HomeMy WebLinkAbout10-1139
2010 FC3 17 r 1: 28
Cl;v?; ;y
Steven J. Schiffman, Esquire
SERRATELLI, SCHIFFMAN, BROWN & CALHOON, PC
2080 Linglestown Road, Suite 201
Harrisburg, PA 17110
(717) 540-9170
sschiffmanc?r?ssbe-law.com
IN RE:
ANN E. KALFAS, a minor by
BRENDA L. KALFAS and
THOMAS J. KALFAS, her
parents and natural guardians,
Petitioners
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
NO.: 16 - 113T (2-
lot
PETITION FOR APPROVAL OF MINOR'S COMPROMISE
AND NOW, comes BRENDA L. KALFAS and THOMAS J. KALFAS, parents
and natural guardians of ANN E. KALFAS, a minor, by and through their attorney,
Steven J. Schiffman, Esquire and the law firm of Serratelli, Schiffman, Brown & Calhoon,
PC, who files this Petition for Approval of Minor's Compromise and in support thereof,
avers as follows:
1. On or about August 19, 2009, the minor child (hereinafter "Ann") sustained
injuries suffered in an automobile accident and was transported to the Milton . Hershey
Medical Center Emergency Department by ambulance. JQzCEO I?eL
ee-? A19 739
,? z37?Qr
2. According to the accident report, Brenda Kalfas and her daughter, Ann Kalfas
were traveling straight in a turning lane. Vehicle 2 which was driven by Jonathan R. Weirich,
II, was motioned by another stopped motorist to enter the turn lane. Vehicle 2 did not see
Vehicle 1 approaching and struck Vehicle 1 after pulling into the turn lane. USAA is the
insurance carrier for Brenda L. Kalfas. Geico is the insurance carrier for Jonathan Weirich,
II. A copy of the accident report is attached hereto as "Exhibit A".
3. The description of Ann's medical history is as follows:
a. Immediately after the accident, Ann was bleeding from her left naris
and upper gums. She was evaluated and sent for a Facial CT. The CT
scan demonstrated a comminuted nasal spine fracture. Plastic Surgery
repaired the laceration to the gumline using chromic sutures. She was
subsequently discharged and was instructed to follow-up with Plastic
Surgery.
b. On August 21, 2009 Ann awoke with some painful right-sided facial
swelling. She was seen by Dr. Lawrence Kass at Milton S. Hershey
Medical Center who diagnosed normal post trauma swelling. Mother
was provided with instructions and Ann was released.
4. Attached hereto as "Exhibit B" are true and correct copies of Ann's
medical records.
-2-
5. A claim was :made on behalf of Ann by her parents and natural guardians.
6. Geico Insurance Company offered, and Petitioners propose to accept on Ann's
behalf, a settlement in the amount of $15,000.00.
7. Ann was treated for her injuries and was discharged from treatment on or about
August 24, 2009.
8. All medical bills were paid by USAA Insurance. There is no subrogation.
9. The Petitioners are BRENDA L. KALFAS and THOMAS J. KALFAS,
parents and natural guardians of Ann E. Kalfas, whose date of birth is January 21, 1997. Ann
and Petitioners all reside at 350 North 27t' Street, Camp Hill, PA 17011.
10. It is the undersigned's opinion that this settlement is reasonable and in the best
interest of Ann.
11. Petitioners, as parents and natural guardians of Ann, desire to execute a release
to be provided by Geico Insurance. Attached hereto as "Exhibit C" is Geico's letter
confirming the settlement amount.
12. Petitioners intend to place the settlement proceeds in a federally-insured
financial institution in the name of the minor, with the provision that no withdrawals can be
made from such account, except for the payment of taxes, until the minor reaches her
majority.
13. Attached hereto as "Exhibit D" is the proposed distribution of the settlement
-3-
funds.
WHEREFORE, Petitioners respectfully request that this Honorable Court grant their
Petition for Approval of Minor's Compromise.
Respectfully submitted,
SERRATELLI, SCHIFFMAN, BROWN
& CALHOON, PC
Dated:
Steven J. Sd&tman, Esquire
ID No.: 25488
2080 Linglestown Road, Suite 201
Harrisburg, PA 17110
(717) 540-9170
Attorneys for Petitioners
-4-
VERIFICATION
Understanding that the making of any false statement would subject us to the penalties
of 18Pa. C.S. Section 4904, the undersigned verify that the statements made in the foregoing
petition are true and correct, to the best of their knowledge, information and belief.
D
Date THOMAS fiU?F.Ag
2 Z 'l?
Date NDA L. AS
rx? ? A
Print CRS W0121546
COMMONWEALTH OF PENNSYLVANIA
POLICE CRASH REPORTING FORM
Case Closed Reportable Crash
AA'500 1 ® Yes r-1 Nn • Yes n No
Page W0121546
FF]
Page 1 of 7
Crash Number
Incident Number v Police Agency Patrol Zone
09081901 22407 L?
fa 20
Agency Name Precinct Investigation Date (MM-DD-YYYY)
h 08 ° 19 = 2009
ou
t
i B
l
H
or
g
owl
umme
s
g
Dispatch rime (mil) Arrival rime (mil) Investigator Badge Number
Y HB-44
d 1205 1206 OFFICER JARED HENR
12 Reviewer Badge Number Approval Date (MM-DD-YYYY)
JUSTIN D HESS 21 08 ° 30 ° 2009
d County County Name _ Municipality Municipality Name
22 Dauphin 407 ummelstown Borough
I pale of bUeek
O sun O Thu
Q F
i
#11
g Crash Time (mil) No of Units People Injured Killed* *If > 00
Crash Date (MM-DD-YYYY) ?? complete
08 19 2009 111200 t ° - j Form F r
Q Mon
O Tue Q Sat
-Wed Q Unk
workzone (lf Yes, Complete O Yes No School Bus O Yes = No School Zone O Yes 0 No Notify PENNDOTO Yes 0 No
Section 29) Related Related Maintenance
Form M
A ,
Intersection Tvoe q way intersection O "Y" Intersection O MUlti-Leg O Off Ramp O Railroad Crossing ° ecial
O Y Intersection Location
O1
o • Midblock O °T" Intersection (? Traffic Circle! O On Ramp O Crossover O Other
Round About ° Sex ®tmrla
J
to
Route Number Segment (Optional) Travel Lanes Speed Limit O North
.2 2018 03 25 O south
House Number (if applicable)
15 -'?
g
Street Name Street Ending East
°' O West
For Mid-block crashes only. Use
Postal House Number and make sure
e EAST MAIN ST p
Q Unknown Principal Roadway Street Name is
filled in if using this option
g
b
Route
Interstate O Turnpike O Turnpike O State -County O Local Road O Private O Other/
g O (Not Turnpike) (East/West) Spur Highway Road or Street Road Unknown
L Route Number Segment (Optional) Travel Lanes Speed Limit O North
°
F
O South
g d
° Street Name Street Ending a O East
O West
e
w o O Unknown
g `o Route Interstate Turnpike Turnpike State County O Local Road Private Other/
d Signing O (Not Turnpike) O (Easl/West) O Spur O Highway O Road or Street O Road O Unknown
Intersecting Rt Hum Or Mile Post Or Segment Marker
h
O Feet
? 1 5! o Nort
O South 10
u Please
x Enter E St Ending
Or Intersecting Street Name g
3 EAST MAIN ST
O East
O west
Or Miles
E
E,. Information -?
®
e
g for 80TId
p Landmarks
g if Using
This O
tion
Intersecting Rt Hum Or Mile Post Or Segment Marker
c
O
?
North
Distance From Crash
Scene to Landmark 1
r p
$ N
.
0
O South
(For Crash between
a
a d E Or Intersecting Street Name St Ending O East
Landmark 1 and
® j
NOVER
HA
ST Owest Landmark 2)
r Degrees Minutes Seconds Degrees Minutes Seconds
i Latitude: Longitude:
®
O Yield Police Officer or
Traffic Control Device
Sign O
-Not Applicable O Traffic Signal Active RR Crossing Flagman
J C:) O Other Type TCD
TCD functionino
Emergency
No Controls O Improperly evice Functioning O Preemptive
Signal
B U
a Controls
Flashing Traffic
Signal Q Stop Sign Q Passive RR O Unknown
Device Not Device Functioning
O Functioning O Properly O Unknown
Crossing Controls
6 Lane Dosed (if "Not Applicable skip rest of the Lane Closure section) Lane Closure O North Q East O North and South Q All
IN CrMA
® O Not Applicable O Partially W Fully Q Unknown pin O South Q West 0 East and West
3 ?
o
Traffic Yes ft No O
t
ured
L)
Fa MM N c 30 Min. O 30-60 Min. O 1-3 his O 3-6 hrs O 6-9 hrs O> 9 hours Q Unknown
e
o
Unknown Q
FORM # AA-500 (12/02) PENINDOT COPY
Print CRS W0121546
POLICE CRASH REPORTING FORM Page:
AA 500 2 Police U. Only ( '7. I'
W0121546
Page 2 of 7
Crash Number 7
Motor Vehicle in Q Hit & Run Vehicle Q Illegally Parked 0 Legally Parked Q Non - Motorized Commercial Vehicle
Type Transport
c Q Yes 0 No
Q Train 0 Phantom Vehicle
Unit Q Pedestrian Q in Pedestrian Wheelchair, etc Skates, Q Previous Disabled From Crash f Yes, Complete Form C)
(I
e
I (if 'Pedestrian` or "Pedestrian on Skates, in Wheelchair, etc", Complete Form M, Section 28)
MI Date of Birth (MM-DD-YYYY)
Unit No First Name
L? 09 O1 1963
O1 BRENDA
Last Name Tele hone Number
Delete?
ALFAS
Q K
F
Address / City / State Zip
2
1350 N 27TH STREET CAMP HILL PA 17011
Driver License Number State Class
g 20246411
Driver or Pedestrian Physical Condition
AlcohoUDru9s Suspected
- No Q Illegal Drugs Q Medication
® Apparently Q Illegal Drug Q Fatigue Q Medication
Normal
O Alcohol Q Alcohol and Drugs Q Unknown Had Been
0 Sick Q Asleep Q Unknown
0
Drinkin
6
Alcohol Test Type
Primary Vehicle Code Violation Charged?
0 Test Not Given Q Breath 0 Other Q Yes ®No
o,
d Unknown if
Q Blood Q Urine Q Test Given NONE
y Unknown
Alcohol Test Results Q Test Refused 0 Results Driver Presence 1=Driver Operated 3=Driver Fled Scene
Vehicle 4=Hit and Run
Test Given,
Q
? 9=Unknown
i
?
"
Contaminated Results ver
2=No Dr
Owner/Driver 00=Not Applicable 02=Private Vehicle Not 04=State Police Vehicle 07=Municipal Police Veh 09=federal Gov Veh
01=Private Vehicle Owned/ Owned/Leased by Driver 05=PENNDOT Vehicle 08=Other Municipal 98=Other
Other State Gov Veh Government Vehicle 99=Unknown
06
L =
01 Leased by Driver 03=Rented Vehicle
Owner First Name Owner Last Name or Business Name (If Pedestrian, skip this Section)
Same as
Driver Q
KALFAS
BREN
&
THOMAS J
Address / City / State I Zip Vehicle Make *Make Code
51
V
l
vo
o
PA 17011
HILL
CAMP
350 N 27TH ST
Model Year Vehicle Model (see overlay)
VIN
I YV 1TS97D6X1017811 1999 S80
License Plate Reg. State Est. Speed Vehicle Towed Towed By
I FBV4800 PA 999 • Yes Q No MARTINS GARAGE
Insurance Insurance Company Policy No
.2 c
ra =Yes Q No Q Un- USAA 002416283U71076
known
E
2 p
Trailin T e 1=Towing Pass. Veh 4=Mobile/Modular Home 7=Semi-Trailer Tag No Tag Tag ?
5=Camper 8=Other
of
2=ToA,ing Truc
Unit No
np
C k
.
t ?
U
Trailing J 3
Trailer 6=Full Trailer 9=Unknown
Utilit
T
i
?
° ng
y
ow
=
J
Units:
v
? -
; Direction of *Vehicle Position
r04
*Movement 01 *See
Overlay
Special Usage
rave L l
2
O
Vehicle Color Vehicle Type 05=Large Truck 20=Unicycle, Bicycle, a
1
O
Passenger
06=Yellow
07 07=Silver 01=Automobile 06=SUV Trincle
01 02=Motorcycle 07 =Van 21=Other Pedalcycle
se & Bu
22
H
l
00=Not Applicable Carrier
01=Fire Veh 13=Taxi
08=Gold ggy
or
=
e
03=Bus 10=Snowmobi 02=Ambulance 21 =Tractor Trailer
01=Blue 09=Brown 04=Small Truck 11 =Farm Equip 23=Horse & Rider 03=Police 22=Twin Trailer
02=Red 10=Orange (If "02°, Complete Form 12=Construction Equip 24=Train
ATV 25=Trolle
3 08=Other Emergency 23=Triple Trailer
h
03=White 11 =Purple
04=Green 12=Other y
=
M, Section 26) 1
Complete 18=Other Type Spec Veh 98=Other
(If "20" or "2I " Vehicle 31 =Modified Ve
11 =Pupil Transport 99=Unknown
05=Black 99=Unknown ,
Form M, Section 27) 19=Unk. Type Spec Veh 99=Unknown
j Initial Impact Point Damage Indicator Gradient 3=Downhill Road Alignment
01 00=Non-Collision 14=Undercarriage
15=Towed Unit
k P
i
t
l O=None 2=Functional
1=Minor 3=Disabling 1=Level 4=Bottom of Hill
5=Top of Hill
hill
Straight
1 Z==Curved
n
s
oc
o
01-12=C
13=Top 99=Unknown 9=Unknown 2=Up
9=Unknown 9=Unknown
101
FORM M AA-500 (12102) PENNDOT COPY
Print CRS W0121546
CORfdf`rilORWEAUN OF PF_HM5VLVANiA
AA A POLICE CRASH REPORTING FORM Page:
AA 500 2 Police Use Only
Page 3 of 7
Crash Number 7
W0121546
9 Motor Vehicle in
O Hit & Run Vehicle O Illegally Parked O Legally Parked Q Non -Motorized
S
Commercial Vehicle
T rans ort
Type e
p
Unit o Pedestrian on Skates, 0 Disabled From O Train O Phantom Vehicle
Q Pedestrian
i
h
P
C
O Yes ® No
ras
rev
ous
in Wheelchair, etc (if Yes, Complete Form C)
(if 'Pedestrian' or "Pedestrian on Skates, in Wheelchair, etc', Complete Form M, Section 28)
Unit No First Name Nil Date of Birth (MM-DD-YYYY)
02 JONATHAN a 11 08 1987
Last Name Telephone Number
Delete?
O WEIRICH;II
Address ! City / State Zip
a 135 CRESTVIEW VILLAGE MIDDLETOWN PA 17057
g Driver License Number State Class
PA
128004540
Alcohol/Drugs Suspected
Driver or Pedestrian Physical Condition
a
a Illegal Drugs Medication
No O O Apparently Illegal Drug Fatigue Medication
Normal 0 Use 0 0
Z
Z
O Alcohol O Alcohol and Drugs O Unknown
Had Been
Q O Sick Q Asleep Q Unknown
Drinking
b
y
Alcohol Test Type
Primary Vehicle Code Violation
Charged.
® 0 Test Not Given Q Breath O Other O Yes No
d
Q Blood Q Urine Unknown if
Test Given 3324
y Alcohol Test Results 0 Test Refused O ReSUIu n Driver Presence 1=Driver Operated 3=Driver Fled Scene
Vehicle 4=Hit and Run
O Test Given,
l
?
0 9
U
k
i
Contaminated Resu
ts
. ver
=
n
nown
2=No Dr
Owner/Driver 00=Not Applicable 02=Private Vehicle Not 04=5tate Police Vehicle 07=Municipal Police Veh 09=Federal Gov Veh
01 =Private Vehicle Owned/ Owned/Leased by Driver 05=PENNDOT Vehicle 08=Other Municipal 98--Other
L 1 Leased by Driver D3=Rented Vehicle 06=Other State Gov Veh Government Vehicle 99=Unknown
Owner First Name Owner Last Name or Business Name (if Pedestrian, skip this Section)
Same as
Driver p IJONATHAN --1 WEIRICH;II
Address / City / State / Zip Vehicle Make *Make Code
d 12
F
or
1 35 CRESTVIEW VILLAGE MIDDLETOWN PA 17057
VIN Model Year Vehicle Model (see overlay)
I 1FTSW31P84ED63160 2004 F350
License Plate Reg. State Est. Speed Vehicle Towed Towed By
YXZ7320 -I PA 999 • Yes O No MARTINS GARAGE
Insurance Insurance Company Policy No
o
p
ra w Yes Q No Q Un- GEICO
known 4069572834
o' Trailing Type 1=Towing Pass. Veh 4=Mobile/Modular Home 7=Semi-Trailer Tag No Tag Year Tag 54
e Unit No, of Unit 2=Towng Truck 5=Camper 8=Other
- Tradinga
9=Unknown
il
6
F
ll T
il
o
°v er
=
u
ra
3=Towing Utility Tra
er
Units:
Direction of a "Vehicle Position C)? 'Movement 15 *See
l
O Special Usage
rave ver
ay
Vehicle Color Vehicle TVioe 05=Large Truck 20=Unicycle, Bicycle, 12=Commercial
Passenger
06=Yellow
OS 07=Silver 01==Automobile 06=SUV Tricycle
1 02=Motorcycle 07=Van 21=Other Pedalcycle
-1 00=Not Applicable Carrier
01=Fire Veh 13=Taxi
08=Gold
01=Blue 09=Brown 03==Bus 10=Snowmobile 22=Horse & Buggy
04==Small Truck 11 =Farm Equip 23=Horse & Rider 02=Ambulance 21 =Tractor Trailer
03=Police 22=Twin Trailer
02=Red 10=Orange
hi
l (if "02", Complete Form 12=Construction Equip 24=Train
AN 25=Trolle
13 08=Other Emergency 23=Triple Trailer
03=W
te 11=Purp
e y
=
M, Section 26) Vehicle 31 =Modified Veh
04=Green 12=Other
wn
05=Black 99
k
U (if "20" or "21", Complete 1B=Other Type Spec Veh 98=Other
Type Spec Veh 99=Unknown
19=Unk 11 -Pupil Transport 99=Unknown
n
no
= .
Form At Section 27)
Initial Impact Point Damage Indicator Gradient 3=Downhill Road Alignment
DO=Non-Collision 14=Undercarriage
11 O=None 2=Functional
1=Minor 3=Disabling 4=Bottom of Hill
1=Level 5=Top of Hill
? 1=Straight
2=Curved
?
01-12=Clock Points 15=Towed Unit 9=Unknown 2=Uphill
9=Unknown 9=Unknown
13=Top 99=Unknown
10
roRM # AA-500 (iyoz) PENNDOT COPY
Print CRS W0121546
COMMONWEALTH of PENNSYLVANIA
POLICE CRASH REPORTING FORM
AA 500 3 P°hce Use Only
Page
W0121546
Crash Number
Person FW
A 1=Driver D Seat Position:
DO=Not A Passenger/Occupant
2=Passenger 01=Driver - All Vehicles
7=Pedestrian 02=Front Seat Middle Position
8=Other 03=Front Seat Right Side
9=Unknown 04=Second Row - Left Side Or
Motorcycle Passenger
05=Second Row - Middle Position
sex
, 06=Second Row - Right Side
.
B F =Female 07=Third Row Or Greater -
®
a M=Male
U =Unknown Left Side
D8=Third Row Or Greater -
a Middle Position
E 09=Third Row Or Greater -
® Right Side
g bury Severity: 10=Sleeper Section of Truckcab
a C O=Not Injured 11=1n Other Enclosed
1=Killed Passenger Or Cargo Area
0 2=Major Injury 12=ln Open Area
3=Moderate (Back Of Pickup, Etc.)
Injury 13=Trailing Unit
4=inor Injury 14=Riding On Vehicle Exterior
B=Injury, Unk 15=Bus Passenger
Severity 98=Other
9=Unknown if 99=Unknown
Injury
01=Shoulder Belt Used
02=Lap Belt Used
03=Lap And Shoulder Belt Used
04=Child Safety Seat Used
05=Motorcycle Helmet Used
06=Bicycle Helmet Used
10=Safety Belt Used improperly
11 =Child Safety Seat Used improperly
12=Helmet Used Improperly
90=Restraint Used, Type Unknown
99=Unknown
Safe &ment Two:
F 00=None Used / Not Applicable
01=Front Air Bag Deployed (For This Seat)
02=Side Air Bag Deployed (For This Seat)
03=Other Type Air Bag Deployed
04=Multiple Air Bags Deployed
05=Motorcycle Eye Protection
06=Bicyclist Wearing Elbow/Knee/Pads
10=Air Bag Not Deployed, Switch On
11=Air Bag Not Deployed, Switch off
12=Air Bag Not Deployed,
Unk Switch Setting
13=Air Bag Removed (Prior To Crash)
19=Unknown If Air Bag Deployed
99=Unknown
Page 4 of 7
G O'=Not Applicable
1=Not Ejected
2=Totally Ejected
3=Partially Ejected
9=Unknown
H Election Path:
OO=Not Ejected / Not Applicable
1=Through Side Door Opening
2=Through Side Window
3=Through Windshield
4=Through Back Door
5=Through Back Door Tailgate Opening
6=Through Roof Opening (Sunroof/
Convertible Top Down)
7=Through Roof Opening (Convertible
Top Up)
9=Unknown
Extrication:
O=Not Applicable
1=Not Extricated
2=Extricated By Mechanical Means
3=Freed By Non - Mechanical Means
8=Other
9=Unknown
GEMS Agency: UNIVERSITY EMS Medical Facility: PENN STATE HERSHEY MEDICAL CENTE
Unit No Person No Date of Birth (MM-DD-YYYY) A B C D E F G H I
O1 O1 DQQe' 09 - O1 - 1963 1? F? 4? O1 03 12 1? 0?
Name / Address / Phone EMS Transport
same as KALFAS, BRENDA L 350 N 27TH STREET CAMP HILL PA 17011 71 i Yes O No
Operator
Unit No Person No DQ Date of Birth (MM-DD-YYYY) A B C D E F G H I
O 1 02 Q e' O 1 - 21 - 1997 2? 06 03 12 0I
Name / Address / Phone EMS Transport
Ei same as ANNIE KALFAS 350 N 27TH STREET CAMP HILL PA 17011 717730 Yes O No
Operator
Unit No Person No Delete? Date of Birm (MM-uu-YtYTJ H D
02 O1 Q 11 - 08 - 1987 1? M? 0? O1 03 99 1? 0? 1?
Name / Address / Phone EMS Transport
same as WEIRICH;II, JONATHAN R 35 CRESTVIEW VILLAGE MIDDLETOWN P Q Yes No
Operator
Unit No Person No Delete? Date of Birth (MM-DD-YYYY) A B C D E F G H I
0 H
Name / Address / Phone EMS Transport
E] Operator Samer O Yes O No
Unit No Person No Delete? Date of Birth (MM-DD-YYYY) A B C D E F G H I
C? O -?[11:10 ??F]
Name / Address / Phone EMS Transport
Same as
Operator O Yes O No
Unit No Person No Date of Birth (MM-DD-YYYY) A B C D E F G H
Delete? I
?J L-J
CD 1 1"""
Name / Address / Phone EMS Transport
SOpereamataosr O Yes O No
FORM K AA-500 (12102) PENNDOT COPY
Print CRS W0121546
Page (I?IIII?InIIII?I?II?III1lI
COMMONWEALTH OF POUC CRASH REPORTING FOlRfll?clB?
AA 500 ¢ Pol ce U. Only . W0121546
Page 5 of 7
Crash Number 7
O=Non-Collision 2=Head On 4=Angle 6=Sideswipe B=HiI Pedestrian
Crash Description 1 1=Rear End 3 Rear to Rear
(Backing) 5=Sideswipe
(Same irecil.n) (Opposite Direction)
7=Hit Fixed Object
9=01herlUnknown
0 0
m d
Relation to Roadway
1 -
1=-0n Travel Lanes
3=Median
5=Outside Trafficway
7=Gore (Ramp Intersecti
U
k
on)
0
0 2=Shoulder 4=Roadside 6=1n Parking Lane nown
n
9=
c o 1=Daylight 3=Dark-Street 5=Dawn B=Other
r a illumination
?
1 2=Dark - No
u
6=Dark - Unknown
§
Street Lights sk
4=Dusk
Roadway Lighting - --
- ---- --
v ?
t
Weather Conditions
1 -
1=ND Adverse
Conditions
3=Sleet
(Hall)
5=Fog
7=Sleet 8 Fog
9=Unknown
c g ?
2=Rain
4=Snow
6=Rain & Fog
8=Other -
E
Road Surface Conditions
?
O=Dry 2=Sand, Mud, Dirt,
Oil 4=Slush 6=Ice Patches
7=or t r -Standing
? 8=Other
1 =Wet
3=snow Covered
5=Ice
oving
or
_ ------
Unit No 1 12 ? ® ?
O1 2??O?
Please Put 3 F --
Events in
Sequential
Order 4 ? ? O
0
E
o Harm Event L/R Most? Utility Pole Number
1 01 ? . ?
a Unit No
02 2 ? O F
C
Please Put 3
Events
Sequential
Order 4 ? 0 ?
First Unit No Harm Event Most Unit No Harm Event
v 02 O 1 vent rn 102 O 1
t e rash 111. Crash
Do not repeat this information m muhipie pages
Environmental Roadway 1 00 2 3
Potential Factors (ER)
00=None 11=Slippery Road Conditions (Ice/Snow)
01 =Windy Conditions 12=Substance On Roadway
02=Sudden Weather Conditions 13=Potholes
03=Other Weather Conditions 14=Broken Or Cracked Pavement
04=Deer In Roadway 15=TCD Obstructed
05=Obstacle On Roadway 16=Soft Shoulder Or Shoulder Drop Off
06=Other Animal In Roadway 28=0ther Roadway Factor
07=Glare 29=Other Environmental Factor
c 08=Work Zone Related 99=Unknown
0
m Possible Vehicle Failures (V) 12 =Wipers
t 13=Driver Seating/Control
00=None 06=Exhaust
° 01=Tires 07=Headlights 14=Body, Doors, Hood, Etc
r 02=Brake System 08=Signal Lights 15=Trailer Hitch
c 03=Steering System 09=Other Lights 16=Wheels
04=Suspension 10=Horn 17=Airbags
11 18=Trailer Overloaded
05=Power Train 11=Mirrors
o 1 2 CJ 19=Unsecure/Shifted
c Unit Trailer Load
U No O 1 00 20=Improper Towing
21 Obstructed Windshield
Unit 02 y 00 2 ?? 99=Unknown
No
Indicated Prime Factor
Do not repeal this information on
multiple pages.
E/R V D P
O 00 O
Unit No Factor Code
02 ? 14
If EIR is the Prime Factor
Type, leave Unit No blank
Harmful Events (Warm Event)
01=Hit Unit 1
02=Hit Unit 2
03=Hit Unit 3
04=Hit Unit 4
05=Hit Unit 5
06=Hit Other Traffic Unit
07=Hit Deer
08=Hit Other Animal
09=Collision With Other Non
Fixed Object
11 =Struck By Unit 1
12=Struck By Unit 2
13=Struck By Unit 3
14=Struck By Unit 4
15=Struck By Unit 5
16=Struck By Other Traffic Unit
21=Hit Tree Or Shrubbery
22=Hit Embankment
23=Hit Utility Pole
24=Hit Traffic Sign
25=Hit Guard Rail
26=Hit Guard Rail End
27=Hit Curb
28=Hit Concrete Or
Longitudinal Barrier
29=Hit Ditch
00=No Contributing Action
01=Driver Was Distracted
02=Driving Using Hand Held Phone
03=Driving Using Hands Free Phone
04=Making Illegal U-Turn
05=Improper/Carele5s Turning
06=Turning From Wrong Lane
07=Proceeding W/0
Clearance After Stop
08=Running Stop Sign
09=Running Red Light
1 D=Failure To Respond To
Other Traffic Control Device
11=Tailgatingg
12=Sudden Slowing/Stop ing
13=Illegally Stopped On Road
14=Careless Passing Or Lane
Change
15=Passing In No Passing zone
16=Driving The Wrong Way On
1-Way Street
Unit O1
No
Nolt 02 1 14 2 ?? 3 4
Pedestrian Action (P) 03=Working
00=None
01=Entering Or Crossing At 04=Pushing Vehicle
05=Approaching Or Leaving Vehicle
Specified Location 06=Working On Vehicle
07=Standing
02=Walking, Running, logging, Sher
Or Playing 99=Unknown
Unit No 01 Unit No O2
30=Hit Fence Or Wall
31=Hit Building
32=HR Culvert
33=Nit Bridge Pier Or Abutment
34=Hit Parapet End
35=Hit Bridge Rail
36=Hit Boulder Or Obstacle
On Roadway
37=Hit Impact Attenuator
38=Hit Fire Hydrant
392t Roadway Equipment
40=Hit Mail Box
41=Hit Traffic Island
42=Hh Snow Bank
43=Hit Temporary Construction
Barrier
48=Hit Other Fixed Object
49=Hit Unknown Fixed Object
50=Overturrt/Roll Over
51=Struck By Thrown Or Falling
Object
52=Pot Holes Or Other
Pavement Irregularities
53=Jacknife
54=Fire In Vehicle
58=Other Non-Collision
99=Unknown Harmful Event
17=Careless Or Illegal
Backing On Roadway
18=Driving On The Wrong
Side Of Road
19=Making improper
Entrance To Highway
20=Making Improper Exit
From Highway
21=Careless Parking/Unparking
22=Over/Under
Compensation At Curve
23=Speeding
24=Driving Too Fast For Conditions
25=Failure To Maintain Proper Speed
26=Driver Fleeing Police (Pol Chase)
27=Driver Inexperienced
28=Failure To Use Specialized Equip
92=Affected By Physical Condition
98=Other improper Driving Actions
99=Unknown
1 00 2 ?? 3 . 4
FORM a AA-500 (12o2) PEtv9NDOT COPY
Print CRS W0121546
COMMONWEALTH OF PENNSYLVANIA
POLICE CRASH REPORTING FORM
AA 500 5 Poke Use Only
Page
W0121546
Page 6 of 7
Crash Number
0
Witness Name Address
I y TERRY WILLARD 3680 ROUNDTOP ROAD ELIZABETHTOWN PA 7176896078
a
Narrative and additional witnesses: Accident Investigation Notification Issued? 0 Property Damage O
Unit 1 was travelling strait in a turn lane. Unit 2 was motioned by another stopped motorist to enter the turn lane.
Unit 2 did not see Unit 1 approaching and struck Unit 2 after pulling into the turn lane.
d
6
z
s
m
w
w
m
e
M
FORM N AA-500 (12102) PENNDOT COPY
Print CRS W0121546
Crash Number: W0121546
Incident Number: 2009081901
<I, I t, * I
Page 7 of 7
f
Unit
x
Yom.
?6??J
?x????? ?
PENNSTATE HERSHEY
/.1 Milton S. Hershey
Medical Center
Patient Name: KALFAS, ANN E
M RN : 0776544
Date of Birth: 1/21/1997
Penn State Hershey Tel: (717) 531-8055
Milton S. Hershey Medical Center
Health Information Services, HU24
500 University Drive
P.O. Box 850
Hershey, PA 17033-0850
Visit Number: 13390378
Visit Type: Clinic
Patient Location: PRS; ;
Patient Gender: Female
...................................................................................
Outpatient Note
RESULT STATUS:
DOCUMENT SUBJECT:
ELECTRONICALLY SIGNED BY:
Name: KALFAS, ANN E
HMC Number: 0776544
DOB: 01/21/1997
Date of Service: 08/24/2009
SERVICE: Plastic Surgery Service.
Final
Mesa, John M (9/4/2009 15:58 EDT); Moyer, Kurtis E
(8/31/2009 09:14 EDT)
OUTPATIENT NOTE
Ann is a 12-year-old female well known to the Plastic Surgery Services status post motor vehicle accident as a restrained
back-seated driver with anterior nasal spine fracture and upper lip frenulum open wound status post irrigation and primary
closure in the emergency room. Patient is about 5 days post trauma. She comes for routine followup appointment.
SUBJECTIVE: Patient comes with both mother and father for followup appointment. She doesn't have any major
complaints at this time. She only has noticed that there is some residual upper lip and nose swelling. She denies severe
pain, signs of infection. She has been taking the prophylactic antibiotics as ordered. She has been washing her mouth
with sterile water.
Patient denies any respiratory symptoms like obstruction, bleeding, discharge, etc.
OBJECTIVE: On physical examination, patient is alert, oriented x3. She is not in distress. She is an average body
habitus.
Face: In this patient, there are no major pathology findings. There is some minor residual swelling of the tip of the nose
and the upper lip. There are no open wounds. There is no major facial asymmetry.
Nose: There is no local tenderness to palpation of the nose. On bilateral rhinoscopy, it is noticed that the nasal septum
is center. The mucosa is intact. There are no open wounds. Nose tip projection. Nose base is adequate for her
facial dimensions. Patient stated that she hasn't noticed any major change in her nose compared with the pre-trauma
appearance.
Mouth: Intraoral examination shows a well-healed upper anterior gingivobuccal sulcal wound. There are a sewn residual
covering sutures still in place. There is no sinus infection.
Date/Time Printed: 9/21/2009 08:29 EDT Page 1 of 2
Printed By: Tice, Cindy L
PENNSTATE HERSHEY
Milton S. Hershey
Medical Center
Patient Name: KALFAS, ANN E MRN 0776544
-----------------------------------
Outpatient Note
......................................
ASSESSMENT: 12-year-old female status post motor vehicle accident as a restrained back passenger with minimally
displaced anterior nasal spine fracture and a well-healed upper lip intraoral mucosal wound with excellent posi-trauma
course. There is no need of surgical or medical issues at this time.
PLAN/RECOMMENDATIONS:
1. A slip with head of bed elevated for at least another week to improve facial swelling.
2. Continue prophylactic antibiotics as prescribed.
3. A Peridex mouthwash or another equivalent (like a Listerine Whitening, etc.,) for an additional week.
4. Avoid any intraoral protective device (like a teeth guard for hockey games for at least 3 weeks for trauma.
5. Consider a facial mask in order to prevent face trauma during contact sports (hockey game) and to avoid using
mouthwash for additional 2 weeks.
6. Nose. A surgical management of her minimally displaced anterior nasal spinal fracture is necessary.
Follow up in Plastic Surgery Clinic p.r.n.
878104
Electronic Signature on File
Electronically Reviewed/Signed by: Kurtis E Moyer, MD Author Signature Dt/Tm:31.08.2009 09:14 AM
Electronically Reviewed/Signed by: John M Mesa, MDCosigner Signature DtlTm: 04.09.2009 03:58 PM
KEM /CO DD: 08124109 DT: 08126109 07:31 AM
Date/Time Printed: 9/21/2009 08:29 EDT Page 2 of 2
Printed By: Tice, Cindy L
PENNSTATE HERSHEY
Milton S. Hershey
qP Medical Center
Patient Name: KALFAS, ANN E
M RN : 0776544
Date of Birth: 1/21/1997
Patient Gender: Female
Penn State Hershey Tel: (717) 531-8055
Milton S. Hershey Medical Center
Health Information Services, HU24
500 University Drive
P.O. Box 850
Hershey, PA 17033-0850
Visit Number: 13395499
Visit Type: Emergency
Patient Location: EMER; ;
......................
Consent
Date/Time Printed: 9/21/2009 08:32 EDT
Printed By: Tice, Cindy L
Page 1 of 28
'atient Name: KALFAS, ANN E
)ate of Birth: 1/21/1997
PENNSTATE HERSHEY
Milton S. Hershey
iv Medical Center
CONSENT FOR MEDICAL TREATMENT
M R N: 0776544
FIN: 13395499
NAME: KALFAO, ANN E ?
NRA: 770544 OOSN:?
No: KASS LAWRENCE E MDR: 48334
DOB: 01/2111987 VISIT DATE: 08121/2009
LOC: EATER SEX: F
NI?INI??I OUT OF sBaS n/ALPHA
MEDICAL AND SURGICAL CONSENT FOR TREATMENT: The undersigned is under the
care of his/her attending physician(s) and hereby consents to and authorizes the Milton S.
Hershey Medical Center (MSHMC) to provide the necessary medical treatments (including
Emergency Department services), surgical procedures, anesthesia, x-ray examinations or
treatments, laboratory procedures, drugs and supplies to the patient as ordered or requested
by the Professional Clinical Staff of the MSHMC. I acknowledge that no guarantee or
assurance has been made as to the results of medical treatments, surgeries, or examinations.
For the purpose of advanced medical knowledge, I consent to the presence of medical
students and other health care trainees. I understand they may participate in my care under
the direct supervision of my attending physician(s).
PATIENTS RIGHTS AND RESPONSIBILITITES: I acknowledge that MSHMC 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.
HOSPITAL MEDICAL RECORD RELEASE AUTHORIZATION: I acknowledge that the
MSHMC Privacy Notice has been made available to me. I understand that MSHMC may
disclose information about me and the treatment I am receiving, for purposes of continuous
• treatment, payment and health care operations.
I agree to hold harmless MSHMC its officers, directors and employees and agents, from any
and all liability, loss, claims, or damages relative to the release of such information.
ASSIGNMENT OF BENEFITS: I assign and authorize payment directly to MSHMC. I
authorize any holder of medical or other information about me to release to my insurance a
carrier and its agents any information needed to determine these benefits or benefits for
related se(vices.
I, the undersigned, certify that I have read, understand, and agree to the provisions contained
within the consent form. The issues addressed on this form have been fully explained to me.
have had the opportunity to ask questions, and all of my questions have been answered to my
satisfaction.
person consenting on behaff of the patient)
1(Rel ions to the atient, if applicable)
7ss to
atie i re)
MR 1181 Rev. 10108 Page 1 of 1
(II?gIIfl I M II'1II1 a ?11e1 CONSENT FOR MEDICAL TREATMENT
?l
ate)
Q9
(Date)
White Copy - Medical Records
Yellow Copy - Patient
C-114" unec Page 2 of 2E
PENNSTATE HERSHEY
Milton S. Hershey
IV Medical Center
Patient Name: KALFAS, ANN E
MRN 0776544
- - - - - - -----------
ED Discharge Instructions
RESULT STATUS: Modified
DOCUMENT SUBJECT: ED Pat Edu
ELECTRONICALLY SIGNED BY:
ED Pat Edu
Penn State Milton S. Hershey Medical Center
Emergency Department Discharge Instructions
Name: ANN KALFAS DOB: 1/21/1997
Chief Complaint: Facial Injury
MRN: 0776544 Visit Date: 08/21/2009 15:50:00
FIN: 13395499 Current Date: 08/21/2009 1 B:17:02
Address: 350 NORTH 27TH ST CAMPHILL PA 170110000
Phone: (717)730-0798
Primary Care Provider:
Name: Coldren, Robert L
Phone: (717) 791-2680
Emergency Department Care Providers:
Primary Physician: Kass, Lawrence E
Secondary Physician:
IMPORTANT: We examined and treated you today on an emergency basis only. This was not a
substitute for, or an effort to provide, complete medical care. In most cases, you must let your doctor
check you again. Tell your doctor about any new or lasting problems. We cannot recognize and
treat all injuries or illnesses in one Emergency Department visit. If you had special tests, such as
EKG's or X-rays, we will review them again within 24 hours. We will call you if there are any new
suggestions. After you leave, you should follow the instructions below.
Follow-Up Instructions
ANN KALFAS has been given these follow-up instructions:
Follow Up With: Where: When:
Robert Coldren 25 West Shore Drive Within Call
Camp Hill, PA 17011 -0000 physician within
(717) 791-2680 Business next business day
Date/Time Printed: 9121/2009 08:32 EDT Page 3 of 28
Printed By: Tice, Cindy L
PENNSTATE HERSHEY
Milton S. Hershey
1W Medical Center
MRN 0776544
Patient Name: KALFAS, ANN E
- - - - ---------------- - -- - ------ - ------------- ------------- --------------------------------- - ---------- - ----- - - -------------------
ED Discharge Instructions .....................................................
Comments:
SMOKING is a major health issue.
-Smoking greatly increases the risk of heart disease, cancer, and stroke.
-If you and your family don't smoke, contine this healthy choice!
-Remember to avoid secondhand smoke.
-If you or anyone in your household does use tobacco products, please
follow any smoking cessation advice/counseling you received while in the
hospital.
-If you would like more information about how to live tobacco-free, please
call one of the numbers below.
PSHMC Smoke Cessation Program 1-800-243-1455
Pennsylvania QUITLINE 1-877-724-1090
Are you or someone you love at the risk of suicide?
Seek help as soon as possible by contacting a mental health professional or by calling:
NATIONAL SUICIDE PREVENTION LIFELINE
AT 1-800-273-8255 (TALK)/1-800-273-8255
Patient Education Materials
ANN KALFAS has been given the following patient education materials:
TRAUMA
FACIAL CONTUSION [no wake-up]
You have a facial contusion, which means a bruise with swelling and sometimes bleeding under the skin.
The swelling should start to go down within two days. Although there is no sign of a serious injury at this
time, symptoms may appear later which could be a sign of a more serious problem. Therefore, watch for the
warning signs below.
HOME CARE:
1) If you have swelling of the face, apply an ice pack (ice cubes in a plastic bag, wrapped in a towel) for 20
minutes every 1-2 hours until the swelling starts to go down.
Page 4 of 28
DaterTime Printed: 9/21/2009 08:32 EDT
Printed By: Tice, Cindy L
PENNSTATE HERSHEY
Milton S. Hershey
IV Medical Center
MRN 0776544
Patient Name: KALFAS, ANN E
___._
ED Discharge instructions 2 If you have scrapes or cuts on our face, clean them daily with soap and water. Apply an antibiotic ointment
or cream (Bacitracin or Neospohn) for the first few days to prevent infection.
3) You may take Tylenol (acetaminophen) or Ibuprofen (Advil, Mothn) for pain, unless another pain medicine
was prescribed.
FOLLOW UP with your doctor or this facility if you do not start to improve within the next 24 hours.
[NOTE: Any X-rays taken will be reviewed by a radiologist. You will be notified of any new findings that
may affect your care.]
RETURN PROMPTLY or contact your doctor if any of the following occur:
-- Increasing facial swelling
-- Fever, redness, warmth or pus from the injured area
-- Jaw pain with chewing or increasing pain in the sinuses
-- Nose looks crooked or cannot breathe through your nose after swelling goes down
-- Seeing double
-- Repeated vomiting
-- Severe or worsening headache or dizziness
-- Unusual drowsiness or unable to awaken as usual
-- Unequal pupils
-- Confusion or change in behavior or speech
-- Convulsion (seizure)
Patient Visit Summary
ANN KALFAS has been given the following list of patient education materials and follow-up
instructions:
Patient Education Materials:
TRAUMA
FACIAL CONTUSION (no wakeup)
Follow-Up Instructions: When:
Follow Up With: Where: Within Call
Robert Coldren 25 West Shore Drive
Camp Hill, PA 17011 -0000 physician within
(717) 791-2680 Business next business day
Comments:
Page 5 of 28
Date/Time Printed: 9/21/2009 08:32 EDT
Printed By: Tice, Cindy L
PENNSTATE HERSHEY
Milton S. Hershey
jP Medical Center
Patient Name: KALFAS, ANN E MRN 0776544
__ _____.
ED Discharge instructions
I, ANN KALFAS, have received the above patient education materials/instructions and have
verbalized understanding:
Patient Signature
Date
MRN: 0776544
FIN: 13395499
Provider Signature Date
Date/Time Printed: 9/21/2009 08:32 EDT Page 6 of 28
Printed By: Tice, Cindy L
PENNSTATE HERSHEY
? Milton S. Hershey
4P Medical Center
Patient Name: KALFAS, ANN E
MRN 0776544
"` ED Discharge Instructions
RESULT STATUS:
DOCUMENT SUBJECT:
ELECTRONICALLY SIGNED BY:
Final
ED Pat Edu
ED Pat Edu
Penn State Milton S. Hershey Medical Center
Emergency Department Discharge Instructions
Name: ANN KALFAS DOB: 01 /21/97
Chief Complaint: Facial Injury
MRN: 0776544 Visit Date: 08/21/09 15:50
FIN: 13395499 Current Date: 08/21/2009 18:04:39
Address: 350 NORTH 27TH ST CAMPHILL PA 170110000
Phone: (717)730-0798
Primary Care Provider:
Name: Coldren, Robert L
Phone: (717) 791-2680
Emergency Department Care Providers:
Primary Physician: Kass, Lawrence E
Secondary Physician:
IMPORTANT: We examined and treated you today on an emergency basis only. This was not a
substitute for, or an effort to provide, complete medical care. In most cases, you must let your doctor
check you again. Tell your doctor about any new or lasting problems. We cannot recognize and
treat all injuries or illnesses in one Emergency Department visit. If you had special tests, such as
EKG's or X-rays, we will review them again within 24 hours. We will call you if there are any new
suggestions. After you leave, you should follow the instructions below.
Follow-Up Instructions
ANN KALFAS has been given these follow-up instructions:
Fallow-Up With: Address: When:
Date/Time Printed: 9/21/2009 08:32 EDT
Page 7 of 28
Printed By: Tice, Cindy L
PENNSTATE HERSHEY
Milton S. Hershey
IV Medical Center
Patient Name: KALFAS, ANN E
MRN 0776544
- - ----------
ED Discharge Instructions
Robert Coldren
Comments:
25 West Shore Drive Within Call
Camp Hill, PA 17011-0000 physician within
(717) 791-2680 Business next business day
SMOKING is a major health issue.
-Smoking greatly increases the risk of heart disease, cancer, and stroke.
-if you and your family don't smoke, contine this healthy choice!
-Remember to avoid secondhand smoke.
-If you or anyone in your household does use tobacco products, please
follow any smoking cessation advice/counseling you received while in the
hospital.
-If you would like more information about how to live tobacco-free, please
call one of the numbers below.
PSHMC Smoke Cessation Program 1-800-243-1455
Pennsylvania QUITLINE 1-877-724-1090
Are you or someone you love at the risk of suicide?
Seek help as soon as possible by contacting a mental health professional or by calling:
NATIONAL SUICIDE PREVENTION LIFELINE
AT 1-800-273-8255 (TALK)/1-800-273-8255
Patient Education Materials
ANN KALFAS has been given the following patient education materials:
Injury & Illness
FACIAL CONTUSION [no wake-up]
You have a facial contusion, which means a bruise with swelling and sometimes bleeding under the skin.
The swelling should start to go down within two days. Although there is no sign of a serious injury at this
time, symptoms may appear later which could be a sign of a more serious problem. Therefore, watch for the
warning signs below.
Date/Time Printed: 9/21/2009 08:32 EDT Page 8 of 28
Printed By: Tice, Cindy L
PENNSTATE HERSHEY
Milton S. Hershey
RP Medical Center
Patient Name: KALFAS, ANN E
MRN 0776544
---
ED Discharge Instructions
HOME CARE:
1) If you have swelling of the face, apply an ice pack (ice cubes in a plastic bag, wrapped in a towel) for 20
minutes every 1-2 hours until the swelling starts to go down.
2) If you have scrapes or cuts on your face, clean them daily with soap and water. Apply an antibiotic ointment
or cream (Bacitracin or Neosporin) for the first few days to prevent infection.
3) You may take Tylenol (acetaminophen) or Ibuprofen (Advil, Motrin) for pain, unless another pain medicine
was prescribed.
FOLLOW UP with your doctor or this facility if you do not start to improve within the next 24 hours.
[NOTE: Any X-rays taken will be reviewed by a radiologist. You will be notified of any new findings that
may affect your care.]
RETURN PROMPTLY or contact your doctor if any of the following occur:
-- Increasing facial swelling
-- Fever, redness, warmth or pus from the injured area
-- Jaw pain with chewing or increasing pain in the sinuses
-- Nose looks crooked or cannot breathe through your nose after swelling goes down
-- Seeing double
-- Repeated vomiting
-- Severe or worsening headache or dizziness
-- Unusual drowsiness or unable to awaken as usual
-- Unequal pupils
-- Confusion or change in behavior or speech
-- Convulsion (seizure)
Patient Visit Summary
ANN KALFAS has been given the following list of patient education materials and follow-up
instructions:
Patient Education Materials:
Injury & Illness
FACIAL CONTUSION (no wakeup)
FolloW_U _Instructions:
Follow-Up With: Address: When:
Date/Time Printed: 9/21/2009 08:32 EDT Page 9 of 28
Printed By: Tice, Cindy L
PENNSTATE HERSHEY
1 1 Milton S. Hershey
4P Medical Center
Patient Name: KALFAS, ANN E
ED Discharge Instructions
Robert Coldren 25 West Shore Drive
Camp Hill, PA 17011-0000
(717) 791-2680 Business
Comments:
MRN 0776544
Within Call
physician within
next business day
I, ANN KALFAS, have received the above patient education materials/instructions and have
verbalized understanding:
Patient Signature Date
MRN: 0776544 FIN: 13395499
Provider Signature Date
Page 10 of 28
Date/Time Printed: 9/21/2009 08:32 EDT
Printed By: Tice, Cindy L
PENNSTATE HERSHEY
Milton S. Hershey
Medical Center
Patient Name: KALFAS, ANN E MRN 0776544
ED Depart Summary
RESULT STATUS:
DOCUMENT SUBJECT:
ELECTRONICALLY SIGNED BY:
Final
Depart Summary
Depart Summary
Penn State Milton S. Hershey Medical Center Emergency Department Depart Summary
PERSON INFORMATION
Name KALFAS, ANNE Age 12 Years DOB 1/21/1997 12:00 AM
Sex Female Language PCP Coldren, Robert L
Marital Status Single Phone (717)730-0798
MRN 0776544 Visit Id Acct# 13395499
Visit Reason Facial Injury Specialty
Enc Type Emergency Med Service Emergency Medicine Referred by
Track Group EMER Trk Gp Discharge 8121 f2009 6:12 PM
Tracking Id 10692438 Checkout 8/2112009 6:17 PM
Checkin W21/2009 3:50 I'M Acuity 4 Dispo Type Routine Dsch
Arrival 8121/2009 3:50 PM Reg Status Start LOS 000 02:27
Address:
350 NORTH 27TH ST CAMPHILL PA 170110000
DIAGNOSIS
SWELLING OR MASS OF EYE
POWERFORMS
SCHEDULING
Type Location
PRS Acute PRS
PHYS DOC NOTES
Start Finish Stale
8/24/2009 3:00 PM 8/2412009 3:30 PM Confirmed
DEPART REASON INCOMPLETE INFORMATION
PROVIDER INFORMATION
Role Assigned Unassigned
Provider
Donavos, George K RN 8121/2009 4:16 PM
Kass, Lawrence E Physician 8/21/2009 4:30 PM
Shannon, Jacob S R.E.S. 8/2112009 4:30 PM 8/2112009 4:31 PM
R.E.S. Not Needed R.E.S. 8/21/2009 4:31 PM
Biggica, Christina M Clerical 8/2112009 4:39 PM
Date/Time Printed: 9/21/2009 08:32 EDT Page 11 of 28
Printed By: Tice, Cindy L
PENNSTATE HERSHEY
1 Milton S. Hershey
Rr Medical Center
Patient Name: KALFAS, ANN E
----------------- - ---------- - ---- - - - ---
ED Depart Summary
EVENTS INFORMATION
MRN 0776544
Event Status Request Date/Time Start Date/Time Complete Date/Time
Event Name
i Complete 8/21/2009 150 PM 8/212009 3:50 PM 8/2112009 3:50 PM
ve
Arr Complete 8/2112009 3:50 PM 8/21/2009 4:14 PM 812112009 4:14 PM
Triage
Arrive Registration Complete 8/21/2009 3:50 PM 8/21/2009 3:50 PM 8121/2009 3:50 PM
8/21/2009 5:35 PM
Registration Complete 8/2112009 3:50 PM
8/21/2009 3:50 PM 8121/2009 5:35 PM
8/21/2009 3:50 PM 812112009 3:50 PM
Arrive MD Bill
ll Complete
Complete 8/21/2009 3:50 PM 8/21/2009 5:42 PM 8/212009 5:42 PM
MD Bi
ive Dictate
A Complete 81212009 3:50 PM 8121/2009 3:50 PM 8/21/2009 3:50 PM
rr
t
t
Di Complete 81212009 3:50 PM 8/212009 5:42 PM 8/212009 5:42 PM
a
e
c
Arrive PT Belongings Complete 8121/2009 3:50 PM 8/2112009 3:50 PM 8/21/2009 3:50 PM
8/21/2009 4:15 PM
Bed Assign PT Belong Complete 8/21/2009 3:50 PM 8/212009 4:15 PM
8/2112009 3:50 PM 8/212009 3:50 PM
Arrive Bed Assign Complete 8/212009 3:50 PM
812112009 3:50 PM 8121/2009 4:15 PM 8121/2009 4:15 PM
Bed Assign
Arrive Med History Complete
Complete 8/212009 3:50 PM 8/21/2009 3:50 PM 812112009 3:50 P
Med History Request 81212009 3:50 PM
8/2112009 3:50 PM
8121/2009 3:50 PM
8/21/2009 3:50 PM
Arrive Update Attend
date ED Attending
U Complete
Complete 81212009 3:50 PM 8/212009 5:15 PM 8/21/2009 5:15 PM
40 PM
4
p
RN Assess Complete 8/212009 4:15 PM 8/212009 4:40 PM :
81212009
8/21/2009 4:30 PM
MD Assess Complete 812112009 4:15 PM
8/212009 4:15 PM 8/21 /2009 4:30 PM
8/2112009 4:30 PM 8121/2009 4:30 PM
Resident Assess Complete
Patient Belongings Request 8/212009 4:15 PM 81212009 4:46 PM
Request Consult Complete 81212009 4:30 PM
8121/2009 4:31 PM
8/21/2009 4:31 PM
8/212009 4:31 PM
MD Assess
A Complete
lete
Com 8/212009 4:31 PM 8121/2009 4:31 PM 8/21/2009 4:31 PM
ssess
Resident
Consult p
Request 8/212009 4:46 PM
8/21/2009 6a 1 PM
Dischargefrransfer Complete 8/212009 5:44 PM
LOCATION INFORMATION
Nurse Unit Room Bed
Arrival
8/212009 3:50 PM EMER Triage
8/21/2009 4:15 PM EMER 41
8/21/2009 6:17 PM EMER Check Out
ORDERS INF ORMATION
Order Type Status Stop Time Provider
Start Time
8/212009 3:50 PM
ED Nursing Charge
Patient Care
Completed 8/2112009 6:16 PM
SYSTEM
8/2112009 3:50 PM ED Visit Patient Care Completed 8/21/2009 3:50 PM SYSTEM
8/212009 3:50 PM Ped Skin Assessment Patient Care Ordered 8121/2009 3:50 PM SYSTEM
on Arrival
8!21/2009 3:51 PM Safety Wristband Patient Care Ordered SYSTEM
Verification
:0] AM
8/22/2009 1 Safety Wristband Patient Care Ordered 8/22/2009 12:01 AM SYSTEM
? Verification
Date/Time Printed: 9/21/2009 08:32 EDT Page 12 of 28
Printed By: Tice, Cindy L
PENNSTATE HERSHEY
MITI Milton S. Hershey
4P Medical Center
Patient Name: KALFAS, ANNE
8/210-009 4:30 PM Physician Consult Consults
Request
8/21/2009 5:44 PM Discharge (ED) Order Sets
8/2112009 5:41 PM Discharge from ED. Patient Care
8/21/2009 5:41 PM Discontinue 1V Patient Care
Document Infusion
8/21/2009 5:44 PM Stop Date/Time on Patient Care
ENLiR
MEDICAL INFORMATION
Allergy Info:
NKA
Prescriptions Given
Completed 8121 /2009 4:46 PM Kass, Lawrence E
Completed 8/21/2009 6:11 PM Shannon, Jacob S
Completed 8/21/2009 6:11 PM Shannon, Jacob S
Completed 8/21/2009 6:11 PM Shannon, Jacob S
Completed 8/21/2009 6:11 PM SYSTEM
DISCHARGE INFORMATION
Discharge Disposition: Routine Dsch
Discharge Location:
PATIENT EDUCATION INFORMATION
Instructions:
FACIAL CONTUSION (no wakeup)
Follow up:
Follow-Up With:
With: Address: When:
Robert Coldren 25 West Shore Drive Camp Hill, PA 17011-0000 Within Call physician
(717) 791.2680 Business within next business day
Continents:
MRN 0776544
ED Depart Summary
Date/Time Printed: 9/21/2009 08:32 EDT Page 13 of 28
Printed By: Tice, Cindy L
PENNSTATE HERSHEY
Milton S. Hershey
RP Medical Center
Patient Name: KALFAS, ANN E
RESULT STATUS:
DOCUMENT SUBJECT:
ELECTRONICALLY SIGNED BY:
ED SUMMARY
Name: KALFAS, ANN E
HMC Number: 776544
DOB: 01/21/1997
Date of Service: 08/21/2009
Kass, Lawrence E (8/24/2009 10:59 EDT)
Ms. Kalfas is a 12-year-old young lady who was sent in by Plastic Surgery for evaluation of some facial swelling. She
was in a motor vehicle accident two days ago, suffered an intraoral laceration and a minor nasal fracture. The laceration
was repaired by Plastic Surgery. She did well the day after evaluation but today woke up with some right-sided facial
swelling. It is minimally painful. There has been no fever or constitutional complaints. There has been no drainage from
the laceration. She has no hearing, vision, or throat complaints. Mother contacted Plastic Surgery who requested they
come in for evaluation.
PAST MEDICAL HISTORY: Otherwise unremarkable.
EXAMINATION: Reveals her to be afebrile. Vital signs are within normal limits. She is awake, alert, breathing, speaking,
moving easily. There is some diffuse soft tissue swelling overlying the right cheek but no erythema, no fluctuance, no
drainage. TMs are normal. Pupils are equal, round, and reactive to light. Zygoma is easily palpable, nontender without
stepoff. Nasal bone is nontender without stepoff. There is minimal soft tissue swelling around the nose. Intra-nares
exam was normal. Intraoral exam reveals a suture laceration at the upper gingival sulcus which appears to be healing
well without evidence of drainage or dehiscence. Her teeth are in good repair, nontender and without blood or other
abnormality. Neck: Supple without adenopathy.
IMPRESSION: Normal post trauma swelling. Plastic Surgery was contacted to advise them of the patient's arrival. They
have requested that she remain here until they can see her. Their evaluation is still pending at time of this dictation.
Case signed out 1700 hours to Dr. Escott.
874801
MRN 0776544
------------------
D Final
Date/Time Printed: 9/21/2009 08:32 EDT Page 14 of 28
Printed By: Tice, Cindy L
P'ENNSTATE HERSHEY
1 Milton S. Hershey
4P Medical Center
Patient Name: KALFAS, ANN E MRN 0776544
---- - ----- -------
ED Summary
addend: Plastics not responding to pages at 1730 hr and mother is requesting discharge. Exam unchanged. Patient will
be discharged with follow-up to them as already planned. LEK
Electronic Signature on File
Electronically Reviewed/Signed by: Lawrence E Kass, MD, FACEP,Author Signature DUTm:24.08.2009 10:59 am
Associate Professor, Department of Emergency Medicine
ViceChair for Education, Residency Director
Hershey Medical Center
PO Box 850, MC H043, Hershey, PA 17033
(717)531-1443 Fax: (717)531-4441
LEK/SDG OD: 08121109 DT: 08121109 19:35
Date/Time Printed: 9/21/2009 08:32 EDT Page 15 of 28
Printed By: Tice, Cindy L
'atient Name: KALFAS, ANN E
?ate of Birth: 1/21/1997
IYf?l?l(INIIIYY I
PENNSTATE HERSHEY
Milton S. Hershey
Medical Center NAME: KA.LFAS, ANN E
MR!: 778544 OOSb:.el?lsa '
?? LAWRENCE E E VIS
IT DATE: Doi: ; OEt?1A21N SEXF: OD/2tf2D09
BLUE CROSS OUT OF 3605 WIALPHA
N
MRN: 0776544
FIN: 13395499
Department of Emergenc y Medicine lrcecora
Date: Temp: 0.1 Rectal Pulse RR BP 02 sat
I
dT
E;
LIMP
ED Pathway
Room Tittle
Physklen Time
CC: PMH:
HPI:
Mods:
Allergies:
Y N Location Ouality Onset
i FHx: Cardiac Y N Diabetes Y N
n:
Pa Radiation Quantity 110 11 Factors
ROS: Unobtainab le - Y N As noted , other Sterns negative Y N Olher.
Constitutional: Wt Change N Y Fewer N Y Chills N Y Weakness N Y Fatigue N Y Soc Hx: ETOH Y N Smoker Y N PPD
Eyes: BkM vision N Y Diplopta N Y E Pain N Y PI DWFOhia N
Other:
ENT, mouth: Sore throat N Y E taxis N Y Ear Pain N Y Rhirtorthea N Y
N Y
3d
l
` Lebo-j-- , Stkidtes:
Cardiovascular: Chest in N Y Pleuritic N Y Exertion N Y al
ms
811
1
R rn N Y Sputum N Y Noma N Orth ea N Y Whee2in N Y
b
hil
N
GI: Ahd Pain N Y Nausea N Y Consti aliDn N Y Diarrhea N Y W
eu
}-`
N Y Y waft
N
/ Ca
N Y j1pphaftla N. Y
N Y M9
Other:
Tmponin I- Myogbbin:
AIM Physical ERam- Rectal: Hemocutt (* 1 (-) PT: PTT:
INR:
T. Bill: Ark Phos:
ALT.
Amylase: Lipase:
UTA: U-HCG (*) ( )
Dntg Screen:
Cultures: Blood 1 2 Unne
Rafidrol' .3cfiedt'b"ozltradi'?' ..I
Study #1:
p See attached PROGRESS NOTE for additional infomtalion: OResult.
MDNI I DWOentlal Diagnosis: 3) B)
7) Study #2:
1) 4)
2) 5) 8) 11 Result
Procedure Note: Study #3:
O Result
EKG:
ED course: Treatment: x' H? Ti '
"Cansult'f7"viie k`°;::a=''`z.tt:°_!l,SS!. -
t)
2)
Response:
a s '° z
Diagnoses Ih .!lent ., -. Wilds "
•,:,
r O Dehydration
A. Fib 17 23M O4 day ? Chest Pain
Discharge Instructions: ease go dlr criecK out sacrata PAIUN too a DVT ? 23hr ? 5 day ? 23hrfrauma
?Com. Acq. Penunonia ? CatklMls
Follow up will
/6f/r
1)
Retum tD emer nc dapart t H
2)
3)
i: Drc"&Tluin?7e;.•
R ' JUNPJS`liide"'S t?re.'SZ
: : a iidlnlalon'1-;.Y. Transtek
V .
.
o• ? Resolved Service. Where:
Improved
'rime: rJ Cctre tomt
? No charas
MR 818 page t of t Rev. 2o9 7' 40 ? 18 paw ??IRIA1I D artmen Emergency Medicine Record
11111 IN 11 Page 16 of 2f
P'ENNSTATE HERSHEY
Milton S. Hershey
VP Medical Center
Patient Name: KALFAS, ANN E MRN 0776544
---------- ..,___._---------- ___---- ......................
ED Assessment Form
DOCUMENT TYPE:
RESULT STATUS:
PERFORM INFORMATION:
SERVICE DATE/TIME:
Piriiiir a ry 1E' -1
Adequate Pain Control Primary: No Pain
t
IIJD(1+leita?euis?eii(
..... ...
ED-Mental Assessment Affect: Appropriate
ED Neuro: No Complaints
Pupil Size, Left: 3.0
Pupil Size, Right: 3.0
ED-Mental Assessment-Thoughts: Coherent
ED Mental Status: Alert, Conscious, Oriented x 3
ED-Mental Assessment-Memory: Intact
ED Speech: Coherent
ED Gait: Steady
Pupil Description
Pupil Size, Left
Pupil Description
Regular
Pupil Reaction
Brisk
Pupil Size, Right
Pupil Description
Regular
Pupil Reaction
Brisk
F A>y? A
Eye Power Grid
Eye, Left not within defined limits
No abnormalities
Eye, Right Not within Defined Limited
Swelling
Ear Power Grid
Ear, Left not withing defined limits
No abnormalities
Ear, Right not withing defined limits
No abnormalities
Nares Power Grid
Nares, Left not within defined limits
No abnormalities
Nares, Right not within defined limits
Date/Time Printed: 9/21/2009 08:32 EDT
Printed By: Tice, Cindy L
ED Assessment Form
Final
Donavos, George K (8/21/2009 16:34 EDT)
8/21/2009 16:34 EDT
Page 17 of 28
PENNSTATE HERSHEY
Milton S. Hershey
4P Medical Center
Patient Name: KALFAS, ANN E
ED Assessment Form
No abnormalities
ED-Throat: No Complaints
ED-Integument: Dry, Pink, Warm
ED-Abdomen: Non-Tender, Soft
ED-GI: No complications
ED-GU assessment: No complications
ED Assessments Bowel Sounds Grid
LLQ:
Present
LUQ:
Present
RLQ:
Present
RL1Q:
Present
16.
ED-Cardiovascular: No Complaints
Monitor: No
ED Chest Pain: No
Pulse Grid
Dorsalis Pedis Pulse, Left:
2+ Normal
Dorsalis Pedis Pulse, Right:
2+ Normal
Radial Pulse, Left:
2+ Normal
Radial Pulse, Right:
2+ Normal
ED Respirations: No Complaints, Airway Patent, Symmetric, Unlabored
Breath Sounds Detailed Assessment Grid
B LL:
Clear
B UL:
Clear
LLL:
Clear
LUL:
Clear
RLL:
Clear
RML:
MRN 0776544
Date/Time Printed: 9/21/2009 08:32 EDT Page 18 of 28
Printed 6y: Tice, Cindy L
PENNSTATE HERSHEY
F1 Milton S. Hershey
VP Medical Center
Patient Name: KALFAS, ANNE MRN 0776544
- ------------------------------------- - - -------------------------------------- - - - ---- -- - ----
ED Assessment Form
Clear
RUL:
Clear
?i i r ? it #itt l
Interdisciplinary Narrative Discipline: Nursing
Interdisciplinary Narrative Text: pt mother, states swelling noted this am, called MD told to come in secondary to post
traumatic swelling continue to monitor awaiting plastics to assess
Date/Time Printed: 9/21/2009 08:32 EDT Page 19 of 28
Printed By: Tice, Cindy L
PENNSTATE HERSHEY
1 Milton S. Hershey
Medical Center
Patient Name: KALFAS, ANN E
DOCUMENT TYPE:
RESULT STATUS:
PERFORM INFORMATION:
SERVICE DATE/TIME:
MRN 0776544
ED Triage Form
ED Triage Form
Final
Smith, Justin T (8/21/2009 16:11 EDT)
8/21/200916:11 EDT
i ?..
Chief Complaint: pt s/p mvc with broken nose on wed, pt has new facial swelling here for re-check
Mode of arrival-ED: Ambulatory, Private Vehicle
Pre-Hospital treatments?: No
Pregnancy Status: Patient denies
Last Tetanus: <5 Years
Nursing Home Resident: No
During last month felt down or depressed: Unable to obtain
During last month felt little interest: Unable to obtain
Allergy / Reaction
NKA
?ig ftf???ig?tiS
Temperature Route: Oral
Temperature: 36.5 DegC
Heart Rate: 72 bpm
Respiratory Rate: 15 br/min
Oxygen Saturation: 99 %
Oxygen Therapy: None
Systolic Blood Pressure: 115 mmHg
Diastolic Blood Pressure: 43 mmHg
BP Location # 1: Left Arm
Patient Weight: 49.900 kg
Weight: 49.900 kg
Weight Method: Patient stated
Eye Opening Response Peds Coma: Spontaneously
Best Verbal Response Peds Coma: Oriented and converses
Best Motor Response Peds Coma: Obeys
Pediatric Coma Score: 15
Fi'u iG?iE? ::_A6 0S3Irt l
..., .. ...
ADLs: Independent
Gait: Steady
Have You Fallen Twice in Six Months: No
Pefls Me'd ii-L I
.... .........
Peds Medical HX I HEENT
Denies:
Patient
Peds Medical HX I Gastrointestinal Grid
Date/Time Printed: 9/21/2009 08:32 EDT
Printed By: Tice, Cindy L
Page 20 of 28
PENNSTATE HERSHEY
PIMI Milton S. Hershey
VP Medical Center
Patient Name: KALFAS, ANNE
MRN 0776544
ED Triage Form
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 I-IX I Muse Grid
Denies:
Patient
P?ds:=:lVledl?aE::H?:??
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 One Grid
Denies:
Patient
RR-Ttbac-Ttn' Ma
.... ...... ..
DCP Generic Code
Tracking Reg. Status
Start
Triage Time
08/21/09 16:13
Tracking Group
EvlER irk Gp
Visit reason
Date/Time Printed: 9/21/2009 08:32 EDT Page 21 of 28
Printed By: Tice, Cindy L
PENNSTATE HERSHEY
Milton S . Hershey
1p Medical Center
MRN 0776544
Patient Name: KALFAS, ANN E
---------------------------------------
ED Triage Form
Facial Injury
Tracking Acuity
4
Page 22 of 28
Date/Time Printed: 9/21/2009 08:32 EDT
Printed By: Tice, Cindy L
PENNSTATE HERSHEY
Milton S. Hershey
VP Medical Center
Patient Name: KALFAS, ANNE MRN 0776544
___..--------- ________________________________________--------------------------- ,_____
Interdisciplinary Narrative Form
DOCUMENT TYPE:
RESULT STATUS:
PERFORM INFORMATION:
SERVICE DATE/TIME:
Interdisciplinary Narrative Form
Final
Donavos, George K (8/21/2009 18:16 EDT)
8/21/2009 18:16 EDT
nit± lrt is i--ir----N i .......
Interdisciplinary Narrative Text: pt mother given d.c instructions understanding pt to home no further complaints
voiced
Date/Time Printed: 9/21/2009 08:32 EDT
Printed By: Tice, Cindy L
Page 23 of 28
PENNSTATE HERSHEY
1 Milton S. Hershey
RP Medical Center
Patient Name: KALFAS, ANN E MRN 0776544
------------ - ---- ---------------- --- - -- - -------- ------ --------
Allergy History
Substance NKA
Recorded Date/Time Recorded By
.. ...... .. ... ...
10/16/2004 16:09 EDT :Wilson, Dorothy Reaction Status Active; Allergy Type Allergy; Reviewed By Wilson,
Dorothy ; Reviewed Date/Time 10/16/2004 16:09 EDT; Recorded On
Behalf Of Wilson, Dorothy
..... _....... --
Date/Time Printed: 9/21/2009 08:32 EDT Page 24 of 28
Printed By: Tice, Cindy L
PENNSTATE HERSHEY
iXT. Milton S. Hershey
VP Medical Center
Patient Name: KALFAS, ANN E
MRN 0776544
Orders
. . .... ...... .........................
Order Date/Time: 8/2112009 17:44 EDT
Order. Document Infusion Stop Date/Time on EMAR
Order Status: Completed Catalog Type: Patient Care
Ordering Physician: SYSTEM, SYSTEM
Entered By: Donavos, George K on 8/21/2009 18:11 EDT
Order Details: 08/21/09 17:44:51, ONCE, Stopping On 08/21 /09 17:4451
_.... .....__. .._ ..... .......... ..............
........
Order Comment: Document Infusion Stop Date/Time on EMAR
..... ........
_.
Date/Time Printed: 9/21/2009 08:32 EDT Page 25 of 28
Printed By: Tice, Cindy L
PENNSTATE HERSHEY
Milton S. Hershey
4P Medical Center
Patient Name: KALFAS, ANN E
__.__ - -
r ers
MRN 0776544
Qrder Date/Time: 8/2112009 17:44 EDT
Order: Discontinue IV .. .. . .. ...
Catalog Type: Patient Care
Order Status: Completed ........ ...... ...
Ordering Physician: Shannon, Jacob S .... . . .....
Entered By: Donavos, George K on 8/21/2009 18 11 EDT
Order Details. 08/21!09 17:44:00, ONCE, Stopping On 08/21/09 17:44 ,00 ............................... ..........
Order Comment:
Order Date/Time, 8121/2009 17:44 EDT
Order. Discharge from ED. ...
Catalog Type: Patient Care
Order Status: Completed
Ordering Physician: Shannon, Jacob
Entered By Donavos, George K on 8%21/2009 18.11 EDT
Order Details. Routine, Requested Discharge Dt 08/21/09 17:44:00, Routine
Order Comment: - ...
Order Date/Time 8/21/2009 16:30 EDT
Order: Physician Consuls Request (Consult, Physician)
- g Type: Consults
:Order Status: Co m pleted Catalo
-
Ordering Physician Kass, Lawrence E .. ..... ..
Entered By: Grella, Venus on 8/21/2009 16.46 EDT
Order Details: STAT, Requested Dt: 08/21/0916:30:00, Service: Plastic Reconstructive Surgery, Reason: called in by you
w/ facial swelling 2 d s/p MVA with intraoral injury, I have or will contact the physician directly, Kass/ED
Order Comment:
Order Date me: 8121/2009 15:51 EDT
Order Safety Wristband Verification ... .. .
Order Status: Discontinued Catalog Type: Patient Care
Ordering Physician: SYSTEM, SYSTEM _
Entered By SYSTEM, SYSTEM on 8/21/2009 22.00 EDT
Order Details: 08/21/09 15:51:00, Midnight
Order Comment: Safety Wristband Verification -- - - --- -
................. _
Order date/Time: $/21!2009 15:50 EDT
Order Ped Skin Assessment on Arrival .. __- . .. .. - -
Catalog Type: Patient Care
:Order Status: Discontinued ,,,,,,,,,,,,,,,,,,,, , ,,,,,, ,,,, „ ,,,,.....................
Ordering Physician SYSTEM, SYSTEM
Entered By: SYSTEM, SYSTEM on 8/21/2009 22:00 EDT
Order Details: 08121/09 15:50-59 - - -
Order Comment: Ped Skin Assessment on Arrival
Date/Time Printed: 9/21/2009 08:32 EDT Page 26 of 28
Printed By: Tice, Cindy L
PENNSTATE HERSHEY
FM Milton S. Hershey
4p Medical Center
Patient Name: KALFAS, ANNE MRN 0776544
Orders
Order Date/Time: 8/21/2,009 15:50 EDT
Order ED Visit
Order Status: Completed Catalog Type: Patient Care
........................................................................................................................................................
Ordering Physician: SYSTEM, SYSTEM
Entered By: SYSTEM, SYSTEM on 8/21/2009 15:50 EDT 11 Order Details: Request Dt: 08/21/09 15:5059
.......... ........ ....... __.......... . ...........
Order Comment: ED Visit
Date/Time Printed: 9/21/2009 08:32 EDT Page 27 of 28
Printed By: Tice, Cindy L
PENNSTATE HERSHEY
1 Milton S. Hershey
Ip Medical Center
Patient Name: KALFAS, ANN E MRN 0776544
-------- - - ------ - -----------
...................................................................
................................
Recorded Date
Recorded Time
Recorded By
Procedure Units
Patient Weight kg
Height /Weight Measurements
......................
Weight
8/21 /2009
16:11 EDT
Smith, Justin T
49.900
Date/Time Printed: 9/21/2009 08:32 EDT Page 28 of 28
Printed By: Tice, Cindy L
PENNSTATE HERSHEY
W Milton S. Hershey
MP Medical Center
Patient Name: KALFAS, ANN E
M RN : 0776544
Date of Birth: 1/21/1997
Patient Gender: Female
Penn State Hershey Tel: (717) 531-8055
Milton S. Hershey Medical Center
Health Information Services, HU24
500 University Drive
P.O. Box 850
Hershey, PA 17033-0850
Visit Number: 13383792
Visit Type: Emergency
Patient Location: EMER; ;
...............................................................................................................................................................................................
Consent
..........................
:............................................................................................................................. .......................... ..................
Date/Time Printed: 9/21/2009 08:33 EDT
Printed By: Tice, Cindy L
Page 1 of 35
Patient Name: KALFAS, ANN E
Date of Birth: 1/21/1997
PENNSTATE HERSHEY
PM Milton S. Hershey
® Medical Center
CONSENT FOR MEDICAL TREATMENT
M R N: 0776544
FIN: 13383792
NAND-KALFA$, ANN E
W9r: 778544
003II:q1NNM
1D: KIWK YABK MDR; 46304
Doe: 01121 t1997 VISIT DATE* 06119/2008
EM
E11
LOG;
SEX: F
INS; II II ? our of SW9 W/ALPHA
p
p
( •. i<
MEDICAL AND SURGICAL CONSENT FOR TREATMENT: The undersigned is under the
care of his/her attending physician(s) and hereby consents to and authorizes the Milton S.
Hershey Medical Center (MSHMC) to provide the necessary medical treatments (including
Emergency Department services), surgical procedures, anesthesia, x-ray examinations or
treatments, laboratory procedures, drugs and supplies to the patient as ordered or requested
by the Professional Clinical Staff of the MSHMC. I acknowledge that'no guarantee or
assurance has been made as to the results of medical treatments, surgeries, or examinations.
For the purpose of advanced medical knowledge, I consent to the presence of medical
students and other health care trainees. I understand they may participate in my care under
the direct supervision of my attending physician(s).
PATIENTS RIGHTS AND RESPONSIBILITITES: I acknowledge that MSHMC 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.
HOSPITAL MEDICAL RECORD RELEASE AUTHORIZATION: I acknowledge that the
MSHMC Privacy Notice has been made available to me. I understand that MSHMC may
disclose information about me and the treatment I am receiving, for purposes of continuous
0 treatment, payment and health care operations.
I agree to hold harmless MSHMC its officers, directors and employees and agents, from any
and all liability, loss, claims, or damages relative to the release of such information.
ASSIGNMENT OF BENEFITS: I assign and authorize payment directly to MSHMC.
authorize any holder of medical or other information about me to release to my insurance a
• carrier and its agents any information needed to determine these benefits or benefits for
related services.
I, the undersigned, certify that I have read, understand, and agree to the provisions contained
within the consent form. The issues addressed on this form have been fully explained to me.
have had the opportunity to ask questions, and all of my questions have been answered to my
satisfaction- I
(Patient's signature or signature ? person consenting on behalf of the patient)
•
MR 1181 Rev. 10108 Page 1 of 1
Ion?IINIII®IMIIIB CONSENT FOR MEDICAL TREATMENT
S4?y
Oa e)
(Dot )
White Copy - Medical Records
Yellow Copy - Patient
Page 2 of 3!
c.,,.iur„caner
PENNSTATE HERSHEY
11 Milton S. Hershey
4P Medial Center
Patient Name: KALFAS, ANN E
RESULT STATUS:
DOCUMENT SUBJECT:
ELECTRONICALLY SIGNED BY:
CONSULT
Name: KALFAS, ANN E
HMC Number: 776544
DOB: 01/21/1997
Dale of Service: 08/19/2009
CHIEF COMPLAINT: Oral laceration
MRN 0776544
Consult
Final
Mackay, Donald R (8/20/2009 11:02 EDT); Grunfeld, Robert
(8/20/2009 09:41 EDT)
HISTORY OF PRESENT ILLNESS: A 12-year-old female patient, back seat passenger side, involved in a motor vehicle
collision. Patient was seatbelted at the time of injury, no loss of consciousness. Patient recalls being thrown forward
during the motor vehicle collision and hit her face on the seat in front of her. Mom is with her and is also being seen
by us for left metacarpal fracture digits 3 and 4. Patient complains of bleeding from the laceration site at her mouth
and headaches, frontal bilaterally, bandlike in quality. Patient also complains that her nose feels stuffy. No loss of
consciousness, no seizures, no nausea, vomiting, no vertigo. No diplopia, no blurry vision. No fevers, no chills. No
braces, no glasses, no retainer, no change in vision, smell, or taste.
PAST MEDICAL HISTORY: Noncontributory
PAST SURGERIES: None
SOCIAL HISTORY: She is going to start grade 7 later on this month. She lives with parents. There are no smokers in the
house.
MEDICATIONS: None
ALLERGIES: None
PHYSICAL EXAMINATION: A 2 cm 2-3 mm left of the frenulum in the upper gum, mucosal tear. No debris, no foreign
body noted. Wound is clean.
Face examination:
Sensation: Trigeminal nerve bilaterally, V1 to V3 intact.
Mandible: No malocclusion noted, no mandibular instability noted. No pain on palpation to mandible bilaterally. No
broken teeth or other dental abnormalities noted on examination.
No maxillary tenderness bilaterally, and no frontal sinus tenderness bilaterally, and no skull lacerations. Cranial nerves in
head and neck are fully intact and tested.
No nasal abnormality externally noted. Otoscope examination of bilateral nares reveals dried blood in left nostril. No
tenderness, no acute bleeding, and no pain currently.
Date/Time Printed: 9/21/2009 08:33 EDT Page 3 of 35
Printed By: Tice, Cindy L
PENNSTATE HERSHEY
Milton S. Hershey
Jp Medical Center
Patient Name: KALFAS, ANN E
MRN 0776544
Consult
............................................................................................
Extraocular movements are intact in all cardinal directions. No other injuries noted.
Vital signs: Temperature 36.1, heart rate 73, blood pressure 127/81, 97% OZsats, patient weighs 49.9 kg.
CT scan head and face done.
Radiology Exam in ation/ Report Findings: There is a comminuted fracture of the anterior nasal spine noted. Mandible is
intact. TMJ anatomically aligned bilaterally. No other facial fractures are seen.
Paranasal sinuses show a mild circumferentially mucosal thickening, particularly in her left maxillary sinus. Mastoid, air
cells, and middle ear cavities are clear. Imaged intracranial structures are unremarkable. Orbits, and orbital contents
were intact.
ASSESSMENT AND PLAN: A 12-year-old female status post motor vehicle collision. Oral mucosal tear with anterior
nasal spine comminuted fracture.
1. Running chromic sutures used for reapproximation of oral mucosa along frenulum. A bilateral infraorbital block was
used for local anesthesia.
2. Followup: Dr. Coldren and Plastics clinic in one week time.
3. Antibiotic coverage double. Dicloxacillin 250 mg t.i.d. one week given to patient.
4. Soft foods for one week.
5. Patient advised to call Plastic Surgery Resident on call at 531-8521 in case has increased pain, bleeding, difficulty
bleeding through the nose, increased headache, vertigo, or any changes in vision, smell, or taste.
870468
Electronic Signature on File
Electronically ReviewediSigned by: Robert Grunfeld, MD Author Signature Dt/Tm20.08.2009 09:41 AM
Electronically Reviewed/Signed by: Donald R Mackay, MDCosigner Signature Dt/Tm: 20.08.2009 11:02 AM
RG IMF DD: 08/19/09 DT: 08120109 08:28 AM
Date/Time Printed: 9/21/2009 08:33 EDT Page 4 of 35
Printed By: Tice, Cindy L
PENNSTATE HERSHEY
Milton S. Hershey
Medical Center
Patient Name: KALFAS, ANN E MRN 0776544
ED Discharge Instructions
:.................................... ........ ............................................... -------- ........................................................................»..........
RESULT STATUS: Modified
DOCUMENT SUBJECT: ED Pat Edu
ELECTRONICALLY SIGNED BY:
ED Pat Edu
Penn State Milton S. Hershey Medical Center
Emergency Department Discharge Instructions
Name: ANN KALFAS DOB: 1/21/1997
Chief Complaint: MVC
MRN: 0776544 Visit Date: 08/19/2009 12:33:00
FIN: 13383792 Current Date: 08/19/2009 18:03:42
Address: 350 NORTH 27TH ST CAMP HILL PA 170110000
Phone: (717)730-0798
Primary Care Provider:
Name: Coldren, Robert L
Phone: (717) 791-2680
Emergency Department Care Providers:
Primary Physician: Fischer, Michelle A
Secondary Physician:
IMPORTANT: We examined and treated you today on an emergency basis only. This was not a
substitute for, or an effort to provide, complete medical care. In most cases, you must let your doctor
check you again. Tell your doctor about any new or lasting problems. We cannot recognize and
treat all injuries or illnesses in one Emergency Department visit. If you had special tests, such as
EKG's or X-rays, we will review them again within 24 hours. We will call you if there are any new
suggestions. After you leave, you should follow the instructions below.
Follow-Up Instructions
ANN KALFAS has been given these follow-up instructions:
Follow Up With: Where: When:
Robert Coldren 25 West Shore Drive Within Call
Camp Hill, PA 17011-0000 physician within
(717) 791-2680 Business next business day
Comments:
Date/Time Printed: 9/21/2009 08:33 EDT
Page 5 of 35
Printed By: Tice, Cindy L
PENNSTATE HERSHEY
1 Milton S. Hershey
Medical Center
Patient Name: KALFAS, ANN E MRN 0776544
»». ED Discharge instructions
,.,»,»,.,,.,»,» .................................
follow up with the plastics clinic as they've arranged
SMOKING is a major health issue.
-Smoking greatly increases the risk of heart disease, cancer, and stroke.
-If you and your family don't smoke, contine this healthy choice!
-Remember to avoid secondhand smoke.
-If you or anyone in your household does use tobacco products, please
follow any smoking cessation advice/counseling you received while in the
hospital.
-If you would like more information about how to live tobacco-free, please
call one of the numbers below.
PSHMC Smoke Cessation Program 1-800-243-1455
Pennsylvania QUITLINE 1-877-724-1090
Are you or someone you love at the risk of suicide?
Seek help as soon as possible by contacting a mental health professional or by calling:
NATIONAL SUICIDE PREVENTION LIFELINE
AT 1-800-273-8255 (TALK)/1-800-273-8255
Patient Education Materials
ANN KALFAS has been given the following patient education materials:
TRAUMA
FRACTURED NOSE [with x-ray]
A fracture may be a minor hairline crack in the bones of the nose- It may also be more serious if the broken
parts are pushed out of place. A fractured nose causes pain, swelling and nasal stuffiness. Sometimes, there
is also bleeding.
A minor fracture will heal in about 3-4 weeks with no additional treatment needed. A serious fracture, causing a
change in shape of the nose, will require straightening of the nasal bones by an ENT doctor (nose specialist).
The best time to do this is immediately after the swelling has gone down, but not more than seven days after
theniurr.
HOME CARE:
Date/Time Printed: 9121/2009 08:33 EDT Page 6 of 35
Printed By: Tice, Cindy L
PENNSTATE HERSHEY
Milton S. Hershey
qP Medical Center
Patient Name: KALFAS, ANN E MRN 0776544
ED Discharge Instructions
1) Apply an ice pack to the nose for 10 minutes every 2 hours during the first 24 hours to reduce pain and
swelling. Continue this four times a day for the next two days.
2) Do not take aspirin-containing medicines since these may promote nose bleeding, You may take Tylenol
(acetaminophen) or ibuprofen (Advil, Motrin) for pain, unless another pain medicine has been prescribed.
3) When blowing your nose, do it gently so you don't cause bleeding.
FOLLOW UP with your physician or this facility as advised. If your nose appears crooked when the swelling goes
down, contact the ENT referral doctor for an appointment within seven days of injury.
[NOTE: Any X-rays taken will be reviewed by a radiologist. You will be notified if there are new findings
that may affect your care.]
RETURN PROMPTLY or contact your doctor if any of the following occur:
-- Continued bleeding from the nose that is not controlled by pinching the nostrils together for five
minutes
-- Increasing facial swelling, pain or redness of the skin over the nose
-- Temperature of 100' F (37.8' C)
-- Headache, excessive drowsiness, repeated vomiting or dizziness
-- Unable to breathe from both sides of the nose after swelling goes down
-- Sinus pain
LACERATION (follow up with the plastics clinic as they've arranged) [all]
A LACERATION is a cut through the skin. This will usually require stitches if it is deep. Minor cuts may be
treated with a tape closure ("Steri-Strips") or Dermabond skin glue.
HOME CARE:
1) EXTREMITY. FACE or TRUNK WOUNDS: Keep the wound clean and dry. If a bandage was applied and it
becomes wet or dirty, replace it. Otherwise, leave it in place for the first 24 hours.
-- If sutures were used, clean the wound daily:
-- After removing the bandage, wash the area with soap and water. Use Hydrogen Peroxide on a cotton
swab (Q tip) to loosen and remove any blood or crust that forms.
-- After cleaning, apply a thin layer of Neosporin or Bacitracin ointment. This will keep the wound clean
and make it easier to remove the stitches. Reapply the bandage.
-- You may shower as usual after the first 24 hours, but do not soak the area in water (no tub baths or
swimming) until the sutures are removed.
-- If a Steri-Strips tape closure was used, keep the area clean and dry. If it becomes wet, blot it dry with a
towel. After the Steri-Strips have been removed it is safe to resume your usual activities.
-- If Dermabond skin adhesive was used, do not scratch, rub or pick at the adhesive film. Do not place
tape directly over the film. Do not apply liquid ointment or creams to the wound while the film is in place.
Do not clean the wound with peroxide and do not apply ointments. Avoid activities that cause heavy
sweating until the film has fallen off. Protect the wound from prolonged exposure to sunlight or tanning
Date/Time Printed: 9/21/2009 08:33 EDT Page 7 of 35
Printed By: Tice, Cindy L
PENNSTATE HERSHEY
PM Milton S. Hershey
Jp Medical Center
Patient Name: KALFAS, ANN E MRN 0776544
- ------ - - -- - - ------------------------------------ - - -- - - ----- --------
ED Discharge Instructions
lamps. You may shower as usual but do not soak the wound in water (no baths or swimming). The film
will fall off by itself in 5-10 days.
2) SCALP WOUNDS: During the first two days, you may carefully rinse your hair in the shower to remove
blood, glass or dirt particles. After two days, you may shower and shampoo your hair normally. Do not touch
the stitches. Do not soak your scalp in the tub or go swimming until the stitches have been removed.
3) MOUTH WOUNDS: Eat soft foods to reduce pain. If the cut is inside of your mouth, rinse after each meal
and at bedtime with a mixture of equal parts water and Hydrogen Peroxide (do not swallow!). Or, you can
use a cotton swab to directly apply Hydrogen Peroxide onto the cut.
FOLLOW UP: Most skin wounds heal within ten days. Mouth and facial wounds heal within five days. However,
even with proper treatment, a wound infection may sometimes occur. Therefore, you should check the wound
daily for signs of infection listed below.
Stitches should be removed from the face within five days; stitches should be removed from other parts of the
body within 7-14 days. If dissolving sutures were used in the mouth, these will fall out or dissolve without the
need for removal. If TAPE CLOSURES ("Steri-Strips") were used, remove them yourself after five days unless
told otherwise. If Dermabond skin glue was used, the film will fall off by itself in 5-10 days.
RETURN PROMPTLY or contact your doctor if any of the following SIGNS of INFECTION occur:
-- Increasing pain in the wound; or fever over 995F (375C) oral
-- Redness, swelling, or pus coming from the wound
-- If sutures come apart of fall out or if Steri-Strips fall off before your next appointment
-- If the wound edges re-open
-- Numbness near the wound, at the time of suture removall
Patient Visit Summary
ANN KALFAS has been given the following list of patient education materials and follow-up
instructions:
Patient Education Materials:
TRAUMA
NASAL FRACTURE, confirmed
LACERATION, All
FolLow-Up_Instructions:
Follow Up With: Where: When:
Date/Time Printed: 9/21/2009 08:33 EDT Page 8 of 35
Printed By: Tice, Cindy L
PENNSTATE HERSHEY
1 Mi ton S. Hershey
jP Medical Center
Patient Name: KALFAS, ANNE MRN 0776544
ED Discharge Instructions
Robert Coldren 25 West Shore Drive Within Call
Camp Hill, PA 17011-0000 physician within
(717) 791-2680 Business next business day
Comments:
follow up with the plastics clinic as they've arranged
I, ANN KALFAS, have received the above patient education materials/instructions and have
verbalized understanding:
Patient Signature Date
MRN: 0776544 FIN: 13383792
Date/Time Printed: 9/21/2009 08:33 EDT
Printed By: Tice, Cindy L
Provider Signature Date
Page 9of35
PENNSTATE HERSHEY
Milton S. Hershey
jr Medical Center
MRN 0776544
Patient Name: KALFAS, ANN E
ED Depart Summary
RESULT STATUS:
DOCUMENT SUBJECT:
ELECTRONICALLY SIGNED BY:
Final
Depart Summary
Depart Summary
Penn State Milton S. Hershey Medical Center Emergency Department Depart Summary
PERSON INFORMATION DOB 1!2111997 12:00 AM
Name K ALFAS, ANN E Age 12 Years
PCP Coldren, Robert L
Sex Female
Language
Phone (717)730-0798
Nlariud Status Single Acctli 13383792
MRN 0776544 Visit Id
Visit Reason MVC Specialty
Med Service Emergency Medicine
Referred by
Enc Type Emergency
Track Group EMER Trk Gp
Discharge 8(19/2009 6:00 PM
Tracking Id 10629189 Checkout 811912009 6:03 PM Dispo Type Routine Dsch
Checkin 8119/2009 12:33 PM Acuity 4
Reg Status Start
LOS 000 05:30
Arrival 8/19/2009 12:33 PM
Address:
350 NORTH 27TH ST CAMPHILL PA 1
70110000
DIAGNOSIS
intraoral laceration and nasal fracture
POWERFORMS
SCHEDULING
PHYS DOC NOTES
DEPART REASON INCOMPLETE INFORMATION
PROVIDER INFORMATION
Role Assigned Unassigned
Provider ?
12:52 PM
009
81191 8119/2009 1:07 PM
Rebekah L
Grumbrecht, R.E.S. _
12:54PM
9/19/2009 8/19/2009 1:14 PM
Bachmann,
Bachmann, Chande RN
S
E
K 8119/2009 1:10 PM
Gozlrausky, Dan
Burgner, Barbara A .
.
.
Clerical 8119/2009 1:11 PM
8119/2009 1:17 PM
8/19/2009 3:31 PM
English, Lori A
l
A RN
Physician 8119/2009 1:25 PM
e
Fischer, Michel 8/ 1912009 3:31 PM
Ackerson, Shannon E
Page 10 of 35
Date/Time Printed: 9/21/2009 08:33 EDT
Printed By: Tice, Cindy L
PENNSTATE HERSHEY
WITI Milton S. Hershey
1W Medical Center
Patient Name: KALFAS, ANN E
MRN 0776544
ED Depart Summary ..........................................................
EVENTS INFORMATION
Event Name Event Status Request Date/Time Start Datelrime
Arrive Complete 8/19/2009 1233 PM 8/1912009 12:33 PM
Triage Complete 8/19/2009 12:33 PM 8/192009 12:55 PM
Arrive Registration Complete 8/1912009 12:33 PM 8/19/2009 12:33 PM
Registration Complete 8/1912009 12:33 PM 8/192009 2:56 PM
Arrive MD Bill Complete 8/1912009 12:33 PM 8/192009 12:33 PM
MD Bill Complete 8/192009 12:33 PM 8/1912009 5:15 PM
Arrive Dictate Complete 8/192009 12:33 PM 8/192009 12:33 PM
Dictate Request 8/192009 12:33 PM
Arrive PT Belongings Complete 8/192009 12:33 PM 8/192009 12:33 PM
Bed Assign PT Belong Complete 8/19/2009 12:33 PM 811912009 12:46 PM
Arrive Bed Assign Complete 8/19/2009 12:33 PM 8/19/2009 12:33 PM
Bed Assign Complete 811912009 12:33 PM 8/19/2009 12:46 PM
Arrive Med History Complete 8/192009 12:33 PM 811912009 12:33 PM
Med History Complete 8/19/2009 12:33 PM 8/1912009 12:56 PM
Arrive Update Attend Complete 81192009 12:33 PM 8/192009 12:33 PM
Update ED Attending Complete 8/19/2009 12:33 PM 8/19/2009 1:43 PM
RN Assess Complete 8/19/2009 12:46 PM 8/19/2009 2:51 PM
MD Assess Complete 8/192009 12:46 PM 8/1912009 1:25 PM
Resident Assess Complete 8/1912009 12:46 PM 8/19/2009 12:52 PM
Patient Belongings Complete 8/192009 12:46 PM 8/192009 4:15 PM
Resident Assess Complete 8/19/2009 12:54 PM 8/19/2009 12:54 PM
Resident Assess Complete 8/19/2009 1:10 PM 8/19/2009 1:10 PM
Resident Assess Complete 8/1912009 1:14 PM 8/192009 1:14 PM
Resident Assess Complete 8/192009 1:17 PM 8/19/2009 1:17 PM
Xray Complete 8/19/2009 1:25 PM 8/19/2009 3:27 PM
Xray Cancel 8/1912009 2:48 PM
Request Consult Complete 8/192009 3:17 PM
MD Assess Complete 8/192009 3:31 PM 8/192009 3:31 PM
Resident Assess Complete 8/19/2009 3:31 PM 81192009 3:31 PM
Xray Complete 811912009 3:42 PM 8119r-)009 3:55 PM
Consult Request 8/192009 3:59 PM
Discharge/ Transfer Complete 8/192009 5:37 PM
LOCATION INFORMATION
Arrival Nurse Unit Room
8/ 19/200912:33 PM EMER Triage
8/ 19200912:46 PM EMER 50
8/192009 1:08 PM EMER 30
8/19/2009 1:13 PM EMER 27
8119/2009 6:03 PM EMER Check Out
ORDERS INFORMATION
Start Time Order
8/ 192009 12:34 PM ED Nursing Charge
Type Status
Patient Care Completed
Slop Time
8/19/2009 6:03 PM
Complete Date/Time
8/19/2009 12:33 PM
8/19/2009 12:55 PM
8/1912009 12:33 PM
8/19/2009 2:56 PM
9/1912009 12:33 PM
81192009 5:15 PM
9/19/2009 12:33 PM
8/19/2009 12:33 PM
81192009 12:46 PM
S/ 19/2009 12:33 PM
8/19/2009 12:46 PM
8/19/2009 12:33 PM
8/192009 12:56 PM
8119/2009 12:33 PM
8/192009 1:43 PM
81192009 2:51 PM
8/192009 1:25 PM
8/19/2009 12:52 PM
8119/2009 4:15 PM
811912009 12:54 PM
8/192009 1:10 PM
8/192009 1:14 PM
8/192009 1:17 PM
8/19/2009 3:56 PM
8/ 19/2009 3:13 PM
8/192009 3:59 PM
8119/2009 3:31 PM
8/19/2009 3:31 PM
8/19/2009 3:56 PM
8119/2009 6:02 PM
Bed
Provider
SYSTEM
Date/Time Printed: 9/21/2009 08:33 EDT Page 11 of 35
Printed 6y: Tice, Cindy L
PENNSTATE HERSHEY
Milton S. Hershey
Jp Medical Center
Patient Name: K ALFAS, ANN E MRN 0776544
- --- - ------ - - ----------------
- - - - --- - --- - ---------- -- - ------
ED Depart Summary
8/19/2009 12:34 PM ED Visit Patient Care Completed 8119/2009 12:34 PM SYSTEM
8119/2009 12:34 PM Ped Skin Assessment Patient Care Completed 8119/2009 6:03 PM SYSTEM
on Arrival
8/19/200912:34 PM Safety Wristband Patient Care Ordered SYSTEM
Verification
8/20/2009 12:01 AM Safety Wristband Patient Care Ordered 8/2012009 12:01 AM SYSTEM
8/19/2009 1:25 PM Verification
CT Scans
Order Sets
Completed
8119/2009 3:56 PM
Gozhansky, Dan
8/19/2009 1:24 PM Facial Bones CT Radiology Completed 8/19/2009 3:56 PM Gozhansky, Dan
8/1912009 2:48 PM CT Scans Order Sets Discontinued 8/19/2009 3:13 PM Gozhansky, Dan
009 2:48 PM
8!19/ Coronal and/or 3D Radiology
gy Canceled 8/19/2009 3:13 PM Gozhansky, Dan
_ Reconstruction C-T
8/19/2009 3:17 PM Physician Consult Consults Completed 8119/2009 3:59 PM Gozhansky, Dan
8/1912009 3:42 PM Request
CT Scans
Order Sets
Completed
8119/2009 3:56 PM
Grunfeld, Robert
8/19!2009 3:41 PM Coronal and/or 3D Radiology
gy Completed 8/19/2009 3:56 PM Grunfeld, Robert
Reconstruction CT
8/1912009 5:37 PM Discharge (ED) Order Sets Completed 8/1912009 6:02 PM Gozhansky, Dan
8/1912009 5:37 PM Discharge from ED. Patient Care Completed 8/19/2009 6:02 PM Gozhansky, Dan
811912009 5:37 PM Discontinue IV Patient Care Completed 8/1912009 6:02 PM Gozhansky, Dan
Document Infusion
8/19/2009 5:37 PM Stop Date/Time on
EMAR Patient Care Completed 8119/2009 6:02 PM SYSTEM
8/20/2009 10:00 AM Ped Skin Assessment Patient Care Ordered 8/20/2009 10:00 AM SYSTEM
10:00 a.m.
8/1912009 6:03 PM Ped Skin Assessment Patient Care Ordered 8/19/2009 6:03 PM SYSTEM
on Arrival
MEDICAL INFORMATION
Allergy Info:
NKA
Prescriptions Given
DISCHARGE INFORMATION
Discharge Disposition: Routine Dsch
Discharge Location:
PATIENT EDUCATION INFORMATION
Instructions:
NASAL FRACTURE, confirmed; LACERATION, All
Follow, up:
Follow-Up With:
Address: When:
With:
25 West Shore Drive Camp Hill, PA 17011-0000 Within Call physician
Robert Coldren (717) 791-2680 Business within next business day
Comments:
follow up with the plastics clinic as they've arranged
Date/Time Printed: 9/21/2009 08:33 EDT Page 12 of 35
Printed By: Tice, Cindy L
PENNSTATE HERSHEY
1 1 Milton S. Hershey
Medical Center
Patient Name: KALFAS, ANN E
MRN 0776544
ED Depart Summary
Date/Time Printed: 9/21/2009 08:33 EDT Page 13 of 35
Printed By: Tice, Cindy L
PENNSTATE HERSHEY
1 Milton S. Hershey
Rr Medical Center
Patient Name: KALFAS, ANN E
RESULT STATUS:
DOCUMENT SUBJECT:
ELECTRONICALLY SIGNED BY:
Name: KALFAS, ANNE
HMC Number: 0776544
DOB: 01/21/1997
Date of Service: 08/19/2009
CHIEF COMPLAINT: Motor vehicle collision.
MRN 0776544
ED Summary
Modified
Gozhansky, Dan (9/2/2009 13:26 EDT); Fischer, Michelle A
(8120/2009 10:39 EDT)
ED SUMMARY
HPI: The patient is a 12-year-old female who was a restrained passenger in a motor vehicle collision earlier today. The
patient had no loss of consciousness. Patient denies any dizziness, blurry vision, headache, lightheadedness, nausea,
or vomiting. The patient is complaining of some pain in her nose and mouth. The patient has some bleeding coming
from her left naris and upper gums. Patient states that she is having no difficulty breathing, no shortness of breath. The
patient denies any chest pain, any back pain, any pain to her extremities.
REVIEW OF SYSTEMS: As per HPI, otherwise 10-point review of systems is negative.
PAST MEDICAL HISTORY: None.
MEDICATIONS: None.
ALLERGIES: No known drug allergies.
FAMILY AND SOCIAL HISTORY: Patient resides with her family in Camp Hill, Pennsylvania.
PHYSICAL EXAMINATION: Vital signs: Temperature 36.1, heart rate 73, blood pressure 127/81, respiratory rate 18,
oxygen saturation 97%. In general, this is a 12-year-old female who is breathing with unlabored respirations. She is
in no apparent distress other than the small amount of bleeding coming from her left naris and upper gums. HEENT:
Patient has left-sided epistaxis and a laceration to her midline upper gumline with nonarterial bleeding. Otherwise,
no other traumatic injuries noted to the patient's head or face. No hemotympanum. Extraocular movements intact.
Pupils equal, round, reactive to light. Neck: Supple; nontender to flexion, extension, and lateral rotation. No C-spine
tenderness. No lymphadenopathy. Chest: Nontender to palpation. Lungs: Clear to auscultation bilaterally. Heart:
Regular rate and rhythm. No murmurs, rubs, or gallops. Abdomen: Soft, nontender, nondistended. No rebound,
no guarding. Extremities: No cyanosis, clubbing, or edema. Nontender to palpation. Full range of motion of all 4
extremities. Neuro: Cranial nerves II through XII grossly intact. Motor and sensory exam within normal limits.
MEDICAL DECISION MAKING AND ASSESSMENT: This is a 12-year-old female presents to the Emergency
Department after a motor vehicle collision who sustained injuries to both her nose and mouth.
Page 14 of 35
DaterTime Printed: 9/21/2009 08:33 EDT
Printed By: Tice, Cindy L
PENNSTATE HERSHEY
P1 Milton S. Hershey
VP Medical Center
Patient Name: KALFAS, ANN E MRN 0776544
-------- - -------------------- - --- --- - --------- - - ----------- - - ---- ----------------
ED Summary
EMERGENCY DEPARTMENT COURSE: Patient was seen and evaluated by myself and Dr. Fischer within the
Emergency Department. Pressure was placed to the anterior of the patient's nose to stop the epistaxis, which controlled
the bleeding well. The patient was also sent for facial CT and Plastic Surgery was consulted for repair of the laceration
and evaluation pending the CT scan results. The CT scan demonstrated a comminuted nasal spine fracture and no
fracture to alveolar ridge or maxillary sinus. The patient was evaluated also for septal hematoma physically, and on
exam, there was no evidence of septal hematoma. Plastic Surgery repaired the laceration to the gumline using chromic
sutures. They provided the patient with prescription for dicloxacillin and arranged followup in clinic.
DIAGNOSTIC IMPRESSION: Nasal fracture and intraoral laceration.
PLAN: The patient was stable for discharge to home. The patient was instructed to return to the Emergency Department
should she have any worsening pain, fevers, chills, swelling, difficulty breathing, increased facial pressure, or any other
concerns. Otherwise, she is to follow up with Plastic Surgery as they have arranged.
870494
Staff:
This patient was seen and evaluated along with the EM resident. I agree with the above history, physical examination and
clinical impression.
Michelle Fischer MD, MPH
Electronic Signature on File
Electronically Reviewed/Signed by: Michelle A Fischer, MD Author Signature Dt/Tm:20.08.2009 10:39 AM
Electronically Reviewed/Signed by: Dan Gozhansky, MDCosigner Signature Dt/Tm: 02.09.2009 01:26 PM
MAF /CO DD: 08119109 DT: 08120109 06:29 AM
Date/Time Printed: 9/21/2009 08:33 EDT Page 15 of 35
Printed By: Tice, Cindy L
PENNSTATE HERSHEY
1 Milton S. Hershey
IV Medical Center
Patient Name: KALFAS, ANN E
MRN 0776544
Head/Neck ....................................................................
RESULT STATUS: Final
DOCUMENT SUBJECT: CT FACIAL BONES WITHOUT CONTRAST-PED
ELECTRONICALLY SIGNED BY:
SERVICE DATE/TIME: 8/19/2009 15:55 EDT
CT FACIAL BONES WITHOUT CONTRAST-PED
PATIENT NAME: KALFAS, ANN E
PATIENT MRN:00776544
PATIENT DOB: 01/21/1997
EXAM DATE OF SERVICE: 08/19/2009
EXAM NUMBER: 5660485
ORDERING PHYSICIAN: KIMAK, MARK
Exam: CT of the face without contrast. 3-D volume rendered reformats.
Clinical History: Facial bone fracture.
Comparison: None
Technique: Helical CT of the facial bones without contrast with coronal and sagittal reformats. Additionally, 3-
D image reconstructions were provided.
Findings: There is a comminuted fracture of the anterior nasal spine. The mandible is intact.
Temporomandibular joints are anatomically aligned. No other facial fractures are seen.
The paranasal sinuses show mild circumferential mucosal thickening particularly in the left maxillary sinus.
The mastoid air cells and middle ear cavities are clear. Imaged intracranial structures are unremarkable. The
orbits and orbital contents are intact.
3-D volume rendered reformats confirm these findings.
Impression: Comminuted fracture of the anterior nasal spine.
DICTATED: OUYANG, TAO
REVIEWED AND SIGNED: OITYANG, TAO
DATE DRAFTED: 08/19/2009 04:40 PM
DATE OF FINAL SIGNATURE: 08/19/2009 05:12 PM
Page 16 of 35
Date/Time Printed: 9/21/2009 08:33 EDT
Printed By: Tice, Cindy L
PENNSTATE HERSHEY
Mitton S. Hershey
RP Medical Center
Patient Name: KALFAS, ANN E
RESULT STATUS:
DOCUMENT SUBJECT:
ELECTRONICALLY SIGNED BY:
SERVICE DATE/TIME:
MRN 0776544
Other .................. »...
Final
CT 3D IMAGE RECONSTRUCTION -PED (Independent wk
stn)
8/19/2009 15:55 EDT
CT 3D IMAGE RECONSTRUCTION -PED (Independent wk stn)
PATIENT NAME: KALFAS, ANN E
PATIENT MRN:00776544
PATIENT DOB: 01/21/1997
EXAM DATE, OF SERVICE.: 08/19/2009
EXAM NUMBER: 5661320
ORDERING PHYSICIAN: FISCHER, MICHELLE
Exam: CT of the face without contrast. 3-D volume rendered reformats.
Clinical History: Facial bone fracture.
Comparison: None
Technique: Helical CT of the facial bones without contrast with coronal and sagittal reformats. Additionally, 3-
D image reconstructions were provided.
Findings: There is a comminuted fracture of the anterior nasal spine. The mandible is intact.
Temporomandibular joints are anatomically aligned. No other facial fractures are seen.
The paranasal sinuses show mild circumferential mucosal thickening particularly in the left maxillary sinus.
The mastoid air cells and middle ear cavities are clear. Imaged intracranial structures are unremarkable. The
orbits and orbital contents are intact.
3-D volume rendered reformats confirm these findings.
Impression: Comminuted fracture of the anterior nasal spine.
DICTATED: OUYANG, TAO
REVIEWED AND SIGNED: OUYANG, TAO
DATE DRAFTED: 08/19/2009 04:40 PM
DATE OF FINAL SIGNATURE: 08/19/2009 05:12 PM
Date/Time Printed: 9/21/2009 08:33 EDT
Page 17 of 35
Printed By: Tice, Cindy L
PENNSTATE HERSHEY
Milton S- Hershey
VP Medical Center
Patient Name: KALFAS, ANN E MRN 0776544
- - - ------- - - ------ - -- - ------- - -- -------- - --------- - --------- - - - ------ -
ED Assessment Form
DOCUMENT TYPE:
RESULT STATUS:
PERFORM INFORMATION:
SERVICE DATE/TIME:
ED Assessment Form
Final
English, Lori A (8119/2009 13:05 EDT)
8/1912009 13:05 EDT
Piri i .
Adequate Pain Control Primary: Yes
Pain Location: Other: MOUTH
Pain Quality: Dull
Pain Alleviating Factors: None
Pain Onset: Sudden
Pain Time Pattern: Acute
Pain Aggravating Factors: Movement, Palpation
Pain Associated Symptoms: None
P$#fi__ tie
Cultural Assessment: Yes
E = i 1; ni 4E -KAWi t on.
ED-Mental Assessment Affect: Appropriate
ED Neuro: No Complaints
Pupil Size, Left: 3.0
Pupil Size, Right: 3.0
ED-Mental Assessment-Thoughts: Coherent
ED Mental Status: Alert, Oriented x 3
ED-Mental Assessment-Memory: Intact
ED Speech: Coherent
ED Gait: Steady
Pupil Description
Pupil Size, Left
Pupil Description
Regular
Pupil Reaction
Brisk
Pupil Size, Right
Pupil Description
Regular
Pupil Reaction
Brisk
... .
Eye Power Grid
Eye, Left not within defined limits
No abrorma ities
Eye, Right Not within Defined Limited
No abnormalities
Date/Time Printed: 9/21/2009 08:33 EDT
Printed By: Tice, Cindy L
Page 18 of 35
PENNSTATE HERSHEY
Milton S. Hershey
4P Medical Center
Patient Name: KALFAS, ANN E MRN 0776544
.........................___..__...________________...____.______- _.___.
ED Assessment Form
Ear Power Grid
Ear, Left not withing defined limits
No abnormalities
Ear, Right not withing defined limits
No abnormalities
Nares Power Grid
Nares, Left not within defined limits
No abnormalities
Nares, Right not within defined limits
No abnormalities
ED-Throat: No Complaints
ED-Integument: Pink, Warm
ED-Abdomen: Non-Tender, Soft
ED-GI: No complications
ED-GU assessment: No complications
ED Assessments Bowel Sounds Grid
LLQ:
Present
LUQ:
Present
RLQ:
Present
RUQ:
Present
ED-Cardiovascular: No Complaints
Monitor: No
ED Chest Pain: No
Pacemaker: None
Pulse Grid
Radial Pulse, Left:
2+ Normal
Radial Pulse, Right:
2+ Normal
??=R€s?i?pr?lsses?iri<?nt
ED Respirations: Airway Patent
ED-Reproductive: No Complaints
ED-Fetal Movement: N/A
In :I T I m nary l? rrt?t Ve
Interdisciplinary Narrative Discipline: Nursing
Interdisciplinary Narrative Text: 1305 Assessment done. pt being eval by Bekaa PA-C. lerglish rr.
Date/Time Printed: 9/21/2009 08:33 EDT Page 19 of 35
Printed By: Tice, Cindy L
PENNSTATE HERSHEY
1 Milton S. Hershey
Jp Medical Center
Patient Name: KALFAS, ANN E MRN 0776544
ED Assessment Form
Eye Opening Response Peds Coma: Spontaneously
Best Verbal Response Peds Coma: Oriented and converses
Best Motor Response Peds Coma: Obeys
Pediatric Coma Score: 15
Communication Barrier Present: No
Primary Language: English
A in A edical l
Aortic Aneurysm Medical History
Denies:
Patient
Respiratory Adult Medical Hx I Grid
Denies:
Patient
HEENT Adult Medical History IIx I Grid
Denies:
Patient
Genitourinary Adult Medical IIx I Grid
Denies:
Patient
Denies GI History
Denies:
Patient
Musculoskeletal Adult Medical Hx I Grid
Denies:
Patient
Endocrine Adult Medical Hx II Grid
Denies:
Patient
Psychiatric Adult Medical Hx I Grid
Denies:
Patient
Neurological Adult Medical IIx I Grid
Denies:
Patient
Hematologic Adult Medical Hx II Grid
Denies:
Patient
Immunologic Adult Medical IIX II
Denies:
Patient
Date/Time Printed: 9121/2009 08:33 EDT Page 20 of 35
Printed By: Tice, Cindy L
PENNSTATE HERSHEY
PXM Milton S. Hershey
lp Medical Center
Patient Name: KALFAS, ANN E MRN 0776544
ED Assessment Form
...........,.....».........».......,
:.......................... ......»,..,,...........,...»»......».......,......,.,...,..,»......»......,,.,...................,..........»,.,......
Oncologic Adult Medical IIx I Grid
Denies:
Patient
?1?€lr
Medical Devices: None
Implanted Metal: No
Pregnancy Status: Patient denies
Date/Time Printed: 9/21/2009 08:33 EDT Page 21 of 35
Printed By: Tice, Cindy L
PENNSTATE HERSHEY
Milton S. Hershey
VP Medical Center
Patient Name: KALFAS, ANN E MRN 0776544
ED Triage Form
DOCUMENT TYPE:
RESULT STATUS:
PERFORM INFORMATION:
SERVICE DATE/TIME:
ED Triage Form
Final
Bilalovic, Erica C (8/19/2009 12:52 EDT)
8/19/2009 12:52 EDT
-
Chief Complaint: Restrained passenger in MVC. No LOC c/o eipstaxis and bleedin gfrom upper gum line. no loose
teeth.
Mode of arrival-ED: Private Vehicle
Pre-Hospital treatments?: Yes
Abuse: No
Pregnancy Status: Patient denies
Last Tetanus: <5 Years
Nursing Home Resident: No
ED Physician Notified-abuse: No
During last month felt down or depressed: N/A
During last month felt little interest: N/A
Allergy / Reaction
NKA
Iff
is
_It?
Temperature Route: Tympanic
Temperature: 36.1 DegC
Heart Rate: 73 bpm
Respiratory Rate: 18 br/min
Oxygen Saturation: 97 %
Pain Intensity: 4
Oxygen Therapy: Room air
Systolic Blood Pressure: 127 mmHg
Diastolic Blood Pressure: 81 mmHg
BP Location # 1: Left Arm
Patient Weight: 49.900 kg
Weight: 49.900 kg
Weight Method: Estimated
(Ylasga?v ea ii a cgem)
Eye Opening Response Peds Coma: Spontaneously
Best Verbal Response Peds Coma: Oriented and converses
Best Motor Response Peds Coma: Obeys
Pediatric Coma Score: 15
cif tits; al# elf:: t
Aortic. Aneurysm Medical History
Denles:
Patient
Respiratory Adult Medical Hx I Grid
Date/Time Printed: 9/21/2009 08:33 EDT
Printed By: Tice, Cindy L
Page 22 of 35
PENNSTATE HERSHEY
P1 Milton S. Hershey
IV Medical Center
Patient Name: KALFAS, ANN E MRN 0776544
ED Triage Form
Denies:
Patient
HEENT Adult Medical History Hx I Grid
Denies:
Patient
Genitourinary Adult Medical Hx I Grid
Denies:
Patient
Denies GI History
Denies:
Patient
At_e:i;
Musculoskeletal Adult Medical Hx I Grid
Denies:
Patient
Endocrine Adult Medical Rx II Grid
Denies:
Patient
Psychiatric Adult Medical Hx I Grid
Denies:
Patient
Neurological Adult Medical Hx I Grid
Denies:
Patient
Hematologic Adult Medical Hx It Grid
Denies:
Patient
Immunologic Adult Medical HX II
Denies:
Patient
Oncologic Adult Medical Hx I Grid
Denies:
Patient
AduitMt?i<
............ ..... ..
Medical Devices: None
Implanted Metal: No
I eli6 b?l:? sst", 1 gistiet?:.. . I
............ .........................
ADLs: Independent
Gait: Steady
Have You Fallen Twice in Six Months: No
P >M' di- - l"U' I
.... .-
..............
Peds Medical HX I HEENT
Date/Time Printed: 9/21/2009 08:33 EDT Page 23 of 35
Printed By: Tice, Cindy L
PENNSTATE HERSHEY
Milton S. Hershey
qF Medical Center
Patient Name: KALFAS, ANN E
Denies:
Patient
Peds Medical HX I Gastrointestinal Grid
Denies:
Patient
Peds Medical HX I Cardiovascular
Denies:
Patient
Peds Medical IIX I Gent Grid
Denies:
Patient
Peds Medical HX I Respiratory
Denies:
Patient
Peds Medical HX I Muse Grid
Denies:
Patient
ed lle t> J
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 One Grid
Denies:
Patient
P 1ig:Mel# I:>Ht:JI:I
_.
Injuries Peds Health History: None
Infectious Diseases Peds Health History: None
Medical Devices: None
Implanted Metal: No
Immunizations Current: Yes
Date/Time Printed: 9/21/2009 08:33 EDT
Printed By: Tice, Cindy L
MRN 0776544
ED Triage Form
Page 24 of 35
PENNSTATE HERSHEY
1 Milton S. Hershey
VP Medical Center
Patient Name: KALFAS, ANNE MRN 0776544
ED Triage Form
R:T rae'leracig
DCP Generic Code
Tracking Group
EMER Trk Gp
Tracking Acuity
4
Tracking Reg. Status
Start
Triage Time
08/19/09 12:54
Visit reason
MVC
?'risp?a re?itsus
- -
Pre Hospital Respirations: 22 br/min
Date/Time Printed: 9/21/2009 08:33 EDT Page 25 of 35
Printed By: Tice, Cindy L
PENNSTATE HERSHEY
WTI Milton S. Hershey
4P Medical Center
Patient Name: KALFAS, ANN E
Interdisciplinary Narrative Form
MRN 0776544
DOCUMENT TYPE: Interdisciplinary Narrative Form
RESULT STATUS: Final
PERFORM INFORMATION: English, Lori A (8/19/2009 14:54 EDT)
SERVICE DATE/TIME: 8/19/2009 14:54 EDT
ut is It ii2 i _ ?i------ ±i
Interdisciplinary Narrative Discipline: Nursing
Interdisciplinary Narrative Text: 1400 pt comfortable at this time. pt awaiting for CT.lenglish rn
DOCUMENT TYPE:
RESULT STATUS:
PERFORM INFORMATION:
SERVICE DATE/TIME:
Interdisciplinary Narrative Form
Final
English, Lori A (8119/2009 14:57 EDT)
8/19/2009 14:57 EDT
Interdisciplinary Narrative Discipline: Nursing
Interdisciplinary Narrative Text: 1450 correction: pt eval by dr gozhansky not PA-c. lenglish rn
DOCUMENT TYPE: Interdisciplinary Narrative Form
RESULT STATUS: Final
PERFORM INFORMATION: English, Lori A (8/19/2009 15:30 EDT)
SERVICE DATE/TIME: 8/19/2009 15:30 EDT
Interdisciplinary Narrative Discipline: Nursing
Interdisciplinary Narrative Text: 1515 report to shannon akerson m.lenglish rn
DOCUMENT TYPE: Interdisciplinary Narrative Form
RESULT STATUS: Modified
PERFORM INFORMATION: Ackerson, Shannon E (8/19/2009 16:19 EDT)
SERVICE DATE/TIME: 8/19/200916:19 EDT
Undated on
08/19109 06:02 pm by Ackerson, Shannon E
Interdisciplinary Narrative Discipline: Nursing
Interdisciplinary Narrative Text: 1515: Report reiceved from Lori, RN. Assumed care of pt at this time. s Ackerson
RN1537: Plastics at the bedside to suture intra-oral lac. Will continue to montior. S Ackesno RN1618: Pt sitting
up in bed. Denies complaints at this time. Will continue to montior. S Ackerson RN1758. Pt and pt mother given
discharge instructions. Denies questions or concerns- verbalizes understanding. Pt ambulated with a steady gait to
checkout with fmaily mmebers. s AckesronRN (modified)
Date/Time Printed: 9/21/2009 08:33 EDT
Page 26 of 35
Printed By: Tice, Cindy L
PENNSTATE HERSHEY
Milton S. Hershey
qp Medical Center
Patient Name: KALFAS, ANN E
MRN 0776544
Medication History Form
DOCUMENT TYPE:
RESULT STATUS:
PERFORM INFORMATION:
SERVICE DATE/TIME:
Alklicatlow
........................
No Historical Medications: None
Medication History Form
Final
Bilalovic, Erica C (8/19/2009 12:56 EDT)
8/19/2009 12:56 EDT
Date/Time Printed: 9/21/2009 08:33 EDT Page 27 of 35
Printed By: Tice, Cindy L
PENNSTATE HERSHEY
Milton S. Hershey
IV Medical Center
Patient Name: KALFAS, ANN E MRN 0776544
Patient Belongings Form
DOCUMENT TYPE:
RESULT STATUS:
PERFORM INFORMATION:
SERVICE DATE/TIME:
Patient Belongings Form
Final
Ackerson, Shannon E (8/19/2009 16:15 EDT)
8/19/2009 16:15 EDT
rt?a##vrs
Valuables/Belongings Grid
Valuables With Patient
Clothes, Patient Valuables
Pants, Shirt, Shoes, Undergarments
Date/Time Printed: 9/21/2009 08:33 EDT
Page 28 of 35
Printed By: Tice, Cindy L
PENNSTATE HERSHEY
Milton S. Hershey
4P Medical Center
Patient Name: KALFAS, ANN E MRN 0776544
- ----- - ----------- -- - - - --- - -------------------------------- - - - -- -------- -------
Peds Skin Assessment on Arrival Form
DOCUMENT TYPE: Peds Skin Assessment on Arrival Form
RESULT STATUS: Final
PERFORM INFORMATION: Ackerson, Shannon E (8/19/2009 12:34 EDT)
SERVICE DATE/TIME: 8/19/2009 12:34 EDT
Skin Turgor: Normal
Skin Abnormality/Location Grid
Skin Abnormality
None
Pressure Ulcer Yes No: No
Ptlitrelii(s>ftirie
Peds Mobility: No limitations
Peds Friction and Shear: No apparent problem
Peds Activity: No limitations/age appropriate
Peds Nutrition: Adequate
Peds Sensory Perception: No impairment
Peds tissue perfusion oxygenation: Excellent
Moisture Bradenl: Rarely moist
Peds Braden Score: 27
Date/Time Printed: 9/21/2009 08:33 EDT Page 29 of 35
Printed By: Tice, Cindy L
PENNSTATE HERSHEY
FM Milton S. Hershey
qP Medical Center
Patient Name: KALFAS, ANN E MRN 0776544
Allergy History
Substance NKA
Recorded Date/Time Recorded by
10/16/200416 - og EDT :Wilson, Dorothy Reaction Status Active; Allergy Type Allergy; Reviewed By Wilson,
Dorothy ; Reviewed Date/Time 10/16/2004 16:09 EDT; Recorded On
Behalf Of Wilson, Dorothy
Date/Time Printed: 9/21/2009 08:33 EDT Page 30 of 35
Printed By: Tice, Cindy L
PENNSTATE HERSHEY
Milton S. Hershey
VP Medical Center
Patient Name: KALFAS, ANN E
MRN 0776544
Orders
Ordering Physician: SYSTEM, SYSTEM
Entered By: Embich, Thomas R on 8/25/2009 10.28 EDT
Order Details: 08/21/09 17:26:52
Order Comment: Ped Skin Assessment on Arrival
Order Date/Tlme:,'8/21/2009 12:55 EDT
Or Ped Skin Assessment on Arrival
Order Status: Discontinued Catalog Type: Patient Care
Ordering Physician: SYSTEM, SYSTEM
Entered By: SYSTEM, SYSTEM on 8/21/2009 14:00 EDT
Order Details: 08/21/09 12:55:11
Order Comment: Ped Skin Assessment on Arrival
Order Date/Time 8/20/2009 10:00 EDT
..... .
Order. Ped Skin Assessment 10:00 a.m.
Order Status: Canceled Catalog Type. Patient Care
Ordering Physician: SYSTEM, SYSTEM
Entered By: SYSTEM, SYSTEM on 8/19/2009 20:01 EDT
Order Details: 08/20/09 10:00:00, ONCE
.. _. ........
Order Comment: Ped Skin Assessment 10:00 a.m. - braden score = or between 19 and 28
.._.....
Date/Time Printed: 9/21/2009 08:33 EDT Page 31 of 35
Printed By: Tice, Cindy L
PENNSTATE HERSHEY
Date/Time Printed: 9/21/2009 08:33 EDT Page 32 of 35
Printed By: Tice, Cindy L
PENNSTATE HERSHEY
PXM Milton S. Hershey
Ip Medical Center
Patient Name: KALFAS, ANN E MRN 0776544
Orders
Order Date/Ti me: 8119/2009 15:17 EDT
Order: Physician Consult Request (Consult, Physician)
Catalog Type: Consults
Order Status: Completed
Ordering Physician: Gozhansky, Dan
Entered By: Blair, Kelly M on 8/19/2009 15:59 EDT
Order Details: STAT, Requested Dt: 08/19/09 15:17:00, Service: Plastic Reconstructive Surgery, Reason: upper gum lac-
eration, I have or will contact the physician directly, Dan Gozhansky 310007
Order Comment:
Order Date/Time: 8/19/2009 13:24 EDT
Order: Facial Bones CT
Order Status Completed Catalog Type: Radiology
Ordering Physician: Gozhansky, Dan
Entered By: , on 8/19/2009 15:56 EDT
.. .... ......
Order Details: STAT, Requested Dt: 08/19/09 13:24:00, ICD9: Facial Bone Fracture 802.8 History: lac to upper gums aft er
MVC, concern for maxillary fracture
Order Comment: Do not send dentures, hearing aids, jewelry or hair pins with Patient to CT.
Order Date/Time: 8/19/2009 12:34 EDT
Order: Safety Wristband Verification
...
.........
Order Status: Discontinued Catalog Type: Patient Care
Ordering Physician: SYSTEM, SYSTEM
Entered By: SYSTEM, SYSTEM on 8/19/2009 20:01 EDT
Order Details: 08/19/09 12:34:03, Midnight
Order Comment: Safety Wristband Verification
Date/Time Printed: 9/21/2009 08:33 EDT Page 33 of 35
Printed By: Tice, Cindy L
PENNSTATE HERSHEY
Milton S. Hershey
Ip Medical Center
Patient Name: KALFAS, ANN E MRN 0776544
Orders
Order Datelrime: 8/191.2009 12:34 EDT
Order. ED Nursing Charge
Order Status: Completed
Ordering Physician SYSTEM, SYSTEM
Entered By: Ackerson, Shannon E on 8/1912009 18:03 EDT
Order Details: Request DI: 08/19/09 12:34:02
Order Comment: ed nursing charge
Date/Time Printed: 9/21/2009 08:33 EDT
Printed By: Tice, Cindy L
... ..... .._.
atalog Type: Patient Care
Page 34 of 35
PENNSTATE HERSHEY
/1 Milton S. Hershey
IV Medical Center
Patient Name: KALFAS, ANN E
MRN 0776544
Height /Weight Measurements
,..........,.,...,,.........,...,......,...,,,,,.,,..,,.
:................................................,.,.............. .,..,,,.....,...,,..,,........... ,.......,,,.,.........,..,..,............
.................................................................................................................................................................................................
Weight
...,..............
:..................................................................,...,............,..................,............................................................... .............
Recorded Date_ 8119/2009
Recorded Time 12:52 EDT
Recorded By Bilalovic, Erica C
Procedure Units
Patient Weight kg
.......................... . 49.900
Date/Time Printed: 9/21/2009 08:33 EDT Page 35 of 35
Printed By: Tice, Cindy L
y
?
THEy MILTON S HERSHEY MEDICAL CENTER MEDICAL RECORD C
PO BOX 853 MR328 (REV 9/00)
HERSHEY, PA 17033
+----------++-----------++----------++-------++--------++----++---++---++-+
100776544 119461564 (102/08/08 1111M:04 A11ROOM/BED111PDQ11ECU117RC11AI
+----------++-----------++----------++-------++--------++----++---++---++-+ NAME iKALFASTANN E i1FEX1101/21/199711A1111S511MRSAl1VRE11 11RELLUT 1
+-------------------------++---++----------++---++--++----++---++---++----+
+----------------------I----------++--------------------++---++------------+
PATIENT ADDRESS CITY ST ZIP CODE
350 NORTH 27TH ST CAMPHILL PA 17011
L +--------------------------------++--------------------++---++------------+
+------------++---------------------------++---------------++-------------+
1PT PHONE 9811PT EMPLOYER 11EMPLOYER PHONE 1) 1
717 730-07
+------------++----------------------------++---------------I++-------------+
+--------------------------++-------------++-------------++---------------+
IKALFASTBRENDA 11717 N730-079$ 11WORK PHONE 112C1 UNTY 1
+--------------------------++-------------++-------------++---------------+
+--------------------------------------------------------------------------+
INSURANCE INFORMATION
NAME POLICY # GROUP NUMBER
BLUE CROSS O UPA849999356 082826
SELF PAY
?r +-- -+
------------------- --------------------------------------------------
I REGISTRAR MRN
+-------------------------------------------------------------------------+
+-------------------------------------------------------------------------+
ICOMMENTS
+-------------------------------------------------------------------------+
+------------------------------------++-----------------------------------+
ATTENDING PHYS 1 11 ATTENDING PHYS 2
46015 RING KEVIN C 0
+----------------- ------ ----- -------- -++---------- ------ ------- -------- ----+
+------------------------------------++-----------------------------------+
IFAMILY PHYSICIAN REFERRING PHYSICIAN
COLDREN ROBERT L SELF REFERRED
2025 TECHNOLOGY PARKWAY NO REFERRING/FAMILY
SUITE: 108 PHYSICIAN
MECHANICSBURG PA 17050
717 791-2680 FAX: 717 791-2686 FAIL:
+------------------------------------++-----------------------------------+
PENNSTATE HERSHEY S00Z180iZ0 :31,.01TSjn ?••• 3 ?o
7Hd 1'lik, Sob 30 lf)o W)uo 3n18 :SNI
- Milton S. Hershey 3 :x3S L6c:t/12rto :900
btrs9LL 'NM
Medical Center sbo90 :#GW s WV I?11N°na :oa
3 NNtl `St1311n1 :39tlN
AUTHORIZATION FOR TREATMENT IN THE EMERGENCY
DEPARTMENT AND RELEASE OF INFORMATION
The undersigned has presented for evaluation and treatment in the Emergency Department. All treatment
and procedures determined to be necessary will be performed by physicians and other members of the
clinical staff. Authorization is hereby granted for such treatment and procedures.
The undersigned has read the above authorization and understands the same and certifies that no
guarantee of assurance has been made as to the results that may be obtained.
I hereby assign and authorize payment directly to the 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.
I acknowledge that the Penn State Milton S. Hershey Medical Center Privacy Notice has been provided to
me.
INSTRUCTIONS: Please read all of the above. An authorization for treatment must be signed before
treatment can be given. Authorization must be signed by the patient, or by an
authorized person in the case of a minor or when the patient is physically or mentally
incompetent.
DATE: ?r ?_w SIGNED:
TIME: I PM or
(authorized person)
Relationship t Patient:
Witness: f
? Privacy Notice Given-Patient unable to sign
? Privacy Notice Given-Patient declined to sign
L AUTHORIZATION FOR TREATMENT IN THE EMERGENCY DEPARTMENT
MR 1012 Rev. 1/08 Page 1 of 1 AND RELEASE OF INFORMATION
Illn?l III II VIII INI 1?1 VIII IIII NI
Name: ANN KALFAS MRN: 0776544
Patient Visit Summary
ANN KALFAS has been given the following list of patient education materials and follow-up
instructions:
Patient Education Materials:
Custom
BACITRACIN OINTMENT (CUSTOM)
Injury & Illness
ABRASION
Follow-Up Instructions:
Follow-Up With: Address: When:
Robert Coldren 2025 Technology Parkway;Suite In 2 days
108 02/10/2008
Mechanicsburg, PA 17050
(717) 791-2680 Business
Comments:
Follow up with your own doctor as needed. Apply bacitracin to the wound 3 to 4
times per day until the wound has healed. You should not dive if the wound is still
oozing. You can cover the wound with a tegaderm as needed when you swim. If
any problems, call your doctor or return to the emergency department.
I, ANN KALFAS, have received the above patient education materials/instructions and have
v balized de tanding:
1eJ_ &j
Patien i a Date Pro ' r Sig ature bate'
MRN: 0776544 FIN: 09461564
Name: ANN KALFAS 5 of 5 Feb/08/2008 12:21:30
MRN: 0776544
PENNSTATE HERSHEY
o -
Milton S. Hershey
17 Medical Center
PROGRESS REPORT
c.
c.
NAME: KALFAS, ANN E
MR4: 778544
MD: MOYER KURTIS E
009: 01/2111997
LOG: PRS
INS: AUTO IN?jjRANCE
NIIAIII III I IIIIN 111
111UPI1INI111 111
0034: 13390378
MON: 27015
VISIT DATE: 08124/2009
SEX: F
STANDARD
MR 6 Rev. 5/08 Page 1 of 2
{
11011111",?y NA INI
PROGRESS REPORT
Date/Time PROGRESS NOTES: (include Name, Title)
PENNSTATE HERSHEY
00M. Milton S. Hershey
® Medical Center
PROGRESS REPORT
m6
PROGRESS NOTES: (Include Name, Title)
I "C- ( - I
#k
MR 6 Rev. 5108 Page 1 of 2
14EIIIIIIIIIIIINIIIIIIIIII PROGRESS REPORT
(awl
t
c.
c.
0
PENNSTATE HERSHEY
Milton S. Hershey
Medical Center
PRACTICE SITE INTERDISCIPLINARY EDUCATION RECORD (IER)
01
NAME: KALFAS, ANN E
MRN: 778544
MD: MOYER KURTIS E
DOB: 01/2111997
LOC: PRS
I?1l?II AUTO [Ills Bi AHCE
105111111112
OOSa: 13390378
Molt: 27015
VISIT DATE: 08/24;2009
SEX: F
STANDARD
May be used by all Practice Site disciplines to summarize and communicate patient teaching.
List pamphlets, handouts given to patient in each section.
Initial Assessment of Patient's Ability to Learn: ? Emotional ? Physical ? Culturai/Reltglou None
? Motivational ? Cognitive Limitations ? Language
Learning Preferences: written ? erbal ? Demonstration ? Group
? Audio al or J
S
Z
W
Document areas that may impact teaching: stratpy Evaluatlon
e
trey:
V = video Key:
C = m 8
W = Written Competent a
D= R = Review s
Assessment corn leted by,
? Dismission
Dam
=
Demonstration r
°?'
O
on
Initials
Date t-
? No education required at this time.
? No education required at this time.
? No education required at this time.
? Patient/Family verbalizes understanding of plan of care and treatment
? Patient/Family verbalizes understanding of basic health and safety
practices related to condition
? PatlenttFamily verbalizes understanding of the safe and effective use of
their medications
Name of medication
? Nutrition related to normal or modified diets or oral health
Exercise program discussed with patientifamily
? Padent/Family verbalizes an understanding of pain
Risk for pain
Importance of pain management
Pain assessment and the use of a pain scale
Process and methods of pain management
? Lifestyle Issues discussed with patient NA due to age
? Patient exhibits need for habilitation or rehabilitation or has a barrier to
communication
Motivation to learn
Physical limitation
Cognitive limitation
Barger to communication
? Smoking Cessation discussed with patient NA
INTERDISCIPLINARY EDUCATION RECORD (IER)
11111 I N N 1111111 Y 11111111111
H
MiltoM Hershey
Medical Center
C HEALTH ASSESSMENT
involvement in child care: Father Yes ?/ No
Name: as
Name:
Name: J'1?
Marital Status: Married Single
Living Together x
What language do you or your child best understand
Who lives in the household l o r ft?'
Family Physician o=dbest a
How doI you or youarn:
a. On onOne Instruction C?
b. Aud Visual Information f
c. Wri en Information
110
Is your
Does a
Does a
Is your
Has yo
Are the
Water I
School
•
NAME: KALFAS, ANN E
MRN: 776544
MD: MOYER KURTIS E
DOB: 01/21/1887
LOC: PRS
IUlllll! 1111111 O 1111111 INSURANCE
I INER111111111
DOW 13380378
?JON: 27015
VISIT DATE: 08124/2009
SEX: F
STANDARD
Date of Birth: 1 7 7
Occupation: ((
Occupation:
Widowed Divorced
Separated
Mother Ye / No
4-?
d. Group Instruction L_
e. Demonstration/Practice _
f. Other
School oncerns: Yes Iiy
Does your child wear a bike helmet? 1 / No
Does y r child use a car seat, booster seat, o seat'b h??6A I No
Do you, or your child have any special needs we should be aware of so that we can better serve you?
Updated
Reviewed B
MR 888 Rev. 7108 jPage 1 of 2)
IN111NNNININN
L.
Rd exposed to anyone who uses tobacco? Yes6? Who?.
one in the househould consume alcohol Ye / No
one in the household use an other substances Yes N3 If yes, tYPe
ild afraid of anyone? Yes / N
child ever been physical) or emotionally hju by anyone
pets : Yes (No
ets ' the household? Yes No Type: 1 '?l O/1?i h?S
e? Ci / Well
Istria ! lI.l11U r 11 I Jt,?`?/
OVER
PEDIATRIC HEALTH ASSESSMENT
PEDItIC HEALTH ASSESSMENT 0
Previous Surgery Complications Date
N we of C rent Medications:
o't S
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Does your child have allergies? es o If ye , please list:
Medications: ?G
Enviromental:
Has the patient ever had or experienced any of the following:
Painful voiding / urinating Yes / Rheumatic fever Yes / N
Bed wetting Yes ! Heart murmur Yes /
Urinary tract infection Yes Palpitations Yes /
Chest pain Yes / a-)
Asthma/wheezing Yes High blood pressure Yes /
Bronchitis VAO / Fainting Yes /
Pneumonia 7e; / No
Sleep Apnea Yes / Difficulty swallowing Yes
Tracheotomy Yes / Diarrhea Yes
Home oxygen therapy Yes / Reflux Yes /
Shortness of breath Yes / Blood in stool Yes /
Constipation Yes /
Seizures Yes ! Food allergies Yes !
Numbness arms Yes / Weight loss Yes /
Numbness legs Yes / Weight gain Yes o
Poor circulation Yes /
Unsteady gait Yes / Is your child toilet trained? 44s
Difficulty speaking Yes / Rashes es
Headaches Yes ! Has your child had the chicken pox? Y N'
Immunizations up to date es No
Could you be pregnant Yes / a
Family Medical History: Childhood Deaths Yes / o-
Diabetes Yes '(No Stroke Ye Asthma Yes
Cancer / No Hypertension r es No Seizures Y / No
Heart Disease e / Nn Anemia/Blood es /(j Arthritis Y / No
Anest sia Complications es / V Disorders
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Name of erson ompleting Form Dat
Relationship to Patient
Signature of person who reviewed and discussed above with the provider. Date
MR 888 Rev. 7108 (Page 2 of 2)
PEDIATRIC HEALTH ASSESSMENT
¦ Government Employees Insurance Company
GEICOO ¦ GEICO General Insurance Company
¦ GEICO Indemnity Company
9e1CO.C01"1i1 ¦ GEICO Casualty Company
One GEICO Boulevard ¦ Fredericksburg, VA 22412-0001
November 18, 2009
STEVEN J SCHIFFMAN
2080 LINGLESTOWN ROAD, SUITE 201
HARRISBURG, PA 17110-9670
CLAIM NUMBER: 0303662270101034
INSURED: Samantha J Wetmore
DATE OF LOSS: 08/19/2009
YOUR CLIENT: Brenda Kalfas and Ann Kalfas
Dear Mr. Schiffman:
This letter confirms our conversation of August 7, 2009, wherein we agreed upon settlement for $15,000.00 on behalf of
each of your clients, Brenda Kalfas and Ann Kalfas. As you know, this settlement is full and final for any and all
damages under the Bodily Injury coverage of Samantha J Wetmore's policy.
To finalize our agreement, please find enclosed a Release and Hold Harmless Agreement for Brenda Kalfas to execute.
Once we have the properly executed Release and Hold Harmless Agreement in our possession, we can issue payment for
Brenda Kalfas's claim. As Ann Kalfas is a minor, payment of her claim in the amount of $15,000.00 will be contingent
upon completion of a minor court approval. Please do not make any alterations to this release or submit any release
which has different language than the attached without our prior approval. It is understood that this settlement is
clean and clear herewith and there are no further entities or individuals that have interest in same. Any negotiation or
disbursement of our payment will be considered a release of all claims.
As you are aware Title 23 of the PA Consolidated Statutes has been amended by § 4308.1, and provides that
overdue child support payments shall be a lien by operation of law against the net proceeds of any monetary
award over $5,000. In accepting this settlement you are confirming that your client has provided proof by way of
statement per the Statute that he/she is not in arrears for child support. If he/she is in arrears, it is your duty to
make payment for the overdue child support out of the proceeds of the settlement as required by the Statute.
Additionally, I have enclosed a Certification of Limits for our insured for this date of loss.
Sincerely,
Justin Sebera
Claims Examiner
800-841-1003 x7835
Enclosures: Release
Hold Harmless Agreement
Certification of Limits
J`, tifbl
SETTLEMENT STATEMENT
We, Thomas J. and Brenda L. Kalfas, parents and natural guardians of Ann E. Kalfas,
approve the distribution of the money received from Geico Insurance Company in the amount
of $15,000.00 as follows:
SETTLEMENT:
Less Attorneys' Fees:
Less Costs Advanced:
(See attached)
TO BANK f/b/o Ann E. Kalfas
AND NOW, this - day of
$15,000.00
$11,058.84
2010, the above Settlement
has been read, understood, and the receipt of a copy thereof acknowledged. I warrant that
my attorney has discussed with me all elements involved in my case. I acknowledge receipt
and acceptance of the final sums set forth above.
$ 3,750.00
$ 191.16
THOMAS J. KALFAS
BRENDA L. KALFAS
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Steven J. Schiffman, Esquire
SERRATELLI, SCHIFFMAN, BROWN & CALHOON, PC
2080 Lingl~stown Road, Suite 201
Harrisburg, PA 17110
(717) 540-9170
sschiffman(a,ssbc-law.com
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IN RE: : IN THE COURT OF COMMON PLEAS
:CUMBERLAND COUNTY, PENNSYLVANIA
ANN E. KALFAS, a minor by :ORPHANS' COURT DIVISION
BRENDA L. KALFAS and :
THOMAS J. KALFAS, her :
parents and natural guardians, : NO.: /~ - «3~ e 1 u e ~, ~~%L~'~,
Petitioners
ORDER
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AND NOW, this ~,~ day of ~~~vr _, 2010, upon
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consideration of the within Petition for Approval of Minor's Compromise, it is hereby
ORDERED that Petitioners are authorized to enter into a Settlement Agreement with Geico
in the gross sum of Fifteen Thousand ($15,000.00) Dollars.
The settlement amount shall be distributed as follows:
$ 3,750.00 to Serratelli, Schiffinan, Brown &Calhoon, PC for attorney fees;
$ 191.16 to Serratelli, Schiffman, Brown &Calhoon, PC for reimbursement
of costs;
$ 11,058.84 to Brenda L. Kalfas and Thomas J. Kalfas, as Parents and Natural
Guardians of Ann E. Kalfas, a minor, to be deposited into a restricted, federally insured
account marked "No withdrawals prior to age 18 without prior court approval, except for the
payment of taxes".
$15,000.00 total amount distributed.
Counsel shall provide to the Court, within ten (10) days from the date of this Order
proof of such deposit.
BY THE COURT:
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U' tribution:
/Steven J. Schiffman, Esquire, 2080 Linglestown Road, Ste 201, Harrisburg, PA, 17110
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