Loading...
HomeMy WebLinkAbout07-6823LUTVO AND ZEKIRA DERVISEVIC, as parents and natural guardians of ADELISA DERVISEVIC, minor, 5243 d Street Carlisle, PA 17013 Plaintiffs V. David A. Schriml 2713 Owego Road Vestal, NY 13850 Defendant : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW . NO. o -?- 6S:?-3 (A I,),,?- M PETITION FOR APPROVAL OF MINOR'S SETTLEMENT AND DISTRIBUTION OF PROCEEDS And now come the Petitioners, by and through their attorney, Nina Milovanovich and Milovanovich & Espinosa, LLC, and, pursuant to Pa.R.C.P. 2039, file their Joint Petition for Approval of Minor's Settlement, and respectfully state the following: 1. Petitioners, Lutvo and Zekira Dervisevic are adult individuals, residing at 524 3`d Street, Carlisle, Cumberland County, Pennsylvania. 2. Petitioner, Adelisa Dervisevic, is a minor individual whose date of birth is January 27, 2000, and who resides with her parents at 524 3`d Street, Carlisle, Cumberland County, Pennsylvania. 3. Petitioners Lutvo and Zekira Dervisevic are the parents and natural guardians of Minor Plaintiff Adelisa Dervisevic. 4. There has been no any previous assignment of this mater to a Judge before this Honorable Court. 5. On September 24, 2006, the minor was a passenger in a Chrysler Town-Country van, operated by her father, in a southbound middle lane on I-81. There were six other family members in the van, in addition to the minor. 6. Suddenly, the van had a flat tire. The driver slowed down and turned on the blinkers, in order to try to move from the middle lane into the right lane, and ultimately onto the shoulder, to change the tire. 7. David A. Schriml operated his vehicle in a careless manner, and hit from behind the van in which the minor was a passenger, causing the van to be pushed over onto the grass divider that was between the southbound and northbound lanes of I-81. 8. As a result of the incident all seven persons in the van, including the minor, suffered injuries. The minor's grandmother died two days later as a result of the injuries she sustained. The Minor's aunt was severely injured, and her uncle, father, mother and cousin sustained injuries of differing gravity as well. 9. The minor was taken via ambulance to the Wilson Memorial Hospital. (A true and correct copies of the ambulance records are attached hereto, marked as "Exhibit A" and incorporated by reference.) 10. At the Wilson Memorial Hospital, the examination revealed that the minor sustained bruising to her lower back, right hip, abdomen, both thighs, as well as skin lacerations. The minor also sustained open grade 2 compound fractures of the right distal tibia and fibula, and/or Salter Harris type II fracture of the distal tibia. 11. On September 25, 2006, the minor underwent surgery consisting of debridement of the compound fracture of the right tibia and fibula, and closed reduction with 2 percutaneous pinning of the right distal tibia with Penrose drain placement. The surgery was successful. 12. The minor was released from the Wilson Memorial Hospital on September 27, 2006 and she returned to Carlisle, with her parents. (True and correct copies of the medical records from the Wilson Memorial Hospital are attached hereto, marked as "Exhibit B" and incorporated by reference.) 13. Upon returning to Carlisle, on September 28, 2007 the minor was seen at Carlisle Pediatrics and was referred to an orthopedist. (A true and correct copy of the records from Carlisle Pediatrics is attached hereto, marked as "Exhibit C" and incorporated by reference.) 14. On September 29, 2006, Dr. Oliverio at Appalachian Orthopedic Center examined the minor.- Between September 29, 2006 and January 16, 2007, the minor had seven appointments with Dr. Oliverio. On January 16, 2007 Dr. Oliverio examined the minor, and found that the surgical wound was completely healed, that pulses were normal, and that the minor had full range of motion of her ankle. Dr. Oliverio instructed the parents that the minor was allowed to engage in age appropriate activities, and to return to gym classes at school. Upon this examination, Dr. Oliverio discharged the minor from further care. (True and correct copies of the records from Appalachian Orthopedic Center are attached hereto, marked as "Exhibit D" and incorporated by reference.) 15. The minor has done well, and her parents have had no reason to schedule any further appointments for any issues related to the injuries she sustained in the above referenced accident. 3 16. As a result of the injuries the minor missed thirty-four days of school. During this time, the teacher came regularly to her home in order to help the minor catch up with the curriculum. Thus, the minor has been able to continue to advance with the same speed as her classmates. After this period, the minor has returned to school, and has not had any problems with learning that could be associated with the accident. (A true and correct copy of the Bellaire Elementary School's records are attached hereto, marked as "Exhibit E" and incorporated by reference.) 17. The minor has fully recovered from her injuries and continues to engage in gym classes and age-appropriate activities. 18. There is some residual scarring on the minor's leg, which is improving as well. 19. The PIP carrier (Encompass Insurance Company), under its policy issued to the minor's parents, paid $5,000, which amount represents the full extent of their coverage for the medical bills. (A true and correct copy of the printout of payments for medical bills from Encompass Insurance Company is attached hereto, marked as "Exhibit F" and incorporated by reference.). 20. At the time of the accident and at all relevant times hereafter, Capital Advantage Insurance Company, a private insurance company provided health insurance coverage to the minor through her father's employer. 21. After the sPIP benefits were exhausted, Capital Advantage Ins. Co. has paid $6,845.22 of the minor's medical bills and has asserted a lien for this amount. (A true and correct copy of the documents proving this lien is attached hereto, marked as "Exhibit G" and incorporated by reference.) 4 22. In an effort to effectuate the best possible recovery for the minor, her counsel has been able to negotiate a reduction in regard to the above referenced lien, so that the amount to be paid is $4,563.48. The savings represent a 1 /3 reduction of the lien originally asserted. (A true and correct copy of the letter from the lien holder indicating their agreement to accept a reduced payment as a payment in full is attached hereto, marked as "Exhibit H" and incorporated by reference.) 23. There is an outstanding bill for Park Avenue Associates in Radiology from Johnson City, NY in the amount of $101.70. (A true and correct copy of the documents proving this lien is attached hereto, marked as "Exhibit I" and incorporated by reference.) 24. Other than those indicated above, there are no other liens or outstanding, unpaid bills for medical services rendered to the minor as a result of the above referenced motor vehicle accident. 25. The minor's parents and natural guardians hired the undersigned counsel to represent them in effectuating their rights and the rights of the minor, and to obtain recovery through settlement or jury award, as well as to prepare and present this Petition for Court approval. 26. Petitioners executed a Fee Agreement providing for payment of one-third (1/3) of the settlement proceeds for attorneys fees. (A true and correct copy of the said Fee Agreement is attached hereto, marked as "Exhibit J" and incorporated by reference.) 27. The above referenced Fee Agreement provides that, in addition to the attorneys' fees, the attorneys should be fully reimbursed for all costs associated with handling the minor's claim. 5 28. The undersigned performed a comprehensive investigation, obtained all relevant medical documentation and other relevant documentation, including the Police Accident Report, documentation about the lien, and all other pertinent documentation. 29. The undersigned has engaged in extensive negotiations with the insurance companies providing coverage for the losses resulting from the accident, and has negotiated a settlement in the amount of $95,000.00 on behalf of the minor. 30. Petitioners believe the settlement to be fair and just, and have communicated their agreement, pending the Court's approval, to the insurance carriers. 31. Although the Fee Agreement provides for the 1/3 fee, Milovanovich & Espinosa, LLC, is willing to reduce their fee to 25% of the total recovery. Thus, Milovanovich & Espinosa, LLC as attorneys for the petitioners, request approval of their fee in the amount of $23,750.00. 32. Plaintiffs believe that the fee of the undersigned is fair and reasonable under the circumstances, and have no objection to paying it. 33. Milovanovich & Espinosa, LLC, has advanced costs in the case on behalf of the Minor in the amount of $480.85. (An itemized bill for costs is attached hereto, marked as "Exhibit K", and incorporated by reference.) 34. In addition to the above referenced itemized costs, it is anticipated that Milovanovich & Espinosa will incur further costs at least in the amount of $100.00, from the time this Petition is filed until it is approved, for additional postage, facsimile and reproduction charges, mileage, long distance telephone charges, etc. 35. Thus, Milovanovich & Espinosa, LLC is seeking Court approval of their costs in the amount of $585.85. 6 36. Plaintiffs believe the bill of the undersigned with anticipated additions is fair and reasonable, and have no objections to paying it. 37. Upon approval by the Court of the proposed settlement, Petitioners will sign a General Release in favor of the Defendants. 38. The undersigned has contacted Ringler Associates, who have prepared a structured settlement proposal through Allstate Life Insurance Company, which has an A+ (Superior) rating. Under this proposal, the amount of $65,998.97 (which represents total settlement amount reduced for attorney's fees, costs and repayment of the lien and outstanding medical bill) is to be used to fund the structured settlement. The payments should be made as follows: a. $15,000 per year for 4 years, beginning on 8/1/1028 and continuing for 4 years (total of $60,000) b. $84,934.00 on the minor's 25th birthday (01/27/2025). Thus, the total amount the minor will receive is $144,934.00. (A true and correct copy of the structured settlement proposal is attached hereto, marked as "Exhibit L" and incorporated by reference.) 39. Allstate Life Ins. Co. (or any other structured settlement company) can guarantee the distribution under the proposal only for 7 days. In order to protect the minor from the volatility of the market, counsel has been able to convince the insurance carrier for the defendant to make a full payment of the structured settlement funding to the structured settlement carrier, so that the proposal is "locked in" and there could be no adverse impact of the market volatility on the funds the minor is to receive. 40. Petitioners desire that the proceeds be distributed as follows: 7 a. $23,750.00 shall be paid to Milovanovich & Espinosa, LLC, for fees; b. $585.85 shall be paid to Milovanovich & Espinosa, LLC, for costs; c. $4,563.48 shall be paid to Capital Advantage Insurance Company for their lien; d. $101.70 shall be paid to Park Avenue Radiology for their invoice for medical services rendered; e. All proceeds due to minor Plaintiff, Adelisa Dervisevic, in the amount of $65,998.97 are to be used as a funding for structured settlement, with the guaranteed yield in the amount of $144,934.00, which amount is to be distributed to the minor as follows: L $15,000 per year for 4 years, beginning on 8/1/1028 and continuing for 4 years (total of $60,000) ii. $84,934.00 on minor's 25th birthday (01/27/2025) 41. It is believed that the proposed settlement is fair and just, and is in the best interest of the minor. 42. All involved parties have reviewed and concur with this petition. WHEREFORE, Your Petitioners respectfully request Your Honorable Court to enter an Order approving said settlement, directing the distribution of the proceeds in accordance with the averments of this Petition, and authorizing the Petitioners to mark the above-captioned action settled and discontinued and to execute and deliver a General Release. Petitioners also respectfully request that Lutvo and Zekira Dervisevic be appointed guardians for the purpose of the guardianship account. 8 Respectfully submitted, DATED: /74/60 F?-? MILOVANOVIC SA, LLC By anovic squire ey ID# 75545 129 East Orange Street, Suite 2 Lancaster, PA 17602 (717) 293-1400 Attorneys for Plaintiffs 9 CERTIFICATE OF SERVICE The undersigned hereby certifies that on this day a true and correct copy of Petition for Approval of Minor Settlement and Distribution of Proceeds was served upon all parties via postage prepaid first class United States mail addressed as follows: Mary Altman Encompass Ins. Co. 333 Glen Street P.O. Box 5000 Glen Falls, NY 12801 Lisa Staff Allstate Ins. Co. P.O. Box 1064 Buffalo, NY 14240 By: ,NkWilo? ovich, Esquire 129 range Street, Suite 2 Lancaster, PA 17602 (717) 293-1400 Attorney ID #: 75545 Attorneys for Plaintiffs zy/off Date L.UTVO AND ZEIQRA DERVISEVIC, as parents and natural guardians of ADELISA DERVISEVIC, minor, 524 3"d Street Carlisle, PA 17013 Plaintiffs V. David A. Schriml 2713 Owego Road Vestal, NY 13850 Defendant : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW NO. a 7- ???3 VERIFICATION We veriA, that the statements contained in this Petition for Court's Approval of Minor's Compromise are true and correct. to the hest of otir knowledge, information and belief. We understand that false statements herein are subject to the penalties of 19 Pa.C.S.A. §4904 relating to unsuom falsification to authorities. ?1 5l0 -- Date Lutvo Dervisevic, individually and as a p nt and Legal guardian of Adelisa Dervisevic, a minor 3 C P-03 ED I Q- Zektra Dervisevic. individually and as a parent and Legal guardian of Adelisa Dervisevic, a minor 7-10-24 15:42 MILOVANOVICH ZO 208 275 ?556 Page 2 LUTVO AND ZEKIRA DERVISEVIC, : IN THE COURT OF COMMON PLEAS OF as parents and natural guardians of : CUMBERLAND COUNTY, PENNSYLVANIA ADELISA DERVISEVIC, minor, 524 3"d Street . Carlisle, PA 17013 Plaintiffs : CIVIL ACTION - LAW V. David A. SchrimI 271.3 Owego Road Vestal, NY 13$50 Defendant . NO. CONSENT OF PETITIONERS AND LEGAL GUARDIANS The undersigned, Lutvo and Zekira Dcrvisevic. Petitioners in the above-captioned action and parents of A.delisa Dervisevic, a minor. have read the foregoing Petition to approve minor's settlement and have reviewed the terms of the Petition and hereby consent to the Petition and hereby agree to said settlement. Luivo Dervisevic, individually and xs a pa ent and Legal guardian of Adelisa Dervisevic_ a minor J e P- 0,3 t'V> C Zekira Dervisevic, individually and as a parent and Legal guardian of Adelisa Dervisevic, a minor 2007-10-24 15;43 MILOVANOVICH 20 208 275 2556 Page 3 q j? --'a I R V ?, t IN) 6. Ir -0 ?0 C . } co D - rat 9124r 12006 5699C DATE OF CALL RUN NO. Prehospita! Care Report 4 - SAS61 NX AGENCY TRACKING #: 0311 7831 AGENCY CODE VEH. ID. Name: Adelisa Dervisevic Agency Name: Superi6r - Broome I MILEAGE E d 1 Address: 524 Third Streetq Dispatch Info.: MVC rollover with entrapment n Begin : : 10,0 Call Rec'd: 16:54 Carlisle, PA 17013 Call Location: 81 South exit 2 Total : 10.6 Enrouts: 16:54 Phone: (570) 241-2140 Location Type: Roadway Location Zip Location Code 13795 0357 Anr'd Scene: 17:07 6 1/27/2000 F 20 Call Type As Rec'd Priority Complete For Transfers Only years ©Emergency From Scene: 17:17 Physician: UNKNOWN E] Non-Emergency None/Unk Transferred From: At Destin: 17:32 Stand-by ? A 0 D ? No Previous PCR B OE Unknown If Previous PCR In Service: 17:58 Care In Progress: Other EMS Prior Agency: 0311 0C Previous PCR# - In Quarters: Mechanism Of Injury © Extrication Req. Seat bell used? Seat Belt Use [] Crew Patient Motor Vehicle Accident (MVA) 10 min. J EDYes f-? No ©Unk. Reported By []Police © Other "My right leg hurts" per crew member Hopkins, pt was standing in the back seat area on arrival, conscious, alert and oriented with her right leg entraped. After removing her leg pinned by seat, pt fully immobilized, right leg splinted and dry gauze dressing applied to open fx Emluns • Primary: Fracture/Dislocation Allergic Reaction F? UnconsciouslUnresp. E) Shock [D Major Trauma OB/GYN Syncope F-1 Seizure E] Head Injury Trauma-Blunt F? Bums Airway Obstruction Stroke/CVA El Behavioral Disorder Spinal Injury E] Trauma-Penetrating Environmental [? Respiratory Arrest General Illness/Malaise [] Substance Abuse (Potential) © FracturelDisloc. [] Soft Tissue Injury F? Heat Respiratory Distress E) Gastro-Intestinal Distress E) Poisoning (Accidental) Amputation ? Bleeding/Hemorrhage Cold Cardiac Related (Potential) ? Diabetic Related (Potential) HazMat Other. D Obvious Death © Moved to ambulance on stretcher/ backboard Medication Administered M Moved to ambulance on stair chair © IV Established Walked to ambulance F] Mast Inflated @ Time: Airway Cleared F? Bleeding Controlled Method Used: E] Oral / Nasal Airway © Spinal Immobilization Esophageal Obturator Airway / Esophageal Gastric Tube Airway © Limb Immobilized © Fixation - Traction R EndoTracheal Tube (Err) Heat Applied Cold Applied © Oxygen Administered @ 12 L.P.M., Method NRB Mask R Vomiting Induced @ Time: Method: @ Tkne 17:16 F-1 Restraints Applied Type: Suction Used Baby Delivered @ Time: County: Artificial Ventilation Method: []Alive F-1 Stillborn ? Mate Female CPR In Progress On Arrival By: Transported in Trendeienburg Position F] CPR Started (Crew) @ Time: Time From Arrest: min. Transported in Left Lateral Recumbent Position [?/] EKG Monitored: sinus to sinus tackTransported With Head Elevated Defibrillation ! Cardioversion / Pacing ® Other 12 poc,pfa,pulse ox trans ALS P-3 Wilson 1B • • • Wilson Regional Medical Center • ••• 032 M Charge Drive's Name Name Name Budder, Theresa A. Foster, Timothy J Critical Care # 172434 EMT - Defib. # 329067 # # Name Name Name Name # # # # • e Provided by NYS EMS ePCR System v4.1 Derived from DOH 3283 (6/94) Page 1 of 5 1 912412006 ssssc adefisa Dervisevic GATE OF CALL RUN NO. 4 - SAS61 NX AGENCY TRACKING 0: 0311-? 7831 AGENCY CODE VEH. to. Hosp. Encounter #: Transporting Agency: Workers Comp?: Unknown Expected Disp. of Trans. Agency: ALS / BLS: ALS w/ Transport Current Medications: > itch medicine Past Medical History: none stated Past Surgical History: unknown Allergies: pt denies iUpon SAS arrival 6 y/o female approx 20 kg fully immobilized on long spine board with cervical collar in place and right lower leg splinted for a 1 open possible fracture of the tibia/fibula. Gauze dressing in place. No bleeding noted. After receiving report from EMT Hopkins, pt moved to stretcher, secured and moved to awaiting ambulance and transport initiated. Father present, refused care and placed in front seat with no noted lInjuries. Patient reassured. Airway clear and self maintained. PERRLA. Speech clear. No noted trauma or injuries to head or neck. Cervical collar in place and pt denies any neck or back pain. Chest free from deformity, lacerations, bleeding or abrasions. Lungs sounds clear with equal bilateral expansion. Abd soft non tender non distended. Neg nausea, or vomiting. Pelvis stable. Oxygen applied via nrm at 12 liters. Pulse ox 99-100%. EKG sinus to sinus tach at 96-112 bpm. Skin warm, pink and dry. Sensory and motor equal times four. with noted deficient with deformity, and open laceration and possible fracture of lower right leg. Leg splinted with gauze dressing in place with no noted bleeding present. Strong equal pedal pulses present. IV initiated in left posterior hand with--20 gauge ns lock with positive flash, neg signs of infiltration noted with initiation of 3 cc normal saline. Pt reassured and vital signs monitored. Hospital notified of impending arrival and transported to 1 B with report and paperwork given to staff nurse on arrival with father present, side rails up, brakes on and bed left in low position. )xygen applied =KG sinus V established mknown if seat belted rnknown rate of speed nknown if loss of consciousness noted Five Mile Point fire Superior ambulances Broome Ambulance New York State Police Vital Signs Resp R Breath I Pulse EKG B P J-D.C. G.C,S. R Pupils I Skin Status'; 22 © Normal ? Decreased © ? 96 . Sys: 124 Alert EO F-T? ® Normal ? Dialed © ? []Unremarkable E ]Cool ? Pale , O C O U ©Regular ? Absent O. Regular Did', OVoice V 5 ? Constricted F-1 ©Warm []Cyanotic P ? Shallow ? Rates 0 O Irregular Pain Level O Pain M ? Sluggish ? ? Moist ? Flushed OS []Labored ? Rhonchi Wh ? Oximetry46: Palp. OUnresp. Tot 15 ? No-Reaction ? ©Dry []Jaundiced eezes E] E] 1 izwone. 10=severe ? Chem Strip: Visual ® Meter Resp R Breath L Pulse EKG B,P. L.O.C. G.C,S. R Pupils L Skin Status 20 0 Norma! © Decreased ? 92 . sinus tack Sys: 136 O. Alert EC 7 ® Normal © [] Dilated ? []Unremarkable E] Cod ? Pale O C O U Regular ? Absent Regular p O Voice V 5 ? Constricted ? R Warm ? Cyanotic (?) P ? Shallow ? Rales ? O Irregular Pain Level 66 O Pain M0 ? Sluggish [] [] Moist [] Flushed OS Labored ? Rhonchi [] Whe zes Oxane 44 e Palp O Unmsp• Tot 15 ? No-Reaction ? R Dry ? Jaundiced ? e ? 100 1, - 1??evere El Chem Strip: =:? ® Visual ®Meter Provided by NYS-EMS ePCR System v4.1 Doi ived from DOH 3283 (6144) Page 2 of 5 AGENCYTRACKING#: ??deiesa Dervisevic 9/24/2006 ?' ? 5699C y 0311 '' 7831 DATE OF CALL RUN NO. 4 - SAS6 1 NX AGENCY CODE VEH. ID. Res :R Breath L :P UISL, -EKG 33 P. J-D.C. BZS. :R -Pupils I. Skin Status, p - 20 I © Normal © ? Decreased E] - 100 sinus . Sys: I 146 • Alert EO 4 I © Normal ® E] ? Dilated ? Unremarkable ? E] Cool Pate 0 C U ? Regular ? Absent El 0• Regular p 0 Voice i V I5 ? Constricted ? ! © Warm ? Cyanotic (. P ? Shallow ? Rates ? 0 Irregular Pain Level - - 80 0 Pain M [:E ? Sluggish R ? Moist ? Flushed OS ? Labored E] Rhonchi El Oxime ya: 4 ] _ L? Palp 0 Unresp. Tot 15 [] No-Reaction E] © Dry ? Jaundiced ? Wheezes ? 99 1=None, eve so=severe ? Chem Strip ? ? Visual [R Meter No Medications For This PCR ALS Procedures 17:24 IV © Saline Lock in Extremities w/ 20g catheter 'Buckler, Theresa A Skull: 0 Not assessed 0• Normal 0 Abnormal JVD Present? Orbits: 0 Not assessed Normal 0 Abnormal Q Not assessed O Yes .0 No Ears: 0 Not assessed Normal 0 Abnormal Nose: 0 Not assessed 0• Normal 0Abnormai Carotid Pulse Present? Mouth: 0 Not assessed Normal 0Abnormai Q Not assessed 0 Strong Neck: 0 Not assessed Normal 0 Abnormal 0 None o Weak 0 Absent Tracheal Deviation Present? 0 Not assessed 0 To The Left Carotid Bruit Present? (?i) Midline 0 To The Right (?) Not assessed 0 Left Side Additional HEENT Comments: 0 None 0 Right Side HEENT reveals PERRLA - - - Iunknown but per bystanders stated that no loss of consciousness, and pt was standing in back seat area Chest: Cardiac Ausculation 0 Not assessed 0• Normal O Abnormal ? Accessory Muscles Used ? Flail Segments Present Retractions ? Subcutaneous Emphysema Present Breath Sounds Not assessed Normal Abnormal Right: 0 0 Left: 0 ?• 0 Additional Chest Comments: full equal expansion no noted trauma (?)Not assessed o Normal 0 Abnormal Describe Cardiac Ausculation Abnormality. Decreased Absent Rates Rhonchi Wheezes ? ? ? ? ? ? ? ? ? ? Provided by NYS-EMS ePCR System v4.1 Derived from DOH 3283 (6194) Page 3 of 5 912412006 I 5699C DATE OF CALL RUN NO. Adelisa Dervisevic 4 - sAs61 tax Abdomen: Bowel Sounds Present? O Not assessed (?)Normal O Abnormal * Not assessed O Yes O No Distended Pelvis: Tender LUQ E] RUQ El Periumbifical (?. Not assessed ONormal OAbnormal LLQ [] RLQ Buttocks: Abdominal Mass Present? Q Not assessed ONormaf Abnormal Genitalia: !f Mass Present, describe... ?. Not assessed ONormal Abnormal Additional Abdominal Comments: non tender non distended no nausea, no vomiting Left Arm/Hand Right Arm/Hand Pulse: Normal Pulse: Normal Cyanosis Capillary Refill: 2 (sec.) E Cyanosis Capillary Refill: 2 (sec.) Describe any abnormalities: Describe any abnormalities: Left Leg/Foot Right Leg/Foot Pulse: Normal Pulse: Normal Cyanosis Capillary Refill: 2 (sec.) Cyanosis Capillary Refill: 2 (sec.) Describe any abnormalities: Describe any abnormalities: I Additional Extremities Comments: right lower leg deformity and open wound with approx 3 inch laceration and/or open fracture.Sp',inted prior to our arrival with strong pulses present and good sensation Left Arm/Hand Right Arras/Hand Motor Function: Normal Motor Function: Normal Sensory Function: Normal Sensory Function: Normal Left Leg/Foot Right Leg/Foot Motor Function: Normal --? Motor Function: perreased Sensory Function: Normal Sensory Function: Normal Back/Spine Additional Neuro Comments: Q Not assessed O Normal O Abnormal unable to fully access back due to pt fully immoblized prior to our arrival denies any other pain or iniury other than right lower leg A6ENCYTRACKINGB: 0? 311 ?? 7831 AGENCY CODE VEH.ID. Provided by NYS-EMS ePCR System v4.1 Derived from DON 3283 (6194) Page 4 of 5 AGOCY true k L_ L Adelisa Dervisevic ,,-- DAMOFCra.L MWfa 4 - SASSINX IDOOME VERO. Scanned 1_maues 8eq Mum.: 1 Date of Scan : 9124MOB 20:38 Description : sinuS to sinus tach Addendum / Errata Date Added: 9/25MDOB 10:57 Added By: 172434 (Bucider, Theresa A - Critical Care) Addendum: Due to computer error several Sentences missing from PCA as documented: Should read as foN N9-. Silver Dodge mini van rear ended whUe driving south on 81 approx 54-60 mph. Extensive rear and damage with compartment Intrusion present. Mini van was forced off the naafi down the embankment into the median. Five Mile Point Fire along with Superior EMS crews exnrioatetd this 6 y/o female who was pinned in the middle seat standing with her right lower leg pinned between the seats. Pt was then fully immobfted, lower right leg splinted and was Wng carried up the hank to our awaiting stretcher. Due to language barrier, ditfbult to yet full Information. OiMid W try Mr&Eh9Apentj Lever ,;P-FR naporrin9 Tad 16 iDVh; from nOH 32fri (6 84} - - -- - Pace 5 db i SE'-2t'7.0?6-SUFI 09.23 PM SUPERIOR EXCHANGE FAX Na. 6?? ?72 86 49 P.007 PGR #: 4-SAS61NX Supplies Used r Otr R. d 2 Mak -AM Fyn QV Rago4ad Ce iaa Monhu E6cvQda 4 4 SUPNy qtr R•.lovked syon a. 3" 40 ==nann= Str- 3inai-r3rnt?n, i?lWv' on: 13901 °.'CI7:?si? D± IIA°CJI;:a! IL°_?°_=rIT1' Tar .?711DL1ic-In:?`_ 'c?T"SC1D"' rnbuianc., trarcpor`?1TID!! !,; UCJIV ?O?J°_f?C) li trl- NJtlrnl r7nV9cHl con d1IlOn I°gWr=S Tr 7naT°" O;% of 1bJ;Hn-_. 'I 1J- 7Drn must bE cnm.Dl°IE!It HTiCI lflfl?c! [)l.' tflE pf14'SI i8n Jl:InO z3r= Oi th= 3-fia it. hiiormnailon about t11= arnbLlidnC?- Trip: t1 V-P n°T!ciary kiann-=, Lc.? Gai= a 23--rVi-- - ~'7ti=ni JrlGln (i a2iJ41% irin-mi . nam_ adrires!:, dicci;arr,? Jatei: O J VLC - Li Pab=ni 1)=ctiricltlDii in--iudL nam_•, address, aom!sslor, ?a[_ : lJC?44Cls ) ?? 1 VVa th=trip (ch eclc correnc'. bOX) )n=Ui av Found trip - Describe the cati=nC : ondiilori at the tirne of pdeup and%or d!Scl :3rcl- than nec3 Sr3T.°d utI1C3Tlon o an ambul3nc . How wall vva-s ills pat!e-ni :able tG ambuiatr; 3ttne time of pickup? (Cnecl- the 3ppropr3t= bolt) J? Patient v::=-c Comm -ly bed confined or onl,% able tU 3rnbUi3te a T=W 7°=L T'MM the bed ='aii=n' ar Jbu;3T-eC, or could h3VE 3MbUi3;ad Ui:?? l?Lali tO the ,=mbulznc '3L=nt 3rr1bui3t°'. ?r cOUIG trail= 3nldbra "°,n-- _;' to the 3 r;c? 4Niti": _=3".? 3nc= ({nolJdi 1= t%c L:-==-- Of . can=, mb.j:= .:r UiJh°_? 44'HIIC°" ?r 4t',???lcRalr 1 -I cri;:: tn-= pnvs;c31 canbfLlo ir,3:' z3Lf3r_ell In7J3Jr + aT7 oulail0nr ii:3-,,3Q= Irar'.?DOr y "J 3!l out _ anc= n?dlcsli}{ n=??= ?3 r??: ='atm-, disor =n_-Mrt:.._z-rib= nature and c=7r== I -I.Z F'aL"3nt 'nag' Medical c3nidition tfl3i rsquired uan? =r by 37L=-t=,h°r: descrlba condition F,3bent had iG b= Te-str3ined b=cau5= x 3 phvsic3l conaiLion: describe condition and n==d Tot T =5tr 31nLS _ Other Condition 1- a; r=qulred 3r'S7Di ?IiOn by 3mbulanc=_ d3SvnLv condifIDD thi y estration the 133 1 "i!zmutiorl With BDDr=n;-qt=facJiiti- t0 care Tor tn= G3tl=n' : °5 ltl0 3{n: fA I A L y Phvsician, nf., i?lP, Rhr. Jl$ 1iarg= Planner Dma Ui signa urn - - --- -- Uf*0dHc70 Semites ? United United Health Services Hospitals Health Services Hospitals Inpatient Coding Summary Patient Name Sex Birth Date Age MR Number Bitting Number DERVISEVIC, ADELISA Female 0112712000 6 4848160 5006246051 Admit Date Discharge Date LOS Newborn Weight Financial Class Disposition 09124106 01:54 PM 09/27/06 04:00 PM 3 N AHR Attending Physician Coder KANELLAKOS, JAMES MD Cathy Cuffaro Patient Type S Hosp Service BMS MDC Code / Text 006 DISEASES & DISORDERS OF THE MUSCULOSKELETAL SYSTEM & CONN TISSUE DRG Code /Text 220 LOWER EXTREM & HUMER PROC EXC HIP,FOOT,FEMUR AGE <13 DRG Weight Average LOS Geometric Mean LOS 1.4373 6,0000 82360 Closed fracture of unspectiffed part, tibia alone f 8249 Unspecified fracture of ankle, open Viz .; ... ?:......r•:::• ..-.n:.:.. -' .. . 61 _ .. _ e E8121 Motor vehda traffic accident (collision), passenger (other than motorcycle) E8495 Injury or poisoning occurring at/in street and highway Fes ..;.,:.•.. Prcycedu . r tIeT?" 7966 Debridement of open fracture of tibialfibula (leg) KANELLAKOS, JAMES MD 09125!06 7916 Closed reduction of fracture with internal fixatio KANELLAKOS, JAMES MD 104125/0ti MR number. 4848160 Billing number: 5006246051 Patient name; DERVISEVIC, ADELISA Admit date, OW/24M 41 X54 PM Discharge date: 09/27106 04;00 PM Date printed: 10/412006 8.50 AM UHS_Abst2Em.doc 02120/06 Template: Abst2fm3cc.doc Confidential Pane' 1 ?- Patient: DERVISEVIC, ADELISA MRN: 4848160 Encounter#: 5006246051 PCP: UNITED HEALTH SERVICES 6y, F Time Seen; upon arrival. Arrived- By ambulance. Clinical Report - Physicians Wilson Memorial Regional Medical Cen Emergency Department 33-57 Harrison Street, Johnson City, Ny 1 Phone: 607.763.6611 Fax: 607.763.64' Registration Date/Time: 09/24/2006 17:49 HISTORY OF PRESENT ILLNESS Chief Complaint- MOTOR VEHICLE COLLISION. Location of injuries- lower back and right hip leg. The accident occurred just prior to arrival. The patient complains of moderate pain. The patient sustained a blow to the head. No neck p consciousness or seizure. Not dazed. Mechanism details- (back seat passenger). right loss of REVIEW OF SYSTEMS The patient sustained skin laceration. No numbness, dizziness, loss of vision, hearing loss or c est pain. No difficulty breathing, weakness, headache, nausea or abdominal pain. No fever, depression, vomiting or urinary problems. PAST HISTORY Negative. Medications: None. Allergies: No known drug allergies. SOCIAL HISTORY Nonsmoker. No alcohol use. ADDITIONAL NOTES The nursing notes have been reviewed. PHYSICAL EXAM Appearance: Patient on a backboard. C-collar in place. Alert. Oriented X3. Patient in mild di Distress appears due to pain. Head: Head non-tender. No Battle's sign or raccoon eyes. Forehead: mild swelling and small ecchymosis. No erythema, tenderness, laceration or deformity. Eyes: Pupils equal, round and reactive to tight. EOM intact. ENT: No dental injury. Pharynx normal. Neck: Painless ROM. Non-tender. Note (after radiologic clearance). CVS: Heart sounds normal. Pulses normal. Respiratory: Breath sounds normal. Chest nontender. Abdomen: Abdomen soft and nontender. No organomegaly. Back: No back tenderness. ROM normal. Skin: Normal skin color and turgor. Skin warm and dry. Extremities: Pelvis stable. Right leg: deformity consistent with a tibia and fibula fracture and DERVISEVIC.'ADET,IS!1 09/24/2006 17:49 MR# 4848160 Visit# 500624ti051 Physici Report 2of7 laceration. Neurovascular intact distally. No tower extremity edema. Upper exts without pain to p lpation. Neuro: Oriented X 3. No motor deficit. No sensory deficit. LABS, X-RAYS, AND EKG X-Rays: C-spine series negative. Chest X-ray negative. Pelvis negative. Rt rib/Fib X-ray: Angulated fracture of the distal right tibia. Fracture of the right fibula. PROGRESS AND PROCEDURES E.D. Course. Fentanyl, DT, Timentin given. Exam after return from radiology no pain to pa neck, chest, abdo, back, pelvis, upper exts, L lower extremity. To Dr Feldman. Discussed case with physician Dr. Kaneltakos. Family counseled in person regarding the diagnosis and need for admission. Disposition: Admitted. CLINICAL IMPRESSION Right distal tibia fracture and right distal fibula fracture. Angulation of fracture present. Open present . head, (Electronically signed by Stephen Gomez, MD 09/24/2406 20:32) Patient: DERVISEVIC, ADELISA MRN: 4848160 Encounter#: 5006246051 PCP: UNITED HEALTH SERVICES 6y, F Clinical Report - Nurses Wilson Memorial Regional Medical C Emergency Department 33-57 Harrison Street, Johnson City, Na Phone: 607.753.6611 Fax: 607.763.E Registration Date/Time: 09/24/2006 17; MVC TRIAGE Initial Assessment Triage time 1637. Acuity: LEVEL 2. BP: 144 / 87. HR: 85. RR: 20. Temp: 97.5 oral. 02 saturation: 100 % room air. Alert. W UNKOWN. --1756 Sue Cudo, RN. Medications (ITCHING MEDICINE). --1756 Sue Cudo, RN. Allergies (UNKNOWN). --1756 Sue Cudo, RN. History Chief Complaint: MOTOR VEHICLE COLLISION. Location of injuries- right leg. y-` This occurred just prior to arrival. (UNKNOWN-LANGUAGE BARRIER). Pain level now: 1 of consciousness. No headache, neck pain or back pain. PAST HX: Unknown. No infectious disease exposure. UNKNOWN. SOCIAL HX: Nonsmoker. No alcohol use. Functional assessment: no impairments noted. abuse. Arrived by EMS and arrived (SUPERIOR). Historian: family. Patient has a primary care ph Sue Cudo, RN. PAST HX: nter F13790 1411 49 0. No loss report of --i 75i Interventions Fall risk assessment completed. High fall risk identified. To treatment room. The patient doe not have ai advanced directive. --1756 Sue Cudo, RN. PHYSICAL ASSESSMENT To room via stretcher (1637). Alert. Oriented X 3. Pupils equal, round and reactive to light. Respirations not labored. Breath sounds within normal limits. Pulses within normal limits. Abdomen soft aid nontender. Limited ROM present in the right lower leg. Capillary refill less than 2 seconds. ucous membranes are pink. Skin is warm and dry. --1800 Sue Cudo, RN. NURSING PROGRESS NOTES Progress 1637. Two patient identifiers checked. Checked patient name and birthdate. C-collar appli . Patient placed on backboard. Call light placed in reach. Side rails up x 2. Bed placed in lowest posit on. Brakes of bed on. Patient ready for evaluation - chart flagged and ED physician notified. --1801 Su Cudo, RN (PATIENT RESTING QUIETLY, AROUSES EASILY. FATHER AT BEDSIDE. SEE PAPER HART FOR VITAL SIGNS.). --1839 Maggie Strebel, R.N. 3 (EAh RINGS REMOVED AND GIVEN TO FATHER.). --1847 Sue Cudo, RN Patient transported to radiology by stretcher. --1847 Sue Cudo, RN 1946. Patient returned from radiology by stretcher. --2023 Sue Cudo, RN BP: 134 / 79. HR: 102. RR: 28. Temp: 98.1. 02 saturation: 97 % room air. --2025 Suel Cudo, RN 201 . FENTANYL 25 mcg diluted with 2 mL NS slow IVP over 1 minute. IV patency established. IV site the ked: no pain, redness, or swelling. IV flushed thoroughly pre- and post-medication administr tion. 025 Sue Cudo, RN BP: 133 / 68. HR: 98. RR: 24. 02 saturation: 100 % room air. --2026 Sue Cudo, RN 1 r 201b. (WET TO DRY DRSG APPLIED. SPLINT APPLIED. ). --2038 Sue Cudo, RN (AOOUSES EASILY. STATES PAIN IMPROVED.). --2038 Sue Cudo, RN (M THER AND FATHER REFUSED TETNUS INJECTION, THEY BOTH STATED THAT IM UNIZATIONS ARE UP TO DATE. COMMUNICATIONS THROUGH FAMILY MEMBERS.). Su Cudo, RN (Pt R AVAILABLE ON CHART.). --2143 Sue Cudo, RN ( P TIENT AND FAMILY CONTINUE TO AWAIT ORTHOPEDIC SURGEON ARRIVAL.). - Cu o, RN (ORTHOPEDIC SURGEON IN EVALUATING PATIENT.). -2221 Sue Cudo, RN 2215. BP: 130 / 80. HR: 117. RR: 20. Temp: 99.2 oral. 02 saturation: 99 %. --2222 Sue 205. TIMENTIN 1 gm IVPB over 15 minutes, via IV pump. IV patency established. IV site pa' , redness, or swelling. IV flushed thoroughly pre- and post-medication administration. F wa ning given to patient. . f-2313 Sue Cudo, RN (DEPORT AND CARE TO AMY, RN.). --2338 Sue Cudo, RN. DIS MON / DISCHARGE itted to general surgery - --2136 Sue Cudo, RN B : 139177. HR: 120. RR: 16. Temp: 98.7 oral. 02 saturation: 99°/4 room air. Patient reports on departure as 1/10. Condition at departure: unchanged. IV line in place and patent Fall risl, assessment completed. No fall risk identified. Admitted to OR -. Transported via stretcher by t R port was given (sue c. called report to peds). Patient's personal items include; belongings w th mother. D parture time: sleeping . comfortably. lungs clear. iv patent. pulses intact. dressing intact. -- St ne. R. N. L elea4ed at 09/24/2006 23:52 by Any Stone, R.N. --2140 Sue , RN ;a: no reaction pain level with IV. given to Amy DF,RV1SF.VIC..ADFLISA 09124!2006 17:40 MR# 4948160„__-- Visit# 3 of 3 lJktlterdfie?tllhSr"'rv+t? ? e . Emergency Departmen DERVISEVIC United , Physician/Provider 500-82451 ?EI-ISA Health Services Orders Dog: oii27/2000 A4114: 4848160 .?- Hospitals Mi Page (rev 65121/04 ADM DATE: F 6Y Circle or check affirmatives, backslash (1) negatives OOT 09/24/2006 17:59 Laboratory Cultures Laboratory Panels . • CBC w/diff • Urine • Cardiac (EKG, Troponin, BMP, CBC, PTJPTT, Old Records, CXR, Port or 2 • PT on Coumadin? • Wound View) • PTT on Heparin? • Blood X • Abdomen (CBC, BMP, Lipase, Hepatic Profile, Dip Urine, Urine HCG) • BMP • CMP • Throat • CSF (Cell Count/Diff, Gram Slain, C and S, Glucose, Protein) • Troponin • CPK + Rapid Strep • STD (DNA ChlamlGC, VDRL, Cervical Swab C and S, Urine HCG) • BNP • Amylase Blood Radiology All reques? lode clinical indicators . Lipase • O Meg • Chest Pain • SOB • NN Pain • LOG • H/A fraurria/P - - • Hepatic Profile • Type + Cross • Serum Acetone • FFP X • ESR • CRP • Type + Screen • T4 • TSH Drug Levels Chest + Porte • Complete (Pneumothorax) Iv P • Monospot • ETOH Abdo • Ftat ie w• 3 View y Quart HCG • Ouant • Digoxin Spins ervic • Thoracic • LS • Coccyx • Portable • Urinalysis • Dilantin • Urine HCG • ASA • Ugirm Tox Screen • Acetaminophen i Unne • Theaphyll;ne CT Contrast Yes No 8UN/Creat • FS Glucose a Brain • Face • Spine: Cervical Thoracic Lumbo-Sacral • Abdomen/Pelvis • Chest • Abdomen Ultrasound • Abdomen • Testicular • Pelvic: Trans ABDO Trans VAG `• HCG Cardiac • EKG • Hoffer ;Monitor • Echocardiogram Respiratory Albuterol 2.5 mg/Atrovent 8.5 mg X Albuterol 2.5 mg X Vaponephrine: 0.25 rnV3cc NS < 6 mos. 0.50 mV3cc NS > 6 mos. ? ASG Room Air 02 via _ ? Peak Flow Xi Pre/Post 0 Old Records Venous Doppler *Lag: Left Right Bilateral RN Orders • Cardiac Monitor O2via Pulse Ox • Saline Lock • Straight Oath • Bag for urine • Foley • NGT • IV _ • IV -0 May be off monitor for iesting/transport ? yes ? No Repeat: BP HR RR Tamp • Consult: • CPEP Detox Physical Therapy L&D meoicatlon urgers Ordw Time Medication Given (Tirne/Wdaiy o. s?z r ?? lVP a?wnROrr,,:rrr, ;..?. •: H08PITAL PROVIDING MEDICAL COMMAND: united _. !! EMERGENCY DEPARTMENT f.-i EMERGENCY DEPARTMENT Modk* Command Msm Memorlel Regional Medice? Cents Binghamton Deneral hospital Healt]i Setvic:t Fadity Harrison Strew 20-42 Mitrhsll Avenue impi tah, Chm* One Box: Johnson Clly, NY 18790 Binghamtan, NY 13803 (687) 763-6611 (607) 752-2231 Patient Name PRE - HOSPITAL E.M.S_ PHYSICIAN MEDICAL COMMAND RECORD Affix P~tSticker P"tHlatorylMedaiAlbrSlae E.M.S AQenf?r ame: '" ' ' __ E.M S. Unit #-! ?1 Level of Care:' : EMT ?1 EMT.CC F' EMT-P !. % None Patient ?e? ? - -! Male • F P CHIEF COMPLAINT: {H.P.I.) IrMgC Allergy to (Subjective Aesesament) _ C - Hypertension Stroke Seizures Diabetes COPD Cardiac r; Outer (Lisa Asthma Primary AnUbment Airway: ereathkq: Circulavon: Current Medications(Liat) Disabulty. Seoondary Aasessmerit Tk" of Cardiac Arnat Hrs. Natidit weight k4. Time CPR Siarled Hrs. I Sbuek by vehicle MPH -: UVA Death of occu intU OVW._ V TIME RESP PULSE B P. acs ?f . , AM OF S002 Hmm" ?' RatG n Alert I? - Rate. i ! Regular Voice T .u . !I r. Shallow l . J Regular Ii C. Pain I, nLbo?ed_ rlve!GU?w- ri umeap. y0- A RESP PULSE B_P. c 0-r ?l GCS?I^ SaOz PAW- FR-m&: ioii I I I clRopular U Voioe S ,- aNow II ^; Regular I 71 Pain I I % 0 Lab?rad UU[eaular Unresp- I ! RESP PULSE BP. rwi acuwau r OF :cics?? _ Sam D "T11 p ? Al r_ a"War :I ! r. Voice i shallow nRegWar ( : ! Pain 3 I? Labored I: '!Ineguiar D unrw. I rREATM81fT IN PROGIIESS: MECHANISM OF INuItY I I CTC Q MPH r tam I i Extrication required f ! a°w"InR Fall at Nat I , KnNa minutes -' MVA D unarmed *moot L? Otter PUPILS L 1, R R PUPILS L R PUPILS L Dab_ / / Tim Will InItal call received M.Q. J D-0. Online Transport Ordered Seat belt used? Transport Started U Yea 0 No Update ] Unknown ETA min. M ? 44 SKIN EKG RYHTHMS lIREwTH aO,wAa 1? Pl WifiW-Tri mar .. iFSR fdY (l'? I I? 0-4 IVR D? L _ .rl n..?.d 1 PVC r r j{ a C>!L, ?:! Pff c:J ottrer -- -- - I . iAW6___j_. SKIN EI(G RYHTHMSI ?h+sAUrwt IP l ^ e 1 NSR i ' Brady. Normal Lj' - a t q .I . ht ??o Fluah PVC { . a ' , , ?J? ? CI SV J Other 1 I Wh4'lM SION Unro -Ti 1iW i EKG F7YNTHMS`I s11EATri OWN Oa i l f/ - - " ma l1 3 Ww Cya do :?Na rJBrady. - . ?r° 1 I Y-TAXIII Roan T0- C 1 Raw 'I 9r; 'Flu ^ol IJ SVT .? . _ - i VVheczes I LU C, a,u flo y I-M4 ftstm Prate W ra* Under- RECORDER: ( ) L 12 Lead I._: 0-Collarlgackboard 1''. IV Samoa Lock n oral Alrwsly !:.1 IV NaCI ? l ro hr -I ET ? ? / ? I., WL modl ! 102LPM -I NO Tube n o=aw Ralle.^ Imr Cardlaa Pacing Cordwc Monks C, End Tidal C02 I Other L Qglp X REQUMW INFORMATION FOR COtiTRgLf.ED suesTANCE ADMiNIBTRA m DetelTime of Order (MdNqj Phyaklin Order CorHnoriad Subetanca or Madtcatlan AdmMh tersd Medleatbn Admluleteted Velunle Adfflk* *atloe , Routs of EMT Adminletration Readbeck a./ Patient Fusporm oWsls M Order D ID.i Addillonal Phpk$on Order. X 1 Initial } x I~ M T IEM MR cQF CARE: (Reuulreds. >aturt Name of Autheirizdnp Physician {PRINT) Authoriskg Phyole en SiSnetvF*KDJD. I have reviewed the wdormatiofl above. it ie comptate and accurate. Pabom to E.D. room Cart transfered, report to GL_ hit;. Additional informadon a fV v x (Print X&I") EUT_'incbWW Iftnaw?e) (EMT d!) OF GINAL - Re6ain at Medial Command FaeNit t COPY 1YELLOW-EM.S l eencylelve to E.M.T. COPY t PINK -tlasplW EA LS ClA W3 USE BUCK WK..P.MNT 1_E01I3LY: Thin roan MUST ik COnrplelad In CCrhplWWA wNh Article $a of the N.Y.$, Pu Nk Healtb Law and Pvt to of the N.Y_C.It.R. VITA I QfrNC Patient Name: DERVISEVIC, ADELISA Date Printed: 24 Sep 2fM)6 Patient ID: 999991,500-624-6051 MR#: 4848160 Time Printed: 23:17 Bed Number: F.D1IB DOB- 01127/2000 F 6Y page: 1 cif 1 ADM DATE: 0912412006 17:59 OOT NBP-S NBP-D NBP-M NBP-R DR PVC SP02 SP02-R 19:54 0:18 V0: 01 :12 mmHg 134 133 13 130 mmHg 79 68 72 80 mmHg 110 97 10 106 b pm - 113 103 1 118 99 % 96 102 GUMS Luilnuii,'m Tcclnwlotio, Unkedi h JIb w7; United ?4k I Hes1)th In"1ViCes 1-ky-spitals PATIENT BELONGINGSIVALUABLES INI p8 r "? DERVISEVIC, ADELISA 500-624.6051 DOB: 01/27/2000 ADM DATE: OOT MR#: 4848160 F 6Y 09/24/2006 17:59 "UHS Hospitals is not responsible for valuables andlor belongings brought by individuals upon admission. Patients are en- couraged to send home their valuables and belongings." i - _...T_ . •8EL -- rs•: DATE: UNIT: 7-1 SENT HOME KEPT TO SAFE LO UNIT CK-UP Dentures: a FUII-Upper/Lower ;-- Partial-Upper/Lower - Sent Home U Kept I I To Safe r-1 U i t Lock-Up I 'l Eyeglasses I I Sent Home Kept U To Safe Lock-Up ' ' Hearing Aid U Right Ei Left ? Both U Sent Home U Kept L To Safe r-1 U i t Lock-Up I I Ambulation Aids - Type: D Sent Home .- Kept _ J To Safe i . U it Lock-Up Prosthesis - Type: U Sent Home +l] Kept I I To Safe 1-1 U i t Lock-Up :i Medications - List Sent Home ! I Kept F1 Pharmacy :_i U it Lock-Up Sent Home L.1 Kept L' Pharmacy I i U i t Lode-Up U Sent Home - Kept I l Pharmacy _ U it Lock-Up r' Cash (Breakdown) I I Sent Home I I Kept - To Safe n O t Lock-Up Sent Home Kept 1=1 To Safe U q t Lock-Up n Sent Home ri Kept C=' To Safe I I Uni t Lock-Up - Sent Home ' Kept I. I To Safe t Un it Lock-Up i 1 Jewelry (Description) /Lt C? ? lk , J_kt_-LJt-1S VSent Home 'Sent Home t__i Kept Kept '- To Safe LI To Safe u, Un : Un it Lock-Up it Lock-Up lothing ;rw•t n Sent Home . Kept To Safe CI Un it Lock-Up ?.: Sent Home Kept 0 To Safe F I Un it Lock-Up D Sent Home U Kept _; To Safe !-Un it Lock-Up -- Sent Home :-1 Kept I !To Safe U Un it Lock-Up I i Other L I Sent Home Kept rJ To Safe : Un ' Lock-Up U Sent Home t_-1 Kept - To Safe FJ UN Lock-Up I have been informed that UHS Hospitals will not be held liable for loss or damage to any of my person property during my hospitalization. This includes, but Is not limited to: clothing, jewelry, eyeglasses, d Mures, hearing aids and cash. I have been informed that UHS Hospitals maintains a safe for the safekeeping n cash, jewelry and other valuables. I understand that I may utilize this safe for my belongings. Articles place in the safe may be claimed by contacting the Security Department through the Switchboard Operator. I understand the hospital is not responsible for items I choose to keep with me during my stay. I verify e above inventory?ps accurate, and any additional items brought into the hospital are solely my responsib lity. Signature: lam'" _ ' Ae >_ Date: (Pafaen or Authorized Re esentative - Relationshi - `-- pr p) Signature: f Date: Nursi Personnel) ORIGINAL ON CHART COPY TO PATIENT 5220211 ev 04.06 0 ai v m r r in N t ?Ar ???p 14 Y'4o:63 Yl OdNaalth Serzrices >f Ir' e ! S 0111 /04 United Health Services 14 T :4 t - a 31 Admission History a a Hospitals *Shaded areas may require follow u "If <14 yrs of age also complete Pec?trjc Ad bon is - BP: i b TPR' tit wt' Patient oriented to room and nurse call system Name patient wishes to be called: Ad ion to Admission Time Referral to Caje Managame , O 3 ?Yes No Primary Care Physician: KsV-'A,_ t Q. Other Physicians: _ i ..7i - i• •'? i Via:. .,_. , ?.:.4. Alzheimer QYes AV Shunt Site Chicken Pox QUnsu ?Yes No Seizure UYea Mastectomy ?Left DRight Measles OUns OYes QNo Diabetes ayes Appropriate Bracelets Applied Dyes ?N/A Mumps OUnsu ?Yes ONo Bleeding/Bruising/Clotting ?Yes Pacemaker QYes Rubella OUn Dyes ONo Blood Transfusion ?Yes Cardiac pYes Hepatitis OUnsu QYes ?No Transfusion Reactions ?Yes Abdominal Dyes Tuberculosis QUnsur ?Yes Blood Pressure O? 04 Orthopedic Dyes Sexually Transmitted QYes ONo Renal Failure pYes Neuro ?Yes Diseases: Specify Stroke QYes Anesthesia Reaction ?Yes MRSA ?Yes DNo Heart Disease ?Yes Respiratory Disease Dyes If yes, describe below Other, cescribe below VRE DYes ? No Mitral Valve Prolapse QYes VRSA ?Yes Referral to Infection Control Nu ONo : pYes ON Ocher comment: Have you been exposed to an Communicable Diseases in the past 4 weeks? ElYrz-GINo ? G Patient has written Advance Ditactives? OYe?fVO `tir tr#'. .. , If yes and NOT here, what is indicated on the form (quote): _ It Yes: Place a copy on Medical Record; Document actions on Kardex I, If No: Proceed to Kardex 1 for further action. Who would you give the health care provider (MO, etc) c Dmentlperrnission to discass your findings with? _i?1I7 SU?`1--- - Who would you like hospital personnel to share medical information with? PATIENTS RIGHTS Patient's Rights have been given and explained to pati&Wsigni6 t other? ?Yes ? No if no, a ain , Learn : r ? Needs: F., K> '' • :.. - .Jl 'Sif .:..• ?Yes ONo ? Brought In OSent to Pharmacy OSent Home :.._ - Medication: Q&I etc Food: Iodine Contrast Tape Adhesive Environment Other :t w Tobacco Use: Have you smoked cigarettes or cigars, even one puff, or used any other tobacco products in the past 12 months? 0Ye No Patient<18 years old, caregiver smoked or used tobacco products in the past 12 months? 0Yes ONO ?N/A Amount How long? If yes, both of the following should occur: ORefwal to discharge planner for discussion with patient regarding tobacco cessation program. pPatient provided with writ-on information and counselling about tobacco cessation _ Recreational drug use? E]Yes ONo Frequency:- How long: Alcohol Use: DYes O Nc Amount How long: _ Have you ever received Treatment? DYes ? No ? Infonmation given to patient Cage Questionnaire: (If yes, automatic referral( G. Have you ever felt that you should cut down on your drinking? Oyes No A. Have people annoyed you by criticizing your drinkirng? ?Yes No G. Have you ever left bad or guilty about your drinking? ?Yes No E. Have you ever had a drink in the a.m. (Eye-Opener to steady your nerves or be rid of a hangover? ?Y No Hearing X?Normal Dlmpaired ! Hearing Aid OWtth Patient Deaf ?Rt 01-t ©Both "NWIt. Vision •-DNormal ?Eye/Reading Classes ?Contact Lenses ?Prosthesis CfWith Patient ?Blind Sueerh QKOrmal ?Difficult to Understand ?Language Barrier Ol-angua a Uscd: OUnable ID Speak (if above co(fideted by an LPN) Signature/Satus: 1, Are you currently in pain? OYes)ONo (If no go to question 7) 2. On a scale of 0-10 (vrit-i 0 being no pain sensation and 10 being the most intense pain imaginable) haw would you score your pain? 01 ?2 ?3 ?4 05 ?6 ?7 ?8 ?9 D10 3. When did the pain start? _ Location? _ 1004. 4. Describe your pain: Halt does it fee17 ?Dull OThrobbing DBuming ?Constant ?Intermittent Other: 5. Are you currently taking any medication for pain? ?Yes ?No if yes, list med"tirxis: ?See Med List 6. Is the pain medication affective? ?Yes ?No 7. Describe any previous or ongoing Instances of pain: 8. What methods of pain control have been helpful in the past:. - 9. What is your personal pain goal? Have you had a tetanus shot in the last 10 years? DYes O No Learning Needs: ?Yes 0No Special Diel/R!5 pionst5uppiement: 11 N/A Meals i! per Day Appetite: Zormal ?increased ?Decreased ODecreased Tasta Caps. ?Yes ONo Bonding: ?Yes ONO Dentures: ?None Upper ?Partial ?Full )alter ?Partial OFull ?With Patient Permanent Bridges ?Yes []No .. Yes to any of the following, obtain a nutrition consult. 01111111112xs=.3Tr.•,-: _ "• 1. Unintentional weight loss of 10 lbs. in last 8 months? DYes No 4. Is the patient at risk for not managing oral secretions ?Yes ?No 2. Does patitxit appear to be underweight? ?Yes No and/or swallowing difficulties? 3. Chewing or oral problems that make it difficult to eat? ?Yes No 5. Does the patient have a pressure sore? DYes LINo If # 4 Is Yes, or if required b the Interdisci linary Care Plan,cornplots the Swallowin Screen refer to th . Swallowing Evaluation St ker). - ? "'KI I'1+.:'.r:i .' .:i.3(Nh`•rw ''i t%:: ?:? '?k •' t.:i...4 w?.k. ??rl::. Bladder. Normal []Frequency []Urgency ODysuria ORetention ?Nocturia Incontinence ONIA []Total 0132y1ime ONlghttime DOcessional GU Assistive Devices: []None O Intermittent Catherterization Ostomy: Type _ Appliance _ Self Cara ClYes ENO Bowel: # of BMs/Day ^_ Date of lest BM Laxatives: UYes ?No Enemas: OYea ?No []Normal []Constipation E3Diarrhea []Incontinent []Pattern Change Bowe! Sounds [)Yes ONo KiT ? y '?i;r tip Y: K' , -+•.'f rl'it ?: :,i..r [:! • •, ,yr :.ar--.-- •s?? r:.?s r.:r.. '. 'nty.: ' . ,.. . ,i.:ki:'v'•.'? .:?•. ?.,«i+ a.±, r •';?:f^???i• _ If the fi'st box and any additional boxes are checked which interfered with Mobility or ADL's, please consult with Physician to request a Physical Therapy or Occupational Therapy Referral. PHYSICAL THERAPY -SCREEN OCCUPATIONAL THERAPY SGREEN ?OOB Attempted unless contraindicated with noted ? Self care attempted unless contraindicated with decrease in function as compared to functional level noted decrease in function as compared to"' prior to current illness functional level prior to illness,' ONew onset weekneWparalysis ONew onset weaknesslparelysis ONew onset balance/coordination deficits ?New alteration in cognativetvisual status k, quipment evaluation ? Need tot energy conservation techniques ON/A f-}Equ+pment Evakualron v:tiz: iar, ;r ?NIA _,. h fn `6F :F.=: "'r r`.'u: ..r'4'y§ •u..'; Problems: []insomnia ONightmares 00rihopnea OSteep Apnea []Pain []other. _ 's 'Y•' i:t•_ ? .}:•... ?W?'1=. ? G:.L; • _yi;:'. FEMALE: [] NIA Is there any chance that you might W pregnant? []Yes ?No If yes, contact primary care physician. Birth Control []Yes ?No Menstruation History: Date LMP: _ _ Last Mamrnogram: _ Monthly Seif Breat Exam; []Yes ?No Menopause OYes ONo Irregular BI ing []Yes ?No Vaginal Discharge OYas ?No Last Pap Smear: Do you have any concems? []Yes Pfio Specify: MALE /A Last Prostate Exam: PSA Test: DYes ONo Monthly Testicular Exam: QYes ?No Do you have any concerns? []Yes ?No Specify: Life Changes: ONone []Changes in Relationship []Job Changts []Financial 1]Traumatic Injury 0Death of Family/Significant Other []Birth of a Child CJMove What do you do to cope with stress or anger? What calms you in a stressful or angry situation? []Music 0Walking ?Talking/with whom? . []Other, Is there anything we can do to help you with any fears or concerns? []Yes ONo Specify Currently under the cane of a Mental Health Professional? []Yes O No Name: List Medications; []See medication List 4 Referral to Casa 'm Suspicion of Abuse or Neglect Immediate Referral io Case Management. Management Under age 18 immediate referral to UHSH Child Abuse Liaison []Yes ONo Includes Child or Adult Abuse Referral to Child Abuse Liaison []Yes [No 4 Mmi T= MIN If yes, automatic referral - ' 1. Do you currently receive home care services, or would you like to receive home care? ?Yeto Agency, if known: 2. Is the admission diagnosis respiratory in nature? []Yes p!'No j' 'F 3. Is the patient on oxygen or respiratory treatments at frame? 13Yes GKO lnr:•,: . •'k Contact person / Guardian - Relationship - Phone # ?t (( I ]f (\j.t5e \/ f 1 S - `r3 J? []Lives alone SupportSystem []Spouse / Significant Other Family in tfie same residence L]Neghbors J friends []Family not present []Family in the separate residence i]None OLives alone E3 Lives with: []Other. Information obtained from: OPatient []Other source: - Reliability: []Good []Poor []Non-communicative _ ?'r: - R,•..::``)" ;fir:' .?.. _ Patient / or Family Educated about the purpose and dangers of bedrails. ,411-lealth []Post Op []Disease process ?Wedications DWound Care [10ther: _. Special Needs I Barriers to Learning ?Readmess to learn assessed Anxiety present []Yes ?No Comment: Method the patient learns best (check all that apply) ? Explainatlon []Demonstration []Printed Material []Audio-Vistia. NOTE: Information from :his section must be entered on the teaching record. Comment - :ilrti,.:?.r. ... ... - . ' i•• .ti .. _ as 71 IN 011 Does the patient present with any of the fallowing: Non-compliance DYes PNo Syncope I per diagnosis []Yes ?No Confusion OYes No History of falls []Yes Q No f t' Weakness []Yes 10 No Inataility to use call bell []Yes dNo Decreased Mobility []Yes No Based on the above assessment is patient fail prone? []Yes ?No Qf<r Is patient at risk for bedrail entrapment? []Yes ?No _ ADDITIONAL COMMENTS -••n. ElPatient Valuables Inventory Form Completed SIGNATUREISTATUS: t DATE: TIME: t Wftx fI*aM Serafces United Health Services DERVISEVIC, ADELISA 500-624-6051 MR#: 4MI60 DOB: 01/27/2000 F 6Y ADM DATE: 09/24/2006 1 7:59 OOT rwn.n CC'RF.F.mNG CHECKLIST L IL The identification and reporting of suspected maltreatment of children under IS years of age is mandated by Child Abuse Liaison is available to assist with this process, as indicated by the following guidelines: If any of the following are present ? or suspected ©, the liaison MUST be called Date: 'l'ime: A1 O I Aasaul? by Pareat/Caregiver Sexual Abuse/Sexual Abuse Exam ,o'-- Child Ltvohtmcnt in Domestic Violence Significant Injury in Child < 1 year of age Such as: # Fracture ? Bum Ill. If a report of suspected maltreatment is No Injury without adequate explanation, or which is not con with the explanation, or which is in an unusual site Significant injury which may be the result of parenVcare action or lack of supervision, such as unwitnessed injury, • Burn Foll/Ncar Drowning Ingestion of toxic substance • Lick of bike helmet/seat belt _ Medical Neglect including: • Delay in seeking care that exacerbates patient's • Inadequately treated illness/injury- Refusal of treatment/AMAIAWOL that places 1 health at risk, includin : • Head Injury Laceration requiri High few . Respiratory, Risk of dehydration Fracture YES a. Hotline called Report Accepted b. PatrentIGuardian Notified e. Protective Custody Taken d. Law Enforcement Notified e. Information Obtained: • Photos • X-hays • Labs: Rape Kit GC IV The liaison may be called in the followia cases as needed: Child/Parent Fl'OWSubstance Abuse Lack of Resources for Basic Needs Mental Health Issues/Suicidc Developmental Delay Behavorial Issues Need for Parenting Education ?J Frequent ED visits (3or more injurics/ilinesscsin past 12 months requiring medical attention) E A &d,6 Date: Signature• Part I - Medical Record Copy part 2 - Hospital LislsoA copy 0(0 law. The sutures S12OW7 uff edh-aUh Sc,%`iaS United DE1%VISt:V1L;, ADELISA Health Services 500-624-6061 MR#: 4848160 Hospitals DOB: 04/27/2000 F 6Y AOKI DATE: 0912412006 17:59 oor IMMUNIZATION AND LEAD SCREENING for all children Uses than 18 years old SECTION I LEAD SCREENING FOR CHILDREN 8 MONTHS TO 6 YEARS Children are now TESTED at age one and age two and assessed at other intervals. Has parent/ ran been asked about ? Yes ? No possible exposure to lead or has a head No Further Action Indicated SEE ACTION INDICATED Level been drawn at primary caregiver's office? ACTION INDICATED: ".<1 Year or > 3 Years: Have parent review list of poferdial sources on reverse side of p arents copy. If parent answers M to any of the lead risk assessment questions, discuss with MD ther to test now or refer for testln g (use check boor below). If age 12 or 24 months: Blood testing for lead is indicated. Discuss with MD whether to l oarform test now or refer for testing (use deck box below). SECTION II IMMUNIZATION SCREENING Parent/Guardian presented proof of immunization. Reviewed with schedule on reverse side of form. ? Yes ? No Parent/Guardian unable to present written proof and ? states imnuritzation up-to-date and receives regular medical pre by Dr. is uncertain about immunization status. ? states child immune to by prior disease or serology. Emergency Departments, Dental Cllrgc, Medicsinter, Hemophiliac, Hospital Admissions ONLY: 1. Child is enrolled in school (pWic, g[ivata or IgIrcichiai) or a licensed day care center and parent/guardian ? Yes ? No ha&M been informed of any imrrwnization deficiencies. 2. Approximate age of last DPT/DT/Td. Date: _ If answer #1 is yes alid 2# was given within last ten years, STOP - Nurse and parent/guardian to sign bottom of form. NO FLIRTHER ACTION INDICATED. Continue to Section III only if answer is NQ. Primary Caro Centers: 1. Records have been received from previous health care provider or hospital newborn record. [] Yes ? No 2. Immunization status reviewed and no deficiencies identified. ? Yes ? No If immunization(s) administered or deferred due to contraindication at this visit, docurnent in Progress Note. Nurse and parenVguardian to sign bottom of form. SECTION III Based on tnfbrmatlon presented and following the recommended sChedulp printed on reverse pa tient sidle of form, the folkyMng actlons are Indicated: Check A, B, or C. ? A. Unable to determine immunization status. REFERRED. ? B. Immunizations are up-to-date; appropriate for age. NO REFERRAL INDICATED. ? C. Child nacds the following immunizations: (CIRCLE) DT,P - MMR - IPV - HIB - Td - Hep 8 - aricella ? The following deficient immunizations were administered at UHSH. Vaccine Given: Manufacturer: Lot Number. Expiration Date: Signature of HCw giving vaccine: Title of HCW: ? Deficient immunizations NOT ADMINISTERED. REFERRED (See below) REASON NOT ADMINISTERED: ? Medical Contraindication, per MD order. ? Religious beliefs ? Parental Refusal ? Referral to appropriate County Health Department ? Referred to private physician. ? Brooome (607) 7713.2862 0 Tioga (607) 687-86M Dr. 171 Chenango (607) 33546(6 ? Other (Specify County & Phone No.) Par?errt/guard;en. please Call for time, date and location of ciinics. Phone No. ? Needs immunizations as above. ? Needs lead exposure assessment or testing. ? Load screening DRAWN. Nelda 1101low up. Nurse's Signature: Date: Parent/Guardian Signature: Parents: Plan" read the beck of your copy of [lots form. '" United Health Services Hospitals DERVISEVIC, ADELISA 500-624-6051 MR#: 4848160 DOS: 01 /27/2000 ADM DATE: ? 6Y OOT 09/24/2006 17:59 PRIORITY ED Admissious: Bed Request/Report Sheet Admit to Cardiac Monitor Y N Admit Service i?r. "Covered Ye •Isolatioa?:. Yes T Special/Culturid/Spirltual Needs:: Yes N P nt Roing directly to 'at6 Lab: / No td Y / No- Reason for admission/diagnosis: QrderRRevicv? es Assigned bed I,imc Advance Directives: Yes / Alleriv: _ Yes o? Vital Suns: lid f•emp -- 11R / 17 RESP 2-0 02 r1 q /D limin Sat Me$icsl HistoryiSurgicai History: r, C r_? . /tom r n Vci r1 / h i>?[.r-!? I /b+ rn V,(- . LA M Q r •e r ? X S? S -? ? ?j 117 -A S, d:g . Neuro: ..? Altered Mental Status NOTES: 0 („! r r / ?'I -C•r ?.?0? Lung Sounds: _ NOTES- e?( 6A, Cardiac Monitor: Rhythm (ifknown): NOTES: FKG: Yes Bowel Sounds: 51 d4re Nauu a/vomiting: - (! - NOTES: GU: Foley: Yes / n Void: Yes / No amt Intake: PO TVA Blcx><1 NOTES: Meds in ER ..Abnormal/Pending Pain Assessment Consults Notified Lawrests Site 1) Y N Uesc. Scale (0-10) 3) Y , N 1•r ern Supplemental 0-2 via 59013:3RHot rep 03.02.Ub - UNITED HEALTH SERVICES HOSPITALS WILSON MEMORIAL REGIONAL MEDICAL CENTER IMAGING SERVICES REPORT RADIOL OGY ? CURR LOC: ST4-B446A ORD NO: 90002 NAME: DERVISEVIC, ADELISA REQST LOC: EMD PT CLASS: E MR#: 4848160 INFO. AT TIME DERVISEVIC, ADELISA DOB: 01/27/2000 AGE: 6Y FC S OF THE EXAM DOB 01/27/2000 MR# 4848160 ADM# 5006246051 ORDERING: ATTENDING: STEPHEN W- MEZ MD PHYSICIAN 000000 UNLISTED WMHER 33-57 HARRISON ST JOHNSON CITY, NY 13790 13790 COPIED: PROCEDURE: PELVIS X-RAY. AP VIEW ORD#:900 2 EXAM DATE: 09/24/200619:21 47832, 13 -REPORT: CLINICAL INDICATION: Trauma. AP view of the pelvis is performed. The right hip is held in frog-leg position. T here is a note from the technologist that there are multiple foreign bodies on the st etcher. Correlation is recommended. At this point, there are multiple radiod nsities overlying the left lower abdomen and pelvis, left upper thigh medially and th medial aspect of the right thigh-buttock. These range in size between roughly 4 m and 7.5 mm. Correlation with the film is recommended. It may be that the pat ient will ?. need to be radiographed off of this particular stretcher and with clothing re oved to assure that these foreign bodies are not within the soft tissues. The bony structures appear intact. Epiphyseal plates are not widened. No I fracture or dislocation is seen. -IMPRESSION: There is no acute bony injury identified. Note should be made that subtle actures -- particularly involving the acetabular regions may be radiographically oc alt, and therefore, if patient has persistent symptomatology, then further imaging wi h either CT or MRI could be considered. Potential foreign bodies as described abov . PROCEDURE: RIGHT TIBIA. FIBULA, X-RAY ORD#: EXAM DATE: 09/2412006 19:53 ACC#: 47 -REPORT: CLINICAL INDICATION: Open fracture. AP and lateral views of the right tibia-fibula are obtained. There is an fracture involving the distal right tibial metaphysis. There is also component involving the metaphysis and extending into the distal diaphysi is widening of the epiphyseal plate both laterally and anteriorly, likely a injury. There is likely a developmental variant or fracture relating to the ... ............. DATE OF DICTATION: 09/2412006 19:30 READING RADIOLOGIST: ANDREA DATE OF TRANSCRIPTION: 09/26/2006 16:21 ELECTRONICALLY SIGNED BY: ANDREA TRANSCRIPTIONIST: LJL SIGNED ON: 09r Cortlident -iityTladce: Truin7i?rmation in tfi?s-cncuiiient>?az ir,ay wave been die`s {o you Trom nor with corir?Irality otec%d"6y ra and s regulations erxt stars ta?vt prohibit you from making further disclowre o1 surh information withpit the specific wnnem conser?t of Uio pw!rsan to whom Use infC or as otherwise permitxxl ty such repulalions. A general euUrxization for Ute n krass of medical or other information is NOT auffident for thr, purpose: if t information i? not the Mended rocipirett you ere he re y notified that any use, diseeminatia?, diatributio? or reproctuction'Of this lntormation is SUidly Wohbtec this 1nfnrmatlon in error, please Immediately notify us et 607-76361t}4 and return this documenUlnx to United HeaIU? Servkes. Radiology Departrt+ent 1 Repionel Medical Csnler. 33-57_Harrison S? Johnson City._NY 13790 ?ia.U.S,_POStaI Servic?e_ Thank (ou; __.___. Printed 7 Sep 26 2006 4:40PM ngulated vertical There Salter 1 ip of the ROTHE MD ROTHE MD 8/200616:40 ter of this rewived Memorial Page 1 of 2 i w UNITED HEALTH SERVICES HOSPITALS WILSON MEMORIAL REGIONAL MEDICAL CENTER IMAGING SERVICES REPORT CURR LOC: ST4-8446A ORD NO: 90002 NAME: DERVISEVIC, ADELISA REOST LOC: EMD PT CLASS: E M R#: 4848160 INFO. AT TIME DERVISEVIC, ADELISA DOB: 01127/2000 AGE: 6Y OF THE EXAM DOB 01/27/2000 MR# 4848160 ADM# 5006246051 rC S ORDERING: ATTENDING: STEPHEN GOMEZ MD PHYSICIAN 000 000 UNLISTED WMHER 33-57 HARRISON ST JOHNSON CITY, NY 13790 13790 COPIED: medial malleolus. This is nondisplaced. There is a similar angulated f acture involving the distal fibular diaphysis. The epiphyseal plate is widened and perhaps slightly displaced involving the distal fibula, and I believe this is a mildly di placed Salter 1 type of fracture. There is soft tissue swelling over both malle li and involving the distal leg. There is gas within the soft tissues. -IMPRESSION: Open fracture of the leg with fractures of the distal tibia and fibula with mild angulation. In addition, there are Salter 1 fractures of the distal tibia and fib la with the one involving the fibula slightly displaced as well. READING RADIOLOGIST: ANDREA ROTHE MD ORDERED BY: STEPHEN GOMEZ MD TRANSCRIBED: by LJL on 09126/2006 16:21 DATE OF DICTATION: 0912412006 19:30 DATE OF TRANSCRIPTION: 09/26!2006 16:21 TRANSCRIPTIONIST: LJL Y`-,o'riii?n?£i"alfty`Tlo?we?-!fie iriformaiion in tfiig'dacu++x:nL'f?i;i i reguiations rind state laws prohibit you from making further di or as othanrise pen+el!ed by such r. julations. A general atdl information is not the Intended redpitirt, you are hereby notifi this information in error, please immediately notify us at GG Regional Medical_Center433-57 Harrison St. duhn*s'm QVI. N) Printed : Sep 26 2D)6 4:40PMi ELECTRONIC SIGNATURE: ANDREA ROTHE MD ADM# 5006246051 READING RADIOLOGIST: ELECTRONICALLY SIGNED BY: SIGNED ON: j Iieve-seen diadosedTo-y- u f wl mw - s w+ confider ?s++re of such intarnaiion without the specific written coon Lution for the release of medical or other information Is IN or to n'to whom r this purpt K iYiC1tV D'. ROTHE MD ROTHE MD 512006 16:40 Services, Radiology Department, ilsbn Niernorlal Page 2 of 2 UnitedHeal i Services United Health Services Hospitals i Patient Name: Dervisevic, Adellsa Patient ID: 4848160 Date of Birth: 01-27-2000 Age: 6 years s Gender: Female Accession Number: 4783243 Location: WMH RAD Referring Physician: Stephen Gomez Md Study Date: 09-24-200618:50 Procedire Types: PELVIS X-RAY, AP VIEW Report In Progress Blank Farm Multiple i ddiodensities on skin surface-L Ad, L pelvis, both thighs. Tech note says these are on stretcher. I cannot r/o fb. May need to re x-ray off stretcher. No fx. Pely' esp acetabular fxs may he difficult to viz on plain film so if needed additional iglaging should be obtained. l Rothe 11 09-24-200618:32 Page 1 of 1 Un tedHealth Services United Health Services Hosp Patient Name: Dervisevic, Adelisa Patient ID: 4848160 Date of Birth: 01-27-2000 Ago: 6 years ti Gender: Female Accession Number: 4783244 Location: WMH RAD Referring Physician: Stephen Gomez Md Study pate: 09-24-2006 19:07 Procedure Types: TIBIA, FIBULA, X-RAY RIGHT Reporf In Progress Rad MD: Xray Lower Extremity Preliminary- Report - Abnormal Preliminary Report: OPEN FX DISTAL LEG Ant_=ulated fxs distal tibia and fibula, Salter 2 Ix with widened e i hyseal plates distal !ibis fibula and di5 lacenwnt mild! of fibula epiph Plate,GAS and STS Andrea Rothe 09-24-2006 20:10 Page 1 of 1 UNITED HEALTH SERVICES HOSPITALS WILSON MEMORIAL REGIONAL MEDICAL CENTER IMAGING SERVICES REPORT _...._._..... ..... _._.._.__......._.._._._..... ------- 09/24/2006 20:05 READING RADIOLOGIST: 09/251200611:00 ELECTRONICALLY SIGNED BY: KMC SIGNED ON. on in docurrient?faz may have been discbeed do joulrom in>o`ords with chi CURR L DC: ST4-B446A/ ORD NO: 90004 NAME: DERVISEVIC, ADELISA REGIST OC: EMD PT CLASS: E MR#: 4B48160 INFO. AT IME DERVISEVIC, ADELI$A DOB: 01/27/2000 AGE: 6Y OF THE M DOB 01/2712000 MR# 4848160 ADM# 5006246051 FC S ORDERIN : ATTENDING: STEPHEN GOMEZ MD PHYSICIAN 000000 UNLISTED WMHER 3 57 HARRISON ST .IOHNSO CITY, NY 13790 13790 COPIED: PROCE URE: -SPINE, CERVICAL COMPLETE, X-RAY EXAM ATE: 09124/200619:52 REPORT: CLINICAL INDICATIONS: Trauma. RADIO ACC#: Seven views of the cervical spine were obtained including multiple crosst views with and without collar. There is no fracture, dislocation, prove tissue swelling or neural foraminal narrowing. The disk spaces are inti appears to be straightening which may reflect spasm. -IMPRESSION: No acute bony injury. The initial crosstable lateral view was also reviewed .? Petro from neuroradiology. READING RADIOLOGIST: ELECTRONIC SIGNATURE: ANDR ROTHE MD ANDREA ROTHE MD ORDERED BY: STEPHEN GOMEZ MD ADM# 5006246051 TRANS RIBED: by KMC on 09/2512006 11:00 DATE OF CTATION: .?. DATE OF RANSCRIP TRANSCRIPTIONIST: regulations state laws prohibit y nr as n e permitted by such n information twt the intended red this into In error. please iml .110 a qpn@i it al Ccntof? 33.57 Fitm Printed : p 26 2006 9:20AM lateral ral soft There with Dr. ANDREA OTHE MD ANDREA OTHE MD 09a 006 09:20 ou from making further distlosurd of sums utfuntwtion wiUhoul the specific written careen! of the person"tq whnm the in anon {kfrt2in6 Vtrations. A general authorisation for the release of medical or offer Information Is NOT s?pufDdent for this purpose. 'If reader of this ent, you aru heroby notified that oily uso, dissemighon, distritxrtinn rr rnprnrtuction of this irlforrrtetion i6 6friGtly pn?th?fed. f received nediaiely notify us at 607-763-6104 and realm thin doctxrter?tffax to lktited Health Services, Radiology Department. W Lvov Wworwl ?i5pn St?,iphnsnn City, NY t37tit3 via U.S: Pnatal Service. Thank You. Page 1 of 1 Unite-eal.tll dServices Patient Name: Dervisevic, Adelisa Patient ID: 4848160 United Health Services Hospitals Date of Birth: 01-27-2000 Age: 6 years Gender: Female Accession Number: 4783247 Location: WMH RAD Referring Physician: Stephen Gomez Md Ludy Date: 09-24-2006 18:33 Procedure Types: SPINE, CERVICAL COMPLETE, X-RAY epod In Progress ad MD: Xray Cervical Spine Preliminary Report - Normal eliminary Report: No Fracture or dislocation of the cervical spiiie secn. l ndrea Rothe 09-24-2006 20:07 Page 1 of 1 UNITED HEALTH SERVICES HOSPITALS WILSON MEMORIAL REGIONAL MEDICAL CENTER IMAGING SERVICES REPORT CURRI REQST INFO. AT OF THE E STEPHEN WMHER 3, JOHNSON COPIED: PROC EXAM ST4-8446A ORD NO. 90003 NAME: DERVISEVIC, ADELISA EMD PT CLASS: E M R#: 4848160 DERVISEVIC, ADELISA DOB: 01/27/2000 AGE: 6Y DOE! 01/2712000 MR#4849160 ADM# 5006246051 FC S ATTENDING: 1MEZ ?AD PHYSICIAN 000000 UNLISTED HARMSON ST Y, NY 13790 13790 IRE: CHEST, 1 VIEW X-RAY TE: 09/2412006 19:55 CLINICAL INDICATION: Trauma. ACC#: 4 Supine AP chest radiograph demonstrates a normal cardiac size and media Lungs clear. No effusion or pneumothorax. -IM ON: No active disease. READING RADIOLOGIST: ANDREA OTHE MD ORDERS BY: STEPHEN GOMEZ MD TRANSCRIBED: by BED on 09/25/2006 11:03 t I ..? DATE OF DATE OF aTION: 09/24=06 20:11 SCRIPTION: 09/25/200619.03 ?NIST: BEL irdbrmatinn is the Intended radpientt,, you are herelr this Intortnetlon error, ph-me immediately notify us Regional tAedir t ent57 htarrison S; Jo4lnsan C Printed : Sep 6 2006 9:20AM ELECTRONIC SIGNATURE: ANDREA ROTHE MD ADM# 5006246051 READING RADIOLOGIST: ELECTRONICALLY SIGNED BY: SIGNED ON: 4n d - yvu om recordri iMifi-c`aNidenf"rd?Cy prateclr?fty'I a of such information without the spercitic written conrsrirtt of tl7e person t0 n for re releaso of medical or other irtfomtotion fe NOT Suitt opt for thi any use, dissemination, distribution or rgxodvaon of this infummow is s1 ti?4 and return thib docurrte»tifax to Uited Hualth Services, Radiology via U.S?P9StaI S?lry?ce.,_..Thank Yc r um. ANDREA R9 THE MD ANDREA Ro HE MD 09/26/2 6 09:20 a alit slate f tai im the informati pertains 9M. if the r of this pmhibik..-d.If recehred arttnent, Wilson Memorial Pale 1 of 1 UnitedHealth Semices United Health Services Patient Name: Dervisevic, Adelisa Patient I D: 4848160 Date of Birth: 01-27-2000 Age: 6 years Gender: Female Accession Number: 4783245 LocatiUn: WMH RAD Referring Physician: Stephen Gomez Md Study Date: 09-24-200$ 19:12 Procedure Types: CHEST, 1 VIEW X-RAY Report In Progress Rad MD: Xray Chest Preliminary Report - Normal Preliminary Report: No evidence of active cardiopulmonary disease. l ?R Andrea Rothe 09-24-2006 20:1 Page 1 of UNITED HEALTH SERVICES HOSPITALS Johnson City, NY REPORT OF CONSULTATION NAME: DERVISEVIC, ADELISA MEDICAL RECORD #: 48 160 DATE OF BIRTH: 01/27/2000 LOCATION: ST4 46A/ 0925 DATE OF ADMISSION: 09/24/2006 RMS ADM #: 50062A6051 DATE OF CONSULTATION: 09/24/2006 CONSULTING PHYSICIAN: James Kanellakos, MD DIAGNOSIS: Grade 2 compound fracture right distal tibia and fibula. HISTORY OF PRESENT ILLNESS: This six-year-old was involved in a motor vehicle accident earlier this evening. She was in a van and the van had a problem with a tire. The tire blew out and the van lost control and went into a ditch. Several other people were hurt in the accident. This patient sustained a laceration of the distal tibia and fibula, along with a Salter Harris type 2 fracture of the distal tibia and a greenstick fracture of the distal fib ula. X-rays revealed varus angulation of the fracture site. Neurologic and vascular examin ations of the right lower extremity remained intact. The patient sustained no other injuries. Tr uma workup was completed by the trauma service. C-spine, chest, and pelvis were all cle red. The patient did not lose consciousness. PAST MEDICAL HISTORY: Unremarkable. PAST SURGICAL HISTORY: Unremarkable. ALLERGIES.- NO KNOWN DRUG ALLERGIES. MEDICATIONS: None known on a regular basis. The patient was given tetanus prophylaxis and IV antibiotics in the Emergency De She received IV Ancef. FAMILY HISTORY: Not obtainable secondary to language barrier. SOCIAL. HISTORY: She is a student and lives with her mother and father. REVIEW OF SYSTEMS: Otherwise negative. Page 1 of 2 t UNITED HEALTH SERVICES HOSPITALS Johnson City, NY REPORT OF CONSULTATION E: DERVISEVIC, ADELISA MEDICAL RECORD #: (SICAL EXAMINATION: I Signs: Stable. d and Neck: No tenderness, no lacerations. C-spine examination, no tendemess nal range of motion. piratory: Bilateral equal air entry. diac: Normal heart sounds. omen: Soft. No organomegaly. usculoskeletal: Upper extremities normal. Lower extremities - Deformity of the right pia and fibula with laceration 3-4 inches over the distal medial leg. Bone is exposed aurological and vascular examination of the right foot was intact. Neurologic examir all other extremities normal. Vascular examination of all extremities normal. Skin ;amination grossly normal. Thoracic and lumbar spine examinations normal with nc nderness. IOGRAPHIC DATA: X-ray reveal Salter Harris type 2 fracture of distal right tibia nstick fracture right distal fibula. ASSESSMENT AND PLAN: A six-year-old with grade 2 compound fracture right dish and fibula. The patient will require irrigation and debridement, closed reduction of thf acture, possible percutaneous pinning of the tibial fracture. Risks, benefits, and Iternatives were explained to the family including the patient's father and mother thrc n interpreter. Major risks of this injury include infection, bleeding, nerve injury, vase i jury, malunion, growth disturbance, and anesthetic risk. Consent was obtained for rocedure. The patient will be taken to the OR emergently for irrigation, debridemen' duction, and possible percutaneous pinning of the fractured tibia. by JAMES KANELLAKOS MD AE 2252 0853 60 istal a tibia gh open Page 2 of 2 UNITED HEALTH SERVICES HOSPITALS Johnson City, NY REPORT OF CONSULTATION NAME: DERVISEVIC, ADELISA MEDICAL RECORD #: 48, 3'160 DATE OF BIRTH: 01/27/2000 LOCATION: ST4 B "6A 0926 DATE OF ADMISSION: 09/24/2006 RMS ADM #: 50062 051 DATE OF CONSULTATION: 0912512006 CONSULTING PHYSICIAN: Michael Aronis, MD HISTORY: Patient is a 6-year-old female involved in a motor vehicle accident with multiple family members involved in a van that was struck from behind. Several other passen ers were injured. This child presented on a long board with a C spine collar in place. She was complain ng mainly of leg pain. PAST MEDICAL HISTORY: She has no major medical problems according to her fat er. PAST SURGICAL HISTORY: No previous surgery. PHYSICAL EXAMINATION: Pleasant, cooperative 6-year-old female, complaining of pain but otherwise she is very calm and cooperative. Head, Eyes, Ears, Nose and Throat: On exam her facial bones are benign to palpatio . Her scalp is benign. No evidence of laceration or ecchymosis. Her extraocular motoo intact. Pupils equal, round, reactive to light. Her nares are negative for blood. Her oral mucosa is benign. Tympanic membranes are benign. Neck: Supple. Normal range of motion. No bony abnormalities. Trachea is midline. subcutaneous air. Clavicles are benign. Shoulders are benign. Lungs: Clear bilaterally. Negative for rates or rhonchi. Bony thorax: Benign. Sternum: Benign. Cardiac: Regular rate and rhythm. Abdomen: Soft, positive bowel sounds, nontender. are No Page 1 of 2 UNITED HEALTH SERVICES HOSPITALS Johnson City, NY REPORT OF CONSULTATION NAME: DERVISEVIC, ADELISA MEDICAL RECORD #: 484$160 POvis: Nontender. H r upper legs are benign to the knee on both sides, her left leg is benign to the ankle ar f t. Right leg has no obvious bruising. Overlying distal foot where there is a wound consistent with an open fracture. She has intact distal pulses and neurovascularly she is in act in the foot. ys demonstrate a tiblfib fracture at the ankle. ,.+ est x-ray and pelvic x-ray showed no acute disease. PRESSION: 6-year-old female involved in a motor vehicle accident with a right leg c cture requiring surgical intervention. She is cleared from a general surgical standpoi 3ceed with the surgical procure. I will follow the patient with you postoperatively. by MICHAEL ARONIS M 512006 0036 6/2006 1219 ae t Page 2 of 2 UNITED HEALTH SERVICES HOSPITALS Johnson City, NY REPORT OF OPERATION NAME: DERViSEVIC, ADELISA MEDICAL RECORD #: 4848160 DATE OF BIRTH: 01/27/2000 LOCATION: ST4 446A 0825 DATE OF OPERATION: 09/25/2006 RMS ADM #: 50062-6051 SURGEON: James Kaneliakos, MD ASSISTANT: PREOPERATIVE DIAGNOSIS: 1. Grade II compound fracture of right distal tibia and fibula. 2. Salter Harris type Il fracture of distal tibia. ANESTHESIA: General anesthesia. INDICATIONS: This 6-year-old was involved in a car accident earlier today sustaining a grade II compound fracture of the right distal tibia and fibula. Neurologic and vascular examination of the right foot were intact preoperatively. The major risks, alternatives nd benefits of surgery were discussed with the patient's father and mother. Consent was obtained. Major risks include but are not limited to infection, bleeding, nerve injury, vascular injury, malunion, nonunion, growth disturbance, anesthetic risks. The patient was brought to the OR in stable condition. She was cleared from a trauma perspective of any other injuries. OPERATIVE PROCEDURE: Under general anesthesia the patient was placed in supi e position. A tourniquet was applied to the right thigh. The right leg, ankle and foot wer prepped and draped in the usual fashion. There was a large circumferential compound area over the anterior medial aspect of the distal tibia. This measured approximately least 7 cm in length. There was no significant contamination and/or debris. The woun edges were sharply d6brided with a #15 scalpel blade and then 3 liters normal Saline nd polymyxin antibiotic were irrigated thoroughly into the wound, irrigating the soft tissues, adipose tissue. Following this the image intensifier was used, the fracture was imaged. There was a S Harris type 11 fracture of the distal tibia and a mildly displaced fracture of the distal fibula which appeared to be a Salter Harris type II as well. Closed reduction was applied to tl distal tibia and fibula fracture, adequate reduction was visualized in the AP and lateral planes with the image intensifier. Pagel o1`2 UNITED HEALTH SERVICES HOSPITALS Johnson City, NY REPORT OF OPERATION E: DERVISEVIC, ADELISA MEDICAL RECORD #: 160 '3iven the compound nature of this injury I elected to place two 2.0 Steinman pins int the ietaphyseal fragment of the Salter Harris type 11 fracture of distal tibia to secure the -acture to allow for dressing changes and splint changes and wound assessment in the iture. Thus, two Steinman pins, 2.0, were placed, one anterolaterally to posterior medially nd the second anteromedially to posterior laterally. Pin position was checked, this d d not iolate the growth plate. ollowing this the distal tibia and fibula were revisualized using the image intensifier, actures remained well reduced and the pins were in good position. The wound was then ioroughly irrigated once more. Subcutaneous layer was closed with #2-0 Vicryl sutures, Kin was closed loosely with #3 nylon sutures. A Penrose drain was placed anterom dially a allow for drainage of any fluids. Bacitracin Gel, Adaptic gauze applied to?11 incisio s and ie two pins. Gauze dressing was then applied along with sterile e 1 A posterior berglass padded splint was applied. The ankle joint, distal tibia and fibula were rei aged nce the splint had set and the fractures remained well reduced and stable. The pati ant >lerated the procedure well and went to the Recovery Room in stable condition. Sh woke with intact neurologic and vascular examination of the right foot. LAN: This patient will require IV antibiotics for at least 48 hours, then be switched t p.o. ntibiotics. She was given IV Ancef 1 gm prior to the procedure and in the Emergency epartment received tetanus prophylaxis and IV antibiotics. She will have the Penrose rain removed in 48 hours and the wound reassessed. ictated by JAMES KANELLAKOS MD PM 512006 0154 5/2006 1402 Page 2 of 2 I, A a I, c ?dNeaIt't Sertrict:? ?c. t ? 41 V ANESTHESIA RECORD ????nnno? MAvoT O p z Am m (n * u s Q H 71 r ?? A i r n a r o z D rn Y Fil .mf vm m2 ((j? =, u ?. ; ¢ en rt? 01 h y i :t1 ? ?J y •-1 3' mn a 4 C , Z c L t . v t, m r 't[w n 'jo- r b :x Z ?Er ` A T27? Y T T r n ? i lP u <> s ? ? Al ? j ? m ? s _ ??` .-. tiC s a a 4tl \ i 3 m r m ? r u+' r ? Y o y ? n ? y T _ 3 ,; cry ;nn ?? A ?`Q .. `+\??1 Z 0?VOIO A film-if r 4 33 p n ?uuU??Q? k r '? a iy y Q J. n m 47 () m ` y z rm O D r' 2 ?. 1 i m { 2 ? m m s a m i ° i gxi 1 M 13 04 C T 1 D> 'rt C ell 2 m mn m rn `Pp > > y O t id z rn o Y r ? K O x m ' 0 x 2 mm - f y ?UU?;IQ?o? T,n U?1D? lO Cn b0pgm y a? v n Grp 3 y(y>• O ,yp rT Ian ? ??r ?? T N u ? p 8 I ?OOC?? m v a Y m H fJ1 ? C = 1 m J ? u, D Z V ?Ti ?? ? { L C m 4 2 ? I I I ? I ? ! w _ m m 3 3. . 13 ' NAMk PLATE _4 r ST b i `i.? PA 17?i t UNITED HEALTH SERVICES HOSPITALS WILSON MEMORIAL REGIONAL MEDICAL CENTER IMAGING SERVICES REPORT CURRI REQST INFO. AT OF THE I ORDERIP JAMES N 65 PENN! BINGHAA COPIED: PROC EXAM RADIOLOGY ST4-B446A' ORD NO: 90005 NAME: DERVISEVIC, ADELISA C: BED PT CLASS: E MRM 4$48160 DERVISEVIC, ADELISA DOB: 01127/2000 AGE: 6Y I DOB 01/2712000 MR# 4848160 ADM# 6006246051 FC S ATTENDING, LLAKOS MD JAMES KANELLAKOS MD 'ANIA AVE 65 PENNSLYVANIA AVE I, NY 13903 BINGHAMTON, NY 13903 LURE: RIGHT TIBIA. FIBULA, X-RAY ORD#: ATE: 09/25/2006 02:02 ACC#: 47 r: Examination of the right tibia done in OR shows satisfactory reduction of the distal tibia and fixation with two pins. Epiphysis are open. Ankle mot maintained. READIN RADIOLOGIST: CHANG S NATARAJAN MD ORDERED BY: JAMES KANELLAKOS MD TRANSCRIBED: by KMC on 09126//2006 06:39 DATE OF D CTATION: 09/251200612:32 - DATE OF SCRIPTION: 09/26/2006 06:39 TRAN$CRI TIONIST: KMC C`on-C5-m floifce: The infrirrnatTan in "tfiTs aoGUmentR regulations a slate Laws Prohibit you from making furthl or as odxvW permitted by such regulations. A garwral Information is of the intended rec- Sd l you are he?eby ne this rrrforma Re.Qior?al l &d n in error, ppl%se Ift nediately notify us at cal Cenfer.. 61 F4?rrison. 1 ..Jutrnson Cily Printed : S 26 2006 9:24AM We of is well ELECTRONIC SIGNATURE: CHANGA S NATARAJAN MD ADM# 5006246051 REACHING RADIOLOGIST: ELECTRONICALLY SIGNED BY: SIGNED ON: L-I *$closed to you Puri reCOfda with ctinfile-ndiiii rch information without the spofic writlert consent the release of medical Or other information is NOT e, dlssaminatlnn, distritnition or reproductitxt of this aid rutum this docranentrtax to United Health Sere CMANGA S NAT CHANGA S NAT. son to whom for 6" PUqX n io4isstrlcty p OePE+r l JAN MD JAN MD 16 09:23 i.-recfiiff i Pertains ter of tftis rerAived Memorial a1of 1 UNITED HEALTH SERVICES HOSPITALS Johnson City, NY DISCHARGE SUMMARY NAME: DERVISEVIC, ADELISA MEDICAL RECORD #: DATE OF BIRTH: 01/27/2000 DATE OF ADMISSION: 09/24/2006 DATE OF DISCHARGE: 09/27/2006 ADMISSION DIAGNOSES: 1. Grade II compound fracture of right distal tibia and fibula. 2. Satter-Harris type II fracture of distal tibia. r- DISCHARGE DIAGNOSES: 1. Grade II compound fracture of right distal tibia and fibula. 2. Salter-Harris type II fracture of distal tibia. RMS ADM #: PROCEDURE: Incision and debridement of compound fracture of right tibia and fibs closed reduction, and percutaneous pinning of right distal tibia fracture with Penrose placement done by Dr. Kannellakos on 9/25106. HOSPITAL COURSE:. This is a 6-year-old female who was involved in a motor veh accident with multiple family members. They were driving in a van that was struck fi behind. Several other passengers were injured including the patient's grandmother died in the accident. The child was brought to Wilson Hospital for evaluation and tr( on a long board with c-spine collar in place. She was complaining mainly of right loi extremity pain. She underwent a number of diagnostic imaging studies. 160 TION: 1002 46051 la, m Pelvis x-ray revealed no acute-bony injury. Right tibia and fibula x-ray revealed open fracture of the leg with fractures of the distal tibia and fibula, with mild angulation. In addition, there were Salter I fractures of the distal tibia and fibula with one involving the fibula slightly displaced as well. Cervical spine x-ray revealed no acute bony injury. hest x-ray revealed no active disease. Right tibia and fibula x-ray done at the operating r m showed satisfactory reduction of fracture of the distal tibia and fixation with two pins, epiphysis open, ankle mortise well maintained. The patient was initially admitted to trauma and Dr. Kannellakos of orthopedic services Was consulted. The case was discussed with the patient's. family, and parents, and she underwent the above procedure as elected by her parents. The patient tolerated her procedure well, was transferred in stable condition to the recovery room and then tot e regular floor. She received intravenous Kefzol for infection prophylaxis up until the d 4X of discharge and now she is going to stay on Keflex p.o. for another seven days for infe tion prophylaxis. Her distal neurovascular status was intact except there was numbness i Page 1 of 2 UNITED HEALTH SERVICES HOSPITALS Johnson City, NY DISCHARGE SUMMARY NAME: DERVISEVIC, ADELISA MEDICAL RECORD #: 4 48160 second, third, and fourth digits in the right lower extremity. There was minimal edem in all digits and the patient was able to mobilize all of her toes. Capillary refill was less tha'I five seconds. Pain was under control with oral analgesics by the time of discharge. The patient did have physical and occupational therapy sessions and is able to ambulate with cr tches and contact guard. DIET: Regular with yogurt and cranberry juice daily while on antibiotics. ACTIVITIES: No weightbearing on right lower extremity. Elevate right lower extremity as much as possible when not ambulating. Notify orthopedic doctor if any neurovascul r changes, change of skin color, fever or chills, increased pain, inability to move right lower extremity, or any other problems. DISCHARGE MEDICATIONS: 1. Keflex 500 mg p.o. t.i.d. times one week. 2. Tylenol with codeine elixir 5 ml q.4.h. p.o. p.r.n. pain. FOLLOW-UP: Follow-up with Dr. Kannellakos today for Penrose removal and cast application, and follow-up with Dr. Belvedere in Pennsylvania home town for further are orthopedically in one week from the day of discharge. The patient will be provided w th x- ray films of right lower extremity and other x-rays done during this admission at discharge. CONDITION ON DISCHARGE: Stable. DISPOSITION, Home. Dictated by TATYANA BOYKO FNP gp?rcr r- v AHB l D09/2712006 1159 f T10J0212006 1116 cc: James Kannellakos, MD Dr. Belvedere, phone # (717) 243-1515 Page 2 of 2 i.ted c)00 0h2 460S1 alth Services 4 P 4 spita.ls 0( 1:V I S r V IC , A1)FL I SA :)1127/2000 F 01/24/06 .:: E-ANESTHESIA EVALUATION NOTE ' 4 f" t" 0 s T Pr posed Surgery L ' ;--?T- 6 S !, 7 o z 1 1 ? l PA RT I f BE COMPLETED BY PATIENT OR NURSE) 1. Have you ever had surgery before? ? YES ? NO If yes, please list type of surgery: 2. Do you know what type of anesthesia you received? ? General ? Spinal ? Were there any problems with the anesthesia? If yes, please specify: 3. Has any dose relative ever had a problem with anesthesia? ? YES ? NO If yes, please specify: 4. Have you ever had an allergy or bad reaction to a drug? ? YES ? NO it yes, list drug and reactions: 5. Have you ever had any major illness or problems with your heart, lunge, liver, kidneys or nervous system? ? YES ? NO If yes, please specify: 8. Have you taken any medications within the past two weeks? ? YES ? NO f yes, what drugs? 7. ave you ever had diabetes, high blood pressure, yellow jaundioe, epatitis, or any major injuries? ? YES ? NO f yes, please specify: 8. re there any other medical problems or illnesses? ? YES ? NO f yes, please specify: 9. o you smoke now or have you smoked in the past? ? YES ? NO How much? How many years? When did you stop? 10, love you ever had a blood transfusion? ? YES ? NO I yes, wten? 11. 1? you have contact lenses? ? YES ? NO 12. 1 lo you have any loose teeth, caps, bridges, braces, dentures r any other prosthesis?. ? YES ? NO I yes, please specify: 13. ave you ever had any bleeding problems? ? YES ? NO I UN ERSTAND THAT DURING THE COURSE OF ANESTHESIA CAPS, CROWNS OR TEETH MAY BE D GED, AND THAT THIS DAMAGE IS NOT COVERED BY ANY TYPE OF INSURANCE. INITIAL: YOU 61UST NOT EAT OR DRINK ANYTHING AFTER MIDNIGHT THE NIGHT BEFORE YOUR $URGER , UNL sS INSTRUCTED 8Y YOUR ANESTHESIOLOGIST OR SURGEON. IF YOU ARE ON ANY MEDJ ATIONS YOU ARE TO TAKE THESE MEDICATIONS IN THE MORNING OF THE DAY OF SURGERY, AS l TRUCTED BY YOUR PHYSICIAN. TURF: DA. rev 01.06 EVALUATION NOTE Date of evaluation? z edical H/ isttxy?Qast & k - 4,41? I Age: _ Sex: M(F) wt_ ! Past surgical History: Anesthetic Rx 61" jj; - /:G ty . qf MiA yf CAUA 3hy3ical a na ! Ai ay r /D u Laboratory/X-ray/?KG 44, ASA Clzsaification III IV V E IN PO Status Anesthesia Plan (C) Patient acceptance above pla : es ? 144 1 I (D) inks, alter atives of anesthesia informed sod discyssed. Initial: fN(., of evaluating Anesthesiologist / Practitioner. PATIENT MEETS ANESTHESIA DISCHARGE CRITERIA O.K. FOR DISCHARGE Ste` p ?3sj ?? s SIGNATURE 012-51.11- Signature o Anesth bOvPractitioner a J_?? t?ritle>'dFrrulth5enicx? OPERATING ROOM RECORD United Plan of Can ' MRS 4848160 Page 1 /5 Fkalth Services S ogrit ss NOW Pr Acct # 98005040633 Print Data 0912512006 Hospitals PrintT 01:42 Patient DERVISEVIC, ADELISA D.03 01/27/2000 Cased 203322 Date 0912512006 Room BOR 03 Patient £ntwed Room 00:15 Delay Code Anesthesia Start Time 00:18 Anesthesia Type GEN Incislon Time 00:48 Wound Ciassificatfon I Procedure Ends 01:40 Films Available in OR (x) Yes () No (} WA Patient Left Room 01"46 Medical Staff Nursing Staff CHO1, SEWNG H: Anesthesiologist Circulating Nurse -1: CRAIG, JACQUELINE SCRUB TECHINURS E - 1: KNOWLES, DIANNE SUE KANELIAKOS, JAMES: Surgeon Proopentive Diagnosis open fracture right Nbia Operative Procedure; INCISION AND DRAINAGE Postoperative Diagnosis: s/p same Irrigation Used: () NIA Irrigation Type Amount LACTATED RINGERS WITH ANTIBIOTICS 3000 CC Packing: (x) NIA Comments Tuba6/Drains () WA Comments Drain Type Smote PENROSE DRAIN 1/4"X 12" RIGHT LEG "Plant () NIA t IMPLANT NAME SERIAL NUMBER LOT NUMBER QTYIM SITE EXP DA t ( NIA Medication Time Drugs DoeacW mount Bqjft Given By 0,48 BACITRACIN 50 000 UNITS X2 IRRIGATION DR KANELLAKOS 0:48 POLYMIXIN 500 000 UNITS X2 IRRIGATION DR KANALLAKOS Uru'ted ?.... Health ACES patient DERVISEVIC, ADELISA Patient Discharge Patient Left Room: 09/25/2006 1:46 OPERATrAG ROOM RECORD Plan of Care Progress Notes D.O.R 01/27/2000 Patient Discharged to: tPACt1 Via (x) Stretcher with Rails Up () Bed with Rails Up { ) Bumpers Skin condition Q transfer from OR CLEAN DRY CASTED Level of Condsiousness C transfer: ( ) Awake & Alert (x) Sedate and Responsive toVerbal Stimuli t) Anesthized with ET Tube and 02 Comments: Accompanied By: J CRAIG '- Accompanied BY. DR CHOI via B. Preop Orders Completed C. Preop C hecklist Completed D. Films available in OR E. Injury related to Inappropriate Pt Identification MR 0 +4848160 Acct# 9M5040633 Case * 203322 Page 2 /5 Print Date 09/T5I200fi Print Tim 01:42 ( ) Crib with Rails Up () Garry { } Ambulate { ) Wheelchair Non_ esponsive (see Nurses Note (} Sedate and Responlaive to Deep a () Intubated with Ett,Ambu 02 and Ci (iij'`betcFier with 'MI-WOp?-( d with U6-Q0--- (} Crib with I ( ) Carry ( ) Wheelchair () Ambulate (x} Yes () No (x) Yes (} No (x) Yes (} No Expected OutcomelEvaluatlon I . Correct Patient for correct surgeon and correct procedure. Expected Outcx>rrre/Evaluatlon: (x) Outcome Met ( ) Did not meat Comment: I F. Anxiety related Ic surgical 1. Patient will experience minimal procedure and unfamiliar anxiety related to holding area and environment surgical procedure Expected Outcome/Evaluation: (x) Outcome Met (} NIA Nursing Intervention a) Pt ID Band checked (x) Yes ( ) b) Pt Name Checked (x) Yes ( ) c) Pt DOB Checked (x) Yes ( ) d) Pt ID Verbally VerifW (x) Yes ( ) e) Before Beginning Procedure: Surgical Timeout Consent, Proper Side or Site Verified With Anesthesia, Scrub Person, Circulator RN f) Oxygen Supply Level Addressed (X) g) DNR ORDER IN FORCE ( ) Yes { ) h) Surgical Consent (x) Yea ( ) i) Anesthesia consent: (x) Yes { ) j) Blood consent: (x) Yes { ) ( )Did riot meet Comment: FAMILY FROM BOSNIA, SON TRANSLATING TO FATHER. PATIENT SPEAKS AND UNDERSTANDS ENGLISH WELL a) Communication ability - limitation. (x) Responds Appropriate () Deafness () Blindness () Muteness ( } Language barrier () See Nurs b) Level of consciousness: (x) Alert ( )Drowsy () Stuperoua o) Emotional () Calm - Relaxed state (x) Anxious () Depressed d) Pro Anesthesia evaluation completed by Anest (x) Yes ( )NO Monitor (x) Yes ( ) NIA (x) NIA () N/A () WA Notes {) Comatose () Fearful sla Staff d/nit+w4Hru10a Services OPERATMIG ROOM RECORD Plan of Care MR # 4848160 Page Urdted- Progress Notes 3 /5 Acct 0 88405040633 Print Dat Health Services e 09125/2008 Hos itaI S Print Ti 01:42 PABOA DERVISEViC, ADELISA 0.0:13 0112T/2DD0 Case# 203322 G. Potential for knowledge 1. Patient knowledge regarding a) Verfication of surgkal site by surgeon with his/her itials deficit related to understanding surgical procedure and mode of on operative site. surgical procedure anesthesia Expected Outcorne/Evaiustion: (x) Yes () No (x) Outcome Met ( ) Did not meet Comment: H. Potential for injury related 1. Patient will have no injuries related to Patient's allergies check with Medical Rec 1 ord and to allergies, allergies: . Expected Outcorne/Evaluation: verbally with panem (x) Outcome Met {x) Yes () 0 ( ) Did not meet Comment: a) Latex Allergy: () Yes (x) o -'CC'JSi A. Potential for alteration in patterns of urinary elimination related to (x) N/A operative procedure C. Potential for injury related to use of electrical equipment () N/A D. Potential for alteration in skin integrity related to skin preparation {) N/A Head/Neck Surgery (X) NIA E. Potential for injury, hypothermia related to exposure () WA F. Potential for alteration In peripheral tissue perfusion related to use of a tourniquet {) N/A Nursing Diagnosis Expected Outcorne/Evatuation Nursing Intervention B. Potential for injury related to 1. Patient will incur no injuries related to a) Patient Position: (x) Supine ( ) Prone ( ) Lithotomy posdionkV positioning Expected Outcome/Evaluation: ( ) Semi-sitting (} Lateral Left () La ral Right (x)Outcome Mat Other: ( )Did not meet b) Positioning Ards: Safety Strap: { } Across Ch Comment (x) waist ( ) Above Knees (}Norte Arms on padded arm boards (x) Right (x Left Skin assessment post op from position Tucked () Right ( Left (x) Satisfactory Steds () Right ( Left () Unsatisfactory, comment Other Positioning aids other {) Doughnut {) Stirrups () Footboard {) Peg Board () Arthrosoopic Leg Holder (} Vac Pac () Axillary Roll () Dog Dish (x) Pillows () Head pins HEAD () Shoudler Moll () Willson Fra Other Gel pad Gel roll (x) N/A A/E Ho" (x) N/A Unified F kmlth Services Pat"t DERVISEMC, ADELISA use of electrical equipment ( ) NIA Serial fit mono 04600078 ESU CONMED #6 (x) D. Potential for alteration in skin integrity related to skin preparation ( ) N/A E. Potential for injury, hypothermla related to exposure ( ) NIA peripheral tissue perfusion related to use of a tourniquet ()WA G. Potential for infection related to surgical procedure OPERATING ROOM RECORD Plan of Cara MR # 4848150 Page 4 15 Progress Notes Accts 98005040ti33 Print 09r=2006 Print Ti 01:42 D.O.5 01/2712000 case # 203322 Patient vin incur no inlunes r a to a) Laser Check: ( )Yes (x) No use of electrical equipment Type: Evaluation b) Pneumatic Power and Electrical check including vi o equipment (X) Outcome Met (axes ( )No { ) Did not meet, comments c) Apply water soluble lubricant to facial hair to make the hair nonflammablei: () Yea ( ) No (x) A Condition of skin after removal of ground pad: (x) Unchanged ipol Cut Coax Blend () 30 30 BLEND 2 1. Patient's skin integrity is maintained Evaluation (x) Outcome Met ( ) Did not meet, comments Skin Assessment: Before Prep (x) Dry and Intact After Surgery (x) Unchanged 1. Patient wig remain within normal temperature range Evaluation (x) Outcome AM ( ) Did not meet, comments Pad Wement AQRLW---BY HvliW LEFT LEG J CRAIG (x) a) Area propped (x) Shaved () Clipped (x) NIA b) Prep Solution used (x) Betadine Scrub (x) Betadine Solution ( } Alcohol ( ) Phisohex () Hibiclens (x) Duramp Other Prep Done By DR KANNIELI.AKOS Pooling of solutions assessed (x) Yes () No a) Temperature monitored by: (x) Temp Strip () Esophageal probe () Ear probe () Rectal probe () Amilary Probe/Swan Ganz Catheter Other b) warm irrigation used: (x)Yes ( )N c) Warm Air Blanket tx1N/A 11, d) Fluid Warming Blanket ) Y x)N 1. Patient is to remain free from signs a) Tourniouets used and symptoms of injury due to Serial Setting m ft extraneous objects. Evaluation Location RIGHT THIGH Placed By ( )Outcome Met Site padded up C 0100 DR KANN LAKOS ( )Did not meet, comments Down a 0:00 Esrnark U, ad Ste padded up 0:0a ( ) Yes (x) No Down 0:00 Total Tim Assessment of extremity MD Notified of tourniquet times Before (x) Dry and intact (} 1 Hour () 1 }tour 30 min { } 1 Hour 15 min () Every5 min until miquet down After (x) Unchanged 1. Avoidance of patient infection relative to surgical procedure Evaluation (x) Outcome Met ( ) Did not meet, comments a) Avoidance of patient infection relative to surgia procedure (x) Yes ( ) No b) Sterilization indicators show parameters met (x) Yes ( ) No c) Contaminated instruments to SPD in covered ntainer (x) Yes ( ) No LpHowommeafrn yrTVU. OPERATING ROOM RECORD ?lllt - Plan of Caro III S 4MI60 Page 5 /5 Progress Notes Health Services Acct x 98005040633 H1C)S ltals Prim TWA 01:42 Patient DERVISEVIC, ADEUSA D10,6 0112712000 Gase ft 203322 NURSING NOTES 8ignaturs: Ll & ' SM. GEN. vi Unit N EsIIINTCHLLL AVt. HARMON ST. AVWTON, JOHNSON CIIY. j ' C N.Y. N.Y. v 1 S? V 1 C. L C• i s 10 Health Services (607) 762-2231 (607) 763.6611 Hospitals R# 1 bA 1 ; Lo SURGICAL COUNTS DOCUMENTATION FORM >?> 2 7 20W ' INSTRUMENTS INITIAL ADD CAVITY 1 FINAL 't • )> Ioweis Clips . ?-6 '. Scissors SPONGES/OTHER INITIAL ADD CAVITY 15 FINAL Hemostats, Str. Lap Packs 5 S __ Hemostats. vd. Kellys - Raytex 4 x 4 Kellys, Long - KO M Stilt Sponges 2 x 2 Thoracic Kcilys Dissectors Allis - - Orain Patties Allis' Long Vessel Loops . Batx.-ocks - Rubber Slxids Dabcocks, Long Vascular Inserts Kc"teo5 NeedtPS + 2 others. Lvng Str. - - MnsryiritciF;, Str. - Mosqudoes. vd. -_ Trocar Seating Cap ?. Needle Hokfars Throat Packs 9 mge K S 1 is R't_•is oroeps Scratch Pad I t Knih) Handle-s gyd? Suction TIpn Cautery Tips 1 / Retrar•2rrs _ 4yectaFile Nfwdles _..._.. -rGWpson et. Miscellaneous G.B. larnps nstr. Inkials: ?? hxstr _.. -- - ... PrriefX1Ure _1. Intr. - L air -am Inatr. Final-Count- rest IntDrrfwt Who Intr. I X-Ray Taken: r7 Yes U No C.V. Intr. Read By: irFu'.liys icrs Hr?+iwks? - _r 1 les Pack Rhwjs . .- i Q 4 L? wJ sc laneous J Z7 k sails R.N_ Sig J / 5218973 Rev. W 2 - -- CH ART C OPY _ y? 7 : Za > r _ took, ? f s % cw_ . 1 f Hc?cttin SeMICO; 10 ^ b 2 4 b O 5 I POST ANESTHESIA CARE 0 F v } ` v , d ° z g ul/27/7000 F Oq/24/06 GATE d j -16C. TW ADIA SSION R.A. r +ulP K A N E L L 0 K IS. JAMES MO Tt 100.1 ;OtatlITION 01 1 AOM"JON 4 T I S T f"??r CALL I `L PA 17013 ALLERLiIES ;; .; , 4 ;3 .i ;; J O S$702412140 l?nnc „„ OUTPUT (? Sider As up Sleeraa Pads' ? Yes NA Chest rube NG Tube pp itt KQ 2nd HOUR 3rd HOUR C` T-Tube ? Drains f? y c:> : C 220 P a*kv Urine Fole y 200 Urine Voided )37 Patient meets extubation criteria ? Y es 180 ROUTE LITERS MIN ON OFF iYesat 160 Beggs Mask 4) 15'6 fry 140 Vent MEDICATION DOSE RTE TIME S IGNATURE • • 120 W S '?'jF I 7:Z t r (j(/ pt? r? n 100 0 8 so 4Q SKIN INTEGRITY INTACT ? OTHER' 20 NAUSEA STATUS IF ' SEE NOTES ADMISSION (I NO ? YES' DISCHARGE ? YES' p IV [ ?] L ? R SITE , IV FTE CODE t?r?o5 HEALTHY 8 INTACT YES [] NO" Y W O A Pulse ? ? Plan. Assess atient 0 10 mirwles and docume t Gi p n . RN assuming care of ost rec v at!&M i d ve report to P i CODE _ADM_ DSCH p o ery per o . p &wwt discharge r-Meria at time of transfer to floor. at ent to Adhhty e 2-Able to move all lour extronQios 7-Able 1o move two exlnonvi%* Rdm t hkd au.., c dolor 12,4 1/ 4 S J` I ?1 O-WwAge w oxwe any ext?Qmity J (?J Q f ?1?1 (? r /? d r n U! 11 4 (?J I Respirotit -n 2-Able to deep breathe wltiaut difflcufty 14i owittions spontaneous but C { fC t f .? L. ;,,,c S ! rZE AL v 1 t S r t Gt C7 L 044o 6p ?neous respirator effort C:? f f r7 r Q G 1L. 4 1"C (it/ ,•1 y Blood p re 2-BP t 206 of re-anesthetic levN id G Du.S S 1?U ?' V r c C r (G 4' c S '? O t S ?ri • p 1-BP t 209E - b09'. d pre-anesthetic level 0-EP g r l e t ft 30% f /? 6X11 "Id 051. Lain f a f A o w rt / a • r er o ess n a o Fro-ewadwfic Isvel ct `?` ?` C k f ), C C 4 1 I' ?.i r rv r ? r. ?i C? W a Cord*OV WW" 2-Fuly alert d able to answer oKreetions 1-Arra,sc:.ble M aain rc rte' rt4 t ?/)/C ' rr? p name c 0-14o response to auditory stirnufi / t ,Q. ?t p r? ?//ol .j SAO, 2-AA to madlin Qsaturrlion si1R an roan air I-Nwds O, inWwk)n to mwr4Wn 0,seRN*6M >90% t 'To Y C 416 ) J' S {) Ct J, Yt') tit C i C ?j ?? L C O) ' aI fJAsawralwn <W% em with a supplement I ) r7+ _/ C'Clo t f'( ,r TOTAL 7RANSFERRE 0d DtSGItARGING AT GONpITION •• - REPORT UIVEN TO ?krY $1-f2rl STHESIOLOrASTSI(iNAIURE{REGUMEaFORAUWTES<rly <<r 5202304 (Rev. 1 ? ) 101 I OTMErt: OTHER: 4 1h H OUR 5 !h H OUR 6 th H OUR IV FLUIDS BLOOD PACU TOTALS --* 5() 220 . Al A NORMAL 65-105 mg/dl CHEMSTRIP (GLUCOSE) - 200 160 s 140 ' r 120 PEDIATRIC PAIN ASSESSMENT ON ADMISSION ON DISCHARGE 100 CRIES Score 80 Wong Score Intervention 60 PAIN SCALE 40 0 1 2 3 4 5 6 7 8 9 10 NO MODERATE SEVERE 20 PAIN 0 I ON ADMISSION EKG STRIP '. •. ......?..-mow rAr4t 1?tt r fi-1 Unittadt=tcattlr ?erZ%iCC^.s United .....?._. Health Services Hospitals PHYSICIAN'S ORDER Admis; Protocol Date: 0 DE4VISEVtC ,ADFE.iSb 01/?71 F 01/24 ?000 /06 KANFLL AX03. JAMES MD 'S-?4 THIRD 37 CARL 1 Si. t PA 17013 - 400000000 S 5702412140 I PCP : COT Time: / V_31? This patient meets medical necessity criteria per InterQual Guidelines. Care Management will continue to follow and assist with services as needed: Admit as Inpatient: Effective t?K 0 ? Order placed in NurseVu: , Initials This }patient dm-s not meet medical necessity criteria for inpatient care per InterQual Gtc;delines at the present time. Care: Management will continue to follow, assist with services as needed and reassess within 24 hours. ? Place in Observation (NO Nmputer entry necessary.) ? Place at Extendckl AmbulatorNurgery Status: Effective ? ardei placed in NurskVu: t.l ll?iAlJ Nurse Care &aL..- Date q Manager: & Tirne?l - 6 Physician's j Date Signature.: _ & Time: U Nurse's Signature: Date & Time: 5801533 rev 07.26.06 Unit Health Sen*es u He H S00b24bOSI : fih Services 4 R4 1 1 b Q nfpviSEVIC ADELISI pitals Dactar's'ragress Rec}y 112003 o 4 o e L WIS. JAIRfS mo X24 T"1E-') St i? r CJ?i;?p; ::0 S 5702412140 p p POS e . OPERATIVE NOTE: PRl ARY SURGEON: DAT OF OPERATION: PRE PERATIVE DIAGNOSIS: C:z u_ >>Cc t r! + FIND! GSlPOSTOPERATIVE DIAGNOSIS:_ OPE TION PERFORMED (Be Specific): DESC RIPTION OF PROCEDURE: L rtf K ASST ANT(S): ANES HESIA. SPEC I ENS REMOVED: ES ? NO DISPOSITION OF SPECIMENS: Cl PATHOLOGY CH%§C- ARDEC ESTIM TED BLOOD LOSS: REP CEMENT: DRAIN , etc.: V_ J d,•a,.•L., , DATE : 1_-kL?, TIME: p SIGNATURE: M.D. 5znM4 r Pv 91031 th*e Health Services United Heo? th Services Hos itals 2?t SQ Vl SE U! G DEPA TMENT OF MEDICAL REHABILITATION PHYSI AL THERAPY SCREENIEVALUATION 5oobMo51 5 4 8'4 81 bU c of?VISFVIC $ADFl1SA . .: o i l 27/2000 F 09/24/06 g a?f t L AKOS. JAMES 14D 524 TH 1 90 ST r CdkL i SLF PA 17013 40C0000ii0 S 5702412140 Diag osis: !? )q- 47"b Ab Wei ht Bearing Status/Precautions: Alttb(R?j' Pain Score (0-10): ??llCl Curr 0 ent History/Past Medical History: !S a ? ar to. 3?(.r 81P hf)VA- Z-' Dpi G . pyrt ?{ /Ei (,t ?? r? mix rkc C7- ?cYvn bu C? c??= ? re '?? r .?ion . ?f ru t Ens WFL Impaired Explain ROM X 13 V t,? it U. Le GUF • { VW t- ank-fie .L'd. 2-0 h r d F- ?( Mus le Strength: _ . VV tt ' r Assis ive Device: O Walker ;(Crutches O Cane C3 Patient's Own Issuec From Valan ce: 2W?GY7. S S't t C- #-- C 6LY Yy Tran fens: c f V 1 S tun Qt -niqk, ?1 n&-., C gi,CarV ? 6n Gait: C -- t Yl {p ti ? ax I l E as GYI.I:{?r4r--& of ' evvIsfun 67. ?,,t ? N VVB t s ?u) - IM 6 t. kt-la rice . reC0 id.c. Cfl - Stair : obt d? eYY .. Othe : Ass p ment: .astra.l /tCf? d? a? &P ka 1t2 ' > arlCL al ? : ?l -fi ca a r z?? ( an re -I?e xn *t-ffar U'Yth nm d f tryk ' 1 1 1 r 611 nn t 'If O'n UR 0dhkvalfh Seruices United Health Sen ices S00b24b05! l` DEPYISfVIC ADELISA ; %A14f1IAt0S. JAM£s NtD K24 TN1j? Q qr riosp><cals C A 7 L 1 51 f PA 1 7 01 3 DEPARTMENT OF MEWCAL REHAB[ LITAIION t: 0 +' 7 G C} 0 0 3 57024 12 140 PHYSICAL THERAPY'SCREEN/EVALUATION PC P : t J T Treatment Plan: 1. Gait training with assistive device. --- C?c.X l to erut_c hcs 2. Education of safety precautions. I reatment Goals: 1. Independent ambulation of level surfaces with axi (tL crufichM- 2. Ascend/descend 12. steps with C? it r without railing with C In A . assistance. 3. Gmsisslen t performance of precautions when ambuiatin with assistive device - r . t A 4 1V?TV Zf '??Wl I l v?l,g? ?1it.. j Goals Achieved: Goals Unachieved: f i Recommendations: Continue physical therapy treatments O No conlin?ied physical therapy services taunt ? deft Yak usz C)? C.r Safety precautions discussed and review sheet issued Signature/Tit Date: r . /?v...aw VJV ..V akov W111[3Y - _77-Yglyall{ Lt r t- 5801013 o? C a 0: -j Q O co M LU w UJ C IL o' F ? IL LU ,? . r?- at r w j f . r- 1 1 Q n-,%: 11VY? ? t • tIJ ? . 2 0 'F J ?. a? r 4 o .? w dk ? £ o C a u N? No } y R 0 W L 4 m p W tll j J z Q d W J Z m O t1 ?' ~ o IL v r s? c c .E m ? eN- I } 11 N 11 N dcav,mt-w e C4 N O*l 1ti? t? N L e ? N N II IL C3VJ[ N r ?F v f A N N d 11 •C?a7a OL N (4 IC #A r,--Kj \ d N - - a iI1'I II 1 I awe awc a ? a as r. V ? to t C E IL W ? z W °? W UrAEedHwffi SeTvi xs United , eaith Services F -1% Hospitals DEPARTMENT OF MEDICAL REHABILITATION PHYSICAL THERAPY DISCHARGE SUMMARY ? i bo q jZ4 OX, J l?r r-I Cam Tarr D 524 AJgla ?frWt' ; pA `? 2 S 1?0 0 Initial Evaluation: tJ Discharge Date: Mental Status: I X t3iagnosis: Objective Findings: WFL Impaired Explain ROM Muscle StrengtWone k/ 4 Sensation Skin Integrity Balance: Sitting static Dynamic Standing Static Me-,)o -- o A J028 Dynamic Mobility. I S CG Min Mod Max LDep Bed Mobility Transfers Sit-Stand Stand Pivot Ambulation DisianCe?-- Equipment O YU--?r'rtE'?4?. . Stairs # 2- Patient/Family Education: Refer to Patient Education Record `J RecommendatiDnWDischarge Location: Equipment lssuedNendor: Goal Achievement: r n((? jj JJ f C' TT • aal u.l.L t t ce v ' ` Vl• ?aV t -N I -it~ `lLFAI-3- V ws--. -` lA-; L k /j Ir Signatuneff ie: Daft: L KEY: 1= Rope;dent ision CG - Conger Gward Min = Mini "Auioance Mod = Max - Mtn mm AesisWm P = t SNF = Skilled Naming Fadlity WFL = YVlthln FundiDIVI Limits ROM a Range I%Wvice Mobon TAD11rM51FADot2lFormMPT DischaFbp /lnnamowi tft~Hen1thServices United Health Services Hospitats, Integrated Progress Record :: `..! ?' 4 4 1b0 DFPV 1 Stv 1C . ADEL 1 $A 01?27Ixa00 f 09I24/o6 A1 0S, JAKE$ MD .: 524 7MIRD $T .. CAk1,tSLF PA 17013 030000000 S 57024 1 2 1 40 PCB': 0DT DATE/ TIMF, FOCUS D=DATA A-AC'!'ION R=RESPf)NSE _ -fV tl11 h-a k e U L a11D P CC. ((k?U? Yk Ct FQ £ - ?'/rt,( C.j?{? d rcte ( f 1 j'PC? a.dcc A I& Z I& mom ? ? ?? ? ??ZVru1 5247794 rev 5104 ?CONTINIJFD ON RFVFfZFr t-IhG United y Health Services Hospitals Integrated Progress Record :. 4948160 DE RV I SI V I C , A^EL I SA 0)/27/2000 E 04/24/06 K1r'ELL&KOS. JAHES KD t. CA PL I SLF PA 17013 CL 0011"'00 5 57024 12140 PC,P : crr A=ACTION K=RESPONSE ?- 44 ec 77 A MEDICAL REHABILITATION Patient has been seen for: Mobility Protocol: Clinician Signatur Vic.. 9/0 n/ ?f Q w g-i 2 7Z&2W un7W .?'c Env ri j-4 h-ijJ*J')-1 /Ll.-. YY? 2 L'olne own avr mo. -cc e? scan ax.i 1 Arr 5207794 rev 5104 C= Unkodxeatth Senkas United ,,. 50 0 b 2 4 bO S 1 . } .t? .... Health Services 4 8 4 81 b D ,?. H 11'c?$ ?.; D E Y t S f Y 1 C ?ADEL1 S A 01!?7/2000 F 04/24/06 t. KA#:ELLAKOS, JAMES K0 Integrated Progress Record 5 2 4 T R I V O ST j C A Q L I St>' PA 17013 C;:oo S 57014 12 140 DATE/ FOCUS D-DA'T'A FCF coy A=AC'T'ION R=Rf, C) 49e TIME r a --PlyOx to rv?in- f Geni?s?nd ?? Q, l.at fpp AM mbut-ah n ss11i rr- d from ?ht -? r , No for= 6f k'W al(f, y?of rev6 uI re. V"/-:T Y Q 6?;k by S10 cry -e? le 4, ut deaw" ?-p pu? e .- ,( r -P Debra Pwdon t, r? ?•?? , C? ?- ,s AC0552605-0 I w- r-- ?T 5207794 rev 5/04 FM 191?? Unitsdt-feAlth se,iaN United ??._ . Health Services Hospitals Integrated Progress Record D=DATA bCpvlsrylC ADELISA :. 01177I2C0 F 09/24 K t;afLt OKDS. JAMf S 00 1 C A"L 1 `_'t F P A 17013 0?rO-QCOO S 5702412140 PCp -nriT A=ACTION R =RESPONSE A-ZO APK t-br ll Y7 .?Z t' I"Rf ICG' ?4?C? h(Ala-t7uy-t _ q701') df.5?Mc-q nn?r Lt.1 , „ter. -AMN 5207794 rev 5104 Unit"Hrnltk$emku :•• United ,..... ;? He-ilth Services Hospitals Integrated Progress Record: ,.yyyv r.PGaf SQ Q b24bQ 51 484S1bo.. DE QY I stv IC . ADEL I SA .... :.. C 1 2 7/ 2030 r; 09/24/06 K A; f t l OK ?S. Ja14 C S MD 524 TH190 ST CAC-*I I SL PA 17413 0i; aUv?Y4 S 57--12412144 TTIVIE FOCUS 77. 17=DATA ' A=ACTION R--RESPONSE -- red it cr`fs btr le dO cur), sc . ,s io ambLutj ? C .'VlS gbh. f4.. 2 t 2•?'?C, r'Lk d'W n G 2 t? c L .0 as-_-45t- ckd ;f i? l to a u?4y'!;- - Etbt_ced -fD ? _ 4kfc q -'FAa.cr? on Vut? Jc s , k ?Q t:r )W- - . c ass " Ven w i It bw 0-n bA !,9ft On. art htYYY-, . iw, -?, cat -? o her M -t A _ ??eCb-yY?S C? ? ? 1? Q ? ? . - c? v? vWis --- In uf61 . • rot Yl -) s ya_u S C) 11M T1 Z?. G h l Gt-? / ' frtan _P T-I, 5207794 rev 5/04 Unit*dHvdth Sm-v r^ United Health Services S 0 0 b 2 4 bO S i Hospitals W 4 8 4 81 b o ; f ?1??1?f? C naI's AlA6 integrate DATA;/ I7ME l? I Lj ?- } 4-1 _ f5i L - T-- a U O c t 04 . ,mot U L!I N ^ N 1C1 r--'^: fA L C r O m T di 4) .._............. Q m ?) m t? u. 3 Ta J .r ?? r 73 ?? 4 ty ^? ti ;n -!S .- r . 5207794 rev 5/04 UnkedHeWtN',prnf w United Health Services --' Hospitals Integrated Progress Record 00b24boSl ;,. y? ?bo.. QE av 1 sf Y 1 C , I??L pq/t41b p1 r27i2000 A!!E$ M4 geii it.L AV0S. j 524 THIO S; pi 17015 CA gL 1 VSLI C.00001DJ10 S 5702412140 Oro • no T DRAM FOCUS n=i)ATA? A-ACTION R=RES QNSF.. : ?• ??j a; X") zf?j • r 'zd _ / Z, ?./ 5207t94 rev 5M u.itedHeidth Smu United Health Services Hospitals Integrated Progress Record DATE/ FOCUS TIME S00b24b0Sl 1494 1b4 ?t;'?Y 1 Sf Y 1? ? AE1?L 1 5A - . . {}112y/?000 F ogIZ4/06:... ..«,,.. "' S?4 TMtRD ST PA 17013 .^„??v`tJt7 $ 57074 1 7 140 QcP: CDT II=DATA A=AC`1ION R=R %PONSE - Ism---?- Z. _ Q( L ' j ... ?p-,#- am-bulabuy-t-c FF. I- I- ?e n?atcz.cns_ cxx Stns P fpc- snc.t. Cc?.wa v . . ?`i'1f1 6n' tdvkrq c.?(.rV ?S16Y? ? vC 5??f '' Y1 try I` ra !t~ : rcJ?. LLx? S '? ?'t C.l?= ?---/ .fix---- 1x?. , r r fs - C_Ct Uk> x6d -,.M0,tft(m lVbV8 VVY.I.U. 0-6-yrhmu pr t a rr?D?Y? - ?r Q ( ? _ Aot I I m -t? r -S -(l IL 0C L J 5207794 rev 5104 UMedHmlih.Services ? S Q 0 6 2 4 6 0 5I ..,._ 4 84 8160 United ,;. 0 I' 9 Y 1SEY IC ADELISA ? - . . h Health Services 0 1/ 2 7/ 7 0 0 0 i 09/t4/06 Hospitals x k 1} E L L A K 0 S, J A M E S N 0 r'•. s 574 Tit I RO ST ` CAFE I SLF PA 17013 Integrated Progress Record: Ovooocooo s 57024 1 2 1 40 PCP: CST r-- DATEI FOCUS I7=DA'T'A A=AC TJON R=RES NSE TIME rev 5/04 Vl1?tMd 1IPAIIII Sl I tHlt:. r O O bMO S j United [IF QY 1 cE . Y I C nEL t s Health Scruices 01/2712000 F 09l24/06 Hospitals Y AN,c ILL AKOS. JAMES KO 'S24 THIQo 5T CAI't1SL E PA 17013 Integrated Progress Record ;' TS 57024 1 2 1 40 ll=DATA A;--ACTION R=RESPONSE TUVE FOCUS 1 - AA 41 -4 j ,r .4 -iy - o % 5247794 rev 5104 UflifeR(F?rn![h Srn>[? urutea Health Services Hospitals H6 A Pediatric 24 Hour ,? k• v.a w wr v r fw - 4R4SSIbO of Ov f S ? c • &OR I to Assessment Flo. ?000 F 04/t-4/06 JAXE3 NO ....?.# s T ?t t ?"8 it ?? Clint t 3i? ?? #7?t•? MAINTAIN ON 0001-0100 0700.1500 1500-2400 s n A M Si • S70!412140 Y DATE: ISOLATION l4l A . V Mondor ti BP IV temp A. : •:. .: - If :: st. ? tq ? ,k - V ¢' 77 (v? t 00 ` l 2-0 3 9?0 300 if- ` r { - UCH 7 U e iry tf holWis;niFrtimurn) ::. ;= PNl A Sl?l1@fT (Eve Time Comfort Scale (0 -10) {? GI t 1 l t!? Intervention Wong-Baker scale Intervention M A ?. Assessment of intervention - - - - - - - 5 } 7.? 1V ASSE MENT ' " .. "' - - ......VASIV ' IV SITE*.- M. :. j _-- -- `_ ;_ :: shu es: ` rlg G ' -' ' invasive L kw ; L y ro Cat ral R tV ; an Sratine faCf P6 :i' ` hlickm .... 1.,•oc?t?;' ? 3 PicC•:'::T:'. TLC Lurnott Gets:`.';"; '`` : ' _ ?•::,-:;;::°': Initials obs Initials obs Initials obs Initials obs BSEIATION ! ft?iE (OBS! O „rN ?,','-, . 0001 1iSitr 0700 11F` Order :.. 7. ny at' > lel? . Ne@0 Redness b P`- MW :;7 Tin .. Tl- •k?: ;Lark:;; GESCRIR'f1V GUIDE € ^9 99 4asct l ui 3hds, feel frrf to document in y=" .6wn words} ... ,y NEUFlOLOG>C L f;AROIpVAr G(j1 AR CKacAenttd,CoasliiM4-LMhwgic;.Olficxj?M4i0ilm 1JIMWm*n,ShrrrdRisch,:AboW-Sp*oo U?ki ftolyibiv.Dy?pha?l; 5o(t, Flat. Bulgix?; Rulsesc orlhl E tyreeent, PKt 4tC, luif,.d, DtaphocefiF.lrre?utacfieart :. rat., Dscreepfs! sansalioce,.limiitd "p?!Y rafilF> 3(? sacvndscAtxmur; IRESPpiATUR1!':. LM Mo QM}>r*hed IrapfsMwVE7lplraWV•W!4iojICWJd", Rwriht, . SWi DMf; ;abgl4'$OB on exertion, $O8 O 14 . - • Nod-pnpduodvtx, Prudx* te.. tt1S1f, Suctioned, TnlrJ?eenn. 'Thin, Ttuck;. [arlaei0ui, QQJW _Tan,Bfoild ;; - : - tfr?std, XMkw • 1A?hlte, Bps 0a1?1, 7ac;hyprbic?itjk?eic P?jiggrs. :.::.? :s:? :,:r ?, - ::::.::: '-' . = - -.. -: ? ! ?." . - tiASTR01liTl q> tl ..°:: ,y Wider, Distended. &I;lame i!?b f, l tpa rr?eprs' YP G Via. En?ests, Dbuyh" onthpated, 'Blacfc lo? C • ` _. _;.. _ . xpdfoupnNAM? . , .. .:[ifoQd vislbls Irroolkkunt ? £rrrlli Naco?a?no nocorp xit • -?!16:.?1ej?!OAl3ErnlR p??f:•8.+?bfe#a, 1 Hai not voided; £QLOf SKIN /:,WOUND/ L""" 'ti, Catheter: MidwelEng Inter ! ieaecrrf Doff, b intact. GA!9: ilfe Duff CFVdd;` XI?Ge. Flakin L> pifOrsllC Rate.Ifc?wnq.8nised :lkDmtY'' : OreemV dry aftowd Y+piikl+w a. Sarosangt*aea * pimi ont size laiapfr RtISTtGontr> r - MUSCOSKELErAL . pilag4birded ROM, UnsW49A weakness, Infant. ": J:Od re Rhdm ?*, PSY4Cif050CUIl _ COrnbay5re Urx hoolseA - q; NMI. Snary?. I^.N".hlEi:?rlk?Q, Throb d "KNovam hAae6 1, #ieet, C ? Spasm. arips. ?:. him PCA d Rspoa$bnnp, T+p91>ptent, 89 • 77 ": '.• :. _.._., :: ...-: •- . Swaddled, pAC?IOr $YWet Ea*- .. ? 46ld fl0f"MK. Qdi;''C.=iwy V" ?-BakAFk = r:?: PATIENT CA RF-MEEQS _ = - - PROTQCOL3 0001 - 0700 0700 - 1500 1500 - 2400 f kldgryw+dsnt P2=AMWd t.. TInaE 1 It?C; ?? ac ?x? a?? ? P3 -Ab lit-al s.' P4 w J' ."aWwS , INITIALS :V 14t»buletfOn (rristeriee)- i l I LL?. _ Oriel (ari?aint of tune} :: ! yZ3i."(? ' . Tom' ' 2 O Trdcbm l cai* Cam : `.. : .::....:: 1wiftOM cr. ToMtalto+ie AgiNlM?t - . Iz-ge `2 TZ I.. 4tJ C ! } Bath - - - Oral ewe HS.Cars :-- 4MHgse/SCD iplofbA is ---' '- _ r?1811+t; ifdrtrarla (type). - - Fm* S? r : , deeiDeri? _..:_. ? ? -- .isle T e of T?bit</ f3r ni l yp a t :: o6itlon Verified ;::: t _ r Tdirilnof ts? tiutritiori :. _ . QHl(iGi:'' ?la>yiiplR??Gyt V01,301% -S spa am '. ° frorinal rM Li ' ••--r..' !^?,.r..M no bilSlit.!y? t t lr?. . Norma .... ..-:.ro:n .;: ..a., .....- .. .: V.9pµ? Aoi? .. .. .. .. .. - 9: t Plonnali;wilhput _ _•??.?' y .'iyy-.? __ '? "Ps ,:.....: , - r. r?'f]f.(Iri.r^.?::..'?. K ?-' !P PedearR:CAif•,.rilObd'sM?prei-R? ..... •?., vdy"'=' J;°„; 1 Pant / P. fa'G ii/Pa r tale - ° WE;$R Racoveir?.•;- q?li?-111 ?1 - FwWOprofapipa; Relaced:tacpi := 0-'itiilaxo4 ft ".I TO?1diR== ;; ?:_?k?3?lYloed??lbmusceuliiti,?rily? oaxwiana?;; ::=:'::.' : 1= f?jimace:zl?hnidtedak _ .. ; . ..: , . . :.. , 1 • inrtr?rper=lilbld moonK??,:lj'l?!!?!?1?It 2•YfyDrOU:Gtl'-boVdxtMlkt: i? Aldfldnd WSW: .. _ .. • _ . ri?YM1 ?11?i'r??ltlno6!!?:'?`=. _,; :. ?`a?lhrb?tY?? ? : ?y? . 1' •??? ° = _ : _ ;_, ... .;•. .; t?M?l4?:lfAIMMl1?:: :_:- • +".`? •.tleatpattemlopthlc tipM!!4 :: 0- Reloxed . .._ ±:::: :F..... PA pa i,s? 27 : lnMldda?ei?:; ?..• "e .. ....:'c 3.. IYlildsaa?d• breal TheVong - Baker Scale for Children Plaase ask the child b point to the Lace Chid irndicatos the On intensity. Document dw corresponds renumber as inckatod ttw dwild. U 5 O 00 OU (B . 0 2 4 6 8 10 . -:.. -_000 1-0700 ". 07110-T50d;:.' - 1500- u lY" ' _00:sell**bu bag I`= z. ? PY :;. 0001 0700 07044SW>; 1500' : I- + v Marty A, t:. .13 1Wublrt ivpt im r1d dolt that ° El Allergy [I DNR -EM vp4lrrtitrta ._. are ickpiii• ? Fall Alert ? Red Sand aCR . .?.;>f?ses?sriieil`i>`every 8?oslrs ''FCr'L ACCT UNTABLE SIGNA Nutt Shift: 42 Day ShUC CZ C-ci Evening Shift y l ?! ?2 UnhodAyAh Scrvicxr: United Health Services pediatric 24 Hour Hospitals 4 G A 0199 t SF iC OADE ,;iSA Assessmert# fftw* t F 01/f4/06 A#'.FtL&V), 5. JINIS 90 $24 1"100 st f. MAINTAIN ON ?1-O7W 0700-1500 1SOa9AW t o* 1 i St f PA 1 70 1 3 ?1 DATE: Ci zb ? ISOLATION: MIA c ti v t! tr ;? o s w. . ht'alctr : ?? .. ...... ?. . .. ?•:: : .. ..? ?. +tf ?..:^ .. ?. rte; t.: ?.: .. ;: LIF - .3 14 rl.: soole .. ... 49 Z ! 13 re I;, Y Z b"r3? Q3 «5 9-7 1 x2f3 q ?3()0 S h I mu T rTbjt il?S- ? ?Gi, i Q? PA ..AsslssMENT (EVE a [yours ninimutn?'_ ' .. Time C3 _ wo comfort scale (0 - 10) -7 } -11"eld Intervention 1 Wong-Baker scale l'C IntouvenGon WYL r n tC ? Assessment of intsrventian J? It - - ... ry IV -S ESSMENT - lF.lNE• TYf E' ?? ;- NVASLVL : TE . ? . M . Invaasus. Lino ?'.. T S L SL Hickman :.;=.,.-:_ ...,..... , .fir . C ocatwrl CO arc! Y' .G: PI it 2 f.: TLS - Tnpl t.umett ' Initials obs Initials obs Initials obs Initials obs - t -Q?M IW f.:?Npi?iv???ix,??w?a??.:.?idt~`,:,=__??_,: -=/Swoiin a•?Oe': G. .•14"',i.iF.'- _..: 3.--?.,,OC:::?I!trK i'O?i.::i.... -_ >. N 0700 $ I?rB,ral. y j ,?_ x'?E7lsrrontiriy3tf: x''?i _T b."Ph"Vott- r .Y? Ash [wrnim :O w..wMTI Sf?#C = JANIS no S24 TRI:PO IT DF?vlsrvjc A?ELI SA 0 1 Z 7/ 7."00 F oq/24/06 4 T H I qo ST [C[d?LISLF PA 17013 ?I 4. i V ?l ?' !?' t! P ,, 0 S 570?412140 r :.. 0001 - 0700 15W - 2A00 `INDICATES SEE PRQGRE56 ' Txa T> TOM NOTES W MALS MMALS ttel mnALS f wru.. . FONTANELLES LEVEL; OF CONSCIO[J.SNES& 1- - ORIENTATION .:: COORDNNATIO"PEFCH W" . NEURO CHECKS=;': = OTHER - PJJCSESANtJRlAS1R ?'- 1 Li L- Tf, 1i SENSATiON/WVEME14T T+i 0:...: APNr-'UDAADYCAROIA __....._..__ ' EDEMA r: '' f?? r• . u OTHER ::.:. :. --- -_ VOL. 7F 7T c •' 'AFti: ATH SOUNDS-F !'C C CIL f, PA NTN?IG COUGH SPUTUM MOPJC4 A TfPSTICS Stw - :: ?y g ABDOMEN- - :)Jc, r CC.. BMEL SOUNDS STOOL T } - Xi DESCRIPTiONZAMDUNT - - TUBESOE 170 AY is - -- "OTHER." •. :. -- '.lJ1?lNECHAEtACTERf&T1?-=: ::?::::.^ _ 2 . VOIDS ------ 1! ? •f•7 1 .A 7 CATHETER • , . i 1 "' ? r r ? i.?J OTHER -_.._...-_... WNL -TV ;am .TL "Ak TUR609'.. f G n C-C ?- \ -- fn" wOUNDANOSK}hl 4DFtQNAGE/DRE88INd':: ' GArosTriENGmn: -. d Y :ffU. cnOWAST CARE:..: CIFICULA11g1J C>4,E-CK3 _ _,...: ° ,: ' :.. ;..;. . > BEHAVIQR r n, L) 12' ra f'! . OTHER ' PHYSiCIAN/PRAVJDF?3 o:. / ISSUE If PkIY9ICKNI!?fiW0ER RESPONSE ----- - - _ J 111 ?.? ? l,`\ - ............._ r?z r a-Lf :UVIERACTION L PLAN OF CARE REViEVYEO '4 w AEI I SA 0 1 ! ?71?0oo 06 . !'"U Aros ` , . JAMES 74 ") I YD ST CA'?L SLR 3 1713 C ;1004CoJ S P 4 70 f 21 40 P nn • Jul + DESCRNTIVE AlIfC?E _ . tol of s iq?e5tie¢ lose love w+ptQs, teei fees to document in your vwri rprcJs -7 NEUIMXO W AL c Aoy?scul :__ DisbNMriMd, ip+gduerxF,'. eti?etgiC 'Dlt t to:Jiro?rse..? gipiiV Siwri?spaed? Absent Speed% fJiiinte jibk Rat :1'st4 Ram: DYW ra;re,r, na tic trEmmmw ' IJnpr?ipable. Doppler Only - aftaa% P ; $ -Cyandic Pale Frust;?id: lXapMO??e ?eg ,Fwbe?rc :: ...._. . , ... , ? . ser?sa?tlan.tirtiMd'r nevru»niCap?hnry [sPlMv" ; 0lrnirrshed Inspiratory/Exy?iiatoryVtytzas, Crackles. Rhaod?i, _ti?pow, lebpred. SOB-on exertm', Sob feet :. :;,: , . _, a ' Norpprodunh?e,,ProdlxeTea, hletfea tiye, 5uc1101ed, Trach Care glv m .'lhitit:T} )t. Tenacious, ?!-Tan, Mood- .. ".. titled, YaMapw, wi:.?: ?TrMaeoss?k'Tachvpi+a Apneac Eplsodss: - GASTROINTESTINAL ,.. M? ti?.r rp?* . Emaait,' Flans, i .C patfod, 01k tarrys- ? OENITDE?AINALiY " l t00rr11>I* bfa?odWalbWt? filcxpltirlerrt''.T :. y?, NO.., m°.W not koided, t^roror..,-?.: ... ? ?'?''?!?•` '... .. -, C". afFleker' kidwaNing;lMarnratf*d, care given, DTV4ke tu?ftarti;.,l a; kff19 Raett: ltcfiirW '0ad: AtS at ap stk 61aF11 ItMIt1Y1xCEp ]i1 . . Prastwl+e sore. Dressing deg intact ' ?•oisirol Drsdnsa?: Serous. SaligLiinsa 3esa lneom Purulent, Sire , Dop* F2eleh Corn=. NUSC ETALr._ ........ p p u . .:mores, Lkrlited,FK?At, Urtsteadyga Weeknew lord, Over P Dagroductve E " torMc- wi1f1 vt, Bintsd7lat Any, Ntaj?It, Ccrinr_e,l3noa7rope?aBve, =t!d.' raa Pain abbin ; 9t4, hull, !i0w Bundy 11 o? , ' ps: Spam t,CSlitatk, kigpdArlte :'HeWp d, Otstracsbn:'AePa l?orKi9?"RAIWd Treatment, PCA.I AP(- ". Paa:AW, Swam Ease, Swaddled, Aodw?& . PAl PHM CARE . PfWTOCCIL3 mot - 0700 0700 - -1500 750- .400 - Pt:. Indepernk" R>A?AigS, TIME 00 ?V 03 _ r4=Dsgind .: • .:. '" INMALS (.ice( 7 ,F +n tc (1` ? ? _ h r t c: ? QCtB;SarrbuM of 3t , • ?r-. O Re{losgoned ? + I'I • fr`1 - - - '7 ,? :17tIfl??atYlGirlk?tb'1NIi?? , _ at p Trdotign / Cast Cue iwt use'- ° -_ kt.ft ON or OFF _ ?? ?tas?aneea -:: - -- ?{ TCDBJ 0 NO let -KilodwAlk ?Y.. + Feedin Tub! Feeding YPe, mt er191n' >_:T , Me kP40iduel ? . ' _ -: Docixe?rtt?oyaitatr _ Position ve;vw ?.?- . 11+1RI)ML MAL N?{op,.?y yet t?t?ir CAPANOVASMIL" NOlrrii,•-V-- Q ? (. i,.•f C l ( / 1 f P,, Y _ tit] At Nr{f? ? - ??}Te1fi zar" Y r:}.!f•h. 14W60rVau" wltr out?dhGougy: •'49•:a .::..: _ - k tub Md?r?710>1bti011Y?.b'BGtillil?;;jq?l•j(b?j.flp,?ij- _ - _ _ - ?T. 6"3.n all Nc fift1? rao . . _ _ R??+?. r?diiab?.anns?dgR. _ _ !rla agd:no btawddsr Mention. +?wkicous nte+rl?xihoe".c?'eipr;:6,?st, nq'aran,ega, _ _ = _ A{ICa;e??netnbracMargaist.lt>?act : : r,;_ :x3' . '71 14 !? 14 r' t 1 1 Un/tedlimIASmiam , 1 . I s t y I c •? Etis?l United Health Services ? ?if2?/t??Q 09/24/06 . Pediatric 24 Hour Assessment F& J A"r S m ST Hospitals L ? ? A- CA >-! t s? F ? ? 174 3 ? i '. . o t5oo i soa2a06 s 5702412140 MAINTAIN ON oo0i'o?v0 070 F r P I Z DATE: _ ISOLATON: tlltaB . ,:' W Mesita ?:.:...:,.;. - - - f3E' :- Isaldtte .:...: today 01 IV m ': L St- ill J [ CK S ? f Z Z7_ )S r? y? ( t , ? . 00 n,7 f _ PAK:ASSESBMEt.(ELYA: hours minimum - Time 3 O Comfort Scale (0 -10) Intervention Wong-Baker scale C' C; Intervention _ Assessment of Intervention _ IV SITE ASSESS NT.:.--:` tv St " Invasive L'Ine S ? T m. Initials obo Irdbals obs Initials obs x)001 5 11F :. 0M. r,2400 .:.:... , . . *iw?aslvE L".rr IV - Peripherak ?`.:,Dial±ysis,Gjtt G Satlydck Aardt = = ii' rrrntti _TLG"?•Triple:?mali;Ckilieter :..; ? =.:.' - INtial$ obs RV?roN ? IN'F&ENrtoK roBSX ?:,Iww rv t, SO. 2. SO-MO V r;:;; g; ?.. 11Y:: ,f I DR iscoritjit i±3d' A ?r?x ? sf'r ?c ., ?Ih?t t sa 0IIt77t? -00 F L9/24/06;'. : . JANE S IK T-41RO S T cA°L I SLE P? tf?1? 8 S70241V40 nfant! Pediatric';+?amforttPaiR.Scale .. : coins: Std BR:J:- Bradyaatdta'ReVDrd ::. :.. V ?6rous .M=Maid' SR=5Wfoca+rery comfort SCSI* :.. U • 13eimcedAyS10E1, i?xercl'feee,. lcntntnitlee - ONPrearipn: . 1 • POWs =TiOMMOWMAdes ?1-,tl?ted - Nb musaterrip?ity, orassionat'• ;:. _ ? : _turrwred6 ii?s ctw. t;.j?? `'._ .:.: : ?: = ? rpi?dorn mov .. ?; ? .. . raft - f?gid en¢gr rep"d *densior? Won o . No mar= 1 i LbO itskeriutl?d il? NIM -1 d OwpkV or -•i 2. Vw" Cry s! So" ?ISing slxW _ . : f -?sgayllrritaWe - AIerL feq;:'?p;lhrastwq , _ :.. ?: s::. - ... ?:... - areslbktg. Ptlttena • : r+uvs,g ineguhr; feeler SW°.Ted 1=: t : `1ANtlAitcatnioilt_ =::', .:. tka*ed .. _ riscatrdOr( ..tw uiWl•9a0DN9... °.•:. ?' !M> tioidrg MED Aie*ated 5 -#. ,'-,". "'` veee! d seorr h e- The Wong Baker Scale for Children _ Please ask the child to point to the face that indicates the pain intensity. Davment the eormsponoJng number as indicated by the diild ? ? e 0 2 4 B 8 10 Shill:::' :ooQi -0700. 0700=150G 15oo-2aUO:::. ' aedetgs: ' -- 02 sift ambu berg: such,::. bump era_ E* 1?sti• •aa+' '1 - - ?.??f ?? y, i3?ien'ICVei. • - DAILY BRA CELET C HE != - V?f#{$y and r:_... ° ????=• ?? ??=?? D O Allergy ? DNR aP!04 t ate brai tai i;' °c ? Fall Alen O Red Band FALL- ALERT PRa!lL: (ALJ,-PATIENt4r:,V.--'LI ?O J10: 0700 ism 00 2400 R. ACC?iFi L6 51GItlF`IRE Night Shift: Day Shift: Evening Shift: ^F4Y F SFY IC IDfL F SA .i,.A C 112 7/ ?OQa F 09124106 . K A?F t L etrCS? JAMES ?p r24 TNIFD ST CA AISL F ?. PA 17015 .; C ?000,, ?0 S 57(]9e„a ?! yjSEylt" AC?ELlsA 127/?aJO A it X d ?( t S, JF S 09/24/()4 Es no S24 TRI St c??t., stf r• , n , ?yvuvoo R t lug DESCRIPTIVE GtM6', (7 * "bk 9: : ?? ' j tr+ 614 urr?ent in yew own : tlnirdow ible,pyept?4& NEUaoLAGicAI." :.::: ? _:?:'. ;.: : t)lllor?lrlted, Car?Auaed:-l?lrgfc. Dtffcuk to°altbt,se;,.1lnresporlslve: ffiumed sPeech,:Abwv Spsaoh, Present. PktM¢-CYsuxc7c. Pala. FM?st?d: aa?it?oretickre heart kd? Edmm t M!pciia; tlopplaF only WDIovASCUTAR .....:::. _ SG+t. t. 81Jl?kV- +atR, i?scraasea:f:YNadM.Umll.a>Riai?mi .CaQIMarSt s > seconds, Murmur::=: rs0MAATORY amid.hed Mhapii?Mry?E?p?ca{aiY ?: Crecrdes.:F onchi. palm: Irr qutar, stm*m, i.abore(t soaoa exm*n, sOg A-m-A;: Srrioned, Track care glvety. ;."Thin, Thick, TentlEions.. Cg: Tail; 8la tE - Apr*9L :. ftaotrprodtxxiw; Prodigy klettac?iiis, • '. >w>Qed, YeNoai;.WNb, fireen. t??i Yiarcoatal, Tiictlypt?ik;. Apnoic Episoda..- • .:: . GMTF1011F11_PTKAL ttitldar. Dlalanded. i Absent, Hyperai?llve, FiypoeK five, tfll?ueea, Ei»?Ilis. flatus, t]Wftm,. Cipnstl &*d. M t W y& tool. FrarllcblQOd visible, InoalliiiirK' ' Naso9estrlo; caaserotslorr,y, Jsjunoela ?y, Cloridl*.Btxning. Incontinent, Has"voilodr .•_ Citi lkiglxllNAFiY : GaNtaMr IndwpNs> 'Y?62rtixTlent. cars givarr.U7i/ [k+e to Vaid. Jae, Fiwft ow#mm*, saw kNKp &uisod;lNxa- 9Kpt w0tN1e! ULCER 3i0n, PrytttitilYl'strre. 9 drgA kdadi= ?Q(p? SljDrainrw::. Serous, Sanguinea?e; Seresanl ilneaus; Punrlent; ft biaper Flash Oontrac- __. Mt79XD31CB$TAL axes,.LiFtbi.MK lhMteaclltQait?]Nsalingss, mFar?t Posil..over Produc6va qwoch f?rpFiiotlc. WBtrtirawn,lsal?lw, itiuntedlFtat A1Nct, P3YCFI Y )C*l vlowt Catinativa: I,pxpoperrslt;ts Dap*"d, AnAom nambrbyrim Denies parnaSl6wjn9;• arp, lCmdiing. Dulf-AC. 80ming, Throb- PAMF' biog. Cr mM, Spa", Cortstark UiCeFniiltalt I; Ltnasaye. Heat Cold, dltracfod,.fiapoaidoNnO, Refused Treatment; F?!t;lltAif, Padnw, Svritt Ease, S Rocked, Otxrtfort, W ang-Baker- PATIENT CARE NEEDS - PROTOCOLS,.. _ 0001 - 0700 0700.150) 1500 - 2400 Pt ' lndepwndwv - P2 ¦ Aaebt of 1: :_: TIME P4r INITIALS } .. .:r. Apo (dWarlce) : .. . 008. {amount of NNW) _ { iglu ( hOLIMOf*M) ?! Cast care : .. )N or Tailairswo to Activity - c : =::. . .a..o.y... .' I Fled" TW* of ToAtt / , . _. F •;Siao ; _. _ ..:. ;:. - efartor: - Pas?tran Veafiei¢_'- - ' 'nabs Telerttrtoe tlo tttrAioo': ^ - • ? I?R11P10t?OGICaL. ::-` ?- _._.: _NOMM1?k_. `' I?16ft di' ?Q{?pted l0 perJOt]:.pIHf7 MJ?AWCU ` ' - R141m? • Reepirs14ot1e reps,fa?. *aA . !44!!?c = :• r{ n#j pi o l ba No1?a1: A b d ain* n a FAg- . f ?( ? , y ? ? , { y ? Norirsal: • Werra, dry. l lvA, IM-No e ' .t )f Q90C11it i 1: .:;- .. taosvrat: pertldluo ea In dutF,xna - m:rao6pKratiw; apeedl d>iar? 6atlollvr•:ikViOUt diqkuky . .:..r..: .._ ? - p.d 6. :,r!P +e . tut#ierlaaiian, t?!a= ?ig4ir?nal; . ?_ .,Cxsr, , _Yac?t?ldlk:'aol?prodiietlV! c ?6 A*;,?;. =- -- - - ' _ .ttlO?Or Ct>t'?OOtrw'.?: ::: :' ?...: i?:. "?yY$?r'vi',7. _?::,t•::?_.: yy,.??:..yy??..::?,?? - t I}.. ?wgy .11.11 Y.?1??:[ilO?f( W4 no _ 61..:.9:'_: r.t 'Wix? . edHeajt1jServicc5 C Q : r..^?.:• ...?.._. Db24b051 Y. ited KARDEX 1 ,of Qv 84 8.? btu alth Services sty r c. A oR 1$ 01/27/2400 F 09/24/06t?.. ; ._ spite t aVRLA1<Os. 1a?f ? sxo Aes+ssment Admission.Rafertat Needed Follow Up•Referra . De pimml A 7a mments ] Car lopulmonary ? Yes ? No ? Yes ? No P C P : JB s ? Yes C.as Manager ? Yes ? No ? Yes ? No ? Yes ? Yes ' Cha in ? Yes ? No ? Yes ? No ? Yes ? Yes infe tion Control RN 0 Yes ? No ? Yes ? No ? Yes ? Yes Foo? & Nutrition ? Yes ? No ? Yes ? No ? Yes ? Yes Phy cal Therapy ? Yes C7 No ? Yes ? No ? Yes ? Yes Occ tional Therapy ( order) ? Yes ? No ? Yes ? No ? Yes ? Yes 5 h Language Pathology { order) 11 Yes ? No ? Yes ? No ? Yes ? Yes Child use UQison ? Yes ? No ? Yes ? No ? Yes ? Yes WOC ? Wourxi ? Ostorny ? Incont hence ? Yes ? No ? Yss ? No ?Yes ? Yes Leer ing Need: Lear ing Need: Lear fn4 Need: Adv nce Directives Initials Date/Follow-up Date If Pa ont Has Advance Directives: 4rnilY rxAiied to bring in (reminder dales) opy placed on Medical Record If pe 4-nt Does Not Have Advance Directives: 4ucation to Patient F Completed/Copy on Medical Record 4py to Patient Pain ?anaqemnt on Admission Initials Date Patient' Personal Pain Goal: Patien arnNy Teaching Booklet Minbuted and Reviewed Patient' rights to effective Pain Management Teaching Explained to Patient/f-amlly Hint of Patient's Stay (optiomly Recoplod: ,wanni I + n k * d H e n i t h S c n * r s p P Y 1 S F Y 1 C . A tl• 1- L 1 1 A Jnited X?NfLLAKOS. JA#tS xo HMth Services KARDEX i S2 4 T K 190 ST CA!?L1SLF PA 17013 Hospitals 0' 0040000 3 57024 12 140 ROOM AGE: ADMISSI S A : 0 In Patient Q Amb Surg. ? Mod Observation ? Extended Amb Sur g. DOCTOR/CONSULTANTS: CONDITION: ? FAIR O SERIOUS ? CRITICAL FAMILYIS.O. PHONE: ADMITTING DX/ -? . OTHER DX / DATE: {.:a' Y•ti?_..:?? ` k '?" ('? ?'' RESUSCITATE: SURGERY 1 PROCEDURE DATE: ISOLATION: ? AFB-Alrbome 0 Airborne ? Contact 1 ? VRE O C-Ditt ? Immunosuppressed ? Droplet Io?; j. iC3?r_? ?;n ` : ?N„ ? MRSA ? VRSA ALLERGIES: Pulse/Resp/BP Temperature 02Saturation Neurocheck DIET /TUBE FEEDINGS: ? FEED ? ASSIST 1&0 WEIGHT CHEMSTRiP ? Every shift ? Every a hr DRAIN 1 TUBES J a) Uy. At Your Request Program: ? Yes ? Assist ? No FLUID RESTRICTION: Schedules: ? Posiiioni ? Ambulation ? Splint ? ROM ? oce TREATMENT(S) / MISCEL»LANEQU5 RESPIRATORY Mobility Protocols: ? 1 ? 2 0 3 ? 4 ? Fail Alert _ ? BeOrail entrapment risk 1 t N I 1 - lan••., S L f D IV bIrLINE LOCK N J I 91 ServkZ KARDEX II rllted F$ealth vices 1-o"` So0b24bOS.t ..,. 4 R4 $1 bU 4. DEFY ISFVIC ADELISA Y: . 01/7.7/2,)00 F 09/24/06. 40 :... . K.Ahrl Ako$, JAMES Si4 TH100 ST f- CARL I SLF P4 17013 C'OOOOOCOO S 5702412140 1'Cp: CCT DA •04DEREDI UlITIAL TESTS lSU+IGLEORDERS ORDERING PARTY ORDEH NUMBER LX&TF• GOMPLFTED ? J -iir 0-s- ' , .. , -cry- rr? a? r iqjace r r? rig I c ho,6k- I , i/ l? fl // -? C5 1! f u-? rap, x f L ct »VUV ITI,ILI. WVV) ..j U?ete?df 1rltJr ti r rctr * Do Not Remove If Record Is Thinned United To Be Reviewed at Discharge* Health Service-s Hospitals PRESCRIM11 ORDER FORM Medication Assessment and Reconciliation DERVISEVIC, ADELISA 500-624-6059 MR#: 4848760 DOB: ol/271200p ADM DATE; F 6Y OOT 09/24/2006 'i7 59 AUTHORIZATION 16 GIVEN TO THE PHARMACY TO DISPENSE A GENERIC AND THERAPEUTIC EQUIVALENT DRUG WHEN A BRAND NAME IS ORDERED UNLESS THE PRESCRIBER REQUESTS THAT THIS BRAND 1$ USED By CIRCLINO THE NAME DA E TIME WRITTEN 9 ? y D(o ALLERGIES /?fr? Information obtained:,?rpatient/Family ? Bottles/List ? Old Records ? Retail Pharmacy ? Other: ? MD Office Records For Prescriber Use _ Home Medicstlons OwAfTkne Fo, r Use CH= (1) EN:H MUM AS Cheek boat to continue Muds M hea Ilsi Dose/RouWFrequenay tlnclude HerbsUOver the CounMrivitsmin*) R"4*n for PRN mods Taken Don se distharge Order See Outer CWder stop ? Patient takes no medications XXXXX NO Ut/ l -h ? k !may sessment History Completed O Date: 2Z Medication As Write additional admission medicabon Orders on physicians order form and / or pre-printed order farms Per PaT Committee Orders for herbals will not be di need. ADM19$1 DISCHARGE PRESCRIBERS SIGNATURE J&Yf- TIME PRIES ER'S SIGNATURE DATE TIME 13 TELEPHONE ORDER READ BACK TO PRESCRIBER AND VERIFIED. i r NURSES SIGNATURE DATE TIME ? TELEPHONE ORDER READ BACK TO PRESCRIBER AND VERIFIED. NURSE'S SIGNATURE DATE TIME 9 c C C I ? ' RRESCRIBER'S C -" DER F0I AU TIQN IS GIVEN TO THE PHARMACY TO DISPENSE A GENERIC AND THERAPEUTIC EQUIVALENT DRUG i uuEN A BRANI NAM IS ORDERED UNLESS THE PRESCRIBER SPECIFICALLY REOUESTS THAT THIS BRAND BE USED BY CAR ;,,MP-NAME. DATE TIME WRTT'EN ALLERGIES: 1 1 HECK .? EA CH ORDER r `r r :. w TF ANSMSED ? U7 0 C) • 1 .? ' W 1.r? 6I ..? • S J ? .ry , y N 1 s ai-P a v{ `r CtSr4 A a n .? r J? ?? p. 5 v c? ;rs "Jo x .p n- 13 K c G i-r cr TELEP READ BACK TO PRESCRIBER AND VERIRED. TIME NOT ED NURSES PRESCRI S MATURE DATE 'TIME DATE TIME WRITTEN ALLERGIES: v Jl C ECK ( } N ?? t C .) EA CH ORDER '? TR A AS RISE /? ru Ci u r) . ) y • Q H 1 ? f 0 (4 „? r M?-? V U Q L. rir o t 4? A, r?iw- s r, v+ :3 I (Z ? ?. s+ ? - Q Gtr - y V 1 w G - NEORIMR READ BACK TO PRESCRJBER AND VERIFIED. 11ME NOTE FtSE`S S •' NOUN VIED ABAREVIATIONS PRESCRIS 31GNATURE DATE ?. TIME DATE I WE WRITTEN ALLERGIES: II " .?` ab y T , ry EA0 I ORDER AS ••1 • _ • ? L ?+? mb 4? q C:1 Y w ra M il m. L J ? TEL , QRDER READ CK TO PRUCRISER AND VERIFIED. z •'a TIME NOTED U UNAMROVED A01REYMTI0018 •'; ... ••a -.. PRESCRI S SIGNATURE DATE X, Z fib s ? i I • PR_ESCRIBER'S ORDER F4_ AUTHORIZATION IS GIVEN TO THE PHARMACY TO DISPENSE A GENERIC AND THERAPEUTIC EQUIVALENT DRUG WHEN A BRAN NAM IS ORDERED UNLESS THE PRESCRIBER SPECIFICALLY REQUESTS THAT THIS BRAND BE USED BY CIRCUNG . - - T 6Mn- DATE TIMF WHi7EN A LERGES: ? HECK ? • ? ? v m ... --? EACH ORDER AS Csr-ry. TRANSCRIBED ZA4 cli Ci C?# r% v00 .4 w _ 40• V _ .-4 • rL 20. C5, vs Cyll p N ZA 'a )w Ilia _ ?? ?1 Al - . O O o. I).- LOO C, cr I L- J =5WOME READ BACK TO PRESCRIBER AND VERIFIED. Q TIME NO D NURSE'S PRESCHI F'S SIGNATURE fIATE TIME 'srt I - sl yi< f: ct DATE TIR'IE WgR,?•T?EN ALLERGIES: _ !UU EA H ORDER AS h :-fr as c? 0 I R SCRIBE: D - _ n Cs s. *u w. -- '!? "Q cs . T3 i `? ?H L Q r r., ,v .c - w 0 .,. -4 r .,at -• C (r cs a La x +- ?. ;++ pow- Af CA to- C - w L sr 4..._ - U X ? p f" rw a top r U ?? 00 TFkLl NE ORDER READ TOP ESCRIBER AND VERIFIED. Q o # H' TIME NOTE 7S -NUR T %NP SI URE .% (,J r PAO P PRESCA113 GNATJRE A r T E Alm •. ?• DATE FIMERITI ENGIESA CH ss "` .,O EA(. ORDER AS F TAA RIBED e. . ijo Co c-, r- z2eki CE r^ (?4?Al to CA - 0 Q a. '?Y vi r+ v? ?. l ?` w tid I I TELEPHONE ORDER READ BACK TOP AND VERIFIED. # f8? LE OT 1 N 'S 9fON UkE1a ;';"+'•' t'% ,n v R RI S NATUR / DATE TIME T Y>' ".?. PRESCRIBER'S ORDER FO AU RIL4TION IS GIVEN TO THE PHARMACY TO DRSPENSE A GENERIC AND THERAPEUTIC EQUIVALENT DRUG WHEN A BRAN NAM IS ORDERED UNLESS THE PRESCRIBER SPECIFICALLY REQUESTS THAT THIS BRAND BE USED BY CIRCLING THE NAME. D 71 p FN JALLERGIES. -: yr fool, HECK ( ) `+s .") A cn C5 C7 E CH ORDER 1W -.V A. -. ,. AS a •.. ?. T NSCRIBEI7 •-? ?"' ?' .? ? t :l va ? '?• tYY 17 ? -n :f ?e{.)C 'G G? o .rl e o o ?.? a e C e? !t ?q / = CnU0 ;il 74 n J ? ??1 ?h '-4 s'M z (C rK ?' -+ 3 Q 'ik. 7 opt XCO?`G?i -- ? , o ter EPHOM RD -A READ BACK TO PRE9 D vERiFIED. " 5 LA ?? GJGt ?P ! ?--• Cl TIME NO U NU NA U .f L??w 16-c4f r / a. f'HL5QRIH H-S SIGN) i • tt DATE TIME WRI• C ECK ( ) EA ORDER AS THA SCIIIDEL ow". 1 7,0,6 ORDER aL?_ t 9U.- J. I ;LEPHOPM OPDER READ BACK TO PRE9CAIQER?ND VEAIF1ED. /t715 -72_3_._ 6 n Tq PMWPRMR READ BACK TO PREameEA AND y RIFIED. - - unir ,or 't7 Cyn'?+?GCa .. ?1 /-- ^.' 117 S L3 W "' 4 I S .. `? to .".] r.J U 1 CL 0 ? n ca N to [] y r V • ? , ?{ Ln p a. •V Vs ` Ir1 .'?i ? ? .jr r i w C? ` co ? O •i. N ,.. `*. tr W p Oi J .. •• jai :. j t7 ?-f .Tt srt ? ?! v ca 0 1- -m W ?..w v -v G ?rUG^+ « • . 44 C4 a -4 A- C3 a •,? s. vi o ? *n f ?A '2 00 ti ? ^11 t- 41 O ra C3 , *kAr?kic t*ikit*ie?#*?riticicYcirkklt-kici?f#Ark?ciF?k11r#,k-kkltlt#?rk*?tkyt**fi*irtir**klr?lr?t**,k**?FIt?IriI?rIF**yt?t UNITE HEALTH SERVICES HOSPITALS PAGE: MED CATION ADMINISTRATION REPORT NAME: DERVISEVIC ADELISA ST4 B446A ATN MD: KANELLAKOS, JAMES MD PT#: 5006246051 MR##: 4848160 AGE: 6 SEX: F ADM DATE: 092406 FRO : 09/24/06 00:01 TO 09/26/06 24:00 M A R PERMANENT CHART COPY ----- RDER INFORMATION -----------?---Q9/24 ------_'09/25 - 1 09/26 ----- --------------------- -------- -------------------------- ----- -------------------------- C FAZOLIN SODIUM 1GM/D5W 50. ML C FAZOLIN SODIU 50. ML IV Q8H Q H ROUTINE ROUTINE ORDERS F 48 HOURS S RX00005 01 0.00 00 .50H 09 25 09:00 TO 09/27 06:30 BT :A VOL: 50 ML IV RA : 100ML/HR RUN-IN: 30 M DRIP TE: ------- + ------------------------- ONE TIME & STAT TE ANUS DIPTHERIA TOXOID PEI) DI HTHERIA/TETANUS 0.5ML TUBE 0.5 ML IM ON E ONCE STAT 0. ML/1 SYRING SY ZNG S RX00002 09 24 20:35 TO 09/24 20:35 F AMYL CITRATE - FE TANYL CITRATE 25. MCG IV ON ONCE STAT 2S CG/0.5 ML 2035 2035 SMS RX00003 09/ 4 20:35 TO 09/24 20.35 0916 MC1508 2238 LW4950 0542 R04707 1406 MC1508 2302 LW4950, -. -- ---..-.-.-- - - - - ------------ - - _ -- ` - - - _ - SEE END F REPORT FOR LIST OF PATIENT ALLERGIES *CANC* -D/C * - NOT ADMI PERMANENT CHART COPY 16:00 09/217/06 FROM W001,OCMARDFI ylr~kak8ttl*tk~klkirlk#~Ir~t*91r~it#~Irirak~kyti~+lr7k~k*~irdr~k~lh~kyt~k~h~ir*11r~rar~rietikrt~#~tk*~kyF~,F**~fr*~Ar~F~k*it**##r~ltik*~rir~lrir9r* UNIT$ HEALTH SERVICES HOSPITALS PAGE: MED CATIbN ADMINISTRATION REPORT NAME; DERViSEVIC ,ADELISA ST4 B44bA ATN MD: KANELLAKOS, JAMES MD PT#: 5006246051 MR#: 4848160 AGE: 6 SEX: F ADM DATE: 492406 FRO : 09/24/06 0001-TO 09/26/05 24:00 M A R - _ PERMANENT^CHART COPY -'--- RDER-INFORMATION'_---------''--_09/24`-__'-__09/25----'---09/26----±--- __---7------------------------- C DEINE C DEINE PHOSPHATE 25. MG zM Q4 PRN EVERY PRN 25 MG/0.83 ML SE ERE FAIN SM RX00008 ,.- 09 25 03:31 TO 10/02 03:31 -CO EINE/-APAP----~-__~_---__~_ ENOL Wi CODEINE ELIXIR 5. ML PO Q4 PRN EVERY PRN 5 /5 ML EL XIR MO PAIN src Rxaaaa~ 09 25 03:30 TO 10/02 03:30 PRN ORDERS **** NO IONS - __-= {}440 R04707 0959 CK7Q31 1858 LW4950 **** 0126 RO4707 ---. ~ 0903 MC1508 1437 MC1508 ------- ----------------------- NURSE zDENTTFICATION R0470 RAYMOND OSTERHQUT REGIS MC1508 MICHELLE CODNER LW$95 LEAH WADE GN CK7031 CURTIS KUNKLE - -- -----`-------" --'----- PATIENT ALLERGIES *NKDA ---------------- SEE END REPORT FOR-LIST OF PATIENT-ALLERGIES *CANC* -b/C- * --NOT ADMI __-_-~-- -------------=--=z=-~-=_=---___-__-____--___-_~=____-_____--_____-_-- PERMAi+tENT CHART COPY 16:00 09/21/06 FROM ~QOI,OCMARDFI *F#+k**?It*ik#h**klt9lr#***tk*?Ir?lr*?r?ir?rilrlr*klryt**IrvF*k?'irlr?ir*Ft**Y4**it?r*9Fat*?tyFAr#ifrIEkAr#k91rk*tic*k*UNITED HEALTH SERVICES HOSPITALS PAGE: MEDICATION ADMINISTRATION REPORT NAME: DER.VISEVIC ADELISA ST4 B446A ATN MD: KANELLAKOS, JAMES MD PT#: 5006246051 MR#: 4848160 AGE: 6 SEX: F ADM DATE: 092406 ====-===========-------------- ----------===`======="~_=========--======_===- FROM: 09/24/06 00:01 TO 09/26/06 24:00 1 V A R PERMANENT CHART COPY -----------_,__-------------------__ ORDER INFORMATION ( 09/24 1 09/25 ? 09/26 --------------------------- ------------------------------------------ ------------ ------------------ ROUTINE ORDERS -------------- SODIUM CHLOR 0. 1000. ML IV Ql Q13.25HR EVERY ROUTINE SMS RX00004 0075.00 013.25H 09/25 03:45 TO 09/25 03:45 BTL:A VOL:1000 ML IV RATE: 75ML/HR RUN-IN: 795 M ,.- SODIUM CHLOR 0.451 1000 .' ML *0419 R04707 _______________________________ ONE TIME & STAT TICARCILLIN/CLAV 1. GM TICARCILLIN/CLA 1. GM IV ONCE ONCE ONCE STAT SMS RX00001 000.OOH 09/24 20:33 TO 09/24 20:33 BTL:A VOL: 0 ML IV RATE: OML/HR RUN-IN: DRIP RATE: 2033 ------------------------------- NURSE IDENTIFICATION --------------- R04707 RAYMOND OSTERHOUT REGIS ------------------------------- PATIENT ALLERGIES --------------- *NKDA -- ------ ---- --------------- SEE END OF REPORT FOR LIST OF PATIENT ALLERGIES i *CANC* - D/C * - NOT ADM] PERMANENT CHART COPY _ 16:00 09/27/06 FROM C4001,OCIVARFI UNITED HEAL-.H SERVICES HOSPITALS MEDICATION ADMINISTRATION REPORT LAST PAGE: 4 NAME: ERVISEVIC ADELISA ST4 B446A ATN MD: KANELLAKOS, JAMES Ml PT#: 006246051 MR#: 4848160 AGE: 6 SEX; F ADM DATE: 092406 MAR FINAL MAR FINAL DISCHARGE DISCHARGE --FRO •-----------------TO--_,_'T =V=A=R;===PERMANENT ?CHART COPY --------------------------------- --- - -------------- ON EFFECT/CHARTING HISTORY IVAR-REAS------------------------------------------------------------------------ -- ------------- -- CHARTING REASON AND EFFECT ------ -_-_ PLLVP 1000. ML IV BOTTLE ID: A VOLUME: 1000 ML RATE: 75 ML/HR RUN-IN: 7953M25HR EVERY 09/25 0345 0419 R04707 REASON: INFUSING r. --------------------------------- R0470 RAYMOND OSTERHOUT NURSE IDENTIFICATION --------------- ------- ____---_ REGIS *NKDA -------'--- PATIENT ALLERGIES --------------- --- --- -- ------ --- ---- -- ------- --------- SEE END OF REPORT FOR LIST OF PATIENT ALLERGIES ------------------------------- _______ *CANC - NOT ADMI ==-=__-_- -------==-'PERMANENT CHAR 1 16:00 09/27/06 FROM 0001, OCIVARF2 7F?r*** **#*'k'*#*k#**?r$k#*##'k#-k###icirihlelr##-k*lr*YF*t*tiirAtkikir 9k#Y***t**iFicityttiF##**iF** UNITE HEALTH SERVICES HOSPITALS PAGE: MED CATION ADMINISTRATION REPORT NAME: DERVISEVIC ADELISA ST4 B446A ATN MD: KANELLAKOS, JAMES MD PT#: 5006246051 MR#: 4848160 AGE: 6 SEX: F ADM DATE: 092406 FRO 09/27/06 -00:01 TO 09/27/06 24.00 M-A R--r- PERMANENT CHART COPY ----- ----------------------------------------------------------------------- RDER-INFORMATION-- ----------------------------------------- 1 09/27 1 _09/28----'-_-09/29----1-- ----- ---------------------------- ROUTINE ORDERS -------------- C PHALEXIN 1331 MC1508 FLEX 500. MG PO O E ONCE ROUTINE 500 MG/1 CAPSUL C AT DISCHARGE SM RX00009 09 27 12:30 TO 09/27 12:30 CE AZOLIN SODIUM 1GM/D5W 0628 R04707 50. ML CE AZOLIN SODIU 50. ML IV Q8H Q8 ROUTINE FO 48 HOURS SM R.X00005 01 0.00 00(.50H 09)25 09:00 TO 09/27 06:30 HT :A VOL: 50 ML IV RA E: 100ML/HR RUN-IN: 30 M DRIP TE: --------------------------- -- PRN ORDERS --------------- CO INE COD INE PHOSPHATE 25. MG IM Q4H PRN EVERY PRN 25 G/0.83 ML SYR NG SE RE PAIN SMS RX00008 09/ 5 03:31 TO 10/02 03:31 **** NO ADMINISTRATIONS **** --- ------------------------------------------- SEE END F REPORT FOR LIST OF PATIENT ALLERGIES *CANC* -D/C * - NOT ADMI PERMANENT CHART COPY 16 : 00 09/21/06 FROM @?001, OCMARDFI ?t##*ir 'kikirik#?klFitiFilr9ti#?Yylr?k?k*?F?F+k#yfr?Ir?IIr?Firfir?k*ylr?lrirrii4?k?lt?k*?iFaF?r?k?F**yt?F?irk*?It***#ik**?lr?F#*?F?kyt*ylrikh UNITE HEALTH SERVICES HOSPITALS LAST PAGE: MED CATION ADMINISTRATION REPORT NAME: DERVISEVIC ADELISA ST4 B446A ATN MD: Y%PMLLAKOS, JAMES MO PT##: 5006246051 MR#: 4848160 AGE: 6 SEX: F ADM DATE: 092406 FRO C T 4 5 E. M+ 0 -09/27/06 -00:01 TO-09/27/06^ 24:00 M-A-R _ -PERMANENT-CHART-COPY - - ------------------------------------ RDER INFORMATION 1 09/27 + 09/28 + 09/29 DEINE/ APAP 0905 MC1508 LENOL W/ CODEINE ELIXIR 1331 MC1508 5. ML FO H PRN EVERY PRN ML/5 ML IXIR D PAINT S RX00007 /25 03:30 TO 10/02 03:30 - - - - - - - - - - - - - - - - - - - - - - - MICHELLE CODNER ----------------------- MC150 *NKDA NURSE IDENTIFICATION --------------- RN R04707 RAYMOND OSTERH PATIENT ALLERGIES --------------- ------------------------------------------------------------ SEE END F REPORT FOR LIST OF PATIENT ALLERGIES *CANC* -D/C * - NOT ADMI PERMANENT CHART COPY 16:00 09/47/06 FROM @001,OCMARDFI Lh*ed+t(alrl;y.°r:>sc? United Health NURSING DIVISION ? I 10 t ?f xt1QQ i 001f4/,1? .k` SerV1CES j 9 t E if 0 f JAIit # 50 Hospitals Patient Discharge instrudk olvW ates S1 CA ri I ?R t PA 17013 PATI T RE>I;PONfE TO SC HA ; f g • ?' 7 . , I. ACTIVITY: 2. VITAL SIGNS: 7)r _?`- Oa 4. VALUABLES (in a s%): OYES 9<0 & PA 7. WOUNDS SIGN STATUS: /6- C YES DiVD PAIN LEVEL: eye iK2iST M[frSiTIAI AI 16itRTf?ItP!Tlt-1t?etlw R AWIn ftsm A M.Nv .14 lmart Laftw hh •unreinutun nar%v?nrra. n-U-0 4 1_1 Q t r A (44 z5iWxtj9z r-- / CC ViL T ) . ?'?5 C {i Dot 5 a.n n h ? -. ' 0, 11_U11d= l.L Afcw \/nd-c m? P T)r_ TEACHING MATERIALS GIVEN: NO SMOKING: Avoid all types of tobacco. Maintain a elmoke-free environment. Ask your doctor or Nurse 01rect (007.703.6665) or the New York State Smokers' Quit Line (1466-NY-QUITS) for assistance in quitting smoking. Pnewavala and Flu Immurthudw Status: CI Pneu acdne phre , ae ordered at diamape 0 Pu vaadne qhw (0ollotler-Fet(uary} as ordered at dim:haMe 13 Immurb aft Pa&*4 arrwiet given to pMlent dace gat wish to order immunixatior. in hoollal: ? Pneumooosi ? Flu vaccine n Patient Inc U08d to blow up V lml dgttw to pet IrnmunWrftp* dog Ws ofte CI No f lo*-up needed: Vaccine ow*aindio lied DISCHARGED: ;HOME E C'''WHEELdaI DESTINATION: OTHER PL SE SPECIFY FOLLOW-UP APPOINTMENT: V/ _L.?.? NOTIFY HEALTHCARE PROVIDER IF: 4112 GENERAL INTRUCTIONS: IF FOR ANY REASON YOUR EMERGENCY DEPARTMENT IMMEDJATELY. 0_ AMBULATORY 0 vt• 141 ?n ?i a. DRASTICALLY, ALWAYS FEEL FREE TO 00 TO THE ? FOR MENTAL HEALTH EMERGENCIES WHEN HEALTHCARE PROVIDER IS UNAVAILA11LE CALL: Mental Health Hotlino: tttle'GH CPEP - (WT) dig- or 1.500 451 DrI Aloohoi I"U": (S07j M-22!17 I UNDERSTAND ALL INSTRUCTIONS GIVEN, e 1e ? PATIENJ/ NIFICANT OTHER TE THAN, OU FO OOSI U ITED H LTH ERVICES. IF YOU RECEIVE SU EY IN THE MAIL, SE LL tIOUT 8 CONTINUE TO SERVE R NURSES SIGNATURE 58W7V rev 01.06 White - Petient Yellow - Medical Record Plnk - Phytllicillrl _.? 2. DIET!, -A L - -- 4T 1 b DISCHARGE MEDICATION/ORDERS CHECKLIST LOCATION: ST4 BED #: B446A MEDICAL RECORD #: 4848160 ATTN. M.D.: KANELLAKOS, JAMES MD PATIENT 5006246051 ADMIT: 092406 DISC: DOB: 01212000 SEX: F PATIENT NAME: DERVISEVIC ADELISA FOR USE AS DISCHARGE INSTRUCTIONS, PLEASE INITIAL NEXT TO EVERY MEDICA ION YOU WISH PATIENT TO CONTINUE, OR CROSS OUT MEDICATIONS WHICH DO NOT AP LY AS APPROPRIATE. ANY ADDITIONAL MEDICATIONS SHOULD BE ADDED IN THE B KS BELOW WITH DISCHARGE ORDERS AND/OR INSTRUCTIONS. DISCHARGE TO: ?''HOMF, SNF ACF BOARDING HOME OTHER HOME WITH HOSPICE CARE HOME WITH: ./NO SERVICES HOMECARE IV THERAPY 02 -jIET: REGULAR CARDIAC DIABETIC oC¢ "? OTHER rr ?2 O z Q LAB: USE OUTPATIENT ORDER FORM ACTIVITY: APPOINTMENT WITH : DOCTOR : DATE : TIME : DOCTOR : DATE : _ TIME SPECIAL INSTRUCTIONS : '717 a -74 OTHER MEDS : pfl' .ems i f C f C. f Z• f ? G -? ? ?'r?' !? ? '7" ! `-•p ,tit ?D orb °F' dI, ? o ?-c p :, ' q n h 4- A PLEASE SIGN BELOW : r Z1,P-WQ 6 DATE if '3n TIME ?`Q7?7 c`~ tom, ?? M . D , D SPD97947 10:38 09/27/06 FROM @OOF,$?SDSPAFI DISCHARGE MEDICATION/ORDERS CHECKLIST PAG E: 1 LOCATION: ST4 BED #: B446A MEDICAL RECORD ##: 4848160 ATTN. M.D.: KANELLAKOS, JAMES MD PATIENT: DERVISEVIC ADELISA ADMIT: 092406 DISC: PATIENT #: 5006246051 SEX: F DOB: 0127 000 PHYSICIAN TO REVIEW ADMISSION MEDICATIONS AT TIME OF DISCHARGE ---------------------------------------------------------------------- ----- ORD ## DESCRIPTION DLY FREQ STR WKLY FREQ STP PR INIT 13 CEPHALEXIN 09128 09:00 10/04 21:00 nn .P . KEFLEX 500. MG TID DAILY CAP R 15 CODEINE 09/25 03:31 10/02 03:31 D IC CODEINE PHOSPHATE 25. MG Q4H PRN EVERY SYRING P SEVERE PAIN 14 CODEINE/ APAP 09/25 03:30 10/02 03:30 ?., TYLENOL W/ CODEINE 5. ML Q4H PRN EVERY ELIXIR P MOD PAIN "To ham`/o r e SPD9794$ 10:38 09/27/06 FROM @00F,Nl9DSPOF2 lIAls?d •, : ? `? United Health Services Hospitals DISCHARGE NOTICE Date: _I I Drell IS;Vic .A"-,LISA 01/Z711?-1300 F 04124/05 K a" l ? Ai(0$, JANE S NO K P4 Ts1 :,a Ali 0A L I S L C^4R.•.T PA 1701$ 5702412140 READ THIS LETTER CAREFULLY - IT CONCERNS YOUR PRIVATE INSU BENEFITS OR MEDICAID BENEFITS OR IF YOU ARE UNINSURED Dear Patient: Your doctor and the hospital have determined that you no longer require care in the hospital ai be ready for discharge on: Day of Week: ate: -4&-k ?'4 IF YOU AGREE with this decisi ou will be discharged. Be sure you have already recei your written discharge plan which describes the arrangements for any future health care you may w IF YOU DO NOT AGREE and think you are not medically ready for discharge or feel that your discharge plan will not meet your health care needs, you or your representative may request a review. Contact the review agent indicated on the reverse side of this letter if you would like a review of the discharge decision. IF YOU WOULD LIKE A REVIEW, you should immediately, but not later than noon of the next business day: Day: Date: 1 1 call the telephone number listed on the rever of this page. IF YOU CANNOT REQUEST THE REVIEW YOURSELF, and you do not have a family membi friend to help you, you may ask the hospital representative at 763-5289 (Wilson Memorial Hospital) or 762-2530 (Binghamton General Hospital), who will request the review for you. IF YOU REQUEST A REVIEW, the following will happen: 1. The reitiew agent will ask you or your representative why you or your representative think need to stay in the hospital and also will ask your name, admission date and telephone nurr where you or your representative can be reached. 2. After speaking with you or your representative and your doctor and after reviewing your record, the review agent will make a decision which will be given to you in writing. 3. While this review is being conducted, you will not have to pay for any additional hospital until you have received the review agent's decision. WSW Rov. LIM ccontimW on bwk) will official side or IF THE REVIEW AGENT AGREES WITH THE DISCHARGE DECISION. you will be financially responsible for your continued stay after noon of the day after you or your representative has been notified of the review agent's decision. IF THE REVIEW AGENT AGREES THAT YOU STILL NEED TO _BE.lNi THE HOSPITAL: for Medicaid patients, Medicaid benctits will continue to cover your stay: for private health insurance patients. coverage for your continued stay is limited to the scope of your private health insurance policy. NOTE: If you miss the noon deadline mentioned on the 1st page of this notice, you may still request a revievy. However, if the review agent disagrees with you, you will be financially responsible for the days of care beginning with the proposed discharge date. If you would like a review of your hospital slay after you have been discharged, you may request a review by the review agent within thirty (30) days of the receipt of this notice or seven (7) days after receipt of a complete bill from the hospital, whichever is later, by writing to the review agent. .M" The Independent Professional Peview Agent (IPRA) for your area and your insurance coverage is: •. (;heck the Oax whin) ind!cafes tho Fahenr's i)f?trli?i y F7iiVOf at discharge.) "I For Medicaid, Commercial Insurance and Self Pay Patients: Island Peer Review Organization 1974 Marcus Avenue, First Floor Lake Success; New York 11042 Phone (800.) 648-4776 (M-F) _1 For HMO Patients: Request an expedited appeal by contacting your HMO member service department. I have received this notice on behalf of myself as the patient or as the representative of the patient. Relationship [gate --- - --Time --- kz5i DERVISEVIC. ADELISA Fl?ilte?dHc?tJtlt Sc rniri'+ 500-624-WSI ?..?.,. ,.. DOB: 0"/27/2400 MRM 4841 160 ? United ADIM DATE: 0924!2006 17 Health Services CONSENT FOR OPERATION OOT 6Y :59 Hospitals AND/OR OTHER PROCEDURE PATIENT: DATE: / a4//V ? 4s 71ME: I, the above mentioned patient, hereby authorize Dr. an -( 71akis and/or other assistants as may be selected by him, to tree the condition or conditions, and/or to perform the operation and/or other procedures which appear indicated by the diagnostic studies and/or inical diagnosis heretofore made. r The operation(s) and/or procedure(s) necessary to treat my con n have been explained tom by Dr. and I understand the nature of the o peration and/or procedure. It has been explained to me that during the course of the operation and/or procedure, unfore3 conditions may be revealed that esquire an extension of the original operation and/or proced different operation(s) and/or prooedure(s) than those set forth in paragraph above. I, therefo horize and request that the above name physician, his assistants, or his designees, perform such o n(s) and/or procedure(s) as are necessary and desirable in the exercise of sound professional jud Jee t The authority granted under the paragraph shall extend to treating all conditions that require ent and are not known to the above physician at the time of the; operation a?lndtor proce dureis comm ed. 1 understand that sales rep resentativeas and/or other observers may be present In the operatin during the operation and/or procedure; and that photographs and/or videotaping may occur fo purpose of diagnostic study or the advancement of medical knowledge with the patient's identity remain anonymous. I have been informed and am aware of certain risks and consequences that are associated with e operation(s) and/or procedure(s) described. I am aware that the practice of.medicine and surge is not an exact science and I acknowledge that no guarantees have been made to me concerning the ejoults of the operation(s) and/or procedure(s). I have also been informed of possible: alternatives for ca or treatment including no treatment, and forseeable risks and benefits. Any tissues or parts surgicall removed may be disposed of in accordance with the accustomed aactice. I also hereby consent to the administration of anesthe sia lsedastion, as necessary, and am aware ere are certain risks, benefits and altematives associated with the administration of anesthessialsedation . I ? 00 / ? Do Not consent to the admission of medical sales representatives and/or other ob rs El Not applicable . My relationship to the pa Is that of Gi (Self or Relationship) .? , ?• ass (S• ?) It of signed by pedant, Indicate reason: PHYSICIAN ATTESTATION I hereby ce"that I diswund th r*s and benetra of, and altema6vea to the above stated operation(a) and/ Procedure(e) with the above ant and/or their health care live. (fie (Deis) (Time) 5202 5rev9.li35 Hat1d r SeMt ic^ tJ ited H alth Services prowl s f v It: a FEL1 SA 11 27/2;:0 F 09I24IOb H spitals K A* L L AX 5. J t s E S 0 U 24 T-.,ST a : 1 Vt.. PA 17413 57424 1 2 1 40 P .P T RE U T FQR AND CONSENT FOR. ANESTHESIA fern anesthesia is relatively safe and uneventful so that virtually everyone can be affurded its benefits. Mo. rations can be performed utilizing general anesthesia, regional anesthesia, such as spinal or epidural ithesia, nerve block anesthesia, or monitored anesthesia care, or combinations of these. The type of sthesia drug(s) and technique(s) will be decided by your anesthesiologist and the. choice and any medically ;ptable alternatives will be discussed with you. Every type of anesthesia has certain risks. Unexpected :tions and complications may occur, however, and vary between patients where medical conditions appear :rwise similar. Ris s and hazards which are recognized by anesthesiologists as substantial and which can occur regardless of ex rience, care and skill of the anesthesiologist include, but are not limited to, broken teeth, allergic reactions pn umonia, phlebitis (inflammation and infection of the veins), nerve injury or paralysis, damage to or failure of a heart, liver, kidneys and/or the brain, and death. In most cases these risks and hazards are rare. Your ane thesiologist will do his best to protect you from such risks and hazards but no guarantee as to the outcome of our anesthetic can he made. At is hospital, the anesthesiologists practice as a group. This means that the anesthesiologist who sees you bef re your surgery, or who is scheduled to administer your anesthetic, may not be the one who cares for you du to unforeseen circumstances. If a Certified Registered Nurse Anesthetist (CRNA) cares for you, it will be u r the direct supervision of an anesthesiologist. DR LWI has talked with me on ?/ - t,)?! (date) about the anesthetic to administered for my operation.) understand that the type of anesthetic drug or method will be chosen by the anesthesiologist who administers or directs the anesthetic, and that the drug or method may be changed, as edically indicated. I have read the above paragraphs, and they have been explained to my satisfaction. risks, benefits, complications and alternative types of anesthesia have been discussed with me and my have been answered to my satisfaction. that I receive anesthesia for my planned surgery. ip to the patient is that of Self fitness (If riot signed by patient, indicate reason below) FOW 105MUS JFOV a/W) (Minor, or other reason) r'a DF 500 V I EVIC, ADEL1sa od Health Servir M:o 12° 20oo Mn#: 4g48I007- arE; so 0912412006 1I7 ; F G w 59 CO SENT FOR CARE 1 USE OF PROTECTED HEALTH INFORMATION X to the following, ? AM/Pt PATIENTS SIGNATURE' OATVTIMF W11 NESS the patient is a minor (under 18), years of age or, is unable to sign for the following reason: The glow consent is given on the patients behalf by- 6b X q, t PARENT/LEGAL GUARDIAN OR HEAL CARE AGENT OTHER I, am presenting myself for care at United Health Servi s Inc., and l voluntarily consent to the rendering of such care, including diagnostic procedures and medical treat- ment, auth&zed agents and employees of the hospital, and by its medical staff, or their designees, as may in their pro- fession I judgement be deemed necessary or beneficial. ackno?nrledge that no guarantees have been made to me as to the effect of such examination or treatment on my condi- tion. l ... CONSENT TO USE PROTECTED HEALTH INFORMATION Our No ice of Privacy Practices provides information about how we may use and disclose protected health information about y u. You have the right to review our notice before signing this consent. As provided in our notice, the terms of the notice ay change. If we change our notice, you may obtain a revised copy by referring to the United Health Services Hospital Privacy Notice. You ha the right to request that we restrict how protected health information about you is used or disclosed for treat- ment, yment or health care operations. We are not required to agree to this restriction, but if we do, we are bound by our aqr ment. By signi g this form, you consent to our use and disclosure of protected health information about you for treatment, pay" ment an health -.,are operations (inclusive of reminder notices) as well as acknowledge the receipt of the United Health Services Inc. Privacy Notice. You have the right to revoke this consent, in writing, except where we have already made disclosur s in reliance on your consent. ASSIGNMENT OF INSURANCE BENEFITS I hereby ssign and transfer to United Health Services, Inc. and each and all of its affiliates sufficient monies and/or bene- fits to wh ch I may be entitled from government agencies, insurance carriers, or others who are financially liable for my hospitaliz tion and medical care to cover the costs of the care and treatment rendered to myself or my dependent. (continued on back) 5213212A rev 02.06 United fleal th Services GUARANTEE OF PAYMENT I understand that some hospital and medical services are not covered by insurance. Non-covered services include private room difference, discharge medications and some hospitalizations for cosmetic surgery, dental and sterilization procedures. I understand I must pay for non-covered services. I give my permission for an analysis of my credit to be done if there are substantial balances owed. I hereby guarantee payment of all hospital charges incurred by the patient named on the face of this sheet from date of admission to date of discharge. Charges shall be the hospital's prevailing or posted charges during the time of patient's hospitalization, a list of which is available for the patient's examination. FOR PATIENTS ENTITLED TO MEDICARE BENEFITS I certify that the information given by me in applying for payment under title XViii of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration and the Centers for Medicare & Medicaid Services or its intermediaries or carriers any information needed for this or a related Medicare claim. I request that payment of authorized benefits be made on my behalf. I assign the benefits payable for physician services to the physician or organization furnishing the services or authorize such physician or organization to submit a claim to medicare for payment to me. BENEFIT QUOTES Insurance benefits quoted to United Health Services, inc. and each and all of its affiliates providers are not a guarantee of payment. Patients are ultimately responsible to confirm benefits with their own insurance company. INPATIENT HOSPITALIOUTPATIENT INFORMATION BOOKLET As an inpatient I have been given a copy of the Patient Information Booklet which explains the Hospital's policy regarding private rooms, personal property, patient's rights and other matters. As an outpatient i have received the Patient's Bill of Rights and Advance Directives. MARKET RESEARCH i authorize United Health Services, inc. and each and all of its affiliates or representatives on its behalf, to contact me for patient feedback about the service it has provided to me. I understand that my name could be picked for feedback based on my specific medical condition, when United Health Services, Inc. and each and all of its affiliates is seeking to improve the health care of its patients with certain conditions. i also understand that this may involve United Health Services, Inc. and each and all of its affiliates disclosing my name and medical condition to an outside company that is contracted to col- lect the feedback for United Health Services, Inc. and each and all of its affiliates. Any such company would be required to keep my name and condition confidential. I understand that if i do not want to participate in this, I may cross out the above paragraph. ..•, 5213212A rev 02.06 Carlisle Pediatric Associates 004 Belvedere Street Carlisle, ?a 17013 oc? i PROGRESS RECORD C\ C61 Dfo:v i , - C- VI wr HT ??C d r-m- p 01^-? ?+? v APPALACHIAN ORTHOPEDIC CENTER, LTD Thomas J. Green, M.D. Daniel P. Hely, M.D. Michael J. Oplinber, M.D. James A. Oliverio, M.D i Dunwoody Dr Phone: (717) 249-6112 Carlisle, PA 17015 Fax: (717) 249-6235 OFFICE RECORDS Dervisevic, Adelisa D013:01/27/2000 09/29/06OFFICE VISIT: Verbal consult on 9/28106 at the request of Dr. Bero. CHIEF COMPLAINT: Broken right leg. HTSTORY OF PRESENT ILLNESS: Adelisa is a 6 year-old female. She was involved in a motor vehicle accident just south of Binghamton, New York. Was seen in a hospital near Johnson City. Was noted to have an open distal tib/fib fracture which she underwent open irrigation and debridement with percutaneous pin fixation. Date of injury and surgery was on the 24th of September, 2006. She's been on Kefiex, 500mg. No complaints., She lives down mere in Carlisle. Seen at Mastand Associates and referred to us. Complains of moderate discomort, 5 out 10. Otherwise no complaints. Complete ROS and PFSH was performed utilizing the patient's Medical History and Screening Form signed, dated, September 29, 2006 with copy placed in the chart. No comments are required. PHYSICAL EXAMINATION: On examination today, Adelisa appears well. Right leg is examined. There is a transverse laceration over the posterior aspect of her leg about two-thirds down the tibia. There's a fi-acture blister just inferior to the incision. No surrounding erythema or discharge. There's two anterior percutaneous pins in place. Pin sites are clean and dry. X-RAYS: Radiographs are obtained today and reviewed from her previous institution. There was a displaced distal tib/fib fracture. Today it is anatomically aligned with two percutaneous pins in place. IMPRESSION: Post irrigation and debridement, open reduction, percutaneous fixation of distal tib fracture. PLAN: New sterile dressing is applied around the pin sites and over the fracture blister. A well-padded, posterior splint is applied. I want her to continue her antibiotics. Well see her back Tuesday to check on her skin for the fracture blisters. We'll delay casting until we're sure that the skin is healing appropriately and there's continued evidence of no evidence of infection. James A. Oliverio, MD/dmg cc: Dr. Bero September 29, 2006 Christopher J Bero MD Masland Associates 220 Wilson St Carlisle PA 17013 RE: Adelisa Dervisevic D.O.B.(01/27/2000) Dear Dr. Bero: i had the pleasure of seeing Ms. Dervisevic in consultation in my office today. As you know, she is a 6 year-old girl referred regarding her right leg, injury. On clinical and roentgenographic evaluation, the findings are that of fracture of the distal tibia. She underwent irrigation and debridement, open reduction and percutaneous fixation at a hospital in New York. She is here for follow up. A new sterile dressing was placed around the pin sites and over the fracture blister. A well-padded, posterior splint was then applied. He will continue with her antibiotics and return here on Tuesday to check on her skin for the fracture blisters, We93 place her in a cast once the skin has healed appropriately and there's no evidence of infection. Thank you for the consultation and for the opportunity to participate in her care. Enclosed is a copy of my office record. Sincerely, JAMES A OUVERiO, M.D. JAO/dmg Enclosure APPALACHIAN ORTHOPEDIC CENTER, LTD Thomas J. Green, M.D. Daniel P. Hely,AD. Michael J. Oplinber, M.D. James A. Oliverio, M.D. 1 Dunwoody Dr Carlisle, PA 17015 Phone: (717) 249_6112 Fax: (717) 249-6235 OFFICE RECORDS Dervisevie, Adetisa DOB:01/27/2000 10/03/06 OFFICE VISIT: Follow up tib/fib fracture right leg. Here for a wound check. No complaints. She's been using Keflex, 500mg., HA On examination today, Adelisa appears well. Pin sites are clean and dry. The blister on the inferior aspect of her incision looks clean. The superficial skin is debrided. The incision is clean and dry. Sutures are intact. No evidence of infection. ASSESSMENT: Post percutaneous pinning open tibia. fracture. PLAN: Follow up next week for suture removal. Clean sterile dressing was applied after the pin sites were cleaned today. New splint was applied. Get x-rays at next weeks visit and apply a cast with window around the pin tract. James A. Oliverio, MD/dmg cc: Dr. Bero 1-0106106 ADELISA MAY NOT RETURN TO SCHOOL FOR AT LEAST 4-6 WEEKS AND UNTIL WOUNDS HEAL ON LEG AND POSSIBLE PIN RFMU,,JAI- LEFT LEG. APPALACHIAN ORTHOPEDIC CENTER, LTD Thomas J. Green, M.D. Daniel P. Hely, M.D. Michael J. Oplinger, M.D. James A. Oliverio, M.D. 1 Dunwoody Dr Carlisle, PA 17015 OFFICE RECORDS Phone: (717) 249-6112 Fax: (717) 249-6235 Dervisevic, Adelisa DOB:01127/2000 10/10/06 OFFICE VISIT: Left distal tib fracture. Here for suture removal. On examination today, pin sites are clean and dry. The wound is healing well. Sutures are removed. Radiographs are obtained. Well aligned distal tibia fracture. No evidence of displacement. ASSESSMENT: Heating left tib/fib fracture. PLAN: Talking with the family, they didn't get her antibiotics after her last visit. Re-emphasized with them that she needs to be on prophylactic antibiotics. We cleaned her pin sites. We applied a sterile dressing and a new posterior splint. She's home schooled now and we'll see her back in 10 days for pin removal and conversion to a cast. James A. Oliverio, MD/dmg cc: Dr. Bero APPALACHIAN ORTHOPEDIC CENTER, LTD Thomas J. Green, MD Daniel P. Hely, MD Mchael J. Oplinger, MD James A. Oliveiio, MD PATIENT: XRAY DATE: DATE OF INTERPRETATION: OFFICE VISIT DATE: ORDERING PHYSICIAN: X-RAY PERFORMED: Left leg, 2 views. INTERPRETATION displacement. RADIOLOGICAL REPORT Adelisa Dervisevic 10/10/2006 10110/2006 10/10/2006 JAMES A OLIVERIO, M.D. 1 Dunwoody Dr Carlisle, PA 17015 (717)249-6112 Tax 1D: 25-1829749 Radiographs are obtained. Well aligned distal tibia fracture. No evidence of DICTATED AND READ BY: JAMES A OLIVERIO, M.D. James A. Oliverio, MD/dmg APPALACHIAN ORTHOPEDIC CBNTSR, Ltd 1 DUNWOODY DR CARLISLE, PA 17015 October 10, 2006 To Whom It May Concern: This is to certify that Adelisa Dervisevic has been under my professional cage. Adelisa was seen in my office on 10/10J06, and is unable to attend school for at least 4 - 6 weeks and until wounds are healed on leg and possible pin removal left leg. RMARKS : Sincerely, • . J OL , Thomas I ('men,'M.D. Daniel P. ? Iely, M.D. Michael I Oplinger, M.D. Tames A. Oliverio, M.A. Appalachian Orthopedic Center Established Patient I Danwoady Dave Cadisk PA 17013 Tetephow: (71'7)d.49-4112 Pu: (717) 249-= MR # Date: t Q Established visit requires 2 of the 3 (History, Exam, and / or Medical Decision Making) I MUM UM (location, severity, timing, quality, dmVkn, context, motifYI 'n factors, Assoc. si ! symIPloins - - q $ 8? ) i PF / EPF : requit=1- 3 elements Detafied I Comprehasive require 4 ckmmu or > 3 chronic conditions Medical History / Screening Form front ?P- I, P-Q? reviewed. l I R06: EPF requires positives and pertin,.nt nngxtives of symipwm(s) related to HPI Detailed recfuires positives and negatives of ernwunwrod system and at least one other system (2-9). . Cornpreheosive requires positives and negatives for 10+ systems w/ statement "aEl attire negative" Normal Abnormal W.-_? I 0 0 Constitutional N8 Ulfta from previms vls ? ? Eyes ( Comment on &11 abnormal findiags: ? ? ?as/NAaelf'hroat 0 ? Cardiovascular . ? ? Gutrointestinal ? ? Geuilbtninny , j ? ? lutegnaoetrtary ? D Mnsailoskektal ? ? Neurologic ? ? Psycbiatrk I ? Q RespiraLaKy f{ Mtory: BPF rtagmm no dEx;umented history. Detailed requires 1 specific item ft um 1 of 3 areas Comprehensive requires at least 1 item from each of the 3 areas Past: Fancily: Social: 0 No aages from previous As-A b le eG _ Date Patient Signature Phy-kcian Signature i I(. I i APPALACHIAN ORTHOPEDIC CENTER, LTD Thomas J. Green, M.D. Daniel P. Hely, M.D. Michael J. Oplinger, M.D. James A. Oliverio, M.D. 1 Dunwoody Dr. Phone: (717) 249-6112 Carlisle, PA 17015 Fax: (717) 249-6235 OFFICE RECORDS Dervisevic, Adelisa DOB:01/271/2000 10/20/06 OFFICE. VISIT: Follow up visit on Adelisa Dervisevic. She is here for pin removal today, distal tibia fracture. No complaints, no pain. PHYSICAL EXAMINATION: On examination today, the pin sites are clean and dry. The laceration has healed. There is still a clean eschar over the medial distal aspect of her leg. No evidence of infection. X-RAYS: X-rays were obtained of her leg, callus formation at the fracture site. IMPRESSION: Healing distal tibia fracture. PLAN: The pin sites are prepped and the pins are removed with difficulty. A wee-padded short leg cast is applied. This is a walking cast; weightbearing as tolerated. i will see her back in three weeks, x-rays, out of cast. James A. Oliverio, M.D. J.40/DS-ah cc: Christopher Bero, M.D. APPALACHIAN ORTHOPEDIC CENTER, LTD Thomas J. Green, MD Daniel P. Hely, NID Michael J. Oplinger, MD James A. Oliverio, MD PATIENT: XRAY DATE: DATE OF INTERPRETATION: OFFICE VISIT DATE: ORDERING PHYSICIAN: X-RAY PERFORMF,D: INTERPRETATION: DIAGNOSIS: RADIOLOGICAL REPORT Adelisa Dervisevic 10120/2006 10/20/2006 10/20/2006 JAMES A OLIVERTO, M.D. 1 Dunwoody Dr Carlisle, PA 17015 (717)249-6112 Tax U. 25-1829749 X-rays were obtained of her leg, callus formation at the fracture site. Healing distal tibia fracture. DICTATED AND READ BY: JAMES A OLIVERTO, M.D. JAO/DS-ah nomxs 1. Green, M.D, Daniel?. Halt', M.D. Micluei J. aplinger, hLD. AppaladiAm Orthopedic Center James A. Oliveric, M.U. Established Patient 1 D uuwaod7 Drive Carlidc, PA 17813 'T&k*a= (717)2494112 FaY:(717)249-623S 1 iVame: i Q ?(? VCU15CTP-3) I- Z-j-ZOOS Date: { Z-'5-Vt4 j Established visit requires 2 d the 3 (History, Ex=, and / or Medical Decision Making) j CC / HPI: (l..ooatim, sevority, timing quality, duration, context, modifying fact=, Asses. signs / symptoms) PF ! EFF : requirm 1- 3 elements Detailed ! Comprehensive mquirt 4 elements or> 3 chronic camditions Medical History / Screening Form from i / reviewed ROS: EPF requires pnaivcs and peatineat negatives of symptom(s) related to HPI Detailed requires positives and negatives of eaeour2ertd system and atlas one otimr system (2-9) Comprehensive n quirees positives and negatives for I D+ systmw wi atatemact "all other negativa" hlornna! ? Abnormal © constit?al D xo es from previous Visit ? ? D Eyes Comment on all Abnormal findings: ? ? Effabcnhrvat 13 ? Cardiovascular ? ? Gastrointestinal ? ? Gemtnarinary ? ? lnteguinut ry D O Muaculoskeletai ? ? Neumlogic I ? ? 12syclnutric 4 ! ? o Itespintary I History: RPF requires no dommmted history, Detailed requim 1 specific item from 16 3 apes Comprehensive requires at least 1 itam from each ol'U 3 tress Past: Fsmilp: Social: No Changes from previous visit Date Physician APPALACHIAN ORTHOPEDIC CENTER, LTD Thomas J. Green, M.D. Darnel P. Hely, M.D. Michael J. Oplinger, M.D. James A. Oliverio, M.D 1 Dunwoody Dr Phone: (717) 249-6 112 Carlisle, PA 17015 Fax. (717) 249-6235 OFFICE RECORDS Dervisevic, Adelisa D08:01/2712000 11/10/06 OFFICE VISrF: Follow up open distal tib/fib fracture. Had percutaneous pinning done at another institution. She's been in a short leg cast. No complaints. On examination today, pin sites are clean and dry. There's still an eschar over the medial aspect of her leg. There's no evidence of infection, Two views of the tibia are obtained. The fracture has callus formation, No evidence of displacement. ASSESSMENT: Healed right distal tibia fracture. PLAN: Weightbearing as tolerated with no cast on. Return to cast on. No PE. Follow up in one month for check of the eschar. James A Oliverio, INID/dmg cc: Dr. Bero APPALACHIAN ORTHOPEDIC CENTER, LTD Thomas J. Green, MD Daniel P. Hely, MD Michael J. Opiinger, MD James A. Oliverio, MD PATIENT: XRAY DATE: DATE OF INTERPRETATION: OFFICE VISIT DATE: ORDERING PRYSICIAN: X-RAY PERFORMED: INTERPRETATION: RADIOLOGICAL REPORT Adelisa Dervisevic 11110/2006 11/10/2006 11/10/2006 JAMES A OI..IVERIO, M.D. Right leg, 2 views. 1 Dunwoody Dr Carlisle, PA 17015 (717)240-6112 Tax 1D: 25-1329749 Two views of the tibia are obtained. The fracture has callus formation. No evidence of displacement. DICTATED AND READ BY: JAMES A OLIVERIO, M.D. James A. Oliverio, MD/dmg APPALACHIAN ORTHOPEDIC CENTER, Ltd 1 DUNW00DY DR CARLISLE, PA 17015 (717)-249-6112 Name: Adelisa Denrisevic ID: 25744 Sex: F Age: 6 Date: 11/10106 Please excuse the above patient from Gym Class due to illnesslinjury. Adelisa will need to be excused as of 11/1312006. She may return on 12131/2006. Return to school on November 13,2006. A"AUkC= M ORTBOPRDIC CWM, Ltd 1 DO MQODiY DR C7IMMA, VA 17015 November 13, 2006 To N2xn I t May Concern: This is to certify that Adelisa Dervisevic has beast uu* my profeasio al care. Mw mother, Zebra Dervisevie bas been off woz i to talus C&re of L3elisa. Adelisa is returning to school, and bar notiNx is sow able to return to her euplWUMt as Of 11-14-06. PJDUUtIC$: Sineorely, 1 ?1.D. t i APPALACHIAN ORTHOPEDIC CENTER, LTD Thomas J. Green, M.D. Daniel P. Hely, M.D. Michael J. 0plinger, M.D. James A. Oliveno, M.D. 1 Dunwoody Dr. Carlisle. PA 17015 OFFICE RECORDS Phone: (717) 249-6112 Fax: (717) 249-6235 Dervisevic, Adelisa DOB:01/27/2000 12/15/06 OFFICE VISIT: CHIEF COMPLAINT: Recheck right leg eschar. HISTORY OF PRESENT ILLNESS: She is here for a recheck of eschar of her right leg. free and happy as always. No complaints. She is back at school. She is pain No other intermittent changes in her review of systems as outlined in her established patient sheet. PHYSICAL EXAMINATION: Adelisa appears well, pleasant. No acute distress. Ambulating without difficulty. The right leg is examined. The area over the posterior medial aspect of her calf where she had a full4hickness abrasion, continues to heat. There Is a 1.5 cm full-thickness eschar, with surrounding scar tissue. The eschar is loose. I debrided it today in the office. The underlining tissue is pink granulation tissue. IMPRESSION: Healing wound, right open tib/fib fracture. PLAN: Continue local would care. Repeat evaluation in three weeks. James A. Oliverio, M.D. JAO/DS-ah cc: Christopher Bero, M.D. / 0 Scho\ 0 d! M ?A November 29, 2006 CARLISLE AREA SCHOOL DISTRICT 623 W. Perin Street Carlisle, Pennsylvania 17013 Telephone: 717-240-6800 Mary Kay Durham, Superintendent Amanda Peterson Milovanovich & Espinosa, LLC 129 East Orange Street, 2nd Floor Lancaster, PA 17602 Re: Adelisa Derviesvic Dear Ms. Peterson: This letter is in response to your request for Adelisa Dervisevic's attendance report. I have attached the report. I want to make mention of the codes listed in the report. The "O" is a code for Medially Excused absence. The "H" code is for those dates she was officially on homebound status. The dates with a dash have not been set up for attendance coding yet. The nurse checked our records and Adelisa was in the health room once this year on August 29th for a minor stomach ache. This was before the accident. I hope this is what you need. Sincerely, Mary Beth Blackburn Secretary .rr N h, !2/1212005 10:32 7172410097 J t BELLAIRE ELEMENTARY rn MoD (7 go mxrn 015 1 rn:g m mzrr. 'Tc)Z Tcl,21 rn70 rr, C1 ? ? ? m = Q tl7? W - 1 -.7 V * ' N M r hr ? ?y '," GJ?. ') N a iv L, y1 .+ N U? ro ..? (y N V1 ?j re gip M ! C N !t ?; 0 .3 N ew 4'1 !?i :n a o ro (ti7C y n, sr, o CO _ cu 4A c ro !t? S S C _ 0% 01 0% Ch ONO C% rn q m ?? r r -1 w r r f r r r 3 ?. r rn o? 10 d+ a+ of c? 0 ` m x o co a 4 i? O O ? N tN7 d o d O V V ? 6 o O 3 3 M 7D K g 3 H S S '17 T a S Z m x a O O .T 40 + w t . O .i ? A l acc a I 19 .r J Q fA N .? T 1 a M t + = Z tt K x N = 7 = N qi b tti t9 A ? n G rD LU Vn CV)J 4Y N t? 0 > an D6 A ? n a FJ H N d+ rn 'n m sn PAGE 02 'It I A 1 ? ?L 0 m O d N (n m d Q? Y z N [C 12/12/2005 10:32 7172410097 BELLAIRE ELEMENTARY PAGE 03 a ti ?"' N m Go :;4 N G map " r ? 0 0 m r ttl?? W mo rn m mC) x i r, C) W ? N rnC1 rmm> w fy 7 CO O rnp+M C 0 6 S Coro !A rnX m C OJ 71 P, rnM? co '`? y y N ? lam ? N' ' v , w N -1 3 s. hJ f0 w N ? °' _ •. . N "Y ' , hS ^ ^ ? ,w ? 1?1 N f9 V W CO a y po G4 ? Ev co A 0 ? ? a ? rn 00 co Ln pNpCA w C) N In N ? NJ? N VI ? N V, ?-1 (A A ?N N ul N NU7 N VIQ ep 4 4 n p p O O lb " v ? ^ C O n O 7 i ' o 01 b O+ 0% R1 :n C.? y C+ ^tl Cr I ql 'J+ PI C 0 + CT 3 r 3 . r r- r° r r r! r 3 r' r r r . rn rn o+ C? 0+ rn ? c? rn cT m v+ 0? yOr 00 OD O6 4b C7 m CD co bD Ob do co OD C o o 4 Ao ° 0 C) o ° 0 0 J V V V r V V ,1 11 , J V V V J s 3 3 smi ern. D ?I u m n y r v Y D D Q ?• 4 3 S; .y V Vv I 1 ? a 1 1 1 1 ' I I S ?` • ' r 1 ? r I 1 • • 1 T • • 1 i T 1 1 I i 1 r . ? . r 1 •Y 7A 1 I I r I I fly 'i 1 y 1 1 1 ?> Y f f ? ? 1 • 1 . I . ? N . ? I 1 S q • 1 1 . r , r Cl I 1 1 1 I I I 1 I 3 ' 1 w1 N 1 1 • • J -l 4y _ r ? ? ? (nl • I ? f I 1 r . i 1 ? Af r I r . r ? I I 1 1 ? r • . • w 00 r? N r N N O 3 12ii2/2006 10:32 717?410e97 r x x yC ? A ? ? 3 A b cr 00 `('o g A f7 "M i! M d OK X :3 Ap R C 11 II b c C ro ° °a vex y c K n (ul Q G n -? D vb - Ut O ti? d ga pad ? pr n Si y m A? m ?' ? oar N v p -7 IV 8 ?Z7n I W d 00 d M IQ gaNbN b O d a II Z? ?. fl ?D a a ? BELLAIRE ELEMaJARY PAGE 04 H1 T Co m? r _ N cy v d+ r O? Po N O O M,.M m Q m-i?' ? c N 1 4 n o tl+ r O? cA N O d T 2m Or+ D N? o, o O J r O oe N O d mG13. m m. '. Nt11 n r tT w N O C',J T_ G) T 'S :. 7? ? a N V1d ro v r O+ ra N :J O !7 ?p CO : !0 O? hr NN,:? o .a o o+ q r 3 01 J tt N O O E Cl fR: h r0 a J?j Nlhn o n o P r ? T. cc hi p O C Ca m-ar°n N , d r- 0+ Ib A? Cf d T OD cr 13 c N rr U ?,' o er r 4+ oo N O O MT, C9 ca c , t?9 NW g' cn D r- Ch m N O O TGy; OC• ',? '* ate" + " Z; ; U7 ;« 4 a N C7 O rn G) M ,N.. a^ i1 NCJS LC, rc p r p m N G O T C? w N 0+ r 0+ m ?.1 i'S O m t? Y D r V1 K ro G n T U*l .-e A r N 1 1 1 I 1 = J oe ? I 1 1 ? v' .n ?V 11?? r r r i ? 1 1 i 1 1 v 5 t?• O !2/12/2005 10:32 7172410097 BELLAIRE ELEMENTARY PAGE 05 1b APPALACHIAN ORTHOPEDIC CENTER, Ltd 1 DUNWOODY OR CARLISLE, PA 17015 (717}2413.13112 Mom: Adelisa Dervisevic ID: 25744 Sex: F Ape: 6 Date: 11/10M please excuse the above patient from Gym Class due to iliness/injury. Adelisa will need to be excused as of 1111312006. She may return on 12/31/2006. Return to school on November 13.2006. r fA!l`* ENCOMPASS. I N S U R A N C E P.O. Box 16203, Reading, PA 19612-6203 November 8, 2006 MILOVANOVICH & ESPINOSA, LLC 129 EAST ORANGE STREET LANCASTER PA 17602 Our Claim Number. Z6021038 N7 Your Client. Adelisa Dervisevic Your Reference Number Date of Loss. 09124/2006 Our Insured. Lutvo & Zekira Dervisevic Insuring Company. Encompass Indemnity Company Dear Ms. Milovanovich: encompassinsurance.com Heather Fehr, A1C Claims Representative Telephone (610) 401-2259 (800) 936-4203 x 12259 Fac s;mb (972) 510-1383 lntemet heat1w.fehf@encoMwssins.com This letter is to inform you that the maximum medical benefit provided under our insured's personal auto policy's Personal Injury Protection coverage has been exhausted. Consequently, we are unable to consider payment for any additional medical bills. It is recommended that your client provide his or her health insurance carrier a copy of this letter in order to expedite the processing of any outstanding medical bills related to the above loss. If you have any questions regarding this claim, please feel free to call. Sincerely, Yfeather Teter, 91C CC: PH - ?A MENT HISTORY :1? ;.?, ALC Z6 :.LAIM# 26021038 DESK* ZM INS/DBA DERVISEVIC, LOT-%F0 ZEKIRA 0/C 0 j.?v ISSDAT PAYEE AMOUNT T1? CVCD TE/ SFX/ CE/DRFT.% PS FRCM/THRU IRSIWITH AP!T/NYH GROSS AMT REASON PC DT RJC 01 1102C6 UNITED HEALTH SERVICES HO 4293.12 21 PIP? MC 061 100476677 C 092406 092706 PIP 005006246051 03 103176 CARLISLE ?EDIP.TRIC ASSOC 04 102306 SUPERIOR X%SULANC£ SERVIC SELECT CLMT LINE NM48ER 14ORE DATA 710 FOLLCW 54.88 21 PIPM MC 0661 100474181 C DOS: 09/28/2006, ?T# PIP 21572 652.00 21 PIN MC 061 100465119 C DOS: 09/24/2006, PT4 PIP 0609- PHA104: SOCRATES, INC. 1201 Broughton Road Pittsburgh, Pennsylvania 152363451 Telephone: (412) 653-8702 E-mail: subrogation(dsocratesine.com Facsimile: (412) 655-6320 THE MATERIAL TRANSMITTED BY THIS FACSIMILE ARE SENT BY AN ATTORNEY OR HISMER AGENT, AND ARE CONSIDERED CONFIDENTIAL AND ARE INTENDED ONLY FOR THE USE OF THE INDIVIDUAL OR ENTITY NAMED. IF THE ADDRESSEE IS A CLIENT, THESE MATERIALS MAY ALSO BE SUBJECT TO APPLICABLE PR1VILAGES. IF THE RECIPIENT OF THESE MATERIALS IS NOT THE ADDRESSEE, OR THE EMPLOYEE OR AGENT RESPONSIBLE OF THE DELIVERY OF THESE MATERIALS TO THE ADDRESSEE, YOU SHOULD BE AWARE THAT ANY DISSEMINATION. DISTRIBUTION OR COPYING OF THIS COMMUNICATION IS STRICCTLY PROHIBITED. FURTHER, THIS INFORMATION HAS BEEN DISCLOSED TO YOU FROM RECORDS WHOSE CONFIDENTIALITY MAY BE PROTECTED BY STATE AND FEDERAL LAW. ANT FURTHER DISCLOSURE OF THIS INFORMATION WITHOUT THE PRIOR WRITTEN CONSENT OF THE PERSON TO WHOM IT PERTAINS MAY BE PROHIBITED. IF YOU HAVE RECEIVED THIS COMMUNICATION IN ERROR, PLEASE IMMEDIATELY NOTIFY US AT (412) 653-8702 AND RETURN THE TRANSMITTED MATERIALS TO US AT THE ABOVE ADDRESS VIA THE U.S. POSTAL SERVICE. WE WILL REUVIBERSE YOUR COSTS UNCURRED IN CONNECTION WITH THIS ERRONEOUS TRANSMISSION AND YOUR RETURN OF THESE MATERIALS. THANK YOU. FACSIMILE COTTER SHEET TO: Ms Nina Milovanovich Kilovanovich & Espinosa, FROM: Elizabeth Demblowski SOCRATES, INC. DATE: Monday, Oct 29, 2007 11:57AN FAX NO: (717) 293-8036 NO. OF PAGES (including cover sheet): 2 PLEASE REPORT PROBLEMS WITH RECEPTION BY CALLING 800-653-3144 AS SOON AS POSSIBLE. MESSAGES TO RECEIVING PARTY: RE: Adelisa Dervisevis Additional BOB rec'd by fax today. Current lien amount is $6,845.22. Thank you . " ? '?,_ :,?. :? 4 . I ?'? ?' ?:?., r: . •? '. ?? 1 ?'' ?' yy??• W ". ':? ,?? f ?. ? ?" i? i ?.? ' ?¢ ? 1 +? ? .} "1 t :{. 'r :` i?-t .???. ? .. Q ? f i ._ -' .? ? .; r ?' ???i, ? , ?? : _ :.: ?. .. .. ?. ,? :. ??:?:: ? ?? ?: :{ ?? . ?i ,. :. } 119 c l q? 1 r Q {? AL J M i f ` ? , ' ,. m n ? SS G _ . 4 aw O ? r t: '.1 ?S l l s ?.' M '? ? ? ? a 0 ' ? J e ? ?o: g? 1 :_.? r /' ?? ?. 41R o? :? `?.' ? ?}? r? i ? :.:. ?: ?: t'.' *j OO. y 0 p O . e . . V fti 7 F 1 tk?.gr• 3` L-M-A-9, ? o a ? ^ N ?= w c q a o Cl Z S. v Q : h p Q r Q +t "g 1 b x y. y _ 6 7 W: c o v a ? Q t a t f t3 ?! 1 { 10128/ 2007 2 ; 9. 47 PM PAGE f - x bervex• ' ? • ' ? fi : ; . , t . : . C 8 p? ,,,,? . C • ' K yy x I Y ? 1 ? Q ?• ? O, Q , ? ? ?+ s O, • ?T :i LE N E&NDM TO F'ACSIM VIA FACSINULE ONLY TO: Nina Milovanovich, Esquire FROM: Beth Demblowski SOCRATES, INC. DATE: October 30, 2007 RE: `Patient: Dervisevic, Adelisa Contract No.: 800618345F Group No.: 00514938 Self-Funded Plan: Giant Foods ** ASO Contractor: Capital Advantage Insurance Company Date of Injury: September 24, 2006 Our client has approved the 1 /3 attorney fee request. Thank you. * This infotmation has been disclosed to you from records whose confidentiality tray be protected by state and federal law. Any firbcr disclosure of this infonnuion without the prior written consent or authorization of the person to whom it pertains may be prohibited. ** The Self-Funded Plan's contractual subrogation interests administered by Capital Advantage hisurance Company are separate and distinct [ruin that of Medicare an for any other Blue Cross Plan(s). SOCRATES, INC. ta%Lta PARK AVENUE ASSOC IN RADIOLOGY 32-36 HARRISON STREET JOHNSON CITY, NY 13790 Check one only. C 0 Cana number INTERPRETATION OF X-RAY SERVICES PERFORMED AT WILSON MEMORIAL HOSPITAL Please direct all inquires and payments to our Billing Office at the address above or at Telephone # (866) 363-5204 Do not call the hospital as they can not help you with this bill Remit to: 161113457 Name Exp. Date PARK AVENUE ASSOC IN RADIOLOGY Signature 32-36 HARRISON STREET 3'667 JOHNSON CITY, NY 13790 LUTVO DERVISEVIC 524 3RD ST CARLISLE PA 17013-1808 PAR 006246051 Client Number Patient Name Patient Phone Due Date Balance Due Amount Enclosed PAR 006246051 ADELISA DERVISEVIC 02/09/2007 $101.70 $ --------------------------------------y------------ __----=---------------------------------------------------------- S< Please tear off and return upper portion to insure proper credit. If you desire a receipt please return entire statement. X 3 ',for Haim: _ 17`3,4. Ya?i..in5ilraitc#:~h as, pa & their portion of the above services. The bal'artce dui is `fiat r-esorisib 1ity: Pax,ment is due upon,recetpt of this statement. If after speaking with someone at (866) 363-5204 you, ar n©t sati5f}ed, caTI our HOTLINE at (866) 380-0679. If payment has been sent within the past 10 days your credit will appear on your next statement. PAR 006246051 PARK AVENUE ASSOC IN RADIOLOGY Balance Due: $101.70 Page 1 of 1 PLEASE READ THE OTHER SIDE OF THIS STATEMENT CONTINGENT FEE AGREEMENT I/We hereby retain and appoint MILOVANOVICH AND ESPINOSA, LLC, to act as my/our attorneys to institute and maintain any claims, law suits, or other such legal proceedings that in their judgment are necessary in connection with my claim for damages lust 'ned from a I/ on year against: AV a'If el VC X 7* & 0-L . and any person, firm, or corporation who may be responsible for my claim for damages, or to obtain an amicable settlement. I/We agree not to settle or adjust the above claim or any proceedings which arise out of the above claim without having first consulted with the above office and having obtained their written consent. I/We hereby covenant and agree that out of the sum recovered from any source on account of said accident, first the expenses of suit, costs, disbursements and expenses in the investigation and trial of the case shall be reimbursed to said attorneys. Said expenses shall include but not be limited to filing fees, service costs, copying costs, court reporter's costs, investigation costs, witness fees, fees for medical records, doctors' reports, expert witness expenses, or any similar costs or expenses. Thereafter, in consideration of the services rendered by the above attorneys I/We hereby covenant and agree to pay to the attorneys for their professional services rendered 33-1/3% percent of any sum recovered from any ource on account of said accident. If the case proceeds to trial, All'I however, I/We agree to pay sum recovered. The swearing of the jury, if a jury trial, or calling of witnesses, or the mtrdduction of evidence, if a trial or arbitration without a jury, shall constitute the dividing line between settlement before and during or after trial. In the event that there is no recovery obtained on this claim, the attorneys will make no charges for time or services. However, any costs or expenses which the attorneys may have advanced on behalf of the claim will be paid by me. All medical bills incurred as a result of the accident, even if previously paid or advanced by the said attorney, shall be chargeable to my share exclusively, unless otherwise paid by insurance. If my/our case is appealed by any party to any appeals court and a recovery is obtained after such an appeal is filed, my/our attorneys will receive 40% of any sum recovered. The remainder of the net recovery will go to me/us, upon deduction of reimbursable costs advanced by my/our attorneys. Recovery means all sums of money received on my behalf as a result of my claim by way of settlement, award or verdict. This Contingent Fee Agreement applies to all proceedings up to and including a verdict or decision at trial or arbitration in the Court of Common Pleas. If, in the discretion of the attorney, further post-trial proceedings, including appeals, are warranted, a new fee arrangement may be required by said attorney. This Contingent Fee Agreement does not apply to any law suit which may be filed against my/our own insurance company for non-payment of medical, work loss or other such first party benefits. If after settlement or trial against the primary Defendant(s), Uwe wish to pursue an uninsured or underinsured motorist claim or an uninsured or underinsured motorist arbitration against my own insurance company, the said attorney reserves the right to withdraw if he believes that such uninsured or underinsured motorist claim or arbitration would be unwarranted under the circumstanes. However, if the said attorney continues to represent me then he shall be entitled to a /(J fee of /o of the recovery from any settlement or award of the arbitrators. If I/We terminate this agreement before any recovery is obtained, I specifically agree that my attorneys shall be entitled to reasonable compensation for all work done and costs incurred in connection with my claim up to the point of termination. I/We agree that reasonable compensation for my attorneys shall be $ 175.00 per hour, $ 85.00 per hour for their paralegal, and $35.00 per hour for their legal assistant/secretary, or such higher rates as shall constitute their standard billing rates at the time that the work is performed. If the court awards counsel fees to be paid by the defendant or if defendants agree to pay counsel fees, the attorneys shall be entitled to the court awarded fees, in addition to our agreed upon contingent fee, except that the amount owed as a contingent fee shall be reduced by the amount awarded by the court. I/We hereby represent that no other attorney has been retained to represent me or the injured person in this case. IN WITNESS WH REOF, I hereunto set my hand and seal this day of A-ZC GCA , 2000 , and acknowledge that I/We have received a duplicate copy of this greement. WITNESS: ae? MILOVANOVICH and-ESPINOSA. LLC By: Milovanovich & Espinosa, LLC 129 E. Orange Street Suite 2 Lancaster, PA 17602 Invoice submitted to: Dervisevic Adelisa c/o Lutvo and Zekira Dervisevic 524 3rd Street Carlisle PA 17013 October 30, 2007 Invoice #175 Additional Charges : Q /Price Amount 10/5/2006 NM Copying cost 2 0.30 Copying cost 0.15 NM Postage 1 0.39 Postage 0.39 10/6/2006 NM Fax 9 9.00 Fax 1.00 10/9/2006 NM Fax 1 1.00 Fax 1.00 NM Copying cost 4 0.60 Copying cost 0.15 NM Postage 1 1.76 Postage 1.76 10/10/2006 NM Copying cost 2 0.30 Copying cost 0.15 NM Postage 1 0.39 Postage 0.39 10/11/2006 NM Postage 1 0.39 Postage 0.39 10/16/2006 NM Copying cost 6 0.90 Copying cost 0.15 Dervisevic Adelisa Page 2 Q /Price Amount 10/16/2006 NM Postage 1 4.88 Postage 4.88 NM Fax 7 7.00 Fax 1.00 11/2/2006 NM Postage 1 0.39 Postage 0.39 NM Copying cost 2 0.30 Copying cost 0.15 11/9/2006 NM Payment for medical records 1 99.06 SIDS (United Health Services Hospital NY) (0036667434) (4096) 99.06 NM Postage 1 0.39 Postage 0.39 NM Copying cost 2 0.30 Copying cost 0.15 NM Postage 1 0.39 Postage 0.39 NM Copying cost 2 0.30 Copying cost 0.15 11/14/2006 NM Payment for medical records 1 19.53 Carlisle Pediatrics 19.53 NM Postage 1 0.39 Postage 0.39 NM Copying cost 2 0.30 Copying cost 0.15 11/15/2006 NM Postage 3 1.17 Postage 0.39 NM Fax 3 3.00 Fax 1.00 11/16/2006 NM Copying cost 6 0.90 Copying cost 0.15 NM Police Accident Report 1 2.25 2.25 11/20/2006 NM Payment for medical records 1 43.82 Appalachian Orthopedic Center 43.82 Dervisevic Adelisa Page 3 Q /Price Amount 11/20/2006 NM Postage 1 0.39 Postage 0.39 NM Copying cost 2 0.30 Copying cost 0.15 NM Fax 3 3.00 Fax 1.00 12/12/2006 NM Copying cost 1 0.15 Copying cost 0.15 NM Fax 7 7.00 Fax 1.00 12/22/2006 NM Postage 1 0.63 Postage 0.63 2/5/2007 NM Copying cost 2 0.30 Copying cost 0.15 2/13/2007 NM Postage 1 8.45 Postage 8.45 Copying cost 134 20.10 Copying cost 0.15 2/21/2007 NM Fax 12 12.00 Fax 1.00 NM Postage 1 0.39 Postage 0.39 Copying cost 4 0.60 Copying cost 0.15 2/22/2007 Postage 2 0.78 Postage 0.39 NM Copying cost 4 0.60 Copying cost 0.15 2/27/2007 NM Fax 3 3.00 Fax 1.00 4/27/2007 NM Fax 3 3.00 Fax 1.00 NM Copying cost 1 0.15 Copying cost 0.15 Dervisevic Adelisa Page 4 Q /Price Amount 4/27/2007 NM Postage 1 0.39 Postage 0.39 5/29/2007 NM Payment for medical records 1 10.00 Hanger Prosthetics & Orthotics 10.00 6/20/2007 NM Fax 5 5.00 Fax 1.00 7/12/2007 NM Postage 1 0.83 Postage 0.83 NM Copying cost 104 15.60 Copying cost 0.15 7/13/2007 NM Fax 2 2.00 Fax 1.00 7/17/2007 NM Payment for medical records 1 22.29 Appalachian Orthopedic Center 22.29 NM Postage 1 0.41 Postage 0.41 NM Copying cost 2 0.30 Copying cost 0.15 8/1/2007 NM Postage 1 0.21 Postage 0.21 NM Fax 3 3.00 Fax 1.00 8/15/2007 NM Postage 1 0.41 Postage 0.41 10/24/2007 NM Fax 3 3.00 Fax 1.00 NM Copying cost 17 2.55 Copying cost 0.15 10/25/2007 NM Postage 1 0.41 Postage 0.41 NM Fax 5 5.00 Fax 1.00 10/29/2007 NM Copying cost 434 65.10 Copying cost 0.15 Dervisevic Adelisa 10/30/2007 NM Postage Postage NM Court costs Filing fee -- Petition to Settle and Compromise a Claim of a Minor Total costs Balance due Page 5 Q /Price Amount 1 5.61 5.61 1 78.50 78.50 $480.85 $480.85 10/31/07 WED 16:31 FAX 6108345442 RINGLER ASSOC x, RINGLER ASSOCIATES.' (610) 834-5553 (soo)869.9450 Fax (610) 634.5442 Or (610) 634.8266 Via Facsimile: (208) 275-2556 October 31, 2007 . Nina Milovanovich, Esquire Milovanovich and Espinosa 129 E. Orange Street Suite #2 Lancaster, PA 17602 RE: Adelisa Aervisevic Allstate File: #2467182032 Dear Nina: Enclosed is the revised proposal you requested with a cost of $65,998.97 in regards to Ms. Dervisevic's claim. As a cornparison, the cost of this same quote is $69,721 through American General Life Insurance Company. I have also enclosed Allstate Life's latest A.M. Best rating, A+ (Superior). Again, this proposal is quoted through Allstate Life Insurance Company and expires on November 7, 2007, or the date of a life company rate change, if earlier. Please feel free to call if you should have any questions or if I could be of further assistance. Sincerely, Michael P. Mullen *W RTNGLER ASSOCIATES MPM:jad Enclosures cc; Lisa Staff, Allstate (Via Email: Lis a.Staff@Allstate.com) fa 002 OMCE COURT AT WALTON POINT • 490 NORRISTOWN ROD • SUITE 251 * BLUE BELL, PA 19422 MAILING ADDRESS: P.O. BOX 1252 • BLUE BELL, PA 19422 w.vwAinglerAssociMes.com OFFICES IN PRINCIPAL CITIES NATIONWIDE Member National Structured Settlements Trade Assnciprlon 10/31/07 WED 16:31 FAX 6108345442 RINGLER ASSOC INDIVIDUALLY DESIGNED SETTLEMENT NAME: Adelisa Dervisevic 1. Colle e Fund: $15,000 per year for 4 years Beginning on $1111$ -plus- Guaranteed Lumn Sum, FEMALE: 01/27/2000 TAX-FREE GUARANTEE 60,000 8- 4,934 $84,934 at age 25 (01/27/25) $144,934 Total Cost: $65,99$.97 THROUGH ALLSTATE LIFE INSURANCE COMPANY Im 003 *These proposals expire on 11/07/07 or the date of a life company rate change, if earlier. "This is an illustration, not a contract. Should it contain any clerical errors, we reserve the right to correct them. 10/31/07 WED 12:40 FAX 6108345442 RINGLER ASSOC 0 004 0 Structured Settlements: How Plaintiffs Benefit 0 Who Bene ts: * Although a structurW settlement is a valuable settlement solution for all parties, it is the plaintiff who benefits the most. A structured settlement's principal and interest are entirely tax-free. Even though a traditional lump-sum cash settlement is free of income taxes, any interest earned on the settlement finds is subject to Federal, State, and local income taxes. ¦ A plaintiffs structured settlement has multiple layers of protection. The annuity contacts that fund the structured settlements are issued by highly rated legal reserve life insurance companies. These annuity contracts are subject to State regulatory requirements, as well as the Federal tax rules governing stnxtuured settlements. ¦ A structuued settlement relieves the plaintiff of the responsibility of managing a large sum of money while providing figure financial security. Structures can reduce money management concerns and costs. Because a stfuctime is a guaranteed source of fiords paid on a tax-fine basis, it is very difficult for even the experienced investor to match the rate-of-retum generated by a structure. ¦ Judges universally support this concept. It is especially appealing in guardianship cases, including minors or incompetents, because judges have the responsiWity of gIxoving settlements. ¦ Plaintiff attorneys can be sure that they have maximised their client's settlement, ensuring sound fiscal management with a very competitive fixed rate-of-return. It also is possible to structure attorney fees. When To Consider St=twed Settlements: • To Prevent Premature exhaustion of funds via poor investments or mist nagement ofassm ¦ To guarantee funds for long-tam medical needs Temporary or permanently disabled plaintiffs ¦ Workers' compensation cases " Guardianship cases, including minors and incompetents ¦ As part of an overall investment portfolio, providing for the fixed income portion " Death cases where the surviving spouse may need monthly or annual income • Severe injury, especially shortened life expectancy, and the mentally disabled ¦ Deferred payments for college funds, retimmrtitrovrtgage payments and attorney fees ¦ Tax drAm-ed annuities for cases involving di=iMi on, wrongful termination, property loss (construction defect), divorce; sexual hwassment and environmental cleanup Michael P. Mullen * 800869-4454 * (fax) 610-834-5442 * _oom Office Corot A Walton Point * 490 Norristawn Road * Suite 251 * Rluc Roo, PEA 19422' www.RinglerAssociato.com 0 2001 Pm&?w Absadmw 0 All RIStft Rmavcd 0 PRrM50 10/31/07 EYED 12:40 FAX 6108345442 RINGLER ASSOC 0]005 Tax Free, Secure Settlement: 0 ¦ It is important to consider the tax implications and security of any settlement. Structured settlement annuities are the only way to make a personal injury settlement completely free of taxes. A stractured settlement's principal and interest are not subjec' tO taxes. ¦ Most people fail to consider the effects Federal, State and local taxes have on the income they expect to receive from a cash investment, and they usually ignore the fees associated with most investment purchases. ¦ pause the Internal Revenue Code allows for a tax-free acvrual and payout of ir?est, plaintiffs receive greater benefits through a structured settlement plan than they would otherwise achieve if they invested the money. ¦ A strwtured settlement is more than an annuity. A structured settlement is a way of protecting all or a portion of the plaintiffs settlement funds. Furthermore, it's a way of increasing the value of the settlement, since settlement annuities not only pay out more than a lump sum, but the entire amount is tax-free. ¦ The key to the security ofa structured settlement is ensuring thatit is done correctly. Plarnti Advantages: Non-'T'axable Income ¦ 1 WIc tax-free guaranteed income (for life, if requested) ¦ Flexibility and convenience of regular payments ¦ Structures can provide funds to pay estate taxes ¦ Deferred payments for college, rdhTieK scholarships, etc. ¦ Combine workers' comp and public benefits + Make mortgage payments with interest deduction ¦ Deferred lump-sum payments Guaranteed Income ¦ Security of multiple layers of protection by Federal and State requirements ¦ Protection for minors ¦ Cnlaratnteed benefits for spouse, children and beneficiaries (may be scholarships, charities, even businesses) ¦ Guarantee future long-term cane with no interruptions Eliminates Investment Risk ¦ Protection from misuse and loss ¦ Competitive raw-of-return on capital i No expense or worry with regard to investment performance Michael P. Mulim • 800- WM50 * (fax) 61M4-W2 s MMU1W4ringlerass%iatcs.vom Office Court at Walton Point * 490 Norristown Rand * Suite 2510 Sluc ML PA 19422 * wwwAinglerAssociates.com 0 2001 Ringier Associates 4 All Rights Reserved 4 PBr7850 10/31/07 WED 16:32 FAX 6108345442 RINGLER ASSOC Allstate's strength. Allstate offers financial strength and stability. Customers also get the peace of mind that comes with having one of the nation's leading life insurance companies fund their structured settlements. Rest assured, You're In Good Hands With Allstate' Our customers have our reassurance that their needs remain our number-one focus. Allstate's experienced staff and superior customer service team are dedicated to providing the uncompromising level of service expected from Allstate. FINIO12 0 005 Our ratings. We're proud to have received high ratings from these independent analysts. All ratings are based on the insurer's financial strength. In the case of Allstate Life Insurance Company of New York, the ratings reflect the relationship to the parent company, Allstate Life Insurance Company. A.M, BEST A+ (Superior) Allstate Life Insurance Company A'+' (g) (Superior) Allstate Life Insurance Company of New York Allstate Life Insurarice Company and Allstate Life Insurance Company of New York each received the second highest of 13 ratings ranging from A++ (superior) to 0 (poor). Allstate We Insurance Company of New Yorks (g) indicates its group atfiliation with Allstate Life Insurance Company. STANDARD & ROOR'S AA {Very Strong) Allstate Life Insurance Company and Allstate Life Insurance Company of New York each received the third highest of 20 ratings rangins from AAA (extremely strong) to CC (extremely weak). MOODY's Aa2 (Fxceilent) Allstate Life Insurance Company and Allstate Life lnsur'ance Company of New York each received the third highest of 21 ratings ranging from Aaa (exceptional) to C (extremely poor). Ratings are as of July 2007 and arc subiet to chanP without notice. FIW012 10/31/07 WED 16:32 FAX 6108345442 [a 006 Why choose Allstate? Allstate Life Insurance Company (Allstate) is one of the largest life insurers in the United States. With total assets of over $100 billion, Allstate is wholly owned by Allstate Insurance Company, which is wholly owned by The Allstate Corporation. The Allstate Corporation is a Fortune 100 company and the largest publicly traded personal lines insurance company in the United States. To date, Allstate has issued over $8 billion in structured settlement annuities. Allstate is a recognized leader in the structured settlement industry. Allstate pays out over $600 million annually to 26,000 structured settlement annuitants. Our focus is safe, secure money management. Throughout Allstate's history, our strategy has been to safely manage money for predictable, steady growth. To support this strategy, we invest in a diverse portfolio of investment-grade bonds and securities, matching high-quality assets with our liabilities. We hold ourselves to the highest standards. Allstate is proud to be among the first members of the Insurance Marketplace Standards Association (IMSA). Our membership signifies our commitment to honesty, fairness and integrity in the sales and service of individual life insurance and annuity products. FIN1012 RINGLER ASSOC. C3 ? R3 -4 C:D LUTVO AND ZEKIRA DERVISEVIC, as parents and natural guardians of ADELISA DERVISEVIC, minor, 524 3d Street Carlisle, PA 17013 Plaintiffs : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW V. David A. Schriml 2713 Owego Road Vestal, NY 13850 Defendant : NO. 2_6 x-3 ORDER OF COURT AND NOW, this is N? day of _K) ° ? , 2--oo, upon consideration of the Petition for Approval of Minor Settlement and Distribution of Proceeds; IT IS HEREBY ORDERED AND DECREED that said Petition is hereby GRANTED, and that the settlement proceeds in the amount of $95,000.00 shall be allocated as follows: 1. The amount of $29,001.03 shall be paid to Milovanovich & Espinosa, LLC for the following: a. $23,750.00 (25% of the total settlement) for attorneys' fees; b. $585.85 shall be paid to Milovanovich & Espinosa, for their costs; C. $4,563.48 for re-payment of the lien to Capital Advantage Insurance Company; d. $101.70 for payment to Park Avenue Radiology for their invoice for medical services rendered; 2. All proceeds due to minor Plaintiff, Adelisa Dervisevic, in the amount of $65,998.97 are to be used as a funding for structured settlement, with the guaranteed yield in the amount of $144,934.00, which amount is to be distributed to the minor as follows: a. $15,000 per year for 4 years, beginning on 8/1/1028 and continuing for 4 years (total of $60,000) . p? 9 1 IQdl '? uHicx? d do 7/9 b. $84,934.00 on minor's 25`h birthday (01/27/2025) BY TH COURT J. DISTRIBUTION: cc: ?C na Milovanovich, Esquire, (Milovanovich & Espinosa S e , Lancaster, PA, 17602) , LLC, 129 E. Orange Street, - teary Altman (Encompass Ins. C 1 1) o,, 333 Glen Street, P.O. Box 5000, Glen Falls, NY isa Staff (Allstate Ins. Co., P.O. Box 1064, Buffalo, NY 14240) J LUTVO AND ZEKIRA DERVISEVIC, as parents and natural guardians of ADELISA DERVISEVIC, minor, 5243 d Street Carlisle, PA 17013 Plaintiffs V. David A. Schriml 2713 Owego Road Vestal, NY 13850 Defendant : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW NO. 07-6823 Civil Term MOTION TO AMEND THE COURT ORDER ISSUED ON NOVEMBER 15, 2007 APPROVING PETITION FOR APPROVAL OF MINOR'S SETTLEMENT AND DISTRIBUTION OF PROCEEDS And now come the Petitioners, by and through their attorney, Nina Milovanovich and Milovanovich & Espinosa, LLC, file this Motion to Amend the Court Order due to a typographical error, and respectfully state the following: 1. On November 15, 2007, the Honorable Wesley J. Wesley Oler, Jr., signed an Order approving Petition for Approval of Minor's Settlement and Distribution of Proceeds (attached as "Exhibit I"). 2. Unfortunately, in paragraph 2(a), there is a typographical error in the above referenced Order in that the Order says that the distribution should begin on 8/1/1028 (emphasis supplied). 3. The paragraph 2(a) should read: $15,000 per year for 4 years, beginning on 8/ 1 /2018 and continuing for 4 years (total of $60,000). 4. The remainder of the Petition and the above referenced Order are all correct, but for this typographical error. 5. All involved parties have reviewed and concur with this Motion. WHEREFORE, the Petitioners respectfully request Your Honorable Court to enter an Amended Order to reflect the correct date of the commencement of the distribution of proceeds. Respectfully submitted, PINOSA, LLC DATED: Xna Milovanovich, Esquire Attorney ID# 75545 129 East Orange Street, Suite 2 Lancaster, PA 17602 (717) 293-1400 Attorneys for Plaintiffs 2 NOV 32007 LUTVO AND ZEKIRA DERVISEVIC, as parents and natural guardians of ADELISA DERVISEVIC, minor, 5243 d Street Carlisle, PA 17013 Plaintiffs V. David A. Schriml 2713 Owego Road Vestal, NY 13850 Defendant : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW :NO. 0'i- Terwt ORDER OF COURT AND NOW, this 1,?Jh _ day of upon consideration of the Petition for Approval of Minor Settlement and Distribution of Proceeds; IT IS HEREBY ORDERED AND DECREED that said Petition is hereby GRANTED, and that the settlement proceeds in the amount of $95,000.00 shall be allocated as follows: 1. The amount of $29,001.03 shall be paid to Milovanovich & Espinosa, LLC for the following: a. $23,750.00 (25% of the total settlement) for attorneys' fees; b. $585.85 shall be paid to Milovanovich & Espinosa, for their costs; c. $4,563.48 for re-payment of the lien to Capital Advantage Insurance Company; d. $101.70 for payment to Park Avenue Radiology for their invoice for medical services rendered; 2. All proceeds due to minor Plaintiff, Adelisa Dervisevic, in the amount of $65,998.97 are to be used as a funding for structured settlement, with the guaranteed yield in the amount of $144,934.00, which amount is to be distributed to the minor as follows: a. $15,000 per year for 4 years, beginning on 8/1/1028 and continuing for 4 years (total of $60,000) 11 b. $84,934.00 on minor's 25th birthday (01/27/2025) BY HE T S , J. DISTRIBUTION: cc: - Nina Milovanovich, Esquire, (Milovanovich & Espinosa, LLC, 129 E. Orange Street, Suite 2, Lancaster, PA, 17602) - Mary Altman (Encompass Ins. Co., 333 Glen Street, P.O. Box 5000, Glen Falls, NY 12801) - Lisa Staff (Allstate Ins. Co., P.O. Box 1064, Buffalo, NY 14240) 12 LUTVO AND ZEKIRA DERVISEVIC, as parents and natural guardians of ADELISA DERVISEVIC, minor, 524 3rd Street Carlisle, PA 17013 Plaintiffs V. David A. Schriml 2713 Owego Road Vestal, NY 13850 Defendant : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW NO. 07-6823 Civil Term VERIFICATION I, Nina Milovanovich, Esquire, hereby verify that I am an attorney at law who represents the Plaintiffs, and that I am allowed to file this Verification pursuant to Pennsylvania Rules of Civil Procedure. MILOV?NWC,If &)KSPMOSA, LLC By: Ni v vich, Esquire 12 r ge Street, Suite 2 L as r, PA 17602 (7 93-1400 Attorney ID #: 75545 Attorneys for Plaintiffs Date: //' r * CERTIFICATE OF SERVICE The undersigned hereby certifies that on this day a true and correct copy of Motion to Amend the Court Order Issued on November 15, 2007 by the Honorable Wesley J. Oler, Jr. was served upon all parties via postage prepaid first class United States mail addressed as follows: Mary Altman Encompass Ins. Co. 333 Glen Street P.O. Box 5000 Glen Falls, NY 12801 Lisa Staff Allstate Ins. Co. P.O. Box 1064 Buffalo, NY 14240 By: Nina it ovich, Esglre 129 E. range Street, Suite 2 Lancaster, PA 17602 (717) 293-1400 Attorney ID #: 75545 Attorneys for Plaintiffs '? AW-' Date 4. ? c_? "F7 4 7 7 C.J LUTVO AND ZEKIRA DERVISEVIC, as parents and natural guardians of ADELISA DERVISEVIC, minor, 524 P Street Carlisle, PA 17013 Plaintiffs V. David A. Schriml 2713 Owego Road Vestal, NY 13850 Defendant : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW NO. 07-6823 Civil Term AMENDED ORDER OF COURT DEC 0 41007p+V V AND NOW, this 11 day of 1)e upon consideration of the Petition for Approval of Minor Settlement and Distribution of Proceeds, and the Plaintiffs' Motion to Amend the Court Order to correct the typographical error, IT IS HEREBY ORDERED AND DECREED that said Petition and the said Motion are hereby GRANTED, and that the settlement proceeds in the amount of $95,000.00 shall be allocated as follows: 1. The amount of $29,001.03 shall be paid to Milovanovich & Espinosa, LLC for the following: a. $23,750.00 (25% of the total settlement) for attorneys' fees; b. $585.85 shall be paid to Milovanovich & Espinosa, for their costs; c. $4,563.48 for re-payment of the lien to Capital Advantage Insurance Company; d. $101.70 for payment to Park Avenue Radiology for their invoice for medical services rendered; 2. All proceeds due to minor Plaintiff, Adelisa Dervisevic, in the amount of $65,998.97 are to be used as a funding for structured settlement, with the guaranteed yield in the amount of $144,934.00, which amount is to be distributed to the minor as follows: C13 CL- aj:a- ___.i LI 1 C-.) I .. . C?7 KV a. $15,000 per year for 4 years, beginning on 8/1/2018 and continuing for 4 years (total of $60,000) b. $84,934.00 on minor's 25th birthday (01/27/2025) BY THE COU J. DISTRIBUTION: cc: Nina Milovanovich, Esquire, (Milovanovich & Espinosa, LLC, 129 E. Orange Street, Suite 2, Lancaster, PA, 17602) L,-`f Mary Altman (Encompass Ins. Co., 333 Glen Street, P.O. Box 5000, Glen Falls, NY 12801) - Lisa Staff (Allstate Ins. Co., P.O. Box 1064, Buffalo, NY 14240) eoP, ?S rh*t?, fa1z10, 2