HomeMy WebLinkAbout98-06945
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IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
Civil Action - Law
Jacqueline J. Brenize,
Plaintiff
vs.
No. 98-6945
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Michael Lee Mentzer,
Defendant
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PRE-TRIAL MEMORANDUM OF PLAINTIFF,
JACQUELINE J. BRENIZE
I. FACTUAL BACKGROUND
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On March 26, 1998 at approximately 3:34p.m., Jacqueline Brenize was
operating a 1992 Chevrolet School Bus transporting eight students to their homes.
Her daughter, Jamie, was also a student on the bus. While Jackie operated the bus
in a southerly direction on Baltimore Road in Southampton Township, Cumberland
County, Pennsylvania, a 1989 Chevrolet S 10 pickup truck operated by Defendant,
Michael Lee Mentzer, in a northerly direction on Baltimore Road, crossed the center
line and struck the school bus head-on. As a result of the collision, Jackie Brenize
sustained a severe contusion/subtle fracture of the sternum as well as a severe
sprain of the right ankle. Despite her injuries, Jackie Brenize attended to the
children on the bus, evacuating them and attending to their needs.
Jackie and her daughter where taken via ambulance to the Chambersburg
Hospital from the accident scene. While Jamie, her daughter, was treated in the
Emergency Room and released, Jackie was admitted on a 23 hour observation
basis for blunt chest trauma and right ankle trauma. The complete hospital record
from the March 26, 1998 through March 27, 1998 hospitalization at Chambersburg
Hospital are altached and marked as Exhibit A.
Jackie was seen in follow-up by Robert Sheep, M.D., on May 1, 1998. At
thaI. time, he noted that Jackie had "sustained a severe contusion or a subtle
fracture of the sternum and also a severe sprain of the right ankle". He noted that
her right ankle was "diffusely ,swollen" and that she was weight bearing partially on
the right ankle. He also noted that she had some spasm of the neck when turning
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her head to the right. He advised her to continue partial weight bearing and
referred her to Dr. Robertson, an orthopedist. He also advised her that concerning
her sternal contusion, it "may take six to eight weeks to totally subside", She was.to
return to Dr. Sheep on an as needed basis. Dr. Sheep's records are attached and
marked as Exhibit B.
On April 2, 1998, Jackie was seen by Dr. Robertson who noted "significant
bimalleolar swelling, pain, tenderness and ecchymosis". He put Jackie in a short
leg walking cast and anticipated that she would be off work for four weeks. He saw
her in follow-up on April 8, 1998 at which time she was fit with an ankle brace and
was told that she could weight bear as tolerated. Her second follow-up was AprjJ
28, 1998 at which time the exam revealed excellent range of motion but mild
weakness, She was authorized to return to work on May 4, 1998 and to follow-up
as needed. Dr. Robertson's records are enclosed and marked as Exhibit C.
Lincoln General Insurance Company, the workers' compensation carrier for
Jackie Brenize's employer, Lee McBeth & Sons has paid medical bills of $2,223.64
and wage loss of $815.50 for a total subrogation claim of $3,039.14. In addition,
Jackie Brenize's unreimbursed wage loss is an additional $420.05,
The recovery period for Jackie Brenize was especially difficult in that her
husband, Michael R. Brenize, was killed in a motor vehicle accident approximately
one month prior to the accident which is the subject of this action. Jackie Srenize
recently widowed with three minor children, was having a difficult enough time
raising her family while ambulatory. Being unable to drive and weight bear lor a
substantial period of time made this situation even worse.
II. LS~!JE OF LIABILITY
Apparently, Defendant is willing to admit negligence.
III. EVIDENTUARY ISSUES
Defendant will raise the admissibility of the death of Plaintiff's husband one
month prior to the action which is the subject of this action.
IV. WITN.E.S.sJ:_S
V. Jacqueline J. Brenize
1015 Heritage Road
Shippensburg, PA 17257
Michael E. Mentzer
.,
LAWOIfICn
OILO't:TO. CDM:IllNQ
I. 601 HOffl PC
330 [JHCOlfri WAY (ASr
PO 8OJ(1lb6
CHAM!lrRSBURG, PA 17:'01
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RogerJ. Robertson, M.D.
Cumberland Valley Orthopaedic Associates
120 North Seventh Street, Suite 101
Chambersburg, PA 17201
Jamie Srenize
1015 Heritage Road
Shippensburg, PA 17257
Jack Kelley (father of Jacqueline Brenize)
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V. J,.IST OF EXHIBITS
1. PhotOg/ilphs of the vehicles,
2. Medical records from Chambersburg Hospital.
3. Medial records from Robert E. Sheep, M,D.
4. Medical records from Roger J. Robertson, M.D.
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VI. SETTLEM!;NT
With clear liability involving a head-on collision with a school bus full of
children, a fractured sternum and severely bruised ankle to a recently widowed
mother of three, provable medicafs and wage loss in excess of $3,000.00, Plaintiff
demanded $15,000.00 in full settlement. Defendant offered $6,000.00 as a first and
final offer and has refused any negotiation.
VII. ESTIMAT!;P LENGTH OF TRIAL
One day.
Date: October 19, 1999
Respectfully submitl,l3d,
DILORETO, COSE(ITINO &
(BO.I..!N. G. i\.p~
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By . , . , . ,
P lip S. G<)sentino....----.
Attorney: for' Plaintiff
Attorne}l.I.D. '#30076
330 Lincoln Way East
P.O. Box 866
Chambersburg. PA 17201
(717) 264-2096
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THE CIiAMBERSBURG HOSPITAL
Department of P,lthology
Name: BRENIZE. JACQUELINE J
Diagnosis: (UNKNOWN DIAGNOSIS)
PJlYsician: SHEEP, M.D. ROBERT E.
Phone#: 263-1211 OR EXT 7479 HOME263-
Account#: 204918
Age: 36Y
Sex:F
Medical Record: 306099
Room: 028,1-02
Admitted: 03/24/98
Discharged: 03/24/98
**...**...***..........*............ COMPLETE BLOOD COUNT ..*.**.........~..........*...*......
DAY.
DATE.
TIHBz
LOC.
2
03/25/98
+0602
2WT
1
03/24/98
1715
ECO
NORMAL
WITS
_________________________M________________________________________________.____________________
wac
RBC
HGB
HCT
MCV
MCH
MCHC
RDW
PLATELET
MPV
6.4
4.11
13.2
39.6
96 R
32.1 R
33.3
12.0
131 L
10.2
DIFFERENTIAL
DIFF METHOD
NEUT
LYM
MONO
EOS
BASO
AUTOl1ATED
63.5
25,6
9.6
1.1
0.2
9.3
4;52
14.4
42.g
95
31.9
33.6
12.0
163
10.2
4-11 K/CMM
4.10-5.10 M/UL
12.3-15.3 G~l\
36-45 \
85-95 CUMIC
27-32 MMG
32-37 \
lSO-400 K/CMM
AUTOMATED
77.8 R
16.1 L
5,4
0,4
0.3
40.0-70.0
20-40
0-10
0'.10.0
0.0-2.0
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CONTINUED
Page:l INPATIE:NT MEDICAL RECORDS COPl', DO NOT REMOVE
Name: BRENIZE, JACQUELINE J
03/25/98
22:00
}I?OM THE MEDICAL REMedi c.sl Record:
Location:
Room:
306099
2k"l'
0284-02
THE CHAMBERSBURG HOSPITAL
Department of Pathology
Name: BRENIZE, JACQUELINE J
Diagnosis: (UNKNOWN DIAGNOSIS I
Physician: SHEEP, M.D, ROBERT E.
Phone#: 253-1211 OR EXT 7479 HOME203-
Account#:2049l8
Age: 30Y
Sex:F
Medical Record: 305099
Room: 0284-02
Admitted: 03/24/98
Discharged: 03/24/88
........._............................... URINALYSIS ..........................................
OATIl.
TIME.
LOC.
03/25/88
+0344
2WT
03/20/88
0616
ECU
NORK.\L
WITS
~----------------------------------------------------------------------------------------------
TYPE Cr,EAN CATCH CLEAN CATCH
COLOR YELLOW YELLOW
CIlARACTER HAZY HAZY
GLUCOSE NEGATIVE NEGATIVE IIEG MG/DL
BILE, NEGATIVE NEGATIVE NEG
KETONES NEGATIVE NEGATIVE NEG MG/DL
SPECIFIC GRAVITY 1.022 1.025 1.003-1.026
BLOOD NEGATIVE LARGE .. NEG
PH 7.0 5.5 5,0-8.0
PROTEIN NEGATIVE TRACE .. NEG MG/DL
UROBILINOGEN 1.0 0.2 0.1-1.0 EU/DL
NITRITE NEGATIVE NEGATIVE NEG
LEUKOCYTES SMALL .. NEGATIVE NEG
WBC'S 5-10 0-5 0-3
RBC'S 0-5 NUMEROUS 0-3
EPITHELIAL CELLS 1+ 1+
BACTERIA 1+ .. TRACE .. NONE
MUCOUS 2+ 1+
YEAST PRESEN"I' .. NONE
\
Dm Of' REPORT
PSge:4 INPATIENT MEDICAL RECORDS COPY, DO NOT REMOVE f'ROM
Nue: BRENIZE, JACQUELINE, J
03/25/90
22:00
THI: MI:DICAL Rmedicsl Record:
Loc.stion:
Room:
3050H
2WT
0284-02
Name: TAYLOR, TAMMI
Diagnosis: (UNKNOWN DIAGNOSISI
Physician: ORNDORF, RASCHID & ASSOCIATES
Phone#: 127 261 1975
TilE, CIIAMIJERSBURG HOSPITAL
Department ot Pathology
Account#: 104541
Age: 19Y
Sex:F
Medical Record: 469099
Room: 0575-01
Admitted: 03/23/98
Discharged: 03/25/98
.................................... COMPLETE BLOOD COUNT .....................................
DAY.
DATB.
TIMllI
LOC.
2
03/24/98
0610
SOBS
1
03/23/98
0835
SOBS
NORMAL
..--------..-----------------------------------------------------------------------------------
tJNITS
WBC 11.0
RBC 4.23
HOB 10.5 to 11.0 to
Ht.'T 33.1 to 34.8 to
MC'J 82 to
MCM 26.0 to
Mt.'HC 31.6 to
RDW 14.0
PLATELET 141 to
MPV 10.3
DIFFEREm'IAL
DIFF METHOD DEL
MOO
MANUAL
BAND 1
NEU'I' 86.1 H
81
LYM 8.9 to
18
MONO 4.7
0
EOS c.~
0
BASO. 0.1
0
RllC MORPHOLOGY 1+ A1llS0
1 + MACRO
PLATELET ESTIMATE sOle ..
"-FOOTNOTES-.. \
DEL REQUEST CREDITED
MOO I'.ANlIAL DIFFERENTIAL ORDERED
SOEe SLT DECREASED
4-11
4.10-5.10
12.3-15.3
36-45
85-95
27-32
32-37
150-400
O-!.l %
40.0-70.0 \
20-40 \
0-10 \
0-10.0 %
0.0-2.0 %
NORM
ADEQ
Pagell INPATI!:NT M!:DICAL
flame: TAYLOR. TAMMI
0J!25/98
':-::00
END OF' REPORT
RECORDS COl'I', DO NOT RE:MOVE FROM TilE: MI:DICAL RF:Medical Record:
Location:
Room:
K/CMM
M/UL
GM%
%
CUMIC
MMO
\
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469099
SOBS
0575-01
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CHAMBERSBURG
HOSPITAL ChlmbM~U,"A
An a6i'jglt ,,{Summi' IIcullh
CONSENT
BRENIZE. JACQUELINE.
204918-7
MRII
03/24198
FOR EXAMINATION, TREATMENT, AND PROCEDURE
Patient Name:
Account #:
Mod Roc N:
Admit Date:
I agree and give my consent to any examination, treatment or procedure that the attending physician or hislher assistants may
deem necessary or advisable during my stay or visit in this Hospital, It is understood Ihat this consent does not include operations
or surgical procedures which might be round necessary. If such operations or surgical procedures are required during my
hospitalization/visit, I understand that I wiil be asked to give specific consent.
, .
"-
Depr,
Patient Signature
OR
Authorized Person'
I
Witness
Relationship to Patient'
Date
. When a patient is a minor, incompetent. or unable to sign. the signature of the person authorized to give consent is required.
AUTHORIZATION FOR RELEASE OF INFORMATION & ASSIGNMENTS OF BENEFITS
I authorize The Chambers burg Hospital to release such information as may be necessary for the comple!ionof insurance claims
relative to this hospitalization visit.
I understand that the Hospital or my physician may disclose and release all or any part of my medical record to any person or
corporation which is or may be liable under a contract to the Hospital or physician, or to the patient or family member or employer
of the patient, for all or part of the Hospital's charge or physician charge, This includes, but is not limited to, hospital or medical
servico companies, insurance companies, workmen's compensation carriers, 'welfare funds. or the patient's 'Cmployer.
I hereby authorize payment directly to The Chambers burg Hospital for the hospital benefits otherwise payable to me, but not to
exceed the Hospital's regular charges for this pr.riodof hospitalization, I understand that I am financially responsible to the Hospital
for charges nc,t covered by this assignment. I assign the benef.ts payable for physician services to the physician or organization
furnishing the services for the physician to submit a claim for me.
If cov'ercd by MedicClle, 1 ce-rtify that the !r:!crm3t!cn s!ven by !TIt:!' in applying for payment under Title XVIII of the Social Security
Act is correct. I request payment of authorized Medicare benefits for me or on my behalf for any services furnished to me, by or in
the Hospital (including physician services' to be made to The Chambersburg Hospital, I authorize any holder or medical and other
information about me to be released to Medicare and its agents as needed to determine these benefits or beMfits for related
se"';ices., I assign the benefits payable for physician services to the physician or organization furnishing Ihe services for the
physician to submit a claim to Medicare ror me. I understand that I am financially responsible to the Hospital lor charges not
covered by this assignment. .
If covered by Medical Assistance, I certify that the information I have provided is true, e,orr.ct, and accurate. I understand that
payment and satisfaction of this claim will be from Fed",ral and State funds, and that any false claims/statement/documents or
concealment of material facts may be piosecuted under applicable Fede..1 and Stale laws.
''''~~ "00".' 'I f}-o,J4/(:; It;"',
Provider: The Chambers burg Hospital
Authorized Person
Relationship to Patient
If covered by Medical Assistance. I understand that 1 am linancially responsibla lor .ervice. performed thaI ara IlQt allowable under
my Medical Assi.tance coverage.
Signature
All AUTHORIZATIONS MUST BE SIGNED BY THE PATIEN1' OR BY AN AUTHORIZED PERSON IN THE CASE OF A
MINOR OR WHEN A PATIENT \5 f*iiV5iCAlt"j' un i"ENiAttY ;::CCMPETE.",fr.
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The Chambers burg Hospital
MEDICATION ADMINISTRATION RECORD
"';,:. L,NUMllE~';" '. AGE,.ISExIHEIGHH\lEIGIi1'i;:'{: ':':":< h:MIS:';
I 2049187 36Y IF I 62 -10 1205
PHYSIC1AN:\': ,:\.',..'\."'i.,\:'..',..:,,:1 FROM: 03/25/9807:00
I SHEEP MD E. ROBERT E TO: 03/26/98 06:59
I ~ NWM.A.R.VEAlfICATlON
OAT~ SICNATURE ~
'....::'SHIfTVEmFle...nON:'. :," "",.:.!N.....,.".,
7;OO.15:OO,'^ 15:01.23:001 23:01,6:59
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0284-02 I BRENIZE. JACQUELINE J
MULTIPLE TRAUMA 23 HR
... SCHEDULED".
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BRENJZt:.,"''''I;QUElINE J 20491S1 3!JG099
TPAGE
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ALLERGIES
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tlEW M,AR VERIFICATION
.._ SIGNATURE
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15:01-23:001 :;", 23:0;~':59
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: NUMBER '.
__..,,_c_"~.,.__
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PAGE
fl03$10-'
(
*Record date and one of the following codes:
DcP=Discussed with Patient
DcF=Discussed with Family
U =unconscious
C =Confused
o =Other - explain on Patient Progress
I ,
jInit!Signature
I '
, I
I r"J ~? r.J C~/'--
Notes .-
MIS ADM. DIAGNOSIS: MULTIPLE TRAUMA
,
DATE NURSING DIAGNOSIS; DATE EXPECTED OUTCOME DATE DATE
& COLLABORATIVE & *DcP ACHIEVED
INIT PROBLEM INIT . & INIT .
,
5-~ I Pain '\,~v' ' Express change in nature ot pa:r11 J-;::i
"" ~I ""1/ within 60 minutes of pain medicat10n. "'fIT
I .
I R/T Multiole lriiuri s .,'
I , .
. ,
,
lmpairea Sk.in lntegrlty :,now t1ssue neal1ng as " ~)' llV
signs or 1nrect10n/hemorrnage QUr1ng
LOS. ,
: R/T AYrasions ana
i Lacerations , ,
I ' ,v ';o-,r{lj,fl'
- whireDii
I A1.ered Mobilitv Maintain ROM to tolerance ,
i bedrest. I
-
, , i
I RtT Bedrest and Ambulate to level of tolerance by I , ,
i Trauma discharge. I
--
, I
, Potential Altered Bow 1 Have active bowel sounds dailv.
, , Elimination ,
I
i
:
I RtT ' tmmobilitv Have soft formed brown stool at least ,
.; , ever~- 3 dav..,
.. .)..... /;' 1'-/...;- ""~. - ,
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RN REVIEW DOCUMENTATION I
..r;...' ..
/3 2l. op . . . DATE DATE
-- 281,-2 .' REV RN SIGNATURE REV RN SIGNATURE
--
, ,
2"'1l'='lC -, 03/24/9~
...,. ' - : ';;UO:H9
~"(/UE. JAC_U( II 'I[ J F
20 ,1(H.dLT(~ AV (:lU L 1 L -;:
slit~P(;SBl'RG, Pi 17257 I
C41Z4/bl 3b1 7 I 7 532-412 : .
. I ,
S~((P HD ( I R05i:~T ( ~-i5 . .~ -I
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THE @AMBERSBURG HOSPITAL
NURSING DIA~NOSIS/EXPECTED OUTCOME FORM
p 036~5 - 28
('
I. MENJiAL STATUS: (check one),
l Alert and Oriented
Other (specify)
II. PHYSICAL STATUS: (assess according to diagnosis)
-< ~'" fh..u, J\ ,.r~ ....A-J
III. ACTI'fl!!..iTATUS: (check one)
rA;bulato/)' Ad Lib
/ Ambulato/)' with help
i
Other (specify)
Stretcher
Other (specify)
-
..;,)/
13 21. o(l
/1'OI~charge Home
( ~;ue Sheet Signed
'<.1: ,> :,~, ,,:,::,:..,..,'.'::.",.',,":',":,'>" '.; i":"":)"":":'-"';:""~:::':':-'::":'" > ..',:,:.:...., ~~:!~'.':'::~' : :'.
IV. MODE OF DISCHARGE: (check one) /
Ambulato/)' Wheelchair
V. PATIENT ACCOMPANIED BY: (ct1€ck where applicable)
Family J Volunteer Nursing Staff
VI. EXPECTED OUTCOME REVIEW:
EXPECTED OUTCOMES/NOT ACHIEVED'
ACTION TAKEN
It...".- c,
[."",,""'
:IND1CATE 'NONE'IF ALL ACHIEVED
R.N. SIGNATURE:
~~d{f/ -
<H
THE CHAMBERSBURG HOSPITAL
t 12 North Se\'rnth Stfl'{'l' P.o. &.. IS7' Ch.am~",burg. Prnn.)'lvanil 17201 . (717) :M.!i111
PA!~~~T DISCHARGE SUMMARY
2"'.< 2
u', -
20 If ..... 1::; -: 03 i <' 4 / ,;, :\ R.3 () , H 9
B 1 ( '11 l E. " Lee u r l I ~ l J r
20 ~ICH~lLrER l~E~UE lL-~
SHIi'i'E(~BUkG.PA 17251 .
,04/Z4H I Hr 11 1 532-41 Z I
SHEEP foO E. ROSERT E S-75
) Discharge to
( ) E,C,F. (
( ) Another Hospital (
()AMA (
..)t~-'9 q? at
Date:
,~
"."
,,:....1'
) Psych
) Rehab
) Other (specify)
A.MJP,M,
,.
,
('
,Date Instr. Readines! Focus Content Media Learning Initials
3iven Document Specific Conlentlaught or
to "A" = see Patient Progrest Notes c: Ol c:
for further documentation 0 c: ,2
:;: U '5 ~
.. or reason teaching was c:
~ , u 2 oS ';;j
not accomplished. - ';;j u, c: l
'" " ::I ~ 0
'0 ,2; ~ 0 c: III
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0. c: ~ " Rarer to Admission Atsessment fonn for learning '0 0.
- III \ll C '" \ll , c: '" '"
\ll ,2; Z '" '" - .2 e: c: needs assessment. :> l!! ::I ::J C 0:
.2: u III E ::I 13 ~ \ll - ii! e
'E 0. .. <II '" '0 \ll .0 .2 c: ~ '0 E <II
Ol w 0: .. a. 1l :c III "This form is not used for leachillg associated with 0 ~ 1l 'tt
.91 '" fl '5 ,r; ... "
'2 \ll '5 t: ,C 'c, i5 III
.. ~ '5 .. 0 "5 $ '0 a;
Time .. \ll \ll r:r - \ll ~ \ll >- clinical pathways. ~ '0 '"
Q. U 0: C z i5 w Q. ::E 0: Z :I: , , ::J .5 > a: z
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INITIALS SIGNATURES INITIALS SIGNATURES INITIALS SIGNATURES
1"A t.l (");,.A c../.;;:;-
, - , , -
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O'A\\BlRSllURG HosrnAL
011 S 1 S .., OJIZ4/9~ . ro_J......'lO".
, ~R3JJ019 Oi.I."t....wuf1L.""l:'111I...)Ji .
. INTERDISCIPLINARY PATIENT
bH!IZt. JlCCUfL I ~( J r An ~fJi.li<JI" .?f Sfjlflll.it IItal,"
20 ,11 CHwH TO H(~U( 1L-~~ EDUCATION RECORD
SHIP!'E~Sllll!lC. PA I 72S j
04/H/bl Hi 71 7 S32.4121
SHEEP ~O ( . QOH RT ( ... ~
S - is ' roOOl9 (0:lI911
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CHAMBERSBURG, PA
24-HOUR PATIENT CARE PLAN NURSING RECORD
MED/SURG
CHAMBERSBURG
HOSPITAL
A.~II/fIlIAI'D/S_,'H''''I~
3;;.". 3hJ-
Date: 3:00 p.m. _ to 3:00 p.m.
ASSESSMENT: Idrcle one) Points
Initial admission assessment (signature),,,,,,,,,, 0
y,... A ~3~
update/revise assessment (signature) ".:".".", ~'11 ,
_7-3
PLANNING: ldrcle one)
Initial care plan development."".""."""""....., 0
Care plan update/revision .. daily,,,,,..,,,,,,,,,,,,, <f;
ldrcle one)
Rounds Q. 30 min, .""""."",,,.,,.,,,,,,.,,,,,,,,,,,..,, 9-
Rounds Q, 1 h, "."",,,,,.,,.,,,,,,.,,,,,,,,,,,,,,,,,.,,,,,,,,, {j/
IMPLEMENTATION:
LEARNING: lcircle as appliell
Planned teaching lextensive)""".""....,,,,,,,,,..,, 9
Daiiy routine teaching"".."""".""",..",,,,,,,,,.... (jI
Coping: lcircle as applies)
Emotional support (extensive) """,....,,,,,,.., 11
l.11 11,7 ).l
NUTRITION: () /,;'"\r~
Diet and appetite percentage ,.. ,,,,,,,,t1', ,..",,"\.V ~
Dinner: D,et %
Breakfast: Oiet -1"..L.l.!4..% 0k
Lunch: Diet -~ [ %
Feedings: Type ... Time
(circle as apply) ,
N,P.O./feeds self """.""".""""""""""""."""..G
Feeds self with help.""".".".".""",,,,,,,,,,,,,,,,,,, 5
Total feeding by personnel.."".""."."."",,,,,,,, 13
Continuous tube/gastric feeding"""".."""..." 4
ELIMINATION: ldrcle as apply)
Toilet without help"..".""""".."",,,..,,,,,,,,,,,,,,,, 0
1&0 .",."".""."."""",,,,.,,,,,,,,.,..,.,,,,.,,,,,,,.,...,,,.,.. 1
BRP with help/bedpan/B,S.C. .",,,,,,,.,,,,,,,,,.,,.,, 7 ....\
Toilet with constant supelVision ."."",,,,,,,.,,,,,, 10
Incontinent care,,,,,.,,,,,,,,,,,.,,,,,...,.,,.,,,,,,.,,.,,,,,,. ~~~
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(circle as apply) Points 3,11 1.7 ).l
Bathes self """"""""""""""...."""".".".".".,," 1
Assisted self. batt) with H5 care """",,,,,.,,..,,,,,, (}I
Bathed by staff with HS care"""""""""""""" 4
Special mouth care """"",,,,,,,,,,,,,,,,,,,,,,,,,,,...,,. 5
MOBllIlY: (circle as apply)
Ambulate/chair /bedrest without assistance ," 0
Ambulate/chair with assistance
(2.4 times/day)""""""".."""""""",,,,,,,,,,,,, 6
Bedrestlchair/turn Q, 2 h, when in bed "".",,(5
ROM Q, 4 h. ,,,,:,,,,,,,,,,,,,,....,,,,,,,,,..,,,,,,,,.....,,,,,,,, 3
Two assists required for elimination/
hygiene/mobilitY", .."..', ""'" ".. ,.... ,,,...... '..,.. 4
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Neuro/neurovascular /Iami checks
(1.4 times/day)"......,,,..,.. ",,,,,,,,,,,,..,,,'..'..,,,, 2
Neuro/neurovascular/lami checks
(q, 2,4 hl.,.........,..,...."""......&
Daily weights .......... ...., "............,....,.........,..' 2
Dialysis weights ,......,..,......,............,..,........,,,.... 3
Blood glucose monitor (1.4 times/day)......,.." 2
8ruitldorsiflexio" checks..."........"..""..,,,..,,..,, 0 r::=rJn
I
TOTAL POINTS .........""....,..".""".."...."."".
TOTAL POINTS (from back) "....".".."....,,,,,,,
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GRAND TOTAL ""..."".",............"",....."".."."
SICNA lURE
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NEUROVASCULAR ASSESSMENT SHEET
CHAMBERSBURG, PENNSYLVANIA
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BRENIZE. JACQUELINE J
Acctll: 204918-7
MR II: 306099
Date" 03124/98
DOB/AGE: 04/24/61 3GY
<H ~~~"~~~~~~:.~~}~~~~~;,
PATIENT
PROGRESS NOTES
0: 10166
R: 6i95
P04265
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SIGNA U ESi1N1T1ALS 1',-\1,
CODES FOR TUBING AND CAP SITES A "ii~SSIW'- 1N111ALS 1N1 51 ,NATURE, IN11 SIGNA U ;/"
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1 - Standard Muhilumon N,5.L, . Nenn.1 'f
2 - Add.A.Lilo O.DiGla1 SalinoLock
3 - elood S<lt M.-Mocftal SG - SWlln Ganl r
4-Burotrol P - Proximal A-Aux, POI1 i\i
B-Broviae S - Sheath PeR ,
G - Graohong
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& VOLUME ADDED l 01SCAAOEO SITE FLOW MlT, S
TIME SITE SOLUTION NURSE RATE TUBING NURSE PUMP NURSE'S INrr. DATE SAT1SF, TIME RATE LEFT NURSE , .
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BRENIZE. JACQUELINE J ,
<M ~~;~'::~~~~~~~~7~~~:~~ I
ACCI #: 204918-7
MR#: 306099
Dale: 03/24/98
. DOB/AGE: 04/24/61 36Y
I.V. Therapy Record
O:~1'
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'~
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CHAMBERSBURG HOSPITAL
Department of Pathology
(717) 267-7154
03/25/98
21:00
NAME:
HII
ACCT:
BRENIZE,
306099
204918
W24628 COLL: 03/25/98 06:02
, ,
INTERIM REPORT
PAGE: 2
AGE: 36'.
SEX:F
REC: 03/25/98 06:07 PHYS: SHEEP, M.D, ROBE:
JACQUELINE J*," PATIENT DISCHARGED .. *
LOC: 2WT (D ROOM: 0284-02
DR: SHEEP, M.D, ROBERT E.
DR: ZUROvJESTE", M. D., EDW
================= PHYSICIAN COPY FOR DR: SHEEP, M.D, ROBERT E. ==============
CARDIAC PROFILE (CONTINUED)
'MAGNESIUM 1.8 [1.8-2.4J MGIDL
LIVER FUNCTION TEST
GPT L 7 [10-60] IU/L
ALK. PHOSPHATASE L 38 [42-121J IU/L
BILIRUBIN, TOTAL 0.8 [0.2-1.2J MG/DL
BILIRUBIN,DIRECT 0.1 [O.0-0.2J MG/DL
ALBUMIN 3.5 [3.2-5.5J G/DL
GAMMA GT L 6 [7 -64 J lUlL
GOT 14 [10-42] lUlL
HEMOGRAM
'WBC COUNT 6.4 [4-11] K/CMM
RBC COUNT <1.11 [4.10-5,10J M/UL
HEMATOCRIT 39.6 [36-45] %
HEMOGLOBIN 13 .2 [12.3-15.3J MG/DL
MCV H 96 [85-95 J FL
MCH H 32.1 [27-32 ] ~U.lG
MCHC 33.3 [32-37J %
RED CELL DIST. WIDTH 12.0 %
AUTOMATED PLATELET L 131 [150-400J !{/UL
MEAN PLATELET VOLUI1E 10.2 FL
AUTOI1ATED DIFF
DIFF METHOD AUTOMATED
AUTO LYMPH % 25.6 [20-40] %
AUTO MONO % 9.6 [0-10] %
NEUTROPHILS 63.5 [40.0-70.0J %
EOS 1.1 [0-10.0] %
BASO 0,2 [O.O-:LOJ %
W,~R 2 ~ ~\99t)
BRENIZE,JACQUELINE J
MR: 306099
PAGE: 2
03/25/98
21:00
,-,,'
03/25/98
21:00
'-'
CHAMBERS BURG HOSPITAL
Department of Pathology
(717) 267-7154
INTERIM REPORT
PAGE: 1
JACQUELINE JB' p;\'rIENT DISCHARGED B'
LOC: 2WT (D ROOM: 0284-02
DR: SHEEP, M.D, ROBERT E.
DR: ZUROWESTE, M.D., EDW
================= PHYSICIAN COPY FOR DR: SHEEP, M.D, ROBER'l' E. ==============
NAME:
H#
ACCT:
, BRENIZE,
306099
204918
W24661 COLL: 03/25/98 03:44
URINALYSIS SCREEN
TYPE
COLOR
CHARACTER
GLUCOSE
BILE
KETONES
SPECIFIC GRAVITY
BLOOD
PH
PROTEIN
AGE:36',
SEI::F
REC: 03/25/98 03:45 PHYS: SHEEP, M.D, ROBE,
CLEA."J CJl.TCH
YELLOW
HAZY
[NEGJ MG/DL
NEGATIVE
[NEG]
NEGATIVE
[NEG] MG/DL
NEGATIVE
1.022 [1.003-1.026]
[NEGJ
NEGATIVE
7.0 [5.0-8.0J
[NEG] MG/DL
NEGATIVE
1.0 [0.1-1.0J E.U./DL
[NEG]
NEGATIVE
SMALL [NEG]
UROBILINOGEN
NITRITE
LEUKOCYTES
URINE MICROSCOPIC
WEC'S
RBC'S
EPITHEAL
BAC'rERIA
MUCUS
**
**
5-10
0-5
1+
1+
2+
W24628 COLL: 03/25/98 06:02
[0-3 ]
[0-3]
[NONE]
/HPF
/HPF
/HPF
AMYLASE
41
REC: 03/25/98 06:07 PHYS: SHEEP, M,D, ROBE,
BASIC METABOLIC
GLUCOSE'
BUN
CREATININE
SODIUM
POTASSIUM
CHLORIDE
TC02
ANION GAP
PANE
H
112
8
0.8
140 '
3.8
111
26
3
L
CARDIAC PROFILE
CPK
CKMB (ASBOTTAXSY}I)
[25-125]
[70-110]
[6-20 ]
[0;5-1.2J
[135-145J
[3.6-5.0]
[101-111]
[21-31]
[5-15J
91 [22-269J
10-6J
NOT INDIC,....TED
BRENIZE,JACQUELINE J
MR: 306099
IU/L
~lG/DL
I-lG / DL
MG/DL
Il'H/L
Il'H/L
m11/L
mH/L
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PAGE: 1
03/25/98
21:00
Exhibit C
: "s\' /,/?:'
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AND NOW, thisaiAay of February, 1999, J hereby certify that I have
served the foregoing Answer on the following by depositing a true and correct copy of
same in the United States mails, postage prepaid, addressed to:
Mr. Philip S. Cosentino, Esquire
DiLORETO, COSENTINO & BOLINGER PC
330 Lincoln Way East
P.O. Box 866
Chambersburg, PA 17201
~~~~
James G. Nealon, III, Esquire
Dated: oa ld.-lR /QC1
, ,
.... ,~. ,'.,:~'''~1~~~~~';~'::~\~'\~.." "'."..r.-...;,....~-,~"..'.~.', '-'~,'~,;<,' :",,;-': .~l~.;.~~:~-',:~'~.,~'...~~.....'. ~.';:~, ", '.' .': .'~ ',': ,', ....> \"
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JACQUELINE J. BRENIZE,
Plaintiff
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNA.
II.
NO. 98-6945
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MICHAEL LEE MENTZER,
Defendant
CIVIL ACTION. LAW
JURY TRIAL DEMANDED
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NOTICE
TO: Lincoln General Insurance Company
You are required to complete the following Certificate of Compliance when
producing documents or things pursuant to the Subpoena.
CERTIFICATE OF COMPLIANCE
WITH SUBPOENA TO PRODUCE DOCUMENTS OR THINGS
PURSUANT TO RULE 4009.23
I, Records Custodian for Lincoln General Insurance Company, certify to the
best of my knowledge, information and belief that all documents or things required to be
produced pursuant to the Subpoena issued on
have been produced,
DATE:
Records Custodian