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AMANDA N. SCHAPPELL, a minor
by and through her natural parents
and guardians Mitchell and Lisa
Schappell,
: IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY, PENNSYLVANIA
Petitioners
NO, 'IS
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v.
CLAIRE'S STORES.
CIVIL ACTION LAW
Respondont
OJUHH
AND NOW, this _ day of _____.. _ .__..._. 1 uno, if is horohy Ordered that a
Hearing on the foregoing Petition for LOilvo to COlnpromiso Minor's Action shall be held
on the
day of
. 1998 ill -_o'clock __In. in Court Room No.
at the Cumberland COUIl'if Courthouso, Ono Courthouse Square, Carlisle,
Pennsylvania.
BY THE COURT:
J,
..
AMANDA N. SCHAPPELL, a minor
by and through her natural parents
and guardians Mitchell and Lisa
Schappell,
: IN THE COURT OF COMMON PLEAS
; CUMBERLAND COUNTY, PENNSYLVANIA
Petitioners
NO.
v.
CIVIL ACTION - LAW
CLAIRE'S STORES,
Respondent
ORDER OF COURT
AND NOW, this ~ day of
(\-j~ h-'~'
, 1998, upon consideration
of the foregoing Petition,
IT IS HEREBY ORDERED that:
1. The above parties may compromise the action set forth in the Petition to
Approve Minor's Compromise for the principal sum of $5,500.00.
2. Mitchell and Lisa Schappell, as natural parents and guardians of Amanda
N. Schappell, minor, are authorized to pay the following counsel fees and other costs
from the amount to which said minor is entitled to receive in this action:
a. $1,370.00 to W. Scott Henning, Esq, as reasonable
attorney's fees; and
b, $160.97 to W. Scott Henning, Esq. as reasonable
expenses;
c. $390.00 to Commonwealth of Pennsylvania;
~~ ""
,- ....~.
c. Direct payment of the net funds in the amount of
$3,583.29 from the lump sum payment into an interest
bearing, federally insured savings account with Petitioners,
Mitchell and Lisa Schappell named as guardians for the
benefit of Amanda K. Schappell, minor. The account is to
be marked "Not to be withdrawn without Court Order of a
Court of competent juriSdiction until minor Petitioner
reaches her majority".
BY TH~ COUR~) l!,
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Petitioners
NO.
1, < '7 '; -'~ L<vJ -r;,.--
, )_ J "',~
AMANDA N. SCHAPPELL, a minor
by and through her natural parents
and guardians MITCHELL and LISA
SCHAPPELL,
: IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY, PENNSYLVANIA
v.
CIVIL ACTION - LAW
CLAIRE'S STORES.
Respondent
PETITION FOR LEAVE TO
COMPROMISE MINOR'S ACTION
Pursuant to Pennsylvania Rule of Civil Procedure No. 2039, Mitchell and Lisa
Schappell, the natural parents and guardians of minor, Amanda N. Schappell, by and
through their attorney, W. Scott Henning, Esq., HANDLER & WIENER, petition this
Honorable Court to enter an Order permitting settlement and compromise of this action
and, in support, aver:
1. Petitioners, Mitchell and Lisa Schappell are the natural parents and
guardians of minor, Amanda N. Schappell, currently age fourteen (14) years old,
whose date of birth December 7, 1983,
2. Petitioners reside with their minor child at 571 Wagner Drive, Carlisle,
Cumberland County, Pennsylvania.
3. Respondent, Claire's Stores, is a business with an address of 1 Carlisle
Plaza Mall, Carlisle, Cumberland County, Pennsylvania.
4. On or ilbout Decomber 6,1997. minor child, Amanda N. Schappell, along
with her Aunt, Tracy Wilson. wore businoss inviloes on IIw promises ot Claire's Stores
at the Carlisle Mall.
5. On or about Dncember 6. 1997, Respondent. Claire's Stores, by an
authorized agent and/or employee, was performing an ear piercing service to Amanda's
lett ear when the ear piercing device "jammed" and got stuck while in the middle ot
the procedure.
6. As a result of this incident Amanda N. Schappell treated with her family
doctor, Verne W. Greiner, M.D. atter experiencing swelling and discomfort in her left
ear, Dr. Greiner diagnosed Amanda with auriculitis and admitted Ms. Schappell to
the POlyclinic Hospital for antibiotic therapy, The minor was subsequently seen for a
follow-up appointment with Dr. Greiner at which time she was released from care.
fA copy of the medical records from Dr. Greiner and POiyclinic Medical Center
pertaining to Amanda's treatment are attached hereto as Exhibit" A".J
7. Respondent has offered the Petitioners a settlement in the amount of
$5,500.00, as full and final settlement of the claim against the Respondent.
8. Petitioners propose to accept the settlement proposal from Respondent
thereby releasing Respondent from any all claims. suits, and other actions arising from
the injuries in the present case.
9. W. Scott Henning, Esq., of HANDLER AND WIENER, has been the
attorney for the minor in this action and he requests the reasonable counsel fees of
$1,375.00 for services rendered pursuant to a Power of Attorney and Contingent Fee
2
Agreement signed by Petitioners. plus costs and expenses of $160.97. The aforesaid
figure of $1,375.00 is calculated upon a contingency fee of 25%. (A copy of said
Agreement and billin{J sUlllmary are attached hereto, made a part hereof and marked,
"Exhibit B".)
1 O. Petitioners believe that this Compromise is in the best interests of minor,
Amanda N. Schappell.
WHEREFORE, Petitioner requests this Honorable Court to;
a. Approve the Compromise above-stated;
b. Authorize the payment of fees in the amount of $1,375,00
and costs in the amount of $160.97 from the funds due the
minor;
c. Authorize the payment of a subrogation lien in the amount
of $390.00 ($585.00 less % attorneys fees) to the
Commonwealth of Pennsylvania from the funds due the
minor;
d. Direct payment of the net funds in the amount of
$3,574.03 from the lump sum payment into an interest
bearing, federally insured savings account with Petitioners,
Mitchell and Lisa Schappell named as guardians for the
benefit of Amanda N. Schappell, minor, The account is to
be marked "Not to be withdrawn until minor Petitioner
3
reaches her majority or without the Court Order of a Court
of competent jUrisdiction".
HANDLER AND WIENER
-------
..c:.--
Attorneys for Peti 'oners Mitchell and
Lisa Schappell on ehalf of their minor
child, Amanda N. Schappell
4
VERIFICATION
I verify that the statements made in the foregoing Petition for leave To
Compromise Minor's Action are true and correct to the best of my knowledge,
information and belief. I understand that false statements made herein are subject to
the penalties of 18 Pa.C,S. ~4904 relating to unsworn falsification to authorities.
I
Date i'.,( ."1/
/)) /i iil Ii ;r -<<Lt., I r~.l:~\1
':7 1
Mitchell Schappell, Parent and Guardian of
Amanda N. Schappell
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Lisa Schappell, Parent and Guardian of
J
Amanda N. Schappell
AUTHORIZATION FOfi TREATMENT ,""110 Itw I""~:'" r'fj ',I It'j',l,Cd! C,\r" ""111;11 m.l; ,f'{lw, .'jf'I,',!.C j:fOC""l,ll"i I~"<J '.uch rrl-'IJIC;tl II,,;l!mcnl
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RELEASE OF MEDICAL INFORMA T10t~ . I """':", I,.~~' ':,. j> "',I' :',,,,, ti'r\ :..,',1..'~1 IfI' ,1:1''':''''1' "1',,'1" 11"1"" r;:r,.., 1'11,','CIOIfl'. .1'.;,(j(i,II",j
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'''''''''~ CO'I'" .:" .'," ',,,,,, 'l"'" AN ADDITIONAL RELEASE IS REQUIRED FOR INFORMATION RELATIVE TO ALCOHOL
ABUSE. DRUG ABUSE, PSYCHOLOGICAL OR PSYCHIATRIC CONDITIONS AND ACQUIRED IMMUNE DEFICIENCY SYN.
DROME (AIDS),
PRE-CERTIFICATION REQUIREMENTS _lIrr,( 'WMwe,' ;~r"~H~,;';' !tlrUJ-p:l'~'(".'q'.'r,~'; ~f'~--:"r!.1 C 1!'Ul lh:'1t ,."d('f':.t.ln!jH1,ll'llsmyr~sDcr:sl'
bllllV 10 COf1l,lCt lht'fn!f) otl,l,n ~l;(tl ~"f~"'LI"(.tI EXCEPTION ~,"': ,; I">
ASSIGNMENT OF INSURANCE BENEFITS -I th!I€Oy Jl.!~CII.l'~ To'{ ~,1,!(jjC.Jr"'ilnrJ'Gr m"':'c.lln~l;11no.:eO.~ne'I!'3 P.1'I,'ltlt.!!oml'und'Jrlhelerms afmy
insurance POhClCSlo bl'" p.lld dlf~CII'lIO P'rlfl.:lc!,>Ht'.lllh Sislt'm It m-, C1:~p.rc.f1:] ~::t1Y$jCI,-Jn Jr:d,'or Ol"'.:f pn'(';I;:I,ll1 <.l~;5")C!,I!I~\I...'lh n,m Cf '...hem tle may deslgnall!
accepls Insuranco .l5Slanl;'l(!r~1 ltwnl t"."'~b'( ol\,lhr:;fI."! m'; ~,h:lj'CJ~'J ;l"oj,cll":"er!,c.11 1nSW<1ncc b'Hl.~':I:;!,; ~.. ~d,': (j.I.,c:!y!O !t'.cse ..hYS1C~,lt"S I under~tand Ihaf I
am flnanClallv 'cspon51blt~ ler nCfl-cc.,'!fI'J s'~r,'ICC';, a~ Nt~11 dS ar','{ C'!'':uC: t;;'~5, CClnSlJr3nce or amCtlnlS ,n e_CI}~,5 of Ifl::.ur.lncp. oenC!I!S j perml! a cepy of thIS
aulhorllllllon II) tlJ tJs,~f11n pl.~C'! 01 t~,-' orll]ln.11
INPATIENTS AND OBSERVATION BED PATIENTS ONLY
PATJENT SELF-DETERMINATION ACT OF 1990 (Advance Directives) -I "cknO'NI~dJe !hill Pmn.lcl,!H~illlh Sy'>lE'm t':i1sprovld~d me Wllh
wrlnen mlormatlon on my rights 10 ma~e health cme trealment"eclSlcns In compliance With lhe Pallent Self-Delefmlna!lon Act 01 1990
PERSONAL VALUABLES - I ur:(h!f~t.:lnd;haf PlnnacleHeallh Sysle~ prO'JldeS laclll!les for lhe salekel?plng of ::In'( 1J,]lu.10Ie and any valuables kepi by the
patient are kept althc pilllenfs flS~ I hereoy accept full responslblhl'I'cr an'( :Jt1rsona e!l,;:cls lalt.en 10 l~e hCspltal room. Including such thlngs.JS dentures. eye
glasses, contact lenses. heating aids and radiOS
MEDICARE INPATIENTS ONLY -I certlrf lr.allhe Informatlcn gl'Jp.n by me In applYing ler P3'I'rr.enl under Tille XVIII 01 lne SOCIal S~curlty Actls cOHeetl
aCknowledge thai I have fl:!CeI'J'Jo a cooy 01 'An Important Message tfcm Me'.::lcme My slgnalure only...lc~r.c'Nled(}es my receIpt of IhlS message from Pinnacle,
Health and does nOI.....alveany 01 my fights 10 requt:'!sl arcvlew or ma~e meilacle ler any payment I mali;::e lhal hle!llTll! reSf!rveda';s are a once hle!lmem<l)llmumof
60 days. If I Should use all my full da,;s and CO-Insurance days, I agree:o use my life!lme reserm dJ'/S ter any remaining CJ'(s
CHAMPUS INPATIENTS ONLY -I acknowledge that I ha'Jerecclved acopyofAn Important f.lessageffcmCHAMPUS -MyslgnatureonJyacknowledges
my recelpf 01 thiS message Irom PI~nacleHeallh System and does r.ot ....al'Je an,! 01 my ngr.ls 10 requesl a (~'JICW or ma~,e me liable lor any payment
AUTHORIZATION MUST BE SIG~j:D BY THE PATIENT'S LEGAL REPRESENTATIVE IN THE
CASE OF IA MINOR, OR WHEN THE PATIENT IS PHYSICALLY OR MENTALLY INCAPACITATED.
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PINNACLEHEALTH
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AUTHORIZATION FOR
TREATMENT
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EXHIBIT
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717-2'i3-12d6
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12/11/97
SCHAPPELL
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PROGRESS RECORD
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PATIENT IOENTlFICATlOtl
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PICC CMIDLIN~ATHETER
TIME ,,,2.6 rlD ordering
SIZE3lli..OL o(3l~ . Lot Number ;')'1<'[ Expiration date II 110D2
Insertion Site L . , R {,fj'5ll1 C Arm Circumference L R:::5 V;u"
TOTAL LENGTH OF CATHETER ?1:0C^"" Cm In 2-D Cm Out IS{
Reason for Insertion I\f:l U; (KS Tip Placement Verification "~u.f'fMWr
BEVELED TIP Y, No Educational pamphlet to patient ~ No_
Blood Return All Ports 'Yes. No Advisory Sign Posted ~ No_
PATIENT TOLERATION Q OoD
ADDITIONAL INFORMATION Inserted by r t-bCO'lHAt- RN -IVf
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Your pliysician(s) j)Lc...!:. tL:. ~ .J.L....!____, has recommended lhat you receive
visiting nurse or other home hoallh services atter you arc discharged from the hospital. A listing
of agencies offering visiting nursing and/or home heallh care services in the region is available
for your review, A represontative from Pinnacle Heallh Hospitals will coni act any of these
agencies, or any other agoncy not listed, upon your request. Selection of this agency is your
responsibility or that of your family, unless your insurance company, health plan, HMO, or
physician (because of special needs) require you to use a particular agency, Basic informalion
on each agency will be provided 10 assist you in your decision,
CHOICE OF PROVIDER: Include Ag''ncy Name Address and Phone Number
1.
(;) ),/- h~!_), ')
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T.~ Co,
2,
Home Heallh Agency {'if 1/ C
Equipment Provider: fJ If r T,:
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3. Other:
~
REASO~ FOR CHOICE: Check all that apply
Previous Relalionship
Patient/Family Preference
Insurance Provider Direclive
Doctor RecommendaliorflDirective Explain:
Hospital Recoinmendation/Diractive Explain:
Other Explain:
7' Patient/Family - No Preference (see below)
I
In the event that you or your family do not have a preferenca from the attached list of available
agencies, Pinnacle Heallh Hospitals can provide this service if you so desire, However, you
should be assured that no such referral is required and that any agency which you desire will
be contacted on your behalf, Your selection of an agency other than Pinnacle Health Hospitals
will in no way affect your care at Pinnacle Heallh Hospitals or prevent you from receiving future
care at Pinnacle Health Hospitals,
I have had the opportunity to review information related to home health care services and
have had my questions answeE.~d to my satisfaction. My selection is as indicaled above.
/"- i~-f1' 5cAu,)d_df
Signal <I
y fl7 o-t/'--"-'L
Relationship (if not patient)
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Comments:
(if unable to obtain signature)
Date
PERSON COMPLETING T'HI~ FORM C~v:tL~
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REFERRALS FOR
HOME HEALTH AND/OR
HOME HEALTH EQUIPMENT
DOCUMENTATION OF CHOICE
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LEVEL OF CARE: -:z::.
ALLERGIES: j..J J<A- __
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PHYSICIAN'S ORDERS
12/11/97
SC!l~?PELL
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Form :t 12.1 Rev 5/97
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AT THE TIME OF DISCHARGE:
I . PATIENT'S DIET: P;h"J"I,Jr
! 1 Speclill..____
II 'CONDITION: i; Illlprovl!d XSlaiJl" : I Oll,,"_
Ill. * ACTIVITIES: >< Re~~lHne 110rnldl tlctIVltll;'; (I'; f()ll~r dIed
strenuous OXQrCISI] ___.~_n._'__ Ills H\)~,lrlc!lon~;
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1 .1 Of) nol dtlve _,,_ ___
._ week~, [] No heavy lilting!
IV. . ~~M.ED1CA_!I()f'l!'Ltl:~f'.'f.iDOSfH REB\!ItlC:o'! ________ ~__
c;;.'/Vtlt..[rr'W~{;).~'I-C":~~} --_d--.-:.::--z::'.!:afv A..iUk' t'-, hN-:u<;J
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'~}-LOW UP APPOINTMENT: Date Time Dr.
!iX-upon d~a%e call ~ / - O{)--t);J- h to schedule a follow-up appoinlmenl with
Dr, 'lu~'.,I;:;Jru,.... to be seen... 10//8' cle)3 :..CCI'3 if one has not already been scheduled,
D Other appointments
DIAGNOSIS:
~
VI.
Le{I- ?2t1/UC~
~~
J~'Z:A /)
PHYSICIAN SIGNATURE/DATE
Nursing
"I have received and understand this W,ritten st ~ment r'?!ardJng discharge instructions,"
Patient! Significant Other Signat"re" lUf -:Jc!Ii,
Patient discharged via: ~u- , In the care of: ~
Date: '=>1IJ-fn Time: I';).. 30 r ~to<..Vi. R:rtc
. .
POLYCLINIC MEDICAL CENTER
s '~ ')
, .
PATIENT DISCHARGE
INSTRUCTIONS
1'1 -,1
. ,
-, - -::: I, ,l 7'::':) I
;' f ':
I ~? I , ~ ~ :;: Ii':.
C . 'L I ,', ,. o.J.' l' , =, I'" ,
~ . .. - _ PA TIENT IDEN'rrFlCATibNI. ; ')
t . ~ ~ - .. ') i , ~ ~J 3 E \/ ~ r flit :~; ~~
\,'-""'".'"
TEMP f 1 TEMP C 08 107 10 III 11 15 11:' 1'':, 16 ,Il 118 ,II 10 ,II ill IJ I. jUl 02 10J 10':' 10\ ICb 01 TEMP C
101.8 \1.0 ~ . r"[I'~'~ [ . 41.0
ffi
' . , . , . . . .
. . . . . . .
104.0 40.0 . , , . . . , r-:- ~--=- -~ ~ 40.0
111 .I~
. . , . . , .
, . . . , . .
102.2 39.0 .'[f~C- r-:- -- J9,O
. . . . . . .
, . . . . . .
100.4 38,0 ~ . ....:..- ....:.-.--:--'- r-:- -~, - 38,0
. I, . , . . .
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98.6 37.0 . . . . , . . 37.0
. ' :-I~--R .
I .,. '--,
. . . . .-
96.8 36.0 . . . . , ,; 36.0
I
96.0 31.0 . 31.0
PULSE I 'i'l. ,0 'IX I ~EIGHI:
,ESPIRAIION )0 I~ 2c ~ty !1
BlOOO PRESSURE r- 1--- -- I-- '-- t-- r-- t- t-- r- _ W._ r - - -- -- - - - - -. i-- -- - --
ll., YESTERDAY
PULSE OXIMETRY I
INTAKE SOLUTIOHI " I I CUTPUT
AMOONT
., RATE I
liME ORAL rUSE BLOOO IV MEO IV CfllNT I IV CfllNT IV CfllNT URINE STOOL
07:00 I
08:00 I
09:00 . -
10:00
11:00 ,
12:00
13:00
14:00
8H' rOYAL I 1 1 I
11:00 I 1 I
16:00
17:00 IW "
18:00 -..
19:00
20:00 ..
21 :00
22:00
aHR TOTAL 1.0 If/V I tiC
23:00 /1 1/
24:00
01 :00
02:00
03:00 -
04:00
01:00
06:00 I
8H' lOTAl I 1 1
24H TOTAL ue. 1 1 _L I
,~ l'HIA<E: (/ c... 're. :aJIPUI
SC-!!?::' " , .1,-' '\ , I - /
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POLYCLINIC MEOICAl CENTER
I ? I ~ :' i .",: I 1 ,
, .. DEPARTMENT OF NURSING
o .. 0 , ' ~ ~ , o-
f .. . , .. PEDIATRICS
C ; '; :. ( '. '. ~: p, 11 7 . ~ ", '~ - I 2 ~ b OBSERVATION RECORD
I .. " ,I ,7 ') ~ I r? 'J 2 E '~ S rEI :: ,"',01
, /:1 ,i! (11
" I' i ~ 0' r; DATE:
I",
, I ~"l
6010.2 7/93
U'
TEJolP f IENP e 08 109 \0, 11 12 I, I" 11\ '0 111 lie 119 20 12\ '122 12} 2' ," IOl IO} '" 10\ 06 07 TENP e
10\.8 41.0 IT .r-". -t 41.0
IT' .
. . ,
. . .
104.0 40.0 . . . , . . --=-1 40.0
\ Tr . , . . . .
. . . , ' , . .
. . . . . , ,
102.2 39.0 . . . ...:... 39.0
T' 'l' . .
, , , . . . .
. . . . . . ,
100.4 38.0 . . , f-'- . ' . . ~~- -"-- 38.0
~ r:T --\-- -
98.6 37.0 ~" I 37,0
T
;, 0
96.8 36,0 \ 36.0
96.0 3\,0 3\.0
PULSE 70 ~>- I \JEIGHT:
RESPIRATION 10 ~ TOOAY
8LOOO PRESSURE -- -- -- i--- -- - - f-T- f-- _ -i-- .- - - - i--- -- - - i--- ,.-- -- -- -- -- - -
, YESTER~/.
PULSE OX,METRI I I /1/" J.
INTAKE
TIME
07:00
08:00
09:00
10:00
11:00
12:00
13:00
14:00
8HR TOTAL
1\:00
16:00
17:00
18:00
19:00
20:00
21:00
22:00
8HR TOTAL
23:00
24:00
01:00
02:00
03:00
04:00
0\:00
06:00
8HR TOT,AL
24H TOTAL
ORAL
TUBE
BLOOO
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AHOONT
RATE
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OUTPUT
IV CT/lNT
IV CTItNT
URt~E
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7 ~ " ': 7 IlrllAKE:
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POLYCLINIC HEDICAl CENTER
OEPARTMENT OF NURSING
PEDIATRICS
OBSERVATION RECORD
OA IE: 1;;;>'/1 <>--
60\0.2 7/93
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DATE: I~ 'J.-Tc,T-- .. aiTE -: --'------:-
NURSING iNfERVE,HION 10809 T6'TI tiF 1~ -1/;:!?: la-j2 2o~~~!!i 24 01 02 OJ 04 05 06 07
ASSISTEO WITH ADL~ (I Hn Md MA): MOBtLITY ---I--~ --:;~ - - -- - -T--
BATHING
EA II NG .p --=-- r[ ---1------ --
DRESSING y- --
--------
TOILETTNG '--" -\-::-=:t- ---- --
ACTIVITY, 110\ Bl;ll/CRlB I _~2______.__
CHAIR/UHEELCHAIR/HELO ::: = ~f- -- - - .-:.:::.::-= :.:: ~t~
IJIBULATEO ~_ L' I...!.-c-r:o-..~ .- - - - f- l.- ~
-
TURNED AND REPOSITIONED Q 2 HRS (R L B A)
DIET/NOURISHMENT (GCt)P), r
I +-
~
\P<fULL BEORAILS UP-~CRIB BEORAILS UP ((,1/,2)
CALL BELL IN REACH
SAfETY PRECAUTIONS:
RESTRAINTS:
.
RESTRAINT RELEASE Q 2 HRS
IV SITE(S) AND RATE(S) CHE~EO Q 1 HRS:
('M...-J..L.~ e..t ~1J--2" a.JJ JfCU v
HW SITE CHECKED Q 8 HRS
IV TUBING CHANGE
INCENTIVE SPIROMETER Q:
OXYGEN THERAPY:
OXYGEN SATURATION (X)
DRAINS/TUBES/CATHETERS:
INCONTINENCE CARE/CHECK a 2 HRS
DIAGNOSTIC TESTS: CX-r~ US, EeG. etc,)
(I,. ni-u ~, II L-JI PIl.A to V'
OTHER (Treatments, Appliances, Procedures)
MONITOR ON WITH ALARMS & LIMITS SET: ~A/B ~CAROIAC
DRESSING CHANGE:
.
-..
"
SIGNATURE I I ^ ~l(.
/ . CARE PROYIDED
. ~ SEE NURSE NOtES
OATE/TIME
INSTRUCTIONS GIVEN/REVIEWED
/ . PT/SO YERBAlIZES OR DEMONSTRATES INSTRUCTIONS
I COMMENTS NURSE
SC,-l~P?':~~
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"
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PINNACLEHEALTH
Hospitals
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r ~ 1 .P~f1.~~I:TtIDftlTrtIC.ATlqtl'~
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c1JI-lHTIIIIATE
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SCHHP ELL
PEDIATRIC
NURSES DAILY RECORD
601/)~'S (3i97}
/...
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--~--_.. --- a E_ -!!..
COlifOAT'Gfuo CCMrlAI~rl ~G~I 0' rAIN/OIICCM'O", I L1PAIN' .. . 1[,E"11 (I.IO):
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'CRy:USIRONG _:=___~~: g~~Ak OSNRlll-o;;NE': .,-
PT/SO PARTICIPATES IN: L}fARE l'::fOECISlc~sIJEOUCAIION
PULSE:L:::fHEARl UTE REGULAR _-.-;-.-: UIRREGUlAR: CI MURMUR
PERIPHERAL MSES: CAPillARY REFIll :7.\,.,Io,[J[;;;:;LJ "UMBNESS U TINGLING:
'RESTRAINED EXT:UUARMUPUl\EI PREIENlU\kI~.I~;;CI:~J=:::__._ . ---.-._-----_.
MOBILlTy:u>'OVEI All EXl [,,}TolERAIEI PREICRIBEDAC!"II' LJlIMITEO MOBllIll:
RESPIRAllaNs:GIllGUlAR~CNlABOAED LRulEi...... ._m UCONGEIIIOH O~-.;;;-oIPU!UM:
BREATH SOUNDS:~lEAR ~fQUAl BllAIERAll' i UABNORMAl BREArN lOUNOI:
NUTR1TION:L~OlERAIES PREICRIBEO OIEI UNPO U~AUIEAIEOI-JVOMI!ING'
BOIIEL lalNaS' (-I-..> STOOL: JNO STOOL AT PRESENT
ABOOl4EN: ~IO'T UNONOIIIENOEO UflRM UDIIIENOED UO!NER:
URINE ;-DClEAR U YEllOll ~ML{)..~,Q UHEMAIURIAUURI~E CLOUD' UOIHER:
SKIN:l.I.kOlOR UITHI~ ~ORMl!JIJARMUtl"UNO BRF.AkOOU~ JUOUNO/lEIIO~/BREAkOO\l~:
.SURGICAL OAESSINGCS): 'DOR,-DINIACI
'INCIIIO~(S): UClEA~UDRyUAPPROXIMAIED UI~CISION REDDENEOUJIENOERUetORAINING: ~A Jr
UIUTURESL SIAPLEIUIIERIIIRIPI INIACI I j,;r WJ\. h L! , .......
"'IV/MU SITE(5): U NO ERYTHEMA IUELlI~G DRAiNAGE
"'PREVIC"JS SITES: -[:fNO ERYIHEMA IUElllNG OR:AINAGE
SELf cARE: ~INDEPENDENT UNEEDI AIIIIIIVE OEVICEI ..:: I UNEEDI PERIO~LJNEEDI PERION & D'VICE~~DEPENDENT
EilV'IRoNtieNT: t>dSA'E UCONDUCIVE TO CARE ..
IN'ORMAIIO~ OBIAINED B':IO V" ~."/\ 1U'\C- IE IN
.
~l~ ~uASlS ~utES I .
'I..OINGS A5 PEA INITIAL UITRY'. ,
., ..cocnplete I f.,~ppllc~ble
PROGRESS
TOYAROS tI
EXPECTED #
OUTCOMEI
. '.
~
1t--L.
I'
,
ARE IHERE ANY ~ PATIENT CARE, EDUCATIONAL, OR DIICHARGE NEEDS BASED ON COLLECIEO I~'ORMAIION?
ASSESSMENT COMPLETED BY
,fjuv
IV)
."
.
..
.
..
.
ADMISSION
ADMllTEDfROM lJED :JADMCfflr.f [":IIO"'E .0,,1" ."- IiMf 13..
HOWAOMlrTEO C~MOUlMOIlV OWH[ElOj,',IH C:S;lllIOl[4 : :r;,\lHiI!O ,
BELONGINGS ~ONE PRESUH Of~ .\OMI5S,Qfj :~: .\Ll SUIT ~jC"'E ',: I1fT.Uj[D:SH fJl[f:N(ji~jrlS ifj'J[~jrOIlV S" :. '/.:..
ORIENTATION TO UNIT LCALlUGtlTIlNHPCQI.l ~J[D CI~/ITIl(jl5 /fl["~,r,M :;1['~["lSICfj ,~MCK:fj(j 7.H .\1 TI',lI5 . ~lTlfjrl ~'PAfIPH tIM~OBCOK
VIT.'L SIG'lS 1 $>?_ . P .9?:. "" _ _. H J.O d"" 1",/;/ L "r r,,,, /;;>. ().. wEIr,,1T NO 1y"r:'[l URCUMfERE'jLf ---.- ,.-..1'-
PAflENT.S REASO" fOR;:9"'155IO" f/.t4-'U...a'-"-i"/-:iW , : L~ /~/ J -.--~(, :' '." !""'J .'. ~ j-'-~~~&-:--:;jAj-
~'.d.LM, -~.6'.,=-r..J;~'1'(....4---'P...--:j''.:'''''''-~'-'-- ,.l-~ V, ...I.~ ./':<-!- '._~
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PAST HOSPITALIZATIONS lUlU/OR 1ll.:,jESS!. M'PROI; ,':.iE DAfE _' 'jCM {[(i"J..L-- ((\'-'I.i.I,,!t.L J!-l~elltJ, ~ .;tI~I_.
o ACCIDENTS/INJURIES = Sdr,(,EH'f __J.o1I-"tld-,-...tLl~1-- 1~
o KIDNEY PROBLEMS I;j V
DDI.'BETES ---.--.-~-
o SEIZURES .____ _..~___.... ----.- -.--.----------- m.__.___._.
Ci LUNG PROBLEMS ________.___.__u__...
o BLOOD TRMlSFUSIQ" _m_~_______________
o GI PROBLEMS
?(EXPOSURE TO COMMUN~CA8LE DISEASE
~rok.-
MEDICATION
C"DNE
DGSE
~i "
_~~Uf'
l,\S: DOSE ~.'E::iC,~IIG~~ DOSE
__ l,\sr DOSE _---.-::lfOlc.:.Tlorl
"&f. ,< ~i~ /'~
{/
OOSE
LASf DOSE
~i
t.4-:1.../~~
.~
COMPLIANCE TO MEDIC~T10fl SCHEDULE ~S ~ NO RE/\sorl
ALLERGHI
s'''MPro~.\5
:'LLE'HJUl
~
S'fMPTOMS
00"E
ENVIRONMENTAL
LIVING ACCOMMDQ,\ TlONS
~,\ TE HOME ~ APARTMENT C~ It'jSil~UTlorj,\L1ZEO == OTHER
SPECIAL CONSIOERMIQNS M HOME :.
.,..2:G'NE 0 NO ftUNNltJG W,\TER 0 STA!RS :::.: rlQ R,\~,lPS c: ~jO PHONE G OTHER
SPECIAL EOUIPME"r
~E
o RESifMtN rs (l'fPCI
:J GLASSES/CONTACTS LJ WITH PAflENT C ;iT HOt.1E
o HOME IV THERAPY
::J HOME MQNnOR
C PROS THESIS {typel
C SPECI/\L TOY IBLAm:ET
l; OTHER
~C~(?~~~
n -, --, - r' - :I q
, -"~i~:"- 17~oOSbl
1 '( .' " i I I . J ~ C
5~1 ~n rq:1~
C\?L"::.i PI '17-2;P'-1230
I 7~ ~1-75bl qUqE~srE IN M1~
tjZ8/'-L1LTHMATE
0:)1111'>71 12111/97
"I TCHELL SCHHPHL
FORM NO 605~.1 (lo/'n) .f
POLYCLINIC MEDICAL CENTER
DEPARTMENT OF NURSING
PEDIATRICS
ADMISSION DATA BASE
BIOPNYSICAL
COGNlnVl/NEURDLOGICAL tle'/el Of con5Clousl1e~s Qllenl.ltlon ~cn,>f}f'tl
ORIENTATION OORIENIED
w DISORIENTED TO 0 TIME
D PLACE 0 PERSO" 0 EVE"T
~ OINTAcr
o NUMBNESS __________
OPARASH,ESloI _____._
OOHIER _______..
SPEECH/HEARING 2"lD PROBLE\IS
DDElICIT ______
o MyRINGOTOMY TUBES ____
LEVU Of RESPONSIVENESS l,~":rN.\!([
[J LETtiMHilC r';';".\lEnr
Ll CONFUSEO rJ 5[O'\IEO
OIAfllr.'BLE
COlliER ___
VISIOH PUPILS __ _
ll\Si EXAM
:;4J PRomP,lS
C01HER__
_____.__._.__.~_ u__._"_
CARDIOVASCULAR {pulses. rhythm, hearl sounds, lIwd rclepllQn. ~omfM\
COLOR (?1'ffiK O'1'ALE 0 JAU"OICE 0 CYMWSIS 0 MOTTlED 0 fLUSI'ED
PULSE RHYTHM ~GULAR 0 IRREGUL.IR ------
PERIPHERAL PULSES [;1fjORMAL
OOTHER
, ~PROBLEMS
D MURMUR
D)V ACCESS Ily",)
DD1HER
GASTROINTESTINAL labdomen, bowel sounds. bleeding. bowel MOils.
swallOWing. comloft. weuJhll ~
D INfMH Ia-WRI METHOD 0 BREAST 0 BOTTLE 0 CUP 0 SPECI>\L ",PPLE
ODTHER
TYPE Of fORMULA
TIME Of fEEDS
lEMP Of fEEDI"GS
AWAKE OURING NIGHT ro fEED 0 YES orm
fOOD 0 RICE CEREAL 0 STRAINED fRUIT 0 PUREED C TABLE CHOPPED
o<HiLO 11 YR & OLDER; METHOD 0 BOTTlE 0 CUP c.'EEDS SELf
fOOD 0 PUREED C TABLE CHOPPED -;:11EGULAR
APPETITE 2"'G'OOO C F}\IA . C POOR
LIKES/DISLIKES
RESTAICTlD"S 0 "O"E
RECWT WEIGHT ~l,IBLE 0 G.II" _LBS Q LOSS _LBS
BOWEL SOU"OS 0 NA ~WRMAL 0 HYPO HYPERACTIVE 0 ABSE1H
"OR MAL BOWEL PoITTER" .. LAST BM _t:tJ.Cl~-
fREOUE"CY _iJL!/" COLOR_~
rolLET WORDS. 0 -
o NO PROBLEMS 0 LOOSE TEETH
o ABDOMI"AL DISTENTlO"
o NAUSEA 0 '10MITI11G
o ArmREXIA'
o REfLUX 0 GT 0 "G
o CONSTlPATID"
o DIARRHEA
o INCOf'I'''ENCE
OOHIER
AMCU"T
OOBEIITY
OENEMi\S
o OSTOMY
o LAXATlVES_
PAIN llVPll. locaTion 'ie'.r:!I!'/1
ODE/liES
[j p,..m ;!'Ipc;!()C1!tr)fll .__
SEVERITY 1 ~ )
f'(jn~
,.)
(;1 (1-"0,.1. ~~r
L.l.))(~' r p{
t/'...-:f
__w...._._. ____. ...._...____.._._
, /5l 6 I B 9 10
L/ se'll!fe
MUSCULOSKELETAL 1110,1,1 s:r':'lI11'\ fUl1cllonl
~VES ML E,< Hit' ~llll(S CH(LQf",If 'j r ,\l MilES rmJ[S i\PPROPI1I.\ IE
l~ INJURY
~ LIMITS IN 80M
:J INAPPROPRI:' TE DPJElOPMen -
!JOTHER _______...._..
RESPIRATORY (rale. tlrealtl soundr,1
BREATHING t::'NO PROBLEMS G DISTRESS
o SHORTrlESS Of BREMH
o NASAL FLARING
o RElRAClIOIlS CJ USES .'CCESSDRY MUSCLES
BREATHSOUHDS ~lE,IR
o ABNORM~~L
o GRUmlflG 0 STRIDOR 0 UPPER AIR'IIo\Y CO"GESlIO"
o COUGH oliOllPRODUCTI'IE C PRODlJCTl'lEISPUTUI.I
CJ TRJ\CHEOSiOMY
o OXYGEN 1/ mm
o SMOKES
OOTHER
URINARY/REPRODUCTIVE ~urJne Color. con!rol, treQuenc'l. com lor!.
.. merrses,dl!'.cn.1rrje)
URINARY r,;1(o PROBLEMS
o I"CO'iTlrlENCE 0 OIAPE"
G UAGENC'( CJ FREOUE~jCY Cl BUR~lING ::: HEMA TUnlA 0 NOCTURIA
o INCREASED OUTPUT 0 DECRE.'SED OUTPUT
CDTHER
REPROBUCTI'IE
fEMALE [?11,\ LAST MENSES i2e.t;.-.-L~i1.AST PAP SMEAR __
SELF BREAST EXAM 0 YES 0 NO
MALE 0 NA SELF TESTICULAR EXAM 0 YES 0 NO
CURRENT BIRTH CONIROl/PROTeCTtON 0 ~l"
0"0 PROBLEMS
OOTHER
J
,:~ 11
l
INTEGUMENT (Skin ;9101, lurgor, Integrity)
HYGIE"E. _~C"'" TEMPER,lfURE 0 HOT 0 'II""'.' [) COOL ~; COLD
SKI". mRY 0 MOIST 0 CLAMMY 0 SCALY
MEMBRAflES G-!;101S1 0 DRY 0 TE.IRS
TURGOR q tHJ&L-
0"0 PROBLEMS I
o WOU"DILESIOflSIBUR"S/ORUISES _____.______ .-------
o RASH/DIAPER RASH _ ~____.__~______._____._~__._~___
,,8
I
"'" ,I
{'"
~JlHER ~~.t in;1.I3-<;i__Jl; ec~ -
_Net!" _{!~_c"'-~~ __':::'_/'.21..~
/-LdluJ7u(hJ "
..
Family Practice Azzocial
~
H;, suia9/Hl!chani c~bur9, Pi.
NAME
PEDIATRIC IMMUNIZATIONS
7Jjti;
EIRTHDATE ~IJ 0.' .~
------ ~--~
RECORD ~
() DJOl1dcL 3c happUL
DATE / KANUF 1 LOT 1 EXP 1 INITIALS DATE 1 HANUF 1 LOT 1 EXP 1 INITIALS
TETRAKoNE (DPT,~)
1.
OPV
l'S/ltol R4
2. ii, I'~L/
3. /()j/7/R4
.
4. /D,//1j'i?5
1/5/<S7
1
1)5/17
DaPT
HHR
1.
2.
DT
2.
OTHER
l.
.~
2.
3.
1.
2.
REp B (RECOMBIVAX HB)
1.
2.
3.
p
j~//?/gr.; Resul ts - /i-Rq..
Resul ts cr
Results
H&H
Date
Resul ts
.,
.,.- '"
,PEDF'L02A/PLW/04D4 94 .
.' ~:":"'''''.:'.':::'''':.>.
. , "
. .
,"'. .'
. ,"..
-~" """ ..
. -;.::. ~<:/"'. ,-
-2-
I /~. (1)/ ,..--
DATE : - ~. IV,',! HT
T%-.,~ P/.I" PJ.-t- B? /I( i" C 1
PR~~EM,..:. C- V (;,.. 'y 1)- ~.", '. v. .
12/18/97 Amanda ~appel
P--Followup
S--S/P 8 days of IV Ceftriaxone for left auriculitis, She is much
improved, no further drainage, or pain,
O--The swelling and tenderness in the ear have resolved completely.
There is really no significant erythema, and the ear is about the same
color as the right one. There's a tiny healed ulcer on the top of the
external ear, but no evidence of crusting or drainage. No regional
adenopathy.
A--An in-dwelling IV catheter is present._ in the right antecubital
space, covered with a sterile dressing. '.
A--Improvement in left folliculitis
P--Switch to Au~nentin 875 mg. bid for the next week. Call if problem
flares. Discussed possible side effects with mother and with patient,
including the possibility of antibiotic associated diarrhea,
vaginitis, allergy. They are to let me know if any problems arise.
Followup as needed.
The skin on the right an~ecubital space was prepped with Betadine, and
the catheter was removed today. Sterile dressing applied. A small area
of tape-related de!:'ma::itis \':as treat,"d \'lith some topical Elocon cream.
MJR/alp
.~
, UJ'i'lMltll ,~(Jl(i{!f:(lJ
TDAJhr( 6a~ q WI f~l /it;({ 'jp /6' S}~0/)'')J jJ r" R{i:2DOC~~~Lo ~
T: . l'l[) A Bp./. ~6"'" --- J C' ..-'" _''..) I 1-" DO 212 (
PAp OBLl)~ I ,Jr.;: r'~~ ~L- f,..1 _ /;"'/'"
u_ ~ If, 11..)1 I )}. .~- ,-./ L'.. .j, ~. ,I, ". 1.>_,-, L I J.'.
5/20/97 Amanda Chappell
P--13 yr. old for PE and recheck of sprained right ankle
S--Past medical history reviewed and essentia:ly unt-emarkable. Had all
her initial immunizations except for hepatitis vaccine. Also due for
MMR booster. Family history reviewed: parents and.siblings all living
and in good health. No family history of familial disease. Social
history: she's in 7th gt-ade, denies tobacco, alcohol or drug use. Diet
fairly typical teenager and is fairly accive physically. Medications
none. Allergies: questionable allergy to ;'.~;o:,icillin, although not
sure; no documentation of this in the old records we received. ROS:
complaining of headaches, mother has hist;Qry of migraines'. No visual
problems. No chest pain, SOB. Menses regular q 28 to 30 days, lasting
5 days light flow. She sprained her right a~f.le about a week ago in
phys. ed. and is here to have this rechecked. She's wearing an air
cast but no real problems at present.
O--Ht. 62 3/4. Wt. 142. EENT exam unremarkable. Neck supple without
thyromegaly or adenopathy. Lungs clear. Heart sounds normal, no
murmur. ;'.bdomen soft, non-te:lde::-, no masses. Neuro logical gross ly
normal. Structural negative, no evidence of scoliosis. Tanner 5 se:<ual
development. Right ankle is non-tender, not swollen and not
ecchymotic. Full ROM and stressin~ the joint does not cause her any
discomfort.
A--Resolving sprain right ankle, otherwise well female
P--MMR booster. Start the hepatitis series in a month. RTC prn. JP/alp
._ .w(
.(,
':)
0' . Cff
DATE -L7d toI'i1 WT J!!L HT
T/CO."::p __R_BP_/_
1'1',0": "II, eO-(' ~erlJ.:Z IL 1:-.( 'i'l
. '- I
~""cC..("'- -\'(,) ~.v.J-(ll. ~<.,l.~~
-- -~..,--
12/10/97 Amanda Schappell
P--Presents with a left ear infection
S--She had he7 left ear cartilage pierced 4 days ago. Last night it
started bec?mlng e~ythem~tous and a little bit swollen and when she
woke up thls mornlng, It was exquisitely tender and swollen. At
school, the nurse removed the earring and got some purulent discharge
and she was sent here for followup. She has complained of hot feeling
although she has not taken her temp. She's had no other systemi~
symptoms of vomi~ing or rigors. She has NKDA and takes no medications
on a regular basls.
O--Her ~emp. is ~00.2. Her left cheek was slightly flushed. She was
no~-toxlC appearlng. The left auricle had a woody appearance and was
qUlte swollen, e~ythematous with almost a violaceous hue. There was
s~me serous crustlng over the piercing site anteriorly and posteriorly
s owed purulent drainage which was expressed. It was exquisitely
tender. She had some submandibular adenopathy but no pre-auricular
adenopathy. The ear canal itself was patent and clear The TM was
normal. . .
:-"'~' r', T, ,\j \\'~ iJ :: "_,'.~.....
I .
f'" "I.. I
I .. II ~ I I .
..
A--Cellulitin of the left ell:', '.'.'0:'1 i:;Ulill' tIlt
infecti.on. ..
I'--I'li.ll go ahead and treat with /III1J':I""11 ill WI', ,.,' Il"'''' I[l "1"" "II .'._
t. . ..' . ., j' .... .' J .J. ..) C OJ
o ~sc ~arr~ ~OIT1P.["f~sscr;.lo;:~llly and LIl ,iJv(~id :jq\;',~'~:~il1lj but f'ncr,l:ra(J,~d
dr-dlnage of the urea. She ~J to rf~Lt:r:~ III /4 ill'!;, for n~ I~Vdllltltiol1 if
~hc:Q~G not been, significant i.l1lp["o~:(~n\l!!lL, U~t!!l ho~;pit.d I i::dlion or
In<;lslon ~nd drainage I~ay be rcquin~d. She'!] Lo cull immediately for
chllls, rigors, systemiC symptom:> 0" i.f need"d. /olKJ/o11p
lllllk':'lj'if\Cj c,"dr':' i l']("j'~
DATE l,tlf/r fen WT/-Pt HT
T qq '::;P' (co RilL BP (-JJ I '&5
t .. . ,... ".~ <::1-r
12/11/97 Amanda Schappell
P--Presents for followup on her left ear cellulitis
S--She had a miserable night last night and was unable to sleep or get
comfortable due to the pain. She now complains of warmth and pain up
into her scalp. Her temp. didn't really go above 99 last night,
however, she's been nauseous and fee-Is' like she wants to vomit. So
far, she's gotten 2 doses of the Augmentin.
O--Her temp. is 99.5 and she's non-toxic appearing. The left ear is
standing out from the side of her head at an abnormal angle. It is
quite erythematous and exquisitely tender. ~pere was an opening where
the earring was and there was some purulent discharge there. The
erythema now extends up into her scalp but the flushing of her left
cheek has resolved. She had tender adenopathy in the submandibular
area as well. _
A--Cellulitis of left ear, not ~esponding to outpatient therapy.
P--Will admit her to Polyclinic for IV antibiotics. She'll be admitted
for 24 hr. observation with further followup pending her progress.
MKJ/alp
J!,'.- ()C; e.{(U.:2.:... '/~i' (
/,...(,( 7 I I // . -
I I ,r. - ,-'" . I , r' . (
(,i iLLL J (j.c(L '-'1.-'.(_(..'; '. , ~
AMANDA N SCHAPPELL
571 HACNER DR
CARLISLE, PA 17013
DISBURSEMENTS
01127/96
02/25/98
06/16/98
06/16/98
06/19/98
09/17/98
09/17/98
09/17/98
09/17/98
09/11/98
09/17/96
BllllNC SUHMARY
Handler end ~lencr
September 17, 1998
BIlled through 09/17/98
81 II nUTber
202788.00000'003 HSH
Beacon Medical Group PC
correspondence Management
Proth of Cumberland County
Proth of Cumberland County
Book Binding Costs
Document Reproduction
Fax Charges
Document Reproduction
postage Costs
Postage Costs
Long Distance Telephone Charges
35.00
36.11
45.50
5.00
2.00
.60
5.00
19.40
6.06
2.39
1.69
.-------.-
Total disbursements for this matter
$ 160.97
. billing timekeeper W. Scott Hennln;
. dBte of last bill
. data of last r~lnder
. lo,t bill through dat&
. bll \ type code S-4
oet'on to be taken
. O:hold enttre bill 311summarv fees and eKp
. lsalr reminder 411b! \ I fen and up
. 2sblll eKp5, hold feel 5-summary fees/detsll e
.
. current .00
. 30 days .00
. 60 days .00
. 90 days .00
. 120 days .00
.
. billing frequency A-12
. last payment
. billing realization
o X
.
.
.
.
it matter 00000
.
.
. 6462 01127/96 35.00
. 5057 02/25/96 36.11
. lCUR 06/16/96 45.50
. lCUR 06/16/96 5.00
. 61NO 06/19/96 2.00
. COpy sl.lTlTlary .60
. fAX sl.lTlTlary 5.00
. 151 sl.ITITIary 19.40
. POS sl.lTlTlary 6.08
. POST Sl.ITITIary 2.39
. TElE sUTIMry 1.69
.
.
. 160.97
.
.
.
. 1CUM 50.50
. 5057 38. "
. 6462 35.00
. BIND 2.00
. COpy .60
. FAX 5.00
. 151 19.40
. POS 6.06
. POST 2.39
. TElE 1.69
.
Total Disbursements $ 160.97 . 160.97
-.---.-... .
TOTAL CHARGES FOR THIS BILL $ 160.97 . 160.97