HomeMy WebLinkAbout03-0790
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
J. IRA LAIRD and TAMMY LAIRD
As Parents and Natural Guardians
Of Brittany Laird
Plaintiffs
NO. C.3 - ,9C>
C(J;L'-r€A-~
v.
CIVIL ACTION - LAW
JENNY R. BIXLER,
Defendant
JURY TRIAL DEMANDED
NOTICE
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 filing 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 relief requested by the Plaintiff. 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 LOCAL
HELP.
Cumberland County Bar Association
2 Liberty Avenue
Carlisle, PA 17013
717-249-3166
1-800-990-9108
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
J. IRA LAIRD and TAMMY LAIRD
As Parents and Natural Guardians
Of Brittany Laird
Plaintiffs
NO.
v.
CIVIL ACTION - LAW
JENNY R. BIXLER,
Defendant
JURY TRIAL DEMANDED
NOTICIA
Le han demandado a usted en la corte. Si usted quiere defenderse de estas
demandas expuestas en las paginas siguientes, usted tiene viente (20) dias de
plazo al partir de la fecha de la demanda y la notificacion. Usted debe presentar
una apariencia escrita 0 en persona 0 por abogado y archivar en la corte en forma
escrita sus defensas 0 sus objeciones alas demandas en contra de su persona.
Sea avisado que si usted no se defiende, la corte tomara me did as y puede entrar
una orden contra usted sin previo aviso 0 notificacion y por cualquier queja 0
alivio que es pedido en la peticion de demanda. U sted puede perder dinero 0 sus
propiedades 0 otros derechos importantes para usted.
LLEVE ESTA DEMANDA A UN ABODAGO INMEDIATAMENTE. SI NO TIENE
ABOGADO 0 SI NO TIENE EL DINERO SUFICIENTE DE PAGAR TAL SERVICIO,
VAYA EN PERSONA 0 LLAME POR TELEFONO A LA OFICINA CUYA DIRECCION
SE ENCUENTRA ESCRITA ABAJO PARA A VERIGUAR DONDE SE PUEDE
CONSEGUIR ASISTENCIA LEGAL.
Cumberland County Bar Association
2 Liberty Avenue
Carlisle, PA 17013
717-249-3166
1-800-990-9108
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
J. IRA LAIRD and TAMMY LAIRD
As Parents and Natural Guardians
Of Brittany Laird
Plaintiffs
NO. C3 - ~cr Q C.,~~l'-r~~
v.
CIVIL ACTION - LAW
JENNY R. BIXLER,
Defendant
JURY TRIAL DEMANDED
COMPLAINT
AND NOW, come the Plaintiffs, J. IRA LAIRD and TAMMY LAIRD as
Parents and Natural Guardians of BRITIANY LAIRD, by and through their
attorneys, Schmidt, Ronca, & Kramer, and respectfully sets forth as follows:
1. J. IRA LAIRD and TAMMY LAIRD are husband and wife and adult
individuals currently residing at 921 Walnut Street, Lemoyne, Cumberland
County, Pennsylvania 17043.
2. BRITIANY LAIRD is the minor daughter of the plaintiffs, J. IRA
LAIRD and TAMMY LAIRD.
3. Defendant JENNY R. BIXLER is an adult individual currently
residing at 451 Latimore Creek Road, York Springs, Adams County,
Pennsylvania 17372.
4. The facts and occurrences hereinafter stated took place on or
about March 3,2001, at approximately 9:30 a.m. on Market Street in Lemoyne
Borough in Cumberland County, Pennsylvania.
5. At the aforementioned time and place, the road surface was dry
and there were no adverse weather conditions.
6. At the aforementioned time and place, BRITIANY LAIRD was
attempting to cross Market Street via the crosswalk that runs parallel to the
intersecting street, North 9th Street.
7. It is believed and, therefore averred that at the aforementioned
time and place, the Defendant, JENNY R. BIXLER was operating a 1988 Buick
Cutlass with the permission of its owner, Mary L. Bixler, traveling west on
Market Street, which intersects North 9th Street.
8. At the aforementioned time and place, the Defendant, JENNY R.
BIXLER struck BRITIANY LAIRD with her vehicle while BRITIANY LAIRD was
in the crosswalk.
9. The negligence of the Defendant, JENNY R. BIXLER caused
injuries and losses to BRITIANY LAIRD, daughter of the plaintiffs, J. IRA
LAIRD and TAMMY LAIRD.
COUNT I
J. IRA LAIRD and TAMMY LAIRD v. JENNY R. BIXLER
NEGLIGENCE
10. Paragraphs 1 through 9 of the Plaintiffs' Complaint are
incorporated herein by reference and made apart thereof as if set forth in full.
11. The accident was caused by the negligence and carelessness of the
Defendant JENNY R. BIXLER individually, jointly, and/or severally and was in
2
no way caused or contributed to by BRITIANY LAIRD, daughter of the
plaintiffs, J. IRA LAIRD and TAMMY LAIRD.
12. The negligence and carelessness of the Defendant JENNY R.
BIXLER individually, jointly, and/ or severally consisted of the following:
a. failing to stop for a pedestrian in a marked crosswalk;
b. operating her vehicle so as to create a dangerous situation
for pedestrians in crosswalks;
c. failing to operate her vehicle in accordance with existing
traffic laws and traffic controls;
d. driving too fast for conditions;
e. inattentiveness;
f. operating her vehicle at an excessive rate of speed under the
circumstances;
g. failing to have her vehicle under control; and
h. failing to keep a reasonable lookout for pedestrians lawfully
in the crosswalk.
13. Defendant JENNY R. BIXLER's negligence in striking
BRITIANY LAIRD while she was crossing a marked crosswalk is most evident
in that her conduct was unlawful in that Pennsylvania's Motor Vehicle Law
states that"... the driver of a vehicle shall yield the right-of-way to a pedestrian
crossing the roadway within any marked crosswalk..." 75 Pa.C.S.A. !3 3542 (a).
3
13. As a direct and proximate result of the motor vehicle accident,
BRITIANY LAIRD, daughter of the plaintiffs, J. IRA LAIRD and TAMMY LAIRD,
suffered severe and what may be permanent injuries, which may include but
are not limited to the following:
a. partial or complete growth arrest;
b. scar formation;
c. numbness;
d. need for subsequent surgery;
e. reflex sympathetic dystrophy;
f. ankle arthrosis;
g. ankle stiffness;
h. neurovascular injury; and
1. compartment syndrome
14. As a direct and proximate result of the motor vehicle accident,
Plaintiffs J. IRA LAIRD and TAMMY LAIRD have incurred medical expenses to
date in excess of Twenty Nine Thousand dollars ($29,000) for the treatment of
BRITIANY LAIRD's injuries, may continue to incur medical expenses in the
future, and thus, a claim for these past and future expenses is made.
16. As a direct and proximate result of the motor vehicle accident,
Plaintiffs J. IRA LAIRD and TAMMY LAIRD have been advised and, therefore,
aver that the aforementioned injuries may be permanent in nature and effect,
and, thus, a claim for these past and future injuries and losses is made on
behalf of their minor daughter, BRITIANY LAIRD.
4
17. As a direct and proximate result of the motor vehicle accident,
BRITTANY LAIRD, minor daughter of plaintiffs J. IRA LAIRD and TAMMY
LAIRD Plaintiff, has undergone in the past, and may continue to undergo into
the future, great pain and suffering, and, thus, a claim for these past and
future losses is made.
18. As a direct and proximate result of the motor vehicle accident,
Plaintiffs J. IRA LAIRD and TAMMY LAIRD, have been obliged to expend
various sums of money and to incur various expenses for the injuries their
daughter BRITTANY LAIRD has suffered and may continue to incur these same
into the future, and thus, a claim for these past and future losses is made.
19. As a direct and proximate result of the motor vehicle accident,
BRITTANY LAIRD has suffered a permanent diminution of her ability to enjoy
life and life's pleasures and, thus, a claim for these past and future losses is
made.
20. As a direct and proximate result of the motor vehicle accident, the
Plaintiffs' daughter, BRITTANY LAIRD, may have and may continue to suffer
permanent loss of her earning power and capacity and thus, a claim for these
past and future losses is made.
5
WHEREFORE, the Plaintiffs, J. IRA LAIRD and TAMMY LAIRD, demand
judgment of the Defendant, JENNY R. BIXLER, in an amount in excess of an
amount requiring compulsory arbitration.
Respectfully submitted,
SCHMIDT, RONCA & KRAMER, P.C.
//
C/~
By:
James onca, Esquire
/ Ct. I.D. #25631
e Street
arri urg, PA 17101
(717) 232-6300
Dated: ~ -)C~Oj
Attorneys for Plaintiff
6
VERIFICATION
I verify that the facts contained in the foregoing document are true
and correct to the best of my knowledge, information and belief.
I understand that intentional false statements herein are made
subject to the penalties of 18 Pa.C.S.A. 94904 relating to unsworn
falsifications to authorities.
Dated: J-IY-{\ ~
,,~,hm ;:;t/ZOJhd
Tammy Lair
AJ~~
fL 'l f"
~ ~ 6
:g -- :tJ
-- p=:
-J
\]( ,
C;_i!.
~"
(,
("') (,
(:::.
.,. 't.1
"'1
d
"-"
-",
-.- ....-J ........
e
SHERIFF'S RETURN - OUT OF COUNTY
CASE NO: 2003-00790 P
COMMONWEALTH OF PENNSYLVANIA:
COUNTY OF CUMBERLAND
LAIRD J IRA ET AL
VS
BIXLER JENNY R
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:
BIXLER JENNY R
but was unable to locate Her
in his bailiwick. He therefore
deputized the sheriff of ADAMS
County, Pennsylvania, to
serve the within COMPLAINT & NOTICE
On March
6th I 2003 , this office was in receipt of the
attached return from ADAMS
Sheriff's Costs:
Docketing
Out of County
Surcharge
Dep Adams County
18.00
9.00
10.00
24.20
.00
61.20
03/06/2003
SCHMIDT RONCA
~~
Sheriff of Cumberland County
KRAMER
Sworn and subscribed to before me
ft::.>
this 10 - day of ~
~ A.D.
~() }J1,H<-, ~
Prothonotar
'.---....------..-..,--....-........,
In The Court of Common Pleas of Cumberland County, Pennsylvania
J. Ira Laird et al
VS.
Jenny R. Bixler
SERVE: sane
No.
03-790 civil
]\Tow,
FebDlary 24, 2003
, I, SHERIFF OF CUMBERLAND COUNTY, PA, do
l:1ereby deputize the Sheriff of Adam~
County to execute this Writ, this
deputation being made at the request and risk of the Plaintiff.
y;/ ~
~~?'e""~<,, .~~e~-M'~
Sheriff of Cumberland County, PA
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,
Sheriff of
County, P A
Sworn and subscribed before
me this _ day of ,20_
COSTS
SERVICE
MILEAGE
AFFIDA VIT
$
$
it"'-
ilf'"
,'"
,-
"
MASON DIXON BUSINESS FORMS, INC. 33000026
iO
,<'"
DATE RECEIVED
SHERIFF'S DEPARTMENT
ADAMS COUNTY, PENNSYLVANIA
COURTHOUSE. GETTYSBURG. PA 17325
DATE PROCESSEI
SHERIFF SERVICE
PROCESS RECEIPT, and AFFIDAVIT OF RETURN
INSTRUCTIONS: See "INSTRUCTIONS FOR SERVICE OF PROCess BY
THE SHERIFF" on the reverse of the last (No.5) copy of this form. PIeue
type or print legibly, insuring r88dabll1ty of an oopIee.
Do not detac:h any copies. ACSD !NY.'
1. PLAINTlFF/SI J. IRA lAIRD and TAMMY LAIRD As Parents and Natural 2. COURT NUMBER
Guardians of Brittanv Laird 03-790 Civil Term
3. DEFENDANT/SI 4. TYPE OF WRIT OR COMPLAINT:
JENNY R. BIXLER Comola in t in Civil Ac tion
SERVE 5. NAME OF INDIVIDUAL, COMPANY, CORPORATION, ETC., TO SERVICE OR DESCRIPTION OF PROPERTY TO BE LEVIED, ATTACHED OR SOLD.
.
Jenny R. Bixler
AT
8. ADDRESS (Street or RFD, Apartment No., City, Boro, Twp., State and ZIP CODE)
451 Latimore Creek Rd., York Springs, PA
7. INDICATE UNUSUAL SERVICE: 0 PERSONAL 0 PERSON IN CHARGE 0 DEPUTIZE 0 CERT. MAIL 0 REGISTERED MAIL 0 POSTED 0 OTHER
Now, . I. SHERIFF OF ADAMS COUNTY, PA., do hereby deputize the Sheriff of
County to execute this Writ and make return therof according to law. This deputation being
made at the request and risk of the plaintiff,
8. SPECIAL INSTRUCTIONS OR OTHER INFORMATION THAT WIU ASSIST IN EXPEDITING SERVICE.
SHERIFF OF ADAMS COUNTY
NOTE ONLY APPLICABLE ON WRIT OF EXECUTION: N.B. WAIVER OF WATCHMAN-Any deputy sheriff levying upon or attaching any property under within writ may leave
same without a watchman, in custody of whomever is found in possession, after notifying person of levy or attachment, without liability on the part of such deputy or the sheriff to
any plaintiff herein for any loss, destruction or removal of any such property before sheriff's sale thereof.
9. SIGNATURE of ATTORNEY or other ORIGINATOR requesting service on behalf of:
~ PLAINTIFF
James R. Ronca, Esg. 0 DEFENDANT
10. TELEPHONE NUMBER
11. DATE
14. Expiration I Hearing date
15, I hereby CERTIFY and RETURN that I 0 have personally served, 0 have served person in charge, 0 have legal evidence of service as shown in "Remarks" (on reverse)
o have posted the above described property with the writ or complaint described on the individual, company, corporation, etc., at the address shown above or on the
individual, company, corporation, etc., at the address inserted below by handing/or Posting a TRUE lInd ATTESTED Copy therof.
18. ~ I hereby certify and return a NOT FOUND because I am unable to locate the individual, company, corporation, etc., named above. (See remarks below)
17. Name and title of individual served 18. A per-. orlUllabIe age and di8Cl'lltion Read Order
then residing in the defendent'. uauel 0
P*e or 1Ibcicle, 0
19. Address of where served (complete only if different than shown above) (Street or RFD, Apartment No., City, Boro, Twp., 20. Date of Service 21. Time
State and ZIP CODE)
REMARKs: The def. has moved & left noforwarding address wi.tb the post 0 fice.
22. ATTEMPTS
25.
MIIea Dep.lnt.
Dep.lnt.
Dep.lnt. o.le
2lKK~ REFUND
125.80 Ck. #8833
AFFIRMED and 8UbllCl'ibed to before me thia
day of
~I Dep. ShertfI) (
Richard S. Keefer
Signature of Sheriff
RAYM)ND W. NEWMAN
SHERIFF OF ADAMS COUNTY
o.te
3/5/2003
Date
3/5/2003
~PublIc
MY COMMISSION EXPIRES
I ACKNOWlEDGE RECEIPT OF THE SHERIFF'S RETURN SIGNATURE
OF AUTHORIZED ISSUING AUTHORITY AND TITLE.
39. Date Received
PROTHONOTARY
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
J. IRA LAIRD and TAMMY LAIRD
As Parents and Natural Guardians
Of Brittany Laird
Plaintiffs
v.
NO. 03-790 Civil Term
JENNY R. BIXLER,
Defendant
CIVIL ACTION - LAW
JURY TRIAL DEMANDED
PRAECIPE
TO THE PROTHONOTARY:
Please reinstate the Complaint filed in the above matter.
Respectfully submitted,
By:
~Ja/ s R. Ronca, Esquire
Supreme Ct. LD. #25631
209 State Street
Harrisburg, PA 17101
(717) 232-6300
Dated: 3-11-00
Attorneys for Plaintiff
()
~;.
<-
-OCr)
rncf"I
-:;;:> ---,
z(
en,'
~,
r:i
:.r~ \~':~
z"..
--c
Pc
:;::.::
~
C'
c..~1
::':J
r.....
!',- .
:J1
.-J
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
J. IRA LAIRD and TAMMY LAIRD
As Parents and Natural Guardians
Of Brittany Laird
Plaintiffs
v.
NO. 03-790 Civil Term
JENNY R. BIXLER,
Defendant
CIVIL ACTION - LAW
JURY TRIAL DEMANDED
PRAECIPE
TO THE PROTHONOTARY:
Please file the attached Proof of Service of the Defendant in the above
matter.
Respectfully submitt ,
SCHMIDT, Ji6NCA & RAMER, P.C.
L-.-/
Jameo/~/R nca, Esquire
Suprtn'iy) t. J.D. #25631
209 Stare Street
Harrisburg, PA 17101
(717) 232-6300
By:
Dated: q....I-O 0
Attorneys for Plaintiff
CERTIFICATE OF SERVICE
AND NOW, this ,1: day of ~ 2003, !, James R. Ronca, hereby
certify that I have served a true and correct copy of the foregoing by depositing a copy
of the same in the United States Mail, postage prepaid, at Harrisburg, Pennsylvania,
addressed to:
Jenny R. Bixler
746 Boston Street
Denver, CO 80230
..
0 c (J
C (.,.) "n
-.,.... :::".
<
"T7 17 -ry
nl ':;:;}
-:':0-
~-:,.. I
(i'J f'.)
<' lJ
1', _--l'......
ZI..J
5>0 ['0
~ ~......) ~-:J
-<
Johnson, Duffie, Stewart & Weidner
By: C. Roy Weidner, Jr.
I.D. No. 19530
301 Market Street
P. O. Box 109
Lemoyne, Pennsylvania 17043-01 09
(717) 761-4540
Attorneys for Defendant
J. IRA LAIRD and TAMMY LAIRD,
as Parents and Natural Guardians of
BRITTANY LAIRD,
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
Plaintiffs
NO. 03-790 CIVI L TERM
v.
CIVIL ACTION - LAW
JENNY R. BIXLER,
JURY TRIAL DEMANDED
Defendant
APPEARANCE
AND NOJlv, this 22nd day of April, 2003, enter the appearance of C. ROY WEIDNER, JR., 1.0. 19530,
on behalf of Defendant in the above captioned suit.
:212470
5774-347
JOHNSON, DUFFIE, STEWART & WEIDNER
BY:~
. oyWe' ,r.
CERTIFICA TE OF SERVICE
AND NO~ this 22nd day of April, 2003, the undersigned does hereby certify that she did this date
serve a copy of the foregoing appearance upon the other parties of record by causing same to be deposited in
the United States Mail, first class postage prepaid, at Lemoyne, Pennsylvania, addressed as follows:
James R. Ronca, Esquire
Schmidt, Ronca & Kramer, PC
209 State Street
Harrisburg, PA 17101
JOHNSON, DUFFIE, STEWART & WEIDNER
BY:/?'t2.1u/-k ,~
'chelle Hagy
o
c:
<::.
-0 i:J
rnF'
Z:T
Z~"
07~7
r::"'C
:.c:::.
::l>c
z(-',
~c:
-7
=.:.
-<
r;.._.#!'
-""
o
W
:1:--
-.u
?O
i"
o
-.'{'j
-r}
;: "
, ,,-,
,....,.....'
5:
_.;,-'1
"...; ~:'1''',
~~
2,>
:D
-<
':::>
\.0
~ .r~hnson, Duffie, Stewart & Weidner
By: C. Roy Weidner, Jr.
J.D. No. 19530
301 Market Street
P. O. Box 109
Lemoyne, Pennsylvania 17043-0109
(717) 761-4540
Attorneys for Defendant
J. IRA LAIRD and TAMMY LAIRD
as Parents and Natural Guardians of
BRITTANY LAIRD,
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 03-790 CIVIL TERM
Plaintiffs
CIVIL ACTION - LAW
v.
JURY TRIAL DEMANDED
JENNY R. BIXLER,
Defendant
DEFENDANT'S ANSWER TO PLAINTIFFS' COMPLAINT
AND NOW, this ~ day of May, 2003, comes Defendant, through her undersigned attorneys,
and answers Plaintiffs' complaint as follows:
1. - 2. Admitted.
3. Admitted in Part. Denied in Part. The identity of Defendant is admitted. Her current
address is denied as averred.
4. Admitted in Part. Denied in Part. It is admitted that a pedestrian/vehicle accident involving
Brittany Laird and Defendant took place on the time and date averred on Market Street in Lemoyne. The
remainder of this averment is denied.
5. -7.
Admitted.
8. Denied. On a contrary, Brittany Laird darted out onto Market Street into the side of
Defendant's car.
9. Denied.
COUNT 1- NEGLIGENCE
J. Ira Laird and Tammy Laird v. Jenny R. Bixler
10. Admitted in Part. Denied in Part. Paragraphs 1-9 hereof are incorporated by reference
herein.
11.-12.
Denied.
13. -20. Denied. After a reasonable investigation, Defendant is without knowledge or
information sufficient to form a belief as to the truth of these averments.
WHEREFORE, Defendant demands that Plaintiffs' complaint against her be dismissed.
NEW MA TTER - MVFRL
21. Defendant is entitled to the restrictions on Plaintiffs' ability to recover damages provided in the
Motor Vehicle Financial Responsibility Law.
WHEREFORE, Defendant demands that Plaintiffs' complaint against her be dismissed.
JOHNSON, DUFFIE, STEWART & WEIDNER
By:
C. Roy Weidner, Jr.
jkr:212597
5774-447
9. Denied.
COUNT 1- NEGLIGENCE
J. Ira Laird and Tammy Laird v. Jenny R. Bixler
10. Admitted in Part. Denied in Part. Paragraphs 1-9 hereof are incorporated by reference
herein.
11.-12.
Denied.
13. -20. Denied. After a reasonable investigation, Defendant is without knowledge or
information sufficient to form a belief as to the truth of these averments.
WHEREFORE, Defendant demands that Plaintiffs' complaint against her be dismissed.
NEW MA TTER - MVFRL
21. Defendant is entitled to the restrictions on Plaintiffs' ability to recover damages provided in the
Motor Vehicle Financial Responsibility Law.
WHEREFORE, Defendant demands that Plaintiffs' complaint against her be dismissed.
EIDNER
By:
jkr:212597
5774-447
VERIFICA T/ON
The undersigned says that the facts set forth in the foregoing answer to complaint are true and
correct. This verification is made subject to the penalties of 18 Pa. C.S.A. 9 4904, relating to unsworn
falsifications to authorities.
~t-BiX~
Dated:
o~
CERTIFICA TE OF SERVICE
AND NOW; this ~ day of jY'f'l.Af .2003. the undersigned does hereby certify that
she did this date serve a copy of the foregoing doc ment upon the other parties of record by causing same
to be deposited in the United States Mail, first class postage prepaid, at Lemoyne, Pennsylvania, addressed
as follows:
James R. Ronca, Esquire
Schmidt, Ronca & Kramer, PC
209 State Street
Harrisburg, PA 17101
JOHNSON, DUFFIE, STEWART & WEIDNER
BY:czt~ K ~~
, , Joni K. Robinson
o
c
S
-oGJ
rn rTl
Z:D
zr;:-
<.n ,,,-:
-:s ~:
r....C
~
~ c(:.,
>- .~
c:
:z
-1
-<
-"
c:>
w
:x
:too
-<
N
W
~
--1
::r: -ri
,n#
..,..,rn
....6
.t..i
(,
'::.t( .
rC:B
g~
-'1
~
-0
::x
~
r:-
....1
"
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
J. IRA LAIRD and TAMMY LAIRD
As Parents and Natural Guardians
Of Brittany Laird
Plaintiffs
NO. 03-790 Civil Term
v.
JENNY R. BIXLER,
Defendant
CIVIL ACTION - LAW
JURY TRIAL DEMANDED
PLAINTIFFS' REPLY TO NEW MATTER
21. Paragraph 21 is a conclusion of law which requires no answer.
WHEREFORE, Plaintiff respectfully requests relief as more fully set forth
in the Complaint in this matter.
Respectfully submitted,
By:
ca, Esquire
, I.D. #25631
209 ate treet
H risbo/g, PA 17101
(717) g;n-6300
Dated: &-5-0 J
Attorneys for Plaintiff
CERTIFICATE OF SERVICE
AND NOW, this 50.. day of June 2003, I, James R. Ronca, hereby certify
that I have served a true and correct copy of the foregoing by depositing a copy of the
same in the United States Mail, postage prepaid, at Harrisburg, Pennsylvania,
addressed to:
C. Roy Weidner, Jr., Esquire
Johnson, Duffie, Stewart & Weidner
P,O. Box 109
Lemoyne, PA 17043-01
()
-,
0 c::~
c: C
'-
~ ,
-Ocr --
c -
mLr ..
z..'
Z ,-
(j)J \L,
-<"-
r:.'>c ,,-)
<
;,;:,-: "
4h :~
)>c: iT.
.L =>
::;! '0
JOHN A. MURRAY, III,
Plaintiff
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
v.
: CIVIL ACTION - LAW
JANICE E. MURRAY,
Defendant
: NO. 03-802 CIVIL TERM
: IN CUSTODY
CUSTODY STIPULATION & AGREEMENT
THIS STIPULATION AND AGREEMENT entered into the day and year hereinafter set
forth, by and between JOHN A, MURRAY, III, (hereinafter referred to as "Father") and JANICE
E, MURRA Y, (hereinafter referred to as "Mother").
WHEREAS, the parties are the natural parents of two children, namely LAUREN
MICHELLE MURRAY, born April 8, 1990, and JOHN ALEXANDER MURRAY, IV, born August
21, 1997, (hereinafter referred to as "Children"); and
WHEREAS, the parties live separate and apart, and wish to enter into an comprehensive
stipulation and agreement relative to physical and legal custody of their Children.
NOW THEREFORE, in consideration of mutual covenants, promises and agreements as
hereinafter set forth, the parties stipulate and agree as follows:
1. Mother and Father shall have shared legal custody of the children,
2. Mother shall have primary physical or residential custody of the children,
3. Father shall have periods of partial physical custody of the children at the following
times:
a.) Every Wednesday, from after school until 7:00 p,m.;
b,) On alternating weekends from after school on Fridays until 7:00 p.m, on Sunday;
and
c.) At other times as the parties may agree,
4, Father agrees to provide transportation for his Wednesday evemng periods of
custody.
5, The parties agree to share transportation for all other periods of custody, so that the
party receiving custody of the children shall provide transportation.
6. The parties agree to alternate custody of the children for the holidays of Easter,
Memorial Day, July 4th, Labor Day, Thanksgiving, Christmas Period A and Christmas
Period B, The Christmas holiday shall be divided into two approximately equal
blocks of time to coincide with the children's break from school.
In the year 2003 and all odd-numbered years, Mother shall exercise custody of the
children on Easter, July 4'h, Thanksgiving, and Christmas Period B and Father shall
exercise custody of the children on Memorial Day, Labor Day and Christmas Period
A.
In the year 2004 and all even-numbered years, Mother shall exercise custody of the
children on Memorial Day, Labor Day and Christmas Period A and Father shall
exercise custody of the children on Easter, July 4th, Thanksgiving and Christmas
Period B.
7. The parties will attempt to accommodate an arrangement where the child shall always
be with the Mother on Mother's Day and with Father on Father's Day. In the event
this requires an exchange of days, the parties will attempt to accommodate each other
to see that the child is with the r,espective parent on their designated Mother's Day or
Father's Day.
8. Each party shall be entitled to exercise one week of vacation with the children each
year, provided that they give the other party at least thirty (30) days advance notice of
the requested time. The vacation time shall encompass the requesting party's
weekend period of custody.
9. The parties shall keep each other advised in the event of serious illness or medical
emergency concerning the children and shall further take any necessary steps to
ensure that the health and well-being of the children is protected. During such
illness or medical emergency, both parties shall have the right to visit the children
as often as he or she desires consistent with the proper medical care of the
children,
10. Neither parent shall do anything which may estrange the children from the other
party, injure the opinion of the children as to the other party, or which may
hamper the free and natural development of the children's love and affection for
the other party,
II. Any modification or waiver of any of the provisions of this Agreement on a
permanent basis shall be effective only if made in writing, and only if executed
with the same formality as this Stipulation and Agreement.
12. The parties desire that this Stipulation and Agreement be made an Order of Court
of the Court of Common Pleas of Cumberland County, and further acknowledge
that the Court of Common Pleas of Cumberland County does, in fact, have
jurisdiction over the issue of custody of the parties' minor children, who have
resided for their entire lives in Cumberland County, Pennsylvania.
13. The parties stipulate that in making this Agreement, there has been no fraud,
concealment, overreaching, coercion, or other unfair dealing on the part of the
other party,
14, The parties acknowledge that they have read and understand the provisions ofthis
Agreement. Each party acknowledges that the Agreement is fair and equitable
and that it is not the result of any duress or undue influence,
IN WITNESS WHEREOF, The parties hereto intending to be legally bound by the terms
hereof, set forth their hands and seals the day and year hereinafter mentioned.
WITNESSETH:
flj1h~t ~ .J/JoJ iltm (] IJJllh!?I1.1j:J1I
Date HN A. MURRAY, III
.~5,= ~~' 9.mu~n
Date ICE E. MURRA
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF C l,{Vl'\ I7er\uV'i
On this C() b day of ~y I \
, 2003, before me, the undersigned
officer, personally appeared JOHN A. MURRAY, III, known to me (or satisfactory proven) to
be the person whose name is subscribed to the within Agreement and acknowledged that he
executed the same for the purpose therein contained,
IN WITNESS WHEREOF, I hereunto set my hand and official seal.
m',,,....___
K. Nota~i~iS~ea'
ansa J Leh N
Carfisle 8oro canh otary Public
My Commission E~~r:;'~8g~~~~~03
COMMONWEALTH OF PENNSYLVANIA
COUNTYOF ~~
On this S:-h day of ~ ' 2003, before me, the undersigned
officer, personally appeared JANICE E. MURRAY, known to me (or satisfactory proven) to be
the person whose name is subscribed to the within Agreement and acknowledged that she
executed the same for the purpose therein contained.
IN WITNESS WHEREOF, I hereunto set my hand and official seal.
,
~ 'fr).. L/-II1AIu J1A-'
Notary P hc
NOTl,RIAl SEAL
AMY M. HARKINS, NOTARY PUBLIC
lEMOYNE BORO., CUMBERLAND COUNTY
. _/!.~..~.2MMISSION EXPIRES JAN. 31, 2005
C)
c
~
-':'03
HilT)
-......-.)
0<--.-.".
zr,-
CO '<
-<--.:
r,;c.;
'""~
~-;C'
~('"'
s>(:-
2.:
~
<=)
W
,-
c::
o
.,
--I
- ,- "'D
"'r.'
m
CJ
,
o
"T,
:-~ ~15
;Ojm
~
:;.-
:D
-<
-0
::c
N
r.-
,::>
v,
: IN THE COURT OF COMMON PLEAS OF
: CUMBERLAND COUNTY, PENNSYLVANIA
: CIVIL ACTION - LAW JUN 0 5 2003 \Y
: NO. 03-802 CIVIL TERM
: IN CUSTODY
JOHN A. MURRAY, III,
Plaintiff
JANICEE. MURRAY,
Defendant
ORDER OF COURT
AND NOW this ~ayof ~V~
, 2003, the attached Custody
BYTHE~T,
Stipulation and Agreement is hereby made an Order of Court.
J.
J
cc: .,Marylou Matas, Esquire
Attorney for Plaintiff
~
t~.t~ ..a..
~~~S
OL>~()9'06
.Aamuel 1. Andes, Esquire
Attorney for Defendant
>-
c~
'12:
c-.
,--
c
9
c::i\
:>--
,-
7~
-::J
.'~~
")~
e_j~
-:8)
1"12
c:z
uuJ
.~&~ 0...
a
:">
.::;)
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
J. IRA LAIRD and TAMMY LAIRD
As Parents and Natural Guardians
Of Brittany Laird
Plaintiffs
NO. 03-790 Civil Term
v.
CIVIL ACTION - LAW
JENNY R. BIXLER,
Defendant
JURY TRIAL DEMANDED
PETITION FOR APPROVAL OF MINOR'S SETTLEMENT
AND NOW, come Petitioners J. Ira Laird and Tammy Laird, as the
Parents and Natural Guardians of Brittany Laird, by and through their
attorneys, Schmidt, Ronca & Kramer, P.C., and petition this Court for approval
of settlement of the above action on behalf of Brittany Laird pursuant to Pa. R.
C. P. 2039.
FACTS
1. The Petitioners, J. Ira Laird and Tammy Laird are the Parents and
Natural Guardians of Brittany Laird.
2, The Petitioners currently reside with the minor Brittany Laird at
921 Walnut Street, Lemoyne, Cumberland County, Pennsylvania, 170433.
3. Brittany Laird, a minor, was born on March 25, 1990,
4. On or about March 3, 2001, at approximately 9:30 a.m., Brittany
Laird was a pedestrian crossing Market Street in a pedestrian crosswalk at the
intersection with North 9th Street in Lemoyne Borough. (See Police Accident
Report attached as Exhibit "A").
5. Brittany Laird was struck by an automobile driven by Defendant
Jenny R. Bixler at that time,
6, This accident caused injuries to Brittany Laird including an open
compound fracture of the left ankle, contusions, and abrasions. (See Medical
Records attached as Exhibit "B").
7. The ankle fracture required two surgeries and has left a scar.
8. A settlement agreement has been reached between Petitioners and
Defendant's insurer in the amount of $22,500.00.
DISTRIBUTION OF SETILEMENT & ASSOCIATED REQUESTS
9. In pursuing the claim against Defendant Jenny Bixler, the
Petitioners engaged the law firm of Schmidt, Ronca, l'x; Kramer, P.C., under a
contingency fee agreement providing for a 33 1/3% fee and reimbursement of
costs. (See Contingency Fee Agreement attached as ]!;xhibit "C"). Petitioner's
counsel has agreed to a reduced fee of 25% in this matter.
10. Schmidt, Ronca & Kramer, P.C., has incurred costs in the amount
of $1, 180,11 to date, relative to obtaining copies of medical records,
investigation, and court filings. (See costs attached hereto as Exhibit "D").
11. Hershey Medical Center has outstanding medical bills for
treatment of Brittany Laird's injuries related to this claim in the amount of
$232.00. (See Medical Bill attached as Exhibit "E").
12. The Petitioners have paid a medical bill out-of-pocket in the
amount of $917.29 to West Shore EMS and request reimbursement of this out-
of-pocket expense, The Lairds have paid additional medical expenses out-of-
pocket, but are seeking reimbursement only of the above amount,
13, The Petitioners request that the Court distribute the settlement of
$22,500.00 as follows:
Schmidt, Ronca & Kramer, P.C.
Attorneys' Fees (25% of $22,500,00) . . , . . , . . . . , . $5,625.00
Schmidt, Ronca & Kramer, P.C.
Costs incurred to date. . , . . . . . . . . . . , . . . . . . " $1,180.11
Hershey Medical Center
Medical Bills Lien ...,....,...'... ,. . . . . , . , ..$ 232.00
J. Ira and Tammy Laird. . . " ...,...,...,....,..,.$ 917.29
J. Ira Laird and Tammy Laird, as Parents and Natural Guardians of
Brittany Laird, a minor, to be deposited into a restricted, federally
insured account marked "No withdraws prior to March 25, 2008, without
prior court approval" . . . , . . . , . . . . . . . . . . . . . . , . , . . . $14,545.60
TOTAL DISTRIBUTION. . , . . . , . . . , . . . , . . . ., . . . , . .. $22,500.00.
14. The Petitioners request that restricted accounts be authorized
without formal appointment of the a Guardian to the estate of the minor, or
entry of security, with Petitioners being authorized and directed to invest these
funds belonging to Brittany Laird as follows:
To invest the funds in one or more accounts in one or more savings
institutions insured by a federal government agency, such accounts not
exceeding the amount to which accounts are insured, and otherwise in
accordance with Pa, R. Civ. P. 2039 (b)(I).
Each Account shall be marked as follows:
"This money shall be held n trust, not to be redeemed, withdrawn,
negotiated, or any way alienated, except for the renewal of its entirety
before, March 25, 2008"
15. If the Court sees fit to approve the settlement, the Petitioners
request that they be authorized to execute the Release attached hereto and
marked as Exhibit "F," and also request discontinuance of the above action.
WHEREFORE, the Petitioners J, Ira Laird and Tammy Laird request this
Honorable Court to enter an order, approving the foregoing settlement,
directing the distribution of proceeds set forth herein, authorizing the
execution of the attached release, and discontinuing this action,
Respectfully Submitted,
By
7
::.
BC
)
, RONCA & KRAMER, P.C.
Date:
'b/Q/06
,
JOINDER
I, TAMMY LAIRD, as Parent and Natural Guardian of BRITIANY LAIRD,
hereby aver that I have read the foregoing Petition and understand, agree, and
approve the contents thereof.
\ ~'
'--' timvnv~ Wh d-
Tammy Lai ,as Parent and Natural
Guardian of Brittany Laird
Date: .3/3)05
I ,
JOINDER
I, J. IRA LAIRD, as Parent and Natural Guardian of BRITTANY LAIRD,
hereby aver that I have read the foregoing Petition and understand, agree, and
approve the contents thereof.
()/1
~l /<~ U~
J. Ir~t*d, as Parent and Natural
Guardian of Brittany Laird
Date: r:J, /7/ oj'
(
'l .A.]' LUMMUNWJ$ALlH UP PENNSYLVANIA
~ POUCEACCIDENT REPORT
@REFER TO L".TRLAY SHEETS REPORTABLE CXJ NON-R[PORTABlE
',\\,,,t,'5I?"'-' -\','\\
: '," JI
I'" 1:::J
PENNoor-Osr-aNLY
}}HNm@~i:{Ji;
, .' ~6L): CJjj
n :. 0653
l~Fq~TlqN<" .
" INCIDENT
t;l; . FR
;' ,ft..,. , \'i:.'ST SHORE REl3ICNAL roLICE
/;I\r,t.
,.~~~~:~~ UHJYNE 14.~~~:OL 1
';.INVESTIGATOR' -. BADGE
CPL. ,), 8. HECK NUMBER
6.APPROVEO BY' BADGE
NUMBER
a.ARRIVAL
TIME
32-2
32-1
0933
7.~~~STlGATI;'- 03/03/2001
I'
IIL,
o
Ij{I 19.PENNOOT
~ PROPERTY
.--.-....--..........................
......ii.i.... "'QN:tiJiifli'ii
;,437.II[G, .. . .... ..................'.....'..... '........
,J :11 PLATE ATX-7394
, ":' IN 40802981402BI
I;. ,.;,:\:Y L BIXLER
.".,.-....,.....'."........,.
.. -.,.-.-.-.--.;..:.;.:.;.:.;.,-,.;.:.:.-....""
ON LJ
yON
yON
yONlZI
,',',
16.,
........,..'...:.........-...'.-,.,-.........',..:...;...-.-..............,',.,..'-.,;.,.,.
,,:::,::,;:::::,;:,:,:::,:,'::::::::::;':::::,::-:::::::,:.;:::::::::::::,:,:,:,::::,,:,,:':'
.' ...... ..,...,..'....13;;:~~;TE.
PA
'J .1
, ',,:;.
,,',
" ,
,.
,ll
;
,51 LATIMJRE CREEK RD.
"
,- YORK SPRlN3S, PA. 17372
44.MAKE orm
I';
"
....
"
Jl
.:\
CUI'lASS
4 SPECIAL 0
USAGE
1 VEHICLE 0
STATUS
4 DRIVER
PRESENCE
46.1N~
Y 11\I NO UNKD
49 VEHICLE
OWNERSHIP
TRAVEL
SPEED
5 DRIVER
CONDITION 1
"
)2
i,'ACT
1
;); 525 958
,1:, !NY R BIXLER
,Ll IATIMJRE CREEK RD
" .;e-'!ORK SPRIN:;S, PA. 17372
!;2':;~~~HOF 03/29/1978 63t-f~1528-883:
~'i ...
!"'CLASS C
;1,.
" It
~ ! -
_.- ICC #
puc #
CARGO 74.GVWR
Booy TYPE
.. f 6 HAZAROOOS
. ~; . MATERIALS
CUMBElill\ND
21.MUNICIPALlTY LEM)YNE OOROU3H
CODE 21
CooE
403A
PRINCffiU ROADWAY INFORMATION
22,RaUl~ NO.OR Ml'iRKEI' STREE:I'
STREET NAME
23.SPHJ 25
LIMIT
3D.CROS --,TREET DR
SEGH. .n MARKER
31.DIREi;IION N
FROH SITE
33,01',; ,liCE WAS
4 CON~ iRUCTlON
ZOJ,~,
36.LEC"LLY Y N
~I~ED? DO
39.PA IITLE OIl
OUT-G, STATE VIN
4o.OIi,., :R
41.O\I'R
AD....'ESS
42.CI' .' ,STATE
& 21PCooE
43. YEAR
2
30
PA
4 TYPE
HIGHWAY
o
5 ACCESS 1
CONTROL
mTERSECTING ROAD:
N:lR1H 91H STREE:I'
]@TYPE I@ACClSS
HIGHWAY N CONT'lOL
IF NOT AT INTERSECTION:
" E W 132.0ISTANCE
., FROM SITE
MEASURED 0 ESTIMATED 0
5 TRAFFIC PRINCIPAL
CONTROL r-n-l
DEVICE ~
~
(...........'.,..,..'.ON'ii'
I37.REG~ ..' '" .
PLATE
',",',"""'-,-'"
# ..'i.' ..,.
i~<';";l\.!:;g~p.i~~wm9i; 26'~~~:'T N~~~
),~~~~DENT (, 'i03/2001 10.0AY OF WEEK SATlJRDI\.Y .' 27.m;':
-'
',!. TIME OF 0 12.NUMBER 1
DAY l" OF UNITS
13.# KILLED 'i 14.# INJURED 15.PRIV.PROP. 0 Ij{I
o I 1 ACCIDENT Y N ~
16.010 VEHICl HAVE TO BE 17.VEHICLE DAMAGE 0
REMOVED FE ,', THE SCENE? O-NONE UNIT 1 X
UNIT 1 UNIT 2 l-LIGHT
2-MooERATE 0
3-SEVERE UNIT 2
44.MAKE
1
IT.
MI.
I NTERSlCTI NG
~
38. STATE
4,.IN~
YL! ~D UN.D
"@:V- CLE
. CRSHIP
,~~. JEL
i sp; :.;.0
j~\_'ER
: C, ,ITlON
;~
63. PHOIJ~
(717)737-4955
. !Ji rl(
I. DEPOSmON
EXHIBIT"" j'
I ?-7-Qj GO '''l
CLASS
68. CAr: ;;1 ER
AD::'ESS
69.CI ',STATE
& 1,PCooE
7D.U'" "T # ICC #
45.Mo..L-(NOT
BO.d TYPE)
4 BOO I
TYPt
o INI' IAL IMPACT
POINI
3 VEHICLE
GR )IENT
NU~';ER PEDESIRIAN
5a.~:~/ER BRITrnNY MAAIE IAIRD
59.~~:~~s 921 WALNUI' STREE:I'
60'iI~;p~~~E LEM:lYNE, PA. 17043
61.~X 62'~~~~H OF 03/25/1990
j\12~ VEH.
I - CONFIG.
7> .NO. OF
, AXLES
.
PAGE:~
puc #
74. GV\;~
CARGO
Booy TYPE
6 HAZARDOUS
MATERIALS
7.RELI~SE OF HAZ MAT
Y . N 0 UNKD
CENTER FOR HIGHWAY SAFETY
/'.. ;.,I;:AL
-,~~" .~ :.,.."
r,
,
_J
:1'.'
,).1. ,:: ,.
IS < C
',~'" .
'\f:',
'".,
1,
it
,
'.
~"-
,
". 'I
j-
I: I
L.
,
,
W~.1. btiUH.J:; WMl:i 1-L1't\,.;.J..U!:.DI..L *:01-0653
f,V:::UTY HERSHEY MEDICAL ~CCIDENT DATE: 03/03/2001
~1T~~HATION H I J K L M
D E F G NAME ADDRESS
1:-,;- 3 1 9 JENNY R BIXLER, 451 IATIMJRE ClffiEK RD, YORK SPRIN3S, 0 0 0 :3 0 0
1'--'
1-- 0 0 0 BRITTANY MARIE lAIRD, 921 WAIDIT STRERr, LEMJYNE, PA. 2 4 6 C 0 1
,L)
[-
-... 86. DIAGRAM: N. 9~" 't
'''''"0 @.~EATHER ~
ii'(l[D S1'
-
J,l.; SCHOOL DISTRICT It p.~ . . ~ ()(;\J,..II:
rC,.\:]lE) _.
,."~. ."".1' OCJ'
bLJ~ ~.. 01- '
-'"-- """ . ..
i Otl ;)f DAMAGED PROPERTY .. - .. #r ~J.;.J
.'.
--- ...
())M\Cje1 <sf .. _ , ,'N .
.- .... ,r:;:r,
---- ~-wl(.
.-.-
... '/ 1 ) " ...~ } ,. .,.
J
.::j;:ENTIFY PRECIPITATING EVENTS, CAUSATION FACTORS, SEQUEN(li OF EVENTS., ~ITNESS STATEMENTS, AND PROVIDE ADDITIQNAL
l : ~__E INSURANCE INFORMATION AND LOCATION OF TCl'.lED VI III ClES I F [NOlIN.
en 03, 2001 I was dispatched to an ar,"ide with a pedestrian struck at the
l1.,n of Ma1:ket Street and N::lrth 9th 81 :Ci Lerroyne , Pa.
.1'1. :val on the scene, I saw a white f, Ile uvenile lying on Market Street at the
Lion of North 9th Street. She was beL J " lforted by t\\O individuals who were
e..; as her father and the driver of Wl , /, I>Blical personnel were arrivin:] at
e ~.rxi t=k over care of the ferrale.
;2 "lith the operator of unit #1 who se. I I C she was westbound on Market Street
h. approached North 9th Street she sa. d destrian dart into her path of travel
,,,., 'Css Market Street fran the mrth 5 .le the roadway at which titre the
~r~ saw her. She said she tried to stc-p and ;werved to the left to avoid the
.....'. and she could see the pedestrian lIas tI) LIB to stop also. She said she was not
:hc)id strik:ir:g the pedestrian.
Lc,',or of unit #1 said that she did n..t see ehe pedestrian lIDtil she was at the
L i :-n because of a truck which was padred ir, the last parking space before the
tlnn.
I (c,PANY .. IJj5Jlr~' (E COMPANY ..-
,.' SJ11.\RThX; PRCX;RAMS AlJIO PIAN I FAllON
V:i.( tY NO UNIT POll C1' NO -
,h..,~152-18813 2
ADDR~ PHON'
.LJne - --
i;lJ,:t: AODR "SS PHONE
":.ne
, ClATIONS INU'WlltU YU. ,tel,,,,, (UNU " Ie Nle
- DO
';.<;,' @"H..UL" 0 0 0
:l"."BlE \'(S' ~ let ~,'"'
i ~ 1.'-' 'OLt I:lS' ;~~~ "0 ,... Ci.iPlETE?' 'U.
," TEST NO TEST .' I NO TEST
O. % 0 REFUSE UNIT 2, O. % 0 REFUSE YES@NDD
0 UNK ' 0 UNK
I
T
i
';,;i.
1/,)
t,.
....'.:7m
:,.j,..
PAGE:~_
CENTER FOR HIGH~AY SAFETY
"l.A 1: LUMMUNWliALlH UF I'h'NNSYL.VANIA
't:7' PAR CON1TNUATJON SHEE'T
9REFER TO oveRLAY SHEETS '-. REPaRTABLE [][I NCN-RrpoRTABLE [~
; r4CIDENT IACCIDENT
lIMBER 01-0r."3 CATE 03/03/2001
d),PERSON IN,.C;'MIION-USI:. OVERLA III SHI::t.1 FOR l:OUE~
Ii. BCD E F G NAME ^,'D
-
-
-
( ..".., , ...
i'n
! The pedesf-rian was lying on Market Street B: ,)
I 'f the int'3rsection and approxirrately 24 fee
I
,
! The pedestrian was transported to Hershey 1', d
: ntervi~ at this tirre.
,:'nvestigation revealed that rrost of the inr
.e vehicle. It appears that the pedestrians i
.e vehicle pullin3 the pedestrian illltil the j
>n March 07, 2001 aJ:out 1230 hours, I inta l
lking and aJ:out to cross Market St. There " .,
, ~ion was blocked but she thought it was ok
,iIB and when she started to =ss the sty,
the car and she fell to the ground.
RESULTS
PENtJOOT USE ON..Y
C:CUNTY ~C1PAL
COOE 21 CODE 403A
RESS H J J K L M
.-. -
-
- ..
-
rc, 'i113.tely 113 feet frcm the noLtheast corner
or rrket St:reet frcm North 9th Street.
i( Center Eor treatment and \-JaB not
L ( the vehicle was on the rig ,t side: of
B' ,t had caught on the right [<ide mirF'c of
01 ,t tore.
~', 1 the pedP..strian who said tl.at she was
.0 t=k ani a car parked there and her
0 oss the street. She did not see an:ything
'L .ere was a car there and she was str {lck
yu. (aNLT IF Ie Nfe
,-
DO
DO
!J).~ROABLE ~!YPE I~RESULTS 4.1NVI ';T1GATlON
USE TEST D NO TES COMl :.ETE?
D RefUSE YES UNO D
D UNIC
PAGE:~
CENTER FOR HIGH~^Y SAFETY
, 3/3/2001 IS:37:58
TRIPSHEET REPORT
~ lA~D # 97593306 Service Name: West Shore EMS Affiliate #: 2) 022
Location Code: 21803 Trip Number: 906]803
Unit #: 03 Crew Assisted: e80 Date: 03/03/200 I
PATIENT INFORMATION:
Name: LAIRD. BRITTNEY
BiJ1h Date: 03/0511990 Age: 10
Sex: F
SSN: 208-58-339~
Address Line I: 921 WALNUT ST
Cit~: LEMOYNE State: PA Zip: 170~3
Phone #: 737-.1955
Member: U
INSURANCE INFORMATION:
Stretcher: Y
Medicall~ Neces"\r~: Y
OTHER INFORMATION:
Reason:EMERGENCY
Location Dctail: 905 MARKET ST. LEMOYNE PA
Chief Complaint: "MY FOOT HURTS"
Allergies: NKDA
Medications: NONE
Past Histor~: NONE
User I: 3813
User 3: 85
INCIDENT INFORMATION:
User 2: BLS O/S 093~
Location: TRAFFIC \VA YOTHER TJpe: PEDESTRIAN Outcomc: TR,I\NSPORTED
Responding Unit T~pe:ALS Nature of Dispateh:ALS ALS/BLS: AI,S
Transp0l1 Mode to Scene: 10 Transpor1 Mode from Scene: 10
Patient Condition on Scene: MODERATE Patient Condition at Facilit~: STABLE
Initial Vital Signs: SYSTOLIC - 112 DIASTOLIC - P PULSE - 92 RESP - 20
Glasgow Coma Scale: EYES - SPONTANEOUS VERBAL - ORIENTED MOTOR - OBEYS COMMAND Score - I.'
Situation of Injury:
Iniur~ Site/TJJle: FACE WAS SOFT-OPEN
HAND WAS SOFT-OPEN
LEGlFooT WAS FRACTUREDIDISLOCA TED
Attendant #1: WELKER RICKY - P #020957
Attendant #2: PA VUC DENNIS - P #0~0217
Dispatch I Enroute I On Scene I Depart Scene I Arrive Dest. I Available IIn Ouarters
Times: 0932 0932 0937 0949 1005 1112
Mileages: 0 0 0 0
ALS INFORMATION:
EKG Initial: NRML SIN EKG Last: NRML. SIN IV Fluids: NRML. SAL
IV Rate: TKO
COMMAND INFORMATION:
Medical Command: PROTOCOL
Command Fadlit) ID#: 1351 Patient Recei,.ed B): 01351
NARRATIVE:
DiD FOR A PEDESTRJAN STRUCK. ARRJVED OIS T/F BLS WIIO YIO FEMALE WHO WAS STRUCK BY A
CAR AT AN UNKNOWN SPEED. PT CIO (L) ANKLE/FOOT PAIN, BLS STATES PT WAS A/A/O X3 AND
DID NOT HAVE LOSS OF CONSCIOUSNESS PT DENIES SOB OR CHEST PAIN. BRIEF PE A/A/O X3
SUPINE ON GROUND. PERLA. TRACHEA MIDLINE. +=BBS: NO CHEST TRAUMA NOTED. ABD SOFT/NTP
WIO DlSTENTlO'J PEL VIS STABLE TO PRESSURE WIO PAIN. BACK/BUTTOCKS BENIGN.
EXTREMITIES S'\1 ABRASIONS TO (R) HAND. (L) ARM BENIGN. (R) LEG BENIGN: (L) LEG BEING
DRESSED BY BLS APPROX 50% CIRCUMVENTIAL LACERATION AT (L) !vlEDIAL ANKLE W/INITlAL
PROTRUDING BONE WINO PEDAL PULSE TO (L) (L) FOOT COOLER THAN (R). POOR CAPILLARY
REFILL (L) WiDUSKY NAILBEDS (L) FOOT. BLS SECURING SPLINT TO (L) FOOT. INITIAL TX
ASSESS: C -SPIl'-.'E IMMOB: (L) ANKLE STRAIGHTENED AND SPLINTED W/O REGAINING (L) PEDAL
PULSE PT TO Amb AND FURTHER TX/ASSESSMENT WHILE ENROUTE. 2ND ASSESSMENT. STILL A/A/O
X3 IN NAD ON LONGBOARD, NO HEAD/F ACIAL DEFORMITY TRAUMA NOTED, SMALL ABRASION TO UPPER
LIP, SKIN WiDICOLOR GOOD. PERLA NO JVD. TRACHEA MIDLINE LUNGS CT A ALL LOBES. NO
CHEST DEFORMITY OR PARADOXICAL BREATHING NOTED. CHEST ATRAUMATIC. ABD: SOFTINTP W/O
DISTENTION. NO ABD TRAUMA NOTED, PEL VIS: STABLE TO PRESSURE WIO TRAUMA NOTED,
EXTREMTlEIS MAE: UPPER EXTREMITIES NO DEFORMITY: SMALL AI3RASION TO (R) HAND. LOWER
EXTREMITIES (R) BENIGN: (L) CAPILLARY REFILL NOW MORE BRJSK: "DUSKY NAILBEDS" NOW
PINK. NO PERIPHERAL PULSES PALPATED. MINIMAL BLEEDING WiDRESSING IN PLACE. PO 98%
4LPM NC 02, TX ASSESS: IMMOBiLIZE: CID: C-COLLAR: ENROUTE IV NSS AT KVO. CMC AT
UNIVERSITY ANTI TO! AND CARE TO RNrrRAUMA TEAM.
DETAIL INFORMATION:
N
Y
RACf TKO
18
PROY': RESPCOMMENTS
020957
IlLS
ALL
ALL CID. STRAPS USED
ALL
ALL
020957
020957 NSS
IlLS
02(J957
020957
ALl.
TIME P. B. H P RHYTHM
09J9
0946 92 20 I]: P
()')..\\
094-1-
()9-l7
0'),:\,-)
0952
0953
0')5) 92 20 III P
U9.'i5 NSR
1000
1005 9(j 16 JJ2P
TREATMENT
ALS OS
VITAl.S
C-COLLAR
LONG BOARD
.IOAMB
LNROLJLE
PERIPHERAL IV
PERIPHERAL lV
YS
EKG
CMC UNIV
:\RRIVE
~RTE
SITE DOSE
"-11
SIGNA TURfS:
PERSON RECEIVING PATIENT
TIME
CREW SIGNA TLm,ES
^#l:~. ~~
\WLKFR RICKY
A#2 'i
':i't,v,-,j;.,I ~e"""'s
,
LAIRD
3/3/2001 20:29:50
TRIP SHEET REPORT
# 97687850 Service Name: West Shore EMS Alliliate #: 21022 D
Location Code: 21803 Trip Number: 9061822 (QJi1'11 ~
Unit #: 60 Date: 03/03/2001 'WI
PATIENT INFORMATION:
Name: LAIRD, BRITTANY
Birth Date: 03/25!l990 Age: J 0
Sex: F
SSN: 208-58-3394
INSURANCE INFORMATION:
Address Line I: 921 WALNUT STREET
City: LEMONYE State: PA Zip: 17043
Phone #: 737-4955
Hosp, Admissn: Y
Hemorrhage:
Y
Stretcher: Y
Medically Necessary: Y
OTHER INFORMATION:
Reason:EMERGENCY
Location Detail: 9TH AND MARKET STREET LEMONYE
Chief Complaint: COMPOUND FX, LEFT ANKLE
Allergies: NKDA
Medications: NONE
Past History: NONE
User I: 32J3
INCIDENT INFORMATION:
Location: TRAFFIC WAY OTHER Type: PEDESTRIAN Outcome: TRANSPORTED
Responding Unit Type:BLS Nature of Dispatch:BLS ALS/BLS: BLS
Transport Mode to Scene: E Transport Mode from Scene: E
Patient Condition on Scene: MODERATE
Patient Condition at Facility: STABLE
Initial Vital Signs: SYSTOLIC - 112 DIASTOLIC - P PULSE - 90 RESP - 16
Glasgow Coma Scale: EYES - SPONTANEOUS VERBAL - ORJENTED MOTOR - OBEYS COMMAND Score - 15
Situation ofInjury:
Injury Site/Type: LEG/FOOT WAS FRACTURED/DISLOCATED, LEG/FOOT WAS SOFT-OPEN
Attendant #1: HORNING MARJORIE - E #038507
Attendant #2: FORSECA MICHAEL - E #145886
Dispatch I Enroute I On Scene I Depart Scene I Arrive Dest. I Available lID Ouarters
Times: 0932 0932 0934 0949 1005 1114
Mileages: 70001 70002 70022 70040
COMMAND INFORMATION:
Medical Command: NONE REQUIRED
NARRATIVE:
Patient Received By: 21022
DISP CLASS ONE ALONG WITH MEDIC 85 81-34 FOR A PEDESTRIAN STUCK AT THE ABOVE ADDRESS,
PRE-ARRIVAL INFO; PEDESTRIAN STRUCK UNKNOWN INJURIES, NOT UNDER VEHICULAR.
O/S;
FOUND AIO Y/O FEMALE LYING IN STREET CAO WITH A COMPOUND FX, TO LEFT ANKLE,
HX: VICTIM
WAS HIT WHILE CROSSING THE STREET, UNKNOWN THE SPEED OF VEH,
PE: PT, CAO TO TIME AND
PLACE, SKIN WARM AND DRY, COLOR NORMAL, PUPILS EQUAL AND REACTIVE, NO FLUIDS FROM EARS
OR NOSE, NO DEFORMITIES TO HEAD OR NECK, LUNGS CLEAR AND EQUAL,NO DEFORMITIES TO OR
TENDERNESS TO CHEST OR RIB AREA, ADB" SNT, PELVIS INTACT, TENDERNESS TO LEFT LEG, (L)
ANKLE WITH COMPOUND FX. NO PULSES PRESENT TO FOOT, FOOT WAS COLD AND DISCOLORED WITH OUT
CAP, REFILL. PLACING PT ON LSB" CHECKED BACK EXAM WAS UNREMARKABLE, PT DENIES ANY
LOC/SOB, NO CHEST,BACK PAIN, ALS O/S, SEE ABOVE FOR VITALS,
TX; PLACED PT ON LSB/C-
COLLAR! ClD/SPlDER STRAPS, AND MOVED PT LITTER WITH OUT PROBLEM OR COMPLAINT FROM PT,
ENROUTE; CLASS ONE CONTINUED TO M/T TO HMC, PLACED PT ON 4 L'S N/C, AFTER SPLINT WAS
APPLIED TO FOOT AND IMMOBILIZED COLOR AND TEMP, RETURNED TO FOOT ALONG WITH THE PULSES,
CAP" WAS LESS THAN 3 SECONDS, NO CHANGE IN PI'S CONDITION CONTINUED TO REMAIN CAO,
STAFF AT HMC GIVEN ALL INFO AND PT TAKEN TO TRAUMA A. SEE ABOVE FOR
PMH/ALLERGIES/MEDS, TRANSPORT WAS UNEVENTFUL. CLASS ONE ALONG WITH MEDIC
85".. ,END..,.. ,038507,
DETAIL INFORMATION:
TIME !' R BIP RHYTHM TREATMENT SRTE SITE DOSE GA !'ROV# RESP/COMMENTS
0936 ASSESS-INITIAL 038507 CAO TO TIME AND PLACE
0940 C-SPINE IMM DV 03S507
0941 BANDAGE 145886
0942 BOARD-LONG CREW
0942 C-SPINE ST ABIL CREW
0943 SPLINT - EXTRE 145886 LEFT ANLKE COMPUND FX.
0951 90 16 1121P VITALS 038507
0952 02 1-9 Ipm 038507
1000 90 118IP
1000 OXYGEN 1-9 LPM 038507
SIGNATURES:
A#l:
CREW SIGNATURES
~ /'
.' . q! !- \ ]( L
HORNnW M;\]UORIE
;i d
d
PERSON RECEIVING PATIENT
TIME
A#2:
FORSECA MICHAEL
A#3:
COMMAND PHYSICIAN lD#
"=:--=--
,-;:;'.:-;"'''':' '<";:'','?
,,<^~"" ,u...",
'.',',_' . ,.\'1f!i _ _"""~,"'-' .
I~')\~ ,) l:2.,
llslr-/j1
0'7:>
209 State Street 717232.6300
f'iRonca & Kramer PC Harrisburg, Pennsylvania 17101 . Fax 717232,6467
.'.FlY UWVERS -
www.srklaw.com
.
January 29, 2003
Hershey Medical Center
Health Information Services HU24
P.O. Box 850
Hershey, PA 17033
Re: Patient
DOB
MSHMC
Adm Dates:
Brittany Laird
3/25/1990
#1132779
November 30, 2001 to present
Dear Sir/Madam:
Please be advised this fInn represents the above-referenced patient for injuries
sustained when she was strUck by a motor vehicle on March 3, 2001. Please
forward to us copies of her medical records for treatment rendered by Dr. David
M. Wallach, Assistant Professor with the Department of Orthopaedics and
Rehabilitation for the above-referenced dates of treatment.
Enclosed is an authorization duly executed by her mother and natural
guardian permitting the release of this information.
If you have any questions, please feel free to call me at any time.
Thank you for your cooperation.
Very nuly yours,
7::~ :7;L:;JR' P.C
Cannen J. Arroyo
Paralegal to: James Ronca, Esq.
/cja
Enclosure
RECEIVED '
SOURCECORP HEALTHSEItYE
JAN 3 1 2003
25.-n] Aeq#/fiJ5"Q'l
patel'" .
_1QiltOI,oPGS ~ #- ('.I T
{d-'i:(L~I. "Im,oe' In!hI.
t~}YN~
209 State Street .717,232,6300
Schmidt, Ronca & Kramer PC Harrisburg, Pennsylvania 17101 Fax 717,232,6467
INJURY LAWYERS
I ?/d I r/
rq
www.srklaw.com
--.
December 13,2001
Hershey Medical Center
Medical Records Department HU24
P 0, Box 850
Hershey, PA 17033
Re: Patient: Brittany Marie Laird
DaB: 3/25/90
Date of Accident: 5/23/01 to the present
DEe 1 9 2Wl
Dear Sir or Madam:
Please be advised that we represent Brittany Laird. I would appreciate you
forwarding to me copies of ALL MEDICAL RECORDS kept on the treatment and
care of Brittany for the above-referenced dates, I have enclosed an executed
Medical Authorization permitting the release of this information, Please bill my
office for the costs involvt'd with this request.
Should you have any questions, please feel free to contact me at any time,
Very truly yours,
SCHMIDT, RONCA & KRAMER, P.C.
~7 ~culMc/
Cindy Garland
Paralegal
JRRjcjg
enclosure
, CQ {rf:v1
d 'J..Y::Ji.j,J"v'j I
FE/. HealthSEIfYf1/_tj/2
Date ~ / -a~<?<eq #f.I2/...!!!... :...:J
# PelS Initials (>" .
~
Recadox~Cap.
dl8 !OURCECORP HfALTH~
Suite D
17L.._
PO. Sex ll17
MaMm,PA.I9:.'65
Prl:61~
l-aJl.525.=
FM61~7
~
SOU?CECORJ?
'-~
Recordex Acquisition Corp., dba SOURCECORP HEAL THSERVE has been retained by
the Medical Record Department of
Milton S. Hershey Medical Center
to fulfill requests for copies of medical records. Enclosed are the reproduced medical
documents specifically authorized by the patient or his/her legal representative. We
wish to emphasize that the increasing demands for patient data pose a rising threat to
the confidentiality of the patient's medical information, SOURCECORP
HEALTHSERVE strives to take every ~nity to safeguard the patients' right to
privacy as outiined in the AHA's Patient Bill of Rjghts. Specificaliy, all patients have the
right "to expect that all communications and records pertaining to their care will be
treated as confidential by the hospital and any other party entitled to review certain
information in such records." As one such party, we ask that all information transmitted
herewith be treated with utmost respect and the dignity such personal medical
information warrants. Please be advised of the following state and federal disclosure
statements governing medical records in Pennsylvania:
lirTIitW~~_
ThisinfOQ11ationhas~en diSc~toYOufro!n.~terec:Ort1iwhOse 1:Pnti~~LitYiS~~
~.~~~~t~J~t~~~\i~i~~~jJl1~'~~~~~~
~,
Based upon guidelines provided by the American Health Information Management
Association, the records should be destroyed after the stated need has been fulfilled.
We thank you for your cooPeration in maintaining the patient's right to privacy. Each
medical record has been carefully reviewed to assure that proper disclosure goes only
to the authorized Requestor. If you have any questions, please do not hesitate to
contact us at 1-800-525-2922 and one of our Customer Service Representatives will be
happy to assist you.
......,,, ........ ........
!!5:l The Milton S, I hey Medical Center
., The College of j""dicme
PROGRESS REPORT
"\
/
ORTHOPAEDIC EVALUATION
THE MILTON S. HERSHEY MEDICAL CENTER
LAIRD, BRITTANY
MSHMC# 1132779
November 30, 2001
DATE OF BffiTH: 03/25/90
mSTORY: The patient is 8 months status post left open tibia.fibula fracture, distal. Since her last
visit, she has no fevers or chills, She is not on any medication,
PHYSICAL EXAMINATION: She is nontender, She only has slightly decreased sensation just
distal to the scar, Her deep peroneal and superficial peroneal mUBcles and sensory function are
intact, Her gait is normal.
1
J
RADIOGRAPHS: X-rays demonstrate persistence of an open physis, Her skeletal age is that of
11,
IMPRESSION: A child who had sustained a left open physeal tibial-fibula fracture.
PLAN: Our plan is to see her back in 1 year's time with a repeat AP and lateral x-ray of the ankle,
)
Dictated by:
dJ~~ IdV
David M, Wallach, M,D.
Assistant Professor
Department of Orthopaedics and Rehabilitation
Pediatric Orthopaedics
" DMW/cbt-0116
, D: 12103/01 T: 12104/01
cc: Medical Recards
File copy
MR 6,1 Rev. 8196
PROGRESS REPORT
!5:1 Milton S, Hershey !\
. College of Medicine
cal Center
BRIll AN' f1'
NJ*AE: LAIRel '110 M
tJ,D: WALl~C.
\ MRN' 11327, . 0
'Doe; 03125{~5~RANCE
INS: ~Ul~
~;~ ,:u~068671
MO#: ,,,<I::>....
SEX: F
DA1E' ~~13QI2001
VISIT .
PROGRESS REPORT
DatelTime
11,30' 01
PROGRESS NOTES: (Include Name, Title)
iY<, ,
\ '
VIS\t -rnl ~\~ n\,,!:1\ rer1..\AChDf\
t>rOc<jS 6bl-'cu'NrI \\\ jGK-.
~-ty(Ljml
I
'1
j
';
)
MR 6 Rev. 6/01
PROGRESS REPORT
PROGRESS REPORT
MD: WALLACH DAVID M
MRN: "12779
008: 25/1990
INS: ~ro INSURANCE
LOC: UREH
aas#: 2900128
MON: 24455
SEX: F
VISIT DATE: 01/14/2003
DatetTime
PROGRESS NOTES: (Include Name, Title)
r1!{
.', ..,
MR 6 Rev. 6/01
PROGRESS REPORT
Ankle XR (> 3 view)
LAIRD, BKITTANY M - 1132779
* Final Report *
OX ANKLE LT 3 OR MORE VIEWS -INT, LAT, AP,
PATIENT NAME: LAIRD,BRITTANY M
PATIENT MRN: 01132779
PATIENT DOB: 25-Mar-1990
EXAM NUMBER: 531A-113001
EXAM: DX ANKLE LT 3 OR MORE VIEWS - INT, LAT, AP ,
ORDERING PHYSICIAN: DAVID WALLACH
Exam:
Exam:
DX ANKLE LT 3 OR MORE VIEWS - INT, LAT, AP ,
DX BONE AGE - LT
THREE VIEWS OF LEFT ANKLE AND AP LEFT HAND FOR BONE AGE
CLINICAL HISTORY: This is a patient status post left ankle
fracture.
DISCUSSION: Comparison is made with multiple prior films, the most
recent from May 22, 2001.
The two screws in the distal left tibial metaphysis are again noted
and stable in position. There is a deformity from the prior
fracture, but there has been progressive healing. There has been
progressive remodeling of the distal fibular shaft fracture.
The bone age film of the left hand correlates with the bone age
standard of 13 years +/- 20 months, (2 standard deviations). The
patient's chronological age is 11 years 8 months; tjus the bone age
matches the chronological age.
IMPRESSION: 1. There has been progressive healing of the left
ankle fracture.
2. The patient's bone age matches the patient's chronological age.
Dr. Boal reviewed the images and discussed the interpretation with
Dr. Lobell,
DICTATED: 16227
REVIEWED AND SIGNED: MARK E. LOBELL, M.D./DANIELLE K.B. BOAL, M.D.
l/beg
Printed by:
Printed on:
Gridley, Laurie A
2/6/20039:01 PM
Page 1 of 1
(End of Report)
Ortho Outpt Note
LAIRD, BKITTANY M -1132779
* Preliminary Report *
ORTHOPAEDIC EVALUATION
PATIENT NJ\ME: LAIRD, BRITTANY M
PATIENT NUMBER: 1132779
SEX: F
DATE OF SERVICE:: 01/14/2003
DATE OF BIRTH: 03/25/1990
DATE OF BIRTH: 03/25/1990
HISTORY: The patient is a 12-year-10-month-old female with a history of a left
open distal tibia and fibular fracture. This was treated on the day of injury with
an irrigation debridement and ORIF. Since that time, she is doing quite well and
is without complaints.
PHYSICAL EXAMINATION: On physical examination, she has 5/5 strength in the
distribution of her tibialis anterior, peroneus longus, posterior tibial tendon,
and gastrocnemius soleus. She has full and painless rau:Je of motion, and her gait
as well as running is symmetric. Her wound is well healed and is now mature. Her
pelvis is level consistent with equal limb lengths.
RADIOGRAPHS: Radiographs were obtained demonstrating a well-healed distal tibia
and fibular fracture without deformity. The screws are in place without ghosting
or other evidence of loosening. In addition, she is having a closure of physis of
both fibula and tibia consistent with an adolescent of her age.
IMPRESSION: A child with a left distal tibia fracture.
PLAN: Our plan is to see her back on an as-needed basis" Indications for return
would be development of pain consistent with infection or hardware loosening.
Printed by:
Printed on:
Gridley, Laurie A
2/6/20039:01 PM
Page 1 012
(Continued)
Ortho Outpt Note
DICTATING MD:
ATTENDING MD:
David M. Wallach, MD
Assistant Professor
DMW/cbt
D: 01/14/2003
Printed by:
Printed on:
Gridley, Laurie A
216/2003 901 PM
T: 01/17/2003 15:52
LAIRD, B~ITTANY M - 1132779
Page 2 012
(End 01 Report)
Ankle XR (> 3 view)
LAIRD, BKITTANY M -1132779
" Final Report "
OX ANKLE L T 3 OR MORE VIEWS - INT, LA T, AP ,
PATIENT NAME: LAIRD,BRITTANY M
PATIENT MRN: 01132779
PATIENT DOB: 25-Mar-1990
EXAM NUMBER: 579B-011403
EXAM: OX ANKLE LT 3 OR MORE VIEWS - INT, LAT, AP ,
ORDERING PHYSICIAN: DAVID WALLACH
Exam: OX ANKLE LT 3 OR MORE VIEWS - INT, LAT, AP
THREE VIEWS OF THE LEFT ANKLE
CLINICAL HISTORY: 12-year-old female status post left ankle
fracture.
FINDINGS: Comparison is made to two views of the left ankle dated
OS/22/01 and 11/30/01.
The two partially threaded screws placed for treatment of a left
distal tibial fracture are unchanged in position. There has been
continued bony remodeling of both the distal tibia and fibula
fracture sites. There has also been interval closure of the distal
tibial physis. The distal fibula physis has nearly closed. The
remaining bony structures of the left ankle are unremarkable. The
ankle mortise and visualized joint spaces of the foot are well
preserved. The soft tissues are unremarkable.
IMPRESSION: Continued bony remodeling of both the distal tibia and
fibula fracture sites. The two partially threaded screws placed
for treatment of the distal tibia fracture are unchanged in
position.
Dr. Hulse reviewed the images and discussed the interpretation with
Dr. Stephenson.
DICTATED: 18020
REVIEWED AND SIGNED: JONATHAN D. STEPHENSON, M,D./MICHAEL HULSE, D.O.
1/ lld
Printed by:
Printed on:
Gridley, Laurie A
2/6/2003901 PM
Page 1 of 1
(End of Report)
F.Y.I.
--
...-
-~'rr(omlGtroll
Recordex Acquisition Corp., d.b.a. FYI HealthSERVE, has been retained by the Medical
Record Department of
Milton S. Hershey Medical Center
to fulfill requests for copies of medical records. Enclosed are the reproduced medical
documents specifically authorized by the patient or his/her legal representative. We
'wish to emphasize that the increasing demands for patient data pose a rising threat to
tl1e confidentiality of the patient's medical information. FYI HealthSERVE strives to take
every opportunity to safeguard the patients' right to privacy as outlined in the AHA's
Patient Bill of Rights, Specifically, all patients have the right "to expect that all
communications and records pertaining to their care will be treated as confidential by
the hospital and any other party entitled to review certain information in such records."
As one such party, we ask that all information transmitted herewith be treated with
utmost respect and the dignity such personal medical information warrants. Please be
advised of the following state and federal disclosure statements governing medical
records in Pennsylvania:
This information has been disclosed to you from records protected by federal confidentiality rules
(42 CFR Part 2). The rules prohibit you from making any further disclosure of this information
unless further disclosure is expressly permitted by written consent of the person to whom it
pertains or as otherwise permitted by 42 CFR Part 2.
This information has been disclosed to you from state records whose confidentiality is protected
by state statute. State regulations limit your right to make any further disclosure of this
information without prior consent of the person to whom it pertains.
I This information has been disclosed to you from records protected by Pennsylvania law.
Pennsylvania law prohibits you from making any further disclosure of this informatipn unless
further disclosure is expresSly permitted by the written consent o~ the person to whom if pertains
or is authorized by the Confidentiality of the HIV-Related Information Act. A genelal
authorization for the release of medical or other information is not sufficient for this purpose. '
"
Based upon guidelines provided /;>y the American Health Information Management
Association, the records should be destroyed after the stated need has been fulfilled.
We thank you for your cooperation in maintaining the'patient's right to privacy. Each
medical record has been carefully reviewed to assure ~hat proper disclosure goes only
to the authorized Requestor. If you have any questions, please do not hesitate to
contact us at 1-800-525-2922 and one of our Customer Service Representatives will be
happy to assist you.
Recordex AcquisitR5rl Corp. dba F.Y.I. Hea/thSERVE.. WVIM'.fyti.com
PO Box 3)17 .17 Lee Boulevard. Sune D. Ma/vem, PA 19355. PH: 61CJ.64O.OOXl.1-ll(X}025-2922 . FAA: 6'~12OCl7
rLI....I........JIf'\1 L
~ The Milton S_ I
. The College of lv,
'Y Medical Center
.::me
PROGRESS REPORT
ORTHOPAEDIC EVALUATION
THE MILTON S. HERSHEY MEDICAL CENTER
LAIRD, BRITrANY
MSHMC# 1132779
November 30, 2001
DATE OF BffiTH: 03/25/90
mSTORY: The patient is 8 months status post left open tibia-fibula fracture, distal. Since her last
visit; she has no fevers or chills, She is not on any medication,
PHYSICAL EXAMINATION: She is nontender, She only has slightly decreased sensation just
,distal to-the scar, Her deep peroneal and superficial peroneal !"uscles and sensory function are
intact, Her gait is normal.
-', RADIOGRAPHS: X-rays demonstrate persistence of an open physis, Her skeletal age is that af
11.
IMPRESSION: A child who had sustained a left open physeal tibial-fibula fracture.
PLAN: Our plan is to see her back in 1 year's time with a repeat AP and lateral x-ray af the ankle,
Dictated by:
&~~ IVftJ
David M, Wallach, M,D,
Assistant Professor
Department of Orthopaedics and Rehabilitation
Pediatric Orthopaedics
DMW/cbt-01l6
D: 12/03/01 T: 12/04/01
cc: Medical Records
File copy
MR 6,1 Rev, 8/96
PROGRESS REPORT
I Ll'llI'''-'Ir\.IL
~ Milton S, Hershey'
., College of Medicine
'a\ Center
f'lOliTANY M
NJ,t.',lAIR('l 'Q~
~o; WAlLA~
MRII: 1132, lit...)
-DQa~ 031%5~N5URANCE
INS: AUT
ac' UREH
~os*; 2068611
MON: 24455
SEX; F
'30/20D~
VISIT OATE: 1 i
PROGRESS REPORT
DatelTime
11'30' 01
PROGRESS NOTES: (Include Name, Title)
g., ,
,I IS, 1; fill "",\~ !"';'t'(\ (u\.\.U:;t'\l'0
, .
'i j:-r-Q'j"" bb\-o.l'('\Ln. -- I'll '!CX:J
-:I11\..iY('Lj\li
')
'\J~
'J_ ~4-
~ V' -...--P
MR 6 Rev. 6/01
PROGRESS REPORT
PENNSTATE
!!S Milton S. Hershey Medical Center
. College of Medicine
Ankle XR (> 3 view)
LAIRD, BRITTANY M - 1132779
* Final Report *
OX ANKLE LT 3 OR MORE VIEWS -INT, LAT, AP,
PATIENT NAME: LAIRD,BRITTANY M
PATIENT MRN: 01132779
PATIENT DOB: 25-Mar-1990
EXAM NUMBER: 531A-113001
EXAM: DX ANKLE LT 3 OR MORE VIEWS - INT, LAT, AP ,
ORDERING PHYSICIAN: DAVID WALLACH
Exam:
Exam:
DX ANKLE LT 3 OR MORE VIEWS - INT, LAT, AP ,
DX BONE AGE - LT
THREE VIEWS OF LEFT ANKLE AND AP LEFT HAND FOR BONE AGE
CLINICAL HISTORY: This is a patient status post left ankle
fracture.
DISCUSSION: Comparison is made with multiple prior films, the most
recent from May 22, 2001,
The two screws in the distal left tibial metaphysis are again noted
and stable in position. There is a deformity from the prior
fracture, but there has been progressive healing. There has been
progressive remodeling of the distal fibular shaft fracture.
The bone age film of the left hand correlates with the bone age
standard of 13 years +/- 20 months, (2 standard deviations). The
patient's chronological age is 11 years 8 months; thus the bone age
matches the chronological age,
IMPRESSION: 1, There has been progressive healing of the left
ankle fracture.
2, The patient's bone age matches the patient's chronological age,
Dr, Boal reviewed the images and discussed the interpretation with
Dr, Lobell,
DICTATED: 16227
REVIEWED AND SIGNED: MARK E, LOBELL, M.D./DANIELLE K,B, BOAL, M,D,
Printed by:
Printed on:
Men, Chanthan
01/17/200211:30 AM
Page 1 of 2
(Continued)
An Equal Opportunity University
PENNSTATE
I!Sl Milton S. Hershey Medical Center
. College of Medicine
Ankle XR (> 3 view)
LAIRD, BRITTANY M - 1132779
l/beg
Printed by: Men, Chanthan
Printed on: 01/17/2002 11 :30 AM
Page 2 01 2
(End of Report)
An Equal Opportunity University
717'232,~L 3~))q
Fax 717.232,6U I www,slKlaw,com.
209 State Street
Schmidt Ronca & Kramer PC Harrisburg, Pennsylvania 17101
----~_.~~-~--~------~--_.~~--~~---- ----
INJURY LAWYERS
June 18, 2001
Hershey Medical Center
Medical Records Department HU24
p, O. Box 850
Hershey, PA 17033
.
Re: Patient: Brittany Marie Laird
DOB: 3/25/90
Date of Accident: 3/3/2001 to the prese.IJNZ2 2.Wl
Dear Sir or Madam:
Please be advised that we represent Brittany Laird. I would appreciate you
fOlWarding to me copies of ALL MEDICAL RECORDS kept on the treatment and
care of Brittany for the above-referenced dates. I have enclosed an executed
Medical Authorization permitting the release of this information. Please bill my
office for the costs involved with this request.
Should you have any questions, please feel free to contact me at any ti!lle.
Very truly yours,
SCHMIDT, RONCA & KRAMER, P.C.
.r
,
.~
~s R~nca
ey at Law
JRR/ caz
enclosure
-;.---
LiL<3tb) ~dfAOf
b ~~~1~
';;;,;ifl\W3- )
~WCK JlO~ LAl1;~ ., X R A Vf\
iF.Y. I.,:
.--
~
........
~-;;!r;rer:tct'~1I
Recordex Acquisition Corp., d.b.a. FYI HealthSERVE, has been retained by the Medical "
.
Record Department of . "0 .
Milton s. Hershey Medical Center
to fulfill requests for copies of medical records. EncLosed are the reproduced medical
documents specifically authorized by the patient or his/her legal representative. We
wish to emphasize that the increasing demands for patient data pose a rising threat to
the confidentiality of the patient'smedical information. FYI HealthSERVE strives to take
every opportunity to safeguard th~ patients' right to privacy as outlined in the A1'lA's
Patient Bill of Rights. Specifically, all patients have the right "to expect that all
communications and records pertaining to their care will be treated as confidential by
the hospital and any other party entitled to review certain information in such records."
As one such party, we ask that all information transmitted herewith be treated with"
utmost respect and the dignity such personal medical information warran\$. Please be
advised of the following. state and federal disclosure statements go'l<;!rf)ing mec!ical
records in Pennsylvania: .'
This information has been disclosed to you from records protected by federal confidentiality rules
(42 CFR Part 2), The rules prohibit you from making any further disclosure of this information
unless further disclosure is expressly permitted by written consent of the person to whol'{l it
pertains or as otherwise permitted by 42 CFR Part 2. . /
This information has been disclosed to you from state recoJds whose confidentiality is protected
by state statute, State regulations limit Your fight ,to ,mak,aJly3urther disclosure of this
information without prior consent'of the person to whom it" pertains; , ~, -
This information has been disclosed to you J(6ii1 records protected by P.ennsylvania law.
- '..r.
Pennsylvania law prohibits you from making any! further disciosure of this information unless
further disclosure is expressly permitted by the written consent of the person to whom it pl;rtains
or is authorized by the Confidentiality of the HN-Related Information Act. A general
authorization for the release of medical or other information is not sufficient for this purpose,
Based upon guidelines provided by the American Health Information Management
Association, the records should be destroyed after the stated need has been fulfilled.
;
We thank you for your cooperation in maintaining the patient's right to privacy. Each
medical record has been carefully reviewed to assure'thaflJroper disclosure goes only
to the authorized Requestor. If you have any questions,pleas~ do not hesitate to
contact us at 1-800-525-2922 and one of our Customer Service Representatives will be
happy to assist you,
Recordex Acquisjtion Corp dba F.Y.1. HealthSERVE 0 WWVt.fyiLccm
PO Box 2017 ~ 17 Lee ~oule'lard ' Suite D ' Malvern, PA 19355 0 PH: 610-6t.O-C€CQ ol-8CO-526-2922 0 FAX: 610-640-3844 f29J7
""""'-:1'%,.
-~~'r"r:'::::.".?;';"'"
THE MILTON S HERSHEY MEDICAL CENTER
PO BOX 853
HERSHEY, PA 17033
MEDICAL RECORD COpy
MR328 (REV 9/00)
'-'-. -'
MRffl\}Z77Q
T RA L"A # 36Z978
72~ 7-} 7"F'"
C3125/1'- >
c. ~, ~) ;~ ;.' , 0 "',!..
l t, ' ;.; r.. ; : T .A ~,Y M
".I\"i
i-t-l-
+ _ - _ _ - _ _ - _ _ + + _ - - - - - - - - - - + + - - - : - - - - - - + + - - -W DJ h~ jJQ,~\J+ + - - -? + H-~ ~ + - -? ~-1 ~ ~ =
1~~~62978 11~~~8~ 11~~~~3/01 11~~~~7 pll~~~~~~iDIILOC II~~~II;RCII~I
+----------++-----------++----------++-------++--------++----++---++---++-+
+-------------------------++---++----------++---++--++----++---++---++----+
!PATIENT NAME IISEXIIBIRTHDATE IIAGEI IMSIIMRSAIIVREIIADVIIREL I
LAIRD BRITTAN'{ M F 03/25/1990 10 S PE
+-------------------------++---++----------++---++--++----++---++---++----+
f +--------------------------------++---------.-----------++---++------------+
PATIENT ADDRESS CITY ST ZIP CODE
921 WALNUT STREET LEMOYNE PA 17043
+--------------------------------++--------------------++---++------------+
+------------++---------------------------++-.--------------++-------------+
I PT PHONE II PT EMPLOYER II EMPLOYER PHONE I' SS# I
717 737-4955 NONE
+------------++---------------------------++---------------++-------------+
+-------------------------++-------------++-----------++------------++----+
I CONTACT II REL II PHONE II WORK PHONE II CO I
LAIRD TAMMY MOTHER 717737-4955 22
+-------------------------++-------------++-----------++------------++----+
+-------------------------------------------------------------------------+
INSURANCE INFORMATION
NAME
AUTO INSURAN
SELF PAY
POLICY #
999999999
\ GROUP NUMBER
~^f}: IX' 0 j}cA-
(YYC!V'~ :~nloJ
+ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ J6~_,~Q~ _ _ _ _ _ ~~J:-! _ _ _ _ _._ _ +
+~~~~~;~~~~~~;;-;~~;-~~~-;~;;;;~-----lf~ujA~-~lif.)IIrt--------------+
+--------------------:-----------------------.--------------------~--------+
+--------------------------------------------.-----------------~--~~-------+
I COMMENTS # I
VERIFY ALL INFO
+-------------------------------------------------------~T-~----.----------+
+------------------------------------++------------------------------------+
IADMITTING PHYSICIAN I IATTENDING PHYSICIAN I
26150 DILLON PETER W 26150 DILLON PETER W
+------------------------------------++-------.----------------------------+
+------------------------------------++-------.-------------------------
FAMILY PHYSICIAN REFERRING PHYSICIAN Ut..'R ~ 0
UPDATE SALNESS KYM A f'
IN PROGRESS PO BOX 850
UNIVERSITY HOSPITAL
HERSHEY' PA 17033
FAX: 717 531-8174 FAX:
+------------------------------------++-----------------------------------+
'-
)
,
~
R6~
NURSE'S NOTES
. tJ. '-h ...f{11ILC t.. Utc~ M g!J.
4-~~ ~ II f- ~GY€-=~ ~ ~~~ .
I~IP d~.~ c- . ~ ;c:r=;;;;:/#(< G
ti~ g1~~ ~ ~ . M~Drt-
tl /J..R...J_ . ~ fn- "'" -r ~. lAJ&tYnri (~A/.d.. C~
+ ~ r '
oJ'-!. ~
jl()o PI. s~
(!dJt , ~,&.2ffi;2. p c;z.U,j
" r
). ,f ~ :f4 a.:\- fl..e.. (.-.J{J.4 ~o --lo ~ .5~",- C
4 rc\.....-w~~ h\.~ ~~Q.- (,),-,.-0 ~ ~~ CAA/I)~ a c{)~~
LON<<' -I-LO~(0DP~. pk~ ~~""".p~.....,--o cUR.
BRACELET"OCATION: I /(w,-;"f BLOODBA J,<k,'5.f- Rlli ~43168 ~l.\,'3llPE>
.;. q r """-' ~IlliIW ~
Support Nurse: 01 a r. Documenting Nurse; /.Ac'~{ ,,~
Physician Signature: I!td...
/(
BVM = Bag Valve Mask
ET = Endotracheal Tube
ABD = Abdomen
RL = Right Leg
LL = Len Leg
RA = Right Arm
LA = Len Arm
LCT = Lell ChestTube
RCT = Right Chest Tube
PH = Pre-hospital
LOC = level of Consciousness
PMH = Past Medic~ History
BH = Bair Hugger
NS = Normal Strength
W = Weakness
FP = Flaccid Paralysis
R = Rigid
DeB = Decerebrate Posture
OCT = Decorticate Posture
CHEST: .-e
..
--
AB[):
.
"l,
ADMITTED TO
TIME OR NOTifiED 0 OR READY TO OR 1/3n
fAMILY NOTifiED @ 011, SrfA\ 0 ~Y
RELATIONSHIP _
C-SPINE CLEARED CY'i'Es mo BJ;:..BR BURN:
C.COLLAR ON: erIES 0 NO ASPEN: '0"YES 0 NO
VALUABLES: 0 W/PATIENT 0 SAfE 0 NONE IiJ.'1i7fAMILY 0 BELONGINGS fORM DONE
o EXPIRED CORONER NOTlfIED@ OTHER:
MATERIAL EVIDENCE TO POLICE 0 YES 0 NO
OffiCER BADGE #
~
TRANSfERRED TO
VIA
.
Oi)$ 21880
f; gf F; ".'::,1 00
'" ,; t:",. ~
PENNSTATE
!51 Milton S. Hershey Medical Center
., College of Medicine .
T F A IJ L
ED TRAUMA/RESUSCITATION FLOW SHEET/ORDER SHEET
TIME RESPONSE STAT PAGED 10.0(0 ED
RESPONSE LEVEL
l<.c>cll e>-f'..ll.o V-> I ~ T'
C-COLLAR
ClorrOWEL ROLL ...--
LONGBO~EO ....--;-. F-
SPLINT ~ (~:b2.Pr
MB/MEOIC #
HELICOPTER
ON. SCENE _INTERHOSPIl1\t>
CHART LABS XR CT
LOSS OF CONSCIO)JSNESS: Lira _UNK _YES_# MIN
ENTRAPPEO: LNO _UNKNOWN _ YES # MIN
SELF EXTRICATED: YES NO
_ EJECTED
HT
CARSEAT ROLLOVER SPIDERED
NONE X _ ST WHEEL BENT _
UNKNOWN _ UNKNOWN
HELMET NONE UNKNOWN
DAMAGE
FRONT ~IN
_ BACK _ MOD
_ BROADSIDED _ HEAVY
R l
_ DRIVER
PASSENGER
FRONT
_ B~CK
V'DESTRIAN BED OF PICKUP
BICYCLE ATV _
GSW CAUMM
DROWNING _ FARM _ INDUSTRIAL
STABBING
OTHER
SPDRT
PMH/PSH
0Cc
~~ ',- ~,f-\V) ~
MEDS
i'J
(
Besl
Verbal
Response
Oriented
Confused
lna ro riatewords
Incorn rehensiblesounds
None
Best
Motar
Response
Dba scommand
Localizes ain
Wittldraws ain
Flexion ain
Ex1ension 'm
None
:l-
2
1
o
1.QP,NFRACTURE
2,AMPUTATlON
3.G!JNSHOTWIJUNl)
4. DEFORMITY
5,STABWQUNO
6. BURN
7. PAIN
8. RASH
E-ECCHYMOSIS
A-ABRASION
C-COlHUSION
L-LACERATION
S-SWElUNG
T-TENOElUIESS
S-SENSATION
PW-PUNCTUAE
WO\.lItD
BURN.FT
PT
SO
HMPAUQ.OBJECT
2
1
o
SystOlic,
Btood
Pressure
>B9mmH
76-i19mmH
50-75mmH
j-49mmH
NoPu\:;\1
Respiratory 10-Z9Imin.
Rate > 29/min,
6-9Im\n
1-5/min
None
To{al Revisell TfaumaScore
3
2
1
-.:..~
3
2
1
o
2
1
o
390 8/00
\
Original ~ Medical Record Yellow ~ Trauma Service - Pink ~ ED
ED TRAUMA/RESUSCITATION FLOW SHEET/ORDER SHEET
....., -'. C,-,,~ \oC
..:IOC: ';rAtJ\'.j IJ Y
o ()
"',""1
~.
_LL
P €t']---.
BP~
,-r:
~
I
GCS
RR
SEDATED PARALYTIC AGENT
SPONTANEOUS RATE -
= 02 MASK UMIN==
_ 02 CANNUlA llMIN_
_ ASSISTED RATE_
_ BVM RATE
_ AIRWAY (ORAUNASAl)
~ m (ORAUNASAll SIZE
_ CRICOTHYROIDO,OMY
TRACH SIZE
LAST TETANUS "t
TENOER
YES
WHERE
SCARS ./
YES ""'NO
WHERE
AIRWAY PATENT
. ~ NO
JVD YES ~
TR.&EA MIDLINE
V"YES NO
, J.
J
'-
~
~
<= L~tes Scale
Sat ~ T I e,H, Used
Im"'l~ J
_ SPONTANEOUS
~ O~ASK
_L-m CANNULA
~ ASSISTED
_ BVM RATE
_ AIRWAY (ORAUNASAl)
_ ETT (ORAUNASAl) SIZE
CRICO TRACH SIZE
~D
:~~N~L~'ro~;;Ev~gp~ll\JN. ,~.,
Time Pupil Pupil ~ Time
Size React Motor Funct,i,on
R L R L RA RL LA ILL GCS
(01..J- :i;;;"( .It. "
iJ nV ":l z.. 9A1 AI'f ~ .~
[Tvl /J .lA,11.t
1",,,;- /I' ?J' 1JI '"
VI~.....~~.
BP
Cardiac 02
P Rh:/lhm RR
.... i<:-
I~
:;)
')'2...
-
" loG
01:>
~ 0 ::>0
''''''
:J/li)
:J.//o
,
11 i 0 ~ _ '1
.~!~
.......e TIME DRUG. DOSE ROUTE tNtT,
2 3 4 5 " 7 R " I'~ TET ~UlT lOTI "o7i;>il'/f)"r~ o"-'.I-.--il '\
!/"I"'Ju. DP~D~ EXP~AW.'" "':J:::". l--J..M "\.eX LJI~
~ lo~1 a.....D..;:'.' ~ ...,.. J DV
TIME TRAM-1M TIME BACK t~'l-l c' A v ;'; 1...-. _ ::c.-v D~
=:~L lop";!,';>' ,~ .., ^^ () :::c:v I fXI..v
=:~L I03'.S I ~ ~ -j -t->^._ ::t::;u M
~",,=:~F IO:i.. M,.~, (..........- \J ::t::-,t.o&.-
T&C# U u
T&S
LEGAL URINE DRUG
lEGAL BLOOD ETOH
OlliER
SITE
CRITICAL VALUES
CRITICAL VALUES
PREPPED WITH POVIDONE-IODINE
DRAWN BY
,.,
RECTAL HEME + ~
TONE 0 GOOD
o DECREASED
o ABSENT
PROSTATE 0 NORMAL
o ABNORMAL
DONE BY TIME
_ N/G (ORAUNASAl)
SIZE _ FR
INSERTED BY TIME _
PERITONEAL LAVAGE
DONE BY DR TIME
RETURN 0 CLEAR 0 PINK
o GROSS BLOOD
AMOUNT INFUSED CC
AMOUNT RETURNED CC
FLUID TO LAB YES~
DD. R
SIZE FR
LCT SIZE FR
R THORACOT
l THORACO
PERICARDIOC
DONE BY
12lEAD EKG YES NO
.~ E
_ICP BOLT INITIAL
_HALO DONE BY 0
Neonatal
~!~
Adult
Non-
Communicative
Time
.c;'Soine
-------.0ateral
~P
_ Odontoid
Swimmers
== CXR
Pelvis
...---.&-c Cystogram
I ~VExtremities
~QI
_ Cranial
_ Abdomen
_ Chest
Other
== Angiogram
1"t.1"II'DIAlt
.. The Milton S
.~
.g, ~-n
c
The College of Medidn'~ T ;, ~) " ,. j ue: ----l 1(1
, c.
Denartment of Emernencv Medicir.e Record (},:) :; 2 \ H"J ell I I 3 d- 77Cf
MRB18
~ Temp: Oral Rectal Pulse I RR SP 02 sat I Last dP 't LMP, ' t..E~ ~alh~a,Y Room Time I PhYSician Time
.. ;,-A " ,
<;e: Z',.,'. PMH:
-
11!,1:
\
,. ~ Meds:
-
/ . i~ \
--------- ./\ Vf )
~~ '" 1 Q. ~" Allergies:
Pain: Y N Location QuaJit ( et ~/ --- FHx: Cardiac y N Diabetes y N
Radiation Quan it 110 t ~ Facto
ROS: Unobtainable ~ Y N As noted, ms negative Y N Other"
Constitutional: We Ghanae N Y Fe\ler N Y Chills N Y Weakness N y Fatigue N y Soc Hx: ETOH Y N Smoker V N PPD
Eyes' Blurrv vision N V Diplopia N y Eye Pain N Y Photophobia N y
ENT, mouth: Sore throat N Y Eptstaxls N y Ear Pain. N Y Rhinorrhea N Y Other:
Cardiovascular: Chest pain N Y Pleuritic N Y Exertion N Y Palpitations N y fabO'~kihiStudles!~!:~1Y"r;/' .JFtH
Respiratory' Cough N Y Sputum N y Dypn.ea N Y Orthopnea N Y Wheezing N Y
GI Abd. Pain N Y Nausea N Y VamilinQ N Y Constipation I'll 1 Diarrhea N Y '. / Neutrophil
GU: Hematuria N Y Dvsuria N Y Frenuencv N Y VaginalD/C N y lncontinenece N Y /------< Atypicals
/ "
Musculoskeletal: Arm "'ain N y Leo oain N Y Back oain N Y Leg swelling N Y
Skin Rash N Y Lesion N Y N Y \ -r-< c"
Neurolonical Numbness N Y Tinnling N y Seizure N Y Syncope Y Dysphasia N Y - --- t-
Psychiatric Suicidal N Y Anxiety N Y Ingestion N Y Depression N y Hallucinations N y Mg
I , ,
Other:
Troponin l Myoglobin.
Physical Exam: Rectal: Hemocult (+ ) (-) PT: PIT:
INR
T. Bili Alk Phos
ALT:
Amylase Lipase
UtA: U-HCG (+) (-)
Drug Screen:
Cullures. Blood 1 2 Urine
R.<Ii.Tci~5"fchOci<lIilklMaB~ wil6i
Sludy#t
[] See attached PROGRESS NOTE for additional information: o Resull: .
MOM! Differential DiaQnosis: I 3) 6)
1) 4) 7) Study #2:
2) 5) 8) o Result
Procedure Note: I
. Study #3:
EKG: o Resu!l
ED course: Treatment:
c:~~lfJtp~~.V;{:A;~;;:,~.9~,~I'(!*,~~~,~~~~i{lfii~~~~~
Response: 1) 2)
"
~~~~'''''~- ',. dl .'OOP },"
;,'il'.'~~lii~,;,;, .,...... ,.,' < AF'bD23hrD4d"Y~
,it, ,~'. , ...,\t1!!',.' "T,>!, "..c,. $,., ,~,;;', ".' .. ,< , "
Discharge Instructions: Please go directly to check out secretary al wailing room desk ' DVT 0 23hr 0 5 day 0 23hr trauma
Deom. Acq. Penumonia 0 CellulitiS
Follow up with within days PJ..",IJit . '
1)
Return 10 emergency department if
2)
3)
",_',~.:,~-"";l " .., ":'; ".'~~:ir'f; ,;Jf~t irjdma~8IOnafu,.':~j~*~;.:;(it ~;'i; ,- "";;NUtrili.r~.;'; Disch' >~' ii"lio' '\,;/,~~.;~J~.~ .'.,',~,V't,';;~';I;~~
I 0 Resolved Service. Where:
D Improved
o Nochanne Time: o Cobra form
Hershe
ledical Center
(
'- -
(
\.
,
r
<..
e:'
'J
f'
.
e
.
.
MRf.2(1191}
.'
. "P~9rATE
'. S The Milton S, Hershey Medical Center
". The College of Medicme .
PROGRESS REPORT
.'
DATE TIME
C,>." .
PROGESS NOTES
o OUTPATIENT
o I NPA TI ENT
NAME - TITLE
PASTORA;,SIE:~I~TS .
Dale: ~ TIme:
Referral Source: Name:
Clergy Other
'--
r::{:L.
Patient:
\ n t\ I'll. Pastoral Visit
Location:
Other
MD RN SW
I
r-
<
'-
I
I
<
Adm
Fa.mily
<
i
f--
I
L
I
L-
I
I
I-
Follow-up:
Chaplain:
r Recorn.
Length of Time,-j L~
"
r-
<
. -.-, .. ..-.-.-"...- -'--- ". I
.
.
.
-
'. . .
.
PROGRESS REPORT
(
i
I
"
c
I-'tNN::) lATE
~ The Milton S, Hersllex Medical Center
- . The College of Medicme .
TRAUMA PATIENT RADIOGRAPHIC "WET READS"
(PRELIMINARY FINDINGS)
'/) '}
1 T
T F: ;, U ii ,~,
e., ~~-,o
-- b -,1._;, \ .
,..)\.:....... I IQ
0,;$ 21880
r ~: j:'
~ , ... ~ ,
The following radiographic studies were performed on this trauma patient, with "wet read"
preliminary interpretations as indicated:
- /.. 'M~ \J I. ,--~ ve..A Cl lJ-) (0 ~
llYChest wtll"" 0 Elbow - (L) vs, (R)
o Abdomen
IJ"Pelvis P').he
o Hip - (L) vs, (R)
o Femur - (L) vs, (R)
~ee - (L) vs, (R) 0 rho
. ~~~r
~OtlAnkleL(l?.,s, (R) eLf. ~H -'-fhk.
o '( "'!'-jVlT~Fr
o Shoulder - (L) vs, (R)
o Humerus - (L) vs, (R)
Radiologist's Signature:
Printed Name:
Beeper#:
Date:
~-
)(A(L-'14
o Forearm - (L) vs, (R)
-313\ Dt
\ I
o Hand/Wrist - (L) vs, (R)
o Cervical Spine
o Thoracic Spine
o Lumbar Spine
o Skull Xrays
o Other Xrays
NOTES:
1, Angiographic/Cardiovascular
Interventional Radiologic procedures
are documented on other forms,
2. All studies on this patient for whom a
"wet read" was provided during the
trauma were "checked" in the
appropriate boxes,
...,..~-
3, A "minus sign". ("-"). indicates
"no significant abnormality."
4. By his or her signature, the Radiologist
who interpreted the studies
"checked/circled" above indicates that
the findings were discussed with the
clinical team,
MR 808 9199
TRAUMA PATIENT RADIOGRAPHIC "WET READS" (PRELIMINARY FINDINGS)
White-Medical Records
Yellow. Radiology
(
PENNSTATE
!!S The Milton S, Hershey Medical Center
. The College of Medicme .
1S~~1~K~
.... ..... C:' .....~, ,..."
i "-.. " 'I;
;'t \,.\ c.. I ~ '-'
003 218110
[ !H R G) 00 0)
.' "".....
TRAUMA TEAM SIGN-IN SHEET
DATE ~'U}
E.DJ MEDICAL COMMAND MD. -Mi I Diu ;J
TFIAUMA NUMBER
TRAUMA STANDBY: Paged at
Hrs,
Trauma Response Stat: Paged at
Hrs,
TRANSFER CARE OF THE ABOVE PATIENT TO THE TRAUMA TEAM AT
HOURS
-
TEAM MEMBER ~ II, NAW: TIME OF
. ARRIVAL
Trauma AlIending [1:, M A~\ 1..'1 J ()
Trauma Team Leader n \/' . '0.5
Senior SurgeryfTrauma Resident "-'
Junior SurgeryfTrauma Resident M.b.. JS[ (~
Junior SurgeryfTrauma Resident \\, { I J:ril
E.D, Resuscitation Nurse 1 r'{, ,!l,'(I ~j 00'-'
E,D, Resuscitation Nurse 2 IOf d 1M
Anesthesia AlIending I~ v..... /o>q-
AnesIhesia Resident
Neurosurgery Resident
Orthopaedics ResidenI
Pediatric Chief Resident
Pediatric Junior Resident .
Respiratory Therapy Technician )(.,j ,j,PJ1J 7n flU
Radiographer Kt.: ^-'--.. 10'"
Radiologist ~ lO"\'
ED EMT ,,';II. y.-/ /2d.c;'
Chaplain \E O~!Q~\.. Iftl.[O
C.T. Technician ~
Trauma Coordinator/Resource Specialist
OR NursefTechnician .~ 51'> (Jl.AJ.f /0 ,"
Emergency Medicine Resident
CONSULTING SERVICES
SERVICE M,D, NAME TIMFOrtONSUL T TIME OF ARRIVAL
'. ,
Original copy' Medical Records
PInk copy. Emergency Dept.
Yellow. Trauma Services
MR 414 Rev, 2/97
TRAUMA TEAM SIGN.IN SHEET
I LI'lI'lJIf"\IL
~ The Milton S, Hersh, ,1edical Center
. The College of Medicine .
:\ ~. U:~ H
3b EO; -:8
ORTHOPAEDIC TRAUMA ASSESSMENT
0:52JSEO
HER 0,) ao GJ
( 51,
History '\ 'de 0
1"
Family .contact phone (
PHYSICAL EXAM
NL
B !.
Neck ~ ~
Spine pl1 ~
Clavicle ~ ~
Shoulder
Arm
Elbow
Forearm
Wrist
Hand
NL
B !.
Pelvis i
Hip
Thigh
Knee
Calf 0
Ankle 0
Foot 0
VASCULAR EXAM
EXTREMETIES
R
L
NEUROLOGICAL EXAM
UPPER EXTREMITY
Motor deltoid
R
L
Sensory C5
MR 523 2/92
f ....L,"'v; 't:l.J+-<>
<:j, Lot.. CB ~;.....- PI- do 810 l""~
ABN
B !.
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
ABN
B !.
0 0
0 0
0 0
0 0
0 pi
0 )$
0 ~
RAD
1,+'
"2-"'
bicep
C6
COMMENTS:
JJ.....k' \{,,\,
1!,c..J.. '. 9S"- ('
0)0t '. rp "l-rP N'-' ~
d,.db ~vr; @
COMMENTS:
pJ ,J, " - stLL
(f, v<:: \15'1\ e ~ v ilJJW\
~'
,1.; ~ tV v1;
ULN
o ~: <3l "1''''''- 0/ ( of; ~ ( Q uJ:,;, _ 8.....Q..
-IO<-v- ~'-"<">'- \-....r...:t:- ~~"""N.k
~ ( l'\ - \.... r SL ,. () '0" ~ ; d::::Ji
Clh. ~ "1;-
FEM ( Cf>op DP PT
7.-.... .V...
t*" I\-
R
L
LOWER EXTREMITY
Motor psoas hip ext quads hams lib ant
R
L
Sensory L2 L3 L4 L5 51
R
L
Rectal: ~, J-.. hyper norm hypo absent
---
Bulbocav: hyper norm hypo absent
wrist flex
wrist ext
tricep
grip
C7
C8
TJ.<:
ext hall long
gastroc
H
H
ORTHOPAEDIC TRAUMA ASSESSMENT
,THOPAEDIC TRAUMA ASSESSMENT
FILMS NEEDED:
J,-,c( .l..'t>'~..:t\-- 1,)
2,)
:3.)
4,)
5,)
X-RAYS
TRAUMA SERIES
AP LAT POS .NEG
~
C-Spine ~ ~ :;iodon 0 0
T -Spine 0 0 0 0
LS-Spine 0 0 0 0
Pelvis )8l 0 - 0
ADDITIONAL FILMS:
FINDINGS:
1,) Av r l...}(.-v\.;....... ~/.J..L. - er- (;~P.
2,) I
a) I
4) I
5,) I
6,) I
7,) I
8,) I
SKELETAL INJURIES
ij
-
,,-....... ,?<;:O
I'"
lit
SUMMARY OF INJURIES
PLAN:
1. (L) ~ G~ ~ 0c. I Olt--\~
2, I
3, I
4, I
5, !
6, !
7, ! _
Orthopaedic Surgeon 77------
FINDINGS:
~
r
e
(
SOFT TISSUE INJURIES
(
l
/1' \ \
. I
, . .
1~f
J
.(
~
~
fRONT
.,,:x
Datel/.:L-/~ Time
\
,
MR 523 2/92
ORTHOPAEDIC TRAUMA ASSESSMENT
3-March 2001 11:00:11
ACUI1Y'
....?"..n.n~.....".c.
_SNAPSHqT'25 mm/sec Adult/Pediatric
11iQQ:1;mv/c~R = 1Q3 PVCs/mi =.0. P1=9FF,n =.OfF...C.2 = OFF,6R= OFF$P02=JQO,N!6P=OFF
Vital Signs Summary Comments
Time Sys / Dia ( Mean l HR/PR Sp02
HH:MM -- mmHg (NIBPl -- BPM % I
10:10 116/67 ( 79 l 88 98 .~ ,;:\) .
10:21 123/76 [ 89) 89 100 t;V .
10:30 101 /66 ( 79 ) 80 100 , ,
I 10:34 110 / 76 [ 86 ) 107 100
l .
10:40 11 7 / 68 [ 86 ) 110 100
11:00 109/ 58 [ 74) 102 100
.,..~-
3-March-2001 09:10:00
,feUllY"
I' ~Jt.r..;:.t UUtlu. 1111:.
09:10
2 Hour (l'abular. Trend Adult/Pediatric
median (averaged) data
11:10
..
TIme HR/PR PVCs Sp02 NIBP (mmHgJ Comments , :
HH:MM BPM /min % S/D(M) ,
09:10
09:15
09:20
09:25
09:30 -
09:35
09:40
09:45
09:50
09:55
c
10:00
10:05
10:08 98 0 OFF OFF
I 10:10 102 0 100 t 16/67 ( 79 )
10:15 95 3 98 OFF
10:20 100 0 100 OFF
10:21 101 0 100 123/76 ( 89)
10:25 90 0 100 OFF
10:30 85 0 100 101/66 (79)
.
10:34 109 0 100 110/76 (86)
10:35 99 0 100 OFF
10:40 103 0 100 117/68 (86)
-
10:45 110 0 100 OFF :. :
10:50 115 0 100 OFF ..,:~- ...
10:55 102 0 100 OFF
11:00 101 0 100 OFF
11:05
11: 10
~rL,J
I '\" f[) Y
v
-
Pagel of 1
;Nl"l') IAI t
/ !$I Milton S. Hershey Medkui Center
. College of Medicine .
19 ~13
T ;~ j, :ji-\ A
--'1 ,(': -- (\
jOC'j It.:
PHYSICIAN'S ORDER SHEET-TRAUMA
(
o~s 2\830
. ,
~'>.
\..~.l "~ ~C\ .~, 'f) I
6 0 lL.:r
INSTRUCTIONS:
1. IN CASE OF NARCOTICS-ADD NARCOTIC LICENSE NUMBER TO SIGNATURE, ALSO INDICATE
DURATION OF ORDER, DOSE AND INTERVAL.
2, STOPPING OF AN ORDER-WRITE AS A NEW ORDER.
DATEfn E
NOTED
DATE. TIME, INITJAL
1, Admit to Trauma Surgery/Dr,
In A,M" change Attending, to Dr.
2. Diagno~is/lnjuries
('\
(
3, Allergies: /if /l11 fj
4, C-spine cleared or unstable
5. Thoracic lumbar spine cleared or stable/unstable in brace
6, Vital signs Q
t-f hr I's/O's Q
/QDWl.
7. Neuro checks Q
t.f hr., Vascular checks
Q !:::t---- h r,
8, Chest PT Q
, Incentive Spirometry Q 1 hr, while awake
9. Turn, cough, deep breathe Q 2 hrs. while awake
10, Maintenance IV fluid
MI1... NSt-w
@ (VDCc
,.
,
,
AUTH liON IS HEREBY GIVEN TO DISPENSE A CHEMICALLY IDENTICAL DRUG (AS COMMENDED BY THE PHARMACY COMMITTEE).
UNLESS T E REaUEST FOR NON-FORMULARY DRUG FORM IS COMPLETED AND SUBMITT FOR THE INFORMATION OF THE PHARMACY COMMITTEE.
rU
c saline.
11, Diet:
/VfV
12, Activity Level
e 0 w
--
e 0-
MR 1,57 -1,7 9/98 P9, 1 of 2
PHYSICIAN'S ORDER SHEET-TRAUMA
,
I
INSTRUCTIONS;
DATEfTlME
?fl/f)/ 1, Labs
r'J/'1J ff--
17, X-rays:
18. Meds:
(
1~ ~1~
T :\ :.. UP;;
:: b 2 Cj --; G
PHYSICIAN'S ORDER SHEET- TRAUMA
C:j S 2] %')
:", R :',))0 00
. . .. - ..,.......
1, IN CASE OF NARCOTICS-ADD NARCOTIC LICENSE NUMBER TO SIGNATURE, ALSO INDICATE
DURATION OF OME~, BOSE AND INTERVAL.
2. STOPPING OF AN ORDER-WRITE AS A NEW ORDER.
PRESCRIBED TREATMENT, MEDICATION .~ND DIET
NOTED
DATE, TIME, INITIAL
I/( fir
,
!1{Otf Ii #A-.j/Y &,J"
Irt;t, ~ 1/ h 11..<.
\- 0 ~-, ~.~ Tv
-~
PI'--
F n:v
~Lcf' c/-...-lo
.
\
Vnlv') fI:I\.Ch. P-\.o'~Pl.A-!.,.\ r,. ,r~,_,II.^.\- ",.Jr. Ii\\ L'\~,. ~
+-;:',.' ~ \J, "~O,,\, J..... (t5Jf">.'\ \<""\0 "
19, ia-(iccupational Therapy/Physical TherapYc;;nsult for evaluation and treatment
o
o Rehab Medicine consult
o
o
o No Rehabilitation or Therapy Services are required
20. Deep yein Thrombosis Prophylaxis:
6 None needed
o
o
o
o
o Hold Enoxaparin dose within 10 hours of placement of spinal or epidural catheter,
o Bilateral lower extremity Duplex Scan every 5-7 days post admission __ -- ;:;:,- ~
o If on~PI study, no Enoxaparin until infusion is completed. ~
21. Call Hou~ Officer for: tfrCt. CO) II 0 ._\j
/ / ~ < 1D 7//,0 ~ ,~
I r\ Fk-Yl 7 (pl' r /' /I ;;9~
~~~~~~,~~/itJ'~~~~~~s~R~~~~"ri3~~~;ti~;~:u~:~;~~/;;:~~~:~~~:O:~E: / / ~D~
MR 1,57 6/~ Pg, 2 of 2 (\.I PHYSICIAN'S ORDER SHEET- T:::-- ~ -
i,
1/
Speech Therapy consult for evaluation and treatment
Nutritional Support Consult
Universuity Recovery Center Consulf
/
I
f
/
Enoxaparin 30 mg, sa Q 8 AM and a B PM OR:
Sequential Compression Devices OR:
Foot Pump Compression Devices
Hold 8 PM and 8 AM Enoxaparin doses for 24 hours prior to planned surgery
J
PEN N STATE
I!5i:! The Milton $, Hershey Medical Center
. The College of Medicme .
l?47-j I~Q
(; 3/l5/1 q 'c
::.'c.'.
DATE OF BillTH
I
o 71Jfw
PENNSTATE
S The Milton S, Hershey Medical Center
. The College of Medic me .
-., ^'-.
7; ., 7- ) ,,; t' ~
C 3/25"" ':',:;
SEX
~~
1>/J
~
-
" ~hJ
--
..--
--
-----
-----
/'
rUW
JL~ oJ
'[,
PENN:::'TATE
9 The Milton S, Hershey Medical Center
.. The College of Medicme .
" " " \ , , , .. , ., ; 0 - -, , , ,
.
0 " , . , / ? , , "
, A "
.. ! \ "
i. A , " P i~ , r A t'l Y ~\ r
,
r, . 1 L " - 'e 1
.' J ! i. L " \j ,
ADMISSION NURSING ASSESSMENT
'"
'" z
in 0
o >-
z "
" u,
" 15
C ~
>-
z
w
a:
a:
:>
u
J
UJ
I
Frequency"
. .
.,'
Height'.1 Weight "... ""L
Head CirCumference: C
(under 2 years> -;
. L~st Taken
,--c . ,.:..,. ",. .'
....,< '.'
": '
....
Date: b Time: I ~ Name Pre1erence:
Type of Admission 0 Planned ~D 0 Outpatient
Admitting Diagnosis/Chief ComplainVPresenting Symptoms:
Name
o Other:
'.
Dosage
~ur<:..
-,', ...
. , , ,
. .'. ,
'. .--c.
. .-,
Mads Brought From Home: 0 No DYes-Sent Home 0 Yes-Sent tn Pharmacy 10r Veri1i9ation " ',' ".,"
Do you wear Glasses: 0 Yes ~ Contacts: .0 Yes ~o Hearing Aid: 0 Ye~Denturest CJYas~
Allergiesl~:;~:~ns ~ne 0 MedICatIOns 0 Food :~ L~tex" 0 Other:, ,"'> ,
~ Past Medical HistOryL (e~. Diabetes, Cancer, Stroke, MI, Seizures, H~pertension/ulmOnary Disease, Hepatitis, Ulcer,~kin Oisor,der"6rthriIlS),,, "
~ Ve('!j ~4.N1:J --K(,~ {lJ4II1/~r ,,".,... . '.' ..'.,;\
. .' ..-, .
,'. " . '..
.... .'
-
:z:
>-
-'
"
w
:z:
.'
I
I" ,
(Explain areas that may impact teaching)
o Physical
o Cognitive Limitations
. .
o Tobacco : 0 No Smoking PolICY Reviewed ~ne
o Cultural/Religio.Lis ~ne'~ " .~
o Language I16lhrrt~./IvOU
Do you use: 0 Alcohol 0 Other Drugs (Explain):
Initial Assessment of Patient's Ability to learn: 0 Emotional
o Motivational
'"
ttl Pre1ened learning Methods }\~ No
z One-an-One Instruction ~ q, AudioNisuallnformation
:;t Group Instruction 0 ~ Demonstration/Practice
~ Wri"en InformatIOn .~ . 0 Other: . ", .
..
'" PalienVFamily Teaching Needs: 0 Yes, explain: ~ ('J.~(r ~. ,
PatienVFamilv Con"ms. Questions 0 None [y(,s, explain''-1}~'' ;. j- / I'~L,
Special Equipment Needs 0 Yes, explain: V . () /
~ ~ 1. The ~ospital routinely screens for domestic violence. Have you ever been physically, sexually or emotionally abused (hurt) by anyone?
~ ffi ~o 0 Yes 0 Past 0 Present . /
:!: b 2. Are you afraid of someone who is close to you? (lAo .' 0 Yes . .
g:> 3. If "yes" to any of the above Questions, write a flufsmg order for a consult to Social SerJices for "Domestic Violence Screen" on the Physlcian Order Sheet.
1. Are you experiencing any of the following: Unintentional weight loss of more than 10 pounds over the past 6 months? 0 Yes [iJ..ffo
z Chewing or swallowing difficulties for more than 2 weeks? ,---~ Yes [Sofio
o
i= Persistent nausea or vo'miting or diarrhea for more than 2 weeks? 0 Yes []..f(o
~ Decreased appetite for more than 2 weeks? . 0 Yes ~
:>
z 2. Are you pregnant or breaslleeding? 0 Yes 0 No
3. If yes to any of the above questions, wnte a nursing order for a consult to Clinical Nutrition for "high fisk screen" on the Physician Order Sheet.
~ A & B Monitor at home? 0 Yes Cli)I1i' Recent Exposures: 0 ChICken Pox. 0 Measles 0 Other: "tho,. v,,-:
~ Immunizations: -r-: ..' : _ .L_
'5 Parent's location during palient's stay: J "4/U1'J!/A4 ,,- J'rli'>>t~~ (l Phone:
~ Currently using seat belt/child safety seat? 0 Yes - o'1!o Brochure.on car seat safety given?
Yes
l!2(
.::a:
o
No
o
o
0'
.-
DYes
ONo
Date'
3/">;(07
Signature:
,j (}/:".J.. ~j.~,." l:I.J
SIGNATURE ON BACK
OF NURSE ON UNIT '
,
~
MR 470 REV 6/00 Pg 1 of 3
ADMISSION NURSING ASSESSMENT
Wt\ite-Chart'
Yello.... - Pharmacy
~:d ~l~('^J~-~ \
\1 -4 t. l'-~ %
~ '"' ,. 'S'
f;: t-~ .~~ \
l~~~~ ~l~ \
~ ~.~. i < ,~ \
:'t>",~ ~ I ~
'.f~\j4~. \
'1': l ~~i\g
.~.... ... .~. \
-~ ,\ ~
~~.'.' .~
~ . ~~.l ~
\ '. .~~~}.G.>;.
,~. ..~ ~ \.
," . '1'-'
~
;:
ffi
(tl
5
z.
z.
c
~
Z.
Q
~
(tl
m
(tl
~
m
Z.
-\
l. '., r
\\
~\
.' Cl
"
~~
\;1... \.
~ \ ~;
,.
;l
'a
:"W-
'"
,.,~
%.
1
'"
~
,.
r
..
!.
;;
.3
!!!
~ \r\ ~
~
pMN
'i
:1
O\SC~~RGE Pl~NNmG
:Xl
Z
'"
Q
z
~
C
:p
0"
C
."z
~~
~S
-,-,
-,0
0"
0'"
0'"
:p'"
-'"
-''''
0"
~~
<
'"
O~
;.
.,,0
~~
p.Yh
..-
cO
ZZ
" >i.
<:<
"..
ro
6;
::n
o
~
(1'
,',' [;
'f4"p. 1< 'f.~ ~
00 005%
-o-\:r>'\)-;I: '_g
3>_:OC ~o tn
-\3>rn_'5:. (fl
Rlzornm \)
~%~~~ ~
_O-1z<:' -
i~~~~ ~
r::i-UG)Z rn
-<O'1J\ii~ ~
-nzO'l"rn ~
Wt:t~~~ ()
rO<J)rn- .:-\
-\~-<--l.{fJ -\
:trnmom 0
~Q)r1\0~ %
:tJJ~~"" -
):>r11_mOJ z..
~Q;"~ :L
:>>..,--0"11 rn
o....t.pJJO
rnJ>()(fl:D '5
o ~ rn ~ g; -.'fJl
'i pc -n (fl' -1!
.-.:p o~ ~
mCO z)> ,--
"!l ~ O:D .-,>
z (f,Q
,. 0'"
z :<
o ,.
f- B
'" '"
~ ~
." :<
o ,.
'!\ '"
o
S
:I:
~
'"
"
."
r
~
f~llS
-g~"'O i
1! 0,:11> 2=,
"'c;l...".. ~
~,~~ ~-<
~cs.~ ~,"O
V.orn "0
....
'"
~.;
~i=
""'~
t\
o
..(
m
o
5
PS~C~ISOC\~l
-<
or-1Lm
, ~~~9
.,~.~ ~ ~ ~
lTI-o{f)O)
:!lrn""'?
rn:OU i'l'
",,-,"";:1m
-oz"8O'
~~"1;lZ
z--\'Ew,
.' 1'\ ~ 0
~rnw
-0"
~ca
0'" ."
-<~m
~o~
~Zz.
-"'co
\;\ '"
o
:Xl
'"
C
."
."
o
~
'2.
'!\
~
Th
~
'"
'"
llEURG
r
<j;;'S'.:3-o (D' pW
,,~_crv,'C-;;l-OQ. Y:"~)>"
~~~~' %-"3'2 ~O -'C:\~
O-'&""<S -00. :::'~ ,.,
~~~~ _-Y' ~ ~~
~ <1> Z ~g
~~'Wll.~.'it t ~ ~ ~
~ ,;2,~ -,~" w~"~",e:!;;rP '.. Z 'i~
~~;.t~\icl~,t~":, Q ~!
,,~-_'c; i_~',l:\~M,,~u~i1::6~-'S> .". ~ ~
",.?: 0%1.,-;2.; ~"~~'~~"::' t/)
;i1';,{,;;,\c>-.'~?'" ..1:;':.','''' (/l \
~ -~'~~~~-~~_~L ..' ~-1'T~~'\:;:~ - m
~ ~.ft:~.~"'" (tl .~
ri"~.'.~"f"f'.L;l.. "'. (~. ~ l!
'~:~,,;,~,,~,,"~i',' -(t::;<':~'(7:: ,- ~
~ "~~~~~~~9~~%~~
~ h~~JE~:9o'5-g~~~c:.
o \>> <::0 ?,*"':JJ-a 'i6 g;. '" 3 ';
9-'3 <1>~ $3"'-%~';Q
~ c
:z:-.
-<
<<..~~~~
'"
'"
c
"
'"
"
:\
.",'Jc","F<>, ~
oooooa
~~~%~
'1)~"'~?
-go~~(Il
.,,:t~o\3
;glP:a%c:
!.%~zi=
rtl fl\ _.,;.I, ~
()O~~,;J
~5"'.,;.I,g
"'%~'Z%.
~ 00
eft z~
!4 eo
i \~
I ~~
'X- ~~
~ :J] 0
~". f~
"'~
~
B
>-:",,\~Y
" ,';~ (:I.::t-\~'#>:-
~cr 'f~\ rl'jc.~
.....o-z.zo f;;Z-:Z~-9.
'" <1>'0 0 '& <1''0'0;2.-
~~qb.; ~~~""~
~a.g<A -~'&- ~
'S.~~ a:~ i
g, ~
.'
'"
"C'l: ,k, ,~t:i'
," \J\\~ir,~~~b'~~u:l'
~. '.g,~'~"~~.s':<<'4
. ~<"'>'Ti\~.o'a'a> '~~
, ~" ~ ~ Th- os;a
." ;a. ~-
S~\M
o
. :;; -< 0
i:\~~" ;;', O"OOm~
~_r./J lfJ' ..(
'.2 g . Ol:L5 0
~~ ,-~~-;gf\ -I"~
~Sl .\6'" 'j( ,,0 i\\'il ~
\''''' z~1ng~o(j) (f)
I{) 0 W. r- (l C)::\ m
J.~ 1'l:Z <" --1:0 ~ Z. ~
to "'O~ '-& Qto me;> \l
_ :p1)'I ;. -'" rn 0 \) ~
"...~"' ~ l> ".. j
c r- OJ fl '{J, 0
I to ~~ ~ ~ ~~ 1
om (j;
:jre, "'"
0:0 ~
8m rn
'" ~
'"
~
o
c
'"
..",--'"'-
F
'"
8
o
."
:Xl
'"
'"
~
:Xl
'"
r
't
~'
:~~l
"0 . --I .
o -~
~ .... /\ :Xl
o . .
:Xl
,/
.\.
(-)
"
(
("
L
'"
r
o
g
."
:Xl
'"
'"
~
i\\
OJ
?g;
"
."
~
-\
~
"
....l~
u", -
t-'tl'il'i.) IAI t
!S The Milton S, Hersh ,1edical Center
., The College of Medicme
':?rr-t""un..../
T l~ i,! t. /
-" -'0 ~ ~
"il,r ... 1:-1
-'J~_lw
0:)3 21880
PER ()G 00 0:)
TRAUMA HISTORY AND PHYSICAL EXAMINATION
IO'/D
L!:,
R.O.S.
t....
DYes 0 No 0 Airbag
o Assault
o Electrical
o Other
Airway: P,,\-r".j.
Field Vitals: P:
Immobilization: (b",
Amnesia?
~
Loss of Consciousness? 0 Yes
.
o Obstructed Intubated: 0 OT 0 NT 0 Trach
Allergies: Nl(o~
Breathing: ~jJ~nh"'A>"~ Breath Sounds: M.ds:
Circulation: P: lto BP: \ \ '" IoD RR: Sat
Oisability: Alert 0 Vocal 0 Painful 0 Unresponsive PMH:
Exposure: COMO!
Procedures: 0 NG-Tube
D Urinary Catheter
PSH:
o A-line: 0 CVP(s):
Chest tube: 0 right 0 lell last Meal:
.
o DPL:
Secondary SUlVey 2nd Ifrtals Temp
HEENT: Head: lYe 1\-"(
Ears: TM's:
Face: Maxilla:
Nose:
Mouth:
Neck: Tenderness:
Last Tetanus:
RR o2SatlUV WI
~~~Z...,..,
Lungs: CI" '?
Back: Tenderness:
Heart: ~rz..
Abdomen: Distention.
Rectal: Tone: ~ Heme:
Pelvis: Stable: -\'
COPYAI
Radial
7.-r(U
Vascular Exam:
Right/Left
Residen S
MR 611 Aev, 3/98
Femoral
7......{Zi'"
Titl8 Date
4Z-z.
Eyes: Pt:::~~lt\
Battle's: t/
Mandible:
Dentitia:
Dentures:
Crepitus:
Crepitus:
Crepitus:
BS:
Tenderness:
(-
I
I
I /'
(~
I
/ I' \
I, :-
A
Trachea ML:
,
/
~l
N
:j.-
Tenderness:
Prostate:
~
LEGEND:
l -laceration \ I
Cfx - closed ~ I
fracture
Olx- open fracture
Ab - abrasion
C - conlusiol'l
TRAUMA HISTORY AND PHYSICAL EXAMINATION
Ori9 . Chart
Copy. Trauma Services
TRAUI'.... HISTORY AND PHYSICAL EXAMINATIl. .
econdary Survey (cont.)
dremity Exam
, \' , ~ \,' I
\\ I \ II/
(01) II!,II
\~(,I \'R,,',',ftJ,'
J"\),!,\~'( !i,!i~
1111,&
L
. 'l
) ,
',' ~
LEGEND:
L -laceration
Clx - closed
fracture
01:.;- open fracture
Ab - abrasion
C - contusion
leurologicalExam '
:ranial Nerves: ; ~h..{
~otor: ''''''I:..
Glasgow Coma ScalelPeds
Eye Opening
1 - None
2 - Open 10 Pain
. Open to CommandNoice
PQfltaneous
al Response
1 - None
2 - Incomprehensible IMoans to Pain
3-1nappropriate/Criesto Pain
- Confused/Consolable
5 - lertI OrientedJ Interacts
otorResponse
1" None
2 - Decerebrate
3- Decorticate
4-Withdraws
localizes Pain
beys
Total: 15
Troponin:
Myoglobin:
CPK:
Amylase:
ICa ,./
;ensory: Pinprick
Proprioception
JTR's ~
tf A tf
T 1.12
c~ ~"t'>cYl
.n
t
L 1-5
O'~IK
,BG: )
_CG:
[-AaYII'
lead:
'0
CT &lalls:: Head:
Abdomen:
Others:
'"
H
Angio;,
T&LS
'robltlriltiSt:
L: LE c,,'"
TRAUMA HISTORY AND PHYSICAL EXAMINATION
Trauma Score
Resp, Rale SSP
0.0 0.0
1 -1-9 1.0-49
2 - >36 2 - 50-69
. 25-35 3 -70-90
- -24 ~>90
GCS
0-3.4
1 - 5-7
2 - 8-10
3 -11-13
. -15
Total:~
U/A:
.
Drug Screen:
ETOH:
BHCG:
~
.
Orl9 - Chart
Copy. Trauma Services
PcNN~TATE
~ The Milton S, Hers!. Medical Center
. The College of Medicine .
\S{~k ~ lo-;d..
6{,2.Q:ro .
PROGRESS REPORT
t~.., _ "'. .
Date!Time PROGRESS NOTES: (Include Name, Tille)
(
,
~
-1-)
MR 6 Rev, 2195
PROGRESS REPORT
PROGRESS REPORT
Date/Time PROGRESS NOTES: (Include Name, Title) .
-=:=z:,
cr
r
(
(
h
~ )11'I Cc.-.'lVS
t1~~ V'1~
6'J'Tt., /VI N
~ rfr-L-
(
J
r ~ ~ .,:: - L - .I,
~rr/ . ~
~ hIM //b Po[ )y{iJ
t(e (/ ~
IN-
~
(
MR 6 Rev. 2/95
PROGRESS REPORT
I 1-1 'II ........., 1r\1 L
~ The Milton S. Hersr 1edical Center
. The College of MedicHle .
',~ r. 'i 1 ~
7 ~l 4 ] - :5 '\,.;: (,
r ~--: .~ " ~. :
-.1'\
C, '7J:
C3IZS/1 ~.
,,~ " ~) ;: ,", ..,
PROGRESS REPORT
~At ~'~-::;A\'( r"i
,~ ! ',_ ~ ,_, ~', ,:;~: [!~ Ii
It 1 ~'
Date/Time PROGRESS NOTES: (Include Name, Title)
z,v') wi,; Ptrcv//L./to
I I'?/::
f'nM-<- f~ c<.- 7~
,~ I
flKdW'" th.:... h.J
7 t1fM /Jb17- ~
(
MR 6 Rev. 2/95
PROGRESS REPORT
PROGRESS REPORT
OGRESS NOTES: (Include Name, Title)
/
~ \
/
(
(
~C~,>liJ-
ftl-. s~ ~€...r
P+ Se"-",
~ c ,,_ ~ 1+
S;::L", >~ '
J;y.,.
1b
~~
r;..",l",
~V\ c-....,J--
-
c... lYv....rc; '"^-j
se.. ,,+, ",...,,,
\,.nl~
/'
f~ .I
MR 6 Rev. 2/95
PROGRESS REPORT
t-'CI..I....)IAlt
~ The Milton S. Hershe "dical Center
. The College of Medicine .
'.:.:i r" ...
,.
7247-3 h.,'
L3/2)/~~.
1 : : ,-' ' ;. ~
~! ) 1
PROGRESS REPORT
l l,
C I .
D. C, \ ; T A t'i Y. i'1.
;: b 1 ) \.,
t .,,', ~'l r E. R \"I
t,:_.
Daterrime
PROGRESS NOTES: (Include Name, Title)
h). i!< S- If Z.
"
"'" /-
I$'- \1.
I
(V,
/><II'> "I
MR 6 Rev. 2/95
PROGRESS REPORT
PROGRESS REPORT
Date/Time PROGRESS NOTES: (Include Name, Title)
c:/..l
(
'-
l
. .
--'--'-
~
.
l.
MR 6 Rev. 2/95
PROGRESS REPORT
I 1-1 ""1 'h...lIr\1 L
!S The Milton S. Hersh( 'edical Center
., The College of Medic".~
b\~~.~l:<' '.: 72A7-} ,~\
:[:tl,"::" '.~',;7E 03/25/1
~, 'j '; J!. ;' 1 ,:; ,l _,
L\: =~ ~f~iITAt-,.Y M
J I I. , C, '., 0 [ ; [R "
f
2 (j 1 ):.
PROGRESS REPORT
DatelTime
slultJ I
. Qu~()
1'106
MR 6 Rev. 2/95
-z.,:-.,'" '
PROGRESS NOTES: (Include Name, Title) .
',!-v,f7/ /)n-r-"""" -12.t.P(A~ D/C,'--rL{}'b: PL j" n/VI //11/1
~ n r1 MA 'r+h -}/ I- 1\ -V.I'VI ( .if) J"f) J n /1 Vl}-/1' I t"!p ~h. ~ n r t?J Jv .
(4., Vl/ AI'\f-/l LiH;/ /J 0', ;: A'7 Jo J n h/ -...LU n J 'ox/)
fJ} ,J"i C ,)-,flI'"rl /\ _ f2r 'had, W')~, n/>, n . ~ 'd/.~ -I-
L1 t /-rYI -c::(1'S/O!' PI. -tAP, <Y )~(Jr()~'~{,( - IJJ-I'.I~S
" /.J _ <V-- ) II ( If) lrf, -t }1/1 fiG , J; P)n V2f71 j-,,1 ~ Ifrn d / fi~ .
'(J!jf... 77..id/IJ2 ~ ~(; )fflj j; ; VtCi /Jd f h JA JJJlII / j))'Ll/l~ /lfh J
1?:j[!.PrJ I1IU+-t...---:<. Il./?I., PJ 110/.4[ fA/JI,,{//J/ l/lL1/P I/JI/J/.f
19-,/c:1!? + l'fjJf /rtJ).:f fJJiillj/l/'/fJlv7,'j.. fiJ/I ' .. /?
..\ l~ ^ r! j /111-./1)1 'p' (J) !fR.J Illp);j r l"0lf~ /)f- --' {/;
- JI U __ 5 PRA/. j/F70U;; 1'Y? ~ ( ~ :17:2::/1 Ii?
1 7 ( 1.j,1 Jr 1)91 j/ tll Vi) - f ~ 'lli> /fl/I (!J../i -If\, /E....'Ji h
'-hi 0/ () '/,\/ j /? ;il q. j7 /),,, 'fl / -h 0 ~1/ j4- /f hl./ - h1
.(,' .; a I ""'-HaJA <4-;:::-. !'d./1J1')/-' /-41,y- 7: Ii 17 hJ {/; 141 J::I (l f/I/J
,,-'nO "ri .~( \()OOflJ-J/n ]/- (Jf--,.... '-:frJ1J1}JfJJ (]f/-,iJJ/
1/1/1 r,-/-- __ r?J A (;,,, If) / JAM) nJ. Lf /J rJ 1('. lM lJ). r
11J/7Jnv; 1M. ,fJ)yJ, fitJ ()f0j'i ./h/) ()J7~ .:.,...,!JV,(I ;-"',{/7
('h, cL I r r . ~ ~ tlVl6 hi rJ An -r-r',.-,L . j)/i /)1_1,., 'Yl X1i//l<-l d _
,;::- -' .4J /VY1 , L / lrI.! /7 /) IV JJ
U..... ...JJ -;- ^.J / 11." -b.. ~ ;J A J1J ,~- -,,~ 'I Uk s-;-,s, ~
. J.~ fL.! ~ ,iJ. ho.. J././l. '"/1<.:.-. nG. J2'J/J, ../)
.mlJ I':l ..'. ::n: 'J!-(ut1)j'. Vv '0,,'.0 -! --r;,~.~:< Q- i>/~
L.JJ, ".f), n. NOli ~~/n/bJ....,7L" J;n2-/?/r-/.((J"
--"fb r v /
,~..:-
PROGRESS REPORT
PENNSrATE
~ The Milton S. Hershey Medical Center
. The College of Medicine
Health information Services
HU24
P.O. Box 850
Her~hey. PA 17033-0850
OPERATIVE REPORT
PATIENT NAME: LAIRD, BRITTANY M
PATIENT NUMBER: 0362978/113277~ATE OF BIRTH: 03/25/1990
LOCATION: 7247 DATE OF SERVICE: 03/03/2001
SEX: F
SURGEON(S): David M, Wallach, M,D,
ASSISTANT(S) :
PREOPERATIVE DIAGNOSIS:
Left open grade III-A ankle fracture,
POSTOPERATIVE DIAGNOSIS:
Left open grade III-A ankle fracture.
OPERATION PERFORMED:
1, Left ankle irrigation and debridement,
2. Open reduction and internal fixation
with 3.5 mm cannulated screws,
ANESTHESIA:
General,
ESTIMATED BLOOD LOSS:
25 cc.
INDICATIONS: Brittany is a 10+-11-year-old female who
had earlier sustained a grade III-A open left tibia, This was as a
result of a pedestrian versus automobile accident, The patient was
brought to our hospital where she was placed on intravenous
antibiotics and was taken to the OR, The indications for surgery are
to not operate would place the child at risk for infection and growth
arrest, The risks of this injury are partial or complete growth
arrest, compartment syndrome, neurovascular injury, ankle stiffness~
ankle arthrosis, reflex sympathetic dystrophy, scar formation and
need for subsequent surgery. The risks for operation itself are that
of placement hardware that may need to be removed in the future,
anesthetic ri~k, and risk of infection, They understood the various
issues, and the family consented for surgery,
OPERATION: The patient was brought ~o~the operating
room where she was transferred from gurney to operating table, After
induction of general anesthetic, the patient was piaced supine on the
operating table, The proximal thigh cuff was applied over Webril to
the left upper thigh, The tourniquet was never raised during the
procedure, It was placed there as a precaution, The left leg was
then prepped and draped in the usual sterile fashion, Debridement
was carried out for devitalized subcutaneous fat and tissue. The
wound was then copiously irrigated with saline using a pulsatile
lavage.
MAR 3 0 2001
Page 1 of 2
,\n Equal Opportunity Unilersily
PATIENT NAME: LAIRD, BRITTANY M
PATIENT NUMBER: 0362978/1132779
The fracture site 'was well visualized and irrigated, With the
patient under muscle relaxation, a gentle reduction was performed,
Direct visualization of the fracture was obtained easily since the
fracture site was visualized in the initial skin wound. An AP
lateral x-rays were obtained demonstrating an anatomic reduction of
the distal physis, Two guidewires were then placed from anterior to
posterior parallel to the physis to engage the posterior fracture
site, These were then depth gauged. The medial screw was 38 mm long
and the lateral screw was 36 mm long, First one screw was
overdrilled and a partially threaded Synthes 3,5 mm screw was used to
lag to the posterior fragment, The second screw was then drilled and
a 3,5 mm x 36 mm long screw was selected and were used to lag the
fracture site, AP lateral x-rays were obtained as well as stress
views'of the ankle joint, Although there was a fracture at the
fibula, the fibular station was anatomic, There was also no increase
in ankle instability with internal external rotation of the ankle,
Therefore, we felt that fixing the fibula would lead to an increased
morbidity, The wound which was irrigated once again was then closed
with interrupted 3-0 nylon, A 1/8 inch drain was left in the deep
tissues and sutured to the skin with a single interrupted nylon,
Our plan was to take her back in two days for repeat irrigation and
debridement and final closure, Final x-rays were obtained and were
deemed satisfactory, Sterile dressing was applied followed by a
three-sided splint, Patient was then aroused and transferred from
operating table to gurney, from gurney to recovery room,
DICTATING MD:
David M, Wallach, M,D,
Assistant professob~
DMW/pas
D: 03/03/2001
T: 03/05/2001 10:53 R: 03/16/2001
c: PCR
Word Proc~ssing Clerk
Ortho Professional Fees
Gregory Farino, M,D,
Amir H, Fayazi, M.D,
Page 2 of 2
PENN SlATE
. I!5:l The Milton S. Hershey' Medical Center
. The College of Medlcme
HllJ.4
p.o. Bo.\ 850
Hershey, FA \ 703~-{)850
Health Inform~,tio[} Stl'vi.Ci.'S
OPERATIVE REPORT
PATIENT NAME: LAIRD, BRITTANY M
PATIENT NUMBER: 1132779 DATE OF
LOCATLON: 7247 DATE OF
SEX: F
SURGEON(S): David M, Wallach, M,D,
ASSISTANT(S): Ronald R, Hugate, M.D,
BIRTH: 03/25/1990
SERVICE: 03/(;'3'/2001
0":1
PREOPERATIVE DIAGNOSIS:
Left grade 3A open ankle fracture,
POSTOPERATIVE DIAGNOSIS:
Left grade 3A open ankle fracture,
OPERATION PERFORMED:
Second-look irrigation and debridement of
open fracture,
ANESTHESIA:
General,
ESTIMATED BLOOD LOSS:
25 cc,
INDICATIONS: Brittany is an ll-year-old female who
sustained a left grade 3A open plantar flexion Salter-Harris II ankle
fracture on Saturday, 3/3/2001. She was taken to the OR in less than
6 hours where she underwent irrigation, debridement and an open
reduction with anterior lag screws, This procedure was then planned
second stage look and irrigation, The risks of this injury include
ankle stiffness, arthritis, growth arrest, partial or complete, scar
formation, bleeding and neurovascular injury. Having understood the
various issues, the family consented to surgical treatment of this,
injury.
OPERATION: The patient was brought to the operating
room where she was transferred from the gurney to the operating
table. After'the introduction of a general anesthetic, the patient
was placed supine on the operating table, Once she had been
anesthetized, her splint was removed and a proximal thigh cuff was
applied. The tourniquet was never raised. The le~was then prepped
and draped in the usual sterile fashion. The sutu,es ~ere .removed
without incident, The proximal and distal flaps were inspected and
found to have viable ends, The muscle was pink and demonstrated
contractibility. The wound was then copiously irrigated with 6
liters of saline using a pulsatile lavage. Once irrigation was
completed, the wound was reapproximated with interrupted 3-0 nylons,
A sterile compressive dressing was applied followed by a three-sided
Page 1 of 2
') ii' '1001
~.J \:" j l) L ,:
.-\n EqtlJ.l OpPortunity University
PATIENT NAME: LAIRD, BRITTANY M
PATIENT NUMBER: 1132779
splint. T-he patieht w'as aroused and transferred from the operating
table to the gurney and from the gurney to the recovery room,
DICTATING MD:
David M, Wallach, M,D.
Assistant Professor
u4
DMW/smc
D:
03/05/2001
T: 03/05/2001 11:47 R: 03/16/2001
c: PCR
Word Processing Clerk
Ortho Professional Fees
Page 2 of 2
PEr'-JNSTATE
~ The Milton S. Hershey Medical Center
., The College of Medicine
Health Information Services
HU24
po. Box 850
Hershey, PA 17033-0850
DISCHARGE SUMMARY
PATIENT NAME: LAIRD, BRITTNEY
PATIENT NUMBER: 1132779
LOCATION:
SEX: F
DATE ADMITTED: 03/03/01
DATE DISCHARGED: 03/06/01
ADMISSION DIAGNOSIS:
Salter-Harris II, grade III-A open distal tibia fracture of the left lower extremity.
OPERATIONS OR PROCEDURES
1. Open reduction internal fixation of the above fracture with irrigation and debridement on 03/03/01.
2. Irrigation and debridement and closure of the above-stated injury on 03/05/01.
BRIEF HOSPITAL COURSE: This is a 10-year-old female who was struck by a motor vehicle from
behind. She was admitted as a trauma in the Trauma Bay. The A TLS protocol revealed that she had an
isolated grade llI-A opcn Salter-Harris II fracture of the left distal tibia. She was taken to the OR on the
night of injury for a washout, open reduction internal fixation, and loose closure. She tolerated this well
and was taken back to the seventh floor postoperatively. She remained afebrile with vital signs stable. She
was on antibiotics. She did well with physical therapy She was taken back to the OR on 03/05/0 I for a
second look and washout The wound was clean at this time and it was closed once again. She was placed
on a splint She was discharged on 03/06/0 I with follow-up.
DISCHARGE MEDICATIONS:
1. Tylenol No.3 tablets one to two p.o. qA-6h. p.r.n. pam.
2. Resume any previous home medications.
DISCHARGE INSTRUCTIONS:
I. Call 531-4800 if there is any questions or concerns.
2. Flatfoot and non-weightbearing to the left lower extremity.
3. Keep the dressing clean, dry and intact until seen by Orthopaedics.
4. Regular diet
.
MAR 1 5 20m
Page 1 of 2
.-\n EqU~1r Oppoflunity University
PATIENT NAME: LAIRD, BRITTNEY
PATIENT NUMBER: 1132779
'.'.
FOLLOW-UP APPOINTMENT: Follow-up appointment is with Dr. David Wallach in 10 days.
DICTATING MD
Ronald R Hugate, MD.
ATTENDING MD:
David M. Wallach, M.D.
Assistant Professor
Department of Orthopaedics and Rehabilitation
RHInes D: 03/06/0 I T: 03/08/0 I
elm 3/8
c WP Clerk - 368351
TRAUMA REGISTRY
*** Dictated but NOT Read ***
-;..- ~-'"
Page 2 of 2
.
-
.
-
.
J L! ~j 'h..J IT\1 L
!5l The Milton S. Hers'
., The College of Meu.
Medical Center
,Je
, '
, ,
72r~7-J
"
,.
, .
~: :;
CJ/;:jji
." :., ( ; ~
PLAN OF CARE
DRG I
EST.
L S
'f,
ACTU.(\L'I' .
LOS j I , ,.
RESIDENT
. r- i ; r ,:. h '{ ;'1
~ Lf ,-.; "
PREFERREONAME: ~ (~~rit'1Jq _ 3
AGE AD~.DATE~' ROOM# _/~::::r
ATTENDING
Initials
PRIMARY NURSE
ATTENDING NURSE
NURSE CONSULTS
NURSl:;CONSULTS
DIAGNOSIS
1.
SOCIAL SERVICE
2
a
DATE
4.
ADVANCED DIRECTIVE YES D
COOE BLUE STATUS _p,11
DITION ~Q
NO C7J
INVASIVE PROCEDURES
ALLERGIES
/JfillA-
Problem Us!
3
4;~,
"",,,,~}.w- ,:;~:;:;;F'kL<:;)","
'"'~" ~
':j;;.cf'I:l/.: ".
;; ~,It,v"tJ:. ..' ~'ti*';::'.
~dJf-li;'~ .
5
6
7
~--
,
DISCHARGE PLAN:
Plan of Care Reviewed with
PatienVSignificant Other: .
~~ -4Pi Sign~.e
~ ~~ )
~
o
Home
Home with Assistance
Other: Explain
o Nursing Home
o Unable to determine on admission
MR 601 REV 3/94
PLAN OF CARE
.
CB =0 Slip on Clipbo d not \0 be drawn by La~
'otifled, Pending", Nolified, Not Scheduled, AQ '" Labs Need 10 be Rec
SCH= Schedurd,_ ,S =Sent,
Date: f2 l.'j:-oay:
D,
Datelday Datei A ':z;;: Day: n
...
W
C
>
l-
S;
;:
U
~ <(
>
-
.
-
..
RN
~RVEN-
~NS
Date: Day:
';'z
- ~ --- -- - ----- -_.~-
!2i..
o ~----_.._._---
zw
i:~
0"
"",
~u
-- -----__.__________.nn __~
----~----f--.--
:jffi :~<{,j~1!J211()7Ly"V'L..lfl ')jWJj T'2//Y ~ __+_________.______
<i ~ ,,*(12 .::..a'-fCC~-K"-r./)IJ'-: > I .. _________ ____n_ _u__u_ _ ..
ITALS ~" ,
Neura) ILV 7~NV
" :7
WTS
I/O
~
~......,-.
1/
~__r.^
['r v '1[./_____________
___MAd ___ _
I/it,
-,4,
.'ur-F
c
!nfll
-- -- flW.
--- --0
, ,,....
~~u
.;' n;,--i/Y J" ') Un ^
7:i -- '';:;;;10
nlTno
. ,nll,^..n~~J'n-tri~-ct .. ..
-- ,/
.J...nA J 'V 1I V
I
1//fITrODa.fZ'
CJl
Z
o
;:
z
w
>
II:
W
I-
;!:
.\'" C'I/_ rt' '11I0U
-:- ----i.. (i;Ji: ~ U
~~ l~fJiPli~n-Fj;;)( ~~(1rJ. >
~.fJiiiJ-- ----.~.~=-----~----- .~~------ un
--~~f!_?)~;;--~' --~~---~ ~==_~__ --==--=-=---=-~--- __ef l
-V-- 0 . _un __ n ___ __ _ LA
_U
fDl
. ,--
___ .u ..__.. ____.____ _.__._._
--- ~
-------e----. .-~--.--. _.
------- --.
--- -. .-----
-----------~ .____.__._.. __.__n_____
.-. -----.-.-.----. ------ .- -- .-~-_____.__ .T4.<.
-- --~
____ _..n________n_
)J --
..-------..----.-- --
.--__1--_.__.___._______.__.
CON.
SULTS
7'fF:?. I f-1 -r - Ad 11 I
T' _r TT
...u~_____ ..
-- .--.-----1--.---.--
-.JI. I~ ~_
- .-
fl
~ L--____..._ .________~..__. __ _~._
5
------- .---__ ______._ ______._ '__'n
-----. e-- .____.._.nn__. _.__
Inilials
--- ---
lnilial,
R\J ~
R\J }L
R\J ::rl
Inilials
Ii N
j
. 0
8
u
~ E
R\J
lAM t'M'O" I.. 11,,) ~ v
IJA; IA ..,~\(\r^'Ul.,
----
,,1--/
1p-11 ('
S6/C ^"~ OC LS ~ ~W
",,(~31) a~O:>3~ NOI1'V:>na3 A~'VNl1dl:>Sla~31N
~ rt GJ"- "rrr /if ~_
IJY .,. r Y1V/, /1 1jI'
f1JnleUo!S 111U aJnleu I lemul
;J'D I '(p /" '/ U
~ ~ li'l ;--"'-J '-'-
7/" )(11 v (fI /I -; (I
". '/ 7 r IR' \
I I I
, ~ (II /I ') <t
t- '/f'"IJ IV
'/
~ ~ '/1/
iI
~ c ~
o n'g. c
en ;::;: _ co
~ ':T (J) ;t
!: !. cg 'V
o$3i~
ll) n iii'
'< III a
;a
l :->'
. {
~UOII~
Ma!^<Jl;j '" ~ = W~a
',ualadUJO:J 'U01SSf'1;)SIQ '" a
=:> 'uaIWM=M
'oap!J\ '" ^
:A3)4
NOI! 'A3~
-yn'''^3 AD3.l~l.S
'i: h. \AlP
c
l:;
m
z
::;
;;;
r
__ .I a5en6uel c:J
3NON rJj' sno!611a~:V1eJn1ln~ CJ
,
':: ~:l (
'" 'j 3 '
H J. r,~ 'tJ 1
I/\u,n
(-Un
::; '-,.
'-l ',,1
'"' 1; ).'
8JnleuOIC:: emu
. I /
7t1 3. ?:'1D->v' ~ or' "'~-;j-rr'/I
v.yrf'r'hS1"~ ~r1
'?11f ;;:p~~:;v;;:~'~
~J- ~~ Q. ~~
:luawd!nb310 asn 9^!l:Ja.>>a yalE'S eq!J:Jsea
~ (fWVIfltJ
)'. 'v 0 w.J[) ",v . "VV1I ()
:suo!Je:J!paw".o asn 8^'l:J8Ua y 81!!S ssn:JslO
.
\,
:.uessaoau l! salepdn luawssassv
SUO!lel!W!1 a^!1!u6o:) D
1~!S^4d D
leUO!Je^!)Or-J CJ (6u!4:JeaJ J:Jedw! };ew JellJ seaJe U!E'ldx3)
leuD!10w3 D :UJea1 OJ ~!I!qV s.Jua!Jed 10 ~u8wssassv lemul
'uo!pas 4:Jea U! lua!lea 01 uaAID s1nOpuB4 'SlalowB4o Isn
"aJeJ JO U81d uo paumno BU!4:Je~ :Jypads 01 J9JaJ O} pasn aq AeVl! 'leUo!ldo SI ABa leudsoH
'BUlU:Je8t )UallBd ale:Jjll(l~WOJ Due 8zuewwns 01 saUl dlJSI e A as" 8 ASV'.!
(~31) O~O:>3~ NOIl,,:>n03 A~'VNl1dl:>SIO~31NI
'. 1 .,
, ;- 1
~U1~!P:>W JO ~jj~IlO:::> ~l/.L ..
J~lU~:::> re~!p~W A~qSJ~H '$ UOll!W ~l/.L e;;
3Wl.SNN3d
.
.
.
a
11
6
PENNSTATE
9 The Mitton S. Hershey Medical Center
., The College of Medicme .
Weight
Admission kg
Yesterday kg
Today kg
Scale 0 Bed 0 Standing
o Chair 0 Infant_
Height
f~~l'lU2779
TPAL"H362978
C:Si('''',C
! ,\ : ,;:'~, i: (,_ : l' 11. t... V I,.t
I ::.., ^;' : . "'" -. ~ t i~' \>0
111-1111f
7247-3 if:
03/2 SI",
Date .1 ~ Cl ~ ;l(j) / ~~~.op Day
171 I/'';j~r I I
Time
40.5-
40 -
~9.5 - 160
~ 39
.3 38.5-
ctl
li> 38 - 130
0. 5 - ""
E 37. ';120 V
CIl 37 - -"110
I- ~
36.5 - 1l.100 1<" ,
36 - 90 .
35.5 - 80
oral =noabbrevialion
R=reclal 7
A=axillary
T= tympanic
150
140
,,'"
. )
)(
't(
j.
80
conned. and X 10
foongraphs
~
40
i
I
"} f- ,
T
I
Respirations y'-'"LJ<{ to VI
BloodPressure~ &m \~/ /1/ I /VV IV,I /V/ II I / / /;
O,Sat
o Rx
Pain ,..
PalriCtrl AcCeplY/N'. ....
Glucometer
.' 2 .
, " 'I .
,~
TIME
Strong
::t Fair
C1
::J Weak
0
U None
Suctioned
iz Lar e
Moderate
::J Small
~
>> <( Scant
Q. None
.. Frothv
..
~ a: Tenacious
:: 0 Thick
~ -'
0 Thin
0 U
- Walerv
..
.. Pre.Pulsel
a
.. Post-Pulse
81 Peak Flow
Before/After
VC or lCJNIF
IPPB
PressureNolum
CPT
Respirations
Initials
." ..' ..: ;..,.. I.:'.'.. .'" ',., . .-:-
_' - , -:.. I....,.,' ,',' . '-..
..,--
////////////
/////////;/i/:/
//,////'//////
////////////
ICOLOR CODE; A-Amber BL:::Black BK:::Brown C:=Clear {j:::(jreen p=p,nk R=Red T=lan W=Whlte Y-Yelfowl
MR-.!l151JQQ 5of6 Nursino Flow Sheet
INSTRUCTIONS'lnilial assessmentcate
I'VULlUC' r cl&..t;#11L I"\::s:s~ssrn,r' '11
; which apply Obtain Comprehensive Assessment fc len neCess8l)1.
~n>" a 5 . r. "-venrnns I
Time :V ".0" ~'-fV<I rH'J
Oriented /)AJiy Oriented J1r1\. r.1 Oriented Y... 'lI- -.
u (Peds age appropriate) (Peds age appropriate) (Peds age appropnate)
'c, Disoriented .... Disoriented Disoriented ,.
. 0
0 Inapprop. words/sounds ., Inapprop. words/sounds Inapprop. words/sounds
~ Deficits/Baseline for Pt. De:ficits/Baseline for Pt. Deficits/Baseline for Pt.
:J
C1l Fontanel (Peds) - _ '. fontanel (peds) Fontanel (Peds)
Z Not Assessed . Npt Assessed . Not Assessed .'
Normal Control Full Slrengt~ ' Normal Control Full Strength ,...lA, .\.,J Normal Control Full Strength - r; t-II- .
Weak I 1.-':' IF Weak I-~K .L..t' Weak w..~ . 'Iar- n. .
0- DeficiUBaseline for Pt. DeficiUBaseline for Pt. " DeficiVBaseHne for Pt. . , ... .
_ co
:J- /' I........ "j:,; ',.
u~ - '.
'" C1l <; '. ..
:J-'" .
:0;'" . .. ". '. ,'>i,'
No{ Assessed Not Assessed .. ... Not Assessed
-
lJllOfm~~t LTlwalTIl / I SkjnCOIO~ ?" Normal Skin color~ -JI.4. 1\51
~f. Pale,C I. ~ AI ;'11: P~~l AL J.... PaiS) Cool 1/,11.',
m Base\lne1orPt. n~ citJ8aseline for Pt. 'beffcitJBaseline for Pt. ...
:J "".. ,.".. ;'. ... .', ,.~..:
u
III ti .. ....."
co .!,;<
> /....... ..." ,..,.,
Not Assessed Not Assessed .... Not Assessed
Regular II Regular \ilIV' .MI .,t Regular
Irregular Irregular ,.:': ::, Irregular ,
. u Murmur .. " Murmur :,. ' ! Munnur .. .:, <.
,!!! Pacemaker . Pacemaker ,.. .. -''.'',-'' Pacemaker .. :,
"
~ Monitored Rhythm ':... Monitored Rhythm . ". 'C,;.' ...'....... Monitored Rhythm ,'"
co .'..,.., '.iX..,1
u .. ..:;..
Not Assessed . Not Assessed " ;.';'.' Nol Assessed :.
Regular :: Regular Il(VV <I"Il' .. Regular '..L
l: Irregular : Irregular . ;.<'" Irregular "! :' ..
~
C1l DOE "f '.,' DOE . ,... ,.... DOE , . """"', ".
-
~iV SOB ... ',' SOB . ". .... -;': SOB , < ...,i:; ,+
. o a. . Ii ;, .......}V3 .,' '''' >+
-
i:'! I".,' i.,' .,.
'0. Not Assessed Not Assessed '." ". Not Assessed
'" Clear 11/ IT~ Clear ..., Clear
C1l
a: Crackles Crackles . Crackles ;;
III Rhonchi Rhonchi Rhonchi
" Wheeze .. Wheeze Wheeze ..,
l:
:J Decreased .... DecreaSed Decreased
0
<Il Absent Absent I Absent
Not Assessed .. Not Assessed '.. Not Assessed . :'."
on Active .lC Active Active .. r.....~'~ .~
a ." Hypoactive Hypoactive Hypoactive ',' 7,'" ..
"
" Hyperactive Hyperactive Hyperactive
0 Absent Absent Absent
<fl
a; ..,
~ . >
0 Not Assessed '. Not Assessed Not Assessed ..... .
ID -
<; Non-distended ~ Non-distended :J<JN' "",I Non-distended
Non-tender on Non-tender ,'JL Non-tender y,; n,
" Distended ..,-
" Distended Distended
E Tender Tender Tender
0
." ~ .
.a .,.-
<(
Not Assessed '""' . Nn' A<s';'''''d
No Dysuria No Dysuria vi, No Dysuria .~ 1M
"
~ Dysuria Dysuria Dysuria , ..'
E
'iii Foley Patent Foley Patent Foley Patent , .
ll. Straight Cath . . Straight Cath , Straight Cath
~ ~o, :. ,^ , ~ot.
Cl ~ Clear Clear Clear
"
ti Cloudy Cloudy Cloudy .
. .. Bloody Bloody Bloody
~
.. .
.,
U Not Assessed Not ~,isessed , Not Assessed
o -d' Q~ity Contact m ~ Ily Contact Mm,. ~( Family Contact \/ vi
-fi co ~es No ~es No Yes - No
>.'u Ac ve In Care A (ve In Care ~~f Active In Care (/'-J
~ ~ es No Yes No Yes No
6 Initials ..,::::::U::_ Initials ' !lr _ Initials ~...\\.L_
ISB - Incentive Spirome DB - Deep Breathe NG - Naso Gastric
0 8 0 0 0 0 0 0 8 8 0 8 0 8 8 0 g 0 0 0 g 0 8 ~
Routine Treatments 0 0 o. 0 0 0 0 0 0 0 0 0 0 0
"- OJ '" '" ~ ~ ;! ~ ~ ~ ~ 5" 0 N .. 0 N <\ '"
0 0 0 N N N N N 0 0 0
AM/PM Care JI;l / r ,^ -
Shave T 1
Shampoo
- ~ 1~ , lA', I l~ I, ~-
Oral Care
Skin Care Y'\....- T
,
Peri/Foley Care V ./ " ) ) j ./ J /~
Anti-Emboli Stockings/SCD On/Off
Suction -
T rach C~re
Chest Physiotherapy
ISB/Cough DB 14, /. /l1,- I. ,J, lAA\ J>rl .JW
Turn (Indicate R-B-L) h 1\A, A.r I\:., " ,/
CT - 20 cm H 0 suction
CT H.,o seal .
NG Placement
NG Irrigation
IV Site/ An .J. U1J % Ji\ ,J>'i J.\( Tot YL 11.... II
Dressings
ROM I r'
Chair/Dangle , f7 1~1-/ I
Ambulate ll\'\' ,'\ :11'" L '~I\. ro~
Leg/Arm Splints On/Off I ~ J'
--: ,I .'
. I; I ,~'
,
d: fil .);~ !'ficf ift 1.....'1.'
I, I ;~
I,:'
..I',
',id,
n"", k
1:0!,V' ~~xl ~tr:';' ,
Days
Iyfy W/Lfr UI) L -to L!A;;- .
q)11/IV M'.h~J-r ~
W/~([)AL-'
d, n do MA,(J M'tf2J ([)}.4'n
;~'" 1h /)':: /1:;;/(11111 -ffl<f
EV~ I ) FrJ7;>'fl Jj .?PW'1'7 (.
. i,''',.--/,?-~^ ~^ II^^.^ t/
~ c., M1RJ'C. IPA01VJejAJ/ Irlf!/'r-J}
I, I"
I.. ',!
i
~
','"
Restraints On/Off ' .; c- C
0 Safety .' , . ,
w
'" MD Order .' I. '", .
:J
0 Chemical . ,
w
'" Side rails t X 2 iX4 V
Circ./q2hrs r
Falls Precautions Initiated ;., '. . "
Food (F) Fluids (FL) Toilellng (T) . , ,....
I ..' ,- ,I
I,;;; .,
. . - '
,I,; I", ;,.sl;
.:,;1 '
"
<"
.
RISK SCORE TUES/FRI
Falls Risk
Score
R L
L R
VI
C
'0
c..
e
'"
VI
VI
"
~
c..
'"
c:
o
:Q
"
c:
~I~
) l
Integument
1.lntact
2-Reddened
3-Breakdown
4-Ecchymotic
~
to
c:
"
E
'"
'"
"
c:
.
\ I
~ W
\
(~
'7
.
, ,
rjp
Edema
+1
+2
+3
+4
'"
Tuesday
Friday
Risk Score
Nights
~G~~
2J~
,)' II
'-J
IF <10 Consult
E.T.R,N.
Consult Sched
ANTERIOR
POSTERIOR
2 of 6
.
.
.
PENNSTATE 3-'$'-0 '\
~ The Milton S. Hers~ey Medical Center
... The College of Medlcme .
Time
40.~-
40
39.5 - 160
~39 - 150
.a 38.5 - 140
ell
Iii 38 - 130
C. 5-- f
E 37. ~120 '"
~ 37 ~110 r-
36.5 - a. 100
36 90
35.5 - 80
oral = no abbreviation
R;rectal 70 _A.../'"
A:llXlllary -,.:--
T ::: Iympanic 60
l' It' 8 J'6 ~D 120 11\
I/. .I1~1 ~~~U~I!t~ IV / IV /I/V I/l; II /
O,Sal v v 1'-
0, Rx
Pa.in'~ fJh,'lf7'': ,(I'D':,,': Ii' '};:,,\" ~
f>eIr1Ciil~piYIN;'(,(;I",)'I" ~
Glucomeler
Date
.3 -S:Q/
BSA
Post-Op Day
Weight
Admission kg
Yesterday kg
Today kg
Scale 0 Bed D Standing
DChair D Infant_
Height
~'13277?
, '.:.A#.J6297t
,'j 1~ 1 g :, :.
''''-'
"""-) 7:
0312:/1
coonect'sndXlo
formgrapns
Respirations
Blood Pressure
f ! A ~<I Y ~:
(; .
n:~: ~,
~~' f
r
01)1~Of\O~h4t;'1l/(JOllr[:5j'iWlr1-' .
I
I 1 I I I I I I
c-
.
./
..
, ~
./
......".,
~
'"
40
'p Q.b
fI
"
l\~
~ I,":,:,
I
"",~~"",,"-i
31t~ ;
TIME
Strong
r Fair
Cl
, ::J Weak
0 None
u
Suctioned
tz Lar e
Moderate
::J Small
0
;:;: n
>. <(
c. None
.. Froth
~
..
0: Tenacious
0 Thick - -
~ -'
0 Thin
0 u
- Wate
..
- Pre-Pulse!
5.
.. Post-Pulse
..
Peak Flow
Before/After
.:
f6
VC or IC!NIF
IPPB
PressureNolum
':'
CPT
Respirations
Initials
/j
BH=l:3rown C=CJear G=Green P=Pmk R=K.ed
Nursing Flow Sheet
Y=Ye\\owl
ICOlOR CODE: A=Amber BL=BJacK
MR-815 2/00 5 of 6
! =1 an W=Whlte
INSTRUCTIONS' Initial assessment cate,
avs
Routine Patient Assessrr
5 which apply. Obtain Comprehensive Assessment fL
,t
Nhen necessary.
.
.
.
a
.
c:
~
'"
-
1:'16
o c..
-
e
'0.
III
'"
0::
;;
~
o
lD
i5
::l
C) :;;
U
'"
-
'"
.c:
U
ijU
" '-
"'''
III 0
c..cn
6
16:m74:
,,^ lIvl ~ Oriented
(Peds age appropnate)
.< '
Fvenmns '
n ". WI'}.
'", .{).. ...,
-
-
I Skin colQr1warm )
~~ ~
'. " c1VBaseline fDr Pt.
; .-,:
. ~.".:. .;;
0':,;" Not Assessed
Time
,!,!
Cl
o
o
~
::;)
'"
Z
Oriented
{Peds age appropriate}
Disoriented'
Inapprop. words/sounds ,',
Deficits/Baseline for Pt.: . ~
Fontanel (Peds) . - ,....
Not Assessed _ ",' ',.y> '.:-'
Normal Control Full Strengtlle..~ ~ ~ - f\',' -
Weak ~ :'"
(r)9~I~ ~ ~
,
0-
- '"
::;)-
" '"
III '"
::;)~
:;: III
.
Not Assessed
~
.!l!
::;)
"
III
'"
>
~~al Skin color/,wamj
t3J.e1. Cool '-""'"
DeficiUBaseline for Pt.
" i'\
Not Assessed
Regular
Irregular
Murmur
Pacemaker
Monitored Rhythm
.
" '.
;cy,:"
.: ,':.' :.,
~~~
.' .~ L "-
-=- ,'i,'," ',.,I"
< :,'~ j~:,
~ n~
"
'"
:0
~
'"
t)
Not Assessed
Regular
Irregular
DOE
SOB
Not Assessed
Clear
Crackles
U) Rhonchi
-g Wheeze
:;, Decreased
t8 Absent
Not Assessed
---:'K
-";'-
. '.
U) Active
-g Hypoactive
~ Hyperactive
~ Absent
Not Assessed
Non-distended
Non.tender
; Distended
E Tender
o
."
D
<I;
-
Not Assessed
~ No Dysuria
~ Dysuria
~
1; Foley Patent
c.. Straight Catn
.
.
Clear
Cloudy
Bloody
Disoriented
tnapprop. words/sounds
De(iciJslBa~eline for Pt.
9ntanel (Peds)
Not Assessed
Normal Cont~o\!)ill Strength
Weak - l-W
DeficitJBaseline for Pt.
>';C..
Not Assessed
Regular
; Irregular
Munnur
Pacemaker
Monitored Rhythm
Not Assessed
Regular
Irregular
DOE
SOB
Not Assessed
Clear
Crackles
Rhonchi
',"" Wheeze
Decreased
<:.'-,<.; Absent
,,{-' Not Assessed
~'-'
Active
Hypoactive
Hyperactive
Absent
IV
~
Not Assessed
Non-{jistended
Non-tender
Distended
Tender
. I"".
Na Dysuria
Dysuria
Faley Patent
, h Straight Cath
Clear
Cloudy
. Bloody
b . t') ~ Not Assessed
.., f'v,. ~..'- ",.. Family Contacl
~11J1 1'"' _ Yes No
\j\(\ N i>\J'I t?'l Active In Care
Yes No
~ .JQ,,' ~ Initials
Nat Assessed
Family Contact
_ Yes No
Active In Care
Yes No
lnitials
Oriented
(Peds age appropriate)
Disoriented
Inapprop. words/sounds
Deficits/Baseline far Pt.
. Fontanel (Peds)
Nol Assessed
-1f;:. ((t" NonnaIControIFullStrengt__
1a: ~t- ~., Weak -rb\ 1:7 .
~ DeflCitJBa~ine'lOrP\. ~
';'J': -::,-
I, 'ic;:
" ..... "1'" Not Assessed :.
a -::'- ml Skincolo~ IMf4. ~-
ale 001 \1.tdk ~
;0.' De lciVBaseline for PI. U
-;: I",
.~: .~ ,
. .." Not Assessed '
~ ';-{:;:f. Regular (
, " ..'.' ...."..' Irregular Ii' /I \
'". '\y-; Munnur
_ Pacemaker
:/ MOnitored Rhythm
E Not Assessed
=]71!:; ~., Regular
"T; "'T;~ Irregula,
..d DOE
-: '. SOB
"
Ii; "1\/
:.:..:.~ ~ ~Not Assessed
~~::.::::. Clear
- d, - Crackles
Rhonchi
Wheez.e
Decreased
"<,, ;'::-, Absent
Not Assessed
'..
. .
rL fj; -:-
,
.
. I. "
I." ..'
Active
Hypoactive
Hyperactive
Absent
Not Assessed
Ill.;
;;
..
lL
',' Non-dislended
Non-lender
Distended
Tender
.,.. -
Nnt A<<p~spn .
No Dysuria
Dysuria
Foley Patent
ii' Straight Cath
" "'nr,
Clear
Cloudy
Bloody
~
",
....
. 'IV l1<- '
'I. \J .
, I--{
Not Assessed
.Family Contact
Yes _ Na
Active In Care
Yes No
Initials
tlAIf
~
Nj[]hts
(\11.1,,~
u VI
'.,.
:,i
.::;
~
.'
y.
......
........
":Ii ~
.
. .
'.:
(1111
.U'
IIJII'. ..
In
.
~
v
. :..
....
~~I-
\! \.
\ \
LL~I.1l::),_
~
'~,
:5 0 :5 is 0 0 0 0 0 0 0 0 0 0 :5 0 8 0 :5 :5 0 8 ~
Routine Treatments 0 >! 0 0 0 0 0 0 0 0 0 0 0 0 ~
... co a> >! ~ '" ;": '" ~ ... ~ a> 0 N '" ~ ;:; 1'j 8 ;'!;
0 0 0 ~ ~ ~ N N N N N
AM/PM Care
Shave
Shampoo .
Oral Care . .
Skin Care
Peri/Foley Care 1<- fUJw 1\ III U
Anti-Emboli Stockings/SeD On/Off II "
Suction
Trach Care
Chest Physiotherapy
ISB/Cough DB
Turn (Indicate R-B-L) \P 'u
CT - 20 em H 0 suction v
CT H20 seal ,
NG Placement
NG Irrigation
IV Site./ II'n Ih'l Ie':! W }\J 1:'1\1
Dressings
ROM
Chair/Dangle 1'\(
Ambulate
Leg/Arm Splints On/Off
Restraints On/Off .... , .' '.' 0 i :'"Ii". h ":' y,.
0 Safety ,... i' 0 ., .)'t I': T .,ii' II ;;tt.,. ),'" ,'.' ;;
w
'" MD Order .. .. .... [ .... , ,,:,1(; -S. :;;;:, :>;; ,,:' ". 'i'.
::>
0 Chemical '. '.. , .. . ... I' .~: 1'", 'ViIG\ J
w
a: Side rails i X 2 iX4 . . . '1,' ....... ", ):1 " ~
Cire./q 2 hrs ,.1-: , ).. . :T :;;; .ii' ;'it;> .rt ['1, ;; 17.
Faits Precautions Initiated '/ .. :, . eJ: .:. '.,: .; if~ I:~ ~
Food (F) Fluids (FL) ToileUng (T) " : .. i .:. 1iT-st :: .;;,d:; ...,. :..
DaSH ~
RISK SCORE TUES/FR1 Falls Risk ,fA~ ' .
Score plY &~.,J~
R L L R -
'" Jl
-
c:
'0 -
0. Integument
'" 1.lntact
~ ~I~ ) l
::> 2,Reddened
'" Evenings
'" 3.Breakdown .,.-
'" 4.Ecchymatic C0 (.ua.f,fl.. f I V 5 , ~ WJ:J !in. -th,"--^-'
~
. , ,
'" I( \ I LiE spliYJ-!S-o(f carl- {A?1
c: Edema
0 lV' +1
111 ij 'rJY
" " III +2
c: +3
~ +4
III - -
c: luesday Nights
'" Friday
E
::> Risk Score
m "II
'"
" tv ~ IF <10 Consult -
E,T, R.N.
ANTERI}'R POSTERIOR Consult Sched
2 of 6
IS8 . Incentive Spiramet~
DB - Deep Breathe
NG . Nasa Gastric
1
'"
'"
Reauired - MUST be cu.llpleted
'.' ". ...... ,.24 Hour Level of Pain Intensity Assessment
. .:: . '. :}~ '.:~2;~;;~ ~~;~r;.J,c:,:'~.;:((',' .~., . '.,' used ." .
0-10 AdUlt. Num~r\~ ~i;1tiP9~~~~~~; o~~ ,~~?:iatric~~~s ~atin~ S;~le \ ~-6A~UltI~eriatric Faces Rating Scale
Ti~< , q30 .-' Least ~ir2}~'h;~tO,; "':\W6r~t over 24 hrs: . r- 'Average over 24 hrs, 0
Narrative Notes
:;no
;i~r-a.S~ .
$
~
~.::;;
Focus Problems
Document critical events (e,g. critical labs, seizures, fever, increase in pain, bleeding, anythmias, rash, respiratory, etc.) or
changes in patient status.
Interventions (Action) for Pain intensity ~ ~ adult (0-10) or >2 child (0-5) and/or patient states pain control is unacceptable
,'", . '. .
Time Focus D-Data A - Action R - Response Initi
Time Temp Cap
Refill
W
\oJ
h f,UUJn. 2-~-"
~0 tlNl'lV I'YCL
"ZSJ::t..
REACT . ..
2-Normal . . . .
1-Sluggish 1mm 2nvn 3mm 4mm 5mm 6mm 7mm 8mm TEMP
O-Absent BEST I CC~I MUIUt'( MUSCULO-SKELETAl W-Wam
EYE OPENiNG 5-0riented X4/Age appropriate verbal 6-0beys commands/spontaneous (Limb Power) C.Cool
C-Closed 20 10 response movement N-Nonnal strength VASCUl.;
swelling or sutures 4-Disorientedlconfused, inappropriate cry 5-Localized pain 4-Active movement against resistance 3-Boundir
4-Spontaneously or speech for age 4-Flexes Withdraws 3-Active movement against grayity 2-Normal
3-0n Command 3-lnappropriate words or sounds 3-Flexes Decorticate 2-Active movement with gravity eliminated 1-Weak
2-To pain 2- Incomprehensible sounds to stimuli 2-Extends Decerebrate 1 ~Frjcker or trace contraction D-Doppler
1 ~No resnonse 1-No resoonse 1-No resnnnse O~No contraction P~Parpatic
40f6
Date 3- s' 0 I .
Site/Solutions/Drug Concentrations
1. _ Pl!J..NS-~~O tct 5,
2. L 6.
3, . 7,
4 8 ~,(/"
Intake
F-I";?'l;}ll/"i j,c-!,:"~) 7~l8S
fRA :c;qf j6,(~:;'g 03/25/1'1 i'J
, ~~ it? 1 ;..~.;~'
~,
" "
, ~,.\ ': ~:,;1
(f ,
06()(
. BHr,
iTola1
~4Hr.
ITotal
~ime Blood NG P.O. Urine OC Results Stool ac ResuHs
1 2 3 4 i 5' 6 7. 'B. Po I OK nK
0700 ~~." :,:.' : ",.,': ~::.\ ,<"' ~
08OOIIl~ I:, ! ,'!:v~~ I :'; '~'Xi lq~ -
:: ! ~ ~6f: . I',' v:~;'r~~'i:~
1100 ~~, I I" \:~ I; "e ~S:
1200 .' ..~ ~.. i>" I'; ~f :
1300", I ~.' ; ~ \}il
1400 :: ~j t' / :f~. c:; :~! ~;~l'!'J; ,}} ........ '" 1Jl
BHr, I:':." P . '.:1'" .:':,'. ~) I,: .. ':'J ':11;\'- J I. '.' ,. .
Tolal ' .:.Ii.'.: ::.' .f,': ,.: '. '. ,,u.. (,..,~. "r It~J .:i"W/' I I I.
1500:~1lP' IY ,,:..~';h;: .', ""1 1&1
1600 I, . : 'w iA d I, I: . '; I ~" l{if,.
qi lL\:f1 . J ,:-'('\ .:. i. I;. :I.:? :
I ,i",: '''; ;"
1700 '--';.' :,: li '. I": 'l, i'i. .;
1BOO ;. '::.' , . ":, 1 ~ . ';": 11': ~;i
, 1900 ,',. I" I .'J:,
= "L" ",",,", _,C !"
2100:, ,r:i ,'{ ~
2200 'r I <~i';I';, ~
BHr, I . . .. : "1" '''',::'.: /):31 I"
Total.'... .: I, '.:: '... :',. ',i, . "..
2300 ..:;. ":'?:' I ;~:::'i (/, ;:X: I~
00001.\. ,,' 1:\ r,;' :1"
0100 "< ,'; I ;;,'. ....~ " "
. .
0200 I . .:. .
0300 i W' I is.'" .
0400 .;, . ..:'" I'.: ~':,;k:;'
0500 . I' .
.
I :
'.c...
/' ~ 114
\ ';"4'
'\,
ul ut
.
~tJ.D
.
~!1)
~------
. D: '90
it I~:;., ~~,
r- O::;;;:?'
e
1
. .
.
50f6
Total 24 Hour Intake
~
____'- \ I~O
( ~ID liSC I) :.
"mtlr24 Hour Output
.
.
.
.
a
.
III
Weight . ,132779
PENNSTATE Admission kg 1-<" 72 ,t 7..., 7'*f
;1 The Milton S. Hershey Medical Center Yesterday kg ;?.\L"AtJt:J2978 03125/\'1,
The Coltege of Medicme . Today kg (:: r).it?' e. ,.:::;
Scale o Bed o Standing t ,\ !l": f'i ~ " '\ f,.,~. y I'
o Chair 0 Infant_ ,
,;Silt I b I BSA ,. , ,", !t k k
Height ',' ,
Date Post.op Day
,
Time l~ I -I I 1 --'I I I 1 I I I I I 1 I I I I I 1
40.5-
40
.39.5 - 160
150 -
~ 39
~ 38.5- 140
:u 38 - 130
E 37.5 - 8:120
Q) 37 ~110
I- ~
36.5 - "-100
36 - 9O~ .
35.5 - 80
oral '" no abbreviation
R= reclal 70
A"8ll.i1~
T:lympanic 60
COIlnect.andX\o ~
form graphs 40
Respirations r;.q
Blood Pressure ~ / / / / / / / / V V / V / / / / 1/ / / / / / I
O,Sat
0 Rx ~
Pain.'. , "".' ',';' . {."" :"', ". "",. I '~~~ ;" ',I:, \~ W
:f',,,
p"liictrlAeceptY~ :<' I,.; .:'S,; <i' '., ':;11 1':1" ",.: .'S", :i~;" "c' 1':" ~;': ';;
31ucomeler
TIME
Strong
J: Fair
"
J Weak
0 None
u
Suctioned .
!z Lar e
Moderale
J Small
0
::; Scant
>. .. .
"- None
.. Froth...
~
$ '" Tenacious
f- 0 Thick ~.
-'
~ 0 Thin
0 u
- Watery
e Pre-Pulse! /' / /' / / /' /' /' / /' /' /
ii
Ul Post.Putse
~ Peak Flow / ,/ / ,/ / / / ,/ / / / /
Before/After
VC or IC/NIF / / ./ / / / / / / .~ / /
IPPB / / ./ /' / / / /1 / /' / /'
PressureNolum
CPT
Respirations
Initials
- - - - - -
ICOLOR CODE: A=Amber BL=l:3tack BH-l:3rown C-Clear G-Green f-'-pmk R-Red I-I an W-Whtte Y-yellow I
MR,.1l,52100 "i0fF; Nursina Flow Sheet
1'(0Ulrne I"allent ASSessmr +
INSTRUCTIONS' Initial assessment categories which apply Obtain Comprehensive Assessment for. .en necessary,
.
Davs EvenmoS I S
Time 1m<>< I
Oriented q;(... Oliented Oriented
., (Peds age appropriate) (Peds age appropriate) (Peds age appropriate)
'0, Disoriented .'. . Disoriented Disoriented
0
'0 Inapprop. words/sounds Inapprop. words/sounds lnapprop. words/sounds
~ Deficits/Baseline for Pt. ., Ocljcits/Bas~ljne for Pt. Deficits/Baseline for pt.
"
'" Fontanel (Peds) - . l=9ntanel (Peds) Fonlanel (Peds)
Z Not Assessed Not Assessed , . '. Not Assessed .'
Normal Control Full Strength n:.. . Normal Control Full Strength . , Normal COntrol Full Strength
Weak ., Weak .. . Weak .
,
0- OeficiUBaseline for Pt. . DeficiUBaseline for Pt. DeficiUBaseline for Pt.
- III
,,- ~ Uti' OL ..' - . ., ../" '., I'
.,,!!
UI '" ..
""" '.. " ...,.'... ... .'
~U1 . .' Not Assessed Nol Assessed
Not Assessed
Normal Skin color/warm Normal Skin color/warm Normal Skin color/warm ~ ~
Pale, Cool Pale, Cool .' .. Pale, Cool . .
~ ,.,
III DeflcitlBasellne for Pt. DeficiUBaseline for Pt. DeficiUBaseline for Pt.
:; . .... ...". ',. ;X{ ..,.. ..',~ '....
., \ .,
UI , .. .. } \. I:ic*'
III
> ; ,'( ..,;' .' .'; ,.....
Not Assessed Not Assessed Not Assessed
Regular Regular ..., " Regular
Irregular Irregular '..'. ".'. , Irregular '. -c-
., Murmur ,. ,...,., Murmur . .. Murmur ...... 'V
III Pacemaker . 1/7
:0 Pacemaker Pacemaker
~ Monitored Rhythm , t~; .~'(' Monitored Rhythm i) .~.~. Monitored Rhythm , '1" '4;~/
III
() "
'['.,,0;......_ ", ]]
Not Assessed ,,- Not Assessed ,j\'?;.',',.. Not Assessed ,
Regular <iX- ...' ;"., Regular - ,,': Regular . '.... '"!'i;v;!: ".'.yT
" Irregular " , -',' Irregular ..", ...... .. Irregular ....v I"'." ..
~
'" DDE , ," DOE i DOE , 1'-', -c-
-
~ 1ii SOB ..,. ,.,' .....,. SOB ;". .' ..,. SOB ..,;, I';." , ,.
0 Q. ..;' .: " ., ~. .. ...'..., I~, ;-0':1
-
III
~ ., Not Assessed ..... Not Assessed ..:., .,.
'0. Not Assessed
UI Clear <oc. '. Clear '. Clear
'"
0:: Crackles . Crackles Crackles .,..', >. .'
UI Rhonchi Rhonchi Rhonchi '.
'0 Wheeze Wheeze Wheeze
" .'
" Decreased Decreased . Decreased
0 Absenl " ..- ,'=
CJ) Absent Absent
Not Assessed "'. Not Assessed '; Not Assessed ; ;.. "..." .
Active ,,,,. ..... Active . Active
UI
'0 Hypoactive Hypoactive Hypoactive
" .
" Hyperactive Hyperactive Hyperactive
0 Absent Absent . Absent
II)
G; . .. S
~ ','. .,' ..'
0 Not Assessed Not Assessed Not Assessed
ID
Cl Non-distended ~ Non-distended . Non-distended .
Non-tender ~ Non-tender Non-tender -,
" Distended Distended Distended . ,-".
"
E Tender . Tender Tender
0
'0 . ~~ ,
.0
<(
Not Assessed 1"0' . No' A<M;~O" ...
No Dysuria No Dysuria No Dysuria '.'
"
~ Dysuria Dysuria Dysuria '.
.!!
n; Foley Patent Foley Patent Foley Patent '. :.
"- Straight Cath . Straight Calh .' ~'rn.~ght Calh . ,....
~ a: "
Cl ~ Clear Clear Clear
"
1; Cloudy Cloudy Cloudy
'" Bloody Bloody Bloody
-
'"
J:
<.> Not Assessed 0: Not Assessed Not Assessed
, Family Contact J Family Contact Family Contact .
0
J:- Yes No Yes No Yes No
CJ .!2 - - - - -
>." Active In Care <t(.. Active In Care Active In Care
UI 0 Yes No Yes No Yes No
Q.CJ)
Initials fIL_ - lnilials ---- Initials ~------"-
.
.
.
,
6
Q.
0 8 8 0 0 8 8 0 0 8 0 0 0 8 8 0 ~ 8 8 0 0 8 8 0
Routine Treatments 0 0 0 0 0 0 0 0 0 0 0 0
" '" '" ;:> ~ '" ;! ';!. ~ ~ ~ '" ~ N .. ;; N '" Cl "' 8
0 0 0 ~ ~ N N N N N 0 0 0
AM/PM Care ,
Shave
Shampoo
- Hi ,
Oral Care
Skin Care W ' I..
Peri/Foley Care ,
Anti-E:mboli Stockings/SeD On/Off
Suction -
Trach Cf:lre
Chest Physiotherapy
ISB/Cough DB
Turn (Indicate R-B-L) W~ f
CT - 20 em H 0 suction
CT HP seal .
NG Placement
NG Irrigation
IVSile-/
Dressings
ROM
Chair/Dangle All
Ambulate fV"Y
Leg/Arm Splints On/Off
ReSlraints On/Off . ..;. ".; ." .... " ... ;, )". ')': ',;. H " :;,s J.:: I;'. ;} I:;" .'.... . !.
0 Safety . . .;. . . " I,. ;. i : .... H' 'Cc; .: )T ..,.. ;T.) ..i; '..
w '" ..
tr MD Order .,...',...: "'. i>, I.' " ;.... !'; ,( I:' /; ',;::, ;.:, ."': I", ' >:. .
::>
0 Chemical .. ..' ..' .... ;, ,.. '. '. : .,. ... 1.:.- .' ';" "j ,:;:, ,,' :''0'; ,.'c i,p' ;::; ;. '. "
w
tr Side~rails l' X 2 iX4 , ..., I "'..: ,; i! "'f; .Yj.. '. ',' :.
Circ..1 q 2 hrs , . .' , .... " i....'.,' , .'j ;'. I,,; Jt; .1: ".". T..,: : ;:
Falls Preca.utions Initiated .i ..... , I..., r. ...' .' " . '. >,] !.t'!; ;" :. I.-~ I; :' ..Y':, t .',' I" I.....
Food (F) Fluids (FLj Toileling (T) ., '.. . "1' ,. 1','.1/; y I,ie I." ,'i' "J.. 1>'1 1,-
Days
RISK SCORE TUES/FRI Falls Risk ~;::
Score l.~ .
R L L R -
In ~
-
r:
'0
) I Integument
'" 1.Jntact
~ ~I~ l
" 2.Reddened
In Evenings
In 3.Breakdown -
'"
~ 4.Ecchymotic
. , c ..
>II "- I ,
r: I( Edema
0 lU +1
u;
c:; " fft +2
r: ,HUJ +3
~ +4
III - -
r: TueSday Nights
'" Friday
E
" Risk Score
Cl ~
'" <:
r: IF <10 Consult .
E.T. R.N.
ANTERIOR POSTERIOR Consult Sched
20f6
IS8 . Incentive Spirometer
DB. Deep Breathe
NG. Nasa Gastric
Q.
-
""
d MUST b I t d " , '" ," ..
Reauire - e comp e e ',' , ,'" ':'e",'''''::''_>";;;":;,,,,
',,' i:' -", _',,' ,., ",,::: ":""::":""',,:',:'!'J'.L":~'\;j~iP07'~:$::'i-~?*:;ft/~);1:::i:!::~l?';':~;::.f:i
24 Hour Levelof Pain Int~;'~i~f!" ~-t" ':d,:"/"
. "",-,",.-, ' ,::' -"-'-'-".';''-'\f>;'';:''''', <A'--<";"':':f.~.f..'M;;;t: i;l l':~.1,~
Circle\vhichs'"' ; _ ' " ',-
"--." ,"-,' ,::,,',':. ',:.._<' '-:C', _', "<:',_,"..:;:"._:\..".,<:~,
0-10 Adult Numeric Rating Scale 0-5 f'eiliatdc FaC;!!'"
',:,':: <:, <-,- ','C' ,:; >':',,:,:>t.~\_/ ~"t .;S.t,'>""T:::'. ':;{~:i'i-
Time
Least over 24 hrs:' ::
~Rating Scale
Narrative Notes
,
.
J~JJ,{,,;,;~:':td,:t~!<1:~;tl::;'::g:~:'\:~':1,:;~,?~r .__."._>:t';~f:\;;,b:t;j~, \ > ,~ t,,?
,-,p'
i\,,'"
"',-:;;:,.;,'.;' ";^ /';;1,'/
>--';?{/::I~:S;<,,> '" /. ~,:',.<_
:2:::~:L7:;:,L-:~f'('"
Date
'"
'0
o
U
~
'c
Signatures/Credentials
3 of 6
Focus Problems
Document critical events (e,g, critical labs, seizures, fever, increase in pain, bleeding, arrythmias, rash, respiratory, etc.) (
changes in patient status,
Interventions (Action) for Pain intensitr,,~ 5 adult(O-IO) or >2 child (0-5) andfor patient states pain control is unacceptabl
Time Focus D -- Data A - Action R - Response In
Comprehensive Assessment (if applicable) NA 0
-pu s T1\feuro, Status' ,,~ 1mb Power Vascular Assessment
Time ':Eye '..6,e51.'; Best, ,',IOla" ',Arm ,~:' : 'Lon', Unne, L"wer Temp
I~L O";nlnn Vemal '.Molor" ,R ,'LIR. R___ L K_ L
1rrP... ./ ~ I "I:';'~,I,',;, ,~"/~-;(l ____ iV ~ /"
~/L~"", ,,:~;::;n,,~ ~., ___..-!--
VI./I;>'l~~';,'I';:'/~ ___________
1./../ ,. 1,,:/:;1' . 'yo-::- ~.::;..... > _____ ____
"7 ~ ,. ' I - -:--:.;.:.- ___ ______
./ ~' ':, I. I, .___'~ ~ ____ _____
.7 ~ - ,': I '", , -,~ ~. ____ ____
I~~c- . , ,I,'. . -~ ~ _____ _____
1./ ./ I I.i:,' ,1:". ,~......;-- _____ _____
~ ~ - -:.- , 1,..' ..___' ~ ~ ____
~ ./ -. ,1"" ~I~ ___, .___
1/ ~ ' , '~~ ___ ___
Cap
Refill
Z-.3
~....,
REACT
2~Normal
1-Sluggish
Q-Absent
EYE OPENING
C-Ctosed 20 to
swelling or sutures
4-Spontaneously
3-0n Command
2-To pain
1-No res anse
4 of 6
........
1mm 2mm 3mm 4mm 5nvn 6mm 7mm 8mm
5-0riented X4/Age appropriate verbal
response
4~Disoriented/confused. inappropriate cry
or speech for age
3-lnappropriate words or sounds
2. Incomprehensible sounds to stimuli
1-No res nse
6-0beys commands/spontaneous
movement
5-LocaJized pain
4-Flexes WIthdraws
3-Flexes Decorticate
2-Extends Decerebrate
1-No res nse
MUSCULQ.SKELETAL
(Limb Power)
N-Normal strength
4-Active movement against resistance
3.Active movement against gra.vity
2-Active movement with gravity eliminated
1-Flicker or trace contraction
O-No contraction
TEMP
W-Warr
C.Coal
VASCUL
3-Boundir
2-Nonna!
1-Weak
D,Dopple
P-pal atk
Reauired - MUST be completed
24 Hour LeveLof Pain Intensity Assessment
, , ~ " ,~," ~~; Ckcl~~~Hi'~h '?2ale 'Was used' , '
0-10 Adult Numeric Rating'SC~I~,~J~i~,P~difi1 "C'~:~:~aii,ng~cill!l. ,..O-6.~dUltlGeriatriC Faces Rating Scale
:' .... "",'~:;:':,:,'G::;,;t:::~;.~;~~t:~'-'\,,~:tt~~:-~::~~~};'j~~;~~:'~~:;,:)?:':)~;2;'LN:(~~;:n:-"ij': ;~:/:'; ."', , "
Least over 24 hI's:'':,; 6rs(Mer24'hrs~" , , Aver~ge ~ver 24 hrs,
. "," " , '-L>.:,"<::l;/"',_'>i"':-F~,,4~,.<::.:
Narrative Notes
Time
--
,
Date
:;-cj-o\
Signatures/Credentials
Q)
'0
o
()
'"
...
'c
Focus Problems
Document critical events (e.g. critical labs, seizures, fever, increase in pain, bleeding, arrythmias, rash, respiratory, etc,) 0
changes in patient status,
Interventions (Action) for :ain intensity,~ 5 adult (0- I 0) or >2 child (0-5) and/or patient states pain control is unacceptabl
Time
D-Data
Focus
A - Action
R - Response
Ini
s
Comprehensive Assessment (if applicable \ NA 0
- Pu IS .i';;'<.. Neuro-Status', :-!;<'V~UmliPower~,~;<;'; Vascular Assessment
Time ",.. ., Eye,:: : 'Best . Best Total I' 'Arm' ,~.. 'iC, I i=, Lower
~ii '~;,D, :~;" ii' :':;;5;
:;0"" IX -;;:;::;: 1',,( !' ;:S' " [;'" I 5 I~':" , ~ ~
"lI\~ U ~, ~I r 0 If ~ ~ ~ ~
IMilJl ./ ~ Y 'c ~ 15 ~Ii -r ~
./ ~, . ' ~ I ,~~ _____ _____
~, ~, ,- . ~I~"'" _____ ___
/ / . ~ ~+: ----- ----
./ ~. ',' ---- ~ ~ -----
../ ~ , ~ ~ ~ '....----
./ '~ ____ I.:..,' ________
REACT
2-Normal
1.Sluggish
Q-Absent
EYE OPENING
C-Closed 2<l to
swelling or sutures
4-Spontaneously
3-0n Command
2-To pain
1-No resnonse
40(6
........
1mm 2mm 3mm 4mm Snvn 6mm 7mm 8mm
5-0riented X4/Age appropriate verbal
response
4-0isoriented/confused, inappropriate cry
or speech for age
3-lnappropriate words or sounds
2- Incomprehensible sounds to stimuli
1-No resoonse
I""'" N'V'V",
6-0beys commandsfspontaneous
movement
5-LocaHzed pain
4-Flexes Withdraws
3-Flexes Decorticate
2-Extends Decerebrate
1-No resoonse
MUSCULQ.SKELETAL
(Limb Power)
N-Normal strength
4-Active movement against resistance
3-Active movement against gr8llity
2-Active movement with gravity eliminated
1~FJfcker or trace contraction
O~No contraction
TEMP
W-War
C-CooI
VASCUL
3-Bound
2~Norma
1-Weak
D-Doppk
P-paloali
Temp Cap
Refill
\iJ ~1;.
1;J L-",3- ^-
\i1( L4
vi '-:1
~~ ~-
vJ V-J.
,--V' <.:1 H
D3te<)-'-/-/UiJ/ ,
J~ o.r. I,Site/Solutions/Drug Concentrations
\)..,1 d (, Ot> 0\:;1-- 5,
), 6
2, 7'
3, '
4 8. <-"
Intake
q113277Q
R,\L;~A062qi8
CiS1121:380
Ai;: J P i, j T T A ~~ Y foJ
721,;'-3 hieS
03125/1G'.:~
c
Blood G
ime 1 2 3 4 5' 6", 7 ,,~l 6 N
0700 I ~ ,,'.;. ,'.;.;.J!:j; 1'::" . "
0800' .,': I " .::..
0900 ' , : "::1;
--' \~ :',:
1100 ,,:,,&:.
1200 ,,~{)'fh
1300.t~JI .
;; ': :;;~ I J:~ ·
1500 , I" ',.,1" ",-,'
...
1600 . Ie w.~
1700 I, "j, "; "",.
1800: :.f.,
(;:>
1900:,...1 ::,~~; ;.:__
2000 I ~! I.~, ' ;
I'" '#". /.
2100: " ....; k,;
2200 . ),y I~:
8 Hr. : ,','.:, ,;, " I ' :, '1:"
Tolal ';,;';': .,...; :' k,
2300 'j .'~ j'" ~ I':~:
0000 n }k; 'Eti;l:~ ! ' .~.
0100 ~:tA;: I If>:,
i\}'J'1'I ,i" 1" .',
o?oo Ib~;.. I' '" " 1'~~!r'};:\I,l~;tl:i~~.
0300 \b'.. 1~~;Y:s. ,{if;:' lb'Y lat(
~ ~ l' :'. '''1~~ , I,N~; 13J.:
0500[ ,\').. .': .'.' , ; 't;: \1 t
060C 1\). , 'i.: 1 ,~~
~o~i I I I .i;:8l\
~~r' ' '1 ('.\~
P.O. Urine ~ Results
,Jut ut
Stool I ~ Resulls .~\
IW
\S'D
'?1)~
1000
l CtT\ lio-D
\ jt 7-S
'~'IlI'~ ~
' Ill.l .
JftJ ..,
..j>,.",(i~., ~
~~;;. ,;,(' ~fy()lr8'$~,:::.~~ ~., , ft]CA
'I----' -
.j.1
,
.
}
dSJ
II-;.v
.
l~f
~#
(pO
;;
,
150
',':
.i.',. 15) L{ClOU'"
,.,; "Y I' ....
~
'-
,\Go' I
~
J?a:l{O
, --
----r- .". . - "
,;zSD
-.---- -,-
,
-----
'~JO 1("jiV "
".,.,' ..', VJ7 2< ~....I'
RJ
.
,
i.
6016
Total 24 Hour Intake
\\\~
.-.
, , ,our Output
\--1 'I -Y
f '
..
,
.
'/'. ~ 1 1
I? i ;' -'~
t )
Date ') I Q "I
Time' / it:
SSA
Post,Op Day
Weight
Admission kg
Yesterday kg l.i '~.
Today , kg i ~
Scale 0 Sed DStandrng" "',' ,
:po ,
o Chair 0 Infant---",-'
Height
It,lH
PENN STATE
9 The Milton S. Hershey Medical Center .
. The College of Medicme
40,5-
40 -
39,5
~ 39 - 150
.a 38,5 - 140
ctl
:v 38 - 130
E 37,5 - 8:120
Q) 37 - ~110 ..
I- "
36,5 - 0..100
-
36 - 90 .:J.
35,5 - 80
oral" noabbrevialion "1<'
R= rectal 70
A= axillary
T=lympanic
cOI1nect.andXlo 50
form graphs 40
Respirations
Blood Pressure
O,Sat
O,Rx
Pain, r;v.~",'. ,
Pain Clrl AcceplY/N
Glucometer
TIME
, Strong
:I: Fair
"
:::> Weak
0
() None
Suctioned
f- Laroe
z Moderate
:::> Small
0
::;; ~cant
>. ..
Q. None
ll! Frothy
.,-
~ is Tenacious
~ -' Thick
B i8 Thin
ll! WaterY
ii. Pre.Pulsel
U) Post-Pulse
~ Peak Flow
Before/After
VC or IC/NIF
. IPPB
PressureNolum
CPT
Respirations
Initials
16
[!:OLUR <;ODE,
"""'1$ 2100 5af6
~';' 6
"':'.:
C}/.?~/f"
.,: f',
\. :;. :' ! ;'\ ,
...A,f' ,..
~.., "if.!
~ ",c. .\
Int'J..O 1r.J.c\ II' lVi4 I I I I I I
I
I I I I I I I I
180
.G?g
. / ,P ~'
. X .
'I. '9'
80
,
Hl '} ~ iD()O I~o
~l /'~~1/~/11 / /VV/ /VI/ /VVV IVI;
,. . "! . '.,
. I... - " ..
~~
R ':~-~iff ,!~-
1'4:,;
,,-
/' /' ,// /~ ,/// // // // /' // /,/ //
/' /1/ / / / / /1/ / / /'
////////////
////////////
A=Amber
Sl Black
tjK-t::lrown
C Cle~r {j=Green p t-'In~
Nursina Flaw Sheet
R=Re;
I I
1 = Ian W=WhJte
,
Y Yellow I
.,,,.,,.........., I 0.....,.., ""~~C~~I'I"
INSTRUCTIONS. Initial assessment categories which apply Obtain Comprehensive Assessment fan
a s
.
~
.!J!
"
I)
'"
III
>
I I)
,!!!
'tl
~
III
U
l:
~
'"
-
~n;
o II.
. -
III
,!::
c.
'"
'"
a::
'"
'tl
l:
"
0
Vl
, '"
'tl
l:
"
0
'"
Q;
~
0
III
(!)
c
m
E
0
'C
.0
<(
C
~
~
n;
II.
:J
(!) ~
m
U
. III
~
III
.r:;
()
,
0
.r:;-
u .~
)0,1)
'" 0
II.Vl
,16
Time
,!1
Cl
o
o
~
"
'"
z
Oriented
(Peds age appropriate)
Disoriented
Inapprop. words/sounds
Deficits/Baseline for Pt.
Fontanel (Peds)
Not Assessed
Normal Control Full Strength
Weak
DeficiUBaseline for PI.
o
0-
_ III
,,-
I)~
'" '"
"""
::0 '"
Not Assessed
Normal Skin color/warm
Pale, Cool
DeficiUBaseline for PI.
Not Assessed
Regular
Irregular
Murmur
Pacemaker
Monitored ~ythm
"\
Not Assessed
Regular
Irregular
DOE
SOB
Not Assessed
Clear
Crackles
Rhonchi
Wheeze
Decreased
Absent
Not Assessed
Active
Hypoactive
Hyperactive
Absent
Not Assessed
Non-distended
Non-tender
Distended
Tender
Not Assessed
No Dysuria
Dysuria
Foley Patent
Straight Cath
Nnl
Clear
Cloudy
Bloody
Not Assessed
Family Contact
~ Yes ~No
Active In Care
Yes No
Initials
I
t:vemnas 1'1,""_
l-h
Oriented
(Peds age appropriate)
Disoriented
Inapprop. words/sounds
. l.. D~ci.tsJBaseline for PI.
;fontanel (Peds)
Not Assessed
.
.en necessary.
Oriented
(Peds age appropriate)
Disoriented
lnapprop. words/sounds
Deficits/Baseline for PI.
Fontanel (Peds)
Not Assessed
tants _.... \,\1
tf)," N'\',
, ,
,,' :,'.
:- "
, Normal Control Full Strength Normal Control Full Strength
Weak ,,~ ,- Weak
'" DeficiVBaseline for PI. DeficiVBaseline for Pt.
- ".:J'~
, Not Assessed ..'.':: :;}. Not Assessed
~al Skin color/warm Normal Skin color/warm
Cool " Jt. ., Pale, Cool
DeficiVBaseline for PI. DeficiU8aseline for Pt.
, .
.
,
I " :,'
I ' , ,: ~ -,
I.';:
..
,
,
.. .
Not Assessed
Regular
Irregular
Murinur
Pacemaker
Monitored Rhythm
Not Assessed
Regular
Irregular
DOE
SOB
Not Assessed
!' '/ " I 't~' trs't Regular
;.'.:; .~6~',0:>:~t:: Irregular
~",'~i\ Jtr.f.' Murmur
Pacemaker
Monitored Rhythm
,
';;
S:,;
~ Not Assessed
>:#" Regular
r' ij;,' >"';'\;'; Irregular
',1-' ..,,', DOE
SOB
("'"l Non-distended
Non-tender
I ,. " ,:' Distended
., .... Tender
> -;:-~
Not Assessed
Clear
Crackles
Rhonchi
Wheeze
Decreased
Absent
Not Assessed
Active
Hy~active
Hyperactive
Absent
Not Assessed
Not Ass~"s~ed '
No Dysuria
Dysuria
Foley Patent
Straight Cath
<. Clear
Cloudy
Bloody
"
Not Assessed
Fcfnily Contact
...JIYes No
}\dive IrlCare
.=JYes No
Initials
~<,
~ ~ -..) '"',
~'d.~ \J!h 'l '
-'
iI~__
Not Assessed
Family Contact
Yes _ No
Active In Care
Yes No
,
':;
~~
' ~~: ---'-'-
,,' -;::7
1.''0. ,,;
f <x, ~,j"
.,
;~ :">"':
,; I
'l:: .:' ,
.' "I':"
"
~
,.
:'
.( ,,;;
Initials
1",\ -"7,, -. ;,~..',';~S,:
'II~'
',;;"~I"
.;:::.:"".
, :'~.li ~'"
':t'/ :');:!; :i~it:h
,;
"
,'X'
,1fJ::;
tI;"
'~li;t
!II' 1..17"
t~:
~~,
~~
~
,~'fO;o/~\;
"
v~.,,,.
~;;" ;
~,.*'~
t.~::. ~
:.;~' ...' ..
~
"
~J
:::_yt 1;1"
/:1';~'1\1l'.'~
~ ,:'.', t:
, "" "
.,: ~
~',~
ii~
..~
~,,,, ;';;]1;.. :..
~f~. .",,"r"<
1';:~*,i*li'OCr
1:"'1"
.
,
,
.
ISB - Incentive Spirometer
DB - Deep Breathe
NG - Naso Gastric
0 8 8 8 8 8 g 0 0 ~ 0 0 g 8 8 0 8 0 8 0 0 0 8 0
Routine Treatments 0 0 0 0 0 0 0 0 0 0 0
to; <Xl '" ~ ~ ~ ~ ~ ~ <Xl N l::j M ~ 0 ~ M ~ '" 8
0 0 ~ ~ ~ ~ N N N 0 0
AM/PM Care
Shave
Shampoo -
Oral Care 11 f1Y' ---
Skin Care r IJ'IY ~
Peri/Foley Care AA
Anti-Emboli Stockings/SCD On/Off -
Suction /
Trach Care /
Chest Physiotherapy / / /
ISB/Cou9h DB :I'M ~. / v' Y /
Turn (Indicate R.B-L) Int 1JA.I, , 7' , (
CT - 20 em H 0 suction
CT H20 seal ,
NG Placement -
NG Irrigation
IV Site./ J.. 1/, /" 1. r.n
Dressings
ROM
Chair/Dangle
Ambulate ,
Leg/Arm Splints On/Off
Restraints On/Off cc -c; ~ ',.' , . , Ii, ,'" ',; / '. '., ..' ;' .' ",' .i
,.
0 Safety ;. " ,-~ ," .' " .. , , !' :. lit/ :/ I.. , , ,;, ,;. ."", :;; ,. i..,
w
0: MO Order " "" ".' , , " " "'.. I.. ,; i; "".' ", lei .%" Ii ,'., , , ,;; " '..', ;;:i ,.' ;t
3
0 Cnemical ., " , ;. " , ". ... er I' ., " .i,; ti' is:'
w ,. .
a: Side rails l' X2 i X4 'I J- ,; , " ',,'..'
Circ'./ q 2 hrs ;" '.', :. , '., " ,c; i;; .... .{ ,;.:.; ,',; i'. i. ,.' '.-"'y ';';~ ;,'
FailS Precautions Initfated ,.. ,; ;, ;'.",',; ". ,', 'I ,,'; .,. " ,,' ;;';:' t, '~ -c; ;: T .: ;re. ,.' .'::'c
Food (F) Fluids (FL) Tolleting (T) , , ;,';' ,. '" " i; ; S c --;:- I ; .'1 ;:. '; , ; ,
Days
RISK SCORE TUES!FRI Falls Risk .
Score
R L L R -
<II
c:
0 . .
,- Integument
~I~ ) l 1-lntact
2-Reddened Evenings .,.-
3-Breakdown
4-Ecchymolic ~Cbt\.W i~
. , , ~ ~ -/;i:J U:f;' c 'thY7V'
\ ! ( Edema
lU' +1 l~~JWp1WL
~ ry +2
+3
+4 J:kJ lifk - ~(W /", j,;,. .If.J" 'L)
- -
lUesaay Nights t / ~~ Q-1 I ~ o~1I1
Friday ~~ur
Risk Score cp
( I'll IF <10 Consult .
(;-W J E,T, R.N,
ANTERIOA POSTERIOR Consult Sched
of6
-
0..
e
"
<II
<II
..
~
0..
Iii
c:
,2
<II
'ij
c:
}
III
C
..
E
"
Cl
..
-
c:
2
Reauired - MUST be completed
24 Hour Level of Pain Intensity Assessment
Circle which scale was used
0-10 Adult Numeric Rating Scale ~~5 ~ediatric Faces Rating Scale 0-6 AdulUGeriatric Faces Rating Scale
Time
Least over 24 hrs,
Worst over 24 hrs,
Narrative Notes
Average over 24 hrs,
.
13-11 · ' , .,V~
\ ~"'" p, J ~"'11 "",""" IC- ",PI1> A ~, ek- vd I j" I t1l C(, Wi , ~ ,
t
~
1
~ ~
\ I
Date '7\'1 \D\
Signatures/C redentials
0tJ ,V
Q)
'0
o
U
'"
.-
c
3 or 6
Focus Problems
Document critical events (e,g, critical labs, seizures, fever, increase in pain, bleeding, arrythmias, rash, respiratory, etc,) or
changes in patient status,
Interventions (Action) for Pain intensity ~ ~ adult (0-10) or >2 child (0-5) and/or patient states pain control is unacceptable,
"'. .
Time
Focu5
D-Data
A - Action
R - Re5ponse
Initic
"
m, M'l\ Dh VOANh)Ilfl\l1R fflS6 J C6V~ ~
I V
-
,
Comprehensive Assessment (if applicable) NA 0
UplS Neuro Status Limb Power ascu ar ssessment
Time S'7" Eye Best Best Total Arm Lea UDDer Lower Tem~".4i Cap
I~L R~ Oaenina Verbal Motor L "---L K____ L 'R___ L Refill
\t:;' I~ ~ 4- S I,., \~ 3kr ~ ...6' ~ ~ ..,.,~ L-~
:}-\nb ..Y'h ~ L{ t; (. 11" ~ hc;:f I.r '5-&' ..<t1 '\I-) lilY'
'\.,'l.,'\i: X i]/f ...\ .J U \~ J4 tJ.6- T' :..-1:1 ~........-n \10 ~
'J Q ,.... --X"
qc{/v >1 U y. C; (^ )~ ~ ~ 'Yl;i. ....-T'\ ~ --w jJJU'
/' ~ ---- ---- ---- ---
~ ~ , ------ ---- ---- ----
./ ./ ------ ---- ---- ---
./ ~ . ---- ---- ---- ----
/ ~ ---- ~ --- ----
./ ---- ---- ---- ------ ---
~ ~ --- ----- .--< ' -----
/ ~ ------ ---- --- ----
REACT . ..
2-Normal . . . .
1-S1uggish lmm 2.'1lm 3mm 4mm 5nvn 6mm 7mm 8mm TEMP
O-Absent BEST BEST MU I u" MUSCULO.SKELET AL W-Warr
EYE OPENING 5-0riented X4/Age appropriate verbal 6-0beys commands/spontaneous (Limb Power) C-Cool
C-Closed 20 to response movement N-Normal strength VASCUL
swelling or sutures 4-Disoriented/confused, inappropriate cry 5-Localized pain 4-Active movement against resistance 3-Boundir
4-Spontaneously or speech for age 4-Flexes Withdraws 3-Active movement against grayity 2.Norrnal
3-0n Command 3-lnappropriale words or sounds 3.Flexes Decorticate 2-Active movement with gravity eliminated 1.Weak
2-To pain 2- Incomprehensible sounds to stimuli 2.Extends Decerebrate 1.Flicker or trace contraction D-Dopple
1-No resnonse 1.No response 1-No resnonse Q-No contraction P-Paloatil
.
4 of 6
D~e ,
~ Site/SOlutiO, ns/Drug Concentrations
l.*~ 5,
2, - U (~~] 6,
3, 7,
4 8, ~,
\".1 ( "
( :,;
'..' "
. ,,,
,)r:, I
~' Intake ut ut
Ime Blood NG P,Q, Urine ~ Results Slool ~ Results I~l V
1 2 3 4 5 6 7 8 0,
0700
.
0800
0900
1000
1100
1200
1300 fRJ\ 100
1400 11/If ( 1ot)- N \1S h
8Hr. \ --.-/ /.^I ) ~
ITotal I,.., (\r l'
11500 ~O \l\ \' v ~ \.
11600 \\5) \ '6D \ l)'
:
1700 510 1,.%
1800 ~~ ~3LJ ./
i 1900 ~ ?>~ ,/ ./
2000 \t.<tl S:31 ./ ,
2100 j V
\~ '1.1 ~ I 30
2200 /
:8 Hr. 1'~ ( I~O ff Y 'DD)
,Total I
~~ ~~ -,;;- () Iv ~
! 2300
0000 "J' ').jt
0100 \ v -
! (llJI ;piC 'l{ciJ
0200
0300 ~ +t :W:
0400 ,
0500 m II: 1 ( \;\j .
060( \ (Jii I'" tI, ' / (j .'~
8Hr. h~ 1/ 1(( KJ l-! '(I,y .
Tolal
'24 Hr. If),~ \-\15 ~S
;Total ,f
Total 24 Hour Intake / (4'.) Total 24 Hour Output II L. \"') 'yX(
) of6 ~ .
,
.
.
.
.- Health System
~ 1
The Milton S. Hersl1ey
Medical Center
:;7;'
~ " -, ;
',., ..'1
! :\ ' V'J;
MEDICATIONRECORDSTAT - P'II: - p~C'. OP
, ,
I ,~ ,
i;
2 r , >)
-4
- ~'" '. J ) )
DATE MEDICATION DOSE DATE ~I ''2 DATE -Y/'-I- DATE' ::V-<. DATE, ~ / /r,
OF ROUTE OF ADMINISTRATION SCHEDULE '- , 'f / r
ORDER EXPIRATION DATE and TIME OF ADMIN, HOURS GIVEN HQURS GIVEN HOURS GIVEN HOURS GIVEN
::{3 yY\SYt ~m%- AM {?f x.1 \)v,~<-j'1
I V N?,O :- -~---:r:- -------- -------- --------
PM ~\' .,'1 ~~ ~'
V~~ GI~^O AM ()PtA v-1
C 3 .,. ------- .:.-,L_n__ -------- --------
r PM 01w 1 -\' ~
, .;.,.. pO ~~D -~~- / ~\
~ 1'') i :11 AM \ 0 t",--
f-. ---_..::._-- -\~~ct~ -- -------- -61/------
PM // 7!.i
,
AM
f-. ---- -------- -------- -------- --------
PM
AM
f-. ---- -------- -------- -------- --------
PM
AM
e-. ---- -------- ------- -------- --------
PM
AM
- ---- -------- ------- -------- --------
PM
AM
- ---- -------- -------- -------- --------
PM
AM
-, ---- -------. ------- -------- --------
PM
AM
- ---- -------- ------- -------- --------
PM
.
DRUG ALLERGIES PERTINENT INFORMATION ,
i '/ ,i '1_1 ;Ji (AI} j~ 1 fh/:f J;:jr 1")1//1'./,(1 " ,J /i , , , r,
, ! I ()
"
RECOPIED BY SECRETARY:
INJECTION KEY ON BACK CHECKED BY REGISTERED NURSE:
INITIAL SIGNATURE INITIAL SIGNATURE INITJAL I. SIGNATURE
-ilv '\11 ,A (i-1V '----'-' ~~- \1.- n... 0, 'PJ ,~f),)
" V - '- ,-' '. " ~
fiY ,1. /
-- - \
t,~ ~, 1\"1 f\1
NAME I RENEWAL DATE II ' I
.
MR 223 10/84
MEOICA TION RECORD
\.....'0
l~
-, ., '......".......... , , . 0' 7 c: c. 7 - ~
~ The Milton S, Hershey Medical Center , .- c r:' , ~ / ? -) " .
. The College of Medicme
, , , Y ~~ .-
MEDICATION RECORD " ~
-" ct,1
, , " , ,
I , I I
DATE MEDICATION DOSE - '.' , DATE,-<'l ::<, i DATE' --:VTF DATE'< /.,c:;, DATE -=<, II
OF ROUTE OF ADMINISTRATION SCHEDULE , -, '{ , r
ORDER EXPIRATION DATE and TIME OF ADMIN, HOURS GIVEN HOURS GIVEN HOURS GIVEN HOURS GIVEN
~3 ~~-(Lb AM -~--
- -------- ------- -------- --------
PM d>'g'
, 4/n I.A"I J~!J AM I,) ( \t'?'l,j' clW'l,0 @)()~ -T-
3(3 \(. ~ ~ -" -- '),~
-/00" - %~f,~~~;; --------
;')';4Xr/Jrl--. PM ~-IO ~Cfi~-.t~'\ \>--
'3/3 ~iY AM Y & ~__n_ '1~...--\
~ 17fJ - ---- nn_~-- 'fnJ'-- --------
PM 2' Y ~\~ :j "",~ )'~ 1J~i'-
,
~~ Au c:er AM .Ii:; -/- ~i\Z€rnU-
- -~-- -------- _~n~-- __n__j
PM }(!G '?~ t.f 11'- Cj~,-
AM I
f- ---- -------- -------- ----------------
PM I
AM I
f- ---- -------- -------- -------- --_____--l
PM
AMI --------
- f----- -------- ------- _______--.J
PM
AM
- f----- ------- -------- -------- --------
PM I
AM
- 1----- -------- -------- -------- --------
PM
AM
- f----- -------- -------- ----n-1n-----
PM
DRUG AllERGIES PERTINENT INFORMATION
\D --
'i i tv
--
, -- ;
-- I
RECOPIED BY SECRETARY, I
INJECTION KEY ON BACK CHECKED BY REGISTERED NURSE,
INITIAL SIGNATURE INITIAL " SIGNATURE INITIAL , SIGNATURE
1'1L- '1/Ut I ,/\(,,;-1 H, I \\ h~ . l\ '~ II -1v7 vI/) )/d//1/1, J(JA =
U ';' ",l- I ,,~ ,N'\,~
. f---- . 0 ~ .c (,/Y
L,'" "1::-\ ", V\\, U
NAME -1.f1.E.NEWAl DATE \\- ~-,
-,
MR 223 10/84
MEDICATION RECORD
~ PennState Gel~inger
~ Health System '
RESPIRATORY CARE RECORD
GENERAUEMERGENCY CARE SERVICES
Date Started
Date
Description
Time
,
:s /~ III)/),;i -t7f./J J..!/}/J//f...----/
'-
/
~
/ \
I
I
/
--:--
The Milton S, Hershey
Medical Center
\ /1/
1{j'1
Rounds
AM/PM
Date Service
Atr/Oz Start
MasklCann Day
NeblMHH Day
CroupelteDay
RxStart
IPPB
Aerosol
CPT
STATTx
MOITx
1$8
USN / Induced
Rx/Snulum
Vent Start
Vent Day
CPAP Day
MonitorSlart
CapnographDay
Oximeter Day
Oximeter Check
Cuff Press. Check
Arterial Puncture
Transport Internal
Airway Box
ExlendedService
,
I
I
~ .\ :-~ l
"", ::' C" nlGOI
. l~ , ! L' t^. D.s <..
2l'38
[ ~ f ;~
(I OJ
r>. .:: t' t, ",' f' .I I. 7.... ~
Wi v-c\ I Br'r1f' h\,
1// /!/I/
'Jh
J-/A1f AO, JA'
, .
--
//3 ;1.(115
ROOM
~/( -....2-
513
Code
x
Disposable Equipment
Disposable Circuit
MOl Spacer
102
103
104
108
302
303
304
305
308
314
602
307
202
203
106
902
903
904
709
711
703
512
507
504
5 vt,
DI
802
803
807
MR 147.A Rev. 4/97
RESPIRATORY CARE RECORD - GENERAUEMERGENCY CARE SERVICES
/
CONSEN! W;ON ADMISSlo..N TO HOSPITAL FOR MEDICAL TREATMENT
/5/);/1(:117// (/)j)~rI ' :';:n1?27;9 724': 3
!1/JC Ti-AI~.At,l,t">q78
PA TlENT NUMBER 31c/}"n,!' ADMISSION DA TE " ." .,'
, '.,... 'jtt, ... "
I, - (O'-r!f)",~~1 L-:IIMI onbehalfbi ,-': :A'Y 'Allim.Jl(l
knowing that I, (helshe) am (is) suffering from a condition requiring hospital care, do hereby voluntarily consenno such hospital carl!
encompassing routine diagnostic procedures A.nd medical treatment by the medical staff of University Hospital, The Milton S. Her-
shey Medical Center, their assistants, or their designees as necessary in their judgement.
I am aware that the practice of medicine and surgery is not an exact science, and I acknowledge that no guarantees have been
made to me as to the result of treatments or examinations in the hospital. For the purpose of advancing medical knowledge I Gon-
sent to the admittance of medical students and other observers in accordance with ordinary practices of this medical facility. This
form has been fulfy explamed to me I certify that I understand Its contents and have agreed to these provIsIons
~2L.nt J.f, (~i /7 d
PA TlENT'S SIGNA RE
PA TlENT NAME
7~' r ')
G 3 / 2 5 I ,.
WITNESS
Patient is unable to consent because he/she is:
~r
CJ undergoing emergency treatment
[] other, describe
'/If) J.1f1111M
G)
CLOSEST RELA TIVE OR LEGAL GUARDIAN SIGNA TURE
WITNESS
mtIl/1 r1L
RELA TlONSHIP
HOSPITAL MEDICAL RECORD RELEASE AUTHORIZA nON/PERSONAL EFFECTS
The Milton S, Hershey Medical Center may disclose information about me and the treatment for which I am being admitted, in.
cluding copies of my medical records, to (7) my health Insurance company, (2) my employer, (3) any person or firm which conducts
reviews of my treatment at the University Hospital, The Milton S, Hershey Medical Center on behalf of my health insurance company
or my employer, and (4) the peer review organization designated by the appropriate governmental bodies to review hospital utiliza-
tion under the Medicare program. .
This information will be used by these parties to determine the medical necessity of the medical and hospital services I will be
receiving, and to promote timely and appropriate discharge from the hospital. The information may also be used to get all or part of
my hospital bill paid, I have read this consent and understand it fully I have had the opportunity to ask any questions relating to this
consent, and any questions I had, have been answered to my satisfaction.
Safety deposit boxes are maintained in the Hospital Financial Management Office for the safekeeping of patient's valuable per.
sonal effects, Patients are urged to avali themselves of this facility as the Hospital does not assume responsibility for any valuables,
The undersigned accepts the full responsibility for any pe,sonal effects taken to the hospitai room, including but not limited to such
things as money, dentures, eye glasses, contact lenses, hearing aids, radiOS, and teleVISion ~e:l;
3 ( 5! 0 I JU'yYL rrlJ-f dLCwtd
DATE ' PATIENT I
DATE
~ENT OR GUARDIAN
PA nENT RESPONSIBILITY AGREEMENT
I, the undersigned, do hereby acknowledge and accept financial responsibility for the payment of all cHarges
3-5-6,
For services rendered to I, the undersigned, do
hereby acknowledge and understand that all charges not covered by insurance will be payable in full prior to or upon date of and
time of discharge. I, the undersigned, authorize the hospital to make a credit investigation if necessary.
I hereby assign and authorize payment directly to The Milton S. Hershey Medical Center Hospital, Pennsylvania State University,
Should the account become delinquent, and should it become necessary for the account to be referred to an attorney or collec-
tion agency for collection or suit, the undersigned shall pay the reasonable attorney's fees or collection expense.
j L/',
Signede;;) Q/ 'b\ ntLI- '\ Cz.J/in Date ::;'-,')-()/
I '
Witness ---r;< () j '{'1m!'! ./1 Date 3- 5 --()(
All persons will be accepted for admission without regard to race, color, creed, religion, national origin or sex.
i' "'..,
, 302978
03/2 5/1<0';
'-, '1 '........ If '\ I 1-
;1 i C;;;,
~ The Milton S, HeJo,,"Y Medical Center
. The College of Medicine
;, , ! ~ \. '( :~I,
MH 1132) 19"
1,AVH*30297e
: ~) ,~ ? 1 Q ,::. ',',
7247-3 ?I 7"0'
03/25/1e;,
CONSENT FOR ANESTHESIA
,
c
r ;\ ~,y !-'
"'~'.
I, LAI J.ZD ) _18 M M I.j ,request the administration of anesthesia to JA-/R.D) J:SR.J/fAf't (
(patient o0sponsible part~ M O-r {f'Z- rl (patient)
to reduce the pain and/or awareness during a surgical or medical procedure, and, authorize the monitoring at vital bodily
funclions by, andlor under the direction of a staffmember of the Department of Anesthesiology of The Milton S, Hershey
Medical Center, A resident physician and/or nurse anesthetist from the Department of Anesthesiology may also
administer anesthetics and be responsible for monitoring vital bodily functions,
1. I agree to the administration ot one or more of the following alternative forms of anesthesia which may be suitable for
the procedure I (or the patient for whom I consent) am about to have, All of the following forms of Anesthesia which I
have checked below have been explained to me (Check those to which you agree):
J- a) GENERAL ANESTHESIA: jncluding intravenous agents and inhaled gases, which will cause
unconsciousness.
b) SPINAUEPIDURAL ANESTHESIA: including needle injections in the back near the spinal cord,
leading to temporary loss of pain sensation and sometimes strength in a large area, usually the lower
half of the body, This may also include the administration of sedatives to help me relax during surgery,
c) REGIONAL ANESTHESIA: including needle injections near major nerves, usually in an arm or leg,
which will temporarily cause me to lose pain sensation and perhaps strength in certain areas of my
body. This may also include the administration at sedatives to help me relax during surgery.
d) LOCAL ANESTHESIA: including local anesthetic agents with or without intravenously administered
sedatives.
2. I do not consent to the administration of
(i1 no exceptions, place "X" in above blank)
3. I understand that any form of anesthesia for which I have given consent may be administered at the time of surgery.
i---
anesthesia.
4, If my spinal, epidural, regional or local anesthetic is not satisfactory for my comfort or to allow the surgery to proceed,
or if my medica! condition requires, I consent to the administration of general anesthesia.
5. I am aware that the practice of anesthesiology is not an exact science and that no guarantees car. be made
concerning the results of administration of anesthetics to me. Common side effects of anesthesia and various
patient monitor'lng procedures include: nausea and vomiting, headache, backache, sore throat or hoarseness, and
soft tissue swelling. In addition, even minor surgery may carry with it major unforeseen anesthetic risks. These risks
and complications include, but are not limited to, dreams or recall of events under genera! anesthesia; corneal
abrasions; damage to the mouth, teeth or vocal cords; damage to the lungs or their linings, the pleura; pneumonia;
numbness; pain or para!ysls; infection; headache; damage to veins, arteries, liver or kidneys; a~veL$e drug reaction
and in rare cases, permanent brain damage, heart attack, stroke, or death. These potential risks apply to me
whether I have a general, regional or local anesthetic.
6. I understand that various patient monitoring procedures may be necessary, and be performed by anesthesiologists.
to monitor or maintain my vita! bodily functions during anestheSia and surgery. These procedures could commonly
include insertion 01 intravenous catheters, bladder catheters, or tubes into the stomach. In some cases specialized
monitoring may require placement of needles or tubes into an artery, into the large veins in the neck or chest, or into
veins in the lungs or heart itself. A flexib!e tube may be placed into the esophagus to view the heart, or brain waves
may be analyzed with needles under the skin 01 the scalp,
MR 770 10/97
CONSENT FOR ANESTHESIA
CONSENT FOR ANESTHESIA
7. I understand that during the course of an operation, unforeseen changes in my condition may arise which would necessitate
changes in the anesthetic care being provi:c:iS!d to me. In that case, I authorize my anesthesiologist, or other physicians or nurse
anesthetists designated by my anesthesiologist, to provide such medical 1reatment, or perform such procedures as are
neces?ary and desirable in the exercise of professional judgment.
8, If lam pregnant, I understand that elective surgery should be postponed until after the baby is born, Anesthetics cross the
placenta and may temporarily anesthetize the baby, Although fetal complications of anesthesia during pregnancy are very rare,
the risks to my baby include, but are not limited fa, bi~h detects, premature labor, permanent brain damage and death,
9, I ce~ify that I have, to the best of my ability, told the anesthesiologist obtaining consent, of all major illnesses I have had, of all
past anesthetics I have received and any complications of these anesthetics known to me, of any drug allergies I have, and of
all medications I have taken in the past year, I have also responded truthfully to any additional questions asked by the
anesthesiologist,
1Q,The nature and purpose of my anesthetic m"nagement have been explained to me, I have had the oppo~unity to ask
questions, and the answers and additional information provided have met with my satisfaction. I retain the right to withdraw this
consent at any time prior to the administration of said anesthetic.
11.1 ce~ify that all blanKS requiring inse~ion of information were completed before I Signed this consent form,
~JaYVVYY1JvjX.~d ~ 3Jl1I~
(Patient's Signature/Oat )lJ.O\\-K,!L (Witness to Patient's Signature/Date)
(or signature of p son consenting on behalf of p~ enl)
~-~.:S\~lD I
Dr,
for the procedure,
MQ\-r\ I) 'i:-'r.JJ
provided the information summarized above and obtained the cons~nt '
~u
3~4i 0 (
1{ f7{ 0) yVJ~
($'l~ '(
~
-,
(Physician's Signature/Date)
MR 770 10/97
CONSENT FOR ANESTHESIA
Health System
ger
The Milton S, Hershey
Medical Center
312-0 fA7 CA1/LD
~ 362 c:; 7'J
"
..... \".tUlh....1lalC vel
CONSENT FOR ANESTHESIA
-
I ~ (2 ",' (PItUc-;'I-{fEIZ-)
I, 7f1~ J..-f'1/ f'/ , request the administration of anesthesia to
(pali t or responsible party) (patient)
to reduce the pain and/or awareness during a surg,ical or medical procedure, and, authorize the monitoring of vital bodily
functions by, and/or under the direcllon of a stafJ member of fhe Department of Anesthesiology of The Milton S, Hershey
Medical Center. A resident physician and/or nurse anesthetist from the Department of Anesthesiology may also
administer anesthetics and be responsible for monitoring vital bodily functions,
1. I agree to the administration of one or more ot the following alternative forms of anesthesia which may be suitable for
the procedure I (or the patient tor whom I consent) am about to have, All of the following forms of Anesthesia which I
have checked below have been explained to me (Check those to which you agree):
-A.- a) GENERAL ANESTHESIA: including intravenous agents and inhaled gases, which will cause
unconsciousness.
b) SPINALlEPIDURAL ANESTHESIA: including needle injections in the back near the spinat cord,
leading to temporary loss of pain sensation and sometimes strength in a large area, usuaJly the lower
half of the body, This may at so inctude the administration of sedatives to help me relax during surgery,
c) REGIONAL ANESTHESIA: including needle injections near major nerves, usually in an arm or teg,
which will temporarily cause me to lose pain sensation and perhaps strength in certain areas of my
body, This may also include the administration of sedatives to help me relax during surgery,
d) LOCAL ANESTHESIA: including local anesthetic agents with or without intravenously administered
sedatives.
2. [do not consent to the administration of
^
{if no exceptions, place "X" in above blank)
3. I understand that any form of anesthesia for which [ have given consent may be administered at the time of surgery.
anesthesia.
4, If my spinal, epidural, regional or local anesthetic IS not satisfactory for my comfort or to allow the surgery to proceed,
or \f my medical condition requires, I consent to the administration of general anesthesia.
5. [am aware that the practice of anesthesiology is not an exact science and that no guarantees can be made
concerning the results of administration of anesthetics to me. Common side effects of anesthesia and various
patient monitoring procedures include: nausea and vomiting, headache, backache, sore throat or hoarseness, and
soft tissue swelling. [n addition, even minor surgery may carry with it major unforeseen anesthetic risks. These risks
and complications include, but afe not limited to, dreams or recall of events under general anesthesia; corneal
abrasions: damage to the mouth, teeth or vocal cords: damage to the lungs or their linings, ~he pleura: pneumonia;
numbness; pain or paralysis; infection; headache; damage to veins, arteries, liver or kidneys; ad~rse'drug reaction
and in rare cases, permanent brain damage, heart attack, stroke, or death. These potential ris~s apply to m.e
whether I have a general, regional or local anesthetic,
6. I understand that various patient monitoring procedures may be necessary, and be periormed by anesthesiologists,
to monitor or maintain my vital bodily functions during anesthesia and surgery These procedures could commonly
include insertion of intravenous catheters, bladder catheters, or tubes into the stomach. In some cases, specialized
monitoring may require placement of needles or tubes into an artery, into the large veins in the neck or chest, or into
veins in the lungs or heart itself. A flexible tube may be placed into the esophagus to view the heart, or brain waves
may be analyzed with needles under the skin of the scalp.
MR 770 10/97
CONSENT FOR ANESTHESIA
CONSENT FOR ANESTHESIA
7. I understand that during the course of a~ op~ration, unforeseen changes in my condition may arise which would necessitate,
changes in the anesthetic-6are being pro'Vided to me. In that case, I authorize my anesthesiologist, or other physicians or nurse
anesthetists designated by my anesthesiologist, to provide such medical treatment, or perform such procedures as are
necessary and desirable in the exercise of professional judgment.
8, If I am pregnant, I understand that elective sU[Qery should be postponed until after the baby is born, Anesthetics cross the
placenta and may temporarily anesthetize the baby, Although fetal complications of anesthesia during pregnancy are very rare,
the risks to my baby include, but are not limited to, birth defects, premature labor, permanent brain damage and death,
9, I certify that I have, to the best of my ability, told the anesthesiologist obtaining consent, of all major Illnesses I have had, of all
past anesthetics I have received and any complications of these anesthetics known to me, of any drug allergies I have, and of
all medications I have taken in the past year, I have also responded truthfully to any additional questions asked by the
anesthesiologist.
10.The nature and purpose of my anesthetic. management have been explained to me, I have had the opportunity to ask
questions, and the answers and additional information provided have met with my satisfaction. I retain the right to withdraw)"
consent at any time prior to the administration of said anesthetic.
11.1 certify that all blanks requiring insertion of information were completed before I signed this consent form.
Mo-rx.a2-
3/3/0 (
llu1
x ~;;g)fo A~d.
(Patient's Signature! ate)
(or signature of person consenting on behalf of patient)
Dr '4n-~C\ "0 I J, -!\C~c<J -e ""-
for the procedure.
provided the information summarized above and obtained the consent
-,
a e)
$(3 Ie \
MR 770 10!97
CONSENT FOR ANESTHESIA
. 1..-1 '1 'hJ I{\I L
~ The Milton S, Hersl<cj Medical Center
. The CoJlege of MedicIne ,
SPECIAL CONSENT FOR OPERATION OR
OTHER PROCEDURE
~~, .
ri
5\'~~(~""1 ILl
n f""" j,",~\-, t4lth \:',._..J'vrc...
f '.\ f'~ I. I:' C C)
~'~ C:A! ~ ':'~ 1\> ~:11
Condition For Which Treatment is Proposed:
1, I hereby authorize my physician, Dr. itJe-\ \ "-L-~ , andlor such other staft
physicians or resident physicians as my physician may designate, to perform upon me (or the patient
identified above) the following operation or procedure (for procedures on all paired organs or
extremities, the side of the body must be specified as left, right, or bilateral, without abbreviations):
\-.\." \ +\rlv.-. -:;:-c";e~....J. DJ-,0,L~ Of"~ \'" I,.\- ~ \;o...Ccv",-, c~ ~q'\-,1:...:t::v.J~;-:,d'-
(~~',w.- C"'~~ ,,,,,,.d;- \..,,-,I,.~ A,...JJ, {Cr ~'" , In thiS consent form, t IS operation or procedure IS
referred to as the "procedure",
2, My physician has discussed with'me the items that are briefly summarized below:
(1) The nature and purpose of the proposed procedure:
+- "-'1'''';' ~ (..,. ",ct~;f '-
(2) The risks of the proposed procedure, including the risk that this treatment may not accomplish the
desired purpose:,..J- '<>v- l', ""'" ""A,~'~ \.,,,,,,,- crY
k.r "-'<.- "-<.A- ~r '5-(' .""')() .j" ~",",.\.l.... p\4k
(3) The feasible alternative treatments:
~
o
(4) What may happen if the proposed procedure is not undertaken: ',~"-d:;,,,,,-
~~~
~~
I
3, I am aware that, in addition to the risks specifically described above, there are other risks that are
present with respect to any surgical procedure, such as severe loss of blood, infection, cardiac arrest,
and blood clots lodging in the lungs, any of which may require additional corrective surgery or result in
death,
4, I understand that during the course of this procedure, unforeseen conditioas-f'nay arise which could
require the nature of the procedure to be altered, or that another operation or procedure be performed,
I therefore authorize my physician, or other physicians designated by my physkian, to provide such
medical treatment, or perform such operation or procedures as the necessary and desirable in the
exercise of professional judgement
5, I am aware that the practice of medicine and surgery is not an exact science, and I acknowledge
that no guarantees have been made to me concerning the results of the proposed procedure,
MR 21 Rev, Page 1 of 2 5100
SPECIAL CONSENT FOR OPERATION OR
OTHER PROCEDURE
S, _CIAL CONSENT FOR OPERATION OR
OTHER PROCEDURE
6, I understand that, during the course of my operation, it may be necessary for me to receive blood
transfusions or blood components, I authorize my physician to administer these to me if it is
determined to be necessary for my care ~nd treatment. I understand that an adverse outcome from a
blood transfusion may sometimes occu'reven though the best available practices have been followed,
7. I acknowledge that the information I have received, as summarized on this form, is sufficient for me to
consent to and authorize the procedure described above I have had the opportunity to ask questions
concerning my condition, and about the procedure, alternatives and risks, and all questions have been
answered to my satisfaction,
8, I impose the following Iimitation(s) regarding my treatment (~so state):
9, I authorize the staff of The Milton S, Hershey Medical Center to preserve for scientific or teaching
purposes any tissues or parts which may be removed in the course of this procedure, and to dispose
of them,
10, i authorize The Milton S, Hershey Medical Center to permit other persons to observe the procedure
with the understanding that such observation is for the purpose of advancing medical knowledge, I
authorize The Milton S, Hershey Medical Center to obtain photographic or other pictorial
representations of the procedure, and to use such representations for scientific or teaching purposes,
11, I certify that all blanks requiring insertion of information were completed before I signed this consent
form,
~~..'<fU^'rl ;J/3/U/
(Patient's Signature/Date)
(or signature of person consenting
on behalf of the patient)
Dr, 1'0_,
for the procedu~, 0
provided the information summarized above and obtained the consent
~~
hysi' s Signature/Date)
I CONSENT TO THE ADMINISTRATION OF ANESTHESIA, RECOGNIZING THE RISKS THEREOF, POSSIBLE ALTERNATIVES, AND
SPECIAL PROCEDURES INCLUDING THOSE DESCRIBED ABOVE, I REALIZE THAT PROCEDURES DIFFERE~TOR IN ADDITION
TO THOSE DISCUSSED MAY HAVE TO BE USED DURING THE ANESTHETIC, I HAVE HAD THE &>PORTUNITY TO ASK
QUESTIONS WHICH HAVE BEEN ANSWERED TO MY SATISFACTION,
; ..,h./o I
Witness
Patient (or parent/guardian)
[For elective procedures, this consent is valid for up to 60 days from the date of patient's signature, unless
,here is significant change in the patient's condition or consent is revoked by the patient.]
MR 21 Rev. Page 2 of 2 5/00
SPECIAL CONSENT FOR OPERATION OR
OTHER PROCEDURE
Hershey Medical Center
Coding Summary Form
Patient Name..
Age....,
Sex.., ,
Account Number.,
Medical Record Number.. .
Admission Date,."
Discharge Date..,
Discharge Disposition..
Attending Physician....
Slalus"
LAIRD, BRITTANY M,
10,
Female
000000021880
00362978
0310312001
03/06/2001
01 . Home
24455 WALLACH, DAVID M, aRT
N . Complete, no attestation needed
DX
1
2
3
4
5
PR
1
2
3
4
DRG ' 220
Memo
Coder_' CK3
Code
823,32
825,25
920
914,0
E819,7
Code
79,36
79,06
86,28
86,28
DX Description
Opn FX Shaft of Tibia and Fibula
Closed Fracture Metatarsal Bone
-Contusion of F ace/ScalplNeck Excl Eye
Abrasion/Fridton Burn Hand w/o lnfection
MV Traffic Accident NOS Inj Pedestrian
PR Description
Open Reduction w Int Fixa FX Tibia
Closed Reduction FX TibialFibula
Nonexcisional Debridement Wound/lnfectionfTibia
Nonexcisjonal Debridement Wound/lnfectionlTibia
LOW EXTR & HUMER PROC EXC HIP,FOOT,FEMUR AGE 0.17
Procedure Date
03/03/2001
03/03/2001
03/03/2001
0310512001
SurQeon
24455
24410
24455
24455
3/12/01
PENN STATE 362970
College of Medicine . University Hospital' Children's Hospital
The Milton S, Hershey Medical Center LAIRD, BRITANNY
>-,. 03/25/90 F
OPERATING ROOM RECORD ,-' WALLACH, DAVID
-
Delay Codes Patient In DATE O,R. SERVICE \J[
~ime: 11 :35 03103102 15 ORTHOPA DICS
Anes, Start Surgeon Start Add'on [ Y] Patient Type: TRMA
Time: 11 :35 Time: 12:01 - Level: FTE: 20
Incision Time Surgery End Instrument Count: [ N] (C)orrect (I)ncorrect (N)/A
Time: 12:25 ' Time: 13:20 Sponge Count: [ C] (C)orrect (I)ncorrect (N)/A
Patient Exit otal Time Estimated Time Needle Count: [ C] (C)orrect (I)ncorrect (N)/A
Time: \3~?:l
Pre.Op, Diag LEFT ANKLE FRACTURE
-
Operation ORIF LEFT ANKLE FRACTURE
,t-Op Diag, SAME AS PRE,OP DIAGNOSIS
Wound Classification 3
Attending Surgeon CODE Scrub:LONG, MARGARET Obi Scrub:
WALLACH, DAVID Relief Name: Time In: Out:
Assistant
FARINO, GREGORY
Assistant
FAYAZI, AMIR Circulator: DEAN, LINDA Obi Circulator:
1istant Relief Name: Time In: Out:
Attending Anesthesiologist
DURBIN, TERRY
Assistant X-ray N Fluoro Y
PORTER, L YNEE Anes, Type GENERAL ANESTHESIA
Post-Op Destination Specimen:
PAR NONE
JS, Tech, BORNEMAN
Post Anest~e~aJ~nit J /u~>.r'
Pertusionist Time In: i Time Out: -r,J ~ Total:
Prosthesis - Implants - Grafts:
Type Description Lot No,: Serial No: Size: Mfg,
SCREW X1 PARTIALLY THREADED 205,36 36MM SYNTHE
SCREW X1 PARTIALLY THREADED 205,38 38MM SYNTHE
" . :c
,
Comments:
I) , n ~ '
Signed By: N \rM Jl .J "-' \'\0>. -Kr-...1I ('iWI\\::
MR 219 REV 8/90
OPERATING ROOM RECORD
PENN STATE 1132779
College of Medicine ' University Hospital' Children's Hospital
The Milton S, Hershey Medical Center LAIRD, BRITTNEY
-, 03/25/90 F
OPERATING ROOM RECORD '-'" '. WALLACH, DAVID
,
Delay Codes Patient In DATE O,R. SERVICE J[
ime: 08:35 03/05/01 12 ORTHOPA DICS
Anes, Start Surgeon Start Add-on [ N] Patient Type: INPT
Time: 08:35 ime: 08:45 Level: FTE: 20
Incision Time :;urgery End Instrument Count: [ N] (C)orrect (I)ncorrect (N)/A
Time: 09:02 ime: 09:40 Sponge Count: [ C] (C)orrect (I)ncorrect (N)/A
Patient Exit otal Time Estimated Time Needle Count: [ C] (C)orrect (I)ncorrect (N)/A
Time: 09:45
Pre-Op, Diag SIP OPEN L T ANKLE FX WI PINNING
Operation I & D L T ANKLE WOUND
r 't-Op Diag, SAME AS PRE-OP
Wound Classification 2
Attending Surgeon CODE Scrub:MCCORKLE, CRAIG Dbl Scrub:
WALLACH, DAVID Relief Name: Time In: Out:
Assistant
HUGATE, RONALD
Assistant
Circulator: YODER, MICHAEL Dbl Circulator:
,istant Relief Name: Time In: Out:
Attending Anesthesiologist
LONG, T
Assistant X,ray N Fluoro N
Anes, Type GENERAL ANESTHESIA
Post-Op Destination Specimen:
PAR NONE
), Tech,
Post Anesthesia Care Unit /D3<./
Perfusionist Time In: 09 LtC, Time Out: Total:
Prosthesis - Implants - Grafts:
Type Description Lot No,: Serial No: Size: Mfg,
NONE
- -
.
Comments:
Signed By: /~"LL
MR 219 REV 8/90
OPERATING ROOM RECORD
~ The Milton S, HerSl'~) Medical Center
. The College of MediCine ,
,
Il:
INTRA OPERATIVE NURSING DOCUMENTATION RECORD
,
c ,
2 : d ,~
E 'j t.., ""-'
;.~
,~ ~ .
~ '"\ ,
-
Pre-Op Checklist:
Hospital 10, Band checked
Verbal Confirmation of Patient I.D,
Verbal Confirmaflon of Operative
Procedure
Pre'Op c:MentKAned
Allergies \L
Safety Belt on
Thermal Unit Temperature
Blood # Typ~een
_ Type/Cross # Units _ None
The Patient identity, surgical Procedure, and surgical
site were verified by the attending surgeon
(Surgeon Signature)
Comments:
PATIENT ASSESSMENT
level of Consciousness and Behavior:
--,/Asleep / Crying
~ Alert ~ Cooperative
Drowsy Anxious
Unresponsive Restless
Talkative Disoriented
Calm
Comments:
Genfl Appearance of Skin:
_ Good Color
Skin intact
Flushed
Pale
Cyanotic
Jaundiced
Diaphoretic
Comments:
Rash
Bruise
Reddened
Area
Mottled
, Abrasion
./ r;r'Slpen V\lound
~ ~,,,-\1iJ l /'
MR 370 Page 1 of 2 5100
Date: ? D I
PhysiPillmpairments or Disabilities
~ None _ Obese
Blind Deaf
Immobile Joint Amputation
Ostomy
Language
Comments:
Prosthesis
Arthritis
INTRA.OPERATIVE CARE
Pos~n for Surgery
~ Supine
Prone
_Lithotomy
Sitting or Fowlers
Georgia Prone
Lateral
Right
Left
Positional Aides:
Pillows
Blanket or towel
rolls
Sandbags
Armboard
Olympus Armboard
Overhead Arm
Support
Long Leg Stirrups
Stirrups
Fracture Table
Other
Comment5:
Disc Table
Montreal lateral
Positioner
Spine Frame
Beanbag
Chan Headrest
Horse Shoe
Headrest
Mayfield Gardner
Headrest with Skull
Points
Foam rings
Skin Preparation: /
Pre'Op Shave: ----/-- Clipped _ Razor _ None
Prep Solution: ~ Betadine Soap
--L-. BetadinJ'.Sglution
A~ Oti(.r ~
Prep Completed by: ' ~ '''-. (
Catheter: _ Yes No
Fe. cc Balloon Urimeter
_ Straight Drainage
_Other
Foley Inserted by:
Comments:
INTRA OPERATIVE NURSING DOCUMENTATION RECORD
INTRA c,. _RATIVE NURSING DOCUMENTATION ReCORD
Drains: Loman
Hemovac ~fl.~
Jackson
Pratt
Penrose
Miller Vac,
Butterily
Duval
Sump
T.Tube
Othe~ /
-NeRiiJsed V
Comments:
;.,
# Used
L-
Size
\/ II
('i
Tourniquet: ~ Yes
Applied by:
Time Up:
Time Up:
Site Applied to:
Electro Surgical uni~ ~
LocaliOn of ~pad:
Applied by: ,
Pre-A.dPlication Skin Condition:
~ Skin intact, no apparent defects
Other
Comments:
No
Pressure
Time Down:
Time Down:
/
v Monipolar # t D (0 Q Bipolar #
Sk~!ondition after removal of ground pad:
Skin intact no apparent defects
Other
Comments:
Chest TUbe~ None Used
~ Right Left
Fe. # Used Fe.
Chest Drainage System ~ Yes
Comments:
# Used
No
MR 370 Page 1 of 2 5100
Packing:
Location:
Material Used:
, Dry
Solution Used:
Other:
Dressing: (0\ None Used
LO~/ ~ ()~~
~ 4 x 4's
Abd's
Band-aid
Collodion
Rte~s
it! Xeroflo 0
Xeroform
Fluffs
Kerlix
~Kling
Benzoin
--:+-- Tubex Gauze
~ Webnl
Type of Tape Used:
Comments:
~
None Used
Wet
~ones Dressing
~ce
-L Splint
Cast
~ Montgomery
Dressing
Pressure
Dressing
~ Opsite
~ Adaptic
~ Eye Pad
Spon)les Used:
~ Ray tee _ Laps
Peanuts Cottonoids '
Spol}ge Count:
-""-- Correct Incorrect
Needje Count:
~ Correct Incorrect
Instrument Count:
Correct Incorrect
Additional Comments:
_ Long Tapes
Tonsil
None
None
/ None
Signature & Date~~~~~~
~(~IOI
(Fr, = French)
INTRA OPERATIVE NURSING DOCUMENTATION RECORD
tTI~I~JIAI C
~ The Milton S, Hershoy Medical Center
. The College of MedicIne
~. .)
, ,
\)3/25/1
\:-1,' 1 <;. -'
l~ -,~ F.,'~f~fA\Y M
D ' '- <.--,', ;;: ~ f l K W
INTRA OPERATIVE NURSING DOCUMENTATION RECORD
2 ciS v
-
Pre-Op Checklist: Yes No Date: ,< -S"-O I
Hospital 1.0, Band checked ..- Physical Impairments or Disabilities
Verbal Confirmation of Patient LD, -- None Obese
~ ~
Verbal Confirmation of Operative - Blind Deaf
--- ~ ~
Procedure ~ Immobile Joint ~ Amputation
Pre-Op Consent Signed~ --r-
Allergies c..J- <1,-' -- Ostomy Prosthesis
~ ~
Safety Belt on -- Language Arthritis
~
Thermal Unit Temperature
'--
Blood # T ype/Screen
~ TypelCross # Units ~one
The Patient identity, surgical Procedure, and surgical
site were verified by the attending surgeon
(Surgeon Signature)
Comments:
PATIENT ASSESSMENT
Level of Consciousness and Behavior:
Asleep Crying
- Alert Cooperative
Drowsy Anxious
Unresponsive Restless
Talkative Disoriented
Calm
Comments:
General Appearance of Skin:
----=: Good Color
Skin intact
Flushed
Pale
Cyanotic
Jaundiced
Diaphoretic
Comments:
Rash
Bruise
Reddened
Area
Mottled
Abrasion
Open Wound
MR 370 Page 1 of 2 5100
Comments:
sjP 7!7 A..c(f' FJ('
INTRA,OPERATIVE CARE
Position for Surgery
--= Supine
Prone
~Lithotomy
Sitting or Fowlers
Georgia Prone
Lateral
Right
Left
Positional Aides:
Pillows
Blanket or towel
rolls
Sandbags
----=- Armboard
Olympus Armboard
Overhead Arm
Support
Long Leg Stirrups
Stirrups
Fracture Table
Other
Comments:
Disc Table
Montreal Lateral
Positioner
Spine Frame
Beanbag
Chan Headrest
Horse Shoe
Headrest
Mayfield Gardner
Headrest with Skull
Points
Foam rings
Skin Preparation:
Pre-Op Shave: ~ Clipped ~ Razor -None
Prep Solution: '>- Betadine Soap
----2::: Betadi8t'SOlution
Alcohol ------.<Elther
Prep Completed by: ~ ~
Catheter: Yes -.-JL No
Fr, cc Balloon Urimeter
~ Straight Drainage
Other
Foley Inserted by:
Comments:
INTRA OPERATIVE NURSING DOCUMENTATION RECORD
INTRA OPERATIVE NURSING DOCUMENTATION RECORD
Drains: Location Size
Hemovac
Jackson
Pratt
Penrose,
Miller Vac,
Butterfly
Duval
Sump
T.Tube
Other
None Used ~
Comments:
# Used
Tourniquet _ Yes
Applied by:
Time Up:
Time Up:
Site Applied to:
Electro Surgical Unit
Location of Ground Pad:
Applied by:
Pre.Appiication Skin Condition:
~kin intact, no apparent defects
Other
Comments:
...-- No
Pressure
Time Down:
Time Down:
~Monipolar # ~ Bipolar #
Skin condition after removal of ground pad:
~Skin intact no apparent defects
Other
Comments:
Chest Tubes .....-None Used
_ Right Left
Fe. # Used Fr,
Chest Drainage System _ Yes
Comments:
# Used
No
MR 370 Page 1 of 2 5100
Packing: ....--
Location:
Material Used:
. Dry
Solution Used:
Other:
Dressing:
Location: e
-----= 4 x 4's
Abd's
Band.aid
Collodion
_ Steri-strips
V""'Xeroflo or
Xeroform
Fluffs
Kerlix
_Kling
Benzoin
Tubex Gauze
~ebril
Type of Tape Used:
Comments:
None Used
Wet
h NoGe us, ed
fL
_ Jones Dressing
-- Ace
_-.-5plint
Cast
_ Montgomery
Dressing
Pressure
Dressing
_ Opsite
_ Adaptic
_ Eye Pad
Sponges Used:
_ Raytec
Peanuts
Sponge Count:
---.:::::. Correct
Needle Count:
.-correct
Instrument Count:
Correct
Additional Comments:
..,...-r.aps
Cottonoids
_ Long Tapes
Tonsil
Incorrect
None
Incorrect
None
Incorrect
"'----None
-;;.--~-
Signature & Date
(Fr, = French)
/~~
INTRA OPERATIVE NURSING DOCUMENTATION RECORD
~ PennState L ...;isinger
~ Health System
PRE-OPERATIVE CHECKLIST
ML\32779
The Milton S, Hershey:: ' l," A # } 6 2 9 7 B
Medical Center :^, # , j P 'c'
o .!. v
~r~~"Yr--~
7247-32 S
03125/h,
iJ.
~ '
" , ~
, '
DNa In" ial
./
No ./
DNa
. 3, History and physical signed and dated, Ves
4, lab work/test completed, if ordered:
D . Hct
D P,egnancy test (within 48 hrs) D Negative D Positive
D Chest X.ray
D EKG
D Other labs (e,g" labs ordered for a,m, of surgery, such as glucose or potassium)
6, Completed, it ordered: D None
~pe & Cross done, Number of units~
o Limited Donor Protocol
o Autologous blood available
o Type & Screen only /11\ ~
.Jl21.-Blood 10 band site \. M 1J1'u.A)"--
, R # from blood band "
b, Living Will/Advanced Directives on chart Ves 0
c, Limited support on chart Ves 0
.8. Removed, if applicable: Not removed:
o Undergarments 0 Contact Lens 0 Wig 0 Weddtng Band Taped
D Dentures D Hai'pins D Prosthesis 0 Hearing Aid
D Glasses D Hearing aide D Other 0 Glasses
D Nailpolish 0 Jewelry (especially if on operative extremity)
.9, a, NPO at b, Peds NPO: Clear liquid or breast milk until , then NPO
.10, If ordered, operative prep done, 11, Special patient devices (e,g" ostomies, pacemaker)
D Ves 0 No Describe @I-l. fliP' (.,{V:JJ- i ~iI\V cDr
IV' On(..
()
~ t
3 _ 5 -oj
, m1J)~u,J
PRE-OPERATIVE CHECKLIST
MR 12 (Rev, 11/97)
.1, Operat'lve permit signed and dated,
2, Old records obtained and sent to OR with chart,
. 5, Allergies:
(specify)
x:' None
D Ves
7, a, Religion A/nl/t/ /,.1,,0,[)
.12, Vital signs at: 3.oS
TPR 3'1\ ,- ll)
BP
~"
14, List meds sent to O,A.:
None
.16,
[ZI Plastic master card on chart,
17. Comments:
Patient preparation complete
Patient 1.0. prior to transport
Ves
t J
:/
~v
,
:/
v
.13, Time of las voi r change: C'tifl
o Foley in place
'~
.15, Meds given ON CALL to O,R,
None Ordered
Time & date
v
Location of patient 10 band
,R,N,
Date
Time
Time
1)
tJ ffO 7
,RN,
Date
,Aide
Date
Time
PR OPERATIVE TEACHING
RECORD see other side
THE MILTON S HbRSHEY MEDICAL CEN~b) .32779 7247-) 7MBS
., ~~!~~Ai)b2978 03/25/199^
r~s 2 " v
'.' v, # 1 P 8v
lAiiS fr,llTA\Y M
J:,.. '., \'\ TEl; w ?{~
PRE-ANE$THESIA EVALUATION
v. .' .
HEIGHT
5' :;../r
em 755' k
PRE.OP DX 1)~1W\\c.0. ~~ 8\ p 0 R\f- ~ tv! kJ ~b ~
PROPOSED OP: \ k. .D L aM'k:l e..
DATE
3 01
AGE SEX RACE
la' P
WEIGHT '
P)t(SICAL STA1US
V'3 4 5 E
STOMACH CONTENTS:
Nf)o -p N/IJ
(c-ct:; w,t
ALLERGIES:
(\J Ie oA
PAST MEDICAL HISTORY
(to be completed by patient)
PREVIOUS SURGERY:
D~TE OPERATION 1'1 11
~~4() \ <!) {I. \ ~ ~ 1:'Iht:_, h
HAVE YOU EVER HAD:
YES NO
A, Respiratory
1.Croup ~
2.Asthma, wheezing
3. Snoring
4.Bronchitis
5.Einphysema
6. Pneumonia
7. Cigarette smoking
a.Cough, nasal congestion,
s I within 2 weeks --
9 oose tee or dentures . ~ ~
10.01 ICU moving neck or jaw _--L-
8. Cardiac
1.Rheumatic fever --
2.Heart murmur ~
3. Irregular heart rhythm
4. Heart attack
5. Heart failure
6.Chest pain
7. Shortness of breath
a.High blood pressure
C, Neurologic
1. Seizures =1=
2. Stroke
3. Unusual muscle. weakness
D, Kidney Disease --
E, Blood Disorder ~
1.Sickle cell
2. Bleeding abnormality
3. Prior blood transfusion
F, Gastrointestinal
1. Hepatitis --
2. Liver disease I
3. Drink alcohol
4.Jaundice
5. Difficulty swallowing
6. Heartburn
7.Hiatal hernia --
G, Endocrine
1.Diabetes --
2.Thyroid disease . __
3. Prednisone or steroid therapy~ I
4.Could you be pregnant? _
H, Family History 01 Adverse =+
Anesthetic Reaction
~ Other Medical Problems
.
>
w
~
M
W
W
Z
<
MEDICAL RECORDS
CURRENT MEDICATIONS:
COMPLICATIONS \\rr 'J..
~f\-7'./JJ.. 0'
. 6,0
o
Ml>O't
'1~
:;(":'1 <ll.?," IV
,-Ii -po <SlUo
:f'RN
(? l',N
--\-S1d l/'v'V0~ P,
w.e.u..Q) ~ MOVv\.
.31410 I
DATE
TIME:
VAILABLE:
UnIts R
o Autologous
CHEST X-RAY:
EKG:
POSTOP CARE:
o Short Stay
DI.G:u,
o Inpatient
THE MILTON S, HERSHEY MEDICAL CENTER
).,. # 1 1 '- j .,' : ~ j - } i' ~ 2 S-
o U'l ~"" C3/25/1Q~"
" i ') if.? 1 3 tl<;
1 l "., B:, i 1 r A ~ Y M
ANESTHESIA RECORD PAGEW Of (J;L
Me Day Year
~ S 1)\
OR Number PHY STM"
\~ -C
Operative proc,rture II
:l tD 10 r "",,Yf,^ ',I'
~rll HT ~WC;I Allergy~ COy~
Preoperative
SP02
\t~ :~r\)'e 1;P ~\
Pre-op Antibiotic
1 IfNiiS",e 180
ART
T Pressure
160
. Pulse
o Aesplfa 140
non
120
100
80
60
40
20
Tyc," ..,'
..,:,,1,,: H
Urine
E.BL"
Position ~.......
ANESTHESIOLOGIST POSTOPERATIVE NOTES:
STATUS ON PACU ARRIVAL: BP ~
POSTOPERATIVE COURSE:
TIME:
DATE:
MR 326 (REV 4/00)
26150
Anesthe~l....-.\: i \- I,. '.j'~ r' C i L ~ W
Machlne{#~
Continuous AneSlhesia Transfer To Incision Surgeon Conlinuous Anesthesia Patient Iden~dlAttending Anesthesiologist
cY%~i.; sw-=e~s 1:02 Tr:~:~~~~o O~5~ J:t-!~.,- ( r~1 ~ / ~
.- Oi..,o,l, I",..l-- \..,,' rDY'. I I I I R ~NA nr '''' 1 QI-1V'-'
~ (G') A'" 1/ , . ) 51 /) 01211- SU,.' :77 A
- " ;to//lr'1h
I
IH1
I I
Procedures Performed by Anesthesiologist
i",theliC Technioue:
Inhalation
I.V.
o Spinal
o Epidural
o Nerve block
o Monitored Care
"
SUMMARY OF INTRAOPERATIVE FLUIDS
DART CATH
o CVP
o Swan Ganz
o TEE
o Endobronch Intubation
o Fiberoptic Intubation
o Hypothermia
o Hypotension
o Hemodilution
TYPE VOLUME
300
u2--
Time
"
"
"
"
"
-,t:.::- i
'.i. .. (~'I '"
(<. ~L
b'j;
'7 ;/
,/ 'X
,1":':,
..
,,- ..,.. ," ,
',' ," ',,"~ "" ;, " ,
,
,
./
, , A;NO;AN~;;LO:;;: ~
, ~ rvlV/~d-~'1
, '."" LYV/ A 1rr.;R rf, '
Temp 1{'.4'~ -SILl vl ~c'st..b---n)
~~,+-
, e'f. +-:t'1 b... <:01 J
I vYl lA, /J~J. /J
VilA J/}~'1J. L.
".- '--0;.
'..
". ',:
, '.
.. ... ..
.. "
,'," .., I ,
,~
p~
, ~', "" '",
......
SPo._m,
UPt)
SIC.m=FNA /A /V7 /" ~./jt&- ')
SIGNATURE- ...i
ATTENDING ANESTHESIOfb;;IST III .
Alr.....'...-.' ....,..__,.....,,...,,,... ,
R
(f)
,/
t'Cl-.I-'J tAl t
~ The Milton S, Hershey Medical Center
. The College of Medicwe '
; <
;,!47-3 ;:';85
03/25/ 1 "1i~,j
;'\ '":.-/ '-
') u 2 1), r. ..J
POST ANESTHESIA CARE UNIT
L 'icj ? ;., i I i A ~"Y M
['I~i..',i" ~~r(R W
Z b 1 50
POST ANESTHESIA CARE UNIT
ORDER SHEET
-
FOR PACU USE ONL Y - BY DEPARTMENT OF ANESTHESIA
TIME:
DATE:
___lr:sloS ! 0 \
t
PAIN:
.
~ MS04 ~ mg IV now, may repeat every ~ min times 2_
0 Demerol_ mg IV now, may repeat every _ min times ~
~I Ketorolac _ mg IV now
'..J
C Fentanyl _ ~g IV now, may ,epeat every _ min times_
0 Acetaminophen _ mg elixir PO or _ mg Suppository PR every _ hr pm
~ Acetaminophen wi Codeine Elixir ---6- ml PO (24 mg Acetaminophen and 2.4 mg Codeinelml)
ovory fir prn
[J Acetaminophen wi Codeine Tablets _ Tablets PO (300 mg Acetamlnophen/30 mg Codeine per Tablet)
every _ hr pm
NAUSEAlVOMITING:
k>}' Ondansetron ~ mg IV, pm nauseaJvomihng
[J Droperidol_ mg IV, pm nausea/vomiting
[J Metoclopramide _ mg IV, pm nausea/vomiting
OXYGEN:
~ o,cL:-:':l L Nasal Cannula to Floor p/Z-rJ
OTHER:
0 Oemerol _ mg IV now for Shivenng
.. -
C Straight Calh PRN Inability to Void
'1
L,
=J
DISCHARGE:
.z: May Discharge Palient To Appropriate Unit When Meets Standard Discharge Criteria
q~ I)~ / flvj(v
Signature'.
1fijP
POST ANESTHESIA CARE UNIT ORDER SHEET
MR 689 4196
.
~
.
-
.
MR 559 9193
"The Collegeo{!vledlc
...... I - j
)'^l'" ,62978
O~S#Z 1,geC
LA I~D 8~1 rrA~V M
JILl0', PETER Ii
POST ANESTHESIA CARE UNIT RECORD
\ -55'
1MB
03/25/199
IME IN \) c, '1 I TIME ~UT ~O '1
AnesthesiologisVAnesthelist ~
Type 01 Anesthesia V8General pidural
- 0 IV Regional 0 Local
SpinallevelOA
\.)...b, G=')
,
_~J -:=,-, / r 1
DATE
o Spinal
Operation
o OtherVQ.....",,<.i,. ~
~)5:S
I' -~
(>~'- .....' )r ,I -
~ A
'IV):s J 3
SignificantHx
PULMONARY EXTUBATlON CRITERIA (Must meet 3)
Dtkneessustainedfor5secs.
Dtheadsustainedlor5secs.
Dstronghandgrasp
DVitalCapacily
TIME EXTUBATED D Extubated by
Airway ~ne D Oral 0 Nasal
Support D Endotracheal D T-PieceD Trach Size
Resp. Alarmsenings On~ ~~
Quality \........s-....~ Ahy1hm \.2...-I"-1~hestlubessite
Sr R ~Iear
soundsL~lear
CARDIAC ~')
Alarm Settings Rhythm ~NSR D 5T D S8 D Other
on-\,V')~f1_ DEctopiCS Dseerhylhmstrip
Pulse Volume
S/QRegular
o Irregular
:\.b ,.5JStrong
On~ Off ~ A-line site
?-- (as applicable) Site
;;;\ Extremity pulse
Or1~Off~~SW n-Ganzsite~pplicab~.
VASC /.") RUE LUE l!i.9'RlE l.ILALE
IVsitJ-.Y Extremity ~ink D pale D dusky
rl\---,), V-Color D
~alerlVintact other
Dother Temperature barmDcool
Dother
o Weak
o Thready
o Doppler confirmed
Capillary
Refill
~riSkDslUggiSh
Dother
NEUROLOGICAL STATUS
Level of C~SCi sness-see Post AnesjQ.e.sit Score Sheet
Pupils earla \Jo1qual ~
Sluggish 0 unequal R Size
o Non-reactive lSize ~
CommandS~follOws commands Dother
Arms D strong bilateral grasp D No strength
Dweakbilaterally Dother
legs o strorlgdorsiflex & exterlsion DNostrength
o Weak Dother
SKIN STATUS
Admission Temperature
_Opo DLightson28"frombed
~ctal DWarmblanketsapplied
mpanlC c:::J HypothermIa blanket applied
core DWarm D~coOI DOlaphoretlc
o axillary 1 n
Operative. ~i e d~e~SSing Type of Dressirlg I- f. J L -5 P l"~
resslr1g dry/intacl 0 No dressing -L - I 0
DRAINS ~
POST ANESTHESIA SCORE
AblE 10 move 4 Extremilies voluntarily or on command _ 2 - ~ ~
Able 10 move 2 Extremities volunlari!y or on command = 1 -- ACTIVITY
Able 10 move 0 Exlremltlesvolunlalllv oron command =0
Able to deep breath and cough freely ~ 2
Dyspnea or Limited Breathing = 1 'RESP'IRATION
Apneic-O
Fully Awake ",2
Arousable on calling", 1 CONSCIOUSNESS
Notrespondmg"O
BP + 20% of Preanesthelic Level =2
BP + 20-50% of Preanesthetic Level ~ 1 CIRCULATION
BP+50%0IPreanesthelicLevel~0
Pink-Narmal=2
Pale,dusky,blotchy,jaundiced,otller=l
Cyanotic=O
COLOR
TOTAL
TIME
IN VI,
:J. 'l
:1.~
I ~
J..1-
).,j.
'1/7',
POST ANESTHESI
POSITIONING OF PATIENT
o HOB
o Pt.toremainllat
DOlher
INTAKE OR
Type
~
TOTAL
OUTPUT OR
;"~.
AmI.
':l-'~()
INTAKE PACU
Type
~~
TOTAL
OUTPUT PACU
..Ju-l' ,,'
DISCHARGE ASSESSMEII!'.....(
Airway status ldJj)patent & Unobstructed D Other
Dlntubated
~TraCheOS10mY
NSR DST DSBDolhec
ectopics Dseedischargenote
o Same as on arrival
FjseediSChargenOle
Vsite patent/intact
Same as on arrival
DSeedischargenote
~ameasonarrival DSeedischargenote
estingquietly,nocomplaintofpain
Continues with pain o Pain relief improved
D Wishes to return to room with no further med.
USeedischargenote
Spinal Level on Discharge:
TOTAL
LABORATORY, X,RAY
PROCEDURE
Rhythm
Neura Status
Vascular
Operative Site
Pain Relief
TOTAL
TIME
RESULTS
READ BY
(ilapplicable)
Actual time VS. lime out by anesthesia 4'
Discharge Score Ie) Tim, ]3i~~
Discharge Nurse .5
Pt. to floor/Speciality Unit (circle one) Room number .~ f
ReV!eWP-d, P /'~,C QU:> /~:'\l r ~?.-;,t_O_"~C:~~-Cltiv<:C:~j~,S 'Nith,~,J.J.._ _ _~..._f~_~!.__._._
bY~~~,"-':'Ulrt!~ Tir.:e
Anesthesiologist Discharge Note: Time
E UNIT RECORD
Amt.
(DATE \/5 I 0 j
IO,d-OI'hv-.-..C5t VIe-. h._Q -h~ PMV
S-' n ~ ,~~-Q,x, (D
\M oY_-:t-;J) \Y1- (0+\r-<--'J~'_
I~.i;t <>'"' t t\).L )V' \..\Q_ --1-.
~ ,~ ...,..-;.........,. ~ ^ 0
{\~.-C\ . (' ~ i L ' I T'I CO lI\/\ ~ G') 0 ~ ,0 ">,J '-
,~{ \'\ "",' ,,0 0 +L>-<J. -- Ub Q/O
- \ \)~4\,."-,.., <-- RJ n 1'v\ R? '
NURSES NOTES
In.
lof!......"..
ALLERGIES
i'.)K- ~ A.
MEDICATIONS GIVEN IN RECOVERY ROOM
TIME DRUG DOSE Rt./Site SIG
.
.,
---------1 --~----.
I
I
--------------....--- i ----~
I
I
SIGI>lAIURE
._~
RN
INITIAL
SIGNATURE
RN
INITIALS
.0-'
~
/ fAJ ;
.
~
.
-
.
PENNSTATE
~ The Milton S, Hershey Medic~l Center
. The College of Medicme
i c)
2 i ~ ..~
POST ANESTHESIA CARE UNIT
[, t :\
~J:~',~ '~S 4~j3Jl
POST ANESTHESIA CARE UNIT
ORDER SHEET
TIME:
DATE:
F~: r: 7c 7 Y - B: D=P:~TMENT OF ANESTHESIA
~' . /
\..~_.--....
PAIN//'
~ MSO,.....i.... mg IV now, may repeat every ~ min times ~
[1 Demero\ ~ mg IV now, may repeat every _ mln times_
0 Ketorolac ~ mg IV now
0 Fentanyl ~ flg IV now, may repeat every ~ min times ~
D Acetaminophen ~ mg elixir PO or ~ mg Suppository PR every ~ hr pm
LJ Acetaminophen w/ Codeine Elixir ~ ml PO (24 mg Acetaminophen and 2.4 mg Codeine/ml)
every ~ hr pm
0 Acetaminophen w/ Codeine Tablets ~ Tablets PO (300 mg Acetaminophen/30 mg Codeine per Tablet)
every _ hr pm
NAUSEAlVOMITING:
/
~ Ondansetron ~ mg IV, pm nausea/vomiting
0 Droperidol ~ mg IV, pm nausea/vomiting
[) Metoclopramide ~ mg IV, pm nausea/vomiting
i ,,./
OXYGEN:
0 0, ~ L Nasal Cannula to Floor
OTHE"R: .
/ /
lvi'/ Demerol t. Ir'tng IV now for Shivering
- , .,
0 Straight Cath PRN Inability to Void
0
0
DISc;t:tARGE:
~ May Discharge Patient To Appropriate Unit When Meets Standard Di~Sharg~ crleria
/ , I /'
-.J
Signature: .
// )/
I
MR 689 4196
POST ANESTHESIA CARE UNIT ORDER SHEET
\
THE MILTON S,HcRSHEY MEDICAL CENTEk
,
,
-. 2n-'o
jo t i0
l' f< Il 1J H A.
OOS 218BO
~1" PRE-ANESTHESIA EV ALUA TION E ~ t f( 0" 00 00
ol j" " " ../ ..I .,.....,
- ~ ~ . . ' ,-;" ....
AGE SeX RACE HEIGHT WEIGHT ' PHYSICAL STATUS
la' F c .;::> 1 2 3 4 5 E
em kg
PRE.OP DX: 'R. \",\ 'vo.... STOMACH CONTENTS:
Ce./'"
PROPOSED OP: v ALLERGIES: N~A
PAST MEDICAL HISTORY
" (to be completed by patient)
PREVIOUS SURGERY: CURRENT MEDICATIONS:
DATE OPERATION COMPLICATIONS ,
, rt
,
,
HAVE YOU EVER'HAD: ,
YES NO , ,
ANESTHESIOLOGIST NOTE
A Respiratory , BP (( I PU0'1 I RESP; I TEMP; I ROOM AIRSA02:
1.CroLJp -- ~J; (, '\ \=
2.Asthma, wheezing --
3. Snoring -- /' .^, F~ cY c.,,\c\<. C-:'j h~l.sc,
4.Bronchitis -- vJ-.
5. Emphysema -- ,OL ' , " ~~ <~ ~u
6. Pneumonia -- <~: r'-'~~<.rc-'t c~,.....\
7. Cigarette smoking -- /)LO C 01\- >::-<:-'1-<.
a.Cough, nasal congestion,
sore throat within 2 weeks -- , , ,
9. Loose teeth or dentures -- ",
10. Difficulty moving neck or jaw __ ,
B, Cardiac
1.Rheurnatic fever --
2. Heart murmur --
3. Irregular heart rhythm -- LvV\c, , c:\ .eL/' h,\..c.\".:l.
4. Heart attack --
5. Heart failure -- 'v\C~~ - {Cf11.. ~S'J- $
6. Chest pain r'\
--
7.Shortness of breath -- /'ll),..~.., sA\ { ..,I, ,,-- j"./ (i. '> ~.,.."'_\ S;:Y-l'-,l"
a.High blood pressure -- ~C'>1 :s~W
C, Neurologic ,,~o )..
1. Sejzures -- OM,""-:o.<'"
2. Stroke -- U \ ~
3.Unusual muscle weakness --
D, Kidney Disease --
E, Blood Disorder
1. Sickle celt --
2. Bleeding abnormality ,
--
3. Prior blood transfuSjion --
F, Gastrointestinal
1. Hepatitis -- ,
2. Liver disease --
3,Orink alcohol --
4.Jaundice --
. 5.Difficulty swallowing -- -c-
6. Heartburn --
7. Hiatal hernia -- ~-
G, Endocrine
1. Diabetes -- ,..-/
2.Thyroid disease -- "
3.Prednisone or steroid ttlerapy__ ~srz1~. DATE
4.Could you be pregnant? -- "'2.. '7
H, Family History of Adverse. .;/ ~)t
Anesthetic Reaction -- PREMEDICATION: FACULTY AN95THESIOLOGlST: DATE:
L Other Medical Problems --
TIME:
HEMATOLOGY: BLOOD AVAILABLE:
Units R o Autologous
CHEMISTRY: EKG: I CHEAj X-RA :~_ ;
~ <"',<=" i v..z
POSTOP CARE: o Short Slay , 0 Inpalien! DLC;lJ,
~
~
iU
!e.
~
"'
w
z
~
MEDICAL RECORDS
THE MILTON S, HERSHEl ..lEDlCAL CENTER
.' '.; 2. t ,-,
Mo Day Year
PHY STAr.
ANESTHESIA RECORD PAGE~OF_
Anesthesia LO
Machine#~
t ~i f ~~
OR Number
1;y
~ 0201 It;:;'
O~rative Procedure({l )
Jf,//^ h<
IE
~~1 HT I~t AlIr;( CO~
Preoprative
SPC,
l~ P~6 7: ;z,
jd'D 1"
Pre-ap Antibiotic
" (-~ -, t",
,-.- -.', ;'..;
. ./;.-,'
"
i" '"; J ~ ,-, 4" ~ ''\ 1
I\ConllnllOUS Anekflu!Sl(~ansfer To Incis~ Surgeon Conllnuous Anesthesia PBliJ Idenlified/Attending Anesthesiologist
I' Care BeQI11S " Surgeon ($I :3:~10/---- Cale.E~II~ ...--.--,,( \..
IUS' lid ~ /22'-" - T'5"( J3 'I' r~"/1 I i ~ ' ))
O;.,.no,;, t') I2..r~ I II I ~y /
)71')1, ~/?5
o Endobronch Intubation
o Fiberoptic Intubation
o Hypothermia
o Hypotension
o Hemodilution
AnestheticTechniaue:
I~ratlon
l:B"1.V.
o Spinal
o Epidural
o Nerve block
o Monitored Care
12. ;+
,)'-1:=7
Procedures Perlormed by Anesthesiologist
Stethoscope.h r7' J.}'i, ',';' "
EKG {~'" <"'.,+ A
SPO, 'j"""llril '1
Temp ~ j 1-
FI02'i Rf .'.#4~~: '0; l.J,
ETAgent /..1/ I,~
ETC02 :, .'J.ii,
PIP/RRfTV ' " I
'.'"
.,R, S,e
'lH;"
JIf, "iLl
;4('.1J3
I, h I,X
,12 r< :?'f'
-r;, .~
I "
DART CATH
o cvp
o Swan Ganz
o TEE
Time
, .. ',', . '",,:. ','l t ,,'
~
P lei!
.,H,..', '" "
REMARKS:
200-'5 AI. /. rI ~ /-orn 4 ~
180 ~'ti7-' )i-n..,oo/h /Vr:- ,
72. /Yl, I.. <..nz.<# ri, ()(!-'.-
160 /0
k L-,,v,", f>..) ,un'.
140 -rl. ,6s:e:L. rB&.z..
120 E ''>is Tr4-l'co/,
100 )j. rn V1N!,RIr~
80 '-0kh I).e.
~
40 :;y ~~
~',;;J.'
(Ocro 00.4
.- >' ',',,'
7 ~ ':;"'M ~,
:;: /.3 '.r,D ~/"--!7r..~,,"
":,.,'. , " //
.. (//j't.-r..c -( ?'io
/)'/-1D
"
M TIME '3rJ :x. \1--... '0 \I I'~ :v
~ Yo.., - ~-;z.J"'11-l _. -;';< ~ ~!/ ,
I ,~. '.;:":;'~ >.> .~.,.., ."," '" :,'.:-: I, " ,:
~ t t'JJi 1mf;t. . 2.,(
~ Il.Dr: "" &Q I "',;., .:',... ,", "
~ PMP-I- /, If
S " , . , I. :
, ..
V Blood 200
^ Pressure
1 Invasw" 180
AR'
T Pressure
160
. Pulse
o Respi<a 140
bon
120
100
80
60
40 c
20
M
o
N
,
T
o
R
S
I
F
L Nervestim : ,.
U
I
o
......
J.. M). 11 ytJ() ----ii>"...:....::,
'l"J .'lIS .,$.<:7)_,>
.-/ ,'.'
Urine
E.B.L.
Position
ANESTHESIOLOGIST POSTOPERA77 r 7
STATUS ON PACU ARRIVAL: BP __
POSTOPERATIVE COURSE:
TIME:
DATE:
MR 326 (REV 4/00)
, ' '" " :1 i'
<;;tc. S(l,'i/?,
1i>1UJ, 'liA! "
'1/..1 1lL. .'JI.<
,If~ .,"'" ",,'
I,~ ,"'.:-1
,"j4, .,J'f I' ". ' ..,,-
, ,
d'.
,
,
, , ~"" I",H
",:,' .:1 '''';, >,.,,'
."-,:,
".. '
1
,
..~ .
R
.-
/
/'r
"
SPO, 1(7:__
Temp Jt-/
/)
S.GNATURE. <..-1/ VA f . ;G-~, i" .
~CRN~/)r (Tt/~/"c,--,c..;.~~
SIGNATURE- v I '
AlTENOING ANESTHESIOLOGIST i I.~-
~^I=\\lr ~I Q~lnOf',~
q(D
<b
SUMMARY OF INTRAOPERATIVE FLUIDS
TYPE
;\15
VOLUME
"
"
"
"
"
"
/71) "
s . "
y "
, /
"
TOTAL
TOTAL
E.B.l.
URINE
60
20
I ,
" --
ATTENDING ANESTHESIOLOGIST NOTES:
r-
.:. \-:,:::,'_.'-\
,~\,.-\
\ - ,{{
f.
_1 .. I.
" "'''-,.10-
/"" ,(1.1.
\ ,
\. ."'-' <
\ . \
.
.
.
.
.
.
MR 559 9193
~ The Milton S, Hersh Iedical Center
., The College of Medlcwe
LAIR, ,iru,NY If
ilK_ 3b2'.18
POST ANESTHESIA CARE UNIT RECORD
OOSII 21880
0312~/1990
TRAM
./'
,,'2(-- , J III '-."f~ f
TIME IN ' J~ TI~T I I I - DATE -.:J A I V I
AnesthesiologisVAnesthetist J Lt 1 1 . J U.A.) I ,
n-ype of Anesthesia eneral o Epidural o Other
o IV Regional 0 Local
o Sp~nal ~ ~lleveJFJ --.r+rlt--n-
OperatIOn Qt=/ r.= ~ CJ.~
Significant Hx
PULMONARY EXTUBATION CRITERIA (Must meel 3)
Dtkneessustainedfor5secs.
Dtheadsustainedfor5secs.
Ds~onghandgraSp
o Vital Capacity
TIME EXTUBAT~ D Exlubaled by
Airway one D Oral 0 Nasal -
Support Endotracheal \ 0 T-PieceD Trach Size_
Resp. I. ^trarfl1ettj~s On \J..,A../ Off_
OualityJ)./r~Rhythm~ Chest tubes site
A G::J Clear ~
Sr. ~
soundsL~r
CAROIAC :::r:;;:--
Alarm Settings Rhythm 0 NSR ~ D 5B D Other
on~OH D Ectopics Dseerhythmstrip
i!: Volume
egular
~rregUlar
tJ'Ft trong
On~Off_ -fine site
LIP( (as applicable) Site
fV1t Extremity pulse
~~sc Op ~Da:~tte asap~~~ab~E
JVsite#-IO{~ ~ Extremity nk Dpale CJdusky
~tenVinlacl -(g ~ Color CJ olher
o other Temperature lli ~rm D cool
5t~her
~jskDslug9iSh
CJother
o Weak
o Thready
o Dopplerconlirmed
Capillary
Refill
NEUROLOGICAL STATUS
Level of ~sness-see Post Anesthesia Score Sheet
Pupils earla 0 equal
Sluggish 0 unequal RSize
i:on-reactive l Size
Commands lIows commands Dother
Arms rOngbi!ateralgrasP:~D: No strength
EeakbitaterallY other
Legs ontYrSifle:., & ..:xten ion D No strength
( .if ,A. other
SKIN STATUS ' JA J j~./,; 0 If
'" lIIdm.,{on Temperafure ~ f.I9r
, fir. lY"D po ~ Lights on 28" from bW
.CJtJ reetal D Warm blankets applied
~mpani~.__~~HYPothermiab!anketapP1ied
Deore ~ DCoolDOiaphoretic
DaxiUary
Operative mreSSing Type of Dressing
ORAINS ' ~ta:hA >=ri N'lfjessj'o
~6J-,
TIME
FiOZ
ROUTE
02 SAT
EKG
/5., )L.f-
~1~r1,
_1~
J/IJ'-V
Able to move 4 EKtremities voluntarily or on command" 2 -.r
Able to move 2 Exlremities voluntarily or on command" 1
Able to move 0 Extremities voluntaril~ or on command" 0
Abletodeepbreathandcoughfreely=2
Dyspnea or limiled Breathing " 1
Apneic=O
Fully Awake =2
Arousable on calling: 1
Notresponding:O
BP t20% of Preanesthelic Level 2
BPt20-50%ofPreaneslheticLevel:l
BPt 50% of Preaneslhetic Level =0
Pink-Normal=2
Pale, dusky. blotchY,iaundiced,other= 1
Cyanolic=O
220
200
180
v
^
160
POST ANESTHESIA SCORE
-<
" ,,'..
u
ACTIVITY
..
RESPIRATION
CONSCIOUSNESS
CIRCULATION
COLOR
TOTAL
TIME IN
!J-
I
/
:9,
~
2)
R
C:P
,p,
~
,~
/'C~
POST ANESTHESI
INTAKE OR
Type
POSITIONING OF PATIENT
DHOB
o Pt.toremainflal
o other
NURSES NOTES
z...,
AmI.
INTAKE PACU
Type ,
TOTAL
OUTPUT OR
TOTAL
LABORATORY, X,RAY
PROCEDURE
TOTAL
RESULTS
REAO BY
TIME
DISCHARGE ASSESSMENT
Airway status
t & Unobstructed D Other
Intubated
D Trac~~my /'
o NSR~ 0 SB 0 Other
Dectopics Dseedischargenote
iEame as on ar,riV31
ee discharge note
Itepatentlmtact
o Same as on arrival
See discharge note
meas on arrival USeedischargenote
Quietly, no complaint of pain
D Continues with pain D Pain relief improved
o Wishes to return to room with no further med.
DSeediSChargenote
Spinal level on Discharge:
Rhythm
Neuro Status
Vascular
Operative Site
Pain Relief
(ifapplicable)
ALLERGIES:
MEDICATiONS GIVEN IN RECOVERY ROOM
ORUG OOSE RUSlte SIG
*W
TIME
Actualtimevs.limeoubQthesia
Discharge Score V~ Ti e'<-
Discharge Nurse
pt, tofloorlSpeciali nit(ci cleone) Room number
ReVieWr PACU slay and postoperative orders with
by , PACUlRN Ti
Anesthesiologist Discharge Note:
Time:
PUu~
:E UNIT RECORD
.
.
.
.
.
~ The Milton S, HeL _y Medical Center
. The College of MedicIne ,
PHYSICAL THERAPY ASSESSMENT
Tt....~M... #- St,.;><J?2,
ooS If; ;)1'090
t- Cl' ""C f-y, f 1>.'7 ".,
D. II~., I 'fe-+-.. vv
0'3/2'11'1'10
F
.;261.10
't Oli"^
se~>';V-
~ Initial Evaluation
_ Discharge Summary
DXfPMH: p+-. 101,_, p,,J v@
I.+- b I O~1. P
c".... -z(g t:..--c;'
cJ'.Jf-.J- +.b,~'
C'~f'-~.(
(:x.
-:,( Ole I
P.l-
{.. h~I" ...,1.1, ~.^.J. .,0, ..A~,..
,
,....,.J... -w'C..~IG-
\,1 N "" 1:> Q (.. P-
Pl.IFamily Report/Goals: P +- ' ~ . _-I
0". 'J-,i- 01.,,. '-- -k ~ ,~.J<, '-''''
( r ,,~d(~~ b~.:f"'te- '3 S~p~) ,
MENTAL STATUS: j-\-- ~ + <!."r"-h..i€.
Alert (j) I N Oriented to: person@ I N PlacE(Y') N Tim& I N
cooperativ~N Able to follow 1 step commandsh Yes 0 No 0 N/A
MUSCLE S ENGTH & ROM: RIGHT LEFT
, (A) = Active @ = Passive Strength ROM Strength ROM
SHOULDER Flexion 0.180 Sf:> woJ<=- 5'fr '-'(v'-
Extension 0-50
Abduction 0.160
Int Rotation 0.70
Ext Rotation 0.90
ELBOW Flexion 0-145
Extension O~O
FOREARM Pronation 0-85
Supination 0-85
WRIST Flexion 0.70
Extension o~ 70
GRASP "
HIP St Leg raise 0.80 '51\ .., (Vi.- M/o') ILwl"l..
Flexion 0.120 .., (,- I
Extension O~25 ~
Abduction 0.45
Adduction 0.30
Int Rotation 0,45
Ext Rotation 0,45
KNEE FleXion 0,135
Extension o~o , oJ
ANKLE Dorsiflex 0-20 fJ,'h \~<a..)
Plantartlex 0-50 ).....11.- }<o
Inversion 0-35 r-', r~
Eversion 0-20 J J
TOES
LEG LENGTH
Comments:
p T ~... S>.,~.
,-I.J c..
~e-)ro-\........ ')
'J
rll. {
h.......
~
TONE/QUALITY OF MOVEMENT
1. Flaccid, no resistance when part is moved
2. Developing tone
3. Fluctuating tone High ~ Low
(JJ Normal tone
5, Hypertonic
6, Hypotonic
FACE
NECK
TRUNK
Right Upper
Extremity
Leff Upper
Extremity
Left Lower
Extremity
QUALITY OF MOVEMENT:
Bradykinesia
Rigidity
Tremors ~ Intention
Tremors ~ Resting
SEN~ATIONIREFLEXES '
t+ -\,,~~\.., ,.Th,J-
,{ ~ t:
..,.--
BALANCE/COORDI
Sitting balance static;
Sitting balance dynamic
Standing balance static
Standing balance dynamic
MR 587 7193
PHYSICAL THERAPY ASSESSMENT
PHYSICAL THERAPY ASSESSMENT
ENDURANCE/CARDIOPULMONARY
HR FB BP
VITALS Pre- Post Pre Post Pre Post
Up'Down_ Steps
Ambulation - Feet
, Cardiac Rehab Exerc.
Comments:
r
FUNCTIONAL ACTIVITIES KEY:
BED MOBILITY Independent: Pt. is able consistently to
.SIT TO SUPINE SUP CG MIN MOD MAX f "^" perform skill safely with no one present.
.SUPINE TO SIT SUP CG MIN MOD MAX fA N/AP Supervision: Pt. requires someone within
.ROLL RIGHT SUP CG MIN MOD MAX NI NIAP arm's reach as a precaution.
.ROLL LEFT SUP CG MIN MOD MAX NIAP Contact Guarding: Therapist is positioned
TRANSFERS with hands on patient but not giving any
,SIT TO STAND SUP CG i MOD MAX N/A NIAP assistance.
WHEELCHAIR <--> MAT SUP CG MOD MAX NIA NIAP Minimal: Pt. is able to complete majority of
.\IfRB!LCHAIR <--> BED SUP CG MI MOD MAX NIA NIAP the activity without assistance (75-100%) (
WIC MOBILITY Moderate: Pt. is able to complete part of the
.LEVEL SUP CG MIN MOD MAX NIAP activity without assistance (50%)
.CURBS SUP CG MIN MOD MAX NIAP Maximal: Pt. is unable to assist in any part
-RAMPS SUP CG MIN MOD MAX NfAP of the activity (0.25%)
NIA: Not Assessed
.PRESSURE RELIEF SUP CG MIN MOD MAX N/AP NIAP: Not Applicable
.WHEELCHAIR PARTS SUP CG MIN MOD MAX NIAP
GAIT AssistiveDevice tJ...... .{''-r7 c. ".... -/.",L,~..J
-LEVEL I SUP~ MOD MAX ~ NIAP Distancel.>' ~O I Weight (
",-@/O I Bearing (WB) Status _LE
.STAIRS I SUP G MIN MOD MAX N/AP Non -WB ~ Partial we %
.RAMPS I SUP CG MIN MOD MAX NIAP Weight Bearing as TolerC3;.ted_~
Comments: 'P+ )'''eh "'--":' ({".I 1 C '--I..-\"'J
SKIN/SOFT TISSUE
Comments: @ rJ.r( SI') .f7r (."'+ r~-hvl-
(
ASSESSMENT:...J::>+-, fa '1-"" W ~ G CD) .0',c,nQ.. f,f" ,_' I) (l.r~..\- -00 3/0~/oI,
.(Y~ ~LAV5' c.,,-r <,(~ul, D-!- "'_b ~ ~....--Iok5 NNBQ<-C.
1"+ r 1",'d.J ,,~~.~+- 'Z L- L-~ +:.... <;.+6:> S;n~).. v.._.s.ferJ <f-
~.. "- ......-h, 'Pr-",,"I ~ee^- sfr...rc..I,;.-.b',"') P+
j .J..zJv-t ' ~ r 7:.-<1- 1> ? ~ e .t~.e r>-- ,) I-Jee.t:..
GOALS: ~'_
C f"-+--c-'" j
~ \N I'.. @ v~ ><"!" I
,r
ro..
{V>AG,
'-L
PLAN OF CARE:
c... , I ( -r::; It '-.J +.-"
-So to. ,,.. c..( '~"V)
1L!~PiSt'S'~
t...~~.
.
-M. ~l..{.e....,. <:I-
Date
3(bt/l/
. PT
MR 587 7193
PHYSICAL THERAPY ASSESSMENT
The Milton S. Hershey
Med.ical Center
W;tJ2779
T PA IJMH 362978
\.; " S ~ 2 , ,i.:? C
L4i:;;.~: p",irrA~iY t.-l
7247-3 7~'E
03/25/1 ~~
21 ' '
OCCUPATIONAL THERAPY INITIAL EVALUATION
DATE: 3\5/0\ t-" TIME:
DiAGNOSIS @~ C\,~ b'/ 511" ORIF 31"', J:. i, b 315
~~.A~
1~3D - P-IIO
Pt., fU~ A A..JY)
DATE OF ADMISSION: 313) 0 I
PAST MEDICAL HISTORY: 0
PRECAUTIONS: FFNi'Ji3 (0L-E- AAI
,
SOCIAL HISTORY:
Lives with: ---D~~ ' I J ;~
Type of house: I Floor 2 Story Home Other
Bedroom on :lr\6.. floor. Bathroom on 2.f\A... floor. '>( tub/shower;
'17.. b-M-k I $1 ~
2 Exterior Stairs erior stairs
walk.-in shower-,:;r-u
Prior ADL Level:
cf)
Equipment:
NA-
PATIENT'S COMMENTS i'~ ,<-Lp~ ~ ~, ~1Vv..A~
~SI'U'C-L~ ,'ULp~ A.poy ~ ~ c, ~, DI~sz.oL
OS~ I bZ-t ~ p b<..A "" \ 51;- ,'f' ~ .
COGNlTlON/PERCEPTION A < 0 " 3, ~ " vL>kAJ~~,
~"''"-'b ~'_Sk-p .l'~' ,
UE EVALUATION RIGHT LEFT
RANGE OF MOTION:
wNL- \lJi-JL
STRENGTH: wf,!1-
WNL-
. GM~\,0NL- GMC:~~ Lf ~i-
COORDINATION: '-r'
FMC: W\-ll- FMC: 1"V-~
w~L.-
~ ~ -
SENSATION: Diminished Absent Diminished Absent
TONE: Flaccid Low (Norm~ Flaccid Low ~rmaf)
High Rigid High Rigid
EDEMA: P 6'
Hand dominance:
Comments:
Occupational Therapy Initial Evaluation - Page I or1
Pilot OT Form 9/99
OCCUPATIONAL THERAPY INITIAL EVALUATION
KEY'
INDEPENDENT: Patient is able consistently to perfonn ililJ safely with no one present.
SUPER VlSION: Patient requires someone within ann's reach as a precaution.
CONTACT GUARDING: Therapist is positioned with hands on patient, but not giving any a.s.si$Ul.llCt.
MINIMAL: Patient is able to complete majority afthe acliviry (750/....100%).
MODERA IE: Patient is able 10 complete part of the activities (250/....50%)
MAX.I1vt.o\L: Patient is Wlable 10 assist in any part Ci.the, iu:tiYity (00/...25%).
DEPENDENT: Patient is unablno complete any paft'b(thc activity.
DE: Upper Extremity
LE: Lower Extremity
GMC: Gross motor coordination
FMe: Fine mOlor coordination
N/A: No\ as.scssW
N/AP: Not applicable
ACTIVITIES OF DAILY LIVING
Self-Feeding (p p s.d: up
(L) P .I\..d '^P
^P~ bc---+U
FUNCTIONAL MOBILITY
RollingL ,.J/A
.
RollingR ,J/A
"
- fJ)A
t-J/I'<
Supine to Sit ~W ffn (C) u:
Sit to Stand Gb
Bed to Chair Cb
Toilet Transfer Gb
Tub Transfer 10iAP
,
GroomingIHygiene
UE Bathing
LE Bathing
DE DressinglUndressing W p 4Ut ~'-F'
LE DressinglUn~reSSing ~'<Al poL- ~ k.6
<t:=>L-
.~
Toileting !'l'Y\..U>L':1 ) '
Light House Cleaning
.JI AP
tJ/AP
Meal PlanningIPreparation
COMMENTS:
BALANCE:
Static sit: Good X Fair _ Poor _
Static stand: Good X- Fair _ Poor _
Dynamic sit: Good.J!{ Fair _ Poor _
Dynamic stand: Good.x.. Fair _ Poor_
COMMENTS:
ENDURANCE:
Good ><
Fair
Poor
COMMENTS:
ASSESSMENT -pt;,,U <'--"--, II:J'o,~~ ~,Ip "'IT c.- @cE ff' A-,
NkJB (0 L.E" FPn..vl'j ..yULd ~ssJ~ ~)~ oJ ~
~ ~' ~ ~"- CSJz w:.. ~ !!SI"'-j' ?+ '$ YVlo~
,; '''1J ()Y0 bf S CL~~ -fn!A..---~ tU:J ~ p+- . uJ II ( (
~ rpot-h-u. ~~ ~O ,{, ~~pOIk.::t.
Pi:. , <.- <? o~ cl..-t_-t;{C" -1-5.., ~~ +0 C/ Ie. fru'7A'-
o. -r, ~\..UYI ' ~ { S s<-<-( (v- so \ U <.cJ...~ ct s. P 'r eLl ;IYIA,l<
'C I ~ ~
P IRECOMMENDA TlONS:
-p 0---'-1. -tv -,f ~
~
pi- 31vlo
~'l~_
I
-d6
--h.o ~ (' -F -/;?f::..s.
,.,o+-! LL.A_e..t",~
<--
5,;0 ,
Signature
Pilot OT form 9/99
~-A-
?~l
(')Jf!.-fL--
3/5/0)
Date
Occupational Therapy Initial Evaluation - Page 2 of2
.
.
.
.
.
THE UNIVERSITY HOSPITAL
THE MILTON S. HERSHEY MEDICAL CENTER
THI: PENNSYLVANIA STATE UNIVERSITY
KEflSHEY, PA 17033
DIRECTOR OF CLINICAL LABORATORIES
M.B_ BONGIOVANNI, M.D
SPECIAL REQUESTS . C~ll 8232
o EXCHANGE "TRANSFUSION
o INTRAUTERINE TRANSFUSION
o FRESH (LESS THAN 8 DAYS)
o LESS THAN 72 HOURS
(PEDIATRIC HEART SURGERY
o VERY FRESH (24-48 HOURS
(PEDIATRIC HEART SURGERY)
o OTHER
-----vm--
~
NUNITS
----ruNi'i'S
~
SPECIFY
CLINICAL PATHOLOGIST EVALUATION
REQUIRED
o LEUKOPOOR
o IRRADIATED
o WASHED
TRANSFUSION
NUMBER
R
43168
OSSMATCH (XMi
(ABO/RH, ANTIBODY SCAEEN, UNITS)
".., COMPONENT
# UNITS
WHOLE BLOOD
PACKED CELLS
GRANULOCYTES (XMG)
[] TYPE ANO SCREEN (ISel
(ABO/RH. ANTIBODY SCREEN, 0 UNITS)
o OB TYPE AND SCREEN (OBTS)
(ABOIAH. ANTIBODY SCREEN. Du. 0 UNITS)
o NEONATAL jRANSFUS10N jNEQ)/,)
(ABO/AH, ANTIBODY SCREEN)
o HOLD SPECIMEN (t-1QLD',
(NO TESTING PENDING ORDERS)
1 i\':j:..;I~, RED PE'.R" UNI,S
EACH TUBE MUST HAIlE
R" LABEL
~u 11'3~7771
:0b2q lf3,
-,\p--f\r
ticcL~
UM,l, ~ !~t; ~ j,
)
, "! ~ :?
PHvSI.:;IA\i"
,3i1. ~ i4
2 i' e ff{~T[
':10
C (;
SIGNATURE
INFORMATION REQUIRED
DIAGNOSIS
ORDERING PHYSICIAN
FOR SURGERY
FOR TRANSFUSION
DATE
DATE
KEEP_UNITS AVAILABLE
(NEW SPECIMEN REQUIRED EVERY 72 HOURS)
PREVIOUS TRANSFUSIONS
DYES DNO
,~-
SPECIMEN COlLECTED
~:'~3/D I
STAT
o ROUTINE
COLLECT ON
,.
<>-
o
u
Ii:
"
'"
u
DATE
",_" .'L..
~ The Milton S, Hers\"J Medica\ Center
. The College of MedicIne '
PROGRESS REPORT
ORTHOPAEDIC EVALUATION
THE MILTON S, HERSHEY MEDICAL CENTER
LAffiD, BRITTANY
MSHMC# Il32779
March 13,2001
DATE OF BIRTH: 03/25/90
lllSTORY: The patient is an ll-year-old female who on 03/03/01, sustained a grade 3A open left
Salter-Harris II distal tibial fracture, She was treated on the day of injury with irrigation,
debridement, and closure, She was taken back to the OR 2 days later for repeat I&D and definitive
closure, Since th~t time she is doing quite well and has been as always extremely comfortable, She
has not had any fevers or chills. Today, the splint was removed. There appears to be some
superficial fat necrosis about the anterior portion of the wound, The sutures were removed, and I
was unable to express any purulence, There did not appear to be any collection deep to the skin, I
instructed her father on wet-to-dry treatments and began her on oral Keflex, She does not look
grossly infected, I feel this is just some fat necrosis from the trauma itself
RADIOGRAPHS: X-rays were obtained demonstrating no shift in position of her fracture
fragments.
IMPRESSION: Superficial fat necrosis,
RECOMMENDATIONS: I will plan to see her back this coming Tuesday to ensure that the wound
is granulating weJl over the site where the fat was extruded, I remain cautiously optimistic, but
time will tell what other interventions will be needed,
Dictated by:
f)~ ~ /dO
David M. Wallach, M,D,
Assistant Professor
Department of Orthopaedics and Rehabilitation
Pediatric Orthopaedics
DICTATED BUT NOT
READ BY PHYSICIAN
DMW/cbt-0061
D: 03/19/01 T: 03/20/01
-;;;.;~~
cc: Medical Records
File copy
MR 6,1 Rev, 8196
PROGRESS REPORT
r Ll ~I "Iv 1/"\.1 C
~ The Milton S, Hershey l'v,"dical Center
. The College of Medicme
NM1E: LAl BRlTTANY M
MD: WAllALn DAVID M
MR#: 1132779
008: 03/25/1990
INS: BLUE CROSS
lOC; UREH
OOS#: 1388174
MD#; 24455
SEX: F
. PROGRESS REPORT
VISIT DATE: 03{16/20\
,"'.
DatelTime
PROGRESS NOTES: (Include Name, Title)
\0 Me. ~ I
0\
~~
<0
z~
Q8
~w
o~
o~
z<
wu
~a
w
~
0
~
~
'" ~
0
I=' ~
z w
"' 0
U <
~
-' ~
-< w
U ~
is w
z
"' 0
:>. ~
>- ~
co ~
'" w
~ ~
'"
co
'"
vi
z
~
S1
"'
'"
,..
.
~
m
In
~
~
o
z
m
'"
m
~
~
>
Q
m
~
o
"
'"
..;
0:
'"
<::
'~
o
z
~
0:
!Jl
~
~
<::
8
n
,.
e-
n
'ii
..;
!Jl
ACTION TAKEN
AVAILABLE
'M
6
'"
m
o
"
>
r
"
m
"
o
"
o
m
ALLERGIES
MESSAGE TAKEN BY
""","",f"'c
DATE
.
#-
.
M~
.,
.
MR 6 Rev, 2/95
PROGRESS REPORT
~,~
~)"
T,,_ ,~ILTON S HERSHEY MEDICAL CENTER
lo.;r-o{, Dr. if~
11'2,;)77'1
f{- c C) ~~ -iCt,A - ~, :1)- c,~ .L~~,
~ / jok- "- d"^-d 1'>1 ')~J;<i"", ,
I 1-1 'A,.,_~4C,^"'~ 7;.'- 01-'.
II.""".'> ' ';:" ,~~ 0
-.
3/1' 101
Or~+:L~
;r "Jt~, oAt! '
." . .
,
.
-.-. ..
.
.
.
.
MR 6 Rev, 2/95
PROGRESS REPORT
,CI~I~JIAI C
IIZ':"\ The Milton S, Hershey Medical Center
. The College of MedicIne '
PROGRESS REPORT
ORTHOPAEDIC EVALUATION
THE MILTON S, HERSHEY MEDICAL CENTER
LAIRD, BRITI'ANY
MSHMC# 1132779
March 20, 2001
mSTORY: The patient is a lO-year-old female who returns to clinic for postoperative visit
following her right ankle surgery. Her incision is well healed following her wet-to-dry dressing
treatments, She had sustained an open right distal tibia fracture, and the wound had begun to
dehisce at her last visit; however, this is now healing well without sign of infection,
PHYSICAL ExAMINATION: She has approximately 5 degrees of motion about the right ankle
due to her pain and stiffness, She is neurovascularly intact and again, her incision appears to be
healing well without signs ofinfectioh now,
RADIOGRAPHS: X-rays were not obtained at today's visit,
PLAN: We will discontinue the wet-to-dry dressing changes for the patient's tibial injury site, She
may begin to shower but will avoid soaking the wound, She is to remain nonweightbearing in her
Cam Walker over the next month, We will see her back in 4 weeks' time for further evaluation with
x-rays, The family was told to call if any problems or questions should arise,
Clinical evaluation and medical decision making described in this dictated note were performed by
David M, Wallach, M,D,
Dictated by Daf?:.;:;:J;f~ jPf iJ
David M, Wallach, M,D,
Assistant Professor
Department of Orthopaedics and Rehabilitation
Pediatric Orthopaedics
DICTATED BUT NOT
READ BY PHYSICIAN
DJZfcbt-Ol04
D: 03/23/01 T: 03/24/01
cc: Medical Records
File copy
,~.-:.;.
.
MR 6,1 Rev. 8196
PROGRESS REPORT
1-1 ~I ~v 11\1 L
~ The Milton S, Hershei Medical Center
. The College of Medlcme '
PROGRESS REPORT
ORTHOPAEDIC EVALUATION
THE MILTON S, HERSHEY MEDICAL CENTER
lAIRD, BRITIANY
MSHMC# 1132779
April 20, 2001
DATE OF BIRTH: 03/25/90
ASSESSMENT: The patient is a II-year-I-month-old female who sustained a right Salter-Harris 11
fracture with a left Salter-Harris 11 fracture of the distal tibia, plantarflexion type, This occurred on
03/03/01, She was treated with irrigation debridement x2 and closed reduction on initial visit. Her
postreduction course was essentially uneventful, She had some small degree of fat necrosis over the
anterior portion of her wound which responded to wet-ta-dry dressings and oral antibiotics. I have
been quite pleased with her progress, She states that she has a small patch of numbness just distal to
the laceration from the fracture. She has normal sensation in the distributions of her deep peroneal
and superficial peroneal nerves over the dorsum of her foot. X-rays were obtained demonstrating
excellent healing and callus, No evidence for growth arrest at this time, Her motion is reasonably
good for someone who has been in a earn Walker.
PlAN: Our plan is to see her back in I month's time with repeat x-rays. She may begin weightbearing
as tolerated,
Dictated by:
j}~/,I /1# /?
~ IVftJ
David M. Wallach, M,D.
Assistant Professor
Department of Orthopaedics and Rehabilitation
Pediatric Orthopaedics
DMW/cbt-0081
D: 04/23/01 T: 04/24/0 I
cc: Medical Records
File copy
MR 6.1 Rev, BI96
PROGRESS REPORT
~, " ".....,.{ ~I L..
~ The Milton S, Herstlwj Medical Center
. The College of Medicme '
PROGRESS REPORT
.;,....
ORTHOPAEDIC EVALUATION
THE MILTON S. HERSHEY MEDICAL CENTER
LAffiD, BRITIANY
MSHMC# 1132779
May 22, 2001
mSTORY: The patient suffered an open grade 1 Salter-Harris II fracture of the left distal tibia-
fibula in March 2001. She was treated with ORIF followed by I&D and closure in the second stage,
She was taken off her Cam Walker 4 weeks ago, and this is a followup visit for her, She has had no
complaints in the meantime, She does have an occasional limp, but no pain, She has a small
amount of numbr:ess below the scar itself. She also complains of some weakness with ambulation,
PHYSICAL EXAMINATION: The patient is awake and alert. She ambulates with very minimal
antalgia favoring the left side, Her scar is well healed, She has a sman area of numbness just
adjacent to the scar (below the scar), Her distal neurovascular exam is otherwise unremarkable,
She has a fun range of motion of the ankle. There is some calf atrophy present,
RADIOGRAPHS: 2 views of her left ankle were taken today, Hardware is stable, The bones have
essentially healed at this point, The physis appears open; however, there is a sman area along the
medial physis, which is unable to be ruled out for arrest at this time.
IMPRESSION: Healing, status post open reduction internal fixation left open tibia-
fibula fracture,
PLAN: The patient is doing well at this point, She can advance her activities now as tolerated,
She will have some weakness mainly due to her calf atrophy, However, this win improve. Back in
6 months, at which time, we will get 2 views of the left ankle and a bone age film to assess for
further growth potential with regard to potential growth arrest problems,
Clinical evaluation and medical decision making described in this dictated note were performed by
David M, Wanach, M,D,
Dictated by Ronald R. Hugate, Jr" M,D, for:
~
~
/0 LJ
David M. Wallach, M,D.
Assistant Professor
Department of Orthopaedics and Rehabilitation
Pediatric Orthopaedics
-;;.:.~-
RRH/cbt-0054
D: OS/22/01 T: OS/23/01
cc: Medical Records
File copy
MR 6,1 Rev, 8196
PROGRESS REPORT
PEN N STATE
...."\::1 Milton S. Hershey Medical Center
College of Medicine
Patient: LAIRD, BRITTANY M
MRN: 1132779
Flowsheet Print Request
Last 120 Results
Printed by; Men, Chanthan
Printed on: 07/27/2001 10:29 AM
Page 3
An EqUlll Opponunity UniVlmity
PENNSTATE
.~ Milton S. Hershey Medical Center
College of Medicine
Patient: LAIRD, BRITTANY M
MRN: 1132779
Flowsheet Print Request
Last 120 Results
Printed by: Men, Chanthan
Printed on: 07/27/2001 10:29 AM
~
Page 4
An Eql.lul Opportunify Univ~r~ily
PENNSTATE
.~~ Milton S. Hershey Medical Center
College of Medicine
Patient: LAIRD, BRITTANY M
MRN: 1132779
Flowsheet Print Request
Last 120 Results
Printed by: Men, Chanthan
Printed on: 07/27/2001 10:29 AM
,"~""';l:b ,;.:1 I
.. ,
,
. ..
..
YELLOW
CLEAR
NEGATIVE
NEGATIVE
NEGATIVE
1. 020
NEGATIVE
5,0
NEGATIVE
0,2
NEGATIVE
NEGATIVE
, ... .. -
,
, . , -
-." I J I 1 I .1 ~_J
Page 1
An Equal Opportunity University
PEN N STATE
....'\::'1 Milton S, Hershey Medical Center
College of Medicine
Patient; LAIRD, BRITTANY M
MRN: 1132719
Flowsheet Print Request
Last 120 Results
Printed by: Men, Chanthan
printed on: 07/27/2001 10:29 AM
Ankle (< 3 . Ankle XR (.. Ankle XR (..
CXR (I-vi..
Pelvis XR
Ankle XR (.. [Multiple)
Fluoro (<6.
Page 2
An Squill OPI'ortul1ily Univcrllil)'
PENNSTATE
.~~ Milton S. Hershey Medical Center
College of Medicine
C-spine XR (2-3 views)
LAIRD, BRITTANY M -1132779
* Final Report *
ox C-SPINE 2-3 VIEWS - RT , LAT, XTAB, SUPINE, AP ,
PATIENT NAME: LAIRD,BRITTANY M
PATIENT MRN: 00362978
PATIENT DOB: 25-Mar-1990
EXAM NUMBER: 76C-03030l
EXAM: DX C-SPINE 2-3 VIEWS - RT , LAT, XTAB, SUPINE, AP ,
ORDERING PHYSICIAN: KYM A SALNESS
Exam:
Exam:
Exam:
Exam:
Exam:
Exam:
DX CHEST 1 VIEW - AP , SUPINE, INSP,
DX PELVIS 1-2 VIEWS - AP , SUPINE,
DX C-SPINE 2-3 VIEWS - RT , LAT, XTAB, SUPINE, AP ,
DX KNEE LT 1-2 VIEWS - AP , LAT, XTAB,
DX ANKLE LT 3 OR MORE VIEWS - INT, LAT, AP
DX ANKLE LT 3 OR MORE VIEWS - INT, LAT, AP
CHEST, PELVIS, C SPINE, LEFT ANKLE AND LEFT KNEE
CLINICAL HISTORY: 10-year-old female struck by car.
DISCUSSION: There are no similar exams available for comparison,
CERVICAL SPINE: The bony alignment is within the range of normal,
There is some mild straightening of the upper cervical spine and 1
rom of anterolisthesis of C2 with respect to C3 but this finding is
within normal limits, There is no evidence of fracture or
dislocation. The lung apices are clear,
CHEST: The cardiomediastinal silhouette is normal, The lungs are
clear, although there is mild hypoinflation, There is no evidence
of fracture, pneumothorax, or effusion. The visualized osseous
structures are unremarkable.
PELVIS: The
maintained,
are normal.
bony alignment is normal, The bony integrity is well
There is no evidence of fracture, The soft tissues
LEFT KNEE:
There is mild hyperextension at the knee, but no
Printed by:
Printed on:
Men, Chanthan
07/27/2001 10:29 AM
Page 1 of 2
(Continued)
An Equul Opportunity University
PENNSTATE
!!5l Milton S. Hershey Medical Center
., College of Medicine
C-spine XR (2-3 views)
LAIRD, BRITTANY M -1132779
evidence of fracture, dislocation, or joint effusion.
LEFT ANKLE: There is a distal transverse distal shaft fracture of
the fibula with anterior displacement of the distal fracture
fragment of 1-1/2 shaft widths, There is also lateral displacement
of about a 1/2 shaft width,
There is a also complex fracture involving the distal tibia,
There is a fracture through the physis with medial displacement of
the proximal tibia by about 1 cm, There is a coronal fracture
through the posterior aspect of the tibia with a fracture fragment
in the interosseous region, There is likely a fracture through the
epiphysis itself as well, The ankle mortise is abnormal, more
narrow medially than laterally, likely related to the
intraarticular component of the fracture of the epiphysis,
There is a lucency in the proximal aspect of the third
metatarsal which may represent a nondisplaced fracture there.
IMPRESSION: 1, Complex left ankle fracture, Triplaner fracture,
2, Mild left knee hyperextension, likely normal laxity, without
other evidence of injury,
3, The cervical spine is clear,
4, The chest and pelvis are within normal limits,
Dr, Hulse reviewed the images and discussed the interpretation with
Dr. Scorza.
DICTATED:
REVIEWED AND SIGNED: LESLIE B, SCORZA, M,D,/MICHAEL HULSE, D,O,
/lem
Printed by:
Printed on:
Men, Chanthan
07/27/2001 10:29 AM
Page 2 of 2
(End of Report)
An Equal Orportunity University
PENNSTATE
.~'1::1 Milton S. Hershey Medical Center
College of Medicine
CXR (1-view)
LAIRD, BRITTANY M - 1132779
* Final Report *
OX CHEST 1 VIEW - AP , SUPINE, INSP,
PATIENT NAME: LAIRD, BRITTANY M
PATIENT MRN: 00362978
PATIENT DOB: 25-Mar-1990
EXAM NUMBER: 76A-030301
EXAM: DX CHEST 1 VIEW - AP , SUPINE, INSP.
ORDERING PHYSICIAN: KYM A SALNESS
Exam:
Exam:
Exam:
Exam:
Exam:
Exam:
DX CHEST 1 VIEW - AP , SUPINE. INSP,
DX PELVIS 1-2 VIEWS - AP , SUPINE,
DX C-SPINE 2-3 VIEWS - RT , LAT, XTAB, SUPINE, AP ,
DX KNEE LT 1-2 VIEWS - AP , LAT, XTAB,
DX ANKLE LT 3 OR MORE VIEWS - INT. LAT, AP
DX ANKLE LT 3 OR MORE VIEWS - INT, LAT, AP
CHEST, PELVIS, C SPINE, LEFT ANKLE AND LEFT KNEE
CLINICAL HISTORY: 10-year-old female struck by car.
DISCUSSION: There are no similar exams available for comparison,
CERVICAL SPINE: The bony alignment is within the range of normal,
There is some mild straightening of the upper cervical spine and 1
rom of anterolisthesis of C2 with respect to C3 but this finding is
within normal limits, There is no evidence of fracture or
dislocation, The lung apices are clear,
CHEST: The cardiomediastinal silhouette is normal, The lungs are
clear, although there is mild hypoinflation, There is no evidence
of fracture, pneumothorax, or effusion, The visualized osseous
structures are unremarkable,
PELVIS: The
maintained.
are normal.
bony alignment is normal. The bony integrity is well
There is no evidence of fracture, The soft tissues
LEFT KNEE:
There is mild hyperextension at the knee, but no
Printed by:
Printed on:
Men, Chanthan
07/27/2001 10:29 AM
Page 1 of 2
(Continued)
Art Equal Opportunity Un(versit~
PENNSTATE
...."::'1 Milton S, Hershey Medical Center
College of Medicine
CXR (i-view) LAIRD,BRITTANYM-i132779
evidence of fracture, dislocation, or joint effusion.
LEFT ANKLE: There is a distal transverse distal shaft fracture of
the fibula with anterior displacement of the distal fracture
fragment of 1-1/2 shaft widths, There is also lateral displacement
of about a 1/2 shaft width,
There is a also complex fracture involving the distal tibia,
There is a fracture through the physis with medial displacement of
the proximal tibia by about 1 em, There is a coronal fracture
through the posterior aspect of the tibia with a fracture fragment
in the interosseous region, There is likely a fracture through the
epiphysis itself as well, The ankle mortise is abnormal, more
narrow medially than laterally, likely related to the
intraarticular component of the fracture of the epiphysis,
There is a lucency in the proximal aspect of the third
metatarsal which may represent a nondisplaced fracture there,
IMPRESSION:
1, Complex left ankle fracture, Triplaner fracture,
2, Mild left knee hyperextension, likely normal laxity, without
other evidence of injury,
3, The cervical spine is clear,
4, The chest and pelvis are within normal limits,
Dr, Hulse reviewed the images and discussed the interpretation with
Dr. Scorza.
DICTATED:
REVIEWED AND SIGNED: LESLIE B, SCORZA, M,D,IMICHAEL HULSE, D,O,
Ilem
Printed by:
Printed on:
Men, Chanthan
07/27/2001 10:29 AM
Page 2 of 2
(End of Report)
An Equul Opportunity Univer~ilY
PENNSTATE
....~ Milton S, Hershey Medical Center
, College of Medicine
Pelvis XR (1-2 views)
LAIRD, BRITTANY M - 1132779
* Final Report *
ox PELVIS 1-2 VIEWS - AP . SUPINE,
PATIENT NAME: LAIRD,BRITTANY M
PATIENT MRN: 00362978
PATIENT DOB: 25-Mar-1990
EXAM NUMBER: 76B-030301
EXAM: DX PELVIS 1-2 VIEWS - AP , SUPINE,
ORDERING PHYSICIAN: KYM A SALNESS
Exam:
Exam:
Exam:
Exam:
Exam:
Exam:
DX CHEST 1 VIEW - AP , SUPINE, INSP,
DX PELVIS 1-2 VIEWS - AP , SUPINE,
DX C-SPINE 2-3 VIEWS - RT , LAT, XTAB, SUPINE, AP ,
DX KNEE LT 1-2 VIEWS - AP , LAT, XTAB,
DX ANKLE LT 3 OR MORE VIEWS - INT, LAT, AP
DX ANKLE LT 3 OR MORE VIEWS - INT, LAT, AP
CHEST, PELVIS, C SPINE, LEFT ANKLE AND LEFT KNEE
CLINICAL HISTORY: 10-year-01d female struck by car,
DISCUSSION: There are no similar exams available for comparison,
CERVICAL SPINE: The bony alignment is within the range of normal,
There is some mild straightening of the upper cervical spine and 1
rom of anterolisthesis of C2 with respect to C3 but this finding is
within normal limits, There is no evidence of fracture or
dislocation, The lung apices are clear,
CHEST: The cardiomediastinal silhouette is normal, The lungs are
clear, although there is mild hypoinflation, There is no evidence
of fracture, pneumothorax, or effusion. The visualized osseous
structures are unremarkable.
PELVIS: The
maintained.
are normal.
bony alignment is normal, The bony integrity is well
There is no evidence of fracture, The soft tissues
LEFT KNEE:
There is mild hyperextension at the knee, but no
Printed by:
Printed on:
Men, Chanthan
07/27/2001 10:29 AM
Page 1 of 2
(Continued)
An Equal Opportunity University
PEN N STATE
~ Milton S. Hershey Medical Center
., College of Medicine
Pelvis XR (1-2 views) LAIRD, BRITTANY M - 1132779
evidence of fracture, dislocation, or joint effusion.
LEFT ANKLE: There is a distal transverse distal shaft fracture of
the fibula with anterior displacement of the distal fracture
fragment of 1-1/2 shaft widths, There is also lateral displacement
of about a 1/2 shaft width,
There is a also complex fracture involving the distal tibia,
There is a fracture through the physis with medial displacement of
the proximal tibia by about 1 cm, There is a coronal fracture
through the posterior aspect of the tibia with a fracture fragment
in the interosseous region, There is likely a fracture through the
epiphysis itself as well, The ankle mortise is abnormal, more
narrow medially than laterally, likely related to the
intraarticular component of the fracture of the epiphysis,
There is a lucency in the proximal aspect of the third
metatarsal which may represent a nondisplaced fracture there.
IMPRESSION:
1, Complex left ankle fracture, Triplaner fracture,
2, Mild left knee hyperextension, likely normal laxity, without
other evidence of injury.
3. The cervical spine is clear,
4. The chest and pelvis are within normal limits,
Dr, Hulse reviewed the images and discussed the interpretation with
Dr. Scorza.
DICTATED:
REVIEWED AND SIGNED: LESLIE B, SCORZA, M,D,/MICHAEL HULSE, D,O,
Ilem
Printed by:
Printed on:
Men, Chanthan
07/27/2001 10:29 AM
Page 2 012
(End of Report)
An Equal Opportunity University
PENN STATE
!5:l Milton S, Hershey Medical Center
., College of Medicine
Knee XR (1 - 2 view, 1 knee)
LAIRD, BRITTANY M -1132779
* Final Report *
OX KNEE LT 1-2 VIEWS - AP, LAT, XTAB,
PATIENT NAME: LAIRD,BRITTANY M
PATIENT MRN: 00362978
PATIENT DOB: 25-Mar-1990
EXAM NUMBER: 76D-030301
EXAM: DX KNEE LT 1-2 VIEWS - AP , LAT, XTAB,
ORDERING PHYSICIAN: KYM A SALNESS
Exam:
Exam:
Exam:
Exam:
Exam;
Exam:
DX CHEST 1 VIEW - AP , SUPINE, INSP,
DX PELVIS 1-2 VIEWS - AP , SUPINE,
DX C-SPINE 2-3 VIEWS - RT , LAT, XTAB, SUPINE, AP ,
DX KNEE LT 1-2 VIEWS - AP , LAT, XTAB,
DX ANKLE LT 3 OR MORE VIEWS - INT, LAT, AP
DX ANKLE LT 3 OR MORE VIEWS - INT, LAT, AP
CHEST, PELVIS, C SPINE, LEFT ANKLE AND LEFT KNEE
CLINICAL HISTORY: 10-year-01d female struck by car,
DISCUSSION: There are no similar exams available for comparison,
CERVICAL SPINE: The bony alignment is within the range of normal,
There is some mild straightening of the upper cervical spine and 1
mm of anterolisthesis of C2 with respect to C3 but this finding is
within normal limits, There is no evidence of fracture or
dislocation, The lung apices are clear,
CHEST: The cardiomediastinal silhouette is normal, The lungs are
clear, although there is mild hypoinflation, There is no evidence
of fracture, pneumothorax, or effusion. The visualized osseous
structures are unremarkable.
PELVIS: The
maintained.
are normal.
bony alignment is normal, The bony integrity is well
There is no evidence of fracture, The soft tissues
LEFT KNEE:
There is mild hyperextension at the knee, but no
Printed by:
Printed on:
Men, Chanthan
07/27/2001 10:30 AM
Page 1 of 2
(Continued)
An Equul O"pl)rl~lnity Ul1iversity
PENNSTATE
.~'i::l Milton S. Hershey Medical Center
College of Medicine
Knee XR (1 - 2 view, 1 knee) LAIRD, BRITTANY M -1132779
evidence of fracture, dislocation, or joint effusion,
LEFT ANKLE: There is a distal transverse distal shaft fracture of
the fibula with anterior displacement of the distal fracture
fragment of 1-1/2 shaft widths, There is also lateral displacement
of about a 1/2 shaft width,
There is a also complex fracture involving the distal tibia,
There is a fracture through the physis with medial displacement of
the proximal tibia by about 1 em, There is a coronal fracture
through the posterior aspect of the tibia with a fracture fragment
in the interosseous region. There is likely a fracture through the
epiphysis itself as well, The ankle mortise is abnormal, more
narrow medially than laterally, likely related to the
intraarticular component of the fracture of the epiphysis,
There is a lucency in the proximal aspect of the third
metatarsal which may represent a nondisplaced fracture there.
IMPRESSION: 1, Complex left ankle fracture, Triplaner fracture,
2, Mild left knee hyperextension, likely normal laxity, without
other evidence of injury,
3, The cervical spine is clear,
4, The chest and pelvis are within normal limits.
Dr, Hulse reviewed the images and discussed the interpretation with
Dr, Scorza,
DICTATED:
REVIEWED AND SIGNED: LESLIE B, SCORZA, M,D,jMICHAEL HULSE, 0.0,
/lem
Printed by:
Printed on:
Men, Chanthan
07/27/2001 10:30 AM
Page 2 of 2
(End of Report)
All. Eq\ltll Opportunity University
PENN STATE
.~'I:"I Milton S, Hershey Medical Center
College of Medicine
Ankle XR (> 3 view)
LAIRD, BRITTANY M - 1132779
* Final Report *
DX ANKLE L T 3 OR MORE VIEWS - INT, LAT, XTAB, AP ,
PATIENT NAME: LAIRD,BRITTANY M
PATIENT MRN: 00362978
PATIENT DOB: 25-Mar-1990
EXAM NUMBER: 102A-030301
EXAM: DX ANKLE LT 3 OR MORE VIEWS - INT, LAT, XTAB, AP ,
ORDERING PHYSICIAN: DAVID WALLACH
Exam:
Exam:
DX ANKLE LT 3 OR MORE VIEWS - INT, LAT, XTAB, AP ,
DX FLUORO UP TO 60 MINUTES - LT ,
PORTABLE VIEWS OF THE LEFT ANKLE AND
INTRAOPERATIVE MATRIX VIEWS OF THE LEFT ANKLE WITH FLUORO TIME
CLINICAL HISTORY: 10 year-old female trauma,
DISCUSSION: Comparison is made to the acute trauma films on the
same date, Submitted for review are three portable Matrix films:
AP, lateral, and ankle mortis views of the left ankle,
FINDINGS: Two partially threaded cancellous screws have been
placed through the distal tibia with near anatomic alignment of the
triplanar fracture, There is improved alignment of the distal
fibula shaft, A drain is in place from the medial approach, The
ankle mortis is symmetric,
IMPRESSION: Near anatomic alignment of the left distal ankle
fracture after ORIF,
Dr, Kathleen Eggli reviewed the images and discussed the
interpretation with Dr, Pettinger,
DICTATED: 16228
REVIEWED AND SIGNED: MARIA T, PETTINGER, M,D,/KATHLEEN D, EGGLI, M,D,
l/ban
Printed by:
Printed on:
Men, Chanthan
07/27/2001 10:30 AM
Page 1 of 2
(Continued)
An r:::quul OI'lP~lrtUllity UnlverKify
PENN STATE
.~~ Milton S. Hershey Medical Center
College of Medicine
Ankle XR (> 3 view)
Printed by:
Printed on:
Men, Chanthan
07/27/2001 10:30 AM
LAIRD, BRITTANY M - 1132779
Page 2 of 2
(End of Report)
An Equal Opportunity Univ~r5ity
PENN STATE
.~~ Milton S. Hershey Medical Center
College of Medicine
Fluoro (<60 Minutes)
LAI RD, BRITTANY M - 1132779
* Final Report *
OX FLUORO UP TO 60 MINUTES - LT ,
PATIENT NAME: LAIRD,BRITTANY M
PATIENT MRN: 00362978
PATIENT DOB: 25-Mar-1990
EXAM NUMBER: 102B-03030l
EXAM: DX FLUORO UP TO 60 MINUTES - LT ,
ORDERING PHYSICIAN: DAVID WALLACH
Exam:
Exam:
DX ANKLE LT 3 OR MORE VIEWS - INT, LAT, XTAB, AP ,
DX FLUORO UP TO 60 MINUTES - LT ,
PORTABLE VIEWS OF THE LEFT ANKLE AND
INTRAOPERATIVE MATRIX VIEWS OF THE LEFT ANKLE WITH FLUORO TIME
CLINICAL HISTORY: 10 year-old female trauma,
DISCUSSION: Comparison is made to the acute trauma films on the
same date, Submitted for review are three portable Matrix films:
AP, lateral, and ankle mortis views of the left ankle,
FINDINGS: Two partially threaded cancellous screws have been
placed through the distal tibia with near anatomic alignment of the
triplanar fracture, There is improved alignment of the distal
fibula shaft, A drain is in place from the medial approach, The
ankle mortis is symmetric,
IMPRESSION: Near anatomic alignment of the left distal ankle
fracture after ORIF.
Dr, Kathleen Eggli reviewed the images and discussed the
interpretation with Dr, Pettinger,
DICTATED: 16228
REVIEWED AND SIGNED: MARIA T, PETTINGER, M,D./KATHLEEN D. EGGLI, M,D,
l/ban
Printed by:
Printed on:
Men, Chanthan
07/27/2001 10:30 AM
Page 1 of 2
(Continued)
An Equal Opportunity University
PENNSTATE
.~~ Milton S. Hershey Medical Center
College of Medicine
Fluoro (<60 Minutes)
Printed by:
Printed on:
Men, Chanthan
07/27/2001 10:30 AM
LAIRD, BRITTANY M -1132779
Page 2 of 2
(End of Report)
An Equal Opportunity University
PENNSTATE
.~~ Milton S, Hershey Medical Center
College of Medicine
Ankle XR (> 3 view)
LAIRD, BRITTANY M - 1132779
* Final Report *
OX ANKLE LT 3 OR MORE VIEWS -INT, LAT, AP,
PATIENT NAME: LAIRD, BRITTANY M
PATIENT MRN: 01132779
PATIENT DOB: 25-Mar-1990
EXAM NUMBER: 496A-031601
EXAM: DX ANKLE LT 3 OR MORE VIEWS - INT, LAT, AP ,
ORDERING PHYSICIAN: DAVID WALLACH
Exam: DX ANKLE LT 3 OR MORE VIEWS - INT, LAT, AP ,
LEFT ANKLE
CLINICAL HISTORY: This patient has had a left ankle fracture,
DISCUSSION: Comparison is made with the previous examination of 3
March 2001. These films are taken through a plaster cast which
does obscure some detail, They do, however, reveal two partially
threaded screws extending from anteromedially to posterolaterally
across the posterior malleolar fracture of the left tibia,
Anatomic alignment has been achieved for the tibia, There is very
minimal anterior displacement of the distal fibular fracture
fragment in relation to its proximal fragment, No other
abnormality,
DICTATED: 4191
REVIEWED AND SIGNED: KATHLEEN D, EGGLI, M,D,/
4 / drnd
Printed by:
Printed on:
Men, Chanthan
07/27/2001 10:30 AM
Page 1 of 1
(End of Report)
An Equal Opportunity University
PENNSTATE
.~ Milton S, Hershey Medical Center
College of Medicine
Ankle XR (> 3 view)
LAIRD, BRITTANYM-1132779
* Final Report *
OX ANKLE LT 3 OR MORE VIEWS -INT, LAT, AP,
PATIENT NAME: LAIRD,BRITTANY M
PATIENT MRN: 01132779
PATIENT DOB: 25-Mar-1990
EXAM NUMBER: 543A-042001
EXAM: DX ANKLE LT 3 OR MORE VIEWS - INT, LAT, AP ,
ORDERING PHYSICIAN: DAVID WALLACH
Exam: DX ANKLE LT 3 OR MORE VIEWS - INT, LAT, AP ,
DIAGNOSTIC ANKLE
CLINICAL HISTORY: ll-year-old female with a left ankle fracture,
out of cast.
DISCUSSION: Comparison is made to the prior examination of
3/16/2001 which reveals interval removal of casting material,
There has been interval healing with callus formation, Two
partially threaded screws are seen traveling from anterior to
posterior in the distal tibia, There is no lucency around the
screws, Alignment is unchanged of the distal fracture fragments,
The ankle mortise appears symmetric, There is some diffuse
osteopenia.
DICTATED: 16906
REVIEWED AND SIGNED: MICHAEL HULSE, D,O,/
l/vlb
Printed by:
Printed on:
Men, Chanthan
07/27/2001 10:30 AM
Page 1 of 1
(End of Report)
An Equul Opportunity Univen;ity
PENN STATE _
.~~ Milton S. Hershey Medical Center
College of Medicine
Ankle (< 3 views)
LAIRD, BRITTANY M -1132779
* Final Report *
OX ANKLE RT 1-2 VIEWS - LAT, AP ,
PATIENT NAME: LAIRD,BRITTANY M
PATIENT MRN: 01132779
PATIENT DOB: 25-Mar-1990
EXAM NUMBER: 432A-052201
EXAM: DX ANKLE RT 1-2 VIEWS - LAT, AP ,
ORDERING PHYSICIAN: DAVID WALLACH
Exam: DX ANKLE RT 1-2 VIEWS - LAT, AP ,
AP AND LATERAL LEFT ANKLE
CLINICAL HISTORY: Comparison is made with previous examination of
04/20/01,
DISCUSSION: Since the previous examination on 04/20/01, the distal
tibial and fibular fractures have healed quite nicely and close to
anatomic alignment with the distal tibial metaphyseal fracture
affixed by two partially threaded screws lying from anterior to
posterior. The bones are osteopenic and there is no other
abnormality,
DICTATED: 4191
REVIEWED AND SIGNED: KATHLEEN D, EGGLI, M,D,/
4/11d
Printed by:
Printed on:
Men, Chanthan
07/27/2001 10:30 AM
Page 1 of 1
(End of Report)
An Equal Opportunity Ul1ivcr~ity
CONTINGENT FEE AGREEMENT
THIS AGREEMENT entered into the
day of
2001, by and between SCHMIDT, RONCA & KRAMER, P,C, and 'J,~l1,/Z~
fll'/ci /f/(hf1\V s' Ltilari r!:l rvrJ bd,/OI.f, hereinafter
I '
, D( rH'JI/j"1 LAIf2J ~ (nlntJ/l
"Cl1ent,. dl
referred to as
WITNESSETH:
The law firm of SCHMIDT, RONCA & KRAMER, P,C" will act as
Client's attorney in negotiating for a settlement, and in bringing a
claim against
::]P'NIYj {3, dM
r(L jln;;c-Ylf'- &4:r
3/':?J~
I I
arising out of an accident which occurred on
, at mAt1,kt--{" rnrrlh '51
/!YfYllo U7.l.vyry d"
County, Pennsylvania.
U/J7()VfJC
"
In addition, SCHMIDT, RONCA &
Township,
KRAMER, P,C" will pursue all claims for under insured or uninsured
motorist benefits to which the Client may be entitled under his/her
insurance policy,
In return, the Client will:
1, Promptly supply accurate information, as requested by
SCHMIDT, RONCA & KRAMER, P,C" and cooperate fully, including making
myself available for meetings with my attorney and for legal
proceedings, Client promises all information supplied will be
truthful and accurate.
2, (a) In any claim brought on Client's behalf, to pay to
SCHMIDT, RONCA & KRAMER, P.C" for its services an amount equal to
thirty percent (30%) of all funds or property accruing to Client as
a result of SCHMIDT, RONCA & KRAMER, P,C. 's services in securing a
settlement of these claims without litigation; an amount equal to
thirty-three-and-one-third percent (33-1/3%) of all funds or
property accruing to Client as a result of SCHMIDT, RONCA & KRAMER,
suit has been filed; and an amount equal
of these claims after a
to -f5~~~?t!_~~n) if
P,C,'s services in securing a settlement
such funds or property are secured after start of trial or as a
result a verdict or judgment, Trial begins at jury selection, In
any matter submitted to arbitration, suit is filed when the
arbitrators are appointed or when a Petition to Appoint Arbitrators
is filed, whichever first occurs, In any matter submitted to
arbitration, trial starts the first day the arbitrators have
convened to hear testimony.
(b) Client agrees not to settle or negotiate the above claim
or any proceedings based thereon.
(c) If Client terminates this Agreement before recovery,
Client agrees that SCHMIDT, RONCA & KRAMER, P.C" shall be entitled
to a fee based upon work done and benefit conferred.
(d) Client agrees to read and follow SCHMIDT, RONCA & KRAMER,
P.C.'s Instructions to Our Clients,
3, To reimburse SCHMIDT, RONCA & KRAMER, P.C" out of any
recovery, in addition to attorneys' fees, all costs and expenses
incurred on Client's behalf in order to make the claim, All such
costs and expenses will be advanced by SCHMIDT, RONCA & KRAMER, P,C,
as they are incurred, Such costs and expenses include, but are not
limited to, filing fees, cost of medical records, copying costs, fax
costs, long distance telephone costs, expert witness fees and
sheriff's service costs,
In the event there is no recovery, U '"
Client will not be responsible for any costs or interest charges.
Costs will be repaid to SCHMIDT, RONCA & KRAMER, P,C" out of
any funds or property collected either by settlement or judgment,
4, Claims for first party medical benefits and income loss
benefits are separate items, SCHMIDT, RONCA & KRAMER, P,C" will
help you process these claims, A separate agreement will have to be
entered into for fees if a major dispute occurs requiring the filing
of suit for these benefits,
The Client has read and does understand this Agreement,
Signed the day and year set forth above,
WITNESS:
Client:
"
e/~L4
, JOvTI'vTMj X(Jj~AA
~
Approved:
SCHMIDT, RONCA & KRAMER, P,C,
By
I have received a copy of this contingent Fee Agreement.
11-
Initials
....
0
.... ci
~ IiI
~
.a.
;::
~
'"
~
S
~
'<
.
:.
co
o
:..
.
.
.
CO
o
:..
.
."
"
'"
"
-
d ~9999Q99g999999~~~~99~~9~9~
,,_..... :1CDCDCO(!l('[)(!ICDCDCDC1l(D(DCDCD:::I:::I::l:::lctlCT>'O:::IctlCO<nO
mnnonnnnoonn~nnCDmCDCDo~omnnn5'
N OJ ^^^;1r" ';1':' ""^^""'" ""@CJOJQJ;It; !::2.t3 A^"ro
0- ------
o c..... C- c... C- c.... c.....
0)0 0000 0
t..,) C c: c: c c c:
""'3 3333 3
~ ~!!!.QL~ ~
~~~~~~~~~~~~~~~~mm~~WW~~~N~
W~N~~~~~~~~MNNN~~WN~N~N~~~~
NNe~~~~~~~~~~m~~N~~~~~~~~Nw ~
OONNNN~~~N~NNNNNOONONNNNNO~ ~
O~OOOONNNONooo800000000000N ~
~ ~~~~gg888~88~8ww8w88Se8wg s
www W N
GlWN
~NCO
~~~
"
'"
NN
WN
0l0l
OOl
Cj)G)G:lG)C,J'101~N(Jl(J'101->'
c.-c...c....c.....CD~OO)..........O......
WWWW......WOOlWW(J)(O
~N..........W.;........lAlV......W.....
UlW-",O CD
~Q:lO""'4
--
"'...
" W
"Ol
~II~~~oo~on~~~~~~~~~z~
~.~~~~~~g5~~~~~~~-~~>g
~ffiffi~.2.a.~2.~~~.3~2.2.~~~~ @
s~~~~~~~~~~a~~~~~~~ n
!Jl )>)> v ~ . - - Q) Q) - 0" s:- - !'l!h!" sn 0
~__~~~~~::l:::l~:::IO~~~~~~ ~
~cr~oooooano ,OO~~~~
~~~:::I:::Ig:::l:::lnng~~~~~~~~ I
Q)~~gg~~gQQ~s~~Q~wSS ~
~rr~~~~~55~a~~~~~~~ ~
N~~^^^^^~~^~~^^NN~N ~
g~~~~~~@~~@~~~@gggg <
~~_33333ao3~,33~~~~ m
......1<"'....roroctl\tlCP-.....ro c:(1)(D.......................
~zz~~~~~g~~8.~~~~~~~
!:2.~"'O"'O""'O'1J::l::l'tllllC/)'"O'tl
9l.~hohhh9.2.hmrohh
ctI CD, . , . . III III . ~ <' .
;0;0 .;1.-<- n'
(D<'D CIlt/l (ll
~"8 00
aa ~~
::J::l (tl (\l
!Ucn~:E~
-a.' il s. ro :;'
. ~::T!i.a.
~g,g~~
Co()Qj~~
~~-< m3:
Sg-Sl.3S
~ ::lCi~~
.. Q.l c: (Q ..
~a~g~
g()~.Q g
~g~S";~
;:!,o.ft
'< () 0'
0"
c -
~'"
"'''
:<
n'
"
'"
nwmO()~()~~~0~5n'"Oa'"O~0~~~()~~~ro
ommooooocncno~~OOOOOO<(l)<'DO~~ctlctl
~ ~~~~~ ~~ ~t/l~m~~roa.-~<~o.(Q
~~m~~~~~~~ffi'::l ~~ffi'QjQjffi't/l5~~Ill~-'5
~~e~t/l~~C~~~~~t/l~t/l~~t/lg~::lt/lg~ga
o~'~ (t) (D_...... ~~ CD row . 0 (t)ro-~
~a~ mm em =~- a.(1)~~
fit::::::::::: cn(Jl (Qf\J <roo (fiG)
~~~ ~? a? rogg ~~a'~
$~i ~l g=. ia~ !~o.~
roOf\J u~ ~a. t/lClln ~~~o
~i~ ~~ ~o ~ c Ow ro
g~~ ~~ ~~ ~ ~ ~~
=' N ~ t;; en ~ t/l
roN ~ ~ (l) ~
S20 0) t S. 5-
~ :;0 0 0
x n; 0
o c
"" ;<
~ ~
3 '"
" ""
'" ~
~
-....
'"
o
:...
.
~
~
co
o
:...
~
..... .:... f'..) .f>.
~~~ W~~ ~NOO ~~~w
~oo~OO~O~f'..)NOO~~~~~~N~~~wo~m~
~~~~~~~~gg~8$~~~~~~~~~~gg~~
-.
'"
o
:...
.
~ ~~~~.............~~~...........
.~ ~~'.....o"o'obbbb~obo cO....s ""-l ""-l ""-l ~ -..1-../ Q} m co ~ 0'1 Ol.l>.
~ gg~?6~~~~~~~~~g~~~~~~~~~:::j~~~~
_ ~~w~m~mM~~~mmmowNom~~w~~~~w
..... ~(Q"""cOCO~WW01~01(}'1U1O)m~""'ONN""'.f>,.p.~~~N
~
'"
N .::;'
0.0.
g;;:
w<n
, .
'"
a
or
=>
'"<
~ 0 W
~ '"
0 a
~ W 0
c a ."
!!!. '" s:
'"
"
'"
Vi'
....
'<
."
.
z
"
3
'" C/)
0 ()
c (')
"
n !: ::r
" l/l 3
z
. - c:
3 0
0 ~ 3 .-
CD ::0
-i ... 0
, ::l
0> 0
" (')
.. "tl III
0>
0 CD l/O
~ :l
o' "
" OJ ill
..
III 3
III CD
:l .'"'
C'l "'0
CD (")
s:
.
3
0
~
o
"
;<
lXl
.
"
,
n
.
~~/~~/~~~L LO;~O
_......~-......!I....II~.._.,'-II._..-
11 Ibl:L,L"'l 1
MS HERSHEY MEDICAL CENTo~
PO BOX 828632
PHILADELPHIA PA 19182-0001
f-'Al::Il:. tl,j
------------------------, STATEMENT OF HOSPITAL ACCOUNT
( D. Dell: 0_ .
t~~~~--~~-~ j ~ (
H~r-<l:.
AMOUNT PAlO
)
L
PATIENTS NAME
N
ACCOUNT NO,
"OMISSION OATE
Ol5CHARGE DATE
STATEMENT DATE
00000000141b3260316011011010000023200
MS HERSHEY MEDICAL CENTER
PO BOX 828632
PHILADELPHIA PA 19182-0001
***********~************
00000172 I SP 0.340
TAMMY LAIRD
921 WALNUT ST
LEMOYNE PA 17043-1444
SNGLP
01
',..111.1.",,1,1,.1.,.1.111.,,11...11.,.,.,11.,11...1.',.11.I
1...111."111.,,,1.,1,.11,...11.'..1.1.,1,1..1,.1.1,..111,1.,1
IM"OR'l'ANT: ~LE"$E OETi\CI-I ANO ,"ETUAN THe': tOP PORTION OF THIS STA,TEMENT Win"! "OJ~ AuMITTANCE TO ASSURE PROPER CAEOll PLEASE WRITE ACCOUNT NUM6EIlI ON T~E CHECK
OX 8248
OUTPATIENT
DME / ORTHOTICS DMf
03/16/01 26825
AFO FRACTURE WALKER SOLID
232.00
-,- :'.
"
i.
-~,
';::i;"l~
Nor
- >-
1).' t
f
232.00
0.00
232.00
Johnson, Duffie, Stewart & Weidner
By: C. Roy Weidner, Jr.
1.0. No. 19530
301 Market Street
P O. Box 109
Lemoyne, PelIDsylvania 17043-0109
(717) 761-4540
Attorneys for Defendant
J. IRA LAIRD and TAMMY LAIRD
as Parents and Natural Guardians of
BRITTANY LAIRD,
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 03-790 CIVIL TERM
Plaintiffs
CIVIL ACTION - LAW
v.
JURY TRIAL DEMANDED
JENNY R. BIXLER,
Defendant
GENERAL RELEASE OF ALL CLAIMS
KNOW ALL MEN BY THESE PRESENTS, that J. IRA LAIRD and TAMMY LAIRD, as Parents and
Natural Guardians of BRITTANY LAIRD (hereinafter for convenient reference "Releasors", or "we", whether
referring to one or more) for and in consideration of the payment made by or on behalf of Jenny R. Bixler, any
insurer, agents, representatives, employees, officers, directors, attorneys, predecessors, and successors, and
all and every person, firm or entity who is or may be liable on account of their actions, (hereinafter for
convenient reference "Releasees," whether referring to one or more) of TWENTY-TWO THOUSAND FIVE
HUNDRED DOLLARS ($22,500.00), the receipt and sufficiency of which is hereby acknowledged, do for
ourselves, our heirs, executors, administrators, successors, insurers, and assigns hereby remise, release, and
forever discharge completely and absolutely Releasees from any and all actions, causes of action, suits, suit
costs, claims, damages and demands of every kind, name or nature whatsoever, known or unknown, whether
in law or in equity, which we or anyone claiming through us in any way may have or will claim or could claim to
have against Releasees, including, but not limited to, any and all claims, damages, losses, costs or injuries
whatsoever based upon or in any way arising out of, related to or resulting from or to result from a certain
incident which is the subject of the above-captioned lawsuit, and any and all claims which we, our heirs,
successors, and assigns have made or could have made, whether accrued or not, whether known or unknown,
whether anticipated or unanticipated and whether or not asserted in a suit now pending.
We intend that this release shall be complete and shall not be subject to any claim of mistake of fact,
or of law, and that it expresses a full and complete settlement of liability denied by Releasees, and,
regardless of the adequacy or inadequacy of the amount paid, this release is intended to avoid these and
future claims or lawsuits against Releasees. The payment referred to herein is in compromise of a doubtful
and disputed claim and such payment is not to be construed as an admission of liability on behalf of
Releasees or anyone on their behalf. To the contrary, Releasees expressly deny any liability.
The Releasors, their heirs, executors, administrators, successors and assigns will indemnify and
save forever harmless the Releasees against any loss or damage of any kind because of any and all claims,
suits, demands or actions including, but not limited to, those for indemnity and/or contribution, whether
made by others on account of or in any manner related to, resulting from, or having any relationship to the
injuries, losses or damages of the Releasors referred to in the above-captioned lawsuit.
In further consideration of the above payments, Releasors will indemnify and hold harmless
Releasees from any and all liability arising from liens and subrogation claims, or claims for reimbursement
or repayment, including any compensation or medical payments due or claimed to be due under the law,
state or federal regulation or contract. This shall include any such claims by any ERISA entity. Releasors
expressly acknowledge that all obligations to satisfy such liens and claims are that of Releasors and not
Releasees. Releasors specifically represent and warrant that, as of the date hereof, no such liens have
been asserted or made, and acknowledge that Releasees are relying on that warranty and representation
by Releasors in making the payments herein set forth.
We acknowledge that the payment made to us is based upon our warranty that we have not otherwise
received any consideration for, nor have we released any person, firm or corporation from any claim or liability
for damages arising from or related to the claim which is the subject matter of this release. The payment
made to us is based upon our warranty that we have not assigned our claim, or any portion of our claim
against Releasees to any other person or organization or their heirs, executors, administrators, successors,
insurers and assigns.
Releasors further certify, state, declare and acknowledge that they have had their own legal
representation throughout these proceedings in the person of James R. Ronca, Esquire and have been
advised by him in all matters pertaining hereto and admit that no representations of fact or opinion have been
made by Releasees or anyone acting on their behalf to induce this compromise or payment or release. In
making this settlement, Releasors certify, state, declare and acknowledge that they have not relied on any
statements or representations by Releasees of either the extent of financial responsibility or extent of legal
responsibility of Releasees and that it is their intention that this release be complete and shall cover all losses,
damages and injuries insofar as they relate to Releasees.
As further consideration for the amount paid by Releasees, we further agree that any suit filed by us,
on our behalf, or by us on behalf of any of our insurers shall be marked settled, discontinued and ended of
record.
This release contains the entire agreement between the parties hereto and the terms of this release
are contractual and not a mere recital.
It is further agreed that this release shall be governed by and interpreted in accordance with
Pennsylvania law as it existed on the date of execution hereof.
The provisions of Pa. R.C.P. No. 229.1 notwithstanding, Releasors agree that the settlement funds
need not be sent to their attorney until Releasees' attorney is in receipt of a discontinuance executed by
Releasors' attorney.
IN WITNESS WHEREOF AND INTENDING TO BE LEGALL Y BOUND HEREBY, Releasors have
hereunto set their hands and seals this day of , 2005.
WITNESS:
(SEAL)
James R. Ronca, Esquire
J. Ira Laird
(SEAL)
Tammy Laird
CAUTION:
READ BEFORE SIGNING - YOU ARE SIGNING A GENERAL RELEASE OF ALL CLAIMS
AGAINST THE RELEASEE.
:241792
5774-447
STATE OF PENNSYLVANIA
ss:
COUNTY OF
ON THIS the day of , 2005, before me, the undersigned officer,
personally appeared J. IRA LAIRD and TAMMY LAIRD, known to me or satisfactorily proven to be the persons
whose names are subscribed to the foregoing instrument, and acknowledged that they executed the same for
the purposes therein contained.
IN WITNESS WHEREOF, I hereunto set my hand and official seal.
Notary Public
:241792
5774-447
CERTIFICATE OF SERVICE
AND NOW, I, Beth E. Steever, and employee of the law firm of Schmidt, Ronca, &
Kramer, P.C., hereby certify that I have served a true and correct copy of the foregoing
Petition for Approval of Minor's Settlement by placing a copy of the same in the United
States Mail, postage prepaid, at Harrisburg, Pennsylvania, addressed to:
C. Roy Weidner, Jr., Esquire
Johnson, Duffie, Stewart & Weidner
P.O. Box 109
Lemoyne, PA 17043-0109
Date: 3/ID}US
,~ Z;SbM)(j
Bet E. Steever
I~.-'L
I
",,\
(.-)
~ll
--'-I
c.)
c',
MAR 1 4 20U5 ~,./ j
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
J. IRA LAIRD and TAMMY LAIRD
As Parents and Natural Guardians
or Brittany Laird
Plaintiffs
v.
i
NO. 03-790 Civil Terml
CIVIL ACTION - LAW
JENNY R. BIXLER,
Defendant
JURY TRIAL DEMAND D
AND NOW this
)l.~
ORDER
daYOf~~
,2005 upon
consideration of the Petition for Approval of Minor's Settlement, it is ereby
ordered that the Petitioners are authorized to execute the settlement ontract
thereby releasing Defendant from future liability as to this claim and
discontinuing this action in exchange for consideration in the amou
$22,500.00, on behalf of their minor daughter, Brittany Laird, distri
proceeds as follows:
Schmidt, Ronca & Kramer, P.C.
Attorneys' Fees (25% of $22,500.00) . . . . . . . . . . . . $5, 25.00
Schmidt, Ronca & Kramer, P.C.
Costs incurred to date. . . . . . . . . . . . . . . . . . . . .. $1, 80.11
Outstanding Medical Bills:
Hershey Medical Center. . . . . . . . . . . . . . . . . . . . $ 2 2.00
Reimbursement to Parents:
J. Ira and Tammy Laird (West Shore EMS). . . . . ..$ 917.29
.
J. Ira Laird and Tammy Laird, as Parents and Natural Guardia s of
Brittany Laird, a minor, to be deposited into a restricted, feder lly
insured account marked "No withdraws prior to March 25, 200 ,without
prior court approval" . . . . . . . . . . . . . . . . . . . . . . . . . . . . $14, 45.60
TOTAL DISTRIBUTION. . . . . . . . . . . . . . . . . . . . . . . . . . $22, 00.00.
Counsel shall provide to the Court proof of such deposit:
J.
d:>
~~l\09
11,f}
D"J
AU:;
"1 11'1l-.t
(, :, i\'i'
()-. \"'" '1"1
0(. d10';'~ JJU~
Ab\j.LU.~;~;j-L~CJ':jJ 3H1 :lO
:!;ji3:1()-CEill:J
209 State Street
Harrisburg, Pennsylvania 17101
717.232.6300
FAX 717.232.6467
www.srklaw.com
Schmidt, Ronc~~ K..ran1erl~c
INJURY LAWYERS
Please respond to Harrisburg office.
March 16, 2005
Honorable Edward E. Guido
Cumberland County Courthouse
One Courthouse Square
Carlisle, PA 17013
RE: Laird v. Bixler
Minor's Settlement Petition - Cost Exhibit
No. 03-790
Dear Judge Guido:
15~ 8 Walnut Street. 3rd Floor
Phi adelphia, PA 19102
2H .790.7303 VOICE
21" .0.46.0942 FAX
...,
In accordance with your request, enclosed is a complete cost ledger i the
above-referenced matter.
If you require anything further, please contact our office. Thank yo for your
consideration.
Very truly yours,
SCHMIDT, RONCA & KRAMER, P.C.
'M/~h4
Todd D. Getgen cT,A/ 7'"
Attorney at Law
TDGj bes
Enclosure
Mar- 16/2005
___.__o r
Date p
Entry#
Received From/Paid To
Explanati.on
Schmidt, Ro~ca & Kramer, PC
Client Ledger
ALL DATES
Page 1
--
Trust
Disbs
Che#
Rcpt#
General
Disbs
'O_~_
BId
Inv#
Rcpts
Fees
Acc ~Et~
Balance
2718 Laird (for Brittany LairdJ, J. Iran & Tammy
01~263 Other-Pedesstrian
May 8/2001
115760
Jun 18/2001
118485
Al:g 22/2001
121924
Aug 29/2001
122563
Oct 15/2001
124726
Feb 1/2002
130654
Apr 26/2002
134722
Jun 13/2002
137726
Aug 22/2002
140738
-..
I TOTALS
PERIOD
END DATE
FIRM TOTALS
PERIOD
END DATE
Matthew E. Hunt
Investigative Services
Expense Recovery 00330
Reimburse Advanced Cost - Office Copies
Recordex Services, Inc.
Medical Records
Expense Recovery 00343
Reimburse Advanced Cost - Office Copies
Hershey Medical Center
Medical Records
F. Y. I. HealthSERVE 1768
Medical Records Laird CJG
Expense Recovery 00388
Reimburse Advanced Cost - Office Copies
Darylene Bracken
typing services
Expense Recovery 00426
Reimburse Advanced Cost - Office Copies
327.50
0.20
88.92
0.50
15.00
21.15
34.50
2.25
1.50
1 - _. UNBILLED
CHE+ RECOV FEES+
454.82 36.70 0.00
454.82 36.70 0.00
CHE+
454.82
454.82
REPORT SELECTIONS
Report:
Requested by:
Finished:
Date Range:
Matters:
Clients:
Major Clients:
Responsible Lawyer:
Introducing Lawyer:
Assigned Lawyer:
Type of Law:
Sort by Resp Lawyer:
New Page for Each Lawyer:
New Page for Each Matter:
Totals Only:
No Activity Date:
Ver:
UNBILLED
RECOV
36.70
36.70
I I BILLED j. BALANCES =j
= TOTAL DISBS + FEES + TAX - RECEIPTS = A/R TRUST
491.52 0.00 0.00 0.00 0.00 0.00 0.00
491. 52 0.00 0.00 0.00 0.00 0.00 0.00
I I .- BILLED F BALANCES -I
= TOTAL DISBS + FEES + TAX - RECEIPTS = A/R TRUST
491.52 0.00 0.00 0.00 0.00 0.00 0.00
491.52 0.00 0.00 0.00 0.00 0.00 0.00
--~-- -
16, 2005 at 11:30:44 AM
FEES+
0.00
0.00
Client Ledger
KLW
Wednesday, March
ALL DATES
01-263
All
All
All
All
All
All
No
No
No
No
Dec 31/2199
5.52.20010715
Firm Totals Only: No
Entries Shown - Billed Only: No
Entries Shown - Disbursements: Yes
Entries Shown - Receipts: Yes
Entries Shown - Trust: Yes
Entries Shown - Time or Fees: No
~lorking ~awyer: No
Incl. Matters with Retainer Bal: No
Incl. Matters with Neg Unbld Disb: No
Trust Account: All
Show Client Address: No
U
Q.
..;l/)
<Il-
l/)
~ 0
....(.)~
~"O,g
oil .: "
ctI m::l
u ..J c:
C >. E
OCt-
O::: m =
......r....<(
\J~
.- ...
Em
.r:
u
en
::;
<I:
M
~
~
~
'"
"iii
"
'"
~ ta
;:c; ~
~ t
8 ~
"
u
e
"
;;
'"
c
~
o
a
o
E
~
::;
~
E
M
Z
"
u
-
~
o
'"
E
~
z
~~~~~~~~8gNM8$~~~~~~~~$~m~~
~~M~~~M~0~~roMroOOON~0w~NMmroo
mO~~~N~MM~~~~~mNNNNNNMMM~~ro
~~~~roww~~~~~~~mqqqqqqqqqq~~
.--..-.........v-....................................
NNOOOOM~oro.--o~omooooroOwOONroN
~~~o~romN......MN......~wmo......ooqV.....mwwNm
~W~OMro~~NroN~~~~OaNN~O~oo0ro~
m.--~~ ~Nro ~mM Mm......
'<t N "'7 .....
'"
"i w
~ ~
(/) '"
~ ~
~ '-'
o '" x
o 8 0::: ro
-g .~ N rn ~
!:1 <ll '8; ~ N (l)
JJ 'ai (.f) ~ 0 ~ 6
.~~ E ~ ~~ 2-~ 3~-a
(l) ~u 8 <ll ~~ ~~ ~t~
g~~~ ~~~ ~~ ~g N.~~
~~O<ll woO::: jB rn~ ~~~
~~~~ 8~~ ~~ u5~ ~~N
O~<ll~ _o:::~ ~~ ww ~Ew
~~f~w~~gw&&m&mm~~~~&~&w~33~
~_~rn~$._w.~5S~~~'c~_~s.~s.~~(/)--(/)~
rn~c>~_~<ll~mw~W~ '~~_m~w~a ~
<ll<ll=~O<ll<ll>Oooooo ~ow~ooooowwo
m~~<U~~EO~~O~U~~u<<~o~oomrnu
'"
~
u
b
(/)e
- ~
'" 0
.~u >.
-g-oc
l'-~~5l'-
~ >-~u~
og.oUO
gQ)EC~
"'OI=:>ro..
2Ci;u~ i?
J]E'O.o5
:cw E:c
m~~Gm
u)~ 0'0 u)
~.(J) g~~.
:g~~'~~
.5S:0:V53
~~ EE
IE IE ~~
00 8.8-
.~ .VlYl &~
~ o0~~o~~ooo0o~~
ffi ~~~ro~gg~~~~~~~
00 ~~~~~~~~~EE~~~~~zz~
E MMMM~~~Vlm~~mmmm~~~M
~ w~wwEE~VlEeeEEEEE w
~ g8gg~~~~~~~~~~~~~~g
w ~~~~~~~~~bb~~~~~~~~
I ~~~~~~~~~55~~~~~~~~
~ roro~~~~ro~~ooro~roro~~~ro
~o ~~==ccg~cuugcggc~~E
mmmmoo~ o~~ooooo~~m
~ u)u)~~~~~.~~~~~~~~~~~~
U ~~~~~~ ~~~~~~~~~~~~
~ ~~~~~~:~~~E~~E~.~~.~~~~~ri
O~~~.~.~~~20~ ~~~~~aa.~
(J)~~~~3~~~~g00~~~~~i~~
<or-
<,>r-
,,<0
~~
"'
r-
"0l0l
<OM"
<ON'
NM(!)
OJ b~~;Z
"T""""M..-Nf').....-<tM............NlO
O>~MMIJ'"JOM....MMMM
::5SU;u:;~~;Z~aaaa
>-
e
g
""
'"
ui~
::;:g
i~
"~
oJ
<00
"''''
NM
NN
N \"'? MMM
~ gM888g8~8MM88888g8ggg~~~~"<t1J'"J
ro NoooooooooOOOOOONONNNOOOOOO
Q ~~~~~~~~~~~~~~~~~~~~~~~~~~~
O~~~N.....N~NM"<t......NNNN~NNNN"""""''''''NNM
..-NNNN~~~~~~~~~rom......-........-..-~~NN~~
~
>-
f-
ro roro(ijro ro
~ ~~~~ ~
o 0000 0
. .--:1--:1. .
ID~~~~~~~~~~~~~x~~~~~~~x~~~~
B u u U ID 0 U U ~ ID ID ID 0 0 u 0 0 0 U 0 0 U 0 U 0 U ID
OIDID~C~IDIDCCCCID~IDIDID~IDIDwIDwwmIDC
>~~~ID~~~~W~ID~~~~~~~~~~~~~~ID
EOOO~OOO~~~~UUOUUOUOUUUUOU~
-,
~
0>
~
a.
;:: ~ ~
~
0 0 ci
<0 <0 co
~ ~
~
~ ;:: ~
~
ci 0 ci
<0 <0 '"
-. ~. ~
.:
>-
c
'"
~
.... ro
<'> ,,;
<0 ::;;
0
0 -e
N
~ .~
...J
f- ro ;;!
-0
f- b
f-
Johnson, Duffie, Stewart & Weidner
By: C. Roy Weidner, Jr.
I.D. No. 19530
301 Market Street
P. O. Box 109
Lemoyne, Pennsylvania 17043-0109
(7] 7) 761-4540
Attorneys for Defendant
J. IRA LAIRD and TAMMY LAIRD
as Parents and Natural Guardians of
BRITTANY LAIRD.
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY. PENNSYLVANIA
NO. 03-790 CIVIL TERM
Plaintiffs
CIVIL ACTION - LAW
v.
JURY TRIAL DEMANDED
JENNY R BIXLER.
Defendant
PRAECIPE TO SETTLE AND DISCONTINUE
TO THE PROTHONOTARY:
Please mark the above captioned action settled and discontinued. including all
counterclaims. crossclaims and inders of additional parties.
Jame
~
JO"d7~EIDNFR
By:
. Roy Weidner, Jr.
SCHMIDT, RON!Z'A & KRAM .
/
By:
DISCONTINUANCE CERTIFICA TE
AND NOW, ;~..~
J..:l... J:/) (J<) suit has been marked as above directed.
A.:.
:241795
5774-447
CERTIFICA TE OF SERVICE
AND NOW, this /fo/hday of August, 2005, the undersigned does hereby certify that she
did this date serve a copy of the foregoing praecipe upon the other parties of record by causing
same to be deposited in the United States Mail, first class postage prepaid, at Lemoyne,
Pennsylvania, addressed as follows:
James R. Ronca, Esquire
Schmidt, Ronca & Kramer, PC
209 State Street
Harrisburg, PA 17101
JOHNSON, DUFFIE, STEWART & WEIDNER
By: 7/~~nZ1.lvr /1 )
ichelle H. Spangle -
:241795
5774-447
~
~
~
<--
e,
N
N
-.
("..
(~.,..
_~.l
..(
-0
~
~
,:!!..,.,
rt'F
..n0..t
:])\.'1)
t_'~l-')
-'7.=8.
c'')--
:,~D.
0'"
.-(
.J>:
::t
'?
r:-
V1
IT
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
J. IRA LAIRD and TAMMY LAIRD
As Parents and Natural Guardians
Of Brittany Laird
Plaintiffs
NO. 03-790 Civil Term
v.
CIVIL ACTION - LAW
JENNY R. BIXLER,
Defendant
JURY TRIAL DEMANDED
CERTIFICATE OF COMPLIANCE WITH COURT ORDER
Plaintiffs' counsel has overseen compliance with the March 26, 2005
Court Order, whereby the minor's settlement funds were deposited into a
restricted, federally insured account with PNC Bank marked "No withdraws
without prior court approval prior to March 25, 2008".
Attached as Exhibit A is a print-out of the account restriction that will
show up on PNC Bank's computer database whenever the account is accessed,
noting the Court Order and the restriction "No withdraws without prior court
approval prior to March 25, 2008".
Respectfully submitted,
SCHMIDT, RONCA & KRAMER, P.C.
Dated: 1Z./7-'1 J-;z.()(J S
-z;;i. ~
Todd D. G;gen, E quire
Attorney I.D. No. 80719
209 State Street
Harrisburg, PA 17101
(717) 232-6300
Attorney for Plaintiffs
[xh;Io;1 A-
o PNCBAN<.
BRITIANY M LAIRD UPAUTMA
J IRA LAIRD III CUST
921 WALNUT STREET
LEMOYNE P A 17043
December 23, 2005
CU53 1 IDS CDAlREA ADD ASSIGNMENT 12/23/05 10.33.56
BANK 40 MS 48000 ACTION COMPLETE
ACCT> BANK PROD> CDA BRANCH 00102 COST CENTER 0000102
CUSTOMER NUMBER 3000109739 SUBPRDCT MT FIXED RATE
NAME LAIRDBRITIANYM SUBOWNER 01 REGULAR
TYPE COURT ORDER
AMOUNT 14,545.60
EXPIRATION DATE 03/25/2008 (FORMAT: MM/DD/CCYY)
DESCRIPTION NO WITHDRAWS WITHOUT COURT APP
ROV AL PRIOR TO MARCH 25, 2008
TYPE OF ASSIGNMENT:
CO ... COURT ORDER HOLD SPECIFIC AMOUNT
TL ... TAX LEVY HOLD SPECIFIC AMOUNT
PL ... PLEDGE FUNDS HOLD SPECIFIC AMOUNT
CL... CONSUMER LOAN COLLATERAL HOLD SPECIFIC AMOUNT
BB ... BUSINESS BANK COLLATERAL HOLD SPECIFIC AMOUNT
PA... POWER OF ATIORNEY (REJECT DEBITS) BALANCE NOT HELD
RA ... REJECT ALL (DEBITS & CREDITS) HOLD ENTIRE BALANCE
RC ... REJECT ALL CREDITS BALANCE NOT HELD
RD ... REJECT ALL DEBITS HOLD ENTIRE BALANCE
PF: I-HELP 2-MSGS 3-PL VL 9-CI34 1 O-Cll 0 ll-CI50 12-C1l5
A Member of The PNC Financial Services Group
JILL PEZZUTO
www.pncbank.com
.
CERTIFICATE OF SERVICE
AND NOW, !, Beth E. Steever, and employee of the law firm of Schmidt, Ronca, &
Kramer, P.C., hereby certify that! have served a true and correct copy of the foregoing
Certificate of Compliance with Court Order by placing a copy of the same in the United
States Mail, postage prepaid, at Harrisburg, Pennsylvania, addressed to:
C. Roy Weidner, Jr., Esquire
Johnson, Duffie, Stewart & Weidner
P.O. Box 109
Lemoyne, PA 17043-0109
Date: r d-f3DJ 05
b>Ht & ~'Ytrurd
Beth E. Steever
n
~:~:
r-~~
f.--:::J
~..~.}
,~.....
o
-n
:::.:1
c_
:1'"
~:;~
r,)
w
,
~ I
~~.:J
:,"'<.