Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
07-4940
f 07HB00041 LAW OFFICE OF SNYDER & DORER 214 SENATE AVENUE, SUITE 503 CAMP HILL, PA 17011 TELEPHONE NUMBER: (717) 731-0988 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MICHELLE POSSENTI AND KEVIN TALHELM, INDNIDUALLY AND AS PARENTS AND NATURAL GUARDIANS OF PAIGE TALHELM, A MINOR, Petitioners VS. NATIONWIDE MUTUAL INSUARANCE COMPANY, Respondent No. d 7- 4 4 ~d ~c,! ~~taw~- PETITION FOR LEAVE TO COMPROMISE MINORS' CLAIM Pursuant to Pa.R.C.P. 2039, Nationwide Insurance Company, by and through its attorneys, Snyder and Dorer, hereby jointly petitions this Court to enter an Order permitting settlement in compromise of this action, and in support thereof, avers the following: 1. Nationwide Mutual Insurance Company (hereinafter "Nationwide"), is a corporation organized and existing under the laws of the State of Ohio and having its principal place of business in Columbus, Ohio, being duly authorized to conduct business in the Commonwealth of Pennsylvania at 1000 Nationwide Drive, Hamsburg, Pennsylvania. 2. Petitioner, Michelle Possenti, is an adult individual residing at 113 Woodview Drive, Mount Holly Springs, PA 17065. She is the parent and natural guardian of Paige Talhelm, a minor, who was born on November 2, 1991. 3. Petitioner, Kevin Talhelm, is an adult individual residing at 7 Todd Road, Carlisle, PA 17013. He is the parent and natural guardian of the minor, Paige Talhelm. 4. On June 26, 2005, Paige Talhelm, who was 13 years old at the time, was involved in a motor vehicle accident while riding as a passenger in a vehicle which was operated by her aunt, Melinda Sassman, who is the sister of the minor's mother. 5. The accident happened in Sacramento, California, when a vehicle driven by a Victor Yantes Leon suddenly moved into the lane occupied by the Sassman vehicle, resulting in a collision between the two vehicles and causing the Sassman vehicle to roll over and exit the highway. 6. Following the collision, Paige Talhelm was transported by ambulance to the University of California Davis Medical Center in Sacramento; California where she wasp admitted overnight for observation and treated for a severe abrasion/road rash to her right .' forearm. The road rash covered the proximal 1/3 of the forearm with two larger areas extending deeper in the subcutaneous tissue. As a result of foreign bodies imbedded in the skin,. the minor .Was required to undergo two debridements using a surgical scrub brush. On the folldwing day, she was discharged with instructions for wound treatment, along with instructions to follow up with her primary care physician in Pennsylvania. (See medical records attached as Exhibit "A".) 7. Paige Talhelm was seen in follow up by her primary care physician at Carlisle Pediatrics in Carlisle, Pennsylvania. She had four follow up visits which consisted of examinations for infection and healing, as well as dressing changes to protect the healing wound. On July 26, 2005, the doctor noted that Paige Talhelm had only two small areas left to heal, and observed that the rest had "healed well". There was no infection. (See medical records attached j as Exhibit "B".) 8. Paige Talhelm has now returned to all normal activities. 9. No medical expenses were incurred by Michelle Possenti and Kevin Talhelm on behalf of Paige Talhelm as a result of the injuries sustained in the June 26, 2005 accident. 10. No known unpaid or out-of-pocket medical expenses exist. a t , 11. No additional treatment is presently anticipated for Paige Talhelm as a result of the injuries sustained in the June 26, 2005 accident, although scar revision may be considered in the future. (See medical records attached as Exhibit "C".) 12. At the time of the accident, Michelle Possenti, the mother of Paige Talhelm, had automobile insurance coverage through Nationwide, which included underinsured motorist ~ coverage. 13. After negotiating a $10,000.00 settlement with the tortfeasor's carrier, whose policy consisted of bodily injury liability limits of $15,000.00 per person/$30,000.00 per accident, Michelle Possenti negotiated-a settlement of the minor's bodily injury claim under her UIM coverage with Nationwide. A full and final settlement was agreed to in the amount of $60,000.00. (See Order of Court approval of settlement with tortfeasor attached as Exhibit "D".) 14. Michelle Possenti and Kevin Talhelm, as parents and natural guardians of Paige Talhelm, believe that the minor recovered from the injuries sustained in this accident. (See Affidavits, attached hereto as Exhibits "E" and "F".) 15. Michelle Possenti and Kevin Talhelm join the Petition and approve the proposed settlement because, under the circumstances, they consider it fair and reasonable compensation for the minor, Paige Talhelm. (See Exhibits "G".) 20. Under the proposed settlement, Paige Talhelm will receive the sum of $79,946.08 as set forth below and in accordance with the attached structured settlement agreement which is incorporated herein by reference. (See Exhibit "H"): To be paid to Paige Talhelm on or about November 12, 2013 (age 22) the sum of $79,946.08. a ~ y ~ WHEREFORE, Petitioners request this Honorable Court to enter an Order approving the settlement and compromise and ordering distribution as set forth in the attached Order. SNYDER & RORER ~ :.;, .,~ .:: .. ~:: ~~_ ;, ,~ ~ ~ - t ~`: ~, By: ~~ JoAnne E Kinze ; squire Attorney~or Nationwide Mutual Insurance Company Dated: ~ ~~ ~'~-1.~..: ~-~J~t.~'~~ i CATION I, Kevin Talhelm, verify that I am the parent and natural guardian of the minor, Paige Talhelm and that I am a joint petitioner in this action. I hereby verify that the statements made in the foregoing Petition for Leave to Compromise Minors' Action are true and correct to the best of my knowledge, information and belief. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to I authorities. KEVIN TALHELM DATE: ~~510 f ~ ~ ti a ~ TION I, Michelle Possenti, verify that I am the parent and natural guardian of the minor, Paige Talhelm and that I am a joint petitioner in this action. I hereby verify that the statements made in the foregoing Petition for Leave to Compromise Minors' Action are true and correct to the best of my knowledge, information and belief. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities. r y ,. <, MICHELLE POSSENTI DATE: "' , i~' ~~N»« ~ ' ~ ~ Y _ UNIVERSITY OF CALIFORNIA MEDICAL CENTER SACR:IMENTO, CALIFOP.NI A Ell I'IZOGi2ESS NOTE (Page 1 of 3) PATIENT: TALHELM, PAIGE 9VW LOCATION: ERWB MR #: 1769260 SEX: F AGE: 13 DATE OF SERVICE: 06/26/2005 DOB: 11/02/1991 EMERGENCY DEPARTMENT N~fTE _, LINKING LANGUAGE: The patient was seen and examined with Dr. Cadogan. I reviewed the resident's note and agree and helped developed a plan of care. HISTORY OF PRESENT ILLNESS: This is a 13-year-old female brought in by ambulance status post ~,'' restrained passenger in a freeway speed rollover MVA. No loss of consciousness. The patient complains of right arm pain only. The patient had a GCS of 15 and stable vital signs in the field. The patient denies headache, nausea, vomiting, neck pain, back pain, chest pain, shortness of breath, abdominal pain or weakness. PAST MEDICAL HISTORY: Seasonal allergies..Medicines: None. ALLERGIES: None. Immunizations: Up-to-date. Surgical history: Inguinal hernial repaiz. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Noncontributory. REVIEW OF SYSTEMS: Positive for abrasions, otherwise negative. PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished female, no respiratory distress. HEENT: Small right temporal abrasion without cephalohematoma. Pupils equal, round, reactive to light. Extraocular muscles intact. No raccoon or battle sign. Face nontender. Oropharynx benign. No malocclusion. NECK: Trachea midline, no JVD. C collar in place. CHEST: Nontender, stable, breath sounds zqual bilaterally. HEART: Regular rate and rhythm without m>!rmurs. ABDOMEN: Soft, nondistended, nontender. PELVIS: Nontender, stable. UNIVEI2:SITY OF C:ILIFORNIA MEDICAL CENTER SACRAAiENTO, CALIFORNIA ED PROGRESS NOTE (Page 2 of 3} PATIENT: TALHET~M, MR #: 1769260 DATE OF SERVICE: PAIGE 06/26/2005 LOCATION: ERWB SEX: F AGE: 13 DOB: 11/02/1991 EXTREMITIES: Nontender except for right arm.~.In the right arm there is a large abrasion over the right forearm and elbow with some lacerations and possible glass. There is tenderness along the areas of abrasion. Distal neurovascular is intact to radial, median, and ulnar nerve distributions. NEUROLOGIC: Alert and oriented times four. GCS 15. Strength and sensation normal except as limited by pain in the right arm. BACK: Nontender throughout. ASSESSMENT AND PLAN: ..'~, A 15-year-old female status post high-speed MVA with scalp abrasion and large right arm abrasion with some small lacerations and possible glass foreign bodies. Will check x-rays including C-spine, chest x- ray, pelvis, and films of the right arm to evaluate for fracture and to evaluate for foreign bodies in the arm. Check labs including serial CBC, CHEM-7, AST, ALT, urinalysis screen. Follow the patient's neurologic and abdominal exams clinically in the Emergency Department. Feel that CT scans are not indicated at this time. The patient will need wound care of her right arm. PRELIMINARY ED DIAGNOSES: 1. Scalp abrasion. 2. Large right forearm abrasion. 3. Status post rollover MVA. ADDENDUM: Care of this patient was signed out to Dr. Ballard at 1800. THIS WAS ELECTRONICALLY SIGNED - 06/26/2005 6:38 PM PST BY: PETER E SOKOLOVE, MD ASSOCIATE PROFESSOR EMERGENCY MEDICINE DEPARTMENT PES:dew(usa128) D: 06/26/2005 06:16 PM ,, • ~ ~:~. ti . F. PATIENT: TALHELM, PAIGE MR #: 1769260 DATE OF SERVICE: 06/26/2005 T: 06/26/2005 06:23 PM _ C#: 1092652 UNIVERSITY OF CALIFORNIA NIC:DICAL CENTER SACRAMENTG, C:ai,IFORNIA ED PROGRESS NOTE (Pale 3 of 3) LOCATION: ERWB SEX: F AGE: 13 DOB: 11/02/1991 ~. _~ .~, ~ -t=~ s tr.;~YrL_ . TY OF CALIFORNI.'. ~'IEDICAL CENTER SACRAMENTO, CALIFOR'vIA CONSULTATION ~P.~ge I of 3) PATIENT: TALHELM, PAIGE 9VW MR #: 1769260 DATE OF SERVICE: 06/27/2005 ORTHOPAEDIC SURGERY CONSULTATION HISTORY OF PRESENT ILLNESS: LOCATION: SEX: F AGE: 13 DOB: 11/02/1991 .:. -- The patient is a 13-year-old female brought in by ambulance tonight, status post motor vehicle accident. The patient was the restrained passenger in the vehicle, which was traveling at highway speeds. The patient denies any loss of consciousness. Her major complaint upon arrival was right arm pain. The patient denies any other problems or complaints at that time. „~• I was asked to see this patient for evaluation of her right forearm road rash/abrasions. PAST MEDICAL HISTORY: Seasonal allergies. Past surgical history: Repair of inguinal hernia. ALLERGIES: None. Medications: None. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: The patient lives with her family in Pennsylvania. REVIEW OF SYSTEMS: Negative, except for right forearm abrasions/road rash. PHYSICAL EXAM: GENERAL: The patient is healthy appearing and in no apparent distress. SECONDARY EXAM: Negative. EXTREMITY: Exam of her right upper extremity reveals significant road rash of her flexor forearm over the proximal 1/3 with two larger areas which extend deeper in the subcutaneous tissue down to just above the fascia. These two areas measure approximately 2 x 2 cm and 3 x 3 cm in diameter. Overall the wound appears fairly clean, except for a few areas of necrotic tissue and debris from the road. The patient received an axillary block prior to my examination. She had a good radial pulse distally. X-RAYS: MR #:1769260 UNIVEhv[TY OF CA%il`'vi~i~IA MEDICAL CENTER SACRAMENTO, CALIFORNIA CONSULTATION (Page 2 of 3) rATIENT: TALHELM, PAIGE 9VW MR #: 1769260 DATE OF SERVICE: 06/27/2005 LGCATION: SEX: F AGE: 13 DOB: 11/02/1991 _ Right elbow and forearm x-rays are negative for any fracture or dislocation. There are multiple radiopaque foreign bodies in the skin in the location of her road rash/abrasions. ASSESSMENT: Right forearm abrasion/road rash, status post Emergency Room irrigation and debridement. PLAN: The patient underwent an irrigation and debridement prior to my examination using six liters of normal saline and a pulsatile lavage. Since her axillary block was still providing some anesthesia, I was able to perform a secondary debridement, debriding some necrotic skin and foreign bodies from the tissue. I was also able to use a surgical scrub brush and Betadine to further debride the tissue of any foreign body. At the end of my procedure, which she tolerated fairly well without any major problems or complaints, her wound appeared clean without any significant contamination. I demonstrated wet-to-dry dressing changes to the patient's parents. They expressed understanding. RECOMMENDATIONS: My recommendations for this patient are that she be discharged with wet-to-dry dressing changes twice a day. She is also to place Xeroform over the abrasions circumferentially around her deeper wounds, which should be packed with wet-to-dry dressing change. I also recommend that she be discharged with Keflex for five days and pain medications. The patient will follow up with her primary care physician in Pennsylvania. I educated the patient's parents regarding signs and symptoms of infection. They expressed understanding and indicated that they would seek medical attention for any problems or concerns. i UNIVE,. ~ITY OF CALIFORNIA MEDICAL CENTER SACRAMENTO, CALIFORNIA PATIENT: TALHELM, PAIGE 9~TFJ MR #: 1769260 DATE OF SERVICE: 06/27/2005 CONSULTATION (Page 3 uf' 3) LOCAT_TON: SEX: F AGE: 13 DOB: 11/02/1991 _ ,;, _ . THIS WAS ELECTRONICALLY SIGNED - 06/29/2005 12:16 PM PST BY: BRANDON J FERNEY, MD RESIDENT DEPARTMENT OF ORTHOPAEDIC SURGERY BJF:dhs(usa124) D: 06/27/2005 02:44 AM T: 06/27/2005 04:34 PM C#: 1092889 -~ y~ +l. .~ ~`j i ~ ~T ~• b ~ - ~r b~a v. . Kt --sg -,¢3'4: - ~ r tie ,. J UNIVERSITY OF CALIFORNIA DAMS EMERGEI~?CY REG (COPY) PATIENT INFORMATION RECORD PAGE 1 ---------- -------------------------------------------- TALHELM ,PAIGE 9vv1 SVC: EDR N/S ERWB FC: V PENDING MEDI-CAL, CM T~IR#: 1769260 9 PT TYPE: E OLD MR#: ACCT# 20-QU'0114997 OUTPT REG DT/TIME: 06/26/05 17:12 INPT ADMIT DT/TIME: FLAGS ADM PCP UPIN: ATT PCN ADM CD ICD9: CPT: PCP PI#: DX PCP ADD: _ INST: ----------=---------------------------- PATIENT INFORMATION: ADDR: 113 WOODVIEW DR MT HOLLY SPRING PA 17065- HOME TEL: 717-486-4808 MSG TEL ADDL ADD: COUNTY 98 OTHER STATE GUARANTOR REL: PARENT GUAR NM: POSSENTI ,MICHELE ADDR 113 WOODVIEW DR MT HOLLY SPRING PA 17065- HOME 717-486-4808 MSG GUAR SSN# 563-59-3590 GUAR DL/ST GUAR SEX •~ ..ATIENT EMPLOYMENT: STATUS: 3 OCCUPATION: NOT EMPLOYED EMPL EMPL ADDR EMPL TEL X LNGTH OF TIME ON JOB: VET: RELATED CONDITION: U.C. EMPLOYEE IND: PT SSN# 000-00-0001 PT DL/ST UNKNOWN UN PT DOB: 11/02/1991 AGE: 13 SEX: F MS: S SP NM: MAIDEN NM UNKNOWN- OTHER NM ETH: BPLACE: RELIGION: LANGUAGE: --------------------------------------- ~CIDENT INFORMATION: ACCIDENT RELATED CONDITION: Y ACC DT/TIME: 06/26/05 00:00 ACC TYPE: AUTO ACCIDENT ACC LOC ER H/A OTHER AMBULANCE CO. ER CMPT MCI MVA GUARANTOR EMPLOYMENT: STATUS: OCCUPATION EMPL EMPL ADDR EMPL TEL X LNGTH OF TIME ON JOB: ------------------------------- NEXT OF KIN REL: OTHER RELATIVE NOK NM SASSNj~N ,MELINDA EVN TEL DAY TEL 916-684-0393 X MSG TEL GUARDIANSHIP PAPERS ON FILE: ------------------------------- REFERRAL: DATE: DR: X PCN: FACILITY: X ----------------------------------------------------------------------------- LAST ADMIT DATE: ESTIMATED LOS: ADVANCE DIRECTIVE INFORMATION: WAS AD INFORMATION AND UCDMC POLICY STATEMENT GIVEN TO PT/REP? DESCRIPTION: DOES PT HAVE AN ADVANCED DIRECTIVE? HAS COPY OF PT'S AD BEEN PLACED IN PT'S MEDICAL RECORD? T & C SIGNATURE: PATIENT GUARANTOR PMHUNVF5 DOCUMENT GENERATED BY: HADSB 18:38 06/26/05 FROM LX9D,PMHUNVF5 li NIVERSITY OF CALIFOR~~:ItA, DAMS BERF:ELEY • DA\'iS • IR\~INE • LCS t,.`vGELES • MERGED • RIl'ERSIDE • S.qN D1FG0 • SAN FRANCISCO 7/26/05 Rhiannon Lucas Nationwide Insurance Comnpany 1000 Nationwide Dr Harrisburg, PA 17110 RE: Paige Talhelm / 1769260 y Y' F.~ {~_ ~~ /~/ ,. _ •'r ~ - _ O SA.tiTA B1RB.gR.q S.q.'~T.y CRUZ b y ~ .2 •~ee~e• UC DAVIS MEDICAL CENTER 2315 STOCKTON BOULEVARD SACRAMENTO, CALIFORNIA 95817 The Health Information Management Department at University of California Davis Medical Center has received a request for medical information regarding the above mentioned patient. The enclosed authorization has been found invalid for the following reason(s). Please refer to the following. Our Compliance Department requires for the authorization to be on the UCDHS form (see attached). The standard UCDHS authorization form approved by the UCD Compliance Officer has been enclosed for your convenience. We are returning the correspondence in its entirety. Please resubmit everything including the requested documents /information, monies or as otherwise stated. We will process your request promptly upon receipt of the requested information and/or documents. Sincerely, ; Karl Moertz Release of Information UC Davis Health System 916-734-5205 . ?~?I~~'ERcTTY OF CALIFORNIA DAVIS EMERGENCY REG (COPY) PATIENT INFORMA'iION RECORD PAGE 2 TALHELM ,PAIGE 9V~1 SVC EDR F/C V PENDING MEDI-CAL, CM MR#$ 1769260 PT TYPE: E OLD MR $$ ACCT # 20-960114997 PLAN CD: 103 MCAL INCOMPLETE PRIORITY: 1 POL#: N/A GROtJP# INS ADDR: I.P.A. NAME: PHONE: - - X REF/AUTH#: REVIEW GROUP ~ _, DAYS AUTHORIZED: CONTACT NAME: PHONE: - - X ON-SITE REVIEW? CONCURRENT REVIEW GROUP: CONTACT NAME: PHONE: - - X PLAN CD: PRIORITY: POL# : ~ ." ROUP#: _NS ADDR: I.P.A. NAME: PHONE: REF/AUTH#: REVIEW GROUP: DAYS AUTHORIZED: CONTACT NAME PHONE: ON-SITE REVIEW? CONCURRENT REVIEW GROUP: CONTACT NAME: PHONE: PLAN CD: PRIORITY: POL#: GROUP#: INS ADDR: I.P.A. NAME: PHONE: REF/AUTH#: REVIEW GROUP: .~YS AUTHORIZED: CONTACT NAME: PHONE: ON-SITE REVIEW? CONCURRENT REVIEW GROUP: CONTACT NAME: PHONE: COUNTY CODE: AID CODE: CARD ISSUE DATE: VALID DATE: PMHRUNF6 DOCUMENT GENERATED BY: HADSB 18:38 06/26/05 FROM LX9D,PMHRUNF6 :-~ . -- ;~,=- _ . .,~'- . ~ .c ~~ ,; ~. ~. ~ „ .. ~ . • _ ,., ~- ~ ~ Y ~ f 9 ~ ~`! UtvIVERSITY Cr CALIFORrti!q ~AVlS ,. , . ~ : +. ...'~ .. ~ ;. HEAt~TH SYSTE!l4 f l ~ , .~ s< ~ .. •;, w ~ i': ' } t -1 ~J` " C~ '3 ~ '~ ?uk~ - 5 ' ~; % r~ , ~? 7 TERMS AND COt~1DITIONS OF SERVICE~'~~~ , 7. FINANCIAL AGREEMENT: I agree to pay The Regents of the University of California for professional, hospital and clinic services, including UCDHS physician services, in accordance with the regular rates and terms of UCDHS. I also agree to pad for other professional services provided ~, by other physicians at UCDHS. When this agreement is signed by my spouse, parent or a financial guarantor, my spouse, parent or financial guarantor shall be jointly and individually liable vdith me for payment, including all collection fees (attorney's fees, costs and collection expenses), in adciiti~n to any other amounts due. Unpaid accounts referred to outside agencies for collection bear interest at the then current legal rate. 8. ASSIGNMENT OF BENEFITS (INCLUDING MEDICARE BENEFITS): I authorize and direct the payment to UCDHS of any insurance benefits including hospital insurance and unemployment compensation disability benefits otherwise payable to or on my behalf for UCDHS services, including emergency services, at a rate not to exceed UCDHS' actual charges. I understand that I am financially responsible for charges not .paid pursuant to this agreement. I further certify that the information given in applying for payment under the Medicare or Medi-Cal programs is correct. I further agree that any credit balance resulting from payment of insurance or other sources n!ay be applied to any other account owed to UCDHS by me. 9. ADVANCE DIRECTIVES: I have an advance directive for health care (e.g., Power of Attorney for Health Gare) ^ Yes ^ No I have provided UCDHS with a current copy of my advance directive ^ Yes ^ No If "No", I understand it is my responsibility to provide UCDHS a current copy of my advar!ce directive. If I want to express my health care wishes, I understand I should speak with my health care provider. 10. PATIENT RIGHTS NOTICE: I would like UCDHS to provide my next of kin or agent with the Patients Rights Notice ^ `des ^ No I have read, agreed to and received a copy of this "Terms and Conditions ofi Service." Signature of Patient Relationship of Representative to Patient ignature of Interpreter (if applicable) .~/ ~/G ~ ~ ,ti Cat, ;,~ J~~ Signature of Witness (requ!red if patient unable to sign) ~~ ~- Date of igning For office use only: EXCEPTIONAL SIGNATURE REQUIREMENTS ARE REFERENCED BELOW. Please check the appropriate box(es) ^ PATIENT iS LEGALLY INCOMPETENT TO SIGN: The court approved guardian or conservator, the attorney in•fact under a Durable Po~.ver of Attorney for Health Care, or family member or other appropriate surrogate must sign as "Patient's Representative." C PATIENT IS PHYSICALLY INCAPABLE OF SIGNING: The patient should give verbal consent, witnessed by a UCDHS employee. The Patient's Represern tativ2" should sign in witness cf the patient having given verba{ consent. The UCCHS amp;oyee .r'tn2ss sha!, also siy-r~. i- __ ~{ `: ~i 'i - J L f • ~ti•f7 ~~;i/a~~~~a P~~ G~ .. .:v~j ~ ~_ f ~ .• f 'Y \ ~r `~~~~' . ~~~ . UNIVERSi' iF rn'-_!FrJR!V!A DraVIS MEDICAL CEivTE.ri ~. !J EP PULSE RESP (TEMP PEDI-WT Room Time Attending Time Room - ~ Z Name ~ ~~~ L~/~ • ~ -• ~ Seen by (Name) ~ ~ Time ~ ~ DRUG ALLERGY Source of history: ~ent I~-other person ~M S ^ records from _ ~~ (~ (~ 1S (,rat / ~'~' w'~S ''r~< MUNIZATIONS tlT~ / c~ ~~ ~ w T ~~Z ~~..i.~ p ~C Jv1/~4-~ L-~ c- MEDS I /1 ~ c t C P S~ P~ ~ 1n a~ u.~ ' w ~ -~b r•.c_s S_ - MEDICAL HX S( ctyo f1 -- r c; ll,t ~ B`LS' SURGICAL HX -- I w~~ /'i1- ~- /-'t. R ~ " FAMfLY HX Nc SOCIAL HX (I~~r f c' u'-j t;hVIEVJ OE= W?rSTE!'riS UNOBTAINABLE: ^ Patient Unable ^ Patient Unstable Slash =not present, Circle =present MedicaUSur9ical Trauma CONSTITUTIONAL: fever, chills, weight change SKIN: rash, hives, lesion rasi ns, ns HEMATOLOGIC: bleeding, bruising cTbT[I roblem, ac ood lass EYES: visual problem, discharge, redness a gin, vision c ange ENT: earache, hearing change, epistaxis, congestion, sore throat ear/nose/mouth/jaw pain, cclusion RESPIRATORY: SOB, wheezing, cough, sputum, hemoptysis, pleuritic CP, leg pain ch~P' S06~ a CARDIOVASCULAR: chest pain, palpitations, syncope, orthopnea, PND, edema lpitations CP GASTROINTESTINAL: belly pain, nausea, vomiting, constipation, diarrhea, bleeding b gin URINARY: dysuria, frequency, urgency, hematuria, nocturia em a • GENITAL: discharge; abnormal bleeding, LMP pain, bleeding MUSCULOSKELETAL: pain, limited motion, redness, swelling ~cR/b~ek/RUE, LUE, RLE, LLE pain jj" i ' NEUROLOGIC: zure ness, weakness, l A2 se weakness numbness incoordination, HA, seizures, dizziness num~l NHYSICAL EX,?SiUt I exam finding: Circle =area for description of abnormal or relevant finding Check - GENERAL: /~ l ~;~~ Ci b~'~ y GrS ~ ~ ,~yj~ ce'/I~ J ^ n~~~~l 'rL~ SKIN: LYMPH NODES: ~ ^ n sions ^ no induration Je Adenopathy: ^ no cervical ^ no axillary ^ nc inguinal S~^0.K ~'~-~_ 'E'CM ~ O~-.c ( vre1t '-~ EYES: Aids & conjunctivae O'PERRL, EOMI ^ nl fundi _ _ _ _.. _ _ _ HENT: 8-ttSad/face nontender Q'Tfl TMs, canals _ _ __ _ _ .__ .... nose, nasal passages ^ nl mouth, throat NECK: -B"~ymmetric w!o mass ^ nl thyroid ^ supple CHEST: !~entender ^ nl breasts _. LUNGS: A-nt'effort~'"n'f auscultation ^ nl percussion CARDIOVASCULAR: ~-rtt sounds w/o murmur, gallop, rub ^ no edema nl cap refill Pulses: ^ nl carotid ^ nl femoral nl pedal ABDOMEN / GI: ~ntender w/o masses ^ no HSM ^ no hernia ^ nl rectal ^ heme (-) GENITALIA M: ^ nl penis ^ nl scrotal contents ^ nl prostate GENITALIA F: ^ nl BUS ^ nl cervix w/o discharge ^ nl uterus ^ nl adnexae MUSCULOSKELETAL: ~on er neck w! FROM~O'"nontender back, pelvis ^ RU UE, RLE, LLE ^ nl joints, nails NEUROLOGIC: ^ nl CN 2-12~~-rtl"§ensation ^ nl Rs, no pathologic reflexes ' . ~-rtl's ngth ^ nl gai/~CS t PSYCHIATRIC: &0 x 3 ^ euthymic ^ good judgment Impressions/Plan w } ~: ~. ,:::. m y~.~ .... ~~~ _. • ' ' ~ CC1 hICl II TI~'~ ~C~ Time Called :5ervic~ ^ ED REVIEW S ~ ~~ ~Z ' ~n Q --,• 20-~4!~Z 14937 - ------. ^ ENT u ! -^ Eye -~• ~ E ... Y ~ ~;~ A .. _ - _ Y N ~=` ^ IM ...:bspesislty r - C Neurology r ~2/Q~./1B8Q:. Ob-Gyn _ ~.. ~O orthopedics ~ - ^ Plastic Surgery ~Q ~ 1 Pq i Gib _ ^ Surgery subspecialty CJ `: ^ Trauma _ . • - _ ^ other _ . ___'~ - - _ RESULTS _LAC~~_~_o.3--PTT . Z{~_---- IVi Chem - -._._ ..---- ~~ - o -~- -q-- ~. ---- -- --- --------------_ Urine --- ----- ..~_--~=_ ____----___---------~-- - -_ ------ -._.___y - ~--- Misc. ~~~y~'t'l3 0 -~-~~ S ~ 7 - ---- _ ~-.__ EKG ^ Radiology consultation to clarify results of ATTENDING NOTE PROCEDURES (Note Time/Describe Procedure) ^ Arthrocentesis - - -..--- -r~_.____-__ ____--------.___-.-- ^ Casting/Splinting ^ Central Line -._ ~~~ 'y __ __,__-,_- ____Lt1_tnt~l_L1U_ . ~~'t=c-s .__4_ C,Q~ 11 ~ S ~ ^ Chest tube -_.. ^ CPR ~ i 7L'~'s1-~Tt~i'f'3- s'~Y7"l~ S'z~f-y~--~-~i- -~------- - ----~- ^ FB Removal ___ . _ -.___.____, x~f ~ -~ ^ Intubation___-_ _ ~ ~ ^ Reduction ___.. _..._~ _~ ^ Paracentesis -I~-~-~~ L G ~r1,.,L7 r~•~~;,jT,- ^ Thoracentesis ^ Suturing ~,~,~~ ~~__~t_~,~_~~_~_ _ --_ _-__ ^ Thoracotomy / !'1 ~ L/k-~ _ _- ^ Other GP~ ~~~~f-~~~~t+~~~-~_-. ^ Present for performance of ^ entire procedure, or ^ key portions of procedure • - DIAGNOSIS ^ 1 ~ 2 1. 3 4 DISPOSITI ^3 ^4 ~-b ^ cc N ^ ADMIT DISCHARGE TIME CONDITION Home ^ Police i ~ Zu I d tr'•~'dQ Pri row ~ # ^ Other ^ AMA ^ LWBS DATE 6(Z? /OS ( mprove ^ Stable ^ Unstable ^ Ex fired O S'L('~ ED Attending nature/Pf # J --.°~` -'' 1 ~ • of ~' A ti A Y i~ :, UNIVERSITY OF CALIFORNIA DAVIS PIIEDICAL CENTER SACRAMENTO, CALi~CRNIA t - ~ 1 f I~ i f ~ ~ ~~ ~ ~ ,`,;:. :~,~ Lab • _- HEM~BC with dill Procedures Time Done Saline lock ~~~ ^ IV-1 ^ IV-2 ^ 02 ^ monitor cardiac ^ pulse ox ^ continuous ^ Foley ^ I&O catheter ^ NG tube ^ suction ^ FS glucose ^ serial ^ PEFR ^ serial ^ urine dip ~rine bedside p~ ^ EKG ^ serial _ X-Ray ^ H&H 1 &3 hr ~'MR G-)"PTT . _ ~: ^ r&s Results/ ^ T&C it: Signature Site CHEM ^ beta hCG ~'chem 7 (BMP) thanol e e ~pase ^ myoglobin ^ troponin I ^ myo/tr 0,3,6 hr URINE U/A ^ amph/coc lox ` ^ barb/benz/op lox Z~ ~ ~ MISC ~ Far order entry, fHi in a f ~CXR ^ PA/Ia~P ^ bedsi _ r ^abd series ^ KUB ~~-spine (~ ^ T-spine ^ L/S spine ~elvis AP ^ bedside ^ L ext ext ~ /v u 3 }`~'~ ^ head CT ^ w/o ^ wAV ^ abd/pelvis CT w11V (trauma) ^ abd CT ^ w/o ^ w/ ^ US o _ i MEDICATION AND SUBSEQUENT ORDERS Time Si Done ~ ~ •~/ c( ~ ~ 3~ ~ G i ~~ ..Ni Site a Reason (stgns/symptoms for each study) b PRIORITY ^ urgent ^ slat ^ life/deatt /,f}- c OXYGEN ^ no ^ yes rt ~' an S • d MOBILITY ^ gurney ^ wheelchair [Q wall e SUPPORT ^ N/A ^ tele ^ vent f PREGNANT ^ no ^ yes Order entry time By (signature) Time Ordered ^ Old UCD Record ^ Outside Record Physician Signature Service! Pager 1. VYi' ~ ~ ~ ~i(e 2. QCJ 3. F O~, 4. '.~ 2-Z S 5• ~ ~J ~ 'f-?i-~ 5 p V 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. ~3~ I l7~a. PI No. Time of Initial Order: " PRESCRIPTIO~1~ ,~...~._.ra~`_,z~_a.. aCTiVI?'Y Vl D ~~m s~++mc ~ A n M ~~~~ ~ ~~~ D rZmc1 V C 4 Z 1 i .~sZa p G°~ C~C~ G°~ ~ G°~ ~ ~OO ~ I ~°~ 0 DEA NO. License No. ~c ~'. e, MD Signature D Print Name ate r f O ~ ¢ ~ W ~ W 2 U d m O U~OU T ` TWO U ¢ N W W !~ N Q N ^ No specific restrictions ^"" Limited use of affected part until seen in follow-up ^ No use of affected part until seen in follow-up ^ Modified work/ no PE for days ^ Off work /school for days ^ No driving ^ Passenger restraint system required for children less than 4 years old or less than 40 pounds. Information sheet provided. ~, MD Signature DISCHARGE INSTRUCTIONS: ~~ ~ 1ti ~~ t~i^.~t1n.. rub i7~ - ITL,i'~i~ i1<<StnCkx~ r --~-, y.. INFORMATION SHEET(S): wound care INSTRUCTION ADJUNCT(S): ^, Interpreter ^ head injury ^ family ^ cast /splint care ^ deASonstration of ^ back or neck pain .. ^ other ^ crisis service ~ ^ other OUTPATIENT FOLLOWUP: ^ Call for Appointment ^ Keep Scheduled Appointment ^ UCDMC Clinic ^ Sacramento County Clinic ^ Meth-Cal Clinic PCP ^ HMO / GMC Clinic ^ other ED LABORATORY & XRAYS: LAB TEST XRAY ^ CBC ^ CXR ^ chemistry ^ eMremity - ^ U/A ^ spine ^ other ^ other ^ Call 734-7761 between 10 am and 10 pm for pending results of MEDICATION /TREATMENTS: ^ ^ tetanus immunization antibiotic(s) other ~ - I acknowledge receipt of instructions Indicated above. I understand that I have had emergency treatment only, and that I may be released before all my medical problems are known or treated. 1 will arrange for follow-up care as instructed above. If my condition appears worse, 1 will cc :tact .my physicfafi or return to the Emergency Department. tien4 Slctnatui'e ~~ ~ °- ~ ` ~ '~ ~rovider~5i°°na°ture 1 ~~~~.~`~ ~~ n~ ns.o . ~. . ,~'r« ',; , . _~ i' 1 1 _ _ _{ ~ L. ~,~ jl- ~-i%~ ~ lid` !, z ~ ,j~' 1F';iE~<;~ Date: ~,~c-~.v'~~ ~~ Ui~~JERSITY OF CALIFORNIA DAMS :; ~ ~ c r? 5 MEDICAL CENTER, SACRAMENTO, CALIFORNIA .~ ~-TRAUMA RESUSCITATION l y ~I ~ :~ ~~~~'~~~ F! QWSHEET • - . ~ ~ d 911 922 933 ti i Ti A SMENT ON ARRIVAL .. ,. me: vat on c Time Pt Arrived in ED:~ "A" AIRLNAY One) Description - Patient YE NO PMH: "B" BREATHING Spontaneous Assisted? ^ Y ^ N Medications: Labored YES Shallow YES O Allergies: Denies ^ Unknown ^ Latex Breath Sounds Present bilateral) Yes ^ No Last Tet us: LMP: Weight: kg. • i "C" CIRCULATIO Radial Pulse YE NO Mode of Arrival: ^ Sac Metro ^ AMR ^ Private Vehicle Other: z Unit #: 3 Bleeding controlled? YE NO U CR < 3 Sec NO Location of Incident: Warm /Dry YE NO ' County of Incident: "D" NEURO ' MECHANISM OF INJURY OI GCS on arrival: E V = M ~ = = MVC vs ~ Intrusion amount: BLUNT: ^ MCC vs Speed: mph ^ Driver Passenge ^ Fro ^ Back R/L ^ Unknown Sensation N/A Deficit Moving All YE NO N/A ExtremRies Deficit = Deticit ^ Ejection Lap Beit ft houlder Belt ^ Helmet ^ No Helmet Descriptors: , , , . , ° ° , , HEAD Rollover ^ Unrestrained ^ Unknown S 1 S Trauma? YES NO use dia ram Airbag ^ Unknown ^ Carseat Nose draina e R N!A mph ^ PEDESTRIAN vs Ear draina e R L N/ . Ejection feet ^ BICYCLE Teeth dama a YES O N/A TM's clear YES NO vs. NECK ^ FALL: Distance Surface S /S Trauma? YE use dia ram ^ ASSAULT: hype) SQ Air YES N JVD YES NO ^ BURN: Source BSA degree Trach midline S ^ OTHER: CHEST / RESPIR R LOC: ^ Yes o ^ Possible ^ Length min ^ Unknown ^ Other PENETRATIN ^ GSW ^ SW S / S Trauma? S mmetrical NO Y use dia ram . . • Flail Cre itus YES Y A: ^ ET ^ NT ^ NP ^ OP Size: Cardiac Rh hm B: 02 ^ NRB ^ Cannula UMin ^ BVM ABDOMEN Cir ne Descri lion C: Infused ml ^ CPR Started ~ S / S Trauma YES use diagram Rigid collar ackboard ^ Papoose Supine /Prone lender YES ^ Accu-check results ^ S t ii Pre Want YES W OB notified ^ Y ^ N p : n Fetal HT YES NO N! Meds: Other: GU /PELVIS V/S: B/P P R S/ S Trauma Y use dia ram V M GCS E Meatus clear YES NO ~ . ~ - IDENTIFY ON FIGURE Pelvis Stabl YES O ,° vacs ` w m° ~i~l eo . BACK ~° v~+ z wfihdrwa 4 ~wa• vrobe a none 1 Ilexbn 3 heomPieb sands 2 R L L S / S Trauma YES O N/ use dia ram B1d°^~Dn z noie1 1 v Deform YES use dia ram Wale Tenderness YES N/A use dia ram Time Arrived SIGNATURES Marxlatay br Trauma Rectal Tone + - Guaiac~ + Vr+'L ED Adendng EXTREMITIES f R 3 ED MD S i S Trauma YE use diagram _ (/ i YES D f N use dia ram e orm g trauma an°~° PULSES MOTOR Cldel R L R ~ L ~ Radial UE - LE DP ~ NP / R 2 Trwma PT Grip senric. Mo Quality B / 1+ / 2+ / 3+ / 4+ Quality 1+ / 2+ / 3+ / 4+ / 5+ _ . a ;,r ~.: _ A , Date: / ~ ~ v Chief Complaint ~_y~HOSPITRl y Mode of Arrival AME Walk ^ Gur; ~y C UVC ^ Carried ^ :Uhit # - `t , ~GC~ S E V M IV No ^" ~'~s~~ Placement ET NT OP NP Yes ^ No ^ Type/Size O2 Given - -__- Placement Accucheck _ Rigid Collar ^ Backboard ^ Splint ^ Papoose ^ Meds given - BP P RR , TEMP PAIN 02 SAT History None ^ Cardiac ^ ' 3 Diabetes _ ^ Triage Tlme - Unknown '^ Primary Nursing Assessment cva ^ BP P RR .TEMP PAIN 02 SAT allergies Latex N DA current meds A. Airway . Last TD Patent Yes ~ No ^ B. Breathing. ,. _ Spontaneous Yes ^ .. ~ No^ nasal flaring Yes ^ No ^ ' Symmetrical :Yeses .: No^ acc. muscle use Yes^ No ^ Labored Yes ^ No^ ' s/s trauma Yes ^ No ^ Shallow Yes ^ No^ flai{ Yes ^ No ^ Diminished LT ^ RT ^ crepitus Yes D N ^ 8reaih Sounds RT C. Circulation LT Cap. Refill <2 sec. Yes: ^ ' No ~ .cardiac rhythm warm- Yes ^ ..; No ^ dry ' Yes ^ No ^ - Diaphoretic " Yes. ^ No ^ Jaundiced ~ Ye§ ~ No'd' Bieeding,Contro0ed Yes ^ No ~ /A D eU o .N r GCS '. E V M ,. sporitarieous 4 orients ~; 5 obeys comds 6 to voice 3 confuse •,4 localizes pain 5 to pain 2 _ - inapp. wonis 3 withdraws 4 `none : t inccmp. sounds 2 flexion 3 ~- Pupil Size R ~ L _ none 1 extenone 1 PERL ,"Yes C~ No O Accucheck E. Sensation ~ ~ F. Pulses RA + RL ~ Quality: 4+ 3+ 2+ 1+ Dop. LA _ LLB Location: Rad DP PT RA~ RL_ G: Movement/Strength LA _.. LL _ ;Quality: 5+ 4+ 3+ 2+ 1+ Moves all extremities well Yes D No ^ ~ 1 COPD ^ CA ^ Ps ch ^ GU ^ Dialysis ^ Asthma O HTN~ ^ Seizure ^ GI ^ Other - Head Yes No ~ unremarkable ^ Cl nose drainage ^ ^ ear drainage ^ ^ teeth damage ^ ~ ^ tm's clear ^ ^ Neck ~. unremarkabi~ ' ~ ~ ^ ^ sq air ^ ^ JVD ^ ^ track midline D ^ Abdomen unremarkable ^ ^ soft ^ ^ nontender ^ ^ s/s trauma ^ ^ firm ^ ^ distended ^ ^ tender ^ ^ masses ^ ^ vomiting ^ ^ . diarfiea ~ ^ ^ last BM GU/Pelvis unremarkable ^ ^ meatus clear ^ ^ pelvis stable ~ ^ ^ discharge ^ ^ color NA ^ bleeding ^ D pad Hr Back s/s trauma ^ ^ deformity - ^ ^ rectal tone normal ^ ^ guiac positive ^ ~ ^ tender ^ ^ Extremities s/s trauma ^ ^ deformity ^ ^ IDENTIFY ON FIGt1RE RA _ RL _ A -abrasion _ LA _ LL ~ -• R L L R AB -abscess H. Pregnant Yes ^ No ^ „ B -burn ` Gravida - Para _ D -deformity FHT Yes ^ No ^ Rate- E - ecchymosis EDC LMP ED -edema OB.Notified Yes ^ No ^ N/A ^ H - hematoma Comments L -laceration ' P -puncture R -rash T -tender/pain ' UNK ^ Two forms of ID checked ^ Armband ^ NA ^ Screened for Domestic Violence ^ -- -- ~,• , _ ,- Time By Whom Procedure Size i Placeme,.. r Eye Opening , / `J' ~ l NC Mask - Best Verbal ~ Oxygen N Response t -.~ :-~ -. :. r~ L Min. Best Motor ~ `'-~ ' ~ ~' ' E Response r.f; r : !' ~ ;?'; A Chest Tube 1' Glascow Coma Scale Score i ' . ' -' ~ i ~:: •-~ ' V Thoracoiomy Inlubated: 3 =Appears to Converse 2 =May Converse 1 =None NGIOG R Pupiilary Response Ri ht g ~''~~` • ~ ® Q 2. 3~4 5 B 7 • • 0 ' Foie y M B Brisk: ++ Slu ggish: + None: 0 Lell . t s ~j Pg ~ EKG Strength: ~ Q U =Unable to assess 2 = Unable to move against • Right ~, ~ Splint ~ 5 =Normal gravity 4 =Slight weakness t =Trace ~ Ice Pack 3 =Moves against gravity.. 0 = None Lefl : ~ . Q Sensation: - Wound Care 1 =Normal T =Tingling ~ Rrght - ~` v Warmin R ? =Hypersensitive 0 = No sensation ~ measures 1=Numb U =Unable to assess - Lett .~ C Mucus Memb~anes/Skin: Color' IV LINES /4' F =Flushed M = Mottled C =Cool Temp ~ P =Pale J = Jaund~ed D -Dry R N =Normal W = Werm M =Moist Cherecler ~ Pulses: , - Frac~al. 1+ =Barely Palpable 0 =Not Palpable. Right v qd+~; _ ' 2+ =Weak ' D =Doppler ~ - Intubatlon , . ~Yl a os 0 ; 3+ =Normal e14 t - Ventilator V 4+ =Full Bounding -' vv~.~" Mode Rate TV Fi02 PEEP - A Capllla RefilL• Number' of Sgconds ` Heart Sounds: N Norrpal R -Rub D = Distant . S ~. M Mur6iur G =Gall FR = Fdi:tion A u6 CMS:;Ititact Distal to . . -y~/~ ~ ~" CBC Chem 7 Lip Pt PTT 8t°k" C . A Art une C = Gast. R =Restraint Fe ` ~ F = rri Line B =. BUm ': T =Traction - T & C!T & S L Edema: ` ' Ri ht t'~ ,' ~ ~O Up A G General Bk Below knee P `Pedal F Facial g ~ . 2+ 3+ l F" ` ~i~ 4eft VJ CBC NO dill #2 R A = Anasa rca A None. • - , . ~ ; ~~' CBC NO dill #3 Chest Expansidn: 5 Sytnmetrjcal": A _ AsymmetPi~al P ° . Trachea: M = Mldline b bevlated Right L =Deviated Lefk Myo/trop 0 U ` N N Dis o tress R =Retractions Nes nation P ` L Labored A idtl S d c ' 1 Myo/trop 3° ~ =, e o e ~ n s. ". - Breath Sounds: AUL Myo/trop 6° M , 0 =Clear : 1 =Diminished FC =-Flee Crackles 0 ~ Absent Right RMk - ~ . CC =Course Crecldes S : = 5tridor R!L N W = Wheez(ng . FR =Friction Rub L{A. - RH = Rhonchi Leff • .. . A LLL . Study Time Done Study "Time Done ' R Secrehopc. s Smau TH =Thick G =Green Amount Y' M = Med N =None T ;Tan Consisteng Ultrasound C Spine ~~U L =urge o =Clear B =Brown , t = Thih Y =Yellow Bl = Blpody Odor Pelvis ~ T Spine Gastrointestinal: ; 5 = SoN R =Rigid . N =Normal l =H po Ayyorr, ,, Abd US Spine y D =Distended t =Tender ? =Hyper Cl =None Bawer Sounds CXR ~ CT Head G NGT/OGT: Placement verified by Asptratiori Extremity ~ CT Abrl ~ pHlGuafac: f.: l' P~~IviS Gastric Output: c=Clear G~Graen e°arnwn BL=elnody CG=Collea Gruuitir • - --._._.....__.-- .. /,; r F1p;.k .. _-•---_.._.. __ TIME BAG # SOLUTION BLOOD PRODUCT SITE # INFUSED VQ Scan 4tdC;tr_~ ... ..... / NITIALS N ME: ~ t ~~ r_. __ ...~.. ~N --- -- ---- __ -~ I _... ... _____._.. _.--_._. l _ r , _.. . Sc.rib? RN - . ~ _..... ~.__t ._. _.._..._.. .._._ _. ._ _ - - _.._._...------- ------- RN __...__..__.........__._._-- ~-----•---- ------- ... TOTAL --- +;+ T1ME AMT I SPECIFY' ..Z~1~Y-~ j-'~ ~ I ~,i~~ ---. _ !. _ i --__~ I {~ _ .. TOTAL _.. +- - _._ . _._ . _ ~, ; I-'C!J. t'HIIV HJJCJJI'/ICIV I VUIUC - ~ ~ ~ ~ PAIN TOOL/RANGE ' f: , ~ _ :ti r^!1,..'j ~+ 1 1 1 ~ ?~' ~ i 'J n~NAPI (0-11j ~,. ~; u ~ _' .. - f .d ~ ~ ? 3=FACES (0-5) ;, 1. S r ~' -. ~ ~' '~ 4=Oucher (0-5) .- n ~ V ? I ~ ~ f~ l7 5=Numaric Scala !n_1n1 .~ ' " " PED PAIN ASSESSMENT GUIDE. USED 6=Comfort Scale 8-40 Pa~l'Too; ~5ed`6am ne.m ci,e6`m'6am"S`5)' r„~ Time ~ ~L ~ '3i? .~ ( ~ ~ ~ 2.%j ~~~ BP ~ !3j tG 1v (I i Il ,~ i - P • ~ Zo i t iaa ~~3 TEMP ~ ---, 7 •~ ~ 3.i ~ -C - PAIN -=--" y ~~ ~° 02 SAT' ~v u ~~ / -~ GCS ~ ~ t 7 « (.T' ' Rhythm $ `~ / Init. (Y) J MEDICATION D E TIM E BY SITE ROUTE T ime Procedure Narrative Att. ~ E3edside ~ ~ RESPONS ~ _ Room.., .,. i'I"ime- _ r RESPONS ' .: ~~ ~.~~ ~ _ - ~~ RESPONSE - ~ ._~.,_. RESPONSE _ _~ ~_ _ U.~?~ .__.. RESPONSE 1 .__.._~-'~ Tl RESPONSE RESPONSE ~ ~ Z.SL.O~•~vv~.. _____.--___~~.. Ct A ~ ~ V J - ~c-,~ . ~ _ .,,~, --- ~ ^~ ~ ,~ V U__ L.~. RESPONSE AS,~ .._ _ `~~-.~--~c-~~..~.._.. ~' ,~ ~ ~ p .~ RESPONSE _!! v . _ . _ .,7~ J y;~~~ • "J ~,S i.. 11; ~ ~"_'~."~-~~iL` ~ y ~ u--~-~ RESPONSE - -- I ~, h - l ~~ ~ ~ ~ ~ ~ r RESPONSE -- ~, .w ~ ,. - ~ --- .p ~/.~.~/ , r ~y ~.. ._. _ { t; ~'~~~ vrvonrr .~rrece ~vrrr rcec rest' u +vt/ u rvr~ i' V "~see• EKU Sfrtf.~ Orders°/-Nurses Notes Faxed Yes O No O NA DtSCHAR tin back C~ ___ CONDITION ADMIT ^ Disr,Fte ' ~G ~W~ fat_~_ Gvrt'-mertts. Improved Transported by f2N ^ Instr'act s to paifient ~] _ _._.._ _ _ WC hanged ~ ^ Other ..,.-... ____._- ~ .,.~ _._...__._` _~.-_ Crutches ^ Vertrafizes understanding No C7 ~__..~_~. _..~..__.____ Stretcher ^ Nand©~ liven. e v ~ Walk ^ L -•----..--_.._,_...._._.._,._.... __._~_ ' IY Infusing ^ tisf-___~.. rJ~. l~ -.. ... __.__.____._.____._... Armband ^ l:.e;~lntirtg Needs Address Y~ ~3"l~To F_7 ___._ - - - -.-----w---._ Green =All Patients .Red =All, Trauma / fCU Patients Specify:~_~ .._.,_.__.,.._. ._.___.._.___._._. _____.._. `-fr ~f __'s~ A~,IERICAtJ MEDICAL RESPONSE-SAC` 1ENT0 VALLEY ~ .~~ ~ ~7a$I~l'j~ ~~~~ ~~36P'~ - DATE ~•~~~~ SERVICE PROVIDER MAST~R ~ UPd~ ~ ~ PROVt'J' EF~,,(U{Jl,Irr) ! -' ._-'~ ~ AMeRICAN h1~~ICA4 ~trSPOniSE ~ -__ :.. ( ~. -.-.+, ~_ I eST MC,DENT ESF• RFSP EST. ARRIyE EST. ASSESSNEt~lT TIW1E E f . ~R.~JSP~It~iE TR~'NSP..CODE PRIG'R1TY ARP ~~ DESTlTIh1E AVAILI~BL~ T)ME~ FORM IJO.n `'~ I' ' r ~ ! ! ; 1 r C. --- -t~ ~ ; I . :, ~ ) i-. •.;~^ I BLS: ALS:~^ ~ •~ _~ ~ ~~. ' S LIC. CALL LOCATION-~C SAME AS PAZiENT'Sp,DDP.ESS _ PHONE ;i DRIVER l • --'-•-- t'om' AGE ~ G MOS. D.O.B. '~ MALE ,y~'FEMALE PATIENT NAME (LAST, FIRST) c°f'~ ; I 'i r I/j;%~ '~ + t I t f : ~ I :- •`~ ... ~. a ~ = j -(~-YRS l ~ ^ - ~ h :.,} . f _ ~ ; u, - -~++f -? rte; i ( ;. .,- ., C:. ; ; t T ~~ ~ PATIENT'SADDRESSISTREET) ~. ~ ~ STA~Z~ , - ~ ~ f _ S.S.N. , % ~; ~ ..il " tJ ` i f'~ _ .MEDICAL HISTORY •^ UNKNOWN DENIED ^ MI p CHF ^ ANGINA ^ COPD ^ CVA ^ HlGH BP D DIABETES ^ CANCER ^ SEIZURES •" CURRENT MEDICATIONS ^ UNKNOWN .~7~NIED ALLERGIf~S~1ME ^ UNKNOWN ^ DENIED WEIGHT KG TIME GCS BP PULSE RESP. EKG BY TIME" °,''fiCS BP PULSE RESP EKG 8Y E V M _ E V M _ ~ T ~ !~ `~' ~ ' f ,HEAD ESSED &WNL NEC~t~ G ^$,'95~ 8 WNL PUPIL ;.~1'PERL • ESSED &WNL CHEST LUNG SOUNDS $ASSESSED A WNL CRAMS E. J° ANA7 ' =`-= ABDOMEN L .~ ' - ~SESSED 8 WNL BACK /'Y'\ ~. TIME: BLOOD R . ., _ : ~ I . C ~:A 6SESSED &WNL ExTREMITJES ~ ~~D~~L CAP R ~ ~ f ~~ ~ _ , , ?`. -STENO SAS &WNL _ NEURO k}ASSE§SED 8 WNL ~ CPR START BY © /~ 4 /~ ~ +~~ ~~-~.~...~-_.~ ~r^ ~~ .~ '~'o ~b'1t/w L. 2vft autr". ~ 7'r .~1~'-S ~-rr~ I ,.,, r, t ` ~^ /~ ~ ~ G ~ ,,,.. o t ~ ~ h~ ~ ~ ~ ~ r ~ `'r P~ .., .,t r ' ~.~.. ~n =~ t- , T ~ /~ '~ ( S ~.Jr~~ x.~ ,''~ t i " W ` ~ ' \ f G~ % f' T ~ ~.J `-~- i I f\rn." (~ t ~ 1:J'-i%:e;. ~ Y`L "i'~ ~ oc.a/ tJ R,K. `~ , ~ ' ';~ ~ ~ C '4t y 1 ~ ~~r f~ T ~ ~'-' i"~r#l ~1%G+sJ! 6''C` G • ._x J •i' f ~f ~if~ 3'~ S ~ ' ~ - ! ~' `~ ~ ~ I . ~ ~ ~ . Z.i . j .?1 ill V 4, ~~ . ` ` TIME: OXYGEN UM BY: ;` - .. .... .....- ^ MASK ^ CANNULA ^ BAG VALVE ^ HHN ^ PULSE OX: before 02 , after Oz _ . AIRWAY: GAG ^ YES ^ NO A IRATOON ^ YES • ^ NO "' ^ OPA ^ NP ^ iJ~ ^ OTI ^ NEEDLE CRIC ,r -• ET SECURED AT CM AT THE USING ~' ~ ~ • ~ _ ~ i;' TUBE SIZE NUMBER ATTE ANATOMY) ''~ ^ =LUNG SOUNDS ^ =CHEST RISE ^ CHORDS VISU M.D. VERIFICATION SIGNATURE: TIME FLUIDS SA UTIONS GAUGE LOCATION f RATE TOTAL VOIUM ~ q OF ATTEMPTS BY ~ ^ 10 f ^ TKO O OPEN ^ BOLUS. 2 x'10 ^ TKO ^ OPEN ^ BOLUS ' IMMOBILIZATION: t -NECK 'BACK ^ LIMB(S) ^ EXTRICATION POSITION: ~ PINE ^ LATERAL Cl PRONE ^ SITTING ^ HEAD ELEV. ^ FEET ELEV. TIME MEDICATION, DOSE, ROUTE, TREATMENT AND RESPONSE BY TIME MEDICATION; DOSE, ROUTE, TREATMENT AND.AESP~?NSE --~- -BY j TIME: HOSPITAL CONTACTED: ^ RCH ^ AFH ^ SDH ^ WMH NE M ~ M.D. FORM LEFT W/PT? ^ YES ^ NO ^ MAR ^ SGH ^ MSJ ^ MHS AMC ^ NONE ^ RADIO ,~ ! ! CONT. ATTACHED? ^ YES ^ NO ` DESTI TI N: r~ ^ RAS CA RANSF~ERF,~TO: PVTM.p. ^ PTFAMILYREOUEST O LAW ^ TRAUMACRITERIA ^ CLOSEST ~ ~{L,J ~'~,~ ~ ^ AMA ~'f. t"~ BH ORDER ^ DIVERSION ^ SPECIALTY CENTER E.D. D.IAGNOSIS/COMMENTS d DEAD AFTER RESUS. D EXPIRED E.D. ^ ADMIT ^ HOME ~ TRANSFER ^ STgNDING ORDERS ^ COMMUNICATION FAILURE ORDERS ~ EN}T~COMPlE1TING RE~ORT SIGNATURE: C' MtCP ^ EMT SECONJ~pRY EMT SIGNATURE: ^ MICP r ~ PRECEPTOR SIGNATURE ^ MICP ^ EMT f 1 ~ t' i .cam ~.-~-~"'--~ ,r !' pl'7,S~c`~ s ~ I !i ~ ;.>\Jr ~. Talhelm, Paige (MRN176926('' Lab Results ` T "' DAMS HEALTH SYSTEM URINALYSIS-COMPLETE (Order# ES7°293) Collection Collection Date and Time Received Date and Time Information g/26/2005 2230 6/26/2005 2241 Com oo Went Vaiue Flaa ~y ugh Units Status COLLECTION Clean Catch Final COLOR Yellow None/Yellow Final CLARITY SI Turbid Clr/SI Turb Final SP GRAVITY 1.019 1.002 1.030 Final pH URINE 7.5 4.8 7.8 Final OCCULT BLOOD URINE Negative Negative Final BILIRUBIN URINE Negative Negative Final KETONES Negative Negative mg/dL Final GLUCOSE URINE Negative Negative mg/dL Final PROTEIN URINE Negative Neg/Trace mgldL Final UROBILINOGEN 0.2 0.2 1.0 EU/dL Final NITRITE URINE Negative Negative Final LEUK. ESTERASE Trace A Negative Final MICROSCOPIC INDICATED Negative Final WBC/HPF 1-3 0 3 Final SQUAMOUS EPI 6-12 A 0 3 EPI/HPF Final AMORPH CRYSTALS Moderate A Rare/Occ Final URINALYSIS-COMPLETE (Order#6679293) on 6/26/05 -Omer Result History Report Other IDS Lab Specimen # 0626: UA00078S Patient Patient Name MRN $@X DOB Home Pho~ Information Talhelm, Paige 1769260 F 11/2/1991 717-486-4808 (13yr) ~t Room Isolation EMER ERWB N Lab Lab. Lab Director Information UC DAVIS MED CTR Ralph Green, MD 2315 Stockton Blvd Sacramento, CA 95817 Order Information URINALYSIS-COMPLETE (Order# 6679293) Order Order Date and Time Department Information 6/26/2005 10:30 PM Emergency Order Authorizing Provider Encounter Provider CONFIDENTIAL - EMR COPY --- Printed by Dvorak, Jeremy 8/15/05 1044 Page 1 of 9 .~ Talhelm, Paige (MRN176926(`' • j "~' PA~'?S HEALTH SYSTEM Providers (07992} Dustin Ballard (05456) Peter Sokolove Priority and riori Class Order Details STAT Normal Lab R@SUItS CBC WITH AUTO DIFFERENTIAL (Order# 6678307) Collection Collection Date and Time Received Date and Time Information 6!26/20051730 6126!20051742 Component Value Ela9 Let High Units Status WHITE BLOOD CELL COUNT 7.4 4.5 11.0 K/MM3 Final RED CELL COUNT 4.55 4.0 5.2 M/MM3 Final HEMOGLOBIN 13.5 12.0 16.0 GM/DL Final HEMATOCRIT 39.9 36 46 % Final MCV 87.7 80 100 UM3 Final MCH 29.7 27 33 PG Final MCHC 33.8 32 36 % Final RDW 12.5 0 14.7 UNITS Final PLATELET COUNT 286 130 400 K/MM3 Final NEUTROPHILS °~ AUTO 45.6 % Final LYMPHOCYTES % AUTO 40.1 % Final MONOCYTES % AUTO 8.0 % Final EOSINOPHIL % AUTO 6.0 % Final BASOPHILS % AUTO 0.3 % Final NEUTROPHIL ABS AUTO 3.32 1.80 7.70 K/MM3 Final LYMPHOCYTE ABS AUTO 2.92 1.0 4.8 KiMM3 Final MONOCYTES ABS AUTO 0.59 0.1 0.8 IUMM3 Final EOSINOPHIL ABS AUTO 0.44 0 0.5 K/MM3 Final BASOPHILS ABS AUTO 0.02 0 0.2 K/MM3 Final CBC WITH AUTO DIFFERENTIAL (Order#6678307) on 6/26/05 -O rder Result Histo ry Report Other IDs Lab Soecimen # 0626:H00395S Patient Patient Name MRN ~ DOB Home Phone Information Talhelm, Paige 1769260 F 11/2/1991 717-486-4808 (13yr) .Unit ~m Isolation EMER ERWB N Lab LHb Lab Dir ector Information UC DAVIS MED CTR Ralph Green, MD 2315 Stockton Bivd CONFIDENTIAL - EMR COPY --- Printed by Dvorak, Jeremy 8/15/05 1044 Page 2 of 9 Talhelm, Paige (MRN176926(''. ~ TT`~ DAMS HEALTI-T SYSTEM Sacramento, CA 58817 Order Information CBC WITH AUTO DIFFERENTIAL (Order# 6678307) Order Order Date and Time Department Information 6/26/2005 5:30 PM Emergency Order Authorizing Provider Encounter Provider Providers (05456) Peter Sokolove (05456) Peter Sokolove Priority and Priority Class Order Details STAT Normal Lab Results BASIC CHEMISTRY PANEL (BCP) (Order# 6678332) Collection Collection DateanctTime Received Date and Time Information 6/26!20051730 6/26/20051742 Com o~nent Value Flag I.ow H19h Units Status SODIUM 140 135 145 mEq/L Final POTASSIUM 3.1 L 3.3 5.0 mEq/L Final CHLORIDE 107 95 110 mEq/L Final CARBON DIOXIDE TOTAL 22 L 24 32 mEglL Final UREA NITROGEN, BLOOD 9 B 22 mg/dL Final (BUN) CREATININE BLOOD 0.7 0.5 1.3 mg/dL Final GLUCOSE 182 H 70 110 mg/dL Final TEST ADDED TO SPECIMEN PREVIOUSLY RECEIVED IN LABORATORY TEST ADDED: HFP DATE/TIME TEST REQUESTED: 06/26/05 1756 REQUESTING PHYSICIAN NAME: SOKOLOVE A HARDCOPY REQUISITION FOR THIS TEST HAS BEEN REQUESTED BASIC CHEMISTRY PANEL (BCP~(Order#6678332) on 6/26!05 -Order Result History Repo Related Tests LIVER FUNCTION TESTS jOrder#6678333) on 6/26/05 LIPASE (Order#6678334) on 6/26/05 Other IDs Lab Specimen # 0626:CI00365S Patient patient Name IYiRL~ ~ DOB Home Phone CONFIDENTIAL - EMR COPY --- Printed by Dvorak, Jeremy 8/15/05 1044 Page 3 of 9 Talhelm, Paige (MRN176926('' ~ ~ T'om` DAMS HEALTH ;5 Y STEM Information Talhelm, Paige 1769260 F 11/211991 717-486-4808 (13yr) ',~1jt RQOm Isolation EMER ERWB N Lab ~ Lab Director Information UC DAVIS MED CTR Ra{ph Green, MD 2315 Stockton Blvd Sacramento, CA 95817 Order Information BASIC CHEMISTRY PANEL (BCP) (Order# 6678332) Order Order Date and Time Department Information 6/26/2005 5:30 PM Emergency Order Authorizing Provider Encounter Provider Providers (05456) Peter Sokolove (05456) Peter Sokolove Priority and Priority ~~ Order Details STAT Normal Lab Results LIVER FUNCTION TESTS (Order# 6678333) Collection Collection Date and Time Received Date and Time Information 6/26/20051730 6/26/20051742 Com oiLnent Value l=1ag ~ Ijlgh Units Status ALBUMIN 4.0 2.9 4.5 g/dL Final ALKALINE PHOSPHATASE 193 H 35 115 U/L Final (ALP) ASPARTATE TRANSAMINASE 27 15 43 U/L Final (AST) BILIRUBIN TOTAL 1.1 0.3 1.3 mg/dL Final ALANINE TRANSFERASE 16 5 54 U/L Final (ALT) TEST ADDED TO SPECIMEN PREVIOUSLY RECEIVED IN LABORATORY TEST ADDED: HFP DATE/TIME TEST REQUESTED: 06/26/05 1756 REQUESTING PHYSICIAN NAME: SOKOLOVE A HARDCOPY REQUISITION FOR THIS TEST HAS BEEN REQUESTED LIVER FUNCTION TESTS (Order#6678333) on 6/26!05 -Order Result History Rem Related Tests CONFIDENTIAL - EMR COPY --- Printed by Dvorak, Jeremy 8/15/05 1044 Page 4 of 9 Talhelm, Paige (MRN176926~', ~ "'~ DAMS HEALTH SYSTEM BASIC CHEMISTRY PANEL ~BGPI~Order#6678332) on u/26/05 LIPASE (Order#6678334) on 6126!05 Other IDs Reflex Order # Lab S.necimen # 6678332 0626:CI00365S Patient patient Name MRN $@X DOB Home Phgne Information Talhelm, Paige 1769260 F 11/2/1991 717-486-4808 (13yr} Slttit Room Isolation EMER ERWB N Lab ~ Lab Director information UC DAVIS MED CTR Ralph Green, MD 2315 Stockton Blvd Sacramento, CA 95817 Order Information LIVER PUNCTION TEST S FOrder# 6678333) Order Order Date and Time Department information 6/26/2005 5:30 PM Emergency Order Authorizing Provider Encounter Provider Providers (05456) Peter 5okolove (05456) PeterSokolove Priority and ~riorit•r Ciao Order Details STAT Normal Lab Results LIPASE (Order# 6678334) Collection Collection Date and Time Received Date and Time Information 6126!20051730 6/26/20051742 Com onent Value E1eg !_owl~!9h Units tus LIPASE 27 13 51 U/L Final TEST ADDED TO SPECIMEN PREVIOUSLY RECEIVED IN LABORATORY TEST ADDED: HFP DATE/TIME TEST REQUESTED: 06/26/05 1756 REQUESTING PHYSICIAN NAME: SOKOLOVE A HARDCOPY REQUISITION FOR THIS TEST HAS BEEN REQUESTED CONFIDENTIAL - EMR COPY --- Printed by Dvorak, Jeremy 8/15/05 1044 Page 5 of 9 Talhelm, Paige (MRN176926t'' LIPASE (Order#667833~ on 6/26/05 -Order Result History Report T "^ DAMS HEALTH SYSTEM Related Tests BASIC CHEMISTRY PANEL (BCPL(Order#6678332) on 6/26105 LIVER FUNCTION TESTS (Order#667833~ on 6/26/05 Other IDs Reflex Order # Lab Specimen # 6678332 0626:CI00365S Patient Patient Name Information Talhelm, Paige alt Room EMER ERWB M13d ~ DOB Home Phone 1769260 F 11 /2/1991 717-486-4808 (13yr) Isolation N Lab ~ Lab Director Information UC DAVIS MED CTR Ralph Green, MD 2315 Stockton Blvd Sacramento, CA 95817 Order Information LIPASE (Order# 6678334) Order Order Date and Time Deaartment Information 6/26/2005 5:30 PM Emergency Order Authorizing Provider Encounter Provider Providers (05456) Peter Sokolove (05456) Peter Sokolove Priority and priority Class Order Details STAT Normal Lab R@SUItS TYPE AND SCREEN (Order# 6678351) Collection Collection Date and Time Received Date and Time Information 6/26/20051730 6126/20051758 PATIENT BLOOD TYPE: O POSITIVE ANTIBODY SCREEN (ORTHO GEL): NEGATIVE Sufficient specimen available to add units until:6/29@1730 Crossmatched units are released approx 1600 on above date. CONFIDENTIAL - EMR COPY --- Printed by Dvorak, Jeremy 8/15/OS 1044 Page 6 of 9 •~ i Talhelm, raige (MRN176926~" ~ 'T'~' DAMS HEALTH SYSTEM TYPE AND SCREEN (Order#6678351) on 6/26!05 -Order Result His or Report Other IDs Lab Specimen # 0626: BB00061 S Patient Patient Name Information Talhelm, Paige ilnit EMER Ir~R11 ~ 1769260 F BQ4m Isolation ERWB N pQB Home Phone 11 /2/1991 717-486-4808 (13yr) Lab l~ Lab Director Information UC DAVIS MED CTR Raiph Green, MD 2315 Stockton Bivd Sacramento, CA 95817 OTC~ET ttlf0l'Iriat1011 TYPE AND SCREEN (Order# 6678351) Order Order Date and Time Department Information 6/26/2005 5:30 PM Emergency Order Authorizing Provider Encounter Provider Providers (05456) Peter Sokolove (05456) Peter Sokolove Priority and Priority Class Order Details STAT Normal Lab Results PROTHROMBIN TIME (PT) (Orden# 6678389) Collection Collection Date and Time Received Date and Time Information 6/26/20051730 6/26/20051742 Component Value ~S Inc H19h Anita Status INR 1.03 0.75 1.19 Final Related Tests APTT STUDIES ~Order#6678390) on 6/26/05 Other IDs Lab Specimen # 0626:CG00183S CONFIDENTIAL - EMR COPY --- Printed by Dvorak, Jeremy 8!15!05 1044 Page 7 of 9 Taihel;n, Faige (b'!~?`~T? ?692C0~~ Patient Patient Name [~Rb S'eX ^~ Information Talhelm, Paige 1769260 F 11/2/1991 (13yr) SJ~it Boom Isolation EMER ERWB N T?~, IaA :CIS HEALTH SYSTEM Home Phone 717-486-4808 Lab ~ Lab Director Information tJC DAVIS MED CTR Ralph Green, MD 2315 Stockton Blvd Sacramento, CA 95817 Order Information PROTHROMBIN TIME (PT) (Ordet# 6678389) Order Order Date and Time Department Information 6/26/2005 5:30 PM Emergency Order Authorizing Provider Encounter Provider Providers (05456) Peter Sokolove (05456) Peter Sokolove Priority and Priority Class Order Details STAT Normal Lab Results APTT STUDIES (Order# 6678390) Collection Collection Date and Time Received Date and Time Information 6/26/20051730 6126/20051742 Component Value F-La9 L~ yjgb Units Status APTT 26.1 21.8 31.5 SECONDS Finai Related Tests PROTHROMBIN TIME (PT) (Orderf16678389~ on 6/26/05 Other IDs Reflex Order # Lab Specimen # 6678389 0626:CG00183S Patient Patient Name M$!y S. ex DOB Home Phone Information Talhelm, Paige 1769260 F 11/2/1991 717-486-4808 (13yr) l~Qit Room Isolation EMER ERWB N Lab ~ Information CONFIDENTIAL - EMR COPY --- Printed by Dvorak, Jeremy 8/15/05 1044 Page 8 of 9 Talhelm, Paige (MRl`d17~92r;0~ ~ i'~, DA«IS HEP.LTH SYSTE'.VI UC DAVIS MED CTR Ralph Green. MD 2315 Stockton Blvd Sacramento, CA 95817 Order Information APTT STUDIES (Ordert~ 6678390) Order Order Date and Tim DeQan?ment Information 6/26/2005 5:30 PM Emergency Order Authorizing Provider Encounter Provider Providers (05456) Peter Sokolove (05456) Peter Sokolove Priority and Priority Class Order Details STAT Normal CONFIDENTIAL - EMR COPY --- Printed by Dvorak, Jeremy 8/15/05 1044 Page 9 of 9 Talhelm, Paige (MRN1769260~ Imaging Results ELBOW 3+ VIEWS, RIGHT (Order# 6678311) (Acc# 28330) FACS Images Show images fcr ELBOW 3+ VIEWS. RIGHT [RADDX00931) To launch xray images, your computer needs Windows 98 or above 8 Internet Explorer (IE) version 5.5 or above. From outside UCDHS, launch VPN before logging into Citrix and EMR. Click here for troubleshooting tIDS, or contact IS Customer Support (734-HELP). Results EXAM DATE: 06/26/2005 ELBOW, 3+ VIEWS, RIGHT: CLINICAL HISTORY: Rollover MVA with right upper extremity abrasion. FINDINGS: Two lateral, oblique, and AP views of the elbow were provided for review without previous films for comparison. There is no evidence of fracture or malalignment. Posteriorly, within the soft tissues, there are multiple 2-5 mm radiopaque objects which may represent foreign bodies, correlate clinically. IMPRESSION: 1. NO EVIDENCE OF ACUTE FRACTURE OR MALALIGNMENT OF THE RIGHT ELBOA. 2. MULTIPLE RADIOPAQUE OBJECTS WITHIN THE SOFT TISSUES POSTERIORLY. SH:cm(rad020) ACC#: 000000028330 D: 06/27/2005 12:48 AM T: 06/27/2005 01:96 AM C#: 1092846 signed: Stephanie Horton, D.O. cosigned: Kiran Jain, M.D. Result History ELBOW 3+ VIEWS. RIGHT (Onier#6678311)_on 6/28/05 -Order Result History Report EXam Exam Date Exam Time Information 6/26/2005 2353 Result Result Date and Time Information 6/28!2005 10:40 AM Status Final result Patient Patient Name ~~ ~ DOB Information Talhelm, Paige 1769260 Female 11/2/1991 ~ 12oom Isolation EMER ERWB N t 1C DAMS HEALTII SYSTEM CONFIDENTIAL -EMR COPY --- Printed by Dvorak, Jeremy 8/15/05 1044 Page 1 of 8 ~, Talhelm, Paige (MRN1769260' • ~ TTY' DAVIS HEALTH SYSTEM ~Cd~'C ELBOW 3+ VIEWS, RIGHT (Order# 66783111 Patient patient Name MBE( S, ex DOB Patient PJ~nQ Information Talhelm, Paige 1769260 Female 11/2/1991 717-486-4808 Allergies: (Not on File) Order Authorizing Provider Encounter Provider Providers (05456) Peter Sokolove (05456) Peter Sokolove Order Order Date and Time Department Information 6/26/2005 5:59 PM Emergency Priority and Priority Class Order Details STAT Normal Insurance Acct Number Financial Class Information 020960114997 O 1 PaYor MISC Patient insurance 061601202 Itt Plan. Plan Number COMMERCIAL 099 INS-MISC Imaging Results FOREARM 2 VIEWS, RIGHT (Order# 8678312) (Acc# 28331) PACS Images Show images for FOREARM 2 VIEWS. RIGHT [RADDX009411 To launch xray images, your computer needs Windows 98 or above & Internet Explorer (IE) version 5.5 or above. From outside UCDHS, launch VPN before logging into Citrix and EMR. Click here for troubleshooting tips, or contact IS Customer Support (734-HELP). Results EXAM DATE: 06/26/2005 FOREARM, 2 VIEWS, RIGHT: CLINICAL HISTORY: Status post rollover MVA with abrasions to the right arm. FINDINGS: Two views of the right forearm were provided for review without previous films for comparison. There is no evidence of fracture or malalignment. Soft tissue defects are noted posteriorly and medially with multiple 2-5 mm radiopaque objects within the soft tissues. Bandage material is also noted. IMPRESSION: 1. NO EVIDENCE OF FRACTURE OR MALALIGNMENT OF THE RIGHT FOREARM. 2. MULTIPLE RADIOPAQUE OBJECTS OVERLYING THE SOFT TISSUES OF THE PROXIMP.L FOREARM AS ABOVE. CONFIDENTIAL -EMR COPY --- Printed by Dvorak, Jeremy 8/15/05 1044 Page 2 of 8 Talhelm, Paige (MRN 1769260` ~ T T~. D A VIS HEAL'T'H SYSTEM SH:cmrrad020) ACC#: 000000028331 D: 06/27/2005 12:17 AM T: 06/2?/2005 01:16 AM C#: 1092839 signed: Stephanie Horton, D.O. cosigned: Kiran Jain, M. D. Result History FOREARM 2 VIEWS. RIGHT (Order#6678312) on 6/2R~n5.Order Result HistorxReport Exam Exam Date Exam Time Information 6/26/2005 2353 Result Result Date and Time Status Information 6/28/2005 10:40 AM Final result Patient patient Name mBN ~ DOB Information Talhelm, Paige 1769260 Female 11/2/1991 Molt 12oom Isolation EMER ERWB N Order FOREARM 2 VIEWS, RIGHT (Order# 6678312) Patient patient Name ~~( ~ QQ@ Patient Phone Information Talhelm, Paige 1769260 Female 11/2/1991 717-486-4808 Allergies: (Not on File) Order Authorizing Provider Encounter Provider Providers (05456) Peter Sokolove (05456) Peter Sokolove Order Order Date and Time Department Information 6/26/2005 5:59 PM Emergency Priority and Priority Class Order Details STAT Normal Insurance Acct Number Financial Class Information 020960114997 O ~ Pavor MISC Patient Insurance 061801202 CONFIDENTIAL - EMR COPY --- Printed by Dvorak, Jeremy 8/15/05 1044 Page 3 of 8 ,. , Talhelm, Paige (MRN176926('~ ' elan. Number COMMERCIAL 099 INS-MISC ' ' - ~" DAVIS HEALTH SYSTEM Imaging Results C-SPINE 4+ VIEWS (Order# 6678309) (Acc# 28328) PACS Images Show images for C-SPINE 4+ VIEWS jRADDX01008J To launch xray images, your computer needs Windows 98 or above 8 Internet Explorer (IE) version 5.5 or above. From outside UCDHS, launch VPN before logging into Citrix and EMR. Click here for troubleshooting tIDS, or contact IS Customer Support (734-HELP). Res u Its EXAM DATE: 06/26/2005 CERVICAL SPINE, 9+ VIEWS: CLINICAL HISTORY: Rollover MVA. FINDINGS: Multiple views of the cervical spine are provided for review without previous films for comparison. There is no evidence of fracture or malalignment. The C1-2 junction is symmetrical. Vertebral body and disc space heights are preserved. No prevertebral soft tissue swelling is seen. IMPRESSION: NO EVIDENCE OF ACUTE FRACTURE OR MALALIGNMENT OF THE CERVICAL SPINE. SH:cm(rad020) ACC#: 000000028326 D: 06/27/2005 12:15 AM T: 06/27/2005 01:19 AM C#: 1092838 signed: Stephanie Horton, D.O. cosigned: Kiran Jain, M.D. Result History C-SPINE 4+ VIEWS {Order#6678309) on 6/28/05 -Order Result History Report Exam Exam Date Exam Time Information 6!26/2005 2351 Result Result Date and Time Status Information 6/28/2005 10:40 AM Final result Patient patient Name MRN ~ DOB Information Talhelm, Paige 1769260 Female 11/2/1991 CONFIDENTIAL -EMR COPY --- Printed by Dvorak, Jeremy 8/15/05 1044 Page 4 of 8 Talhelm, Paige (MRN176926(-' ~ ~ ~ T"~ DAMS HEALTH SYSTEI~1 l3QOm Isolation EMER ERWB N Order C-SPINE 4+ VIEWS (Order# 6678309) Patient patient Name II~BM $gg DOB Patient Phone Information Talhelm, Paige 1769260 Female 11/2/1991 717-486-4808 Allergies: (Not on File) Order Authorizing Pr ovider Encounter Provider Providers (05456) Peter Sokolove (05456) Peter Sokolove Order Order Date and Time Department Information 6!26/2005 5:59 PM Emergency Priority and priorFty Class Order Details STAT Normal Insurance Acct Number Financial Class Information 020960114997 O 1 Pavor MISC Patient Insurance 061601202 112 ~I a IJaD Number COMMERCIAL 099 INS-MISC Imaging Results PELVIS 1 OR 2 VIEWS (Order# 6678310) (Acc# 28329) PACS Images Show images for PELVIS 1 OR 2 VIEWS [RADDX00976j To launch xray images, your computer needs Windows 98 or above & Internet Explorer (IE) version 5.5 or above. From outside UCDHS, launch VPN before logging into Citrix and EMR. Click here for troubleshooting tins, or contact IS Customer Support (734-HELP). Results EXAM DATE: 06/26/2005 PELVIS, 1 PR 2 VIEWS: CLINICAL HISTORY: Status post rollover MVA. FINDINGS: Single AP view of the pelvis was provided for review without previous films for comparison. There is no evidence of fracture or CONFIDENTIAL -EMR COPY --- Printed by Dvorak, Jeremy 8/15/05 1044 Page 5 of 8 , r • , Talhelm, Paige (MRN 176926('` ~ ~ T rr", DAMS HEALTH SYSTEM dislocation. Stool and gas overlie the sacrum maki*~g *_he evaluation of fractures limited. Soft tissues are unremarkable, no bony lesions are seen. IMPRESSION: NO EVIDENCE OF ACUTE FRACTURE OR DISLOCATION OF THE PELVIS. LIMITED EVALUATION OF THE SACRUM. SH:cm(rad020) ACC#: 000000028329 D: 06/27/2005 12:12 AM T: 06/27/2005 01:11 AM C#: 1092837 signed: Stephanie Horton, D.O. cosigned: Kiran Jain, M. D. Result History PELVIS 1 OR 2 VIEWS (Order#6678310) on 6/28/05 -Order Result History Re o~rt Exam Exam Date Exam Time Information 6/26/2005 2345 Result Result Date and Time Information 6/28/2005 10:40 AM Status Final result Patient patient Name M.RN ;~ DOB Information Talhelm, Paige 1769260 Female 11!2!1991 Room Isolation EMER ERWB N Order PEwls 1 oR 2 vlEws (order# sslss~o~ Patient patient Name mRPl ~ QQ)~ Patient Phone Information Talhelm, Paige 1769260 Female 11/2!1991 717-486-4808 Allergies: (Not on File) Order Authorizing Provider Encounter Provider Providers (05456) Peter Sokolove (05456) Peter Sokolove Order Order Date and Time IZepartment Information 6/26/2005 5:59 PM Emergency Priority and Priority Class Order Details crAT Normal CONFIDENTIAL - EMR COPY --- Printed by Dvorak, Jeremy 8/15/05 1044 Page 6 of 8 ,, TalheIm, Paige (MRIv 1769L60' T ""DAMS HEALTH SYSTEM Insurance acct Number FJD~n~laLClass Information 020960114997 O 1 Pavor MISC patient Insurance 061601202 !Q Pia PlaA Number COMMERCIAL 099 INS-MISC Imaging Results cHEST 1 VIEW (order# ss7s3os) (Acc# 2s327) PALS Images Show images for CHEST 1 VIEW [RADDX00980j To launch xray images, your computer needs Windows 98 or above ~ Internet Explorer (tE) version 5.5 or above. From outside UCDHS, launch VPN before logging into Citrix and EMR. Click here for troubleshooting tiDS, or contact IS Customer Support (734-HELP). Results EXAM DATE: 06/26/2005 CHEST, 1 VIEW: CLINICAL HISTORY: Rollover MVA. FINDINGS: Single AP view of the chest was provided for review without previous films for comparison. The lungs are clear and the costophrenic angles are sharp. The cardiac silhouette is within normal limits. There is no tracheal deviation, the mediastinum is unremarkable. No bony or soft tissue abnormalities are identified. IMPRESSION: NO EVIDENCE OF AN ACUTE CARDIOPULMONARY PROCESS. SH:cm(rad020) ACC#: 000000026327 D: 06/27!2005 01:92 AM T: 06/27/2005 02:53 AM C#: 1092869 signed: Stephanie Horton, D.O. cosigned: Kiran Jain, M.D. Result History CHEST 1 VIEW (Order#66783081 on 6128/05 -Order Result History Report Exam Exam Date Exam Time Information 6!26/2005 2340 CONFIDENTIAL -EMR COPY --- Printed by Dvorak, Jeremy 8115/05 1044 Page 7 of 8 ~~ Talhelm, Paige (MRN176926~ Result Resuii Daie and Time Information 6/28/2005 10:40 AM Status Fin ~ result Patient Patient Name information Talhelm, Paige ' ~ ~ ~ -; DAVIS HEALTH SYSTEM ~iy ~ ~~ 1769260 Female 11/2/1991 tJoit Room Iso{ation EMER ERWB N Order CHEST 1 VIEW (Order# 6678308) Patient Patient Name ~$~ ;zex DQ@ patient Phone Information Talhelm, Paige 1769260 Female 1112!1991 717-486-4808 Allergies: (Not on File) Order Authorizing Provider I:D000nterProvider Providers (05456) Peter Sokolove (05456) Peter Sokolove Order Order Date and Time Department Information 6/26/2005 5:59 PM Emergency Priority and Priority Class Order Details STAT Normal Insurance Acct Number Financial Class Information 020960114997 O 7 P~y_or MISC Plan. P_!aa )!LuIDl~t COMMERCIAL 099 INS-MISC Patient Insurance 061601202 IQ CONFIDENTIAL - EMR COPY --- Printed by Dvorak, Jeremy 8/15/OS 1044 Page 8 of 8 FROM ' (FR;3JUId ~0 20G5 10:21 /ST. 10: 20/N o. 6$16204346 P 3 Name: TALHELM, PAIGE ~Cl C~1ICI~ ~ t !~ ! :~' SA#: 01349857 j i~ ~} 3 ~ ~Q06 hb . 4~e~~c~! Dep~ ~~:= ' ~~` ;~:~: .,, H12969000 06/26/05 American Med R nse W. $843.81 $759.43 H12969001 06/26/05 R nts1UCD PBGI IM Hemet 584.05 $75.64 014788600 06/26/05 U. C. Davis Medical Ctr. $18549.50 $9 739.60 031333600 0626/05 R ents/UCD PBGI IM Hemet $338.00 $338.00 032532900 06x26/05 R ntslUCD PBG/ IM Hemet 5242.00 $217.80 032532901 06/26/05 R ntsJUCD PBG1 IM Hemet $48.00 54 320.00 N67005200 07101!05 Sutter Medical Foundation 5256.00 $236.00 062190900 08/04/05 Giessw~ein Plastic Su x70.00 $35.00 Carlisle Pediatric Assoc. $15,721.4? ~ Y ~ USE f'nTI~NT ~~T` - ~ - ` '` JNIVERSiTY OF CALIFORNIA DAVIS ` "' _ ~, :'~ `' ~` ~ s~ S MEDICAL CENTER '. ~ ceCF.AI!4ENT0, CALIFORNIA ~. ° EMERGENCY DEPARTMENT r~: ~~~1 ~-- PAST MEDICAL HISTORY: e.P PULSE RESP. TEMP. PUPILS PRESENT MEDICATIONS: PRE-HOSPITAL TREATMENT & SUPPLIES: s ~` DATE /TIME TREATMENT i VITAL SIGNS ASSESSMENT ~' ~-~[ ~ ~or~ -c~ ~~ ~' ~ c~~ ~ vern-~~~ ~ ~Yt ~ ' ~ ' ~ ~-~~-~ - cam. CL's ~ ~~- ~ L V~.l•'Vti~i CX~~k - • ,. ~ " C) I y pp e-~.1~ ~• - 11~.t~ r~ ~ ' ' `'ifs-Q t' ~f'~ . ~:~`~-~.F.~ Q.12~1^,-' C~ ~ ClYVV2. YYl I ~~ ~ D _.._...___.._...__ ./ ,~ ,r i i `~ ADMINISTRATION ,. i ~ .fit Yo.r-s . .. 1 _~'.~~ ~ .~~,v~~ iY.~~ c~~~~o~ ~~7s . . ~ ~ }~ Q ."' ~,~ -` ~ ? Q - 9 b Q 1 i $ ~ ~ 7 V ~ P.;J A ~ ]<iEALtiF~ ~l'STEM ACKNC~NVl=~i7GEMEN~f~':.QF i ECEIPT: NOTICE OF PRIVACY- PRAC~'ICES _ _ ~;,< < The UC Davis Health System Notice of Privacy Practices provides information about how ~~e may use and disclose protected health information about you. In addition to the copy we are providing you, copies of the current notice are available by accessing our Web site at http://web.ucdmc.ucdavis.edu/compliance/ and may be obtained~throughout t7C Davis Health System. I acknowledge that I have received the Notice of Privacy Practices. ~ ~ ~~G~,~ ,1 ~~~ ~~~~ Signature of Patient or Patient's Representative Print Name SS Interpreter (if applicable] Written Acknowledgement Not Obtained Date ., . •,, ~0~ Relationship to Patient Please document your efforts to obtain acknowledgment and reason it was not obtained. ^ Notice of Privacy Practices Given -Patient Unable to Sign D Notice of Privacy Practices Given -Patient Declined to Sign ^ Notice of Privacy Practices Mailed to Patient -Awaiting Signature ^ Other Reason Patient Did Not Sign Signature of UC Davis Health System Representative Print Name Date Department PROGRESS REC9RD ~QrL? ~ -~ f e re~~, (~^n~ U 5~ ~ R ~ ~-~ (tip ~~)~ t ~~ I~ `d ~/~ t J ~° U ~ ~ >c I.. rn,..J~ S tG L I B!! ~CCVbr.~ GL. At r1F ~ ,~ Esc ..ct~ ~~Cy._. ~ w,aoCro~. r+~., , A~._~ '~~viL~ ~ ~.t-4cC~ w n~.,nf.. ~~ ~ r Tl -~ X75 Y`P_rX Y? ~~~ C<1'_rr`^ ~/ct_-~1 C~Sa dl ~i fit ~._.. lil/L ~ ~-c.~ RR®Gr"c~SS REGaR~ ' U ~e~ `~a-~~c,Ql..~1 f ~_.GZ ~ c~ '~ ~ r~~C3 ~ i ~ '~ i h n ~,r--. i ~~~ n ~ x l mC~ ~ 1 M~ S~z~.~ ~- V u Q ~ 6.2C..~- ~,~ ~_ '1- 5-05 /.~s ./ wD~~ ~~t i ~ ~' frr arc ~X ~~ ~ r1 ~/ - o ~ ~ -- ~ n - - - QENERAL R BYES tHROAT NECK i~lEAAT c~. v r' ~--- c u ~ S ~ cF- Lc ( C A9Q J ~ ~9-+~' ~ ,r - cc r ~ EXTREM i~{EURO. ~~ S ~ ,~~ . ~. ~ J ~cv'14 ~. .~ ~~. , fi~~ .~ ~'~ ,! Name: ~ C' ,~. r ~ ~t~ /~li~~ Doa: I ~'~ ~-~If o'- 11yrs. Date: ~ ~ , ~ ~~ ~.~ Ht. ~~ Wt ~r~~ ~ B.P. r~ (r;~ Allergies J Interval History Psychosocial PE. !Normal / Abnormal ^ Illness/injury/surgery Home Gen. App. C] 1 Beth f`J G. U. I~ Head O"~Neck t3~ Tanner stayed L"yes O'Chest G~ U/A C] V. A. Q' Tanner stage.~Ext. C~' Education/employment Ears Q"Lungs O~ Neuro. ~ ~v~~^F? - ~,<,f~-ems ' Nose C'Ji Heart t~ Skin C~ f ~ ' Meds ~./ ~, :~~~-- , ~~, -`~ =~ BackC Abdomen O Throat C .~ ( ,tu-. Z.y ~ Activities _ Comments t ~ ~ D ,'c~._,.,~ .Health maintenance Drugs/a.1~`ohollcigarettes ' Counseling Dentist Q 1~..~ e-~ Vision Q Q i H ear ng Sexuality - Impression Menstrual History - 5 ~R ~~~~ 1 '~' ~ ~,~ ~ ~ ~-~ .p ~va~+a.~a.+z`c~~`~ f - `~~.~ x i~_ n Concerns Suicide/depression "" Treatment -,(cztic c..<,~aj- _ Q _ ~z :n-~.Q ~i~ w rl 1 l ~ `~ a f ~.ti,~ Follow-u z -,~-, ~ 13yrs. Date: Ht. Wt B.P.. Allergies Interval History Psychosocial PE. /Normal / Abnormal IfA Illness/injury/surgery Home Gen. App. Q Teeth O G. U. O Head O Neck O Tanner stage- Eyes 0 Chest O U/A l7 V. A. O Tanner stage„ Ext. C] Education/employment Ears ^ Lungs O Neuro. t] Nose ^ Heart D Skin O Meds Throat O Abdomen O Back. D Activities ...------• .... ...................................1 Comments Health maintenance Drugs/alcohollcigarettes Counseling Dentist Q Vision G Hearing (~ -- Sexuality impression Menstrual History Concerns Suicide/depression Treatment Follow-u ~~ tr xS__ Eg r11~~A' i ~~~K ~~a~ Af~~• --tia~' ~x~`REM .,..-. t~v~'~ -~ ~~-~~~ .~ ~:~ . ~ ~' GRASS Ft~VQR~ `~ ~ ~"'~ ,_.-- ,~ a~ ~~ ~~ ~..- ~, ~t G ~ ~.-e _ ~ w~~...---- ,s i" ~ ~ ~L l `,. ~k ~ 7~ A ~ . Y ' ` ~` ~"".~^ v S ~ / ~~ ~.~ 'P ~- ~~--~°`~ ,-- "~ --,- ~__. ._ ~ .~ . PRO~'RESS REC~R~ 4J _----~ .f- n ~ c3v_..._-----~ f •~ ~ ~ ~ J t`~ __---~-j~`` .~ z ~~ -- G ~~,~ M C ~ ~~ ~~ hwC'` `t'C.~~~ 4:... `.11-~~ 1 . ~ ~ ~~.~~ 4, ~~,~ ~ SD t .~ -i` ~ In ~ ~ ~ - .._: ti ;. p R ~'~~~ i I-I. ~~ ~ 7` ~,er g~~ ~ e~ ~~~ c ~`~' Y.. ,%~ ~~ ::3 . j` :". !'~« 4`~~ ~ -~, ~; ~~ a~; 4'T'' L! 'I _t ~ , ~3 , y. .~ ~ ~' a ' V" E.. p - r~ ~~ F b ' ~" w Provided courtesy of Mead Johnson Nutritionals, maker of Enfamil®, ProSobee~', Nutramigen°, Pregestimilm, Poly-Vi-Flor°, and Tempra°. L-B 10-3-89 ~ ~J~-p l~ u ~~ - -- ~ ~~>~ ,~ - ~ ~ ,~ -- c~c S (v0 3 '`- ,~ f .~- _ _ 1,-/~~ PATIENT Date; ~~ I ime:. _.~~'1 Patient: _ _ ': a ~~'~.; ~~ Reason for Ca11:` ~ /' . ~~ ,;: f~~e$etlt Med~G =~ ~v r I~ecoi~rner~d.~t~"~ns/Pr~~~~~ptttisx ~T__~_ r ~ ~ f f t :i k~. ic, '~~- ~:, o ~~. S F '. c " t? `3 «?~ a . s(.~) ~ ~_ f ~ i ~ ,,' _, ~ ~ r ' . i ' cps ~ 10SE i'NROAT HEART .~- ~ C l~P a- EXTREM lEURO, °` ~, t_-- ~N ~ ~\ +~ Name: T"a~ ~, Ta ~ i1 t? (l'1r1 DOB: ~ ~ - Z - ~ i 7g Date: ~ ~ Z ~ - () (~ Ht. ~ ~ ~~`~" ~ ~ ~ B.P.. ~ ~U/j b Allergies ~ l~~ ' - ~- 5y -~ b f / t Interval Histo ry h~~~ .~~~ ce(` Ps chosocial y PE. /Normal / Abnormal ^ School ~ `~'~~- ' U Family relationships Gen. App. C~eeth -N O'Ext. ' O'' ' 5 ~ ~ ~ ~ P 2 i5~ ~~`_ _ f -~~ P°"~~ Head Eyes C] eck C~'~ungs O Neuro ~ Skin [~ Gl- `R"''~ ~" `(~x'~^"~~ ~a-.~t t Ears e N O1-teart C~" Abdom 0- Back en C3' 0- I{Iness/injury/surgery ,.~,( ~ _ Peer relationships os Throat O'G. U. ~ Comments beds Health maintenance Dentist ~ ~ i n lcs~l (~ ~~ Vision C~" Z~~20 o c~ Hearing ~ ~ c~,,,~s~,~ ~u Concerns ~~ 9yrs. Date: Interval History School Illness/injury/surgery Activities /interests S b CCe~ . ~'~ . Mood Impression r, ~ Appetite /Sleep g~ ~ ~~~. ~ o ~ CtiR1~, Ja~~t dK a(~ ~~~ . Treatment Television C~~ _ Follow-u iU ~~ wcc ~kG Ht. 1IVt B.P.. - Allergies Psychosocial PE. /Normal / ~ Abnormal ^ Family relationships Gen. App. Head ^ Teeth ^ Neck O G. U. ^ Tanner O stage Eyes ^ Chest O Ext. O Ears O Lungs O Neuro ^ Nose ^ Heart ^ Skin ^ Peer relationships Throat ^ Abdomen ^ Back ^ Comments Meds Health maintenance Dentist ^ Vision ^ Nearing D Concerns Activities /interests Mood ~ Impression Appetite /Sleep Treatment Television Follow- .' a~~ ,~ '` ~ . -- .. ~, s- _- ~ / l ' F.._-~-..~ __ --'_ .1 _.._...... Fit`./sf3T s I - N15D. i_~.... _ ..---._.. ----d FXTF?kM. ~ ~ per-iJitC). f ~__... __..__._.. ~ X L, .~ ... Z~ ~ ` 0 ^~l to - c~v~ (~'"l rf S u~-yl Lam. ~'j ~) ! j ->! C' '~~_. 7 ~ CI Z-- ~- - ~1n1 S d d l~ AGE G VVT ~~_ ~ !~T a~ t-IG ~ ~~~ , !bU [ o ~ Z /u! - a Di*~P iR!T1~ MfTR L2 `_ Provided courtesy of Mead Johnson Nutriiionals, maker of Enfami!®, ProSobee®, Nutramigerr~, Pregestimil19, Poly-Vi-Flom, and Tempram. L-B10~&89 A _ _. ~ r - a ~ ~ P , ~aECGi~t[t~r;Ei"' ~~ ~~~~tir~~~` ~~~~~1~-t~' ~E~~~~ra~, ~, E o J ~ ~~ ' ~ ~~~ ~X ~~~ Fi ~ / O S Name ~ _.(,~- Birth D een __ ate rst ate Race Six Insurance Hospital Address Phone_ _ Obstetrician Address Phone _ R f d b erre e y /L Father's Name ~~ ~ ,,li ,Q ~TZ , Phona.~ ~S- 90 g ~_ _.._Address Mother's Name /' L, ~• '"e ~l~s-Q-~"'1 ~~dr'1°-s`~ ~S~ ~ ~~d! ~ Phone Patietlt ~:1 IItY: Record Number: ~latl' UI :~it~iu: [ have read or have had exptaincd to rile the information regarding the dis.:ases and vaccines listed below. [ ha~•e had a chance to ask questions that ~cete ;,,~,wered to my satisfaction. t believe (understand the benefits and risks of the vaccines cited and ask that the vaccines listcd be given to me or to [hC rson na Vaccine mca aoove Ior ~ Datc Given mltUv .u~ur r ~~~~ ~uu ,qee ~~~r~~~ •~ ~~ Site Given- -- Vaccine Dianufacturer Vaccine Lat k [nitials Signature of Parent or Guardian ,!DPT H' 3 7 - ~ L. tit DPT N f B p - ~ - -1 tit T IdIC~ ~~' tit DPT/DaPT~ ~ Z' ~ ' ~1 ~ nt DPTNaPTS r~ ~~ ~ ~ -~ I tit DTP/Hib 1 [~t I DTP/Hib 2 t>t I DTP/Hib 3 I tit DTP/Hib a I •• tit OPV/IPV 1 ~ J ~ i I PO/IM I oPVitPV z 3-J - ~ Z P.o~M OPV/IPV 3 5- 3 - q ~. Pow OPV/IPV ~ ~~ ~Z" ~ ' 9 T - PO/IIv1 I ~, ~-z9-q3 s ~>~ ~-~ r - - ~ so He B ! ~"Z~ •9 3 Iu I He B 2 3 ~ 3-g tit' He B 3 4 Z Q t' 2- I ...) tit Tine/PPD ~~~~ ~a Td - trot kl c ~ $-t4- ! a -~~ rZc 1._ ~. r, 1 O • ~ J~ a~,~ ~\ ~~ "~1l7 t1ru lS J7~/: atuie o~ irr (:L[/1c li ~I:l1Lll rsarW.Ur Jf~t- ~+•r~-" ~-•-p ~~••_ RA Right Arm T Left Arm LA RT Right Thigh LT Lcft Tltigh (Please C•se Rn• erse Side il.llare Sit;narrrrcs.dre •\•eededl O Orel K~•iPC 7/9a ~xH~~~-~ ti FROM :CARL PEDS FAX N0. :7172436708 May. 25 2006 04:43PM P2 CARLISLE PEDIATRIC ASSOCIATES A PROFESSIONAL CORPORATION STEPHEN J. KREBS, M.D. HOLLY C. HOFFMAN, M.D. J. LYNN HOFFMAN, M. D. EUSEO ROSARIO, JR., M. D. DEBORAH RAUBENSTINE, M.D. ELENA MAN, M.D. DIANNA RUDY, PA-C 804 BELVEDERE STREET, CARLISLE, PA 17013 May 25, 2006 ~a3-lean To Whom It May Concern: R.e. Samuel Talhelzu, I)OII 9-15-97 Paige Talheln~, T)OJ3 11-2-91 Jack Talhel,rn ))UB 1-IO-99 This letter serves to document that all medical issues related to the motor vehicle accident in which these cbi,ldren were invaTvcd on 6-26-20Q5 have resolved or have cgncludecl treatment. Jack and Sam were cleared on their initial hollow-up visit here on 7-5-05. Paige req~aircd multiple visits for dressing changes and wnuod care for her right arm, but her injw.y healed by August 2005 and she ha.5 needed no further treatment related to this injury siaace that time. All childre~.l are now cleared from their medical injuries in reference to the ahc~ve accident. Thank yau. With Regards, r` . ~t-------' --- c:_, Holly C. Hoffman Mi) ~X~~ ~ ~ 1J APR 5 t inn? MICHELE POSSENTI AND KEVIN TALHELM AS PARENTS AND NATURAL GUARDIANS OF PAIGE TALHELM, A MINOR, JACK TALHELM, A MINOR AND SAMUEL TALHELM, A MINOR IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNA. DOCKET NO: ©'`I - ~'1'j,S c... [ u~C,~ ~%Ll~'~ Plaintiffs v. VICTOR YANTAS LEON Defendant ORDER AND NOW, this cl ~ day of ~~ti , 2007, upon consideration of the Petition for Approval of Minor's Settlement, it is hereby ordered and decreed that the Petitioners, as parents and natural guazdians of Paige Talhelm aze authorized to enter into a settlement in the gross sum of $10,000. Petitioners are authorized to sign a release and mark the matter settled, discontinued and ended as to the above Defendant. The settlement amount shall be distributed as follows: TO: Michele Possenti and Kevin Talhehn, as Parents and Natural Guardians of Paige Talhelm, to be deposited into a restricted federally insured account, "No Withdrawals Prior to Age 18, without prior court approval. " TOTAL AMOUNT Ft3R DISTRIBUTION ,~ 10,000 Counsel shall provide to this Court, within 30 days of the date of this ORDER proof of such deposit. r, /. R BY THE COURT: AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA ss COUNTY OF CUMBERLAND Michelle Possenti, parent and natural guardian of Paige Talhelm, a minor, is over twenty-one (21) years of age, and being duly sworn according to law deposes and says: 1. I hereby understand and agree that Paige Talhelm has recovered from the injuries she sustained in the accident of June 26, 2005, except for possible scar revision in the future. 2. I read all of the foregoing and fully understand same anal affix my signature hereto under oath as a free, voluntary, and uncoerced act and deed. 3. I approve of the proposed settlement because, under the circumstances, I consider it fair and reasonable compensation for my daughter, Paige Talhelm, for whom I am the parent and natural guardian. 4. It is further understood and agreed that once the Court has approved the settlements as outlined in this petition, no further claim can be made against Nationwide Insurance Company for any of the injuries sustained by minor, Paige Talhelm, whether now known or unknown, including any and all claims for past and/or future medical expenses. t i ~~ ~chelle Possenti, parent and natural guardian of minor Paige Talhelm Date: ~ - I R -O`er COMMONWEALTH OF PENNSYLVANIA Sworn to and S bscribed NOTARIAL SEAL Befor me this~day . DARCIE A. NEIL Notary Public of , 2007. Boro of Carlisle, umberiane County MY Commission Expires Nov. 24, 2009 Not~nt.DUblic ~XH1151~ l . , AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA ss COUNTY OF CUMBERLAND . Kevin Talhelm, parent and natural guardian of Paige Talhelm, a minor, is over twenty-one (21) years of age, and being duly sworn according to law deposes ~ and says: 1. I hereby understand and agree that Paige Talhelm has recovered from the injuries she sustained in the accident of June 26, 2005, except for possible scar revision in the future. 2. I read all of the foregoing and fully understand same and affix my signature hereto under oath as a free, voluntary, and uncoerced act and deed. 3. I approve of the proposed settlement because, under the circumstances, I consider it fair and reasonable compensation for my daughter, Paige Talhelm, for whom I am the parent and natural guardian. 4. It is further understood and agreed that once the Court has approved the settlements as outlined in this petition, no further claim can be made against Nationwide Insurance Company for any of the injuries sustained by minor, Paige Talhelm, whether now known or unknown, including any and all claims for past and/or future medical expenses. evin Talhelm, parent and natural guardian of minor Paige Talhelm Date:~g`a~ Sworn to and Su cribed Befo e me this 1~ day of , 2007. Not~Public COMMONWEALTH OF PENN~ANIA NOYAR SEAL pARCIE A. NEIL, Notary Public MyrCommission E pare bNovn 24, ~9 ALL Si~TE" L. ~.~t Bt:G :'~~-0Flt~ FD1i fit. ~.iCLF I] ~x~-~~13i-~ 07HB-00041 LAW OFFICE OF SNYDER & DORER 214 SENATE AVENUE, SUITE 503 CAMP HILL, PA 17011 TELEPHONE NUMBER: (717) 731-0988 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MICHELLE POSSENTI AND KEVIN TALHELM, INDIVIDUALLY AND AS PARENTS AND NATURAL GUARDIANS OF PAIGE TALHELM, A MINOR, Petitioners VS. NATIONWIDE MUTUAL INSUARANCE COMPANY, ~ ~ . Resporidet~t OINDER IN No. We, Michelle Possenti and Kevin Talhelm, parents and natural guardians of Paige Talhelm, a minor, do hereby join in the Petition of Nationwide Insurance Company for Court Approval of Minor's Settlement/Compromise. ~ ~ ~ Michelle ossenti, parent and natural guardian of minor plaintiff, Paige Talhelm Date: /~ Kevin Talhelm, parent and natural guardian of minor plaintiff, Paige Talhelm Dater? ~ ALL-STATE®LEGAL &IO-222-0.50 E011 flEDYCLED f • ~ , RELEASE AGREEMENT This Release Agreement ("Agreement") is entered into among Paige Talhelm, a minor, by her parents and natural guardians, Michelle Possenti and Kevin Talhelm, Michelle Possenti and Kevin Talhelm, individually (hereinafter collectively referred to as "the Parties"). The "Insured" shall mean Michelle Possenti, her, respective heirs, executors, administrators, personal representatives, successors and assigns; and the "Insurance Company" shall mean Nationwide Insurance Company of America, its successors and assigns. I. RECITALS A. On or about June 26, 2005, at or near Interstate 80, Sacramento, Sacramento County, California, Paige Talhelm sustained personal injuries as a result of an automobile accident - - --- (hereinafter refierr-3-fo as tfie ccurrence ~ n connection wit - -e ccurrence, ensure as asserted a claim against Nationwide Insurance Company of America. B. The Parties desire to enter into this Agreement to provide, among other things, for certain payments in full settlement and discharge of all claims and actions of the Insured for damages arising out of or due to the Occurrence, on the terms and conditions set forth herein. NOW THEREFORE, it is hereby agreed as follows: II. UNDERINSURED MOTORIST RELEASE AGREEMENT Know all men by these presents: That, for sole consideration of the promise to make the periodic payment referred to in Subparagraphs IV.A.(1) and (2) from the Insurance Company, the Insured in her capacity as an insured does hereby forever release and discharge the Insurance Company of and from all claims of whatsoever kind and nature prior to and including the date hereof growing out of the Underinsured Motorist Coverage of an Automobile Insurance Policy number 5837 D 690193 issued by the Insurance Company to Michelle Possenti, and resulting from the Occurrence. III. INJURIES KNOWN AND UNKNOWN The Insured fully understands that the Insured may have suffered personal injuries that are unknown to the Insured at present and that unknown complications of present known injuries may arise, develop or be discovered in the future, including, but not limited to, subsequent death or disability. The Insured acknowledges that the consideration received under this Agreement is intended to and does release and discharge the Insurance Company for any claims for, or consequences arising from, such injuries and the Occurrence; and the Insured hereby waives any rights to assert in the future any claims not now known or suspected even though, if such claims were known, such knowledge would materially affect the terms of this Agreement. IV. PAYMENTS TO INSURED A. Periodic Payment. The Insurance Company hereby agrees to pay or cause to be __ _ _ __ -_ paid the following Periodic Payment: (1) To Paige Talhelm ("Payee") the following guaranteed lump sum payment: Seventy Nine Thousand Nine Hundred Forty Six and 08/100 Dollars ($79,946.08) to be paid on or about November 12, 2013. (2) Should Paige Talhelm die before November 12, 2013, then the remaining guaranteed payment set forth in Subparagraph IV.A.(1) shall instead be paid, subject to the provisions of Subparagraph IV.A. (3) below, as it becomes due, to the estate of Paige Talhelm ("Beneficiary"), with the last guaranteed payment to be made on or about November 12, 2013. (3) Paige Ta!he!m sha!I have the right, after reaching _the age of majority, to submit a request to change the Beneficiary by filing a written request with the owner of the annuity. This request will be reviewed by the owner of the annuity, and if approved by the owner of the annuity and the issuing annuity company it will become effective. Said request will be made in writing by Paige Talhelm. C. Nature of Payments. All sums set forth in this Paragraph IV constitute damages on account of personal injuries or sickness, arising from the Occurrence, within the meaning of Section 104(a)(2) of the Internal Revenue Code of 1986, as amended. 2 V. FINANCING OF PERIODIC PAYMENT OBLIGATION A. Assignment of Obligation. It is understood and agreed by and between the Parties hereto that the Insurance Company may, as a matter of right and in its sole discretion, assign its duties and obligations to make such future payments as set forth in Subparagraphs IV.A.(1) and (2) to Hartford Comprehensive Employee Benefit Service Company ("Assignee") pursuant to a "Qualified Assignment and Release," within the meaning of Section 130(c) of the Internal Revenue Code of 1986, as amended, attached as Exhibit A. When the Periodic Payment obligation is assigned to Hartford Comprehensive Employee Benefit Service Company, Hartford Life Insurance Company and Hartford Life, Inc. have represented that they will provide written guarantees of such obligation. Such assignment is hereby accepted by the Insured without right of rejection and in full discharge and release of the duties and obligations of the Insurance Company and all Parties released by this Agreement with respect to such future payments. If the Insurance Company '~ assigns the duties and obligations as provided _herein, it is understood and agreed _by_ and between the Parties that Hartford Comprehensive Employee Benefit Service Company, as the Assignee, shall make said future payments directly to the respective Payees designated in Subparagraphs IV.A.(1) and (2). The Parties expressly understand and agree that, with the Insurance Company's assignment of the duties and obligations to make such Periodic Payment to Hartford Comprehensive Employee Benefit Service Company pursuant to this Agreement, atl of the duties and responsibilities otherwise imposed upon the Insurance Company by this Agreement with respect to such Periodic Payment shall cease, and instead such obligation shall be binding solely upon Hartford Comprehensive Employee Benett Service Company. The Parties further understand and agree that when the assignment is made, the Insurance Company shall be released from all obligations to make such Periodic Payment and Hartford Comprehensive Employee Benefit Service company shall at all times be directly and solely responsible for, and shall receive credit for, the Periodic Payment, and that when the assignment is made, Hartford Comprehensive Employee Benefit Service Company assumes the duties and responsibilities of the Insurance Company with respect to such Periodic Payment. B. Third Party Payment. It is further understood and agreed by the Parties that all future Periodic Payments as set forth in Subparagraphs IV.A.(1) and (2) may, solely at the option of the Insurance Company, or its Assignee, Hartford Comprehensive Employee Benefit Service 3 ~ • v Company, be financed by the purchase of an annuity contract (the "Annuity Contract") from Hartford Life Insurance Company (the "Annuity Issuer"). When such an Annuity Contract is purchased, the Assignee, Hartford Comprehensive Employee Benefit Service Company, shall be the owner of the Annuity Contract and shall have and retain all rights of ownership in the Annuity Contract. For its own convenience, the Assignee shall direct Hartford Life Insurance Company to make all Periodic Payments directly to the respective Payees designated in Subparagraphs IV.A.(1) and (2). Such payments will be applied against the obligation of the Insurance Company or its Assignee and shall operate as a pro tanto discharge of the scheduled obligations set forth in this Agreement. C. Status of Insured. The Insured shall, at all times, remain a general creditor of the Insurance Company or its Assignee and shall have no rights in the Annuity Contract nor in any other assets of the Assignee. The Insurance Company or its Assignee shall not be required to set aside sufficient assets or secure its obligation to the Insured in an~r_manner whatsoever_ The Insured acknowledges that the Insured has no right to receive the present value of the payment due the Insured pursuant to Subparagraphs IV.A.(1) and (2), or to control the investment of, or accelerate, defer, increase or decrease the amount of any payment required to be made to the Insured. The Insured shall only be entitled to receive the payments specified in Subparagraphs IV.A.(1) and (2), as they are due. VI. NO CHANGES IN FUTURE PAYMENTS Neither Paige Talhelm, her estate, nor any subsequent beneficiary or recipient of the payment or any part of the payment under this Agreement, shall have the right to, and may otherwise be prohibited or restricted under applicable law to accelerate, commute, or otherwise reduce to present value or to a lump sum the payment or any part of the payment due under this Agreement. Neither Paige Talhelm, her estate, nor any subsequent beneficiary or recipient shall have the right to transfer, assign, anticipate, mortgage, or otherwise encumber in advance any payments or any part of any payments due under this Agreement. Any transfer of the periodic payments by the Insured may subject the Insured to serious adverse tax consequences. 4 VI1. ADEQUATE CONSIDERATION The Insured agrees and acknowledges that the Insured accepts payment of the sums that the Insured is to receive pursuant to this Agreement as a full, complete, final and binding compromise of matters involving disputed issues regardless of whether too much or too little may have been paid. VIII. ENTIRE AGREEMENT This Agreement contains the entire agreement between the Insured and the Insurance Company with regard to the matters set forth herein. There are no other understandings or agreements, verbal or otherwise, in relation thereto, between the Parties except as herein expressly set forth. IX. READING OF AGREEMENT In entering into this Agreement, the Insured represents that the Insured has completely read all terms hereof and that such terms are fully understood and voluntarily accepted by the Insured. X. FUTURE COOPERATION All Parties agree to cooperate fully, to execute any and all supplementary documents and to take all additional actions that may be necessary or appropriate to give full force and effect to the terms and intent of this Agreement which are not inconsistent with its terms. XI. DRAFTING Of DOCUMCNT AND RELIANCE BY INSURED The Insured warrants, represents and agrees that the Insured is not relying on the advice of the Insurance Company, or anyone associated with them as to the legal and income tax or other consequences of any kind arising out of this Agreement. Accordingly, the Insured hereby releases and holds harmless the Insurance Company, and any and all counsel or consultants for them from any claim, cause of action or other rights of any kind which Insured may assert because the legal, income tax or other consequences of this Agreement are other than those anticipated by the Insured. 5 C ~ ~ ~ The undersigned, and each of them, warrant and represent that no promise, inducement or agreement not herein expressed has been made to them and that this Agreement constitutes the entire agreement between the Parties hereto and that the terms of this Agreement are contractual and not mere recitals. The undersigned, and each of them, have read the foregoing Agreement and fully understand it, and have been advised by counsel of their own choosing as to the propriety and legal effect of executing the same, and neither the Agreement nor the compromise and settlement recited herein were induced by fraud, coercion, compulsion or mistake, nor is this Agreement nor the compromise and settlement made by the undersigned in reliance upon any statement or representation of any of the Parties hereby released, or their representatives, agents or attorneys. XI1. COURT APPROVAL The Parties agree that the Insured will file petitions for all necessary court approvals, that all such petitions and orders shall be in a form satisfactory to afl Parties, and that this Agreement will not be effective until such approvals have been obtained. XII1. CONTROLLING LAW This Agreement shall be construed and interpreted in accordance with the laws of the Commonwealth of Pennsylvania. 6 XIV. SIGNATURES This Agreement may be executed in counterparts, each of which shall be deemed to be an original and all of which shall be deemed to constitute one and the same document. Dated: °~.~ / ' ~'~-~ Michelle Possenti, individually, an as parent and natural guardian of Paige Talhelm, a minor, Insured Dated: 7~2 5~© ' 4------- Kevin Talhelm, individually,.. and as parent and natural guardian of Paige Tdlhelm, a minor, Insured Dated: Y I S ~ "/ `~}(~ • ~3, u.C~ _ - Duly Authorized Representative for Nationwide Insurance Company_of_America_____ ______.____ .___ _ APPLICABLE TO PENNSYLVANIA ONLY: For your protection, Pennsylvania requires the following to appear on this form: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. 7 r ~ y 07HB00041 LAW OFFICE OF SNYDER & DORER 214 SENATE AVENUE, SUITE 503 CAMP HILL, PA 17011 TELEPHONE NUMBER: (717) 731-0988 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MICHELLE POSSENTI AND KEVIN TALHELM, INDNIDUALLY AND AS PARENTS AND NATURAL GUARDIANS OF PAIGE TALHELM, A MINOR, No. Petitioners VS. NATIONWIDE MUTUAL INSUARANCE COMPANY, Respondent JoAnne E. Kinzel, Esquire, hereby certifies that she is the attorney for the Respondent herein, and that she caused a true and correct copy of the attached Petition for Leave to Compromise Minors' Claim to be served by regular first class mail upon: Michele Possenti 113 Woodview Drive Mount Holly Springs, PA 17065 Kevin Talhelm 7 Todd Road Carlisle, PA 17013 Date: August 17, 2007 ~nne E. Kinzel, Esquire Attorney for Respondent ~ ~ C 1 l ....~ `~ ~ „ ~ . ~, _ - ~ `~1 = -4 a ~ - - , , ~ ~ ~ ~-, "~ 4 . .-C ,i 07HB00041 LAVV OFFICE OF SNYDER & DORER 214 SENATE AVENUE, SUITE 503 Cr~A1P HILL, PA 17011 TELEPHONE NUMBER: (717) 731-0988 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MICHELLE POSSENTI AND KEVIN TALHELM, 4 INDIVIDUALLY AND AS PARENTS AND NATURAL GUARDIANS OF PAIGE TALHELM, A MINOR, Petitioners VS. NATIONWIDE MUTUAL INSUARANCE COMPANY, 'AUG 2.2 2001 Respondent .ORDER OF COURT. AND NOW, this 23'~ day of / , 2007 upon consideration of the Petition for Leave to Compromise Minor's Action and after hearing, it is hereby ORDERED and DECREED that the proposed settlement in the total amount of Seventy-Nine Thousand Nine Hundred Forty-Six Dollars ($79,946.08) is approved and distribution is to be made as follows: Total Settlement: 79 946.08 ,~ TO: Paige Talhelm, a minor, the sum tv be deposited in the name of the minor only in federally insured savings accounts, certificates of deposit or credit union accounts or accounts investing only in securities guaranteed by the United States government or a Federal government agency managed by responsible financial institutions. The account(s) shall be marked "not to be withdrawn until the minor reaches the age of twenty-two (22) years, except for the payment of local, state, and federal income taxes on earnings of the certificate or account or upon further Order of the Court." 79 946.08 BY THE COURT: t i I4 ,~ ~ r"i - a~-,~+ .,. ~'.: ~i 07HB00041 LAW OFFICE OF SNYDER & DORER 214 SENATE AVENUE, SUITE 503 CAMP HILL, PA 17011 TELEPHONE NU141BER: (717) 731-0988 IN THE COURT OF CUMBERLAND COUT MICHELLE POSSENTI AND KEVIN TALHELM, INDIVIDUALLY AND AS PARENTS AND NATURAL GUARDIANS OF PAIGE TALHELM, A MINOR, COMMON PLEAS QTY, PENNSYLVANIA No. Petitioners VS. NATIONWIDE MUTUAL INSUARANCE COMPANY, Respondent AND NOW, this day of , 2007 upon consideration of the Petition for Minor's Compromise of Paige Talhelm, by and through her parents and natural guardians, Michelle Possenti and Kevin Talhelm, a hearing is hereby set for , 2007 at , in Court Room , at which time testimony in support of the Minor's Compromise shall be produced. BY THE COURT: 1. i 3 07HB00041 LAW OFFICE OF SNYDER & DORER 214 SENATE AVENUE, SUITE 503 CAMP HILL, PA 17011 TELEPHONE NUMBER: (717) 731-09$8 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MICHELLE POSSENTI AND KEVIN TALHELM, INDIVIDUALLY AND AS PARENTS AND NATURAL GUARDIANS OF PAIGE TALHELM, A MINOR, Petitioners VS. NATIONWIDE MUTUAL INSUARANCE COMPANY, Respondent No. N r.. ~ CF ea - _..., Q -Z.~ -, ~.:~ _~_ e ; ; ... .-. __ - ~, _ ~ f"~l f" ~~ _r i - c~ ~ -; i -- -:, ~.. ~~ _~ j~~ _- c.? rc = ~ `T1 ~<~ PETITION FOR LEAVE T4 COMPROMISE MINORS' CLAIM ~ Pursuant to Pa.R.C.P. 2039, Nationwide Insurance Company, by and through its ~, attorneys, Snyder and Dorer, hereby jointly petitions this Court to enter an Order permitting settlement in compromise of this action, and in support thereof, avers the following: 1. Nationwide Mutual Insurance Company (hereinafter "Nationwide"), is a corporation organized and existing under the laws of the State of Ohio and having its principal place of business in Columbus, Ohio, being duly authorized to conduct business in the Commonwealth of Pennsylvania at 1000 Nationwide Drive, Harrisburg, Pennsylvania. 2. Petitioner, Michelle Possenti, is an adult individual residing at 113 Woodview Drive, Mount Holly Springs, PA 17065. She is the parent and natural guardian of Paige { Talhelm, a minor, who was born on November 2, 1991. 3. Petitioner, Kevin Talhelm, is an adult individual residing at 7 Todd Road, {Carlisle, PA 17013. He is the parent and natural guardian of the minor, Paige Talhelm. 4. On June 26, 2005. Paige Talhelm, who was 13 years old at the time, vas involved in a motor vehicle accident while riding as a passenger in a vehicle which was operated by her aunt, Melinda Sassman, who is the sister of the minor's mother. 5. The accident happened in Sacramento, California, when a vehicle driven by a Victor Yantes Leon suddenly moved into the lane occupied by the Sassman vehicle, resulting in a collision between the two vehicles and causing the Sassman vehicle to roll over and exit the highway. 6. Following the collision, Paige Talhelm was transported by ambulance to the University of California Davis Medical Center in Sacramento, California where she was, admitted overnight for observation and treated for a severe abrasion/road rash to her right forearm. The road rash covered the proximal 1/3 of the forearm with two larger areas extending deeper in the subcutaneous tissue. As a result of foreign bodies imbedded in the skin, the minor was required to undergo two debridements using a surgical scrub brush. On the following day, she was discharged with instructions for wound treatment, along with instructions to fallow up with her primary care physician in Pennsylvania, (See medical records attached as Exhibit "A".) 7. Paige Talhelm was seen in follow up by her primary care physician at Carlisle Pediatrics in Carlisle, Pennsylvania. She had four follow up visits which consisted of 'examinations for infection and healing, as well as dressing changes to protect the healing wound. On July 26, 2005, the doctor noted that Paige Talhelm had only two small areas left to heal, and ~' observed that the rest had "healed well". There was no infection. (See medical records attached ~I as Exhibit "B".) 8. Paige Talhelm has now returned to all normal activities. 9. No medical expenses were incurred by Michelle Possenti and Kevin Talhelm on ~i behalf of Paige Talhelm as a result of the injuries sustained in the June 26, 2005 accident. ~ 10. No known unpaid or out-of-pocket medical expenses exist. 11. No additional treatment is presently anticipated for Paige Talhelm as a result of the injuries sustained in the June 26, 2005 accident, although scar revision may be considered in the future. (See medical records attached as Exhibit "C".) 12. At the time of the accident, Michelle Possenti, the mother of Paige Talhelm, had automobile insurance coverage through Nationwide, which included underinsured motorist coverage. 13. After negotiating a $10,000.00 settlement with the tortfeasor's carrier, whose policy consisted of bodily injury liability limits of $15,000.00 per personl$30,000.00 per !I accident, Michelle Possenti negotiated. a settlement of the minor's bodily injury claim under her ~' UIM covera e with Nationwide. A full and final settlement was agreed to in the amount of I~ g -- _ ___ $60,000.00. (See Order of Court approval of settlement with tortfeasor attached as Exhibit "D".) 14. Michelle Possenti and Kevin Talhelm, as parents and natural guardians of Paige Talhelm, believe that the minor recovered from the injuries sustained in this accident. (See Affidavits, attached hereto as Exhibits "E" and "F".) 15. Michelle Possenti and Kevin Talhelm join the Petition and approve the proposed settlement because, under the circumstances, they consider it fair and reasonable compensation for the minor, Paige Talhelm. (See Exhibits "G".) 20. Under the proposed settlement, Paige Talhelm will receive the sum of $79,946.08 as set forth below and in accordance with the attached structured settlement agreement which is incorporated herein by reference. (See Exhibit "H"}: To be paid to Paige Talhelm on or about November 12, 2013 (age 22) the sum of $79,946.08. WHEREFORE, Petitioners request this Honorable Court to enter an Order approving the settlement and compromise and ordering distribution as set forth in the attached Order. SNYDER & DORER ~,~ i ;~` ~ By: .. ~-~.. ~.~ JoAnne E. Kinzer; esquire Attorney-for Nationwide Mutual Insurance Company Dated: i l~ti `~..,~.,t_.~.~'~~.~L ~~~'lr~`~ .j ERIFICATION I, Kevin Talhelm, verify that I am the parent and natural guardian of the minor, Paige Talhelm and that I am a joint petitioner in this action. I hereby verify that the statements made in the foregoing Petition for Leave to Compromise Minors' Action are true and correct to the best of my knowledge, information and belief. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities. ~~ KEVIN TALHELM DATE: ~f5 ~~ ERIFICATION I, Michelle Possenti, verify that I am the parent and natural guardian of the minor, Paige Talhelm and that I am a joint petitioner in this action. I hereby verify that the statements made in the foregoing Petition for Leave to Compromise Minors' Action are true and correct to the best of my knowledge, information and belief. I understand that false statements herein are made subject ~ to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to I authorities. ,, , -~ ~ ,' 4 Z~ MICHELLE POSSENTI DATE: ~~ ~ ~XN1C~~~ l \I~'ERSI'TY OF C:~t,IFOR`i:: MEDICAL CE\ThR S:~Cit~~lE1'TO, C:~LIF(~R~~L. ED I'_iZOGi2i:SS ~iOTi~: (Page i of 3) rr~'IE~IT: TALHELM, y;R #: 1769260 .,~.TE OF SERVICE PAIGE 9VW Ob/26/2005 .iCCATION : ER[vB SEX: F AGE: 13 DCB: 11j02/1991 EMERGENCY DEPARTMENT NOTE LINKING LANGUAGE: The patient was seen and examined with Dr. Cadogan. I reviewed the resident's note and agree and helped developed a plan of care. HISTORY OF PRESENT ILLNESS: This is a 13-year-old female brought in by ambulance status post ~ ' restrained passenger in a freeway speed rollover MVA. No loss of consciousness. The patient complains of right arm pain only. The patient had a GCS of 15 and stable vital signs in the field. The patient denies headache, nausea, vomiting, neck pain, back pain, chest pain, shortness of breath, abdominal pain or weakness. PAST MEDICAL HISTORY: Seasonal allergies. Medicines: Bone. AT.~LERGIES: None. Immunizations: Up-to-date. Surgical history: Inguinal hernial repaix. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Noncontributory. REVIEW OF SYSTEMS: Positive for abrasions, otherwise negative. PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished female, no respiratory distress. HEENT: Small right temporal abrasion without cephalohematoma. Pupils equal, round, reactive to light. Extraocular muscles intact. No raccoon or battle sign. Face nontender. Oropharynx benign. No malocclusion. NECK: Trachea midline, no JVD. C collar in place. CHEST: Nontender, stable, breath sounds equal bilaterally. HEART: Regular rate and rhythm without m>>rmurs. ABDOMEN: Soft, nondistended, nontender. PELVIS: Nontender, stable. C'~I~TRSIT~~ OP (::1LIFOR\l~~ 1i~1)IC;~I_. CF,tiTi:R ED PROGRCSS \O~TF (Yaec 2 of 3) rATIENT: TALHELM, PAIGE ;~iR #: 1769260 LATE OP SERVICE: 06,'26;'20C5 LOCATION: ERWB SEX: F AGE: i3 DOB: llj~2/1991. EXTREMITIES: Nontender except for right arm._;.In the right arm there is a large abrasion over the right forearm and elbow with some lacerations and possible glass. There is tenderness along the areas of abrasion. Distal neurovascular is intact to radial, median, and ulnar nerve distributions. NEUROLOGIC: Alert and oriented times four. GCS 15. Strength and sensation normal except as limited by pain in the right arm. BACK: Nontender throughout. ASSESSMENT AND PLAN: ~• .. ~, A 15-year-old female status post high-speed MVA with scalp abrasion and large right arm abrasion with some small lacerations and possible glass foreign bodies. Will check x-rays including C-spine, chest x- ray, pelvis, and films of the right arm to evaluate for fracture and to evaluate for foreign bodies in the arm. Check labs including serial CBC, CHEM-7, AST, ALT, urinalysis screen. Follow the patient's neurologic and abdominal exams clinically in the Emergency Department. Feel that CT scans are not indicated at this time. The patient will need wound care of her right arm. PRELIMINARY ED DIAGNOSES: 1. Scalp abrasion. 2. Large right forearm abrasion. 3. Status post rollover MVA. ADDENDUM: Care of this patient was signed out to Dr. Ballard at 1800. THIS WAS ELECTRONICALLY SIGNED - 06/26/2005 6:38 PM PST BY: PETER E SOKOLOVE, MD ASSOCIATE PROFESSOR EMERGENCY MEDICINE DEPARTMENT PES:dew(usa128) D: 06/26/2005 06:16 PM ¢~..:_ ___~~.'.. ___~'++!?, ; T? '~~.K~'~'~~z-.T'c~t ^ r ~ ~"' aTSr'A'~;i''-~c•~nz~++- ; `.s~-^^~ tT.": tt ~ .. ~ ~~'~~. ~ r'~. •-• i r~' /~C• r~ fi~ a~~i..,;st,A"~.3~~ti-'.2#~ ~ ~a,5?'Li:f :~'~:2.~i....eY".4.'~:.r..r~ t3~~ ..:e:±.. °.:.~``,~,s .rl ~ .M..~ .~ ~':`{'. ct~"i~•~..N_~#., +i~;'~i~'3'..:n. C'~if~"ER:+1~1'1~ C?F C_~LIFOR\~1:1 ~IED(C:\L CUTER S:~C2~11E\"I~ti, C:ii.i-~Gi~I:l ED I'RnGiZESS 1OTE (1'a~;c 3 of 3) aTIENT: TALHELM, PAIGE N1R # : 1769260 ATE GF SFk'vICE: 06%26/2005 T: 06;26/2005 06:23 PM . C#: 1092652 ;,C~::ii~~N: ERiNB SEX : F GE : 13 DOB: 11,~~02% 199 ~ _. n ....,.. ,.,,.... ...`~ ......,.~... ?~FyQuA4~*~~',er',~' ~kT~ FwY-ate IU. ~1 lr ~~'~` Fa+'lKf } .]>"'ttQr'*vI~ T~"i!r^^"r'_"~ y t~`fQ ri -9s~ g~__a;'+.°'-'~ •~f'~,'~~~,}.1P`z~Jw'~s~i.... _.~-, ~. !.~~R~'~'«: 'd.:~~•~~~i ' ,~4i `S'~rgP.» , .'~ ~tE1)IC'AL CENTER S:~CR_~~1E~T0, CAL1FORti1:~ COySCLT:iTI~'~ (I'abe 1 of 3) :.~T1ENT: TALHELM, PAIGE 9VW MR #: 176960 DATE OF SERVTCE: 06;'27j20C5 ORTHOFAEDIC SURGERY CONSL'LTATiON HISTORY OF PRESENT ILLNESS: ~~crrlcN: SEX: F AGE: 13 DOB: 11%G2~1991 ~. -- The patient is a 13-year-old female brought in by ambulance tonight, status post motor vehicle accident. The patient was the restrained passenger in the vehicle, which was traveling at highway speeds. The patient denies any loss of consciousness. Her majox complaint upon arrival was right arm pain. The patient denies any other problems or complaints at that time. ,~~ I was asked to see this patient for evaluation of her right forearm road rash/abrasions. PAST MEDZCAL HISTORY: Seasonal allergies. Past surgical history: Repair of inguinal hernia. ALLERGIES: None. Medications: None. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: The patient lives with her family in Pennsylvania. _-- REVIEW OF SYSTEMS: Negative, except for right forearm abrasions/road rash. PHYSICAL EXAM: GENERAL: The patient is healthy appearing and in no apparent distress. SECONDARY EXAM: Negative. EXTREMITY: Exam of her right upper extremity reveals significant road rash of her flexor forearm over the proximal 1/3 with two larger areas which extend deeper in the subcutaneous tissue down to just above the fascia. These two areas measure approximately 2 x 2 cm and 3 x 3 cm in diameter. Overall the wound appears fairly clean, except for a few areas of necrotic tissue and debris from the road. The patient received an axillary block prior to my examination. She had a good radial pulse distally. X-RAYS: 1~ ~` ~t MR # :17 6 9 2 6 0 .~y~ I +4 YI~R Jy rr._.'~.s ~,~(~ •.. r:~~4 ~T~~ "q ,~+F~~.. ~~ P~~~~.~N.C.~","~; ~ '7~w ~ .S ~. y c ~~ .~6 3 ~~ T~'S~:3~~s .Ir~'~i.. •+ta~ +.°_.~n-, f~.. ..;i~x.. W#'`. CQI., x'~. •e~ .... k~'.~p4~'~in d ' C'N1VI~:h~1'T1' OF C:~i.ii i~i~:~I:~ ~~IED1CAi. CENTER S.-~CR.a~IEN'TO, C:1LIFORNI:~ COVSL1L'T:~TION (Pane 2 of 3) ::-~ =ENT : TALAEI,M, PAIGE 9VW _•,_;rAmiO~; b1R #: 1769260 SEX: F y3E: '~3 FATE OF SERV'c~'E: CE{27/2005 ~ DOB: 11; 0~; 199,E Right elbow and forearm x-rays are negative.,(:or any fracture or dislocation. There are multiple radiopaque foreign bodies in the skin in the location of her road rash/abrasions. ASSESSMENT: Right forearm abrasion/road rash, status post Emergency Room irrigation and debridement. PLAN: The patient underwent. an irrigation and debridement prior to my examination using six liters of normal saline and a pulsatile lavage. Since her axillary block was still providing some anesthesia, I was able to perform a secondary debridement, debriding some necrotic skin and foreign bodies from the tissue. 2 was also able to use a surgical scrub brush and Betadine to further debride the tissue of any foreign body. At the end of my procedure, which she tolerated fairy well without any major problems or complaints, her wound appeared clean without any significant contamination. I demonstrated wet-to-dry dressing changes to the patient's parents. They expressed understanding. RECOMMENDATIONS: My recommendations for this patient are that she be discharged with wet-to-dry dressing changes twice a day. She is also to place Xeroform over the abrasions circumferentially around her deeper wounds, which should be packed with wet-to-dry dressing change. I also recommend that she be discharged with Keflex for five days and pain medications. The patient will follow up with her primary care physician in Pennsylvania. I educated the patient's parents regarding signs and symptoms of infection. They expressed understanding and indicated that they would seek medical attention for any problems or concerns. ~I~~r, .~\•r~ c~FrC.LLIhUx~I,, `~LI/I~:~ ~ `~~ l ~I` 5.•~CIZ:~~IE:4T0, C:~LIFOR.\L~ tiTIEti'~ : TALHELM, PAIGE 9~;W ;~;R # : 1769260 SATE CF SERVICE: C6127,'20C5 CO,tiSI:LTA"TIO~i (Fade 3 of 3) .~.: H. S ~'X : F A"E : 13 ~vB : 11,'02/1991 .:. . . THIS WAS ELECTRC.'VICALLY SIGNED - 06/29/2005 12:16 PM PST BY: BRANDON J FERNEY, MD RESIDENT DEPARTMENT OF ORTHOPAEDIC SURGERY BJF:dhs(usa124) D: 06/27/2005 02:44 AM T: 06/27/2005 04:34 PM C#: 1092889 ..r i~. -;'+ T '^4~{Y}~~ ^r. ~ ~ ~ X~~ ~h Y.. F, f . ~X~. N.PyY . S'r 4O~\ ~LT~1~~~ VN d L r! L. • :~ ~J Y .!Iyk v~ w Y I~ s+*iY^ X511{ YTr . ~ .... ~~:_~.Ty!^r ~i.~F~s ._~.. ~ +"_"'.._r_. a. ` .. ~~ ~. .. v9 f41 '........ _.. t... ,. ,~:,..,..... .tta-.- ......~._._~ _. __. ~_. +_. 'fir ~e!~°._N+6 •s•r...:~wr.~p . .r.i:;~'• __~ . ~_.~ ~ - _ ~n~ __~ ~... _.: ....t! 1 L .. _ _ _ .._ _ _ _ .~ ITT ~r_~...:_=:;~ ,._.__.~ ~v.'d Ct~~. "rte T 1 _V,~~ Et~btiB ~C: ~ Y:itiL_'_':~ ._ ___. _.. _ _. ''.%~i- ~t~.:_, ,i~l ------------------- ~UTF'?' ?~'~~~ _, .~N'.E: ----------------- ~~~; ~c'~'J5 _. .~:: -------------------------- ~i~FT ~.D°~IiT L^', _~:`.~E. -------------- r i~AGS ~ AD:~1 PC? UPIN: ( ATT . PCN ADM CD iCD9: CPT: PCP PI#: I DX PCP ADD: --------------------------------------- PATIENT INFORMATION: ADDR: 113 WOODVIEW DR MT HOLLY SPRING PA 17065- HOME TEL: 717-486-4808 MSG TEL ADDL ADD: COUNTY 98 OTHER STATE .ATIENT EMPLOYMENT: STATUS: 3 OCCUPATION: NOT EMPLOYED EMPL EMPL ADDR EMPL TEL X LNGTH OF TIME ON JOB: VET: RELATED CONDITION: U.C. EMPLOYEE IND: PT SSN# 000-00-0001 PT DL/ST : UNKNOWN UN PT DOB: 11/02/1991 AGE: 13 SEX: F MS: S SP NM: MAIDEN NM UNKNOWN- OTHER NM ETH: BPLACE: RELIGION: LANGUAGE: --------------------------------------- ~CIDENT INFORMATION: ACCIDENT RELATED CONDITION: Y ACC DT/TIME: 06/26/05 00:00 ACC TYPE: AUTO ACCIDENT ACC LOC ER H/A OTHER AMBULANCE CO. ER CMPT MCI MVA INST: GUARANTOR REL : PARENT GUAR NM: POSSENTI ,MICHELE ADDR 113 WOODVIEW DR MT HOLLY SPRING PA 17065- HOME 717-486-4808 MSG . GUAR SSN# 563-59-3590 GUAR DL/ST GUAR SEX .• GUARANTOR EMPLOYMENT: STATUS: OCCUPATION EMPL . EMPL ADDR EMPL TEL X LNGTH OF TIME ON JOB: ------------------------------------- NEXT OF KIN REL: OTHER RELATIVE NOK NM SASSNjAN ,MELINDA EVN TEL DAY TEL 916-684-0393 X MSG TEL GUARDIANSHIP PAPERS ON FILE: ------------------------------------- REFERRAL: DATE: DR: X PCN: FACILITY: X ----------------------------------------------------------------------------- LAST ADMIT DATE: ESTIMATED LOS: ADVANCE DIRECTIVE INFORMATION: WAS AD INFORMATION AND UCDMC POLICY STATEMENT GIVEN TO PTfREP? DESCRIPTION: DOES PT HAVE AN ADVANCED DIRECTIVE? HAS COPY OF PT'S AD BEEN PLACED IN PT'S MEDICAL RECORD? T & C SIGNATURE: PATIENT GUARANTOR PMHUNVFS DOCUMENT GENERATED BY: HADSB i8:38 06/26/05 FROM LX9D,PMHUNVF5 ir•\I~~ERSITI' OF C'~I.IFOR~L-~, D.~~ZS P~~ ,:_„v. M ~ i~ iiER1+ELF]' DVV'15 IR\1\t: Lh., '\GLLCti • U4Ri:ED ia~~_RSILlE SV\ 1~l}Gn • ~.A\ FR~ltiCI5C0 ~a~;as ~~ Y ~`2~ ~'~B6B' 7/26/05 Rhiannon Lucas Nationwide Insurance Comnpany 1000 Nationwide Dr Harrisburg, PA 17110 RE: Paige Talhelm / 1769260 l;C D.g\ IS ?MEDICAL CENTER .315 STOCKTOA BOI;LE~:~RD SACR~.~fE~TO, CALIFOR'~1,~ ~ ~;' The Health Information Management Department at University of California Davis Medical Center has received a request for medical information regarding the above mentioned patient. The enclosed authorization has been found invatid f6r the following reasons}. Please refer to the following. Our Compliance Department requires for the authorization to be on the UCDHS form (see attached). The standard UCDHS authorization form approved by the UCD Compliance Officer has been enclosed for your convenience. We are returning the correspondence in its entirety. Please resubmit everything including the requested documents /information, monies or as othe-wise stated. We will process your request promptly upon receipt of the requested information and/or documents. Sincerely, ~~ Karl Moertz Release of information UC Davis Health System 916-734-5205 ._..~.,,~.~_ .-_ _, _ _~_ _ _~t_ _.__....____v _.. ~......_ ---_.~ .. ._ , rLAN CL : "i 03 MCAL IT~CCi~'i~ :r,TE FRICRITY : 1 PGL#: NiA ~:~RCi;P# I?~TS ADDR I.P.A. NAME: PHONE: - - X REF/AUTH#: REVIEW GROUP ~ _~ DAYS AUTHORIZED: CONTACT NAME: PHONE: - - X ON-SITE REVIEW? CONCURRENT REVIEW GROUP: CONTACT NAME: PHONE: - - X PLAN CD: PRIORITY: 2OUP## : .. _NS ADDR: I.P.A. NAME: PHONE: REF/AUTH#: REVIEW GROUP: DAYS AUTHORIZED: CONTACT NAME PHONE: ON-SITE REVIEW? CONCURRENT REVIEW GROUP: CONTACT NAME: PHONE: PLAN CD: PRIORITY: POL#: GROUP#: INS ADDR; I.P.A. NAME: PHONE: REF/AUTH#: REVIEW GROUP: .~YS AUTHORIZED: CONTACT NAME: PHONE: ON-SITE REVIEW? CONCURRENT REVIEW GROUP: CONTACT NAME: PHONE: COUNTY CODE: AID CODE: CARD ISSUE DATE: VALID DATE: PMHRUNF6 DOCUMENT GENERATED BY: HADSB 18:38 06/26/05 FROM LX9D,PMHRUNF6 ~\ ~ r , , ~ , ~ ... t r Y - ~ , ~i UhIVERSlTY OF CAUFORr:!A r„~v ? --~ ~' Q ~ r j rH~A! TH SYST~yEPA f vZ~ub% LJ4~-... - TERMS AND CONDITIONS OF SERVICE 7. FINANCIAL AGREEMENT: I agree to pay The Regents of the University of California fc professional, hospital and clinic services, including UCDHS physician services, in accordance wit the regular rates and terms of UCDHS. I also agree to pay for other professional services provide by other physicians at UCDHS. When this agreement is signed by my spouse, parent or a financi~ guarantor, my spouse, parent or financial guarantor shall be jointly and individually liable vvith m~ for payment, including all collection fees (attorney's fees, costs and collection expenses), in adciiti~; to any other amounts due. Unpaid accounts referred to outside agencies for collection bear ii~tere at the then current legal rate. 8. ASSIGNMENT OF BENEFITS (INCLUDING MEDICARE BENEFITS): i authorize and direct the payment to UCDHS of any insurance benefits including hospita{ insurance and unemploymen compensation disability benefits otherwise payable to or on my behalf for UCDHS services including emergency services, at a rate not to exceed UCDHS' actual charges. I understand tr!at am financially responsible for charges not paid pursuant to this agreement. i further certify that thf information given in applying for payment under the Medicare or Medi-Cal programs is correct. further agree that any credit balance resulting from payment of insurance or other sources play bE applied to any other account owed to UCDHS by me. 9. ADVANCE DIRECTIVES: I have an advance directive for health care (e.g., Power of Attorney for Health Care) ^ Yes ^ Nc I have provided UCDHS with a current copy of my advance directive ^ Yes ^ Nc If "No", I understand it is my responsibility to provide UCDHS a current copy of my advarice directive. If I want to express my health care wishes, I understand I should speak with my health care provider. 10. PATIENT RIGHTS NOTICE: I would like UCDHS to provide my next of kin or agent with the Patients Rights Notice ^ Yes ^ No I have read, agreed to and received a copy of this "Terms and Conditimras of Service." o ~ ~ ~~fZ~~~' Signature of Patient Ig' atute of Patient's pres tative Relationship of Representative to Patient ignature of Interpreter (if applicable) 7 ~~ , Signature of Witness (required if patient unable to sign) ~~ ~~ Date of Signing For office use only: EXCEPTIONAL SIGNATURE REQUIREMENTS ARE REFERENCED BELOW. Please check the appropriate box(es) ^ PATIENT iS LEGALLY INCOMPETENT TO SIGN: The court approved guardian or conservator, the attorney h•-fact under a Durable ?o~.ver of Attorney for Health Care, or family member or other appropriate surrogate must sign as "Patient's Representative." C PATIENT IS PHYSICALLY !NC.4PABLE OF SIGNING: The patient should give verbal consent, ~,viinessca by a i:CDH5 employae. The ' Paiient's Reprasern tatva"' shnu;d syn in witness ct the pa;knt having given verbal consent. T'lc UCCHS amplayee ::;tress I•,e.'; clso s;y;;. -- ---- - ~ { - 1 /~{ '1 r• - „' , 1 ~_. f V1.1.,,~ ~~i~~iJi,~ti~ v,~,ti c~ '~;~ t', r~\ > •~ Ui~IiUE~Si' iF !:' ^.! !~OR'`;!:a D;>VIS 141EDICAL Ci=iv i ~:i ~ _ U ~ --x-1-1-J_ ~--__. ~ ----- a ~P PULSE I~~ ~~ ~ ~~ Room Time Attending Time _J RESP TEAP ?ECI-VrT 1 ~ i Name Room __ Q Z ^____. o~oL~C _ _ . _ _ . _ . - Seen fr iName' y ~ ~ P Csi Tame -1 2v DRUG ALLERGY Source of history: ~ent ~7-other person ~~ -s ^ reco~ ds from (~ ~ 7 j5 l (~.f1 ~ I / (~~ ~ UJtS ''~~-c ~ MUNIZATIONS GtT}~ Q ~ ~/ ~ ~' ~~~. cwt P ~ /Vt/a~~ ~ c- MEDS T~~ C O C~ /~.•~ ea i`r CJrt I h ~ c t C P S~ ~ ~ to a~ cc. --- ' w ~. -~ b r~-c.. z 5 _ MEDICAL HX SURGICAL HX -- , FAMILY HX Nc SOCIAL HX r r`~~rr ,: ~ ,y,; k;I:L'tEV'J 01= SYSTi:.I'A'z; UNOBTAINABLE: ^ Patient Unable ^ Patient Unstable Slash =not present, Circle =present MedicaUSureical Trauma CONSTITUTIONAL• fever chills weight change SKIN: rash, hives, lesion rasi ns, ns HEMATOLOGIC: bleeding, bruising c roblem, ac ood loss EYES: visual problem, discharge, redness a atn, vision c ange ENT: earache, hearing change, epistaxis, congestion, sore throat ear/nose/mouth~aw pain, elusion RESPIRATORY: SOB, wheezing, cough, sputum, hemoptysis, pleuritic CP, leg pain ch pp~~i!u~ SOBr ~ CARDIOVASCULAR: chest pain, palpitations, syncope, orthopnea, PND, edema wrralpitations C' GASTROINTESTINAL: belly pain, nausea, vomiting, constipation, diarrhea, bleeding b ain URINARY: dysuria, frequency, urgency, hematuria, nocturia em a . GENITAL: discharge; abnormal bleeding, LMP pain, bleeding MUSCULOSKELETAL: pain, limited motion, redness, swelling ytac~JUE, LUE, RLE, LLE pain NEUROLOGIC: weakness, numbness, incoordination, HA, seizures, dizziness Hum Hess, weakness, I~,A2',"seizure rHYSICAL E7:/4ttii Check - exam finding: Circle =area for description oiabnormal or relevant finding GENERAL: ^ n ~tt __ ci'b~•~5 v`a~S `f'° ^ ^ ~ ~0/~a-'~l"` ~ 'tL~ SKIN: LYMPH NODES: no induration n sions Adenopathy: ^ no cervical ^ no axillary ^ nc inguinal ~ $?!r`~u [ mac, y~ ®® 'f'~ ~ ~ o''-~ ~ ~~~~ EYES: Aids & conjunctivae 0"PERRL, EOMI ^ nl fundi RENT: 8"tt2'ad/face nontender ^'TSl TMs, canals nose, nasal passages ^ nl mouth, throat NECK: metric w/o mass ^ nl thyroid ^ supple CHEST: [~]..~aentender ^ nl breasts LUNGS: ~-rit'effort~"n'{ auscultation ^ nl percussion CARDIOVASCULAR: ~rtl sounds w/o murmur, gallop, rub ^ no edema nl cap refill Pulses: ^ nl carctid ^ nl femoral nl pedal ABDOMEN / GI: ~J-n3ntender w/c masses ^ no HSM ^ no hernia ^ nl rectal ^ heme (-) GENITALIA M: ^ nl penis ^ nl scrotal contents ^ nl prostate GENITALIA F: ^ nl BUS ^ nl cervix w(o discharge ^ nl uterus ^ n{ adnexae MUSCULOSKELETAL: ~on er neck w/ FROM~'nontender back, pelvis ^ RU UE, RLE, LLE ^ nl joints, nails NEUROLOGIC: nl~TRs, no pathologic reflexes ^ nl CN 2-1?~-rtt'§ensafion ^ ~ f,~-rft"~ngth ^ nl gaitx? GCS ~_ PSYCHIATRIC ~~&0 x 3 ^ euthymic ^ good judgment ImpressionslPlan k1f1E~1~/-,L 9~'~~ut2~3~ - _ Time Called Service _ ED REVIEW - 1 ~ _ Crisis 1, .. -' ENT -c~ q~ un .° 20-~~;^:'t4`33? _ .Eye rC ~ ~ • Y ~ ~!'ti ~ . - Y ~ _ ~ IM subspecialty t ~ Z /~ ~. / 1 Q 80 r . .`•^ { ---- - Neurology _ ~ Ob Gyn ~I ~~O orthopedics ~'vrt ^ Plastic Surgery q ~ i Pq i G[~,_ ^ Surgery subspecialty ~,J ^ Trauma -• - ^ other RESULTS PROCEDURES (Noce Time,~Describe Procedure) LABTESTS~EKG-_ __ - X-RAY ^Arthrocentesis______. __________.____ __.__.--. .. .___ ._ Hem e)(.~ ~- _ - ^ Casting/Splinting _ "~'~ 'y (p _ _ ~- ^ Central Line _ _ . __ ~1-LT1_%t~h-G~J_I!k] . ~~'t'L$_ _•~._ __C. ~ i_~ S r-~'O-?--- _ - - - _, - --- - --- -- I-V~ - -/- - --- --- - - ^ Chest tube - -----~c~l JYt=h'~-$'•e~~~ G---S'~~ryt;~ _ _ C'-~ti $ S - Chem - _ ~/ ~ ~ - ~ 1 _ q --------- _ ^ FB Removal ---__-° ~$ jr..__ -_ -- ----- ---- - - Urine --_ - ----- -__. _._._..~__ ^ LP L~~ D ~ ~ r~.~±yj.G~L~• _U ~~ _ . _ . ----_ ___- ._----- _-_ - _ .__-_ ^ Reduction _ _ _. -.. -_--___ _____ _-_ _C~?_~ ^ Paracentesis _-_I}__~72 hP _ C. G _ _~fL~~~a r._ ____,F, ~~_~ O ~ ^ Thoracentesis ~.~~~-~ ~ ~ t ~(-IT:~'--~i~t ~- Misc. _ __~-__ ~ Q _. D Suturing __-_-_~~ ,- _______,~__._.__-___ _t_~C/sLK S ?? _-. _- ~ ^ Thoracotomy.- ! h ~1~ ~ _ .__ ~~ ----- _--------_ __~._ --___ -- ~ ^ Other _ -_-_.__ -------- --- D EKG ___ __ _ ___ ___ ! h --~,_ _ _ _____ _ --__ ^ Radiology Consultation to ~ Present for performance of ^ entire procedure, or clarify results of ~ key aortlons of procedure _ Procedure Signature/PI# ATTENDING NOTE ..___._...__ ______.__.__- • DIAGNOSIS 1 ^1 ^2 - ^3 ^4 ~ ^ cc DISPOSITION ^ ADMIT ~JDISCHARGE TIME CONDITION Home ^ Police '~ b ~~ I d ~'~~ Pri rov ~ #' ^ Other ^ AMA DATE /~ S 6 /~, mprove Stable ^ Unstable ~ '~ ^ LWBS l ( ( ^ Ex fired ~ j ED Attending nature/Pf #~ 'r 0 t. ' ~ 1 UNIVERSITY OF CALIFORNIA E7RVi5 h1EDICAL CENTER SACRAMENTO, CALi~CRhr'IA ~' [ % ~ i %; ~ ~{~ ~`.,.: ,. s Lab 4" :~:. , Procedures Time Done ,Saline Icck 1 ~ "~ ^ IV-1 t ^ IV-2 ^ 02 ^ monitor cardiac ^ pulse ox ^ continuous ^ Foley ^ I&O catheter ^ NG tube ^ suction ^ FS glucose ^ serial ^ PEFR ^ serial ^ urine dip ~rlne bedside ^ EKG ^ serial ~ X-Ray HEM~BC with dill ^ H&H 1&3 hr ~INR G1PTT _ ^ T&S ^ T&C Signature f R Sites CHEM ^ beta hCG ~ f:~ ~ ~chem 7 (BMP) 1 ~~ For order entry. fill. in a-f ~PICXR ^ PAAa3,8 AP ^ 6edsi r ^ abd series ^ KUB ~~-spine (~ ' ^ T-spine ^ US spine pelvis AP ^ bedside ^Lext .~ ext ~ "tom 3 ^ head CT ^ w/o ^ w/IV ~ ^ abd/pelvis CT wflV (trauma) ^ abd CT ^ w/o ^ w/ ^ US ^ MEDICATION AND SUBSEQUENT ORDERS Time Signature ~ Site Done ~ ~ 3L ; ~~~~~`-5~-~- 3 I J '"'; U myoglobin ^ troponln I ^ myo/tr 0,3,6 hr URINE~YU/A ~ ~1 ^ amph/coc lox ^ barb/ben~Jop lox MISC ^ ^ .. ~. a Reason {signahymptoms for each stud b PRIORITY ^ urgent ^ slat ^ life/de~ ~,{~ c OXYGEN ^ no ^ yes an S • d MOBILITY ^ gurney ^ wheelchair ^ ul e SUPPORT ^ WA ^ leis ^ vent f PREGNP.NT ^ no ^ yes Order entry time ey (signature) Time Ordered ^ Old UCD Record ^ Outside Record Physician Signature Service/ Pager ' I p 2. ~ C9 3. F O ~'. G 4. .... 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. i3?v~ ~ l7~a. PI No. Time of Initial Orde ' PR~uCRlP~lG~V N D 4 ~ ~ ' p Din;C ~ W Q a -. ~ ~ ` ~ .. mNi~v waw _ _ .__ .r ox~~o ~amo ~ v l ~~ •~~~ ~ /~ ~~ D ~ wz~co v l ~ L-/ { m . 00 C 9 L. .J ~J Zf -- / m p(7~W m; '~ > Z a U¢Nf ~ ~ (/~\~J~u~J I/\'/,^fU-J I'~'j~I' ~(\ ((~~~\\~ /\~ 1I'nI`~\\~J`{n''~ ~/ ~./ ~ U ~~ ~ ~~ L! U V O ~ W N ta/1 0 ~- DEA No. License No. f?r i i~'!~'Y ^ No specific restrictions ^" Limited use o~ffected part until seen in follow-up ^ No use of affected part until seen in follow-up ^ Modified work/ no PE for days ^ Off work /school for days ^ No driving ^ Passenger restraint system required for children less than 4 years old or less than 40 pounds. Information y sheet provided. ~, ~ ~ ~~~ ~~s MD Signature MD Print Name mate MD Signature DISCHARGE INSTRUCTIONS: ~~ ~ ^ r'•~n *-w ~~~ ~'r.w ~ ~7~ _~? C~~'rr`5 iI~SSZ b~Yf/ , ~` INFORMATION SHEET(S): wound care INSTRUCTION ADJUNCT(S): ^_. Interpreter ^ head injury ^ fatuity ^ cast /splint care ^ derinonstratfon of ^ back or neck pain - ^ other - '" ^ crisis service ,~-- ^ other OUTPATIENT FOLLOWUP: ^ Call for Appointment ^ Keep Scheduled Appointment ^ UCDMC Clinic ' •' ^ Sacremento County Clinic ' ^ Meth-Cal Clinic PCP ^ HMO / GMC Clinic ^ other ED LABORATORY & XRAYS: LAB TEST XRAY ^ CBC ^ CXR ^ chemistry ^ extremity - ^ U/A ^ spine ^ other ^ other ^ Ca11734-7761 between 10 am and 10 pm for pending results of MEDICATION /TREATMENTS: ^ tetanus immunization ^ antibiotic(s) ^ other - I acknowledge receipt of instructions indicated above. I understand that I have had emergency treatment only, and that I may be released before all my medical problems are known or treated. I wilt arrange for follow-up care as instructed above. If my condition appears worse, I will cc. tact ~y physiciafi or return to the Emergency Department. D~fien+'Cinnsfii~n ~ .'_ / ~ ~roVfdee~'~Sinna°ture ~ ~~ti-~~.- ra~7 C7~ Date 1.: ~ ~- a. , .. . i - ', Date: ~1~~1 ~- ~~ 1 .~; ... j «~(~- '~- ~ ~~~= x`': ~," ~~ ~ Lli~~v'ERSITY OF CALIFORNIA DAB'! `' ~° ; ~~• c e :~ 5 MEDICAL CANTER, SACRAMENTO, CALIFORNIA ~~ i-~`~~~TRA~"JIA RESt~SCITATIQN ~~ ,~ ~5~8C~ FLO~JVSFiEET ~ ~ _ _ _ SMFNT f~N dRRIVAI Activation Time 911 922 933 r Time Pt Arrived n ED:~ "A" Aln~"JAY One) Description PMH: Patient YE NO "B" BREATHING dic tio M Spontaneous Y Assisted? ^ Y ^ N ns: e a Labored YES Allergies: Denies ^ Unknown ^ Latex Shallow YES O Breath Sounds Present bilateral) Yes D No Last Teta us: LMP: Weight: kg. ~ ~ "C" CIRCULATIO Radial Pulse YE NO Mode of Arrival: D Sac Metro ^ AMR D Private Vehicle Other: Unit #: 3 Bleeding controlled? YE NO U Location of Incident CR < 3 Sec NO : Count of incident: - Warm 1 Dry YE NO « y " " '' MECHANISM OF INJURY O D NEURO G ' ~ CS on arrival: E = V = M = BLUNT: MVC vs Intrusion amount: ^ MGC vs Speed: mph ^ Driver Passenge ^ Fro ^ Back R/L ^ Unknown Sensation ~ IIeficlt Moving All YE NO N/A Extremities Deficit = Deficit = ^ Ejection ft Lap Belt houlder Belt ^ Helmet ^ No Helmet Descriptors: ~ ~ . ~ ~ ~ • HEAD Rollover ^ Unrestrained ^ Unknown S / S Trauma? YES NO use dia ram Airbag ^ Unknown ^ Carseat Nose draina e R N/A ^ PEDESTRIAN vs. mph Ear draina e R L N/ ^ BICYCLE vs. Ejection feet ^ FALL: Distance Surface Teeth dame a YES O N/ TM's clear YES NO NECK S /S T ? ^ S rauma YE use dia ram A SAULT: (type) SQ Air YES N JVD YES NO ^ BURN: Source BSA degree Trach midline S ^ OTHER: CHEST! RESPI R LOC: ^ Yes o O Possible ^ Length min ^ Unknown PENETRATIN ^ GSW ^ SW ^ Other S / S Trauma? ~~~ NO Y use dia ram .. e Flail YES Cre s Y A: ^ ET D NT ^ NP ^ OP Size: Cardiac Rh m B: 02 ^ NRB ^ Cannula UMin ^ BVM ABDOMEN Cir ne Descrf lion G: Infused ml ^ CPR Started ® S / S Trauma YES use diagram Rigid collar ackboard ^ Papoose Supine !Prone D Splint: ^ Accu-check results Tender Pre Want YES YES N/A 08 notified D Y D N Fetal HT YES NO N/ Meds: Other: GU /PELVIS V/S: B/P P R S/ S Trauma Y use die ram GCS E _ V _ M ^ Meatus clear YES NO ~~~~ ca~ sponlan•ouE'sJabays IDENTIFY ON FlGURE Pelvis Stabl YES O to voice tocaFzea p eo 4 iFT BACK ro M i ~a.xrw, s incompi~.' wsourwa z R L L S i 5 Trauma YES O WA use die ram °"0"°b" z ione1 ~t v Reform YES use die ram Tenderness YES N/A use die ram Tim. arrives SIGNATURES Msrrdatory i« Trauma Rectal Tone + - Guaiac + ~ ><fl~ Eo ntt•mmg E XTREMITIES R 3 ED e~ S ! S Trauma YE use diagram D eformi YES N use diagram Trawa. nseaaaq PUL SES MOTOR QMef R L R L ~ Radial UE NP ! R 2 Trauma DP .{~ LE PT G i r p ~• ~ Quality ~ / 1+ / 2+ / 3+ / 4+ Quality 1+ / 2+ / 3+ / 4+ / 5+ _. , . ~_, ~• - - . t _ ~ ~, ' r'^~HOSPI~AL _ _ _ _ _ _ __ [~1ode ,f ,arrival _, Aiv1E --,~1',ik -_ G ~,~ ~ ''~^JC '_, _ ~. +' ~ .. ~, ~ iV Nc ~ r~`~s~1' Placement • i ~ - v '- I ET PvT OP ^JP Yes ,~ Nn ^ ~~ i TYPe, Sipe ~ -V '~~~~~ Pla~^ement _ '\~., ~ ~ ~ Rigid Collar L7 Backboard ^ Splint u Date: ~ - ~~ v Meds given Chief Complaint BP P RR , - History None ^ Cardiac ^ Diabetes - ^ Triage Time - Unknown '"^ Primary Nursing Assessment cva ^ B P RR .TEMP PAIN 02 SAT allergies Latex NKGA current meds A. Airway Patent Yes ^ No ^ Last TD B. Breathing. ,. Spontaneous yes ^ - No^ nasal flaring Yes ^ No ^ Symmetrical Yes C] No^ acc. muscle use Yes ^ No ^ Labored- Yes ^ No CI s/s trauma Yes ^ No ^ Shattow Yes ^ NoCI flail Yes ^ No ^ Diminished LT ^ RT ^ crepitus Yes ^ N ^ Breath Sounds RT C. GirculaNon LT ..n Cap. Refill <2 sec. Yes O No ^ cardiac rhythm warm Yes O Nod - dry.. Yes p No ^ Diaphoretic Yes ^ No ^ Jaundiced Yes 0 No'O Bleeding Controlled Yes ^. No O~/A D. Neuro GCS• E V M sporitarieous 4 orient ~i 5 to voice. 3 confuse d to pain 2 - inapp. words 3 none 1 income. sounds 2 Pupil Size R .~ L _ none i PERL Yes ^ No Accucheck E. Sensation ~ ~ F. Pulses obeys comds 6 localizes pain 5 withdraws 4 flexion 3 extension 2 none 1 RA ~ RL ~ Quality: 4+ 3+ 2+ 1+ Dop. LA _ Ll. - Location: Rad DP PT RA ._ RL G: Movement/Strength LA - LL _ Quality: 5+ 4+ 3+ 2+ 1+ Moves all extremities well -Yes ^ No ^ RA_ RL~ H. Pregnant Yes ^ No ^ `Dravida - Para - FHT Yes ^ No ^ Rate EDC LMP OB.Notified Yes ^ No ^ N/A ^ Comments Two forms of ID checked ^ Armband ^ Screened for Domestic Violence ^ .~ 0~ Given ________~. _ _ Ac~uchccl< ---___- Papoose ^ TEMP PAIN 02 SA~ COPD ^ CA ^ Psych 1 GU ^ Dialysis ^ Asthma HTN ^ Seizure ^ GI I Other Head Yes h unremarkable ^ [ nose drainage ^ [ ear drainage ^ C teeth damage ^ C tm's clear ^ C Neck .. unremaikabl~ ' ~ • ^ C sq air ^ C JVD ^ C traoh mfdline ^ C Abdomen unremarkable ^ C soft ^ C nontender ^ C s/s trauma ^ C firm ^ C distended ^ C tender ^ C masses ^ G vomiting ^ ^ diarfiea ^ ^ Last BM _ GU/Pelvis unremarkable ^ ^ meatus clear ^ ^ pelvis stable ~ ^ ^ discharge ^ ^ color NA ^ bleeding ^ ^ pad Hr .Back s/s trauma ^ deformity ^ rectal tone normal ^ guiac positive ^ tender ^ Extremities s/s trauma ^ deformity ^ O ^ IDENTIFY ON FIGdRE A -abrasion R L L R AB -abscess ., B -burn D -deformity • E - ecchymosis ED -edema H - hematoma L -laceration P -puncture R -rash T -tender/pain UNK O NA ^ -- - ~ - ____ ---- ---- - ~L, F _-- - ~ Opening •~~ ':13,k • Best Verbal _ N Response i , :~ -. .i L "J, n. Best t,9otor ~ ~~ ~ -~ ~. ---+-- E ~ C t; !' 7 `i ,; Response i '~ '~~'` ~ Glascow Coma Scale Score i ~ - % ~ / : : ~ ~ --- - - - _----- _ -~_- e r ~_.,IC..~_ i `~ b tub:+ed: ? =Appears tU Cenve;s £ - "y tay C c verse t - gone =4-~ ~ Pupiliary Response ~,~° ~ ~J~a C~a ' ~~~ O ~ . ® ~ Right ~~' ~ 2~ 3~4 5 6 7 8 1° F, ~i' - ~ .--~ _ M Brisk: ++ Slug ish: + None: 0 Lett ~ P°+d ~ ~ EKG ~ Strength: ~ ~ - Q U =Unable to assess 2 = Unable to move against Ri ht g J ~, I Splint ! ~ 5 =Normal gravity 4 = Sii ht weakness 1 Tra ~ g = ce Left ~ ' Ice Pack 3 = tdoves against revity 0 = None yN Sensation: - Wound Care i =Normal T=Tingling .s Rrght O,le Warming R T =Hypersensitive 0 = No sensation ~ measures 1=Numb U =Unable fo assess Leh ~ ~ C Mucus Membranesl5kin: Color IV LINES A F =Flushed M =Mottled C =Cool Temp P =Pale J = Jaundked D.=Dry. {~ N =Normal W = Warm M =Moist Character p Pulses; Radial ~ 1+ =Barely Palpable 0 ;= Not Palpable. ` Right p,Fa ° Intubatfon 2+; =Weak 0;=Doppler- a os p 3+ =Normal Ractrol Ventilator v 4+ =Full Boi,nding leM o.vy'w Mode Rate N FI02 PEEP A- Ca ilia Refill; Number of Seconds Heart Sounds: N Norinel p =Rub D = D>slant ~. rJ M Murfiiur G = GaNo FR = Fdption Aub , CMS Intact Distal to ` CBC Chem 7 Lip Pt •PTT ~ ~ . .. A =Art une c = Gast• R =Restraint F - Ferrj Line 8 =Bum . T = Traction T & C!T & S Edema: t~ ~ L G =General Bk Bel w k Right , ('~ ~ U ~0 UP A- = o nee P =Pedal f = Festal, j F°"" 2+ 3+ ~~ ~ JF CBC NO diff #2 R ~~ A' = Anasaroa 0 ` ,. .,.. Lett. V ~ CBC NO dill #3 Chest Expansion: S Sytnmetiical A . Asymmetfiral P r Myo/trop 0° Trachea: M = Mk1Ane b bev{ated R{gM L = Lleviated LeIE __ . U aespiration: N - No lxstress R = Retractlans Myo/trop 3° ~ L -.Laboree A =. neic/M Sec onds Breath Sounds: - AUL Myo/trop 6° M , 0 =Clear . 1 q Diminished FC =Fine Creckles 0 =Absent Right RMI; CC =Course Crackles S = Strldor R!l N W = Wheezing FR =Friction Aub LUL ~ H Lett ww = Rhonchi R a • t /1 LLL Study Time Done Study 'Time Done R Secretioft:, ~ -s = Smaq TH = rnick G =Groan Amount ~~ ~~ ~. ~ Y" M =Mad N =None T =Ten Consistency Ultrasound C Spine ~y'~-~ L =Large t? =Clear B =Brown 7 =Thin Y =Yellow BL =Bloody Odor Pelvis T Spine l7 Gastrointestinai: n n,en S = Sott R =Rigid . N =Normal 1- =Hypo ttlo Abd US Spine D =Distended t = Tender T =Hyper D = Notre Brw+er Sounds CXR ~) CT Head G NGT/OGT; Placement verified t±y Aspiratlort Extremity ~ ~ CT Abrl ~ pHlGuafac: i , r pr,l,iiti GBStrIC OUtptJt: C=C.leor G.Green 9=Nmwn aL=Bl;wdy Cr'-Co1Me (in ~iM _ ___-..._-__ .___.-_...._..._ (; i hit--. k TIME SOLUTION BAG # BLOOD PRODUCT SITE # INFUSED c. ' '.a~,,r ~ VD Scan ANC;Ir.• ~ - ---. NITIALS N ME: ~ t 1 __ N - - S r;rlbe RN .__. . 1 -. - i ~ .. _ ~. S t ~.lJ't~1/J ----RN P _.~_-. _ _.. .. ---.-._- _~"OTAL-~------ -.-- -,~~~ L~ ~ t , ~r~ ~I lt"' ~ r+ ~ D --1 ~- I-~---~ 4 I TIME I AMT L~FEC.•IFY` _._ . ~._. i. _ •-•-_... .L .. ~...-. _- t i I - -- --...~ _ . .. I TOTAL .....__ i t F'CV. r'N'IV ,HJ~CbJlVICIV I ~UIUC PAIN TOOL.-RANGE .. .. ~ 3=FACES iu.5~ _ l '~ ^, ~ ~J ~=+vl.merir :;~I~ i 0-1171 -. •. _ ~=C;;mfcrt Scale ~'-44 f~ED P_ AIN ASSESSMENT G_ UlDE. USED ~ ;_`-'"~b1`'~ ~~~~", ~~~ `',°m'~~'' F:3'~;':'.,~ . Pain Tool Used 61m ~;prn_~~rn t'>_rn___.___ ~~;'~ Time J7~~ ~ '3~ ~~ i;~i~ ~1-0 :'.;;~ -~, I I r-- ~ ~ P ZD 11 !a~ ~3 RR l7 r ~-~ _ TEMP ~ `_' ,3~7 ~- \ ~~ -~ PAIN ' --~' ~ AIL ~~ 02 SAT' ~j ~ U l y Gcs l , ~ ~ 15 ~ • ~ Rhythm s `~ / Init. ~ ~ ~-- --- MEDICATION D E TIM E BY SITE ROUTE l ime Procedure Narrative Att, ~ t3edside ~ / ~ _._~ Room.._...,._,, ffime _.__ ' RESPONS, - - ~*- ~ ~- ~ RESPONS. ~ 5t r`P ~~ ` %~* RESPONSE -~~ " ~! RESPONSE ---r-`['~ ~ --- ~ t1.~19GL' ._ " ~"~ _ l RESPONSE ~ __. _ ~c;_~C Q,L T~ ~a~`~` RESPONSE RESPONSE y ~,~~ ~ (~ y ~ RESPONSE --_. u~- -= -~-- --- ~ RESPONSE --~---.TIIA',~ `~~--~~ .____ __ _ .._ -- ~-.~._w_____~ -.. , ' - . ~ ~ fy ~ ... ~ RESPONSE ~. ~ ..~ _ ~_- ~ ~~. _~L].~1 A~~~~ i~ l ~. RESPONSE _~ _ ~ ~, `' l RESPONSE ~ _.......~L~ `~ L~Yl1_.12~1~1.~ ~ Ui1~l~U,~,'.~ lilU[I III I~ OIICCL 1iV111fJIBlC T E''9 L1 1VU LJ IVH Orders /.Nurses Notes Faxed Yes ^ No ^ NA CONDITION ADMIT ^ Improved ~ Transported by RN ^ Unchanged WC ^ Crutches ^ Stretcher ^ Walk ^ ' IV Infusing (] Armband ^ Green =All Patients ,Red =All, Trauma /ICU Patients u Discha GGS E~ V..~ Fvl_'~ Gofnments: Instnact s tv ~Safient Q _ ~_,~____.....___. Other _ .-.--- __ ~ ._,_____~._..~_.__.__..__.__ Vert3atizes understanding N~ [_1. _ __.______~_. ~_...._..__-. iianAouts Given° e n C~ _ ~ -----_.,__.___._.._---__-.---...__ Lisi _____,.. r v ~ .~ I _..... -~~~1.~~1S_ _ __ ...~__._ __. __.----------- . Learrtirtg fVeedE AddressE~l, 4`~~,L-~"Nn"F;l~ _._._ ^_..__-.-----__._.. - ~ ~.. .. ~- ~ ^.... a ,. ~I~ ,. ~L ~, ~ ., _. i -, L -: F 1'~. :t_--~'N~~ =V I ~.. ~ ._ L ~ ~ .~~,r~ i.~ 4 rJ~~~~ _ A~ 3 l'L A~" ~ ~ ~ i ~ ~ "`iii - _ 7 . ~~ : , J =_ Ahl FIC .1 .1=71~^.~t i,~ rUl ~ i ~ - -- ~<<~ ~: ... ~ :~ - ...~5 ,- - ~,J ~ J,P~I~~~ ~ .r ~. ~.:~, -- ;,,I ~,.~ G _ ;,~. ,:~ 716 ~ 2 i . ~ ..,v _ . c~~eni~-~ FHl.tii_ -~ L.C. - ^ ~ P.+ : vT ,~`: i > _LT " I CITY i T},' ° ' ~ ~S "J. ~ T !~./:~~~~; '.f ~. :~ } ! ` i t ~{ice ~I~ ~^~ Ii-' ~ ~ j IAEDIGrL HISTORY a !JNKNOWN ~OEN(ED C MI ^ CHF ^ ANGINA C COPD G CVA ~ H!GY BP ~ DIABETES a CANCER i~ SEIZURES CURRENT MEDICATIONS '~ UNKNOWN ,~~NIED ALLERGI~SjIMEI~f~ G UNKNOWN ^ DENIED // WEIGHT KG TIME GCS E V M BP PULSE RE.SP. EKG BY TIME' GCS E V M BP - PULSE RESP. EKG BY ~r~ ; yy~~ .HEAD „~ ~C~S1~J`~ WNL NEGjk'r-~ ~~o~SE~SFA~'NNL l ` ' ~ j , I, PUPIL~_, ERL r : CHEST ESSED 8 WNL .~ v ~• ~ .(t SSED 8 WNL SS E LUNG U NDS / '6~A S O L.t ~.. /" CRAMS ANAT. ,;,: ± , ABDOMEN ~~ BACK ~~-lbS~SSEDBWNL BLOOD ;:~ TIME ~ ; VIC __... -:._ ESSED 8 WNL Ej(TREMfT1E5 d/ ESSED &WNL CAP REZEJLL .$K1N ~ &WNL NEURO ESSEDavvNt: ~a x ~ CPRSTA BY ~ ....~-_ 3 r tin o i~1 J Ya ~. ~->l~ duct` ~ , (.~.~ r.,!~ ~T I~ °~ ~~ C:'-~~ ~ 'F~ ~G ~C" 2 c r~ r...., " ~ a 5 ~ to ~ `c- f°~~-Q c r--- C//\ ~. ,~ i I ~ra."~ (- !~ ~N~~l'~I!Oi~ ~A :^._ '1~.` ~oc./ ~ 4~~c~ ~ ". ~ `^.. v1' `, //~~ ~ 1 \'C. 4n~t: ~r~n _i ~r'1~ i 1tJ'.~..C /\ { 1-..O ~.. .4's'~ (. 4 ~ R/ I V~Lti~~~ e~','I o ~ h ° `~•5' n :n cl f sum ~1`° ~~.. + ~j "t'fn ~ S (r TIME: OXYGEN CJM _ Bh ^ MASK ^ CANNULA ^ BAG VALVE ^ HHN O PULSE OX: before Oz , after 02 s~ AIRWAY GAG ^ YES ^ NO A PIRATION ^ YES • ^ NO '' f ^ OPA ^ N~ ^ iJTI ^ OTI d NEEDLE CRIC !~ ~' ET SECURED AT CM AT THE USING ~ ~ ~ ~ ~ B • ANATOMY) TUBE SIZE: NUMBER ATTE '" ^ =LUNG SOUNDS ^ =CHEST RISE ^ CHORDS VISU D M.D. VERIFICATION SIGNATURE: TIME FLUIDS S0 UTIONS GAUGE LOCATK)N ~ RATE TOTAL VOLUME q OF ATTEMPTS BY 1 ^ Iv ^ IO ~ _ d TKO ^ OPEN ^ BOLUS 2^I ~ O ^ TKO ^ OPEN ^ BOLUS IMMOBILIZATION: . -NECK ~1`BACK ^ LIMB~S- ^ EXTRICATION POSITION: ., •' PINE ^ LATERAL d PRONE ^ SITTING ^ HEAD ELEV. ^ FEET ELEV. TIME MEDICATION, DOSE, ROLRE, TREATMENT AND RESPONSE BY TIME MEDICATION; DOSE, ROUTE, TREATMENT AND. RESP-0NSE - ,- -BY• ~f G ,,~=~ `s rte. / .~p.~~ ~_`•: ~ TIME: HOSPITAL CONTACTED: ^ RCH ^ AFH ^ SDH ^ WMH ^ MAR ^ SGH ^ MSJ ^ MHS AMC ^ NONE NE M p RADIO ~N, ,~j /'~ ~G. ~' 1'--((''"' M.D. FORM LEFT W/PT? d YES ^ NO CONT. ATTACHED? d YES ^ NO DESTIIyATI N: ~ J ~ ~l.,i r ~~ C_.,,: ^ RAS ^ AMA CASE 7RANS~ERf,~(1T0: 1 ~~. (-" ""~ ~ PVT M.D, ^ PT FAMILY REQUEST (] LAW ^ TRAUMACRITERIA ^ CLOSEST BH ORDER ^ DIVERSION ^ SPECIALTY CENTER L STgNDING ORDERS ^ COMMUNICATION FAILURE ORDERS E.D. DIAGNOSIS/COMMENTS ^ DEAD AFTER RESUS. d EXPIRED E.D. ^ ADMIT ^ HOME ^ TRANSFER EMT; Cg1V1PLG~i1NG R~ORT SIGNATURE ^ n~nCP ^ ennr SECON1JARY EMT SIGNATURE: ^ MICP L~rt4T PRECEPTOR SIGNATURE: c n,ncP ~ eMr Talhelm, Paige (MR'~'1?6926('' ' "' BAS"IS HEALTH SYSTE!~1 L.ia~ tZeSUItS UP.INALYSIS-COMPLETE (Order# E579:.°3) Collection CQII~cti.Qn_D~~an_d_Timst R~c~iY~Q.aia_anslJ.ime information 8/26/2005 2230 6/26/2005 2241 Component Value Fig ~ Hlgb tin-ita ~ COLLECTION Clean Catch Final COLOR Yellow None/Yellow Fina4 CLARITY SI Turbid Clr/SI Turb Final SP GRAVITY 1.019 1.002 1.030 Final pH URINE 7.5 4.8 7.8 Final OCCULT BLOOD URINE Negative Negative Final BILIRUBIN URINE Negative Negative Final KETONES Negative Negative mg/dL Final GLUCOSE URINE Negative Negative mg/dL Final PROTEIN URINE Negative Neg/Trace mgldL Final UROBILINOGEN 0.2 0.2 1.0 EU/dL Final NITRITE URINE Negative Negative Fina! LEUK. ESTERASE Trace A Negative Final MICROSCOPIC INDICATED Negative Final WBC/HPF 1-3 0 3 Final SQUAMOUS EPI 6.12 A 0 3 EPI/HPF Final AMORPH CRYSTALS Moderate A Rare/Occ Final URINALYSIS-COMPLETE (Order#6679293) on 6/26/05 -Order Result History Report Other IDs Lab Specimen # 0626:UA00078S Patient patient Name M6i!i ;~( DOB Home Phone Information Talhelm, Paige 1769260 F 11!211991 717-486-4808 (13yrj !/nit Room Isolation EMER ERWB N Lab ~ Lab Director Information UC DAMS MED CTR Ralph Green, MD 2315 Stockton Blvd Sacramento, CA 95817 Order Information URINALYSIS-COMPLETE (Order# 6679293) Order Order Date and Time Department Information 6/26!2005 10:30 PM Emergency Order Authorizing Provider Encounter Provider CONFIDENTIAL - EMR COPY --- Printed by Dvorak, Jeremy 8/15/05 1044 Page 1 of 9 Talhelm; Paige (MR'v'1?6926~' `-~ ~,_~`.?S HEALTH SYSTEM Providers ,07992 Dustin Ballard .05456) Peter Sokoiove Priority and Prio_risy tslas~ Order Details STAT Normal Lab Results CBC WITH AUTO DIFFERENTIAL (Order# 667$307) Collection Collection Date and Time Received Date and Time information 6!26/20051730 6/26/20051742 Com op Went Y~i~ FJa9 i.~ Hi9h U.o-tt~ 6satsle WHITE BLOOD CELL COUNT 7.4 4.5 11.0 KlMM3 Final RED CELL COUNT 4.55 4.0 5.2 M/MM3 Final HEMOGLOBIN 13.5 12.0 16.0 GM/DL Final HEMATOCRIT 39.9 36 46 % Final MCV 87.7 80 100 UM3 Final MCH 29;7 27 33 PG Finai MCHC 33.8 32 36 % Final RDW 12.5 0 14.7 UNITS Final PLATELET COUNT 286 130 400 K/MM3 Finai NEUTROPHILS °~ AUTO 45.6 % Final LYMPHOCYTES % AUTO 40.1 % Final MONOCYTES % AUTO 8.0 % Final EOSINOPHIL %AUTO 6.0 % Final BASOPHILS % AUTO 0.3 % Final NEUTROPHiL ABS AUTO 3.32 1.80 7.70 K/MM3 Final LYMPHOCYTE ABS AUTO 2.92 1.0 4.8 IVMM3 Final MONOCYTES ABS AUTO 0.59 0.1 0.8 K/MM3 Final EOSINOPHIL ABS AUTO 0.44 0 0.5 KIMM3 Final BASOPHILS ABS AUTO 0.02 0 0.2 K/MM3 Final C~BC WITH AUTO DIFFERENTIAL (Order#6678307)_gn 6/26!05 -Order Result History Report Other IDs Lab specimen # 0626:H00395S Patient Patient Name MQh11 ~ ~ Home Phone Information Talhelm, Paige 1769260 F 11/2/1991 717-486-4808 (13yr) SLO.i! QQom isolation EMER ERWB N Lab ~ Information UC DAMS MED CTR 2315 Stockton Blvd tab Director Ralph Green, MD CONFIDENTIAL - EMR COPY --- Printed by Dvorak, Jeremy 8/15/05 1044 Page 2 of 9 Talhclm, Paige (MR~,'176926f`' Sacramento, CA S5817 i'r' DriVIS HEAL:I-~ cYSTF'!~1 Order Information CBC WITH AUTO DIFFERENTIAL (Order# 6678307) Order Qtder Date and Time Department Information 612612005 5:30 PM Emergency Order Authorizing Provider Encounter Provider Providers (05456) Peter Sokolove (05456) Peter Sokolove Priority and Priority Clasa Order Details STAT Normal Lab Results BASIC CHEMISTRY PANEL (BCP) (Order# 8678332) CoNection Goliectio~n Date and Time Received Date and Tuna Information 6/26120051730 6(26120051742 Com op Went YaitL@ F1aS L~ I~IB-h ~ S~~ SODIUM 140 135 145 mEq/L Final POTASS{UM 3.1 L 3.3 5.0 mEq/L Final CHLORIDE 107 95 110 mEq/L Final CARBON DIOXIDE TOTAL 22 L 24 32 mEgIL Final UREA NITROGEN, BLOOD 9 8 22 mgldL Final (BUN) CREATININE BLOOD 0.7 0.5 1.3 mg/dL Final GLUCOSE 182 H TO 110 mg/dL Final TEST ADDED TO SPECIMEN PREVIOUSLY RECEIVED IN LABORATORY TEST ADDED: HFP DATE/TIME TEST REQUESTED: 06/26/05 1756 REQUESTING PHYSICIAN NAME: SOKOLOVE A HARDCOPY REQUISITION FOR THIS TEST HAS BEEN REQUESTED BASIC CHEMISTRY PANE~BCP~.(Order#6678332) on 6126!05 -Order Result History Report Related Tests LIVER FUNCTION TESTS (Order#6678333j on 6126!05 LIPASE (Qrder#6678334} on 6126/05 Other iDs Lib Specimen!! 0626:CI00365S Patient patient Name ~ ~ DOB Home Phone CONFIDENTIAL - EMR COPY --- Printed by Dvorak, Jeremy 8/15/05 1044 Page 3 of 9 Talhelm, Paige (:~IRti 176926('' Information Talhelm, Paige 176926u F 11;2;1991 (13yr) t;ri Room iss>latl4a EMER ERWB N T rr DAVZS HEALTH S`i'STEPYI 717-486-4808 Lab L~ Lab Direct4[ Information UC DAVIS MED CTR Ralph Green, MD 2315 Stockton Blvd Sacramento, CA 95817 Order Information BASIC CHEMISTRY PANEL (BCP) (Order# 6678332) Order Order Data and Time Department Information 6!26/2005 5:30 PM Emergency Order Aut_-+orizing Provider Encounter Provider Providers (05456) Peter Sokolove (05456) Peter Sokolove Priority and Priority Class Order Details STAT Normal Lab Results LIVER FUNCTION TESTS {Order# 6678333) Collection collection Date and Time Received Date and Time Information 6/26/20051730 6/26/20051742 Component Value F1aS LQtec Hlg6 Units status ALBUMIN 4.0 2.9 4.5 gidt Final ALKALINE PHOSPHATASE 193 H 35 115 U/L Finai (ALP) ASPARTATE TRANSAMINASE 27 15 43 U/L Final (AST) BILIRUBIN TOTAL 1.1 0.3 1.3 mg1dL Final ALANINE TRANSFERASE 16 5 54 UiL Final (ALT) TEST ADDED TO SPECIMEN PREVIOUSLY RECEIVED IN LABORATORY TEST ADDED: HFP DATE/TIME TEST REQUESTED: 06/26/05 1756 REQUESTING PHYSICIAN NRME: SOKOLOVE A HARDCOPY REQUISITION FOR THIS TEST HAS BEEN REQUESTED LIVER FUNCTION TESTS (Order#6678333) on 6126105 - Order Result History Repo rt Related Tests CONFIDENTIAL - EMR COPY --- Printed by Dvorak, Jeremy 8/15/05 1044 Page 4 of 9 Talhelm, Paige (~iR.'v l 76926' " "' DAVIS HEALTH S~"STEM 9ASV_C CHEMIySTRY PANEL jBCPI IQrder#66783321on G/~.~/~5 LfPASE (Ord~r#6678334~_on 6/2!05 Other IDs Reflex Order # Lab Specimen # 6678332 0626:C100365S Patient Patient Name I!rlBN ~Bx 12Q@ Home Phone Information Talhelm, Paige 1769260 F 11/2/1991 717-486-4808 (13Yr) li_oil Room lsolat on EMER ERWB N Lab ~ Lab Director Information UC DAMS MED CTR Ralph Green, MD 2315 Stockton Bfvd Sacramento, CA 95817 Order Information LIY~R FUNCTIQiV TESTS (Ordsr# 81378333} Order Order Date and Time Department Information 6126!2005 5:30 PM Emergency Order Authorizing Provider Encounter Provider Providers (05456) Peter Sokolove (05456) Peter Sokolove Priority and Priority Class Order Details STAT Normal Lab Results LIPASE (Order# 8678334) Collection Collection Date and Time Received Date and lime Information 6/26/20051730 6/26!20051742 Com oo Went Y~iuB E1ag b~ til9h !tolls status LIPASE 27 13 51 U/L Final TEST ADDED TO SPECIMEN PREVIOUSLY RECEIVED IN LABORATORY TEST ADDED: HFP DATE/TIME TEST REQUESTED: 06/26/05 1756 REQUESTING PHYSICIAN NAME: SOKOLOVE A HARDCOPY REQUISITION FOR THIS TEST HAS BEEN REQUESTED CONFIDENTIAL - EMR COPY --- Printed by Dvorak, Jeremy 8/15/05 1044 Page 5 of 9 Talhelm, Paige (MRN 1769261' "~ DAVIS HEALTH SYSTEM LIPASE10rder(?6678334~_on 6126/05.Order Result Histo~R~ort Related Tests BASIC CHEMISTRY PAIvEL_(~l3CP~ O(~ rder#66783321 on 6/26105 LIVER FUNCTION TESTS (Order#667833,3~ on 6!26!05 Other IDs Reflex Order # Lab Specimen # 6678332 0626:C100365S Patient Patient Name NiRti ;~ l~ Home Phone information Talhelm, Paige 1769260 F 11/2/1991 717-486-4808 (13yr) ~i1t Room Isolation EMER ERWB N Lab Lak Lab Director Information UC DAVIS MED CTR Ralph Green, MD 2315 Stockton Blvd Sacramento, CA 95817 Order Information LIPASE (Order# 6678334) Order Order Date and Time Department Information 6/26!2005 5:30 PM Emergency Order Authorizing Provider Encounter Provider Providers (05456) Peter Sokolove (05456) Peter Sokolove Priority and Priority ~~ Order Details STAT Normal Lab 1~8SUItS TYPE AND SCREEN (Order# 6678351) Collection Collection Date a~Ume Received Date and Time Information 6126/20051730 6/26/20051758 PATIENT BLOOD TYPE: O POSITIVE ANTIBODY SCREEN (ORTHO GEL): NEGATIVE Sufficient specimen available to add units until:6/29@1730 Crossmatched units are released approx 1600 on above date. CONFIDENTIAL - EMR COPY --- Printed by Dvorak, Jeremy 8/15/OS 1044 Page 6 of 9 Ta;helin, raige (NIRNI7ey~6~'~ "" DA~'IS HEALTH SYSTEM 7YFE_AND SCREEtJ jprder#6678351~on 6/26/05_Or~r Result Histo~Report Other IDs ~,Soecimen # 0626:BB00061S Patient patient Name Information Talhelm, Paige ~n1! EMER MBI!1 ~ 1769260 F Boom Isolation ERWB N DQ)3 Home Phone 11 /2/1991 717-486-4808 (13yr) Lab i~ Lab Director Information UC DAVIS MED CTR Ralph Green, MD 2315 Stockton Blvd Sacramento, CA 95817 01'181' ~{1~01'111atitNt TYPE AND SCREEN (Order# 6678351) Order Order Date and Time Department Information 6/26/2005 5:30 PM Emergency Order p~thorizing Provider Encounter Provider Providers (05456) Peter Sokolave (05456) Peter Sokolove Priority and Priority Class Order Details STAT Normal Lab Results PROTHROMBIN TIME (PT) (Order# 6678389) Collection Collection Date and Time Received Date and Time Information 6/26!20051730 6l2ti120051742 Component yalue .Flag LAC HI9h Units Status INR 1.03 0.75 1.19 Final Related Tests APTT STUDIES (Order#6678390) on 6/26/05 Other IDs Lab Specimen # 0626:CG00183S CONFIDENTIAL - EMR COPY --- Printed by Dvorak, Jeremy 8/15/05 1044 Page 7 of 9 __ _ _ Ta;hel;rl. Pai^~ (?~1R'_`YTI?5Q'60~ iTr DAMS HE.ILTH: SYST~_VI Patient patignt~_n~ Mi3t~ ~x SOS H~~h~e Information Talhelm, Paige 1769260 F 11i2i1991 717-486-4808 (13yr) l~n Boom i~Iat14Q EMER ERWB N Lab L~ Lab Director Information UC DAVIS MED CTR Raiph Green, MD 2315 Stockton Blvd Sacramento, CA 95817 Order information PROTHROMBIN TIME (PT) (Order# 6678389) Order Order Date and Time Department Information 6/26/2005 5:30 PM Emergency Order Auth ing Provider Encounter Provider Providers (05456) Peter Sokolove (05456) Peter Sokolove. Priority and Priority ~& Order Details STAT Normal Lab R@SU~tS APTT STUDIES (Order# 6678390) COIIeCtion Collection Date and Time Received Date and Time Information 6/26!20051730 6/26/20051742 Component Yalue ~ Lit kil9h Units Status APTT 26.1 21.8 31.5 SECONDS Final Related Tests PROTHROMBIN TIME (PT1(Orderlf66783891 on 6126/05 Other IDs Reflex Order ~ Lab Specimen a 6678389 0626:CG00183S Patient Patient Name l~B1~i ~ 2Q13 Home Phone Information Talhelm, Paige 1769260 F 11/211991 717-486-4808 (13yr) i~t Boom Isolation EMER ERWB N Lab Lab Information CONFIDENTIAL - EMR COPY --- Printed by Dvorak, Jeremy 8/15/05 1Q44 Page 8 of 9 Tall~~arn, Paige (~ 1R''.17594b0~ j fr L~A~~IS HEALTH SYSTF'.1~1 UC DAVIS MED CTR Ralph Green. MD 2315 Stockton Blvd Sacramento, CA 95817 Order Information APTT STUDIES (Order# 6678390) Order Order Date and Time Department Information 6/26/2005 5:30 PM Emergency Order puthorizingprovider Encounter Provider Providers (05456) Peter Sokolove (05456) Peter Sokolove Priority and Priority Iris Order Details STAT Normal CONFIDENTIAL - EMR. COPY --- Printed by Dvorak, Jeremy 8/I S/OS 1044 Page 9 of 9 Talh~elm, Paige {l~~iR~' 1769260 i iC DAMS HEALTH SYSTEM Im2ging Results ELBOW 3+ VIEWS, RIGHT (Order# 6678311) (Acc# 28330) FACS Images Shaw imagcs_fcr ELBOW 3~ VIEWS,_RIGHT~ADDX00931~ To launch xray images, your computer needs Windows 98 or above 8 fntemet Explorer (IE) version 5.5 or above. From outside UCDHS, launch VPN before logging into Citrix and EMR. Click here for troubleshooting tips, or contact iS Customer Support (734-HELP). Results EXAM DATE: 06/26/2005 ELBCW, 3+ VIEWS, RIGHT: CLINICAL HISTCR.Y: Rollcver MVA with right upper extremity abrasion. FINDINGS: Two lateral, oblique, and AP views of the elbow were provided for review without previous films for comparison. There is no evidence of fracture or malalignment. Posteriorly, within the soft tissues, there are multiple 2-5 mm radiopaque objects which may represent foreign bodies, correlate clinically. IMPRESSION: 1. NO EVIDENCE OF ACUTE FRACTURE OR MALALIGNMENT OF THE RIGHT ELBOW. 2. MULTIPLE RADIOPAQUE OBJECTS WITHIN THE SOFT TISSUES POSTERIORLY. SH:cm(rad020) ACC#: 000000026330 D: 06/27/2005 12:98 AM T: 06/27/2005 01:96 AM C#: 1092896 signed: Stephanie Horton, D.O. cosigned: Kiran Jain, M.D. Result History ELBOW 3+ VIEWS. RIGHT (Order#6678311).on 6/28/05 -Order Result History Repo Exam Exam Date Exam Tlme Information 6/26/2005 2353 Result Result Date and Time Information 6128/200510:40 AM Status Final result Patient Patient Name m$t( $BX DOB Information Talhelm, Paige 1769260 Female 11/2!1991 ~ Room 1;t41aSI4r! EMER ERWB N CONFIDENTIAL -EMR COPY --- Printed by Dvorak, Jeremy 8/15/05 1044 Page 1 of S Talhelm, Yaige (?~1R'~'1769260` ~rde~r T Tr nA~'1S HEALTH SYSTE'~1 ELBOW 3+ VIEWS, RIGHT (Order:.' 66783111 Patient patignS~me M£si~ Sex D21} Patient_PhQna Information Talhelm, Paige 1769260 Female 11/2/1991 717-486-4808 Allergies: (Not on File) Order Authoriztng_Provider )~r~ounter Provider Providers (05456) Peter Sokolove (05456) Peter Sekolove Order Order Date and Time Deaa~tnent Information 6/26/2005 5:59 PM Emergency Priority and Prioril~ Cia~s_ Order Details STAT Normal Insurance p~ ct~Number Financial Class Information 020960114997 O 1 Payer MISC Patient Insurance 061 BOi 202 Ip Plan. P1sn Number COMMERCIAL 099 INS-MISC Imaging Results FOREARM 2 VIEWS, RIGHT (Order# 6678312) (Acc# 28331) PACS Images Show images for FOREARM 2 VIEWS RIGH~RADDX009411 To launch xray images, your computer needs Windows 98 or above & Internet Explorer (IE) version 5.5 or above. From outside UCDHS, launch VPN before logging into Citrix and EMR. Click here for troubleshooting tips, or contact IS Customer Support (734-HELP). Results EXAM DATE: 06/26/2005 FOREARM, 2 VIEWS, RIGHT: CLINICAL HISTORY: Status post rollover MVA with abrasions to the right arm. FINDINGS: Two views of the right forearm were provided for review without previous films for comparison. There is no evidence of fracture or malalignment. Soft tissue defects are noted posteriorly and medially with multiple 2-5 mm radiopaque objects within the soft tissues. Bandage material is also noted. IMPRESSION: 1. NO EVIDENCE OF FRACTURE OR MALALIGNMENT OF THE RIGHT FOREARM. 2. MULTIPLE RADIOPAQUE OBJECTS OVERLYING THE SOFT TISSUES OF THE PROXIM.~L FOREARM AS ABOVE. CONFIDENTIAL -EMR COPY --- Printed by Dvorak, Jeremy 8/15!05 1044 Page 2 of 8 Talhelm, Paige (vIR~'~'1769~6~` aCC#: ~~OG00026331 C: OEi2i/2GC5 12:17 AM T: 0512?;2005 01:16 AM C#: 1092839 r 1r D ~,-rc l~t:_:>iT .TH SYSTEM signed: Stephanie Horton, D.O. cosiq;,ed: Kiran Jain, M. D. Result History FOREARM 2 VIEWS RIGHT (Order#6678312~gn 6!28/05 -Order Result History Rem Exam Exam Date Exam Time information 6/26/2005 2353 Result Result Date and Time Status Information 6/28/2005 10:40 AM Final result Patient Patient Name M.RN ~ DQS Information Talhelm, Paige 1769260 Female 11/2!1991 tlDJS Boom Isolation EMER ERWB N Order FOREARM 2 VIEWS, RIGHT (Order# 6678312) Patient Patient Name M@N ~ 120 Patient Phone Information Talhelm, Paige 1769260 Female 11/2/1991 717-486-4808 Allergies: (Not on File) Order Authorizing Provider Encounter Provider Providers (05456) Peter Sokolove (05456) Peter Sokolove Order Order Dat and Time Department Information 6/26/2005 5:59 PM Emergency Priority and Priority Siam Order Details STAT Normal insurance Acct Number Financial Class Information 020960114997 O 1 Payor MISC Patientlnsurance 061801202 Ip CONFIDENTIAL - EMR COPY --- Printed by Dvorak, Jeremy 8/15/OS 1044 Page 3 of 8 Talhelm, Pare (MR'~1176926(' Plan COMMERCIAL IN'S-MISC Pl~ti Nt~mb~r 099 '-~ DAMS HEALTI-: S ~'STE'_t~ Imaging Results C-SPINE 4+ VIEWS (Order# 6678309) (Acc# 28328} PACS Images Show images for C-SPINE 4+ VIEWS ~RADDX0100~ To launch xray images, your computer needs Windows 98 or above & Internet Explorer (IE) version 5.5 or above. From outside UCDHS, launch VPN before logging into Citrix and EMR. Click here for troubleshooting tins, or contact IS Customer Support (734-HELP). Resu its EXAM DATE: 06/26/2005 CERVICAL SPINE, 4+ VIEWS: CLINICAL HISTORY: Rollover MVA. FINDINGS: Multiple views of the cervical spine are provided for review without previous films for comparison. There is no evidence of fracture or malalignment. The C1-2 junction is symmetrical. Vertebral body and disc space heights are preserved. No prevertebral soft tissue swelling is seen. IMPRESSION: NO EVIDENCE OF ACUTE FRACTURE OR MALALIGNMENT OF THE CERVICAL SPINE. SH:cm(rad020) ACC#: 000000028328 D: 06/27/2005 12:15 AM T: 06/27/2005 01:19 AM C#: 1092838 signed: Stephanie Horton, D.O. cosigned: Kiran Jain, M.D. Result History C-SPINE 4+ VIEWS (Order#6678309~on 6/28/05 -Order Result History ReR4rt Exam Exam Date Exam Time information 6126!2005 2351 Result Result Date and Time Information 6/28/2005 10:40 AM Status Final result Patient patient Name lIABM S, ex p~ Information Talhelm, Paige 1769260 Female 11/2/1991 CONFIDENTIAL -EMR COPY --- Printed by Dvorak, Jeremy 8/15/05 1044 Page 4 of 8 Ta1l~elm, Paige ('~IR'~T176426C'' ' "' DA~~IS HEALTH SYSTEi~1 Unit Rv9m EMER ER`A~B isQlatfor! N Order C-SPINE 4+ VIEWS (Order# 6678309) Patient patient Name M$Nu!@x QS213 Patient Phone Information Talhelm, Paige 1769260 Female 11/2/1991 717-486-4808 Allergies: (Not on File) Order Authorizing Provi~ Encounter Provider Providers {05456) Peter Sokolove (05456) Peter Sokolove Order Order Date and Time Der?artment Information 6/26/2005 5:59 PM Emergency Priority and Priority Class Order Details STAT Normal Insurance Acct Number Financial Ciass Information 020960114997 O ~ Pavor MISC Patient Insurance 061601202 112 i'Jan PJ~ Number COMMERCIAL 099 INS-MiSC Imaging Results PELVIS 1 OR 2 VIEWS (Ordet# 6678310) (Acc# 28329) PACS Images Show images for PELVIS 1 OR 2 VIEWS [RADDX009761 To launch xray images, your computer needs Windows 98 or above & Internet Explorer (IE) version 5.5 or above. From outside UCDHS, Paunch VPN before logging into Citrix and EMR. Click here for troubleshooting tins, or contact IS Customer Support (734-HELP). Results EXAM DATE: 06/26/2005 PELVIS, 1 PR 2 VIEWS: CLINICAL HISTORY: Status post rollover MVA. FINDINGS: Single AP view of the pelvis was provided for review without previous films for comparison. There is no evidence of fracture or CONFIDENTIAL -EMR COPY --- Printed by Dvorak, Jeremy 8/15/05 1044 Page 5 of 8 Talhelm, Paige (.tifR'v 176926f'~ r Tr DAMS HEALTH Sit"STEM ~is;ocation. Stool ar.d gas overlie the sacrum makir.c *_!-:e _ __:atron .f fracr.;;res 1~mited. Soft tissues are ur,remarkab'_e, ..:, bony lessons are seen. _^:PF.ESSiON: NO EVIDENCE vF ACUTE FRACTURE OR DISLOCATION CF iEE ?EiVIS. ?LIMITED EVATUATICN CF THE SACRUM. SH:cm(rad020) ACC#: 000000028329 D: 06/27/2005 12:12 AM T: G6/27/2005 01:11 AM C#: 1092837 signed: Stephanie Horton, D.O. cosigned: Kiran Jain, M. D. Result History PELVIS 1 OR 2 VIEWS LOrder#6678310) on 6!26!05 -Order Result Historx Re or Exam Exam Date E» Time Information 6!26/2005 2345 Result Result Date and Time Status Information 6/28/2005 10:40 AM Final result Patient Patient Name AASM S:sx DOB Information Talhelm, Paige 1769260 Female 11!211991 Roo m Isolation EMER ERWB N Order PELVIS 1 OR 2 VIEWS (Order# 6678310) Patient Patient Name lHf~l ;i8~t QQ@ Patient Phone Information Talhelm, Paige 1769260 Female 11/2/1991 717-486-4808 Allergies: (Not on File) Order Authorizing Provider Encounter Provider Providers (05456) Peter Sokolove (05456} Peter Sokofove Order Order Date and Time Department Information 6l26I2005 5:59 PM Emergency Priority and Priority Class Order Details cTAT Normal CONFIDENTIA L - EMR COPY --- Printed by Dvorak, Jeremy 8/15/05 1044 Page 6 of 8 Talhehn, Faige (':VIR'~' 1769~'(i0' T T'" DAVZS 1-TEALTH S~'STEM Insurance AccLNumber Information 020960114397 1 paYOI MISC PIaQ Plan Number COMMERCIAL 099 INS-MISC Fisza ns~L~La~ O Patient Insurance 061601202 I~ Imaging Results CHesr ~ viEw (order# ss~ssos) (Acc# 2s3z7) PACS Images Show images for CHEST 1 VIEW IRADDX009801 To launch xray images, your computer needs Windows 98 or above I~ Internet Explorer (IE) version 5.5 or above. From outside UCDHS, launch VPN before logging into Citrix and EMR. Click here for troubleshooting tins, or contact IS Customer Support (734-HELP). Resu Its EXAM DATE: 06/26/2005 CHEST, 1 VIEW: CLINICAL HISTORY: Rollover MVA. FINDINGS: Single AP view of the chest was provided for review without previous films for comparison. The lungs are clear and the costophrenic angles are sharp. The cardiac silhouette is within normal limits. There is no tracheal deviation, the mediastinum is unremarkable. No bony or soft tissue abnormalities are identified. IMPRESSION: NO EVIDENCE OF AN ACUTE CARDIOPULMONARY PROCESS. SH:cm(rad020) ACC#: 000000028327 D: 06/27/2005 01:92 AM T: 06/27/2005 02:53 AM C#: 1092869 signed: Stephanie Horton, D.O. cosigned: Kiran Jain, M. D. Result History CHEST 1 '/IEW (OrderJ/6678308) on 6/28/05 -Order Result Histor~Report Exam Exam Date Exam Tlme Information 6/26/2005 2340 CONFIDENTIAL -EMR COPY --- Printed by Dvorak, Jeremy 8/15/05 1044 Page 7 of $ T ll~elm, Paige (~'1~IR1'~ 1?6926~ DAMS HEALTH SYSTE'~1 Result ~uii ~a~and Mme S~sitt~.s Information 8;2812005 10:40 AM Firal result Patient patient Na1n~ 1+1~ $~IS DQ@ Information Talhelm, Paige 1769260 Female 11/2/1991 tlttit i349m 4s i~tiQn EMER ERWB N Order CHEST 1 VIEW (Orderlf 6678308) Patient ~fent Name ME31Y ;xex ~ Patient Phone Information Talhelm, Paige 1769260 Ferrate 111211991 717-48fi-4808 Allergies: (Not on File) Order ~thorizin a Provider Encounter Pr elder Providers (05456) Peter 3okotove (05456) Peter Sokolove Order Q~eLDate and TLme I)eoaQsn$nt Information 6/26/2005 5:59 PM Emergency Priority and Prio~ty Class Order Details STAT Normal Insurance Acct Number Financial Class Information 020960114997 O 1 P~y_o~ MISC Patient 1 suran a 081601202 tQ PiaII P.J;~n Nld11>b@I COMMERCIAL 099 INS-MISC CONFIDENTIAL - EMR COPY --- Printed by Dvorak, Jeremy 8/15/05 1044 Page 8 of 8 F n ,~ I~ Name: . A~.HELm, PAIGE ~,_.~, ; ,~~ SA~t: 01343857 i;.f~ a U r:€~~ !~L~~. r'r'i~vw~f`~ UFrI ~ ~. H12969000 ~~?~ ~~ .r,; 06/26/05 P ~ American Med R nse W. " r $843.81 .. Y}:^ $759.43 N12969001 06126/05 R ntslUCD PBGJ 1M Hemat $84.05 575.64 014788soo os2sros u. c. Davis medical ctr. ~~8 54s.5o $s 739.60 031333800 0626/05 R ents/UCD PBGJ IM Hemat $338.00 $338.00 032532900 08/26/05 R ntslUCD PBG/ IM Hemat $242.00 $217.80 032532901 06126/05 R ents/UCD PBG/ IM Hemat $48.00 $4 320.00 N67005200 07/Oi/05 Sutter Medical Foundation $258.00 $236.00 082190900 08/04/05 Giesswein Plastic Su $70.00 $35.00 Carlisle Pediatric Assoc. $15,721.47 ..~t rA`It N-~ "ten,.. i . - ~ ~ , v ~ ~ ; ,~ y ~ t~ ~ uillVEnSITY OF ~'-AI-IFORNIA DAVIS _ Iv9EDICAL CENTER cerpnngFNTO, C:ALiFORNIA EMERGENCY DEPARTMENT (~ c12. PAST MEDICAL HISTORY: e.P PULSE RESP. TEMP. PUPILS PRESENT MEDICATIONS: PRE-HOSPITAL TREATMENT & SUPPLIES: ~. ... DATE i TIME TREATMENT /VITAL SIGNS ASSESSMENT 4` ~~ ~ c~,e~c,; -c.~ ~~ ~ ~,~ ~~~ ~ verr.~~~.~. 6~ 1_ ~~~v ~ !'nom ~~ ~ ~-- O . T-A . c. ~ a ~au,~. ~ 1-u.~ ~~`, v c1 cif m i ~. t h V J ' cvt ~ C I J Q ~'~ . ~ `~ TU ~ .D _.__.---_.___ _ ,,- Y ADMINISTRATI .. ' ''~ '. ,.. •j 1 ~_~ '~`~ ~ tJMVE~S11'Y ~~' L'/~tl~L.t..s ~ c, -, ruriat c.rriii(S t '' ~.,} Q "" ~ ~ 2 Q, 9 b01 j .s ~ ~ ~ ,a V ~ A;d A :;~. ~': ~i't~AL~~ SYST£M -i y ,! c ~> Z 7 17~-~8~-4$s~ll ACKNG~WLc~7GE~UlENT QF . ECEIPT: i`JOTfGE JF PRiVAGY PRACTICES"- ~; ~ - _ __ .. - ; l"he UC Gavis Health System Notice of °rivacy Practices provides information about how ~~~e may use an disclose protected health information about you. In addition to the copy we are providing you, copies of the current notice are available by accessing our Web sit at http://web.ucdmc.ucdavis.edu/compliance/ and may be obtained:'throughout l7C Davis Health System. I acknowledge that I have received the Notice of Privacy Practices. .~~C~~~~,clt ,~('~ ~ ~~ Signature of Patient or Patient's Representative ~; Print i ~SS Interpreter (if applicable) Written Acknowledgement Not Obtained 6 ~ Date „ d~ Relationship to Patient Please document your efforts to obtain acknowledgment and reason it was not obtained. ^ Notice of Privacy Practices Given -Patient Unable to Sign D Notice of Privacy Practices Given -- Patient Declined to Sign D Notice of Privacy Practices Mailed to Patient -Awaiting Signature O Other Reason Patient Did Not Sign Signature of UC Davis Health System Representative Print Name Date Department ~XN11~1 1 ~~~~~~~ R~Ct~~li~ ~~ -- 1.- ~ v~-~`-~",a~ fin, ~w . ~~ ~ E `„' f.. ~~ ., d ~ ~ ~ s ~c; nr,~~ 5=~ - u 1i G ~f„u-....~ r------ ~ ~ ~ _ ,.. _ ~ r ~~ --- N r'~. / L_.. _ ~ o ...~ b ~ -~ -~C~Gn~SS r~~CaR~3 ~`_~~~ ~~ ~- ~ rl,{- '-\ 4 ,r l ~ ~ 577-~.~c y c .:1 ~' ~ x~~t ~+ -~~"~ ~~ /~ T~ ep ~ QEMERAL R gYEB THROAT ~` aVECK ABD ~ ~ . ~Ct,~- ~vl c( rs EXTREM tVEURO. ~ S ~ ~ ~ ~ w i n ! ..t • o ~~- ; - ~ - -- - _ --- - - --- -- - _ Div - ~-~~ c S:,c~.J~t.. ~-v.Q "~ ~ ~-- ~-~ ~ . -~~ r`iame: '~f~ I ~~; j' ~ ~ ~.', ~l~ ~ 1~~ 1 DOES: ~ ~ ~ ~ .~_ _. , 11vr:~. Date: ~~~ ~I ~ ,,_ ~ Ht ~~.~ ~ Wt l~--v•, E3.P.'~:~LLj Allergies vi i i {nten~al Ffistory ---- ~ Psychosocial ~ i PC. r Normal / Abnormal Illres~~iniuryisurgery Home - Gen. AFp. E7 eeth O G. U. :~r Head O Neck 3~ Tanner staye Lyes ^ Chest ~ U%A :] ~ V. A. C]~ Tanner stage.:T Ext. ~.:~' Education!employm~nt ~ Ears 0"Lungs ~ Neuro.0" ~, ;~ ~~v %~E -- x,~,~e; I Nose Car- Heart ~ Skin ^, i. PJleds `. k,~ ~ ~-=:;~~-~ ~~=~ .~~- - Throat -Abdomen C]'Back .~ M 1 r ._ -,-- . . --.'...". ~~ ~~ ~ , • ~ ~ Activities _ Comments i ~~ c~ ~.,~ {~ 4' ,Health mainienrjnce Drug's/alC~oho1/cigarettes ~ Counseliny Centist ^ J ~ ~..~ e-~ Vision Cl Nearing Q Sexuality - Impression Menstrual History - ,~ ~~~~ S ~-- 5 ~w .'LQQ ~? -~ ~ ~ ~ ~ Concerns Suicide/depression - 'T'reatment ~~(c~~c c..<;ti,~7j- . ,. J :I?a~ ~:~F - iii -~- Follow-u 2 .,--, / i~;___... '13yrs. Date: Ht. Wt B.P,. Allergies Internal History Psychosocial PE. /Normal / Abnormal ~ Illness/injury/surgery Home Gen. App. ^ Teeth ^ G. U. ^ Head ^ Neck ^ Tanner stage Eyes ^ Chest ^ U!A ^ V. A. O Tanner stage` Ext. ^ Educationlemployment Ears O Lungs O Neuro. O Nose ^ Heart ^ Skin ^ ~ Meds I Throat ^ Abdomen ^ Back ^ Activities __ Gomment~ Health maintenance Drugslalcohol/cigarettes I Counseliny Dentist ^ Vision C} f-searing ^ _.__ Sexuality Impression Mensarual History Concerns Suicide/depression Treatment Follow-u PROGRESS F~tE.C:OR~7 - - ~~ i"~ ~ --- --- ~ r ~ - - ---- :,,gyp' ~i '-., a, , ° - ~ ~ , - t :~~s ` f1-iftC1Al `SA.sx-`1"Z" tit,-o f' c~ ~ c~ .~.._ ~ ~-'1-~~,~ ..~ c.r~ iGC1. -itAR7 - At1D. - .. . _ ____ y~uHt- . t • (~'~ G ~-Q~~~ - "~ ! ~ f~ Tc~C~. ~~. ~', , o -_- ; - ~~~~tl ~ f~ ,'~ -, ~ ~~ ~. PROGRESS RECORD ~-- , , IC1!!~` Ir} ~ - ~ - ,_, ~-F_- ~ .-,.~.~ ~ t ~ ~ i~ ~ , _ _,_ ~, ~-- n~ yf~ _ J 7 ~" ~ ~..r,-_! s1-L-r4 ~ (^vt P~ C Cam'-'4~iCi.~ lo~tl~2 tl~l~rct~ ~ -~-~- /ff~ ~ ~/ rt r~~ ~- /Y10~ /1Li~tW ~. r~/ .rL~6 - -- -- -- -~"'^~~~rZ-GNIA/'~~ C wu. ~ _yu.~.ri.* v c / ~ ~ wubecc~. ~ •Ac 4~ Ounla- : f vt- Iru...~.~~t~. ~~~~ J C~ t ~k. s « G ~, ds. ~a ~ ~ - o'Y ~ G Jc~~ ~~ o ~ y(ar • ~i .. r•coA~.e~/'~it gyn.. "f ~I ! 1 .1 11 ~-- I - ~~~ .~ ^'. ~; Q iZ S f~~..a.~~ r~l - ----- ---- -- c. ~.', ______ ._ ~___ -- ~ ~c_ V ~~ -~-r..t~-l~ j' ~~~~ ~ _~. r -~ ~~ ' ~... ~ .. ~; t - e ,, ` ~-, " : ~; 4°Y ~ .. w-~~ -~ ~ r, ,~ ~-2.. ~~ ~..i ~.u.s _~ Y ~ `~~ r ~ J ~ w i Provided courtesy of Mead Johnson Nutritionals, maker of Enfamil°, ProSobee~, NutramigenQ, Pregestimil~, Poly-Vi-Flom', and Tempra'~. L-B 10-3-69 rl l~~m~~ ~ ~ ~ ~ f ~ ( ~ ~ F a ~ ~ ~-; x~ ~ + r ~, ~,<~ ~-w " *`Pl~~~irt~~t~i~` ~1 d~ ~ Y. i ;, - ~ ~ ~ ~ I ~}''~ k ~, ~' b t A I M e~ Cx ~x ~', 3~ +. :~ 1~,rF'~t; S.-S.~ 4 F _ f tk~ K+rt•'p~5 '!'~ r ~ N ~ °iF I f ~ IENERA( FI-p8 --- _ POSE (,~- 1'HROA7 ~~,~-_ ' V ~ HEART ~' ` .~ ~ c ' -~ up a~ ~ ~ ~ ExrREM _ lEURO. ~~ - ~~ ~ ° ~ jICIN / a iMP .~1 Pt.~IN: C~-(c ~ '~' S ~ I C ~ vu C ~ ~,Ry ~_~ r .. rill. / ~ J~ ,~ ~~ N "~ Na,,,c: ~ ~2 i .~ J ~ c~. I h ~ ~ rr, ~ c~ ~ ,s f ~Y Date: -I ~ ~ " ~ ~ Ht. ~ I~ ~~~+ Wt ~ C~ ~ ~y t o Interval History ,,.~L~~~ ~,~, ~e1~~ Psychosocial School -- ~ ~~~~~ Family relationships ~ 1~ 2 ~S~ Pc~~ -5 ~ ~ _ ~,.~1~ . Illness/injury/surgery Peer relationships C~~-- ~b`~~ -~leds Health maintenance Dentist I~ ~ i n tcs~ (, ~ Vision O' Zo~ZO o tom. ~' Hearing ~ P c~,,,,so-~-.,. 6eU. . Concerns ~~ I' 9yrs. Date: Interval History School lllnesslinjurylsurgery Meds Health maintenance Dentist ^ Vision ^ Hearing ^ Concems Activities / interests S G cCe.(Z ~~- _ Mood r' ~ a Appetite /Sleep f g~ 1 ~ ~ Ja.~c~ dK I a(~ ~~~ _ Television ~,~ _ Ht. Wt Psychosocial Family relationships Peer relationships DCO: ~ I - ~ _ ~:~ I B.P.. ~ ~`~'/Cj~ Allergies ~ PV rC ~~~ pE. /Normal J Abnormal ^ Gen. App. C~l'`feeth ^'Ext. O' Head C]-Neck ^'Neuro O~ Eyes C3'tungs ~ Skin O- Ears (3'Fieart Q- Back O- Nose 0" Abdom en ^" Throat l3'G. U. C~ Cofiments Impression \~~C t x-l ~~ o CC Treatment f Follow- ~'1Cv-~j, ~ItG. . B.P.. PE. J Normal c Allergies Abnormal ^ men. App. ^ Teeth ^ G. U. O -lead ^ Neck ^ Tanner stage =yes ^ Chest ^ Ext. O =ars ^ Lungs ^ Neuro ^ Vose ^ Heart O Skin O throat ^ Abdomen ^ Back ^ ,omments Activities /interests Mood Impression Appetite / 51eep Television Treatment ~~ lr~a~-4 ; o ~~~! f (J`p U N ~ k~ ~/i ~ ~ ~ 1f1 _ ~_ , L ~L tom- ~,, .d _ - -` i `~ i ~ - -- _ _.~_ - - - - --".. ~. r . hb `M~ --- ~~--~------ _._. _.,.._. r i ------- T•Hff<~~i ~ - --- ---- __ . _._. _~.y ~- ~ ' - - - - fir4:K F, F.;, FiT r-.5~. ____ - .. _ ..--- _~ld ~~rjJ~tl'3• ~ _~ i _.}_ _i _ ------ _...._. ,. . !~O ~'~ J ~~ ,' n -. 7 ~ Cl L '~lw S ~- ~a~ 1~G c VV? ~~- l3 MT a~ ~~ k a Provided courtesy of Mead Johnson Nuiriiionals, maker of Enfamili9, ProSobee~', Nutramigen®, Pregestimiim, Poly-Vi-Flor®, and Tempra®. t_-eto-3as x ~~ ~ 31~f 1^", . ~aRL PE~'~ FtiX ND. . ;'17243ETD8 ^'3u. ~5 ~©05 @4: 43r^M ~2 CARLISLE PEDIATRIC ASSOCIATES A PROFESSIONAL CORPORATION STEPHEN J. KREBS, M,n. HOLLY C. HOFFMAN, M,D. J. LYNN HOFFMAN, M.D, ELISEO ROSARIO, JR., M.D. DEBORAH RAUBENSTINE, M.D. ELENA MAh1, M.D. DfANNA RUDY, pA-C 804 BELVEDERE STREET, CARLISLE. PA 17013 May 25, 2U0G 243-194;3 To Whom It May Concern.: R.c. S~unucl Talhelzu, UOB 9-I 5-97 Paige 'falhcln~, D013 11-2-91 Jack Talhelm ).)UB 1-10-99 'i'bis lettex serves to document that all rnedicnl issues related te- the .motor vohicle accident in which these children were invnlvrd oII 6=3t~-200# have icsolvcd ar have concluded treatment. Jack and Sam were cleared ~n their initial I:ollow-up visit here on 7-5-OS. Paige req>Jircd multiple visits for dressing changes and wound care for her right arm, bu.t her injwy healed by August 2005 and she has needed no furth~7 treatment related to this injury sna.ce that time. All childrelt are now Tared from their medical injuries in reference to the ahc~ve accident. Thank you. With Regards, r~ T ~:~ , Holly C. Hoffinan MD _r~ .. ~.~.~- MICHELE POSSENTI AND KEVIN TALHELM AS PARENTS AND NATURAL GUARDIANS OF PAIGE TALHELM, A MINOR, JACK TALHELM, A MINOR AND SAMUEL TALHELM, A MINOR IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNA. DOCKET NO: ~'Y - j'1'GS L~. t v ~ C,~~/Lh-~ Plaintiffs v. VICTOR YANTAS LEON Defendant . ORDER AND NOW, this ~ ~ day of A~ ~ - , 2007, upon consideration of the Petition for Approval of Minor's Settlement, it is hereby ordered and decreed that the Petitioners, as parents and natural guazdians of Paige Talhelm aze authorized to enter into a settlement in the gross sum of $10,000. Petitioners are authorized to sign a release and mazk the matter settled, discontinued and ended as to the above Defendant. The settlement amount shall be distributed as follows: TO: Michele Possenti and Kevin Talhelm, as Pazents and Natural Guardians of Paige Talhelm, to be deposited into a restricted federally insured account, "No l~thdrawals Prior to Age 18, without prior court approval. " TOTAL AMOUNT FOR DISTRIBUTION ,~ 10,000 Counsel shall provide to this Court, within 30 days of the date of this ORDER proof of such deposit. BY THE COURT: Ex~~~3~T VIT COMMONWEALTH OF PENNSYLVANIA ss COUNTY OF CUMBERLAND . Michelle Possenti, parent and natural guardian of Paige Talhelm, a minor, is over twenty-one (21) years of age, and being duly sworn according to law deposes and says: 1. I hereby understand and agree that Paige Talhelm has recovered from the injuries she sustained in the accident of June 26, 2005, except for possible scar revision in the future. 2. I read all of the foregoing and fully understand same and affix my signature hereto under oath as a free, voluntary, and uncoerced act and deed. 3. I approve of the proposed settlement because, under the circumstances, I consider it fair and reasonable compensation for my daughter, Paige Talhelm, for whom I am the parent and natural guardian. 4. It is further understood and agreed that once the Court has approved the settlements as outlined in this petition, no further claim can be made against Nationwide Insurance Company for any of the injuries sustained by minor, Paige Talhelm, whether now known or unknown, including any and all claims for past and/or future medical expenses. '? .c_ ~~ ~'~ i~ 1Vfl"chelle Possenti, parent and natural guardian of minor Paige Talhelm ~ Date: ~~ ~- -Q'~ COMMONWEALTH OF .PENNSYLVANIA Sworn to and S bscribed NOTARIAL SEAL Befor me this~day DARCIE A. NElL, Motary Public of L- , 2007. Boro of Carlisle, Cumberland County My Commission Expires Nov. 24, 200 Not~n~9t~blic ~x~1~3iT ID~-~"IT COMMONWEALTH OF PENNSYLVANIA ss COUNTY OF CUMBERLAND Kevin Talhelm, parent and natural guardian of Paige Talhelm, a minor, is over twenty-one (21) years of age, and being duly sworn according to law deposes and says: 1. I hereby understand and agree that Paige Talhelm has recovered from the injuries she sustained in the accident of June 26, 2005, except for possible scar revision in the future. 2. I read all of the foregoing and fully understand same and affix my signature hereto under oath as a free, voluntary, and uncoerced act and deed. 3. I approve of the proposed settlement because, under the circumstances, I consider it fair and reasonable compensation for my daughter, Paige Talhelm, for whom I am the parent and natural guardian. 4. It is further understood and agreed that once the Court has approved the settlements as outlined in this petition, no further claim can be made against Nationwide Insurance Company for any of the injuries sustained by minor, Paige Talhelm, whether now known or unknown, including any and all claims for past andlor,,future medical expenses. ~ ~~~ evin Talhelm, parent and natural guardian of minor Paige Talhelm Date: - 16_L,~ ~~ Sworn to and Su cribed Befo e me this ~~ day of ~ , 2007 ,~ Not ublic COMMONWEALTH OF pENNSYLVANiA NOTAR SEAL DARCfE A. NE4L, Notary Public Boro of Carlisle, Gumberlar!d County My Commission Expires Nav. 24, 2009 nu slAie ivs~~~ soc-z?2 oso eoii ne cvaFu ~x~li3iT 07HB-00041 LA~V OFFICE OF SNYDER & DORER 214 SENATE AVENl1E, SUITE 503 CAMP HILL, PA 17011 TELEPHONE NUMBER: (717) 731-0988 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MICHELLE POSSENTI AND KEVIN TALHELM, INDIVIDUALLY AND AS PARENTS AND No. NATURAL GUARDIANS OF PAIGE TALHELM, A MINOR, Petitioners VS. NATIONWIDE MUTUAL INSUARANCE COMPANY, Respondent I1V We, Michelle Possenti and Kevin Talhelm, parents and natural guardians of Paige Talhelm, a minor, do hereby join in the Petition of Nationwide Insurance Company for Court Approval of Minor's SettlementlCompromise. Michelle Possenti, pazent and natural guardian of minor plaintiff, Paige Talhelm Date: ~ ~~ ~ ~~ ~ ~, ~ ., 7 Kevin Talhelm, parent and natural guardian of minor plaintiff, Paige Talhelm Date: ~ / ~ G' RELEASE AGREEMENT This Release Agreement ("Agreement") is entered into among Paige Talhelm, a minor, by her parents and natural guardians, Micheile Possenti and Kevin Talhelm, Michelle Possenti and Kevin Talhelm, individually (hereinafter collectively referred to as "the Parties"). The "Insured" shall mean Michelle Possenti, her, respective heirs, executors, administrators, personal representatives, successors and assigns; and the "Insurance Company" shall mean Nationwide Insurance Company of America, its successors and assigns. I. RECITALS A. On or about June 26, 2005, at or near Interstate 80, Sacramento, Sacramento County, California, Paige Talhelm sustained personal injuries as a result of an automobile accident (hereinafter referred-tows tfe "Occurrence"). In connection with the Occurrence; the Insured has asserted a claim against Nationwide Insurance Company of America. B. The Parties desire to enter into this Agreement to provide, among other things, for certain payments in full settlement and discharge of all claims and actions of the Insured for damages arising out of or due to the Occurrence, on the terms and conditions set forth herein. NOW THEREFORE, it is hereby agreed as follows: II. UNDERINSURED MOTORIST RELEASE AGREEMENT Know all men by these presents: That, for sole consideration of the promise to :rake the periodic payment referred to in Subparagraphs IV.A.(1) and (2) from the Insurance Company, the Insured in her capacity as an insured does hereby forever release and discharge the Insurance Company of and from all claims of whatsoever kind and nature prior to and including the date hereof growing out of the Underinsured Motorist Coverage of an Automobile Insurance Policy number 5837 D 690193 issued by the Insurance Company to Michelle Possenti, and resulting from the Occurrence. III. INJURIES KNOWN AND UNKNOWN The Insured fully understands that the Insured may have suffered personal injuries that are unknown to the Insured at present and that unknown complications of present known injuries may arise, develop or be discovered in the future, including, but not limited to, subsequent death or disability. The Insured acknowledges that the consideration received under this Agreement is intended to and does release and discharge the Insurance Company for any claims for, or consequences arising from, such injuries and the Occurrence; and the Insured hereby waives any rights to assert in the future any claims not now known or suspected even though, if such claims were known, such knowledge would materially affect the terms of this Agreement. IV. PAYMENTS TO INSURED A. Periodic Payment. The Insurance Company hereby agrees to pay or cause to be paid the following Periodic Payment: (1) To Paige Talhelm ("Payee") the following guaranteed lump sum payment: Seventy Nine Thousand Nine Hundred Forty Six and 08/100 Dollars ($79,946.08) to be paid on or about November 12, 2013. (2) Should Paige Talhelm die before November 12, 2013, then the remaining guaranteed payment set forth in Subparagraph IV.A.(1) shall instead be paid, subject to the provisions of Subparagraph IV.A. (3) below, as it becomes due, to the estate of Paige Talhelm ("Beneficiary"), with the last guaranteed payment to be made on or about November 12, 2013. (3) Paige Ta!he!m sha!I ha~~e the right, after reaching .the age of majority, to submit a request to change the Beneficiary by filing a written request with the owner of the annuity. This request will be reviewed by the owner of the annuity, and if approved by the owner of the annuity and the issuing annuity company it will become effective. Said request will be made in writing by Paige Talhelm. C. Nature of Payments. All sums set forth in this Paragraph IV constitute damages on account of personal injuries or sickness, arising from the Occurrence, within the meaning of Section 104(a)(2) of the Internal Revenue Code of 1986, as amended. 2 V. FINANCING OF PERIODIC PAYMENT OBLIGATION A. Assignment of Obligation. It is understood and agreed by and between the Parties hereto that the Insurance Company may, as a matter of right and in its sole discretion, assign its duties and obligations to make such future payments as set forth in Subparagraphs IV.A.(1) and (2) to Hartford Comprehensive Employee Benefit Service Company ("Assignee") pursuant to a "Qualified Assignment and Release," within the meaning of Section 130(c) of the Internal Revenue Code of 1986, as amended, attached as Exhibit A. When the Periodic Payment obligation is assigned to Hartford Comprehensive Employee Benefit Service Company, Hartford Life Insurance Company and Hartford Life, Inc. have represented that they will provide written guarantees of such obligation. Such assignment is hereby accepted by the Insured without right of rejection and in full discharge and release of the duties and obligations of the Insurance Company and all Parties released by this Agreement with respect to such future payments. If the Insurance Company assigns the duties and obligations as provided herein, it is understood _and_ agreed by and_._ between the Parties that Hartford Comprehensive Employee Benefit Service Company, as the Assignee, shall make said future payments directly to the respective Payees designated in Subparagraphs IV.A.(1) and (2). The Parties expressly understand and agree that, with the Insurance Company's assignment of the duties and obligations to make such Periodic Payment to Hartford Comprehensive Employee Benefit Service Company pursuant to this Agreement, all of the duties and responsibilities otherwise imposed upon the Insurance Company by this Agreement with respect to such Periodic Payment shall cease, and instead such obligation shall be binding solely upon Hartford Comprehensive Employee Benefit Service Company. The Parties further understand and agree that when the assignment is made, the Insurance Company shall be released from all obligations to make such Periodic Payment and Hartford Comprehensive Employee Benefit Service Company shall at all times be directly and solely responsible for, and shall receive credit for, the Periodic Payment, and that when the assignment is made, Hartford Comprehensive Employee Benefit Service Company assumes the duties and responsibilities of the Insurance Company with respect to such Periodic Payment. B. Third Party Pavment. It is further understood and agreed by the Parties that all future Periodic Payments as set forth in Subparagraphs IV.A.(1) and (2) may, solely at the option of the Insurance Company, or its Assignee, Hartford Comprehensive Employee Benefit Service 3 t. Company, be financed by the purchase of an annuity contract (the "Annuity Contract") from Hartford Life Insurance Company (the "Annuity Issuer"). When such an Annuity Contract is purchased, the Assignee, Hartford Comprehensive Employee Benefit Service Company, shall be the owner of the Annuity Contract and shall have and retain all rights of ownership in the Annuity Contract. For its own convenience, the Assignee shall direct Hartford Life Insurance Company to make all Periodic Payments directly to the respective Payees designated m Subparagraphs IV.A.(1) and (2). Such payments will be applied against the obligation of the Insurance Company or its Assignee and shall operate as a pro tanto discharge of the scheduled obligations set forth in this Agreement. C. Status of tnsured. The Insured shall, at all times, remain a general creditor of the Insurance Company or its Assignee and shall have no rights in the Annuity Contract nor in any other assets of the Assignee. The Insurance Company or its Assignee shall not be required to set aside sufficient assets or secure its obligation to the Insured. in any manner whatsoever. The Insured acknowledges that the Insured has no right to receive the present value of the payment due the Insured pursuant to Subparagraphs IV.A.(1) and (2), or to control the investment of, or accelerate, defer, increase or decrease the amount of any payment required to be made to the tnsured. The Insured shall only be entitled to receive the payments specified in Subparagraphs IV.A.(1) and (2), as they are due. Vl. NO CHANGES IN FUTURE PAYMENTS Neither Paige Talhelm, her estate, nor any subsequent beneficiary or recipient of the payment or any part of the payment under this Agreement, shall have the right to, and may otherwise be prohibited or restricted under applicable law to accelerate, commute, or otherwise reduce to present value or to a lump sum the payment or any part of the payment due under this Agreement. Neither Paige Talhelm, her estate, nor any subsequent beneficiary or recipient shall have the right to transfer, assign, anticipate, mortgage, or otherwise encumber in advance any payments or any part of any payments due under this Agreement. Any transfer of the periodic payments by the Insured may subject the Insured to serious adverse tax consequences. 4 VII. ADEQUATE CONSIDERATION The Insured agrees and acknowledges that the Insured accepts payment of the sums that the Insured is to receive pursuant to this Agreement as a full, complete, final and binding compromise of matters involving disputed issues regardless of whether too much or too little may have been paid. VIII. ENTIRE AGREEMENT This Agreement contains the entire agreement between the Insured and the Insurance Company with regard to the matters set faith herein. There are no other understandings or agreements, verbal or otherwise, in relation thereto, between the Parties except as herein expressly set forth. IX. READING OF AGREEMENT In entering into this Agreement, the Insured represents that the Insured has completely read all terms hereof and that such terms are fully understood and voluntarily accepted by the Insured. X. FUTURE COOPERATION All Parties agree to cooperate fully, to execute any and all supplementary documents and to take all additional actions that may be necessary or appropriate to give full force and effect to the terms and intent of this Agreement which are not inconsistent with its terms. XI. DRAFTING OF DOCUMENT AND RELIANCE BY INSURED The Insured warrants, represents and agrees that the Insured is not relying on the advice of the Insurance Company, or anyone associated with them as to the legal and income tax or other consequences of any kind arising out of this Agreement. Accordingly, the Insured hereby releases and holds harmless the Insurance Company, and any and all counsel or consultants for them from any claim, cause of action or other rights of any kind which Insured may assert because the legal, income tax or other consequences of this Agreement are other than those anticipated by the Insured. 5 The undersigned, and each of them, warrant and represent that no promise, inducement or agreement not herein expressed has been made to them and that this Agreement constitutes the entire agreement between the Parties hereto and that the terms of this Agreement are contractual and not mere recitals. The undersigned, and each of them, have read the foregoing Agreement and fully understand it, and have been advised by counsel of their own choosing as to the propriety and legal effect of executing the same, and neither the Agreement nor the compromise and settlement recited herein were induced by fraud, coercion, compulsion or mistake, nor is this Agreement nor the compromise and settlement made by the undersigned in reliance upon any statement or representation of any of the Parties hereby released, or their representatives, agents or attorneys. XII. COURT APPROVAL The Parties agree that the Insured will file petitions for all necessary court approvals, that all such petitions and orders shall be in a form satisfactory to all Parties, and that this Agreement will not be effective until such approvals have been obtained. XIII. CONTROLLING LAW This Agreement shall be construed and interpreted in accordance with the laws of the Commonwealth of Pennsylvania. 6 XIV. SIGNATURES This Agreement may be executed in counterparts, each of which shall be deemed to be an original and all of which shall be deemed to constitute one and the same document. }, Dated: '~~~ /.- ~ ~f /%lf ~ .' ',;~ ~ ` %~ `~ 'y"~ `f-' Micheife Possenti, individually, and as parent and natural guardian of Paige Talheim, a minor, Insured to . 7~2 ~~~'~ " ~ i~---C,/~~- ~a d Kevin Talheim, individually, and as parent and nati~rai guardian of Paige Talheim, a minc-r, Insured Dated: X r c~ ~ ~ ~~l,Q-+~'t,?~;rn _ 1 1 I ~ : _~l~l. ~ t:t~Y Duffy Authorized Representative for Nationwide Insurance Company of America__ _ APPLICABLE 1'O PENNSYLVANIA ONLY: Igor your protection, Pennsylvania requires the following to appear on this form: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. 7 V r I O7HB00041 LAW OFFICE OF SNYDER & DORER 214 SENATE A~'ENl'E, SGITE 503 CAMP HILL, PA 17011 TELEPHONE NU'.~1BER: (717) 731-0988 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MICHELLE POSSENTI AND KEVIN TALHELM, INDNIDUALLY AND AS PARENTS AND NATURAL GUARDIANS OF PAIGE TALHELM, A MINOR, Petitioners VS. NATIONWIDE MUTUAL INSUARANCE COMPANY, Respondent No. TIFICATE OF JoAnne E. Kinzel, Esquire, hereby certifies that she is the attorney for the Respondent herein, and that she caused a true and correct copy of the attached Petition for Leave to Compromise Minors' Claim to be served by regular first class mail upon: Michele Possenti 113 Woodview Drive Mount Holly Springs, PA 17065 Kevin Talhelm 7 Todd Road Carlisle, PA 17013 1( ,~ ~~~, Date:_ August 17, 2007 ~nne E. Kinzel, Esquire Attorney for Respondent 07HB00041 L.~W OFFICE OF StiYDER & DORER 214 SEti.-ATE A~'E~CE, SL;ITE 503 C:1~IP HILL, P~ 17011 TELEPHONE NGIIBER: (717) 731-0988 IN THE COURT OF COMMON PLEAS CL'AIBERLAND COUNTY, PENNS~'LVANIA MICHELLE POSSENTI AND KEVIN TALHELM, INDIVIDUALLY AND AS PARENTS AND NATURAL GUARDIANS OF PAIGE TALHELM, No. 07-4940 Civi( Term A MINOR, Petitioners VS. NATIONWIDE MUTUAL INSUARANCE COMPANY, Respondent OF (;OURT AND NOW, this ~=day of ltidw. , 2008 this Court's Order of August 23, 2007 approving settlement of the m nor's claim shall be amended as follows: Pursuant to the attached "RELEASE AGREEMENT", a copy of which is attached hereto and incorporated herein by reference, the minor, Paige Talhelm, shall receive the guaranteed sum of $79,946.08 to be paid on or about November 12, 2013, the occasion of her 22"d birthday. Said guaranteed lump sum payment of $79,946.08 has been funded by an initial investment by Nationwide Mutual Insurance Company of $60,000.00 pursuant to the agreement between the minor's parents and Nationwide Mutual Insurance Company as set forth in the Petition for Leave to Compromise Minor's Claim. The lump sum payment shall be made in accordance with the terms and conditions of the attached "RELEASE AGREEMENT" BY THE COURT: ~~ ~ ~~ ~ ~~,t~ i,~ >'i ~f~~ 'E ~_.. ~1~~~t~- ~INf~~ ~ ~ ~~ d ~ - a~~ BQDZ ~~f~~~~~ RELEASE AGREEMENT This Release Agreement ("Agreement") is entered into among Paige Talhelm, a minor, by her parents and natural guardians, 1~1ichelle Possenti and Kevin Talhelm, ~,lichelle Possenti and Kevin Talhelm, individually (hereinafter collectively referred to as "the Parties"). The "Insured" shall mean Michelle Possenti, her, respective heirs, executors, administrators, personal representatives, successors and assigns; and the "Insurance Company" shall mean Nationwide Insurance Company of America, its successors and assigns. I. RECITALS A. On or about June 26, 2005, at or near Interstate 80, Sacramento, Sacramento County, California, Paige Talhelm sustained personal injuries as a result of an automobile accident (hereinafter referred to as the "Occurrence"). In connection with the Occurrence, the Insured has asserted a claim against Nationwide lnsurance Company of America. B. The Parties desire to enter into this Agreement to provide, among other things, for certain payments in full settlement and discharge of all claims and actions of the Insured for damages arising out of or due to the Occurrence, on the terms and conditions set forth herein. NOW THEREFORE, it is hereby agreed as follows: I1. UNDERINSURED MOTORIST RELEASE AGREEMENT Know all men by these presents: That, for sole consideration. of tha promise to make the periodic payment referred to in Subparagraphs IV.A.(1) and (2) from the Insurance Company, the Insured in her capacity as an insured does hereby forever release and discharge the Insurance Company of and from all claims of whatsoever kind and nature prior to and including the date hereof growing out of the Underinsured Motorist Coverage of an Automobile Insurance Policy number 5837 D 690193 issued by the Insurance Company to Michelle Possenti, and resulting from the Occurrence. III. INJURIES KNOWN AND UNKNOWN The Insured fully understands that the Insured may have suffered personal injuries that are unknown to the Insured at present and that unknown complications of present known injuries may arise, develop or be discovered in the future, including, but not limited to, subsequent death or disability. The Insured acknowledges that the consideration received under this Agreement is intended to and does release and discharge the Insurance Company for any claims for, or consequences arising from, such injuries and the Occurrence; and the Insured hereby waives any rights to assert in the future any claims not now known or suspected even though, if such claims were known, such knowledge would materially affect the terms of this Agreement. IV. PAYMENTS TO INSURED A. Periodic Payment. The Insurance Company hereby agrees to pay or cause to be paid the following Periodic Payment: (1) To Paige Talhelm ("Payee") the following guaranteed lump sum payment: Seventy Nine Thousand Nine Hundred Forty Six and 08/100 Dollars ($79,946.08) to be paid on or about November 12, 2013. (2) Should Paige Talhelm die before November 12, 2013, then the remaining guaranteed payment set forth in Subparagraph IV.A.(1) shall instead be paid, subject to the provisions of Subparagraph IV.A. (3) below, as it becomes due, to the estate of Paige Talhelm ("Beneficiary"), with the last guaranteed payment to be made on or about November 12, 2013. (3) Paige Ta!he!m shall ha~~u the right, after reaching .the age of majority, to submit a request to change the Beneficiary by filing a written request with the owner of the annuity. This request will be reviewed by the owner of the annuity, and if approved by the owner of the annuity and the issuing annuity company it will become effective. Said request will be made in writing by Paige Talhelm. C. Nature of Payments. All sums set forth in this Paragraph IV constitute damages on account of personal injuries or sickness, arising from the Occurrence, within the meaning of Section 104(a)(2) of the Internal Revenue Code of 1986, as amended. 2 V. FINANCING OF PERIODIC PAYMENT OBLIGATION A. Assignment of Obligation. It is understood and agreed by and between the Parties hereto that the Insurance Company may, as a matter of right and in its sole discretion, assign its duties and obligations to make such future payments as set forth in Subparagraphs IV.A.(1) and (2) to Hartford Comprehensive Employee Benefit Service Company ("Assignee") pursuant to a "Qualified Assignment and Release," within the meaning of Section 130(c) of the Internal Revenue Code of 1986, as amended, attached as Exhibit A. When the Periodic Payment obligation is assigned to Hartford Comprehensive Employee Benefit Service Company, Hartford Life Insurance Company and Hartford Life, Inc. have represented that they will provide written guarantees of such obliga±ion. Such assignment is hereby accepted by the Insured without right of rejection and in full discharge and release of the duties and obligations of the Insurance Company and all Parties released by this Agreement with respect to such future payments. If the Insurance Company assigns the duties and obligations as provided herein, it is understood and .agreed by and. between the Parties that Hartford Comprehensive Employee Benefit Service Company, as the Assignee, shall make said future payments directly to the respective Payees designated in Subparagraphs IV.A.(1) and (2). The Parties expressly understand and agree that, with the Insurance Company's assignment of the duties and obligations to make such Periodic Payment to Hartford Comprehensive Employee Benefit Service Company pursuant to this Agreement, all of the duties and responsibilities otherwise imposed upon the Insurance Company by this Agreement with respect to such Periodic Payment shall cease, and instead such obligation shall be binding solely upon Hartford Comprehensive Employee Benefit Service Company. The Parties further understand and agree that when the assignment is made, the Insurance Company sha{I be released from all obligations to make such Periodic Payment and Hartford Comprehensive Employee Benefit Service Company shall at all times be directly and solely responsible for, and shall receive credit far, the Periodic Payment, and that when the assignment is made, Hartford Comprehensive Employee Benefit Service Company assumes the duties and responsibilities of the Insurance Company with respect to such Periodic Payment. B. Third Party Payment. It is further understood and agreed by the Parties that all future Periodic Payments as set forth in Subparagraphs IV.A.(1) and (2) may, solely at the option of the lnsurance Company, or its Assignee, Hartford Comprehensive Employee Benefit Service 3 Company, be financed by the purchase of an annuity contract (the "Annuity Contract') from Hartford Life Insurance Company (the "Annuity Issuer"). When such an Annuity Contract is purchased, the Assignee, Hartford Comprehensive Employee Benefit Service Company, shall be the owner of the Annuity Contract and shall have and retain all rights of ownership in the Annuity Contract. For its own convenience, the Assignee shall direct Hartford Life Insurance Company to make all Periodic Payments directly to the respective Payees designated in Subparagraphs IV.A.(1) and (2}. Such payments will be applied against the obligation of the Insurance Company or its Assignee and shall operate as a ro tanto discharge of the scheduled obligations set forth in this Agreement. C. Status of Insured. The Insured shall, at all times, remain a general r.reditor of the Insurance Company or its Assignee and shall have no rights in the Annuity Contract nor in any other assets of the Assignee. The Insurance Company or its Assignee shall not be required to set aside sufficient assets or secure its obligation to the. Insured in any manner whatsoever. The Insured acknowledges that the Insured has no right to receive the present value of the payment due the Insured pursuant to Subparagraphs IV.A.(1) and (2), or to control the investment of, or accelerate, defer, increase or decrease the amount of any payment required to be made to the Insured. The Insured shall only be entitled to receive the payments specified in Subparagraphs IV.A.(1) and (2), as they are due. VI. NO CHANGES IN FUTURE PAYMENTS Neither Paige Talhelm, her estate, nor any subsequent beneficiary or recipient of the payment or any part of the payment under this Agreement, shall have the right to, and may otherwise be prohibited or restricted under applicable law to accelerate, commute, or otherwise reduce to present value or to a lump sum the payment or any part of the payment due under this Agreement. Neither Paige Talhelm, her estate, nor any subsequent beneficiary or recipient shall have the right to transfer, assign, anticipate, mortgage, or otherwise encumber in advance any payments or any part of any payments due under this Agreement. Any transfer of the periodic payments by the Insured may subject the Insured to serious adverse tax consequences. 4 VI1. ADEQUATE CONSIDERATION The Insured agrees and acknowledges that the Insured accepts payment of the sums that the Insured is to receive pursuant to this Agreement as a full, complete, final and binding compromise of matters involving disputed issues regardless of whether too much or too little may have been paid. VIII. ENTIRE AGREEMENT This Agreement contains the entire agreement between the Insured and the Insurance Company with regard to the matters set forth herein. There are no other understandings or agreements, verbal or otherwise, in relation thereto, between the Parties except as herein expressly set forth. IX. READING OF AGREEMENT In entering into this Agreement, the Insured represents that the Insured has completely read all terms hereof and that such terms are fully understood and voluntarily accepted by the Insured. X. FUTURE COOPERATION All Parties agree to cooperate fully, to execute any and all supplementary documents and to take all additional actions that may be necessary or appropriate to give full force and effect to the terms and intent of this Agreement which are not inconsistent with its terms. XI. DRAFTING OF DOCUMtNT AND RELIANCE BY INSURED The Insured warrants, represents and agrees that the Insured is not relying on the advice of the Insurance Company, or anyone associated with them as to the legal and income tax or other consequences of any kind arising out of this Agreement. Accordingly, the Insured hereby releases and holds harmless the Insurance Company, and any and all counsel or consultants for them from any claim, cause of action or other rights of any kind which Insured may assert because the legal, income tax or other consequences of this Agreement are other than those anticipated by the Insured. 5 The undersigned, and each of them, warrant and represent that no promise, inducement or agreement not herein expressed has been made to them and that this Agreement constitutes the entire agreement between the Parties hereto and that the terms of this Agreement are contractual and not mere recitals. The undersigned, and each of them, have read the foregoing Agreement and fully understand it, and have been advised by counsel of their own choosing as to the propriety and legal effect of executing the same, and neither the Agreement nor the compromise and settlement recited herein were induced by fraud, coercion, compulsion or mistake, nor is this Agreement nor the compromise and settlement made by the undersigned in reliance upon any statement or representation of any of the Parties hereby released, or their representatives, agents or attorneys. XII. COURT APPROVAL The Parties agree that the Insured wi11 file petitions for all necessary court approvals, that all such petitions and orders shall be in a form satisfactory to all Parties, and that this Agreement will not be effective until such approvals have been obtained. XIII. CONTROLLING LAW This Agreement shall be construed and interpreted in accordance with the laws of the Commonwealth of Pennsylvania. 6 XIV. SIGNATURES This Agreement may be executed in counterparts, each of which shall be deemed to be an original and all of which shall be deemed to constitute one an/d the same document. Dated: ~~~--`~ I ` -~/%~j~ ~'/~ ~ `~ ;:' . - ;~ ~-, .._.. Michelle Possenti, individually, and as parent and natural guardian of Paige Talhelm, a minor, Insured Dated: 7~2 > f c" ~ l'~,''~- Kevin Talhelm, individually, and as parent and natural guardian of Paige T~Ihe{m, a minor, Insured Dated: ~~ i ~~ ~'y ~i"LC~Uti(.~n... 1 ' ' • ..~Ll. C.t1~} Duly Authorized Representative for Nationwide Insurance Company of America__ APPLICABLE TO PENNSYLVANIA ONLY: For your protection, Pennsylvania requires the following to appear on this form: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of mis{eading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.