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Home My WebLink About07-6713 Metzger, Wickersham, Knauss & Erb, P.C. By: Francis J. Lafferty, N, Esquire Attorney I.D. No. 84009 P.O. Box 5300 3211 North Front Street Hamsburg, PA 17110-0300 Attorneys for Plaintiffs (717) 238-8187 fj lna,mwke.com IN RE: ORPHAN'S COURT OF CUMBERLAND COUNTY, PETITION FOR APPROVAL OF PENNSYLVANIA SETTLEMENT OF THE CLAIM OF JOHN J. CHIARA, a minor, BY NO. ~ ~- L '2I ~ ~~ ~~~ JOHN S. CHIARA and JOAN CHIARA his parents and natural guardians PETITION FOR APPROVAL OF COMPROMISE AND SETTLEMENT OF MINOR'S CLAIM 1. Petitioners are John Chiara and Joan Chiara, parents and natural guardians of John J. Chiara, who was born on May 18, 1991, and who resides at 1320 Carlisle Road, Camp Hill, Cumberland County, Pennsylvania with his mother and father. 2. On January 12, 2007, John J. Chiara suffered personal injuries when he was involved in an automobile accident while a passenger in a vehicle driven by James Sipe. A copy of the police report of the accident is attached hereto as Exhibit "A". 3. John J. Chairs was transported by ambulance and air transport from the scene of the accident to Hershey Medical Center where he was treated for head, back, pelvis and hip pain. He was treated, kept overnight and released the next day. The emergency room records of the hospital are attached hereto as Exhibit "B." 384683_1.DOC 4. John J. Chiara had three additional follow-up visits at Hershey Medical Center for his injuries. He has since recovered from the injuries. Attached hereto as Exhibit "B" are medical records. 5. The Hartford, the liability insurance carrier for the driver, has offered $65,000.00 to settle the claim of John J. Chiara against Dennis and Sandra Sipe. Attached hereto as Exhibit "C" is a letter of October 5, 2007, from Ringler Associates advising settlement in the amount of $65,000.00. 6. All medical expenses up to $5,000.00 have been paid through John's parent's automobile insurance Policy with Motorist's, and private health insurer, Highmark Blue Shield. This is no lien being asserted in this matter. See letters attached hereto as Exhibit "D." 7. Petitioner has entered into a Contingent Fee Agreement with her attorney, Francis J. Lafferty, IV, Esquire, of the law firm of Metzger, Wickersham, Knauss & Erb, P.C. in the amount of twenty-five percent (25%), which fee agreement is attached hereto as Exhibit "E." The agreement also allows for reimbursement of expenses incurred by the law firm. 8. Counsel for Petitioners has incurred expenses in the handling of the claim as follows: Photocopies $68.40 Postage $28.33 Facsimile $5.00 Medical Records Costs $160.84 Filing Fee for Petition $78.50 Total Costs $341.07 384683-1 WHEREFORE, Petitioners respectfully request that this Honorable Court approve the settlement and authorize Petitioners to execute all necessary settlement agreements and releases. Respectfully submitted, METZGER, V~T~~ZSHAM, KNAUSS & ERB, P.C. By: Francis J. L erl~, IV'; Esquire Attorney I. . No. 84009 P.O. Box 5300 3211 North Front Street Harrisburg, PA 17110-0300 (717) 238-8187 Attorneys for Petitioners Dated: November (~, 2007 384683-1 VERIFICATION I, John S. Chiara, am the Petitioner and parent and natural guardian of the minor, John J. Chiara. I have read the forgoing Petition and agree with the contents thereof. I hereby certify that I join in the request for approval of the proposed settlement, which I have discussed with my son, John J. Chiara, and which we believe is reasonable and in the best interests of John J. Chiara. I hereby verify that the facts stated in the foregoing Petition are true and correct to the best of our knowledge, information and belief. I understand that the facts set forth in the Petition are made subject to the penalties of 18 Pa. C.S.A. §4904 relating to unsworn falsification to authorities. John S. Ca, as parent and natural guardian John J. Chiara Dated: ACS 3b ~ 384683-1 M VERIFICATION I, Joan Chiara, am the Petitioner and parent and natural guardian of the minor, John J. Chiara. I have read the forgoing Petition and agree with the contents thereof. I hereby certify that I join in the request for approval of the proposed settlement, which I have discussed with my son, John J. Chiara, and which we believe is reasonable and in the best interests of John J. Chiara. I hereby verify that the facts stated in the foregoing Petition are true and correct to the best of our knowledge, information and belief. I understand that the facts set forth in the Petition are made subject to the penalties of 18 Pa. C.S.A. §4904 relating to unsworn falsification to authorities. Jo C ara~ paarent and natural Qu di of John J. Chiara Dated: U 384683-1 ~xh~bli'/~ Print CRS W0049663 t t COf11~iUlOR1~4l~ALYO-0 O~ ~EBdR15YLlfAly' IA POLI~D: CRA50~ RE~ORYIAIG CORM Case dosed Reportable Crash AA~'S00 1 A Yes (~ No A'Yes n No Page 1 of 7 iuiiiauiiiou~uii ~~._.. -~ ~ ~w~~~ incident Plumber Police envy Patrol Zone ~ UAT20070100340 21104 ® g Agen Flame Prednct Investi anon Date (MM-DD-YYYY) _~ O1 - ]2 - 2007 hi All T U owns p pper en Dispatch Time (mil) Arrival Time (mii) Investigator Badge Plumber V 2007 2010 OFFICER B. SUNDAY 23-12 ~ Reviewer Bad a Plumber Approval Date (MM-DD-YYYY) 2313 O1 - 18 ~ 2007 P t J B d e er eau uy County County Flame RAunicipality Municipality Flame Q8v of bNeek s 2] Cumberland -~ 104 pper Allen Township O Sun O Thu ® Crash Date (MM-DD-WYY) Crash Time (mil) Flo of Units People Injured Killed° °If > 00 complete O Mon ~ Fri O Tue Q Sat 01 - 12 - 2007 2000 2 6 4 0 Form F O Wed O Unk Workzone (!f Yes, Complete O Yes ~ No School Bus O yes ~ No School Zone O Yes ®No form M, Section 29) Related Related Notify PEP1P1D0T0 Yes a No Maintenance s ~ ~ x 3 intersection Tvoe Multi•Leg ° ~ 4 Way Intersection O "Y" Intersection O O Off Ramp O Railroad Crossing Intersection 64l;dt14II 00 O Midblock O •T" Intersection O Traffic Circle/ ~ On Ramp O Crossover O Other Round About • 5mm Oy2Pla Route Plumber Segment (Optional) Travel Lanes Speed Limit O North House Plumber (if applicable) 02 45 ~ O south m Strea4 Flame Stree4 Ending ~ O East For Mid-biotic crashes onl Use Y~ a EAST LISBURN ~ o` ~ West O Unknown postal House Number and make sure Prindpal Roadway street Name is e filled in if using this option Interrtate ~ Tumpike Tumpike State County Local Road Private Other/ O O ~~ O O O ~ O O or Street Road Highway Road Unknown (Not Tumpike) (EasdNlest) Spur w Route Plumber 5e ment (Optional) Travel Lanes Speed Limit O North r . ___ S 02 35 _ M e South Street Flame Street Ending ~ O East e °-' O West ARCONA ~ o` O Unknown s ,~ ~ Q Interstate O Tumpike O Turnpike O State O County ~ Local Road O Private O Other/ ~ (Not Turnpike) (EastNVest) Spur Highway Road or Street Road Unknown Intersecting Rt Plum Or Mile Post Or Segment PAsrker Feet ~ ° O N h ~ ~ e E ~.~ ort O South 0 ~ Pl ~ Or Intersecting Street Flame St Ending ~ O East ~ ease Enter ~ ~ E O West Or Miles Information ~ ~ ^ 'O for BOTH ~ ~ e v Landmarks g if Using This Option Intersecting Rt Plum Or PAile Post Or Segment AAarker ^s ° ~ ~ A ~ O North Distance From Crash Scene to Landmark t ~ . O South ti x ~ ~ Or Intersecting Street !dame St Ending ~ O East (for Crash between Landmark 1 and ~ ~ ~ ~ O west Landmark 2) Degrees Minutes Seconds Degrees Minutes Seconds ~ latitude• Longitude: - TrafPc Control Device Police Officer or O Yield Sign O flagman O Not Applicable O Traffic Signal Alive RR Crossing O Other Type TCD ~ Tt~ ~^~OA!^o Device Functioning Emer en O No Controls O O Preemptive Improperly Si nal Controls O Flashing Traffic ~ Sto Sin Passive RR Signal p g O Crossing Controls O Unknown g Device Not Device Functioning O Functioning ~ Propedy O Unknown ~ L8n€~ (!f "Not Applipble `, skip rest of the Lane Closure section) lane closure O North O East O North and South Q All p O Not Applicable O Partially d Fully O Unknown O South O West ~ East and West (N,S,E,1N) e ICdl~tc Yes ~ No O D.CtQl(Led Unknown Q O < 30 Min. ~ 3D-60 Min. O 1-3 hrs O 3-6 hrs O 6-9 hrs O > 9 hours O Unknown Foma w iu-a~ f~amz) P~NNDOT COPY http://www.dot6.state.pa.us/icons/PrintImages/XmlFiles/20070035811 brillhart2398200701... 1 /19/2007 Print CRS W0049663 n r t ~®G1Sl1R~®~1~1¢1~.V1?9 ®I~ I~~f~Irb~~7~.l9A~99l~1 (~Od9~ (~~~6ra R~~®6~81l0~s ~®RRfil Page: ~00 2 Pdice Use Only ~ .~ Page 2 of 7 wiiiiiiiiirin ~~,~~ ~ W0049663 ° Motor Vehicle in O Hit & Run Vehicle O Illegally Parked O Legally Parked ONon -Motorized ~ Commercial Vehfde ~ Transport Type Un/t Pedestrian on Skates, Disabled From O Train O Phantom Vehicle O Pedestrian O O O Yes ®No C Previous Crash in Wheelchair, etc (If Ye; Complete Form C) ~ (If 'Pedestrian' or "Pedestrian on Skates, in Wheelchair, etc", Complete Form M, Section 28) Uni4 No First Name RAI Date of Birth (MM-DD-YYYY) O1 JAMES ~ 09 26 1989 Last Name Telephone Number Delete? O SIPE 7177379277 Address / G /State Zi 316 BLACKSMITH RD CAMP HILL PA 17011 Driver License Number State Class 28780834 PA Alcohol/Drugs Suspected Driver or Pedestrian Physical Condition ~ $ Ille al Dru s O Medication ~ No O 9 9 Apparently Illegal Drug Fati ue Medication ~ Normal O Use O g O ~ O Alcohol O Alcohol and Drugs O Unknown O Had Been O Sick Q Asleep O Unknown Drinkin a ~ Alcohol Test Type h O Oth i Primary Vehicle Code Violation Charged? u er ® Test Not G ven O Breat Q Blood O urine O Te t G ~n~f DUTIES AT STOP SIGNS a Yes O No s s y Alcoho/ Test Results O Test Refused O Resuh wn T t Gi Driver Presence 1=Driver Operated 3=Driver Fled Scene Vehicle 4=Hit and Run ven, es O O i d R tu ~ ~ C t ~ k ontam na e esu • 2=No Driver 9=Un nown OtaneNDriver OQ=Not Applicable 02=Private Vehicle Not 04=State Police Vehicle 07=Municipal Police Veh 09=federal Gov Veh 01=Private Vehicle Owned/ Owned/Leased by Driver 05=PENNDOT Vehicle 08=Other Municipal 9B=0ther 02 Leased by Driver 03=Rented Vehicle 06=Other State Gov Veh Government Vehicle 99=Unknown Same as Owner First Name Owner Last Flame or Business Name (!f Pedestrian, skip this Section) Driver ~ SANDR.A A SIPE Address / Gty 1 State /Zip Vehicle Wlake •RAalce Code 316 BLACKSMITH RD CAMP HILL PA 17011 Volkswagen 30 VIN NAodel Year Vehicle Rllodei (see overlay) 3VWTD81H6VM10299] 1997 ~ JETTA License Plate Reg. State Est. Speed Vehfde Towed Towed By GJS8359 PA 010 ~ Yes O No ZIMMERMANS AUTO Insurance Insurance Company Policy No a ~ Yes O No O known SENTINAL INS CO 1 39PH457637425498 Trailing T 1=Towing Pass. Veh 4=Mobile/Modular Home 7=Semi-Trailer Tag No Tag Year Tag St _ Unrt No. of ^ U~ ^ 2=Towing Truck S=Camper B=Other ~ a g °' 3=Towing Utility Trailer 6=Full Trailer 9=Unknown Unite Direction of ~ wVehide Position e T- 01 •R9ovement 01 *See O l Special Usage rav e ver ay Vehfde Color Vehicle Type 05=Large Truck 20=Unicycle, Bicycle, 00 12=Commercial Passenger 06=Yellow ~5 07=Silver 01=Automobile 06=5UV Tricycle ~1 02=Motor cle 07=Van Z1=Other Pedalcycle c 00=Not Applicable Carrier _ 08=Gold 01=Blue 09=Brown Y 03=Bus 10=Snowmobile 22=Horse & Buggy 04=Small Truck 11=Farm Equip Z3=Horse & Rider 01=Fire Veh 13=Taxi 02=Ambulance 21=Tractor Trailer 03=Police 22=Twin Trailer 02=Red 10=Orange (If "01°, Complete Form 12=Construction Equip 24=Train 08=Other Emergency 23=Triple Trailer 03=White 11=Purple M, Section 16) 13=ATV 25=Trolley Vehicle 31=Modified Veh 04=Green 12=Other 05=Black 99=Unknown 18=Other T Sec Veh 98=Other (d "20" or "11 ", Complete 19=Unk T ec Veh 99=Unknown peeS 11=Pupil Transport 99=Unknown . y p Form M, Section 17) lnftial Impact Point Damaoe indicator Gradient 3=Downhill Road Alignment 00=Non-Collision 14=Undercarria a 09 0 - 2 l i T d U i g k 5 O=None 2=Functional ~ 1=Minor 3=Disabling 4=Bottom of Hill ~ 1=Level S=Top of Hill 1=Straight ~ 2=Curved 1 1 =C Po nts 1 owe n t oc = 9 k U 2=Uphill k k 9 U 13=Top 99=Unknown = n nown 9=Un nown n nown = FORM M AA-500 (72/02) PENNDOT COPY http://www.dot6.state.pa.us/icons/PrintImages/XmlFiles/2007003 5 8 1 1 brillhart2398200701... 1 /19/2007 Print CRS W0049663 T r t: (ir®(~tIRA®rt~1~V11~ ~ ~fEf~R7~~7~l9~iR99l~ (~d8~~ 2~~~ 98~f;~~TBiYG ~®R~il Page: AA 500 2 ~~~ u~ oniy 3~ Page 3 of 7 mwiiii~~i ~_._r, ~ W0049663 o ~ Motor Vehide in rVne ~ Transport O Hit & Run Vehicle O Illegally Parked O Legally Parked ONon -Motorized Commercial Vehide Unit Pedestrian on Skates, Disabled From Q Train O Phantom Vehicle O Pedestrian O O O Yes ~ No ~ in Wheelchair, etc Previous Crash pf Yes, Complete Form C) (It 'Pedestrian' or 'Pedestrian on Skates, in Wheelchair, etc", Com lete Form M, Section 28) Unit No First Name Pfll Date of Birth (MM-DD-YYYY) 02 AARON S^ ] 0 28 1984 Last Name Tele hone Number Delete? O TRIMMER 7179437859 Address / Ci 1 State Zi t; 1537 MAIN ST MECHANICSBURG PA 17055 Driver License Plumber State Class 27524844 PA 6 ~ AlcohoUDruos Suspected Driver or Pedestrian Physical Condition ~ No Q Illegal Drugs O Medication ~ NoPmalntly O IUseal Drug O Fatigue O Medication ~ O Alcohol O Alcohol and Drugs O Unknown Had Been O Suk O Asleep Q Unknown O -~ Dunkin ~ •b p Alwhol Test Tyre ~ Test Not Given Q Breath O Other Primary Vehicle Code Violation Charged? y O Blood O Urine O Unknown if O Yes O No a Test Given ~ Alcohol Test Results O Test Refused Q Unknown Resuhs T t Giv Driver Presence 1=Driver Operated 3=Driver Fled Scene Vehicle 4=Hit and Run ~~ ~ O es en, Contaminated Results ~ 2=No Driver 9=Unknown Otnmer/Dritrer 00=Not Applicable 02=Private Vehicle Not 04=State Police Vehicle 07=Muniapal Police Veh 09=Federal Gov Veh Ot=Private Vehicle Owned! Owned/Leased by Driver 05=PENNDOT Vehicle 08=Other Municipal 98=Other 02 Leased by Driver 03=Rented Vehicle 06=Other State Gov Veh Government Vehicle 99=Unknown Same as Owner First Name Owner last Name or Business Flame (h` Pedestrian, skip this Section) Driver p CURRAN S TRIMMER Address /City /State /Zip Vehide PAake °Pflake Code 1540 MAIN ST MECHANICSBURG PA 170557055 Dodge 07 VIN Wlodel Year Vehicle Phodel (see overlay) 3B4GW12W6GM632770 1986 ~ RAM CHARGER License Plate Reg. State Est. Speed Vehide Towed Towed By GLA1662 PA 035 ~ Yes O No ZIMMERMANS AUTO Insurance Insurance Company Policy No o ~„ ~ Yes p No O un" USAA 0209832S3G71014 known s g ~ Trailing T 1=Towing Pass. Veh 4=Mobile/Modular Home 7=Semi-Trailer Tag No Tag Year Tag St ~ Unit No. of ~ U~ ~ 2=Towing Truck S=Camper B=Other (~ g d v 3=Towing Utility Trailer 6=Full Trailer 9=Unknown ~-J Units Direction of ~_ W ~ •Vehide Position O1 "INlovement 01 °S~ ~ ~ Speda/ Usage ra Overlay Vehide Color Vehide Tyne 05=Large Truck 20=Unicycle, Bicycle, 00 12=Commercial Passenger 06=Yellow 03 07=Silver 01=Automobile D6=5UV Tricycle cle 07=Van 21=Other Pedalcycle 06 02=Motorc 00=Not Applicable Carrier 08=Gold 01=Blue 09=Brown y 03=Bus 10=Snowmobile 22=Horse & Buggy 04=Small Truck 11=Farm Equip 23=Horse & Rider 01=Fire Veh 13=Taxi 02=Ambulance 21=Tractor Trailer 02=Red 1D=Orange (If "02", Complete Form 12=Construction Equip 24=Train 03=Police 22=Twin Trailer 08=Other Emergency 23=Triple Trailer 03=White 1 i=Purple M, Section 16) 13=AN 25=Trolley Vehicle 31=Modified Veh 04=Green 12=Other 05=Black 99=Unknown (!f "20" or "1J", Com lete 18=Other Type Spec Veh 98=Other p 19=Unk T ec Veh 99=Unknown e S 11=Pupil Transport 99=Unknown . yp p Form M, Section 27) lnitia! Impact Point Damage indiptor Gradient 3=Downhill Road Alignment 11 00=Non-Collision 14=Undercarriage 01-12 Cl k P i t 15 T i d U O=None 2=Functional a 1=Minor 3=Disabling 4=Bottom of Hill ~ 1=Level S=Top of Hill 1=Straight a 2=Curved = oc n o s = owe n t 9 U k 2=Uphill k k 13=Top 99=Unknown = n nown g=Un nown 9=Un nown FORM / M-500 (77!02) PENNDOT COPY http://www.dot6.state.pa.us/icons/PrintImages/XmlFiles/20070035811 brillhart23 98200701... 1 /19/2007 Print CRS W0049663 CORflAfl0611di/E~iLYI~I OF PEf~f~SYL!/~1RIIle~ POLICE CR~,SQ~ B3EPOItTlftl~s ~06tR11 Page AA 500 3 PoAce Use Only Page 4 0~ 7 uiiiiiiiii~ui Gash Number W0049663 Person Tvne: Q 1=Driver Seai Position: Safe~~uinmeni One: ; ~ OD=Not APassenger/Occupant E 00=None Used /Not Applicable ~j O=Not Applicable 2=Passenger 7=Pedestrian 8=Other Ot=Driver -All Vehicles 01=Shoulder Belt Used 1=Not Ejected 02=Front Seat Middle Position 02=Lap Bek Used 2=Totally Ejected 03=front Seat Right Side 03=Lap And Shoulder Belt Used 3=Partially Ejected 9=Unknown 04=Second Row -Left Side Or 04=Child Safety Seat Used 9=Unknown Motorcycle Passenger 05=Motortycle Helmet Used 05=Second Row -Middle Position 06=8i cle Helmet Used ~-'~ Election Path: 06=Second Row -Right Side 10=Safety Belt Used Improperly ® ~~Female B M=Male O=Not Ejected /Not Applicable 07=Third Row Or Greater - 11=Child Safety Seat Used Improperly Left Side 12=Helmet Used Improperly 1=Through Side Door Opening 2=Through Side Window a a U =Unknown 08=Third Row Or Greater - 90=Restraint Used, Type Unknown Middle Position 99=Unknown 3=Through Windshield ~ C r~y Severrtv: 09=Third Row Or Greater - 4=Through Back Door Right Side Safety Eouioment Two: S=Through Back Door Tailgate Opening p F 00=None Used /Not Applicable 6=Throw h Roof 0 ping (sunroof/ 10=51ee er Section of Truckcab rt D e ~ ~ O=Not Injured 1=Killed Conve ible Top own) 11=1n Other Enclosed 01=front Air Bag Deployed (For This Seat) 7=Through Roof Opening (Convertible Passenger Or Cargo Area 02=Side Air Bag Deployed (For This Seat) Top Up) e ~ 2=Major Injury 3=Moderate 12=1n Open Area 03=Other Type Air Bag Deployed (Back Of Pickup, Etc.) 04=Multiple Air Bags Deployed 9=Unknown Injury 4=Minor Injury B=Injury, Unk 13=Trailing Unit 05=Motorcycle Eye ProtecGOn 14=Riding On Vehicle Exterior 06=Bicyclist Wearing Elbow/Knee/Pads Extrication: 15=Bus Passenger 10=Air Bag Not Deployed, Switch On ~ O=Not Applicable Severity 9=Unknown if Injury 98=Other 11=Air Bag Not Deployed, Switch Off 1=Not Extncated 99=Unknown 12=Air Bag Not Deployed, 2=Extricated By Mechanipl Means Unk Switch Setting 3=Freed By Non -Mechanical Means 13=Air Bag Removed (Prior To Crash) g=Other 19=Unknown If Air Bag Deployed 9=Unknown 99=Unknown ~ EMS Agency: WEST SHORE Medical Facility: HERSHEY MEDICAL Unit No Person No ~ O1 O1 Delete? Date of Birth (MM-DD-YWY) A B C D E F G H I O 09 - 26 - 1989 1^ M^ 4^ O1 00 O1 0^ 0^ 0^ Name /Address /Phone Same as EMS Transport ~ operator SIPE, JAMES M 316 BLACKSMITH RD CAMP HILL PA 1701 l 71773 a Yes O No Unk Pdo Person No O 1 02 Date of Birth (MM-DD-YYYY) A B C D E F G H I ~p e~ 08 - 31 - 1989 2^ ~ 0^ 03 03 O 1 0~ 0^ blame /Address /Phone Same as EMS Transport ~ operator MICHAEL HAYDT 634 LEWISBERRY RD NEW CUMBERLAND PA 17072 O Yes a No Unit No Person No O 1 03 Date of Birth (MM-DD-YYYY) A B C D E F G H I ~O e~ OS - 16 - 1987 2^ ~ 4^ 06 03 00 ~ 0^ Flame /Address /Phone Same as EMS Transport ~ operator BRAD WILLARD 57 CENTER DR CAMP HILL PA 17011 7179999999 O Yes ~ No Unit No Person Mo O 1 04 Deletes Date of Birth (MM-DD-YYW) A B C D E F G H I O OS - 14 - 1991 2^ M~ 4~ 04 03 00 0^ a 0~ Flame /Address /Phone Same as EMS Transport ~ operator NICHOLAS PROVENZA 7TH ST 432 APT 2 NEW CUMBERLAND PA 170 O Yes ~ No Unit No Person No O 1 OS Date of Birth (MM-DD-YYYY) A B C D E F G H I ~O e7 OS - 18 - 1991 2^ M^ 4^ OS 02 00 0^ 0^ Name /Address /Phone Same as EMS Transport ~ operator JOHN CHIARA 1320 CARLISLE RD CAMP HILL PA 17013 71773733 S Yes O No Unit No Person No 02 O 1 Date of Birth (MM-DD-YYYY) A B C D E F G H I DeQ e7 10 - 28 - 1984 ~ M^ ~ 01 03 00 ~ 0^ 0^ Name /Address !Phone ~ same as TRIMMER, AARON S 1537 MAIN ST MECHANICSBURG PA 17055 717 EM5 Transport Operator O Yes ~ No PORIN ~ MS00 (1710?) PENNDOT COPY http://www.dot6.state.pa.us/icons/PrintImages/XmlFiles/20070035811 brillhart2398200701... 1 /19/2007 Print CRS W0049663 J c®~~®~~~~L~~ ®~ ~E~~sv~~~~u~, P®0_I~E C6d~+56~9 6~~P®RYB~G ~®I~fi~l Page AA 500 4 ~~ t,=e only Page 5 of 7 W0049663 Crash Description O=Non-Collision 2=Head On 4=Angle 6=Sideswipe B=Hit Pedestrian ~ 1=Rear End 3=Rear to Rear S=Sideswi a (Opposite Dinactbn) ~ c o irectbn) 7=Hit Fixed Object 9=OtherNnknown (Backing) (Same E Relation to Roadvvay a 1=0n Travel Lanes 3=Median 5=Outside Trafficway 7=Gore (Ramp Intersection) 0 2=Shoulder 4=Roadside 6=1n Parking Lane 9=Unknown ~ € r ~ Illumination 2 ~ 1=Daylight 3=Dah~ Street S=Dawn B=Other 9 6=Dark -Unknown 2 D rk - N N - = a o _ _ Street Ughts 4=Dusk Roadway Lighting ~ dv _ _ _,~ tNeather Conditions a t=Condditio~e 3=Sleet (Hall) 5=Fog 7=Sleet & Fog 9=Unknown ~ 6=Rain & Fog B=other 2=Rain 4=Snaw v _ _ ___ ' __ __ __ _ _ Road Surface Conditions Q O=Dry 2=Sand, Mud, Dirt, 4=Slush 6=Ice Patches g=Other-~ Off 7=W ter Standing 1=Wet 3=Snow Cov e_red 5=1~ or Moving _ _ _ Harm Event L/R IUlos47 Utility Pole INumber Harmful Events (Norm Eventl 30=Hit Fence Or Wall 9 12 ^ ® ~ _~ 01=Hit Unit 1 31=Hit Building 2 32=Hit Culvert i i Unit No 02=H t Un t 03=Hit Unit 3 33=Hit Bridge Pier Or Abutment O O 1 2 ~ ^ 04=Hit Unit 4 34=Hit Parapet End 05=Hit Unit 5 35=Hit Bridge Rail 36=Hit Boulder Gr Obstacle ffi Please Put Events in 3 ~ ^ ~ c Unit 06=Hit Other Tra 07=Hit Deer On Roadway 08=Hit Other Animal 37=Hit Impact Attenuator ! Sequential 09=Collision With Other Non 38=Hit Fire Hydrant c o Order 4 ~ ^ O ~ ~ Fixed Obyect 39=Hit Roadway Equipment 11=Struck B Unit 1 40=Hft Mail Box 41 Hit Traffic Isl nd a = a 12=Struck By Unit 2 ~ 13=Struck By Unit 3 42=Hit Snow Bank o Harm Event L/R fWostt Utility Pale Wumber 14=Struck By Unit 4 43=Hit Temporary Construction 15=Struck B Unit 5 Barrier ~ t 01 ~ ~ ~ 16=Struck By Other Traffic Unit 48=Hit Other Faed Ob1ect 49=Hit Unknown Fixed Object T O Sh bb 21 Hi d Unit No ree r ru ery = t W ~ O2 2 ~ ~ ~ ~ Z2=Hit Embankment 50=OverturNRoll Over 23=Hit Utility Pole 51=Struck By Thrown Or Falling n Object c Si 24 Hit T aff e g = r i 25=Hit Guard Rail 52=Pot Holes Or Other ~ Please Put ~ ~ ~ ~ 3 ~ E i 26=Hit Guard Rail End Pavement Irregularities 27=Hit Curb 53=Jacknife vents n Sequential - 28=Hit Convete Or --- --- 54=Fire In Vehicle -- Order ~ ~ ^ O Longitudinal Barrier 58=Other Non-Collaon 29=Hit Ditch 99=Unknown Harmful Event First Unit No Harm Evertt 1fAost Unk iNo Harm Evert Driver Action (D) 17=Careless Or Illegal armful ~ ~ l~ful ~ ~ ~ O1 12 ve~nt'rn 01 12 00=No Contributing Action Backing On Roadway d 18=Driving On The Wrong 01 i W Di t t D t~h thrash = r ver as s rac e 02=Driving Using Hand Held Phone Side Of Road ~ Do not repeat this information a+ multlde pages 03=Driving Using Hands Free Phone 19=Making Improper - 04=Making Illegal U-Tum EnVance To Highway Environmental / Roadwav Potential Factors (E/RJ ' OO Z ~ 3 ~ 05=Improper/Careless Turning 2t>^Making improper Exrt 06=Tumm9 From Wrong Lane From Highway arkin 07=Proceedin W/0 21=Careless Parkin Nn 00=None 11=51ippery Road Conditions (Ice/Snnw) g g p g Clearance After Stop 22=OverNnder 01=Windy Conditions 12=Substance On Roadway 02=Sudden Weather Conditions 13=Potholes 08=Runnin Stop 5i n Com nsation At Curve g d 03=Other Weather Conditions 14=Broken Or Cracked Pavement 04=Deer I R d 15 TCD Ob t ct d 09=Running Red Light 23=Spee ing 10=Failure To Respond To 24=Driving Too fast for Conditions n oa way ru = s e Other Traffic Control Device 25=Failure To Maintain Proper Speed 05=Obstacle On Roadway 16=Soft Shoulder Or Shoulder Drop Off l t 06 Oth A i R d R d F 28 O h 11=Tail stingg 26=Driver Fleeing Police (Pol Chase) i l i dg = er n ma o oa way er = t oa way actor ow ng/Stop 12=Su den S ng 27=Driver tnexpenenced ~ 07=Glare 29=Other Environmental Factor 08=Work Zone Related 99=Unknown 13=Illegally Stopped On Road 2g=Failure To Use Specialized Equip 14=Careless Passing Or Lane g2=Affected By Physical Condition Ch m Possible Vehide Failures M 12=Wipers ange 98=Other Improper Driving Actions 15=Passing In No Passing Zone gg=Unknown E 00=None 06=Exhaust 13=Driver 5eating/Control 16=Drmn9 The Wrong Way On w 14=8 Doors, Hood, Etc 01=Tires 07=Headlights 1-Wa Street Y ~ ~ 02=Brake System 08=Signal Lights 15=Trai er Hitch 03=Steering System 09=Other Lights 16=Wheels Uni4 ~ OI 9 07 2 2'] 3 4 ~ 04=Suspension 10=Hom 17=Airbags ~ 05=Power Train 11=Mirrors 18=Trailer Overloaded •c c v 19=Unsecure/5hifted Unit ~ ~ ~ Trailer Load No O 1 , OO 2 2o-Improper Towing Noh O2 t OO 2 ~ 3 ~ s 21=Obstructed Windshield Unit 02 t 01 I ~ 99=Unknown N pedestrian Action (P) 03=Working 00=None 04=Pushing Vehide o 05= roachin Or Leavin Vehicle 01=Entering Or Crossing At APP , 9 9 ecified Location 06=Working On Vehicle S Indicated Prime factor Unk No Factor Code p 02=Walking, Running, Jogging, 07=Standing 98=Other Do not repeat this information on multiple pages. O 1 O7 Or Playing 99=Unknown E/R V D P Unit No 01 OO Unit No U2 00 Q Q ~ Q If ElR is the Prime Factor Type, leave Unit ,Vo blank t: u r u FORpI I AA-S00 (1T/02) p~w~oor co~v http://www.dot6.state.pa.us/icons/PrintImages/XmlFiles/2007003 5 8 1 1brillhart2398200701... 1 /19/2007 Print CRS W0049663 COMMOiVWEALTH OF PEIdNSYLVAMIA POLICE CRASFI REPORTING FORM page AA 500 5 ~°~'~ "~ °ny 6~ Page 6 of 7 ~I~I~I~I~E~~I~II~ CrashAlumber W0049663 "~" y "~~0° n~ PENNDOT COPY http://www.dot6.state.pa.us/icons/PrintImages/XmlFiles/20070035811 brillhart2398200701... 1/19/2007 Print CRS W0049663 Crash Number: W0049663 Incident Number: UAT20070100340 Page 7 of 7 D e East Lisburn Rd .Arcona Rd ~.,- , : ;~ http://www.dot6.state.pa.us/icons/Printlmages/XmlFiles/2007003 5811 brillhart2398200701... 1 /19/2007 F_xh~b;} Q + THE MILTON S HERSHEY MEDICAL CENTER MEDICAL RECORD C PO BOX 853 MR328 (REV 9/00) HERSHEY, PA 17033 NAME: CHIARA, JOHN Mph; 26150 MD: DILLON PETER W Mpq; 750D215 SEX: M DOB: 0511811991 STANDARD `:y~~~ INS; AUTO INSURANCE LOC; VISIT DATE: 01/1212007 OOSM: 10500215 +----------i~~i-------------F~-i~----------+-F--------~-I----------F~-----~-+---++---+i---I- (MR# (IO10500215 +I01/12/07 (I10M31 PII1440/OIDIILOC I'IPESII~RCIIP~ ICHIARATJOHNE IIMEXII05/18/1991IIA15IISSIIMRSAIIVREII IIREL I1320ECARLISLESRD (ICAMP HILL IIPA II17011ODE PT PHONE PT EMPLOYER EMPLOYER PHONE 1717 737-3380II I) II ICHIARATJOAN IIMOTHER II717O737-3380IIWORK PHONE II21O INSURANCE INFO NAME ~ POLICY # ~ lJ~ '~ GROUP NUMBER AUTO INSURAN ~r~ ~ S ~ ~1 AD01122007 HIGHMARR BS ~~ i d ZAR102886125001 ~ ~`D 02522435 SELF PAY ~ ~ (I9 Q~ ~\~ 0 DIAGNOSIS:\MULTIPLE TRAUMA ---------------------------------------------------------- ~-yl-?- ~ 1-- + - + (COMMENTS I IA26150IDILLONSPETER W IIA261 OIDILLONSPETER W FAMILY PHYSICIAN REFERRING PHYSICIAN e 1800ECARLISLEEROAD NOLREFERRING/FAMILY ~^~ ~ 3 2~0~' PHYSICIAN CAMP HILL PA 17011 717 737-3465 FAX: 717 737-8561 FAX: PE~INSTATE ~..J"`'"~ ~1~>I1 S. HP.Y3~y ~(~1C.c~ ~CII~E:T ~:Ollr~ Uf ~I~Clllle ED TRAUMA/RESUSCITATION FLOW SHEET/ORDER SHEET I NAME: CHIARA, JOHN I MD: DILLON PETER W I MR#: 7500215 I DOB: 05118/1991 INS: AUTO INSURANCE ~ LOC: ~ OOS#: 10500215 DATE o TI RESPONSE STAT PAGED ~ RESPONSE LEVEL 1 2 3 AGE TIME PT RR ED ~1 EMS REPORT I/~C~(X /L~~r1P(7 l uY~ EMS MEDS GIVEN AMB/MEDIC # p Bp HELICOPT R ON-SCENE INTERHOSPITAL R~LLARE CHART _ CT LONGBOARD/KED LOSS OF CONSCIOSJSNESS: _NO .INK _YES # MIN MAST ENTRAPPED: 0 _U!N WN _YES # MIN SPLINT SELF EXTRICATED: YES NO MVC ~`°CAR _ DRIVER _ BELTED _ EJECTED _ WINDSHIELD _ DAMAGE _ PICKUPPASSENGER _ AIRBAG _ # FT _ BROKEN _ FRONT _ MIN MPH _ TRUCK _ FRONT _ CARSEAT _ ROLLOVER _ SPIDERED BACK _ MOD _ VAN BACK ~CNONE X ST WHEEL BENT _ _ BROADSIDED _ HEAVY _ PEDESTRIAN _ BED OF PICKUP _ UNKNOWN _ UNKNOWN ~_ R _ L MOTORCYCLE _ BICYCLE _ ATV _ HELMET _ NONE _ UNKNOWN _ FALL _ FT _ GSW _ CAUMM _ BURN _ DIVING _ DROWNING _ FARM _ INDUSTRIAL _ SPORT _ STABBING _ OTHER IV GAUGE SITE SO ' A T. I P ENT? #1 / N MEDS #2 Y/N #3 ,,,r^~ Y / N ALLERGIES 1~ Eye Opening S ontaneous To voice q CHEST RE LABORED BREATH SOUNDS R L EAR Response To rain 2 2 0 T SOUNDS ~ None 1 1 _YES PRESENT ~ PRESENT ABSENT _ _ MUFFLED Best Oriented 5 _YES _ CLEAR ~ ~G Verbal Confused WHERE , (( DIMINISHED Response Ina ro date words 3 3 ~RF PITUS _ _ Incomprehensible sounds 2 2 . } ~ PARADOXICAL None 1 1 F `" _YES CH T SYMMETRICAL OTION Best Obe command 8 W HERE YES _ NO N O _YES Motor Response Localaes in Withtlraws (oainl 4 4 PAB AEYSIS PARATHFCIG PI II cl=c oetni i E Apply this score to GCS ~ GCS portion of Trauma Score ~ GLASGOW 13 -15 q COMA g -12 SCALE (GCS) 6 - 8 2 (Total Points 4 - 5 1 from above) 3 p Systolic > 89mm Ha 4 Blood 76-89mm He Pressure 50-75mm Hp 2 1-49mm Hp 1 No Pulse Respiratory 10-29/min. Rate > 29/min. 6-9/min. p 1-5/min. ~ None p Total Revised Trauma Score TIME SERVICE CALLED ENT TIME RO MD# : 26150 I -- SEX: M STANDARD VISIT DATE: 01/12/2007 SEX - v ~ UVT f lU 1 IQ MEMBER ANESTH. ATTEND. \~ I SR. TRAUMA RES. SPONTANEOUS RATE: SEDATED PARALYTIC AGENT 02 MASK L/MIN ~02CANNULA L/MIN~ _ ASSISTED RATE BVM RATE _ AIRWAY (ORAUNASAL) _ ETT (ORALMASAL) SIZE T CRICOTHYROIDOTOMY _ TRACH SIZE LAST TETANUS ABDOMEN PELVIS SOFT _ RIGID _ TENDER _ YES NO STABLE UNSTABLE DISTENDED WHER _ PRIAPISM GUARDING BOWEL SOUNDS SCARS \! _YES ~CNO - BLOOD ~ MEATUS _ YES _ NO WHERE / DECREASED PALE -HOT _ CYANOTIC _ COOL MOTTLED _ COLD DRY MOIST _ ACYANOTIC 1.OPEN FRACTURE E-fCCHYMOSIS 2. AMPUTATION A-ABRASIDN 3. GUNSHOT WOUND C-CONFUSION 4. DEFORMITY L-LACERATION S. STAB WOUND S-SWELLING 6. BURN T-TENDERNESS 7. PAIN PW-PUNCTURE B. RASH WOUND BURN-FT PT SC I-IMPALED OBJECT Original -Medical Record Yellow -Trauma Service Pink -'ED MR 690 02/05 ED TRAUMA/RESUSCITATION FLOW SHEET/ORDER SHEET (1111111 hill II 111111 IIIII IIIII itll llll l~ YES _ N YES 0 ~HEA M DLINE YES _ NO ~` INTAKE TOTAL I - NURSE'S NOTES INCLUDES: 1. Assessment 4. Response ' ,.~ ~ n~ 2. Plan 5. Ongoing Assessment j n~~ ~ ~`( Q, 3. Intervention 6. Disposition/Final Assessment I ~' ~ ~ ` ~ ,i ~ ~ ~fI,U i ~ ~ - C ~ ~~ ~ ~-~~ cep -?~7 r~!-rn~nn ~ ~~ ~~ r~i• -a~wo~ ~ - ~-h\~ ~r,n ~ A • nr~ ~ ~'~ -~c,~ ,n ~ ~- ~ ~ ~o~~IVS cam' ~~~ -Frn~m rave` l~ t~x~ D ~ (i ~ n ,,~ I a . ~ ~r ~ - i `c ~ ~av~ G . ~ i r/ . /fi D T TEMPERATURE COLOR CREFILLY SENSATION MOVEMENT PULSE W-Warm N-Normal R-Rapid N-Normal A-Active S-Strong C-Cool P-Pallor S-Sluggish T-Tingling W-Weak W-Weak CD-Cold F-Flushed A-Absent NB-Numbness P-Paralysis A-Absent H-Hot C-Cyanotic P-Pain and A-Absent R-Regular II I 110~iV ~" it BRACELET LOCATION: ID ~`~~ f BLOO~ ~ ~ 834861. Do u enting Su - rregu ar physician Signature: BVM =Bag Valve Mask LCT =Left Chest Tube NS =Normal Strength • ~ ~ • • ~ • • i. ET = Endotracheal Tube RCT =Right Chest Tube W =Weakness ABD =Abdomen PH =Pre-hospital FP =Flaccid Paralysis 2 3 4 5 6 7 8 9 RL =Right Leg LOC =Level of Consciousness R =Rigid LL =Left Leg PMH =Past Medical History DCB = Decerebrate Posture HEAD: RA =Right Arm BH = Bair Hugger DCT =Decorticate Posture LA =Left Arm pUPll REACTIVITY: B =Brisk F =Fixed S =Sluggish D =Dilated N = Nonreactive CHEST: ADMITTED TO ® REPORT TO TIME OR NOTIFIE Y TO OR ABD: FAMILY NOTIFIED ~ RELATIONSHIP C-SPINE CLEARED: ^ YE ~NO Y DR. EXTREM: C-COLLAR ON: YES ^ NO ASPEN: YES ^ NO VALUABLES: W/PATIENT ^ SAFE ^ NONE ^ W/FAMILY ^ BELONGINGS FORM DONE ^ EXPIRED CORONER NOTIFIED ~ BURN: MATERIAL EVIDENCE TO POLICE: ^ YES ^ NO OFFICER BADGE # OTHER: TRANSFERRED TO VIA i PENNSTATE' NAME: CHIARA, JDHN Milton S. Hershey Medical Center N MD: OILLON PETER W MD#: 26150 ~ f, MR#: 7500215 ~ College of Medicine I DOB: 05/19/1991 SEX: M I TINS: AUTO INSURANCE STANDARD LOC: TRAUMA HISTORY AND PHYSICAL EXAMINATION ~,00S#~ 105002,5 VISIT DATE: 01 /1 212007 ~ -w-b Date: 112 D~ Time:2~~,1' T_Y~re.atr~tlma ~ . Brief tlis'to~-~Me~hatri~m Qf:lnju ry) - VC Belted? ^ Yes ^ No ^ Airbag /S~ o ~ ,~ /Yll~G' ,h,Q~ Pedestrian ^ MCC ^ Assault " C o ^ Fall ^ Burn ^ Electrical ^ GSW ^ Stab ^ Other Fislti ~eseis~i~ti9t~ 1.:': ,~~ , : ti: i. Airway: eU(..c,Jc IV's: ~ R.O.S. Field Vitals: P: BP:Itio ~.dRR: I--} Immobilization: Fluid: Amnesia. s ^ No Loss of Consciousness? ^~es-B-Idtr~ Fie l Notes: d a[ Ut~e~: Y , '~ ~ ~ ,r ~ ~ ~t/~S4 ~i~~1 ~'" ~R:. .-~ t :...a i S t" y~ + s r f.+ Airway: atent ^ Obstructed Intubated: ^ OT ^ NT ^ Trach Allergies: N ~Q Breaths g: Breath Sounds: Meds: Circulation: P: $~ BP: 1310 ~-~ RR: (g Sat: (,OD Disability: lert ^ Vocal ^ Painful ^ Unresponsive PMH: D Exposure: t/V Procedures -Tube r PSH: rhP~tr~~t,a• r'i ~ ~~ ~~-fee, -~ Last Meal: ast Tetanus: ~-CCP~iVI'' -Set:Bn~r n-e~+ ' 2nd Vitals: Temp• P: ~ BP: RR: 02 Sat: O V vVT fl , ` v HEENT: Head: q, Eyes: 3~~ % ~(, c ~ Ears: TM's: ~,p,L ~ Battle's: _, Face: Maxilla: ~ Mandible: ~ ~ - / J - ~ I; ~ ~ Nose: ~„~,~,~,~- Dentitia: ~ ~~-^ ( 1 Mouth:~~~ Dentures: ~ .~,~ ' `` ~ J /~ ~ Neck: Tenderness: Crepitus: Trachea ML: , _ s Chest Wall: Tenderness: ~ Crepitus: ~ 1 ~ I Lungs: ~~~- ~ ti ~ t \ Back: Tenderness: ~ Crepitus: a C.~ I I , ~ 1 ~~i 1/.: Heart: 5 152 '~ Abdomen: Distention: BS: Tenderness: ~ , ~ ~ `~ - Rectal: Tone o Heme: Prostate: i' Pelvis: Stable: Tenderness: '' Vascular Exam: Radial RighULeft ~ ~- Femoral DP PT ~ LEGEND: L -laceration cfx-closed ~ fracture Resid r Title Hate (L ~~ Time a. .m. a ~ Ofx-open fracture Ab -abrasion C -contusion .,.,~ ~ ~ uw i i , i aav rwn.~ ~ t Orig -Chart MR 611 Rev. 3/98 TRAUMA HISTORY AND PHYSICAL EXAMINATION Copy- Trauma Services TRAUMA HISTORY AND PHYSICAL EXAMINATION Sa~a~B :may i~nt~ ,' Extremity Exam /r, ~. s \ //~~ J. ,;\ ~ "~~` ~ / p ~~~` "~; .~~ ~ ~ -~.~ ~ , i ~ ~ ~ , i i i1 I 1 ~ ' ~ ~ ~ `~ , '~ , ~,_.~ ~ j .~.~ !,1) ~ , ~ ~i Ii X111. ~ (I ~ I: 1! i ~i F LEGEND: L -laceration Cfx-closed fracture Ofx-open fracture Ab -abrasion C -contusion a =~' ~~~~ °;,ri { '' ~ spinal cord Injury: Glasgow Cama Scale/Peds Eye opening Trauma Score Cranial Nerves: ~ 1_~ 1 -None 2 - Open to Pain Resp. Rate SBP MOtOr: ~., Open to Command/Voice (4 )Spontaneous 0 - 0 0 - 0 1 -1-g 1 - 0-49 ,- T 12 erbal Response 1-None 2 - >36 2 - 50-69 SenSOry: PlnprlCk 2-Incomprehensible /Moans to Pain 3 -Inappropriate / Cries to Pain 3 - 25-35 3 -70-9D 10-24 ~ >90 Proprioceptio ~ ~° ~ Confused I Consolable Alert /Oriented /Interacts ~ CS DTR's ~. L 1 Motor Response 0 - 3-4 ~ 1 -None 2 - Decerebrate 1- 5-7 2 _ g_i 0 3 -Decorticate 4 -Withdraws 3 -11-13 Jr - Localizes Pain Obeys /~-14-15 t/ l ''L t! tt , Total: Total: ~;e ~~ - PT: ~ Troponin: U/A: l ~~ Ce ~~~ PTT: Myoglobin: ~3 ~~ (, ~ t3 T:Bili: CPK: Drug Screen: ~~ •S S'~ ~•g ALT: Amylase: ABG: ALP: ICa: ETON: ECG: TEE: nl t2 BHCG: .` CXR: Pelvis{.-~j `S>ia~-s: Head: Q "' CSpine: Lat '~ - ~- Extremities Abdomen: ~j ~S AP ~ Others: Otlontoitl kngio: f'Gt T & L S Ines: __.. UfS:' S~ u ~ 4,w~> :a.. :z$#teai~ng la~i. S /k~tsLc~' ~ • x Attending SignaturelDate/rlme •~ ,~~tx '~ V Orig -Chart Copy - Trauma Services MR 611 Rev. 3/86 TRAUMA HISTORY AND PHYSICAL EXAMINATION PENNSTATE I ' Milton S. Hershey Medical Cente: College ~~Medl~+ ne MD;EDILLONRPETERHW • MR~i : 7500215 - DOB: 05/18/1991 f INS: AUTO INSURANCE TRAUMA TEAM SIGN-IN SHEET OOS~i; 10500215 Date TRAUMA LEVEL Trauma Standby paged at MDN: 26150 SEX: M STANDARD VISIT DATE; 01/12/2007 .TRAUMA NUMBER 1 2 3 hrs Trauma Response paged at hrs ED Attendin Trauma Attendin Trauma Team Leader PGY4/5 Senior Trauma Resident PGY 4/5 Junior Trauma Resident PGY Z3 Junior Trauma Resident PGY 2/3 Junior Trauma Resident PGY 1 Junior Trauma Resident PGY 1 Emer enc Med. Resident PGY 2/3 Emer enc Med. Resident PGY 2/3 Emer enc Med. Resident PGY 1 Trauma Ph sician Extender Trauma Ph sician Extender Anesthesiolo Attendin lar 2 , 2 ~' Anesthesiolo Resident 'µ ~. 1, 2 Certified Re istered Nurse Anesthetist Res irato Thera Radiolo Attendin Radiolo Resident Radio ra her #1 Dia nostic Radio ra her #2 Dia nostic Radio ra her CT ~ ~ (5~, ~ Emer enc Medicine EMT ~ ~ Cha lain 2 OR Technician /Nurse o`t{c? Pediatric Critical Care Attendin . Pediatric Critical Care Resident ~', S I a Child Life S ecialist Trauma Coordinator /Case Manager PGY =Post Graduate Year Original Copy -Medical Records Pink Copy -Emergency Dept. MR 414 Rev. 4104 TRAUMA TEAM SIGN-IN SHEET Yellow Copy -Trauma Services .i'- . P.ENNSTATE NAME: CHIARA, JOHN F,~p~; 26150 MD: DILLON PETER W - Mtltori s. Hershey Medical Center MR#: 7500215 SEX: M DOB: 0511811991 STANDARD College of Medlcuie INS: AUTO INSURANCE LOC: VISIT DATE: 01(1212007 - OOSN: 10500215 HIS RY AND PHYSICAL EXAMINATION I 1 SYCHIATRI VALUATION ^ ADMISSION NOT Identifying data - , ~ ~/' Source and reliability f the history cc / , ~ (3 ri ~ ,J V r V(/ Y"YZ j ~ l ~ d /~1.. ~ _ ~ _ .. wr .._ / __ _ i ,a/ , ' / ~ 1 ,`, ~ ' ,nn n rt ~ ~ IM.~ P~ ll ir1 i )~ i ~. ~t n~C1 Current functioning sleep I' Activities of d I living Energy Attention /con anon Self-concept Impulse control Panic I anxiety sxa-- s i / C y appetite wt change interest ~i~'ff~ nhedonia L memory{-pq/~/ .^. Current treatment status --~ ~~~ ~' ~ ~- I"~'6"l ~ UV/~7~~ ~ ~ ~~' °~K~C ! ~'' "~ `J''` ` SIGf~ MR 9 REV (SIGNATURE MUST PP AR AT END OF REPORT) Current Meds /doses /frequency .~ Aller ies: Famil Histor _I -i ~y Other Rental Status Exam (MMSE score, if done General description: j Mood A ect Hallucinati /ill ions Speech: rate ,. ~ vol articulation spontaneity coherence Thou ht rocess: associations rate abstraction Thought Conte t: self harm other harm assessment of suicide /homicide risk delusions obsessions compulsions preoccupations phobias !~ Orientation: person Memory: immed. sight -- place recent Judgment time ~~~ HISTORY AND PHYSICAL EXAMINATION j PENNSTATE w Milton S. Hershey Medical Center `~ College of Medicine HISTORY AND PHYSICAL EXAMINATION Impr,~sion: l r v1/~- ,) t/V ~ ~_. 1 `- } _ x1 ^ resume previous care: - refer to ^ outpatient `„ f ^ partial ^ irrtensive outpatient " i~ ~i~ ^ drug /alcohol rehab inpt outpt ~ 1~ ^ prescrq~tions given ~ '~ (dose /amounts) ^ medication changed ^ no further follow up needed ^ discharge AMA ^ other / 1\ ^ Inpatient hospital¢ation ~ `ai~ reason why admission is needed: estimated length of stay: SIGNATURE MR 9 REV 6/01 T E D RY AND H SICAL EXAMINATIO NAME: CHIARA, JOHN MD: DILLON PETER W MDq: 26150 MRq: 7500215 DOB: 05/18/1991 SEX: M INS: AUTO INSURANCE STANDARD LOC: OOSII: 10500215 VISIT DATE: 01/12/2007 CONTINUED ON RE TIME A. 1 ~ .M. PAGE PENNSTATE Milton S. Hershey Medical Center College of Medicine PROGRESS REPORT NAME: CHIARA, JOHN MD. DILLON PETER W MR#: 7500215 DOB: 05/18/1991 INS: AUTO INSURANCE LOC: OOS#: 10500215 MD#: 26150 SEX: M STANDARD VISIT DATE: 01/12/2007 DATE TIME PROGRESS NOTES, ^ INPATIENT ^ OUTPATIENT NAME -TITLE t f3 ~. ~ ~~ t~ ° Mme. -~ '- t _ ~ `_ ~. .~~~' r l ~' ~. fi ,~ _.__ ~ MR 6-2 (1191) Page 1 of 1 ~~~~~~~~ ~~~~~ ~~ ~~~~~~ ~~~~ ~~~~~~ ~~~~ ~~~~ PROGRESS REPORT f ./ t Patient Name MRN ~~~~1~ .j DRUG AND ALCOHOL ASSESSMENT 1. Does the patient use drugs/alcohol to deal with any problem`s? 2. Does the patient acknowledge that D/A use is a problem?..... 3. Has the patient experienced withdrawal symptoms when stopping use of alcohol or drugs? .......................... 4. Has the patient's drug/alcohol use impacted his/her behavior and relationships with others? .................................. 5. Has the patient experienced emotional problems when stopping use of alcohol or drugs? ................................... Y~R Y 'V N Y J/ Y N YV N ___ ~N N 6. Has the patient ever been in drug and alcohol treatment? (Where) Y 7. Has the patient ever abstained from using drugs or alcohol? ~Y Longest period of abstinence? How long ago? 8. Does the patient typically use D/A: alone or 9. Is the patient living with someone who uses: alcohol or 10. Does the patient have friends who use: alcohol or 11. Has the patient ever experienced an overdose? (List substance`q 12. Is the patient accepting the need for D/A treatment at this time? For any affirmative answex above, list details below by ques i with othe;s~ 1 ~ drugs`' drugs . Y ~p~ , ~j r1 Y N t~ - ~ `~f tion number: Signature ~" Print Name ~ D~~ Date l/~~ l1 U / Time / l DRUG AND ALCOHOL HISTORY ~ Complete For All A f A Substances Used In History ge o First U e mount Used Currently / Recently Date of Last Use Route of Use (IV, snort, drink, smoke) Progression of Use Alcohol ` . Mari'uana e~j~ J ~j Hallucinogens Heroin ~ „ Methadone Other Opiates (snQ~ify): ~ - Amphetamines ~~~ ~ ' Crack /Cocaine ~~ oressants: (Barbiturate .nzodiazepines} ` ) Club Drugs Ecstasy, Ketamine, etc. ~ a ~// Prescription Drugs not as Prescribed (specify): C„~er (speci ): Ci arettes /Tobacco ~'`' ux5 (re: D&A Use): Placement Level Recommendation Description of Justification for Placement Levels 1A Outpatient 1 B IOP 2A Partial Hospitalization 3A Medically Monitored lnpt. Detox 3B Inpt. Rehab 3C Long Term Rehab (90+ days) 4A Medically Managed Inpt. Detox 4B Inpt. With Medical Hospital Needs Signature Date Time PENNSTATE ' NAME: CHIARA, JOHN MD. DILLON PETER W MRIi : 7500215 DOB: 05/18/1991 INS: AUTO INSURANCE LOC: OOS#: 10500215 MD#: 26Y50 Milton S. Hershey Medical Center College of Medicine PROGRESS REPORT i~ SEX: M STANDARD VISIT DATE: 01/12/2007 DATE TIME PROGRESS NOTES ^ INPATIENT ^ OUTPATIENT NAME -TITLE II, ~`~ 11~ ~ `L r ` t ~~ i ~An ; MR 6-2 v2 (1l91) PROGRESS REPORT White Copy -Medical Record Yellow Copy -Trauma Services Pink Copy -Nurse Manager PENNSTATE Milton S. Hershey Medical Center College of Medicine CONSENT FOR MEDICAL TREATMENT NAME: CHIARA, JOHN MD: OILLON PETER W MR#: 7500215 DOB: 05/16/1991 INS; AUTO INSURANCE LOC: OOSq: 10500215 MDk; 26150 SEX; M STANDARD / ry --1 Visit Date C/ VISIT DATE: 01/12/2007 ~ J/r I, (or \/Gt' 19i~ ~~ /(~ ~i~' on behalf of _~ o~h ! L3 ~U )knowing that I (helshe) am (is) suffering from a condition requiring hospital care, voluntarily consent to such hospital care encompassing routine diagnostic procedures and medical treatment by the Professional Clinical Staff• of Penn State Milton S. Hershey Medical Center, its assistants, or their designees as necessary in theirjudgment. I am aware that the practice of medicine and surgery is not an exact science, and I acknowledge that no guarantees have been made to me regarding the outcome of treatments, procedures or examinations performed in the hospital. For the purpose of advancing medical knowledge I consent to the presence of medical students and other health care trainees, and understand they may participate in my care under the direct supervision of my attending physician in accordance with ordinary practices of this medical facility. ~'~ . ADVANCE DIRECTIVES I have an Advance Directive: Yes.` No Undersigned unable to answer If Yes, I have been asked to provide a copy of my a Directive to Penn State Milton S. Hershey Medical Center for inclusion in my medical record. If No, an informa 10 ~ acket regarding Advance Directives has been offered to me. PATIENT RIGHTS AND RESPONSIBILITIES I acknowledge that Penn State Milton S. Hershey Medical Center has provided me with written information on my rights and responsibilities as a patient. I am aware that a Patient Representative is available to me if I have additional questions or otherwise wish to speak with one. MEDICARE INPATIENTS I certify that the information provided by me in applying for payment under Title XVI II of the Social Security Act is correct. I acknowledge that I have received a copy of "An Important Message from Medicare". PERSONAL EFFECTS I understand that a safe is available in the Cashier's Office for maintaining patient valuables. Patients are encouraged to utilize this service, as Penn State Milton S. Hershey Medical Center does not assume responsibility for any patient valuables or items brought to the hospital. The undersigned accepts full responsibility for all personal effects, including but not limited to money, dentures, eyeglasses, contact lenses, hearing aids, radios, and jewelry. HOSPITAL MEDICAL RECORD RELEASE AUTHORIZATION I acknowledge that Penn State Milton S. Hershey Medical Center Privacy Notice has been offered. to me. I understand that Penn State Milton S. Hershey Medical Center may disclose information about me and the treatment I am receiving, including copies of my medical record for purposes of treatment, payment, and Medical Center operations as described in its Privacy Notice. I agree to indemnify and hold harmless Penn State Milton S. Hershey Medical Center, its officers, directors, employees and agents, from any and all liability, loss, claims, or damages relative to the release of such information. Continued on Reverse MR 887 Rev. 7/04 Pale 1 of 2 ~ ~~~~~~~~ ~~~~~ (~ ~~~~~~ (~~~~ ~~~~~ ~~~~ (~~~ CONSENT FOR MEDICAL TREATMENT CONSENT FOR MEDICAL TREATMENT AUTHORIZATION TO APPEAL INSURANCE DENIALS I authorize Penn State Milton S. Hershey Medical Center to file grievances with my insurance company, third party payors, case utilization and managed care review organizations which may be necessary to challenge denials of authorization or payment for a healthcare service. ASSIGNMENT OF BENEFITS I assign and authorize payment directly to Penn State Milton S. Hershey Medical Center. I authorize any holder of medical or other information about me to release to my insurance carrier and its agents any information needed to determine these benefits or benefits for related services. PATIENT RESPONSIBILITY AGREEMENT I, the undersigned, acknowledge and accept financial responsibility for the payment of all charges. I acknowledge and understand that all charges not covered by insurance will be payable in full immediately upon receipt of billings, whether interim or final billings. I authorize the hospital to make a credit investigation if necessary. Should the account become delinquent, and should it become necessary for the account to be referred to an attorney or collection agency, the undersigned shall pay the reasonable attorney's fees and expenses associated with collection. I, the undersigned, certify that I have read, understand, and agree to the provisions contained within this consent form. The issues addressed on this form have been fully explained to me. I have had the opportunity to ask questions, and all of my questions have been answered to my satisfaction. Patient's Signature Date Witness Date Patient is unable to consent because he/she is: Legal Guardian or Closest Relati~a's Signature ~~~~ Relationship A minor Undergoing emergency treatment Other, describe. j ~~ r'~ lam/ / / Witness D e Witness Signature for Telephone Consent Date All persons will be accepted for treatment without regard to race, color, creed, religion, national origin or sex. MR 887 Rev. 7104 Page 2 of 2 ~ ~~~~~~~~ ~~~~~ ~~ ~~~~~~ ~~~~~ IIIII (~~) (~~~ CONSENT FOR MEDICAL TREATMENT . Penn State Milton S. Hershey Medical Center TRAUMAANESTHESIACQNSULT ~ --.. <. 1 ~` ~ ~. t. Date DI 12 Hei ht Time 1 ~-8 Wei ht A e ~ ex Consulted by Emergency Department Dr. NAME; CHIARA, JOHN MD: DILLON PETER W MR#; 7500215 MD#: 26150 DOB: 05/18/1991 INS: AUTO INSURANCE SEX: M LOC; STANDARD OOS#: 10500215 VISIT DATE: 01/12/2007 ,-- Attending Dr. ' ~~~ Q, # (Q 27 Resident/CRNA # ;~ :al Exam ~ Assessment & Plan CC/: a' MVC C General Appearance Assessment: , ^ Fall Vital Signs: // x ~( ~J ASA PS E ' ~ BP %77 Pulse ° In uries ^ MCC Temp S,Oz IODq ~a 6~ P ^ Other Glasgow Coma Scale = l5 Nebo: HPI: L9' Intact ^~Cervical Collar in place Airw~' C'YAdequate ^ Belted ^ ^ Marginal [9~ J lt b d ^ n e e ^ Difficult ^ Loss of consciousness HEENT: ^ Needs Intubation due to ^ Entrapped ^ Teeth ~- ~-)- en~' ion: V ^ Airway: Malampati Score ~ C7 Adequate spontaneous ^ ^ Needs Mechanical Vent PM Hx: Pupils: Size R~ L ~ Circulation: ^ Patient unresponsive due to ~1C~inimal Blood Loss ^ Allergies ~ 1~1,. Gh ems ~ React R Z L ~ ^ Shock Grade Che Level of Pain (1 - 10) ^ Drugs ~lear to auscultation ~h1~- Trachea rrudhne Plan: ^ Labored breathing ^ Requires Intubation ^ ^ Accompany to CT Scan ^ Medical ^ ^ O ^ No further intervention ^ Surgical 411-P~ Heart: (~ Regular rate & rhythm ^ ~ ~ Pulses full ROS: ^ ^ Non-Contributing ^ AAbd~en: ^ ^" Benign ^ ^ Tender ^ ^ Bowel sounds SHx• Y ~ Tobacco Y EtOH Y / Drugs_ Faguly History: ^/ Non-Contributing CODE: Extr~nities: C~ No apparent fx GU: ^ Foley 99241 99242 99243 99244 99245 Form 270-106 (Rev. 5105) " PENN STATE ~Iilt~an ~ ~e~ M.ic~ Gentr~r ~ll +af 11~edacine Penn State Milton S. Hershey Medical Center Tel: (717} 531-8055 Penn State College of Medicine Health information Services, HU24 500 University Drive P.O. Box 850 Hershey, PA 1 703 3-0850 Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 Patient Sex: Male Date of Birth: 5/18/1991 Patient Location: I EDU, 1440, 14 Visit Number: 10500215 Visit Type: Inpatient E D T r a n s p o r t N. o t e D o c u m e n t Final Document Electronically Signed by: per contribution per contribution Signed By: Stark, Christopher L (2/23/2007 11:24:18 AM); Dubin, Michael B (1/21/2007 10:37:02 AM); Wood, Clayton (1 / 19/2007 10:56:26 AM) ED TRANSPORT NOTE Name: CHIARA, JOHN HMC Number: 7500215 DOB: 05/18/1991 Date of Service: 01 /12/2007 FLIGHT NUMBER: 07-0099-A. SEX: Male. DISPATCH INFORMATION: Life Lion requested for a stat response to Cumberland County to assist Medic 81 on an auto accident. No further information was received en route. Weather was not a significant factor during his transfer. This patient ultimately presented with an altered mental status and pelvic injuries, requiring transfer to the closest regional trauma center, being The Hershey Medical Center. Source of information is from Medic 81 paramedic Herman. INCIDENT TIMES: Dispatched 2057, lift off 2102, arrived on-scene 2110, patient contact at 2112, departed scene at 2118, and arrived at Hershey at 2123. HISTORY: Paramedic Herman from Medic 81 reports that the patient was a rear seat passenger who was not wearing a seat belt, traveling in a vehicle which was struck in a lateral type impact on the driver's side. Damage to the vehicle was described as extensive. Initial arriving EMS units encountered this patient seated on the roadway beside the vehicle upon their arrival. It is unknown how the patient was removed from the vehicle. The patient is amnestic to the event, complains of nonspecific left hip discomfort. Loss of consciousness is questionable. The patient admits to marijuana use tonight. Denies other drug or alcohol ingestion. PAST MEDICAL HISTORY: Significant for ADD. MEDICATIONS: Unknown. ALLERGIES: The patient has no known drug allergies. Date Printed: 5/5/2007 Time Printed: 10:50 AM PE~II~~T~TE ~>~- ~. ~~y ~ tear Cvlleg~e of ediicxnie Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 E D T r a n s p o r t N o t e D o c u m e n t Final Document Electronically Signed by: per contribution per contribution Signed By: Stark, Christopher L (2/23/2007 11:24:18 AM); Dubin, Michael B (1/21/2007 10:37:02 AM); Wood, Clayton (1/19/2007 10:56:26 AM) Paramedic Herman reports significant findings on exam includes an altered mental status with a repetitive speech pattern and also severe pain elicited upon stressing of the pelvis. The patient also reported to be hypotensive with an initial blood pressure of 80/60, however, the patient was not tachycardic. Blood pressure has responded well to a fluid challenge. TREATMENTS PRIOR TO LIFE LION CONTACT: Consisted of full spinal immobilization on a long spine board. This included application of a rigid cervical collar and cervical immobilization device. The patient had been placed on nasal oxygen at six liters per minute and two IVs were established as follows: lactated ringers via a #16 gauge Angiocath in the left antecubital fossa and lactated ringers via a #16 gauge Angiocath in the left hand. The patient had received 500 cc of lactated ringers prior to Life Lion contact. PHYSICAL EXAM: This is a 15-year-old male encountered in the rear of the transferring ambulance at the landing zone with Paramedic Herman in attendance. The patient remains fully immobilized on the long spine board, is continuing to ~eceive nasal oxygen at six liters per minute and IV fluids at a KVO rate. The patient is awake, alert, appears in no acute distress, continues to complain of left hip discomfort. He remains amnestic to tonight's event. I am giving him a GCS of 4;" 4, 6, to equal 14. Blood pressure is 100 by palpation. Pulse rate of 90. A respiratory rate of 16. 02 saturation is 100% Cardiac monitor is a normal sinus rhythm without ectopy. Skin is warm and dry without pallor or cyanosis. Limited examination of the head, due to the immobilization devices, finds no outward signs of head trauma. The frontal, temporal, and parietal regions of the skull are intact. Facial bones, including the mandible, are also intact. There is no fluid discharge from the nose, ears, or mouth. Pupils are mid position at approximately 5 mm bilaterally and are reactive to light. There is no dental trauma. Airway is naturally maintained. Respirations are regular and non-labored. Limited assessment of the neck, due to the cervical collar placement, finds no signs of anterior neck trauma. The trachea is midline. There is no JVD. Paramedic Herman reported no significant findings to the cervical spine, back, or buttocks prior to immobilization on the long spine board. Assessment of the anterior and lateral chest walls finds no signs of external trauma. The rib cage is grossly intact. No paradoxical movements are noted upon respiration. Lung sounds are present, clear, and equal bilaterally. The abdomen is soft, nontender, and also externally atraumatic. The pelvis is stable when stressed, although pain is elicited on the left side. No external trauma is visualized. No incontinence is noted. Examination of both the upper and lower extremities finds no signs of gross trauma or deformity. Motor function and sensation are intact in all four extremities, along with peripheral pulses which are strong and regular. Rate is concurrent with the cardiac monitor, which continues to show a normal sinus rhythm without ectopy. The previously noted IV sites on the left arm remain patent with no signs of infiltration. Approximately 500 cc of lactated ringers has been infused. TREATMENT AND PROGRESS: Consent for air transport and emergency treatment was received from the patient's father at the landing zone. Life Lion rendezvoused with the transferring ambulance at the Holy Spirit helipad. The crew then received report from Paramedic Herman. The patient was assessed by the Life Lion crew. He was transferred from the ambulance onto the Life Lion litter, where he was secured with multiple straps. The patient was then transferred to the aircraft, where he was loaded and secured into the primary position. Once on board, he was connected to the Propaq monitor to allow continuous noninvasive blood pressure, pulse oximetry, and cardiac monitoring. Nasal oxygen was continued at six liters per minute. IV fluids were maintained at KVO rate. Once airborne, the patient was continually Date Printed.• 5/5/2007 Time Printed: 10: SO AM i1t~t~n S. ~~ ~ ~`~ter +~ of lk~ed~-cu~e Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 E D T r a n s p o r t N o t e D o c u m e n t Fina! Document Electronically Signed by: per contribution per contribution Signed By: Stark, Christopher L (2/23/2007 11:24:18 AM); Dubin, Michael B (1/21/2007 10:37:02 AM); Wood, Clayton (1/19/2007 10:56:26 AM) reassessed with no marked changes in his physical exam noted. Medical command was contacted at The Hershey Medical Center with a patient report. No further orders were received from Dr. Choe. TIME BP P R Cardiac Monitor Sp02 Glasgow Coma Score 2112 100/palpatio n 90 16 Normal sinus rhythm 100% 14 2118 141/76 90 16 Normal sinus rhythm 100% 2123 132/77 88 18 Normal sinus rhythm 100% IMPRESSION: Altered mental status, pelvic injury secondary to a motor vehicle accident. DISPOSITION: Life Lion arrived at The Hershey Medical Center without incident. The patient was off loaded from the aircraft and transferred into the trauma room. Report was given to the awaiting trauma team with Dr. Choe in attendance. Upon transfer of care, the patient remained fully immobilized on a long spine board, both IV sites remained patent. No signs of infiltration. Approximately 600 cc of lactated. ringers has been infused. There was no urine output. Valuables left with the patient consisted of his partially removed clothing and unknown contents. EMS equipment left with patient consisted of a long spine board, three long board straps, a rigid cervical collar, and a cervical immobilization device. Date Printed: 5/5/2007 Time Printed: 10:50 AM PE~IST~1~E iltQn ~. rsh Rica Winter C€r of Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 L-__ E D T r a n s p o r t N o t e D o c u m e n t Final Document Electronically Signed by: per contribution per contribution Signed By: Stark, Christopher L (2/23/2007 11:24:18 AM); Dubin, Michael B (1/21/2007 10:37:02 AM); Wood, Clayton (1/19/2007 10:56:26 AM) #551427 Review/Sign: Clayton Wood Review/Sign: Michael B Dubin, Flight Nurse Review/Sign: Christopher L Stark, DO CW /DMB DD: 01/13/07 DT: 01/13/07 07:30 Date Printed: 5/5/2007 Time Printed.' 10:50 AM PENST~TE . ~itcm ~. H~ ~Wl~ic~ It~r C+~l~ of lt~edi~ine Patient Name: CHIARA, JOHN J PSUHMC M1tN: 1133563 E m e r g e n c y D e p a r t m e n t N o t e D o c u m e n t Fina! Document Electronically Signed by: Choe, Thomas S 1/13/2007 3:34:16 PM ED SUMMARY Name: CHIARA, JOHN HMC Number: 7500215 DOB: 05/18/1991 Date of Service: 01 /12/2007 CHIEF COMPLAINT: Pediatric trauma. HPI: The history is limited, as the patient has no recollection of the accident. According to paramedics, the patient was a rear seat passenger, sitting in the middle, unbelted when they were T-boned on the driver's side. The patient was outside of the vehicle when the paramedics arrived. He is not sure how he got out there. It did not appear that he was ejected. ie likely walked out. He did complain of some left-sided hip pain initially, but-that has since resolved. He has no pain at this time. He is without complaints, although he does not remember the injury. He does not complain of any significant headache. PAST MEDICAL HISTORY: ADD. MEDICATIONS: None. ALLERGIES: He has no known drug allergies. SOCIAL HISTORY: He lives in Camp Hill, Pennsylvania REVIEW OF SYSTEMS: At least ten systems were reviewed and negative, unless otherwise indicated on the chart or HPI. On exam, his temperature is 36.1, pulse is 88, respirations 18, BP 136/77. The patient is backboarded and collared. . HEENT exam: Normocephalic, atraumatic. Pupils equal, round, and reactive to light. Extraocular movements are intact. There is no midfacial tenderness TM are clear bilaterally, without hemotympanum. Neck is in a C-collar, without midline tenderness, stepoff, or deformity. Lungs are clear bilaterally. Breath sounds are equal-bilaterally. CVS: Regular rate and rhythm. No murmurs, rubs, or gallops. Abdomen is soft, nontender, nondistended. Bowel sounds are normal. Musculoskeletal exam reveals no tenderness to his hip. He has full range of motion. His pelvis is stable. Neurologic exam: The patient is awake and alert, oriented x3. His GCS is 15. Cranial nerves II through XII are intact. Motor is 5/5 all extremely. Sensation intact to light touch all extremities. ED COURSE: This is a 15-year-old male who is a Level 2 Trauma seen in the Trauma Room. Primary and secondary surveys were performed in the Trauma Room. X-rays of his chest and pelvis were performed. I did review and did not see any acute abnormality. Lateral C-spine was also negative, as reviewed by myself. Patient then went to CAT scan, Date Printed.• 5/5/2007 Time Printed: 1 ~ •SO AM PE1~STATE tin S. rl~hey lie Ct~r C+a~~l~e of ie~l~ine Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 E m e r g e n c y D e p a r t m e n t N o t e D o c u m e n t Final Document Electronically Signed by: Choe, Thomas S 1/13/2007 3:39:16 PM where he had CT of his head, neck, facial bones, and abdomen and pelvis. The cervical spine, facial, and head CT were read by radiologist as negative for acute abnormality. No fracture or bleed. Abdomen and pelvis films were reviewed by myself. I did not see any evidence of intraabdominal injury. We are pending final reading by the radiologist. Blood work is remarkable for a K of 5.7; however, this was a hemolyzed specimen. Otherwise, his electrolytes were normal. CBC was normal. Amylase was 533. The patient was admitted to the Pediatric Trauma Service in stable condition. CLINICAL IMPRESSION: Acute concussive head injury status post MVC. #80189 Review/Sign: Thomas S Choe, MD TSC NSC DD: 01/12/07 DT: 01/12/07 23:41 Date Printed: 5/5/2007 Time Printed: 1 ~ •50 AM P~~lt~fATE iita~n 5. H~r~le~ ~ meter of 1'~edu~ine Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 A b d o m i n a l / G I D o c u m e n t( s) Document Electronically Signed by: Final CT ABDOMEN WITH CONTRAST-PED PATIENT NAME: CHIARA, JOHN PATIENT MRN:07500215 PATIENT DOB: 05/18/1991 EXAM DATE OF SERVICE: 01/12/2007 EXAM NUMBER: 1773133 ORDERING PHYSICIAN: DEFLITCH, CHRISTOPHER CT OF THE ABDOMEN AND PELVIS WITH IV CONTRAST CLINICAL INFORMATION: 15-year-old male motor vehicle accident TECHNIQUE: A helical CT of the abdomen and pelvis was performed during dynamic bolus administration of IV contrast imaged every 3 mm using bone and abdominal algorithms. COMPARISON STUDY: There are no prior studies for comparison. FINDINGS: The included•portions of the lung bases are clear. There are no rib fractures identified. ABDOMEN: The liver, gallbladder, pancreas, spleen, adrenal glands, and kidneys enhance normally without evidence of traumatic lesion. Hollow viscera of the abdomen are unremarkable. No abnormal free or loculated gas or fluid collections are identified. No osseous fractures or adenopathy identified. PELVIS: The solid and hollow organs of the pelvis are unremarkable without evidence of acute injury. There is however, what appears to be fat and soft tissue density within a loop of bowel in the lower pelvis best seen on images 109 through 126. This could represent a transient intussusception. No free fluid is seen. There is a mildly comminuted left superior ramus pubic fracture without significant surrounding soft tissue swelling. Additionally, there is a fracture of the left sacral ala. The left pubic ramus fracture demonstrated significant point tenderness on palpation. IMPRESSION: There is no evidence of acute infra-abdominal injury. No acute injury to the pelvic soft tissues identified. Mild comminuted fracture of the -left superior pubic ramus and minimally displaced fracture of the left sacral ala. Likely transient intussusception, seen best on images 109 through 126 in the lower pelvis. Findings communicated to the pediatric trauma team at the time of the examination. Date Printed: 5/5/2007 Time Printed: 10: SO AM PE~li~fATE ~il~ri S. ~ie~ Aic Ge~ter ll of lie ' 'r>~ Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 ~ A b d o m i n a l / G I D_o c u rr e n t( s) Document Electronically Signed by: Final Dr. Brandon M. Repko is the dictating resident. Attending radiologist signature indicates review of both the images and the report and that the attending radiologist agrees with the interpretation. Preliminary reports may not have been reviewed as yet by the attending radiologist. DICTATED: REPKO, BRANDON REVIEWED AND SIGNED: HULSE, MICHAEL DATE DRAFTED: 01/12/2007 11:12 PM DATE OF FINAL SIGNATURE: 01/12/2007 11:52 PM Date Printed: 5/5/2007 Mme Printed: 10:50 AM PENt~STATE Iilttm S. ~r~h~y ~ ter ~~ ~ ~lediue Patient Name: CHIA~, JOHN J PSUHMC MRN: 1133563 D i s c h a r g e S u m m a r y D o c u m e n t Final Document Electronically Signed by: per contribution per contribution Signed By: Dillon, Peter W (2/2/2007 1:48:03 PM); Cherenfant, Jovenel (2/1/2007 3:46:56 PM) DISCHARGE SUMMARY Name: CHIARA, JOHN J HMC Number: 1133563 DOB: 05/18/1991 Date of Admission: 01/12/2007 Date of Discharge: 01/13/2007 Physician: Dillon, Peter W Service: Ped Surgery Discharge Diagnosis: Mild comminuted fracture of the left superior pubic ramus and minimally displaced fracture of the ,eft sacral ala following a motor vehicle collision. Surgical Procedures: None Vaccinations Received This Hospital Stay: No vaccinations were given this hospital stay. Discharge Medications: 1. acetaminophen-codeine(Tylenol with Codeine #3 (300/30)) 1 tab by mouth every 4 hours, as needed for Pain -Mild. Brief History of Present Illness: John is a 15 year old male brought to Pennstate Children's Hospital as a trauma level 2 following a motor vehicle collision during which he was a rear seat unrestrained passenger. The details of the mechanism are unclear. Patient was amnestic to the event and was found outside of the car walking towards the paramedics on the scene. Hospital Course: Upon arrival to the trauma bay, trauma protocol was implemented. He was hemodynamically stable and GCS 15 on initial exam. Primary and secondary surveys revealed no gross traumatic injuries. CT scan of the head, spine, and abdomen were relatively normal except for Mild comminuted fracture of the left superior pubic ramus and minimally displaced fracture of the left sacral ala. The orthopedic team was consulted and assessed the fractures to be mild and nonoperative. They recommended weight bearing as tolerated on the lower extremities. The physical therapy team also evaluated the patient and found him to be mobile and independent enough for home discharge. The psychiatry team also evaluated the patient for screening of recreational drug use, which the patient denied. He was discharged to home approximately 24 hours after discharge Date Printed: 5/5/2007 Mme Printed: 10:50 AM PENNSTATE ~lt~n ~. ~~y Ilic~i meter ~vll of 1M~edi~e Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 ~ D i s c h a r g e S u m m a r y D o c u m e n t Final Document Electronically Signed by: per contribution per contribution Signed By: Dillon, Peter W (2/2/2007 1:48:03 PM); Cherenfant, Jovenel (2/1/2007 3:46:56 PM) Exam on Discharge: Afebrile, stable vital signs cranial nerves 2-12 grossly intact, 5/5 musculoskeletal strength all throughout CTAB, RRR soft NT/ND active bowel sounds extremities intact Care Instructions: Refrain from heavy lifting or extraneous activities for the next 6 weeks. Diet Guidelines: Resume regular diet as tolerated Activity Guidelines: PHYSICAL THERAPY -remember, your crutches always stay with your LEFT leg. And on the stairs, UP WITH YOUR GOOD LEG FIRST (RIGHT) AND DOWN WITH YOUR BAD LEG FIRST (LEFT). Weight bearing as tolerated on both legs. Call your doctor if: fevers greater than 101 degrees Farenheit, persistent abdominal pain with nausea and vomiting, and inability to ambulate Follow-Up Appointments: 1. Follow up with Pediatric Surgery at University Physican Center .Our office will call you within hte next few days to schedule a follow up appointment. 2. Follow up with Orthopedic pediatric fracture clinic in 2 weeks .The office will call you for the exact time of the appointment. Date Printed.' 5/5/2007 Time Printed: 10:50 AM PEI~I~STATE Iil~vn S. ~~c~h~ 1!i~ ter ~ of ' 'ne Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 D i s c h a r g e S u m m a r y D o c u m e n t Final Document Electronically Signed by: per contribution per contribution Signed By: Dillon, Peter W (2/2/2007 1:48:03 PM); Cherenfant, Jovenel (2/1/2007 3:46:56 PM) 106790 Review/Sign: Jovenel Cherenfant, MD Review/Sign: Peter W Dillon, MD Pediatric Surgery: Drs. Robert Cilley, Peter Dillon, Andreas Meier, Kerry Fagelman, Brett Engbrecht Coleen Greecher MS RD CNSD, Janet Shields MSN CRNP CS, Lynn Simmons MSN CRNP JC /TBL DD: 01/28/07 DT: 01/30/07 11:12 Date Printed: 5/5/2007 Time Printed: 10:50 AM PEIVSTATE ,it€>rln ~. ~l~h~y ~~ ter ~ of edi~ine Patient Name: CHIA1tA, JOHN J PSUHMC MIZN: 1133563 I D/ C I n s t r u c t i o n F o r m D o c u m e n t Final Document Electronically Signed by: English, Lori A 1/13/2007 7:21:33 PM PENN STATE MILTON S. HERSHEY MEDICAL CENTER 1-717-531-8521. PATIENT DISCHARGE INSTRUCTIONS If you have any questions, please contact your physician. Date of Admission: 01/12/2007 late of Discharge: 01/13/2007 Physician: Dillon, Peter W Service: Ped Surgery Discharge Diagnosis: Mild comminuted fracture of the left superior pubic ramus and minimally displaced fracture of the left sacral ala following a motor vehicle collision. Surgical Procedures: None Vaccinations Received This Hospital Stay: No vaccinations were given this hospital stay, Date Printed: 5/5/2007 Time Printed.• 10: SO AM PEN~TATE ~iit~n S. H~h~y 14ic ter ~lle~+e of Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 D/ C I n s t r u c t i o n F o r m D o c u m e n t ~ Fina[ Document Electronically Signed by: English, Lori A 1/13/2007 7:21:33 PM Discharge Medications: Medication Dose Fre uenc S ecial Instructions acetaminophen-codeine 1 tab by mouth every 4 hours, as (Tylenol with Codeine #3 needed for Pain -Mild (300/30)) Care Instructions: Refrain from heavy lifting or extraneous activities for the next 6 weeks. Diet Guidelines: Resume regular diet as tolerated Activity Guidelines: PHYSICAL THERAPY -remember, your crutches always stay with your LEFT leg. And on the stairs, UP WITH YOUR GOOD LEG FIRST (RIGHT) AND DOWN WITH YOUR BAD LEG FIRST (LEFT). Weight bearing as tolerated on both legs. Call your doctor if: fevers greater than 101 degrees Farenheit, persistent abdominal pain with nausea and vomiting, and inability to ambulate Follow-Up Appointments: Provider Location Date Time Remarks ediatric Surgery niversity Physican Center ur office will call you within hte next few ays to schedule a follow u a pointment. rthopedic pediatric e office will call you for the exact time of the acture clinic in 2 weeks ppointment. Date Printed: 5/5/2007 Mme Printed.• 10:50 AM PENIVSTATE ~ltan ~. ~ ~i t`e.~rt;~r Ca11 ~f Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 .Procedure WBC Hgb Hct RBC MCV MCHC MCH Units K/uL g/dL % M/uL fL g/dL pg Ref Range [4.8-12.0] [14-18] [39-50] [4.6-6.2] [82-96] [32-36] [28-33] 1/12/2007 Fri 0 9:40:00 PM 11.1 14.6 40.5 4.82 84.0 36.0 30.3 1/12/2007 9:40:00 PM Complete Blood Count w Differential: [[Lavender tube; Panel includes WBC count, RBC count, Hgb; Hct, Platelet count and Differential]] Procedure RDW Plts MPV Type of Diff: Neut% Lymph% Ut11ts % K/uL fL Ref Range [12.0-16.4] [140-340] [8.7-12.5] [35-71] [25-45] 1/12/2007 Fri 0 9:40:00 PM 12.1 173 9.6 AUTO 76 18 Procedure Mono% Baso% Eos% Neut, Abs Lymph, Abs Mono, Abs Baso, Abs Units % % % K/uL K/uL K/uL K/uL Ref Range [0-10] [0-2] [0-6] [1.7-8.5] [1.2-5.4] [0.0-1.2] [0.0-0.2] 1/12/2007 Fri 0 9:40:00 PM 5 0 1 8.5 2.0 0.6 0.0 Procedure Eos, Abs Units K/uL Ref Range [0.0-0.7] 1/12/2007 Fri 0 9:40:00 PM 0.1 Date Printed: 5/5/2007 Time Printed.• 10: SO AM PE~II~~TA~'E ~. r~ Il~ed'a~ +t~ ~ ~~ Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 ~ C h e m i s t r y j Procedure Na K Cret Glu Units mmoUL mmol/L mg/dL mg/dL Ref Range [135-145] [3.5-5.0] [0.8-1.4] [70-120] 1/13/2007 Sat 0 5:30:00 AM 138 1/12/2007 Fri 0 11:35:00 PM 137 3.7 1/12/2007 Fri 0 9:40:00 PM 135 5.7 0.8 113 1/13/2007 5:30:00 AM Sodium Level: [[Green gel tube; Test included in the Electrolytes, Basic Metabolic Panel, Comprehensive Metabolic Panel, and Nephrology Panel.]] 1/12/2007 11:35:00 PM Sodium Level: [[Green gel tube; Test included in the Electrolytes, Basic Metabolic Panel, Comprehensive Metabolic Panel, and Nephrology Panel.]] 1/12/2007 9:40:00 PM Sodium Level: [[Green gel tube; Test included in the Electrolytes, Basic Metabolic Panel, Comprehensive Metabolic Panel, and Nephrology Panel.]] 1/12/2007 11:35:00 PM Potassium Level: [[Green gel tube; Test included in the Electrolytes, Basic Metabolic Panel, Comprehensive Metabolic Panel, and Nephrology Panel.]] 1/12/2007 9:40:00 PM Potassium Level: [[Green gel tube; Test included in the Electrolytes, Basic Metabolic Panel, Comprehensive Metabolic Panel, and Nephrology Panel.]] 1/12/2007 9:40:00 PM K: LIEMOLYZED SPECIMEN 1/12/2007 9:40:00 PM Creatinine Level: [[Green gel tube; Test included in the Basic Metabolic Panel, Comprehensive metabolic panel, Nephrology Panel, and Renal Panel]] 1/12/2007 9:40:00 PM Glucose Level: [[ Green gel tube; Test included in the Basic Metabolic Panel, Comprehensive Metabolic Panel, and Nephrology Panel.]] Date Printed: 5%5/1007 Time Printed: 10: SO AM ~~~~~~ A+~ltan S. rshe~ ~i~ ter of ed Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 ~ C o a g u l a t i o n 1 Procedure PT TNR PTT Units second second Ref Range [9.2-11.9] [0.88-1.13] [24-34] 1/12/2007 Fri 0 9:40:00 PM 12.1 1.15 26 1/12/2007 9:40:00 PM Prothrombin Time w/ INR: [[Blue tube]] 1/12/2007 9:40:00 PM PT: Error retrieving previous result(s) 1/12/2007 9:40:00 PM PT: QUESTIONABLE RESULT, NEW SPECIMEN REQUESTED HEMOLYZED SPECIMEN 1/12/2007 9:40:00 PM INR; Error retrieving previous result(s) 1/12/2007 9:40:00 PM INR: QUESTIONABLE RESULT, NEW SPECIMEN REQUESTED HEMOLYZED SPECIMEN t/12/2007 9:40:00 PM Partial Thromboplastin Time: [[Blue tube]] 1/12/2007 9:40:00 PM PTT: Error retrieving previous result(s) .1/12/2007 9:40:00 PM PTT: QUESTIONABLE RESULT, NEW SPECIMEN REQUESTED HEMOLYZED SPECIMEN Date Printed: 5/5/2007 Time Printed: 10.•50 AM PENI~~ATE i'iton S. whey l~ica~ ter ~vlleg~e of ~=ane Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 L i v e r / G I 1 Procedure Amylase Units unit/L Ref Range [20-80] 1/12/2007 Fri 0 9:40:00 PM 33 1/12/2007 9:40:00 PM Amylase Level: [[Green Separator tube]] Date Printed: 5/5/2007 Time Printed.• 10:50 AM FFNi'~~TATE __ ilt+an ~. ~ ~~ ter +~oll of ~u'~~dli~ Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 T o x i c o l o g y ~ Procedure EtOH med Amphet Barbiturates Benzos Units mg/dL Ref Range [<10] 1/13/2007 Sat 0 12:40:00 AM NONE DETECTED NONE DETECTED NONE DETECTED 1/12/2007 Fri 0 9:40:00 PM <10 1/13/2007 12:40:00 AM Drugs of Abuse w NO confirm, Urine: [[Urine, random]] Procedure Cocaine Marijuana Units Ref Range 1/13/2007 Sat 0 12:40:00 AM NONE DETECTED PRESUMPTIVE POSITIVE DRUG RESULT Procedure Opiates Units Ref Range 1/13/2007 Sat 0 12:40:00 AM PRESUMPTIVE POSITIVE DRUG RESULT Date Printed: 5/5/2007 Time Printed: 10:50 AM PEIV~STATE S. ~I~rshey A+ie it~r a~' Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 I B l o o d B a n k ~ Procedure ABO/Rh Antibody Scr Expires at 0600AM on R Number Component Units Ref Range 1/12/2007 Fri 0 9:30:00 PM A NEGATNE 01/15/2007 R34861 RED CELLS POSITIVE Procedure # Units Units Ref Range 1/12/2007 Fri 0 9:30:00 PM 0 Date Printed.• 5/5/1007 Time Printed: 10:50 AM P~1~i~5TATE Hilton ~. H~ie~ I4ir meter +Cv of ` '~~ Patient Name: CHIAItA, JOHN J PSUHMC MRN: 1133563 Procedure Containers received to hold Units Ref Range 1/12/2007 Fri 0 9:40:00 PM GREEN 1/12/2007 9:40:00 PM Containers received to hold: RED Date Printed: 5/5/2007 Time Printed: 10:50 AM P'E~I~TATE ~:t~m S. H~hey ~'~ ~r Cvll~±e of d~~,te Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 ~ H e a d / N e c k - S t u d y ~ Final CT FACIAL BONES WITHOUT CONTRAST-PED PATIENT NAME: CHIARA, JOHN PATIENT MRN:07500215 PATIENT DOB: 05/18/1991 EXAM DATE OF SERVICE: 01/12/2007 EXAM NUMBER: 1773137 ORDERING PHYSICIAN: DEFLITCH, CHRISTOPHER ROUTINE NONCONTRAST FACIAL BONE CT, CERVICAL SPINE CT AND HEAD CT CLINICAL HISTORY: 15-year-old male motor vehicle accident. TECHNIQUE: A routine helical CT of the facial bones was performed using soft tissue and bone algorithms. Routine sagittal and coronal reconstructions were performed. A routine noncontrast head CT was performed. A routine helical CT of the cervical spine was performed using soft tissue and bone algorithms. COMPARISON: There are no prior studies for comparison. DISCUSSION: BRAIN: Attenuation of the brain parenchyma (including gray white differentiation) is normal without evidence for mass, hemorrhage, or midline shift. No abnormal infra or extra axial fluid collection is identified. The size and configuration of the ventricles and sulci is normal. The quadrigeminal plate cistern is open. No evidence for herniation is seen. There is mild mucoperiosteal thickening in the right frontal sinus and left middle ethmoid sinus. The visualized portions of the orbits, paranasal sinuses, mastoid air spaces, and calvarium are otherwise unremarkable. CERVICAL SPINE: The cervical spine was imaged from the craniocervical junction through the upper portion of T1. The vertebral bodies, disc spaces, alignment, and paravertebral soft tissues are intact without evidence for acute fracture, subluxation or dislocation. The visualized portions of the lung apices are unremarkable. FACIAL BONES: The orbits, orbital contents, and visualized paranasal sinuses are unremarkable. There is no evidence of facial bone fracture. The skull base is intact. The mastoid air cells are normally aerated. The soft tissues are unremarkable. IMPRESSION: No evidence for acute traumatic injury to the head or face. No cervical spine fracture or intracranial hemorrhage is seen. Date Printed: 5/5/1007 Time Printed: 10:50 AM PE1~~JSTA~E ~Iil~n ~. ~Li~y I!u~ecic nt~r C~ cif ' 'ne Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 H e a d / N e c k - S t u d y Final Dr. Brandon M. Repko is the dictating resident. Attending radiologist signature indicates review of both the images and the report and that the attending radiologist agrees with the interpretation. Preliminary reports may not have been reviewed as yet by the attending radiologist. DICTATED: REPKO, BRANDON REVIEWED AND SIGNED: KALAPOS, PAUL DATE DRAFTED: 01/12/2007 10:51 PM DATE OF FINAL SIGNATURE: 01/13/2007 09:36 AM Date Printed: 5/5/2007 Time Printed.• 10:50 AM PE~IST~~"E ~1 5.~ h~ Il+aic meter +ca a ~ Patient Name: CHIARA, JOHN J PSUHMC MRN; 1133563 H e a d / N e c k - S t u d y Final CT HEAD WITHOUT CONTRAST PED PATIENT NAME: CHIARA, JOHN PATIENT MRN:07500215 PATIENT DOB: 05/18/1991 EXAM DATE OF SERVICE: 01/12/2007 EXAM NUMBER: 1773129 ORDERING PHYSICIAN: DEFLITCH, CHRISTOPHER ROUTINE NONCONTRAST FACL~I. BONE CT, CERVICAL SPINE CT AND HEAD CT CLINICAL HISTORY: 15-year-old male motor vehicle accident. TECHNIQUE: A routine helical CT of the facial bones was performed using soft tissue and bone algorithms. Routine sagittal and coronal reconstructions were performed. A routine noncontract head CT was performed. A routine helical CT of the cervical spine was performed using soft tissue and bone algorithms. COMPARISON: There are no prior studies for comparison. DISCUSSION: BRAIN: Attenuation of the brain parenchyma (including gray white differentiation) is normal without evidence for mass, hemorrhage, or midline shift. No abnormal infra or extra axial fluid collection is identified. The size and configuration of the ventricles and sulci is normal. The quadrigeminal plate cistern is open. No evidence for herniation is seen. There is mild mucoperiosteal thickening in the right frontal sinus and left middle ethmoid sinus. The visualized portions of the orbits, paranasal sinuses, mastoid air spaces, and calvarium are otherwise unremarkable. CERVICAL SPINE: The cervical spine was imaged from the craniocervical junction through the upper portion of T 1. The vertebral bodies, disc spaces, alignment, and paravertebral soft tissues are intact without evidence for acute fracture, subluxation or dislocation. The visualized portions of the lung apices are unremarkable. FACIAL BONES: The orbits, orbital contents, and visualized paranasal sinuses are unremarkable. There is no evidence of facial bone fracture. The skull base is intact. The mastoid air cells are normally aerated. The soft tissues are unremarkable. IMPRESSION: No evidence for acute traumatic injury to the head or face. No cervical spine fracture or intracranial hemorrhage is seen. Date Printed: 5/5/2007 Time Printed.' 1 D: 50 AM ~1+~lton ~. Her .~ t;t~er of 1V~edi~ine Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 H e a d / N e c k - S t u d y ~ Final Dr. Brandon M. Repko is the dictating resident. Attending radiologist signature indicates review of both the images and the report and that the attending radiologist agrees with the interpretation. Preliminary reports may not have been reviewed as yet by the attending radiologist. DICTATED: REPKO, BRANDON REVIEWED AND SIGNED: KALAPOS, PAUL DATE DRAFTED: 01/12/2007 10:51 PM DATE OF FINAL SIGNATURE: 01/13/2007 09:36 AM Date Printed.• 5/5/2007 Time Printed: 10:50 AM ~'fAll ~. ~~'~' l~l,~t.t+~l t .E'~1>~T ll r~rf ~.1itxne Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 ~ S p i n e - S t u d y ~ Modified X-RAY SPINE 1 VIEW- CERIVICAL PEDS PATIENT NAME: CHIARA, JOHN J PATIENT MRN:01133563 PATIENT DOB: 05/18/1991 EXAM DATE OF SERVICE: 01/12/2007 EXAM NUMBER: 1773108 ORDERING PHYSICIAN: DEFLITCH, CHRISTOPHER AP CHEST, LATERAL C-SPINE, AP PELVIS Clinical History: I S year old male motor vehicle accident Comparison: None. DISCUSSION: Chest: The patient is lying on a backboard. There is no evidence of pneumothorax. The lungs are clear. The cardiomediastinal silhouette is within normal limits. There is no radiographic evidence of acute bony abnormality. C-spine: One lateral view of the cervical spine is submitted. Shoulders obscure visualization of C7-T1. There is normal alignment and positioning of the vertebral bodies. The vertebral body heights are well maintained. There is no swelling of the prevertebral soft tissues. There is no fracture or subluxation. Pelvis: The patient is lying on a backboard. There is questionable lucency at the medial aspect of the left superior pubic ramus. There is no evidence of additional fracture or dislocation. The soft tissues are grossly normal. IMPRESSION: Normal chest. Unremarkable but limited lateral cervical spine. Questionable lucency at the medial aspect of the left superior pubic ramus. This corresponds to the nondisplaced fracture of the superior pubic rami, seen best on the CT. Dr. Brandon M. Repko is the dictating resident. Attending radiologist signature indicates review of both the images and the report and that the attending radiologist agrees with the interpretation. Preliminary reports may not have been reviewed as yet by the attending radiologist. Date Printed.' 5/5/2007 Time Printed.• 1 D.•50 AM i PE~1I'~STATE ~iltan S. ~~rs~y Aie ~r ~ll ofd ~` 'ne Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 ~ S p i n e - S t u d y ~ Modified DICTATED: REPKO, BRANDON REVIEWED AND SIGNED: HULSE, MICHAEL DATE DRAFTED: 01/12/2007 11:27 PM DATE OF FINAL SIGNATURE: 01/13/2007 09:29 AM Date Printed: 5/5/2007 Time Printed.• 10:50 AM PE~Jt~+f~TA~'E iltcm S. ~> 1~~ ter u of ~V~ed>l~lne Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 S p i n e - S t u d y Final CT CERVICAL SPINE WITHOUT CONTRAST-PED PATIENT NAME: CHIARA, JOHN PATIENT MRN:07500215 PATIENT DOB: 05/18/1991 EXAM DATE OF SERVICE: 01/12/2007 EXAM NUMBER: 1773136 ORDERING PHYSICIAN: DEFLITCH, CHRISTOPHER ROUTINE NONCONTRAST FACIAL BONE CT, CERVICAL SPINE CT AND HEAD CT CLII~TICAL HISTORY: 15-year-old male motor vehicle accident. TECHNIQUE: A routine helical CT of the facial bones was performed using soft tissue and bone algorithms. Routine sagittal and coronal reconstructions were performed. A routine noncontrast head CT was performed. A routine helical CT of the cervical spine was performed using soft tissue and bone algorithms. COMPARISON: There are no prior studies for comparison. DISCUSSION: BRAIN: Attenuation of the brain parenchyma (including gray white differentiation) is normal without evidence for mass, hemorrhage, or midline shift. No abnormal infra or extra axial fluid collection is identified. The size and configuration of the ventricles and sulci is normal. The quadrigeminal plate cistern is open. No evidence for herniation is seen. There is mild mucoperiosteal thickening in the right frontal sinus and left middle ethmoid sinus. The visualized portions of the orbits, paranasal sinuses, mastoid air spaces, and calvarium are otherwise unremarkable. CERVICAL SPINE: The cervical spine was imaged from the craniocervical junction through the upper portion of T1. The vertebral bodies, disc spaces, alignment, and paravertebral soft tissues are intact without evidence for acute fracture, subluxation or dislocation. The visualized portions of the lung apices are unremarkable. FACIAL BONES: The orbits, orbital contents, and visualized paranasal sinuses are unremarkable. There is no evidence of facial bone fracture. The skull base is intact. The mastoid air cells are normally aerated. The soft tissues are unremarkable. IMPRESSION: No evidence for acute traumatic injury to the head or face. No cervical spine fracture or intracranial hemorrhage is seen. Date Printed: 5/5/2007 Time Printed: 10:50 AM . ~E~~:J' l/~rTE ~1tfln S. ~l~ersh~y ~. ~r of 11~edicane Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 ~ S p i n e - S t u d y ~ Final Dr. Brandon M. Repko is the dictating resident. Attending radiologist signature indicates review of both the images and the report and that the attending radiologist agrees with the interpretation. Preliminary reports may not have been reviewed as yet by the attending radiologist. DICTATED: REPKO, BRANDON REVIEWED AND SIGNED: KALAPOS, PAUL DATE DRAFTED: 01/12/2007 10:51. PM DATE OF FINAL SIGNATURE: 01/13/2007 09:36 AM Date Printed: 5/5/2007 Mme Printed: 10:50 AM PEI~~IST~-TE iltvon ~. H~r~h.~y ~.i.~. r C€>!ll of 1!dc~nne Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 P e I v i s/ G U - S t u d y Modified X-RAY PELVIS AP 1-2 VIEWS - PEDS PATIENT NAME: CHIARA, JOHN J PATIENT MRN:01133563 PATIENT DOB: 05/18/1991 EXAM DATE OF SERVICE: 01/12/2007 EXAM NUMBER: 1773107 ORDERING PHYSICIAN: DEFLITCH, CHRISTOPHER AP CHEST, LATERAL C-SPINE, AP PELVIS Clinical History: 15 year old male motor vehicle accident Comparison: None. DISCUSSION: Chest: The patient is lying on a backboard. There is no evidence of pneumothorax. The lungs are clear. The cardiomediastinal silhouette is within normal limits. There is no radiographic evidence of acute bony abnormality. C-spine: One lateral view of the cervical spine is submitted. Shoulders obscure visualization of C7-T1. There is normal alignment and positioning of the vertebral bodies. The vertebral body heights are well maintained. There is no swelling of the prevertebral soft tissues. There is no fracture or subluxation. PeIvis: The patient is lying on a backboard. There is questionable lucency at the medial aspect of the left superior pubic ramus. There is no evidence of additional fracture or dislocation. The soft tissues are grossly normal. IMPRESSION: Normal chest. Unremarkable but limited lateral cervical spine. Questionable lucency at the medial aspect of the left superior pubic ramus. This corresponds to the nondisplaced fracture of the superior pubic rami, seen best on the CT. Dr. Brandon M. Repko is the dictating resident. Attending radiologist signature indicates review of both the images and the report and that the attending radiologist agrees with the interpretation. Preliminary reports may not have been reviewed as yet by the attending -adiologist. Date Printed: 5/5/2007 Time Printed: 10:50 AM PE~II~,~TE Stan ~. ~1ey ~ C~t~r Cap of ' Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 P e l v i s! G U - S t u d y Modified DICTATED: REPKO, BRANDON REVIEWED AND SIGNED: HULSE, MICHAEL DATE DRAFTED: 01/12/2007 11:27 PM DATE OF FINAL SIGNATURE: 01/13/2007 09:29 AM Date Printed: 5/5/2007 Time Printed.• 10.•50 AM PE~II~STATE ~t~ ~. ~ Ilie~ Winter CQII of ' 'ne Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 P e l v i s/ G U - S t u d v Final X-RAY PELVIS 3 OR MORE VIEWS PATIENT NAME: CHIARA, JOHN PATIENT MRN:07500215 PATIENT DOB: 05/18/1991 EXAM DATE OF SERVICE: 01/13/2007 EXAM NUMBER: 1773356 ORDERING PHYSICIAN: DILLON, PETER Exam: AP, inlet, and outlet views of the pelvis. Clinical History: 15-year-old male status post motor vehicle accident. Comparison studies: Previous CT from 1/12/2007. Findings: Subtle bony deformities are seen at the left sacral ala and left superior pubic ramus, consistent with known fractures seen on previous CT. There is no evidence of interval displacement. No new fractures are identified. Visualized bowel gas pattern is nonobstructed. Overlying soft tissues are unremarkable. impression: Subtle bony deformities at the left sacral ala and left superior ramus, consistent with known fractures seen on previous CT. No new fractures visualized. Dr. Karen M. Brown is the dictating radiology resident. Attending radiologist signature indicates review of both the images and the report and that the attending radiologist agrees with the interpretation. Preliminary reports may not have been reviewed as yet by the attending radiologist. DICTATED: BROWN, KAREN REVIEWED AND SIGNED: BROWN, KAREN / FLEMMING, DONALD J DATE DRAFTED: 01/13/2007 12:04 PM DATE OF FINAL SIGNATURE: 01/13/2007 01:24 PM Date Printed: 5/5/1007 Time Printed: 10:50AM PE~I~STATE ~~>n S. ~~iey laic it~r Call~ge o~ Mt~xe Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 P e l v i s/ G U - S t u d y Final CT PELVIS WITH CONTRAST-PED PATIENT NAME: CHIARA, JOHN PATIENT MRN:07500215 PATIENT DOB: 05/18/1991 EXAM DATE OF SERVICE: 01/12/2007 EXAM NUMBER: 1773134 ORDERING PHYSICIAN: DEFLITCH, CHRISTOPHER CT OF THE ABDOMEN AND PELVIS WITH IV CONTRAST CLINICAL INFORMATION: 15-year-old male motor vehicle accident TECHNIQUE: A helical CT of the abdomen and pelvis was performed during dynamic bolus administration of IV contrast imaged every 3 mm using bone and abdominal algorithms. COMPARISON STUDY: There are no prior studies for comparison. FINDINGS: The included portions of the lung bases are clear. There are no rib fractures identified. ABDOMEN: The liver, gallbladder, pancreas, spleen, adrenal glands, and kidneys enhance normally without evidence of traumatic lesion. Hollow viscera of the abdomen are unremarkable. No abnormal free or loculated gas or fluid collections are identified. No osseous fractures or adenopathy identified. PELVIS: The solid and hollow organs of the pelvis are unremarkable without evidence of acute injury. There is however, what appears to be fat and soft tissue density within a loop of bowel in the lower pelvis best seen on images 109 through 126. This could represent a transient intussusception. No free fluid is seen. There is a mildly comminuted left superior ramus pubic fracture without significant surrounding soft tissue swelling. Additionally, there is a fracture of the left sacral ala. The left pubic ramus fracture demonstrated significant point tenderness on palpation. IMPRESSION: There is no evidence of acute infra-abdominal injury. No acute injury to the pelvic soft tissues identified. Mild comminuted fracture of the left superior pubic ramus and minimally displaced fracture of the left sacral ala. Likely transient intussusception, seen best on images 109 through 126 in the lower pelvis. Findings communicated to the pediatric trauma team at the time of the examination. Date Printed: 5/5/2007 Time Printed: 10: SO AM PE~lI~~T~TE ~ilt~m ~. fey Iic meter lt~e of ~~ Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 P e l v i s/ G U - S t u d y Fina[ Dr. Brandon M. Repko is the dictating resident. Attending radiologist signature indicates review of both the images and the report and that the attending radiologist agrees with the interpretation. Preliminary reports may not have been reviewed as yet by the attending. radiologist. DICTATED: REPKO, BRANDON REVIEWED AND SIGNED: HULSE, MICHAEL DATE DRAFTED: O 1 / 12/2007.11:12 PM DATE OF FINAL SIGNATURE: 01/12/2007 11:52 PM Date Printed: 5/5/2007 Time Printed.• 10:50 AM ~E~~T~T~ lttyn- S. Hershey ~i ~r ~:a-ll+e of 1~V~eci~e Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 C h e s t - S t u d y Modified X-RAY CHEST PA OR AP VIEW- PEDS PATIENT NAME: CHIARA, JOHN J PATIENT MRN:01133563 PATIENT DOB: 05/18/1991 EXAM DATE OF SERVICE: 01/12/2007 EXAM NUMBER: 1773109 ORDERING PHYSICIAN: DEFLITCH, CHRISTOPHER AP CHEST, LATERAL C-SPINE, AP PELVIS Clinical History: 15 year old male motor vehicle accident Comparison: None. DISCUSSION: Chest: The patient is lying on a backboard. There is no evidence of pneumothorax. The lungs are clear. The cardiomediastinal silhouette is within normal limits. There is no radiographic evidence of acute bony abnormality. C-spine: One lateral view of the cervical spine is submitted. Shoulders obscure visualization of C7-T1. There is normal alignment and positioning of the vertebral bodies. The vertebral body heights are well maintained. There is no swelling of the prevertebral soft tissues. There is no fracture or subluxation. Pelvis: The patient is lying on a backboard. There is questionable lucency at the medial aspect of the left superior pubic ramus. There is no evidence of additional fracture or dislocation. The soft tissues are grossly normal. IMPRESSION: Normal chest. Unremarkable but limited lateral cervical spine. Questionable lucency at the medial aspect of the left superior pubic ramus. This corresponds to the nondisplaced fracture of the superior pubic rami, seen best on the CT. Dr. Brandon M. Repko is the dictating resident. Attending radiologist signature indicates review of both the images and the report and that the attending radiologist agrees with the interpretation. Preliminary reports may not have been reviewed as yet by the attending radiologist. Date Printed.• 5/5/2007 Tirne Printed: 10:50 AM PE~STATE ~. ~~cy 11?u ter ~ ..nee Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 ~ C h e s t - S t u d y ~ Modified DICTATED: REPKO, BRANDON REVIEWED AND SIGNED: HULSE, MICHAEL DATE DRAFTED: 01/12/2007 11:27 PM DATE OF FINAL SIGNATURE: 01/13/2007 09:29 AM Date Printed: 5/5/2007 Time Printed; 10: SO AM PEIi~T~TE ittm ~. ~ A~ t+~r of tVi~ne Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 A b d o m e n - S t u d y Final CT ABDOMEN WITH CONTRAST-PED PATIENT NAME: CHIARA, JOHN PATIENT MRN:07500215 PATIENT DOB: 05/18/1991 EXAM DATE OF SERVICE.: 01/12/2007 EXAM NUMBER: 1773133 ORDERING PHYSICIAN: DEFLITCH, CHRISTOPHER CT OF THE ABDOMEN AND PELVIS WITH IV CONTRAST CLINICAL INFORMATION: 15-year-old male motor vehicle accident TECHNIQUE: A helical CT of the abdomen and pelvis was performed during dynamic bolus administration of IV contrast imaged every 3 mm using bone and abdominal algorithms. COMPARISON STUDY: There are no prior studies for comparison. FINDINGS: The included portions of the lung bases are clear. There are no rib fractures identified. ABDOMEN: The liver, gallbladder, pancreas, spleen, adrenal glands, and kidneys enhance normally without evidence of traumatic lesion. Hollow viscera of the abdomen are unremarkable. No abnormal free or loculated gas or fluid collections are identified. No osseous fractures or adenopathy identified. PELVIS: The solid and hollow organs of the pelvis are unremarkable without evidence of acute injury. There is however, what appears to be fat and soft tissue density within a loop of bowel in the lower pelvis best seen on images 109 through 126. This could represent a transient intussusception. No free fluid is seen. There is a mildly comminuted left superior ramus pubic fracture without significant surrounding soft tissue swelling. Additionally, there is a fracture of the left sacral ala. The left pubic ramus fracture demonstrated significant point tenderness on palpation. IMPRESSION: There is no evidence of acute infra-abdominal injury. No acute injury to the. pelvic soft tissues identified. Mild comminuted fracture of the left superior pubic ramus and minimally displaced fracture of the left sacral ala. Likely transient intussusception, seen best on images 109 through 126 in the lower pelvis. Findings communicated to the pediatric trauma team at the time of the examination. Date Printed: 5/5/2D07 Time Printed: 10: SO AM FEN~JSTATE ~tiltcm S. ~~y laic ter Ca11 of ~~1 Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 1 A b d o m e n - S t u d v 1 Final Dr. Brandon M. Repko is the dictating resident. Attending radiologist signature indicates review of both the images and the report and that the attending radiologist agrees with the interpretation. Preliminary reports may not have been reviewed as yet by the attending radiologist. DICTATED: REPKO, BRANDON REVIEWED AND SIGNED: HULSE, MICHAEL DATE DRAFTED: O 1 / 12/2007 11:12 PM DATE OF FINAL SIGNATURE: 01/12/2007 11:52 PM Date Printed: 5/5/2007 Time Printed: 10:50 AM PEN~ISTATE ~'i1t~n S. fey ~i~ meter +Cv of ~'4~die Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 M u s c u l o s k e l e t a l - S t u d y Final X-RAY FEMUR LEFT - PEDS PATIENT NAME: CHIARA, JOHN PATIENT MRN:07500215 PATIENT DOB: 05/18/1991 EXAM DATE OF SERVICE: 01/12/2007 EXAM NUMBER: 1773140 ORDERING PHYSICIAN: DEFLITCH, CHRISTOPHER LEFT HIP TWO VIEWS LEFT FEMUR FOUR VIEWS CLINICAL HISTORY: 15-year-old male motor vehicle accident, restrained lap belt COMPARISONS: There are no prior studies for comparison. DISCUSSION: Left hip: There is a fracture of the left superior pubic symphysis, question comminution. There is no other fracture or dislocation identified. The femoral head is well maintained. Left femur: Four views of the left femur demonstrate no fracture or dislocation. There is no joint effusion or soft tissue swelling. There is limited evaluation of the femur on the AP views due to the rod overlying the patient. IMPRESSION: Likely left superior pubic symphysis mildly comminuted fracture. No acute osseous injury of the left femur identified. Dr. Brandon M. Repko is the dictating resident. Attending radiologist signature indicates review of both the images and the report and that the attending radiologist agrees with the interpretation. Preliminary reports may not have been reviewed as yet by the attending radiologist. DICTATED; REPKO, BRANDON REVIEWED AND SIGNED: HULSE, MICHAEL DATE DRAFTED: O 1 / 12/2007 11:16 PM DATE OF FINAL SIGNATURE: 01/13/2007 09:33 AM Date Printed: 5/5!2007 Time Printed: 10:50 AM PEN[~STATE t~ S. rsh ~ iter ~:ae of lt~edicin~ Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 M u s c u l o s k e l e t a l - S t u d y Final X-RAY HIP UNILATERAL 2 OR MORE VIEWS LEFT - PEDS PATIENT NAME: CHIARA, JOHN PATIENT MRN:07500215 PATIENT DOB: 05/18/1991 EXAM DATE OF SERVICE: 01/12/2007 EXAM NUMBER: 1773139 ORDERING PHYSICIAN: DEFLITCH, CHRISTOPHER LEFT HIP TWO VIEWS LEFT FEMUR FOUR VIEWS CLINICAL HISTORY: 15-year-old male motor vehicle accident, restrained lap belt COMPARISONS: There are no prior studies for comparison. DISCUSSION: Left hip: There is a fracture of the left superior pubic symphysis, question comminution. There is no other fracture or dislocation identified. The femoral head is well maintained. Left femur: Four views of the left femur demonstrate no fracture or dislocation. There is no joint effusion or soft tissue swelling. There is limited evaluation of the femur on the AP views due to the rod overlying the patient. IMPRESSION: Likely left superior pubic symphysis mildly comminuted fracture. No acute osseous injury of the left femur identified. Dr. Brandon M. Repko is the dictating resident. Attending radiologist signature indicates review of both the images and the report and that the attending radiologist agrees with the interpretation. Preliminary reports may not have been reviewed as yet by the attending radiologist. DICTATED: REPKO, BRANDON REVIEWED AND SIGNED: HULSE, MICHAEL DATE DRAFTED: 01/12/2007 11:16 PM DATE OF FINAL SIGNATURE: 01/13/2007 09:33 AM Date Printed: 5/5/2007 Time Printed: 10:50 AM PEN~STATE 1t~n ~. ~er~isey ~ ter C€~ll of 1'~e Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 P a t i e n t E d u c a t i o n ( E D) ED Pat Edu ~ D e p a r t S u m m a r y ( E D) ~ Depart Summary Penn State Milton S. Hershey Medical Center Emergency Department Depart Summary PERSON INFORMATION Name CHIARA, JOHN Age 15 Years Sex Male Language Marital Status Single Phone 7177373380 MRN 7500215 Visit Id Visit Reason ; MVC Specialty Enc Type Inpatient Med Service Ped Surgery Track Group EMER Trk Gp Discharge Tracking Id 3596698 Checkout 1/13/2007 7:31 PM Checkin 1/12/2007 9:23 PM Acuity 2 Arrival 1/12/2007 10:31 PM Reg Status Start Address: 1320 CARLISLE RD CAMP HILL Pennsylvania 170110000 DIAGNOSIS POWERFORMS SCHEDULING DOB 5/18/1991 12:00 AM PCP Acct# 10500215 Referred by Dispo Type Adm Univ Hos LOS 000 22:08 Date Printed: 5/5/2007 Time Printed: 10: SO AM P~~VI~STATE ~~~ S. Hfhey die Cuter Call of ' ' Patient Name: CHIARA, JOHN J PSUI-IMC MRN: 1133563 D e p a r t S u m m a r y ( E D) PHYS DOC NOTES DEPART REASON INCOMPLETE INFORMATION Depart Action Incomplete Reason Diagnosis Patient Admitted Discharge Instructions Patient Admitted Patient Understanding Patient Admitted PROVIDER INFORMATION Provider Rote Choe, Thomas S Physician Martin, Leanne P RN Dillon, Peter W Physician R.E.S. Not Needed R.E.S. Assigned 1/12/2007 9:44 PM 1/12/2007 9:55 PM 1/12/2007 11:25 PM 1/13/2007 6:56 AM Unassigned 1/12/2D07 11:25 PM 1/13/2007 7:14 AM RN Kelly, Amy B RN EVENTS INFORMATION Event Name Event Status 1/13/2007 7:14 AM 1/13/2007 7:12 PM Request Date/Time Start Date/Time 1/13/2007 7:12 PM Complete Date/Time Date Printed.• 5/5/1007 Time Printed.• 10:50 AM PE~ISTATE ~i t>~ ~. ~~yy Aiie ter ~c~illege of ' ' e Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 Arrive Complete 1/12/2007 9:23 PM 1/12/2007 9:23 PM 1/12/2007 9:23 PM Triage Complete 1/12/2007 9:23 PM 1/12/2007 11:49 PM 1/12/2007 11:49 PM Arrive Registration Complete 1/12/2007 9:23 PM 1/12/2007 9:23 PM 1/12/2007 9:23 PM Registration Complete 1/12/2007 9:23 PM 1/12/2007 10:27 PM 1/12/2007 10:27 PM Arrive MD Bill Complete 1!12/2007 9:23 PM 1/12/2007 9:23 PM 1/12/2007 9:23 PM MD Bill Complete 1/12/2007 9:23 PM 1/12/2007 11:14 PM 1/12/2007 11:14 PM Arrive Dictate Complete 1/12/2007 9:23 PM 1/12!2007 9:23 PM 1/12/2007 9:23 PM Dictate Request 1/12/2007 9:23 PM Arrive PT Belongings Complete 1/12/2007 9:23 PM 1!12/2007 9:23 PM 1/12/2007 9:23 PM Bed Assign PT Belong Complete 1/12/2007 9:23 PM 1/12/2007 9:24 PM 1/12/2007 9:24 PM Arrive Bed Assign Complete 1/12/2007 9:23 PM 1/12/2007 9:23 PM 1/12/2007 9:23 PM Bed Assign Complete 1/12/2007 9:23 PM 1/12/2007 9:24 PM 1/12/2007 9:24 PM MD Assess Complete 1/12/2007 9:24 PM 1/12/2007 9:44 PM 1/12/2007 9:44 PM RN Assess Complete 1/12/2007 9:24 PM 1/12/2007 11:49 PM 1/12/2007 11:49 PM Resident Assess Complete 1/12/2007 9:24 PM 1/13/2007 6:56 AM 1/13/2007 6:56 AM Patient Belongings Complete 1/12/2007 9:24 PM 1/12/2007 11:49 PM 1/12/2007 11:49 PM PT Care Complete 1/12/2007 9:40 PM 1/12/2007 10:34 PM EDT Task Complete 1/12/2007 9:40 PM 1/12/2007 10:34 PM Lab Collect Collected 1/12/2007 9:40 PM Urine Collect Complete 1/12/2007 9:40 PM 1/12/2007 10:35 PM IV Care Complete 1!12/2007 9:40 PM 1/12/2007 10:36 PM Request Consult Complete 1/12/2007 9:40 PM 1/12/2007 10:17 PM Xray Cancel 1/12/2007 9:40 PM 1/12/2007 9:45 PM Xray Complete 1/12/2007 9:41 PM 1/12/2007 9:47 PM 1/12/2007 10:35 PM Lab Collect Complete 1/12/2007 9:43 PM 1/12!2007 9:43 PM 1/12/2007 9:44 PM Lab Collect Complete 1/12/2007 9:43 PM 1/12/2007 9:43 PM 1/12/2007 10:23 PM Xray Cancel 1/12/2007 9:44 PM 1/12/2007 9:46 PM 1/12/2007 10:30 PM Date Printed: 5/5/1007 7<me Printed: 10: SO AM FE~V~ISTA-TE ilttm S. €~~ry ~ writer ~~ of ~li~ine Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 Xray Complete 1/12/2007 9:44 PM 1/12/2007 9:46 PM 1/12/2007 10:35 PM Xray Complete 1/12/2007 9:44 PM 1/12/2007 9:46 PM 1/12/2007 10:35 PM Xray Cancel 1/12/2007 9:44 PM 1/12/2007 9:46 PM 1/12/2007 10:21 PM Xray Complete 1/12/2007 9:44 PM 1/12/2007 9:47 PM 1/12/2007 10:46 PM Xray Complete 1/12/2007 9:44 PM 1/12/2007 9:47 PM 1/12/2007 10:46 PM Xray Cancel 1/12/2007 9:44 PM 1/12/2007 9:46 PM 1/12/2007 10:21 PM Lab Collect Complete 1/12/2007 9:59 PM 1/12/2007 11:39 PM 1/12/2007 11:39 PM Consult Request 1/12/2007 10:17 PM Admit Complete 1/12/2007 10:34 PM 1/12/2007 10:47 PM PT Care Request 1/12/2007 10:34 PM EDT Task Complete 1/12/2007 10:34 PM 1/12/2007 11:33 PM Rx Request 1/12/2007 10:34 PM ~_ab Collect Cancel 1/12/2007 10:34 PM 1!12/2007 10:41 PM Request Consult Request 1/12/2007 10:34 PM Lab Collect Complete 1/12/2007 10:38 PM 1/12/2007 11:13 PM 1/12/2007 11:13 PM Lab Collect Complete 1!12/2007 10:40 PM 1/13/2007 12:21 AM Lab Collect Cancel 1/12/2007 10:41 PM 1/13/2007 10:31 AM Lab Collect Complete 1/12/2007 11:14 PM 1/12/2007 11:14 PM 1/12/2007 11:28 PM MD Assess Complete 1!1212007 11:25 PM 1/12/2007 11:25 PM 1/12/2007 11:25 PM Rx Request 1/13/2007 12:07 AM MD Assess Complete 1/13/2007 6:56 AM 1/13/2007 6:56 AM 1/13/2007 6:56 AM MD Assess Complete 1!13/2007 7:14 AM 1/13/2007 7:14 AM 1/13/2007 7:14 AM Resident Assess Complete 1/13/2007 7:14 AM 1/13/2007 7:14 AM 1113/2007 7:14 AM Request Consult Complete 1/13/2007 9:53 AM 1/13/2007 10:45 AM Xray Complete 1/13/2007 9:59 AM 1/13/2007 11:19 AM 1/13/2007 11:48 AM Request Consult Complete 1/13/2007 10:12 AM 1/13/2007 10:48 AM Date Printed: 5/5/2007 Time Printed.• 10: SO AM PEIV~S~TATE iltan S. ~3~ie~ II-aic t+~r twlle of iV~e~c~n-e Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 Request Consult Request 1/13/2007 10:12 AM Request Consult Request 1/13/2007 10:32 AM Rx Request 1/13/2007 10:33 AM Rx Request 1/13/2007 6:31 PM MD Assess Complete 1/13/2007 7:12 PM 1/13/2007 7:12 PM 1/13/2007 7:12 PM Resident Assess Complete 1/13/2007 7:12 PM 1/13/2007 7:12 PM 1/13/2007 7:12 PM DischargelTransfer Request 1/13/2007 7:21 PM LOCATION INFORMATION Arrival Nurse Unit Room Bed x/12/2007 9:23 PM EMER Waiting Room 1/12/2007 9:24 PM EMER TRB 1/12/2007 10:59 PM EMER 14 1/13/2007 7:31 PM EMER Check Out ORDERS INFORMATION Start Time Order Type Status Stop Time Provider 1/12/2007 9:24 PM ED Nursing Charge Patient Care Completed 1/12/2007 11:40 PM SYSTEM 1/12/2007 9:40 PM ED Trauma Adult Level 2 Order Sets Ordered 1/12/2007 9:40 PM Dillon, Peter W 1/12/2007 9:39 PM Neuro Check Patient Care Completed 1/12/2007 10:34 PM Dillon, Peter W 1/12/2007 9:39 PM Pulse Oximetry Continuous Patient Care Completed 1/12/2007 10:34 PM Dillon, Peter W 1/12/2007 9:39 PM Vital Signs Patient Care Completed 1/12/2007 10:34 PM Dillon, Peter W Date Printed: 5/5/2007 Time Printed: 10.•50AM PE~II~ST~4~"E ~l~n S. ,~h~y erica ~r ~'~ll of M ' 't~~ Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 1/12/2007 9:39 PM Oxygen Saturation patient Care Completed 1/12/2007 10:34 PM Dillon, Peter W Checks 1/12/2007 9:39 PM Communication to Patient Care Ordered 1/12/2007 9:39 PM Dillon, Peter W Nursing 1/12/2007 9:39 PM Cervical Collar Patient Care Application Completed 1/12/2007 10:34 PM Dillon, Peter W 1/12/2007 9:39 PM Oxygen Therapy Respiratory Care Ordered Dillon, Peter W 1/12/2007 9:39 PM P0C Guaiac Nurse Patient Care Completed 1/12/2007 10:35 PM Dillon, Peter W 1/12/2007 9:39 PM Urine Chemstick patient Care Nurse POC Completed 1/12/2007 10:35 PM Dillon, Peter W 1/12/2007 9:39 PM Peripheral IV Patient Care Insertion Completed 1/12/2007 10:36 PM Dillon, Peter W 1/12!2007 9:39 PM Glucose Level Laboratory Completed 1/12/2007 9:39 PM Dillon, Peter W 1/12/2007 9:39 PM Potassium Level Laboratory Completed 1/12/2007 9:39 PM Dillon, Peter W 1/12/2007 9:39 PM Sodium Level Laboratory Completed 1/12/2007 9:39 PM Dillon, Peter W 1/12/2007 9:39 PM Arterial Blood Gases Laboratory w/ Hgb and 02 Sat Ordered 1/12/2007 9:39 PM Dillon, Peter W 1/12/2007 9:39 PM Amylase Level Laboratory Completed 1/12/2007 9:39 PM Dillon, Peter W 1/12/2007 9:39 PM Complete 81ood Laboratory Count w Differential Completed 1/12/2007 9:39 PM Dillon, Peter W 1/12/2007 9:39 PM Creatinine Level Laboratory Completed 1/12/2007 9:39 PM Dillon, Peter W 1/12/2007 9:39 PM Blood Type/Antibody Laboratory Screen Ordered 1/12/2007 9:39 PM Dillon, Peter W 1/12/2007 9:39 PM INroRthrombin Time w/Laboratory Completed 1/12/2007 9:39 PM Dillon, Peter W Partial 1!12/2007 9:39 PM Thromboplastin Laboratory Completed 1/12/2007 9:39 PM Dillon, Peter W Time 1/12/2007 9:39 PM Physician Consult Consults Request Completed 1/12/2007 10:17 PM Dillon, Peter W 1/12/2007 9:40 PM ED Trauma Order Sets Radiology Set Completed 1/12/2007 10:44 PM Dillon, Peter W 1/12/2007 9:39 PM Chest XR Radiology Canceled 1/12/2007 9:45 PM Dillon, Peter W 1/12/2007 9:39 PM Pelvis XR Radiology Canceled 1/12/2007 9:45 PM ^illon, Peter W 1/12/2007 9:39 PM C-Spine XR Radiology Canceled 1/12/2007 9:45 PM Dillon, Peter W Date Printed: 5/5/2007 Time Printed: 10:50 AM PE1~I~STATE ~It~n ~ ~ ~~ r ~ ~ ter ll off' ~ . . Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 1/12/2007 9:39 PM Head CT. Radiology 1/12/2007 9:39 PM Alcohol Level (not .Laboratory Legal) 1/12/2007 9:39 PM Drugs of Abuse w Laboratory NO confirm, Urine 1!12/2007 9:41 PM Diagnostic Radiology Exams Order Sets 1/12/2007 9:41 PM Hip XR Radiology 1/12/2007 9:41 PM Diagnostic Radiology Exams Order Sets 1/12/2007 9:40 PM Femur XR Radiology 1/12/2007 9:40 PM Lab specimens to Laboratory hold 1/12/2007 9:30 PM Blood Type/Antibody Laboratory Screen 1/12/2007 9:44 PM Chest CT (Apex to Radiology Adrenals). Abdomen CT 1/12/2007 9:44 PM (Diaphragm to Iliac Radiology Crest). 1/12/2007 9:44 PM Pelvis CT (Iliac CrestRadiology to Symphysis Pubis ). 1/12/2007 9:44 PM L-Spine CT .Radiology 1/12/2007 9:44 PM C-Spine CT Radiology 1/12/2007 9:44 PM Facial Bones CT Radiology 1/12/2007 9:44 PM T-Spine CT Radiology 1/12/2007 9:58 PM Added on Lab order Laboratory 1/12/2007 10:34 PM Peds Trauma Order Sets Admission 1/12/2007 10:31 PM Admit. Patient Care 1/12/2007 10:32 PM Admitting Diagnosis Patient Care 1/12/2007 10:32 PM Vital Signs Patient Care 1/12/2007 10:32 PM NPO Dietary 1/12/2007 10:33 PM Bedrest Patient Care Completed 1/12/2007 10:44 PM Dillon, Peter W Discontinued 1/12/2007 9:58 PM Dillon, Peter W Completed 1/12/2007 9:39 PM Dillon, Peter W Completed 1/12/2007 10:34 PM Pastor, Danielle M Completed 1/12/2007 10:34 PM Pastor, Danielle M Completed 1/12/2007 10:35 PM Pastor, Danielle M Completed 1/12/2007 10:35 PM Pastor, Danielle M Completed 1/12/2007 9:40 PM Dillon, Peter W Completed 1/12/2007 9:30 PM DeFlitch, Christopher J Canceled 1/12/2007 10:30 PM Dillon, Peter W Completed 1/12/2007 10:35 PM Dillon, Peter W Completed 1/12/2007 10:35 PM Dillon, Peter W Canceled 1/12/2007 10:21 PM Dillon, Peter W Completed 1/12/2007 10:46 PM Dillon, Peter W Completed 1/12/2007 10:46 PM Dillon, Peter W Canceled 1/12/2007 10:21 PM Dillon, Peter W Completed 1/12/2007 9:58 PM Dillon, Peter W Ordered 1/12/2007 10:34 PM Cortes, James Completed 1/12/2007 10:47 PM Cortes, James Ordered 1/12/2007 10:32 PM Cortes, James Ordered Cortes, James Discontinued 1/13/2007 10:31 AM Erdahl, Lillian M Ordered Cortes, James Date Printed: 5/5/2007 Time Printed: 10:S0AM PENN~TATE ~t~an S. Homey l~e~ miter ~lle~ of ' '~ Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 1/12/2007 10:33 PM Intake and Output Patient Care Ordered 1/12/2007 10:33 PM Call HO PatienYCare 1/12/2007 10:33 PM Cervical Collar Patient Care Application 1/12/2007 10:33 PM Communication to patient Care Nursing 1/12/2007 10:31 PM Dextrose 5% Wlth 0 9 / N CI 1000 Pharmacy L . a m ° 1/12/2007 10:34 PM Hematocrit Laboratory 1/12/2007 10:34 PM Sodium Level Laboratory 1/12/2007 10:34 PM Social Service Consults Consult 1/12!2007 10:33 PM Intake and Output Patient Care 1/13/2007 6:00 AM Intake and Output Patient Care 1/12/2007 11:00 PM Hematocrit Laboratory 1/13/2007 5:00 AM Hematocrit Laboratory 1/12/2007 10:34 PM Level of Care: Floor Patient Care 1/12/2007 11:00 PM Sodium Level Laboratory 1/13/2007 5:00 AM Sodium Level Laboratory 1/12/2007 10:38 PM Added on Lab order Laboratory 1/12/2007 10:40 PM Neuro Check Patient Care 1/12/2007 10:40 PM Neuro Check Patient Care 1/13/2007 6:00 AM Neuro Check Patient Care 1/12/2007 10:40 PM Potassium Level Laboratory 1/12/2007 10:41 PM Sodium Level Laboratory 1/12/2007 11:00 PM Sodium Level Laboratory 1/13/2007 5:00 AM Sodium Level Laboratory 1/12/2007 10:46 PM Patient Education Patient Care Documentation 1/12/2007 10:46 PM Patient Education Patient Care Documentation Cortes, James Ordered 1/12/2007 10:33 PM Cortes, James Completed 1/12/2007 11:33 PM Cortes, James Ordered 1/12/2007 10:33 PM Cortes, James Ordered 2/11/2007 10:30 PM Erdahl, Lillian M Discontinued 1/12!2007 10:39 PM Cortes, James Discontinued 1/12/2007 10:41 PM Cortes, James Ordered 1/12/2007 10:34 PM Cortes, James Completed 1/12/2007 11:33 PM Cortes, James Completed 1/13/2007 6:09 AM Cortes, James Canceled 1/12/2007 10:40 PM Cortes, James Canceled 1/12/2007 10:40 PM Cortes, James Ordered 1/12/2007 10:34 PM SYSTEM Canceled 1/12/2007 10:41 PM Cortes, James Canceled 1/12/2007 10:41 PM Cortes, James Completed 1/12/2007 10:38 PM Dillon, Peter W Ordered Cortes, James Completed 1/12/2007 11;39 PM Cortes, James Completed 1/13/2007 6:10 AM Cortes, James Completed 1/12/2007 10:40 PM Cortes, James Discontinued 1/13/2007 10:31 AM Erdahl, Lillian M Completed 1/12/2007 11:00 PM Cortes, James Completed 1/13/2007 5:00 AM Cortes, James Ordered SYSTEM Completed 1/12/2007 11:33 PM SYSTEM Date Printed: 5/5/2007 Time Printed: 10:50 AM '~illl ~. ~.G~` ~1t~ ~1~Ct ~'t1 O°f 1 Patient Name: CHIARA, JOHN J 1/13/2007 6:00 AM Patient Education Patient Care Completed Documentation 1/12/2007 10:46 PM Ped Admit Patient Care Completed Assessment 1/12/2007 10:46 PM Ped Admit2 Patient Care Completed Assessment 1/12/2007 10:46 PM Ped Ongoing A Patient Care Ordered ssessment 1/13/2007 12:01 AM Ped Ongoing Patient Care Completed Assessment 1/13/2007 8:00 AM Ped Ongoing Assessment Patient Care Completed 1/19/2007 8:00 AM Weight Patient Care Ordered 1/12/2007 9:40 PM Alcohol Level (not Laboratory Completed Legal ) 1/13/2007 12:07 AM ondansetron Pharmacy Ordered 1/13/2007 12:05 AM morphine Pharmacy Ordered 1/13/2007 12:10 AM Communication to Patient Care Ordered Nursing 1/13/2007 2:00 PM Intake and Output Patient Care Completed 1/13/2007 2:00 PM Neuro Check Patient Care Completed 1/13/2007 2:00 PM Patient Education Documentation Patient Care Completed 1/13/2007 4:00 PM Ped Ongoing Assessment Patient Care Completed 1/13/2007 11:00 AM Sodium Level Laboratory Canceled 1/13/2007 9:52 AM Physician Consult Consults Completed Request 1/13/2007 9:58 AM Pelvis XR Radiology Completed 1!13/2007 10:00 PM Intake and Output Patient Care Ordered 1/13/2007 5:00 PM Sodium Level Laboratory Canceled 1/13/2007 10:00 PM Patient Education Patient Care Ordered Documentation 1/13/2007 10:00 PM Neuro Check Patient Care Ordered 1/14/2007 12:01 AM Ped Ongoing Patient Care Ordered PSUHMC MRN: 1133563 1/13/2007 6:10 AM SYSTEM 1/13/2007 12:20 AM SYSTEM 1/13/2007 8:26 AM SYSTEM SYSTEM 1/12/2007 11:38 PM SYSTEM 1/13/2007 8:26 AM SYSTEM SYSTEM 1/12/2007 9:40 PM 1 /14/2007 12:06 AM 1 /16/2007 12:04 AM 1/13/2007 12:10 AM , 1!13/2007 2:07 PM Cortes, James 1/13!2007 2:10 PM Cortes, James 1/13/2007 2:10 PM SYSTEM 1/13/2007 4:02 PM SYSTEM 1/13/2007 10:31 AM Cortes, James 1/13/2007 10:45 AM Erdahl, Lillian M 1/13/2007 11:48 AM Price, Shawn L 1/13/2007 10:00 PM Cortes, James 1/13/2007 10:31 AM Cortes, James 1/13/2007 10:00 PM SYSTEM 1/13/2007 10:00 PM Cortes, James 1/14/2007 12:01 AM SYSTEM Dillon, Peter W Pastor, Danielle M Pastor, Danielle M Pastor Danielle M Date Printed: 5/5/2007 Time Printed: 10.•50 AM ~E~tvS~r~TE ~'11~~ S. ~er~h~y ~i~ writer ~ o~ ~r~:d~~ne Patient Name: CHIARA, JOHN J PSL)HMC MRN: 1133563 Assessment 1/13/2007 10:03 AM Physician.Consult R t Consults Completed 1/13/2007 10:48 AM Cherenfant, Jovenel eques Advanced Prac 1/13/2007 10:12 AM Nurse Psych Consults Ordered 1/13/2007 10:12 AM SYSTEM Referral 1/13/2007 10:31 AM Advance Diet as Dietary Ordered Erdahl, Lillian M Tolerated 1/13/2007 10:32 AM PT Evaluation and Order Sets Ordered 1/13/2007 10:32 AM Erdahl, Lillian M Treatment 1/13/2007 10:31 AM PT Evaluation Consults Completed 1/13/2007 3:07 PM Erdahl, Lillian M 1/13/2007 10:32 AM PT Treatment Consults Ordered Erdahl, Lillian M 1/13/2007 10:33 AM acetaminophen- Pharmacy Ordered 1/16/2007 10:32 AM Erdahl, Lillian M oxycodone 1/13/2007 10:33 AM acetaminophen- Pharmacy Ordered 1/16/2007 10:32 AM Erdahl, Lillian M oxycodone 1/14/2007 6:00 AM Intake and Output Patient Care Ordered 1/14/2007 6:00 AM Cortes, James 1/14/2007 6:00 AM Patient Education Patient Care Ordered 1/14/2007 6:00 AM SYSTEM Documentation 1/14/2007 8:00 AM Ped Ongoing Patient Care Ordered 1/14/2007 8:00 AM SYSTEM Assessment 1/14/2007 6:00 AM Neuro Check Patient Care Ordered 1/14/2007 6:00 AM Cortes, James 1!13/2007 6:31 PM acetaminophen- pharmacy Ordered 2/12/2007 6:30 PM Cherenfant, Jovenel codeine 1/13/2007 2:00 PM Out of Bed Patient Care Ordered Erdahl, Lillian M 1/13/2007 7:20 PM Communication to Patient Care Ordered 1/13/2007 7:20 PM Erdahl, Lillian M Nursing 1/13/2007 7:21 PM Discharge Order Sets Ordered 1/13/2007 7:21 PM Cherenfant, Jovenel 1/13/2007 7:20 PM Discharge. Patient Care Ordered 1/13/2007 7:20 PM Cherenfant, Jovenel 1/13/2007 7:21 PM Discontinue IV Patient Care Ordered 1/13/2007 7:21 PM Cherenfant, Jovenel MEDICAL INFORMATION Allergy Info: NKA F Date Printed: 5/5/2007 Time Printed: 10: SO AM . P~~~~T,~~E i1i ~. H~rs~hey ~~ C+~t~er ll of ' 'ne Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 D e p a r t S u m m a r y ( E D) Prescriptions Given Prescription Display acetaminophen-codeine (Tylenol with 1 tab, PO, q4h, PRN, tab, 0, 0, 01/13/07 18:32:10, Pain -Mild, Print DEA Number, given Codeine #3 (300/30)) to patient, 30038, Prescription Dispensed Indicator DISCHARGE INFORMATION Discharge Disposition: Adm Univ Hos Discharge Location: PATIENT EDUCATION INFORMATION Instructions: Follow up: Follow-Up With: Date Printed: 5/5/2007 Time Printed: 10: SO AM Header Page Patient Name: CHIAR.A, JOHN J Date of Birth: 5/18/1991 12:00:00 AM Medical Record Number: 1133563 Financial Number: 10500215 Admission Date: 1/12/2007 10:31:00 PM Discharge Date: 1/13/2007 7:00.:00 PM Patient Type: Inpatient Facility: HMC Patient Location: HMC 1EDU Destination: Hershey Medical Center Reason: Legal ************************************************************************ Requester: Hershey Medical Center Date and Time Printed: 5/5/2007 10:48:31 AM Printed By: Shiner, Crystal L Device: hisu230201 ' PEN~f S~~TE ~ltv~a ~. ~~ laic meter Cvlleg~e of 1V~;di~n Penn State Milton S. Hershey Medical Center Tel: (717) 531-8055 Penn State College of Medicine Health Information Services, HU24 500 University Drive P.O. Box 850 Hershey, PA 17033-0850 Patient Name: CHIARA, JOHN 1 PSUHMC MRN: 1133563 Patient Sex: Male Date of Birth: 5/18/1991 Patient Location: 1 EDU, 1440, 14 Visit Number: 10500215 Visit Type: Inpatient ~ H e i g h t / W e i g h t - M e a s u r e m e n t ~ Procedure Weight Units kg Ref Range 1/12/2007 Fri 0 11:48:00 PM 78.000 Date Printed: 5/5/1(/07 Time Printed.• 10:49 AM PE~V~ST,4TE ilttm 5. weary laic Otter of ~~~etne Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 A l l e r g i e s Substance: NKA U date Dt Tm Updated By 1/12/2007 11:48:41 PM Martin, Leanne P 1/12/2007 11:48:41 PM Martin, Leanne P Category: Drug; Reaction Status: Active; Type: Allergy; Date Printed: 5/5/2007 Time Printed: 10:49.4M ~E~~~~ ~ilt~nt S. ~~ ~i~ C:~rtter +~~ of ' Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 1 N a m e H i s t o r v 1 Name Be in Effective Date/Time End Effective Date/Time CHIARA, JOHN J 3/7/2001 7:16:17 PM Current CHIARA, JOHN 1/12/2007 9:38:43 PM 1/14/2007 12:56:22 AM TRAUMA, 7500215 1/5/2007 9:50:50 PM 1/12/2007 9:38:43 PM Date Printed: 5/5/2007 Time Printed: 10:49 AM PE~II~STATE ~t~n ~. I~~y Iic~t Cdr of ~'~ Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 M e d i c a l A d m i n i s t r a t i o n R e c o r d ~ Date Printed: 5/5/2007 Time Printed: 10:49 AM Patient Name: CHIARA, JOHN J PRN MRN: 1 133563 acetaminophen-codeine(Tylenol with Codeine #3 (300!30)) I tab (Order Id =170074792.00) 1 tab, tablet, PO, q4h, PRN, Pain -Mild, Routine, 01/13/07 18:31:00, 30 day, 02/12/07 18:30:00 Order Entered By: Cherenfant, Jovenel Pharmacist: Meier, Joanna accepted on 01/13/07 18:38 ACTION(S) CHARTED @ ADMIN TIME(S) ADMIN DETAIL(S) acetaminophen-codeine phos 300-30 tab(Tylenol with Codeine #3 (300/30)) l tab (Order Id = 170074792.00) 1 tab, tablet, PO, q4h, PRN, Pain -Mild, Routine, 01/13/07 ] 8:31:00, 30 day, 02/12/07 18:30:00 Product Note: Acetaminophen 300 mg/codeine 30mg Maximum 4gm acetaminophen daily from all sources. Check if patient is also receiving (darvocet, percocet tylenol with codeine) Order Modified/Verit"ied By: Meier, Joanna ACTION(S) CHARTED @ ADMIN TIME(S) ADMIN DETAIL(S) Discontinue Ol/13/07 22:00 Performed By: SYSTEM morphine 2 mg (Order Id = 169861620.00) 2 mg, injection, IV, q2h, PRN, Pain -Mild, Routine, 01/13/07 0:05:00, 3 day, 0]/16/07 0:04:00 Order Entered By: Pastor, Danielle M Pharmacist: Vissering, Thomas accepted on 01/13/07 00:09 ACTION(S) CHARTED @ ADMIN TIMES} ADMIN DETAIL(S) morphine carpuject 2 mg / mL syr. inj.(morphine) 1 mL = 2 mg (Order Id =169861620.00) 2 mg, injection, IV, q2h, PRN, Pain -Mild, Routine, 01/13!07 0:05:00, 3 day, 01/16/07 0:04:00 Order ModiSed/Verified By: Vissering, Thomas ACTION(S) CHARTED @ ADMIN TIME(S) ADMIN DETAIL(S) Discontinue 01/13/07 22:00 Performed By: SYSTEM ondansetron(Zofran) 4 mg (Order Id =169862635.00) 4 mg, injection, IV, ONCE, PRN, Nausea and Vomiting, Routine, 01/13/07 0:07:00, 01/14/07 0:06:00 Order Entered By: Pastor, Danielle M Pharmacist: Vissering, Thomas accepted on 01/13/07 00:09 ACTION(S) CHARTED @ ADMIN TIME(S) ADMIN DETAIL(S) ondansetron 4 mg / 2 mL vial inj.(Zofran) 2 mL = 4 mg (Order Id =169862635.00) 4 mg, injection, IV, ONCE, PRN, Nausea and Vomiting, Routine, 01/13/07 0:07:00, 01/14/07 0:06:00 Product Note: Change stop type to physician stop Order ModiFied/Verified By: Vissering, Thomas ACTION(S) .CHARTED @ ADMIN TIME(S) ADMIN DETAIL(S) Discontinue Dl/13/07 22:00 Performed By: SYSTEM acetaminophen-oxycodone(Percocet-5/325) 2 tab (Order Id = 169978477.00) 2 tab, tablet, PO, q4h, PRN, Pain -Moderate, Routine, 01/13/07 10:33:00, 3 day, 01/16/07 10:32:00 Order Entered By: Erdahl, Lillian M Pharmacist: Leiby, Amy accepted on 01/13/07 10:37 ACTION(S) CHARTED @ ADMIN TIME(S) ADMIN DETAIL(S) Percocet /generic equiv (5 / 325) tab(Percocet-5/325) 2 tab (Order Id = 169978477.00) 2 tab, tablet, PO, q4h, PRN, Pain -Moderate, Routine, 01/13/07 10:33:00, 3 day, 01/16/07 10:32:00 Product Note: Acetaminophen 325mg/oxycodone Smg. Maximum 4gm acetaminophen from all sources daily Order Modified/Verit"-ed By: Leiby, Amy ACTION(S) CHARTED @ ADMIN TIME(S) ADMIN DETAIL(S) Med Given 01/13/07 11:17 01/13/07 11:15 acetaminophen-oxycodone 2 tab PO Patient Name: CHIARA, JOHN J MRN: 1133563 Pain Intensity 5 Reason for Medication: Pain -Moderate Perform:English, Lori A Med Given 01/13/07 16:35 OI/13/07 16:35 acetaminophen-oxycodone 2 tab PO Pain Intensity 5 Reason for Medication: Pain -Moderate Perfonn:English, Lori A Discontinue 01/13/07 22:00 Performed By: SYSTEM acetaminophen-oxycodone(Percocet-5/325) 1 tab (Order Id =169978483.00) 1 tab, tablet, PO, q4h, PRN, Pain -Mild, Routine, 01/13/07 10:33:00, 3 day, 01/16/07 ]0:32:00 Order Entered By: Erdahl, Lillian M Pharmacist: Leiby, Amy accepted on 01/13/07 10:37 ACTION(S) CHARTED @ ADMIN TIME(S) ADMIN DETAIL(S) Percocet /generic equiv (5 / 325) tab(Percocet-5/325) 1 tab (Order Id =169978483.00) 1 tab, tablet, P0, q4h, PRN, Pain -Mild, Routine, 01/13/07 10:33:00, 3 day, 01/16/07 10:32:00 Product Note: Acetaminophen 325mg/oxycodone Smg. Maximum 4gm acetaminophen from all sources daily Order Modified/Verified By: Leiby, Amy ACTION(S) CHARTED @ ADMIN TIME(S) ADMIN DETAIL(S) Discontinue 01/13/07 22:00 Performed By: SYSTEM CONTINUOUS INFUSIONS Dextrose 5% with 0.9% NaCI(DS - 0.9% NaCI) 250 mL Every Bag 250 mL, IV, Routine, 0(/12/07 22:31:00, 30 day, Hard Stop, 02/11/07 22:30:00, 125 mL/HR, 2 HR, 250 Order Comment: for infant only Order Entered By: Cortes, James Pharmacist: Vissering, Thomas accepted on 01/13/07 00:03 ACT10N(S) CHARTED @ ADMIN TIME(S) ADMIN DETAIL(S) Begin Bag Bag 1 01/13/07 00:20 01/13/07 00:20 Dextrose 5% with 0.9% NaCI 250 mL IV Volume: 250 mL Rate: 125 mL/HR Site:.IV, Peripheral Perform:Martin, Leanne P Begin Bag Bag 2 01/13/07 09:15 01/13/07 09:15 Dextrose 5% with 0.9% NaC1250 mL IV Volume: 250 mL Rate: 125 mL/HR Site:.IV, Peripheral Perform:English, Lori A DSW and 0.9% Sodium Chloride(DS - 0.9% NaCI) 250 mL Every Bag 250 mL, IV, Routine, 01/12/07 22:31:00, 30 day, Hard Stop, 02/1 ]/07 22:30:00, 125 mL/IiR, 2 HR, 250 Order Comment: for infant only Order Modified/Verified By: Vissering, Thomas ACTION(S) CHARTED @ ADMIN TIME(S) ADMIN DETAIL(S) DSW and 0.9% Sodium Chloride(D5 - 0.9% NaCI) 250 mL Every Bag 250 mL, IV, Routine, 01/12/07 22:31:00, 30 day, Hard Stop, 02/11/07 22:30:00, 125 mL/I-IR, 2 HR, 250 Order Comment: for infant only Administration Note:2nd bag hung at 0915am on 1/13/07. Order Modified By: English, Lori A ACTION(S) CHARTED @ ADMIN TIME(S) ADMIN DETAIL(S) Dextrose 5% with 0.9% NaCI(DS - 0.9% NaCI) 1000 mL Every Bag 1000 mL, lV, Routine, 01/12/07 22:31:00, 30 day, Hard Stop, 02/1 1/07 22:30:00, 125 mL/FIR, 8 HR, 1000 Order Comment: Hepwell when patient tolerates 500 ml po Order Modified By: Erdahl, Lillian M Pharmacist: Leiby, Amy reviewed on 01/13/07 10:37 ACTION(S) CHARTED @ ADMIN TIME(S) ADMIN DETAIL(S) (Order Id =169849112.00) (Order Id =169849112.00) (Order Id =169849112.00) (Order Id = 169849112.00) D5W and 0.9% Sodium Chloride(DS - 0.9% NaCI) 1000 mL Every Bag (Order Id = 169849112.00) Patient Name: CHIARA, JOHN J 1000 mL, IV, Routine, 01/12/07 22:31:00, Hard Stop, 02/11/07 22:30:00, 125 mL/HR, 8 HR, 1000 Order Comment: Hepwell when patient tolerates 500 m! po Order Modified/Verified By: Leiby, Amy ACTION(S) CHARTED @ ADMIN TIME(S) ADMIN DETAIL(S) Discontinue 01/13/07 22:00 Performed By: SYSTEM MRN: 1133563 PE~li~f STATE ~n S. ~~er~h~ey ~ Winter +Cnnege of 1'di€ci~,te Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 P e d i a t r i c A d m i s s i o n A s s e s s m e n t ~ P F ~ Pediatric Admission Assessment Form 01/13/07 00:10 am Performed by Martin, Leanne P Entered on 01/13/07 00:20 am Pediatric Vital Signs Temperature Route Oral Temperature 37.3 DegC Fi02 100 ~ Heart Rate 108 bpm Oxygen Therapy Room air Respiratory Rate 16 br/min Pain Intensity 3 Systolic Blood Pressure 128 mmHg Diastolic Blood Pressure Left Arm 57 mmHg BP Location # 1 Right Arm Allergy Allergy Reaction 1. NKA Primary Paia Adequate Pain Control Primary No Pain scale used primary 0-10 Pain scale Respiratory Rate 18 br/min Worst Pain intensity over 24 hrs. 7 Pain Location Hip, left Pain Intensity 3 Pain Duration 4 HR BIDMC Sedation Score 0 Pain Onset Sudden Pain Time Pattern Acute Pain Aggravating Factors Movement, Palpation Pain Associated Symptoms None Peds Canna Eye Opening Response Peds Coma Spontaneously Best Motor Response Peds Coma Obeys Best Verbal Response Peds Coma Oriented and converses Drug Effect No Patient Tube No Pediatric Coma Score 15 Neurological Swallowing Difficulty Other: unable to assess Gait Unable to assess Anterior Fontanel Description Closed Posterior Fontanel Description Closed Cry Description Other: N/A Neuro Detailed Pupil Assessment Grid Pupil, Left Pupil Description Regular Pupil Reaction Brisk Pupil, Right Pupil Description Regular Pupil Reaction Brisk Pupil Size, Left 3.0 Date Printed: 5/5/20(17 Time Printed: 10:49 AM PEN~STATE S. Hexsl~ey ~ C`e~t~r +CC€~ of ~ ..,ne Patient Name: CHIARII, JOHN J PSUHMC MRN: 1133563 P e d i a t r i c A d m i s s i o n A s s e s s m e n t ( P F ~ Pediatric Admission Assessment Form 01/13/07 00:10 am Performed by Martin, Leanne P Entered on 01/13/07 00:20 am Neuro Detailed Pupil Size, Right Characteristics of Speech Neurological Strengths Grid Left Upper Extremity Strength Tone Sensation Right Upper Extremity Strength Tone Sensation Left Lower Extremity Strength Tone Sensation Right Lower Extremity Strength Tone Sensation Level of Consciousness Symmetry of Face Eye/Ear/Noes/Throat Troat Not within defined limits Sensory Barrier Cardiovascular Heart Rhythm Heart Sounds Monitor Apnea/Bradycardia Monitor Monitor Rhythm Pacemaker CV Detailed Nail Bed Color Clubbing Present Capillary Refill CV Detailed Pulses Grid Dorsalis Pedis Pulse, Left: 2+ Normal Dorsalis Pedis Pulse, Right: 2+ Normal Radial Pulse, Left: 2+ Normal Radial Pulse, Right: 2+ Normal CV Detailed Extremity Temp Grid Arm, Left: Warm Arm, Right: Warm Foot, Left: Warm Foot, Right: Warm Hand, Left: Warm Hand, Right: Warm Leg, Left: Warm Leg, Right: Warm 3.0 Clear Normal or 5/5 Normal Intact Normal or 5/5 Normal Intact Normal or 5/5 Normal Intact Normal or 5/5 Normal Intact Alert Symmetri c No abnormalities No Regular S1S2 Yes No Sinus, Tachycardia None Pink No < 3 Seconds Date Printed.• 5/5/2007 Time Printed: 10:49 AM • ~~~~~ ~iltfm S. ~~, tic ~r to of ~'~edit~ine Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 P e d i a t r i c A d m i s s i o n A s s e s s m e n t ~ P F Pediatric Admission Assessment Form 01/13/07 00:10 am Performed by Martin, Leanne P Entered oa 01/13/07 00:20 am Cv Detailed Torso: Warm Respiratory Respirations Respiratory Pattern Cough Sputum Amount Reap Detailed-PEDS Breath Sounds Detailed Assessment Grid BLL: Clear BUL: Clear LLL: Clear LUL: Clear RLL: Clear RML: Clear RUL: Clear Tracheostomy Tube Pediatric Ventilated Gastrointestinal Stool Color Bowel Program GI Symptoms GI Detailed Abdomen Palpation Bowel Sounds Grid LUQ: Present RUQ: Present LLQ: Present RLQ: Present Genitourinary Urine Color Urine Description Bladder Program Muaculoakeletal ADLs Spinal Precautions Skin Skin Integrity Skin Turgor Mucous Membrane Description Restraint Skin Abnormality/Location Grid 1. Skin Abnormality Location Skin Abnormality Unlabored Regular None None No No Other: unable to assess No None Non-Distended, Non-Tender, Soft Unable to assess Other: unable to assess No Moderate assist Cervical spine Intact Normal Dry, Pink No Face Other: abrasion Date Printed: 5/5/2007 Time Printed: 10:49 AM PENI~STATE -_ I~ilt+~n S. ~>~y ~ 'c ~~a~l, of 1'~e ' ' Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 P e d i a t r i c A d m i s s i o n A s s e s s m e n t ~ P F ~ Pediatric Admission Assessment Form 01/13/07 00:10 am Performed by Martin, Leanne P Entered on .01/13/07 00:20 am Pediatric Skin Risk Score Peds Mobility Very limited Peds Friction and Shear No apparent problem Peds Activity Bedfast Peds Nutrition Inadequate Peds Sensory Perception No impairment Peds tissue perfusion oxygenation Excellent Peds level of risk Moderate (17-23) Peripheral IV Peripheral IV Assess/Intervention Grid 1. Peripheral IV Activity Assessment Peripheral IV Site Other: L hand IV Catheter Size #16 gauge IV Site Condition No complications IV Drainage Description None Infiltration Score 0 Phlebitis Score 0 2. Peripheral IV Activity Assessment Peripheral IV Site Other: L wrist IV Catheter Size #16 gauge IV Site Condition No complications IV Drainage Description None Infiltration Score 0 Phlebitis Score 0 Date Printed: 5/5/2007 Time Printed.' 10: 49 AM iiltvn S. whey ~ici c,;~t~r +Call+~e of e , . Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 ~P e d i a t r i c O n g o i n g A s s e s s m e n t_ ( P F) D Pediatric Ongoing Assessment Form 01/13/07 08:00 am Performed by English, Lori A Entered on 01/13/07 08:26 am Review Neurological Within Defined Limits Eye, Ear, Nose and Throat Within Defined Cardiovascular Within Defined Limits Respiratory Within Defined Limits Gastrointestinal Within Defined Limits Genitourinary Within Defined Limits Musculoskeletal Within Defined Limits Integumentary Within Defined Limits Parent Involvement W/in Defined Limits IV Present Primary Pain Adequate Pain Control Primary Pain Cultural /Non Communicative Standard Pain Scales Cultural Assessment Peds Cama Eye Opening Response Peds Coma Best Motor Response Peds Coma Best Verbal Response Peds Coma Drug Effect Patient Tube Pediatric Coma Score CV Detailed Nail Bed Color Clubbing Present Capillary Refill CV Detailed Pulses Grid Radial Pulse, Left: 2+ Normal Radial Pulse, Right: 2+ Normal CV Detailed Extremity Temp Grid Arm, Left: Warm Arm, Right: Warm Foot, Left: Warm Foot, Right: Warm Hand, Left: Warm Hand, Right: Warm Leg, Left: Warm Leg, Right: Warm Torso: Warm Respiratory Respirations Respiratory Pattern Cough Sputum Amount GI Detailed Abdomen Palpation Bowel Sounds Grid LUQ: Present WDL's WDL's WDL's WDL's WDL's WDL's WDL's WDL's WDL's Present No Pain Yes Yes Spontaneously Obeys Oriented and converses No No 15 Pink No < 3 Seconds Unlabored Regular None None Non-Distended, Non-Tender, Soft Date Printed: 5/5/1007 Time Printed: 10:49 AM lleg~e of ..nee Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 ~ P e d i a t r i c O n g o i n g A s s e s s m e n t ( P F) D Pediatric Oagoing Assessment Form 01/13/07 08:00 em Performed by English, Lori A Entered on 01/13/07 08:26 am GI Detailed RUQ: Present LLQ: Present RLQ: Present Pediatric Skin Risk Score Peds Mobility Peds Friction and Shear Peds Activity Peds Nutrition Peds Sensory Perception Peds tissue perfusion oxygenation Peripheral iV Peripheral IV Assess/Intervention Grid 1. Peripheral IV Activity Peripheral IV Site IV Catheter Size 2. Peripheral IV Site IV Catheter Size Slightly limited No apparent problem Bedfast Inadequate Comment: pt npo No impairment Excellent Assessment Other: L hand #16 gauge Other: L wrist #16 gauge Pediatric Ongoing Assessmeat Form 01/13/07 04:00 pm Performed by English, Lori A Entered on 01/13/07 04:02 pm Review Neurological Within Defined Limits WDL's Eye, Ear, Nose and Throat Within Defined WDL's Cardiovascular Within Defined Limits WDL's Respiratory Within Defined Limits WDL's Gastrointestinal Within Defined Limits WDL's Genitourinary Within Defined Limits WDL's Musculoskeletal Within Defined Limits WDL's Integumentary Within Defined Limits WDL's Parent Involvement W/in Defined Limits WDL's IV Present Present Primary Pain Adequate Pain Control Primary No Pain Pain Cultural /Non Communicative Standard Pain Scales Yes Cultural Assessment Yes Peds Coma Eye Opening Response Peds Coma Spontaneously Best Motor Response Peds Coma Obeys Best Verbal Response Peds Coma Oriented and converses Drug Effect No Patient Tube No Pediatric Coma Score 15 Date Printed: 5/5/2007 Time Printed: 111:49 AM PE~1(~STATE ltan S. ~i~y ~ic~ +t~r cif ledi~ne Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 P e d i a t r i c O n g o i n g A s s e s s m e n t ( P F) Pediatric Ongoing Assessment Form 01/13/07 04:00 pm Performed by English, Lori A Entered on 01/13/07 04:02, pm CV Detailed Nail Bed Color Pink Clubbing Present No Capillary Refill < 3 Seconds CV Detailed Pulses Grid Radial Pulse, Left: 2+ Normal Radial Pulse, Right: 2+ Normal CV Detailed Extremity Temp Grid Arm, Left: Warm Arm, Right: Warm Foot, Left: Warm Foot, Right: Warm Hand, Left: Warm Hand, Right: Warm Leg, Left: Warm Leg, Right: Warm Torso: Warm Respiratory Respirations Respiratory Pattern Cough Sputum Amount GI Detailed Abdomen Palpation Bowel Sounds Grid LUQ: Present RUQ: Present LLQ: Present RLQ: Present Pediatric Skin Risk Score Peds Mobility Peds Friction and Shear Peds Activity Peds Nutrition Peds Sensory Perception Peds tissue perfusion oxygenation Peripheral IV Peripheral IV Assess/Intervention Grid 1. Peripheral IV Activity Peripheral IV Site IV Catheter Size 2. Peripheral IV Site IV Catheter Size Unlabored Regular None None Non-Distended, Non-Tender, Soft Slightly limited No apparent problem Bedfast Inadequate No impairment Excellent Assessment Other: L hand #16 gauge Other: L wrist #16 gauge Date Printed: 5/5/2007 Time Printed: 10:49 AM PFNt~IISiATE .~iltan 5. ~n~y ~ ~r of ed%rane Patient Name: CHIARA, JOHN J FSUHMC MRN: 1133563 ~ E D T r i a g e F o r m ( P F) ' ED Triage Form 01/12/07 11:48 pm Performed by Martin, Leanne P Entered oa 01/12/07 11:49 pan ED Triage CczRplaint Chief Complaint MUC Allergy Reaction 1. NKA TriaQa vital Signs Weight 78.000 kg Weight Method Other: per pt ED Triage TrackiaQ DCP Generic Code Tracking Acuity 2 Tracking Reg. Status Start Triage Time 01/12/07 23:49 Tracking Group EMER Trk Gp Visit reason MVC Date Printed: 5/5/2007 Time Printed.• /0:49 AM ~N~s~A-~ alt ~. ~~ey C;vlleg~e of 14~ ' 'n~ Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 E D A s s e s s m e n t ( P F) ED Assessment Form 01/12/07 11:49 pm Performed by Martin, Leaame P Entered on 01/12/07 11:49 pan NureinQ Narrative/ED ED Narrative 1 see trauma documentation for previous charting ED Assessment Form 01/13/07 06:23 am Performed by Martin, Leanne P Entered on 01/13/07 06:24 am Nursing Narrative/ED ED Narrative 1 see trauma documentation for previous charting 1/13/2006 0010- Pt's HOB raised to 45 degrees, denies any pain. Fluids started into patent IV. Attempting to urinate. LMartin, RN 0025- Pt voided clear yellow urine, specimen .collected and sent. LMartin, RN 0100- Pt laying on stretcher, NSR on monitor, denies complaints. LMartin, RN 0230- Pt boosted in bed, remains NSR on monitor, denies complaints, mother at bedside, IV fluids infusing without Complication. LMartin, RN 0400- Pt laying on bed, eyes closed, respirations unlabored, sinus on monitor. LMartin, RN 0520- Lab drawn from PIV and sent. Pt denies complaints. LMartin, RN 0550- VSS, no change in pt's assessment. Voided clear yellow urine. Requesting po intake-paged peds trauma. LMartin, RN Date Printed: 5/5/2007 Time Printed.• 10:49 AM PE~iF~ISTATE ~tt~n ~. fey h~ic~ Ce~t~r Cv~ o~ ' ` e Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 V i t a l S i g n s ( P F) Vital Signs Form 01/13/07 05:50 am Performed by Martin, Leanne P Entered oa 01/13/07 06:38 am Vital Sivas Temperature 37.2 DegC Temperature Route Oral Heart Rate 88 bpm Oxygen Saturation g9 $ Respiratory Rate 16 br/min Pain Intensity 5 Oxygen Therapy Room air BP Location # 1 Right Arm Systolic Blood Pressure 135 mmHg Diastolic Blood Pressure 69 mmHg Monitor Rhythm Sinus Vital Signs Form 01/13/07 08:27 am Performed by English, Lori A Entered oa 01/13/07 08:28 am vitas Sivas Temperature 37.3 DegC Temperature Route Oral Heart Rate 85 bpm Oxygen Saturation 100 $ Respiratory Rate 16 br/min Pain Intensity 0 Systolic Blood Pressure 132 mmHg Diastolic Blood Pressure 77 mmHg Vital Signs Form 01/13/07 02:00 pm Performed by English, Lori A Entered on 01/13/07 02:19 pm vital siQa6 Heart Rate 78 bpm Oxygen Saturation 9g $ Respiratory Rate 16 br/min Pain Intensity 1 Oxygen Therapy Room air BP Location # 1 Left Arm Systolic Blood Pressure 114 mmHg Diastolic Blood Pressure 54 mmHg Date Printed: 5/5/2007 Time Printed: 10:49 AM ~E~~T~~ i1#c~~i ~. ~er~ ~.~ writer Cwlle.~e of N~d%t~ne Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 E D N u r s i n g N a r r a t i v e F o r m ( P F) ~ ED Nursing Narrative Form 01/13/07 07:05 a:n Performed by Martin, Leanne P Entered on 01/13/07 00:22 am IIpdated oa 01/13/07 07:06 am by martin, Leanne P 01/13/07 06:35 am by martin, Leanne P 01/13/07 06:19 am by martin, Leanne P 01/13/07 02:54 am by martin, Leanne P Nursing Narrative/ED ED Narrative 1 see trauma documentation for previous charting 1/13/2006 0010- Pt's HOB raised to 45 degrees, denies any pain. Fluids started into patent IV. Attempting to urinate. LMartin, RN 0025- Pt voided clear yellow urine, specimen collected and sent. LMartin, RN 0100- Pt laying on stretcher, NSR on monitor, denies complaints. LMartin, RN 0230- Pt boosted in bed, remains NSR on monitor, denies complaints, mother at bedside, IV fluids infusing without complication. LMartin, RN 0400- Pt laying on bed, eyes closed, respirations unlabored, inus on monitor. LMartin, RN 0520- Lab drawn from PIV and sent. Pt denies complaints. LMartin, RN 0550- VSS, no change in pt's assessment. Voided clear yellow urine. Requesting po intake-paged peds trauma. LMartin, RN 0620- Spoke with DPastor from peds surgery. Will wait till morning rounds to changed diet-pt aware and verbalized understanding. LMartin, RN 0705- Report and care to oncoming RN. LMartin, RN (modified) ED Nursing Narrative Form 01/13/07 08:28 am Performed by English, Lori A Entered on 01/13/07 08:29 am IIpdated on 01/13/07 11:29 am hY English, Lori A Nursing Narrative/ED ED Narrative 1 see trauma documentation for previous charting 1/13/2006 0010- Pt's HOB raised to 45 degrees, denies any pain. Fluids started into patent IV. Attempting to urinate. LMartin, RN 0025-'Pt voided clear yellow urine, specimen collected and sent. LMartin, RN 0100- Pt laying on stretcher, NSR on monitor, denies complaints. LMartin, RN 0230- Pt boosted in bed, remains NSR on monitor, denies complaints, mother at bedside, IV fluids infusing without complication. LMartin, RN Date Printed: 5/5/2007 Time Printed: 10:49 AM PENNS7ATE ~. ~ ~ ~ ~~ Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 E D N u r s i n g N a r r a t i v e F o r m ( P F) ED Nursing Narrative Form 01/13/07 08:28 am Performed by English, Lori A Entered on 01/13/07 08:29 am Nursing Narrative/ED 0400- Pt laying on bed, eyes closed, respirations unlabored, sinus on monitor. LMartin, RN 0520- Lab drawn from PIV and sent. Pt denies complaints. LMartin, RN 0550- VSS, no change in pt's assessment. Voided clear yellow urine. Requesting po intake-paged peds trauma. LMartin, RN 0620- Spoke with DPastor from peds surgery. Will wait till morning rounds to changed diet-pt aware and verbalized understanding. LMartin, RN 0705- Report and care to oncoming RN. LMartin, RN 0730 pt resting, but easily arouses with verbal stimuli. pt in no acute distress. Adult at bedside. Ccollar in place, pt sitting up at 30 degree angle. siderails up x2. lenglish rn 0930 pt offered pain medicine, but declined. awaiting peds surgery to eval.lenglish rn 1030 dr dillion and residents in to eva1. pt given liquids and graham crackers. parent at bedside. Dr. price of ortho in to eval.lenglishrn , 1100 pt given turkey sandwich. iv fluids hepwelled. pt tolerates fluids well. lenglishrn 1115 pt medicated with 2 percocets for moderate pain. pt updated that PT will be here to eval for walking. psych MD in to speak with pt. lenglishrn 1130 pt to xray.lenglishrn 1150 pt returned from xray.lenglish rn (modified) ED Nursing Narrative Form 01/13/07 02:18 pm Performed by English, Lori A Entered oa 01/13/07 02:18 pm Nursing Narrative/ED ED Narrative 1 see trauma documentation for previous charting 1/13/2006 0010- Pt's HOB raised to 45 degrees, denies any pain. Fluids started into patent IV. Attempting to urinate. LMartin, RN 0025- Pt voided clear yellow urine, specimen collected and sent. LMartin, RN 0100- Pt laying on stretcher, NSR on monitor, denies complaints. LMartin, RN 0230- Pt boosted in bed, remains NSR on monitor, denies complaints, mother at bedside, IV fluids infusing without complication. LMartin, RN Date Printed: 5/5/2007 Time Printed: 10.49 AM PE~lt~S~ATE A~'ltan ~. H~.-,~ ~~ ~r ~ll of ~edicixa~ Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 E D N u r s i n g N a r r a t i v e F o r m ( P F) ED Nursing Narrative Form 01/13/07 02:18 pat Performed by English, Lori A Entered oa 01/13/07 02:18 pat Nursing Narrative/ED 0400- Pt laying on bed, eyes closed, respirations unlabored, sinus on monitor. LMartin, RN D520- Lab drawn from PIV and sent. Pt denies complaints. LMartin, RN 0550- VSS, no change in pt's assessment. Voided clear yellow urine. Requesting po intake-paged peds trauma. LMartin, RN 0620- Spoke with DPastor from peds surgery. Will wait till morning rounds to changed diet-pt aware and verbalized understanding. LMartin, RN 0705- Report and care to oncoming RN. LMartin, RN 0730 pt resting, but easily arouses with verbal stimuli. pt in no acute distress. Adult at bedside. Ccollar in place, pt sitting up at 30 degree angle. siderails up x2. lenglish rn 0930 pt offered pain medicine, but declined. awaiting peds surgery to eval.lenglish rn 1030 dr dillion and residents in to eval. pt given liquids and graham crackers. parent at bedside. Dr. price of ortho in to eval.lenglishrn 1100 pt given. turkey sandwich, iv fluids hepwelled. pt tolerates fluids well ..lenglishrn 1115 pt medicated with 2 percocets for moderate pain. pt updated that PT will be here to eval for walking. psych MD in to speak with pt. lenglishrn 1130 pt to xray.lenglishrn 1150 pt returned from xray.lenglish rn 1400 pt sitting up in bed. Awaiting PT consult. PT called. lenglish rn 1415 PT here to eval.lenglishrn ED Nursing Narrative Form 01/13/07 07:25 pm Performed by English, Lori A Entered on 01/13/07 07:30 pm Nursing Narrative/ED ED Narrative 1 see trauma documentation for previous charting 1/13/2006 0010- Pt's HOB raised to 45 degrees, denies any pain. Fluids started into patent IV. Attempting to urinate. LMartin, RN 0025- Pt voided clear yellow urine, specimen collected and sent. LMartin, RN 0100- Pt laying on stretcher, NSR on monitor, denies complaints. LMartin, RN 0230- Pt boosted in bed, remains NSR on monitor, denies Date Printed: 5/5/2007 Time Printed: 10:49 AM P'E1'~lt~~'FATE iltan ~ S.~~r~ 1Vic~ it~rr ~ll of 1'4~ede Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 ~ E D N u r s i n g N a r r a t i v e F o r m ( P F) ~ ED Nursing Narrative Form 01/13/07 07:25 pm Performed by English, Lori A Entered on 01/13/07 07:30 pm NursiaQ Narrative/ED complaints, mother at bedside, IV fluids infusing without complication. LMartin, RN 0400- Pt laying on bed, eyes closed, respirations unlabored, sinus on monitor. LMartin, RN 0520- Lab drawn from PIV and sent. Pt denies complaints. LMartin, RN 0550- VSS, no change in pt's assessment. Voided clear yellow urine. Requesting po intake-paged peds trauma. LMartin, RN 0620- Spoke with DPastor from peds surgery. Will wait till morning rounds to changed diet-pt aware and verbalized understanding. LMartin, RN 0705- Report and care to oncoming RN. LMartin, RN 0730 pt resting, but easily arouses with verbal stimuli. pt in no acute distress. Adult at bedside. Ccollar in place, pt sitting up at 30 degree angle. siderails up x2. lenglish rn 0930 pt offered pain medicine, but declined. awaiting peds surgery to eval.lenglish rn 1030 dr dillion and residents in to eval.c collar removed by dr- erdahl. pt given liquids and graham crackers. parent at bedside. Dr. price of ortho in to eval.lenglishrn 1100 pt given turkey sandwich. iv fluids hepwelled. pt tolerates fluids well. lenglishrn 1115 pt medicated with 2 percocets for moderate pain. pt updated that PT will be here to eval for walking. psych MD in to speak with pt. lenglishrn 1130 pt to xray.lenglishrn 1150 pt returned from xray.lenglish rn 1400 pt sitting up in bed. Awaiting PT consult. PT called. lenglish rn 1415 PT here to eval.lenglishrn 1445 peds surgery resident states,^It will be hours before I can come down to discharge pt". pt and father aware. lenglish rn 1645 pt taking fluids, no complaints. I contacted peds surgery concerning pt discharge. peds surgery resident unable tocome down to do discharge. Dr. dillon called by charge nurse. pt dad aware that another peds surgery resident will be down to discharge pt. dad angry, but easily calms down. lenglish rn 1800 pt medicated for pain. Awaiting disposition. pt eating dinner. Dad given food tray.lenglishrn 1925 iv removed intact x2. no bleeding from sites. discharged with Date Printed: 5/5/2007 Mme Printed.• 10:49 AM }~~~ib1~ ~itQn S. ~Ih~y ll~ic~ meter C~leg±~ of !~'r~in~ Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 E D N u r s i n g N a r r a t i v e F o r m ( P F) ED Nursing Narrative Form 01/13/07 07:25 pm Performed by English, Lori A Entered on 01/13/07 07:30 pan Nursing Narrative/ED dad.lenglishrn V N u r s i n g A s s e s s m e n t F o r m ( P F) IV Nursing Assessaneat Form 01/12/07 09:39 pan Performed by Martin, Leanne P Entered on 01/12/07 10:36 pan Peripheral xv Peripheral IV Assess/Intervention Grid 1. Peripheral IV Activity Field start Peripheral IV Site Other: L hand IV Catheter Size #16 gauge IV Site Condition No complications IV Drainage Description None Infiltration Score 0 Phlebitis Score 0 IV Dressing Condition Dry, Intact IV Site/Line Care Secured with tape, Tubing changed IV Dressing/Activity Reinforced, Transparent IV Flow/Patency Flushes easily, Positive Blood Return, No complications Lab drawn No 2. Peripheral IV Activity Field start Peripheral IV Site Other: L wrist IV Catheter Size #16 gauge IV Site Condition No complications IV Drainage Description None Infiltration Score 0 Phlebitis Score 0 IV Dressing Condition Dry, Intact IV Site/Line Care Secured with tape, Tubing changed IV Dressing/Activity Reinforced, Transparent IV Flow/Patency Flushes easily, Positive Blood Return, No complications Lab drawn No ~N e u r o I o g i c a l A s s e s s m e n t F o r m ( P F) Neurological Assessment Form 01/13/07 05:45 am Performed by Martin,. Leanne P Entered on 01/13/07 06:10 am G1aaQOw Coma Eye Opening Response Spontaneously Best Verbal Response Oriented Best Motor Response Obeys simple commands Drug Effect No Date Printed: 5/5/2007 Time Printed: 10:49 AM P~~STA~E ~ t~ S. r~hey IVI ter arf Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 ~N e u r o l o g i c a l A s s e s s m e n t F o r m ( p F Glasgow Coana Patient Tube Glasgow Coma Score Peda Coana Eye Opening Response Peds Coma Best Motor Response Peds Coma Best Verbal Response Peds Coma Drug Effect Patient Tube Pediatric Coma Score Neuro Detailed Pupil Assessment Grid Pupil, Left Pupil Description Pupil Reaction Pupil, Right Pupil Description Pupil Reaction Pupil Size, Left Pupil Size, Right Characteristics of Speech Neurological Strengths Grid Left Upper Extremity Strength Tone Sensation Right Upper Extremity Strength Tone Sensation Left Lower Extremity Strength Tone Sensation Right Lower Extremity Strength Tone Sensation Level of Consciousness Symmetry of Face Neurological Sensory Perception Swallowing Difficulty Hallucinations Present Neurological Symptoms Gait Neurological Assessmeat Form 01/13/07 05:45 am Performed by Martin, Leaane P Entered oa 01/13/07 06:10 am No 15 Spontaneously Obeys Oriented and converses No No 15 Regular Brisk Regular Brisk 4.0 4.0 Clear Normal or 5/5 Normal Intact Normal or 5/5 Normal Intact Normal or 5/5 Normal Intact Normal or 5/5 Normal Intact Alert Symmetric No impairment Other: unable to assess None None Unable to assess Date Printed; 5/5/1007 Time Printed.• 10:49 AM P~~JI'~~`fATE ~ru~~ ~. Bey taica~ it~r ll of 11~ ' ` ,~ Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 N e u r o l o g i c a l A s s e s s m e n t F o r m Neurological Assessment Form 01/13/07 02:00 pm Perfoxa~ed by English, Lori A Entered on 01/13/07 02:10 pm G1asQow Caapa Eye Opening Response Spontaneously Best Verbal Response Best Motor Response Oriented Drug Effect Obeys simple commands Patient Tube No Glasgow Coma Score No 15 Pede Canna Eye Opening Response Peds Coma Best Motor Response Peds Coma Spontaneously Best Verbal Response Peds Coma Obeys Drug Effect Oriented and converses Patient Tube No Pediatric Coma Score No 15 Neuro Detailed Pupil Assessment Grid Pupil, Left Pupil Description Pupil Reaction Regular Pupil, Right Brisk Pupil Description Pupil Reaction Regular Pupil Size, Left Brisk Pupil Size, Right 3.0 Characteristics of Speech 3.0 Neurological Strengths Grid Clear Left Upper Extremity Strength Tone Normal or 5/5 Sensation Normal Ri ht U g peer Extremity Intact Strength Tone Normal or 5/5 Sensation Normal Left Lower Extremity Intact Strength Tone Normal or 5/5 Sensation Nornial Right Lower Extremity Intact Strength Tone Normal or 5/5 Sensation Normal Level of Consciousness Intact Symmetry of Face Alert Symmetric P F ) Date Printed: 5/5/2007 Time Printed: !0: 49 AM PE1~I'~STATE ~ ~. wry 14~iea~ miter Cull of e ' 'x,~ Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 O r t h o p e d i c A s s e s s m e n t F o r m ( P F) Orthopedic Assessanent Form 01/12/07 10:33 pm Performed by Martin, Leanne P Entered on .01/12/07 11:33 pan Musculoakeletal Spinal Precautions Cervical spine P a i n R e s p _o n s e F o r m ( P F) Pain Response Form 01/13/07 12:15 pm Performed by English, Lori A Entered oa 01/13/07 02;07 paa Pain Reapoase Pain Intensity Response 2 Pain Reapoase Form 01/13/07 05:35 pan Performed by English, Lori A Entered oa 01/13/07 07:17 pm Pain Reapoase Pain Intensity Response 3 ~ P a t i e n t B e l o n g i n g s F o r m ( P F) ' Patient Belongings Form 01/12/07 11:49 pan Performed by Martin, Leanne P Entered oa 01/12/07 11:49 paa Valuables/Baloagings Valuables/Belongings Grid Valuables With Patient Clothes, Patient Valuables None Comment: see trauma documentation P h y s i c a l T h e r a p y E v a l u a t i o n F o r m ( P F ) Physical Therapy Evaluation Form 01/13/07 03:00 pm Performed by Letendre, Amy L Entered oa 01/13/07 02:45 pm IIpdated oa 01/13/07 03:06 pan by Letendre, Aagy L 01/13/07 03:03 pan by Letendre, Aagy L Cieaeral Info Therapy Orders PT eval and treat, clear for DC Precautions to Rehabilitation Treatment WBAT Pain Symptoms Yes Date Printed: 5/5/2007 Time Printed: 10:49 AM PENI~STA~'E ~ rrr~ _ ~, ~.. Patient Name: CHIARA, JOHN J P h y s i c a l General Info Orientation Safety/Judgment Basic Command Following PT Activity Level PT Diagnosis PT Past Medical History PT Subjective Information PSUHMC MRN: 1133563 T h e r a p y E v a l u a t i o n F o r m ( P F ) Physical Therapy Evaluation Form 01/13/07 03:00 pan Performed by Letendre, Amy I, Entered on 01/13/07 02:45 pan Home Environment Living Environment Lives With Job Responsibilities Prior Functional Level Grid Bed Mobility: Independent Transfers: Independent Ambulation at Home: Independent Community Ambulation: Independent Stairs: Independent Car Transfers: Independent Toilet Transfers: Independent Upper Extremity Bathing: Independent Lower Extremity Bathing: Independent Upper Extremity Dressing: Independent Lower Extremity Dressing: Independent Grooming: Independent Identifies parents, Identifies self Intact Intact per nsg verbal order OOB and C spine clear, team removed C collar and wants crutch training 15yo MVA s/p L pubic rami fx, sacral ale fx, post concussive ADD pt reports he wants to go home today. Per nsg, team removed C collar and cleared spines lives in 2 story with parents Parent(s)/Guardian 9th grade student Primary Pain Adequate Pain Control Primary Yes Pain Intensity 4 Neuro *NOT VALUED* Left Upper Extremity: Intact Right Upper Extremity: Intact Left Lower Extremity: Intact Right Lower Extremity: Intact *NOT VALUED* Left Upper Extremity: Intact Right Upper Extremity: Intact Left Lower Extremity: Intact Right Lower Extremity: Intact PT Cognition a bit impulsive, but otherwise okay Mueculoakeletal Right Upper Extremity Range of Motion Left Lower Extremity: Within normal limits Right Lower Extremity: Left LE Within normal limits Range of Motion Detailed Left Lower Extremity Strength limited by pain Limited Date Printed.' 5/5/2007 Time Printed.• 10:49 AM PE~V~JSTA~~ . ion S. ~y Nfc~ meter of 11~ne Patient Name: CHIAR.A, JOHN J PSUHMC MRN: 1133563 P h y s i c a l T h e r a p y E v a l u a t i o n ~ P F ) Physical Therapy Evaluation Form 01/13/07 03:00 psn Performed by Letendre, ~y L Entered oa` 01/13/07 02:45 psn Muaculoskelatal Right Lower Extremity Strength Mobility/Balance Transfer Toilet Supine to Sit: Minimal assist, with L LE Sit to Supine: Minimal assist Sit to Stand: Standby assist Stand to Sit: Standby assist Bed to/from Chair: Standby assist Gait Training Grid Ambulation Attempt 1 Ambulation Level Person Assist Ambulation Device Utilized Ambulation Distance Weightbearing Status Weightbearing Maintained Ambulation Quality Gait Training Comment Education PT Education Grid 1. Education Topics PT Individuals Taught Barriers to Learning Teaching Method Teaching Evaluation 2. Education Topics PT Individuals Taught Barriers to Learning Teaching Method Teaching Evaluation Assessment Rehabilitation Potential Additional Comments PT Assessment PT Total Evaluation Time Plan PT Frequency PT Plan/Goals Established w Pt/Caregiver DC Reco~mnendations PT Anticipate D/C Services Needed Upon D/C (PT) Activity Guidelines Limited F o r m Standby assistance 1 Crutches 150 ft as tolerated Yes good Dad present for session, observed crutch training Ambulation with. crutches Patient, Father None evident Demonstration, Explanation Returns demonstrations correctly, Verbalizes understanding Stairs Patient, Father None evident Explanation Verbalizes understanding Comment: reviewed on multiple occasions procedure to perform stairs comfortably. Pt and father feel confident they can do them at home and were able to recite method Good pt has no additional skilled needs at this time 30 minute Discontinue Yes Home with assistance none PHYSICAL THERAPY - remember, your crutches always Date Printed: 5/5/2007 Time Printed.• 10.•49 AM P~~JSTi~TE ~tvm ~. ~e~ lick meter of 1'4~ed~c Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 P h y s i c a l T h e r a p y E v a l u a t i o n F o r m ( P F Physical Therapy Evaluation Form 01/13/07 03:00 pm Performed by Leteadre, Amy L Entered oa 01/13/07 02:45 pm DC Recom~mendatione stay with your LEFT leg. And on the stairs, UP WITH YOUR GOOD LEG FIRST (RIGHT) AND DOWN WITH YOUR BAD LEG FIRST (LEFT) Right LE Strength Right Lower Extremity Strength Grid Hip Flexion: Good 4 Hip Extension: Good 4 Hip Abduction: Good 4 Hip Adduction: Good 4 Hip External Rotation: Good 4 Hip Internal Rotation: Good 4 Knee Flexion: Good 4 Knee Extension: Good 4 Ankle Dorsiflexion: Good 4 Ankle Plantarflexion: Good 4 Ankle Inversion: Good 4 Ankle Eversion: Good 4 Left LE Strength Left Hip Flexion Strength Hip Flexion: Poor 2 Hip Extension: Poor 2 Hip Abduction: Poor 2 Hip Adduction: Poor 2 Hip External Rotation: Poor 2 Hip Internal Rotation: Poor 2 Knee Flexion: Poor 2 Knee Extension: Poor 2 Ankle Dorsiflexion: Poor 2 Ankle Plantarflexion: Poor 2 Ankle Inversion: Poor 2 Ankle Eversion: Poor 2 ~ S p i r i t u a l C a r e N o t e F o r m ( P F Spiritual Care Note Fora 01/12/07 09:22 pan Performed by Hurst, Casey Entered oa 01/13/07 00:43 am Updated on 01/16/07 07:29 am by Derricksoa, Paul Spiritual Cara Note Pastoral Services Visit Trauma Pastoral Services Offered Guiding, Support Pastoral Impact Start Somewhat upset, anxious Pastoral Impact End Mildly upset Length of Visit 90 minute Date Printed.• 5/5/2007 Mme Printed: 10:49 AM PE1~i~ST.A~'E ~tvm S. ~~ lt~e~ic ~r ~'~-lle of ~'~ne Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 S p i r i t u a l C a r e N o t e F o r m ( p F~ Spiritual Care Note Form 01/12/07 09:22 pan Performed by Hurst, Casey Spiritual Care Note Entered on 01/13/07 00:43 am Pastoral Intervention Pastoral service Follow up Conversation Pastoral Services Comments Yes 01/12/07 @ 9:22p Reported to pediatric Level 2 Trauma for a 15 year old male involv d i of e n a MVA. Patient was in the middle of the backseat the vehicle with several of his friends. He arrived conscious thou h h , g w en I spoke with him he could not remember some of the details of th on e accident. I was informed that his parents were the way here. Before speaking with parents I talked with patient for a fe w minutes. He said he was scared (of the entire experience) and th t h a e had some pain on his left side near his pelvis and butto k had c . I met with mom and dad and immediately told them I especially communicated with John and that he was stable. Mother was upset because she thought he was fine then heard about th he e flight. After I explained the process of trauma exam and that was at least responsive they both felt better. After about 30 i came m nutes I was able to get a doctor to talk to them and they to the bay to see him. to Patient ended up with a concussion and has some kind of i njury be his pelvis. He was expected to spend the night here and would further evaluated tomorrow. Mother, father and n , ow aunt were present and were relieved and much lower on stress and i another anx ety level at this point. I had to excuse myself and tend to his family. I left them with patient so they coull follow him to room whenever he was transferred. Chaplain: Casey Hurst P h y s i c i a n D i s c h a r g e I n t s r u c t i o n s F o r m( P F Physician Discharge Instructions Form 01/13/07 06:32 pan Performed by Cherenfant, Jovenel patient Discharge Instructions _ ~C Entered on 01/13/07 06:47 pan Discharge Diagnosis Principle Mild comminuted fracture of the left Date Printed.• 3/3/2007 Time Printed: 1(1:49 AM PE~ISTATE 'iltcm S. H~ie~ N1ecic ter +Cca of 1V~ ' 'n~ Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 P h y s i c i a n D i s c h a r g e I n s t r u c t i o n s F o r m ( P F) Physicists Discharge Instructions Form 01/13/07 06:32 pats Performed by Cheretsfatst, Jovenel Entered oa 01/13/07 06:47 pm Patient Discharge Instructions - HMC superior pubic ramus and minimally displaced fracture of the left sacral alts following a motor vehicle collision. Procedures None Medication Review Complete Discharge Medication Reconciliation Completed Discharge Care Instructions Refrain from heavy lifting or extraneous activities for the next 6 weeks. Diet Guidelines Resume regular diet as tolerated Activity Guidelines PHYSICAL THERAPY - remember, your crutches always stay with your LEFT leg. And on the stairs, UP WITH YOUR GOOD LEG FIRST (RIGHT) AND DOWN WITH YOUR BAD LEG FIRST (LEFT). Weight bearing as tolerated on both legs. Call Your Doctor: fevers greater than 101 degrees Farenheit, persistent abdominal pain with nausea and vomiting, and inability to ambulate Phys FU Grid 1. Phys Disch Provider Pediatric Surgery Phys Disch Clinic University Physican Center Phys Disch Comment Our office will call you within hte next few days to schedule a follow up appointment. 2. Phys Disch Provider Dr Knaub from Orthopeadic surgery Physician Discharge Suxamary ~C Brief History John is a 15 year old male brought to Pennstate Children's Hospital as a trauma level 2 following a motor vehicle collision during which he was a rear seat unrestrained passenger. The details of the mechanism are unclear. Patient was amnestic to the event. Physicists Discharge Instructions Form 01/13/07 06:47 pao Performed by Cherenfaat, Jovenel Entered on 01/13/07 06:53 pm Patient Discharge Instructions - ~C Discharge Diagnosis Principle Mild comminuted fracture of the left superior pubic ramus and minimally displaced fracture of the left sacral alts following a motor vehicle collision. Procedures None Medication Review Complete Discharge Medication Reconciliation Completed Discharge Care Instructions Refrain from heavy lifting or extraneous activities for the next 6 weeks. Diet Guidelines Resume regular diet as tolerated Activity Guidelines PHYSICAL THERAPY - remember, your crutches always stay with your LEFT leg. And on the stairs, UP WITH YOUR GOOD LEG Date Printed: 5/5/2007 Time Printed.• 10:49 AM ~t~n S. ~i~ ~7;e~ ~r ~-1~,e~e of ' Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 P h y s i c i a n D i s c h a r g e I n s t r u c t i o n s F o r m( P F) Physician Discharge Instructions Form 01/13/07 06:47 pm Performed by Chereafant, Jovenel Entered on 01/13/07 06:53 pm Patient Discharge Instructions - FCC FIRST (RIGHT) AND DOWN WITH YOUR BAD LEG FIRST (LEFT). Weight bearing as tolerated on both legs. Call Your Doctor: fevers greater than 101 degrees Farenheit, inability .persistent abdominal pain with nausea and vomiting, and Phys FU Grid to ambulate 1. Phys Disch Provider Pediatric Surgery Phys Disch Clinic University Physican Center Phys Disch Comment Our office will call you within hte next few days 2. Phys Disch Provider to schedule a follow up appointment. Dr Knaub from Orthopeadic surgery Physician Discharge Siutmiary ID2C Brief History John is a 15 year old male brought to Pennstate vehicle Children's Hospital as a trauma level 2 following a motor passenger. collision during which he was a rear seat unrestrained to The details of the mechanism are unclear. Patient was amnestic the event and was found outside of the car walking towards the Hospital Course paramedics on the scene. Upon arrival to the trauma ba trauma Y. protocol was initial implemented. He was hemodynamically stable and GCS 15 on exam. Primary and secondary surveys revealed no gross traumatic relatively injuries. CT scan of the head, spine, and abdomen were superior normal except for Mild comminuted fracture of the left pubic ramus and minimally displaced fracture of the left sacral fractures ala. The orthopedic team was consulted and assessed the to be mild and nonoperative. They recommended weight bearing as also tolerated on the lower extremities. The physical therapy team evaluated the patient Physician Discharge Instructions Form 01/13/07 06:56 pan Performed by Cherenfant, Jovenel Entered on 01/13/07 07:04 pan Patient. Discharge Instructions - I~2C Discharge Diagnosis Principle Mild comminuted fracture of the left superior pubic ramus and minimally displaced fracture of the left sacral ala following a motor vehicle collision. Procedures None Medication Review Complete Discharge Medication Reconciliation Completed Discharge Care Instructions Refrain from heavy lifting or extraneous Date Printed: 5/5/2007 Time Printed: 10: 49 AM ~~ l~vfftle Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 P h y s i c i a n D i s c h a r g e I n s t r u c t i o n s F o r m( P F) Physician Discharge Instructions Form 01/13/07 06:56 pm Performed by Chereafaat, Joveael Patient Discharge Instructions Entered on 01/13/07 07:04 pm - F~lC Diet Guidelines activities for the next 6 weeks. Activity Guidelines Resume regular diet as tolerated PHYSICAL THERAPY - remember, your crutches always LEG stay with your LEFT leg. And on the stairs, UP WITH YOUR GOOD FIRST (RIGHT) AND DOWN WITH YOUR BAD LEG FIRST (LEFT). Weight Call Your Doctor: bearing as tolerated on both legs. fevers greater than 101 degrees Farenheit, inability persistent abdominal pain with nausea and vomiting, and Phys FU Grid to ambulate 1. Phys Disch Provider Pediatric Surgery Phys Disch Clinic University Physican Center Phys Disch Comment Our office will call you within hte next few days 2. Phys Disch Provider to schedule a follow up appointment. Dr Knaub from Orthopeadic surgery Physician Discharge Summary ESC Brief History John is a 15 year old male brought to Pennstate vehicle Children's Hospital as a trauma level 2 following a motor passenger. collision during which he was a rear seat unrestrained to The details of the mechanism are unclear. Patient was amnestic the event and was found outside of the car walking towards the Hospital Course paramedics on the scene. Upon arrival to the trauma bay, trauma protocol was initial implemented. He was hemodynamically stable and GCS 15 on exam. Primary and secondary surveys revealed no gross traumatic relatively injuries. CT scan of the head, spine, and abdomen were superior normal except for Mild comminuted fracture of the left pubic ramus and minimally displaced fracture of the left sacral fractures ala. The orthopedic team was consulted and assessed the to be mild and nonoperative. They recommended weight bearing as also tolerated on the lower extremities. The physical therapy team independent evaluated the patient and found him to be mobile and the enough for home discharge. The psychiatry team also evaluated patient patient for screening of recreational drug use, which the denied. He was discharged to home approximately 24 hours after discharge Exam On Discharge Afebrile, stable vital signs Date Printed.• 5/5/2007 Time Printed.• 10:49 AM PE~I~I~TATE ~t~om S. rsh~y ll+ic. meter Ca-~e of e ' ' e Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 P h y s i c i a n D i s c h a r g e I n s t r u c t i o n s F o r m ( P F) Physician Discharge Instructions Form 01/13/07 06:56 pan Performed by Chereafaat, Jovenel Entered on 01/13/07 07:04 pm Physician Discharge 3uaanary IBC strength cranial nerves 2-12 grossly intact, 5/5 musculoskeletal all throughout CTAB, RRR soft NT/ND active bowel sounds extremities intact Physician Discharge Instructions Form 01/13/07 07:19 pan Performed by Cherenfaat, Jovenel Entered on 01/13/07 07:20 pm Patient Discharge Instructions - E~KC Discharge Diagnosis Principle Mild comminuted fracture of the left superior pubic ramus and minimally displaced fracture of the left Procedures Medication Review Complete Discharge Care Instructions Diet Guidelines Activity Guidelines LEG Call Your Doctor: inability Phys FU Grid 1. Phys Disch Provider Phys Disch Clinic Phys Disch Comment 2. Phys Disch Provider Phys Disch Comment sacral ale following a motor vehicle collision. None Discharge Medication Reconciliation Completed ` Refrain from heavy lifting or extraneous activities for the next 6 weeks. Resume regular diet as tolerated PHYSICAL THERAPY - remember, your crutches always stay with your LEFT leg. And on the stairs, UP WITH YOUR GOOD FIRST (RIGHT) AND DOWN WITH YOUR BAD LEG FIRST (LEFT). Weight bearing as tolerated on both legs. fevers greater than 101 degrees Farenheit, persistent abdominal pain with nausea and vomiting, and to ambulate Pediatric Surgery University Physican Center Our office will call you within hte next few days to schedule a follow up appointment. Orthopedic pediatric fracture clinic in 2 weeks The office will call you for the exact time of the appointment. Physician Discharge Instructions Form 01/13/07 07:21 pan Performed by Chereafant, Jovenel Entered on 01/13/07 07:21 pm Patient Discharge Instructions - HMC Discharge Diagnosis Principle Mild comminuted fracture of the left superior pubic ramus and minimally displaced fracture of the left sacral ale following a motor vehicle collision. Procedures None Date Printed: 5/5/2007 Time Printed: 10:49AM .ut~n ~. fey lica~ ~r +~ll ., of I1~' ' `n Patient Name: CHIAR.A, JOHN J P h y s i c i a n PSUHMC MRN; 1133563 D i s c h a r g e I n s t r u c t i o n s F o r m( P F) Physician Discharge Instructions Form 01/13/07 07:21 pan Performed by Cherenfant, Jovenel Entered on 01/13/07 07:21 pm Patient Discharge Instructions - ffi~C Medication Review Complete Discharge Medication Reconciliation Completed Discharge Care Instructions Refrain from heavy lifting or extraneous activities for the next 6 weeks. Diet Guidelines Resume regular diet as tolerated Activity Guidelines PHYSICAL THERAPY - remember, your crutches always LEG stay with your LEFT leg. And on the stairs, UP WITH YOUR GOOD FIRST (RIGHT) AND DOWN WITH YOUR BAD LEG FIRST (LEFT). Weight bearing as tolerated on both legs. Call Your Doctor: fevers greater than 101 degrees Farenheit, inability persistent abdominal pain with nausea and vomiting, and Phys FU Grid to ambulate 1. Phys Disch Provider Pediatric Surgery Phys Phys Disch Disch Clinic Comment University Physican Center Our office will call you within hte next few days 2. Phys Disch Provider to schedule a follow up appointment. Phys Disch Comment Orthopedic pediatric fracture clinic in 2 weeks The office will call you for the exact time of the appointment. M e d i c a t i o n R e c o n c i l i a t i o n F o r m P F Medicatioa Reconciliation Form 01/12/07 10:34 pan performed by Cortex, James Entered on 01/12/07 10:34 pan Medication Reconciliation Form Medication Reconciliation Status Medication Reconciliation completed Medication Reconciliation Form 01/13/07 07:04 pan Performed by Cherenfant, Joveael Entered on 01/13/07 07:04 pm Medicatioa Reconciliation Form Medication Reconciliation Status Medication Reconciliation completed Date Printed: 5/5/2007 Time Printed: 10.•49 AM PEI~STATE `itton S. ~~ laic nt of 1'~e eg~e d~~e Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 P h y s i c i a n D i s c h a r g e I n s t r u c t i o n s F o r m ( P F) i Physician Discharge Itsstructioas Form 01/13/07 06:32 pm Performed by Chereafaat, Jovetsel ~ Entered on 01/13/07 06:47 pm Patient Discharge Instructions - SDSC Discharge Diagnosis Principle Mild comminuted fracture of the left left superior pubic ramus and minimally displaced fracture of the Procedures sacral alts following a motor vehicle collision. Medication Review Complete None Discharge Medication Reconciliation Completed Discharge Care Instructions Refrain from heavy lifting or extraneous Diet Guidelines activities for the next 6 weeks. Resume regular diet as tolerated Activity Guidelines PHYSICAL THERAPY - remember, your crutches always LEG stay with your LEFT leg. And on the stairs, UP WITH YOUR GOOD FIRST (RIGHT) AND DOWN WITH YOUR BAD LEG FIRST (LEFT). Weight Call Your Doctor: bearing as tolerated on both legs. fevers greater than 101 degrees Farenheit, inability persistent abdominal pain with nausea and vomiting, and to ambulate Phys FU Grid 1. Phys Disch Provider Pediatric Surgery Phys Disch Clinic University Physican Center Phys Disch Comment Our office will call you within hte next few days 2. Phys Disch Provider to schedule a follow up appointment. Dr Knaub from Orthopeadic surgery Physician Discharge Suamiary FIDIC Brief History John is a 15 year old male brought to Pennstate vehicle Children~s Hospital as a trauma level 2 following a motor passenger. collision during which he was a rear seat unrestrained to The details of the mechanism are unclear. Patient was amnestic the event. Physicists Discharge Instructions Form 01/13/07 06:47 pm Performed by Chereafant, Jovenel Entered on 01/13/07 06:53 pm Patient Discharge Instructions - I~dC Discharge Diagnosis Principle Mild comminuted fracture of the left superior pubic ramus and minimally displaced fracture of the left sacral alts following a motor vehicle collision. Procedures None Medication Review Complete Discharge Medication Reconciliation Completed Discharge Care Instructions Refrain from heavy lifting or extraneous activities for the next 6 weeks. Diet Guidelines Resume regular diet as tolerated Activity Guidelines PHYSICAL THERAPY - remember, your crutches always J stay with your LEFT leg. And on the stairs, UP WITH YOUR GOOD EG Date Printed: 5/5/1007 Time Printed: 10:49 AM . , h F PE~di~STATE ~ttl~l S. r~ 1Vica it~r of ~~ Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 P h y s i c i a n D i s c h a r g e I n s t r u c t i o n s F o r m ( P F) Physician Discharge Instructions Form 01/13/07 06:47 pan Performed by Chereafant, Joveael Entered on 01/13/07 06:53 pan Patient Discharge Instructions - FIIdC FIRST (RIGHT) AND DOWN WITH YOUR BAD LEG FIRST (LEFT). Weight bearing as tolerated on both legs. Call Your Doctor: fevers greater than 101 degrees Farenheit, persistent abdominal pain with nausea and vomiting, and inability to ambulate Phys FU Grid 1. Phys Disch Provider Pediatric Surgery Phys Disch Clinic University Physican Center Phys Disch Comment Our office will call you within hte next few days to schedule a follow up appointment. 2. Phys Disch Provider Dr Knaub from Orthopeadic surgery Physician Discharge Swmnary HDaC Brief History John is a 15 year old male brought to Pennstate Children's Hospital as a trauma level 2 following a motor vehicle collision during which he was a rear seat unrestrained passenger. The details of the mechanism are unclear. Patient was amnestic to the event and was found outside of the car walking towards the paramedics on the scene. Hospital Course Upon arrival to the trauma bay, trauma protocol was implemented. He was hemodynamically stable and GCS 15 on initial exam. Primary and secondary surveys revealed no gross traumatic injuries. CT scan of the head, spine, and abdomen were relatively normal except for Mild comminuted fracture of the left superior pubic ramus and minimally displaced fracture of the left sacral ala. The orthopedic team was consulted and assessed the fractures to be mild and nonoperative. They recommended weight bearing as tolerated on the lower extremities. The physical therapy team also evaluated the patient Physician Discharge Instructions Form 01/13/07 06:56 pm Performed by Cherenfaat, Joveael Entered oa 01/13/07 07:04 pan. Patient Discharge Instructions - FaSC Discharge Diagnosis Principle Mild comminuted fracture of the left superior pubic ramus and minimally displaced fracture of the left Procedures Medication Review Complete Discharge Care Instructions sacral ala following a motor vehicle collision. None Discharge Medication Reconciliation Completed Refrain from heavy lifting or extraneous Date Printed: 5/5/2007 Time Printed: 10:49 AM P~~lSTATE ~1tan ~. ~ ~,ic ,ter ll of ' ' e Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 P h y s i c i a n D i s c h a r g e I n s t r u c t i o n s F o r m ( P F) Physician Discharge Instructions Form 01/13/07 06:56 pan Performed by Cherenfant, Joveael Entered oa 01/13/07 07:04 pm Patient Discharge Instructions - 81KC activities for the next 6 weeks. Diet Guidelines Resume regular diet as tolerated Activity Guidelines PHYSICAL THERAPY - remember, your crutches always stay with your LEFT leg. And on the stairs, UP WITH YOUR GOOD LEG FIRST (RIGHT) AND DOWN WITH YOUR BAD LEG FIRST (LEFT). Weight bearing as tolerated on both legs. Call Your Doctor: fevers greater than 101 degrees Farenheit, Persistent abdominal pain with nausea and vomiting and inability , to ambulate Phys FU Grid 1. Phys Disch Provider Pediatric Surgery Phys Disch Clinic University Physican Center Phys Disch Comment Our office will call you within hte next few days to schedule a follow up appointment. 2. Phys Disch Provider Dr Knaub from Orthopeadic surgery Physician Discharge Sw~miary HI+lC Brief History John is a 15 year old male brought to Pennstate Children's Hospital as a trauma level 2 following a motor vehicle collision during which he was a rear seat unrestrained passenger. The details of the mechanism are unclear. Patient was amnestic to the event and was found outside of the car walking towards the paramedics on the scene. Hospital Course Upon arrival to the trauma bay, trauma protocol was initial implemented. He was hemodynamically stable and GCS 15 on exam. Primary and secondary surveys revealed no gross traumatic relatively injuries. CT scan of the head, spine, and abdomen were normal except for Mild comminuted fracture of the left superior pubic ramus and minimally displaced fracture of the left sacral fractures ala. The orthopedic team-was consulted and assessed the to be mild and nonoperative. They recommended weight bearing as tolerated on the lower extremities. The physical .therapy team also evaluated the patient and found him to be mobile and independent the enough for home discharge. The psychiatry team also evaluated patient for screening of recreational drug use, which the patient denied. He was discharged to home approximately 24 hours after discharge Exam On Discharge Afebrile, stable vital signs Date Printed: 5/5/2007 Time Printed.' 10:49 AM PE~I~TATE .............. ~ilt~n ~. ~~1~ N~~ it~r allege o~ Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 P h y s i c i a n D i s c h a r g e I n s t r u c t i o n s F o r m ( P F Physician Discharge Instructions Form 01/13/07 06:56 Pm Performed by Chereafaat, Jovenel Entered on 01/13/07 07:04 pm Physician Discharge Su:maary I•DaC strength cranial nerves 2-12 grossly intact, 5/5 musculoskeletal all throughout CTAB, RRR soft NT/ND active bowel sounds extremities intact Physician Discharge Instructions Form 01/13/07 07:19 pm Performed by Chereafaat, Jovenel Entered on 01/13/07 07:20 pm Patieat Discharge Iastructions - ~aC Discharge Diagnosis Principle Mild comminuted fracture of the left superior pubic ramus and minimally displaced fracture of the left Procedures Medication Review Complete Discharge Care Instructions Diet Guidelines Activity Guidelines LEG Call Your Doctor: inability Phys FU Grid 1. Phys Disch Provider Phys Disch Clinic Phys Disch Comment 2. Phys Disch Provider Phys Disch Comment Patient Discharge Instructions - IBC Discharge Diagnosis Principle left Procedures sacral ala following a motor vehicle collision. None Discharge Medication Reconciliation Completed Refrain from heavy lifting or extraneous activities for the next 6 weeks. Resume regular diet as tolerated PHYSICAL THERAPY - remember, your crutches always stay with your LEFT leg. And on the stairs, UP WITH YOUR GOOD FIRST (RIGHT) AND DOWN WITH YOUR BAD LEG FIRST (LEFT). Weight bearing as tolerated on both legs. fevers greater than 101 degrees Farenheit, persistent abdominal pain with nausea and vomiting, and to ambulate Pediatric Surgery University Physican Center Our office will call you within hte next few days to schedule a follow up appointment. Orthopedic pediatric fracture clinic in 2 weeks The office will call you for the exact time of the appointment. Physician Discharge Iastructioas Form 01/13/07 07:21 pm Performed by Chereafant, Jovenel Entered on 01/13/07 07:21 part Mild comminuted fracture of the left superior pubic ramus and minimally displaced fracture of the sacral ala following a motor vehicle collision. None Date Printed: 5/5/2007 Time Printed: 10:49 AM PE1~lSTATE iltc>!n ~. r~hey 14~cic miter ll of ' 'ne Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 P h y s i c i a n D i s c h a r g e I n s t r u c t i o n s F o r m ( P F) Physician Discharge Instructions Form 01/13/07 07:21 pm Performed by Cherenfant, Jovenel Eatered oa 01/13/07 07:21 pm Patient Discharge Instructions - HIdC Medication Review Complete Discharge Care Instructions Diet Guidelines Activity Guidelines LEG Call Your Doctor: inability Phys FU Grid 1. Phys Disch Provider Phys Disch Clinic Phys Disch Comment 2. Phys Disch Provider Phys Disch Comment Discharge Medication Reconciliation Completed Refrain from heavy lifting or extraneous activities for the next 6 weeks. Resume regular diet as tolerated PHYSICAL THERAPY - remember, your crutches always stay with your LEFT leg. And on the stairs, UP WITH YOUR GOOD FIRST (RIGHT) AND DOWN WITH YOUR SAD LEG FIRST (LEFT). Weight bearing as tolerated on both legs. fevers greater than 101 degrees Farenheit, persistent abdominal pain with nausea and vomiting, and to ambulate Pediatric Surgery University Physican Center Our office will call you within hte next few days to schedule a follow up appointment. Orthopedic pediatric fracture clinic in 2 weeks The office will call you for the exact time of the appointment. I O r d e r s S e c t i o n 1 Mnemonic Action Order Status Type of Order Chest XR Order Completed Radiolo y Ordering Physician Order Placed By DeFlitch, Christopher J Contributor system, IDXOE01 Review Information Nurse Review, Not Reviewed - Doctor Cosign, Accepted -DeFlitch, Christopher J, 1/16/2007 11:39:08 AM Order Details Routine, Requested Dt: 01/12/07 21:29:04, Views: "`Standard Views Date Printed: 5/5/2007 Time Printed: 10:49 AM PENNSTATE Milton S. Hershey Medical Center • ®College of Medicine ORTHOPAEDIC TRAUMA ASSESSMENT NAME: CHIARA, JOHN MD: DILLON PETER W MR#; 7500215 DOB: 05/18/1991 INS: AUTO INSURANCE LOC: OOS#: 10500215 MD#: 26150 SEX: M STANDARD VISIT DATE: 01/12/2007 History of Injury: l ~ ~ ~^' Vv~ v ~- Attending on Calf: v~b Consult Date: l ~ 3 a7 Date of Iniury: ~ ~ 2 ` °'~ Consult Time:. pq~(y AM/PM Mechanism_of Injury: Sia nificant Past Medical History ^ unknown Addictions: motor vehicle ^ hypertension ^ hepatic disease ^ tobacco ^ motorcycle ^ coronary artery disease ^ HIV smoke~P~~ ^ pedestrian struck ^ peripheral vscular disease ^ hepatitis B B chew ^ fall ^ congestive heart failure ^ cancer ^ alcohol ^ industrial ^ diabetes (~~~ ^ stroke ^ narcotics ^ ^ farm ^ COPD ^ spinal cord injury ^ unknown assault ^ asthma ^ ^ other ^ gunshot ^ artrial fibrillation ^ non-ambulator ^ other ^ renal failure ^ anticoagulated Orthopedic inj ries 1. L e Y (?,e: l u 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Open Lift Right ^ y~ D ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ D ^ ^ ^ ^ ^ ^ ^ ^ Resident comments: (/~ PEAT ~ ~~ ~~~ Attending summary and plan: Expected period of non-weight bearing• right leg left leg right arm left arm 6 weeks ^ ^ ^ ^ 12 weeks ^ ^ ^ ^ Expected period of Sc~e bracina• Cervical: D 6 wks ^ 12 wks *TLSO: ^ 6 wks ^ 12 wks Resident signature: Attending signature date: ~ / 3 ~ ~ time: AM/PM MR 874 Page 1 of 2 72/02 ORTHOPAEDIC TRAUMA ASSESSMENT *TLSO = Thoraco--lumbar-sacral orthisis i~~ LEFT /i t Other Injuries: ^ Head injury ^ Aortic dissect. ^ Pneumvthorax ^ Splenic injury ^ Hepatic injury ^ Renal injury ^ Bowel injury ^ Bladder rupture Orthopedic Trauma Physical Examination L SOFT TISSUE INJURIES RIGHT ~1\ -- HYSICAL EXAM NL ABN R L R L Neck ~ ~ ^ ^ Spine ^ ^ Clavicle ^ ^ Shoulder ^ ^ Arm ^ ^ Elbow ^ ^ Forearm ^ .^ Wrist ^ ^ Hand ^ ^ NL R L Pelvis ~ ^ Hip .~) ^ Thigh ,i~ ~ Knee Calf Ankle Foot ABN R L ^ ,~ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ VASCULAR EXAM EXTREMETIES RAD ULN FEM POP DP PT R ~~' ~f 2~ NEUROLOGICAL EXAM UPPER EXTREMITY Motor deltoid bicep wrist flex wrist ext t~cep grip R .; / L `~ ,. Sensory C5 > C6 C7 C8 T1 R ~~~~~ LOWER EXTREMITY Motor ppsoas R S/~ hip ext quads hams tib ant ext hall long gastroc L ~ L r - ~ls Sensory L2 L3 L4 L5 S1 R~~,~ L Rectal: hyper norm hypo absent T T Bulbocav: hyper norm hypo absent y y SKELETAL INJURIES X-RAYS Additic TRAUMA SERIES n ~ AP LAT POS NEG 1 K- C-Spine ^ ^ ^ odors ^ ^ 2. _ T-Spine ^ ^ ^ ^ 3. - 4 LS-Spine ^ ^ ^ ^ ~ - Pelvis ~ ~1 ^ t-- a~,~ n_.c~~.. „~ 6. _.~ i j ies needed: A P .,c,~, c,c.f o-u f~4.f ~r(vr~ t MR 874 Page 2 of 2 12/02 ORTHOPAEDIC TRAUMA ASSESSMENT FRONT BACK . PEN,NSTATE Milton S. Hershey Medical Center College of Medicine ,~ . - _ ~tlt ~L~~Of~~Al~l~~' {~i~1'T' ~#-IEET _ PENN STATE MILTON S. HERSHEY MEDICAL CENTER BLOOD BANK HERSHEY, PA 17033 DIRECTOR OF CLINICAL LABORATORIES .:' a ,.:,a A SPECIAL REQUESTS -CALL 8232 ^ IXCHANGE TRANSFUSION VOL INTRAUTERINE TRANSFUSION VOL ^ FRESH (LESS THAN 8 DAYS) # UNITS ^LESS THAN 72 HOURS (PEDIATRIC HEART SURGERY) N UNITS ^ OTHER SPECIFY CLINICAL PATHOLOGIST EVALUATION REQUIRED ~LEUKOREDUCED ^ IRRADIATED NUMBER ^ CROSSMATCH (ABO/RH, ANTIBODY SC COMPONENT PACKED CELLS GRANULOCYTES(XMG) HPC-STEMCELLS (XMMS) X4861 NAMEcTRA A, 7500215~~ !~~^~~~~ MD: DEFLITCH ~~T~~~~' MD#: 46325 MR#: 7500215 DOB: 01/01/19 SEX;~I~J UNITS) INS: SELF PAY SELPPAY LOC: EMER #UNITS OOS#: 10500215 VISIT DATE: 03/06/2007 ~'_"~~_ ^ 7~T1'PE AN.D SCREEN (TSC) (ABO/RH, ANTIBODY SCREEN, 0 UNITS) ^ OB TYPE AND SCREEN (OBTS) (ABO/RH, ANTIBODY SCREEN, 0 UNITS) ^ NEONATAL TRANSFUSION (NEOX) (ABO/RH, ANTIBODY SCREEN) ^ HOLD SPECIMEN (HOLD) (NO TESTING PENDING ORDERS) 1 ADULT RED PER 4 UNITS EACH TUBE MUST HAVE R# LABEL CHART COPY [,~„~~/ TIME: ~ ~~ RECIPIENTS IDENTIFICATION VERIFIED, SPE DATE:~z~d CIMEN COLLECTED ANp BLOOD BAND APPLIED BY: INFORMATION REQUIRED DIAGNOSIS ~~l'~/ ORDERING PHYSICIAN ^ ROUTINE FOR SURGERY COLLECT ON: DgTE FOR TRANSFUSION KEEP UNITS AHEADATgIl~MES (NEW SPECIMEN REQUIRED EVERY 72 HOURS) PREVIOUS TRANSFUSIONS ^ YES ^ NO DATE cis iaev~rooi 4L>If~IIG4L LABORAT`C~~Y (Vlfl'~LU~~-'~~~~ ~~ t S. ~ry ~ic~.~ +t~r ege of N~Cane Patient Name: CHIARA, JOHN J PSiJHMC MRN: 1133563 O r d e r s S e c t i o n Mnemonic Action Order Status Type of Order C-S ine XR Order Com leted . Radiology Ordering Physician Order Placed By DeFlitch, Christo her J Contributor system, IDXOE01 Review Information Nurse Review, Not Reviewed - Doctor Cosign, Acce ted -DeFlitch, Christopher J, 1/16/2007 11:39:08 AM Order Details Routine, Requested Dt: 01/12/07 21:29:03, Views: *Standard Views Mnemonic Action Order Status Type of Order Pelvis XR Order Completed Radiology Ordering Physician Order Placed By DeFlitch, Christopher J Contributor system, IDXOE01 Review Information Nurse Review, Not Reviewed - Doctor Cosign, Accepted -DeFlitch, Christopher J, 1/16/2007 11.39.08 AM Order Details Routine, Requested Dt: 01/12/07 21:29:03, Views: *Standard Views Mnemonic Action Order Status Type of Order Discontinue Diet Patient Order Discontinued Dietary Dischar ed • Ordering Physician Order Placed By SYSTEM SYSTEM Review Information N/A Order Details 01/13/07 20:57:54 1/13/2007 8:57:54 PM: discharge order Mnemonic Action Order Status Type of Order Discontinue IV Order Discontinued Patient Care Ordering Physician Order Placed By Cherenfant, Jovenel Cherenfant, Jovenel Review Information N/A Order Details 01/13/07 19:21:00, ONCE, Stopping On 01/13/07 19:21:00 Date Printed: 5/5/2007 Time Printed: 10:49 AM ~E~,~4 tc~n o~f~~~ 1'dic C~riter ~4 Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 ~ O r d e r s S e c t i o n Mnemonic Action Order Status Type of Order Dischar e. Order Discontinued Patient Care Ordering Physician Order Placed By Cherenfant, Jovenel Cherenfant, Jovenel Review Information Nurse Review, Not Reviewed - Order Details Stable for Dischar e, Attending: Dillon, Peter W, Requested Discharge Dt: 01/13/07 19:20:00 Mnemonic Action Order Status Type of Order Dischar a Order Discontinued Order Sets Ordering Physician Order Placed By Cherenfant, Jovenel Cherenfant, Jovenel Review Information N/A Order Details N/A Mnemonic Action Order Status Type of Order Communication to Nursin Order Discontinued Patient Care Ordering Physician Order Placed By Erdahl, Lillian M English, Lori A Review Information Nurse Review, Not Reviewed - Doctor Cosign, Accepted - Erdahl, Lillian M, 1/13/2007 7:45:46 PM Order Details _ 01/13/07 19:20:00, c collar maybe removed, cspine cleared. Mnemonic Action Order Status Type of Order Out of Bed Order Discontinued Patient Care Ordering Physician Order Placed By Erdahl, Lillian M English, Lori A Review Information Nurse Review, Not Reviewed - Doctor Cosi n, Accepted - Erdahl, Lillian M, 1/13/2007 7:45:46 PM Order Details 01/13/07 14:00:00, ad lib, Physician Stop Date Printed: 5/5/1007 Time Printed.• 10:49 AM PENt~STATE ~l~n S. H~he~ 14iica~ C'~ter CQlle of Patient Name: CHIARA, JOHN J PSUI-EvIC MRN: 1133563 O r d e r s S e c t i o n Mnemonic Action Order Status Type of Order acetamino hen-codeine Order Ordered Pharmacy Ordering Physician Order Placed By Cherenfant, Jovenel Cherenfant, Jovenel Review Information N/A Order Details 1 tab, PO, q4h, PRN, tab, 0, 0, 01/13/07 18:32:10, Pain -Mild, Print DEA Number, given to patient, 30038, Prescription Dispensed Indicator Mnemonic Action Order Status acetaminophen-codeine phos Order Discontinued 300-30 tab Ordering Physician Order Placed By Cherenfant, Jovenel Cherenfant, Jovenel Review Information Nurse Review, Not Reviewed - Pharmacist Verify, Accepted -Meier, Joanna, 1/13/2007 6:38:25 PM Order Details 1 tab, tablet, PO, q4h, PRN, Pain -Mild, Routine, 01/13/07 18:31:00, 30 day, 02/12/07 18:30:00 Type of Order Pharmacy Mnemonic Action Order Status Type of Order DSW and 0.9% Sodium Modify Discontinued Pharmacy Chloride Ordering Physician Order Placed By Erdahl, Lillian M Leiby, Amy Review Information Nurse Review, Not Reviewed - Order Details 1000 mL, IV, Routine, 01/12/07 22:31:00, Hard Stop, 02/11/07 22:30:00, 125 mLlHR, 8 HR, 1000 Mnemonic Action Order Status Type of Order Percocet /generic equiv (5 / Order Discontinued Pharmacy 325) tab Ordering Physician Order Placed By Erdahl, Lillian M Erdahl, Lillian M Review Information Nurse Review, Not Reviewed - Pharmacist Verify, Accepted -Leiby, Amy, 1/13/2007 10:37:16 AM Order Details 1 tab, tablet, PO, q4h, PRN, Pain -Mild, Routine, 01/13/07 10:33:00, 3 day, 01/16/07 10:32:00 Date Printed: 5/5/2007 Time Printed.• 10:49 AM ~i'lt~a ~. Ihc~ lei 1ttS ~'~ of ~it~ine Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 ~ O r d e r s S e c t i o n Mnemonic Action Order Status Type of Order Percocet /generic equiv (5 / Order Discontinued Pharmacy 325) tab Ordering Physician Order Placed By Erdahl, Lillian M Erdahl, Lillian M Review Information Nurse Review, Not Reviewed - Pharmacist Verify, Accepted -Leiby, Amy, 1/13/2007 10:37:16 AM Order Details 2 tab, tablet, P0, q4h, PRN, Pain -Moderate, Routine, 01/13/07 10:33:00, 3 da , 01/16/07 10:32:00 Mnemonic Action Order Status Type of Order Dextrose 5% with 0.9% NaCI Modify Discontinued Pharmacy Ordering Physician Order Placed By Erdahl, Lillian M Erdahl, Lillian M Review Information Nurse Review, Not Reviewed - Pharmacist Verify, Reviewed -Leiby, Amy, 1/13/2007 10:37:16 AM ,~_~_ 1000 mL, IV, Routine, 01/12/07 22:31:00, 30 day, Hard Stop, 02/11/07 22.30.00, 125 mL/HR, 8 HR, 1000 1/13/2007 10.33.14 AM. Hepwell when patient tolerates 500 ml po Mnemonic PT Treatment Action Order Order Status Discontinued Type of Order Consults Ordering Physician Erdahl, Lillian M Order Placed By Erdahl, Lillian M Review Information Nurse Review, Not Reviewed - Order Details Requested Dt: 01/13/07 10:32:00, gait training please per Orthopedics recommendation Mnemonic Action Order Status Type of Order PT Evaluation Order Completed Consults Ordering Physician Order Placed By Erdahl, Lillian M Erdahl, Lillian M Review Information Nurse Review, Not Reviewed - Order Details Routine, Requested Dt: 01/13/07 10:31:00, Left Leg - Weightbearing as Tolerated Date Printed.• 5/5/2007 Time Printed.• 10:49 AM PE~lt~~TATE t~ ~. ~ l~e~ie meter age of 1'4~e ' 'ne Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 O r d e r s S e c t i o n Mnemonic Action Order Status Type of Order PT Evaluation and Order Completed Order Sets Treatment Ordering Physician Order Placed By Erdahl, Lillian M Erdahl, Lillian M Review Information N/A Order Details N/A Mnemonic Action Order Status Type of Order Advance Diet as Tolerated Order Discontinued Dietary Ordering Physician Order Placed By Erdahl, Lillian M Erdahl, Lillian M Review Information Nurse Review, Not Reviewed - Order Details 01/13/07 10:31:00 Mnemonic Action Order Status Type of Order Advanced Prac Nurse Psych Order Discontinued Consults Referral Ordering Physician Order Placed By SYSTEM SYSTEM Review Information Nurse Review, Not Reviewed - Order Details O 1 / 13/07 10:12:49 1/13/2007 .10:12:49 AM: Advanced Prac Nurse Psych Referral Mnemonic Action Order Status Type of Order Ph sician Consult Re uest Order Com leted Consults Ordering Physician Order Placed By Cherenfant, Jovenel Cherenfant, Jovenel Review Information Nurse Review, Not Reviewed - Order Details Routine, Requested Dt: 01/13/07 10:03:00, Service: Psychiatry, Adult, Reason: s/p MVC with presumptive positive marijuana on tox screen, please assist in counseling and treatment, I have or will contact the physician directly, Pediatric Surgery #1141 Date Printed: 5/5/2007 Time Printed.• 10:49 AM PE~VI~STATE Il~lt~on ~. ~r~he~ 1VI~~ meter C~lle~e of ed~rr~n~e Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 ~ O r d e r s S e c t i o n Mnemonic Action Order Status Type of Order Pelvis XR Order Com leted Radiology Ordering Physician Order Placed By Price, Shawn L Price, Shawn L Review Information Nurse Review, Not Reviewed - Order Details Routine, Requested Dt: 01/13/07 9:58:00, Views: AP Inlet ~ Outlet, ICD9: Pelvic Fracture 808.8 History: 15 yo MVA Mnemonic Action Order Status Type of Order Ph sician Consult Re uest Order Completed Consults Ordering Physician Order Placed By Erdahl, Lillian M Erdahl, Lillian M Review Information Nurse Review, Not Reviewed - Order Details Routine, Requested Dt: 01/13/07 9:52:00, Service: Orthopaedics, Reason: Left sacral ala and pubic ramus fracture, please assist in evaluation and management, I have or will contact the physician directly, Pediatric Surgery #1141 Mnemonic Action Order Status Type of Order Communication to Nursin Order Discontinued Patient Care Ordering Physician Order Placed By Pastor, Danielle M Pastor, Danielle M Review Information Nurse Review, Not Reviewed - Order Details 01/13/07 0:10:00, T/L cleared; may increase angle of head of bed. _ Mnemonic Action Order Status Type of Order ondansetron 4 mg / 2 mL vial ' Order Discontinued Pharmacy in Ordering Physician Order Placed By Pastor, Danielle M Pastor, Danielle M Review Information Nurse Review, Not Reviewed - Pharmacist Verify, Accepted - Vissering, Thomas, 1/13/2007 12:09:48 AM Order Details 4 mg, injection, IV, ONCE, PRN, Nausea and Vomiting, Routine, 01/13/07 0:07:00, 01/14/07 0:06:00 Date Printed: 5/5/2007 Time Printed.• 10:49 AM I PENNSTATE tfln ~. ~ I1~ic meter GQ11 of ~ ' 'ne Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 ~ _ O r d e r s S e c t i o n Mnemonic Action Order Status Type of Order morphine carpuject 2 mg / ' Order Discontinued Pharmacy mL s r. in . Ordering Physician Order Placed By Pastor, Danielle M Pastor, Danielle M Review Information Nurse Review, Not Reviewed - Pharmacist Verify, Accepted - Vissering, Thomas , 1/13/2007 12:09:48 AM Order Details 2 m ,injection,lV, q2h, PRN, Pain -Mild, Routine, 01/13/07 0:05:00, 3 day, 01/16/07 0:04:00 Mnemonic Action Order Status Alcohol Level not Le al) Order Completed Ordering Physician Order Placed By Contributor s stem, Sl Review Information Nurse Review, Accepted -Martin, Leanne P, 1/12/2007 11:48:06 PM Doctor Cosign, Not Reviewed - Order Details STAT, Blood, Lab to Collect, starting at 01/12/07 21:40:00, ONCE, stopping at 01/12/07 21 Mnemonic Action Order Status mor hive Order Completed Ordering Physician Order Placed By Contributor system, PYXISOI Contributor syst~ Review Information N/A Order Details injection, Pyxis, ONCE, 01/12/07 23:16:16, Physician Stop, 01/12/07 23:16:16 Mnemonic Action Order Status Wei ht Order Canceled Ordering Physician Order Placed By SYSTEM SYSTEM Review Information Nurse Review, Not Reviewed - Order Details 01/19/07 8:00:00, gWeek Type of Order Laboratory ESTOE01 Collected Type of Order PYXISOI Type of Order Patient Care Date Printed: 5/5/1007 Time Printed: 10.•49 AM PE~I~ST~~'E ~iltan S. H~hey 1~1et,i meter ~Cvl1 of ~V Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 O r d e r s S e c t i o n 1/12/2007 10;46:33 PM: routine weight at admission Mnemonic Action Order Status Type of Order Ped On oin Assessment Order Discontinued Patient Care Ordering Physician Order Placed By SYSTEM SYSTEM Review Information N/A Order Details 01/12/07 22:46:33, gshift-nursing 1/12/2007 10:46:33 YM: Yed Ongoing Assessment Mnemonic Action Order Status Type of Order Ped Admit2 Assessment Order Completed Patient Care Ordering Physician Order Placed By SYSTEM SYSTEM Review Information N/A Order Details 01/12/07 22:46:33 1/11/lUU~/ 10:46:33 YM: Yed Admltl Assessment Mnemonic Action Order Status Type of Order Ped Admit Assessment Order Completed Patient Care Ordering Physician Order Placed By SYSTEM SYSTEM Review Information N/A Order Details O 1 / 12/07 22:46:32 1/1"1/100•/ 10:46:31 YM: Yed Admit Assessment Mnemonic Action Order Status Type of Order Patient Education Order Discontinued Patient Care Documentation Ordering Physician Order Placed By SYSTEM SYSTEM Review Information Nurse Review, Acce ted -Martin, Leanne P, 1/12/2007 11:48:06 PM Order Details 01/12/07 22:46:32, gShift Date Printed.• 5/5/2007 Time Printed: 10:49 AM PE~I~S`TATE ilt~m S. ~~ 14ic Center C'~llege of 1'~edilc~ne Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 ~ O r d e r s S e c t i o n 1/12/2007 10:46:32 PM: Patient Education Documentation Mnemonic Action Order Status Type of Order Sodium Level Order Discontinued Laboratory Ordering Physician Order Placed By Cortes, James Cortes, James Review Information Nurse Review, Not Reviewed - Order Details Priority, Blood, Clinician to Collect, starting at 01/12/07 22:41:00, q6h, sto ping at 01/15/07 22:40:00 -~ --~ - _• ~~..•....•• b.a LLLL,L,, 1 VJL ulVl1.LLLGU lll L11Ci D1cGLi V1ylcS, nasic ivietaooiic ranee, Comprehensive Metabolic Panel, and Nephrology Panel.]] Mnemonic Action Order Status Type of Order Potassium Level Order Completed Laboratory Ordering Physician Order Placed By Cortes, James Cortes, James Review Information Nurse Review, Accepted -Martin, Leanne P, 1/12/2007 11:48:06 PM l1~~-~ T_._'1_ - v14V1 LVLLil1J STAT, Blood, Clinician to Collect, starting at 01/12/07 22:40:00, ONCE, stopping at 01/12/07 22:40:00 1/12/2007 10:40:55 PM: [[Green gel tube; Test included in the Electrolytes, Basic Metabolic Panel, Comprehensive Metabolic Panel, and Nephrology Panel.]] Mnemonic Action Order Status Type of Order Neuro Check Order Discontinued Patient Care Ordering Physician Order Placed By Cortes, James Cortes, James Review Information Nurse Review, Not Reviewed - Order Details 01/12/07 22:40:00, Shift Mnemonic Action Order Status Type of Order Added on Lab order Order Completed Laboratory Ordering Physician Order Placed By Dillon, Peter W Martin, Leanne P Review Information Nurse Review, Acc ted -Martin, Leanne P, 1/12/2007 11:48:20 PM Order Details STAT, alcohol level, collected at 01/12/07 21:40:00, Added at 01/12/07 22:38:00 - -- --- • -_•--~• • • --•-• «-•L~ _~.tLLL,OL Ol1L,Lllu L.~ u~cu w auu ~o~<<s~ w sarnp-es inat are alreaay m the lab, It an appropriate sample is Date Printed: 5/5/2007 Teme Printed: 10:49 AM PE~i~ST~TE li1~n S. ~]f~>tey ~i meter ~ll of ~+"~;~l~lne Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 ~ O r d e r s S e c t i o n available, the test(s) will be performed. Refer to the RESULTS tab in POWERCHART to check the status of your request.]] Mnemonic Action Order Status Type of Order Level of Care: Floor Order Discontinued Patient Care Ordering Physician Order Placed By SYSTEM SYSTEM Review Information N/A Order Details Re uest Dt: 01/12/07 22:34:42 ~~i~t~nn~ 1n.Zn..1'1 Da.f. i.._.,.t _rr__-- r,_-- Mnemonic Action Order Status Type of Order Social Service Consult Order Discontinued Consults Ordering Physician Order Placed By Cortes, James Cortes, James Review Information Nurse Review, Not Reviewed - Order Details Priority, Requested Dt: 01/12/07 22:34:00, Trauma Assessment Mnemonic Action Order Status Type of Order Sodium Level Order Discontinued Laboratory Ordering Physician Order Placed By Cortes, James Cortes, James Review Information Nurse Review, Acce ted -Martin, Leanne P, 1/12/2007 11:48:20 PM Order Details Routine, Blood, Clinician to Collect, starting at 01/12/07 22:34:00, q6h, stopping at 01/15/07 22:33:00 vt~tznn~ ~n•zn.ni n~~r. rrr......_ __, ~_L_- •,-__~ ~_ _, -- -- ~~--•---. b... ~».,.., .~~~ 11iV1{14V4 111 1116 Li1Gl+u {./ly ~c,, Da„~ ivteutoollc ranee, ~;omprehenslve Metabolic Panel, and Nephrology Panel.]] Mnemonic Action Order Status Type of Order Hematocrit Order Discontinued Laboratory Ordering Physician Order Placed By Cones, James Cortes, James Review Information Nurse Review, Acce ted -Martin, Leanne P, 1/12/2007 11:48:20 PM Order Details Routine, Blood, Clinician to Collect, starting at 01/12/07 22:34:00, q6h, stop ing at 01/15/07 22:33:00 t /t 7Mnn~ i n•zn.n i n~,r. rrr ,...,._.1.._ ~_L-- '''_-. '._ -, - - -- - - - - - ---- ~~---. ---..... ~».,.., .,,,,~ .1aVaLt4Vt{ 111 u1~, t.v111~/1cLC DlUVU I.UUIlI, ana the ~,ompiete tstooct count with Date Printed: 5/5/2007 Time Printed.• /0:49 AM PE~1~1ST..~TE ~it~n S. ~r~h Mies meter ll ~f ' 'ne Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 O r d e r s S e c t i o n 1 Differential]] Mnemonic Action Order Status Type of Order Dextrose 5% with 0.9% NaCI Order Discontinued Pharmacy Ordering Physician Order Placed By Cortes, James Cortes, James Review Information Nurse Review, Not Reviewed - Pharmacist Verify, Accepted - Vissering, Thomas, 1/13/2007 12:03:43 AM Order Details 250 mL, IV, Routine, 01/12/07 22:31:00, 30 day, Hard Sto , 02/11/07 22:30:00, 125 mL/HR, 2 HR, 250 1/12/2007 10:34:41 PM: for infant only Mnemonic Communication to Nursin Action Order Order Status Discontinued Type of Order Patient Care Ordering Physician Cortes, James Order Placed By Cortes, James Review Information Nurse Review, Not Reviewed - viuci iciaii~ 01/12/07 22:33:00, T and L spine cleared, head of bed > 30 degrees. Mnemonic Action Order Status Type of Order Cervical Collar A lication Order Com leted Patient Care Ordering Physician Order Placed By Cortes, James Cortes, James Review Information - Nurse Review, Accepted -Martin, Leanne P, 1/12/2007 11:48:20 PM Order Details 01/12/07 22:33:00, Sto ping On 01/12/07 22:33:00, Hard collar Mnemonic Action Order Status Type of Order Call HO Order Discontinued Patient Care Ordering Physician Order Placed By Cortes, James Cortes, James Review Information Nurse Review, Not Reviewed - Order Details 01/12/07 22:33:00, T> 38.5 Date Printed: 5/5/2007 Time Printed.• 10:49 AM ~~~STATE iitt€» ~. ~> 1ViI C~nt~r +~alleg~e of ' 'nee Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 ~ O r d e r s S e c t i o n 1 Mnemonic Action Order Status Type of Order Intake and Ou ut Order Discontinued Patient Care Ordering Physician Order Placed By Cones, James Cones, James Review Information Nurse Review, Not Reviewed - Order Details 01/12/07 22:33:00, gShift Mnemonic Action Order Status Type of Order Bedrest Order Discontinued Patient Care Ordering Physician Order Placed By Cones, James Cones, James Review Information Nurse Review, Not Reviewed - Order Details 01/12/07 22:33:00 ' Mnemonic Action Order Status Type of Order NPO Order Discontinued Dieta Ordering Physician Order Placed By Cones, James Cones, James Review Information _ Nurse Review, Not Reviewed - Order Details 01/12/07 22:32:00, No Exceptions Mnemonic Action Order Status Type of Order Vital Si ns Order Discontinued Patient Care Ordering Physician Order Placed By Cones, James Cones, James Review Information Nurse Review, Not Reviewed - Order Details 01/12/07 22:32:00 Mnemonic Action Order Status Type of Order Admittin Dia nosis Order Discontinued Patient Care Ordering Physician Order Placed By Cones, James Cones, James Review Information Nurse Review, Not Reviewed - Order Details 01/12/07 22:32:00, Dx: Trauma, Multiple 959.8 Date Printed: 5/5/2007 Time Printed: 10:49 AM PEN~STr~TE ~t~n ~. ~~ ~~ ter Comae of 14'~ed~e Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 O r d e r s S e c t i o n 1 Mnemonic Action Order Status Type of Order Admit. Order Completed Patient Care Ordering Physician Order Placed By Cortes, James Cortes, James Review Information Nurse Review, Not Reviewed - Order Details Routine, Requested Admit Dt: 01/12/07 22:31:00, Admit, Floor, Peds Surgery, Dillon, Peter W, trauma, LOS: 1-3 days Mnemonic Action Order Status Type of Order Peds Trauma Admission Order Com leted Order Sets Ordering Physician Order Placed By Cortes, James Cortes, James Review Information N/A Order Details N/A Mnemonic Action Order Status Type of Order added on Lab order Order Completed Laboratory Jrdering Physician Order Placed By Dillon, Peter W Martin, Leanne P Review Information Nurse Review, Accepted -Martin, Leanne P, 1/12/2007 11:47:53 PM Order Details STAT, alcohol level, collected at 01/12/07 21:40:00, Added at 01/12/07 21:58:00 1/12/2007 9:59:01 PM: [[This request should be used to add test(s) to samples that are already in the lab. If an appropriate sample is available, the test(s) will be performed. Refer to the RESULTS tab in POWERCHART to check the status of your request.]] Mnemonic Action Order Status Type of Order T-S ine CT Order Canceled Radiology Ordering Physician Order Placed By Dillon, Peter W Contributor s stem, IDXOE01 Review Information Nurse Review, Accepted -Martin, Leanne P, 1/12/2007 11:47:53 PM Doctor Cosi n, Accepted -Dillon, Peter W, 1/16/2007 7:46:29 AM Order Details STAT, Requested Dt: 01/12/07 21:44:36 Date Printed: 5/5/2007 Time Printed: 10: 49 AM P~f~t~STA~E ~t~n ~. ~~y l~ica~ r ~ll of ~, ' 'ne Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 O r d e r s S e c t i o n ~ Mnemonic Action Order Status Type of Order Facial Bones CT Order Completed Radiolo y Ordering Physician Order Placed By Dillon, Peter W Contributor system, IDXOE01 Review Information Nurse Review, Accepted -Martin, Leanne P, 1/12/2007 11:47:53 P M Doctor Cosi n, Accepted -Dillon, Peter W, 1/16/2007 7:46:29 AM Order Details STAT, Requested Dt: 01/12/07 21:44:35 Mnemonic Action Order Status Type of Order C-S ine CT Order Completed Radiology Ordering Physician Order Placed By Dillon, Peter W Contributor system, IDXOE01 Review Information Nurse Review, Accepted -Martin, Leanne P, 1/12/2007 11:47:53 PM Doctor Cosign, Accepted -Dillon, Peter W, 1/16/2007 7:46:31 AM Order Details STAT, Requested Dt: O 1 / 12/07 21:44:3 5 Mnemonic Action Order Status Type of Order L-S ine CT Order Canceled Radiology Ordering Physician Order Placed By Dillon, Peter W Contributor s stem, IDXOE01 Review Information Nurse Review, Accepted -Martin, Leanne P, 1/12/2007 11:47:53 PM Doctor Cosign, Accepted -Dillon, Peter W, 1/16/2007 7:46:31 AM Order Details STAT, Requested Dt: 01/12/07 21:44:34 Mnemonic Action Order Status Type of Order Pelvis CT (Iliac Crest to Order Completed Radiology S m h sis Pubis). Ordering Physician Order Placed By Dillon, Peter W Contributor s stem, IDXOE01 Review Information Nurse Review, Accepted -Martin, Leanne P, 1/12/2007 11:47:53 P M Doctor Cosign, Acce ted -Dillon, Peter W, 1/16/2007 7:46:30 AM Order Details STAT, Requested Dt: 01/12/07 21:44:34 Date Printed: 5/5/2007 Time Printed: 10.•49 AM PE~fi~STA~E ilt~ S. Her~h~y 1Vic writer ~l~e~e of edic~e Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 ~ O r d e r s S e c t i o n -1 Mnemonic Action Order Status Type of Order Abdomen CT (Diaphragm to Order Completed Radiology Iliac Crest). Ordering Physician Order Placed By Dillon, Peter W Contributor system, IDXOE01 Review Information Nurse Review, Accepted -Martin, Leanne P, 1/12/2007 11:47:53 PM Doctor Cosign, Acc ted -Dillon, Peter W, 1/16/2007 7:46:33 AM Order Details STAT, Requested Dt: 01/12/07 21:44:33 Mnemonic Action Chest CT (Apex to Order Order Status Canceled Type of Order Radiology Ordering Physician Order Placed By Dillon, Peter W Contributor system, IDXOE01 Review Information Nurse Review, Accepted -Martin, Leanne P, 1/12/2007 11:47:53 PM Doctor Cosign, Accepted -Dillon, Peter W, 1/16/2007 7:46:32 AM order Details STAT, Requested Dt: 01/12/07 21:44:33 Mnemonic Action Order Status Type of Order Blood T e/Antibod Screen Order Com leted Laboratory Ordering Physician Order Placed By Contributor system, SUNQUESTOE01 Review Information Nurse Review, Accepted -Martin, Leanne P, 1/12/2007 11:47:52 PM Doctor Cosign, Not Reviewed - Order Details STAT, Blood, Lab to Collect, starting at 01/12/07 21:30:00, ONCE, sto ping at 01/12/07 21:30:00, Collected Mnemonic Action Order Status Type of Order Labs ecimens to hold Order Completed Laboratory Ordering Physician Order Placed By Contributor system, SUNQUESTOE01 Review Information Nurse Review, Accepted -Martin, Leanne P , 1/12/2007 11:47:52 PM Doctor Cosign, Not Reviewed - Order Details collected at 01/12/07 21:40:00 Date Printed: 5/5/2007 Time Printed.• 10.•49 AM ~1t~f~l S. ~~' 1Vi.!ca~ ~lt~r +C'w11,,e,. cif ' 'ne Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 O r d e r s S e c t i o n ~ Mnemonic Action Order Status Type of Order Femur XR Order Completed Radiology Ordering Physician Order Placed By Pastor, Danielle M Pastor, Danielle M Review Information Nurse Review, Accepted -Martin, Leanne P, 1/ 12/2007 11:47:52 PM Order Details STAT, Requested Dt: 01/12/07 21:40:00, Left., Views: *Standard Views, ICD9: Trauma 959.8 History: trauma Mnemonic Action Order Status Type of Order Hi XR Order Completed Radiology Ordering Physician Order Placed By Pastor, Danielle M Pastor, Danielle M Review Information Nurse Review, Accepted -Martin, Leanne P, 1/ 12/2007 11:47:52 PM Order Details STAT, Requested Dt: 01/12/07 21:41:00, Left., Views: *Standard Views, ICD9: Trauma 959.8 Histo :trauma Mnemonic Action Order Status Type of Order Jia nostic Radiolo Exams Order Completed Order Sets Ordering Physician Order Placed By Pastor, Danielle M Pastor, Danielle M Review Information N/A Order Details N/A Mnemonic Action Order Status Type of Order Dia nostic Radiolo Exams Order Com leted Order Sets Ordering Physician Order Placed By Pastor, Danielle M Pastor, Danielle M Review Information N/A Order Details N/A Mnemonic Action Order Status Type of Order Drugs of Abuse w NO Order Completed Laboratory confirm, Urine Ordering Physician Order Placed By Dillon, Peter W Martin, Leanne P Review Information Nurse Review, Accepted -Martin, Leanne P, 1/12/2007 11:47:09 PM Order Details STAT, Urine, Clinician to Collect, startin g at 01/12/07 21:39:00, ONCE 1/1Z/2UQ7 y:4U:ly YM: ~~Urme, randomJJ Date Printed: 5/5/2007 Time Printed: 10:49 AM a PENSTATE ~t~n S. i~h~y l~ic~ writer allege of 1V~edi~ixlue Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 O r d e r s S e c t i o n 1 Mnemonic Action Order Status Type of Order Alcohol Level not Le al) Order Discontinued Laboratory Ordering Physician Order Placed By Dillon, Peter W Martin, Leanne P Review Information Nurse Review, Accepted -Martin, Leanne P, 1/12/2007 11:47:09 PM Order Details STAT, Blood, Clinician to Collect, starting at 01/12/07 21:39:00, ONCE, sto ping at 01/12/07 21:39:00 1/ll/LUV / y:4V:ly rM: ~(Ureen gel tube. use betadme prep. Gray tube is also acceptableJJ Mnemonic Action Order Status Type of Order Head CT. Order Com leted Radiology Ordering Physician Order Placed By Dillon, Peter W Martin, Leanne P Review Information Nurse Review, Accepted -Martin, Leanne P, 1/12/2007 11:47:09 PM Order Details Stat, Requested Dt: 01/12/07 21:39:00, ICD9: Trauma 959.8 History: Trauma .vnemonic Action Order Status Type of Order C-S ine XR Order Canceled Radiology Ordering Physician Order Placed By Dillon, Peter W Martin, Leanne P Review Information Nurse Review, Accepted -Martin, Leanne P, 1/12/2007 11:47:09 PM Order Details Stat, Requested Dt: 01/12/07 21:39:00, All, Views: *Standard Views, ICD9: Trauma 959.8 History: Trauma Mnemonic Action Order Status Type of Order Pelvis XR Order Canceled Radiology Ordering Physician Order Placed By Dillon, Peter W Martin, Leanne P Review Information Nurse Review, Acce ted -Martin, Leanne P, 1/12/2007 11:47:09 PM Order Details Stat, Requested Dt: 01/12/07 21:39:00, Views: *Standard Views, ICD9: Trauma 959.8 History: Trauma Date Printed: 5/5/2007 Time Printed: 10:49 AM • PE~l~STATE ttm ~. they l~ic~ tax ~:€>llle of 11~edic~xe Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 O r d e r s S e c t i o n Mnemonic Action Order Status Type of Order Chest XR Order Canceled Radiolo Ordering Physician Order Placed By Dillon, Peter W Martin, Leanne P Review Information Nurse Review, Acce ted -Martin, Leanne P, 1 / 12/2007 11:47:09 PM Order Details Stat, Requested Dt: 01/12/07 21:39:00, 1 view - AP or PA (Limited), Views: *Standard Views, ICD9: Trauma 959.8 History: Trauma Mnemonic Action Order Status Type of Order ED Trauma Radiolo Set Order Com leted Order Sets Ordering Physician Order Placed By Dillon, Peter W Martin, Leanne P Review Information N/A Order Details N/A Mnemonic Action physician Consult Request Order Order Status Type of Order Consults Ordering Physician Order Placed By Dillon, Peter W Martin, Leanne P Review Information Nurse Review, Accepted -Martin, Leanne P, 1/12/2007 11:47:09 PM Order Details Stat, Requested Dt: 01/12/07 21:39:00, Service: Anesthesia/ Pre-Op Evaluation, Reason: Trauma, I have or will contact the physician directly, choe 8333 Mnemonic Action Order Status Type of Order Partial Thrombo lastin Time Order Completed Laboratory Ordering Physician Order Placed By Dillon, Peter W Martin, Leanne P Review Information Nurse Review, Accepted -Martin, Leanne P, 1/12/2007 11:47:09 PM Order Details Stat, Blood, Clinician to Collect, starting at 01/12/07 21:39:00, ONCE, stopping at 01/12/07 21:39:00, Collected Date Printed.• 5/5/2007 Time Printed: 1 ~ •49 AM • ~ P~N~ST~TE ~4~iltcmt S. ~~cy II teir {~alleg~e of N "ne Patient Name: CHIARA, JOHN J PSUHMC MRN: 1' 133563 1 O r d e r s S e c t i o n 1 1/12/2007 9:40:19 PM: [[Blue-tube]] Mnemonic Action Order Status Type of Order Prothrombin Time w/ INR Order Com leted Laboratory Ordering Physician Order Placed By Dillon, Peter W Martin, Leanne P Review Information Nurse Review, Accepted -Martin, Leanne P, 1/12/2007 11:47:09 PM Order Details Stat, Blood, Clinician to Collect, starting at 01/12/07 21:39:00, ONCE, stopping at 01/12/07 21:39:00, Collected 1/1L/LVU/ y:4V:ly YM: 11t31ue tubeJJ Mnemonic Action Order Status Type of Order Blood T e/Antibod Screen Order Canceled Laboratory Ordering Physician Order Placed By Dillon, Peter W Martin, Leanne P Review Information Nurse Review, Accepted -Martin, Leanne P, 1/12/2007 11:47:09 PM Order Details Stat, Blood, Clinician to Collect, starting at 01/12/07 21:39:00, ONCE, stopping at 01/12/07 21:39:00 1/ 1L/LVU / y:4u:1y rM: llxect (non-get) tube; llettver to Blood 13ank. Additional Blood Bank arm band and requisition are required .. (R number identification).]] Mnemonic Action Order Status Type of Order Creatinine Level Order Completed Laboratory Ordering Physician Order Placed By Dillon, Peter W Martin, Leanne P Review Information Nurse Review, Acce ted -Martin, Leanne P, 1/12/2007 11:47:09 PM Order Details Stat, Blood, Clinician to Collect, starting at 01/12/07 21:39:00, ONCE, stopping at 01/12/07 21:39:00, Collected i/ i L/Lw t y:~+v: i a rive: 1L~reen gei tube; 1 est mcluaea m the basic Metabolic Yanel, comprehensive metabolic panel, Nephrology Panel, and Renal Panel]] . Mnemonic Action Order Status Type of Order Complete Blood Count w Order Completed Laboratory Differential Ordering Physician Order Placed By Dillon, Peter W Martin, Leanne P Review Information Nurse Review, Accepted- Martin, Leanne P, 1/12/2007 11:47:09 PM Order Details Stat, Blood, Clinician to Collect, starting at 01/12/07 21:39:00, ONCE, stopping at 01/12/07 21:39:00, Collected Date Printed: 5/5/2007 Time Printed: 10:49 AM PE~J~f SATE __ ~tar~ ~. ;r~hey~ Mica ter of ' ' Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 ~ O r d e r s S e c t i o n 1/12/2007 9:40:18 PM: [[Lavender tube; Panel includes WBC count, RBC count, Hgb, Hct, Platelet count and Differential]] Mnemonic Action Order Status Type of Order Am lase Level Order Completed Laboratory Ordering Physician Order Placed By Dillon, Peter W Martin, Leanne P Review Information Nurse Review, Accepted -Martin, Leanne P, 1/12/2007 11:47:09 PM Order Details Stat, Blood, Clinician to Collect, starting at 01/12/07 21:39:00, ONCE, stopping at 01/12/07 21:39:00, Collected i/ acicvvi ~.--v.7o rive. ~~ V1GG11 JGpGTGLUI LUDefJ Mnemonic Action Order Status Type of Order Arterial Blood Gases w/ Hgb Order Canceled Laboratory and 02 Sat Ordering Physician Order Placed By Dillon, Peter W Martin, Leanne P Review Information Nurse Review, Acce ted -Martin, Leanne P, 1/12/2007 11:47:09 PM 11...7.._ ll..~..:1.. 3tat, Blood, Arterial Syringe, Clinician to Collect, starting at 01/12/07 21:39:00, ONCE, stopping at 01/12/07 21.39.00, Collected 1/12/2007 9:40:18 PM: [[Heparinized syringe on ice; Deliver immediately to lab on ice. Panel includes Arterial Blood gas, Hgb and 02 Sat]] Mnemonic Action Order Status Type of Order Sodium Level Order Completed Laboratory Ordering Physician Order Placed By Dillon, Peter W Martin, Leanne P Review Information Nurse Review, Acc ted -Martin, Leanne P, 1/12/2007 11:47:09 PM Order Details _ Stat, Blood, Clinician to Collect, starting at 01/12/07 21:39:00, ONCE, stopping at 01/12/07 21:39:00, Collected 1 /Y /1 I/1AAr-I _- ~~~ / ~ •-*~. _ ~ . ~... ll"i~.c7i yG7 LuUG, ~ GAl u7~tuucu uT uLe J/lecLroly[es, ISaS1C 1V1eLaDO11C Yanel, e:omprehenSlve Metabolic Panel, and Nephrology Panel.]] Mnemonic Action Order Status Type of Order Potassium Level Order Completed Laboratory Ordering Physician Order Placed By Dillon, Peter W Martin, Leanne P Review Information Nurse Review, Accepted -Martin, Leanne P , 1/12/2007 11:47:09 PM Order Details Stat, Blood, Clinician to Collect, startin at 01/12/07 21:39:00, ONCE, stop ing at 01/12/07 Z 1:39:00, Collected ., a~,/ovv / ~.w. ao i ivi. ~~Vicctl b'G1 LLLUG, t GJL u1clUUeu m Lne r,lecirOly[eS, tsasLC Metabolie Yanel, comprehensive Metabolic Panel, Date Printed.' 5/5/2007 Time Printed: 10:49 AM P~~I~~T~TE ~t~m S. ~~ Aic writer [:vll of Mee ' Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 O r d e r s S e c t i o n 1 and Nephrology Panel.]] Mnemonic Action Order Status Type of Order Glucose Level Order Completed Laboratory Ordering Physician Order Placed By Dillon, Peter W Martin, Leanne P Review Information Nurse Review, Accepted -Martin, Leanne P, 1/12/2007 11;47:09 PM Order Details Stat, Blood, Clinician to Collect, starting at 01/12/07 21:39:00, ONCE, sto in at 01/12/07 21:39:00, Collected i i i~i~uu t y:~+u: i a rive: 11 green gei tune; 1 est mciuaea m trie basic Metabolic Yanel, comprehensive Metabolic Yanel, and Nephrology Panel.]] Mnemonic Peri heral IV Insertion Action Order Order Status Com leted Type of Order Patient Care Ordering Physician Order Placed By Dillon, Peter W Martin, Leanne P Review Information Nurse Review, Acce tied -Martin, Leanne P, 1/12/2007 11:47:09 PM Vt~lVl LCiL0.11J J 1/12/07 21:39:00, Peripheral 1V, ONCE, 2 large bore IV's if not started pre-hospital Mnemonic Action Order Status Type of Order Urine Chemstick Nurse POC Order Completed Patient Care Ordering Physician Order Placed By Dillon, Peter W Martin, Leanne P Review Information Nurse Review, Acc tied -Martin, Leanne P, 1/12/2007 11:47:09 PM Order Details Stat, 01/12/07 21:39:00, ONCE, Stopping On 01/12/07 21:39:00 Mnemonic Action Order Status Type of Order Stool Guaiac Nurse POC Order Completed Patient Care Ordering Physician Order Placed By Dillon, Peter W Martin, Leanne P Review Information Nurse Review, Accepted -Martin, Leanne P, 1/12/2007 11:47:09 PM Order Details Stat, 01/12/07 21:39:00, ONCE, Stopping On 01/12/07 21:39:00 Date Printed: 5/5/2007 Time Printed: 10.•49 AM PE1~ST~TE ~l~ri ~. ~~e~ lid ~t~;r ~~ of ~i~in~e Patient Name: CHIARA, JOHN J PSUIIMC MRN: 1133563 ~ O r d e r s S e c t i o n 1 Mnemonic Action Order Status Type of Order O en Thera Order Discontinued Res iratory Care Ordering Physician Order Placed By Dillon, Peter W Martin, Leanne P Review Information Nurse Review, Accepted -Martin, Leanne P, 1/12/2007 11:47:09 PM Order Details 01/12/07 21:39:00, Non-rebreather Mask, Fi02 15, Kee 02 Sat > 92 Mnemonic Action Order Status Type of Order Cervical Collar A lication Order Completed Patient Care Ordering Physician Order Placed By Dillon, Peter W Martin, Leanne P Review Information Nurse Review, Accepted -Martin, Leanne P, 1/12/2007 11:47:09 PM Order Details Stat, 01/12/07 21:39;00, Ri id (Aspen) Collar, Stopping On 01/12/07 21:39:00 Mnemonic Action Order Status Type of Order Communication to Nursin Order Discontinued Patient Care Ordering Physician Order Placed By Dillon, Peter W Martin, Leanne P Review Information Nurse Review, Accepted -Martin, Leanne P, 1/12/2007 11:47:09 PM Order Details Stat, 01/12/07 21:39:00, Turn up room temperature, warming lights, warm blankets, warm fluids. Mnemonic Action Order Status Type of Order Ox en Saturation Checks Order Completed Patient Care Ordering Physician Order Placed By Dillon, Peter W Martin, Leanne P Review Information Nurse Review, Acce ted -Martin, Leanne P, 1/12/2007 11:47:09 PM Order Details Stat, 01/12/07 21:39:00, ONCE, Stoppin On 01/12/07 21:39:00 Mnemonic Action Order Status Type of Order Vital Si ns Order Com feted Patient Care Ordering Physician Order Placed By Dillon, Peter W Martin, Leanne P Review Information Nurse Review, Acce ted -Martin, Leanne P, 1/12/200 7 11:47:09 PM Order Details Stat, 01/12/07 21:39:00, ONCE, q 5 min x 2, q 15 min x 2, q 30 minx 2, then hourly while in the ED, Sto in On 01/12/07 21:39:00 Date Printed: 5/5/2007 Time Printed.' 10:49 AM P~~1~TATE ~. ~ laiea~ ter G€~~le~e of due Patient Name: CHIARA, JOHN J PSUHMC MRN: 1133563 O r d e r s S e c t i o n Mnemonic Action Order Status Type of Order Pulse Oximetr Continuous Order Completed Patient Care Ordering Physician Order Placed By Dillon, Peter W Martin, Leanne P Review Information Nurse Review, Accepted -Martin, Leanne P, 1/12/2007 11:47:09 PM Order Details Stat, 01/12/07 21:39:00, ONCE, Stopping On 01/12/07 21:39:00, Continuous while in ED Mnemonic Action Order Status Type of Order Neuro Check Order Completed Patient Care Ordering Physician Order Placed By Dillon, Peter W Martin, Leanne P Review Information Nurse Review, Accepted -Martin, Leanne P, 1/12/2007 11:47:09 PM Order Details Stat, 01/12/07 21:39:00, ONCE, Hourl while in ED, Stopping On 01/12/07 21:39:00 Mnemonic Action Order Status Type of Order ED Trauma Adult Leve12 Order Completed Order Sets Ordering Physician Order Placed By Dillon, Peter W Martin, Leanne P Review Information N/A - Order Details N/A - Mnemonic Action Order Status Type of Order ED Nursin Char a Order Completed Patient Care Ordering Physician Order Placed By SYSTEM SYSTEM Review Information N/A Order Details Request Dt: O 1 / 12/07 21:24:22 1/ 1L/LVV / y:L4:LL Y1V1; eQ nurSlrig Criarge "' Date Printed: 5/5/1007 Time Printed: 10:49 AM Exl~~b~~ C ® RINGLER ASSOCIATES® ~~ ~ (609) 714-8860 (Medford) i (973) 257-1525 (Morristown) _~ Toll Free (877) 565-6500 Fax (609) 714-8862 October 5, 2007 SENT VL4 FACSIMILEAND MAIL Frank .Lafferty, Esquire IvIETZGER WICKERSHAM 3211 N. Front Street Harrisburgh,PA 17110 Re: John Chiara vs. Dennis & Sandra Sipe Hartford Claim # YUZ AL 02952 Rinsler Associates File #2-12766 Dear Frank: This letter will serve as confirmation that your client has chosen the following annuity plan. The annuity will be provided by Hartford Life, an A+ rated life carrier by the A. M. Best Rating Service. lEIartford Accident & Indemnity Company will assign their obligation via a Uniform Qualified Assignment and Release (sample attached) to Hartford Comprehensive Employee Benefit Service Company (CEBSCO) who will act as Assignee on behalf of the defendant. Hartford Life will guarantee the obligation assumed by Hartford CEBSCO through the issuance of a Corporate Guarantee (sample attached). The settlement includes the following benefts: Details of annuity: Guaranteed Lump Sum of $45,150.00 payable on 10/31/2016 Cost of Annuity: $ 30,000.00 Cash Up Front: $35,000.00 Total Settlement: $65,000.00 The attached annuitant questionnaire needs to be completed as soon as possible and returned to our office by fax. If your client is designating a specific beneficiary, please include this beneficiary designation in the Order for Judgment for approval by the court. We will also need a copy of the Filed summons and complaint to prepare the Settlement Agreement and Release, please fax at your earliest convenience to me at the above fax number. We will draft release and provide after Hartford review to you for your review and execution by the Guardian ad Litem for this claimant. 105 ATSION ROAD, SUITE C • MEDFORD, NJ 08055 45 PARK PLACE SOUTH, PMB 183 • MORRISTOWN, NJ 07960 BFillionC~3ringlerassociates.com • EBrupbacherCa3ringlerassociates.com www.RinglerAssociates.com OFFICES IN PRINCIPAL CITIES NATIONWIDE Member National Structured Settlements Trade Association Please mark your file to fax a copy of your proposed order to our attention as soon as it is available. Again, if your client intends to designate a specific beneficiary for the annuity it should be so stated in the order. For your convenience please return the following to us: • Fax of complaint • Completed annuitant questionnaire/copy of birth certificate • Fax a copy of proposed order If you have any questions, please don't hesitate to contact me. Yours tr y, _ AJ_,~ Sue Og~~vie Ringler Associates, I c FAXED TO; Michael Trapasso ,Claims Representative CX~~b~+ D A ~'~ STATE LEGAL° 80G-222 0510 y r~y JUft ! : L' / Id4:'Jbp i GHM/~RKm BLUE SHIELD M IMop~MO/it Ilewroo el h~ ib Cx~t OM BUa W laf! AHOd~YOR ~L1I1@ 20, 2047 RE: Patient N#me: John C4istra N[ember Id #:1028861250010 Gt~oup #: OZ5224-35 Accident Date: 01!12107 Dear Melanie, p,2 Please be advised that Highmark Blue Shieid is not pursuing subrogation for injuries sustained in the accident listed above. Thcrefare, we do not have a lien anal our files are closed regarding this matter. If }rou have any questions, please feel free to call me at the number listed below. Sincerely, ~~ ~ . . Nfike Whiting Subrogation Reviewer Highmark BS 1-866-306-1062 SbMowidc OPL Diriaioal(3SS_DcptlSnlxoUYo Subro C.cttu - tndw.doc CONTINGENT FEE AGREEMENT I, Cvb~~ individually and as parent and natural guardian of ~ ~l C~~~d retain and authorize the law firm of Metzger, Wickersham, Knauss & Erb, P.C., to do whatever they deem necessary or desirable in order to represent me and my o~ in all claims for compensation and reimbursement for personal in~~//j~~uries, wage loss, medical expense and other damages resulting from an I-~J~o ~ that occurred on 1/12/2007. 1. ATTORNEY'S FEES: The fee of the attorneys shall be contingent as follows: (a) Twenty-five percent (25%) of gross recovery; (b) SHOULD THERE BE NO RECOVERY BY SUIT OR SETTLEMENT, SAID ATTORNEYS DO NOT HAVE ANY CLAIM AGAINST US OF ANY KIND FOR LEGAL SERVICES RENDERED. 2. EXPENSES OF LITIGATION: I acknowledge responsibility for all expenses incurred on our behalf to pursue our claim/case and my attorney shall be reimbursed out of the balance, after deduction of attorneys fees, of any recovery for all legal expenses which have not already been paid by me. I do hereby agree to pay all expenses incurred by our attorney in the preparation and presentation of this case and do understand that these expenses include, but may not be limited to, costs of medical reports and records, stenographic expenses connected with depositions, expert witness fees, photocopying charges, and mileage charges connected with the rendering of legal services. I understand that I am responsible for payment of these expenses regardless of the eventual outcome of the case and further understand that if our attorney deems it necessary, I may be asked to advance these costs prior to the incurring of any such expenses or the scheduling of any deposition. Page 1 of 3 3. APPEAL: I hereby further agree that our attorney may charge us reasonable additional compensation if it is necessary to try the case more than once, if the case is appealed, or if proceedings in other courts are necessary because of the change of circumstance of a party or for other reasons. 4. AUTHORITY: I hereby further agree that our attorney is hereby authorized to bring suit or to settle and compromise the claim, to execute all documents pertaining thereto, and to do all lawful acts requisite for effecting the claim on our behalf. 5. MEDICAL EXPENSES AND LIENS: I further authorize my attorney to pay out of any proceeds of settlement or trial any unpaid medical bills or liens for treatments or services or workers' compensation liens made necessary by the injuries sustained in this accident, or back child support payments owed to Pa.SCDU. I understand that my attorney is not guaranteeing the payment of any medical bills or liens, and they remain solely my responsibility. 6. INVESTIGATION OF MERITS OF CASE: I agree that our attorney accepts this employment on the condition that he will investigate this claim, and if it appears to be a recoverable claim, he will proceed to handle the claim; but if, after investigation, the claim does not appear to be recoverable, said attorney shall then have the right to rescind this Agreement. 7. EARLY TERMINATION: I hereby further agree that if I decide to terminate this authority before any settlement is offered or any award is obtained the firm shall be entitled to reasonable Page 2 of 3 compensation for all work done on the case up to that point. I agree that reasonable compensation for Francis J. Lafferty, IV, Esquire, or any other attorney involved in the handling of this case, shall be Two Hundred Dollars ($200.00) per hour, and other employees One Hundred Dollars ($100.00) per hour, or such higher rate as shall constitute his/her standard billing rate at the time that the work is performed, or the agreed upon percentage fee in paragraph one of this Agreement, whichever is greater. 8. WITHDRAWAL: I agree that our attorney may withdraw from this case at any time after reasonable notice to us, and I agree to keep him advised of our whereabouts at all times and to cooperate at all times in the preparation and trial of this case, to appear upon reasonable notice for depositions and Court appearances, and to comply with all reasonable requests made of us in connection with the preparation and presentatioq of this case. 9. CONFLICT: I also understand that if the investigation reveals that a parent is contributorily negligent in causing the accident the attorney's representation will solely be limited to representing the injured minor and there will be no representation of the parent. I also waive any conflict of interest that may arise by my meeting with the attorney to discuss the case. P~ IN WITNESS WHEREOF, I have signed below on this al( day of ~N~"7~_, 2007. p~`~~~ o~~ C, MET WI M, KNAUSS & ERB, P.C. TORNEY: Francis J. Lafferty, IV, Esquire Page 3 of 3 P~ R * O~C~i Q ~ W ,-~- ?~ --•~ N ~y _~ _ i...:J ~ '.1'} . ~~ j i r,:..... ~: 1 -} t._j ..fm. 7 - -_ C.til . _i"l -~ _I -~ w Metzger, Wickersham, Knauss & Erb, P.C. By: Francis J. Lafferty, IV, Esquire Attorney I.D. No. 84009 P.O. Box 5300 3211 North Front Street Harrisburg, PA 17110-0300 Attorneys for Plaintiffs (717) 238-8187 f l~xnwke com IN RE: PETITION FOR APPROVAL OF SETTLEMENT OF THE CLAIM OF JOHN J. CHIARA, a minor, BY JOHN S. CHIARA and JOAN CHIARA. his parents and natural guardians . ORPHAN'S COURT OF . CUMBERLAND COUNTY, . PENNSYLVANIA NO. 0'7 - L7 ~ 3 ~',c.er~Q ~.t~.- DECREE AND NOW, this _~^ day of l 1~o v 2007, upon consideration of the Petition for Approval of Compromise and Settlement of minor's claim, it is hereby ORDERED and DECREED that the settlement for the Boss sum of Sixty-Five Thousand Dollars ($65,000.00) is APPROVED. Counsel fees and expenses are found to be fair and reasonable and are also approved as set forth below. The distribution is directed as follows: $16,250.00 to be paid to Metzger, Wickersham, Knauss & Erb, P.C., for counsel fees; 2. $341.07 to be paid to Metzger, Wickersham, Knauss & Erb, P.C., as reimbursement for costs and expenses; 3. The Petitioners request that the remaining sum of $2,481.99 be available to them immediately for refunds of amounts expended by minor Petitioner's parents on his behalf in this action and for minor Petitioner's daily necessities; and 384683-1 ,... b~l~!'dAIJw~N JI.~Nf~'7 ~~~'?~~~Wfl~ Q~ :~ did ~ I ANN t~OZ J~iq~.ad ~Hl. 3~:±.£~-Cf31~ 4. The balance of $45,926.94 to be placed in a restricted, federally insured bank account in the name of the Minor Plaintiff, with the provision that no withdrawal may be made from any such account until the Minor Plaintiff attains majority, except as authorized by a prior Order of this Court. Proof of deposit shall be promptly filed of record. ~ i ~~'~ cc: Francis J. Lafferty Es ire~etzger, Wickersham, 3211 North Front Street, Harrisburg, Pa 17112 ;~01~ichael Trapasso, Hartford Insurance Company, 21 Christopher Way, CN 3605, Eatontown, NJ 07724 384683-1 Metzger, Wickersham, Knauss & Erb, P.C. By: Francis J. Lafferty, IV, Esquire Attorney LD. No. 84009 P.O. Box 5300 3211 North Front Street Harrisburg, PA 17110-0300 Attorneys for Plaintiffs (717) 238-8187 11~a,mwke.com IN RE: PETITION FOR APPROVAL OF SETTLEMENT OF THE CLAIM OF JOHN J. CHIARA, a minor, BY JOHN S. CHIARA and JOAN CHIARA his parents and natural guardians ORPHAN'S COURT OF . CUMBERLAND COUNTY, PENNSYLVANIA . NO. 07-6713 Civil Term AMENDED DECREE AND NOW, this Z day of ~ o ~ , 2007, upon consideration of the Petition for Approval of Compromise and Settlement of minor's claim, it is hereby ORDERED and DECREED, that the settlement for the gross sum of Sixty-Five Thousand Dollars ($65,000.00) is APPROVED. Counsel fees and expenses are found to be fair and reasonable and are also approved as set forth below. The distribution is directed as follows: 1. $16,250.00 to be paid to Metzger, Wickersham, Knauss & Erb, P.C., for counsel fees; 2. $341.07 to be paid to Metzger, Wickersham, Knauss & Erb, P.C., as reimbursement for costs and expenses; 3. The Petitioners request that the remaining sum of $2,481.99 be available to them immediately for refunds of amounts expended by minor Petitioner's parents on his behalf in this action and for minor Petitioner's daily necessities; and 384683-1 d~ ~ ~ it ~ y~ 7 ~_. ~:~~ ~~~ ~ ~' , n }~{~..fjttf VY `s 1+ 't si ~ t w, r 4. The balance of $45,926.94 will be placed in an annuity from Hartford Life Insurance Company. A guaranteed lump sum of $68,750.00 will be payable to John J. Chiara on October 31, 2016. BY THE COURT: U~ J. . t,c.~cs c~ U jer ~~. cc: rancis J. Lafferty, Esquire, Metzger, Wickersham, 3211 North Front Street, Harrisburg, Pa 1 11 ichael Trapasso, Hartford Insurance Company, 21 Christopher Way, CN 3605, Eatontown, NJ 07724 ~ ~ ,. . ^ ~~ ~~. ~% 384683-1