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HomeMy WebLinkAbout08-5758• IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHAN'S COURT DIVISION STORM FICKES, a minor, by his parent and natural guardian, WILLIAM FICKES, 8 Plaintiff NO.: Og - S*#jS V. SANDRA LYNCH, Defendant PETITION FOR APPROVAL OF THE COMPROMISE AND SETTLEMENT OF MINOR'S CLAIMS TO THE HONORABLE JUDGES OF THE SAID COURT: The Petition of Storm Fickes, a minor child, by and through his father and natural guardian, William Fickes, by his attorney George H. Eager, Esquire, respectfully represents: 1. The petitioner is Storm Fickes, a minor, who was born on April 4, 1998. 2. His Social Security number is 169-78-3771. 3. Defendant Sandra Lynch, is an adult individual with a last known address of 1615 South Mountain Road, Dillsburg, York County, Pennsylvania. 4. Defendant Sandra Lynch is insured by State Farm Insurance Company for liability under policy number 6429068381001 which is being handled by Terry Calloway, Claim Representative, State Farm Insurance Co., P.O. Box 142, Concordville, PA 19331-0142. 5. Melissa Dawn Shenk, the mother of the Petitioner and William Fickes, the father of the Petitioner, were never married. The Petitioner resides with his father, William Fickes and his stepmother, Teresa Fickes, at 936 Linton Hill Road, in Duncannon, Perry County, Pennsylvania. A copy of the permanent custody order is attached hereto as Exhibit A. 3 • • 6. On or about November 26, 2006, the Petitioner was running east from West Simpson Street and entered South Market Street from the sidewalk. 7. At the same time, Defendant was operating her vehicle on East Simpson Street and turned left onto South Market Street and collided with the Petitioner, knocking him to the ground, at approximately 6:16 p.m. A copy of the police report filed in this matter is attached hereto and marked Exhibit B. 8. After the accident, Storm moved himself to the curb and stayed at that location until Westshore EMS arrived. A copy of the Westshore EMS report is attached hereto as Exhibit C. 9. As a result of this accident, Storm Fickes sustained bodily injuries including a left femur fracture. He was admitted to Hershey Medical Center and underwent open reduction internal fixation to his left femur on November 27, 2006. A copy of Storm Fickes' records from Hershey Medical Center are attached hereto and marked Exhibit D. 10. After he was discharged from Hershey Medical Center on November 28, 2006, he was non-weight bearing until he began outpatient PT at First Choice Rehabilitation Specialists. He attended PT and was discharged with a home exercise program on February 21, 2007. A copy of his records from First Choice Rehabilitation Specialists are attached hereto and marked Exhibit E. 11. The State Farm policy insuring Sandra Lynch had policy limits of $100,000.00/$300,000.00. 12. An agreement has been reached between State Farm Insurance Company and William Fickes, the parent and natural guardian of the Petitioner, wherein State Farm Insurance 4 Company will be paying an amount of $81,300.52 for the injuries sustained by the Petitioner on behalf of Defendant Sandra Lynch, their insured. 13. The Petitioner's father had a policy of underinsurance through American International South Insurance Company (AIG). 14. The policy limits of the AIG Insurance Company's policy number AIGM2630304 are $100,000/$300,000. 15. An agreement has been reached between AIG and William Fickes, the parent and natural guardian of the Petitioner, to pay underinsured motorist benefits to the Petitioner in the amount of $10,000.00. A copy of the executed Release is attached hereto is Exhibit F 16. The adjuster handling the file at AIG is David Alessio and his mailing address is P.O. Box 8220, Corapolis, PA 15108. 17. William Fickes, the parent and natural guardian of said Petitioner, understands that his minor child, Storm Fickes, upon attaining their majority at age eighteen (18), will be unable to re-open this matter against the Defendant and that by agreeing to this settlement, he waives any further rights of recovery against the Defendant or the insurance carriers as a result of the injuries sustained in this accident. 18. William Fickes, the parent and natural guardian of said Petitioner understands that the proceeds are to be retained on behalf of the minors, as directed by the Court, until the minors attain their respective ages of majority, eighteen (18) years. Further, William Fickes, the parent and natural guardian of said Petitioner, may not expend said funds for her own use and benefit or for the benefit or use of her respective children without prior approval of the Court. 5 19. The settlements are in the best interests of the minor Petitioner by permitting recovery and investment of this recovery, and by avoiding the expenses and risks of litigation. 20. There was an outstanding medical lien in the amount of $11,275.65 Accent on behalf of Blue Cross/Blue Shield has waived. A copy of State Farm's May 27, 2008 letter to Accent is attached hereto as Exhibit G. 21. There are outstanding medical costs in the amount of $28.83 to Young's Medical Equipment. Copies of the invoices are attached hereto as Exhibit H. 22. In consideration of the aforesaid payments, William Fickes, the parent and natural guardian of said Petitioner shall execute a final release of all claims. A copy of the proposed Release is attached hereto as Exhibit I. 22. The settlement proceeds for the Petitioner totaling $91,300.52 will be placed in a restricted savings account in the Petitioner's name. It is understood that the Petitioner nor anyone else will be able to access this account without Court approval or until the Petitioner obtains the age of majority (18) on April 4, 2016. WHEREFORE, Petitioner requests that this Honorable Court enter an Order authorizing the proposed settlement as set forth herein. DATE: BY: EAGER, SPINELLO, QUINN & STENGEL G€orge H. Eage squire Attorney for P ' tiffs I.D. No. 277 1347 Fruitv a Pike Lancaster, PA 17601 (717) 290-7971 6 VERIFICATION I, WILLIAM FICKES, the parent and natural guardian of STORM FICKES, a minor, hereby verify that the averments of the attached Petition for Leave to Compromise Minor's Action are true and correct to the best of my knowledge, information and belief. To the extent that any of the averments of the Petition for Leave to Compromise Minor's Action are based upon an understanding or application of law, I have relied upon counsel in making this Verification. I understand that I am subject to the penalties of 18 Pa.C.S. Section 4904, relating to unswom falsification to authorities for any false statements made herein. WILLIAM FICKES Dated: kJ- /_0 0 5 U 30% PCW r • SIAM GRANT R? KES V. MELISSA DAWN SHENK r? u :IN THE COURT OF COMMON PLEAS :OF TSE 41'r JUDICIAL DISTRICT ;OF PENNSYLVANIA - :PFARY COUNTY BRANCH :NO. FC-2006-306 ORD ' R AND NOW, February 8, 2007, the parties appearing in Court, l'l ktiif being represented by Joseph Hltchings, Esquire, and Defendant being pro se, bat having indicated to the Court that they have reached an agent, the following is entered as an i Order of Court: I. The parties shall have shared legal custody of the minor child, Storm M. B, date of birth, April 4,1998. This nseans that both parties mast consult each other iaag to major medical, educational, and religious decisions pertaining to the child. parties shall have full and complete access to all medical records and educational ds of the child. 2. Father shall have primary physical custody of the d0l and Mother shall r-) C-) i, m{ Gi m N perio& of partial custody w fellows: a. Wednesday after school until Thursday morning at which time Mother shall deliver the child-to school. b. Sundays at 9:00 a.m until Monday morning at which time Mather shall deliver the child to school. If Monday is a holiday, Mother would get to keep the child until that evening. co The pick-mps on Wednesday after school and Sunday mornings shall be at )Father's residents'. CERTIFIED ATRUE COPY DEPUTY PROTHONOTARY 3. In the event that Mother must work during her periods of partial custody, Father shall receive notice of who will, be caring for the child. 4. If the child is playing outside, he shall not be unsupervised, Le., an adult shall supervise his play at all times. 5. The parties shall share the holidays as they can agree upon. 6. Mother shall always have Mother's Day and Father shall always have Father's Day with the child. 7. Mother would provide Father contact information regarding any caregiver of the child other than Mother herself: In other words, Mother will provide a telephone number whereby the child could be reached. & The Court is requesting that Father contact the school and make arrangements for the child to speak with the counselor concerning a recent incidence of catting, 9. The parties are encouraged to attend a co-parenting elass. The Court is not regairfmg that at this point, however, is strongly suggesting that the parties look into that. :10. The Court Is ORDERING the parents to attend the Seminar for Separated UJ s d Parents, within-60 days of today's date: If parents fail-to do so they maybe subject to contempt. .., i r cc: 3oseph Hftchings, Esq. Befendant, pro se Court Administration BY THE COURT, KAT1W A. MORROW, JUDGE 0 rr ,+fv Point CRS A0000075 COMMONWMTH of KWSYLVMNA PONCE CRASH RVOR7M KMM cm Goad tseparabk oub AA.W i e Ya ow a Ya 0 No Page 1 of 8 ? I ,.._. ? 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Orr um g ¦?WW?1pptt 9rArtveraSeadngLaWd q pP?a 28-090 kww 1 1hhaWNhoeg WaF 011 04" ANpls Wuntww 066.Edmit T 01. ve, 07 is /?Ax?11 ?. Ex i•War Sxeel 03S7s1em ? l1gMF 17 Ai A ?Q No p t L: J 2 ? 3 ? 4? . 1 a9 OS.Pawer Train 11.lAinas 111.Taler Orwbaded J UAW 10011 No 61 t 00 2 L .? l T 00 : 3 4 No _ aedwir t.e1M -ob ?l ? ? ? No 11 02 t 00 2 03'4"o'ki'q teahn0 veNda ? V 00 0 ni11rq or Canwq At ahkk on tr or? 1 wIacaYon ? : Md1o lhdt Na Faeter fade o.r.11,.. >" .? .wa..q.. 02 01 mo o -w ;,g.11ur+1gg i. 0 2 a ?awg 9nlvawn E/R v o r N unit No OT 00 thllt1o02 01 Hcror EAT tr the frdme O O O • r^ km We rvo o11a"t M a AIMI, IUAR PENNWT COPY htfivIlumm1r /1/lflri atatP no ?1Qrirr%nt/Pr;ntTMAOPCI JIT ii7iipgn n6i /1111 / 71 kprrvv?7 7 / /ffi6i T i innnnni; 0 . Print CRS A0000075 7 I COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM pop Page 6 of S. 0. AA SW 5 ""0nt crab NW464t A0000075 I ! t t ' I i i wt "ss Name mu mom 1 RUD I SPROUL 117 SOUTH CHESTNUT ST MECHANICSBURG 7174320150 1 JENNIFER FREEDMA 112 EAST SIMPSON ST MECHANICSBURG PA 7177662337 MarraWs and adQl WW wi warn "at krwsti gbn fWraoWn l POR • PMpuny Damps O x M Reportable accident Unit 1 operated by Lynch was turning left from East Simpson Street onto South Market Street. Pede stdan Juvenile was running east from West Simpson Street sidewalk, and ran into the path of unit 1. No damage to unit t, pedestrian transported to Holy Spirit Hospital wit h a broken lag. No citations issued PERWOT COPY httn•/Juntinit AMA atotP no nerrnne/PrinfimonaatvmivaPannn6v)nn7A 1 b?r?+n,'r7 r 7,)nnxv 1 t + nnnnne . Vdat CRS A0000075• ¦ • Page 7of8 HUMMMA 1111111mll J mmm Now o va"a om mmo pop AA SM M O A000N75 fo Anawm to tho bebar to morw to and Ndmd T"Q we on wom y s Yea N a No U . unknom unto No Etg1n. SI>yt iM Ddwt III 11 Eye ftwdlm HdMILI as a. No "dMd 1 ¦ RA Ht%* ftsma+N pratectim t HdwAMM C la No lltknet [] Fye Prokctlon a 1 s Fd H" ? P n er Q •MC E I,.I,n 2.3h S* 3 s 90 I1eln d 2 o 311 St* 3 a lug "AM g asse El tag Metres $10 i S ? ? Sande al urdf o1 1W& lag Pones 9 ¦ U wm ? Hek+xc Slap On1 9 x "n"n a I" Parts Q Mot SIaY On? PARK ? Orer Mk1e Bcats Wool 14 0 It" hu ? o a D"WAM „ Unk ob ALCO et Y • Yes ? Pasaegal 1ldextT UnR No lbLCt1l Y a Yn N. No rl a PesstW? HeNrelT 0.fb U* W&CMa D ?T (? T U r Urlam a HadT Rd11dNST j Un1t No 01 L._._J of ¦ MAW Cmvmb el tWaWJM tu, 91 • Mow claws% at IMISMOM in a Al i1U u*n • No Crourwltl 02 s Al II101111' i • No Cmsa 4 t 03. NwHatowdan Csawmb 03. Nm 4wwc bn cm "nh e yes 04 a 0" AMM 5 s In 14adweT O Yes DATM kalm Aoaes 04. In oph ONat el l *mcdon 06 Not In ROWW 07. Mod n O No O Nd ri tntasectan 06 . Not ^'' llaedwef mW Osa 1" 09 a Shod* a 08 09. gWad o" O ulk ' 10 a Skkralk d O s<1 o It O lvt 10 • cc 9dwFA i on Ilod •0,d? O Pdkant ke oreetWanIm. a > l 12. 13 a Owtidt ltik oy OOnk O b%Ctk 12¦atofmONand 13.OL%* TrAk+wy O Unknown % a sated P"tdirals 99 99 a UIIkn0atl O Unknown 99 s U*AWMM ph" new? []LOW Chanel ' Cawvdon O gag Terns o ? )dVftt zone wig Sign 09 p bnl sedwnn M* Mwoot O ap orl wa O Adwnce weming Antis [? O Ya r diet p > ??de a ' O Trensiion Aral ltmdtlx ?JCSeOt hferar w or kare O ul0sr CompaM O Ye Awn O bTanki p Can4dT O ww O Ta blIbn Aree O w k p 00W IN ME ftaft SbU noao O 0dw p Un ALMIUMMM AdOtionel WarWWmNHeo t r Irrrn?//?rnanv ?1nFiK nM?s .?.. ??. /;......all)v+w1Tm..??vrVmlr.;l.,,rlnn.ct ?nn-r>>1,........?^?, '?,I nA4I t 1 1 YIAMMG '"0101e'y1eO1Vlwo PBNNwr COPY I Print CRS A0000075• Crash Number. ADWW75 Incident Number. 2006110609 East Simpson Street South arket Street Page 8 of 8 . West Simpson Street L North arket N St et hnn•llwww dnt6 ctop no 1?CP?ns?e/Drin4?.n?nseN.+.i1::1??Yfnn?t ?M?? t t.......?? t "Ane I + I + • • / V???`I? x Wennsylvania EMS Report 0 Station Unit Name & No. 1 PCR No. Date F Station B Station - 2102218 3074993 11/26/2006 tion ' F Municipality & Incident Zip PSAP Incid. No. 't St d _t -0 et St 1 Mark ' Mechanicsburg Boro, 17055 C152411 J 00 3 1k S 2 Receiving Agency University Hospital - Hershey Patient Name Crew Storm Fickes C #1 Potter, Donald P 023292 Street Address C #2 Dougherty, Jacqueline E 145663 400 96 Linton Hill Road r hle C #3 Wh A E 145335 Zi S y, y s a City p tate Duncannon PA 17020 C #4 Horning, Robert E 145406 Sex Age DOB Phone No. Male 8 Years 04/04/1998 (717) - Times Cd Patient Number Social Sec. No. Pt. Weight 911 18:17 A14 169-78-3771 Dispatch 18:17 r 18:20 Private Physician Driver's License Arrive ve Ar Scene 18:20 Contact 18:20 Transporting Assist Units Assist OS Out On-Scene Dest. In Depart Scene 18:43 157800 157822 157842 Arrive 19:09 Available 20:13 Response Outcome Medical Command Physician MC Time In Quarters 20:13 Transported Chief Complaint: Pedestrian Struck - Lt Upper Leg Injury Current Meds: None Allergies (meds): None PMHx Not Stated Narrative Dispatched by 911 center Class One for Pedestrian Struck - immediate response. Dispatch info states an 8 yo male with a leg injury. Arrived on scene to find the patient sitting on the curb surrounded by bystanders and first responders. According to information gathered at scene, the patient stepped off the curb into the roadway without first clearing traffic, where upon he was struck by a vehicle traveling at an unknown rate of speed. Vehicle impacted patient on the left lateral aspect of the knee/thigh knocking him to the ground. Patient was able to move himself from the roadway to the curb where he was encountered by EMS. There was no reported loss of consciousness, and his only complaint is pain in his left lateral knee/thigh. On P.E. the child is CAO x 3 and in significant pain from his leg injury. Skin is warm, dry with good skin tone. Pupils are = and reactive to light. HEENT shows no evidence of open or blunt force trauma - we did note a small abrasion to the forehead, however patient states it is from a prior skateboard accident. Trachea is in the midline. Chest exam shows good excursion with clear and = breath sounds bilaterally, there is no chest wall trauma evident. Abdomen is soft and nontender with no evident trauma. Pelvis is stable to palpation and non-tender. Extremity exam reveals a swollen, deformed, painful area on the left lateral aspect of knee and thigh, there is also several small abrasions present. There is + movement in the other extremities and + neurovascular status distal to the injury site. Patient has the left leg in an flexed position and unable to straighten the leg due to extreme discomfort. Back exam is unremarkable. Neuro exam is unremarkable. GU exam shows no incontinence. Printed On: 11/26/2006 21:41 EMStat Reporting(c) 1998-2006, Med-Media, Inc. All Rights Reserved 0 ?.1 w (VN N 0 ON N S'ennsylvania EMS Report 0 Unit No PCR No. 1 Date B Station - 2102218 3074993 11/26/2006 5 E1vt Date of Birth Social Security Number PSAP t N"rje 04/04/1998 169-78-3771 C l 52411 Patient's leg was maintained in the position it was found and splinted using a pillow. He was placed on a LSB and a c-collar was applied. An IV of RL was started in the the left wrist and run at 100cc W per hour. Enroute to University Hospital, medical command was contacted for trauma alert. Received orders for pm pain control 0.1 mg/kg Morphine IV with one (1) follow dose. During 4i6 transport patient remained stable, and received a total of 6 mg Morphine for pain control. Upon arrival at University patient was more comfortable, less anxious, but still c/o significant pain at W injury site. Patient taken to trauma room and report given to trauma admitting team. Billing and HIPPA paperwork completed with parent. Time P R B.P. %Ox. ET C02 Glasgow Rhythm Treatment Provider.; Response/Comments 18:20 Pt contact -ALS Cl Assessment 18:25 Extricate patient from CI-C4 Splint leg with pillow street to MICU 18:27 / l l LSB and C-Collar C2, C3, C4 Applied 18:30 120 20 128/62 4/5/6 Initial VS; Resp. Effort: Normal; Perfusion: Normal 18:35 IV RL w/ 18 ga left Wrist Cl X1@100 cc Hr 18:43 Enroute University Cl, C2 Hospital 18:45 120 / 100 Normal Cl Sinus 18:50 120 20 118/P 98 4/5/6 C1 Resp. Effort: Normal; Perfusion: Normal 18:55 / /1 Contact MC University Cl Hospital 18:59 130 20 / 100 4/5/6 3 mg MS041VP Cl 19:09 Arrive University C l, C2 Patient to trauma room -> report t Hospital trauma team 19:09 130 20 122/86 100 4/516 Normal 3 mg MS04IVP Cl Resp. Effort: Normal; Perfusion: Sinus Nonnal Printed On: 11/26/2006 21:41 EMStat Reporting(c) 1998-2006, Med-Media, Inc. All Rights Reserved C1 tJl N Fr N Provider V,_Jage: 2 of 3 evennsylvania EMS Report is Unit No PCR No. 1 Date B Station - 2102218 3074993 11/26/2006 S Date of Birth Social Security Number PSAP tNj°1e 04/04/1998 169-78-3771 C152411 y.. Fickd Anterior Printed On: 11/26/2006 21:41 EMStat Reporting(c) 1998-2006, Med-Media, Inc. All Rights Reserved Posterior Provider Page: 3 of 3 O ON N .p O 'T ?- T • 1 t_ a a, H A .WEST SHORE EMS - EMS • 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011 Phone #: (800) 367-0512 Federal Tax ID: 23-2463002 PATIENT NAME: STORM FICKES INSURANCE: AIG 0600461010 CAPITAL BLUE CROSS UPP840956628 3074993E WILLIAM FICKES 96 LINTON HILL RD DUNCANNON, PA 17020 PATIENT NUMBER: 56766 CALL NUMBER: 3074993E DATE OF CALL: 11/26/2006 TIME OF CALL: CALLER: %TM SHORE EMERGENCY MEDICAL SERVICES INSU INS1 FROM: 200 BLOCK S MARKET ST TO: HERSHEY MEDICAL CENTER REASON(S) FRACTURED LEG - CLOSED FOR TRANSPORT INVOICE DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT ALS EMERGENCY LEVEL 1 A0427 1.0 1015.98 1015.98 ALS MILEAGE A0425 20.0 11.32 226.40 CERVICAL COLLAR A0382 1.0 59.75 59.75 10GTT TUBING A0394 1.0 8.78 8.78 SYRINGE (1 CC) A0394 2.0 1.70 3.40 EKG ELECTRODES (4PK) A0396 1.0 4.70 4.70 RINGERS LACTATE 1000CC A0394 1.0 4.43 4.43 MORPHINE 10MG A0394 1.0 19.34 19.34 Total Charges 1342.78 DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT MVA WRITE-OFF 01/17/2007 834.50 Auto Insurance Payment - AIG 01112007 01/17/2007 508.28 Total Credits 1 42.7 PLEASE PAY THIS AMOUNT - INVOICE DUE UPON RECEIPT -?? $0.00 RFTI IRNFr1 rn4I= _I( FFF - -Vii nn DETACH ALONG PERFORMATION AND RETURN STUB WITH PAYMENT AMOUNT DUE 0.00 PATIENT NAME: FICKES, STORM M CALL NUMBER 3074993E AMOUNT $ PATIENT NUMBER: 56766 BILLING DATE: 12/0512007 ENCLOSED YIS?4 VISA AND MASTER CARD ACCEPTED WEST SHORE EMS - EMS 205 GRANDVIEW AVE CAMP HILL. PA 17011 0 EXI,?6't ? • • • /AUTHORIZATION TO DISCLOSE HEALTH INFORMATION Patient Name: Storm Fickes Date of Birth: 04 / O4 / 1998 \"lJ a Social Security Number. 169-78-3771 i authorize the use or disclosure of the above-named individual's health information as described below- The following individual or organization is authorized to make the disclosure: Iiershey 1jedical Center, 500 University Drive, Hershey, PA 17033 2. The type and amount of information to be used or disclosed is as follows: (include dates where appropriate) problem list medication list list of allergies immunization record most recent history and physical most recent discharge summary laboratory results from x-ray and imaging reports from consultation reports from entire record ._ML other CI3AR.TONB Date t - y dg Request # ' Pages $D Assoc non pro cne cent pat std abs oomp (date) to ( ) log plu scan (date) to (date) (doctors' names) 3. 1 understand that the information in my health record may include Information relating to sexually transmitted disease, acquired Immunodeficiency syndrome (AIDS), or human immunodeficiency virus (H11). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse. 4. This information may be disclosed to and used by the following individual or organization: Eager, Spineilo, Quinn & Stengel, 1347 Fruitville Pike, Lancaster, PA 17601 for the purpose of civil litigation. b. 1 understand I have the right to revoke this authorization at any time. I understand if i revoke this authorization i must do so in writing and present my written revocation to the 1 \ health information management department 1 understand the revocation will not apply 1 to information that has already been released in response to this authorization. I 8L6L06Z LPL 130 N31SNNin00-l13NldSb30d3= ?C 7?d / //, g & /a, Header Page Patient Name: FICKES, STORM M Date of Birth: 4/4/1998 12:00:00 AM Medical Record Number: 1066842 Financial Number: 07761914 Admission Date: 11/26/2006 7:23:00 PM Discharge Date: 11/28/2006 6:34:00 PM Patient Type: Inpatient Facility: HMC Patient Location: HMC 7MBW Destination: Hershey Medical Center Reason: Legal ************************************************************************ Requester: Hershey Medical Center Date and Time Printed: 1/4/2008 1:44:29 PM Printed By: Twigger, Barbara Device: HISU30006 THE MILTON S HERSHEY OICAL CENTER *MEDICAL RECORD C PO BOX 853 MR328 (REV 9/00) HERSHEY, PA 17033 NAME: FICKES, STORM M MO: ENOBRECHT BRETT MRS: 1088842 MDMt 28080 SEX: M DNS: AUTO INSURANCE LOC: STANDARD OOS#: 7781914 VISIT DATE: 11/28/2008 +----------++-----------++----------++-------++--------++----++---++---++-+ 101066842 11707061914 11D11/26/06 11TI07ME23 P111440-02D11LOC 1+----------++-----------++----------++-------++--------++----++---++---++-+ +-------------------------++---++----------++---++--++----++---++---++----+ NAME 1FICKESTSTORM M 11MEX1104/04/19981iAG811SS11MRSAl1VRE11 11REL I LUT +-------------------------++---++----------++---++--++----++---++---++----+ +--------------------------------++--------------------++---++------------+ PATIENT ADDRESS CITY ST JJZIP CODE 96 LINTON HILL ROAD DUNCANNON PA 17020 4+1 ------------------------- ------------------------------------------+ +------------++---------------------------++---------------++-------------+ 1PT P834E599311PT EMPLOYER 11EMPLOYER PHONE 11 717 +------------++---------------------------++---------------++-------------+ +-------------------------++-------------++-----------++------------++----+ IFICKESCONTACTWILLIAM G 11RELFATHER 117PH17ONE834-599311WORK PHONE 11500 1 --------------------- _----++-------------++-----------++------------+-----+ +------------- N-------------------------------------------------+ INSURANCE IN: NAME AUTO INSURAN BLUE CROSS 0 SELF PAY )RMAT---- ? ,j POLICY # 5181545919 UPP840956628 Y GROUP NUMBER AD112606 082802 0 +-`?-_--?_---___-_________________--_ ------------------------ ------------------ DIAGNOSIS : \MQLTIPP +------------------------------------------------------------ +----------------------------------------------------------- - -----------+ (COMMENTS +-------------------------------------------------------------------------+ +------------------------------------++-----------------------------------+ ADMITTING PHYSICIAN 26060 ENGBRECHT BRETT W ATTENDING PHYSICIAN 26060 ENGBRECHT BRETT W +------------------------------------++-----------------------------------+ +------------------------------------++-----------------------------------+ FAMILY PHYSICIAN REFERRING PHYSICIAN c? SELF REFERRED NOV 2 8 2006 NO REFERRING/FAMILY PHYSICIAN . FAX: FAX: ------------ i---------'----------------++-----------------------------------+ PENNSTATE F, C, ki l siw Milton S. Hershe edical Center d?A (Z' of 064;3 s k College of Medicine CONSENT FOR ANESTHESIA I, Js p1; Ali ip request the administration of anesthesia to r Qgk z (patient or legal guardian) (patient) to reduce the pain and/or awareness during a surgical or medical procedure, and authorize the monitoring of vital bodily functions by, and/or under the direction of an attending anesthesiologist in the Department of Anesthesiology of Penn State Milton S. Hershey Medical Center. I understand that a resident physician and/or nurse anesthetist from the Department of Anesthesiology may also administer anesthetics and be responsible for monitoring vital bodily functions. I further understand that medical students and other health care trainees may observe and/or participate in my care under the direct supervision of the attending anesthesiologist. Hereinafter, "I" or "my" shall refer to myself or the patient for whom I am providing consent, as appropriate. 1. Based upon the explanation provided to me, I consent to the administration of one or more of the following alternative forms of anesthesia which may be suitable for the procedure I am about to have (check those to which you agree). '?/a) GENERAL ANESTHESIA: including intravenous agents and inhaled gases, which will cause unconsciousness. b) SPINALIEPIDURAL ANESTHESIA: including needle injections in the back near the spinal cord, leading to loss of pain sensation and sometimes strength in a large area, usually the lower half of the body. This may also include the administration of sedatives to help me relax during surgery. C) REGIONAL ANESTHESIA: including needle injections near major nerves, usually in an arm or leg, which will temporarily cause me to lose pain sensation and perhaps strength in certain areas of my body. This may also include the administration of sedatives to help me relax during surgery. d) LOCAL ANESTHESIA: including local anesthetic agents with or without intravenously administered sedatives. 2. 1 do not consent to the administration of anesthesia. (if no exceptions, place "X" in above blank) 3. 1 understand that any form of anesthesia for which I have given consent may be administered at the time of surgery. 4. If a spinal, epidural, regional or local anesthetic is not satisfactory for my comfort or to allow the surgery to proceed, or if my medical condition requires, I consent to the administration of general anesthesia. 5. I am aware that the practice of anesthesiology is not an exact science and that no guarantees can be made concerning the results of administration of anesthetics. Common side effects of anesthesia and various patient monitoring procedures include: nausea and vomiting, headache, backache, sore throat or hoarseness, and soft tissue swelling. In addition, even minor surgery may cant' with it major unforeseen anesthetic risks. These risks and complications include, but are not limited to, dreams or recall of events under general anesthesia; corneal abrasions; damage to the mouth, teeth or vocal cords; damage to the lungs or their linings, the pleura; pneumonia; numbness; pain or paralysis; infection; headache; damage to veins, arteries, liver or kidneys; adverse drug reaction and in rare cases, permanent brain damage, heart attack, stroke, or death. These potential risks apply to me whether a general, regional, spinal, epidural or local anesthetic is administered. MR 883 (Rev. 5/04) Page 1 of 2 CONSENT FOR ANESTHESIA 6. 1 understand that various"ant monitoring procedures may be nsary, and may be performed by anesthesiologists, to for or maintain vital bodily functions .g anesthesia and surgery. These procedures could commonly include insertion of intravenous catheters, bladder catheters, or tubes into the stomach. In some cases, specialized monitoring may require placement of needles or tubes into an artery, into the large veins in the neck or chest, or into veins in the lungs or heart itself. A flexible tube may be placed into the esophagus to view the heart, or brain waves may be analyzed with needles under the skin of the scalp. 7. 1 understand that during the course of an operation, unforeseen changes in my condition may arise which would necessitate changes in the anesthetic care being provided. In that case, I authorize my anesthesiologist, or other physicians or nurse anesthetists designated by my anesthesiologist, to provide such medical treatment, or perform such procedures as are necessary and desirable in the exercise of professional judgment. 8. If l ern pregnant, J.-understand that elective surgery should be postponed until after the baby is born. Anesthetics cross the placenta and may temporarily anesthetize the baby. Although fetal complications of anesthesia during pregnancy are very rare, the risks to my baby include, but are not limited to, birth defects, premature labor, permanent brain damage and death. 9. 1 authorize Penn State Milton S. Hershey Medical Center to permit other persons to observe the procedure with the understanding that such observation is for the purpose of advancing medical knowledge. I authorize Penn State Milton S. Hershey Medical Center to obtain photographic, pictorial or video representations/recordings of the procedure, and to use such representations for scientific or teaching purposes. 10. 1 certify that I have, to the best of my ability, informed the anesthesiologist obtaining consent, of all major illnesses I have had, of all past anesthetics I have received and any complications of these anesthetics known to me; of any drug allergies I have; and of all medications I have taken in the past year. I have also responded truthfully to any additional questions asked by the anesthesiologist. 11. The nature and purpose of my anesthetic management have been explained to me. I have had the opportunity to ask questions, and all questions have been answered to my satisfaction. I acknowledge that the information I have received, as summarized on this form, is sufficient for me to consent to and authorize the procedure described above. I retain the right to withdraw this consent at any time prior to the administration of said anesthetic by so informing my anesthesiologist. 12. 1 certify that all blanks requiring insertion of information were completed before I signed this consent form. Y ?A J , LAQa 1? I h(J (Patients Signature/Date) (or signature of person consenting on behalf of patient) K " // 2 ass (Witness to Patient's Signature/Date) Dr. 11, Laia provided the information summarized above and obtained the consent for the procedure. MR 883 (Rev. 5/04) Page 2 of 2 CONSENT FOR ANESTHESIA PENNSTATE Milton S. Hershe & ical Center College of Medicine NAME: FICKES, STOk MD: ENGBRECHT BRETT MR#: 1088842 DOB: 04/04/1998 INS: AUTO INSURANCE LOO: 7781914 MD#: 26060 SEX: M STANDARD CONSENT FOR ANESTHESIA Dosx• VISIT DATE: ,1/26/2006 I, tJXLi4+q c , request the administration of anesthesia to (patientl?L le al'guardian (patient) to reduce the pain and/or awareness during a surgical or medical procedure, and authorize the monitoring of vital bodily functions by, and/or under the direction of an attending anesthesiologist in the Department of Anesthesiology of Penn State Milton S. Hershey Medical Center. I understand that a resident physician and/or nurse anesthetist from the Department of Anesthesiology may also administer anesthetics and be responsible for monitoring vital bodily functions. I further understand that medical students and other health care trainees may observe and/or participate in my care under the direct supervision of the attending anesthesiologist. Hereinafter, "I" or "my" shall refer to myself or the patient for whom I am providing consent, as appropriate. 1. Based upon the explanation provided to me, I consent to the administration of one or more of the following alternative forms of anesthesia which may be suitable for the procedure I am about to have (check those to which you agree). a) GENERAL ANESTHESIA: including intravenous agents and inhaled gases, which will cause unconsciousness. b) SPINAL/EPIDURALANESTHESIA: including needle injections in the back near the spinal cord, leading to loss of pain sensation and sometimes strength in a large area, usually the lower half of the body. This may also include the administration of sedatives to help me relax during surgery. C) REGIONAL ANESTHESIA: including needle injections near major nerves, usually in an arm or leg, which will temporarily cause me to lose pain sensation and perhaps strength in certain areas of my body. This may also include the administration of sedatives to help me relax during surgery. d) LOCAL ANESTHESIA: including local anesthetic agents with or without intravenously administered sedatives. 2. 1 do not consent to the administration of A (if no exceptions, place W in above blank) anesthesia. 3. 1 understand that any form of anesthesia for which I have given consent may be administered at the time of surgery. 4. If a spinal, epidural, regional or local anesthetic is not satisfactory for my comfort or to allow the surgery to proceed, or if my medical condition requires, I consent to the administration of general anesthesia. 5. 1 am aware that the practice of anesthesiology is not an exact science and that no guarantees can be made concerning the results of administration of anesthetics. Common side effects of anesthesia and various patient monitoring procedures include: nausea and vomiting, headache, backache, sore throat or hoarseness, and soft tissue swelling. In addition, even minor surgery may cant' with it major unforeseen anesthetic risks. These risks and complications include, but are not limited to, dreams or recall of events under general anesthesia; comeal abrasions; damage to the mouth, teeth or vocal cords; damage to the lungs or their linings, the pleura; pneumonia; numbness; pain or paralysis; infection; headache; damage to veins, arteries, liver or kidneys; adverse drug reaction and in rare cases, permanent-brain damage, heart attack, stroke, or death. These potential risks apply to me whether a general, regional, spinal, epidural or local anesthetic is administered. MR 883 (Rev. 5/04) Page 1 of 2 CONSENT FOR ANESTHESIA 6. 1 understand that variou. ent monitoring procedures may be i Alsary, and may be performed by anesthesiologists, to , ?tor or maintain vital bodily functions ?g anesthesia and surgery. These procedures could commonly include insertion of intravenous catheters, bladder catheters, or tubes into the stomach. In some cases, specialized monitoring may require placement of needles or tubes into an artery, into the large veins in the neck or chest, or into veins in the lungs or heart itself. A flexible tube may be placed into the esophagus to view the heart, or brain waves may be analyzed with needles under the skin of the scalp. 7. 1 understand that during the course of an operation, unforeseen changes in my condition may arise which would necessitate changes in the anesthetic care being provided. In that case, I authorize my anesthesiologist, or other physicians or nurse anesthetists designated by my anesthesiologist, to provide such medical treatment, or perform such procedures as are necessary and desirable in the exercise of professional judgment. 8. If I am pregnant, I understand that elective surgery should be postponed until after the baby is born. Anesthetics cross the placenta and may temporarily anesthetize the baby. Although fetal complications of anesthesia during pregnancy are very rare, the risks to my baby include, but are not limited to, birth defects, premature labor, permanent brain damage and death. 9. 1 authorize Penn State Milton S. Hershey Medical Center to permit other persons to observe the procedure with the understanding that such observation is for the purpose of advancing medical knowledge. I authorize Penn State Milton S. Hershey Medical Center to obtain photographic, pictorial or video representations/recordings of the procedure, and to use such representations for scientific or teaching purposes. 10. 1 certify that I have, to the best of my ability, informed the anesthesiologist obtaining consent, of all major illnesses I have had, of all past anesthetics I have received and any complications of these anesthetics known to me; of any drug allergies I have; and of all medications I have taken in the past year. I have also responded truthfully to any additional questions asked by the anesthesiologist. 11. The nature and purpose of my anesthetic management have been explained to me. I have had the opportunity to ask questions, and all questions have been answered to my satisfaction. I acknowledge that the information I have received, as summarized on this form, is sufficient for me to consent to and authorize the procedure described above. I retain the right to withdraw this consent at any time prior to the administration of said anesthetic by so informing my anesthesiologist. 12. 1 certify that all blanks requiring insertion of information were completed before I signed this consent form. J ?iU- ?s?- J ! l ? l? z7 cry (Patie is Signature/Date) (Witness to Patient's Sig ature/Date) (or signature of person consenting on behalf of patient) Dr. 4*0TAC Cie-, provided the information summarized above and obtained the consent for the procedure. MR 883 (Rev. 5/04) Page 2 of 2 CONSENT FOR ANESTHESIA PENNSTATE Milton S. He ,.Fy Medical Center ® College of Medicine SPECIAL CONSENT FOR OPERATION OR '-20V51 5 ( Condition For Which Treatment is Proposed: L.Qzk- Qt2sa?.. 1. 1 authorize my physician, Dr. sa-4 1( - , and/or such other staff physicians or resident physicians as my physician may designate, to perform upon me (or the patient identified above) the following operation or procedure (for procedures on all paired organs or extremities, the side of the body must be specified as left, right, orAilateral, wjhout abbreviations): referred to as the "procedure". In this consent form, this operation or procedure 2. My physician has discussed with me the items that are briefly summarized below: (1) The nature and purpose of the proposed procedure:_ '-I s?'U' za (2) The risks of the proposed procedure including the risk that this treatment may not accomplish the desired purpose: k&"L, . LO , .??/ "nsse?( S.'a rw. 3) The feasible alternative treatments: (4) What may happen if the proposed procedure is not undertaken: e. n, ^L 3. I am aware that, in addition to the risks specifically described above, there are other risks that are present with respect to any surgical procedure, such as severe loss of blood, infection, risks associated with anesthetic administration, cardiac arrest, and blood clots lodging in the lungs, any of which may require additional corrective surgery or result in death. 4. 1 understand that during the course of this procedure, unforeseen conditions may arise which could require the nature of my procedure to be altered, or that another operation or procedure be performed. I therefore authorize my physician, or other physicians designated by my physician, to provide such medical treatment, or perform such operation or procedures as are necessary and desirable in the exercise of professional judgement. 5. 1 am aware that the practice of medicine and surgery is not an exact science, and I acknowledge that no guarantees have been made to me concerning the results of the proposed procedure. MR 21 Rev. 06/04 Page 1 of 2 SPECIAL CONSENT FOR OPERATION OR OTHER PROCEDURE SI.4L CONSENT FOR OPERATION C• OTHER PROCEDURE 6. 1 agree to receive blood or blood products if this need arises during my surgery. I understand that transfusions are not risk-free, although blood is carefully tested. The risks of transfusions include, but are not limited to: 1) fever, hives, or shaking chills; 2) Infections: Hepatitis B, Hepatitis C, HIV, Human T Cell Lymphotropic Virus (HTLV), and other, unknown infections; and, 3)reactions from a mismatch of blood types. I understand that a transfusion can always be refused. I understand that receiving my own blood may be a possibility which I should discuss with my doctor. 7. 1 acknowledge that the information I have received, as summarized on this form, is sufficient for me to consent to and authorize the procedure described above. I have had the opportunity to ask questions concerning my condition, and about the procedure, alternatives and risks, and all questions have been answered to my satisfaction. 8. 1 impose the following limitation(s) regarding my treatment (if none, so state): 9. 1 authorize the staff of Penn State Milton S. Hershey Medical Center to preserve for scientific or teaching purposes any tissues or parts which may be removed in the course of this procedure, and to dispose of them. 10. 1 authorize Penn State Milton S. Hershey Medical Center to permit other persons to observe the procedure with the understanding that such observation is for the purpose of advancing medical knowledge. I authorize Penn State Milton S. Hershey Medical Center to obtain photographic or other pictorial representations of the procedure, and to use such representations for scientific or teaching purposes. 11. 1 certify that all blanks requiring insertion of information were completed before I signed this consent form. (Patient's Signature/Date) (or signature of person consenting on behalf of the patient) rnc? (witness to Patient's Signature/Date) Dr. L?? A; & "I Z provided the information summarized above and obt fined the consent or t procedure. 4'uolok (Physician's Signature/Date) [For elective procedures, this consent is valid for up to 60 days from the date of patient's signature, unless there is significant change in the patient's condition or consent is revoked by the patient.] MR 21 Rev. 06/04 Page 2 of 2 SPECIAL CONSENT FOR OPERATION OR OTHER PROCEDURE PENNSTATE Milton S. Haley Medical Center ® College of Medicine CONSENT FOR MEDICAL TREATMENT NAME : STRETORM M MD: EN BT MRN: 106 DOB: 04/04/1098 INS: AUTO INSURANCE LOG: OOSN: 7761914 MDN: 26060 SEX: M STANDARD VISIT DATE: 11126/2006 c Visit ate I, (or?m on behalf of _ Y - I r knowing that I (he/she) am (is) suffering from a condition requiring hospital care, voluntarily consent to such hospital care encompassing routine diagnostic procedures and medical treatment by the Professional Clinical Staff of Penn State Milton S. Hershey Medical Center, its assistants, or their designees as necessary in their judgment. I am aware that the practice of medicine and surgery is not an exact science, and I acknowledge that no guarantees have been made to me regarding the outcome of treatments, procedures or examinations performed in the hospital. For the purpose of advancing medical knowledge I consent to the presence of medical students and other health care trainees, and understand they may participate in my care under the direct supervision of my attending physician in accordance with ordinary practices of this medical facility. ADVAN DIRECTIVES I have an Advance Directive: Yes No Undersigned unable to answer If Yes, I have been asked to provide a copy my vance Directive to Penn State Milton S. Hershey Medical Center for inclusion in my medical record. If No, an information packet regarding Advance Directives has been offered to me. PATIENT RIGHTS AND RESPONSIBILITIES I acknowledge that Penn State Milton S. Hershey Medical Center has provided me with written information on my rights and responsibilities as a patient. I am aware that a Patient Representative is available to me if I have additional questions or otherwise wish to speak with one. MEDICARE INPATIENTS I certify that the information provided by me in applying for payment under Title XVIII of the Social Security Act is correct. I acknowledge that I have received a copy of "An Important Message from Medicare". PERSONAL EFFECTS I understand that a safe is available in the Cashier's Office for maintaining patient valuables. Patients are encouraged to utilize this service, as Penn State Milton S. Hershey Medical Center does not assume responsibility for any patient valuables or items brought to the hospital. The undersigned accepts full responsibility for all personal effects, including but not limited to money, dentures, eyeglasses, contact lenses, hearing aids, radios, and jewelry. HOSPITAL MEDICAL RECORD RELEASE AUTHORIZATION I acknowledge that Penn State Milton S. Hershey Medical Center Privacy Notice has been offered to me. I understand that Penn State Milton S. Hershey Medical Center may disclose information about me and the treatment I am receiving, including copies of my medical record for purposes of treatment, payment, and Medical Center operations as described in its Privacy Notice. I agree to indemnify and hold harmless Penn State Milton S. Hershey Medical Center, its officers, directors, employees and agents, from any and all liability, loss, claims, or damages relative to the release of such information. Continued on Reverse 1II?IIIINII III1111 l rz CONSENT FOR MEDICAL TREATMENT QNSENT FOR MEDICAL TREATST AUTHORIZATION TO APPEAL INSURANCE DENIALS I authorize Penn State Milton S. Hershey Medical Center to file grievances with my insurance company, third party payors, case utilization and managed care review organizations which may be necessary to challenge denials of authorization or payment for a healthcare service. ASSIGNMENT OF BENEFITS I assign and authorize payment directly to Penn State Milton S. Hershey Medical Center. I authorize any holder of medical or other information about me to release to my insurance carrier and its agents any information needed to determine these benefits or benefits for related services. PATIENT RESPONSIBILITY AGREEMENT I, the undersigned, acknowledge and accept financial responsibility for the payment of all charges. I acknowledge and understand that all charges not covered by insurance will be payable in full immediately upon receipt of billings, whether interim or final billings. I authorize the hospital to make a credit investigation if necessary. Should the account become delinquent, and should it become necessary for the account to be referred to an attorney or collection agency, the undersigned shall pay the reasonable attorney's fees and expenses associated with collection. I, the undersigned, certify that I have read, understand, and agree to the provisions contained within this consent form. The issues addressed on this form have been fully explained to me. I have had the opportunity to ask questions, and all of my questions have been answered to my satisfaction. Patient's Signature Date Witness Date Patient is unable to consent because he/she is: A minor Undergoing emergency treatment Other, describe I " Guardian or Closest Relative's Signature Da a fitness Date L/rd -I AC(- Relationship Witness Signature for Telephone Consent Date All persons will be accepted for treatment without regard to race, color, creed, religion, national origin or sex. MR 887 Rev. 7104 Pa e 2 of 2 IIII?Ii?MI?I nifill CONSENT FOR MEDICAL TREATMENT PENNSTATE vk__? ® Milton S. Hers edit Center College of Medicine ED TRAUMA/RESUSCITATION FLOW SHEET/ORDER SHEET NAME: STORM M MD: E BRETT MRN: 1 DOB: 04/04/1998 INS: AUTO INSURANCE LOC: 003#: 7761914 MDN: 26060 SEX: M STANDARD VISIT DATE: 11/28/20081 DATE 'a b - III RESPONSE STAT PAGED TIME P ARRIVED 1?\ J EMS REPORT: I- • EMS MEDS GIVEN: CC AMB/MEDIC# HELICOPTER ON-SCENE INTERHOSPITAL CHART _ LABS _ XR _ CT LOSS OF CONSCIOUSNESS: _NO _UNK -YES # MIN ENTRAPPED: _NO -UNKNOWN -YES -# MIN SELF EXTRICATED: YES NO P RESPONSE LEVEL 1 1 21 3 AGE I& SEX// 1 WT LAR _CID/TOWEL ROLL LONGBOARD/KED MAST SPLINT _ MVC -CAR _ DRIVER _ BELTED _ EJECTED _ WINDSHIELD _ DAMAGE _ PICKUP _ PASSENGER _ AIRBAG _ # FT _ BROKEN _ FRONT _ MIN Mffi _ TRUCK = FRONT = CARSEAT _ ROLLOVER _ SPIDERED = BACK _ MOD ??VAN BACK NONE X ST WHEEL BENT _ BROADSIDED _ HEAVY ,kDESTRIAN _ BED OF PICKUP -UNKNOWN -UNKNOWN _ R _ L MOTORCYCLE _ BICYCLE _ ATV _ HELMET- NONE- UNKNOWN _ FALL _ FT _ GSW _ CAUMM _ BURN _ DIVING _ DROWNING _ FARM _ INDUSTRIAL _ SPORT _ STABBING _ OTHER IV A GE SITE SO #1 .S' • #Z #3 Eye Spontaneous Opening To voice Response To pain None Best Oriented Verbal Confused Response inappropriate words Incomprehensible sound None Best Obeys command Motor Localizes pain Response Withdraws (pain) Nxlon (peln) Extension (pain) None Total Apply this score to GCS GCS portion of Trauma Score GLASGOW 13-15 COMA 9-12 SCALE(GCS) 6-8 (Total Points 4-5 from above) 3 Systolic > 89mm Ho Blood 76-89mm Ha Pressure 50-75mm Hg 1.49mm Ho No Pulse Respiratory 10.29/min. Rate > 29/min. 1-5/min. None e Total Revised Trauma Score kill MR 690 11/02 ` L 'N AMT. INF SEDATED PARALYTIC AGENT _ SPONTANEOUS RATE _ 02 MASK UMIN _ 02 CANNULA UMIN ASSISTED RATE _ BVM RATE _ AIRWAY (ORAL/NASAL) _ ETT (ORAUNASAL) SIZE _ CRICOTHYROIDOTOMY TRACH SIZE MEDS Llr_& I LAST TETANUS CHEST REAP LABORED BREATH SOUNDS HEART SOUNq$ _ YES PRESENT PRESENT _ PIlHV ABSENT MUFFLED _ NO _ YES CLEAR WHE DIMINISHED C ITUS PA ADOXICAL NO _ YES CHEST MMETRICAL OTION WHERE ES -NO NO _ YES -'SOFT _ TENDER/ -4ASTABLE _ RIGID _ YES _ NO _ UNSTABLE _ DISTENDED WHERE PRIAPISM ARDING ARS _ BLOOD SOUNDS 1 YES -NO MEATUS Y S -NO WHERE - DECREASED PALE OT PYANOTIC _ COOL _OTTLE _ COLD DRY _ ACYANOTIC MOIST SERVICE TIME TIME CALLED ARRIVE ORTHO W 1 9 N. SURG ENT OPHTH. 1. OPEN FRACTURE ESCCHYMOSIS 2. AMPUTATION A-ABRASION 3. GUNSHOT WOUND C-CONTUSION 4. DEFORMITY L-LACERATION 5. STAB WOUND S -SWELLING 6. BURN T-TENDERNESS 7. PAIN S-SENSATION 8.RASH PW-PUNCTURE WOUND BURN - FT PT SC I-IMPALED OBJECT Original - Medical Record Yellow - Trauma Service Pink - ED ED TRAUMA/RESUSCITATION FLOW SHEET/ORDER SHEET ARWAY PATENT _ YES _ NV JVD -,YES _ NO TRA MIDLINE YES _ NO f NEUROLOGIC EVALUATI( ?I .?. Time _Pupil Pupil Time Warm "Pain Size React Motor Function Cardiac 2 Lites Scale R L R L RA RL LA LL GCS Rhythm P BP R Sat cL T / Q H. Used 'v N \ "LlO Neonatal C 1' :- (IV Pediatric .L •?, 2 Adult - ?. ct) Non- tl Communicative Child FOLEY YES NO - HEME + - SIZE FR BLOOD AT MEATUS INSERTED BY TIME RECTAL HEME + TONE ? GOOD ? DECREASED ? ABSENT PROSTATE ? NORMAL ? ABNORMAL DONE BY TIME N/G (ORAUNASAL) SIZE FR INSERTED BY TIME PERITONEAL LAV G L DONE BY DR IME RETURN ? CLEA ? PINK ? GROSS BLOOD AMOUNT INFUSED CC AMOUNT RETURNED CC FLUID TO LAB YES NO RCT SIZE FR CVP R L LCT SIZE FR A-LINE R THORACOTOMY CUTDOWN L THORACOTOMY BY: PERICARDIOCENTESIS TEE ECHO DONE BY 12 LEAD EKG YES NO ']Q BOLT INITIAL READING HALO DONE BY DR - AIRWAY (ORAUNASAL) - ETIF (ORAUNASAL) SIZE - CRICO TRACH SIZE _ • NURSE'S NOTES INCLUDES: 1.Assessment 2. Plan c (s??• 3. Intervention Oki. A a a _ Response Ongoing Assessment .,. Disposition/Final Assessment iim r ¦ ,-, -o, I ii(15c? A.mHA 14 R Nsf.ldAli. /I Ai a 10fiA ?d fYlrL?? .r?? C? 1 1 ?/1 C?t?, (A!? d SZ J ?eAL[[ s=Y G BRACELET LOCATION: IQ&LM A' fbi TEMPERATURE COLOR CAPILLARY SENSATION MOVEMENT PULSE WI A REFILL BLOOD BAND - V # W - Warm N - Normal R - Rapid N- Normal A - Active S - Strong 1 C - Cool P - Pallor S - Sluggish T - Tingling W - Weak W - Weak Documenting Nurse: CD - Cold F - Flushed A - Absent NB-Numbness P - Paralysis A - Absent H - Hot C - Cyanotic P - Pain and Support NUr A - Absent R -Regular. I - Irregular Physician Sig re: Pupil Size (MM) BVM = Bag Valve Mask LCT = Left Chest Tube NS = Normal Strength • w w • . • • • ET = Endotracheal Tube RCT = Right Chest Tube W = Weakness 2 3 4 5 6 7 8 9 ABD = Abdomen PH = Pre-hospital FP = Flaccid Paralysis RL = Right Leg LOC = Level of Consciousness R = Rigid LL = Left Leg PMH = Past Medical History DCB = Decerebrate Posture HEAD: RA = Right Arm BH = Bair Hugger OCT = Decorticate Posture LA = Left Arm PUPIL REACTIVITY: B - Brisk F . Fixed S -Sluggish D - Dilated N - Nonreacgve CHEST: ADMITTED TO REPORT TO TIME OR NOTIFIED OR READY TO OR ABD: FAMILY NOTIFIED ® BY RELATIONSHIP C-SPINE CLEARED: ? YES ? NO BY DR EXTRE . YES ? NO ASPEN: ? YES C COLLAR ON ? NO - : ? VALUABLES: ? W/PATIENT ? SAFE ? NONE ? W/FAMILY ? BELONGINGS FORM DONE BURN: ? EXPIRED CORONER NOTIFIED ® MATERIAL EVIDENCE TO POLICE: ? YES ? NO OFFICER BADGE # OTHER: TRANSFERRED TO VIA PENNSTATE Milton S. Hersh edical Center ® College of Medkmi e ORTHOPAEDIC TRAUMA ASSESSMENT NAME: TRAUMA, 700535 MU: DEFLITCH CHRIST' • MD#: 46325 MR#: 7005351 008: 01101/1900 SEX: U INS: SELF PAY SELF PAY LOC: EMER OOS#: 7761914 VISIT DATE: 01/13/2007 History of Injgry: Attending on Call: - C kJLQ 9=1- Consult Date: Z? o W f - Date of Injury: 00ci " . Consult Time: iq?_ t AM9 =Wlsl Mech anism of Injury: Sig nificant Past Me is I s ? unknown Ad i motor vehicle ? hypertension ? hepatic disease ? tobacco ? motorcycle ? coronary artery disease ? HIV - smoke(PPd)-- ? pedestrian struck ? peripheral vscular disease ? hepatitis B B chew ? fall ? congestive heart failure ? cancer ? alcohol ? industrial ? diabetes ? stroke ? narcotics ? farm ? COPD ? spinal cord injury ? unknown ? assault ? asthma ? ? other ? gunshot ? artrial fibrillation ? non-ambulator ? other ? renal failure ? anticoagulated Orthooedic Open Left Right ? 2. ? ? ? 3. ? ? ? 4. ? ? ? 5. ? ? ? 6. ? ? ? 7. ? ? ? 8. ? ? O 9. O ? O 10. ? ? ? 11. ? O ? 12. ? ? ? Resident comments: Q ©?. Bq'a- W;4a V,-, M%i (z) MW v 6,?g- 1 1 1 N 1''? .1c, P. LLL"y V Attending summary and plan: Expected period of non-weight bearing: right leg ft I g right arm left arm 6 weeks ? ? ? 12 weeks ? ? ? Expected period of Spine bracing: Cervical: ? 6 wks ? 12 wks *TLSO: ? 6 wks ? 12 wks Resident signaturV`? / AM M Attending signature: date: v time: ODD (2 P MR 874 Page 1 of 2 12102 ORTHOPAE IC TRAUMA ASSESSMENT *TLSO = Thoraco-lumbar-sacral orthisis %-hopedic Trauma Physical Examinati R INJURIES L SOFT TISSUE INJURIES RIGHT ?1\ BACK LEFT Other Iniuries: ? Head injury ? Aortic dissect. ? Pneumothorax ? Splenic Injury ? Hepatic injury ? Renal injury ? Bowel Injury ? Bladder rupture PHYSICAL EXA M AB N R L R L R L R L Neck 19 1?L ? ? Pelvis I?. ) ? ? Spine ? ? ? ? Hip ?1 ? ? Clavicle g -d ? ? Thigh -P ? ? ?r Shoulder a ? ? ? Knee 01 ? ? 9 Arm ?- ? ? Calf ?-a P- ? ? Elbow ? ? Ankle ?cl ? O Forearm -? ? ? Foot ? ? Wrist i X- ? ? Hand Zp 6 ? ? VASCULAR EXAM EXTREMETIES 1'p DP R 2r " L 2t NEUROLOGICAL EXAM UPPER EXTREMITY Motor deltoid bicep wrist flex wrist ext tricep 9[iP R ? f. Sensory R 4 C6 C7 C8 V L LT LOWER EXTREMITY Motor ias hip ext quads hams tib ant ext hall Ionagast%g R S L tG,^, 41,^,? L5 "51 ?----- Sensory Lr ? L4 - R ? t L 1- a Rectal: hyper norm hypo absent yT yT Bulbocav: hyper norm hypo absent X-RAYS TRAUMA SE RIES AP L AT POS N G C-Spine ? ? ? odon ? ? T-Spine ? ? ? ? LS-Spine ? ? ? ? Pelvis ? ? ? 2. «G< :?? 3. ? 4. 5. 6. MR 874 Page 2 of 2 12/02 ORTHOPAEDIC TRAUMA ASSESSMENT FRONT Penn State Milton S. Hers edical Center TRAUMA ANESTHESIA NSULT Date 4G Height Time (A td weight Age 'K sex Consulted by Emergency Department Dr. NAME: '? 7005351 MD: UEF G1RI3T0 MR#: 700 DOB: 01/0111900 INS: SELF PAY LOC: EMER OOS#: 7761914 MD#: 46325 SEX: U SELF PAY VISIT DATE: 01/13/2007 Attending Dr. I D?'? ??tsl?? # Resident/CRNA cNSEN # Assessment & Plan CC: ? MVC ? Fall 13 CC Other DLO S}? HPI: ? Belted ? Unbelted ? Loss of consciousness ? Entrapped Sz / p . Gc1,11: General Appearance Vital Sin I BP C( Pulse Sp Temp Glasgow Coma Scale = Neuro: Intact Cervical Collar in place ? _ ? _ HEENT. Teeth 1?a(A: Airway: Malampati Score Z_ Pupils: PM Ha: Size R L 3 ? Patient unresponsive due to Allergies N" A React R Z L Z Drugs Medical CP Surgical ' Non-Contributing S Y / obacco Y / tOH Y N Drugs Family History: VNon-Contributing 10 Clear to auscultation Trachea midline ? Labored breathing ? 13 H rt: Regular rate & rhythm ? Murmur ? Pulses full Abdomen: .lam Benign ? Tender ? Bowel sounds Extremities: ? No arent fx GU: ? Foley ? Assessment- ASA PS E Injune ?ss ..j . Adequate ? Marginal ? Difficult ? Needs Intubation due to --' dequate spontaneous ? Needs Mechanical Vent Circulation: Minimal Blood Loss ? Shock Grade Level of Pain (1-10) Plan: ? Requires Intubation ? Accompany to CT Scan ? OR ? No further intervention 13 IW i, e ? ? die d mss. ??' CODE: 99241 99242 99243 99244 99245 Form 270-106 (Rev. 5/05) PENNSTATE Milton S H I Medical Center College of Medicy ule TRAUMA TEAM SIGN-IN SHEET TRAUMA NUMBER I-ry-e TRAUMA LEVEL 1 Trauma Standby paged at hrs ,. r t C ?GC_ J, -? ?yv 1, NAME: 'T 7005351 MD: DEFLI n CHRISTO MDN: 46325 MR#: 7005351 008: 01101/1900 SEX: U INS: SELF PAY SELF PAY LOC: EMER 0060: 7761914 VISIT DATE: 01/13/2007 2 3 Trauma Response paged at hrs ED Attending Trauma Attending Trauma Team Leader PGY4/5 Senior Trauma Resident PGY 4/5 Junior Trauma Resident PGY 2/3 Junior Trauma Resident PGY 2/3 Junior Trauma Resident PGY 1 Junior Trauma Resident PGY 1 Emergency Med. Resident PGY 2/3 Emergency Med. Resident PGY 2/3 Emergency Med. Resident PGY 1 Trauma Physician Extender Trauma Physician Extender Anesthesiology Attending Anesthesiology Resident Certified Registered Nurse Anesthetist Respiratory Thera _ U Radiol9gy Attending Radiology Resident Radiographer #1 (Diagnostic) Radio ra her #2 (Diagnostic) Radiographer (CT) f I , S 1P1; Emergency Medicine EMT Chaplain 1107 OR Technician / Nurse ; :. Pediatric Critical Care Attending Pediatric Critical Care Resident ICA-W Child Life Specialist Trauma Coordinator / Case Manager PGY - Post Graduate Year Original Copy - Medical Records Pink Copy - Emergency Dept. MR 414 Rev. 4104 TRAUMA TEAM SIGN-IN SHEET YellowCopy - TraumaServices PENNSTATE 0 0 Milton & u--hey Medical Cater C dIgp of Methane Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 1 N a m e H 1 s t o r v 1 Name Be in Effective Date/Time End Effective Date/Time FICKES, STORM M 11/26/2006 7:21:13 PM Current TRAUMA, 7005351 11/26/2006 7:24:34 PM 11/26/2006 7:44:20 PM TRAUMA, 7005351 11/14/2006 6:57:11 PM 11/26/2006 7:24:34 PM FICKES, STORM 5/5/2000 8:47:38 PM 11/26/2006 7:21:13 PM Date Printed: 11412008 Time Printed: 1:49 PM • • Mon & Hattie Medical Coder Cefte of Medieme Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 A I I e r a 1 e s Substance: Bee sting Update Dt Tm Updated B 11/26/2006 10:24:46 PM Mahoney, Am K Reaction Status: Active; Date Printed: 11412008 Time Printed: 1:42 PM FENNSTATE Milton S. Hershe :dical Center ig College of MedicHie TRAUMA HISTORY AND PHYSICAL EXAMINATION NAME: S, STORM M MD: E 2T BRETT DOB: 04/04/1996 INS: AUTO INSURANCE LOC: OOSN: 7761914 MDN: 26060 SEX: M STANDARD VISIT DATE: 11/26/2006 0 • • Date: Z O Q Time: o: ly a of Trauma ;'` 7 Brief History (Mechanism of Injury) ? MVC Belted? ? Yes ? No ? Airbag Pedestrian ? MCC ? Assault • r Fall ? Burn ? Electrical ? GSW ? Stab ? Other jE:dn Filti AesfiIS Airway: IV's: R.O.S. Field Vitals: P: BP: RR: Immobilization: Fluid: Amnesia? El Yes o Loss of Consciousness? ? Yes WNo Field Notes: Primary Survey Trauma History, r Airway: Patent ? Obstructed Intubated: ? OT ? NT ? Trach Allergies: Breathing: „Q Breath Sounds: Mods: Circulation: P: BP: RR: Sat: Disability: 16 Alert Vocal ? Painful ? Unresponsive PM H: Exposure: Procedures: ? NG-Tube ? Urinary Catheter PSH: ? A-line: ? CVP(s): Chest tube: ? right ? left Last Meal: ? OPL: Last Tetanus: C.Qlldry;sllk?(@y ';, 2nd Vias: Temp: P: BP Se: ::. RR: WT 02 Sat HEENT: Head: Eyes: - Z-- Ears: TM's: Battle's: Face: Maxilla: Mandible: Nose: Dentitia: 1 Mouth: Dentures: ?, t I Neck: Tenderness Crepitus: Trachea Chest Wall: Tenderness: Crepitus: Lungs: CZ& 7C6 Back: Tenderness: Crepitus: Heart: Abdomen: Distention: ( BS: Tenderness: ' - Rectal: Tone: Prostate: , Pelvis: able: Tenderness: ? LEGEND: Vascular xam: R Right/Left 1_ ial Fe oral DP +A- PT _r/ -,A( L -laceration c1x-closed fracture n fracture ON Resident Signature Title Date Time a.m./p.m. 0 -ope Ab -abrasion C -contusion COPYRIGHT, 1998 POGHS , ' Orig - Chart MR 611 Rev. 3/98 TRAUMA HISTORY AND PHYSICAL EXAMINATION Copy- Trauma Services &MA HISTORY AND PHYSICAL EXAMSION Extremity Exam s LEGEND: L -laceration I Cfx-closed fracture Ofx- open fracture Ab -abrasion C -contusion 1ti?'1! 1l\ Y; ---111 i I • spinal cord injury: GI88gDW Coma Scale/Pods Eye Opening Trauma Score Cranial Nerves: c?N C' 2 - Open W Pain Resp. Rate SBP Motor: 4 03Q 3- Open to CommandNoice 4 - Spontaneous 0-0 0-0 1 -1-9 1 0-49 T 1-12 Verbal Response 1- None - 2 - >36 2 - 50-69 Sensory: Pinprick IV Pain s /Moans 3 - I at rii / Ci P i 3-25-35 3-70 90 4-10-24 4 ->90 Proprioception r e e a n appropr 4 - Confused / Consolable 5 Al I t / O i d ccs DTR's ) L 1 5 - r ente er nteracts / Motor Respond 0 4 - 2 - Decerebrate 1 .5- 2 - 5-10 3 - Decorticate 4 - Withdraws 3-11-13 ? ^ 5 - Localizes Pain 6 - Obeys 4-14-15 0 0 r N Total: I cj / Zi Total: L lie f 1EO?1#r "a kE,3, PT: Tro onin: U& PTT: M oglobin: T:Bili: CPK: Drug Screen: ALT: Amylase: ABG: ALP: ICa: ETON: ECG: TEE: BHCG: CXR: Pelvis: Head: CSpine: Lat Extremities: Abdomen: AP Others: Odontoid ". T& L Spines: yn1 J 1Z C ?' ( V O 1 ^^ ?ZV I_ 1 r5 - Z" G 1 r t.- C' (1 _SL? .1J - N, P C _ Alta In Signatur /Date Ime - ` f `/ `ar 9 Orig - Chart Copy- Trauma Services MR 611 Rev. 3/98 TRAUMA HISTORY AND PHYSICAL EXAMINATION 0- • Milton & I sy Medical meter CAfte of Medicine Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 P e I v 1 s/ G U - S t u d y Final X-RAY PELVIS AP 1-2 VIEWS - PEDS PATIENT NAME: FICKES, STORM M PATIENT MRN:07005351 PATIENT DOB: 0410411998 EXAM DATE OF SERVICE: 11/26/2006 EXAM NUMBER: 1694053 ORDERING PHYSICIAN: MEADOR, STEVEN A EXAM: AP supine chest x-ray CLINICAL HISTORY: 8-year-old boy, hit in lower body by car COMPARISON STUDIES: There are no comparison studies. DISCUSSION: Trauma board artifact partially obscures the chest. The cardiomediastinal silhouette is unremarkable. The lungs are clear without evidence of pneumothorax. The bony structures are unremarkable. IMPRESSION: No evidence for acute traumatic injury to the chest is identified. FRONTAL PELVIS CLINICAL INFORMATION: 8-year-old boy, hit in lower body by car COMPARISON STUDY: There are no comparison studies. FINDINGS: There is no evidence of fracture or of dislocation. Bony mineralization is normal. The bowel gas pattern is nonobstructive. Artifact from the trauma board overlies and partially obscures the pelvis. IMPRESSION: No acute fracture seen. C-SPINE CLINCIAL HISTORY: 8-year-old boy, hit in lower body by car DISCUSSION: The cervical vertebrae are visualized through T1 on the lateral view. The visualized cervical vertebrae are anatomically aligned. The visualized cervical vertebral body heights and disc spaces are maintained. The prevertebral soft tissues are normal in appearance. Laterally, the lateral masses of C1 align with C2. Medially the dens is partially obscured by overlying teeth. Impression: Limited odontoid view. Otherwise, unremarkable cervical spine radiographs Date Printed: 11411008 Time Printed: 1:44 PM 0 • Milton & Eh3he MxHcal Cuter College of Medleme Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 P e 1 v i s I G U - S t u d y Final LEFT KNEE, 2 VIEWS CLINICAL INFORMATION: 8-year-old boy, hit in lower body by car COMPARISON STUDY: There are no comparison studies FINDINGS: There is a spiral fracture through the distal metadiaphysis of the left femur with apex medial angulation of the fracture. There is approximately 2 cm overlap of the fracture fragments with one half shaft width posterior displacement of the distal fracture fragment. There are no other acute fractures or dislocations. There is associated soft tissue swelling IMPRESSION: Distal left femur fracture as described above. LEFT FEMUR, 2 VIEWS CLINICAL INFORMATION: 8-year-old boy, hit in lower body by car COMPARISON STUDY: There are no comparison studies FINDINGS: There is a spiral fracture through the distal metadiaphysis of the left femur with apex medial angulation of the fracture. There is approximately 2 cm overlap of the fracture fragments with one half shaft width posterior displacement of the distal fracture fragment. There are no other acute fractures or dislocations. The left femoral head well contained in its respective acetabula. There is associated soft tissue swelling IMPRESSION: Distal left femur fracture as described above. Dr. Rebecca Sivarajah is the dictating resident. Attending radiologist signature indicates review of both the images and the report and that the attending radiologist agrees with the interpretation. Preliminary reports may not have been reviewed as yet by the attending radiologist. DICTATED: SIVARAJAH, REBECCA Date Printed: 11412008 Time Printed: 1:44 PM • N S. Her ey M?edil Cuter Conege of bwi&e Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 S e i n e - S t u d v 1 Final CT CERVICAL SPINE WITHOUT CONTRAST-PED PATIENT NAME: FICKES, STORM M PATIENT MRN:07005351 PATIENT DOB: 04/04/1998 EXAM DATE OF SERVICE: 11/26/2006 EXAM NUMBER: 1694060 ORDERING PHYSICIAN: MEADOR, STEVEN A CT of Cl/C2 Clinical history: 8-year-old male hit by car Technique: Routine noncontrast CT scan of C1/C2 is performed Discussion: There are no comparison studies. There is no evidence of acute fracture. Vertebral bodies are anatomically aligned. Vertebral body heights and disc space are maintained. There is endotracheal tube. The paravertebral soft tissues are unremarkable. Impression: No acute abnormality of C1/C2 Dr. Rebecca Sivarajah is the dictating resident. Attending radiologist signature indicates review of both the images and the report and that the attending radiologist agrees with the interpretation. Preliminary reports may not have been reviewed as yet by the attending radiologist. DICTATED: SIVARAJAH, REBECCA REVIEWED AND SIGNED: CHOUDHARY, ARABINDA K DATE DRAFTED: 11/26/2006 08:31 PM DATE OF FINAL SIGNATURE: 11/26/2006 09:58 PM Date Printed: 11412008 . Time Printed: 1:44 PM PENNSTATE • • IV Coffege Milton & Harpy 1Vkdical Cater of WkWe Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 $ D l n e - S t u d y Final X-RAY CERVICAL SPINE LIMITED 2-3 VIEWS - PEDS PATIENT NAME: FICKES, STORM M PATIENT MRN:07005351 PATIENT DOB: 04/04/1998 EXAM DATE OF SERVICE: 11/26/2006 EXAM NUMBER: 1694054 ORDERING PHYSICIAN: MEADOR, STEVEN A EXAM: AP supine chest x-ray CLINICAL HISTORY: 8-year-old boy, hit in lower body by car COMPARISON STUDIES: There are no comparison studies. DISCUSSION: Trauma board artifact partially obscures the chest. The cardiomediastinal silhouette is unremarkable. The lungs are clear without evidence of pneumothorax. The bony structures are unremarkable. IMPRESSION: No evidence for acute traumatic injury to the chest is identified. FRONTAL PELVIS CLINICAL INFORMATION: 8-year-old boy, hit in lower body by car COMPARISON STUDY: There are no comparison studies. FINDINGS: There is no evidence of fracture or of dislocation. Bony mineralization is normal. The bowel gas pattern is nonobstructive. Artifact from the trauma board overlies and partially obscures the pelvis. IMPRESSION: No acute fracture seen. C-SPINE CLINCIAL HISTORY: 8-year-old boy, hit in lower body by car DISCUSSION: The cervical vertebrae are visualized through T1 on the lateral view. The visualized cervical vertebrae are anatomically aligned. The visualized cervical vertebral body heights and disc spaces are maintained. The prevertebral soft tissues are normal in appearance. Laterally, the lateral masses of CI align with C2. Medially the dens is partially obscured by overlying teeth. Impression: Limited odontoid view. Otherwise, unremarkable cervical spine radiographs Date Printed: 11412008 Time Printed: 1:44 PM Afilton & Huey Medical Canter Coflew of Nwidw Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 1 S p i n e - S t u d y 1 Final LEFT KNEE, 2 VIEWS CLINICAL INFORMATION: 8-year-old boy, hit in lower body by car COMPARISON STUDY: There are no comparison studies FINDINGS: There is a spiral fracture through the distal metadiaphysis of the left femur with apex medial angulation of the fracture. There is approximately 2 cm overlap of the fracture fragments with one half shaft width posterior displacement of the distal fracture fragment. There are no other acute fractures or dislocations. There is associated soft tissue swelling IMPRESSION: Distal left femur fracture as described above. LEFT FEMUR, 2 VIEWS CLINICAL INFORMATION. 8-year-old boy, hit in lower body by car COMPARISON STUDY: There are no comparison studies FINDINGS: There is a spiral fracture through the distal metadiaphysis of the left femur with apex medial angulation of the fracture. There is approximately 2 cm overlap of the fracture fragments with one half shaft width posterior displacement of the distal fracture fragment. There are no other acute fractures or dislocations. The left femoral head well contained in its respective acetabula. There is associated soft tissue swelling IMPRESSION: Distal left femur fracture as described above. Dr. Rebecca Sivarajah is the dictating resident. Attending radiologist signature indicates review of both the images and the report and that the attending radiologist agrees with the interpretation. Preliminary reports may not have been reviewed as yet by the attending radiologist. DICTATED: SIVARAJAH, REBECCA Date Printed: 11412008 Mme Printed: 1:44 PM E?I 0 • P IVSA i TE 10 Coflep Mon & Hashe Medical Center of Medidne Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 1 C h e s t - S t u d v 1 Final X-RAY CHEST PA OR AP VIEW- PEDS PATIENT NAME: FICKES, STORM M PATIENT MRN:07005351 PATIENT DOB: 04/04/1998 EXAM DATE OF SERVICE: 11/26/2006 EXAM NUMBER: 1694052 ORDERING PHYSICIAN: MEADOR, STEVEN A EXAM: AP supine chest x-ray CLINICAL HISTORY: 8-year-old boy, hit in lower body by car COMPARISON STUDIES: There are no comparison studies. DISCUSSION: Trauma board artifact partially obscures the chest. The cardiomediastinal silhouette is unremarkable. The lungs are clear without evidence of pneumothorax. The bony structures are unremarkable. IMPRESSION: No evidence for acute traumatic injury to the chest is identified. FRONTAL PELVIS CLINICAL INFORMATION: 8-year-old boy, hit in lower body by car COMPARISON STUDY: There are no comparison studies. FINDINGS: There is no evidence of fracture or of dislocation. Bony mineralization is normal. The bowel gas pattern is nonobstructive. Artifact from the trauma board overlies and partially obscures the pelvis. IMPRESSION: No acute fracture seen. C-SPINE CLINCIAL HISTORY: 8-year-old boy, hit in lower body by car DISCUSSION: The cervical vertebrae are visualized through T1 on the lateral view. The visualized cervical vertebrae are anatomically aligned. The visualized cervical vertebral body heights and disc spaces are maintained. The prevertebral soft tissues are normal in appearance. Laterally, the lateral masses of CI align with C2. Medially the dens is partially obscured by overlying teeth. Impression: Limited odontoid view. Otherwise, unremarkable cervical spine radiographs Date Printed: 11412008 lime Printed: 1:44 PM PENNSIATE • • 10 iV11tvli S. Ishey Medical meter College of Medicine Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 C h e s t - S t u d y Final LEFT KNEE, 2 VIEWS CLINICAL INFORMATION: 8-year-old boy, hit in lower body by car COMPARISON STUDY: There are no comparison studies FINDINGS: There is a spiral fracture through the distal metadiaphysis of the left femur with apex medial angulation of the fracture. There is approximately 2 cm overlap of the fracture fragments with one half shaft width posterior displacement of the distal fracture fragment. There are no other acute fractures or dislocations. There is associated soft tissue swelling IMPRESSION: Distal left femur fracture as described above. LEFT FEMUR, 2 VIEWS CLINICAL INFORMATION: 8-year-old boy, hit in lower body by car COMPARISON STUDY: There are no comparison studies FINDINGS: There is a spiral fracture through the distal metadiaphysis of the left femur with apex medial angulation of the fracture, There is approximately 2 cm overlap of the fracture fragments with one half shaft width posterior displacement of the distal fracture fragment. There are no other acute fractures or dislocations. The left femoral head well contained in its respective acetabula. There is associated soft tissue swelling IMPRESSION: Distal left femur fracture as described above. Dr. Rebecca Sivarajah is the dictating resident. Attending radiologist signature indicates review of both the images and the report and that the attending radiologist agrees with the interpretation. Preliminary reports may not have been reviewed as yet by the attending radiologist. DICTATED: SIVARAJAH, REBECCA Date Printed: 11412008 lime Printed: 1:44 PM Mbon S. Hambey Medical Center CoBep of Mledieine Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 M u s c u I o s k e I e t a I - S t u d v Modified X-RAY KNEE 1-2 VIEWS LEFT - PEDS PATIENT NAME: FICKES, STORM. M PATIENT MRN:01066842 PATIENT DOB: 04/04/1998 EXAM DATE OF SERVICE: 11/26/2006 EXAM NUMBER: 1694067 ORDERING PHYSICIAN: ENGBRECHT, BRETT EXAM: AP supine chest x-ray CLINICAL HISTORY: 8-year-old boy, hit in lower body by car COMPARISON STUDIES: There are no comparison studies. DISCUSSION: Trauma board artifact partially obscures the chest. The cardiomediastinal silhouette is unremarkable. The lungs are clear without evidence of pneumothorax. The bony structures are unremarkable. IMPRESSION: No evidence for acute traumatic injury to the chest is identified. FRONTAL PELVIS CLINICAL INFORMATION: 8-year-old boy, hit in lower body by car COMPARISON STUDY: There are no comparison studies. FINDINGS: There is no evidence of fracture or of dislocation. Bony mineralization is normal. The bowel gas pattern is nonobstructive. Artifact from the trauma board overlies and partially obscures the pelvis. IMPRESSION: No acute fracture seen. C-SPINE CLINCIAL HISTORY: 8-year-old boy, hit in lower body by car DISCUSSION: The cervical vertebrae are visualized through T1 on the lateral view. The visualized cervical vertebrae are anatomically aligned. The visualized cervical vertebral body heights and disc spaces are maintained. The prevertebral soft tissues are normal in appearance. Laterally, the lateral masses of C1 align with C2. Medially the dens is partially obscured by overlying teeth. Impression: Limited odontoid view. Otherwise, unremarkable cervical spine radiographs Date Printed: 11411008 Time Printed: 1:44 PM • • Mon & HMedical Unter College of Medicine Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 M u s c u I o s k e 1 e t a I - S t u d y Modified LEFT KNEE, 2 VIEWS CLINICAL INFORMATION: 8-year-old boy, hit in lower body by car COMPARISON STUDY: There are no comparison studies FINDINGS: There is a spiral fracture through the distal metadiaphysis of the left femur with apex medial angulation of the fracture. There is approximately 2 cm overlap of the fracture fragments with one half shaft width posterior displacement of the distal fracture fragment. There are no other acute fractures or dislocations. There is associated soft tissue swelling IMPRESSION: Distal left femur fracture as described above. LEFT FEMUR, 2 VIEWS CLINICAL INFORMATION: 8-year-old boy, hit in lower body by car COMPARISON STUDY: There are no comparison studies FINDINGS: There is a spiral fracture through the distal metadiaphysis of the left femur with apex medial angulation of the fracture. There is approximately 2 cm overlap of the fracture fragments with one half shaft width posterior displacement of the distal fracture fragment. There are no other acute fractures or dislocations. The left femoral head well contained in its respective acetabula. There is associated soft tissue swelling IMPRESSION: Distal left femur fracture as described above. Dr. Rebecca Sivarajah is the dictating resident. Attending radiologist signature indicates review of both the images and the report and that the attending radiologist agrees with the interpretation. Preliminary reports may not have been reviewed as yet by the attending radiologist. DICTATED: SIVARAJAH, REBECCA Date Printed: 11412008 rime Printed: 1:44 PM • • Alton S. HwdW Medical Center College of Medidne Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 M u s c u I o s k e 1 e t a I - S t u d v Modified X-RAY FEMUR LEFT - PEDS PATIENT NAME: FICKES, STORM M PATIENT MRN:01066842 PATIENT DOB: 04/04/1998 EXAM DATE OF SERVICE: 11/26/2006 EXAM NUMBER: 1694066 ORDERING PHYSICIAN: ENGBRECHT, BRETT EXAM: AP supine chest x-ray CLINICAL HISTORY: 8-year-old boy, hit in lower body by car COMPARISON STUDIES: There are no comparison studies. DISCUSSION: Trauma board artifact partially obscures the chest. The cardiomediastinal silhouette is unremarkable. The lungs are clear without evidence of pneumothorax. The bony structures are unremarkable. IMPRESSION: No evidence for acute traumatic injury to the chest is identified. FRONTAL PELVIS CLINICAL INFORMATION: 8-year-old boy, hit in lower body by car COMPARISON STUDY: There are no comparison studies. FINDINGS: There is no evidence of fracture or of dislocation. Bony mineralization is normal. The bowel gas pattern is nonobstructive. Artifact from the trauma board overlies and partially obscures the pelvis. IMPRESSION: No acute fracture seen. C-SPINE CLINCIAL HISTORY: 8-year-old boy, hit in lower body by car DISCUSSION: The cervical vertebrae are visualized through T1 on the lateral view. The visualized cervical vertebrae are anatomically aligned. The visualized cervical vertebral body heights and disc spaces are maintained. The prevertebral soft tissues are normal in appearance. Laterally, the lateral masses of C 1 align with C2. Medially the dens is partially obscured by overlying teeth. Impression: Limited odontoid view. Otherwise, unremarkable cervical spine radiographs Date Printed: 11411008 77me Printed: 1:44 PM PENNSFATE • • MWon S. I y Medical Cuter Colleie of Medicine Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 M u s c u I o s k e I e t a I - S t u d y Modified LEFT KNEE, 2 VIEWS CLINICAL INFORMATION: 8-year-old boy, hit in lower body by car COMPARISON STUDY: There are no comparison studies FINDINGS: There is a spiral fracture through the distal metadiaphysis of the left femur with apex medial angulation of the fracture. There is approximately 2 cm overlap of the fracture fragments with one half shaft width posterior displacement of the distal fracture fragment. There are no other acute fractures or dislocations. There is associated soft tissue swelling IMPRESSION: Distal left femur fracture as described above. LEFT FEMUR, 2 VIEWS CLINICAL INFORMATION: 8-year-old boy, hit in lower body by car COMPARISON STUDY: There are no comparison studies FINDINGS: There is a spiral fracture through the distal metadiaphysis of the left femur with apex medial angulation of the fracture. There is approximately 2 cm overlap of the fracture fragments with one half shaft width posterior displacement of the distal fracture fragment. There are no other acute fractures or dislocations. The left femoral head well contained in its respective acetabula. There is associated soft tissue swelling IMPRESSION: Distal left femur fracture as described above. Dr. Rebecca Sivarajah is the dictating resident. Attending radiologist signature indicates review of both the images and the report and that the attending radiologist agrees with the interpretation. Preliminary reports may not have been reviewed as yet by the attending radiologist. DICTATED: SIVARAJAH, REBECCA Date Printed: 11412008 lime Printed: 1:44 PM • • Milton a Henh ey Medical Cater College of Medi6we Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 M u s c u I o s k e 1 e t a I - S t u d y Final X-RAY FEMUR LEFT - PEDS PATIENT NAME: FICKES, STORM M PATIENT MRN:01066842 PATIENT DOB: 04/04/1998 EXAM DATE OF SERVICE: 11/27/2006 EXAM NUMBER: 1694660 ORDERING PHYSICIAN: Engbrecht, Brett Exam: Fluoroscopic views of AP and lateral left knee, AP and lateral left femur. Clinical History: 8-year-old male status post left distal femoral metaphyseal fracture. Comparison studies: Previous x-rays from 11/26/2006. Findings: Fluoroscopic images of left knee: There has been interval placement of a lateral sideplate with fixation screws proximal and distal to the fracture site. An additional lag screw is seen spanning the fracture fragments in the anterior posterior direction. There is reduction of the previously noted fracture fragments. Overlying soft tissues demonstrate the intraoperative nature of these images. No other fractures are seen. Left femur: Again seen are postoperative changes status post open reduction and internal fixation status post left distal femoral metaphyseal fracture. There has been no change the position of the lateral sideplate with fixation screws and anterior to posterior lag screw. There has been interval placement of a long leg cast spanning the knee and the distal femoral fracture site. No new fractures are identified. Overlying soft tissues are unremarkable. Impression: Intraoperative reduction and plate/screw fixation of left metaphyseal distal femoral fracture with placement of cast. Dr. Karen M. Brown is the dictating radiology resident. Attending radiologist signature indicates review of both the images and the report and that the attending radiologist agrees with the interpretation. Preliminary reports may not have been reviewed as yet by the attending radiologist. DICTATED: BROWN, KAREN REVIEWED AND SIGNED: BROWN, KAREN / CHOUDHARY, ARABINDA K DATE DRAFTED: DATE OF FINAL SIGNATURE: 11/27/2006 06:01 PM Date Printed: 11412008 Time Printed: 1:44 PM PENNSTATE • 41 Milt S. Hexhey Medical Center Coder of Miediane Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 Procedure WBC Hgb Hct RBC MCV MCHC MCH Units K/uL g/dL % M/uL fL g/dL pg Ref Range [4.8-13.5] [12-15] [36-44] [4.0-5.8] [74-82] [30-34] [25-30] 11/28/2006 Tue 1 6:30:00 AM 28.0 11/27/2006 Mon 0 12:05:00 PM 28.9 11/26/2006 Sun 0 5:31:00 PM 11.3 11.9 33.6 4.24 79.2 35.4 28.1 11/28/2006 6:30:00 AM Hematocrit: [[Lavender tube; Test included in the Complete Blood Count, and the Complete Blood Count with Differential]] 11/28/2006 6:30:00 AM Hct: SPUN HEMATOCRIT 11/27/2006 12:05:00 PM Hematocrit: [[Lavender tube; Test included in the Complete Blood Count, and the Complete Blood Count with Differential]] Procedure RDW Plts MPV Type of Dif -.. Neut% Lymph% Units % K/uL M % % Ref Range [12.0-16.4] [140-340] [8.7-12.5] [30-66] [30-55] 11/26/2006 Sun 0 5:31:00 PM 12.1 278 9.4 AUTO 68 24 Procedure Mono% Baso% Eos% Neut, Abs Lymph, Abs Mono, Abs units % % % K/uL K/uL K/uL Ref Range [0-10] [0-2] [0-6] [1.4-8.9] [1.4-7.4] [0.0-1.4] 11/26/2006 Sun 0 5:31:00 PM 6 1 1 7.7 2.7 0.7 Procedure Baso, Abs Eos, Abs Units K/uL K/uL Ref Range [0.0-0.3] [0.0-0.8] 11/26/2006 Sun 0 5:31:00 PM 0.1 0.1 • Date Printed: 11412008 nme Printed: 1:44 PM ton, HxfiC Chet' CbRege of NkAdne Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 C h e m 1 s t r Procedure Na K Cret Glu Units mmol/L mmol/L mg/dL mg/dL Ref Range [135-145] [3.5-5.0] [0.8-1.4] [70-120] 11/26/2006 Sun 0 5:31:00 PM 136 3.0 0.4 193 Date Printed: 11412008 Time Printed: 1:44 PM 10 1'JJl1AU1 S.Hash@ Medical College of Medicine Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 C o a g u l a t i o n 1 Procedure PT INR PTT Units second second Ref Range [9.2-11.9] [0.88-1.13] [24-34] 11/26/2006 Sun 0 5:31:00 PM 11.4 1.08 27 Date Printed: 11412008 Mme Printed: 1:44 PM 0 0 10 Milton & Horsley Cat Unter Collep of NkdWne Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 I L 1 v e r / G 1 1 Procedure ALT Amylase Units unit/L unit/L Ref Range [10-50] [20-80] 11/26/2006 Sun 0 5:31:00 PM 22 36 Date Printed: 11412008 Tune Printed: 1:44 PM • • muwu a Pw ? ITAMUUu %'Ouxr C of Medicine Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 B l o o d B a n k 1 Procedure ABO/Rh Antibody Scr Expires at 0600AM on R Number Units Ref Range 11/26/2006 Sun 0 7:50:00 PM A NEGATIVE 11/29/2006 R41979 NEGATIVE 11/26/2006 Sun 0 7:30:00 PM NOT DONE NOT DONE 11/29/2006 ND Procedure Component # Units B Comments Units Ref Range 11/26/2006 Sun 0 7:50:00 PM RED CELLS 2 11/26/2006 Sun 0 7:30:00 PM RED CELLS 0 See Below 11/26/2006 7:30:00 PM B Comments SPECIMEN RECEIVED WITHOUT R NUMBER ON LABEL DUE TO QUESTIONABLE IDENTIFICATION, SPECIMEN IS REJECTED; RECOLLECT REQUIRED; CALLED TO: EMT OUF 11/26/2006 7:30:00 PM # Units: Corrected from 2 on by <Unknown> 11/26/2006 7:30:00 PM B Comments: Corrected from SPECIMEN RECEIVED WITHOUT R NUMBER ON LABEL DUE TO QUESTIONABLE IDENTIFICATION, SPECIMEN IS REJECTED; RECOLLECT REQUIRED; CALLED TO: on by <Unknown> Date Printed: 11412008 lime hinted.- 1:44 PM • • mon & Hh1VZ acal Cater Cortege of Nwid e Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 Procedure Containers received to hold units Ref Range 11/26/2006 Sun 0 5:31:00 PM GREEN Date Printed: 11412008 Time Printed: 1:44 PM 0 • MUton S Hashe Medical Center Co?11+ W of Mbdldne Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 R e s p! r a t o r y T h e r a p y D o c u m e n t a t i o n F o r m ( P F) Respiratory Therapy Doci ntation Form 11/26/06 08:25 pm Performed by Hatter, Harry F Entered on 11/26/06 08:26 pa Mechanical Ventilation Artificial Airway Grid 1. Artificial Airway ETT ETT/Trach Tube Size 5 ETT Secured at: 23.00 cm Location Lips Ventilator Settings Grid 1. Mechanical ventilation Vents Servo 300 Mechanical ventilation Mode SIMV/VC, Pressure Support Pt range Adult Frequency (Set) 14 br/min CMV Rate 30 br/min Tidal Volume (Set) 350.0 mL Mech. Vent Fi02 (Set) 60 % PEEP (Set) 5 cmH20 PSV 5 cmH2O Ti 1.00 second Trigger Flow Measured Ventilator Parameters Grid 1. Frequency (Total) 14 br/min Vte 350.00 mL MV 5.00 L P peak 30 cmH20 P mean 11.0 cmH20 ETC02 39 mmHg Sp02 100 $ Mech Vent Fi02 (measured) 60 Resusitation Bag Yes Alarm Volume Yes Ventilator Charge Initial Charge Ventilator R e s p i r a t o r y T h e r a p y T i m e / E q u i p m e n t F o r m ( P F) Respiratory Therapy Time/Equipment Form 11/26106 07:18 pm Performed by Hatter, Harry F Entered on 11/26/06 07:18 pm RT Time/Zquipment Patient Procedure Trauma RT treatment duration 35 minute Date Printed: 11412008 lime Printed: 1:47 PM 0 - 0 NBi m i RwAg Medical Cuter College of Mwidne Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 T r e a t m e n t F o r m ( P F) Treatment Form 11/27/06 08:00 pm Performed by Lingle, Julie K Entered on 11/27/06 10:40 pm Routine Treatments Incentive Spirometry Predicted Volume 750 cc Incentive Spirometry Times Performed 2 Incentive Spirometry Volume Achieved 600 cc Cough and Deep Breathe Done Treatment Form 11/27/06 10:00 pan Performed by Lingle, Julie K Entered on 11/27/06 10:41 pm Routine Treatments Incentive Spirometry Predicted Volume 750 cc Treatment Form 11/28/06 07:30 am Performed by Wissler, Jodi L Entered on 11/28/06 07:37 am Routine Treatments Incentive Spirometry Predicted Volume 750 cc IV Site checked Yes Positioning Pressure Area Prevention Measures Pillow Standard Safety Bed in low position, Call device within reach, Siderails Up x 2, Wheels locked Treatment Form 11/28/06 09:50 am Performed by Wissler, Jodi L Entered on 11/28/06 09:44 am Routine Treatments Incentive Spirometry Predicted Volume IV Site checked Cough and Deep Breathe Activity Activity Status ADL Ambulation Patient Effort Activity Assistance Assistive Device 750 cc Yes Done up to chair Fair Moderate assistance Walker Treatment Form 11/28/06 12:00 pm Performed by Wagenheim, Sharon A Entered on 11/28106 12:07 pm Routine Treatments Incentive Spirometry Predicted Volume 750 cc Incentive Spirometry Times Performed 1 IV Site checked Yes Date Printed: 11412008 lime Printed: 1:47 PM b1ften & Eknhq Medical Center Cdlege of Mew Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 I- T r e a t m e n t F o r m ( P F) Treatment Form 11/28/06 12:00 pan Performed by Wagenheim, Sharon A Entered on 11/28/06 12:07 ym Routine Treatments Incentive Spirometry Volume Achieved 800 cc Incentive Spirometry Patient Effort Fair Cough and Deep Breathe Done Treatment Form 11/28/06 12:32 pm Performed by Wagenheim, Sharon A Entered on 11/28/06 12:33 pm Routine Treatments Incentive Spirometry Predicted Volume 750 cc IV Site checked Yes Treatment Form 11/28/06 02:00 pan Performed by Wissler, Jodi L Entered on 11/28/06 01s40 pan Routine Treatments Incentive Spirometry Predicted Volume 750 cc IV Site checked Yes Cough and Deep Breathe Done Treatment Form 11/28/06 04:05 pm Performed by Wissler, Jodi L Entered on 11/28/06 04:10 pa Routine Treatments Incentive Spirometry Predicted Volume IV Site checked Activity Activity Status ADL Ambulation Patient Effort Activity Assistance Assistive Device 750 cc Yes' Ambulating in hall Fair Moderate assistance Crutches, Wheelchair C a r e C o o r d i n a t i o n I n i t i a l A s s e s s F o r m ( P F) Care Coordination Initial Assess Form 11/28/06 09s56 am Performed by Warnagiris, Kathleen A Entered on 11/28/06 10:12 am Updated on 11/28/06 12:00 psi by Warnagiris, Kathleen A Initial Assessment CC Patient Type Simple CC Anticipated Discharge Date 11/29/06 Date Printed: 11412008 Time Printed: 1:47 PM PENNSTATE • • MBlton & iced" Medical Center Coll of Widne Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 C a r e C o o r d i n a t i o n I n i t i a l A s s e s s F o r m ( P F) Care Coordination Initial Assess Form 11/28/06 09:56 am Performed by Warnagiris, Kathleen A Entered on 11/28/06 10:12 am Initial Assessment CC Primary Language English CC Mental Status Alert, Oriented and converses, Agitated CC Support System Parent CC Provide Transportation Yes CC Home Transportation Private Vehicle CC Name of Support System William Fickes, dad, 834-5993 CC Current Living Situation Home with Others CC Name of Current Living Facility resides with his father, stepmother and i sib. Financial Information CC Primary Insurance Blue Cross/Blue Shield Care Coordination Narrative CC Narrative 11/27/06 Attempted to visit pt and family however they were asleep in the room. SW to follow up in the am. Cindy Greene,LSW #3442 11/28/06 Sw met with pt. and pt.'s father to introduce herself and SW services. Father stated that his son was hit by a car while visiting his mother in Mechanicsburg. He presented as very verbal, polite yet obviously angry, believeing that this accident was "highly preventable". Father was unsure if the women who hit pt. provided anyone with her car insurance. SW obtained the health Insurance for the pt. : Blue Cross/ Blue Shield, Group # 086341, UPA840956628. SW spoke with PT while they were begining their assessment of pt. Questioned DME needs. Unclear at this time. Will assess for wheel chair. Sw to follow for support and d/c planning. Kate Warnagiris, MSW #4400 11/28/06 SW contacted Jason L. from Young's Medical to order a wheel chair for pt. Father has requested that the chair be delivered to pt.'s room. SW will provide Young's with all necessary infomation. Kate Warnagiris, MSW #4400 (modified) Date Printed: 11412008 Time Printed: 1:47 PM • • 10 Cd&W lUaltoirl & Eksbe Medical dff of WAdne Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 N u r s i n g I V A s s e s s m e n t F o r m ( P F) Nursing IV Assessment Form 11/28/06 06:15 pm Performed by Wissler, Jodi L Entered on 11/28/06 06:18 pm Peripheral IV Peripheral IV Assess/Intervention Grid 1. Peripheral IV Activity Discontinue Peripheral IV Site other; left wrist IV Catheter Size #18 gauge C a r e C o o r d i n a t i o n P r o g r e s s N o t e F o r m ( P F ) Care Coordination Progress Note Form 11/27/06 03:51 pm Performed by Greene, Cindy D Entered on 11/27/06 03:52 pan Care Coordination Progress Note CC Narrative 11/27/06 Attempted to visit pt and family however they were asleep in the room. SW to follow up in the am. Cindy Greene,LSW #3442 Date Printed: 11412008 Time Printed: 1: 47 PM • • Mon & I aAW Medical Cuter College of bledidne Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 S p i r i t u a l C a r e N o t e F o r m ( P F) 1 Spiritual Care Note Form 11/26/06 07:15 pm Performed by Hurst, Casey Entered on 11/26/06 08:37 pm Updated on 11/18/06 07:51 am by Derriakson, Paul Spiritual Care Note Pastoral Services Visit Trauma Pastoral Services Offered Prayer, Support Religious Preference Lutheran Pastoral Impact Start Somewhat upset, anxious Pastoral Impact End Somewhat upset, anxious Length of Visit 60 minute Pastoral Intervention Conversation, Prayer Pastoral service Follow up Yes Pastoral Services Comments 11/26/06 & 7:15p Responded to level 2 trauma. Patient is an 8-year-old male. He was struck by an automobile after he ran into the street. Transported by ambulance to HMC. Parents (Melissa Shenk and William Fickes, as well as step mother Theresa) were on scene almost simultaneously. I took them all to the quiet room, where I explained the process. They were very happy to have prayer. I went back and checked on patient to tell him his parents were here. I stayed with him for about 10 minutes as his leg was positioned for imaging. He was a little upset, but pain did not seem to be a major issue. His parents were promptly informed by doctors and allowed to come back to the bay. Mom and dad were relieved he was alive, had no extensive injuries, but still appeared a little shocked even an hour later as news came back that he would need surgery. At this time Tyler relieved me and 2 introduced them to him. Casey Hurst Spiritual Care Note Pastoral Services Visit Pastoral Services Offered Religious Preference Pastoral Impact Start Pastoral Impact End Length of Visit Pastoral Intervention Pastoral service Follow Up Pastoral Services Comments with Spiritual Care Note Form 11/27/06 01:46 pm Performed by Sokolowski, Susan R Entered on 11/27/06 01:49 pm Follow Up Support Lutheran Calm, relaxed Calm, relaxed 15 minute Conversation Yes 11/27/06 - trauma follow-up. Pt was tired from the surgery he had this morning, but was able to share me what had happened to him. His grandmother and great- grandmother were with him in the room. All gave thanks that a Date Printed: 11411008 nme Printed: 1:47 PM 0 0 NMtm & EbrsW Magical eater Qdkp of Medidme Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 S p i r i t u a l C a r e N o t e F o r m ( P F) Spiritual Care Note Form 11/27/06 01:46 pm Performed by Sokolowski, Susan K Entered on 11/27/06 01:49 pm Spiritual Care Note that broken leg was the extent of his injuries. Pt wondering if he will be home in time for Christmas - grandmothers assured Pt he will be. T r e a t m e n t F o r m ( P F) Treatment Form 11/27/06 12:00 pm Performed by Sweigart, Jill A Entered on 11/27/06 12:19 pm Routine Treatments Cough and Deep Breathe Done Treatment Form 11127/06 02:00 pm Performed by Sweigart, Jill A Entered on 11/27/06 02:26 pm Routine Treatments Incentive Spirometry Predicted Volume Incentive Spirometry Times Performed Incentive Spirometry Volume Achieved Incentive Spirometry Patient Effort Cough and Deep Breathe 750 cc 5 500 cc Fair Done Treatment Form 11/27/06 04:00 pm Performed by Lingle, Julie X Entered on 11/27/06 10:38 pm Routine Treatments Incentive Spirometry Predicted Volume 750 cc Positioning Turn & Positioning Elevate extremity to level of heart, Head Of Bed Up Standard Safety Bed in low position, Call device within reach, Siderails Up x 2, Wheels locked Treatment Form 11/27/06 06:00 pm Performed by Lingle, Julie M Entered on 11/27/06 10:39 pm Routine Treatments Incentive Spirometry Predicted Volume Incentive Spirometry Times Performed Incentive Spirometry Volume Achieved Incentive Spirometry Patient Effort Cough and Deep Breathe 750 cc 3 500 cc Good Done Date Printed: 11412008 Time Printed: 1:47 PM Alton s H College of Medicine Center Penn State Milton S. Hershey Medical Center Tel: (717) 531-8055 Penn State College of Medicine Health Information Services, HU24 500 University Drive P.O. Box 850 Hershey, PA 17033-0850 Patient Name: FICKES, STORM M Patient Sex: Male Patient Location: 7MBW, 7266, 01 Visit Type: Inpatient PSUHMC MRN: 1066842 Date of Birth: 4/4/1998 Visit Number: 07761914 1 O p e r a t i v e N o t e D o c u m e n t Modified Document Electronically Signed by: per contribution per contribution Signed By: Troxell, Corey (11/30/2006 1:10:00 PM); Segal, Lee S (11/29/2006 1:55:27 PM) OPERATIVE REPORT Name: FICKES, STORM M HMC Number: 1066842 DOB: 04/04/1998 Date of Service: 11/27/2006 SURGEON: Lee Segal, MD ASSISTANT(s): Corey Troxell, MD and Dan Heaston, MD PREOPERATIVE DIAGNOSIS: Left distal femur fracture. POSTOPERATIVE DIAGNOSIS: Same. OPERATION PERFORMED: Open reduction, internal fixation of left distal femur fracture. ANESTHESIA: General COMPLICATIONS: None. DRAINS: None. FLUIDS AND EBL: Per Anesthesia. DISPOSITION: The patient tolerated the procedure well and transferred to PACU in stable condition. INDICATIONS: Storm is an 8-year-old male who sustained injury to his left distal femur on 11126/2006. He was a pedestrian and was struck by a slow moving motor vehicle. He was brought into Hershey Medical Center as a trauma. X- rays show a displaced distal femur fracture near the metaphyseal diaphyseal junction. The fracture was above the physis, and did not extend down into the physis. The patient was admitted to the hospital on our Pediatric Surgery service. He was placed in five pounds of Buck's traction and given adequate pain medicine. He was taken to the OR the following Date Printed: 11412008 Time Printed: 1:44 PM PENNST'ATE • 0 Mon & HershW Medical Cuter + Ak%e of Medicine Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 L_ O p e r a t i v e N o t e D o c u m e n t Modified Document Electronically Signed by: per contribution per contribution Signed By: Troxell, Corey (11/30/2006 1:10:00 PM); Segal, Lee S (11/29/2006 1:55:27 PM) morning on 11/27/06 by Dr. Segal. PROCEDURE: The patient was identified in pre-operative area. Surgical site was marked, and he had been taking to the Operating Room Suite. He underwent successful induction of general anesthesia. He was placed on an OSI radiolucent tablet in the supine position. A small bump was placed under the left hip. The left lower extremity was then prepped and draped in the usual fashion. C-arm was used to identify the location of the fracture site as well as the location of the distal femur physis. Following this, a skin incision was drawn on the lateral aspect of the distal femur, approximately at the junction of the anterior 1/3 and posterior 2/3 of the lateral femoral condyle, and extending proximally along the shaft of the femur. A ten blade scalpel was used to incise through the skin and through the subcutaneous tissue, any bleeders were coagulated with Bovie. Skin retractors were placed. The fascia of the T-band was then incised with a knife and then extended proximally and distally with Mayo scissors. The vastus lateralis muscle was then exposed. It was elevated anteriorly to find the intermuscular septum. The lateralis was then dissected through close to the intermuscular septum taking care to coagulate any perforating vessels into the vastus lateralis muscle. Dissection was carried down onto the bone. Incision Was made with a 15 blade knife longitudinally over the bone laterally through the periosteum. The periosteum was then elevated both anteriorly and posteriorly off the femur. Homan retractors were placed around the bone. The fracture site was irrigated and hematoma was curetted out. The fracture pattern was then visualized directly, and a reduction maneuver was performed with traction on the leg as well as direct manipulation of the distal fragment. Once anatomic reduction was obtained, a reduction forceps was placed across the fracture site. Following this, a 4.5 mm cannulated cortical screw was placed across the fracture site. It was placed in an anterior and proximal to posterior and distal orientation across the fracture site. A guide wire was placed and then was drilled with standard interfrag technique. Excellent purchase was achieved across the fracture site. A second interfrag screw was attempted slightly distal to this, and starting slightly more medial, however, did not achieve very good bite and was later removed. Following this, a 3.5 mm locking LCDCP 3.5 mm plate was selected. Care was taken not to place the plate too distal, so that it would be disrupting the blood supply to the physis. The plate was placed distal enough where one bicortical screw was able to be placed in the most distal screw. This was a locking screw. Two locking screws would be able to be placed in the most proximal hole and one unicortical cancellous screw 3.5 mm was able to be placed in the next to last distal hole. This last one was in a nonlocking cancellous 3.5 mm screw. I felt that the fracture fixation was very stable. The wound was irrigated well. After reduction forceps were removed, C-arm fluoroscopy on AP and lateral showed anatomic reduction of the fracture site. Direct visualization of the fracture also showed anatomic reduction. Following this, the fascia was closed over the IT band with 2-0 Vicryl interrupted sutures. Subcutaneous tissue was closed with interrupted 3-0 Vicryl sutures, and the skin was closed with 4-0 running subcuticular PDS stitch. Steri-Strips were applied, as well as Xeroform and sterile 4x4s and a sterile Webril. A long-leg cast was then placed with a good supracondylar mold. The patient tolerated the procedure well. He did receive Kefzol pre-operatively and postop sponge and needle counts were correct. Dr. Segal was present for the case. Date Printed: 11412008 lime Printed: 1:44 PM 0 0 Ngltoii & Ebmbey hiWical Unter CACP of Nwiame Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 O p e r a t i v e N o t e D o c u m e n t Modified Document Electronically Signed by: per contribution per contribution Signed By: Troxell, Corey (11/30/2006 1:10:00 PM); Segal, Lee S (11/29/2006 1:55:27 PM) 4244 Review/Sign: Corey Troxell, DO Review/Sign: Lee S Segal, MD CT /IHS DD: 11/29/06 DT: 11/29/06 13:22 Date Printed: 11412008 Time Printed: 1:44 PM PENN STATE 1066842 College of Medicine • University Hospital - Children's Hospital The Milton S. Hershey Medical Center FICKES, STORM 04/04/98 M ' 1? I"I RE ::... .. SEGAL. LEE Delay Codes DN atient In Time: 07:44 DATE O.R. SERVICE 11/27/06 01 ORTHOPAE ICS Anes. Start Time: 07:44 Surgeon Start Time: 08:55 Add-on [ Y ] Patient Type: INPT Level: ASA: 1 Incision Time Time: 08:05 Surgery End ID/7- Time: Instrument Count: [ N) (C)orrect Sponge Count: [ C) (C)orrect (Oncorrect (N)/A (Oncorrect (N)/A Patient Exit 1-? Time: Total Time Estimated Time Needle Count: [ C) (C)orrect Misc Count: [ C) (C)orrect (I)ncorrect (N)/A (Oncorrect (N)/A Pre-Op. Diag LEFT FEMUR FRACTURE Operation ORIF LEFT FEMUR Post-Op Diag. SAME AS PRE-OP DIAGNOSIS Wound Classification 1 Attending Surgeon SEGAL, LEE CODE 7915 Scrub.: MITCHELL, RANDY Relief Name: Time In: Dial Scrub: Out: Assistant HEASTON, DANIEL S00247 Assistant Circulator: STRATTON, DEBORAHDbI Circulator: stant Relief Name: Time In: Out: Attending Anesthesiologist SUKERNIK, MIKHAIL Assistant X-ray N Fluoro Y Anes. Type GENERAL ANESTHESIA Post-Op Destination PAR ,'-)es. Tech. Perfusionist Prosthesis - Implants - Grafts: Specimen: NONE Post Anesthesia Care Unit Time In: Time Out: otal: Type Description Lot No.: Serial No: Size: Mfg. SEE NURSES NOTES ?ommerr#s .: ! . coney troxell r4 gism ms3 assisting Dr Segal 214.630 x1 4.5 fully thread cannulated screws 214.628 x1 mm locking screws self tap W/ star drive 212.110 28mm x1 212.112 32mm x1 Signed By: BAD 710 DMI OK]n AnCMATIKItl onn11A offr+nr)n i PENN STATE • College of Medicine • University Hospital • Children's Hospital The Milton S. Hershey Medical Center 212.119 45mm x1 3.5mm LCP Plate 223.561 6 hole 85mm x1 4.0 cancellous full thread 206.014 14mm x1 VJA 1066842 FICKES, STORM 04/04/98 M SEGAL, LEE Signed By: awv,5:?-14__ L( I &-I ?C'Yo MR 219 REV 8/90 OPERATING ROOM RECORD PENNSTATE ® Milton S. Hershey !K ical Center 0 1 842 nncA 72-66-1 7MRu _ ?VLLV?. V Vl 111W.1V11LV f 10 ]y 74 04/04/1998 P F!CKES T S ORm M M F nlr, p Rf f:rlT BRETT M OPERATIVE PROCEDURE CHECKLIST 26060 Surgery/Procedure Name: 091E Cf ()D U: n- r_x.. Date: l1 -27-06 13mumanbd ch"k Imltlab To be completed and accompany all patien having an operative and/or invasive procedure. P? chat complete 1. Informed Consent completed, signed/dated within 60 days. (Note: consent must indicate side as applicable) 2. Anesthesia Informed Consent completed, signed/dated within 60 days. Pediatric patients-to be completed on floor or Same Day Unit / Outpatient Areas Adult only: ? to be done in holding area ? floor ? Same Day Unit 1 3. History and Physical signed and dated within 30 days 4. Old records obtained and sent with chart 5. Correct and legible identification bracelet on patient 6. Living Will and Advanced Directives: 7. Verbal communication with patient and/or family member/significant other to verify a Correct patient b Correct procedure to Informed Consent including site of incision laterality, if applicable) c) Correct procedure verified to OR/Procedure Schedule 8. Allergies: 04 9. Latex Allergy: ? Yes 9f No, ? chart labeled, ? bracelet on, OR, notified 1 j 10. Isolation precautions: OR notified @ _Type: //A '4' 11. Blood Identification band: Transfusion #: R Location of Band ?f 6, ? N/ []Type & Screen []Type & Cross # of Units: s' -¢k- a? /3g f ' 12. NPO @ Date: f ( Time: Day of Surgery meds taken with: ,l 13. Operative preparation done: /A []Shower []Shave []Bowel Other (specify) f 01 14. Special patient devices (e.g. Pacemaker, implants) Specify: ? Pacemaker/AICD chart labeled /?A N? 15. All personal Items must be removed prior to Holding/OR Area. Check any items left with patient ? Undergarments ? Glasses ? Contact Lenses ? Hearing Aid ? Prosthesis ? Denture ? Jewelry/Body Piercings ? Other 16. Vital Signs: Time: U T: 3!s i , P: 1 b , RR: 20 , BP: / 3 & (L), Room Air Oxygen SAT % ? IMP 17. Time of last void/diaper change/self cath 65" W4_w. f []Foley in place Orin _ o t 18. Urine Pregnancy test, if ordered: Results: ? Positive ? Negative 03 91A 19. Pre-procedure mediation given: ? Noe ? No pre-procedure medication ordered M di ti ith h 't44 6;516 t ti t e ca ons sen w n? pa en : Medications given on call: Time: 20. Last Glucose mg/dL" Anticoagulant/Antiplatelet ? yes Who Time: Date & Time last dose: Treatment: Medication name: too[ K° "Normal glucose ranges: ages 3 and up 70-120; 1 yr. Old - 50-130; 1 month old 40-140; Below 1 month, 30-100 21. SITE ID: Correct surgical site marked by surgeon or designee - To be completed on floor or Same Day Unit for Pediatric patient 22. To OR/Procedure Room @ (?1 l D 23. Comments: MR 12 Rev 3106 Page 1 of 2 11MMUN11111IIII OPERATIVE PROCEDURE CHECKLIST OPERATIVE PROCEDURE CHE403T TIME OUT i 8 LABEL I Procedure #11011X3-eL? T Out occurs immediately prior to procedure Patient Identification Correct site/side if applicable Agreement on procedure to be done Availability of implants/equipment Imaging studies in room if applicable Correct positioning of patient Procedure #2 Time Out occurs immediately prior to procedure Patient Identification Correct site/side if applicable Agreement on procedure to be done Availability of Implants/equipment Imaging studies in room if applicable Correct positioning of patient Procedure #3 Time Out occurs immediately prior to procedure Patient Identification Correct site/side if applicable Agreement on procedure to be done Availability of implants/equipment Imaging studies in room if applicable Correct positioning of patient Procedure #4 Time Out occurs immediately prior to procedure Patient Identification Correct site/side if applicable Agreement on procedure to be done Availability of implants/equipment Imaging studies in room if applicable Correct positioning of patient Pre-oD / Pre-Drocedure Education Record Assessment of Patient's Ability to Learn: STRATEGY EVALUATION (Explain areas that may Impact teaching). KEY: KEY: 11 Emotional El Physical C1 Cultural/Religious V=video C=Competent =Written R=Review [] Motivational C] Cognitive Limitations ? Lan9ua9a D D=Discussion ? None DEMO=Demonstrate ? Documented on PowerChart Educational Objectives Following instructions, the ? patient ? significant other will: Date Initial Strategy Eval 1. Describe pre-operative procedures/events the day of surgery. 2. Describe pre-operative procedures/events the day of surgery. ? IV ? NG tube ?Drains ? Casts ? Foley Catheter ? Chest tube ? Invasive Lines (CVP, arterial, etc.) 3. Describe post-operative equipment. ? Monitor ? Passive motion (CPM) machine ? Trapeze ? Crutches ? TED stockings 4. States understanding of pain scale. ? Yes ? No Scale used: Current level of pain Location: 5. Identify pain control measures. ? PCA ? Epidural catheter ? Blocks ? Prescriptions 6. State expected progression of diet and activity. 7. State rationale and describe procedure for respiratory care ? ISB ? TC&DB ? Chest PT ? Suctioning 8. Identify unit they will be in post-op (tour optional) ? Private Room ? Intermediate Care ? Intensive Care Outpatient Unit 9. OUTPATIENTS: Discuss care at home. Initial Code MR 12 `Rev 3106 Page 2 of 2 IINinIIII 1111ININ OPERATIVE PROCEDURE CHECKLIST PENNSTATE Milton S. He yMedical Center MD:EENO RE(.l SRETM M MD#: 26060 19 MR#: 1066842 College of Medicine DOB: 04104/1998 SEX: M INS: AUTO INSURANCE STANDARD INTRA OPERATIVE NURSING DOCUMENTATION RECORD 'DC: 008#: 7761914 VISIT DATE: 11/26/2008 Pre-Op Checklist: Y_QS No Hospital I.D. Band checked Verbal Confirmation of Patient I.D. Verbal Confirmation of Operative'. 1 Procedure r Pre-Op Consent Signed Allergies CAS-e?. Safety Belt on Thermal Unit Temperature IiOn4 Date: •LI /w Physical Impairments or Disabilities None Obese Blind Deaf Immobile Joint Amputation Ostomy Prosthesis Language Arthritis Comments: I 'b p(-p n_ 'r- Asstbk o-1 Ssk,,rt Blood # N4( 7 / 7 Type/Screen Type/Crossu # Units None The Patient identity, surgical Procedure, and surgical site were verified by the attending Sur on (Surgeon Signature) Comments: ?unt_ ,? e 1 ??q ck??,( QQ PATIENT ASSESSM NT Level of Consciousness and Behavior: Asleep Crying Alert Cooperative _ Drowsy Anxious Unresponsive Restless Talkative Disoriented Calm Comments: - r ?e C4-V- General Appearance of Skin: Good Color Rash Skin intact Bruise Flushed Reddened Pale Area Cyanotic Mottled Jaundiced Abrasion Diaphoretic Open Wound Com nts: STD 02 -BuLki 'tZ TtEr (2-e INTRA-OPERATIVE CARE Position for Surgery Supine Prone Lithotomy Positional Aides: Pillows _ Blanket or towel rolls Sandbags Armboard Olympus Armboard Overhead Arm Support Long Leg Stirrups Stirrups Sitting or Fowlers Georgia Prone Lateral Left Right Disc Table Montreal Lateral Positioner Spine Frame Beanbag Chan Headrest Horse Shoe Headrest Mayfield Gardner Headrest with Skull Fracture Table Points Other Foam rings _?a Comments: Gta?h ? 42% -Iv-a42-1 C!! Arz 1 Skin reparation: Pre-Op Shave: Clipped Razor None Prep Solution: Betadine Soap Betadine Solution A ohol ?ther ,al?,tp Prep Completed by: Ai a 1 Catheter: Yes' L3 No Fr. cc Balloon Urimeter Straight Drainage Other Foley Inserted by: Comments: MR 370 Page 1 of 2 5/00 INTRA OPERATIVE NURSING DOCUMENTATION RECORD INTRA O&TIVE NURSING DOCUMENTATION &RD 41 Drains: Location Size # Used Hemovac Jackson Pratt Penrose Miller Vac. Butterfly Duval Sump T-Tube Other None Used Comments: Tourniquet: Yes No Applied by-:Z? Pressure T Time Up: Time Down: Time Up: Time Down: 111701, Site Applied to: Electra Surgical Unit None Used Location of Gro Pa (Z,?].fi?' J-4 -1_gA Applied by:-?' Pre-Application Skin Condition: _ Skin intact, no apparent defects Other Comments: Monipolar # C90 ?- Bipolar # Ski condition after removal of ground pad: Skin intact no apparent defects Other Comments: Chest Tubes 4.?_ None Used Right Left Fr. # Used Fr. # Used Chest Drainage System Yes No Comments: Packing: None Used Location: Material Used: Dry Wet Solution Used: Other: Dressing: None Used o Location: 4 x 4's Jones Dressing Abd's Ace Band-aid Splint Collodion Steri-strips Cast Montgomery Xeroflo or Dressing Xeroform Pressure Fluffs Dressing Kerlix Opsite Kling Adaptic Benzoin Eye Pad Tubex Gauze Webril Type of Tape Used: Comments: Sponges Used: Raytec Laps Long Tapes Peanuts Cottonoids Tonsil Sponge Count: Correct Incorrect None Ne le Count: Correct Incorrect None ns rument Count: Correct Incorrect None Additional Co ments. i 00 S ' , s?. f) Signature & Date Z"7/vL (Fr. = French) MR 370 Page 1 of 2 5/00 INTRA OPERATIVE NURSING DOCUMENTATION RECORD PENNSTATE ® Milton S. Hershey cal Center College of Medicine NAME: 'MA, 7005351 MD: D ? CHRISTO MRM: DOB: 0 1900 INS: SELF PAY LOC: EMER DOW 7761914 ANESTHESIA RECORD PAGE 1 OF Anesthesia ~ Machine III_ Mo Day Year OR Number PHY STAT Cantinuow Anestiasla TraMfer To InCblon Surgeon Contlnuous Ana Can Begins Surgeon Transfer to Can Ends Z6 06 lG? I:C-f 14KO Anesth. Operative Procedure ???? ?rYl Diagnosis L-i sc +?e Fzrz HT YYT ? , Con3ent Procedures Performed by Anesthesiologist ? ArwathMc Tachnicus• ? nhalatlon T! j 4 J ? ? ART CATH ? Endobronch Incubation V. Preoperative ? CVP ? Fiberoptic Intubstlon ? Spinal SPO, BP Pulse Rasp Temp ? Swan Ganz ? Hypotenslon ? Epidural [I TEE ? Hypothermia ? Nerve block ? Hemodllution ? Monitored Care Pre-op Antibiotic Time TIME: rio 7000 M E D t y[.I y ?yyr ?gx?aau " ?`yIC y/s ?a ?+ly.g FA'' s a r 4 C A T L .Y 1 E i #? y «5h'_ a..i.A 'a"' k -bN CY 3a 0 S U # u. 5a N 'S n R m .is ffl,k], Biaoa 200 A PrMura k"W" 180 T pmsART m" 160 Puce 0 R aro- 140 120 100 80 60 40 20 M awuroewP 0 EKG N SpO, I Tamp T 0 F10, R ET Agent S ETCO, PIPIRRITV L Nerve stim U I D S lire Urine E.B.L. ai27 ,V. Gtr,. '.'"# GIr'' +4E?u N it Poslgon ANESTHESIOLOGIST POS E STATUS ON PACU ARRIVAL: BP P! R POSTOPERATIVE COURSE: SIGNATURE- TIME: ResklenVCRI I - / SIGNATURE- MDN: 46325 SEX: U SELF PAY VISIT DATE: 01/13/2007 CQ? ? /v < sl A . ENIS?A.( SUMMARY OF INTRAOPERATIVE FLUIDS TYPE VOLUME mL ML OTAL mL mL mL mL TOTAL mL E.B.L. mi. URINE ml. * 7777 REMARKS: wa o4kA?cd. Z 200 1800 rD ?-L 160 ?tf 140 120 O rlrs. -?? C l?- 100 80 60 40 20 WA . estheaia Machine Checked ?T?q Patient ldendfled ?reop Condition Assessed: .F, t i4?111 O Unchanged from Initial Evaluation 77,,--- 11 Except: SPO, Temp Immediately Available Throughout Present for Induction, Emeryence, and: ? Present Throughout DATE: u ll "11 I ATTENDING AN=EGIOLOGI97 It Ct„ MR 326 (REV JIM) MEDICAL RECORDS PENNSTATE ` w. Milton S. Hershey NW-cal Center • College of Medicine ?sl?t ?rb? t.2 bllw??! w ANESTHESIA RECORD PAGE of ohm ! STQ#M M M Mo Day Year OR Number PHY STAT continuous An•ethesla Transfer To Incl•lon -Swrow ue Atb Ong AnestMs b F t f V Can Begins yy Su 111V 5 Transfer to Qn,76 y p Operethn Procedure /2 f f' Diagnosis ,4 _ J^? ., t y M a •. Sur eon g Abe l HT WT „ Allergy '4--d4 1 f, Consent Procedures Performed b Anesthesiolo ist y g Anesthetic Tachniaus: Prooperetlve ? ART OATH El Endobronch Intubation Inhalation ' I.V. SUMMARY OF INTRAOPERATIVE FLUIDS SPO= BP ule Rasp Temp CVP ? Fib•roptic Irdubatlon ? Spinal TYPE VOLUME r 2c f?_ 8 ? Swan Ganz ? TEE Hypotension ? Hypothermla ? Epidural ? Nerve block ( ? /7 ? Hemodllution ? Monitored Care ? [ Pre-opAntiblotle Time . ON,-j -j ML M TIM ?b TOTAL ml. E ! i s 1 x mL fifi L C 14 C-- ` c r mL A mL T 0 TOTAL ? ml- `i' J?7 ml E.B.L. URINE :. REMARKS: A Blood A Prsseura 200 200 "' ?l • .r 1 ?rrvA ?T 180 R T 180 Y 4- J Pmsure 160 160 S c, dpi c.l r? • Pules 140 0 ra.xptra 140 M 4. L c. 1- 120 120 ( F r d?4 r ^ . 4g,, I t 100 4 2 ' 01 1 1 / I ry 1 0 100 A 144 80 80 60 60 40 T /-c 40 20 h 20 Stathoscope ? Ir7v? 0 EKG Sr fie S f" • I fye;" ; 6vO /ti0 ) T Temp t')I 0 FIO, .;. C,. 0.;? 6...5? ?3, . `.: v (?' ... V.. ?:? ??Y?f?v to S ET Agent ETCO, ?. .: L• L? ? 1 F PIPIRRRV 1( L 61 ? L Nerve stun U I D S ATTENDING ANESTHESIOLOGIST NOTES: Anesthesia Machine Checked Patient Identified Urine Preop Condition Assessed: E.B.L. Unchanged from initial Evaluation Positlon Except: ANE STHESIOLOGIST POSTOP ERATIVE N g STATUS ON PACU ARRIVAL: BP P /r R ?? q V,7 4 APO Ta SPO ` 1 , mp Immediately Available Throughout, POSTOPERATIVE COURSE: Present for Induction, Emergence, and: SIGNATURE- TIME: Resident(CRNA DATE: SIGNATURE- ATTENDING ANESTHESIOLOGIST Present Throughout MR 328 (REV 8105) MEDICAL RECORDS PENNS_TATE Milton S. Hersheygdical Center ip College of Me CH POST ANESTHESIA CARE UNIT RECORD NAME M0; E : r STOT7RM M MR#: 1T BRE 10 42 MD#: 28080 DOB: 04/0411998 INS; AUTO INSURANCE SEX: M LOC: STANDARD OOS#: 7781914 VISIT DATE: 1 ? V_? SPw C ?07 15° G • • 0 1/ 11 u I .'-, .1 11/28/2008. TIME IN TIME OUT ATE V t-0 TIME C7 (? p AnesthesiologisUAnesthetist/ =Sv+W?''4se Fi02 jape of Anesthesia 8 General ? Epidural ? Other ? IV Re ional ? Local ROUTE g ? Spinal S final 1 0 02 SAT Operation -j EKG nificant Hx It I. L Si 220 g PULMONARY EXTUBATION CRITERIA (Must meet 3) 200 t knees sustained for 5 secs. t head sustained for 5 secs. strong hand grasp Vit i l C 180 a apac TIME EXTUBA Extubated by V A 15 Airway one 0 Oral D Nasal 9? 0 Support T-Piece Trach Size Endotracheal F Resp. Alarm settings On I Off Ouality Rhyth Chest tubes site B/P 140 Clear ? `? Br. R 120 Sounds Clear PULSE CARDIAC 100 Alarm Settings Rhythm = NSR DrjtST = SB = Other On Ott Ecto ics = see rhythm strip Rulse Volum e' eqular O Wear Irregular 0 Thready ? xStrong O Doppler confirmet(/p? 50 On _ Off _ ne site (( ;;?? ? ) ?, } (as applicable) Site remity pulse 110 40 _ On Swan-Gan z site a applicable e VASC LU RUE OW E L&dWRLE LE 20 IV sit L' , ' I % re fly LY-Axink = pale = dusky alor RESP. patenUlntact = other TEMP. = other Temperature warm = cool PAIN SCALE other Capillary .Brisk = sluggish Ref ill =other NEUROLOGICAL STATUS Level of C usness-see Post Anesth s!a Score Sheet Pupils Rearla Vkqual = Sluggish ? unequal R Size Non-reactive L Size d _W Ova Command follows commands =other POST ANESTHESIA SCORE TIME IN Arms strong bilateral grasp = No strength weak bilaterally = other O Able to move 4 Extremities voluntarily or on command = 2 Able to move 2 Extremities voluntarily or on command =1 ACTIVITY Able to move Ex d voluntarily or on command = 0 Legs strong dorsillex 8 extensi = No stye nth g -'?C5r1 Weak t q , 0. SKIN STATUS wtc ale to deep breath and cough lreel eey = 2 Dyspnea or Limited Breathing =1 RESPIRATION Apneic = 0 a Adm' in Temperature (= po Lights on 28- from bed C-Al Fully Awake = 2 lling Noturesbponding - 0 = t CONSCIOUSNESS rectal Warm blankets applied tympani !, (= Hypothermia blanket applied Pcore Warm )Dry " Cool = Diaphoretic BP + 20% of Prearresthatic Level = 2 BP + 20-50% of PreanestMtk: Level =1 CIRCULATION BP + 50% of Preanesthetic Level = o = axillary Operative il? it ressing Type of Dress! 14 cirk* Ni -M Pink-Normal . 2 Pale, dusky, blotchy, jaundiced, other =1 COLOR Cyanotic = 0 LV' DRAINS Dressing dryffntact dressing Ai uy? TOTAL MR 559 9/93 1 I 4 POST ANESTHE • • POSITIONING OF PATIENT NURSES NOTES /DATE C? Pt. to remain flat ? other ( V it 0-1 ?ed INTAKE OR INTAKE PACU Type Amt Type Amt. ` l L 1 0 -12 lb - , itia L, SAIL ti.? Wt TOTAL TOTAL OUTPUT OR OUTPUT PACU L U w ?- T T L TOTAL A O LABORATORY - X-RAY • __ II __ __ CK,4v? C n Z,3 PROCEDURE TIME RESULTS READ BY v ?9 DISCHARGE ASSESSMENT Airway status Patent 8 Unobstructed Other Intubated ? Tracheostomy Rhythm 0 NSR V1 ST ? SB ? Other ectopics ? see discharge note Neuro Status Same as on arrival See discharge note Vascular IV site atentlintact p Same as on arrival See discharge note Operative Site Same as on arrival ? See discharge note P i R li f R ti tl l i t f i i a n e e ng qu y, no comp n es e a o pa n Continues with pain Pain relief improved ? Wishes to return to room with no further med . ? See discharge note Spinal Level on Discharge: (if applicable) ALLERGIES: N?WV? MEDICATI S GIVEN IN RECOVERY ROOM TIME DRUG DOSE Rt./Slte SIG. Actual time vs. time o by anesthesia J J V Discharge Score Time % Dischar e Nurse g Pt. to floor/Speciality Un (circle one) Room number Reviewed P C stay and postoperative orders with by PACU/RN Time Anesthesiologist Discharge Note: Time: q INITIAL SIGNATURE p INITI SIGNATURE 1141 -"" A 1 0 U ) CARE UNIT RECORD PENNSTATE Milton '.ershey Medical Center College Medicine III-5-u- PRE-ANESTHESIA EVALUATION AGE SEX RACE HEIGHT C Cm WEIGHT p k j? PHYSICAL STATUS J2 3 4 5 PRE-OP DX- (D MAV f4 PROPOSED OP:? PREVIOUS SURGERY' E * I/ 14-Is I qlc?TW-M M04 ltio S35 DDB 14p?' 4?0???? phi 1?? CONTENTS: ALLERGIES: PAST MEDICAL HISTORY (to be completed by patient) HAVE YOU EVER HAD: YES NO A. Respiratory 1. Croup - 2. Asthma, wheezing 3. Snoring - 4. Bronchitis - 5. Emphysema - 6. Pneumonia - 7. Cigarette smoking - 8. Cough, nasal congestion, sore throat within 2 weeks 9. Loose teeth or dentures - 10. Difficulty moving neck or law - B. Cardiac 1. Rheumatic fever - 2. Heart murmur _ 3. Irregular heart rhythm - 4. Heart attack - 5. Heart failure -- 6. Chest pain - 7. Shortness of breath 8. High blood pressure C. Neurologic 1. Seizures - 2. Stroke - 3. Unusual muscle weakness - D. Kidney Disease _ E. Blood Disorder 1. Sickle cell 2. Bleeding abnormally 3. Prior blood transfusion F. Gastrointestinal 1. Hepatitis 2. Liver disease - 3. Drink alcohol 4. Jaundice 5. Difficulty swallowing 6. Heartburn 7. Hiatal hemia G. Endocrine ?- 1. Diabetes 2. Thyroid disease - 3. Prednlsone or steroid therapy_ - 4. Could you be pregnant? - H. Family History of Adverse Anesthetic Reaction 1. Other Medical Problems - - r, W -tom iL 1 . MHZA1 . CU RENT EDICATIONS:G ANESTHESIOLOGIST NOTE RESP: TEMP: '? ''x,56 ? 4le?kR, Il It111a.t?s? ' lmrNwwsaht? JL'L? W& ? ', np?? L iat?ww c t cti (9 pry CA ' i• ? ANESTHESIOLOGIST: DATE: PREMEDICATION: FACULTY ANESTHESIOLOGIST. DATE: TIME: HEMATOLOGIF. rl;? *1 BLOOD AVAILABLE: V UrMO R ? AUWMVQ s CHEMISTRY' EKG: CHEST X-RAY: ',Try 4111K 11t PREOPERATIVE EVALUATION REQUESTED BY DR. MEDICAL RECORDS 7P, b RE?AKIETIE$IA.EYAL?'kl0N. ?.` PENNSTATE Milton S. Hershey t,0 Center College of Medicine PROGRESS REPORT NAME: FI% TORM M MD: ENOBR 1ETT MR#: 10668 DOB: 04/04/1998 INS: AUTO INSURANCE LOO: DOS#: 7761914 MD#: 26060 SEX: M STANDARD VISIT DATE: 11/26/2006 DATE TIME PROGRESS NOTES ? INPATIENT TPATIENT NAME - TITLE 1 ?vCp Z s ollaty ,--) ft, 'n z lub 471 e- rew AM Llle? White Copy - Medical Record PROGRESS REPORT Yellow Copy - Trauma Services MR s 2 v2 (7/91) Pink Copy - Nurse Manager PENNSTATE NAME: FIC? ORM M MD: ENOBRE SETT MD#: 28080 Milton S. Hersh Medical Center MRN: 1088842 1998 SURANCE SEX: M College of Medicine INSDDB:A A:UTO IN TANCE STANDARD LOC: PROGRESS REPORT oosx: 7781914 VISIT DATE: 11/26/2006 MR 6 Rev. 6/01 PROGRESS REPORT PENNSTATE Milton S. Hershey Medical Center ® College of Medicine PROGRESS REPORT NAMEOWS, STORM MD: ENGBRECHT BRETT MR#: 1066842 DOB: 04/04/1998 INS: AUTO INSURANCE LOC: DOSN: 7761914 MDB: 28060 SEX: M STANDARD VISIT DATE: 11/26/2006 Date/Time PROGRESS NOTES: (Include Name, Title) < < 7 ov pos P • M 2 AA%A1IP 1;4-ftif 09 F L:? S-?'c '?- S'jacirlb^-4. G ? TA• FK9(- c .. v i= 001 L T"N E Ar zra-b PICO 75> L 10 ?r•_ s FtAbn& ?.? z.a k 3 0j 0tiVgrOrz?- I.Ic V'- T? PjW f4=1,J• s a . X1 MR 6 Rev. 6101 PROGRESS REPORT • PROGRESS REPORT • Date/Time I PROGRESS NOTES: (Include Name, Title) i /_. I%,, v L JL C4 I a 1 0 Pf Rn4Q 3?, 5 fG r -H t O s to;,L TA) i n d c?ia( ,P( 0 aasol encocviov vt. to ',use. '?13. W; Il eonfi?l,c? ?r/ ?-?n: llt d??u%?,P,,?? ?? zV o? e pop s 5"111 X1r Ms g-011O S o-re-. oS :ao S: Pt. t 0XA--is~iP • Dtp..iz y N y Si; i?w-p!r 4 wA4& -• = e--irwgo l??x ??•c t D Faa w Sy f" h?e? ASS wpy1-4 owes-n-0.5 . to'. v tTRvs : -r 38 ' -r37 s 12? ???-?vtf Zd zo -Z-4 ? - 3 l goo -?? ?' !Z ? S L, Gtp ; 7do ce, 1.3 I << )e- r Gig 51-e?h. ?E . r4 Am p I?Gf?1Vl'• ?ECicct.A full NtK/J,n DJdff ' S S kA, - (r s '• C-M- g k6n © Bs SnElf, r4 D NT _ A- . 8 y m e Poo I '31F- D 1 F r- J ac kQ ,4i.. - wvgG - tat i FfYCw - T Tt"P oY iGit r SDLvFD vt••!, - co,r-? ra "6. i 7-0' 3 L> 6 Fb - pVW RoyDN.r Tr?.o?-.l? r?oTE Ms?t MR 6 Rev. 6/01 PROGRESS PENNSTATE Milton S. Hersh , Ivledical Center College of Medicine PROGRESS REPORT NAME: , STORM M MD: E iT BRETT MRN: 10 2 DOB: 04/040999 INS: AUTO INSURANCE LOC: OOSN: 7761914 MON: 26060 SEX: M STANDARD VISIT DATE: 11/26/2006 t Date/Time PROGRESS NOTES: (include Name, Title) cavm ?-Q 1>0s4r -. 9 L -? v p-- E CT U 'y S ` t6 S `y 2d cl a L- ADO: fr ML/bG CS LJ - yAc LAST- PA C -A-&5 ,. J Ps s' r_ m v c'- <-`a_ A k 1-7--7 » . 1 rat Sh - xj-r C730 s l - D6,.4 / Ps MJ) S ZS W71- 7?eS' 19 G MR 6 Rev. 6101 ` PROGR ] SS EPORT r- Wllf IiIM S LS 47K r r t -F: P. _ _. 1 , . i ILIA %A. IU w str;,,d t0 -r ?? • PROGRESS REPORT • Date/Time I PROGRESS NOTES: (Include Name, Title) MR 6 Rev. 6101 PROGRESS REPORT • • Wton & Hembe Mescal Cater College of 14dne Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 1 O r d e r s S e c t i o n I Mnemonic Action Order Status Type of Order Chest XR Order Completed Radiology Ordering Physician Order Placed By Ammons, Daniel M Sel as, Christopher J Review Information Nurse Review, Accepted - Mahoney, Am K, 11/26/2006 10:02:57 PM Order Details Stat, Requested Dt: 11/26/06 19:04:00, 1 view - AP or PA (Limited), Views: *Standard Views, ICD9: Trauma 959.8 Histo : Trauma Mnemonic Action Order Status Type of Order ED Trauma Radiolo Set Order Completed Order Sets Ordering Physician Order Placed By Ammons, Daniel M Sel as, Christopher J Review Information N/A Order Details N/A Mnemonic Action Order Status Type of Order ED Nursing Charge Order Discontinued Patient Care Ordering Physician Order Placed By SYSTEM SYSTEM Review Information N/A Order Details Request Dt: 11/26/06 19:02:14 a ai c. vi t.vvv /.vL. l•t rlYl. GU HUL511% unarge Date Printed: 11412008 Time hinted: 1:49 PM • • 10 Mon & I mhey Medical Cmiter College of Medidle Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 1 O r d e r s S e c t i o n 1 Mnemonic Action Order Status Type of Order Chest CT (Apex to Order Canceled Radiology Adrenals). Ordering Physician Order Placed By Ammons Daniel M Contributors stem, IDXOE01 Review Information Nurse Review, Accepted - Mahoney, Amy K, 11/26/2006 10:02:57 PM Doctor Cosign, Not Reviewed - Ammons, Daniel M Order Details STAT, Requested Dt: 11/26/06 19:12:56 Mnemonic Action Order Status Type of Order Head CT. Order Canceled Radiology Ordering Physician Order Placed By Ammons, Daniel M Sel as, Christopher J Review Information Nurse Review, Accepted - Mahoney, Am K, 11/26/2006 10:02:57 PM Order Details Stat, Requested Dt: 11/26/0619:04:00, ICD9: Trauma 959.8 Histo : Trauma Mnemonic Action Order Status Type of Order C-S ine XR Order Completed Radiology Ordering Physician Order Placed By Ammons, Daniel M Sel as, Christo her J Review Information Nurse Review, Accepted - Mahoney, Am K, 11/26/2006 10:02:57 PM Order Details Stat, Requested Dt: 11/26/06 19:04:00, All, Views: *Standard Views, ICD9: Trauma 959.8 Histo : Trauma Mnemonic Action Order Status Type of Order Pelvis XR Order Completed Radiology Ordering Physician Order Placed By Ammons, Daniel M Sel as, Christo her J Review Information Nurse Review, Accep ted - Mahoney, Am K, 11/26/2006 10:02:57 PM Order Details Stat, Requested Dt: 11/26/06 19:04:00, Views: *Standard Views, ICD9: Trauma 959.8 Histo : Trauma Date Printed: 11412008 nme Printed: 1:49 PM • • N 91ton Sr Iashey 1Vli x ical Center Coffege of bledl&e Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 O r d e r s S e c t i o n Mnemonic Action Order Status Type of Order C-S ine CT Order Completed Radiology Ordering Physician Order Placed By Ammons, Daniel M Contributors stem, IDXOE01 Review Information Nurse Review, Accepted - Mahoney, Amy K, 11/26/2006 10:02:57 PM Doctor Cosign, Not Reviewed - Ammons, Daniel M Order Details STAT, Requested Dt: 11/26/06 19:12:57 Mnemonic Action Order Status Type of Order -L-Spine CT Order Canceled Radiolo Ordering Physician Order Placed By Ammons, Daniel M Contributors stem, IDXOE01 Review Information Nurse Review, Accepted - Mahoney, Amy K, 11/26/2006 10:02:57 PM Doctor Cosign, Not Reviewed - Ammons, Daniel M Order Details STAT, Requested Dt: 11/26/06 19:12:57 Mnemonic Action Order Status Type of Order Pelvis CT (Iliac Crest to Order Canceled Radiology S m h sis Pubis). Ordering Physician Order Placed By Ammons, Daniel M Contributors stem, IDXOE01 Review Information Nurse Review, Accepted - Mahoney, Amy K, 11/26/2006 10:02:57 PM Doctor Cosign, Not Reviewed - Ammons, Daniel M Order Details STAT, Re uested Dt: 11/26/06 19:12:56 Mnemonic Action Order Status Type of Order Abdomen CT (Diaphragm to Order Canceled Radiology Iliac Crest). Ordering Physician Order Placed By Ammons, Daniel M Contributors stem, IDXOE01 Review Information Nurse Review, Accepted - Mahoney, Amy K, 11/26/2006 10:02:57 PM Doctor Cosign, Not Reviewed - Ammons, Daniel M Order Details STAT, Requested Dt: 11/26/06 19:12:56 Date Printed: 11412008 lime Printed: 1:49 PM PENNSTATE • • N lton S. Fksheey Medical Center College of Medidae Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 1 O r d e r s S e c t i o n Mnemonic Action Order Status Type of Order Femur XR Order Canceled Radiology Ordering Physician Order Placed By Budge, Matthew D Budge, Matthew D Review Information Nurse Review, Accepted - Mahoney, Am K, 11/26/2006 10:02:57 PM Order Details STAT, Requested Dt: 11/26/06 19:16:00, Left., Views: *Standard Views, ICD9: Trauma 959.8 Histo : trauma Mnemonic Action Order Status Type of Order Diagnostic Radiolo Exams Order Discontinued Order Sets Ordering Physician Order Placed By Budge, Matthew D Budge, Matthew D Review Information N/A Order Details N/A Mnemonic Action Order Status Type of Order T-S ine CT Order Canceled Radiology Ordering Physician Order Placed By Ammons, Daniel M Contributors stem, IDXOE01 Review Information Nurse Review, Accepted - Mahoney, Amy K, 11/26/2006 10:02:57 PM Doctor Cosign, Not Reviewed - Ammons, Daniel M Order Details STAT, Requested Dt: 11/26/06 19:12:58 Mnemonic Action Order Status Type of Order Facial Bones CT Order Canceled Radiology Ordering Physician Order Placed By Ammons, Daniel M Contributors stem, IDXOE01 Review Information Nurse Review, Accepted - Mahoney, Amy K, 11/26/2006 10:02:57 PM Doctor Cosign, Not Reviewed - Ammons Daniel M Order Details STAT, Requested Dt: 11/26/06 19:12:57 Date Printed: 11412008 lime Printed: 1:49 PM Milton & Hush • ral Cuter College of Medidne Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 O r d e r s S e c t i o n Mnemonic Action Order Status Type of Order Admit. Order Com leted Patient Care Ordering Physician Order Placed By Gidvani, Sandee N Gidvani, Sandee N Review Information Nurse Review, Accepted - Mahoney, Am K, 11/26/2006 10:02:57 PM Order Details Routine, Requested Admit Dt: 11/26/06 19:23:00, Admit, Floor, Peds Surgery, Engbrecht, Brett W, evaluate and stabilize, LOS: 1 week Mnemonic Action Order Status Type of Order Peds Trauma Admission Order Com leted Order Sets Ordering Physician Order Placed By Gidvani, Sande N Gidvani, Sandee N Review Information N/A Order Details N/A Mnemonic Action Order Status Type of Order morphine Order Completed Pharmacy Ordering Physician Order Placed By Contributors stem, PYXISOI Contributors stem, PYXISOI Review Information N/A Order Details injection, Pyxis, ONCE, 11/26/06 19:25:44, Physician Stop, 11/26/06 19:25:44 Mnemonic Action Order Status Type of Order Knee XR Order Canceled Radiology Ordering Physician Order Placed By Budge, Matthew D Budge, Matthew D Review Information Nurse Review, Accepted - Mahoney, Am K, 1 1/26/2006 10:02:57 PM Order Details STAT, Requested Dt: 11/26/06 19:17:00, Left., Views: *Standard Views, ICD9: Trauma 959.8 Histo : trauma Mnemonic Action Order Status Type of Order Hi XR Order Canceled Radiology Ordering Physician Order Placed By Budge, Matthew D Budge, Matthew D Review Information Nurse Review, Accepted - Mahoney, Am K, 1 1/26/2006 10:02:57 PM Order Details STAT, Requested Dt: 11/26/06 19:17:00, Left., Views: *Standard Views, ICD9: Trauma 959.8 History: trauma Date Printed: 11411008 Time Printed: 1:49 PM • • Mon & Hwdw Medical Center College of Maine Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 1 O r d e r s S e c t i o n 1 Mnemonic Action Order Status Type of Order Bedrest Order Discontinued Patient Care Ordering Physician Order Placed By Gidvani, Sandee N Gidvani, Sandee N Review Information Nurse Review, Acce pted - Mahoney, Am K, 11/26/2006 10:02:57 PM Order Details 11/26/06 19:24:00 Mnemonic Action Order Status Type of Order NPO Order Discontinued Dietary Ordering Physician Order Placed By Gidvani, Sander N Gidvani, Sande N Review Information= Nurse Review, Accepted - Mahoney, Am K, 11/26/2006 10:02:57 PM Order Details 11/26/06 19:24:00, No Exceptions Mnemonic Action Order Status Type of Order Vital Signs Order Discontinued Patient Care Ordering Physician Order Placed By Gidvani, Sandee N Gidvani, Sandee N Review Information Nurse Review, Accepted - Mahoney, Am K, 11/26/2006 10:02:57 PM Order Details 11/26/06 19:24:00 Mnemonic Action Order Status Type of Order Admitting Dia nosis Order Discontinued Patient Care Ordering Physician Order Placed By Gidvani, Sande N Gidvani, Sandee N Review Information Nurse Review, Accepted - Mahoney, Am K, 11/26/2006 10:02:57 PM Order Details 11/26/06 19:23:00, Dx: Trauma, Multiple 959.8 Date Printed: 11412008 Time Printed: 1:49 PM PENNSTATE 0 0 19 Cdlege Mon & Hershey Medical Center of Medidne Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 O r d e r s S e c t i o n 11/26/2006 7:26:25 PM: Level of Care: Floor Mnemonic Action Order Status Type of Order Social Service Consult Order Discontinued Consults Ordering Physician Order Placed By Gidvani, Sande N Gidvani, Sandee N Review Information Nurse Review, Accepted - Mahoney, Am K, 11/26/2006 10:02:57 PM Order Details Priori, Requested Dt: 11/26/06 19:25:00, Trauma Assessment Mnemonic Action Order Status Type of Order Dextrose 5% with 0.9% NaCI Order Discontinued Pharmacy Ordering Physician Order Placed By Gidvani, Sandee N Gidvani, Sande N Review Information Nurse Review, Accepted - Mahoney, Amy K, 11/26/2006 10:02:57 PM Pharmacist Verify, Reviewed - Gunawan, Sesil a, 11/26/2006 10:36:34 PM Order Details 250 mL, IV, Routine, 11/26/06 19:23:00, 30 day, Hard Stop, 12/26/06 19:22:00, 72 mI.JHR, 3.5 HR, 250 11/26/2006 7:26:24 PM: for infant only Mnemonic Action Order Status Type of Order Spine Precautions Order Discontinued Patient Care Ordering Physician Order Placed By Gidvani, Sandee N Gidvani, Sande N Review Information Nurse Review, Accepted - Mahoney, Am K, 11/26/2006 10:02:57 PM Order Details 11/26/06 19:24:00, Full Spine, At All Times Mnemonic Action Order Status Type of Order Call HO Order Discontinued Patient Care Ordering Physician Order Placed By Gidvani, Sandee N Gidvani, Sande N Review Information Nurse Review, Accepted - Mahoney, Am K, 11/26/2006 10:02:57 PM Order Details 11/26/06 19:24:00, T> 38.5 Date Printed: 11412008 Time Printed: 1:49 PM PENNSTATE is n U mton S. Her; W Medical Colter College of , .oe Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 1 O r d e r s S e c t i o n 11/26/2006 7:34:15 PM: Ped Ongoing Assessment Mnemonic Action Order Status Type of Order Ped Admit2 Assessment Order Completed Patient Care Ordering Physician Order Placed By SYSTEM SYSTEM Review Information N/A Order Details 11/26/06 19:34:15 11/LV/LVVV l.ilt.1J rlYl. rOutlullllLL txz;lsu bme11t Mnemonic Action Order Status Type of Order Ped Admit Assessment Order Completed Patient Care Ordering Physician Order Placed By SYSTEM SYSTEM Review Information N/A Order Details 11/26/06 19:34:15 11?LV/LVV0 t:114:1J riw: rea Aamlt assessment Mnemonic Action Order Status Type of Order Patient Education Order Discontinued Patient Care Documentation Ordering Physician Order Placed By SYSTEM SYSTEM Review Information Nurse Review, Accepted - Mahoney, Am K, 11/26/2006 10:02:57 PM Order Details 11/26/0619:34:15, Shift 11/LU/4VVV /:J'+:1J r1V1: ranent roucation uocumentauon Mnemonic Action Order Status Type of Order Level of Care: Floor Order Discontinued Patient Care Ordering Physician Order Placed By SYSTEM SYSTEM Review Information N/A Order Details Request Dt: 11/26/06 19:26:25 Date Printed: 11412008 Time Printed: 1:49 PM Mon & Ekshey Medical Center College of Medicine Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 1 O r d e r s S e c t i o n Mnemonic Action Order Status Type of Order Trauma Profile Default Order Completed Laboratory ordered b lab).. Ordering Physician Order Placed By Contributors stem, SUN UESTOE01 Review Information Nurse Review, Accepted - Mahoney, Amy K, 11/26/2006 10:02:57 PM Doctor Cosign, Not Reviewed - Order Details STAT, Collected at 11/26/06 17:31:00, Ordered b the lab Mnemonic Action Order Status Type of Order Labspecimens to hold Order Completed Laborato Ordering Physician Order Placed By Contributors stem, SUN UESTOE01 Review Information Nurse Review, Accepted - Mahoney, Amy K, 11/26/2006 10:02:57 PM Doctor Cosign, Not Reviewed - Order Details collected at 11/26/06 17:31:00 Mnemonic Action Order Status Type of Order Weight Order Canceled Patient Care Ordering Physician Order Placed By SYSTEM SYSTEM Review Information Nurse Review, Accepted - Mahoney, Amy K, 11/26/2006 10:02:57 PM Order Details 12/03/06 8:00:00, Week 11/26/2UU6 "/:34:16 YM: routme weight at actnussion Mnemonic Action Order Status Type of Order Ped Ongoing Assessment Order Discontinued Patient Care Ordering Physician Order Placed By SYSTEM SYSTEM Review Information N/A Order Details 11/26/0619:34:15, shift-nursing Date Printed: 11412008 Mme Printed: 1:49 PM • • Mon & Hershey HAiral Center College of HAW= Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 1 O r d e r s S e c t i o n 11/26/2006 9:24:16 PM: Target Dose: Tylenol 15 mg/kg 11/26/2006 21:24:04 Mnemonic Action Order Status Type of Order morphine carpuject 2 mg / Order Discontinued Pharmacy mL s r. in'. Ordering Physician Order Placed By Reynolds, Brandon Reynolds, Brandon Review Information Nurse Review, Accepted - Mahoney, Amy K, 11/26/2006 10:02:57 PM Pharmacist Verify, Accepted - Gunawan, Sesil a, 11/26/2006 10:40:20 PM Order Details 1.5 mg, injection, IV, 2h, PRN, Pain, Routine, 11/26/06 21:23:00, 3 day, 11/29/06 21:22:00 11/26/2006 9:24:16 PM: Target Dose: morphine 0.05 mg/kg 11/26/2UU6 21:23:25 Mnemonic Action Order Status Type of Order ondansetron Order Completed Pharmacy Ordering Physician Order Placed By Contributors stem, PYXISOI Contributors stem, PYXISOI Review Information N/A Order Details injection, Pyxis, ONCE, 11/26/06 20:37:09, Physician Stop, 11/26/06 20:37:09 Mnemonic Action Order Status Type of Order Crossmatch Order Completed Laboratory Ordering Physician Order Placed By Contributors stem, SUN UESTOE0I Review Information Nurse Review, Accepted - Mahoney, Amy K, 11/26/2006 10:02:57 PM Doctor Cosign, Not Reviewed - Order Details Routine, Collected at 11/26/06 19:50:00, Ordered b the lab Mnemonic Action Order Status Type of Order Chest XR Order Canceled Radiology Ordering Physician Order Placed By En Brecht, Brett W Contributors stem, IDXOE01 Review Information Nurse Review, Accepted - Mahoney, Amy K, 11/26/2006 10:02:57 PM Doctor Cosign, Accepted - En brecht, Brett W, 11/26/2006 10:14:24 PM Order Details Routine, Requested Dt: 11/26/06 19:42:54, Views: *Standard Views Date Printed: 11411008 nme Printed: 1:49 PM • Milton & Hm y Medical Cen-ter College of bkdi&e 0 Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 1 O r d e r s S e c t i o n 1 Mnemonic Action Order Status Type of Order Traction Order Discontinued Patient Care Ordering Physician Order Placed By Budge, Matthew D Budge, Matthew D Review Information Nurse Review, Accep ted - Mahoney, Am K, 11/26/2006 10:02:57 PM Order Details STAT, 11/26/06 21:40:00, Traction Type Buck's, Traction Location Leg, Left, 5 lbs., ONCE, Stopping On 11/26/06 21:40:00 Mnemonic Action Order Status Type of Order morphine Order Completed Pharmacy Ordering Physician Order Placed By Contributors stem, PYXISOI Contributors stem, PYXISOI Review Information N/A Order Details injection, Pyxis, ONCE, 11/26/06 21:43:09, Physician Stop, 11/26/06 21:43:09 Mnemonic Action Order Status Type of Order Dextrose 5% with 0.45% Order Discontinued Pharmacy NaCl and KCl 10 mE /L Ordering Physician Order Placed By Reynolds, Brandon Reynolds, Brandon Review Information Nurse Review, Accepted - Mahoney, Amy K, 11/26/2006 1 0:02:57 PM Pharmacist Verify, Accepted - Gunawan, Sesil a, 11/26/2006 10:37:00 PM Order Details 500 mL, IV, Routine, 11/26/06 21:22:00, 30 day, Hard Stop , 12/26/06 21:21:00, 72 mLHR, 6.9 HR, 500 Mnemonic Action Order Status Type of Order acetaminophen 325 m caplet Order Discontinued Pharmacy Ordering Physician Order Placed By Reynolds, Brandon Reynolds, Brandon Review Information Nurse Review, Accepted - Mahoney, Amy K, 11/26/2006 10:02:57 PM Pharmacist Verify, Acce pted - Gunawan, Sesil a, 11/26/2006 10:40:00 PM Order Details 325 mg, su , PR, 4h, PRN, Fever/Pain, Routine, 11/26/06 21:24:00, 30 day, 12/26/06 21:23:00 Date Printed: 11412008 7Fme Printed: 1:49 PM N81twm & Wiley Medical meter College of Wdidne Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 1 O r d e r s S e c t i o n Mnemonic Action Order Status Type of Order midazolam Order Co leted Pharmacy Ordering Physician Order Placed By Contributors stem, PYXISOI Contributors stem, PYXIS01 Review Information N/A Order Details injection, Pyxis, ONCE, 11/27106 7:21:34, Phy sician Stop, 11/27/06 7:21:34 Mnemonic T Ac?on Order Status Type of Order Communication to Nursin Order Discontinued Patient Care Ordering Physician Order Placed By P lawka, Tamara K P lawka, Tamara K Review Information Nurse Review, Accepted - Sweigart, Jill A, 11/27/2006 7:32:08 AM Order Details 11/27/06 7:11:00, c-s ine cleared b eds sur er today at lam. Mnemonic ction F Order Status Type of Order Blood Type/Antib Screen r der Completed Laborato Ordering Physician Order Placed By Contributors stem, SUN UESTOE01 Review Information Nurse Review, Accepted - Mahoney, Amy K, 11/26/2006 10:56:52 PM Doctor Cosign, Not Reviewed - Order Details Routine, Blood, Lab to Collect, starting at 11/26/06 19:30:00, ONCE, stopping at 11/26/06 19:30:00, Collected Mnemonic Action Order Status Type of Order cefazolin Order Co leted Pharmacy Ordering Physician Order Placed By Troxell, Core Troxell, Core Review Information Nurse Review, Accepted - Mahoney, Amy K, 11/26/2006 10:02:57 PM Pharmacist Verify, Accepted - Gunawan, Sesil a, 11/26/2006 10:39:16 PM Order Details 500 mg, injection, IV, To OR, Routine, 11/26/06 22:00:00,7 dg, 12103/06 21:59:00 Date Printed: 11412008 Time Printed: 1:49 PM • • y bled1C8Y Ce lter A8ltcni & I le College of N ine Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 1 O r d e r s S e c t i o n 1 Mnemonic Action Order Status Type of Order Anesthesia Post Anesthesia Order Completed Order Sets Care Unit Ordering Physician Order Placed By Sukernik, Mikhail R Sukernik, Mikhail R Review Information N/A Order Details N/A Mnemonic - Action Order Status Type of Order ro ofol 7 0rder Completed Pharmacy Ordering Physician Order Placed By Contributors stem, PYXIS01 Contributors stem, PYXISOI Review Information N/A Order Details injection, Pyxis, ONCE, 11/27/06 8:17:49, Physician Stop, 11/27/06 8:17:49 Mnemonic Action Order Status Type of Order rocuronium Order Completed Pharmacy Ordering Physician Order Placed By Contributors stem, PYXISOI Contributors stem, PYXISOI Review Information N/A Order Details injection, Pyxis, ONCE, 11/27/06 8:17:49, Physician Stop, 11/27/06 8:17:49 Mnemonic 7 Action Order Status Type of Order Patient is Now in OR 0rder Completed Patient Care Ordering Physician Order Placed By Stratton, Deborah A Review Information N/A Order Details STAT, 11/27/06 7:44:00 Mnemonic Action Order Status Type of Order fentan 1 Order Completed Pharmacy Ordering Physician Order Placed By Contributors stem, PYXISOI Contributors stem, PYXIS01 Review Information N/A Order Details injection, Pyxis, ONCE, 11/27/06 7:21:35, Physician Stop, 11/27/06 7:21:35 Date Printed: 11412008 Time Printed: 1:49 PM • • Mon. & Hashey Medical Center Goflege of Medidlnle Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 1 O r d e r s S e c t i o n 1 Mnemonic Action Order Status Type of Order Anesthesia Post Anesthesia Order Completed Order Sets Care Unit Ordering Physician Order Placed By Sukernik, Mikhail R Sukernik, Mikhail R Review Information N/A Order Details N/A Mnemonic Action Order Status Type of Order ondansetron Order Discontinued Pharmacy Ordering Physician Order Placed By Sukernik, Mikhail R Sukernik, Mikhail R Review Information Nurse Review, Accepted - Sweigart, Jill A,. 11/27/2006 8:35:06 AM Pharmacist Verify, Reviewed - Hu, Robert Rei-Huang, 11/27/2006 10:59:18 AM Order Details 4 mg, injection, IV, ONCE, PRN, Nausea and Vomiting, Routine, 11/27/06 8:31:00, 24 HR, 11/28/06 8:31:00, Maximum Dose: 4m 11/27/2UU6 8:33:U6 AM: FACU UNLY Mnemonic Action Order Status Type of Order morphine Order Discontinued Pharmacy Ordering Physician Order Placed By Sukernik, Mikhail R Sukernik, Mikhail R Review Information Nurse Review, Accepted - Sweigart, Jill A, 11/27/2006 8:35:06 AM Pharmacist Verify, Reviewed - Hu, Robert Rei-Huang, 11/27/2006 10:59:18 AM Order Details 1 mg, injection IV, 3min, PRN, Pain, Routine, 11/27/06 9:29:00,2 HR, 11/27/06 10:28:00, PACU only 11/27/ZUU6 8:33:U3 AM: YAUU UNLY Mnemonic Action Order Status Type of Order Criteria for Transfer Order Patient Care Ordering Physician order Order Placed By Sukernik, Mikhail R. Sukernik, Mikhail R Review Information Nurse Review, Accepted - Sweigart, Jill A, 11/27/2006 8:35:06 AM Order Details 11/27/06 8:30:00, Must Meet Discharge Criteria Date Printed: 11412008 Time Printed: 1:49 PM • • Eton I fey Medical Cater College of Niediane Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 f O r d e r s S e c t i o n 1 Mnemonic Action Order Status e of Order F y a neosti mine Order Completed Ph x rmacy Ordering Physician Order Placed By Contributors stem, PYXISOI Contributors stem, PYXISOI Review Information N/A Order Details injection, Pyxis, ONCE, 11/27/06 9:02:38, Physician Stop, 11/27/06 9:02:38 Mnemonic Action Order Status Type of Order hen le hrine Order Completed Pharmacy Ordering Physician Order Placed By Contributors stem, PYXISOI Contributors stem, PYXIS01 Review Information N/A Order Details injection, Pyxis, ONCE, 11/27/06 9:02:38, Physician Stop, 11/27/06 9:02:38 Mnemonic Action Order Status Type of Order 1 co rrolate Order Completed Pharmacy Ordering Physician Order Placed By Contributors stem, PYXIS01 Contributor system, PYXIS01 Review Information N/A Order Details injection, Pyxis, ONCE, 11/27/06 9:02:37, Physician Stop, 11/27/06 9:02:37 Mnemonic Action Order Status Type of Order ondansetron Order Completed Pharmacy Ordering Physician Order Placed By Contributors stem, PYXISOI Contributors stem, PYXISOI Review Information N/A Order Details injection, Pyxis, ONCE, 11/27/06 9:02:37, Physician Stop, 11/27/06 9:02:37 Mnemonic Action Order Status Type of Order Oxygen Thera Order Completed Respiratory Care Ordering Physician Order Placed By Sukernik, Mikhail R Sukernik, Mikhail R Review Information Nurse Review, Accep ted - Sweigart, Jill A, 11/27/2006 8:47:16 AM Order Details 11/27/06 8:33:00, Face Tent, Fi02 2, Kee 02 Sat > 95, Stopping on 11/28/06 8:32:00, 24, HR Date Printed: 11412008 Time Printed: 1:49 PM Milton a Hmhey Medical Center College of bkdi'&e Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 1 O r d e r s S e c t i o n 1 Mnemonic Action Order Status Type of Order Intake and Output Order Discontinued Patient Care Ordering Physician Order Placed By Troxell, Core Troxell, Core Review Information Nurse Review, Accepted - Sweigart, Jill A, 11/27/2006 10:43:24 AM Order Details 11/27/0610:29:00, Shift Mnemonic Action Order Status Type of Order Neurovascular Checks Order Discontinued Patient Care Ordering Physician Order Placed By Troxell, Core Troxell, Core Review Information Nurse Review, Accepted - Sweigart, Jill A, 11/27/2006 10:43:24 AM Order Details 11/27/06 10:29:00, Left Leg, with vital signs Mnemonic Action Order Status Type of Order S/P Procedure: Order Discontinued Patient Care Ordering Physician Order Placed By Troxell, Core Troxell, Core Review Information Nurse Review, Accepted - Sweigart, Jill A, 11/27/2006 10:43:24 AM Order Details 11/27/06 10:29:00, ORIF left distal femur, Stop ping On 11/27/06 10:29:00 Mnemonic Action Order Status Type of Order Ortho Peds Lower Extremity Order Completed Order Sets Ordering Physician Order Placed By Troxell, Core Troxell, Core Review Information N/A Order Details N/A Mnemonic Action Order Status Type of Order [ lidocaine Order Completed Pharmacy Ordering Physician Order Placed By Contributors stem, PYXISOI Contributors stem, PYXISOI Review Information N/A Order Details injection, Pyxis, ONCE, 11/27/06 9:02:39, Physician Stop, 11/27/06 9:02:39 Date Printed: 11412008 Time Printed: 1:49 PM • • lVffiton S. Kelley Medical Cater College of Wdicne Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 O r d e r s S e c t i o n 1 Mnemonic Action Order Status Type of Order Straight Catheterize Order Discontinued Patient Care Ordering Physician Order Placed By Troxell, Core Troxell, Core Review Information Nurse Review, Accep ted - Sweigart, Jill A, 11/27/2006 10:43:24 AM Order Details 11/27/06 10:29:00, Straight Urinary Catheter, q6h, PRN, If patient not voiding on own after 3rd straight catheterization, place foley catheter and call HO Mnemonic Action Order Status Type of Order Weight Bearing Order Discontinued Patient Care Ordering Physician Order Placed By Troxell, Core Troxell, Core Review Information Nurse Review, Accepted - Sweigart, Jill A, 11/27/2006 10:43:24 AM Order Details 11/27/06 10:29:00, Restriction: Non Weight Bearing Mnemonic Action Order Status Type of Order Advance Diet as Tolerated Order Discontinued Dietary Ordering Physician Order Placed By Troxell, Core Troxell, Core Review Information Nurse Review, Acce pted - Sweigart, Jill A, 11/27/2006 10:43:24 AM Order Details 11/27/06 10:29:00 Mnemonic Action Order Status Type of Order Call HO Order Discontinued Patient Care Ordering Physician Order Placed By Troxell, Core Troxell, Corey Review Information Nurse Review, Accepted - Sweigart, Jill A, 11/27/2006 10:43:24 AM Order Details 11/27/06 10:29:00, T> 38.5, SBP > 180, SBP < 80, HR> 160, HR< 60, 02 Sat < 92%, or change in mental or neurological status Date Printed: 11411008 Mme Printed: 1:49 PM Nffltom & Hershey 1! icat Center College of Wdi+ne Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 1 O r d e r s S e c t i o n 1 Differential]] Mnemonic Action Order Status Type of Order cefazolin Order Com leted Pharmac Ordering Physician Order Placed By Troxell, Core Troxell, Core Review Information Nurse Review, Accepted - Sweigart, Jill A, 11/27/2006 10:43:23 AM Pharmacist Verify, Accepted - Hu, Robert Rei-Huang, 11/27/2006 11:01:21 AM Order Details 564 mg, injection, IV, 8h, Routine, 11/27/06 11:00:00,3 doses/times, 11/28/06 3:00:00 11/27/2UU6 1U:33:29 AM: Target Vose: xetzoi Lu mg/cg 11iLIiLuuo iv:3V:Lo Mnemonic Action Order Status Type of Order Oxygen Thera Order Discontinued Respiratory Care Ordering Physician Order Placed By Troxell, Corey Troxell, Core Review Information Nurse Review, Accepted - Sweigart, Jill A, 11/27/2006 10:43:24 AM Order Details 11/27/06 10:30:00, Nasal Cannula, Fi02 2, Keep 02 Sat> 92 Mnemonic Action Order Status Type of Order Turn, Cough and Deep Order Discontinued Patient Care Breathe Ordering Physician Order Placed By Troxell, Core Troxell, Core Review Information Nurse Review, Accepted - Sweigart, Jill A, 11/27/2006 10:43:24 AM Order Details 11/27/0610:30:00, 2hWA 6a-10 Mnemonic Action Order Status Type of Order Incentive S irometr Order Discontinued Patient Care Ordering Physician Order Placed By Troxell, Core Troxell, Core Review Information Nurse Review, Acce pted - Sweigart, Jill A, I V27/2006 10:43:24 AM Order Details 11/27/06 10:30:00, 1hWA (6a-10p) Date Printed: 11412008 Time Printed: 1:49 PM PENNSrATE • 0 1Vuttm S. Hershey Medical Center College of Medidne Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 1 O r d e r s S e c t i o n Mnemonic Action Order Status Type of Order PT Treatment Order Discontinued Consults Ordering Physician Order Placed By Troxell, Core Troxell, Core Review Information Nurse Review, Accepted - Sweigart, Jill A, 11/27/2006 10:43:24 AM Order Details Requested Dt: 11/27/06 10:31:00 Mnemonic Action Order Status Type of Order PT Evaluation Order Completed Consults Ordering Physician Order Placed By Troxell, Core Troxell, Core Review Information Nurse Review, Accepted - Sweigart, Jill A, 11/27/2006 10:43:24 AM Order Details Routine, Requested Dt: 11/27/06 10:31:00, Left Le - Non Wei tbearin , crutch training Mnemonic n V Order Status Type of Order Hematocrit Order Discontinued Laboratory Ordering Physician _ Order Placed By Troxell, Core Troxell, Core Review Information Nurse Review, Accepted - Sweigart, Jill A, 11/27/2006 10:43:24 AM Order Details Routine, Blood, Lab to Collect, starting at 11/28/06 5:00:00, AM, sto in at 12/01/06 4:59:00 - --?,. -VA. u..avvuuva LUUG, 1 VOL ui%;luuou m ule %.omplme niooa Count, ana the t ompiete blood Count with Differential]] Mnemonic Action Order Status Type of Order Hematocrit Order Completed Laboratory Ordering Physician Order Placed By Troxell, Core Troxell, Core Review Information Nurse Review, Acce pted - Sweigart, Jill A, 11/27/2006 10:43:24 AM Order Details Routine, Blood, Lab to Collect, starting at 11/27/06 11:30:00, ONCE, stopping at 11/27/06 11:30:00 _1? V.jj./_Y ruvl. tti-dveItuer tune; i est mciuaea m the Complete blood Count, and the Complete Blood Count with Date Printed: 11412008 lime Printed: 1:49 PM PENNSTATE • U Man & Imo: y Medical framer College of bkdi&e Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 O r d e r s S e c t i o n Mnemonic Action Order Status Type of Order cefazolin Reschedule Completed Pharmacy Ordering Physician Order Placed By Troxell, Core Rower, Larry A Review Information Nurse Review, Accepted - Sweigart, Jill A, 11/27/2006 10:43:23 AM Pharmacist Verify, Reviewed - Hu, Robert Rei-Huang, 11/27/2006 11:01:21 AM Order Details 564 mg, injection, IV, 8h, Routine, 11/28/06 0:00:00, 3 doses/times, 11/28/06 16:00:00 Mnemonic Action Order Status Type of Order Femur XR Order Co leted Radiology Ordering Physician Order Placed By Troxell, Core Troxell, Core Review Information Nurse Review, Acce pted - Sweigart, Jill A, 11/27/2006 10:43:24 AM Order Details Routine, Requested Dt: 11/27/06 10:34:00, Left., Views: *Standard Views, ICD9: Femur Fracture 821.00 Histo : s/ orif Mnemonic Action Order Status Type of Order Diagnostic Radiology Exams Order Completed Order Sets Ordering Physician Order Placed By Troxell, Core Troxell, Corey Review Information N/A O F rder Details N/A Mnemonic Action Order Status Type of Order acetaminophen-codeine phos Order Discontinued Pharmacy 300-30 tab Ordering Physician Order Placed By Troxell, Core Troxell, Core Review Information Nurse Review, Accepted - Sweigart, Jill A, 11/27/2006 10:43:24 AM Pharmacist Verify, Accepted - Hu, Robert Rei-Huang, 11/27/2006 11:04:44 AM Order Details 1 tab, tablet, PO, 4h, PRN, Pain - Mild, Routine, 11/27/06 10:33:00, 30 day, 12/27/06 10:32:00 Date Printed: 11412008 Time Printed: 1:49 PM PENNSTATE • • Miftm & I hey Medical Center College of bkdi&e Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 O r d e r s S e c t i o n MMMM" Mnemonic Action Order Status Type of Order Femur XR Order Completed Radiology Ordering Physician Order Placed By En brecht, Brett W Contributors stem, IDXOE01 Review Information Nurse Review, Accepted - Sweigart, Jill A, 11/27/2006 11:24:32 AM Doctor Cosign, Accepted - En brecht, Brett W, 11/27/2006 2:23:25 PM Order Details Routine, Requested Dt: 11/27/06 11:17:09, Views: *Standard Views Mnemonic Action Order Status Type of Order cefazolin Modify Completed Pharmacy Ordering Physician Order Placed By Troxell, Core Hu, Robert Rei-Huang Review Information Nurse Review, Accepted - Sweigart, Jill A, 11/27/2006 11:11:27 AM Order Details 600 mg, injection, IV, 8h, Routine, 11/27/06 16:00:00, 11/28/06 8:00:00 11/27/2006 11:01:21 AM: Dose modified to 600mg per policy of pediatric standard dose Target Dose: Kefzo120 mg/kg 11/27/2006 10:30:26 Mnemonic Action Order Status Type of Order Patient Transferred Order Completed Patient Care Ordering Physician Order Placed By SYSTEM SYSTEM Review Information N/A Order Details Request Dt: 11/27/06 10:55:25 11/27/2006 10:55:25 AM: Criteria for Transfer Order Completed Mnemonic Action Order Status Type of Order cefazolin Reschedule Completed Pharmacy Ordering Physician Order Placed By Troxell, Core Rower, Larry A Review Information Nurse Review, Accepted - Sweigart, Jill A, 11/27/2006 10:43:23 AM Pharmacist Verify, Acc epted - Hu, Robert Rei-Huang, 11/27/2006 11:01:21 AM Order Details 564 mg, injection, IV, 8h, Routine, 11/27/06 16:00:00,3 doses/times, 11/28/06 8:00:00 Date Printed: 11412008 lime Printed: 1:49 PM Muton a Iers4ey Medical Cater College of Medicine Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 1 O r d e r s S e c t i o n Mnemonic Action Order Status Type of Order acetaminophen 325 m caplet Modify Discontinued Pharmacy Ordering Physician Order Placed By Heaston, Daniel R Mariano, Jr, John P Review Information Nurse Review, Accepted - Patterson, Lauren P, 11/28/2006 2:51:46 AM Order Details 325 mg, tablet, PO, 4h, PRN, Fever/Pain, Routine, 11126/06 21:24:00, 12/26/06 21:23:00 Mnemonic Action Order Status Type of Order acetaminophen 325 m caplet Modify Discontinued Pharmacy Ordering Physician Order Placed By Heaston, Daniel R Heaston, Daniel R Review Information Nurse Review, Accepted - Lingle, Julie M, 11/27/2006 11:02:50 PM Pharmacist Verify, Reviewed - Mariano, Jr, John P, 11/27/2006 11:56:40 PM Order Details 325 mg, soln, PO, 4h, PRN, Fever/Pain, Routine, 11/26/06 21:24:00, 30 day, 12/26/06 21:23:00 Mnemonic Action Order Status Type of Order neosti mine Order Completed Pharmacy Ordering Physician Order Placed By Contributor system, PYXISOI Contributors stem, PYXISOI Review Information N/A Order Details injection, Pyxis, ONCE, 11/27/06 12:42:14, Physician Stop, 11/27/06 12:42:14 Mnemonic Action Order Status Type of Order 1 co rrolate Order Completed Pharmacy Ordering Physician Order Placed By Contributor system, PYXISOI Contributor system, PYXISOI Review Information N/A Order Details injection, Pyxis, ONCE, 11/27/06 12:42:13, Physician Stop, 11/27/06 12:42:13 Mnemonic Action Order Status Type of Order Fluoroscopy XR Order Completed Radiology Ordering Physician Order Placed By En brecht, Brett W Contributors stem, IDXOE01 Review Information Nurse Review, Accepted - Sweigart, Jill A, 11/27/2006 11:24:32 AM Doctor Cosign, Accepted - En brecht, Brett W, 11/27/2006 2:23:24 PM Order Details Routine, Requested Dt: 11/27/06 11:17:10 Date Printed: 11412008 lime Printed: 1:49 PM Milton S, Ihey Medical Cater College of Wdidne Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 1 O r d e r s S e c t 1 o n 1 Mnemonic Action Order Status Type of Order Communication to Nursin Order Discontinued Patient Care Ordering Physician Order Placed By Troxell, Core Troxell, Core Review Information Nurse Review, Accepted - Wissler, Jodi L, 11/28/2006 10:43:58 AM Order Details 11/28/06 10:34:00, petal to of long le cast before discharge Mnemonic Action Order Status Type of Order Knee XR Order Completed Radiology Ordering Physician Order Placed By En brecht, Brett W Contributors stem, IDXOE01 Review Information Nurse Review, Accepted - Wissler, Jodi L, 11/2812006 8:28:41 AM Doctor Cosign, Accepted - En brecht, Brett W, 11/28/2006 12:55:36 PM Order Details Routine, Requested Dt: 11/26/06 19:23:09, Views: *Standard Views Mnemonic Action Order Status Type of Order Femur XR Order Co leted Radiology Ordering Physician Order Placed By En brecht, Brett W Contributor system, IDXOE01 Review Information Nurse Review, Accepted - Wissler, Jodi L, 11/28/2006 8:28:41 AM Doctor Cosign, Accepted - En brecht, Brett W, 11/28/2006 12:55:38 PM Order Details Routine, Requested Dt: 11/26/06 19:23:09, Views: *Standard Views Mnemonic Action Order Status Type of Order Out of Bed Order Discontinued Patient Care Ordering Physician Order Placed By P lawka, Tamara K P lawka, Tamara K Review Information Nurse Review, Accepted - Wissler, Jodi L, 11/28/2006 8:26:40 AM Order Details 11/28/06 8:10:00, with assistance-non wei ht-bearin on affected le Date Printed: 11412008 rime Printed: 1:49 PM • • Mo. S fey MAW Ca ter Coffege of WcUidne Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 1 O r d e r s S e c t i o n Mnemonic Action Order Status Type of Order Discontinue Diet Patient Order Discontinued Dietary Discharged Ordering Physician Order Placed By SYSTEM SYSTEM Review Information N/A Order Details 11/28/06 19:14:53 11/28/2006 7:14:53 PM: discharge order Mnemonic Action Order Status Type of Order Discharge Follow-up Care Order Completed Patient Care Ordering Physician Order Placed By Reynolds, Brandon Reynolds, Brandon Review Information Nurse Review, Accepted - Wissler, Jodi L, 11/28/2006 6:03:07 PM Order Details A ts: Please set u follow u a t. with Dr. Segal in orthopedic sure in 10-14 days. Mnemonic Action Order Status Type of Order Discontinue IV Order Completed Patient Care Ordering Physician Order Placed By Reynolds, Brandon Reynolds, Brandon Review Information N/A Order Details 11/28/06 18:00:00, ONCE, Stopping On 11/28/06 18:00:00 Mnemonic Action Order Status Type of Order Discharge. Order Discontinued Patient Care Ordering Physician Order Placed By Reynolds, Brandon Reynolds, Brandon Review Information Nurse Review, Accepted - Wissler, Jodi L, 11/28/2006 6:03:07 PM Order Details Routine, Requested Discharge Dt: 11/28/06 18:00:00, Routine, Attendin : En brecht, Brett W Mnemonic Action Order Status Type of Order Discharge Order Completed Order Sets Ordering Physician Order Placed By Reynolds, Brandon Re olds, Brandon Review Information N/A Order Details N/A Date Printed: 11411008 lime Printed: 1:49 PM Milton I Ha?dicat Center Crouege of NkxRd, e Patient Name: FICKES, STORM M Patient Sex: Male Patient Location: 7MBW, 7266, 01 Visit Type: Inpatient Penn State Milton S. Hershey Medical Center Penn State College of Medicine Health Information Services, HU24 500 University Drive P.O. Box 850 Hershey, PA 17033-0850 PSUHMC MRN: 1066842 Date of Birth: 4/4/1998 Visit Number: 07761914 Tel: (717) 531-8055 P e d i a t r i c A d m i s s i o n A s s e s s m e n t ( P F ) Pediatric Admission Assessment Form 11/26/06 10:00 pm Performed by Mahoney, Amy K Entered on 11/26/06 10:32 pm Allergy Allergy Reaction 1. Bee sting Pedro Coma Eye Opening Response Peds Coma Spontaneously Best Motor Response Peds Coma Obeys Best Verbal Response Peds Coma oriented and converses Pediatric Coma Score 15 Glasgow Coma Eye Opening Response Spontaneously Best Verbal Response Oriented Best Motor Response Obeys simple commands Glasgow Coma Score 15 Neurological Swallowing Difficulty None Gait Unable to assess Neuro Detailed Pupil Assessment Grid Pupil, Left Pupil Description Regular Pupil Reaction Brisk Pupil, Right Pupil Description Regular Pupil Reaction Brisk Pupil Size, Left 3.0 Pupil Size, Right 3.0 Characteristics of Speech Clear Level of Consciousness Alert Symmetry of Face Symmetric 6-17 Develop Grade in School 2nd Attends School Regularly Yes Eye/Ear/Nome/Throat Eye Power Grid 1. Eye, Left not within defined limits No abnormalities Eye, Right Not within Defined Limited No abnormalities Ear Power Grid 1. Ear, Left not withing defined limits No abnormalities Ear, Right not withing defined limits No abnormalities Nares Power Grid Date Printed: 11412008 lime Printed: 1:47PM • • Mon. & :hey Meth atl Center C of Medi&e Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 P e d i a t r i c A d m i s s i o n A s s e s s m e n t ( P F ) Pediatric Admission Assessment Form 11/26/06 10:00 pm Performed by Mahoney, Autry R Entered on 11/26/06 10:32 pm Eye/Ear/Nose/Throat 1. Nares, Left not within defined limits No abnormalities Nares, Right not within defined limits No abnormalities Troat Not within defined limits No abnormalities Sensory Barrier No Cardiovascular Heart Rhythm Regular Heart Sounds S1S2 Monitor No Cv Detailed Nail Bed Color Clubbing Present Capillary Refill CV Detailed Pulses Grid Dorsalis Pedis Pulse, Left: 2+ Normal Dorsalis Pedis Pulse, Right: 2+ Normal Radial Pulse, Left: 2+ Normal Radial Pulse, Right: 2+ Normal CV Detailed Extremity Temp Grid Arm, Left: Warm Arm, Right: Warm Foot, Left: Warm Foot, Right: Warm Hand, Left: Warm Hand, Right: Warm Leg, Left: Warm Leg, Right: Warm Torso: Warm Respiratory Respirations Cough Remy Detailed-PZDB Breath Sounds Detailed Assessment Grid BLL: Clear BUL: Clear LLL: Clear LUL: Clear RLL: Clear RML: Clear RUL: Clear Gastrointestinal Bowel Movement Last Date GI Symptoms GI Detailed Abdomen Palpation Bowel Sounds Grid LUQ: Present Pink No < 3 Seconds Unlabored None 11/25/06 None Non-Distended, Non-Tender, Soft Date Printed: 11412008 lime Printed: 1:47 PM • • N91ttn & EWrsh_y Medical t ter Co &W of Medic We Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 P e d i a t r i c A d m i s s i o n A s s e s s m e n t ( P F ) Pediatric Admission Assessment Form 11/26/06 10:00 pm Performed by Mahoney, Amy K Entered on 11/26/06 10:32 pm QI Detailed RUQ: Present LLQ: Present RLQ: Present Musculoskeletal Musculoskeletal Joint Assessment Grid 1. Joint Location Joint Assessment Range of Motion Description ADLs Special Orthopedic Devices Skin Skin Integrity Skin Turgor Mucous Membrane Description Skin Abnormality/Location Grid 1. Skin Abnormality Location Skin Abnormality 2. Skin Abnormality Location Skin Abnormality Peripheral iv Peripheral IV Assess/Intervention Grid 1. Peripheral IV Activity Peripheral IV Site IV Catheter Size IV Site Condition IV Drainage Description Infiltration Score Phlebitis Score IV Dressing Condition IV Dressing/Activity IV Flow/Patency Leg, left Tender to palpation other: fracture site splinted Moderate assist Splint Intact Normal Moist Face other: brush burn to forehead Other: scattered to extremities Bruising, Skin Tear Assessment other: left wrist #18 gauge No complications None 0 0 Dry, Intact Transparent Flushes easily, No complications Date Printed. 11412008 Mme Printed: 1:47 PM • • M31tor & Hmhey Medical Center College of Medicare Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 P e d i a t r i c A d m i s s i o n A s s e s s m e n t I I ( P F ) Pediatric Admission Assessment II Form 11/26/06 10:00 ym Performed by Mahoney, Amy A Entered on 11/26/06 10:27 pm Admission History Admitted From Transport Mode Accompanied by Names Isolation Precautions Room Orientation Height/weight Weight Weight Method Allergy Allergy 1. Bee sting Primary Pain Adequate Pain Control Primary Pain scale used primary Pain Location Pain Intensity Acceptable Pain Intensity Pain Alleviating Factors Pain Onset Pain Time Pattern Pain Aggravating Factors Pain Associated Symptoms Pain Interventions Pain Cultural /Non Cc=aunicative Standard Pain Scales Cultural Assessment Sources For Pain Physiological Cause For Pain General Info Accompanied by Who has Residential Custody? Information Given by Parent's Marital Status Current Medications Chief Complaint Current Meds Power Grid 1. Medication Health Habits Recreational Drug Type Tobacco Type Alcohol Type Emergency Department Litter mom dad grandparents None Yes 28.200 kg Estimated Reaction Yes 0-10 Pain scale Upper leg, left 6 3 Opioid Medication Gradual Intermittent Movement Crying Opioid Medication Yes Yes Yes other: injury Mother, Father Mother, Father Mother, Father married pt struck by car at low speed dx with left femur fx None Denies Denies Denies Date Printed: 11412008 Mme Printed: 1:47 PM PENNSTATE • • Nstm a *rshey Medical Center College of Medicine Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 P e d i a t r i c A d m i s s i o n A s s e s s m e n t f i ( P F ) Pediatric Admission Assessment ix Form 11/26/06 10:00 pm Performed by Mahoney, Amy R Entered on 11/26/06 10:27 pan Pods Medical Ex I Peds Medical HX I HEENT Denies: Patient Peds Medical HX I Gastrointestinal Grid Denies: Patient Peds Medical HX I Cardiovascular Denies: Patient Peds Medical HX I Gent Grid Denies: Patient Peds Medical HX I Respiratory Denies: Patient Peds Medical HX I Musc Grid Denies: Patient Pods Medical Ex II Denies Endocrine History Ped Denies: Patient Peds Medical HX II Hemat Grid Denies: Patient Peds Medical HX II Neuro Grid Denies: Patient Peds Medical HX II Behavioral Grid Denies: Patient *NOT VALUED* Denies: Patient Peds Medical HX II Onc Grid Denies: Patient Pods Medical Nx III Injuries Peds Health History Infectious Diseases Peds Health History Infectious Disease Exposure Last 21 Days Medical Devices Implanted Metal Immunizations Current Psychosocial Domestic Concerns Emotional Support Available Financial Concerns Re Hospital/Disch Security Object Psychiatric Admission Chronic/Terminal Illness Freq Visits Religious Preference Parental Involvement Parent/Caregiver Present Parent/Caregiver Involvemnt Child's Care Parent/Caregiver Interaction with Child Parent/Caregiver Interact w/Care Team Parental concerns addressed Fractures None No None No Yes None Yes No None No No Lutheran Yes Actively participates Frequent interaction Discusses care, feelings, concerns Yes Date Printed: 11412008 Time Printed: 1:47 PM NBlton Sr Hmhey Medical Center College of Medi ne Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 P e d i a t r i c A d m i s s i o n A s s e s s m e n t I I ( P F ) Pediatric Admission Assessment 11 Form 11/26./06 10:00 pm Performed by Mahoney, Any A Entered on 11/26/06 10:27 pm Nutrition Home Diet Regular Weight Change No Pediatric Skin Risk Score Peds Mobility Very limited Peds Friction and Shear Potential problem Peds Activity Bedfast Peds Nutrition Excellent Peds Sensory Perception No impairment Peds tissue perfusion oxygenation Adequate peds level of risk Moderate (17-23) Peds Action taken Implement Pediatric Pressure Ulcer Prevention Protocol Education/Discharge Educational Needs Assessed Yes Date Printed: 11412008 Time Printed: 1:47 PM • • Medkal Cater Milton & Hashe y + offege of Wdidne Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 P e d i a t r i c O n g o i n g A s s e s s m e n t ( P F) Pediatric Ongoing Assessment Form 11/27/06 00:01 am Performed by Peters, Kelly B Entered on 11/27/06 00:25 am Review Neurological Within Defined Limits Eye, Ear, Nose and Throat Within Defined Cardiovascular Within Defined Limits Respiratory Within Defined Limits Gastrointestinal Within Defined Limits Genitourinary Within Defined Limits Musculoskeletal Document Assessment Integumentary Document Assessment Parent Involvement W/in Defined Limits IV Present Primary Pain Adequate Pain Control Primary Pain scale used primary Pain Location Musculoskeletal Musculoskeletal Joint Assessment Grid 1. Joint Location Joint Assessment Range of Motion Description ADLs Special Orthopedic Devices Skin Restraint Skin Abnormality/Location Grid 1. Skin Abnormality Location Skin Abnormality 2. Skin Abnormality Location Skin Abnormality Peripheral IV Peripheral IV Assess/Intervention Grid 1. Peripheral IV Activity Peripheral IV Site IV Catheter Size IV Site Condition IV Dressing Condition WDL's WDL's WDL's WDL's WDL's WDL's Document assessment Document assessment WDL's Present Yes 0-10 Pain scale Upper leg, left Leg, left Tender to palpation Other: fracture site splinted Comment: placed in bucks traction by ortho Moderate assist Splint No Face other: brush burn to forehead Other: scattered to extremities Bruising, Skin Tear Assessment other: left wrist #18 gauge No complications Dry, Intact Pediatric Ongoing Assessment Form 11/27/06 11:30 am Performed by Sweigart, Jill A Entered on 11/27/06 11:36 am Review Neurological Within Defined Limits WDL's Eye, Ear, Nose and Throat Within Defined WDL's Cardiovascular Within Defined Limits WDL's Respiratory Within Defined Limits WDL's Gastrointestinal Within Defined Limits WDL's Genitourinary Within Defined Limits WDL's Musculoskeletal Document Assessment Document assessment Date Printed.- 11411008 Dme Printed: 1:47 PM • • NUIt+on S. Hwshey Mesd1cal Cmiter College of Need dne Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 ?P e d i a t r i c O n g o i n g A s s e s s m e n t ( P F) Pediatric Ongoing Assessment Form 11/27/06 11:30 am Performed by Sweigart, Jill A Entered on 11/27/06 11:36 am Review Integumentary Document Assessment Parent Involvement W/in Defined Limits IV Present Primary Pain Adequate Pain Control Primary Musculoskeletal Musculoskeletal Joint Assessment Grid 1. Joint Location Joint Assessment Range of Motion Description ADLs Special Orthopedic Devices Skin Restraint Skin Abnormality/Location Grid 1. Skin Abnormality Location Skin Abnormality 2. Skin Abnormality Location Skin Abnormality Peripheral IV Peripheral IV Assess/Intervention Grid 1. Peripheral IV Activity Peripheral IV Site IV Catheter Size IV Site Condition IV Drainage Description Infiltration Score Phlebitis Score IV Dressing Condition IV Flow/Patency Document assessment WDL's Present No Pain Comment: Sleeping Leg, left Other: Cast Other: Limited Moderate assist Splint No Face other: brush burn to forehead other: scattered to extremities Bruising, Skin Tear Assessment other: left wrist #18 gauge No complications None 0 0 Dry, Intact No complications Pediatric Ongoing Assessment Form 11/27/06 04:00 pan Performed by Lingle, Julie M Entered on 11/27/06 10:38 pm Review Neurological Within Defined Limits Eye, Ear, Nose and Throat Within Defined Cardiovascular Within Defined Limits Respiratory Within Defined Limits Gastrointestinal Within Defined Limits Genitourinary Within Defined Limits Musculoskeletal Document Assessment Integumentary Document Assessment Parent Involvement W/in Defined Limits IV Present WDL's WDL's WDL's WDL's WDL's WDL's Document assessment Document assessment WDL's Present Date Printed: 11412008 Time Printed: 1:47 PM • • Nikon & Mrshey Medical Center College of Medi&e Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 IP e d i a t r i c O n g o i n g A s s e s s m e n t ( P F) Pediatric Ongoing Assessment Form 11/27/06 04:00 Pm Performed by Lingle, Julie X Entered on 11/27/06 10:38 pm CV Detailed Nail Bed Color Clubbing Present Capillary Refill Musculookeletal Musculoskeletal Joint Assessment Grid 1. Joint Location Joint Assessment Range of Motion Description ADLs Special Orthopedic Devices Skin Skin Integrity Skin Turgor Mucous Membrane Description Restraint Skin Abnormality/Location Grid 1. Skin Abnormality Location Skin Abnormality 2. Skin Abnormality Location Skin Abnormality Peripheral IV Peripheral IV Assess/Intervention Grid 1. Peripheral IV Activity Peripheral IV Site IV Catheter Size IV Site Condition IV Dressing Condition IV Flow/Patency Pink No < 3 Seconds Leg, left Other: Cast Other: Limited Moderate assist Cast Intact Normal Moist, Pink No Face Other: brush burn to forehead Other: scattered to extremities Bruising, Skin Tear Assessment Other: left wrist #18 gauge No complications Dry, Intact Positive Blood Return, No complications Pediatric Ongoing Assessment Form 11/28/06 00:01 am Performed by Patterson, Lauren P Entered on 11/28/06 03:07 am Review Neurological Within Defined Limits Eye, Ear, Nose and Throat Within Defined Cardiovascular Within Defined Limits Respiratory Within Defined Limits Gastrointestinal Within Defined Limits Genitourinary Within Defined Limits Musculoskeletal Document Assessment Integumentary Document Assessment Parent Involvement W/in Defined Limits IV Present Primary Pain Adequate Pain Control Primary Pain scale used primary Pain Intensity WDL's WDL's WDLIs WDL's WDL's WDL's Document assessment Document assessment WDL's Present Yes 0-10 Pain scale 0 Date Printed: 11411008 7ime Printed: 1:47 PM • • 1Vliltm & Harm Nheffical meter C4fi a of bui&e Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 P e d i a t r i c O n g o i n g A s s e s s m e n t ( P F) Pediatric Ongoing Assessment Form 11/28/06 00:01 am Performed by Patterson, Lauren P Entered on 11/28/06 03:07 am Primacy Pain Pain Onset Post operative Pain Time Pattern Acute CV Detailed Nail Bed Color Pink Capillary Refill < 3 Seconds CV Detailed Pulses Grid Dorsalis Pedis Pulse, Right: 2+ Normal CV Detailed Extremity Temp Grid Arm, Left: Warm Arm, Right: Warm Foot, Left: Warm Foot, Right: Warm Hand, Left: Warm Hand, Right: Warm Leg, Left: Warm Leg, Right: Warm Torso: Warm Respiratory Respirations Unlabored GI Detailed Abdomen Palpation Non-Distended, Non-Tender, Soft Bowel Sounds Grid LUQ: Present RUQ: Present LLQ: Present RLQ: Present Musculoskeletal Musculoskeletal Joint Assessment Grid 1. Joint Location Leg, left Joint Assessment Other: Cast Range of Motion Description Other: Limited ADLs moderate assist Special Orthopedic Devices Cast Skin Restraint No Skin Abnormality/Location Grid 1. Skin Abnormality Location Face Skin Abnormality other: brush burn to forehead 2. Skin Abnormality Location Other: scattered to extremities Skin Abnormality Bruising, Skin Tear Peripheral IV Peripheral IV Assess/Intervention Grid 1. Peripheral IV Activity Assessment Peripheral IV Site other: left wrist IV Catheter Size #18 gauge IV Drainage Description None Infiltration Score 0 Date Printed: 11412008 Time Printed: 1:47 PM 0 9 Naton & Ekilhe 1Vledkw tinter College of Medicine Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 P e d i a t r i c O n g o i n g A s s e s s m e n t ( P F Pediatric Ongoing Assessment Form 11/18/06 00:01 am Performed by Patterson, Lauren P Entered on 11/18/06 03:07 am Peripheral IV Phlebitis Score 0 IV Dressing Condition Dry, Intact IV Flow/Patency No complications Pediatric Ongoing Assessment Form 11/18/06 07:30 am Performed by Wissler, Jodi L Entered on 11/18/06 07:37 am Review Neurological Within Defined Limits WDL's Eye, Ear, Nose and Throat Within Defined WDL's Cardiovascular Document Assessment Document assessment Respiratory Within Defined Limits WDL's Gastrointestinal Within Defined Limits WDL's Genitourinary Within Defined Limits WDL's Musculoskeletal Document Assessment Document assessment Integumentary Within Defined Limits WDL's Parent Involvement W/in Defined Limits WDL's IV Present Present Primary Pain Adequate Pain Control Primary Yes Pain scale used primary 0-10 Pain scale Pain Intensity 0 CV Detailed Nail Bed Color Pink Capillary Refill < 3 Seconds CV Detailed Pulses Grid Brachial Pulse, Left: 2+ Normal Brachial Pulse, Right: 2+ Normal Dorsalis Pedis Pulse, Left: 2+ Normal Dorsalis Pedis Pulse, Right: 2+ Normal Femoral Pulse, Left: 2+ Normal Femoral Pulse, Right: 2+ Normal Popliteal Pulse, Left: 2+ Normal Popliteal Pulse, Right: 2+ Normal Posttibial Pulse, Left: 2+ Normal Posttibial Pulse, Right: 2+ Normal Radial Pulse, Left: 2+ Normal Radial Pulse, Right: 2+ Normal CV Detailed Extremity Temp Grid Arm, Left: Warm Arm, Right: Warm Foot, Left: Warm Foot, Right: Warm Hand, Left: Warm Hand, Right: Warm Leg, Left: Warm Leg, Right: Warm Torso: Warm Date Printed: 11411008 Time Printed: 1:47 PM PENNSTATE • • Milton S. fkrsbgr Medkal Center College of MeMne Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 P e d i a t r i c O n g o i n g A s s e s s m e n t ( P F) Pediatric Ongoing Assessment Form 11/28/06 07:30 am Performed by Wissler, Jodi L Entered on 11/28/06 07:37 am Musculoskeletal Musculoskeletal Joint Assessment Grid 1. Joint Location Leg, left Joint Assessment Other: Cast Range of Motion Description Other: Limited ADLs Moderate assist Special Orthopedic Devices Cast Peripheral IV Peripheral IV Assess/Intervention Grid 1. Peripheral IV Activity Assessment Peripheral IV Site Other: left wrist IV Catheter Size #18 gauge Pediatric Ongoing Assessment Form 11/28/06 04:05 ym Performed by Wissler, Jodi L Entered on 11/26/06 04:09 ym Review Neurological Within Defined Limits Eye, Ear, Nose and Throat Within Defined Cardiovascular Document Assessment Respiratory Within Defined Limits Gastrointestinal Within Defined Limits Genitourinary Within Defined Limits Musculoskeletal Document Assessment Integumentary Document Assessment Parent Involvement W/in Defined Limits IV Present Primary Pain Adequate Pain Control Primary Pain scale used primary Pain Intensity Cardiovascular Heart Rhythm CV Detailed Nail Bed Color Capillary Refill CV Detailed Pulses Grid Brachial Pulse, Left: 2+ Normal Brachial Pulse, Right: 2+ Normal Dorsalis Pedis Pulse, Left: 2+ Normal Dorsalis Pedis Pulse, Right: 2+ Normal Femoral Pulse, Left: 2+ Normal Femoral Pulse, Right: 2+ Normal Popliteal Pulse, Left: 2+ Normal Popliteal Pulse, Right: 2+ Normal Posttibial Pulse, Left: 2+ Normal Posttibial Pulse, Right: 2+ Normal Radial Pulse, Left: 2+ Normal WDL's WDL's Document assessment WDL's WDL's WDL's Document assessment Document assessment WDL's Present Yes Wong Baker Pain Scale 0 Regular Pink < 3 Seconds Date Printed: 11412008 Time Printed: 1:47 PM • • Man & H ley Medical Cater College of Medicine Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 ?P e d i a t r i c O n g o i n g A s s e s s m e n t ( P F Pediatric ongoing Assessment Form 11/28/06 04:05 pm Performed by Wissler, Jodi L Entered on 11/28/06 04:09 pm CV Detailed Radial Pulse, Right: 2+ Normal CV Detailed Extremity Temp Grid Arm, Left: Warm Arm, Right: Warm Foot, Left: Warm Foot, Right: Warm Hand, Left: Warm Hand, Right: Warm Leg, Left: Warm Leg, Right: Warm Torso: Warm Musculoskeletal Musculoskeletal Joint Assessment Grid 1. Joint Location Joint Assessment Range of Motion Description Ambulatory Devices ADLs Special Orthopedic Devices Skin Skin Integrity Restraint Skin Abnormality/Location Grid 1. Skin Abnormality Location Skin Abnormality 2. Skin Abnormality Location Skin Abnormality Peripheral IV Peripheral IV Assess/Intervention Grid 1. Peripheral IV Activity Peripheral IV Site IV Catheter Size Leg, left Other: Cast Other: Limited Crutches Moderate assist Cast Intact No Face Other: brush burn to forehead Other: scattered to extremities Bruising, Skin Tear Discontinue other: left wrist #18 gauge Date Printed: 11412008 Time Printed: 1:47 PM 'ENNSTATE FICKES, STORM M M11tOII S. Hers .Medical Center NQBRECHT BRETT MD#: 26060 10e6942 9 04/04/1998 SEX: M College of Medicine INS: AUTO INSURANCE STANDARD LOC: o0S#: 7761914 VISIT DATE: 11/29/; 4 W PLAN OF CARE DRG[?:] EST. ? ACTUAL LOS LOS ATTENDING RESIDENT PREFERRED NAME: n/i/ PRIMARY NURSE Unit Initials AGE r ADM.DATE 1//;? (910? ROOM # ?ol PRIMARYNURSE REASON FOR ADMISSION PRIMARY NURSE L ATTENDING NUR DIAGNOSIS 1. NURSE CONSUL 2 NURSE CONSUL 3 SOCIAL SERVICE 4 DATE INVASIVE PROCEDURES . ADVANCED DIRECTIVE YES ? NO CODE BLUE STATUS CONDITION ALLERGIES _ Problem List Expected Outcomes We Initials t (met) Date 'Initials Ito T 2 3 4 5 6 7 8 DISCHARGE PLAN: Horne 1 Home with Assistance J Other: Explain Q Nursing Home 0 Unable to determine on admission Plan of Care Reviewed with Patient/Significant Other: Q?g Signature l PLAN OF CARE MR 763 Rev. 11/97 PENNSTATE • Mlton S. Hershey Medical center NTERDISCI PLI NARY EDUCATION RECORD (IE NAME: FICKES, STORM M MO: ENOBRECHT BRETT MR#: 1066842 DOB: 04/0411998 INS: AUTO INSURANCE LOG: OOSN: 7761914 MON: 26060 SEX: M STANDARD VISIT DATE: 11126/2006 May be used by all disciplines to summarize and communicate patient teaching. Hospital Day is optional. May be used to refer to specific teaching outline on plan of care. List pamphlets, handouts given to patient in each section. Initial Assessment of Patlenrs Ability to Learn: (Explain barriers that may Impact teaching) ? Emotional ? Physical ? Cultural/Religious one ? Motivational ? Cognitive Limitations ? Language Learning Preferences: (How do you best learn) ? One on One Instructions ? Audio-Visual Information ? Written Information ? Group Discussion ? Demonstration/ Practice ? Other Assessment updates if necessary: Strategy Key: V = Video; W_= Written; P_= Discussion; Dem = Demonstration Evaluation Ke • F= Com tent- R = Review ollowing instruction, the patient and/or significant other (list) will: H a i0 ? w a m W F- d a r-d W C F- C1 rn 3 q G = C Tv G C ?/ ? r I l CooY-\ ? ?n ??- ? G 1 t I Initial Signature Initial Signature Inal SI ature INTERDISCIPLINARY EDUCATION RECORD (IER) MR-157 - Rev 2/03 (Number will be assigned by Nursing Practice Committee After Approval) PENNSTATE NAME: FICKES 8TOAM M MO' E/'2i? BRETT MOr: 26060 RN* 108684 Milton S. Hershey Medical Center U DOB: 04104/1998 SEX: M • College of Medicine Imo: AUTO INSURANCE STANDARD 0080: 7761914 V181T DATE: 11121 • DRG _ E6T. ACTUAL 1Y PLAN OF CARE Los ? Los ATTENDING PREFERRED NAME: F. RESIDENT Unit tnitlalai 2F R (j 07 111 7a?? AOM.DATI: AGE • . ROOMf1 PRIMARY NURSE PRIMARY NURSE REASON FOR ADMISSION C PRIMARY NURSE DWGNOSI5 ATTENDING NUR 1 , NURSECONSUL 2 NURSE CONSUL 3 SOCIAL SERVICE 4• DATE . INVASIVE PROCEpURE§ % ' '; :•'r , ;;x ; ,: . ?? :: ?. : = : _ w • ADVANCED DIRECTIVE YES ? NO .; , ; , .. . . :• ' < ,?F?,`'1: ;' ;;; ; .;., ,:y: ?te•r?c „ `: t:t sL i? • "' ?''i r?i''N ? ' s CODE BLUE STATU • r? ...ti ?.: .?5 ?:{: 1:Lri :.:'?;4,:. ;yi .. . .: . ' : :• : ' R e?.C7?•i Mr, 4 I i %••., . r .._ :Y . •at : < F? ?.?•r: 'i?•':i1ti l ai $t+H?: y S:k ? °r .N • ?4.?r•?A4 S.Yi' • t r1 Y CONDITION .. ..ICi D, r . -• ..a. - -. j`. yL,f!a '??t .. t'• •?r1..?.^i:' ?'?'f ?L .`•:q.;1>?a?+-r?: la: ?.`!"•?.;.?;7?:St •?. ?'. .;? ? ' .. • •??' ?.. ''t; ` ? t•, ,'v?! ?:t.CRQtG7 • t ? ? t l - : .:k is i:i- '.r^.i ki dp r-? t i iv`a'I .n '± Y+>v • " .•. : a a•; L I t ?./rif. ' L? ? + ;..-h?ti N • eF? '?rw?:' i$:?? ' kt ?y? •>"ti~{ tQ 'I' ' ? ? k{? r?it'r h? ? '? rf '? ' ' ? _ t - • 2 t? .Y - ? " 1; ? A'r• +S s •: ,9, 'S: :- •':i ? k "-' :b?• '•'`:YYZY: ;'l wStv s :•1`f ?1 t g g ? ' ' r j . : . ' i . ., , ? =si ? fE;4 ?2;' ? ' Itg-Yi Problem List F_xpeCtad Outcomes oft Now* -4 ft :i113A;4yw ,c.; Yµ aj. V0 1 8 7 e DISCHARGE PLAN: Pion of Care Reviewed with Patient/Significant Other. 0 Horne Nursing Home OW" Sig natur Home with Assistance [] Unable to determine an admission t Other: Explain PLAN OF CARE PENNSTATE 0- Mflton S. Hershey Medical Center FINAL NURSING PROGRESS NOTE U NAME; FICKES, STORM M0 ; E4131 HT BRETT MFIC 1066842 DOB: 0410411998 GE INS: 0 'NSURPN INS AUT LOC: OOS#. 776`1914 MO#: 26060 SEX: M STANDARD VISIT DATE: 1112612006 Discharge Summary (may be done up to 24 hours prior to discharge) Date Initials Course of hospitalization: (may write "concur with Day of Discharge Form") 2g -?" Resolution/Status of each problem on the problem list: '04, 1 b?C d `E sc r???1 c?y TIC 3 ruj . ve+ ?v?.? ? A2) 'ht C- le-66, ; k1S*LLc.'hav-t ?e vie v-ems « wcat'T-6 VIel. ?t off( - 11-W Discharge Checklist ..........explain any "no" answer below *Y O N I,, \ es 1. Physician order written for discharge ......................................................... o 2. All invasive lines and tubes that are not needed for home care are removed...... ® Yes O No 3. Medications brought from home are returned ............................................ O Yes O No ® NA 4. Prescriptions given to patient or family ....................................................... 4p Yes O No O NA 5. Personal belongings taken ......................................................................... ® Yes O No O NA (Bathroom, closet, cabinet, bedside stand, over-bed table checked) 6. Copy of Day of Discharge form given to patient or family .......................... ® Yes O No O NA 7. Copy of patient education instructions or materials given to patient or family....... ® Yes O No O NA 8. Follow-up appointment scheduled or discussed with patient ..................... ® Yes O No O NA 9. Is patient weak or unable to walk without assistance? ............................... ® Yes O No O NA If yes, staff member accompanied patient to vehicle ................................. 0 Yes O No O NA 10. Discharge conversation with patient includes the following points............ ® Yes O No O NA • Strive for very good care a Complete survey in the mail • Pur ose to improve service and reward staff Explanation for "no" answers: MR 1014 5104 Page 1 of 1 FINAL NURSING PROGRESS NOTE • • Milton & fey Medical Center College of W d e Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 P h y s i c a l T h e r a p y E v a l u a t i o n F o r m ( P F ) Physical Therapy Evaluation Form 11/28/06 10:15 am Performed by Haskell, Kelly Entered on 11/28/06 02:29 pm Updated on 11/78/06 04:41 pan by Letendre, Amy L 11/78/06 03:37 pan by Haskell, Kelly General Info Reason for Referral to Physical Therapy Precautions to Rehabilitation Treatment Orientation Safety/Judgment Basic Command Following PT Activity Level PT Diagnosis PT Past Medical History PT Subjective Information Haase Environment Living Environment Lives In Lives With Rehabilitation Stairs Grid Inside Stairs Number of Stairs Outside Stairs Number of Stairs Stairs Rail Patient's Responsibilities Job Responsibilities Prior Functional Level Grid Bed Mobility: Independent Transfers: Independent Ambulation at Home: Independent Community Ambulation: Independent Stairs: Independent Car Transfers: Independent Toilet Transfers: Independent Upper Extremity Bathing: Independent Lower Extremity Bathing: Independent Upper Extremity Dressing: Independent Lower Extremity Dressing: Independent Grooming: Independent Living Situation Decreased mobility, Decreased Strength, Patient/Caregiver education NWB LLE, Long leg cast Oriented x 3 Intact Intact Out of bed Pt. is 8 yo male who was struck by a car when he stepped into the street while walking with his 12 yo brother. Pt. is s/p ORIF of the Left distal femur. Unremarkable Per nsg, okay to see pt. Dad at bedside during evalutation. Pt. lives in single story home with 5 stairs to enter with rail on the left. Single level home Parent(s)/Guardian, Other: Dad and step-mom 0 5 Rail on left going up Hobbies, Play, Schoolwork, Self care Pt. is in the 2nd grade and was an active child prior to injury. Home with family care Neuro *NOT VALUED* Left Upper Extremity: Normal Right Upper Extremity: Normal Left Lower Extremity: not tested due to long leg cast Date Printed: 11412008 71me Printed: 1:47 PM • • Milton S. Harpy Medical ter l+ege of N"dne Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 P h y s i c a l T h e r a p y E v a l u a t i o n F o r m ( P F ) Physical Therapy Evaluation Form 11/28/06 10:15 am Performed by Haskell, Kelly Entered on 11/28/06 02:29 pm Neuro Right Lower Extremity: Normal *NOT VALUED* Left Upper Extremity: Normal Right Upper Extremity: Normal Left Lower Extremity: not tested due to long leg cast Right Lower Extremity: Normal PT Cognition intact Balance Score Balance Tests Performed Kansas University balance scale Sitting Balance Score 2 Standing Balance Score 2 Musculookeletal Right Upper Extremity Range of Motion Left Upper Extremity: Within normal limits Right Upper Extremity: Within normal limits Left Lower Extremity: Limited Right Lower Extremity: Within normal limits Left Upper Extremity Range of Motion Left Upper Extremity: Within normal limits Right Upper Extremity: Within normal limits Left Lower Extremity: Limited Right Lower Extremity: Within normal limits Left LE Range of Motion Detailed Pt. in long legged cast, Extremity ROM was not assessed Left Upper Extremity Strength Normal Right Upper Extremity Strength Normal Left Lower Extremity Strength Limited Right Lower Extremity Strength Normal 5 Mobility/Balance *NOT VALUED* Sit to Supine: Moderate assist, Multiple verbal cues to motivate pt., Pt. able to prop self on elbows and assist with scooting. Scooting: Moderate assist Sit to Stand: Moderate assist Stand to Sit: Minimal assist, For cast assistance Gait Training Grid Ambulation Attempt 1 Ambulation Level Moderate assistance Person Assist 1, 2 Ambulation Device Utilized Rolling Walker Ambulation Distance 10 feet Weightbearing Status NWB LLE Weightbearing Maintained Other: Pt. with occasional non-compliance with weight bearing as he put weight through his heel during ambulation Ambulation Quality Fair - Gait Training Comment Pt. extremely anxious during ambulation. Pt. needed moderate/maximal verbal cues to maintain weight bearing. Date Printed: 11412008 71me Printed: 1:47 PM • • Mon S. Hershey Meacal Center College of Mktene Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 P h y s i c a l T h e r a p y E v a l u a t i o n F o r m ( P F ) Physical Therapy Evaluation Form 11/28/06 10:15 am Perforated by Haskell, Kelly Entered on 11/28/06 02:29 pm Education PT Education Grid 1. Education Topics PT Individuals Taught Barriers to Learning Teaching Method Teaching Evaluation 2. Education Topics PT Individuals Taught Barriers to Learning Teaching Method Teaching Evaluation Assessment Rehabilitation Potential PT Problem List Additional Comments PT Assessment PT Total Evaluation Time Goals PT Short Term Goals Grid Patient Will Perform Bed Mobility With Assistance Needs Time Frame to Reach Short Term Goal Short Term Goals Date Established Patient Will Perform Transfer With Assistance Needs Time Frame to Reach Short Term Goal Short Term Goals Date Established Patient Will Ambulate With Assistance Needs Device for Goal Distance for Short Term Goal Time Frame to Reach Short Term Goal Short Term Goals Date Established Patient Will Ambulate Stairs With Assistance Needs Device for Goal Stairs Rail Method of Stair Mobility Distance for Short Term Goal Time Frame to Reach Short Term Goal Short Term Goals Date Established Additional Physical Therapy Goal 1 Physical Therapy plan of care Father None evident Explanation Verbalizes understanding Ambulation with roller walker Patient, Father None evident, Emotional state Demonstration, Explanation Needs practice/supervision, Returns demonstrations correctly, Verbalizes understanding Good Ambulation deficits, Bed mobility deficits Pt. presents with the above deficits. Pt. will benefit from 2-3 additional sessions of physical therapy to increase ambulation tolerance and weight bearing compliance. 45 minute Minimal assistance 1-2 days 11/28/06 Contact assistance 1-2 days 11/28/06 Minimal assistance Roller walker Comment: Pt. may transition to crutches when appropriate 50 feet 1-2 days 11/28/06 Moderate assistance Other: Rail and AD Rail on left going up Step to acending with Right 5 stairs 1-2 days 11/28/06 Caregivers will be safe and independent with guarding and assisting pt. with transfers, Date Printed: 11412008 Time Printed: 1:47 PM • • NEt+on & Hwahey Medical Cater College of Medicine Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 P h y s i c a l T h e r a p y E v a l u a t i o n F o r m ( P F ) Physical Therapy Evaluation Form 11/28/06 10:15 am Performed by Haskell, Kelly Entered on 11/28/06 02:29 pm (coals ambulation, and stairs PT Additional Goal 1 Time Frame 1-2 days. est. 11/28/06 PT Weight Bearing Status NWB LLE Plan PT Frequency Twice daily PT Duration Other: 2-3 additional visits PT Anticipated Treatments Bed mobility training, Caregiver training, Gait training, Safety education PT Plan/Goals Established w Pt/Caregiver Yes DC Recommendations PT Anticipate D/C Home with assistance PT Home Equipment Needs Walker, Wheelchair Services Needed Upon D/C (PT) OPPT Wheelchair Specifics Wheelchair will need left elevating leg rest. Left LE Strength *NOT VALUED* Hip Flexion: Pt. in long leg cast. Pt. unable to move throughout full range of left hip due to weight of cast. P h y s i c a l T h e r a p y T r e a t m e n t F o r m ( P F ) Physical Therapy Treatment Form 11/28/06 03:29 pm Performed by Letendre, Amy L Entered on 11/28/06 03:35 pm General Info PT Activity Level Treatment Mobility/Balance Training Provided PT Treatment Response PT Total Treatment Time Education PT Education Grid 1. Education Topics PT Individuals Taught Barriers to Learning Teaching Method Teaching Evaluation Education Referral Made to crutch training Yes needs a firm approach 25 minute Ambulation with crutches Patient, Mother, Father None evident, Emotional state Demonstration, Explanation Needs further teaching, Needs practice/supervision, Needs reinforcement Physical Therapy, other: outpatient Date Printed: 11412008 Time Printed: 1:47 PM • • N91ton & shey? Medical Center College of Medicine Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 P h y s i c a l T h e r a p y T r e a t m e n t F o r m ( P F ) Physical Therapy Treatment Form 11/28/06 03:29 pm Performed by Letendre, Amy L Entered on 11/28/06 03:35 pm Assessment Rehabilitation Potential Good PT Problem List Ambulation deficits, Balance deficits, Bed mobility deficits, Decreased activity tolerance, Strength/Range of motion deficits, Transfer deficits Additional Comments PT Assessment Pt requires additional crutch training - he is unable to ambulate independently Plan PT Frequency PT Anticipated Treatments PT Plan/Goals Established w Pt/Caregiver DC Recommendations PT Anticipate D/C Services Needed Upon D/C (PT) Mobility/Balance *NOT VALUED* Supine to Sit: Minimal assist Sit to Supine: Minimal assist Scooting: Moderate assist Sit to Stand: Minimal assist Stand to Sit: Minimal assist Gait Training Grid Ambulation Attempt 1 Ambulation Level Person Assist Ambulation Device Utilized Ambulation Distance Weightbearing Status Weightbearing Maintained Ambulation Quality Gait Training Comment Discontinue Balance training, Bed mobility training, Gait training, Therapeutic exercises, Transfer training Yes Home with assistance OPPT, will need crutches (416" to 5'2") and 12 or 14 inch wide WC with elevating legrests and rear antitippers for school use Moderate assistance 1 Crutches 30 ft NWB L Other: 75% of time poor but improving advanced to crutches for this session, pt having a temper tantrum R e s p i r a t o r y T h e r a p y D o c u m e n t a t i o n F o r m ( P F ) Respiratory Therapy Documentation Form 11/26/06 08:25 pm Performed by Hatter, Harry F Entered on 11/26/06 08:26 pm Clinical Documentation Mechanical Ventilator Select Yes Date Printed: 11411008 Ttme Printed: 1:47 PM Patient Name: FICKES, STORM M . • SCHEDULED MEDS ceFAZolin(Kefzol) 564 mg (Order Id =155768510.00) 564 mg, injection, IV, q8h, Routine, 11/27/06 11:00:00, 3 doses/times, 11 /28/06 3:00:00 Order Comment: Target Dose: Kefzol 20 mg/kg 11/27/200610:30:26 Order Entered By: Troxell, Corey Nurse : Sweigart, Jill A accepted on 11/27/06 10:43 Pharmacist: Hu, Robert Rei-Huang accepted on 11/27/06 11:01 ACTION(S) CHARTED @ ADMIN TIME(S) ADMIN DETAIL(S) ceFAZolia(Kefzol) 564 mg (Order Id =155768510.00) 564 mg, injection, IV, q8h, Routine, 11/28/06 0:00:00, 3 doses/times, 11/28/06 16:00:00 Order Comment: Target Dose: Kefzol 20 mg/kg 11/27006 10:30:26 Order Rescheduled By: Rower, Larry A Nurse : Sweigart, Jill A accepted on 11/27/0610:43 Pharmacist: Hu, Robert Rei-Huang reviewed on 11/27/06 11:01 ACTION(S) CHARTED @ ADMIN TIME(S) ADMIN DETAIL(S) ceFAZolin(Kefzol) 564 mg (Order Id =155768510.00) 564 mg, injection, IV, q8h, Routine, 11/27/06 16:00:00, 3 doses/times, 11/28/06 8:00:00 Order Comment: Target Dose: Kefzol 20 mg/kg 11/27/2006 10:30:26 Order Rescheduled By: Rower, Larry A Nurse : Sweigart, Jill A accepted on 11/27/06 10:43 Pharmacist: Hu, Robert Rei-Huang accepted on 11/27/06 11:01 ACTION(S) CHARTED @ ADMIN TIME(S) ADMIN DETAIL(S) cefazolin(Kefzol) 6 mL - 600 mg (Order Id =155768510.00) 600 mg, injection, IV, q8h, Routine, 11/27/06 16:00:00,11/28/06 8:00:00 Order Comment: Dose modified to 600mg per policy of pediatric standard dose Target Dose: Kefzol 20 mg/kg 11/27/2006 10:30:26 Product Note: CEFAZOLIN 600MG 16ML IV SYR. Order Modified/Verified By: Hu, Robert Rei-Huang Nurse : Sweigart, Jill A accepted on 11/27/06 11:11 ACTION(S) CHARTED @ ADMIN TIME(S) ADMIN DETAIL(S) Med Given 11/27/06 17:30 11/27/06 17:30 ceFAZolin 600 mg IV Perform1ingle, Julie M Med Given 11/28/06 03:08 11/18/06 00:30 ceFAZolln 600 mg IV Perform:Patterson, Lauren P Med Given 11/28/06 07:42 11/28/06 07:40 ceFAZolin 600 mg IV Perform:Wissler, Jodi L Completed 111206 08:03 Performed By: SYSTEM UNSCHEDULED MEDS ceFAZolin(Kefzol) 500 mg (Order Id =155630599.00) 500 mg, injection, IV, To OR, Routine, 11/26/06 22:00:00, 7 day, 12/03/06 21:59:00 Order Entered By: Troxell, Corey Nurse : Mahoney, Amy K accepted on 11/26/06 22:02 Pharmacist: Gunawan, Sesilya accepted on 1126/06 22:39 ACTION(S) CHARTED @ ADMIN TIME(S) ADMIN DETAIL(S) cefazolia(Kefzol) 5 mL - 500 mg (Order Id = 155630599.00) 500 mg, injection, IV, To OR, Routine, It 126/06 22:00:00, 7 day, 12103/06 21:59:00 Order Modified/Verified By: Gunawan, Sesilya ACTION(S) CHARTED @ ADMIN TIME(S) ADMIN DETAIL(S) Med Given 11/27106 10:5 11127/06 07:50 ceFAZoI 500 mg IV Perform:Sukernik, Mikhail R Proxy:Rower, Larry A Complete 11/27/06 10:35 Performed By: Rower, Larry A MRN: 1066842 PRN Patient Name: FICKES, STORM M MRN: 1066842 0 acetaminophen(Tylenol) 325 mg (Order Id a 155628048.00) 325 mg, supp, PR, q4h, PRN, Fever/Pain, Routine, 11/26/06 21:24:00, 30 day, 12/26/06 21:23:00 Order Comment: Target Dose: Tylenol 15 mg/kg 11/26/2006 21:24:04 Order Entered By. Reynolds, Brandon Q Nurse : Mahoney, Amy K accepted on 11/26/06 22:02 Pharmacist: Gunawan, Sesilya accepted on 11/26/06 22:40 ACTION(S) CHARTED @ ADMIN TIME(S) ADMIN DETAIL(S) acetaminophen 325 mg supp.(Tylenol) 1 supp - 325 mg (Order Id m 155628048.00) 325 mg, supp, PR, q4h, PRN, Fever/Pain, Routine, 11/206 21:24:00, 30 day, 12/26/06 21:23:00 Order Comment: Target Dose: Tylenol 15 mg/kg 11/26/2006 21:24:04 Product Note: Maximum 4gm acetaminophen daily from all sources. Check if patient also receiving percocet, darvocet or tylenol #3. Order Modified/Verified By: Gunawan, Sesilya ACTION(S) CHARTED @ ADMIN TIME(S) ADMIN DETAIL(S) acetaminophen 325 mg supp.(Tylenol) 1 supp - 325 mg (Order Id -155628048.00) 325 mg, soln, PO, q4h, PRN, Fever/Pain, Routine, 11/26/06 21:24:00, 30 day, 12/26/06 21:23:00 Order Comment: Target Dose: Tylenol 15 mg/kg 11126/200621:24:04 Product Note: Maximum 4gm acetaminophen daily from all sources. Check if patient also receiving percocet, darvocet or tylenol U. Order Modified By: Heaston, Daniel R Nurse : Lingle, Julie M accepted on 11/27/06 23:02 Pharmacist: Mariano, Jr, John P reviewed on 11/27/06 23:56 ACTION(S) CHARTED @ ADMIN TIME(S) ADMIN DETAIL(S) acetaminophen 325 mg caplet(Tylenol) 1 tab a 325 mg (Order Id =155628048.00) 325 mg, tablet, P0, q4h, PRN, Fever/Pain, Routine, 11/26/06 21:24:00, 12/26/06 21:23:00 Order Comment: Target Dose: Tylenol 15 mg/kg 11/26/2006 21:24:04 Product Note: Maximum 4gm acetaminophen daily from all sources. Check if patient is also receiving (darvocet, percocet tylenol with codeine) Order Modified/Verified By: Mariano, Jr, John P Nurse : Patterson, Lauren P accepted on 11/28/06 02:51 ACTION(S) CHARTED @ ADMIN TIME(S) ADMIN DETAIL(S) Discontinue 11/28/06 22:01 Performed By: SYSTEM acetaminophen-codeine(Tylenol with Codeine #3 (300/30)) 1 tab (Order Id =155769938.00) 1 tab, tablet, PO, q4h, PRN, Pain - Mild, Routine, 11/27/06 10:33:00, 30 day, 12/27/06 10:32:00 Order Entered By, Troxell, Corey Nurse : Sweigart, Jill A accepted on 11/27/06 10:43 Pharmacist: Hu, Robert Rel-Huang accepted on 11/27/06 11:04 ACTION(S) CHARTED @ ADMIN TIME(S) ADMIN DETAIL(S) acetaminophen-codeine phos 300-30 tab(Tylenoi with Codeine #3 (300/30)) 1 tab l tab, tablet, P0, q4h, PRN, Pain - Mild, Routine, 11/27/06 10:33:00, 30 day, 12/27/06 10:32:00 Product Note: Acetaminophen 300 mg/codeine 30mg Order Modified/Verifled By: Hu, Robert Rei-Huang ACTION(S) CHARTED @ ADMIN TIME(S) ADMIN DETAIL(S) ed Given 11/27106 17:34 71:3 acetaminophen-codeine 1 tab PO Pain Intensity 4 Reason for Medication: Pain - Mild Perform:Lingle, Julie M Med Given 11/18/06 13:58 11/28/06 13:58 acetaminophen-codeine 1 tab PO Pain Intensity 2 Reason for Medication: Pain - Mild Perform:Wissier, Jodi L Med Given 11/28/06 18:17 11128106 18:17 acetaminophen-codeine 1 tab PO Pain Intensity 0 Reason for Medication: Pain - Mild Perfonn:Wissler, Jodi L (Order Id o 155769938.00) Discontinue 11/28/06 22:01 Performed By: SYSTEM Patient Name: FICKES, STORM M MRN: 1066842 0 0 morphine 1 mg (Order Id o 155715012.00) 1 mg, injection, IV, g3min, PRN, Pain, Routine, 11/27/06 8:29:00,2 HR, 11/27/06 10:28:00, PACU only Order Comment: PACU ONLY Order Entered By., Sukernik, Mikhail R Nurse : Sweigart, Jill A accepted on 11/27/06 08:35 Pharmacist: Hu, Robert Rei-Huang reviewed on 11/27106 10:59 ACTION(S) CHARTED @ ADMIN TIME(S) ADMIN DETAIL(S) Discontinue 11/27/06 10:55 Performed By: Dion, Kendra L morphine 1.5 mg (Order Id =155627899.00) 1.5 mg, injection, IV, q2h, PRN, Pain, Routine, 11/26106 21:23:00, 3 day, 11/29/06 21:22:00 Order Comment: Target Dose: morphine 0.05 mg/kg 11/26/2006 21:23:25 Order Entered By: Reynolds, Brandon Q Nurse : Mahoney, Amy K accepted on 11/26/06 22:02 Pharmacist: Gunawan, Sesilya accepted on 11 /26/06 22:40 ACTION(S) CHARTED @ ADMIN TIME(S) ADMIN DETAIL(S) Med Given 11/26/06 22:34 -- 11/26/06 1:50 morphine .5 mg IV Pain Intensity 8 Reason for Medication: Pain Perform:Mahoney, Amy K *Response* 11126106 22:34 11126/06 22:20 Pain Response Form Pain Response Pain Intensity Response: 4 Perform:Mahoney, Amy K morphine carpaject 2 mg / mL syr. inj.(morphine) 0.75 mL =1.5 mg 1.5 mg, injection, IV, q2h, PRN, Pain, Routine, 11/26/06 21:23:00,3 day, 11/29/06 21:22:00 Order Comment: Target Dose: morphine 0.05 mglkg 11/26/2006 21:23:25 Order Modlfied/Verified By: Gunawan, Sesilya ACTION(S) CHARTED @ ADMIN TIME(S) ADMIN DETAIL(S) (Order Id =155627899.00) Med Given 11/27/06 :0 11/27106 00:07 morphine 1.5 mg IV Pain Intensity 8 Reason for Medication: Pain PerformTeters, Kelly B Med Given 11/27/06 04:41 11/27/06 04:41 morphine 1.5 mg IV Pain Intensity 8 Reason for Medication: Pain PerformTeters, Kelly B Med Given 11/27/06 13:04 11/27/06 13:04 morphine 1.5 mg IV Pain Intensity 5 Reason for Medication: Pain Perform:Sweigart, Jill A Med Given 11/27/06 22:44 11/2710618:00 morphine 1.5 mg IV Pain Intensity 5 Reason for Medication: Pain Perform1ingle, Julie M Med Given 11/27/06 23:03 11/27/06 23:03 morphine 1.5 mg IV Pain Intensity 4 Reason for Medication: Pain Perform:Lingle, Julie M Med Given 11/28/06 07:21 11/28/06 03:40 morphine 1.5 mg IV Pain Intensity 5 Reason for Medication: Pain Perform: Patterson, Lauren P Med Given 11/28106 09:43 11/28/06 09:43 morphine 1.5 mg IV Pain Intensity 0 Reason for Medication: Pain Perform:Wissler, Jodi L Discontinue 11/28/06 22:01 Performed By: SYSTEM ondansetron 4 mg 4 mg, injection, IV, ONCE, PRN, Nausea and Vomiting, Routine, Order Comment: PACU ONLY Order Entered By: Sukernik, Mikhail R Nurse : Sweigart, J111 A accepted on 11/27/06 08:35 (Order Id - 155715030.00) 11127/06 8:31:00, 24 HR, 11/28/06 8:31:00, Maximum Dose: 4mg Pharmacist: Hu, Robert Rei-Huang reviewed on 11/27/06 10:59 Patient Name: FICKES, STORM M 0 0 ACTION(S) CHARTED @ ADMIN TIME(S) ADMIN DETAIL(S) Discontinue 11/27/0610:55 Performed By: Dion, Kendra L CONTINUOUS INFUSIONS Dextrose 5% with 0.45% NaCI and KCI 10 mEq/L(DS - 0.45% NaCI + 10 mEq/L KCI) 500 mL Every Bag 500 mL, IV, Routine, 11/26/06 21:22:00, 30 day, Hard Stop, 12/26/06 21:21:00, 72 mUHR, 6.9 HR, 500 Order Entered By: Reynolds, Brandon Q Nurse : Mahoney, Amy K accepted on 11/26/06 22:02 Pharmacist: Gunawan, Sesilya accepted on 11/26/06 22:37 ACTION(S) CHARTED @ ADMIN TIME(S) ADMIN DETAIL(S) Begin Bag Bag 1 11/26/06 22:00 11/26/06 22:00 Dextrose 5% with 0.45% NaCI and KCI 10 m 500 mL IV Volume: 500 mL Rate: 72 mL/HR Site: .IV, Peripheral Perform:Mahoney, Amy K D5W - 0.45% NaCI + 5 mEy KCI(D5 - 0.45% NaCI + 10 mEq/L KCI) 500 mL Every Bag 500 mL, IV, Routine, 11/26/06 21:22:00, 30 day, Hard Stop, 12/26/06 21:21:00, 72 mUHR, 6.9 HR, 500 Order Modified/Verified By: Gunawan, Sesilya ACTION(S) CHARTED @ ADMIN TIME(S) ADMIN DETAIL(S) Discontinue 11/28/06 :01 Performed By: SYSTEM MRN: 1066842 (Order Id m 155617854.00) (Order Id - 155627854.00) Dextrose 5% with 0.9% NaCI(D5 - 0.9% NaCI) 250 mL Every Bag (Order Id - 155614515.00) 250 mL, IV, Routine, 11/26/06 19:23:00, 30 day, Hard Stop, 12/26/06 19:22:00, 72 mUHR, 3.5 Hl?, 250 Order Comment: for infant only Order Entered By: Gidvani, Sandeep N Nurse : Mahoney, Amy K accepted on 11/26/06 22:02 Pharmacist: Gunawan, Sesilya reviewed on 11/26/06 22:36 ACTION(S) CHARTED @ ADMIN TIME(S) ADMIN DETAIL(S) Discontinue 11/26/06 1:2 Performed By: Reynolds, Brandon Q PENNSTATE • 0 19 Milton. Hathey 1V5udical Center college of Med%clne Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 L- V 1 t a I S i g n s ( P F) Vital Signs Form 11/26/06 09:37 pm Performed by Bartell, Sharon Entered on 11/26/06 09:38 pm Vital Signs Temperature 36.8 DegC Temperature Route Temporal Heart Rate 126 bpm Oxygen Saturation 99 % Respiratory Rate 26 br/min Oxygen Therapy Room air BP Location # 1 Right Arm Systolic Blood Pressure 140 mmHg Diastolic Blood Pressure 73 mmHg Vital Signs Form 11/27/06 04:16 am Performed by Peters, Kelly B Entered on 11/27/06 04:17 am Vital Signs Temperature 36.1 DegC Temperature Route Temporal Heart Rate 104 bpm Respiratory Rate 20 br/min Oxygen Therapy Room air BP Location # 1 Right Arm Systolic Blood Pressure 133 mmHg Diastolic Blood Pressure 72 mmHg Vital Signs Form 11/27/06 11:50 am Performed by Kreiser, Vanessa L Entered on 11/27/06 12:36 pm Vital Signs Temperature 38.3 DegC Temperature Route Temporal Heart Rate 115 bpm Oxygen Saturation 95 % Respiratory Rate 28 br/min Oxygen Therapy Room air BP Location # 1 Right Arm Systolic Blood Pressure 119 mmHg Diastolic Blood Pressure 73 mmHg Vital Signs Form 11/27/06 12:38 pm Performed by Kreiser, Vanessa L Entered on 11/27/06 12:38 pm Vital Signs Temperature 38.0 DegC Temperature Route Temporal Date Printed: 11412008 Time Printed: 1:47 PM PENNSfATE is • Milton & fey Medical Center CAW of Medicine Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 V i t a I S i g n s ( P F) Vital Signs Form 11/27/06 04%00 pm Performed by Kreiser, Vanessa L Entered on 11127/06 04%37 pm vital signs Temperature 38.2 DegC Temperature Route Temporal Heart Rate 105 bpm Oxygen Saturation 97 % Respiratory Rate 20 br/min Oxygen Therapy Room air BP Location # 1 Right Arm Systolic Blood Pressure 105 mmHg Diastolic Blood Pressure 59 mmHg Vital Signs Form 11/27/06 09:20 pm Performed by Munoz, Kris A Entered on 11/27/06 09:20 pm vital signs Temperature 38.0 DegC Temperature Route Temporal Heart Rate 114 bpm Respiratory Rate 24 br/min Vital Signs Form 11/27/06 11:05 pm Performed by Lingle, Julie M Entered on 11/27/06 11:05 pm vital signs Temperature 38.5 DegC Temperature Route Temporal Vital Signs Form 11/28/06 01:00 am Performed by Munoz, Kris A Entered on 11/28/06 01s19 am vital signs Temperature 37.8 DegC Temperature Route Temporal Heart Rate 124 bpm Oxygen Saturation 98 % Respiratory Rate 20 br/min Oxygen Therapy Room air Vital Signs Form 11/28/06 05:00 an Performed by Munoz, Kris A Entered on 11/28/06 05:19 am vital signs Temperature 37.4 DegC Temperature Route Temporal Heart Rate 118 bpm Respiratory Rate 18 br/min Date Printed: 11412008 lime Printed: 1:47 PM PENNSrATE • • Milton & fey Medical Center College of bledidne Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 V i t a l S i g n s ( P F) Vital signs Form 11/28/06 08:35 am Performed by Kreiser, Vanessa L Entered on 11/28/06 09:07 am vital Signs Temperature 37.4 DegC Temperature Route Temporal Heart Rate 112 bpm Respiratory Rate 24 br/min BP Location # 1 Right Arm Systolic Blood Pressure 100 mmHg Diastolic Blood Pressure 61 mmHg vital signs Form 11/28/06 12:00 pm Performed by Wagenheim, Sharon A Entered on 11/28/06 12:32 pm vital signs Temperature 36.0 DegC Temperature Route Temporal Heart Rate 119 bpm Oxygen Saturation 96 % Respiratory Rate 20 br/min Pain Intensity 3 Oxygen Therapy Room air Systolic Blood Pressure 113 mmHg Diastolic Blood Pressure 63 mmHg Date Printed: 11412008 Time Printed: 1:47 PM 0 • Milton S. Hmhey M,u ical C eater C kV of Widne Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 N e u r o v a s c u l a r F o r m ( P F) Neurovascular Form 11/27/06 11:36 am Performed by Sweigart, Jill A Entered on 11/27/06 11:38 am Right Upper Assessment Neurovascular RLU Nail Bed Grid Right Hand: Pink Right Thumb: Pink Right Index Finger: Pink Right Middle Finger: Pink Right Ring Finger: Pink Right Pinky Finger: Pink Neurovascular RLU Cap Refill Grid Right Hand: < 3 Seconds Right Thumb: < 3 Seconds Neurovascular RLU Pulses Grid Radial Pulse, Right: 2+ Normal Neurovascular RLU Edema Grid Hand: None Left Upper Assessment Neurovascular LLU Nail Bed Grid Left Hand: Pink Left Thumb: Pink Left Index Finger: Pink Left Middle Finger: Pink Left Ring Finger: Pink Left Pinky Finger: Pink Neurovascular LLU Cap Refill Grid Left Hand: < 3 Seconds Left Index Finger: < 3 Seconds Neurovascular LLU Pulses Grid Radial Pulse, Left: 2+ Normal Radial Pulse, Right: 2+ Normal Right Lower Assessment Neurovascular RLL Nail Bed Grid Right Foot: Pink Right Great Toe: Pink Right Second Toe: Pink Right Third Toe: Pink Right Fourth Toe: Pink Right Fifth Toe: Pink Neurovascular LLU Cap Refill Grid Right Foot: < 3 Seconds Right Great Toe: < 3 Seconds Neurovascular LLU Extremity Grid Right Hip to Knee: Pink Right Knee to Ankle: Pink Right Foot: Pink Right Great Toe: Pink Right Second Toe: Pink Right Third Toe: Pink Right Fourth Toe: Pink Right Fifth Toe: Pink Torso: Pink Neurovascular LLU Temperature Grid Right Hip to Knee: Warm Right Knee to Ankle: Warm Date Printed: 11412008 Time Printed: 1:47 PM PENNSTATE . • • 10 CAW 1V131ton & Hmhe?? Medical meter of &WIdne Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 1 N e u r o v a s c u l a r F o r m ( P F) 1 Neurovascular Form 11/27/06 11:36 am Performed by Sweigart, Jill A Entered on 11/27/06 11:38 am Right Lower Assessment Right Foot: Warm Right Great Toe: Warm Right Second Toe: Warm Right Third Toe: Warm Right Fourth Toe: Warm Right Fifth Toe: Warm Torso: Warm Neurovascular LLU Pulse Grid Dorsalis Pedis Pulse, Right: 2+ Normal Neurovascular LLU Edema Grid Pedal: None Left Loner Anne* anent Nail Bed Desc Left Second Toe Left Foot: Pink Left Great Toe: Pink Left Second Toe: Pink Left Third Toe: Pink Left Fourth Toe: Pink Left Fifth Toe: Pink Capillary Refill Left Foot Left Foot: < 3 Seconds Left Great Toe: < 3 Seconds Left Second Toe: < 3 Seconds Left Third Toe: < 3 Seconds Left Fourth Toe: < 3 Seconds Left Fifth Toe: < 3 Seconds Neurovascular LLE Temperature Grid Left Great Toe: Warm Left Second Toe: Warm Left Third Toe: Warm Left Fourth Toe: Warm Left Fifth Toe: Warm Neurovascular Form 11/27/06 01:05 pm Performed by Sweigart, Jill A Entered on 11/27/06 01:05 pan Right UtWer Assessment Neurovascular RLU Nail Bed Grid Right Hand: Pink Right Thumb: Pink Right Index Finger: Pink Right Middle Finger: Pink Right Ring Finger: Pink Right Pinky Finger: Pink Neurovascular RLU Cap Refill Grid Right Hand: < 3 Seconds Right Thumb: < 3 Seconds Neurovascular RLU Pulses Grid Radial Pulse, Right: 2+ Normal Neurovascular RLU Edema Grid Date Printed: 11412008 Time Printed: 1:47 PM 0 0 Mon & Huthey Malkal meter Collep of Medicine Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 N e u r o v a s c u l a r F o r m ( P F) Neurovascular Form 11/27/06 01:05 pm Performed by Sweigart, Jill A Satered on 11/27106 01:05 pm Right Upper Aaaeamwnt Hand: None Left Upper Aaaesament Neurovascular LLU Nail Bed Grid Left Hand: Pink Left Thumb: Pink Left Index Finger: Pink Left Middle Finger: Pink Left Ring Finger: Pink Left Pinky Finger: Pink Neurovascular LLU Cap Refill Grid Left Hand: < 3 Seconds Left Index Finger: < 3 Seconds Neurovascular LLU Pulses Grid Radial Pulse, Left: 2+ Normal Radial Pulse, Right: 2+ Normal Right Lower Asnesament Neurovascular RLL Nail Bed Grid Right Foot: Pink Right Great Toe: Pink Right Second Toe: Pink Right Third Toe: Pink Right Fourth Toe: Pink Right Fifth Toe: Pink Neurovascular LLU Cap Refill Grid Right Foot: < 3 Seconds Right Great Toe: < 3 Seconds Neurovascular LLU Extremity Grid Right Hip to Knee: Pink Right Knee to Ankle: Pink Right Foot: Pink Right Great Toe: Pink Right Second Toe: Pink Right Third Toe: Pink Right Fourth Toe: Pink Right Fifth Toe: Pink Torso: Pink Neurovascular LLU Temperature Grid Right Hip to Knee: Warm Right Knee to Ankle: Warm, Right Foot: Warm Right Great Toe: Warm Right Second Toe: Warm Right Third Toe: Warm Right Fourth Toe: Warm Right Fifth Toe: Warm Torso: Warm Neurovascular LLU Pulse Grid Dorsalis Pedis Pulse, Right: 2+ Normal Neurovascular LLU Edema Grid Pedal: None Date Printed: 11412008 nme Printed: 1:47 PM PENNSTATE • • 10 NUIton Sr shey 1!ledica Getter College of Medicne Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 N e u r o v a s c u l a r F o r m ( P F) Neurovascular Form 11/27/06 01:05 pan Performed by Sweigart, Jill A Entered on 11127/06 01:05 pan Left Lover Assessment Nail Bed Desc Left Second Toe Left Foot: Pink Left Great Toe: Pink Left Second Toe: Pink Left Third Toe: Pink Left Fourth Toe: Pink Left Fifth Toe: Pink Capillary Refill Left Foot Left Foot: < 3 Seconds Left Great Toe: < 3 Seconds Left Second Toe: < 3 Seconds Left Third Toe: < 3 Seconds Left Fourth Toe: < 3 Seconds Left Fifth Toe: < 3 Seconds Neurovascular LLE Temperature Grid Left Great Toe: Warm Left Second Toe: Warm Left Third Toe: Warm Left Fourth Toe: Warm Left Fifth Toe: Warm Torso: Warm Flap Assessment Neurovascular RLU Edema Grid Hand: None P a i n R e s p o n s e F o r m ( P F) Pain Response Form 11/26/06 10:20 pm Performed by Mahoney, Any K Entered on 11/26/06 10:35 pm Pain Response Pain Intensity Response 4 Pain Response Form 11/27/06 00:37 am Performed by Peters, Kelly B Entered on 11/27/06 03:08 am Pain Response Pain Intensity Response Patient sleeping Pain Response Form 11/27/06 05:11 am Performed by Peters, Kelly B Entered on 11/27/06 05:14 am Pain Response Pain Intensity Response 2 Date Printed: 11412008 Mme Printed: 1:47 PM • • Mon n Sr r shey Medical Center +Collep of Me ' ' e Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 I P a i n R e s p o n s e F o r m ( P F) Pain Response Form 11/27/06 01:34 pa Performed by Sweigart, Jill A Entered on 11/27/06 01:38 pm Pain Response Pain Intensity Response Patient sleeping Pain Response Form 11/27106 06:34 pm Performed by Lingle, Julie M Entered on 11/37/06 10:39 pm Pain Response Pain Intensity Response 3 Pain Response Form 11/27/06 06:30 pm Performed by Lingle, Julie M Entered on 11/27106 10:44 pm Pain Response Pain Intensity Response 2 Pain Response Form 11/27/06 11:33 pm Performed by Patterson, Lauren P Entered on 11/28/06 03:07 am Pain Response Pain Intensity Response 0 Pain Response Form 11128/06 04:10 am Performed by Patterson, Lauren P Entered on 11/28/06 07:21 am Pain Response Pain Intensity Response 0 Pain Response Form 11/28/06 10:13 am Performed by Wissler, Jodi L Entered on 11/28/06 09:47 am Pain Response Pain Intensity Response 0 Pain Response Form 11/28/06 02:58 pm Performed by Wissler, Jodi L Entered on 11/28/06 02:43 pm Pain Response Pain Intensity Response Patient sleeping Date Printed: 11412008 Time Printed: 1:47 PM Page 1 Flawsheet Print Request Patient FICKES. STORM M Printed by: Battle, Carmen E Page 3 Flowsheet Print Request Patlant: FICKES. STORM M Printed by, Battle, Carmen E Flowsheet Print Request Page 4 Patient: FICKES, STORM M Printed by. Battle. Carmen E Page 5 Flowsheet Print Request Patient: FICKES, STORM M Printed bv: Battle_ Carman ?J Page 6 Flowsheet Print Request Patient: FICKES, STORM M Printed by., Battle, Caren E Mon S. Ekshey 1CCiI 1# College of Medi&e Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 P a t i e n t E d u c a t i o n ( E D) ED Pat Edu D e p a r t S u m m a r y ( E D) A Depart Summary Penn State Milton S. Hershey Medical Center Emergency Department Depart Summary PERSON INFORMATION Name FICKES, STORM M Age 8 Years Sex Male Language English Marital Status Single Phone 7178345993 MRN 1066842 Visit Id Visit Reason ; Specialty Enc Type Inpatient Mod Service Ped Surgery Track Group EMER Trk Gp Discharge Tracking Id 3325334 Checkout 11/2712006 12:21 AM Checkin 11/2612006 7:00 PM Acuity Arrival 11126/2006 7:23 PM Reg Status Start Address: 96 LINTON HILL ROAD DUNCANNON Pennsylvania 170200000 DOB 4/04/1998 12:00 AM PCP Acct# 7761914 Referred by Dispo Type Adm Univ Hos LOS 000 05:21 DIAGNOSIS POWERFORMS SCHEDULING Date Printed: 11412008 Time Printed: 1:44 PM • E ABtmi & Bhshey Medical Canter +CoUege of Nkxffane Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 D e p a r t S u m m a r y ( E D) PHYS DOC NOTES DEPART REASON INCOMPLETE INFORMATION Depart Action Incomplete Reason Diagnosis Patient Admitted Discharge Instructions Patient Admitted Patient Understanding Patient Admitted PROVIDER INFORMATION Provider Role Chiicoat, Kaitlin A RN Ammons, Daniel M Physician EVENTS INFORMATION Event Name Event Status Arrive Complete Triage Request Arrive Registration Complete Registration Complete Assigned 11/26/2006 7:04 PM 11/26/2006 9:17 PM Request Date/Time 11/26/2006 7:00 PM 1112612006 7:00 PM 11/26/2006 7:00 PM 11126(2006 7:00 PM Start DatefTime 11/26/2006 7:00 PM 11126/2006 7:00 PM 11/2612006 7:56 PM Unassigned Complete Date/Time 11/26/2006 7:00 PM 11/26/2006 7:00 PM 11126/2006 7:56 PM Date Printed: 11412008 Time Printed: 1:44 PM 0 , • 19 Miltcn S.I alley NkAcal Center College of Me ' ' Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 Arrive MD Bill Complete MD Bill Request Arrive Dictate Complete Dictate Request Arrive PT Belongings Complete Bed Assign PT Belong Complete Arrive Bed Assign Complete Bed Assign Complete MD Assess Complete RN Assess Request Resident Assess Request Patient Belongings Request Xray Complete Xray Cancel Xray Cancel Xray Cancel Xray Cancel Xray Complete Xray Cancel Xray Cancel Xray Cancel Admit Complete PT Care Request Rx Cancel Request Consult Request Lab Collect Complete 11/26/2006 7:00 PM 11/2612006 7:00 PM 11/2612006 7:00 PM 11/26/2006 7:00 PM 11/26/2006 7:00 PM 11/26/2006 7:00 PM 11/26/2006 7:00 PM 11/26/2006 7:00 PM 11/26/2006 7:01 PM 11/2612006 7:01 PM 11/26/2006 7:01 PM 11/26/2006 7:01 PM 11/26/2006 7:04 PM 11/26/2006 7:13 PM 11/26/2006 7:13 PM 11/26/2006 7:13 PM 11/26/2006 7:13 PM 11/26/2006 7:13 PM 11/26/2006 7:13 PM 11/26/2006 7:13 PM 11/26/2006 7:17 PM 11/26/2006 7:26 PM 11/26/2006 7:26 PM 11126/2006 7:26 PM 11/26/2006 7:26 PM 11/26/2006 7:38 PM 11/2612006 7:00 PM 11/26/2006 7:00 PM 11/26/2006 7:00 PM 11/26/2006 7:00 PM 11/26/2006 7:00 PM 11/26/2006 7:01 PM 11/26/2006 7:00 PM 11/26/2006 7:01 PM 11/26/2006 9:17 PM 11/26/2006 7:13 PM 11/26/2006 7:41 PM 11/26/2006 7:00 PM 11/26/2006 7:01 PM 11/2612006 7:00 PM 11/2612006 7:01 PM 11/26/2006 9:17 PM 11/26/2006 7:40 PM 11/26/2006 8:23 PM 11/26/2006 8:23 PM 11/26/2006 8:23 PM 11/26/2006 8:23 PM 11/26/2006 8:23 PM 11/26/2006 8:23 PM 11/26/2006 8:23 PM 11/26/2006 7:47 PM 11/26/2006 7:34 PM 11/26/2006 9:24 PM 11/26/2006 7:38 PM 11/2612006 7:38 PM Date Printed: 11412008 Time Printed: 1:44 PM • • 10 Moll & Hwshey NxHcal Gaiter of hkdicne WkSe Patient Name: FICKES, STORM M Xray Cancel 11/26/2006 7:42 PM Lab Collect Collected 11/26/2006 7:55 PM Rx Request 11/26/2006 9:24 PM Rx Request 11/26/2006 9:51 PM Lab Collect Complete 11126/200610:50 PM Discharge/Transfer Complete 11/27/2006 12:21 AM LOCATION INFORMATION Arrival Nurse Unit 11/26/2006 7:00 PM EMER 1112612006 7:01 PM EMER 11/26/2006 9:33 PM EMER 11/27/2006 12:21 AM EMER ORDERS INFORMATION Start Time Order Type 11/25/2006 7:02 PM ED Nursing Charge Patient Care 11/26/2006 7:04 PM ED Trauma Order Sets Radiology Set 11/26/2006 7:04 PM Chest XR Radiology 11/26/2006 7:04 PM Pelvis XR Radiology 11/26/2006 7:04 PM C-Spine XR Radiology 11/26/2006 7:04 PM Head CT. Radiology 11/26/2006 7:12 PM Chest CT (Apex to Radiology Adrenals). PSUHMC MRN: 1066842 11/26/2006 7:43 PM 11/26/2006 7:55 PM 11/2612006 7:55 PM 11/26/2006 10:50 PM 11/26/2006 10:52 PM 11/27/2006 12:21 AM 11/27/2006 12:21 AM Room Bed Waiting Room TRB Chart Check Out Status Stop Time Provider Ordered 11/2612006 7:02 PM SYSTEM Completed 1112612006 8:23 PM Ammons, Daniel M Completed 11126!2006 7:40 PM Ammons, Daniel M Completed 11/26/2006 7:39 PM Ammons, Daniel M Completed 11/2612006 7:40 PM Ammons, Daniel M Canceled 11/26/2006 8:23 PM Ammons, Daniel M Canceled 11/26/2006 8:23 PM Ammons, Daniel M Date Printed: 11412008 77me Printed: 1:44 PM • • rfton S. Ekrjhey Medical Center CoQege of Hed dne Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 Abdomen CT 11126/2006 7:12 PM (Diaphragm to Iliac Radiology Canceled 11/26/2006 8:23 PM Ammons, Daniel M Crest). 11/26/2006 7:12 PM Pelvis CT (Iliac Crest bi h i P Radlology Canceled 11/26/2006 8:23 PM Ammons, Daniel M to Symp ys s u s). 11/26/2006 7:12 PM L-Spine CT Radiology Canceled 11/26/2006 8:23 PM Ammons, Daniel M 11/26/2006 7:12 PM C-Spine CT Radiology Completed 11126/2006 8:23 PM Ammons, Daniel M 11/26/2006 7:12 PM Facial Bones CT Radiology Canceled 11/26/2006 8:23 PM Ammons, Daniel M 11/26/2006 7:12 PM T-Spine CT Radiology Canceled 1112612006 8:23 PM Ammons, Daniel M 11/26/2006 7:17 PM Diagnostic Order Sets Discontinued 11/26/2006 7:47 PM Budge, Matthew D Radiology Exams 11/26/2006 7:16 PM Femur XR Radiology Canceled 11/26/2006 7:38 PM Budge, Matthew D 1112612006 7:17 PM Hip XR Radiology Canceled 11126/2006 7:47 PM Budge, Matthew D 11/26/2006 7:17 PM Knee XR Radiology Canceled 11/26/2006 7:38 PM Budge, Matthew D 11/2612006 7:26 PM Peds Trauma Admission Order Sets Ordered 11/26/2006 7:26 PM Gidvani, Sandeep N 1112612006 7:23 PM Admit. Patient Care Completed 11126/2006 7:34 PM Gidvani, Sandeep N 11/26/2006 7:23 PM Admitting Diagnosis Patient Care Ordered 11/26/2006 7:23 PM Gidvani, Sandeep N 11/26/2006 7:24 PM Vital Signs Patient Care Ordered Gidvani, Sandeep N 11/26/2006 7:24 PM NPO Dietary Ordered Gidvani, Sandeep N 11/26/2006 7:24 PM Bedrest Patient Care Ordered Gidvani, Sandeep N 11/2612006 7:24 PM Call HO Patient Care Ordered 11/26/2006 7:24 PM Gidvani, Sandeep N 11/26/2006 7:24 PM Spine Precautions Patient Care Ordered Gidvani, Sandeep N 11/26/2006 7:23 PM Dextrose 5% with 0.9% NaCl 250 ml Pharmacy Discontinued 11/26/2006 9:21 PM Reynolds, Brandon Q 11/26/2006 7:25 PM Social Service Consults Ordered 11/26/2006 7:25 PM Gidvani, Sandeep N Consult 11126/2006 7:26 PM Level of Care: Floor Patient Care Ordered 11/26/2006 7:26 PM SYSTEM 11126/2006 7:34 PM Patient Education Documentation Patient Care Ordered SYSTEM 11126/2006 10:00 Patient Education Patient Care Ordered 11/26/2006 10:00 PM SYSTEM PM Documentation 11/27/2006 6:00 AM Patient Education Patient Care Ordered 11/27/2006 6:00 AM SYSTEM Date Printed. 11412008 nme Printed: 1:44 PM ' • • TE PENNSTA 19 N91ton & Hashe Mcdkal meter College of Nye dne Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 Documentation 11126/2006 7:34 PM Ped Admit Patient Care Completed 11/26/2006 10:32 PM SYSTEM Assessment 1112612006 7:34 PM Ped Admit2 Patient Care Completed 1112612006 10:27 PM SYSTEM Assessment 11/26/2006 7:34 PM Ped Ongoing Patient Care Assessment Ordered SYSTEM 1112712006 12:01 Ped Ongoing Patient Care Ordered 11/27/2006 12:01 AM SYSTEM AM Assessment 11/27/2006 8:00 AM Ped Ongoing Patient Care Ordered 11/27/2006 8:00 AM SYSTEM Assessment 12/03/2006 8:00 AM Weight Patient Care 11/26/2006 5:31 PM Lab specimens to Laboratory hold Trauma Profile 11/26/2006 5:31 PM Default (ordered by Laboratory lab).. 11/26/2006 7:42 PM Chest XR Radiology 11/26/2006 9:23 PM morphine Pharmacy 11/26/2006 9:24 PM acetaminophen Pharmacy Dextrose 5% with 11/2612006 9:22 PM 0.45% NaCl and KCI Pharmacy 10 mEq/L 500 mL 11/26/2006 9:40 PM Traction Patient Care 11/26/200610:00 ceFAZolin Pharmacy PM 1112612006 7:30 PM Blood Type/Antibody Laboratory Screen MEDICAL INFORMATION Allergy Info: Bee sting Prescriptions Given Ordered Completed Completed Canceled Ordered Ordered Ordered Ordered Ordered Completed SYSTEM 11/26/2006 5:31 PM Engbrecht, Brett W 11/2612006 5:31 PM Engbrecht, Brett W 11/26/2006 7:55 PM 11/29/2006 9:22 PM 1212612006 9:23 PM Engbrecht, Brett W Reynolds, Brandon Q Reynolds, Brandon Q 12126/2006 9:21 PM Reynolds, Brandon Q 11/26/2006 9:40 PM 12/0312006 9:59 PM 11/26/2006 7:30 PM Budge, Matthew D Troxell, Corey Engbrecht, Brett W Date Printed: 11412008 Time Printed: 1:44 PM 0 0 Mon S. Ilershey Medical Center College of 1' edidne Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 D e p a r t S u m m a r y ( E D) 1 DISCHARGE INFORMATION Discharge Disposition: Adm Univ Hos Discharge Location: PATIENT EDUCATION INFORMATION Instructions: Follow up: Follow-Up With: Date Printed: 11412008 nme Printed: 1:44 PM • • Milton & Ek* Magical Center College of bkdi t Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 D 1 s c h a r g e S u m m a r y D o c u m e n t J Final Document Electronically Signed by: Engbrecht, Brett W 12/12/2006 7:24:13 AM DISCHARGE SUMMARY Name: FICKES, STORM HMC Number: 1066842 DOB: 04/04/1998 Date of Admission: 11/2612006 Date of Discharge: 11/2812006 DISCHARGE DISPOSITION: Home in stable condition. ADDRESS: 96 Linton Hill Road, Duncannon, PA 17020. PHONE NUMBER: 717-834-5593 HERSHEY MEDICAL CENTER ATTENDING: Dr. Engbrecht. HERSHEY MEDICAL CENTER RESIDENT: Pediatric resident. ADMISSION DIAGNOSIS: Trauma, pedestrian versus automobile. PRINCIPAL DISCHARGE DIAGNOSIS: Left distal femur fracture. PROCEDURES: Open reduction internal fixation of left distal femur fracture. BRIEF COURSE: Storm is a 9-year-old male who was walking across the street at night and was hit by an automobile. He denied any loss of consciousness or hitting his head. He is complaining of left arm pain and was unable to walk. He was sent here as a trauma alert. He had a full physical exam, and films of the C-spine, chest, pelvis, left knee, as well as cervical spine CT were done. These were all devoid of any acute pathology with the exception of a left distal femur fracture. He was intubated and sedated in the trauma bay and the fracture was reduced and splinted. The following morning (11/27/06), the patient was taken to the OR by orthopedics for an ORIF of the fracture. This went without any complications. Postoperatively he was gradually advanced to a regular diet, which he tolerated. On 11/28106, he worked with physical therapy at mobilization with the assistance of crutches. A wheelchair was also arranged for him to go home with. At the time of discharge he was tolerating a regular diet. His pain was well controlled on oral pain medications, he was afebrile and his vital signs were stable. DISCHARGE MEDICATIONS: Tylenol #3, 300/30 one tablet every four hours as needed for pain. Date Printed: 11412008 Time Printed: 1:44 PM • • 91 1V01ton whey Medical Cater !CoUeg9e of bledi+cine Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 D i s c h a r g e S u m m a r y D o c u m e n t Final Document Electronically Signed by: Engbrecht, Brett W 12/12/2006 7:24:13 AM 24430 Review/Sign: Brandon Q Reynolds Review/Sign: Brett W Engbrecht, MD Pediatric Surgery: Drs. Robert Cilley, Peter Dillon, Andreas Meier, Kerry Fagelman, Brett Engbrecht Coleen Greecher MS RD CNSD, Janet Shields MSN CRNP CS, Lynn Simmons MSN CRNP BQR /DO DD: 12/11/06 DT: 12/11/06 22:25 Date Printed: 11412008 Mme Printed: 1:44 PM • • Mon I Mrs1 ? scat meter CdAep of Med eme Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 D/ C I n s t r u c t i o n F o r m D o c u m e n t Final Document Electronically Signed by: Reynolds, Brandon Q 11/28/2006 5:59:08 PM PENN STATE MILTON S. HERSHEY MEDICAL CENTER PATIENT DISCHARGE INSTRUCTIONS ADMISSION DATE: 11/26/06 DISCHARGE DATE: 11/28/06 DISCHARGE DISPOSITION (Home/Other): Home stable condition ADDRESS: 96 Linton Hill Rd. Duncannon, PA 17020 PHONE NUMBER:717 834-5993 HKC ATTENDING MD: Dr. Engbrecht HMC RESIDENT: Pediatric Surgery Residents ADMISSION DIAGNOSIS: Trauma, pedestrian vs. automobile PRINCIPAL D/C DIAGNOSIS: Left distal femur fracture PROCEDURES: Open reduction internal fixation of left distal femur fracture BRIEF COURSE: Storm is a 9 year old male who was walking across the street at night and was hit by an automobile. He denied any loss of conciousness or hittingin his head. He was complaining of left leg pain and was unable to walk. He was sent here as a trauma alert. He had a full physical exam, and films of c-spine, chest and plevis, left knee, as well as a cervical spine CT. These were all devoid of any acute pathology with the exception of a Left distal femor fracture. He was intubated and sedated in the trauma bay and the fracture was reduced and splinted. The following morning (11/27/06), the patient was taken to the OR by Orthopaedics for ORIF of the fracture. This went without complication. Post operatively he was gradually advanced to a regular diet which he tolerated. On 11/28/06 he worked with Physical therapy at mobilization with the assistance of crutches. A wheelchair was also arranged for him to go home with. At the time of discharge he was tolerating a regular diet, his pain was well controlled on oral pain medications, he was afebrile and his vital signs were stable. DISCHARGE MEDICATIONS (List name/dosage/route/frequency, in patient language): Medication Dosage Route Frequency Tylenol #3 300/30 1 tablet every 4 hours as needed for pain. SERVICES / FREQUENCY Nursing Care Aide / Homemaker X Physical Therapy Date Printed: 11412008 Time Printed: 1:44 PM PENNSTATE • 0 Milton & Hmhey Medkal Center CofiW of Medicine Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 Respiratory Therapy Occupational Therapy Speech Therapy Social Services Nutritional Care Hospice Care The following must be completed for all trauma patients: Functional status at discharge 1. Feeding 2. Locomotion 3. Expression 4. Transfer Mobility 5. Social Interaction Key: 4 5=Not Applicable 3 4=Complete Independence 4 3=Independence with Device 4 2=Modified Dependence 4 1=Complete Dependence Vaccination Status at Discharge: Y N Influenza Vaccination Given Y N Pneumococcal Vaccination Given InA In ORDERS/INSTRUCTIONS (Diet, Activity, etc.): 1. Activity as tolerated (non weightbearing on Left lower extremity) to continue with outpatient physical therapy for strengthening as mobility. 2. Cast care instructions per handout. 3. Diet as tolerated. 4. Please call 531-8521 and ask for the Pediatric orthopaedic surgery resident on call if any of the following occur: fever>101.5F, persistant nausea/vomitting, numbness or worsening pain in Left leg, blue toes, changes in mental status, difficulty breathing, or any other concerning issues. FOLLOW-UP APPOINTMENTS (List clinic, visit date/time): Follow up with Dr. Segal in Orthopaedic surgery in10-14 days. You will be contacted with the exact date, time, and location of the appointment. If you have any questions you can call 531-8521 and ask to be connected the the pediatric orthopaedic surgery clinic. Author (Type name):Brandon Reynolds (Electronically signed) (SAVE but DO NOT SIGN this document until the patient is ready for discharge. Once you sign this form, it can not be modified further except with an addendum at the bottom) Signature Nurse: (To discharging nurse, please document the following on your last paper progress note: Discharge instructions were reviewed with the patient/guardian/responsible person, a copy Date Printed: 11412008 Time Printed: 1:44 PM • • Mon S, Hwshe liedl Center 10 College of bled dne Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 I D/ C I n s t r u c t i o n F o r m D o c u m e n t 1 Final Document Electronically Signed by: Reynolds, Brandon Q 11/28/2006 5:59:08 PM of the discharge instructions was given to the patient/guardian/responsible person and all questions were answered.) Signature Patient/Responsible person: Date Printed: 11412008 Time Printed: 1:44 PM 12?1IO? • • Header Page Patient Name: FICKES, STORM M Date of Birth: 4/4/1998 12:00:00 AM Medical Record Number: 1066842 Financial Number: 07832576 Admission Date: 12/11/2006 4:21:27 PM Discharge Date: 12/12/2006 11:59:59 PM Patient Type: Clinic Facility: HMC Patient Location: HMC UREH Destination: Hershey Medical Center Reason: Legal Requester: Hershey Medical Center Date and Time Printed: 1/4/2008 1:43:45 PM Printed By: Twigger, Barbara Device: HISU30006 PENNSTATE Milton S. Hershey edical Center College of Medicine NEW PATIENT INFORMATION- PEDIATRIC OUTPATIENT REHAB CLINIC NAME:0ES, STORM M • 24480 MD#. MD: SEGAL LEE MR#: 1088842 DOB: 04/04/1998 SEX: M INS: AUTO INSURANCE STANDARD LOG: UREH 008#: 7832578 VISIT DATE 12111/2008 Today's Date CibrlQ Referring Physician Pediatrician r cr- Other Physicians or Therapists who see your child Why is your child being seen today? Is the problem getting worse Sam bette (circle one) How long has your child had the problem? .:: c) - u 1.PD 5 Does your child have pain? Ye No if yes, describe the pain How severe is the pain? (circle one) Previous x-rays, studies tests, (list name, location, Previous treatments (brace therapy) N I // - Prior injuries and illness Prior surgeries N 1'y1C i 1 - a? - C) Current medications Allergies 6-MC111 rVQCAi Birth History (circle) Full term or premature Birth weight Developmental History Age of first sitting Age of first words Any problems using hands or Walking Allergy? Yes No L____- Vaginal or C-section Bottom first or head first delivery Complications ce MR 840 Rev 10/01 Pg 1 of 2 NEW PATIENT INFORMATION _ .^ Over please • • -NEW PATIENT INFORMATION- 'PEDIATRIC OUTPATIENT REHAB CLINIC Family History Dad's age 3© Any Health problems n O Mom's age 3_ Any Health problems IV(D Brothers and sisters ages and health problems Social History School J u man r S I? Grade Usual report ca grade a Favorite Activities 0 Icuj X 6014 Sports SIB. yna I 1 Employment Review of System (check all that apply to your child) - Fever _ Vision problems _ Speaking problems _ Weight loss _ Glasses _ Swallowing problems _ Weight gain _ Deafness Numbness in arms or legs - Change in appetite _., Dizziness Change in teeing in arms or legs - Diarrhea _. Ringing in ears _ Poor coordination - Constipation _. Sinus problems ! Memory problems - Abdominal pain r Shortness of breath Balance problems - Gastrostomy tubetbutton _ Asthma ,'? ears diapers Chest pain _ Cough Urine problems - Heart problems - Tracheostomy - Menstrual problems _ High blood pressure _ Behavior problems - Pregnancies Skin rash _ _ Sleep problem ` Eating or drinking problems „ Skin sores ! Depression - Growth changes Skin lump _ Bleeding problem - Hair changes Eczema Explain checked items UUec-Ars U I - hQa -? w ?-?- Questions for the doctor or nurse r• Parent/Guardian signature""' 9 Date Do not write below this line j Blood Work MRI CT Brace Surgery Therapy Cast Surgery RTC X-rays Referrals to Attending Sighnature MR 840 Rev 10/01 Pg 2 of 2 NEW PATIENT INFORMATION- PEDIATRIC OUTPATIENT REHAB CLINIC PENNSTATE • W Milton S. Hershey Medical Center College of Medicine AUTHORIZATION FOR BENEFIT ASSIGNMENT AND INFORMATION RELEASE NAME: FICKE0ORM M MD: SEOAL LEE MR#: 1088842 DOB: 04/04/1998 INS: AUTO INSURANCE LOC: UREH OOS#: 7832578 MD#: 24480 SEX: M STANDARD VISIT DATE: 12/11/2008 I hereby assign any benefits payable to Penn State Milton S. Hershey Medical Center for providing medical services. I understand that I am responsible for any balance in excess of the benefits/contract payable by this plan. Penn State Milton S. Hershey Medical Center may disclose information about me and the treatment I am receiving, including copies of my medical record for purposes of treatment, payment and medical center operations as described in our Privacy Notice. I acknowledge that I have been offered the Penn State Milton S. Hershey Medical Center Privacy Notice. ?i ?l re of Patient or Patient's representative ? C.- 01- // `0(0 Date _5 o m _rn Relationship to Patient Print Name Privacy Notice Offered - Patient Unable to Sign Privacy Notice Offered - Patient Declined to Sign Other DO NOT COPY THIS FORM. ORDER FORMS FROM HMC STORES, CAT. #83092 MR 889 (Rev. 3/04) • N (ES, 8TORFA M EE L MDN: 24480 DOB: 04/04/1998 INS: AUTO INSURANCE SEX: M STANDARD U7 OW LOC: M: 783 832578 OS ISIT DATE: 12/11/2008 PEDIATRIC HEALTH ASSESSMENT 51ep -Mother's Name: i Q r05CA f-i r- t-e3 Occupation: Fathers Name: 1 11(C' m C C ?le Occupation: 1 UC C f 1 UPr Parents Marital Status: Married Single Widowed Divorced Living Together Separated L-- Parental involvement in child care: Father Yes / No Mother Yes/ No What language do you or your child best understand 6rV v S CT- Who lives in the household J*[? e j2 mbk-hef C l ?. Family Physician or Pediatrician: How do you or your child best loam: a. One on One Instruction b. Audio Visual Information c. Written Information d. Group Instruction e. Demonstration/Practice f. Other Is your child exposed to anyone who uses tobacco? Ye / No Who? Does anyone in the househould consume alcohol? Yes 0-20) . Does anyone in the household use any other substances Ye ! No If yes, type Is your child afraid of anyone? Yes No Has your child ever been physically or emotionally hurt by anyone: Yes No Past / Present Are there pets in the household Yes No Type: Cs=t"rte` cam, Water type? C' ell School District School Concerns: YesV No Does your child wear a bike helmet Yes No Does your child use a car seat, booster seat, or seat belt? Yes No Do you or yourild have any special needs we should be aware of so that we can better serve you? rn% I= • Previous Surgery Name of Current Medications: Q?42,6 winc4 , Complications E Date Does your child have allergies? (yey/ no If yes please list: Medications: Enviromental : Sr v ct t C!C w" -A-C-) ? ? n G S Has the patient ever had or experienced any of the following: Painful voiding / urinating Bed wetting Urinary tract infection Asthmalwheezing Bronchitis Pneumonia Sleep Apnea Tracheotomy Home oxygen therapy Shortness of breath Seizures Numbness arms Numbness legs Poor circulation Unsteady gait Difficulty speaking Headaches A es Ono ye / no ye no yes / no yes / n yes no yes no yes / no yes / o yes / no yes/ o yes n yes o yes / yes V-O- yes no Rheumatic fever Heart murmur Palpitations Chest pain High blood pressure Fainting Difficulty swallowing Diarrhea Reflux Blood in stool Constipation Food allergies Weight loss Weight gain yes no yes no yes no yes o yes / o yes / no yes/ o yes/ o yes/ o yes no yes n yes / no yes / yes/ o Is your child toilet trained? Oee /no Rashes yes no Has your child had the chicke n pox? yes /0 immunizations up to date as no Could you be pregnant yes no Family Medical History: Childhood Deaths yes no Diabetes (y e3/ no Stroke yes n Asthma yes/ o Cancer ye / no Hypertension yes n Seizures yes / no Heart Disease yes no Anemia/Blood Disorders yes no Arthritis yes / no Name of Person Completing Form Date Rela o ship to Patient ,(? Nrdton S Hershey Medical Winter College of Niediane Patient Name: FICKES, STORM M Patient Sex: Male Patient Location: UREH, , Visit Type: Clinic Penn State Milton S. Hershey Medical Center Tel: (717) 531-8055 Penn State College of Medicine Health Information Services, HU24 500 University Drive P.O. Box 850 Hershey, PA 17033-0850 PSUHMC MRN: 1066842 Date of Birth: 4/4/1998 Visit Number: 07832576 O u t p a t i e n t N o t e D o c u m e n t Modif ed Document Electronically Signed by: per contribution per contribution Signed By: Troxell, Corey (1/12/2007 10:09:40 AM); Segal, Lee S (12/13/2006 8:24:30 AM) OUTPATIENT NOTE Name: FICKES, STORM M HMC Number: 1066842 DOB: 04/04/1998 Date of Service: 12/11/2006 SUMMARY: Storm was here today. He is 2 weeks postop status post ORIF left distal femur fracture who sustained a motor vehicle versus pedestrian accident. He was placed in along leg cast postoperatively. He has been toe-touch weightbearing left lower extremity. He is without any pain now. He is not requiring any pain medications. He is tolerating cast well. There is no rubbing on the superior aspect of the cast where it had been peddled, has come apart. PHYSICAL EXAM: Left lower extremity: Normal sensation of the toes. He was able to plantar flex, dorsiflex the toes. There is no rubbing of the cast, proximally there is no rubbing of the cast either. X-RAYS: AP and lateral of femur were taken today. These show excellent anatomic alignment of distal femur. The hardware is in place. There is no evidence of hardware failure or loosening or breakage. IMPRESSION: Two weeks status post ORIF left distal femur fracture. PLAN: At this time, I will keep him toe-touch weightbearing and continue his long leg cast for another 4 weeks. We will see him back in 4 weeks, at that time we will recheck x-rays AP and lateral of the left femur. If he shows evidence of fracture healing, callous, we will likely remove him from his long leg cast. Patient seen and examined with Dr. Segal. Date Printed: 11412008 Time Printed: 1:43 PM • • Miltm & Hershey laical ter CdIkW of bkdi&e Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 O u t p a t i e n t N o t e D o c u m e n t -Wj Modified Document Electronically Signed by: per contribution per contribution Signed By: Troxell, Corey (1/12/2007 10:09:40 AM); Segal, Lee S (12/13/2006 8:24:30 AM) 25790 Review/Sign: Corey Troxell, DO Review/Sign: Lee S Segal, MD CT /CO DD: 12/11/06 DT: 12/12/06 22:49 Date Printed: 11412008 Time Printed: 1:43 PM PENNSTATE • Mon S. Hwshey 1V cal Winter College of W ' 'ne Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 M u s c u I o s k e I e t a I - S t u d y Final X-RAY FEMUR LEFT - PEDS PATIENT NAME: FICKES, STORM M PATIENT MRN:01066842 PATIENT DOB: 04/04/1998 EXAM DATE OF SERVICE: 12/11/2006 EXAM NUMBER: 1720534 ORDERING PHYSICIAN: SEGAL, LEE EXAM: Left femur x-ray TECHNIQUE: AP and lateral views of the left femur CLINICAL HISTORY: Left distal femur fracture, postop COMPARISON STUDIES: Prior left femur x-ray studies from 11/27/2006 and 11/28/2006. DISCUSSION:There isplate and screw fixation of the distal femurwith near anatomic alignment of the fracture fragments. The radiolucent fracture line is less well seen with sclerosis at the prior fracture site. The femoral head is in normal anatomic alignment with the acetabulum. IMPRESSION: Stable postoperative changes with no hardware complication. Dr. Sumukh Patil is the dictating resident. Attending radiologist signature indicates review of both the images and the report and that the attending radiologist agrees with the interpretation. Preliminary reports may not have been reviewed as yet by the attending radiologist. DICTATED: PATIL, SUMUKH REVIEWED AND SIGNED: PATIL, SUMUKH / CHOUDHARY, ARABINDA K DATE DRAFTED: 12/12/2006 08:25 AM DATE OF FINAL SIGNATURE: 12/12/2006 10:32 PM Date Printed: 11412008 Time Printed: 1:43 PM PENNSTATE Milton S. Hersh ,?lvledical Center College of Medicine PROGRESS REPORT 0 E • • NAME: FICKE- M MD: SEGAL LE MRN: 1066842 DOB: 04/04/1998 INS: AUTO INSURANCE LOC: UREH OOS#: 7832576 MDN: 24460 SEX: M STANDARD VISIT DATE: 120112006 MR 6 Rev. 6/01 PROGRESS REPORT PENNSTATE IV Milton S. Hershey Medical Center College of Medicine 40 PENN STATE MILTON S. HERSHEY MEDICAL CENTER BLOOD BANK HERSHEY, PA 17033 DIRECTOR OF CLINICAL LABORATORIES SPECIAL REQUESTS - CALL 8232 ?EXCHANGETR WSFUSION VOL ? INTRAUTERINE TRANSFUSION ? FRESH (LESS THAN 8 DAYS) N UNITS ? LESS THAN 72 HOURS (PEDIATRIC HEART SURGERY) M UNITS $" * < U; ?OTHER !.?.i CLINICAL PATHOLOGIST EVALUATION REQUIRED ?LEUKOREDUCED s, ?IRRADIATED ?WASHED f31 (ABO/RH, ANTIBODY SCREEN, 0 UNITS) ? OB TYPE AND SCREEN (OBTS) DIAGNOSIS ? ROUTINE (ABO/RH, ANTIBODY SCREEN, 0 UNITS) ORDERING PHYSICIAN ? NEONATAL TRANSFUSION (NEOX) FOR SURGERY COLLECT ON: (ABO/RH, ANTIBODY SCREEN) DATE ? HOLD SPECIMEN (HOLD) FOR TRANSFUSION (NO TESTING PENDING ORDERS) KEEP UNITS AHEAD ATALDATE LTIMES 1 ADULT RED PER 4 UNITS (NEW SPECIMEN REQUIRED EVERY 72 HOURS) ? L ST HAVE B R TRANSFU3 10N3 PREVIOU DATE ? YES NO CHART COPY TRANSFUSION AFO NUMBER R41979 351 NAME: TRAUMA, 7005 - ,r IN1111111 MD: DtF.LIT 'H CIiRIST 8325 MR#: 7005351 ;y/qg DO: 01/01/1900 SEX-. U CROSSMATCH (XM) (A /RH, ANTIBODY SCREE ,UNITS) INS: SELF PAY SELF PAY LOC: EMER COMPONENT AUNITS DOW 7781914 VISIT DATE: 0111312007 PACKED CELLS SIGNATURE TIME : I? GRANULOCYTES (XMG) RECIPIENTS IDENTIFICATI VERIFIED DATE: I t`X+' !3 HPC STEMCBLL3 (XMMS) , . SPECIMEN COLLECTED AND BLOOD BAND APPLIED BY. x a ,1 ? TYPE AND SCREEN (TSC) INFORMATION REQUIRED - 4n STAT VOL • • III ? 1 /n E • Header Page Patient Name: FICKES, STORM M Date of Birth: 4/4/1998 12:00:00 AM Medical Record Number: 1066842 Financial Number: 07885259 Admission Date: 1/17/2007 1:55:32 PM Discharge Date: 1/18/2007 11:59:59 PM Patient Type: Clinic Facility: HMC Patient Location: HMC UREH Destination: Hershey Medical Center Reason: Legal Requester: Hershey Medical Center Date and Time Printed: 1/4/2008 1:42:40 PM Printed By: Twigger, Barbara Device: HISU30006 PENNSTATE a Milton S. Hershey Medical Center 9 College of Medicine AUTHORIZATION FOR BENEFIT ASSIGNMENT AND INFORMATION RELEASE NAME: FICKES, ST MD: SESAL LEE MRO: 108884? 998 DOB: 04/0411998 INS- AUTO INSURANCE LOG: UREN 0088: 7885259 MD#: 24480 SEX: M STANDARD VISIT DATE: 01/17/2007 I hereby assign any benefits payable to Penn State Milton S. Hershey Medical Center for providing medical services. I understand that I am responsible for any balance in excess of the benefits/contract payable by this plan. Penn State Milton S. Hershey Medical Center may disclose information about me and the treatment I am receiving, including copies of my medical record for purposes of treatment, payment and medical center operations as described in our Privacy Notice. I acknowledge that I have been offered the Penn State Milton S. Hershey Medical Center Privacy Notice. Signature of Patient or Patient's representative Print Name /- 1'7 -67 Date Relationship to Patient Privacy Notice Offered - Patient Unable to Sign Privacy Notice Offered - Patient Declined to Sign Other DO NOT COPY THIS FORM. ORDER FORMS FROM HMC STORES, CAT. #83012 MR 889 (Rev. 3/04) PF-NNSTATF- 1CM W iViilton a Hiersliley Medical Center C+ouege of Medicine Penn State Milton S. Hershey Medical Center Tel: (717) 531-8055 Penn State College of Medicine Health [nfonnation Services, HU24 500 University Drive P.O. Box 850 Hershey, PA 17033-0850 Patient Name: FICKES, STORM M Patient Sex: Male Patient Location: UREH, , Visit Type: Clinic PSUHMC MRN: 1066842 Date of Birth: 4/4/1998 Visit Number: 07885259 1 O u t p a t i e n t N o t e D o c u m e n t Final Document Electronically Signed by: per contribution per contribution Signed By: Segal, Lee S (1/18/2007 7:25:28 PM); Heaston, Daniel R (1/18/2007 2:03:15 PM) OUTPATIENT NOTE Name: FICKES, STORM M EMC Number: 1066842 DOB: 04/04/1998 Date of Service: 01117/2007 Chief complaint is left femur fracture. HISTORY: Storm is a 9-year-old who sustained a left distal femur metaphyseal fracture on 11/26/06, was treated with open reduction and internal fixation with lag screw and bridge plate on 11/27/06, now returns to clinic. He has been nonweightbearing in a long-leg cast. He has had no problems with the cast. His pain is well controlled. PHYSICAL EXAM: Cast taken down. The patient was awake, alert, in no acute distress. Skin is intact. Incision site is healing well without erythema or drainage. He is neurologically intact distally in all motor and sensory nerve distributions with 2+ pulses, brisk capillary refill. He is very stiff about the knee with range of motion. He has pain to palpation right over the fracture site. X-rays taken today demonstrate appropriate position of the fracture site. There is no backup, breakage, or loosening of hardware or screws. There is abundant callus formation on both AP and lateral views. There is still fracture line present and visible. ASSESSMENT AND PLAN: Status post ORIF of left distal femur. We will discontinue his cast today starting with physical therapy for range of motion, gait training. He should maintain his nonweightbearing status. We will see him back in 3 weeks with repeat x- rays of the left knee for comparison and possibly advance his weightbearing status at that time. All questions and concerns were answered. Date Printed: 11412008 Time Printed: 1:42 PM Nrdton ley Mxffcal e1C + odege of Medidne Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 1 O u t p a t i e n t N o t e D o c u m e n t Final Document Electronically Signed by: per contribution per contribution Signed By: Segal, Lee S (1/18/2007 7:25:28 PM); Heaston, Daniel R (1/18/2007 2:03:15 PM) 87284 Review/Sign: Daniel R Heaston, MD Review/Sign: Lee S Segal, MD DRH /CO DD: 01/17/07 DT: 01/18/07 06:58 Date Printed: 11411008 Time Printed: 1:41 PM Atari & HersW Medical C:wter College of WkWe Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 M u s c u I o s k e I e t a I - S t u d y Final X-RAY FEMUR LEFT - PEDS PATIENT NAME: FICKES, STORM M PATIENT MRN:01066842 PATIENT DOB: 04/04/1998 EXAM DATE OF SERVICE: 01/17/2007 EXAM NUMBER: 1780073 ORDERING PHYSICIAN: SEGAL, LEE AP and lateral views of the left femur and long leg cast. Comparison to prior study of December 11, 2006. Fracture Post surgical change of open reduction and fixation of comminuted distal left femoral fracture is seen. Side plate and screws and solitary crossing screw maintain the fracture in satisfactory position and alignment. There is increased callus and no evidence of complication. Impression: Further healing at the comminuted distal femur fracture status post open reduction and fixation DICTATED: BOAL, DANIELLE REVIEWED AND SIGNED: BOAL, DANIELLE DATE DRAFTED: 01/17/2007 05:41 PM DATE OF FINAL SIGNATURE: 01/17/2007 05:41 PM Date Printed: 11412008 Time Printed. 1:42 PM PENNSTATE ® Milton S. Hers Medical Center College of Medicine PROGRESS REPORT 1 NAME: FICKOSTORM MD: SEOAL LEE MRN: 1088842 DOB: 04/04/1998 INS: AUTO INSURANCE LOC: UREH OOSN: 7885259 MDN: 24480 SEX: M STANDARD VISIT DATE: 01/17/2007 MR 6 Rev. W01 IIIM1111IIIIII11111IIIIIII PROGRESS REPORT x'; ..... FEIN • - 15se?bner BEAM= 3i7ce.rt??aLD . • ,. lif?InMiegnr?i Pedtatrk 1Van?er3• . Mad V A4 Mdw{rF4afr, ?a Tdid M7)014= IN - Oshn-,a® snodtaekaw ee?aar?..?? Apod?gNkrss . 1<ofa?reAWta,EN,'allK AmedGiBNwrt . ?ieGendai TWo MM 83>4194 JwrroorNMMnMA Milfoa 8. Me k C7etStet Pawn SUM Milwn !L Hcehq Modica) C=dw e aaT* P.O. Naa usik Hq*c% PA 170334E50 (717) 5318321 PCSZwjr- NAMB?Z' V IO+ LOnx DoB . HT WT ADDRF•SB DA79 MIERTNO.04 !J;;. ALLB OM 1NDIG IMN ® I? All Rawc?iptioM r3Qc'•P ovzve- CJ?:a Les s. soo-A MJ). NAIWH (M w PrW) M.PMA SUBSTPPtTJ IM PIAMS8 KOJDA. MD?Q43237-6 At ORDOR R* A BRAN KAMB PRWUCTTO std DIS1'RIVm THE WV"NSA _.? PSIMMOM MU*r HANDWRMDRAND MCLUARr OR WLAND b=JCALLY NBCBSWY V IN THL3 VACK BOWW. A6.A. Ith](1. N4, This tax (Iftmt lp aorr)r auadnns o aglteltib b'Ifalri?lat5 inE wkw for a aped?lc mw be PdWk*4 owdkWnW.gr al am , ft m d ae p itl ? s oaappftbitr law. AM i?pp?opt,I uao,•d obOx or ?pYh9 of tMs iax is ?CgY pttattpthd and rtggr slrpject you to aahtdnal.ot' ctvA pstm*. If you hawr rwWwd V* hi WW, A6Ma MWO to am** 1 I401-asflQ ails ww ao va can wwVs for mb= ar da tuc don of Von doo mtwft .: tic • • ai ?, • • ************************************************************************ Header Page Patient Name: FICKES, STORM M Date of Birth: 4/4/1998 12:00:00 AM Medical Record Number: 1066842 Financial Number: 07979812 Admission Date: 2/8/2007 1:02:06 PM Discharge Date: 2/9/2007 11:59:59 PM Patient Type: Clinic Facility: HMC Patient Location: HMC UREH Destination: Hershey Medical Center Reason: Legal Requester: Hershey Medical Center Date and Time Printed: 1/4/2008 1:41:36 PM Printed By: Twigger, Barbara Device: HISU30006 Milton & Her6.TMW1'cal meter Q &p of Hied dne Patient Name: FICKES, STORM M Patient Sex: Male Patient Location: UREH, , Visit Type: Clinic Penn State Milton S. Hershey Medical Center Penn State College of Medicine Health Information Services, HU24 500 University Drive P.O. Box 850 Hershey, PA 17033-0850 PSUHMC MRN: 1066842 Date of Birth: 4/4/1998 Visit Number: 07979812 Tel: (717) 531-8055 O u t p a t i e n t N o t e D o c u m e n t Final Document Electronically Signed by: Segal, Lee S 2114/2007 3:05:03 PM OUTPATIENT NOTE Name: FICKES, STORM M HMC Number: 1066842 DOB: 04/04/1998 Date of Service: 02/08/2007 Storm now returns for followup 2 months status post ORIF, left distal femoral metaphyseal fracture with cast removed three weeks ago. Radiographs revealed further interval healing. Plan now is to begin and progress to full weightbearing as tolerated. We had started physical therapy 3 weeks ago for range of motion and strengthening only. Plan at this time is to see Storm back in 6 months. Return to clinic at that time, x-rays, AP and lateral of the left femur. Do not anticipate any problems in the future. Would consider hardware removal only if clinically indicated or if symptomatic. 44873557 CC: Byung D Chang, MD PO Box 356 106 Center Drive New Bloomfield, PA 17068 Review/Sign: Lee S Segal, MD LSS /CO DD: 02/08/07 DT: 02/13/07 10:26 Date Printed: 11412008 Time Printed: 1:41 PM PENNSTATE 0 • Milton a Hershey Medical Center College of Medicine Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 M u s c u I o s k e 1 e t a I - S t u d y Final X-RAY KNEE 1-2 VIEWS LEFT - PEDS PATIENT NAME: FICKES, STORM M PATIENT MRN:01066842 PATIENT DOB: 04/04/1998 EXAM DATE OF SERVICE: 02/08/2007 EXAM NUMBER: 1818029 ORDERING PHYSICIAN: SEGAL, LEE AP lateral view of the left knee. Comparison to prior study of January 17. A year-old status post open reduction and fixation of distal femoral fracture. Now out of cast Side plate and screws traverse the mildly comminuted distal diaphyseal fracture in satisfactory position and alignment. There is further bony bridging and callus formation at the fracture site. No complications noted. Surrounding soft tissues are normal. Impression: Satisfactory position alignment and further healing status post open reduction and fixation of distal femoral fracture. No complications noted DICTATED: BOAL, DANIELLE REVIEWED AND SIGNED: BOAL, DANIELLE DATE DRAFTED: 02/08/2007 04:08 PM DATE OF FINAL SIGNATURE: 02/08/2007 04:08 PM Date Printed: 11412008 Time Printed: 1:41 PM PENNSTATE Milton S. Hers Medical Center College of Medicine PROGRESS REPORT NAME: F;Mftk STORM MD: SE MRN: 10 DOS: 41W,996 INS: AUTO INSURANCE LOO: UREH OOSM: 7979812 MDM: 24460 SEX: M STANDARD VISIT DATE: 02/08/2007 MR 6 Rev. 6101 (il i mil l imi ll illi PROGRESS REPORT • Header Page Patient Name: FICKES, STORM M Date of Birth: 4/4/1998 12:00:00 AM Medical Record Number: 1066842 Financial Number: 08526786 Admission Date: 8/16/2007 11:09:30 AM Discharge Date: 8/17/2007 11:59:59 PM Patient Type: Clinic Facility: HMC Patient Location: HMC UREH Destination: Hershey Medical Center Reason: Legal Requester: Hershey Medical Center Date and Time Printed: 1/4/2008 1:40:22 PM Printed By: Twigger, Barbara Device: HISU30006 PENNSTATE Milton S. Hershey Medical Center. 10 College of Medicine PROGRESS REPORT • • 1-1 NAME: FICKE8, STORM M MD: SEW LEE MRN: 1088842 DOB: 04/04/1908 INS: BLUE CAM OUT OF LOG: UREH WOO : 8528788 MOO: 24480 SEX: M SOS W/ALPHA VISIT DATE: 08/18/2( MqR, 8 Rev. g g/01 page 1 OF 2 PROGRESS REPORT IIIINA11111I Mon S. I shey hleWcal (;en W College of Wd%ine Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 M u s c u I o s k e I e t a I - S t u d y Final X-RAY FEMUR LEFT - PEDS PATIENT NAME: FICKES, STORM M PATIENT MRN:01066842 PATIENT DOB: 04/04/1998 EXAM DATE OF SERVICE: 08/16/2007 EXAM NUMBER: 2147551 ORDERING PHYSICIAN: SEGAL, LEE STUDY: Three views of the left CLINICAL HISTORY: 9-year-old male with a left distal femur fracture COMPARISON: Multiple films, most recent 2/8/07 FINDINGS: Again noted is a malleable plate with multiple screws in the distal left femur that are unchanged in position without evidence of hardware loosening, infection or failure. When compared to the most recent film dated 2/8/07 there has been significant interval healing of the comminuted distal femoral fracture. Callus has been resorbed, the bone has been remodeled and distinct fracture lines are no longer visualized. The distal femur is anatomically aligned. Femoral head is seated well within the acetabulum. There is mild muscle atrophy noted. IMPRESSION: 1.) Significant interval healing of the distal femur fracture with anatomic alignment and no evidence of hardware complications. Dr. Keith C. Kaplan is the dictating resident. Attending radiologist signature indicates review of both the images and the report and that the attending radiologist agrees with the interpretation. Preliminary reports may not have been reviewed as yet by the attending radiologist. DICTATED: HULSE, MICHAEL REVIEWED AND SIGNED: HULSE, MICHAEL DATE DRAFTED: 08/16/2007 01:51 PM DATE OF FINAL SIGNATURE: 08/16/2007 07:40 PM Date Printed: 11412008 Time Printed: 1:40 PM PENNSTATE 0 0 Milton & Ekshey? Medical Cater Call of bledidne Patient Name: FICKES, STORM M PSUHMC MRN: 1066842 1 O u t p a t i e n t N o t e D o c u m e n t Final Document Electronically Signed by: Segal, Lee S 8/19/2007 9:28:27 PM OUTPATIENT NOTE Name: FICKES, STORM M EMC Number: 1066842 DOB: 04/04/1998 Date of Service: 08/16/2007 Storm now returns for followup 8 months status post ORIF left distal femoral metaphyseal fracture. He has done well, played baseball. Has normal range of motion, full quadriceps strength. Equal leg lengths. Plate is asymptomatic. Incision is well healed. Plan at this time, we will see the child back as needed. I would only remove hardware if symptomatic. All questions were fully answered. 461461 Review/Sign: Lee S Segal, MD LSS /CO DD: 08/16/07 DT: 08/18/07 09:06 Date Printed: 11412008 Time Printed: 1:40 PM • L` Ex ?+, bi t E JAN-26-2007 FRI 09:28 AM FAX N0, r. uiiul %W irst Clio ke .MID - iLkehabilitation INITIAL EVALUATION tlownilkna la 2 Kacq CL. S. 101 MetAtallwAug, PA 17066 991-1607 - Pala B91-1804 MW 1790 old 71a11 Rd., s. r ERm. PA 17319 WA-0554 - mIn 932-10W N;difa 565. Nvaad. }kdifhs. PA 17032 9964598 - F7x1 996.6785 r1 11. 2tdbfter 8L tlanaver, PA 17331 M3-2526 - FAM 03246M HnrrbU4y s99 S. ArlbWa Ave. "Antebwtl, PA 17109 667.8740 - Fast 657-6267 LON1110n 912 AusaeA Dr. Lebanon, PA 17042 274-3298 - Fast 274-2300 Lemoyne 55D N. 12" 3L Lmoyae, PA 1?043 737.9910 • Fax 737-2ets Llntda19zm i ?Quw lm. ..ru% PA 17112 920-5002 - P9ta 920-8e24 :Nacnar "bunt 3 loan Pot"a Lnn & 3 MehanlCv1M% PA 17050 79o,5404 • Faze 790-5409 Navgmtt 32 W. Shari t Nd. NmvpoM PA 17074 W.9954 - Fro; 061-9975 Pladnom 70161annowa ad, Hnnlt,ima PA 17112 579.7525 York 3323 »1fllda ad., 9, 6 York PA 17409 T794262 - Mo 779-WW2 DATE: 1-19-07 PATIENT: Storm Flakes DATE OF BIRTH: 44-98 PHYSICAL THERAPY DIAGNOSIS: Left Femoral Fracture with OR1F 12-1-06 PHYSICIAN: Dr. Segal cc: Dr. Chang DATE OF INITIAL EVALUATION: 1-19-07 • -PROBLEM- LIST/FUNCTION-AL MMITATIO 1. Hip Functional Scale 80% (Normative 100%) 2. Knee Functional Scale 480A (Normative 100%) 3. Ambulates NWB with crutches 4. Knee AROM: 15 =50° 5. Swelling Midpatellar Girth R/l. 30.0/31.0 cm. 6. Strength; Deferred TREATMENT PLAN: 1. Modalities 2. Thar Ex 3. Manual Therapy Short Term Goals (in 4 weeks): 1. Improve Hip Functional Scale to 700/16. 2. Improve Knee Functional Scale to 90"1x. 3. Improve Knee AROM trh 0°-95°. 4, Increase Strength to within 75% of opposite side. Long Term Goals (in 8 weeks): 1. Improve Hip Functional Scale to 100%. 2. Improve Knee Functional Scale to 100%. 3- Improve Knee AROM to 0°-140°. 4. Increase Strength to within 100% of opposite side. FREQUENCY/DURATION: 3 times. per week for # weeks IIL63au-r. , P.T. Signature Physician Slgntatu Please sign tend return to our office. Should you ha free to. contact our Newport ofFlce. This patient's t •- -4 10?i' 'g +a-- nD ECLrnpyfPJ v 1/124/0 7 any questions or further recommendations, please feel nplete evaluation form is available to you upon request. 32 W. Shortcut Road • Newport, PA 117074 - Phone: 567-9954 • Fax: 567.9975 Albut4l # E SIGN ATUR P GR?PTIONlQpILY NOTES pTIENT NAME pES ATE ? ? ? f ?! 1-2-S Gn j her (?U(` mob. ?l -1v -I i 2 Pte---- C`? ' 4-:e I v N ) '4- t ?T P•G• Rehabilitation Specialists, First Choice a PATIENT NAME .5?? -?Svt ACONT # DATE DESCRIPTION/DAILY NOTES SIGNATURE a bl on 1L. o-)?-(-C? C?-DQ4 hul -?-anw2c "rlw-\ *..i Gam. ?i C7 •--? acS 8..,o r nh S / a-( G AJo fi r s CE" se. "?2:? First Choice Rehabilitation Specialists, P.C. PATIENT NAME S]?Z& -ri GK Q S A&UNT # L ?`L 7 S DATE DESCRIPTION/DAILY NOTES SIGNATURE r r 'r r Z1144 4anLO)-f Z-7 -4- nL ` r - . 0 5?JP4--Q '-n 4?? r r icy f ( c ?(i , PC- e 41ebrq P-6 r CL C U ?- L J First Choice Rehabilitation Specialists, P.C. • Virr&Uhoice ch-albgllitation vAPeCILMILSts •t o4LQ4M--- rp-, G ?[??d?J 3?; lu'1 PROGRESS NOTE: awm m ddc DATE: 2-21-07 a 1W a.,& 1D1 PATIENT: Storm Fickes DATE OF BIRTH: 4-4-98 mwtwajco S PA Jim" PHYSICAL THERAPY DIAGNOSIS: Left Femoral Fracture with ORIF 12-1-06 591-1w' - 1?0 5m-lm PHYSICIAN: Dr. Segal cc: Dr. Chang DATE OF INITIAL EVALUATION: 1-19.07 rlaar. IM01dTaIlA.&F NUMBER Olt VISITS: 10 Bum, PA 17319 + • rm 933-10110 TREATMENT PLAN (CURRENT): 1- Thar Ex H' " s6 s. allver aa, PROBLEM LIST/FUNCTIONAL LIMITATION STATUS: fWj1r.PAI== Initial Evaluation: Currant: E95-saws! - rax, 004706 1. Hip Functional Scale 80% (Normativs• 100%) 1. Hip Fupct(Qnal Scale 100%. (Notmadve.1001%) Z..Knee Functional Sole 48°/s (Normative 100%) ' '72. Knee Functional Scale 9896 (Nonnative 100%) flamom 3. Ambulates NWB with crutches 3. Ambulates without assistive device 1 too W4tdboqW 4. Knee AROM: 15°-500 4. Knee AROM: 10 =1400 ? F? aa?-save S. Swelling Midpwallw Girth RJL 30,0/31.0 cm. 5. Swelling Midpatellar Girth R/L 30.5/31.5 am- 6. Strength: Deferred 6. Strength: lueumms Quadriceps mm force R/L 18,6116.4 kg, - 12% deficit Mhoun Ave. (with complaints of left knee pain) 1 M 17109 Hamstring mm tbrca R/L 8.6/8, l kg. 45670 ' F°" 457-dW Hip ABD mm force R/L 7.2/6.6 kg. Ldwon 7. Step Down Failure Ted R/L 9/6 inches %2 %and 9k. 8. LE Anterior Reach Test R/L 24/17 Inches L keftn,141 Ina ? i 274.22" • Flu 474-2M 'Short Term Goals: 1. improve Hip Functional Scale to 7090 - Met 660 N. 12'" st 2. Improve Knee Functional Scale to 90% - Met lam", PA 1704±1 3. Improve Knee AROM to 0'1 9-W - Partially Met 737-ams - Fax, 757 .uja 4. Increase Strength to within 75`3`4 of opposite side - Met Long Term Goals: 1. improve F?1R Functional Scale to I QQ% - Met no?er>za. 2. Improve Kn6 Functional Scale to 1006/o - Partially Me I NA " °f.. `_a 3, improve Knv* AROM to 00A W - Partially Met ! H - ! , 4. Increase Strength to within 100% of oplimbe'side - Partially Met Mechanaclbneg 3 aaram F9WC 1 W 5.a -Coma+eatr: Rewmmen4 continuing physkal,dmVy to conaenimto on weight-bearing umngthening. melf"10 102. PA 1790 LL 7?o-s1o? • rues 790.5496 FREQUENCY/DURATION: 3x%wk for4 weeks ' uaa2 sbafta Piculae sign atld return to ourpfface, Should.yuu have any questions or tlrrther recommendations, please to WPWI rA 1701+ feel *w.tQl;ontaet our Newport office. Ills patient's complete evtaluation forth is available to you upon 567.9954 - Fat: 567-9M request, 121num 7018 jmmm n PA ; a Naullebury, PA 17112 r 579-7519 P.T. Signaats dock 2511 Cadwe A4,15 Wk, PA 174M 779-at11A • F?aa 774.0612 4 Physician Sign t . pate 32 W. Shortcu Road • Newport, PA 17074 • Phone: 567-9954 • Fax: 567-9975 PATIENT NAME V? f-;' C65 ANT # (o DATE DESCRIPTION/DAILY NOTES SIGNATURE -3-5-0-7 S: 's dad cs - da ? a s+oro ? f 1), u - k 4 7) 1 t s r i- r A Azv r City 'In I "A '01 ?. r r r N?^ v( r ®? - - - :b?& A - 1 1 - o J... '1A r r D AA First Choice Rehabilitation Specialists, P.C. PATIENT NAME qOUNT#_ 1 657 ?-?5- First Choice Rehabilitation Specialists, P.C. WFirst Chollc* Re1L'1La illif&fion Upecialists • =W-I06b84a- VIED-, B01Mne"sdale 2 xa«y CL, s. lol PROGRESS NOTE: Mechancsburg, PA 17055 DATE: 3-21-07 591-1807 - Fax: 591-1809 PATIENT: Storm Fickes DATE OF BIRTH: 4-4-98 PHYSICAL THERAPY DIAGNOSIS: Left Femoral Fracture with ORIF 12-1-06 Etters PHYSICIAN: Dr. Segal cc: Dr. Chang 179oold7tailRd.,S.F DATE OF INITIAL EVALUATION: 1-19-07 Etters, PA 17319 938-0584 - Fax: 932-1062 NUMBER OF VISITS: 18 Halifax TREATMENT PLAN (CURRENT): 1. Ther Ex 36 S. River Rd. Halifax, PA 17032 PROBLEM LIST/FUNCTIONAL LIMITATION STATUS: 896-8898 - Fax: 8%-8785 Progress Report 2--21-07: Current: Hanover 1. Hip Functional Scale 100% (Normative 100%) 1. Hip Functional Scale - Not Tested MEkhelbergerSL 2. Knee Functional Scale 98% (Normative 100%) 2. Knee Functional Scale 100% (Normative 100%) ier, PA 17331 3. Ambulates without assistive device 3. Ambulates without assistive device 6o2-2526 - Fax: 632-2506 4. Knee AROM: 10°-140° 4. Knee AROM: 10°-140° Harrisburg 5. Swelling: Midpatellar Girth R/L 30.5/31.5 cm. 5. Swelling: Midpatellar Girth R/L 31.0/31.0 cm. 899 S. Arlington Ave. 6. Quadriceps mm force R/L 18.6/16.4 kg. - 12% deficit 6. Quadriceps mm force R/L 23.7/21.3 kg. - 10% deficit Harrisburg, PA 17109 (with complaints of left knee pain) (with complaints of left knee pain with quadricep 657-8240 - Fax: 657-6267 Hamstring mm force R/L 8.6/8.1 kg. insertion and just distal)) Hip ABD mm force R/L 7.2/6.6 kg. Hamstring mm force R/L 12.4/11.3 kg. on Lebanon 912 Russell r. 7. Step Down Failure Test R/L 9/6 inches Hip ABD mm force R/L 12.0/13.9 kg. Lebanon PA 17042 8. LE Anterior Reach Test R/L 24/17 inches 7. Step Down Failure Test R/L 9/9 inches 274-2298 - Fax: 274-2398 8. LE Anterior Reach Test R/L 25/24 inches Lemoyne Short Term Goals: 550 N. 12-' SL 1. Improve Hip Functional Scale to 70% - Met Lemoyne, PA 17043 2. Improve Knee Functional Scale to 90% - Met 737-9818 - Fax: 737-2815 3. Improve Knee AROM to 0°-95° - No Progress Linglestown 4. Increase Strength to within 75% of opposite side - Met 2200 Dover Rd. isburg, PA 17112 Long Term Goals: .-0-5002 - Fax: 920-5224 1. Improve Hip Functional Scale to 100% - Met 2. Improve Knee- Functional Scale to 100% - Met 3 Baden F Powell owel Ln., S. 3 3. Improve Knee AROM to 0°-140° - No Progress 3 Eid Mechanicsburg, PA 17050 4. Increase Strength to within 100% of opposite side - Met 790-5404 - Fax: 790-5406 Comments: Patient discharged with HER Newport 32 w. shortcut Rd. Please sin and return to our office. Should ou have an questions or further recommendations, please Newport, PA 17074 g y any 567-9954 - Fax: 567-9975 feel free to contact our Newport office. This patient's complete evaluation form is available to you upon request. Platinum 7015 Jonestown Rd. Harrisburg, PA 17112 579-7525 York P.T. Signature 2323 Carlisle Rd., S. 5 York, PA 17408 779-0252 - Fax: 779-0512 Physician Signatur Date 32 W. Shortcut Roiy - Newport, PA 17074 - Phone: 567-9954 - Fax: 567-9975 FIRST CHOICE REHABILITATION SPECIALISTS D?fianf 1 `)1)I' AW at, 1 W007 Account # 1 /? /(_]' I lD`rt' I- Trea ment # 1 2 3 4 5 6 Date 1 )19 10 1 II?D 2 "v Eval/Reeval/time 1 1 1 mi l - Ultra Sound Cont/Pulsed Httz/Intensit / l E-stim/type settin s lea (? lop 1 /©0 too L o s 1 S*- .WA 34 h0q-) 3-& I-20,?, '34 3ML i 3'0k 10 /To ? 30 hl jl V,/) C 'IS jg: 0-0 5d. lVh/ • e. Z^ P401ti+6_4 ?rvnn RpY+??YI s a s,v '" mnot ?t?? ? 1/ ? Fac ??? S C ,. L• u ?C a- '?,? law ?? p ? e• LIE code and time sc) 13?3 -30 /?t) code and time ( 1 U 10 code and time code and time total Rx time 1 40 1 An 0 Initials i N/C/I N/C/I 0/0/0 = re sets/resistence 01 N/C/I v = same as pre ions date FI T CHOICE REHABILITATION SPE LISTS Patient .qT U r mW::- (- e c, Ye P oo-7 Account # ( b 47S- Treatment # 1 2 3 4 5 6 Date - - '?o-OZ 1 O Eval/Reeval/time Ultra Sound Cont/Pulsed Hrta/intensit 1 E-stim/type settin s (00 . 100. b o. 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GENERAL RELEASE AND INDEMNITY AGREEMENT FOR MINOR'S CLAIMS CLAIM NO.: 06-00461010 KNOW ALL MEN BY THESE PRESENTS: WHEREAS , on or about November 26, 2006 an event occurred, resulting in bodily injuries to Storm Fickes a minor, 8 years of age, herein referred to as the minor, and: WHEREAS, claims are made for money compensation for such injuries by the Undersigned, for themselves and as parents, guardian, or next friend of the minor (the minor and the parents of the minor, for themselves and as guardian or next friend, being herein referred to as the claimants) and, whereas a dispute has arisen with respect to the legal liabirdy for such injuries, said liability being expressly denied: NOW, THEREFORE, the claimants in full accord and satisfaction of such disputed claims, do hereby acknowledge the receipt of the sum of Yen Thousand Dollars Dollars, ($10,000.00), and, in consideration thereof, the claimants do hereby remise, release and forever discharge William Fickes AMERICAN INTERNATIONAL SOUTH INS. CO., _ Its successors and assigns, and/or his, her, their heirs, executors and administrators, and also any and all other persons, associations and - ---corf+oratmns, whrstierherein rtam d toru?-no rid wrt? e'trfAf'riritii ie one o?i4fbTe persons arid7o- en Mig spec r-f'cally named - above, may be jointly or severally liable to the claimants herein, of and from any and all claims, demands, rights and causes of action of whatsoever kind and nature arising from, and by reason of, any and all KNOWN AND UNKNOWN, FORESEEN AND UNFORESEEN bodily and personal injuries, damage to property, and the consequences thereof, which heretofore have been, and which hereafter may be, sustained by the said minor and by the said claimants and by any other person or persons having a legal interest therein in consequence of such event and injuries, and: FURTHERMORE, The Undersigned parents, guardian or next friend of the minor do hereby expressly stipulate and agree, in consideration of the aforesaid payment, to indemnify and forever hold harmless all released hereby, its successors and assigns, and/or his, her, their heirs, executors and administrators against loss from any and all further claims, demands and Actions in law or in equity that may hereafter at any time be made or brought by the said minor, or by anyone on behalf of said minor, for the purpose of enforcing a further claim for damages on account of the injuries sustained in consequence of the aforesaid event, and the parents, guardians or next friend hereby waive any and all Fights of exemption, both as to real and personal property, to which they may be entitled under the laws of this or any other state as against such claims for reimbursement or indemnity. It Is also agreed that those who are hereby released. shall not be estopped or otherwise barred. from asserting arid. expressly reserve-the light to assert any claim.or cause of action they may have. against the. claimants or any others. IN WITNESS 'WHEREOF, the hand and seal of the Undersigned is set hereunto this day-of Witness: Address: Witness: X Address: - - S."ala aE • SS County of x SRS of k w"di= of NM FMnd Address fo L R? 4 ?(rncr,?n ?'lQ r2 1.7 0 d6 X 9 IMTUR6 A,ddmss:gQ 1-4 vks? But ? • • zIuno4ni on P4 t 10A0 On this day of .20 , before me personalty appeared to me personally known, and known to be the persons individually or jointly described in and who executed the above instrument and who ,acknowledged to me the act of signing and sealing thereof. ANY PERSON WHO KNOWINGLY AND WTTH.INTENT TO DEFRAUD ANY INSLIKANCH, 0R-UTHER PERSON FILLS AN APPLICATION FOR INSURANCE OR STATEMENT 056L?rW.CONTAINING ANY MATERIALLY FALSE•TNFORMATION OR CONCEALS FOR T iE PURPOSE OF MISLEADING, ENFbRMAM CONCERNING ANY FACT MATERIAL THERRTO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME"AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. A1G for AMERICAN INTERNATIONAL SOUTH INS, CO. CL9197 P".7173 A31 0 0 State Fannin gun rA?r Providing Insurance and Financial Services Home Office, Bloomington, Illinois 61710 ?N.YIANt? May 27, 2008 ACCENT ATTN LORI REANEY PO BOX 69006 OMAHA NE 68106 RE: Claim Number: RE: Insured: Date of Loss: Dear Ms. Reaney: 18-8979-555 4721 Storm Fickes Kenneth Lynch November 26, 2006 • Concordville opwAom Center One State Farm Drive PO Box 142 Co mrdvillle, PA 19331-0142 This letter will confirm our conversation of May 23, 2008, whereby you indicated that Accent on behalf of Blue Cross/Shield will not be asserting their lien of $11,275.65 for medical payments made for Storm Fickes. You also indicated that your file would be closed. We will move forward with our court approval. Sincerely, Terry Calloway Claim Representative 888 713 4694 ext 743 5868 State Farm Mutual Automobile Insurance Company 28/735/ 527015 cc: Attorney George Eager Eager, Spinello, Quinn & Stengel 1347 Fruit Pike Lancaster, PA 17601 •' - •• ?X??b;t N w:.f !:1 rr 3:. 3. t: ?., Ici RZ th L? f/ S S 0 v^ t;?e I 69 F 7 0 a z W ?. W m w LL cc J U o a z L-i LU ~ w Z w w C ? o a ;P. I-! s ltl ? x IL F- W .Jzz 3v 0 fi ..•-E".FL" i z ' z CC z w N r•-F ;? 4 0 ( L _ L Z O C=; x a C l ....' Y` .... H 2 w Z > 0 0 0 O w w U I I w w Q L? J d a 0 0 W V W ?• U aj z a J ?. W ' a m Q Z v _a n. y .r' p W x U O F- W U W O f? 6 U rF }. N ~ J L; o Z '' 0 f O F- IL a t i u iii. y, U a t? Z U1 ° •r W T `_' w 0 W C7 'ti F O Z Q x ti Z U i ?i u:! ht4 Q Z Q !:. v z ?. : ? U Z 4 .?... w J e . ? ?: i.J i 1.:5 z V Q ° \:D wJ m 3G .i0 Lin i. a VI 0 t w i 4 ?• • i•-•i x-2 Wr Qf , LJ "'z J %'' I <WLi Li CC 03 CtJ _?.. ...: Y v. :Z t T" i7.3 y•,? ii.. W W _ a '•J :.+.. ?.,., ? •,w tr U ?.. o i. M O a c 5 , C a $ 3 w y, U ? j 9 Z C C = d H aZ E 0 E E 0 6 0 b C C R Cp?_ SC C y? T .C y r 0 s a V LU W CL 5 a O LO d R -+ a 16 C p a ?o 3 C d }!1 µ9 C. V 1? Y nr IC L°t ra ? ?-+ i ? ` n r ?t -r^'t Z C.? Q • M A ? A ? d .3 4 v w I?JJ `r'}' G Q a V Z s ? ?" 4 t^t d O Q W S. a W z r r Q 60 . W ul s ,?, ??•TT? C o U O• O )' O Q Lull a h ? ?f3i a j ?./ u W ?S"• F? w 4 . 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W ' -43 N N ?? y-k ?.. r y W f... c:.: • E?xb,d t Z • RELEASE For the Sole Consideration of is EIGHTY-ONE THOUSAND, THREE HUNRED DOLLARS AND FIFTY-TWO CENTS ($81,300.52), the receipt and sufficiency whereof is hereby acknowledged, the undersigned as a parent and natural guardian of Storm Fickes, hereby releases and forever discharge Sandra Lynch, her heirs, executors, administrators, agents, and assigns liable or, who might be claimed to be liable, none of whom admit any liability to the undersigned but all expressly deny any liability, from any and all claims, demands, damages, actions, causes of action or suits of any kind or nature whatsoever, and particularly on account of all injuries, known and unknown, both to person and property, which have resulted or may in the future develop to Storm Fickes from an incident which occurred on or about the November 26, 2006, at or near the intersection of East Simpson Street and South Market Streetin Mechanicsburg Borough in Cumberland County, Pennsylvania. The Court Order in the Minor's Compromise Petition permits this Release to be signed by the parent and natural guardian of the above named minor plaintiff. This release expressly reserves all rights of the party released to pursue her legal remedies, if any, against the undersigned, their heirs, executors, agents and assigns. It is understood that this release and any payment made pursuant thereto is a compromise settlement and not an admission of legal liability and this settlement is being made merely to avoid the expenses of litigation. Undersigned hereby declares that the terms of this settlement have been completely read and are fully understood and voluntarily accepted for the purpose of making a full and final compromise adjustment and settlement of any and all claims, disputed or otherwise, on account of the injuries and damages above mentioned, and for the express purpose of precluding C7 • forever any further or additional claims arising out of the aforesaid accident. Undersigned hereby accepts draft or drafts as final payment of the consideration set forth above. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or a statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. In Witness Whereof, has set their hands and seals this day of , 200_ In presence of: Witness Signed: X VViIliam Fickes, P/N/G of Storm Fickes Address Irj N Pl T iF,' SEP 3 0 2008 ORIMUL IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHAN'S COURT DIVISION STORM FICKES, a minor, by his parent and natural guardian, WILLIAM FICKES, C Plaintiff NO.: V. ?- -- 1, SANDRA LYNCH, Defendant ORDER AND NOW, this of 2008, upon consideration of Plaintiffs Petition for Settiment of a Minor's Claim, it is hereby ordered that: This Honorable Court approves the Settlement described in Plaintiffs Petition and authorizes the distribution of proceeds of the Settlement as follows: (a) Payment in the amount of $81,300.52 from State Farm Insurance Company placed in an interest bearing account on behalf of Storm Fickes (date of birth: 04/04/98), a minor, until 04/04/2016 or upon prior Order of Court; (b) Payment in the amount of $10,000.00 from AIG Insurance Company placed in an interest bearing account on behalf of Storm Fickes (date of birth: 04/04/98), a minor, until 04/04/2016 or upon prior Order of Court; (c) Payment of medical bills from Young's Medical Equipment attached hereto as Exhibit H in the amount of $28.86; (d) This Honorable Court authorizes William Fickes, parent and natural guardian of Storm Fickes, minor, to execute a Release releasing Sandra Lynch (Defendant) and State Farm Insurance Company; and, (e) This Honorable Court orders that the proceeds of the Settlement, except as otherwise provided in the proposed Distribution, shall be placed in a Blocked Account, which deposits are insured by a Federal Governmental Agency and further orders that no withdrawal can be made from such • account until the minor attains the age of 18, exci prior Order of Court. DATED: 10 ' 6 -dg J. t? S"3•? d NUZ z V18 tp IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHAN'S COURT DIVISION STORM FICKES, a minor, by his parent and natural guardian, WILLIAM FICKES, Plaintiff V. SANDRA LYNCH, Defendant NO.: 08-5758 Civil Term PROOF OF DEPOSIT TO THE PROTHONOTARY: Pursuant to the Court's Order, Plaintiff has deposited the settlement proceeds set forth in the Court's Order in a federally insured, interest-bearing account with PNC Investments, Mechanicsburg, Pennsylvania. This Proof of Deposit is attached hereto as Exhibit A and is incorporated herein by reference. EAGER, SPINELLO, QUINN & STENGEL DATE: BY: George H. Eage squire Attorney for Plaintiff I.D. No. 27740 1347 Fruitville Pike Lancaster, PA 17601 (717) 290-7971 ?Xti r 6; ?h ?}- 30 ,% e o. ' V. 2009 3 ; "PM -Zf0,y-9c, 1 ? }? F^rUU?1 ? ? ??PY? ?_an O PFNONVESTMENTs w"ow6ft HILLIARO LYONS CENTER P.Q. Box 32160 Date I L I ?U O , , I gismo, KY 40232 Received of A 6ri of VV? 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