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HomeMy WebLinkAbout01-05384IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA Brenda Brownewell, individually and as pazent and natural guardian of Amber Brownewell, a minor 216 Hill Street Mt. Holly Springs, PA 17065 Plaintiffs Allen Stutenroth 551 Summit Drive Cazlisle, PA 17013 Defendant Civil Action -Law / } / ~-7'~' No - 3~~ -266 l_.~ U t 1 `€~-r"~ Jury Trial Demanded PRAECIPE FOR WRIT OF BUMMON3 TO THE PROTHONOTARY OF SAID COURT: Please issue A Writ of Summons in the above-captioned action. X A Writ of Summons shall be issued and forwazded to ( )Attorney (X) Sheriff Scott B. Cooper, Esquire Schmidt, Roaca 8s Kramer, P.C. 209 State Street Harrisburg, PA 17101 (717) 23c2y-6300 Date: / /2 Q/ Signature of Attorney Supreme Court I.D. No. 70242 WRIT OF SUMMON8 TO THE ABOVE NAMED DEFENDANT: YOU ARE NOTIFIED THAT THE ABOVE-NAMED PLAINTIFFS HAVE AN ACTION AGAINST YOU. Prothoaotary 0 Date: ~- ~ p~c/ ~/ll~izr-Y Deputy ( )Check here if reverse is issued for additional information ~kF~i~LL+T.-°~~a~f. _=SrM1. Bl3-4..iyueawAa.... x-aF~ ~,..< ,.~v.u.,an+~ra4rec&~udsE'~a~Ykuio'~s5aflrt~5v%n~ec"a el~ahcrk rWi&~ '°""-'~+a1a an~ ~c '~ I (1 ~ ~) 1 ~c ~/ v n ^p CJ m c~, G mac- ~~; ~~ d -~ .~' c•~ 't. ?, ;; ,~;~ CJ~~ T. ~i IN THE COURT OF COAZ>MON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA Brenda Brownewell, individually and as parent and natural guardian of Amber Brownewell, a minor 216 Hill Street Mt. Holly Springs, PA 17065 Plaintiffs Allen Stutenroth 551 Summit Drive Carlisle, PA 17013 Defendant Civil Action -Law No. 2001 Jury Trial Demanded NO. CUMBERLAND COUNTY Please serve the Writ of Summons on the Defendant listed below at the address listed and in the manner indicated. Allen Stutenroth 551 Summit Drive Carlisle, PA 17013 $erutce by CumberUxnd County Sher If you have any questions, please contact Tammie at (717) 232-6300. Thank you! SHERIFF'S RETURN - REGULAR CASE NO: 2001-05384 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND BROWNEWELL BRENDA ET AL VS STUTENROTH ALLEN KENNETH GOSSERT Sheriff or Deputy Sheriff of Cumberland County,Pennsylvania, who being duly sworn according to law, says, the within WRIT OF SUMMONS was served upon STUTENROTH DEFENDANT the at 1535:00 HOURS, on the 19th day of September, 2001 at 551 SUMMIT DRIVE CARLISLE, PA 17013 by handing to ANN STUTENROTH, WIFE a true and attested copy of WRIT OF SUMMONS together with and at the same time directing Her attention to the contents thereof. Sheriff's Costs: Docketing Service Affidavit Surcharge So Answers: 18.00 ~ ~j ~/ 3 .2 5 ~ 4 / ¢,aE .00 10.00 R. Thomas Kline .00 31.25 09/20/2001 SCHMIDT RONCA & KRAMER Sworn and Subscribed to before By: me this ab'~ day of ~/ [pZ/^w~-~^-+ metro/ A . D . ~~ Qi z ~ , 'P othonotary _.._ ~. .. 1 ......: .. _ I ~tlcwrel-.23'... ~ ~ Brenda Brownewell, individually as parent and Natural Guardian of Amber Brownewell, a Minor IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA Plaintiffs, v. Allen Stutemoth, CIVIL ACTION- LAW NO.Ol-5384 Defendant. JURY TRIAL DEMANDED PRAECIPE FOR ENTRY OF APPEARANCE To the Prothonotary: Kindly enter my appeazance on behalf of the Defendant, Allen Stutenroth in the above- capfioned matter. Respectfully submitted, I.AW OFFICES OF ANN WALDHERR Date: October 10, 2001 Jo C. Swartz, Jr., Es 'r I.D. N0.62012 Hillside Corporate Center 5001 Louise Drive, Second Floor Mechanicsburg, PA 17055 Attorney for Defendant Allen Stutenroth _ I `!_ ; CERTIFICATE OF SERVICE I, John C. Swartz, Jr., Esquire, hereby certify that I have this 10 ~' day of October 2001, caused to be served via first class United States Mail, postage prepaid, a true and correct copy of the foregoing pleading upon the following: Scott B. Cooper, Esquire 209 State Street Harrisburg, PA 17101 C John C. S , Jr. # y~ ca G -ate o ~ ~~ ~ T' ~, _ ~~ h ~t ~ y ~} ~~ ° ~ ~' _ '~`'°?C`i ~ ~~ .~ ~ -C ~~ ~~ F 0 APR 6 2004 f IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA Brenda Brownewell, individually and as parent and natural guardian of Amber Brownewell, a minor Civil Action -Law No: O 1-5384 Plaintiffs v. Allen Stutenroth Defendant. ORDER AND NOW, this _ day of r ~ , 2004, it is hereby ORDERED AND DECREED as follows: 1. That the settlement terms as set forth in the foregoing petition on behalf of the minor, Amber Brownewell, are approved. 2. The court approves this settlement in the lump sum of ONE THOUSAND DOLLARS ($1,000.00) to be distributed as follows: To Brenda Brownewell, As the Parent and Natural Guardian Of Amber Brownewell, a Minor $ 1,000.00 Tmtal: ~ 1,000.00 3. That the settlement be paid directly to the Petitioner on behalf of her minor daughter to invest said sums in either Certificates of Deposit and/or Savings Account at Members lgt Federal Credit Union, 5000 Louise Drive, _. -` 31W:66#` _.au ~,'w., ,t. : .,Y.re`s .t-,....,, € ~ ~-. .... ,. i..>. *w ,xv ~k~s'~..~c..: ', _ __~:~~t#1~ce~~an - - _ -- - - ~ a,~,,~, }- N O ~~ ~_ ~ :~ L~~ ~ ['°'~ ~?- ~~ ~ ~ .~ CC ~ :S 1_ '~4 f.Ll { Cy. 1J cv Cl <~~~ F. fYVfi Mechanicsburg, PA 17055, as such sums not to exceed those insured by F.D.I.C. 4. That said money invested and placed into a Savings Account and/or Certificate of Deposit shall not be deemed withdrawn, negotiated, cashed, or alienated in any way until the Petitioner's minor's eighteenth (18) birthday which is April 24, 2005, except by Order of this Court. 5. The law firm of Schmidt, Ronca, 8v Kramer, P.C., shall oversee the directives set forth in the preceding paragraph. 6. The Petitioner is directed to execute the Release attached to the Petition as Exhibit "E". By The Court: ~-~ APR 1 6 2x04 Brenda Brownewell, individually and as parent and natural guardian of Amber Brownewell, Civil Action -Law a minor No: O 1-5384 Plaintiffs v. Allen Stutenroth Defendant. PETITION FOR APPROVAL OF COMPROMISE SETTLEMENT AND DISTRIBUTION OF PROCEEDS FOR AMBER BROWNEWELL, A MINOR AND NOW, comes the Petitioner, Brenda Brownewell, as the Parent and Natural Guardian of Amber Brownewell, a minor, and respectfully avers as follows: 1. The Petitioner, Brenda Brownewell, is the Parent and Natural Guardian of Amber Brownewell, a minor, both currently residing at 61 Partridge Circle, Carlisle, PA. 2. The Petitioner's daughter, Amber Brownewell, is a minor, date of birth, April 24, 1987, who resides with her at the above mentioned address. 3. On October 19, 1999, Petitioner's minor, Amber Brownewell, was injured in an automobile accident caused by the driver of another vehicle, Allen Stutenroth, which collided with her vehicle. (See Police Report attached hereto as Exhibit "A") ~.,~ i- 4. The motor vehicle collision took place on October 19, 1999 at the intersection of east Pomfret Street and south Hanover Street in the Borough of Carlisle, Cumberland County, Pennsylvania. Mr. Stutenroth traveled through a red light, colliding with Brenda Brownewell's vehicle. 5. As a direct and proximate result of the collision, Amber Brownewell, suffered left rib pain and back pain. (See records of Carlisle Hospital at Exhibit "B") 6. The Petitioner has reached a compromise with Kemper Insurance Company, the insurer for Allen Stutenroth, regarding a claim for injuries sustained by Amber Brownewell in the form of a lump sum of One Thousand Dollars ($1,000.00) in full settlement of the minor's claim. 7. The Petitioner is satisfied that the offer of settlement is just and reasonable and is willing to accept said offer, if approved by the Court. (See joinder attached as Exhibit "C") 8. In pursuing claims against Allan Stutenroth, Petitioner engaged the law firm of Schmidt, Ronca 8v Kramer, P.C., under a Contingent Fee Agreement, that the said law firm should be paid 30% of a settlement obtained prior to filing suit. (See Contingency Fee Agreement attached hereto as Exhibit «D,~ 9. Petitioner's attorneys have agreed to reduce their fee to 25% in the settlement of the claims of Brenda Brownewell and have agreed to deduct no fee from the settlement of the minor, Amber Brownewell. _ ,~ _~.~ ..._.. __._., v . ~,~ 10. Schmidt, Ronca 8v Kramer, P.C., has incurred costs relevant to obtaining copies of medical records. However, all costs were taken from the settlement of Brenda Brownewell and it was agreed that no costs would be taken from the settlement of the minor. 11. The Petitioner requests that the Court distribute the present payment of $1,000.00 to be paid in settlement of Amber Brownewell claims as follows: To Brenda Brownewell, As the Parent And Natural Guardian Of Amber Brownewell, a Minor $1,000.000 Total: $1,000.00 12. The Petitioner requests that this payment be authorized without formal appointment of a Guardian of the minor, or the Entry of Security, with the Petitioner, Brenda Brownewell, being authorized and directed to invest the funds belonging to Amber Brownewell, a minor, as follows: A. To invest said sums in a Savings Account with Members 1st Federal Credit Union, 5000 Louise Drive, Mechanicsburg, PA 17055, each Account not to exceed such sums as are fully insured with F.D.I.C. and/or; B. To invest said sums in a Certificate of Deposit Members 1st Federal Credit Union, 5000 Louise Drive, Mechanicsburg, PA 17055, each Certificate not to exceed such sums as are fully insured with F.D.I.C. ~ x~_ 13. The Savings Account and/or Certificate of Deposit opened on behalf of Amber Brownewell as a result of the anticipated settlement shall be marked as follows: A. This money shall be held in trust not to be redeemed withdrawn, negotiated, or any way alienated except for the renewal in its entirety until the age of majority of the minor, Amber Brownewell, which is April 24, 2005, except by order of this Court. 14. Based on the above, the Petitioner approves of this petition and requests this Honorable Court to issue an order allowing the Petitioner to execute the Release attached hereto as Exhibit "E". WHEREFORE, the Petitioner, Amber Brownewell, requests this Honorable Court enter an order approving the foregoing Compromise Settlement directing the distribution of proceeds to the Petitioner as set forth herein. Respectfully submitted, Schmidt, Ronca 8s Kramer, P.C. By: /~ Scott B. Cooper ,Esquire 209 State Street Harrisburg, PA 17101 (717) 232-6300 ~ Attorney I.D. #70242 DATE: "; r'~/0 ~ Attorney for Petitioner f y' "~ ' ~ g' _ ~ COMMONWEALTH OFPENNSYLVAN/A ' I POLICE AC~'IbENT REPORT XX. REFER TO OVERLAY SHEETS "^^^'r REPORTABLE ~ NON-REPORTABLE Q PENNDOTUSE ONLY POLICE INFORMATION ACCIDENT LOCATION t. INCIDENT ~( 20. COUNTY CCO ~ (~ ~ NUMBER ( (J m ~ d ~ ' .G 2. AGENCY 1 ' - ` ~ Q C ~ 21. M I IP U~ j C 7 NAME ~ \ ~ Y £ ~~`~ 3 PRECWCT 3 W, ~~ 7'~ a 20NE ~ PRINCIPAL ADWAY INFORMATION 6. INVESTIGA / BADGE ~ `. /SCE NUMBER 22. ROUTE NO. OR ,~~1'~"~ sr- ~3 STREET NAME 17~',~000 6. APPRO Y BADGE J 23. SPEED 2a. TYPE 25.ACCESS J NUMBER v LIMIT HIGHWAY CONTROL 7. INVE DATE 6. ARRIVAL rl E ~D; Q3 /NTERS CTING ROAD: T IN F R TrOFU•, rie~ 26. ROUTE NO.OR E~ FLS S „STREET NAME Cr T O/n T, r 9. ACCIDENT ~ 10. DAY OF ~ 27. SPEED 26. TYPE 29. ACCESS / _ ~ DATE ~ LIMIT HIGHWAV CONTROL 1 t. TIME OF I` 12. NUMBER nn IF NOT AT INTERSECTION: DAY ~ 7 OF UNITS O~ t3. N KIL 1a. N INJ RED 15. PRIV. PROP. 30. CROSS STREET OR ~~ ACCIDENT V ^ N ^~ SEGMENT MARKER i6. DID VEHICLE HAVE Tv BE REMOVEG 7. VEHICLE DAMAGE 37. DIRECTION N S E W 32. DISTANCE "'- FROM THE SCENE? 0 -NONE UNIT 1 ® FROM SITE FROM SITE FT. 'MI. UNIT 1 UNIT 2 i • LIGHT 33. DISTANCE WAS D 2•MODERATE URED STIMATED Y ~ ~ Y D N 3 • SEVERE UNIT 2 ® 3a. CONSTRUCTION ZONE 35. TRAFFIC PR(I~NCIPAL INTERSECTING L i 6. HAZARDOUS ~~''77 ^ 9. PENNDOT ^ ^ ® DEVICE I f' MATERIALS Y LJ N PROPERTY Y N UNIT # 1 UNIT # 2 38_ LEGALLY Y N 37. REG. T 1 - ~ ~ ~ 36. E 36. LEGALLY Y N 37. REG. ~r 3B. T E PARKED? ^ ^ PLATE I ! ~/• PARKED? ^ ^ PLATE ~ ^~57~ 39: PA TITLE OR ~~77 OUT•OF•STATE VIN ~ Sa1d 39. PA TITLE OR _ OUT•OF-STATE VIN ~ S` aO. OWN ~^ - "- 40. OWNE - AN S?'IJ?~.v T - emu/ , ~, at. NER ~ ' ' ' ~' " S j 41.OWNER ~ t ~ S - f } - ADORESS ) )J ~^. J ADDRESS J / a2. CITY, STATE ~ 7 ~/ 42. CITY, STATE ~ j & ZIPCODE - , & ZIPCODE 43. YEAR O aa, MAKE TC'l_ ` a3. YEAg9Q / 4a. AKE a5. MODEL - (NOT 46. INS. 45. MODEL - (NOT a6. INS, ~ BODY TYPE) C.IITU,I° Y N ^ UNK ^ BODY TYPE) y LY N ^ UNK ^ 67. BODY 48. SPECI 49. VEHICLE 47. BODY 46. SPECIAL 49. VEHICLE ' TYPE USAGE OWNERSHIP ~ ~ NPE USAGE OWNERSHIP 50. INITIAL IMPAC ~ 51. VEHICLE 52. TRAVEL ~ 50. INITIAL IMPACT „ 51. VEHICLE 52. TRAVEL pQ POINT STATUS SPEED POINT STATUS SPEED ~ 54 ~ ~ 3 54 % GRADIENT ~ PRESENCE ~ COND TION GRAD ENT ~ PRESENCE ' ~ COND 710N 5E. DP.IVER // `` 57. &T E - 5fi. DRIVER 57. BT ~ 9 NUMBER QD NUMBER / ' 56. DRIVER ~ 56. DRIVER ° NAME i n NAME r £iV U 59. DRIVER 59. DRIVER j V ADDRESS 1 ` ADDRESS ~T 60, CITY, STATE ^f - ~ 60. CITY, STATE ,,L / ~' /7 &ZIPCODE !^1• ` ~ BZIPCODE - C t lE N R• 0.1 61. SE{~ 62. DATE OF 63 P NE 7~ ~ 61. S 62. DATE OF ~/ / -I` `~ 63 E O. I 77 ` //1 BIRTH 0 BIRTH J 6 J p 64. COMM. VEH. 85. DRIVER ~ ~ 66. DRIVER y ^~ t D ~~ 64. COMM. VEH. 65. DRIVER /'~ 66. DRIVER 3 G ' ~ Y ^ N CLASS / "~rl^ "1 SSN Y ^ N CLASS ~^- J SSN 67. CARRIER 87. CARRIER 68. CARRIER - 86. CARRIER ADDRESS -- - ADDRESS 69. CITY, STATE _ 69. CITY. STATE - & ZIPCODE - ~ & ZIPCOOE 70. USDOT N ICC N ~~ PUC ~ 70. USDOT N ICC ~,___ PUC a 2. VEH. .CARGO 74. GVWR 2. VEH. 73. CARGO 74. GVWR CONFIG~~ DY TYPE CONFIG-~~ OOY TYPE 75. NQ. OF 6. HAZARDOUS T7. RELEASE OF AZ MAT ^ ~ 75. NO. OF - ~~ 8. HAZARDOUS MATERIALS 77. REL SE Q~F H~ MAT Y ~ N L7 UNK ^ AXLES -~' MATERIALS N UNK Y AXLES AAdS (1192) 18 0 418 5 PAGE: ~ INVESTIOATINe AGENCY ,~.Y.~..''~ _ "tea :u.. rwvm~'®.u.< ..a:rug...,....s~.,~.:.a.,..a.m...__.._....._-..~~ V:StgEYNiNfLe •.. _.....I .. .,... ~..- ,., __ ~~ ~ ~ -ui 4x2 ~..~m.e,tv.~. >t 78. RESPONDING EMS AGENCY ~ ;5 ~ r'YYn11?~n`~~ .mgVG,l~yG4~ INCIDENT#: ~ /O-7 79. MEDICAL K:''LITY S ,-y L ~ ~ -°--. ACCIDENT DATE: /b / •f9 .PEOPLE INFORMATION - 8 C D E F G NAME ADDRESS H I J K L M t I r?1 6S l ~ a>~ s ~~fe ~ ~ ~ 3 ~ a 3 l a _LS'/>t ~ L _ rur~,Ebr~ ~-~ ~mnl~t Q. ~ ; ~ A• ~ ~ ~ ~. F t~ 3 ! ~ ,n ~~ ~~.gl~~Jl aid .1 T _ ,. 87. ILLUMINATION OROAD SURFACE ® 62. WEATHER ~ ~ B6. DIAGRAM E R£T :Sf ' 84. PENNSYLVANIA SCHOOL DISTRICT (IF APPLICABLE) 85. DESCRIPTION OF DAMAGED PROPERTY : . : ~ : OWNER .................. .... .. . .. . ....~~. ................ .. .................... ..... i ADDRESS ...... .... :....... ..........:............ ......: . ........... S~ SY PHONE . . ...... . .. { 87. NARRATIVE • IDENTIFY PRECIPITATING tVENTS, CAUSATION FACTORS, SEOV DET LS, LIKE INSURANCE INFORMATION AND LOCATION OF TOWEp VEHICL ENCES OF EVENTS, WITNESS STATEMENTS, AND PROVIDE ADDITIONAL ES. IF KNOWN. - --_~ ,A \~\ L ~ r ~~ ~~~ C ~~ V~ QE Ai 7,1 !` 1QIT ~lJ _ C o rN ~ S7' >'-~)C? 1~e T S. al/r,~ T_ / ~f ~+ ~ 5 a ~i; I ~v '~v o.~ ,` ,. t~.vi f' •rr~ 1 e ;~~ :1 ti c ~±L ~ ~ ir ~ n ;use 0 ~ ~` D?' eC 7~e 7A V Or 7~ ~IE'~~; i .,,pL UY tt S E\ TitWT 7 :4 t VI uIJE ~ ~£~/• I 44n1 ~Oila fV ~'n ._.., e ;c1>` ~ i , . ~ ;~~ w;~/ • ' ~go~ ~ ~. ~v~; e off' C '~ l) ~C /UO'~ II ~4S n IeI4Al 7D g ~S 6 S ; ti~l L ~/ ~ N 14Q~. vnmuv,' t91 ~ W-iJC _ iNSURANCE INFORMATION COMPANY Cm E ~ INSURANCE INFORMATION COMPANY ., ~- • -~\ G UNIT ~\ ~ 7 P NLO Y ~ ~~~~ U2T /` ~ P NLO Y ~O~ 88. NAME ADDRESS PHONE WITNESSES NAME ADDRESS PHONE 89. VIOLATIONS INDICATED 90. SECTION NUMBERS (ONLY IF CHARGED) TC NTC uNlr ~ :C ' ~ ~ Q_ 3 ~ era UNIT 2 - a a i. PROBABLc USE 2. TYPE T~ T ES 3. RESULTS NO TEST R F SE 1 PUSE ABLE 2. TEST 3. AESUL75 ~`~q-'QNO TEST l"J REFUSE y,, INVESTIGATION COMP TE? UNIT1 ~ ~ ( (/') E U 0.__B~Oa UNK UNIT2 ~ 0•__8~9a UNK YES NO AA~s (1192) ~ Q O a'I O C PAGE: ~ INVESTIGATING AGENCY Carlisle Hospital 246 Parker Street CarliBle, PA 17013-0310 a 717.245-SSOb V CONVENIENT CARF/FMFRl:FAIf'v occle-renrrn.r MEO. REC. NO. PEG. OATE/YIME BY OP. LOCATION OF PATIEM - - - PAT. TP. -- -- - SVC. -~ -.. FC. ._. PLN .~ ACC _.. JOB ... M ...~.........-.1 w~. Pp11ENT NUMBED 640810 10/19!99 21:4 DR 3 40 75 A 0521906 ' PREVIOUS NAME BIRTHPU\CE ACp{OENi pATEI TIME LOCATION PRE.CERT.NO. NONE PA / ! NAME/AOORE55/PHONE/AGE/SB%/RACE/M.S. ( 7 1 7) 4 6 6- B 7 7S PAPENT/OTHER EMPLOYEq BRD4iNE4tELL, Ai46ER A. Il2Y F k S _216 HILL ST 04!24/87 210-66-1363 ' ~iT HOLLY 5PRINDS PA17065 • NAME1ApORE53l PHONEI gELAPON/O.O B.ISOC-$EGNO' ~ 717 t Af16-p775 lY0 V GUAMNTORS EMPLOYER BRD~tPlEhlELL, BRENDA K. PA DAME CD~4?IISST_OA! ' 216 HILL ST 165-64-3289 HARRISBURD, PA AfT HOLLY SPRINDS, PA17065 NAME/AOORESSI PHONEIRELATIONISOCSEGNO. EMERGENCY NOTIFY BRDkNE4lELL, BRE~9DA (717)486-8775 ' ~ 1B ERIE INSURANCE GROUP 75 BLUE CROSS 361 43 YMH168643289 C140650 BRD4lAlE41ELL AIfBER 01 BRD4lHEMELL BRENDA K. 43 INSUPANCE COMMENT MEDICAL INEUPANCE AUTO ERIE KEYSTONE REASON FOq VIEIT E0./ATTENDING ~ • :DIVA TO BE EVAL - DUARFFPrC-7' D'gidTHDkY J COMMENT A y p t~~Sl ISDLATIDR ALERT M BRIEF VISIT 26700 GASTRO/RENO SLIDE 26060 - ALL ADDITIONAL CHARGES CLASS I VISIT 26710 KIDDE TOURNIQUET 26048 ~ ~ ~ I CLASS II VISIT 26720 OCL PER FOOT 79670 1 I , ~ I CLASS III VISIT 26730 F.S.B.S. 80081 ~ r % 1g~ A ~ D ~~ I ' __ _ _ _ CLASS IV VISIT 26740 TUBE GAUZE PER FOOT 26074 ' ' ~I CLASS V VISIT 26750 ED STAT ESTAT i C.~ ~ ~~ • ~ i i 1 1 MINOR SUTURE EDS 01 PULSE OX POXED 1 I ~ ~ I ~ ' i MEDIUM SUTURE EDS 02 EXTENDED CHARGE I 26760 : -----'-"--'-'----'~ : '-"--------------' `~ 1 { I I MAJOR SUTURE EDS 03 EXTENDED CHARGE II 26770 i ~ ' INTUBATION EDS 04 1 1 ~ / 1 ~ I I IV SET UP EDS 06 ---------------------' --"----~ . ~-------------_____~. . : ------------------- \ PELVIC EXAM EDS 14 , 1 i I i II I 1 i 1 1 I NITRO SET-UP EDS 16 ~ i ~ ~ ~ I I I ~ ~ \ / ~ M 26031 ----------""'------ --------- ~--------'---'- CAST, SCOTCH SHORT AR r ~ ___ _____ ___________ i i i i t CAST, SCOTCH LONG ARM 26032 ~ i 1 1 I I ~' CAST, SCOTCH SHORT LEG 26033 i , I ~ 1 ' , i 1 ' 1 ~ 1 I I CAST SCOTCH LONG LEG 26034 1 ~ 1 --------% ~ ----' ~ , CAST ROLL, PLASTER 26075 i ' i 1 1 1 { 1 II B/P MONITOR 26037 1 1 1 1 1 I I ~ I PACER PADS 79064 I~ _______- ~ ~~____________________ ~; NAME: BROWNEWELL, AMBER. CHIEF COMPLAINT: HPI: on collision. The child got She had delayed onset of some takes a deep breath or moves. PMH: MRN: 640810 DOS: 10/19/1999 MOTOR VEHICLE ACCIDENT. This is a 12-year-old female who was the front seat passenger, seat belted, in a head out of the car, walked around, had no pain. discomfort in the left rib cage area when she No shortness of breath. None. PHYSICAL EXAMINATION: GENERAL: Alert, oriented female. Temperature 37.0, pulse 76, respirations 16, blood pressure 130/60. She is not producing any stridor. There is no accessory muscle use to breathe. She seems comfortable. She has no tracheal deviation. LUNGS: Clear to auscultation, bilaterally. HEART: Regular rate and rhythm, no murmur. ABDOMEN: Soft and nontender. She does have some minor pain on palpation in the mid axillary line, left fourth and fifth rib area. No bony deformity on palpation. LABS/XRAY: X-ray of left rib series per ED&B interpretation negative. DIAGNOSIS: CHEST WALL CONTUSION. PLAN: For this musculoskeletal injury, advised ice, Tylenol or Advil. ~`.' PAUL FRANKE, M.D. D 2301 EST 10/19/1999 T.1407 EST/798/38576 10/20/1999 CARLISLE HOSPITAL EMERGENCY DEPARTMENT RECORD y....i .. ..,_ _~~..,. .. . __._ .:._ , ,_. .. ...... e CARLISLE HOSPITAL 246 PARKER STREET CARLISLE. PA 77073.0310 CONVPNIFNT f AAF/EMFR(:FNCV OC:f]ICTL)nrl~u TEMP. ~ ~ P `~ qEE; ~ 9.t` ,'~ '~J,,\V BY TIME\~ \ (^/V, •~N\ IASTTE}pNU3 ERGIES _...._ ~ ,-..._..~_.._...~~.......-..~v~. MEGICINES: NUflSING ASSESSMENT: FOR NU SEE NURSING ' RSING ASSESSMENT DOCUMENTATION SHEET TIME ~~;1 HISTORY i ~: A,{u ©f`/91 1. i 7' f'i. PHYSICAL EXAM TIME PHYSICIgN ORDER # f~ `~ fury 11 ~ L{~ 1~~TE~PR LTATIC3 ~4 ~~. !v ~ ~ LABS. p 4 ~~~ ~~ ~- ~: ~ s'L x ' SIG RE GNATUPE M.D. I NATURE CONSULTING PHYSICIAN PRESCRIPTIONS GIVEN NONE ^ ! olsgasmoN ^ ^ ^ ^ DS TRANS OTHER HOM ADMIT O ADMISSION DIAGNOSIS: TIME FGISCNARGE CONDITION ON DISCHARGE ' ' DIAGNOSIS: ' n ~ - 3 A41 PROVED ^ SAME ~ (./ ~ (,~(~/ DISPOSITION FROM ED CONVENIENT ^ CARE CENTER REASGN FGR vlsr ~ Arr. PHrs. ms. NOTIFIED TIME INIT. RESPONDED PiVG BE 7 EVRL ^~ ~ 0 FAMILY PNYS , PATIENT NUMBER ~521'?Oc, PATIENT NAME BR~~~IE4iELLp AMBER fl. flEG. GAT6TIME AGE ~rJl~vl~3 ~~:9? 12Y SN/RGMS F!~ HOW ARRIVED S A FR.n5n0. lRFV 61401 .~ ~ ~ .. #3R. = TREATMENT IN PROGRESS ON ARRIVAL: ^ CPR Down Time ^ Airway - ^ Oral ^ Nasal -Size ^ Airway, Endotracheal -Size ^ Agway, Nasotracheal -Size ^ IV -Solution Site Size Saline Lock Site Size ~l S~ Pupils: Right -Size Reaction Left - Size _ Reaction ^ N/A upi ¢es. 1 • 4 20 5 3® 6 ^ Monitor -Rhythm Rate ^ Oxygen - ^ Mask, ^ NC - UMin ^ Spinal Immobilization, ^ Mast ^ Pressure Dressing ^ Other Visual Activity: OD OS ^ NIA ^ With Glasses rl Without Glasses DRUGS: Vital Signs: POX: _ Extremities: ^ N/A ^ Laceration ^ Deformity ^ Abr25ion ^ MAE = INITIAL NURSING REVIEW: TIME: LMP: POX: REASON FOR VISIT; [}~P.AUMA ^ MEDICAL ^ PSYCHOSOCIAUEMOTIONAL Weight: PAST MEDICAL HISTORY - ___. S~~JECTIV~• Cause of Injury History p>; Pr_ ent es What (re of nt tel u) ~. ~i ^ rl \. I ~ r C OBJ C IVE: Pt?y ical Information hat you are ble ose) ~ r qtr SAFETY: Are you or have you ever been afraid for your safety in your home? ^ Yes ^ No MOUNT EKG STPIP MERE: PATIENT PROBLEM: Nursing Diagnosis _ Coping, Ineffective _ Mobility, Impaired _ Airway Clearance, Ineffective _ Fluid Volume, Alterations in: _ Noncompliance _ Anxiety Gas Excharge, Impaired _ Self Care Deficit _ Breathing Patterns, Ineffective _ Hyperthermia (Fever) _ Skin Integrity, Impaired _ Cardiac Output, Decreased _ Infection, Potential _ Thought Process, Alt. in Comfort, Alterations in: _ Injury, Potential Tissue Pertusion, Alt. in: Communication Impaired r~ Knowledge, Deficit _ Other by NURSE'S SIGNATURE o~r~we~I, Other: NuasEs min. aerie ~ scnie ~ rrooa ~ s~r PLAN OF CARE: ^ Maintain Patient Airway ^ Monitor Cardiovascular Status ^ IV~ ^ 8P Monitor ^ EKG ^ Cardiac Monitor ^ Safety Measures ^ Restraints ^ Suicide Precautions ^ Seizure Precautions ^ Slde Rails Up Comfort Measures ^ Pain Control ^ Position far Comfort Prepare for Exam Explain Procedures Emotional Support Patient Teaching Discharge Instructions Other Other Carlisle Hospital and Health Services Capynghi t9eY NURSING DO~UMENTATiON IV FLUIDS TYPE IAMT SITE SIZE TIME RATE -ENiPTS SIGNATURE =MEDICATIONS etl. Dose ,te Time ignature ~. ~ ' 1 ^ IV D/C'd with catheter intact TREATMENT /PROCEDURE 71h1E5 IV TOTAL = ^ RESP. TREATMENT PO Urine Oiher TIME TIME TIME TIME ^ AIRWAY-TYPE TIME SIZE ^ NASOGASTRIC 7U8E SIZE TIME SITE _ AMT IN =NOTIFICATION OF: AMT OUT TOTAL TOTAL TOTAL ^ Hospital Social Worker ^ Family Doctor ^ FOLEY SIZE ^ Family ^ Police ^ Coroner ^ Consultant TIME COLOR ^ Oz @ VIA =INTAKE: TOTAL = OUTPUT: ^ Crisis Intervention ^ Nursing Home ^ Other = VITAL SIGNS • ^ ON Bp MONITOR TIMES: EKG CXR LABS DRAWN UA ABG _ ^ PULSE OX Time BP P R NOTES: tom. \ M-~' lam-- ~~PATIE DISPOSITION: ^ Admitted to: ^ For Observation to: ^ Transferred to: ^ Morgue PATIENT'S LILY BA I n INDERSTANDING OF DISCHARGE INSTRUCTION HARGE: W ITTEN INSTRUCTIONS GIVEN ^ Litter ^~/Self Computer ^ Carried ~ ramily description ambulatory ^ Friend ^ Arnbulatory with Assistance ^ Police ^ Wheelchair ^ Valuables ^ Ambulance ^ Monitored Litter ^ Other 1~~~(~1t~~ ~M~ ^ Other Instructions by MD -- NURSES J'IGNATURE Sf+fxx.~l..'. Nams vluvl,I N~i~~We~~ Roam # Likes to be called Agee Escort Ht Wt Present ~ ~ Usual. - Vital Si : T ~ ~ R /rp , BP Sa02 1 Head Circ ALLERG ES N TIVITIg$S^~: escyd3e rg coon) Medication ~ ~~I - {11 V~ Sc ^N/A ~ Food ^ N/A Environmental (latex, tape)_. ~ .. _ ^ N/A Exposure to Infectious Disease ^ Yes ^ No If yes, iis~. Immunizations Current ^ Yes ^ No 0 N/A Comments Date: I D' l~- l / Time: ~~~ Triage Stratus: Mode of Arrival: Accompanied By: ^ Priority I P i ri ^ Q,LS ^ BLS 7 police ^ Friend ^ r o ty II Ambulatory Pazent ~ Family C1Prioriby III ^ Wheelchair ^ Self ^ Cther ^ N/A ^ Corned ^ Stretcher , R o r visit - j Onset of mptoms Treatment prior to amva- TETANUS STATUS: ^ Within 5 yrs ^5-10 yrs ^Mcre than 10 yrs ^ Unlmown ^ N/A CURRENT MEDICATIONS: (Rx, OTC, Herbs, Vitanins) Med Dose Last Dose/Time 1. 2. 3. 4. MEDICATIONS: ^ None ^ Home ^ To Pharmacy G @ Bedside HABITS: TOBACCO USE ALCOHOL INTAKE Never Smoked ^ Chew ^ Snu ff ~[7~-tlone ^ Ex Smoker (Date Stopped ^ Occasional ^ Smokes (Amt per day) ^ Daily (Amt) STREET DRUGS ^ Yes ^ No Type(s) MENTAL STATUS: Mo~~dlAf'fect: Thought: Memory: Speech: ,'S'Appropriate u-C1ear/ ~-htfact C~-Pt6nnaUClear ^ Blunted/Flat Spontaneous ^ Lnpa'ved ^ Silent ^ Defersive ^ Vague/ ^ Recent ^ Talkative ^ Apprehensive Disconnected ^ Distant Past C Repetitive ^ Restless/ ^ Disoriented ^ Mumbling Combative ^ Slow to answer Language Barrier? Yes No ^ Crying If, yes, language spoken: P[[11LLSE: RESP: ~Regulaz ^ Irregular ^ Normal ^ Wheeze ^ Rapid C FuIU ^ Weak ^ Shallow ^ Labored ^ Stridor Bounding ^ Deep ^ Retractions COLOR: ~/ Normal Flushed ^ Dusky ^ Cyanosis ^ Pale ^ Jaundiced _ _ ^ Nailbeds ^ Circumoral _ ^Other S Warm ^ Cool ^ Rash ^ Ecchymosis Dry ^ Clammy ^ ema ^ Other LUNG SOUNDS: Right: dear ^ Crackles ^ Rhonchi ^ N/A ^ Diminished ~ Wheeze ^ Absent Left: ~ Clear C Crackles ^ Rhonchi ^ Diminished ^ Wheeze ^ Absent PAT[EN' P ASSESSMENT FORM NO OIIOA (7199) C2TI15)Q H~S'~ltii.l PAIN: ^ Denies ^ N/A Severity cation of Pails ~ ~'i~' 012145678910 ^ Constant ^ 11 ^ Radiating ^ Intermittent Q harp ^ Bum' ^ Other Triage/Signature: ~ ^ N/A PREVIQ $U~RG~ }t~ ~ ^ N/A Implantable Devices: ^ Yes ^ No If yes, explain Other Devices: MEDICAL HISTORY/PSYCHIATRIC HISTORY: C N/A ^ Seizures ^ Liver Disease C Pregnant ^ Hypertension ^.Bleeding Tendencies LMP ^Cazdiac Disease ^ C ^ Depression ^ Chest Pain s ^ Anxiety ^ MI a ^ Transfusion ^ Ulcer ^ Emphysema Reaction ^ CA ^ COPD ^ Yes G No ^ Kidney Disease ^ Home'Oxygen ^ Other: ^ Diabetes ^ Cough ^ Glaucoma . ^ Dyspnea FAMILY IS ^ Diabetes ^Cazdiac Disease ^ Hypert ^ Other ^ N/A LEARNING & COMP HrHJNICATION: How do you best learn? ^ Writing^Visual ^Read CDemonstration Whom do we teach? ^ Patient ^ Other Barriers to Teaming? ^ Yes C No CulturaVReligion Needs: ^ Yes ^ No Dentures: ^Upper ^Lower ^None Brought to hospital?^YeslL~o Vision:^Glasses^Contacts^None Brought to hospital? ^YesCf:3Qo Sight: ^ Blind ^ Diminished Hearing Aid:^RtCLt^Both^None ught hospital? Yes o Q Hearing: ^ Deaf ' ? ',l// RN SIGNATURE: Reviewing RN: /A ^ Copy to Pharmacy PATIENT IDENTIFICATION ~. ~. _ ~~r -. Carlisle HOSpltd,i DEPARTM~~JT OF RADIOLOGY and Health Services 246 Parker Street . P.O. Box 310 • Carlisle, Pennsylvania 17013-0310 • (717) 249-1212 CARLISLE IMAGING ASSOCIATES, P.C. BROWNEWELL, AMBER A. 12Y 216 HILL ST MT HOLLY SPGS, PA 17065 LEFT RIBS WITH CHEST 10/19/1999 X-RAY #135754 MED. REC. #640810 DR. GUARRACINO - ER No fracture or other bony abnormality is noted in the visualized portions of the left ribs. No pleural effusion, pneumothorax or pulmonary contusion is noted. IMPRESSION: Negative left ribs. JDT/pl T: 10/20/1999 09:12 am JAM~D . .. , -.. >:c.-.>~ TAGGART, M.D. Carlisle Hospital -- Emergency Departm BRO EWELL AMBER 24Cs Parlor St. Carlisle, PA 17013 -- (717} _45-5500 10/19/x9 10:SOpm 640810 DISPOSITION SUMMARY Patient: BROWNEWELL AMBER SS #: Current Ph: CURRENT Address: City: _ Zip: Arrival: 10/ 19/9 9 10: 50 p m Disch: 10/19/99 11:04 pm MD ED: Paul Franke. M.D. PMD: Res/PAlNP: PMD Ph: Dx #1: Chest Wall Contusion ICD-9 #1:922.1 #1 Dx Engl: CONTUS.ESW Rx #1: Tylenol (Acetaminophen) 1 or 2 capsules by mouth every 4 to 6 hours as needed #50 capsules #1 Dx Span: CONTUS.SSW Rx#1 Printed: 10/19!99 11:04pm ~ r .. Follow-up: EMERGENCY DEPARTMENT E/D CARLISLE HOSPITAL CARLISLE. PA F/U MD Ph: 717-245-5500 F1U D/T: Other Instr: ICE IBUPROFEN OR TYLENOL AS DIRECTED. RETURN TO ER IF SHORT OF BREATH MY SIGNATURE BELOW INDICATES: > I have received and understood the oral instructions regarding my current medical problem. > I will arrange follow-up care as instructed above. > I acknowledge receipt of the written instructions as outlined on any previo ag ( ill re an review these instructs X /w~~ ~ _ X ati nt (or Legal Guar ' )Signature Sta ( stn Age/DOB: _ Medical Record: 640810 Disposition: xw,......~... ~.: ..v... .~.. ~ L _ ~~ Carlisle Hospital and Health Services PATIENT'S NAME: /~~1t~) ~~~ (~ 151A V p.(s~~p INSURANCE CO,; ~1II,'LU U ,T~],L2 KQ3,V1~Nl~ Statement to Permit the Release of Medical Information and Payment of Medicare and / or Other Health Insurance Benefits and / or Ph sician. I authorize Carlisle Hospital as the holder of medical information pertaining to me to release the necessary and appropriate medical information to the fiscal intermediary of the Social Security Administration and/or to my primary or supplemental health insurance company or its designated review agency for payment for services rendered. I authorize the Carlisle Hospital's and/or the physician's billing agent to submit a claim to Medicare or other health insurance on my behalf, or to request, on a one time only basis, from the Social Security Administration, such information necessary to complete the claim submission process. I am the individual to whom the information record pertains, or am authorized to consent, on behalf of the individual, to the release of the information record. Iunderstand that any false statement or representation knowingly and wilfully made or caused to be made for use in determining rights to Medicare bens ats cr paynrtents may be punishable by a fire of net more than $10,000.00 ar one year in prison, or both. I request that payment of authorized benefits be made on my behalf. I assign the payment of inpatient or outpatient hospital benefits to Carlisle Hospital for those services provided by Carlisle Hospital and/or I assign the benefit payable for physician services to the physician. I certify that the information given by me in applying for payment of services under Title XVIII of the Social Security Act or for any/all other health insurance is correct. Patient's Signature SSN Date Responsible Party if patient Unable to Sign Relationship Date (If different from patient or if patient is a minor.) i..._.. ----- I tv.,r-~i- Date bL~ Reason patient could not sign. White Copy -Healthcare Billing Canary Copy • Medical Records /Ancillary Departments AD 1825 (5/99) Carlisle Hospital and Health Services CONSENT TO NOSPITAL ADMISSION AND MEA~D--I~ppCA((L~~yyTREATDfENT Name of Pr_tending Physician (s) : ~I~,~.t3~ Date of Admission: 1"Il1l,I~L~I Time: (AM) (PM) _ 1. I, (or acting on behalf of) M1 ~~p ~nn w ~q Name Of Authorized Representative {1~,~~,lY ~ F U t'l(~t-YC•~ ~ suffering from a condition requiring hospital care, hereby Name Of Patient consent to rendering of such care, which may include routine diagnostic procedures and such medical treatment as the named attending physician(s) or other of the hospital's medical staff consider to be necessary. 2. I understand that the practice of medicine and surgery is not an exact science and that diagnosis and treatment may involve risks of injury, or even death. I acknowledge that no guaranc._.es have been made to me as to the result-of examination or treatment during this hospital_zw:.ion. s. I understand that: (A) It is customary, absent emergency or extraordinary circumstances, that no substantial procedures are performed upon a patient unless and until he or she has had an opportunity to discuss them with the physician or other riealth professional to the patient's satisfaction; (B) Each patient has the right to consent, or to refuse consent, to any proposed procedure or therapeutic course; and (C) No patient will be involved in any research or experimental procedure without his or her full knowledge and consent. 4. I understand that many of the physicians on the staff of this hospital, including the attending physician(s) named above, are not employees or agents of the hospital but, rather, are independent contractors who have been granted the privilege of using its facilities for the care and treatment of their patients. Further, I realize that among those who attend patients at this hospital are medical, nursing, and other health care personnel in training who, unless requested otherwise, may be present during patient care as apart of their education. Still or motion pictures and closed circuit television monitoring of patient care also may be used for educational purposes or for documentation of the clinical course unless a patient expressly requests otherwise. 5. I release CARLISLE HOSPITAL from all responsibility for all articles which I am retaining or will have with me during my stay at the hospital. I understand this includes clothing, bridgework, false teeth, eyeglasses, jewelry, money, radio, razor or any other item kept in my possession. I understand I may deposit valuables in a safe provided by the hospital; only if this is done will the hospital assume any responsibility for the safekeeping. 6. I hereby acknowledge that I have received written information on the topics of Patient Rights and Advance Directives. Date of Signature: ~-l~~-t`~M {SIGNATURE OF PATIENT} {SIGNATURE OF WITNESS} (If patient is unable to consent or is a minor, complete the following:) Patient [is a minor years of age] [is unable to consent because]: ~Y l,-1/mot-~/~' ~U14 ~ ~C.~P`~Zt o A~(C~i SI~ATVRE OF Lh~G L GUARD-/ T{SIGNATURH OF ITNESS} CLOSEST AVAILABLE RELATIVE} AD G315 (10/91) _.. .... I _. _.. ... .. amhu~6wene~m~m.._ }-. Carlisle I~ospital ~ v 246 Parker Stresl . Grliels. PA 170Y3-0310. 717-24b-5600 CONVENIENT CARE(EMERGENCY REGISTRAT101 NEC. R6(,`, NO, R G pI.1E,.TIAQ, BV C)P. LOGtTION OF PATIEM PAT. TP SPC. F,C. PW ACC J~ APJ Mr1Fl1r'MIYeFR """`""°°"~'`""~'°"'°E'~"'"'~'wS. 1717)486-8775 PATIEM:OTMEN EMPLOYF0. BRGkNEMELL, AMBER A. 12Y F R S 216 HELL ST 04f24/87 210-66-1363~P • MT HDL Y pp 7 5 NAME' ACCRE$$ PrIJ._ FELATION: 0 08 ' SOUSELNC. t 717 } 4 B 6 - B 7 7 5 • GUAMNipIS EMPLOYER BRp!(NEBELL, BRENDA K. 216 HTLL ST 168-64-3289 PR CANE CO1lMISSI(IN NRRRTSBURG, PR f HpLLV SPRI ADPNES> >Nf~= a_tAT10k. 4Y BLUE CP.ftSS 361 YkF(f E8643289 43 C1406~0 BRDflNEkELL, BkENDA (717)486-8775 18 BLUE CROSS 361 43 YkH166643284 C140650 BACK PRIN PCP KRETZING NEliVILLE RllGNICK, Ht11lARD L rcm er7nu al GDT u BRIEF VISIT 26700 GASTRO/HEMO SLIDE 26060 ALL ADDITIONAL CHABtiES GLASS I VISIT 26710 KIDDE TOURNIOUE7 28048 ~ ~ ~ r r r CLASS II VISIT 26720 OCL PER FOOT 79670 , ~ ~ CLASS III VISIT 26730 F.S.B.B. B00B1 ~ i . ~__-y--------------- _--___ ___----_--_ , CLASS IV VISIT 26740 TUBE GAUZE PER FOOT 26074 , ~ r i ,~ CLASS V VISIT 26750 _ ED STAT ESTAT ~ i 1 i I I i MINOR SUTURE EDS 01 PULSE OX PORED ~ ; MEDIUM SUTURE EDS 02 EXTENDED CHARGE I 26760 ~ ^-"-""""" ' : ~^'""°""-""""` ~ 1 1 r MAJOR SUTURE EDS 03 EXTENDED CHARGE II 26770 I ~ ~ INTUBATION EDS 04 i - i ~ r . 1V SET UP EDS O6 ~-----------------'--'--°--'°~ i^---__^-'----------~. i ----------------'--~ r i i PELVIC EXAM EDS 14 I i r r i ~ i r i ~ ~ NITRO SET-UP EDS 16 r i r 1 i r i i i CAS M 26031 _ _ _ -- -- ` , 'r __ T` .~-- ~~~ T SCOTCH SHORT AR _ '-°------- ------ --- ` ---------- ---- __ ---- --'------- CAST, SCOTCH LONG ARM 26032 ~ ~ ~ ~ ~ CAST SCOTCH S!-10Ri LEG 26033 o r r r r i 1 ~ ' 1 r r r 1 . ~ i ~ i ~ CAST. SCOTCH LONG LEG 26034 `--------_'-~--~-'------------' ~----'-----°-------' '----°-------------~ CAST flOLL, PLASTER 26075 i ~ ~ r i t i I i I B,~P MONITOR 26037 , 1 i t r r r 1 i r r ~ PACER PADS 79064 i ~ T , ~ ER-0508 (REV. 619E ~. _w..~ TREATMENT IN PROGRESS ON ARRIVAL: ^ CPR Dawn Time ^ Airway • ^ Oral ^ Nasal -Size ^ Airway, Endotracheal -Size [] Airway, Nasotracheal-Size min. ^ IV • Solution Site Size (] Mannar -Rhythm Rate [] Oxygen - ^ Mask, ^ NC - UMin ^ Spinal tmnwtrlization, ^ Mast [] Pressure Dressing ^ Other saune acts sae arze I Pupil Sizes: ~ Vlsugt Activity: `Extremities: Pupils: ^ N!A t . q • OD ^ Laceration Right - Slze z ~ 5 • OS ^ Deformiry- Reaplon N!A ^ Abrasron . Let; - SIB 3 B ~ ~ with Glasses ^ MAE .V Reartinn _ - _ O Without Glasses • INITIAL NURSING REVIEW: REASON FORVIS!T: ^' PAST MEDICAL HISTORY_ SUg,1ECTIVE: Cause of t~1AP: tllness QVhat ifte pattern POX: SAFETY: Are you or have you ever been afraid for your safety in your home? ^ Yes ^No MpUNT fKG STRIP HERE. PATIENT PR08LEM: Nursing Diagnosis ~ Goplrlg, Ineffective _ Mobility, Impaired Airway Clearance, Ineffective Y _ FWid Volume, Alterations in: Noncompliance ~ Anxiety - Gas Exchange, Impaired Self Care Deficit ~ _ Breathing Patterns, Ineffective _ Hypenhermia (Fever) Skirt Integrity, Impaired C~rdiac Output, Decreased Infection, Potential _ Though Rrocess, Att. In: ~ ~Comfort, Alterations in: _ Injury, Potential Tissue Perfusion, Ah. irc ~~ Communication Impaired `Knowledge, Deficit ,Other OUTCOME!GOAL• Expected by Discharge: NURSE'S SIGNATURE ~~,,,_,. P ~t t (, ~ ~R~R f NURSE'S SIG: 'sR Pet01S~941 J] MEDICAL ^ NNNE ) KNUE I !_~]F DRUGS: Vital Signs: POX PLAN OP CARE: [] Maintain Patient Airway ^ Monitor Cartliovaseulaz Status IV BP Monitor EKG Cardiac Monitor ^ Safety Measures ^ Restraints ^ SWcide Precautions Seiwre Precautions Side Rails Up ^ Comfort Measures ^ Pain Control ^ Position for Comfort ^ Prepare for Exam - Q Explain Procedures ^ Emotional Support [] Paaent Teaening - ^ Discharge Instructions , ^ Other - ^ Other _ Carlisle Hospital and Health Services CaPYnaht 1992 NURSING DOCUMENTATIQN EMERGENCY!]EPARTMENT ~„ _ ~~ ~~.u AR~LISLE iiOSPITAI zos PARICE _ ,.EE7' caausu3, vA (~~otS-o3t0 CON,, NT_CARE/EMERGENCY REGISTRATION ~-~ ;~sE xESPt_ 1 !\Wf1 ~ lJ ep~ I _. sr,-- n~~O uett~le~Awa-~-..~ ~' r1~.~. .:.~ . MEDICIx UPSpdG ASSESSMEM. 5EE FOR NURSING ASSESSMENT NURSING DOCUMENTATION SHEET M+E iB Nlsroxr ROS: SH: PMH: ~ FH: PIi`i510AL E%AM VF nuE• ai+~s~cwNOaoc-~ EB INTERPRETATION OF: 'C1- JABS: EKG: X-RAY: ~~ run SiD~UTUAE CCx311LTW0 PM/E~CUN PAESIFIPRONS DdVEF NQ IUN E aD~MR O8S SgAP1S OTHER ADMISSION DUGNOSIS' PMF OQQP DGtCHMDE oNwiiDN DN q9C DE DIAGNOSIS' F1/Q ~ AdPFlOVED - .... _.___ _.. ._ _ __- -- _ _~ DISPOSITION FROM . COPNEMIENT -_ ^ CARE CENTER ' REnsoN FOR VSrt ATT. PHVS. ws. NOl1FlED nME INIT. RESP8I~E . A N 6 CK PAI rAletr PNr 39000 PAT,FNT NUNBFA P~t1ENi NAl1E 0568794 BROMNENEL4, pNBER p. AEG WTErtIME 20!28/99 21:1 46E 12Y EA•MCDNS HwV Al0iMC6 F/N S N en~wOn mcv. ort TYPE f AMT ~ SRE SRE TIME ApTE p~~ SIGNATURE a µEDKiA710NS ' Map. Dc ,outs Tima SlgnaWre ^ IV DlG'd with catheter intact TREATMENT PROCEDUAETIMES IY TOTAL= i ^ RESP.TREATMENT PO Urine Other TIME TIME TIME TIME ^ AIRWAY ~ TYPE TIME S4ZE ^ NASOGASTAIG TUBE SIZE TIME SITE , T M T 0 . NOTIFICATI6N OF: IN A AM 7 U TOTAL TOTAL. TOTAL ~ Hospital Social Worker ~ Family DOMO• ^ FOLEV SIZE ^ Family ^ Police ^ Coroner ^ Consultant TIME DOLOR ^ Oa C VIA = INTAKE: TOTAL F OUTPUT: ^ Crisis Intervention ^ Nursing Home ^ Other = VITAL SIGNS -', D ON 8P' MONITOR TIMES. EKG CXR LABS DRAWN UA A$G D PULSE OX Time BP P R: NOTES: =EVALUATION AND DISCHARGE NOTES:/ Pi C • G a r ri PATIEN FAµ1LY BALIZED UNDERSTANDING OF DISCHARGE INSTRUCTIONS: DISPOSITION: pISCHAR6E: dRITTEN INSTRUCTIONS GIVEN L~ ] Admitted to: ^ Utter ^ Se1P ~/ frt:omputer ^ Carried C§'f~amity ^ Prescnpt~on ] For Observation ambulatory ^ Friend _ _ __-~ ~-"- o. O,Am1?ulatory:with Assistattoe--^-POlica "`-`--- - - ^Other 7 Transferred to: ^ Wheelchair ^ Valuables ~ Ambulance Q Verbal In5u uctione by MD µorgue ^ Monitored Litter p Other // ~~y ~ ' -""~~~~'// " J'~ '" ~~ /(/~~(~J" ~ -" c NURSESSIGNATURE ATIENT SNAMEr~ ~' ' J Name V~GwNLwii_1 i l~tfs~~ Roomk Likes to be called Age~_ Esrot* _ H'. ~ Wt,('resent Usua Viii; +',gls: T_ s~' Pico R ,'L BP ,; ~ aO2 Ne'a~Cec _ ALLERGI /SENSMIVITTES: Describe reaction) .^ Medication ~ 7 N z . ~ ~ `~ C[ r . uN!A Food ^ NfA Environmental (latex, tape) ~ N!A Exposure to Infectious Disease'u Yes ~ No If yes, list Imnwni~ations Cturent ^ Yes C No :! N!A Com,t:%nts TETANUS 5TATUS:. Within 5 yrs CS-]0 yrs .41oro than 10 yrs ~: Unknown ~ N!A CURRENT MEDICATIONS: (Rx, OTC, Herbs, Vitamins) Med Dose Last DoselI'ime 2. 7. Date: ta• rf.~t4 Time: Zi 5 Triage Sfatus: Mode of Arrival: Aaompanied By; Priority I Ajj,,SS ~ BLS - Pplice ~ Friend C Pyy'~ri~y iI Cs'Amhulatory 'Parent G Family C~'Priority Ill :7 Wheelchair 7 Self C Other u^ N,~A ~ Carried C Stretcher Reasoq for visit _ tik ~.,,ti Onset of Symptoms c n r ~n:, i; .- *MS.t ~..•, ., n , r. Treatment prior to arrival PA[N: ~ Denies ~ N:A Location of Pain Severity 0123456 Constant retmittent 78910 -' Dull C Radiating C Sharp C Burning _: Other TriagerSignature: S (/°i.,,.~,~.- . NrA PREVIOUS SURGERY: : N%A Implantable Devices: C Yes ~ No If yes, explain Other Devices: 9. MEDICATIONS: G None -Home ~ To Pharmacy C @ Bedside ILIBITS: !~ I It TOBACCO USE ALCOHOL INTAKE C Never Smoked =Chew ~] Snuff L7 None G Ex Smoker (pate Stopped_`) C Occasional C Smokes (Amt per day) C Daily (Amt___!, STREET DRUGS ^ Yes C No Type(s) MENTAL STATUS: nyc n~~fo~<,,;;e. MoodlAffect: Thought: Memory: Speec4: ^ Appropriate C~ Clear! C Intact [] NormaUCleaz u Blunted,'Flat Spontaneous C Impaired ^ Silent ^ Aefensive G Vaguel (1 Recent w TaUtadve _• Apprehensive Discanaected C Distartt Past ^ Rcpctitive Restless! G Disoziented ~ Mumbling Combative ~ Slow to artswer Language Barrier? Yes No Cr~y'EEing ~ If, yes, language spoken: Pi2'Regular C. irregulaz {3'Normal B Wheeze C Rapid 7 FuIU G Weak C' Shallow G Labored G Stridor Bounding C~ Deep '? Keoactions ~O,L'tSR: ormai Pale 'arm t ,:~a Flushed ~ Dusky a Cyanosis Jaundiced C Nailbeds C C'ucumoral COther_ _ _. _ _- , Cool ^ Rash ^ Ecchymosis ry =~ Clammy ~ Edema C Orher .UNG SOUNDS: Right; C Clear G Crackles . Rhonchi '. NIA C Diminished Wheeze ~ Absent Left: C Cleaz G Crackles ~ Rbonchi Diminished C Wheeze G Absent PATIENT ASSESSMENT FORM 607fnA (7N9) Carlisle Hospital MEDICAL HISTORY/PSYCHIATRICHISTORY: ~ NIA Seizures ~ Giver Disease ~ Pregnant Hypertension C Bleeding Tendencies LMP Cardiac Disease C CVA .Depression u ChesT Pain C Arthritis C Anxeety MI C Asthma ~ Transfusion G Ulcer C Emphysema Reacfion u CA C COPD =Yes C No C Kidney Disease "Home Oxygen ~ Other. C Diabetes G Cough +O Glaucoma C Dyspnea FAMILY HISTORY: ~ Diabetes ~ Cardiac Disease C Hypertension ^ CA u Other C N/A LEARNING & COMMUNICATION: How do you hest Team? QWritingCVssual Read =Demonstration Wham do we teach? ~ Patient C Other Barriers to Teaming? C Yes C No CulnaaVReligion Needs: C Yes C No Deotures: ^_Upper C`Lower CNone Brought to hospital?CYesCNo Vision:~GlassesCContacts~None Brought to hospital?CYes::Ne Sight: ^ Blind ~ Diminished Hearing Aid;CRtCLtG$oth None Brought to hospital7~YesCNo Hearing; G Deaf C~ Diminished RNSIGNATURE: f ~Z-.;,,~M1~ RevicwingRN: __- CN/A ^ Copy to Pharmacy PATIENT IDENTiFICAT[ON .anise nospnat -Emergency Department i46 Parker St. Carlisle, PA 17013 - {7, 955500 ,~~ )(SPOSITION SUMMARY 10' 10:4_pm Patient: BROWNEWELL. AMBER SS #: Current Ph: CURRENT Address: City: _ Zip: Arrival: iD/28199 10:48om MD ED: Donna Fehrenbach. D.O. PMD: ReslPA/NP: Robert Weiser PA-C PMD Ph: ^ Dx #1: Thoracic Strain ICD-9 #1:847.1 #1 Dx Engl: SPBACK,E5W D isch: 10/28/99 10:54 om Follow-up: KRETZING,HAROLD G 850 WALNUT BOTTOM ROAD #1 Dx Span: GARLISLE. PA FIU MD Ph: 7172431515 FIU D1T: NEXT WEEK Other Instr: May return to worWschool: 10.29-99 Restrictions: NO GYM CLASS FOR 1 WEEK. vIY SIGNATURE BELOW INDICATES: 1 have received and understood the oral instructions regarding my current medical problem. I will arrange follow-up care as instructed above. I acknowledge receipt of the written instructions as outlined on this and any revious pages . will read and review these instructions. y ~ eL~ X ~ . 'Patient (or Legal iardian) Signature Sta (Wanes ignature AgelD06: Medical Record: 640810 Disposition: JOINDER I, Brenda Brownewell, individually and as parent and natural guardian of Amber Brownewell, a minor, hereby state that I have read the foregoing Petition and reviewed it with my attorney, Scott B. Cooper, Esquire, and that I understand, agree and approve the contents thereof and join in the Petition. ~ rB'enda Bro ewell, as Parent and Natural Gu rdian of Amber Brownewell CONTINGENT FEE AGREEMENT THIS AGREEMENT entered into the y, S~ day of y~l/Od'ui~fl.L°/'~ - - - --- -- =_-' - 1999, by and between SCHI~IIDT,-iZON~A"&-KRAMER~=-PC.-~and..Brenda_ ,_. Brownewell, hereinafter referred to as "Client." WITNES5ETH: The law firm of SCHMIDT, RONCA & KRAMER, P.C., will act as Client`s attorney in negotiating for a settlement, and in bringing a claim against Allan J. Stutenroth or anyone else arising out of an accident which occurred on October 19, 1999, at the intersection of South Hanover and Pomfret Streets, Cumberland County, Pennsylvania. In addition, SCHMIDT, RONCA & KRAMER, P.C., will pursue all claims for underinsured or uninsured motorist benefits to which the Client may be entitled under his/her insurance policy. In return, the Client will: 1. Promptly supply accurate information, as requested by SCHMIDT, RONCA & KRAMER, P.C., and cooperate fully, including making myself available for meetings with my attorney and for legal proceedings. Client promises all information supplied will be truthful and accurate. 2. (a) In any claim brought on Client's behalf, to pay SCHMIDT, RONCA & KRAMER, P.C., for its services an amount equal to 30$ of any recovery made prior to filing suit; 33-1/3~ of any recovery made after filing suit and before trial starts; and 40~ of any recovery made after a trial starts. In any matter 1 ~~ ~.. _~ ~,~~,~~~ submitted to arbitration, suit is filed when the arbitrators are appointed or when a Petition to Appoint Arbitrators is filed, -----whche-crer__fr_st occurs. Tn any matter submitted to arbitration, ------------------ ------------ trial starts the first day the arbitrators have convened to hear testimony. In the event that any settlement is made on a structured or deferred payment basis, SCHNIIDT, RONCA & KRAMER, P.C., shall be entitled to receive their percentage based on the cost of the structured settlement, paid as a lump-sum at the time of settlement. (b) I agree I will not settle or negotiate the above claim or any proceedings based thereon. (c) If Client terminates this Agreement before recovery, Client agrees that SCHMIDT, RONCA & KRAMER, P.C:, shall be entitled to a fee based upon work done and benefit conferred. 3. To reimburse SCHMIDT, RONCA & KRAMER, P.C., out of any recovery, in addition to attorney's fees, all costs and expenses incurred on Client's behalf in order to make the claim. All such costs and expenses will be advanced by SCHMIDT, RONCA & KRAMER, P.C., as they are incurred. Such costs and expenses include, but are not limited to, filing fees, cost of medical records, copying costs, fax costs, long distance telephone costs, expert witness fees and sheriff's service costs. In the event there is no recovery, the Client will not be responsible for any costs or interest charges. Costs will be repaid to SCHMIDT, RONCA & KRAMER, P.C., out of any funds or property collected either by settlement or 2 judgment. 4. Claims for medical benefits and income loss benefits _.... are separate items. SCHMIDT, RONCA & KRAMER, P.C:, will heap-you- process these claims. A separate agreement will have to be entered into for fees if a major dispute occurs requiring the filing of suit for these benefits. The Client has read and does understand this Agreement. Signed the day and year set forth above. WITNESS: I have received a copy of this renda Br newell Individually and as Parent And Natural Guardian of Amber Brgf4~ewe11, a Minor Approved: SCHMIDT, By P.C. tin~nt Fee Agreement. 7~ %' 'In' ials 3 FILE No.235 D1i14 'D4 16:33 ID:LAW l7FC bF ANNA WALbHE=RR EAX: PAGE 1 • ,. . R ~ ~' S~ Of' AI,I.,(.'LAIMti fl)17 l~NI) IN GC)N911)Ii,RA'f(()N OF the payment to us ol'lhc sum of One'I'housund )o It4rs f,~1.DD0;002, and other good and vflluahle a~nsiderution, we, firenc(g, l3rownewal and t~gpk Isenhere. uarenls and s!uurdanti ol'Anilier Rrowncwcll. a mig<~, being ul'lawl'ul age, have released and discharged, and by tltust: presents do I`or said minor, her heirs, executors, adminisU•utors and assigns, release, acquit and litrcvor discharge AL,~,AN J. S'I;I I'I'IiNRO'I'I I tt(11 J~LM'f I:IL IN!iIIItAN('I: C'(?MI'r~NIh,S trod any and ell olhut• pcr5una, firms and c:orporationa al~ taxi 1'rum any and ttll actions, causes ol'action, claims ur demands lirrdamages, costs, loss of use, loss of services, expanses, campensulinn, conscyuential damage or any other thing whatsoever tin account nl•, or in tiny way growing; out ul; uny and all known and unknown pursonul igjurics turd death and pr(iperty damage resulting or to result I'rurn as occut•rencc ur ut:oidcnt: the( httppcned un ur about t w 1'>°i duv of O~tther 1499 ut ur near the intcrseclion ol'Soulh Flanovcr Street and Fatst Pomfret tilreet. lio ogt~ll olY'arlislc. Cumberhnid C'ounly. I'ennsvlvaniu. stll~ llrcidenl beinu the_ subject matt • n' e ' i,galiun lateflt)tlOned In Iil'egdtt lirownewcll, individug~jv and as parent arte~ uaturnl guardian nl'Amhel;134•uwnevYe~l, a minor v, Allen ,I. Stutenrolhr Ruckot 1Vo. UI-S38h. Civil'l'crm. Cumherhtnd Cnun~. C:nurlol'Comnuta l'Icas, I'uuisylvanitt We hereby acknowledge and assume all risk, chance ur hazard that the said injuries or damage may bo or hcamte permanent, progressive, greater, nr nurre extensive than is now known, anticipuwd ur oxpectul. No premise or inducumcnt which is nut herein expressed has been mach to us, and in exccul.ing ibis release we do not rely upon uny statement or rcprosenta(ion made by uny pu•son, Frm or corporation. huroby released, or troy ttgenl, physician, doctor nr any utlrrn• parson roprescnting them ur uny ul'thcnt, concu•ning the nature, extcm or duration oFsaid dtnnagcs ur Iossts nr the legal liability ihmcli~r. ~~ r1Lt No.~3b U1i14 '04 16:33 ID:LAW OFC OF AhINA WALDHFRR FAX: ~~ y .. PAGE 2 . ~ We understunei lhat this settiement is the arntpramisc ui't.t dnuhtfiri and dispatcci cluirct, and that the payment is not to he construed as an tuimission al' liability on the part of the pciwons, lirms and cot'porations herehy rclcasul by whom liahility is expretisly denied. We further ttbrue that this release shttll not be pleaded by us as a bnr to any claim or suit. 'Phis rclettse contains the I'N'ITRI? A(iRk:1.SMliN"f betwwn the ptu•ties her•eta, and the terms ol'this release arc contructutd and not a mere rccitttl. We flrrther slate that we have carefully read the farcgoing release ttnd know the anttcn[s thereof, and wo sign the same as uur awn I•ree act. W I'I'Nl?5S our hands and seals this .. day of - _-.. . ... __. , 2004. WI'1'NlitiSliS CAiI'17UN! ItIsA!)}3}iFOR}iS1UNIN(i _ .. - Itrcnda I?,rnwnewcll (ttddross) Mttrk ltienbcrB (tuldross) .~ .. ~~~ . . CERTIFICATE OF SERVICE AND NOW, this ~ day of April, 2004, I, Scott B. Cooper, Esquire, counsel for the Plaintiff, hereby certify that I have, this day, served a copy of the foregoing Petition by serving a copy of the same in the United States mail, postage prepaid, at Harrisburg, Pennsylvania, addressed to: John C. Swartz, Jr. Wagenfeld Levine 2 Penn Center Plaza, Suite 1120 1500 John F. Kennedy Blvd. Philadelphia, PA 19102 DATE: Respectfully submitted, SCHMIDT, RONCA, 8s KRAMER, P.C. Scott B. Cooper I.D. #70242 209 State Street Harrisburg, PA 17101 (717) 232-6300 Attorney for Plaintiffs -~-'~wv'-~"k,~$~~~i~,w~t` ~a~e~#. ~41bsi~1 ..a,~...an -~~..~ ._„ie.,.~ ,Dx+r~+~r~criav' ._d`-_: Safi - _ _ 9 i ~. (' !-,) ~^ -':1 1_ __ _ ~' ' : _ r. ~ 'O "~' :~1 - -~ _ ~ ,- ' r N : .i l~; ~ ' i C:U /~~"