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HomeMy WebLinkAbout97-05295 ;),.,,' '1.-_' :: .~.~' ':J,~(:::;:~\t~l;iij:':J,~' "I'I """,Iim,cl, " . ',; iyr:i ::;,Ilr;"~~:; " \_'.':t-\!~.- ,:,,:,.,I"':I'};ii'>'" 'H ll~ -'( "~I' \ .. f./11,I, " I ,\, ", ! ',:-~\,-.-':,' .:t,.",.,'/( ,',: t,: ~ _ ,. /;'P' ~:I'~'~I'U '. ,q.A" "'i:":,:",':i; ~\ Ii '.f -J) '. , " ,I ., , '., I .' I , " ., " , , ~ ,. .~ (:lQ , , I , I , ., ." " , -I: " !. 1 ,I' " , .1 , . ,,\1 I, , , .. ~ , " , , I f', " I, " , , I, I" " " I, 3 '3 ~ r ,I ,,' I", ".'_j " 'I;, " , , , ,. , " " " " " .', '.' ., , I \1'1 I" ii, '! ,r , , , 'I' ," 'I Ii, ./,\,01"1:, , 1",1 I' " I' , " I' ',' 'I tl " " " I ," ,'1'1 " " " i"f , '!i! , ' '.. " ' " "', tI, " 11"'>11 ','IJ ' L , " " , , ,:, ,,, , " " ' I,. " II'. ., :1 ; ',I. i" ,I " '1 1'1 I " ", "tl , "I' ,,' " , ," I , ,I 'I , " '. ,J, 'i' ", ~, l " 'j' '1 " " " ,,' \ ',\ " ~. ~ f-. , ., .' 1'-' ," , " '. I " ., , ' , L, " " , , " , ,II '.i/ i,'; I " '" ';\ ,.', ',1 I i' I :i.:,'i\I',.,,',! ; !}II"I, I' ,"1 " liil -" I JI:! 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". ,If "},}} :q'f'~ ,', ,': ;::~r~~J j '!--i9.~ ! lr/JJ /' ::-;:,:;\.'it' .'. ,I'" 'j' ',;~,!:,,~,~~l ," ,!c"')~ '." '1-,,!,,~;I<~ ,I ',\\./It' ',I; ,;<\R If, , , ,i'l ',..d -' I ;\~ ," '/;:~ ,,-'i:.',U' 1'1-'-' ", '-~,:~:I~r!:' ',j'",q ','- L~~ "1<11 ,'Itll , ,',1'",I,,! '11,',iN "', ,.,(1 I, 'I,' .. I, " , , ", 'I' '" , ,:: 1 '-'1 'i-/' " ! THOMAS EDWARD BOWERS, IN THE COURT OF COMMON PLEAS OF Plaintill' on behalf of his minor children RAGENE TEREASE BOWERS. . CUMBERLAND COUNTY, PENNSYLVANIA RACHEL LYNN BOWERS. RYAN mOMAS BOWERS. RODNEY LEE BOWERS. CIVIL ACTION. LAW RILEY TAYLOR BOWERS, and RISA LAUREN BOWERS. v, NO, 97-:rL1.:L.. TERM USA GA YE BOWERS and MAX SALEEM. Defendants PROTECTION FROM ABUSE ftRV PROTECTION ORDER AND NOW, lhi. day of September. 1997. upon presentation and consideration of the within Petition, and upon finding Ihat the plaintill: Thomas Edward Bowers, on behalf of his minor children, Ragene Terease Bowers, Rachel L.ynn Bowers, Ryan Thomas Bowers, Rodney Lee Bowers, Riley Taylor Bowers, and Risa Lauren Bowers, who reside with the defendants at 1615 Mathew Drive, Camp Hill, Cumberland County. Pennsylvania, are in immediate and present danger of abuse rrom the detendants, L.isa Gaye Bowers, their mother. and Max Saleem, their step-father, the lollowing Temporary Order is entered. The defendant, Usa Gaye Bowers (SSN. Unknown)(DOB 9/29/65), and Max Saleem (SSN. Unknown)(DOR Unknown). now residing at 1615 Mathew Drive, Camp Hill, Cumberland County, Pennsylvania, are hereby enjoined from physically abusing the minor children, Ragene Terease Bowers, Rachel Lynn Bowers, Ryan Thomas Bowers. Rodney Lee Bowers. Riley Taylor Bowers, and Risa Lauren Bowers, or from placing them in fear of abuse, The defendants are ordered to stay away from the plaintill's current residence loclted It 831 Fremont Street, Apt. 12, Lancaster, L.ancaster County, Pennsylvania, a residence which is' leased by the plaintiff, and is ordered to stay away from any residence the plaintiff mlY in the future establish for himself The delendant, Max Saleem, is prohibited from having any direct or indirect contact with the minor children, including. but not limited to, telephone and wrillen communications, and the defendant, Lisa Gaye Bowers, the mother of the children, is prohibited from having any direct or indirect contact with the minor children. except during supervised visits, The defendants are enjoined from harassing and stalking the minor children, The defendants are enjoined from entering the schools and day care facility of the minor children, A violation of this Order may subject the defendant to: i) arrest under 23 Pa,C,S. 56113; ii) a private criminal complaint under 23 Pa,C.S, 56113,1; iii) a charge of Indirect criminal contempt under 23 Pa,C.S. ~6114. punishable by imprisonment up to sil. months and a nile of 5100,00-51.000,00; and iv) civil contempt under 23 Pa,C.S, 56114,1. This Order shall remain in effect until modified or terminated by the Court and can be extended beyond its original expiration date if the Court finds that the defendants have committed an act of abuse or has engaged in a pall ern or practice that indicates risk of hann to the minor children, Temporal)' custody of Ragene Terease Bowers. Rachel Lynn Bowers. Ryan Thomas Bowers. Rodney Lee Bowers. Riley Taylor Bowers, and Risa Lauren Bowers, is hereby awarded to the plaintiff, Thomas Edward Bowers, the defe//da11l.~ are ordered to del/I'er the mi//or ,'hi/tlrell to the clutody of the plaintif/. Thomu.~ l-:dwurd Howers. Jhe Sheriff~ /)epartmelll ellltl or elllY law I!fIfo,,'eme11l agtncy willi jurisdictio// to I!I!fo"'1! thi.~ Order shall C1....~ist thl! plai11l!ff ill retrievlllg the childnn. 4. Since approximately March 1997, the delendants have allempted to cause and has intentionally, knowingly, or recklessly caused bodily injury to the parties' minor children, and have placed them in reasonable leal' of imminent serious bodily injury, have knowingly engaged in n course of conduct or repeatedly commiued acts toward the minor children under circumstances which have placed them in reasonable leal' of bodily injury. This has included, but is not limited to, the following specific instances of abuse: a) On or about August 10, 1997, the plaintiff' discovered bruising about the backs and buuocks of the parties' 5-year old son, Riley, while bathing him. The child told the plaintiff that his mother, the defendant, had struck him and his 11- year old brother, Ryan, repeatedly with a hanger. According to the children, this incident occured on Friday, August 8. 1997. The plaintiff notified the ChildLine Hotline and took both children to Lancaster General Hospital to be examined. Cumberland County Children & Youth Services investigated the allegalions and filed a report of "indicated" abuse against the defendant (See Exhibit A, incorporated by reference and auached hereto) The agency has opened a Protective Services case on the children. b) On or about June 21, 1997, the plaintilf was told by his 7-year old son, Rodney, that his step-father, Max Saleem, struck him on his penis with a broom handle and choked him. The plaintiff reported this incident to Lancaster County Children & Youth Services. c) In or about March 1997, when the plaintiff asked his son, Riley, why he had scratches on his ear and bruising on his cheek, the child told him that his step- father struck him on the helld 1I1llllhe ~Ille of the Ill~e wllh II helt The plllhlllf1's 4- year old daughter, /tiSII, who !lIId II red IIl11rk Oil her Ih1llh, lold him thlll her step. father had IIlso stru~k her on the lell with Ihe hl'll dllrinlllhe ~lIl11e incident d) Since IIpproxinllltely MlIr~h 1')')7, Ihe dcli.'fldllJII~ hllve IIho~ed Ihr minor children in WIIYS including, but not Iilllill'd to, ~triking them" ilh ohje~lK, ~hoklng screaming al them, and threatening Ihem wilh phy~kllllllnm In IIddition, on or aboul Augusl 21, 11)'17, one of Ihe ~hihh'l'n ~lIid Ihlll the defendllnt, SlIlelm, kicked the door in oHer Iheir lIIother lo~ked him 0111. IIml when he l!ot in the house, he grabbed her by Ihe f'n~e IInd ~llllel'/ed it !'cllrin!! Ihr their ~lIlcty. one of the older children ran tOll ncil!hblll"~ hOllle IIml reported the incidenttolhe East Pennshoro Township Jlolic~. During IInolhcr incident the mother of Ihe ~hildren made Ragene eat eggs off' of the l1olll' The ~hildren~' lIIother hu~ threatened them repeatedly telling them that they will end lip in lil~ter hml1e~ or a ~hildrcn's home where terrible IhinM~ will !lIIllpen 10 them if they loldlheir lillhcr, the plaintiff. about the abusive incident~ Ihal hltve o~cured The plllintiff ICllr~ thatlhe SlIlety and welfare of his ~hildren lire III risk while Ihey ~onlinlle 10 re~ide in Ihe same household with the defendant~' pl'Upen~ity lilr violenl behavior towlIrd the children and each other. S. The plaintitl' believe~ and therefore aven Ihllllhe minor ~hildren are in immediate and present danger of abuse from the delendant~ lInd thaI they are in need of protection from such abuse. 6. The plaintitl' desires that the defendanl. Ma~ Saleem, be prohibited trom having any direct or indirect cllnta~t with the minor children, including, but not limited to, telephone and 12. The parties have a Custody Order (BOWERS v. BOWERS, No. 94408-1995, Court of Common Pleas of Lancaster County, Pennsylvania) entered on November 15, 1995 (see Exhibit B. incorporaled by reference and all ached hereto) 13 The plaintitl' has no knowledge of any custody proceedings concerning this children pending before a court in this or any other jurisdiction. 14. The plaintiff does not know of any person not a party to this action who has physical custody of the children or claims to have custody or visitation rights with respect to the children. 15. The best interests and permanent welfare of the minor children will be met if custody is temporarily granted to the plaintiff pending a hearing in this malleI' for reasons including: a) The plaintiff is a responsible parent who can best take care of the minor children and provide for their emotional and physical needs. b) The defendants have shown by their abuse of the minor children that they are not an appropriate role models for the minor children. WHEREFORE, pursuant to the provisions of the "Protection from Abuse Act" of October 7, 1976,23 P.S. ~6101 ~ SSj., as amended, the plaintiff prays this Honorable Court to grant the following relief: A. Grant a Temporary Order pursuant to the "Protection from Abuse Act:" I. Ordering the defendants to refrain from abusing the millQr children or from placing them in fear of abuse. telephone and wrillen communicalions, and that the defendant, the mother of the children, be prohibited lrom having any direct or Indirect contact with the minor children, except during supervised visits. 3. Ordering the detendants 10 retrain from harassing and stalking the minor children. 4. Prohibiting the defendants trom entering the schools and day care facility of the minor children 5. Ordering the defendants to stay away from the plaintiff's currenl residence located at 831 Fremont Street, ApI 12, Lancaster, Lancaster County, Pennsylvania, and ordering the defendanls to stay away from any residence the plaintiff may eSlablish for himself pending a final order in this mailer. 8, Schedule a hearing in accordance with the provisions of the "Protection from Abuse Act," and, after such hearing, enter an order to be in effect for a period of one year: 1. Ordering the defendants to refrain from abusing the minor children or from placing them in fear of abuse. 2. Ordering the defendant, Max Saleem. to refrain from having any direct or indirect contact with the children including, but not limited to, telephone and wrillen communications, and that the defendant, the mother of the children, be prohibited from having any direct or indirect contact with the minor children. except during supervised visits. 0030346.01 r ", /1/1.1" I,. , l"'m '" " ", """'..'11 I,.. . 1/.. II' Ifi "I" II~+ q ,l II " I I-},.,~ 'II NI 'III I' iII/' /" , II' .' ' I/M, /11'1-/-1 f III " III ~, ,',I!.'~ .Ii~l! I "II;r IivlF.N I 1'" I II I I . I ,~,II. , I I .1111 ,Ill, I.J i ,It. \" ,:,' I 11.0\ " I I, . ~ t I I, , '/' II , I I.'". , , f" IN THE COURT OF COMMON PLEAS OF LANCASTER COUNTY, PENNSYLVANIA THOMAS E. BOWERS v. ',. m of :l: 'fl No, 4408 1995 !.1 0 fH '0" . I.' ..,; ." (. . - .., !:.). .t:- o' , . ",. :i . P'", U ~J".\ "'1' .t:- :1.1 :.1 .. ~ ORDER (I Co) " I\) LISA G, BOWERS AND NOW, THIS Ilf .71day of ~ "'W!.-~~~1995, following a custody conference which was held before Custody Conference Officer, Susan M. Kadel, Esquire, and was attended by each of the parties hereto and their counRel, and an Agreement having been reached, and after the parties having waived any objection to the conference being held before said Custody Conference Officer, the fOllOWing Order is hereby entered regarding custody of the parties' minor children, namely: Ragine Bowers, Rachael Bower., Ryan Bowers, Rodney Bowers, Riley Bowers and Risa Bowers. EXHIBIT B 0030346.01 1. The parties shall have shared legal custody of the children, so that each shall participate equally in major decisions affecting the best interests of the children, including, but not limited to, medical, religious, and educational deciuior&s, and each parent shall have access to medical, d~ntal and school records. 2. Mother shall have primary physical custody of the children. 3. Father shall have supervised visitation of the children every Wednesday from 6:30 p.m. until 9:00 p.m. at Glad Tidings Assembly of God Church and the first Sunday and third Saturday of each month from 9:00 a.m. to 6:00 p.m. Pursuant to the Court'. October 26, 1995 PFA Order entered against Father, Pastor Alan Richard Ryman, or any other supervising individual, shall be accountable to the Court for supervision and shall execute an ,1'1 affidavit of accountability. di' 4, Father shall be permitted to contact the children by'j telephone one time per week before 8: 30 p.m.. at a time of hi.,J choosing. -2- > (;: o. (:. ..~~ ... t) -, ~) ,"-!" ~l c.'; "'J.,: Cr';:i ~l:: .. ., .... ..... ; ~;! ; I ),.: \0 ""J . ~ . '- ,'.. " l.~ fi.: ll,~ tJ.. tl. .I h, (T)::\.. ~-~ Vl ~ b r... 11' >. ,_i' ,. " ",' " , . ,'" .' " >> . 'IWh 11'/ ':; 1":1'IIIW 1)I:C,lILAE I"" .'.t.: NU: J ,)~.,? 'li}'j':.:'Y', p "'lt1NON\Y~:ALTII OF' PENNSYLVANIA, rnUNTY OF CUMBERLAND n I] \oIg:B.~! _"T.!l~) M.A 5.... E !!_I1__~J~ D _.____"._ __... .._0 0_ V~:; . ng\olfJ!.~',;..J.IUA. G,\YE _J?lt:;Jl!_J'1r,:Ji_l~.tlJ;;.:L.._._._o..__.____o._~____, ShC'I'U.f Uf' DlJ'puty Sheriff ,~f I:IJMBEHLAND County, Pellrlsylvo"lia, who being ~uly OWOHI ac,:ouding to law, soy:a, I,h", ...ithin p..Rr;LTt.r.;IJ.Q1:LffWM Al,LtmE_________ was served \I P U n..m]__\i~IiiL.1..I.S1L..rd.b..Y. E the d'>f-?nd.,nt., at. '.17:J5;~, flOUHS, on the 2f,;.!J1 day Qf ;jeptemo,.o.;>f' 1'3")7 at .._.~~~Jl~._ ~~^M.f_.__f!J11~_1 701 L_______._. ,CUMBERLAND , ("H,nt. y, P"nnsy 1 vania, by handlng to UlL~,..Q!i.YE BOWE@ " tflJP '.nd att"""tl!?d 'copy (Jf th'! _l'ROTECrIQIJ....FR'1llLll.e.illili-___ t.o',l'?ther ...Uh TEMPORARY FROTEr;TION ORDE:!Lt!Q.TICE MLQ..J:gJITION and ."t thl!? s'fmF./ t.im"-' dlro;oc+..l.ng [-flU' aU:enU"n to the contents thex;eof.. " Sheriff's Costs: Dockeoting Service Affidavit Surcharge .18,00 '3.30 .00 2.00 So ,an?~~~<~~ H. ThfJnliHJ r<llIH?, Sher1.1i $L'J. 31D" 00/00/0000 . ~ . " . . bY./Jd&..~ ~ . . '. . ~"pIJty ~": . , '.,' , ., Swor'n and, 3ub:3crib~d t.n bE-lf()r.:/ m~ 'il- I _ i t.hlS ~_. day of~L. 19_'l~.... A. O. ..__( l d. {.'... "". ~~JI.~~.________ .~ r'~:tll)ll')'_~~ )), t/(,--- /(.- . t/ (/".1 (. l.Jl 1'1'(;. . (1//. . Ii / ~j )J ,LI!'<:,.) '4A'~(' .', .~/ .,1), , ; .' ...:/' II. (. if" ,I( Il J',<) (?(!I/? /t.,(;l,( . I ,.:2l( ;':;' 1...;1 d (h' l-,C- ,.../:' l, ..;t:/ (!\; j/") ,,/)),J II' . c.") I" < (,.('1 <"-')/L." ,.I, ( I , I,'j.,., '.l' I . / ( // . .J " () jr,]l~" ~ (~ , ./'/If-J,Pl "'1 ) , (, / ),"" , ".)/,'] . /; ,C,.U...I( . J!X\{..f I .;;>....., .- ~ l.', , ' , , " ,. , , '. , '! . , , I I I) , '.1' , , I . 'i' , " I. ," ; . , . ' .,'.. - . . _"_:; ___I' EMERGENCY DEPARTMENT 'J ~.""",., ~ r:Y ~,~~IP.AL~CeRQOW'G'~-__, ~. LANCASTER GENERAL HOSPITAL Mlmhrll~Il..I>l11 H....hh AIIi~I"I.. 15M Ncrth O'JIt. Str..t, PO. Bolt 3555, uncut", PA 17604-3565 T~111'2go.~11 "T I .1 ,rrm!\l/I:IJ '11"('1"" ." , , .', ,". .1,'1 . .,,).1, ,.,....' ' ~' , ", l, ;-:--r""" ,,"I< '" '.':' "~-L""'" _r""~' ",CO,", '" t. ':, I, ,,: i'l(~ I ! I!lH 1'1:.' ,"',.)l'I" !Il! I, l. 'If, I I \ '1'" I:~ql,l!::r:": '. I.. I' i ,.., n , 1'1 .. I' I ,. \ ' I,!' ~,l I! I.. I I :~I t : . ill I' !':! I' I " 11" ,III,' III'W:'lli~Il'1 ~ I.. 1.1'1 , ~~ cdtl ~*- ~./ L PH"., 1::1111...0 ~~IO' ,jn,,~"" MEOIC;'TIONsfff ..' ALLERG'ESl lh~ ~~ct1 J~ r ;to p,..:/..f I~ cf fI ~ ..t:f+ l~~~~ f'.----~_.. _@~ p--J I-~lc~ ~~~l~ V~~~I-',)~v-rr~ '" '",,'" ----- .:..,~-=:....~ TETANUS S1'ATUS; Q "ITS; '. , /I/AAJ:.-:J "mlONO 1tHY$IClNf""-TVM @ PUH MEDICATIONS USED NUA81 ... . P" -..:: ,~t.' ,} DISCHARGE CONDITION: SATISFACTORY 0 FAIR 0 AUTHORIZATION TO RELEASE INFORMATION: I hereby authorize The Lencaster Generel Hospital to release the above in'orm.tIO~"led by my In",ce Company. SI ned: ;Y/./h ;f;~;"'-;.I 1- i\ 1'1 OC~ 0 a~p'I'lIO 0 . . . VALUABLES 1. MONEY ( ) PATIENT HOME (SIG) .. '2. JEWELRY WATCH ( I PATIENT ( ". .:A-~~~ \:'.,\'~ \.), ,') H~~~ (SIG~. :' . 3, ~EGLASSElI>-"-o CLOTHES ._._.,.__.. - ___...._,,='''' \. }.~:l\\ OENTURES 'UPPER LOWER .' I ( ) PATIENT () CASHIER r~-" ..-- _. .1..._ - ... .........,.mo:JlW~.. HOME (SIGI ~" ---,'~ ~~ - -- ..... .- , \. \ l' ~-"''::'-':'' ~.~'~-:.-~- 4. MISC. .',,^ . ( ) PATIENT ) CASHIER ') HOME (SIG) ~ r"- WALLET ( ) CASHIER RING OTHER ) CASHIER .--~"i'j~, \ .. \, """. "-.~" \ ""t ...."'. ...~'. . ~ ~ 1""\-. V " .' ". , ~; ~, r '._ , ..~ , DISCHARGE AGAINST ADVICE . ~, . . contrary to llie advice of the attending physician, Dr.' , or of his assistant or designee. I acknowledge that I have been informed of the risk in,olved, and I hereby release the attending physician and/or l1is assistant or his designee and the hospital from all responsibility lor any III eHects which may result from this discharge against advice, .: IN.m.'l1 P"lIltf1t1 '.\ ... . i . \: is being discharged from The Lancaster General Hospital $Kpllltlllll 01 p.u.nl Of 01 ~n *,ll'IoI1r~ 10 *" lOf him . N'. -~ Clillll w...... fREA TMENT CONSENT FORM -'~7k', .. ~.~ ~" do hereby ~I~f'cons~nl;o "'~~y' pro:edures and to s~ch medical, ob~;e;~~;, 'Na~ -~;.. ~u;~ ~~.~~ t::: '--' -\ - .. , his assistants' or his designees ij's is necesSary In hls'judgem~,"1 or Jr.th.~ judgement of any of Ihem..includlng the performance of such diagnostic prOCedures to dete.rmlne thlt presence'O{J"'lIC\tQua.Qf.. communicable diseases as may be deemed advisable to facilitate my treatm~nt and/or protect- me. hospital pel'lOfll14ll" physicians and other patients. .. __ ., _. ___ ___... OM ,I,,". I am aware thaI the ~ractlce of medicine and surgery IS not an exact science and I acknowledge thaI no guarant~. have betn made to me as to the result of treatments or examinations In the hospital The form has been fully explained to me and I certify that I understand Its contents. ;:j"II',IIl"",..I"l''''''ll N.ll"H (If patient is unable to consent or IS a minor, complete the fCllowing): Patient (is a minor, years of age) or IS unable to consent because ., , r- .-, ., ".i!.1t111l1l\",,'I..If!;JI'...."'It,," , " I -:' ,: I . 1M.. Emergency Department MEDS/DOSAGES: -~ ..~-~- Protocol Algorithm PT.NAME:_(?,lr" rd.-y!.." 'PuUUd' OATI!:g;'C.h'~ I 701 '14 < ~'7 5.'" FMD: PMH: ALLERGIES: u- TETANUS: <5yr> <IOyr> TRIAGE ACUITY: /' L U vN A L-LJ" Thrlal v-U'otnt N.N'"Cn.U~ R..Roulln. REASSESS: U:) 30 mln, in WR N/R: > 1 hr. in WA CONDITION: Stable V Unstable DISPOSITION: ED-LFC_FHS_ OTHER Time BP P R T SA02 TRIAGE: ?Ju.'7 SUSPECTED CHILD ABUSE Initial Gras ow hou Iy Assess and report any suspecled abuse traum s)l.~lIe Is CC: '5"'ltD. ~t. ~ (;-2) Nollfy Social Service, Ex!, 7264 (eve/nights call nlflJ .:.;r.; '?() Zo Z ':h~ ~ Vi qz-. Operator) and Nurslng Supvs. ~ . U..-LR eI .Wl.~ tf-t-." (C.~ ContacT Children & Youth Agenr.y: tU;7A.-u-i '8-., ,/ ' A~'I-L-. Days. 298.7925 Eve/nights. 396.8085 fn., '7:f-A.<..J-L.... tu~-r~ Photo of Injured areas taken by physician (at gt:w."jc. a tA.. ~~ tn-, their dlscrelion) document on back of photo. PI. t-u.-Ifu.. (C..s ~ .I2.,y . name, 70N, date, lime, Identify area In photo, tape to MO "Treatment Progress Record' 1m[ €.c.ch..:J; l. ~. Q/J U",""~],r If medical records are requested by outside rj-fl:Y P:1:~j)<dtU. {L'l~U authorities - consent must be obtalned on ? .J ^- ../. ~ ~~~ h".. 4 "Releaee of Informallon" torm and the requesting ~; J(.. person directed to the Clinical Correspondence ~ H,. t.." 1.<;'_ ,JJ.~ '-~ Secretary In Medical Records from 8:30 a.m. . II/. ~ 'Ail _ .-/.L 5:00 p.m. (weekdIlYs) or call 290.5813 N_. Call Security to remove suspected abusers that IqlJo l\J.li'7~, I'__o\,~:./ e.VA (UJ..1'r./11 threaten pI/staff safety l:l~"\ ..,,~. AO..... r..... l.~ (I,.U.... File a CY.47, Make 3 caples, Give cuples 10 the C:d... ..... M, ! u . Ao following: - ~. r-:- . /Nt. flL,'4.1 ~ -Original: Lane. Co. Children and Youth Sac, Sve, Agency II In ED, t.NI(I,,~., I J 1'... .. Cti 'J A" -ED Cho/ge.Nurse to send form to CYA if not 1'I:l,., ~ 1'15)' (11. I " ~. '* 0-... r ..! ..~ In ED ~~ ~ -PT. Chert /-'iJ(J ,-'13 .3 ;:) - - U -Risk Management - 11_ I I. ,~A_~ C:>mmunlcate Involvement of Children Youth ": Iq<;'f ~ /I. .~ '- ~-t t'..V-~~ Social Service Agency to family LQH A.2842-08 ~ f...... ,Ju~ J ;: 11h< J~. "-~. AlA .j)J~'" t Tlmo GLASCOW - MEDICATIONS IV / Blood I 0 . Pupt;a Fluldl Plod, - % % MEOS. 0000 AouI, 'M. 1'ypol 'SlIe """ JJ:;. I'oIeI e,. """"' ""'" Total Tlm, """"'.. ,.. tV, NOT Blood 0IIw OIIW 0IIw 1lltol - ld /Z., REPORT OF .SUSPECTED CHILD ABUSE (CHILD PROTECTIVE SERVICE LAW - p,S, " 2201 - 2224) INSTRUCTIONS TO MANOATUO PERSONS: Any plt.onl,wno, In Ihe COUI" 0' thllr Imployml"'. Occupltion. or ptlulu of 1".1' plo'...lon com. Into IIIQnl.e' wlln 1II1'\lld,," Ihlll "POrl ~, nu.. . 'Iporl 10 tt. ",1'" 10 C"'''JLi". IIOO.U2'0:n:U Wftl" th.y tin. ,...on 10 bllllVI, on thl b..11 0' Itlll, ml'UClI, l)Io'...lon.1 0' ..Hh.~ ".Ininl tnd IMPI"'"". """ . lithlld 1II0mlt'll Iit,for. U..", In lh,l, plO'....IO".1 or .)"11:1.1 IIplolty i. . vlotlm of cll'l~ Mun. Within'" l'Iour' ,It., Ih, 0'11 ,.port, .,nd 0"' cop." <)1 lhlt "pOrl 10 Ihe Child "0111I11"1 Se,"I'" Unit of thl County Chlldra" .n4 'foul" A""IIIY, NOTE: If Ihl el'llld ".. b..n I..." Into CUlt ad." you mutl Ilia Immldll'lly conUcl Ihl County Child,," end Youlh .,.ney wf'I". u,. .bu.. 04C"".lt. E~CEPT 'OR SIGNATURE, PLEASE PRINr OR TYPE 1. NAMa 0' CHIl.D IL.II. Plnl. Inl!I.I) 1.V~;:rz...S R,Le"" I. AOD"ISS tSln". Clly. "". Zip CQ"}l / ~ h- (f) <( ffA-eL UR 1A. '''ISINT l.OCATION I' DI"II'INT THAN AIlOVI SOC. SIC. NO. ISIRTHDA TI /0-3-'1/ COUNTY SIX ~M 0, C!. a rYJ;? If; / (J d- 170/( COI.,INTY ~ ~ 1-1, / ( soc. SIC. NO. A~I T1LI'HONI NO. 3J 717 - 7.:J C~.(Y ,o~ /7d Om h SOC, SIC. NO. Aal T11.1,HONI NO. ~c1C -lJ~ 'Iq I - I...j<:l '" t7~ (7~ :... - soc. SIC. NO. InIH.II AOD"ISS iSl,..,. 810l.0 leA InIH.11 I AOORISS 151'.". C~W. lit.. Zip Colt.' rf(" <::.... iF 4. l.IO...l. OI.,lAplIDIAN o~ ADDRISS ISu.". City. SII" . IIp Cod.t COUNT V 5. Al.l.IQIO 'IRPSTRATOR 11.'11. III,... Inlti.rr-- SOC. SIC. NO. A1LATION$HIP TO CHU.a .1 rht'r COUNTY C Aca"l 5 lsudl. City. $1.1. . Zip Cod.1 -) IYJ Ii'. J 5. IIAMIl.Y HOUSIHOL.D COM'OSITION lI.11Gludlnl AbOY. H.mlll ...M FI, Inl REL'" TIONSHIP TO CHILD N M L FI, Inll It RELATIONSHIP TO CHILD .... 8. C. '.., DISC"181 INJU"'UICONOITIcJ'N AND WHY YOU SUS'ICT AIUSI IGLICT. INCl.UDI IVIDINCI 0' '''1011I ..ausl TU THIS CHll.C OR SIILING. t'LIAsa 1'1111" TO O,"OSITI 01110" ADDITIONAL IN'OAMATION.I :::l D. e. F, 010 TI1.' _I'CIDI c:....,,~...I"'''' c.,~ ,d" S- $if 7 , $~OV~ la.Jl#Il1___~, tj.... pd.." ~~~ ~#.-.6), 5~~~.!.~P'- } , COUNTY WHIIU "BY 51 OCCU"".O 7. ACTION' TAKIN 0" ...au 0 II TAKIN NOTII-leA' O TION 0' 0 )(-"""YS 0 ~OT04 0 IoIOS"TAL.' 0 'OLlel CO"ONIPI QltAPMS IlATION NOTI"IO INTrAL) OTHlfI IS"clfyl O MIOICAL 0 IMI.OINey 0 IXAMIH4 CUSTOCY AflON TAKIN flTLI alii ".L.ATIONSM." TO CHILD J">1 . >- N. O"b CHILOLINI U Ii ONl. Y SOU.CS OM. ON. 0 "" A AL Ol~; TO ~ LL.LJ COl'flmOnwl.\tft of 1II.""".,h"",. "'.'''' "ICIPII.O ....~ ~IlOMC"Sr . . CI"."",.nl af l,bllo W.lf.r. PLEJ,SE NOTE THE EXACT LOCATION OF THE INJURY BY PL..CING A LETTER OR NUMBER ON TIlE MODEL BELOW. USI THE LINES BENEATH THE MODEL TO DESCRIBE THE CORRESPONDING INJURY THAT EACH LETTER OR NUMBER REPRESENTS. . , . . ~. '" :> :;) OJ :> J )'. ,., S " >" - ,. -< Fh., P.lmtt L.to.Oornl L.t.. PII",.r Rt.,Oonll , PLEASE CHECK TH& CATEGORY 0' INJURIES DESCRIBED BELOW: ~ PHYSICAL INJURIES o SexUAL ABUSE o PHYSICAL NEGLeCT 0'11011 CY.' 4 tll' ~. LANCASTER GENEAAt HOSPITAL. _u.-_oj>IoIU...... LEA Charge Code . EMERGENCY MEDICINE DEPARTMENI' Charae Sheet :~~~7!Jir~~&)1 Charg.. Completad Chargee Checked Primary Num Inltlala: Charge RN Inltlale: ~~ LaveluO. Non-Urgent Chao.. It ADDroarfate: Critical Care 1st Hour Critical care Add. 30 MIn. AIRWAY AND CARDIAC Bag . Valve. Mask Code "R. Response Code "5. Response C02 Monitoring, Continuous CPR (emergency) EKG Appt Endo Tube. Intuballon Equipment Monitor Tracing Nasal/oral Alrway . Oxygen Admin . Pacer Defib Pads Perlcardlocenllsls Tray Pulse OX Single Reading Pulse OXimeter Monitoring Thrombolytic Infusion " EHI Anterior Nose Bleed Packing Dental Tray Ear Wax Removal Eplstat . Posterior Nose Bleed Eye Burr Tlp Morlan Therapeutic Lens (Chargll tor IV Solution) Posterior Nose Bleed Packing (Cotton Belle, ael Foam, ate). Pr_petch Eye Shield EMERGENCV SERVICES Muat Pick On.: Level I Emergency Room Vlalt _ l.!JlIel II Emergency Room Vlelt .....-Gv.. III Emergency Room Vlalt V levellY emergency Room Vlalt Level V Emergency Room Vlalt PrlmeNIIt ER Non-Emergent Left wtthout being _n by MD, NO CHARGE Drug Admlnlatnltlon Only MED SURG AND TUBES Absorbent Pads >6 Accu-check Glucose TESt Blood Alcohol Klt and Procedure Breath Alcohol Conflnnalion Breath Alcohol Screen __ Blood Transfusion Disposable Scrubs Disposable Slippers Disposable Speculum Edllch Tube Insertlonllavage Endo Trach Suction Catheter and Equipment enemaKlt Gastric Lavage HemoccuJt Test Hickman Repair Klt 1M sa Injection 1M Injection, Antlblotlc IV Start Lumbar Punctura Tray NG Tube Procedure end equipment OB Klt PedlaJyte Penrose Drain Phlebotomy Procedure Posey V... Restraint Protective Restraints. (10ft Wrtet) Rape Exam Kit __ Shroud Urlnlllysis - Dlpltlck Yankauer . Suction and Equipment -..........- ORTHOPEDIC Active Ankle Brace AII' Splint Application Appllc Post Long Arm Splint and Equlpmllnt Application Short Arm Splint and Equipment (Includes Gulter, Sugar Tong, Thumb Spica, Volar Splints) Bucks Traction Kit Balanced Suspension Bryants Traction Cast Orthopedic Supplies (No Application Fee) Cervical Collar Clavicle Brace Crutches Hare Tractfon Knee Immobilizer Knee Sleeve wMsco Padded Alum Splint Rib Belt Robert Jones Splint Appl Russells TracIlon Shouldor Immobilizer Sling Strapping Ankle - Ace Wrap Strapping Knee . Ace Wrap Strapping Wr1st'elbow - Ace Wrap , Universal Toe Splint Velcro Finger Splint Velcro Thumb Splint Spica .....elcro Wrist Splint Walking Heel . " , TRAUMA AND WOUND CARE Arrow Emerg Infusion Device. 8.5 Catheter Arrow Trauma KIt Arrow - shealh/Wlre Guide . Multllumen Catheter Arterial IV LJne Kit Aulotransfuslon Kit Central Una Kit (Percutaneous Sheath Intro, Tray) Chest Tube and Equipment Cut Oown Tray Oebrlment Skin TIssue OlspoMble BP Cuffs " Large Bandage Supplies Mast Application Periocardlocentesls Tray Plastic Suture Tray (+ Sutures) Pressure Infusor Bag, Dlsp Rapid Infusor (Equipment) Removal Of Foreign Body, Skin Small Bandage Supplies Sterile NSSIH20 Stryker Irrigation Equipment Subungal. Release Suture Tray end Sutures Suture Removal KIt Thoracotomy Tray Touml-cot Tracheotomy Tray TRAUMA RESUSCITATION Trauma Tray __ Treatment Of Bums 1st Oegr/LMa than ll% Treatment Of Bums 2nd Oegr/8-10% Treetment Of Bums 3rd Oegr/GrMter than 18% Wound Irrigator System UROLOGICAL Bladder Irrigation Caude Catheter Foley Catheter - (Tray & Insertton) Foley Catheter (Only) Leg Bag __ Pedlabic Urine Bag Straight Catheter Urine Slralner Other. (. ) Seclusion. Restraint · Extra equlpm.nt or charge for bundled Item . look In Charg.. Book and writ. the number precMdlnll the .rtIcla, ~- LANCASTER GENERAL HOSPITAL ~l...~_tl""".""""" Ma NORTH DUKE STREET, PO. BOX 306&, l.ANCASTER, PA 17004.36M 'ID. TAl 10 U.1MNU EMERGENCY MEDICINE DEPARTMENT AFTERCARE INSTRUCTIONS TO PATIENT NOTE: The exemination and ~aalment you have raceivad in tha Emargency Departmenl heve been rendered on an emergency basis only, and are notlntanded to be a substitute for or an effort to provide complete madlcal care. Your follow.up doctor (named below) Will receive a copy 01 your records and all test reports. It Is Important thai you leI him check you again, and thaI you report to him any new or ramainlng problems Blthat time, because It Is Impossible ta recognize and Ireel all elements ollnlury or Illness In a single Emargancy Dapartmenl visit. Meanwhile, FOLLOW THE INSTRUCTIONS BELOW as Indlceled for you, . ll(lW[/~!i. flll r Y 'r ^ YI. 111{ 111.17E\..077'J 011110/')/ ()(J(J!','):lfo:ll l()'M!',:I'I~. lill!; MArnll':W IJrl CAMP HJI 1. r'A 1/011 o WOUND CARE (cuts, ebraslons, bums elc.) Keep the dressings clean and dry eJevate the wound to help relieve soreness and help speed wound ~eallng, _ Despite the greatesl care, any wound can be Infected, It your wound becomes red, swollen, shows pus or red streaks, or feels more sore Ins teed of less sors as deys go by, you must report 10 your doctor right away. o SPRAIN AND FRACTURE, SEVERE BRUISES Elevate the Injured part to lessen swelling, It pillows natten, use chair cushions with pillows or blankets for comfort. Ice packs also help prevenl swelling, especially during lt1e first 48 hours. Place Ice In plastic or rubber bag, cloth covar. It you h8'le an elattlc bandage, rewrap it If too tight or loose, It you heva a Cllt, keep II periectly dry at all times, Walt 48 hours lor the cestlo become strong before you allow pre5Sure or. weight on any pert of the cast. Wrtggle loe~ or flngers to help prevent swelling in the cast. This should 6a done often it It does not causa pain. It the part swells anyway or galS cold, blua or numb, or If pain Increases In aeventy, have it checked promplly. Your care has been provided by: Lanc8slar Emergency Associates. LTD. o HEAD INJURY INSTRUCTIONS Report 10 your doctor Immediately If anything listed occurs (even within several months), Persistent heedache Persistent vomiting, stiff neck, fever Unequal pupils (one pupil large, one smalll Confusion or unusual drowsiness Convulsions or unconsciousness Stumbling or olt1sr problems wilh nonnal use 01 anns or lags; or areas of skin numbness. Nole: Stimulata patlent hourly the flral night 10 check for the.. signa. o ABDOMINAl. PAIN There Is Insufficisnt evidence 10 warrant the diagnosis 01 any acute abdominal condition requiring surgery, This may change with lt1a passage 01 time. For your safety you should observe tha following rules: 1, Follow the ordem given you regarding dlel, medicine, etc, 2, Saa your personal phYSICian for reevaluation in 24 hours. 3, Increasing and persistent pain, increasing soreness In ab. domen, distention, perslslant vomiting, fever may Signify a change and require reevaluation before that tima. In such an event call your personal physician or the doctor taking his calls. If you are unable 10 locate them, call the Emergency doctor for --: _. _ .1 furthe(1?)s~ructlIlllS: r~ IUJ &l.~ a...J.../TI. OD(;!~Iorfollow.up o AVOId any use 01 lt1e injured part o Allow only limited use 01 the part, o Umll general activity EKGIX.ray readings are emergency reectngs only. You WlII be notilled by lelephone if any discrapencles exisl. Yes 0 (Tetanus No 0 OTHER I CTIONS: ~NERAL INSTRUCTIONS ' _ Call to arrange an appoinlment al hla office to see Dr. care. Call sooner if you think necessary, Until you see him: Follow label Instructions for any prescription given by the Emergency Physician. _, M.D. Data I hereby acknowledge receipt 01 the instructions Indicated above. I understand that I hav had emergency trealment only, and lhat I may be released be/ore all 01 my medical problems are known or treal d. I will arrange for 101l0~ as Instruc~ Wltnass iMlal IJ4 Dale<<) X iJ?'Vl- ~ (Panent or representative signature) : .~:.' " nED4~T^~ENT" ." "'l!:"C"','" : INSTRUCCIONES AL 'PACIENTF. Ot:';;,,:~;- :: -.;;~. 7~MIENTO MEDICAL I'h)i,~: : ':'!),I 'r:1I1(",.,'!': :1.13 ',; "V:I:~I_' :';\.,1 JI' .; :.j i :\~ '. ,j .'; ': .~";11 ;,:'.: ~ ,J::;le,j ocr un base Je urgt:nClil, y no puede a t,I):.i:fH' ~':'tJ IU*'1I1Ip"11'" ",P}il "wdorll) rOlT'rk'f), Su met'jlca fJe fl)mHfB :rn~I'\:i:"a(~o JblllCI '/8 J fee:Clr copias de sus datos meclir:l')s Y 1e 1 " re.;u,I~'J03 !JO ~".1lT:efle,. Es nHJv ImCQrtcnle Que III >n~OI[) :0 ee l'l'.leo un 011'() exam en camelete, val mlsmo trempo indlquele al doc. IOII.lI,jjJl';It'i;t.'i l'IUd',c.l.:j, v ~Hj(~II~H1,~ ~l.d 111: sa I~ 4UllarOllt porqlJ'? ~s ImpOl,ILll/d i! ~dUEr 0 CUI,Jr 1.0085 problemas medlcas en ura Vlslta en Ie saia l.: ;111';1<;.;li";..;., :1;.lS;n ~I.I ';,W ";';O':'L,; I,jc>::cr ''';\3 :':I1',;I,J, ~'GUI: (,,;~'c.:);c/'~~)..~ .~i~~II:H1tej, -. WOUND CARE ICuts, ~br3slons, Burns) ';11 .;,;,,;r, .r~ sensa';lcn JoJrmida, oJ dolor fuerte, lIame.a CUICAOO De HeRIC~3lCJrtadura3, Quemacums) ,II "'~"'r.o I1n'eGI:;!>;I~ente La heri,1a tralla ,;,~" ,.,r 'rnl;l~ '1 ;~C1 HE,~D WOUNDS EI.;vante la hanoa ~ora oliviaI' ~I dolor y dY~u~( " liERIDAS DE LA CABEZA ';~:JI!e 1'1~5 rRcido , . i.-a"~ .1 su rneolco InlTltiOl(ltamente :;1 Ilene algunas de ,~.,;I'.a~e ha daoe buen cuidade '1a'/ !a ~c~lbllld:lC de ;n, :J'; iintomds 3IguI6l1Ias:' . . , . . . facclon SI camele an .;clcr. SI >is 'nIl31"005. :il 1av ~n deler que 11') se ie q\Jlte, Cll;. ,; ';11 nay ma$ OOI.;r en vel oe '"el":, 'lame 31 de,;- \11;("0 'It)mll~. .;.;eilo e~tcr~"cido, fiebre. ',:.. "'I'-.;dialel~~ntll. P':CI'J:~:; ~'~,: no 3.;n eJuJI (UnaJrJ~de Y IJna' Pll' U! S;lRAIN AND -RACTIJFiE 'l,"~n2' TCRC::CUR,~3, ~RACTURA.s '( .::::m:"S;CNES I";,;,,,'j le"i'l;,r.~~sitiHdjd .. ~ '.: ,:, ,.'; ~'..:\2i:':~rr;': ::3r',~ ~'::,'''';' ji \q 1,'II,_.,~': \:vli'~t..,s:crt~5 r) ;rr.t;ns~[~",:la' :;.~.. 1 :'~,: '1!',('r,"l~,1'3 " :i '!!:J rt~'~:'r "":'" 111"',:r,"!"'r!':' :~ O~~~I,?"",~:~ '"!f! '!~~' I~-: '1"~"f)-= I') las ryler"t1S' "artes de la . ;:r: : l'(~.~:'., ",~ ,r)iJ; ~'~.c: scr ,icrrl"ic~s ., C'l~1.;re8a$ 1.10 h,elo I":"~"," )' :le'lp',11l ".Ne< fir, ',. 'kla: Stimule at paciente la primera 110che para ver sl el . . :Ion, .' ;c~c,a ,"eme crura"la .je I.,S ,)(lmams..; 1);JCleme :Iene unas de estas slntomas, ,'~,;,,:, ilIelO en una oclsa ~~ clasuco 0 en ["" ABCOMINAL PAIN . DOLOR DEL ABDOMENlESTOMAGO ',e "'1 datos medj,;c, sulic:eme oara nacer un ~,l~'~ . :~IS de GlrUJl8 pcr Sll I]GltJr del J':~Grn~n l~erfJ!o :I;'~ >_lhJe hacr:r FJ~: S'qlJe ~an la clela y la mediCln, ,)ue $e Ie diO a usted el n-:I~(~iC': Haga uria clla con su meolco oe familia 24 horas :.;s:'~.;s oe eSla v,.,ta, . 3, ilay dolor muY fUorte, mu~ho ,0m110 y n.:bre lIame a su 'n~~Ir.',) 'nmediatarr:ente. Si no p.eoe 3 communicar con ..u ,~"dlco, lIame a la sala de emorgel1cla para mas :r.::-.:::i6nes medlcas. I,._....,r, . St :I~:'.r: '~r '';:'(:Ji~ ce e!a:)UC~ reOtJl1,:rlO SI 12"i rr..., ~"":,,do Q muy rcIQaoo. 31 'i.~r'€ un rr,:iC<?lg '~,sr~ 31 'r: ':13]": 56C~ ,3i~lr.prG. ::~~~ft:S..: iJ j~c(a~ n~s,ii (ju.: J:;)t~d ~~r~gJ ~raSSj~i'1 \j ':'!l?~r; ,:r~ 1,1:5 r.~:~',=~ jf~ iU .,..,:f~~ ,\h,j";"!~ I~$ ~,?lj"s ~e I::! rrla~o 0 -1el piel~ mLJch3.s ',ece~ ;' j:a ~: la acc:6~ no Ie de 1 Ud m\'~~~ ~c'cr E.::e .,~.". ch:~c Ie protege arlllS de rntl~I"'aci6n. !'Oi, d~splJe; 11l ha~er lodo I'>.?'I inflamac;6n 'In c~m,;: trISTRUCC:ONE3 GeNERAL L.1d.1l1~ J la ~:!r.;"Q oje! dcctcr .__..____ .____ ::~';,.\ ';.j/:~( JI~J ..,tJ. ~n __._____ ..____,.___ dias oera continuar su trataC1lerlO I-I,:lsta qua J6ted vila al lcet:,. rrJme la madlr.ind ,:cmc ~'it.1l~drr:I1~\j ~n III t:'ct,~11.3, N" l.Js;1la cartl? ~~'Jl! r:'ueroc ~m~ rc "I?rida. No lJsa rrl't:~')lt:~n f'~t;I.!~"r.'? I~ 1)~1e r:cn la hl=)('i;3 '_ ,:.';1:.3.' ;,~,3<? :' -',: I'~;l~:.' ....liC'.O 1p. n:H'frt, L~'S ';';.::iIJIIBdM oitl~; 1(CI',;1rRf"I1~. ,;>J1A3 I'lf'lq S"1C ,eirioJ ,.::~IC..:.~ 1.',jP.glJ 1~r.:!t' -= OQS con mas detalle. " .. - ",- ;,""-, ':,1, '>,';, ' '.;' rei." .. 1'% ;rJ,'IQ IlU"~I~ par 151elo110. ',i'" ,n;1 no. T"'.lnus ~f(; r--, '....ci.:,~,_.__ '.:,-; "t,. 1':':'~"'''1 . ~ ...., . r _ ..1 . ..1 : ~ ;.J urrJ~"" "1':- I;r' r: !I~~a.~ r. ;1,:.35 .1 ~i~tt:::.: (> '. ..~..., ;.,~q...:...::'.~'..:..... "::,:.:..l ~J~t;jl';.; ....1'.1; , : I..... ,1..1,,;": . .'; 1 :3\: ";,,, ,j...."', , ~- Emergency Department MEDSlDOSAGES:_ er- -;""';> PT, NAME: 1<... ~ ~ 701 1 ~ f 'i'l PMH: -H- a...ff-- ~L"'" protoc'ol Algorithm !3z,.,. J I!.I !>' DATI!: '8/'0 /S r FMD:_ ALLERGIES: .tJ TETANUS: <~yr> <lOyr> TRIAGE ACUITY: ./ L U VN R l.-w.. nv.lt U"Urollf'll N.Non.Urgent R.ROUllne REASSESS: U:> 30 min. In WR N/A: > 1 hr. In WR CONDITION: Stable V" Unstable DISPOSITION: ED V"FC_FHS OTHER Time BP P R T SA02 TRIAGE: ~;~ SUSPECTED CHILD ABUSE Initlat I~~~~ ~~ ~ou Iy Auess and report any suspected abuse traum all CC: g1cJ /)v~~ f,. f:;7) .:. I.... Notify Social Service. Ex!. 7264 ("va/nights call ( 701) 4!' g; /1, ~7 171" 'fa ~~ t..o-h ;t.T' ~. 'hi .....r- Operalor) and Nursing Supvs. I!. L<..J.. "'s /J,,,,,-~~ li.CuyC'~ Contse! Children & Youth Agency: tun...JJZ.~V tfh Uk ' Days. 299.7925 Eve/nights' 396.8085 lifo. , j /... 1J..t:C(.c.k. (!4U e Photo 01 Iniured areas taken by physician (at 0.. '-I!-.L ,,<~ ~, 6'....:., ~'- their discretion) document on back 01 pholo . PI, 'inm/'';:' . "S.1L2, A"~ cot ~ name, 70N, date, time, identity area In photo, tape to MD "Treatment Progress Record- li'ir ~ '~4~ M-~ ~ If medical records are requested by outside IL... f L J.J. ,.L.J26... tJJt: authorities . consent must be obtained on ~'u. ,.- u 411, U I L- .....:, _ 'Releue of Inlormatlo.," form and the r~questlng person dlre,1ed to the Clinical Correspondence \qCP !}, ~ \c..J..!;\~ C' ""'.....rV+."l' ey /lJ'If'lr- C Secretary In Medical Records from 8:30 a,m. ' q:'.D 5:00 p.m. (weekdays) or call 290-5913 d". .. ;" J c,.,.,,~" , C...~ Cail Security to remove suspected abusers that '-"-'" oJ J, CvL .~... ,,4/. ,.... lhreaten pl/staft salety .r., . I , ~f'I~1'J ./.' ., File a CY,4r. Make 3 copies, Give copies to the (I. ' '''-0. I .. '..... -- .t0J7/ ~ following: jQ.~- 1'154 (lj,L4 -d," . (J ~ G.,*,=,,' -Original: wine, Co. Children and Youth Soc. . A " Svc, Agency II In ED, J-8o -'13 :l _ /13 I_~ .J=.. . /7 A_.~! - .~. -';;uJ,.u. -ED Charge ~UI38 to send form to CYA If not !I '7i"., ~.. ../! . J fDA.'. A(7';" C!.. y. U In ED , -at) :x') -PT. Chart )))/0 ~ ~ J '" ' . . I ~~ .r. j. . sa -Risk Management - Communicate Involvement 01 Children Youth , '-'_J1./,A, i.- " .tJ /. ,'h-'_' Al ~ Social Service Agency to family lGH A.2802.Qll ~~ ~ 11m. GLASCOW -- MEDICATIONS IV /= I 0 . ....... FluIdO - 1% % MEOS. DoH Rout. 'not. ""po/ .Slt. AmI .t;. Foloy Eyoo -.. ....., TOIoI 11m. - In! I,V. NOT - 0llI0t oe... 0llI0t - 1bIoi D- e, ~. I:..ANCASTER GENEIW. HOSPITAL. Me~ a...na.. H.J\h AUI..... EMERGENCY MEDICINE DEPAR1MENT , Ch.rae Sheet Prlmery Nurse Inltlell: Chlrge RN Inltlale: flfl- " N~'.c;:~W $'; So /] ED It: 'J - (, ~ <?-t- Chlrglla Completed Chargea Checked LEA Charge Code ~~. Llvel MO" Non-Urgant EMERGENCY SERVICES Muet Pick One: Levall Emlrgency Room Vlllt Livelli Emergency Room Vlalt /Uvellll Emergency Room Vlllt /' LlvellV Emergency Room Vlllt Llvel V Emergency Room Vlllt PrlmeNet ER Non-Emergent __ Lift without being lien by MD, NO CHARGE Drug Admlnlltrlltlon Only Choa.. If ADDroDrtata: Critical Cere 1 at Hour Critical cere Add_ 30 Min. AlRWAV AND CARDIAC 88g . Valve - Mask Gode 'R' Response Gode 'S' Response CO2 Monitoring, Continuous CPR (emergency) EKG Appl Endo Tube . Intubation Equipment Monitor Tl'llclng Nasallorall>Jrway .Oxygen Admin PllC8r Deftb Pads ~ericardlocentlsls TI'llY Pulse OX Slngla Reading Pulse Oximeter Monitoring Thrombolytic Infusion . " , MJ!D SURG AND TUBES Absorbent Pads >6 Accu-check Glucose TEsI Blood I>Jcohol KIt and Procedure Breath I>Jcohol Confirmation Breath I>Jcohol Screen Blood Transfusion DlspoQ"ble Scrubs Disposable Slippers Disposable Speculum Edllch Tube InserUon/lavage Endo Trsch Suction Catheter and Equipment Enema I<lt Gastric Lavage Hemoccull Test Hickman Repair KIt 1M sa Injecllon 1M Injectlon, Antibiotic IV Start Lumbar Puncture Tray NG Tube Procedure and- Equlpmant OB KIt Pedlelyte Penrose Drain Phlebotomy Procedure Posey Vest Restraint Protective Restralnts - (110ft Wrlst) Rape Exam KIt Shroud __ Uri~alysls - Dipstick Yankauer . Suction and Equipment mI Anterior Nose Bleed Packing Dental TI'llY Ear W8J< Removal Eplstat . Poetertor Nose Bleed Eye Burr Tip Morlan Therapeudc Lens (Charge tor IV Solution) __ Posterior NOli Bleed Packing (Cotton BallI, Gel Foam, etc). . Pres.spatch Eye Shield LlIHM'.""" ORTHOPEDIC Acttve Ankle Brace AII' Splint Application Appllc Post Long Arm Splint and Equipment Application Short Arm Splint and Equipment (Includes Gulter, Sugar Tong, Thumb Spica, Volar Splints) Bucka Traction Kit Balanced Suspension Bryan18 Traction Cast Orthopedic Supplies (No Application Fee) Cervical Collar Clavicle Brace Crutches Hare Traction Knee Imll'K)blllzer Knee Sleeve wNlsco Padded Alum Splint Rib Belt Robert Jones Splint Appl Russells Traction Shoulder Immobilizer Sling Strapping Ankle - Ace Wrap Strapplng Knee - Ace Wrap __ Strapplng Wrist/elbow - ""e Wrap Universal Toe Splint Velcro Finger Splint velcro Thumb Splint Spica Velcro Wrist Splint Walking Heel '. , TRAUMA AND WOUND CARE Arrow Emerg Infusion Oevk:e - 8.5 Catheter Arrow Trauma KIt Arrow - sheathlwfre Guide. Multilumen Catheter Arterial IV Une KIt Autotrans1uslon KIt Central Une KIt (Percutaneous Sheath Intra, Tray) Chest Tube and Equipment Cut Down Tray Oebrlment Skin 11asue Olspoeab,. BP CufIa , Large Bandage Supplies Mut AppllClltion Periocardlocentesls Tray PlulJc Suture Tray (+ Sutural) Pressure Infusor Bag, Olsp Rapid Infusor (Equipment) Removal Of Foreign Body, Skin Small Bandage Supplies Sterile NSS~20 Stryker Irrigation Equipment SUbungal Release Suture Tray and Sutures Suture Removal KIt Thoracotomy Tray Touml-cot Tracheotomy Tray TRAUMA RESUSCITATION Trauma Tray Treatment Of Bums 1st Oegr/Leu than ll% Treatment Of Bums 2nd Qegr/8-18% Treatment Of Bums 3rd Degr/Grestar thin 18% WoundlmgatorSystem , UROLOGICAL __ Bladder Imgation Caude Catheter Foley Catheter - (Tray & Insertion) Fol8y Catheter (Only) Leg Bag Pedlalrfc Urine Bag Straight Catheter Urine Stralner Other: (*) Seclusion . Restralnt · ExtnI equipment or charge for bundltd Item . took In Charll" Book and write the number pr_dlng lIla arUcle. ~- LANCASTER GENERAL . HOSPITAL ~L..._..lto.k)o'"...... &55 NOATH OUI<! STREET. PO. BOX 345&, LANC,A.STER, PA 11004.3655 'ID. TAllO n-l:MIW EMERGENCY MEDICINE DEPARTMENT AFTERCARE INSTRUCTIONS TO PATIENT NOTE: The examlnetion and treetment you have racelved in the Emergency Department have been rendered on an emergency basis only, and are not Intended to be a substitute lor or an eHon to provide complete medical care, Your follow.up doctor (named below) WIll receive a copy of your records and alltesl reports. It Is Importanlthat you let him check you again, and that you report 10 him any new or remaining problems atthel tima, because It Is Impossible to recognize end treat all elements of Injury or illness In a single Emergency Department visit, Meanwhile, FOLLOW THE INSTRUCTIONS BELOW as Indicated for you. . f1C1wrrm. IlYAN T / II. I;.>fl . O??'} " OO()!.1(.:1I1 /(I'J-t !,:l')~ 1(, I~; MA flHF.W OIl r:AMP IHlI I'A l10l1 o WOUND CARE (CUIs, abrasions, burns elc.) Keep the drasslngs c1aan and dry Elevate the wound to help relieve soreness and help speed wound healing. Despite the greatest care, any wound cen be Infeclad, II your wound becomes red, swollen, shows pus or red streaks, or feels more sore i"slead 01 less sore as days go by, you musl report to your doctor right away, Your care has been provided by: Lancaster Emergency Associales. L TO. o SPRAIN AND FRACTURE, SEVERE BRUISES Elevate the injured pert to lessen swelling. II pillows Hatten, use chair cushions with pillows or blankets for comfort. lca packs also help prevent swelling, ospecially during the first 48 hours, Place ice in plastic or rubber bag, cloth cover. II you hlive an ellltlc bendege, rewrap It If too tighl or loose. II you have a cuI, keep It perfectly dry at all times. Wall 48 hou~ for the cast to become strong bafore you allow pressure or weight on any part of the cast Wriggle toes or fingers 10 help prevent swelling In the cast This should be done often 1111 does not cause pain. II the pert swells anyway or gelS cold, blue or numb, or If pain Incrllases In sevanty, have it checked promptly, , . \ o JliNERAL INSTRUCTIONS l.L' Call to arranga an appointment It his olllce to see Dr. care, Call sooner if you think neces~ry. Until you see him: Follow label Inslructions for any prescnpllon given by Ihe Emergency Physician, o HEAD INJURY INSTRUCTIONS Report to your doctor Immediately If anything IIsled occurs (even within several months). Perslstenl headache Perslstenl vomiting, still neck, fever Unequal pupils (one pupil large, one smalij Confusion or unusual drowsiness Convulsions or unconsciousness Stumbling or other problems With normel use 01 arms or legs; or arees of skin numbness, Notl: Sllmulata pltl.nt hourly tha Hrat night to check lor !ha.. signa, o ABDOMINAl, PAIN There is Insufficient evidenca to warranl tha diagnosis of any acute abdominal condition requiring surgary. This may change with the passage of time. For your safety you should observe the following rules: 1. Follow the orders glvan you regarding dlel, medicine, etc, 2, See your persbnai physlclen for rlIevaiuation In 24 hours. 3, Increasing and persistent pain, Increasing SOrlll18SS In ab- domon, dislantion, persistent vomiting, fever may signify a change and require reevaluation belore thaI time, In such an event call your personal physidan or !he doctOllaklng his calls, If you are unable to locate them, call !he Ernargency doctor for furth slructions. j ._ in a;J /')'I. d 'LA .....teys for follow.up o Avoid any use of lI1e Inlured part . 0 Allow only limited use of !he part, o Urn it genaral activity EKGIX.ray readings are amergency rasdlngs only. You will be notified by telephone ,f any dlscrllpancies exist. Yes 0 (Tetanus No 0 type: OTH R INS rRUCTIO S: .0. Oat I h.reby ecknowledga r elpt 01 the instructions indica above. I understand at I hava had amargancy treatment onty, and IIlIt! may be raleased before all of my mltdlcal r lame are known~r traet arranga (fOIlOW'UP c "' as Instruc~bova. Wll11ess Initial . Dete ,_Jls/lA.8Y IPalltnt or representdvt lignIaMI) ~, ~.:~ ','IG( ," :IJ'.~ ;it":-!' (J,;:. 3tJ,( :.:';5 ~ll~C,l:i~'''''' IJ'mn:i'i~'I,lnl.l 171~~,1.:.~.;j . . DEPARTM!:~lrc ~E ~i,1ERGE:ICUS INSTRUCCIONES AI. PACIENTE ~~SPUE:3 DE r?AnMIENTO MEDICAl. NOTA: EI '1~.:J.1\.t.l!l /' 'r,ltilr.,r;,"''1 '1lJl'J !',\ ';( ,. ':c :leu ,~" i,l ~', ,) >~ ;'''lj'~':I''':-'.1 ':;~ ': i\111,L'i'1';; ..::::~r1 !:cr ,m bas.; Jt1 '..:r,,:~rl:(.l Y": ';l..:'iall a ~IJt~tf~lIr ~~lle ~rl:ttc,",ll!"!') ~:,q1.1 t;uir1~dl~ '~''''~'~'r: SIJ ",~rt',~" ~~ 1:~""II,.1 IIN~I'I~'r:"fl!j" ,1b~lcl':A 1 rQ~I"jr l:OOIO:i ~ft 'i1J~ ~1j3tCB ltP.r:1ir.~'i '/ rje :iI,S rt:~ultat10$ 11U f);tJIMnt1$, E$ rl'll"y Imr:cr:UI'113 OW? SU (',edIC') 10 rift :1 usted un C!(O f!);FimtJn ccmr;I~111 Y AI ml:\lllO hamoo InrtltllJete al ocr;. l..:,t pfr:lbltima~ IlIJtJ'joJ,S. l) pr\JCllmM~ '~l..~ Ilf) SJ IljIJull,\Ic:n, P"II.~,l".I~ vb In'IlIJSI~le ,) "jdOe' tJ cur,lr 1000as ~r~lltlftnllS rneolG8S 81l una '/l'ilta I:!n 10 said 'l~ 'llnefg~r.Cla. HJo(.:\ ~u ~lta ':;i'. ~u 4':L~tCI .;~ IJrndl.1. ...:~~tJ ":Oll :c.;~ c:cr;)iJlc~ :)'~l..iGnfe~, -! WOUND CARE ICuts, Abrasions. 3um~) en C~h;r ~n;; ."nSJC:0n aormlua, 0 dolor fu~rle. llama a CUI DADO DE HERIDAS (Cortaduras, Quamaduras) SIJ .no.dlco Inme,jialr,lnente . . La h~r;r1a tll~re~1 :1: ~-.;r '11':'PI;l:, )p.CJ. ..., HEAD WOIJNDS EI"'lrtnle fa 11d(,ua ~,;ra ""'''n' "I dOlor y ayuddr , HEIiIDAS DE LA CABEZA cur,lll" '~dS r.1pl~C L1an'e ,) 5U Iredico 'nlnedlSlements SI Ilene algunas de Aunq"e 1101 dado b~en eUldado l~dY la PCslblhdad de in- las .intcmCiS ilgulenter . lace:,:,.. S, ,;.1rr.1:19 ~n e,;10r. " 85 Intlal11ads. II nJ'j Un ,~CI';r qLe1') 5e I" qUite. pUo .: 511 'la, '11.!, ':<:l/lI 'JIi"?: ,:e 'renos. 1I.11r9 .11 ,:e,> ~tuchc ',omll';. CLllllo enICrpp.cldo. liabre. '~rf~r:;e,ji.lt':n'!?I'tt' PU~I:~1!';S ":::ljl~ rl:)I:I' ~t;ual lU~3 :1r~;"'1t3 Y l.:ra Pt?- 3PF.lINol.NO FRACTURE ':~o;"" TCRC::uURAS, FR.lCTURAS '( C::NTUSIONES ',L"ee. '. G'~;gc, :"s.:sii;,I"j~d C::":"j.'lf(~ ';1 ~.lItt! ',~p'i i::~{W:I;. ~,."'J ~i~~'l"~il( 'oj 'r~"ln1iJ' c..:;f''.'!;IS~I:r''I::'i j "'I:\~I'l~~ii;I'r:i,1 c:c-l'" 'wl':3 1!r;11:h,1'1"'!'ji 5! ~I'! :!'::!'~"'Jr, ',;').1 1'rr:<:r~~~$ -;';' r=rr:CIt:,n:E ':+d w~8r l.-l-:r",Jr~cS.-: a~ ~!c~"',1~' ':,1i~eS riG '..I :1 7' ;1-, ; ,.l!(':.::s .:.: ~iel .,U~ ,!;,~r' '!~r""';d:)s '.:'~ Il~(":'j,.~ ~ '~r: '1',:: ',.!"~I:'I:" ':,:tP'!~dl? .'::If1t~-: r4~.,. ~jotJ: Stjmul~ .JI rJacl~nte IJ ~rimer:J nocr.~ ',ar! '1t!!' 51 el " """ .;:' . ,,;.;,; : . 'nm ,1I1,..rrA Ie I..S pnmAf~s;:j IMr.lente ti~nll 'mJS de ~513$ slntomas, . 1'>1 i. >,;.; :'510 e 1 IIl'a oclsa r:e CI~StlCO 0 en I"~ - A3CCMINAL PAh'l . ,j "C:, OOUIi C.:L .~BDOMcNIESTOMAGO ,~I i": I,in .";1'1'';;'; Jl~ ~1~.s(I~lj t".;~I.lI'~t'lQ 51 ';0 rtl<-.i' r,l: "T, ";,J::.S r~;,;;;<r..; ~;..rlr~:~I'ie ~~Id 'ldcer l..II' apr,,;:,,:a~;v 0 n'~y" h':!~Il";'~ :'JI.;r :~.3 ~~ ;"'1.;,,"1. ,::- ~L., ,:,:;IG( ,~.? .~::;:':'''''''';'1 =r:'r') 0 -::1 "'-I" n l' oil".. ',. .~...' " r ...." ..o"..,~ 'cr."l" ,',I,,:'. '..,. .J.~,~.. h!"l!."." ~~ .~ ~ t";'..I_"L:\.,;,~'':::,'. ),.~,,,,l.;I:;;o)...........l;;l ''''~... lo:;_ C1 __ ":'~;:I.;i;:;t3 .Hl Jr;ra.i .~J:;t':i ,~Ut; ;.:~'ica pcr:gJ r,~S~Sil,jn ~llJIJP. ('.J" 1.'3 !:~~a y la 'TI~diclI"~ r.UI? S~ I~ 11i,.i a 'Jst~d.::;1 j>~'=C I:' la:: ':,1r~..;d ".:9 :iG .r:'.:k~~. 'ir~':tCJ .. \h~.:\,} I;S ,,~tiOQS ~t? ,1 ''11.111'.11: ':1;1 ::;:en r.1L.cl"as', e"=~$ '3' .~ hac;a Jl1a clIa con su meolCO de larrll!la ,ol noras dla 31 '3 1CCicr re '3 :0 1 Ud. "I"~cho defer. E,!~ ~xr,r. :es~:" ;0;).. ~n YISila, t:ir::o Ie Jr"fege arre~ de ;nfl13I~:!~io!" ::. SI fiat \J~lul' n1uy luelta, iTIu~no 'wOlnI(O ~ ilt30re llama a $U Si' dli~r.ue~ d~ haee' tono M'I ihfldrr~ci6n. un ':3mbh) Ir.;G'C,; r"'~GC,a:6men:Q. Si n.o ~u6oe a commUl,lcar con ;~r.edlc:;, ilJ;::e a la sala d~ emargerc:a "lra mas ii~strl..~cj,;r.~s :,..~diC3S. . INSTRUCCIONE3 G2NEM/\L L::1m8 1 ',1 :r;~:nJ ;;i ;;.:c:~.- .___ 'r1tan'ip"'!Q. 1-',,$ra<L~ '"sled 'lea ?-I acetof: TOr1"A 'n m~~!c!r.l'~omc esti :ndictdc en '3 tete I'.], N~ usa la carte ~e su cuomo con la henda, No usa ,"ucne.ccn frecl,anela :a oa~fe ccn la herloa. 'J..sC,1r,ese:, :O1.,~3 <"1ucr,; .1e nada. . co> "~\U,I~do.! c..1 'afalo"rJm~ y In ~',;,a han sido leldas rapldJs Lu..~o ~erJn le'oas con INS delatle. ~. ,1r:,18.; )1: 'Jr':~.I12'i:~~l ,;...n.1 ~ifl1rr:r"::i1 .; ()r~Ci~fra ~ 'r;:I~ICalJiT1~S ,oj rr.1S ';1':)1110 I)OSllJud ~or t~le'Ollo. 31 -, '!Ij r-" _p.,ra :'dC,?,'.lrI,; ,;11<1 ':rJ ___._________ dlas oem ccnllnuar su j",',:r::.,r'J '16 7";r~'I'Lj Cil;s: __,___._,_..._____. ____) __ ':'''/'''';1'';' .-.- -, .._,-- ,---------- -..--.--,--" --------..------...---.- '~...~.~~: '.e,,:l""; , " ~ ~ , , ~.I"':':' _:. :' :.~. ',~~.,) Jt: ... ,!'Ie .. ,d'l :',r I,' '.., ! Je ,;':2nCI.l : """ T':~(~IC~ '"j ~12 ~Ic; pr';lld:"\~S .....~ '1':1:; y ,11;:~S ce ~.,:.' },...I;_ -'.. _~... :'~.'~~'~.~.:lJ.;~: ~):; ;a~r;:..:e :1" ,:,;'. :,'.' ''';:1.' ,.11:.~ r" .. ., '~:..} - . ilf:di'