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HomeMy WebLinkAbout07-1765MICHELE POSSENTI AND KEVIN TALHELM . AS PARENTS AND NATURAL GUARDIANS OF PAIGE TALHELM, A MINOR, JACK TALHELM, A MINOR AND SAMUEL TALHELM, A MINOR Plaintiffs v. VICTOR YANTAS LEON Defendant IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNA. DOCKET NO: d ''r -~~-(~ PETITION FOR COURT APPROVAL OF MINORS' COMPROMISE PURSUANT TO Pa.RC.P. 2039 AND NOW, come Petitioners, Michele Possenti AND Kevin Talhelm, as parents and natural guardians of Paige Talhelm, a minor, Jack Talhelm, a minor, and Samuel Talhelm, a minor; and Victor Yantas Leon, by and through his counsel, Dickie, McCamey & Chilcote, P.C., and Petition the Court for Approval of Minors' Compromise as follows: A. THE PARTIES 1. Michele Possenti, a parent and natural guardian of Paige Talhelm, a minor, Jack Talhelm, a minor and Samuel Talhelm, a minor, resides at 113 Woodview Drive, Mount Holly Springs, Cumberland County, Pennsylvania, 17065. 2. Kevin Talhelm, a parent and natural guardian of Paige Talhelm, a minor, Jack Talhelm, a minor and Samuel Talhelm, a minor, resides at 7 Todd Road, Carlisle, Cumberland County, Pennsylvania, 17013. 3. Paige Talhelm, a minor, being born on November 02, 1991, resides at 113 Woodview Drive, Mount Holly Springs, Cumberland County, Pennsylvania, 17065, with her parent, Michele Possenti. 4. Samuel Talhelm, a minor, being born on September 15, 1997, resides at 113 Woodview Drive, Mount Holly Springs, Cumberland County, Pennsylvania, 17065, with his parent, Michele Possenti.l 5. Jack Talhelm, a minor, being born on January 10, 1999, resides at 113 Woodview Drive, Mount Holly Springs, Cumberland County, Pennsylvania, 17065, with his parent, Michele Possenti. 6. Victor Yantas Leon, the tortfeasor, resides at 6166 Liberty Island Road, Dixon California, 95620. 7. At the time of the subject motor vehicle accident, Victor Yantas Leon was the operator of a motor vehicle covered under a Farmers policy of motor vehicle insurance at policy number 95 16827-00-58. A true and correct copy of the applicable Farmers Declarations page is attached hereto as Exhibit "A." 8. The Farmers policy of motor vehicle insurance at policy number 95 16827-00-58 provided for liability limits in the amount of $15,000 per person and $30,000 in the aggregate. Exhibit "A." 9. This matter has been resolved short of litigation and no filings have been made with this Court prior to the filing of the within Petition. 10. Petitioners, Michele Possenti and Kevin Talhelm, on behalf of their minor children, are not represented by counsel. 1 Samuel Talhelm is aurisric. 2 B. THE ACCIDENT 11. On or about June 26, 2005, Michele Possenti and her minor children were in Sacramento, California, visiting family. 12. On or about June 26, 2005, Michele Possenti and her children, while passengers in a vehicle operated by Petitioner's sister, Melinda Page Sassman, were involved in a rollover- type motor vehicle accident with Victor Yantas Leon, the operator of a vehicle owned by Carlos Yantas Leon, on US 50 East, Sacramento, California. A true and correct copy of the Traffic Collision Report relating to this accident is attached hereto as Exhibit "B." 13. Within the Sassman vehicle were a number of passengers, including Melinda Paige Sassman (4/25/1966), Jordan Sassman (9/4/91), Paige Talhelm (11/2/91), Jack Talhelm (1/15/99), Samuel Talhelm (9!15!97) and Michele Possenti (12123!63.) 14. Leading up to the accident, Victor Yantas Leon, attempted to pass the Sassman vehicle, resulting in a rollover-type collision. Exhibit "B." 15. All persons within the Sassman vehicle sustained injuries to varying degrees.2 16. Liability for this accident is not disputed at this time. 17. At the time of the accident, Victor Yantas Leon did not maintain his own policy of motor vehicle insurance. 18. Neither Victor Yantas Leon nor Farmers Insurance object to this Court's jurisdiction over the minor's compromise. 1. Paige Talhem 19. Paragraphs 1- 18 above are incorporated by reference as if fully set forth herein. z Melinda Sassman sustained injuries and is still under treatment. Jordan Sassman sustained injuries, including to her finger. Michele Possenti sustained injuries to her ribs, right shoulder/rotator cuff and injury throughout her back. Michele Possenti was required to wear a sling for two weeks. Michele Possenti does not have medical insurance and has approximately $16,000 in outstanding medical expenses. 3 20. As a result of the aforementioned accident, Paige Talhelm sustained injuries to her arm requiring debridement surgeries and follow-up care. All known medical records relating to Paige Talhelm are attached collectively hereto as Exhibit "C." See also, photographs attached hereto as Exhibit "D." 21. Paige Talhelm has resulting scarring that may require plastic surgery in the future. 22. She also underwent some psychological counseling. 23. Paige Talhelm is not currently under treatment. Exhibit "E." 2. Jack Talhelm 24. Paragraphs 1- 18 above are incorporated by reference as if fully set forth herein. 25. As a result of the aforementioned accident, Jack Talhelm treated at the UC Davis ER with one follow-up visit with his family physician, Dr. Holly Hoffman, for minor bumps and bruises on his left side. All known medical records relating to Jack Talhelm are attached collectively hereto as Exhibit "F." 26. Jack Talhelm no longer receives medical treatment and is fully healed following this accident. Exhibit "E." 27. There are no activities that Jack Talhelm cannot perform at this time because of injuries sustained in this accident. 3. Samuel Talhelm 28. Paragraphs 1- 18 above are incorporated by reference as if fully set forth herein. 29. As a result of the aforementioned accident, Samuel Talhelm treated with ER, was admitted for less than a day and underwent diagnostic studies because he was non-verbal 4 and therefore could not voice complaints to treating physicians. All known medical records relating to Samuel Talhelm are attached collectively hereto as Exhibit "G." 30. Samuel Talhelm's injuries consisted of bumps and bruises across the mid- section from a seatbelt. Exhibit "G." 31. Samuel Talhelm no longer receives medical treatment and is fully healed following this accident. Exhibit "E." 32. There are no activities that Samuel Talhelm cannot perform at this time because of injuries sustained in this accident. Exhibit "E." C. SETTLEMENT 33. Following the accident, Petitioners, as well as other injured family members involved in the accident, underwent settlement negotiations regarding the $30,000 aggregate limits available under the terms of the applicable Farmers policy of insurance. 34. Pursuant to agreement, the aggregate limits of the aforementioned are to be distributed amongst all injured persons as follows: 1. Jordan Sassman $3,000 2.. Melinda Sassman $7,000 3. Michele Possenti $8,000 4. Samuel Talhelm $1,000 5. Jack Talhelm $1,000 6. Paige Talhelm $10,000 35. The entire proceeds are to be shared among the aforementioned and there are no proceeds available under the terms of the Farmer's Policy being withheld. 36. Petitioners have agreed to accept $10,000 for full and final settlement of all claims relating to Paige Talhelm. 37. Petitioners have agreed to accept $1,000 for full and final settlement of all claims relating to Jack Talhelm. 5 38. Petitioners agreed to accept $1,000 for full and final settlement of all claims relating to Samuel Talhelm. 39. Paige Talhelm has a pending claim for under insurance proceeds under a policy of insurance maintained on the Sassman vehicle through Nationwide Insurance.3 40. Petitioners have agreed, contingent upon Court approval, to accept the aforementioned offers as full and final settlement of any and all potential liability claims against Mr. Leon. 41. The settling parties propose to enter into a general release attached hereto as Exhibits "H," "I" and "J." 42. Without Court approval of Court of the Minors' compromise, due to the nature and extent of injuries sustained by all persons involved, the aggregate limits of the applicable Farmers policy have been exceeded and would otherwise have to be paid into a California Court for disbursement through interpleader, a process that would significantly increase delay of payment to petitioners and other injured parties and will increase expenditure of time and resources of all involved. 43. Petitioners are not represented by counsel in this matter; therefore, attorneys' fees are not at issue. 44. Settlement for the aforementioned amounts is in the best interest of the minor children and should therefore be approved accordingly for reasons set forth at length above. WHEREFORE, the Petitioners, Petitioners, Michele Possenti, as parent and natural guardian of Paige Talhelm, a minor, Jack Talhelm, a minor and Samuel Talhelm, a minor, and Victor Yantas Leon, by and through Dickie, McCamey & Chilcote, P.C., attorneys for Farmers 3 Nationwide Insurance has advised that under California law, under insurance proceeds may not be distributed until conclusion of settlement with the tortfeasor. 6 Insurance Company, respectfully request that this Honorable Court grant their Petition for Court Approval of Minor's Compromise in the amount of $10,000.00 for Paige Talhelm, $1,000 for Samuel Talhelm and $1,000 for Jack Talhelm. 7 Respectfully submitted, CAMEY & CHILCOTE, P.C. 3~d r ~ Date: 1 Charles E. ddick, Jr., Esquire Attorney I. No: 55666 Jason P. Mc icholl, Esquire Attorney I.D No. 89062 1200 Camp Hill Bypass Suite 205 Camp Hill, PA 17011 (717)731-4800 Counsel far Payee Dated: ~ ~~~~,~.,~ ~~~~ Michele Possenti, as Parent and Natural Guardian ,/ l~ i Dated: ~ ~ ~ ~ ~ ~ ~,: ~ ~ . ~ ~~~ ,,~._. . Kevin Talhelm, as Parent and Natural Guardian BAR ~ ~ :?I~il i c ~ xi ~~ ~ ~0"'p°"y"°"1e' DECLARATIONS FARMERS INSURANCE EXCHANGE, LOS ANGELES, CALIFORNIA AN INTER-INSURANCE EXCHANGE, HEREIN CALLED THE COMPANY Transaction type: NEW BUSINESS The Effective date is from TIME APPLIED FOR . * * * * The policy may be renewed for an additional polity teen of six months each time the Company offers to renew by sending a bill for the required renewal premium, and the insured pays said premium in advance of the respective renewal date. The Polity is issued in reliance upon the statements in the Declarations. Insured's name and address: PoGrynmber: 95 16827 - 0 0 - 5 8 CARLOS YANTAS LEON Padry edi6arc 0 3 6616 LIBERTY ISLAND EHec4eedoRe: 03-18-2005 RD Expaolion die: 0 9 -18 - 2 0 0 5 DIXON CA 95620-9400 Expiropontime: 12:01 A.M. Standard Time Issuing of~ite: P. O. BOX 1900 Lawrence J Simpson PLEASANTON , CA 9 4 5 6 6 Agerd ra: 9 5 17 3 0 7 Agent phara (7 0 7) 6 7 8 -12 9 5 Desanptiai of vehicle <::. ~1rllr:::> ~>:>"~::: '".. ..:....:_;..:::>::.:;:::<;:.:»::::~:::::;:.;:>;::;;::.:,:,,:>.::...>;: .............................. r::>~~11t~:~a~IlaRf'<;;;; .......................... ................... :::::;.:.. X106 1997 SATURN SC2 1GBZG127XVZ257389 Maja NYnor Acct 0 0 0 Cover"0es * ~ ~ e~ereede aF delrc. (See Reverse Side f« Grieraaa Desiarabar6] ~E ::.;:::::: ..~:::.:: ,:.:: 15 i 3 0 2 5 15 I 3 0 COV ~ ~tx NOT COV NC ~ NC NC NC NC ; »~ ~" Each i Ea ch Eadr ~ Ea dt '~" "' Person Oca-rence Person ' Ocarrarce ~ x~ NOT COV 8~• ~~ Premium 6y coverage 124.10 13.70 xx~cgxxaacc NOT COV Endorsement mn~dters E1140 E1154 E1201 E1248 S9046 59052 S9054 S9064 E9007 C-1 258531 E1027 CA014 Messages /rating information CAR SYMBOL(T). COVERAGE FOR E9007 I5 C-1 GARAGING ZIP CODE TO RATE: 95620 ANNUAL MILEAGE: 08000 PLEASURE USE EXCESS VEHICLE PLEASE CONTACT YOUR FARMERS AGENT FOR A FREE FARMERS FRIENDLY REVIEW TO ENSURE THAT YOUR FAMILY IS PROPERLY PROTECTED AND THAT YOU ARE RECEIVING ALL OF THE DISCOUNTS/CREDITS, COVERAGES AND PACKAGE POLICIES AVAILABLE. 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TtJLt ER1CA A SAV/1(iE (iN17J1961) 73]0 87RA'11'OI lD PL aR70q SACS/<1~ti'PD CA 953@ f91~ (NJIMi®OML1nTMIS4PCR7m!!1^ TJYi@ITO: DESSIa~ES~JS7aE5: (-{ YCi Y OF YIOIEM[.#YE MOTI/IED Y r~` 4 o~ ~I F T o T a ^ a o a a ^ ^ ww~snfla.aAOaa>~ Tc~pt10NE SW.ATJNE G. ZoURii 2119!1961 25301 QtUx 1V YALJEY PJCwY t~l25 1.MFat- RAN(7;1 Clt 42894 [~41~73s pMRNlOONLYI't10lM/Sl~OICIEO eYc TN~dl70. ' V1CiM OF V IDLB/T .gt1E M9TIFED i~ C3 ^ C C7 ^ O D ^ G ^ NAME I O.OB. f ADDNE~ ~ . ~*~~ 1 (RWIRAONL1711YW1r01t1'EO9Y_ 7MtBITge OE( pJUR64: 1~ICT141OF YIDIBtT [7i;ME MOTIF EO PFffPAA'aEa'$ NAME -i4N1$Qt DAY YE#R RPWEYYBCSNAME MD. l>41Y TERN K. I>E's 1.A MORA 11706 - - --- bf261S(JOS Jul 06 05 11:O8a fax Jul OS 2005 4:I2Ph CSP 5Th1E OF CAI,IFORNCA S~TCH..D~AGRAM mss GATE 4F INCIDENT ~ 11"520 18290 I y;~+~ u, s-5~v ~s a 1AEfAlaW~lC7fiML pKTANO 9W WEl C~rFR tarn 1 r t3~w uec V-l ov~R.TkR+vt~G ---,I-- I , ~--~- 8R 12R--~r-12 R.--+f;--t2R-+~-t2R-~M EB-1 ~ ®-2 y FB~3 i E&4 ~ I l I I I I I. i L 1 I - I 1 I I I I I I -' I 1 ~ t I I I ~ I 1 I t I I [ I ~ I S I I -'~ , I l I 4'k ~~~ ~~ i I i I 1 4 ~` l I I 1 t ! ~ { r ` I I I ~ I I 1 ~ I ~ r I V I +~ ~~ t I ~~~ 1 I ~ V~-a I I -I I v-t I I i I I f 707 253 2929 9189225 'r -12R EB-5 5 p.6 ~~ ~q,~p wNTT ~ /1E nare~r s- aA nat p.6 E. Gp.RCfA Jul 06 05 11:OBa fax Jul OS 2005 4:12PN CSR .STATE OF CALIFORMA FAGTUpL. DWQRAM 707 253 2929 9169225' p.7 DAl'E OF INCIDEh1T T.ME NCIC NUt1~ER c~rrli.:cK ~.~. ivuneo-R X126/2005 1°32fl 9280 _--- 016929 (~,-06-104 ALL MEASURt~IEAfIS uRE APPRiOJOMATE AND-NOT TO SCALE UNLESS STATED (SCALE= c~ us- o ~a p.7 ---t-- i I --~- tt t21L--~•~--1Yft--Tr-12R.--+~--12R.--rl.--1214 10f~ I~ItTAt GUAROM4 .-_ ._. EB-1 ~ EB-2 y E'e-3 ; EB-4 ` E9~ ! i - I oar,wo cwrv~. csxr~+rnnu~ I i j I aa~ w- Tr uat 1~-~ITCl•MER NFOtfSN -...- - -- I I ( t (ONDIMAY I ( t { arnio reuaw uiE ( i 1 ( 6otIDNmR c twE ( I l 1 I ( I 1 11SPMLT 9f OtaOER I I 1 i - I + ( t 1 I 1 I I I I I I 1 ( I ( 1 I I t 1 1 I ( I I 1 1 i I E 1 I 1 - f ( i i I • ( I- I I 1 ~ I 1 I I dEFfERBafi BLVD {JJC f. I ! I ( I i - 1 - INVgy~pv3aaaa I I ( { w-f~arar~r-po~+ 1 j 1 I ~t~aroam PoR~ I t I I McrroaEAFa>~R I I I wea: os' ~seu I I ! ! t ~ I r t - 1 I I 1 f I ~ l I I 1 ( I 1 I . ( ( } - ( ( I f I i ( I . I I ( 1 I 1 ( I I I j I I i ~ 1 I 1 I I i 1 '1 I I I ; I I I ( 1 L. ( 1 f I ~( . ... I 1 I I Y-1 snd V-2 wets r moved fivm the zoadwsy to reduce the roatl+vay haxatd and bo expCditt the fl, ~w of tcpllic. ~-1 way tot~~ed by H d~ R tvw, and Y-2 was to~odby Dan's Miamian tow. PREPARED BY I.D. NUMBER OATS REVIEWER'S NAME I )ATE E. fARC1A ~ 016929 _ 06126/2005 ,„ 3u1 06 05 11:09a Jui 05 2005 4:12PM fax CSf 707 253 2929 9169225 i p,8 S3'A'[E OF CALIlTOEit`IlA E o i c ~r r:aa^ is tanna~t R .. ~ ~"""'~ 061Z~6/ZDaS 132Q 9280 11706 05-06 -104 T ACTS: z 3 wanFi:earroK: I was dispatched to a call of an injury traffic coq'~sion, with an err:bulanoe 4 rr3sporrdirrg at 1624 hours. i responded from Harbor BI. / W. Capital Ave, and arriired on 5 serene at 1629 hours. Ail times, speeds and rrreasuremerrtri in this investigation z re 8 approocimate. Messrm:merrts were taioen by estifrratian, except where otfrerwiae trdicbrted. 7 8 At the soerw of this calws~n, US 5t) E1B is a eastboundtw~estb0und freEway 9 cansis#ng of five i2 ftt~t tralYfc lanes. The roadway is sb^s~igtrt and bvei. The su:faa: is 10 con~poseii prirr+sn'ty of Gor~cr+ate. The firaf5c lanes are separated by radsed vrAtBe 'aotts dad. 11 The cenbar divider is tondened by a st9ei guardrail. The cetrier dnrid~x is s~aratr~d from 12 the #1 lane by a pairrtsd solid yeilsow 1ir~e. Th® right shoulder is separated iron tx:e #5 13 traffic lane by a paired solid white Ilne. 14 15 . PI1RT{Eg: 1s 17 PARTY i 1 [iltielincta ~asssmanl w~ located pt the scene. party Melinda Sassn ran was 18 identifed by rs valid C:~ driver's license. Melinda Baseman was pkaced ~ a party by 19 tfre follawing items: . zo Z 1 - Drier statemerHs ZZ - Driver~injuries 23 - DrivQr is registered ~ owner 24 25 F4~Q.F~XLT DrivF3r # 1's vehide, was situated On its right side. V 1 was removed from 26 the oerrter divider by its Mission tow to reduce the roadway hazard and expedite the flow 27 of traffic, Vehicle darrraae is triajor raNover.dernage to the entire right Bide, roof; hood, IeRt 2& side, windshield. 2s 30 PARTY ~ 2 tVicbr Y lion was locathd at Lire scene. Party Victor yanta:~ I-ean was 31 identified by a valid driver's I'uxnae from Peru (Q41815053). 1 obgined his right thumb 32 print an the back of C~HP 215 citation number 49377UW. Leon was placed as a party by 33 the fdbwing items: 34 35 -Driver staternerrtrz 36 37 SATURN 4Door t3river # 2's vehic~, was located on its wheel. V 2 was reneoved from 38 - the 1#1 lane by H & R flow do reduce the roadway hazard and to expedite the tlan~ of tr~rR'ic_ 39 Vehicle damage is rr ale to the right rear quarter panel, trunk, rear window, ti8h° side, rvaf, 40 windshield, hoed, rig`rt front iGsnder. 41 42 .PHYSICAL EVtDEN~ Damage to V-t and V 2 nonbed. CHP Officer E. Garcia took 7 43 digital photographs atthe scene_ 44 ASLEF 8Y .D. N RCVIEYY~ 1Witig UI ~" K DE tJ>< MORA 11706 {)BI26t20dS ~- p.e Jul os os li:ose Jul 05 2005 4:12PM STATE 4F CALII'ORNIA fax CSR 707 253 2929 9169225" i p.$ a 8 OF TE I 1 T Tint !C NUMBER FF1 I.Q. N 06126120Q5 ~ 1 ~i20 ~ 9280 117t]5 Orr' 06 104 '! STATEMENTS: 2 3 4 PAtZTY # 1 t;Moiinda Sas~m~t related in essence that~she was dri~ting V 1 an eastbo~~nd US 5 Sd. She was driving from f3adega Bay enroute to her home in EUC Gro,we. she does rat know 6 haw fast she was traveling o- what lane she waa in. Ali of a sudden V-2 came over ft+or-~ another 7 lane. She does hat know what happened sister that. 8 9 p~11f #~ ~( 1„(~n~ i.,~n1 related in essence his statement in Spanish to CNP r ~ff'roer E. 1t) Garcia #18929. Officer Gerc:ia typed his statement vrFlich is attached. He can also be rsactted eR 11 telephone nwnber (707) 885.3373. 12 13 PASSENC~R #1 SJordan 58SSmanl was contmc*ed at the scene. Jordan Sassman rE~ated in 14 esser~ that she was r+dang ~ V-1 `s rri-ddle front east at the time of the calFisicn. She v gas 15 wearing her seatbelt and d'-d rat know how the ralC~siDn took place. 16 97 PA99EN'OER #2 tPslste Taih~~1 was car~taded at the scene. Palge Taltreh:r related in 18 essence that she was riding in V-1'.s right front seat at the tithe of the ooUision. She wa t wearing 19 her seatbelt. 20 21 PASSENGER #3 {Jack Ts~heMnl was contacted at the some. His mother Mlchetle Ptssetrti 22 related in essence that Jade wag riding in V 1's left near seat at the time ofi the traffic colisian. He 23 was are>amrig his searttrelt 24 25 ~A~SS~tGER all4 (Samuel 1'Nl~eiml was conlac~ed at the scene. His mctl~er MidteUe Peasants 2li related in essence that Samuel was wearing his seatbelt white rwd'ri9 iri V-'l's middle res~ seat at 27 the time of the traffic collision. 28 28 PASSENGER t#5 pYRchella P 1 was contaceed at the scene. Michelle Possent+ mlated in 30 essence that she was riding in V 1's right rear seat >st the time of the tratric collision. S ~e was 31~ westing her seatberi. She t ad no idles how the traffic collision took place. 32 33 PASSENGER #6 SPsdro Yarrtrra Lsonl was Contacted at the scene. Pedro Yentas Leon was 34 identified by a CA driver's l~.~nse (D8t]Z9t301}. He related in essence that he was riding in V-2's 35 right front scat at the time of the traffic collision. He wac wearing h~ eeeibelt. CNP OiiiCer 38 Garcia obtained further info ~mation. 37 . 38 WITNESS # 1 (John Gli/lntrlu~- was cxarttacted per telephone cor-veraation on 08-26-~ at approx. 39 1954 hours. John Givinsld :elated in essence that he was driving his vehicle in the if1 -one of 40 eastbound US 5t7 at approximately 65 mph. He heard a "wh~.° He saw debris rob n front of 41 his tsar. He then saw V-9 rc~l! aver the top ~ V Z. V-1 and V-2 were either in the tF3 or 84 lane. 42 V-1 continued overtuming r~ the roadway: Ne applied his bratces and tried to avoid the dsbrfs. 43 He stopped his vehicle and walked lrp iio V 1 which was overturned on its side. Sever~.t good p.9 sr r.o. r~~+rs,wusr ~a~~ K DE LA MORA 11706 .061'2612005 Jul 06 05 11:09a fax 707 253 2929 p. 10 Jul 05 2005 4: 13P!! CSF 9169225' i p, lq sz~r~ ol~ r,~oxxla ~~~MENT P ~~ TE ~~=t~tT - - Y1 FIf~R L D. N BER 06126!2005 1~32ff 9280 11706 05.06144 1 Sarnaritaans were helping the people get out of V-Z. His.v~e Merry catbed 911, Z 3 Wfff!~SS, # 2 ~ rcy GirrMa~i was contacted per telephone oanversation on OB-26-0~ at 4 approx.1950 hours. Marcy C~niutski related in essence that sloe was riding in the right fr~snt seat 5 01` the vehicle driven by her h~aabernd .fohn {witness #1}. Sire saw V 1 rotting aver V 2. ~I-1 then 6 oorrta~ued overtumirtig on the roadway. V 1 and V 2 may have been in a slower lane. V •1 cx~lidex! 7 with the guardrail on the center divider and landed on ~ side. V 2 was spinning before coming to 8 a stop. She did not observe She initial impact between V t and V-2_ 9 10 NATNESS # 3 tErfc~ Sava~c~ was rantacted per telephone conversation an Q6-26-05 «t apprayc. 11 20f35 hours. Savage related in essence that she was driving her vehlde in the #6 lane cif 12 westbound US 50 at approxirnabely 65 mph. She was preparing to exlE at Harbor Blvd. 13 approximately 1l2 to 1 mile away. She saw V-9 overturning appraxirnately 3 tim~2s. Shr: was 14 approximately 4 car lengths aviary when she observed V 1 overtttm'rng. V 1 may have b een in the 15 slaw lane and ended up in the feat lane. Y 2 appeared to be a srrraii Eclipse vehicle. She did trot 1$ observe the impact betvreen V-1_ ar-d V-2. She was rot able to estimate the speed of V -1 or V 2. 17 She stopped her vehicle on f.he•right shoulder orb wiled 911 oa her oelipt-one. Th~xe tivem 18 approximately 30 people around V 1 so she continued on her way to wait. 19 20 WITNF,~S rik4 tSuTansre G. f~our„pl was ooniectad by telephone on 06-27.05 at apQnncimatety 21 1405 hours. Suzanne relafrsd in essence that she was dri+rirrg her vehicle In the #2 lard of 22 eastlsotlnd VS 50 art approximately 85 to 7U mph. Traffic vvaa light to moderate. V-2 anus 23 traveling in the i1Ki lane at•appraximatefy 65 tQ 70 mph appro~aimately 5 car lengths in frrmt of her. 24 V 1 was traveling in the #4 lclne of approb~r 65 to 70 mph approxlma~ry 4 car krnlths in 25 front of her. She had a dear view of the ttaiil'ic coliisian. Suddenly V-2 changed lanes from the tKi 76 lane into the #4 lane less that'r~ car lengths directly in front of V-1. She did not ohsenn: a tom 27 signal from V-2. Approxima~i~ety 2 or 3 s~onds later V 1 rear-ended V 2. V 1 vverbumE.d several 28 times and came to rest on tl~e center divider. V~ was swerving around and carne m e .atop. She 28 stopped her vehicle on the right shoulder and her daughter Becky called 911- Many people 30 stopped at the scene tQ assist. V-2 caused this cvihsion by making the lane change ac cfase tD 31 V-1. 32 33 34 OPINION~AND CONCLt1S1 S: 35 36 37 SliNi~iIARY: P-1 (11~linda Sassman) was driving Y 1 in the if4 lane of eastbound US 5Q at 38 approximately S5 W i 0 mph. P 2 {Vigor Yentas t_e~on) was driving V 2 in the #3 lane of 39 eaatbaunti VS 50 ai a~pproaimately 65 to 70 mph approximately %s car length in 1 rant of V 1 _ 40 P-2 changed lanes from the #3 fans into the #4 land dirocsly in front of V 'l, V-1 rear-ended 4i V 2. V-1 ovectumed several times an the roadway. V 2 swerved out of control ;end came 42 to rest in the #1 fans facing the oncoming eastbound trsffrc. V 1 continttetl overturning and 43 collided with V 2's wit~dshiekf and roof. Y 1~ came to rest on its right side on the center 44 divider. (Based on ttie staterrteins). . REVIL°YYEtt' [iMAC Uli~ K. DE LA MiDRA 11706 06~2E312006 Jul D6 05 i1:10a fax Jul OS 2005 4:15PM CSF 707 253 2929 8165225 i p.ll STATE OF CALit O[tN[A P ~ P a tl~+ci c Hume c i.a. OEJ2612005 1620 9280 917D6 05-08404 1 ~4RE_A_ +~F I<~ACT: 2 1). The first AOI was estimated b~ be epRrox..7 mines (3,886 ft) west ai SR 64 (3~ ~ffarson 3 BI1rd.) and approximately 16 feet twrttt of tt~e sQUttt roadway edge of eastbound E.S 50 (V-1 4 vs. V 2). 5 2). The second AOI was visually estimated b be approx..6 aides (3,188 ft.? west of SR 64 6 ~ (Juan Bhrd.j arld orpprQxin:ately 6 fleet south of th® north roadway edue of ex dbound 7 U S 50 (V-1 onrertumin~ Darer V 2). 8 The AOl's were based on the stabemerria. Otfioer Garcia used his -CHP patrol vel ode 9 odometer tv the measur+emer~t to d+stferson Bird. frorr+ the first A01. 1a 11 GAUgE: 12 P-2 (V(ctor Yentas Lin) was in viatatiorl of section 21658{a) VG - unsafe lane change. 13 14 16 REC4Nl~AENDATIbNS: 16 Cornpiahrt to tie tiled (cltetian trumbar 49377t11N) aaai~lst P 2 (lfictor Yarrtas Leon) for vi elation of 17 section 125t?0(a) VC -unlicensed driver. 18 19 2a z1 22 - - 23 24 25 26 27 28 29 - 30 31 32 33 34 35 37 38 39 40 41 42 43 44 BY ! R QA 8 irAill~ OA' ~~ K. DE to MORA •[ 1706 X2812005 p.ll Jul 06 D5 li:ila fax 707 253 2929 JU1 D5 20D5 4:15PM CSfl' 31&9225' ~ p. 12 S'T'ATE OF CAL.TFURNIA I~ARRA1rNErSUPPLEN{ENT~L p,4r3>= . ~~ OF i T TIfJIE NGC UMB I.D. NuIN$ ~' 46126J2Q05 1E2D 9280 016929 -05-t)6-i04 1 Sta~metents: 2 Yator Yentas LJean (Party #! <'.) was carttac6ed at the scene b91 Ofl"ic;er De l..a Mora (lD 1 t i'06), 3 who requested t obtain a statement fir+~rt Lreott, beczuse Leon only spoke Spanish. I can acbeal 4 Lean at the scene and he related the #olk~wing informatbn: he was driving.his vehicle in tte #3 5 lane of US~a0 eastbamd at 6t} mph. He l~+artged labs into the #4 Pane because he nee fed to 6 exit at Jei'~on Blvd. Af#er moving info the #4 #ane. he kx~ked in his rear view rnirrar anti 7 observed tine truck apprrnclmatefy Z00' behind him approaching the rear of his vehicle aE ;thigh $ fate of speed. The tnrc;k theft lilt him hard from behind, going ova his vetticte and r~usir g Leon 9 ~ lase control a>: his vehicle.` °F:~n's vehide spun out of contrd and came to rest in tfie k ne 10 facing on coming traffic. 11 12 Passenger Pedro Yalnta Leon (V-2's right fivnt passenger) was conlacled at file acacia end 13' related the fbgowing iMormatiorl: he was seated in the rrgfit~t front passenger seat of the ve:ttide as 14 Vigor Leon was driving. Thee moved into the #~ lane th exit .feffersalT, when they were t pit from 15 i~ehlnd. The truck ttracfi hit them roNad over the roof and caused them to bse control. Alta ~r tfleh' 16 car spun out of cx~ntrol and they strapped, he obserrred the truck, which was rvNing,land p ass i 7 them. - 18 19 Passenger Pedro Yenta Leon was contacted via telephone on 0&28-2005 at approximat>ly 1~4t5 20 ours and clarified some details. Pedro Leon stated that when his brothel Victor Yenta Lean was 21 going to exit Jef'terson Blvd he put on his ri~tt tum signet, looked over his right shoulder;trld 22 stated that the vehicle was 200' back, H~Kbrot#rer then looked in his rear view mirror and changed 23 into the #4 lane. While they were already in the fans, his brother stafiad that the car was 1vt 24 braking, as tl}e car behind them approached. Al{ of a sudden they fek an impact #rorn trei~tnd, 25 causing his brother to lose control of his car, which spun two times, corning to rest facing 26 oncoming traffic. As they were stopped, they observed the car, which was stll! rotiirrg, ro l over 27 the front windshield of their car and rontlnued roiling past them. 28 p. 12 /IR 9 I.G. N E pq E. GARCiA 016928 06J1'612005 ti Talhelm, Paige (MRN 1769260) Lab Results UC DAVIS HEALTH SYSTEM URINALYSIS-COMPLETE (Order# 6679293) Collection Collection Date and Time Received Date and Time Information 6/26/2005 2230 6/26/2005 2241 ~: _. ~ ~ ~~ . ~ F ~ ~ Rr. ':» - .ua w ~. Com~gnent ~~ Ela3 Low ~!9h ~~ Status COLLECTION Clean Catch Final COLOR Yellow NonelYellow Final CLARITY SI Turbid Clr/SI Turb Final SP GRAVITY 1.019 1.002 1.030 Final pH URINE 7.5 4.8 7.8 Final OCCULT BLOOD URINE Negative Negative Final BILIRUBIN URINE Negative Negative Final KETONES Negative Negative mgldL Final GLUCOSE URINE Negative Negative mgldL Final PROTEIN URINE Negative Neg/Trace mgldL Final UROBILINOGEN 0.2 0.2 1.0 EUldL Final NITRITE URINE Negative Negative Final LEUK. ESTERASE Trace A Negative Final MICROSCOPIC INDICATED Negative Final WBC/HPF 1-3 0 3 Final SQUAMOUS EPI 6-12 A 0 3 EPIlHPF Final AMORPH CRYSTALS Moderate A RarelOcc Final ~~~ ^~ 4 U L' .. URINALYSIS-COMPLETE ~Order#6679293) on 6/26105 -Order Result History Resort Other IDs Lab Specimen # 0626:UA00078S Patient Patient Name Information Talhelm, Paige U[1.IS EMER MLtN ~ 1769260 F Room Isolation ERWB N DOB Home Phone 11 /2!1991 717-486-4808 (14yr) Lab ~ Lab Director Information UC DAVIS MED CTR Ralph Green, MD 2315 Stockton Blvd Sacramento, CA 95817 Order Information URINALYSIS-COMPLETE (Order# 6679293) Order Order Date and Time Department Information 6!26!2005 10:30 PM Emergency Account Acct Number Information 020960114997 COPY -Protected Health Information - 08/30/2006 14:04:32-MR0202 Page, l of ~ 0 Talhelm, Paige (MRN 1769260) UC DAVIS HEALTH SYSTEM Order Authorizing_Provider Encounter Provider Providers (07992) Dustin Ballard (05456) Peter Sokolove, MD Specimen Collection Date Collection Time Resulting Agencv Information 6/26/2005 10:30 PM UC DAVIS MED CTR Priority and Priority Class Order Details STAT Normal Lab Results CBC WITH AUTO DIFFERENTIAL (Order# 6678307) Collection Collection Date and Time Received Date and Time Information 6/26/20051730 6/26120051742 ~. ~., :, Y'~. w~ Com op nent V~l~e Flag b9~ Huh ni ~tu.$ WHITE BLOOD CELL COUNT 7.4 4.5 11.0 K/MM3 Final RED CELL COUNT 4.55 4.0 5.2 M/MM3 Final HEMOGLOBIN 13.5 12.0 16.0 GM/DL Final HEMATOCRIT 39.9 36 46 % Final MCV 87.7 80 100 UM3 Final MCH 29.7 27 33 PG Final MCHC 33.8 32 36 % Final RDW 12.5 0 14.7 UNITS Final PLATELET COUNT 286 130 400 K/MM3 Final NEUTROPHILS % AUTO 45.6 % Final LYMPHOCYTES %AUTO 40.1 % Final MONOCYTES °k AUTO 8.0 % Final EOSINOPHIL %AUTO 6.0 % Final BASOPHILS % AUTO 0.3 % Final NEUTROPHIL ABS AUTO 3.32 1.80 7.70 K/MM3 Final LYMPHOCYTE ABS AUTO 2.92 1.0 4.8 K/MM3 Final MONOCYTES ABS AUTO 0.59 0.1 0.8 K/MM3 Final EOSINOPHIL ABS AUTO 0.44 0 0.5 K/MM3 Final BASOPHILS ABS AUTO 0.02 0 0.2 K/MM3 Final ~~ ; ~ ~C~ ' ~~ o _ ~ _ .. ~mwrt+ ». %1~4~mflDicLA d.~+"J. . . CBC WITH AUTO DIFFERENTIAL (Order#6678307) on 6/26/05 -Order Result Histor y Reoort Other IDs Lab Specimen # 0626:H00395S Patient Patient Name IIeRN ~i DOB Home Phone Information Talhelm, Paige 1769260 F 11/2/1991 717-486-4808 (14yr} COPY -Protected Health Information - 08/30/2006 14:04:32-MR0202 Page 2 of 10 Talhelm, Paige (MRN 1769260) UC DAVIS HEALTH SYSTEM Room Isolation EMER ERWB N Lab 1~a4 Lab Director Information UC DAVIS MED CTR Ralph Green, MD 2315 Stockton Blvd Sacramento, CA 95817 Order Information CBC WITH AUTO DIFFERENTIAL (Orderly 6678307) Ober Order Date and Time Deoarfinent Information 6/26!2005 5:30 PM Emergency Account Acct Number Information 020960114997 Order Authorizing Provider Encounter Provider Providers (05456) Peter Sokolove (05456) Peter Sokolove, MD Specimen Collection Date Collection Time ResultingsQgencv Information 6/2612005 5:30 PM UC DAVIS MED CTR Priority and priority Class Order Details STAT Normal Lab Results BASIC CHEMISTRY PANEL (BCP) (Order# 6678332) Collection r~np~fien D atp and Time Received Date an d Time Information 6/26/20051730 6/26/20051742 Com og nent Yallt~ Flag I.~ High !!n-tta ~~ SODIUM 140 135 145 mEq/L Final POTASSIUM 3.1 L 3.3 5.0 mEgIL Final CHLORIDE 107 95 110 mEgIL Final CARBON DIOXIDE TOTAL 22 L 24 32 mEq/L Final UREA NITROGEN, BLOOD 9 8 22 mgldL Final (BUN) CREATININE BLOOD 0.7 0.5 1.3 mgldL Final GLUCOSE 182 H 70 110 mg/dL Final ., y 4 ~, TEST ADDED TO SPECIMEN PREVIOUSLY RECEIVED IN LABORATORY TEST ADDED: HFP DATE/TIME TEST REQUESTED: 06/26/05 1756 COPY -Protected Health Information - 08/30/2006 14:04:32-MR0202 Page 3 of 10 Talhelm, Paige (MRN 1769260) UC DAVIS HEALTH SYSTEM REQUESTING PHYSICIAN NAME: SOKOLOVE A HARDCOPY REQUISITION FOR THIS TEST HAS BEEN REQUESTED BASIC CHEMISTRY PANEL (BCP) (Order#6678332) on 6/26!05 -Order Result History Reoort Related Tests LIVER FUNCTION TESTS lOrder#6678333) on 6/26/05 LIPASE LOrder#6678334) on 6126!05 Other IDs Lab Specimen # 0626:CI00365S Patient Patient Name MBM ;;ex QQ.@ Home Phone Information Talhelm, Paige 1769260 F 1112/1991 717-486-4808 (14yr) Room Isolation EMER ERWB N Lab ~ Lab Director Information UC DAVIS MED CTR Ralph Green, MD 2315 Stockton Blvd Sacramento, CA 95817 Order Information BASIC CHEMISTRY PANEL (BCP) (Order# 6678332) Order Order Date and Time Department Information 6/26/2005 5:30 PM Emergency Account Acct Number Information 020960114997 Order Authorizing Provider Encounter Provider Providers (05456) Peter Sokolove (05456) Peter Sokolove, MD Specimen Collection Date Collection Time Resuitin aencv Information 6/26/2005 5:30 PM UC DAVIS MED CTR Priority and Priority Class Order Details STAT Normal Lab Results LIVER FUNCTION TESTS (Ordee# 6678333) Collection Collection Date and Time Received Date and Time COPY -Protected Health Information - 08/30/2006 14:04:32-MR0202 Page 4 of 10 Talhelm, Paige (MRN 1769260) UC DAVIS HEALTH SYSTEM Information 6126!20051730 6126120051742 Component Value F~ 1_ow ~ ~~ $ ALBUMIN 4.0 2.9 4.5 g/dL Final ALKALINE PHOSPHATASE 193 H 35 115 UIL Final (ALPj ASPARTATE TRANSAMINASE 27 15 43 U/L Final (AST) BILIRUBIN TOTAL 1.1 0.3 1.3 mg/dL Final ALANINE TRANSFERASE 16 5 54 U/L Final (ALT) ,~ . ~ . .. ,~ - ~ , TEST ADDED TO SPECIMEN PREVIOUSLY RECEIVED IN LABORATORY TEST ADDED: HFP DATE/TIME TEST REQUESTED: 06/26/05 1756 REQUESTING PHYSICIAN NAME: SOKOLOVE A HARDCOPY REQUISITION FOR THIS TEST HAS BEEN REQUESTED LIVER FUNCTION TESTS (Order#66783331 on 6!26!05 -Order Result History Report Related Tests BASIC CHEMISTRY PANEL (BCP)..(Order#6678332) on 6126/05 LIPASE (Order#6678334) on 6/26105 Other IDs Reflex Order # Lab Specimen # 6678332 0626:C100365S Patient Patient Name Information Talhelm, Paige N~ ~ 1769260 F QQ@ Home Phone 11/2/1991 717-486-4808 (14yr) EMER Room 1 i n ERWB N Lab ~ Lab Director Information UC DAVIS MED CTR Ralph Green, MD 2315 Stockton Blvd Sacramento, CA 95817 Order Information LIVER FUNCTION TESTS (Order# 6678333) Order Order Date and Time Department Information 6/26/2005 5:30 PM Emergency Account Acct Number Information 020960114997 COPY -Protected Health Information - 08/30/2006 14:04:32-MR0202 Page 5 of 10 Talhelm, Paige (MRN 1769260) UC DAVIS HEALTH SYSTEM Order Authorizing Provider F.~icounter Provider Providers (05456) Peter Sokolove (05456) Peter Sokolove, MD Specimen Collection Date Collection Time Resulting Agencv Information 6/26/2005 5:30 PM UC DAVIS MED CTR Priority and Priority Class Order Details STAT Normal Lab R@SUItS LIPASE {OMer# 6678334) Collection Collection Date and Time Received Date and Time Information 6/26!20051730 6126120051742 Related Tests BASIC CHEMISTRY PANEL (BCP) (Order#6678332) on 6126/05 LIVER FUNCTION TESTS (Order#6678333) on 6/26105 Other IDs Reflex Order # Lab Specimen # 6678332 0626:CI00365S Patient Patient Name INRN ~ ~ Home Phone Information Talhelm, Paige 1769260 F 11/2/1991 717-486-4808 (14yr) Sln~ Room Isolation EMER ERWB N Lab Lak Lab Director Information UC DAVIS MED CTR Ralph Green, MD 2315 Stockton Blvd Sacramento, CA 95817 Order Information LIPASE (Order# 6678334) COPY -Protected Health Information - 08/30/2006 14:04:32-MR0202 Page 6 of 10 Talhelm, Paige (MRN 1769260) UC DAVIS HEALTH SYSTEM Order Order Date and Time department Information 6/26/2005 5:30 PM Emergency Account Acct Number Information 020960114997 Order Authorizing Provider Encounter Provider Providers (05456) Peter Sokolove (05456) Peter Sokolove, MD Specimen Collection Date Collection Time Resulting Agencv Information 6/26/2005 5:30 PM UC DAVIS MED CTR Priority and Priority ~$ Order Details STAT Normal Lab Results PROTHROMBIN TIME (PT) (Order# 6678389) Collection Collection Date and Time Received Date and Time Information 6/26/20051730 6/26120051742 ~' ~ Component Value Flaa !~ iii~h ~!~ Status INR 1.03 0.75 1.19 Final Related Tests APTT STUDIES (Order#6678390) on 6/26/05 Other IDs Lab Soecimen # 0626:CG00183S Patient Patient Name Information Talhelm, Paige 511111: EMER N! tLN ~ 1769260 F Room Isolation ERWB N DOB Home Phone 11!2!1991 717-4861808 (14yr) Lab ~ Lab Director Information UC DAVIS MED CTR Ralph Green, MD 2315 Stockton Blvd Sacramento, CA 95817 Order Information PROTHROMBIN TIME (PT) (Order# 6678389) COPY -Protected Health Information - 08/30/2006 14:04:32-MR0202 Page 7 of 10 Talhelm, Paige (MRN 1769260) UC DAVIS HEALTH SYSTEM Order Order Date and Time Department Information 6/26/2005 5:30 PM Emergency Account Acct Number Information 020960114997 Order Authorizing Provider Encounter Provider Providers (054) peter Sokolove (05456) Peter Sokolove, MD Specimen Collection Date Collection Time Resulting Agencv Information 6/2612005 5:30 PM UC DAVIS MED CTR Priority and Priority Class Order Details STAT Normal Lab Results APTT STUDIES (Order# 6678390) Collection Collection Date and Time Received Date and Time Information 6/26/20051730 6/26/20051742 Comp9nent Value E1ag 1_°w Hi9h Units Status p~p~ 26.1 21.8 31.5 SECONDS Final Related Tests PROTHROMBIN TIME (PTuOrder#6678389) on 6126/05 Other IDs Reflex Order # Lab Specimen # 6678389 0626: CG00183S Patient Patient Name MRN ~ DOB Home Phone Information Talhelm, Paige 1769260 F 11/2!1991 717-486-4808 (14yr) Room Isolation EMER ERWB N Lab ~ Lab Director Information UC DAVIS MED CTR Ralph Green, MD 2315 Stockton Blvd Sacramento, CA 95817 Order Information APTT STUDIES iOrder# 6678390) COPY -Protected Health Information - 08/30/2006 14:04:32-MR0202 Page 8 of 10 Talhelm, Paige (MRN 1769260) UC DAVIS HEALTH SYSTEM Order Order Date and Time Department Information 6/2612005 5:30 PM Emergency Account Acct Number Information 020960114997 Order AuthoriziIIg Provider Encounter Provider Providers (05456) Peter Sokolove (05456) Peter Sokolove, MD Specimen Collection Date Collection Time Resulting Aaencv Information 6/26/2005 5:30 PM UC DAVIS MED CTR Priority and Priority ~~ Order Details STAT Normal Lab Results TYPE AND SCREEN (Orderla~ 6678351) Collection Collection Date and Time Received Date and Time Information 6126120051730 6/26/20051758 ~, PATIENT BLOOD TYPE: O POSITIVE ANTIBODY SCREEN (ORTHO GEL): NEGATIVE Other IDs Lab Specimen # 0626:BB00061S Patient Patient Name M~F' f( S~ !~ Home Phone Information Talhelm, Paige 1769260 F 11/2/1991 717-486-4808 (14yr) ~RiS Room Isolation EMER ERWB N Lab I~ Information UC DAVIS MED CTR 2315 Stockton Blvd Lab Director Ralph Green, MD COPY -Protected Health Information - 08/30/2006 14:04:32-MR0202 Page 9 of 10 Talhelm, Paige (MRN 1769260) Sacramento, CA 95817 UC DAVIS HEALTH SYSTEM Order Information TYPE AND SCREEN (Order# 6678357) Order Order Date and Time DeQartment Information 6/26/2005 5:30 PM Emergency Account Acct Number Information 020960114997 OMer Authorizing Provider Encounter Provider Providers (05456) Peter Sokolove (05456) Peter Sokolove, MD Specimen Collection Date Collection Time Resulting Aaencv Information 6/26/2005 5:30 PM UC DAVIS MED CTR Priority and Priority Class Order Details STAT Normal COPY -Protected Health Information - 08/30/2006 14:04:32-MR0202 Page 10 of 10 Talhelm, Paige (MRN 1769260) UC DAVIS HEALTH SYSTEM Imaging Results ELBOW 3+ VIEWS, RIGHT (Order# 6678311) (Acc# 28330) PACS Images Show images for ELBOW 3+ VIEWS RIGHT [RADDX00931 ] Click here for General Information or Troubleshooting TiQs on launching PACS Images from the EMR, or contact I,S. Customer Support at 734-HELP. Results EXAM DATE: 06/26/2005 ELBOW, 3+ VIEWS, RIGHT; CLINICAL HISTORY: Rollover MVA with right upper extremity abrasion. FINDINGS: Two lateral, oblique, and AP views of the elbow were provided for review without previous films for comparison. There is no evidence of fracture or malalignment. Posteriorly, within the soft tissues, there are multiple 2-5 mm radiopaque objects which may represent foreign bodies, correlate clinically. IMPRESSION: 1. NO EVIDENCE OF ACUTE FRACTURE OR MALALIGNMENT OF THE RIGHT ELBOW. 2. MULTIPLE RADIOPAQUE OBJECTS WITHIN THE SOFT TISSUES POSTERIORLY. SH:cm(rad020) ACC#: 000000028330 D: 06/27/2005 12:48 AM T: 06/27/2005 01:46 AM C#: 1092846 signed: Stephanie Horton, D.O. cosigned: Kiran Jain, M.D. Result History ELBOW 3+ VIEWS. RIGHT (Order#6678311 Lon 6!28105 -Order Result History Report Exam Exam Date Exam Time Information 6/26/2005 2353 Result Sesult Date and Time Information 6/28/2005 10:40 AM Status Final result Patient Patient Name MRN $ga pQB Information Talhelm, Paige 1769260 Female 11/2/1991 ~It 12oom Isolation EMER ERWB N COPY -Protected Health Information - 08/30/2006 14:05:07-MR0202 Page 1 of 9 Talhelm, Paige (MRN 1769260) UC DAVIS HEALTH SYSTEM Order ELBOW 3+ VIEWS, RIGHT (Order# 6678311) Patient patient Name MRN ~r l~@ Patient Phone Information Talhelm, Paige 1769260 Female 11/2/1991 71786-4808 Allergies: (Not on File) Order Authorizing Provider Encounter Provider Providers (05456) Peter Sokolove (05456) Peter Sokolove, MD Order Order Date and Time Department Information 6/26/2005 5:59 PM Emergency Priority and Priority Class Order Details STAT Normal Web Links Radiology facilities Ordering Physician Rad Contact Info Insurance Acct Number Financial Class Information 020960114997 O 1 Payor MISC Patient Insurance 061601202 ID Plan P_1~9 Llumber COMMERCIAL 099 INS-MISC 2 Payor MISC Patient Insurance 01349657TPA Q Plan ~ Number PPO/HMO/EPO- P99 MISC Imaging Results FOREARM 2 VIEWS, RIGHT (Order# 6678312) (Acc# 28331) PACS Images Show images for FOREARM 2 VIEWS. RIGHT [RADDX00941-] Click here for Genera! Information or Troubleshooting Tips on launching PACS Images from the EMR, or contact I.S. Customer Support at 734-HELP. Results EXAM DATE: 05/25/2005 FOREARM, 2 VIEWS, RIGHT: COPY -Protected Health Information - 08/30/2006 14:05:07-MR0202 Page 2 of 9 Talhelm, Paige (MRN 1769260) CLINICAL HISTORY: UC DAMS HEALTH SYSTEM Status post rollover MVA with abrasions to the right arm. FINDINGS: Two views of the right forearm were provided for review without previous films for comparison. There is no evidence of fracture or malalignment. Soft tissue defects are noted posteriorly and medially with multiple 2-5 mm radiopaque objects within the soft tissues. Bandage material is also noted. IMPRESSION: 1. NO EVIDENCE OF FRACTURE OR MALALIGNMENT OF THE RIGHT FOREARM. 2. MULTIPLE RADIOPAQUE OBJECTS OVERLYING THE SOFT TISSUES OF THE PROXIMAL FOREARM AS ABOVE. SH:cm(rad020) ACC#: 000000028331 D: 06/27/2005 12:17 AM T: 06/27/2005 01:16 AM C#: 1092839 signed: Stephanie Horton, D.O. cosigned: Kiran Jain, M.D. Result History FOREARM 2 VIEWS RIGHT (Orderl~6678312) on 6128105 -Order Result History Report Exam Exam Date Exam Time Information 6!26/2005 2353 Result Result Date and Time $ Information 6/28/2005 10:40 AM Final result Patient Patient Name MRN ~ I?~ Information Talhelm, Paige 1769260 Female 11/211991 ~@ ~glation EMER ERWB N Order FOREARM 2 VIEWS, RIGHT (Order/ 6678312) Patient Patient Name MRN $ex DOB Patient Phone Information Talhelm, Paige 1769260 Female 11/2!1991 717-486-4808 Allergies: (Not on File) Order Authorizing Provider Encounter Provider COPY -Protected Health Information - 08/30/2006 14:05:07-NIR0202 Page 3 of 9 Talhelm, Paige (MRN 1769260) UC DAVIS HEALTH SYSTEM Providers (05456) Peter Sokolove (05456) Peter Sokolove, MD Order Order Date and Time Department Information 6126!2005 5:59 PM Emergency Priority and Priority Class Order Details STAT Normal Web Links Radiology facilities Ordering Physician Rad. Contact Info. Insurance Acct Number Information 020960114997 1 Payor MISC Financial Class O Patient Insurance 061801202 ID Plan Plan Number COMMERCIAL 099 INS-MISC 2 Payor MISC Patient Insurance 01349657TPA Q Plan P.la-n Number PPO/HMO/EPO- P99 MISC Imaging Results C-SPINE 4+ VIEWS (Order# 6678309) (Acc# 28328) PACS Images Show images for C-SPINE 4+ VIEWS [RADDX010081 Click here for General Information or Troubleshooting Tias on launching PACS Images from the EMR, or contact I.S. Customer Support at 734-HELP. Results EXAM DATE: 06/26/2005 CERVICAL SPINE, 4+ VIEWS: CLINICAL HISTORY: Rollover MVA. FINDINGS: Multiple views of the cervical spine are provided for review without previous films for comparison. There is no evidence of fracture or malalignment. The C1-2 junction is symmetrical. Vertebral body and disc space heights are preserved. No prevertebral soft tissue swelling is seen. IMPRESSION: COPY -Protected Health Information - 08/30/2006 14:05:07-MR0202 Page 4 of 9 Talhelm, Paige (MRN 1769260) UC DAVIS HEALTH SYSTEM NO EVIDENCE OF ACUTE FRACTURE OR MALALIGNMENT OF THE CERVICAL SPINE. SH:cm(rad020) ACC#: 000000028328 D: 06/27/2005 12:15 AM T: 06/27/2005 01:14 AM C#: 1092838 signed: Stephanie Horton, D.O. cosigned: Kiran Jain, M.D. Result History C SPINE 4+ VIEWS (_Order#6678309~ on 6/28/05 -Order Result History Resort Exam Exam Date Exam Time Information 6/26/2005 2351 Result Result Date and Time Status Information 6/28/2005 10:40 AM Final result Patient Patient Name 11~ ~ DOB Information Talhelm, Paige 1769260 Female 11/2!1991 IltZit Room Isolation EMER ERWB N Order C-SPINE 4+ VIEWS (Order# 6878309) Patient Patient Name ~ ~ ~B Patient Phone Information Talhelm, Paige 1769260 Female 11/2/1991 717-486-4808 Allergies: (Not on File) Order Authorizing Provider Encounter Provider Providers (05456) Peter Sokolove (05456) Peter Sokoiove, MD Order Order Date and Time Department Information 6/26!2005 5:59 PM Emergency Priority and Priority Ciass Order Details STAT Normal Web Links COPY -Protected Health Information - 08/30/2006 14:05:07-NIR0202 Page 5 of 9 Talhelm, Paige (MRN 1769260) Radiology facilities Ordering Physician Rad Contact Info UC DAMS HEALTH SYSTEM Insurance Acct Number Financial Class Information 020960114997 O 1 Pryor MISC Patient Insurance 061801202 Q Plan P~ Number COMMERCIAL 099 INS-MISC 2 Payor MISC Patient Insurance 01349657TPA !~ P!a_n Plan Number PPO/HMO/EPO- P99 MISC Imaging Results PELVIS 1 OR 2 VIEWS (Order# 6678310) (Acc# 28329) PACS Images Show images for PELVIS 1 OR 2 VIEWS [RADDX00976] Click here for General Information or Troubleshooti_g Tins on launching PACS Images from the EMR, or contact I.S. Customer Support at 734-HELP. Results EXAM DATE: 06/26/2005 PELVIS, 1 PR 2 VIEWS: CLINICAL HISTORY: Status post rollover MVA. FINDINGS: Single AP view of the pelvis was provided for review without previous films for comparison. There is no evidence of fracture or dislocation. Stool and gas overlie the sacrum making the evaluation of fractures limited. Soft tissues are unremarkable, no bony lesions are seen. IMPRESSION: NO EVIDENCE OF ACUTE FRACTURE OR DISLOCATION OF THE PELVIS. LIMITED EVALUATION OF THE SACRUM. SH:cm(rad020) ACC#: 000000028329 D: 06/27/2005 12:12 AM T: 06/27/2005 01:11 AM C#: 1092837 COPY -Protected Health Information - 08/30/2006 14:05:07-MR0202 Page 6 of 9 Talhelm, Paige (MRN 1769260) UC DAVIS HEALTH SYSTEM signed: Stephanie Horton, D.O. cosigned: Kiran Jain, M.D. Result History PELVIS 1 OR 2 VIEWS (Order#6678310) on 6/28105 -Order Result History Reoort Exam Exam Date Exam Time Information 6/2612005 2345 Result Result Date and Time $ Information 6/28/2005 10:40 AM Final result Patient Patient Name I~RN. ~ I~ Information Talhelm, Paige 1769260 Female 11/2/1991 Knit Room ~4.I~t-9Q EMER ERWB N Order PELVIS 1 OR 2 VIEWS (Order# 6678310) Patient Patient Name If~.131Y ~ )~ Patient Phone Information Talhelm, Paige 1769260 Female 11/2/1991 717-486-4808 Allergies: (Not on File) Order Authorizing Provider Encounter Provider Providers (05456) Peter Sokolove (05456) Peter Sokolove, MD Order Order Date and Time Department Information 6/26/2005 5:59 PM Emergency Priority and Priority ~~ Order Details STAT Normal Web Links Radiology facilities Orderin4 Physician Rad. Contact Info. Insurance Acct Number Information 020960114997 7 Pavor MISC i~o Number COMMERCIAL 099 Financial Class O Patient Insurance 061601202 ID COPY -Protected Health Information - 08/30/2006 14:05:07-MR0202 Page 7 of 9 Talhelm, Paige (MRN 1769260) UC DAVIS HEALTH SYSTEM INS-MISC 2 Pryor MISC Patient Insurance 01349657TPA !Q P~.n P.Jen. Number PPO/HMO/EPO- P99 MISC Imaging Results CHEST 1 VIEW (Order# 6678308) (Acc# 28327) PACS Images Show images for CHEST 1 VIEW [RADDX009801 Click here for General Information or Troubleshooting TIDE on launching PACS Images from the EMR, or contact I.S. Customer Support at 734-HELP. Results EXAM DATE: 06/26/2005 CHEST, 1 VIEW: CLINICAL HISTORY: Rollover MVA. FINDINGS: Single AP view of the cheat was provided for review without previous films for comparison. The lungs are clear and the costophrenic angles are sharp. The cardiac silhouette is within normal limits. There is no tracheal deviation, the mediastinum is unremarkable. No bony or soft tissue abnormalities are identified. IMPRESSION: NO EVIDENCE OF AN ACUTE CARDIOPULMONARY PROCESS. SH:cm(rad020) ACC#: 000000028327 D: 06/27/2005 01:42 AM T: 06/27/2005 02:53 AM C#: 1092869 signed: Stephanie Horton, D.O. cosigned: Kiran Jain, M.D, Result History CHEST 1 VIEW (Order#6678308) on 6/28/05 -Order Result History Report Exam Exam Date Exam Time Information 6/26/2005 2340 Result COPY -Protected Health Information - 08/30/2006 14:05:07-MR0202 Page 8 of 9 Talhelm, Paige (MRN 1769260) Information Result Date and Time $ 6/28/2005 10:40 AM Final result UC DAVIS HEALTH SYSTEM Patient patient Name 11A.131!I. ~ i~ Information Talhelm, Paige 1769260 Female 11!2/1991 ~i $4~ !$4leti_2R EMER ERWB N Order CHEST 1 VIEW (Order# 6678308) Patient Patient Name MRN ~ PQ.~ Patient Phone Information Talhelm, Paige 1769260 Female 11/2/1991 717-486-4808 Allergies: (Not on File) Order Authorizing Provider Encounter Provider Providers (05456) Peter Sokolove (05456) Peter Sokolove, MD Order Order Date and Time Department Information 6!26/2005 5:59 PM Emergency Priority and Priority Class Order Details STAT Normal Web Links Radiology facilities Ordering Physician Rad. Contact Info. Insurance Acct Number Information 020960114997 1 P~vor Plan P n Number COMMERCIAL 099 INS-MISC 2 Payor MISC Patient tnsurance 01349657TPA ID MISC Financial Class O Patient Insurance 061601202 llZ Plan PJeQ Number PPO/HMO/EP0- P99 MISC COPY -Protected Health Information - 08/30/2006 14:05:07-MR0202 Page 9 of 9 UNIVERSITY OF CALIFORNIA MEDICAL CENTER SACRAMENTO, CALIFORNIA ED PROGRESS NOTE (Page 1 of 3) PATIENT: TALHBLM, PAIGE 9VW MR #: 1769260 DATE OF SERVICE: 06/26/2005 EMERGENCY DEPARTMENT NOTE LINKING LANGUAGE: LOCATION: ERWB SEX: F AGE: 13 DOB: 11/02/1991 The patient was seen and examined with Dr. Cadogan. I reviewed the residents note and agree and helped developed a plan of care. HISTORY OF PRESENT ILLNESS: This is a 13-year-old female brought in by ambulance status post restrained passenger in a freeway speed rollover MVA. No loss of consciousness. The patient complains of right arm pain only. The patient had a GCS of 15 and stable vital signs in the field. The patient denies headache, nausea, vomiting, neck pain, back pain, chest pain, shortness of breath, abdominal pain or weakness. PAST MEDICAL HISTORY: Seasonal allergies. Medicines: None. ALLERGIES: None. Immunizations: Up-to-date. Surgical history: Inguinal hernial repair. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Noncontributory. REVIEW OF SYSTEMS: Positive for abrasions, otherwise negative. PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished female, no respiratory distress. HEENT: Small right temporal abrasion without cephalohematoma. Pupils equal, round, reactive to light. Extraocular muscles intact. No raccoon or battle sign. Face nontender. Oropharynx benign. No malocclusion. NECK: Trachea midline, no JVD. C collar in place. CHEST: Nontender, stable, breath sounds equal bilaterally. HEART: Regular rate and rhythm without m>>.rmurs. ABDOMEN: Soft, nondistended, nontender. PELVIS: Nontender, stable. UNIVERSITY OF CALIFORNIA MEDICAL CENTER SACRAMENTO, CALIFORNIA ED PROGRESS NOTE (Page 2 of 3) PATIENT: TALHELM, PAIGI3 MR #: 1769260 DATE OF SERVICE: 06/26/2005 LOCATION: ERWB SEX: F AGE: 13 DOB: 11/02/1991 EXTREMITIES: Nontender except for right arm. In the right arm there is a large abrasion over the right forearm and elbow with some lacerations and possible glass. There is tenderness along the areas of abrasion. Distal neurovascular is intact to radial, median, and ulnar nerve distributions. NEUROLOGIC: Alert and oriented times four. GCS 15. Strength and sensation normal except as limited by .pain in the right arm. BACK: Nontender throughout. ASSESSMENT AND PLAN: A 15-year-old female status post high-speed MVA with scalp abrasion and large right arm abrasion with some small lacerations and possible glass foreign bodies. Will check x-rays including C-spine, chest x- ray, pelvis, and films of the right arm to evaluate for fracture and to evaluate for foreign bodies in the arm. Check labs including serial CBC, CHEM-7, AST, ALT, urinalysis screen. Follow the patient's neurologic and abdominal exams clinically in the Emergency Department. Feel that CT scans are not indicated at this time. The patient will need wound care of her right arm. PRELIMINARY ED DIAGNOSES: 1. Scalp abrasion. 2. Large right forearm abrasion. 3. Status post rollover MVA. ADDENDUM: Care of this patient was signed out to Dr. Ballard at 1800. THIS WAS ELECTRONICALLY SIGNED - 06/26/2005 6:38 PM PST BY: PETER E SOKOLOVE, MD ASSOCIATE PROFESSOR EMERGENCY MEDICINE DEPARTMENT PES:dew(usa128) D: 06/26/2005 06:16 PM UNIVERSITY OF CALIFORNIA MEDICAL CENTER SACRAMENTO, CALIFORNIA ED PROGRESS NOTE (Page 3 of 3) PATIENT: TALHELM, PAIGE MR #: 1769260 DATE OF SERVICE: 06/26/2005 T: 06/26/2005 06:23 PM C#: 1092652 LOCATION: ERWB SEX:. F AGE: 13 DOB: 11/02/1991 UNIVERSITY OF CALIFORNIA MEDICAL CENTER SACRAMENTO, CALIFORNIA CONSULTATION (Page 1 of 3) PATIENT: TALHELM, PAIGE 9VW MR #: 1769260 DATE OF SERVICE: 06/27/2005 ORTHOPAEDIC SURGERY CONSULTATION HISTORY OF PRESENT ILLNESS: LOCATION: SEX: F AGE: 13 DOB: 11/02/1991 The patient is a 13-year-old female brought in by ambulance tonight, status post motor vehicle accident. The patient was the restrained passenger in the vehicle, which was traveling at highway speeds. The patient denies any loss of consciousness. Her major complaint upon arrival was right arm pain. The patient denies any other problems or complaints at that time. I was asked to see this patient for evaluation of her right forearm road rash/abrasions. PAST MEDICAL HISTORY: Seasonal allergies. Past surgical history: Repair of inguinal hernia. ALLERGIES: None. Medications: None. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: The patient lives with her family in Pennsylvania. REVIEW OF SYSTEMS: Negative, except for right forearm abrasions/road rash. PHYSICAL EXAM: GENERAL: The patient is healthy appearing and in no apparent distress. SECONDARY EXAM: Negative. EXTREMITY: Exam of her right upper extremity reveals significant road rash of her flexor forearm over the proximal 1/3 with two larger areas which extend deeper in the subcutaneous tissue down to just above the fascia. These two areas measure approximately 2 x 2 cm and 3 x 3 cm in diameter. Overall the wound appears fairly clean, except for a few areas of necrotic tissue and debris from the road. The patient received an axillary block prior to my examination. She had a good radial pulse distally. X-RAYS: MR #:1769260 UNIVERSITY OF CALIFORNIA MEDICAL CENTER SACRAMENTO, CALIFORNIA CONSULTATION (Page 2 of 3) PATIENT: TALHSLM, PAIGE 9VW LOCATION: MR #: 1769260 SEX: F AGE: 13 DATE OF SERVICE: 06/27/2005 DOB: 11/02/1991 Right elbow and forearm x-rays are negative for any fracture or dislocation. There are multiple radiopaque foreign bodies in the skin in the location of her road rash/abrasions. ASSESSMENT: Right forearm abrasion/road rash, status post Emergency Room irrigation and debridement. PLAN: The patient underwent an irrigation and debridement prior to my examination using six liters of normal saline and a pulsatile lavage. Since her axillary block was still providing some anesthesia, I was able to perform a secondary debridement, debriding some necrotic skin and foreign bodies from the tissue. I was also able to use a surgical scrub brush and Betadine to further debride the tissue of any foreign body. At the end of my procedure, which she tolerated fairly well without any major problems or complaints, her wound appeared clean without any significant contamination. I demonstrated wet-to-dry dressing changes to the patient's parents. They expressed understanding. RECOMMENDATIONS: My recommendations for this patient are that she be discharged with wet-to-dry dressing changes twice a day. She is also to place Xeroform over the abrasions circumferentially around her deeper wounds, which should be packed with wet-to-dry dressing change. I also recommend that she be discharged with Keflex for five days and pain medications. The patient will follow up with her primary care physician in Pennsylvania. I educated the patient's parents regarding signs and symptoms of infection. They expressed understanding and indicated that they would seek medical attention for any problems or concerns. UNIVERSITY OF CALIFORNIA MEDICAL CENTER SACRAMENTO, CALIFORNIA CONSULTATION (Page 3 of 3) PATIENT: TALHELM, PAIGE 9VW MR #: 1769260 DATE OF SERVICE: 06/27/2005 LOCATION: SEX: F AGE: 13 DOB: 11/02/1991 THIS WAS ELECTRONICALLY SIGNED - 06/29/2005 12:16 PM PST BY: BRANDON J FERNEY, MD RESIDENT DEPARTMENT OF ORTHOPAEDIC SURGERY BJF:dhs(usa124) D: 06/27/2005 02:44 AM T: 06/27/2005 04:34 PM C#: 1092889 UNIVERSITY OF CALIFORNIA DAVIS EMERGENCY-REG (COPY} PATIENT INFORMATION RECORD PAGE 1 TALHELM ,PAIGE 9VW SVC: EDR N/S ERWB FC: V PENDING MEDI-CAL, CM MR#: 1769260 9 PT TYPE: E OLD MR#: ACCT## 20-960114997 ---------------------------------------------------------------------------- OUTPT REG DT/TIME: 06/26/05 17:12 INPT ADMIT DT/TIME: FLAGS ADM PCP UPIN: ATT PCN ADM CD ICD9: CPT: PCP PI#: DX PCP ADD: PATIENT INFORMATION: ADDR: 113 WOODVIEW DR MT HOLLY SPRING PA 17065- HOME TEL: 717-486-4808 MSG TEL ADDL ADD: COUNTY 98 OTHER STATE .ATIENT EMPLOYMENT: STATUS: 3 OCCUPATION: NOT EMPLOYED EMPL EMPL ADDR EMPL TEL X LNGTH OF TIME ON JOB: VET: RELATED CONDITION: U.C. EMPLOYEE IND: PT SSN# 000-00-0001 PT DL/ST UNKNOWN UN PT DOB: 11/02/1991 AGE: 13 SEX: F MS: S SP NM: MAIDEN NM UNKNOWN- OTHER NM ETH: BPLACE: RELIGION: LANGUAGE: ---------------------------------------- ~CZDENT INFORMATION: ACCIDENT RELATED CONDITION: Y ACC DT/TIME: 06/26/05 00:00 ACC TYPE: AUTO ACCIDENT ACC LOC ER H/A OTHER AMBULANCE CO. ER CMPT MCI MVA INST: ------------------------------------- GUARANTOR REL: PARENT GUAR NM: POSSENTI ,MICHELE ADDR 113 WOODVIEW DR MT HOLLY SPRING PA 17065- HOME 717-486-4808 MSG GUAR SSN# 563-59-3590 GUAR DL/ST GUAR SEX GUARANTOR EMPLOYMENT: STATUS: OCCUPATION EMPL EMPL ADDR EMPL TEL X LNGTH OF TIME ON JOB: ------------------------------------- NEXT OF KIN REL: OTHER RELATIVE NOK NM SASSMAN ,MELINDA EVN TEL DAY TEL 916-684-0393 X MSG TEL GUARDIANSHIP PAPERS ON FILE: ------------------------------------- REFERRAL: DATE: DR: X PCN: FACILITY: . X ----------------------------------------------------------------------------- LAST ADMIT DATE: ESTIMATED LOS: ADVANCE DIRECTIVE INFORMATION: WAS AD INFORMATION AND UCDMC POLICY STATEMENT GIVEN TO PT/REP? DESCRIPTION: DOES PT HAVE AN ADVANCED DIRECTIVE? HAS COPY OF PT'S AD BEEN PLACED IN PT'S MEDICAL RECORD? T & C SIGNATURE: PATIENT GUARANTOR PMHUNVF5 DOCUMENT GENERATED BY: HADSB 18:38 06/26/05 FROM LX9D,PMHUNVF5 EMERGENCY REG (COPY} UNIVERSITY OF CALIFORNIA DAVIS PATIENT INFORMATION RECORD PAGE 2 ---------------- ---------------- TALHELM ,PAIGE --------- ---- ------------- 9VW ---- ---- SVC -------- -------- EDR ------------- ------- -------------------- F/C V PENDING --------------- --------------- MEDI-CAL, CM MR# 1769260 ---------------- ---------------- PT TYPE: E ------------- ------------- OLD ---- ---- MR # -------- -------- ACCT # -------------------- -------------------- 20-960114997 --------------- --------------- PLAN CD: 103 MCAL INCOMPLETE PRIORITY: 1 POL#: N/A GROUP#: INS ADDR: I.P.A. NAME: PHONE: - - X REF/AUTH#: REVIEW GROUP: DAYS AUTHORIZED: CONTACT NAME: PHONE: - - X ON-SITE REVIEW? CONCURRENT REVIEW GROUP: CONTACT NAME: PHONE: - - X PLAN CD: POL#: ?~OUP# _NS ADDR PRIORITY: I.P.A. NAME: PHONE: REF/AUTH#: REVIEW GROUP: DAYS AUTHORIZED: CONTACT NAME PHONE: ON-SITE REVIEW? CONCURRENT REVIEW GROUP: CONTACT NAME: PHONE: ***********************************************************~~~*~~*~~,r~c~,t***,r*** PLAN CD: POL#: GROUP#: INS ADDR: PRIORITY: I.P.A. NAME: PHONE: DEF/AUTH#: REVIEW GROUP: .~YS AUTHORIZED: CONTACT NAME; PHONE: ON-SITE REVIEW? CONCURRENT REVIEW GROUP: CONTACT NAME; PHONE: COUNTY CODE: AID CODE: CARD ISSUE DATE: VALID DATE: PMHRUNF6 DOCUMENT GENERATED BY: HADSB 18:38 06/26/05 FROM LX9D,PMHRUNF6 ~ A ~, ~ ~ ~ ,', ~ ~ i4 f Ce ~ g ~ ~ 5 ~ ~ ' ~ 4Fj;N1A DAVIS ~ ~° ~ '~ .`~ Y ~ : `ir 1E ~' ~+ ~ t1NIVERSITY~F~CA~~': ~: USE P~TIE[~T PLa'1'~ ~ M ~ .~ ~ H NTH a5~f57E~1 TERMS AND i/ODITf`+bNS OF S - , . ~ '~ : _, r "r~'~t~ 7. FINANCIAL AGREEMENT: I agree to pay The Regents of the University of ~aliforriia~`for professional, hospital and clinic services, including UCDHS physician services, in accordance with the regular rates and terms of UCDHS. I also agree to pay for other professional services provided by other physicians at UCDHS. When this agreement is signed by my spouse, parent or a financial guarantor, my spouse, parent or financial guarantor shall be jointly and individually liable with me for payment, including all collection fees (attorney's fees, costs and collection expenses), in addition to any other amounts due. Unpaid accounts referred to outside agencies for collection bear interest at the then current legal rate. 8. ASSIGNMENT OF BENEFITS (INCLUDING MEDICARE BENEFITS): I authorize and direct the payment to UCDHS of any insurance benefits including hospital insurance and unemployment compensation disability benefits otherwise payable to or on my behalf for UCDHS services, including emergency services, at a rate not to exceed UCDHS' actual charges. I understand thiat i am financially responsible for charges not paid pursuant to this agreement. I further certify that the information given in applying for payment under the Medicare or Medi-Cal programs is correct. I further agree that any credit balance resulting from payment of insurance or other sources may be applied to any other account owed to UCDHS by me. 9. ADVANCE DIRECTIVES: { have an advance directive for health care (e.g., Power of Attorney for Health Gare} ^ Yes ^ No I have provided UCDHS with a current copy of my advance directive ^ Yes ^ No If "No", i understand it is my responsibility to provide UCDHS a current copy of my advance directive. If I want to express my health care wishes, I understand I should speak with my health care provider. 10, PATIENT RIGHTS NOTICE: I would like UCDHS to provide my next of kin or agent with the Patients Rights Notice ^ Yes ^ No 1 have read, agreed to and received a copy of this "Terms and Conditions of Service." Signature of Patient Relationship of Representative to Patient Signature of Interpreter (if applicable) ~v GEC,' Signature of Witness ~ (required if patient unable to sign) ~~ Date of Signing For office use only: EXCEPTIONAL SIGNATURE REQUIREMENTS ARE REFERENCED BELOW. Please check the appropriate box(es) ^ PATIENT IS LEGALLY INCOMPETENT TO SIGN: The court approved guardian or conservator, the attorney-in-fact under a burable Power of Attorney for Health Care, or family member or other appropriate surrogate must sign as "Patient's Representative." ^ PATIENT IS PHYSICALLY INCAPABLE OF SIGNING: The patient should give verbal consent, witnessed by a UCDHS employee. The "Patient's Represen- tative" should sign in witness of the patient having given verbal consent. The UCDHS employee witness shall also sign. -r~Rnn~ ante (',(~NnITI(~NS nF SERVICE TERMS AND CONDITIONS OF',S~RVICE ~, K :. , 1. UCDI~S: ~The~ UC-~ Dav-is. Health :System (UCDHS) is .part of ..the .University of California and is comprised of fhe UCD~~ Medical°;~Cente~r, its hospital-based clinics, he Primary Care Network clinics, the UCDHS Davis Meet: ~~gtip,. end the UCDHS School of Medicine. 2. MEDICAL CONSENT: I consent to any medical treatments or procedures (except for complex procedures which require special consent}, X-ray examinations, drawing blood for tests, medications, injections, taking of medical photographs, videotaping, laboratory procedures, and hospita! services rendered to me under the general and special instructions of the attending physicians or other physicians of UCDHS assisting in my cars. I also consent to my admission to UCDHS Medical Center if this is deemed necessary for my care. Ali of the terms and conditions of this agreement shall also apply to such admission. 3. RELEASE OF INFORMATION: UCDHS will obtain my written authorization to release information about my medics! treatment, except in these circumstances when UCDHS is permitted or required by law to release information (see UCDHS' Notice of Privacy Practices for a description of the specific circumstances ur~;fer which UCDHS may release this infiormation). For example, UCDHS may release a copy of my patient record to insurance companies, health care service plans, governmental agencies, workers' compensation carriers, or other entities which may be liable for all or any portion of UCDHS' charges. 4. TEACHING, RESEAP?CH AND IiEA~.TI-ICARE INSTIT~fTION: The University of California, including UCDHS, is a teaching, research a.nd he«lthcare institution. l understand that residents, interns, medical students, students of ancillary health care professions (e.g., nursing, x-ray, rehabilitation therapy), post-graduate fellows, and other trainees may observe, exarr-ine, treat and participate at the request and under the supervision of the attending physician in my care as part cf the University's medical education programs. I understand that my health information may be used and .shared with researchers who engage in research related to my treatment, health condition, or ... medical or physical status. I further understand that the University of California, including UCDHS, may use my medical information and specimens for teaching, study and research purposes, including the development o€ potentially commercially useful products. Any use of these materials and information by UCDHS or other institutions will be in accordance with state and federal law, including all laws and regulations governing confidentiality of patient records. r r ~ ~t ~~`• R bpi^.- '~~E 5afel `R: ~. P~:RSONAL aALa.°.~:~~~.,~. LCDHS ri~as~~~..~,a freprcof u fL~ for ~; ~ee~°~~g ,~ :r~oney are valuables. UCDHS shall ~«t be liable for t`~e 'css of or damage to any money, jev~°elry, glasses, dentures, furs or other articles of unusual value grid shall not be liu4le far loss cr damage tc any personal property, unless deposited in UCDHS' safe or locked storeroom. 6. USE AND DISCLOSURE OF MEDICAL INFORMATION: The State of Califiornia Information Practices Act requires UCDHS to provide the following information to individuals who supply information about themselves: As a patient of UCDHS, you will be asked to submit information about yourself, such as your address any phone number, Social Security number, insurance information, medical history and treatment, and other persona! information. The principal pu~ose for requesting this information is to ensure accurate identification, continuity of medical care; and payment for such care. University policy and California and federal law and regulations auth~i~ize the maintenance of this information. Furnishing all information requested is mandatory uri(pss otherwise noted. Failure to provide such information may affect your medical care andlor insurance benefits and coverage. The information you provide may be disclosed to others, as described in ~tir Notice of Privacy Practices. You have the right to review your medical information and the right to request restriction of access to your medical information, as described in the Notice of Privacy Practices. ~~ FF // 1; yj -r~r~nn.~ ANt7 ~C)NDETlONS ~F SERVICE UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER ~~E PA'TI~N~~-~'~ b~3 ~~.~ ~ ~.2~ 9~~ ~ t ~9 ~7 ~ / P4- - ~('3 ~ ~~ ~ ~ ' * 1r ~~~! A ;„:~ ~ ~~.: Y 3r :' *•.~ CHIEF COMPLAINT * ~ ~ ~ ~ Y ~'--~`'~ 3 ~' ~~/~ BR? ~ ~ PULSE RESP TEMP PEDI-VJT . ~: 7 Pfl ~ ~ ~ - RoomTlme Room ~ 2 5 ~~ L.C~d Attending Tlme Name HISTORY OF PRESENT ILLNESS Seen by (Name) ~>~p ~ ~~ ~ Time ~ 2d DRUG ALLERGY Source of history: J~ent G7-dfher person ~''~ S ^ records from 3 (~ ~ ~ ~~ ~ ( / '~ ' w'~S ~~+^t MUNIZATIONS ~'T~ a ~/ ~ ,~` ~r~ „~w.s dC M/s4-, ~ LA c_ MEDs ~ . C O ~ /~.- ea i r W /L ( - l rn ~` c. c C •P Sm - k arc IiC.~ w ~ -~ b rt-s S_ MEDICAL HX Sca~~ -- r arl~ ,~ SURGICAL HX f u-i l /' K.(, ~ . FAMILY HX Nc SOCIAL HX l r'Yr s ~ ~; REVIEW OF SYSTE~AS UNOBTAINABLE: ^ Patient Unable ^ Patient Unstable MedicaVSuraical CONSTITUTIONAL: fever, chills, weight change SKIN: rash, hives, lesion HEMATOLOGIC: bleeding, bruising EYES: visual problem, discharge, redness ENT: earache, hearing change, epistaxis, congestion, sore throat RESPIRATORY: SOB, wheezing, cough, sputum, hemoptysis, pleuritic CP, leg pain CARDIOVASCULAR: chest pain, palpitations, syncope, orthopnea, PND, edema GASTROINTESTINAL; belly pain, nausea, vomiting, constipation, diarrhea, bleeding URINARY: dysuria, frequency, urgency, hematuria, nocturia Slash =not present, Circle =present Trauma rasi ns, ns c roblem, ac ood loss ain, vision c ange earlnose/moutfYaw pain, elusion ch SOf~ alpitations be ain em a GENITAL: discharge; abnormal bleeding, LMP pain, bleeding MUSCULOSKELETAL; pain, limlted motion, redness, swelling ~ecR/UE, LUE, RLE, LLE pain NEUROLOGIC: weakness, numbness, incoordination, HA, seizures, dizziness Hum Hess, weakness, LrAe'seizure PHYSICAL EXAPo7 Check ' exam finding: Circle area for description of abnormal or relevant finding GENERAL: SKIN: JJJJ~ __ . _ .._ ~" ~ ~ i ~._ . ^ nd4~~h ^ n sions ^ no induration Rb/~-s ~ a,~S i/~~~+-°~^ -~ hr< JL __ _. ... LYMPH NODES: „ .... Adenopathy: ^ no cervical ^ no axillary ^ no inguinal 5~."0.u (, ~-c _ _.'~ ~?-.~ ~t ~_.-"~i '- EYES: Aids & conjunctivae 0"PERRL, EOMI ^ nl fundi _ _ _ _ __ _ _ RENT: F}tte~d/face nontender l3'PSt TMs, canals nose, nasal passages ^ nl mouth, throat __ _. . NECK: -B~y'mmetric w/o mass ^ nl thyroid ^ supple _ _ _ _ _ _ CHEST: f~.Rentender ^ nl breasts _ _ __.. .. _ _. _ -_____ LUNGS: p-rd'effort~B~ auscultation ^ nl percussion .._.__ _ ___. _ _ .__ _ __ _ _ __ __ ._ _ _ _ CARDIOVASCULAR: ~-rtf sounds w/o murmur, gallop, rub ^ no edema _ _. _. ___ _ . nl cap refill Pulses: ^ nl carotid ^ nl femoral nl pedal _ _ ABDOMEN / GI: FJ-rlo'ntender w/o masses ^ no HSM ^ no hernia ^ nl rectal ^ heme (-) . _ _ _._ GENITALIA M: ^ nl penis ^ nl scrotal contents ^ nl prostate _. _ _ _. GENITALIA F: ^ nl BUS ^ nl cervix w/o discharge ^ nl uterus ^ nl adnexae _ MUSCULOSKELETAL: ~on er neck w/ FROM ~ nontender back, pelvis _ ^ RU UE, RLE, LLE ^ nl joints, nails _. .. _. NEUROLOGIC: ^ nl CN 2-12~C3-nh'~ensation ^nl.~Rs, no pathologic reflexes _ _ 'G ` _ _ _. _. CS ~.2~~ __ _ __ _ -rtt s ngth ^ nl gait~ PSYCHIATRIC: &O x 3 ^ euthymic ^ good judgment _ Impressions/Plan " c. SI? PA'~i~+NT PiLA. ~ [Q ~ ((^~~ .: '~ ^~ ,~ ' X41 ~ ~ -~, M1 f. - Pa ~ ~ °;.~t ESULTS ~~~5- ~~ ...._._.. _._._. ~._ _ ._.. _._____._~.__.__._.___._ _____r. __ __ ._._.._._.___ .__ .__._ ___ __ . _ ._______. O EKG _ _____ __ ___ ~_~ _-____~____W~~ ,_ ^ Radiology consultation to clarify results of ATTENDING NOTE -____ _.. __ 4, CONSUi_TATIQNS Time Called Service ^ ED REVIEW ^ Crisis _ _ _. ._ ..- -- ^ ENT _ _ _ ^ IM subspecialty ._ ____--___~ _ __. ^ Neurology _- _ __ Ob-Gyn _ . __ . _--- . _ __ ~O orthopedics ._ ._ _ _ -- ^ Plastic Surgery. _._ _ _ ____ . _ ^ Surgery subspecialty -__-_ _ _ _ ^ Trauma .---.._ _._~_ --------._.__ ^ other -----`~----- --- PROCEDURES (Note Time/Describe Procedure) ^ Arthrocentesis_ _.. ^ Casting/Spiinting r._ ._.._.. _ ^ Central Line _-_____.. x,11 i~-~~-LYL~~~>,'f.~ c ~1~r ~ ~~S___ ^ Chest tube .___._._~, tr ~~~~.~, ~-.- ^ CPR ' ^Cutdown__.._`~2.Y cz~~~..___~-B-tr~ _.~_..._ ^ FB Removal __. -U~~-__.._~_.._. .. _.. .. J~' ^ Reduction _.__..___.. _ ~ ~-~; ~_ ^ Paracentesis ...,_ ..._...,~'~'~ ~~' _,G~~'.__L._._~r'~i.L!1_.~'.t~e.~17___.__ ^ Thoracentests __ ~~'t-r~--~x ~ ~~ ~ _.~,.~_~ ^ Suturing _ _ ^ Thoracotomy __. !. ~`? ._ __~....~.~- __ . __ __.~.__.._ ....__ ..- ^ U.S.~_.._.. _ ^ Other _r.._ __.._... _ ~' ~" +'~. ` ~' t ~ ~ 5 ~`-~t7' l~'~~ ~..__. ...__ti_.._ ~.. . _ .___ __..__..________ _ _ __._ 1~ G~f___ ^ Present for performance of ^ entire procedure, or ^ key portions of procedure Procedure Signature/PI# _ _ _ D15POSITION s _:.~.,- . ^ ADMIT ~ DISCHARGE TIME Home (J' L~ ^ Police ^ Other DATE ^ AMA ~~~~ /~~ ^ LWBS ` CONDITION Improved rrt n Stable ^ Unstable ^ Ex tred ED Attendi ~ ; ;~. . ~ 113E ' _~, " ~~_. ,~ L „, <..~~~r~~ ~ . ; UNIVERSITY OF CALIFORNIA DAVIS '_' `' ''~ ' ~ MEDICAL CENTER ~` ~ SACRAMENTO, CALIFORNIA. A }~ /5~ ~ ~5 t ~~~~ ~?~~ r~+~ ~1~,V~~~'Wr~ A ~~ ~ ~ y T ~.. °~ f a ~ ~ 11/' /~ ~+ 9 ~/~~~Re~ .: ~ ~ n:, ~~~} ~ ~~~ ~ ~ ~~ s ~ , .p~w /~,` y` /p~~ ~ / •M~R 1hF ~'~~V~~hY ~ Lab ~ ,T 7 ' HEM~BC with dill ; ^ H&H 1&3 hr ~'MR "PTT n.y "- ~ ;. , ^T&S . Procedures Time Done Signature Results/ Site ^ T&C its CHEM ^ beta hCG Q Sa ne lock ~ _~~. _ ~c~em i (BMP) 1 . ^ IV-2 a ti ^ 02 se ~ p G ^ monitor cardiac ^ myoglobin ^ pulse ox ^ continuous __ troponin I ^ Foley ^ i&O catheter ^ NG tube ^ suction ^ myoRr 0,3,6 hr URINE U/A ^ amph/coc tox ^ FS glucose ^ serial ^ barb/benz/op tox ^ PEFR ^ serial MISC ^ ^ urine dip marine bedside p .~,;~ ~ Q,,,,, v"7 ^ ^ EKG ^ serial ^ X-Ray For order entry, fill in a-f ,~CXR ^ PAIIa~,O AP ^ bedsi ^ abd series ^ KUB ~~-spine ~~ ^ T-spine ^ US spine ~elvis AP ^ bedside ^ L ext ~'R ext W /'tGW 3u ., ^ head CT ^ w/o ^ w/IV ~ ^ abd/pelvis CT w/IV (trauma) ^ abd CT ^ w/o ^ w/ ^ US ^ ~ MEDICATION AND SUBSEt7~UENT ORDERS E' PI No. I Time of Initial Time Ordered ^ Old UCD Record ^ Outside Record Physician Signature Service/ Pager Time one Signatur 1 ~ b)'L G ~ ` ~~ ~ p D 2. ~U' 3• ~ O~•, ~ 4 '-~ ' - l s. 7. 8. 9. 10. 11. 12. 13. 14. 15. ~ me ! Signature ~ Site a Reason (signs/symptoms for each study) b PRIORITY ^ urgent ^ stat ^ life/deatl V,f{- p c OXYGEN ^ no ^ yes ,-.~ ~' o.K S ~ d MOBILITY ^ gurney ^ wheelchair ^wall e SUPPORT ^ N/A ^ tele ^ vent f PREGNANT ^ no ^ yes Order entry time By (signature) _~ Results/ Site T~9 . ... 4 r. e t~~l~~zt~rve_A-eE PRESCRIPTION: - D ' a~m q ~,. l r r< t r r, n ~Nma vs.. g tf~ ~~~ >~as 2~-1 S;s~ma G?G°~~~C~~~p~~Oo ~~ ~o A ~~~ aWaQ ~+ W ~ ~ o Vamp aoza ~~~U 2 OFZ OQ~+++ W = W ACTIVITY DEA No. License No. MD Signature MD Print Name ate ~. ^ No specific restrictions ^ Limited use of affected part until seen in follow-up ^ No use of affected part until seen in follow-up ^ Modified work/ no PE for days ^ Off work /school for days ^ No driving ^ Passenger restraint system required for children less than 4 years old or less than 40 pounds. Information sheet provided. MD Signature DISCHARGE INSTRUCTIONS: r` {i, ~1 f..., _ I 1 ~1 ~'^ - e:~ ~ i ~ C~ INFORMATION SHEET(S): [~'`' wound care INSTRUCTION ADJUNCT(S): ^. interpreter ^ head injury - ^ family ^ cast /splint care ^ demonstration of ^ back or neck pain ~.-- ^ other ^ crisis service ^ other '""`• OUTPATIENT FOLLOWUP: ^ Call for Appointment ^ Keep Scheduled Appointment f' ^ UCDMC Clinic - ^ Sacramento County Clinic ^ Medi-Cal Clinic PCP ^ HMO / GMC Clinic ^ other Eb LABORATORY & XRAYS: LAB TEST XRAY ^ CBC ^ CXR ^ chemistry ^ extremity - ^ U/A ^ spine ^ other ^ other ^ Call 734-7761 between 10 am and 10 pm for pending results of MEDICATION /TREATMENTS: ^ tetanus immunization _ ^ antibiotic(sj ^ other I acknowledge receipt of instructions -indicated above. I understand that I have had emergency treatment only, and that I may be released before all my medical problems are known or treated. I will arrange for follow-up care as instructed above. If my condition appears worse, 1 will contact my physiciat~or return to the Emergency Department. Patient'Sjciiiature ~ • ~ v- ~ `f~rovider~ianature 1 ~£, `• c~ nap TA~,t"S~ ~ ,~IG1= ~Y~ tit r:' r _ I r ~ ~, i ~ ' ACKf~W~~`~GEME ~ :~ .:F: PT: NOTICIE CF PRIVACY PRACT~E~.,~~~.. „~ ~ The UC Davis Health System Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. In addition to the copy we are providing you, copies of the current notice are available by accessing our Web site at ht~~//web.ucdmc.ucdavis.edu/compliance/ and may be obtained throughout UC Davis Health System. I acknowledge that I have received the Notice of Privacy Practices. Signature of Patient or Patient's Representative ~ ,, r II Print ~ SS Date d~ :~. ~~r~t1~Se~ris ,1_ K~STEM r~~ R ^1C ~; ~~ `~~, Relationship to Patient Interpreter (if applicable) ---------------------------------------------------------------------------------- Written Acknowledgement Not Obtained Please document your efforts to obtain acknowledgment and reason it was not obtained. ^ Notice of Privacy Practices Given -Patient Unable to Sign ^ Notice of Privacy Practices Given -Patient Declined to Sign ^ Notice of Privacy Practices Mai{ed to Patient -Awaiting Signature ^ Other Reason Patient Did Not Sign Signature of UC Davis Health System Representative Print Name Date Department USE PAT17=NT PLATE rt ?. ,. r. _ ~ b~s~ ,~-_ ~~.~ ~ ~ ~ ~ ~ UNIVERSITY OF CALIFORNIA DAMS MEDICAL CENTER SACRAMENTO, CALIFORNIA EMERGED Y DEPARTMENT .1.; PAST MEDICAL HISTORY: 8•P PULSE RESP. TEIAP, PUPILS PRESENT MEDICATIONS: PRE-HOSPRAL TREATMENT & SUPPLIES: D TE /TIME TREATMENT 1 VITAL SIGNS ASSESSMENT ~t ~t ~ GOC}r ~ ~' c't ^ v~~Z~ 4~ ~~._ 4 ~ ~ ~YL . ~~-itiL~M . Cam C I y ~ ~, ~ ,: ,~.~~ ~. ~~-~..c.n ~~w a-L~ ._....__...._..M.._..._.. ~, ~' ~ U `` ~. Irv - t ~~ C D - ._.___._ '° ,. ~`~-. `~ ,.t, .,~ .-' ~~` .~''~ " ,~ ;- EMERGENCY ADMINISTRATION qy Y-t try tN ~7 hYF°~' t ~~ ~~~F, A ~,°; +Y. L ~ 'v e-.' A G UNIVERSITY OF CALIFORNIA DAVIS ~. ~ ~ ~ ~ ~ MEDICAL CENTER, SACRAMENTO, CALIFORNIA TRAUMA RESUSCITATION ~~ ~d I~(~~~ ~~, ~7:!~'~8~ FLOWSHEET Ilafa•' USE F~ATIT .~'L~~ - ~ ~ ~ ~ ~ ~ 911 922 933 i v SMENT ON ARRIVAL._~'` ` - me: Acti ation T Time Pt Arrived in ED: "A" AIRWAY One) Description Patient - YE NO PMH: "B" BREATHING Spontaneous Assisted? ^ Y ^ N Medications: Labored YES Shallow YES O Allergies: Denies ^ Unknown ^ Latex Breath Sounds Present bilateral) Yes ^ No Last Teta us: LMP: Weight: kg. .. ~ "C" CIRCULATIO Radial Pulse YE NO Mode of Arrival; O Sac Metro ^ AMR ^ Private Vehicle Other: Unit #: ~ Bleeding controlled? YE NO _ CR < 3 Sec NO Location of Incident: Warm /Dry YE NO County of Incident:. "D" NEURO MECHANISM OF INJURY MOI n arrival: E = V = M GCS o = BLUNT: ~MVC vs P Intrusion amount: ^ MCC vs Speed: mph Sensation N/A Deficit Deficit ^ Driven Passenge ^ Fro ^ Back R/L ^ Unknown Moving All YE NO N/A Extremities Deficit = ^ Ejection Lap Belt ~ Helmet Descriptors: ft houlder Belt ^ No Helmet HEAD Rollover ^ Unrestrained ^ Unknown S / S Trauma? YES NO use diagram Airbag ^ Unknown ^ Carseat Nose drainage R L N/A mph ^ PEDESTRIAN vs Ear drains e R L N/A . Ejection feet s BICYCLE Teeth damage YES NO N/A TM's clear YES NO w . ^ F NECK ace ^ FALL: Distance Bur S /S Trauma? YE use die ram ^ ASSAULT: {type) SO Air YES N JVD YES NO BURN: Source BSA degree Trach midline S`' O ^ OTHER: CHEST / RESPIR OR LOC: ^ Yes o ^ Possible ^ Length min ^ Unknown S / S Trauma? NO use die ram PENETRATIN ^ GSW ^ SW ^ Other S mmetrical Y O Flail Cre itus YES Y O A: ^ ET ^ NT '^ NP - ^ OP Size: Cardiac Rh hm B: 02 ^ NRB ^ Cannula UMin ~ BVM ABDOMEN Ci r On e Descri tion C: infused mf ^ CPR Started (~ S / S Trauma YES use diagram Supine /Prone id collar ackboard ^ Papoose Ri Tender YES . g -check results ^ Acc li S Pre Want YES N/A OB notified ^ Y ^ N u nt: p ^ F l T YES NO N/A eta H Meds: Other. GU /PELVIS V/S: B/P P R S/ S Trauma Y use die ram V M GCS E Meatus clear YES NO _ ' IDENTIFY ON .FIGURE Pelvis Stabl YES O oden spontanepu a ~ s ca voice~acalizes ~nw a BACK " to pain 2 - wXhtlrawx 1 Inepp. words S none 1 flexion 3 incanplete sa,~ds z R ~„ L S / S Trauma YES O N/A -. use die ram exianson z none ~ ~ v DefoRrt YES use die ram none Tenderness YES NIA use die ram rl„e n~d~ed si~Nn-ruaES Mendaory ror rra~Fne ~~ Rectal Tone + - Guaiac + ~ G`~ eo unending EXTREMITIES a 3 eo Mo S / S Trauma YE use diagram ~ rmi YES D f N use dia ram e o g trauma Anendmg r PULSES MOTOR cNer ~i' R L R L ~~ Radial UE DP '' -( LE NP I R 2 Trauma PT Grip service Mo Quality Q) / 1+ / 2+ / 3+ / 4+ Qua-ity 1+ / 2+ / 3+ / 4+ / 5+ ~~~ E ~;3 .. iL1 ~} t ~r r . ~. at'.. ! e i:. !4 ~d ~i 1 A 4rf j `. ~~ <t~l ~1~ ,. ~ . ~~ 't ~~ Date: ~ i~ ~~ ~ ^/ ' Chief Complaint. . ,w__ ~_ Mode of Arrival AMB ^ Walk ^ Gurney ^ WC ^ Carried ^ lJ~tit # j GC~ E V M IV No ^" ~~s~7` SPlacement ET NT OP NP Yes ^ No ^ Type/Size Placement Collar ^ Backboard ^ OZ Given Accucheck Splint ^ Papoose ^ Meds given . BP P RR TEMP PAIN 02 SAT History None ^ -. Cardiac ^ Diabetes ' ^ Triage" Time Unknown ^ Primary Nilrsing Assessment cva ^ ,. ,. ..• .: , ._ .:,. allergies BP. P.. ~ RFi TEMP .. PAIN `.02 SAT tex NKDA. current coeds A.. Airway' '.Patent Yes ^ No ^ ` ' Last TD B. Breathing • Spontaneousrt Yes ^ • NoC~ nasal flaring Yes ^ No ^ Symmetrical •Yes ~ No^ acc, muscle use Yes ^ No ^ L$bored Yes ^ No^ s/s trauma Yes ^ No ^ • Shallow ~ Yes ^, No CJ flail Yes ^ No ^ ' Diminished. .-LT ^ RT ^ crepitus Yes ^ N O 'Breathe Sounds RT C. Circulation LT 'Cap. Refill <2 sec: Yes O ' ' No ^ cardiac rhythm warm Yes D ... No dry Yes O No Diaphoretic Yes- No Jaundiced Yes ^ .` No ^ Bleedmg,Controlled Yes ^ No ^ /A D. Neuro, GCS :~ E V M :. sporitaneous 4 orients 4°, 5 obeys comds to voice 3' confuse 4 localizes pain -, to".pain 2., ~ - iriapp. words 3 withdraws i1'one 1 inconip, sounds 2 flexion Pupil $ize R _ . `L~ none 1 extension none PERL Yes ^ No ^~ AccUcteck ' E. Serisation ~ ~ F. Pulses RA _` RL ~ Quality: 4+ 3+ 2+ t+ LA T LLB. Location: Rad DP PT . _ RA - RL -. G: Movement/Strength LA - LL ,Quality: ~+ 4+ 3+: 2+ 1+ Moves aN extterrtiities Well Yss ^ No ^ RA`_ RL LA ~ LL H: Pregnant `° Yes .^ No ^ Gravida - Para FHT Yes ^ No [] Rate EDC LMF " :OB_Notified, Yes O No ^ N/A C7 - Comments Dop. -~ COPD ^ CA O Psych ^ GU ^ Dialysis ^ Asthma ^ HTN ^ Seizure ^ GI ^ Other Head Yes No unremarkable ^ ^ nose drainage ^ ^ ear drainage ^ ^ teeth damage ^ ^ tm's clear ^ ^ Neck unremarkable ^ ^ sq air ^ ^ JVD ^ ^ trach midline ^ ^ Abdomen unremarkable ^ ^ soft ^ ^ nontender ^ ^ s/s trauma ^ ^ firm ^ ^ distended ^ ^ 'tender ^ ^ masses ^ ^ vomiting ^ ^ . diarrhea ~ ^ ^ last BM GU/Pelvis unremarkable ^ ^ meatus clear ^ ^ pelvis stable ^ ^ discharge ^ ^ color NA ^ bleeding ^ ^ pad Hr .Back s/s trauma ^ ^ deformity ~ ^ ^ rectal tone normal ^ ^ guiac positive ^ ^ tender ^ ^ Extremities s/s trauma ^ ^ deformity ^ ^ IDENTIFY ON FIGURE R L L R v A -abrasion AB :abscess B -burn D -deformity E - ecchymosi; ED -edema H - herriatoma- L -laceration P -puncture R -rash T -tender/pain UNK ^ NA ^ ..~ ~ . Time ~ ~; Time By Whom Procedure Size Placement Opening ..± Oxygen NC Mask , Best Verbal Rtsporise ." • : "t f~i °; f n-. r't ` ~ ~~ ~, c. • L Mrn N '`E` Best Motor se; R sp .i.. .x a _.. '-~ ' « ' • ~' ~4~~ '-~~~~ ~ LL,, VO ~ e on . Chest Tube ~~ 1 Gl~'scoW•Corna Scale Score i ~ ~% t k-? ... . ' ThoraCOtOm ;~U.. inlutiated. 3 = "~ ° onverse 2.-May Converse 1 . None_ Appears to C ~ . y Response Pu illa 1s NG/OG p ry ~ ~ • Ri fit g ~ el"'~ ,~ Foley O {~ 8 2. 3~ 4.5~ 6~7 Bnski ~+ - slue ish~ + . Niinef 0 Lett ~ ~~~ ~ 2~. , I EKG 5treyngth: '.. a§sess 2 = Unable to move against U = Un3bie to Right . ~ ~ ' ~" . ' . ` , . Splint 3~ 5 = Nom>at gravity 4 ~ Slight weakness ~ 1 Trace ~ L ft'` ~ _ Ice Pack = 3 =Moves egainst.ptavfty -..0 L None' e ~ `. , ~S T ` Wound Care ~ " ensa lon: Tingling t'=Normal,.,: ,_ T= flight ~ ~ ~/ Warming measures ;R . ~ ? =Hypersensitive m - No sensailon ~ -Numb ~ ll -Unable to assess - - Left ~~ ;C Mucus MembraneslSkin: = l Color T ~ y ~ f ~ f / f ~ I ES A F =Flushed M =Mottled C -Coo .. emp y , .~ W L, = . - IV L N P -Pale J =.Jaundiced D. Dry^ J R N ~ Normal W -.Warm ' M -Moist :•-. Character ~ ~ f D Pulses Radial. ;. ~ 1+ =Barely Palpable D -Not Paipalile RighC o4~~ ~ 1 ~ ~ , F ~, Incubation a OS ;~ 2+ =Weak D =Doppler 3+ -N al + Radiril y Ventilator . ,v , orm , . ~+ = FuII Bounding ~ Lett ____ o•p~ ~ / ~ Mode Rate TV FI02 PEEP Capillary Refill Number of Seconds " - A S ~ N - Nomral R =Rub D =Distant Heart Sounds: ~ i ~ ~, '- ..., M.,= Murmur..., G = Gallo FR = Fi9cti4n Rub . IV ~ N CBC Chem 7 Lip Pt PTT >13k~ ~ , •~ ~ U ~. CMS A -'~ Intact f5istal to: - Art Line C =Cast R =Restraint F ~ em Life : B =,Bum T =Traction T & C/T & S L Edema: G =General Bk =Below knee Right ~i~ ~,u>~ `_ i f~ ~ / U `~ P =Pedal ' F Facial ' ,Z` ~O UP A S =Sacral ' Prnirlg ~ 1+ 2+ 3+ ~}~ CBC NO dill #2 R A = Anaserce o None Left ~ Q ~~,- CBC NO dill #3 Chest Exparlsfon: S =: Symmet"rical A = Asymtnctrioal __.. P trachea: M = Midhne R = bewated Right L =Deviated Lest U N No Distress a = RetreMirnis i i p ° esp rat on:. L =..Labored A = A neicl# Seconds . N. Myo/trop 3 ~ Breath Sounds ~ Ftut. Myo/trop 6° M , 0 =Clear . ~ =Diminished R'i M g RML 0 F0 =. Fine Crackles 0 =Absent Cb =Course Crackles ,• S = 5tddor RLL `~ W .p Wheezing FR =Friction Rub LUL ~ ! ~ • ~AA fi fili ~ Rhoncht ~~ ~ Left 1.L1, /f l.,l 'Time Done Time Done Stud Stud ~ Secretion; - -. S ~ Small tH =Thick r =Green Amount ` - y y '_' ~ ~ ~ Med N . =None T -Tan M Cbhsisterlcy • _ . -- -- Ultrasound C Spine ~. ~ L =Large 0 = Clear 6 =Brown B d f h - Cobr ,~ -- . .. - y in Y =Yellow L = B oo t =T ,: Pelvis '7 ~L T Spina Gastromtestilial nbtlomew Abd VS Spine S =Soft R = Ftigkl N =Norma! 1 ~ Hypo D =Distended t = Tender T =Hyper 0 = Nohe aowat Sounds - CXR ~~ CT Head _ NG`t/OG1': F~tacemeni verified by Aspiration _ Extremity ~ CT Abrl ~ pNlGuaiac: ~ ~~ _-- ._ ~ .~ r-, i DntviS _. ~ -_ ' . (a8SII1C OUtptlt: C=Cleai G=Green B=Brown BL=Bloody OG_Calfw Gtcund , ~. - '---- - r; r rl~:~k TIME BAG # BLOQOb PRODUCT SITE # INFUSED TIM E ~1 M1 SFE C;IP Y VO Scan NITIALS !tt>lGIC? N ME• -.. __. _.._....._...._. / 1 . ------.... ___ ._ ..... ...._......_ _._l ...._.... _...__. .. .~_ . I J. _ _i ~~~ ~ . _ N __ ~_ _ _ _..,.._ f _.,.. _. ._ ~ ._ 1 ~t:rlbe RN ~ ~ i : t ~ RN "I'C?TAL TOT AL i t'CU. YHlIV HJJCJJIVICIV 1 I~UIUt ~:>t+~~~ PAIN TOOL/RANGE ~ - 1=NIPS (0-7) ' # ~ -~ ~ ,~ -.. ~ ,.I Ok : , ~ C ~. •~ ~ G l 1. $ `% ~ ?` ti cr ~ y ~ ?~NAPI (0-11) I ; ;.-: ~ ,~ 3=FACES (0-5) ~ ., ~ ~ ~ ~ ~ ~ 5=Numeric Scale (0-10) " ~ ~ F ~^ ~ ~. 6=Comfort Scale 8-40 ,' 7=Unable to access, (e.g. chemical paralysis): own o~ ins o ccGCCnn~~n~-r ri {{nF { {~Fn ~ o~:~ T..~, ~,~~a ~,m ~~~, ~~..,_~,.,, o~c ~. - - - - - - P ~ ?.r'7 t ~ t ~ '~ ~ RR ~ ~ ~~' TEMP ~ '-~ 7 '•-_ \ ~;~ ....,,~ , PAIN --~' y ~ {(1, 02 SAT ~ ~ 7; / Gcs l ~ t ~ 1~ ~~ . ~ _.._ Rhythm ~ << . ~. \ Init. MEDICATION U D06E TIME BY 511 t rtVU I t /' , - ~ RESFONS -~:--- ~ ~ L 51± RESPONS RESPONSE RESPONSE RESPONSE " ..~ ~, RESPONSE RESPONSE _ TF'ime r 1 '/ ,-~~t RESPONSE ----#_..,.... -~1 -- ~ ~~-~`'`~~7 ~ •--.._ ~~.._..! _ _ _ . • }, RESPONSE _._.U ~_ • . 5,~..t,~.i~. _ il,_~~ _#'_'~- .. _ _.. _ .____ . - . <<~ - RESPONSE -~--_r~_..._~ ... ~ r Y' '~ _ ~~~~ ti ~~~ 1~~-~ ~. YY~~.~ RESPONSE ~ .. ~. ~~~~L..~4~?~ ~~1C~!'...`-"^•~ Clothing Shee# Complete Yes D No ^ - NA DfSCN~1R .-- ~^ ~ec~ EKG Strtps Orders /::~lutses Notes Faxed Yes ^ No. EJ NA ~ ~, can back t7 __.__- CONDITION AESMIT Cl #3i~cha ,~ ~fi5 ~ i`~_- Garr-rnpr~t~: Improved Transported by #N C7 #ns~uct >~>s t~ pa~ert# i~ ~ - .,.~ _..______ we ^ Crutches ^ ~et"13itii.7e~ ttrtdt2i-'tdit`!g ids G# ___....._..., .__..... c _ ,~ .. Stretcher ^ Handaut~ G:pert, std iv] I .~. ~. -- .-_ walk !~ List w.._~.,,._.__ ~ ~ _~ v ~._~ .. _~„_ ,.~_...~.~__._-_-- !'~! Infusing C7 ,""" Armband d i`a~rx1ltu,~ t~eedG ieSSe Y~:~.C ~o t7 _w.=. .__.__ __ Green =All Patients . Rid = Atl Trauma 1 tG~ P`~ti~~lls. S~lei:iiy:~~~ ~T ~- S~ \, LAW OFFICES OF ~ ~( "' DICKIE, MCCAMEY & CHILCOTE, P.C. 6 /// c~ 1200 CAMP HILL BYPASS '~ Q/ SUITE 205 CAMP HILL, PENNSYLVANIA Q 6" 1 701 1-3 700 TEL. 717-731-4800 FAx. 717-731-4803 W W W.DMCLAW.COM Misty D. Lehman Paralegal Carlisle Pediatric Associates 804 Belvedere St. Carlisle, PA 17013 ltE: ?aige Lee Ta~l-~elm DOB: 11/2191 SS#: 199-72-2463 DOA: 6 Our File N F-168 Dear Medical Records Clerk: mlehman@dmclaw.com June 23, 2006 ~~~ ~ Enclosed please find an executed authorization allowing us to obtain the records and films of Paige Lee Talhelm. Kindly forward his entire medical record chart from before 06/26/05, to the current date. Please be sure to include: • Any/all hospital admissions including consultation reports, discharge summaries, radiology reports, nurses notes, doctors notes, and history and physical, etc. • Any/all doctor's office visits, including all bills • Any/all medical reports you may have in your file pertaining to this patient. • Please note that this medical authorization will expire after one year from the date this patient has signed the release. • These records are required for the specific purpose of legal investigation Please forward his medical records as soon as possible directly to my attention. Of course we will reimburse you for all reasonable copying fees that apply. In the meantime, should you have any questions, please feel free to contact me. Very truly yours, DICKIE, MCCAMEY & CHILCOTE, P.C. Ilti rt~ 9.~ s--~ Misty D. Lehman Enclosures PITTSBURGH + PHILADELPHIA ~ WASHINGTON, D.C. + NEW JERSEY ~ NORTH CAROLINA + OHIO + WEST VIRGINIA 412-281-7272 215-425-2289 888-434-5566 856-354-0192 704-334-1108 740-284-1682 304-233-1022 PROGRESS RECORD ~~ ~1-~ -~ ,r-ec~ r~S~ GSM _ 11" U ~ S = ._. L; r.~ ~ S ~ ~. ~ u C r ~kya rw.~ GL. nt Nf P/~ /J~..ct~ lc?~.G. ~ Zr w„roCro~. Q,-ou,~wl~a-~. ~ ~ r~u.[ ~ O~e.Lo-c ~ ~t Tc~ /~,,., n(~,/~,~ ' ~J" '' ~.t~r~..ct.~ ~( ~r.(.Lli.td c Jam: 2~ ~(u ~.w~ X//.l.r. ~n~. _ ra ~ ri C. n, n (.:. , n'~ ~ O~wC., a r~ c l.~.cV ' I t ~L- Q v-, • ~,,,~ /~J /~ 1 Gv (' ~ L J S pp `~ ~c~ ~~ J o~rN• . ~-_ ,~„ a ~. ~~~---- I -~-~I -05 r~~~ Yv cs ~ r~ VJr,~_v~cAG ~ .P, PROGRESS RECGR~ ~~ • tr ~ ~' ~ - OS ~.Sg / W ou,~U -T , r~.t / ~ TEMP BP HR taENERAI _- EYES THROAT JVECK +~EART ~ V ,T vV. L K .~ S l d- ~ ~ ~~ EXTREr4t NEURO. ~ . ~ S ~'~ i n i -~- - ~. 3 • AUTHORIZATION FOR THE RELEASE OF INFORMATION INCLUDING PERSONAL HEALTH INFORMATION PROTECTED BY LAW Patient Information: Name: Paiee Lee Talhelm n Date of Birth: 11/2/91 DOA: 6/26/05 Social Security Number: / ! C~ J ~ ~ ' a`/~ 3 1. I authorize the following persons or organizations ("Releasor(s)") to release/disclose information about the patient identified above in accordance with the provisions of this authorization: Giesswein Plastic SurQerv. 5 Brookwood Avenue. Suite 1. Carlisle. PA 17013. 2. Name and address of person(s) or organization(s) to whom/which health information should be released/disclosed (ARecipient(s)@): The law fum of Dickie McCamey & Chilcote P C its employees agents and expert consultants• 1200 Came Hill Bvpass, Suite 205, Camp Hill, PA 17011. 3. Purpose of disclosure (intended use of information): Review evaluation and/or use in connection with a legal claim or lawsuit or potential legal claim - 4. Description of infom~ation: a. All health information and other infom~ation and things about the patient within the knowledge of or in the control or possession of the Releasor(s), no matter who originally prepared or received the information, including but not limited to: X All information related to diagnoses, prognoses, conditions, tests, procedures, surgeries, treatments and care, including but not limited to the following inpatient and outpatient medical/health records: orders, notes and reports of any health care provider; history and physicals; admission records; discharge records; medication records; clinical flow charts; tests and test results; laboratory, history, cytology, pathology, radiology, autopsy and other reports. X Films, videos, CDs, disks, tapes and other media on which information about me is kept, including for example, x-rays, CT scans and echocardiograms. X Specimens, hardware, blood or body fluids from my body, including specimens contained in blocks and slides. X Pham~acy, drug and prescription records, including NDC numbers and drug information handouts. X Billing records, including all statements, itemized bills and insurance records. X Office, clinic and other medicaUhealth information, records and notes prepared by or for, received from others by or maintained by the Releasor(s) or their staffs, whether typed, handwritten or in other forms. X Memoranda, letters, a-mails and other forms of communication about me, whether created, sent or received by the Releasor(s). b. The following information may also be released unless my initials appear after the word "NO": X HIV-related Infom~ation (HIV is the virus that causes AIDS) NO X Mental Health (Psychiatric) Records NO X Information concerning drug and/or alcohol dependence, abys~aftd/or treatment NO ~, sKG_ foJ~GC ~ (1 S c. Other specific information: My/all medical record n the above referenced: inela~i n~i o~ d. For the time period 6/26/05 to present 5. I understand that: a) if the Releasor is a health care provider, the Releasor may not condition treatment, payment, enrollment or eligibility for benefits on my execution of this authorization unless allowed by federal law and I was informed of the condition prior to the treatment, enrollment or benefits; b) there is a potential for information disclosed pursuant to this authorization to be subject to re-disclosure by the Recipient(s) and no longer to be protected under federal law (45 C.F.R. § 164.508); c) unless earlier revoked, this authorization will expire 180 days after the date of execution; and d) this authorization is subject to my written revocation at any time, but my revocation will not affect information that has already been released or disclosed. (If the Releasor is a Health Care Provider, a description of how to revoke is provided by the Releasor through the Releasor's Notice of Privacy Practic/e or through,'other means.) Date:=. )~ ~ I (`~~~ rd - G.E' L!~ 1 ~4 L.F}~L-t,~~ ~ [Signature of p1atient]I c., If patient cannot sign: ~) ~ "~ ~! u~ - I f ~ J~~( ~~ [Signature of authorized representative] [Relationship to patient or authority to act on behalf of patient] PYOyYess Notes ., .~ - ~'D !~'~SS Ot~S' e20381 -Medical Arts Press 1-800-328-2179 PYOyvess Notes BIRTHDATE / PAGE ^M il~D~/91 - - ~~~ Paige Talhelm • - -' '+"`-' -••-^• ~~+•a• 08/04/05 CC: Wound, right arm. HPI: Paige is a 13-year-old who is known to me from previous unrelated care who now sustained a wound to the right arm secondary to a MVA. O: It is a superficial abrasion. There is some traumatic tattoo seen in the skin. There are no open wounds. I examined the entire extremity. The patient has good ROM of her shoulder, elbow, wrist and fingers. She has good capillary refill and sensation distally. She has good gross motor strength. P: I explained to mother that for now I would like to like the scar mature. We will the see how the cosmetic result will be. In about six months we can then discuss if there i anything that needs to be done in order to make it look better. I also instructed moth and patient in great detail concerning sun protection and scar management. PG/naz C 0-~~.-~o,~ ~~~p ~~S Ott' Y203B1-Medical ARS Prosa 1.800-328-2179 Consultation Note Patient Name: Paige Talhelm Date: November 21, 2001 Chief Complaint: Crush injury to right index finger. HPI: Paige is a ten-year-old Caucasian female who was brought in by her mother. The patient had her finger crushed last Monday night in a car door. She was seen at Carlisle Hospital where an X- ray revealed a Salter II fracture. The report was reviewed and so was the X-ray. I was asked to see the patient in follow-up. PMH: Is unremarkable. The patient has always been very healthy. The patient has never been severely sick. Medications: The patient presently takes Keflex and Tylenol with Codeine for the pain. Allergies: None. The ROS and past medical conditions were done. FH: Is unremarkable. Father and mother are in good health and so are two brothers. Examination: Ten-year-old Caucasian female in no acute distress. The patient has some swelling in the tip of her right index finger. The bone is not exposed. The patient has limited ROM of her DIP joint, but overall she seems fairly comfortable. There is no axial deformity. There is some subungual hematoma, but I cannot entirely see if the hematoma was drained. There is a little bit of crusting on top of the nail, but I cannot remove it because of some discomfort. The epinuclear fold seems to be intact. The patient has good capillary refill and sensation distally. Plan: I discussed with the parents the need for protecting this finger. She most likely will heal the injury spontaneously without any further need for medical intervention. If there, however, should be a problem, the parents know to call me~ Peter Giesswein, M.D. PG/nar CARLISLE REGIQNAL MEDICAY, CENTER RADIOLOGICAL INTERPRET~ITION PATIENT NAME: TALI'lELM PAIGE Y, X~RAY#: 463132 EXAM DATE: 11/1.9/2001 ORDERING: DONNA M. FEHRENBACH,MD ME ATTENDING: CONSUI,~T ING : HOLLY C . H . T~3OFFMAN, MD PE HISTORY: FINGER INJURY/PAIN ~'IN4ER ZNJURYf PAIN RIGHT INDEX FINGER MED REC #: 463132 ACCOUNT #: 92121.55 D.O.S.; 11./02/1991 ROOM: ER There is a 'vertically oriented fracture through the distal phalanx of the index finger. This dose not appear to vioJ.ate the epiphyseal plate which would therePare make this a Salter II type fracture. IMPRESSION: Nondisplaced Salter 21 fracture of the distal phalanx of the index finger, f Ih2ia~ SI M DANE WALLISCH,MD MED INTERPRETING PHYSICIAN DATE DICTATEb: 1.1/20/2001, DATE TRANSCRIBED; 11/20/2001 IOATE SIGNED: 11/20/2001 TRANSCRIPTIONIST: LMW 8674906 REPRINT FINGB,R(S) 11dTN 2,VTEW5 PA4E Z OF 1 Z0/i0 3J17d QC~I dSOH 31SI'I~Id0 8bL58bZLtt 89~9t T00Z/tZ/ZZ [ledger] Giesswein Plastic Surgery PAGE: 1 PATIENT LEDGER GUARANTOR #:049901-00 PATIENT #:049901-01 ASSIGNMENT :yes-yes LAST PAY DT:O1/30/02 LAST PAY $ 17.20 LST PLN PAY:03/09/06 LST PLAN $ 35.00 AT COLLECTN: 0.00 INSURED #1 Talhelm, Michele 113 Woodview Drive Mt Holly Springs, PA Talhelm, Michele Talhelm, Paige L 113 Woodview Drive Mt Holly Springs, PA 17065 EMPLOYER NAME: REF DOCTOR:hff Hoffman, Holly 17065 DATE :06/28/06 D.O.B:11/02/91 CHART: HOME :717-486-4808 EMRG :717-486-4808 EMPLY: S S #: CLASS:aa DR:png INSURED #2 Talhelm, Kevin 113 Woodview Drive Mt Holly Springs, PA 17065 PLAN 1 :CSAA POLICY #:061B01202 FR:**/**/** GROUP #:date 06/26/2005 TO:**/**/** DATE BILL DR• CPT/PROCEDURE 11/21/01 144711 png 12/28/01 12/28/01 01/30/02 Payment Notes: First Form Printed Last Form Printed OFFICE: gps 08/04/05 210851 png 10/27/05 02/09/06 03/09/06 03/09/06 Payment Notes: First Form Printed Last Form Printed OFFICE: gpS PLAN 2 :AmeriHealth POLICY #:01349657TPA GROUP #:094737 CHECR #•PLAN FR:**/**/** To:**/**/** ~~ ~~ 99242-Office Consultation - Level 2 0 PAYMENT-THANK YOU U$06453890:United Healthcare I Writeoff:United Healthcare Ins Co PAYMENT-THANK YOU 1504 pt resp for United Healthcare Ins on 11/27/01 for for United Healthcare Ins on 11/27/01 for Dx:816.12-Open Fracture Dis 99213-Office Visit - Level 3 PAYMENT-THANK YOU 0000 PAYMENT-THANK YOU OOOO:CSAA PAYMENT-THANK YOU 3845641:AmeriHealth Writeoff:AmeriHealth No response from Insurance Carri Benefits exhausted $20 copay for CSAA on 08/08/05 for for AmeriHealth on 02/09/06 for Dx:881.10-Complicated Forea Last statement printed on 06/05/06 for CURRENT 031-060 061-090 Patient 0.00 0.00 0.00 Plan 0.00 0.00 O.DO 146.00 68.80- 60.00- 17.20- 146.00 E?nl 146.00 E?n 0.00 <------ 0 70.00 D.oo 0.00 35.00- I5.00- 70.00 E?n 70.00 E?n 20.00 <------ 20.00 Balance for Talhelm, Paige L 20.00 Balance for Plan 0.00 09i-120 120+ 20.00 0.00 0.00 0.00 AMERk;AN MEDICAL RF°SP~ISE•-SACftAMRNTQ VAL4.EY Patient Care Report C~~~!~" s~RwbsP ~ ~ .ak ®ia,~a. ales Nei = ° ~ i~~Sq ~A99E981~1~NT11 TR~NSP.~pE PR~l11TY T~TIME E `..: c•^• •7,/ ~,/~ +{ ~! PORM NO;F 7 .L LI 6 2 LACAliO C3 AS AE63 PtiONEi DpNERSi.~. ENr NAME {LAST, sn t ~` D MO 9 ~ , ~ ^ MALE EMALE Rar~Nrs 4d J ~ s ?70 ~~` MEpICAL. HISTORY UNKNOWN EI? [] MI ^ GHF ANGINA ^ COPD CVA fl NIGH ~P D DIABETES D CANCEA ^ SEIZURES CURRENTMED(CJQ1QlVs C] UNKNOWN p UNKNOWN Q DENIED WEIGkff KG TIME GCS E M M 6P PULSE RESP. EKG BY TIME GCS E V M BP PULSE flESP. EKG BY 6 4 ~ ~ ` ~ tQ 1 ~ ._-- HEAP Vrtll HEC "' ~0 a wNl PUP _ - CIlEST r ssr~'o ~ iL 6t+Nti Sa0Na9 -a.A:,y[asEO a wrK CnAi~9 . Ae W1A. EiACK .G-DawNl. r gL00D TIME. P6WIC seDawwl ~7cTREMITIB9 seEOaw-u dd CAPAF~ILL eK1N rL7A6S SsED3YrNl NEURO ~A88£89FDaWNI C CPlKSTART 8Y ~.- ~ ~'4'a ~ ~Cr` t a a.S ' d O n ow e. o ~ i G ~ ~ ~ ,~ Pa o ~ ~- ~~ l a ~ en ~- ~ ~- n (' ~ 4"^ c TIME: OXYGEN RY' ^ MASK ^ CANNIULA ^ BAGWLWB l7 HHN ^ PULSE OX boforeOt ~ aKerOt AIAWAI~ GAG ^ YE9 ^ NO TIOM DYES ^ NO ^ OPA D N . ^ NTI O OTi_ O NEED4E CRlC TIME; ET SECURED AT CM AT THE USING B • ANATO TUBE St7~: NUb~ER • d + kUNG SOUNDS ^ +~ CHEST RISE ^ OHORRS VISU M.D VERIFICATION SIGNATURE: Ta7AE Fl.11L03 UTION9 QAUGE LOCATION RATE' 70TALVOL NOFATTEN~TS BY 10 ~ - D TKO ^ oPEl~l ^ sows 2 ° 0 ^ TKO o aPt.p ^ saUs LNdMOBI[.IZATION: ~x fl 11M8~ q 1=X1R1ClQLt1N ~~~ E Ll LATEWyI ^ PROb(E [! SITTING p FAD ELEV. t7 FEEI'EIEV, CATION, DOSE, ROUTE, TREATTIEN7 AND A6SPDNsE 8Y nME MEDKATION, D06E, f~UTE, TAEATMe-rfANDRESPONSE BY ED TIM@ M I yy .. ,, Zv ~~ ~ ~ TIME: HOEPITN. CONTAOTF.De q RCN ^ AFH ^ SDH D WMH Q MAR d SGH Gl MSJ C] MH9 C Q NONE E Cl AAOIO ,,,,* ~ MA. FORM LEFT WRT? ^ YES ^ NO CONT ATTACNEO? Q YFS D NO L~ST1 fF i] AA9 p TU ~r'' D PVT M.D. D PTFAMILY REQUEST p LAW p TPAUMACPoTEfl1A Q CLOSEST HOADER ^ RSION p SPECIALTY ER ^ Q DDS Q COMMUNICATION FAIwAE ORDERS E.D. OV1GN0319/COMNiENTS ^ DEAD AFTEfl RFSUS. CI EXPIRED E D. [] ApM1T q HOME A TRANSFER E $L NG RE ORT SIGNATURE: d ~P ^ I SEW RY ti1dT SIGNATURE: A MICP '~'bNr (Ar1GLh, N PRECEPTOR SIGNATURE, o MIOP D Ebf1 q on~Air•i~.ae f l 1 ....741 V'~~I ~ BILUND OFFECF. CORY nuvtaee~ i lrsv S RUlZ I~nh;b~1- 7J rµitMF 100 41 94 111 1~rd~n Sas~m~n I'ai~' Talhclm Michele Pt~s^~cnci Michele Pc~ssenti Micheir Pc~~.~nti Pa~c T"~Ihetm ~Xh~b~t E FROM :CARL PEDS FAX N0. :7172436706 May. 25 2006 04:43PM P2 CARLISLE P'EDlATRIC ASSOCIATES A PROFESSIONAL CORPORATION STEPHEN J. KREE3S, M.D. HOLLY C. HOFFMAN, M.D. J. LYNN HOFFMAN, M.D. ELISEO ROSARIO, JFt., M. D. DEBORAH RAUBENSTINE, M.D. ELENA MAN, M.D. DIANNA RUDY, PA-C 804 BELVEDERE STREET, CARLISLE, PA 17013 May 25, 2006 aa3-lsaa To Whom It May Concern.: R..e. Samuel Talhelani, DOII )-15-97 Paige 'falhelm,l~OF3 11-2-91 Jack Talhelna 1.)013 1-10-99 'Phis latter serves to document that-all medical issues related t~ the .motor vehicle accident i.n which thane children were involved ou 6-26-2005 have resalvcd or have concluded treatment. Jack at~d Sain were cleared on their initial :follow-up visit here on 7-5-05. Paige required multiple visits for dressing changes and wnuad care for her right arm, but her injury healed by August 2005 and she has needed no further treatment related to this inj~cry since that time. All childrexl are now cleared from their medical injuries in reference to the ahvve accident. Thank you. With K.egards, C., dolly C. kloffman 1VlD II ,w, i y``~ ~~1 X .'.~~-AMERIEAN MEp~CAL R~SFONSE-~SACRAMENTQ VAU.EY bsfls~~ f~:r..e !'J.4..w.i ~ ~ ~ ~ ~ A AN M DICAL RE$P $B MAeTER # ~I #} ~ VIE T-- -- - -- E ~ E T.. EST ASSESS ~ >xET TyA~~SP 1~IE ?RAN9R W P 11flE~F,y~JST. AVA(I.ABiE TIME FaRl4k NO '] L+ ~ ~ O /(~ L-- B f (J CALL. ~. L3 >~A~AB P ADDRESS PNON i ~"~/ r ~~ DRIVER'8 LIC, - PHT~~'(~ Jf C ~.- AaE O ,0 ~~ G7 FEIWALE PAl'IEN1' ($fRE~fl ~ _ ~7r~1a ~ I S .N .J ~ '~~ ' ~~ M~C+U. HI8'foA R UNKAOWN OfN p MI [7 GHF D ANGWA O COPO p CVA . q HKiH BP ^ pIAB$Tf.B Q CANCER CI ~1711AES _ , CURRENI'MEDi0AT1ON8 C7 U KNOUIW~! PETIIED ALt,ERl31ES(!YlED) p UNKNOYYN EA WEIQNT KQ TIME 4C8 ~ V BP PULSE • RESP. - EKG SY TUNE GCS E V M 9p PUISf pESP. fKG SY 6 ~ /~ ~ a a o f a .~ ~~ PUPIt.s a ~. cH~sT •~assfssent!µn • At#DOM~1 S,,n tWNI. • ~, U ^+sapa ~- 9 ' aaesESgevawNL .+ _ N CR4t+ils MECH. ANAT. BLOODSU(iAft TIME: f~i-VlC ~ fp WNk 6 S /SSE~.Pt CAPfiF71LL SKIN Cl +kwrn NEUAO Q am~L CPR START7f-~ BY ,-- -'- .. A ~~ ' °~ ~. :~ < - o~ r ~-- .- ~. z' TIA~: OXYGEN lJM pY; Q MASK ^ CANptlllA q BAGVAI.VE p HNN p PUi•8E OX: b9faraOi ~ efterOt ARiWAM QAQ E9 ^ NO ~ p YE9 NO ^ OPA ^ NPA p Nll ^ OTI ^ NEEOLECRIO TIME: fTSECUREO/IT CM AT THE TOM USINQ ¢y,,_._~.-„_ TUBESlZE: NUMBERATfEMPT3: L7 = LUNG SOUNDS C7 m Cli RISE ^ CHORPS VISUALIZED M,D. V~FICATKNV SIGNATURE: TgdE D6 SOLUTIONS OAUSI~ L44ATION TE ' TOIALVOLUME k OFATFEMPTS BY G IY a p p d TKO p OPEN O BOWS ^ lV $pyo - - -taTKO_ narEEN ppaWS IMM08N-RATION: 'NECK BWCK Cl LIMB(31 p EXTRICATION ~~~ SUPINE _ p tATERA~ p PAQME ^ StTTNrG CJ FAD ELE-' D FfETEIEU TIMF ~ MEDlCATION,DOSE,ROUiE,TREu1TMENi'ANDRESPONSE BY TIME I,AE:aV~qTSQN,~39F,RUk>;fE,7REATN~NTANUHF,SPCi~E ~y • TIME: HOSP1IXL COFJfACTED: C] RGH O AFH d SDIi Q NE MIICN p M.D, 1=UR1d LEFT WRT7 N(1 CI MAR ^ SON D MSJ D MHS OMC C7 NONE q RADIO ~ CONT. ATT ED4 O DFSTINAT j•~ L7 AA& TRAN9FERREbTO: d PVt M.A. C] Fi~pMILY RBQUEST 1J rERU1 ' p CLOSEb1' ' p 11 d T ORDER p DIVERSION ^ 9P000ILTYC NTER BTANOINGORDER6 COMMUNICATION F/Ui.UREORDERS ~~ O{NQ~{8S{SfOOl~#Q~fiIT$ ^ DEADAFTER t7 EXPIR£DE D. p ADMIT fJ HOME O TRANSFER • EMTCOMPL SIQNATUHE7 ^ MCP a EMT SECOND R MICPr.i~NllT PRECEPTOR SIGNATURE. a MICP ^ EMi PRINT NANIF•. 91LI.IN[J OFPIOE COPY RevfSeb 11/85 S RUIZ a Talhelm, Jack (MRN 1769580) UC DAVIS HEALTH SYSTEM Imaging Results cHEST z vlEws i;oraer# ss~s~~s~ (Acc# 2s29s~ PACS Images Show images for CHEST 2 VIEWS [RADDX009811 Click here for General Information or Troubleshooting Tips on launching PACS Images from the EMR, or contact I.S. Customer Support at 734-HELP. Results EXAM DATE: 06/26/2005 CHEST, 2 VIEWS: CLINICAL HISTORY: Status post MVA with pain. FINDINGS: PA and lateral views of the chest were provided for review without previous films for comparison. The lungs are clear and the costophrenic angles are sharp. The cardiac silhouette is within normal limits. There is no tracheal deviation, the mediastinum is unremarkable. No bony or soft tissue abnormalities are seen. IMPRESSION: NEGATIVE CHEST X-RAY. SH:cm(rad020) ACC#: 000000028296 D: 06/27/2005 12:12 AM T: 06/27/2005 01:09 AM C#: 1092835 signed: Stephanie Horton, D.O. cosigned: Kiran Jain, M.D. Result History CHEST 2 VIEWS jOrder#6678178~ on 6128105 -Order Result History Resort Exam Exam Date Exam Time Information 6/26/2005 2210 Result Result Date and Time Information 6/28/2005 10:40 AM Status Final result Patient Patient Name ililgN_ ~ DOB Information Talhelm, Jack 1769580 Male 1/10/1999 ~i Room I i n EMER ERWB N COPY -Protected Health Information - 08/30/2006 14:02:59-MR0202 Page 1 of 2 Talhelm, Jack (MRN 1769580) Order UC DAVIS HEALTH SYSTEM CHEST 2 VIEWS (Order# 6678178) Patient patient Name MRN ;~ !?S2@ Patient Phone Information Talhelm, Jack 1769580 Male 1/10/1999 717-486-4808 Allergies: (Not on File) Order Authorizing Provider Encounter Provider Providers (05456) Peter Sokolove (05456) Peter Sokolove, MD Order Order Date and Time Department Information 6/26/2005 5:29 PM Emergency Priority and Priority Class Order Details STAT Normal Web Links Radiology facilities Ordering Physician Rad. Contact Info. Insurance Acct Number Information 020960261996 1 Pavor MISC Financial Class O Patient Insurance 061601202 Q ~ i~ Number COMMERCIAL 099 INS-MISC 2 Pavor MISC Patient Insurance 01349657TPA ifz Plan ice. Number PPOlHMO/EPO- P99 MISC COPY -Protected Health Information - 08/30/2006 14:02:59-MR0202 Page 2 of 2 Talhelm, Jack (MRN 1769580) UC DAVIS HEALTH SYSTEM Lab Results URINALYSIS-COMPLETE (Order# 6678977) Collection Collection Date and Time Received Date and Time Information 6/26/2005 2035 6/26/2005 2048 Com op nest Value El;tS L~ H~9h ~~ Status COLLECTION Clean Catch Final COLOR Yellow NonelYellow Final CLARITY Clear CIr/Sl Turb Final SP GRAVITY 1.014 1.002 1.030 Final pH URINE 8.0 H 4.8 7.8 Final OCCULT BLOOD URINE Negative Negative Final BILIRUBIN URINE Negative Negative Final KETONES Negative Negative mgldL Final GLUCOSE URINE Negative Negative mg/dL Final PROTEIN URINE Negative Neg/Trace mg/dL Final UROBILINOGEN 0.2 0.2 1.0 EU1dL Final NITRITE URINE Negative Negative Final LEUK. ESTERASE Negative Negative Final MICROSCOPIC NOT INDICATED Negative Final Other IDs L.ab Specimen # 0626: UA00069S Patient Patient Name MRN ;zed ~ Home Phone Information Talhelm, Jack 1769580 M 1!10/1999 71786-4808 (7Yr) ni R~2!'-n Q EMER ERWB N Lab Lai Lab Director Information UC DAVIS MED CTR Ralph Green, MD 2315 Stockton Blvd Sacramento, CA 95817 Order Information URINALYSIS-COMPLETE (Order# 6678977) Order Order Date and Time Department Information 6/26/2005 8:35 PM Emergency Account Acct Number Information 020960261996 Order Authorizing Provider Encounter Provider Providers (05456) Peter Sokolove (05456) Peter Sokolove, MD COPY -Protected Health Information - 08/30/2006 14:03:04-MR0202 Page 1 of 2 Talhelm, Jack (MRN 1769580) UC DAMS HEALTH SYSTEM Specimen Collection Date Collection Time Resulting Aaencv Information 6126/2005 8:35 PM UC DAVIS MED CTR Priority and priority Class Order Details STAT Normal COPY -Protected Health Information - 08/30/2006 14:03:04-MR0202 Page 2 of 2 : .~ ,~ ~l~ ~L~X~L ....r~ ~'"RR~f~, ~~~.~+ '~~s~+,F,k xf"r tti j r ~ ~y }$ }~ UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTEf C¢"rt9EF COyF~IiyL;=.~'VT / - ` (~ ~;~~ ~~~ ~~'~'~~.' ~rwi~;ii(~ ~~~ ' ~: ~', BP -~~/~-y PULSE ~Z RESP'~ TEMP ~~~ PEDI-WT ~ D ~> ;x;: Room Time Room Attending Time (~rP~- REVIEW OF SYSTEMS UNOBTAINABLE: ^ Patient Unable ^ Patient Unstable Slash =not pneserrt, Circle = p-esent Medical/Surgical Trauma CONSTITUTIONAL: fever, chills, weight change SKIN: rash, hives, lesion acerations HEMATOLOGIC: bleeding, bruising clo+~~~ ••+ ~~; ,~ ~;; ~ ss EYES: visual problem, discharge, redness eye-'pat ision c ange ENT: earache, hearing change, epistaxis, congestion, sore throat 'n, meleeelnsien RESPIRATORY: SOB, wheezing, cough, sputum, hemoptysis, pleuritic CP, leg pain ei+eeF~airr,-66B-- CARDIOVASCULAR: chest pain, palpitations, syncope, orthopnea, PND, edema EPror~alryitstiows GASTROINTESTINAL: belly pain, nausea, vomiting, constipation, diarrhea, bleeding beH~ryjein URINARY: dysuria, frequency, urgency, hematuria, nocturia Frerrratt7rl~ GENITAL: discharge; abnormal bleeding, LMP ~-ryai~~, -,i~._".g • MUSCULOSKELETAL: pain, limited motion, redness, swelling scr4M1+~n4/RI ~c ~ ~ ~c o~ "' ~ ~~~ NEUROLOGIC: weakness numbness incoordination HA seizures dizziness re PHYSICAL E:t<;k1? Check = nomia! exam finding; Cirefe = arm ror descripfion of atxtormal or rielevant find/ng GENERAL: `~I appearance SKIN: ~~ rash, lesions io induration LYMPH NODES: Adenopathy: jg-RO cervical ono axillary p~no inguinal EYES: e-nl lids 8 conjunctivae [t3.PERRL, EOMI ^ nl fundi RENT: ghead/face nontender ^ nl TMs, canals ~aFKTbse, nasal passages`~nl mouth, throat NECK: ~-Sprnmetric w/o mass L~fSf'thyroid supple CHEST: ntender ^ nl breasts LUNGS: (effort ~rtrauscultation ^ nl percussion CARDIOVASCULAR: nl sounds w/o murmur, gallop, rub p~rro edema [~J-nl cap refill Pulses: carotid r^.nt'femoral nl pedal ABDOMEN / GI: ~~ntender w/o masses ~}no HSM [i~^fiii hernia ^ nl rectal ^ heme (-) GENITALIA M: Q.nf-penis ^ nl scrotal contents ^ nl prostate GENITALIA F: ^ nl BUS ^ nl cervix wJo discharge ^ nl" uterus ^ nl adnexae MUSCULOSKELETAL: j~-nantender neck w/ FROM [z}nontender back, pelvis (~FfIUE,LUE,RLE,LLE (~tfl joints, nails NEUROLOGIC: (~,i1.6N 2-12 [>~tl-sensation ^ nl DTRs, no pathologic reflexes (~.nhstrength ^ nl gait ^ GCS PSYCHIATRIC: ("'jA'&O x 3 ^ euthymic ^ good judgment Impressions/Plan '~`~"Y* K~~'~o-ti'~-~, ~*. Nti~ rAt L 3Zn TT~C~iF` +e~ `~. ,~;~ ~ Y_ f t ? yam' :k ? f ~ ,,`q 'v*~„ . ~, SSSFFF a ~ th. ~~ ~,~~ ,~ . +i$t ~,I t z,3. "~,~~,~ ~; ~~ y a 4?4+; ,.•~' .. r ~; ~ ~~ ~. ~` ~ ~ ~ ~ .:.nc qr il, .;~~ .A{ ~ ~ ~ rw «~. a... ~,. _ ~'~?~ ~a~..~Y ~s:3.:a~.~~~FS~7~"®"1~~-V': S'V"e~7,C7'~.:i o4'~`m`S ;m i'~`~§ o . ,'[~ ;-a 4d Sn'~ r~sr ~'rFs~i'u-`'',A.r,'~S. r... -? . r.:~!'a? ..... .ti4-n.. ..-,.!.~ - ~,: wr ~" ' ~~ ~~r: _ .~ ~^ ~„1,. T~ ~'1.Q~i Yh / ~ LG~-' `' ~' .~,. C0~lSULTF,T1t~i~i'S Time Called Service ^ ED REVIEW ^ Crisis ^ ENT .. ^ Eye __ . ~_. : ~] IM subspecialty ~j Neurology ^ Ob-Gyn ^ Orthopedics ^ Plastic Surgery ^ Surgery subspecialty ^ Trauma ^ other _ _ . _ . 3ESULTS PROCEDURES (Note Time/Describe Procedure) AB TESTS/EKG X-RAY ^ Arthrocentesis ~m D ) ~ _ l'? ^ Casting/Splinting ~ ~ /'`-- ^ Central Line ^ Chest Tube ^ CPR hem ^ Cutdown ^ FB Removal ^ I & D ____ rine 5 ~~ ~ ~{"~ ~~ ~ _ I + D 1 ^ LPubation _ ^ Reduction ^ Paracentesis ^ Thoracentesis list. _ _ _ _ ^ Suturing ^ Thoracotomy __ ^ U.S. ^ Other ] EKG _. ^ Radiology consultation to ^ Present for performance of ^ entire procedure, or clarify results of ^ key portions rn procedure Procedure Signature _• i DIAGNOSIS 1. 2. 3. 4. ^1'~2 - _ I^3 `04 •.~ riZf. rr,... - ~.~-- DISPOSITION ^ ADMIT DISCHARGE TIME CONDITION • ^ Home ^ Police ^ Improved Provider Sig ^ Other DATE Stable h i' I°lU ~r~~ ^ AMA b f ~ ~ a S ^ Unstable 2 )-{ ^ LWBS ^ Expired ED Attending ature ~ UNIVERSITY OF CALIFORNIA MEDICAL CENTER SACRAMENTO, CALIFORNIA ED PROGRESS NOTE {Page 1 of 2) PATIENT: DOE, GABE EM LOCATION: ERWB MR #: 1769580 SEX: M AGE: 125 DATE OF SERVICE: 06/26/2005 DOB: 01/01/1880 EMERGENCY DEPARTMENT NOTE The patient was seen and examined with Dr. Oshita. T reviewed the Resident note and agree and helped develop the plan of care. HISTORY OF PRESENT ILLNESS: Six-year-old male brought in by ambulance status post restrained rear- seat passenger in roll-over MVA. The patient is without any complaints. No trauma was noted in the field. The patient had a GCS of 15 and stable vital signs in the field. The patient denies headache, nausea, vomiting, chest pain, shortness of breath, abdominal pain, extremity pain, numbness, or weakness. PAST MEDICAL HISTORY: None. Surgical History: None. Medicines: None. ALLERGIES: None. Immunizations: Up to date. FAMILY HISTORY AND SOCIAL HISTORY: Noncontributory. REVIEW OF SYSTEMS: As above, otherwise noncontributory. PHYSICAL EXAMINATION: Well-developed, well-nourished male in no respiratory distress. VITAL SIGNS: Blood pressure 118/54, pulse 124, respirations 16, temperature 36.4. HEENT: Scalp normocephalic, atraumatic. Pupils equal, round, reactive to light. Extraocular movements intact. Face nontender. No raccoon or battle signs. Oropharynx benign. No nasal discharge. NECK: C-spine nontender, full range of motion, without pain. Trachea midline. No JVD. CHEST: Nontender, stable. Breath sounds equal bilaterally. HEART: Regular rate and rhythm without murmur. ABDOMEN: Soft, nontender, nondistended. PELVIS: Nontender, stable. EXTREMITIES: A few millimeter abrasion over the right knee. Nontender, no effusion. Full range of motion. All extremities are nontender, full range of motion. BACK: Nontender throughout. NEUROLOGICAL: Alert, awake, appropriate, answers questions normally. Strength 5/5, sensation normal to light touch. ASSESSMENT AND PLAN: A six-year-old male status post roll-over MVA whose only evidence of trauma is a small abrasion to the right knee which mom states may have happened prior to the accident. We will check a chest x-ray to rule out intrathoracic injury, urinalysis to rule out hematuria, and will UNIVERSITY OF CALIFORNIA MEDICAL CENTER SACRAMENTO, CALIFORNIA ED PROGRESS NOTE (Page 2 of 2) PATIENT: , MR #: DATE OF SERVICE: LOCATION: SEX: AGE: DOB: follow the patient's neurological and abdominal exams clinical in the Emergency Department to evaluate for occult intra-abdominal injury. Feel that further labs or CT scans are not indicated at this time. Signed out to Dr. Ballard at 1800. THIS WAS ELECTRONICALLY SIGNED - 06/26/2005 6:34 PM PST BY: PETER E SOKOLOVE, MD ASSOCIATE PROFESSOR EMERGENCY MEDICINE DEPARTMENT PES:sh{usal35) D: 06/26/2005 05:57 PM T: 06/26/2005 06:00 PM C#: 1092635 UNIVERSITY OF CALIFORNIA DAVIS EMERGENCY REG (COPY) PATIENT INFORMATION RECORD PAGE 1 TALHELM ,JACK 9EM SVC: EDR N/S ERWB FC: V PENDING MEDI-CAL, CM MR#: 1769580 0 PT TYPE: E OLD MR#: ACCT# 20-960261996 ---------------------------------------------------------------------- OUTPT REG DT/TIME: 06/26/05 17:10 INPT ADMIT DT/TIME: FLAGS ADM PCP UPIN: ATT PCN ADM CD ICD9: CPT: PCP PI#: DX PCP ADD: --------------------------------------- PATIENT INFORMATION: ADDR: 113 WOODVIEW DR MT HOLLYSPRINGS PA 17065- HOME TEL: 717-486-4808 MSG TEL ADDL ADD: COUNTY 98 OTHER STATE ,TIENT EMPLOYMENT: STATUS: 3 OCCUPATION: NOT EMPLOYED EMPL EMPL ADDR EMPL TEL X LNGTH OF TIME ON JOB: VET: RELATED CONDITION: U.C. EMPLOYEE IND: PT SSN# 000-00-0001 PT DL/ST UNKNOWN UN PT DOB: 01/10/1999 AGE: 6 SEX: M MS: S SP NM: MAIDEN NM N/A- OTHER NM ETH: BPLACE: RELIGION: LANGUAGE: -------------------------------------- ~CCIDENT INFORMATION: ACCIDENT RELATED CONDITION: Y ACC DT/TIME: 06/26/05 00:00 ACC TYPE: AUTO ACCIDENT ACC LOC INST: GUARANTOR REL: PARENT GUAR NM: POSSENTI ,MICHELE ADDR 113 WOODVIEW DR MT HOLLYSPRINGS PA 17065- HOME 717-486-4808 MSG GUAR SSN# 563-59-3590 GUAR DL/ST GUAR SEX GUARANTOR EMPLOYMENT: STATUS: OCCUPATION EMPL EMPL ADDR EMPL TEL X LNGTH OF TIME ON JOB: ------------------------------- NEXT OF KIN REL: OTHER RELATIVE NOK NM SASSMAN ,MELINDA EVN TEL DAY TEL : 916-684-0393 X MSG TEL GUARDIANSHIP PAPERS ON FILE: REFERRAL: DATE: DR: X PCN: FACILITY: ER H/A ER CMPT X ----------------------------------------------------------------------------- LAST ADMIT DATE: ESTIMATED LOS: ADVANCE DIRECTIVE INFORMATION: WAS AD INFORMATION AND UCDMC POLICY STATEMENT GIVEN TO PT/REP? DESCRIPTION: DOES PT HAVE AN ADVANCED DIRECTIVE? HAS COPY OF PT'S AD BEEN PLACED IN PT'S MEDICAL RECORD? T & C SIGNATURE: PATIENT GUARANTOR PMHUNVF5 DOCUMENT GENERATED BY: HADSB 18:39 06/26/05 FROM LX9D,PMHUNVF5 EMERGENCY REG (COPY) UNIVERSITY OF CALIFORNIA DAVIS PATIENT INFORMATION RECORD PAGE 2 ---------------- TALHELM ,JACK ------------- 9EM ----- SVC ------- EDR -------------------- F/C V PENDING --------------- MEDI-CAL, CM MR# 1769580 PT TYPE: E OLD MR # ACCT # 20-960261996 PLAN CD: 103 MCAL INCOMPLETE PRIORITY: 1 POL#: N/A GROUP#: INS ADDR: I.P.A. NAME: PHONE: - - X REF/AUTH#: REVIEW GROUP: DAYS AUTHORIZED: CONTACT NAME: ~ PHONE: - - X ON-SITE REVIEW? CONCURRENT REVIEW GROUP: CONTACT NAME: PHONE: - - X PLAN CD: POL#: ^ROUP#: S ADDR PRIORITY: I.P.A. NAME: PHONE: REF/AUTH#: REVIEW GROUP: DAYS AUTHORIZED: CONTACT NAME PHONE: ON-SITE REVIEW? CONCURRENT REVIEW GROUP: CONTACT NAME: PHONE: PLAN CD: POL## GROUP#: INS ADDR: PRIORITY: I.P.A. NAME: PHONE: REF/AUTH#: REVIEW GROUP: )AYS AUTHORIZED: CONTACT NAME: PHONE: ON-SITE REVIEW? CONCURRENT REVIEW GROUP: CONTACT NAME: PHONE: COUNTY CODE: AID CODE: CARD ISSUE DATE: VALID DATE: PMHRUNF6 DOCUMENT GENERATED BY: HADSB 18:39 06/26/05 FROM LX9D,PMHRUNF6 1 ~ ~ ~ ~ r ; t ~~ it~ '. ~ .. ~ ;. fit?--9!~ ~ :2Q-~' ~t~ ~• ~~ ~ : ~ 5 TA ~~~Ljti ~ ~~~~ ~ II~ ~~' ~ 'E~': UNIVERSITY OF CALIFOIR~IIb D~S F ~' ~ / I ~ /~ 9 ~ j ?•. "<`~ ~ _.b.. ~: -:.. HEALTH. SYSTEM ` , TERMStAJD CONDITIONS OF SERVICE ~. 7. FINANCIAL AGREEMENT: I agree to pay Th'b Regents of the Universityif California for professional, hospital and clinic services, including UCDHS physician services, In accordance with the regular rates and terms of UCDHS. I also agree to pay for other professional services provided by other physicians at UCDHS. When this agreement is signed by my spouse, parent or a financial guarantor, my spouse, parent or financial guarantor shall be jointly and individually liable with me for payment, including all collection fees (attorney's fees, costs and collection expenses), in addition to any other amounts due. Unpaid accounts referred to outside agencies for collection bear interest at the then current legal rate. 8, ASSIGNMENT OF BENEFITS (INCLUDING MEDICARE BENEFITS): I authorize and direct the payment to UCDHS of any insurance benefits including hospital insurance and unemployment compensation disability benefits otherwise payable to or on my behalf for UCDHS services, including emergency services, at a rate not to exceed UCDHS' actual charges. I understand that I am financially responsible for charges not paid pursuant to this agreement. I further certify that the information given in applying for payment under the Medicare or Medi-Cal programs is correct. I further agree that any credit balance resulting from payment of insurance or other sources may be applied to any other account owed to UCDHS by me. 9. ADVANCE DIRECTIVES: I have an advance directive for health care (e.g., Power of Attorney for Health Care) ^ Yes. ^ No I have provided UCDHS with a current copy of my advance directive ^ Yes ^ No If "No", I understand it is my responsibility to provide UCDHS a current copy of my advance directive. If I want to express my health care wishes, I understand I should speak with my health care provider. 10. PATIENT RIGHTS NOTICE: I would like UCDHS to provide my next of kin or agent with the Patients Rights Notice ^ Yes ^ No I have read, agreed to and received a copy of this "Terms and Conditions of Service." Signature of Patient Relationship of Re/p~re/sentative to Patient Signature of Witness (required if patient unable to sign) V~ or Sig ature of Patient's Representative Signature of Interpreter (if applicable) Date of Signing For office use only: EXCEPTIONAL SIGNATURE REQUIREMENTS ARE REFERENCED BELOW. Please check the appropriate box(es). ^ PATIENT IS LEGALLY INCOMPETENT TO SIGN: The court approved guardian or conservator, the attorney-in-fact under a Durable Power of Attorney for Health Care, or family member or other appropriate surrogate must sign as "Patient's Representative." ^ PATIENT IS PHYSICALLY INCAPABLE OF SIGNING: The patient should give verbal consent, witnessed by a UCDHS employee. The "Patient's Represen- tative° should sign in witness of the patient having given verbal consent. The UCDHS employee witness shall also sign. 71463-257 (6/03) TERMS AND CONDITIONS OF SERVICE Page 2 of 2 USE Pfi.TiENT PI..~RTE ,„~"'~~~~°-.'-~=~~w'4 ~'- ` ~ PRESCRIPTION ~i~m ~^^ ~a y N ; C 4c .~ ~ ~~ ~ ~~~m ~~~ ~~~~D AcDm 1 r Z+~~7~. pG°~C~~~[~~p~~OO~I ~° ACTIVITY '~ c¢~~ w^ ¢ - R~ N 3 1. ^ No specffic restrictions ^ Umlted use of affected part until seen in follow-up '^ ' ( -' ^ No use of affected part until seen in follow-up t ,` ~ r' ^ 3 `~' Modified work/ no PE for days ^ Off work /school for days DEA No. ^ No driving License No. ^ Passenger restraint system required for children less than 4 years old or less than 40 pounds. Information sheet provided. ': MD Signature MD Print Name Date MD Signature INFORMATION SHEET(S): ^ wound care INSTRUCTION ADJUNCT(S): ^ interpreter ^ head injury ^ family ^ cast /splint care ^ demonstration of ^ back or neck pain ^ other ^ crisis service ^ other OUTPATIENT FOLLOWUP: ^ Call for Appointment ^ Keep Scheduled Appointment ^ UCDMC Clinic ^ Sacramento County Clinic ^ Medi-Cal Clinic PCP ^ HMO / GMC Clinic ^ other ED LABORATORY & XRAYS: LAB TEST XRAY ^ CBC C,~, CXR ^ chemistry ^ extremity ^ U/A ^ spine ^ other ^ other ^ Call 734-7761 between 10 am and 10 pm for pending results of MEDICATION /TREATMENTS: ^ tetanus immunization ^ antibiotic(s) ^ ;other I acknowledge receipt of instructions indicated above. 1 understand that 1 have had emergency treatment only, and that 1 may be release before ali my medical problems are known or treated. I will arrange for follow-up care as instructed above. If my condition appears worse, will contact my physician or return to the Emergency Department. "~ Pa#i~ht~ Si {nature `~ ~ - '~~' ~ -Provider Si nature ~- f~, Date ~ ,~~ ~, ~: ~t t ~ f,~ ~ % f' ~ i t= ':+ ,? S':,..a'' f •°~,s ~ - iG% i%! 'j „'% i (~7 ~'~ `"r 't„G'f(~f.`~ L"fir r sz~~. ,'FLA..E / C~ Procedures ^ Saline lock ^ IV-1 ^ IV-2 ^ 02 ^ monitor cardiac ^ pulse ox ^ continuous ^ Foley ^ I&O catheter ^ NG tube ^ suction ^ FS glucose ^ serial ^ PEFR ^ serial rme dip ^ urine bedside pg EKG ^ serial ~1 ^ C-spine ^ T-spine ^ US spine ^ pelvis AP ^ bedside ^ L ext ^ R ext ^ head CT ^ w/o ^ wflV ^ abd/pelvis CT w/IV (trauma) ^ abd CT ^ w/o ^ w/ ^ US MEDICATION AND SUBSEQUENT ORDERS a- .~ , ~t UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER SACRAMENTO, CALIFORNIA Time Ordered ^ Oid UCD Record ^ Outside Record Physician Signature Service/ Pager 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. Reason (signs/symptoms for each study) PRiORtTY ^ urgent ^ stat ^ life/deatl urney O Wheelchair ^ wal NIA ^ tele ^ vent ~L~ of Initia Orde _..-~-...+w.-z--.-...x.vw..'...r:?.'t..i,.~a ",~'z••+'Tlt>G'...:.^ -:.: :.:.j F"~ -.-•--~-r-.. -•- -_-•,- ~T~:~ ... _-_ _ _` ~~'~~:^. - -_ . 5_r.* F'CU. F'HIIV HJJCJJIVICIV I I~UIUC PAIN TOOURANGE 1=NIPS (0=7) ~,~Jf~• 3=FACES (0-5) ~~ ~~ 4=Oucher (0-5) 5=Numeric Scale (0-10) 6=Comfort Scale 8-40 ' a ~ n a o i ~i a ~ ~ ~ ~ ~ nn F ITT ~ ~ ~ i n F t ~ ~ F n ~ 7~,Unable to aoc~ ss, (e.g. the ~ical ~aMalysis); DIC Time 8P (~ ~ , ~, v ~~ - P ' Z ct " ES3" RR ~ TEMP ~ 02 SAT (CYO .--- - C GCS ~ (r Rhythm ~ ~. Init. MEDICATION DOSE V TIME BY SITE ROUTE I Ime . (o3C RESPONSE RESPONSE RESPONSE RESPONSE RESPONSE_ ,~ RESPONSE RESPONSE ~~ RESPONSE RESPONSE 7'~.~ Tans ~_.... - o~ uU~ I ~ Mv~.-~-r - ~P r'crm ~C~_._ LG. ~.__ Nc ~rff __~ r u i_Si_.~. 1"R .t SCI U ~ ! ~ f r-ZC= _~ tin t~i-~__~ -~ ~_.I /A~ `~__ _~ ~2~5 C I ~Y~~ ~ 1~-1 ~ ~C: ~~ RESPONSE ~ _ Clothing Sheet Complete `!es ^ Ncs ^ NA ^ - ~ ~ ~ Y~ ~ ~ ~~~y~~ fee IrKG StriP.w flISCHAR :Order§. (:Nurses Notes Faxed Yes.Cl . No ^ . 1VA Cl an back L`]._.:___ .. -n,. CONDITION ADN11T ^ t3i~har~e I~ t~~S E_. <.~ V'.<._.~_ ~~1__~. Gbrt}t°n~r~ts: Improved d Tran~pcuted by ~fJ O lnstructrons Ira petlent ~. ,..,._.____w_._.__._. Unchanged ^ t3th~t',...:., we ^ ~,.,_~.. .._ ~._.... ~..--~-~- - --. -_.~ Crutches ^ Vert~~liiz~s und~rstandirrg des I~ Rrs ^ ...~_._.._ .~.~_ _..._ Stretcher C7 Hatidotrts ~lV~f~ 'Yefi Ci N~ ~ _~,~ ~__._,.._.~._._. ~_ Walk ^ t..ls~fi ~~... 11( Infusing {~ j .~.~...~,.::.~..._- .~~._.. 1 ,_.... _. ._. Armband ^ L~erttrng hieetl:~ Adl~res~~d ~`~;a ^ fi1~ {~ ~._.~ . __. _ Green =All C~~ti~:rlts ,1=~d =Ail Tr~luma f l~:.t~ Pati~t~tt~ ~pe>~rty: _ -. .,~. ...,.-~...~,...~ _,....,...,.w..~._f,.._,. ~..~._.----~--.. ~~ ~- ~ ~. 176-95-80 TALHELM A~.1ACK6/05 ORD 9E ~~~ AKA: DDE, GABE M M 01/10/1999 ERWB FC: V Da«. chef 176-95-80 -ADM ORD DOE ,GABE EM . AKA: ' M 0110111 B80 FC: Trfag~ D:__._ T~... I: Primary Nursing'Assessment BP ;. =:P : RR' TEMP.. PAIN.: 02 SAT `~' 'A: Airway' . Patent Yes ^ No ^ .' B., BreatFiing Mode of Arrival' AM Walk ^ Gurney ^ WC ^ Carried ^ Unit # GCS E .~ V ~_ ~--~- _ IV N Yes ^ Placement _ ET NT OP P Yes ^ No ^ Type/Size Placem t Rigid Colla Backboa~Splint ^ Meds given O2 Given Accucheck _ Papoose ^ BP P RR TEMP PAIN 02 SAT History None ^ Cardiac ^ Diabetes ^ Unknown ^ cva ^ CQPD ^ CA ^ ~GU ^ Dialysis ^ HTN ^ Seizure ^ Other Psych Asthma GI ^ ^ ^ alfergieS - Head Ye No Latex NKDA unremarkable ~ ^ current meds nose drainage ear dr ina e ^ ^ O ^ g a teeth dama e ^ ^ -Last TD g tm'e rlnar f-! 1-l .Spontaneous Yes Nod nasal flaring Symmetrical ,Yes~T~ No^ acc. muscle use Labored Yes No^ s/s trauma .Shallow Yes.O'~° No^ flail Diminished . LT ^ RT ^ crepitus grf;ath Sounds RT C. Circulation LT Cad. Refill, <2 sec. Y~ No O . cardiac rhythm warm Ye No O -' drY Yes ^ ' Np,F Diaphoretic Yes ^ t~ '" Jaundiced Yes ^ N~`. Bleeding Controlled 'Yes d No ^ N/~ R, Neuro -GCS E ~ V ~ M spontaneous 4 = oriented 4 `: 5 io voice 3 : cohfused ~4 to pain 2 inapp. words 3 none 1 ihcomp, sounds 2 Pupil Sire I~.`-'L ~~-~'-- norie 1 PERL - Y No ^ Accucheck Yes ^ No `fr Yes ^ No~_ Yes ^ N~~- Yes ^ N~ Yes ^ N f~ obeys comds 6 localizes pain 5 withdraws 4 flexion 3 extension 2 none 1 E. Sensation ~ ~~ F. Pulses RA '~' RL , Quality: 4+ f3+ 2+ 1+ Dop. Two forms.,of ID checked ^ Armban Screened for Domestic Violence ^ ~` ~~ Neck unremarkable ~T~ ^ sq air ^ ^ ~vD ^ ^ trach midline ^ ^ Abdomen unremarkable ,~C'~~ ^ soft ^ ^ nontender ^ ^ s/s trauma ^ ^ firm ^ ^ .distended ^ ^ `tender ^ ^ masses ^ ^ vomiting ^ ^ diarrhea ~ ^ ^ last BM GU/Pelvis unremarkable ,.13' ^ meatus clear ~ ^ pelvis stable ^ ^ discharge ^ ^ color NA ^ bleeding ^ ^ pad Hr Back s/s trauma ~"~ ^ deformity ~ ^ ^ rectal tone normal ^ ^ guiac positive ^ ^ tender ^ ^ Extremities s/s traurtia ~ ^ deformity ~" ^ ^ IDENTIFY ON f R L L v A -abrasion AB - abscess B -burn `__~- deformity E - ecchymo ED -edema H - hematon L - laceratior P -puncture R -rash T -tender/p~ UNK ^ NA ^ - - . . - .:, , .,; _ Time ' Time By Whom Procedure Size Placement Eye - Opening - . Oxygen NC Mask '$est Verbal Respohse L Min. N : _ B'est#~lotor.' ' ~ _ 'F iies~onse. , Chest Tube Gla"scow.Goma'Scale Score ThOraCOlOmy ,~ . Intubated. 3'=Appears to Converse .2 -May Converse t= None p ill A s g~ NG/OG rR ~ aly e ponse up r- ~ ~;'; ~ ~ Right . e~,i ~` ..e~°~ FOt ey ~ 2. 3~ 4.5~ 8~7 8 + Bask' ~r+ Slu lsh None: O `Lek ale ' P°"~ EKG I . , . , Strength'-, ~ , U 3bl a Unable t st U t 2 e i ' FSrght r D e ssess o mov n = nr o = aga l N a ' r ' S lint p ~ atura r 5 q 4 _ Shghf weakness 1 = ~rac~e Ice Pack '' - 3 ~'luloves ageiost gravity ~ o =None Lett i ~~,~'~- ~ Wound Cafe ~ Sensatloh:, :; 1 . Normal T =Tingling ` Right ~ ~ ;/~ Warming measures R ? = HypersensNive B = No;sensaUgn 1=Numb U = Unabe to assess Leh ' t `~~+~ ° , ;C; Mucus MembraneslSkin: Cobr j ~ IV LINES ~ F =Rushed M -Mottled C -Cool Temo r ~ P = P81e J = Jaundiced , - D =Dry ` R N = Normal W -Warm M '- AAOist Gh9raCler . . p Pulses: . ~ t3adial. ' ~ 1+ = RareVy Palpable 0 =Not Patpeble Rr9rit = P~p°~ ., f y 2+ ~= Weak. D Doppler e ` ~ Intubation a os ~ ~ 3+ := Nom,al ' ' Radial Ventilator '(S V 4+ ,Full Bounding .. , . Left ~~. o •?.~y . ._ s ~ Mode Rate TV FI02 PEEP Capillary Refitl: Number of,5etonds _ . , .. ~ A -i$` 1' N = Norrfral ti -Rub D rJislant Heart Sounds: M _ Murrrrur„ . G = Gelb _FR - FttCtign Rub • - CBC Chem 7 Lip Pt PTT BA , ~ r ~ ' ~CMS.Intact Distal to:' A'..=Art Line` C = Gast R =Restraint f . Fem Une B =Burn .,... T =Traction T & C/T & S L Edema: - G `= General Bk Below knee Rrgfrt ~'~ R' 5~ ._ ~ ,. ' J UA TOX UPT P =Pedal F Facial: ~~ ~ rfltng 2+ 3+ t c ~ / CBC NO dill #2 R rce O se A .- Ana fJone . , Left '~~ ~ ~~ ... , CBC NO dill #3 Ghest Expansion: S = Symme~~ical A . Asymmetrioai Myo/trop 0° P +~ Trachea: M = Midline • R t3cwiated Right L = De~riated Left V N = No Distress R =Retractions M /t 3° Respiration: L' =Labored A = A,~'neic/# Seconds ,. . _ rop yo Breath Sounds: Rut _ ° , Myo/trop 6 IYI 0 ' =Clear 1 =Diminished Right RML FC =Fine Crackles 0 =Absent _ • ~ - CG ='Course Grackles S = Stndor FtL4 , _. ,. N W = Wheeling FR =Friction Ruh Lafl __.. - Lt1L -- _ - _ • ~ ~ • • ''"A . Rlt = Rhonchi .. LLL - 5tudy Time Done Siudy 'Time Done R SecretiotS:- ' 'S =Small 7H ='f`fiick G =Green Amount - _ - - Ultrasound ~ C S ine ~ Y M = Med N =None T =Tan L ~ a =C B Cwtsi5tsndy p ' . Large lear 6 = rawn C l _... __. - , T = Thm Y =Yellow BL =Bloody o or . _ ... Pelvis T Spine 'Gastrointestinal: Abiitlrn6r, 5 =Soft R =Rigid - N = fJormal 1 = Nypb ~ ' Abd US Spine D ='Distend?d 7 = Tentler ? = fiyper L5 Y None Brawel Saunas - ~ - - CXR CT Head NG~'IbGt: Placement verified aay Aspiratiafl -- ~ _ ... Extremity CT Abd ~ pHlGualac: ,i. ~ __--_ t. l r'~, oi4 - Gastric OutpWt: a~car Gucreen B=9+nwn a[r-aiawr ec-con.. car~„,nn _ _ ~.~ ... r t kJ~ k __.__.__ ._ __ TIME BAG # SOLUTION INFUSEb BLOOD PRODUCT SITE T"IM E AM7 SFE GIF , Y 1 ----- .. __._ _..._ .. ..__.---. _.. ... _. ...... _ .. . ._ __ VQ Scan NITI LS ANCyU:' N M _.-- --------- ~ 1 >~ ' - ------- _- -.._ _._ ..._ .._..-_ ._ _. .~. _.._ _...:.__ t ..~ ... ~ .j _ ` SI( P, FIN J(.rll?e i'3N _-- __ _-- . r f_ __ _ _~ + ___ _ . __ _ ._ .... _ ... _. ...-._. _ .__ . _ _ _ I ~ ~ _ _ . ._ -- -- _ ~ ._ . t - i .. . _ f~N TOTAL _._~__.__ _ T __._. i.}T ._.~.- . AL ............._ 1 _ _ _ .. _-_._ .. -.. ~ . _.. ~,~ ~ ~v`G. `~rtsG ~M ~ ~~ I f~GQM #~ b~T ~ pt ~ CI~I~~WL~~MENT OF RECEIPT ~' NOTICE OF PRIVACY PRACTICES The UC Davis Health System Notice of Privacy Practices provides information about low we may use and disclose protected health information about you. In addition to the copy we are providing you, copies of the current notice are available by accessing our Web site at htt~://web.ucdmc.ucdavis.edu/compliance/ and may be obtained throughout UC Davis Health System. I acknowledge that 1 have received the Notice of Privacy Practices. i a u e of Patient or Patient's epresentative Date ____. . ~ f~I r~:l~c~a~ ~~sse~~ /ai ~%'l Print Name Relationship to Patient Interpreter (if applicable) . Written Acknowrledgement Not Obtained Please document your efforts to obtain acknowledgment and reason it was not obtained. ^ Notice of Privacy Practices Given -Patient Unable to Sign ^ Notice of Privacy Practices Given -Patient Declined to Sign ^ Notice of Privacy Practices Mailed to Patient -Awaiting Signature ^ Other Reason Patient Did Not Sign Signature of UC Davis Health System Representative Print Name Date Department 70000-789 (3/03) ACKNOWLEDGEMENT OF RECEIPT: NOTICE OF PRIVACY PRACTICES MR 03/037 E~T.~NCipEiQT ~ ~ EST REP. . ~ EST. ARRIVE :~_ EST. ASSESSMENT TljylE ` ` EST. TRpI~iSR TIME TRANSP. CODE ~ =f ' ~ PRfOP,ITY ARRI~FfJEST.7IME AVAILABLE TIWIE~ FORM N0. 4 71 ~~ _ ~ ~a ~ BLS: ALS % 6-yi~ • v _ ~ ~_ ~ ~_J :~ ~ -~ , 6 6 ~. 0 CALK LO~IQJ?l, ^ SAME,AS PATIENT'S ADDRESS, r ` PHONE # DRIVER'S LTC. L- ~ '_+ PATIE UaIANIE{ ~ FIBS . ~ ~ l ~ ,. AGE;='` p TvIOS - D,O. Bf "ALE ^ FEMALE ~ PATIENT S ADDRESS (STREET') ~ , ` C~ r STATE ZIP ~. S.S.N. MEDICAL HISTORY ^ UNKNOWN DENIED ^ MI ^ CHF ^ ANGINA ^ COPD ^ CVA ^ NIGH BP ^ DIABETES ^ CANCER ^ SEIZURES ` CURRENT MEDICATIONS ^ UNKNOWN ~ DENIED ALLERGIES (MED) ^ UNKNOWN ~'tSENIED WEIGHT KG ` TIME GCS BP PULSE RESP. EKG BY TIME GCS BP PULSE RESP. EKG BY E V M E V M :i' I~EAp ^ ASSESSED & WNl -~~~ !] ASSESSED B,,WNL I PUPILS Q PERL CHEST ^ ASSESSED &WNL LUNG'SOUND~S,i' ^ ASSESSED &WNL,- % ~ CRAMS °-~°~`~""~ ., - " ~ ~ MECH. ANAT. ABDOMEN <<_O ASSESSED &WNL gp0~ O ASSESSED &WNL <,.' ! BLOOD SUGAR TIME; ^ JIC .«.:J=7 93SE ED &WNL ~:. s ~ r ; EXTREA~ff'IES ~ ASSESSED 6 WfvL CAP REFILL - ; , .~ . v SKIN ^ ~yASSElS!S~D &WNL NEURO ^ ASSESSED &WNL CPR START TIME: BY ,.:• ~.~- i~ f'. ~2`.'~ ~•~ ~..:%^-~" .~`~<`'E~rv'ti' f'!~>=~ .-ri ' ,C f ~~ •~~° - 14~G. rf~.-"~ r /-~ .:~. f.Y--car ~i?..: 4' c-i=,~!'~xP ( ` . ,'° ~ t "" 1. ~'~ ~ ~ Lr Lr ~ /.~ F ' ~ ~ ~ i.r~ 1 ~. ~ ..,•i'TY':. ~t%~'%4 j i...~ rte. .v j?;'£- ( ~? i ./3~ ~.r"""~`.JT". - ~^J _ ~, % ~ ~ I ~ - r 1 ,,. f} - ','~~r'^~~'C`? -e,1: .il :r-^~ - ~_'~ ?"~`.,~ ~'~°r ..~ Iy n~ ..",1 ~ =:.' f3/ -~ rC ( : + - . _ . , . . ~ ~ ~._'"".` Il is r -i~. ,~ ! ,,. '~ - ~ J ~ r s'~~ ~ L~. r p/ / `..1-~-:./.. ^~•` r /~"`rc,+t s:~ f~'J~` •Sr er^,~..y ".~.,. -..•.~.:y~. X.G~ 3 .G ....p• ~ ..L- ~ TIME: OXYGEN UM BY: ___.___ _ _.__ ^------_~-° '-•-•°-~•'~--°- ^ MASK ^ CANNULA ^ 8AG VALVE ^ HHN ^ P ULSE OX:before Oz ,after Oz ~, AIRWAY: GAG ~LTYES ^ NO ASPIRATION ^ YES „PJ"NO ^ OPA ^ NPA ^ NTI q OTI ^ NEEDLE CRIC -• ET SECURED AT CM AT THE USING BY: TUBE SIZE: NUMBER ATTEMPTS; (ANATOMY) L ~ j G =LUNG SOUNDS ^ =CHEST RISE ^ CHORDS VISUALIZED M.D. VERIFlCATION SIGNATURE: L 71MC kTUIDS SOLUTIONS GAUGE LOCATION ~~,.$ATE TOTAL VOLUME q OF ATTEMPTS BY ~~ ~~`^ q 10 °--ti_ ^ TKO ^ OPEN ^ BOLUS - 2g1V ^ t0 ^ TKO ^ OPEN q BOLUS IMMOBILIZATION: (r7fNECK BACK ^ LIMB(S) ^ EXTRICATION POSITION: ~ ,E7`-SUPINE ^ LATERAL ^ PRONE ^ SITTING ^ HEAD ELEV ^ FEET ELEV. TIAAE MEDICATION, DOSE; ROUTE, TREATMENT AND RESPONSE BY TIME.. _MEOTCATION, DOSE, ROUTE, TREATMENT AND RESPONSE BY ----~ -r-...-- TiMc: HOSPITAL CONTACTED: ^ RCH ^ AFH ^ SDH ^ WMH ~{] PHONE _ MICIU #~fIGA~E ~ I - __ ftq.D.~ _ FORM LEFT W/PT? ©'~^-q NO k l i~ ^ MAR q 5GH ^ MSJ ^ MHS f~}-L}rrDMC ^ NONE ^ RADIO .~%" ~~ ` 1 CONT. ATTACHED? ^ Y~ES"'C}°td4.. 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VOL BY ^ N ^ TKO ^ OPEN ^ 80LUS V ~ ^ N ^ K) ^ TKO ^ OPEN ^ BOLUS ~'-~ +~ ~~ _ ~ " ' T RANSPORT POSRION: OPINE ^ LATERAL ^ PRONE ^ SITTING ^ HEAD ELEV. ^ FEET ELEV. ^ LEFT LATERAL RECUMBANT T TIME MEDICATION, TREATMENT AND R sPONSE BY TIME MEDICATION, TREATMENT AND RESPONSE BY A - ' T M ,: E N T ~ .usECarr.una,waw H ~ ~ ^ RAS ~ HOSPITAL ^ BASE TMIECOIlMCTED ~~ ~ ~ M.D. OR MICN # /NAME CONT. FORM ATTACHED? $ . "~ ^ AMA ^ NOTIFICATION ONLY CONTACTED ^ YES ^ NO P ^PVT M.D. ^ Pi /FAMILY REQUEST ^ IAVU ^ TTU\UMA CRITERUI ^ DCF ^ BH ORDER ^ DIVERSION ^ SPECUILTY CENTER ^CLOSEST ^ NO PREF. D E S C~G RBPdRT S16NATURE SECONDARY PARAMEDIC/EMT/ PRECERTOR NAME ~ ?~ ~ ~.„~.x ~ ", `~" ~~,,~~ ~: LEFTw/PATIENT/UNABLE TOSIdN~«-'1' f~~.,~t~i +Y'' a F . ~ QLl Svy ~ ,/.!- # ^ FORyI LEFT WI HOSPITAL T OMP NOTIFIED: ^ CPS ^ APS ^ PEDESTRU~N ^ ELDERLY, NEEDS REFERRAL i ] snc CITY WORKERS C .``, , 07/07/06 16:13:05 PRINT REQUESTED BY TERMINAL SFD6432 Incident History for:#F05070333 07/07/06 16:11:15 CLOSED INCIDENT Closed B2 22VA 29B2 MULTIPLE VICTIMS LOC EB US50 AT PIONEER BRIDGE ,SAC (V) SRC(TEL) YOLO 375-6474 Map:168C4 TB:297A5 PREM: CODE 3 JUR:22 BATT:Bl 0626 EB 880 AT JEFFERSON REQ 1 MEDIC ONLY FOR MCI MCI W/7 PTS ENT:06/26/05 164143 DSP:06/26/05 164203 RSP:06/26/05 164308 ONS:06/26/05 164826 ALS:06/26/05 164826 /164143 ENTRY (510020 ) D4 SUGG RELREQ DISP $ASNCAS VOICED VOICED *ENROUT ASSGER AIQ SPELL (510060 ) (510060 ) (510060 ) (510060 ) (510060 ) (224799 ) (510129 ) (510129 ) (510131 ) M2 M2 M2 M6 M2 M SUGG ASSG VOICED *ENROUT SUPP AIQ *ONSCNE *T2 *TA *AOR CLOSE (510060 ) (510060 ) (224799 ) (510020 ) (510129 ) (225878 ) (225878 ) (225878 ) (225878 ) (510129 ) M2 M2 TXT: M2 M6 M6 M6 M6 REQ 1 MEDIC ONLY FOR MCI MCI W/7 PT S WSE41 (P-FR,S-FS1) M2+ (P-XPT) WSE41 [00.0] (P-XPT) $22F05030812 [01:05] (P-XPT,S-ALS) [EB 880 AT JEFFERSON] ,YOLO REQ 2ND MEDIC M2+ (P-TYPE [M] ) [00.0] (P-TYPE [M] ) [00:38] PER YOLO COUNTY CANCEL 2ND MEDIC [04:44] {UCD} {UCD} FIRE ** FIRE INCIDENT SYSTEM -- MASTER RECORD INFORMATION ** INC-NO 050030812 Supp-Exp Inc-Date 062605 Inc-Type 32 CALL 05070333 Act-Take Prop-Use Pro-Clas Inv-Act I-Case Inc-Adr EB US50 AT PIONEER BRIDGE City SAC_ County _ St CA Zip Mli Map DBA EDP AA-MA _ FPD Disp-Grp Sl Pat-Nam Occupant Oc-Phone Pat-DOB Rept-Bv Re-Phone Owner Own-Adr Manager Man-Adr Ow-Phone O-City O-St _ O-Zip Ma-P one M-City M-St _ M-Zip Res-Dis (tenths) Alr-Srce 1 Alr-Code 1 Fin-Unit M02 Trans FID Staffing 004 Staf-Hrs .9 Duration Fm-Date 06260 5 To-Date 062605 Rcv-Tim 164143 Dis-Tim 164203 Arr-Tim 164203 Ctl-Tim Clr-Tim 164203 Res-Tim Batalion 1 Shift A Rpt-Unit Juris 22 Priority 1 Amb Rescue? Count Next Control F952050626183839 _ Mast-RN 211491 Inciden t Type - EMS CALL (29B2) _ Action Taken - RUNT ** FIRE INCIDENT INC-NO 050030812 ADDRESS EB US50 AT SYSTEM -- UNIT RUN TIMES AND STAFFING ** Mast-RN 211491_ Supp-Exp Inc-Date 062605 Inc-Type 32 PIONEER BRIDGE Pro-Clas FIRE INCIDENT STAFF HOURS (FIRST IN UNIT) Unitl M02+ Dis- Tirol 1642 Al Clr-Tirol 1643 Stafingl 2 Stf-Hrsl Unit2 M06+ Dis- Tim2 1643 A2 1648 Clr-Tim2 1709 Stafingl 2 Stf-Hrs2 .9 Unit3 Dis- Tim3 A3 Clr-Tim3 Stafing3 Stf-Hrs3 Unit4 Dis- Tim4 A4 Clr-Tim4 _ Stafing4 Stf-Hrs4 Units Dis- Tim5 A5 Clr-Tim5 Stafing5 Stf-Hrs5 Unit6 Dis- Tim6 A6 Clr-Tim6 _ Stafing6 Stf-Hrs6 Unit? Dis- Tim7 A7 Clr-Tim7 _ Stafingl Stf-Hrs7 Unit8 Dis- Tim8 A8 Clr-Tim8 _ Stafing8 Stf-Hrs8 TOT-STAF 4 TOT-HRS .9 Next Control F952050626183839 Recno 212485_ NARR ** FIRE INCIDENT SYSTEM -- FIRE REPORT NARRATIVE ** INC-NO 050030812 Supp-Exp Inc-Date 062605 ADDRESS EB US50 AT PIONEER BRIDGE REPT-DID 54875 ** COMPANY MEMBERS ** Company M06_ Shift B CPCR CC AO F1 S4875 F2 ** NARRATIVE ** 1055 AT SCENE? _ Mast-RN 211491_ Inc-Type 32 Pro-Clas F3 Next NARR Control F952050626184012 Recno 453258 ** FIRE INCIDENT SYSTEM -- FIRE REPORT NARRATIVE ** Mast-RN 211491_ INC-NO 050030812 Supp-Exp Inc-Date 062605 Inc-Type 32 ADDRESS EB US50 AT PIONEER BRIDGE Pro-Clas REPT-DID G7286 ** COMPANY MEMBERS ** Company M02_ Shift A C4... .. CC AO ** NARRATIVE ** 1055 AT SCENE? _ Fl G7286 F2 C7139 F3 Next Control F799050626194112 Recno 453282_ NARR ** FIRE INCIDENT SYSTEM -- FIRE REPORT NARRATIVE ** INC-NO 050030812 Supp-Exp Inc-Date 062605 ADDRESS EB US50 AT PIONEER BRIDGE REPT-DID P2825 Mast-RN 211491_ Inc-Type 32 Pro-Clas ** COMPANY MEMBERS ** CC AO Fl P2825 F2 55754 F3 ** NARRATIVE ** Company M06_ Shift A 1055 AT SCENE? _ SEE PCR Next Control F848050626205353 FMED ** FIRE INCIDENT SYSTEM -- MEDICAL REPORT ** INC-NO 050030812 Supp-Exp Inc-Date 062605 ADDRESS EB US50 AT PIONEER BRIDGE Med-Unit M06 Hosp-Cod UCD * !!! One FMED for each Transported Patient !!! Name TALHEM, SAMMY __ Sor_ * Dispatch Time * Code 2 Time * On Scene Time * Hospital Enroute Time * Hospital Arrival Time * Clear Time * Beginning Mileage * Ending Mileage Comments 1643 1648 1658 1709 1709 10.0_ 15.0 DL St Patient Type TRA * RES Age 47_ * CAR * MED CPR Performed at any Time? N * CTC Pulse Regained at any Time _ * TRA * OBS * PSY 5.0 Recno 453238 Mast-RN 211491 Inc-Typ 32 Call 05070333 Ref-No Next Contro F848050626205312 Recno 284314_ Talhelm, Samuel (MRN 1769581) Lab Results UC DAMS HEALTH SYSTEM BLOOD COUNT (Order# 6680434) Collection Collection Date and Time Received Date and Time Information 6!27/2005 0330 6/27/2005 0337 .'14ftbh~iA0..'. w ~ Com ol~ nent Value ~1 g ~i F~lgh l~oi1~ Status WHITE BLOOD CELL COUNT 7.3 5.0 14.5 IUMM3 Final RED CELL COUNT 4.00 3.9 5.3 M/MM3 Final HEMOGLOBIN 11.9 11.5 13.5 GM/DL Final HEMATOCRIT 34.8 34 40 % Final MCV 86.9 77 95 UM3 Final MCH 29.7 27 33 PG Final MCHC 34.1 32 36 % Final RDW 13.0 0 14.7 UNITS Finaf PLATELET COUNT 146 130 400 K/MM3 Final PLATELET ESTIMATE, SMEAR Final Comment: PLATELET CLUMPS PRESENT, AUTOMATED COUNT APPEARS ADEQ UATE ti,~.~- ~. ` : ; ~~~ ti. BLOOD COUNT (Order#6680434) on 6/27/05 -Order Result History Report Other IDs Lab Specimen # 0627:H00128S Patient Patient Name Information Talhelm, Samuel ni D7PA MRN ~ 1769581 M Room Isolation 7773 N DOB Home Phone 9/15/1997 717-486-4804 (8Yr) Lab 1~ Lab Director Information UC DAVIS MED CTR Ralph Green, MD 2315 Stockton Blvd Sacramento, CA 95817 01'del' ~t1f01'll'tatlOtl BLOOD COUNT (Orderif 6680434) Order Order Date and Time Department Information 6/27/2005 3:30 AM D7 Pediatrics Account Acct Number Information 020960262994 Order Authorizing Provider Encounter Provider COPY -Protected Health Information - 08/30/2006 14:00:58-MR0202 Page 1 of 13 Talhelm, Samuel (MRN 1769581) UC DAMS HEALTH SYSTEM Providers (09686) Kelly Tung (06569) Jason London, MD Specimen Collection Date Collection Time Resulting Aaencv Information 6/27/2005 3:30 AM UC DAMS MED CTR Priority and Priority Class Order Details STAT Normal Lab Results BLOOD COUNT (Order# 6679332) Collection Collection Date and Time Received Date and Time Information 6/26/2005 2245 6/26/2005 2302 «., Component Value FIa9 Low ~ Units Stratus WHITE BLOOD CELL COUNT 10.0 5.0 14.5 K/MM3 Final RED CELL COUNT 3.68 L 3.9 5.3 MIMM3 Final HEMOGLOBIN 11.0 L 11.5 13.5 GM/DL Final HEMATOCRIT 32.0 L 34 40 % Final MCV 86.9 77 95 UM3 Final MCH 29.9 27 33 PG Final MCHC 34.4 32 36 % Final RDW 12.8 0 14.7 UNITS Final PLATELET COUNT 237 130 400 K/MM3 Final Other IDs Lab Specimen # 0626:H00465S Patient Patient Name MRN ~ D Home Phone Information Talhelm, Samuel 1769581 M 9/15/1997 717-486-4804 (8Yr) ni Room 1 0l i D7PA 7773 N Lab L~ Lab Director Information UC DAMS MED CTR Ralph Green, MD 2315 Stockton Blvd Sacramento, CA 95817 Order Information BLOOD COUNT (Order# 6679332) Order Order Date and Time Department Information 6/26/2005 10:45 PM D7 Pediatrics Account Acct Number COPY -Protected Health Information - 08/30/2006 14:00:58-MR0202 Page 2 of 13 Talhelm, Samuel (MRN 1769581) Information 020960262994 UC DAVIS HEALTH SYSTEM Order Authorizing Provider Encounter Provider Providers (07992) Dustin Ballard (06569) Jason London, MD Specimen Collection Date Collection Time Resulting Agencv Information 6/26/2005 10:45 PM UC DAVIS MED CTR Priority and n' j Class Order Details STAT Normal Lab Results URINALYSIS-COMPLETE (Order# 6679190) Collection Collection Date and Time Received Date and Time Information 6/26/2005 2150 6/26/2005 2214 a'q.~ MAOtIfl L' _ . 3..F1... Com og nent Value Fig I•ow bjgLi Units Status COLLECTION Catheterized Final `URINE VOLUME 1.0 Final Comment: *10 mL required for accurate microscopic. COLOR Yellow None/Yellow Final CLARITY SI Turbid Clr/SI Turb Final SP GRAVITY 1.020 1.002 1.030 Final pH URINE 7.5 4.8 7.8 Final OCCULT BLOOD URINE Negative Negative Final BILIRUBIN URINE Negative Negative Final KETONES Negative Negative mg/dL Final GLUCOSE URINE Negative Negative mg/dL Final CLINITEST Negative Negative Final PROTEIN URINE Trace Neg/Trace mg/dL Final SULFOSAL Positive A Negative Final UROBILINOGEN 0.2 0.2 1.0 EU/dL Final NITRITE URINE Negative Negative Final LEUK. ESTERASE Negative Negative Final MICROSCOPIC INDICATED Negative Final WBC/HPF 3-6 A 0 3 Final RBC/HPF 3-6 0 6 RBC/HPF Final BACTERIA/HPF Occasional Neg/OcGFew Final RENAL EPI 50-100 A 0 1 EPI/HPF Final Comment: MANY CLUMPS SEEN TRANS EPI 6-12 A 0 2 EPUHPF Final s~_ ... .. .E. ~,,...' '~y,. ~ ' ~.~ i1 URINALYSIS-COMPLETE (Order#6679190) on 6/26105 -Order Result History Report COPY -Protected Health Information - 08/30/2006 14:00:58-MR0202 Page 3 of 13 Talhelm, Samuel (MRN 1769581) UC DAVIS HEALTH SYSTEM Other IDs Lab Specimen # 0626: UA00076S Patient Patient Name ~ ~ ~ Home Phone Information Talhelm, Samuel 1769581 M 9/15/1997 717-486-4804 (8yr) !/nit Room ! D7PA 7773 N Lab Late Lab Director Information UC DAVIS MED CTR Ralph Green, MD 2315 Stockton Blvd Sacramento, CA 95817 Order Information URINALYSIS-COMPLETE (Order# 6679190) Order Order Date and Time Denartment Information 6!26/2005 9:50 PM D7 Pediatrics Account Acct Number Information 020960262994 Order Authorizing Provider Encounter Provider Providers (07992) Dustin Ballard (06569) Jason London, MD Specimen Collection Date Collection Time Resulting Agencv Information 6!2612005 9:50 PM UC DAVIS MED CTR Priority and Priority Ciass Order Details STAT Normal Lab Results BLOOD COUNT (Order# 6678573) Collection Collection Date and Time Received Date and Time Information 6/26/20051900 6/26/20051910 . a_ - ,.~. _ . _ ~ - ~~} Component Value ~ ~ b!9h Units Status WHITE BLOOD CELL COUNT 8.0 5.0 14.5 K/MM3 Final RED CELL COUNT 3.93 3.9 5.3 M/MM3 Final HEMOGLOBIN 11.7 11.5 13.5 GM/DL Final COPY -Protected Health Information - 08/30/2006 14:00:58-MR0202 Page 4 of 13 Talhelm, Samuel (MRN 1769581) UC DAVIS HEALTH SYSTEM HEMATOCRIT 34.4 34 40 % Final MCV 87.5 77 95 UM3 Final MCH 29.8 27 33 PG Final MCHC 34.0 32 36 % Final RDW 12.9 0 14.7 UNITS Final PLATELET COUNT 231 130 400 IUMM3 Final Other IDs Lab Soecimen # 0626:H00422S Patient Patient Name MRN S, ex ~ Home Phone Information Talhelm, Samuel 1769581 M 9!15/1997 717-486-4804 (8Yr) ~0_i1i Room Isolation D7PA 7773 N Lab 1~ Lab Director Information UC DAVIS MED CTR Ralph Green, MD 2315 Stockton Bivd Sacramento, CA 95817 Order Information BLOOD COUNT (Order# 6678573) Order Order Date and Time Department Information 6/26/2005 7:00 PM D7 Pediatrics Account Acct Number Information 020960262994 Order Authorizing Provider Encounter Provider Providers (05456) Peter Sokolove (06569) Jason London, MD Specimen Collection Date Collection Time Resulting Ag ncv Information 6/2612005 7:00 PM UC DAMS MED CTR Priority and ri Class Order Details STAT Normal Lab Results BASIC CHEMISTRY PANEL (BCP) (Order# 6678371) Collection Collection Date and Time Received Date and Time Information 6126120051752 6/26120051803 COPY -Protected Health Information - 08/30/2006 14:00:58-MR0202 Page 5 of 13 Talhelm, Samuel (MRN 1769581) UC DAVIS HEALTH SYSTEM Com onent Value Fig ~ ~ Units Status SODIUM 139 135 145 mEq/L Final POTASSIUM 4.2 3.3 5.0 mEq/L Final CHLORIDE 106 95 110 mEq/L Final CARBON DIOXIDE TOTAL 24 24 32 mEq/L Final UREA NITROGEN, BLOOD 17 8 22 mg/dL Final (BUN) CREATININE BLOOD 0.3 L 0.5 1.3 mgldL Final GLUCOSE 102 70 110 mg/dL Final BASIC CHEMISTRY PANEL (BCP) (Order#6678371} on 6/26105 -Order Result History Report Related Tests LIVER FUNCTION TESTS jOrder~6678372) on 6/26/05 LIPASE (Order#6678373) on 6/26/05 Other IDs Lab Specimen # 0626:CI00370S Patient patient Name Information Talhelm, Samuel D7PA MRN $gl~ 1769581 M Room Isolation 7773 N ~~ Home Phone 9/15/1997 717-486-4804 (8Yr) Lab I,a4 Lab Director Information UC DAVIS MED CTR Ralph Green, MD 2315 Stockton Blvd Sacramento, CA 95817 ~~d@C ~t1f01'IZ'18tlOtl BASIC CHEMISTRY PANEL (BCP) (Order# 6678371) Order Order Date and Time Deoartment Information 6/26/2005 5:52 PM D7 Pediatrics Account Acct Number Information 020960262994 Order Authorizing Provider Encounter Provider Providers (05456) Peter Sokolove (06569) Jason London, MD Specimen Collection Date Collection Time Resulting Agencv Information 6/26/2005 5:52 PM UC DAVIS MED CTR COPY -Protected Health Information - 08/30/2006 14:00:58-MR0202 Page 6 of 13 Talhelm, Samuel (MRN 1769581) Priority and Priority Class Order Details STAT Normal UC DAVIS HEALTH SYSTEM Lab Results LIVER FUNCTION TESTS (Order# 6678372) Collection Collection Date and Time Received Date and Time Information 6126/20051752 6/26120051803 Com op vent Value Jaq J_ow ~.9- Units Status ALBUMIN 3.9 2.9 4.5 g/dL Final ALKALINE PHOSPHATASE 176 H 35 115 UIL Final (ALP) ASPARTATE TRANSAMINASE 22 15 43 U/L Final (AST) BILIRUBIN TOTAL 1.1 0.3 1.3 mg/dL Final ALANINE TRANSFERASE 14 6 63 U/L Final (ALT) LIVER FUNCTION TESTS (Order#6678372Ln 6126!05 -Order Result History Report Related Tests BASIC CHEMISTRY PANEL (BCP~(Order#6678371) on 6/26/05 LIPASE (Order#6678373) on 6/26105 Other IDs Reflex Order # Lab Specimen # 6678371 0626:CI00370S Patient Patient Name Information Talhelm, Samuel D7PA LH.R-N ~x 1769561 M Room Isolation 7773 N ~i3 Home Phone 9/15/1997 717-486-4804 (8yr) Lab Lai Lab Director Information UC DAVIS MED CTR Ralph Green, MD 2315 Stockton Blvd Sacramento, CA 95817 Order Information LIVER FUNCTION TESTS (Order# 6678372) Order Order Date and Time Department Information 6/26/2005 5:52 PM D7 Pediatrics Account COPY -Protected Health Information - 08/30/2006 14:00:58-MR0202 Page 7 of 13 Talhelm, Samuel (MRN 1769581) UC DAVIS HEALTH SYSTEM Information Acct Number 020960262994 OMer Authorizing Provider Providers (05456) Peter Sokolove Specimen Collection Date Information 6/26/2005 Priority and Priority Class Order Details STAT Normal Encounter Provider (06569) Jason London, MD Collection Time Resulting Aaencv 5:52 PM UC DAVIS MED CTR Lab Results LIPASE (Order# 6678373) Collection Collection Date and Time Received Date and Time Information 6/26/20051752 6/26/20051803 Component Value ~ l.ow bjgF~ Units Status LIPASE 27 13 51 U/L Final w..s; ~' LIPASE (Order#6678373) on 6/26/05 -Order Result History Report Related Tests BASIC CHEMISTRY PANEL (BCP) (Order#6678371) on 6/26/05 LIVER FUNCTION TESTS (Order#6678372) on 6/26/05 Other IDs Reflex Order # Lab Specimen # 6678371 0626:CI00370S Patient Patient Name M6M ~ DOB Home Phone Information Talhelm, Samuel 1769581 M 9/15/1997 717-486-4804 (8Yr) Room Isolation D7PA 7773 N Lab Lao Lab Director Information UC DAVIS MED CTR Ralph Green, MD 2315 Stockton Blvd Sacramento, CA 95817 Order Information LIPASE (Order# 6678373) COPY -Protected Health Information - 08/30/2006 14:00:58-MR0202 Page 8 of 13 Talhelm, Samuel (MRN 1769581) UC DAMS HEALTH SYSTEM Order Order Date and Time Department Information 6/26/2005 5:52 PM D7 Pediatrics Account Acct Number Information 020960262994 OMer Authorizing Provider Encounter Provider Providers (05456) Peter Sokolove (06569) Jason London, MD Specimen Collection Date Collection Time Resulting Aaencv Information 6/26/2005 5:52 PM UC DAVIS MED CTR Priority and ri Class Order Details STAT Normal Lab Results CBC WITH AUTO DIFFERENTIAL (Order# 6678377) Collection Collection Date and Time Received Date and Time Information 6/26/20051752 6126/20051803 F. '. Y y ~~Y Com oo nent Value ~I g Lbw F1igLi ni Status WHITE BLOOD CELL COUNT 8.3 4.5 11.0 K/MM3 Final RED CELL COUNT 4.13 L 4.5 5.9 M/MM3 Final HEMOGLOBIN 12.2 L 13.5 17.5 GM/DL Final HEMATOCRIT 35.8 L 41 53 % Final MCV 86.7 80 100 UM3 Final MCH 29.4 27 33 PG Final MCHC 33.9 32 36 % Final RDW 12.8 0 14.7 UNITS Final PLATELET COUNT 269 130 400 K/MM3 Final NEUTROPHILS %AUTO 40.3 % Final LYMPHOCYTES % AUTO 48.4 % Final MONOCYTES % AUTO 9.1 % Final EOSINOPHIL % AUTO 1.8 % Final BASOPHILS % AUTO 0.4 % Final NEUTROPHIL ABS AUTO 3.36 1.80 7.70 K/MM3 Final LYMPHOCYTE ABS AUTO 4.03 1.0 4.8 K/MM3 Final MONOCYTES ABS AUTO 0.75 0.1 0.8 K/MM3 Final EOSINOPHIL ABS AUTO 0.15 0 0.5 K/MM3 Final BASOPHILS ABS AUTO 0.04 0 0.2 KlMM3 Final Other IDs Lab Specimen # COPY -Protected Health Information - 08/30/2006 14:00:58-MR0202 Page 9 of 13 Talhelm, Samuel (MRN 1769581) UC DAVIS HEALTH SYSTEM 0626:H00402S Patient Patient Name MRN $ga iN~.@ Home Phone Information Talhelm, Samuel 1769581 M 9115/1997 717-486-4804 (8Yr) SlIIlt i2oom Isolation D7PA 7773 N Lab 1~ Lab Director Information UC DAVIS MED CTR Ralph Green, MD 2315 Stockton Blvd Sacramento, CA 95817 Order Information CBC WITH AUTO DIFFERENTIAL (Order# 6678377) Order Order Date and Time Department Information 6/26/2005 5:52 PM D7 Pediatrics Account Acct Number Information 020960262994 Order Authorizing Provider Encounter Provider Providers (05456) Peter Sokolove (06569) Jason London, MD Specimen Collection Date Collection Time Resulting Agencv Information 6/26/2005 5:52 PM UC DAVIS MED CTR Priority and Priority Class Order Details STAT Normal Lab Results PROTHROMBIN TIME (PT) (Order# 6678479) Collection Collection Date and Time Received Date and Time Information 6126/20051752 6126/20051803 .~.lP,L ~. ~~s. .,Y. z ~~~ afro ~~ rt. .. vs ~i+?ri S"yo- ~aLwL`':a~ai9FPkestf- Com o~ Value FJeq I.ow High its Status INR 1.17 0.75 1.19 Final Related Tests APTT STUDIES (Order#6678480) on 6/26/05 COPY -Protected Health Information - 08/30/2006 14:00:58-MR0202 Page 10 of 13 Talhelm, Samuel (MRN 1769581) Other IDs Lab Specimen # 0626:CG00185S Patient patient Name Information Talhelm, Samuel !leis D7PA ~ ;ism 1769581 M Room Isolation 7773 N UC DAMS HEALTH SYSTEM i?Q@ Home Phone 9/15/1997 71786-4804 (8yr) Lab 1~ Lab Director Information UC DAVIS MED CTR Ralph Green, MD 2315 Stockton Blvd Sacramento, CA 95817 Order Information PROTHROMBIN TIME (PT) (Order# 6678479) Order Order Date and Time Deuartment Information 6/26/2005 5:52 PM D7 Pediatrics Account Acct Number Information 020960262994 Order Authorizing Provider Encounter Provider Providers (05456) Peter Sokolove (06569) Jason London, MD Specimen Collection Date Collection Time Resulting Agent Information 6/26/2005 5:52 PM UC DAVIS MED CTR Priority and ri Class Order Details STAT Normal Lab Results APTT STUDIES (Order# 6678480) Collection Collection Date and Time Received Date and Time Information 6/26/20051752 6/26/20051803 Com op Went Value Stag ~ Hi r Units Status APTT 30.3 21.8 31.5 SECONDS Final Related Tests PROTHROMBIN TIME (PT) (Order#6678479) on 6/26/05 COPY -Protected Health Information - 08/30/2006 14:00:58-MR0202 Page 11 of 13 Talhelm, Samuel (MRN 1769581) UC DAVIS HEALTH SYSTEM Other IDs Reflex Order # Lab Specimen # 6678479 0626:CG00185S Patient patient Name MRN S. ex DOB Home Phone Information Talhelm, Samuel 1769581 M 9/15/1997 717-486-4804 (8Yr) lZnit ~~ Isolation D7PA 7773 N Lab ~ Lab Director Information UC DAVIS MED CTR Ralph Green, MD 2315 Stockton Blvd Sacramento, CA 95817 Order Information APTT STUDIES (Order# 6678480 Order Order Date and Time Department Information 6/26/2005 5:52 PM D7 Pediatrics Account Acct Number Information 020960262994 Order Authorizing Provider Encounter Provider Providers (05456) Peter Sokolove (06569) Jason London, MD Specimen Collection Date Collection Time Resulting Agency Information 6/26/2005 5:52 PM UC DAVIS MED CTR Priority and ri ri Class Order Details STAT Normal Lab Results TYPE AND SCREEN (Order# 6678424) Collection Collection Date and Time Received Date and Time Information 6126/20051752 6126/20051817 ,. ~~ ~ ~ M~ PATIENT BLOOD TYPE: O POSITIVE ANTIBODY SCREEN (ORTHO GEL): COPY -Protected Health Information - 08/30/2006 14:00:58-MR0202 Page 12 of 13 TYPE AND SCREEN (Order#6678424) on 6/26/05 -Order Result History Report Other IDs Lab Soecimen # 0626:BB00062S Patient Patient Name Information Talhelm, Samuel l~oiS D7PA MRN ~ DOB 1769581 M 9/15/1997 (8Yr) Room Lsolation 7773 N Home Phone 717-486-4804 Lab ~ Lab Director Information UC DAVIS MED CTR Ralph Green, MD 2315 Stockton Blvd Sacramento, CA 95817 Order Information TYPE AND SCREEN (Order# 6678424) Order Qrder Date and Time DeQartment Information 6/26/2005 5:52 PM D7 Pediatrics Account Acct Number Information 020960262994 Order Authorizing Provider Encounter Provider Providers (05456) Peter Sokolove (06569) Jason London, MD Specimen Collection Date Collection Time Resulting~gencv Information 6/26/2005 5:52 PM UC DAVIS MED CTR Priority and Pri Ciass Order Details STAT Normal COPY -Protected Health Information - 08/30/2006 14:00:58-MR0202 Page 13 of 13 Talhelm, Samuel (MRN 1769581) UC DAVIS HEALTH SYSTEM Imaging Results T-SPINE 2 VIEWS (Order# 6678238) (Acc# 28308) PACS Images Show images for T-SPINE 2 VIEWS (_RADDX01046J Click here for General Information or Troubleshooting Tips on launching PACS Images from the EMR, or contact I.S. Customer Support at 734-HELP. Results EXAM DATE: 06/26/2005 THORACIC SPINE, 2 VIEWS: CLINICAL HISTORY: Trauma, nonverbal patient. FINDINGS: AP and lateral views of the thoracic spine are provided for review without previous films for comparison. There is no evidence of fracture or malalignment. The vertebral body and disc space heights are preserved. Incidentally noted is contrast material within the collecting system from prior CT exam. The right clavicle is incompletely seen, but suspicious for a distal 1/3rd fracture. Dedicated films are recommended. IMPRESSION: 1. NO EVIDENCE OF FRACTURE OR MALALIGNMENT IN THE THORACIC SPINE. 2. INCOMPLETELY SEEN, POSSIBLE RIGHT CLAVICULAR FRACTURE. DEDICATED FILMS ARE RECOMMENDED. SH:cm(rad020) ACC#: 000000028308 D: 06/26/2005 10:14 PM T: 06/26/2005 10:34 PM C#: 1092781 signed: Stephanie Horton, D.O. cosigned: Kiran Jain, M.D. Result History T-SPINE 2 VIEWS (Order#6678238) on 6/29/05 -Order Result History Report Exam Exam Date Exam Time Information 6/26/2005 2200 Result Result Date and Time Information 6/29/2005 7:38 PM Status Final result Patient Patient Name MRN ~ )~ Information Talhelm, Samuel 1769581 Male 9/15/1997 ni Room Isolation D7PA 7773 N COPY -Protected Health Information - 08/30/2006 14:01:05-MR0202 Page 1 of 17 Talhelm, Samuel (MRN 1769581) UC DAVIS HEALTH SYSTEM Order T-SPINE 2 VIEWS (Order# 6678238) Patient patient Name MRN S. ex pQ@ Patient Phone Information Talhelm, Samuel 1769581 Male 9/15/1997 717-486-4804 Allergies: AMOXICILLIN Order Authorizing Provider Encounter Provider Providers (05456) Peter Sokolove (06569) Jason London, MD Order Order Date and Time Department Information 6/26/2005 5:40 PM D7 Pediatrics Priority and p i r' Class Order Details STAT Normal Web Links Radiology facilities Ordering Physician Rad. Contact Info. Insurance Acct Number Financial Class Information 020960262994 O 1 Payor MISC Patient 01349657TPA Group 094737 Insurance Number ID Elan Elan Number COMMERCIAL 099 INS-MISC 2 Payor MISC Patient 061601202 Grouo 094737 Insurance Number ~ Plan Number PPO/HMO/EPO- P99 MISC 3 Payor MCAID Patient 22273817 Groun 094737 Insurance Number Q Plan PJ_~n Number OTHER ST G96 MCAID -MISC Imaging Results C-SPINE 2 OR 3 VIEWS (Order# 6678797) (Acc# 28307) COPY -Protected Health Information - 08/30/2006 14:01:05-MR0202 Page 2 of 17 Talhelm, Samuel (MRN 1769581) UC DAVIS HEALTH SYSTEM PACS Images Show images for C-SPINE 2 OR 3 VIEWS [RADDX01007] Click here for General Information or Troubleshooting Tiffs on launching PACS Images from the EMR, or contact I.S. Customer Support at 734-HELP. Resu Its EXAM DATE: 06/26/2005 CERVICAL SPINE, 2 OR 3 VIEWS: CLINICAL HISTORY: Trauma, nonverbal patient. FINDINGS: Three views of the cervical spine were provided for review without previous films for comparison. There is no evidence of fracture or malalignment. C1-2 cannot be fully evaluated; however, please see CT of the C-spine from the same date. The vertebral body and disc space heights are preserved. No prevertebral soft tissue swelling is noted. However, the prevertebral soft tissues are at the upper limits of normal, again see CT of the C-spine from the same date for further details. IMPRESSION: 1. LIMITED EVALUATION OF THE CERVICAL SPINE WITHOUT EVIDENCE OF FRACTURE OR MALALIGNMENT FROM C2 THROUGH T1. 2. PREVERTEBRAL SOFT TISSUES AT UPPER LIMITS OF NORMAL. SH:cm(rad020) ACC#: 000000028307 D: 06/26/2005 10:12 PM T: 06/26/2005 10:22 PM C#: 1092778 signed: Stephanie Horton, D.O. cosigned: Kiran Jain, M.D. Result History C-SPINE 2 OR 3 VIEWS (Order#6678797) on 6/29/05 -Order Result History Report Exam Exam Date Exam Time Information 6/26/2005 2200 Result Result Date and Time Information 6/29/2005 7:38 PM Status Final result Patient Patient Name MRN ~ DOB Information Talhelm, Samuel 1769581 Male 9/15/1997 r it Ro m i n D7PA 7773 N COPY -Protected Health Information - 08/30/20Q6 14:01:05-MR0202 Page 3 of 17 Talhelm, Samuel (MRN 1769581) UC DAVIS HEALTH SYSTEM Order C-SPINE 2 OR 3 VIEWS (Order# 6678797) Patient Patient Name MRN ~ 12Q@ Patient Phone Information Talhelm, Samuel 1769581 Male 9/15/1997 717-486-4804 Allergies: AMOXICILLIN Order Authorizing Provider Encounter Provider Providers (05456) Peter Sokolove (06569) Jason London, MD Order Order Date and Time Department Information 6/26/2005 5:40 PM D7 Pediatrics Priority and Priority Class Order Details STAT Normal Web Links Radiology facilities Ordering Physician Rad. Contact Info. Insurance Acct Number Financial Class Information 020960262994 O 1 Payor MISC Patient 01349657TPA Group 094737 Insurance Number lD P~ PJ~n Number COMMERCIAL 099 INS-MISC 2 Payor MISC Patient 061801202 Group 094737 Insurance Number ID Plan Number PPO/HMO/EPO- P99 MISC 3 Payor MCAID Patient 22273817 Group 094737 Insurance Number Plan Plan Number OTHER ST G96 MCAID -MISC COPY -Protected Health Information - 08/30/2006 14:01:05-MR0202 Page 4 of 17 Talhelm, Samuel (MRN 1769581) Imaging Results UC DAMS HEALTH SYSTEM CT L-SPINE (Order# 6678244) (Acc# 28314) PACS Images Show images for CT L-SPINE [RADCT00934j Click here for General Information or Troubleshooting Ties on launching PACS Images from the EMR, or contact I.S. Customer Support at 734-HELP. Results EXAM DATE: 06/26/2005 CT LUMBAR SPINE: INDICATION: Patient with trauma. TECHNIQUE: Transaxial CT scan of the lumbar spine obtained after uneventful administration of Omnipaque-300 IV contrast with corona! and sagittal reconstructions. The alignment of the lumbar spine appears in anatomic position without evidence of fracture, dislocation, or subluxation. No abnormal paraspinal masses identified. IMPRESSION: 1. UNREMARKABLE CT OF THE LUMBAR SPINE WITHOUT EVIDENCE OF FRACTURE OR DISLOCATION. 2. PLEASE ALSO REFER TO CT OF THE ABDOMEN FOR ADDITIONAL SEPARATE REPORT. Dr. Gorges present for discussion and review of the case. HP:co(rad042) ACC#: 000000028314 D: 06/27/2005 02:36 PM T: 06/27/2005 02:42 PM C#: 1094500 signed: Huan Pham, M.D. cosigned: Sandra Gorges, M.D. Result History CT L-SPINE (Order#6678244) on 6/27/05 -Order Result History Report Exam Exam Date Exam Time Information 6!26!2005 2116 Result Result Date and Time Information 6/27/2005 4:36 PM Status Final result Patient Patient Name MRN S. ex D B Information Talhelm, Samuel 1769581 Male 9/15/1997 COPY -Protected Health Information - 08/30/2006 14:01:05-MR0202 Page 5 of 17 Talhelm, Samuel (MRN 1769581) UC DAMS HEALTH SYSTEM Room Isolation D7PA 7773 N Order CT L-SPINE (Order# 6678244) Patient Patient Name I~IY ;t~X )~ patient Phone Information Talhelm, Samuel 1769581 Male 9115/1997 717-486-4804 Allergies: AMOXICILLIN Order Authorizing Provider Encounter Provider Providers (05456) Peter Sokolove (06569) Jason London, MD Order Order Date and Time De_rtartment Information 6/26/2005 5:40 PM D7 Pediatrics Priority and Priority Class Order Details STAT Internal Referral Web Links Radiology facilities Ordering Physician Rad. Contact Info. Insurance Acct Number Information 020960262994 1 Pavor MISC Financial Class O Patient 01349657TPA Grouu 094737 Insurance Number ID Plait P~ Number COMMERCIAL 099 INS-MISC 2 Payor MISC Patient 061601202 Grouu 094737 Insurance Number ID Plat Pia. Number PPO/HMO/EPO- P99 MISC 3 Payor MCAID Patient 22273817 Groun 094737 Insurance Number ID Plan Pin. Number OTHER ST G96 MCAID -MISC COPY -Protected Health Information - 08/30/2006 14:01:05-MR0202 Page 6 of 17 Talhelm, Samuel (MRN 1769581) UC DAVIS HEALTH SYSTEM Imaging Results CT HEAD (Order# 6678240) (Acc# 28310) PACS Images Show images for CT HEAD [RADCT009311 Click here for General Information or Troubleshooting Tiffs on launching PACS Images from the EMR, or contact I.S. Customer Support at 734-HELP. Results EXAM DATE: 06/26/2005 CT HEAD: INDICATION: Critical trauma. TECHNIQUE: Noncontrast CT scan of the head obtained without comparison. FINDINGS: No intracranial hemorrhage, mass, midline shift identified. Ventricles, sulci and cisternal spaces appear unremarkable. Incidental findings of arachnoid cyst in the right middle cranial fossa. Calcification of pineal gland also identified. There is normal gray- white matter differentiation. Soft tissues and bony structures appear unremarkable. IMPRESSION: 1. NO EVIDENCE OF INTRACRANIAL INJURY. 2. INCIDENTAL NOTE IS OF THE RIGHT MIDDLE FOSSA ARACHNOID CYST. DR. LATCHAW WAS PRESENT FOR DISCUSSION AND REVIEW OF THE CASE. HP:mh(rad016) ACC#: 000000028310 D: 06/27/2005 02:40 PM T: 06/27/2005 02:47 PM C#: 1094520 signed: Huan Pham, M.D. cosigned: Richard Latchaw, M.D. Result History CT HEAD LOrder#6678240) on 6/27/05 -Order Result History Report Exam Exam Date Exam Time Information 6/26/2005 2113 Result Result Date and Time Information 6/27/2005 10:04 PM Status Final result COPY -Protected Health Information - 08/30/2006 14:01:05-MR0202 Page 7 of 17 Talhelm, Samuel (MRN 1769581) UC DAVIS HEALTH SYSTEM Patient patient Name NlS~! $BX p0B Information Talhelm, Samuel 1769581 Male 9/15/1997 !Zoom Isolation D7PA 7773 N Order CT HEAD (Order# 6878240) Patient patient Name MRN ~ pQ~ Patient Phone Information Talhelm, Samuel 1769581 Male 9/15/1997 717-486-4804 Allergies: AMOXICILLIN Order Authorizing Provider Encounter Provider Providers (05456) Peter Sokolove (06569) Jason London, MD Order Order Date and Time Department Information 6/26/2005 5:40 PM D7 Pediatrics Priority and Pri ri Class Order Details STAT Internal Referral Web Links Radiology facilities Ordering Physician Rad. Contact Info Insurance Acct Number Information 020960262994 ~ Payor MISC Financial Class O Patient 01349657TPA Group 094737 Insurance Number iD PSI r~ Plan Number COMMERCIAL 099 INS-MISC 2 Payor MISC Patient 061601202 Group 094737 Insurance Number Q lan Sri L~lumber PPO/HMO/EPO- P99 MISC S Payor MCAID Patient 22273817 Group 094737 Insurance Number COPY -Protected Health Information - 08/30/2006 14:01:05-MR0202 Page 8 of 17 Talhelm, Samuel (MRN 1769581) UC DAMS HEALTH SYSTEM !Q Plan P~ Number OTHER ST G96 MCAID - MISC Imaging Results CT ABDOMEN + CT PELVIS, WITH CONTRAST (Order# 6678955) (Acc# 28311) PACS Images Show images for CT ABDOMEN + CT PELVIS WITH CONTRAST [RADCT00955] Click here for General Information or Troubleshooting Ties on launching PACS Images from the EMR, or contact I.S. Customer Support at 734-HELP. Results EXAM DATE: 06/26/2005 CT ABDOMEN PELVIS: INDICATION: Patient with critical trauma . TECHNIQUE: CT of the abdomen/pelvis obtained after uneventful administration of Omnipaque 300 IV contrast without adverse reaction reported. No previous study available for comparison. FINDINGS: Bilateral lung bases appear unremarkable. Abdomen: Liver, gallbladder, spleen, pancreas, adrenal glands, and kidneys appear unremarkable. Incidentally note is retroaortic renal vein. Visualized stomach and bowel appear unremarkable. No free fluid or free air seen in the abdomen. Pelvis: Bladder is well distended. No free air or free fluid. The visualized bowel appears unremarkable in the pelvis. Shotty mesenteric lymph nodes present. Incidental note is of spina bifida occults at the level of S1. No evidence of acute fracture, dislocation or subluxation. Soft tissue is unremarkable. IMPRESSION: 1. NO EVIDENCE OF INTRA-ABDOMINAL AND PELVIC INJURY. 2. OTHER INCIDENTAL FINDING IS AS ABOVE. DR. GORGES IS PRESENT FOR DISCUSSION AND REVIEW OF THE CASE. HP:mh(rad016) ACC#: 000000028311 D: 06/27/2005 02:30 PM T: 06/27/2005 02:34 PM C#: 1094477 COPY -Protected Health Information - 08/30/2006 14:01:05-MR0202 Page 9 of 17 Talhelm, Samuel (MRN 1769581) UC DAMS HEALTH SYSTEM signed: Huan Pham, M. D. cosigned: Sandra Gorges, M.D. Result History CT ABDOMEN + CT PELVIS WITH CONTRAST (Order#6678955) on 6/28/05 -Order Result History Report Exam Exam Date scam Time Information 6/26/2005 2104 Result Result Date and Time Status Information 6!28(2005 2:57 PM Final result Patient Patient Name IItl3N_ $gzc QQ@ Information Talhelm, Samuel 1769581 Male 9/15!1997 ~i R~2m_ la~~i2~ D7PA 7773 N Order CT ABDOMEN + CT PELVIS, WITH CONTRAST (Orderly 6678955) Patient Patient Name Ii~N ~ ~ Patient Phone Information Talhelm, Samuel 1769581 Male 9115/1997 717-486-4804 Allergies: AMOXICILLIN Order Authorizing~rovider Encounter Provider Providers (05456) Peter Sokolove (06569) Jason London, MD Order Qrder Date and Time Department Information 6!26!2005 5:40 PM D7 Pediatrics Priority and r' i Class Order Details STAT Internal Referral Web Links Radiology facilities Ordering Physician Rad. Contact Info. Preis Insurance Acct Number Information 020960262994 1 Pryor MISC Financial Class O Patient 01349657TPA Insurance L Group 094737 Nstm~t COPY -Protected Health Information - 08/30/2006 14:01:05-MR0202 Page 10 of 17 Talhelm, Samuel (MRN 1769581) UC DAVIS HEALTH SYSTEM Plan Plan Number COMMERCIAL 099 INS-MISC 2 Payor MISC Patient 061601202 Group 094737 Insurance Number !Q Plan Pl.;~n. N~Ln] PPO/HMO/EPO- P99 MISC 3 Payor MCAID Patient 22273817 Grouo 094737 Insurance Number !~ Plan Plan Number OTHER ST G96 MCAID -MISC Imaging Results CT C-SPINE (Order# 6678243) (Acc# 28313) PACS Images Show images for CT C-SPINE [RADCT0092~ Click here for General Information or Troubleshooting Tips on launching PACS Images from the EMR, or contact I.S. Customer Support at 734-HELP. Resu Its EXAM DATE: 06/26/2005 CT CERVICAL SPINE: INDICATION: Status post critical trauma. TECHNIQUE: Transaxial CT scans of the upper cervical spine obtained with coronal and sagittal reconstructions. No prior study available for comparison. FINDINGS: No evidence of dislocation, subluxation or malalignment. Prevertebral soft tissue thickness is within normal limits. 1 cm cervical lymph nodes. Please identify. No abnormal paraspinal soft tissue masses. IMPRESSION: UNREMARKABLE CERVICAL SPINE CT WITHOUT EVIDENCE OF INJURY. DR. GORGES IS PRESENT FOR THE DISCUSSION OF THE CASE. HP:sl(rad018) COPY -Protected Health Information - 08/30/2006 14:01:05-MR0202 Page 11 of 17 Talhelm, Samuel (MRN 1769581) ACC#: 000000028313 D: 06/27/2005 02:45 PM T: 06/27/2005 02:53 PM C#: 1094542 signed: Huan Pham, M.D. cosigned: Sandra Gorges, M.D. UC DAVIS HEALTH SYSTEM Result History CT C-SPINE (Order#6678243) on 6/27/05 -Order Result History Report Exam Exam Date Exam Time Information 6/26/2005 2059 Result Result Date and Time Status Information 6/27/2005 4:36 PM Final result Patient Patient Name MRN ~ ~ Information Talhelm, Samuel 1769581 Male 9/15/1997 Room Isolation D7PA 7773 N Order CT C-SPINE (Orders 6678243) Patient patient Name MRN $g~c D~ Patient Phone Information Talhelm, Samuel 1769581 Male 9/15/1997 717-486-4804 Allergies: AMOXICILLIN Order Authorizing Provider Encounter Provider Providers (05456) Peter Sokolove (06569) Jason London, MD Order Qrder Date and Time Department Information 6/26/2005 5:40 PM D7 Pediatrics Priority and Priority Class Order Details STAT Internal Referral Web Links Radiology facilities Ordering Physician Rad. Contact Info Insurance Acct Number Financial Class Information COPY -Protected Health Information - 08/30/2006 14:01:05-MR0202 Page 12 of 17 Talhelm, Samuel (MRN 1769581) 020960262994 O 1 Payor MISC Pia Plan Number COMMERCIAL 099 INS-MISC UC DAVIS HEALTH SYSTEM Patient 01349657TPA Grouo 094737 Insurance Number lQ 2 Payor MISC Plan Plan Number PPO/HMO/EP0- P99 MISC Patient 061801202 Insurance Grouo 094737 Number 3 Payor MCAID P.I;Itn Plan Number OTHER ST G9fi MCAID -MISC Patient 22273817 Groun 094737 Insurance Number !2 Imaging Results PELVIS 1 OR 2 VIEWS (Order# 6678239) (Acc# 28309) PACS Images Show images for PELVIS 1 OR 2 VIEWS [RADDX00976] Click here for General Information or Troubleshooting Tiffs on launching PACS Images from the EMR, or contact I.S. Customer Support at 734-HELP. Results EXAM DATE: 06/26/2005 CLINICAL HISTORY: Critical trauma. TECHNIQUE: Pelvis x-ray, portable single AP view. Comparison: None. FINDINGS: The bones are skeletally immature. Visualization is somewhat limited by underpenetration. Otherwise, no large displaced fractures are seen. Soft tissues are unremarkable. IMPRESSION: 1. LIMITED NEGATIVE PORTABLE PELVIS. COPY -Protected Health Information - 08/30/2006 14:01:05-MR0202 Page 13 of 17 Talhelm, Samuel (MRN 1769581) UC DAMS HEALTH SYSTEM MCK:jj(rad017) ACC#: 000000028309 D: 06/26/2005 07:52 PM T: 06/26/2005 07:56 PM C#: 1092690 signed: Michael Kuo, M.D. cosigned: Kiran Jain, M.D. Result History PELVIS 1 OR 2 VIEWS~Order#6678239) on 6/28!05 -Order Result History Report Exam Exam Date Exam Time Information 6/26/2005 1804 Result Result Date and Time Status Information 6/28/2005 10:40 AM Final result Patient patient Name ~ ~[ ~ fnformation Talhelm, Samuel 1769581 Male 9/15/1997 ~!>i Room Isolation D7PA 7773 N Order PELVIS 1 OR 2 VIEWS (Order# 6678239) Patient Patient Name N S. ex D B Patient Phone Information Talhelm, Samuel 1769581 Male 9115/1997 717-486-4804 Allergies: AMOXICILLIN Order Authorizinq.provider Encounter Provider Providers (05456) Peter Sokolove (06569) Jason London, MD Order Order Date and Time DeRartment Information 6/2fi/2005 5:40 PM D7 Pediatrics Priority and P ' ri Class Order Details STAT Normal Web Links Radiology facilities Orderino Physician Rad. Contact Info. Insurance COPY -Protected Health Information - 08/30/2006 14:01:05-MR0202 Page 14 of 17 Talhelm, Samuel (MRN 1769581) Information Acct Number Financial Class 020960262994 O 1 Payor MISC Patient Insurance IQ P!a!z el;~ Number COMMERCIAL 099 INS-MISC 2 Payor MISC Patient 061601202 Grouo 094737 Insurance Number ID P_leD. P1;Itt1 Number PPO/HMO/EPO- P99 MISC 01349657TPA Grouo 094737 Number UC DAVIS HEALTH SYSTEM 3 Payor MCAID Patient 22273817 Insurance Grouo 094737 Number Per P1aQ Number OTHER ST G96 MCAID -MISC Imaging Results CHEST 1 VIEW (Order# 6678236) (Acc# 28306} PACS Images Show images for CHEST 1 VIEW jRADDX00980j Click here for General Information or Troubleshooting Tiffs on launching PACS Images from the EMR, or contact I.S. Customer Support at 734-HELP. Resu Its EXAM DATE: 06/26/2005 CLINICAL HISTORY: Critical trauma. CHEST X-RAY: Portable single AP view. No comparison. FINDINGS: Evaluation is limited because bilateral lung apices are not included on the image. Otherwise, the trachea, mediastinal, and cardiac contours are normal. Lungs are grossly clear without evidence of large pneumothorax or pleural effusion. No fractures are identified. The abdomen demonstrates no evidence of free air. IMPRESSION: LIMITED NEGATIVE PORTABLE CHEST X-RAY. COPY -Protected Health Information - 08/30/2006 14:01:05-MR0202 Page 15 of 17 Talhelm, Samuel (MRN 1769581) UC DAVIS HEALTH SYSTEM MCK:dg(rad004) ACC#: 000000028306 D: 06/26/2005 07:46 PM T: 06/27/2005 12:25 PM C#: 1092687 signed: Michael Kuo, M. D. cosigned: Rebecca Stein-Wexler, M.D. Result History CHEST 1 VIEW (Order#6678236) on 6/28/05 -Order Result History Report Exam Exam Date Exam Ti me Information 6/26/2005 1725 Result Result Date and Time Status Information 6/28/2005 12:21 PM Final result Patient Patient Name MRN S. ex DOB Information Talhelm, Samuel 1769581 Male 9/15!1997 ~1 Room Isolation D7PA 7773 N Order CHEST 1 VIEW (Order# 6678236) Patient patient Name MRN $gx DOB Patient Phone Information Talhelm, Samuel 1769581 Male 9/15/1997 717-486-4804 Allergies: AMOXICILLIN Order Authorizing Provider Encounter Provider Providers (05456) Peter Sokolove (06569) Jason London, MD Order Order Date and Time Deoartment Information 6/26/2005 5:40 PM D7 Pediatrics Priority and Priority Class Order Details STAT Normal Web Links Radiology facilities Ordering Physician Rad. Contact Info. Insurance COPY -Protected Health Information - 08/30/2006 14:01:05-MR0202 Page 16 of 17 Talhelm, Samuel (MRN 1769581) Information 020960262994 1 Pavor MISC Number COMMERCIAL 099 INS-MISC UC DAVIS HEALTH SYSTEM Financial Class O Patient 01349657TPA Group Insurance Number !~ 094737 2 Pavor MISC Patient 061801202 Insurance !Q Group 094737 Number ~ P1ao. Number PPO/HMO/EPO- P99 MISC 3 Pryor MCAID Patient 22273817 Grouu 094737 Insurance Number !Q ~ Plan Number OTHER ST G96 MCAID -MISC COPY -Protected Health Information - 08/30/2006 14:01:05-MR0202 Page 17 of 17 Talhelm, Samuel (MRN 1769581) Atathor Service Author Tvoe Janet Sue Carter (none) .PA/FNP Related Notes Original Note :CARTER, JANET SUE at 07/09/2005 1804 PATIENT: TALHELM, SAMUEL 9EN LOCATION: D7PA MR #: 1769581 SEX: M AGE: 7 DOB: 09/15!1997 ADMISSION DATE: 06/27/2005 DISCHARGE DATE: 06/27/2005 INPATIENT DISCHARGE SUMMARY DISCHARGE DIAGNOSIS: Multiple contusions. OPERATIONS: None. UC DAVIS HEALTH SYSTEM Filed 06/27/2005 0000 PROCEDURES: CT of the head, abdomen, pelvis and C-spine on 06/2612005. COMPLICATIONS: None. INFECTIONS: None. CONSULTATIONS: None. HOSPITAL COURSE: This is a 7-year-old boy who was involved in a rollover motor vehicle crash who presented with abdominal pain. Of note, the patient is autistic, and it is difficult to do a physical assessment on him. Please see the initial HS~P for his Emergency Department course. He was admitted to the Acute Care Ward to be ruled out for an intra-abdominal injury for which he was ruled out with stable hematocrits, normal white count, nontender abdominal exams, and negative CT of the abdomen. He was transitioned to a regular diet, which he is tolerating well. He has received no pain medication. He is currently medically stable for discharge home. DISCHARGE PLAN: 1. Discharge home. 2. Regular diet. 3. No strenuous activity for two weeks. 4. Follow up with Trauma Surgery or primary care physician in one week. 5. Call or return to the Emergency Department for fever, chills, nausea, vomiting, constipation, diarrhea, change in his mental status. DISCHARGE MEDICATIONS: No medications for discharge home. THIS WAS ELECTRONICALLY SIGNED - 07!11/200510:30 AM PST BY: JASON LONDON, MD THIS WAS ELECTRONICALLY SIGNED - 07/09/2005 6:03 PM PST BY: JANET CARTER, RN, NP NURSE PRACTITIONER DIVISION OF TRAUMA SURGERY DEPARTMENT OF SURGERY JC:ddh(usa213)dw D: 06/27/2005 T: 06128/2005 05:11 PM C#: 1094472 Author Peter E Sokolove ~~ Author Tvoe (none) `PHYSICIAN: Filed 06/26/2005 0000 COPY -Protected Health Information - 08/30/2006 14:01:09-MR0202 Page 1 of 3 Talhelm, Samuel (MRN 1769581) FACULTY Related Notes Original Note : SOKOLOVE, PETER E at 06/26/2005 1752 PATIENT: DOE, HEATH EN LOCATION: MR #: 1769581 SEX: M AGE: 125 DATE OF SERVICE: O6/26/2005 DOB: 01/01/1880 UC DAMS HEALTH SYSTEM EMERGENCY DEPARTMENT NOTE LINKING LANGUAGE: The patient was seen and examined with Dr. Cadogan. I reviewed the resident note and agreed, and helped developed a plan of care. HISTORY OF PRESENT ILLNESS: A 7-year-old male with history of autism brought in by ambulance status post restrained passenger in roll-over MVA at moderate speed. The patient had no complaints in the field, stable vital signs with a Glasgow Coma Scale of 15. No signs of trauma per EMS. Per mom, the patient is acting at his baseline mental status. The patient is unable to provide any history. PAST MEDICAL HISTORY: 1) Seizures. 2) Autism. Medications: Depakote. Surgical history: Both noncontributory. ALLERGIES: AMOXICILLIN. REVIEW OF SYSTEMS: The patient is unable. PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished male, in no respiratory distress. VITAL SIGNS: Blood pressure 96140, pulse 99, respirations 20 unlabored. HEENT: Normocephalic, atraumatic. Pupils are equal, round and reactive to light. Extraocular movements intact. No raccoon or battle signs. Oropharynx benign. Pacifier in mouth. Face nontender. NECK: C- collar in place. Trachea midline. No JVD. CHEST: Nontender, stable breath sounds equal bilaterally. HEART: Regular rate and rhythm without murmur. ABDOMEN: Soft, nondistended, nontender. PELVIS: Nontender and stable. EXTREMITIES: Nontender throughout full range of motion. BACK: Nontender throughout. NEUROLOGIC: Alert, awake, cries during exam, otherwise nonverbal. Moves all extremities equally and active purposeful movements, at her baseline per mom. ASSESSMENT AND PLAN: A 7-year-old male status post roll-over MVA without external signs of trauma and normal vital signs. It is difficult to evaluate the patient because of his baseline autism. We will check Trauma x-rays including films of the chest, x-ray, pelvis and C-spine. We will also obtain labs including serial CBCs, them 7, type and screen, urinalysis. We will check CT scan of the abdomen and pelvis to rule out intra-abdominal injury given the patient's unreliable exam. We will continue to monitor the patient in the Emergency Department. PRELIMINARY ED DIAGNOSES: 1. Status post roll-over MVA. 2. Autism. Signed out to Dr. Ballard at 1800. THIS WAS ELECTRONICALLY SIGNED - 06/26/2005 6:35 PM PST BY: PETER E SOKOLOVE,MD ASSOCIATE PROFESSOR EMERGENCY MEDICINE DEPARTMENT PES:seb(usa109) COPY -Protected Health Information - 08/30/2006 14:01:09-MR0202 Page 2 of 3 Talhelm, Samuel (MRN 1769581) D: 06/26/2005 05:33 PM T: 06/26/2005 05:41 PM C#: 1092626 UC DAVIS HEALTH SYSTEM COPY -Protected Health Information - 08/30/2006 14:01:09-MR0202 Page 3 of 3 PATIENT INFORMATION R~C:uxli rriv~ .~ TALHELM ,SAMUEL 9EN SVC: TRM N/S D7PA FC: P MR#: 1769581 0 PT TYPE: T OLD MR#: ACCT# 20-960262994 ---------------------------------------------------------------------------- OUTPT REG DT/TIME: INPT ADMIT DT/TIME: FLAGS ADM 06569 LONDON, JASON PCP UPIN; ATT 06569 LONDON, JASON PCN ADM CD : X ICD9: CPT: PCP PI#: DX AUSTISTIC MALE MVA PCP ADD: INST: PATIENT INFORMATION: ADDR: 7 TODD ROAD : CARLISLE PA 17013- HOME TEL: 717-249-3487 MSG TEL ADDL• ADD COUNTY 99 GUARANTOR REL: GUAR NM; TALHEM ,KEVIN ADDR 7 TODD KOAD CARLISLE PA 17013- HOME 717-249-3487 MSG GUAR SSN# 189-50-9524 GUAR DL/ST Ut>IKNOWN UN GUAR SEX M• :~TIENT'• EMPLOYMENT: STATUS: 3 OCCUPATION: NOT EMPLOYED EMPL EMPL ADDR EMPL TEL X LNGTH OF TIME ON JOB: VET: RELATED CONDITION: U.C. EMPLOYEE IND: PT SSN# 000-00-0001 PT DL/ST NONE UN PT DOB: 09/15/1997 AGE: 7 SEX: M MS: S SP NM: MAIDEN NM NONE OTHER NM ETH: C BPLACE: RELIGION: LANGUAGE: E ENGLISH .:CIDENT INFORMATION: ACCIDENT RELATED CONDITION: Y ACC DT/TIME: 06/26/05 00: 00 ACC TYPE: ACC LOC GUARANTOR EMPLOYMENT: STATUS: 1 OCCUPATION PROF/TECH EMPL GEORGE WESTIN BAKERI EMPL ADDR EMPL TEL 717-270-7028 X LNGTH OF TIME ON JOB: NEXT OF KIN REL: NOK NM SASSMAN ,MELINDA EVN TEL DAY TEL 916-684-0393 X MSG TEL GUARDIANSHIP PAPERS ON FILE: ------------------------------------- REFERRAL: N DATE: DR: X PCN: FACILITY: ER H/A ER CMPT X ----------------------------------------------------------------------------- LAST ADMIT DATE: ESTIMATED LOS: ADVANCE DIRECTIVE INFORMATION: WAS AD INFORMATION AND UCDMC POLICY STATEMENT GIVEN TO PT/REP? DESCRIPTION: DOES PT HAVE AN ADVANCED DIRECTIVE? HAS COPY OF PT'S AD BEEN PLACED IN PT'S MEDICAL RECORD? T & C SIGNATURE: PATIENT GUARANTOR PMHUNVF5 DOCUMENT GENERATED BY: HPCJP 15:41 06/27/05 FROM D714,PMHUNVF5 .• ~ .~. ~ ~ ~~ ~-- itr:._.. ,._~ U1V1 V.G nU1 i i vi .... .~.~.. __~.___ PATIENT INFORMATION RECORD PAGE 2 TALHELM ,SAMUEL 9EN SVC TRM F/C P MR# 1769581 PT TYPE: T OLD MR # ACCT # 20-960262994 PLAN CD: P99 AMERIA HEALTH ADMIN PRIORITY: 1 POL#: 01349657TPA GROUP#: 094737 INS ADDR: 720 BLAIR MILL RD HORSHAM PA 19044-0975 I.P.A. NAME: PHONE: REF/AUTH#: REVIEW GROUP: DAYS AUTHORIZED: CONTACT NAME: PHONE: ON-SITE REVIEW? CONCURRENT REVIEW GROUP: CONTACT NAME: PHONE: PLAN CD: G96 GATEWAY HLTH PLAN PRIORITY: 2 POL## : 22 2 73 817 'ZOUP# _1S ADDR: P.O. BOX 11718 ALBANY NY 12211- I.P.A. NAME: ] PHONE: REF/AUTH#: REVIEW GROUP: DAYS AUTHORIZED: CONTACT NAME PHONE: ON-SITE REVIEW? CONCURRENT REVIEW GROUP: CONTACT NAME: PHONE: PLAN CD: POL#: GROUP#: INS ADDR: PRIORITY: I.P.A. NAME: PHONE: ~'^F/AUTH#: REVIEW GROUP: .YS AUTHORIZED: CONTACT NAME: PHONE: ON-SITE REVIEW? CONCURRENT REVIEW GROUP: CONTACT NAME: PHONE: COUNTY CODE: AID CODE: CARD ISSUE DATE: VALID DATE: PMHRUNF6 DOCUMENT GENERATED BY: HPCJP 15:41 06/27/05 FROM D?14,PMHRUNF6 UC DAVIS MEDICAL CENTER - HEALTH INFORMATION MANAGEMENT DEPT SACRAMENTO,CALIFORNIA Coding Summary Name: TALHELM, SAMUEL MR#: 1769581 Visit Type: I Inpatient Acct#: 020960262994 Admit Date: 06-27-2005 Birthdate: 09-15-1997 Sex: M Male Discharge Date: 06-27-2005 Age: 7 DR: 06569 LONDON, JASON A. ASSOC Discharge Status: O1 Birth Wght: Payor: 06 Contracts Secondary Payor: DRG: 262 TRAUMA TO THE SKIN, SU$CUT TISS & BREAST AGE 0-17 LOS: 1 days Trim Point: days Weight: 0.2588 GMLOS: 2.20 days Outlier: days Payment: AMLOS: --------- 2.20 days -------------- ASC Payment: --------------- NOT SUBJECT ---- Charges: $31,657.00 Admit Dx: - ------------ --------------------------------- 868.00 INTRA-ABDOM INJ NOS-GLOB AGNOSES: Principal Dx: 924.8 MULTIPLE CONTUSIONS NEC 06-30-2005 Secondary Dx: 299.00 AUTISTIC DISORD-CURRENT 780.39 OTH CONVULSIONS E816.1 LOSS CONTROL MV ACC-PSGR ICD9 PROCEDURES: Ep# Dr. Name Date 88.01 C.A.T. SCAN OF ABDOMEN 87.03 C.A.T. SCAN OF HEAD D7441 GORGES, SANDRA W. 06-27-2005 08320 LATCHAW, RICHARD E. 06-27-2005 CPT PROCEDURES: Ep# Dr. Name Date ~ ,_: ~~ .~ =~~ x~.~ ~ °~ UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER ~~, , b _~~ 3 . .~. ~ 3 - 9 ~ t~ ~ £~ 2 ~ ~ ~ ;~ CIiIEF coMPLAI~-~ ~~~ ~" ~ 7i2- ~Q~ ~.~~ ~~AYi~~ ~ E3~ ~~ '`~~: _ . M f1 ~,t # ! E.i`~ ~ ~~~~~ { ~' =' -. ~~y~' BP _~ y~ PU[L~SE RESPn ~ TEMP PEDI-WT ~~; ~ Gl ~ V-1 ~ ('-~~ ~N!1, t,1~ ~ ~•} ~ Room Time '' ,,~~**~~ Room Attending Time~s~L HISTORY OF PRESENT ILLNESS Seen by (Name) e~ ~'7~4~ ' Tirne DRUG ALLERGY Source of history: ^ patient • other person ecords from '~ c5t ,YVt. Q1pL c ~ ~ ~~~ IMMUNIZATIONS Lp o ~~ ~ l 1r3.~ S ( •CL W w. ~-_ 'f!- - MED S wa ( ~ S ~.+.1•~n.c-s.~ ~C S ~~L-'~' .ter _ ~ t` }~ S 0 >~ ~ / ,, oc`C ova t ~-~--.~ ~.~: w~...~ jo ... + ~ - Pvt - /,wlo .~. 1 {~/q ~0.~'~- MEDICAL HX ~Ci-i (l-Il P~~- -f' Q c~-t'/l W1.o ~ , t ~ S,Q ~ Z.w~+-~~ SURGICAL FDC FAMILY HX REVIENI OF SYSTEPAS CONSTITUTIONAL: SKIN: HEMATOLOGIC: EYES: ENT: RESPIRATORY: CARDIOVASCULAR: GASTROINTESTINAL: URINARY: UNOBTAINABLE:~Patient Unable ^ Patient Unstable ~ Slash =not pnesen~ Cfrc-e - pn~ent Medical/Surgical ~~ \ Trauma fever, chills, weight change rash, hives, lesion abrasions, lacerations bleeding, bruising clotting problem, acute blood loss visual problem, discharge, redness eye pain, vision change earache, hearing change, epistaxis, congestion, sore throat ear/nose/mouthfjaw pain, malocclusion SOB, wheezing, cough, sputum, hemoptysis, pleuritic CP, leg pain chest pain, SOB chest pain, palptations, syncope, orthopnea, PND, edema CP or palpitations belly pain, nausea, vomiting, constipation, diarrhea, bleeding belly pain dysuria, frequency, urgency, hematuria, nocturia hematuria ENITAL: discharge; abnormal bleeding, LMP pain, bleeding USCULOSKELETAL: " pain, limited motion, redness, swelling neck/back/RUE,LUE,RLE,LLE pain NEUROL OGIC: weakness, numbness, incoordination, HA, seizures, dizziness numbness, weakness, LOC, seizure PHYSICAL E:iAM - - GENERAL: Check. l exam find}ng; Cinxe =area for description of abnom-al or relevant Ending ^ nl - `~? i,r~.- 1 Ttr`C_.Cti.1`~~-~,,, SKIN: no rash, lesions ^ no induration ' LYMPH NODES: Adenopathy: ^ no cervical ^ no axillary ^ no inguinal EYES: ,[.}Tlflids & conjunctivae.~'PETiRL, EOMI ^ nl fundi RENT: ~ad/face nontender [~-rrt TMs, canals [~.r+l-nose, nasal passages J~rtl"mouth, throat NECK: ^ symmetric w/o mass ^ nl thyroid ^ supple CHEST: ^nontender ^ nl breasts LUNGS: ~-r~t effort $ril auscultation ^ nl percussion CARDIOVASCULAR: ~-nt sounds w/o murmur, gallop, rub ^ no edema ` ^ nl cap refill Pulses: ^ nl carotid ^ nl femoral ^ nl pedal .. ABDOMEN / GI: nontender w/o masses ^ no HSM ^ no hernia ^ nl rectal ^ heme (-) GENITALIA M: ^ nl penis ^ nl scrotal contents ^ nl prostate .. GENITALIA F: M ^ nl BUS ^ nl cervix w/o discharge ^ nl uterus ^ nl adge xae „ USCULOSKELETAL: `S ~-rfontender neck w/ FROM [~-nontender back, p ~~ ~ eT~s elv is L ~ I nl RUE,LUE,RLE,LLE ^ nl joints, nails ~ ~o"vq®'~.~1+5 N(f~ NEUROLOGIC: ~ ^ nl CN 2-12 ^ nl sensation ^ nl DTRs, no pathologic reflexes PSYCHIATRIC: ^ nl ngth ^ nl gait~CS ^ ~$~ ^ &O ^ euthymic ^ good judgment a ~ /~- ~ on-~bc~ ~ 1 Impressions/Plan n~n~~ y'1 m~~ F.. ~, 11'AC~7'~cwin, v ova ~nr~rir r~ ~ ~~ ~- ~ ~ ' ~,~ tt ,L- .: '` k' ~~.. l ~~ U-1~ SQ vw1 tA.~C. ~ f ~. calvsuLTAnal~s Time Called Service ^ ED REVIEW ^ Crisis _ ^ ENT ^ Eye _. . ^ IM subspecialty ^ Neurology ^ Ob-Gyn ..... .. _ - ^ Orthopedics ^ Plastic Surgery ^ Surgery subspecialty ^ Trauma .. ^ other _ RESULTS PROCEDURES {Note Time/Describe Procedure) ~'' LAB TESTS/EKG X-RAY L'b'~rl~{.Q, ^ grthrocentesis lem~ H."1 ~~~ ]'2~/1 ~~ ~ ~ '~,~C ~ ~ ~~~'Yt ~ O. ~'+` ~ "_ ^ Casting/Splinting ^ Central Line Sb~ . .. W ~`~ ~ 3 ~ ~ ~ ^ Chest Tube 1~~• I~f4'1 ITT : ~i~~•3/ ^ CPR... [3'1 °~D 7 0 z CS' t~..~.....c Q ^ Cutdown ^ FB Removal 4- O -3 . ^ I Z3< ~ trine- C Ir a{ot~ ~~Vh i ~ ~ ^ LPubation il~" ~. 1, C Ljj f 7.51 ~'1- ~}' ^ Reduction 3'°~ ~~ ~ ,~.~,~,t' z ~ e 5 C t _ ^ Paracentesis i ^ Th t oracen es s ._ ~~~• -- . , .>~~t ' . Iq'l' l1(P~ O~W ~ e ~ s ~,,,` ~ '~ ^ Suturing ^ ThoracotomY ~ ~~rIRSG'. 2'j ~. _ T~ 'r~~ ~, ^ us. ^ Other J EKG . _... __ .. _. _ . __ ^ Radiology consultation to ^ Present for performance of ^ emire procedure, or clarify results of ^ key porficns ar procedure Procedure Signature DIAGNOSIS 1 2 3 4 G DISPOSITION ~~ r7 ~r V ^1 ^2 ^3 ^4 l~ ^ cc ^ DISCHARGE TIME CONDITION ^ Home _ I ^ Police ~ >~~ ^ Improved Pri rovi ro--- ^ Other DATE ^ Stable ^ AMA ~ 1 ~ r bS ^ Unstable ~~~ ^ LWBS I l ^ Expired ED Attending gnature )'v „/~_ `, ;wr~vWr~ -.errar~-irT. n; SACRAMENTO FIRE SERVICES ~,.,~# OF ~IGEINANC,IENG y`~t EMNDEIANGE ~ ~- patient Care Report ' DATE ~ ~~ ''~ ` ~vixrwv~A "COd(PANYtF etiG111E-JTRUCK x` j ! MEDIC ~~ MEDIC C-4' INCIDENT# ~ -. ~; ~ 1 ~ TRANSFER~OF CARE P ~. ~ = '_ 1 ` ' SAC CITY FIRE ^ ALS ^ BIS ; ~] > .. _~ nME To :~ A fNGfTRK- ENG/TRK - MEDIC ~ MEDIC ~~ PT i ,, TRANSPORT ~ ARRNE CODETOSCENE ''_ ,r DISPATCH ,ARRIVE DISPATCH , ARRlVE - CONTACT i -- ~ ~ _ DEST CODE TO HOSP ' CALL LOCATION Includlnq ZiP CODE !" ~, t_' ~ f- ~ ~ ~. ZIP CODE . '~ ~~ ' PHONE # ~~ SOCIAL SECURITY # ~ w D SAME AS PATIENT ADD i_.-- -"' "' f' '' ~ `I ( t : ~ ~ ' E PATENT NAME ~ - ~ ! AGEgr ,.^MOS 'D.O.B. ~ (` ~ MALE ^FEMALE ~ N BLAST, FIRST M.1.) s• : ,"'' ~~ >' , '-}~ /^ YRS ^-.•.~.". ^ PREGNANT PATIEMADDRESS tr X•' CTfYlLiP .. INSURANCEI# P .~. _ r ' _ R .~, ~ ,,;• t.r' ~ •' Q~UNKNOWN ^DENIED ^CARDIAC ^CHF ^ASTHMA ^COPD ^CVA ^HTN ^DUU3ETES ^CA ^SEIZURES ^GI ^PSYCH M A R f[`TUNKNOWN ^DENIED ~ ~ ~ ~ CST UNKNOWN ^DENIED Y V TIME ~G V SAA BP PULSE RESP EKG BY CAPTAINS NOTES A r , ~:- , p ~ ~..; ~, i ~ ~~ _ - CAPTAIN DID# INITIALS ~ $ ~ ~ i.. ; J 1: $ HEAD NE K - WT Jn '.,, ~-- ^ LAP BELT ^ SHOULDER BELT E C-ASSESSED&WNL YJA~~DBWNL KG J r AIRBAG ^ CAR SEAT ^ HELMET C ST SOUNDS PUPIL CAPILLARY REFILL ASSESSEDBWNL L'Jh33FSS®ECI_EARSiLAT C~PERL R-'~ ~ NORMAL ^ DELAYED ^ NONE. N K BLOOD SUGAR ASSESSE08WNL ASSE3.5ED6WNL PRE GLUCOSE POST GLUCOSE P~1.VIC A .ASS. ~&WNL ASSESSEDSWNL ~~ ~' TIME: f! _ TIME: # R Y SKIN : ' NE(JRO ~ APGAR#1 , ; ~ ' ' npcAR#z p ASSESSma,Wru Qp~yym TIME # ~,, TIMES # .. Parartledic. EMT. Gd riar188.. :- ~ .. i rte`" _.' . ,. , -` N A is {'~ i , ,., _ ,,, i v :s.~:; w..; ....,~..~,.-,-...~..,.:. ~ ',,,~"" R R ~- r L.. bXYGEN, ~r ~ ~~~ ~ ~ ^ 02 SAT Y ^ 02 SAT y SUCCESSFUL A TM:,__-JM _ (7M ~ L,IM _ [] BLOW BY ^ CANNULA' D MASK ^ BAG VALVE ^ HHN INTUBATION? ' ^ YES ~ NO ^ OPA : ~' ,TIME .^ NEEDLE CRIC ~ ^ CHEST DECOMP , ~. , TIME TIME ~ ~ TIME > L] NPA ° S¢E ,_ `LyTIME R. TIME - ^ ROOM AIR ^ ROOM AIR A TIME: ,' ~~ ET SECURED AT CM AT THE USING BY , TUBE NUMBER OF ATTEMPTS . SIZE ` ^ '- ~ Y VERIFICATION OF ^LIDOPREP ^SELLK:KMAN. ^VISUAL¢EDCORDS ^EXPIRATORYMIST'~IG ^=CIiESTRISE NTI I OTI # BY -- ^ Other # BY: TUBE PLACEMENT:^mLUNGSOUNDS ~^GOODFEFCOLORCHANGE ^TUBERECHECKEDAMBIHOSPI~eiE~rreor.I ^NTI/OTl#_ BY: ^Other# BY: TIME FLUIDS SOLUTION GAUGE ATTEMPTS LOCATON RATE TOT. VOL. BY ' ^ V 10 ^ TKO ^ OPEN ^ BOLUS ^ IV ^ IO ^ TKO ^ OPEN ^ BOLUS IMMOBILIZATIPN: T RANSPORT POSTf10N: • IECK: ^ 4d:K ' ^-U S ~ ,SUPINE ^ LATERAL ^ PRONE ^ SITTING ^ HEAD ELEV. ^ FEET ELEV. ^ LEFT LATERAL RECUMBANT T R TIME MEDICAl10N,TREATMEHTANDRESPONSE ' BY TIME MEDICATION,TREATMENTANDRESPONSE BY E ....~. ::. A T ~~- ~ ~ O M E N T ~~ . -`~- - lbEtONTINWTgN FdiM -DESTINATION ~ ~ ~~ . >. ^ RAS , ~' t~'; ^ BASE TIMECONiACTEO HOSPITAL f' ~ M.D. OR MICN # /NAME CONT. FORM ATTACHED? HOSPTAL ^ AMA , ^ NOhIFICATtON ONLY CONTACTED ' ^ YES ^ NO ^PVT M.D. ^ PT i FAMILY REgUEST ^LAW ^ TRAUMA.CRRERIA ^ DCF ^ BH ORDER ^DIVERSION ^ SPECIALTY CENTER ^CLOSEST ^ NO PREF. D PARAMEDIClEMT COMPLETING REPORT SIGNATURE SECONbARY PA{2AMEDIC/EMTf PRECERTOR NAME . , PATIENT INITIALS E S ..; ,'~ ;: ~ '' _ ^ FORM LEFT wf PATIENT! UNABLE TO SIGN/ T _'.t ~' # `~ ' '-J~ ' i # ^ FORM LEFT w/ HOSPRAL NOTIFIED: ^ CPS ^ 11PS ^ PEDESTRIAN ^ ELDERLY, NEEDS REFERRAL ^ SAC CITY WORKERS COMP HOSPITAL t ~ , r~ ~ r~ ~,' ,~ r ~ ~ r~z;. Lab Time Signature Site ~.,i. (~ -,;~~ ~ : ~ ~ d.3 t ~ ~ ~ ~. ; «.~ ~ ~ Done `~ '.~'~~ !' ~~~.~~ rg~~ ~~ _ - r: ,_ HEM~BC with dill ~ . ,... .:_. i-- ~ -, -IRR~TT - '..~ ;xx. &s Time Results/ ;.~~, Procedures Done Signature Site CHEM beta hCG ,., _ ~~^~~Saline I c , _._ _ ~'Ehem 7 (BMP) =~ 5 ~,11f.1 _ ~`~ ^ ethanol ' _ ^ IV-2 ^ hepatic panel ^ 02 _ ^ lipase monitor ca iac .` ^ myoglobin - ~iulse ox continuou ~ ^ troponin I ^ myo/tr 0,3,6 hr ^ Foley ^ I&O catheter I ^ NG tube ^ suction URINE /A ~ ~~-y~'~ ^ FS glucose ^ serial phicoc tox _ f~t'~LJ( ~, barb/benrJop tox C~`~_~- ^ PEFR ^ serial MISC . ,. ^ urine dip ^ urine bedside pg ^ ^ ~ G ^ serial ^ ~"~ X-Ray ` Time Done ~ ~~~ /~g( CXR ^ PA/tat g! AP bedside j~jb (,4 abd series ~KUB C-spine. 3 v1~„J -spine pelvis AP C~edside (~13b L ext // ^ R ext dead CT w/o ^ w/IV ~bd/pelvis CT wAV (lrauma) ^ abd CT ^ w/o ^ w/ ~ ^ US For order entry, fill in a-f a Reason (signs/symptoms for each study b PRIORITY ^ urgent ^ stat ^ life/deat c OXYGEN ^ no I d MOBILITY ^ gume~ e SUPPORT ^ N/A f PREGNANT ^ no Order entry time:_ By (signature) lyes ^ wheelchair ^ wa (-ltele f~lvent ~.F~CJ/~ MD Signature "~ 1 Z6 17Z~' PI No. Time of Initial Orc DILATION AND SUBSEQUENT ORDERS 176-95-8 2o_sso2s2EATH osl~sro5 EN D©E ~ AKA: FC: ji -~/~ 01!01/1990 1: ~J~"~C.J D: T' }~, Date: `,LI 2~~ ~ t~~ Chief Complaint iV IYV u ..._ ET NT OP NP Yes ^ No ^ Type/Size Placement Rigid Collar ^ Backboard ^ Meds given OZ Given _ _ Accucheck _ Splint ^ Papoose ^ P I RR History None ^ Cardiac ^ Diabetes ^ Triage Time Unknown ^ Primary Nursing Assessment Cva ll i BP P RR E P P IN 02 SAT a erg es atex N DA current meds A. Airway Patent Yes ^ No^ Last TD 6. Breathing Spontaneous Yes^ No^ nasal flaring Yes^ No ^ Symmetrical Yes No^ act. muscle-use Yes^ No Labored Yes^ No^ s/s trauma Ye "N ^ Shallow Yes^ No^ flail Ye o ^ Diminished LT ^ RT ^ crepitus ~ Ye No ^ Breath Sounds RT LT C. Circulation Cap. Refill <2 sec. Yes ^ No ^ cardiac rhythm warm Yes ^ No ^ dry Yes ^ No ^ ~ % '" Diaphoretic Yes ^ No ^ '`.1 Jaundiced Yes ^ No ^ Bleeding Controlled Yes ^ No ^ ~1 D. Neuro GCS E V _ •spontaneous 4 t: . on ed i. 5 obeys comds fi ~ to voice 3 _ fused 4 localizes pain 5 _ -' to pain 2 i .words 3 withdraws 4 none 1 'n p; sounds 2 flexion 3 Pupil Size R ` L _ none 1 extertsion 2 none 1 PERL Yes CI No ^ Accucheck E. Sensation F. Pulses RA _. RL - Quality: 4+ 3+ 2+ 1+ bop. LA - LL _ Location: Rad DP PT RA - RL G. Movem~,nt/Strength LA _ LL Quality: 5+ 4+ + 2+ 1+ .Moves extre mities welt Yes ^ No ^ RA RL L LL ~ H. Pregnant Yes ^ No ^ Gravida ~ Para FHT Yes ^ No ^ Rate EDC LMP OB Notified Yes ^ No ^ N/A ^ Comments Two forms of ID dhecked ^ Armband ^ Screened for Domestic Violence ^ .. _ ~. .. ., _ .-. .. r. ..~...-........ ....,~.~.,.... COPD GU HTN Other t TEMP V~ 02 SAT ^ ^ Psych ^ ^ ialysis ^ Asthma ^ ^ Seizure ^ GI ^ Head Yes No unremarkable ^ ^ nose drainage ^ ^ ear drainage ^ ^ teeth damage ^ ^ tm's clear ^ Neck unremarkable ^ ^ sq air ^ JVD ^ ^ trach midline D ^ Abdomen unremarkable ^ C soft ^ C nontender ^ C s/s trauma ^ C firm ^ C distended ^ C tender ^ C masses ^ C vomiting ^ C diarrhea ^ C last BM GU/Pelvis unremarkable ^ I meatus clear ^ ~ pelvis stable ^ discharge ^ color NA bleeding ^ pad Hr Back s/s trauma ^ deformity rectal tone normal ^ guiac positive ^ tender ^ Extremities s/s trauma ^ deformity C7 E A - abra: R L L R AB - abs .. B -bum D - defoi E - etch ED - edc H -hem L -lacer P -punt R - rasF T -tend UNK NA ^ Oxygen NC Mask C ~ L1. p l I GP 9` 6t~~ ~ (~ 2 1 _ a gt G • ~ Chesi Tube ~~•AVPOM` r~` ~ le Score _ + ~ Thoracotomy ~• + FG-' ~~rs to Cdnverse P =May Converse 1 =None ~y6299~ ~ ~ _ N 6o 1 sesponse 9 ~ • ~ 0 ~ NGIOG ~~ ~~* ~ ~~~.1 \ , ~ - 2~~e Right ~~ Foley p~ Ogt 51 '('• M 2~ a ~ Bnsk: ++ Slug ish: + None: 0 heft Pe EKG ~ p'. s :-. Strength: ssess 2 = Unable to move against to Un bl U Right ~` J r~ Q a a e = a 1 Splint vity Normal ~ gr 5 ht weakness 1 =Trace ~ J~ Ice Pack T . _ 3 -~ MoJas against grayiry D = None •, Left ~,~ ~ _ WOUnd Care Q Sensation: 1 =Normal T = Tingling Ri nt g J~ Y Warming measures R ? = Wypersensitive 0 = No sensation, .~=Numb U =Unable to easess - Lett dyd ~ ... .. L C Mucus MembraneslSkin: ; Cobr A "F =Flushed M -Mottled C =Cool Temp IV LINES P =Pale J =Jaundiced D - Diy R., N = Nomral W =Warm M =Moist` Character D pulses: Radral . .. ~ ~+ ='Barely Palpable -0 =Not Palpable k D =Do pler 2+ We Ri9nt o pb' Intubation a os 0 p : a Normal 3+ - Radial • Ventilator ~ . 4+ =Full Bounding Left oQ"~rd'~ Mode Rate TV FIO2 PEEP Capillary Refill. Number of Seconds ~. A as - N -Normal R ~ Rub D =Distant Heart Soundsi M =Murmur G =;Gall FR = FrctiorS Rub „ - _ _ . CB h m 7 p Pt A ,C U CMS Intact Distal to: , A= An Line C -Oast R= Restraint F = Fem Line =B =Bum T =Traction . & C & S L .Edema: G =General 'Bk =Below knee Right, ~ P~~~ l F =Facial P d P UA OX UPT A e a = 5 -Sacral ' Pitting ~ 1+ 2+ 3+ ~~ CBC NO d'tff #2 ;R A = Anasarca 'D =None Left ~' ~~ BC NO dill #3 Chest Expansion S =Symmetrical A =Asymmetrical P ~ ' ' o/tro 0° M R = C3ewated Rights L = peviated Lett f trachea: M - M~dhne Sn t~ p y U Dis tress ti i R s e d ~ L L ° ~ = ~b on: ra e p ' A = A ne #.Sec bnds ' Myo/trop 3 L' .Breath Sounds: .. ' " ' . RUL ( l , My0ltrop 6° "M 0 _ Clear b = biminished Crackles 0 =Absent ' FC =Fi Right RML Q O ne CC =Course Crackles.. S = Stridor RLL Q - N' W _ Wheezing FR =Friction Rub L -., LUL ~ • • w Ii RH = Rhbnchi eft ~L Time Done Time Done Stud St d R Secretion: lt TH = Tliidt G -Greed ~5 = sm Amount u y y a T T n N ' No C Y a = ne : M = Med l = onsistency. ; ' Ultrasound C Spine ~ ear B Brown L =Large 0 =c ll BL od Y Y 9 T i Color ow =. y = e k~ =Th n ; _ - Pelvis T Spine Gastrointestinal . ~ l ~ = M R Fli id tJ - N rm b S ' Abdom9n . Abd pine ~ . g o a yp ; S. = oft ~ D = Distentled T - Tehdet. ~ =.Hyper 0 -None Bowel sounds CXR CT Haad r G NGT/OGT: Placemeht verified by Aspiration Extremity CT Ab '-' 1 ~ pH/Guafac; CT Pe vl CT Neck ', Gastric Output: c_c~ar c-Gre~~ ~ei~n s~=e~ay cG-cake Ground • ' TIME BAG # ' B~0 D PRODUCT SITE # INFUSED • :.. ~ ,. _ TIM E AMT SPE CIF Y CT Chest / ~ -t-JI.J ~.LC 1 ~~°'.~ VO Scan ANGIO / i / INITI L NAME: / edside RN / ~~` ~ ~ fi~r.~' ~s~ibe RN / • 111L1IL411 ~7/111VLL ~7L AKA: OOE, HEATH EN M 09/15/1997 ERWB FC: V \" '/ 3=FACES (0-5) 4=Oucher (0-5) 5=Numeric Scale (0-10) D: T: I: PED •PAIN ASSESSMEN GUIDE USED 6=Comfort Scale 8-40 PannTool Usedc6am 6e.g. che6 m-6amlys`S)' Dic Time ~ ~~ Iy. a ~I • BP - t ~~ ~ ~~7 ~ (f/I d P Il1t iP iv~ ~' •~' ( TEMP '- ~" ~ ~> PA{N u~ u~~ 02 SAT ~ ~$/• ~~ '~ ~~ Gcs p Rhythm ~- - ~T ~ ~ fnif. M MEDICATION SE TIME BY SITE ROU TE Time- Procedure . Narrative Att._~ Bedside _. `~ ~~~ .~ ~ (~ Room /Time______ RESPONSE ~ ~ ___.~ _ RESPONSE rte` ,L " ..J~~~.~_._ _' ~~ ~ m ~~y~ ~ ~ t,,p .~ , ~.~: RESPONSE ,~,~„~ ~ r V ~' ~ ~• ~"" RESPONSE. ~U - ~ °- - ~ RESPO NSE ~~~' ~ _ cam['-T -~~ ~ ~~ - - RE$PgNSE ~ (~~ - ~ ~- RESPONSE ` ~~ RESPONSE 'vt;C` G~-• ~ ~ GtC.~C~ ~~ , , ~ ~ ~~ T RESPONSE RESPONSE ' '` -~~.. RESPONSE ~ ~~J '~ ' ~I t~.~-~i^C " ~~ ._ ^ ~`, RESPONSE tS ~ ~ `~W . "--`-"T~ lJnchanged Clothing Sheet Complete Yes ^ ~ 1~ ^ NA~ Orders./ Nurses Notes Faxed Yes No ^ N ^_ CONDITION AD 1~ Improved D Transported by RN ^ WC ^ Crutches O Stretcher O DISCHARGE Discharge ^ GCS E_ V_ M_ Instructions to patient ^ Other Verbalizes understanding Yes ^ No ^ Handouts Given Yes ^ No D See: tft~ 5vtps orl .back ^ _ Is:. -~ Walk ^ List ' fusing ^ ' and ~ Learning Needs Addressed Yes ^ No I Green =All P~ients„ Recd= All Trauma (ICU Patients _ Specify: JJ !_ ,f~ I ~ ~ ~t ~ ~~. I-~~} ~^ MEDICAL CENTER, ~ ~ SACRAMENTO, CALIFORNIA ~^; //r[ /(i TRi~-~JNfA ~IESUSCITA-TION Date: _"`~ v .~. v; _~ ~ .,.~~:.~ ~ ~,~ r . L., y ~i ~+ it • ~ Activation Time: 911 >~~ 933 .. "l r - r ~.v vv ~ n c ~ ~ «_ A~ S MENT ON ARRIVAL Time Pf Arrived in gip: "A" AIRWAY;.' One} Description Patient YES NO PMH: "B" .BREATHING ~~ ':' ~ c SpontaneQUS Y Assisted? ^ Y Medi ations: Labored YES O -- Shallow YES O Allergies: ^ Denies ^ Unknown ^ Latex Breath Sounds Present bitaterall Yes ^ No Lasi-Tetanus:. LMP: Weight: kg. • "C" CIRCULATI Radial Pulse S NO Mode: of Arrival: ^ Sac Metro ^ AMR ^ Private Vehicle ^ Other. Unit #: Bleeding controlled? S NO N /~_ rT CR < 3 Sec YE NO Location of Incident: Warm /Dry YES NO County of Incident: "D" NEURO S R MECHANI M OF INJU Y (MOI) GCS i V l E M va = on arr : = = BLUNT: MVC vs Intrusion amount: CC vs Speed: mph Sensation Deficit YES Deficit = NO NIA ^ Driver ^ Passenger ^ Front ^ Back R/L ^ Unknown Moving All YES Extremities Deficit = NO N/A l7 Ejection ^ Lap Belt.: ^ Helmet Descriptors: ~ , , ~ , . ~ ~ , ~ ~ , ft ^ Shoulder Belt ^ No Helmet HEAD: ^ Rollover ^ Unrestrained ^ Unknown S / S Trauma? YES NO use dia ram O Airbag ^ Unknown ^ Carseat ` Nose drainage R L N!A ^ PEDESTRIAN vs. mph Ear draina e R L N/A Ejection feet BICYCLE vs Teeth dama a YES NO N/ TM's clear YES NO . a " NECK ce Surf fl FALL: Distance. S /S Trauma? YES use dia ra m ^ ASSAULT: (type) SQ Air S O JVD YES NO ^ BURN: Source BSA degree . Trach midline YES NO OTHER: CHEST / RESPIRA RY LOC: _ ^ Yes ^ No ^ Possible ^ Length min. Unknown S / S Trauma? NO use dia ram S mmetrical PENfETRATING: ^ GSW ^ SVJ ^ Other • Flail Gre itus YES YES O A: O ET ' ^ NT ^ NP ^ OP Size: Cardiac Rh hm B: 02 ' ^ NRB ^ Canhula UMin ^ BVM ABDOMEN Ci rcle One Descri tion C: IVlnfused ml ^ CPR S ed ~ S / S Trauma YES NO use diagram igid collar- Backboard Supin /Prone Tender YES NO ^ lint: = ^ Accu-c eck results Pre Want YES NO /A B notified ^ Y ^ N g Fetal HT YES NO Meds: Other: GU /PELVIS V/S: B/P P R S / S Trauma YES NO use dia ram GCS E ~ V M Meatus clear YES NO d e p n s + IDENTIFY ON FIGURE Pelvis Stable YES NO taneou oneys com a a ori nted 5 s o M volts 3 bcalizes pain 5 confused 4 BACK a peen z wm,draws a inapp. werda a none 1 flexidn 3 iricdmplete eainds 2 R L L R S/ S Trauma YES N/A use dia ram extenelen z rwne , rwne t " Deformi YES O use dia ram T d YES NO / di en erness use a ram Time nrrtied SIGNATURES Mandatory for Trauma Rectal Tone + - Guaiac + - p ~ ~'yrE.EO nnendtrg EXTREMITIES R s eo Mo S / 5 Trauma YES O use diagram f D i YES di e orm t use agram trauma Aaend~ PULSES MOTOR cnief R L R L R 3 Trauma Rfldlal UE z DP LE a Trauma PT Grip . seM~e fao Quality 0 / 1+ / 2+ / 3+ ! 4+ Quality 1+ / 2+ ! 3+ / 4+ / 5+ 176-95-81 20-960262994 ADM 06/26/05 ORD DOE ,HEATH EN AKA: M 01/01/1880 FC: 0: T: I: ~ ~~~~ ~...) z. ~. C~ S~ t~~~~ ~~~v~- I~"- " Chief Complaint ~ IA,' k ~ [_w Age ~ Date Time ~~ ~ 911 HISTORY OF PRESENT ILLNESS r~s~~~,.~J '! S ~~ - UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER, SACRAMENTO, CALIFORNIA INITIAL HISTORY AND PHYSICAL r~ ,~ ~... ^ PMH, FH, SH, ROS Unobtainable. Reason: Medications- dPl~ n _ _ ' 1-l Nnna f-1 I Inknnwn J~ Past Allergies (Med) r Operations Medical ^ None ^ Unknown ,u,~„~y~ G ~ ~f None ^ Unknown History prior Illnesses Specify s~ ^ None ^ Unknown ^ Cardiac ^HTN ^ Diabetes ^ Other s(Mit FAMILY Specify HISTORY Noncontributory ^ Unknown ^ Cardiac ^HTN ^ Diabetes ^ Other SOCIAL ®CSingle ^ Married Tobacco ETON Drugs Type of Drugs HISTORY ^ Unknown ^ Yes o ^ Yes No ^ Yes No Gen ^ Chills Eyes ^ Discharge ^ Redness ENT ^ Neck pain D Dysphagia Resp ^ Pleuritic pain ROS ^ Fever ^ Wei ht loss ^ Corrective lenses ^ Vision difficul ^ S eech difficu ^ Ex istaxis ^ SOB ^ Cou h ^ Wheezin Card/Vasc I D Hematochezia ^ Melena GU ^ Hematuria ^ Dysuria All ^ Murmur ^ Chest pain ^ Palpitations Abdominal in ^ Nausea ^ Diarrhea ^ UTI ^ Stones ^ Chest Pain systems negative Musc-Skeletal Neuro Psych , t as ce ^ Weakness ^ Extremity pain ^ Back pain ^ Syncope ^ Seizure ^ HA ^ Schizophrenia ^ Depression ^ Hallucination p ex marked HEME ENDO SKIN ^ Bleeding ^ Anemia ^ Thyroid disease ^ Disorder ^ Lac. ^ Contus. ^ Abrasions TEMP BP P RR PULSE OX a, GLASGOW COMA SCALE >N HEAD Spontaneous. No evidence of trauma : To voice ES EYE OPENING ............. To pain ..............~ No evidence of trauma 1 N NT one ................. ~ No facial inju x w o dental injury Oriented ....... ,~ VERBAL Confused........... N NECK RESPONSE Ina ro riate.....: pp p } ^Non-tender without stepoffs S incomprehensible ...~ a REP None .............:...~ E ual breath sounds /~ Obeys commandC.~ 91 Regular rate and rhythm MOTOR Localizes pain .....:.. Withdraw -Pain.....: ABD RESPONSE Flexion -Pain......... ^ Non-tender Extension -Pain..... Unable to adequately examine ~ None ....................... ~~~ I~~I~~~~T F~~.~T'~ 176-95-81 24-960262994 ADM 06/26/05 ORD DOE ,HEATH EN AKA: M 01/01/1880 FC: D: T: I: UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER, SACRAMENTO, CALIFORNIA .., INITIAL HISTORY AND PHYSICAL G ITAL/RECTAL Genital Exam Normal Rectal Exam -Normal tone ^ Heme Neg. O BACK ^ Non-tender without stepoffs ~ V+n! V MEURO ^ CNS Normal ~v ~,~ - t ~.~ EXT MITIES o Fractures No Trauma ^ Bony Tenderness or Abnormality 1. Laceration 2. Abrasion 5.Open fracture 6. GSW 3. Contusion 4. Deformity 7. SW 8. Other PULSES ,~5 7L' OTHER OTHER OTHER LAB RESULTS CT#1 ~ 'Z , Z3 HCT#2 d I Z HCT#3 ~.p ~ (~ Z3 I Z ~~R I.Z 'BC Amylase/lipase Z~ 3-C U!A 3,..{, t,,j So=loo c~• f ther fOH TOX LFTs ~S~LZ 6~ Other XRAYS Ri ht Left KR ril /~ ~ CT Brain - nl /© or- Humerus nl / nl / ~Ivis nl , CT Chest - nt / Forearm nl / nl / spine nl ! CT Abd /pelvis - nl /O ~ ~4 ~ Hand nl / nl / spine nl / - CT Facial Bones - nl / Femur nl / nl / -s~nl / r G~ CT Spine - nl / Tib /Fib nl / nl ! her Other Other P OBLEM LIST R PLANS (~, ~ ,C " V'+' ~/ i ~'1- ~~ / ~~ O _ ~ ~ ~Lf~ 4' 4' I _ ~f ~.~ ~j~~~~ YSICIAN NAME: ~ ~IGNATURE: ~~" "' PI# ---u-= BEEPER# `~`~~ Z 63-126 (10/03) TRAUMA ADMISSit~N ~SSIc~~M1=AIT ~nQea •----.-- -- bHI.RNmuv ~ v, ...-.~.. _..... Talhelm, Samuel 17695 81 PHYSiCtANS PROGRESS RECORD DATE NOTE PROGRESS OF CASE, COMPLICATIONS, CONSULTATIONS, CHANGES IN TIME Date: 06/$1~OSIS. CONDITION ON DISCHARGE, IN~~T~ TO PATIENT. reviewed the resident's progress note, as well as relevant laboratory and radiographic tests. I have co armed selected aspects o the resident s physical exam. After discussion of the AccrccmPnt and Plan - - 1 crash yesterday. Because mechanism of injury, he is at risk for antra-abdominal injury. C7 scan is negative for any signs of solid organ injury. Will continue to monitor his abdominal 2. Closed head iniurv: head CT negative for Jason A. L.;djdon MD, MPH MEDICAL ~.:tn i ~R, SACRAMENTO, CALIFORNIA PHYSICAN PROGRESS RECORD Trauma / Emerl?ency Sur¢erv Ward Follow-Up Note ID : ~ .G a.,t..l.~-S w~ '-V'~ ~-'~'""e~~ ~~~?~ i ~" ~ II c~~-~.f ~'tv C~ ~ ~ r, v..z... Name: ~~G~,l ~Un~ 1VIR# ~ ~G~ ~, ~ DOA ~~~ DATE: Injuries: Procedures Nutrition Mobility Proph ST: 4R~~~ PT/OT: Interval History: Physical Exam: Tmax;~~ i P: a _ ~ Gen: ~~~ f '(I.~P/ HEENT: ~~ C~~#~' cv: ~~ Pulm: L l3 Abd: ~,~F` ~ Ext: ~,~C) t,~, j~ Neuro: Interval Labs: •~/~"~ ~~~ BP: ~,. RR: ~r Problem/Iniurv List and Plan i. ~~o :yA Z~ Sew ~. C,6C , , ~l~ u~~.~~-~.~ Ati: I/O: ~ ~os//` Siunature• ~-t~~~i `3'" _ ,1~'ID PI#: ~(~ ~ Pager #: 762-5511 20-960251ae4 HUM; O6l2l;/U5 TALFfELM ~,SAh~.lEL AKA: DOE, HEAT EN EDR91~Kp9pVE PETER E ~ ~ PHYSICIANS PROGRESS RECORD TRUE MR# DATE NOTE PROGRESS OF CASE, COMPLICATIONS, CONSULTATIONS, CHANGES IN TIME DIAGNOSIS. CONDITION ON DISCHARGE, INSTRUCTIONS TO PATIENT. Y/ ~1~7 b~sS l SACRAMENTO, CALlFORNlA PHYSICIAN'S ORDERS DATE HOUR USE BALL POINT PEN DIRECTIONS: CHECK (J) OR COMPLETE ( )THOSE ORDERS TO BE CARRIED OUT ON THIS PATIENT. ~ ~ 1. Admit to Traurr}~ ^ Blue ~ Gold ~ervice - Ward: Weight , 2. Diagnosis: ~b--thr~ ~ Ma-'C f-~Cf2~ ~ 3. Condition: Allergies: 4 . 5. Vitals Signs [~q 4 hours with I&Os and abdominal assessment Neuro checks q 2 hour(s) or ^ Neuro Checks q hour(s) Vascular checks q hour(s) of Notify H.O. (Pager )anytime:: ._ Temp > than 38.5°C HR > 130 or < 60 RR > 30 or < 12 BP sys > 160 or < 90 , , , Urine Output < 120 cc in 4 hours Change in Neuro Vascular or Abd Exam , , . Any Hct result that is 5 less than the baseline ED Hct of 6. Activity: ^ Bedrest or~ Ambulate d lib or ^ 7. Spine Spine cleared ~] Futl spina! precautions ^ Only cervical spine precautions ^ Only thoracolumbar spine precautions 8. Orthotics to place Aspen collar after 24 hours if patient still in full or cervical spine precautions . 9. Nursing ^ Cough/Deep Breath/Incentive Spirometer q 1 hour while awake ^ Foley to gravity ^ Wound Care: Clean with 1/2 strength HzOz and apply Bacitracin TID ^ Wound Care: NS wet-to-dry TID to 10. Diet: N.P.O. or 11. Intravenous Fluids ~D5 0.45NS with 20 meq KCI/L @ ~~ cc/hour . , ^ LR @ cc/hour or ^ , 12. PRN Medications: E]'fVone 13. Scheduled Medications ^ None Y 14 Labs: \ . ; ~ `.~, ~'STAT CSC q 6 hours (0400 1000 1600 2200 schedule) ~~ , , , Discontinue after third ward CBC . Add Lipase to second ward CBC ~ ~j ~.~ . ^ ~/ 15 No t)fy H (Pager ~) upon arrival to ward O . . . . 16 Add" Tonal Orders ^ None . Attending Physician Name: 1.~ P.I.# Beeper # Ordering Physician's Signature: P.I.# ~~/~ Beeper #~ 279 6 95~ ~ DM: 06/26/05 TALHELM ,SAMUEL Arw: coy ~~~^.r cr. M 09115/1997 ERWB FC: V EDR SOKOLOVE, PETER E TRUE MRN Dr~TE FIC~U~i USE BALL fiQlNT F'EN 1 ~ Patient ER~t.: A`C @~i `c'v't 1'wvC ~g~ ~~N t'"°Y.A~I.'4 ~~."~' t~rderi~z; Pi~ysiciaro Signature ftttert€1atg ~'hysieian Name ,Ir~4.D. Pf. # beeper: Eeeper: i'SATE ~ E-1Ct.If ; USE BALL POINT PEN '~ Patier2t it.: ~ t• n 1 ~~ r ~ ~Q~~mV m ~(pp ooh--off ~ ptnO~N ~ ~0~~3~~ m~-~ X00 mm """ ~ m z~.o QO mn C~ ~ ~~ lyyG Ordering Pf~ysiciart Signature ,M.D. P.1. # ~~% Beeper: Attersiing Physician h(aine ,M.t}. P.l. ~ BeepeE: 20-96026299 AUn~ v~ TALHELM SAMUEL pf(A; UOt, HtHV E-~ Epq ~~KOLOVE ~~ETER E ~ v TRUE MR# Date: ~ Attending M.D.: SACRAMENTO, CALIFORNIA PHYSICIAN'S ORDERS ~~'fl~ PI #: Resident M. D.: PI #: ^ Patient is a UCD Managed Care Patient DISCHARGE TO: ~ Home ^ Board and Care ^ Shelter ^ Other: DISCHARGE NOTE: ii~~~~,,~LL Q Reason for admission: -' ~bV V.Q'~M~.~ ~~t.5dl. Outcome of hospitalization including significant findings, procedures performed/treatment rendered, and any complications: Discharge diagnosis: (no a breviations) 1" t~t,C~ t•tp~.. G~D'XstU,SL Condition on discharge: Medically Stable for discharge ^ Other, FOLLOWUP CARE: //1~~, Labs/Xray to be done prior to next medical appointment: ^ None or Referral toffor: (Requires referral fo discharge planner) ^ Resume previous home health orders ^ Home Health: ^ Name/# ^ Physician of Treatment: Skilled nursina for: ^ Medication management/teaching ^ IV ^ Symptom Assessment/Control ^ Home Clinical Assessment ^ Wound/Ostomy Care: Rehab: ^ Evaluation and treatment by: ^ PT ^ OT ^ Speech therapy O Hospice: Clinic Follow-up: It is recommended that you receive follow-up therapy or care in the clinic(s) listed below. PleasE ^ contact the clinics directly at the number(s) listed below AND/OR ^ contact the Discharge Concierge at 1-800-2UCDAVI~ (1-800-282-3284) to arrange your appointment(s) within 3 business days of discharge. (MD must complete HDAR for .discharge concierge-facilitated appointments: HDAR should be faxed to DC Concierge at 4-5011) CLINIC/THERAPY PHONE N none listed caN discharge condo at number iven above WHEN? SPECIFIC PHYSICIAN? (If applicable) If you have trouble making these appointements, call 1-800-2-UC DAVIS for help. 1NSTRUCTIONSTO PATIENT/FAMILY/CAREGIVER• Diet: ~RegularMo restrictions ^ Or: ^ Increase food intake (SPECIFY GRAMS OF Na, Pro, Chol, # of calories in ADA diet, etc) Fluid restriction: I~1 None ^ increase fluids ^ Restrict to cc/24 hou Activity restrictions: ^ None ^ Increase exercise/m bilization ~Or: (J~ ~'Y~Ok.~ ~ 1~r ~ WB~P.I I~ Patient may return to work/school: ~l Yes, (date) ^ No, requires further work SignsJSymptoms to watch for:~tnfection Pain ^ Other: (For Heart Failure patients only) a+gh yourseH daily and contact your doctorrf you gain 2 pounds overnight or 5 pounds in a weE If you smoke, PLEASE STOP! For Discharge Medications Ordering Physician Signature: ORDERS NOT VALID UNTtL Date/rme Noted Time: Enteral feedings ^ Diabetes Instruction/monitoring ^ Social Services ^ Ostomy/Wound Nurse referral i Discharge Modica ~on Orders Form. Jam' _ ~.~-~,t.~~ By RN: M.D. PI #: ~" 1 i6-95-81 g 20-980262994 ADM:06/26!05 1'A. ol1ELMT~Sq~L M 09/1~,;;,~7 cn'Jrci rc;: v EDR SO{(pLpVE, PETER F Tee i SACRAMENTO, CALIFORNIA PHYSICIAN'S ORDERS (916) 734-2011 For Nursing initial box when Faxed to Outpatient Rx PHYSICIANS DIS HARGE MEDICATION SUPPLIES AND ORDERS ~ ~ Date: Time:~ ' RX given to patient 0 1. To facilitate the discharge process, the original copy will be given to the patient so they may have their discharge prescription(s) filled at the pharmacy of their choice. 2. All orders must bear the name of a licensed physician and include their Ca. License number, PI#, and their DEA# if a controlled subs ce is prescribed. 3. Schedule II prescriptions must be written on a California Triplicate Blank. Exemption to Triplicate orders for "terminally ill" patie must also be written on a separate prescription blank, ident~ed with "11159.2 exemption" and limited to one drug per prescriptio lank (CA Health & Safety Code 1159.2}. 4. Prescriptions required by the physician to be filled at UCDMC will be subject to the following restrictions: a. Medical supplies and food supplements will be limited to the items listed on the back of this form. b. All over the counter medications will be dispensed in manufacturer's quantity and containers. 5. See back for additional prescribing information and Medi-Cal coverages. (Physician write patienf name for scheduled Ill, IV controlled medications) PHARMACY PATIENT NAME PRESCRIPTIONS DO NOT DISPENSE AT PATIENT WT.: THIS TIME ALTERNATE DRUG NAME STRENGTH QTY R ILL DIRECTIONS SUPPLY 1. ~ 2. ~ 3. ~ 4. ~ 5. ~ 6. ~ 7. ~ TAR/Code 1 INFORMATION: Diagno ' Resume Previous Meds ^ Y, N, ^ N/A ^ Bring All Medications to Next linic Visit Justifications: Pr ri tions that do not contain ail re uired information will not be filled. "~ " f `-tom D . ~~tt.~-c ~ ~ ~©~~. ` ~~~~~-~1-- ~t~J I I g PLEASE COMPLETE ALL COLORED AREAS CHART COPY DEPARTMENT OF RADIOLOGY RADIOLOGY FAXED PRELIMINARY REPORT Patient Name ~~ ~ Medical Record Number ~ ~ ~ S `~ 1 ER Location (area) Exam Type Radiologist Preliminary Findings: I ~ ~ r ~ ~il,.l~ SACRAMtNIU, GALIrIJtSivtH '~` 1~ L~ _~ Radiologist Pager # UNIVERSITY OF CALIFORNIA DAMS MEDICAL CENTER ADVANCE DIRECTIVE INFORMATION ADVANCE DIRECTIVE FOR ADMISSION OF 06/27/05 - -------------------------------------------------------------------------- _ _IENT NAME: 'IALHELM ,SAMUEL 9EN PATIENT NO: 20-960262994 1769581 D7PA 7773#01 ISOL: N --------------------------- - -------------------------------------------------- ate of Advance Directive Screening: 06/27/05 Nurse's Initials: HPCCRW The patient and/or patient representative has received advance directive information and the UCDMC policy statement. G NO,OTHER REASON Does the patient/patient representative state the patient has an advance directive? a. Was a copy of the advance directive provided by the patient? YES - Place a copy of the advance directive in the patient's medical record. No further action is required. NO - Make two attempts to obtain a copy of the patient's advance directive from the patient/patient representative. 1st Attempt: User ID: 2nd Attempt: User ID: b. Does the patient wish to complete an advance directive at this time? YES - Instruct the patient to contact ont of the resources listed on the back of the informational brochure. NO - No action is required. 14:57 06/27/05 FROM D707,NSHADVFI D7FC9469 USE ~'~r=~~~- ~:~~ ~~~~• 176-95-81 8 2o-960262994 ADM:O6l26105 TALHEI-M SAMUEL AKA: DOE, HEATFI EN TRM lLONDON~ ASON FL• \J 7DI IC ~~DY UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER, SACRAMENTO, CALIFORNIA NURSES' PROGRESS RECORD GENERAL INFORMATION Admitted From: ^ Home ER ^ Clinic: ^ Other: A e: ''`~ Admitted to Rm No:'~ - Date: •Z~•D5 Time:b With Whom• SID Band Checked ''h '~~'~,` Inter reter Used ^ Yes ^ No ^ Unable to obtain information ^ Unres onsive ^ No si nifica other resent ^ U date due ;:.• ~_ ~c.~nL~~ 'was ~• A1nC~~rY~, .q 1 ~ o e~- ~l ~o~l r~~n.t ^-~ 04~' HEALTH HISTORY ~,.. _. :V1fh 't~i~~i~Yctii'.~b;~ 1 f!~1 . ~}to~he`~bi~s. i f:. Has our child been in the hos ital before? ^ No ~ Yes If es, describe:h.. ~' ,rv~ ~ta~y rn2- i Has our child had a serious illness? -~ ' No ^ Yes If es, describe: Do ou have concerns about this hos ital sta ? ^ No es If es, describe:. iJ~ ~~- ''lrrtmtisatrori~ `f~re~~ro~'rcfiild's•immuriizatirs=current? es ^ No ^ Don't know Ex lain: r ,: " Qurt. ° . ' ox?; ^ Yes No _ _ _ nt" ~ unicable ~iseas_e'~Chickert pox, measles"tiepatitrs, efe:) e ~ ~ _ When ^ Yes o What `AL~ERG1L~v/REA~TItJFiS~ Dru ~1~~.-~. Foods: -~__ _- Other: I~ItEDIGATIONS (IiiCI~` "s t3TC, Herb.;#~ },T '<rne`t't and'1/itam#nS Medications/Dose Usual Times Last Taken Reason for Takin How does our child like to take med~cme~ ~ ~.~ ~'r~" ~~~ ~. '? ~ ~~~x~ ,.,~; AIIVASSESS. ~'-~ t<.: s ~T - t - ------r-- - . ; ;%-ioW{dbes' ~i:~r c ~av°e tich~t_m aitS~~~ ~ '' >~ : ~- ~' ~~.~rt-~-. -~y~.L,~ _1~ 1 -~ ~ h - ,~~~'t~0~ •.~.~UfJ,.~ ~. ~` .©UI''CJirl `i'+L° ~. ~. ~~ >S ~ i ~a ,~,`; ~w•.'~e~~`~!'V~r~e•~J1„-4.~ _ _ r _V+Eh~[v~rt5`rel~tf es~, ~ i~~is~~to; e `il3e_ .~.~~~~~~. .7 s~k ~s`'-~x`~~ ~,. _-' `~~`~ .. : : . ,.,. .r ... .-,., 7 _x - Y...+. ~ a.? .Is ~our,:cYiil`d eurxe iq:,pain7. if°so v~1~~~=~s~ t~ • in. -goal #or:. oer ~~~~ C~ =~ct~~:~;~ ~}-~'~- _~_- SOCIAL HISTORY What lan ua a do ou find easiest to s eak, read, and/or write? 1-~- The hos ital is stressful for man eo le. What can we do to make i easier for ou and our child? Do ou have an reli ious reference? `l~~ Are there an cultural or reli ious custom`s ou would like us to be aware of? Is there an hin that would make it difficult to visit our chi-d while in the hos ital? ` ' ov ~ ^ Children at home • ^ Work hours CJ Trans ortation ^ Other: DISCHARGE PLANNING INFORMATION Who lives in our home? ~,~n S~ ,,1;°~W a Who can assist ou if ou need hel with our child at home? ~~ Have ou been receivin hel from an a encies? CI No ^ Yes If es, lease list: ^ Home Health ^ Visitin Nurses ^ CCS ^ Re Tonal Center er: ~`U2,>1~~! - ' ~~ °--l 1-tc, Antici ated a ui ment needs: In the car does your child use: Infant carseat ^ Convertible car seat ^ Booster seat Seatbelt ^ 20-960262994 AD SAMUEL T ALDHELM TN EN M 0911511997 EFIW B FO: V TRM LONDON, JASON INFANT/TODDLER/PRESCHOOL 0 - 4 rs + 11 mos NUTRITIONAL-METABOLIC Use a ^ bottle ^ s ecial ni to ^ breast feeds ^ cu ^feedin tube ^ ther: Need assistance with feedin ? ^ Yes ^ No Have a s ecial diet or formula? ^ Yes ^ No Describe: Feedin Re imen: Have an roblems eatin or swallowin ? ^ Yes ^ No Describe: Food Likes: Food Dislikes: ELIMINATION Pott trained? ^ Yes ^ No S ecial words for urine and stool: Usin dia ers for da and ni ht? ^ Yes ^ No ^ Ni ht onl Havin roblems with urination? ^ Yes ^ No Wet his/her be ^ Yes ^ No Havin an chan es in bowel movements or fre uenc ? ^ Yes No Describe: Often have diarrhea or consti ation? ^ Yes ^ No Descri ACTIVITY/CO NG What are our child's favorite la activities and to s? Does our child have an s ecial safe considerations? Yes ^ No ^ Altered mobili ^ Medication Effect ^ General eakness ^ A e Related ^Dia nosi s Related Use an s ecial a ui ment or su lies for routine care ^ Yes ^ No Describe: Describe our child's dais routine -Bed time: Na Time: T e of bed at home: Other dail activities: Parent/Care fivers desired invo{vement: ^ Bat ^Feedin ^Dia er Chan es ^ Other: GRO TH AND DEVELOPMENT Infant/Toddler: ^ Smiles ^ Babbles ^ ords ^ Combines Words ^ Lifts head while t in on stomach O Rolls front to back ^ Sits alone ^ ree /crawl ^ Pulls to stand ^ Walks alone Preschool: An concerns about our chi 's s eech? ^ Yes ^ No Describe: Does our child attend reschool? Yes ^ No What is the best wa to teach our c Ild new thin s? Infant/Toddler/Preschool: Have di ' ult hearin ? D Yes ^ No Uses a hearin aid? ^ Yes ^ No Have difficult seein ? ^ Yes ^ No Wear lasses? ^ Yes ^ No S IN ASSESSMENT DIAGRAMMING CODE Q@~, ~ EC = Ecchymosis A =Abrasion v ~ SI =Suture line E =Erythema R =Rash L =Laceration B =Burn P = Petechiae C =Contusion S =Scar r D = Decubitus I =Incision Cst=Cast Dsg =Dressing G =Skin Graft J ^ Clear and Intact Admitting Nurse's Signature: Date: Time: Refer to Nurses Progress Record for Admission Assessment. " ~ l LUU,J • L' C7 • lr `~ NURSING ADMISSION ASSESSMENT RECORD 2 of 4 o~n~ nro~r~ 176-95-81 8 20-960262994 ADM: 06/26/05 TALHELM SAMUEL AKA: DOE, HEATFI EN M 09/16/1897 ERWB FC: V TRM LONDON, JASON SCHOOL AGE 5 rs -11 rs+11 mos) W~~ . Mt: 22-~..v kg Heigh '~-"7 cm .~ ~ P BS SR' 28 B/P w~~ NUTRITION Have a s ecial diet? ^ Yes o Describe: Have routine meal times? ^ Yes ' No Describe: Feedin Re imen: Have an roblems eatin or swallo in ? ^ Yes o Describe: Food Likes tiV6.-~ Food Dislikes ELIMINATION ' Havin roblems with urination? ^ Yes o Wet his/her bed? ^ Yes ^ No c:~ t~l- , Havin an chan es in bowel movements or fre uenc ? ^ Yes o Describe: Often have diarrhea or consti anon? ^ Yes ~ No Describe: ACTIVITY/COPING What are our child's favorite la activities and to s? tt~R• Does our child have an s ecial safe considerations? Yes ^ No ^ Altered mobili ^ Medication Effect ^ General Wea Hess ^ A e Related is nosis Related Use an s ecial a ui ment or su lies for routine care? ^ Yes No Describe: Describe our child's dail routine: Bed time:8: ~ - vv`-- Other dail activities: ParenUCare fivers desired involvement ath eats ssist with Activit ^ Other: GROWTH AND DEVELOPMENT po ou have an concerns about our child's s eech? ^ Yes o Describe: ~~ u Does our child have difficult hearin ? ^ Yes ~'No Use a hearin aid? ^ Yes No Does our child have difficult seein ? ^ Yes No Wear lasses? ^ Yes No What school does our child attend? Grade: What is the best wa to teach our child new thin s? ~,{,~;~ SKIN ASSESSMENT DIAGRAMMING CODE EC = Ecchymosis A =Abrasion ~1, Si =Suture line E =Erythema V R =Rash L =Laceration B =Burn P = Pi~techiae C =Contusion S =Scar I ~` D = Decubitus 1 =Incision Cst= Cast Dsg =Dressing G =Skin Graft J ~ ^ Clear and Intact t~ Admittin Nurse's Si nature: V~ I°1t- Date• -2"1- Time: ~1~ Refer to Nurses Progress Record for Admission Assessment. NURSING ADMISSION ASSESSMENT RECORD 3 of 4 ~Clll ATOIl~C t 176-95-81 8 20-960262994 ADM:08/28!05 TALHELM T~SAMUEL M OA/1511AA7 FRWR F[:• v . ''~ ADOLESCENT 12 - 18 Years Vile TM ~ht: k t: cm B/P NUTRITION Are ou on a s ecial diet? ^ Yes ^ No Describe: What are our favorite foods? Have ou had an recent wei ht Voss or wei ht ain? ^ Yes ^ No Des e: Have ou had an chan a in a etite or thirst? ^ Yes ^ No Describe ELIMINATION Do ou have an roblems with urination? ^ Yes ^ No Descri Have ou had an chan es in bowel movements br fre uenc ? es ^ No Describe: Do ou often have diarrhea or consti ation? ^ Yes ^ No en? PERSONAUS IAL Have ou ever had a eriod? ^ Yes ^ No Date of last er' d: Are there an roblems? ^ Yes ^ No Are ou sexual! active? ^ Yes ^ No Are ou sin an rotection? ^ Yes ^ No Do ou drink alcohol? ^ Yes ^ No Do ou smoke? ^ Yes ^ No Do ou user reationaf dru s? ^ Yes ^ No Are ou involved in an activities? ^ Yes ^ o What school do ou attend? Grade: What are our interests? Do ou have difficult hearin ? ^ Yes No Use a hearin aid? ^ Yes ^ No Do ou have difficult seein ? ^ Yes No Wear lasses or contacts? ^ Yes ^ No Use an s ecial a ui ment or su lies f routine care? ^ Yes ^ No Describe: SKIN/BODY ASSESSMENT DIAG AM • • • ~ ~ t & _ DIAGRAMMING CODE * OUTLINE AFFECTED AREA EC = Ecchymosis A =Abrasion AND INSERT APPROPRIATE SI =Suture line E =Erythema LETTER FROM DIAGRAM G R =Rash L =Laceration CODE B =Burn P = Petechiae C =Contusion S =Scar D = Decubitus I =Incision Cst= Cast Dsg =Dressing G =Skin Grait ^ Clear and Intact r REHAB TIENTS ONLY - FUNCTIONAL INDEPENDENCE MEASUREMENT Pre-Illness/In'u Admit Level Levels Groo In 7 6 5 4 3 2 1 7 6 5 4 3 2 1 7 Com lete lnde endence Timel , Safe1 Am latin 7 6 5 4 3 2 1 7 6 5 4 3 2 1 6 Modified Inde endence Device ~' Tr sferrin 7 6 5 4 3 2 1 7 6 5 4 3 2 1 Modified De endence tin 7 6 5 4 3 2 1 7 6 5 4 3 2 1 5 Su envision rtoiletin 7 6 5 4 3 2 1 7 6 5 4 3 2 1 4 Minimal Assist Sub'ect = 75% + Bowel 7 6 5 4 3 2 1 7 6 5 4 3 2 1 3 Moderate Assist Sub~ect = 50% + Bladder 7 6 5 4 3 2 1 7 6 5 4 3 2 1 Com fete De endence 2 Maximal Assist Sub'ect = 25% + 1 Total Assist Sub'ect = 0°I° + C Cues i.e. VerbaVGesturaV Admittin N urse's Si nature: Date: Time: Refer to Nurses Progress Record for Admission Assessment. • • • • NURSING ADMISSION ASSESSMENT RECORD 4 of 4 IJSE PA.TII°N~ Pi.•ATE UNIVERSITY OF CALIFORNIA DAVIS X., a ~;•.~~ ~~~,,s~ ;;INEDICALCENTER, t~z: ~ ~. . ~ +~ ` ~ . ~ SACRAMENTO, CALIFORNIA ~~~`~'~'~ ~` `~~~`~- ~;~ ~ PROGRESS RECORD Ali ~l Ct~~ ~ ~ ~ f~.i~ ti ~ ~ S~'"~~~~~3~..~~. J>~~~;~"`-~y, ~_~ ~ to [. r~:i PRE PROCEDURE ~~~,y~,,~^ k. ~^-~ Known allergies/sensitivities (Y)~ (N) ^ ,Age _-~ 1 Admission height weight ~ Pain (Y) ^ (N) ^ Intensity ~"'~ Site Aldrete Score Vital signs Time:`~_ T ~ ~ ~ -l- ' '- B/P~_ R ~ Sa02% ~_ Fi02 ~ "1 r. NPO since: date J J ~~ HAHours since: ~ ~t~ ~~ Solids ^ Liquids ^ Primary Language: (other than English) iti 1~`~ Y'~6w~'~~.,~ '°~-~- Special Problems/Dis bilities: (e.g. visual/hearing, developmentally delayed) LJ f~ Pre-procedure teaching completed MPER ^ Progress Note ^ Nurse Note ^ Other Premedication given (N) ^ (Y)~\n~ Time: `~ S IV/ eplo Swan Ganz ^ Ce//ntra~~l Line ^ Arterial Line ^ Other ^ Consent form signed ^o Informed consent note in progress record ^ Diagnosis: ~-~'~~'''~ a ~~ Procedure Plan: C~ 'g" ~~G~`''1 Site verified ~ i Plan for Sedation: Moderat~ Deep ^ "(Deep sedation shall be administered only under the direction of an anesthesiologist or a physician whose trainin and privileges specifically include deep dation; per UCDHS Policy #X1Q11~-23) Date: ~ `~ Time: ~~`~ RN Signature: ~ i"''`~' MEDICAL DATA ^ I have assessed the patient immediately prior to the start of the procedure and the patient remains a candidate foi sedation. ^ History and physical completed and present on chart ^ The indications, risks, complications and alternatives for the procedure and sedation have been explained to the patien and/or guardian and are documented in the Medical Record. ^ I have written and signed, initial medication orders for sedation. , ^ Site verified -Note in the Medical record is required. ASA STATUS select one ^ 1. Normal healthy patient ^ 2. Mild controlled systemic disease & no functional limitations ^ 3. Moderate to severe systemic disease that limits activity but not incapacitating ^ 4. "Severe systemic disease that is a constant threat to life and is functionally incapacitating ^ 5. 'Moribund patient not expected to survive without the procedure `Consider anesthesia consult for ASA #4 & #5 Date: Time: Signature: M.D. PI#: r #: G,j y~lA u".8'"TI Er'SF i ~.::r~L-i.~i~. - .:) + Y+~~ ~. E... ~a ~~~~ fii 4.. x~~ 2.+ ~ F~l ,iw ,ri. K kv F { -•'w` ']n~ 1. w" ij l~ ~., UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER, 'a ~+ L I> ~A~ERAMENTO, CALIFORNIA PROGRESS RECORD Time: ~ rj~ INTRA PROCEDURE ALDRETE SCORE (adiapted) •oeep Sedation pre post D/C Sedation Standard of Care Patient shall be continuousl monitored usin rele a t ActivUy M°"es a ax'ramnie5 ~°I'""ara,' °r ~"'mand Moves 2 extremities voluntarily or command Moves 0 extremities volurttari or command 1 o 1 0 2 1 0 y g v n physiologic assessments including, but not limited to Respiratlon Spontaneous unlabored respirations Dyspnea A nea ~ J T~ 0 1 0 2 1 0 B/P, pulse, resp rate, 02 saturation, LOC, and cardiac rhythm (as indicated). ctrwtatton BP changed < 20% at preanesthetic level BP changed 20 - 50% of preanesthatic level BP than ed > 50% of reanesthetb level ~-'~ 1 0 1 0 2 1 0 SCL Sedation ~ Conscbus- near Isval Awake, alert, normal response to auditory stimuli Mik11y drowsy lxrt awake, slow response to auditory stimuli Drowsy, delayed response to badness & touch Very drowsy, arouses ony io prodd'mg, shaking, pain No re5 nse 3 2 1 0 4 ~ 2 1 0 4 3 2 1 0 Oz Saturetbn Able to maintain OZ Saturetbn > 9296 on room air Needs OZ inhalation to mafntaln Oz saturation > 90% Oz saturation < 90% even with Oz su ement ~ 1~ 0 1 0 2 1 0 Procedure r1 ]~,~~1 r~ , f--~ Total Time: Start ~? op ~"1~~ Score: PAIN SCALE USED: ~ TIME: MED RO U T E DOSE DOSE DOSE DOSE DOSE DOSE DOSE DOSE DOSE DOSE DOSE DOSE DOSE DOSE DOSE DOSE 1 , ,/ - ~ " w r SIGN: ~;" _C ,` SIGN: P.S. 200 i r i ; 1 i i i ~ i i i PS =PRE SEDATION I I I I ~ 1 ; i I i I I ~ 1 I r ; i i i I { , , j ; j V 150 B P i i i i i i ~ i ; i . . A a i i i i i i i ~ i i i ~ i I ~ PU E I i I I i i i i o L ~ I ! I 1 100 ' " ' ' ~ i i~ i ' i RESP. # i i I i ~ i i I I I I i i I I I I i ~ I i ~ i ; I i i i i I ~ i i I ' I I i ~ ! i ; ~ I I i i i 1 1 I i I I 1 ; I i I 1 i ! I Resp r ""~ Sp02 (~ C. SCL { ~.~~ . - ~~ C.`~ DateTme: ~~ ~~~~ ~~ 1 n ~ f~fl~i SSE ~,-y-~E~: - - ~ UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER, SACRAMENTO, CALIFORNIA PROGRESS RECORD 3e"' .7 • Time: 'NTRA PROCEDURE ?~tLDRS7'E SCORE (adapted} •~p Sedation ' ., ~ Pre pest D/C Sedation Standard of Care Activity Moves 4 extremities vdurttadty or commarxi Moves 2 extremities voluntarity or command Moves o extremities vaunted or command 2 7 o 2 t 0 2 1 0 'atient shall be continuous) monitored usin relevant Y g physiologic assessments including, but not limited to Respiration spontaneous unlatxxed respirations Dyspnea nee 2 1 0 2 1 0 2 1 0 3/P, pulse, rasp rate, 02 saturation, LOC, and cardiac fiythm (as indicated). Circulation BP changed < 20% of preanesthetic level BP changed 20 - 50% of preanesthetic level BP > so% of reanesthetic level 2 1 0 2 1 0 2 1 0 ~~ Sedation i Consdous- tress level Awake, alert, normal response to auditory stimuli Mikity drowsy bu[ awake, skxw response to auditory stimuli Drowsy, delayed response to budness & touch Very drowsy, arouses only to prodding, shaking, pain No res nee 4 3 2 1 0 4 3 2 t 0 4 3 2 1 0 ~ Saturatbn Able to maintain Oz Saturation > 92% on room air Needs Ox inhalation to maintain Oz saturation > 90% Oz saturation < 90% even with Ox su lament 2 1 0 2 t 0 2 t 0 Procedure Total Time: Start stop Score: .PAIN SCALE USED:' TIME: MED ROUTE DOSE DOSE DOSE DOSE DOSE DOSE DOSE DOSE DOSE DOSE DOSE DOSE DOSE DOSE DOSE DOSE SIGN: SIGN: P.S. ' I ~ I ~ ~ ~ ' 200 ~ I I I t i i ~ . ~ ! ; ! i l ~ I i 1 i P5 =PRE SEDA710N , ~ I , 1 I I I ' i 1 k 1 ~ ~ 1 I I i v , , t t i I 1 I i ~ ~ 1 I ! tso B.P. 1 1 1 1 I ~ r 1 ! n I ) 1 I I I 1 1 ! i I 1 I 1 1 t J I 1 I i i~ PULSE o ~ ' 1 i I I I I I ' ' I f ' ; ; i I l I , ~ 1 100 ; i i I I i I 1 i i i i I ~ 1 i 1 s i I I ~ 1 ~ ' I i t . I I 1 1 I t ! f I i t 1 1 I I I 50 ~ ! I I ' f I ! 1 1 I ( i I 1 ~ I ~ ~ ~ I I ~ 1 1 ' I I I ! 1 1 ~ f I 7 ~ I i t 1 i ! I I I I I ! I i I 1 I Rasp Sp02 SCL Signature: Datelfime: ~~fl~~"II~NT ~t~~,~`~.., ~ ':; .'~ t ~ C .. ~ ~ ~ ~ ~ ~ ~ ~ ,~ ~ UNIVERSITY OF CALIFORNIA DAVtS ~ - .~ ~. i ~; ~ to ~ ~ tt ~ r ~ ~ ~} ~ ~ ~ ~ i,~ ~, ~ ~ ~ MrMEDCCAL CENTER, ~ ~ ,,.~ aSACRAMENTO, CALIFORNIA ~ ~` ~' ~ ~`~ ~' ~.-~ ~ ~ +~ ~ I -~ ~ ~ ~ v PROGRESS RECORD ,~ • (PLEASE INITIAL EACH ENTRY) TIME COMMENTS ~ `~' ~ ~ - ~~. .~ v ~~ t: • DischargelTransfer: Belongings: ^ none ^ yes Type/disposition Ora! Fluids: ^ Yes ^ No ^ n/a IV dc'd: Time To: ^ home ^ other unit Report to: Via: ^ wheelchair ^ ambulatory Accompanied by: ^ carried ^ other Signature: ~innat~ ~rc• Discharge Inst. Given to: Sinnafi iro• Time: Post-Recovery Discharge Assessment ^ n/a ^ This patient meets all criteria for discharge Date/Time: Date/Time: Date/'~ime: ~~~ ~~-~1~ ~~~~ ~ ~ PAIN RATING Tool Used: 176-95-81 8 960262994 ADM: 06/26105 0 Pain Assessment Guide: l/R T 24' Body Fluid Status - 2 TALHELM SAMUEL ange oo Pain 1 =NIPS (0-7) O AKA: DOE, HEATFI EN M 09115/1997 ERWB FC: V 2 = NAPI (0-11) 3 =Faces Scale (0-5) O TRM LONDON, JASON .4 = Oucher (0-5) 5 =Numeric Scale (0-10) (Q .2~-~~ VV'f Z'~ °~ ~'k YESTERDAYS WT. OFC DATE VITAL SIGNS INTAKE OUTPUT IV SOLUTION: Amt Infused Over Last Hour ~ Site ~ •m Cr. ~ °- ~_ a O chi .v ~ ~ i0 L O 7 O ~ y ~ p °Sy ~ ~ LL' ~ N N ? ~ ~ O '~ m U A y/1 "Z y~ ~ ~~ , ~ o °~ Tn ~ m C7 C7 ~ -°o -°o ~ ~ > w 0 m c ~ w m in ~ F H = Q m a ~ z ~ rn v> . z z O H n t 7 ,. . 8 --: ~,. _ , ; • . o; 11 j~ 12~ ~ ~"- - ~ ' _ 13 ; ~. 14 ,, ~ ~, ~~ ~ 15 is r . ~. _ ,~; , ~, 17 j 18 12 HR. TOTAL 19 u:a,M ~ ; • 21 -~ ~. ~`. 23 ,,;f; - 24: ,... 1 2; 3 4 5 12 HR. TOTAL 24 HR. TOTAL I I I ~ ~ ~ PEDIATRIC FLOWSHEET 1 OF 6 UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER, 176-5`J-$ ~ $ SACRAMENTO, CALIFORNIA 20-980282994 ADM: 06!26105 TALHELM SAMUEL Pediatric Flowsheet AKA: DOE, HEATFI EN M 09/16/1997 ERWB FC: V TRM LONDON..lA8~N K ey -Over 2 yrs. of Age -Glasgow Coma Scale -Record Best Numerical Response 7 1 , ~ Danm9 q Sponterreous 3 To Speech 2 To Pain 1 None 2 . Best Wrbal 5 OrkMad 4 Conlueed 3 Irsspp WoNs 2 Iraomp Sounds 1 Nona - y ~, ~, R S ~ S Petit ad 4 Wlddrews 3 Floc to Pdn 2 p tD 1 None or Develo mental/ Dela ed than 2 rs L = Ne w Bottle STOOLS ~ U ~ ess Ke - ~ ~~ . • ~ 3 To VWce 2 To Pain 1 Nona T =Transitional Y =Yellow W =Watery K =Gray MU = Mucousy G =Green B Ur ~ a 2 Beet Verbd . e.st tlwt« R 5 Coos. Babbles 4 brit Cry 3 Crl~ to Pain 2 Moans W Pain 1 None a svdM+ 5 Tourcen~r' a v a Abn Flsxbn z Abn Exton t Morn rawn F =Formed B = SD =Seedy LG =Large J ~ +. eascew Coma 9eeM Seon L =Loose BL =Bloody Soft SM =Small S Q 5. FonWtMs F Fmt B ~^B D Dapresead T Tense S son U Fwi = C =Constipated M =Moderate W 6, Aetivlty SL ttl.apn A L J tea '~'" SZ ~N° ' 1.+ 2.+ kwa 3.+ tmuw Z a awl . ,~wr° n n .u~ COMMENTS 7. P„~,,,,ry s onse R • ht Ri see e p ++ =Brisk z ~ 3 ~ 4• s g Reaction Si . - =None Left ze & SWn M D N W Reacton Coior ~ ~~ ~~ Dusky ~~ / M M ist D D Q = = ry o ~ ~i; j] J ,laundk:ed C Grcumoral Aerogarrosle G Gray W =warm ! C = Cooi - V 9. Cap Reflll 1+ S 3 secs Right UP• ~•~La'+• ~• 2+ > 3 secs Left Up. ExtAow. Ext. j Q 10. Cardiac N =Normal M =Murmur R =Rub G = Galbp Sounds R =Regular I =Irregular Rhytfxn Q 11. PUlses O Not Palpable 1+ Barely Palpable 2+ Weak Right UP• ~~~'''~ ~• V 3f Normal ~ 4+ FUM Borxttflrtg D Doppler LeR Up. FxtJLow. Ext / I S i rCD6 - WA ^ r nc p WA ^ AerosollCPT ';~~ 12.Resp Effort SR Supnsstemal Retr. SUR Subatemel Retr R Intercostal Rev CR AB NF U TYpe }, Superclevictdar Rah A bdominal Breath Neeal Flaring Unlebored !Z 1+ Mikt 2+ Moderate 3t Severe SBVerity ~ ` ~ 13.Bresth O RH W -~ S RUL Q Sounds Clear Rhonchi Wheezes Dkninished Stridor Right RLL ~ n 2 3+ UAC Post R - rA FR 1+ + L IJJ ~ Friction Rub Fine Bales Medium Bales Coarse Bales Upper rwaY o Left LUL ~m ~: C n ~ st~cb LLL t4 P l a SM M LG T TH 0 Amount n $eu or ~ Smell Med. Largo Thin Thitlc None te C B BL O onSlS nCy ` W White Y Yenow G Green Brown Bloody Clear Cobr ; ~ sstro- 15 G S D R ~ T nder T Abdomen -- ,. . t Intestinal Spry 0 Diaterxled i y e N Bowel Sounds None er H p t'lorrne MU SD L ABD Girth (cm) _ ': ~: ~ W Watery Murxwsy seedy Loose Stools ~ ~ , ? ~ S Son Y Velbw G Green B Brown ~~~ BL B SM Smen M ~~ LG ~ ~ f Vt~^ ~ CJ+'~ ~ l~~ G G2 Y A H F C Cobr ,: i . ~ a 16.Urins yy~ Amber Hematuda Fdey Condom Visual Inspection `"'' ~,:.~ „y ~ . { C7 V Void CL Claxly O Cher S Ssdmant D Diaper I InooM Device L L s = sae t i t R str lnb 17 R ~ EroO`v ap = ra n s es - . e a W Wrist 4 a PdM Comments Section PO$ItlOrl$ R = On Right Side T Trerdelertbe rg ~ 18.PosMlon L = on Len Side F = Rat Mobility ; U S = Supine TX = Treetion Siderails Up (n P Prone I Intent seat Untie/ROM .T. ~ T = HOB Up :y ; 008 Up Ad Lib ROM = Berge of Motion -= - 19. MobOity BR = Bedrest D = Dangb ' - C = Chair H = Held INITIALS - __ AMB = Ambulate _ PEDIATRIC FLOWSHEET 2 OF 6 176-95-81 8 20-960262994 ADM:06/28!05 TA pHELM T~SAMUEL TRM ~LONDONEJA80N FC: V PEDIATRIC FLOWSHEET 3 OF 6 use ~~a~~N-~ ~~.~-~~ 176-95-81 8 20-960262994 ADM:06l26/05 TALHELM T~SAMUEL TRM !CONDONE AEON FC: V ~~~w ~• w~~~f~~ ~rrT A A!" /~ aE P~TIEN~ ~L~~ 176-95-81 S 20-960262994 ADM: 06126105 TALHELM SAMUEL AKA: DOE, HEATFI EN TRM ILONDONEJASON FC: V - , ,r~ a ~_ CARE N/A TIME CARE N/A TIME Diet Breakfast Lunch Dinner Snack Oral Care E e Care NPO Fole Care Umbilical Care TPN Bath Peri Care ER i V Diet Alarms /'d ri Band % Taken T of Isoiation N/A ^ T of Bed Ovefiead Warmer ^ isolette ^ Crib ^ Adu Cal Gt. ~_ - ~ TIt71e Slte tR N EIT iE TI O R SOIutIOCI Dr sg Lee ACtlOll . L t P N C S e d7 ~ ~ N NSWO LEN ~ e T ~N c RULE T ~ Lv Ir ~ E TNS OLE V~ ` ~~IZ~~ ~ ~~ 1L RUL N W N rte. CLEAR TENDER RED PURULENT SWOLLEN CLEAR TENDER RED PURULENT SWOLLEN CLEAR TENDER RED PURULENT SWOLLEN CLEAR TENDER RED PURULENT SWOLLEN CLEAR TENDER RED PURULENT SWOLLEN CLEAR TENDER RED PURULENT .SWOLLEN CLEAR TENDER RED PURULENT SWOLLEN CLEAR TENDER RED PURULENT SWOLLEN f'~p. ~ x~',?-n it r~F~~`d a.~ awl _ ~. , 1h ^YJ" e Time Type/Site Care / Appearance r ~,~~. ~ _ f a. - ~ - ..;. ~ - r,r~,_r , ,, .. ~ ~ ._, t ... .~ , 6 ~ ~ d ~ ~ L II \V ~ v Diagramming Code EC = Ecchymosis SL =Suture line A =Abrasion E= Erythema ^ =Clear R =Rash B =Burn L =Laceration P = Petechia C =Contusion D = Decubitus S =Scar Nurse's Initials 1- y Time ~~J ^+~r~IATOI/+ CI A\11/CLICCT C AC C ~sE Pi~TlENT I~L~''~ SEDATION SCALE KEY: CONSCIOUS SEDATION CHECKLIST 0 - (none): awake, alert ~ Consent done 1 ~ G ~n C _ ~ 1 a 1 - (mild): occasionally drowsy, ~ PUParent education done 20-980262994 ADM: 06126105 easy to arouse D Code sheet present TALHELM SAMUEL 2 - (moderate): frequently drowsy, O Emergency equipment present AKA: DOE, HEATH EN easy to arouse ~ Reversal agents present M 0911611997 ERWB FC: V 3 - (severe): somnolent, difficult ~ Cont, monitoring with propak TRM LONDON, JASON to arouse -^• •-- • •--" S - (sleep): normal sleep, easy to arouse '„ 4:. ~ ~~ n A ,Time Temp HR RR BP 02Sat GCS SRatinton Comments Time Test/Procedure Site Done By Time ,y - Test/Procedure Site Done By 0~3~ C'.t~ ~ ,~Y1 ~ r~L~~ ~ Time -Ar.. nk - 4 d . .Y. 9r~~~.~.5,{' URINE TESTS Specific Gravity Glucose Ketones Protein Bilirubin Blood pH REFERENCE RANGES Leukocytes Fasting Glucose 85-95 mg/dl 1 year 30-110 mg/dl b (Adult F H 11 8 15 lt M 13 17 8 Ad 8 8 MISC. TESTS g ) . . u . . . ( ) - Hgb (Pads) 0-2 wks 14-24/1 mo 11-17/2 mo-2 yr 10-14 mg/dl Urine pH 5-7 / SpecNic Gravity 1.002-1.035 Other Urine tests, Coloscreen and Gastroccult negative Ryr r~~: ~' ~ _ ~~ ~'J •~' ' `' ~ ~1~ p ~~ ,,fi't' x i ~z'~ ~•; TIME INITIALS SIGNATURE TIME INITIALS _ SIGNATURE • • 1! 1J u r ~;,• ~ ~ 76-9581 ~ PAIN RATING 20-9802~"2g4 llDl,i: OG;2vlGu Too! Used: TALHELM SAMUEL Pain Assessment Guide: 24° Body AKA: DOE, HEAT EN pain ToollRange Fluid Status M 09!15/1997 ERWB FC: V O EDR SOKOLOVE, PETER E 1 =NIPS (0-7) TRUE MRfi 2 = NAPI (0-11) 3 =Faces scale (0-5) 0 4 = Oucher (0-5) 5 =Numeric Scale (0.10) DATE !~~~C~ wT. YESTERDAYS wT. OFC VITAL SIGNS INTAKE OUTPUT IV SOLUTIONS Amt Infused Over Last Hour t ~ . Site rn ~ 3 ~ Cr. O O n -° m ~ CC L O 7 Y LL v O1 u~i ~ t-- a ~ Z `m ;ti o 1- m w 'S ~ oC F-- O U a C7 O[ .N m ~ C'S m E ~ aC 2 n- ~ Q N T O C7 C3 E ~ ~ ~ ~ C'3 ~ m {= F- x rr m a u_ O ~ o_ z z w ~ m cn ~ z ~ in 7 ~ ~ ,: 1 ,.: air z /) ~.k ' 9 l~ X11` - - ~- - _ ; s ~ ~;~.~ _s - _ - '_.~::~ - ,~ ~'- .,' 7 13 - D~ I' 1 '~ ~' ,, p i ~ y; 15 I, - I ~ I i f - __ _~ -_ --.. ~~ 17 12 HR. TOTAL 19 f ~ :Y SQL k.. ~ } _ - ~, 21 - - - - - -}- -- I _~ _. , , .- _- I' . , . . ~' ~' ~ ~ -„ ~ , 2~ y ~ ~ 1 23 -- ~24 r ~ ~ ~ - -~- ~ ~ ~ ~ 1 ~ - - - ~ ~~~ ~ ~~~- ~ - ~- ~ ~ ,: - -- i ~j } f ~Ja.~ F . r. v N' J a ~ ~ 3 ~ ~ ~ T r 4 -~-- - -- ~ - -~-- j, ~6 12 HR. TOTAL 24 HR. TOTAL SSE ,A~'C9E~t'T I tt~- 176-95-81 8 20-960262994 ADM: 08/18105 TALHELMSAMUEL AKA: DOE, HEAT Ef EpR I~jKOLOVE WETERFE ~ V TRUE MR;w S X= Ne w Bottle STOOLS T =Transitional Y =Yellow W =Watery K =Gray MU = Mucousy G =Green F =Formed B =Brown SD =Seedy LG =Large L =Loose BL =Bloody S =Soft SM =Small UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER, SACRAMENTO, CALIFORNIA Pediatric Flowsheet Key -Over 2 yrs. of Age -Glasgow Coma Scale -Record Best Numerical Response 7 1. Eya Opanlrg 4 Spontaneous 3 To Speech 2 To Pain 1 None - . 2 asst Verbal Response 5 Oriented 4 Conlueed 3 Inapp Words 2 Irtcomp Sounds 1 None & asM Alston Response 6 Convnands 5 pLocalzed 4 Withdraws 3 Flex to Pain 2 PEdxbM ro 7 None ,~ Ke -Less than 2 rs. or Develo mental) Dela ed V 1. Eye Opsn{na 4 Spontaneous 3 To Voke 2 To Pain 1 None _ "-. i ~ rt 2 Baet Verbal Response 5 Coos, aabbbs 4 Inl[ Cry 3 Cdes to Pain 2 AAoans W Pain 1 None ~~; O 3. Best Motor Response a Spontaneous 5 To 7puchws 4 od~nws 3 Abn Flexion 2 Abn Exton i None ~ ~+. J p 4. clwcoar roma scale scare ~ 5• ~p~a F Flat B Bu i DDe ressed T Tense 3 Soft U Full C=Constipated M=Moderate W SL A L J SZ 1.+ 2.+ 3.+ 6. Activity Sbeping Awake Limp, Jittery selzura, Acura with ActWe IrrNaMe COMMENTS z °",e` Hypotomc cemalaton samulatbn - ~ * , n YY F Yn.C i 1~„"~ ;1 ~. ': ~ i ~~r.;, ti_ ~~ 5 y t s, <ia-. -; ru cP '.. ~.: __ h rf 7. Pupfllary Response B i k 2 ~ 3 • 4.6 Right Stze r s ++ = Reaction + =Sluggish = None . . Left Size 8 7 6 Reacton ~ 8. Skin N Normal W Pale D Dusky M Mottled Color Q D=Dry/M=Moist J C A G ~ Jaundiced Circumoral crocyanosis Gray W =Warm / C =Cool . ~ 9. Cap Refill 1+ ~ 3 Secs Right Up. ExtJLow. Ext. ~ "/ j 2+ > 3 Secs Left Up. Ext.A_ow. Ext. ~ ` ~_ 10. Cardiac N =Normal M =Murmur R =Rub G = Galbp Sounds ~ R =Regular I =Irregular Rhythm Q 11.Pulses O Not Palpable 1+ Barely Palpable 2+ Weak Right Up. ExtJLow. Ext. V 3+ Normal 4+ Full Bounding D Doppler Left Up. Ext./Low. Ext. N/A ^ Inc Spir/TCDB N/A ^ Aerosol/CPT 12.Resp Effort SR Suprastemal Retr. SUR Substemal Retr R Intercostal Retr } S R N U s TYPe ~ clavicular Retr u al Flari nlebored Abdominal Breath a 1+ Mika 2+ Moderate 3+ Severe Severi Q 13.Breath O RH W ~ S Right RUL ~ Sounds Clear Rhonchi Wheezes Diminished Stddor RLL ~ ~ FR 1+ 2+ 3+ UAC Post R L W ~ Friction Fine Medium Coarse upper a~ Left LUL Rub Rates Rates Rates a~ LLL 14.Pulmonary SM M LG T TH 0 Amount Secretions smart Mad. Large rnin rniuk None Consistency _ W Y G B B O White Yelbw Green roown ooddy Clear Color S D R T Abdomen 15.Gastro- Soft Distended Rigid , Tender Intestinal g t j N Bowel Sounds None Hyper Hypo Normal NG pH/GUaIaC W MU SD L ABD Girth (cm) ~ Watery Mucousy Seedy Loose S Y G B Stools Soft Yelbw Green Brown BL SM M LG '~ BI Small Moderate Lan Y A H F C Color 16.Urine Yellow Amber Hematuna Foley Condom Visual Inspection d ~ V CL O S D I ` Void Cloud Clear Sediment Dia r Incont. Device EL = Elbow L = Leg S = See Restraints 17. Restraints W Wrist 4 = 4 int CommertLS Sectb n Positions 18 Position R = On Right Sid T = Trendelenberg - . L = On Left Side F = Flat Mobility __ (~ s = Supine TX = Traction Siderails Up fp P = Prone I = Infant Seat ~ t = HoB Up Untie/ROM 19.Mobility 008 Up Ad Lib ROM = Range of Motion BR = Bedrest D Dangle C =Chair H = Held INITIALS AMB = Ambulate oCIIIATQI('` CI f1\AlC41GGT 7 C1G R 1~'8-95-81 8 20 960262994 ADM: 06126105 ~ ALHELM ,~ ,'AKA: DOE,~HEAERW~ FC: V 1 ~ 09115!1.9 EVE, PETER E rDR gOK. ' TRUE MR~~ ~..~~.,. ~~ n~a-cucCT 4 C1F i ~~ -. . t ,: 1_ ., +-- I I:.4 ~__ ~;. __ -r--- -~---- --i--- 176-95-818 TALHELM D,M~.A /MUEL AKA: DOE, HEATIi EN M 09/15/1997 ERWB FC: V EDR 8OKOLOVE, PETER E TRUE MRN Shift Nurse's Full Signature Initials ~:. P RN Assessment and Management RN / INIT. DRUG-DOSE INIT. DRUG-DOSE INIT, DRUG-DOSE ROUTE-FREQ. ROUTE-FREQ. ROUTE-FREQ. tl Time Patient Assessment ± RATING Drug /Dose /Route /Site Results Rp~NG Initial ,t.. .... ~ _. _~ `~~~ 176-93'81 8 20-9602629;4 ADM: 06/26/05 TEA pH~~MT~SAMUEL M 09!15/t 997 ERWB FC: V EDR SOKOLOVE,PETER E TRUE MRfi~ SEDATION SCALE KEY: 0 - (none): awake, alert 1 - (mild): occasionally drowsy, easy to arouse 2 - (moderate); frequently drowsy, easy to arouse 3 - (severe): somnolent, difficult to arouse S - (sleep): normal sleep, easy to arouse CONSCIOUS SEDATION CHECKLIST O Consent done [~ Pt/Parent education done O Code sheet present L~ Emergency equipment present D Reversal agents present O Cont. monitoring with propak ~, ,~ ~ ,~r; ~~ z~l ~~, ~~SITRE/4'T MTS F~ ~.4~~~*l-~,~~f~ IPA ~~ Time Temp HR RR BP 02Sat GCS SRaiin°n Comments Time Test/Procedure Site Done By Time Test/Procedure Site Done By -1., ~ ~'~~ ~ ~. LAB TESTS F. - - f . , ~~; Time URINE TESTS Specffic Gravity Glucose '' Ketones Protein Bilirubin Blood 1~ - pH REFERENCE RANGES LeUkOCyteS Fasting Glucose 65-95 mgldi 1 year 30-110 mgk11 MISC. TESTS Hgb (Adult F) 11.8-15.8 (Adult M) 13.&17.8 Hgb (Pads) 0-2 wks 14-24tt mo 11.17/2 mo-2 yr 10-14 mg/dl Urine pH 5-715pecAic Gravity 1.002-1.035 Other Urine tests, Coloscreen and Gastroccult negative ~~ _SIGN pT~l1 RES. TIME INITIALS SIGNATURE TIME INITIALS SIGNATURE • • • 176-95-81 8 20-960262994 ADM: 06/26/05 TEA poELMT~SAMUEL M 09/15/1987 ERWB FC: V EDR SOKOLOVE, PETER E TRUE MR~i PLEASE BRING THIS FORM AND ALL MEDICATIONS TO NEXT CLINIC APPOINTMENT Signs & Symptoms to watch for: "'/p n~.() (11' ~" ~~~ ~ D~lh ~ /~ e'f~TO...~, --~' ~l~'~i II/~'J Report these symptoms to ~~ unable to access services, calf the MEDICATIONS FOLLOWING DISCHARGE. C7 ^ See Attached List of Discharge Meds Rx (with patient on admission) returned ~~- at hone #) _ /,3 I - J .~L ~7 If you are at (916) 34-201 and ask for the Physician on call for: Food/Drug Interactions: Medication Safety Pamphlet given Medication Instruction given Resume Previous Medications UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER, SACRAMENTO, CALIFORNIA NURSES PROGRESS RECORD ^ Yes, ^ No, ^ N/A ^ Yes, ^ No, ^ N/A ^ Yes, See MPER, ^ No, ^ N/A ~YYes, ^ No, ^ N/A ~Cj Regular, No restrictions ^ Fluid Restrictions; instructed on daily weights ^ Other: ACTIVITY LEVEL (N/A for infants & toddlers) Patient can perform all activities of daily living for himself ^ Yes,-~ No Has someone available to assist him/her ~ Yes, ^ No, ^ N/A Patient can resume normal activities with nor strictions _ .~~,~.~ G' Y s, J~' No If No, please list specific restrictions: ,~ jj ~ t1.Sbt~~~' ~ ~"' 'y Tom" ~ ~~ Patient can resume Physical Education Activities ^ Yes,, No, ^ N/ Patient may return to work or school: ~ Yes, Date: S' ^ No, requires urt er follow-up EQUIPMENT/SUPPLIES Patient sent home with following equipment and supplies: SPECIAL INSTRUCTIONS RE~ PATIENT EDUCATION Yes given; ^ No; ^ Patient/Family needs further instruction on: ^ Provided smoking cessation instruction. USE P~ITIENT i~LATE UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER, 176 95-8 ~ SACRAMENTO, CALIFORNIA 20-980282994 ADM:06l26105 T~ o~,~MT rSAMUEL NURSES PROGRESS RECORD ~ V P V ETER E E, EDR gOKOLO TRUE MR~1 Special Instructions Continued REFERRALS PatienUFamily was referred to the following: (Please indicate the name of agency, if known) ^ CNS referral: ^ Home Health: ^ UC Davis Health System or ^ Other ^ Community Agency ^ Other: Phone number where patient can be reached: ~)~~-~ ~o r I understand the above instructions: atie UPatient Representative Signature Instructions Given By: Was an interpreter used ford "char a instructiori~? ^ If yes, Interpreter Signatur PATIENT BELONGINGS Belongings/valuables release slip given to patienUpatient representative: IMMUNIZATIONS (for children only) Immunization Card Given: R.N. Signature ^ Yes, No ^ Yes, ^ No, ~' NIA ^ Yes, ^ No~ N/A Date CAR SEAT INSTRUCTION N r Adult) California Law states that all children under the age of 6 years, or weighs g less than 60 pounds, be transported in a child passenger restraint system meeting federal vehicle safety requirements. 1 understand the instructions regarding car seats. a PatienUPatient Representative Signature Dafe of Discharge: ~'d Time: Condition upon Discharg Stable Discharge Iocation:.~Home, ^ Sub-Acu Discharged to whom, N me: child ~'m'1 b~~c-- ParenUGuardian Identification, if applicable ^ California Driver's License # _ ^ Other Photo ID # ,~ relationship must specify for infant or • NODMAR FORM COMPLETED: ^ Yes ^ No - ~ N/A _ ^ Other F ... CND1 ~k 20-96026299 •~ 176-95-8-1 PROBLEM LZST AS OF 06/1'i/us PT NAM E: TALHELM ,SAMUEL 4EN D7PA 7773#O1 ISOL: N ADMIT DRTE: 06/27/05 PT NO: 20-960262994 ADM DX: AUSTISTIC MALE MVA ENTERED - BY # PROBLEM STATUS STS UPDATE BY 06/27 HNFMS 4 ACUTE CARE TRAUMA PATIENT ACTIVE 06/27 HNFMS 06/27 HNFMS 3 COPING ACTIVE 06/27 HNFMS 06/27 HNFMS 2 KNOWLEDGE DEFICIT ACTIVE 06/27 HNFMS 06/27 HNFMS 1 DSCH PLAN: TO HOME ACTIVE 06/27 HNFMS NURSING RED RED RED RED CARE PLAN PROBLEM LIST RED RED RED RED NURSING 04 :. o/27/OS FROM D709,CPHPRHFI D7FC9962 >T NAME: TALHELM ,SAMUEL 9EN ADM DX: AUSTISTIC MALE MVA ?T NO. 20-960262994 D7PA 7773#O1 ADMIT DATE: 06/27/05 ISOL: N ___.tERED - BY ------------ PROBLEM RELATED TO ------- ---------- EVIDENCED HY STATUS 06/27 HNFMS 4 ACUTE CARE TRAUMA PATIENT MVA (MOTOR VEHICLE ACCIDENT) ------------ IAI ACTIVE 06/27 EO: PT DEMONSTRATES PHYSIOLOGICAL STABILITY 06/27 ACTIVE ORD# 23 MONITOR BOWEL SOUNDS 06/27 ACTIVE ORD# 22 NPO + 06/27 ACTIVE ORD# 21 Q4H BLD DRAWS(ALT CBC & H/H) +Q6 H LABS 06/27 ACTIVE 06/27 HNFMS 3 COPING CRISIS pF HOSPITALIZATION RESISTIVE BEHAVIOR ACTIVE 06/27 EO: PT DEMOS NORM DEVELPMNTL COPING STRATEGY 06/27 ACTIVE ORD# 20 ENC PLAY THERAPY/FREE PLAY 06/27 ACTIVE ORD# 19 PERFRM PROC IN TX ROOM (6M-6Y7 06/27 ACTIVE 06/27 HNFMS 2 KNOWLEDGE DEFICIT DX, TX MOC QUESTIONS ACTIVE 06/27 E0: UNDERSTANDS/DEMO: CARE OF TRAUMA PT 06/27 ACTIVE ORD# 18 EXPLAIN TX AND PROCEDURS 06/27 ACTIVE ORD# 17 SEE PATIENT EDUCATION RECORD RECORD TEACHING 06/27 ACTIVE 27 HNFMS 1 DSCH PLAN: TO HOME ACTIVE 06/27 EO: HCT STABLE 06/27 ACTIVE EO: TOTALLY DEPENDENT 06/27 ACTIVE NT' 'NG RED RED RED RED TOTAL CARE PLAN RED RED RED RED NURSING 04:24 06/27/05 FROM D709,CPHTCPFA D7FC9461 CNDI ** 1769581 ** FINAL PROBLEM LIST - PRIN'i'~u ~o~< - - - - - - - - .,.._ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PT NAME: TALHELM ,SAMUEL 9EN D7PA 7773#O1 ISOL: N ADMIT DATE: 06/27/05 PT NO: 20-960262994 - - - - - - - - - - - ADM DX: AUSTISTIC MALE MVA - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ENTERED - BY # - - - - - - - - - - - PROBLEM STATUS STS UPDATE BY 06/27 HNFMS 4 ACUTE CARE TRAUMA PATIENT RESOLVED 06/27 HPCCRW 06/27 HNFMS 3 COPING RESOLVED 06/27 HPCCRW 06/27 HNFMS 2 KNOWLEDGE DEFICIT RESOLVED 06/27 HPCCRW 06/27 HNFMS 1 DSCH PLAN: TO HOME RESOLVED 06/27 HPCCRW NURSING RED RED RED RED PROBLEM LIST-DISCHARGE RED RED RED RED NURSING 14: 6/27/05 FROM D707,CPHPRBFA D7FC9467 ~TD1 ** 20-960262994 ** 176-95-8-1 FINAL CARE PLAN -- PXlivrnu T NAME: TALHELM ,SAMUEL 9EN ADM DX: AUSTISTIC MALE MVA T N0: 'LO-960262944 D7PA 7773#O1 ADMIT DATE: 06/27/05 ISOL: N - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ~.:ERED - BY - - - - - - - - - - - - - - - - - PROBLEM RELATED TO EVIDENCED BY ------------ STATUS ------ ------------- 06/27 HNFMS ------- ---------- 4 ACUTE CARE TRAUMA PATIENT MVA (MOTOR VEHICLfi ACCIDENT} IAI RESOLV£ 06/27 06/27 HNFMS E0: PT DEMONSTRATES PHYSIOLOGICAL STABILITY D6/27 COMPLETE 06/27 HNFMS ORD# 23 MONITOR $OWEL SOUNDS 06/27 D/C 06/27 HNFMS ORD# 22 NPO + 06/27 D/C 06/27 HNFMS ORD# 21 Q4H SLD DRAWS(ALT CBC & H/H) +Q6 H LABS 06/27 D/C 06/27 HNFMS 3 COPING CRISIS OF HOSPITALIZATION RESISTIVE BEHAVIOR RESOLVE 06/27 06/27 HNFMS £0: PT DEMOS NORM DEVELPMNTL COPING STRATEGY 06/27 COMPLETE 06/27 HNFMS ORD# 20 ENC PLAY THERAPY/FREE PLAY 06/27 D/C 06/27 HNFMS ORD# 19 PERFRM PROC IN TX ROOM (6M-6Y) 06/27 D/C 06/27 HNFM3 2 KNOWLEDGE DEFICIT DX, TX MOC QUESTIONS RESOLVE D6/27 06/27 HNFMS EO: UNDERSTANDS/DEMO: CARE OF TRAUMA PT 06/27 COMPLETE 06/27 HNFMS ORD# 18 ERPLAIN TX AND PROCEDURS Ob/27 D/C 06/27 HNFMS ORD# 17 SEE PATIENT EDUCATION RECORD RECORD TEACHING 06/27 D/C 27 HNFMS 1 DSCH PLAN: .TO HOME RESOLVE 06/27 06/27 HNFMS EO: HCT STABLE 06/27 COMPLETE 06/27 HNFMS EO: TOTALLY DEPENDENT 06,/27 COMPLETE N~' 'NG RED RED RED RED FINAL CARE PLAN RED RED RED RED NURSING 14:57 06/27/05 FROM D707,CPHFCPFA D7FC9466 CND1 ** 17695p1 * 20-960262994 *FINAL CARE PLAN-CARE PROVIDERS -- PRINTED 06/27/05 CHART COPY PT NAME: TALEELM ,SAMUEL 9EN PT NO: 20-960262994 SIGNON NAME SZGNON NAME ------ ------------------------- ------ ------------------------- 00000 STAFF DOCTOR, 05956 SOICOLOVE, PETER E EARCLN EMERGENCY MEDICINE CLINIC HNFMS MICHELE L. SANCHE2 HPCCRW INDY R. WYNHOFF,RN NURSING RED RED RED RED CARE PROVIDER-DISCHARGE RED RED RED RED NURSING 14:57 06/27/05 FROM D707,CPHPRVFA D7FC9468 Opp . f kE~ ?H ~.. t ~. k fi t~21tiI /1880~.~. ~ ~ eL Cat} !~ s t€ ~ ~l'~` 1~ I` F: ~ =,. ~~., »~ _ < ~ ~`'~/t 5~'9? ~- A WL„ DGf#1UIENT40F RECEIPT: ' 1 ?--4615- "~' I ~ CE~ls ~ L E T ~ >'E E C~ I- C 1- L E PRIVACY PRACTICES r.. ~_ .., The UC Davis Health System Notice ofi Privacy: -Practices provides information about how we may use and ~~ _ disclose protected health information about-you. In addition to the copy we are providing you, copies of the current notice are available by accessing our Web site at http://web.ucdmc.ucdavis.edu/compliance/ and may be obtained throughout UC Davis Health System. I acknowledge that 1 have received the Notice of Privacy Practices. of Patient or Patient's Representative ~~~ Date IL Print Name Relat~i ship to Patient interpreter (if applicable) -------------------------------------------------------------------------------------------- Written Acknowledgement Not Obtained Please document your efforts to obtain acknowledgment and reason it was not obtained. ^ Notice of Privacy Practices Given -Patient Unable to Sign ^ Notice of Privacy Practices Given -Patient Declined to Sign ^ Notice of Privacy Practices Mailed to Patient -Awaiting Signature ^ Other Reason Patient Did Not Sign Signature of UC Davis Health System Representative Print Name Date Department 70000-789 {3103) ACKNOWLEDGEMENT OF RECEIPT: NOTICE OF PRIVACY PRACTICES MR 0310 - ~~~.~~~.~ s ~~~~~~~ ~~~¢ ~ ~~'~ _•~~-~~~~"Ii. ~ ~ s~ ,~ UNIVERI'Ty'~F CALIFORNIA DAVIS ~ j~ ~JSE TNT ~'~ ~ t:;~t ~ ~~, f ~2 ~'~ r$~0 -~7~ K . ~ HEALTH SYSTEM .$ ~~ - 7 _ .~ TEF~M D CONDITIONS, QF SERVICE 4 t 7. FINANCIAL AGREEMENT: 1 agree to pay The Regents of the University of California for professional, hospital and clinic services, including UCDHS physician services, in accordance with the regular rates and terms of UCDHS. i also agree to pay for other professional services provided by other physicians at UCDHS. When this agreement is signed by my spouse, parent or a financial guarantor, my spouse, parent or financial guarantor shall be jointly and individually liable with me for payment, including all collection fees (attorney's fees, costs and collection expenses), in addition to any other amounts due. Unpaid accounts referred to outside agencies for collection bear interest at the then current legs( rate. 8. ASSIGNMENT OF BENEFITS (INCLUDING MEDICARE BENEFITS): I authorize and direct the payment to UCDHS of any insurance benefits including hospital insurance and unemployment compensation disability benefits otherwise payable to or on my behalf for UCDHS services, including emergency services, at a rate not to exceed UCDHS' actual charges. I understand that I am financially responsible for charges not paid pursuant to this agreement. I further certify that the information given in applying for payment under the Medicare or Medi-Cal programs is correct. I further agree that any credit balance resulting from payment of insurance or other sources may be applied to any other account owed to UCDHS by me. 9. ADVANCE DIRECTIVES: i have an advance directive for health care {e.g., Power of Attorney for Health I have provided UCDHS with a current copy of my advance directive If "No", I understand it is my responsibility to provide UCDHS a current directive. If I want to express my health care wishes, I understand 1 should care provider. Care) ^ Yes ^ No 0 Yes ^ No copy of my advance speak with my health 10. PATIENT RIGHTS NOTICE: would like UCDHS to provide my next of kin or agent with the Patients Rights Notice ^ Yes ^ Nc I have read, agreed to and received a copy of this "Terms and Conditions of Service." ignature o anent i Patien s prese five ,N1~4 ~ 1 Rel lohship of Representative to Patient igna e f it ss (required if patie ble to sign) Signature of Interpreter (if applicable) Date of igning For office use only: EXCEPTIONAL SIGNATURE REQUIREMENTS ARE REFERENCED BELOW. Please check the appropriate box(es) ^ PATIENT IS LEGALLY INCOMPETENT TO SIGN: The court approved guardian or conseroatcr, the attorney-in-fact under a Durable Power of Attorney for Health Care, or family member or other appropriate surrogate must sign as "Patient's Representative ^ PATIENT IS PHY5ICALLY INCAPABLE OF SIGNING: The patient should give verbal consent, witnessed by a UCDHS employee. The "Patient's Represen- tative" should sign in wtness of the patient having given verbal consent, The UCDHS employee witness shall also sign. 71463-257(6/03} TERMS AND CONDITIONS OF SERVICE Page 2 0 "~ TERMS AND_CONpITIONS OF SERVICE- ~'' 1. UCDHS: The UC Davis Health Sysfer~t (~UC~h~S) is' part of the University of California and is comprised of the UCDHS Medical Center, its hospital-based;: clinics,< thy- Primary"Car~e Network clinics, the UCDHS Davis Medical Graup, and the UCDHS Schaol of Medicrr~e~:: ~ w - 2. MEDICAL CONSENT: ! cansent to any medical treatments or procedures .(except for complex procedures which require .:;special consent}, X-ray examinations, drawing blood for tests; medications, injections, taking of medical photographs, videotaping, laboratory procedures, and hospital services rendered to me under the general and special instructions of the attending physicians or other physicians of UCDHS assisting in my care. !also consent to my admission to UCDHS Medical Center if this is deemed necessary far my care. Al{ of the terms and conditions of this agreement shall also apply to such admission. 3. RELEASE OF INFORMATION: UCDHS will obtain my written authorization to release information about my medical treatment, except in those circumstances tiRrhen UCDHS is permitted or required by law to release information (see UCDHS' Notice of Privacy Practices for a description of the specific.. circumstances under which UCDHS may release this information}. For example, UCDHS may release a .copy of my patient record to insurance companies, health care service plans, governmental. agencies, workers' compensation carriers, or other entities which may be liable for all or any portion of UCDHS' charges. 4. TEACHING, RESEARCH -AND HEALTHCARE INSTITUTION: The University of California, including UCDHS, is a teaching, research and healthcare institution. I understand that residents, interns, medical students, students of ancillary health care .professions (e.g., nursing, x-ray, rehabilitation therapy), post-graduate fe1(ows, and other trainees may observe, examine, treat.. and participate at the request and. under the supervision of the attending physician in my care as part of the--University's medical education programs. I understand that. my health information may be used and shared with:- researchers who engage in .research related to my treatment, health condition, or medical , or physical status..1 further understand that the University: of California,. including UCDHS, may use my medical information and specimens for teaching, study and research purposes, including the development of potentially commercially useful products. Any use of these materials and information by UCDHS or other institutions will be in accordance with state -and .federal law, including all laws and regulations governing confidentiality of patient records. 5. PERSONAL VALUABLES: UCDHS maintains fireproof safes for the safekeeping of money and valuables. UCDHS shall not be liable for the lass of or damage to any money, jewelry, glasses, dentures, furs or other articles of unusual value and shall not be. liable for loss or damage to any personal property, unless deposited in UCDHS' safe or locked storeroom. 6. USE AND DISCLOSURE Ot= MEDICAL INFORMATION: The State of California Information Practices Act requires UCDHS to provide the following information to individuals who supply information about themselves: As a patient of UCDHS, you will be asked to submit information about yourself, such as your address any phone number, Social Security number, insurance information, medical history and treatment, and other personal information. The principal purpose for requesting this information is to ensure accurate identification, continuity of medical care, and payment for such care. University policy and California and federal taw and regulations authorize the maintenance of this information. Furnishing all information requested is mandatory unless otherwise- noted. Failure to provide such information may affect your medical care and/or insurance benefits and coverage. The information you provide may be disclosed to others, as described in our Notice of Privacy Practices. You have the right to review your medical information and the right to request restriction of access to your medical information, as described in the Notice of Privacy Practices. 7-~a~~-~~7(6/03ti TERMS ~ItiD CONBITfONS t~F SERVICE Par-~o -f of 3 LAW OFFICES OF DICKIE, MCCAMEY & CHILCOTE, P.C. 1200 CAMP HILL BYPASS SUITE 205 CAMP HILL, PENNSYLVANIA 17011-3700 TEL. 717-731-4800 FAx. 717-731-4803 WWW.DMCLAW.COM Misty D. Lehman Paralegal Carlisle Pediatric Associates 804 Belvedere St. Carlisle, PA 17013 RE: Samuel Possenti Talhelm DOB: 9/15/97 SS#: 285-02-9762 DOA: 6/ ~!Ai~~,, ~ Our File No . FF-168 ,~ Dear Medical Records Clerk: Q~~ecn{ o ~ b~tAo S ~~ mlehman@dmclaw.com Enclosed please find an executed authorization allowing us to obtain the records and films of Samuel Possenti Talhelm. Kindly forward his entire medical record chart from before 06/26/05, to the current date. Please be sure to include: • Any/all hospital admissions including consultation reports, discharge summaries, radiology reports, nurses notes, doctors notes, and history and physical, etc. • Any/all doctor's office visits, including all bills • Any/all medical reports you may have in your file pertaining to this patient. • Please note that this medical authorization will expire after one year from the date this patient has signed the release. • These records are required for the specific purpose of legal investigation Please forward his medical records as soon as possible directly to my attention. Of course we wiii reimburse you for aii reasonable copying fees that apply. In the meantime, should you have any questions, please feel free to contact me. June 23, 2006 Very truly yours, DICHIE, MCCAMEY & CHILCOTE, P.C. Misty D. Lehman Enclosures ~` 1, S i~ PITTSBURGH + PHILADELPHIA + WASHINGTON. D.C. + NEW JERSEY ~ NORTH CAROLINA ~ OHIO ~ WEST VIRGINIA 412-281-7272 215-925-2289 888-434-5566 856-354-0192- 704-334-1108 740-284-1682 304-233-1022 ~r rv, i, o l I n l ~.. ,. ~ .,. "l~-5 -05 J - / IJ~.i - 1 ~ ~ ~- - o HeAO - E~ NOSE THROAT LUNC~.S ~-- HEART QEM: EXTR SKIN `~ NN U P'I.IJV: ~~--- ~~~ _ - ~~ GZEMEF~,4.L HEAD E~Y~:a ..__... -- ~- -~r- 1---_..,_,.. __ ~ ~ `. RR~~ JJ LUIS-.;4 -- ABD -. _ / _...i.. NEURO. SKM a" - 30 -v 5- -. ~ ~ a A M. i a ~,. Y `~ l ~~'.7 "il'l ~ n U M- ;. ~ ~ ~~~ n-~ . c_ ~~ ~., << ~~~f cr L -~-~ !~ ~ 0 HEAL? -__..- __-.-- EARS __ MOSS ---•-~ -- ..__...~_._~__ THROAT _. .--"-- _ 7 .. _ ..._.._ Ultdt39 ----- -.--- ; HEART ANT. i EXTR'EM S6ltN N• ~~' ~ ~ Iti .r ~ 2 -- ~~- C ., WY` ~ ttG ~S~~e ,. IMP' HR ~`' C 4 - d ~ ~~ V ~~--~~ppQQ -VH'f3 ~~ ~~_" ~~ (~ THRROAT ~-- LUNG HEART •~ ~ ~~ i ~\ u EXTREIiA ~~ .~ ti - ~ IN 'r GEP!EF1AL - ~ _ ~_ Fi~D ~r_s Nosy ~-- N~cx LUNG ABD NEURO. i _ ~ ~~_,3.OL ~ w 1 ~ ,~ /J' i PROGRESS RECORD ~ . )t, )G ~ ~~ r~ ~ ~ 9 -(5~ ~x~, b.+ N GENERAL RELEASE AGREEMENT OF MINOR'S COMPROMISE FOR SAMUEL TALHELM KNOW ALL MEN BY THESE PRESENTS that I, Michele Possenti and Kevin Talhelm, as parents and natural guardians of, Samuel Talhehn, a minor, for the sole consideration of One Thousand Dollars ($1,000) to us in hand paid by VICTOR YANTAS LEON and FARMERS INSURANCE COMPANY, Payers, the receipt whereof is hereby acknowledged, have released and discharged, and by these presents do for myself, my heirs, executors, administrators and assigns release and forever discharge the said Payers, their insurance companies and all other persons, firms and corporations, both known and unknown, its heirs, executors, administrators, affiliates, successors and assigns, of and from any and all claims, demands, damages, actions, causes of action, or suits at law or equity, of whatsoever kind or nature, for or because of any matter or thing done, omitted or suffered to be done by anyone prior to and including the date thereof on account of known or unknown injuries, losses and damages allegedly sustained by Michele Possenti and Kevin Talhehn, as parents and natural guardians of, Samuel Talhehn, a minor, arising out of damages allegedly sustained in relation to a motor vehicle accident occurring on or about June 26, 2005. This agreement and release is at all times intended to be consistent with the terms of the Petition for Leave to Compromise Minor's Action filed with the Cumberland County Court and resulting Court Order approving the minor's compromise for $1,000.00 which are collectively attached hereto as an Exhibit. We understand that Payers, by reason of agreeing to this compromise payment, neither admit nor deny liability of any sort, and said Payers have made no agreement or promise to do or omit to do any act or thing not herein set forth and we further understand that this Release is made as a compromise to avoid expense and to terminate all controversy and/or claims for injuries or damages of whatsoever nature, known or unknown, including future developments thereof, in any way growing out of or connected with said incident. We admit that no representation of fact or opinion has been made by the said Payers or anyone on its behalf to induce this compromise with respect to the extent or nature of damages and that the sum paid is solely by way of compromise of a disputed claim, and that it is specifically agreed that this Release shall be a complete bar to all claims or suits for losses of whatsoever nature resulting or to result from said incident. It is further understood and agreed that this is the complete Release Agreement and that there are no written or oral understandings or agreements, directly or indirectly, connected with this Release and settlement which are not incorporated herein. This Agreement shall be binding upon and inure to the successors, assigns, heirs, executors, administrators and legal representatives of the respective parties hereto, including, Michele Possenti and Kevin Talhehn, as parents and natural guardians of, Samuel Talhehn, a minor. It is further understood and agreed and made a part hereof that neither the undersigned Plaintiffs nor any of their attorneys, agents or other representatives, will in any way divulge to any person whatsoever or publicize or cause to be publicized in any news or communications media, including but not limited to, newspapers, magazines, journals, radio or television, the facts, terms or conditions of this Release and settlement. All parties to this Agreement expressly agree to decline comment on any aspect of the Release and settlement to any member of the news media. This paragraph is intended to become part of the consideration for the settlement of this claim. It is further understood and agreed that we, the undersigned, are responsible for the payment of any lien or charges against this settlement sum. Should any person or entity make a claim for 2 payment of any liens or charges against Payers, its attorneys, agents, servants, and/or employees, we hereby agree to indemnify and hold harmless Payers, its attorneys, agents, servants, and/or employees from any and all liens, charges, fees, costs, interest, demands, and any and all other sums, including payment of all costs and attorneys fees. The undersigned hereby declare for themselves that the terms of this settlement have been completely read, fully understood, and voluntarily accepted for the purpose of making a full and final compromise, adjustment and settlement of any and all claims on account of the injuries and damages mentioned above, and for the express purpose of precluding forever any further or additional suits arising out of the aforesaid claims. IN WITNESS WHEREOF, I have hereunto set my hand this day of 2007. In the presence of Witness CAUTION: READ BEFORE SIGNING Witness Michele Possenti, as parent and natural guardian of Samuel Talhelm Kevin Talhehn, as parent and natural guardian of Samuel Talhelm 3 f7 ~Xh; b GENERAL RELEASE AGREEMENT OF MINOR'S COMPROMISE FOR JACK TALHELM KNOW ALL MEN BY THESE PRESENTS that I, Michele Possenti and Kevin Talhelm, as parents and natural guardians of, Jack Talhelm, a minor, for the sole consideration of One Thousand Dollars ($1,000) to us in hand paid by VICTOR YANTAS LEON and FARMERS INSURANCE COMPANY, Payers, the receipt whereof is hereby acknowledged, have released and discharged, and by these presents do for myself, my heirs, executors, administrators and assigns release and forever discharge the said Payers, their insurance companies and all other persons, firms and corporations, both known and unknown, its heirs, executors, administrators, affiliates, successors and assigns, of and from any and all claims, demands, damages, actions, causes of action, or suits at law or equity, of whatsoever kind or nature, for or because of any matter or thing done, omitted or suffered to be done by anyone prior to and including the date thereof on account of known or unknown injuries, losses and damages allegedly sustained by Michele Possenti and Kevin Talhelm, as parents and natural guardians of, Jack Talhelm, a minor, arising out of damages allegedly sustained in relation to a motor vehicle accident occumng on or about June 26, 2005. This agreement and release is at all times intended to be consistent with the terms of the Petition for Leave to Compromise Minor's Action filed with the Cumberland County Court and resulting Court Order approving the minor's compromise for $1,000.00 which are collectively attached hereto as an Exhibit. We understand that Payers, by reason of agreeing to this compromise payment, neither admit nor deny liability of any sort, and said Payers have made no agreement or promise to do or omit to do any act or thing not herein set forth and we further understand that this Release is made as a compromise to avoid expense and to terminate all controversy and/or claims for injuries or damages of whatsoever nature, known or unknown, including future developments thereof, in any way growing out of or connected with said incident. We admit that no representation of fact or opinion has been made by the said Payers or anyone on its behalf to induce this compromise with respect to the extent or nature of damages and that the sum paid is solely by way of compromise of a disputed claim, and that it is specifically agreed that this Release shall be a complete bar to all claims or suits for losses of whatsoever nature resulting or to result from said incident. It is further understood and agreed that this is the complete Release Agreement and that there are no written or oral understandings or agreements, directly or indirectly, connected with this Release and settlement which are not incorporated herein. This Agreement shall be binding upon and inure to the successors, assigns, heirs, executors, administrators and legal representatives of the respective parties hereto, including, Michele Possenti and Kevin Talhehn, as parents and natural guardians of, Jack Talhehn, a minor. It is further understood and agreed and made a part hereof that neither the undersigned Plaintiffs nor any of their attorneys, agents or other representatives, will in any way divulge to any person whatsoever or publicize or cause to be publicized in any news or communications media, including but not limited to, newspapers, magazines, journals, radio or television, the facts, terms or conditions of this Release and settlement. All parties to this Agreement expressly agree to decline comment on any aspect of the Release and settlement to any member of the news media. This paragraph is intended to become part of the consideration for the settlement of this claim. It is further understood and agreed that we, the undersigned, are responsible for the payment of any lien or charges against this settlement sum. Should any person or entity make a claim for 2 payment of any liens or charges against Payers, its attorneys, agents, servants, and/or employees, we hereby agree to indemnify and hold harmless Payers, its attorneys, agents, servants, and/or employees from any and all liens, charges, fees, costs, interest, demands, and any and all other sums, including payment of all costs and attorneys fees. The undersigned hereby declare for themselves that the terms of this settlement have been completely read, fully understood, and voluntarily accepted for the purpose of making a full and final compromise, adjustment and settlement of any and all claims on account of the injuries and damages mentioned above, and for the express purpose of precluding forever any further or additional suits arising out of the aforesaid claims. IN WITNESS WHEREOF, I have hereunto set my hand this day of 2007. In the presence of: Witness CAUTION: READ BEFORE SIGNING Witness Michele Possenti, as parent and natural guardian of Jack Talhehn Kevin Talhelm, as parent and natural guardian of Jack Talhelm 3 GENERAL RELEASE AGREEMENT OF MINOR'S COMPROMISE FOR PAIGE TALHELM KNOW ALL MEN BY THESE PRESENTS that I, Michele Possenti and Kevin Talhelm, as parents and natural guardians of, Paige Talhehn, a minor, for the sole consideration of Ten Thousand Dollars ($10,000) to us in hand paid by VICTOR YANTAS LEON and FARMERS INSURANCE COMPANY, Payers, the receipt whereof is hereby acknowledged, have released and discharged, and by these presents do for myself, my heirs, executors, administrators and assigns release and forever discharge the said Payers, their insurance companies and all other persons, firms and corporations, both known and unknown, its heirs, executors, administrators, affiliates, successors and assigns, of and from any and all claims, demands, damages, actions, causes of action, or suits at law or equity, of whatsoever kind or nature, for or because of any matter or thing done, omitted or suffered to be done by anyone prior to and including the date thereof on account of known or unknown injuries, losses and damages allegedly sustained by Michele Possenti and Kevin Talhelm, as parents and natural guardians of, Paige Talhelm, a minor, arising out of damages allegedly sustained in relation to a motor vehicle accident occurring on or about June 26, 2005. This agreement and release is at all times intended to be consistent with the terms of the Petition for Leave to Compromise Minor's Action filed with the Cumberland County Court and res ltin~ Court Order aaaroving the minor's compromise for $10,000.00 which are collectively attached hereto as an Exhibit. We understand that Payers, by reason of agreeing to this compromise payment, neither admit nor deny liability of any sort, and said Payers have made no agreement or promise to do or omit to do any act or thing not herein set forth and we further understand that this Release is made as a compromise to avoid expense and to terminate all controversy and/or claims for injuries or damages of whatsoever nature, known or unknown, including future developments thereof, in any way growing out of or connected with said incident. We admit that no representation of fact or opinion has been made by the said Payers or anyone on its behalf to induce this compromise with respect to the extent or nature of damages and that the sum paid is solely by way of compromise of a disputed claim, and that it is specifically agreed that this Release shall be a complete bar to all claims or suits for losses of whatsoever nature resulting or to result from said incident. It is further understood and agreed that this is the complete Release Agreement and that there are no written or oral understandings or agreements, directly or indirectly, connected with this Release and settlement which are not incorporated herein. This Agreement shall be binding upon and inure to the successors, assigns, heirs, executors, administrators and legal representatives of the respective parties hereto, including, Michele Possenti and Kevin Talhelm, as parents and natural guardians of, Paige Talhelm, a minor. It is further understood and agreed and made a part hereof that neither the undersigned Plaintiffs nor any of their attorneys, agents or other representatives, will in any way divulge to any person whatsoever or publicize or cause to be publicized in any news or communications media, including but not limited to, newspapers, magazines, journals, radio or television, the facts, terms or conditions of this Release and settlement. All parties to this Agreement expressly agree to decline comment on any aspect of the Release and settlement to any member of the news media. This paragraph is intended to become part of the consideration for the settlement of this claim. It is further understood and agreed that we, the undersigned, are responsible for the payment of any lien or charges against this settlement sum. Should any person or entity make a claim for 2 payment of any liens or charges against Payers, its attorneys, agents, servants, and/or employees, we hereby agree to indemnify and hold harmless Payers, its attorneys, agents, servants, and/or employees from any and all liens, charges, fees, costs, interest, demands, and any and all other sums, including payment of all costs and attorneys fees. The undersigned hereby declare for themselves that the terms of this settlement have been completely read, fully understood, and voluntarily accepted for the purpose of making a full and final compromise, adjustment and settlement of any and all claims on account of the injuries and damages mentioned above, and for the express purpose of precluding forever any further or additional suits arising out of the aforesaid claims. IN WITNESS WHEREOF, I have hereunto set my hand this day of 2007. CAUTION: READ BEFORE SIGNING In the presence of Witness Witness Michele Possenti, as parent and natural guardian of Paige Talhelm Kevin Talhelm, as parent and natural guardian of Paige Talhelm 3 ~ ~ ''Q ~... ~ ~ ,. ., . V "''Q ~ - [J t ~ 1 - - r ,,, ~ -r-t C~f i --~ i 'i7~-j ~~ } ~ "`P r '~ ~.. ~~ ` ~ J ITl -.y ~ .~ ~.~ MICHELE POSSENTI AND IN THE COURT OF COMMON PLEAS KEVIN TALHELM AS PARENTS AND NATURAL OF CUMBERLAND COUNTY, PENNA. GUARDIANS OF PAIGE TALHELM, A MINOR, JACK TALHELM, A MINOR AND SAMUEL TALHELM, A MINOR DOCKET NO: 0'`l - ~' f („~' ~~ ~ ~~~ Plaintiffs v. VICTOR YANTAS LEON . Defendant ORDER AND NOW, this ~ ` day of /-I,~r~ , 2007, upon consideration of the Petition for Approval of Minor's Settlement, it is hereby ordered and decreed that the Petitioners, as parents and natural guardians of Samuel Talhelm are authorized to enter into a settlement in the gross sum of $1,000. Petitioners are authorized to sign a release and mark the matter settled, discontinued and ended as to the above Defendant. The settlement amount shall be distributed as follows: TO: Michele Possenti and Kevin Talhelm, as Parents and Natural Guardians of Samuel Talhelm, to be deposited into a restricted federally insured account, "No Withdrawals Prior to Age 18, without prior court approval. " TOTAL AMOUNT FOR DISTRIBUTION ~ 1,000 Counsel shall provide to this Court, within 30 days of the date of this ORDER proof of such deposit. _ ~G%' // BY THE COURT: ~ ~,p" P~~~ a-~ l ~~ MICHELE POSSENTI AND IN THE COURT OF COMMON PLEAS KEVIN TALHELM AS PARENTS AND NATURAL OF CUMBERLAND COUNTY, PENNA. GUARDIANS OF PAIGE TALHELM, A MINOR, JACK TALHELM, A MINOR AND SAMUEL TALHELM, A MINOR DOCKET NO: ~''l - ~'?'(,S l.. t v~C,~~ \ Plaintiffs v. VICTOR YANTAS LEON Defendant ORDER AND NOW, this ~~ day of F~ ~! , 2007, upon consideration of the Petition for Approval of Minor's Settlement, it is hereby ordered and decreed that the Petitioners, as parents and natural guardians of Paige Talhelm are authorized to enter into a settlement in the gross sum of $10,000. Petitioners are authorized to sign a release and mark the matter settled, discontinued and ended as to the above Defendant. The settlement amount shall be distributed as follows: TO: Michele Possenti and Kevin Talhelm, as Parents and Natural Guardians of Paige Talhelm, to be deposited into a restricted federally insured account, "No Withdrawals Prior to Age 18, without prior court approval. " TOTAL AMOUNT FOR DISTRIBUTION ~ 10,000 Counsel shall provide to this Court, within 30 days of the date of this ORDER proof of such deposit. BY THE COURT: ~ ~ ,t ~~ ,1 ,..i l.~._.~,..., l.., V.7 ti MICHELE POSSENTI AND KEVIN TALHELM AS PARENTS AND NATURAL GUARDIANS OF PAIGE TALHELM, A MINOR, JACK TALHELM, A MINOR AND SAMUEL TALHELM, A MINOR Plaintiffs v. VICTOR YANTAS LEON . Defendant IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNA. DOCKET NO: C~ ~' ~ '?ls..~ ~l u ~ l ,~~.2. '''~ ORDER AND NOW, this Q" day of ~~ ~ , 2007, upon consideration of the Petition for Approval of Minor's Settlement, it is hereby ordered and decreed that the Petitioners, as parents and natural guardians of Jack Talhelm are authorized to enter into a settlement in the gross sum of $1,000. Petitioners are authorized to sign a release and mark the matter settled, discontinued and ended as to the above Defendant. The settlement amount shall be distributed as follows: TO: Michele Possenti and Kevin Talhelm, as Parents and Natural Guardians of Jack Talhelm, to be deposited into a restricted federally insured account, "No Withdrawals Prior to Age 18, without prior court approval. " TOTAL AMOUNT FOR DISTRIBUTION ~ 1,000 Counsel shall provide to this Court, within 30 days of the date of this ORDER proof of such deposit. c O ~~ BY THE COURT: ~ i I ,. F c MICHELE POSSENTI AND KEVIN TALHELM AS PARENTS AND NATURAL GUARDIANS OF PAIGE TALHELM, A MINOR, JACK TALHELM, A MINOR AND SAMUEL TALHELM, A MINOR Plaintiffs v. VICTOR YANTAS LEON Defendant IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNA. DOCKET NO: 07-1765 Civil Teram PROOF OF DEPOSIT The Court approved three separate petitions for Court Approval of Minor's Compromise which were filed on Apri19, 2007 and entered the following Orders, copies of which are attached hereto. 1. Order approving minor's compromise of Paige Talhelm in the amount of $10,000; 2. Order approving minor's compromise of Samuel Talhelm in the amount of $1,000; and 3. Order approving minor's compromise of Jack Talhelm in the amount of $1,000. Pursuant to the aforementioned Court Orders, proof of deposit into a restricted federally attached hereto. 4. Proof of Deposit, Paige Talhelm, $10,000; insured account prohibiting withdrawls prior to the age of 18 without court approval, are 5. Proof of Deposit, Samuel Talhelm, $1,000; and 6. Proof of Deposit, Jack Talhelm, $1,000. Date: May 11, 2007 Respectfully submitted, DICHIE, MCCAMEY & CHILCOTE, P.C. Charles E. addidlc; Jr., Esquire Attorney I . No: 55666 Jason P. icholl, Esquire Attorney I. . No: 89062 1200 Camp Hill Bypass Suite 205 Camp Hill, PA 17011 Tele: (717) 731-4800 Counsel for Defendant 115669 CERTIFICATE OF SERVICE AND NOW, May 11, 2007, I, Misty Lehman, hereby certify that I did serve a true and correct copy of the foregoing PROOF OF DEPOSIT upon all unrepresented parties of record by depositing, or causing to be deposited, same in the U.S. mail, postage prepaid, at Camp Hill, Pennsylvania, addressed as follows: By First-Class Mail: Kevin Talhelm 7 Todd Road Carlisle, PA 17013 Michele Possenti 113 Woodview Drive Mt. Holly Springs, PA 17065 Date: May 11, 2007 isty Le an 2 f ~~~ MICHELE POSSENTI AND KEVIN TALHELM AS PARENTS AND NATURAL GUARDIANS OF PAIGE TALHELM, A MINOR, JACK TALHELM, A MINOR AND SAMUEL TALHELM, A MINOR Plaintiffs v. VICTOR YANTAS LEON Defendant IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNA. DOCKET NO: V ~~ ~ 1 C~ ORDER AND NOW, this day of , 2007, upon consideration of the Petition for Approval of Minor's Settlement, it is hereby ordered and decreed that the Petitioners, as parents and natural guardians of Paige Talhelm are authorized to enter into a settlement in the gross sum of $10,000. Petitioners aze authorized to sign a release and mark the matter settled, discontinued and ended as to the above Defendant. The settlement amount shall be distributed as follows: TO: Michele Possenti and Kevin Talhelm, as Parents and Natural Guardians of Paige Talhelm, to be deposited into a restricted federally insured account, "No Withdrawals Prior to Age 18, without prior court approval. " TOTAL AMOUNT FOR DISTRIBUTION ~ 10,000 Counsel shall provide to this Court, within 30 days of the date of this ORDER proof of such deposit. BY THE OURT: • J. . ~ ~ ~~ ~ MICHELE POSSENTI AND KEVIN TALHELM AS PARENTS AND NATURAL GUARDIANS OF PAIGE TALHELM, A MINOR, JACK TALHELM, A MINOR AND SAMUEL TALHELM, A MINOR Plaintiffs v. VICTOR YANTAS LEON Defendant IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNA. DOCKET NO: ~'`l -- (' f (~' e~ ~ ~~~ ORDER AND NOW, this ~ ` day of /a,•,r ~ , 2007, upon consideration of the Petition for Approval of Minor's Settlement, it is hereby ordered and decreed that the Petitioners, as pazents and natural guazdians of Samuel Talhelm aze authorized to enter into a settlement in the gross sum of $1,000. Petitioners aze authorized to sign a release and mark the matter settled, discontinued and ended as to the above Defendant. The settlement amount shall be distributed as follows: TO: Michele Possenti and Kevin Talhelm, as Pazents and Natural Guardians of Samuel Talhelm, to be deposited into a restricted federally insured account, "No Withdrawals Prior to Age 18, without prior court approval. " TOTAL AMOUNT FOR DISTRIBUTION ~ 1,000 Counsel shall provide to this Court, within 30 days of the date of this ORDER proof of such deposit. BY THE COURT: ~ 3 ., ~ooz e t aea ~~'g MICHELE POSSENTI AND IN THE COURT OF COMMON PLEAS KEVIN TALHELM AS PARENTS AND NATURAL OF CUMBERLAND COUNTY, PENNA. GUARDIANS OF PAIGE TALHELM, A MINOR, JACK TALHELM, A MINOR AND SAMUEL TALHELM, A MINOR DOCKET NO: O'1 -17L,5` ~u ` C~rdL,,~ Plaintiffs v. VICTOR YANTAS LEON Defendant ORDER AND NOW, this day of , 2007, upon consideration of the Petition for Approval of Minor's Settlement, it is hereby ordered and decreed that the Petitioners, as pazents and natural guardians of Jack Talhelm are authorized to enter into a settlement in the gross sum of $1,000. Petitioners aze authorized to sign a release and mark the matter settled, discontinued and ended as to the above Defendant. The settlement amount shall be distributed as follows: TO: Michele Possenti and Kevin Talhelm, as Pazents and Natural Guardians of Jack Talhelm, to be deposited into a restricted federally insured account, "No Withdrawals Prior to Age 18, without prior court approval. " TOTAL AMOUNT FOR DISTRIBUTION .~ 1,000 Counsel shall provide to this Court, within 30 days of the date of this ORDER proof of such deposit. o 1 r t.: [:7 [~i i x; ~_..; i.,r.. t° 3 r."; ,'1' ~~. L'. s° Y,? rr~ }:7 ~~ r.~ t r„r~ .rra eY '~,~ ~'~ r- ,' b ci, ;p.;q ~ d ~ 7 U O~ 6 ~ Q ~ m N z ~ C m m 9 z~ ~ 00 2 ~ O r m v m U m Y N G d Z d ~ .~ m m Q Q '~ T O A 4 ~s C N a a ~° 0 oU W N l6 ~_ ~ i ~ ~ E o ~ W .N O ~ aU ~ m ~ av o a iV -~ m ~_~ r G ~ Z ~ y ~ d C t/i = O 3 -~ o ti o '$ a a d a z c U CL ~ d p 4 ~Vi } N y N O Ng~ _ O r a t ~ F & M Trust P.O. Box 6010 Chambersburq, PA 17201-6010 OWNERSHIP OF ACCOUNT -PERSONAL PURPOSE ^ INDIVIDUAL ^ ^ JOINT -WITH SURVIVORSHIP land not as tenants in eommon) ^ JOINT - NO SURVIVORSHIP (as Unants in oommonl ^ TRUST -SEPARATE AGREEMENT: ^ REVOCABLE TRUST DESIGNATION AS DEFINED IN THIS AGREEMENT Name and Address of Beneficiaries: OWNERSHIP OF ACCOUNT -BUSINESS PURPOSE ^ SOLE PROPRIETORSHIP ^ CORPORATION: ^ FOR PROFIT ^ NOT FOR PROFIT ^ PARTNERSHIP BUSINESS: COUNTY & STATE OF ORGANIZATION: AUTHORIZATION DATED: DATE OPENED 05/11/2007 BY 172 INITIAL DEPOSITS 10.000 • 00 ^ CASH ^ CHECK ^ HOMETELEPHONEM 717-486-5092 BUSINESS PHONE # 717-486-5092 DRIVER'S LICENSE # E-MAIL EMPLOYER MOTHER'S MAIDEN NAME Name and address of someone who will always know your location: _ BACKUP WITHHOLDING CERTIFICATIONS TIN: 199-72-2463 ~ TAXPAYER I.D. NUMBER - The Taxpayer Identification Number shown above (TIN) is my correct taxpayer identification number. ~ BACKUP WITHHOLDING - I am not subject to backup withholding either because I have not been notified that I am subject to backup withholding as a result of a failure to report all interest or dividends, or the Internal Revenue Service has notified me that I am no longer subject to backup withholding. ^ EXEMPT RECIPIENTS - I am an exempt recipient under the Internal Revenue Service Regulations. SIGNATURE: 1 certify under penalties of pery'ury the statements checked in this :action and that I am a U.S. person (including s U.S. rosident alienl. .~. _ ,-. n ,, n i A sr _ _ . X1992 Banken slams, Ina., St. Cloud; MN Form MPSC-lA2-PA 11/22/2000 ACCOUNT 71-06203 NUMBER ACCOUNT OWNERISI NAME & ADDRESS PAIGE LEE TALHELM BENEF PAUTM MICHELE A POSSENTI CUSTODIAN 113 WOODVIEW DRIVE (MOUNT HOLLY SPRINGS PA 17065 gK NEW ^ EXISTING TYPE OF ^ CHECKING ^ SAVINGS ACCOUNT ~ MONEY MARKET ^ CERTIFICATE OF DEPOSIT ^ NOW ^ This is your (check onel: ~ Permanent ^ Temporary account agreement. Number of signatures required for withdrawal 1 FACSIMILE SIGNATURE(S) ALLOWEDl ^ YES ^ NO fX J L SIGNATURE(S) -The undersigned agree to the terms stated on wary pa a of this form and acknowledge receipt of a completed copy. The undersigned further authorize the flnsndal Institution to verify credit and employment history and/or have a credit reporting agency prepare a credit report on the undersigned, as individuals. The undersigned also acknowledge the recdpt of a copy and agree to the terms of the fopowing disclosurelsl: $~ Deposit Account ~ Funds Availability ~ Privacy BX Electronic Funds Transfer gX Truth in Savings ^ 1 It-: rX`i'CM ~~~ ~'~'lt~r 1 L PAIGE LEE TALHELM BENEF PAUTM I.D. # 199-72-2463 0.0.6. 11/02/1991 121: + - ~ +, ~ ~ ~OSS~-~u I ~~~ MICHELE A POSSENTI CUSTODIAN I.D. # 563-59-3590 D.o.6. 12/23/1963 (3): I.D. # 141: LX LD. # D.0.8, D.O.B. ^ Authorized Signer (Individual Accounts Only) [X _ LD,# D.O.B. J (page f of 21 YOUR DEPOSIT ACCOUNT TERMS AND CONDITIONS AGREEMENT -These terms govern the operation of this account unless varied or supplemented in writing. Unless it would be inconsistent to do so, words and phrases used in this document should be construed so that the singular includes the plural and the plural includes the singular. As used in this form, the words "we," "our," or "us" mean the financial institution and the words "you" or "your" mean the account holderls-. This account may not be transferred or assigned without our written consent. Much of our relationship with our deposit customers is regulated by state and federal law, especially the law relating to negotiable instruments, the law regulating the methods of transferring property upon death and the rights of surviving spouses and dependents, the law pertaining to estate and other succession taxes, the law regarding electronic funds transfer, and the law regarding the availability of deposited funds. This body of law is too large and complex to be reproduced here. Any provision that appoints us as an agent is not subject to the provisions of 20 Pa.C.S.A. Section 5601 et seq. (Chapter 56; Decedents, Estates and Fiduciaries Code). By exercising any of our rights under this agreement, we do so for our sole benefit. The purpose of this form is to: (1) summarize the rules applicable to the more common transactions; 121 establish rules to govern transactions or circumstances which the law does not regulate; and 13) establish rules for certain events or transactions which the law already regulates but permits variation by agreement. We may permit some variations from this standard agreement, but any such variations must be agreed to in writing either on our signature card for the account or in some other written form. LIABILITY -Each of you agrees, for yourself (and the person or entity you represent if you sign as a representative of another) to the terms of this account and the schedule of charges that may be imposed. You authorize us to deduct these charges as accrued directly from the account balance. You also agree to pay additional reasonable charges we may impose for services you request which are not contemplated by this agreement. Each of you also agrees to be jointly end severally liable for any account deficit resulting from charges or overdrafts, whether caused by you or another authorized to withdraw from this account, and the costs we incur to collect the deficit including, to the extent permitted by law, our reasonable attorneys' fees. DEPOSITS • Any items, other than cash, accepted for deposit (including items drawn "on us") will be given provisional credit only until collection is final (and actual credit for deposits of, or payable in, foreign currency will be at the exchange rate in effect on final collection in U.S. dollarsl. Unless otherwise disclosed, interest on non-consumer accounts will be paid only on collected funds, subject to minimum balance or other limitations, if any. We are not responsible for transactions initiated by mail or outside depository until we actually record them. All transactions received after our 'daily cut-off time" on a business day we are open, or received on a day in which we are not open for business, will be treated end recorded as if initiated on the next fdlowing business day that we are open. WITHDRAWALS • Unless otherwise clearly indicated on the account records, any one of you who signs this form including authorized signers, may withdraw or transfer all or any part of the account balance at any time on forms approved by us. Each of you (until we receive written notice to the contrary) authorizes each other person signing this form to endorse any item payable to you or your order for deposit to this account or any other transaction with us. We may charge against your account a check, even though payment was made before the date of the check, unless you have given us written notice of the postdating. The fact that we may honor withdrawal requests which overdraw the finally collected account balance does not obligate us to do so, unless required by law. Withdrawals will first be made from collected funds, and we maY. unless prohibited by law or our written policy, refuse any withdrawal request against uncollected funds, even if our general practice is to the contrary. We reserve the right to refuse any withdrawal or transfer request which is attempted by any method not specifically permitted, which is for nn amount less than any minimum withdrawal requirement, or which exceeds any frequency limitation. Even if we honor a nonconforming request, repeated abuse of the stated limitations (if any) may eventually force us to close this account. We will use the date a transaction is completed by us (as opposed to the day you initiate it) to apply the frequency limitations. On interest-bearing accounts other than time deposits, we reserve the right to require at least seven days' written notice before any withdrawal or transfer. Withdrawals from a time deposit prior to maturity or prior to the expiretion of any notice period may be restricted and may be subject to penalty. See your notice of penalties for early withdrawal. ACH AND WIRE TRANSFERS -This agreement is subject to Article 4A of the Uniform Commercial Code in the state in which you have your account with us. If you originate a fund transfer for which Fedwire is used, and you identify by name and number a beneficiary financial institution, an intermediary financial institution or a beneficiary, we and every receiving or beneficiary financial institution may rely on the identifying number to make payment. We may rely on the number even if it identifies a financial institution, person or account other than the one named. You agree to be bound by automated clearing house association rules. These rules provide, among other things, that payments made to you, or originated by you, are provisional until final settlement is made through a Federal Reserve Bank or payment is otherwise made as provided in Article 4A-403(a) of the Uniform Commercial Code. If we do not receive such payment, we are entitled to a refund from you in the amount credited to your account and the party originating such payment will not be considered to have paid the amount so credited. If we receive a credit to an account you have with us by wire or ACH, we are not required to give you any notice of the payment order or credit. OWNERSHIP OF ACCOUNT AND BENEFICIARY DESIGNATION -You intend these rules to apply to this account depending on the form of ownership and beneficiary designation, if ony, specified on page 1. We make no representations as to the appropriateness or effect of the ownership and beneficiary designations, except as they determine to whom we pay the account funds. Individual Aeeount - is owned by one person. Joint Acwunt - Witfi Survivorship (And Not As Tensnts M Common) - is owned by two or more persons. Each of you intend that upon your death the balance in the account (subject to any previous pledge to which we have consented) will belong to the survivorls-. If two or more of you survive, you will own the. balance in the account as joint tenants with survivorship and not as tenants in common. Joint Account - No Survivorship (As Tenants In Common) - is owned by two or more persons, but none of you intend (merely by opening this account) to create any right of survivorship in any other person. We encourage you to agree and tell us in writing of the percentage of the deposit contributed by each of you. This information will not, however, affect the "number of signatures" necessary for withdrawal. Revocable Trust Account - If two or more of you create such an account, you own the account jointly with survivorship. Beneficiaries acquire the right to withdraw only it: 11) all persons creating the account die, and 12- the beneficiary is then living. If two or more beneficiaries are named and survive the death of all persons creating the account, such beneficiaries will own this account in equal shares, without right of survivorship. Any such beneficiary may withdraw all or any part of the account balance. The personls) creating this account type reserve the right to: 11) change beneficiaries, 12) change account types, and 131 withdraw all or part of the deposit at any time. Corporate, Partnership. snd other Organizetiorial Aeeounta - We will usually require a separate authorization form designating the person permitted and conditions required for withdrawal from any account in the name of a legal entity such as a partnership, corporation, or other organization. We will honor such authorization according to its terms until it is amended or terminated in writing by the governing body of such organization. STOP-PAYMENTS - Astop-payment order must be given in the manner required by law and must be received in time to give us a reasonable opportunity to act on it before our stop-payment cut-off time. Our stop-payment cut-off time is one hour after the opening of the next banking day after the banking day on which we receive the item. Additional limitations on our obligation to stop-payment are provided by law, A stop-payment order must precisely identify the number, date and amount of the item, and the payee. We will honor estop-payment request by the person who signed the particular item, and, by any other person, even though such other person did not sign the item, if such other person has an equal or greater right to withdraw from this account than the person who signed the item in question. A release of the stop-payment request may be made only by the person who initiated the stop-payment. AMENDMENTS AND TERMINATION -From time to time we may amend any term of this agreement upon giving you reasonable notice in writing or by any other method permitted by law, including, in appropriate circumstances, posting notice in our building. We may also close this account at any time upon reasonable notice to you and tender of the account balance personally or by mail. Notice from us to any one of you is notice to all of you. STATEMENTS - You must examine your statement of account with "reasonable promptness." If you discover (or reasonably should have discovered) any unauthorized payments or alterations, you must promptly notify us of the relevant facts. If you fail to do either of these duties, you will have to either share the loss with us, or bear the loss entirely yourself (depending on whether we exercised ordinary care and, if not, whether we substantially contributed to the loss). The loss could be not only with respect to items on the statement but other items forged or altered by the same wrongdoer. You agree that the time you have to examine your statement and report to us will depend on the circumstances, but that such time will not, in any circumstance, exceed a total of 30 days from when the statement is first made available to you. You further agree that if you fail to report any unauthorized signatures, alterations, forgeries or any other errors in your account within 80 days of when we make the statement available, you cannot assert a claim against us on any items in that statement, and the loss will be entirely yours. This 60 day limitation is without regard to whether we exercised ordinary care. The limitation in this paragraph is in addition to that contained in the first paragraph of this section. DIRECT DEPOSITS - If, in connection with a direct deposit plan, we deposit any amount in this account which should have been returned to the Federal Govemment for any reason, you authorize us to deduct the amount of our liability to the Federal Govemment from this account or from any other account you have with us, without prior notice and at any time, except as prohibited by law. We may also use any other legal remedy to recover the amount of our liability. TEMPORARY ACCOUNT AGREEMENT - If this option is selected, we may restrict or prohibit further use of this account if you fail to comply with the requirements we have imposed within a reasonable time. SET-OFF -You each agree that we may (without prior notice and when permitted by Iaw1 set off the funds in this account against any due and payable debt owed to us now or in the future, by any of you having the right of withdrawal, to the extent of such persons' or legal entity's right to withdraw. If the debt arises from a note, "any due and payable debt" includes the total amount of which we are entitled to demand payment under the terms of the note at the time we set off, including any balance the due date for which we properly accelerate under the note. This right of set-off does not apply to this account if: lal it is an Individual Retirement Account or other tax-deferred retirement account, or (b) the debt is created by a consumer credit transaction under a credit card plan, or (c) the debtor's right of withdrawal arises only in a representative capacity. We will not be liable for the dishonor of any check when the dishonor occurs because we set off a debt against this account. You agree to hold us harmless from any claim arising as a result of our exercise of our right of set-off. FACSIMILE SIGNATURES -You authorize us, at any time, to charge you for all checks, drafts, or other orders, for the payment of money, that are drawn on us regardless of by whom or by what means the facsimile signaturelsl may have been affixed so long as they resemble the facsimile signature specimen on page 1 of this agreement, or that are filed separately with us, and contain the required number of signatures for this purpose. AUTHORIZED SIGNER (Individual Accounts Only) - An authorized signer is someone you designate to conduct transactions on your behalf, but does not have any ownership or rights at death unless named as a Revocable Trust beneficiary. The designation of an authorized signer does not create a power of attorney; therefore, the authorized signer is not subject to the provisions of 20 Pa.C.S.A. Section 5801 et seq. (Chapter 56; Decedents, Estates and Fiduciaries Code). RESTRICTIVE LEGENDS - We are not required to honor any restrictive legend on checks you write unless we have agreed to the restriction in a writing signed by one of our officers. Examples of restrictive legends are "must be presented within 90 days" or "not valid for more than 51,000." Customer Service Account Titling Uniform Transfers to Minors Act (UTMA) Account Title: Jane Bell BENEF PAUTMA John Bell CUSTODIAN Revised 03/10/2005 Ownership: Only one beneficiary and one custodian are permitted. Funds deposited to the account represent an irrevocable gift to the minor. Interest is taxable to the minor. The donor may not reclaim the funds as his own at any time thereafter. The custodian is responsible for the control of the funds until the minor reaches the age of majority, which in this case is 21 years of age. When minor reaches age 21, custodian must authorize release of funds. Account should be closed and new account opened. Transaction Authority: The minor has no transaction rights to the account. The custodian is the only person able to transact business on the account. Funds being withdrawn must be used for the minor's benefit. Financial institutions are not responsible for monitoring the use of funds. A successor custodian may be named at any time. You must contact Deposit Operations for the current procedures on how this must be documented. On the resignation, death, or removal of a custodian, a revised signature card for the successor custodian must be executed. Account Type Restriction: F&M Trust does not offer a checking account for this type of registration. TIN: The minor's social security number is used and verified. Custodian may sign W-9 certification. Documents Required: Signature Card Documents Required Upon the death of the minor, the funds are transferred to the In the Event of Death: minor's estate. If the custodian passes away before the minor reaches 21 years of age and a successor custodian has not been previously appointed, a successor custodian can be appointed at that time. Relationship Code: Code Di plaX Description 466 Beneficiary Minor 400 Primary Custodian S ~~_ 'O 0 N O N N"S -~ ~( ~ p~ O amp mm JJ O n 0 2ZZZ m ~ ~ v o m 3 m N ~ ~ 7 ~ F C~ m ~, ~ O Q p ~ O O N' m w T 3 ¢7 9 ff.K ; N N m n 6 b a ~. m A ~ ~ ~ 3 S pi O O ~ ~ 91 n. ~yy ~ ~ T' p ~_ N, Zr, ~ ~ N sg ~+ r O~ y~ ~ 3 N O. p ~ O ~ 3~0 m Z w ~ C N ~fl N p N -, O ~~ W. O ~ C a~ ~i e~~ i ^i 1y::~. i~ ~~ ~~, :1i ~;i t-' ~~`. ~ rj Y"a~ .., ~.:1 '..k'~- r...J C~, =Try 0 0 ---- ^ CERTIFICATE OF DEPOSIT 016-2ND, 0 8 5 7 3 2 p~ ~~+~- P.O. Box solo NON-NEGOTIABLE NON-TRANSFERABLE and re ulations of this Bank i d f t re rulo ll li bl ti t t f T g . ng an ca e ex s u u s o a app icate is subjec fllh7 1 Chambarsburg, PA 17201 This certi rx iNO P SAMUEL POSSENTI TALHELM PA ~ TIN 285-02-9762 TYPE OF CERTIFICATE ~ AUTOMATIC RENEWAL (At prevaiAng rate on renewal date) 001 MICHELE A POS5ENTI CUSTODIAiJ ~~ Y ^ TIN 563-59-3540 ' T ^ SINGLE MATURITY (No Interest paid after maturity) A g p PHONE # 717-486-5092 1 ] 3 WOODVIEW DRIVE f ®°D 1 Year Growth CD - E MOUNT HOLLY SPRINGS PA 17 DATE OP BIRTH ^ IRA THE SUM OF ONE THOUSAND ANDXX/100 DOLLARS $ 1000.00 PROD TYPE TEAM ISSUE DATE MATURITY DATE INTEREST RATE SOURCE OF FUNDS FREQUENCY OF DISPOSITION OF INTEREST PAYMENT AUTHORIZED BANK SIGNATURE INTEREST PAYMENT ^ MAIL ®COMPOUNDED C,~ OFFICE PICKUP DEPOSIT T0: ^ DOA ^ SAVINGS ACCT. NO. - ^ MONTHLY ~ C~ SEMIANNUALLY BY SIGNING THIS DOCUMENT, UNDER PENALTIES OF PERJURY,1 CERTIFY THAT THE ABOVE NUMBER IS MY CORRECT TAXPAYER IDENTIFICATION NUMBER. I CERTIFY THAT 1 AM NOT SUBJECT t0 BACKUP WITHHOLDING, ERHER BECAUSE I ^ QUARTERLY HAVE NOT BEEN NOTIFIED THAT 1 AM SUBJECT TO BACKUP WITHHOLDING AS A RESULT OF A FAILURE TO REPORT ALL ^ ANNUALLY INTEREST OR DIV{DENDS, OR THE INTERNAL REVENUE SERVICE HAS NOTIFIED ME THAT I AM NO LONGER SUBJECT TO BACKUP WITHHOLDING. I CERTIFY THAT {HAVE RECEIVED THE TRUTH•IN-SAVINGS DISCLOSURE. ^ AT MATURITY BANK COPY 1 . or less DEPOSITOR'S SIGNATURE Certificate of Deposit Truth-in-Savings Disclosure ~~~ os/11/2007 Rice: If the maturity date or rate information is not provided on this form, then 'ormation about maturity and rates will be provided by sepazate notice. ~finitions: "We;' "our;' and "us" mean the issuer of this account and "you" and "your" an the depositor(s). durity Date: This account matures 05/11/2008 e below for renewal information.) e Information: The interest rate for this account is 3,57 °!° with an annual centage yield of 3 ~ %. This rate will be paid until the maturity date mentioned Ye. merest will be compounded semi-annually merest will be credited ^ Monthly ^ Annually ^ Quarterly ^ at Maturity ^ Semi-Annually ~est begins to accrue on the business day you deposit any noncash item (for example, a k). mnual percentage yield assumes that interest remains on deposit until maturity. A ~rawal of interest will reduce earnings. tp Up" Interest Rate Option: If this is a "Bump Up" Certificate, you have the option to ;e the interest rate one time during the original term of the certificate. The new interest vffi be the then-current rate being offered for a certificate of deposit with a term equal to ~newal term. The new rate will remain in effect until the maturity date stated on the Cate. You must sign a request form to initiate the rate change. num Balance Requirement: You must make a minimum deposit to open this account rust maintain this minimum balance on a dai]y basis to earn the annual percentage lisclosed. :e Computation Method: We use the daily balance method to calculate the interest on count. This method applies a daily periodic rate to the principal in the account each coon Limitations: You cannot make deposits to this account during a term (other than d interest). You cannot withdraw principal from this account without our consent on or after maturity. (For accounts that automatically renew, there is a ten-day grace after each renewal date during which withdrawals are permitted without penalty.) Interest accrued during a term can be withdrawn: ^ Monthly ^Sami-Annually ^ at Maturity ^ Quarterly C~ Annually Interest earned during one term that is not withdrawn during or immediately after that term is added to principal for the renewal term. Early Withdrawal Penalty: If we consent to a request for a withdrawal that is otherwise not permitted, you may have to pay a penalty. The penalty will be for the following number of days' interest on the amount withdrawn: ^}~91 ^ 182 ^ 365 ^ 730 ^ 1'6ere are certain circumstances, such as the death or incompetence of an owner, where we may waive or reduce this penalty. See your plan disclosure if this account is part of an IRA. Renewal Policy: ^ Single Maturity: If checked, this account will not automatically renew. No interest will accrue after the maturity date. Automatic Renewal: ^ If checked, this account will automatically renew on the maturity date. Each renewal term will be the same as the original one, beginning on the maturity date. ^~checked, this account will automatically renew on the maturity date. Each renewal will for a term of 012 months, beginning on the maturity date. You must notify us in writing before or within aten-day grace period after the maturity date if you do not want this certificate to automatically renew. We reserve the right to stop automatic renewal by written notice to you before maturity. If this account is not automatically renewed, then no interest wID accrue after maturity. The rate for each renewal term will be determined by us on or just before the renewal date, and will be paid until the next maturity date. On accounts with terms of longer than one month we will remind you in advance of the renewal and tell you when the rate will be known for the renewal period. Current Rates: The interest rate and yield are accurate as of 05/1112007 You may call our Freedom Access Center at 261-3662 or 1-888-261-3662 to obtain current rate information. '~'p T Member R~ 1 FDIC ,~ Customer Service Account Titling Uniform Transfers to Minors Act (UTMA) Account Title: Jane Bell BENEF PAUTMA John Bell CUSTODIAN Revised 03/10/2005 Ownership: Only one beneficiary and one custodian are permitted. Funds deposited to the account represent an irrevocable gift to the minor. Interest is taxable to the minor. The donor may not reclaim the funds as his own at any time thereafter. The custodian is responsible for the control of the funds until the minor reaches the age of majority, which in this case is 21 years of age. When minor reaches age 21, custodian must authorize release of funds. Account should be closed and new account opened. Transaction Authority: The minor has no transaction rights to the account. The custodian is the only person able to transact business on the account. Funds being withdrawn must be used for the minor's benefit. Financial institutions are not responsible for monitoring the use of funds. A successor custodian may be named at any time. You must contact Deposit Operations for the current procedures on how this must be documented. On the resignation, death, or removal of a custodian, a revised signature card for the successor custodian must be executed. Account Type Restriction: F&M Trust does not offer a checking account for this type of registration. TIN: The minor's social security number is used and verified. Custodian may sign W-9 certification. Documents Required: Signature Card Documents Required Upon the death of the minor, the funds are transferred to the In the Event of Death: minor's estate. If the custodian passes away before the minor reaches 21 years of age and a successor custodian has not been previously appointed, a successor custodian can be appointed at that time. Relationship Code: Code Di Slav Description 466 Beneficiary Minor 400 Primary Custodian 4' z O N =t .~, ~ ~ O m m ~?p o~~ a m °' m og $ N. ~Z N N 7 y 3 x.~ G~ m ~- a ~ ~ ~ 3 ~~ ~ N O nC3 o y m m ~~t ~A i .~ '~a 6y ~ .. N ~j Yq ~ 1 7 .p p'~ r P1 b n N T ~i '~r~` n m AN ~ t~ J m 4„ m L i,}t Y• O ~ m Y' ~no xis x m '? o i~{~ Qs ~ ~ Y+ i '~ G ~ ~ ~ 3 ~y ltd N 9 r'' ~ Z ~ d 9 m 4 O ~ CERTIFICATE OF DEPOSIT 016-2Np, Q $ 5 7 3 ~ p~ ~~+T P.O. Box 6010 NON-NEGOTIABLE NON-TRANSFERABLE TRlJ~7 I Chembersburg, PA 17201 This certificate is subject to all applicable existing and future rules and regulations of this Bank. ' TX IND TYPE OF CERTIFICATE P JACK MILES TALHELM BENEF Ppuflnl} [~ TIN 274-04-4980 [~ AUTOMATIC RENEWAL (At prevailing rate on renewal date) 001 y MICHELE A POSSENTI CUSTODIAN ^ TIN 563-59-3590 ^ SINGLE MATURITY (No interest paid after maturity) B O PHONE >k 717-486-5092 113 WOODVIEW DRIVE Q CD 1 Year Growth CD E PATE OF BIRTH MOUNT HOLLY SPRINGS PA 17 ^ IRA THE SUM OF NE THOUSAND AND XX / 10 DOLLARS $ 1 000.00 PROD TYPE TERM ISSUE DATE MATURITY DATE INTEREST RATE SOURCE OF FUNDS FREQUENCY OF DISPOSITION OF INTEREST PAYMENT AUTNORIZED BANK SIGNATURE INTEREST PAYMENT ^ MAIL ~H COMPOUNDED `' OFFICE PICKUP DEPOSIT TO: ^ DDA ^ SAVINGS ACCT. NO. ~ X ^ MONTHLY BOVE NUMBER IS MY CORRECT F H T THE Y T A A L~ SEMIANNUALLY BY SIGNING THIS DOCUMENT, UNDER PENALTIES OF PERJURY, I CERTI TAXPAYER IDENTIFICATION NUMBER.1 GERTIFY THAT l AM NOT SUBJECT TO BACKUP WITHHOLDING, EITHER BECAUSE I KUP WITHHOLDING AS A RESULT OF A FAILURE TO REPORT ALL C ^ T TO BAC QUARTERLY HAVE NOT BEEN NOTIFIED THAT I AM SUBJE ^ ANNUALLY INTEREST OR DIVIDENDS, OR THE INTERNAL REVENUE SERVICE HAS NOTIFIED ME THAT I AM NO LONGER SUBJECT TO BACKUP WITHHOLDING. I CERTIFY THAT I HAVE RECEIVED THE TRUTH-IN-SAVINGS DISCLOSURE. ^ AT MATURITY BANK COPY t r. or lase DEPOSITOR'S SIGNATURE Certificate of Deposit Truth-in-Savings Disclosure ate: 05/11/2007 atice: If the maturity date or rate information is not provided on this form, then formation about maturity and rates will be provided by separate notice. Interest accrued during a term can be withdrawn: ^ Monthly ^Sami-Annually ^ at Maturity ^ Quarterly CIF Annually afinitions: "We;' "our;' and "us" mean the issuer of this account and "you" and "your" aan the depositor(s). aturity Date: This account matures OS/ 1112008 ' :e below for Rnewal information.) to Information: The interest rate for this account is 3.57 °!° with an annual xentage yield of %. This rate will be paid until the maturity date mentioned we. 3.60 Interest will be compounded semi-annually Interest will be credited ^ Monthly ^ Annually ^ Quarterly ^ at Maturity ^ Semi-Annually rest begins to accrue on the business day you deposit any noncash item (for example, a ck). annual percentage yield assumes that interest remains on deposit until maturity. A hdrawal of interest will reduce earrvngs. ,cop Up" Interest Rate Option: If this is a "Bump Up" Certificate, you have the option to nge the interest rate one time during the original term of the certificate. The new interest will be the then-current rate being offered for a certificate of deposit with a term equal to renewal term. The new rate will remain in effect until the maturity date stated on the ificate. You must sign a request form to initiate the rate change. imam Balance Requirement: You must make a minimum deposit to open this account must maintain this minimum balance on a daily basis to earn the annual percentage i disclosed. nce Computation Method: We use the daily balance method to calculate the interest on account. This method applies a daily periodic rate to the principal in the account each section Limitations: You cannot make deposits to this account during a term (other than tad interest). You cannot withdraw principal from this account without our consent >t on or after maturity. (For accounts that automatically renew, there is a tenday grace .d after each renewal date during which withdrawals aze permitted without penalty.) Interest earned during one term that is not withdrawn during or immediately after that term is added to prinapal for the renewal term. Early Withdrawal Penalty: ft we consent to a request for a withdrawal that is otherwise not permitted, you may have to pay a penalty. The penalty will be for the following number of days` interest on the amount withdrawn: ^ 91 ^ 182 ^ 365 ^ 730 ^ 'here are certain circumstances, such as the death or incompetence of an owner, where we may waive or reduce this penalty. See your plan disclosure if this account is part of an IRA. Renewal Policy: ^ Single Maturity: if checked, this account will not automatically renew. No interest will accrue after the maturity date. Automatic Renewal: ^ If checked, this account will automatically renew on the maturity date. Each renewal term will be the same as the original one, beginning on the maturity date. ^.j~ checked, this account will automatically renew on the maturity date. Each renewal will Abe for a term of 012 months, beginning on the maturity date. You must notify us in writing before or within a tenday grace period after the maturity date if you do not want this certificate to automatically renew. We reserve the right to stop automatic renewal by written notice to you before maturity. If this account is not automatically renewed, then no interest will accrue after maturity. The rate for each renewal term will be determined by us on or just before the renewal date, and will be paid until the next maturity date. On accounts with terms of longer than one month we will remind you nt advance of the renewal and tell you when the rate will be known for the renewal period. Current Rates: The interest rate and yield are accurate as of 05/11/2007 ' You may call our Freedom Access Center at 261-3662 or 1-888-261-3662 to obtain current rate information. Member ~~ FDIC ~ '. w Customer Service Revised 03/10/2005 Account Titling Uniform Transfers to Minors Act (UTMA) Account Title: Jane Bell BENEF PAUTMA John Bell CUSTODIAN Ownership: Only one beneficiary and one custodian are permitted. Funds deposited to the account represent an irrevocable gift to the minor. Interest is taxable to the minor. The donor may not reclaim the funds as his own at any time thereafter. The custodian is responsible for the control of the funds until the minor reaches the age of majority, which in this case is 21 years of age. When minor reaches age 21, custodian must authorize release of funds. Account should be closed and new account opened. Transaction Authority: The minor has no transaction rights to the account. The custodian is the only person able to transact business on the account. Funds being withdrawn must be used for the minor's benefit. Financial institutions are not responsible for monitoring the use of funds. A successor custodian may be named at any time. You must contact Deposit Operations for the current procedures on how this must be documented. On the resignation, death, or removal of a custodian, a revised signature card for the successor custodian must be executed. Account Type Restriction: F&M Trust does not offer a checking account for this type of registration. TIN: The minor's social security number is used and verified. Custodian may sign W-9 certification. Documents Required: Signature Card Documents Required Upon the death of the minor, the funds are transferred to the In the Event of Death: minor's estate. If the custodian passes away before the minor reaches 21 years of age and a successor custodian has not been previously appointed, a successor custodian can be appointed at that time. Relationship Code: Code Display Description 466 Beneficiary Minor 400 Primary Custodian