HomeMy WebLinkAbout99-07014a
9
A
ftb
19
Angelika Sarkisova, : IN THE COURT OF COMMON PLEAS OF
Plaintiff
CUMBERLAND COUNTY, PENNSYLVANIA
VS.
NO. 99- 70/y CIVIL TERM
Glen M. Plank, Jr.
Defendant : PROTECTION FROM ABUSE
NOTICE OF HEARING AND ORDER
YOU HAVE BEEN SUED IN COURT. If you wish to defend against the claims set forth
in the following papers, you must appear at the hearing scheduled herein. If you fail to do so, the
case may proceed against you and a FINAL Order may be entered against you granting the relief
requested in the Petition. In particular, you may be evicted from your residence and lose other
important rights
? cam.
A hearing on this matter is scheduled on the ?y7! day of November, 1999, atlv.m.,
in Courtroom No. A_ of the Cumberland County Courthouse, Carlisle, Pennsylvania.
You MUST obey the Order that is attached until it is modified or terminated by the court
after notice and hearing. If you disobey this Order, the police may arrest you. Violation of this
Order may subject you to a charge of indirect criminal contempt which is punishable by a fine of up
to S 1,000.00 and/or up to six months in jail under 23 Pa.C.S. §6114. Violation may also subject you
to prosecution and criminal penalties under the Pennsylvania Crimes Code. Under federal law, 18
U.S.C. §2265, this Order is enforceable anywhere in the United States, tribal lands, U.S. Territories
and the Commonwealth of Puerto Rico. If you travel outside of the state and intentionally violate
this Order, you may be subject to federal criminal proceedings under the Violence Against Women
Act, 18 U.S.C. § 2261-2262.
You should take this paper to your lawyer at once. You have the right to have a lawyer
represent you at the hearing. The court will not, however, appoint a lawyer for you. If you
do not have a lawyer or cannot afford one, go to or telephone the office set forth below to find
out where you can get legal help. If you cannot find a lawyer, you may have to proceed
without one.
CUMBERLAND COUNTY BAR ASSOCIATION
2 LIBERTY AVENUE, CARLISLE, PENNSYLVANIA 17013
TELEPHONE NUMBER: (717)249-3166
AMERICANS WITH DISABILITIES ACT OF 1990
The Court of Common Pleas of Cumberland County is required by law to comply with the
Americans with Disabilities Act of 1990. For information about accessible facilities and
reasonable accommodations available to disabled individuals having business before the court,
please contact our office. All arrangements must be made at least 72 hours prior to any
hearing or business before the court. You must attend the scheduled conference or hearing.
Angelika Sarkisova,
Plaintiff
Glen M.Plank, Jr.
vs.
Defendant
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 99- 7ui / CIVIL TERM
PROTECTION FROM ABUSE
TEMPORARY PROTECTION FROM ABUSE ORDER
Defendant's Name: Glen M. Plank, Jr.
Defendant's Date of Birth: 3/31/65
Defendant's Social Security Number: Unknown to Plaintiff
Name of Protected Person: Angelika Sarkisova
AND NOW, this 11 `-Ulday of 1999, upon consideration of the attached
Petition for Protection from Abuse, the court hereby enters the following Temporary Order:
1. Defendantshall not abuse, harass, stalk or threaten Plaintiff in any place where
she might be found.
? 2. Defendant is evicted and excluded from the residence at or any other permanent
or temporary residence where Plaintiff may live. Plaintiff is granted exclusive possession of the
residence. Defendant shall have no right or privilege to enter or be present on the premises.
3. Except as provided for in the Custody Order regarding the parties' minor child,
Defendant is prohibited from having ANY CONTACT with Plaintiff at any location, including,
but not limited, to any contact at Plaintiffs current residence, and any other residence she
may, in the future establish for herself, and her place of employment. Defendant is specifically
ordered to stay away from the following locations for the duration of this Order: Plaintiff's
residence located at 73 Richland Lane, Apartment G7, Camp Hill, Pennsylvania, and
Plaintiffs place of employment located at Camp Hill Care Center, 46 Erford Road, Camp Hill,
Pennsylvania.
4. Except as provided for in the Custody Order regarding the parties' minorchild,
Defendant shall not contact Plaintiff by telephone or by any other means, including through
third persons.
? w. W=
? 5. Pending the outcome of the final hearing in this matter. Plaintiff is awarded
temporary custody of the following minor child/ren:
Until the final hearing, all contact between Defendant and the child/ren shall be
limited to the following:
The local law enforcement agency in the jurisdiction where the child/ren are located
shall ensure that the children are placed in the care and control of Plaintiff in
accordance with the terms of this Order.
6. Defendant shall immediately relinquish the following weapons to the Sheriff's
Office or a designated local law enforcement agency for the delivery to the Sheriff's Office:
All handguns, shotguns, rifles, or any other firearms he may possess.
Defendant is prohibited from possessing, transferring or acquiring any other
weapons for the duration of this Order.
7. The following additional relief is granted:
The Cumberland County Sheriff's Department shall attempt to make service at
Plaintiff's request and without pre-payment of fees, but service may be
accomplished under any applicable Rule of Civil Procedure.
This Order shall be docketed in the office of the Prothonotary and forwarded
to the Sheriff for service. The Prothonotary shall not send a copy of this Order
to Defendant by mail.
This Order shall remain in effect until modified or terminated by the Court and
can be extended beyond its original expiration date if the Court finds that
Defendant has committed an act of abuse or has engaged in a pattern or
practice that indicates risk of harm to Plaintiff and/or minor child.
Defendant is required to relinquish to the sheriff any firearm license Defendant
may possess. Defendant's weapons and firearm license may be returned at the
expiration of the Protection Order after Defendant has submitted a written
request to the Court for the return of the weapons and the Court has notified
Plaintiff of the request and given Plaintiff an opportunity to respond. A copy
of this Order shall be transmitted to the chief or head of the police department
of Harrisburg and the sheriff of Dauphin County.
Defendant is enjoined from damaging or destroying any property owned jointly
by the parties or owned solely by Plaintiff.
Defendant is to refrain from harassing Plaintiffs relatives.
8. A certified copy of this Order shall be provided to the police department where
Plaintiff resides and any other agency specified hereafter: The East Pennsboro Police and
Pennsylvania State Police Departments.
9. THIS ORDER SUPERSEDES ANY PRIOR PFA ORDER.
? ANY PRIOR ORDER RELATING TO CHILD CUSTODY
10. THIS ORDER APPLIES IMMEDIATELY TO DEFENDANT AND SHALL
REMAIN IN EFFECT UNTIL MODIFIED OR TERMINATED BY THIS COURT AFTER
NOTICE AND HEARING.
NOTICE TO DEFENDANT
Defendant is hereby notified that violation of this Order may result in arrest for
indirect criminal contempt, which is punishable by a fine of up to $1,000.00 and/or up to six
months in jail. 23 Pa.C.S. §6114. Consent of the Plaintiff to Defendant's return to the
residence shall not invalidate this Order, which can only be changed or modified through the
filing of appropriate court papers for that purpose. 23 Pa.C.S. §6113. Defendant is further
notified that violation of this Order may subject him/her to state charges and penalties under
the Pennsylvania Crimes Code and to federalcharges and penalties under the Violence Against
Women Act, 18 U.S.C. §§ 2261-2262. Any protection order granted by a court may be
considered in any subsequent proceedings including child custody proceedings, under title 23
(Domestic Relations) of the Pennsylvania Consolidated Statutes.
NOTICE TO LAW ENFORCEMENT OFFICIALS
This Order shall be enforced by the police who have jurisdiction over the plaintiff's
residence OR any locations where a violation of this order occurs OR where Defendant may
be located. If Defendant violates Paragraphs I through 6 of this Order, Defendant may be
arrested on the charge of Indirect Criminal Contempt. An arrest for violation of this Order
may be made without warrant, based solely on probable cause, whether or not the violation
is committed in the presence of law enforcement.
Subsequent to an arrest, the law enforcement officer shall seize all weapons used or
threatened to be used during the violation of this Order OR during prior incidents of abuse.
Weapons must forthwith be delivered to the Sheriff's office of the county which issued this
Order, which office shall maintain possession of the weapons until further Order of this Court,
unless the weapon/s are evidence of a crime, in which case, they shall remain with the law
enforcement agency whose officer made the arrest.
BY THE COURT, J
C/ c? Lc!C?ci IJ•li??(C??_ Judge
`/ ? y J
Angelika Sarkisova, : IN THE COURT OF COMMON PLEAS OF
Plaintiff
Glen M Plank, Jr.
VS.
Defendant : PROTECTION FROM ABUSE
PETITION FOR PROTECTION FROM ABUSE
CUMBERLAND COUNTY, PENNSYLVANIA
:NO. 99- *70/y CIVIL TERM
The Plaintiff is Angelika Sarkisova.
2. The name of person who seeks protection from abuse is Angelika Sarkisova
3. Plaintiffs address is 73 Richland Lane, Camp Hill, Pennsylvania.
4. Defendant's address is 5836 Locust Lane, Harrisburg, Pennsylvania
Defendant's Social Security Number is unknown to Plaintiff.
Defendant's date of birth is March 31, 1965.
Defendant's place of employment is unknown to Plaintiff.
5. Defendant is Plaintiffs former spouse.
6. Plaintiff and Defendant have been involved in the following court action for protection
from abuse:
Case name Case No. Date filed Court
Sarkisova v Plank 98-4325 October 1999 Dauphin County Common Pleas
7. The facts of the most recent incident of abuse are as follows:
On or about November 8, 1999, Defendant became angry and punched Plaintiff
in the cheek causing her to hit the wallwith such force that she became
disoriented. Defendant's girlfriend grabbed Plaintiff by the shirt, and held it
tightly around her neck causing her to gasp for air, and Defendant punched
Plaintiff in her ribs, kicked her in the knee, dragged her outside by her hair, and
pushed her head against the sidewalk causing bruising and soreness. Defendant
held the parties' three year- old son during this incident risking his safety and
exposing him to the violence. The police were called to the scene, and Plaintiff
was taken to Holy Spirit Hospital by ambulance.
8. Defendant has committed the following prior acts of abuse against Plaintiff.
a) In or about the beginning of October 1999, on two separate occasions,
Defendant threatened Plaintiff saying that the Protection From Abuse Order filed
in October 1998 expired, the game was over, and he was going to get his guns
back. He further threatened that he was free now and he knew what he was
going to do, causing Plaintiff to fear for her safety.
b) In or about October 1998, a Protection from Abuse order was entered in
Dauphin County Common Pleas Court by the Plaintiff against the Defendant.
Plaintiffs fear of abuse is exacerbated because of Defendant's history of abuse
which included the following: grabbed, kicked, choked, and punched Plaintiff;
pushed her into a sliding glass door, held a gun to her, and threatened to kill
Plaintiff specifying at times to leave her as a vegetable. On several occasions,
Defendant shot squirrels and stated to Plaintiff he wished he could do the same
thing to her causing her to fear for her life.
9. Defendant has used or threatened to use the following firearms and/or specific weapons
against Plaintiff: A handgun.
10. The following police departments or law enforcement agencies in the area in which
Plaintiff lives should be provided with a copy of the Protection Order: East Pennsboro Police and
Pennsylvania State Police.
11. There is an immediate and present danger of further abuse from Defendant.
WHEREFORE, PLAINTIFF REQUESTS THAT THE COURT ENTER A
TEMPORARY ORDER, AND AFTER HEARING, A FINAL ORDER THAT WOULD DO
THE FOLLOWING:
A. Restrain Defendant from abusing, threatening, harassing, or stalking Plaintiff in
any place where Plaintiff may be found.
B. Prohibit Defendant from having any contact with Plaintiff either in person, by
telephone, or in writing, personally or through third persons, including, but not limited
to, any contact at Plaintiffs residence or place of employment.
C. Prohibit Defendant from having any contact with Plaintiffs relatives.
D. Order Defendant to temporarily turn over any and all fireanns and weapons to
the Sheriff of this County and prohibit Defendant from transferring, acquiring or
possessing any such firearms and/or weapons for the duration of the Order.
L. Order Defendant to pay the costs of this action, including filing and service fees.
F. Order Defendant to pay $250.00 to reimburse one of Legal Services, Ine.'s
funding sources toward the cost of litigation in this case.
G. Order the following additional relief, not listed above:
Defendant is required to relinquish to the sheriff any firearm license Defendant
may possess. Defendant's weapons and firearm license may be returned at the
expiration of the Protection Order after Defendant has submitted a written
request to the Court for the return of the weapons and the Court has notified
Plaintiff of the request and given Plaintiff an opportunity to respond.
Defendant is enjoined from damaging or destroying any property owned jointly
by the parties or owned solely by Plaintiff.
Defendant is to refrain from harassing Plaintiffs relatives.
H. Grant such other relief as the court deems appropriate.
1. Order the police or other law enforcement agency to serve Defendant with a
copy of this Petition, any Order issued, and the Order for Hearing. The Petitioner will
inform the designated authority of any addresses, other than Defendant's residence,
where Defendant can be served.
Plaintiff prays for such other relief as may be just and proper.
Date:
Respectfully submitted,
an Carey, Attorney for laintiff
LEGAL SERVICES, INC.
8 Irvine Row
Carlisle, PA 17013
F.- .
V_ICAERIFTION
O"S
I verify that I am the Plaintiff as designated in the present
action and that the facts and statements contained in the above
Petition are true and correct to the best of my knowledge. I
understand that any false statements are made subject to the
penalties of 18 Pa.C.S. §4904, relating to unsworn falsification
to authorities.
•2. %r "
Dated. n /G '79
Angelika Sarkisova, Plaintiff
_; 0.
_s R
?T
J?'?
??
C?
N
n?
\V
V
1
1 _, ?.. Z
? .?
? ?t?
e;?
u --
?..
i
RE: (4L C?-
Pages
Enclosed copies are true and complete reproductions of the original which are housed at
Holy Spirit Hospital. The original records were made in the regular course of business at
or near the time of the matter recorded. This certification is given pursuant to 42 Pa.C.S.
Ch. 61 subch. E (relating to medical records) by the custodian of the records in lieu of
his/her personal appearance.
Date: Signed:
Gi
Sworn to and subscribed before me this o-?3J day of )( 414.4 t(f8L 19 "
71
Notary Public
My commission expires:
Notarial Seal
Marryyalice Mull, Notary Public
Camp Hill goro. Cumberland County
My Commission Expires Aug. 13, 2007
A Service of Holy Spirit Health System 1 I? y i `t51 /L, 5
503 North 21st Street • Camp Hill, PA 17011-2288
(717) 763.2100
The Spirit of Caring
ADM. DATE: 11/0811999
The time is now 2302.
The patient was involved in an alleged assault with multiple complaints of multiple injuries.
While I watched up in X-ray, one of the nurses approached me and said that she complained
also of some hip pain; it was not clear which side, I think she said both sides. I was requesting
x-rays, so I endorsed that as well.
I reviewed all her x-rays. I saw no obvious fractures. She's already been cleared. We'll provide
a soft cervical collar for her.
On reexamination, she just complains of some mild discomfort. Photographs apparently were
obtained, and I'm going to send her home to followup with her own doctor, return if she needs to
and she will decide how she is going to pursue this beyond the Emergency Room. I took her off
from work from the 8"' to the 1& because there were just concerns about pain. I gave her
information on head injury, neck strains, strains and sprains. I recommended ice, Tylenol or
Advil.
ADDENDUM:
CAT scan of her brain I fissure, but no fracture or bleed. I just called down to Dr windows in showed Yo orkal 851-2217, and he toldn
me this was
g eat clinical significance. So we're sending her home as described before9enital and not of acute, nothing trauma related, and it probably was JD/jjr
DOC M 7125
D: 11/08/1999
T: 11116/1999 10:50 P
006900
1of1
_Y SYIKI I rlvar, I r+" NAME: Sarkisova, Angelika
Camp Hill, PA MR#: 397502
17011 ROOM: ER1
DR.: JON A DUBIN, D.O.
EMERGENCY ROOM
ADDENDUM ORIGINAL
ADM. DATE: 11/08/1999
CHIEF COMPLAINT/
HISTORY 01= PRESENT ILLNESS: This is a 37 year-old white female who is here via
ambulance, immobilized on a long board and hard cervical collar. She came from Long
Meadow Apartments where she lives. Her chief complaint was "my ex-husband hurt me.: She
alleges assault by her ex-husband. His name is Glen Plank. This happened around 19:40.
She tells me that her husband came to pick up their 3 year-old son and he was there with his
girlfriend and the girlfriend apparently starting verbally abusing her. The patient said that she
told her to stop, and leave them alone, it was between she and her ex-husband, at which point
an altercation ensued. The patient tells me that her husband punched her in the right cheek is
where she points to, once. She did not pass out at that point. She said that his girlfriend then
"knocked my against the opposite wall in the hallway," They she said "my ex-husband punched
me in the right ribs," is where she points to. Then she went on to say the girlfriend was "kind of
choking me," "grabbed me by my clothes and had her hands around my neck." She said that
she was kicked in the right knee by her ex-husband. She was knocked to the ground outside as
they were going through the door. She said she hit the back of her head on the concrete with
transient loss of consciousness, she thinks, she cannot account for about 30 seconds. She
woke up and saw her kids running around. She complains of a mild headache. She cannot
quantify it for me. She complained of pain initially in the right side of her neck, not the midline.
When I went to examine her she wasn't quite sure if it was midline or not so she remained
immobilized pending cervical spine x-rays. She did not volunteer but admitted to nausea
without vomiting. She denied any shortness of breath or other chest pain beside that at the right
costal margin where she said she was punched. She denies any jaw pain or dental injury. She
denies any change in her vision. She denies any possibility of pregnancy before we x-ray. She
said the duration of the whole attack was five to ten minutes. She denies any sexual assault.
She is not sure if she is pressing charges, but Police were involved and she would like to have
photos done if we found anything on her that would be worth recording. She said this has
happened to her many times in the past. She had a protection from Abuse order X 2 against
him in the past. Again, the whole incident began when he came with his girlfriend to pick up
their baby who she said did not want to go with him.
PAST MEDICAL HISTORY: She denies.
PAST SURGICAL HISTORY: She denies.
ALLERGIES TO
MEDICATIONS: None.
SOCIAL HISTORY: Denies tobacco, illicit drug or ETOH use.
FAMILY MEDICAL
HISTORY: Her doctor is Dr. Cox and she is declining Crisis at this time.
REVIEW OF SYSTEMS: Musculoskeletal, Cardiovascular, Respiratory, GI/GU, HEENT,
Psychiatric, Endocrine. Hem atologic/Lymphatic: See Chief Complaint/HPI. All others negative.
SPIRIT HOS
Camp Hill, PA
17011
EMERGENCY ROOM REPORT
1 of 3
NAME: Sarkisova, Angelika
MR#: 397502
ROOM: ER1
DR.: JON A DUBIN, D.O.
ORIGINAL
NAME: Sarkisova, Angelika
MR#: 397502
PHYSICAL EXAMINATION: She was conscious, alert and oriented X 3, in no apparent
distress. Ver$ matter of fact, laying supine on the long board with hard cervical collar.
VITAL SIGNS: As recorded on the Nurse's Assessment.
HEAD: She complains of tenderness across the right zygomatic arch of her cheek, without
deformity , step-off or ecchymosis. She denies any diplopia or change in vision. No Battle or
raccoon signs as far as I could tell. I did temporarily remove her collar to see if she had any
midline tenderness and there is no CSF or blood, otorrhea or rhinorrhea. No hemotympanum.
No hyphemas are noted.
EYES: Conjunctiva without discharge or injection. Lids without lesions. PERRL.
FUNDUSCOPIC: No hemorrhages, exudates or papilledema bilaterally. Optic discs normal
ENT: She complained of some tenderness across her forehead, not so much her nose, is
epistaxis.
Mouth: Lips, teeth and gums normal.
Jaw: No evidence of injury to her jaw.
NECK: She complained of some tenderness, she thinks in her midline, but she is not sure
when I examined her so we replaced the collar pending x-ray clearance.
LUNGS: Normal respiratory effort. Breath sounds equal. No rales, rhonchi or wheezes.
CHEST: She has a little bit of tenderness in the right costal margin, without step-off or
ecchymosis. She had symmetric breath sounds, not distant. Remaining exam of her chest
was unremarkable. No other tenderness besides right costal margin.
CARDIAC: Regular rate and rhythm, without murmurs, ectopy, rubs or gallops. No pedal
edema.
ABDOMEN: Pelvis is stable to palpation.
SKIN: She had a small, yellowish bruise on her shin, but other than that, there was no
evidence of injury to her skin.
EXTREMITIES: * She had complained of pain in her right knee. She has a full range of motion
without deformity or effusion of her knee. Sensation is intact. Good pulses. Remaining exam
of her extremities is unremarkable.
NEUROLOGIC: Alert and oriented to person, place and time. Cranial nerves intact. Sensory
and motor functions normal. Reflexes symmetrical.
2of3
HOLY SPIRIT HOSPITAL
Camp Hill, PA NAME: Sarkisova, Angelika
17011 MR#: 397502
ROOM: ER1
EMERGENCY ROOM REPORT DR.: JON A DUBIN, D.O.
ORIGINAL
NAME: Sarkisova, Angelika
MR#: 397502
PSYCHIATRIC: Oriented to person, place and time. Mood and affect appropriate. She
seems matter-of fact, and only mildly upset about what happened to her. Actually very matter of
fact.
DIAGNOSTIC
IMPRESSION: Alleged assault with head injury and questionable transient loss of
consciousness, less than 30 seconds, with headache, with normal neurologic exam.
2. Right cheek/ zygomatic pain.
3. Neck pain, questionably midline.
4. Right knee and shin pain.
5. Right anterior rib pain.
DIAGNOSTIC
PLAN: C-spine, when that is cleared than routine C-spine., then routine chest, right ribs, right
tibia and fibula, right knee, CT scan of the brain and skull for head injury with brief loss of
consciousness and headache.
INTERVENTION: The patient is declining Crisis. She is made NPO pending results of her x-
rays, ice, will do photograph with consent, right tibia and whatever other bruising or injuries
we can find.
JDfjrs
DOC #: 7105
D: 11/08/1999
T: 11/16/1999 8:10 P
006883
HOLY
Camp Hill, PA
17011
EMERGENCY ROOM REPORT
3of3
NAME: Sarkisova, Angelika
MR#: 397502
ROOM: ER1
DR.: JON A DUBIN, D.O.
ORIGINAL
Initial Lab &X-Ra y Orders:
Labs I Urine specimens .
[ 1 Acetaminophen I I ESR .
[ J Alcohol ( I Glucose
I 1 Amylase/Lipase ( I HCGS
I 1 APTT ( I Liver
( J Blood Cultures Profile
( I BMP ( J Lyles
( I CBCP ( J PTP
( I CMP [ I Salicylate
( I CRPI [ I Serum Acetone
I I Digoxin [ I Theophylino
( J Dilantin [ I Thyroid Profile
[ I Tox Screen
[ I Urine Tox Screen
I Thrombolytic Labs
I Type 8 Cross _x of units
1 Type 8 Screen
I U/A
I Urine C 8 S
I Workman's Comp Drug Scree
I Other
Radloloov
I ]Abd/Obstr.Sedes ( JKUS
I I Ankle R L [ J L/S Spine
( IQlavicle R L ( IMandible
".Spine Lateral
ICa ( INasal
/
rv Spine Routine ( IOrbit R L
J Chest ? n. / Port / TPA
` [ J Pelvis .
I J Elbow
R
( J Facial L [ 1 PY ram IVf
( ibs ?gJ
( J Femur R
L L
( I Shoulder R L
[ J Finger R L ( I Skull
[ I Foot R L [ I Sternum
I ]Forearm R L I IT ine
I ]Hand R L I lb/Fib 4W L
I I Hip R
11 H eras R L
L ( J Toe R L
( J Wrist
[ Knee G
L R L
[ ]Other. Time/CRTtim 2. 011 "
spec Procedures-
Ultrasound:
( ]Abdomen CTScan or?(ax. ?•6,7
( 1 Duplex Doppler ( J Vo scan j?
( 1 Gallbladder
( J Other.
[ 1 Pelvic
Cultures
[ IBeta Strap AG /Culture ( ]Sputum CdS
[ 1 Cervical [ J Stool C a S C7
I] Chlamydia I J Stool O& P
( I GC Culture I J Stool C. Difficile
BIIIN Classification: 11 Wound C a S
I 1 Laval I [ J Follow up (J Accident
[ 1 Level II [ 1 Case I I J Medical
I I Leval in [ I Medical Non-Emergency
( ]Level IV
( J Level)&aa
TimeSeerl ?r1-7 b
Cardiac Resp/ratory
[ IMonitor ( JABG'spagedal
I I EKG paged at I I Peak Flows Before/After Rasp. Tx.
1102 UMm. [ IRespiratorlTx.
( 102 Saturation
Emergency Care Unit
Physician Order Sheet
20&ECU REV. 199 JD. aR. MD
Medications ( IV's / Additional Orders
CONSENTTO MEDICAL TREATMENT
I HEREBY CONSENT AND AUTHORIZE Holy Spirit Hospital, its agents, and employees, to the rendering of medical care, which may include
routine diagnostic procedures and such medical treatment as my attending or consulting physician considers to be necqssary. I also under-
stand it is customary, absent-emergency or extraordinary circumstances, that no substantial procedures will be performed upon me unless or
until I have had an opportunify to discuss them with a physician or other health care professional to my satisfaction. If I am'a competent adult, I
have the right to consent or 4efuse to consent. I understand that the practice of medicine and surgery is not an exact science and that diagno-
sis and treatment may Involve risks of injury or even death and acknowledge that no guarantee has been made to me as to the results of any
examination or treatment in this Hospital.
I understand many of the physicians on the staff of Holy Spirit Hospital are not employees or agents of the Hospital, but rather are Independent
contractors who have been granted the privilege of using these facilities for the care and treatment of their patients. Further, I realize this
Hospital Is a teaching Hospital and at the Hospital are health care personnel In training who, unless expressly requested otherwise, may participate
or may be present during my care as part of their education. Still or motion pictures and closed circuit monitoring of patient care may also be
used for educational purposes, unless I expressly request otherwise.
I understand that in order to ensure a safe environment for patients, visitors and staff all property on the premises of Hot piriit os flat is
subject to reasonable search and/or seizure at any time without further notice. Initi
RELEASE OF MEDICAL INFORMATION
authorize Holy Spirit Hospital to release to requesting health insurance carrier(s), their representatives and auditors, and any referring health
care providers, such diagnostic and therapeutic information (including any information relating to treatment for alcohol and subclance abuse
andlor treatment of osychia'r c disorders. and/or confidential HIV related information, as may be necessary for them to determine benefit enti-
tlement; to process payment claims for health care services provided during this hospitalization/treatment episode, and for continuing
care/treatment. A photocopy or carbon copy of this authorization shall be considered as effective and valid as the original. The undersigned
also authorizes Medicare, when applicable, to release to another insurance carrier, upon their request, medical information needed to make
payment upon that claim.
1 understand and consent that the manufacturer of any implantable device inserted by my physician during the course of my r er /procedure
may be provided with my identification Information, including social security number, as mandated by Federal Law. Initia
'
INSURANCE ASSIGNMENT OF BENEFITS66w* MMMMMMWAMW
I authorize payment directly to Holy Spirit Hospital and my treating physicians of all benefits payable under my insurance policies. I understand
I am responsible to the Hospital for all charges not covered by this assignment. Initi z' S
STATEMENTTO PERMIT PAYMENT OF MEDICARE BENEFITSTO PROVIDERS, PHYSICIANS AND PATIENT
I request payment of Authorized Medicare benefits to me or on my behalf for any services furnished me by or in Holy Spirit Hospital including
physician services. I authorize any holder of medical and other information about me, to release to Medicare and its agencies any information
needed to determine these benefits for related services.
MEDICAL ASSISTANCE RECIPIENT Inthatsr ?
My signatures certifies that I received a service or items from Holy Spirit Hospital and Dr. on the date listed below.
I understand that payment for this service or item will be from Federal and State funds, and that any false claims, statements, or documents, or
concealment of material may be prosecuted under applicable Federal and State Laws.
have read and agree with the above statements.
I have read and understand each of the sections contained above. I understand that by signing this document, I am agreeing and
providing the authorization/ consent contained in each of the above sections where my initials are located. I have had the opportuni-
ty to ask questionVeg"Ing each of these sections and all such questions asked have been answered to my satisfaction.
Signatu Witness
Relationship to Patient F-rZ Time __I 1 IT")" f ...- Date
HOLY SPIRIT HOSPITAL, CAMP HILL, PA
CONSENT FOR TR&ITMENT/RELF.ASE OF INFORMATION
I NS UR,I NCE ASST GNA,I ENT
t4?JbSJ9 OR 397502 E
SA?KIsOvh JNGELiKA
7 RICHLAxO LANE ER1
CAxi HILL PA 17011
C, I/to/1962 731-6272
194-72-7565 ED GROUP
SIM aEC IMEO, nrrir I 1 1/08/99
r HART ropy .;?._
)ale:
T e-
Assess
Vital Signs
Monlt
P siclan Assassin
02 = /
Lung Assessment
Visual Acuity
Diagnostics:
EKG
Labs 1
PC%R1Port. C-Spine _-,
ant to Radii y
eturne from Radiology
Procedures:
Respiratory Treatment
Ice
Foley Insertion
NG Insertion
Wound Care
SplintlOCUSling/Crutches
Miscellaneous:
10)
S
l
0
i
'
ca
e (
.
Pa
n
Level of Consciousness
\
Slderalis
Intake 8 Output
Patient Education Info
Other:
Time:
cy
Inltla
w?
? ct
IV_ erapY -? ? Rath, 7
Date Time Amount S I Ion Cat at r Site Rate Control Condition Attempts Initials
f
Condition Codes:
Initial: Sign ur
0-No Inflamation 3-Pain
Control:
Initial: Signature:
7-Edema 4-Hardness i•AVI
Initial: Signature:
2A•Erylhema 5-Warmth 2•StalMaster
initial: Signature: 213oEcchymosis
_. . .
:
I 'A NR 397502 E
Holy Spirit Hospital ; t 2 K e S O Y it , A N S E L I K k
Camp Hill, PA 7 1IC=!LA':D LANE ER1
Emergency Patient Documentation C I M P sr ILL PA 17 011
^1/t +/1962 731-6272 4
194-72-7565 ED GROUP
205 ECU Revised 5196 JD, BR, MD
11/013/91)
CHART COPY
t CIIP AILL PA 17.011
I/1r I b 2 731-62w
--7565 EJ GR
? Telephone Messgges ? Other ? Physician's Advice
? Telephone Orders ? Pharmacy/RX Receipts
8
in
n??4k°3 F 1
ytMt1(5?13?Sva.
K21(051
•..
341°502.
s®vIL ' f? .
cm,= I
is
? Telephone Messages
? Telephone Orders
LLANEO II E3"7502 E
Ov1 ,ALl'A
^i. 'L A• L L ?] PhFF E
9
? Other C I , I L L y ;an'sl4flgif
° 1 t I 0 2 ? j'harpzaq/RX Rei
1•14.72-7505 EC GROUP
11/3/9-1
6
4
2
Sew O& , At
'falbI5'41 V
Holy Spirit Hospital
Department of Radiology and Diagnostic Imaging
Camp Hill, Pennsylvania 17011
(717) 763-2600
PATIENT: SARKISOVA, ANGELIKA
MRM 397502 r
SOC SEC: 184-72-7585
ORD DR: JON DUBIN M.D.
PT TYPE: E
ADM DATE: 11/0811999
LOCATION: ER1-
DICTATION DATE: Nov 9 1999 12:00A
TRANSCRIPTION DATE: Nov 9 1999 11:27A
ARRIVAL DATE:
HOSP SERVICE: ER1
***Final Report***
EXAMINATION: UNILAT RT RIBS (3V) 71101 - Nov 8 1999
COMMENTS: Indication: Injury.
Multiple views of the right ribs fail to demonstrate fracture or other bony abnormality.
CONCLUSION: Normal right ribs.
DICTATED BY: TIMOTHY FARRELL M.D. / DMR
DATE OF EXAM: Nov 81999
SIGNED BY: TIMOTHY FARRELL M.D.
DATErrlME: Nov 101999 9:11P
Dater M.D./D.O.
Re-,jilts re sewed by 4D
Imaging Services Consultation
Page 1
Holy Spirit Hospital
Department of Radiology and Diagnostic Imaging
Camp Hill, Pennsylvania 17011
(717) 763-2600
PATIENT: SARKISOVA, ANGELIKA
MR#: 397502 •"
SOC SEC: 184-72-7565
ORD DR: JON DUBIN M.D.
PT TYPE: E
ADM DATE: 1110811999
LOCATION: ER1-
DICTATION DATE: Nov 91999 12:56P
TRANSCRIPTION DATE: Nov 9 1999 1:25P
ARRIVAL DATE:
HOSP SERVICE: ER1
***Final Report***
EXAMINATION: CT BRAIN, UNENHANCED 70450 - Nov 8 1999
COMMENTS: INDICATION -injury.
A preliminary emergency interpretation was rendered by Dr. Peiffer.
There is an arachnoid cyst present in the right middle cranial fossa. There is no midline shift present.
There are no areas of unusual tissue density present. There is no evidence of hemorrhage.
CONCLUSION: No acute abnormality.
DICTATED BY: TIMOTHY FARRELL M.D. I DG
DATE OF EXAM: Nov 81999
SIGNED BY: TIMOTHY FARRELL M.D.
DATErrIME: Nov 9 1999 2:37P
pate ?----- -
)/? Z")'. 0.
V
Imaging Services Consultation
Page 1
Holy.Spirit Hospital
Department of Radiology and Diagnostic Imaging
Camp Hill, Pennsylvania 17011
(717) 763.2600
PATIENT: SARKISOVA, ANGELIKA DICTATION DATE: Nov 9 1999 8:45A
TRANSCRIPTION DATE: Nov 91999 11:42A
MRM 397502
SOC SEC: 184-72-7565
ORD DR: JON DUBIN M.D.
PT TYPE:
ADM DATE: E
11/08/1999
ARRIVAL DATE:
LOCATION: ER1- HOSP SERVICE: ER1
"Tinal Report'
EXAMINATION: RIGHT KNEE (6V) 73564 -Nov 8 1999
COMMENTS: Indication: Injury.
Examination of the right knee reveals no evidence of fracture or dislocation. No bone or soft tissue
abnormality is identified.
CONCLUSION: Normal right knee.
DICTATED BY: TIMOTHY FARRELL M.D. / DMR
DATE OF EXAM: Nov 8 1999
SIGNED BY: TIMOTHY FARRELL M.D.
DATE/TIME: Nov 91999 1:14P
pates vedt
Imaging Services Consultation
Page 7
_l
Holy Spirit Hospital
Department of Radiology and Diagnostic Imaging
Camp Hill, Pennsylvania 17011
(717) 763-2600
PATIENT: SARKISOVA, ANGELIKA
MR#: 397502
SOC SEC: 184-72-7565
ORD DR: JON DUBIN M.D.
PT TYPE: E
ADM DATE: 11/08/1999
LOCATION: ER1-
DICTATION DATE: Nov 9 1999 8:45A
TRANSCRIPTION DATE: Nov 9 1999 11:40A
ARRIVAL DATE:
HOSP SERVICE: ER1
***Final Report***
EXAMINATION: RIGHT LEG (2V)
COMMENTS: Indication: Injury.
73590 -Nov 81999
Examination of the right leg reveals no evidence of fracture or dislocation. No bone or soft tissue
abnormality is identified.
CONCLUSION: Normal right leg.
DICTATED BY: TIMOTHY FARRELL M.D. / DMR
DATE OF EXAM: Nov 8 1999
SIGNED BY: TIMOTHY FARRELL M.D.
DATE/TIME: Nov 91999 1:14P
M•O?/O ?•
0'te ce,,levjedbV
F? . dts .. i
Imaging Services Consultation
Page 1
Holy Spirit Hospital
Department of Radiology and Diagnostic Imaging
Camp Hill, Pennsylvania 17011
(717) 763-2600
PATIENT: SARKISOVA, ANGELIKA
MRM 397502
SOC SEC: 184-72-7565
ORD DR: JON DUBIN M.D.
PT TYPE: E
ADM DATE: 11/08/1999
LOCATION: ER1-
DICTATION DATE: Nov 9 1999 8:45A
TRANSCRIPTION DATE: Nov 91999 11:31A
ARRIVAL DATE:
HOSP SERVICE: ER1
'Final Report'
EXAMINATION: X-TABLE LATERAL C-SPINE (IV) 72020 -Nov 81999
COMMENTS: Indication: Injury.
Prevertebrai soft tissues are normal. Seven cervical vertebrae are adequately seen. No alignment
abnormalities are noted in the lateral projection.
CONCLUSION: Normal cross table lateral view of the cervical spine.
DICTATED BY: TIMOTHY FARRELL M.D. / DMR
DATE OF EXAM: Nov 8 1999
SIGNED BY: TIMOTHY FARRELL M.D.
DATE/TIME: Nov 91999 1:14P
?wiev:edbl
Imaging Services Consultation
Page 1
Holy Spirit Hospital
Department of Radiology and Diagnostic Imaging
Camp Hill, Pennsylvania 17011
(717) 763-2600
PATIENT: SARKISOVA, ANGELIKA
MRM 397502 F
SOC SEC: 184-72-7565
ORD DR: ED GROUP M.D.
PT TYPE: E
ADM DATE: 11/08/1999
LOCATION: ER1-
DICTATION DATE: Nov 9 1999 8:45A
TRANSCRIPTION DATE: Nov 9 1999 11:45A
ARRIVAL DATE:
HOSP SERVICE: ER1
'Final Report'*'
EXAMINATION: PELVIS AND LEFT HIP (3V) 73510 - Nov 8 1999
COMMENTS: Indication: Injury.
The left hip joint and the visualized bones and soft tissues are normal.
The bones, joints and soft tissues of the pelvis are normal.
CONCLUSION: Normal left hip and pelvis.
DICTATED BY: TIMOTHY FARRELL M.D. / DMR
DATE OF EXAM: Nov 81999
SIGNED BY: TIMOTHY FARRELL M.D.
DATE/TIME: Nov 91999 1:14P
ed bV
Imaging Services Consultation
Page 1
Holy Spirit Hospital
Department of Radiology and Diagnostic imaging
camp Hill, Pennsylvania 17011
(717) 763-2600
` PATIENT: SARKISOVA, ANGELIKA
MRM 397502
SOC SEC: 184-72-7565
ORD DR: JON DUBIN M.D.
PT TYPE: E
ADM DATE: 1110811999
LOCATION: ER1-
EXAMINATION: CERVICAL SPINE (6V) 72052
COMMENTS: Indication: Injury.
DICTATION DATE: Nov 9 1999 8:45A
TRANSCRIPTION DATE: Nov 9 1999 11:36A
ARRIVAL DATE:
HOSP SERVICE: ER1
***Final Report***
Nov 8 1999
Alignment is normal and the disc interspaces are preserved. No bony abnormalities are seen. There is no
encroachment on the neural foramina. The atlanto-axial relationships appear normal.
CONCLUSION: Normal cervical spine.
DICTATED BY: TIMOTHY FARRELL M.D.1 DMR
DATE OF EXAM: Nov 8 1999
SIGNED BY: TIMOTHY FARRELL M.D.
DATEITIME: Nov 91999 1:14P
/I M.DJD ^•
Date
1...: opts reviev:ed by
Imaging Services Consultation
Page 1
Holy Spirit Hospital
Department of Radiology and Diagnostic Imaging
Camp Hill, Pennsylvania 17011
(717) 763-2600
PATIENT: SARKISOVA, ANGELIKA DICTATION DATE: Nov 9 1999 8:45A
MRM 397502 : TRANSCRIPTION DATE: Nov 9 1999 11:24A
SOC SEC: 184-72-7565
ORD DR: JON DUBIN M.D.
PTTYPE: E
ADM DATE: 11/08/1999 ARRIVAL DATE:
LOCATION: ER1- HOSP SERVICE: ER1
"Tinai Report""`
EXAMINATION: CHEST PA AND LATERAL (2V) 71020 - Nov 8 1999
COMMENTS: Indication: Injury.
Heart size and pulmonary vasculature are normal. The lungs are clear. No significant bony abnormalities
are seen.
CONCLUSION: Normal chest.
DICTATED BY: TIMOTHY FARRELL M.D. / DMR
DATE OF EXAM: Nov 8 1999
SIGNED BY: TIMOTHY FARRELL M.D.
DATEITIME: Nov 91999 1:14P
nxe _.?-?? n.M1 ^./0.0.
Imaging Services Consultation
Page t
( ply Ice packs Intermittently for-days to reduce swelling.
(' 1 ACe wrap for support for days.
( ) Wear splint ( ) At all times until follow-up.
( ) For activity as needed.
( I Use sling for support.
( ) Use crutches: () As needed, weight bearing as tolerated.
( ) At all times. NO WEIGHT BEARING
NE ACK U /i•ra,?0?
(r Wear camcal collar for support far days.
( ) Rest, avoid banding, lifting, strenuous activity for days.
( ) Apply moist heal for minutes times daily
beginning In hours.
RIT INSTRUCTIOryS
AD K
OH worWschcolfromlo A?
( ) Light Duty until:
Restrictions:
(1 No gynJsports until
( ) Follow Instructions on Workmen's Compensation Forth,
() Wear eye patch for hours.
( ) It nose bleed recurs, pinch nose firmly for 5 minutes
continuously, return if bleeding not controlled.
( ) The prescribed antibiotic may reduce the effectiveness of
,medication you are currently taking. Check package
Instructions or consult with Pharmacist
( ) The interpretation of your X-Rays are preliminary reading.
Your films will be reviewed by a radiologist. You or your
physician will be contacted it there Is a change in the
diagnosis.
Additional Instructions: n
3:
( ) The following medicines may cause drowsiness:
DO NOT DRIVE OR OPERATE MACHINERY WHILE TAKING:
FOLLOW-UP This is our recommendation for follow-up. If your
Insurance HMO) requires a physician referral for specialty
cons ion, IT IS YOUR RESPONSIBILITY TO OBTAIN THE
ESSARY APPROVAL.
( ) Follow-up with: () r center
- Family Doctor
( ) WorkNet
In days for. ( ) Follow-up
( ) Suture removal
( )Call as soon as possible for appointment
( ) Pick up your X-Rays from the Radiology Department prior to
your follow-up appointment. Call 763.2696 to have films
ready.
( ) See your physician or specialist if not improved in
( ) Return to Emergency Center it you feel your condition is worsening.
especially if -
( ) Your blood pressure was elevated. Please have it
rechecked by your physician.
( )Test •results have been given to you. Take them with you to
the follow-up appointment. -
Test its given: OCBC ?CMP ?EKG OX-RAY COPY -
?BMP ?RECORDS COPY CHART OGLUC.
&YPATIENT VERBALIZES UNDERSTANDING
I hereby acknowledge receipt of these instructions and
understand them. I understand that 1 have had emergency
treatment 01 and that I may be released before all of my
medical problems are known or treated. I will arrange for
follow-up care as 1 h9vdbeen instructed. It is your respon.
sibility to notify you)('Pdmary rCare Physician of this visit. ?-
SIGNATURE•V•C.1,t•:(F?.?r
Patient or Responsible Pergoq Date
HOLY SPIRIT HOSPITAL EMERGENCY CENTER
503 NORTH 21ST STREET CAMP HILL, PA 17011.2288 (717) 763-2316
() Vanitha Abraham, M.D. 038840L
( ) Thomas Aldous, M.D. 017075E
( ) Salvatore Alfano, M.D. 025502E
( ) Ramesh Amm. M.D. 016727E
( ) Glen Daughtry, D.O.OS006776E
( ) Jon Dubin, D.O.OS 006991L
DATE
P
) Robert Hynick, D.O. 05 UU14UU-L
) Richard Luley, M.D. 029960-E
) Phillip Maguire, M.D. 015063-E
) Lawrence Paul, M.D. 039524-L
) Frank Pmcopio. M.D. 003643-E
) Howard Rudnick, M.D. 070962-LEi
i::? :V `W' S Y=A
J
() David Spurrier, M.D. 023502-E
( ) Alan Teplis, M.D. 030018-E
(> Elaine Thallner, M.D. 057303-L
( ) David 7timmerman, M.D. 005636-E
?f. Vn41
;19 RR 39_?7?QQ
SIGNATURE .._M.DID.O. DEAN ' 1 4 Y I: n u d- A N C E L I X A(r'` I E ,TIMES
IN ORDER FOR A BRAND NAME PRODUCT TO BE DISPENSED, THE
PRESCRIBER MUST HAND WRITE "BRAND NECESSARY' OR''BRAND
MEDICALLY NECESSARY" IN TIIE SPACE BELOW.
DLAREL 0SUBSTTTUfION PERMISSIBLE
CIKP HIL ?p?? ',
cl/10/195 7 ( ?
194-72-756 `EO GROUP
11/08/99
•1
-.w4..
178 (5/99)
EMERGENCY CENTER URGI CENTER DISCHARGE INSTRUCTIONS HOLY SPIRIT HOSPITAL
(717) 763-2316' ®(717) 763.2424
The examination and umment you have reccivd in the Emergency Center have Men mndemd on an emergency basis only, and are not intended to be a subaimta for or an effort to provide
complete modiat care. If you develop new problems or complications contact your physician or the Emergency Center. FOLLO)Y THE INSTRUCTIONS CHECKED BELOW.
patient Information: Patient Information sheets contain Important Information to review and keep.
I I Abdominal pain
- (I Conjunctivitis O Fever/Ped. Fever ( ) Losor?n
i
k S O Seizuro
( I S
r /
1
( ) Alcohol reaction O COPD (1 Flu tra
n
ec o
roa
( ) Allergic reaction : () Comeal abrasionnoreign body OF uro ( ) Nosebleed j-I grains and Strains
( ) Asthma ( ) Croup/bronchitis Iache
P l l Otitis Media O Threatened Miscarriage
() Back pain ( ) Crutch walking ool Injury
( 1 ) Pediatric Head Injury l l Toothache
( I Bites-Human/AnimaVlnsect () Diarrhea and Vomiting/Ped. Vomiting ( I Hypertension ( )Pediatric URI l l URI and Colds
( ) Burn ( I Drug/Alcohol abuse/addiction ( ) ImmunizatimVTelanus ( )PIDND I I UTI and Pyetonephritis
( ) Chest Pain ( I Febrile Convulsion ( ) Kidney Stones 0 Rash () Other
WOUND CARE
' () May gently wash over wound in 24 hours with soap and water or
peroxide. Do not soak in water.
( 1 Change dressing -times daily. Redress with Bacitracin/Neosporin
and sterile dressing.
( ) Keep wound clean, dry, covered. () Telanus/Diptheria Booster given.
SPRAINS, STRAINS, BRUISES, FRACTURES
( ) Ell idle the Injured pan for- days to reduce swelling.
( pply Ice packs intermittently for-days to reduce swelling.
) Ace wrap for support for days.
( ) Wear splint ( I At all times until follow-up.
( I For activity as needed.
( ) Use sling for support.
( ) Use crotches: () As needed, weight bearing as tolerated.
( ) At all times. NO WEIGHT BEARING
NE ACK
(r Wear cervical collar for support for days.
( ) Rest, avoid bending, lilting, strenuous activity for days.
( ) Apply molst heat for minutes times daily
beginning in hours.
ADD F' f(ONALINSTRUCTIOJ%
o
o
OH worWschool Irom t
( ) tight Duty until:
No gym/sports until
1 Follow Instructions on Workmen's Compensation Form.
Wear eye patch for hours.
If nose bleed recurs, pinch nose finely for 5 minutes
continuously, return if bleeding not controlled.
The prescribed antibiotic may reduce the effectiveness or
medication you are currently taking. Check package
instructions or consult with Pharmacist.
The interpretation of your X-Rays are preliminary reading.
- Your films will be reviewed by a radiologist. You or your
physician will be contacted if there is a change in the
diagnosis.
Additional Instructions:
MEDICATIONS
( ) Continue present medications except:
( ) Us Advi Ibruprofon) r Tylenol a needed for pain, fever
according to package Inst age, weight.
( ) Use the following medicines according to package
Instructions:
t:
2:
3:
( ) The following medicines may rouse drowsiness:
DO NOT DRIVE OR OPERATE MACHINERY WHILE TAKING
FOLLOW-UP This is our recommendation for follow-up. If your
Insurance (HMO) requires a physician referral for specialty
consuAauioon, IT IS YOUR RESPONSIBILITY TO OBTAIN THE
?Ed'ESSARY APPROVAL
(( ) Fallow-up with: () r Center
Family Doctor
( ) WorkNet
in days for. (I Follow-up
( )Suture removal
( ) Call as soon as possible for appointment
( ) Pick up your X-Rays from the Radiology Department prior to
your follow-up appointment. Call 763.2696 to have films
ready.
( 1 See your physician or specialist It not Improved in
( ) Return to Emergency Center it you feel your condition is worsening,
especially if
( ) Your blood pressure was elevated. Please have It
rechecked by your physician.
( ) Test results have been given to you. Take them with you to
the follow-up appointment.
Test results given: ?CBC OCMP DEKG OX-RAY COPY
/OBMP ? RECORDS COPY CHART ?GLUC.
('PATIENT VERBALIZES UNDERSTANDING
I hereby acknowledge receipt of these instructions and
understand them. I understand that I have had emergency
treatment gnly and that I may be released before all of my
medical problems are known or treated. I will arrange for
follow-up care as I h3vd been are Physician (s your rvis /L'' •?
sibiliry, to notify your Primary Care , of this visit. it. 1\)
SIGNATURE: i I- ! r,. "-? '-
Patient or Resoonsible Persoe Datr
HOLY SPIRIT HOSPITAL EMERGENCY CENTER
503 NORTH 21ST STREET CAMP HILL, PA 17011-2288 (717) 763-2316
( ) Vanitha Abraham, M.D. 038940L ( ) Robert Hynick, D.O. OS 004400-L ( ) Ranjana Sharma, M.D. 031265-E
( ) Thomas Aldous, M.D. 017075E ( ) Richard Lulcy. M.D. 029960-E ( ) David Spurner, M.D. 023502-E
( ) Salvatore Alfano, M.D. 025502E ( ) Phillip Maguire. M.D. 015063-E ( ) Alan Teplis, M.D. 030018-E
( ) Ramesh Arom, M.D. 016727E ( ) Lawrence Paul, M.D. 039524-L ( ) Elaine Thalincr, M.D. 057303-L
( ) Glen Daughuy. D.O. 05006776E ( ) Frank Procopin, M.D. 003643-[ David Zimmerman. a1.D. 005676-E
( ) Jon Dubin, D.O. OS 006991 L ( ) Howard Rudnick. M.D. 040H62-L.-1 ~V!"::?-a't+),
Date:
Name:
FMD:
_J CHIEF
TRIAGE: -
Log-[n Time:
`t `j Age Triage Time: -!
A Time to Exam Room:
Place In[ury occurred: [ ) Home [ JPauslry I r paramedic
Inlormetion obtained from: atlont -Family/S.O. -Records
[
Eztremlty Eveluellon: warm Coal resent! Absent Desllnstion: ECU EDF
Skin Temp
Delermlty Yos/NO paroslhesla Present!Absent We:
Skin Colo pink /Cyanotic/hloeled P Signature:
g/p; Pulse Ox.:
Intervention: Pulse: Respirations:
nccFSSMENT Temp:
Allergies/Reactions: Lalex•Yes/ o
"k r c tf7c.MlelghL•=-scaletestimate (I1 pertinent)
s
Last Tetanus: LMP:
Or O,U,-Corrective arises (1
Subjectivgi
objective:
V
Past"Medical/Surgical History: - '
there Are advance directiv s is copy available?
nt had exposure to measles chickenpox or TB in past monnth?
t
ie
Has pa
' LAV" 1-
Went m cardiac output demonstrated by improved vs antld iagnosctests
C ac output, alteration in Imr
ecroaso or relief of discomfort lams of fluid vol. imbalance
decrees in sy
monstrated b
d
omforl, alteration in -
alteration in
Fluid volume y
e
_Impr yqQUM in fluid val.
I radgas xchangodem0 tmtedh Improved
i ?alien and vital signs
y9
for infection
,
Impaired gas exchange _-
- ecr sei ym toms' i nginfectionorpotenl
edbyverbalizalion
' return demonstration
Polential/Actual Infection
t ed wl ge a
Imp
Knowledge Oelicit R.N.
Assessment completed at by M.A
Data obtained by: cords sent
[ J Ad
Admission Called: tried to anon
at is Tran /erred t
it
-tG a
Ilj 1 ds ?t eft.
Report Call 1
? [ tisfactory •IgI . led!
1 XXX llL 1 C
10 at
Disposition: Discharge r
\.\"' 'ojy Spirit Hospital
Camp Hill, PA
ECU Nursing Assessment
201.ECU yar 6m Rav.JD. Po en
7 1IC:iL1x0 Lilt[ ER1
C1'p HILL PI 17011
01/10/1962 731-6272
114-72-7565 ED GROUP
11/08/99
4SH ER FORM REG QATE: 11/08/99 19:53 PT#k: 14216519 MR4: 397502
)ME: SARKISOVA ANGELIKA SS ft: 184-72-7565
)DRESS: 7 RICHLAND LANE /CAMP HILL /PA/17011 PHR: 717-731-6272
(RTHDATE: 01/10/1962 AGE: 37 SEX: F MS: X RACE: 1 GEO: 043080
1PLOYER: CAMPHILL CARE CENTER OCCUPATION: KITCHEN HELP
JDRESS: /HARRISBURG /PA/ PH#I:
-IURCH: CHRISTIAN AMD: NONE
3MMENT:
EMERGENCY CONTACT INFORMATION
AME: SOGOMONOVA ,ZHANNA REL TO PT: R WORK PH 4:
DDRESS: 1422 FORT AVE /HARRISBURG /PA/1709V PH #!: 717-540-9162
AME:
DDRESS:
REL TO PT: WORK PH i#:
PH B:
CASE INFORMATION
DMIT DR: 150018 ED GROUP REG SOURCE: ED PATIENT TYPE: E
,TTND DR: 180018 ED G HOSP SERV: ER1 FINANCIAL CLS, W
EFER DR: VISIT CLINI C CODE: ER1
,OMIT DX: ICU-9 DX:
:OMPLAINT: ALLEGED ASSAULT
,MB BRT IN BY: EAST PENN BRT IN BY: AMBULANCE
:OMMENT:
ACCIDENT INFORMATION
)ATE/TIME: ACC IND: JOB RELATED: LOCATION:
)ESCRIPTION:
GUARANTOR INFORMATION
DAME: SARKISOVA ANGELIKA PT REL TO GUAR: S SS #6: 184-72-7565
4DDRESS: 503 N 21ST ST /CAMP HILL /PA/17011 PH ##: 717-763-2459
EMPLOYER: CAMPHILL CARE CENTER CONTACT NAME: MARY JAMES RN
ADDRESS: /HARRISBURG /PA/ PH #i:
INSURANCE INFORMATION
PLAN INSURANCE CO COB POLICY # GROUP ##
SUBSCRIBER REL PC VFY CARD PRECERT/RUTH 4 PRECERT PHONE U
1
- N - -
INSUR.ADDRESS:
2
INSUR.ADDRESS:
3 002 HEALTH AMERICA IPZ40P 1 18472756501 1006260007
SARKISOVA ANGELIKA S Y Y - -
INSUR.ADDRESS: PO BOX 263.0 PITTSBURGH PA 15230
4
INSUR.ADDRESS:
COMMENTS: FMD: PT REG BY SISTER, NO PT CONTAC
T, NO COPY OF CARD, COPIER BRO KEN
PATIENT NAME: SARKISOVA ANGELIKA PTN: 14216519 MR#I: 397502
REGISTERED BY: STFUS EDITED BY:._ ••, .. ,• •_ DATE: 4L.- END OF DOCUMENT
20:00 11/08/99 FROM HGD6,ERREGSFI
COMMONWEALTH OF PENNSYLVANIA IF DEPARTMENT OF HEALTH • VITAL RECORDS
MARRIAGE LICENSE APPLICATION
TYPE/PnINT IN PERMANENT BLACK INK, 9-26-95 STATE FILE NO.
L COUNTY ISSUING LICENSE M. IVREITMADFULP- Cl I Y. 110110, TOWNSHIP M. COUN IY G. DATE OF M'ARRIAGE(MIInlh, 0,, ieni)
Dauphin _ -Harri.sbur r
-?--
-Dauphin---
4n. NAME OF Poison FERfGRMRIG CEREMONY 411. TITLE -------
4C.AOUIILC•501'1'ff15001'fI1FORM1UNG CEIICAroNY ISbeel,Cq cr Town, Ll.dn, l.,p COly)
Rev. Daniel D Ressetar Priest 5501 LoCUlsL Ln. IIb Pa 17109
GROOM BRIDE
5.1. TIME IFrst, MAft Lasll SL. NA,.IE 11'usL AE,UI^, Lase - -------
Glenn Maurice Plank, Jr. Angelika Sarkisova
GI. IIESIMNCE- COy, 110,lvw ulnP LL. COUNTY
--
Gc•TAIE
-- --- -
..c. MAI0LN`.U--NN -AMIE IIt J410 ll --'--
Lower Paxl'on Twp Dauphin PA
h.(111ITT II IACCI uk, F vqn CVUnlryl /L OAILOF0111111 !c k ClASRItNOIUA Y Gl. 1IE iUCNLE Cily, 11 La sl I Go.000N7Y-- YI. STATC -_
PA 3-2 65 I 30 Lower Paxton Iwp (Dauphin f PA
O,r.NUMIILRur IIIIS)NINIIAGL II 111 JLVIOU5LY)IMIIIITOLASIAI
etc. ww"Iy) 06.11 JJn=n,an ??,nl LIn
W
ct AIINIALLENULO
[)AIL
M
m
O III "III IIIILACE ItWaUt0T ) CUUNY) IC.[) -or 1111181 IIAGCLASTIIINIIIUAY
AIL
Armenia [oT merle 1-10-62 L 33
V
Y)
Ist I
Vn
,
ay, Yn,r) 11IIQQ
OA.NUM1IIICT10T 11115JAIIIYAPI! R-Ifl'IIEMOUSLY MARRIED
ST
I
. LA
MAI
IUAGC rNDEO
Fnsl, SncunJ, ele.ISyeNy)
IS "W
Op.Ily rMallr,Jrvo¢q annulund OI. UAIf:
IMWnllr
Y
(l
IIMRSAUSSIIILE UCB:ASCt 91U
l
W
C000AIIOfl
E
h
M
=r
t
b
l
"
2nd
,
UarJ
ay,
.
y
.
(
ry on
q
Orar
n
canP
ntaJl
I
'
ElnlmnMrylSVfvnJary Cdlsgc Divorce G-1
D
-66
IO 121 (ldw SII
LvING YES
-1 F-1
AAAAIIII JJ (( Oc. NIANSMISSRILL OSEASEi -TIM. EDUCATION (SPCO1Y ONi L.11'elnraJnc.14cl^u)-
Ebm^nMry/Fvconlary ? CoGgln
tOa. USUAL O------IIGN------- --- ------- ----'---------- 1012) (Lam 5.1
lim
Maintenance Supervisor
EXINO ?YES 3
v
ITV. PAIIIER'S NAME (Ilnl, M16dIIn,LasN - )
IOU. USUAL OCCU?A1lON ?- - 'F
Glenn M. Plank
Sr llbg. Hosp. Nurse ICU i
,
.
IIU.UIG1111'LACG 151a1^m Fu'egn CVwlryl 114 FAG TEN'S NAMEIFxsU IANJIn.lasll -----'V
IV PA Yurey Sarkisova
y 12n. MO111E11'S NAMEIPU;I, ,AdJN, LASII Itd. UITURPLAL'[ISlalvvr l°acgn L'ovnliy)
Beverly Plank Armenia
I•. 12c M14U0E11.^.UItr1AME I3J. UIO TIIPLAL'G (StalwrFvmgn Cuunlry) 120.MO NIEO'S NAME IFrsI, Ahr1JIq 11.) '•
-
Cunningham
PA 1 I
Yelena Sarkisova
TSI.FAT I IEI I'S iIESIUCNCE
PA
- 12c. IMIDENSUIINAME t2L Ulllf IPIAOE ISUL11 er F.1, Cmrruyl
Galustyan Armenia
14v
FAniLi FS USUAL OCCUrN ION
Truck Driver
12U. FAIIIEII'9 ?ESIUENCE
Deceased
I A,. NO I I ILI I'S RESIDENCE O FAIIICR'SUSVALOCCUPAIION ---'-
PA
I6s.M0111E11'S VSIIAI OCCUPAtI@1 15U. MOTI JEWS RESIDENCE -----
Librarian Lower Paxton Twp
An DOE.^•APPLICAN t SATISFY ALL PI IOVISIONS IN
PT:NNSYLVANIA'SMARRIAGE TWIN?
?NO YES
s
w I6U. MOT) IEB'SUSUALOCCUPAIION -
.'
o
( Dauphin ManorNUrsing Home
1 .15Y/EMENEU,INSANE Oil OF UNSOUND MIND, OR UNDERA QUMIUTANSIUP III. DOES APPLICANTSA1lSFYALL PROVISIONS IN
-
PENNSYLVANIAS MARRIAGE IAtYT I
I L.1
NO
YTS
(SEC L^I^wl J
L1J
2 . IS LITTLER THE INFLUENCE OF INIO%ICAIING LIQUOR 0(1 t1AlICOIIC DRUG. O .IS OF TIIE PROIIIIIIIEUDEGNEE OFCONSANGUINI FY OR AFFINITY.
S IGNAIUUE OF PARENT 5H GUAliUTANGIVING CONSENT, IFIIEOUIREU S IGNATURE OFPARENTOR GUARUTAN GIVING -CONSENT. IF REQUIRED
WE, THE UNDERSIGNED, IN ACCORDANCE WAIT TIIE STATEMENTS HEREINAFTER
SOLEMNLY SWEAR ARE TRUE AND CORRECT TO THE BEST OF OUR KNOW LEDGEAND CONTAINED, 111E FACTS AS SET FORTH WHEREIN WE AND EACH OF US DO
BELIEF
00 MAKE APPLICATION TO TI IE CLERK OF ORPHA
'
,
NS
COURI TO MARRY.
S IGNAIUREOFGROOM ^
SIGNATURE OF BRIDE
V
SWORN AND SUBSCRIBED To BEFORE MET141S 6-a DAY0F_A41t. ,q.p„T9?
SEAL
DATE LICENSE WAS ISSUED ?Y? ??J- ???
CLERKOPHANS''CDI ON
NO. /_ ?; VOL. C /q
's5
ANGELIKA SARKISOVA, IN THE COURT OF COMMON PLEAS OF
PLAINTIFF CUMBERLAND COUNTY, PENNSYLVANIA
V.
GLEN M. PLANK, JR.,
DEFENDANT 99-7014 CIVIL TERM
ORDER OF COURT
AND NOW, this -2-L*N_day of November, 1999, following a hearing,
the petition of Angelika Sarkisova for the entry of a protection from abuse order, IS
DENIED. The temporary order entered on November 19, 1999, IS yIACATED.
By the Court,
i '
Edgar B.
Joan Carey, Esquire
For Plaintiff ,,, e«L a??9Y
e°;p P
Arthur K. Dils, Esquire
For Defendant
J.
:saa J1 la-y 1q4
2
GCJi?Y
•a
I Li U,VI`V
SHERIFF'S RETURN - OUT OF COUNTY
CASE NO: 1999-07014 P
COUNOTYWOFLCUMBERLANDSYLVANIA:
SARKISOVA ANGELIKA
VS.
PLANK GLEN, JR.
Sheriff, who being duly sworn according
R. Thomas Kline for the within
to law, says, that he made a diligent search and inquiry
named defendant, to wit: PLANK GLEN JR
Him in his bailiwick. He tnereiore
but was unable to locate Pennsylvania.
DAUPHIN County,
deputized the sheriff of
to serve the within PROTECTION FROM ABUSE
On November 30th, 1999 this office was in receipt of
DAUPHIN County, Pennsylvania.
the attached return from
.
So answer, -/
Sheriff's Costs:
Docketing 18.00 G/??? r'?
Out of County 9.00 omas ine, eri
Surcharge 8.00
Dep. Dauphin Cc 25.50
?Q 11/30/1999
Sworn and subscribed to before me
this 1 j 6? day of f Qc" ?'"
19A.D./
ro ono ary
W I f f
Mary Jane Snyder
Itcal Estate Dclxup
William T. Tulh
Solicitor
Dauphin County
Harrisburg. Pcnnsylcania 17101
p11:(717)255-2660 thx:(717)255.2889
Jack Lotwick
Sheriff
Commonwealth of Pennsylvania SARKISOVA ANGELIKE
vs
County of Dauphin PLANK GLEN N JR
Sheriff's Return
Ralph G. McAllister
Chief Ikputc
Michael W. Rinehart
Assistant Chief DcPuly
No. 2415-T - - -1999
OTHER COUNTY NO. 99-7014
AND NOW: November 22, 1999 at 6:OOPM served the within
PROTECTION FROM ABUSE upon
PLANK GLEN N JR by personally handing
to DEFT 1 true attested copy(ies)
of the original PROTECTION FROM ABUSE and making known
to him/her the contents thereof at 5836 LOCUST LANE
HARRISBURG, PA 00000-0000
Sworn and subscribed to
before me this 23RD day of NOVEMBER, 1999
\5? ZA) 6 f a??
PROTHONOTARY
So Answers,
lel°/
Sheriff of Dauphin County, Pa.
By197ae-a? ?-
Deputy Snerif
Sheriff's Costs:$0.00 PD 00/00/0000
RCPT NO
MS
' J
In The Court of Common Pleas of Gamberland County, Pennsylvania
AngeliKa SarKisova
VS.
U.Len M. Plank, .Jr. No 99 7U14 Civil
Now, November 19, 19 99 , I, SHERIFF OF CUMBERLAND COUNTY, PA, do
hereby deputize the Sheriff of oaupnin County to execute this Writ, this
deputation being made at the request and risk of the Plaintiff.
Sheriff of Cumberland County, PA
Affidavit of Service
Now,
within
upon
at
by handing to
a
copy of the original
and made known to
So answers,
the contents thereof.
Sheriff of County, PA
Sworn and subscribed before
me this _ day of , 19
19_, at o'clock M. served the
COSTS
SERVICE $
MILEAGE
AFFIDAVIT
S
11/ '
19/99 PRI 16:13 PAY 717 240 6573
TRANSMISSION OK
TY/RX NO
CONNECTION TEL
CONNECTION ID
ST. TIME
USAGE T
PGS.
RESULT
CUNO CO PROTHONOTARY
xixxxssxsxsxxxuxxiss
ssx TX REPORT xxx
SxSTxixxixxSiSSSxx111
1595
92490779
11/19 16:09
03'33
2
OK
1%9.70/% la0D1
11/19/99 FRI 16:06 PAX 717 adn Rs7a
-- I.". au rRUItlUilulAKI I"I - /D /Y C. 1 16001
FaaxaxSaxiFFYYFxixxit
sax TX REPORT ssx
saxsxssxxxaxxasxxaxxx
TRANSMISSION OK
TX/RX NO 1593
CONNECTION TEL 92490779
CONNECTION ID
ST. TIME 11/19 16:02
USACE T 03'34
PCS. 6
RESULT OK
11/19/99 FRI 16:00 PAX 717 240 6573 CU14B CO PROTHONOTARY 70/'f Q f?001
xzxxsxxxsxxzxxxsszxxxassxxx
ssx ERROR TX REPORT a:xx
sszzxxxxxzzxxsxxsxazzsxxxxr.
TX FUNCTION WAS NOT COMPLETED
TX/RX NO 1592
CONNECTION TEL 92490779
CONNECTION ID
ST. TIME 11/19 15:54
USAGE T 05'56
PGs. 7
RESULT NG
7 »001