HomeMy WebLinkAbout01-18-05
MADELINE DELA YE, a Minor, by her parent,
and Natural Guardian JENNIFER DELA YE
2814 Rathton Road
Camp Hill, Pennsylvania
COURT OF COMMON PLEAS
CUMBERLAND COUNTY
ORPHAN'S COURT DIVISION
NO. ;;2 I - OS - 005,3
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MINOR'S COMPROMISE
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Petitioners,
vs.
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REA & DERICK, INC.
1200 Market Street
Lemoyne, Pennsylvania
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Respondent.
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PETITION TO APPROVE MINOR'S SETTLEMENT
TO THE HONORABLE JUDGES OF SAID COURT:
This Petition of Jelmifer Delaye, as parent and natural guardian of Madeline Delaye (a
Minor), respectfully represents:
1. The Petitioner is Jennifer Delaye, as parent and natural guardian of Madeline
Delaye (a Minor).
2. The Minor, Madeline Delaye was born on August 26, 2003.
3. The Minor resides with her parent, Jennifer Delaye, at 2814 Rathton Road, Camp
Hill, Pennsylvania.
4. On November 28, 2003, the Minor was prescribed Reglan. The Respondent
dispensed Reglan with incorrect instructions, resulting in an overdose. The Minor was taken to
the emergency room at Holy Spirit Hospital with seizures. She was stabilized at the emergency
room and transported by ambulance to Hershey Medical Center on November 29,2003. The
Minor was placed under observation for twenty-three hours. The Minor was discharged on
November 30, 2003. Upon discharge, the Minor was back to her baseline condition.
5. Attached are reports from Holy Spirit Hospital and Hershey Medical Center.
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6. The case was settled with the respondent for $21,945.32, which includes
$6,945.32 as payment for the Minor's medical bills. Attached is a copy of the Settlement
Agreement and Release.
7.
the Minor.
The Petitioner will deposit $15,000 of the settlement funds in a college fund for
WHEREFORE, the Petitioner requests that the Court approve this settlement.
Respectfully submitted,
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PRY _675249_1!JLAPOINTE
VERIFICATION
!, Jennifer Delaye, as parent and natural guardian of Madeline Delaye (a Minor), hereby
verify that the statements made in the foregoing Petition to Approve Minor's Settlement are true
and correct to the best of my knowledge, information and belief. The undersigned understands
that the statements herein are made subject to the penalties of 18 Pa. C.S.A. 94904 relating to
unsworn falsification to authorities.
I
Dated: ~ /'6;
fI
,200!,
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PRY __675249 _I/JLAPOINTE
.
SETTLEMENT AGREEMENT AND
GENERAL RELEASE
1. KNOW ALL PERSONS, that we, JENNIFER DELAYE and
PIERRE-JEAN DELAYE, individually and as parents and natural guardians of
MADELINE F. DELAYE (a Minor), (hereinafter the "Undersigned"), in consideration of
payment of TWENTY ONE THOUSAND NINE HUNDRED FORTY-FIVE
DOLLARS AND THIRTY-TWO CENTS ($21,945.32) and other valuable
consideration, the receipt and sufficiency of which is hereby acknowledged, for our heirs,
executors, administrators, successors and assigns, do hereby release and quitclaim unto
REA & DERICK, INC., CVS, INC., CVS PHARMACY, INC. and CVS
CORPORATION, their subsidiaries and affiliated corporations, and all persons acting on
behalf of said aforementioned corporations, individually, and in their capacity as
employees of said corporations (hereinafter the "Releasees"), as to all manner of actions,
causes of action, debts, dues, claims and demands, both in law and equity, and in
particular, as to any and all claims arising out of a certain alleged incident, which allegedly
occurred on November 28, 2003 at Rea & Derick, Inc., store no. 1622, located at 1200
Market Street, Lemoyne, Pennsylvania. It is the specific intent and purpose of this
instrument to release and discharge any and all claims and causes of action of any kind or
nature whatsoever, whether known or unknown and whether specifically mentioned or not,
which against said Releasees said Undersigned and MADELINE F. DELAYE ever had,
now have, or in the future may have for or by reason or means of any matter or thing
whatsoever arising out of said incident.
2. The Undersigned hereby agree to indemnify and hold harmless the
Releasees from any claims made by MADELINE F. DELAYE, third-parties or other
individuals whose claims comprise or are derivative of the injuries andlor pain and
suffering, including medical liens/bills, consortium or other derivative causes of action,
arising out of the incident referred to above.
! .
Settlement Agreement and General Release
Page 2 of2
3. The Undersigned understand that this is a disputed claim and that the
payment specified herein is not to be construed as an admission of liability on the part of
the Releasees, but on the contrary, liability is expressly denied by them.
4. As a result of this disputed claim, the Undersigned agree that the facts of
this claim, or the fact that any money was paid on this claim, or the amount of money paid,
shall be kept confidential and not disclosed or published by the Undersigned and/or
MADELINE F. DELAYE to any form of media, including but not limited to periodicals,
newspapers, or television, except if required by court order.
IN WITNESS WHEREOF, we have hereunto set my hand this / R- day of
~4(flO'~ 20<S: l
A~11~
LAYE,
m 1 a lyand t and natmal
guardian of MADELINE F. DELA YE (a
Minor)
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PRY _685655_1/JLAPOINTE
Madeline Delaye (Minor) Release
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DELAYE, MADELINE F - 1367437
* Final Report *
Peds ole Summary
DISCHARGE SUMMARY
PATIENT NAME, DELAYE ,MADELINE F
PATIENT NUMBER, 1367437
LOCATION, 7118
SEX, F
DATE ADMITTED' 11/29/2003
DATE DISCHARGED: 11/30/2003
DATE OF BIRTH: 08/26/2003
ADMISSION DIAGNOSIS:
Metoclopramide toxicity.
DISCHARGE DIAGNOSIS:
Dystonia secondary to metoclopramide, resolved.
OPERATIONS OR PROCEDURES:
None.
BRIEF HISTORY:
This is a twelve-week-old female (twin) with a five-week history of poor
feeding, projectile nonbilious vomiting, and constipation - which was
previously worked up at Holy Spirit from November 7-11, in which pyloric
stenosis was ruled out. The patient was placed on Zantac for reflux, and
recently prescribed Reglan (metoclopramidel on 11/28 at 5 mg per 5 ml, but
the dosing was to give one tsp four times a day, which is about 10-fold the
normal dose for this patient. The patient's weight is 5.67 kg. Because of
this high dosage, the patient became dystonic on 11/29 at 8:30 p.m. and was
rushed to Holy Spirit. The patient was given normal saline boluses, IV
Valium, and then IV Benadryl, in which 7.5 mg IV total was given once Reglan
toxicity was suspected. After a few hours, the patient resumed to her
baseline neuro exam, and was then transferred to HMC. No extrapyramidal side
effects were observed at HMC. She was here for a 23-hour observation.
PHYSICAL EXAMINATION ON ADMISSION:
In general: sleeping, in no apparent distress. She was tearing when agitated
by examiner. Vital signs: temperature 37, heart rate 176, respiratory rate
42, 02 96% on room air, blood pressure 108/80. Weight 5.64 kg, which is 37th
percentile, height 59 em which is 27th percentile. HEENT: She does have
positive torticollis to the right side, which has been present for quite a
few weeks. Her eyes had red reflexes bilaterally. Her TMs were not
visualized, but her pharyn."{ was pink without exudate. Her heart was regular
rate and rhythm. She had a soft Grade 2/6 systolic murmur. Her lungs were
clear to auscultation bilaterally. Her abdominal exam was soft, non tender ,
and nondistended, no hepatosplenomegaly was appreciated. No mass or olive
was appreciated upon palpation. Extremities: Femoral pulses were +2/2 and
she had good capillary refill, less than two seconds. Her neuro exam: She
had good Moro reflex. She could grasp, and there was good suck reflex. No
stiffness. She had full flexion and passive extension.
Printed by:
Printed on:
Shiner, Crystal L
2/17/20043:03 PM
Page 1 of2
(Continued)
(
Peds DIG Summary
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DELAYE, MADELINE F - 1367437
LABS FROM HOLY SPIRIT: Remarkable for ALT 83, AST 38, T-bili 0.02, alk phos
251.
HOSPITAL COURSE: Benign and uneventful.
then discharged her aft'2r evaluating her
which remained stable.
We observed her over 23 hours and
labs and her clinical appearance
DISCHARGE MEDICATIONS: Zantac 15 mg p.o. twice a day. This is 5 mg per kg
per 24 hours.
DISCHARGE INSTRUCTIONS:
Nutramigen ad lib, 3-4 oz every four hours.
Follow up will be with Peds GI and Peds GI will call for an appointment to
evaluate her reflux and poor feeding: however, her metoclopramide toxicity
has ceased.
#289735
DICTATING MD:
Kathryn E Seraphin, AI
ATTENDING MD:
Kathryn R. Crowell, MD*
KES/rem
D: 12/14/2003
T: 12/15/2003 10:52
c: WP Clerk
YOKE Y. TAN, MD*
153 SOUTH 32ND STREET
CAMP HILL, PA 17011
Printed by:
Printed on:
Shiner, Crystal L
2/17/20043:03 PM
Page 2 of 2
(End of Report)
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Recordex AcqJ~itioo Colp.,
cI>a SOIIRCECORP HEAL THSERVE
SuiteD
17Lee Boulevard
PO Box 3017
Malv<m, PA. 19355
PH: 610-Q4(Uli00
l.axJ-525-2922
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Recordex Acquisition Corp., dba SOURCECORP HEALTHSERVEhas been retained by
the Medical Record Department of
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to fulfill requests fof;ropies of medical records. Endosed are the reproduced medical
documents spedficallY'"authorized by the patient or hiS/her legal representative. . We
wish to emphasize that the Increasing demands for patient data pose a rising threat to
the confidentiality of' the patient's medical infonnation. SOURCECORP
HEAL THSERVE strives to take every opportunity to safeguard the patients' right to
privacy as outlined in the AHA's Patient Bill of Rights. Specifically, all patients have')he
right "to expect that all communications and records pertaining to their care wil( be
treated as confidential by the hospital and any other party entitled to review certain
Information In such records." As one such party, we ask that all information transmitted
herewith be treated. with utmost respect and the dignity such personal medical
information warrants. Please be advised of the following state and. federal disdosure
statements governing medical records In Pennsylvania:
Based upon guidelines provIded by the American Health Information Management
AssocIation, the records shouid be destroyed after the stated need has been fulfilled.
We thank you for your cooperation in maintaining the patient's right to privacy. Each
medical record has been carefully reviewed to assure that proper disclosure goes only
to the authorized Requestor. If you have any questions, please do not hesitate to
contact us at 1-800-525-2922 and one of our Customer Service Representatives will be
happy to assist you.
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MR9 6101
SIGNATURE .
rSt'7h'n
HISTORY AND PHYSICAL EXAMINATION
TITLE
/c/J ~/
DATE
III:? !//.J
CONTINUED ON REVERSE
TIME
Z
PAGE
r
Flowsheet Print Request
139
5.9* H
109
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Printed by: Shiner, Crystal L
Printed on: 2/17/2004 3:03 PM
Page 1
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9/0]
CVS/pharmacy~
January 21, 2004
Penn State Hershey Medical Center
500 University Dr.
Hershey, P A 17033
Attention Medical Records
Claimant:
Date of Incident:
File:
Madeline Delaye
11/28/03
03-GL-5446
Dear: Sirs:
Attached is a medical authorization signed by Jennifer Delaye the mother of Made1ine Delaye.
Please forward all documentation, including medical notes and billing related to the treatment of
this patient for the incident, which occurred on or around November 28,2003.
I have also enclosed a self-addressed stamped envelope is enclosed for your convenience in
returning the requested information.
K!i;i;p
Albert J Ryan
Risk Management Department
Enclosures: Authorization
SOURCEC()R~l!EALTHSE:jJllat
ReQ#:.l21 /."C?_~flltlal$:oo.Dat~. .....
Pages: , FIChe. Images. '. - ,
........ 0 FS 0 r,',TH 0 NURSEs NOT€S
_ "-i\J DS 0 X RNi'S 0 MirIIMUl! NEOESSARV
~p 0 LASS 0 ENTIRE
o ER 0 f'RO~,RESS NOTES 0 OTHER
o CONS 0 ORDERS
o OR 0 t5r>';DlCA110NS
o EKG 0 VERBAL INfO
~
cc
Jennifer Delaye
2814 Rathtone Road
Camp Hill, P A 17011
-
CoP~ :sen+ ~ 10; (( (/29
1- 30 -0 Cf
Cfl.r-~ Y' ';)."';b; C-
ONE CVS DRIVE, WOONSOCKET RI 02895 401-765-1500 / ~
(
CVS/pharmacy@
February 10, 2003
Jennifer Delaye
2814 Rathton Road
Camp Hill, P A 17011
RE:
Date of incident:
File Number:
Madeline Delaye
11/28/03
03-GL-5446
Dear Ms. Delaye:
Would you please give me a call after you have an opportunity to review your daughter medical
records so we can discuss a resolution to your daughter claim. I can be reached at 1-800-784-5911
option I then 2 then extension 7918 or 401-765-1500, extension 7918. Thank you for your
anticipated cooperation.
Sincerely,
Albert J. Ryan
Risk Management
ONE CVS DRIVE, WOONSOCKET RI 02895 401-765-1500
::. /l0;~i, ~::t5
Mode of Arrival: BLS 0 ALS 0 Other 0 T I1CJ q @ p
Triage Chief Complaint ' 'lp-U,
/;f tU;( C I c~ .:1 fMIr: C/ e.-4 4u./r<AR.....;
,4Lt:.t~ u '_~ ,/Tncr-:'1'<i hU:e.2 ~!f.P.A h/!.LuJj-
~ i'- c:.~Q..-<U~
. I. _h ~ . . ,
0'::>a.C-/",-, CL/r /,J-v... ci. '>'- ~ 4R. rn..ct.u Al.J
~.izf j/
Vital Signs:
Rhythm:
Airway
Oxyge\l
IV Therapy:.
Dextroslick:' .
Medications;.
Splint
EMS
Signature
Medications:
Info obtained by:
Dose
Meds Unknown 0
Triage
20t-Ecu 1102 10'.\'l Rev. LS
(
---
FMD:! (lit)
BP:
O,SAT
Cry 111
R
PMH Checklist: None 0 MI 0 HTN 0 CAD 0
CHF 0 ASTHMA 0 CANCER 0 STROKE 0
NIDDM 0 IDDM D
Surgeries 0
IU/ /~{)) 7~
(J I-Ia~ Iffct~
/ rna /) ,a:JC
Other 0 If i' Ua!t.
I' {/
Allergies
;l/ KA
Latex Allergy Yes D No D
Immunizations: UTO D Not UTO 0
Tetanus LMP
HOHD Speaks Enolish: YesD NoD
Treatment @ Triage
EMT 0 Medic 0
Meds
~
list D Bottles D Patient 0
Dose Meds
t-<.!K.
&O"f'S
Log In:
Triage:
Room:
Advanced Directives
YesD NoD
Attached
YesD NoD
Exposure to measles, chxn pox, Tl
YesD NoD
PAIN ASSESSMENT
Location
Intensity Scale /10
Adult 0 Wong Baker D
Character:
Ache 0 Dull D Sharp D
Pressure 0 Burning D
Throbbing D Radiating D
Duration
Frequency
What relieves Pain?
Triage Notes:
Dose
1.
Skin Color: WNL 0 Mottled D Cyanotic D
Skin Temp: Warnn D Cool D
Distal Pulses: YesD NoD
Edema: YesD NoD
Deformity: YesD NoD
Ecchymosis: Yes D No D
Triage to Radiology at
Injury: Place Occurred:
Location On Body:
Horne D Work D Other D
Holy Spirit Hospital
Camp Hill, PA 17011
John R. Dietz ECU
Nursing Assessment
CHART COpy
" ",'., "5 .q $IH28
T.Ttj'J'r .J'!~?EL';Zt F
(-~'l~ '~1fi(HrE 9.0
t .l'l? ,>J r II
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(:[LJYf .PtE
It/2'1/03
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Etll
H 17011
711-'lIlOZ
(0 GROil!'
Z ')q 209708240
, :<
.ct.
C
'Directions: This iorm is to be completed and accompany patient to another facility.
Please check appropriate box. .
(
Copy of E.CU. Chart
Documentation of History \./"""
Documentation of Treatment - Medications ../
X-Rays /
Laboratory Studies v'
EKG v
Other:
Dentures: ~
Upper '\
Lower \
Valuables: i
Money All rl hth Il'& I'rnPJ:X5
Ring(s) J \u~V\ "(r\ rrro /) hv
Watch I , h\NI\\'\ I"~ J
Glasses '. 1
\
Prosthesis \
Clothing \
Medications (own)
Persons &/or Departments Notified: ./ DATE TIME BY WHOM
Doctor 1},---1 , 11-fJD Dr ~ Ucl.::Jf1.
,
Family viI kt.d.::l- 1:1.00 1ft U UCtl11
Clergy (f) -
Police (/; -
~
Physician Accepting Patient "rrr D~~l/ ~F --Zitib DyMucl<m
Ambulance Company for Trip Sheet l\IIt!(.tlw- 'l:L40 ::;ecret2-Vl!y-
Method of Transfer WS- ALS u
YES
NO
DATE:
I I. 'Yl'fB
vl~""w",
RN
HOLY SPIRIT HOSPITAL
CAMP Hill. PA
EMERGENCY & OUTPATIENT SERVICES
TRANSFER CHECK LIST
i n SIH28
r-L~" .jJnEL1~E f
:::: I <~ .~ ~ r ~,! O. '-; r no
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f'l 17011>j;,
731-9802;':1. -
EO GROUP:;;!
Z q<j lO,)70aZ40';',';
..~I,.,
FORM 183 {9/02l
Initial Lab & X-Ray Orders:
Labs
[ ] Acetaminophen
] Acetone (SACE)
) Alcohol (ALGO)
J Amylase/lipase
] APTT
] BBH
] Blood Cultures
[ JBMP
~BCP
1 CMP
] RP1
! J Digoxin
[ 1 Dilantin
RadioloqV
[ 1 AbdlObstr. Series
[ lAnkla R L
I ] Clavicle R L
[ ] Cerv. Spine .fit. I Lat.
~heSl Rtn. B TPA
V J""Erbow R L
( I Facial
[ ] Femur
l 1 Finger
[ ] Foot
[ J Forearm
[ ] Hand
[ 1 Hip
I ] Humerus
t 1 Knee
( J Other:
) DOAS
] ESR
J Glucose
J HCGS
J HIV
] Liver
Profile
] Lytes
J Phenobarb
J prp
] Salicylate
] Th€>o
A L
R L
R L
R l
R L
R L
A L
R l
REASON:
c
] Thrombolytic Labs
J Tox Screen
I ] Urine Tox Screen
J T8HR
J Type&Cross _ # of units
(BOR)
[ ] Type & Screen
1)Q'UA: r\A1>IP [ J DIAG.
[ ] unnfC'& S
[ ] Urine HCG
{ ] we Breath Aleo Test
[ ) we Drug Screen
[ ] Other:
JKUB
] US Spine
] Mandible
J Nasal
JOrbi;:
J Pelvis
] Pyelogram IVP
] Ribs R
] S~oulder R
J Skull
lSlernum
J T/Spine
jTib/Fib R L
jToe__ A L
{ } Wrist R L
Time/CAT/In!.
R
L
L
L
(),
Special Procedures:
Ultrasound: CT: (W=With contrast; WO=Without)
[ ] Abdomen {I Abdomen/Pelvis W WO I ] va Scan
[ ) Duplex Doppler [ J Brain/Head W WQ [ J Echo-
[ ] Gallbladder [1 Chest W WO cardiogram
[ J Pelvic! [ J Spiral chest for PE '
Transvaginal (J Other:
REASON:
Time/CRT/lnt.
Specimens/Cultures
J Bela Strep AG Rapid
J CervicaVGenital
] Chlamydia
] GC Culture
] Monospol (rapid)
J Sputum C & S
jStoolC&S
jStoolO&P
) Stool C. Difficile
1 Trichomonas
JWoundC&S
1 Other:
(
Cardiac
[ ] Monitor
[ IEKG
( J02_UMin.
( I 02 Saturation
Medications I IV's I Additional Orders J m/;.6 .,10'
Respiratory
[ ] ABG's
[ 1 Peak: Flows Before/Aller Resp Tx.
[ I Respiratory Tx.
IV: NSS/ DSWI LR/ DS/.4SNS/ DS.9N
WO/KVO/infuse at mlslhr
] Obtain old records
]T
] Protocol initiated for:
~ --
(j-';J
.----
('''C''l !.,...
AtZ
Initials: -n-o-;"signature: .\ /' ~ RNIMA
Initials: ~ Signature: Q.l ~jL I -:: V RNlMA
Dictated: Ha~,ComPleted CRITICAL CARE: _ hrs.
Diagnostic '~on~RL-
. .,
Billing Classification:
PHYSICIAN CHARGE FACILITY CHARGE
[ ) Level I ( j L~vel I
[ 1 level II r 1 Level Il
[ J level III I ] Level III
f ) leve~ IV I 1 level IV
[ 1 level V [ ] level V
J Accident
] Medical
1 Case 1
] Extended Hrs.
Holy Spirit Hospital
Camp Hill, PA
John R. Dietz Emergency Center
Physician Order Sheet
206.ECU REV. 10/00 WlMc
CHART COPY
-
ULi'cI
~A~
Signature:
Date:
Time:
M~
.c70
v
~'
.. i~7
~ -""?"'~:'~-
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~: ~-i . .'~ ;0(L' 'if r '."'~_,..~~
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C :"~'!:t - t.. p~ ul/~~
'15.0 ' "" 7 . 17011..,i,
; ,.' ,,,) . 3l.'1!102' ,';.'111 '
l _/-.i':lJ;f ;;~GR:.:~.._. .:;_~::~i~it~~-.
, i.
Ourethra\ discharge
Ovaginal discharge
Ovaginar bleeding
Ofoley present_#
\1.lb 1-!';:/- -5c..JLe.
y~ to rm 'If 7.[) .i\~ . ,m ~A lltla-t1 Ti.5CLc~ 27l/) SIf>::"DllU.. 41<'- \3Cis, OL ~t-
1r-, ~(\ .-P.r nn0",-i-t-f4?' .Jrrh ,\1 {) hA" bhcl-.... I q+./. . 't?_l~ 4()i-s. -Llv/
Nt" \1J\I';'(jf.~<,: I~ V..QX r...e:Ji;l! 211(\ CX\)1V1iJ1. lT3D !<epoA. roW \1J~bbtL(.7 U~\,
Iv ir\lti2~--tt2.4a 7f<)-+;'C+.. NSS OOcc +Iu irr' u tV-rl.~ (tJ.W . nil;
\-,o\\.,\s 'S1-.:l!+e:\ ,TG"d'kJ M.:lSt-:. . <:::;',\ctltrYi'\..41 :Vf :~ ii1~~T~1i#:.. ,fO/' ~d
V1-:>S.J tt \..l ~vi 0 QlrU ~ ,'P1 t(';.k r:J l?S . -4tl ,1J't
21CYt> Y;:1\l(.VVV\ O. S"",,- PR Q ll\~C\.1c" - ~ "-4lt \...
211)C1, VlllJm l..vna --1V . Obt)t\l,;n \),',V\..C. C c,';::-12- ~ ADMIT/DISCHARGE/TRANSFER
.D-,.,..,'",., + \~ iST __ . discharged laccompanied by:
l -if': . (03mbulatory Ow/c Qambulance
-g,;:-n;aV-u\ S",,., \\J . UD~ rei;;.;(p~. ( to: Dhome Dnurslnghome DAMA OaR
\201'00 .71JJ(J ~ (06/ p+ mC1K -MdJ(;. -. Ddischargei~~~~;~OnSgiVento:
I '" s < h III d. r V\i I r, ,.., e s::; - 71 ...._ JaPatienl Dfamily Dparent Dotper:
I... -..) \ . ~ansferred to H l'V1C- lQCOnsent signed
1..!"LS 2. S ,,,... u \ V ~{"):>~, 11 < Ii'! Clold records sent to floor DC/othing sheet done
i1.\40 12-'1-';1-- ''''0 - "'4 , IV bO(tJ< (0f\1h1e.L- Sl:-C,f)Yld'~I~igna reo ..@_
-r- --=-=- -.>" ~ , . . 00 arge []AdmlSSlon 023tlr Obs . Room#
1~01w XT1u. or~~ )..\/1.4 ;i:T/L.....J. 14 t16V\J eportcalled@n3D 10 -liMe RN/LPN
tY.:\n.... r...eH D\J NlDl-r\ i:ik\l1nt>,., .-.-. Condit~~~SfactOry CJCritical Orn;:>oasedlomorgue
t.(tr).;! b ~k.. ' 1 T 7 etmproved;,I: ,i.]\soale T~llo'
1\4S HIl. \trO\~ ' bz.. sJ-i:'-1'{'( _ . -co. N Signature: l lIil.Li -II' )@Z310
Holy Spirit Hospital \ .;",1?,iJ'
Camp Hill, PA 17011 ; .,. .,,, 5 J ;. \- ., '~.;.
John R. Dietz ECU " . .' ", ! ",8 r
~fll~E ~~\DELf::E r
,~,,':n"().~( ,'0 ERf"',":
~ILl fl 11011
U:OJ 731-"J80Z '.
i
\
Appearance:
GeMra/: Cofor: Temp: Speech:
[JWNL OWNL Owacm Qnormal
I:lffaif Opale Deaol Dloud
Oobese Dflushed Dhot Oslurred
Oemacialed Ocyanotic Odry Otalkative
Ojaundlced Ddiaphoretic Omumblin!~
Gail Qmott\ed Orash Obaby
ON/A Dnormal Oabnofmal
Mental Status:
Oconscious Ouncooperative
Olethargic Ocombative
Oconfused Oanxious
Oriel'lted to: qhysterical
Operson Response to Stimuli
Oplace Oappropriate
Olime Odelayed
Orestraintiseclusion-fJow sheet
Neuro Q NJA
Oheadache
Ostiffneck
Dneck pain
Ofacial droop
Onumbness.
GUI GYN
Odenies sls
Ofrequency
Durgency
DDysuria
OHematuna
Dretenlion
OOther:
ONfA
a flank pain l J R
ORadiating:
SeVElrity _/10
OPERL R l
Size
Pinpoint 00
Dilated 0 0
Fixed [J [J
Sluggish 0 0
non-reactive Q 0
Oweakness
PATIENT OBSERVATIONS:
Completed by: Time:_
Protocol Initiated:_EKG done_Labs done_X-ray done
DC~lI bell within reach QSide rails up >:2 OCompanion with patient
DER nrOcedure eXr'llained
NURSING ASSESSMENT:
( /7""
'J7 1/
v-/"
. r-" .,
-VI \T.i4"t
... '-
IV Therapy \cOl1ditiQn codes: 0"'00 inllarnmallon/corrplicatiOll 1-ooerna 2:erylhema 3:ecchymo:>is
4::.pain 5:hardness 6=warmth 7-leaking)
Solution Size Site Rate AlIelTflls Condo
Date!
""..
Ami
moc, I...vAn MC
IF lAd. ""Ii I
C:;:";-f- X;;l?:lcr
7) ---1W
1./
Oatel
Time
2o+s
Notes
;\15
1110
Patient Observation / Assessment / Notes
2D1-Ecu 9/03 10'" Rev. LlW
CHART COpy
(
Respiratory:
Osymriletrical
and unlabored
DJabored
o SOB
Dcough
Qproduclive~
C102~L via_
%Sat
Gastrointestinal ON/A
QDenies pain Isymptoms
Qnausea OdiarrtJea
Ovomiting Qconstipation
OHematemesis
Last 8M
OAbdomen lender
Odistended Ofirm Qsoft
Oabras\on:
Dlaceration
Oecchymosis.
Ddeformily
Dburns
Obleeding"
Oedema Oerythema
Trauma 0 N/A
Location
Cardiovascular:
Cldenies
a Monitored rhythm: See
nursing Assessment
Qpacer
l:J.ederna'.
aChest paIn
area:
Severity _f10
Deonslant Clsharp
Dintermittent Oduil
Qbuming Qheavy
OSOB Opleuritic
Qnon-radiating Dradiating:_
Onausea
a denies s1s
o carf tenderness R Il
Owarmlh Oredness
Ocapi\laryrefill
Drapid Dderayed
EENT
Eyes
ObluCTed vision L I R
r:Jdouble vision L I R
OPhotophob!a L I R
ONJA
Ears Nose Throa!
Acuity: L_I_ OPain UR Ocongestion [)sore
R~_ Odischarge Odrainage DdrooJing
Dwith lenses Depistaxix l J R Odysphagia
-
RN Signature:
Medications
Time:
Initial
Date!
Time
Drug
Route
Site
tnitial
Response
Date!
Time
Notes
I . (pr'
O' {'; ~.
~
9')":j- .)!l-1203
rrL4V[ ..pr~
..
fG CROCJP
nil 2')~7{)H"
~ 1 ~... '" . _ _
(
(
DATE A.... P.M. Ml'DlCATIOtI AND/OR TREATMENT SIGNATURE
'D-40 A\tIOrt-~\~s!)0-4 {v ~ M L, COI\;;.dif NL Yu2cL. i / flp.
t't \'er(\<:)\'\'\) 'J$\eep _ \-\f2- \3~S S5d1 - ~3kzsi(ml G, l~vbL~.
m \\Jr f\4t Us D.Jit'JSS ~S orclQtc€i----------!( 1/ \ '-
--I- If (.J ~ 3 _ See: 0 ---'1. 117'
23ro v+ 4v)V\:sA:~\\r7'j 4D \1 Me \;~d ALS ------ (1
uu
HOLY SPIRIT HOSPITAL
CAMP HILL, PENNSYLVANIA 17011
EMERGENCY AND OBSERVATION RECORD
PATIENT CARE NOTES
~IJ[,~: '1 " """ ". ......
~ tell H . HOEll ~,E f .' ."
F t~l{ 1~THO~E ~o
~ Ct.", HILL
f ~ ~)"j"i\?>/2~()j
"l::o.<1-0~-12Qj
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E:ll}~:1
l'.t \1011.;:~
73t-qgOl.~ ~
Ie G.'ROUP ..._'::~<ii~~
lSS 20.70$2'0 v'
'OR" NO. ,.0 (2/95)
Holy Spirit Hospital to
o(rtment of Radiology and Diagnd....c Imaging
,CaIYlP HiII._ Pennsylvania 17011
(717) 763-2600
PATIENT:
MR#:
SOC SEC:
ORD DR:
PT TYPE:
OOB:
LOCATION:
DELAYE, MADELINE F
513428
999-08-1203
PUSHPA MUDAN MD.
E
08/26/2003
ER1-
DICTATION DATE: Nov 30 2003 7:40A
TRANSCRIPTION DATE: Nov 30 2003 7:40A
ADM DATE: 11/29/2003
ARRIVAL DATE: 11/29/2003
HOSP SERVICE: ER1
***Final Report***
EXAMINATION: CHEST PORTABLE 71010 .11/29/2003
COMMENTS: Indication: Respiratory distress, seizure 3 month-old
Portal chest at 2155 hours shows a normal cardiothymic silhouette. There is no congestion. There is no pneumonia.
The stomach is mildly gaseous distended and this may reflect air swallowing.
CONCLUSION: No active disease in the chest.
DICTATED BY: HOWARD BRONFMAN M.D. / PSC
DATE OF EXAM: 11/2912003
SIGNED BY: HOWARD BRONFMAN M.D.
DATE/TIME: Nov 30 2003 7:40A
Date ../",L
I' .
R_........"'-jy-..D~;"
Imaging Services Consultation
Page 1
RUP DATE: 12/01/03
RUN TIME: 1033
HOLY SPIRIT HOSPITAL, CAMP Hf"~, PA l70n
DEPARTMENT OF LABORATORY MEDICINE
STEPHENSON S~P. SWAMIDOSS M.D., DIRECTOR
PAGE 1
LOCATION
Name':
Acct#:
Reg:
ColI: 11/29/03-2143 Status: COMP Reg #: 03009241
Reed: 11/29/03-2143 Sub Dr: ED GROUP
Spee #: 1129:UP00012S
Ordered: URINP
Test
YELLOW
CLEAR
6.0
URINP
> COLOR
> CLARITY
> pH
> SPEC. GRAV.
> GLUC.
> KETONES
> BILl.
> OCC. BLD.
> PROTEIN
> NITRITE
> LEUK. EST.
NEGATIVE
NEGATIVE
DEPARTMENT
Of/Ie ,1. ,
'., ',....
---~L.-,,".i,,:).
,v , ,
J 'v.
':""<' I i
'IS fie','
"ell-lerj
by' .
-......:: i J
~M.D~D.
.-------
RUN. DATE, 11/29/03
RUN TIME, 2211
HOLY SPIRIT HOSPITAL, CAMP HI~=, PA 17011
DEPARTMENT OF LABORATORY MEDICINE
STEPHENSON S.P. SWAMIDOSS M.D., DIRECTOR
PAGE 1
LOCATION
Name:
Acct#:
Reg;
DELAYE,MllDELINE F
000022196638 Unit/l':
11/29/03 Disch:
EO GROUP
ER1: '
Spec #, 1129,L00592S
Ordered, CBCP, DIF, CMP
Comments: B CUL X 1
Test
CBCF
WEC
RBC
HGB
HCT
MCV
MCH
MCHC
RDW
PLTC
MPV
DIF
> SEG
> LYMPH
> BAND
> MONO
> EOS
> NRBC
> SMUDGE CELLS
> POlK
CMF
> RNDM GLUe.
> CA.++
> ALT
> AST
> ALK. PHOS.
> T PRO
> ALB.
> T BILL
> BUN
::. CREAT.
>
>
>
>
NA
K
CL
e02
Call, 11/29/03-2135 Status, COMP Reg II, 03007851
Reed, 11/29/03-2136 Sub Dr, MUDAN,PUSHPA R MD
E
."-,:--:-"-.:--.
I
c=
CONFIRMED
CONFIRMED
11.8
'4.22
11.5
34.4
81.5
;n.2
33.4
12.2
488
8.9
6.0-17.5 K/UL
2.70-4.60: M/UL
9.5-14.5 GM/OL
28.0-42.0 %
77.0-115.0 FL
26.0-34.0 UUG
29.0-37.0 GM/DL
10.8c15.9 %
140-500 K/UL
8.9-12.$ FL
17
, 77
'2
2
2
o
'0
1+
1
L
H
25-35
45-65
0-15'
4-10 %
0~5
0-0
0-0
I
L
148
9.9
83
38
251
.!;.5
3.8
0.2
8
0,.1
H
65-140 MG./DL.
9.0-11. (} MG ./DL.
13-45 U/L
9-80 U/L
<449 U/L
4.4-7.6 G/DL
3.8-5.4 G/DL
0.0-1.0 MG./DL.
4-19 MG./DL.
0.2-0.6 MG./DL.
133-145 mM/L
3.5-5.1 mM/L
96 -108 mM/L
22-30 rnM/L
H
L
J
139
4.7
i05
16
(
\
(
PHYSICIAN ASSESSMENT AND CERTIFICATION
.". 'ocT~.,'.c F""e,'JM Ie I ~ a ~/h~hcl-r't>v,
tientConditi~-' ~
_~ patic~t has been"stabilized such that within n::asonable medica~ pr.obabifity. no material .deterioration of the patient's condition, o"r
of the unborn child(n:n), is lik~ly to result from transfer.
The patient's'condition l1as not stabilized.
The patient is in labor.
ransfer Requiremc!lts . /. r /l /d I"} ~.
~ereceivingfac:ility. ~ . _
. (Name of Facility)
~~~~-~~~~., I
<:JAZ T~ dJt;i>eef4:a-:r~-,cA~ 1/ :v;;lo 2:,
~dfitlcIPhOne No. / . _ Dale
The rccdving facility has agreed to accept transfer nate medical treatment as acknowl-cdged by:
.' . . . . , 13~ ' ('
amcIPhone No. ~ C::d.f ?</-;i:;};,
edical records of me examination and treatment of me palient ~ provided althe time of transfer. j)f--. ~ k~
~ CPA-iJpy,
. has available space and qualified
.
The patient will be transferred by qualified personnel and transportation equipment as required. including the use of necessary and
medically appropriate, life :support t:nC3.S\1tt$. .
. \f\JSAL S
Transport AgencY
Provider Certifieation
I have ~""a.rnincd the patierit and explained the follow:ing risks and benefits ofgein
~.
. ,
, ._d._'_ ,__H
" ._--,-----_._~
Base.d on these. reasQnahle risks and benefits to the: patient and/or the unborn child(ren). and based- upon .the i,nformation availab-le at the time of the
patient's _examination.. I ce~i-fy that the medical benefi_ts're~onab-Iy to be exp~cted from the provision of appropriate: medical .trtatmcnt at .another
mt . . 1 facj~~ty outyreigh. t?e ipcrwai ris if any. to ~c individual' edical condition ftOm.Cffect~n.!e=feJ" '.' .... .
I~ . . .,1/ 21f/(J '3'
I .
IgnatUTe 0 physician or other quahfied medical person.
0f:;r ~'IA.'CiA^ ,>S'
'f Date
1
, I
,:.\ 'I/./1 J?'J1 '1"' or
~ ...,.U.;
'11q.O~. 1203
rrun .l'll'
11I2Q/03
,.. :- 'J' :.1 Ij[? 51 J4Z8 .E ;'1\
'fLAY[ .'{AbElINE f'~;'''''
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t 1 '.> "! l L tll.!'.'>1
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731- '18 O~ .......ft
EO GROllI' "11
Z '19' i()~7~082'40
Title
,
-:' .
PHYSrCIANASSESSMENT AND CERTIFICATION
(?L;l.vrA ~~ ~A/\ - LA
~+c~'J) ~p(Cl--(01
tient Condition /-_. I
. ~. -. J!I'e'l~'~-' "',",,,. c'''',n,
_~he patient has b~n.stabilized such that within reasonable medical probability, no material deterioration olr~,,\E~~t;~S:;;;fci~dJ~-g-r
of the unborn child(ren). is likely 10 result from transfer.
~ason for Transfer
1/? J'i!.<c<-l~M Y - Ir'
I
i/\
The patient's condition llas not stabilized.
The patient is in Jabor.
,.,,-,q
~-'\~ ,,"," \
--an, fer Requireme.lIts . /. r ,.., /J ,-, t .
'\----' Therece~ingfaeility,~ ~ j\Ay-LfJ U2A.-{.kfl.
(Name DfFacllity) -
personnel for treattnent as acknowledged by:' ,
~. - T cu./\" dJA1/;ed4"a-Y...>t~T'A 'Dt..~
NJrnclTitlcJPhone No. I
~n:e receiving facility has a~ to aceept ":""sfer
.-' , 13(> C
amclPhone No. ' ;Jv\ D:d'f cJ-lIel:;,he I ~
edical =rds of the examination and treatment of the patient arc provided at the rime of transfer. P!2- ~ k ~
. has available space and qualified
/I/Pj/O .~
Date
P)JyBitliin
~ .
Approp
ro date medic:a1 tre.a.tm.ent as acknowledged by:
.r
/1/1
InitiaJ
.. /~'". :-' .
\.,.----'" The plltient will be transfe<r:d by qualifi~ personnel and transportation equipment as required,
medically appropriate life support measureS. -
. l\l S A LS
including the use Df necessary and
Transpon Agency
>rovider Certification
have e.."Camined the patierit and explained the followtng risks and benefits of bein
')
.' -J4Ixr:.:i-A.e Ce
transferred/refusing
,/
{,Jv/--l uJ-
ltt't,"':t;':'. . ...
~" clr '(-;1/1../-, "
Base.d on thes~ reasonable risks and benefits to the patient and/or the: unborn child(ren), and based- upon the information available at the time of the .
patient's .cxaminatio14 1 certify that the medical benefi_tsrca5onably to be expected irom the prevision of appropriate. medical- .treatment a1 another
mfe.lfaci.~_ity O~tweigh 1:he i~cr6a.sed riskJJ.i iff an an.: Y. to .tJ:Ic in~i~id~~/.h1edjcal.condi.lion frO'. m effecting 9'e. tranSfj ". . "~ .
/If',' " ........ I~' '. ." / . .)/!2J(/V::j'
19nazllre 0 physician or other,qualified medical person,' 1 Date .
. 0-))' /D{vtAyiDI'Ci/l/\.-S '
Title _._ J' 1 .
....... J
I f
~ "- : .- I ")
N ,.'_':, ~1 513428
.('_uri, .'(ADELINE F
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t\: f' '- III
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fA 17011'
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