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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 ?G(14?'? l 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 6PO4 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 ~~ ~, ~. . ,~ #t~ir~ ~~ ~^~r ., ~J'` ~. ~~~. ~'~ ~~Y 2010FE{i 23 ~i9 ~: f Cltz P . , v ,_ ` ~ ~ ~ 'I~` ; J~ ~ ` ~ / k t ~ ) `~ ` t l 1 f 4 `i 1 ~ ~( ~ l/~IA~ 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 5 ~B ~9zo~o~ 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 .- ~. ~I AND NOW, this ~,~ day of ~~~vr _, 2010, upon __~~ 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: ~? ~ p U' tribution: /Steven J. Schiffman, Esquire, 2080 Linglestown Road, Ste 201, Harrisburg, PA, 17110 a~~3~~v ~i'Y~