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HomeMy WebLinkAbout12-6693MICFIAEL, J. O'CONNOR & ASSOCIATES, LLC By: David A. Miller, Esquire Attorney l.D. No. 89063 608 West Oak Street, P.O. Box 201 F~r7ackppville,P~~A 17931 5 / ~-O?~-~) ~ VO IN RIB LOGAN GREEN, a minor By BRIAN GREEN .AND AMI GREEN, His Parents and Natural Guardians . , ~ ~ ~ ~ :''i ! , i« ~ h IN THE COURT' OF COMMON PLEAS • OF CUMBERLAND COUNT"Y ; Docket #: _ ~ ~P ~ ~ ''>,,a U 1. ~ ~eV 6l1 ~~ PETI"PION FOR LEAVE TO COMPROMISE MINOR'S ACTION Pursuant to Pa R.C.P. 2039 a.nd Cumberland County Local Rule of Civil Procedure 2039, Brian Green and Ami Green, the parents and natural guardians of minor, Logan Green, by his Attorney, David A. Miller, Esquire of Michael J. O'Connor & Associates, petitions this Court to enter an Order permitting settlement in compromise of this action, and in support avers the following: 1. On Saturday, July 9, 2011, at 8:15p.m., then 14 year old Logan Green was a passenger in a Gea Metro automobile driven by Jacob Peffer. The car was stopped at a stop sign at the intersection of Lisburn Road and Locust Point Road. Mr. Peffer drove into the intersection. He did not have the right of way. He negaigently put his vehicle directly in the path of a Honda Pilot sport utility vehicle. The Pilot had the right of way and no stop sign or stop light. The Pilot drove into the Metro on the side Logan Green was sitting on. Logan Green was injured in the collision. (A copy of the Pennsylvania State Police -Carlisle Crash Report is attached as Exhibit "A"}. (., ~, ~ ~ ~i~~6 2. Brian Green and Ami Green, of 322 Mt. Allen Drive, Mechanicsburg, PA 17055, are natural parents/guardians of minor, Logan Green, who was born on July :? 1, 1996, and who is presently 16 years of age and resides with his natural parents. 3. As a result of the July 9, 2011 collision, minor sustained traumatic injuries in the nature of head Laceration, multiple abrasions, neck pain, and headaches. He v-as initially treated at Hershey Medical Center on July 9, 2011, wherein he received X-rays and MRIs, and CatScan to determine his injuries. Minor's parents have confirmed with the providers that follow-up appointments were necessary for suture removal. 4. Petitioner's have incurred the following Medical expenses for the treatment of the minor: Hershey Medical Center DOS: "x/9/2011- 9/14/2011 $15,466.00 Silver Springs Ambulance DOS: 7/9/2011 $1,010.00 HOWEVER, Safe Auto Insurance and Pennsylvania Employees Benefit Trust Fund (PEBTF) has covered all medical expenses. PEBTF has a lien of $1,612.77; neither counsel nor Petitioner has been made aware of any additional outstanding liens. 5. A copy of all medical reports, records and bills related to this action are attached as Exhibit "B". 6. Jacob Peffer was covered by an automobile insurance policy from Liberty Mutual Insurance Company. The policy had liability limits of $15,000.00 (Fifteen Thousand Dollars). A copy of the policy limits have been attached for your convenience and marked as Exhibit `'('"' 7. There are no wipaid liens with the Department of Public Welfare with respect to the above-referenced case. 8. Petitioners and counsel seek approval of the settlement on behalf of minor in the amount of $18,000.00 negotiated with Petitioners' insurer, Safe Auto, because they believe that. it represents a full and fair settlement of the case, equal to or greater than that which may be obtained should the matter be fully litigated. 9. Of this amounC $15,000 is the policy limit of Defendant Jacoh Pfeffer's automobile liability insurance. It is anticipated that Safe Auto will seek subrogation of this amount from Defendant's Pfeffer's insurer, Liberty Mutual Insurance Company. 10. The remaining $3,000 is in settlement of Petitioners' underinsurance claim with their insurer. Safe Auto. 11. Petitioners approve of the proposed settlement because they consider it to be fair and reasonable and to adequately compensate minor for the injuries sustained and expenses incurred. 12. Counsel was retained by the Petitioner to represent the minor on a contingent fee basis. A copy of the fee agreement is attached as Exhibit "D". In prosecuting this action on behalf of the minor-plaintiff, counsel has incurred the following expenses: State Police Crash Report Unit $ 8.00 Medical records, Healthport $129.46 Cumberland County Prothonotary $103.50 TOTAL $240.96 13. Petitioners further approve the proposed distribution contained in the form order attached. 14. 'The sum of Ten Thousand Five I-Iundred Twenty-Eight Dollars and Fifty- Two Cents ($10,528.52) shall be distributed to the benefit of Logan Green, a minor, to be placed in one or more federally insured savings accounts or federally insured. savings certificates in the name of the minor so that the amount deposited in any one such savings institution shall not exceed the amount to which accounts are insured, and to be marked ``NOT TO BE WITHDRAWN UNTIL THE MINOR REACHES THE AGE OF EIGHTEEN (18,1. EXCEPT FOR THI PAYMEIyfT OF LOCAL, STATE AND FEDERAL INCOME TAXES ON INTEREST EARNED BY THE SA`JINGS ACCOUNT' OR CERTIFICATE, IF ANY, OR UNTIL FURTHER ORDER OF THIS COURT." 15. If the Court sees fit to approve this proposed compromise, it is requested that the Petitioners be authorized to execute a good and sufficient General Release.. A copy of the proposed release is attached hereto as Exhibit "E". WHEF~EFORE, Petitioners requests that this Court enter an Order approving the settlement. and compromise, allowing, counsel fees and ordering, distribution as set forth in the attached order. ~i R ectfully submitted, ~ - -- David A. Miller, Esquire Michael J. O'Connor & Associates 608 West Oak Street P.O. Box 201 Frackville, PA 17931 Attorney for the Petitioners Attorney I.D. No.: 89063 .f Brian Green, Petitioner Ami Green, Petitioner IN RI: LOG.AN GREEN, a minor By BRIAN GREEN AND AMI GREEN, : His Parents and Natural Guardians IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUN"Ty' Docket #: AFFIDAVIT I, David A. Miller,l='squire, being duly sworn according to law, depose and state that I am an attorney in good standing with the Bar of the Supreme Court of Pennsylvania and represent the parties in the above-captioned matter. As noted in the Petition for Leave to Compromise Minor's Action filed with this Court: minor was injured on July 9, 2011, when he was a passenger in a vehicle driven by Jacob Pfeffer, who proceeded without proper clearance and struck the oncoming car driven by Steven Laudenslager. This accident resulted in head laceration, multiple abrasions, neck pain, and headaches. He was initially treated at Hershey Medical Center on July 9, 2011, wherein he received X_-rays, MRIs, CatScan and medical treatment. Minor's parents have confirmed with the providers that follow-up appointments were necessary for suture removal and no further extensive treatment was needed at this time. (All of the medical records were attached at Exhibit `'B" to the Petition.) A settlement offer in the amount of $18,000.00 was tendered by Betsy Kelly of Safe Auto. Of this amount, $15,000 is the policy limit of Defendant Jacob Pfeffer's automobile liability insurance. The remaining $3,000 is in settlement of Petitioners' underinsurance claim with their insurer, Safe Auto. I hereby state that in my professional opinion the settlement offer tendered by the insurer was fair and just. Additionally, I feel that given the uncertainties of litigation, my client's acceptance of this settlement offer on behalf of their minor child was in his best interest. I certify that the information set forth in this affidavit is true and correct to the best of m}~ information, knowledge and belief. Respectfully submitted, David _--. filler, Esquire Michael J. O'Connor & Associates 608 West Oak Street P.O. Box 201 Frackville, PA 17931 (570) 874-3300 Attorney for Petitioner Attorney ID: 89063 State of _~` '' i~ '>t i jll`/Ii~h-- County of _ .\)[' ~~~- ~1 ~ _ Subscribed and swarm to before me this `'% da of _ ~ t' ,7~'" . ~ , 2012. _~ y , ~.~~ Notary Public ,, My commission expires ~~ _~~" , 20~. ,, t~alt~~~t`i~h's!~a,LTH o_F PEPJ4~SYL!/~A€~d~,`i ----- ----- --N~tari~l Heal ri~=~~eri~e A. 1Nagner, eVet<rry Public otter T"~rp., 5rtiuylkill County _ A-ty C; a°nmission Expires Je~~. 3~, 2053 An, ri,e~ Pennsylvania Associakion of Notaries IN KE: LOGAN GR>~;EN, a minor By BRIAN GREEN AND AMI GREEN, His Parents and Natural Guardians IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNT`.~'~ Docket #: VERIFICATION I, Brian Green, father and natural guardian of minor, Logan Green, i?eing duly sworn according to law, depose and say that the facts set forth in the said Petition for Leave to Compromise Minor's Action are true and correct to the best of my krxowledge, information and belief. I understand 1;hat statements herein are made subject to the penalties of 18 PA CS Section 4904, relating to uns~worn falsification to authorities. ~~ BRIAN GREEN IN RE: IN "~CHE COURT OF COMMON PI_F;AS LOGAN GREEN, a minor OF CUMBERLAND COLTNT`~' By BRIAN GREEN AND AMI GREEN, His Parents and Natural Guardians VERIFICATION I, Ami Green, mother and natural guardian of minor, Logan Green, being duly sworn according to law, depose and say that the facts set forth in the said Petition for heave to Compromise Minor's Action are true and correct to the best of my knowledge, information and belief. I understand that statements herein are made subject to the penalties of 18 PA CS'Section 49~J4, relating to unsworn falsification to authorities. ,_, ~~ Date: ~~-_~~~=-is~__ -~~~ 4~L~~~-~ ""~Z,,-- ~_;;-~-~ ~-)- AI~~GREEN I\ ~ \, AA-SOOTx Commonwealth of Penns+ Incident Number H02-2042947 crash Involves: Police Crash Report ,' DUI `_~ Fatality O Hit and Run L: Commercial Vehicle t~,' NIA ~_.~ Work Zone ~ ATV ~ Snowmobile ~Ivania PAGE 1 REPORTABLE CRASH ,_) State Police Vehicle Local Police Vehicle '~ i Commonwealth Vehicle ) Local Gov Vehicle T.. 1- - ;? A ~ gency Name PA STATE POLICE°_ -CARLISLE YES 20 07(0912011 c - - _ _ - __ Dispatch Time Arrival Time Investigator Badge Number I 21:30 hrs. 21:41 Ixs. LONG, DAVID C II 10440 ~~~-~ ° Reviewer Eaclye ('dumber I roval Date Reviewer A , , c pp 07869 i 07(2112011 HOWELL, DOUGLAS W _ _ - --- - - -- -- r ate of Crash TTii ie of Crash ~D~ay of the Week Crash Description NGLE 07/09/2011 21 26 Ixs I SATURDAY A l ' - - - - -- ---- -- County _- Municipality CUMBERLANp MONROE TVJP -- ---- - «°. o - Weather Condtions Relation to Roadway NO ADVERSE CONDITIONS ON TRAVEL LANES ----------- ---- m ` -- - -- Road Surface Conditions Illumination v DARK-NO STREET LIGHTS DRY _ # of UnitsTOf People # of Injured ~# Killed EMS Agency Medioal Facikhi 002 003 ~ 002 I Q00 YELLOW BREECHES EMS ~ HERSHEY MEDICAL CENTER School Bus Related School Zone Related PennDOT tJotified Type of Intersection TSpecial Location NO ~NO NO 4 WAY INTERSECTION l NOTAPPLICABLE _ --- --- _ Work Zone Work Zane Type Wherein Waf< one d NO ___-_ _- j _ _ I - __ _ ___ ~ r ~ - - - __ Officer Present 1Work Zone CharactEristics eed Limit W. rkei s f resent x c ~ p 1 ., Road Closed ~ Wot'k on Shoulder ~ Intermittent or f logger I ~~ Lane Cloaire ~ with Detour l~ or Median ~_J Ma.~ing Work ~ ` ontrol ~ Other _ m Route Si. nin Route rJumher (Segment Number Travel Lanes Speed Limit I~?r~entation 9 9 I ~ ° ~ ! EAST 04 45 MPH STATE HIGHWAh' 2004 - - ~ R ~ __ _ _ - --- -- - ~t. Endin - - ___ __ -- ~ - House Number .areetName g c STATE HWY 2004 ! HIGHWAY a d -- - TPoute Siyniny Route Number Segment (dumber Travel Lanes Speed Lunit C~~ientation ~ c7 SOUTH STATE HIGH WA f 1007 25 M PH Used in ~ a ~ Intersection - _ - - ---- - -- --- -- -~ -- ---- -- -- -- _- --- Clashes trees I.ai ie St. Endiny v !! S LOCUSTPOINT HIGHWAY -' ,~ ~ - F et v <- P-route slumber Oi Mile Post Tenths Or Segment Marker ,Ramp Use Only .- Y ~ c t6 " ~ ° c -- -- - -- - --- - - ___ ..- O J _- _ -_ -"_ __ __ - - -- v beet I^lamc Street Endiny Oi INiI•_s Tenths 1 O -- - m l- __.._ __ _ _ ._ -._._ ___ __ ____ _ _ _. _ ti Route rluinber IOr Mde Post Tenths Or Segment Marker Ramp Use Only - th b t i _ LL , s e ove en ry f he a __ __ __-_ ~ listance from the Crash ~ ~ - _- _ _ - -_--- _ _ ~ .Meet riamF street Endiny I Scene to Landmark 1 ~ u! J I ^ la ~ ~ Degrees Minutes 'i Seconds Decimal DAyrees Minutes arconds Decimal Latitude: ' 753 Longitude: 77 Q3 '' 1}5 810 40 ~~11 Traffic Control Ce~'ice Traffic Control Functioning ~°u STOP SIGN DEVICE FUNCTIONING PROPERL`! v J Lane Closed !Lane Closure Direction Traffic Detoured Estunated Time t losecl FULLY ALL (N, S,E,Wj' NO ~ 30 60 MIN r _~: -- _:_- -_:: _. ___ _----._ - - ------ - __._ _.-- - Environmental!Roadway Potential Factors (EiR- - ----- - --- - Factor I Factor? Factor3 NONE 0 First Harmful Event in the Crash Most Harmful Event in the Crash i ~ - Unit Number Harmful Event Unit Number armful Event 001 ~ STRUCK BY UNIT 2 001 STRUCK BY UNIT 2 Indicated Prime Factor 'Unit NNumber Prime f=actor Driver Action DRIVER ACTION 001 PROCEEDING WIO CLEARANCE AFTER STOP ~ Prime Fac6~i En ~iron';entaVRoacMe, Prime Fac1m'Vehicle Failure Prime Factor PNdestrian A~h~n w Road Surface 1 pa Special Jurisdiction Printed At: PA State Police -Carlisle 10!0612011 07:22 AM Page 1 Form #: H02-2042947 Aa-sGOTx Commonwealth of Penns Ivania PAGE 2 Incident Numlae?: HOZ-2042947 y Crash Involves: Police Crash Report REPQRTABLE CRASH DUI ~-,~ Fatality ~ ~ Hit and Rung Ia Commercial Vehicle `~ State Police Vehicle !Local Police Vehicle ~~i N+A ~._; Work Zone C_1 ATV r, ~ Snowmobile ~. i Commonwealth Vehicle i Local Gov Vehicle __ _ _ -- i 0 c 0 `c v -- - Unit Number ape Unit Ganmerc?a e uc, e 001Motor Vehicle in Transport L No - _ _ -- - First Name MI Last Name °uffix DOB Telel hone Number 07!19/1994 (717) 315-6608 JACOB M PEEPER I - - -- _- __ - -- ---- - - __._-- ~__.__~ - -- -- State ',Z?p Code - ------ Street Address ?~~ 1 PA 17055 904 CORING LN MECHANICSBURG (USA) __ --- Gender License IJumber License State Class Expiration Date OvmerlDriver MALE 30472679 PA C 07(20/2014 PRIVATE VEHICLE OWNED/LEASED BY DRIVER - - - ---- Dnver Presence Physical Condition Primary Vehicle Cade Violation Person ".barged DRIVER OPERATED VEHICLE APPARENTLY NORMAL VC 3323 I YES ----- Alcohol/Drugs Suspecb=d Icohol Test Type Alcohol Te..t Results NO TEST NOT GIVEN Driver Action PROCEEDING W1O CLEARANCE AFTER STOP _ - ~_ Pedestnan Action _._ Pedestrian Signals Pedestrian Clothing Pedestrian Location -- ---- 1st Harmful Event Left or P.ight Side P~lost Hanni<il Utility Pole um er STRUCK BY UNIT 2 YES 2nd Harmitil Event Left or Right Side Pdost Hamifld Utility Pole Number HIT EMBANKMENT LEFT NO --- 3rd Harmful Etient _._ Left or Right Side Most Hamifld Utility Pole um er 4th Harmful Etient Left or Right Side Most Harmful Utility Pale Number Owner First Nay~7e Owner MI Owner Last Name or Business PJame r~uffi:< DENISE M SEFFER Sheet Address- 143 W VINE ST Ciy SHIREMANSTOWN {USA) Sta?:e Zip Code PA 17011 Vehicle Type Special Usage vo~~emment Equipment Number AUTOMQBILE NOT APPLICABLE Pdodel Year 'Jehicle Make 1991 'OTHER Vehicle Model 'JPhicle Colo METRO RED r VIN 2C1MR24G8M6778090 License Plale Rey. Sta te Est. Speed Vehicle Towed Towed By HRD2835 PA 005 YE5 BOORES Insurance Insurance Company (Policy Number YES LIBERTY MUTUAL ~ A062883374504007 Expiration Date I f14;01i7012 Direction of Travel Vehicle Position Vehicle Movement JnitiaM Impact Point SOUTH RIGHT LANE "CURB" LEAVING A PARKED P OSITION ', 3 O'CLOCK ' - - Damage Indicator Gradient DISABLING BOTTOM OF - - -g Road Ali nment Possible Vehice Failures HILL STRAIGHT NONE _ -- -- _ __ - # of Units Type Unit 1 0 Tag Number Tag Year ITac ~tat.~ ~ _ ___ _ Unit PJ1ake ~ _ Unit Griner ~L.- - --- I e Type Umt .' Tag Numb=_r ~ Tag Yaar Tau Mate ~ ~ N - __-- -.-_ ---- - IUmt Make _- -_- - -__ - -_ - - __..' _-- '- Unit (Trmer _ _.- _- _.- _. - _ - _ __ I ' iEnyine Si_e i,Passenyer? ~, I c c ;, _ a Dm.er He met T pe 0 Saddle Bay/T?unk? Trailer? Helmet Stayed On? DOT/Snell Designation? Eye Protection? Oliver Erkic~tion --- Long Sleeves? Long Pant ~rer Ankle Boots? ~ Passenger Helnnrt Type Helmet Stayed On? DO"flSnell Designation? Eye Protection? Lony Sleeves? Lcng Pants' Grer Ankle Boots? - i -- - _ _ _ - ---- - v ~Passengei` u - ------- - ----T - ~ - _ _ --- -- Helmet? - _ -- --- - _ 1- --- T ~ Head Lights % Rear Reflectors d d Printed At PA State Police -Carlisle 10/06/2011 07:22 AM Page 2 Form #: HD2-20.12947 AA-sooTx Commonwealth of Penns Ivania PAGE a Incident Number: HO?_-2042947 y Crash Involves: Police Crash Report REPORTABLE CRASH DUI ~,~ Fatalih/ n Hit and Ftun ~ ~ Commercial Vehicle ~_i State Police Vehicle Local Police Vehicle ~~i IJ/A ~ : Work 2:one `J ATV `~ Snowmobile ~~ Commonwealth Vehicle `._i Local Gov Vehicle 0 0 N v z v a v y __ Unit Number }pe Unit Commercial Vehicle 002Motor Vehicle in Tralasporf No r 111111 -- -- - - - - - - - _-_ - - - - - -- FirstName MI Last Name ouffu DGB T~ lerhone Number STEVEN h1 LAUDENSLAGER 10116!1970 I 117) 697-7212 Street Address _- _ Ciry 1.,tete iZip Code 2166 MERRIMAC AVENUE MECHANICSBURG F'A 17055 _~ -- -- - K --- -- - -- Gender T icense Number License State Cla_s Ex cation Date Owner/Driver MALE 2232 339 PA C 10/17/2014 PRIVATE VEHICLE OWNED/LEASED BY DRIVER Driver Presence Physical Condition Pumary Vehicle Cade Violation ~ Peisar Cho god DRIVER OPERATED VEHICLE APPARENTLY NORMAL NONE I NO -- - Alcohol/Drays '_?uspeete,:{ Icohol Test Type Alcohol Test Results N O TEST N OT GI VEN Driver action NO CONTRIBUTING ACTION Pedestrian Action Pedestrian Signals Pedestrian Clothing Pedestrian Location i I J~ --~- - -- _. ___. _._ _.. _.. _ _._-- ' I st Harmful E:?nt ole Number ,.Left or Right Side Most Harmfid IJtility F HITUNIT1 'fES 2nd Harmfia Event Left or Right Side Most Hamtfid Utility F'ole Number 3rd Harmful E~: ent Left or Right Side Mast Hamtfid Utility F'ole Number 4th Harmful Event Left ar Right Side Most Harmfid Utility Pole Number Ovmei First N rme STEVEN Ovmer MI ~Owmer Last Name or Business tJame IScrfti'{ it , M (LAUDENSLAGER _-~ Sheet Address City ~ e 2166 MERRIMAC AVENUE PA i 17055 MECHANICSBURG - - Vehicle Type - -- I Special Usage C~c,~em~n?nt F_quipment Number NOT APPLIC,4B tvsdel .ear Vehicle Ivlake 2009 ,HONDA hiEle Color VIIJ ~, Vehicle Model - PILOT I OTHER ~ SFNYF484596004334 ; License Plate Reg. St -- - __ ate Est. Speed ehicle Towed Towed By ETM8380 PA 050 YES COLSONS Insurance Insurance Company Policy Number Expiration Dare YES MOTORIST MUTUAL 76760674311603A 02i24~201;? Direction afTiavel Vehicle Position Vehicle Movement Initial Impact Point EAST RIGHT LANE "CIJRB" GOING STRAIGHT I! 11 O'CLOCK - ---- - --- __- '---- L _ -- --- Damage Indicates Gradient _ -- Road Alignment Possible Vehicle Failures DISABLING DOWNHILL STRAIGHT ,NONE ~ of Units T;p.~ Unit I ag Numher Tay `r'ear !Tay ~ a?e ~ ° ~L----- ,N., c ___ Unit tv1ake _ '.Unit O~nmer ', ~ e . , Type Unit _ Tag Number Tay 1 ear Tau State ~ ~ E r- __ _ Ur~it P~1ake - - _- --- -- - - -- --- --T _- . --- __ Unii Owner Enyuie ~i. e ~Passenger'~ _ _ ~1- - - --- ------- ' Saddle BaglTivnk? Trader? Driver E location? ~~ c L Driver Helmet Typ? Helmet Stayed On'? DOTiSnell Designation? Eye Protection? ' Lnng Sleeves? Long Part.: , Over Ankle Boots? i ' i ~ Passenger Helm?t Tyme i IPeves. Lang Farts" Cher Ankle Boots. Helmet stayed On. DOT;Snell Desi nation. E e Protection. Lanr : ' a Passenger? rtermerr CJ T ~, ~ ,Head Lights ~' iRear Reflectors ' '' n. i_ - _ _--- --- -----~- - ----- Printed At: PA State Police -Carlisle 10!06!2011 07:22 AM Page 3 Forme:H02-2042947 i'-,A-500 TX Commonwealth of Penns Ivania PAGE 4 Incident Number: H02-2042947 y Crash Involves: PO~ICe CI'a5~'1 fZe~?OCt REPORTABLE CRASH DUI ~,; Fatalityi '`~ Hit and Run L~ Commercial Vehicle ~_ State Police Vehicle ,,; La:al Police Vehicle ~i N!A ~..: Work Zone ~,~ ATV ~~ Snowmohile {.,) Commonwealth Vehicle l .. Local Gov Vehicle - - - - -- ~rf x -r - MI Last PJanre ° OB Und # Per, 7n No. First Name 001 ~ 001 JACOB M PEEPER tote `07!1911994 __ ___ -- treet Address Cry _.ip Code 904 LORINCa LN [MECHANICSBURG (USA) F'A 17055 c _ - _ _ - - 'R Phone Nwnber EPAS Transport Person Type TGender Injury ~e eiity e (717} 315-6648 NO DRIVER LMALE MODEF;ATE INJURY o - - --- --- - - -_ - _ ---- Seat Position Safety Equipment 1 d DRIVER -ALL VEHICLES LAP AND SHOULDER BELT USED ~ Safety Equipment Extrication AIR BAG NOT DEPLOYED - SWII-CH ON NOT EXTRICATED Ejection Election Path NOT EJECTED NOT EJECTED/NOT APPLICABLE r Unit # TF'er n No ~Fu ~t Name MI Last Name ~ r~ffi't DOE 001 002 I LOGAN M GREEN 07!21!1996 ~ Street Address City fate :?ip Code 322 MT ALLEN DR MECHANICSBURG PA 17055 Phone Numbew EMS Transport Person Type ~G"e"nder Injury Se verity 8 (717} 222_-4256 YES _ PASSENGER ~ I mALE ~ INJUR`f, UNKNOWN SEVERITY '~ Seat Position Safety Equipment 1 -~ a FRONT SEAT RIGHT SIDE LAP AND SHOULDER BELT USED a Safety Equipment ? Extrication AIR BAG NOT DEPLOYED - SWITCH ON NOT EXTRICATED Ejection Ejection Path I- NOT EJECTED INOT EJECTEDlNOT APPLICABLE Unit # Per ~n PJo TFiist Name MI Last PJame affix DOB 402 04 ~ STEVEN M LAUDENSLAGER 10116(1970 i-- - -1. - - - -- ~ ~_ - _ _ _ _ Street Pddres=_. City State Zip Code 216fi MERRIMAC AVENUE MECHANICSBURG __ PA 17055 I o -- '~ Phone Number ENIS Transport Person Type Gender Injury Severity E (717) 697-7212 NO DRIVER ALE -_- NOT IM1IJURED ~ - - --- - -_--_ - -- Safet E w ment 1 _- - - - - c Seat Position y q P ~, d DRIVER -ALL VEHICLES LAP AND SHOULDER BELT USED '~ Q- -1 °w Safety Equil.nient 2 Extricaton ~ MULTIPLE AIRBAGS DEPLOYED NOT EXTRICATED - - - - --- Ejection Ejection Path NOT EJECTED NOT EJECTEDtNOT APPLICABLE First Name MI Last Name Suffix Phone Number ''^ JIM ~_ POOLE +717 503-7530 I~ - _ __ _ __ _ I State Zi ~ Code Street Addres:> ~ Cib TP 439 WOODLAND DR DILLSBURG PA ~ 17019 ---- _- - ----- -- - -- -- _- - - -- _ L--- Fnst Name N11 Last Name Suffix Fh ne tlumbi.r N ROBERT ~ MAST ~ ~gr17) 243 5249 - -_ - - __ - - _- - °' - --- Male ~i Code Street Addi es,, Ciry p ~,~ 28 COBBLESTONE DR CARLISLE IJF'A 17015 Printed At: PA State Police -Carlisle 1 010 6 /201 1 D7:22 AM Page 4 Form #: HO'1.-2042947 GA-500 TX Incident Number. H02-20x2947 Crash Involves: ...)DUI `~ Fatality/ riN1A Ci Work2:one y c~ 'o r ocus Point Rd. ^_5 Il~ph NARRATIVE Commonwealth of Penns' police Crash Report Hit and Run ~ Commercial Vehicle C~ ATV ~. Snowmobile -m v Lamed 22fk Roadway s c S tB (/1 j <° ~e5 W ~ . o F~~~ / D ~~~~ ~ io -6 ~L / ~ o~ ~ O hip X ,~~~ CJ ~ i Q J~ R\ I QIO\; = ~Ivania PAGE 5 REPORTABLE CRASH {_; State police Vehicle ,' Local Police Vehicle ~, % Commonwealth Vehicle '~. ' Local Gov Vehicle 3'`JG>T 3~J ~~L..u.i~ ~ ~ J~ __ ':- 1 - ~ Unit= Final Rest_ ~ rJ C ~~~ ~( J~~ ~ r~ s' Q cn ~ I - C rJ Crash Synopsis This crash occurred as Unit 1 was stopped on S. Locus Point Rd. at its intersection with W. Lisburn Rd and Unit 2 i was traveling E on W. Lisburn Rd. Unit 1 proceeded without proper clearance and was struck by Unit 2. Injuries were present on scene however the severity is unknown. Both Units towed from the scene. ~' - ---- - -- Crash Details SYNOPSIS: This crash occurred as Unit 1 was stopped on S. Locus Point Rd at its intersection with W. Lisburn Rd. and Unit 2 was traveling E. on W. Lisburn Rd. Monroe Twp. Cumberland County. Unit 1 proceeded without proper clearance from the S. Locus Point Rd. stop sign and was struck by Unit 2. PHYSICAL EVIDENCE: !I Physical evidence consisted of both Units with disabling damage. Unit 1 was at an uncontrolled final rest against the roadside embankment facing E in the W bound lane of W. Lisburn Rd. and IJnit 2 was at final rest in the right lane of travel of W. Lisburn road at the point of impact. INTERVIEWS: Printed At: PA State Police -Carlisle 10/06/2011 07:22 AM Page 5 Form ~: HD::-204?947 NA-544 TX Incident Number: H02-2042947 Commonwealth of Pennsylvania PAGE s crash Involves: n Police Crash Report REPORTABLE CRASH DUI `~ Fatalih/ `J Hit and Run ~~ Commercial Vehicle (i State Police Vehicle ~,.'. Lo~;al Police Vehicle ~~ NIA ~ Work2:one ~~ ATV ~~ Snowmolrile ~,,% Connnanwealth Vehicle ~..~ Loral Gov Vehicle j On 07/09111 at 2145 hours Operator 2 was interviewed on scene. Operator 2 related that he had been traveling on W. Lisburn Rd. going to his residence in Mechanicsburg. Operator 2 further related that he travels this road often and ~ knew this was a bad intersection. When he crested the top of the hill he saw the other Unit stopped on S. Locus Point Rd. Operator had been traveling apprax 50 miles per hour and when he saw the other Unit he began to brake. '~ As he was braking and appraaching the intersection the other Unit pulled out and he attempted to maneuver away from the other Unit but was I.Inable to and he struck him. On 07109!11 at 2155 hours Operator 1 was interviewed on scene. Operator 1 stated that he was unfamiliar with this road. He was looking for his friends house who lives in the area. He had been looking at his phone to call his friend for better directions. Operator 1 further related that he saw the other Unit coming over the hill. He thought that it was a four way intersection and he pulled out. When he realized that the other Unit wasn't stopping he tried to swerve into the there lane of travel to avoid being struck directly in the side. ', On 07/09/11 at 2200 hours Witness 1 was interviewed on scene. Witness 1 related that he was traveling directly ~' behind Unit 2 and he too saw the Unit stopped on S. Locus point Rd. and as the approached the intersection the red car just pulled nut. The car in front of the witness attempted to avoid contact but there was nothing he could do. On 07!09111 at 2205 hours Witness 2 was interviewed on scene. Witness 2 explained that he was traveling W on W. Lisburn rd approaching S. Locus Point Rd. Witness 2 related that he observed the red car, start and stop as if he ', wasn't paying attention. When the other car was approaching the intersection the red car just pulled out and there was nothing either of the two drivers could do. News release pl•epared and placed in the crash attached file Accident notices issued. Operator 1 was cited for VC 3323. Printed At: PA State Police -Carlisle 10106/2011 C'~7:22 AM Page 6 Form tk: H02•?.0.12947 ~~~ _~ _~..--~ °- _~~~ ~. PENI~S~ATE NE:RSHEY ~~ ~~.t011 S . ~~1 S~le~/ Medical Ce~ite~ Patient Name: GREEN, L.OGAN M M RN : 7510053 Date of Birth 7!21/1996 Patient Gender: Male Penn State Hershey Tel: (717) 531-8055 Milton S. Hershey Medical Center Health Information Services, HU24 500 University Drive P.O. E3ox 850 Hershey, PA 17033-0850 Visit Number; 10510053 Visit Type: Inpatient Patient Location: 7M13W; 7264; 01 Discharge Summary RESULT S`I'ATIJS DOCUMENT SUE3JECT: ELEGTRONICALLY SIGNED BY: Name: GREEN, LOGAN M HMC Number: 7510053 DOB: 07!21 /1996 Date of Admission: 07/09!2011 Date of Discharge: 07/10!2011 Reason for Discharge: Stable for Discharge Physician: Dillon, Pe#er W Service: Ped Surgery Discharge Diagnosis: Trauma-MVC Surgical Procedures: None Vaccinations Received This Hospital Stay: No vaccinations were given this hospital stay. Final D/C Summary Dillon,Peier W (7!14/2011 16:37 EDT); Lin,Yu Kuan (7/10/201 1 18:14 EDT) DISCHARGE SUMMARY Discharge Medications: 1. Acetaminophen (ace#arninophen 650 mg oral tablet) 1 tab by mouth every 4 hours, as needed for Fever/Mild Pain. Brlef History of Present Illness: Pt is a 14 year old male who transported in as a level 2 trauma activation. Patient was a restrained passenger in a MVC. Pt had no LOC at the scene, but was initially amnesiic to the accident. As EMS arrived, patient was combative and had repetitive speech pattern, however his vitals were stable. Once EMS laid him down, he stopped his repetitive speech and responded appropriately, He was transported to HMC for definitive care. Hospital Course: In the ED, tat was found to have a 3-4 cm laceration over the right frontal scalp. Pt had no other pain or obvious injuries or complaints. His laceration was stitched up in the ED. The pt was admitted to the pads surgery service for observation overnight. A CT of the head was negative for iniracranial hemorrhage, and was read as normal, except for the right scalp Date/Time Printed: 9/28/2011 09:52 EDT Printed ay Shiner,Crystal L Page 1 of 139 ~'Ef~I~ST~4TE HERSHEY 1~1 Nr.~ton S. Hershey Medirwa~ Center Patient Name: GREEN, L~GAN M MRN 7510053 Discharge Summary lac. The pt had a CXR and pelvic x-ray, which were negative. A c spine x-ray was read as negative and the patient's c spine and collar removed the foilawing morning. The patient's diet was advanced as tolerated and his activities were advanced once C spine was cleared. Patient tolerated a regular diet and regular activity prior to discharge. The did well the day after admission and avas discharged home in stable condition on 7!10/11. Palieni will follow up for suture removal in 7-10 days, Exam on Discharge: Vitals Temp Pulse BP RR SpO2 F1O2 Date Wt(kg) Wt(Ib) 07/10 01:48 36:3 71 131/59 18 99 --- 07!10 56.2 124 07/10 00:46 ---- 77 ----- 11 99 --- 07/09 56.1' 125 Initial Wi: 07/09 56.7 kq 125 Ib NAD RRR CTAf3 soft, NT, ND Exi- FROM, well perfused Neurologically intact Care Instructions: You may take Tylenol as needed for pain (use as prescribed on the package}. bo nat soak your head wound in water for 5 days. Sponge bath the area, please keep head out of the shower scream and swimming pool. Diet Guidelines: Resume regular diet as tolerated. Drin{< plenty to fluids Activity Guidelines: Resume regular activity as tolerated. Do not aver do it. Avoid any activity that may lead to another head injury for at least 4 weeks. Call your doctor if: Please cail 71 7 531-8521 and ask to speak to the pediatric surgery resident on call for persistent fever (over 100.4),nausea, vomiting, increased headaches, or any other concerns- You can also reach us during regular office hours by calling 717 531-8342 Call us for any concerns or questions. Follow-Up Appointments: Unscheduled Penn State -Hershey Follow-Up Appointments. 1. Follow-Up appointment with PETER W DILILON has not yet been scheduled. 346267 Date(Time Printed: 9/28/2011 09:52 EDT Page 2 of 139 Printed fay: Shiner,Crystal L PE~INSTATE HERSHEY ~ Milton S. ~e~ shey Medical Ccnte~ Patient Name: GREEN, LOGAN M MRN 7510053 ........... ...... .....~ ............. ..........................`..Discharge,Summary .., .`.. ,,......~.......,, ... _ .......~........_. ___......~.. Electronic Signature on File CG: Jeanne N Larson, MD 1 Kacey Court Suite 10 i Mechanicsburg PA 17D55 Electronically Reviewed/Signed by: Yu Kuan Lin, MD Author Signaturo Dt/Trn: l Q07.2D 1 i 06:14 PM Electronically Reviewed/Signed by: Peter W Dillon, MDCoslgner Signature DUTm: 14.D7.2011 04:37 PM Pediatric Suryery: Drs. Robert Cilley, Peter Dillon, Brett E_ngbrecht, !terry Eagelrnan, Dorothy Nocourt, Mary Santos Coleen Ureecher MS RD CNSD, Janet Shields MS1V CRNP, PNP-BC, Lynn Simmons MSN CRNP YL /AMO DD: 07/f 0/11 D ~C~ D7/i 0/11 14:47 Date/Time Printed. 9/28/2011 09:52 EDT Page 3 of 139 Printed By: Shiner,Crys#al L PEI N' STATE HERSHEY ~~ T~I~tO:E1 S. ~elS~lf'~t ~eC~1~;c1T ~~II~eT Patient Name: GREEN, LOGAN M MRN 7510053 .............. _....... .................._..........,........ ..............,......._...Consent.... ..............~..............,.,..._ ................... .................... Date/Time Printed: 9!28/2011 09:52 EDT Page 4 of 139 Printed By Shiner,Crysial L Palient Name. GREEN, LOGAN M Date of Blrth: i 121 /t 99D " Final' P[:NNSTATE: HERSHEY _ ~ Milton S. Hershey Medical Center f~ONSENT FOR MEDtCAI. TREATMENT PIAEIE: GREEN IAGA.k M A•FiH: 7510055 nog oEPLtrcN cHatslo OODI 071271tfl8fi LOC: EIAEFl INS: AUTO INSUAAIJCE IIII! IIIIIII1111111111 I I I III IIII HIII IIII RII 1111 111111 IIII IIII OOSN: 1D51 Q053 A10d: 4GU25 VIS[T DATC: U7l'J9!2G11 SEX: Ll STANDANU M RN: 7510053 FIN: 1051D053 11AEDICAL ANb SURGICAL CONSENT FOR TREATMENT: The undersigned is under the care of hislher attending physician(s) and thereby consents to and authorizes the Milton 5. Hershey Medical Center (MSNMC) to provide the necessary medical treatments (including Emergency Department services), surgical procedures, anesthesia, x-ray examinations or treatments, lahoratory procedures, drugs and supplies to the patient as ordered or reyrlr ted by the Professional Clinical Staff of the MSNMC. I acknowledge that no guarantee or assurance has been made as to the results of medical treatnneMs, 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 supervlslon Of nIy attending physidan(s). ~.ONSENT TO ACCESS, REVIEYY AND RETAIN PREVIOU5 PRESCRIPTION MEDICATION INFORMATION: 1 consent to and authorize MSNMC healthcare providers to access and review any of my electronic prescription medication history infonmation which may be available through 5urescripts Database, including but not limited to, nrescnptions ordered and/or filled for me at any pflarmacy which participates in the Surescripts Database. I understand t11at this historical prescription information will then become a permanent part of my electronic medical record at ttte Milton S. ftershey Medical Center. PATIENTS RIGHTS AND RESPONSI61LIT1ES: l acknowledge that MSNMC has provided me with written information on my rights and responsibilities as a patient. I am aware that a Patient Represeniatfve is availahle to rltr_ if I have additional questions nr otherwise wish to speak with one. HOSPITAL MEDICAL RECORD RELEASE AUTHORIZATION: !acknowledge thaC the MSNMC Privacy Notice has tle~n made available to me. I understand that MSNMC may disclose information about me and the treatment I atn receiving, for purposes of continuous i.reatment, payment and health care operations. ASSIGNMENT pF BENEFITS: I assign and authorize payment directly to M5FIMC. I authorize any holder of medical or other information about me to reiease to my insurance carrier and its agents any information needed tc determine fhese benefits or benefits for related services. I the undersigned, certify that I have read, understand, and agree to the provisions contained within thl ~ consent form. llxm issues addressed on this town have been fully explained to m~e. I have had the opportunity to ask yuestions, ,and all of my questions have been answered to my satisfaction. dl~~+.1d~~ W .__~_T.r-_._. l1~If,~ 111-`---- ----rJ-------- PM I ati~_~nt~ Sigr~alure (or sign Wre of person contenting c>n be a!f of the patient oats Time liela[ighship.to the patient, if applicable (~ 1 _:.~ ~~-- ~~'--- - - - - -L-- --- ~ ~- -- PM hlitflest to Patiants Signature Ualr time MN 1181 Fuyc t at t nrv ~~l t Illl~lllllllllllAlllllllp~l~~lllllll! CONSENT FOR MEDICAL TREATMENT '/u'hNe 1. c~iy -Medical Hetords Vcl(nw Copy -Palient Facility: HMG Page 5 of i39 PENN~TATE HERSHEY 1~ Hilton S. Hershey 1Vle~lical Center Patient Name. (aREEN, LOGAN M []aielTime Printed' 9/28/2011 09:52 EDT Coi7sult MRN 7510053 Page 6 of 139 Printed By: Shiner,~rystal L Patient Name. GI~F_(=N, LO:aAN M Date of E3irth: 7/21,'1996 ` Final ` PE:NNSTATk HERSHEY Milton S. Hershey Medical Center TRAUMA ANESTHESIA CONSULT - _~ _ _ _-- I~IIIIIIIIIItI l~ llllll~l ll1111111I1i1 NAlJE: GR Et-N, LOOpN !.1 MRq: 7570053 POSfI: t051005:t /~ tO: OE FLiTpt CftHISTO rxrN: 16325 p08: 07/21)1896 V15Ii LWTE: 07; 0~120tt t~-~~1' IM9' SELF PAY SELr PAY NIIII~IUUIIIItliIE Date ~~ ___ Hei ht_ Y • Wei t- --- Trme __ ~1 _ 0 A e - Sex Consulted by Emergency [3epartmenk Dr. __-_., rr History- L___ _ _. CCv' t?f~MvC ~IIelted Unbelted ^ Fall ~ _~}{Z.o~"e~ ^ MCC ^ Other ~~c'` RYL• Time of !n nt• _ Injuries: _., .-------- Level ofPain { 1 - 10)_ Mechanism of lrJjtuy: _-~tt((t ~__._~ Location: ---_-.._~ -. Function impairmeal: Loss of consciousness ¢St~.I4:--t-l-.r-- PNi lilt: ------ u' ..L.UC.- tYl listory obtained~~~,fr~~o/m~~EMS u Allergies -_~hl.~- ^ L)ntgs ~~~,,~ - ---- U Medical _ _ ~~ _ U Surgical ~}„A,--a..~ _ RUS: t..~,y,~ Y 1 N Diabetes Y 1 N Chest Pain/Chest Pressure Y 1 N Short of BreathlRespiratory Distress YIN Dizziaess X I N Nausea/Vomiting YIN Dysuria Y /' N Deformity O~ --- A1l other systems reviewed-negative .S'Hlx: Y i N "Tobacco Y i N CtOii Y i Ir Urugs Fa®uy iilstory: C] Non-Contributing Physical Exam _ _ General Appearance Vital Signs• $O Bp \ Pulse __ SPO, __-~ Temp -_ ~ Glasgow Coma Scale = -_~ -__ fV yrO: t~ tact Cervical Collar in place: iiEE]VT: LestR>a.~-+-• ~~r.,,~{, Teeth v~ Airway: Malampati Score - _-_ _- Pupils: "~, ,~ Size R.T _ J _- -~ 6~i^.__ Rea~c~•tR~ - _ L -- -- to auscultation Ctd' 'f'Iachea midline E7 Labored breathing ^ --- __ Hl~: Regular rate & rhythm ^ ur Pulses full u _~. _ _ C.! - -- _ ------- A men: Benign ^ Tender ^ Bowel sounds O _..~ _..._- U -~ ~__~.T ---- Ex dties:' t~l Mo apparent tin GU: ^ Foley fsaw and evaluated the patient and agree c with the resident's plan as written. Aqe°ding Signatura: ^ I pBrsOnally perl`OrnliBd the eYaluatlOn. Residenl/(:RNA Signature: MR 1153 Rev. 9109 Page 1 of 1 TRAUMA ANESTHESIA CONSULT I III~III Illu fl tINN INN ICI IINi NI ~N M R N: 75 t 0053 FIN: 10510053 Assessutcgt & Plen ~~~ Assessment ASAPS __~__ L [njurics ----- - --- - ------ - Ai~uate ^ Marginal L] Difficult Veof • n: Adequate spontanecJUs ^ ldeetls Mechanical Vent Cir lion: Minimal B-ood lAS6 ^ Sbock Grade f 2 3 4 i <75UmL, 15% volulnc 2 = 750-1500mL, 15-.30% volume 3 = 1500-2001hn1,, 30-40% volume 4 - 2000-2500rnL, 4U-50%volume Anesthetic Plan: ^ Discussed care with trauma team Leader ^ Reviewed x-r,Jys ^ Reviewed laboratory results Ct Meets criteria fitr immediate [nduction & Entubation ^ Accompany W C'f Scan Q Accompany to OR ^ AnalgesialSedarion ^ _-___ _ - - Monitoring.- _ _ --- fd< No ftuthu'r ink;rvenlion Uate:_ J_]Lt.l____- - -Time:-_~~~-' Green fogy-Medical Record Blue Copy-9illing Facility: HMC Page 7 of 139 PE~JNSTATE HERSHEY I~1 Milto~~ S. Hersh~:y Medical Center Patient Name: GREEN, LC)G.AN M MRN 7510053 N& P DatelTime Printed 9/28/2011 09:52 EDT Page 8 of 139 Printed By Shiner,C;rystal L i Patient Name: GREEN, €_GC3AN M Date of Birfh: 7'21 i 1996 " F'Inal ` PENNSIATE HE:RSFiEY - __--- - ~ Milton S. Hershey ®Meciical Center TRAUMA HISTORY AND PHYSICAL EXAMINATIpN I h1i41 VIII INIi l~Nllll III IIN INI Nll NALSE: GRELN LOGAN t4 EI B: 7510053 r OUS#; ID}S OD51 . AID: DEFLITCn CNFiSTO pD$: OT72t !1696 EIOC: 46"425 VISIT GATE: Dr; oY12011 LOC: EMER IIIIIiII11111~1I~1lI SEX: t.1 S£LF PAY MR N: 75 f D053 FIN: 10510053 Datr ~ Tlme 7. 2(~ Type DI Trauma -Brief History {Mechamsin oii~lnjury) ~`~ ~ ~ f~' # ~'~` ~' t~MVC Betted? i~res ^ Nu C 1 AirbaSi r ~~~~~`- ~~ ~~ ~ y I~r-~ ^ Pedestrian ^ MCt; F] Assault ^ Fatl L7 Burn C7 Electrical ~~ ~~ O 6SW ^ Stab ^ Other Field'IiesuscitaUnn ~;.~ ~t ~- ,~;~ .w~. ~~ _; ~g r; Airway: ~~ IV's: R.O.S. FiBldVitals: P' ~__ _ BP•Il ~ RR f~Ll.@ Immobilization i_. 1_. >I FIDid Amnesia? ~ Yes U No Loss of Cansciuusness? ^ Yes ^ ND G a Field Notes: Prisnary`Survey '' 'r~'-~ ~'.TraumaHisloty _ .}• ~ ~_ _-_'_ 4_ ~_ ~, --- - - _ dirway: [B patent ClOhstrucfed Incubated: ^OT ^ N7 ^ Trach ANorpies' ~~ Breathing: ~ Breath Sounrk: Meds: Ctrchlatton: P' ~ '~ RR: Sat: DisaDltity_ ~ Alert ^ ~ cal ^ Palnlul ^ Unresponsive PMN: Elcpasure: "' Procedures Cl NG-Tube ^ Urinary Catheter t'SR: L] Aline: _ ---._ -. ^ CVt'(s): _„___..._ _ Chest tube' ^ right ^ lefl test meat: J q l _ ` L7 ppL Last Tetanus -- __ T- _ __. _ ..__ ---- __ - NEENT: Head, Uiials: Temp: __ 1': __ _.BP: __ RR: _ 02 Sat:_ WT_~ Seconds Survey; 2nd ,~ Eyes: ~ ,~ ~ ' - _ - ---- - Ears: TM's: L~,,/ __ _ __ 8att[e's: at5 - ~- _ _ __ ` I~ ~~ 1~ Face Maxilla. ~~-- _--_ Mandl6le: ~f ~_ -__, =- ._, ~ 1 _-- Nose. ~ Llentitia: I~~ ~ ~ ~ { ~` Mouth: N]~--- Dentures: _.. ~ J \ ~I } ~ ~ ~ I ~ _ _ _ ---- -- -- __ -_- _..------- ~ 1 Neck: Tendernes,: N-~ ~Crepitus: ~ trachea MII_~ I ~ ____ _ r - If ; ~ 4 Chest 91fa11: Tenderness: ~~( Crepilus: ~ ; ~ }~~~ ~ ~ f i ~ I - _ __ _ I ---- -- - - Lunys: ~~ 1 ~ i ~ ~ --- ------- --- ------- _-- 4 ~ F~:.I i t ~ r ~ I'~~, " ~ f 8ar,k Tenderness: NT ~;~ 1 ` ^l;repitus: ~ ' ~ ~~ ~>~c_ ~ ______ __- __ { _ . ____- - - t'~ - -- .- r Heart _`~_ _.. - _ ~~~ _- - - - - - _- b Abdomen: Distenlron: 65: Tenderness: ~ , ` i ' - - ------ ---_~ _ -_----~1r-- ___._ _ r . f Rectal: Tone Hence: ~ ~alh~.if ~,,{l;*'ostate: T ~ ---- -- - ----- a I_EGENU: ~ J~ Aeiuls. 5tabic ~, tenderness: ~ `~ -..~ -_._ _ ___ _ --------~-_-__._~ _~__ ~ ~ L -lacerration Vascular Exam Radial Femorai DP PT j i aX -cloyed < fracture ~ NighULeh O~~" '~'--~.~, '`':J "'~'OLX -open -~-- Besrdenl Siynawre Tltte Date Time a m /p. m. tsar Lure Ab -abr ~sion ~ -J'~~f~ ,.~''m Gam""... ~~- t; -contusion °- --- COPYRIGHT, ;998 P'(in5 ~4ig Chad hAR 6 t 1 Rev_ 5148 TRAUMA HISTORY AND PHYSlGQL E:XAMIPfATION c;epy -Trauma SrTrvfeos ~ fI111111111111 III IIUIlIIII IIII IIII Facility: HMC Page 9 of 139 PatlentName. GREEN, LOC]AN M Date of Birth: 7/21/199Fi " Flnal " TRAUA9A HISTORY AND PHYSICAL EXAMINATION - -- _ _ _ 'SCCOAdary'.SUtYey (cant:) •~ --_. - _.~ ~~ ' _ _.. - - _ ~ -T-- :_ ---- - -- --. __ --- EnremltyErem - -- r r~~" _ ~~\ - +1 ~ `,. ~ ___ LEGEND I ~' ~ ~ 5 \~~ \ ( 1 1- aceraGon 2-trdGfUfB / ~~~ ~ _~~ ~'~-~ 3--dhrasion d-contusion ~,l f/ ~ ( ~ ' ~`~ 1~ r `,( Neurological Erdm ~ ,. y ~ Glasgow Coma Scale Traarna St:Ote Cranial Nerves ,~ SPlnal Card Injury: ` ~----~ -` ~~ ~ ~- ° t-~ Eye Opening 1 -None 2 O P i Hssp. Hale S8P MOtO r: ~ - pcn In a n 3 - Open to CemmaadlVU+ce 0 ~ 0 0 - 0 ---- - ----------------- ---_ --- - - - ---- ---- ' , • T A - Spa,taneous Porhal Response 1-1-9 1-048 - Sensory: Pinprick '-_ ~_., -_ _ _ - 1-12 t -None 2 - Incornprel~nsmletMOaus to Patn 2 - >36 2 - 50 69 3 - 25-35 3 -?(t-9D _ Pro rioce lion __ P P ~ _ ___ _ °~' 3 - InatrprnpriatafCnes la Pain A•CoMusc4lCunsola6le 4 - 10-24 4 - ; 90 _ ~TH'S _ v~ ~- N - -~_ ~- ~ .. F3~ L 1-5 5.41erUU,ienleNlnlerads Respnnse o GCS 0-;i-4 ~ ~ J - ~ 7 ~ Na .. __ _ -- - _- - - ~~ 2 - Oecerebrate 1 - 5-7 - 3 - Dewdicale Z - 8-10 4 - Wllbdraws 3 -11-13 ro s- --~ rA _--- -- __ _ - 5 -Localizes Pain 6.Obeys 4 -14-i5 . Total: 7atal: _ i ~ _- -.. `laUi/Studipatvfilu~ted s PT: Troponin: UJA: ~/ /i PTT: Myoglobin: -.____-- ----~ - ~-~---~\ T:BIII: --- -- CPK: t3rug Screen: ---- _ ------- - ----- - --- I ~ ALT: Amylase: ----- _.. _ ABG: ALP: Ica: ETOH: ECG: 7EE: BHCG: ;X-Ra s~= CSR: Pelvis: ACT Scans: ! Head: ii~a~:J CS ine: Lat - P - --------- Extremities: - AAdomen: --~ - AP -- - _ _ _ - - - ---- Others: -_-~_- Odontoid `Angta ~` ~ T & L S Ines: {U1S~ yil'roAtem Ctst ~ ~5 ~ J :Alt®ndfng Nate/P~ian i; I-----__ -__ - --- -- ---- Attending ';ignatbrrJDatelrime Orig - CtSaA MH 617 Rev. 5100 Copy- Tt~umuf;ernces TRAUMA HISTORY AND PHYSICAL EXAMINATION MRN: 7510053 FIN: 10510053 Facility HMG Page 10 of 139 PEN~lSTATE HERSHEY ~V~~tc~n S. Hershey Nledseal Center Patient Name: UREEN, LOGAN M MRN 7510053 ..... ....... :~ Phone Message RESUi_T STATUS: Final DOCUMENT SUBJECT: Phone Msg ELECTRONiC:ALLY SIGNED BY: Frc-n~: Shirk, ~3everly .T To: Diilo-~, Peter W; Sent: 07/1 1./20111 15:41.:52 El~'1' Subject: Phone Msg P`f>~ar~~ ~ll~~~a~tr Uk to Lease Message? Call Back Number: Afi Number: Best time to Call? Message/Reason for Call: Post-discharge phone call completed at this time. I spoke with Logan's mother, who reports that she is pleased with his proyress since discharge. He slept well last night, and appears well today. He complained of headache only once, relief with Tylenol PRN. He is eating/drinking well without nausea. The frontal suture line appears intact wtihaut drainage. Reinforced discharge instructions -may shower, pat dry avoid comb to area, also concussion instructions with activity restrictions. ;the expressed understanding. Confirmed follow-up appointment with pediatric surgeons on 7/20111. If questions/concerns anise prior to that lime, she will call back. Beverly Shirk,. RN Pediatric Trauma Care Coordinator DateCTime Printed: 9/28!2011 09:52 EDT Page 11 of 139 Printed ey 5hiner,Crystal L PENNS~TATE HERSHEY /~1 Miltt~n S. Her~he~ Medical Center Patient Name: GREEN, LOGAN M MRN 7510053 ........... .......................,.,......._.................................ED Discharge Instructions..........«...........,.............._.............,.............................` RESULT STATUS: Finaf DOCUfV1ENT SUBJECT: ED Pat f_du ELECTRONICALLY SIGNED BY: ED Pai Edu Penn State Milton S. Hershey Medical Center Emergency Department Discharge Instructions Name: LOGAN GREEN DOB: 7/21!1996 Chief Complaint: MVC MRN: 7510053 Visit Date: 07/09/2011 22:46:00 FIN: 10510053 Current Date: 47/10.12011 01:29:34 Address: 322 MOUNT ALLEN DR MECHANICSBURG PA 170550000 Phone: r 717)796-3196 Primary Care Provider: Name: Larson, Jeanne N Phone: {717) 591-0961 Emergency Department Care Providers: Primary Physician: Dillon, Peter W Secondary Physician: IMPORTANT: We examined and treated you today on an emergency basis only. This was not a substitute for, or an efifort to provide, complete medical care. In most cases, you must let your doctor cheek you again. Tell yraur doctor about any new or lasting problems., We cannot recognize and treat ail injuries or illnesses in one Emergency Department visit. If you had special #ests, 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 LOGAN GREEN has been given these follow-up instructions: ___. No follow up information was provided. Da1e/Time Pr~nled: 9/2S/2011 09:52 EDT Page i2 of 139 Printed By Shiner,Crystal L PE~11~S~~TE HERSHEY ~1 N~~lton S. ~-~ershey Med~c~1 Center Patient Name: GREEN, LOGAN M MRN 7510053 ..... ~~ .ED Discharge Instructions 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 ar anyone in your household does use tobacco products, please follow any smoking cessation advice/counseling you received while in the hospital. -If ycu would like more information about how to live tobacco-free, please call one of the numbers below. PSHMG 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 r;TALK)/1-800-273-8255 Patient Education Materials LOGAN GREEN has been given the following patient education materials: No instructions were provided. Procedures and Tests Performed Order Name Order Date/Time Status Adult Skin Assessment on Arrival 07/09/11 22:09:04 Completed ED Assessment 07/09/11 22:09:04 Completed Physician Consult Request 07109/11 22:09:32 Completed Head CT. 07/09/11 22:09:32 Completed Urine Analysis, Basic & Microscopic 07/09/11 22:09:32 In Process Partial Thromboplastin Time 07/09/11 22:09:32 Ordered Date/Time Printed: 9/28/<'?011 09:52 EDT Page 13 of 139 Printed By: Shiner,Crystal L PENNSTATE HERSHEY 1~.1 Milton S. ]C~ershey Medical tenter Paiieni Name: GREEN, LOGAN M MRN 7510053 ~D Discharge Instructions Proihrombin Time w/ INR _ 07/09/11 22:09:32 Ordered Lipase Leve! 07/09/11 22:09:32 Ordered Amylase Level 07/09/11 22:09:32 Ordered ALT 07!09/11 22:09:32 Ordered Complete Blood Count w Diff 07/09/11 22:09:32 Ordered Basic Metabolic Panel 07/09/11 22:09:32 Ordered Oxygen Saturation Checks 07/09/11 22:09:32 Completed Peripheral IV Insertion 07/09/11 22:09:32 Completed Ghest XR 07/09/11 22:10:13 Completed Pelvis XR 07/09/11 22:10:27 Compleied C-Spine XR 07/09/11 22:19:16 Completed Ped Skin Assessment on Arrival 07/09/11 22:22:05 Completed Trauma Profile, Peds, Default (lab ordered) 07/09/11 22:30:44 Completed Blood Type/Antibody Screen 07/09/11 22:32:38 Completed Peripheral IV Insertion 07/09!11 22:47:36 Compleied Med Dosing Weight 07/09/11 22:49:20 Completed Medications Given During Your Emergency Department Visit Medication Date/Time Given Dose acetaminophen 07!10/11 00:14 650 mg Sodium Chloride 0.9% (NaCI 0.9% 1,000 mL) 07/10/11 00:57 Begin Sag 1,000 mL acetaminophen 07/10/11 01:14 0-10 Pain scale PENN STATE MILTON S. HERSHEY MEDICAL CENTER Printed and given to Patient: 10-JUL-2011 HOME MEDICATIONS: GREEN, LOGAN M ~~-~ if you have any questions, please contact your Physician/Pharmacist. Allergies: No Known Drug Allergies Please Take the Following Medications Date/Time Printed: 9/28/2011 09:52 EDT Page i4 of 139 Printed sy Shiner,C:rystal L I PEN~J STAGE HE:RSY~EY /~1 Milton S. Hershey Medical (tenter. Patient Name: GREEN; LOCaAN M MRN 751oQ53 ... _..... ~ .. _.. ,_ .. _......~ ....... . ......~.............~..... E-D,Discharge,lnsfrucfrons. ,.. ..._ ,_....., ........... .........................._....~...., ~~Medication _ Dose Special Instructions Patient Visit Summary GREEN, LGGAN M has been given the following list of patient education materials and follow-up instructions: Patient Education Materials Follow- ~,In~truc#ions I, GREEN, LGGAN M, have received the above patient education materials/instructions and have verbalized understanding: Patient Signature Date Provider Signature Date UatelTinie Printed: 9/2$/2011 09:52 EUT Printed By: Shiner,Crystal L Page 15 of 139 PENNSTATE HERSHEY IVli~ton S. Hershey Medical Center Patient Name: GREEN, LOGAN M MRN 7510053 ED Transport Note bate/Time Printed: 9/28/2011 09:52 EDT Page 16 of 139 Printed Sy: Shiner,Crysial L Patient Name. GREEN, LGUAN M Date o€ Birth: 1121'1996 t d 0'7110/2011 23:39 7176225449 " Final " WS-EM~i X STAFION F'At,~ 01/03 Ij ~~ ~~ Fenosylvania EMS Report - ssxvtu Nsme - ---~ -- - SaAea ~ Upk NRme, Na. & iypc -- iNnt Sk~ore F2v18 X 5tedm f2! 2102282/ aIIGV Iattideot Locatbn --T -- County, Maaletpatlty dt laeidat Zip W- Ltsbum & S. t.ocast point Rds., MecbRniabury5, PA 17035 - CVMk161tt1tND, Moaroo Towmhip T Wipiuns strtet or FTigAway et gassy uotrets(ty ttospitel- tietshey "+:~~`~~; ~ PRtieatNHme - ;x ; ~e;H~r{r ' ~IJ~~~rt; rs~ _.^ liessall,Wiliiant Cts 15 StreRlAddrtn C2:137t11,Atbotah 0a 322 Mt. A{lea l)r. ~--- Ca i , tt: - Zl $l t t ~ i... ~ ~y p a c C4: s s~, Muhaaiub PA 17053 „~w. Sea Age sie ~:;° ' BOB Phrat No. Primary Caregivers ~~ 1 t~p- Male l41(eats ~ 3' 07/ 21T1y% (717-7 963196 ~,_s„ s_.:.v,s^._ ~i!ll~' ` ;~~ r a:'~•...• • PatlentNuselxr l 9«1a13ee.Na PtwetgMt , • . x=; '~' Tsaume A73_10053__ - - 55 k Oo-9rsae Oat il~i4~i~1 PrivaccPAyeigaw Drires'sLiespx '' " TnesportlagAnbtUelot Aairtp8 Sihcr S ri Twp t:N[5 21:33 _ Ftespoase Ttmt: 2 Rerpaase 0utcotae Nature of tacideat SR Time: 1" T~catsd, Transported by EM9 - ALS A[S O$ Time: 10 ~'Blodc _ _ ___~ 1&ft~'F:ime: 29 Llpttts and Sums Lighte sad Strops Dnl~ation Time: 67. retlen f;onltuoa oa seeae fatieat Coadlgos at pau7tty TOfal Time: 111 Motkrex sovud Tear Out o4 1 R7 _ Qaarter~ chief Compteiat: MVA,; heed Istjatr Carrtat Mods: NonR Alterglre (tt:cdst: Nxrrn PMltn: ~~ Naae PC[t Na Bate 1tk299t 07/09/2011 PSAP food. NO. ._._ 691017 _.. o60t2a P M7'-P ~ - I~ i;MT 16t46z ~.,~ BrWer. Bat to Sit: Dispatch: 2 t_2d H•a[OatR: 21.24 prriveSttne: 21:37 (fr Cpatact 21:35 Q Dtpari Setae. 21:4`7 1j,~ Arrive: 2L]2 ~ Available: 23:14 $ In QaeNer9: 23;22 ~ - •~ss.. fY~~ ~ .,..: -::;,x-.,,.1;.1 -niw eenle.tM~,y _ ~ti~;~ ~ •:~~.:•. ,`:k,~ ;e _ <:r.ar -iywlr:wl, ..n~_+_ nr s iC~ . •<< .c ;i ;ri:+ f 7.'F!@d".. - ~.v.. w ~ • '! 7nt?~ L~;' I•al~ ~~ - ~5,~ ~ i,l"~ f~: •• , .. _~'_ ..yh- : }- 91dc~l'~Aiidl~.: .. , ._ ..., =SaFI'!l:~r0 wr.. • r 71A I~H ~°r. nvia313s _. .,+. ...rvy. _-i:°-.~,^•. .. .disk isn:-: ~::.;.. ,... ...L~..t<. ~ '.. '...~~~,_ s.....,. Bax 25-06. Medic 88 dispatched by Cumberland County 411 with'West Share SL5, Silver Spring BL5 turd k iCelltcttnue to an auw accident. Responded as A.ulb. 88tj41cdic 88. Life Lion was placed on standby by Aritb_ 2~2 on their arrival. Atrivod O/S to finds 2 vehicle accident, t AI.S and 2 $LS patients. A1.S patient is a td. yeaftoid male, a restrained flout seat passenger of a car that wss struck in the right front by en 5Z3Y. Unknown if' there was any [.OC. f,-fe was self-extricated, and fownd by FD to be ambulating. 1?D is iteepotting him to bo 'resiatant/combative to tPeat7fttmt, and having repetitive speech pattern. tie has a 1.5" laceration to the right superior temporal. region of his head, with bleedlrtg controlled. He C/Q right head pain. Upon contact, FD and BLS ate securing hiBr iu a standing position onto a L513 with C-w31ar applied. i#e is not eambative, and; attempting to coopefate. }le is diaphoretic before being placed supine on tkte f.Sl3 and secured __' ~lt~E'~~~ ~'i/~ ider Printed On: D711 oi2o 1 l 23' 13 I EM51atRegoninp,(c) tQgB 21111, Med Media, Inc. Ali ttigJus itaaved. Pagts: I of 2. MRN: 1510053 FIN: 10510053 Facility: HMC Page 17 of 139 Patient Name. CaFiELN, i_C7CiAN M Date of Birth: 7/211 °~ 99Ei 'Final 07/i0/2011 23:39 7174225449 WSEMS X STATION r' P , }; j~ I~ l ~. Ir PAGE 02/03 Y'enl~sylvania E1VKS Repolrt ServiwNwmo Unit No PCRNo• ~~ Wext Sbme L•M5 EZ / ZrOZZ821 M[CU 1112998 07/092011 PeHentName ~ Dafeaf);ireh 3vrtalSeturftyNUiabe= R'61t.P Logandrorn 07/2ifi996 - - 091017 ," (laIi) 14-yenrald male, SS kg. Awake, a1eA altd oriented to Berson end place. Spe~b is clear and coherent, remains repetitive for a while with ilnp[rn~etnCat over tune. Skin is pink, warm and drying. PEARL. Nas -acetatiou as described ahnve. No other head or facial trauma noted. No bleEding from nose, ears or Rlouth, Cervical spins palpated intact and without pain. Chest and thoraciclllxmbarbsck oppasr atratunatic, sad ie not pawful vn pal patiozt. /#1)do-tlem it SN7'. Fair strength and equal movement of all extremities without visible injury noted, poise 4x 100% on 6 L/min, cxnnula_ I:SBS=147 rrtg.ldl- BKG shows NSR {Tx) ALS assess, C-pine stabi8zation maintained as he is secured onto LS~• ki£e lion taken offstnndby. patient moved to stretcher, to ambulance fur further assessment. Enroute University Hosplral. 02 cannula, IEtC:G monimring applied. Patient is maro calm, and his speech is oror+e normal, still occasionally asking repeated questions. Initiated an 1V NS3 KVO. E585. CIVIC- #8376 for Level u "Trauma. Initialed a 2nd N, a Sallee lock. Trapsport was unevent~Itl, Aarived at University. Transferred patient eare/urfo. to tilt: Ell. Trauma Team. Patient to xrauma Room 2. Case #7510053. ALS in sexvice. kr ,. ,.. !G'vi~ei~HUU 1+. ..I ,.°sv ~'~~_~t'~. 11 :.. ':4r.4F.Y1: ~iI.V }.L:kFti ~rc}~.~i , ~ , : 'ell':6Lrl' ve : i [S N K • , a J ~• • ~ ~ ~,~, ° ~ ~ ~ ~ -.:IIM!.~... IiF.~ ~ , _ ~• I .f.~ c\,hj:r~ ~~~'~Llfiiii +'''~~ :o .. ~:'y }r1E ~ ice' :~ ~„ ~ { . . I ~. :, : :. •~ t:~•Y :: ; ~" .b,•: : iNT~aP '::.. Ji~:'i af.:. ;i:,. ,.i:~,. '~ ;~ F _. . ..else ~1.. S . ~• ,:li~ ' ~"' ~ ! ~ " ` ...~latlr. { . .I.i' l.+C~d.:~" S ~ , . ..: .: i i _ __ ii~ .?:S3G:iiut' q s : ' ~' d i " ~ • :ia - : : c: _ -i _~?.. a ; ._., i.. >5d .:~',:••`!a.t6r.; ~:~ .... ~,;!eef .a.::r..."i.::2:~.oliic°~a,:,~:-~ .,. .:,,... ..,.y~h."~!:. - -~' ; a:c; _ ... f'! , . .. r : , x F:.:x ~fl~ h. :~ - 21:3$ Ino:mmb:9pineltmn*olrilGetion Other ~----_-~ 2138 Inmulb: Sptnat tmeaobilitarict+ Nest n,lVilliam 21:40 Mlte_ Assessment-Adu~l; Sucwsf: (11 Neese 11, Williso - --- --- - 2 i:43 Ytt~s: Pulse: S0; Rasp: Z0: B.P.: IRUS4; l}C$: 4/4/b; Rtsp. Edon: Normal; Olhcr _ Y~sion: Normal ___-___._~ 21:46 _ F.KO/Defi6: CeNiu Monbot; ItbYrlan: Normal Sinus Rhythm; RTryOno at Ftoyp{rat Hrsso IF, -vpRsm .. Normal Simla Rhythvr; Lead: R , 21.53 rvrlo: Yanous Access•Exdentiq; Sno°osr I+I: Locuion: FmeaeuvLcA; fluid; lrwse 4 Wiilimn __ Normal Srdtne; Site: I8 G; Rote; TKQ Complfutiun: Ttont 2x:48 i Vitals: P°1m: 80; ResID:26; B.P,: Iz4l6ia; (',C$: a13/d ___._ thha _ 22:06 Mis°: Contact Med[c91 Command; $uuesc t/1 -- ~- Hpsc D, WiIlimn N83~6 -~ ~ --. ----- 22:03 Vitals: Pubes: 80; Rasp: 19; Orcimetry: 19096; H.P : 120Y10; OC9: 41516 Otllrr ~2:04 Misc. Blued dtuuose Artaiysia: Suc..vs: 1/1 ~ Hesse U, William 107 mgJe4. 22:07 tVAO: Yetous Aocen-$xbot6ity Sara7s: 111; Latafiosrt An[eeubiud-l.e~ Fluid: N~~ r/, William _ 9alinaLock; Sint: IS G; Rate:'l'KO; Comptiati°a: Noat -._ _ ....-.----- 2z:t3 Vitals- Pu$c; 84; Resp: lg; Oldrndry: 100%B.[r. 12G/70;GCS; 4/3l6 - ___ 41ha---~- -~-- --- Paitried Oa: OTIIUiZUI l 23:13 EM5ta1 Rryoxtiug(c) 1998-20! 1, Mad Medle, ino. All Rigids Reserved. Frov Page: 2 of 2 MflN: 7510053 FIN: 30510053 Facility HMC Page 18 of 139 Pafient Name: (aHEEN, LOGAt~! M Date of Birth: 7121 11 99 6 `Final " Facility: HMC PENI~~TATE HERSHEY ~1 Nrilto~~ S. Hershey Medical Center Patient Name: GREEN, LOGAN M MRN 7510053 Inpatient Note RESULT STATUS: Modified DOCUMENT SUBJECT: ELECTRONICALLY SIGNED BY: Dillon,Peter W (711012011 09:42 EDT); Budde,Bradley (711 a/2011 06:05 E DT) Addendum by Diiton, Peter W on .luly 10, 2011 09:42 14 yo male involved in motor vehicle accident awake and alert in ED laceration to scalp repaired in ED Hemodynamics stable no complaints This am HEEENT - perrla, wound clean and dry Neck -non-lender Lungs -clear Cor -rr Abd -soft, non-tender Ext -non-tender Imp -stable s/p rnva head laceration, soft tissue bruises Plan - d/c home. follow up in 10 days Electronic Signature on Fie Electronicall y Reviewed/Signed by: Peter W Dillon, MD Author Signature pt~Trrr: 10.07.2011 019:42 AM Pediatric Surgery.' Drs. Robert Cilley, Peter Dillon, L3rett Engbrecht, Kerry Fagelman, Llorothy Rocourt, Mary Santos Coleen Greecher MS RD CNSD, Janet Shields MSN CRNP, YNP BC, Lynn Simmons MSN CRNP PWD DD: 07,10/11 PEDIATRIC SURGERY INPATIENT PROGRESS NOTE Name: GREEN. LOGAN M Patient Number: 7510053 DOB : 07/21 / 1996 Date of Service: 07/10/11 Surgical Hospital Day/Procedure: No procedures found Date/Time Printed. 9!28!'2011 09:52 EDT Page 20 of 139 Printed By: Shiner,Crystal L PE~INSTATE HERSHEY Milton S. Hershey Medic~.l Center Patient Name: GREEN, LOGAN M Inpatient Note SEJBJECTI~/E_:_ MVC trauma came in overnight Vitals 'Temp Pulse BP RR Sp02 FI02 07110 01:48 3:6.3 71 131 /59 18 99 --- 07/10 00:46 ----- 77 ----- 11 99 --- 07/09 4?3:10 - -•- 75 ----- 24 100 --- 07/09 23:00 ---- 84 ---- 18 100 --- 07/09 22:58 --~- 83 ----- 17 100 --- 24 Hr Tmax: 36.3 at 07/10 01:48 Initial Wt: 07/09 kg 1251b Recorded Input Output Balance 07/09 7a-3p 0 0 0 3p-11p 0 0 0 11 p-7a 95 950 -855 24 Total S35 950 -855 07108 7a-3p 0 0 0 3p-11 p 0 0 0 11 p-7a 0 0 0 24 Total 0 0 0 **Refer to the I-VIEW - 1&O tab for details Physical Exam General: NAD HEENT :__ R scalp lac Heart : RRR Chest : CTAE3 Abdomen :_ soli, NT, ND Extremity :_ FROM, well perfused No Latest CBC or BMP Found, Date/Time Printed: 9/28/2011 09:52 EDT Printed i3y: Shiner,C;rystaf L MRN 7510053 II Da#e Wi(kg} Wi(Ib} ~ ~ 07/10 56.2 124 ~ { 07/09 56.7 125 ~ 107/09 56.0 '123 I ~ 07/09 56.0 123 { ~ 07/09 56.7 125 Page 21 of 139 PE~J~ISTATE HERSHEY IVri~ton S. l~ershey 1V~edical Center Palient Name: GREEN, LOGAN M MRN 7510053 Inpatient Note fVtost Recent 24hr Labs as of 07/10 0029 Color (u) :3ee Flowsheet Appear (u) See Flowsheet Glu (u} NEGATIVE Bili {u> See Flowsheet Ketones PEGATIVE SG 11.010 Hgb (u) See Flowsheet pH (u) Ei,5 Prot (u} NEGATIVE Urobili C1.2 Nitrite (u) :>ee Flowsheet Leuk Est See Flowsheet Baci (u) See Flowsheet WBC (u) NONE RBC (u) NONE 07109 2230 Component See Flowsheet # Units 0 Expires at 0600 See Flowsheet R Number See Flowsheet ABOlRh See Flowsheet Antibody Scr See Flowsheet ABO Recheck >ee Flowsheet 07!09 2225 WBC 6.27 RBC 4.14 Hgb 11.2 N c1 'ti~4.2 M G V >r'~2.6 MCH 2'7.1 MCHC~ 32.7 RDW 12.9 Plts 171 M P ~i 9~.6 Glu 127 Na 142 Qa#e/Time Printed: 9/28!2011 09:52 EDT Printed By Shiner,C;rys#al L L L L ~-i F'age 22 of 139 ~'EI~NSTATE HE:R~HEY ~~tJ11 S. ~~~S~ley N~ec~ical Center Patient Name: GREEN, L4GAN M MRN 7510053 Inpatient Nate K :3.1 L C I- 111 f ~l HC03 ;?0 L Anion Gap 11 Green (Lithium See Flowsheet Blue See Flowsheet ALT .6 L Amylase ',~8 Lipase 77 Studies: Pending or Completed in the La~1 24 Hours No studies found Active Inpt Meds: None Active PRN Meds: acetaminophen 650 mg PO q4h One Time Meds: None Active IV Meds: Sodium Ghloride 0.9% 1,000 mL (NaCI 0.9% 1,000 mL} 1,000 mL 95 mUHR ASSESSMENT : 14 yo male sp trauma PLA 1 )__. ADAI 2 )_ Clear C spine once film reads final 3 }_ Dispo planning Electronic Signature on File Electronh:atl y Reviewed/Signed by: Bradley Budde, MD Author Signaterre Dt/Tm: t 0.07201 i 06:05 AM Bfi (JLr: 07/ 1 C7,~ t t Date/Time Printed: 9!28/2011 09:52 EDT !'age 23 of 139 Printed By 5hiner,Crystal L PE~~S~ATE HERSHEY _ ~11Vr~Iton S. Hershey Medieal Center Patient Name: GREEN, LOC;AN M MRN 7510053 .......~ ' ED Depart Summary RESULT STATUS: Final DOCUMENT SUBJECT: Depart Summary ELECTRONICALLY SIGNED BY: Depart Summary Penn State Milton S. Hershey Medical Center Emergency Department Depart Summary PERSON INFORMATION Name GREEN, I OGAN M Sex Male Marital Status Single MRN 751005.3 Visit Reason MVC knc Type Inpatient Track Group EMER Trk Gp Tracking Id 18967493 Checkin 7!09/2011 10:08 PM Arrival 7/09/2011 10.46 PM Address: PA DIAGNOSIS POWERFORMS SCHEDULING PHYS DOC f`~OTES Age 14 Years Language English Phone (717796-3196 Visit Id Specialty Med Service Ped Surgery Discharge CheckouE 711 0/201 1 1:29 AM Acuity 2 Reg Status Start DEPART REASON INCOMPLETE INFORMATION Deport Acflon lliagnosis llischarge Lislructions Patient Understanding lr><compilete Reason Patient Admitted Patient Admitted Patient Admitted PROVIDE=R INI=ORMATItDN Provider Mummers, Barbara (; Hughes, Allison DaielTime Printed: Printed By: hole Clerical RN 9/28/2011 09:52 EDT Shiner,Crystal L Assigned 7/09/2011 10:14 PM 7/09/2011 10;44 PM DOB 7/21/1996 1:2:00 AM PCP Larson, Jeanne N Acct# 10510053 Referred by Dispo Type Adm lJniv Hos LOS 000 0321 Unassigned 7/09/2011 10:29 PM Page 24 of 139 PENNSTATE HERSHEY ~~ M~tC)I1 S . ~+L I ~~1.~~ Medical Center Patient Name: GREEN, LOtaAN M Gyani, Pri'ya R.IE.S. ]?illon, Peter W Physician R.E.S. Nol Needed R.1F_5. EVENTS INFORMATICIN Event Name 1?vent Status Arrive Complete Triage Complete Arrive Registration Complete Registration Complete Arrive Ivlll Bill Compl<te Mll Bilt 1Zequest Arrive I_)ictate Complete llictate Request Arrive P'1" 13elungings Complete I3ed Assign P`T Belong Complete Arrive Bed Assign Complete Bed Assign Complete Arrive Me.d History Complete. Med Ilistoiy Complete Arrive Update Attend Complete Update 131) Attending Complete. Mll Assess Complete Resident :ltisess Complete Patient Belongings Complete Xray Complete Xray Complete P't' Cane Request 1V Care Complete Lab Collect Collected Urine Collect Collected Request Consult Complete Xray Complete Consult. Request Xray Cancel Xray Cancel Xray Cancel Xray Canna Xray C'ancxl Xray Cancel Xray Complete I.al> C'ol(cet Curnplctc MRN 7510053 .~..ED Depart Summary,........_........... ___.......... _...,._ .._.....~ ................... 7/09/2011 10:48 PM "71091'201 l 10:56 PM 7/09/2011 10:56 PM ?/09%20] 1 10;56 PM Request llate/'I'ime 7/09/20 t 1 1U:0$ PM 7/09/201.1 10:08 PM 7/09/2011 10:08 PM 7/09/2011 10:08 PM `//09/201:1 10:08 PM 7/09/2011 10:08 PM 7/09/2011 IO:DB PM 7/091'2011 10:08 PM 7/09/2011 10:08 PM 7109%201:1 10:08 PM 7/091201:1 10:08 PM 7/D9/20ll 10:08 PM 7/09/2011 10:08 PM 7/09/2011 10:08 PM 7/09/201 a 10:08 Plvl 7/09/2011 10:08 PM 7/09/201 110:09 PM 7/09/2011 10:09 PM 71091201:1 10:09 PM 7/09/202'1 10:10 PM '7/09/2011 10:10 PM 7/097201/ 10:10 PM 7/09!2011 10;10 PM 7/09/2011 10:10 PM 7/09/201:[ 10:10 PiVI 7/09/201:1 10:10 PM 7/09/2011 10:10 PM 7/09/201 P 10:14 PM 7/09/2011 10:16 PM '7!09/21111 10:16 PM 7/09%2011 10:16 PNl 7/09/2011 10:16 PM 7/09/2011 10:16 PM 7/0972011 10:16 PM 7/09/2011 lU: l9 PM 7/09/2011 10:32 PM Star/ Date/'l'ime 7/09/2011 10:08 PM 7/09/2011 10:51 PM 7/09/2011 10:08 PM 7/09/2011 10:25 PM 7!09/2011 10:08 PM Campfete Date/Time 7/(}9/2011 10:08 PIv1 7/09/2011 10:51 PM 7/(}9/2011 10:08 PM 7/09/2011 10:25 PCvI 7/(}912011 10:08 PM 7/09/2011 10:08 P>Vt 7/()9%2011 10:08 PNl 7109/2011. 10:08 PM 7/09/2011 10:09 PM 7/09/2011 10:08 PM 7/09/2011 10:09 PM 7!09/2011 10:08 PM 7109!2011 1.0:48 PM 7/09/2011 10:08 PM 7/09/2011 11:02 PM 7/D9/2011 10:56 PM 7/09/'2011 1(7.49 PM 7/09/2011 11:30 PM 7/09/201 110:10 Plvl 7/D9/2011 i0: LO PM 7/U9/2011 10:10 PM 7/09/2011 10:36 l'Ivi 7/09/201 l 10:19 PM 7/09/2011 10:32 PM 7/()912011 10:08 P141 7/U9%20ll 10:09 PM 7/09/2011 10;08 PNi 7109%2011 10:09 PM 7/09/2011 10:08 Ptit. 7/09/201 E 10;48 PI4i 7/09/2011 10:08 PR4 7/09/2011 11:02 Ptvl 7/09/2011 10:56 PM 7/09!2011 10;49 PM 7/09/2011 11:30 PA~I 7/09/2011 10:24 PM 7709/2011 10:25 PM 7/(}9!'2011 11:09 PM 7!()9/2011 10:14 PM 7/09/'2011 10:44 PN( 7/09!2011 10:4G PIV•L 7/09/2011 10:40 PM 77(19/201 110:40 PiUI 'I/0912011 10:40 PNl 7/(19/2011 10:40 PNi 7109/201 110:40 PM 7/09/2011 10:27 PNI 7/09/2011 11:3:? PM Date/Time Printed: 9/287?_~D11 09:52 EDT Page 25 of 139 Printed t3y: Shiner,Crystal L PENNSTATE HERSHEY 1~1 I`IZilto~l S. Hershey Medic~.l Center Patient Name: taREEN, L.OGAN M MRN 7510053 ........................_..... ..............:,.......... ............................ED•Depart Summary.....,...........,.....................................,............_..~..,..........~ Rx Cancel 7/09!2011 1.0:49 PM 7/09/2011 11:0"2 PM Request Consult Request 7!09/2011 10:49 PM ]tx Request 7/09!2011. 10:50 PM Resident Assess Complete 7/09/2011 ]0:56 PNI 7/09/2011 10:56 PM 7/09f'2011 10:56 PM Rx Reyuest 7/09/2011 11:03 PM Admit Complete 7/09/201 111:56 PM 7/10/201 112:04 AM DischargelTransfer (:omplete 7!10!2011 1:29 AM 7/10/2011 1.29 AM 7/10/2011 1:29 AM LOCATION INFORMATION Arrival Vurse Uuil 7109/'ZU11 10:08 Pbl 6MEiR 7/09/2011 10:09 PM L1VILiR 7/09/2011 10:37 1'M liM> iK 7/10/20I 1 1:29 AM 1;MI'sR ORQERS INFORMATION Start Time Order 7~+pe 7/09/'2011 10:25 Green on bald iu PM Laboratory Laboratory 7/09/2011 10:"2_i `li•auma Profile., PM 1'eds; Default (lab Laboratory ordered) 7/0912UI110:30 RlocxE PA1 ~YPelAntibody Laboratory Screen 7/10/2011 12:01 Safety/Quality A1~4 Verification Patient Care 7109/20 t 1 10:10 YM Chest Xlt Radiology 7/09%2011 10:1{) PM Pelvis XR Radiology Abdome»I Pelvis '7/09%2011 10: L6 CT (Diuphrag~n to PM Symphysis Radiology Pubis). 7/09/2011 10:16 Chest C`1` fApc;x PM to Adt'enalsj. Radiology bate/Time Printed 9/28/2011 09:52 EDT Printed By: Shiner,Cl•ysia! L 1%oom 'Triage 2 40 Check Out lied Status Stop Time Provider Completed 7/091'2.011 10:25 PM ~ eI'litch, Chuistopher Completed 7!09!'2011 1{}:25 PM DeFlitch, Cluistophcr J Completed 7/09/2011 10:30 PM ~ eFlitch, Christopher Completed 'I/10!2011 12:32 AM SYS'1')~:M Completed 7/09/2(}1l 10:24 PM DeFlitch, Christopher r Completed 7/09/2011 10:25 PM J el~litoh, Christopher Canceled 7/09/2011 10:4.0 PM 1~!eFlitch, Christopher .I Canceled 7/09/2011 I0;40 PM DeFlitch, Christopher Page 26 of 139 PE~NSTATE HERSHEY _ 1~11Vrilton S . ~~ershey Medical Center Paiieni Name: GREEN, LdGAN M MRN 7517053 ..... .... ...... ....... .`_ ,...... ,,.. ____..__ ..,........ ._, ED Depart` Summary_ _......., , ..... .._......,... _. ,. _....._._..,_.. ,....»_.._._.._._... PM /2011 10.16 C-Spine (; 1' Radiology Canceled 7/09/'2011 10:40 PM DeFlitch, Christopher /~ /2011 10.16 Facial Bones CT Radiology C~.ureeled 7/09/2011 10:40 PM DeFHtch, Chrislupher 7/09%201 1 10:16 ,1, Spine CT Radiology Canceled 7/09J20ll 10:40 PM DeFlitch, Christopher PM 12011 10:7 6 L,_Spine C'1' Radiolugy Canceled 7/09/2011 10:40 PM DeFlitch, Christopher PM 7/09/201 1 10:19 ' C, Spine KT; Radiology Completed 7/09%201 i 10:27 PM DeFlitch, Christopher T M 7/10/2011 8:00 AM Vita) Signs Patient C;ue Ordered 7/iCl/2011 8:00 AM Budde., Bradley 7/ 10/201 1 12:00 PM Viral Signs Patient Care Ordered 7/l0/201 l 12:00 PM Budde, Bradley 7/09/2011 10:7 Piv1 intake and Output Patient Caze Completed 7/09/2011 11:08 PM Budde, Bradley 7110%2011(1:00 Alv1 Intake and Oulpu[ Patient Care Ordered 7/10/2011 6:00 AM Budde, Bradley 7/ i 012011 12:01 Cervical Col lau• AM Care Patient Care Completed 7/10/201 ] 12:32 AM Budde, Bradley 7/10/2011 8:010 Cervical Cellar AM Cure Patient Cue Ordered 7/10/2011 8:00 AM Budde, Bradley 7/10/2017 10:00 IER Pediatrics AM Dorm. Patient Dire Ordered 7l1 CV2011 10:{)0 AM SYSTEM 7/09/2011 10:25 Blue an Hold in L.aboralory Completed '7/09/2011 10:25 P1Y1 DeF7itch, Chrislupher Pl~f 1_ahoratory J 7/09!'2011 11:55 PM Admit. Patient Caze Completed 7/10/2011 12:04 AM Budde, Bradley 7/09/2011 i 1:5~i IER Patient Safet y P i C d PM Form at ent are Or ered 7/09/2011 11:56 PM SYSTl3M 7/10/2011 8;00 IER Patient Safet y AM Form y12h Patient Care Ordered SYS'I'FM 7/1'1/2011 11:56 CJpdate Nursing PM Q72 Hrs Plan of Patient Care Ordered SYSTEM Care 7/09/201 1 10:30 Neuro Check Patient Care Completed 7!09/2011 11;1)8 PM DeFlitch, Christopher PM 7/09/2011 1 ] :3O Plvl i~ieuro Check Patient Carr: Com leted p 7/09/2011 11:5 l PIVI DeFlitch, Christnpher 1 7/10/2011 12:30 Neuro Check Patient Care Canceled 7109 !'2011 11;55 PI~1 DeFlitch, Christopher Alvi , J 7/10/2011 1:30 AM Neuro Check ~ 1 anent Caze Canceled 7/09!201 1 11:55 PM llePlitc.h, Christopher 3 7/10/201 l 2:30 A~VI iVeuro Check Patient C:ur, Canceled 7/09/2011 11:55 PM DeFlitch, Christo~hei 1 J 7/10/2011 3:30 Alai h`euru Check Patient Care Canceled 710<)12011 11:`15 PM DeFlitch Ch~isto Sher ~ 1 1 Date/Time Printed: 9/28/2011 09:52 EDT Page 27 of 139 Printed By: Shiner„Crys tal L PE~!l~~TA~E HERSHEY I~i.~ton S. ~-Iers,hey Medical Center Patient Name: GREEN, LOGAN M MRN 75100153 ......._....... ............ .._ . ...~ ....................... ED Depart Summary ` ~ , 711 0/20 1 1 4:'30 ...... ...... _........,.., ., ...... . ,... , ,..,,...... ......~.... AM Neuro Check Palient Care Canceled DeFlitch, Christopher 7/09/20 T 1 11:55 PM 7/ 10/2011 5:30 J A 1VI Neuro Check Patient (,are Canceled 7/09/2011 ll :SS PM DeFlileh, Christopher 7/10/2011 G:30 AM ~Ic,ur-~ ('heck Patient Care Canceled ?!09%2011 11:55 PM J)el~lttctt, Christotrirer 7<10/'2011 7:30 AM Neuro Check Patient Care Canceled 7/091'2011 11:55 PM ~)eFlitclt, Christopher 7/10/201 ] 8:30 AM Neuro Check Patient Care Canceled 7/Oy/'2011 11:55 PM J)ehlttch, Chrisurptrer 7/10!2031 9:30 AM Neuro Check Patient Care Canceled 7/09/2011 11:55 PM ~)eFlitch, Christopher 7/10/2011 10:30 AM News Check Patient Care Canceled lle]?litch, Chri stn Sher 7/09/201 1 1 1:55 PM 1 7!10/2011 1 I :30 'T AM Neuro Check Patient Care Canceled 7/09I201~ 11:551'Nl ~)eFiitch, Christopher 7/10/2011 1 2:30 1>~,1 Neuro Check Palient Care (:anceled 7/09/2011 II:SS PM J)eFlitch, Christopher 7!09/2011 10:45 PM Vital Signs Patient Care Completed 7!09/'2011 11:68 PM ~)eFlitch, Christopher 71091'2011 1 t :15 PM Vital Signs Patient Care Completed 7/09/2011 11:10 PM ~)et~htch, Ch~istophr_.r 7/1012011 1?;0(J AM Vital Signs Patient Care Cam:eled 7/(?9!201 l 13 :55 PM J)eF7itch, ChrisloPfzer 7/10/2011 1;00 A~1 Vital Signs Patient Care Canceled TleFlitch, Christopher 7/09/201 1 1 1;55 PM 7/10120112:00 ~ J Ahl Vital Signs Patient Care Canceled 7/09!2011 11:55 PM ~yeF[ttch, Christopher 7/10/2011 3:00 AM Vital Signs Palient Cue Canceled 7/09/2011 11:55 PM GeFtrtc;h, Christopher 7l T 0/20114:00 l AaVT Vital Signs Patient Care Canceled 7/09/2!)11 t 1:55 PM 1/CeFlitch, Christopher 7/ 1012(311 _5:00 J AY1 Vital Signs Patient Care (`anceled 710)/201 l 1 L•551'M Jtel?litch, Christopher 7/ 1 0/20 1 1 6:00 AEI Vital Signs Patient Care Canceled 7/09/2011 11,55 P~1 I~eF7itch, Christopher 7/ l0/2011 7:00 •T AM~ Vita] Signs Patient Care Canceled 7/09/2011 1 ];55 PM D'ehlitch, Christopher 7/10/20! 1 8:(10 T AM Vital Signs Patient Care Canceled 7/09{2011 11:55 PM 13~e.1!Ltch, Christopher 7/ l or2o119, o0 1 AM Vital Signs Patient Care Canceled 7/09/2011 11:55 PM D~ePliteh, Christopher '1/ 10/2011 10:00 .T AM Vital Signs Patient Care Canceled 7109/21:111 1l:SS PM 1~e1;1«ch, Christoph~::r 7/ ] 0/201 t 11:00 T AM Vital Signs Patient Crue Canceled 7/09!20!! 1 11;55 PM DeFlitch, Christopher I Date/Time Printed: 9/28/2011 09:52 EGT Printed By: Shiner,Crys#al L Page 28 of 139 PENNTAT~ N_F.RSI--BEY ~11Vri1tcxY S. Hershey Medical Center Patient Name: GREEN, LO~~AN M 7110!2011 12:00 Vital Signs Patient Care PM 7/10!2011 1:00 Vital Signs Patient Care PM 7/09/20111.0:50 acetaminophen Pharmacy PM MRSA 7/(612011 10:50 Surveillance (NY),Laboratory Plvt Pollawup (g7day) 7/0912.011 10:50 Utilization PM Managetnent .Patient Carr, laeview 7/09/201 1 10:50 PM NPO Dietary 7/09/201 1 10:49 Peds Trawna PM Admission Order Sets 7/09/2011 10:46 Admit- Patient Cart. PM 7/09/'2011 10:4`1 Admitting PM Diagnosis Fatieni Care: 7/09!2011 10:48 Primary PM patient Care ResidenUlnlern '7/09/2011 10:4"J PM Vital Signs Patient Care 7/09/201 ] 10:41 PM NPO Dietary 7/09/2011 10:4"1 PM Bedrest Patient Care 7/09/2011 10:4; PM Intake and Oulpul Patient Carc 7/09/ZO11 10:47 PeripheralI'V PM Insertion Patient Care 7/09/2011 10;47 Peripherally PM Routine Care Pa[ient Care 7/09/2011 10:47 PM tall HO Patient Care 7/09!2011 10:47 Cervical Collar PM Care Patient Care 7/09/2011 10:4;' ~['horacic Spine PM Cleared Patient Care 7/09120 I 1 10:4i' 4 .umber Spi ne PM (/eared Patieut Care 7/09/201 110;47` lle:asose. Sr7~ with P>/1 09% NaCI `i00 Pharmacy mL. 7/09/201 1 10:48 &x ia1 Service PM Consults ('onsult DaielTime Printed 9/28/2011 09:52 EDT Printed By' Shiner,Crystal L MRN 7510053 ED Depart Summary Canceled 7/09/2011 11:55 PM DeF7itch, Christopher .T Canceled 7/09/201 1 11:55 PM lle~litclr, Christol-~her Ordered 8/08/2011 10:49 PM Budde, Bradley Ordered 1/07!'2012 11;00 PM SYSTEM Ordered 710.9/2011 10:50 PNI SYSTEM Ordered Budde, Braciiev Ordered 7/09%2011 10:49 PM Budde, Bradley Completed 1/09/2011 10;50 PM Budde, Bradley Ordered 7/09 201 1 10:47 PM Budde, Bradley Ordered 7!0912011 10:48 Plvl Budde, Bradley Ordered 71]0/20i 1 8:00 PM Budde, Br•ar-ley DISCONTIN ?/09/2011 10:50 PM ' Budde, Bradley UI sD Ordered Budde, Bradley Ordered Budde, Bradley Completed 7109/2011. 11:08 PNt Budde, Bradley Ordered Budde, Bradley Ordered 7/09,~20I 1 10:47 PM Budde, Bradley Ordered Budde, Bradley Ordered 7/09/2011 10:47 PM Budde, Bradley Ordered 7/09!2011 10:4? PM Budde, Bradley D[SCONTIN 7!0 /20 1 ' UI;D 9 1 11:02 PR 1 Budde, Bradley Ordered "7/0912011 10:48 PM Budde, Bradley Page 29 of 139 PEN~ISTATE HERSHEY M~ton S. ~er5hey Med.icai Center Patient Name: GREEN, LOGAN M ED Depart Summa 7/09/2011 10:49 Ped Admit2 MRN 7510053 PM Assessment Patient Care Ordered 7/09!2011 10:49 PM SYSTEM ?109/201 110:49 Initiate Paper Plan PM of Care Patient Cme Ordered 7/09/201 150:49 PM SYSTEM 7/09/201 1 10:4.9 1.eve/ oI Care: PM Fluor Patient Care Ordered 7/09/201 1 10:49 1'M SYSTEM 7/09/201:1 1(1:49 i'vted During PM Weight Patient Care Completed 7/09!2011 10:49 PM l3udde, Bradley 7/09/2011 10:50 5k~n Assessment PM ou Arrival to Unit Patient Care Ordered ?10912.011 10;50 PM SYSTEM Peds 7109/201I ]0:50 IER Pediatrics PM Form Patient Care Ordered SYSTE?Vf 7/12/"2011 10:51 I~pressiou PM ticreening patient Care Ordered 7/12/2.011 10:51 PM SYSTEM 7/09/2011 10:09 ED Nursing PM ('harge patient Care Completed 7/09!2011 t 1:50 PM SYSTEM 7/09%2011 10:22 Ped Skin PM Assessment on Patient Care Completed 7/09/2011 11:08 PM SYSTEM An ival 7/09/2011 10:09 PM lsl~ Visit Patient Care Completed 7/09/2011 10:09 PM SYSTh~IV[ 7/09/2011 10;09 PM Ell Asse~ssmcnt Patient Care Completed 7/09/'20] 1 1 LO$ PM SYSTEM 7/09%201 ] ] 0:09 Adult Sldn PM Assessment on Patient Care Completed 7/09/20] 1 11:08 PM SYSTEM Arrival 7/09/201110:09 ~IafetylQuality PNI l erification Patient Care Ordered SYS`1'EM 7109/20] 1 70:10 ] ; D Trauma Peds Order Sets Ordered 7/09/2011 10:10 PM ~)eFlitch, Christopher 1'M 7/09/2011 10:09 Oxygen patient Care Completed 7/09!2011 I1:09 PM I)ePlitch, Christopher PM Satiu-atiott Checks ) 7/09/2011. 10:09 M Neuro Check Patient Care DIS CONTIN 7/09/2011 11:55 PM Budde, Bradley P iTFD 7/09/2017. 10:09 Pulse Oximetry patient Care Ordered DePlitch, Christopher PM ("ontinuous •T 7/09/2011 113:39 Vital Signs Patient C.ue Completed 7!09!2011 11:15 PIv[ L)eItlitch, Christopher PM 7 7/09/2011 11:39 PM Vital Signs Patient Cue DISC:ONTIN 7/09/2011 l I:SS PM Etudde, Bradley UED 7/09/2011 10:09 Peripherally patient Care Completed 7/09/`L(311 ] I :09 PM ~)eFlitch, Christopher PM Insertion 7/09/2011 10:09 Ilasic Metabolic Laboratory Ordered 7/09/201 1 10:09 PNI DeFlitch, Christopher PM 1'anc:l •1 Qaie/Time Printed: 9/28/2011 09:52 EQT Page 30 of 139 Printed By: Shiner,Crystal I• PER!N~TATE HERSHEY 1~1 N~~tan S. Hershey Medical Center Patient Name: (aREEN, LO(.aAN M ED Depart Summary (~omplet~ Blocxi 7/49%2(111 lO:OS~ Count w Laboratory PM 1)ilferential 7/U9/2d 11 10:05 ;II:I' T.evel Laboratory PM 7/09/2011 10:09 PM Amylasr, Levcl Laboratory 7/49/2011 10:05 l ,ipase I_eve! Laboratory PM 710912d t 1 10:09 Pmthrumbin Time PM w! INR L aburalory Partial 7/4)/201110;09 I'hrurnboplastin Taboratory PM I'irrre 7/09/2411 14;09 Urine Analysis, Basic ~ Laboratory PNI Mtc;roscOPIC 'I/09/2011 10:09 Physician Consult P~NI Request Consults 7/09/2411 ] O:ld ED Trauma PM Itadiaiogy Set Order Sets 7/09/2011 10:00 PM Head C'1'. Radiology 7/09/2011 1 L0"?~ Sodium Chloride PM 0.9°h l ,000 rnI, Phanuac y 7/10/201 l 8:Od [IJR Patient Safety AM Form y12h Patient Care: MEDICAL INFORMATION Allergy Info: NKA Prescriptions riven DISCHARGE INFORMATION Discharge Disposition: Adm Univ Nos Discharge Location: PATIENT EDUCATION INFORMATION Instructions: Daie/Time Printed: 9/2812(?11 09:52 EDT Printed By: 5hiner,Crysial L MRN 7510053 Ordered 7/49/2411 10:(19 PM DeFlitch, Chtistcalrher Ordered 7/09/'2011 14:09 PM DeFlitch, Clu-istopher ,f Ordercd 7/09/2011 14.(}9 PM DeFlitch, Christopher DeFlitch, Christul~her Ordered 7/09/2011 10:09 PM Ordered 7/09/2011 10:09 PM DeFlitch, Chrislolrber 1 Ordered 7/09/2011 10:09 PM I)eFlitch, Cheistu~her 1 Ordered 7/091'2011 10:09 PM DeFlitch, Christ~l~,~her Completed 7/09d'2011 10:1 PM DeFlitch, Christalaher -I Cumpleted 7/09/2011 1U:4~ PM J eFlitch, Chtistcgpher Completed 7!091'2011 14:4 PM lleF7itch, Christopher Ordered 8/0812011 11:02 PNI Budde, Bradley Ordered 7/10,x2011 8:0(} AIVI SYS`I'RM Page 31 of 139 PE~Vf~~~ATE HERSHEY R~1 Miltan S. Hershey 1Vleciical Center Patient Name: GREEN, LOGAN M MRN 7510053 .....,~ ED Depart Summary Follow up: Follow-Up With: When Comments: Dale/Time Printed: 9/28/2011 09:52 EbT Page 32 of 139 Printed fay: Shiner,Crystal ~. PEI~~l~TATE HERSHEY _ ~.1 Milton S. /Hershey MCed:ical Center Patient Name: GREEN, LOGAN M MRN 751~J053 .., `."................•..,`.. ` ......:..........._., _ ,....._,............. `_•...ED•Summary ................._............._.....•.•.....................................•....,......... RESULT STATUS: DOGUMENT SUBJEGT: ELEGTRONIC:ALLY SIGNED BY: Trauma -major Final Trauma -major Kimak,Mark J (7/10/2011 19:27 1=DT} Patient: GREEN, LOGAN M MRN: 7510053 OOS: FlN: 10510053 Age: 14 years Sex: Male DOB: 7/21/1496 Associated Diagnoses: None Author: Kimak, Mark J Basic information Additional information: Ghief Complaint from Nursing Triage Note :Visit Reason. 7/~?J2017 22:14 Visit reason MVC History of Present lilness The patient presents with major trauma and the patient was a passenger in an au#o accident. EMS stated he was combative at the scene. there was a reported right scalp lesion. there was no reported LOC. he currently is cheat. he complains of a headache. he denies chess or abdominal pain. he was a trauma team response. Review of Systems ENMT symptoms: Negative except as documented in HPI. Respiratory symptoms: Negative except as documented in HPI. Cardiovascular symptoms: Negative except as documented in HPI. Gastrointestinal symptoms: Negative except as documented in HPt. Genitourinary symptoms: Negative except as documented in HPI. Musculoskeletal symptoms: Negative excepl as documented in HPI. Neurologic symptoms: Headache. Additional review of systems information: All other systems reviewed and otherwise negatives. Health Status Allergies: . Alleroic Reactions (AID NKa Medications: Launch Medications List (Selected). documented Medications Documented acetaminophen 650 mg oral tablet: 1 tab, PO, q4h, tab, PRN: Fever/Mild Pain Past Medical/ Family! Social History Medical history Psychiatric: attention deficit hyperactivity disorder. Family history: Unknown. Soeiai history: Family/social situation: Lives with parent(s). Daie,~l"ime Printed: 9/28/2011 09:52 EDT Printed By: Shiner,Crystal L Page 33 of 139 PERIN~7ATE HERSHEY ~.1 M~~on S. Hershey Medical Centier Patient Name: ~aREEN, LOGAN M MRN 7510053 ... ....... .,, ..`. ......, . , .. _._....,.. ................................ ED,Summary .,......_ ,_ ..._ .......`.,~.., ......,, .. _ .....,~........ ,.,,, Physical Examination Vital Signs Vital Sign;. 7j 1l;/'L01~1 1.1:00 Temperature 36.3 AegC LOW (Pa~eliminary} Temperature Route Tempo°aL ~~'r~:~liminary} Heart Rate J7 bpm ( Feel.i;nir.ary} Respiratory ltat_e 16 br/n~~in (P r~,~Lini~inarp) Sp02 99 °s (Pr el_iminsryl /J'10/?071 0£1:15 Systol.9_c Blood Pressure 119 mmF?g (('relin~inary~ Diastolic Blood 1':'ressnre 65 mmHg (;?rr-1l iminary) BP Location # 1 Right llrm ;Pr~~el.iminary} Cuff Pulse }'resst.ire 54 n~m[3g (Peel inii~~ai:y) 7 / 1 :?/2.0 I 1 0fi.: 00 Temperature 36.3 DegC LOW T~~mpee~atur:~ Route 'empor.al I~eart Rate 5l bpm 12espir.atory Rate 16 br/miu Sysl=oli.c Blood Piessu~°e 1 Uf; m:nHq_ Diastolic 131ood i ress~~ee 39 nmHq IlP Location II 1 Right Arm Cuff P~alsa Pressure 67 n~:nHg 5p02 ~7 7/li!/2011 02:00 Temperature Central Warm 7 / 1 ii / 2.0:1 0:L : 4 £3 Temperature 36.3 DegC LOW Tempera°ature Route 7'a;7~poral heart ktate 71 bl~ni espirator_y Rate 13 l,r /min 3ysto"sic B7.ood P~-~, ,sure 1 :31 mmHg Diasto]_i_;. Blood Pressure 59 rotnklg BP Location # 1 Lett A?-n ~-',uff Pulse Pressure 72 mmHd 5p02. 9~3 =:; 7/L!1!20:11 OG:46 1leart Rate 77 bp~n Respiratory Rate 11 br/mini Oxygen Therapy Room air. :p02 H~~ n 7/~~I2011 23:10 Heart Rate 7'~ bt~n~ Respiratv,r:y Rate 24 t~rimi_n Oxygen Therapy R~> om air :ip02 ( lt)\~ '6 'r/~~,; L0~11 23:00 Heart Rate 84 lJpn~ Respiratory Rate t£3 hr%mi_n Oxygec 'Therapy Roca. air `=pO2 1 t' C) 7/ 9i 10'; _ 22: 5~i heart Rate £i ~ bpm Date/Time Printed 9/28/2011 09:52 EDT Page 34 of 139 Printed By: Shiner,Crystal L PENNS TATS HEl~SHE~' ~ M~1tc»~ 5. Hershey Medical Center Patient Name: GREEN, LOGAN M MRN 7510053 .................. ...... ....._........................,._......_....,.....................ED Summary.................................,.................................,.,........._............., Respiratory Rate, 17 br/rain Oxygen Therapy Room air Sp02 100 ''s I/9/2.i-)1? z'G:19 Temperatuze 36.1 DegC LOW Temperature Route Oral Heart Rate 86 bprn Respiratory Rath 18 br/min 9ysto7 is Blood Tress-are 1~ 5 mm~Ng Diastoli-c 37ood Pressure '75 mmHg Oxygen Therapy R.c~om a:i.r SpO~ 100 .,r Measurements. ?/70/2017. 01:9 He:i.gY~t 1.70 cm Height Method Pai:ient stated Patient Weight 56.25 kg Body Mass Index 19.46 kg,Im2 Body Surfa^e Area 1.65 raL ~~J`?/2,07.]_ 2?_:93 {?anent Weight 56.690 k~~I Weight 56.000 k~ Weight 56.000 kq Weight Method Estimated 7/~a/2n1 2.?_:l~ Patient Weight 56.690 ;tq VJeighY_ 56.690 kq Weight Method ~stin:,~te~! General: Alert. Skin: Warm, dry. Head: Normocephalic, 4 cm parietal scalp laceration. Neck: Trachea midline, collar in place. Eye: Pupils are equal, round and reactive to light, extraocular movements are intact, normal conjunctiva. Ears, nose, mouth and throat: No pharyngeal erythema or exudate. Cardiovascular: Regular rate and rhythm, No murmur, Normal peripheral perfusion. Respiratory: Lungs are clear to auscultation, respirations are non-labored. Chest wall: No deformity. Back: No step-otis. Musculoskeletai: I~lo swelling. Gastrointestinal: Sofl, Non distended, Normal bowel sounds, No organomegaly. Neurological: Alert and oriented to person, place, time, and situation, CN I1-Xlk intact, motor + ligh# touch full in alt 4 distal limbs. Psychiatric: Coopers#ive. Medical Decision Making Trauma team: Trauma criteria met. Differential Diagnosis: Abrasions, head injury, neck injury. Results review: Lab results :Laboratory. r/10/G011 GL 58 MRSr'~ 5urveillanc~e, oft Admission hCRSA NGT del ~~ci=ed. Date/Time Prirtied: 9/28/2011 09:52 EDT Page 35 of 139 Printed By: Shiner.,Crystal L PENNS7ATE HERSHEY ~1 N~ilton S. Hershey 1Vledical Center Patient Name: GREEN, LOGAN M MRN 7510053 7; r i"x/201=~_ 0.):29 Color (u) YELLOW Appear (u) CLEAR Glt1 (u) NEGATIVE n~q,/c~J., Ail_ (u) NE;GATI_VE Ketones NEiGATIVF' ~~lq/cl , SG 1.07.0 Hgb (u) NE~CA.TIVE pH (u) F,.S unit Prot- ('a) NEGATIVE mq/<),`, Urobili 0.2 EU%dL IQitrite (u) NE';(YATIVE Leak Est 2cE,GA'1:IVE WSC (u) 2vONE /HL'F RkiC (u} N[iNE /HP E' Beat (u) MODERA7.'E 7/c~/201? 22x30 ABO/Rh ABO/Rh A130 Recheck ABO Recheck Anti_bocly S^r NEGATIVE Expires at 0fi00AM o;~ 07/12/2011 R Number R3197:~ Component REI) CELLS R Unity 0 7/x/2071 22x25 Na 192 mmol/1. K 3.1 mmol/L LUW C1- lil mmol/L HI HC03 20 mmoi/L LOW Anion Gah 11 mmol/L Glu 127 mg/dL HI Hgb 11.2 g/dL LOW Hct 39.2 ~ LOW RBC 9.14 M/uL LOW MCV 132..6 iL :KC1IC 32.7 ~/dL MCH L7.1 pg RUW 12.9 `s P1Y.s; L71 K/uL MPV 0.6 f'1, ALT <6 unitJL LOW Lipase 77 unit/L Amylase 5H unit/L Green (Lithium liepat~ic~) Specilten available from 0 to days baser) on :> pec.inlen stahili t:y. Please ur;e addon order- i?~ yot~~ wish t~, r;rder testing,. 81ue Specieten av~; i i,;bl~~ from 0 fi o days based on s pecimen stability. Please ttse addon ~~rdt~t i l you wish tc order testing., date/Time Printed: 9/28/20tl1 09:52 EDT PagE: 36 of 139 Printed By. Shiner,Grysta! L PENNSTATE HERSHEY 1~11Vril.t~n S. Hershey Medical Center Pa#ient Name: GREEN, LO~GAN M MRN 751(}053 .............. ..............................................__._._..,....._.......,.,...,ED`Summary....._...........,........._.._...................................,.._............._...... Head Computed Tomography: No acute disease process. C-Spine X-Ray: No fractures. Chest X-Ray:. No acute disease process. Peivis x-ray fiindings No fracture. Impression and Plan Diagnosis Head injury 959.01 (I(:D9959.01) Plan Candiiion: Stable. Disposition: Admit. Addendum leaching-Supervisory Addendum-Brief I participated in the following activities of this patients care: the medical history, the physical exam, medical decision making. I personally performed: supervision of the patient's care, the medical history, the physical exam; the medical decision making. The case was discussed with: the resident. Signatures: Electronically ReviewedlSigned (10-JUL-2011 19:27:00) by: Mark J Kimak, MD Date/Time Printed: 9/28/2(111 09:52 EDT Pape 37 of 139 Printed 13y. Shiner,Crystal L PEN~IST~TE HERSH~I~ 1~.1 Milton S. Hershey 1Vledical Center Patient Name: GREEN, LOCxAN M MRN 7510053 _...._:._ _.. _ ..__ _ .. _ ............. ..............._.............. Patient Discharge Instructions."._..... __....__........... _._... _..........._.............._ ...__.,..., RESULT STATUS; Final DOCUMENT SUBJECT: ELECTRONICALLY SIGNED BY: Boesch,Robert E (7110/2011 14:14 EDT) PENN STATE MILTON S. HERSHEY MEDICAL CENTER 1-717-531-8521 PATIENT DISCHARGE INSTRUGTlONS If you have any questions, please contact your physician. Date of Admission: 07/(}9/2011 Date of Discharge: 0 711 0/201 1 Reason for Discharge: Stable for Discharge Physician: Dillon; Peter W Service: Peci Surgery Discharge Diagnosis: Trauma-MVC Surgical Procedures: None Vaccinations Received This Hospital Siay: No vaccinations were given this hospital stay. Care Instructions: You may take Tylenol as needed for pain {use as prescribed on the package). Date/Time Printed 9/28/201 1 09:52 EDT Page 38 of 139 Printed By: Shiner,Crystal L PEN~ISTATE HERSHEY _ ~'~ ~1~tQll S. ~~rS>}1~y ~~1Cc`ll ~~Il~e~ Pa#ient Name: GREEN, LGGAN M MRN 751 4053 Patient Discharge lnstrucfions po not soke your head wound in water for 5 days. Sponge bath the area, please keep head out of the shower stream and swimming paol. Diet Guidelines: Resume regular diet as tolerated. Drink plenty to fluids Activity Guidelines: Resume regular activity as tolerated. Do not overdo it. Avoid any activity that may lead io another head injury for at least 4 weeks. Call your doctor if: Please call 717 531-8521 and ask io speak to the pediatric surgery resident on call far persistent lever (over 100.4),nausea, vomiting,increased headaches, or any other concerns. You can also reach us during regular office hours by calling 71 7 531-8342 Call us for any concerns or questions. Follow-Up Appointments: 1~nscheduled Penn State - HMC Follow-U~ Appointments Your appointment with PETER W DILLON has not yet been scheduled. If you have not been contacted with this appointment information within two business days, please cal! 53i-1404. Discharging Provider: Lin, Yu Kuan PENN STATE MII.:TON S. HERSHEY MEDICAL CENTER Printed and given to Patient: 10-JUL-20t 1 HOME MEDICATIONS: GREEN, LOGAN M _.-i If you have any questions, please contact your Physician/Pharmacist. Da#e/Time Printed: 9/28/241 109:52 EDT Page 39 of 139 Printed By: Shiner,Crystat L PENNS~ATE HERSHEY _ Milton S. Hershey Medical Center Patient Name: GREEN, l_OGAN M MRN 7510053 .._...._.___.,._.....__. ... ...:..........................~..._..........,Patient Discharge lnstructions,.__................_._.........:........,...........,..._............ Allergies: No Known Drug Allergies Please Tike the Following Medications Medication _ Dose Speciallnstructions acetaminophen 1 tab - by mouth -every 4 hours, .as (acetaminophen 650 mg oral tablet) needed for Fever/Mild Pain Other Medication Instructions: This medication list is what we currently have on file far you. If this list does not agree with the medication you are taking or how you are taking the medicine, please notify our office. 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, continue this healthy choice! - Remember to avoid secondhand smoke. - It you or anyone in your household does use tobacco products, please follow any smoking cessation advice/counseling you received while its the hospital. - If you would like more information about how to live Tobacco free, please call the numbers or access the websites below: PSF~MC Care Line 1-800-243-1455 Pennsylvania Free ~UITLlNE 'I-800-QuitNow (1-800-784-8651) http:/f1800quitnow.cancer.gov httpa/www.determinedtoquit.com Date/l'ime Printed: 9/28/2011 09:52 EDF Page 40 of 139 Printed By Shiner,C:rysta! L PEN~1 STA1~E HEI~SH EY Date/Time Printed: 9/28/2011 09:52 EOT Page 41 of 139 Printed By: Shiner,Cryslal L PENN~-TATE HERSHEY 1~11Vr~ton S. Hersey Med.i-cal Center Patient Name: GREEN, LO{aAN M MRN 7510053 Earocedure _1NRC Hgb Mci R6G MCU MGHC M(H ~F2C~W Units K/uL g,1dL °I° M7uL fL g,~dL pg Q/o Reference 1~ange [4.5-13 5} [13.0-t6.0~ {37 49] (4.5Q 5 30] [78-98j [31-37] (26-35] [1 1.5-14 ~}. Collected U~te/Time'.. .. 7!9/2011 2:25 EDS ` 6.27 112 ' >: 34.2 ~ 4.14 r 82.6 32.7 27.1 12.9 Procedure Plts Mt='V tJrrits ;' K/uL fL', Reference Range [17t-340] [9 0 T2.2] ;.`- Collected C1aielTime 7/9/2011 ?_2:25 EDT 171 9.6 Date/Time Printed: 9/28/2011 09:52 EDT Page 42 of 139 Printed f;y: Shiner,Crystal L PENI~STATE HERSHEY 1~11Vr~ton Sa ][~er~hey medical Center Patient Name: GREEN, LC~GAN M MRN 7510053 ..~ .. ............ .. ............ __.........." .....~ ....... .., ..~ Chemistry ..... ~....~..._....,.~....... ..... _......,......... ... , ~ .................,...._. -.procedure Na K ~f~ HC03 Anion Gap `Gtra Units mmdUL , ,mmoUL namol/L` mmol,~L mmoUL' my/dL R~ierence Rang6 :(137 145] [3.5-5. 1] [96-1U7], [22-30] [5 14] [74,1afi] ; Coilecied Date/Time _ ,. ;7/9/2011 22:25 EDT 142 3.1 r .,. 111 " 20 r 11 127" Daie~Time Printed: 9/28/2U11 U9:52 EDT Page 43 of 139 Printed By: Shiner,Crystal L PEN~lS~ATE HERSHEY ~1 MiltUn S. Hershey Medical Center Patient Name: Gf1EEN, L~C3AN M Date/Time Printed: 9!28/2011 09:52 EDT Printed By: Shiner,Crysial L MFiN 7510053 Page 44 of 139 PE~~S rA~E H~~~~E~ 1VItltOll S. ~-IerSh~y Medic~.1 Center Patient Name: GREEN, LOGAN M MRN 7510053 ......_. ................. _.................,......,..._..............«............~..,.........Liver/Gf.......~....~.._............_..................................,_...._........_.,.............._. Procedure ALT Lipase ; Amylase` i Units unit/L unit~L unit/L Rcfert~nce ~{ange [13-69] [23-300] [30-.110) Co!lecisd Rate/Time ;7!9/2011 22:25 f=DT <6 r 77 ,, 58 Date/Time Printed: 9/28(2011 09:52 EDT Page 45 of 139 Printed ey Shiner,Crysial L IA PENNSZATE HERSHEY ~11Vri1ton S. Hershey Mec~i~;a1 Center Patient Name: GREEN, LOG~AN M MRN 7510!)53 ..................... ..........,... ......... ................ ..........._._........... ....Urine~....._ . __..... ....................... _... ...._ ,. .................................~ Procedure Calar {u) Appear {uj " Glu (u) ~,il (rr) Ketones UnItS Reference Rar~c~e (NEUj _ ]NEG] [NEG] >, Coilected Date/Time. 7/10/2011 00:29 FDT YELLOW O1 CL1=AR°1 NEGATIVE°1 NEGATIVE°1 NEGAjIVE~'' t~rocedure SG Hob {u) p.N {u) Prot (u) Urobili ~>litrite (uj` kJhits Unit EUldL f~eferenee Range [NEG ] . 4.:5 8.0 [ 1 {NEG] [o j 1 a~ ~ [NEG Collected DaielTrme 7/10/?011 00 ~9 EDT 1.010°' N EGA~IVEO1 6.5"' N EGATIVE' 0.2°1 NEGATIVE°t C?Yocedure- Leuk Est '1ld13C{p) Fi[3C(u} Bact(u) Units ~teference Lange .. (NEG] [0 4]: . [0-4] [NONE] CoUscted QatelTime . ;, _ _ , 7!10/2011 40:29 EDT _ NEGATIVE O1 .. ..: NONE°' NONE°t . M4DERATE~°' Order Comments -... 01: Urine Analysis, Basic & Microscopi c (UA, Basic & Microscopic) [[Urine, sterile cont ainer]] Date/'rime Printed. 9/2812011 09:52 EDT Printed 13y: Shiner,Crystal L Page 46 of 139 PENN~TATE HERSHEY # N~~tOn S. Hershey Medical Cente~_~ Patient Name: GREEN, LOGAN M RESULT STATUS: DOCUMENT SUBJECT: ELECTRONICALLY SIGNEC) BY: SERVICE DATE/TIME: MRN 7510053 Final X-RAY CHEST PA OR AP VIEW- PEDS 7/9!2011 22:24 EDT X-RAY (:HEST PA OR AP VIEW- PEDS PAT.IENI' NA.MEs: GREEN, LOCiAN M PATILN 1' MRN:07~ 10053 PATIIiN[' D()B: 07/21/1996 EXAM DAf'E t71~ SERVIt:`E: 07/09/?013 EXAM NUMBER: 7017592 ORDEI2JNG E'HYSICIAI\f : DE1~LI`I'CH, CE1lzIS I'OPHER EXANIINA'1`I()t~l: AP radiographs of the pelvis. AP portable radiograph of the chest. Lateral x-ray of the spine Cervical spine. CLINICAL HISTORY: Trauma. COMPA RIS(lN: Notre FINDIN(S: Pelvis: No li•artures. Bone mineralization is normal Soft tissues are normal. Chest: Cardiomediastinal silhouette is normal in si2c. and contour. Pulmonary vasculature is n~>rnral. No parenchymal op~icity effusion or pneumothorax. The bones are normal. "Ihe radiolucent line transvcrsing the left upper thorax anci the lateral clavicle is secondary Co the superimposed cervical- collar. Cervical spine: The cervical spine is viewed from the crauiocervical junction through the superior end plate of T2. 'There is anatomic alignment of the cervical spine. 'There is mild straighter~:ing of the cervical lardosis secondary to cervical collar°. No fracture. No loss of vertebral body height or disk space height. Posterior elements are intact. The Cac;ette joints rue appropriately aligned. No prcvertebral sofC tissue sw~~:llitrg. IMPIi~;SSION; No tlaun~a to the cervical spine, chest, or pelvis. Date/Time Printed: 9/28/2011 09:5?_ EDT Printed 6y: Shiner,Grys#al L F'age 47 of 139 PENNSTATE HERSHEY _ M~1 M~ton S. Hershey Medical Center Patient Name: GREEN, LOCaAN [vl Chest MRN 7510053 The findings sue-re discussed with Dr. Pastor by HJK at the time of the trauma. Dz'. fieathcr 3. Kaneda is the dictating resident. Attendiuf, radiologisl signature indicates review of both the images and the report and that thF attending radiologist. agrees with the interpretation. Preliminary reports may not have been reviewed as yet by the attending radio]ogist. D1C'1'AI'ED: I?(;GL,I, Kf1I'IILEEN REVIE'~V[:D AND SIGNED: EGGI,1, KATHLL'EN DAl'E DRAI~~11iD: 07/091`ZOI I 11:20 PM llAI'E 0~~ F31~fAT SIGNAl'UI2E: 07/10/201.1 09:27 AM Da#e/Time Prinied: 9/28/2011 09:52 EDT Page 48 of 139 Printed sy: Shiner,Crystal L PE~lI~STATE HERSHEY_ Milton S. lHershey Medical Center Patient Name: GREEN, LOGAN M MIEN 7510053 . Head/Neck RESULT STAf US: Final DOCUMENT SUBJECT: CT HEAD WITHOUT CONTRAST PEf;~ ELECTRONICALLY SIGNED BY: SERVICE DATE/TIME: 7/9/2011 22:43 EDT C;T HEAD WI'nIOUT (YOI~T'I'RAST PN:D I'A['11-~,N l' NAMli: GREEN, i,OGAN M PAT'IENT' MRN:075100ti3 PAI'LEN~1' Df)B: 07/21/1996 1:XAM .(~A77? Oh SERVICE;: 07/09/2011 L.XAM NUMIi}~R: 7(317:94 ORDF,RING NI IYSIC'IAIV: DEhLIT(,H, (~I}RISTOPIiliR EXANIINATION: C'I' HEAD Wl'I'IIOCfT C`ON'L'}2AST PF,D CLINIC"AL HISTORY: SS:`Iiauma 959.8; COMPARISON: None TECHNIQUE: Routine tomographic images of the brain are obtained from the skull base to the vertex without intravenous contrast. FINDIN(US: 'There is a small laceration along the right: frontal scalp. No associated bony abnorrnalily. `T'ile gray-white matter attenuation is normal with. no focal mass, mass effect or calcification. 1'he vent>zcles anti extr,3-axial spaces are normal. No evidence of he~marlhage is seen. fhe calvariunr is intact The sinuses are c}car. IMPRESSION: Sma11 laceration along the right fior~tal scalp. No intracranial hemorrhage. Date/Time Printed: 9/28/2011 09:52 EDT Page 49 of 139 Printed By' Shiner,~Crystaf L PE~11~ST~TE H~~SH~Y _ !`~1 Milton S, I-Hershey Medical Center Patient Name: GREEN, LOCaAN M MAN 7510053 ........................ .........................................................~.......... Head/Neck............................_..............~.......~............_.......~..~.._........... 'I'he lindii~gs wca~e discussed with Dr. Pastor following the CT examination by l-IJK. Dr. Ileal~icr J. Kaneda is the dictating resident. Attending radiologist signature indicates review of both the images and the report and that the attending radiologist agrees with the interpretation. Prelimiliary reports niay not have been reviewed as yet by the attending radiologist. DICTAT~:D: Nt_)UYEN, DAN ItEVIE`VEI7 ~aND SIGNL;ll: NGUYEN, DAN llATE DkAl~'I7~:D: 071091?011 11:02 PM DATE OF FINAL, SIGNAI:`UI2E: 07/091201.1 11:44 PM Date/Time Printed. 9/28/2011 09:52 EDT Page 50 of 139 Printed By: Shiner,Crystal L i9 l'E~INS_ TOTE HER_S_HEIC _ Milton S. Hershey Medical Centier Patient Name, ~xt~EEN, LOGAN M MRN 75-!0053 ...~..~....~...... ...............~..............................._.......................,.._...Pelvis/GU.................~................~.....,...,..................................................,.., RESULT STATUS: dOCUMENT SUBJECT: ELECTRONICALLY SIGNET) BY: SERVICE dATE!TIME: Final X-RAY PELVIS AP 1-2 VIEWS -PEDS 7I9l20i 1 22:25 EDT X-RAY PELVIS AP 1-2 VIEWS -PEDS PAT'll;N[' NAME: GREEN, LOGAN M PATIENT' 1VIRN:075T0053 PAT'1L1.N C I70B: 07/21/1996 EXAM DATE 01~' SERVICE: 07/O9/2011 EXAM NUMBEk: 7017593 ORL7EIi1NG P1IYSICTAN: DEIiLITCH, CTTRISTOPIIER EXAMINATION: AP radiographs of the pelvis. AP portable radiograph of the chest. Lateral x-ray of the spine cervical spine. CLINICAL HISTORY: "Trauma. COMMA RISON: None FINDINGS: Pelvis: No fractures. Bone nuneralization is normal. Salt tissues are normal. Chest: E,`ardion~icdiastiual sill~ouette is normal in size and contour. Pulmonary vasculature is normal. No pareuchynial opacity effusion or pueumothorax. The bones are normal. 't'he radiolucent line transversing the left upper thorax anti the lateral clavicle is secondary to the superimposed cervical collar. Cervical spine: The cervic,:zl spine is viewed from Che craniocervical junction through the superior end plate of "1'2. There is az~atamic aligi~nient of the cervical spine. 'T'here is mild siraightenii~g of the cervical lordosis secondary to cervical collar. No fiaclure. No loss of vertebral body height or disk space height. Posterior elzments <:u-c i~ltact. The fa~cette joints are appropriately aligned. No prevertebral soft tissue swelling. IMPRESSIOI~1: No trauma io the cervical spice, chest, or pelvis, date/Time Printed: 9!28/2011 09:52 EDT Printed By Shiner,C:rystal L Page 51 at 139 e P~NNSI~TE I~ERSHIEY 1~1 Miltan S. Hershey Medical Center Patient Name: GREEN, LOGAN M MRN 7510053 Pelvis/GU I'he lindings were discussed with Dr. Pastor by HJK at the time of the trauma. llr. Heather J. Kaneda is the dictating resident, Attending radiologist signature indicates review of both the images anci the report and that the attending radiologist agrees with the interpretation..Preliminary reports may not have been reviewed as yet ~y the atlClldll]b I'ad]OlO~lst. DICTATEl:7: L;G(_~1,I, KA'I'HL11L:N REVIEWI?ll AND SIGNED: LGGLI, KATHLEL'N DATE Dt2Ah1'tD: (}7/0912011 11:20 PM DA`I'T:: Ol~ h1NAL SIGNAL UK E: 07/10/2011 09:27 AM DatelTime Primed: 9/28/201 1 09:52 EDT Page 52 of 139 Printed By: Shiner,Crystal L ~~~~~^raT~ H~~st~E~ ~ ~ll~[)11 ~. Hershey Medical Center Patient Name: GREEN, LOGAN M MRN 7510053 ... _.__ . ..... ...... . ....... ...___......._._........._., ..,.._....,..~...,.....Sprne «....,........_... ......._.......... ....._. ................~.................. RESULT STATUS: Final DOCUMENT SUBJECT: X-RAY SPINE 1 VIEW- CERIVICAL PEI:)S ELECTR(JNICALLY SIGNED BY: SERVICE. DATF(TIME: 719/2011 22:26 EDT X-RAY SPIh(E 1 VIEW- CERIVICAL PEDS PATtEN'1' NAME: GRIsIsN, LOC'rAN M PAI'Il?N"I' MRN:07510053 1'~1TI>11V"C D(:)B: 07/21/1996 EXAM DALE OF S.1~KVkC;E: 07/09/2011. E?~AM NI~M l3ZR: 7017602 ORDERING ]?11YS1CIAN: DEFLITCH, CHRISTOPIIER EXAMINATION: AP radiographs of the pelwis. AP portahle radiograph of the client. Lateral x-ray oi~ the spine cervical spine. CLINICAL HISTORY: ">,rawna . ('OMPARIS()N: None FINDII~IGS: Pelvis: No fractures. Bone a~ineraliz,ation is normal. Soft tissues are normal. Chest: C'ardia~r~ediastinal silhouette is normal in site and contour. Pulmom~ry 'vaseulatui•e is normal. No parenchymal opacity effusion or pneumot.horax. The bones are normal. The radiolucent line transversing the left upper thorax anct the lateral clavicle is secondary to the superimposed cervical collar. Cervical spine: 't`he cervical spine is viewed from the craniocervical junction through the superior end plate of T2. 't'here is anatomic alignment of the cervical spine. 'There is null straightening of the cervic:ai tordosis secondary to cervical collar. No fi~aeture, No loss of vertebral body height or disk space height_ Posterior elements are intact. The lacette joints are appropriately aligned. No prevertebral soft tissue. swelling. IMPRESSION: No traum~~ to the cervical spine, chest, or pelvis. DatelTime Printed. 9l28;Z011 09:52 EDT Printed By Shiner,Grystal L Page 53 of 139 PEN(~STATE HERSHEY N~ilton S. Hershey Medical Center Paiieni Name: GREEN, LO(aAN M MRN 7510053 Spine ............. ......................,...,.,.................,..........,.._ ....................._......., The liudings were discussed with Dr. Pastor by HJK at the time of the trauma. Dr. Heather J Kaneda is the dictating resident. Attending radiologist signature indicates .review o~ both the images and the report and that the. attending radiologist ~igrees with thr, interpretation. 1''rcliminary reports may not have been reviewed as yet by the attending radiologist. llIC`l'AI'ED: F;GGLl, 1CATHLLl;N REVIEWED ANIa SIGNED: F;GGLI, KACHLI:LN DAl'li 1)iZAF'TFD: 07/09/2011 11:20 PM DAl'C; G1~ FINAL SIGNA"rtIRL: 07/10/2011 09:27 AM Daie/Time Printed: 9/28/201 t 09:52 EDT Wage 54 of 139 Printed By Shiner,Crys#al L PENN~TATE HERSHEY 1~1 N~ilta~~ S. Hershe~r 1Viedical Center Patient Name: GREEN, LOGAN M MRN 7510053 ............. ...._ .,.. ......~.. _ .........._......~.~.....,..............~....,......,..,...... ............,..........~.,...,.................... _......... _..........................._.........y ED Triage Farm DOCUMENT TYPE=; ED Triage f=orm RESULT STATUS: Final PERFORM INFORMATION: Spanos,Rachel A (7/9/2011 22;14 EDT) SERVICE DATE/TIME: 7/9/2011 22:14 EDT ED Triage Form 07/09/1 1 10: i 4 pm Performed by Spanos, Rachel A Entered on 07/09/11 10:51 pm ED Triage Complaint Chief Complaint MVC- Pt wearing seatbelt- ? LOC- defer 1o ED Trauma flow sheet Mode of arrival-EC? Ambulance Pregnancy Status N/A Last Tetanus Unknown During last month felt down ar depressed Unable to obtain (patient unconscious, intubated, delirious, etc) Allergy Reac,-iion 1. N KA Triage Vital Sign Temperature Route Temperature Heart Rale Respiratory Rate SpO2 Pain Intensity Pain scale used primary Oxygen Therapy Patient Weight Systolic Blood Pressure Diastolic Blood Pressure Weight Weigh# Method Glasgow Coma ScalelED Oral 36.1 DegG 86 bpm 18 br/min 100 5 0-10 Pain scale Room air 56.690 kg 135 mmHg 75 mmHg 56.690 kg Estimated Eye Opening Response Peds Coma Spontaneously Best Verbal Response Peds Coma oriented and converses Best Motor Response Peds Coma Spontaneous Pediatric Coma Score 15 Functional Assessment Da#e(Time Printed: 9/28/2011 09:52 EDT Page 55 of 139 Printed By Shiner,Crystal L PENNSTATE ~ERSHE'~ .____ ~11V~iltc~n S. ~ers~ey Medical Center Pa#ien# Name: GREEN, LOGAN M MRN 75 t005;~ ................... ......,..............~......._...~...,..............~.....ED Triage Forrri................................~.. , ....... ....................~.............. Have YOLI Fallen Twice in Si;K Monihs Unable to assess Peds Medical Hx 1 Peds Medical HX l HEENT Denies: Patient Peds Medical HX f Gastrointestinal Grid Denies: Patient Peds Medical HX I Cardiovascular Denies: Patient Peds Medical I-iX I Gent Grid Denies: Patient Peds Medical HX I Respiratory Denies: Palient admitted with urinary calheter in place No Peds Medical HX I Musc Grid Deniee~ Patient Peds Medical Hx II "NOT VALUED" Denies: Patient Peds Medical HX If Hemat Grid Denies: Patient Peds Medical HX 11 Neuro Grid Denies: Patient Peds Medical HX II Behavioral Grid Attention Deficit/Hyperactivity Disorder: Patient `NOT VALUED` Denies: Patient. Peds Medical HX 11 Onc Grid Denies: Patient ED Triage tYacking DGP Generic Cade Tracking Group EMER Trk Gp Tracking Acuity 2 Tracking Reg, Status Start Triage Time 07/09/11 22:51 Visit reasar, MVC Ambulance List Ambulance List Other: 272 DatelTime Printed: 9!28/2011 09:52 EDT Page a6 of 139 Printed By: Shiner,Cr+,lstal L PENNSTAI-E HERSHEY ~1 Milton S. Hershey Medical Center Patient Name: GRI.EN, LOGAN M 1F_R Pediatrics Form MRN 7510053 DOCUMENT TYPE': IER Pediatrics Form RESULT S")-ATUS: Final PERFORM INFORMATION: Boesch,Robert E {7/10/2011 14:00 EDT) SERVICE DATE/TIME:: 7/10/2011 14:00 EDT IER Pediatrics Form 07!10/11 02:00 pm Performed by Boesch, Robert E Entered on 07/10/11 02:15 pm General Topics IER Genera! Topic 000000001 Logan and his Dad verbalized understanding of all DC instructions prior to DC. All questions have been answered as shown by signature on DC summary. IER General Method 000000001 Printed Instructions, Verbal Explanation IER General Evaluation 000000001 Verbalizes understanding IER General Taught 000000001 Patient, Father DatelTime Printed 9/28/2011 09:52 EDT Page 57 of 139 Printed By Shiner,Crysial L PENNSTAI-~E HERSHEY /~11V~ilton S. ~ershcy IVle~ical Center Patient Name: GREEN, LOGAN M MRN 7510053 Interdisciplinary Narrative Form DOCUMENT TYPE: Interdisciplinary Narrative Form RESULT STATUS: Final PERFORM INFORMATION: Hughes,Aliison (7/9/2011 23:00 EDT) SERVICE DATE/TIME: 7/9/2011 23:00 EDT Interdisciplinary Narrative Form 07/09/11 1~ 1:00 pm Performed by Hughes, Allison Entered on 07/09/11 11:06 pm Interdisciplinary Narrative Interdisciplinary Narrative Discipline Nursing Interdisciplinary Narrative Text assumed care of pt. from Rachel S., RN. see trauma sheet for previous charting. pt. resting in litter with MD suturing at bedside. family a# bedside call bell within reach. pt. aao x 3 neurologically intact. ahughes,rn DOCUMENT TYPE: RESULT STATUS: PERFORM INFORMATION: SERVlGE DATE/TIME: Interdisciplinary Narrative Form Final Hughes,Allison (7/9!2011 23:53 EDT) 7/9/2011 23:53 EDT interdisciplinary Narrative Form 07/09/1 1 11:53 pm Performed by Hughes, Allison Entered on 07!09!11 11:55 pm Interdisciplinary Narrative interdisciplinary Narrative Discipline Nursing Interdisciplinary Narrative Text pi. waiting suturing at this time. report called to Jennifer strayer, RN on peds floor. pi. waiting laceration closure before sent up to floor. ahughes,rn DOCUMENT TYPE: Interdisciplinary Narrative Form RESULT STATUS. Final PERFORM INFORMATION: Hughes,Allison (7/10/2011 00:14 EDT! SERVICE DATE/TIME: 7/10/2011 00:14 EDT Interdi~;ciplinary Narrative Farm 07110/11 00:14 am Performed by Hughes, Allison Daie(T-ime Printed: 9/28/2011 09:52 EDT f-'age 58 of 139 Printed By: Shiner,Grystaf L PENNSTAfE HE~iSHEY Milton S. Her~h~y 1Vled1Ga1 Center Patient Name: GREEN, LOGAN M MRN 7510053 Interdisciplinary Narrative Form Entered on 07/10/11 00:15 am interdisciplinary Narrative Interdisciplinary Narrative Discipline Nur:;ing Interdisciplinary Narrative Text pi. medicated as per EMAR for 8/10 pain. MD in io suture. ahughes,rn DOCUMENT TYPE: RESULT STATUS: PERFORM INFOFiMATiON: SERVICE DATE/TIME: Interdisciplinary Narrative Farm 07/10/11 00:25 am Performed by Hughes, Allison Entered on 07/10/1 1 00:25 am Interdisciplinary Narrative Form Fina! Hughes,Allison (7/10/2011 00:25 EDT} 7/10!2011 00:25 EDT Interdisciplinary Narrative Interdisciplinary Narrative Discipline Nursing Interdisciplinary Narrative Text pt. voids 600mL in urina! at this time. ahughes,rri DOCUMENT TYPE=: RESULT STATUS: PERFORM INFORMATION:. SERVICE DATE/TIME: Interdisciplinary Narrative Form 07/10J11 00:31 am Performed by Hughes, Allison Entered on 07/10/11 00:31 am Interdisciplinary Narrative Form Final Hughes,Allison (7110/2011 00:31 EDT} 7/10/2011 00:31 EDT Interdisciplinary Narrative Interdisciplinary Narrative Discipline Nursing Interdisciplinary Narrative Text urine collected and sent as ordered. ahughes,rn DOCUMENT TYPE=: Interdisciplinary Narrative Form RESULT STATUS: Final PERFORM INFORMATION: Hughes,Allison (7/1012011 00:58 EDT} SERVICE DATE/TIME: 7/10/2011 00:58 EDT Date!-time Printed: 9/28/2011 09:52 PDT Page 59 of 139 Printed E3y: Shiner,Crystal L PENNSTATE HERSHEY ~.1 Milton S. Hershey Medical Center Patient Name: GREEN, LOGAN M MRN 7510053 tnterdiseiplinary Narrative Form Interdisciplinary Narrative Form 07/10/11 00:58 am Performed by Hughes, Allison En#ered on 07/10/1 1 00:58 am Interdisciplinary Narrative Interdisciplinary Narrative Discipline Nursing interdisciplinary Narrative Text NSS infusing as ordered. pt. wailing transport to floor. ahughes,rn DOCUMENT TYPE.: RESULT STATUS: PERFORM INFORMATION: SERVICE DATE/TIfJIE: Interdisciplinary Narrative Form 07/10/11 01:28 am Performed by Hughes, Allison Entered on 07(10/11 01:28 am In#erdiscip{inary Narrative Interdisciplinary Narrative Form Final Hughes,Allison (7/10/2011 01:28 EDT) 7/10/2011 01:2$ EDT inlerdisciplinary Narrative Discipline Nursing Interdisciplinary Narrative Text pt. transfered to floor at this time via transport tech. pt. in NAD at time of transfer. ahughes,rn Date/Time Printed: 9/28/2011 09:52 EDT Page 60 of 139 Printed By: Shiner,Grystal L PE~INSTACE HERSHEY ~~tOll s. ~~er~he~ ~1rledical Center Patient Name: GREEN, LOGAN M MRN 7510053 Med Dosing Weight Form DOCUMENT TYPE: Med Dosing Weight Form RESULT STATUS: Final PERFORM INFORMATION: Budde,Bradley {7;9/2011 22:49 EDT} SERVICE DATE/TIME: 7/9/2011 22:49 EDT Med C)osing Weight Form 07{09/11 10:49 pm Performed by 8udde, Bradley Entered on 07/09/11 10:49 pm Med Dosing Weighi Weight 56.000 kg DafelTime Panted: 9/28/2011 09:52 EDT Page 61 of 139 Printed By Shiner,Crystal L PE~INSTATE HERSHEY Milton S. Hershey Medical Center Patient Name: GREEN; LOGAN M MRN 7510053 ....__._ ~...,..... _ ......... _ ......................_._..,,....._....._._.Medication History Form...,..._.........,......_....,.._,_: ~............_.....,................... DOCUMENT- TYPE: Medication History Form RESULT STATUS: Final PERFORM INFOHPAATION: Hughes,Allison {7/9/2011 22:47 EDT SERVICE DATEITIME: 7/9/2011 22:47 EDT Medication History Form 07/09(11 10:47 pm Performed by Hughes, Allison Entered on 07/09/11 10:48 pm Medication List Historical/Home Medications on Arrival Completed Medication Lisl Order Compliance:. Obtained Performed by: Budde, Bradley;Pertormed Dafe: 07/10/1 1 07:19 am acetaminophen SIG:~I tab, PO, q4h, tab, PRN: Fever/Mild Pain Provider: Budde; Bradley Date: 07/10!11 07:19 am Status: Ordered Date/Time Printed: 9/28/2011 09:52 EDT Page 62 of 139 Printed By: Shiner,Crystal L PENNSTATE HERSIHEY Milton S. Hershey Medical Center Patient Name: GREEN, LOGAN M MRN 7510053 ..... ..... ,...... ......... ................... ti _.......,., .. _ .............. .......................... ,. Pairs Response Form. ~ ......_._ .. , ............ _ _ .. _.. ...........,......... DOCUMENT TYPE: Pain Response Form RESULT STATUS: Final PERFORM INF©RMATIOIV Hughes,Allison (7/1 01201 1 01:14 EDT SERVICE DATE/TNME: 7/10/2011 01:14 EDT Pain Response Form 07/10/11 01:14 am Performed by Hughes, Allison Entered on 07/10/11 00:58 am Pain Response Pain Intensity Response 2 Pain scale used primary 0-10 Pain scale Date~~ime Printed: 9/28/2011 09:52 EDT Page 63 of 139 Printed By' Shiner,Crysial L PEN~ISTATE HE~iSHEY ~ MIltUI1 S. Hershey Medical Center Patient Name: GREEN, LOGAN M MRN 7511)053 _._.__.... __...... ._......._....._... ~_...~......_.._..~ ................ Patient Belongings Form......................._.............,....... , ......_...__............ ~... , DOCUMENT TYPE: Patient Belongings Form RESULT STATUS: Fina! PERFORM INFORMATION: Hughes,Allison (719/2011 23:30 EDT} SERVICE DATE/TIME: 7/9/2411 23:34 EDT Patient Belongings Form 07/09/11 11:30 pm Performed by Hughes, Allison Entered on 07/09/11 11:34 pm VaiuableslBelong ings Valuables/Belongings Grid Valuables With Patient Clothes, Patient Valuables Nane Comment: see trauma sheet Date/Time Printed_ 9/28/2011 09:52 EDT Page 64 of 139 Printed By: Shiner,Crystal L PE~IN~TA,TE HERSF---MEY ice! Milton S. ~-Iershey Medieal Center Patient Name: Gf~EEN, LOGAN M MRN 7510053 Pediatric Admission Assessment tl Form DOCUMENT TYPE: Pediatric Admission Assessment fl Farm RESULT S fATUS: Final PERFOR(t~i INFORMATION: Sirayer,Jennifer L (7/10/2011 02:00 EDTy SERVIGE DATE/TIME: 7/10/2011 02:00 EDT Pediatric Admission Assessment II f=orm 07/10/11 0?_:00 am Performed by Hughes, Allison Entered on 07/10/11 00:34 am Updated an 07/10/11 02'.:19 am by Strayer, Jennifer t_ Admission History Admitted From Emergency Department Transport Mode Litter Accompanied by ,4Names dad Brian Isolation Precautions None Patient admitted to hospital with Peripheral IV Contact Person Phone Number mom- Ami Green dad- Brain Green Chief Complaint MVC- Pt wearing seatbelt- ? LOC- defer to ED Trauma flow sheet Patient offered hosp safe for valua bles Noi Applicable Clinical Height/Weight Patient Weight 56.690 kg Weight 56.00 kg Weight Method Estimated Allergy Allergy Reaction 1. NI<A Primary Pain Adequate Pain CaMrol Primary Yes Pain scale used primary 0-10 Pain scale Pain Intensity p Pain Guttural /Non Communicative Standard Pain Scales Yes Culturak Assessrnent Yes Da1e/Time Printed 9/28/2011 09:52 EDT Page 65 of 139 Printed By Shiner,Crystal L PENNSTATE HERSHEY 1~11Vrilto~~ S. Hershey 1Viedical Center Patient Name: GREEN, LOGAN M MRN 7510053 ... Pediatric Admission Assessment ll Form Sources For Pain 'Yes Physiological Cause For Pain other: head injury and siiches Signs of pain No General Info Accompanied by Father, Sibling Who has Residential Custody? Parent, Mother, Father Information Given by Patient, Father Parent/Primary Caregiver mom - Ami dad- Brian Parent's Marital Status Married Current Medications Historical/Nome Medications on Arrival Completed Medication List Order Compliance: Obtained Performed by: Budde, Bradley;Performed Daie: 07/10/11 07:19 am acetaminophen S1G:1 tab, PC), q4h, tab, PRN: Fever/Mild Pain Provider: Budde, Bradley Date; 07/10/11 07:19 am Status: Ordered Health Habits Pediatrics Cigarette Smoking No Smoker in House No Alcohol Type Denies Recreational Drug 1-ype Denies Peds Medical Hx 1 Peds Medical HX I NEENT Denies: Patient Peds Medical HX I Gastrointestina- Grid Denies: Patient Peds Medical HX I Cardiovascular Denies: Patient Peds Medical HX I Gent Grid Denies; Patient Date/Time Printed: 9/28/201 1 09:52 EDT Page 66 of 339 Printed By: Shiner,Crystal L PEIVNSTATE HERSHEY ~~ MtltOn S . der S~Ie~T Medical Center Patient Name: GREEN, L©GAN M Peds Medical HX !Respiratory Denies: Patient Peds Medical HX I Musc Grid Denies: Patient MRN 751405:3 Pediatric Admission Assessment ll Form Peds Medical Hx. II "NUT VALUED` Denies: Patient Peds Medical HX II Hemat Grid Qenies: Patient Peds Medical HX II Neuro Grid Denies: Patient Peds Medical HX II Behavioral Grid Attention DeficitlHyperactiviiy Disorder: Patient kNOT. VALUED` Denies: Patient Peds Medical HX 11 Unc Grid Denies: Patient Peds Medical t-tx !II Injuries Peds Health History None Infectious Diseases Peds Health History None infectious Disease Exposure Last 4 weeks No Exposure to head lice in past two weeks No Medical Devices None Implanted Metal No Immunizations C~m_rrrent Yes LanguageiGommunication Assessment If patienl infant or elderly mom Ami dad Brian Communication Bander Present No P/G/S Communication Barrier No Primary Language English P/G!S Primary Language English Psychosocial Domestic Concerns None Adult Staying with Child at Hospital none Emotional Support Available Yes Financial Concerns Re Hospital/Disch No Security Ubjecf None Psychiatric Admission No Date/lime Primed 9/28/2411 09:52 EDT Printed By: Shiner,Crystal L Page 67 of 139 PENNSTATE HE_RS_HE_Y Milton S. Hershey Medical Center Patient Narne: GREEN, LOGAN M MRN 7510053 `.., ...... .... ` ...................Pediatric`Admission Assessment ll`Form................. _, ..... ......,....,,,..,..` Chronic/Terminal Illness Freq Visits No During last month felt down or depressed Unable to obtain (patient unconscious, intubated, delirious, etc) Religious Preference Christian Suicide Risk Asse:>sment Recent suicidal thoughts/attempts No Are you presently suicidal No Do you have a plan No Any previous suicide attempts No Parental Invoiveme~nt ParentlCaregiver Present Yes Parent/Caregiver Involvemnt Child's Care Actively participates Parenf/Caregiver interaction with Child Frequent interaction Parenf/Caregiver Interact w/Care Team Discusses care, feelings, concerns Parental concerns addressed Yes Nutrition Home Diet Regular Peds High Risk Nutrition Persistent N/V!D in Infant (0-12mo) >1 week: No Persistent N/V/D in Child (> 1 yr} > 2 weeks: No Tube Feedings Assessment: No Total Parenteral Nutrition {TPN}: No High Risk Dx: Short Gut, FTT, Vented Pts: No High Risk Dx: Cystic Fibrosis, Malnutrition: No Difficulty Swallowing or Chewing: No Modilied Diet (Other than Regular Diet or Infant Formula): No Feeding Ability Complete independence Weight Change No Appetite Good Education Educational Needs Assessed Yes Barriers to Learning None evident Learning Preferences Verbal Explanation Room Orientation Yes IER Safety Topic 000000001 Nand Hygiene as an important infection deterrent, All caregivers complete hand hygiene on entering the room, All caregivers complete hand Date/Time Printed: 9x2$/2011 09:52 EDT Page fib of 139 Printed By: Shiner,Crystal L PENI~STATE HERSHEY 1Vriltan S. Hershey Med~.cal Center Pa#ient Name: GREEN, LOGAN M MRN 7510053 Pediatric Admission Assessment 11 Form hygiene prior to physical contact with patient IER Safely Method 000000001 Verbal Explanation IER Safety Evaluation 000000001 Verbalizes understanding IER Sa#ety Taught 000000001 Patient, Family member, Father IER Safety Topic 000000002 Respiratory Hygiene decreases the spread of airborne germs IER Safety Method 000000002 Verbal Explanation IER Safety Evaluation 000000002 Verbalizes understanding IER Safety Taught 000000002 Patient, Family member, Father IER Safety Topic 000000003 Two patient identifiers are used for safe procedure and drug administration, flame and birthday wiN be asked frequently for identification IER Safety Method 000000003 Verbal Explanation IER Safety Evaluation 000000003 Verbalizes understanding IER Safety Taught 000000003 Patient, Family member, Father IER Safely Topic 000000004 Contact Isolation may be necessary for certain cultured germs IER Safety Method !)00000004 Verbal Explanation IER Safety Evaluation 000000004 Verbalizes understanding IER Sa#ety Taught 000000004 Patient, Family member, Father IER Satety Topic 00000004fi Falls can occur to any patient during hospitalization IER Safety Method 000000006 Verbal Explanation IER Safety Evaluation 000000006 Verbalizes understanding IER Safety Taught 000000006 Patient, Family member, Father IER Safety Topic 000000008 Significance of the colored armbands, Importance of alerting nurse if any armband is removed IER Safety Method 000000008 Verbal Explanation IER Safety Evaluation 000000008 Verbalizes understanding IER Safety Taught 000000008 Patient, Family member, Father Pediatric Falls Assessment Peds Falls Age 13 years old and above Peds Falls Gender Male Peds Falls Diagnosis Neurological diagnosis Peds Falls Impairments Oriented to own ability Peds Falls Environmental Patient placed in bed Peds Falls Response to Surgery More than 48 hours/none Peds Falls Medication Usage Other medications/none Peds Falls Score 12 Peds Falls Humpty C~umpty Credit The Miami Children's Hospital Humpty Dumpiy Falls Prevention Program (TM) DatelTime Printed' 9/28/2011 09:52 EDT Page 69 of 139 Printed By: Shiner,Crysial L PEN~ISTATE HERSHEY ~1 Milton S. Hershey lVlecllcal Center Patient Name: GREEN, LOGAN M MRN 7510053 ............,. .................`.,~............. Physician`Discharge.`Instructions Form....,......, ,.., ..... _ .... ....................~. DOCUMENT TYPE=:: Physician Discharge Instructions Form RESULT STATUS: Final PERFORM INFORMATION: Budde,Bradley (7;1012011 00:58 EDT} SERVICE DATE/TIME:: 7/10/2011 00:58 EDT Physician Discharge Instructions Farm 07/10/11 00:58 am Performed by Budde, Bradley En#ered on 07/i0/11 01:13 am Paiieni Discharge Nnstructions -HMC Discharge Diagnosis Principle Trauma-MVC Procedures None Diet Guidelines Resume regular dies as tolerated. Drink plenty io fluids Activity Guidelines Resume regular activity as tolerated. Do not over do it. Avoid any activity that maay lead to another head injury for at least 4 weeks. Cali Your Doctor: Please call 717 531-8521 and ask to speak to the pediatric surgery resident on call for persistent fever (over 100.4),nausea, vomiting,increased headaches, or any other concerns. You can also reach us during regular office hours by calling 717 531-8342 Gail us for any concerns or questions. Follow Up Apppoiniments Follow up Care has been addressed Physician Discharge Summary HMC Brief History Pt is a 14 year o!d male who transported in as a level 2 trauma acfivation. Patient was a restrained passenger in a MVC. Pt had no LOC at the scene, but was initially amnesiic to the accident. As EMS arrived, patient was combative and had repetitive speech pattern, however his vitals were stable. Once EMS laid him down, he stopped his repetitive speech and responded appropriately. He was transported to HMC for definitive care. Include Hospital Course No Date/Time Printed: 9/28/2011 09:52 EDT Printed By: Shiner,Grystal L Page 70 of 139 PENI~STATE HE_R_SNEY _ ~ M[~ton S. Hershey ~Vlec~ical Center Patient Name: GREEN, LOGAN M MRN 7510053 ., _........ _. :. ..............................Physician` Discharge Instruct>'ons Form` ~`.~........... .~..'._ ....................`.~....` Hospital Course In the ED, pi was found to have a 3- 4cm laceration over the right frontal scalp. Pt had no ocher pain or pbvious injuries or complaints. His lacera#ion was stitched up in the ED. The pt was admitted to the peds surgery service for observation overnight. A CT of the head was negative for intracranial hemorrhage, and was read as normal, except for the right scalp lac. The pt had a CXR and pelvic x-ray, which were negative, A c spine x-ray was read as negative and the patient's c spine and collar removed the following morning. The patient's diet was advanced as tolerated and his activity were advanced once c spine was cleared- Patient tolerated a regular diet and regular activity prior to discharge. The did weH the day after admission and was discharged home in stable condition on 7/10/11. Patient will follow up for suture removal in 7-10 days. Exam On Discharge NAD RRR CTAB soft, NT, ND Exi- FROM, well perfused Neuralogicaily intact DOCUMENT TYPE: RESULT STATUS: PERFORM INFORMATION.: SERVICE DATE/TIME: Physician Discharge Instructions F=orm 07/10/11 07:19 am Per#ormed by Budde, Bradley Entered on 07/10/11 07:21 am Patient Discharge instructions - HMC Physician Discharge Instructions Form Final Budde,Bradley (7/10/2011 07:19 EDT1 7/i 0/2011 07:19 EDT Discharge Diagnosis Principle Trauma-MVC Procedures None Discharge Care instructions You may take Tylenol as needed for DatelTime Printed: 9/28/2011 09:52 EDT Printed By Shiner,Crystai L Page 71 of 139 ie PE~l~lSTATE HEIRSHEY ~111~i.1to~1 S. Hershey medical Center Patient Name: GREEN, LOGAN N1 MRN 7510053 _ _. _. ._.. ....... ...........~ .................~Physician Discharge `Instructions` Form ................ _ ., .. ~ .............. ~.., ........ pain (use as prescribed on the package). Diet Guidelines Resume regular diet as tolerated. Drink plenty to fluids Activity Guidelines Resume regular activity as tolerated. Do not over do it. Avoid any activity chat may lead to another head injury for at least 4 weeks. Call Your Doctor Please call 717 531-8521 and ask to speak to the pediatric surgery resident an call far persistent fever (over 100.4),nausea, vomiting,increased headaches, or any other concerns. You can also reach us during regular office hours by calling 717 531-8342 Call us for any cancerns or questions. Follow Up Apppointments Follow up Care has been addressed Physician Discharge Summary HMC Brief History Pt is a 14 year old male who transported in as a level 2 trauma activation. Patient was a restrained passenger in a MVC. Pt had no LOC at the scene, but was initially amnestic io the accident. As EMS arrived, patient was combative and had repetitive speech pattern, however his vitals were stable. Once EMS laid him dawn, he slopped his repetitive speech and responded appropriately. He was transported to HMG for definitive care. Include Hospital Course No Hospital Course In the ED, pt was found to have a 3- 4cm laceration over the right frontal scalp. Pt had no other pain or pbvious injuries or complaints. His laceration was stitched up in the ED. The pt was admitted to the peds surgery service for observation overnight. A GT of the head was negative for intracranial hemorrhage, and was read as normal, except for the right scalp lac. The pt had a CXR Date/Time Printed' 9/28/2011 09:52 f=DT Printed By: Shiner,Crystal L Page 72 of 139 ~~N~S~~TE H~RSr~~~ 1~.11V~ilton S. Hershey 1Vledic~.1 Center Patient Name: Gf3EEN, LOGAN M MRN 7510053 Ph .. _ __ . __.____________________ ....,._............................. ................................ysrcian Discharge Instructions Form ..,,.._...._._.._............_............_.,._.,,.._.........., and pelvic x-ray, which were negative. A c spine x-ray was read as negative and the patient's c spine and collar removed the following morning. The patient's diet was advanced as tolerated and his activity were advanced once c spine was cleared. Patient tolerated a regular dies and regular activity prior to discharge. The did well the day after admission and was discharged home in stable condition on 7/1U/11. Patient will follow up for suture removal in 7-1t3 days. , Exam On Discharge Vitals Temp Pulse BP RR SpO2 FIO2 Date Wt(kg} Wt(Ib) 07/10 01:48 36.3 71 131/59 18 99 -••- 07/10 56.2 124 07/10 00:46 ---- 77 ----- 11 99 --- 07/09 56.7 125 Initial Wt: 07(09 56.7 kg 125 Ib NAD RRR GTAB soft, NT, ND Ext- FROM, well perfused Neurologically intact DOCUMENT TYPE: RESULT STATUS. PERFORM INFORMATION: SERVICE DATE/TIME: Physician Discharge Instructions Form 07/10/11 09:41 am Performed by Budde, Bradley Entered on 07/10/11 09:43 am Physician Discharge Instructions Form Final Budde,Bradley (7,10/2011 09:41 EDT) 7!10/2011 09:41 EDT Patient Discharge -n:>iructions - HMC Discharge Diagnosis Principle Trauma-MVC Procedures None Discharge Care Instructions You may take Tylenol as needed for pain (use as prescribed on the package). Do not soke your head wound in water for 5 days. Sponge bath the area, Date/Time Printed: 9/28l201i 09:52 EDT Printed Sy Shiner,Crystal L Page 73 of 131 PEL~NS~AT~ HERSHEY ~a/1:ilton S. Hershey Medieal Center Patient Name: GREEN, LOGAN M MAN 7510053 ......._..,...._......_ .. ........,....,.............Physician Discharge Instructions Form.»_....._............._.......... ,......»._.»,.....,...»..... please keep head out of the shower stream and swimming pool. Diet Guidelines Resume regular diet as tolerated. Drink plenty to fluids Activity Guidelines Resume regular activity as tolerated. Do not over do it. Avoid any activity that may lead to another head injury for at least 4 weeks. Call Your Doctor: Pease call 717 531-8521 and ask to speak to the pediatric surgery resident on call for persistent fever (over 100.4},nausea, vomiting,increased headaches, or any oilier concerns. You cart also reach us during regular office hours by calling 717 531-8342 Call us #or any concerns or questions. Follow Up Apppoirrtments Fallow up Care has been addressed DOCUMENT TYPE:: Physician Discharge Instructions Form RESULT STATUS: Final PERFORM INFORMATION: Lin,Yu Kuan (7/10/2011 14:07 EDT} SERVICE DATE/TIME: 7/10/2011 14:07 EDT Physician Discharge Instructions Form 07/10/11 02;07 pm Performed by Lin, Yu Kuan Entered on 07/10/11 02;07 pm Patient Discharge Instructions - HMC Discharge Diagnosis Principle Traurna-MVC Procedures None Discharge Care In~:truciions You may take Tylenol as needed for pain (use as prescribed on the package}, Do not coke your head wound in water #or 5 days. Sponge bath the area, please keep head out of the shower stream and swimming pool. Diet Guide(irres Resume regular diet as tolerated. Drink plenty io fluids Activity Guidelines Resume regular activity as tolerated. Do not over do it. Avoid any activity Thai may lead to another head injury for at least 4 DateCl~Ime Printed: 9{28/2011 09:52 EDT Page 74 of 139 Printed By: Shiner,Crystai L PENNST~TE NERSH~Y Milton S. Hershey Medical Center Patient Name: GREEN, LOGAN M MRN 7510053 Physician Discharge !ns#ructions Form weeks. Ca11 Your Doctor Please call 717 531-8521 and ask to speak to the pediatric surgery resident an ca41 for persistent fever (over 100.4),nausea, vomiting,increased headaches, ar any other concerns. You can also reach us during regular office hours by calling 717 531-8342 Cakl us for any concerns or questions. Fallow Up Apppoiniments Follow up Care has been addressed Physician Discharge Summary HMC Brief History Pt is a 14 year old male who transported in as a level 2 trauma activation. Patient was a restrained passenger in a MVC. Pi had no LOC at the scene, but was initially amnestir, to the accident. As EMS arrived, patient was combative and had repetitive speech pastern, however his vitals were stable. Once EMS laid him down, he stopped his repetitive speech and responded appropriately. Fie was transported to HMC for definitive care. Include Hospital r;ourse No Hospital Course In the ECG, pt was found to have a 3- 4cm laceration over the right frontal scalp. Pt had na other pain or pbvious injr-ries or complaints. His laceration was stitched up in the ED. The pt was admitted to the peds surgery service for observation overnight. A GT of the head was negative for intracranial hemorrhage, and was read a:> normal, except for the right scalp lac. The pt had a CXR and pelvic x-ray, which were negative. A c spine x-ray was read as negative and the patient's c spine and collar removed the fol{awing morning. The pa#ieni's diet was advanced as tolerated and his activity were advanced once c spine was cleared. Patient tolerated a Date(Time Printed. 9/28/2011 09:52 EDT Page 75 of 1351 Printed By Shiner,Crysiat L PE~INSTATE HERSHEY 191Vrilton S. Hershey Medical Center Patient Name: GREEN, LOGAN M MRN 7510053 ~~v Physician Discharge lnsfrucfions Porm regular diet and regular activity prior to discharge. The did well the day after admission and was discharged home in stable condition on 7/10/11. Patient will follow up for suture removal in 7-10 days. Exam On Discharge Vitals Temp Pulse BP RR SpO2 FiO2 Date Wt(kg) Wt(!b) 07!10 01:48 36.3 71 131/59 18 99 --- 07/10 56.2 124 07/1000:46 ---- 77 ----- 11 99 --- 07/09 56.7 125 Initial Wt: 07109 56.7 kg 125 Ib NAD RRR CTAB soft, NT ND Ext- FROM, well pertused Neurolagically intact DatelTime Printed. 9/28/2011 09:52 EDT Page 76 of 139 Printed i3y: Shiner,Crystal L PEIVI~STATE NERS_HEY __ ~.11V~~Iton S. Hershey Medical C'cnter Patient Narne: GREEN, LOGAN M MRN 7510053 ....... Quality Measures ort Arrival Farm DOCUMENT TYPE: RESULT STATU~~: PERFORM INFORMATION: SERVIGE DATE/TIME: quality Measures on Arrival Form 07/09/1 110:48 pm Performed by Budde, Bradley Entered on 07/09/11 10:49 pm Quality Measures on Arrrival Line Infection Urinary Tract Infection VTE Risk Score Decubitus (pressure) Ulcer quality Measures on Arrival Form Final Budde, Bradley (7!9/2011 22:48 EDT) 7/9/2011 22:48 EDT Patient does NOT have an existing vascular access catheter (line) Patient does NOT have a Catheter Related Urinary Tract Infection 0 to 1 paint -Low Risk Patient does NOT have a Decubitus Ulcer DOCUMENT TYPE: Qualify Measures on Arrival Farm RESULT STATUS: Final PERFORM INFORMATION: Budde,Bradley {7;9/2011 23:55 EDT) SERVICE DATE/TIME: 7/9/2011 2.3:55 EDT Quality Measures on Arrival Form 07/09/1 t 11:55 pm Performed by Budde, Bradley Entered on 07/09/11 11:55 pm Qualify Measures on Arrrival Line Infection Urinary Tract Infection VTE Risk Score Decubitus {pressure;- Ulcer Patient does NOT have an existing vascular access catheter (line) Patient does NOT have a Catheter Related Urinary Tract infection 0 to 1 point -Low Risk Patient does NOT have a Decubitus Ulcer Date>-rime Printed: 9/28/2011 09:52 EDT Printed By: Shiner,Crystal L Page 77 of 13~t PENNSTATE HERSHEY ~ N~ilton S. Hershey lVled:~ca1 Center Patient Name: GREEN, LOGAN M MRN 7510053 Spirituaf Care Nate Form DC}CUMENT TYPE: Spiritual Care Note Form RESULT STATUS: Final PERFORM INFORMATION:: Dorsey,Bernard A (7110/2011 00:18 EDT) SERVICE DATE/TIME: 7!10/7.011 00:18 EDT Spiritual Care Note Form Entered On: 0711 0/201 1 00:27 Performed Orf: 07/10/2011 00:18 by Dorsey, Bernard A Spiritual Care Note Pastoral Services'Jisit : Trauma Pastoral Services Offered : Guiding, Support Religious Preference : Christian Pastoral impact Start : Upset, a concern Pastoral Impact End : Calm, relaxed Length of Visit : 30minute Pastoral Intervention : Conversation Pastoral service Follow up : Yes Pastoral Services Comments : 07/09/2011@2212hrs Pediatric Trauma, L2, i4y.o. Caucasian, male arrived to trauma bay #2 via West Shore EMS slp MVA. Met wish patient's sister already in ED registration, escorted her to Quiet room. Oriented sister and patient's father to procedure and approximate time line. 2240hrs patient moved to room #40 in ED, connected family with patient and physician in room #40. Chaplain Bernard A. Dorsey Dorsey, Bernard A - 07/10/2011 00:18 Date/Time Printed: 9/28l20i 1 09:52 EDT F'age 78 of 139 Printed By: Shiner,Crystal L PENN~TATE HE~SHEY____-_- ~.1 Milton S . Hershey Medical Center Patient Name: GREEN, LOGAN M Allergy History MRN 751p053 Date/Time Printed: 9!28!2011 09:52 EDT Page 79 of 139 Printed By Shiner,Crystal L PEN~ISTATF ~{E~SHEY N~ilton S. Hershey Medical Center Patient Name: GREEN, LOGAN M MRN 7510053 . ... ... ... ...... ... ...... ......................... .........~.....~.Measurements............... .._..................... .. .. .. .....,............................ ReCnrded Cate ;.> .. 7i10~2011 7/9l?011 .7`9/2011 1/9/2011 Recorded-Tune 0.1:48 EDT ' 22:49 EDT 22:49 EDT X2.14 EDT- _ Recordec~'By _ __ E;lawd,l`ina M ' Budde,Bradl®y Nughes,glli~n Spanas,F3achel A F?rocediare W Unit . ; _ :Height..... cm . , 17~ - Hesght Method Patrent stated :patient Weight kg .. 56.25 . - . ... _. .. - 56.690°' ......... 56.690 , Weight kg . - 5h.000 .. o~ 56.000 56 690 :Weight Method _ - Estimated°t Estimated :Body Mass Index...... .. kg/m2._ 19 46 - _ . :Body Surface Area m2 1.65 - - - Order Comments 01: Ped Admit2 Assessment Ped Admit2 Assessment DatelTime Printed: 9/28/201 1 09:52 EDT Page 80 of 139 Printed By Shiner,Grys#al L PENNSTATE HERSHEY M~.111nilton S. Hershey Medical Center Patien# Name: GREEN, LOGAN M MRN 7510053 ..,..........Vifal.Signs.. ....................\,....._ `........ `_... `..........._...~......................»., I~~cQrdsd ante 7/1oi2o1 ~ 7110,'2011 7itoi2o~ Recorded Time 08~Oq!~DT 02.00 EDT 01:48 EbT Recorded 6y B.oe5ch,Rabert ~ Slrayer,Jennifer L ~Iawd.Tina M Procedure Units _ _ Temperature !DegC _ _ 36.3'- ,. , - , ; 36.3' Temperature; Route _ ,. .. Temporal . _ _. . Temporal Temperature Central _.__. _._ _ _ ..._.. - Warm __ :Heart Rate bpm .......... ....._.... 51 _ .'1 __ _ Respiratory Rate. _ .br/min.. _ . ~ 16 _. 18 Systolic Blood Pressure tnmHg ......... 106 _ _. _ . _ _ X31 .. :Diastolic Blood Pressure .... mmHg 39 - ._.__... 59 BP Location # 1 ...._ Ri h# Arm 9 - _ Left Arm Cuff Pulse Pressure _ ... mmHg _ 67 ~.> , Sp02 ___ _ ._ _ .. ... % _ .~___........._......•...... 97 ._ _ ... _... - ...... _ _.~~ . _ v Recorded 1~~1e 7/l0/2Q11 7/9/2011.' 7i9(2p1 1 Recorded Time 00;461~DT 23:1.0 EDT, 23:00 EDT Recorded sy Hugtle5 Allison HugheS,Alli:~on Hughes;Alli~on f~rocedz,re Units _ , _ :Heart Rate _ .. :.bpm _ _;_ 77 _ 75 .:.;.::. 84 Respiratory Rate _ . br/min... ........, ... . 1.~...... ....... 24 8 -- Oxygen Therapy . _. : . •Room-air _ _ _ Room air _, Room air Sp02 _ . % .. ~. ......... 99.. .. 100........_. _10 Recorded D.ate~ 7191.2p1 t 7!912011' Recorded Time 22,5$ EQT 22;14 EI7T Recorded Sy _ Hr~ghe5,AUGSOh Spanos,Rachel A Prpceture : Units - _. Temperature DegC__ _ _: ;_., _ 36.1 Temperature Route ;._ - _ ..._ Oral :Heart Rate , bpm .. .. , 83 __ _ 86 Respiratory Rate br/mm 17 Systolic Blood Pressure ~ :mmHg - j3~ :Diastolic Blood F'ressure __ ;mmHg - 75 ' Ox en Thera Y9..._ . _.. pY Room air Room air SpO2 % 100. _. .. _.. ... _..100 ; DatefTime Printed: 9/28/2011 09:52 EDT Page $1 of 139 Printed By: Shiner,Crystai L PENI~ST~TE HERSI~EY IV~~ltan S. ~-Hershey Medical ~cnter Patient Name: GREEN, LOGAN M MRN 7510053 Pain Assessments Recorded C3ate 7/10/211 7(1020'11 R®cordc~d Time > 08;00 EDT .02:00 EDT Recorded ~y ,, ~3oesch,Roberl E _, ! Sfrayer,,lerinifer L f~rc~cedure Units: _ :Standard Pain Scales _ - _ ' Yes c, ;Adequate Pain Control primary No Pain Yes O1 , -- :earn scale used primary __, ~ ~ _. 0 10 Pain scale _. i)-10 Pain scale" .; _ _. . ...... Sources For Pain - o Yes ;Physio{ogical Cause For Pain . - _ _ Other; head injury and stiches°1 .. _ .. Signs of pain . . , ... No o, .... :Cultural Assessment : ~ - Yes °i _ ___ _ _ Pain Intensity_ _. _. _, _. __ ... 0 .. _ _ _ _ ~ <» Recpr.cled Date 7/10/2011 7!10.72011 719/2011 Recorded Time. 01:4 EDT OQ:i4 EDT 2~•#4'EDT Recorded By Hughes,Allison Huc~h~~,ARison Spanos;Rachet A Pr4~edur•~. Units :Pain scale used primary 0-10 Pain scale 0-10 Pain scale 0-10 Pain scale :Pain {ntensity - 6 5 :Pain Intensity Response 2 - - Order Comments 01: Ped Admit2 Assessment Ped Admit2 Assessment Date/Time Printed. 9/28/2011 09:52 EDT Page 82 of 139 Printed By Shiner,Crysial L PEI~~(ST~TE HERSHEY _ /1 Miltr~n S. ~Iershey Medical Center Patient Name: GREEN, LUGAN M MRN 7510053 Intake & Output 3NTAK~ - (tri.L} - 7/9/2011 - 7/10/201 1 7/10.2011 - 7!11!2011 All time in EDT 7a.m. - , 3p.m. - .11p m -:: Total 7a.m. 3p.m. - _. :11p m. - Tatal 3p.m. 11p.m.: 7a.m. - 3p.m. 11 p.m. 7a.m. Sodium Chloride 0.9% 1 .. _._ '475 ,000 mL(1000 mL - - A75 _, :475 - 475, Sodium Chloride 0.9%} _ _, :Oral FEuids _ 660 _.. 660 . '8 Hour Total - .... -.. .. 475 _ . 1135 - 24 Haur Taial _. 475 11 35 QUTPUT - (mL) 7/9/2011 - 7/10!2011 _ ... 7/10/201 1 - 7/1112011 .. .; All time in EDT 7a, m. - 3p. m. >1~Ip.m. Total ` 7a.m. 3p.m. - 11p m. - Total 3p.m. 11p.m. 7a.m. 3p.m. 11 p.m. 7a.m, . .Urine Voided ..... - - :950 950 1350 - _ 1350 ;8 Hour Total .. _950 1350 - - 24 Hour To1ai _ _ _ _ -. _ ... S50 - .. 1350 Clinical Range Total #rom 7/92011 to 7/11!201 f Toia! Intake 'Tatai Output Fluid Balance 161U _ __.. 2300_ ................... ,_.. _ -690- _ _ __ Daie(Time Printed: 9!28/2011 09:52 EDT Page 83 of 139 Printed By: Shiner,Crystal L PENNSTATE HERSHEIC ~111~i1ton S. Hershey Nled.ical Center Patient Name: GREEN, LOGAN M Cardiovascutar Documentation MRN 7510053 R®corded,Qaie 7/i0/2i711 7l~Q/2011 Record9d lime 07:47 EDT '' 02:00 EDT Recorded ~3y _. .. _ goesch,Robert E - 5trayer;Jennifer L Prc~eedure : Linits Heart Sounds Regular Regular ;Monitor ___ No _..__ Na :Pulses Right Arm Radial, Normal, Palpable - :Pulses Lefi Arm . , ~ Radial, Normal, Palpable _ `.Pulses Right l_eg _ .. Dorsalis Pedis, Normal, Palpable - ;Pulses Left Leg __ Dorsalis Pedis, Normal, Palpable :Temperature Peripheral UVarm .. - Capillary Refip Peripheral < = 2 Seconds _Skin Color _ , _ _,. f'irik ., ._ . _..... fink Nail E3ed Color _ Pink _ Pink Regarded date' 7/10/20 I1 Recorded Time 02:40 EDT Recorded By 5trayer,Jerinifer t_ faroC~dure Units Pulses Right Ar-m ~ ~~ ~ ~~ Radial, Normal, Palpable :Pulses Left Arm _.......... _....... .. p Radial Normal Pai able ;Pulses Right Leg .. Dorsalis Pedis, Normal, Palpable .... ~ ;Pulses Left Leg ~ _. _... .... Dorsalis Pedis, Normal, Palpable :Temperature Peripheral Warm Capillary Refill Peripheral _- _, ,. ,.,. _,.< ~ = 2~Seconds Date/Time Printed: 9/28/2071 09:52 EDT Page 84 of 139 Printed By: Shiner,Grystal L PENNSTATE HERSHElC N~ilton S. Hershey Medical Center Paiieni Name: GRF_EN, LOGAN M MRN 751005:3 G!/GU/Reproductive Documentation ~......y Recorded bale: 7fl0,?2011 ~~ 7!10;2011 Recorded Time: 09:00 EDT 07~47'EDT _ Recda'ded By Lay;Amy ~3o$sGh,Ro6ert E Procedure: ;; >;> Units _ ;Bowel Sounds All Quadrants _ - Present _ Abdominal Palpation All Quadrants, - Non-gislended, Non-Tender, $oft , ;Bowel Movement Lasi Date _ __ 7/9/2011 GI Symptoms ........... .. c.._. - None _ Urine Color - ,,.< Yellow _.. _. Yellow Urine Description Clear Clear ;Urine Odor Odorless __ _ _. Odorless t~ecordcd mate x'/10/201 1 ; I10/?_01'1 . recorded Trme~ 0:00 CDT ,, 02 OO EDT f~ecorded By', ;;. : Strayer,JEnnifer L St~ayer,Jennifer L Pr~oc~dure _ . :: - Units _ , , :Bowe! Sounds Ail Quadrants _ _.. - _ ~ _ Present _ _ __ Abdominal Palpation All Quadrants ~ ~ _ Non distended Non Tender, Sofi ;bowel Movement Last Date _... 7!9!2011 _ ~ "' Gf Symptoms _ ~ None _ __.._..... . . _ _ _ Urine Color , ....... .......... _ ....Yellow _ ._ .__.. Urine Description Clear Urine Odor Odorless _ _..... _ ; Record~ci l3~te: ~r19/201 1 13ecai~ded Time:. 22:14 EpT ReGOrded 13y, Spanos,Rachel A Procedure . . Units, _ :. ;Pregnancy Status _ N/A Date/Time Printed: 9/28/2011 09:52 EDT Printed By: Shiner,Crystal L Paye 85 of 139 PENNSTAT~ HERSHEY ~~ MIltU11 S. Hershey Medical Center Patient Name: GREEN, LGGAN M MRN 7510053 HEEIVT Doc~~mentation Recorded.Date 7/t012011 7r10r2011 'Recorded Time 07:46 EDT 02 00 ED`t~ f~ecorded By. Boesch,Robert E Strayer,J~nnifer L Rrocediure Units _. ,,. -.; ,,: _ ::. Facial Movement Symrnetric resting/crying Symmetric resting%crying Date/Time Printed. 9/28/2011 09:52 EDT Page 86 of 139 Printed Hy: Shiner,Crystal L PE:NNSTATE HERSHEY _ 1 M~ton S. Hershey medical Cer~~er Patient Name: GREEN, t.OGAN M MRN 7510053 ........,_.._... . __. ...~..... ...... lntegumentary Documentation ' ........ ......... ...... ................ , , F~ecorded Cate 7ita/2oti . ._... ...._.... ........,...._.._,_......._.. Zl1ol2a~i Recorded `lime 07:48 EDP Q7 4E3 CDT _. PtOC dUf"e Recorded 13y ; Boesch,Robert P _ f~o~sch,Roiiert F~ < 4 LinltE _ __ _ :basic Skin Assessrrtent Skin Turgor _ _ _ ,_ _, ; . Pink. Warm Mucous Membrane Description Normal ... _ - _. _. _ :Peds Mobility Moist Prnk ....... . ........ . ; Peds Activity ___ . Slightly limited Peds Sensory Perception Occasionally ambulates - ...... Moisture Braden t .... No impairment .Peds Friction and Shear Rarely moist _ __ ., ..... Peds Nutrition _ .._ Na a anent ro pP p blem ;Peds tissue perfusion oxygenation :.. inadequate _. .... Peds Braden Score ' Ex cellent .. Left, Other: hip _ , _ .. ....._.._ __..., _ 2A _ . _. ... :Skin Abnormality _ :Leff, Other. sholder__ __ Abrasion, Ocher- Sktn Abnormality _ _.. _ . left Right Hand; Other. palm of hands _ _ _, ` _ Abrasion _ Skm Abnormality _ ... .. ..... .. _ . . Right, Head _ _.. _ _ ......... _ Abrasion .... _. Skin Abnorma-ity .. _ ,_ ... _. __ ___ ,.. _ - Other: stiches Recorded'pat~t~ l'11072d1ti 7/10/201.1 _ Recorded Time 07:15 EDT 02QQ E'QT Pracedtir e Recorded By BoeUch,Robert E _ ' StrayerJerinifer L .. ,.:.. ;Skin Turgor _ r~it5 k~ _. _ _,. _.._. Mucous Membrane Description .. ormal ;Peds Mobility ~ _ . Moist Pink _.. ,Peds Activity - _ __ SlrgMly limited _ _ __.... .. .....:..... ;Peds Sensory Perc:epiion ..... - • ed B Mast _ ......... ;Moisture Bradenl _ _ _ __.... _ No impairment ,...._,.. Peds Friction and Shear .. _ _.. ~ R arely moist __.._ ... __ ._. ;Peds Nutrition No a ar pp ant problem __ ._ ... :Peds tissue perfusion oxygenation ~.. __. _ nadequate _ :Peds Braden Score Excellent _.. -Head of bed... _ _ ,.. _ _ .. . 22 .. _ :Leff, Ocher: hip _ _ Yes _. _ _ _ - :Skin Abnormality _. :Left, Other: shofder _ _ __ - . Abrasion, Other. Skin Abnormality _ .. .. _. _ _ _. .._. :Leff Righi t~i3hd, Other: palm of hands _ .Abrasion _ .... ........ Date/Time Printed 9/2$/2011 09:52 EDT ................... ...................... _ _ .. _ _ .. Printed By Shiner,Crystal L Page 87 of 139 PE~l1~5TA~E HERSHEY M~ton S. Hershey Medical Center Patient Name: GREEN, LOGAN M MRN 7510053 ........... ... ......`.....,.~....,....~...,....,,,lctegumentary Documentation., ..................., ..... ... ....,........~. ` ......... Recbrded'{)ate ' < 7!i0/20 f 1 7/1.0/01-( Recorded `Time. 07':45 EDT- 0,2,QQ EDT Recordetl }~y __ Boesch;Robert a= Strayer,Jertnifer L Procedure !!nits . ... :Skin Abnormality _ _ - Abrasion _ Right, Wead ~.. _ _ _ __, , .._ , :Skin Abnormality - Ocher: ~tiches R$cOrd~d.pate ~'~ 7/ 1(312011.. Recorded Time a2:OQ .EDT R~~Q~d~d Fay: ~trayer,Jennifer L , .,. .. procedure Unfits F3asrc Skm Assessment Pink.., Warm 'Turn patient ...... .. . Supine :Head of Bed _ .. ___.. ,.. _ . Xes :Air Mattress . ... ... _....... No __ ;Specialty Bed _ ...`Vo._....._....: Date/Time Printed: 9!28!2011 09:52 EDT Page 88 of 139 Printed By: Shiner,Crystal L PE.~1f~~T~TE HERSHEY Milton S. Hershey Medical Center Patient Name: GREEN, LOGAN M MRN 7510053 Lines & Procedures Documentation Recorded Date 7/10124 l 1 ',7/10l2Q11 Recorded-Time >'14.07 EDT #2:00 ~D~` ~iecorded By _ _. i3oesch,Rpbert E' Bgesch,f2obertE Proded~+re Units : :Left, Antecubital .: , Peripheral I~~ Activity ~ ~ ~ Discontinue Assessment Convert to tiepwell IV Site Condition . ~ No complications No complicaiions Infiltration Score __... . _ .... .... _ .... ........ ...~. __ Phlebitis Score _ -- -.... , ..,.... , _.. -... .. _ _ .. __ a V Flow/Paiency - No complications, Hepwell iV Drainage Description - None IV Dressing Condition - _. Dry Intact IV DressinglActrvity __._ . _ . __ _. ,.. Transparent :Left, Forearm :Peripheral IV Activity ~~ Discontinue Assessment iV Site Condition No complication, _. Na complications lnfiliration Score - 0 ;Phlebitis Score - 0 IV Flow/Patenc Y .._ _.. - ._.__ .. _. No complications IV Drainage Description - None IV Dressing Condition _. - Dry, Intact IV Dressing/Activiiy ~ _,. Transparent Recorded Date T110l201 I 7/10/~(j11 Recorded Time <10.52 EDT 09.00`EDT Recorded 8y Boesch,Robert ~ ., Boesch,Roberi E Procedure Units Left, Antecubital ; ;Peripheral IV Activity .. . .. ~ Assessment, Convert to Hepwelt Assessment, Convert to Hepwell ..... IV Site Condition No complicatrons .. .. ~ No complications Infiitraiion Score _ p 0 _ :Phlebitis Score _....._ ,.... -,. .. .. ,. ,. 0 _ _ ~ . ; tV Flow/Potency ~ ~ ~ No complications, Hepwelt No compiicatians, Hepweti IV Drainage Description ,. _ _ . None None !V Dressing Condition. Dry lntaci Dry, Intact ;IV Dressing/Activity Trans arent Transparent Left, Forearm Peripheral tV Activity .. ~ Assessrneni Assessment tV Site Condition _ _., _ _._ . ,_ ,. , No complications _ Nocompfications infiltration Score o _ . __... 0 :Phlebitis Score _ p _ .. .. _ {~ _ _ 'IV Ftow/Potency No complications ._ No complications 1V Drainage Description. None None iV Dressing Condition Dry, Intact Dry, Intact Date/Time Printed: 9/28/2011 09:52 EDT Page 89 of 139 Printed By: Shiner, Crystal L PEN~ISTATE HERSHEY _ Mi1to~1 S. Hershey Medical tenter Patient Name: GREEN, L~GAN M MRN 7510053 Lines & Procedures Dacurnentation __ Recorded Dafe - _ `>~f10/2011' _ _ .. 7,10,+'2011 Recorded Time t0 52 EDT 09:00 EDT Recorded 8y Boesch,RObert E ~3oesch.Roberi F Procedure Un>ts IV DressinglActivity Transparent ,.. Recorded Date 'I~70/2011 7/10/~l t Recorded Time 07.48 EDT 07;48 EDT Recorded By ,._. ... Boesch,Rol3sri E Boesch Robert E Procedure Units . `Left, Antecubital _ :Peripheral IV Activity Assessment; Convert to Hepwell - IV Site Condition - No camplications Infiltration Score - 0 Phlebitis Score _ ..... ..... _ ._.._... _ _ _. __ _ _Q IV Flow/Patency No complications, Hepwell - 1V Drainage Description None - IV Dressrng Condrtron ~ Dry, Intacl - IV Dressing/Activity Transparent - Left, Forearm 'Peripheral IV Activity ~ ~ Assessment - IV Site Condition ! - No complications Infiltration Score - 0 ... :Phlebitis Score _......, ....._ ..._..... _ ..... __ 0 __ IV FlowlPatency No complications - IV Drainage Description None - IV Dressing Condition ~ ~ Dry, Intact - lV Dressing/Activity .. _ _ ,... Transparent - Recorded Date - _ 7`~1 ~/?O1 I >. 7,~10/2Q 11 .Recorded Time Q0:22 EDT 05:40 EDT Recorded By Strayer,Jennifer L S1rayer;Jennifer L Procedure Units _ _ . :Left, Antecubital ~Penpherak IV Actrvrty _.. Assessment, Conver# to Hepwel! : ~ ~ Assessment, Convert to Hepwell IV Site Condrtian i No complications .. _. ~ No complications Infiltration Score ~ 0 .... . ; p _.. Phlebitis Score _,... _ _.,._,.. _,. 0 _... _ ,, : _ _ _ _ . 0 iV Flow/Patency .. ~ ~ No complications Hepwell No complications, Hepwell 1V Drainage Descnption None None _. IV Dressing Conditron ,. _ __ - Dry, Intact ~ _ _ ,, _ _ _._ _: Dry, Intact ;IV DressinglActiviiy Transparent Transparent 'Left, Forearm ..; ;Peripheral IV Aciivrly Assessment Assessment Date/Time Printed.. 9/28/201 1 09:52 EDT Page 90 of 139 Printed By Shiner,C rystal L PENNSTATE HERSHEY Milton S. Hershey Medical Center Patient Name: GREEN, LOGAN M Lines & Procedures Documentation MRN 7510053 Recorded faafe. 7!1072011 7l10/2QT1 Recorded Time 06:22 EST 05:40 EDT _ Recorded Sy _ ,. Slrayer;Jeiinrfer L Strayer,Jennifer L __ _ _ Procedr~re lJnits - : IV Site Condition ~ No complications No cornplicatians _ :Infiltration Score _ _ _ _... 0 . __ 0 Phlebitis Score 0 0 iV Flow/Patency No complications _ , No complications __ IV brainage .Description . . None _.. _._._. .. _.. _.... _ done IV Dressing Condition. _.... ~ __ .. _ . ............._ Dry_ Intact._ ............. ; ..... _ . Dry, Intact IV Dressing/Activity Transparent Transparent Recorded Date ' 7/10/?011 7i 10/201 I Recorded Time 04:20 EDT 03:10 EDT Recorded ~y ;_ Strayer,JQi~nifer L _ wtrayer,Jennifer L :;: Procedirrs ' Unirts - ;Leff, Antecubital _ _ , _ ;Peripheral IV Activity ; Assessment: Convert to Hepwell :Assessment, Convert to f-fepwell IV Site Conditio~~ No complications No complications ;Infiltration Score _ 0 _.. 0 :Phlebitis Score ... . _.. 0 0 IV FlowlPatency ,, No complications, Hepwell ~' . - No complications, f-lepwell C2 1V Drainage Description "None None IV Dressing Condition Dry, Intact Dry, Intact IV Dressing/Activity Transparent Transparent Left, Forearm :Peripheral IV Activity Assessment Assessment ;IV Site Condition ~ No complications No complications Infiltration Score _ __ _ _ 0 0 :Phlebitis Score 0 0 _ IV Flow/Patency _ ... No complicationsc~ .... .: No complications 05 ;IV Drainage Description Norte None ;lV Dressing Condition , ........... _ ... _, , Dry, Intact.... ., Dry, Intact 1V Dressing/Activity Transparent Transparent Corrected Results G1: lV Flow'Patency Corrected from Flushes easily, No cornplicaiions, Positive Blood Return on 7/10/2011 04:53 EDT by Strayer, Jennifer l_ C2: I V Flow/Patency Corrected from Flushes easily, No complications, Positive Blood Return on 7/10/2011 04:53 EDT by Strayer, Jennifer L C4: lV Flow/Patency Corrected from Flus hes easily, No complications on 7/10/.2011 04:53 EDT by Strayer, .Jennifer L Dale/Time Printed' 9/28/2011 09:52 EDT Page 91 of 1:39 Printed By: Shiner,Crystal L I~ENN~TATE HERSHEY ~'.1 Milton S. Hershey Medical Center Patient Name: GREEN, LOGAN M MRN 7510053 Lines & Procedures DQCUmenfation Corrected Results C5: IV Flow/Patet7cy Corrected from Flushes easily, No complications on 7/10/2011 04:53 EDT by Strayer, Jennifer L: _. Recorded Date: -'7r10L2011 _ _ . 711p/201 I Recorded T(me 'DQ 30 Et)T 02;00 CO1 Recorded Sjr Strayer,Jennifar L Steayer,Jeiinifer L ,:,; Prncedurrr Units ,, Left, Antecubital Peripheral IV Activity Assessment, Convert to Hepwell Assessment, Convert to Hepwell 1V Site Condition ~ No complications No complications infiltration Score 0 U Phlebitis Score 0 0 ;IV Row/Patency No complications, Hepwellc' See 8elowT' fV Drainage Description ___ _ None. _ ..._. . __ None IV Dressing Condition Dry, Intact Dry; Intact 'IV Dressing/Activity Transparent , , Transparent :Left, Forearm . . _. __ ...,.... _ ___ ...... _ _.. Peripheral IV Activity Assessrnenl Assessment IV Site Condition No complications ~ No complications ;Infiltration Score 0 0 :Phlebitis Score _ _.. ,,-.: _ o _, ..... _ 0 IV Flow/Patency ... _ ;.._.......... .... No complications cs ...................... . Flushes easily, Na complications ..... IV Drainage Description l None None IV Dressing Condition Dry, Intact ~ Dry, Intact V Dressing/Activity Transparent Transparent Textual Results Ti: 7/10/2011 02:00 EDT (IV FlawlPatency) Flushes easily, No complications, Positive Bload Return Correc#ed Results C3: IV Flow/Patency Corrected from Flushes easily, No complications, Positive Blood Return an 7/10/2011 04:53 EDl- by Strayer, Jennifer L C6: IV Flow/Patency Corrected from Flushes easily, No complications on 7/10/21)11 04:53 EDT by Strayer, Jennifer L Date/Time Printed: 9/28/2011 09:52 EDT Page 92 of 139 Printed By: Shiner,Crystal L PE~IN~TATE HERSHE~C 11 Miiton S. ~ershe~ Medical Center Patient Name: GREEN, LOGAN M MRN 7510053 Ntusculoskeletal Documentation Reeprdtd €]ate~ 7%10/2011 7/10/2011 -Recorded Time -07:48 EDT -02'00 EdT Recorded By i3oesch,Robert E ' Sirayer,Je~nifer L _._ Procedure Ur7i4s __ Musculoskeietal Spinal Precau#ions CervicaW spine Cervical spine Date/Time Printed: 9/28/2011 09:52 EDT Page 93 of 139 Printed By. Shiner,Grystal L. PEIV~IS_ TATS HERSHEY Milton S. Hershey Medical Center Patient Name: GREEN, LOGAN M MRN 7510053 Neurological Documentation f~~careled f~~#~ 7/10/2011 F{egorded'~"ime '' 07;46 EbT Recorded By Boe~ch,Robert E ... _._ Pros;edure ' - Units .:; . , ;Tone,Upper Extremity _ _ Normal, Moves all extremities ' Tone,Lower Extrernily ~ ~ Normal, Nlaves all extremities .. . Pupils Size,Right tnm _ . 4 Pupils Size,Left i-nm 4 Pupil Reaclion,Righf Brisk Pu il.R.. .. p' eaction,Left __.. ___....._............ _. Brisk Pupil Description,Right Regular Pupil Description,Left Regular ;Eye Opening Response Peds-Coma Spontaneously Best Verbal Response Peds Coma Oriented and converses :Best Motor Response Peds Coma Spontaneous ('ediatric Coma Score 15 Level of Consciousness Neuro Alert, Active :Neurological Symptoms None ADCs Independent Facial Symmetry Symmetric :Gait Unable to assess Swallowing, Difficulty NPO Arousahle To _ ; . .. .l`o voice ;Orientation Neuro Detailed See Below' ;Speech Pattern Clear .Movement Newborn ~ ~~ ~ _...... ~ Active, Moves all extremities Textual Results 71: 7110/2011 07:46 EDT {Orientation Neuro Detailed} Person, Place, Time, Reason for Admission Recorded Date. 7f1012011 Record+d Time: '~ 02:00 FDT _ _ F~ecorded By ,~trayer,.lennifer'C , ProCedure .; <I~tnits _ > ,, :Eye Opening Response Peds Coma .. ;; . Spontaneously Best Verbal Ftesporise Peds Coma ._ .; Oriented and converses :Bess Motor Response Peds Coma _. Spontaneous :Pediatric Coma Score 15 Neurolo rcal S m tam 9......y.p...° ................ ... None . . :ADCs ~ Independent ;Facial Symmetry Symmetric :Gait (Unable #o assess Swallowing i7ifficuliy _ .. - , _ ...._ _. , - , .. _.. NPR DatelTime Printed: 9/28/2011 09:52 EDT Page 94 of 139 Printed By Shiner,Crystal L PEN~ISTATE HERSHEY Milton S. Hershey Medical Center Patient Name: GREEN, LOGAN M MRN 7510453 Neurological Documentation I~e,corded Date 7I10/2~f1 ~tecorded T'ime' 02:00 }=0T Recorded t3y Strayer,Jennifer L Pr©cedure Units Movement Newborn Active, Moves all extremities r Recorded Date:. 7/1 Of20#,1 7l9/~011 Recorded Trme 02:Q0 EDP' 23:30 EDT Recorded By Strayei,Jenriifer L Fiughes,Allison Pro~sdure . , ,: Elriits . Tone,U er Extremit .. _.. pp ... ___ .. Y __ ......_. .. _........ . Normal, Moves ail extremities _........... ................. - Tone,Lower Extremity Normal, Moves all extremities - :Pupils Size; Right mm 4 3 :Pupils Size;Left inm : 4 3 __ :Pupil Reactron,Righi _ __ _.. __ Brisk Brisk :Pupil Reaction,Left _ Brisk _ . ..., Brisk :Pupil Description,Right __ .. _ Regular Regular , ;Pupil Description,Left ......_ ..._.... . _........ .. ............Regular............ _.. _. _. __ Regular. ....... :Eye Opening Response Peds Coma - Spontaneously Best Verbal Response Peds Coma - Oriented and converses :Best Motor Response Peds Coma - Sporiianeous ;Pediatric Coma Scare - 15 :Level of Consciousness Neuro Alert, Active Alert Neurologrcai Symptoms ~ - None AD Ls _ _ _ , _ , . .. _ _. Independent , .,,..... Facial Symmetry .. ~ Symmetric Gait _. Unable io assess ;Swallowing Difficulty _ _ - __ _ _ ... _ .. _ - NPO .... _..._ ,. Hallucinations Present - None Arousable To _. . ,. .... _To voice - Orientation Neuro Detailed See BelowF-' :Speech Pattern _ . ..... , ..._ __ _Ciear - Textual Results T2: 7/10/2011 02:00 EDT (Orientation Neuro Detailed) Person, Place, Time, Reason for Admission Recorded Datei 7f9/2011 - ~3ecorded Time: 22:14 EDT Ffiecorded By,< Spanos,Rachel A f'ra~edute _ Utri#s __ :Eye Opening Re ponse Peds Coma Spontaneously .... .. ; Best Verbal Response Peds Coma Oriented and converses Best Motor Response Peds Coma Spontaneous ~Pediairic Coma Score _ ~ 5 Date/Time Printed: 9!28/2011 09:52 EDT Page 95 of 139 Printed By: Shiner,Crystal L PENl~~TATE HERSHEY ~9 Mi1to~1 S. Hershey Medical Center Patient Name: GREEN, LOGAN M MRN 7510053 iVutrifion Documentation Recorddd bate .._. 7/10/201 1 Recorded Time " 02 00 EdT E~ecorded By Strayer,Jenn~fer L >> Procedure Units Appetite _ Good O1 Order Comments 01: Ped Admit2 Assessment Ped Admit? Assessment Da#e/Time Printed 9/28/2011 09:52 EDT Wage 96 of 139 Printed By Shiner,Grystal L PE[V~lSTATE HERSHEY ~1 lVrrilton S. Hershey Medical Center Patient Name: GREEN, LOGAN M MRN 7510053 PsychoSocial Ped Documentation >~ecorded Date: 7/10/2011 I~ecarded Time 07'4$ EbT I~ecorii®d By BoesCh;Fiabert E Procedure > > .:: ` Uni#s _, . . _ ParentlCaregiver Present ~ Yes :Parent/Care aver Relationshr g.. .. .........p. ..... - ;. ,.. ._ ` "' " " Dad ParentlCaregiver Involvemnt Child's Care .. .. ... : Aciivel artici ates Y P P :Parent/Caregiver Interaction with Child .. _. . ....... Frequent interaction !ParentlCaregiver Interact w/Care Team . _ See Below T+ __ 'Paren#al concerns addressed Yes BehaviorvEmotiona! Assessment _.. Pleasant, Cooperative, Calm :Mood-Emotional Assessnieni ... __ _ ......_..._ .Ha..p,~...._ _......_ P .._ Textual Results T1: 7,!10!2011 07:48 EDT (Parent/Care giver Interact w/Care Team) Discusses care, feelings, concerns Recorded 4aie 7/1'0%20i~1 recorded Time 07:46 EDT _ Retarded By Boesch,•3ohert E ' _ Procedure 'Units . ,. ;Behavior-Emotional Assessrent Pleasant, Cooperative, Calm :Mood-Emotional Assessmer~t ,_ ; Recorded,Daie 7/10/~~:'11 Recorded Tirne 02,00 ~C?T _„ Recorded By Strayer,Jennifer L Procedure. : Units , . Parent/Garegiver Present _ _ ...... _ .: _ Yes of :Parent/Caregiver Involvemnt Child's Care. ~ Actively participates O1 ,ParentlCaregiver Interaction with Child ~ ~ Frequent interaction O1 Parent/Caregiver Interact w/Care Team ... ~~ ~ See BelowT2Ot Parentalconcemsaddressed_ ... ._ _. Yes 6i _ ... __ _. Textual Results T2 7/10/2011 02:00 EDT (ParentlCaregiver Interact w/Care Team) Discusses care, feelings, concerns DatelTime Printed: 9/28/2011 09:52 EDT Printed By. Shiner,Grystal L Page 97 of 139 PE~I~ISTA~CE HERSHEY ~1 N~iltan S. Hershey Medical Center patient Name: GREEN, LOGAN M MRN 7530053 PsychoSocial Ped Documentation Order Comments C~1: Ped Admit2 Assessment PE~d Admit2 Assessment Date/Time Printed 9/28/2011 09:52 EDT Page 98 of 139 Printed By: Shiner,Crystal L PENNSTATE HERSHEY Iil~iltcxl S. Hershey 1VIed ica~ Center Patient Name: <aREEN„ LC)GAN M Date/Time Printed: 9/28/2011 09:52 EDT Printed fay: Shiner,C;rystal L MRN 7510053 F'age 99 of 139 P~.4~NSTATE HE€~SHEY Milton S, lE~ershey Medical Center Patient iVame: GREEN. LOGAN M MRN 7510053 Respiratory Therapy Documentation Recorded' gate 7(10[20 i 1 Recorded -dime ' 0200'ED7 ' Recorded, gy ,_ ~trayer',Jennifer'1: procedure Units ,:. :Barriers 1o Learning Nane evident O1 Order Comments 01: Ped Admit2 Assessment ped Admit2 Assessment Date/Time Printed: 9/28/201 t 09:52 EDT Printed By: Shiner,Crystal L Page 100 of 139 PENNSTATE HERSHEY 1~1 Mi1to~1 S. Hershey Med.~cal Center Patient flame: GREEN, LC-GAN M MRN 7510053 Routine Care Docurnentatian l~~eQrded~!]ate 7110/2011 Recorded'1'ime 07:45 EDT . F3ecorded By _. _ Boesch,l~abert E Procedure Uni#s` Safely Wris# Band Verification See Below T' Patient has the followtng _ Peripheral IV Standard Safety . ~ See Below T' _ _._: Srde Rails Up Dona Skin Care .........: Done ... Peds Falls Age .. 7 3 ears old and above y _ .......... _... :Peds Falls Gender ~ _...... .. _. Male .. _... Peds Falls Diagnosis __ _ - Neurological diagnosis Peds Falls Impairments Oriented to own ability _Peds Falls Environmental ~ Patient placed in bed Peds Fails Res once to Sur er = ~ P g Y r ' More than 48 hours, none :Peds FaIIs Medication-Usage '_. Other medications/none __. .._._ _. ..,. _, ..... . , .,_ ' Peds FaIIs Score ,. _, ..... _ 1` :_._ ;Peds Falls Humpty Durnpty Gredit ~ ~ ~~ See BelawT' Cervical Collar Care Done :Transport Mode Leiter Textual Results __ T1: 7/10/2011 07:45 EDT (Safety Wrist Band Verification) Patient identification, Fall risk (Yellow) T3: 7/10/201 1 07:45 EDT (Standard Safety) Bed in low position, Call device within reach, Night light , Sideraiis Up x 2, Wheels lacked T5: 7/10/2011 07:45 EDT (Peds Fails Humpty Dumpty Credit} The Miami Children"s Hospital Hump#y Dumpty Falls Prevention Textual Results ~T6: 7110!201 1 05:21 EDT (Peds Falls Humpty Dumpty Credit} The Miami Children's Hospital Humpty Dumpty Falls Prevention Fi~cQtded Qate 7~`1O.f201 I ' Neeorded Time 04 00 C-D T f-tecorded By Strayer,Jennifer L F~roced,ure Urits :Pediatric Falls Risk Protocol Observed High Risk Protocol Observed o3 Date/Time Printed: 9/28/2011 09:52 EDT Page 101 of 139 Printed By Shiner,Grystal L P~~v~STArE H~:~s~~~ r~ N~iton s. Hershey ~Vledical Centel Patient Name: GREEN, LOGAN M MRN 7510053 Routine tare Documentation Recorciad L7ate 7l1~/2011 ,{~ect~rded Time 03.40 FDT .. _ .. Recorded lay ,, , Sirayer,Jenriifer L ' ..Procedure Units ;Pediatric Falls Risk Protocol Observed ~ High Risk Protocol Observed °+ .. . Peds Falls Humpiy Dumpty Credit n oa See Below Textual Results T7: 7!10/2011 03;40 EDT' (Peds Fails Humpty Dumpty Credit) The Miami Children's Hospital Humpty Dumpty Falls Prevention `` Recorded Date 7!10/2b1'1 7!10/2011 Recardad Time 03.19 ELT 0? OO EDT _. _ .. Recorded Eby _ Strayer,Jennifer L _. Sirayer,Jennifer L i? r©cedra re Units <. : - ,, :Standard Safety ., _. See Below T^ ;Bath _. _ Partial :Pediatric Falls Risk Protocol Observed High Risk Protocol Observed OS _.. ~ - , Peds Falls Humpty Dumpty Credit . See Below T8 U5 ~ _. :Transport Mode . _ .. _ __ ; _ .Litter slsolation Precautions - ..,; Norte ;. Do Not List - _. No Transport Accompanied By - None :Respiratory Needs _ _ _ None _ ;. Textual Results T4: 7!10!2011 02:00 EDT (Standard Safety) Bed in low position, Call device within reach, Night light, Siderai{s Up x 2, Wheels locked T8: 7./10/201 1 03:19 EDT (Peds Falls Humpiy Dumpty Credit) The Miami Children's I~ospital Humpty Dumpty Falls Prevention `' F~eccird~d date '7l10.~2011 C~ecarded Time 02'00 EC~T Recorded By Sirayer,Jenni#er L Procedllre _, Units _ :Peds Falls Aye , ~ 13 years old and above os Peds FaIIs Derider : _ _ _Male °s . . Peds Falls Dragnosi __. _ ...._.... ... .. ..... ... _ .Neurological diagnosis°B Peds Falls Impairments _.. Oriented to own ability os .. . _ : Peds Falls Environmental ;. .. .... ........_. ...__ ._.....45.. ... Patient placed in bed .::. Reoofel~d L?~~e _ 711 Q~~01`t 'RecgCeied Ti~r~e 02'00 EpT Recorded fay Slrayer,Jennifer 1. Procedure : . : , Units - . . Safety Wrist Band Verification See Below T2 Date/Time Printed: 9/28/2011 09:52 EDT Printed By: Shiner,Crystal L Page 102 of 139 PENI~d~TATE HERSHEY ~ M~ton S. Hershey Medical Center Patient Name: CUREEN, LGGAN M MRN 7510053 ' Routine Care Documentation ; I~ecordad C]ate> 7/10/201 1 Rt~corded Time... 0200 EDT __ _ ~iecorded Fay -Sire er,Jennifer l_ __ Y ; Prczeedue~ Units Patient has the following ~ Peripheral I'd .Side Rails Up _ _ Done.... .. _ - Bathed by ............ ......... -Staff _ . __._. . Skin Care Done Pediatric FaIIs Risk f'roiocol Observed ~ High Risk Protocol Observed Cervical Collar Care ~ Dane Textual Results T2: 7/10/2011 02:00 EDT (Safety Wrist Band Verification) Patient identification, Fall risk (YeAow) . ...... Recorded bate 7110/2K111 l~ecarded Time 02:00 CDT Recorded By Sirayer,Jenr'rfer L _.. Procedure Units -: :Peds Falls Response. to Surgery More than 48 hour../none os Ped Falls Medication Usage, Other medications. none _Peds Falls Score. _.... _........... _ ..._........... _ .... __....~.2.Oe ..._;............_: ;Peds Falls Humpty Qumpfy Credit _ _ _ See Below r9oa Textual Results T9: 7/101201 1 02:00 EDT (Peds Falls Humpty Dumpty Credit) The Miami Children's Hospital Humpty Dumpty Falls Prevention Rei»A,tdad I?~1e 7/10/2Q11, 7/9/?011 Recorded Time Q0:01 EDT 2'?;49 EDT Recorded Sy Hughes,Alli.,pn Hughes,Al(ison Proc~:clrrre > Units _ :Safety Wnst Band Verification ~ ~ Patrent identification O1 Pa#ient has the following _ ..._ _ _. _.... Peripheral IV o, _.... __ _ _ _.. Transport Mode _. ____ _ _ .,.... _ __,. Litter O6 :Isolation Precaulions None ~s : Order Comments ......... ............................. 01: Safety/Quality Verification Safety/Quality Verification 02: Pediatric Falls High Risk Protocol Pediatric Falls High Risk Protocol t~3: Pediatric Falls High Risk Protocol Pediatric Falls High Fiisk Protocol C)4: Pediatric Falls High Risk Protocol Pediatric Falls High Risk Protocol GatelT'ime Printed: 9/28/2011 09:52 EDT Page 103 of 139 Printed 8y Shiner,Crysial L ~'ENI~STATE HERSHEY 1V~iiton S. I-Hershey Medical Center Patient Name: GREEN, LOGAN M MRN 7510053 Routine Care Documentation Order Comments OS: Pediatric Falls High Risk Protocol Pediatric Fails High Risk Protocol Per Policy from Pediatric Falls Assessment. 06: Ped Admit2 Assessment Ped Admit2 Assessment Date/Time Printed: 9128/'L011 09:52 ED7 Page 104 of 139 Printed By: Shiner,Crystal l_ PE~iNSTATE HERSHEY M~1 IV~ilton S. Hershey N~edical Center Patient Name: GREEN, LC~GAN M MRN 7510053 ....... ...... .._. ...._... ..........,..........,.......,.,.,....... ,......orders,..., ............,....,......................._. ... _ ......._~..._.....,.....,. :U IICI GU oy. aiun~p,~auren i~ on ~I iviLU I I UL:UL CU i :Order Details: 07!12111 23:56:06, g72h :Order Comment: Update Nursing Q72 Hrs Plan of Care ..................................... Date/Time Printed: 9!28/2011 09:52 EDT Page 105 of 139 Printed By: Shiner,Crystal L PE~~SrAT~ H~~s~~~ _ Milton S. Hershey Medical Center Patient Name: GREEN, LOGAN M MRN 751{~OS~s .... ......... ......................~.........................~................:......_.............,,,..,._........................, ~..,....,..~...........,.................... ,..............,................,.z ... ...... Orders _. Order Date.~Time T110/2011'.14~2ib-EDT Order: Dicr.aniinue Diet Patient pischarged .. __. _. ... .:Order Status: DISCONTINUED Catalog Type: Dietary ordering Physician: SYSTEM _.. - .Entered Ely: 5`fSTEM on 7/10/2011 18:00 Et)T :Order Details: 07!10/11 14:26:52 __, _. _: :Order Commenf discharge ~~rder __. Order Date/Tirs~e. 7MC]I2b11 14.07.1]7 _. ;Order: DisconiFnue IV :Order Status: Completed :Catalog Type Patient Care .Ordering Physician: Lin;Yu Kuan ':Entered By: Boesch,Robert F on 7/10/2011 14:16 EDT Order Details: 07/10%11 1407:00 ONCE Stopping On 07/10/11 14:07 00 __ :Order Comment: :Order DateiTir»e: 7110/2011 14t07 ~pT __ . __ ... :Order: Discharge. :Order Status: DISCONTINUED :Catalog Type: Patient Care Ordering Physician: Lin,Yu Kuan ;Entered By: SYSTEM on 7(102011 18.00 EDT Order Details: Stable for Discharge, Attending: Dillon, Peter W, Requested Discharge Dt: 07/10/11 14:07:00 :Order Con~ment: Order Date~'l'ime: 7"/1D/2011 11:31! E171' ,; Order: Nursing Diei Orders Order Status: DISCONTINUED ;Catalog Type: Dietary Ordering Physician. Dilion.Petdr W Entered By: SYSTEM on 7/10/2011 18:00 EDT Order Details: 07/10/11 71:31:00, Please send up regular date Lunch Tray. Thanks! Order Comment: Date/Time Printed: 9/28(2011 09:52 EDT Page 106 of 139 Printed By Shiner,Crystal L PENf~STATE HERSHEY Milton S . Hershey Medical Center Patient Name: GREEN, LOGAN M , Orders MRN 7510053 Order bale/Time 711D/2011 09:40 EnT ... Order: Discharge Follow Up Appointment (Follow Up Appointment) Order Status: Completed iCatalag Type: Patient Care _, Ordering Physician: Budde,Bradley :Entered By: Smiih,Melinda on 711 11201 1 09:03 EDT :Order Details: 07110/11 9:40:00, HMC Provider?, peds Burg, Dillon, Peter W, 1-3 Weeks, suture removal, right scalp lac, Was patient consulted/seen by requested service?, ONCE, Stopping On 07/10!11 9:40:00, please schedule for next wed, 7/20/11 __ __ -,_,_ .. girder Comment: _ _- ,..._ :.. __ :Order: Date/Time: 7110!2011 Q93Q"EUT ;Order: GSpine Cleared (Cervical Spine Cleared} :Order Status: DISCONTINUED :Catalog Type: Patient Care :Ordering Physician: Radtka,John F Entered By: SYSTEM on 7/10/2011 18:00 EDT _ _ _ .. :Order Details 07110/11 9 30:00 ONCE, Sioppmg On 07/10/11 9 30:00 =Order Comment: Order<D~ielTitna: 7/1A/2411~: g9t30: EpT .:: :Order: Advance Diet as Tolerated Instructions :Order Status: DlSC:ONTINUED :Catalog Type: Dietary _.. :Ordering Physician: F3adtka,John F .__ Entered By: SYSTEM on 7110)2411 18:00 EDT :Order Details: 07/10/11 9:30:00, Starting Diet Plan: Clear Liquid Diet, Goa! Diet Plan: Regular Diet, Nursing Instructions :Place separate dies order., pediatric patient :Order Comment: :Order Date,rfi-ri~ 7/i0/2017'iJ9:29 EDT .. Order: Out of Bed (0013) Order Status: DISCONTINUED Catalog Type: Patient Care :Ordering Physician: Radtka,John F ;Entered 6y: SYSTEM on 7/10/2011 18:00 EDT Order Details: 07l10/~1 9:29:00 .... _... 'Order Comment: Daie/Time Printed 9/28!2011 09:52 EDT Page t07 of 139 Printed By Shiner,Crystal L PENRISTATE_HEIZSHEY__ Milton S. Hershey 11~ed~c~ Center Patient Name: C;REEN, LOGAtV M MRN 7510053 Date/Time Printed: 9/28/2011 09:52 EDT Page 108 of 139 Printed By: Shiner,Crystal L PE~lNSTATE HERSHEY I~111~iIta~1 S. I-~ersl~ey Medical Center Patient Name: GREEN. LOC~AN M .._..... _. _ _ Orders MRN 7510053 Date/Time Printed 9/28/201 1 09:52 EDT Page 109 of 139 Printed E3y: Shiner,Crysial L PENNSTATE HE~~HEY ~11V.Cilton S. Hershe~r Medical Center Patient Name: GREEN, LOGAN M . Orders :Order Datell`ine~ 7/9/201'1 23;39 r=pT ;Order: Vital Signs <7rder Status: DfSCOIVT1Nl1Eb Calalog Type: Patient Care :Ordering Physician: Budde,Bradley ;Entered By: Budde,Bradley on 7/9/2011 23:55 EDT Order Details: STAT, 07/09/11 23:39:00, q1h Order Comment: MRN 7510053 Date/Time Printed: 9128!2011 09:52 EDT Page 110 of 139 Printed By Shiner,Crystal L PENN~TATE HERSHEY _ 11/riltan S. Hershey Medical tenter Patient Name: GREEN, LOGAN M MRN 7510053 Date/Time Printed: 9/28/2011 09:52 EDT Page 711 of f 39 Printed By: Shiner,Crystal i_ PEIVNSTAT_E HERSHEY _ 11 Milton S. ~Iershey Medical Center Patient Name: GHEEN, LOG.AN M MRN 7510053 Orders Order f]atel7ime 7,9/2011 22:4 E13T ..,. _, .. .... Order: Med Dosing Weight Order Status: Completed :Catalog hype: Patient Care :Ordering. Physician: Budde,Bradley •.. . ~En#ered By: Budde,Bradfey on 7/9/2011 22:49 EDT _..... . ... Order Detarls: 07/09/11 22:49:00 Crder Comment: Da#e/Time Printed: 9/28/2011 09:52 EDT Page 112 of 139 Printed By: Shiner,Crystal L PENNSTAYE HERSHEY _ 1 N~~Iton S. ff~ers~ey Medical Cente~° Patient Name: GREEN, LOcaAN M MRN 7510053 Orders rder• Gat~lTirrie 7/912t}1,1.22 47 EDT Order: Peripheral IV Routine Care ,:_ _. -- .. Order Status: DISCONTINUED _ ....._... .._ ___ _ _ _._....._ ....... Catalog Type: Patient Gare Ordering Physician: Budde,E3radley__ _ , _,. , .: _ _ ; :Entered By: SYSTEM on 7/10/2011 18:00 EDT...... __ . __ _ . __ __ ___ Order Details: 07/09/11 .22:4.7:00 __ ........_ .. _........ _..._; _ __ _ . Order Comrrieni ___ __ - _ _ - _ _ _ _ _ __._ _. :Order C1ate/Ttme: 7!9/2011 22:47 I~bT ,.,:. . ;Order. Peripheral IV Insertion Order Status: Com leted i? ......... ... ........ ._. _ _ ,. ,.._ ... _ _ .., . Catalog TYpe: Patient Care Ordering Physician: t3udde,Bradley ..... --. . :Entered By: Hughes,Allison on 7/9/2011 23:08 EDT :Order Delails 177/09/77 22.47:00, Peripheral IV ___ .. _ _ _ _ ..., -Order Camment: _ .... .........._ . __ ..... ............ ...... Order pc~te~finte. 7l9/2p17 2~;47,~13T .............................. _ __ ..._,.. . ,_ Order: NPO _ _ ............. >':,; Order Status: DISCONTINUED __._.. _ _ _..._.__ _._ _._ ...... ?Catalog Type: Dietary :Ordering Physician: Budde,Bradley ..... . - - , Entered 8y Budde,Bradiey an 7/9/2011 22:50 EDT ,_ 9rder Detad~. 07/09/11 22:4700, NPO No Exceptions _ ___ __ _ _.__._ __ _... _. ;Order C;ommeni: Order CiaterTim~ P/9/2011 22:47 ~D7 ;, ....... .............................. :Order. Lumbar Spine Cleared -- - Order Status: DISCONTINUED .. __ _ _ . _..... _ ....... _ _.. _ .........._. ;Catalog 'Type: Patient Care ;Ordering Physician Budde,8radley _. , __ _ _ _ __ __ _ _ :Entered By: SYSTEM on 7/10/2011 18:00 EDT _____ ........ .............._ __ ;Order Details 07/09/11 22:47:00, ONCE, Stopping On 07/09!1 f 22:47:00 :Order Comment: _ _ _... _...........__ .. ..... ................. ......... {7rder Datei7jme 7/9E2011 22.:47 EDT` _. _ .,. ;; ,.. :Order: Intake and Output (I&q) ,._ Order Status. D#5CONTINUED ,_ __ _- __ .. .Catalog Rype: Patient Care _ . :Ordering Physician Budde,Bradiey _.. _. :Entered By: SYSTEM on 7/1G/2011 18:00 ED"f _ _ __.. ... _... _ _ __.... _.. ........ _.. Order Details: 07!09/11 22.47:00, gShift :Order Comment: -- - _ . ._ ___ Date/Time Printed: 9/28/2011 0952 EDT Page 113 of 139 Printed By: Shiner,Crystal L PENNSTATE HE~SIHEY ~1 N~ilton S. I~er~hey Mec~i.ca~ Center Patient Name: GREEN, LOG,AN M MRN 751Q053 date/Time Printed: 9!28/2011 09:52 EDT Page 1114 of i39 Printed $y: Shiner,Crystal L PENN~TATE HERSHEY R~1 Milton S. Hershey Medical Center Patient Name: GREEN, LOC~AN M . Orders Order Da#e~fimi 7J9l2n11 22;46 ED7. _. ;:::.. :Order: Admit. MRN 7510053 _ ....... ......... .._..._. ......g yp ....., .__ _ ....... _ _ _ _ ____......... rder Status: Completed ;Caialo T e: Patient Care <]rdering Physician: 13udde,Bradley :Entered By: EIy,John M on 7r9/2011 22:50 EDT ... .. _. :Order Details: Rautine, Requested Admit Df: 07/09/11 22:46:00, Inpatient {Admit}, Floor, Peds Surgery, Dillon, Peter W, floor, obs, LOS; 1-5 Order Comment: -- .._ _ __. rder Date/~f ime: 7/g12U11 22c3g f_l3T Order: Vital Signs ..,.... ___ Order Status Completed Catalog Type: Patient Care Orderiny Physician: DeFlitch,ChristopherJ __...__ Entered By: SYSTEM on 7/9/2011 23:15 EDT Order Details: STAT, 07/09/1 ~ 22:39:00 g30ntm Far 2 dosesfi~mes, Stopping On 07/09/11 23:15:x0 Order Comment: __ _. _ ._ .rder. pate/Tlrria: 7/~31^*07.1 22 ~3U. CDT < .:: ,. _ ,:.. Order. Blood Type/Antibody Screen (TYPE AND SCREEN) ..... rder Status: Completed ;Catalog Type: Laboratory ............. :Ordering Physician: DeFlitch,Christopher_ J Entered By: SYSTEM on 7/9%2011 23:33 EDT .... Order Details: STAT, Blood, Lab to Collect, starting at 47/49/11 22:30:00, ONCE, stopping at 07/09/11 22:30:00 !Collected, 3 day _. Order Comment: Qrder Da#e/Titrie: '719/2011 22':28 EDT ;:, :Order Trauma Prohle Peds,Default (lab ordered} (TRAUMA DEFAULT PEDS LEVEL2) .._.... :Order Status: Completed :Catalog Type: Laboratory Ordering Physician: DeFfitch,Christopher J _.... Entered By: SYSTEM on 7/9/2011 23:00 EDT _. Order Details STAT Collected at 07/09/11 22:25:00, Ordered by the lab, 2 day Order Comment: Date/Time Printed: 9/28/2011 09:52 EDT Page 115 of 139 Printed By: Shiner,Crystal L PENN~TATE HEK~HEY _ ~11VIi~to~~ s. Her~~ey N~ec~ic:a1 ~enCer Patient Name: GREEN, LOGAN M MRN 7510053 ................. _...........................................~.........._............_.....-Orders Order Daie7Time~ 719/201'1 22:2S.EaT :Order: Blue on Hold in Laboratory {EXTRA BLUE} Order Status: Completed ~ :Catalog Type: Laborator/ _... _ _. . :Ordering Physician: DeFlitch Chnstopher J __ _._... :Entered By: SYSTEM on 7/9/2011 22:31 EDT :Order Details: Routine; Callec:ted at 07109/11 22:25:00, Ordered by the lab, 2 day Order Comment: Order-Date/Time: 779/2D1 i 22::22 1D7 Order: Ped Skin Assessment on Arrival ___ Order Status: Completed Catalog Type Patient Care Ordering Physician: SYSTEM Entered By: Nughes,AlGson on 7/9/2011 23:08 EDT 'Order Details: 07!09111 22:22:05 !Order Comment: Ped Skin Assessment on Arrival Ordet' )~ate~Tirna 7/972011 22..19 f•:D7 :... .... Order: G Spine XR {OXCSP) Order Stains: Completed Gatalog Type: Radiology Ordering Physician: DeFlitch,Chrisiopher J :Entered By' Contrbutor, system lDKOE01 an 719/2011 22 27 EDT Order Details: STAT, Requested Dt: 07/09!11 22:19:12, Views: "Standard Views Order Comment Ord®r Date?Timc~: 7/912D11 22:113 ~DY Order: T--Spine GT {UCTSP) __ . _.... Order Status: Canceled ;Catalog Type: Radiology ,. Orderin Ph sician. l'3eFlrtch,Chr+stopher J Entered By: Contributor system,IDXOE01 on 7!9!2011 22:40 EDT Order Details: STAT; Requested Dt: 07/09/11 2?_:16;01 Order Comment: Date7Time Printed: 9/28/20 t 1 09:52 EDT Page 116 0# 139 Printed By: Shiner,Crysta! L ~E~~SrATE H~RS~~Y 1'1 N~i~tcn~ S . Hershel MedXCal Center Patient Name: GREEN, LO~SAN M MRN 7511)053 Date/Time Printed: 9/28/2011 09:52 EDT raga 117 of 139 Printed By Shiner,Crystal L PENNSTATE HE~ZSHEY 11 Milton S. Hersl~.ey Medical `enter Patient Name: taREEN. LOGAN M MRN 7510053 orders _. .. Order Date/Time• 7/9!2011 22:10 EbT :..,. _ , ;Order: Chest XR (OXCHEST;i _. :Order Status: Completed ~ ~ Catalog Type: Radiology :Ordering Physician: beFlitch,Christopher J Entered By: Contrrbutor_system,lDXOE01 on 7/9/2011 22.24 EDT .... . ....... Order Details: STAT, Requested Dt. 07/09/11 22 10A9, Views:Standard Views _-- ,. :Order Gomment: r er_ atE, rrne: 7/9l2bii 22109 EDT' - __ . ;,,. :Order: SafetyiQuality Verification ;, Order Status L7ISCONTWUEf] _ _. _............_..... __ ... _._ ..- ___ . Gatalo 7 e Patierit Care ' g :: yp ~ _ .... 'Ordering Physician: SYSTEM _ ..... .. . .. . ......... . . _ ___... ............: Entered 8y: SYSTEM on 7/10/2011 18:00 EDT _.. Order Details 07/09%11.22 09:04 Midnight ... . Order Comment: Safety/Quality Verification Ufder patelTirrme: 7I9I~011 22.;09 ~faT Order. ED Assessment ....: Order Status Completed ................ .......: Catalog Type: Patient Care `Ordering Physician: SYSTEM . . ..........; :Entered By: Hughes,Allison on 7/9%2011 23:08 EDT ......... ............................... .... Order Details. 0!10911 i 22:09 04, ONCE, Slopping On 07/09/11 22:09.04 Order Comment: ED Assessment .; Order Date.rl`iin~: 7/9/2011 22;09 fCIT _ _ ........ ..... :Order. Adult Skin Assessment: on Arrival :Order Status Com leted p ____. ::Catalog Type: Patient Care :Ordering Physician: SYSTEM _ - .... Entered Bye Hughes,Allison on 7/9/2011 23:08 EDT Order Details: 07109!11 22.09:04 :Order Comment: Adult Skin Assessment on Arrival _.... __ C)rder.DaferTime''7/~,12{tii 2'.09 EDT .. :Order: ED Visit ;.. -, . , ,, Order Status: Com leted _. _... _ .-. ~_..... .. __.. .. __ .. ,.... . -. - - - - Catalog Type: Patient Care .... Ordering Physician: SYSTEM ..... :Entered By: SYSTEM on 7/9/2,011 22:09 EDT Order betails: Request Dt: 07/9/11 22:09:03 Order Comment: ED Visit _. __ _ _ - _ ____ :. ._ ., Date/Time Printed: 9/28/201 i 09:52 EDT Page 118 of 139 Printed By: Shiner,Crysial L PE~l~I~TATE HERSHEY _ N~iltan ~ . Hershey Med~_ca1 Center Patient Name: URF_EN, LOcaAN M MRN 7510053 Orders ;Or er [?ater'Time: 7/9/2011 X2:09, ~pT _:,:: Order: ED Nursing Charge _.. Order Status: Completed Catalog Type: Patient Care Ordering Physician: SYSTEiNI .. Entered By: Hughes,Allison on 7/9/2011 23:50 EDT Drder Details: Request Dt: 07/09/11 22:09:03 .Order Comment: ed nursing charge __ Order Date/Time: 7/9}2411 22.09 EDT - >, _.. _ .. Order: Urine Analysis,Basic & Microscopic (UA,Basic & Microscopic} _.....:. :Order Status. Completed ,Catalog Type: Laboratory :Ordering Physican: DeFli#ch,Christopher J !Entered By: SYSTEM on 7/10/2011 01:31 EDT _ __ _ ._ Order Details: S IAT, Unne Clinician to Collect starting at 07/09/11 22:09:00, ONCE for 2 day, Collected Order Gommenl [[Urine, sterile container]] :Order pate/Tine T!9%2p112~~09 ~[t7 :Order: Pulse Oximetry Gontinuous ........ Order Siafus: DISCONTINUED Gatalog Type: Patient Care :Ordering Physician: Dillon:Peter W _... Entered B Stum Lau _... y:........ P,.,.._ ren N on 7/10/2011 01.43 EDT Order Details: STAT, 07/09/11 22:09:00 continuous while in ED Order Comment: Date/Time Printed: 9/28/2011 09:52 EDT Page -119 of 139 Printed By: Shiner,Crystal L PENN~TATE HERSHEY N~ilton S. ~-I~rsl~ey N~edical tenter Patient Name: c:~REEN, LOGAN M MFiN 7510G53 Orders :Order atelTime 7/91Zi]11-.2209,~~7~ .. _ _: Order: Peripheral 1V lnseriion Order Status: Completed ~ ~ ,Catalog Type: Patient C~-re .:, ;Ordering Physician: QeFlitch,Christopher J __ .... :Entered By: Hughes,Allison on 7/9/2011 23:09 EDT ....... . .... :Order Detarls 07109/11 22 09:00 Peripheral IV ONCE STAT, at least one large bore 1V rf not started pre-hospital :Order Comment: Order>Date/Time:~d9/20i 1 22:09 EC'3T Order: Partial Thromboplasiin T-me (PTT} ___ _ _. _. .._ .... r er tatus: anceled ,Catalog hype: Laboratory ;Ordering Physician: DeFiitch,Christopher J __... :Entered By: Contributor system,SUNQUESTOE01 on 7/12/2011 04:34 EDT :Order Details; STAT, Blood, Clinician to Collect, starting ai 07;09%11 22.09:00, ONCE, 2-day, stopping at 07/09!11 :22:09:00, Gollected :Order Comment: (jBlue tube]] Order Date/Tme 7/572011 22:;09 CDT _: Order: Oxygen Saturation <.:: >.,. ;....: Checks ; _ . . Order Status Completed ;Catalog Type- Patient Care Ordering Physician: DeFlitch,Christopher J .. ........ Entered i3y: Hughes,Allison on 7/92071 23.09 EDT Order Details: STAT, 07/09/11 22:09:00, ONGE, Stopping On 07/09!11 22.09:00, while on room air Order Comment: .... r er Da#erl`ime: 7/912011,22:OS EDl' Order: Neuro Check ... .. . Order Statu ~ DISCONTINUED Catalog Type: Patient Care Orderrng Physician: Budde,Bradley .Entered By: Budde,Bradley on 7!9/2011 23:55 EDT Order Details: STAT, 07/09!11 22:09:00, q1 h Order Comment: OrderC]ate!l~ime: xl9'120i1 22109 EUT Order: Lipase Level Da#e/Time Printed- 9/28/201 1 09:52 EDT Page 120 4f 139 Printed By: Shiner,Crystal L PENNSTATE HERSHEY _ ~1 Milton S. Hers~e~r Med.i_ca1 Center Patient Name: GREEN, LOGAN M MRN 7510053 Orders (Jrder DatelTirne_ 7~9/2d1'1 22:09 EDT Order: Intake and Output (I&O} Order Status: DISCONTINUED 'Catalog Type: Patient Care Ordering Physician: Entered By: SYSTEM on 7/ 1012011 18:00 EDT Order Details: (17/09/11 22:09:00, q1h Order Comment: _ _ __ _ ___ _ _ _ _, __ _ ,, Order galel7ime: x/9/2011 22:09 EDT Order: Head GT. ,. , LOrder Siatus~ Completed Catalo T e: Radiolo ... _ ......... ............ J .YE?... ...SY........... :Ordering Physician: DeFlitch,Christopher J Entered By: Contributor_system,IDXOE01 on 719/201 i 22:44 EDT ... _ __ _. Order Details. Staff Requested Dt 07/09/11 2~ 09 00, lCD9: Trauma-959.8 History; Trauma :Order Comment: r ec laate/Tiirte T/9T2011 22,09~:Et]T ,Order: Complete Blond Count w Differential (CBC w Platelets and Diff} _ . __ ,Order Status: Canceled _ Catalog Type: Laboratory. _......_ _ _ _. :Ordering Physician: DeFlitch,Christopher J Entered B Contributor y ystem SUNQUESTOE~y on 7/12/2011 04:34 EDT Order Details: STAT, Blood, Clinician io Collect, starting at 07109/11 22:09:00, ONCE, 2 day, stopping at 07/09/11 22:09:00, Collected __ _.. :Order Comment [[Lavender tube Panel includes WBC count RBC count, Hgb, Hct, Platelet count and Differential]] __._ Order-Date/Tirr~e 719(201'1 22:09 ED'T' . _< . Order- Basic Metabolic Panel (BMP) _...._; Order Status Canceled :Catalog Type: Laboratory Ordering Physician DeFlitch,Chnstopher J :Entered By: Contributor system,SUNQUESTOE01 on 7/12/2011 04:34 EDT _ .. . __ __ Order Details: Sl`AT, Blood, Clinician to Collect, starting at 07;09/11 22:09:00, ONCE, 2 day, ,topping at 07/09/11 22:09:00, Collected _. ;Order Comment [[Green gel tube Panel rncludes Na K, CI, C02, BUN, Creaf/GFR, Glucose, Ca]] Order Date%Time: 7!9/2011 22:09 ED7 _,.. _ _,,. _ :Order: Amylase t_evel _ .. :Order Status: Canceled Catalog Type: Laboratory :Ordering Physici-3n: DeFliich,Christopher J _ .. :Entered By: Contributor system,SUNgUESTOE01 on 7/12/2011 04:34 EDT ....... :Order Details: STAT, Blood, Clinician to Coilec;t, starting at 07/09/11 ~2~-09:00, ONCE, 2 day, sfoppirig at 07/0%11 :22:09:00, Collected Order Comment: [[ Green Separator #ube]] Date/l'ime Printed: 9/28/2011 09:52 EDT E'age 121 of 139 Printed By Shiner,Crystai L PENNSTATE HERSHEY _ ~1 I~I~ilion S. Hershey Medical Center Patient Name: GREEN, LOGAN M MRN 7510053 Orders :Ord®r [)~te!Time 7i9/2t?11 22;09 ~Dl" >>. ,, C)rder: ALT Level _ _ , Order Status: Canceled -- - ~-- ;Catalog Type: Laboratory 0rderm Ph sician: DeFlitch,Ghrisio her J ;... _.g.. y-. ~. . __ _. . P.._....... ...-_. _. ;Entered gy: Contribuior_system,SUNQUESTUE01 on 7/ t2/2011 04:34 EDT ' ' ' ' ' • _. ..................................: Order Details: STAT, Blood, Clinician to Collect, slatting at 07/09/11 22:09:00, ONCE, 2 day, stopping ai 07109/11 22:09:00, Collected - _ ,- _... Order Comment: [[Green gel tube; Tesi included in the Comprehensive Metabolic Panel, Hepatic Function Pane! and Liver;' ;Profile]] Date/Time Printed: 9/28/201 i 09:52 EDT Printed By: Shiner,Crystal L Page 122 of 139 PENi~ST~TE HE~I~SHEY _ /~1 Miltan S. Hershey Medical Center Patient Name: GREEN, LOGAN M MRN 7510053 Medication Orders Da1elTime Printed: 9/28/2Ct11 09:52 EDT Page 123 of 139 Printed By Shiner,Crystal L PENi~STATE HERSHEY R~11V~ilton S . Hershey 1VIed]ca1 ~en~er Patient Name: GREEN, LOGAN M Medication Administration Record MRN 7510053 ..,.,..,,.,,,,..,,..,.,..,,..Medications ._......_......,. ......................._...................,.. _......,.,.,.,,.,...,,,,,.,,,,,,. ... ,::: Admin Date/Time. 711012011; 01 14 CDT 'Charted ot3rtelT-me: 7r10120:'ti 00:58 EDT __ Medication Name: acetaminophen ' Admin f?eiails: Firial 'Pain Inlensiiy Response: 2; Pain scale used primary: 0-10 Pain scale 'Action Details: Order: Budde,Bradley 7/9/2011 22:49 EDT; Perform: Hughes,Aliison 7/10.12011 00:58 EDT; VERIFY: ~Hughes,Allison 7(10/2011 00:58 EDT Admirl.DateiT-rr~re '~/10/201100,14_~DT Charted>Q~te/T1tne::'7/10/201 1 00 14EDT IVfedication Name. acetaminophen :Ingredients: acetaminophen 650 mg :Admin Details: (Auth) PO Pain Intensity: B; Pain scale used primary: 0-10 Pain scale Action Details: Order: Budde,Bradley 7/9/2011 22:49 EDT; Perform: Hughes,Allison 7/10/2011 00:14 EDT; VERIFY: Hughes,Allison 7/10/2011 00:14 EDT _. _ _ ____ Reason far Medication: Hughes,Allison 7/10/2011 00:14 EDT Fever/Mild Pain Continuous Infusions :Admin Date/'Time: 7/11312011 1 1:Oa EDT 10 7l14f207 Charted DatelTimlea 71rt0t2o11 07:5 E[)T :11:59 EDT ° ,000 m L , , ... . ,,., . Medication Name: Sodium Chloride 0.9/0 1:., Ingredients: Sodium Chloride 0.9% 95 mL Admin Details: {Infuse) (Auth) 95 mL, 95 mUHR, .IV, Peripheral Action Details; Order: Budde,Bradley 7/912011 23:03 EDT; Perform: Boesch,Robert E 7/10/2011 07:44 EDT;, VERIFY: Boesch,Robert E 7/10/2011 07:44 EDT Admin D.ate/lime: ~110i2011 10:00 E=DT'ta 7110/2011 Charted D~rfelTime>,7/10f~011 07:45 E[~T 10:59 EDT Medication Name: Sodium Chloride 0.9% 1,000 mL ;Ingredients: Sodium Chloride 0.9% 95 mL .. _ __ .._ ;Admin Details: (infuse).(Auth) 95 mL, 95 rnUHR, :IV, Peripheral 'Action Details: Order: Budde,Bradley 719/201 ~1 23:03 EDT; Perform: Boesch, Robert E 7/10/2011 07:~'f4 EDT;, VERIFY: Boesch.Robert E 7/10/2011 07:44 EDT Admin Date/Tune: 7110!2011 09;00=E17T tt~`7/107,2011 Ghairted Qate!'fime:. T/101201.1 137:45 ~(~ 1 Q9,59 EDT :Medication Name' Sodium Chloride 0.9% 1,000 mL ___ _ _ __ , :Ingredients: Sodium Chloride 0.9% 95 mL :Admin Details: (Infuse) (Auih) 95 mL, 95 m VHR, .lV, Peripheral ... :Action Details: Order: Budde,Bradley 7/9/2011 23:03 EDT; Perform: Boesch,Robert E 7/10/2011 07:44 EDT; VERIFY: Boesch,Robert E 7/10/2011 07:44 EDT Date/Time Printed. 9/28/2011 09:52 EDT !'age 124 of 139 Printed By. Shiner,Crystal L 4'E~II~ISTAT_E HE.RS~EY /~11Vrilton S. Hershey 1Vledical Center Patient Name: GREEN, LOGAN M MRN 7510053 Medication Administration Record ,. .. . ................ ............. .... ............. ......... .......Continuous ,Infusions ,...................................... .................................., Adrtttn 1}afQlTirne: 7I10/20y t 08:00 Ef}T to~l10I20 i 1 Charted D$1eiTtrrie:7,10/2011 p'7,a5 EG3T :08.:59 E(7T ' , , _,. _ __ :Medication Name: Sodium Chloride 0.9% 1,000 mL .. Ingredients: Sodium ChYonde 0 9% 95 mL !Admin Detarls: (infuse} (Auth} 95 mL, 95 mUHR, :IV, Peripheral .. !Action Details: Order: Budde,Bradley 7/9/2011 23:03 EDT; Perform Boesch,Robert E 7/10/2011 07:~~4 EDT; VERIFY: Boesch,Roberi E 7/10/2011 07:44 EDT ... . Admn.Datel7ime:.7~10%201 1 07 00 CDT to 7~10f?Ql 1 Charted bateRime: 7(74f20t1 Q7~45 FDT 07:59 EDT ,. ... !Medication Name: Sodium Chloride 0.9% 1,000 mL :Ingredients: Sodium Chloride 0.9% 95 mL Admin Details: (Infuse) (Auth) 95 mL, 95 mUHR, .IV, Peripheral ,._ _ _ __ :Action Details: Order: Budde,Bradley 7/9%2011 23:03 EDT; Perform: 6oesch,Robert E 7/10/2011 07:44 ED1'; VERIFY: Boesch,Roberi E 7/10/2011 07:44 EDT Admt.n QateZTime:'170/2b 11 OB;Q0:1/D`f to 7'10/~'1't ~ Charted DateTme :71't0/~Ll {7 {16;22 EDT :06:59 ED`f .. _ .. Medicai~on Name: Sodium Chloride 0.9% 1,000 mL Irigredienis: Sodium Chloride 0.9%95 mL __ __ :Admin Details (tnfuse) (Auth} 95 mL 95 mLJHR . IV Peripheral :Action Details: Order. Budde,Bradley 7/9/2011 23:03 EDT; Perform: Strayer,Jennifer L 7/10/2011 06:22 EDT; VERIFY Strayer,Jennifer L 7/10/2011' 06:22 EDT _ ... .:. Admin Date/'fime: 7i t0i2011 05;00 Et3T to 7/1Q/2011 Ghart~d l}a#teiTrm~ 7/10~~011 0622 ~;DT 05;59 E177 : :Medication Name: Sodium Chloride 0.9%1,000 mL :Ingredients: Sodium Chloride 0.9% 95 mL :Admin Details: (Infuse) (Auth) 95 rnL, 95 mIJHR, .IV, Peripheral Action f)etails: Order: ~iudde,Bradley 7/9/2011 23:03 EDT; Perform: Strayer,Jennifer L 7/10/201 1 0E3:22 ED'T; VERIFY: Strayer,Jer~nifer L 7/10/201 "I 06:22 EDT Admin DalelTime:~/1b/2011 04:00 EDT to 7/70120.11 Charted Date/Time: 7/1pt2011:Q6:22 L_DT 04.:59 EC3T :Medico#ion Name: Sodium Chloride 0.9% 1,000 mL. :Ingredients: Sodium Chloride 0.9% 95 mL Admin Details (Irituse} (Authj 95 ml_, 95 mUHR, .IV Peripheral,., 'Action i7etails: Order: Budde,Bradley 7/9/2011 23:03 EDT; Perform: Strayer,Jennifer L 7/10/2011 Of:22 EDT; VERIFY: Sirayer,Jennifer L 7/10/2011 06:22 EDT DaieCTime Printed: 9/28/2011 09:52 EDT Page 125 of 139 Printed 8y: Shiner,Crystal L PENNSTATE HERSHEY ~4 N~~ton S. Hershey Medical Center Patient Name: GFtEEN, LOGAN M MRN 7510053 .. ~.... ..... ...__ . ..... ............ ....... ... .Medrea`tion, Administration Record ....... ._ . _..._._......._ ....,... _....... _...........,. ... ........... ........ ..... ........ .... ...................,,...... Continuous, infusions ..............,, ..,....,................'......, .,.,.,........,.....,.....,,,..,... Admin.[~~telTitrie; 7110/201/ 03.OO:EDT to 711.0120(1 Charted q~if~/Time: 7,10/2011 Q6:22 EL7T _. Q3:59 EQ7 _. Medication Name. Sodium Chloride 0.9% 1,000 mL Ingredientsc Sadrum Chionde 0.9% 95 mL Admin Details: (infuse) (Auth) 95 mL, 95 mUk~R, .IV, Perip era .... .... ~Activn getails: Order: Budde,Bradley 7/9/2011 23:03 EDT; Perform. Strayer,Jennifer L 7/10!2011 06:.22 EDT, VERIFY: Strayer,Jennifer L. 7!10/2011 06:22 EDT _ >. ~: ~Admlrtba:telTirne. 7/10/25711 02:OCt EDT to 7!10E201i Chairted E]afe/7ime: 7/1!0f2011 02:23 EC)'f~ '02:59 EDl~ .. . ,.. _ _... _. Medication Name: Sodium Chloride 0.9% 1,000 mL Ingredients: Sodium Chloride 0.9% 95 mL _ _ .... . ~Admin Details: (lniuse) (Auth) 95 mL, 95 mUHR .IV Periphe€al _. _,. :Action Details: Order: Budcte,Bradley 719/201 1 23:03 EDT; Pe€form. Strayer,Jeririifer L 7/10(2011 02:22 EDT, VERIFY: Slrayer,Jennifer L. 7/10/2011 02:22 EDT .. .. Admiri Daiel'lme 71~012017OtJ.57,~C1T ;:Charted DaieR~me ;7/lCrf2(J11 ©0:57 EDT. Medication Name. Sodium Chloride 0.9% 1,000 mL :Ingredients: NaCI 0.9% 10Ci0 mL Admin Details: (Begin Baggy (Auth) 1000 mL 95 mUHR IV Penp~ierak . . . .. . :Action Details: Order: Budde,Bradley 7/9/2011 23:03 EDT; Perform. Hughes,Allison 7/10/2011 00:57 f/DT, VERIFY: Hughes;Allison 7/10/2011 OC>:57 EDT _ Date/Time Printed: 9/28/2011 09:52 EDT Page 126 of 139 Printed By Shiner„Crystal L ~'E~INSTATE HERSHEY N~1.t~n S. Hershey ~ltledical Center Paiienl Name: GREEN, LtJGAN M MRN 7510053 Height/Weight Measurements .. ......... ........ .................. .........................................'....,.. Height......................,...................................................,.............. Recorded Date- 711Q/201'1 Recorded Time ' 01:48 ERT Recorded By Flawdl-ina M _ __ _ . i'rocedure ' Units !Height cm 170 ..................................................................,................................Weight..........................~..................,....,.........,,...... ,.,,...~..........,..~..,.......,. Recorded pate' 711(~I2011 7/912011 7/9/201 i 'Record®d Time 01;48 EbT 2x:49 EDT 22;14 PE]T ~tecorded gy' Flauvd,Ttna fvl Hughes,Alfison Spanos,Rachei A Rrocedure Units :.. , ,, , . :Patient Weight kg :, 56.25 . _ 56.690 °t 56.690 Order Comments 01: Ped Admit2 Assessment Ped Admit2 Assessment DaielTime Printed: 9/28/2011 09:52 Ef]T Page 127 of 139 Printed By: Shiner~,Crystal L PE~II~STATE HEI~S~EY Milton S. Hershey Medical Center Patient Name: GREEN, LOCAN M MRN 7510053 ,.. Scanned Blood Bank Document DatelTime Printed: 9/28/20 1 1 09:52 EDT Page 128 of 139 Printed By: Shiner,Crysial L Patient Name: GREEN, I_i)GAN M MRN: 7510053 Date of Birth: 7l2'rT996 FIN: 10516053 * Final ` PENN STATE M T TRANSFUSION "`gyp R3 ~ 4?5 I II~II IINI INII i~N III IIII ~I III IL ON 3. HERSHEY MEDICAL CENTER ~ NALIE: TRAUMA, 7510053 ~ BLAODBANK El<i!!: 7510059 OOSH: Y0570053 HERSHEY PA 17033 MD: DEFLITCH CHRISiO R9DN: 40325 ~ , DIRECTOR OF CLINICAL LABORATORIES ^ CROSSMATCH ~ 00B: 01/01!1900 VtSST DATE: 10!'09!2011 LOC: EMER SEX: U M.R.00NGIOVANNI,M.D. (ABO/RH,ANTTBODYSCREE ,UNITS) F PAY SEt_F PITY INS: SPECIAL IEQUESTS -CALL 8232 COMPONENT AUNITS I IIIIII~~~IMIIII III ~ PACKED CELLS SIGNATUAE j3J ~Z'2 ' ^Ex(:HANGE TRANSF.USiON _ TIME: Y ~ C VOL GFLINULOCVTE3 (XMG) _1 RECIPIENTS IDENTIFICATION VEREF I Z W HpC STE-M E L IED, DATE: 7 F Q fC ^INILYAUTERINE T7ilWSFUSIDN • C L S (XMMS) SPECLMENCOLIFCTEDANDt3LOODB/UJUAPPUEOBY ~ VOL : S ~ L~FRESH{LE55THAN8OAYS} ~TYPEAND SCREEN (TSC) (ABOlRH ANTIBODY SCREE=N 0 UNITS )NFQRNATIDN REQUIRED ~jrSTAT - ~ ~ 8 UNITS , , ) ~~~"('"'` °' j , ~~ ~~ ~ ^Lt-bS THAN 72 FLOURS ^ OB Tl'PE AND SCREEN (08793 DIAGNOSIS ~ ~ ~~ N (PEOIATRLC .SURGERYy MUNITS (ABOlRH.ANTIElOOYSCREEN,0UNITS) DADERINGPHV'SICIAN ^ROUTINE O ^OTHER ^ NEONATAL'YRANSFUSION {NEOX) ~ FOR SURGERY. _,~ COLLECT ON: U (h PEdr:1r (ABOI TIBODY SCREEN) ^AIE CLINICAL PATHOLOGIST EVALU ION _ pE IMEN (HOLD) FOA TMNSFUSION _Y,,,_ REpUIRLRI (NO TESTING PENDING ORDERS) DAYS KEEP_ UNITS AHEAU AT ALS. TIMES LJ tEUKOREDUCED ~ ^IAFIADIATEO 1 ADULT RED PER 4 UNITS EACH TUBE MUST HAVE (NEW SPECIMEN REQUIL(EU.LVERY T2 HOUf lS) ~ ~ AY LABEL ppEV16US TRANSFUSIONS ^waSHED ^ Yes ^ NO ~ DATE Facility: NMG Page t29 of 139 PENNSTATE HERSHEY_ 111liltvn S. der shay Medical Center Patient Name: GREEN, LOGAN M MRN 7510Ci53 Scanned Inpatient Chart Date/lime Printed: 9/28/2011 09:52 EDT Page 130 of 139 Printed By Shiner,C;rysial L PatlentName: C~~'F E=N, LcX3AN M Date of Birth: 7/2? r 1996 Final ` MRN. 7510053 FIN: 10510053 F'ENNSTATE 1-iERSH(=Y IGI~N~Irl~NlNIIIJIrrlrl~lr(1nNN Milton S. Hershe NAAfE: PREEN, LOGAN N y two"JOZiio05PtrEa w N~Du~~as10sooass ~; Medical Center tea: o7rzt naafi VjSjF PATE: 07/UV/20ri 1'_._ _ _ _ Loft 7A®w 7264- 7 SE%: Il _.__._.__ ___ - ___.-_._---__ NS: AUTO }N HANCF STANAARU P1AN UF' CARE DRG ~~ EST. ~~ ACTU I~' ~u~~~~lro~~ ~__ A,TTMSUING - ~ PREFERRED tJAMF:. L-?J ~. _ V~ ~, _ ____ F1ESl~CNT -_. ___. j q~E_, t "U.- ADM. UAft -_RO:)Mq.. _J_(X.I(Jr.1'~._____.._ _. - _.. .~ - ~--__ i InitiaY _ _.. _ - - _ _. _ ~_- ._~ __ FRIT2AHY NURSE - __. - --- - --- flEASON fOR -~1Cl,t,~~-~"~n t ~ n~ a,, _ __ ~ RITE-MYN[i tJURSE ____-___ __. _-..-. __- ___- _ AOAAI,p$ION ~ _ f~UHSE COtJSVETS __.. .. __ I -__.... - __.. __ .._ __-___- ___-..____ _. .....__~._._ ---' D4AGNOSIS RURSc C[NJSUE7S _.. .__.__-_._ 1. _________ _. ___ __-.___ _. _.___ _.. _ __ _ __ JU G;AI_SEHVIGE_,T_. z. _ -___. _. __ -_ _.___.__ ..__.__.. ____.. __. _ ____ .____. _.___ _- ~.-_~._. _ I __._ 4. __ __ --._.__ _._.-_-.-___ _-__.__-__.__._- .-._ CAT& INVASIVE PROCFpURES ADVANCEDiftECTiVE YE~u i_--] NO J. _J I __--- __ __ . ^ - CODE BLUE STATUS ____ --- ---- ------._ _--- - _ __. -__- CONOlTION ~..- .__._ r __ ._- ---___.. _ _ ___ - _ ALLERGIES ' Problem Llst ENpeded putcomes I 6atC (nmels -~ m~ Date Initigls .._._ .. .._ _...._~- --- !f - . --- z - --- -- ~- (, {{`~. ~a W~~~ Y~c.~e ~ g~~~ ~ to ~4~ 7 ~~t5~ ~f ~4l}~,C,~E(jri !t~- SUa,J«. si~e_ ~7Y~oe -4a `d~C..- ~~~ ~~~ ~ Q _ ___ _ __~._.__ t ----- - p, ~: ~,~ b~~\~ SEGO ~, t,>~t~ '7 ~lnoc,,lec~~e_.~~~.c..~' ~ P4 ~~~, b ~e_P~`P~~~7~pr,or ~ov~. - k~ u .._-_, __ _--- r e- _ DISCf iARG E PLAN: j Plan of Care Hoviewed with t~aUenvSfgniticent Othec i Date SIUJTature j-.. ~ Home ~ Nursing Home ( / ~ _ I_3 home with Assistance {~ Unable to determine un admision ~! 1~ ~~6%~~ !/ ~ - i_I Other: Explain- MA~~~~figg0rrlyyREVp 6/Q9iuayJ~, tlwgqr ~~~~lIII R~II r~~ur iris ~NI urn N~~ PLAN OF CARE F=acility- HMG Page 131 of 139 Patient Nama: GRkFN, LGGAN M Sate of Birth: 7/?i i 199& Facility: HMC * Final Mp N: 7510653 FIN: 10510053 ..- ,~ - ---- --- !~ __. --~..___ -_ .=} --- -. __~ _ -- - ---- __ - -------- -- - l _! Page 132 of 139 ~; ~,i: I Patient Name. GIi~EN. L~~ESAN M Date of Birth: ~~21/1986 ' Fina! ` N I'ENNSTAi E HERSHEY ~ Milton S. Hershey ' ~ ~ Medical Center FINAL Nl1RSING PROGRESS NOTE IIIWIIII I~INI(I IIII IIIII Igll qll IIII NAME: GREEN, LOOA ~! ~ MRY.: 1510053 OOSk: 7051 0053 M0: Di LLON PETER :Y YpA: 26150 OrIB: 07!21!1888 YSSST DATE: Oil0U X1011 LOC: 7A6Y/ 7284-~ SEX: M N5: AUTO INSURPNCE STPNDARD IIIIIiNlll~nlllll M R N: 7510053 FIN: 10510053 Discharge summary (rtlay be done up to 24 hours prior to discharge) a<!te Initials Course of hospitalization: (may write "concur with Day of Discharge Form'") __._ ~ / St ~~~11~ W l ~~ ~ ~ 1 ~ . ~ / ~~ _. - - --- esotutionlStatus of each problem on the problem list: I~ a; n ~ ~~' ,~ ~-I, cc° G~~ ~` e,1 -~ ~~~ U /fir 2~ MSC- ~ ~ 1+`11~~CC.~"iG~l _~~~ ~aS t<'1Q S~S ~~ r>~ 1 ~eC+-C~arti ~~ ~~ ©Gt,~ ~(~~. fC t ~' -~ !Q~ a- -1-G i"'t t j ~ LV~ t' ~ t~~} ~ U~I J U ~ f C ~a~_ oc~ ~~ U~~baltLe~P vnc~crs~~~~ ~~ alb Y1/ ~~~-~~ ~~ Discharge Checklist ..........expiain any "no" answer below 1 Physician order written for di h '~ se arge ...................... ...,, ~ Yes O Na ~~ 2'. Alf invasive lines and tubes that are not needed far home care are removed...... ®Yes O No 3. Medications brought from homy are returned ............................................ O Yes O No ~ NA 4. Prescriptions given to patient or family ................ _..._ .. .............. O Yes O Na t~ NA 5. Personal belangings taken ........................... - (~ Yes O No t;i NA (bathroom, closet, cabinet, bedside stand, over-bed table cherked} fi. Copy of Day of Discharge form given to patient or family .......................... CU Yes O Na (,~ NA 7. Copy of patient education instructions or materials given to patient or family....... ®Yes O Na (.;~ NA 8. r=ollow-up appointment scheduled or discussed with patient ..................... ~ Yes O Nn C,~ NA 9. !s patient weak or unable to walk without assistance? .................... ......... O Yes @J No (~~ NA If yes, staff member accompanied patient to vehicle ................................. O Yes O Na (~ NA 1Q. Discharge conversation with patient includes the following points..........., ®Yes O No O NA • Strive far very good care • Complete survey In the mail • Purpose to improve service and reward staff ~xplanafion for "no" answers: I ---- - -- ---- -~-_-_._J~`- - I I - _~1__ __ _ -- -- ntR tole RbY Ewa Pane ~ or ~ FINAL NURSING PROGRESS N®TE Illlflq 111 q (IIIII IIIlI III Ilq III IIII Facility: HMC Page 133 of 138 Patient Name. GREEN, I.OGAN M Date of Birth: 7/2111996 C~ MRN: 7510053 FIN: 10510053 Final ` _.-. PENNSIATF FlERSHEY IfII~~~li~inlliniil~liliiMlli~ I NAPE: GitEEIJ LO(:41J N *~~~ E6itl: 75t T105~ OOSB: 105100.53 lrLiltOTl S. HersETey ~ RO: DEFLiTCH CHFl13T0 AVJII: 48x25 ~MedicalCenter aos:or~z~llaes v1sLTOarE:07rGa+a,I ' LOCI EAtEn SEX: M _ ___ __ .- _ _ IIIIII~~~~IIIIN~ SELF PRY J fED TRAUMAr'RE5U5CITATIpN ~LUW SHEETtQRDER SHEE'•,, _ __,,,, , /- HATE . RESPONSE LEVEL. 1 2 3 A6E SEX WT . o T ME ftE5P0NSE STAT PAGED _ TIME PT ft iVED ~ I (,(i'Y1~ " >L .. _ EMS REPOR _ ~~- it , ~=-~-------- ~ -- - - '- --- ~ EM5 MEDS G - i _ AMBfNIEDIC rf - - _.. _ __...._.. ~ - _ _ BP _ GCS- _ J ~ _ .~:-MA, r_ ~Jb~ _. ..-may EN • Nfs~ ' Je+Ps HELICOPTER _~ RAGGE ~ __ MEMBER iM ON SCENE ___ INTERHOSPiTAL~~ C-COLLAR ___._CIDlFOWEL ROLL TRAUMA ATTEND CHART _-.___ LA05-_ XR C __.~ ~ / LONGBOARD~KEO ( ~ V], . ' ' O IO NE D UN YES ' EW! '1 --~ a T O EDAFTEND, LASS OF C NSC US SS: _ K , ~_____J MIN _N MAS _~______ ~ _ _ _ -- AMIN f_NTRAPPED: NO YES = N MOWN SPLINT ANESTH. ATTEND. __ SELF EXTRICATED: YES . __ _ N0,__ _______._.~-_ _-_ SR. TRAUMA RES. r>~~~; ;; M ANISM OF INJUR1f .-~u .,s•>, ` F ~ ~~ T ~iE ~~ I , ._ _ _ ' IELD MVC ~ I ~ ~ ~O O~ ~ R EODS M ~ ~ O~N A ~~ \J ASSENGER _ AiRRAG _ q ~ __ FRONT P ~(MiN y ~ SPIDERED BACK ' Y MOU MYyi` TBUCK \/ FRONT GAflSEAT ROLLOVER ~ PARALYTIC SED 02 MASK UMIN . VAN ll1"`~~~ gAGK .~ _ . ~6 AOSIOED 1 _HEpV'f NONE X STW}iEELDENT ~ 02CANNULA iJMIN~ . ~ -__ _ PEDESTRIAN BED OF PICKUP UNKNOWN _ UNKNOWIJ , ~R L - - ~ - ///~ _ _ASStSTED NATE ~_ OVM RATF. ~- MOTORCYCLE _ BN:YCLF UNKNUTAIN ATV _ HELMET _ NONE ~_AIRWAY(ORAUNASAL) __ FAl1 Fl GSW _ CAUMM - ETT (ORAUNASAL}SIZE _ _ - __ OURN _ DIVING DROWNING ~ FARM _ IND115TRIAL SPORT __- STA881N6 .__ DIHEH ___~~ - - - CRICOTHYROIDOTOMY _ TRACK SIZE "" °• PMWPSH ,: ~l,,UiD RE~USfr17~1T1~N --~---- _-_- V IV G UGE 0 AMT INF.. P ENT? i'1 ~ ~ Y N MEDS_ ~'---- _,_.__ LAST TETANU ,,#2 _ #3 G ~ R ~ -- Y / N flGI S ,_ _ _ ALLE . _ 4 _ 6LASGOW~,COMA.SCALE .. 1°.fRIINNRYS1iFIVEY,BYDR ~~` ..:Y"..,4,`~ri. _;.~''' $~••` ~''~ + -- Es'a sdaiarcnas- __ _ _ _ Openupl Tagolu q q 9 CHEST DMEN PELQIS --- - HEART SGUNDS SOFS _ TENDER STABLE ~Q$P LAgORE6 BREATH SDUND. R __ Hrpo~s T1~ __ 2 ~ J'y.10 yES -PRESENT ~ PRESENT __ ___ RIGID __ YES NO UNSTABLE i e -- 1 i ._ _ NDED WN E S PRIAPISM . __ TE ER PIN AOSEN[ _ _ MUfftED _ _ DI _ Best _ Orienlae _ 5 5 ~ D -- YES CLEAR _ ._ .,.~ GUARDING SCARS __._ OLOOD& vertral Coatesad _ 4 ~ WHERE..______ DIMSNISIIEU _ _ gOWELSOUNOS -__ YES ND HTEARLS Response fnaMroBrialetyords - 3 ' 9 C PITUS PAMDOxICAL _ YES _ NO WHERF.______ _ trcan-paeOmslWa sounds 2 2 YES CH ST SYMMEFRiCAt MDi[DN DECREASED D none , HERE .____ Yk5 NO U YES - -- - Bc;t Otye canmar,d u 6 ..r +, ~ "n ~ -A - L f ~a-y:{3-.s.-~,'9 ~ .: ... E:M iT~ S~~5 PS+ _x:>r~ ,-.`::: ~ . Sft-1~; '' - ~`•.°' - ~l~.T'~.~HEA~~ _~~ ~ . Aqulor i. esuain Response Wllhdrtv5 a11j_ s 4 5 4 .. . . . . ~ '"~'- (• PARAL SIS PARRTHESI SES FAIN _ PALLOR { K A WAY PATENT • Hoxionn~ialn~__._ -_ 3 3 RA - - NOTIC COAL ~ CY "YES _ EnLtnnSa, ain ----5~ 2 - - 2 - _ .. -~. --'-- - U[ A - - MOFTLEO COLD ,i D _. YES NO Nane -- I - -_._.. --- - _ - __ RL ~' _ _ ORY MOIST 'IIEA M DLINE (RQf' - __ - --- _ `-__ ACYANOTtC . X YES NO To5e1 - ApplyPoisscorewG LL _ I __ _ _.. .__ ~... _-_ _- F" GC potlinn el Tmrma Sco ' ' ~',~" ~SON;SU4TATlQN : IIISED'~TR R A' O #_: „ ° . ;- - . ~ E AUM •SG q T ME ' r GLASGOW 13.15_-- coanR s ,z q ~ SERVICE I CRLLED TIME ARRIVE ~ Cti ,,~ ` ~ _.____ _"--~-- u:Rrt IGCSt @-$__ -_ -_ ~- z 2 ORTHO LOPEN FBAGRIRE EECCHMUSlS •... " e .. (Tool Pdats q ~ 5 1 1 -._ - 2.IMPDTA1faN ' A-ABR4510N , f U _ -------~- lro.n al:ove 3 __ 1 ..~. _•-._ D _ - D SURG N 3.GBNSIIOT WDUriD G-CDNTNSION .a {~ 1ITY L { ACEMTMtf - /~ • DEf ~ . . - . ~ e. ORT, Nf LING S ~ Systaac :GAmm Hn < PLASTIC -S S. STAB WOUND C BURN T-TENDERNESS B ~ ~~ ~ , BIaeJ 7d-89mn H~_.~ 9 - - . .~ PNN PW-PUNCTNRE ~-~ 7 PrrnNUm SO-TSmn HO -- 2 2 ENT - . B. RASH WOUN9 1 _ 1-09mm Iiq-__- _ _ hloPOlse _ _ 1 1 B OPHTH. -- BURN ~ R PI Resplrato ry fo-2Rrmin..-___, A q V -_-~ - SC ~ Ram ;29lmla' _ 3 ~ -_ ~ 14MP4LED OBJECT 6-lmin. _ _ - __. 2 2 __. _ f-5lmm , I t ~ D ~ Total Revised Tr mo Scam _. J -_L_-. -_- ~_ _ Original - Medicak Record Yellow - Trauma Sr3TVlce Pink - E:D MR 690 Rev- ut t ED TRAUMAJFtESUSCITATION FLAW SHEETlORDER SHEET ., :, I ii111N1 lily II IItNI I till lilll N1 Ilil Facility: I-iN1C Page 134 of 139 i Patient Name. GRf.EN, LOGAN M Dale oT E3irth: 71:1 J 199ti ` Final S T'ME TRAM tM TIME BACK -_ .__ TRAM-SF --_.---TRAM 2M _ ~_ _ IRAN 2F _~~_` _ 711A41-3M _ TRAM$E ~_~__`_ GiRaM P ---- rae>~ u -_-~ - ras _ _ _ _~ __, _ _ L£GAL URINE URUG ' _. _ - IFGAL 81.OUD ETON ._ O1NETi ___`__ SITE ~„ --__Y_ CRIUGALVALUES _____ CRtTiCALVALUES ~_~ PREPYEL~ WITH POVIDONE-IODINE _.__ DRAWN BY _ FOLEY Y.ES NO HEMS + - BLOODAT T S _.~_~___!__ INSERTED BY __, _,__ ,TIME RECTAL jiEN~ +~ - TONE ~ GOITD OECREASEO ABSENT PROSTATE LJ NORMAL f~ A AL DUNE BYE TIM~~ N/G (ORAI/NASAL) SIZE __,,~ FR INSERTED RY~___ TIME_ _ PERITONEAL LAUAGE _ DONE BY DR,~ TIME _ RETURN LJ CLEAR ^ PINK GROSS BLO[iD AMDUNT.lNFUSED ___ _ CG AMOUN R URNEO CC FLl11D T YES N _ RCT SIZ FR CVP R l LCT SE FR LINE ___- RTNO COTOM Ul'SOWN __ ._~ ~ T RACOTOMY BY'. ,_ _ P CARDIOCENIFSIS TEE ECHO _ _ NE BY _ ___ __ 12 LEA EKG YE5 NO ~IJEllROI-0_G. IC 1CP BOLT INITIAL READING HALO DONE BY DFI MRN: 7510053 FIN: 10510053 Time c-Spina 1_ateral _____ _ __ _ Odonto(d Swimmers -~~_ CXR __.____ Pelvis _,__ Cystograrn _`~_ Extremities ~~i J'~ rArna~ ,_.-_ A omen _-,-- Chest - _ __ _ r'31her _.. _____ Angicrgram I:OUS RAPE: SP» _ F O_ _ _ ~ 02 MASH _ 02CANNULA l1M?N _ _ IANIN._- .._ _ _ ASSISTED HATE ____~__ pVM HAT[____~_ _, AIRWAY {UfiAU NASAL) __ err{opal Aaa51u.J slze _~CflIGD iRACNSJZk_ Facility: I iMC Page 135 of 139 Patient Name: GREEN, LC~i_,AN M Date of Birth: 7~21!199b ~~~~E'S ~~T~~ ~__._-~~V ~~c -tult~ ~ f TEMPEN W-Wa C-Coo C~O-Cc H-Hot MRN: 75 t 0053 FIN:tO5t0053 Final' INCLUDES: i. Assessment <l_ Response 2- Plan fr. Ongoing Assessment 3. Intenlentiort Ei. DispgsilioNFinal Assessment ~ ~ ~ i~ e . _ _ ~ ~ ~-~ca . ~--. '~_~` c111 CSC , _ ~ ~ ~. .~ -~-1~`~-'~ s~..~-fir ~ ----- ____----~~'--~~~`'~_ - j . ~_~ ,~CC'nl~ . - tTUtIE COLOR CAEFILLy SENSATION MBUEMENT PULSE rn N-Normal R-Rapid N-Normal A-Active 5-Strong P-Pallor S-Sluggish T-1`tngling W-Weak W-Weak ld t=-l=lushed A-Absent NB-Numhness P-Paralysis A-Absent C•Cyanodc P-Pain and A-Absent R-Regular I-Irregular - -- _ - --- f `____-~_ - ___~ _ _~ __ __~~ BRACELET LQCATIDN: Ill__ . _ - __ et_ooD eAraD ___` __ l~31475 ~~J~~ ,. D cum Nng rse:_" __ upport use. ~_ i Physician Signature: _ _ _ I _ _-__._- ------ ----- I , ~~a s ~~~~~ S , ~r~aft~y.;f e dol,~,~ s < ~ _. . ~. ~ =u ~..': ~~ ', ~ +MaT_CjR T1FIE~11 N r~.. T..'~ & .. '.= ~ . ~ ~ I BVM = Ba Valve Mask LCT = Lett t~esl Tube PSS = Normal Strength • ~: ~ E I_ Endotracheal Tube RCT =Right Chest Tube W=Weakness A8D = Abdornerr Ptf ._ Pre-hospital FP -Flaccid Paralysis Z g q , 6 7 8 9 ~ _ _ - R L =Right Leg LOG -- Level of Consciousness R =Rigid __ ._ _ _PZ ,IRFJ~URIE'~r E;_ 1 ` ~` ~ f1~•~,~~ _~ _ ' Lt .Left Lr.V PMN =Past Medical Ristory DCB . Decerebrate Posture HEA D: - - - RA = RiEnt Arm BFE -Bair Hugger DCT = Decorticate Posture _ _ ___ _ ___ _ - - ~~ ~ I r IA Left ArnY PUPIL nFA1:1fVITY B eneh F FIXw1 S $IUpYtsn 0 OA Led N Nonreaclive CHEST x'~ >.~ ~K~~~~. rv .,~ .nom r , r .~ .rf d-_ _..:i ....._. ._. ADMITTED 70. ~ ~i-- .__ „~ REROR7 TtA - ~ '-- -- -- TIME OR N6fIFIEO _ OR READY___~~_ TO OR_____ _..__r_---_ ___ ..~. _, _- ------ A8[3: FAMILV NOTIFlEU @i -_~_,y BY _.. -- _-- RELATIONSHIF'__ __ ~.-v- _ .-r C-SPkNE f LEARED: I I YES ~ NO BY DR _ -- EXTREM , . __~ ~__ ___ C-fOLLAR 0 YES L NU ASPEN: U YES LJ NO -- -- - - - - ABCF S` V C D - ' -' - " " ' ` - A U . ONE t? WIFAMICY 1PATlENT C1 SAFE NONE O L=l BELUTAifRGSFORM i JEXPIRED CORONER NOTffIED ®_ __ _ ._- _~-- ___-~_- BUAN _- __ MATERIAL EVN)ENCE TO POLICE. 3 YE5 i7 NO _ . - __ _ ~-..-__-- --._._._~_ .- ---.-_ OFFICER _ - ---------- BADGE p _._._~~_- -- - --- _-- ---- - - ~ -- OTHER: - -- --- _ _ ---- ~ -- TRANSFERREDTU _ !V VIA '- ~_'.__. _ __ - - --- - T Fac;tNfy: HMC Page 136 of 139 PENNSTA~E HERSHEY M~1 Milton S. Herstley Medical Center Patient Name° GREEN, LC)GAN M MRN 7510053 Administrative Document Date/Time Printed. 9/28(2011 09:52 EDT Page 137 of 139 Printed E3y: Shiner,(:,rystal L Patient Name: GREEN. L~iUAN M Date of Birth: 7i2'i199fi "Final " PENNSTATE HERSHEY 1~!I Milton S. Hershey :Medical Center TRAUMA TEAM SIGN-IN SHEET MRN: l510053 F{N:10510053 IIIhI III ICI 1111 I~1 IYII 1~111IIII NA6fE: GNE£N, IOGP.N L1 AIRa; 7510053 00Sx: 10510053 Ia0: OEFtITCN g7R1570 rmd: 46325 000: 07/Z1 !1996 VISIT DA"rE: tl7l09%21317 tOC: Eld[fl SEX: M INS: $ElF PAY SELF PnY Illlllllllll~llnlll Date- ---_._ _ _ Tl4A MA NtJMBF_R . _ TRAUMA LEVEL - `~ 1 2 3 7Yaurna Standby paged at ~ hrs Trauma ~2esponse paged at _ _ __ -hrs '+`t R+4 PWF ~b4 " vF" ffYMC- - ii: Yu ~SPONSE ~~ a iM,BER ~ ~ t - , ,tom t. AME~ - ' ,~ ~_ ~ - ._ ''Time orAri'Gal ,_ ED Attending _ T_ _ - TraumaAttending -- Trauma Team Leader {PGY4/5) ~«~ ~ _- _ _ _ _ Senior Trauma Resident (PGY 4/5) Junior Trauma Resident (PGY 213} ___ __ ___ _ ~ Junior Trauma Resident PGY 213) '- Jullior Trauma Resident (PGY 1} _ __ _ _ _ _ ~~ ~ __ Junior Trauma Resident PGY 1 _ Emergency Med. Resident (PGY 2%,;) Emergency Med. Resident (PGY 2/3~~ 1=merq, envy Med. Resident (PGY 1~ _ `-- Trauma Ph sician i=xtender __ - Trauma Physician Extender Anesthesiolo Atiending Aneslhe_siolog Resident _ - ~ Certified Re istered Nurse Anesthetist _ _ ____ _ __ _ ~ ~~ - ~ ~ _ _ Respiratory Therapy ~ ---- _ ~ ,~~ _RadiologyAttending -__~ -`-- _-- _ -- ~ - Radiolo Resident - ~-; ---~~-- ~~~- Radio ra her #1 (Diagnostic) _ _ ___ Radio ra her #2 iyDiagnosiiC) _- Radio ra her C'i'~ ----- --- ------ - ---_ -- m E ergency Medicine EMT ~~`~~ _ _ Chaplain -- a~S~ ~,-~'~-- ClR Technician /Nurse - ~' ~`_ _ Pediatric Critical Care Attending _____ ~ - -_-- Pediatric Critical Care Resident _ ~ .._..,~i~ ~ . y~` ~~ , -~- ~;~_~ ~~o _ _ Child Life S~eciaiist ~T Trauma Coordinator (Case Manager Q +1"~~=' 1 1 J~ ,nw,+r _~nt ,,~ C NS-`~1l„~1!CN..~..,.:..., M~EiRS` - - VNAiVI ^~ ~~ t i ` ~ I~~~~IF 'N.F~rn~orva~t __- Orthopaedics (Pager 2002) iVeurosurgery (Pager 1001) ..-~ - --u-- Plastic Surgery -_ T - ._..-~ FNT _~ _____-_ __ _ - - - -- -- r~r =rest waauate rear IVIR 414 Rev. 1108 Page 7 of 7 IINlIIN111111111,8iIN11tWIIIINII• ~ TRAUMA r~-M sIGN-IN sHE~T Original Cop y -Medical Records Pink Cnpy -Emergency Depf. 'yellow Copy -Trauma Services Facility: hIMC Page 138 of 139 MAN. t5too5~ Firy, 1~5tp053 ntNarne-GftEEN,1_C~G~N ~~ of 8irth~ 7121 ~199E~+ Final PAGE20F2 ,; Pa9° 13` Facility . H~yC /~ r ,~ PE~II~~TATE HEf~SH~Y ~1 Milton S. Hershey s Mecl:ical Center Patient Name: GREEN, L_OGAN M M RN : 7510053 Date of birth: 7/11/1996 Patient Gender: Male RESULTSrarus: DOCUMENT SUBJECT: ELECTRONICALLY SIGNED BY: July 20, 20 t 1 Name: GREEN, LOGAN M HMC Number: 7510053 D08 : 07/21 / 1996 Date of Service: 07/20!201 11 Jeanne N. Larson, M.D. 1 Kacey Court Suite 101 Mechanicsburg, PA 17055 Dear Dr. Larson: Outpatient Letter Final Penn State Hershey -del: X717) 531-8055 Milton S. Hershey Medical Cen#er Health Information Services, HU24 500 1)niversity Drive P.O. Box 850 Hershey, PA 17033-0850 Visit Number: 16275508 Visit 'Type: C}inic Patient Location: PC02 Rocourt,Dorothy V (7/21/2011 10:09 EDT) I had the pleasure of seeing Logan in our Pediatric Surgery Office for a followup visit after being involved in a motor vehicle collision. As you know, Logan sustained a scalp laceration and concussion on the 9th of July following a rno#or vehicle collision. He was admitted for observation, where his laceration was repaired and his concussive symptoms resolved. Mom repot#s that since his discharge, he had 2 episodes of headaches that have now resolved. He has no complaints of photophabia. No further episode of headaches. He is eating well and having normal bowel movements. He has resumed his usual activities. PHYSICAL EXAM- His weight is 55.5 kilos. He is in no apparent distress, pleasant 15-year-oid teenager. HEENT: He has a right frontal scalp laceration that is wet! healed with sutures intact. Heart is regular rate. Lungs are clear to auscultation bilaterally. Abdomen is soft, nontender, nondistended. Extremities, no focal deficits. The sutures were removed and there is no evidence of infection, the suture line was intact. He #oleratecl the procedure well. DatelTime Printed: 9/2812011 10:03 EDT Page 1 of 11 Printed By. Shiner,Crystal L PENNSTA~E HERSHEY N~~1tc:~n S . Hershey Mec~ica~ Center Patient iUame. GREEf~i, LOGAN M MRN 7517053 .......... ......... _ .._..... _......~.....~..~..............~......~.....~~~utpatient Letter~._.._......~..................... ,..................~......~................... Logan was instructed chat for the remaining of the summer all activities will involve both fee# on the ground. V_ogan is allowed to go :awimming and he may wash his hair, He has done well and may now follow up with us on an as-needed basis. Thank you for allowing us to participate in his pare. 367321 Electronic Signature on F=tie CC: Jeanne N Larson, MU 1 1Cac+ey Court Suite 101 Mechanics(aurg ,nA 170ti5 Sincerely, Dorothy V Rocourt, MD Author Signature Dt/Tm: 21.07.2011 10:09 AM Pediatric Surgery: Drs. Robert Ci1ley, Peter Dillon, Brett Engbrechi, Kerry Fageiman, Dorothy Rocourt, Mary Santos Cofeen Gree~r;her MS RD CNS1? .Ianet Shields MSN CRNP, PNP-BC, (.yon Simmons MSN CRNP DVR/CU UD: lJZi2Q/1 1 D7.: 07/21/11 f3: i4 Date/T'ime Printed: 9128/2011 10:03 EDT Page 2 of 11 Printed By: Shiner,Crystal L ~~~v~S~ATE H~RS~~Y 1 Nriltan S. Hershey Medical Center Patient Name: GREEN, LC7CaAN M MRN 751053 . ...._.... ...._..._ ......... ......._..........._.............,..........outpatient Ndte.......... ......... ......... ........................................~... DatelTime Primed: 9(28!2011 10:03 EDT Page 3 of 11 Printed By Shiner,Crystal L Patient Narne: GREEN, LOGAN M MHN: !510053 13ate of Birth: !(?11199f3 F4N: 111275508 `Final ` NENNSIATE HERSHEY ll ~, ~ IIll~I~I~VIGl11i1l~li~~IlIIUN Milton S. Hershey MedicalCen~r ~Qas3 r_o~;.~ !. CI I.LEY RLf)ER7 E oo~: ,6z,55~e AlDM: 2&075 ~ISII047F:07{20120!7 7(2,/]596 IOC; C02 SEX: N EAL7HPEp102 COVRY 15-367 AMBULATORY HEALTH VISIT I~ify'~I'I'fII~~~II' !l® 1 u Health Maintenance O t_.onsultati4n U Acute Care Faflaw-up Referred bylAddress: _-__ -_- ____- --' ---~ - - ~t ~ -- - -y~~ ----- _ ------- Medicatiansl[)osage ----- _ _ _. Nursing ~J~~ f~~r--~Yr~~•~ ~ .s ~ ~} ~. ~!~°a-~.4-~ 3. fain Scale --Peron.. 4- r I I! I I .1-L_J _ ~g_ 1 2 3 4 5 6 7 8 9 10 ~ No Pain Severe Pain -----_- -~ ~-- --~~ P~"1 Subjective Signa ure . ~~P 14U~ a ,~c,~.a, ;e.~ ~~li~ . 4~or~.uea~ ~/c. ~u.+~ G~1,~ ~ F~~'~t,'^~~, ~~ ~~ ~ ~~,.o1,n ~.en k-4A x2 .e~lt,e, o~ 141e, ll,,,LVr,~. ,N~~e ~ 1 a V ~. Objective: Vital-Signs: BP Pu Measurements: Weight a ~~ ~4~~ V^~ ~JT~~t~ Respiratory J__._ MAl,LL7 ~ lA ~ 4RRr~.~j Lab AssessmenfJDiago osis/Plan 2. 3. 4. 5. NeXt VISIt' SIGN,4i"URE~ .. ,, l-- ------ IATI MR f67 Rev. V08 Paga 1 of 1 IMlll{{l~llF~lll~lfiNf NN1~! ratwre °C Oral ^ Re<_tal CliAxillary ^ cm % Head Ciro rm. tAYL~S, ~l}'Cxn/ ;~'W'Ltl1A'~. a.~ ,~kla1[.C AMBULATORY HEALTH VISIT 3~ ~ ~.~_, L~Pe dictation t E7 1 et[er to M.p. BATE ~~~IME '~ 13 Z White - Medical Records Canary Ilepartrnenf Facility: Hospital Based Q(fices Page 4 of 71 PENNS~ATE HERSHEl~ _ M~l- Milton ~. Hershey Medical Center Patient Name: GREEN, LOCaAN M MRN 7510053 Patient Health History Date/Time Printed: 9/28/2011 10:03 EbT Page 5 of 11 Printed By: Shiner,Crystal L Patient Name: GREEN, 1 )GAN M Bate of Birth: 7121 i 199(i ' Finat ` PENNSTATE HERSHEY Milton S. Hershey Medical Center PEDIATRIC HEALTH ASSESSMENT - - ~ r Patient's Name: ~ {g,~,,P~l- Mother's Name: -,~___°__ Fathors Name~`r' ~ ~~ ~ ~ ti~ -- Parents Marital Status: Married _Y Single Living Together C ~~N I~0 X11 N{I ~{N ICI INII {N! MII NAME: 0.REEN LDQkM M I mrse: Tsloos3 oosn; Is27ssa9 tlD; CILLEY ROBERT E PSON; 2&075 D08: 67/21 !7999 VISIT OATC-: U//20 12011 LOC: PC62 SEX: !A INS: KEYSTONE NEALTHPL AM2 f,OPAY 1ti-361 ~_~Iflllii~lliflllift ---_-_.__ -_____-~ Date of Girth: ~ _ _ - - Ocrupation:~~~~~~'.~ , Widowed ____4 Divorced _____~ Separated ____--__---- - - _ _ Pat eniai involvement in child care: Father ~ t No Mosher Ye 1. No What ianguayo do you or your child best understand J ~ ~~ ____~_ _ Who lives in the household A'~~1/~-~ l r~_g~£rP~C~~ k~7tV~w11 ~.-_______________ y - Farnily Physician or Pediatrician: ~ Q lli,yLVt-Q. ~A.T"`~ L~ `____.______ ____-f Haw do you or your ahitd best team: a ~Dns nn One Instruction ~ d. Group Instruction b .4u<fio Usual Information e. Demonsirationr'Practice c. Written Infannation f. Other is your child ex¢osed to anyone who uses tobacco? -ill 1 No Who? ~4!-~f _ Does anyone in the househoufd consume alcohol? Yes !~~ Does anyone in the household use any other substances Yes ! ~ If yes, type _~___ _ _ -_____ ___J 1s your child afraid of anyone? Yes ~ ~ Has your child: ever been physically or emotionally hurt by anyone: Yes /® Are there pets in the household? ! No Type_ ~lf1l~ , ~/~-~-{J~~>~';, ~.p j'` T~____-__-_-_-. Water type? it 1,, pWeft ~/ ~` Sclxlol District IVbe-4,1~QKt~-~ ~t? T _ __._._____-__________.. ,rte 5chaoi ~Cancenls: Yos Does your child wear a bike helmet? Yes /~ Does, your child use abooster seal, or eat bet . ~ s / No Do you u{r~your child have andspecial needs we should be awara of so fhat we can better serve you? ___ ----- Reviewed E MRl30H F7ev. 7108 (Page I a12) I Ali it l IiNi I# ~I~ Ii~l lll l l f iN Itil Oi/EFi! PEDIATR#C HEALTH ASSESSMENT MRN: 7510053 FIN: 16279.5QA Facility: Hospital Based Gffice> Page 6 of 1 t Patient Name: GREL"N, LOGFlN ~V7 MRN: 7510053 Date of Birth: 7/21/1996 FIN:1G275508 Final 1'EDIATRtC HEALTH ASSESSMENT Previous Surgery Com I' 11 ns p ___~~~__ _ _ _ -- - E -~_---------- f Name of Current Medications: Does your child have allergies'? Yes ! c~ tf yes, please Gst: ~ r Medications: Enviromental: Has the patient ever had or experienced any of the following: Painful voiding !urinating Yes / o ' ~ Rheumatic fever Yes / N Bed wetting Yes / Heart murmur Yes 1 Urinary tract infection Yes 1 Palpitations Yes / Chest pain Yes Asthmalwheezing Yes 1 High blood pressure Yes Bronchitis; Yes / Fainting Yes o Pneumonia Yes 1 Steep Apnea Yes / Difficulty swallowing Yes Tracheotomy Yes ! Diarrhea Yes ! Home oxygen therapy Yes / o Reftux Yes ! o Shortness of breath Yes / o Blood in stool Yes { Constipation Yps / Seizures Yes / Food allergies Yes / Numbness arms Yes ! o Weight toss Yes / Numbness legs Yes / o Weight gain Y~ 1 0 Poor circulation Yes ! o tlnsleady gait Yes ! [s your child toilet trained? 1 Difftculty speaking Yes / E2ashes ~~',~- o Headaches Yes I o Has your child had the chicken pox? Yes 1 0 lmmunizafions up to date / o __ _ Could you be pregnant es 1 0 Family Medical History: Childhood Deaths Yes / Diabetes ! No Stroke Ye 1 No Asthma ~ I No Cancer I No Hypertension e • 1 No Seizures Yes / Heart DiseasE, es 1 No Anemia{glood es /~ Arthritis (~ / Na Anesthesia Complications Yes /® Disorders ~~----~~ ~--~' _..----~ Name of Person Completing Form ------- - - - Dat Relationship.to Patientr - ,,~ a - ------- -- ____ -_ 1 ignature of person who reviewed and discussed above with the provider. Date MR 886 Rev.~7lp6 (Page 2 of 2) PEDIATRIC HEALTH ASSESSMENT Facility: Hospital Based Offices Page 7 of 11 k~E~1NSFATE HERSHEY Milton S. Hershey Medical Center Patient Name: GREEN, LOGAN M MRN 7510053 Rllergy History , ,", , ."" , „ .. Substance NKA •~ecorded Dat~fTima _,f~ecorded (3y _.. ,. „ _ . :7/9/2011 22:49 EDT Spanos,Rachel A Reaction S#atus Active; Allergy Type Allergy; Reviewed By Kimak, Mari< J; Reviewed Dafe(Time 7/10/2011 19:17 EDl-; Retarded On Behalf Of Spanos,Rachel A Daie/7ime Printed: 9/28/!011 10:03 EDT Page 8 of 11 Printed fay: Shiner,Crystal L ~~ STATEMENT OF PHYSICIAN SERVICES ~~~~~~~~~ ~--~~~~H~~,'~ BRIAN D GREEN ___ _______.______~_.~~~_ 322 MOUNT ALLEN DR ~tl~Il ~. ~~~1.~h€:~ MECHANICSBURG PA 17055.6107 ~'~~ C~`e~t~r. ACCOUNT # 7510053 IF ANY QUESTIONS, vLEA$E coNracr: MSHMC PATIENT FINANCIAL SERVICES PHtflCl~E?!U~E ,, ~~x DATE ~`~lb~~' ~~~ ~ ~~ ~ ~~F~~PTdUN. PAGE 2 of 2 5TATEMENT ,T_ HATE: 05/04/12 LAST STATEMENT DATE: 10105!11 FED TAX ID # 251857035 IHS ~'CHAR4E A[~Jt~M~i'T~~ t. ' }~ '. ~~,~u BAUWCE SU!lIARY RESPONSIl1LE PARTY POLICY 5 "TOTAL ~ GUARANIYIR RESPONSIBILITY ~ .. P~ ~ ~,0q rn N N 61 ____________.____________ /MPOjtTAN7; PLE_A~£pET11CH,}{QID RETURN BOTTOM ADfi:'~ION OF STA7EME~IfT WlTN YOUR PAYM€NT,_____,____ , 5TATEMENT DATE: GUARANTOR RESPONSI$ILITY: MINIMUM PAYMENT: BF6 05/04/12 S 64.00 ~ 64,0Q MSHMC PHYSICIANS GROUP BILLING SERVICES P O BOX 654 HERSHEY PA 17033-0654 I~~~IIJ~L~~1.611„6~1~,Il~~~lf~„~IL~IN~~~~II~~II~L~LI n~ar- MSHMC PHYSICIANS GROUP TOr MSHMC PHYSICIANS GRl7UP PO BOX 643313 PITTSBURGH PA 15264-3313 OFFICE USE ONLY 0000751D053 UP ODOODDDOODD064DD050412 00000587 02 BRIAN D GREEN 322 MOUNT ALLEN DR MECHANICSBURG PA ;1.7055-6107 MSHMC PHYSICIANS GROUP STATEMENT OF PHYSICIAN SERVICES ~~~"~ ~., ~"_~~.~~~:.~j BRIAN D GREEN __ __._.__ _ ___..____.~._ _ 322 MOUNT ALLEN DR ~ ~1~~~t~ . -~~-L,~~~ MECHANIC3BURG PA 170! ~•'~~1L%~-~ ~--~Tl~~~ ACCOUNT # 7510053 IF ANY Q~~,o i~~1R~3~~~ racT MSHMC PATIENT FINANCIAL SERVICES DA;1tE E Q'~ D.CI~~PTI¢I~I »i PATIENT: LOGAN M GREEN 7510p53 1 of x 6107 STATEMENT DATE: as-aa-~ 2 VAST STATEMENT DATE: 10-05-'~ 1 FED TAX ID # 251857035 INIS CHARGE PA~fNI / R AbJi~~~'~~ CE 1051D053 07/04/11 TO D7/IO/li PERFORMED BY: THOMIL*~ M DUNK MD DIV OF ANESTHESIA PLI~E OF SVC: EMERGENCY ROOM 07/09/11 44241 959.D1 DBS OFFICE/ER CONSLT-PROF 88.00 04/13/11 MAXIMUM BENEFITS PAID D.OD 10/D5/11 CBC PAYMENTS 26.03- ld/05/11 CBC CONTRACTUAL AD.A~ 36.47- iOl05111 BALANCE TRANSFER* 25.00 16275506 PERFORMED BY: DOROTHY V ROCOURT MD DIY PEDIATRIC SURGERY PLACE OF SVC: OP PHYSICIAN ~ 07/20/11 99212 959.6 OUTPATIENT VISIT EST 64.00 * 08/10/11 CBC PAYMENTS 1D.4T- ~ 08/10!11 C8C CONTRACTUAL ADJ* 28.53- ~ DT120111 ADVANCE PREPAY PAYMENT 25.D0- * D9128/11 B/C TAKEBACK io.47 ~ D7/20/li OUTPATIENT VTSTT EST 64.OD- ~ DB/10/11 CBC CONTRACTUAL AD.1~ 28.53 * 08110/11 BALANCE TRANSFERS 25.00- ~ 07/2D/11 94212 959.8 OUTPATIENT VISIT EST b4.D0 ~ 05/04/12 BALANCE TRANSFER TO GUAR _- -- 64.00 BALANCE: LOGAN M GREEN 964.00 _. !i ~ INDICATES NEW FINANCIAL ACTIVITY SINCE LAST BILL. N N `~ :E01* WE HAVE NOT RECEIVED YOUR PAYMENT IN FULL. YOUR ACCOUNT IS PAST DUE. PLEASE SEND PAYMENT IMMEDIATELY. IF PAYMENT HAS BEEN MADE, THANK YOU AND DISREGARD THIS BILL, PLEASE NOTE: TO KEEP YOUR ACCOUNT CURRENT, OUR POLICY ;IS TO APPLY YOUR PAYMENT TD THE OLpEST OUTSTANDING BALANCE. THANK YOU FOR USING MSilIC PHYSICIANS GROUP FDR YOUR PHYSICIAN SERVICES. IF YDU HAVE ANY QUESTIONS REGARDING THIS BILL, PLEASE CONTACT US AT 717-531-5064 DR 800-254-2614, BETWEEN $:QOAM AND 5:30PM MONDAY THROUGH WEDNESDAY OR BETWEEN 8:00AM AND 4:30PM TNURSDAY AND FRIDAY. ^ CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK iii ~ MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA :L7033 Statement nn: 11/01/1:L at 10:56 AM Guaranto7~ : GREEN BRIAN D 3 2 2 MOUN'i' ALLEN DR NIECHANICSBURG, PA 17055-0000 Patient : GREEN 1:~OGAN M Visit #: 10510053 Date ~ Svc Code ~ Description ~ Units Debits `; Credits 07/09/11. 16604 PEDS L'VL IT TRAUMA b~;'/ 1 8840.00 I 07/09/11. 42342 7 PEDS PRIVATE RM :L 2246.OJ I 07/09/11. 46472 EMERGENCY VISIT, LEVE :L 10'?2.0~.+ 07/09/11 466.20 VENIPUNCTURE :L 24.Oi) 07/09/11 467:17 NONINVAS PULSE OX, MU .L 141.O1a 07/09/11 46794 TV PUMP, SINGLE LINE 1 3.00 07f09f11 46931 IV INF,HYDRAT,UP TO 1 1 308.00 07/09/11 46932 TV INFU,HYDRAT;EACH H 1 190.00 07/09/11 , 101003 ABO BLOOD GROUP 2 108.Ot) 07/09/11 ~ 101004 ANTIBODY SCREEN ]_ 107.0() 07/09/1,1 1010(}5 RH TYPE 1. 54.00 07/09/11 104009 AMYLASE, BLOOD 1. ~g.OC; 07/09/11 104060 GLUCOSE, BLOOD 1 21.OC+ 07/09/11 104097 LIPASE 1 70.00 07/09/1=~ , 104156 SGPT (ALT) 1 24.OC~ 07/09/1:L ! 104398 ELECTROLYTES 1 45.OC 07/09/1"1 105656 CBC W/PLT AUTO 1 45.00 07/09/11 245553 LIDOCATNE-EPINEPHRINE 2 3.00 07/09/11 307101 CHEST 1 VIEW 1 185.0+) i .07/09/11 307201 SPINE 1 VIEW ANY LEVE 1 213.00 ~ 07/09/11 307220 PELVIS 1.-2 VIEWS _ 1 244.00 07/09/11 310501 CT HEAD UNENHANCED 1 1165.00 07/09/11 622023 :LRRIGATION SOD CHL 0. 1 2,00 07/10/1:L 100031 MRSA BY PCR 1 257.0() 07/10/11. 105011 i1RINALYSIS-BASIC & M1' 1 57,00 07/10/1:E 247831 ACETAMINOPHEN 325 MG 2 3,OC1 u, 07/10/11 621043 IV 0.9o:LVACL 500ML 1 3.00 07/10/11 621044 I V SODIUM CHLORIDE 0 1 2.00 07/10/11 627070 IV EXT SET 90 W/FLASH 1 16.OC~ 09/12/1.7. 902040 AUTO/WORK COMP PAYMEN -1 5000,00- 09/14/11 92000:L BLUE CROSS CONTR ADJ -1 2525.00- * - Not posted ~ Balance: ~ 7941.00 MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY L)RIVE HERSHEY, PA 17033 Statement on: 10/26/11 at 04:28 PM Guarantor; GREEN BRIAN D 322 MOUNT ALLEN DR MECHANICSBURG, PA 17055-0000 Patient: GREEN LOGAN N[ Visit #: 16275508 f Date ~ Sv c Code ~ Description ~ Units Debits ( Credits 07/20/11 75526 OP VISIT, EST PT, LEV 1 75.40 08/03/11 902002 BLUE CROSS PAY HOSP -1 43.75- 08/03/11 920001 BLUE CROSS CONTR ADJ -1 31.25- 09/28/11 902002 BLUE CROSS PAY HOSP 1 43.7~> * -- Not posted ~ Balance: ~ 43.75 ~ - ~~ ~ ~ ~ ~ eRlaN o GREEN ""~" ~ ~e 2 V N . ~' ` _____ 322 MUUNTALLEN DR ~ MECHANlCSEtL1RG PA 17055•&707 1:C~ ao- ~~~Y~~ ~ ~ .'~~~`~~~.~ ~-=~~1~~ ACCt3UNT# 751A053 srare~ue~r ®arE: 10!26/11 ~asr srnr~~wr oA-r~; 10/05/11 -~ IF AMY QUESTIORS, PLEASE coNrACr MSHMC PATIENT FINANCIAL SERVICES FED TAX iD 257857035 .,,.. ~: (`g3)y~~OW E'~"Tl~ ~ bEd3CR1PTi~~+l ~ ,, lf~ ;,~f'fAFt[~~ /~/~~~~'~~~~~`~t !~~ , ~1y~ ~ a>a PATIENT: L~GAN F1 GREEN 7"510D53 10510D53 PERFORMED BY: KATHLEEN E66LI MD DIV OF DIAL RADIOLOGY PLACE OF SYC: INPATIENT D7109/11 7202025 959.I4 SPINE SING VIEW pNY LVL 70.OD D4/I3I11 MAxIMIJrI BENEFITS PAID D.DD 1D/~/11 C8C PAYMENT* 12.17- 1D/45/11 CBC CONTRACTUAL AD.1* 57.83- O.DD D7/09/11 7217026 959.19 PELVIS AMERPOSTER 80.OD D9/13/I1 MAXIMIkI BENEFITS PAID D.DD 10105!11 CBC PAYMENT* 13.24- 10/D5l11 CBG CONTRACTUAL ADJ~ 66.71- O.OD D7/09/11 7101D26 09/13/11 ID/D5/11 IO/05II1 959.14 CHEST I VIEW ~1AXIMUM BENEFIT5 PAID CBC PAYMENt~ CBC CONTRACTUAL AD.l~ 83.DD o.DD I3.85- 69.I5- D.DD PERFiHiMED BY: OAN T NaIYEN MD DI1i OF DIA~G RADIOLOGY DT/A9/1I 7D45026 92D C'C HEAD I~IENHANCED 388.D0 D9/13/11 MAXIMt~I BENEFITS PAID D.OD 1D/D5/11 CBC PAYMENTS 66.91- 10/D5/1I CBC CONTRACTUAL A0.H~ 32I.D9- D.DD PERFORMED BY: MARK KIMAK MD DIY OF EMERB ROOM PLACE ~ SVC: EMERGENCY ROOM N DTJD9/I1 99285 459.D1 EMERGENCY VI5I7" 5I8.DD ~ D9/I3/11 MAxIMUM BENEFITS PAID O.DO ~' 10lD&11I CBC PAYMENTS 263.7D- ID/DS/11 CBC CONTRACTUAL AOJ~ 254.3D- D.DO PERFORMED BY; THOMAS M DUAN MD DIV OF ANESTHESIA D7/09/11 49241 459. D1 OBS OFFICE/ER CONSLT-PROF 88.D0 D9/13/11 MAXIMUM BENEFITS RAID D.DD 10/Q5111 CBC PAYMENTS 26.03- 1D/D5/11 CBG CONTRACTUAL ADJ~ 36.97- lOVDS/I1 BALANCE TRANSFERS ~.DD PERFD161ED BY; PETER N DILLON MD DIV PEDIATRIC SURGERY PLACE OF SVC: INPATIENT D7/1D/1I 94222 454.8 INITIAL H~PITAL CARE 4$4.DD D9/13/lI MAXIMt~I BENEFITS PAID O,OD 10/05/11 CBC PAYMENTS 188.64- 10/05/11 CBC CONTRACTUAL ADU~ 295.36- D.00 2 aP 2 STATEMENT DATE: 10/2.6/11 LAST STATEMENT LATE: 10/05/11 1F ANY G}UESTf~NS, PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES h ,. .,,. ~ 08/10!11 Cl3C CONTRACTUAL AD.I~ ~ O7/201II ADVANCE PREPAY PAYl1ENT * 09/26!11 B/C TAKEBACIC ~ O7/20/lI Ol~l'PATIENF YZSYT EST ~ 08f10/11 CBC CaiJfRAiCTUAL AO,I~ ~ OD110/II BALANCE TRANSFEIt3~ FLED TAX ID # 251857035 IRIS:' CHAt~+~ir AE}~~~~~I~I'Ir;~~A ct~.`E-~' . .::28.53- ~.aa- 1a.47 &4.00- 28.53 2s.aa- ~ a7/2a/lI 99212 959.5 aUfPATIENf VISIT EST CAR 64~.a0 BALANCE: LOSAN M GREEN SD.Oa -~_-- ~ INDICATES NEW FINANCIAL ACTIVITY SINGE LAST BILL. IF YOU NAVE ANY QUESTIONS ABOUT THE AMDIAIf YDUR INSURANCE COMPANY PAID, CONTACT TNEM DIRECTLY. FOR ANY OTHER QUESTIONS REGARDING YOUR BALANGE~ PLEASE CONTACT OUR OFFICE. IF PAYMENT NAS BEEN MADEs TNANK YOU AND DISREGARD TNIS SILL. GIVE TO PCF2 TNANK YOU FOR USING MSIlIC PNYSTCIANS GROUP FOR YQUR PNYSICIAN SERVICES. IF YOU HAVE ANY QUESTIONS RESARDING THIS BILL, PLEASE CONTACT US AT 717-531-b064 OR 800-254-2619, BETWEEN B:DOAM ANa 5:30PFI MOI+~AY THROUGH WEDIJESDAY OR BETWEEN B:DORM AND 4:30PM1 THURSDAY AND FRIDAY. BALANCE SUMMARY RESPONSIBLE PARTY POLICY # TOTAi. ~ CAR PA SAFE AUTO AUTOMAXED~AD09D9I1 $ b4.OD a ~ GUARANTOR RESPONSIBILITY $ 0.00 ---__.----------------.._.___ ~+~rbRrakr._a,~~gs~ ngracy aan l{€_TUgnr eurroM a~r[pu of srAr~6L~NrlL'Lt[! rnu[t raY~f~uT--,-----_____..____..~~_------. STATEMENT DATE: Gl7AAANTOR R£SPONSIBILlTY: MINIMUM PAYMENT: BF'G 10/26/11 ~ 0.00 $ OAO MSHMC PHYSICIANS GROUP BILLING SERVICES ~ o Box 854 HERSHEY PA 17033-0854 000[175710053 UP DOOCIflQQDtiOCIUDlallf]71U267~1 1~~~16LI~~~i~iRq~~~l~~i~~ll~~~li~~~dbllh~„I(~~IIRI,~LI ~aj+ MSHMC PHYSICIANS GROUP BRIAN Tl GREEN Ta MSHMC PHYSICIANS GRDUP 3~2 MOUNT ALLEN DR PO BDX 643313 MECHANICSBURG PA 17D55--6107 PITTSBURGH pA 15264-3313 OFFICE USE ONLY £OR CREDIT CARD PAYMENT, PLEASE F1115N INPORMATION BEWV/ = ='='---==`_ - = = CNECKONE ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ 7510053 VISA CARD NUMBER ocP BATE O.OO -Disc `~~_ Jr€i ~'=__= HC: FBBO ~~ GARDHQLDER NAME (PRINT} : -- _- --- CREDIT CARD SIGNATURE '~' MSHMC PHYSICIANS GRI ^ GFIEGK BOX AND ENT!=R ANY ADDRESS OR INSURANCE CQRREC'TIONS ON BACK Please Remil Payment To: Silver Spring Ambulance & Rescue Assn Billing Office PO Box 726 NeW Cumberland, PA 17070-0726 QUESTIONS ABOUT THIS BILL? Phone: 877-214-6018 Espanol: 866-724-4114 Fax: 717-214-6020 Email: info@ambulancebillingoffice.com Date of Service: 7/9/2011 21:33 Please visit our websit:e to provide insurance crr make payment, and Patient Name: GREEN, LOGAN M. for additional payment options and frequently asked questions: From <Motor Vehicle Accidenf> To HERSHEY MEDICAL CENTER WWW.ambulanCeb1111ngOfflCe.COm * * * * * * * This accoznzt is Past Due * * * * *'* * Your account r°ernirn~s unpaid despite our previous billing requests, Your accozn7t is rzoly z.rnder collection revietiv and may be forwarded to our collection agency if a`his bill rerlaains unresolved. ,r,. ~~ ~ ; ~ ~ , , 7109/11 BLS Emergency Transport A0429 1.0 650.00 650.00 7/09111 Mileage A0425 24.0 15.00 360.00 Total __. ~ 1,010.00 0.00 0.00 DETACH ANO RETURN BOTTOM PORTION WITH YOUR PAYMENT. We accept payment in' full by check* credit card or efertron(c Please Make ChecK Payable To: check deduction. Please indicate your payment choice below Silver Spring Ambulance & and fill in required information. If other arrangements are necessary, please call us at 877-214-6D1$. R2SCUE Assn -_ J Cv ~ DISCOVER' ~'~ J Credit Card: '. MASTtItCARD ~J VISA ^ AMERICAN EXPRESS ^ DISCOVER i - _- -- ~~~ - ~I ~i,y~~,, .~~ ~,: hir., v Electronic Check Lleduction (- Please send a voic'_~ check OR provide ir~formatlon below: - - - -- - i, i __ .. ,.i Uie~' n I coin' f i. ih,; i_- Please make any correct ons to address below. LOGAN M. GREEN 322 MOUNT ALLEN DR C/O PARENTS MECHANICSBURG, PA 17055 `Returned d~eda - You v; ill ''-.e responsible for all incurred bank fees permissible under state law. ~ /'~ f /'~~ LMG 6/13/2012 10:57:52 AM PAGE 2/004 F'ax Server Policy Declarations _____ ___ __/?~_summary_of_ynur._.auto.insurance_coverage _ _ _ - Thank you for renewing with us. Your declarations are effective as of 04101/2011 , INSURANCE INFC)RMATION Named Insured: Denise M Peffer Policy Number: A06-288-337450-40 1 7 Policy Period: 04/01 /2011.04/01 /2012 12:01 AM standard time at the address of the _ _ Named Insured as stated below, _ Mailing Address: 143 W Vine SL Shiremanstown PA _ 17011-6347 T ___ Affinity Affiliation: Highmark _ VEHICLES COVERED BY YOUR POLICY - Liberfy Mutualr ACTION REQUIRED Pleasc review and keep for your recur QUESTIONS ABOU YOU R POLIC'Y? By Phone 1-71 ~7-795-8703 1-800-7 22-5164 Liber~:y Mutual Offi 5000 Ritter Rd Ste 103 Mechanicsbury PA 170L~5 To repore a claim 1-sao-2eLAtMs (1-8010-225-2467) ds. T ce VEH YEAR MAKE MODEL ~ VEHICLE !D NUMBER'_ 1 2004 CORD F-150 1 FTP~JV145X4KD65580 2 1991 CHEVROLET GEO METRO 2C1 MR2468M6778090 COVERAGE DETAILS Yaur total annual policy premium for all covered vehicles is shown below. A premium is shown for each type of coverage you have purchased for each vehicle. Where no premium is shown, you have not purchased the indicated coveraye for that vehicle. THIS POLICY COVERS COLLISION DAMAGE TO RENTAL VEHICLES. COVERAGE INE'ORMATION Tatait Aiintx~i~ 1Pallc~ Prern~uln „ , ~fdur dlsC~s'~t~ts aft~"bett~tifs have beon apptiL~ InEtudes sta~~ fifes tax and Idcal 5tx~~har~~. ' :~ :.. :: r i'F~I~ {~, ~i~"t' ~t3UF~ f\C~T'(~ It11~.WR~1NC~ ~ILL,III~ti! ~II~fLL Brv,)<#IGLEII ~EPA1~A`f1~LY :: !, Limited Tort Option Selected (:f~ljn~tlPed Rllotollsts`ktas"$he~ R~JeCt~Cl` U~idercri~uced Njotd~~~;hlas B~eerE Rejeeteck AU-f0 4L10 10 10 Pagel of4 LMG __ _COVERAGE_fNFORMATION..-(continued)__..._ _ ___ -_ -_ __.____ ___ __ COVERAGE LIMITS PREMIUM PER VEHICLE ANNUAL PREMIl1M f~ER VEH[CLE; ~ ~ ::.. i:.:: .~i t ;: ;.. .:....:. ..... vtall ual:.Ra e.::Rr tarn' ~nurdr~ikat~rtLS°artdF3~~f~~x;3`k~~~~sif;aT~~i~~d ~rtwlwdes ~ka>ks~;~a~es tax ~ Ia~aFs~iren;~rge 6/13/2012 10:57:52 AM PAGE 3/004 Fax Serve~° ^15COUNTS AND IBENEFlT5 „_ Yoi.ir discounts and benefits have been applied to your Total Annual Policy Premium. VEHICLE DISCOINTS Anti-Lock Braking System Anti-Theft Device(s) Passive Restraint POLICY DISCOUNTS o Group Savings P-us® a Nluiti-Car DRIVER INFORMAT1011t VEIi 1 VEH 2 Yes Yes Yes o Preferred Auto Rating Plan (Preferred Driver) URiVER NAME LICENSE NUMBER ~ STATE _ DATE OF 131f~TH 1 . Denise M PefFer ~ PA To ensure proper coverage, please contacC us to add drivers not listed abave- AUTU921U 1U 1U Page2of4 LMG 6/13/2012 10:57;52 AM PAGE 4!004 __ ----- --- SAFfE DRIVER-INSU- RAAtGE--R6AN--.._ --- Fax ;server Safe Driver Insurance Plan Credit: As A fZesuft Of: Violation SC0 No Charge Accident SCO No Charge ENCIORSEMEIVTS -CHANGES TO YOUR POt,ICY ._ Amendment of Policy Provisions -Pennsylvania AS3692 12 10 Pennsylvanla First Party Benefits Coverage Endorsement PP 05 51 11 92 Limited Tort Alternative Information Notice AS210S 04 9J New Vehicle Replacement Cost Coverage AS21 12 10 Q9 Split Liability Limits PP 03 09 04 86 Nuclear, Bia-Chernical & Mold Exclusion Endorsement AS2221 04 05 Coverage For Darnage To Your Auto Exclusion Endorsement F;' 13 O1 12 99 Master the First Liberty Insurance Corporation Endorsement 23LO 10 89 PENNSYLVANIA MINIMUM QU07'E The laws of the Commonwealth of Pennsylvania, as enacted by the General Assembly, only require that you purchase liability and first-party medical benefits coverages. Any additional coverages or coverages in excess of the limits requited by law are provided only at your request as c=nhancements to basic coverages. VEH 1 VEH 2 Bodily Injury $ 15,000 Each Person $ 30,000 Each Accident Property Damage S 5,000 Each Accident First Party Benefits $34 $55~ $5,000 Medical Benefits $0 Funeral Expense Premium Per Vehicle $205 $251 Total Premium: $456 AUT(7 4210 10 10 Page 3 of 4 .~ CONTINGENT FEE AGREEMENT KNOW .ALL MEN BY THESE PRESENTS, THAT I, Brian and Ami Gr•ecn, as individuals and parents and legal guardians of Logan Green, 322 Mt. Allen Drive Mechanicsburg, PA 17055, party of the first part, do make, constitute and appoint MICIL 4EL J. O'CONNOR & ASSOCIATES, LLC, ATTORNEYS AT I,f~.W, 28 North 32°`~ Street, # 1, Camp I3i11, PA 17011, party of the second part, as my true anti lawful attorizey for me to institute and maintain an action at law, negotiate a settaenaent, superintend and. prosecute to the final termination by suit or action, if necessary, a claim for monetary compensation and/or damages arising out of any incident/accident involving any responsible: party or parties for the purpose of obtaining a~~.d recovering damages res~.tl~ing from aui incident/accident which occurred on JULY 9, 2011. [f is hein;g understood and agreed: 1. I shall not be responsible for I am not incurring any hourly legal fees for services performed by or on behalf of my attonzey other than those mentioned hereinafter. 2. The attorney's fees shall be: (a} Thirty-three and one-third percent (33 1/3%) of any gross sum. recovered by way of settlement prior to the start of any action iii court; and after an action is started in court up io and inchtding the first trial;, (b) Forty percent (40%) of any gross amount recovered if this case or claim is appealed. beyond the local comity or district court; (for purposes of this Agreement, appeal shall also include presentation of briefs and/or argument before any Court en Banc;) and {c:) In the event that this attorney-client relationship is terminated by choice of the client before the tune of settlement, trial or any other disposition, then I agree that my attorney shall be entitled to payment of his fee according to the herein agreed percentage of whatever offer of settlement he may have negotiated to th.e date of breach or.• termination, or to payment of his fee based upon time Factually expended at his prevailing rate, whichever is greater. 3. Regardless of whether there is a recovery of monies in this case, this litigation will result in costs and expenses being incurred. It is understood that rro court costs, litigation expenses, depositions fees or other expenses shall be deducted in determining attorney's fees due and owing. I hereby authorize my attorney to pay out of my 66-2/3% or 6d% share, as the case may be, of the amount recovered, all monies necessary to pay all such costs and expenses. 1 understand there is no guarantee, warranty, or other representation that I will be successful and recover any sums of money in this case, 4. 1 do authorize my attorney to pay out; of Illy share of any proceeds by settlement or trial any unpaid balance for h•eatment or services made necessary by the injuries or damages arising out of t:he incident referred to herein and of which my attorney has been made aware. In the event there are any interest such as Blue Cross, workrrlen's compensation, subrogated insurance programs or any legitimate interest that. have legal right to a portion of the proceeds by virtue of having already made payments, as a result ol'the incident referred to herein, I hereby authorize my attorney to make such distribution accordingly. 5. Counsel may withdraw as counsel for client and terminate this conl:ract 1.'or any just reason by notifying client in writing. Some examples of reaons for termination include, but are not limited to, client's failure to cooper,:cte with cour-sel or any request by client which would require counsel to violate the Code of Professional Responsibility. If representation is terminated by client or counsel for airy reason, my attorney sha.il be entitled to immediate reimbursement of costs, disbursements, and expenses and payment of his fee according to the herein agreed percentage of whatever offer of settlement he may have negotiated to the date of the breach or termination, ar to ;payment of his fee based. upon time actually expended at his prevailing rate, whichever is @;reater. I understand that during the course of representation, Michael J. O'Ccmnox & Associates will maintain copies of all documents relating to my case. At the conchision of the case, Michael J. O'Connor & Associates will permanently retain an electronic Dopy of my file. A hard copy of my file will be kept for 30 days. If I do not pick up my hard paper file within 30 days or make other such arrangements, it will be destroy~.d in accordance with Michael J. O'Connor & Associates' file destruction policy. This agreement shall be binding upon heirs, adminisi:rators, assigns and executors of the parties hereto. IN WITNESS WHEREOF, and intending to be legally bound hereby, the ~~art:ies have hereto set. their hands and seals this ~,~ _ day oi' SEP'I'EMBEIt, 2011. WITNESS: ~~ _ _ -SEAL} rian and Ami reen, as individuals and parents and legal guardians oii Logan Green // I~//~~//JJ~~'' f Parties of the First Part MICHAEL J. O ANNOR & ASSOCiA7`F.S, LC,[' Parties of the Second- 7Part :4..._~ 1 __-/ ~/' i RECEIPT, SUBROGATION AND ASSIGNMENT AGREEMENT' WHEREAS, Logan Green, a minor, is covered under a policy of insurance, belonging to Ami Green, with Safe Auto Insurance Company (hereafter, "Safe Auto"), policy number PA00693999; and WHEREAS, Ami Green acid Brian Green are the parents and guardians of Logan Green; and WHEREAS, said policy was in effect on July 9, 2011; and WHEREAS, said policy provided UM/UIM benefits of fifteen thousand and 00/ 1 UO dollars ($15,00) per person, thirty thousand and 00/100 dollars ($30,000) per accident; and WHEREAS, On July 9, 2011, man Green was struck by a motor vehicle, while the said Lo pan Greed was a passenger in a vehicle operated by Jacob Peffer, as a result of which Loan _Green sustained cerrtain injuries and losses; and WHEREAS, Jacob Peffer was responsible for the injuries and losses sustained by Liman Green, for which Jacob Peffer was covered by a policy of insurance providing liability coverage in the amount ot~ fifteen thousand and 00/ 100 dollars ($15,000); and WHEREAS, the carrier for the responsible parry, that carrier being Liberty Mutual _F ire Insurance Company offered the policy limits of fifteen thousand and 00/100 dollars ($15,000), in return for which Liber~ Mutual Fire hisurance demanded a General Release, releasing its insured and the carrier; and WHEREAS, Safe Auto wishes to retain its subrogation rights against the responsible party, Jacob Peffer, thereby precluding Ami Green and Brian Green, as parents and ug ardians of Logan Green, fr~:~rn executing the requested General Release; and WHER~,AS, Ami Green and Brian Green, as parents and guardians of Lo an Green, and Safe Auto desire Ito resolve this matter under the guidelines of Duley-Sand v. bVest American Insurance C'om~uury, 564 A.?d 9fi5 (Pa. Super. 1989). NOW, THEREFORE, this day of , ?012, the parties a}ree as follows: IlPage 1. Ami Green and Brian Green, on behalf of Logan Green and as parents and~uardians of Logan Green, shall. not execute a General Release, releasing Jacob Peffer, Libert~Mutual ]Fire Insurance, or anv other person- firm, .:orporation, entity, or by any other paper which would, to any extent whatsoever, jeopardise the subrogation interests of Safe Auto; ?. Safe Auto tendered to Arni Green and Brian Green., on behalf of Logan Green azid a~arents and ui; ardians of Loan Green and their attorney, Matthew Kloiber, a sum in the amount of eighteen thousand and 00/100 dollars ($18,000); of which, fifteen thousand and 00/100 dollars ($15,000) represents, and was the substitution of. the policy limits offered by Libertv Mutual Fire Insurance• and, the remaining three thousand and 00/ l OCI dollars ($3,000) offered by Safe Autq Insurance Company in settlement of Logan Green's underinsured motorist claim against Safe Auto (policy number PA00693999). 3. In consideration of the payment of three thousand dollar and 00/100 dollars ($3,:)00.00 Ami Green and Brian Green, on behalf of and as sole parent and guardian of Loan Green, do hereby release and forever discharge Safe Auto its officers, employees, agents, successors and assigns frarn any and every clain-~ under the above designated Safe Auto policy coverage issued to Ami Green arising out of the automobile collision occurring on Ju~__9 2011: 3. Safe Auto shall retain the subrogation rights to the entire amount of the underinsurance settlement, phis fifteen thousand and 00/100 dollars ($15,000) which Safe Auto paid to Ami Green and Brian Green, as parents and.. guardians of Loan Green, iii substitution of the policy limits of Libertv Mutual Fire Insurance Comnai~ insured, Denise Peffer. In furtherance of this agreement, Ami Green and Brian Green, ae~~ents and guardians of Logan Green hereby assigns, sells, transfers and sets over to Safe Auto each and every claim and demand arising out of the .Iuly 9, ?011 automobile accident and agrees to fully cooperate vid/or to tal~_e- through a representative of Safe Auto such legal action as may be necessary and appropriate to recover the damages sustained by Logan Green against acid from any person(s) or entity(ies) which maybe liable therefore. 4. Ami Green and Brian Green, as~arents and guiirdians of Logan Green, and her atto~ ney, Matthew Kloiber, agree to present this settlement to the appropriate ~Jrphan's Court as required by Pc~nnsyivania Law. 'Pare DATI~: DAT I?. DATI- DATE: STATE OF PENNSYLVr1NIA. ) SS: COUN"f'Y OP _ ) Ami Green, as parent and guardian of Logan Green Brian Green, as parent a.nd guardian of Logan Green Debra Matherne, Attorney with Michael J. O~Cormor and Associates SAFE AUTO REPRESENTATIVE S~~ orn to and subscribed before me this _ dap of _.___ , 20 c2. NOTARY PUBIL[C My commission expires: You are notified that Pennsylvania Law provides as follows: Any person who knowingly and with intent to injure or defraud any insurer files an application or claim containing false, incomplete or misleading information shall, upon conviction, be subject to imprisonment for up to seven years and payment of a fine of up to $15,OOtJ.00. 3Page MICHAEL J. O'CONNOR & ASSOCIATES, LLC By: David A. Miller, Esquire Attorney I.D. No. 89063 608 West Oak Street, P.O. Box 201 Frackville, PA 17931 570-874-3300 ,- , - . ~~ 1 '~,~ { !~ ~ 1, '` l t t F ~t f ~''' 1 " kti V ' ~~~ ~ ~`i ~' `~'~~ S~ L~ ~t 1 P r ~ `~ ~ ~~N IN RE: LOGAN GREEN, a minor By BRIAN GREEN AND AMI GREEN, His Parents and Natural Guardians IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY Docket #: 126693 ORPHAN'S COURT DIVISION AMENDED PETITION FOR LEAVE TO COMPROMISE MINOR'S ACTION Pursuant to Pa R.C.P. 2039 and Cumberland County Local Rule of Civil Procedure 2039, Brian Green and Ami Green, the parents and natural guardians of minor, Logan Green, by his Attorney, David A. Miller, Esquire of Michael J. O'Connor & Associates, petitions this Court to enter an Order permitting settlement in compromise of this action, and in support avers the following: 1. Petitioners and counsel seek approval of the settlement on behalf of minor in the amount of $18,000.00 negotiated with Petitioners' insurer, Safe Auto, because they believe that it represents a full and fair settlement of the case, equal to or greater than that which may be obtained should the matter be fully litigated. 2. Petitioners approve of the proposed settlement because they consider it to be fair and reasonable and to adequately compensate minor for the injuries sustained and expenses incurred. Counsel was retained by the Petitioner to represent the minor on a contingent fee basis. In prosecuting this action on behalf of the minor-plaintiff, counsel has incurred the following expenses: State Police Crash Report Unit $ 8.00 Medical records, Healthport $129.46 Cumberland County Prothonotary 103.50 TOTAL 2$ 40.96 4. Petitioners have incurred the following Medical expenses for the treatment of the minor: Hershey Medical Center DOS: 7/9/2011- 9/14/2011 $15,466.00 Balance outstanding of $107.50 Silver Springs Ambulance DOS: 7/9/2011 $1,010.00 Balance outstandin¢ of $1,010.00 HOWEVER, Safe Auto Insurance and Pennsylvania Employees Benefit Trust Fund (PEBTF) have only covered some medical expenses. PEBTF has a lien of $1,612.77. Counsel and Petitioner have been made aware of additional outstanding liens in the amount of 1 117.50. 5. Petitioners further approve the proposed distribution contained in the form order attached to the original Petition. 6. The sum of Ten Thousand Five Hundred Twenty-Eight Dollars and Fifty- Two Cents ($10,528.52) shall be distributed to the benefit of Logan Green, a minor, to be placed in one or more federally insured savings accounts or federally insured savings certificates in the name of the minor so that the amount deposited in any one such savings institution shall not exceed the amount to which accounts are insured, and to be marked "NOT TO BE WITHDRAWN UNTIL THE MINOR REACHES THE AGE OF EIGHTEEN (18), EXCEPT FOR THE PAYMENT OF LOCAL, STATE AND FEDERAL INCOME TAXES ON INTEREST EARNED BY THE SAVINGS ACCOUNT OR CERTIFICATE, IF ANY, OR UNTIL FURTHER ORDER OF THIS COURT." 7. If the Court sees fit to approve this proposed compromise, it is requested that the Petitioners be authorized to execute a good and sufficient General Release. A copy of the proposed release is attached to original Petition as Exhibit "E". WHEREFORE, Petitioners requests that this Court enter an Order approving the settlement and compromise, allowing counsel fees and ordering, distribution as set forth in the Order with the Petition for Leave to Compromise Minor's Action. Respectfully submitted, ~~ -_.__- David filler, Esquire Michael J. O'Connor & Associates 608 West Oak Street P.O. Box 201 Frackville, PA 17931 Attorney for the Petitioners Attorney I.D. No.: 89063 IN RE: LOGAN GREEN, IN THE COURT OF COMMON PLEAS OF a minor, by BRIAN GREEN CUMBERLAND COUNTY, PENNSYLVANIA and AMI GREEN, his Parents CIVIL ACTION -LAW and Natural Guardians NO. 12-6693 CIVIL TERM IN RE: PETITION AND AMENDED PETITION FOR LEAVE TO COMPROMISE MINOR' S ACTION ORDER OF COURT AND NOW, this 28`~ day of November, 2012, upon consideration of the Petition and Amended Petition for Leave To Compromise Minor's Action, it is hereby ordered and directed that the Petitioner is authorized to enter into a settlement on behalf of Logan Green ("the Minor") in the gross amount of $18,000.00. Petitioner is further authorized to sign the Receipt, Subrogation and Assignment Agreement. IT IS FURTHER ordered and directed that the settlement's funds of $18,000.00 shall be allocated as follows: (a) $107.50 to Hershey Medical Center for a balance outstanding; (b) $1,010.00 to Silver Springs Ambulance for a balance outstanding; (c) $1,612.77 t-o~tl"ie P~nsylvania Employee Benefit Trust Fund for a lien; (d) $4,500.00 to Michael J. O'Connor & Associates, LLC, for counsel fees; (e) $240.96 to Michael J. O Connor & Associates, LLC, for reimbursement of costs; and (f) the balance of $10,528.77 to the Minor. COUNSEL (and not the Parents and/or Guardians to the Minor) is hereby authorized and specifically directed to execute all documentation necessary to deposit the funds belonging to the Minor in one or more Federally insured savings accounts or Federally insured savings certificates, and with a Federally insured bank or savings institution having an office in Cumberland County, and so that the amount deposited in any one such savings institution shall not exceed the amount to which the accounts are insured, and to be titled and restricted as follows: Logan Green, a Minor, not to be withdrawn, assigned, negotiated, or otherwise alienated before the Minor attains majority, except upon prior Order of Court. The depository may pay over the fund when the Minor attains majority, upon the order of the late Minor, without further Order of this Court. WITHIN thirty (30) days from the date of this Order, counsel for Petitioner shall file an Affidavit with the Court of Common Pleas certifying compliance with the Order. Counsel shall attach to the Affidavit a copy of the savings account or savings certificates reflecting the required restrictions and shall pay such fee as may be required by the Court. The Affidavit shall further contain a specific averment by counsel that counsel, and not the Parent(s) and/or Guardian(s) of the Minor, established the account(s) and deposited the funds t herein as directed above. BY THE COURT, Christylee >:~. Peck, J. ~. avid A. Miller, Esq. O'Connor & Associates, LLC 608 West Oak Street P.O. Box 201 Frackville, PA 17931 Attorney for Petitioner :rc ~ ~h Ct,~-~ ~ ~ Ccrn n ~ R ;, ~, ~. dy'~ ~~ ~~nv ~~ ~:~~ 8Z ~~~ ZfrJ~? ~~~ f ae't. 1 k f ! ~~ IN RE: LOGAN GREEN, IN THE COURT OF COMMON PLEAS OF a minor, by BRIAN GREEN CUMBERLAND COUNTY, PENNSYLVANIA and AMI GREEN, his Parents CIVIL ACTION -LAW and Natural Guardians NO. 12-6693 CIVIL TERM IN RE: PETITION AND AMENDED PETITION FOR LEAVE TO COMPROMISE MINOR' S ACTION ORDER OF COURT AND NOW, this 28~' day of November, 2012, upon consideration of the Petition and Amended Petition for Leave To Compromise Minor's Action, it is hereby ordered and directed that the Petitioner is authorized to enter into a settlement on behalf of Logan Green ("the Minor") in the gross amount of $18,000.00. Petitioner is further authorized to sign the Receipt, Subrogation and Assignment Agreement. IT IS FURTHER ordered and directed that the settlement's funds of $18,000.00 shall be allocated as follows: (a) $107.50 to Hershey Medical Center for a balance outstanding; (b) $1,010.00 to Silver Springs Ambulance for a balance outstanding; (c) $1,612.77 to the Pennsylvania Employee Benefit Trust Fund for a lien; (d) $4,500.00 to Michael J. O'Connor & Associates, LLC, for counsel fees; (e) $240.96 to Michael J. O Connor & Associates, LLC, for reimbursement of costs; and (f) the balance of $10,528.77 to the Minor. COUNSEL (and not the Parents and/or Guardians to the Minor) is hereby authorized and specifically directed to execute all documentation necessary to deposit the funds belonging to the Minor in one or more Federally insured savings accounts or Federally insured savings certificates, and with a Federally insured bank or savings institution having an office in Cumberland County, and so that the amount deposited in any one such savings institution shall not exceed the amount to which the accounts are insured, and to be titled and restricted as follows: Logan Green, a Minor, not to be withdrawn, assigned, negotiated, or otherwise alienated before the Minor attains majority, except upon prior Order of Court. The depository may pay over the fund when the Minor attains majority, upon the order of the late Minor, without further Order of this Court. WITHIN thirty (30) days from the date of this Order, counsel for Petitioner shall file an Affidavit with the Court of Common Pleas certifying compliance with the Order. Counsel shall attach to the Affidavit a copy of the savings account or savings certificates reflecting the required restrictions and shall pay such fee as may be required by the Court. The Affidavit shall further contain a specific averment by counsel that counsel, and not the Parent(s) and/or Guardian(s) of the Minor, established the account(s) and deposited the funds t herein as directed above. BY THE COURT, „, I Christylee L~. Peck, J. D id A. Miller, Esq. 'Connor & Associat 60$ West Oak Street es, LLC P.O. BOX 201 Frackville, PA 17931 Attorney for Petitioner ,~ t-= n ~ ~~ ` , ' m ~~ ~ ~~° ~_ r~^°_ :rC ~~' ~ 8-. .el .~a~ ~ ww ~ ~t'I R --- •C: v ~ _C: ~ ~~ ~~ tis _,,w .. __ , , . ~'~ «~ ~r7 _.,