSBURG PA 17257- A#3 Arrive Scene 14:48 I Cumberland Co. Incident # Medic Unit A#4 Depart Scene 15:05 n 9685 Mileage Arrive Fac. 15:23 f Out On-Scene Dest. In Available 16:00 0 0 91238 91248 0 In Quarters Chief Complaint: LEFT SHOULDER PAIN, HEAD LACERATION, LACERATIONS BOTH ARMS RESULT OF Current Meds, : m!lNE Allergies (meds): NKDA PMHx: IOMI OCIIF UCOPD U^BP UDlab, U Cancerl2!3 None Known I Narrative: DlSP A TCHEDIRESPONDED TO ABOVE LOCATION CLASS I RESPONSE FOR AN AUTO ACCIDENT. ARRIVED O/S TO FIND THIS 14 Y/O WIM SITIING IN THE BACK SEAT OF A VEHICLE INVOLVED IN MV A. PT ClO LEFT SHOULDER PAIN, HEAD LACERATION, LACERATIONS TO BOTH LEGS. HPI: PT STATES HE WAS BACK SEAT DRIVER SIDE PASSENGER IN VEHICLE IN MV A. PT VEHICLE SUSTAINED MODERATE/SEVERE FRONT AND LEFT SIDE DAMAGE IN COLLISION WITH ANOTHER VEHICLE. PT DENIES WEARING SEA TBET AND DENIES LOSS OF CONSCIOUSNESS. WINDOW BROKEN OUT BESIDE PT, PT STATES HE HAS NO PMH, PE: PT IS CAOX4, SKIN PINK, WARM, DRY, LUNG SOUNDS PRESENT/CLEAR. ABD SNT. PUPILS EQUALIREACTIVE. PT HAS GOOD PULSES, MOVEMENT, SENSATION ALL EXTREMITIES. PT HAS INCREASED PAIN UPON PALPATION OF LEFT SHOULDER. NO DEFORMITY, CREPITUS, BRUISING NOTED. PT liAS A LACERATION TO THE LEFT SIDE OF HIS HEAD, PT HAS LACERATIONS TO BOTH ARMS AND MULTIPLE ABRASIONS TO BOTH ARMS AND RIGHT LEG.PE OF CHEST, BACK, PELVIS UNREMARKABLE, ASSESS VITALS. P.84, R.16, BIP 140/76, TREATMENT: FIRE DEPT CREW APPLIED STIFNECK COLLAR AND BANDAGED HEAD LACERATION PRIOR TO BLS ARRIVAL O/S, BLEEDING WAS CONTROLLED. AI,A2, AND FIRE DEPT CREW EXTRICATED PT ONTO LSB AND IMMOBILIZED WITH CID AND STRAPS, PLACE PT ON 4 LPM 02 VIA CANNULA, PLACE IMMOBILIZED PT ON LITIER AND MOVE TO AMBULANCE. TRANSPORT TO CARLISLE HOSPITAL ED, PT REMAINED STABLE THROUGHOUT TRANSPORT. ARRIVE AT CHED AND PLACE PT IN ROOM 6, GIVE VERBAL REPORT AND TRANSFER PT CARE TO ED STAFF, @ 1996, Med Media, Inc. Page I ~~ , , -" ~ ~" ~ .."i Pennsylvania EMS Report Service Name Service No. IlnCident No. I Date Carlisle Community Ambulance 2100244 9902705 07-08.1999 Patient Name Date of Birth Social Security No. Medical Command Physician WENDELL MYERS 09/24/84 . . Time P R BIP Rhythm Treatment Provider Resp/Comment 14:55 84 16 140/76 SEE NARRATIVE A1,A2.0 15:05 76 16 1281P VITALS, 02 4 LPM 02 Al 15:20 76 16 144/72 VITALS AI @ 1996. Med Media.lne, Page 2 ~~o~. PrOVl er e - . -. Carlisle Community Ambulance Pennsylvania EMS/On-Scene Report ~:"~;i'iirjl;n 1 mT'1C"T:"-"~""l".""'"1 ,,,,,. "'''' - i',"'~':j"ld~'dJ!)>.!i"-JA~f 't,(,;,",::I).',~." J!,~Jia ~'l"r '--"'-""'i..i........"-'" ~_.. _ '"~"""............;.a......_~j_~,~I._~___~h.~"~. 9902705 2100244 9685 7/8/99 Transported 4.40 EMT, 002259 EMT, 144538 5 . . . . . . . . 84 16 140/76 I 4. Sponl. 5 . Orient 6. Obeys 91131814 . retz~~. ~ " ~, =~~ I, ~' I' ~ Iii [r: " ~i l! ,; " Ii r i , I i I' P I: t I!' F' j, I I , ]~ 1 f;' I' [ t F , ~ , " OP\' MYERS JR. ~[NO[LL K, 07 1 0 91 q q b 7 20 R I C [ R 0 ~ Carlisle Hospital o q 12 41 R 4 S ~ I P Pf N S a ~ R C. P A ~ qnd Health Services HOLICK I[FFREY 8 Me. ' f. ' 0"0 c; B l' ~ 0 8 3 2 'do1\~NT TO HOSPITAL ADMISSION AND \ . ' M I;{' T}lfApmNT N"mj loTfl Attending C(; !/ I( .., D~te of Admission: Time: (}\ (AM)_(PM)_ acting on behalf of) J Name Of Patient consent to rendering of such care, which may include routine diagnostic procedures and such medical treatment as the named attending physician{s} or other of the hospital's medical staff consider to be necessary. Name Of Authorized Representative , sUffering from a condition requiring hospital care, hereby 2. I understand that the practice of medicine and surgery is not an exact science and that diagnosis and treatment may involve risks of injury, or even death. I acknowledge that no guarantees have been made to me as to the result of examination or treatment during this hospitalization. 3. I understand that: (A) 'It is customary, absent emergency or extraordinary circumstances, that no substantial procedures are performed upon a patient unless and until he or she has had an opportunity to discuss them with the physician or other health professional to the patient's satisfaction; (B) Each patient has the right to consent, or to refuse consent, to any proposed procedure or therapeutic course; and (C) No patient will be involved in any research or experimental procedure without his or her full knowledge and consent. 4. I understand that many of the physicians on the staff of this hospital, including the attending physician(s) named above, are not employees or agents of the hospital but, rather, are independent contractors who have been granted the privilege of using its facilities for the care and treatment of their patients. Further, I realize that among those who attend patients at this hospital are medical. nursing, and other health care personnel in training who, unless requested otherwise, may be present during patient care as a part of their education. Still or motion pictures and closed circuit television monitoring of patient care also may be used for educational purposes or for documentation of the clinical course unless a patient expressly requests otherwise. 5. I release CARLISLE HOSPITAL from all responsibility for all articles which I am retaining or will have with me during my stay at the hospital. I understand this includes clothing, bridgework, false teeth, eyeglasses, jewelry, money, radio, razor or any other item kept in my possession. I understand I may deposit valuables in a safe provided by the hospital; only if this is done will the hospital assume any responsibility for the safekeeping. 6 . I hereby Patient Rights and received written information on the topics of Date of Signature: {SIGNATURE OF PATIENT} {SIGNATURE OF WITNESS} (If patient is unable to is a minor ____ years minor, complete the following:) consent ecause]: /-1 ( /l/ 0/{ L (""' ~TURB OF WITNESS} AD 0315 (10/91) {SIGNATURE OF LEGAL GUARDIAN OR CLOSEST AVAILABLE RELATIVE} '><.. , ~. . J!L ~~, ' if '-'. .;" \) ~ Cai'llsle Itospital ~, and lIealth Services Depl of Pathology 246 Pa{kerSI., Carflsle, PA 17013-0310 MYEIIS J1\, WENDELL K. DOB:09/24/19B4 AGE 14 YRS M (000) 832497 000-00-0000 (717) 532-7970 6720 RICE RD DR SEDLACK, JEFFREY D. (atte~ding phy: SEDLACK, JEFFREY D. ) - " ., 'lsr ~~l7,' ~' ., "--,-,:>,,',- , ; "i,:~,"-amJ._~oskd"Admln.[jirrti'Cfor CI" I L b t 'R rt'buCkkyU Chang, ;",0.. P~lhQk>glst ", , ml(~f1,,1l.0f~.grYj, ep2."J,,{inry-~;,9~~!d":P;:!.tho'~st OBSERVATION ROOM REPORT PRINTED 09JUL99 TIME 2233 ADMITTED 08JUL99 PAGE 1 DAY OF STAY COLL. DATE (, TIME PROCEDURE BLOOD CELL COUNT HGB HCT FRI 002 09JUL99 0615 EMR 08JUL99 1600 }1EFERF;N:CE, UNITS "-.i'""" OBJUL99 12.2L s 12.B 36.SL s 37.8L 1600 " " IV OFF FOR 2 MINUTES -.'.". ;' -;;' _':',;"'o,<? '" - - -- - - - ' " -'~',,, ~J_ ",-:~- .-!':r'~':-':_,'i;' [12.5-15.0]g/dL """""",,,.,, 1M ;0~49 .,oJ % 1,'?'':;), i, '~"::':;,-wv,fr;,,'~_?::i?~Il ,;: :::~~J; <?{:~i~~~-~~~~~i~f~;~i"i'!~~~~;~~~~\~i::~:;:fg~~~);;~~t~' DAY OF STAY COLL. DATE & TIME PROCEDURE CK CK-MB TROPONIN I EMR OBJUL99 1600 ,;':" s 195 s 2.0 8 < 0.3 ","""","'''' ' .!WFI'Jt~CF; .Wp;:rs 'i",y;~;;/,:;~;'.0'io/:21;'f11;e<{3~~~:l'2'J' 'tilL' i, .0,c5,91 ng /mL dgjinLJ nsi/mL ,,';.:c,'," ""-6.' !: -,~';}:->-j" ;,! Footnotes and Symbols L ~LOW, s =STAT .-, :' '"\",:r~ ~;'~~~I~q~r~)f~~~j-f;~~~t1~:;t'+~t;~'~:'::~~VI;:;Ji-:i~:. ,c;'t::,;< HEMATOLOGY CARDIAC IttBllS J1\, WENDEt.t. 'K. . End of Report " , - ,"",,~>.") , . 'J to 'I ~ Carlisle HospitaL ~, and Health SeIVices 246 Parker Street . P,O, Box 310. Carlisle. Pennsylvania 17013-0310. (717) 249.1212 DEPARn"._I~T OF RADIOLOGY !1 'I ij Ii '. 'I i Ii 'I 11 :j CARLISLE IMAGING ASSOCIATES, P.C. MYERS JR., WENDELL K. 6720 RICE ROAD SHIPPENSBURG, PA 17257 14Y 07/08/1999 X-RAY #143245 MED. REC. #832497 DR. FAL~ T. - E.R. COMPLETE CERVICAL SPINE AP, lateral, the spine is subluxation. oblique, and odontoid views of the cervical spine show in good alignment. There is no evidence of fracture or The cervical soft tissues appear normal. IMPRESSION: Normal complete examination of the cervical spine. LEFT CLAVICLE Views of the left clavicle on two projections reveal a fracture of the distal aspect of the left clavicle. There also appears to be widening of the coracoclavicular distance suggesting ligamentous disruption. IMPRESSION: Fracture of distal aspect of the left clavicle. vLr KEITH S. PUMROY, M.D. KSP/Cp8 T: 07/09/1999 10:44 am ! .11 ~.IIIl! '11 "Ii. '11\' I ~. '" ~, I~~,' " I :....~ Carlisle Hospi~ ~, and Health Services 246 Parker Street. P,O, Box 310. Carlisle. Pennsylvania 17013.0310. (717) 249.1212 DEPART~T OF RADIOLOGY CARLISLE IMAGING ASSOCIATES, P.C. MYERS JR., WENDELL K. fi720 RTCF. ROAD SHIPPENSBURG, PA 17257 14Y 07/08/1999 X-RAY #143245 MED. REC. #832497 DR. FALVO - ER PORTABLE SUPINE CHEST AT 1615 HOURS ON 08 JULY 1999 I I I II I I I , PORTABLE LATERAL CERVICAL SPINE AT 1559 HOURS ON 08 JULY 1999 Although the upper cervical spine is slightly flexed anteriorly in this immobilized image, cervical alignment, disc spacing, and adjacent deep soft tissues are grossly normal in appearance. Although the distal left clavicle appears to be fractured or separated, the lungs are symmetrically expanded, cardiomediastinal appearance is normal, and chest wall structures appear grossly intact. Overlying EKG leads are present. IMPRESSION: No acute thoracic pathology. ~ RAND J. CUTHBERTSON, M.D. RJC/eh T: 07/08/1999 08:51 pm i( , ill'i'l,l'!I':':t!'!"'i! , .,.." : ..1\.. 'n,. JI. IfUDt1.L I.' , )~ ,1:'"1''''' uto 'tCl Ill, " i-..~."t4I.. ,11"un'lI. II .t. .nUell Juran f.~ ,'46" ::~:' OUS8, eo 832'tQ ~,j } "1.10 ' , . ~ PATIENT I ENnnCAOON DATE DRqERED 4"''7 V L.---- , . < , ., .~. " ,.' ," . ." '. '~ Carfisle Hospital ~, and Health SelVices 246 PARI<ER STREET.. P,O. BOX 310 CARLISLE. PA. 17013-0310 PHYSICIAN'S ORDERS . :.t ORDERS NOTED BY .,., , '1&8, , I~_"'COPYHASBEENREM~ .' 'li-"" wmtANOMRtMflf\!NTEO fORM. . CHART COPY -- - - ~"':t': ;jO" "HH JR, lo'E/lOILt. r: tl/~~'" ~1~~ ~ICr p, ("14'-. ~~I'r["S~f'Q, ra 5\ i\ la. nURET :1 ~(l t4 nOSRIPO 83~.ql ~ Carlisle Hospital ~, and Health SeIVices 246 PARKER STREET" p,o, BOX 310 CARLISLE, PA. 17013.Q310 1: 'n. \N~A iJA.. V. f)\~(1..f PATIENT IDENTIFICATION 'l'> IJ PHYSICIAN'S ORDERS DATE ORDERED ORDERS NOTED BY //6/C; , \, 1:> Js k\\," 0-- \\, \:'\\ V.\\ , \~\ 1-\\ '(.\\ 'J.. Po 1\, 'l) I ti} (,<j \1) "4 C.') ~ )1-4 1.) 'S , \"" '::4 .'11:- ._tiJ__~:_1. . ~ d. ~ t.. Q.. ~ ( V\t".." .u!.e':i.._.J~.~h.,v--..:. ~ a.~ i, ~~ ~ \\\ j;,. ...,:: vI.J..c. V, '. C1FP" t'!'I' v.. .. ,..__...~....__..._._...... ::"'('--'- ~( Fv-;~ - <,;;Jv..-4.-.. '(lL> ','/7 I(~': ..,1.\.. l-~\ r:w' b"", /...c-,- ,., J:..b () \ (? , -y.\.,'r....... '."f...-.;--;------.L.-.:.- .' . ,'.i, 'II,. .- .,:11f'/ ;'-'\/" ./ ~ " "'-.., NO 1815f121921 WHEN TIiE NUMBER "4" COpy HAS BEEN REMOVED, REPlACE WITH ANOTHER IMPRINTED FORM. '-IIMII f:l:!' ,f,; o ~l' MYERS JR, wENDELL K. PROGRESS ..,NOTF!; Pi I ATTENDING PHYSICIAN J 4b P D110~/qq b120 RICE RO PQ/2i.41R4 SH I PP!NS8URG, ., ., 01 I'. "FFRry n ND UU::fr'lC'U O.;lC"l" 1 PATE jh , ~, '~ I NOTES:r D "" ""-.-- -, """,,,,,__n. , i f~ \-.rt-\ h"'Vv0-:> -LJp' 0 tJ\() ~h~ VA.. ~ ~ iJlfT d~~ fJL- \J), ~'h I {-.JJ.Jjl,.. I / )< , , " 9/83 .'') 1625 OH . "URS JR, fa IHHOHL k. . 07/0P/qq b720 RICE RJ oQ/24/A'4 S"IPPENSBURG. PA , ~I~I Ark JEFFREY 0 "0 I UU::H.',L.V L'-'~' ... DATE o PROGRESS ,NOTES )ATTENDIHG PHYSICIAN 2 <I. F . NOTES SHOlJ' D .... . " av ~'~"M fl) I o . .. 9/8' NO 1625 ~ " ~ ' ~i llATE W "- 01, -C\!\ ()~ to \ \ (::1., 1l0SP/POST OP rl ~ \ "' ..... y ANTIBIOTIC 1 2 JIfIr 40' 250 . 04 Oll .12, 1!!. 20 24 04 08 12 16 20 24 04 08 12 16 20 24 04 08 12 16 20 24 04, 08 12 16 20 24 p 2 U 240 2 l " 230 2 5 220 2 E 39 210 -~ --~- '2 200 12 T 190 :1 E. '80 , M 170 1 P 3.' 160 " - '50 :1 '40 1 '30 1 120 ' I- ,- 1 37' 110 1 - 100 1 90 80 70 f-::,.~ ~ \L 3.' 80 '7 -1---.. "0 --:>--:0 E-: ~ ~/- TIME 1/ f585 / V RES"ULT WEIGHT/SCAlE V 51? 07.1a 15.23 23-07 07.15 15-23 23-07 07-15 15.23 23-07 07.15 15-23 23.07 07-15 15-23 23-07 P,O, TUOEfEEO ~ IV !z . HR, ToTAL 24 HR, TOTAL VQIDED Ul\INE EalEY ~ 0 DRAINS o HR, TOTAL 24 HR, TOTAL , ffi ACTUAL I ",I I o RENAl OUTPUT '. ' " ~ Carlisle Hospital ;- r. ~HU Jt. 11ft tt( 1;1, l. and Health Services r,! :'()4'''' ~l~O IIltt ~!) C~!1(fq4 $'IP'[ISetitt. ,. CLINICAL RECORD H '\.IC(, JrrtltT o 110 146 , fJOSP lEO 832ttCn No-0325f2198) ,.', 50 40Q 40 30 20 '0 39" 00- 90 80 70 60 380 50- 40 30 20 10 37~ 00- 90 80 70 60 360 50- 40 30 35' '-1:"! !l '.'': ..' Carlis,,~ Hospitat Medicatioll Admillistratioll Record N01305A' (REV 919/94) Nlf/"f!: MYERS JR, WENDELL K. Room H: 1)395 D 30'-l j) . .M.. From 07/09/99 at 07:01 to 07/10/99 at 07:00 DAY SHIFT EVENING SHIFT NIGHT SHIFT NO DOSE ROUTE FREQUENCY START STOP 0701.1500 1501.2300 2301.0700 B"-L'+"-o.t.i<'\ C>l~t. -\" -to.<.iolL 'Yg 6Qoo../ff!: alOc_ \ o..<-U1"\i,,,^~ W ~o.C.I"\'-"C.I"" ~icl ~)~ 1 Oq j{/G ;}./oo_ 00_ ~....". 1='....', .IA" 'I .J ) ~ ThIgh km Abdomoo INITIALS SIGNATURE INmALS S1GNATlJRE lVC.leflvent LAT-Iellant Ihlgh lO-lelldellold UQ. Ielt lower quad RVC.rlgtltvont RAT. flghl.rld thigh AO.,rghtdeRold RLQ.rlghllowerquad k'// .?J/ / /1. lDC.lefldorsat LlT.loftlalt/'lfgh RLA.,Ighllalarm lUQ-1eftupperquad . ,V""- ROC . rig'll dorsal RLT.rIghIIa11hlgh LLA.leltlaleralarm RUO. right upper quad '-.} lVL.Ief!vBslal Rvt.rlghlYlIIslat N.N.P.O. R.Refu!l'!l:f;f P.OnPass NN - NauseaNomlllng . Adm/.utlm Date: 07-08-99 T-Tas1lng AX', 14 YRS s.,<: Male IIr.: WI.: Fina"cial H, 000058180 Plly.ridall: SEDLACK, JEFFREY D. .,-1 Allergies: PaReft: 1 ,.. end of report It, PI, Name: IIYERS JR, WENDELL K. "-l'~ji: I e QJ/ MR#: 832t97 .. " ~ ""'" Carlisle Hospital f fro'" Medication Administration Record NO/30SA (REV 919/94) -- \OC . " ' ~~~ Allergies: ',','~' OH 07/0~/qq Oq/24/~4 SEJUCK HYERS JR, wENDELL K. 6120 RICE RO SHIPPENSBURG, PA JEFFREY 0 HO 246 P Name: Room #: I' 1( Age: Sex: HI.: WI.: Financial II: Phy.ridan: " oos8ieo 832Lj'1l c A' ;..1 . From ,101.. at""'M 10 ',\...1.. at ,,~... I rhlyTSHIFT EVENING SHIFT NIGHT SHIFT NO DOSE ' , ROUTE FREQUENCY START STOP 0701.1500 1501-2300 2301.0700 . M.s\-"I" '-ttoo 'I. Yg ""j fO q. 't-l. \...H~ ^...~\ . "^: \ . . . " . !!!!!!!!!!. !!!!i!!. ~ ~ lNtTlAlS SlaNATURE INITIALS SIGNATURE lYe-lIftvenl LAT-leftllrllthlgh LQ.l8ftdellold UO -left lower quad ~J!/-..d-- /L. RVC . light venl RAT. rlghl and thigh RO-r1ghtdeltolcl RLO-rlghllowerquad /(// 1DC.left don:al L1.T.leftlallf11gh RLA-righl lit arm WO -11ft upper quad ROC - right dotsel RLT-r1ghl lal thIgh UA-l8ft:lal8ralann RUQ - rlghl upper quad '-.l' lVl-Ief(vaslat RVl.rlghlvulal N-N.P.O. R-Refused P-OnPan NN - NauseaNomlllng Admission Dale: T-Telllng Page I: PI. Name: MR#: , ~iR~~ C~rlis,. Hospital, Medication Administration Record NOlJOSA (/lEV 9/9/94) '..:" ARt: Sl'.t: HI.: WI.: Altr~le"b H H Y[ R S JR. wEN 0 ELL V, r 07/0~/qq b720 RICE R~ oq/24/~4 5HIPPENSBURC. PI S E :' LAC K. J E f F R E Y D H D 2 4 /, , OOS81PO 832~~1 r A I Tn Nr,mr: Room#: Finandal #: Physiciall: , . ..-..-..-..-. .. '~h_'_"_'_.~____ ---.... .. .-----.- -- .. . . Fron0'\/f\tt4 at.;1O,,\Cl toO'llY1q~ at 6100 DAY SHIFT EVENING SHIFT NIGHT SHIFT NO .. DOSE ROUTE FREQUENCY START STOP 0701.1~00 1501.2300 2301.0700 ~h,,-~r'\ 6\ t-. \ n--.e..,+ '6\0 ik OqOD .}t~O 4:> +6.0 0.-\ \ ttW (AJ\ <Jr\ S ~ ~,-\r 6-.c.:. '" '6\0 @ 6Sr-. ll~ oqto'j: J-L~'f {}..(~\hCJ F A tAct... - - . !!!!!!!!!! Thigh ~ ~ INITIALS, SIGNATURE INmALS S1GNAltJRE lVC-leftvenl LAT-leflant Ihlgh LO-Ieftdeftold ue -lefllower quad RVC.rlghlvenl RAT - right and thigh RO-rlghldellold Rla - right lower quad lDC.'eft dor..' llT.ll!lltlalthlgh RLA-rlghlllll.lrnl lUa . Iell upper quad ROC. rfd1t dorsal RlT-rigf1Ilatlhlgh 1LA. left lateral arrn RUa.tlghlupperquad lvt-III'II vas lal AVl-righl vas Iat N.N.P.O. R-Refused p. On Pass NN. Naus~aIVC!~mng Adnrir.tiotl Dat~: T-Tesllng Page": Pt. Name: MRN: - ""',' Carlisle Hospital Medication Administration Record N0130SA (REV 919194) '\ ~ Ag!!': Sex: HI.: WI.: ,l:.i, 'I' 0 B I' MY[ R S AII,rgies,"O ' JR. WENDEll K. . 7/0R/lQ 6720 RICE RO OQI24/A4 SHIPPENSBURG, PA sr~lACK. JrFFREY 0 NO 246 P . 0058180 832~gl AnD Name: Room H: Flrull1dnlll.' Pfly.rfrinn: FronO')o'\C{4 a9d-tO to010Cl4!at ()(U) DAY SHIFT EVENING SHIFT NIGHT SHIFT NO DOSE ROUTE FREQUENCY START STOP 0701-1500 1501.2300 2301-0700 h\1J~ I') \{60~ YO QlY." Iv. ')I~ ,;t.;k-Cl~ (}g(5.t1:'J rfl""\ (JcUll . . I . ~ ~ ~ ~ IIIlTJALS . SIGNAlURE IHmALS SIGNATURE LVC-l8ftvent LAT. left ant Ihlgh lO-leftdellokf ua.1tft lower quad RVC.rlgh!venl RAT-rlghtandlhlgh RO-rlgtttdellold RLQ-tlghllowerqllld tJ~ 11' A.A.h. ,.0 lOC.!eftdorsl;l UT.llIftlatthlgh FILA . right Iat ann LUQ . left upper quad ROC -1Igh1 dor..1 RLT.'~11111h1!tl lLA . left laUll'alenn Rue. right upper quad l l,Vl. left v.. lit Rvt.tlghlvl,lal N-N.P.O. R.RMused P.OnPass tw. NausllaNomIlIng Admission Date: T. TesQ1g Pagel: Pt. Name: MR#," ..= I _ I , _ ~"" < ~-" -~-~- .~ ~ ^ , Fit Tub Site Site CAlh Rate IV, SITE, #'OF STICI<S, CIS DIFFiCULTY, SOLUTION/HEP Date Time Chg Chg Cilte Cond GA CC LOCI<; COMMENTS' , , ' j Init. 1'l.tj.7'l <0 $',- N55-11 .t. ,'~ If tZ.~. 1 V -".h<;~ r,(2k.~-n.Lce4- 1,;'1" ' J/,",cl II\! "? /./Jl-- . --"------" "."- C TUBING TYPE CODE SITE CONDITION INIT SIGNATURE !NIT SIGNATURE P . PUMP I -- NO COMPLICATION 11) 11",.<'''- 10. PS - PUMP SECONDARY Ct./. NP . NON PUMP 2 - TENDERNESS A - ANESrnESIA M . MINIDRlP 3 -- PHLEBITIS · S - SECONDARY MED B . BURETROL 4 INFILTRATION · MB . MICROBORE PCA - PCA PUMP 5 IV OUT BLD - BLOOD BP - BLOOD PUMP LF - LEUKOCYTE FILTER "Rerer 10 IV Relaled Phelbltls & Infillration Policy & Procedure- Documentation & Site & Condition on nurses notes per policies ~ Carlisle Hospital NURSING SERVICES IV RECORD NO 0915 (9/98) PATIENT IDENTIFICATION t, I:. t 'l"l MYERS JR, WOOHl K. 07/0R/~q 6770 RICE RO OQ/74/A4 SHIPPENSBURC, PA SfJlHK, JffFREY 0 MO 24E> P r~S8180 q32~91 Ai:T1 ,..,-',J _ u .~~~ -. . '<(iIf--' FIt Tuh, Sile Site Calh Rate IV, SITE, # OF STlCKS;CISDIFFiClJL TY,~OLUTIONIHEP: Date Time Chg Chg Cilre. COl1d GA CC' LOCK; COMMENTS .... .' '.' Init . . .. , TUBING TYPE CODE SITE CONDITION INIT SIGNATURE INIT SIGNATURE P . PUMP I -- NO COM PLICA TION PS . PUMP SECONDARY NP . NON PUMP 2 TENDERNESS A . ANESTHESIA M . MINIDRlP 3 - PHLEBITIS · S - SECONDARY MED B-BURETROL 4 -- INFILTRATION' MB - MICROBORE PCA - PCA PUMP 5--IVOUT BLD-BLOOD BP - BLOOD PUMP . .. LF - LEUKOCYTE FILTER " I'ATlENT lDENTlllICATION 'Refer to IV Relllted I'helhltls& Infiltration Policy & I'rocedure- Documentation & Site & Condition on nurses notes per policies ~ Carlisle Hospital NURSING SERVICES IV RECORD " ~VfRS JF. w[NOELL K. . '10",QQ b120 RICE FO "111',Q, SHIPPENSRUPG. PI '",:LICk. JEFFREY) HD 246 P 00581PO 832~ql "1 NO 0915 (9/98) A ~. T 1 __.. ^ n .~~~ F 'REFLECTED IN PATIENT OUTCOME/EVALUATION AREA - SEE BACK AME AME vz;./IJ EYES OPEN QUALITY IWNl I<'!( N BEST VERBAL I MOTOR ,< (0 E SHAllOW U EXT. MoveMENT R DYSPNEA' R 'ARMilEG' l CROWING' 0 PUPil SIZE I n STAIOOAOUS' REACTION l RETRACTING' B COMPLIANT 1< IT GRUNTING' R E NON COMMUNICATIVE' E NASAL CONGESTION H S tAIRWAY CONGESTION' A ANXIOUS' Y NON COMf'ltANT' P NASAL FlARING' I I 0 SLEEPS f WNL R TRANSMIITED R FUSSY' A DIMINISHED' TEMPERAllJRE I WARM kit. T 0 CRACKLES' COOL R RHONCHI' HOT Y WHEEZES' I SQUEAKS' MOISTNESS (DAY 1/.1' COUGH I NON PRODUCTIVE MOiST PRODUCTIVE' DIAPHORETIC' lOOSE TURGOR / WNt TIGHT EOEMA' :b CROUPV' I PERIORBnAl EDEMA' TRACHEOSTOMY :M N FONTANEL I WNl ABDfWNl T ....I( E COLOR I wNl DISTENDED' A G PAt.E B FIRM' U -----.!:~y~-~~-------- - 0 BOWEL SOUNDS I WNl lit/I M - _. E ASt!EN' HYPERACTIVE N CYANOTIC' HYPOACTIVE T JALlNOICEO' ABSENT' A MUCOUS MEMBRANE I WNl 'k'J/ NAUSEA' R y DRY VOMITING' SENSAAON' WNl In FEEO TUBE ASPIRATE AMT. . TINGLING' DIARRHEA' NUMBNESS' CONSTIPATION INTEGRJTY I WNl STOOL fWNl STAGE' ill? CONSISTENCY (SIZE INelS10N IWNl G FLATUS I DRSO DRY & INTACT f NO PLACEMENT CHECK IV SITE I Wfll 7TL '//.11 G NO DRAINAGE COlOR U DIVERSION HEARTRATE I WNl [y,.( BLADDER/WNl IkA' C MURMUR' BLADDER PALPABLE' A IRREGULAR' FREQUENCV' R TACHYCARDIA DVSURIA' 0 I BRADVCARDIA URINE COlOR/APPEARANCE V PERIPHERAL PULSES 'WNl I'M MALODOROUS' />. DIMINISHED GU DISCHARGE" AMTK:OLORS S ABSENT' CA~LLARYRERLL'WNl , HOMAS Slc;N + I. M WNL 7d1 0 , FLOPPY' I 0 ,"'! q {' NY[ P. S JR, WENDElL K. " RIGID' to' t 01l0R/'H b720 RICE RO c STRONG '" OQIl4/R4 R .. S~'PP[NSBURG. PA WEAK Y SHRill' I HJLACK. Jf FF R[Y 0 MO Z4b P ,ww~_.~~ _ ~ " "~ PEDIATRIC NURSING DOCUMENTATION SHEET NO 0450 (81112) DATE' OOS8180 A J T" 832LfCll J." , ,~ ~';~(- I if, i;~ I'-' ~ I" !i;~ 'I.'. .;' r! i' r: " ~ ;,; t" k (~ rr r,i i r , ij ~ li L- V IT I' 1 i I I' ~ r: I , i , I I , [ \ I I I , , , ~- -- ~ > -'". ' ~ ." ~ '" '0,: Lhh :8 d 'HZ, ^ I d :l ~ a ~ '; -; ,) ~ T J.., ~ j ! i /I " ' lddl"'-; v,",/~ XPLANA TIONS I MEANINGS I CODES PEDIATRIC NURSING DOCUMENTATION SHEET DATE: NO 0450 (61921 '~WRO, COMA SCALE CODE fXTRFMlTY MOVEMENT JUl o 9 1999 . REFLECTI:.O IN PATIENT QUTCOMEJEVAlUATION AREA. SEE BACK fSI'QtlSf I , , 4 5 6 .1 ., ., .. TIME PUPIL REACTION VOICES UNDERSTANDING ryes ,n TO f;roNTA . OPE.N Nr-Vilt "AIN SOUND NlOUS !'411J{ ;(il~;tt FLooR ROUTINE CON REACTIVE SIDE RAILS INCOMP INArl'no FUSED NON REACTIVE IEABAL NONE PRIATE ORIENTED CALL LIGHT SOUNDS WORDS CONVER P SATION PUPILS mm . e '&0 1. ,e 3-. ~ A DIAPER CARE EXTEN FLEXION HUlON LOCAL OIlEYS ..,e.. T MOTOR NONF. WITH IlES COM SIaN ABNOR DRAW "III MANUS I C I A MONITOR . E MIST TENT NE;URO: EXT. MOVEMENT " ~4 ~ Normal Sllenglh ~2 '" SC"ereweakness N +:) _ Mifdweakness +1 ",Noresponse T RESPIRATORY 'SOl BI:HAVIOR: SLEEPS I WNL . Able to tall asleep una,ded belween peftods 01 care and does nol display I PHOTO THERAPY signSo'sleepdepr;vahon P IVSffE INTEGUMENTARY: TURGOR I WNL . When skin pinched. felurns to original position withoullaaving A IV PUMP pl'ak R EOEMA .1 - Smaffpllnolrel<lined .:J . I ,;?~ p,1 rellllllt.d E DIET .2.I'/l-p,'sOnlere'alned ./l.:]J/l"p,lretalned N FONTANEL I WNL ~ott non lr>n~o to palpllalion May be ~hghl1y deplcssed NSS DROPS COLOR I WNl P1I1" na,t beds and mucous membranes T BULB SYRINGE MUCOUS MEMBRANES I WNL . Moist and pink FEEDING SENSATION I WNL Ab!e loleel I'ghl touch and locate wilh eyes closed T INTEGRITY' WNL Noopon01 rt>ddcn('d:lre1\S E BURPING STAGE I Reddentld area lhat does I10t lesQlve wilhin 30 min. of pressufe rehef. A POSITIONING P FEEDING STAGE If . Skm bliSfe, Of svperliciaJ weak in skin wilh fedness m surrounding sFfin. C STAGE III Skin break with deep tiSSUIl involvernel11 (noliry EntelOstomal Therapisl) H BtPMONITOR STAGE IV Deep ulceralion Wllh inVOlvement 01 tissue. muscle and bone I INCISION I WNl . WOUlld edges weN ;lppro~imafed wiftl no ecchymosis. edema. ffldneSS. or HEPARIN LOC drainage. N FORCE flUIDS G IV SITE / WNl. . No redness or swelling ot sileo Good blood relu,", Skin temp. same as surfOunding CAR~!l~,,!__ l\klnl~t1f1IV 'IIION 'lhllHI) CARD I VAS: HEART RATEfWNL . NB:80 .180. I wkto:J mos: 80. 220.:Jmosto2yrs: 70. 150.210 HAND WASHING lOynl 60. 110 tOy~loadull'50.90 PERIPHERAL PULSES. Pedal and Rad,a! CAPlll.ARY REFIl.l- Relurn of blood wilhin 5 seconds. HOMAS SIGN .Pam ifllhocllllondorSIt1e~ion MOTOR I WNl . fly 2 mos ITl:lY lurn s,do 10 bar;k. By /I mDS r1111Y grasp obll'!cl!\ wIlh bolh hands. By 6 mos ml1f I'um QV(1( compllll'p.'r fly 8 mor; nlny s,1 wl!ll nlorm. By g mos may Cfl1WJ. /lold own boIlla.'Br 10 0100; mny ",,1110 slnrn:tll1g poMlol1 By 1 I mos rllllY "CIlII!\O" alonq 'urniluro fly 12 mos mlly sland n'ono . ftESPIAATORY: QUALITY I WNl fvcnchc!\IexcurSl0n&UlllaboredpaUertl Lungsc1eaf nME Avefage Rates NB 10 2 mo~ 40 60. 3 moSlo 1 )'f'30.40.2104yrs:23 .30.610 tOyrs'20 21, E 10 Yf, toadvlJ' '6 .20 NOTE: FOf each deg'eeo1 lemp, elevation. Ihe R A Inc.reases by 4 pel mh M PATTING bVSPNEA Labored or dlllicult bre",hing .maybepainrul ROCKING ORTHOPNEA. Com'ortable breathing al angle 0145 deglees or grealer. 0 CRACKLES. Heardcmefly Off inspir'a1ion ptO(fuced by I/uid or tiner bmnchi T TLC "HONCH! tlMrd on in"lJ!irnlion A p.xpira'ion: produCfld by nirpassinqlhroughmucolls illlargef I REASSURAOCE anway. 0 WHEEZE. Noisy whistling. may be heard on inspiration but mOle common 00 e.puation N CONVERSAffON .Il,BD: WNL. Sofl. non dislended. non lend~r. A PLAY BOWEL SOUNDS / WNl .5 kll2 !;lUIgles per mrnole L UPDATE PARENT GI f GU BLADDER: WNl - Voiding I'll leasll. per shiff. clear palp.to amber urine With lainl iuomalic odor PARENT HERE " least:JOcclhror240<:c1shilt.Child,en.I.2ccillg1hr S PALPABLE. Bladder distended and tell as smooth Irrm mass abOlle Ihe symphysis pubis: U PARENT CAllED FReQUENCY Vaidingmorelhanonceq3'6hOllrs P DVSURIA . Pallllut 01 dltlicull urination. P SIBLING VISIT MALODOROUS. Unpteasanl Of loul odor. a- PARENT PARTICIPATION IN CARE GU DISCHARGE. Vaginal. pemle or urelhral. FUNDUS I WNl. . Fundus fi,m R CODE M-MOTHER GP GRANDPARENT O.OTHER T . F FATHER INlT . NURSING 51 AFF PT. PATIENT -'-' V .. ~. ^ p, MYERS JR. .1I.~O[lL L / . , b720 RICE Rn 07l0~/qq ')lj? oQ/?4/B4 S HIP PE N S ~ URC . PA S[)lAO. J[fFREY n HO Z4b NOIIVnTIf^33V1100. 0058180 832't'll ~J~ A, TJ C DIET; Fill IN OIET, NOTE ANY CHANGES, CIAClE APPROPRIATE DESCRIPTIONS: SHIFT 0700.1500 1500 - 2300' 2300 - 0700 0 FEEDING TUBES: P.PEG 0 QASTROSTO"1Y L'lEVINE E.ENTRIFLEX COM~ISElFIPARENT ~/( 0 AMOUNT:' Q.GOOD HA.lR P.POOR BOTTLES: R-REGULAR P.PLAYTEXNURSER 8 NIPPLES:, A.REGULAR P.PREM1E N.NUCK SHOWER I TUB S FLUIDS: F.FORMUlA BR.BREAST MILK ~.ElECT. SOL. CL-ClEAR LIQUIDS ORAL CARE R// : H DIET /. AMOUNT CALORIE CT, TPN PPN Y ~~ I BREAKFAST tI i/60~ SELF ASSIST G FEED I SKIN CARE LUNCH RESTRICT FLUIDS E FOLEY CARE SUPPER FORCE FLUIDS N E HAIR CARE SUPPLEMENT SNACK AM PM HS CORD CARE N ENTERAL FORMULA FOG /TUBE P G L E SPECIAL DIAPER CARE U T RATE I BOTTLE NIPPLE R nME I T FLUIDS ISEE CODESI I AMOUNT FED 0 N FEOSY IINITLS OR p. PARENTI SUCK, B,STRONG W,WEAK .,EAGER 8,SLOWLY EN,CENC BURPS: E.EASILY D.OIFFICULT R'RETAINED .WSWET BURP E,EMESIS AMOUNT OF TIME TO FEED nME 8 DIAPER: IStSATUAATED 'W1WET IDIOAMP . L STOOLS: SIZE I M COLOR I CONSISTENCY N Q1oo'15OO 15OO.23QO 23QQ . 01QQ : BODY SECRETION CODES A ,\11FT COLOR: G.. Green Y.. Yellow T.. Tan B.. Brown Bt.. Black WH", White MA.. Maroon R.. Red T VOIDING /<'/1" o .. Orange CQ.. Colfee Ground ST.. Straw l Y ..lig~t VeUow DY.. Dark Yellow LA.. light Amber I DA.. Dark Amber TE.. Tea CR.. Cranberry P.. Pink OR.. Grey BD.. Bloody DR.. Dark Red 0 HNV RU.. Ruba BE.. Serosa A.. Amber N CATH8T/FOLEY CONSISTENCY: W.. Watery S.. Soft M.. Mucousy F.. Formed l.. loose p.. Pasty MS.. Mushy H .. Hard TH.. Thick FR.. Frothy DATE LASTBM I STOOL APPEARANCE: C.. Clear M.. Mucousy CD.. Cloudy Cl.. Clots S.. Sediment SD.. Seedy FL.. Flecks T..Tarry KA..Kool~ic1 SED REST I MAY BE HELD SllE: SM.. Smear S.. Small M.. Moderate l.. Large TURN 0 HOURS T TIME A ooSI RM I CHAIR I WC R C E T PLAYPENIINFANT SEAT A I T STROLLER / PLAYROOM M V HOS t E I SRPISSC N T AMB . /U( T Y UP AD LIB c SUPERV, D OFF FLOOR c SUPERV, R A SASSINET I ISOLETTE r N S CAGED CRISI YOUllfBED) A'/( A SIDE RAILS UP WHEN APPROPRIATE A"A' T DEPART TO MODE INn RETURN DISPOSITION INIT , .<K R ,8 LOW SED POSITION A Yi' 0 T CALL BELL IN REACH s y p RESTRAINTS ISEE FMSI . 0 R SEIZURE PRECAUTIONS T INIT SIGOA TuRE INIT SIGNATURE rW ~h'" I. f,lh J'A :Pz. -fA " S .. - I ~/ - Q - N A - , ~ 1:1{' HYERS JR. WENDElL K. T - '" U , 07/0R/H 6720 R ICE RD R - ',' 01124/R4 SN' PH NS BURG. PA 8 - SE:lACK. JEFFREY 0 HO 246 P - ..; i ~,_~ ,',. D"nlll.nU~ NIIR!::IIIIr:l nnr.IIMFNTATlnN !,;HI"ET NO....101I1t PEDIATRIC NURSING DOCUMENTATION SHEET 0058180 A L T'i .-_.~ tr.., I;" ~; f_'- 'i i~ t-. , , '; r Ii , , 832Ltql ~ ~'~"ifi.~ -, ~ ~ "~ liIIo.. _._1', . . PEDIATRIC PATIENT OUTCOME EVALUATION OATE: TIME :..:z& - t:?k/ MYHS JR. wENDELL I. '1 c~/qq &720 RitE HO 1 ;/'"11. ~f-IPP[~::.?C~~,. PA ., ""f' ,:: I,' 24b P If ~L 't'1l - <' . I . . . PEDIATRIC NURSING DOCUMENTATION SHEET NO 04!50f8J921 DATE: JUl'O 8 1999 , . . . REFLECTED IN PATIENT UTCOMElEVALUATlON AREA. SEe BACK TIME In/< f'(,.... 111'100.7 TIME L:wI ( " 1>420 EYES OPEN ( " '{ QUAUTY IWNL ~AA fA". 6~ N E BES! VERBAL I MOTOR "\ r..- ,; I~ (. SHALLOW U EXT. MOVEMENT R ... '" ~,( 4'{ DYSPNEA' R _lARIM.!GI._ l 3 It '1 !/. CROWING' 0 ,.. -" ...- ... - - -- - - PUPil SIIE I R ..., . ~ e SIRIDDROUS' REACTION l .~ ~ (. - RETRACTING' . COMPLIANT 'J." (,~ ,,'" R GRUNTING' E NONCQMMUNICATlVE' E NASAL CONGESTION H s ..__tM~\jAr~Q~~T!2~' .- A ANXIOUS' V .-- -' -..---- .,.. . /I NoN coMPLIANT" NASAL FLARING' , , 0 SLEEPS I WNl R mANSMl1lED R FUSSY' A DIMINISHED' TEMPERATURE I WARM r'J" p"" ,&1 T CRACKLES' 0 COOl R RHONCHI' HOT Y WHEEZES' I SQUEAKS' MOISTNESS I DRY "A,'-' r.Nl rJJ COUGH J NON PRODUCTIVE M01ST PRODUCTIVE' -----..----.- -~-- .- DIAPHORETIC' lOOSE TURGOR I WNl n... ['NI fI') TIGHT EDEMA' CROUP\" I PERIORBITAL EDEMA' TRACHEOSTOMY Ii FONTANEL/ WNl , ABD I WNL ~.LJ I f"" A'\ T COlOR/WNl n, . rNt Jl-' DISTENDED' , E }1 A G PALE f~ B FIRM' U FLUSIIED 0 BOWEL SOUNDS IWNl "...A A^ M ASHEN' HYPERACTIVE E N CYANOTIC' HYPOACTIVE Ir^^ T JAUNDlCEO' ABSENT' A MUCOUS MEMBRANE /WNL '.. .\ r. A~ NAUSEA' ~ R - y DRY . VOMITING' ~ - SENSATION I WNl 'A..A f^^ IP FEED TUBE ASPIRATE AMT. TINGLING' DIARRHEA' NUMBNESS' CONSTIPATION INTEGRITY I WNl STOOL IWNL STAGE' liL CONSISTENCY / SIZE INCISION fWNl G FLATUS . ~"J rN\ b:J I NO PLACEMENT CHECK DRSG DRY & INTACT I IVSlTE/WNL '..A ""&.0. G NG DRAINAGE COLOR U DIVERSION HEARTRATE I WNt '...l J^^ A) BLADDER I WNl C MURMUR' BLADDER PALPABLE' A IRREGUlAR' FREQUENCY' R TACHYCARDIA DYSURIA' D I BRADYCARDIA URINE COlOR/APPEARANCE V PERIPHERAL PULSES f WNL '..fA,' f^^ ",1 MAlOOOAOUS' A DIMINISHED , GU DISCHARGE'/ AMTJCQlORS S ABSENT' CAPILLARY REFIll I WNl HOMAS SIGN + I. " . WNl J,." 11'1I p'J 0 , FtOppy' . i" JR, wE NOEl L K. 0 C ?', ~Y[RS . RIGID' l Q7IO"/QQ b720 R ICE RO c STRONG CQ/?4/R4 S~IPP[NSBURG. PA A WEAK JEFFReY :) "0 246 P y SHRILL' 5LJlACK, OOS8180 I' T t'\ 832lf9l " ,'."> ~ 'I I L'f,.J r:t; .Ji T d ,I ,. ., , EXPLANATIONS I MEANINGS I CODES PEDIATRIC NURSING DOCUMENTATION SHEET DATE:JlIl NO 045() (61921 NEURO, COMA SCALE CODE EXTREMITY MOVEMENT o 8 1999 . REFLECTED IN PATIENT OUTCOME/EVALUATION AREA. SEE hACK RESPONSE , , , 4 5 6 " " ,3 " TIME PUPIL REACTION VOICES UNDERSTANDING rvfS NI VlII III III !,1'1\N1A . OPEN PAIN SOUND NE\JUS SlUt;GISH FLOOR ROUTINE , REACTIVE SIDE RAllS INAPPRO C"" VERBAL NONE INCQMP PRIATE fUSED ORIENTED NON REACTIVE CAll LIGHT SOUNDS WORDS Cc>NER P SAllON PUPILS mm . e 1&0 ,.~. 3- 4 , A EXT!:N rlEXION fLtXION lOCAl. OBEYS ..,... T DIAPER CARE MOTOR NONE SION ABNOR WitH lIes COM I CIA MONITOR DRAW PAIN MANOS E MIST TENT NEURO: EXT. MOVEMENT. ~<l ~ NOf,n:t1 Slrength ~2 ~ Severe weakness N .3~Mddwe<lkness +1..Noresponse T RESPIRATORY ISOL eeH,a,VIOR: SLEEPS' WNl Ab!e to lall asleep unaIded be.wecn penods o' care and does not dis play I PHOTO THERAPY signso's'eepdepriva'ion. P IV SITE INTEGUMENTARV: TURGOR' WN'L . When skin pinched. returns 10 original position wllhou'leaving A IVPUW peak. R EDEMA ,1. Smal'pi' no' relfllned 'J ~ "2- pl' retained E DIET ,2. 14-p,tsom('IPtainpd .4 ~ 314" pit re'alfled N NSS DROPS FONTAN'Ell WNL. 5011 non.'ensf"o Palp,tat,on May be slightly depressed COLOR I WN'L P,flk naIl bl'rls and mucc,us membranes T BULB SYRINGE MUCOUS MEMBRANES I WN'l . MOIStllnd plflk T FEEDING SENSATION I WNL . Ablll to leellight tOllch and 'ocate with eyes closed INIEQRITY I WNL NOOPllnorlf!r.ldlmec1Il!(!:'~ E BURPING STAGE I . Reddened area t"a' does not resolve wit"in 30 min. 01 pressure relief A POSITIONING'; FEEDING STAGE" . Skin blis.el 01 superlicial b<laak in skin wi'h redness of surrounding skin C STAGE 111. Skin break with deep .issue involvement {notify Enterostoma! Therapisll H BtPMONITOR STAGE IV . Deep ulcl!lation with involvement 01 tissue. muscle and bone. 1 HEPARIN LOC IN'CISION' I WN'l . Wound edges well aPbro~imated wilh no ecchymosis. edema. ,edness_ or N drainage. G FORCE flUIDS IV SITE I WN'L No redness O' oswemn!1 Cil site Good blood relurn Skin temp_ same as SUffounding sk.nj~"\lIV'tnwShl!"'1 CARE PL^N CAROl VAS: HEART RATE I WNL. Ne: 80 18a. 1 wk/o3mos:8Q. 22a. 3mos 102 yrs: 7a- ISO. 2 to HAND WASHING lOy's'fiO.t'O toYlstondult 50.90 PERIPHERAL PULSES. Pedal and Rad,al CAPILLARY REFILL Rc'urn 01 blooo w,.h,n 5 seconds HOMAS SiaN .r~lllln I'''' tAU 0" "or~,rrf'~lon MOTOR I WNl By? mo. mAy Iu," sldo 10 h=\r.k. fly 4 mo~ mlly !1ra~p obJec'~ wl'h bolh hllnd~ fly 6 mos m;1~ .".n ov,..r co"'pll!'P'Y Ry a mn~ IlIlly sll Wf!11 alona. By 9 mos ma~ clllwl. hold own hollle. By '0 mo.. mllY pull 10 SIMdmg pMlllon By 11 mas may .crUlse-lllong fUlfliturc fly 12 mo~ mray sland ..... RESPIRATORY: QUALITY I WNL . Even r."P.tl e~cursion & unlabored pallern lungs r.lerar n.E :UJ< Avelage Rates NB 10 2 mo~ 40 60. J mos 10' yr: 30.40.2104 yrs' 2J 30.6to10yrs20 ,I. E 10 r's 10 adull' 16 . 20 NOTE: For each degree of temp. elevation. Ihe R R increases by 4 per min. M PATTING DYSPNEA lnborr.d or ddhcull bflmlhing ml'tybnpninful 0 ROCKING ORTHOPNEA. Comlortable breathmg al angle 0.45 degrees or greater. CRACKLES. Heard r.hieny on insplraliOI1 produced by Quid or bner bronchi. T TLC RHONC", . Heart! on inspirahon & e~pirlJlion: produced by air pasosing Ihrough mucous.n larger I REASSURANCE aIrWay 0 WHEEZE . Nois~ whislling . may be hea'd on inspiration but more common on e~p"atlon N CONVERSATION ABD: WNl . Soft. non dIstended. non lender A PLAY BOWEL SOUNDS I WNl. 510 12 gurgll!s per minute. L UPDATE PARENT 011 au BLADDER: WNl . VOiding at teaslt ~ per shrll. c'ear pale 10 amber urine wllh I;nnt alomatlc odor PARENT HERE V_p .. leasl3Occ:hlor 24Qcc1shill.Childlefl., 2r;r::illg'hr S PALPABLE. Bladder dislended and lelt as smooth lirm mass above the symphysis pubIS U PARENT CAlLED FREQUENCY. Vording more I"an once q 3 .6 hours P SiBliNG VISIT DYSURIA P3mlulordlllrr.ullurinnllon P MALODOROUS. Unpleasant or loul Ol:klr 0 PARENT PARTICIPATION IN CARE GP GU DISCHARGE. Vaginal, pefllle or Urethral. FUNDUS I WNl- Fundus lirm R CODE M . MOTHER GP GRANDPARENT O.OTHER T F FATHER INIT . NURSING STAFF PT. PATIENT Ii :.' ~ l ~YfRS JR, WENDEll K. 07/0R/QQ 1,720 RICE RO .:zp. o Q / ? 41..R 4 SHIPPENSBURG. PA S[:l ICK, JEffREY 0 HO 246 P NOI1\fn1\f^33WO:J OOS8180 832't9l Al'T1 C DIET: FilL IN DIET, NOTE ANY CHANGES. CIRCLE APPROPRIATE .DESCRIPTIONS SHIFT 0700.1500 1500.2300 2300-07 0 D FEEDINO TUBES: P.PEG Q.GASTROSTOMY LUVINE E.ENTRIFLEX COMP PARTIAL! SELF' PARENT E AMOUNT: Q GOOD F.FA!R P.POOR BOTTLES: R-REGUlAR P.PLAYTEX NURSER NIPPLES: A.REGUlAR P.PREMIE N.NUCK SHOWER; TUB B FLUIDS: F.FORMUtA aA.BREAST MilK e.ELECT. SOl. CL.ClEAR LIQUIDS H ORAL CARE DIET ,AMOUNT CALORie CT. TPN PPN Y H SCARE ~--~- 0 --.--.--. -- _._...._--~- ------- --- - BREAKFAST SELF ASSIST FEED I SkiN CARE LUNCH RESTRICT FLUIDS E FOLEY CARE SUPPER FORCE flUIDS N E IiAIRCARE SUPPLEMENT SNACK AM PM HS CORD CARE N ENTERAL FORMULA U FOG/TUBE P 0 L E SPECIAL DIAPER CAnE T RATE I somE NIPPLE R nME I T FLUIDS ISEE CODESI I AMOUNT FED 0 N FED BY f1NITLS OR P , PARENTI lUCK I!TR9~Q W W[M !!.AJl~".8LO.l'!l Y IN WIG ---. .-. --,--- -.-. -----.- .--- ....- -.....--- .--.... .u_.._._....____ ---.,-.,.-. -.-.-.---- --,--_. -_. BURPS, BEASIL Y D DIFFICULT A-RETAINED WB.WET BURP E.EMESIS AMOUNT OF TIME TO FEED nME E DIAPER: ISISATURATEO rWjWET tOjOAMP L STOOLS: SIZE I M COLOR I CONSISTENCY N A SHIFT 0700-1500 1500-2300 2300-0700 BODY SECRETION CODES ,COLOR: G.. Green y" Yellow T "Tan B.. Brown BL = Black WH.. While MA.. Maroon R" Red T VOIDING I'.".L I, 0.. Orange CG.. Coffee Ground' ST" Slraw LY = Light Yellow DY.. Da~ Yellow LA = Ughl Amber I I, DA.. Dark Amber TE.. Tea CR.. CranbeffY p.. Pink GR.. Grey BD", Bloody DR.. Da~ Red 0 HNV RU .. Ruba SE.. Serosa A" Amber N CATHSTIFOLEY CONSISTENCY: W.. Watery S.. Soft M.. Mucousy F" Formed L" Loose p.. Pasty MS.. Mushy H.. Hard TH .. Thick FR.. Frothy DATE lAST BM I STOOL APPEARANCE: C" Clear M.. Mucousy CD.. Cloudy eL.. Clots S.. Sedlmanl SO.. Seedy Fl.. Fie T.. Tarry KA '" 1<001 Aid BED REST IMAY BE HELD SIZE: 8M.. Smear S.. Small M.. Moderate l.. large TURN 0 HOURS T TIME A 009 I RM I CHAIR J WC R C E T PLAYPEN I INFANT SEAT A I T V STROLLER I PLAYROOM M HOB ~ /', .n ;'i} E I SRP ISSC N T AMB T Y UP AO LIB c SUPERV, 0 OFF FLOOR c SUPERV, R A BASSINET IISQLmE I CAGED CRIB I YOUTIl1i'EO {!,.<AA. ,;1<\ N s A SIDE RAILS UP WHEN APPROPRIATE " .. 4'l T DEPART TO MODE INIT RETURN DISPOSITION IN F /':,.,,- AY R E LOW BED POSITION A T ""._n _ A" 0 CAU BELLIN REACH s Y RESTRAINTS 'SEE FMSI P 0 R SEIZURE PRECAUTIONS T INIT SIGNATURE INIT SIGNATURE " S ('M rM. A.I (l" (I. n,,,.\ ~ ,,_ .0./ - I 4" ,A'A ,., - 0 - N ~r A - \. (}f..i: ~Y[RS JR. wENOElL K. T U - r fJ7IO"/qq 6720 RICE RO R - CQ/'4/R4 SHIPPENSBURG. PA E - 5LJLACK. HfFRrY ~ "0 24& P - ~==~ ~ IU:liiil_'"'~ ;-- " . . . Pf:nfA n:llr. N'{/'RSfPIIG CJ(X;fJMENTA TlON SHEET NO ()4l!50ff!192J PEDIATRIC NURSING DOCUMENTATION SHEET If'''''' ,,," - , ~" ~~"'~'Allrnf'-.:i I :J I' i I ., j 1 !', 'i . . . ._--t-.___"._,..__",~~. 0058180 832lfcn -,~~.~ . ~~~.~ - ~ , L ~ , , ----'"" ,OAT' JUL 0,8 1999 PEDIATRIC PATIENT OUTCOME EVALUATION ii 11 " II ,I .:1 " :1 II il i1 " " 1/f' ~ I 'H n124/R4 ~Y(PS JR, wfNDElL K. bur IlICE RD SHIPPEHSBUIlG, pA "<<DfY n .,., 246 P HC ,7::,',-\',1 1 , ~ t .." l r r " " ~~~. II NL,okme _)./011(lYlrl ('A tLJ'h.l.o'!t.1'5: _._ Room # \ "- e!\ to DC ca..,e'J ......~_.... -=--r Age Ll Escort . III Wt I'!l'sent . :l. Usual V~~I sl" ~i;PT;i:'8f 11i'P'7-t}~Jc!:c'?T)--: ALLEllGlESl, iffI'lSITIVIl,JES: (D~scribe reaction)' Medication _. ____.\,j 14) f\; . Food t6 Envlioilii",ninl (tnie'", ilijie).. . J!J' . . .. .. u.~ Exposure to Infectious Disease 0 yes 0 No lfyes, list Immunizations Current G Yes DNo 0 N/A Comments TETANUS STATUS: :JWithin 5 yrs U5.toyrs LlMore UlanfOY;S- nUnknown ON/A CURRENT MEDICA nONS: (Rx, arc, Ilerbs, Vilnmins) Med Dose Last Doseffime 1._-!liIMc),--2J' 2, J, 4, 5, 6, 7. 8, 9, 10. MEJlICATIONS: U None U lIome U To Phnnnney IJ@ Bedside IIADITS: TOBACCO USE ALCOHOL INTAKE Ii Never Smoked n Chew II Snnff n None U Ex Smoker (Dnte Stupped ----.J U Occasional 11 Smokes (Amt per day) . 0 Daily (Amt STREET DRUGS n Yes n No Type(s) MENfALSTATUS: J lOOd/Alfcet: Thought: ~emory: ~pe ch: Appropriate (I Cleorl I~ !ntoct . onnoVCleor o BluntedIFl.1 Spont.neous 0 lmp.ired Silent IJ Defensive 0 V.guel [l Recent 0 T.ik.tive o Apprehensive Disconnected IJ Distant Post 0 Repetitive 11 Restless! [l Disoriented II Mumbling Comb.tive 0 Slow to answer Language Barrier? DYes UNo fl Crying If, yes, language spoken: fULSE: /J jt.egulor 'I IlTegular l!Fulll CJ Weak Bounding gJLOR: i.'! ~urlllftl IJ Flnshed U Pale ,] Jaundiced RESP: . 1I Nonnal o Shallow o Deep [j Wheeze U Ropid U Labored OStridor o Retractions L1Dusky rl Cyonusis o Nailbeds [] Circumoral o Other S~: -tr.W<l im q Cool U Rnsh IJ Ecchymosis Prtlry [l Clammy n Edg]O 0 Other LUNG SOUNDS, Right: Clear 0 Crackles IJN/A ~iminiShed [lWheeze Left: 'Cleor 0 Crackles o Diminished [l Wheeze CRhonchi ~Absent [] Rhonchi UAbsept PATIENT ASSESSMENT FORM NOOllnA(6J99) ~ Carlisle Hospital < i .. ",1 I I :1 I I Date:.i( e/Cjr Time: .~dC> Triage Status: IJPriorityl o Priority " IJ Priority '" LJN/A Mode of Arrival: nALS flBLS o Ambulatory IJ Wheelchair [J Carried o Stretcher Reason for visit ...____._.lV\ ~ '.~___.._ p--"-\J ___.._.__ Accompanied By: II Police 0 Friend o Parent OFamily o Self 0 Other Ooset of Symptoms Treatment prior to arrival PAIN: 0 Denies 0 NI A Location of Pain Severity o 1 2 3 4 5 6 7 8 9 10 n Constant 0 Dull 0 Radiating n Intenniltent 0 Sharp 0 Other Triage/Signalure: 0 PREVIOUS SURGE DN/A Implantabl,e Devices: 0 Yes 0 No If yes. explain Other Devlces: MEDICAL H1STORYIPSYCHIATRIC HISTORY: o Seizures n Liver Disease n Pregnant LI Hypertensiun LI U1eedillg Tendencies LMP o Cardiac Disease 0 CV A U Depression [J Chest Pain IJ Arthritis [) Anxiety o MI 0 Asthma 0 Transfusion o Ulcer n Emphysema ~acf '--<:J [ICA UCOPD .' [J Kidney Disease n Home Oxygen . , Other: o Diabetes I' Cough LI Glaucoma 0 Dyspnea FAMILY HISTORY: 0 Diabetes 0 Cardiac Disease o Hypertension 0 CA [) Other LEARNING &.COMMUNlCATION: How do you best learn? OWriting OVisual OReod ODemonstralion Whom do we teoch? 0 Patient 0 Other Barriers to leaming? 0 Yes [l No CultumllReligion Needs: 0 Yes 0 No Dentures: oUpper DLower ONone ought to hospital? UYos UNo Vision: llGlasses OContacts ONone rought to hospital? DYes ONo Sight: 0 Blind [) Diminished Hearing Aid:DRt th lone B Hearing: 0 ~ 0 Dished RoviewingRN: DN/A o Copy to Phannacy PATIENT IDENTIFICATION i'.." ..,~ 1': ~RI "YERS JR, WENDElL K, ~ 07/0~/qq b720 RICE RD OQ/24/A4 SHIPPEHS8URG, PA SE :LACK. Jf FFRfY 0 HD 246 P OOSe180 832~9l I r T" PSYCHOSOCIAL & FUNCTIONAL ASSESSMENT UNIT INTRODUCTION: ~V l.J.f'all Light I.-i'Siderails -:med Controls fA'Visiting Regulations !'11lR !'!'Patient Rill of Rights Valuables to Sare IJ Ves uNo P1ntcrcom R"Meal Time lJ{5moking Regulations DEVELOPMENTAL AGE: (Check only those lhat apply) , 'Infant '1 Early Childhood IJ Middle Childhood I 'Latc Childhood "'Adolescent llAdult (~ Geriatric Occupation ~l Lives Alone .. "lLives with: .PMt<,n.,ti.c:...:l..il.<& U t-:) U Unable to manage adult ADL's [ ; Abuse suspected~.. . ! JTenninal iIInes,$ ! I Inadequate financial resources. I I Recellt loss or social isolation : !Cognitive hnpaimlent snspected_____. , I Religious or cultural beliefs YOll want us to know about? -~.~-------_._----.-- , 'lIelp will be needed after discharge '". Help was needed with the following before admission ':' Shopping U Chores 11 Men! Prefl ! II ,Rnndry FUNCTIONAL STATUS: rndep Needs Assist 'J ['(" I"" ;J P r"...-- IF II V (I Dep o Bathes Feeds Oresses Trnmifcrs Walks Bcd Mubility Toileting UBladder l.iBowel !'Both Ostomy U Specify type (cath/ostomy) History of Falls LI Ves I"'No Is this recent change functional status'} U Yes '.J No ASSISTlVE DEVICES: , 'Bed Side Commode : I Walker U Elevated toilet Seat 0 Cane IJ Right Hand 'J Crutches [J Left Hand F.OlICATlONAL NF.EnS: (Check all that apply) ~ Request for Additional Healthcare Info. (Explain):."__..._,,_..._.,,.____________~ ~Pre and Post-Procedure Teaching CReproductive C Diabetic C: Breast Self Exam "HeartlLungs/CHF CiTesticular Self Exam o Activity ~ Other o Medications [: Other 1.": II t/ IY r, II 11 II [I o IJ ~ J PATIENT ASSESSMENT NOOlt08(2f99) ~ Carlisle Hospital . ;.~ , ^ <t~~ : NUTRITION: l!Food Intolerances: UDiet Restrictions: l:"3-'None OSugar IlSait OFat OOther II Chewing/Swallowing Difficulty UNutritional Supplement: o EnsurelSustacal UHerbs o Other uAppetite: OOood CFair UPoor [iWeight: Change: liStable OGain__lbs, x~mos LlLoss Ibs. x_mas D1nvoluntary +/. 10 Ibs.!3 mos CONSULTS NEEDED: ONutrition Services 0 Social Work DRehab Services - Physician's Order Necessary IJOstomy/Skin Care [11'1. Ed UDiabetes Ed, 'lather ::.:.I Pharmacist - Medication infonnation C Infection Control UChaplaio U Oncology Nurse o Psychiatric Liason COther REVIEW OF SYSTEMS Has patient evidenced any of the following now or in the past 30 days: NEUROLOGICAL: C Headache 0 Dizziness 0 Seizures 0 Numbness/ringling [" Gait Problems [] Tinnitus 0 Sensitivity to Light [] Diplopia Comments: /)ur., f RESPIRATORY/CARDIO VASCULAR:, [] Cough lJ Short of Breath [] Snoring/Sleep Apnea I J Tx for T6 i.I Night Sweats 11 Edema II Chest Pain 1.1 Palpitations LI TB Screen Sbeet needed Comments: /JU-nc.- GASTROINTESTINAL: o Painffendemess [J Vomiting 0 Nausea [J Diarrhea 0 Constipation 0 Tony Stools [J Bleeding rJ Last Bowel Movement_____~ U Incontinent Comments: /Yh1"?U. ," GENITOURINARY /REPRODUCTIVE: U PainlBuming/llching IJ Discharge 0 Bleeding 0 Dribbling [J Frequency 0 Nocturia 0 Oliguria fJ Incontinenl U Last Menstrual Period _ U Menopause n Breast Change o Prostate problems Comments: /J1A1rLL- RN Signature: (! _ ~f.JU-"v fZ~ DateITime: 7/8'.' P ATlENT IDENTIFICATION '1. "'[RS JR, ,,[NOELL K. l!~Q/qq bl20 RICE RO 1/?4/A4 SHIPPENSBURG. PI ~., : LA CK. J r FF R [Y 0 H 0 246 P 0058180 832~91 j A ~ T ~ -. DAVID C. BAKER; ,M.D. . -'i.4:,-"'~li'_" 1ilII.'~~ ~~- -o''ll!!ii i PATIENT BILLING INFORMATION FORM (P1ease print al1 information) DAVID C. BAKER, M.D. NAME W QJIr\:>\ \ t: \'1\ .:J".rs 0. SEX ....i... M _ F ADDRESS ~ 7 ~O Rice rJ- OM ~\j;NJ n",\'u..~ \lA 1/~5} sslt ,0,;;)- (..(,,-I.:>qBIRTHDATE 9/CltI/~'/ MARITAL STATUS:Ls_M_D_W I HOME PHONE 6?J.;l.7Q,O WORKPHONE AGE: EMPLOYER FAMILY/REFERRING~HYS~IAN:.o-, K,(7:1-?,,') FAMILY/REFERRING DOCTOR ADDRESS: 0oJl/.e.de.E' J'--o.rr), y Prnd, Ce. ALLERGIES TO MEDICATIONS CURRENT MEDICATIONS SPOUSE'S NAME SPOUSE'S WORK PHONE IF MINOR, MOTHER OR FATHER'S ~ ( A )e.rl 00. I r ). \hOlY', WORK PHONE ~("'f:tfa..~ m "In - ~ 5:?D l/ /.jt.o liobh("Y"oQJJ... (\JU.\k ~. -"f. PRIMARY llEALTH INS~CE .,; . ADDRESS POLICY' GROUP# INSURED PATIENT SPOUSE!OTHER(NAME) INSURED""S"DATE OF BIRTH c!y IS FATHER CARD COpy ATTACHED SECONDARY HEALTH INSURANCE ADDRESS POLICY# GROUp# INSURED PATIENT SPOUSE/OTHER (NAME) INSURED""S"DATE OF BIRTH CARD COpy ATTACHED IS VISIT RELATED TO: WORKMAN COMP: NO YES DATE AUTO ACCIDENT: NO ---X- YES DATE rrq9 EMPLOYERLAUTO INS COMPANY F.n f' -:Ins.u..r:l:d~C€ ADDRESS VO (ly,j ~Ol~ ~nic.,,>h(M~ VA t/(J5$ POLICY# , . ROUP I authorize Dayid C. Baker, MD. to acc"ept this signature on file as authorization to submit a claim to my insurance company. l\1y signature authorizes that payment may be made di~ctJ)' to David C. Baker, MD. If Workman's Compensation or Auto Accident, .r authorize the release of my medical records if requested to secure my insurance paymenl I also authorize release of my medical records to. any pb).sici~ to wbom I am referred for furtherwo.n..-up. Regan:fless of insurance benefits, I undersbnd that I remain financially responsible (or all fees for services rendered. ~~pa~.Ll i/J~5l19 Signature Authorized ,< "--"~-~ ~ ~ ~"'~ , . " . ""8 , AUTOMOBILE ACCIDENT INFORMATION NAME OF PATIENT: -s NAME OF INSURED: fY>,. INSURANCE COMPANY: t": \\ -e -:T:flSLA 10-. \l c-e ADDRESS OF INSURANCE: f>,(), {/)O'i r;l0 I ~ (Y)Qc..h P R ) 7055 C.IClUYl . ..BOJd6YNUMBER: ()\ Dn ()L(~5qdl.o DATE OF ACCIDENT: 7,/ ~/ q9 DESCRIPTION OF ACCIDENT: (please be specific; i.e. how accident occurred, right or left sidellimb injured, etc.) /p I I ..s,' rip - Fru,c.fured (l;(/M.J1Jn€. ~~ 14d){;>s nn !,i~W ()rm <S+I ~(.\'f <" or-, I p.{' -I- .\irlf' of .(Oc.e - ,~ . .- Ii , _ _ ~ ".' _'.'.'. _ _1, __ ~' ,-;: , ~ D-' yo, ~o\3 '0\~~ Qp );055 9 ~ . ~W1Y0~~ C/o.(/'l'l \\\u.()\ocr . O\D\,7DL/35 9;;)(0 l- '6 CD - 3 8 ~ ~ J 30Lf ;UIIH~- -," , , '. ~, '~,~ '. c\\ ~ NAI\-IE lDUlo.a.eL rr,\1U':;, ADDRESS li7 ().O ~ f-vCt. ed. 3-u..fp PHONE (HOME) 53~ - 7170 DAVID C. BAKER, M.D. 850 WALNUT BOTTOM ROAD CARLISLE, PA 17013 &11 ?) ,IS- 1 [J)f"\ 'd,()D \' AGE...f:L-TODAY'S DATE 7-q-qq DATE OF BIRTH .' q - ;ilf "6'1/ - PHONE (WORh..) INSURANCE 0JJJv PLACE OF EMPLOYMENT - FAI\ULY DOCTOR L~'~~ REFERRED BY f?)r, .5ed/o..C-J&" FAMILYIREFERRED DOCTOR ADDRESS ALLERGIES I\.)ICO A SMOKER YES ~O MEDICATIONS 1\ ),jy\.Q -/caloJ.'--'-'\ ~ PREVIOUS SURGERIES ru~ HA VE YOU EVER BEEN TREATED FOR DRUG OR ALCOHOL ABUSE? YES_NO PROBLEM h It- Clo-.\ll~ PREVIOUS X-RAYS CH ER-- fJ-f-cr'1 m\J4 '11 q- I '1 ~ < JL:L 1.~; 1999)~ c;j J0..0\fi.~) r+ ~~ ~~. (;):00) \~ OJ0-\}JU-.. ~ ~ a.... <::,;-\09 -::,\~ Q..J::> 6 ~ c:u:::, ~ '-\D ~\-.... 0'i"-. \..0c:uL.~ ~~ ~, ~ ~~ CN'\ ~ ~ ~ ~~<". jJ\d-sL ~ ~ ~\.:A6 C:>...J'-O u..x--G . ~ V-JD...D 0-...>-... ~d~ ~ ~ v:::. o-OC. ?~ r:>~, (J-\-. \...DG..r-> \Gtu:>~ ~ ~ 0 " . , <,---,-- 'L. \2... - f,.." ~ .". rv~~ ~ -\:;,-~<e:, C ~l..L~~'-- ~V'> ~"" ~ 'o~ ow:::. ~9 . Wendell is one week status po'St distal c avicle fracture .~e feels bett:r. This distal clavicle fracture should reform through the per~osteum. He ~s to use the splint as needed for pain. I will see him back in three weeks. DeB ------------------- ,,,.~-- ~- ~~~. ~" .~ ~~ J__ l"J<J -.'''" ... . "\.~'W~~~ces '. ">'. 246 Parker Street. P,O, Box 310. Carlisle. Pennsylvania 17013-0310. (717) 249-1212 DEPARl :NT OF RADIOLOGY I ..'CARI,ISI,E IMAGING ASSOCIlI'l'ES.. P.C. , r ~ HYERS JR., WENDELL K. 6720 RICE ROAD SHIPPENSBURG, PA 17257 14Y ()7/08/1999 X-RAY #143245 MED, REC, #832497 DR. FAl.VO.. T. - I.R, , , r ~. COMPLETE CERVICAL SPINE I AP, lateral, the spine is subluxation. IMPRESSION: oblique, and odontoid views of the cervical spine show in good alignment. There is no evidence of fracture or The cervical soft tissues appear normal, . /' - /' . Normal complete examination of the cervical spine. r~EFT CLAVICLE Views of the left clavicle on two projections reveal a fracture of the distal aspect of the left clavicle. There also appears to be widening of the coracoclavicular distance suggesting ligamentous disruption. IMPRESSION: Fracture of distal ,aspect of the left clavicle. . FS?/CPS T: 07/09/1999 10:44 am 7 K.~r" KEITH S. PUMROY, M,D. \ , ,; / RADIOLOGY FILE ,l.u~_~'~ "-"'i~~>,., , AESTHETIC AND RECONSTRUCTIVE SURGERY OF CENTRAL PA, P.C. ;- . ~ - ~~ ~ I '. "', " :H " - PATIENT"S NAMe' t . l^l",V'\rlQ \ \ ^^'{Q\~ OATE MO. OAT VIII. SUBSECl.ENTVISfTS AHIJ FINDfHGS (0 .l t- C 7/16/99 Wendell Myers All sutures were removed today. Instructions were given regarding scar care. He is going to return to see me on a prn basis. JPS/klf cc: Jeffrey Sedlack, M.D. dh c:. , "- C 10/6/99 Wendell nyers The patient returns today to have me check the scars. He still has fairly prominent scars. The facial SCars are a total of 5 em. The right forearm act,ually encompasses an area of 5 x 7 em. and the left arm is about is Cffi~ The scars are quite prominent. I could palpate probably a piece 'of glass in the subcutaneous tissues of the right forear'm.. Cu:r:cently this< does not buther him.. Scar=- are prominent because of thei:r width af!d color. I have recommended that we use Mederm~ on these ar8ae and keep an eye on them far now. If after the scars have matured in SiX months to a year, we will a scar l"'evision would ~aPfJr"opriatt;'t we cwuld perfOl"Cll it at that time. JPS/kl:f ~ ...- , , ARS 24 .J }..- .;:r.J(-:d ?f':l WiIliamP.Gtaham,IlI.MD. ~ {/ . L...... ~ /~n.M.D. LR\ LawreDCeK. Thompson. IlL MD. . ,~, , .- ,,1- 'Mia .. " 1 . r " '", 2H ENIENT CARE/EMERGENCY RE~{R1nON Ml:DlClNl:5: SEE '~3 HISTORY 105: 'MH: I...J, .' t, ;1. iYSICAL EXAM ME t:?r'-e. (f 1:..fj!.!-;j"i::'-.LI\;l. ." ,3-{ , " ( ';,.UL , 'M$V' .::.'....., C c.,.~ ~ '/)",.S ~Jb /. I"..,' hl~A';. < (O.A.'~ ,./ .~~ T.J \;).\;'t'N'- ~16 ,- ~;"'I ~l!.I\'<N,.~:., SIGNATUflE CONSULTING PH C;yy-- "."._./V PRESCflIPTJONS GIVEN DISPOSITION o 0 HOME ADMIT TIME Of DISCHARGE o OTHER ON ON DISCHARGE SAME 0 IMPROVED c()u,\.> ,. .) , OSONFOfIVISIt},J ~-'15) ~, MVA r.\c c' ~D 0 CONVENIENT n,vw,') 1ARl\.\iI(.) ( DISPOSITION FROM CARE CENTER 'l~~ An.f'HVS. INS NOTIFIE.D TIME INIT. RESPONDED " p ~(..CJ,V nerr NUMSER PAnENT NAME REG.DATEffIME 0058180 MYERS MENDELL K. 7/08/99 15:38 '" ~ NONE 0 -"'ll-';l;,"~.,i;, o " !~~~-""'"'-~=.""'.~=,. ~- ~~ -"--, '~~ '" ~ - ;;: " ~, To: John P. Stratis, M.D. . From: Carlisle Hospital . 7-9-99 5:32pm p. 1 of 1 MYERS JR., WENDELL K. MR #832497 07/08/1999 ER to 304-0 CHIEF COMPLAINT: Multiple complex lacerations, right forearm and left face after motor vehicle accident. HISTORY OF PRESENT ILLNESS: This is a l4-year-old white male who was an unrestrained passenger in a Suburban, which his father was driving, when it was involved in a motor vehicle accident. The patient was brought to the emergency room and was evaluated by Dr. Sedlack who noted complex lacerations to the right forearm and left face, and he called me to evaluate and treat the pa- tient. PAST MEDICAL HISTORY: Significant for no known allergies. The patient has had previous lacerations and repair. He takes no medications. EXAMINATION: The patient is awake and alert. He has obvious lacerations of the left cheek and temple area and lacerations of the right forearm. These are multiple with areas of devitalized skin and subcutaneous tissues and foreign body, glass. The PLAN is for debridement of these tissues and repair. The patient will be admitted to Dr. Sedlack's service for observa- tion. JPS/kw 0: 07108/1999 - 06:42 pm T: 07/09/1999 c John P. Stratis, M.D. John P. Stratis, M.D. , Page 1 of 1 CARLISLE HOSPITAL EMERGENCY ROOM RECORD v' 97-99-99 95:23 RECEIVED FROM: P.91 ~ ,~~~_. .. . , ,. .'10: John P. StraUs, M.D. . From: Carlisle Hospital . 7~9-99 4:'13pm p. lof 1 MYERS JR., WENDELL K. 304-0 07/09/1999 MR# 832497 DATE: 07/08/1999 PERFORMED BY: John P. Stratis, M.D. PREOPERATIVE DIAGNOSES: Comple. laceration of the right forearm and left face status-post motor vehicle accident. POSTOPERATIVE DIAGNOSES: Comple. laceration of the right forearm and left face status-post motor vehicle accident. PROCEDURE: Repair. ANESTHESIA: 1% Xylocaine with epinephrine. INDICATIONS FOR PROCEDURE: A 14-year-old white male who was involved in a motor vehicle accident. He was an unrestrained passenger. He sustained comple. lacerations of the right forearm and left face. These involved multiple lacerations with nonvia- ble tissue and shards of glass within the wounds. The plan is for repair. The procedure is as follows. Oath areas were first cleaned with saline solution and then in jected with local anesthetic. They were then cleaned with Beta- dine solution and saline. The wounds were all examined. There were multiple wounds, totaling about 10 to 12 cm on the forearm and only 3 cm on the face. Nonviable tissues were excised using scissors and forceps. Each wound was probed, and glass was re- moved when found. Some protruding fat was also debrided from one of the wounds. The fo'...earm wounds were then closed with inter- rupted and runnin9 5-0 Prolene suture. This was dressed with Adaptic and dry gauze and Kling. After the facial lacerations were debrided, tney were closed with interrupted 6-0 nylon su- ture. This was dressed with bacitracin ointment. The patient tolerated the procedure well. He is being admitted for observa- tion under Dr. Sedlack's service. JPS/kw 0: 07108/1999 - 06:40 pm T: 07/09/1999 c John P. Stratis, M.D, , John P. Stratis, M.D. MYERS JR., WENDEll K. 304-0 MR# 832497 07/08/1999 09/24/1984 John P. Stratis, M.D. Page 1 of 1 CARLISLE HOSPITAL PROCEDURE NOTE 97-99-99 94:113 RECEIVED FROM: P.9l -'-"'-~,~..~.""""""~..- -_.- , CARLISLE HOSPITAL ". - "'.'''',--, I, ,I ~, Carlisle Hospital ~, and Health Services 246 p.rk.rStreet C.rl~I.. PA 17013.0310 (717) 249.1212 OUTPATIENT RECORD BG.OONNA PATlENTIOTHEREMPlOVER MVERS, MEGAN N. 6720 RICE RO SHIPPENSBURG, PA NAMfIAOORF.S9Ir1lONEI'IlELA TIONIO 0 ",/SOO.SEC.NO. GUARANTORS EMPlOVER MYERS SR, WENDELL K. 6720 RICE RO HOFFMAN MILLS SHIPPENSBURG, PA 17257 164-60-3353 SHIPPENSBURG, PA NAMEIADoRESSn>HONE/RElATIONI'SQC.SECNO. EMeRGENCY NOTIFY MYERS, DONNA J. (7171532-7970 1.8 K. 03 \ qq.d FrankO ATTENOlNGFAMILY ABD MALL CONTUSION CONCUS- SION SIP MVA ~l'Im 3 TO 5 RNS OBS 304B SEDLACK, JEFFREY 0 MD FRONKO, GERALD E 085 CUMB SOUTHAMPTON TMP DEPARTMENT ISO? N '. " --~ "~ " .' , I~' l~ I: OPt ~Y[RS, MEGAN N. o 7 I 0 q I q 1 b 7 lOR I C [ R 0 S) c r I H 't I 0?tlJ/10 S~IPPENHURG. PA arlse ospla, 51 DLAO, JEffREY 0 NO EN (, and HealthSerVlCes 00 S 8 0 0 8 2ll2l:c1sIlNT TO HOSPITAL ADMIS IOi( MEDICAL TRIlATM C~NH At'TO .( Name of Attending Physician . ~ C1 Date of Admission, / Time: /NO (AM)_____(PM)___. acting on behalf of) Name Of Patte consent to rendering care, which may include routine diagnostic procedures and such medical treatment as the named attending physician{s) or other of the hospital's medical staff consider to be necessary. Name Of Authorized Representative , suffering from a condition requiring hospital care, hereby 2. I understand that the practice of medicine and surgery is not an exact science and that diagnosis and treatment may involve risks of injury, or even death. I acknowledge that no guarantees have been made to me as to the result of examination or treatment during this hospitalization. 3. I understand that: (A) It is customary, absent emergency or extraordinary circumstances, that no substantial procedures are performed upon a patient unless and until he or she has had an opportunity to discuss them with the physician or other health professional to the patient's satisfaction; I I. i; ~ (B) Each patient has the right to consent, or to refuse consent, to any proposed procedure or therapeutic course; and I: i f:; No patient will be involved in any research or experimental procedure without his or her full knowledge and consent. 4. I understand that many of the physicians on the staff of this hospital, including the attending physician(s) named above, are not employees or agents of the hospital but, rather, are independent contractors who have been granted the privilege of using its facilities for the care and treatment of their patients. Further, I realize that among those who attend patients at this hospital are medical, nursing, and other health care personnel in training who, unless requested otherwise, may be present during patient care as a part of their education. Still or motion pictures and closed circuit television monitoring of patient care also may be used for educational purposes or for documentation of the clinical course unless a patient expressly requests otherwise. (e) , 1;" , [:- :~ , i;: ~ ~ t ~ I S. I release CARLISLB HOSPITAL from all responsibility for all articles which I am retaining or will have with me during my stay at the hospital. I understand this includes clothing, bridgework, false teeth, eyeglasses, jewelry, money, radio, razor or any other item kept in my possession. I understand I may deposit valuables in a safe provided by the hospital; only if this is done will the hospital assume any responsibility for the safekeeping. 6. I hereby acknowledge that I have received written information on the topics of Patient Rights and Advance Directives. Date of Signature: t-'\,~.qC\ {SIGNATURIl OF PATIIlNT} {SIGNATURE OF WITNESS} " (If patient is unable to consent or is a minor, complete the following:) Patient [is a minor ____ years of age] [is unable to consent because] : /h ,'1Lt( C. ;Z~~ATURB OF WITNESS} '~GN~l~B~~U~~ CLOSBST AVAILABLIl RBLATIVB} ('1'Y1 O'rf\ AD 03lS (10/91) w,""""" "~ ~. .~~.; "- -" ~ \ '. , ' ",. /' , . ~ Carlisle Ho;pJtal and - ~, Health Servi~~slRl " Yf R S, HE G ANN. ~ .. 07/0R/QQ 6720 RICE RC PATIENT'S NAME:D~ .. C?f 23/ QC S HI PP ENS BtR G. P A . JS!...:.!:~CK, JEFfREY D HO EHERG INSURANCE CO.: ~8008 211213 j CONN AUTO Statement to Permit the Release of Medical Information and Pavment of Medicare and / or Other Health Insurance Benefits and / or Phvsician, I authorize Carlisle Hospital as the holder of medical information pertaining to me to release the necessary and appropriate medical information to the fiscal intermediary of the Social Security Administration andlor to my primary or supplemental health insurance company or its designated review agency for payment for services rendered, I authorize the Carlisle Hospital's andlor the physician's billing agent to submit a claim to Medicare or other health insurance on my behalf, or to request, on a one time only basis, from the Social Security Administration, such information necessary to complete the claim submission process. I am the individual to whom the information/record pertains, or am authorized to consent, on behalf of the individual, to the release ef the information/record. I understand that any false statement or representation knowingly and wilfully made or caused to be made for use in determining rights to Medicare benefits or payments may be punishable by a fine of not more than $10,000.00 or one year in prison, or both, I request that payment of authorized benefits be made on my behalf. I assign the payment of inpatient or outpatient hospital benefits to Carlisle Hospital for those services provided by Carlisle Hospital andlor I assign the benefit payable for physician services to the physician. I certify that the information given by ine in applying for payment of services under Title XVIII of the Social Security Act or for any/all other health insurance is correct. Patlellt's Signature SSN Date t-f Date Insured Person's Signature ~ Of different from patient or If patient I~ Date " -_._~....~ Witness WhRe Copy' HeeRhear. Billing Canary Copy. Medical Records/ Ancillary D.parlmenta AD 1825 (5/99) -- -~ .:...'~ > ':i;:,:' l' 't." Diet: .b;tL./d:1".--' Activit}.: ~~ ~ . DresslnglPersonal Care Instructions: '. .' 'f ... \.. 4' 'I " Follow-up appointment with Physician: ~ ~t1d" ~ Other follow-up apl?.Olntments: Supplies sent with patient: :..... o Horn. H..1th NUlne R.dwood Horn. H.alth S.rvlces . 245-5600 o Other agency SERVICES: 0 Skilled nursing 0 Homo health ald. 0 P.T, DO.T. 0 S.T. , 'E! MEDICATIONs: ILlST. ELOWl NAME "- DOSAGE INSTRUCTIONS . . ',(j,,80 CI..~c '"~ dt:,'lCi I.m..'. . q;;lJ,:;l t:: E,.J.' . . . . I have received and understand the Instructions on my medications and on fOOd/drug InteraCtions for these medications. Thlslnlonnatlon Is provided for educational purposes. Any recd'mmendations from my physician will supercede this Information PatlentorResponslblePartySignature: ~, .LYvl'Y'1o.9 r}'~ I,.J Date: '7-q~~9' RN Signature: ,k'~/-- Physician Signature: ~~ /-;;..--- ~ Patient Id.nlfflcation . Carlisle Hospital and Health Services , 248 PARKER ST., P.O. BOX 310 CARUSLE, PA.17013-0310 .' DiSCHARGE INSTRUCTIONS '~l ~YEPS. HEGI~ N. 7/0~/qq ~lZ0 RICE RD ?ll}/'OS~IPP[NSBURG. PA .[~lACf. JEFfR[Y ~~O EBERG 0058008 211213 MR 0410 (03i97) C~"N AuTO MEDlCAt R~CORDS "' ~ 00 "'~ 'l;, " ri., 'J Date of 0 Surgery/Procedure ') I ~ '..,~ 'Admission/Preop Diagnosis 'CC/HPI ~ > \v l l- ,.1 ~a....:. U\!.T"'-.:.-' rn~....,~......",_ <5'.-l 6v",--\~.._ r''''''-'I'' t:.,.l z. ivI" '" \- ~ l,.., \\(.4 Q..., ~ , ...... V\ AAP \~ *Past Significant Surgery or Illnesses b\'-'~ ROS ~L ~ 'Allergies ~Lp 'Meds 1$ FH 'su nw..... ........~..\.A. ~l.~ =~~.~===e...=====.~=====================================c==ceccccc=cee======================== BP 'Mental Status *Heart P ~ R Temp 'General Condition ----11~ Wt. ~ >1<:' "''''" ~r -MI"'J - 6\^tJ ~.I.l-, Vll\.\ I"L\.. a.:'-":R. ~~ ;,' ~~, \ *Lungs Other \--.i1.oIoU .1.... .:i,... 1:. '-6 c.....-'.""",-,, @) s,d\(\ ~ fir- 11 ~ .Ir.\..:.... Iv....) .. 5r--~ f>~ \ I >;;l /.Jl.-." Af;W- t-L I~ oJ.. \ ~ G~,.l 'Planned Treatment/Procedure ~' Date ?h'~1 Physician's Signature ~ 'CONDITION AT TIHB OF PROCBDVRB/TRBA~ o UNCJWI'GBD .' DATE INITIALS r 'Co~lete all starred ALL patients. Complete all other lines pertinent to pati~nts planned procedure or medical cond1tion. ai~ roE6l"'" I'h')~< 1 ~ Carlisle Hospital ~, and Health Services AMBULATORY CARE RECORD . "HRS. MEGAN N. ~)~o./qq t720 RICE RD n'll3/QO SHIPPENS9URG, fA E"ERG 5id05(8bd~ff RE Y 2-i~213i N(Ln1n~ 11/9~1 - '. I' POSTOPERATIVE NOTE: .Postoperative Diagnosis ,~ 1:1 ji ji j I! -",-" " ' *P:r:ocedure *Surgeon/Assistants Complication .Specimens Drains/I..plants uat:e EBL Disposition: ....m........._=__.......==_==_......======_==__a.....a=a..a.......aaa_=__=_.........a___=_=_=_ ~nYS1C1an'B ~1gnature 'ROGRESS !lOTHS ~ Carlisle Hospital ~ and Health SelVices AllBULATORY CARR RECORD . - NO 0106 (1/96) < 'j.~ ft',' ~: OPt ~YERS.,HrQ," N.' 07/0R/99 b7Z0 RICE RO 01123/90 SHIPPENSeURG. PA St :lACK. JEFFRfT 0 HO EHERI I 0058008 211213 :, COHMI_ . .. . ~lt l~~ ~-IiIIII--=-'~ "'t" " " __I ~ Ca'l'lisle Hospital ~, and Health Services 2.46 P.rker Street , Carll.le, PA 17013.0310 . 717-245-5500 REG.DATE/TlME BY OP. 15:30 -"';;1 CONVENIENT CARE/EMERGENCY REGISTRATIOt PLN ACe JOB MOA pATIENT NIIM8ER DG. DONNA PA <717>532-7970 N. ' "'9VFMS 02123/90 ',' OOO-OO-OOO!>, PA 17257 NAME/AOOREjlSIPHONE'IRElATlONfD.O.B./SOC-SEC.NO. (717) 532 7970 SR MVERS, MENDELL ~. 6720 RICE RD SHIPPENSBURG, PA 17257 NAME f ADDReSS I PHONE f RElATION I SOC-SEc-NO. 164-60-3353 COMMERCIAL AUTO CARRIER 75 K. 03 PATIENT I011-IER EMPLOYER HOFFMAN MILLS SHIPPENSBURG, PA VERS, DONNA J. (717)532-7970 18 PRE.calT.NO. FMD CPA MVA TO BE EVAL NECK PAIN RANKE, PAUL MO OFFMAN,J LVNN BRIEF VISIT 26700 CLASS I VISIT 26710 CLASS II VISIT 26720 CLASS III VISIT 26730 ClASS IV VISIT 26740 CLASS V VISIT 26750 CONVENIENT CARE I 27020 CONVENIENT CARE" 27025 MINOR SUTURE EDSOl MEDIUM SUTURE EDS 02 MAJOR SUTURE EDS 03 INTUBATION EDS 04 IV SET UP EDS 06 CARDIAC MoNITOR EDSll PELVIC EXAM EDS14 NITRO SET.UP EDS16 CAST, SCOTCH SHORT ARM 26031 CAST, scorcH LONG ARM 26032 CAST, SCOTCH SHORT LEG 26033 CAST, SCOTCH LONG LEG 26034 CAST ROLl, PLASTER BIP MONITOR PACER PADS GASTRO/HEMO SUDE KIDDE TOURNIQUET OCL PER FOOT F,S,B.S, TUBE GAUZE PER FOOT ED STAT PULSE OX EXTENDED CHARGE I EXTENDED CHARGE" 26075 26031 79064 26060 26048 79670 60081 26074 ESTAT POXEO 26760 26770 ~~-------------- --------------" f ." I I I I I I I , I , I I , , , ,------------------------------~ ~~-------------- --------------', I I I I I I I I I I I I I , , , ,------------------------------~ ALERT N ~~-------- --------~, , I I I I , I , I , I , I , , , ,-------------------~ ~~------------------~, , I , , , , I I I I I I I I , , ,-------------------~ ~-------------------, , , I I I , I I I l' I ' I ,. , , ,-------------------~ ~-------------------... ' , , I , I , I I I , I I I , I , , , ,-------------------- (~-------- --------~\ (~-------------------', 1 II I I 11 I I II I I II I l J I J ,-------------------" \,-------------,------~~ ~~-------- ---------, I~--------- ---------... I 'f \ , 'I I I I. I I II I I II I I II I I " ' \ I \ ) ,-------------------~ ,-------------------~ ~~-------- ---------, I , I , I I I I , , I I , , , , ,-------------------~ ~-----------_._------, , , , , , I I , I I I I I I I , , , ,-------------------- (~-------- ---------\ (~-------------------'\ I II I I II I I II I I II I I I, I l J l : ,-------------------~ ,--------------------, ER-0508 (REV, 8196) ~ "...... - -"'<:~ _._ J , ~~ " , ' . '6:>\J ",/ NAME. MYERS. MEGAN MRN: 277273 DOS: 07/08/1999 CHIEF COMPLAINT: MOTOR VEHICLE ACCIDENT. HPI: The patient is a 9-year-old female who was involved in a motor vehicle accident this was apparently in the rear seat. It is unknown if she was She presents with complaints of neck pain. She denies any afternoon. She belted or not. other problems. PMH: Otherwise negative. She is currently up-to-date with her tetanus shot. She denies any other problems. She is somewhat frightened. ROS: MEDS: None. ALLERGIES: NO KNOWN DRUG ALLERGIES. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 37.6, pulse 88, respiratory rate 24, blood pressure 112/70. GENERAL APPEARANCE: She is awake, alert and oriented. HEENT: Extraocular motions are intact. Pupils are e9ual, round and reactive to light. NECK: Supple. Tenderness to the poster~or aspect. LUNGS: Clear to auscultation in all fields. HEART: Regular rate and rhythm without murmurs or wheezes. ABDOMEN: Soft and nontender. There are no masses. There is some ecchymosis seen over the right lower quadrant which appears to be tender. There is no rebound tenderness. EXTREMITIES: Without cyanosis or clubbing. NEUROLOGICAL: Her neurological examination reveals no gross abnormalities. LABS/XRAY: Cross table C-spine x-rays were cleared. She had a CT scan of the abdomen and pelvis and also negative. Her laboratory work CBC, amylase, Basic lipase and liver function tests were ordered. Dr. Sedlack was consulted. the head which was Metabolic Profile, ED COURSE: PLAN: fJr~fRV The patient was admitted to the hospital under Dr. Sedlack's care for observation. ROBERT WEISER, P.A.-C D 2259 EST T 1324 EST/783/58310 07/08/1999 07/10/1999 " CARLISLE HOSPITAL EMERGENCY D)i:PARTMENT RECORD ~~ - ~ ~. ~ - ~~ , , ~ ^~ -" .~ ',".L _\: I, (' COh..ENIENT CARE/EMERGENCY REGISTRATION MEDICINES: () jV(vA- V,J; ~ ~ ~ ItJ ~r ~ FOR NURSING ASSESSMENT SEE NURSING DOCUMENTATION SHEET l) C f t::J nos: PMH: SH: n.': PHYSICAL E fflmHf ~ ~ G /I.U<.--- r?"t:" v PRESCRIP110NSGlVEN NONE 0 DIAGNOSIS, (]);.It \r g; .' o 0 TRANS OTHER CONOITlOO ON DISCHARGE SAME OlMPROVED ADMISSION DIAGNOSIS: REASON FCfl VISIT MVA TO BE EVAL NECK PAIN 'AnEffl' IUIIIR 0059009 'ATtEIIF~ MVERS MEGAN N~ A ,,- .~ - ,. "~ ..; "."'''''~ . . . . , . TMEHr.. PROClRESS ON ARRIVAL: Time o Iliwoy. 0 Nasal. Size o AIrway. ~ee ize o AIrway. Nasob-JleaJ - Siz o ",.SoIution ~J.nrln:lnr:r. ~~" ",,,,.,.~ . r I'" It Righi, Size 3-n':~'-;-" f:leactlon f!!:t11yf J Left. Size ~ Reaction ~Sk..> - INmAL NURSING REVl~. REASON FOR VISIT: TRAUMA PAST MEDICAL HISTOR ' Slzo o Monitor. Rhythm Rate o Oxygen. 0 Mask. 0 NC . UMin Spinal Immobilization. o MASI_..~_._.,__ ._.___.__~__.__~_______. o f""OSSllf8 Orfl!'lslng 0 Olllnr _~___.__,.,._.~ DRUGS: min. ffi.!n rlmll m,UD . . .' .. ..e ~. 5. 3. 6. Vlm/OIJH/Jlly ~~ "~ ON/A o With Gla.sses o Wilhoul Gla.sses Fpll/llllll/llU Llf/!f O'.fSfA'n~"'" o Defnrmily (g) f4r:> AbraSIon o MAE o MEDICAL TIME: 0 o PSYCHOSOCIAUEMOTIONAL LMP: Weight: POX, SUBJfCTIVE: Cause of tnlmylHlslo\y of Present Illness (Whal the palient lells you), HilA - OBJECTIVE: SAFElY: Are you or have you ever been afraid for your safety in your home? 0 Yes DNo MOUNT EKG STRIP HERE: '-;:L PATIENT PROBLEM: Nursing Diagnosis _ Coping, Ineffective _ Mobility, Impaired PlAN OF CARE: Airway Clearance, Ineffective _ Fluid Volume, Alterations In: _ Noncompliance o Maintain Palient AIIWaY - Anxiety Gas Exchange, Impaired Self Care Deficit o Monitor Cardiovascular Status - Breathing Patterns, Ineffective = Hyperthermia (Fever) = Skin Integrity,lmpaired o IV 0 BP Monitor - cardiac Output, Decreased _Infection, Potential _ Thought Process, Alt. in: ~ 0 EKG 0 Cardiac Monitor - Comfort, Alterations In: _Injury, Potenllal _ Tissue Perfusion, Alt. in: afety Measures communication Impaired Knowledge, Deficit Other i Restraints 0 Suicide Precautions A' r ,.....> h IV't- Seizure PrecauUons OUTCOME/GOAL: Expected by Discharge: 'isJ Side Rails Up J /G,r.. O~V imfort Measures NURSE'S SIGNATURE Pain Control Position for Comfort "~Nt """ flOOR 10 I-~- C~Ij,lng OWE Explain Procedures ~~ Emollon'" Support 1v\.:J~ I " Patient Teaching , Discharge Instructions o Other 'Q.O)~i:l~' HfGH N, . ewelry o Other 70R/CERO ~ Carlisle Hospital . IJJ~1C SH/PP[NS8~RG, PA ther: I lid, HfFRrr 0 HO tHERG and Health Services 0058008 211213 -,... NURSE'S NURSING DOCUMENTATION eoGdlll!3ll9l I ' 19lG: EMERGENCY DEPARTMENT ~ r 0 ~~ ~ ~~ - ~-- Jiliiirn~,; IV FLUIDS TYPE I AMT l\"-.'<:.. '. ,'.. SITE SIZE 1'~"J'177, TIME RATE ATTE~PTS SIGNATURE 1(..1" f)<;<<.j. I. J-(( = MEDICATIONS Mod, Dose Aoute Time Signature o IV DIC'd with catheter intact mEATMENT I PROCEDURE TIMES o RESP, TREATMENT TIME . liME TIME TIME o AIRWAY. TYPE TIME _ SIZE o NASOGASTRIC TUBE SIZE _ T1ME_ SITE AMT IN AMT OUT o FOLEY SIZE TIME COLOR o O,@ VIA - VITAL SIGNS. 0 ON Bp MONITOR IVTOTAL- PO Urine Other TOTAL TOTAL TOTAL - NOTIACATION OF: o Hospital Social Worker o Family o Police o Crisis Intervention o Nursing Home o Family Doctor o Coroner o Consultant o Other - INTAKE: TOTAL _ OUTPUT: TIMES: EKG CXR LABS DRAW'" L1" UA l5la ABG o PULSE OX TIme BP P A NOTES: I f.IxJ \~, 1N:Pl1m.tv (oJ f_ .J> . :,. ..}.-, II .r,.IJ"A r.- ~.IJ.t. w.LJF's -;:;; ~(H., rJynrJ.~), d'J",~A lind' -:J,,"ln.'" I", ..J......AAAZr>-.!j I.~~V) J /I J.. JI~w"d,-I{lW;:. ~ Ji~r-I- \,<<:;1.-1, /.Jr <:J.~qtw~ VI~.b' .n.1Lwed J.n fJ./U .n. ./0 ( cidi.J' ..ttc.. 0./n VlII.",,,,,... ,r::;.)/lAv. ':11. ~' --.-Ji-t.. ,':'r CI... .L.,I ~1i1JJ..'" A.J tJ\ /)}- ./J!.u.Alllflllv, L . ?-p ~Vr1,~ -1-0 I'" JlI~ J t....J) JJt'JJ...~dL tE1J U .. -, \ ....----J1C kv /h /)r~ ~ A / /" .....J"V'l CT YJl'L""9',, A d.A /~ .I'J.- /A'.J ( , /Lu. .~,/I 10 A" A~. /Jf~ II' & f , /., ~ ,~/ 7Un~I/.a M "'./;, ,A.//A.7) f!o ~ U_ '77-;,. / /jh/-f ~ h /-h; -:?.L .U/77/ ad ////~-Vif) f Ii/if nffi -;ran.. /I/" /..-/"Z, YJ">./,. .J / ~ / J I1J / 'r / ,v v I ~ 1 / / fI MI / o PAT1ENT/FAMILY VERBAU~UND S't ''P'"' v' . 61~CHARGE INSmUCTIONS: I DISPOSmON: DISCHAIlGE: 0 WRmEN INSmUCTlONS GIVEN o Admllled to: [] Liller ~ Self 0 Computer [] Carried ryJ 0 Family 0 Prescription o For Observation tJ Ambulatory 0 Friend to: [J Ambulatory with Assistance 0 Police o Transferred to: tJ Wheelchair 0 Valuables [J Ambulance [] Monitored litter ~ EVALUATION AND DISCHARGE NOTES: 1'5~ I fJ. lJ.!J II&' .~. !fA '.tJlj J t7 .32 IV " o Other o Verbal Instructions by MD o Morgue PATIENT'S NAME []~~ /~~-~4 _ NURSES SIGNATURE ~.""""_.,, -' ". ..,' ~., ,. ~ n~I, ~llU. NtnAN O!IO~/qq 6720 RICE RO N. ~i;U /qo S H I pre H S BUA C. P A ~ Carlislo Hospital oosc8odeFFAEY 211 1 EHPA' and Health Services CO H 2 JONSttNTT HOSPITAL ADMISSION AND H AUT 0 DRL~REATMENT Name of Attending PhYSifia~CU\)~{ ~.~ Date of Admission: ~~\,~ .1 - Time: (AM)_(PM)_ ",.... \~1l' r'. .. acting on behalf of) Name Of Authorized Representative , suff~ring from a condition requiring hospital care, hereby Nome Of Pol I consent to renderin f such care, which may include routine diagnostic procedures and such medical treatment as the named attending physician(s) or other of the hospital's medical staff consider to be necessary. 2. I understand that the practice of medicine and surgery is not an exact science and that diagnosis and treatment may involve risks of injury, or even death. I acknowledge that no guarantees have been made to me as to the result of examination or treatment during this hospitalization. 3, I understand that: (A) It is customary, ~bsent emergency or extraordinary circumstances, that no substantial procedures are performed upon a patient unless and until he or she has had an opportunity to discuss them with the physician or other health professional to the patient's satisfaction; (B) Each patient has the right to consent, or to refuse consent, to any proposed procedure or therapeutic course; and (e) No patient will !oe involved in any research or experimental procedure without his or her full knowledge and consent. 4. I understand that many of the physicians on the staff of this hospital, including the attending physician(s) named above, are not employees or agents of the hospital but, rather, are independent contractors who have been granted the privilege of using its facilities for the care and treatment of their patients. Further, I realize that among those who attend patients at this hospit~l are medical, nursing, and other health care personnel in training who, unless requested otherwise, may be present during patient care as a part of their education. Still or motion pictures and closed circuit television monitoring of patient care also may be used for educational purposes or for documentation of the clinical course unless a patient expressly requests otherwise. 5. I release CARLISLE HOSPITAL from all responsibility for all articles which I am retaining or will have with me during my stay at the hospital. I understand this includes clothing, bridgework, false teeth, eyeglasses, jewelry, money, radio, razor or any other item kept in my possession. I understand I may deposit valuables in a safe provided by the hospital; only if this is done will the hospital assume any responsibility for the safekeeping. 6. I hereby acknowledge that I have received written information on the topics of Patient Rights and Advance Directives. Date of Signature. {SIGNATURE OF PATIENT} .' {SIGNATURE OF WITNESS} (If patient is~nable to consent or is a minor, complete the following:) patient [is a minor ~ years of age] [is unable to c because] : AD 0315 (10/91) SI OF LBGAL GO CLOSEST AVAILABLE RELA: OF WITNES '" " "~~bJ:;kfil" . Ii' ~ 1"" f' i~ I r: I"'. ',' ; If: m ~.'. , " ~ ", F:: " I' .J ~ Carllsle-Hospit.al ~, and Health Services ~!~:':;~~1.:~~,""".~~.'!~~3:,!3'r:......._._..._.___._.____..<?~I_~ical laboratory Report MYERS, MEGAtl N. OBSERVATION ROOM REPORT Dcm:02/23/1990 Jl.Gf;; 9 YHS F' (000l277273 000-00-0000 (717/ 53~>7970 67;W fUCB F(D DR SE:DU\('Y;, .JBF'FRf::Y D. (at:t.l2l1d.inSJ phy: SE!)l,l',C:l:;., dEF'F',H,E~: :U. ..:;:,~.f/JgM~.~~elilJJtAtllil!~ffll~T[ifJ/k$~~~tJrJ~ t.~^y O~~ S'_l"AY COLL. DATE & '1'n4f:!~ PHQCEDUf,E 8LOOD eEL~ COUN~ WEe, .t' s 6.0 RIlC' s 4,64 HGB. " 1.3.0 HCll~ is 3$,8 Hell s 79.31.. MCIl " 28.0 l<l(:!.lC s 35. 3 RDW s 13,0 PL'l' s 196 AtI'l'OMIl.TElJ tlII!'FEREmrl\L NEu',r % s 59.8 1.,YMP[-! 'i s 29. S MONO'!. s ;1.4 l::OS ~ a ,7 BJV30'i. s .3 Nl':-:u1' it s 3,58 L'lNPll U s 1. 78 MONO~ . .56 ,BOS , B .04 BMO ~ B ,02 E/%' 08JUl,99 ___,.Hl.l.Q......__._.___ ,., DAY OF S'l'AY CO!'!". D1\1'E & TIME _J.Jij,!L___. PHOC~!lUPJ5 CIil!:H cmmTITUENTS FASTING BUN N/\ ,l{ C1J C02 Gr..TJCOSE . CRE(~ lJILT 'I' BILl lill E:HR O~'3.10L99 s UNf,'. S 1911 s 1.42 s 3.6 s 10~ s 21.7 s 97 s .6 s ,2 s .1 Footnot.es and S:,..l'G.bol::~ tJ ~LOW r H =HtOH t B ""STAT ';'/."" . lOO3 24 (~/9flj WIlHam J. Posk.'\; AdmIn, Director buci-k:"t1 Ch~l'\tl, M.D.. Palhologls-f Henry S. Crl!lJ., M.D., Pat!loIQ~J!!~1 PRINTED 09JUL99 'I'TN'E 2;.!3J ADf.11T'f1~D 08dUL89 PAGE: H.EFERE..NCg UNITS ,(3. e'-.ll.. () I X3.0^3 (3: 58.5, ~6jl{lO^6 ..(13,.O-15,S)gjdL (11,0.4:\:0)% (30. O~.99. 0] UN" 3 [27.0-~4,Olr'G (32.0_-36. OJ ~:j/d[, rll,G..16,(iJ~ I 1,:1 O--';l.OO} X1D"'2, [.16.0.-'76. OJ 'ti [tR.n~.s8,Ol!#i [1.0"IG,O]'l> [.0,,5. OJ % l .0'-2,0-] 't [1:~O..B.80IXID^3 [1,OO-4.2CIIXI0^] (,()O. .60l:x:10^3 [.00-.401 XIO^:) [,OC!'.201 l!:lO":l ':",-:" .' RNPBR8NCg' UNITS [7;'18) mg/Ul ii46.1S~1" MNO!.;j\, [3.6'5.21 ~~OL/L . [104"Hlj 11MOl,,1u (21. Q<~2 ._OJ MNOI../L 170-1101 "',;/61' [.3..,8), mgidl (;O.j',Oltf./j/d'l . {..9:.-: ~ 3.:1. ~~mH/.~~~,: -,,,J -.--.-----..--.....~...................i.iERi:i~- MEG.Mt N~-..-...-.-.--:~.:~~.:.?..........................;~...'.'.'.'.-~AG.~: --~-r- :;!:~",' ,."- :- .', fI!,MATOI.OGY CHEMISTRY COlltillued... " , Lsog ;~4 (OI9l"l) '. , ' '" , ' ..J I' ' I!'It\ Car,l1s1e IlOOllltal I ~ and Health Services '" i ~_j...:..m;f.~~:~rii";:,,~.~ '7"'$",~.,.,..__,_....__qr~ical L9bor~tor~.F3.ep.~rt I MYERS, ME<lMI N. OBSERVATION ROO!.l IU1PORT D{)B:02/23/1990 Ai'.Wi 9 YES F (OOOf~l77273 000--00"0000 (717) 53;~-7970 6'7~~O F~TCE ED DR S~~DL1'\CK > J'EF,FHE'I" D. (ci t l:.*?ndinq ph:..-: SEDI.AC}~, ~J&~E"FREY D. ." ~jgM!~~~ji~m Willlarh d._flooka, Admin, (l~tllJ:(:IM . '; bU.::kkytl dheng, M,D" PrJltmk'g!sl H~'fll',/ S~ ?.~t, ~tD:\~.::thot:~gl~f.._.___ PRIN'l'ED 'rIME P.,DB:I'I"t'BD 09JUr.99 '22 :n O~{,JUL~J9 .PACrl 2 t~,.." . r)A): OJ? S'I'l'\..Y cot,t, , DATE & TIME PROCEOURE _ ''',.'' CREM ,CONS'I'II.t'llEln:'S P-LI3UMIN' ENZYMES, .. AI.I(' PHOS HEVgRE:NCEl unrrrG " FJIf{ o g,TUL9 9 1610 s 4,0 (:(:4~':5'~-ri] g'm/dl s 25611 r::"'-1'r'''''' _AS'I',,: S .28 ,~", I -;:AuI" S 33 A.t1"lLliSE: s 73 T.,!PA.SE s 204 l.llPA8E Valul:."f:s m.:l:/ b(! elevated e"u:li(~r or than do amylasE' values. 1.3E;( un.1 ,l1.S;:::rz.J . .u(I.. [22eSt]' tilL [2,~:)-:J..,15J. U/l~ [114.;.2fJ6j UIT-, r-eITlr.1.ln elevated ItXlq,?'J:" .in p,::'!.tlet(~atiti.r~ ,",)',,"',""''''',' '" ~ I' '. . " . r~'" :..',.." i ...".,...,~-, ,', ,'1'.'. "Fm.',tnotes and S:ymb-ols H ...HI:CH. S ,""..STAT .:~""" -,,, "".\ , C/./E.M/smi' HOFF!'>tt',.N, ..1'. LYf:JN MYERS, MEGAN ti. E.nd of Repml ,.,." "P"." ~ ~. - , ' I o~:'" '.' . '11~ . Carlisle Hospititl and Health Services 246 Parker Street. P,O, Box 310. Carlisle. Pennsylvania 17013-0310. (717) 249.1212 DEPARn.._m OF RADIOLOGY CARLISLE IMAGING ASSOCIATES, P.C. MYERS, MEGAN N. 6120 RICE ROAD SHIPPENSBURG, PA 17257 07/08/1999 X-RAY #143242 MED. REC. #277273 J!- DR. FRANKE - ER 9Y CERVICAL SPINE A single lateral view of the cervical spine shows the spine is in good alignment. There is no evidence of fracture or subluxation. The cervical soft tissues appear normal. IMPRESSION: No fracture or subluxation is seen in the single lateral examination of the cervical spine. R- ./ <J KEITH S. PUMROY, M.D. KSP/pl T: 07/09/1999 09:54 am .' CII^f1T1P1 fiSH. ~IAN '_.>>Ob.-' 1 I I .1 II " " " " :~ :~ :1 II " II I I ~ -~ ~ -,,~-~ ~~ "-~,c,_., ~:i DEPARTh.._l\IT OF RADIOLOGY ~-i c :'1 i: !-i '. ~\,. \J ~Carlisle Hospita.l ~, and Health Services 246 Parker Street. P.O. Box 310. Carlisle. PennsylvanIa 17013-0310. (717) 249-1212 . . CARLISLB IMAGING ASSOCIATBS, P.C. MYERS, MEGAN N. 6720 RICE ROAD SHIPPENSBURG, PA 17257 9Y 07/08/1999 X-RAY #143242 MED. REC. #277273 DR. FRANKE -- ER CT SCAN OF THE BRAIN Axial sections were obtained without the use of intravenous contrast. The ventricles, sulci and cisterns are normal. No focal masses or areas of increased or decreased attenuation are seen in the brain. No abnormal shift of the midline structures is noted. There is no evidence of intra or extra-axial hemorrhage. IMPRESSION: Negative CT scan of the brain. CT OF THE ABDOMEN AND PELVIS The attending physician did not wiSh oral contrast to be administered. Intravenous contrast was utilized. No abnormalities are seen at the lung bases. There is some fluid distention of the stomach. This may be due to air swallowing. There is abundant bowel gas. No free air is seen. No abnormalities of the liver, spleen, pancreas, or kidneys are seen. IMPRESSION: Negative CT scan of the~omen and pelvis. \.)l>\ DAVID R. ROYAL, M.D. DRR/eh T: 07/08/1999 09:10 pm tJ( .' elll\l 1 T /PI-!YSf(;'^N ~ , , .--.. ' ',<L -..~ "".~< ~' 'lMh_" " ., ~~.l:' lIHIlS. KrClN If. ~7'~~/~' b710 ~ICf ~o r:/~5/~~ SH'PP(MS'~R'. ,. ~l:l.tr~ )r"R(' D ~o tlrAt n05Bu08 c11213 ~ Carlisle Hospital and Health Services 246 PARKER STREET" p,o, BOX 310 CARLISLE, PA.17013.0310 ", !t.;. ~ ~ M~l,,\w', ('i\Vj~v'\.1 PATIENT IDENTIFICATION PHYSICIAN'S ORDERS DATE ORDERED ORDERS NOTED BY fll' ~j-) I~ Lz ~t-\. ~ i/6/<j") c.j~f vfj vl) A) ~) (}5 vh III -l tflS'\> ~b ~h ---".-..-----.--.. ..-" -~) " NOt815(12192) WHEN THE NUMBER .... COPY HAS BEEN REMOVED, REPLACE WITH ANOn-tER IMPRINTED FORM. CIlART CI,'I'Y " '"'.- ',', ~ ~, . ,,' 4 ,-, .. " , , ... O'H '.' ~,.RS. "EGAN . 0110A/~q b120 RICE RO O?I?l/~O SHIPPlHSeURG, PA S(OLACK. JEfFREY 2i~al3 "k&"" AUTO NOT ~ h........ " ,-,....., , I. " ",'.:" . :1~' 'j '" Ii: ~ , -- ."'~,,"- " 9/8"--''') 162.5 ~..~ ~ II - .. ~ . . __r / " ., IERS, KEGH bUO RICE RD SH I PPlNSBl'PC .-. ~""-'" (: '.. I ..., " - ~.., . g~;OR/qq 071l3lqO PI ...._'. "J~",~,,~~, o=c_ ~ . .' , ~GRESS NOP'<: f S{ OLACk. Jt FF REV D KO 0058008 211213 ~NDING PHYSICIAN 1 .: CO"" I TO . dATE NOTES nO .... RV . . . . ... . . .. .. ,.. .. .. , , , . ... .. .' ,", :'" ....-. ',"-." .'~'~ . .~-. . " , .- . , , ! .. ..- ", ~ l' ~ 9/6"-''') 1625 Se. "'. 250 04 08 12 16' 20 24 04 08 12 16 20 24 04 08 12 16 2024 04 08 12 16 20 24 04 08 12 16 20 24 240 230 220 210 - 200 '90 '80 '10 160 150 '40 130 120 37" 110 100 90 /~ .~ RESP. RATE TIME Mo"'" _~~. DATE HOSP/POS10P AII11BIOTlG 1 P U L' S E 39' T E. M P 38" FSBS RESULT WE1GfiTISCALf/ ~llI11"fT P,O, TU8EFEEO ~ IV !z 8 HR, TOTAL 24 HR, TOTAL VOIDED URINE FOLEY ~ o DRAINS I HR, TDTAL 24 HR, TOTAL ..AC"",- o RENALQUlPUI' al NO<I32S (2190) -- "'~ .~ ~-, '. " ) ) ry - Ll'{.,-l:{1:\ ')0..<... ()Q ) ~ 2 .~ ,. ~ ~~" ~ \C \ "\ IJ. '-4 , , " !, , "i' ~ , - , 1\ II. . ,wig V :1 I J,.q. s;r1.4- 15-23 ~'07 07.15 15-23 23-07 07-15 15-23 23-07 07-15 15.23 23-07 07-15 15-23 23-07 ./ 01.15 I I Carlisle Hospital and Health SelVices CLINICAL RECORD ,I I T I n, HU$. ",nH II. C1 'il~/1j1 l.1to tlct 1I(i fo'/d/H! ,1I,"IItUt,l, U. .. ~1;,tH. JOUH Ii l!0 . UIl.. onsaoos c?"a13 1 t'~'lI .11 HI 1iI__."",_-" 250 40" 240 230 220 210 39" 200- '90 '80 110 160 38" '50- 140 130 120 110 37" too- 90 80 10 60 36' 50- 40 30 35" I , . ~""" From 07109/99 at 07:01 to 07110/99 at 07:00 DAY SHIFT EVENING SHIFT NIGHT SHIFT NO DOSE ROUTE FREQUENCY START STOP 0701.1500 1501-2300 2301.0700 SODIUM CHLORIDE!OML INJ 07-08.99 PEN 2ML"lEA FL PEN 001 BEFORE & AFTER MEDS OR EACH SHIFT FOR 1. V. CAP FLUSH HEPARIN FLUSH INJ 1ML VIAL 07-08-99 PEN 10 UNIT / 1 ML " 1 VIAL FL PEN 002 BEFORE&AFTER MEDS OR EACH SHIFT IBUPROFEN-rPEDIAPROFENT"SUSP. 07-08-99 PEN 400 MG / 20 ML " 2 EA PO Q4H 003 **"NOTE DOSE*'" ~tt.N ~o..v,.-. !!!!!!!!!!. !!!!R'!. ~ Abdomon INITIALS SIGNATURE INmAlS SIGNATURE lVC-l8ftve"1 LAT-leftantlhlgt1 LQ.lefldellold UQ. left lower quad AVC . flghl vent RAT. right and thigh RO-r1ghldeftold RlO-r/ghllowerquad /(/ A..../"Il /fi-- lOC-leftdorSllI UT.leftllllllhlgh ALA . flghllal ann LUQ -left upper quad '2 ROC . right dorsll RLT.rtghllllllhlgh 1lA . left lalBfsl arm RUQ . right upper quad '-...1' lVL. left vas 1111 RVl- right vall lal N.N.P.O. R . Refused p.OnPass NN. NausellNomlllng Admls.tion Dalt: 07-08-99 T-Teallng ~-.", '" ~. > H . ~ .,~ , ~ .- ~ '. CarliStc1 Hospitat Medication Administration Record NOl30SA (REV 9/9/94) AI/ergie,,, NO KNOWN PATIENT ALLERGI Nomt: mRS, MEGAN N. Room#: Ag" 9 YRS 5"" Female HI..' 137,0 CM ~ 364c.. WI" 29,5 KG f"inancial" 000058008 Physician' SEDLACK JEFFREY D PaRt #: 1 MR', 277273 ... end of report." PI, Name: HYERS, lIEGAIIll. -~"_,,"'d,c: C. I'v\ iW ~,~ "~~, I' li:<l:1:Wi...~i'l , " , , :1 I. .1 'Carlisle Hospital Medication Administration Record NOIJOSA. (REV 919194) Allergies: o R \~j}~. >> HilS, M [ G H .'1 07/0"/1~ b7Z0 Ille[ p: 0:'/.'3/10 SHIPPENSPlI'~ ' S[~LACK. J[FFR(Y D.;' , 0058008 2112- ,I \1 :i I !I I I Name: Room #: Age: Sex: HI,: WI.: COH Al'TO FtMndnf 'o' r'I)'.,'dlln.' FromO'J m 9~ at \q4D t<O){)::\qq at moo DAY SHIFT EVENING SHIFT NIGHT SHIFT NO DOSE ROUTE FREQUENCY START STOP 0701.1500 1501.2300 2301.0700 m~... l\OO~ PO Q41v, 'h J.;ZI") ~ fr" V' 1MI') . I. . .' !!!!!!!!!! !!!!ill. ~ ~ INmALS SIGNATURE INITIALS SIGNATURE LVC.leltvent . LAT.l8hantlhlgh LO-leftdellold lJ.a . 18ft lower quad VO. f1t u. I -vvf!,J AVC.rlgttt""" RAT - right and thigh RO-r\gt1tdeltold ALQ - rtghllower quad If', . LDC.leftdorl.1 llT-leftlatlhlgh RLA - right Il!lIllrm wa -18ft upper quad RllC'''f''_ RLT.~1M\hIFo \1.A-~~TlAen'I\ RUQ.....-- lVl-leflvttlal RVl. rlgfItvatlllt N-N.P.O. R-Refuted p. On PillS NN. NIUlIeaNomIlIng Admbllon Dare: T-Telllng I I j !I II II :[1 II ~ j I I I I I :1 Pagel: PI. Name: MR#, ~1INl"" "IW"_~ ". " t' PEDIATRIC NURSING DOCUMENTATION SHEET NO 0450 IlMI2J DATE: JUL 09 1999 " ~~, 'if!!- 'REFLECTED IN PATIENT OUTCOMElEVALUAT1ON AREA - SEE BACK liME liME ~ EYES OPEN QUAUTY IWNL N ,.If Ii E BEST VERBAl I MOTOI1 SHAl\.OW , U EJ<T, MOVEMENT R DYSPNEA' I' i R (ARMlLEG) l CROWING' I 0 . ,- - - - - - - - - PUPIL SIZE I R STRIDORCUS' , REACTION l RETRACTING' B COMPlIANT F. GRUNTING' R E NON COMMUNICATIVE' E NASAL CONGESTION H A ANXIOUS' S tA,RWAY CONGESTION' Y NON tQMPlIANT' P NASAL FLARING' I I 0 SlEEPSIWNl R TRANSMJTTED R RJSSr A OIMINISHED' mlPERATURE 1 WARM .""'J/i' T CRACKLES' 0 COOl R RHONCHI' HOT y WHEEZES' I SQUEAKS' MOIST'NESS , DRY kW COUGH / NON PRODUCTIVE MOIST PRODUCTIVE' DIAPHORETIC' lOOSE TURGOR' WNL ""'j/jj liGHT EDEMA' CROUPY' I PER~AlEOEMA' , TRACHEOSTOMY N FONTANEl/WNt ABD / WNL IF}/ T COlOA I WNl IVH DISTENDED' E A G PALE B FIRM' U FLUSIIEO D BOWEL SOUNDS IWNl IK',{ M ASHEN' , HVPERACTNE E " CYANOTIC' HYPQI,ClIVE T JAUNDICED' ABSENT' A MUCOUS MEMBRANE I WNt , 1.1<// NAUSEA' R y DRY VOMITING' SENSATIDH I WNt I vI' FEED TUBE ASPIRATE AMT, TINGlING' DIARRHEA' NUMBNESS' , COOSTIPA TION INTEGRITY I WNt I In/ . STOOL/WNl STAGE' CONSISTENCY /SIZE INCISION IWNl G FLATUS I NG pLACEMENT CHECK DRSG DAYllNTACT I IVsntlWNt .PI I1'l1 G NO DRAINAGE COlOR U DNERSION HEARllIATEIWNt fV}7 BLADDER IWNl Wt c MURMUR' BLADOER PALPABLE' A IRREGUlAR' FREQUENCY' R TACHYCARDIA DYSURIA' D I BRADYCARDIA URINE COlOR/APPEARANCE V PERlPtrERAL PUlSES I WNl r1"A MAlODOROUS' A DIMINISHED GU DISCHARGE'I AMT/COlORS S ABSENT' CAPIllARY REFILL I WNl HOMAS SIGH, I, . WIll I 1./.1/ "} . , flOPPY' r . r HI MYERS. H[ GIN N. . RIGtD' C STROIIG \ (l7l0./~q 1>770 RICE PO R - O?ln/~a SH I PH NS BURG. PA y SNRIl/.' SI:JLACk. JH f R [y 0 "0 EHERG OOSP008 ,.......11 I "TI'I 211213 - ~~ .~^b. . ~" ~ 1 . ...,.. . ~~'~ , . -"~'j~>Q V" " .. . " .. . ,Et2' 2 ><IJO T . !llJ1N'] '. \.... L. .. ! I d jj If P . " -Yd . 'J ~ 1 0 ~ N l d d I .; ;: b I \ ' I I EXPLANATIONS I MEANINGS I eODES PEDIATRIC NURSING DOCUMENTATION SHEET DATE: NO 0450 (6192) NElJRO: COMA SCAtE CODE EXTREMITY MOVE ENT JUl o 9 1999. REFLECTED IN PATIENT OUTCOMElEVALUATlON AREA. SEE BACK RESPoNse , 2 3 . 5 6 .1 ., .3 . nME PUPIL REACTION VOICES UNDERSTANDING [V[g Nl:VE".tt TO TO !lI'Otl1A . . OPEN PAIN SOUND 'EOUS SLUGGISH FLOOR ROUTINE CON . REACTIVE SIDE RAilS INCOMP lNAPpno FUSEO NON REACTlV CALL LIGHT VERBAL NONE SOUNDS PRIATE COOVER. ORIENTED WORDS SAlION PUPilS mill . e P 1&0 EXTEN FLEXION FtEKIQN LOCAL OBEYS ..,e,e, :.I~ DIAPER CARE MOTon NONE SION ABNOR WITll. IlES COM, ..,.. ~ CIA MONlTOR OIl" PAIN MANOS MIST TENT NE~RO: EX'. MOVEMENT. ..4 ~NOfmaIS!feng'h ..2 e Severe weakness N .3~Mildweakness +1 "No response T RESPIRATORY ISOL BEftAVIOA: SLEEPS I WNL . Able 10 lall ask!ep unaock1d belween Penods 01 care and does not d iplay I PHOTO THERAPY llilJns01 slee.odeprivahon p IVSfTE INTeGUMENTARY: TURGOR I WNL. When skin pinched. relurns to original position without lea 00 A IV PUMP ...k R EDEMA .1 ~SmllllpitllOtletalned .3 ~ 112" pit r(!tained E DIET '2~ 1'4" pll some lelained .4,.314"pilretalned N NSS DROPS FONTANEllWNl Soil non-Ienseto palpilalron May be slightly depressecl. T COLOR I WNl Pink nl'lil bods and mucous membranes BULB SYRINGE MUCOUS MEMBRANES I WNl . MOist and pink T FEEDING SENSATION I WNl. Abte 10 leellight touch and locate with eyes closed. INTeGRITY, WNl . No otren or reddened are~ E BURPING STAGE I . Reddened area lhat does nol resolve within 30 min. 01 pressure reliel. A POSITIONING D FEEDING ST AOE n . Skin br.ster or superliciat break in skin with redness 01 !;Urrounding skin. e STAGE III. Skin break wilh deep tissue involvement (nomy Entelostomal Therapist). H BIPMONITOR STAGE IV . Deep ulceratiOn with involvement ollissue. muscle and bone. I HEPARIN lOC INCISION I WNl. Wound edges well approximated With no ecchymosis. edema. redness. or dlainage. N FORCE FLUIDS IV SITE I WNL . No ledness Dr swelling of sile Good blood retum. Skin lemp_ same as suno nding G sklnl!ltlIlIVftowSlll!llt) ~!!~~~~" CARDIVAS:KEARTRAf€fWNl. N9:80.180.1 wkto 3 mos: 80 .m.3mosto2yrs:70-1 >0.210 HAND WAS/-IING IDylS' 60. 110. 10 yrslo adu'" 50.90 PERIPHERAL PULSES. Pedal and Radial. CAPILLARY REFIll. Relurn 01 blood within 5 seconds. HOMAS SIGN. .Pain In!he call on dorSillexion MOTOR I WNl . By 2 mOll mlly!urn sido 10 back: By 4 mos may grasp objects with both hands: B 6m" may lurn OVAr eomple'ely: By 8 mos mny sil well nlon(!: 8y 9 mOll mny ernwl. hold own bollte By 10 moll mlly pull 10 slllndi/lg posllton. By I I mM mny .CIUt~(l' nlong lurnilurn: By t2 mo!! ml'ly I; ""d oIcne RESPIRATORY: QUALITY I WNl . Even chesl e~cursion & unlabored paltern. lungs clear. nME Avelage Rales: NB 10 2 mo~: 40.60. J mOll 101 yr: 30.40.2104 yrs: 23.30.61010 yrs' 0.21. E PATTING 10 yrs 10 adult: 16 . 20. NOTE: For each degree 01 temp. elevation.lhe R.R. increases by 4 per min. DYSPNEA . labored or dillicult brealhinlJ . may be painlu1. M ORTHOPNEA. ComIOl1ab1e brealhing at angle 01 45 degrees Of grealer. 0 ROCKING CRACKLES. Heard Chiefly on inspiration produced by lIuid 01 liner bronchi. T TlC RHONCHI . Heard on Inspiration & e~piration: produced by air passing Ihrllugh mucous in ~ gm I REASSURANCE . ailWay. 0 WffEEZE. Noisy wltisfling . may be heard on inspiration bul more common on e~piralion N CONVERSATION AID: WNl . SolI. non distended. non lender. A PLAY BOWEL SOUNDS f WNl- 510 12 gurgles per minute. L . UPDATE PARENT 01 f OU BLADDER: WNl . Voiding at least 1 ~ per shill. clear pale 10 amber urine with laint arom '"" odor .. feast3OCclfu-0I24Occfsh1ft.Cf1ifdren.f.2cc/tlgrflr. S PARENT HERE PAlPABllE. Bladder distended and left as smoolh r.rm mass above lhe symphysis pubis: U PARENT CAlLED FREQUENCY - Voiding more than once q 3 . 6 hoUrs. p StBLlNG VISIT DYSUmA ' Painful or dlrroc:utt urination. p MAl.ODOROUS. Unpteasanl or loul Odor. a PARENT PARTICIPATION IN CARE au DtSC"ARGE. Vaginal. penile or urell1lal. FUNDUS I WNl. Fundus firm. R CODE M. MOTHER GP . GRANDPARENT O. OTHER T F. FATHER IN'T . NURSING STAFF PT. PATIENT ,<,< . .-- F r -rp ,- .4= ~ . .' '. . /)/ "u'-'- rr'" , , , r ~Y[FS. HGA~ N. '. (I P '.- ~ ~ -~~~ ~ C7l0~/q') b720 R 1 C [ FD -, SHIPPENSBURG. PA C?I?J/H) S[jLA(y'. JE H liE Y C MO EKERG NOll "m" A3 3WOO 0058008 (0"" AUTO 211213 _0' ..... "~ <~ "~ t, ., , ' , PI=n1ATRIC NlIR!=:ING DOCUMENTATION SHEET "~",,,-~," '" " ," ~; g DIET: FILL IN DIET, NOTE ANY CHANGES,CIRCLE APPROPRIATE. DESCRIPT\ONS~ SHIFT 0700 - 1500 1500.2300' 2300 - 070(' D FEEDINQ TUBESt P.PEG a,GASTROSTOMY HEVINE E-ENTRtFLEX COMPI PARTIAL i&LE>l>ARENT P/ AMOUNT: O-GOOl;> F.FAIR P.POOR BOTTLES: R.REGULAR P.PLAYTEX NURSER E NIPPLESt fI.REGUlAA P,PREMIE' N.NUCI( SHOWER / TUB S FLUIDS: F.mRMULA IA.BREAST Mill< E.ElECT. SOL. Cl.ClEAR lI0UIDS ORAL CARE .Y// H DIET ~ CALDRIE CT, TPN PPN Y H.S. CARE BREAKFAST <J SELF ASSIST FEED 0 I SKIN CARE WNCH RESTRICT fLUlO$ E FOlEV CAflE SUPPER FORCE FLUIDS N E HAIR CARE SUPPLEMENT SNACK AM PM HS CORD CARE N ENTERAL FORMUlA FOG I TUBE P G L E U SPECIAL DIAPER CARE T RATE I BomE NIPPLE R TIME I T FLUIDS 'SEE CODESI I AMOUNT FED 0 N FED BY lINITLS OR p. PARENTI SUCK, I-STRONO W,WEAK E.EAGER B,SLOWl Y EN~ ENC BURPS: E,EASILY D,DIFFICULT R.RETAINED WI,WETBURP HMESIS AMOUNT OF TIME TO FEED TIME ! DIAPER: '81 sATURATED ,W, WET 'D'DAMP L ITOOLI: SIZE I M COLOR T CONSISTENCY N SHI" 0700-1500 1500-2300 2300.0100 ~gr6:Eg~EJ:~e~ C.:'~~:IIOW T.. Tan I.. Brown BL. Bladt WH.. White MA. Maroon R = Red A T VOIDING vr O. Orange CO. Cofle~ Ground ST.. Straw l Y . Light Yellow DY.. Dark Yellow LA ..light Amber I DA.. Dark Amber TE. Tea eR. Cranberry p. Pink GR.. Grey BO.. Bloody DR.. oalk Red 0 HNV AU.. Flubs SE. Serosa' A.. Amber N CATHSTIFOlEi' CONSISTENCY: W.. Watery 8. Solt M.. Mucousy F.. Formed l. loose P. Pasty MS. Mushy H . Hard TH. Thick FR~. Frolhy . DATE lAST 1M I STOOl APPEARANCE: C. Clear M. Mucousy CD.. Cloudy CL __ Clols S. Sediment SO -- Seedy Fl. Flecks T.Tarry KA.I(oolAld lED REST I MAY BE HELD 8tZE.: 8M.. Smear S. Small M.. Moderate L . large TlJRNO HOURS T TIME A OOBIRMICHAlRIWC R C E T PLAVPEN IINFANT SEAT A I T V BTROLlER I PLAYROOM M HOI t E I IRP IISC N T AMI K/C T Y UPAO L11; SUPERV, D OFF fLOOI\ ; SUPERY, R A 8AS$INET I ISOLETTE I ~ N S CAGED CRIBfVOUTH BEO ~ A SIDE RAILS UP WHEN APPROPRIATE T DEPARl TO MODE INIT RET\lR1i DlSPOSITlON INIT F R . ! LOW lED POSITION A H T CALL IELLIN REACH 1/K . y RESTRAINTS 'SEE FMS' P ! 0 R SEIZURE PRECAUTIONS T INIT SIGNATURE INtT SIGNATURE , .J" 10 P2! ~ ,B\... . S IhAl n. t. ---- - I '-.J' - Q " N - " A - r r Pi MYERS. "EGAN N. T U - " 0110"/'1'1 b710 lllCE RD R - ounne SHIPPENSBURG, PA ! - Sf ~UCK. J[F r REV :) "0 EHERG NO 04!O lOiS" PEDIATRIC NURSING DOCUMENTATION SHEET 0058008 ,........... lilT" 211213 ~_,oli, "M.>, ~~ l . I ~ ~ -- '1l''l~'" , ' . PEDIATRIC PATIENT OUTCOME EVALUATION DATE, JUL' 0 9 1999 liME /1Md . ,~, .... ,,, .,., ~ /~~ - /2c7~ d-.,f1<.~~- .;::"....~~ ",. 't:.a./ - .Aj,A A~/. ~, ~~ ph hA"//.-"'/" ~ .~ " ~ . ....-c....-- j' ~J , " ?' ;:P'./ ~.r:/-. .d... . /.:P~' ~k~ /A~. - ,. ,,/~ .././ /, h~ d7/.. ~ ;" A:J." ~M Jli/<<. ,dJ ' ~ ./ A - ./ ....:u ~. b~.A; o~4. ~/ ./.Uer ./ '. - /, /- AA <J~-.L A-,. VA" ~ .:..L .A- d 'V ',' " . f~.F L HHllS. MEUN II. i 07/08/~~ 6720 R ICE RO , . " II q ;:' s'iPPEN5dIiG, PA " . . "" i I:': :;j , i\ I) [it jii i;) i'-' :-J j,i ~~{ r:, '-i :~} '" r'j I'l I' 1;( !) i.i i: !A ~ i f ~ ~ i I I' i1 II n Ii ti .~ ij I :j 11 ,j ! ~ ,I ,jfFfPlY" EIIERG :lC . ,OOr 2 , ,213 ;,.,,~ HT~ >' ,,' Ii" .i " ~.- , .' . " . '. " O. 'I Ifj ~. , E: L2L. 2 r; DO, .".JI, 9H3H3 -: i~ . A .1 ~ J i . , ., ,,1 ' I I . . - , , EXPLANATIONS I MEANINGS I CODES PEDIATRIC NURSING DOCUMENTATION SHEET EXTREMITY MOVEMENT DAT~ 0 8 199!B NO 0450 (6192) NEURO: COfolA SCALE CODe . REFLECTED IN PATIENT OUTCOME/EVALUATION AREA. SEE BACK RESPONSE , 2 3 . 5 6 .1 .2 .3 ., TIME PUPIL REACTION VOICES UNDERSTANDING EYES TO TO SPQN1A- . --- _. - - >-- - OPEN NEVER PAIN SOUND NEDOS SLUGGISH FLOOR ROUTINE . REACTIVE SIDEAAILS INAPPRO. con, VERBAL NONE lNCQMP PRIATE FUSED ORIENTED NON REACTIVE CAll LIGHT SOUNDS WORDS CONVER. P SATION PUPILS mm . e 1&0 '-2.2..', 6 A DIAPER CARE EXTEN. FLEXION FLEXION lOCAL. OBEYS ..,... T MOTOR NONE WlTH, IZES COM, SION ABNOR. DRAW PAIN MANOS I C/AMONlTOA E MIST TENT NEURO: EXT. MOVEMENT. +4~NormalStrenglh +2 = Severe weaknesi> N +3.. Mild weakness +l..Noresponse T AESPIAA TORY ISOl BEHAVIOR: SLEEPS I WNL. Able to lall asleep unaided between periods 01 care and does not display I PHOTO THERAPY signsolsleepdeprivetion. P IVSlTE INTEGUMENTARY: TURGOR I WNl. When skin pinched. relurns to original position wilhoutleaving A lVPUMP peak. EDEMA - -t 1 = Small pit not retained +3 = 112" pit retained -t2=114"pitsomelelained +4=314"pitletwned FONTANEL I WNl. Solt. non.tense to palpitation. May be slightly depressed. COLOR I WNL . Pink nail beds and mucous membranes MUCOUS MEMBRANES I WNL. Moist and pink. SENSAnON I WNL - Able 10 leellight lauch and locate wilh eyes closed. INTEGRITY f WNl- No open or reddened areas. STAGE I . Reddened area that does not resolve within 30 min. 01 pressure reliel. STAGE II . Skin blisler or superficial break in skin with redness 01 surrounding skin. STAGE III. Skin break with deep tissue inYQlvemenl (nolify Enleroslomal Therapist). ' STAGE IV . Deep ulceration with involvement ollissue. muscle and bone. INCISION I WNl. Wound edges well approximated with no ecchymosis. edema. redness. or drainage. IV SrTE I WNL - No redness or swelling 01 site. Goad blood relurn, Skin lemp. same as surrounding skin (see IV Flow Sheet). CARD/VAS: HEARTRATEIWNl-NB:BO. 180. 1 wklo3mos:BO .220.3mOSI02yrs: 70 '150.210 10 yrs: 60 .110.10 yrs10 atIult 50.90. PERIPHERAL PULSES. Pedal and Radial. CAPILLARY REFILL - Return 01 blood within 5 seconds. HOMAS SIGN. <tPain In the callan dorsl"exion. MOTOR I WNl. By 2 mas may turn side 10 back; By 4 mas may grasp objects with both hands: By 6 mos may lurn over completely: By 8 mas may sit well alone: By 9 mos may crawl. hold own'boIUe: 'By 10 mas may pull to standing position: By 11 mas may "cruise" along lurniture: By 12 mas may sland alone. RESPIRATORY: QUAUTY I WHL - Even chest excursion & untabored pattern. lungs clear. Average Rates: NB 10 2~: 40.60.3 mas 10 1 yr: 30.40.210 4 Yls: 23. 30. 610 10 yrS: 20. 21. 10yrs 10 adull; 16 -20. NOTE: For each degree ollemp. elevation. the R.R. increases by4 pel min. DYSPNEA - Labored or difficult breathing - may be painlul, ORTHOPNEA - Comfortable breathing at angle of 45 degrees or greater. CRACKLES. Heard chiefly on Inspiration producecl by fluid Of Iinel bronchi. RHONCHI. Heard on inspiration & expiration; produced by air passing lhrough mucous in lalger airway. WHEEZE. Noisy whistling - may be heard on inspiration but more common on expiralion ABD: WNl . Soft, non diSlended, non lender. BOWEL SOUNDS f WNL - 510 12 gurgles per minule. GII GU -BLADDER: WNL. Voiding 81leest 1x per shill. clear pale 10 amber urine with laint aromallc odor 81 leasl3Occ:fhror2400c1shiit.Children.1-2ccIkg/tlr. PALPABLE. Bladder distended and lell as smoolh firm mass above lha symphysis pubis.. FREQUENCY - Voiding more lhan once q 3 . 6 hours. DYSURIA - Painful or diflicult urination. MAlODOROUS. Unpleasanl or loul odor. QU DISCHARGE - Vaginal. penile or urethral. FUNDUS I WNl FUlldus fitm - NOIJ.Vn1VAa awo ~,,- R E N T DIET NSS DROPS BULB SYRINGE FEEDING BURPING POSITIONING - FEEDING B I P MONITOR HEPARIN LOC FORCE FLUIDS CARE PlAN HAND WASHING T ,E A C H I N G 1lME '0 E PATTING M 0 ROCKING T TLC I REASSURANCE 0 .~ N CQNVERSA TION A PlAY L UPDATE PARENT S PARENT HEllE U PARENT CAllED P SIBLING VISIT P 0 PARENT PARTICIPATION IN CARE R COD~ M MOTHER QP c,RAllnPARENT D'DTHER T , r 'Mill II II/II 1/1I"~II/II~'Alt ~I Wltlll ~_._~ r 00, MYERS, MEGAN H. t' 07/0H/Qq b720 RIC[ fiD O?/21/QO SHIPPENSBCRG. Pi S[~lACK. JEFFREY 0 MO ENERt 0058008 211213 COHM AuTO ~.~ . . 'I .. PEDIATRIC NURSING DOCUMENTATION SHEET NO.... 1M2' DATE: JUt 0 8 1999 ';';" ".', u"~i I.d 'to ~:. -f.tlli' . REFLECTED IN PATIENT 001"'1"\1 E!EVALUATlON AREA - SEE BACK 1111( TIME Il'i~ .~~ 1...'0 EVES OPEN J.. QUAUTY fWNl '. r.A I,.. N eEST VERBAL I MOTOR ~ I/~ '''' ,( r. E SHAllOW U 00. MOVEMENT R ~.. . JJ/ [.,{ DYSPNEA' R (ARtMEGL_~~_~~~ ,"='1 _'l it {.( -- CROWING' 0 - - 1- PU1'llSlZEI R ... + ~ STRIDOROUS' REACTION l -~ + ~ 0 RETRACTING' 8 COMPliANT V... r " GRUNTING' R E NON COMMUNICATIVE' E NASAL CONGESTION H A ANXIOUS' S tAIRWAY CONGESTION' V NON COMPLIANT' P NASAL FLARING' , I 0 SLEEPS I WNl R TRANSMITTED R FUSSY' A DIMINISHED' TEMPERAtuRE f WARM I... r A'J T . 0 CRACKLES' COOl R RHONCHI' HOT -c V WHEEZES' I SQUEAKS' MOISTNESS I DRY ;. IA) COUGH I NON PRODUCTIVE MOlST PRODUCTIVE' DIAPHORETIC' lOOSE tuRGOR IWNl ',.. d~ Ih~ TIGHT EDEMA' CROUPY' I PERIORBITAl EOEMA' TRACHEOSTOMY N FONTANEl/WNl ABD/WNl (.... r.. 1 ":3 T COlOR I WNl '. , r.. kJ DISTENDED' E A G PALE B ARM' U FLUSIIED 0 BGWEl SOUNDS I WNl " ". -1 M ASHEN" HYPERACTIVE E N CYANOTIC' HYPOACTIVE T JAUNDICED' ABSENT' A MUCOUS MEMBRANE I WNl "d r.. 1.,,9 NAUSEA' C/; R 1?5 y DRY VOMITING' SENSATlDIlIWNl I " A - r FEED TUBE ASPIRATE AMT. TINGLING' DIARRHEA' NUMBNESS' CONSTIPATION INTEGRm'/WNl Po., . STOOL IWNl STADE' ..b.nalS!'" CONSISTENCY I sIre I INClSlONIWNt -olJ G FlATUS I NG PLACEMENT CHECK DRSG DRY I INTACT I I IVSlTE/WNt ill i"... - I.... G NG DRAINADE COlOR U DIVERSION NEARmATE IWNl I,.. r.. .? BLADDER IWNl C MURMUR' .. BlADDER PAlPABLE' A IRREGUlAR' FREOUENCY' IR TACHYCARDIA DYSURIA' D I BRADYCARDIA URINE COlORfAPPEAfWfCE V PERtPNERAl PUlSES I WNt '... ~ ~'1 MALODOROUS' A DIMINISHED GU DlSCHARGE'I AMTK:OlORS S ABSENr CAPIllARY REfIll I WNl ,,, ~.? HOMAS SIGN .1. i~;l , .. do} .< . WNt 0 T flOPPY' t ,.., fl ~ ~YERS. MEGIN M. 0 . RIGIO' 01/0"/QQ b7Z0 RICE RO c S1ROOG o?ln/Q() SH1PPEHSBVllG. PA R WEAK SlJLACK, JE rr RfY 0 KO EBERG y SHRill' I 0058008 rnMII IIIITn 2ll2l3 C DIET: FILL III tlIET NOTF ANY CHANGES_ CIRCLE APPROPRIATE DESCRIPTIONS SHIFT 0700.1500 1500.2300. 2300 . 0700 0 0 FEEDINQ TUBES: fl PEG Q,GASTnOSTOMY (LEVINE E.ENTR!FlEX COMP PARTIAL. SELF PARENT E AMOUNT: Q GOOD F.FAiJ~ P POOR BDTTlES'R-REGUlAR P.PlAYTEX NURSER MtPPlE!: " "EaUL^~ P.Pl\EMIE. N-NUCK " SHOWE.R TUB 9 FlUID!: F rorWULA BFlnREAST MILK E Et ECl SOl CL-CLEAR LIOUIDS H ORAL CARE DIET AMOUNT CALORIE CT. TPN PPN y H.S.CARE 'R~"fA~l jflf ~~mjT G fffl' I jl'IIIU.nf -.,_.. - - --.,-_._-~ - ._--_._-~-_. ..- ~UNCH ,__ ---,._-- '~S.~If!_~UI.Q~____ ..__~_~_ E i9~EY CARE .- .."------ SUrrER N ronl;f fllJlUH E IIAlflCAnr ... ..-----. SUPPLEMENT SNACK AM PM NS CORD CARE N ENTERAL FORMULA FOG, ruBE U P G l E SPECIAL DIAPER CARE T RATE I BOne' NIPPLE R TIME I T FLUIDS (SEE CODESI I AMOUNT FED 0 N FED BV INITlS OR P . PAREN'n SUCK S.STRONG W.WEAK E,EAGER S.SLOWlY EN.cENC BURPS; E.EASll Y D.OIFFICUl T A.RETAINED WB.WET BURP E"EMESIS AMOUNT OF TIME TO FEED tIME E DIAPER: ISI SATURATED (\"1 WET 101 DAMP l STOOLS: SIZE ... I M COlOR I _.. __..~9NSISTENCY N - A SHIFT 0700-1500 1500.2300 2300-0100 BODY SECRETION CODES COLOR: G.. Green y.. Vellow T" Tan B K Brown BL = Black WH.. While MA ~ Maroon n ~ Red T VOIDING ,I.. , 11'')/ o '" Orange CG '" CQllee Ground ST", Slraw l V.. Light Yetlow DV.. Dark Yellow lA.. light Amber I DA .. Dark Amba( TE E Tea cn '" Cranberry P '" Pink GR.. Grey BD,= Bloody DR", Dark Red 0 HNV RU .. Ruba SE.. Serosa A.. Amber N CATH ST I FOLEY CONSISTENCY: WE Watery S" Soli M.. Mucousy F.. Formed l", loose P = Pasty MS.. Mushy H.. Hard TH.. Thick FR.. Frothy OAtE lAST BM I STOOL APPEARANCE: C.. Cle8r M.. Mucousy CD.. Cloudy CL = Clots S.. Sediment SD.. Seedy Fl = Flecks T.. Tarry KA ..1(001 Aid BED REST/MAY SE HELD SIZE: SM.. Smear S.. Small M '" Moderale L", Large TU~NO HOURS T TIME A 008 f RM I CHAIR I we R c E T PLAvPEN I INFANT SEAT A I T V STROllER,PlAYRooM M I 8RP / sse NOB ~ /'1... h) E N T AMB T Y UP AD LIB ,SUPERY. 0 OFF FLOOR' SUPERV. R A BASSINET / ISOlETTE I CAOED CRIs:;" YOUTH BED Cltl.\..- ..') N 9 A SIDE RAllS.uP WHEN APPROPRIATE I'l A.O.'\... 4) T DEPART TO MODE INIT RETURN DISPOSITION lNIT f I'lI1.l .1? R E lOW BED POSiTION A T '.1,,1'-" IJl N CALL SELLIN REACH . Y RESTRAINTS ISEE FMSI P 0 R SEIZURE PRECAUTIONS . t INIT SIGNATURE INIT SIGNATURE 9 ('rn r"". ^.\ 'I, (I J/)/ /rt IU.'It..t?;J ~ 1 I M' irk". A.) - 0 N 1 - A - I ,. ~" .y[~S. HEGAN N. T - . u c7rR/~q 1,720 R ICE RC R - O?1?3/~C SHIPPENSBrRG, PA E - $[ .lLlCK, J[FFRfV 0 HO EHERG '"'~ c'e .' .tl"~ -~-- "~I~I" -~ .~. . I " . . . pl=nl4T.fUC NIIR!'lING DOCUMENTATION SHEET NO 0450 181921 PEDIATRIC NURSING DOCUMENTATION SHEET ., . 005,8008 r ,-; \\ N A" T" - 'I" "" '. 2ll2l3 _w ~ ~~ - ~~ I I ,.. PEDIATRIC PATIENT OUTCOME EVALUATION O'TE JI,tL 0 8 1999 , tiME ) ~ ' I -' ~ /)?jlqJ_ OJ_LJUY--t .n I~/r- F1/'lfL1Q.,v.r. AJJ~U./J~ pur,J - - ~ , I / _4.-).dC_lllol' 'S..lr ~.cI,<f"-,_),(,/y' tUn/;ll,.f.- ".rf",u... h,',.luL- <'naNd, 1,,(,n ,/~~ ,,,(~,/ 5,t_Vi ~"'.i.,~,,;)r/li.v_"_h .,h,.[ /"":':: do:; .p~~.5~-J:.l',.1 V(./~~lrlV U ,3/ ~YlRS. ~[GAN N, I '1fce{q~ 0720 RICE RO . ,/';, IQf'l ~IJ I PPfN~Q\~~r.. ". .f '.PH' .': EMERG !! or ,?~1213 ", ~..,. - ~~ -"~ cl ~ ~-~-- . I .1 n /1"111' .fvk(~UJI l{.LlII~. . 1i1J1J1/I1I Likes to. be ca'(~_________. D"....-.'__--=-~_=___Age -q~ Escot1 lit i17,~'n .. \\I.tr~Iit:.Sf<\jusua~~ - VilaISi~'-{1 'J3~-~~Q . _-.-__ R _'_ _.-= Ill' H;:1. SaOl 1, lIead Cire AI.l.ERG ES/SENSITIVITIES: Desed e reaction) .-.----- Medication ~. Food 1:ll\'hlllltlll'nlnl (llIlro,<,I[lI'(') Exposure to Infectious Disease-- C"Ves L No-If yes:l~-----~ hnmllninllinnsCurrenl ~lYcsl-1N(1 I;N/A -- Commenls 1f.rANilS slXiUs:, IWiITiill 5yrs IIS:TOyrSlIMoreiJiaiilo yrs-- '"' Unknown L N/A C1fIlIlENT MEIlICATIONS: (Rx, OTC, IIerbs, Vitamins) Mcd Dose Last Doserrime L 2._ J. 4. u~_~ 5. fi. 7. 8. . 9. 10. 1\IF.IlIC^ TIONS: {j None; I Home r1 To Pharmacy r~ @ Bedside IIAllrrs, /, TOB ceo USE tJ Po Neve noked' I C Jew I I Snuff 1 : Non , "." Smll (Date StOP~d__ J LJ oee.,aSl tal , 'Smok.. (AI er dayt. ___ II Daily (A I__..._J S'I REET DRUl, II Ves II Type(s) ~n:NTAI.STATlJS: -~. .. __..u ..-.-.- Mood/AITeet: l11Ought: Memory: Speech: ~^ppropriate~ Clear/ 'Ylntaet ~ NormallClear , I BlunledlFlat Spontaoeous ~ I Impaired LI Silent rJ Defensive 1 I Vague! :.:J Recent 0 Talkative I I ^rpTehensive Disconnected 1 Distant Past 1'1 Repetitive 'Restless! I' Disoriented U Mumbling Combative ! _~ Slow to answer Language Barrier? DYes [INo ~ Crying If, yes, language spoken: RESP: :1 Irregular --"';.Nomml L. Weak [I Shallow IJDeep ____ PULSE: "" Rcgular ,Fulll Bounding "- COl.OR: ~Nlllmlll '.: Pale _J Wheeze l Labored ;"] Retractions I JRapid ClStridor .1 Fhl<hed "..1 Jaundiced II n""ky II Cyau",;, [J Nailbeds U Circumoral ,10tber SKIN: ::-f Warm .1 Cool IJ Rasb U Ecchymosis .... Dry 'Clammy L! Edema ,., Other LUNG SOUNIJS: RigIit"<J Clear ] Crackles , : N/ A r:: Diminished :J Wheeze l.eft: ""Clear J Crackles U Diminished :J Wheeze nRhonchi U Absent C I Rhonchi ~J Absent PATIENT ASSESSMENT FORM NOlllIll^(61'101 ~ Carlisle Hospital . Ilalc. )=).: l2~~;;;_!i.I~"-.::;/ ~-:c~c!~L!.:::=:.~~~~ " Triage Status: '- ~ode of Arrival: Accompanied By: '" Priority I 'i! ALS [1 BLS 1] Police Il Friend "] Priority II i:! Ambulatory ,,0 Parent c: Family u Priority III L: Wheelchair -V Self U Other r N/ A U Carried 1] Streteber Reason tl~is~(K~~d ~/A Onset of Symptoms Treatment prior to arrival PAIN: ~enies U N/ A Location of Pain Severity o I 2 3 4 5 6 7 8 9 10 1""1 Constant 0 Dull iJ Radiating 1J Intermittent ::J Sharp 0 Burning C Other Triage/Signature: j/Y},c:r:....-I L I~~~) IN/A tREVIOUS SURGERY: rJ.hv..;" ~ Implantable Devices: [] Ves [j No If yes, explain Other Devices: - MEDlCALHISTORYIPSYCHIATRIC HISTORY: fJ Seizures n Liver Disease i ! Pregnant U Hyperlension L1lJ1eeuing Tenueneies LMI' o Cardiac Disease 0 CV A [~ Depression : J Cbest Pain fl Artbritis 11 Anxiety :: MI iJ Asthma [j Transfusion I:j Ulcer [, Emphysema Reaction LJCA nCGPD [] Ves DNo I] Kidney Disease :.1 Home Oxygen I] Other: e ' 1 Diabetes , I Cough 'b.-il-- r:Glaucoma I'Dyspnea C lAllA ~ F AMIL Y H1STOR V: U Diabetes D Cardiac Disease o Hypertension 0 CA IJ Other LEARNING & COM1\tUNICATION: How do you best learn? OWriling,pVisual DRe,;(N Demonstration Whom do we leach? [] PaliltDt '!;i Other~....+ Barriers to teaming? ~1 Yes""O No "Y--..::.!..":' CulturallReligion Needs: 'J Ves'iJ No Denlures: UIJpper ULow_one Broughtlo hospital? DVes DNo Vision: reGlasses rlcon.t. ... one Brought to hospital? DVes UNo Sight: U Blind Ii Dim is Hearing Aid:L,Rt DLI uBo one Brought 10 hospital? UVes DNo Hearing: L Deaf Q Diminished RN SIGN;j:iiRE:F1J!"""..JIc.,(/,,,; LJ Reviewing RN: LJ Copy 10 Phannacy PATIENT IDENTIFICATION DN/A , " 'MlillrJ. r\tA~~EGAN N c7i~~~~ ~~-~ICE RC . ~ :li.l-jl"~A...q~ PPE NS BL: R G. P A S~L'c~qLJ~rREY 0 HO EHERG OOS8008 2ll2l3 "r",~M A"T^ __.1 L ,,.I,~~~- .~, ""- " ..' PSYCIIOSOl'lAL & I'lJNCTIONAL ASSIiSSMI';NT UNIT INTROIJUCTION: ?TV vCall Lighl .;J.iiderails .-1 Bed Controls r;.-visiting Regulations ;.-rBR yl'alient Bill of Rights ""III!lhh's to SlIfl' 'I Yes I 'No ytntcrcom v<Mcal Time ~moking Regulations IlEVF.J.OPMENTAL AGE, (Chec~ nnly thnse thai apply) Infant . , Early Childhood ;;'-Middle Childhood 1.alc Childhood Adolescenl IIAdult Gl'ri<llric Occllrntion_~__~________. i Lives Alone -(ives wilh:uAuord'J.1cLt<-!JlCL J- hud.lu'L~ lln..hlc to mmmge ndult ADL's Ahuse slIspected _. _ .. ._ I :Tl'rlllinal i1hll'SS , ,Inadequate financial resources j Recrnt loss or social isolation 'Cognitive impairment sllspected ) Reli~ioll~ or wllmal helief.o; you want liS to know about? -------~_. . Ilelp will be needed after dischaTge _ __.~_ Help was needed with the following before admission Shopping I j Chores .: Meal Prep [I Laundry I'lIN( .1I0NAJ. STAIl!S: Indep Needs Assist : .1 ~ j [Y Dep I' I. I' II I: L' [ llathcs Feeds Uresses Tmnstcrs Walks Bed Mobility Toileting :_: Bladder Bowel , IMh Ostomy L Specify type (cath/ostomy) lIi"oryof Falls ,rYes I.. No Is this recent change functional status? I ' Yes ~..~ No ASSISTlVE DEVICES: Bed Side Commode . 1 WalkeT '._: Elevated toilet Seat ! . Cane ~ I Right Iland . Crulches L: Left Hand EDUCATIONAL NEEDS: (Check all that apply) Hcqul'sl rut" Auditiumd IlcallhcUlc 11110. (Explain):____.._._.__. .._._.__.--.._... _.__.__._ Pre and Pust.Prucedure Teaching . _ Reproductive ~- Diabetic r: Breast Self Exam HeartiLungs/CHF :-:-. Testicular Self Exam 1 'Activity ~Other~~.____ .. Medications ' (Jlher I.... I- I- .J .1 .1 I I' i' I...! PATIENT ASSESSMENT NOOItIJR (2/991 c;l Carlisle Hospital .. .,... NUTRITION: r-I Food Intolerances: LJDiel Restrictions: L~;--- CISugar llSalt nFat [,ather :. I Chewing/Swallowing Difftcully I iNutritional Sllpp1clllcnt: I :Ensurc/Suslacal j illcrbs 1.1 Other o_.~_._.___.__ :"iAppelite: ~()d ,-'Fair ;.IPoor t!Weight: Change: f iStable C!Gain ~__lbs. x~mos [;Loss lbs. X_IDOS OInvoluntary +/- 10 Ib,.!3 mos CONSULTS NEEoEIJ: IINutrition Services ~ Social Work r,l Rehab Services - Physician's Order Necessary r'IOstomy/Skin Care LlPL Ed , ) lJiabetes Ed. .cOlher . ._._____.._._ ..-i Phanllacisl - Medicalion information :.= infeclion Control e.: Chaplain llOncology Nurse [] Psychiatric Liason I~Other REVIEW OF SYSTEMS Has patient evidenced any of the following now or in the past 30 days: NEUROLOGICAL: . '1lcaJachc I i l)iz1.inc$s Li Sdzurcs U NUlIllmcssfl'ingling :: Gait Problems :] Tinnitus [] Sensitivity to Light :-} Diplopia Comments: /J1ltJf/!.J:...__.. RESPlRATORY/CARo!O VASCULAR: U Cough : : Short of Breath L: Snoring/Sleep Apnea II Tx for 'I'll, j Night Sweats II Edema I i Chest Pain I : Palpitations l. ~ 1'B Screen Sheet needed Comments: /J'l-rI'IL - GASTROINTESTINAL: o Painffendemess C Vomiting L Nausea I] Diarrhea C' Coo'lipation 0 Tarry Stools [J Bleeding [I Last Bowel Movement_,_.._ U Incontinent Comments: //1.r/'l.(_ GENITOURINARY/REPRODUCTIVE: i I PainIRuming/ltching II Discharge ri Bleeding lJ Dribbling CJ Frequeocy J Nocturia 0 Oliguria n Incontinent LJ Last Mcnstrual Period _ U Menopause 11 Breast Change U Prostate pmblems Comments: /I1...oyl-(. j RN Slgnnture: {lJ71.bL\..,)-J('J Date/Time: ____tifo~ i9'1"<;'_~_ PATIENT IDENTIFICATION 'Y[RS, MEC,AN N, . "/ql b720 RICE RD ,\/qo SHIPPENsrVRG, PA 'A'"~ JEFFREY D ~C EHERG JOSrb08 2ll2l3 ... lLTC ~...~...~"=.">>>' -~ ..,~~ .,,~..~. 'I f-' , ' ~ ,- CARLISLE PEDIATRICS - . . ()lI(jyo 'j' /~y), r.l~ t::> JM)'~'C"'J J JO. gl'u'('O",J,..( /Jvy:>; /"" . 'ty-Jwl)- s 7yrs, Date: Interval IIlness/injurylsu rgery Meds Health maintenance Dentist a Vision a Hearing a Concerns 9yrs, Date: i025-Cl ~ Interval History School If,76Y<<.J:-- S"'''P . d<0 ....dL IlInesslinjurylsurgery (lJ fr- f) l~lq1 - sR-- ( U<'l tvtS 51 <.M. _I OlbA h-.....\.)M, Meds ~ Health maintenance Dentist g-- , Vision a Hearing a Concerns f;S;!..'!J,~',--) Name: (Y)\,son HI. Wt Psychosocial Family relationships Peer relationships Activities I interests Mood Appetite I Sleep Television HI. 5~ Psychosocial Family relationships Peer relationships Activities I interests S uatrvJ2.C Mood Appetite I Sleep Surneb~i;, /V!JJrl Television . . m.~-c( :J 'DOB: 2. 2:?J-g 0 BP.. Allergies PE. I Nonnal ,( Abnonnal . Gen, App, a Teeth a Ext, a Head , a Neck a Neuro 0 Eyes a Lungs 0 Skin a Ears a Heart a Back 0 Nose a Abdomen a Throat a G. u. a Comments Treatment Follow-u r;uz--:- B:P.. iOLho Allergies UYfJ- PE. I Normal ,( Abnormal . Gen, App, ~eeth (l.G, U, 0- Head , l31ileck G-Tanner stage .;:;- Eyes Q-ehest !3:'Ext. 13-- Ears l31.ungs ErNeuro cr Nose l3"Heart IT Skin 8" Throat ()..Abdomen 6 Back eY 'c;~.~'~~~]""".""""""""""""'" . I Follow-u Impression tJD .' . Treatment r " ~.~-,~ -""""""~~ J!f ;; . I 0" CARLISLE HOSPITAL _'~~-' ~ .....~"~" .'1 ,- ."' -'". '''-': , J ,I ~ CarJilsle Hospital ~, a'lld Health Services 246 Parker Slreel Carlisle, PA 17013.0310 (717) 249.m2 OUTPA', RECOI 07/09/99 0059091 \ nr-Cl nATl'm~r- PFlE.CERT.NQ, Bll.DDNNA PA PATIENTIOTHEREMPlOVEA MVERS, SHANNON BROOKE 6720 RICE ROAD 5V F W S .05/17/94 000-00-0000 SHIPPENSBURG, PA 17257 N^~r;IAnoR'FSS!PHONEIRr;LATIOWO"O f1ISOC.SEC.NQ GUARANTOR'S EMPlOVER MVERS SR, WENDELL K. HOFFMAN MILLS 6720 RICE ROAD 164-60-3353 SHIPPENSBURll, PA SHIPPENSBURG, PA 17257 NAMEIAOOIlESSIF'HOOEIRELATIONISOC-SEC-NO. EMERGENCY NOTIFY MVERS, DONNA J. (717)532-7970 1.8 WENDELL K. \ 03 ABDOMINAL CONTUSION SIP MVA FMlr1:ltRL ~EDS 3 TD 5 RNS DBS 304C q,U.J E81J..1 AT'T'WDINGFAMlLY SEDLACK, JEFFREV D MD FRONKD, llERALD E 085 CUMB. SOUTHAMPTON TMP DEPARTMENT ISO? N .. o' , , .. , }! I l I ..~. ' ", OBl "YERS. SHANNON ~g.,[ C 7 / 0 R rq q 6 7 2 0 R I cr R 0 A 0 Liarlisle Hospital o 5/ I 7/14 S HIP P [ N S ~ eRG. p and Health Services S [ : LA Ck, J[ tF R EY c "0 E HER G o Q 5 8 0 81 1 b <lf~~ TO HO~ITAL ADKISSI DI TR~NJ' . . CO"" Au T o. ..> c tPf J ( Name of Attending Phys~ (s):. C V1 Date of Mmiseion: / I hime: /f?".<:O (AM)_(PM)_ .._ 1. I. (or . aoting on behalf of) ..:.~, f'r\. Name Of Authorized Representative ( _.A unrcY\ I I. ' llQ:<:S . suffering from a condition requiring hospital care, hereby Name Of Patient .0 consent to rendering of such care, which may include routine diagnostic procedures and such medical treatment as the named attending physician (a) or other of the hospital's medical staff consider to be 'necessary, 2. I understand that the practice of medicine and surgery is not an exact science and that diagnosis and treatment may involve risks of injury, or even death. I acknowledge that no guarantees have been made to me aa to the result of examination or treatment during this hospitalization. 3. I understand that: (A) It is customary, absent emergency or extraordinary circumstances, that no substantial procedures are performed upon a patient unless and until he or she has had an opportunity to discuss them with the physician or other health professional to the patient's satisfaction; (B) Each patient has the right to consent, or to refuse consent, to any proposed procedure or therapeutic course; and (e) No patient will be involved in any research or experimental procedure without his or her full knowledge and consent, 4. I understand that many of the physicians on the staff of this hospital, including the attending physician(sl named above. are not employees or agents of the hospital but, rather, are independent contractors who have been granted the privilege of using its facilities for the care and treatment of their patients. Further, I realize that among those who attend patients at this hospital are medical, nursing, and other health care personnel in training who, unless requested otherwise, may be present during patient care as a part of their education, Still or motion pictures and closed circuit television monitoring of patient care also may be used for educational purposes or for dooumentation of the clinical course unless a patient expressly requests otherwise. 5. I release CARLISLE HOSPITAL from all responsibility for all articles which I am retaining or will have with me during my stay at the hospital. I understand this includes clothing, bridgework, false teeth, eyeglasses, jewelry, money, radio, razor or any other item kept in my possession, I understand I may deposit valuables in a safe provided by the hospital; only if this is done will the hospital assume any responsibility for the safekeeping. 6, I hereby acknowledge that I have received written information on the topics of Patient Rights and Advance Directives. Date of Signature: 1\-<6-q~ {SIGNATURB OF PATIBIlT} {SIGNATURB OF WITNESS} " ~ or is a minor, complete the following:) [is unable to oonsent because] : ,,47.'>> cY/ '/?'7~IGNATURE or WITNESS} AD 0315 (10/91) (If patient is unable to consent Patient [is a minor ____ years of age] I I .f PATIENT'S NAME: ~ Carlisle .HosPital and ~, Health~~,~~o lliRs. SHANNCN'OO n. 07/0~/qq t720 RICE R::AS '-LA) 05/171Q4 S"IPP[NSPlOr,. PI SF:LACV.. )[FFilEY : Me nn~pnPl lb;C2~ '- INSURANCE CO.: CcMM AlTO Statement to Permit the Release of Medical Information and Pavment of Medicare and / or Other Health Insurance Benefits and / or Phvsician, .' l I authorize Carlisle Hospital as the holder of medical information pertaining to me to Telease the necessary and appropriate medical information to the fiscal intermediary of the Social Security AdministTation and/or to my primary or supplemental health insurance company or its designated review agency for payment for services rendered. I authorize the Carlisle Hospital's and/or the physician's billing agent to submit a claim to Mcdicare or other health insurance on my behalf, or to request, on a one time only basis, fTom the Social Security Administration, such information necessary to complete the claim submission process, I am the individual to whom the information/record pertains, or am authorized to consent, on behalf of the individual, to the release of the information/record, I understand that any false statement or representation knowingly and wilfully made or caused to be made fOT use in determining rights to MedicaTe benefits OT payments may be punishable by a fine of not more than $10,000,00 or one year in prison, or both. I request that payment of authorized benefits be made on my behalf. I assign the payment of inpatient OT outpatient hospital benefits to Carlisle Hospital for those services provided by Carlisle Hospital and/or I assign the benefit payable for physician services to the physician. I certify that the information given by me in applying for payment of services under Title XVIII of the Social Security Act OT for any/all other health insurance is correct. SSN Date -1/~ Date Insured Person's Signature (II dlllerent Irom pellenl or II pellen~mlnor~ Dale " B-JDA :~::s~ pallent coold nm sl9n)3 8 WhIt. Copy. H..Rhc.", Billing C.n.ry Copy. Medic.' Records' Anclllery Dep.rtment. AD 1825 (5/99) ~~ -~ - - 'L.cl; 'J ., DiBl: Activity: , I /O:r~.Jd'A~ fA- ..:?~. \...- ( ~. DrBsslng/Personal CarB Instructions: ,/ " , FQllow-up appointment with Physician: ..a.,., ~ ,.-?u2Jt1;2/., t , Other follow.up appolnlmBnts: SUppliBS sent with patient: o Horn. H..fth Nu.... R.dwood Horn. H..lth S.rvlces . 245.5600 o Oth.r ag.ncy SERVICES: 0 Sklll.d nursing 0 Horn. h..fth aid. 0 P.T, DO,T. 0 S.T, MEDICATIONS: (UST BELOW) . NAME DOSAGE INSTRUCTIONS .... . - CIa;.!,;) f81J"I : . I have rBCBIVBd and undBrstand thB Instructions on my medications and on food/drug Interactions far these medications, This Information Is provided for educatioJJ:nal p.urpos~s, Any recamm~ndatlons from my physician will supercede this information, PatlBnt or Responsible Party Signature: "'" () n! VA \..) I) Y.t. t) Date: 1- 9- '? '1 . \.-J' RN SlgnaturB: f~~ 'PhYSiCian Signature: ~ Carlisle Hospital and Health Services 5 Pati.ntld.ntiflcation . " OPt HYERS, SHN~~N eROOKE 07/0~/q~ 67tO RIce ROAO 05/17/Q4 SHIPPENSP~RG PA sreller, JEffR[Y 0 ftO' ENERO 0058081 lbQS2b C0ftft AUTO 246 PARKER ST" P,O. BOX 310 CARUSLE, PA, 17013-0310 DISCHARGE INSTRUCTI0NS IoIR 0410 (03/97) MEDICAL RECORDS 1i: , , . ~' , Date of Surgery/Procedure 'Admission/Preop Diagnosis 'CC/HPI $" IN a S't - *Past Significant Surgery or Illnesses ~' LL-~~ \ ..~ '- "^f L j,.L ROS to> t", '^y 'Allergies *Meds ~ f'J\.(p FH Vvw-.~ :~~..====:::::::~==~:~::!~:================================================================= R Temp *General Condition Wt, BP 'Mental Status *Heart Y\.NL rQ...,,,r po;:;, n Z:. L. e &it, .th->l I'Y1> ~U A ~~~~ ~ p (,- ..L .....tv\ S.. (,"\. IV- I$~ ~ s:.. , ""8 .Lungs Other r......\--.:- \.......'^-. ~ @ flSlr ~ rt'}w,--LA- "a...-t... ("llE\./v9 4;h~ \J\\l;"~ e"...~~ r- Il~~ "'t\W 'Planned Treatment/Procedure POO Date ",/e,I-r.:.. Physician's Signature ~ 'CONDITION AT TIKI!: OF PROCI!:DURI!:/TRIlATIII!NT o llNCHANGI!:D DATI!: INITIALS 'Complete all starred ALL patient,. Complete all other lines pertinent to pat1ents planned procedure or medical condition, . ;h},e...~ I 5""""'''b~ ~ Carlisle Hospital ~, and Health SelVices AMBULATORY CARl!: RI!:CORD Q~~r r C~r MYERS. SHANNON BROOKE " 07/0~/qq 6720 RICE ~OAD O~/17/q4 SHIPPENSbU~G, PA S[ ;:lUCK, JE FFREY 0 "0 E"ERG 0058081 lb952b NO 0106 (1/96) i' ~ ~.~ k~~~~~_ I; , J___ , '5.: , , . POSTOPERATIVE NOTE: 'Postoperative'Diagnosis *procedure *Surgeon/Assistants Complioation *Specimens EBL Drains/Implants Disposition: Date pnys~c~an's ~~gnature .S.C....==....====.B.._.========_._m==============.acc========ccec====c=====...================ PROGRESS NOTES .,.. 1 " ""! '.lYr~s. S~AN~IlN BROOKE 1 07/0~/~1 671.0 RICC ROAD I 0S/17/Q( S"IPP[NSPfRO, PA S' :Lao, J[FFREY 0 HO EMERG aOSSO?l lb9S2b \ it tIt\ Carlisle Hospital ~ and Health Services AMBULATORY CARE RECORD CO H' !TO !. ' NO 0106 (1/96) , . !' , , , . ~ Carlisle,Hospital ~, and Health SeIVices 246 Parker Street CI Cllrllllle, PA 17013.0310 . 717.245-6500 ~G,w..1'Ell\ME BY 01>. 15:30 , "' ., CONVENIENT CARE/EMERGENCY REGISTRATION ACCIOENTDATElnME DO.DONNA PA 07/08/99 NAME/AOOReSS/flHl)NE/AaEfsex/AACE/M.8. ( 71 7) 532-7970 PATleNTfOTHEAEMPLOYEFl BROOKE '5V F W S 05/17/94 000.,00-0000 17257 NAMEIADORESSIPH()I\1EfAELAnON/D,O.Il_ISOC.SEc-NO. ( 71 7 ) 532 7970 GUARAlfTOR'SEMPlOYER MVERS SR, WENDELL K. HOFFMAN MILLS 6720 R ICE ROAD SHIPPENSBURG, PA 17257 NAME I AOORESS I PHOr<!E I RELATION f Soo.SEC-NO. 164-60-3353 SHIPPENSBURG, PA COMMERCIAL AUTO CARRIER 75 WENDELL K. 03 FI'IO CPA MVA TO BE EVAL ABD ABRASIO N BRIEF VISIT 28700 CLASS I VISIT 28710 CLASS II VISIT 28720 CLASS III VISIT 28730 CLASS IV VISIT 28740 CLASS V VISIT 267S0 CONVENIENT CAR~ I 27020 CONVENIENT CAR~ II 27025 MINOR SUTURE EDS01 MEDIUM SUTURE EDS 02 MAJOR SUTURE EDS 03 INTUBATION EDS 04 IV SET UP EDB 08 CARDIAC MONITOR EDS11 PELVIC EXAM EDS14 NITRO SET.UP EDS16 CAST, SCOTCH SHORT ARM 26031 CAST, SCOTCH lONG ARM 26032 CAST, SCOTCH SHORT LEG 28033 CAST, SCOTCH LONG LEG 26034 VERS, DONNA J. (717)532-7970 18 CAST ROLL, PLASTER 26075 DIP MONITOR 26037 PACER PADS 79084 GASTRO/HEMO SLIDE 26D6D KIDDE TOURNIQUET 26048 OCL PER FOOT 79670 F.S.D.5, 80081 TUBE GAUZE PER FOOT 28074 ED STAT ESTAT PULSE OX POXED EXTENDED CHARGE I 26760 EXTENDED CHARGE II 26770 ALVO, THOMAS C. D.O. OFFMAN,J LVNN ISOLATION ALERT N ALL ADDii1~NI\(;CHAIli:l~fi'.{f. ., ,'-------- --------~, I I , I , I , , , , , , I , , I ,------------------., ,~-------- --------~, , I I , , , , , , , , , , , , I ,-------------------, ,'------------------~, , I , , , I , , I , I , , , , I ,------------------., ,'-------- ---------, , I , , I I , I , , , , , , , I ,-------------------~ {~-------------- --:~----------'\ (~-------- ---------) I II I I II I I II I I I' I I II I I II I \ I \ I ,------------------------------~ ,-------------------; ,'------------- --------\ ,'-------- ---------, I II I 'I II: " , " , " , \ I \ I ,------------------------------~ ,-------------------~ ",".,,, ~--------- ---------, , , , , , , , , I , , , , , , , , , ,-------------------~ ~--------- ---------, , , , , , , , , , , : ' I ' \,--------------------) ~-------------------, , , , , I , , , , , I I I I , , ,-------------------~ ,~--------- ---------, , ' , ' , ' , ' , I , : \ ) ,-------------------~ ~-------------------, , , , , , , , , , , I , , , I , , , ,-------------------- ~--------- ---------, , , , , , , I I , , , , : I , ) ,-------------------- ER.o5OIl (REV. 81981 , , ./ J 0'- NAME: MYERS, SHANNON MRN: 769526 DOS: 07/08/1999 CHIEF GOMPLAINT: MOTOR VEHICLE ACCIDENT, HPI: This is a 5-year-old female who was in a motor vehicle accident today. She apparently had a lap belt on in the back seat. She presents to the emergency room, She denies complaints right now and she denies a headache or visual changes, She denies abdominal pain or nausea or vomiting, or any weakness in her arms, She was transferred by ambulance on a back board w~th ICDs and a neck brace in place, PMH: Apparently negative. She denies any complaints at this time. None. ROS: MEDS: ALLERGIES: NO KNOWN ALLERGIES. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure is 110/70, pulse 120, respirations 20, pulse oximetry on room air is 97%, This is a 5-year-old female who is lying on the exam~nation table with a neck brace on and on a back board, who appears to be in no acute distress, HEENT: Head: Normocephalic, atraumatic. Eyes: Pupils are equal, round, reactive to light and accommodation. Extraocular movements are intact. Throat is moist and pink without erythema. Ears are clear without hemotympanum. NECK: Supple and nontender. She has full range of motion. LUNGS: Clear to auscultation in all fields without wheezing or crackles. HEART: Regular rate and rhythm without obvious murmurs or rubs. ABDOMEN: Soft and flat. There is a superficial linear ecchymosis noted on the lower left side of her abdomen, apparently from the seat belt. She is nontender there. EXTREMITIES: Without abrasions or tenderness, and without cyanosis, NEUROLOGIC: Neurovascular status shows that manual muscle testing is 5/5 in both the upper and lower extremities. Sensation appears to be intact to light touch. Diagnostics: Urine dip stick did not show any evidence of blood. ED COURSE: The patient was evaluated by Dr. Fronko, as well as Dr. Sedlack, trauma surgeon. She will be admitted to the observation unit tonight. Dr. Sedlack will be the admitting physician. The patient appears to be in no distress and does not have any injuries with this motor vehicle accident. She was talkative and sitting on the examination table throughout her stay here in the emergency room. LABS/XRAY: PrJ~ ~ She will be. discharged to Dr. Sedlack's care. ROBERT WEISER, P.A.-C D 2253 EST T 1358 EST/738/58303 07/0B/i999 07/10/1999 CARLISLE HOSPITAL EMERGENCY DEPARTMENT RECORD .""=~.~'~ -. -- ~ ~il5 , , COt..cNIENT CARE/EMERGENCY REGISTRATION ALLERG'''u~ ' MEDICINES: ~4.{Jy () FOR NURSING ASSESSMENT SEE NURSING DOCUMENTATION SHEET {'C(l'AC (// t. nos: PMH: ,4-. SH' P!; PH'<SlCALE'M-tt- e d<? c7r,-Y1( ",.~ C s: NT' 1)4- /Vnnl., /~f n<_""" c&,r..~/ C'~ (l ~1P~ ~ ~ ~. .I ~ X,IlA Y; ()6S REASON FOR VISIT ,.... o 0 TRANS OTHER CONOJTION ON DISCHARGE o SAME DIMPROVEO ADMISSION DIAGNOSIS: D. . , "j3D""" NO" ~'-''''' DIAGNOSIS: S) lY\ \/1'1 " 005BOBl MVERS SHANNON BROOKE "]I~P /jb@b MVA TO BE EVAL ABO ABRASIO N 'AT1!NT NUM8IIR PAT1!NT NAMe 7/0B/99 A --,'- - " "~. -iL - " . , , - TREATMENT IN PROGRESS ON ARRIVAL: DRUGS: D CPR Down Time min. D Monitor - Rhythm Rate 0 Airway - 0 Oral 0 NI'I!'lal - Size o Oxygen. o Mask, o NC . l/Min , 0 Airway, Endotracheal - Size o Spinal Immobilization, r 0 Airway, NasetrBcheal - Size o Mast V~al SIgns: Ih<-qt{ 0 (/ C , 0 IV - SolutiDn SlIe Size o Pressure Dressing o Other I POX: Saline lock Site Size " Pupil Sizes: Visual Activity: Extremities: ON/A , , Pupil.: ON/A ,. 4 00 o Laceration i _.._------~-~ Righi. Size Reaction left. SIze Reaction ~ INITIAL NURSING REVIEW: REASON FOR VISIT: D TRAUMA PAST MEDICAL HISTORY. 2. . 5. 6. OS DN/A o With Glasses o Wllhout Glasses o Deformity o Abrasion DMAE 3. D MEDICAL TIME: D PSYCHOSOCIAl/EMOTIONAL LMP: Weight POX: OBJECTIVE: Physical Information (What you afe able to see). C SAFETY: Are you or have you ever been afraid for your safety in your home? 0 Yes DNo MOUNT eKG STRIP HERE' MOO. lroIIi. 1'0.001'0 ~ PlAN OF CARE: o Maintain Patient Airway o Monitor Cardiovascular Status o IV 0 BP Monitor o EKG 0 Cardiac Monitor o Safety Measures o Restraints 0 Suicide Precautions o Seizure Precautions o Side Ralls Up o Comfort Measures o Pain Control o Position for Comfort ..,.EtPrepare for Exam ~xplain Procedures .. ff:Emotional Support ~tlentTeaching ffDischarge Instructions D Other o Other ~ Carlisle Hospital ~, and Health Services Copyright 1992 NURSING DOCUMENTATION EMERGENCYDEPA~ENT PATIENT PROBLEM: Nursing Diagnosis ~lrWay Clearance, Ineffective 1L!.:. ~nxiety Breathing Patterns, Ineffective - Cardiac Output. Decreased comfort, Alterations in: communication Impaired _ Coping, Ineffective Fluid Volume. Alterations in: = Gas Exchange. Impaired _ Hyperthermia (Fever) Infection. Potential = Injury, Potenllal Knowledge, Deficit _ Mobility, Impaired _ Noncompliance Self Care Deficit = Skin Integrity, Impaired _ Thought Process. All. In: Tissue Perfusion, Alt. in: -Other NURSE'S SIGNATURE ~~s Clothing "' Jewelry r ,~": ~YERS, S~ANNON eROOkE Olh~r: 07/0Q/11 6720 RICE ROAO OS/I7IH S~IPPENS8VRG. PA st :LACK. J[ FFRfY 0 HO [HERG NURSE'S ER20'(}9'S8081 lb952b SIG: . . - - - ~- ~, ~~ ~... . . . . :' ~.,: IV FLUIDS , . TYPE I AMT - SITE SIZE TIME RATE # SIGNATURE ATUMPTS - MEDICATIONS Mad. 003. Route TIm. Signature o IV D/C'd with catheter intact TREATMENlT I PROCEDURE TIMES IV TOTAL = o RESP. TREATMENT liME TIME TIME TIME o AIRWAY. TYPE TIME _ SIZE o NASOGASTRIC lUBE SIZE _ TlME_ SITE AMT IN AMT OUT o FOLEY SIZE TIME COLOR o O,@ VIA PO lJTln. Other TOTAL TOTAL TOTAL - NOTIFICATION OF, o Hospital Social Worker o Family o Police o Crisis Intervention o Nursing Home o Family Doctor o Coroner o Consultant o Other TOTAL INTAKE: OUTPUT: = VITAL SIGNS. 0 ON Bp MONITOR TIMES: EKG CXR LABS DRAWN j/J! PuA ABG ~ PULSE ox:il % Tim. BP P R NOTES: D/l. C d' .. 10/ kl / ,/ / -/ A # m~ I A , ./ "I-- fJlJ wd.L/LIUq /. Jd~./ ../ /- ";,,... A j //,.,. /Jj,,~ .h Il.d.u 0" ~_- _ / /,..::r7'h /7" ./ /. /' ~. 1 _ t' /~~ 2J-.. ru,lrtcf. /~ hJ ~-r/7?I/U' /U/. ~A /../ }I./O f!l..-: /I1x ;{O-k) Iv a/~cL ~r-1 "/,, /~{/,A./ . - ,/1'/:..T:A/.4 I .? ~?V 1/1 ;[(J,pJ?1 )//1,/'4::;0' /A"'-1.(/4 .hJ /, --V-, J1A' VL L //"Id/ _ noAJ wh_ v(dI'/1' _../ ( ./... t1 ./, J t J4:/S .~ IN) :<0 .r, ('...~ /,'tJ.. -m -;/T1u~hu >7# I /~"... -..:::;. I(/~ ff r hi .i1.....!/ u /~.J'/') V J/. "7: 47';. '1-... _ /l A 7)- , "7J /' .A-.r> ./1 /;, .r7:. ~ .rl' A / /I ~ ,#' J ./ ,,/ I I" ~f/ / / / / -/ ..., 1~ J~ ~ /(/1 AA/ A ;yn/ uf --rv . / I lr:J 3 s -' = EVALUATION AND DISCHARGE NOT~S, '7 / / / y/~, I . ). f<'t( II '-'--- o PATIENT/FAMIL Y VERBAUZED UNDERSTANDING OF DISCHARGE INSTRUCTIONS: DlSPOSmON: DISCHARGE: 0 WRmEN INSTRUCTIONS GIVEN o ArtmitlAct to: n UttAr 0 Sel' 0 Computer o Carried 0 Family 0 Prescription o Ambulatory 0 Friend o Ambulatory with Assistance 0 Police o Wheelchair 0 Valuables o Ambulance o Monitored Utter o For Observation to: o Transferred to: .' o Other o Verbal Instructions by MD o Morgue PATIENT'S NAME $lther ~ ' !1n/1on ~~R~URE Cumberland Valley Hose Co. Ambulance Pennsylvania EMS/On-S~ene Report l~A'.:>AtNM","~~}Ii[".IWj;~~tl,~;.;tJ"'"~'Jm~~,",~I..uifft,',Affl'.I....Ff!l:I.~I,.i~,a~IIAtV ~Q.r,~il 9900884 71 8/99 Transported 253 2100302 9685 ''( Ii T':>""-lc. ot3v '7-~ ShBnnon Myers F 05 Shbg PA 17257 ~ee.lto.u~":r'~t:.'Vll:4~~;;'\~l~~~;'~i\\Wt';.ii(~..":~I/il;:i.f.!dftl&fitl"l/Mel) C6d.1!,:j:, I '",""" ~.",.-... ...,:~".... "illt Y . .. .._-!jl of j~" .' _.....,..I'.....'J..,.'.,~_..,......,. ~\,~..... RI's 233 & 174 Newville, PA Penn Township 2\922 I'''''A~. ., ........',.,;.' A-B-,.t ~1lA'.i1..." -.~Iflt 3~. ,.,..." AltIl'I....!1.,... '.'. '....1 ' . r.;l"'1. tl" 'l!T.,,,, !U8" "t.r f ~","".. - t.~">>.,." "h. UII ....,..".,-,.., ~..~.._ ~...., . ~'h"""'" _.~,.~_., . ~., '.\,.,.._.~.~...",...,... .,...~..,~..... -",,,~.(iI5..~1##.i' Weaver, Cheryl Dangler, Kim EMf.P, 039627 EMT, 04767\ 1l,,~.,~~~_jIE;l~gJlJJJ't$:lf.,",d;t~'A~".~\i,I~l(.i!~~Q.6f.(~ 14:42 14:42 14:54 15:09 15:21 16:20 16:42 1]~e,ft,ltt!l1.A.,_*;'nm.tViiTlIlYl1~ftl.._'CII,"ltl!lltU~ ~filii'&lfI,'~'f,'ir,-@diia'~I'!!_:;Pil_t>.!] ~~.iilo~l!lI', 120 20 110/40 I 4 - Sponl. 5 -Orienl 6 -Obeys Carlisle Hospital None Required. 00358 Vehicular ~:t)'i:s.\lt"):;:i. .'.'.'. J/(ili t.... Speed 40+ mph, Inlruslon 12+", Selr"xlrlcaled, Walking aner Accldenl, 'None QIIQllll14 . - ., -" "' Pennsylvania EMS Report !\eh'lceNlI{I1c ServlteNo. -] indd,n. No. 10'" Cumberland VBlley 1I0se Ambulance 2100302 9900884 07-08-1999 Incident I,OCRtion MCO Receivln@:Facility Rt's 2JJ & 174 Newville, I'A 21922 Carlisle Hospital r.llentN"rnc Phone No. Ag' Oate ofOirth Social See. No. Sox p Shannon Myer~ (717) 532-7970 05 051\7/94 - - F a t Street Address Crew Times 1 6720 Rice Rd AHI Weaver, Cheryl P 039627 Dispatch 14:42 e City Stare Zip Al/2 Dangler, Kim E 047671 e....." 14:42 n t Shbg PA 17257- AH3 Arrive Scene 14,54 1 AI.S Unit AH4 Demrt Scene 15,09 n Mileage Arrive Fac. 15,21 f Oul On-!kene Oest. In Available 16,20 0 42573 42585 42597 42617 In Quarters 16:42 Chief Complaint: abdominBI CUTTent Meds, : none Allergies (meds), NKOA PMHx: IDMI DCII' Deoro UADP Uo;.b. 0 C.n",,1:8I None Kno"" I abdominal ecchymosis sip MVC Narrative: . DLS WBS dispatched class I to the above location as lhe 4th due DLS unit on an MVC wi multiple victims, CC&I/PI: Upon arrival, we found pre-hospital personnel talking with a 5 yr. old female, Bwake & alert, crying, standing IIpright in A field At the Accident scene. The only information available Ifom the personllel was that she had blood on her shirt &. III her hair butlhey were unable to find on open wound. The potientlold us she wos the middle-rear-sent passenger wearing 0 lop belt only, but not in 0 child seat. The vehicle was not Assessed At the time ofthe incident because ont's distance If 011I the patient. Fire department personllellater Bdvised me that the vehicle WBS a 99 Suburban wi 12+" fronl end intrusion & 6+" In/ruslon on Ihe rear possenger door ofthe driver's side. PMII: As above. MEDS: As above, ALLERGIES: As above. " PE: ncuro: AAO x 4 skin: PWD cranium: straumatic, - blood or CSF: ears, nose or mouth, pupils: PERRL, neck: BtraumBUc, trachea midline, - ",VU, chest: BtraumBtic, symmetrical Bppearance wi inspiTation, lungs: clear all fields, Bbdomen: 4" X 114" ecchymotic line running lateral from her navelloward her Rank (7 lfomseatbeIt7), abdomen otherwise son... non.tender, posterior IT~nk: no pain on palpBtiOll, not'visually assessed due to patienl packaging, pelvis: alTaumatic, extremities: healing superficiAl AbrA.ion over It. knee, extremities otherwise atraumBUe, + distal pulses & cap. refill < 2 sees, TX: Flow chari. @ 1996, Mod ModI.. rnc, rage I Provider Name Pennsylvania EMS Report Service Na,me Servl<:eHo. IllICident No. IDale Cumberland Valley I lose Ambulance ZJOO302 9900884 07-08-1999 Pa\lenl Name Dale ofnirth Social Security No. Medical Command Physician Shannon Myers 05/17/94 - - Time P R ' DIP Rhvthm TreBtment Provider Reso/Commenl 14:54 all on scene 14:55 . . Al access 10 patienl 14,56 AI report from on4scene peTsonnel. personnel had c-sp, stblztn, 14:51 orimary tTHuma assessment AI see narrative 14:59 patient packaging Al.A2, c-collar, ped spine other board w/ c-spine stabilizer 15:04 transferred to stretcher AI,A2, by ped board other 15:01 Iransrerred to ambulance AI,A2, by stretcheT other 15:09 120 20 110/40 conlinued w/2ndary AI enroute assessment 15,14 112 20 continued to monitor AI reporl to CaT lisle Hospilal 15:20 104/40 continued 10 monilor AI see narrative 15:21 an comnleled Iransnorl 15:23 CBre IransreTred 10 ER slarr an report bv A I D1SP: The patienl's grandmother Brrived on scene just prior to our depBrture, W. asked h.r to rid. in Ih. patient cnmpsrlmenlln help calm the pBtienl. We Iransported Ih. palienl class 2 10 Carlisi. Hospital. She Temained stabl. wlo Incident during the tTansport, Notification was mad. to the hospital by A I. Car. was transferred 10 Ih. ER slalfupon our arrival wilh 8 report by AI. Cheryl E. Weaver, EMT-P ,. l\:) 1996.. Mod Modi" Inc. i I Page 2 Provider Nam. , , ,. ,i h ,'" . - ",~ . - '.~. Cumberland Valley Hose Co. Ambulance Patient Services Charge Form Trip Nu,!,ber 9900884 Patient Name Shannon Myers Is Member: NO Date 7/8/99 Pallent Information Ouarontor's Address: 6720 Rice Rd Shhg, PA 17257 Phone #: 7175327970 Gurantor's Date or Birth: 5117194 Guarantor's Sex: F Social Security No: Transported From: Rl's 233 & 174 Newville, PA Crew 1 Weaver, Cheryl Transported To: CeTlisle "ospital CreW 2 DangleT, Kim Service Type/Charges PTehospital Call - A0360 LOBded Mileage @ A0380 Welt Time minutes No - Unconsciousness or Shock present? No - Bed confined before tronspoTI? No - Stretcher required? No - Visible Hemorrhage present? No - Bed confined aner transport? Chief Complaint Bhdominal ecchymosis sIp Mvc ICD-9 Code(s) Insurance Infonnatlon IComDanv. OrouD H. ID H. other inrormation) .. , stock Charges stOG\{ Ad~ On Charges (H'rilt In any addi,'onallteml wed) Qty Code Oeser/pilon 1 10 C-Collar ped board 2 cravats dappler dappler lubrieBnt .' I ~ Carlisle 1I0spllal ~, and Health Services 246 P.r.., 5b... . Carll.I., rA J70J'.03JD . 7J1.24S.5S00 m:o D"TE/TIME 81' Cl" 15:30 ") CONVENIENT CARE/EMERGENCY REGISTRATION Oo.DDNNR PR N"'AE AOORf:SS 9>HONEf"OEISO'''''CE/MS (717)532-7970 DROOkE5V F M S 05/17/9~ 000-00-0000 "U'! lJJIlEU P~E Rt\),110N soc SEe.1oft) P"l1ENT 01HEA!:MPlOYEA PRE CERT NO O:J'''I....,01'lS EM"'tOvE" 164-60-3353 HOFFMAN MILLS E"'EqGEt.rC~ NOll~' SHIPPEHSBURG, PA 17257 MVERS, DONNA J. (717)532-7970 . 18 COMMERCIAL AUTO CARRIER 75 17257 ....."E ":lOAfS! !>HONE 'MlAlION 'D 0 II - SOC,SEC.NQ ( 7 1 7 ) 5 3 2 - 7 ':1 7 0 MVERS SR, MENDELL K. 6720 RICE ROAD MENDELL K. 03 HVR TO BE EVRL ABO RBRRSIO N FHO CPA BRIEF VISIT 28TDD CLASS I VISIT 28110 CLASS" V1SIT 28120 CLASS III VISIT 28130 CLASS IV VISIT 28740 CLASS V VISIT 2B7S0 CONVENIENT CARE I 27020 CONVENIENT CARE" 27025 MINOR SUTURE EDS01 MEDIUM SUTURE EDS 02 MAJOR SUTURE eDS 03 INTUBATION eDS 04 IV SET UP eDS 08 CARDIAC MONITOR EDS 11 PELVIC EXAM EDSf4 NITRO SET.UP EDS18 CAST, SCOTCH SHORT ARM 2SD31 CAST, SCOTCH lONG ARM 28032 CAST, SCOTCH SHORT lEG 28033 CAST, SCOTCH lONG lEG 28034 ~~_.- .--.- "'-~, - .- CAST ROLL, PLASTER 26075 B/P MONITOR 28031 PACER PADS 790114 GASTROIHEMO Slice 26DBO KIDDE TOURNIOUET 28048 OCL PER FOOT 79870 F.S.B.5. 80081 TUBE GAUZE PER FOOT 26074 ED STAT ESTAT PULSE OX POXED EXTENDED CHARGE I 267BD EXTENDED CHARGE" 26770 EO AnENOING RLVD, THOMAS C. D.O. . IDFFHRN, J L VNN ISOLATION ALERT N ALL ADDITIONAL CHARGES ,..-------------------, ,...--------... ----...----.. I, ' J J ' 'I I " I " ' 'J I \ : \ I ,-------------------, ,-------------------;, ,...------------------..., ,...--------- ---------, I 't ' I II I , II II ' I II ' I 11 I I II I \ : \ " ,-------------------, ,-------------------- r'-------------------\ {--------------------'\ I II t I t I I I II I I " I I II I I II I , , \ " ,-------------------, ,-------------------- -------------------- ...-------------------, , .., , , I 'I I I II I I II I I II I I " I I I, , 1 'I , \ , \ , ,-------------------, ,-------------------- r'------------ - --------------'~ r'------------------'\ r--------------------'\ I ~, ( : f f I I ; I II I I II J I I ,,----~-------------------------,' ',-------------------, ~--------------------, ,--------------- --------------.., ,--------- --------', ,---------- ---------', I ", t I I II t I I I II II I I If r t I I I' II 1 I II II I , I \ 1 \ " \,------------------------~-----,' ,-------------------, ,-------------------- .- - . .-..- ---- ._,-- -.---" .,. - ER.o5Oll (REV. lI!OO) .. . ,.,.. ...... ._H " . , ,-. AuthorlziUon I REOUEST THAT "AYMENT OF AUTHORIZED MEDICARE BENEFITS OF OTHER BENEFITS i3E MADE ON MY IlEHALr TO TilE CUMBERLAND VALLEY HOSE CO.'2 AMBULANC~ SERVICE FOR ANY AMBULANCE SERVICE PROVlDEO TO ME 13Y THE CUMBERlAND VALLEY HOSE CO,t2. I AUTHORIZED AtlY HOLDER OF MEDICAL INFORMATION OR DOCUMENTATION ABOl1T ME TO RElEAsE TO THE ~EALTH CARE FINANCING ADMINISTRATION AND ITS CARRIES AND AGENTS, AS WELL AS TO THE CUMBERlA/ID VALLEY HOSE CO. ;2, ANY. INFORMATioN OR DOCUMENTATION NEEDED TO DETEIWIIIE THESE BENEFITS PAYABLE FOR RELATED SERVICES OR ANY SER~ICES PROVIDED TO ME BY THE CUMBERlAND VAllEY HOSE CO..2 OR SERVICES CONTRACTED WITH THE CUMBERLAND VALLEY HOSE CO.'2 NoW OR IN THE FUTURE, I ALSO HAVE BEEN NOTIFIED THAT MEOICARE AND OTHER INSURANCE COMPANIES WILL ONLY PAY FOR AMBULANCE SERVICES WHICH ARE DETERMINED TO BE "'REASONABLE AND NECESSARY" UNDER SECTION 1862('111) OF THE MEDICARE LAW. IF MEDICARE ANo OTHER INSURANcE CoMPAHIES DETERMINE THAT A PARTICULAR .sERVICE, AlTHOUGH IT WOULD OtHERWISE ~E COVERED, IS NOT REASONABLE AADNECESSARY UNDER THE PROGRAM STANDARDS, MEDIcARE AND OTHER INSURANCE COMPANIES WIll:' liKELY DENY:P,a;i'MENT FOR THAT SERVICE. CDNSEOUENTlY. THE CUMBI:RlJJID VALLEY HOSE CO. '2 IS PROVIDING ME WITH THIS NOTICE 11/ THE I:VENT THAT MEDlcME D.R ANOTHER tNSU~~E CDMPAIIY, DENIES PAYMENT BECAUSE THE SERVICES WERE bECLARED," flOT ~EASONABlE AND NECESSARY". I AGREE TO BE PERSONALLY AND FULLY RESPONSIBLE fOR PAYMENT. I ALSo AGREE THAT IF MY INSUFWlcE DOES tlOT PAY, THAT I AN. kESPONSIBlE FOR THE PAYMENT WITHIN 90 DAYS, OTHERWISE, I WILL BE I\ESPOSIBLE FOR COLLECTION COSTS AT A RATE OF 20% OF THE TOTAL BilL IF REFERRED TO OUTSIDE COLLECTION ~GENCY. I ~..wz.dt&/ 711. )7;'{.f...u.~ (~()~ (S1G ATURE OF PATIENT, BE,nFICIARY OR OTHER AUTHORIZED PERSONI , 1- ~- qq (DATE) "ATlENT'S tlAME~trt\J iY\ ~,r::-. DATE OF SERVlCEI-~~qq , TRIP t-lUIlBER ()clOD "<t . "'=-~ = -. ~ ~.= -- " MIIUII.OIl1 ll'lv/C' , tiimlJill:iiHI lilliei' lliH6 '-U'HI'A", 'Hi. , tleld I;M!l h'fltll' ~ZS7 3 \111 be'"' gC:;-IJUlllldlloll 0f-,r] "I ~ till/lilt "'tldllll , \:J,I, '"tld,"tl tic .11011 /'t ".11I' tt!wtUIIl" Alii _ 1JoU _,_,_ llu !Juc. 9tc, liD, !lI"ld . , . --- Mtlreu ellr "/tOlf.' I chl.lcutHIII.IIII /1/.10'1 III /'1"'"111I11'''1 II" t .",IIt ""ytlel'" t. ".., M,dle'llllflot11 11011I; MI ellr- tvA tOl'tI tJl^llllll:!l litH eA ot II!; t1 M.dldlhm'l hoh!: ^"flll'''! Jloht: I't tte'lv.d 1.11 (fJ~ tlm' b.ll tlltlll . It It.." 111'., tlUllrlf,,1 11:1 . . . Clllnlrltnlt ~._~":'::~:..=_:::=':'~=;'::~~=:~~:~.';~~-=~=~:~tt:::_~~'::-..:':~~";, ;(, /'''') .J...'...."".., ....... . . ,,1) '..4' (,.), ~,..t.. ...., . \I , -:t-,.~,; '.;;; I ( 'V'.. .... ...-.....__. .\. r. /"'.. I'~" \, I 'I, ." "" ... '."....~:.",. ~' ~...... 1.1 ""4--~ .-. ._...:~...,,-\._._.... . ,~,_...:...-:,,'"-,,-----_......_-.;;.I;_.. ~;:..._-_.......--.1... ..-..-.-. 1.0 f): ~ (' '~~, ' ( t..,,,,::;:, 'r;,.. .'.,.. I., , .- - ..... 1 ',1 . ,,' 11,~:;~ ....._'b ...f" J; Io-k..---~.~.__. .,...._~. ......-...... -"'--'-::'.'";'~ '''__'''''''''!' .-..- (:.~. ~;.... d. "1..7''''''''''' -.. ~~ ,~tJ;;L "..~ 4~ org sf. 'blll ~ 110'1' ~I Avl" ~OOIrI " \S}llct'!.5 "35 ~1 ~9 \$1\ 1 !5!:::. <;( 9(p~s- - ~,'J>--' -1. ,.-, " ,-. -~'.! . COt' HYERS, S~INNON BR~n' o 7 lOR I ~ 1 b 71 0 RICE R 0 A 0 Carlisle Hospital 05/11/~4' s~ I PPENSHRG, Pi and Health Services SEJlACK, HUREY ~ MO [' OOS8081 lb~S~ Em . L. ,'Wa~11 'Y\: UJ.,Q,ding PhY,5C.i Date of Admission: '-\ Time: (AM)_(PM)_ or Authorized Representative , suffering from a condition requiring hospital care, hereby acting on behalf of) Nllmt Of Patient consent to rendering of au care, which may include routine diagnostic procedures and such medical treatment as the named attending physician(s) or other of the hospital's medical staff consider to be necessary, 2. I understand that the practice of medicine and surgery is not an exact science and that diagnosis and treatment may involve risks of injury, or even death. I acknowledge that no guarantees have been made to me as to the result of examination or treatment during this hospitaliz"tion. 3, l understand that: (A) It is customary, absent emergency or extraordinary circumstances, that no substantial procedures are performed upon a patient unless and until he or she has had an opportunity to discuss them with the physician or other health professional to the patient's satisfaction; (B) Each patient has the right to consent, or to refuse consent, to any proposed procedure or therapeutic course; and (e) No patient will be involved in any research or experimental procedure without his or her full knowledge and consent. 4. I understand that many of the physicians on the staff of this hospital, including the attending physician(s) named above, are not employees or agents of the hospital but, rather, are independent contractors who have been granted the privilege of using its facilities for the care and treatment of their patients, Further, I realize that among those who attend patients at this hospital are medical, nursing, and other health care personnel in training who, unless requested otherwise, may be present during patient care as a part of their educ"tion. Still or motion pictures and closed circuit television monitoring of patient care also may be used for educational purposes or for documentation of the clinical course unless a patient expressly requests otherwise. 5, 1 release CARLISLB HOSPITAL from all responsibility for all articles which I am retaining or will have with me during my stay at the hospital. I understand this includes clothing, bridgework, false teeth, eyeglasses, jewelry, money, radio, razor or any other item kept in my possession, I understand I may deposit valuables in a safe provided by the hospital; only if this is done will the hospital assume any responsibility for the safekeeping, 6, 1 hereby acknowledge that I have received written information on the topics of Patient Rights and Advance Directives, Date of Signature:~~<t;-c:r~ {SIGNATURE OF PATIEm} " {SIGNATURB OF WITNESS} able to years or is a minor, com [is unable to con SS 0315 (10/91) - ~~ "".=-~ LB03 24 (~I9B) j .~ Carlisle Hosp:lal ~, and Health Services Depl 01 Pslhology 248 Parl<a' el., Carll,'s, PA 11013.0310 MYERS, BRANNON BROOKE DOB:05/17/1994 AGE 5 YRS F (000)769526 000-00-0000 (7171 532-7970 6720 RICE ROAD DR SEDLACK, JEFFREY D. (attending phy: SEDLACK, JEFFREY D, ) ,,"_..' -'.r' <,,;::;:/.., ,; 'i. >.<,-;:{ ~Y'J,;!i~+i:tlh;*i';F:':~'\f<:'"({'< ClinicCJ,1 LaborCJ,tor~- 8ep' art' ,,,'. .'. ',"'._~,O,,,,, _, ,,"'" ,;, ,'. ~,',h'","",- .. cl.,_ ,..,', ',' d'-""'"'''''', . 'A/llijilfu J.J'~k., Admin. 6ltllct6' 6tii>kfIYu'6hl!~ij, M,6:,Paloologlol . 'i"!''V S.()rl'I.M,O,~_~~1l101ogI'1 PRINTED 09JOL99 TIME 2233 ADMITTED 08JUL99 OBSERVATION ROOM REPORT PAGE 1 ;',),".'1'. ';1: ,,-, ,. " ',' {:"', ~-;'.s::,; r >,"1 DAY OF STAY COLL, DATE & TIME PROCEDURE BLOOD CELL COUNT HGB HCT FRI 002 09JUL99 0630 .N., 12.4 37.1 ~,~;~:E~~~~~~~;';t~~~,t,:r~1~t~,; ;',: . '~i;';;. '.'5;"~~~'~'~'*lcft~r~~~~;~r6J~(~r::ji;I~~\'; ,".' - .1',' tiC".:' ~':'_\.,;.:V? ". "_: ",i:, ' '-'/ A ';-- ,j "I -~':>{~:::$!,,:::'\'7{J;:!,.3 .:', <;~,1'; '; ~: , . . . ~",~' " ,,,,,")\~,'.)>-;r""'0',"i'--T' - I " n, HEMATOLOGY ..~~tf'~;"{< :;;~~i,i~~~~~i~~~~_i~r44tr~~:~ :::~~~:ilR60l(B.. "~~~;f..~"t\\;?\~~J!.\j~~_fh~{j:, Ene! Qf Report , _I "" I'~"" IIHI'$. S~lllI!O" ~ItOOC' ("I)~!~~ '.,1ft! PIt! ""Hi r<./IJI1l ~.I"I~5P\H. 1'. H;~ln. !~~HH t":J III i OOSHOPl lb~52b ~ CarlIsle Hospital and Health Services 246 PARKER STREET" P.O. BOX 310 CARLISLE, PA, 17013-0310 { .., . ,.; c '\'f\~)U\.~ ) >h"n(\"n PATIENT IDENTIFICATION PHYSICIAN'S ORDERS DATE ORDERED ,)e)cjC ORDERS bQ, vl C f\LIW\ 'l)i.t\ f\ \-II \< T~ O-c C~ NOTED BY Js l,6\\~n(,",., (2\\ .)\\ LI+ ~ -Ai'v\G.\. \'.'-1 Q\ ------.-. -1.,'l'~7- 10/ ''ill -'I-.I ,-Z;ftw,L,~_YlfQ..!!!<9-f~ '{L.. ~'- r~' '-.. /'1/. ..L?:;C; NO t815(t2J921 WHEN THE NUMBER '4' COPY HAS BEEN REMOVED. J1EPLACE WITH ANOTHER IMPRINTED FORM. (;I1^,n 1;' 'I'Y "~" -- .. <~" -:1; -"., OPU 07/0Q/11 IlS/17/H , A K "VERSo SHANNON BHOOKE 6720 Riel ROAD p S.HIPPENSPlRG. PA ATTENDING PNYSICIAN JEFFREY 0 HD [HE G (2tJ/JS :' fJt3JJ.+, 7/3P9 f DATE f( OFt::mlJlJ NOTES SHOll D s-. ,.. Lid kfl.. ~'3.r ;.... 'c.b 0- 1...0 C- .-. '.?;y . ,l.. J ~ ;Ii .([) cd; r. .' . , 9/83.~O 1625 <~"-~ ~ "~'" ~ " ~ ^ '=- ".- , -..-..-"tiL '. : ' ~., OPC 07/06'/" q H' S. SHANNON p. 'on b7,O RICE RoaD G PA , .. 05/17/Q4 SHIPPENseCR . .PROGRESS .NOTES Sl~r\~Cpil~~HRE Y o HO EHET"Tf"NDING PHYSICIAN I lbQS2b . ( !b1fe: auT 0 Notta ....",.. 0 -- .... "aN '/ /'l ' \t'l .' \U~ . \UA .' 'M J(Jh ~~. . , vV~ ' V (J../l. M...- , .^\" ~vt/l J il-.- · frzrl .. , ... . , l~ . '. j. \ . . , , , ' . . , '. . ,. , '. , . ,. , . , , . ., . , , . , " . . , '. , , " . .' 1- 9/83. NO 1625 i",,- -~ """""I. ~- . ~, DATE ''\'1 .~ 1\ <{ - L1l\ cC\ \0 \ \ I~ HOSPIPOST OP r la.... ~ ::k ') <...J ANTIBIOTIC 1 , 2 ,~ 40' 250 J)! itB 12 16 20 24 04 08 12 16 20 24 04 08 12 16 20 24 04 08 12 16 20 24 04 08 12 1620 24 , p U 240 " l . 230 , S 220 , E 39 '10 , _ _.n 200 :2 T 190 1 E. 180 1 M 170 1 P 38~ 160 1 lSO 1 140 1 130 1 120 1 37' ItO ./ / 1 100 1 90 I..... 0 ~ "7 ., 60 ~ ,. 30 / t? B 10, (JP 35" p Ii.. ". ReSP.RATE I" TIME / FS8S /' RESULT WEIGHTISCALE /' SIIIFT/ 07-15 15.23 23-07 07-15 15.23 23-07 07-15 15.23 23-07 07-15 15-23 23-07 D7-15 15-23 23-07 .~ TUBE FEED ~ IV !z B HR, TOTAl 24 HR. TOTAl VOIDED omNE FOLEY ~ 0 DRAINS 8 HR. TOTAL 24 HR, TOTAL as ACTUAl 1 1 1 1 ,,1 1 1 1 o RENAL 0UTPUf , ~ Carlisle Hospital . t ntt!i$. ~,q U!'11 l!ftoOU , and Health Services {': '!1t1!o\ :~'l t'~O lIt( IIlUll (-"'1114 ~.~,pn.nttll. Pi i CLINICAL RECORD ~ ( . (I ~ ~. JU un c 110 UUO' DOS{'O@l 1bQS2b . N0.0325 (2198) .' .:~ 50 40~ 40 30 '0 10 39' 00- 90 BO 70 60 3B~ 50- 40 30 '0 10 370 00- 90 80 70 60 360 50- 40 30 35' t"'~ AUTO - Car.lisl,t! Hospital Medicatioll Admillistratioll Record NOl30SA (REV 9f?194) N",,,,, MYERS, SHANNON BROOKE R""",#: . 6364-C AR" 5 YRS Sa: Female 1/1.: 107,0 eM WI.: 37,0 LBS Finnncml~ 000058081 Phy."cian: SEDLACK JEFFREY D " AllaRie,,: NO KNOWN PATIENT ALLERGI 3u,tf\ . , 11 , e. t\I\cw A From 07/09/99 at 07,01 to 07110/99 at 07:00 DAY SHIFT EVENING SHIFT NIGHT SHIFT NO DOSE ROUTE FREQUENCY START STOP 0701-1500 1501-2300 2301-0700 SODIUM CHLORIDE 10 ML INJ 07-08-99 PKN 2ML=1EA FL PRN 001 BEFORE & AFTER MEDS OR EACH SHIFT FOR I,V, CAP FLUSH HEPARIN FLUSH INJ 1ML VIAL 07-08-99 PRN 10 UNIT / 1 ML = 1 VIAL FL PRN 002 BEFORE&AFTER MEDS OR EACH SHIFT ACETAMINOPHEN PED, LIQUID ~ML 07-08-99 PRN 320 MG / 10 ML = 2 EA PO Q4H 003 AS NEEDED FOR PAIN de:;. _.6.. 1\..h1 '...NOTE DOSE.... T) \~O, d.I.fQ"",) ('0 'b cj Iu.> Oll>.\ .0"'''' I ~ :!!l!i!!. ~ ~ INITIALS SlGNAlURE INmAlS SIGNAlURE LVC.leftven.t LAT-1eftantthlgh. Lo-lelldeRold LtC. left lower quad RVC.rlgNvenl RAT. r!ghlend thigh Ro.rlghldeno\d RlQ-rfghllowerquad kr :t'Z/d:/A. lDC.leftdorsal llT-leltIalthigh RlA.rlghtlalerm wa .Iell upper quad ROC . right dorsal RtT.r!ghllalthlgh u.A . left lateral arm RUe. right upper quad I..J' lVl.lehvaslal RVl.righlvatlal N.N.P.O. R.Relu5Q~ p.OnPass NN. Nau~eaNOfIllllng Adm;.uirm Dl,'e: 07-08-" T.Tesllng PaRt #: 1 ... end of report". PI. Name:. HYERS, 81lA1lN01f BROOKE MR #: 769526 ~...w ...... ~ .........~ ~ " Carlisle Hospital Medicatioll Administratioll Record NOl30SA (REV 919/94) A~e: Sex: HI.: Wt.: i.< ;"" 0 ~ l ,:;:,,\P " YE R S. S H ANN Q N PRO C i ( . qq '720 RICl ROAO MI"8I."O 7 1 0 'lc 1 ''14 S ~ I P P t N S B l R G. P A 0<;/171 0 "0 l"l' .. SDlHK. JlffREY.1 CjC,2b t. 0058081 b- . CQ"~ AuTO , . Name: Room #: FitWlrfnlN: Phy,firfnn: From O')D<:{ 'll .1 ItJS'StoOl~ .1 (f16o DAY S~!fT EVENING SHIFT NIGHT SHIFT NO DOSE ROUTE FREQUENCY START STOP 0701-1500 1501-2300 2301-0700 lj\~b\ ,.:IS~ \l'O (}t\<. '!r v{" r~h /J 01)- O~-6\'l Ij\~\ ;).\'\0 ""'0 'PO 1'1\0 Q~k 'fIn f~h . . . rc- . - . . ~ ~ AIm ~ INmAlS SIGNA1URE INITIALS SIGNATURE LVC.lllftvent LAT-Iellenf\hlgh lO.leftdeltokl llQ-leftlowerqued RVC'flghtvenl RAT. rlghttnd Ihlgh RO-rlgtttdellold RlQ-rlghllowerquad lDC. left dorsal UT.l8fl:latlhlgh RLA . rlghllllt ann lUQ . left upper quad ROC - right dorsal RLT.rlghtllllthlgh lLA - leIIlel9rlllarm RUO . fight upper quad lVl-IBft vas Iat RVl.rtghlvaalat N-N.P.O. R-Refused P.OnPSII NN. NluseaNomltlng II Admission Date: T-T.'11ng Pm.,.., p, w",,"., uP.. .__0"""'_' ..._...........~'= ~, LJ "'-'" ! ! , ' ' PEDIATRIC NURSING DOCUMENTATION SHEET NO 0450 f8192J DATE: JUl 0 91999 TIME ~ TIME . REFLECTED IN ~ OUTCQMElEVALUATION AREA. SEE BACK 1 EYES OPEN QUALITY I WNl . I N BEST VERBAL J MOTOR fA E SHAllOW U 00. MOVEMENT R .,. DYSPNEA' R IARM~EG' l r.J-' CROWING' 0 PUPil SIZE I R . ~"" J. STRIDOROUS' REACTION l RETRACTING' 8 COMPLIANT Vb GRUNTING' R E NON COMMUNICATIVE' E NASAL CONGESTION H A ANXIOUS' S 'l'AIRWAY CONGESTION' r NON COMPLIANT' P NASAL FLARING' I 0 SlEEPSfWNl R TRANSMITTED R FUSSY' A DIMINISHEO' TEMPERAtuRE I WARM L/v T CRACKLES' -,- 0 COOl R RHONCHI' HOT Y WHEEZES' / SQUEAKS' MOISTNESS / DFlY IR COUGH / NON PRODUCTIVE MOIST PRODUCTIVE' OIAPHOflETIC' lOOSE tuRGOR fWNl I~ TIGHT EDEMA' CROUPY' I PERIORBITAL EOEMA' TRACHEOSTOMY Ii FONTANElIWNl.. A8D IWNl 1>>'( T COLOR f WNl v// DISTENDED' E A G PAlE B FIRM' U rLUSllEO 0 BOWEL SOUNDS I WNl M HYPERACTIVE E ASHEN' N CYANOTIC' HYPOACTIVE T JAUNDiCED' ABSENT' A MUCOUS MEMBRANE IWNl 1/;/ NAUSEA' R Y DRY VOMITING' SENSATION I WNl rK/(. FEED TUBE ASPIRATE AMT. TINGLING' DIARRHEA' NUMBNESS' CONSTIPATION INTEGRrTY fWNl. -;b STOOL fWNl STAGE' CONSISTENCY I S~E INCISION I WNl G FLATUS I NG PLACEMENT CHECK DRSO DRY liNT ACT I IV SITE fWNL G NG DRAINAGE COlOR U DIVERSION HEARmATE I WNl KA' BLADDER IWNl IA'A C MURMU"' BlADDER PAlPABLE' A IRREGUlAR' FREOUENCY' R TACHYCARDIA DYSURIA' 0 I BRADYCARDIA URINE COLORfAPPEARANCE V PERIPNERAL PULSES I WNl ~ MAlOODROUS' A DIMINIS"ED GU DISCHARGE'I AMTICOlORS S ABSENT' CAPILLARY REFlLL/ WNl HOMAS SIGN + ,. -- . WNl K1( PROOKE 1 . <YEwS. S"ANH'N , FLOPPY' . - , l ,.., ~ I q 'l &720 R ICE ROAD . RIGID' , " '17/~4 SkIPPENSBlRG. PA C STRONG J' F F RE Y .. IW [HERG R WEAK i . L 1\ ~ I' , lb'1S2b y SHRU' OOC8081 , , , I ! i .1 ,1 c :'. ~ r.f l L 1 0 ,. "" ~ < . ~. ~ ~ I H ] q2~I,qL iei T ,J r" I II i) o ::J}. .GU~jJlf In:J> :'lJ~lt:lSN]ddl..~ t'blllt"J ."! Yf:_o.l. 11 f 11 '0 ,_ ,. I _ .~ EXPLANATIONS I MEANINGS I CODES PEDIATRIC NURSING DOCUMENTATION SHEET , DATE: JUl NO 0450 (6192) . NEUAO. COMA SCALE CODE EXTREMITY MOVEMENT o 9 19~ . REFLECTED IN PATlENTOUTCOMEIEVALUATION AREA. SEE BACK , " .2 .3 ., :RfSPONSf 1 2 3 , 5 6 TIME PUPIL REACTION VOICES UNDERSTANDING ! ry[g Nlvfn Tn 10 !lI'ON'" , UproN PAIN SOUNO N[UUS 8LUHOtSll flOOR ROUTINE , . REACTIVE CON SID,E RAilS , INCOMP INArl'RO rusEO NON REACTIVE I VERBAL NONE SOUNDS PRIATE CQNVER. ORIENTED CALL LIGHT i WORDS SAlION PUPilS mm . _ P 1&0 , l.fe3e. ! A DIAPER CARE i MOTOR EX1EN FLEXION HEXION lOCAt OBEYS .e..,. T NONE SION ABNOR WITH Ill'S COM I CfAMONlTOR i ORAW PAIN MANOS E MIST TENT NEURO: EXT. MOVEMENT. ..4 "NormaISlreng'h +2 ~ Severe weakness N .3rMlldweakne!lS +1 ~ NOfesponse T RESPIRATORY ISOL BEHAV10R: SLEEPS' WNl Able 10 lall asleep unaided belween peflods 01 care And does not display I PHOTO THERAPY ~Ig"s 01 sleep deprivallon. p IV SITE INTEGUMENTARY: TURGOR I Wltl . When skin pinched. relurns to o';glnal position withoulleaving A ..,' R IV PUMP EDEMA .1. Snmllpllnolretililled .3 ~ 1.2" plllelained E DIET ..2" 1:4~pitsomeretained .4 ~314"pitretamed N NSS DROPS fONTANEL I WNl . Soft non,lnn'lfl to plllflilation MIlY be !lllghlly deprll~sp.d T COLOR I WNl rmk nllll beds and mucou~ membr;\nes BULB SYRINGE MUCOUS MEMBRANES I WNl . Moi!ll and pink. T FEEDING SENSATION I WNl . Able to leel lighl louch and locale wilh eyes closed INTEGRITY f WNl Noo~norlt'ddened3rnlls E BURPIN~ STAGE I . Reddened srea lhat does not resolve wilhin 30 min, 01 pressure reliel. A POSITIONING P FEEDING STAGE n . Skm blister or superficial break in skin with redness 01 surrounding skin C STAGE m- SkIn break wilh deep lis~ue in\IQlvemenl {notlly Enlerostornal Therapist) H B f P MONITOR STAGE JV . Deep ulcelalion with involvemenl 01 tissue. muscle and bone. I HEPARIN lOC INCrslON / WNl . Wound edges well applO~imated wilh no ecchymosis. edema. redness. or N drainage G FORCE flUIDS IV SITE I WNl . No redness or swelling 01 site. Good blood return. Skin temp. same as surrounding !IkllllflflfllVr!ow!;hflflll CARE PLAN CARD / VAS: HEART RATE IWNl. NB. 80. IBO 1 wkI03mos:80.220.3 mosto 2 yrs: 70.150.210 HAND WASHING IOyrs 60. 110. 10yrsloadull' 50. 90 PERIPHERAL PULSES. Pedal and RadIal CAPIllARY REF1ll . Relurn 01 blood within 5 seconds HOMAS SION 'Pllin in thl! call on dorSlll(!~ion MOTOR I WNl . By 2 mo~ may lurn side 10 back: By 4 mas may grasp objeds wilh both hands: By 6 mos may lurn ovel comptelely. By 8 mas may sil Wl!lI alone. By 9 mas may crl'lwl. hold own bollle: By 10 mO!l may pull 10 ~tanding posilion; 8y 11 mas may 'crulse" along lurnilure: By 12 mos may stllnd ",Orll'O RESPIRATORY: QUALITY I WNl Evenehestexcursion&untabofedpatlern_lungsclear TIME AvulflgeR:tI1l! N8102mos 40.60. 3 mos 10 I YI: 30.40.2104 yrs.23. 30.610 10 yrs: 20 21. E IOytslOadull 16 20 NOTE: For ench degree 01 temp. elevation. Ihe RR lncreases by 4 pel min M PATTING DYSPNEA labored or ddlictJlt breathing may be painlul. 0 ROCKIN~ ORTHOPNEA - Comlortable blealhmg al angle 0145 degree~ or greater. CRACKLES Heard chreny on insplralion produced by fluid Ollmer bronchi. T TlC RHONCHI. HeArd on inspiralion & expiratkln: produced by air passing IhlOugh mucous in larger I REASSURANCE mM" 0 WHEEZE. NotS, whIstling' may be heard on inspiration but more common on explralion. N CONVERSATION ABD: WNl Soil. non d,~tended. non lender A PLAY BOWEL SOUNDS' WNl . 510 12 gurgl1ls per ml1lule L UPDATE PARENT GII GU BLADDER: WNl. Voiding at l1lasllx per shdl. clear pale to amber urine wilh lailll aromatiC odor PARENT HERE ., Ioasl30ctlhror 24Occ1shi".Chltdfen.1 2ccikg1hr. S PALPABLE. Bladder distended and fell as smooth firm mass above the symphysis pubis: U PARENT CALLED FREQUENCY VOiding mole than once q 3 . 6 hours P DYSURIA PninlulordllliCullUflnntion P SiBliNG YISIT MALODOROUS. Unpleasant or 101,11 odor. 0" PARENT PARTICIPATION IN CARE au DISCHARGE. Vaginal. penile or metllral. R . fUNDUS I WNl. Fundus lirm CODE M . MOTHER GP. GRANDPARENT O. OTHER T F -FATHER INIT . NURSING STAFF PT. PATIENT ,. ~VERS. S".~NGN BROOKE "1 !~./q1 bllO RICE ROlD . '/11/14 S"IPp(NserRG. Pl , . t'r JI FFREY 0 ~D E"ERG ~h~pbFl lbYS2b NOI!Vn1V^33WOO. ., C:MM ACTO ~~~, ~ ~ ".'>K ".,,,'" 0= .' __J~ ~~ 1--- , . . \ D~m"TRIr. NIIR~INn nnr.IIMI=NTATION SHEET g DIET: Flll.lN,t;llE1, NOn ANY CHANGES. CIRCLE APPROPRIATE DESCRIPTIONS: SHIFT 0100 - 1500 1500 - 230<1' 2300.0700 0 FEEDING TUBE':, P.PEG Q.GASTROSToMY l,;.lEVINE E.ENTRIFlEX CO {SELF/PAAENT V"// AMOUNT: a-GOOD F.F^IR,P.f'OOR' BOTTLES:A.REGUlAR P.PlAYTEXNURSER I NIPpllEfh A.REGUlAR P,PREMIE N.NUCK SHOWER /TUB 1 FLUII)S: F.FORMUlA BA,BREAST MilK E.El~CT: SOL. Cl.ClEAA LIQUIDS ORAL CARE /("/'/ H DIET AMOUNT CALORIE CT, TPN PPN y H.S. CARE BREAKFAST tJ \O;~" SE,F ASSIST FEED G I SKIN CARE LUNCH RESTRICT FLUIDS E FOLEY CARE SUPPER FORCE FLUIDS N E HAIR CARE SUPPLEMENT SNACK AM PM HS CORD CARE N ENTE~AL FORMULA FOG/TUBE P G L E U SPECIAL DIAPER CARE T RATE I BOTTlE NIPPLE A TIME I T FLUIDS 'SEE CODES> I AMOUNT FED 0 N FED BY IINITLS OR p. PARENTi SUCK:' &.STRONG W,WEAK HAGER ULOWL Y EN.iENC BURPS: I.EASILY D.DIFFICUL T R.RETAtNED WB.WETBURP E.EMESIS AMOUNT OF TIME TO FEED nME I DIAPER: ISISATUAATED IW WET rDIDAMP L ITooLB: SIZE I COLOR M I CONSISTENCY N BHI" 0700-1500 1500.2300 23",'100 BODY SECRETION CODES A COLOR: a.Green Y.Yellow T.Tafl B"Brown BL..BIacl\ WH.Whlle MA..Mafoon R"Red T VOIDING K/( o. Drenge ca. Colfee Ground ST.. Straw L Y . light Yellow DY. Dar1t Yellow LA.. light Amber I HNV DA. Dark Amber TE .. Tea CR. Cr.mberry p. Pink GR. Grey BD. Bloody DR,. Dar1t Red 0 AU . Rube SE. Serosa A. Amber N CATH ST / FOLEY CONSISTENCY: W. Watery S.. Solt M.. Mucousy F.. Formed L.. Loose p.. Pasty MS.. Mushy H .. Hard TH.. Thick FR.. Frothy DATE lAST BM I STOOl APPEARANCE: C.. Clear M.. Mucousy CD" Cloudy CL. Clots S.. Sediment SO.. Seedy Fl.. Flecks T..Tarry KA..l<ooIAld BED REST/MAY BE HELD SIZE: 8M.. Smear S. Small M.. Moderate l.. large !UANQ HQURS T TIME A ooB I RM I CHAIR lwe R C E T PLAYPEN /INFANT SEAT A I T V STROLLER I PLAYROOM M NOB ~ E I BRPIBSC N T AMB A/Ji' T Y UP AD LIB; SUPERV, D OFF FLOOR; SUPERV, R A BASSINET I ISOLETTE r 'CAGED CRlt1fOUTN C> .0/ N I. A BIDE RAILS UP WHEN APPROPRIATE T DEPART TO MODE INIT RETURN DISPOSITION INIT F ,vA' R I lOW BED POSITION A N T CALL BELLIN REACH v/t" B y RESTRAiNTS 'SEE FMS> P 0 R SEIZURE PRECAUTIONS T INIT SIGNATURE INIT SIGNATURE , :tw " ,,1.00.., i//~ ;P'}/h ~ ~ 0 8 -~ I vr --< Q PROOKE 1 N - "Y[RS. SHl~n'N A - - , ,I ,,(t I q '1 b7l0 RICr ROAD T u - "'17I~4 S~IPPfNSHRG. PA R - J'ffRE~ ., liD EMERG E - .~ i 1. A ~ \' . lb'i52b - OOC8Of 1 , NOOi""/921 PEDIATRIC NURSING DOCUMENTATION SHEET : ': !-\ ~ 6 L 1 0 , - """',: 0-'- PEDIATRIC PATIENT OUTCOME EVALUATION O<TE'JUl 0 9 1999 liME t?.fd.?- ~~ /.A ~A' b/ c/. AA./:? L'.A ....,.A. ., _v'->>A "'4 /. /,..,. '/. _~ ~ i'. t)/Jr~' . _ /y I>A A. . / A..IJ? ".. j)~4.J""/';./;&' ~~ {1A/A" e /.,.. - - L.~. /.~O~/ _.. /,7 .//...:: """'- h__" / <:T - .Lf-.2/ - ~.~ _ ..A ~ A. ~.d/A 7 .. '7/. -.L. ~ ?" ~ ':- #. - .~' ~ ..,/- .L .A-... 'J/ . " .01'1' 1\'.'~~/'t" ".117/H HlERS. SHAH"ON BROOKE t~~,. IllCf r~a:: S-IPPENSHPG. PA ~,r : L A r Jl rr PET ~ .~ [" (P G 'OOS~JFl lb~~2b ,...... u ." ""ft ~~ ~ = , , PEDIATRIC NURSING DOCUMENTATION SHEET NO OdSO (8/92) DATE: JUl 0 8 19!19 TIME 1P3.... '_0. Ih"O EYES OPEN L ~ 10/ N BEST VERBAl/MOTOR r~/_ ;; c. of ~ , IE U EKT. MOVEMENt R +. " << R IARM~E@ l ... to 1'1 .1 0 PUPil SIZE' R + l , I REACTION l ,I, " B COMPLIANT 'I... r ,,9 R E NON COMMUNICATIVE' E H S A ANXIOUS' V NON COMPLIANT' P I r ",:J I 0 SLEEPS' WNl R R FUSSY' A TEMPERATURE/WARM ".u r. I...] T 0 COOl R HOT V MOISTNESS I DRV ' ", r. 1) MOlST DIAPHORETIC' tuRGOR fWNl ',;J . r.. A;J EDEMA' I PERIORBITAL EDEMA' -c N FONTANElIWNl T COLOR / WNl ~" ItJ - E A G PALE B U FLUSHED 0 M ASHEN' E N CYANOTIC' T JAUNDICED' A MUCOUS MEMBRANE / WNl 1",,, r ~ R Y DRY SENSAnON / WNl II,,, TINGliNG' NUMBNESS' INTEGRITY I WNl "'~.- STAGE' ~.:r INCISION IWNl G I DRSG DRY & INTACT I IV SITE IWNl G U REARmATE I WNL , r_ AA C MURMUR' A IRREGUlAR' R TACHYCARDIA :tlh D I BRADYCARDIA V PER1I'ItERAL PULSES IWNl I... ,r__ I...;) A DIMINISHED S ABSENT' CAPILLARY REFIlL IWNl I. ,,:> HOMAS $lGN ..I- I. . WNt J.-;;-v. lA 0 , FLOPPY' 0 . RIGID' C STRONG R WEAK Y SHRILL' " " 1" . REFLECTED IN PATIENT OUTCOMElEVAlUATlON AREA.. SEE BACK /..'3'0 ~n ~_ 4.6, TIME QUAlITY /WNl SHAllOW DYSPNEA' CROWING' STRtDOROUS' RETRACTING' GRUNTING' NASAL CONGESTION tAIRWAY CONGESTION' NASAl FlARING' TRANSMITTED DIMINISHED' CRACKLES' RHONCHI' WHEEZES' I SOUEAKS' COUGH f NON PRODUCTIVE PRQOUC1WE' LOOSE TIGHT CROUPY' TRACHEOSTOMY ABD fWNl DISTENDED' FIRM' BOWEL SOUNDS / WNl HYPeRACTIVE HYPOACTIVE ABSf:NT' NAUSEA' VOMITING' FEED TUBE ASPIRATE AMT. OIARRHEA ' CONSTIPATION' STOOL' WNl CONSISTENCY' SIZE FLATUS NG PlACEMENT CHECK NG DRAINAGE COLOR DIVERSION BlADDER 'WNl BlADDER PALPABlE' FREOUENCY' DYSURIA' UR~E COLOR/APPEARANCE MAlODOllOUS' GU DlSCHARGE'1 AMTICOlORS r u.< b.~ A'J j'i", n .b .'"., r.. ,d"J + I OPt ~Y[RS. S~ANNaN qROOH C7/0R/QQ 6720 RICE ROAD 05/I7!Q4 S~IPPENSBURG. PA 51 }lAO. JEfFR(y D KO tMERG OOSP081 lbQS2b (:'10' A lJTO - ~" ~. "~ Cl2Scr" T dU",'- ll~JHJ 'h A l~ H If Y. ''J,n:'SNlddl.-. q/l 1- :XPLANA TlONS f MEANINGS f CODES PEDIATRIC NURSING DOCUMENTATION SHEET EXTREMITY MOVEMENT DATE;/UL o 8 1999 NO 0450 (6192) NEURO: C~A SCALE CODE . REFLECTED IN PATIENl' OUTCOMElEVALUATI~N AREA. SEe BACK ,1ESPONSE I , , . 5 6 .1 ., " .. TIME PUPil REACTION VOICES UNDERSTANDING rv(g 10 10 'irONIA , OP!:.N NtV[11 PAIN SOUN() NE;QUS SlUOOISH FLOOR ROUTINE 'OIl . REACTIVE SIDE RAllS INCQMP IN^,'I'no FUSEO NONREACflVE VERBAL NONE SOUNDS PAlATE COOVER. ORIENTED CALL LIGHT WORDS SAllON PUPILS mm . e P 1&0 ,.,.,.4 , A DIAPER CARE EXTEN FLEXION fLEXION LOCAl- OBEYS ......: T MOTOR NONE WITH. '''' COM. SION ABNOR DRAW PAIN MANOS I C I A MONITOR E MIST TENT NeURO: E){T. MOVEMENT . .4 ~ NOlmi'ltShength .2_Severeweakness N .:J.M,rdweakness +1 ~ NOlesponse T RESPIRATORY ISOl BEHAVIO~: SLEEPS' WNl. Able 10 fall asleep unaIded betwl!en penods 01 care and does nol display I PHOTO THERAPY signs 01 sleepdepnvallon P lVSfTE INTEGUMlNTARY: TURGOR I WNL. When skin pmched. felurns to original posllion wllhoulleaving A IV PUMP ...k R EDENl^ .1 ~Smallpilnol'elained .3='i2"pilfelained E DIET .2~ 14.pllsomerelained .4 = 3.4" pit relalned N FONTANEL I WNl . Solt. non-Ienselo pfllpitlllion May be sligl'lly depressed NSS DROPS COLOR I WHl r"'knl)llbedsltndmucousmembr:lnes T BUlB SYRINGE MUCCJUS MEMBRANES I WNL . Mo;st and pink T FEEDING SEN$ATION I WNL . Able 10 leer lighllouch and locale wilh eyes closed INTEt)RITY I WNl . No opon or rp.ddened IImas E BURPING ST>\OE I . Reddened area thaI does nol'esalve wilhin 30 Itlln 01 !'fessure rellel A POSITIONING P FEEDING ST >\GE n . Skin bllSler or superficial break in skin wilh rednl;!ss 01 surrounding sIIln C STAGE 01 Skin break wilh deep lissue involvement {nOlify Enlerostomal Therllpis!) H BIPMONITOR STA.OEIV Deep ulceralion with involvemenl 01 tissue. mu!!;cle and bone I INClalON I WHL . Wound edges well ('lpplo~imaled wilh no ecchymosis. edema, redness. ar HEPARIN LOC drainitge. N FORCE FLUIDS IV srtE I WNl ' No redness 0< swelling 01 sile, Good blaod return, Skin lemp_ same as surrounding G ~kllll~"l! IV '11,1'1 SllI.toll CARE PLAN ~-- . __ .___.'._M"'_L_~.~_'_'__' CARDfVAS:HEARTRATEfWNL-NB-OO. 18<1, I wk10 3 mos 00. 220. 3mos 10 2yos: 70. 150_ 210 HAND WASHWG IOyr!! 60.110 IOyrsloRllulf 50.90 PERIPHERAL PULSES. Pedal and Rad,al CAP1llARY REFill. Relurn of blood wllhin 5 seconds MaMAS SION .rllm In Ih~ call on dOI~lll~~ioll MOTOR / WHl By 2 mos may lu,n sid!! 10 bac~. By" mos may glll!lp obll!cls wllh bolh hands: By 6 mos mlly lu," 0"'" compl"l!!ly Oy II noM may S1l w"n alonl! By 9 ,"os rMy c.awl hold own bollia: By 10 mos ,":ty pull 10 standll'O pos'l.on, By 11 mos may 'crUlse" 1'IIong!u,nllUIf' Oy 12 mas may sland .Ion. RESP1RAtORY: QUALITY / WNl FVl!n chf!sl f!~cu,sion & unlabon'd panern Lung!: Clll;'!f TIME 1/%;> ,q,O Ave'l!lgeRale!' NBlo2m~"0. 60. 3 mos 10 1 YI:30.-40. 2104 yrs'23. 30.610 IDylS: 20 21. E IOrrllloadufl 16 20 NOTE: ForellCh dcgIee 01 temp, elevation. rheR R irrcre$tlS by 4 per mfn M PATTING DYSPNEA. labored or ddltculf breathIng. m3y' be painlul 0 ROCKING ORTliOPNEA . Comfortable brealhlng at angle ol45 deg'~ or grealer. CRACKLES. Heard chIefly on inSplration prod~ by lluid or finer bronchI T TlC RHONCHI Hellrd on inspiration & e~pir!llion: produced by air passing Ihrough mucous in larger I REASSURANCE rr,,, .~... 0 ',.M "'... WHEEZE. Noisy wfuslUrtg. /flay be heard Off inSpfrafiotr but more common on eltpl'aIIon N CONVERSA TIQN ABD: WNl. Soft. non dislended. non lender. A PLAY BOWEL SOUNDS fWNl. 5 to 12gurgtes per minute. L UPDATE PARENT 011 au BLADDER: WNl . Voiding 1I11aa!d 1 ~ per shllt. clear pale 10 amber urine wllh lainl aromallc odor PARENT HERE ':;.0 .. least 30ce'hror 240cc1shin, Ch~dren. 1 .2ee!kgillf, S PAl"ABlE. Bladder d"lStended and lell as smoolh firm mass above !he symphysis pubis U PARENT CAllED FREQUENCY Votding more thlln once q 3 . 6 houlS P DYSURIA. Pamlul or dlllicull urinat,on P SIBLING VISIT MALODOROUS. Unp~asanl or foul odor. 0 PARENT PARTICIPATION IN CARE ~p GU DISCHARGE. Vaginal. penile or urethral. fUNDUS 1 WNl - Fundus linn R CODE M . MOTHER GP . GRA.NDPARENT O.OTHER T F FATHER IN'T. NURSING STAFF PT. PATIENT '~ ~;.. I I e J-ll 07l0"/qq 0<;/11/14 ~YERS. SHANNON P.ROOKE b720 R.I CE R.oAD SHIPPENSaURG. PA Sf. :LAcK, JHFREY iJ "0 0058081 lbQS2b E"ER.G NOIJ.Vn1V^33WOO, C')~~ AUTO 'M ,~. .~_ <'.I ~_~.......'~f=. . . PFnlATRIC NURSING DOCUMENTATION SHEET ~w"t" C DIET: FILllNpIET, NOTE ANY CHANGES. CiRCLE APPROPRIATE DESCRIPTIONS: SHIFT 0700 . 1500 1500.2300' 2300 . 0700 0 0 FEEDINO TUBES: p.PEG a GASTROSTOMY LHVINE E.ENTRlFLEX COMP I PARTIAL I SELF I PARENT E AMOUNT: 0.-000:0 f.FA1R P POOR BonlES: R.REGULAR !P.PlAYTEX NURSER NIPPLES: R.REOUlAR P.PREM1E N.NUCK SHOWER t TUB 9 FLUIDS: F.FORMUlA BR.BREAST MilK H:lECT. SOL. CL.ClEAR LIQUIDS H ORAL CARE DIET AMOUNT pALORIE CT, TPN PPN Y H,S, CARE BREAKFAST SELF ASSIST G FEED I SKIN CARE LUNCH RESTRICT FLUIDS E FOLEY CARE SUPPER FORCE FLUIDS N E HAIR CARE SUPPLEMENT SNACK AM PM HS CORD CARE N ENTERAL FORMULA FDGtTUBE .u P .G L E SPECIAL DIAPER CARE T RATE I BOTTlE NIPPLE R TIME I T FLUIDS ISEE CODESI I AMOUNT FED ,0 N FED BY 'JNITLS OR'P. PARENTI SUCK: B.STRONGW.WEAK E.EAGER 9.SLOWL YEN., ENC BURPS: E.EASIL Y D.DIFFICUL T R.RETAINED ,WB.WET BURP E.EMESIS AMOUNT OF TIME TO FEED TIME E DIAPER: 151 SATURATED {WI WET IDIOAMP L STOOLS: SIZE I M COLOR I CONSISTENCY N 0700.1500 1500.2300 BODY SECRETION CODES . A SHIFT 2300.0~ COLOR: G '" Green V.. Yellow T .. Tan B" Brown BL.. Black WH.. White MA.. Maroon R a Red T VOIDING 1',11 0.. Orange CG.. Coffee Ground ST.. Straw LV.. light Yellow DY.. Dark VeUew LA.. Ughl Amber I OA .. Dark Amber TE.. Tea cn.. Cranberry P.. Pink OR to Grey BO a Bloody DR.. Dark Red 0 HNY RU .. Ruba SE.. Serosa A.. Amber N CATH STi FOLEY CONSISTENCY: W.. Watery S" Soli M.. Mucousy F.. Formed L..loose P.. Pasty MS.. Mushy H.. Hard TH '" Thick FA '" Frothy DATE LAST BM I STOOl APPEARANCE: C" Clear M a Mucousy CD.. Cloudy CL a Clots S a Sediment SO a Seedy FL a Flecks T..Tarry KA..KooIAid BED REST I MAY BE HELD SIZE: 8M.. Smear S.. Small M.. Moderate L.. large TURN 0 HOURS T TIME A 0081 RM / CHAIR J we R C E T PLAYPEN I INFANT SEAT A I T V STROLLER I PLAYROOM M HOB i' I~H' Ai> E I BRPIBSC N T AMB T Y UP AD LIB c SUPERV. 0 OFF FLOOR c SUPERV, R A BASSINET I 1S0WfE. 1 CAGED CRIII'i YOUTH BEib /'_ ,U A~ N 8 A SIDE RAILS UP WHEN APPROPRIATE /1.. \ ..d T OEPART TO MODE INIT RETURN DISPOSITION INIT F ;.,.. 'A~ R E LOW BED POSITION . T Iv: L' 'b N CALL BELLIN REACH S Y RESTRAINTS ISEE FMSI P 0 N SEIZURE PRECAUTIONS T INIT SIGNATURE INIT SIGNATURE ~" " (1, /,1M h "')0 ) ,E'.JJ : s ('IV\ f' (V\,... ...., - < I I JJ ,~ ..1 ,.a ;.J - 0 1 N // - f ,. A - q Pl ~ yo S, S~A~NqN qROOKE Y 07l0R/QQ 6720 RICE ROAO u - R .. - 05/17!Q4 SHIPPEHSBURG. PA E - Sf)LAO, JEFFREY 0 NO [HERG .. 11I004501811I21 PEDIATRIC NURSING DOCUMENTATION SHEET GOSPORl (:"1'114 AUTO lbQS2b . ~"_ ~.-'o. ,- j" ~ ;,....~- PEDIATRIC PATIENT OUTCOME EVALUATION " 'v K Yf RS. S~AN"ON nOOk t'l "~A,~Q b1?n RI(f ROlD i]/'lti C:""IPPlNS~t~~. PA J;If~!Yc~:: EKERG ~ 'O'Ql ~~2b ',~ _: 1':': . (' ,,,",, \ ~ r'- '-:r4 A I.... ~ ~ -. _~~~~e~ Name Likes to he ca\led E;cort -..--. . HI_ JQ2c. VltaTSI s' BP Sa02 ALi,ERGlF. SF.NSITlVITIE : ( Medication~ Food Env,nmn'"e1\tn1 (lateK, tupe)=-__ "_.". -~------- Exposure to Infectious Disease U Yes U No lfyes, list Immuni7.3tions Current n Yes nNo II N/A Comments I -3"((- Js R Head Circ escooe reaction) 'ilITANliSSTATlIS: IIWithin 5 yrs 1"15-10 yrs UMore lhan 10 yrs [I Unknown C N/A Cl1RRENT MEDICATIONS: (Rx, OTC, Herbs, Vitamins) \, Me~ Dose Last Dosemme 2._._ ~ 3, 4._.______________. 5,_.._.._.. 6... .u_m....__ 7._____.___ 8..____.__ 9. 10,_ MEDICA nONS: n None 0 Home n To Phannacy n@ Bedside HABITS: TOBACCO IJSE ALCOHOL INTAKE '1 Never Smoked '.I Chew IJ Snuff n None '1 Ex Smoker (Dale Slopped _..J U Occasional U Smokes (Amt peT daYL._ n Daily (Aml__J STREET DRUGS [J Yes 0 No Type(s) MENTAL STATUS: fo.1p6d1AfTecl: Tbmight: Memory: Speech: fi Appropriate l'fClearl --rJlntact o,NonnallClear U BlunledIFlat Spontaneous [I Impaired f] Silent o Vefensive [\ Vagnel 0 Recenl 0 Talkative [ 1 Apprehensive Disconnected II Distant Pasl II Repetitiye ,., Restless! U Disorienled U Mumbling Combative n Slow 10 answer Language Barrier? DYes ONo ':' Crying If, yes, language spoken: PjJ/..SE: )": RegulaT [] IrregulaT nFulll UWeak Bounding CQLOR: R1'Nonnal '1 Flnshed U Pale U Jaundiced RJ1Sp. {'!'Nonnal o Shallow I] Deep o Wheeze ,.\ Rapid '] Labored OStridor o Retractions n Onsky n Cyanosis U Nailbeds U Circumoral o Other ~IN: -. yWann 0 Cool U Rash 0 Ecchymosis CI Dry 0 Clammy [J Edema 0 Other LUJjG SOUNDS: Right: U Clear 0 Crackles ))'fl/A 0 Diminished 0 Wheeze Left: 0 Clear J Crackles [J Diminished U Wheeze [] Rhonchi U Absenl [] Rhonchi '] Absent PATIENT ASSESSMENT FORM NO OIlOA (6199) c;, Carlisle Hospital - ~""- Date: J\ t )'19 Time: -1SZD Triage Status: n Priority I [J I)iority 11 .,j21'riority III nN/A Mode of Arrival: ,OALS IJZCs U Ambulatory o Wheelchair U Carried o Stretcher ReaMforvisjt ~p ~r/qd --.r-{LJA/:/- Dt'~ Y /J A1lVf1- o . Onset of Symptoms Treatment prior to arrival Accompanied By: n Police [J Friend ,0 Parent ..kI1""amily o Self 0 Other PAIN: ODeaies 0 N/A Location of Pain Severity o I 2 3 4 5 6 7 8 9 10 o Constant 0 Dull [] Radiating o Intennillent 0 Sh~ BA~,?g .0 ?Jhe~ Triage/Signature: (~ ON/A '~~~~' [ Implantable DeVICes: 0 Yes [JNo If yes, explain Olher Devices: MEDICAL HlSTORYIPSYCHIATRlC HISTORY: o Seizures 0 Liver Disease [J Pregnant n Hypertension 11 Bleeding Tendcncics LMP o Cardiac Disease 0 CV A 0 Depression o Chest Pain [] Arthritis 0 Anxiety [] MI [] Asthma [J Transfusion D Ulcer [J Emphysema Reaction LJCA nCOPD [] Yes ONo o Kidney Disease [1 Home Oxygen D Other: [.1 Diabetes [J Cough [] Glaucoma [J Dyspnea FAMILY HISTORY: LJ Diabetes 0 Cardiac Disease o Hypertension 0 CA 0 Other LEARNING & COMMUNICATION: How do you best learn? OWriting OVisual ORe;,d I. Demonstration Whom do we teach? 0 Patient 0 Other Barriers to learning? 0 Yes D No CulturallReligion Needs: [J Yes 0 No Denlures: UUpper ULower ONone Brought to hospital? DYes ONo Vision: DOla..es DContacts ONone Brought to hospital? DYes ONo Sight: [J Blind I] Diminished Hearing Aid:LJRt DLI DBoth ONone Brought to hospital? DYes ONo Hearing:_c:.?eaf D~yf) RNSIGNATIJRF:: ___ ReviewlngRN: ON/A U Copy;to Phanllacy . PATIENT IDENTIFICATION '": "YlRS. SHANlInN PROOKE ~7/0./qq b7l0 RICE ROAD nr,/llIQ4 SHIPPENSB~RG. PA 5t ~LA~r, J[FfREY 0 HO [HERG OOS80P.l lbYS2b 1 eM'11[;0 " PSYCHOSOCIAL & FUNCTIONAL ASSESSMENT UNIT INTRODUCTION: P'fV !""Call Light c.rsiderails iil1led Controls l'fYisiting Regulations j)-BR ",fatienl Rill of Rights V.luables to Safe IJ Yes ..!11\i~ pJntercom HMeal Time ).ISmoking Regulations OEVELOI'MENTAL AGE: (Chec~ only I1mse that apply) :.; Infant rJ Early Childhood 0'Middle Childhood (~Lale Childhood IJAdolescenl UAdult U GeriatTic Occupation D Lives Alone _ 'I Lives with:ll.A .hL.,.1~toj.rlitilkk /- .~ot;;t . UUnable to n&;g;-adult AOL's r; Abuse suspected _.. IJTenninal illness !J Inadequate fmandal resources ! 1 Recent loss OT social isolatiol1____ ~ !Cognitive impaimlent suspected f 1 Religious or culluml beliefs YOll want us to know about? -.._------- - ---,----- "Help will be needed afier discharge_ ;-; Help was needed with the following before admission I.' Shopping U Chores ;1 Meal Prep n (,anndl)' FUNCl'IONAL STATUS: 'ndep Needs Assist [] .~ f7' i.J r.r (J I,Y II r..: [I K I>'" Dep o II Bathes Feeds Dresses Transfers Walks Bed Mobility T oileling 'c Bladder II Rowel f'Roth Ostomy U U Specify lype (cath/ostomy) /. History of Falls lJ Y es f~o Is this Tecent change functional slatus'? II Yes 'J No ASSISTlVE DEVICES: , 'Bed Side Commode : 1 Walker (J Elevated toilet Seat 0 Cane Ll Right Hand [I Crutches 0 Lefi Hand F.OUCA TIONAL NEEDS: (Check all that apply) C Request for Additional Healthcare Info. (Explain), ::::::Pre and Post-Procedure Teaching o Diabetic " Heart!Lungs/CHF UActivity [) Medications IJ n 1"1 l' [! o I' u OReproductive o Breast Self Exam o Testicular Self Exam !JOther C Other PATIF.NT ASSESSMENT NODI lOB (2199) ~ Carlisle Hospital - ~'''i':Ri', NUTRITION: r"IFood Intolerances: UDietRestrictions: ~one o Sugar USalt [JFat [I Other I-I Chewing/Swallowing Difficulty UNutritional Supplement: IJEnsnrelSustacal UHerbs nOther f""JAppetite: ~od CFair o Poor [lWeight: Change: [lStable OGain_lbs. x_mos o Loss Ibs. x_mas [I InvolUl1tary +/- 10 Ibs.l3 mos CONSULTS NEEDED: ONutrition Services 0 Social Work []Rehab SeTvices - Physician's OrdeTNecessary lJOstomy/Skin Care OPt. Ed [I Diabetes Ed, OOther o Phannacist " Medication information [I Oncology Nurse o lofection Controi lJ Psychiatric Liason UChaplain [I Other " REVIEW OF SYSTEMS Has patient evidenced aoy of the following now or in the past 30 days: NEUROLOGICA L: C Headache 0 Dizziness 0 Seizures 0 Numbnessffingling [' Oait Problems [I Tinnitus 0 Sensitivity to Light IJ Diplopia Comments: /U,,-w-L- RESPlRATORY/CAROIO VASCULAR: o Cough lJ Short of Breath [I Snoring/Sleep Apnea lJ Tx for TB lJ Night Sweats lJ Edema [I Chest Pain [I Palpitations 0 m Screeo Sheet needed Comments' /J1..4f<.(... GASTROINTESTINAL: o Painffendemess 0 Vomiting 0 Nausea [] Diarrhea [I Constipation 0 Tarry Stools [] Bleeding [] Last Bowel Movement lJ Incontinent Comments: /V!.ir7!..( ~ GENITOURINARYIREPRODUCTlVE: U PainlBuming/ltching lJ Discharge [j Bleeding [I Dribbling [J Frequency lJ Nocturia 0 Oliguria 11 Incontinent lJ Last Menstrual Period _ U Menopause [] Breast Change o Prostate problems Comments: /IIUrU / RN Signatnre: {1 /J(A.Ju...Ji?~ DateITime: 7 4:b9'7" ~ PA r NTIDENTIFrCATlON "P' "VERS, SHI.NNON OROOKE 1 ~7/0"/ql b720 RICE RO~O 1 r~/17/q4 SHIPPENSPtRQ. p~ ~.I-LI~r, JffFREY D HO EHERG OOS80Pl lb9S2b c~'nl ALTO CARLISLE PEDIATRICS 11-ICYC)b ~~-~-- = IT EMP .;EN(t: ....~ I' C: EVES NOS .. () ;~,,' ; NEO~ LUN ,:. u;:;~r:n ABD. GEN . cvT",!::~," NE"':~J. ~ \.., .w_~. -'-=-~ """,-cni ~ 1 i:'j I": I': ."Jhc{,,\I".~' /J ~ (,/).. ci '( ~'i IJl. >I' N~ ~ .;=;; ..-., ~. ..J ~ Y'1.:>bl Q . ~ I ~ --- 0'-"'tt. e> h:-c.~ If s 6V SV/)- tt0iJiJ. L_._.._....~ ~- ..-.,....-... ." 0' 0 < .--rw-- ---; _.._-~ .-. - . '; ~ -'~"'~1 \ ~ - . .. t._:-l~ HC cerv./-e.--<--'>;S --. if eM? ,:c;;';:,. ...:... :...~;." E\..::;.... . __", ';.'-"':'': fj<,;;.:;:." i'ECK Hr." *,2.::. E:~',-;"'-, 1\.tL~;-\'_j H' N'I ~ 0& .. 'i - -. -.---- - .-----. ;"'1; 0.) PU'OJ7L. \..J,".'," "j.' ~ elW\ ,- t> nvft -rcP~ S.ec ;1/1. L - - ~ ) ~~ - ',~ - , 1'- i Uniform Qualified Assignment and Release Claimant: WENDELL K, MtYERS WENDELL K. ~YERS JR~. MEGANB,MJ1~RS C~ SHANNON B, M,tYERS ENREST F, HELM Assil(nor: PENN NATIONAL INSURANCE COMPANY Assil(llee: AEGON Assil(llment Corporation Annuity Issuer: Monumental Life Insurance Company Effective Date: This Agreement is made and entered into by and between the parties hereto as of the Effective Date with reference to the following facts: A. Claimant has executed a settlement agreement or release dated (the "Settlement Agreement") that provides for the Assignor to make certain periodic payments to or for the benefit of the Claimant as stated in Addendum No, 1 (the "Periodic Payments"); and B, The parties desire to effect a "qualified assignment" within the meaning and subject to the conditions of Section 130( c) of the Internal Revenue Code of 1986 (the "Code"), NOW, TIIEREFORE. in consideration of the foregoing and other good and valuable consideration, the parties agree as follows: 1. The Assignor hereby assigns and the Assignee hereby assumes all of the Assignor's liability to make the Periodic Payments, The Assignee assumes no liability to make any payment not specified in Addendum No. 1. 2, The Periodic Payments constitute amounts received under workmen's compensation acts as compensation for personal injuries or sickness within the meaning of Sections l04(a)(I) and 130(c) of the Code, or damages on account of personal injwy or sickness in a case involving physical injury or physical sickness . . 3. The Assignee's liability to make the Periodic Payments is no greater than that of the Assignor immediately prece'!;ng this Agreement. Assignee is not required to set aside specific assets to secure the Periodic Payments, The Claimant has no rights against the Assignee greater than a general creditor. None of the Periodic Payments may be accelerated, deferred, increased or decreased and may not be anticipated, sold, assigned or encumbered 4, The obligation assumed by Assignee with respect to any required payment shall be discharged upon the mailing on or before the due date of a valid check in the amount specified to the address of record 5. This Agreement sball be governed by and interpreted in accordance with the laws of the Commonwealth oflU:R~', Pet\~\v;"", a. O~ 6, The Assignee may fund the Periodic Payments by purchasing a "qualified funding asset" within the meaning of Section 130( d) of the Code in the fonn of an annuity contract issued by the Annuity Issuer, All rights of ownership and control of such annuity contract shall be and remain vested in the Assignee exclusively. _ilJI" , ' ., ~. 'k 7, The Assignee may have the Annuity Issuer send payments under any "qualified funding asset" purchased hereunder directly to the payee(s) specified in Addendum No, 1. Such direction of payments shall be solely for the Assignee's convenience and shall not provide the Claimant or any payee with any rights of ownership or control over the "qualified funding asset" or against the Annuity Issuer. 9, In the eveBt the Settlement Agreement is declared terminated by a court of law or in the event that Section 130(c) of the Code has not been satisfied, this Agreement shall terminate, The Assignee shall then assign ownership of any "qualified funding asset" purchased hereunder to Assignor, and Assignee's liability for the Periodic Payments shall terminate. 8, Assignee's liability to make the Periodic Payments shall continue without diminution regardless of any bankruptcy or insolvency of the Assignor, 10. This Agreement shall be binding upon the respective representatives, heirs, successors and assigns of the Claimant, the Assignor and the Assignee and upon any person or entity that may assert any right hereunder or to any of the Periodic Payments. 11. The Claimant hereby accepts Assignee's assumption of all liability for the Periodic Payments and hereby releases the Assignor from all liability for the Periodic Payments. Assignor: PENN NATIONAL INSURANCE COMpANY Assignee: AEGON Assignment Corporation By: By: Authorized Representative Authorized Representative Title: Title: Claimant: WENDELLK. MEYERS ~ K ~ ::t: WENDELL K, MEYERS JR. W K~' MEGANB, MEYERS W IL ~..b..., SHANNON B. MEYERS 1<,1\1I~AJ.., ENRESTF, HELM d~9'-jl By: Approved as to Form and Content: By: ~-"'"~~ Claimant's Attorney . -- _;11I;_ , . Addendum No. 110 Qualified Assignment and Release BENEFITS FOR: WENDELL K. MEYERS Beginning 11/01/2000, $302,11 payable monthly for 30 years certain and life, Last guaranteed payment is due 10/01/2030. BENEFITS FOR: WENDELL K. MEYERS JR Beginning At Age 18 (09/24/2002), $7.500,00 payable annually for 4 years certain only. Last guaranteed payment is due 09/24/2005, Beginning At Age 25 (09/24/2009), $147,24 payable monthly for 15 years certain and life, Last guaranteed payment is due 08/24/2024. BENEFITS FOR: MEGAN N, MEYERS Beginning At Age 18 (02/23/2008), $4,492,31 payable annually for 4 years certain only, Last guaranteed payment is due 02/23/2011. BENEFITS FOR: SHANNON B. MEYERS Beginning At Age 18 (05/17/2012), $6,050,63 payable annually for 4 years certain only, Last guaranteed payment is due 05/17/2015. BENEFITS FOR: ERNESTF, HELM Beginning 11101/2000, $433,76 payable monthly for 10 years certain and life, Last guaranteed payment is due 10/01/2010. Initials Claimant W ~o{\'\ W lLM1 W 'i-fV\} W \((Y\J e F-N Assignor Assignee - - ~ ~ . - ~u -~u-uu ii:OOA ~eTTrey ~. brass ~ "IL" 410-560-0960 P.10 Structured settlement benefits from Monumental Life Insurance Company l A Transamerica Company t '1.:' ~, . 'It ~ .~ . , , J ., '. , , ;r. ( ! /1 -" \ I ~, ; \0 .< \ :( .'1 J i' ~ , , " \ () ., , ~~. :t. ,\ . . I'" -1'/' " ,\ \ .' : 1 ,. ,t . ~ ,'. FOR THE INJURED CLAIMANT Tho injury claim ha< heen setlled and Ihe claimant i.... ((lnsitlcring rakin~ paYlTIl~nt~ through a slru(:tur"'.d !;€:ttlemClll in~re:ad of a lump sum nf r.ash afLer im1llt":diatf:: needs hl\\'C bcen m~t. The daitn;tllr may ask:'Whal~ in it for me?" Thl~rf': aTe: many rca~on"i \vby a 5lnu.:turcd ~l.".rtlemenl may be. he:fft':f for the claimallt than a one'lime pilyll1l':nt of c.:nsh: l:taynu::nts arc guarantf:f':.d. Then: is no net.d for the dailllullllO y.-orry ahOUL ups and downs in the fimiT1Cial markels. Mu::..tlllVCnc:;tme:nts do nol g11.uantec their pl'rI'Ol'mancf:. Periodic,: payment!=i undfor a structured Sl."1tlf.ml.':nt <.:onLract issued and ~uarl.t(tt('l~d hy McmumeILltill.i1e In!;urance Cc.lII\pan~' will ensure the claimant:'; present .lnd tUf'ure nccu:" til"..~. miP.t. P~\ymcnls are tax-fret":. t;ndcr CllCl'en1 l',pdf':ral tax law, ~tr\lct1.\rt:<.l sc.'ulcuHm( payments arc [rL'e frol11 fet!t,rt\l ;tI<'OI11<': tax when a phy.ical injury i:; involved. * Unlike a t>l1'uc."t\lTl."d ~l,tll..~mC"nr.lf the daimaIll ta.'kC'S..l In1"l111 !;um of nlsh and iu\.ct>lg ii, the: invt~stmcnt carniJlg$ ma)' ht' l;)Xahk. It addre<ses lhe claimatll'!; sp..dfk needs. lly lal<.ing, part ill ,h(" c;f':ttlr.mt~nt, the dairtltUlt c~U\ hell' dt'$ign a "rrlemenllhal will pl\wide nor l1nly for prcsent nccd~, but rUl1m." n(,,:l.':ds ::\s well. The daiml.trH can arran~f: pa}'mcnLo.; lhat will n.'pla"~l~. income, provide for IIlcdic.:al lrf:atmt~nt. set up college rundio, p.l}' for rehahilil,niu" u" phlll for reTirement. And a ~tl'ut.tun,,;d :=orttlement C~tn be designed $(1 that the claimant will not (lutli.vt': [he: mone:y. This is c~pl'l.:'iall>' iml'nrtant when industry stue.lil'::' havl" ~hown that recipien~ o[lump $llm.~ nf (,';.Jsh wnd In ~pl"nd [hem quickly. A study colldt1etcd by The RUller Crtllll' ,hnw..d that 1~% If 1 '~Otj(1 l')f all accident vlctims cornplc.'ldy spl'rll thl"ir t'f..'lllf,'IIH~llht within rwo months, "nil that 90% of Ihem hat! .pelll il an will.;" five yea~".l."k MCJ1lbcI(,)1 ~EGON~ -..-....... T .- fOR A(;ENT l1SE ONLY Hi~hly ratted sC'cutity. '\o1o[luulcn,all .iff: lnsuram:e Cumpany. a TranSl,UJu:d('a l~ompany amI a rnemhl".T of the AE<.10N Insurance (;rtHlP, i:l> rated AhA (I ~I nl' 11 c.:atf..~goric::. ^AA ro CCC) by Standard ant! Pu"r" for il< ahilily to ml'~1 pnli<:yholder fimuwlal ohligations and A+ (2'''' of 15 e'lI.gorks A I , lU F) b)' A.'!v1. De~l fut' Iln.meial strcnglh and opt"rating perfLlfJn;U\c(',".'~' Its rate~ of relurn are: c.:Olnpl.~litiv~ with lho~c 1.)1' flthf':f .'lttr1.\durcd ~f':ttlE':ment providf....'s. and tht~n~ arc no ongoing nT hi.dden management ff'€"s. A~SUTCd paymcllts, Stnu'tllrf'd setlleIIlClll ubligallcII1S can ho a""lllet! by At'GON AS$ignmr.nt Corpunnitlll tlH'ollgh an IRe -,,,"iOTl 1.10 Qt1alified A$signl1lellL !'t1rlher, PFL Life In~uri.\IH,:c Cmnpall'~~ also a mcmbcr or t h", I\EGON Insuran,,:e Group. guat'(mtp(>$ thf' obligations of AE(jON t\ti~ignm.....nt Corporalion. -,et:tlred crctliwr slalU$ is I1fk..d ror Ihose daimaul~ wan1ing an t~Vf:n greater degree of .sccur'ily. H:'irate: planning. SctllL'lTll'llt$ ("an hr. la,.p;e enough lo <.:rcalc an cst,Ui," lax hahili.ty. Munurncnu.d I i1'e In~1Jranc.e Company pnl\'idl.'~ an l-'.51at..... Phmnin~ CommUlali4..m Ridl'I' iH no ("n:E1t, whkh allows the bcru.-ikiary W ("om111ntl.': an aRreed upun Pf..'ccc..'Jltage 01 the: :l>tnl(.~tun~d settlement illlu a lump sum of <.;ash upon the death or the: claimant. , Ie. hI' frl:"(' }r"fIl.l,',II'/',d lIh'I)/tll' III\:. lIIJiPLUlI1l ml('~!. 1.llr,lIrl.l'.11i11~'t I~'quilrtrlf'll/~ /If' f'~/Iutl".rfmm Itir'/'n!f !ltldn II'I't!J/lI! IOircrl{l: I'I (J) 1'11111' Inrl'/'I1fJ1 n"I'NUU' (.'Ildt'. ~... 'i,IIO~',,: Tht' I~ufl,'/' (;'1IItl1,l.iJ., H..hul'ClII. ffnl, I<rliy {, T"tlf'r, 'C:rll!fI1l'lIill Pml lilt' (;Ilid,': 1','/)/IIwl 1/'I.i1lIY" I IU.; 1')I)?, ....... RClflrl,\;~ 11(lm A :\.1 f{,'" .'://I'l'Ill~ Ilpmllll'! l~rlh.. !lI1UrahfJ "II'tl,~1I1 .lI'rilI1f11'1'Ii/1ll,1: l'l'I;li,rl1wn,.. ,l/lhr 1I1(11/,,-.rIY 'd'4/i...." II' !II(' ,w'llI~ 1~11111. m.~llrlml.l' ill.h~'1)f. &4!ill,,?~ '1("'1 "'((,mel'llIl mltll'IItIl'~ rc/kt:1 ir!l LLlPl'nf ,J/'!r'i11/'1 1'1 Ih' (Jml/'lmy~ 11'111,,)' 111m....' (INi.~tilf(lr" II/I'~ ";,lJlm.. /' I,'t1II'<1jl..1J!I~"II 1m fh.. "llm1""'iv~ .illl'lllf 1UIIIIPlllll."'. (nI/1lI1,1:~ 1111 .,1' h'/'ru.ul', 10tXI.) M.IY'Wlhff\'(liJ.I"'I.jllull,/tAln Pi'll 1.'.... 11m" Ill"). 1\.";11 U ~ l<.l~ FI,wi~I~1 p(llky r~lrnl 1I~1. .,\,1.1 i) l-t .'IJ~~t-ll .",~ ..... ...... - - ~~,IIi1>d CONTINGENT FEE AGREEMENT Weod<oll ....d 0""'''"," (YJ'je.r.. ,"d""d.Je.\ly ""6 O^ be-ho,\- or ovC"Co...lldr....." We, W~6<.I\..'J'r I Gh:;:::~!y~ CV<l , retain and authorize the law firm of Metzger, Wickersham, Knauss & Erb, P,C., to do whatever they deem necessary or desirable in order to represent us in all claims for compensation and reimbursement for personal injuries, wage loss, and economicandotherdamagesresultingfrom an o'ltY:'lder.1- nn IjRJq~ . I 1. Attornev's Fees: The fee of the attorneys shall be contingent as follows: (a) Thirty-three and one-third percent (33 1/3%) of gross recovery; (b) SHOULD THERE BE NO RECOVERY BY SUIT OR SETTLEMENT, SAID ATTORNEYS DO NOT HAVE ANY CLAIM AGAINST ME OF ANY KIND FOR LEGAL SERVICES RENDERED, (c) ~ VV" 1110( Co\"",;.".. 2, Expenses of Litigation: Will be- a. h./"'^\1r -h"'L ('eI'c,<J\1- (.;l.s;'<ro) Crl,n!l"'"'l- k... 0" IS"''''!> c-ecwv, Actual expenses incurred on the business of the client shall be borne by the client and my attorney shall be reimbursed out of the balance, after deduction of attorneys fees, of any recovery for all legal expenses incurred in the prosecution of this claim which have not already been paid by us, We do hereby agree to pay all expenses incurred by our attorney in the preparation and presentation of this case and do understand that these expenses include, but may not be limited to, costs of medical reports and records, stenographic expenses connected with depositions, expert witness fees, photocopying charges, and mileage charges connected with the rendering of legal services, We understand that we are responsible for payment of these expenses regardless of the eventual outcome of the case and further understand that if our attorney deems it necessary, we may be asked to advance these costs prior to the incurring of any such expenses or the scheduling of any deposition. Document#: 153985.1 ~- "" J I ."" ~~ ';cli';': 3, We hereby further agree that my attorney may charge us reasonable additional compensation if it is necessary to try the case more than once, if the case is appealed, or if proceedings in other courts are necessary because of the change of circumstance of a party or for other reasons, 4, We hereby further agree that our attorney is hereby authorized to bring suit or to settle and compromise the claim, to execute all documents pertaining thereto, and to do all lawful acts requisite for effecting the claim on our behalf. 5. We further authorize our attorney to payout of any proceeds of settlement or trial any unpaid medical bills for treatments or services made necessary by the injuries sustained in this accident and any workers' compensation liens, 6, We agree that our attorney accepts this employment on the condition that he will investigate this claim, and if it appears to be a recoverable claim, he will proceed to handle the claim; but if, after investigation, the claim does not appear to be recoverable, said attorney shall then have the right to rescind this Agreement. 7, We hereby further agree that if we decide to terminate this authority before any settlement is offered or any award is obtained the firm shall be entitled to reasonable compensation for all work done on the case up to that point. We agree that reasonable compensation for Clark De Vere, Esquire, or any other attorney involved in the handling of this case, shall be One Hundred and Ten Dollars ($110,00) per hour, or such higherrate as shall constitute his standard billing rate at the time that the work is performed, 8, We agree that our attorney may withdraw from this case at any time after reasonable notice to us, and we agree to keep him advised of our whereabouts at all times and to cooperate at all times in the preparation and trial of this case, to appear upon reasonable notice for depositions and Court appearances, and to comply with all reasonable requests made of us in connection with the prepariltion and presentation of this case, -2- - " - ~"' -- IN WITNESS WHEREOF, we have signed below on this ~ day of r To.J{ '( ,1999, ~ 1,( YV\'fJ/J L. ' CLIENT: ~ B ~~-9- CLI NT: METZGER, WICKERSHAM, KNAUSS & ERB, P ,C, ~~_, L::;.... ATTORNEY: Clark DeVere, Esquire - 3 - I~~ ." ~ ~ ,./;j ! SETTLEMENT AGREEMENT AND RELEASE This Settlement Agreement and Release ("Settlement Agreement") is entered into on , 2000 by and among, Wendell K. Myers, Jr., Megan N, Myers and Shannon B. Myers, minors, by Wendell K. Myers and Donna J, Myers, their parents and natural guardians ("Releasors") and Gary E, Sheaffer ("Sheaffer"), Osborn Printing Company ("Osborn"), and Penn National Insurance Company (collectively, "Releasees"). Recitals A, On or about July 8, 1999, Releasors were injured in an accident occurring at or near the intersection of Routes 233 and 174, Cumberland County, Pennsylvania, Releasors allege that the accident and resulting physical and personal injuries arose out of certain alleged negligent acts or omissions and have made claim seeking monetary damages on account of said bodily injuries, B, Penn National Insurance Company is the liability insurer of Sheaffer and Osborn and as such would be obligated to pay any claim or judgment obtained against them arising from this accident, to the extent the loss is covered by its policy, to the extent of the limits of that policy and provided that all applicable terms of that policy had been complied with, and subject to Osborn's bankruptcy, C, The Parties desire to enter into this Settlement Agreement in order to provide for certain payments in full settlement and discharge of all claims which are or might have been the subject of this action, upon the terms and conditions set forth herein, Page I of9 Document #: } 86068.} I, -~ "--~-lt! , AGREEMENT The parties agree as follows: 1, Release and Discharge In consideration of the payments called for herein the Releasors completely release and forever discharge Releasees from .any and all past, present or future claims related to the subject accident. Released are all past, present and future officers, directors, stockholders, attorneys, agents, representatives, employees, successors in interest, and all other persons who were or might have been subject to this action. This release includes all demands, actions, claims, or rights to compensation which the Releasors now have, or which may hereafter accrue as a result of the alleged act or omission, This shall be a fully binding and complete settlement between the parties to this Settlement Agreement and Release, The Releasors specifically preserve and do not release or discharge any claim and/or action they may have against any medical provider for any treatment or lack of treatment, including malpractice, and any claims, actions and/or rights they may have for income/health insurance/medical benefits from any entity, including, but not limited to, Erie Insurance Exchange, but specifically excluding Gary Sheaffer, Osborn Printing and Penn National Insurance Company and its affiliates, 2, Pavments In consideration of the release set forth above, Penn National Insurance Company, on behalf of Sheaffer and Osborn, hereby agrees and is obliged to pay the following sums in the designated manner: Page 2 of9 Document#:18606~1 H'C,j A, Payments due at the time of settlement as follows: L To Wendell K. Myers, Jr.: $2,500,00 2. To Metzger, Wickersham, P,C, for attorney fees: $20,000,00 B, Periodic Payments as set forth in Addendum I. See attached Addendum I. All sums set forth in this Paragraph 2 and Addendum I constitute damages on account of personal injuries, arising from an occurrence, within the meaning of Section 104(a)(2) of the Internal Revenue Code of 1986, as amended, 3, I Releasors' Rillhts to Payments Releasors acknowledge that the Periodic Payments cannot be accelerated, deferred, increased or decreased by them; nor shall they have the power to sell, mortgage, encumber, or anticipate the Periodic Payments, or any part thereof, by assignment or otherwise, 4, Releasors' Beneficiarv Any payments to be made after the death of any Releasor pursuant to the terms of this Settlement Agreement shall be made to such person or entity as shall be designated in writing by Releasor to Penn National Insurance Company or its Assignee, Any revocation thereof shall not be effective unless it is in writing and delivered to Penn National Insurance Company Page 3 of9 Document#:18606&1 - I' . f!L~ ' , andlor the Assignee, The designation must be in a form acceptable to Penn National Insurance Company or its Assignee before such payments are made, 5, Oualified Assignment The Parties hereto acknowledge and agree that Penn National Insurance Company andlor Sheaffer and Osborn will make a "qualified assignment", within the meaning of Section 130(d) of the Internal Revenue Code of 1986, as amended, of Penn National Insurance Company's andlor Sheaffer and Osborn's liability to make the periodic payments to AEGON Assignment Corporation (herein after referred to as "Assignee"), Any such assignment shall be accepted by the Releasors without right of rejection and shall completely release and discharge Sheaffer and Osborn and Penn National Insurance Company from such obligations hereunder as are assigned to the Assignee, The Releasors recognize that, in the event of such as assignment, the Assignee shall be their sole obligor with respect to the obligations assigned, and that all other releases that pertain to the liability of Sheaffer, Osborn and Penn National Insurance Company shall thereupon become fmal, irrevocable and absolute, 6, Right to Purchase an Annuitv Penn National Insurance Company or the Assignee shall fund their obligation to make periodic payments through the purchase of an annuity policy from Monumental Life Insurance Company (hereinafter referred to as "Annuity Carrier"), Penn National Insurance Company or the Assignee shall be the owner of the annuity policy and shall have all rights of ownership, Sheaffer, Osborn, Penn National Insurance Company or the Assignee may have the Annuity Page 4 of9 Document #: 186068.1 -- "~-~"-" -" ,,~,,',i , , Carrier mail payments directly to the Releasors, The Releasors shall be responsible for maintaining the currency of the proper mailing address and mortality information to Monumental Life Insurance Company, 7, Discharge of Obligation The obligation of the Assignee to make each installment payment shall be discharged upon the mailing of a valid check in the amount of such payment to the address designated by the party to whom the payment is required to be made under this Settlement Agreement. Checks lost or delayed through no fault of the Assignee (e,g" if lost by the Postal Service) shall be promptly replaced by the Assignee, but the Assignee is not liable for interest during the interim, 8, Release Releasors hereby acknowledge and agree that the Release set forth in Paragraph 1 hereof is a complete release as set forth above, and they further expressly waive and assume the risk of any and all claims for damages which exists as of this date but of which the Releasors do not know or suspect to exist, whether through ignorance, oversight, error, negligence, or otherwise, and which, if known, would materially affect their decisions to enter into this Settlement Agreement. Releasors further agree that they each have accepted payment of the sums specified herein as a complete compromise of matters involving disputed issues of law and fact, and they assume the risk that the facts or law may be otherwise than they each believe, It is understood Page 5 of9 Document #: 186068.1 I, t>< !~, and agreed by the Parties that this settlement is a compromise of a doubtful and disputed claim, and the payments are not to be construed as an admission of liability on the part of Sheaffer and Osborn, by whom liability is expressly denied, .1 "I I " .'i 9, Warrantv of Capacity to Execute Agreement Releasors represent and warrant that no other person or entity has or has had any 0:1 i1 ]'1 :1 'I [J " I ~:j :~1 ~ !I II ;1 "I II II I! " II I ,I J 11 ~ :1 II t:! " interest in the claims, demands, obligations, or causes of action referred to in this Settlement Agreement except as otherwise set forth herein; that they have the sole right and exclusive authority to execute this Settlement Agreement and receive the sums specified in it; and that they have not sold, assigned, transferred, conveyed or otherwise disposed of any of the claims, demands, obligations, or causes of action referred to in this Settlement Agreement. 10, Entire Agreement and Successors. in Interest This Settlement Agreement contains the entire agreement between Releasors, Sheaffer, Osborn and Penn National Insurance Company with regard to the matters set forth herein and shall be binding upon and inure to the benefit of the executors, administrators, personal representatives, heirs, successors and assigns of each, 11, Governing Law This Settlement Agreement shall be construed and interpreted in accordance with the laws of the State of Pennsylvania, Page 6 of9 Document #: 186068.1 12, Additional Documents All parties agree to cooperate fully and to execute any and all supplementary documents and to take all additional actions which may be necessary or appropriate to give full force and effect to the basic terms and intent of this Settlement Agreement. 13, Effectiveness This Settlement Agreement shall become effective following execution by all of the Parties, Dated: BY: Wendell K. Myers, Jr., minor, by Wendell K, Myers and Donna 1. Myers, his parents and natural guardians I' Dated: BY: ! Megan N. Myers, minor, by Wendell K, Myers and Donna J, Myers, her II II ], parents and natural guardians i' Dated: BY: Shannon B, Myers, minor, by Wendell K, Myers and Donna J, Myers, her parents and natural guardians Penn National Insurance Company BY: TITLE: DATE: Page 7 of9 Document #: 186068.1 .,,1 > ADDENDUM I SCHEDULE OF PERIODIC PAYMENTS Payable to Wendell K. Myers, Jr., if living, Otherwise; to Wendell K, Myers (Beneficiary), and if neither are living, Donna 1. Myers, the following: Beginning at Age 18 (09/24/2002), $7,500,00 payable annually for 4 years certain only, Last guaranteed payment is due 09/24/2005, ;1 'I ,I 'I \ I I j II 'I Beginning at Age 25 (09/24/2009), $147,24 payable monthly for 15 years certain and life. Last guaranteed payment is due 08/24/2024, Payable to Megan N, Myers, if living, Otherwise; to Wendell K. Myers (Beneficiary), and if neither are living, Donna J, Myers, the following: Beginning at Age 18 (02/23/2008), $4,492,31 payable annually for 4 years certain only. Last guaranteed payment is due 02/23/2011, Payable to Shannon B, Myers, if living, Otherwise; to Wendell K, Myers (Beneficiary), and if neither are living, Donna J, Myers, the following: Beginning at Age 18 (05/17/2012), $6,050,63 payable annually for 4 years certain only. Last guaranteed payment is due 05/17/2015, Dated: BY: Wendell K. Myers, Jr., minor, by Wendell K. Myers and Donna J, Myers, his parents and natural guardians Dated: BY: Megan N, Myers, minor, by Wendell K. Myers and Donna J, Myers, her parents and natural guardians Page 8 of9 Document #: 186068.1 ~- :..y" > > , Dated: BY: Shannon B. Myers, minor, by Wendell K. Myers and Donna J. Myers, her parents and natural guardians Penn National Insurance Company BY: TITLE: DATE: Page 9 of9 Document #: 186068.1 tloll ~,~ . ~""' .' . VERIFICATION I, Wendell K, Myers, Sr., individually and as paTent and natural gUaTdian of Wendell Myers, Jr., Megan N, Myers and Shannon B, Myers, minors, have read the foregoing Petition for Approval of Minor Plaintiffs' Compromised Settlements and do sweaT or affirm that the facts set forth in the foregoing Petition aTe true and correct to the best of my knowledge, information and belief, I understand that this Verification is made subject to the penalties of 18 Pa,C.S,A. 94904, relating to unsworn falsification to authorities, Date : I (J , :3 -:;2000 ~~~{~,ee~' and natural gUaTdian of Wendell Myers, Jr" Megan N, Myers and Shannon B, Myers Document #: 185095.1 ~, ~ " i, '-0 ",. > VERIFICATION I, Donna J. Myers, individually and as parent and natural guardian of Wendell Myers, Jr" Megan N, Myers and Shannon B. Myers, minors, have read the foregoing Petition for Approval of Minor Plaintiffs' Compromised Settlements and do swear or affirm that the facts set forth in the foregoing Petition are true and correct to the best of my knowledge, information and belief, I understand that this Verification is made subject to the penalties of 18 Pa,C.S.A 94904, relating to unsworn falsification to authorities. Date (0-3-;;)(:DD Donna 1. Myers, a arent atural guardian of Wendell Myers, Jr" Megan N, Myers and Shannon B. Myers Document #: 185095.1 , ) . . -~,;~ i I I ,I .1 I I :1 VERIFICATION The undersigned hereby certifies that he is the attorney for Plaintiffs Wendell Myers, Jr., Megan N, Myers and Shannon B. Myers, Minors, by Wendell K. and Douna 1. Myers, parents and natural guardians and that the facts in the foregoing Petition for Approval of Minor Plaintiffs' Compromises Settlements are true and correct to the best of his knowledge, information and belief, and that said matters relating to the Petition for Approval of Minor Plaintiffs' Compromised Settlements are as known to the undersigned as to the clients Plaintiffs Wendell K. Myers, Jr., Megan N, Myers and Shannon B, Myers, Minors, by Wendell K. and Donna J, Myers, their parents and natural guardians, said knowledge being based upon information contained in the attorney's file in this matter, and further states that false statements herein are made subject to the penalties of 18 Pa, C,S,A, 94904 relating to unsworn falsification to authorities, ~ ~- Clark De V ere, Esquire Dated: 10-3-00 Document#:18509~1 1-1 ,~ i";~ , . :> CERTIFICATE OF SERVICE I, Clark DeVere, Esquire, of the law firm of Metzger, Wickersham, Knauss & Erb, P,C" hereby certify that I served a true and correct copy of the forgoing document(s) with reference to the foregoing action by fust class mail, prepaid postage, this ~ay of CJe.7"u.f>e/' , 2000 on the following: Gary E. Sheaffer and Osborn Printing Co., c/o Stephen E. Geduldig, Esquire Thomas, Thomas & Hafer, LLP 305 North Front Street, Sixth Floor P.O, Box 999 Harrisburg, P A 171 08 r- :::,.--- -:-.. Clark DeVere, Esquire Document #: 185095.1 , WENDELL K. MYERS, JR., MEGANN, MYERS AND SHANNON B, MYERS, minors, by WENDELL K, MYERS and DONNA 1. MYERS, their parents and natural guardians and WENDELL K, MYERS, DONNA J. MYERS and ERNEST F, HELM, in their own right, Plaintiffs vs. GARY E, SHEAFFER and OSBORN PRINTING CO" Defendants " " .'L";;'.~' "~, - - i~ IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW /'1 Le...- NO. DC> - ..20'-0 \...:tc..>~ /~ JURY TRIAL DEMANDED NOTICE TO DEFEND TO: Gary E. Sheaffer 104 Carlisle Street Gettysburg, PA 17325 -and- Osborn Printing Co, 3055 Biglerville Road Big1erville, P A 17307 YOU HAVE BEEN SUED IN COURT, If you wish to defend against the claims set forth in the following pages, you must take action within Twenty (20) days after this Complaint and Notice are served, by entering a written appearance personally or by attorney and fuing in writing with the Court your defenses or objections to the claims set forth against you, You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the Court without further notice for any money claimed in the Complaint or for any other claim or reliefrequested by the Plaintiffs. You may lose money or property or other rights important to you, YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE, IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP, Cumberland County Bar Association 2 Liberty Avenue Carlisle, PA 17013 (717) 249-3166 or (800) 990-9108 Document #: 171724. J .~, . .; '. - ,-~ - WENDELL K, MYERS, JR" MEGAN N. MYERS AND SHANNON B. MYERS, minors, by WENDELL K. MYERS and DONNA J, MYERS, their parents and natural guardians and WENDELL K, MYERS, DONNA 1. MYERS and ERNEST F, HELM, in their own right, Plaintiffs IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW NO. {)"{} - ,:}O(;O Ce:xJ J.e.w,.- vs. GARY E, SHEAFFER and OSBORN PRINTING CO., Defendants JURY TRIAL DEMANDED CIVIL COMPLAINT 1. Plaintiffs Wendell K. and Donna J. Myers, husband and wife, are adult individuals residing at 6720 Rice Road, Shippensburg, Franklin County, Pennsylvania, 2, Plaintiffs Wendell K, and Donna J, Myers, are the parents and natural guardians of minor Plaintiff Wendell K. Myers, Jr., who resides with them and who is 15 years old, having been born on September 24, 1984, 3, Plaintiffs Wendell K. and Donna J, Myers, are the parents and natural guardians of minor Plaintiff Megan N, Myers, who resides with them and who is 10 years old, having been born on February 23, 1990, 4, Plaintiffs Wendell K. and Donna J, Myers, are the parents and natural guardians of minor Plaintiff Shannon B, Myers, who resides with them and who is 5 years old, having been born on May 17, 1994, Document #: 171724.1 --a, 5. The minor Plaintiffs have selected Plaintiffs Wendell K. and Donna J. Myers, as their parents and natural guardians, to represent their interests in this action. 6. Plaintiff Ernest F, Helm is an adult individual residing with the Myers' family at 6720 Rice Road, Shippensburg, Franklin County, Pennsylvania. 7, Defendant Gary E, Sheaffer is an adult individual residing at 104 Carlisle Street, Gettysburg, Adams County, Pennsylvania, 8, Defendant Osborn Printing Co, is a Pennsylvania corporation with a principal place of business at 3055 Biglerville Road, Biglerville, Adams County, Pennsylvania, 9, On July 8, 1999, Plaintiffs Wendell K. and Donna J. Myers were the co-owners of a 1993 Chevrolet Suburban station wagon with Pennsylvania Registration Plate No, AFY1896, 10, On the aforesaid date, Defendant Osborn Printing Co. was the owner ofa 1990 Chevrolet Scottsdale cab chassis based box truck, 11. On the aforesaid date, at approximately 2:30 p.m., Plaintiff Wendell K. Myers was operating his 1993 Chevrolet Suburban station wagon eastbound on State Route 174 in Penn Township, Cumberland County, Pennsylvania approaching the intersection of State Route 233 with the remaining Plaintiffs in his vehicle, 12, At the aforesaid time and date, Defendant Gary E, Sheaffer was operating the 1990 Chevrolet Scottsdale cab chassis based box truck with the permission of Defendant Osborn Printing Co. and within the scope of his employment with Defendant Osborn Printing Co, -2- Document #: 171724.1 , , '.~.- ~. 13, At the aforesaid time and date, Defendant Gary E. Sheaffer was operating the aforesaid truck southbound on State Route 233 approaching the intersection with State Route 174 in Penn Township, Cumberland County, Pennsylvania, 14, At the aforesaid time and date, Plaintiff Wendell Myers' direction of travel was a through highway with no traffic control devices. 15, At the aforesaid time and date, Defendant Gary E, Sheaffer's direction of travel was controlled by stop signs in each direction on both sides of the highway at the intersection as well as clearly marked stop warning signs before reaching the intersection. 16. At the aforesaid time and date, Defendant Gary E. Sheaffer failed to heed the warning signs and also the stop signs at the intersection and, proceeded into the intersection, and violently struck the Plaintiff vehicle as it was proceeding lawfully through the intersection, 17, At all times relevant hereto, Defendant Gary E, Sheaffer was an employee, servant, workman and/or agent of Defendant Osborn Printing Co, and was acting within the scope of his employment with Defendant Osborn Printing Co. and Defendant Osborn Printing Co, is vicariously liable for his acts, commissions or omissions as though it performed the acts, commissions or omissions itself and is subject to the doctrine of respondeat superior, 18, Defendants owed a duty to other lawful users of the roadway in the Commonwealth of Pennsylvania to operate their vehicle in such a way as to not cause harm or damage to said other persons and to the Plaintiffs in particular. 19. The negligence, carelessness and recklessness of Defendant Gary E, Sheaffer aconsisted of the following: - 3 - Documenl #: 171724.1 "-~- """"'!tl (a) Failing to stop at a stop sign in violation of 75 Pa,C,S.A, ~3323 and applicable law; (b) Failing to yield the right-of-way to Plaintiffs' vehicle in violation of 75 Pa.C,S,A. ~3323 and applicable law; (c) Failing to obey traffic control devices in violation of 75 Pa,C,S,A, ~311l and applicable law; (d) Failing to slow his vehicle or otherwise heed the stop sign warning signs; (e) Failing to observe the roadway ahead for the presence of other vehicles; (f) Failing to slow or stop the vehicle he was operating so as to avoid a collision; (g) Failing to apply the brakes to the vehicle he was operating or take other evasive action to avoid the collision with Plaintiffs' vehicle; (h) Failing to maintain adequate control of the vehicle he was operating in order to avoid a collision; (i) Failing to give warning to Plaintiffs of his impending collision with Plaintiffs' vehicle; G) Operating his vehicle in careless disregard for the safety of persons and/or property in violation of 75 Pa,C,S,A. ~3714 and applicable law; (k) Failing to keep his vehicle under proper and adequate control so as not to expose other users to an unreasonable risk of harm; (1) Operating his vehicle too fast for the conditions existing at the aforesaid time and place in violation of 75 Pa,C,S,A. ~3361 and applicable law; (m) Exceeding the applicable maximum speed limit in violation of 75 Pa.C,S,A. ~3362 and applicable law; (n) Otherwise operating his vehicle at an unsafe speed; -4- Document #: 171724.1 " .-, "'-, "I:: (0) Failing to keep alert and maintain a proper lookout for the presence of other motor vehicles on the streets and highways; (P) Failing to familiarize himself with the roadway and his surroundings; (q) Failing to pull over or stop to obtain his bearings before proceeding into the intersection; (r) Not paying attention to his surroundings; (s) Reading a map at the time he was traveling through the intersection or performing other distracting activities instead of paying attention to where he was driving; (t) Failing to obtain proper directions before he began to operate the vehicle; and (u) Driving his vehicle in reckless disregard for the safety of persons or property in violation of 75 Pa,C,S,A. ~3736 and applicable law, 20, As a direct and proximate result of the collision and the negligent, careless and reckless conduct of Defendant Gary E, Sheaffer, Plaintiffs sustained personal injuries and damages as more fully set forth herein. 21. In addition to being vicariously liable for the acts of its employee, servant, workman and/or agent, Defendant Osborn Printing Co. was also negligent, careless and reckless as follows: (a) Failing to properly train its employees, servants, workmen and/or agents in the operation of its vehicles; (b) Failing to provide its employees, servants, workmen and/or agents with proper directions before allowing them to operate its vehicles; - 5 - Document #: 171724.1 ~ ;,-, .~ . - -,&, (c) Failing to ensure that its employees, servants, workmen and/or agents are familiar with the roadways and route of travel before allowing them to operate its vehicles; (d) Failing to properly supervise or control its employees, servants, workmen and/or agents while they are operating its vehicles; (e) Hiring and/or retaining employees, servants, workmen and/or agents who may be unfit or incompetent to operate its vehicles; (0 Failing to have in place proper procedures, rules, regulations, protocols or safety measures to ensure that other motorists are not endangered by the operation of its vehicles by its employees, servants, workmen and/or agents; (g) Sending out its employee, servant, workman and/or agent for an errand or job without proper instructions, directions and/or guidance; and (h) Failing to take proper precautions to protect Plaintiffs and other lawful users of the roadway from the negligent, careless and reckless actions of its employees, servants, workmen and/or agents. 22. As a direct and proximate result of the collision and the negligent, careless and reckless conduct of Defendant Osborn Printing Co" Plaintiffs sustained personal injuries and damages as more fully set forth, 23, The Defendants violated Pennsylvania Statutes in effect at the time of the accident and are negligent per se and as a matter of law, COUNT I - NEGLIGENCE Plaintiff Wendell K. Mvers. Jr. v. Defendants 24. Paragraphs 1 through 23 hereof are incorporated herein by reference as if fully set forth, -6- Document#: 171724.1 _'-l .- __I . .0 ., -:~' 25, As a direct and proximate result of the collision and the negligent, careless and reckless conduct of Defendants, Plaintiff Wendell K. Myers, Jr, sustained and in the future may sustain, serious and debilitating injuries, some of which are or may be permanent, and which include, but not are not limited to, the following: (a) Left clavicular fracture with ligamentous disruption; (b) Complex lacerations of the left face with shards of glass within the wounds; (c) Complex lacerations of the right forearm with shards of glass within the wounds; and (d) Lacerations of the left arm and abrasions on the right leg. 26, As a direct and proximate result of the aforesaid collision, negligence, carelessness and recklessness of Defendants, Plaintiff Wendell Myers, Jr. has undergone and in the future will undergo great physical pain, mental pain, discomfort, inconvenience, distress, embarrassment and humiliation, present, past and future loss of his ability to enjoy the pleasures of life and limitations in pursuit of daily activities, all to his great loss and detriment, 27. As a direct and proximate result of the aforesaid collision, negligence, carelessness and recklessness of Defendants, Plaintiff Wendell Myers, Jr. has been permanently scarred, deformed and disfigured. WHEREFORE, Plaintiff Wendell Myers, Jr., demands judgment against Defendants, either individually and/or jointly and severally, for the aforesaid damages in an amount which exceeds the limits of compulsory arbitration in Cumberland County, Pennsylvania, plus interest and/or damages for delay and costs of prosecution, -7- Document #: 171724.1 0' ., COUNT II - NEGLIGENT INFLICTION OF EMOTIONAL DISTRESS Plaintiff Wendell Mvers. Jr. v. Defendants 28. Paragraphs 1 through 27 hereof are incorporated herein by reference as if fully set forth. 29. Aside from the physical injuries sustained as a result of the impact from the accident, Plaintiff Wendell Myers, Jr. has suffered fright, shock, anxiety and other emotional distress directly traceable to the peril in which the aforesaid Defendants' negligence placed him, 30. The emotional distress arises from the traumatic accident, viewing the accident scene, viewing the injuries sustained to family members, being separated from family members who were taken to different hospitals and not knowing the condition of family members, WHEREFORE, Plaintiff Wendell Myers, Ir" demands judgment against Defendants, either individually and/or jointly and severally, for the aforesaid damages in an amount which exceeds the limits of compulsory arbitration in Cumberland County, Pennsylvania, plus interest and/or damages for delay and costs of prosecution, COUNT III - NEGLIGENCE Plaintiff Mel!an N. Mvers v. Defendants 31, Paragraphs 1 through 30 hereof are incorporated herein by reference as if fully set forth, 32. As a direct and proximate result of the collision and the negligent, careless and reckless conduct of Defendants, Plaintiff Megan N. Myers sustained and in the future may - 8 - Document #: 171724.1 "~~ . " ~, ,. ~ .'. . sustain, serious and debilitating injuries, some of which are or may be permanent, and which include, but not are not limited to, the following: (a) Trauma and injury to her neck; (b) Trauma and injury to her abdomen including abrasions; (c) Possible closed head injury; and (d) Headaches, 33, As a direct and proximate result of the aforesaid collision, negligence, carelessness and recklessness of Defendants, Plaintiff Megan N, Myers has undergone and in the future will undergo great physical pain, mental pain, discomfort, inconvenience, distress, embarrassment and humiliation, present, past and future loss of her ability to enjoy the pleasures of life and limitations in pursuit of daily activities, all to her great loss and detriment. 34, As a direct and proximate result of the aforesaid collision, negligence, carelessness and recklessness of Defendants, Plaintiff Megan N, Myers has been permanently scarred, deformed and disfigured. WHEREFORE, Plaintiff Megan N, Myers, demands judgment against Defendants, either individually and/or jointly and severally, for the aforesaid damages in an amount which exceeds the limits of compulsory arbitration in Cumberland County, Pennsylvania, plus interest and/or damages for delay and costs of prosecution, -9- Document #: 171724.1 ~ . -~.- . _~c COUNT IV - NEGLIGENT INFLICTION OF EMOTIONAL DISTRESS Plaintiff Mel!an N. Myers y. Defendants 35, Paragraphs 1 through 34 hereof are incorporated herein by reference as if fully set forth, 36, Aside from the physical injuries sustained as a result of the impact from the accident, Plaintiff Megan N, Myers has suffered fright, shock, anxiety and other emotional distress directly traceable to the peril in which the aforesaid Defendants' negligence placed her. 37, The emotional distress arises from the traumatic accident, viewing the accident scene, viewing the injuries sustained to family members, being separated from family members who were taken to different hospitals and not knowing the condition of family members. WHEREFORE, Plaintiff Megan N, Myers, demands judgment against Defendants, either individually and/or jointly and severally, for the aforesaid damages in an amount which exceeds the limits of compulsory arbitration in Cumberland County, Pennsylvania, plus interest and/or damages for delay and costs of prosecution. COUNT V - NEGLIGENCE Plaintiff Shannon B. Myers Y. Defendants 38. Paragraphs 1 through 37 hereof are incorporated herein by reference as if fully set forth, 39. As a direct and proximate result of the collision and the negligent, careless and reckless conduct of Defendants, Plaintiff Shannon B, Myers sustained and in the future may - 10 - Document#: 171724.1 - - '; ~" sustain, serious and debilitating injuries, some of which are or may be permanent, and which include, but not are not limited to, the following: (a) Trauma and injury to her neck; and (b) Trauma and injury to her abdomen including abdominal contusion. 40. As a direct and proximate result of the aforesaid collision, negligence, carelessness and recklessness of Defendants, Plaintiff Shannon B. Myers has undergone and in the future will undergo great physical pain, mental pain, discomfort, inconvenience, distress, embarrassment and humiliation, present, past and future loss of her ability to enjoy the pleasures of life and limitations in pursuit of daily activities, all to her great loss and detriment. 41, As a direct and proximate result of the aforesaid collision, negligence, carelessness and recklessness of Defendants, Plaintiff Shannon B. Myers has been permanently scarred, deformed and disfigured. WHEREFORE, Plaintiff Shannon B, Myers, demands judgment against Defendants, either individually and/or jointly and severally, for the aforesaid damages in an amount which exceeds the limits of compulsory arbitration in Cumberland County, Pennsylvania, plus interest and/or damages for delay and costs of prosecution. COUNT VI - NEGLIGENT INFLICTION OF EMOTIONAL DISTRESS Plaintiff Shannon B. Mvers v. Defendants 42. Paragraphs 1 through 41 hereof are incorporated herein by reference as if fully set forth, - 11 - Document #: 171724.1 ;~.,~~, ""~~~ 43, Aside from the physical injuries sustained as a result of the impact from the accident, Plaintiff Shannon B. Myers has suffered fright, shock, anxiety and other emotional distress directly traceable to the peril in which the aforesaid Defendants' negligence placed her. 44. The emotional distress arises from the traumatic accident, viewing the accident scene, viewing the injuries sustained to family members, being separated from family members who were taken to different hospitals and not knowing the condition of family members, WHEREFORE, Plaintiff Shannon B, Myers, demands judgment against Defendants, either individually and/or jointly and severally, for the aforesaid damages in an amount which exceeds the limits of compulsory arbitration in Cumberland County, Pennsylvania, plus interest and/or damages for delay and costs of prosecution. VII - NEGLIGENCE Plaintiff Wendell K. Mvers v. Defendants 45, Paragraphs I through 44 hereof are incorporated by reference as if fully set forth, 46, As a direct and proximate result of the collision and negligent, careless and reckless conduct of Defendants, Plaintiff Wendell K. Myers sustained and in the future may sustain, serious and debilitating injuries, some of which are or may be permanent and which include, but are not limited to, the following: (a) Irregular deep laceration on the left scalp; (b) Contusions over the left upper chest with tenderness; (c) Abrasions and tenderness of the abdomen; (d) Abrasions on the left anterior calf; - 12- Document #: 171724.1 .~ , ,'"'"b .~ ". "." (e) Large laceration on the left arm and forearm with particularly the left elbow; (t) Possible left radius fracture; (g) Closed head injury; and (h) Multiple abrasions, cuts and scarring of different areas of the body, 47, As a direct and proximate result of the aforesaid collision, negligence, carelessness and recklessness of Defendants, Plaintiff Wendell K, Myers, was hospitalized, underwent several surgeries including skin grafts and other significant treatment and was forced to incur medical bills and expenses for the injuries he has suffered and will continue to incur medical bills and expenses in the future, 48, As a direct and proximate result of the aforesaid collision, negligence, carelessness and recklessness of Defendants, Plaintiff Wendell K, Myers, was forced to incur medical bills and expenses for the injuries to his children and the minor Plaintiffs and may continue to incur medical expenses in the future for them. 49, As a direct and proximate result of the aforesaid collision, negligence, carelessness and recklessness of Defendants, Plaintiff Wendell K. Myers, has suffered and may suffer a loss of earnings, may suffer permanent disability, impairment and/or loss of earning capacity, 50, As a direct and proximate result of the aforesaid collision, negligence, carelessness and recklessness of Defendants, Plaintiff Wendell K. Myers, has undergone and in the future will undergo great mental and physical pain and suffering, mental anguish, discomfort, anxiety and distress, embarrassment and humiliation, past, present and future loss of his ability to - 13 - Documenl #: 171724. J " = ~ ~~~" ~ .1- -~.o'itl' I I I ! enjoy the pleasures of life and a severe limitation in his pursuit of daily activities, all to his great loss and detriment. 51, As a direct and proximate result of the aforesaid collision, negligence, carelessness and recklessness of Defendants, Plaintiff Wendell K, Myers, has been permanently scarred, deformed and disfigured, 52. As a direct and proximate result of the aforesaid collision, negligence, carelessness and recklessness of Defendants, Plaintiff Wendell K. Myers, has sustained incidental costs associated with his injuries including medication expenses, WHEREFORE, Plaintiff Wendell K. Myers, demands judgment against Defendants, either individually and/or jointly and severally, for the aforesaid damages in an amount which exceeds the limits of compulsory arbitration in Cumberland County, Pennsylvania, plus interest and/or damages for delay and costs of prosecution. COUNT VIII - NEGLIGENT INFLICTION OF EMOTIONAL DISTRESS Plaintiff Wendell K. Mvers v. Defendants 53, Paragraphs 1 through 52 hereof are incorporated herein by reference as if fully set forth, 54, Aside from the physical injuries sustained as a result of the impact from the accident, Plaintiff Wendell K. Myers has suffered fright, shock, anxiety and other emotional distress directly traceable to the peril in which the aforesaid Defendants' negligence placed him, - 14 - Document #: 171724.1 . h . "-- 55. The emotional distress arises from the traumatic accident, viewing the accident scene, viewing the injuries sustained to family members, being separated from family members who were taken to different hospitals and not knowing the condition of family members. WHEREFORE, Plaintiff Wendell K. Myers, demands judgment against Defendants, either individually and/or jointly and severally, for the aforesaid damages in an amount which exceeds the limits of compulsory arbitration in Cumberland County, Pennsylvania, plus interest and/or damages for delay and costs of prosecution. IX - LOSS OF CONSORTIUM Plaintiff Wendell Mvers v. Defendants 56, Paragraphs I through 55 hereof are incorporated herein by reference as if fully set forth, 57, During all relevant times, Plaintiff Wendell K, and Donna], Myers, were husband and wife, and solely as a result of the collision, the aforesaid negligence, carelessness and recklessness of Defendants and as a result of the injuries to Plaintiff Donna ], Myers, the Plaintiff Wendell K. Myers has been deprived of the assistance, companionship, consortium and society of his wife and has lost her services to him all to his great loss and detriment which may continue indefinitely. WHEREFORE, Plaintiff Wendell K, Myers, demands judgment against Defendants, either individually and/or jointly and severally, for the aforesaid damages in an amount which exceeds the limits of compulsory arbitration in Cumberland County, Pennsylvania, plus interest and/or damages for delay and costs of prosecution, - 15 - Document #: 171724.1 . '~ . x - NEGLIGENCE Plaintiff Donna J. Mvers v. Defendants 58, Paragraphs I through 57 hereof are incorporated by reference as if fully set forth, 59, As a direct and proximate result of the collision and negligent, careless and reckless conduct of Defendants, Plaintiff Donna 1. Myers sustained and in the futUTe may sustain, serious and debilitating injuries, some of which are or may be permanent and which include, but are not limited to, the following: (a) Displaced fracture of her left fifth finger; (b) Trauma and scarring to her right leg; (c) Traced blood in the urine; and (d) Multiple contusions including on her ribs and abdomen, 60. As a direct and proximate result of the aforesaid collision, negligence, carelessness and recklessness of Defendants, Plaintiff Donna 1. Myers, was hospitalized, underwent several sUTgeries and other significant treatment and was forced to inCUT medical bills and expenses for the injUTies she has suffered and will continue to incUT medical bills and expenses in the future. 61. As a direct and proximate result of the aforesaid collision, negligence, carelessness and recklessness of Defendants, Plaintiff Donna J. Myers, was forced to incUT medical bills and expenses for the injUTies to her children and the minor Plaintiffs and may continue to incUT medical expenses in the future for them, 62, As a direct and proximate result of the aforesaid collision, negligence, carelessness and recklessness of Defendants, Plaintiff Donna J, Myers, has suffered and may - 16 - Document #: 171724.1 J~~ ~~ ~ suffer a loss of earnings, including loss of homemakers' and/or household services, may suffer permanent disability, impairment and/or loss of earning capacity, 63. As a direct and proximate result of the aforesaid collision, negligence, carelessness and recklessness of Defendants, Plaintiff Donna 1. Myers, has undergone and in the future will undergo great mental and physical pain and suffering, mental anguish, discomfort, anxiety and distress, embarrassment and humiliation, past, present and future loss of her ability to enjoy the pleasures of life and a severe limitation in her pursuit of daily activities, all to her great loss and detriment. 64. As a direct and proximate result of the aforesaid collision, negligence, carelessness and recklessness of Defendants, Plaintiff Donna 1. Myers, has been permanently scarred, deformed and disfigured, 65, As a direct and proximate result of the aforesaid collision, negligence, carelessness and recklessness of Defendants, Plaintiff Donna J, Myers, has sustained incidental costs associated with her injuries including medication expenses, WHEREFORE, Plaintiff Donna J. Myers, demands judgment against Defendants, either individually and/or jointly and severally, for the aforesaid damages in an amount which exceeds the limits of compulsory arbitration in Cumberland County, Pennsylvania, plus interest and/or damages for delay and costs of prosecution, COUNT XI - NEGLIGENT INFLICTION OF EMOTIONAL DISTRESS Plaintiff Donna J. Myers v. Defendants 66, Paragraphs 1 through 65 hereof are incorporated herein by reference as if fully set forth. - 17 - Document #: 171724.1 ------ ---- -""'''',......_-.<t ~~~~ " ill ." - 'M:, 67. Aside from the physical injuries sustained as a result of the impact from the accident, Plaintiff Donna J, Myers has suffered fright, shock, anxiety and other emotional distress directly traceable to the peril in which the aforesaid Defendants' negligence placed her. 68. The emotional distress arises from the traumatic accident, viewing the accident scene, viewing the injuries sustained to family members, being separated from family members who were taken to different hospitals and not knowing the condition of family members. WHEREFORE, Plaintiff Donna J, Myers, demands judgment against Defendants, either individually and/or jointly and severally, for the aforesaid damages in an amount which exceeds the limits of compulsory arbitration in Cumberland County, Pennsylvania, plus interest and/or damages for delay and costs of prosecution, XII - LOSS OF CONSORTIUM Plaintiff Donna J. Mvers v. Defendants 69, Paragraphs 1 through 68 hereof are incorporated herein by reference as if fully set forth, 70, During all relevant times, Plaintiff Wendell K. and Donna J. Myers, were husband and wife, and solely as a result of the collision, the aforesaid negligence, carelessness and recklessness of Defendants and as a result of the injuries to Plaintiff Wendell K. Myers, the Plaintiff Donna 1. Myers has been deprived of the assistance, companionship, consortium and society of her husband and has lost his services to her all to her great loss and detriment which may continue indefinitely, - 18 - Document #: 171724.1 ~-~".",. . ~ .-~~ WHEREFORE, Plaintiff Donna J, Myers, demands judgment against Defendants, either individually and/or jointly and severally, for the aforesaid damages in an amount which exceeds the limits of compulsory arbitration in Cumberland County, Pennsylvania, plus interest and/or damages for delay and costs of prosecution, XIII - NEGLIGENCE Plaintiff Ernest F. Helm v. Defendants 71. Paragraphs I through 70 hereof are incorporated by reference as if fully set forth, 72, As a direct and proximate result of the collision and negligent, careless and reckless conduct of Defendants, PlaintiffEmest F, Helm sustained and in the future may sustain, serious and debilitating injuries, some of which are or may be permanent and which include, but are not limited to, the following: (a) Fracture of the cervical spine at C2; (b) Fracture of the cervical spine at C7; (c) Fracture of the thoracic spine at T1 ; (d) Left clavicle fracture; (e) Fracture of the left sixth rib; (f) Fracture of the left seventh rib; (g) Fracture of the left eighth rib; (h) Fracture ofthe left ninth rib; (i) Myocardial contusion and possible myocardial infraction; G) Head injury involving concussion and loss of consciousness; (k) Laceration of scalp; - 19 - Document#: 171724.1 I. . ~, , ~ ~ "', (I) Lacerations, hematoma and multiple abrasions at multiple areas of his body; and (m) In'egularity of lateral cortical surface of the proximal right tibia and tibial plateau fracture and possible tibial fracture. 73, As a direct and proximate result of the aforesaid collision, negligence, carelessness and recklessness of Defendants, Plaintiff Ernest F, Helm, was hospitalized, underwent a repair of the scalp laceration, central venous pressure line was inserted in the left femoral vein and was given a Miami J-collar and figure eight brace for his cervical, thoracic and clavicle fractures and other significant treatment and was forced to incur medical bills and expenses for the injuries he has suffered and will continue to incur medical bills and expenses in the future, 74, As a direct and proximate result of the aforesaid collision, negligence, carelessness and recklessness of Defendants, Plaintiff Ernest F, Helm, has undergone and in the future will undergo great mental and physical pain and suffering, mental anguish, discomfort, anxiety and distress, embarrassment and humiliation, past, present and future loss of his ability to enjoy the pleasures of life and a severe limitation in his pursuit of daily activities, all to his great loss and detriment. 75, As a direct and proximate result of the aforesaid collision, negligence, carelessness and recklessness of Defendants, Plaintiff Ernest F, Helm, has been permanently scarred, deformed and disfigured, 76, As a direct and proximate result of the aforesaid collision, negligence, carelessness and recklessness of Defendants, Plaintiff Ernest F, Helm, has sustained incidental costs associated with his injuries including medication expenses, - 20- Document #: 171724.1 ,-" ~"....-.- ", ., -" "'. .~ . ~ '0' "~'" WHEREFORE, Plaintiff Ernest F, Helm, demands judgment against Defendants, either individually and/or jointly and severally, for the aforesaid damages in an amount which exceeds the limits of compulsory arbitration in Cumberland County, Pennsylvania, plus interest and/or damages for delay and costs of prosecution, COUNT XIV - NEGLIGENT INFLICTION OF EMOTIONAL DISTRESS Plaintiff Ernest F. Helm v. Defendants 77, Paragraphs 1 through 76 hereof are incorporated herein by reference as if fully set forth. 78, Aside from the physical injuries sustained as a result of the impact from the accident, Plaintiff Ernest F, Helm has suffered fright, shock, anxiety and other emotional distress directly traceable to the peril in which the aforesaid Defendants' negligence placed him. 79, The emotional distress arises from the traumatic accident, viewing the accident scene, viewing the injuries sustained to family members, being separated from family members who were taken to different hospitals and not knowing the condition of family members, WHEREFORE, Plaintiff Ernest F, Helm, demands judgment against Defendants, either individually and/or jointly and severally, for the aforesaid damages in an amount which - 21 - Document #: 171724.1 ~"......... - J' ~ ~~-c:? exceeds the limits of compulsory arbitration in Cumberland County, Pennsylvania, plus interest and/or damages for delay and costs of prosecution. Respectfully submitted, METZGER, WICKERSHAM, KNAUSS & ERB, P,C, By: ---- --,.., Clark De V ere, Esquire Attorney LD, No. 68768 3211 North Front Street P,O, Box 5300 Harrisburg, PA 17110-0300 (717) 238-8187 Attorney for Plaintiffs Dated: <1/3/00 - 22- Document #: 171724.1 I:"~'~ a>"= ~~~ -~ - ~ '. -- VERIFICATION We, Wendell K. Myers and Donna J, Myers, as parents and natural guardians of minor Plaintiffs Wendell K. Myers, Jr" Megan N, Myers and Shannon B, Myers, hereby certify that the following is correct: The facts set forth in the foregoing Civil Complaint are based upon information which we have furnished to counsel, as well as upon information which has been gathered by counsel and/or others acting on OUT behalf in this matter. The language of the Civil Complaint is that of counsel and not OUT own. We have read the Civil Complaint, and to the extent that it is based upon information which we have given to counsel, it is true and correct to the best of OUT knowledge, information, and belief. To the extent that the content of the Civil Complaint is that of counsel, we have relied upon such counsel in making this Verification. We hereby acknowledge that the facts set forth in the aforesaid Civil Complaint are made subject to the penalties of 18 Pa. C,S.A. g4904 relating to unsworn falsification to authorities. Dated: 3~ 3\ ,OD w~ K (Vl~ 4, Wendell K. Myers GrrvnJ\B (Y)tY A <1 / Donna J, Mye Dated: 3-31-00 Document #: 171724.1 -- ~ - " ". ". . , ~ .- ,C ."'J VERIFICATION I, Wendell K. Myers, hereby certifY that the following is correct: The facts set forth in the foregoing Civil Complaint are based upon information which I have furnished to counsel, as well as upon information which has been gathered by counsel and/or others acting on my behalf in this matter. The language of the Civil Complaint is that of counsel and not my own, I have read the Civil Complaint, and to the extent that it is based upon information which I have given to counsel, it is true and correct to the best of my knowledge, information, and belief. To the extent that the content of the Civil Complaint is that of counsel, I have relied upon such counsel in making this Verification, I hereby acknowledge that the facts set forth in the aforesaid Civil Complaint are made subject to the penalties of 18 Pa, C,S,A. 94904 relating to unsworn falsification to authorities. Dated: 3~ 31 ~oo /AJ~;!p1~ k, Wendell K. Myers Document #: 171724.1 "~ '"'~- -" VERIFICATION I, Donna J. Myers, hereby certify that the following is correct: The facts set forth in the foregoing Civil Complaint are based upon information which I have furnished to counsel, as well as upon information which has been gathered by counsel and/or others acting on my behalf in this matter, The language of the Civil Complaint is that of counsel and not my own. I have read the Civil Complaint, and to the extent that it is based upon information which I have given to counsel, it is true and correct to the best of my knowledge, information, and belief, To the extent that the content of the Civil Complaint is that of counsel, I have relied upon such counsel in making this Verification. I hereby acknowledge that the facts set forth in the aforesaid Civil Complaint are made subject to the penalties of 18 Pa, C,S,A. 94904 relating to unsworn falsification to authorities, Dated: 2> -3 I-co fk/Y1D~ m~ Donna J, M s Document #: 171724.1 "'" ,_. . """ ii, VERIFICATION I, Ernest F, Helm, hereby certify that the following is correct: The facts set forth in the foregoing Civil Complaint are based upon information which I have furnished to counsel, as well as upon information which has been gathered by counsel and/or others acting on my behalf in this matter. The language of the Civil Complaint is that of counsel and not my own. I have read the Civil Complaint, and to the extent that it is based upon information which I have given to counsel, it is true and correct to the best of my knowledge, information, and belief, To the extent that the content of the Civil Complaint is that of counsel, I have relied upon such counsel in making this Verification, I hereby acknowledge that the facts set forth in the aforesaid Civil Complaint are made subject to the penalties of 18 Pa, C,S,A. 94904 relating to unsworn falsification to authorities, .31 ~ co Dated: 9 - e~!Sy~ Ernest F, Helm Document #: 171724.1 <" ,. ^ Stephen E. Geduldig, Esquire Attorney 1.0. No. 43530 THOMAS, THOMAS & HAFER, LLP 305 North Front Street Post Office Box 999 Harrisburg, Pennsylvania 17108 (717) 237-7100 E-Mail: seq@tthlaw.com "~,' , ~,-~ ~~-, " ~,"c::.. ','._ ' ,~ _ _~.' -'- .'.. .'.~- - ,. ':,., '-~'I ! Attorneys for Defendants: GARY E, SHEAFFER and OSBORN PRINTING CO, WENDELL K. MYERS, JR., MEGAN N. MYERS and SHANNON B. MYERS, minors, by WENDELL K. MYERS and DONNA J. MYERS, their parents and natural guardians and WENDELL K. MYERS, DONNA J. MYERS and ERNEST F. HELM, in their own right, Plaintiffs v. GARY E. SHEAFFER and OSBORN PRINTING CO., Defendants IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION -- LAW NO. 2000-2060 JURY TRIAL DEMANDED PRAECIPE FOR ENTRY OF APPEARANCE TO THE PROTHONOTARY: Please enter the appearance of Stephen E. Geduldig, Esquire, and Thomas, Thomas & Hafer, LLP, as attorneys for Defendants, Gary E. Sheaffer and Osborn Printing Co., in the above-captioned matter, reserving our right to answer or otherwise plead to Plaintiffs' Complaint. if 60 ( IJ{J By: :91808,1 Respectfully submitted, THOMAS, THOMAS & HAFER, LLP ?U~ 4&; STEPHEN E. GEDULDIG, ESQUIRE Attorney I.D. No. 43530 Attorneys for Defendants, GARY E. SHEAFFER and OSBORN PRINTING CO. ". , , <,.'--, _~ " ~ _ '0' _,,_ ,.._ c,,, , _" ; -'.e-._ ,'", ,'_"~O_"'C.::<'-,-_.. ' _r' ,~. ',','. ' " ,_ i I I , . CERTIFICATE OF SERVICE I hereby certify that a true and correct copy of the foregoing document was served by depositing the same in the United States Mail, po::~~prepaid, at Harrisburg, Pennsylvania, on the lCjNY\ day of April, 2000, on all counsel of record as follows: Clark DeVere, Esquire METZGER, WICKERSHAM, KNAUS & ERB Post Office Box 5300 Harrisburg, Pennsylvania 17110-0300 Attorneys for Plaintiffs TBO~S, THO~S & HAFER, LLP .-- ~"~I - -~,,"'-"_ ~""'- ..i~ ('1~>f'"_ '_."l~L'" " '" ,~ 7__" .., - ,'.c__ ~., -,' ,~J - ,. < ,~ -,~ ~ . L. ,,- - " ~ -" ",'". 0 CJ () C {::::J "T: s: :hoo -0 [' ~'..:! .. , Q1Q'i ..'-oJ z.__ "7,. e75>,. -<.. ~~C_'-J .. ~~3 ._.~ r"'J i ';"l..,_ ~:;! ~~ (,) ~':'D -< u, -< ,,~~ .. IJ'" .. J >1 SHERIFF'S RETURN - OUT OF COUNTY CASE NO: 2000-02060 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND MYERS WENDELL K JR ET AL VS SHEAFFER GARY E ET AL R, Thomas Kline , Sheriff or Deputy Sheriff who being duly sworn according to law, says, that he made a diligent search and and inquiry for the within named DEFENDANT , to wit: SHEAFFER GARY E but was unable to locate Him in his bailiwick. He therefore deputized the sheriff of ADAMS County, Pennsylvania, to serve the within COMPLAINT & NOTICE On April 17th, 2000 , this office was in receipt of the attached return from ADAMS Sheriff's Costs: Docketing Out of County Surcharge Dep. Adams Co 18,00 9,00 10.00 35.20 ,00 72 .20 04/17/2000 METZGER, WICKERSHAM so~~ R, Thomas Kline Sheriff of Cumberland County Sworn and subscribed to before me this /q ~ ;2 rnro (Jr- day of ()f" j A.D. o '--rw.ol.., ~ ' Prothonotary .. "~ - SHERIFF'S RETURN - OUT OF COUNTY CASE NO: 2000-02060 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND MYERS WENDELL K JR ET AL VS SHEAFFER GARY E ET AL R, Thomas Kline , Sheriff or Deputy Sheriff who being duly sworn according to law, says, that he made a diligent search and and inquiry for the within named DEFENDANT , to wit: OSBORN PRINTING CO but was unable to locate Them in his bailiwick, He therefore deputized the sheriff of ADAMS County, Pennsylvania, to serve the within COMPLAINT & NOTICE On April 17th, 2000 , this office was in receipt of the attached return from ADAMS Sheriff's Costs: Docketing Out of County Surcharge 6.00 .00 10,00 ,00 .00 16.00 04/17/2000 METZGER, WICKERSHAM ;::::~ County Sworn and subscribed to before me this Jt?'f:: day of 121'1<, '1 V .2c-rro A. D , Q"'R (,1 ~,OP'd ~ prothonotarf - ,- ~="~,>~" - '-. .-,., In The Court of Common Pleas of Cumberland County, Pennsylvania Wendell K. Myers. Jr., et. al. VS. Gary E. Sheaffer. et. al. Serve: Gary E. Sheaffer No. 20-2060 Civil Now, 4/4/00 , 20" <' , I, SHERIFF OF CUMBERLAND COUNTY, P A, do . hereby deputize the Sheriff of Adams County to exe.cute this Writ, this deputation being made at the request and riSkoft?~ ~f Sheriff of Cumberland County, P A Affidavit of Service Now, ,20_, at o'clock M, served the within upon at by handing to a copy ofthe original and made known to the contents thereof, So answers, 20 '- V DVWabOOlWll A 2HE~11:.1:. COSTS stiDD ~S: sr MILEAGE HE@lfN€U $ County, PA Sworn and subscribed before me this _ day of $ i3Wl_~'- ~"""""'''~~''-~~_~ilIIImliI~tle;''-'I':-*r,!;h(i;[MlJ;l~~llimj[]lllII-_'''' --~. ". A1Nnoo swvov JJIH3HS qz :Z d q-._ I 03^1303~ "!I!!!IL .. ~,. ". 0."__ ~~ - ~ ~" ~HMlliIlij 11' ",---... _.~- -~ ~-,- -~."- '.;-~ .; . '"''~''' "--. , " J - . "'.j In The Court of Common Pleas of Cumberland County, Pennsylvania Wendell K. Myers, Jr., et. al. VS. Gary E. Sheaffer, et. al. Serve: Osborn Printing Co N o. 20-2060 Civil N W 4/4/00 o , , 200 Q , I, SHERIFF OF CUMBERLAND COUNTY, P A, do hereby deputize the Sheriff of Adams County to exe.cute this Writ, this deputation being made at the request and risk ofthe Plaintiff. .// ~ . ~~~~l Sheriff of Cumberland County, P A Affidavit of Service Now, ,20 ,at o'clock M. served the within upon at by handing to a copy of the original and made known to the contents thereof. So answers, VDVW~';G;Q~Uriffof 2HE8lll COSTS SOl Yb8 i:P' smR~ ,20_ MILEAGE 1:5 E C ~ tMHJ>A VIT County, PA Sworn and subscribed before me this day of $ $ _~;;.i.. J. "'= ..., . -_iIiIliIIIilllill~~1&lJ",jl,.j,MB~~U~"'~la' M.iI:' l_~'~_"" L____ "~"iliil!rMJ;~a~ AINnoo SWVOV :UIH3HS QZ :Z d q-.. I 03^1303~ -_. -~"- ,'~" ~ .~." ~__, 1 . ^_ . ,,. ~ ~ - ,. . -" "~ . -'~....." Stephen E. Geduld!g, Esquire Att~ey 1.0. No. 43530 THOMAS. THOMAS & HAFER, L.LP 305 North Front Street Post Office BoxS99 Harrisburg, Pennsylvania 17108 (717) 237.7100 E-Mail: seq@tthlaw.com Attorneys for Defendants: GARY E. SHEAFFER and OSBORN PRINTING co. WENDELL K. MYERS, JR., MEGAN N. MYERS and SHANNON B. MYERS, minors, by WENDELL K. MYERS and DONNA J. MYERS, their parents and natural guardians and WENDELL K. MYERS, DONNA J. MYERS and ERNEST F. HELM, in their own right, Plaintiffs- IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA v. CIVIL ACTION -- LAW NO. 2000-2060 GARY E. SHEAFFER and OSBORN PRINTING CO., Defendants JURY TRIAL DEMANDED ~?~~'_:;',~--;;;o,;;"--:;--===__- . ...CERTI FfcATE "'PREREQUISITE TO SERVICE OF SUBPOENAS ._U PURSUANT TO RULE 4009.22 . -,~~-~~~~._~ ,,,<<to '~^':";"::' :~.::::'" -"~ As a prerequisite to service of subpoenas for dGcuments and things pursuant to Rule 4009.22, Defendant certifies that: 1. A Notice of Intent to Serve Subpoenas with cGpies of the subpoenas attached thereto was mailed or delivered to each party at least twenty days prior to the day .on which the subpoenas were .s.ought tG be served; 2. A copy of the Notice of Intent, including the proposed subpoenas, is attached to this Certificate; 3. No GbjectiGn to the subpoenas has been received; and 4. The .subpoenas which will be served are identical to the subpoenas which are attached to ths! NGtice of Intent to Serve Subpoenas. THOMAS, THOMAS & HAFER, LLP Sl"X> (CO STEPHEN E. GEDULDIG, ESQUIRE 305 NORTH FRONT STREET - 6TH FLOOR HARRISBURG, PA 17108 (717) 237-7119 ATTORNEY FOR DEFENDANTS Altorneyl.O NO. 43530 THOMAS, THOMAS & HAFER" L.L.P 305 North Front Street Post Office 80x 999 Harrisburg, Pennsylvania 17108 (717)237-7100 E-MaJl: seo@tthlaw,com Attorneys for Defendants' GARY E. SHEAFFER and OSBORN PRINTING CO. WENDELL K. MYERS, JR., MEGAN N. MYERS and SHANNON B. MYERS, minors, by WENDELL K. MYERS and DONNA J. MYERS, their parents and natural guardians and WENDELL K. MYERS, DONNA J. MYERS and ERNEST F. HELM, in their own right, Plaintiffs I~ THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA v. CIVIL ACTION -- LAW NO. 2000-2060 GARY E. SHEAFFER and OSBORN PRINTING CO., Defendants JURY TRIAL DE~NDED NOTlCEOEJNTENT.TO..SERV.E.SUB~OENAS IO~~. PRODUtEDOCUMENTSAND.THINGS FOR.. DISCQV.EgY_PURS_UANT:rO~RULE4QO:9.21 '" "--'--'-=-"--'--;-" -~':~:.;] , TO: Counsel and Parties of Record Defendants, Gary E. Sheaffer and Osborn Printing Co., intend to serve subpoenas identical to the ones attached to this notice. You have twenty (20) days from the date listed below in which to file of record and serve upon the undersigned an objection to the subpoenas. If no objection is made, the subpoenas may be served. THOMAS, THOMAS & HAFER, llP S~ 305 NORTH FRONT STREET - 6TH flOOR HARRISBURG, PA 17108 (717) 237-7119 ATTORNEY FOR DEFENDANTS Date: May 8, 2000 "" ~ I, .. ,. . Stephen E. Geduldig, Esquire Allomey 1.0. No. 43530 THOMAS, THOMAS & HAFER. LlP 305 North Front Street Post Office Box 999 Harrisburg, Pennsylvania 17108 (717)237-7100 E-Mail: seq@tthlaw.com Altomeys for Defendants: GARY E.. SHEAFFER and OSBORN PRIN11NG CO. WENDELL K. MYERS, JR., MEGAN N. MYERS and SHANNON B. MYERS, minors, by WENDELL K. MYERS and DONNA J. MYERS, their parents and natural guardians and WENDELL K. MYERS, DONNA J. MYERS and ERNEST F. HELM, in their own right, Plaintiffs IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA v. CIVIL ACTION -- LAW NO. 2000-2060 GARY E. SHEAFFER and OSBORN PRINTING CO., Defendants JURY TRIAL DEMANDED SUBPOENA TO PRODUCE DOCUMENTS OR THINGS FOR DISCOVERY PURSUANT TO RULE 4009.22 TO: Custodian of Records. Erie Insurance GrauD. 4901 Louise Drive. MechanicsburQ. PA 17055 (Name of Person or Entity) Within twenty (20) days after service of this subpoena, you are ordered by the court to produce the following documents or thmgs; A comDlete CODV of the first party benefits files. includinQ but not limned to printouts of first party benefits payments reQardinq insureds: Wendell MYers. Sr., Donna MYers, Wendell MYers. Jr.. Meaan Mvers. Shannon Mvers and Ernest Helm. Policv No.: Q070306684H. Dale of LoSs: 7/8/99 at: Thomas. Thomas & Hafer. LLP. 305 N. Frant St. P.O. Box 999. Harrisburo. PA 17108- 0999 (Address) You may deliver or mail legible copies of the documents or produce things requested by this subpoena, together with the certificate of compliance, to the party making this request atthe address listed above. You have the right to seek in advance, the reasonable cost of preparing the COfJies or prOducing the things sought If you fail to produce the documents or things required by this subpoena, within twenty (20) days after its service, the party serving this subpoena may seek a court order compelling you to comply with it THIS SUBPOENA WAS ISSUED AT THE REQUEST OF THE FOLLOWING PERSON: NAME: Stephen E. Geduldig, Esquire ADDRESS: P.O. Box 999, Harrisburg. PA 17108-0999 TELEPHONE: (717) 237-7119 SUPREME COURT 10#: 43530 ATIORNEY FOR: Defendant BY THE COURT: DATE: Prothonotary/Clerk, Civil Division Seal of the Court Deputy (4/97) ,c' ~ ----,,, ,.;};o-- , _ -:;L;j1-:', - - ,-_ -~..: _/;0iL;_:,:';;-.;,i:"'\",~:t<;'_: "':,; "_Y{~<,~ CERmllilc.&TEli?)t;;iSER\{I€E~""? .. ??, ,--,- 'O_~'" --_". '-,c!~c'.;d>_";H'nf;-,r::-'"",,-:-->;, - , "'c-' T\, '-" I, STEPHEN E. GEDULDIG, ESQUIRE of the law firm of THOMAS, THOMAS, & HAFER, LLP do certify that I served the foregoing document on the following person(s), by depositing the same in the United States Mail, postage prepaid, at Harrisburg, Pennsylvania addressed as follows: Clark DeVere, Esquire METZGER, WICKERSHAM P.O. Box 5300 Harrisburg, PA 17110-0300 THOMAS, THOMAS & HAFER, LLP May 8, 2000 STEPHEN E. GEDULDlG, ESQUIRE :94547.1 . ""'--"'---~-~--- --~~-- "...r. . ,.:~dRjIFH:;ATn:jU.E_~vicE. - ~. _.--~ ^- ," -- -. w,.".."li't5f;o':;<' ',,", "~,,;'h'i I, STEPHEN E. GEDULDIG, ESQUIRE of the law firm of THOMAS, THOMAS, & HAFER, LLP do certify that I served the foregoing document on the following p-erson(s), by depositing the same in the United States Mail, postage prepaid, at Harrisburg, Pennsylvania addressed as follows: Clark DeVere, Esquire Metzger, Wickersham Post Office Box 5300 Harrisburg, PA 17110-0300 THOMAS, THOMAS & HAFER, LLP ..sl~(~ STEPHEN E. GEDULDIG, ESQUIRE :94551.1 ,~ '" Stephen E. Geduldig, Esquire Attorney I.D. No. 43530 THOMAS, THOMAS & HAFER, LLP 305 North Front Street Posl Office Box 999 Harrisburg, Pennsylvania 17108 (717) 237-7100 E-Mail: seQ@tlhlaw.com " - ~ 'H_ '. __" . <-~ .- . ~q\' ,," !~ l~ r ,~ I. f: h, I I !; I I I; I b Attorneys for Defendants: GARY E. SHEAFFER and OSBORN PRINTING CO. ~ " I" ~. 'iI 11- WENDELL K. MYERS, JR., MEGAN N. MYERS and SHANNON B. MYERS, minors, by WENDELL K. MYERS and DONNA J. MYERS, their parents and natural guardians and WENDELL K. MYERS, DONNA J. MYERS and ERNEST F. HELM, in their own right, Plaintiffs v. GARY E. SHEAFFER and OSBORN PRINTING CO., Defendants IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ~, r, , I CIVIL ACTION -- LAW NO. 2000-2060 JURY TRIAL DEMANDED NOTICE TO PLEAD TO: Plaintiff and her counsel: YOU ARE HEREBY NOTIFIED TO FILE A WRITTEN RESPONSE TO THE ENCLOSED NEW MATTER WITHIN TWENTY (20) DAYS OF SERVICE HEREOF OR A JUDGMENT OF NON PROS MAY BE ENTERED AGAINST YOU. ~()\. \00 By: :96684.2 Respectfully submitted, THOMAS, THOMAS & HAFER, LLP ST HEN E. GEDULDIG, SQUIRE Attorney I.D. No. 43530 Attorneys for Defendants, GARY E. SHEAFFER and OSBORN PRINTING CO. -~~ -" ~ -, "e,',= ,- ,'0" ... ,,-'I -'" '"""," __O-'~'e,,,,, . , ".A_>' ~- ,-'~-,<- " "-,"",,,,-,- ',-_"~' -.,~-'.'~- "~',""<-_" "'-,,-="" ",'L,'- '''<c' -8< ,- "" _0,_,., Iii [:;' l:" Stephen E. Geduldig, Esquire Attorney 1.0. No. 43530 ( r' I i;' k I THOMAS, TI10MAS & HAFER, LLP 305 North Front Street Post Office Box 999 Harrisburg, Pennsylvania 17108 i: ~ if (717) 237-71QO E-Mail: sea(Q)tthlaw.com Attorneys for Defendants: GARY E. SHEAFFER and OSBORN PRINTING CO. i: I.. Ii ,~ WENDELL K. MYERS, JR., MEGAN N. MYERS and SHANNON B. MYERS, minors, by WENDELL K. MYERS and DONNA J. MYERS, their parents and natural guardians and WENDELL K. MYERS, DONNA J. MYERS and ERNEST F. HELM, in their own right, Plaintiffs IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA I: I. I I;' , , F ,,- 1: f" GARY E. SHEAFFER and OSBORN PRINTING CO., Defendants JURY TRIAL DEMANDED i I I I. t: i !: I' ~ ; Ii Ii I [. I I' ,. ,. ~: v. CIVIL ACTION -- LAW NO. 2000-2060 ANSWER AND NEW MATTER OF DEFENDANTS, GARY E. SHEAFFER and OSBORN PRINTING CO., TO PLAINTIFFS' COMPLAINT AND NOW, come Defendants, Gary E. Sheaffer and Osborn Printing Co. ("Defendants"), by and through their undersigned counsel, Stephen E. Geduldig, Esquire, of Thomas, Thomas & Hafer, LLP, and file the following Answer and New Matter to Plaintiffs' Complaint: 1. -6. It is admitted, based on information and belief, that the Plaintiffs are who they say they are. To the extent ... . ."I~ ,-__, ",. ,_ ,u --.--, ' _ , ,- ~'" ,-, ",- '-ol ,.~~ ._-' that paragraphs 1-6 purport to aver additional facts, same are denied pursuant to Pa. R.C.P. 1029(e). 7. It is admitted that Defendant, Gary E. Sheaffer, is an adult individual residing at 104 Carlisle Street, Apartment 1, Gettysburg, PA 17325. 8 . Admitted. 9. Denied pursuant to Pa. R.C.P. 1029(e}. 10. Admitted. 11. Admitted in part and denied in part. It is admitted that on July 8, 1999, at approximately 2:30 p.m., Plaintiff, Wendell K. Myers was operating a Chevy Suburban east on SR 174 in Penn Township, Cumberland County, Pennsylvania, when he was involved in an accident at or about the intersection of SR 233 with a vehicle driven by Defendant, Gary E. Sheaffer, and that the other Plaintiffs were in the Suburban at the time of the accident. To the extent that paragraphs 11 purports to aver additional facts, same are denied pursuant to Pa. R.C.P. 1029 (e) . 12. Admitted. 13. Admitted. 14. Admitted. 15. Admitted. 16. It is admitted that Defendant, Gary E. Sheaffer, failed to stop at the stop sign at the intersection and caused 2 '~.c .i' ~i, H ~ c 1-: I ,. , i: ~ \ if " :-: , i, I; ;' it ii it i! t , j, ) ~- ; } " ~ > - ~-" ~ -"" -""'- ,,-- ." ~" ",. , ",'"~,,,p .' ,= . ~ ,--,-,,,' ^,," the accident involving the Plaintiffs. To the extent that paragraph 16 of Plaintiffs' Complaint purports to aver additional facts, same are denied pursuant to Pa. R.C.P. 1029 (e) . 17. Admitted. 18. Admitted that Defendant, Gary E. Sheaffer, failed to stop at the stop sign at the intersection and this caused the accident involving the Plaintiffs. To the extent that paragraph 18 of Plaintiffs' Compliant purports to aver additional facts, same are denied pursuant to Pa. R.C.P. 1029(e). 19. (a)-(u). Defendant, Gary E. Sheaffer, admits that he is responsible for the subject accident. The remainder of paragraph 19(a) through (u) are denied as legal conclusions. To the extent that there are factual averments in paragraph 19(a)- (u), same are denied pursuant to Pa. R.C.P. 1029(e). 20. Defendant, Gary E. Sheaffer, admits that he is responsible for the accident. To the extent that paragraph 20 purports to aver additional facts, same are denied pursuant to Pa. R.C.P. 1029(e). 21. (a)-(h). It is denied that Defendant, Osborn Printing Company, was negligent, careless or reckless. 22. Denied as legal conclusions and pursuant to Pa. R.C.P. 1029 (e) . 23. Denied as legal conclusions. 3 'J, ."., ~! " i. i ! I r( [~ L i I !. Il I I I" ! 1: I, , ~ r-~ i! , t;1 Lj }] I"~ , ,. !~ " ~. -~- -- ~e~"""""' ~_ _" _"_ ^~ WHEREFORE, Defendants, Gary E. Sheaffer and Osborn Printing Co., respectfully request that Plaintiffs' Complaint be dismissed in its entirety and judgment entered in their favor. COUNT I - NEGLIGENCE P1aintiff, Wende11 K. Myers, Jr. v. Defendants 24. No response is required as this is a paragraph of incorporation. 25. (a)-(d). Denied as legal conclusions and pursuant to Pa. R.C.P. 1029(e). 26. Denied as legal conclusions and pursuant to Pa. R.C.P. 1029 (e) . 27. Denied as legal conclusions and pursuant to Pa. R.C.P. 1029 (e) . WHEREFORE, Defendants, Gary E. Sheaffer and Osborn Printing Co., respectfully request that Plaintiffs' Complaint be dismissed in its entirety and judgment entered in their favor. COUNT II - NEGLIGENT INFLICTION OF EMOTIONAL DISTRESS P1aintiff, Wende11 Myers, Jr. v. Defendants 28. No response is required as this is a paragraph of incorporation. 29. Denied as legal conclusions and pursuant to Pa. R.C.P. 1029 (e) . 4 '''" .. ~~ ~' l', r,- I!: f~" I~ l!: r I;, 1~ !,;: li i: ~, i~ -~ Wi ~; if: ~: f , , t I ! t' t ~, i: I [ II " , I: t: I;' I I: , r I j' j' . ,j.',' ,.'" ."",--- "' ,- ,~~~...' ~'~_,_, '-=_"r. '-, c- -, - - , ~--i "' <-,--' . , ~--<, ~f:' 30. Deni~d as legal conclusions and pursuant to Pa. R.C.P. ii r L' it I; 1:- 1029 (e) . it WHEREFORE, Defendants, Gary E. Sheaffer and Osborn Printing ," Co., respectfully request that Plaintiffs' Complaint be . ,-. !~ ., .. ~\ COUNT III - NEGLIGENCE Plaintiff, Megan N. Myers v. Defendants if;' i~' ~j !'; t~ ,: .. f dismissed in its entirety and judgment entered in their favor. 31. No response is required as this is a paragraph of incorporation. 32. Denied as legal conclusions and pursuant to Fa. R.C.P. 1029 (e) . 33. Denied as legal conclusions and pursuant to Pa. R.C.P. 1029 (e) . 34. Denied as legal conclusions and pursuant to Pa. R.C.P. 1029 (e) . WHEREFORE, Defendants, Gary E. Sheaffer and Osborn Printing Co., respectfully request that Plaintiffs' Complaint be dismissed in its entirety and judgment entered in their favor. COUNT IV - NEGLIGENT INFLICTION OF EMOTIONAL DISTRESS Plaintiff, Megan N. Myers v. Defendants 35. No response is required as this is a paragraph of incorporation. 5 ,~. ,~, ~ __'___~"-'_ '=d--"~- ,~"- ,'''_' _".-,,_ "'_,__""_' m..__'__' 'k<" ,-,- - ~ ' . ~ .~:'" I; I I I '. 36. Denied as legal conclusions and pursuant to Pa. R.C.P. i:, !'" !' 1029 (e) . 37. Denied as legal conclusions and pursuant to Pa. R.C.P. I ,. I' :i, I:t " 1029 (e) . WHEREFORE, Defendants, Gary E. Sheaffer and Osborn Printing i;~ : '1' i ~ ~; Co., respectfully request that Plaintiffs' Complaint be COUNT V - NEGLIGENCE P1aintiff, Shannon B. Myers v. Defendants ~i f'1 l' !i ~! ~j dismissed in its entirety and judgment entered in their favor. 40. (a)-(b). Denied as legal conclusions and pursuant to Pa. ~_i ~: ~. H [ ~~ I,' ,. ~] r i: r' j1 I: t~ I I, i', ,. r I: I, 38. No response is required as this is a paragraph of incorporation. 39. (a)-(b). Denied as legal conclusions and pursuant to Pa. R.C.P. l029(e). R.C.P. l029(e). 41. Denied as legal conclusions and pursuant to Pa. R.C.P. 1029 (e) . WHEREFORE, Defendants, Gary E. Sheaffer and Osborn Printing Co., respectfully request that Plaintiffs' Complaint be dismissed in its entirety and judgment entered in their favor. 6 "' _.,"_L_'... ~,. . .~, ,-- ,-" ,~-,,"', - , - '-' -- -.--'-' ;,,' -- .. "~L,H ,l' er COUNT VI - NEGLIGENT INFLICTION OF EMOTIONAL DISTRESS Plaintiff, Shannon B. Myers v. Defendants ~~ " 42. No response is required as this is a paragraph of incorporation. 43. Denied as legal conclusions and pursuant to Pa. R.C.P. 1029 (e) . 44. Denied as legal conclusions and pursuant to Pa. R.C.P. 'i~ e, ri ~~ I: ii I: 1029 (e) . WHEREFORE, Defendants, Gary E. Sheaffer and Osborn Printing Co., respectfully request that Plaintiffs' Complaint be dismissed in its entirety and judgment entered in their favor. COUNT VII - NEGLIGENCE Plaintiff, Wendell K. Myers v. Defendants 45. No response is required as this is a paragraph of incorporation. 46. (a)-(h). Denied as legal conclusions and pursuant to Pa. R.C.P. 1029(e). 47. Denied as legal conclusions and pursuant to Pa. R.C.P. 1029 (e) . 48. Denied as legal conclusions and pursuant to Pa. R.C.P. 1029 (e) . 49. Denied as legal conclusions and pursuant to Pa. R.C.P. 1029 (e) . 7 . " - '" - _.~ -~, . -- .~- - ----, ,.-' ~^" - ^~, " '_J"___"_ ,,,.-,,-.,- ,---"-,, "- 50. Denied as legal conclusions and pursuant to Pa. R.C.P. 1029 (e) . 51. Denied as legal conclusions and pursuant to Pa. R.C.P. 1029 (e) . 52. Denied as legal conclusions and pursuant to Pa. R.C.P. 1029 (e) . WHEREFORE, Defendants, Gary E. Sheaffer and Osborn Printing Co., respectfully request that Plaintiffs' Complaint be dismissed in its entirety and judgment entered in their favor. COUNT VIII - NEGLIGENT INFLICTION OF EMOTIONAL DISTRESS Plaintiff, Wendell K. Myers v. Defendants 53. No response is required as this is a paragraph of incorporation. 54. Denied as legal conclusions and pursuant to Pa. R.C.P. 1029 (e) . 55. Denied as legal conclusions and pursuant to Pa. R.C.P. 1029 (e) . WHEREFORE, Defendants, Gary E. Sheaffer and Osborn Printing Co., respectfully request that Plaintiffs' Complaint be dismissed in its entirety and judgment entered in their favor. 8 ",- "l-ii;j ~ Ii 1'1 ~:! :;1 ::;1 I} !i : I: ~ II ,. ! L ~ ,. I i , ~ ._, '" '_,~, ,,__ __ _0 ",~," __ "~" ,,~ '00' '", --,---,"-~,-..~", -.~ ..-~,_, ~ ~""--- ." ,-, =. -~,--- ~,~"'-'-'-,.,-" ,- =.';;.' i~i jW ,-, to;:: , I:' I. , , COUNT IX - LOSS OF CONSORTIUM Plaintiff, Wendell Myers v. Defendants ~i: v. '1-;' r!, I!: 56. No response is required as this is a paragraph of ~; B! 57. Denied as legal conclusions and pursuant to Pa. R.C.P. i,' ~ ~- !~J. 11: I~ illi !:: i: ~: ~:, l' incorporation. 1029 (e) . WHEREFORE, Defendants, Gary E. Sheaffer and Osborn Printing Co., respectfully request that Plaintiffs' Complaint be COUNT X - NEGLIGENCE Plaintiff, Donna J. Myers v. Defendants I ~!j Ii li. ,. Ii: " !: ji: ~ , I II' Ii' , Ii: I', !, I "' " I I I: I~ I. I " 1 " F i dismissed in its entirety and judgment entered in their favor. 58. No response is required as this is a paragraph of incorporation. 59(a)-(d). Denied as legal conclusions and pursuant to Pa. R.C.P. 1029(e). 60. Denied as legal conclusions and pursuant to Pa. R.C.P. 1029 (e) . 61. Denied as legal conclusions and pursuant to Pa. R.C.P. 1029 (e) . 62. Denied as legal conclusions and pursuant to Pa. R.C.P. 1029 (e) . 63. Denied as legal conclusions and pursuant to Pa. R.C.P. 1029 (e) . 9 - - ~ ,.. --"" - ;~, ,'-~..-, -, ~,.- ~'" ~-,..", ___,,,,-~__,,, c'~ .'-....iii,i 64. Denied as legal conclusions and pursuant to Pa. R.C.P. 1029 (e) . 65. Denied as legal conclusions and pursuant to Pa. R.C.P. 1029 (e) . WHEREFORE, Defendants, Gary E. Sheaffer and Osborn Printing Co., respectfully request that Plaintiffs' Complaint be dismissed in its entirety and judgment entered in their favor. COUNT XI - NEGLIGENT INFLICTION OF EMOTIONAL DISTRESS Plaintiff, Donna J. Myers v. Defendants 66. No response is required as this is a paragraph of incorporation. 67. Denied as legal conclusions and pursuant to Pa. R.C.P. 1029 (e) . 68. Denied as legal conclusions and pursuant to Pa. R.C.P. 1029 (e) . WHEREFORE, Defendants, Gary E. Sheaffer and Osborn Printing Co., respectfully request that Plaintiffs' Complaint be dismissed in its entirety and judgment entered in their favor. COUNT XII - LOSS OF CONSORTIUM Plaintiff, Donna J. v. Defendants 69. No response is required as this is a paragraph of incorporation. 10 ..- ". ' "',...~ - ,,_, "o-',.""-,_~,, -, '. "_ _~ . r~g;:;'( 70. Denied as legal conclusions and pursuant to Pa. R.C.P. 1029 (e) . WHEREFORE, Defendants, Gary E. Sheaffer and Osborn Printing Co., respectfully request that Plaintiffs' Complaint be dismissed in its entirety and judgment entered in their favor. COUNT XIII - NEGLIGENCE P1aintiff, Ernest F. He~ v. Defendants 71. No response is required as this is a paragraph of incorporation. 72(a)-(m). Denied as legal conclusions and pursuant to Pa. R.C.P. 1029(e). 73. Denied as legal conclusions and pursuant to Pa. R.C.P. 1029 (el . 74. Denied as legal conclusions and pursuant to Pa. R.C.P. 1029 (el . 75. Denied as legal conclusions and pursuant to Pa. R.C.P. 1029 (e) . 76. Denied as legal conclusions and pursuant to Pa. R.C.P. 1029 (e) . WHEREFORE, Defendants, Gary E. Sheaffer and Osborn Printing Co., respectfully request that Plaintiffs' Complaint be dismissed in its entirety and judgment entered in their favor. 11 _.'__0 " - ~ -" - - ~._< ,- - ~-' ..,. ..- , '.--"-" ,_ ~ ,,~.., ~_,_~_< _",-_ h __ -- ,_ -, ,,,' ,,, , ,-, ','- , ~ - ~ ;., f l i'" ). ,;: ~- j-- COUNT XIV - NEGLIGENT INFLICTION OF EMOTIONAL DISTRESS Plaintiff, Ernest F. He1m v. Defendants t, I' < r , 77. No response is required as this is a paragraph of I;' I r incorporation. 79. Denied as legal conclusions and pursuant to Pa. R.C.P. , '. I i ! r ,} j,' I' l , ~ 78. Denied as legal conclusions and pursuant to Pa. R.C.P. 1029 (e) . 1029 (e) . f: ~; WHEREFORE, Defendants, Gary E. Sheaffer and Osborn Printing t I; r k Co., respectfully request that Plaintiffs' Complaint be dismissed in its entirety and judgment entered in their favor. NEW MATTER 80. Paragraphs 1-79, above, are incorporated herein by reference as if fully set forth at length. 81. Plaintiffs' claims are limited by the provisions of the Motor Vehicle Financial Responsibility Law. 82. This action is stayed by the corporate Defendant's filing of Chapter 11 bankruptcy. 12 ~", ,,", -~. ~~ ~-~, .,-";c,",,,,. .~--.~-_ .,,-,- '.',< __I_"_C~__ ~" '"'ii; WHEREFORE, Defendants, Gary E. Sheaffer and Osborn Printing Co., respectfully request that Plaintiffs' Complaint be dismissed in its entirety and judgment entered in their favor. Respectfully submitted, THOMAS, THOMAS & HAFER, LLP ~!}I!ov By: ~--1 :96684.1 STEPHEN E. GEDULDIG, ESQUIRE Attorney I.D. No. 43530 Attorneys for Defendants, GARY E. SHEAFFER and OSBORN PRINTING CO. 13 - " ~-"~.." -,,, . " o' " ~,-C" '11 ~I VERIFICATION I, Robert Schlein, President of Osborn Printing Company, hereby verify that the averments made in the foregoing document are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S.A. 4904 relating to unsworn falsification to authorities. ((JI/6~ Robert Schleln .--.-, -- < o'~_ ~,",,--- ,. -.;, :f~ . CERTIFICATE OF SERVICE I hereby certify that a true and correct copy of the foregoing document was served by depositing the same in the United States Mail, postage prepaid, at Harrisburg, 2YJ- Pennsylvania, on the ~I day of May, 2000, on all counsel of record as follows: Clark DeVere, Esquire METZGER, WICKERSHAM, KNAUS & ERB Post Office Box 5300 Harrisburg, pennsylvania 17110-0300 Attorneys for Plaintiffs THOMAS, THOMAS & HAFER, LLP 1iIj' ,,- ~ "~" ~ N_" ,___", .'-r> .......~."~,=~... "=0 " ~" , 'I' --,' . "'-' ..,.,-- ~ ~ -~-' l~ ~, . j 0 C? 0 ; C C, "T'l s: ~= 7;,:1] -qCJ~ ;G nlfll '" --. Z:.:o , ~,~-~ ~-? ~.f~:: (/; -r,.. ()t,J) -<..r._ ~CJ .--1::",-, -0 - ' '. -'-~'n .J.>' .-.... :::~ :~ f~j~ -",.\.'" j;~ C;-? '.J -I -7 N (>- ~ <" (-'> =< . ~ ,: -,,~, - ,. ""j,-, WENDELL K. MYERS, JR., MEGAN N. MYERS AND SHANNON B. MYERS, minors, by WENDELL K. MYERS and DONNA 1. MYERS, their parents and natural guardians and WENDELL K. MYERS, DONNA J. MYERS and ERNEST F. HELM, in their own right, Plaintiffs IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYL VANIA CIVIL ACTION - LAW NO. 2000-2060 vs. GARY E. SHEAFFER and OSBORN PRINTING CO., Defendants JURY TRIAL DEMANDED PLAINTIFFS' REPLY TO DEFENDANTS' NEW MATTER 80. No response required because this is a paragraph of incorporation. If a response is required, the averments are conclusions of law for which no response is also required. To the extent that paragraphs I through 79 of Defendants' Answer admit the allegations of the Plaintiffs' Complaint they are also hereby admitted. To the extent that paragraphs I through 79 of Defendants' Answer deny the allegations of Plaintiffs' Complaint they are denied and Plaintiffs incorporate herein by reference their Complaint filed in this action as if fully set forth at length. 81. Conclusions of law, no reply required. If a reply is required, the averments are denied pursuant to Pa.R.C.P. No. 1029(e). By way of further reply, Defendants do not specify how Plaintiffs' claims are limited by the MVFRL and therefore no reply is required. 82. Conclusions of law, no reply required. If a reply is required, the averments are denied. By way of further reply, the Plaintiffs attach hereto as Exhibit "A" and incorporate herein by reference a copy of Chief Bankruptcy Judge Robert Woodside's Order lifting the automatic stay and permitting this action to proceed. Document #: 177029.1 - ." -" .....-~..,::, WHEREFORE, Plaintiffs demands that Defendants' New Matter be dismissed and that judgment be entered in their favor and against Defendants, either individually and/or jointly and severally, for the damages claimed in the Complaint filed in this action plus interest and/or damages for delay and costs of prosecution. METZGER, WICKERSHAM, KNAUSS & ERB, P.C. By: ~"....-::-"" Clark DeVere, Esquire Attorney LD. No. 68768 3211 North Front Street P.O. Box 5300 Harrisburg, PA 17110-0300 (717) 238-8187 Attorney for Plaintiffs Dated: June &,.. 2000 -2" Document #: 177029.1 ~I )li~~i , In re: OSBORN PRINTING COMPANY Debtor No. 1-99-04945 \-\a.rriSbu~~;,\\>t.. ~\..EO illl/E-= . t.\~'( \ \ 1.000 UNITED STATES BANKRUPTCY COURT FOR THE MIDDLE DISTRICT OF PENNSYLVA Chapter 11 ORDER AND NOW, this J J-tN day of 'f'\)6.. 'J Court l\\<ruptc~ 'y Cletl< _ oepu' pet -= , 2000, upon consideration of the Petitioners' Motion to Lift the Automatic Stay, it is hereby ORDERED and DECREED that the automatic stay is lifted for the limited purpose of permitting an action pending in the Court of Common Pleas of Cumberland County, Pennsylvania, captioned Wendell K. Mvers. Jr.. Megan N. Mvers and Shannon B. Mvers. minors. bv Wendell K. Mvers and Donna J. Mvers. their oarents and natural guardians and Wendell K. Mvers. Donna J. Mvers and Ernest F. Helm. in their own right v. Gary E. Sheaffer and Osborn Printing: Co., docketed in the Court of Common Pleas of Cumberland County, Pennsylvania at 2000-2060, to proceed. It is further ORDERED and DECREED that Wendell K. Myers, Jr., Megan N. Myers and Shannon B. Myers, minors, by Wendell K. Myers and Donna J. Myers, their parents and natural guardians and Wendell K. Myers, Donna J. Myers and Ernest F. Helm, in their own right, may not collect, or attempt to collect any recovery from the Debtor, Osborn Printing Company, in said litigation in excess of the insurance coverage available to Debtor on this claim. BY THE COURT: 1M IIilllleIt do WoOO6tile Robert J. Woodside, Chief Bankruptcy Judge Document#: /74395./ . ~ - ,~-~ '.E: VERIFICATION We, Wendell K. Myers and Donna J. Myers, as parents and natural guardians of minor Plaintiffs Wendell K. Myers, Jr., Megan N. Myers and Shannon B. Myers, hereby certifY that the following is correct: The facts set forth in the foregoing Plaintiffs' Reply to Defendants' New Matter are based upon information which we have furnished to counsel, as well as upon information which has been gathered by counsel and/or others acting on our behalf in this matter. The language of the Plaintiffs' Reply to Defendants' New Matter is that of counsel and not our own. We have read the Plaintiffs' Reply to Defendants'New Matter, and to the extent that it is based upon information which we have given to counsel, it is true and correct to the best of our knowledge, information, and belief. To the extentthat the content of the Plaintiffs' Reply to Defendants' New Matter is that of counsel, we have relied upon such counsel in making this Verification. We hereby acknowledge that the facts set forth in the aforesaid Plaintiffs' Reply to Defendants' New Matter are made subject to the penalties of 18 Pa. C.S.A. g4904 relating to unsworn falsification to authorities. Dated: {.,~8~OO (;J~ I! MLMt--D WendellK. Myers lr Dated: Co-'B'-OO ~ ~ 8 ~.ew Donna J. Myers U Document#: 177029.1 "~ iH::Y, VERIFICATION I, Wendell K. Myers, hereby certify that the following is correct: The facts set forth in the foregoing Plaintiffs' Reply to Defendants' New Matter are based upon information which I have furnished to counsel, as well as upon information which has been gathered by counsel and/or others acting on my behalf in this matter. The language of the Plaintiffs' Reply to Defendants' New Matter is that of counsel and not my own. I have read the Plaintiffs' Reply to Defendants' New Matter, and to the extent that it is based upon information which I have i I' i: given to counsel, it is true and correct to the best of my knowledge, information, and belief. To the extent that the content of the Plaintiffs' Reply to Defendants' New Matter is that of counsel, I have relied upon such counsel in making this Verification. I hereby acknowledge that the facts set forth in the aforesaid Plaintiffs' Reply to Defendants' New Matter are made subject to the penalties of 18 Pa. C.S.A. 94904 relating to unswom falsification to authorities. Dated: r;;,- 8-06 ~rsJ{ (Vt~ Document #: 177029.1 . . ..' -- ~ =""'-T'-' VERIFICATION I, Donna J. Myers, hereby certif'y that the following is correct: The facts set forth in the foregoing Plaintiffs' Reply to Defendants' New Matter are based upon information which I have furnished to counsel, as well as upon information which has been gathered by counsel and/or others acting on my behalf in this matter. The language of the Plaintiffs' Reply to Defendants' New Matter is that of counsel and not my own. I have read the Plaintiffs' Reply to Defendants' New Matter, and to the extent that it is based upon information which I have given to counsel, it is true and correct to the best of my knowledge, information, and belief. To the extent that the content of the Plaintiffs' Reply to Defendants' New Matter is that of counsel, I have relied upon such counsel in making this Verification. I hereby acknowledge that the facts set forth in the aforesaid Plaintiffs' Reply to Defendants' New Matter are made subject to the penalties of 18 Pa. C.S.A. 94904 relating to unsworn falsification to authorities. Dated: Co- 'B-co ~~ 8 01,,0'" Donna 1. Myers :J Document #: 177029,1 "~ ~ - "~ , - -~"~ VERIFICATION I, Ernest F. Helm, hereby certify that the following is correct: The facts set forth in the foregoing Plaintiffs' Reply to Defendants' New Matter are based upon information which I have furnished to counsel, as well as upon information which has been gathered by counsel and/or others acting on my behalf in this matter. The language of the Plaintiffs' Reply to Defendants' New Matter is that of counsel and not my own. I have read the Plaintiffs' Reply to Defendants' New Matter, and to the extent that it is based upon information which I have given to counsel, it is true and correctto the best of my knowledge, information, and belief. To the extent that the content of the Plaintiffs' Reply to Defendants' New Matter is that of counsel, I have relied upon such counsel in making this Verification. I hereby acknowledge that the facts set forth in the aforesaid Plaintiffs' Reply to Defendants' New Matter are made subject to the penalties of 18 Pa. C.S.A.~4904 relating to unsworn falsification to authorities. . Dated: b - ~-cr Q !?~ ~JI"IAA--- ErnestF. Helm Document #: 177029.1 ., ,~ CERTIFICATE OF SERVICE I, Clark DeVere, Esquire, of the law firm of Metzger, Wickersham, Knauss & Erb, P.C., hereby certify that I served a true and correct copy of Plaintiffs' Reply to Defendants' New Matter with reference to the foregoing action by first class mail, postage prepaid, this J"ll<Qay of June, 2000 on the following: Gary E. Sheaffer and Osbom Printing Co. c/o StephenE. Geduldig,Esquire Thomas, Thomas & Hafer, LLP 305 North Front Street P.O. Box 999 Harrisburg,PA 17108 METZGER, WICKERSHAM, KNAUSS & ERB, P.C. -;::~-- ~ Clark De Vere, Esquire Document #: 177029.1 ~"'. ~. "~ . -~ , ,~ ~~~; 0: - ~\ WENDELL K. MYERS, JR., MEGAN N. MYERS AND SHANNON B. MYERS, minors, by WENDELL K. MYERS and DONNA J. MYERS, their parents and natural guardians and WENDELL K. MYERS, DONNA J. MYERS and ERNEST F. HELM, in their own right, Plaintiffs IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW NO. 2000-2060 vs. GARY E. SHEAFFER and OSBORN PRINTING CO., Defendants JURY TRIAL DEMANDED *' AND NOW, this:>'> day of ORDER O~ ,2000, upon consideration of the Petition for Approval of Minor Plaintiffs' Compromise Settlements, it is hereby ORDERED and DECREED that the settlements for the gross sum of Fifty Thousand Dollars ($50,000.00) for Wendell Myers, Jr., Fifteen Thousand Dollars ($15,000.00) for Megan Myers and Fifteen Thousand Dollars ($15,000.00) for Shannon Myers are APPROVED. Counsel fees are found to be fair and reasonable and are also approved as set forth below. The distribution is directed as follows: (I) To be paid to Wendell Myers, Sr. and Donna Myers, who are appointed guardians of Wendell Myers, Jr., the sum of Twenty-Five Hundred Dollars ($2,500.00) for the immediate benefit of Wendell Myers, Jr.; (2) To be paid to Metzger, Wickersham, P.C. for counsel fees for all three minor Plaintiffs - Twenty Thousand Dollars ($20,000.00); (3) To paid to Metzger, Wickersham, P.C. for expenses - $0.00; and (4) The balance: Wendell Myers, Jr. - Forty Thousand Dollars ($40,000.00); Megan Myers - Ten Thousand Dollars ($10,000.00); and Shannon Myers - Ten Thousand Dollars ($10,000.00), as agreed by the parties and guardians, to be placed in a structured settlement pursuant to the Uniform Document #: /85095.1 -", ~.--~ .. ~ '~h: .. Qualified Assignment and Release attached to the Petition with assignor as Penn National Insurance Company, the assignee AEGON Assignment Corporation and the annuity issuer as Monumental Life Insurance Company. Wendell Myers and Donna Myers, as parents and natural guardians of Wendell Myers, Jr., Megan Myers and Shannon Myers, minors, are authorized to sign the Settlement Agreement and Release, attached to the Petition and discontinue this action upon the delivery of the cash payment of Twenty-Five Hundred Dollars ($2,500.00) and the transfer of the remaining funds into the structured settlements. J. cc: -~ /.JJ Clark DeVere, Esquire - counsel for Plaintiffs ~ . e.... ~ Stephen E. Geduldig, Esquire - counsel for Defendants ~ /. jv.X.tJv Document #: /85095./ J1;/r i1l~"l:I!rb' - ilI:d~-~~"-"-.a;:~ ".~'~-~'fill!!!t.J'>;~1!;ii;~'lIi_..~~~_Iii'- t~F~ 11; ;fI 0/ ~ 4f:o ~..liIIlliiiIiIl~~~~___"~' \-t"\,i",1 i\"l FS\\. \N.,:k\ ~! 'i ,. \ . _~ '-'w'1!'\~n'" rr-<"'. ,.' ~l,..L<,., II. \V }'Jj\11U:,,! I','"" " 1"",' ,r'" 'j::J .(j \ 7 .'"JD tlO -: v - ,-, --IIIIiiIiII1IIiIJ*! . '" j',)