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PYS510 Cumberland county Prothonotary'a Office
Civil Caae Inquiry
1998-06373 GESSNER MARGIE A (VS) GWB MICIIAEL
Page
1
Reference No..:
Case Type,.,..: PROTECTION FROM ABUSE
Judgment.,...,: ,00
Judge Asaigned: HOFFER GEORGE E PJ
Disposed Dasc,:
------------ Case Comments -------------
t~11ed....I...:
Time......... :
Execution Date
Jury Trial, , , ,
Dispoaed Date,
Higher Crt 1.:
Higher Crt 2.:
11/10/1998
9:42
0/00/0000
0/00/0000
................................................................................
General Index Attorney Info
GESSNER MARGIE A PI.AINTIFF FAMILY LAW CLINIC
CONFIDENTIAL
101 WILLOW GROVE
CARLISLE PA 17013
GIBB MICHAEL DEFENDANT
C C P
1101 CLAREMONT ROAD
CARLISLE PA 17013
..*t....*.*...........................................t...ttt...................
* Date Entries *
t,.........................".........................it..............,.........
11/10/1998
11/10/1998
- - - - - - - - - - - - - FIRST ENTRY - - - - - - - - - - - - - -
PETITION FOR PROTECTION FROM ABUSE BILLED COUNTY
-------------------------------------------------------------------
TEMPORARY PROTECTION ORDER 11/10/98 IN RE HEARING 11/13/98 AT
10:30 A M IN COURTROOM NO 3 GEORGE E HOFFER P JUDGE
-------------------------------------------------------------------
SHERIFF'S RETURN FILED
Litigant,: GIBB MICHAEL
SERVED : 11/10/98 CARLISLE PA - CAMPGROUND TEMP PFA
~~::::::::_~~~:~~-~~-~~:_~~~~~~~~~~--------------------------------
FINAL ORDER OF COURT - DATED 11/19/98 - BY EDWARD E GUIDO J - COpy
PERSONALLY GIVEN AND COPY FAXED AND MAILED TO PSP 11/20/98
- - - - - - - - - - - - - - LAST ENTRY - - - - - - - - - - - - - -
11/12/1998
11/20/1998
********************************************************************************
* Escrow Information *
* Fees & Debits Bea Bal Pvmts/Adi End Bal *
********************************~***************~*******************************
IFP REIMBURSE
35,00 35,00 .00
------------------------ ------------
35,00 35,00 .00
********************************************************************************
* End of Case Information *
********************************************************************************
-
MAROIE A. GESSNER,
Plaintiff
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION.LA W
IN PROTECTION FROM ABUSE
v,
MICHAEL OIBB,
Defendant
NO, 9il - 6373 CIVIL TERM
FINAL ORDER OF COURT
Defendant's Name: Michael Oibb
Defendant's Date of Birth: unknown
Defendant's Social Security Number: unknown
Names of All Protected Persons: Margie Gessner
AND NOW, this 19th day of November, 1998, the court having jurisdiction over the parties and the
subject-matter, it is ORDERED, ADJUDICATED and DECREED as follows:
Plaintiffs request for a final protection order is granted,
1, Defendant shall not abuse, stalk, harass, threaten the Plaintiff or any other protected person in any place
where they might be found.
2, Defendant is prohibited from having any contact with Plaintiff at any location, including but not
limited Plaintiffs residence or place of employment. Defendant is specifically ordered to stay
away from the following locations for the duration of this Order:
(a) 101 Willow Grove Road, Carlisle, PA 17013
(b) any residence established by the Plaintiff, either permanent or temporary
4. Defendant shall not contact the Plaintiff by telephone or by any other means, including through third
persons and writing,
5,
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Defendant shall not have any contact with Plaintiffs relatives,
6, The costs of this action are waived as to the Plaintiff andilll1'8JCd 6n Dcfcndanl.
7. BRADY INDICATOR.
a, The Plaintiff is a person who has cohabitatcd with thc Dcfcndant.
b, This ordcr is being entered aftcr a hearing of which thc Dcfcndant reccived actual notice and
had an opponunity to be heard,
c, Paragraph 1 of this Order restrains the Dcfcndant from harassing, stalking, or threatening
the Plaintiff,
d, Dcfcndant rcpresents a crcdible threat to thc physical safcty of the Plaintiff
and the terms of this Order prohibit Dcfcndant from using, attempting to use, or threatening
to use physical force against the Plaintiff or protected person that would reasonably be
expected to causc bodily injury,
8. All provisions of this order shall expirc in one year, on November 19, 1999.
NOTICE TO TIlE DEFENDANT
VIOLATION OF THIS ORDER MAY RESULT IN YOUR ARREST ON THE CHARGE OF
INDIRECT CRIMINAL CONTEMPT WHICH IS PUNISHABLE BY A FINE OF UP TO $1,000,00 AND/OR
A JAIL SENTENCE OF UP TO SIX MONTHS. 23 PA.C,S. ~ 6114. VIOLATION MAY ALSO SUWECT
YOU TO PROSECUTION AND CRIMINAL PENALTIES UNDER THE PENNSYL VANIA CRIMES CODE.
THIS ORDER IS ENFORCEABLE IN ALL FIFTY (50) STATES, THE DISTRICT OF COLUMBIA, ~
TRIBAL LANDS, U.S. TERRITORIES AND THE COMMONWEALTH OF PUERTO RICO UNDER THE "
VIOLENCE AGAINST WOMEN ACT, 18 U,S.C, ~~ 2261-2262. IF YOU TRAVEL OUTSIDE OF THE 'I
STATE AND INTENTIONALLY VIOLATE THIS ORDER YOU MAY BE SUBJECT TO FEDERAL I
CRIMINAL PROCEEDINGS UNDER THAT ACT, 18 U,S.C. ~~ 2261 -2262. IF PARAGRAPH 12 OF I
THIS ORDER HAS BEEN CHECKED, YOU MAYBE SUBJECT TO FEDERAL PROSECUTION AND
PENALTIES UNDER THE "BRADY" PROVISIONS OF THE GUN CONTROL ACT, 18 U,S.C. ~~ 922(G),
FOR POSSESSION, TRANSPORT OR RECEIPT OF FIREARMS OR AMMUNITION,
NOTICE TO LAW ENFORCEMENT OFFICIALS
The police who have jurisdiction over the plaintiffs residence OR any location where a violation of this
order OCcurs OR where the defendant may be located, shall enforce this order, An arrest for violation of
Paragraphs 1 through 7 of this order may be without warrant, based solely on probable cause, whether or not
the violation is committed in the presence of the police. 23 Pa,C.S. ~ 6113.
Subsequent to an arrest, the police officer shall seize all weapons used or threatened to be used during
the violation of the protection order or during prior incidents of abuse, The [insen the appropriate name or
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title) shall maintain possession of the weapons until furthcr ordcr of this court, Whcn the defendant is placed
under arrest for violation of the ordcr, the dcfcndant shall be takcn to the appropriate authority or authorities
before whom defendant is to be arraigned, ^ 'Complaint for Indircct Criminal Contcmpt' shall then be
completed and signed by the police officer OR the plaintiff, Plaintifrs presence and signature are not required
to file the complaint.
If sufficient grounds for violation of this ordcr arc a1lcged, the dcfcndant shall be arraigned, bond set
and both parties given notice of the date of the hearing.
BY THE COURT:
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Edward E, Guido. Judge
If entered pursuant to the consent of the plaintiff and dcfendant:
Margie A, Gessner
Michael Gibb
NOV 1 0 1998
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IN THE COURT OF COMMON PLEAS OF
CUMOERU,ND COUNTY, PENNSYLVANIA
CIVIL ACfION-LA W
IN PROTECfION FROM ABUSE
MARGIE A, GESSNER,
Plaintiff
MICHAEL GlOB,
Defendant
NO, 98 - (,. :.; 7 3
CIVIL TERM
NOTICE OF HEARING AND ORDER
YOU HAVE BEEN SUED IN COURT, If you wish to defend against the claims set forth in the
following pages, you must appear at the hearing scheduled herein. If you fail to do so, the case may proceed
against you and a FINAL Order may be entered against you granting the relief requested in the Petition, In
particular, you may be evicted from your residence and lose other imponant rights,
-y, It/: 3d
A hearing on the matter is scheduled for the L, day of November, 1998, at_ o'clock ff.m"
in Courtroom , :3 at the Cumberland County Courthouse, Carlisle, Pennsylvania.
You MUST obey the Order that is attached until it is modified or terminated by the court after notice
and hearing, If you disobey this Order, the police may arrest you. Violation of this Order may subject you
to a charge of indirect criminal contempt which is punishable by a fine of up to $1,000,00 and/or up to six
months in jail under 23 Pa,C.S. ~ 6114. Violation may also subject you to prosecution and criminal penalties
under the Pennsylvania Crimes Code. Under federal law, 18 U,S,C, ~ 2265, this Order is enforceable
anywhere in the United States, tribal lands, U,S, Territories and the Commonwealth of Puerto Rico. If you
travel outside of the state and intentionally violate this Order, you may be subject to federal criminal
proceedings under the Violence Against Women Act, 18 U.S,C, ~~ 2261-2262.
YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. YOU HAVE THE RIGHT
TO HAVE A LAWYER REPRESENT YOU AT THE HEARING. THE COURT WILL NOT, HOWEVER,
APPOINT A LAWYER FOR YOU, IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE,
GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET
LEGAL HELP, IF YOU CANNOT FIND A LAWYER, YOU MAY HAVE TO PROCEED WITHOUT
ONE,
Cumberland County Bar Association
2 Liberty Avenue
Carlisle, Pennsylvania 17013
(717) 249-3166
other agency specified here;aner: I'ennsylvani;a Sl;Ile Police.
6, TillS ORDEI~ APPLIES IMMEDIATELY TO DEFENDANT ANI> SIIAI.L REMAIN IN EFFECT
UNTIL MODIFIED OR TERMINATED BY TillS COllin AI'TER NOTICE ANI> IIEARING,
NOTICE TO TilE UEFE;'o;UA;'o;T
I>efend;anl is herchy notified Ih;at viol;alion of Ihis Order may resull ill ;IITesl for indirect crimin;al
contempt, which is punish;ahlc hyaline of ul' to $I,OOO,IKl and/or up to six mOlllhs ill j;ail, 23 Ps,C,S * 6114.
Consent of thc PI;aintitT 10 Dcfend;ant relurn 10 thc residence slm" not valid;alc Ihis Order, which can only he
changed or modilied through the tiling of appropriate court papers fllr th;u purpose, 23 Pa.C,S, * 6113.
Dcfend;lnt is further nOlilied Ihat viol;ation of this Order may suhject him/hcr 10 Slatc ch;arges ;and pen;alties
undcr thc Pcnnsylvania Crimcs Codc and III fcderal charges and pcnalties under the Violcnce Against Womcn
Act, 18 U,S,C, ** 2261-2262.
NOTICE TO LAW ENFORCEillENT OFFICIALS
This Ordcr sh;a" he cntilrced hy thc policc who havc jurisdiction ovcr the plaillliff's rcsidcncc OR any
location whcrc a violation of this order occurs OR whcrc thc dcfendalllm;ay he locatcd. If dcfcnd;ant violatcs
Paragraphs I through 6 of this Order, defend;ant m;ay bc arrcstcd on thc charge of Indircct Criminal Contempt.
An arrest for violation of this Order may be m;ade without warralll, h;ascd solcly 011 prohahlc c;ausc, whcther
or not the violation is eommilled in the presencc of law cnforcemcnt.
Subsequent to an arrest, the l;aw enforcement officcr shall scize ;all wc;apons used or thre;atened to be
used during the violation of this Order OR during prior incidcnts of ;ahusc. Wc;apons must forthwith he
delivered to the Sheriff's office of thc county which issued this Ordcr. which office sh;all mailllain posscssion
of the weapons until funher Order of this court, unless the wcapon/s arc cvidcnce of a crime, in which casc,
they shall rem;ain with the l;aw enforcement agency whosc officer made Ihc ;arrcst.
BY THE COURT:
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MARGIE A, GESSNER,
Plaintiff
v,
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION-LAW
IN PROTECTION FROM ABUSE
MICHAEL GlBB,
Dcfcndant
NO, 98 - '.; '/ ~
CIVIL TERM
PETITION FOR PROTECTION FROM ABUSE
Margic A, Gessner, Plaintiff, through hcr altomcy, thc Family Law Clinic, hereby asserts the following:
I, Plaintiff is an adult individual and is filing this Petition on behalf of herself. Plaintiff seeks protection
only for herself.
2. Plaintiff's current addrcss is confidential, but she previously resided at 101 Willow Grove, Carlisle, PA
17013,
3, Defendant is an adult individual and is currently incarcerated in the Cumberland County Prison located
at 1101 Claremont Road, Carlisle, PA 17013. Defendant's date of binh and Social Security Number
are unknown to Plaintiff,
4. Plaintiff and Defendant are former se"ual partners,
5, Plaintiff and Defendant have not been involved in any court actions against each other.
6. Defendant has been involved in a prior criminal court action for theft and receiving stolen propeny for
which he was sentenced I I to 23 months, but was released on parole during the time of the incident of
abuse mentioned below. Defendant has since been reincarcerated for violation of that parole.
7. Plaintiff and Defendant have no children together.
8. The facts of the most recent incident of abuse are as follows:
On Friday, October 16, Defendant was released on parole from prison and Plaintiff agreed to pick him
up from prison and take him to the Carlisle Campgrounds where he was planning to stay. When he
arrived at the Campgrounds, Defendant found out that he would not be able to afford to stay there and
Plaintiff took him back to her residence which she shares with a roommate, Chip Nester. On that
weekend, Defendant purchased and smoked appro"imately $700,00 worth of crack cocaine and he and
Plaintiff engaged in a se"ual relationship through Friday, October 23, 1998. On the evening of October
23, 1998 at Plaintiff's former residence at 101 Willow Grove Road, Carlisle, PA 17013, Defendant
indicated that he was leaving to purchase more crack cocaine, and Plaintiff insisted that he not do so.
Defendant then grabbed Plaintiff by the throat, shoved her against a sink and squeezed her throat until
she was gasping for breath, Ocfendantthen became belligerent, calling Plaintiff vile names, and he
attempted to throw a beer botlle at her, The bottle hit the wall instead, and Defendant then left the
residence.
Defendant returned later with a bag of crack cocaine, which he smoked, After he smoked the drugs,
Plaintiff and Defendant began to argue about his use of the drugs, Plaintiff went to her bedroom and
Defendant said to her, .You'lI get yours later.. Defendant then went to the bedroom, grabbed
Plaintiff by the throat and began choking her, To escape, Plaintiff kicked Defendant in the leg.
Defendant then pushed Plaintiff into the wall and punched her in the eye, nose and face. Defendant then
threw Plaintiff into a closet door, causing her to fall to the floor, While Plaintiff was on the floor,
Defendant proceeded hit her in the head with his elbow. In an attempt to escape once again, Plaintiff
kicked Defendant in the knee and got him out of the bedroom, She locked the door but Defendant then
kicked in the bottom half of the bedroom door, came into the bedroom and punched her in the face.
Plaintiff managed to get away and grabbed a utility knife from her dresser, Defendant then hit
Plaintiff in the head with a metal attachment to a vacuum cleaner, knocking her to the floor. In self-
defense, Plaintiff then kicked Defendant in the knee and grabbed him by his hair, exposing his neck,
She held the utility knife to his neck, and when Defendant attempted to grab the knife from her hand,
he was cut. Also, Defendant had his hand over the blade and Plaintiff, in fear that he would take the
knife and use it against her, pulled the knife out of Defendant's hand, cutting his palm.
Defendant then left the residence and Plaintiff called the police, who came to her residence and called
an ambulance. Plaintiff was taken to the Carlisle Hospital, where her injuries were treated, Defendant
was later arrested and placed baek in prison for violation of his parole. He has been charged with
parole violation and aggravated assault, No charges were filed against Plaintiff, Defendant has since
contacted Plaintiff from prison by telephone and by mail, and Plaintiff remains in fear of Defendant.
9. The police department or law enforcement agency in the area in which Plaintiff lives is the North
Middleton Police Department. That Department should be provided with a copy of the protection order,
10, There is a danger of further abuse and harassment from the Defendant.
WHEREFORE, Plaintiff requests that the following relief be granted in a Protection from Abuse Order:
a, Restrain Defendant from abusing, threatening, harassing, or stalking Plaintiff in any place where
Plaintiff may be found.
b, Prohibit Defendant from having any contact with Plaintiff either in person, by telephone, or in
writing, personally or through third persons, at any location, including but not limited to any
contact at Plaintiff's residence or place of employment.
c, Prohibit Defendant from having any contact with Plaintiff's relatives,
d, Grant such other relief as the Court deems appropriate,
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MARGIE A. GESSNER,
Plaintiff
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION-LAW
IN PROTECTION FROM ABUSE
v.
MICHAEL GIBB,
Defendant
NO. 98 - 6373
CIVIL TERM
CONSENT AND APPROVAL POR APPEARANCE UNDER Pa.B.A.R. 322
Date
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THOMAS M. PLACE
ROBERT E. RAINS
KATHERINE C. PEARSON
Supervising Attorney
DONALD MARRITZ
Staff Attorney
I hereby consent to the appearance of Brad Harker, a Certified
Legal Intern under the supervision of an attorney, in the
above-entitled Protection From Abuse proceeding before the
Honorable Edward Guido at 3:30 p.m. on Thursday, November 19, 1998.
Date )-;rJ- 18
'C)
As the supervising attorney for Brad Harker, certified under
Pa.B.A.R. 322, I approve of his appearance on behalf of the
above-named client in the above-named proceeding.
FAMILY LAW CLINIC
45 North pitt Street
Carlisle, PA 17013
717/243-2968
~ PETITIONER'S
i. EXHIBIT
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c;l Carlisle Hospital.
COMMONWEALTII OF l'ENNSYI.VANlA
COUNTY OF C'flJ) /'ukn.d
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CERTIFICATION OF RECORDS
Namc of Paticnt: /17o'fj.LG G c:;;<:; /J!? f~
Mcdical Rccord Numbcr (s): . 0 (),G, '-/ C, '2.,
Numbcr ofpagcs in thc mcdical rccord:
,q
Thc copics ofthc rccord J(lr which this ccrtilication is madc arc truc and complete
rcproductions ofthc original or microlilmcd mcdical records which arc hOllscd in
Carlislc Hospital. Thc original rccords wcrc madc in thc rcgular coursc of
busincss at or ncar thc timc of thc mattcr rccordcd. This ccrtilication is givcn
pursuant to 42 Pa. C.S. Chaptcr 61 Sub-Chaptcr E (rclating to mcdical rccords by
thc custodian thc rccords in licu of is/her pcrsonal appcarancc.
Dircctor, Mcdical Rccords
~~.~
Arlcnc Sicbcr, A.R.T.
Dircctor, Mcdical Records
Sworn and subscribed bcforc mc this
l..~day of IV":,,,";,, her 19 'lr
f!. iv ,"
NOTAIIIAI. SEAL
JACQUWNEC. WOLF, NOTARY PUBliC
CARliSLE BORO, CUMBERLANO CO., PA
IIYCOIlMISSION EXPIRES IlAY20, 21m
:I ,\'lIh~idi"l'/Il!r('f/I'/i,~"'lftl.~Jli'f/1 tlllIl /lmllll .'i,'!','iI'/'s.
246 Parker Slre,lo P.O. Box 310 0 (arlille. PA 17013.03100717.249.1212
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~.(jarllsle Hospital
. ~, and Health Services
246,.,11., St,..t . C..II.I., PA .7013-0310 . 717.245.5500
illIG OAl(,11U(
to:'':;/9[1 C2:4:t
HMI!IMlOI'lfIl'l'ttClftl: /Alll!,,lU'fIACC IU,
GESSNER, HARGIE R.
101 MILLOH GROVE RO
CARI.I SLE, PR
'5Cl(MC'.O
GESSNER, ijARGIE ~_
101 W 11.11111 BRlIvr liD
CRRl ISLE, PR
NAIoI! I AOOAfSS I PHONf 'A{LA'oONl ~OC-S(CNO
CONVENIENT CARE/EMERGENCY REGISTRATION
A""I,."..T!'I,'l :'\.11
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PA!ilNf (J1>tfll(l,II1U"P>
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11120/68
206-54-6602
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1/013
EUEHCiEN:v,"omv
BLANKS CUSIOOJAL
~344 D~ANDV tAME
MECIIANICSBURG, Pil
NEtHOR, CIIIP ROOlllfl;lE
(717)258-4278
RSSRULT VICTIM P05518L[ NO
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BRIEF VISIT 26700
CLASS I VISIT 26710
CLASS II VISIT
CLASS III VISIT 26730
CLASS IV VISIT 26740
CLASS V VISIT 26750
CONVENIENT CARE I 27020
CONVENIENT CARE II 27025
MINOR SUTURE EDSOl
MEDIUM SUTURE EDS 02
MAJOR SUTURE EDS 03
INTUBATION EOS 04
IV SET UP EDS 06
CAROIAC MONITOR EDS11
PELVIC EXAM EDS 14
NITRO SET-UP EDS 16
CAST, SCOTCH SHORT ARM 26031
CAST. SCOTCH LONG ARM 26032
CAST, SCOTCH SHORT LEG 26033
CAST, SCOTCH LONG LEG 26034
26075
26037
79064
GASTRO/HEMO SLIDE 26060
KIDDE TOURNIOUET 26048
OCL PER FOOT 79670
F.S.B.S. 80081
TUSE GAUZE PER FOOT 26074
ED STAT ESTAT
PULSE OX POXED
EXTENDEO CHARGE I 26760
EXTENDEO CHARGE II 26770
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6UARRACINO, ANTHONV J
NO FAMILV,DOCTOR
ALL ADDITIONAL CHARGES
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[1 Pdl<! 0 .JilllnUI(;('(J 0 CIrcumoral
----.-.-------
SKIN: 0 Cool [J EeJmnil
C~a~m rJ c.'mnrr.y 0 r;Cch'lmo~is
[5-t1ry [) n,nrl NUnSE SIGNATURE
o Audible
Wheeze
o Retractions
10.
= TREATMENT IN PROGRESS ON ARRIVAL:
o CPR Down Time
o Airway. DOra! 0 Nn5al - Sizo
D Airway, Endotracheal. Size
D Airway, Nasotrachoat . Sizo
o IV. Solution
Lung Sounds: Right
ON/A
. J1J3.....M.J....Al. v1 ::\
Size
o Monitor. Rhythm _________ F1afe______
o Oxygon. 0 M,;]$k. fJ NC. UMlrJ ____
o Spinal Immobllj2i:l!I~m,
o Masl
o Prf:zsure Drm,sin;1 ~l..:)lIl~r
Mental Assessment: QJu_,j1../l,..~
P}.oQ(I-AI~m::l. "':lUn'll:. 0 USfl{!N;ll:
Q-1I11prop"'<lle g-crC""llsnon:i1flllOU5 ~l1al!CI!Jar
o Blunlnd-f,.:J! 0 V<lqu(J,D,sGOnrl'cll'(j 0 Sdenl
o DnfrmSlve 0 DI~;or'l:II!,tU [J Talkative
o Appruthrlslv~' [] ~;j:I'N 10 "(:~Jw(~r 0 Rcpot!live
o nfJ3l:(l~~;jC()I'rbal:v(, [J Mumbling
DRUGS:
n1ln
Site
F~ ?f:-
Vilal Sign" (.;;1. -l~.
POX:
leI!:
o Rajas 0 Rhonctli 0 Normal
o Wt1eOlO 0 Ab:mnl 0 Olrlllnif;tW(J
o Aulos 0 Rhonchi 0 Nom1dl
o WllflOZO 0 Absent 0 Drf:'lIn:shod
Visual Activity:
00 ___
05__
"ON!A
o WllhGt<l~;:;os
o WltrlQul (;:'I$~;C~
Mommy:
.E]lIlLdct
o Impaired
o HOGenl
o DlslantPasl
,.
Pupils:
Aighl.Size
ReaClion
Sizo
Roaction
_~g.wel SoundslAbd:
.2J ACllve rJ t. ;..
0"11P'; Cll!y;)'!r
To I'<llpdltt)[l _____
ExtremIties:
o MAE __.
o Uoforlllity_
rJ A_!m:l::>ion
o NIA
Pupil Sizes:
4.
2. 5.
3.6e
loft.
flN/A
= INITIAL NURSING REVIEW:
REASON FOR VISIT; O. T,f1AUf>jA q MEDICAL
PAST MEDICAL HISTORY~'lLL_L:..I:\___
I 0 Olidur:lnt~ __ .__ _ _ _
"-~--1i10
TIME:_D_ti__
o PSYCHOSOC1AliEt.10nOr,JAI.
'"
LMP'
I/)
m'"
>-
UJ
"
>=
Z
UJ
U
\Nnigtll:___
Cause 0 I 'ury/\ljSt&ypf PreSerl r'ne:;s (What ~'<rpa"e""e"(Y'OUI:W-{2'r-jf~~ ~~_~
l\.l..J.>>&uL\..v.:Lu.'IL,~R_.D,LC__ ~Ub! ~~_s.tu....
~ '
1l..U.L\--% €.:m f{ .___ PLAN OF CARE:
C_ Malntmn PatlAnt Airway
U onitor Cardiovascular StAtus
[ IV 0 BP Monitor
o E 'G 0 Cardiac Monllor
o Salety O<lSllrOS
o Rest lints 0 SuIcide Precautions
o Seizl re Precnutions
o Sid Rails Up
o Comf f1 Measures
PATIENT PROBLEM: Nursing Diagnosis _ Coping, Ineffective Mobility, impJimd 0 P. In Control
- Airway Clearance, Ineffechve Fluid Volume, Alteration:; in' ~=: Nmlcomplianco osilion for Comfort
- Anxiety = Gas Exchanne, Imp<1ired Self Care DefiCit 0 repora for Exam
Breathing Patterns, lnoHeclive _ Hype~hefmin (F?'/er) ~_= Skin Integrity, Impaired. .' Explain Procedures
= Cardiac Output,. Doc~eased InfaCllo_n, Potential ~__ TholJghl Process, Alt..ln. Q Emotional Support
- Comfort, ~Ite.'atlons I~: __I~Jury, Pol~nt!C.ll. . m~ rJ55Ue Pertu31on, Alt. In: J Pallent Toaching
- Commun,ea',on Impalrod . .__:~Wledge. D81~____-=.=-0,'i~:.'.===____ ':'-=1:J Dischargo Instructions
OUTCOME/GOAL: ExpeCle~bY ~5 'hnrQo0'_ t~_____.____.______ [J oOllie'
f . l J~ II . 0 _ \ . - ther
. ~~~____.____ I.JUHSE'S Slc;r>JATUHE -
o
JECTIVE: Physoeallnforma"on (Vlhat~ble to <'(fl. tl-tb.<<<.:Lc.lJ.LC\;:-~~_
- l' -' ~-7~~l&4'--rP.~~~~
(!tCi~~_~1.Mi...A.tL~~__
C.r1llle HOlpltal - Emergency Department
248 Parker St. Carlllle, PA 17013 - (717) 245.5500
GESSNER MARGIE
10/24/98 3:03am
DISPOSITION SUMMARY
Patient: GESSNER MARGIE
S5#:
CURRENT Address:
City:
Current Ph:
Age/DOB: _
Zip:
Medical Record: 066462
Arrival: 10/24/98 3:03am
Disch: 10/24/98 4:07am
Disposilion:
MD ED: Anthonv J. Guarracino. DO
Res/PNNP:
Ox #1: Contusion (UnsDecified Site)
ICD-9 #1: 924.9
Ox #2: Assault IBv Other. UnsDecified Meansl
ICD-9 #2: E968.9
PMD:
PMD Ph:
#1 Ox Engl: CONTUS.ESW
#2 Ox Engl: ASSAUL T.ESW
#1 Ox Span: CONTUS.SSW
#2 Ox Span: ASSAUL T.SSW
~1ei1
Follow-up: DOCTOR FROM THE LIST
FlU MD Ph:
FlU OfT, 5 Davs
Other Instr: ICE TO FACE 4 TIMES OAIL Y. TYLENOL FOR PAIN. RETURN IF INCREASING PAIN.
MY SIGNATURE BELOWINOICATES:
> I have received and understood the oral instructions regarding my current
medical problem.
> I will arrange follow-up care as instructed above.
> I acknowledge receipt of t,h e written instructions as outlined on this and C
any previous page(s). I will read and review these instructions. ~
("'. :/1/1,
X /; X r \iU;'U.A, ~
ali nt (or. gal Guardian) Signature Staff (Witne ) Signature
l'cIIIIsylv3nin EMS RCJlort
Service N,"ll:' ServlI;e No Iru;idcnt Nil Doale
Carlisle Community Amhulalu:e 2100214 98040.11 10-24-1998
IncllJcntloclllOfl f\.1{'f) KCCCI\lllg l'aclhty
101 Willow Gro\'e Rd. 21920 C.rlisle 1I0spil.1
1'lIli(,l1INilllM:' J'hurlt: Nil Age "atcufUlIth SUI:131 Set. Nu. Se.\
p Margie A. GC!isllcr (717) 258.-1278 29 11/22/68 206-54-6602 F
II
t SlIeet Atltltt'\!t l'IC\\ Tillie'
i 101 Willow GnJ\'e Rd. Mil Luger,Brian E 089672 Uispatch 01:52
C t..:'uy Stale lip MI2 r-.fagaro, Vincent I' 026555 Fnroutc: 01:53
11
t Corlisle pA 17013- MIJ Arrive Scene: 02:04
I Cumbcrl:md Co. hlCldcnlll Mcdlcl)nit Af/4 D\'()3rtSccnc 02:18
11 13966 Mileage Arrivcl:ac. 02:29
f OUl OIl-Scene Delit In A'o'uilnbl.;o 02:58
0 0 021659 021665 0 In Quarters 03:00
Chief Complaint: head, facial pain: possible nose f.,<
Current l\ e S.: none
Allergies (meds): NKDA
PMllx: MI eliI' ulerine CA 4 yrs .go
Amb 240 dispatchc<Vrcsponding to the ubo\'c incidcllt location for an assault victim, Class 2
response. Enroute was advised by EOC that North Middleton PD were OIS, and that the assailant
was already .Ilhe hospil.1. AOS, and w.s greeled by Nouh Middlelon PD Officer Vincent who g.ve us. briefhislory of
the situation aud notified us that he would have pt walk out of house to Amb. so that crime scene was not disturbed. Pt was
ambulatory. Pt walked out of house and got into Amb. and sat on streicher. Securcd pt to litter. HPI: pt stated that she was
in a confrontation with prescnt boyfriend who wanted her to du something (unknown what and did not ask) and when she
refused he st.rled 10 be.t her up. She resisted, sl.ling th.l she cut him in the neck .nd hands wilh a knife. She said th.t it
was self defense since she did not know what else to do to stop him from beating her. She was crying and was worried that
she fat.lly wounded him.nd kept st.ting, "I didn'l know whal clse 10 do". EXAM: pt alerl, .w.ke, orienled. HEAD: pi
stated that the top ofhcr head was tender due to assailant striking her several times. No blood, contusions, or lacerations
seen. EYES: PEARL. FACE: eOlllnsion on righl cheek, just under right eye. Nose was bruised, swollen, .nd appe.red to
be fmetured. Pilip was swollen .nd h.d blood on il. CHEST: no c/o p.in. No lrouble bre.lhing. ADD: soft, non-lender.
EXTREMITIES: bruising .nd tenderness on left fore.rm. Rest of exam unrem.rkoble. TX: placed cold p.ek on pi nose
.nd right cheek. Monitored vilals and LOC enroule to C.rlisle Hospit.! ED. Pt condition remained uneh.nged. Enroute
m.de DLS notilie.tion p.leh into CHED. At Hospit.I, tr.nsferred 1'1 to ED bed ff 4 and gave verbal repoUlo ED st.ff
(Debbie, RN .nd Kelly, ER Tech.) Amb. 140 wenl av.i1.ble wilhout fuuher incidenl. EONlbjl
...~..
)
-------
~/-/-.
//
~-_.~~----.
.--.-----~._.._-----
.--.--.---
@ 1996. Med Media, Inc.
Page I
/7 _ / /
. D IJZJt
'. ~ ~~er N.me
l'ennsylvl1uln EMS Itcpol't
Service Nllmc
Carli, I. Commuuity AlI1bul,u<.
P,tientName
ScrvlO;c Nil
Incident ~n
nil Ie
2100214
980,1041
10.24.1998
Dale or With SO(lill SCClIIlly Nil.
Medical Cumnund l'h)'JIClan
Margie A. Gessner
11/22168
206,S4-6602
Time I' R WI' Ilhylhlll Tn'.IlII1t'IH Provider Hcsp/Comment
02:18 70 22 124172 icc pack AI
@ 1996. Mcd Media,lnc.
Page 2
Carlisle Community Ambu!:lIlce
PCllnsylvania EMS/On-Scclle Report
~ GarlL~le Hospital
ti' and Health Services
CONSBIIT
TO HOSPITAL ADMISSION AND
IIEDI CAL TRBA THlENT
I'(l("r - /
, .( 1"1
Date of Admission,
Attending Physician (s),
111::x.LI'.,i'
Time,
(lIM)_(PM)_
Name ot
1. I, (or
\ .
r S'-J 'YlL(
acting on behalf ofl
A,
Name or Authorlud RtprtMnlatJ",
, suttering trom a condition requiring hospital care, hereby
ame or p itD.
consent to render! g of such care, which may include routine diagnostic procedures and sueh
medical treatment as the named attending physicianlsl or other of the hospital's medical
staff consider to be necessary,
2, I understand that the practice of medicine and surgery is not an exact science and
that diagnosis and treatment may involve risks of injury, or even death. I acknowledge that
no guarantees have been made to me as to the result of examination or treatment during this
hospitalization,
3. I understand thatl
(A) It is customary. absent emergency or extraordinary circumstances, that no
substantial procedures are performed upon a patient unless and until he or
she has had an cpportunity to discuss them with the physician or other
health profesaional to the patient's satisfaction;
(B) Each patient has the right to consent, or to refuse consent, to any
proposed procedure or therapeutic course; and
Ie) No patient will be involved in any research cr experimental prccedure
without his or her full knowledge and consent.
4. I understand that many of the physicians on the staff of this hcspital, including
the attending physician(s) named above, are not employees or agents of the hospital but,
rather, are independent contractors who have been granted the privilege of using its
facilities for the care and treatment of their patients. Further, I realize that among those
who attend patients at this hospital are medical, nursing, and other health care personnel
in training who, unless requested otherwise, may be present during patient care as a part of
their education. Still or motion pictures and closed circuit television monitoring of
patient care also may be used for educational purposes or for documentation of the clinical
course unless a patient expressly requests otherwise.
5. I release CARLISLB HOSPITAL from all responsibility for all articles which I am
retaining or will have with me during my stay at the hospital. I understand this includes
clothing, bridgework, false teeth, eyeglasses, jewelry, money, radio, razor or any other item
kept in my possession. I understand I may deposit valuables in a safe provided by the
hospital; only if this is done will the hospital assume any responsibility for the
safekeeping.
6. I hereby acknowledge that I have received written information on the topics of
Patient Rights and Advance Directives.
,])1 Vl t eLL!
R;./I\ VLU Iv u'!......,
{SIGNATURE OF WITNESS}
consent or is a minor, complete the following:)
of age] [is unable to consent because] :
{SIGNATURE OF LBGAL GUARDIAN OR
CLOSBST AVAILABLE RBLATIVE}
{SIGNATURE OF WITNESS}
AD 0315 (10/91)
"
~ Carl~ll H~pltal
~ and Health SelVlces
146 P.,." s...... . C.III.I., PA 17013.0~!O_~!I..!:.~!!:~~~_
NO. [)All.t.,. .,;- I'" ~"<..,. ..."..,
IOOU98 19:23
GESSNER, KARGIE A.
101 MIllOM GROVE RD
PA
'ftOC.S!CWJ
GESSNER, KARGIE A.
101 MIlLOM GROVE RD
PA
~
CONVENIENT CARE/EMERGENCY REGISTRATION
tA.l .;-- ,~,ec-__=< t:""" ~..;;7
P.,
(717l2~8-~270
29V F H D
11/20/60
206'54-6602
."'t
1"1'('1' V"'{l'lll,''''<J.!M
/
17013
( 7 1 7 ) :' ~ rt A .. ~I OJ 8
BL.INKS CU510illlll.
&344 CR~NDY I nNI
i>I[CIIAiIIC';f~tJ~G, PA
(j./JAJW,T:..n'5,...rlO'Ol
206-54-bt.O:!
17'j13
E..tl'lGE~::YNO':'Y
NESTOR, CHIP RDD~~AT[
(717l258-4278
RECHECK BLEEDING HIl NONT
GO AWAY HERE 1024398
BRIEF VISIT 26700
CLASS I VISIT
CLASS II VISIT 26720
CLASS III VISIT 26730
CLASS IV VISIT 26740
CLASS V VISIT 26750
CONVENIENT CARE I 27020
CONVENIENT CARE II 27025
MINOR SUTURE EDSOl
MEDIUM SUTURE EDS 02
MAJOR SUTURE EDS 03
INTUBATION EDS 04
IV SET UP EDS 06
CARDIAC MONITOR EDS11
PELVIC EXAM EDS14
NITRO SET-UP EDS16
CAST, SCOTCH SHORT ARM 26031
CAST, SCOTCH LONG ARM 26032
CAST, SCOTCH SHORT LEG 26033
CAST, SCOTCH LONG LEG 26034
CAST ROLL, PLASTER 26075
BIP MONITOR 26037
PACER PADS 79064
GASTRO/HEMO SUDE 26060
KIDDE TOURNIQUET 26048
OCL PER FOOT 79670
F.S.B.S. 80081
TUBE GAUZE PER FOOT 26074
ED STAT ESTAT
PULSE OX POXED
EXTENDED CHARGE I 26760
EXTENDED CHARGE II 26770
~---------~---- --------------,
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,_________M____________________""
COYLE, JOHNSON G
NO FAMILY DOCTOR
5376330
....(llIl'JolO
ALL ADDITIONAL CHARGeS
I~-------- --------....
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ER.<J508 (REV. 8/86)
GESSNER, MARGIE A
MR 11066462
10/26/1998
CHIEF COMPLAINT: Bleeding hemorrhoids and post traumatic headache
HISTORY OF PRESENT ILLNESS: This 29-year-old female was seen here two nights ago, after
being beaten by her paramour. She was punched in the face several times and struck with the wand of
a vacuum cleaner, but otherwise was not struck with a hard object, nor thrown to the ground. She was
not unconscious In the assault. Since that time, she has had constant bitemporal headache, without
vomiting, with occasional nausea after meals She has felt listless, but has not had dizziness, vertigo
or syncope.
REVIEW OF SYSTEMS: Negative for vomiting or diplopia. Positive for bright red rectal bleeding, for
three days, which began after having a hard stool. She has not had rectal pain. All other systems
unremarkable.
PAST MEDICAL HISTORY: Patient's previous emergency department chart was reviewed in detail.
The nurse's notes are reviewed and agreed with. There is a history of hemorrhoids in the past.
SOCIAL HISTORY: Margie is here with a friend, with whom she is now staying. The batter is in jail.
She is seeking a family physician in the York area and has chosen Dr. Kovacs after discussing this
with me.
HISTORY OF PRESENT ILLNESS: This is a generally healthy, medium sized, white female, with a
resolving hematoma of the right infraorbital area. There is no soft tissue swelling there.
HEENT: Extraocular muscles are intact. There is no diplopia. The tympanic membranes are normal.
The temples are slightly tender without objective swelling.
NECK: Shows full painless range of motion.
NEUROLOGIC: Shows no focal weakness in coordination, nor tremor. Patient is not ataxic.
EXTREMITIES: The right posterior calf has a 10 cm resolving ecchymotic area, otherwise there are no
signs of significant physical injury, except slight tenderness of the neck to palpation without objective
soft tissue swelling or ai/way compromise.
RECTAL: Reveals a single external hemorrhoid which bleeds when examined. I did not do a digital
exam because of her discomfort and because of the obvious bieeding source.
ABDOMEN: Noted to be soft, non tender.
LABORATORY/X-RAY: None indicated.
EMERGENCY DEPARTMENT COURSE: I discussed the findings of head injury with the patient and
her friend. I felt she was stable for discharge. She was given a prescription for Anusol suppositories
and VicDdin for the headache. She was asked to call or return if she had severe headache, vomiting or
abnormal behavior, otherwise she was to use the suppositories for three Dr four days until the bleeding
stops, See Dr, Kovacs for follow-up care. I also advised her to have him check a sigmoidoscopic exam
because of the history of bieeding after it had stopped.
FINAL DIAGNOSIS:
1. Bleeding hemorrhoids.
2. Post traumatic headache.
JGC/dk
0, 10/26/1998 - 09:05 pm
T, 10/29/1998
DVI:101859
Johnson G. Coyle, M.D.
Page 1 of 1
ORIGINAL
CARLISLE HOSPITAL
EMERGENCY ROOM RECORD
CARUSLE HOSPITAL
~'7 IG~ Jl[ r!'Vk~ I" r J7".1:.o r""=___J~""
~Ai'USW.""
,.. PARKER STREET CARLISLE Pol 1701J.oJ10
ANd-fl_
CONVENIENT CAREiEMERGENCV REGISTRATION
"01(,"'.
FOR NURSING ASSESSMENT
SEE NURSING DOCUMENTATION SHEET
(/
'-jy(.~-
r,:,;/~,J C,(O ~ ,k(l~ c.r/_~~"':3< S..L',z - ~l..<.-\.L~ ~Z-
I -; .A.t!... .1dlri,e .
.
"-I D II>^<~, &\Ju-..
~ ~'\ I)., r-- "o-w-G,{;.' (.A ~ !;1t...u. _~'''-f'-4..
, .f1J.f),ljL.)- Jt<,t.i-e..-~e.( jJIJ j:. T E1 Jdf.~~1]V.-
PH'rS1CAI.!lIAM , , .
.:::!:.
-~ -^-
~ ~t~l"","" ~ --1.iVt~(/-
, .II'';
r
--. ~
'--"
TIME PHYSICIAN OROE"!
u."
ADMISSION DIAGNOSIS'
.LJ .11
O:1'!2 ~ R 111 'v:..c..; II IJ. .~ r l--n..~
J't./ Jdn.l JJ_iJ.,;----e'_ +-i' c..... _l,_(~d_~L0-uc_
RWON FOR VlSfT ~
RECHECK BLEEDING HA WONT
GO AWAY HERE 1024398
'~;:17 J'
"AMI~VPHYS
/ \ L
'1 !b M:~~~J )'\',"EJ:.I- -
'~"TV"" "","'-"'" ""'<ON< I-'.L
PFlESCRI~IONS O~N l. ) / NONE 0
.k .n~~.
.,~o 0 0 0 I
H~ME ADMIT OBS TRANS OTHER
TII,leQ;OISCfWlOE I ~omONOOOlSC~E
.8il S- 1.0 SAME ld1ClPROVEO
- ./ CO~IENT
DISPOSITION FROM er ED 0 CARE CENTEA
-:'(NOnFIEO'i~1;, ,'l\;t,T1MEX1ii $ 1~!TIffll"~~ONQ'EQ;
PATIENT NUMBER jPATIENT NAME
5376330 GESSNER, HARGIE A.
98999
jRfG OA.TflTIME '''Of ./SXiflCll.4S HOWAARIVEO
10/26/98 13:231 29VjF/W D W
"'~I
1
~ CllrIL,"'1I0SI'II.II
~ illulllt'allh St'''-II'l'S
D1fIvtQt~t...____'" "
NAME /LI~. ~ -' ----
ROOM ". __.._~~~ .___ PO~--1--- __ . p I lr.;I~'lISlil"i', ""lJ:II'U~ "'1"1,)1 Affh'WIWI!'I'.
illiA T ....L ./1. []Pmmtyl I_--lf.:~ ~'.~UL$ [JPOllt:., ~tjond
VI~AL SIG~'f-E-PI_;ljX= u;;'-:'~~~9..r,1_&(;. I U;;:~;:::: ::, (1 ~;;:::::.';.'::'~ H ;;:;;~nl 8 6':~~:y
ALLERGlF.S 7f!.. ._________ I . 1 ~ ,'",.j '~
TE1ANUSSTAT~;,." r I ('lllUfC')fJ'P'I!llIJ_.'_r'__J.~ t_tl~~,~-
CURRENT MEDICATIONS 0 \"JIIINl ~ Yf!ar~ 10 YfJ"". ~~~ ~
lIM".'''..~~''~.'~Y''~":-_SL'!'''''' I "Ae.r~--~~/}3:-d;;~iii;,~~p~' ,..~!::! 'JJ
1. _____.u___._.______.___. 'O'l",':101 S,'I',:lnq" /...tJ1<4. e..... f _..I;
2. t-A"""'7?1/-r- ---- . .-1 nUf!.'flq Act un'Cortll 'U"', -- -----. --
3. ,/J'l V IV) ___._____IJ.:~;~;~;;~~~;:;::';:~~;~~s _~-U~ll ~ ~'~~ [J
4, ~ ~J2-.-,---____- PULSE: 1 RESP: Q Sn,"ow 0 Rup'd
5. ~ 1t:;C;: ~ ~ Rllgu,"r 0 1I"':p:.,, ~~:""..,, I J 0111'0 [J SlOW
___ __[J Full 0 Wualo' _ 0 l dl)orceJ 0 Slndor
6. COLOR: 0 Du:,y,y 0 Cyanotic
7. -,--- [)C G:J'Jd 0 F:u~.h(j(j [J NalltJec1s
B. _____ 0 P,11e 0 JautldlcNI 0 ~j.rC::.Jmoral
f:' ~~~;'m B g~~~"'y ~u~~~~~~
a TREATMENT IN PROGRESS ON ARRIVAL: DRUG .
o CPR Down Timo min [J Monitor - R1l'/lhrn ___,__ R;l~f)__
o Airway. 0 Oral 0 Nasal- SIze [J Ql'"ygen - 0 M:l$k, 0 ~C. UMlfl___
o Airway. Endotracheal. Size 0 S;::lIflUllmmobJ!lZat1on.
o Airway, Nasotrachcal- Size 0 Masl_______________
o IV _ Solution Site _ Size 0 F'W5sure Dre;,:}!nq 0 01I1e~_
Lung Sounds: Right 0 Ralas 0 Rt>onc;hl rJ Normal Mental Assessment:
o N!A 0 "-'MOZO 0 Ab!;enl 0 Dlrrunl~t,(Jd ~~'AH{d, ~hl
~ e:J Ap;:llopllalo tJ Clo<l:,'SpOnl.1n(Jous
left 0 Aale:> 0 Rtlonctll ,.(::J Normal 0 OIur,lcd,'Ftill [J V3:-luoliJ'~Corlfll:C~Ccl
o Wheeze D Absent 0 Olnufllstwd 0 Dclcn:;IYIl [] Dle,onon!:!Cl
Visual Activity: 0 Appr!!hen!l;.o 0 SlOW 10 An~'MIr
o R05110ssICorl1t..atl.c
00
os
OtJ!A
o With GI<.lq~!!s
o Wll!lout GI;J!:;:,L:~
SING DOCUMENTATION. ~ME"GWCYO[J>AnTM~'n
,.
,: TIlIAOE NOTE
n.,~7Z!-;-'i~.:'l.t.~
o Audible
Wheeze
o RetractIons
Vital Signs:
POX:
Pupils:
Right-Size
Reaclion
left" Size
Reaction
S:r.I~d1
[2"T':'"Of'T,,11/Cluar
[J S,I!!pl
o Till...allv<;:
o HOpullllie
o MurnLJling
~oy:
rJ Inlac1
o Impaired
o Recent
o DiMant Past
Pupil Sizes:
..
1 .
2.
5.
6.
3.
o N/A
Bo~ounds'Abd: lr "air "lOll
~CII"::: 0 n'rl -t"~~r-
o Hypo 0 r~yP\'(..5,:l.Q -- -"
OOuadr:lnts -
DNIA
'"
= INITIAL NURSING REVIEW:
TIME:
D MEDICAL D PSYCHOSOCIAUEMOTIONAL
(/)
ffi'"
Iii
"
>=
z-
w
"
o
PATIENT PROBLEM: Nursing Diagnosis _ Coping, Ineffective _" Mobiiity. Impaired
_ Airway Clearance, Ineffective Fluid Volume, Alterations in: Noncompliance
__ Anxiety = Gas Exchange, Impaired - Sull Care Deficit
_ Breathing Patterns. Ineffective _ Hyperthermia (Fover) = Skin Integrity, Impaired
~ardiac Output, Decreased Infection. Potential Thought Process, AIL in:
../L... ~omfort, Alterations In~ = Injury, Pot~ntial - Tlssuo Perfusion, Alt in:
Communication Impaired Knowledge, Deficit Othor
OUTCOME/GOAL: Expected by Discharge: i1" C~+FCD'j." QL.
-.ll.AI, re~r-J I<Uf'SE'S SIGNATURE
PLAN r- CARE:
o Maintain Patient Airway
o Monitor Cardiovascular Status
o IV 0 BP Monitor
o EKG 0 Cardlao Monitor
o Safety Measures
s.{;J~ 0 Suicide Precautions
o Seizure Precautions
o Side Rails Up
o Comfort Measures
o Pain Control
[2"Positlon for Comfort
[lI'P!.cpare for Exam
[:YgXplaJn Procoduros
~;notjonal Support
[3"Patlont Teaching
o Discharge Instructions
o Other
DOtller
~ Carlisle Hospital
ti' and Health SeJ'\ices
Name of
CONSBNT TO HOSPITAL ADMISSION AND
KBDI L\nIIlNT
Attending Physician (7S)' ~ ~~
Admisoion: I' () i!.t. Time:
.
(AMl_(PM)_
Date of
I, (o~ 7ll
Name or P.UID
consent to rendering of such care, which may include routine diagnostic procedures and ouch
medical treatment as the named attending physician(s) or other of the hospital's medical
staff consider to be necessary.
lr Aulhorind Rtprucolathc
, suffering from a condition requiring hospital care, hereby
acting on behalf of)
2. I understand that the practice of medicine and surgery is not an exact science and
that diagnosis and treatment may involve risks of injury, or even death. I acknowledge that
no guarantees have been made to me as to the result of examination or treatment during this
hospitalization.
3. I understand that:
(A) It is customary, absent emergency or extraordinary circumstances, that no
substantial procedures are performed upon a patient unless and until he or
she has had an opportunity to discuss them with the physician or other
health professional to the patient's satisfaction;
(B) Each patient has the right to consent, or to refuse consent, to any
proposed procedure or therapeutic coursei and
(C) No patient will be involved in any research or experimental procedure
without his or her full knowledge and consent.
4. I understand that many of the physicians on the staff of this hospital, including
the attending physician(s) named above, are not employees or agents of the hospital but,
rather, are independent contractors who have been granted the privilege of using its
facilities for the care and treatment of their patients. Further, I realize that among those
who attend patients at this hospital are medical, nursing, and other health care personnel
in training who, unless requested otherwise, may be present during patient care as a part of
their education. Still or motion pictures and closed circuit television monitoring of
patient care also may be used for educational purposes or for documentation of the clinical
course unless a patient expressly requests otherwise.
5. I release CARLISLE HOSPITAL from all responsibility for all artic~es which I am
retaining or will have with me during my stay at the hospital. I understand this includes
clothing, bridgework, false teeth, eyeglasses, jewelry, money, radio, razor or any other item
kept in my possession. I understand I may deposit valuables in a safe provided by the
hospital; only if this is done will the hospital assume any responsibility for the
safekeeping.
6. I hereby acknowledge that I have received written information on the topics of
Patient Rights and Advance Directives.
Date of Signa:ure:) / ~~:5? r
f~~: ~ttf~r ','
C#~E OF WI"l'NBSS}
(If patient is unable to consent or is a minor, complete the following:)
Patient [is a minor _ years of age] (is unable to consent because] :
{SIGNATURE OF LEGAL GUARDIAN OR
CLOSEST AVAILABLE RELATIVE}
{SIGNATIJRE OF WI~ESS}
AD 0315 (10)91)