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Home My WebLink About05-4386 IN RE: Markus R. MacNamara, Erin G. MacNamara, and Mollie M. Goodling, Minors, By Susan M. MacNamara, parent And Natural Guardian IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA . No:o.-j~'I3Y~ G'~IA ; -.-. - -j 'WIQN ~~ PETITION FOR APPROVAL OF MINOR COMPROMISE SETTLEMENT AND DISTRIBUTION OF PROCEEDS PETITION FOR APPROVAL OF COMPROMISE SETTLEMENT AND DISTRIBUTION OF PROCEEDS FOR ACCIDENT INVOLVING MINORS MARKUS R. MACNAMARA. ERIN G. MACNAMARA AND MOLLIE M. GOODLING AND NOW, comes petitioner, Susan M. MacNamara, as the Parent and Natural Guardian of Markus R. MacNamara, Erin G. MacNamara, and Mollie M. Goodling, by and through her attorneys, Schmidt, Ronca, & Kramer, P.C., and respectfully avers as follows: 1. Petitioner, Susan M. MacNamara, is the biological Parent and Natural Guardian of MARKUS R. MACNAMARA, ERIN G. MACNAMARA, and MOLLIE M. GOODLING minors, all of whom resides at 312 North West Street, Carlisle, Cumberland County, Pennsylvania 17013. 2. The minors' current ages and birthdates are as follows: ERIN DOB: 3/29/1990 DOB: 10/28/1991 DOB: I('"Vj25/1996 AGE 15 MARKUS AGE 13 MOLLIE G. AGEg 3. On June, 9, 2005, Susan M. MacNamara's car with herself and all of her children was struck when a pickup truck driven by Jack Weller crossed the center line into the MacNamara's lane of traffic. 4. Mr. Weller's insurance company wishes to resolve the case for its applicable limits. 5. Jack Weller's insurance policy carries a 25/50 split limit providing coverage of $25,000 for anyone injured party and an aggregate total of $50,000 for all persons injured in the accident. (See Weller Declaration Sheet attached hereto as Exhibit A). 6. Susan MacNamara's own msurance policy has Underinsurance coverage of 15/30 providing $15,000 per person and $30,000 total per accident. 7. As a direct and proximate result of the collision, Susan M. MacNamara, an adult, suffered by far the most serious injuries. Susan sustained fractures of her pelvis in four places. She has been put in a walker with minimum weight bearing. She remains unable to work up to the date of this Petition. (See Susan M. MacNamara's medical records attached hereto as Exhibit B.) 8. An allocation of the full $25,000 available from Weller's policy and the full $15,000 from the underinsurance policy to Susan M. MacNamara is consistent with the damages she suffered in the accident, and will not in any way impair the recoveries to which her children are entitled. 9. The second most serious injuries were suffered by Markus R. MacNamara. Markus suffered multiple lacerations and contusions to his face, knee and legs which required closure with stitches. He had a large swelling on his head. He developed leg pain which required care with his pediatrician. He also fractured two teeth. His teeth will have to be monitored for five years to detect any pulp damage. (See Markus R. MacNamara medical records attached hereto as Exhibit C). 10. The other two minors, Erin G. MacNamara and Mollie M. Goodling did not suffer any injuries which required any treatment beyond the Emergency Room on the day of the accident. Erin suffered a contusion to her left thigh. Mollie suffered considerable fright and minor injuries. 11. The carrier for Jack Weller has agreed to pay the balance of the split limit to the minors as follows: Markus R. MacNamara $ 15,000 Erin G. MacNamara $ 5,000 Mollie M. Goodling $ 5.000 Total limit $ 25,000 12. Schmidt Ronca and Kramer, P.C. will limit its attorney's fee to 25% on the proceeds distributed to the Minor Plaintiffs' and all expenses related to minors' claims shall be paid from Susan M. MacNamara's recovery. 14. As none of the injuries to anyone of the children, or to all three children together are likely to result in a recovery by verdict in excess of $25,000, allowing Susan M. MacNamara to recover the full amount of the "split limit" does not impair or affect the children's recovery. 15. Petitioner is satisfied that the offer of settlement is just and reasonable and is prepared to accept said offer, if approved by the Court. 16. There are no unpaid liens, claims, or debts concerning the claim of Petitioner, other than the injury claim here presented for settlement upon the Court's Approval. 17. Disbursement of the settlement of $25,000 is, therefore, requested as follows: Schmidt, Ronca, & Kramer, P.C., Attorneys fees (25%) $ 6,250.00 Schmidt, Ronca, & Kramer, P.C., For reimbursement of costs $ 000.00 Susan M. MacNamara, as Parent and Natural Guardian of Markus R. MacNamara, a minor, to be deposited into a restricted, federally insured account $ 11,250.00 Susan M. MacNamara, as Parent and Natural Guardian of Erin G. MacNamara, a minor, to be deposited into a restricted, federally insured account $ 3,750.00 Susan M. MacNamara, as Parent and Natural Guardian of Mollie M. Goodling, a minor, to be deposited into a restricted, federally insured account. $ 3,750.00 TOTAL AMOUNT OF DISTRIBUTION: $25,000.00 15. The account into which the proceeds of this settlement going to Petitioner on behalf of each minor, shall be placed in a federally insured savings account and/or Certificate of Deposit. 16. Each savings account and/or Certificate of Deposit opened on behalf of each minor as a result of the anticipated settlement shall be marked as follows: "This money shall be held in trust, not to be redeemed, withdrawn, negotiated, or any way alienated, except for the renewal of its entirety before the minor's 18th birthday, except by order of the Court. " 17. The law firm of Schmidt, Ronca, & Kramer, P.C. shall oversee that the directives concerning these funds be carried out accordingly. WHEREFORE, the Petitioner, Susan M. MacNamara, requests that this Honorable Court enter the order attached hereto, approving the foregoing compromised settlement, allowing her to execute any release needed to effectuate the settlement as set forth above. Respectfully Submitted, SCHMIDT, RONCA, & KRAMER P.C. ./ By: /./? Terry S. y n, squire Attorney f; r Pe tioner Attorney LI;k 36807 209 State Street Harrisburg, PA 17101 (717) 232-6300 Date: o t/p6jo 5 VERIFICATION I, Susan M. MacNamara, verify that the facts set forth in the foregoing Petition for Approval of Compromise Settlement and Distribution of Proceeds for Accident Involving Minors Markus R. MacNamara, Erin G. MacNamara, and Mollie M. Goodling are true and correct to the best of our knowledge, information, and belief. We understand that this Verification is made subject to the provisions of 18 Pa.C.S. !34904, relating to unsworn falsification to authorities. -.L-l~ JJ~, '; , " ." ,,1 , ' . 'l / ;, .I'J / I IJ.~. lli)/A"u..... Susan M. MacNamara Date: ()~10{ I 8B/IB/85 89:17:25 Jack H WlIlhr MUles '},46:t:09 7. -354-515B->Fax AUlD POLICY WORKSHEETS PAGE AurO/HO DISCOUNT: , BY- RNC TRAN- 2 DATE COI 006 PROCESS CD: Vicky M Wilner RR Bux t8i1S , POL ICY EFF EXP 05/15/05 11/151115 TRANSACTION EFF EXP GOOD PAY DISCOUNT: ENOORSEHENT EFF EXP PRINT I Y TYPE DEe, loysvil1R PA 110~7 FILE OA.1E RA Tf Cu.ss DATE DATE CODE CODE CANCl PCT 5/15/05 11/15/'35 S/15/05 1l/1S/0~ 4/11105 lAST NAME Weller ldhllan " 17 IMTNL PL RT o VH VEHCl YEAR I'lAKE HODEL SERIAL NUtlSER SYM AGE 1ft STTR: USE LIA PHY CLASS tl 00001 2000 FORD RNGIl:XL/Xl T IFTYR14V3YT&26299 12 5 91 3791 lj Y Y 88032A 12 00002 1999 FORD ESCORT LX IFAFPIOP5XWl122lil 91 3791 Y 885128 PPR911l FORCE RT OT: RSN CANe CAN DATE 0/01100 SCHED EXPER eft eR Page 8E13 PA 758788 ~7/'j9 16 FORCE PRO-RATA: 51lboIs, 6 FILE ORG eHG CD AC RAT~ DAT~ SHCARPROoGGS BIRTH PRIlAO VO LIC X R TO 0 S F T S OFF CHOY) ClS CHYl C C TIER AGE OlE LIC HUHIER H Pi o/uP 09/10/35 880 Ll/93 5 Z 69 nISI 1I949H~~ F H D2 V 0'/0'11 06/Dl/50' 885 07100 1'1 2 5t; 0'6/66 192'6208 VE. LIM/DEo NO 25/50 250411 HOOOD 100l/S001l 1500 MISC. USE 15/30 15/31 y 50 01 251 01 5nu 15 Bl fL 5/11/15 PO FL 5/11/15 HED EXP FL 5/11/15 UBI fL ST 5/11/15 urH Fl ST 5/11/15 COMP FL 5/11/15 COlL FL SlllllS II FI.. 5/11/15 PO FL 5/11115 HED EXP Fl 5/11/15 UBI F'L ST 5/l1/1~ UIH fL 5T EKtlQRSEMEH1 GI10151 0205 ILOl)lO 0702 LCDIt lOSt; PAPE 0999 PP0315 0886 PP0405 0188 PP0419 080Z PPOt.i23 0802 PP05S1 069ti 1'1'1301 lZ99 PR86 0185 IHTNl EFFEt:TIVE EXPIRE COY. CODE LIMIT/OED VH VEHCl DATE DATE 10 BOOOO 5/05/15 5/11115 PA PLUS Fl V 5/05115 5/15/15 5/DS/1S 5/15/15 5/15/15 5/15/15 5/DS/IS 5/05/15 5/05/15 5/05/15 5/85/15 5/'5115 25/50 250'80 10000. IS/3D 15/30 so 25. 25/511 25011. ltHIOIHI 15/30 15/311 VEH S1 A. TUS DO' P P HH F S A R A 0 I' BASE CLASS CLASS CLASS F T AR 11 A T R l W T RATE FAC 1 FAC 2 FAC ~ TIER 3 D <4 OtiZ8. 7411 .840 2 ON Ill&S .6S0 .HI 2 o ODe o OFF C SSNO 110/00 DO/DO ....T FAC '05 09' OP FIRST NO NAME III J.ck 12 Vicky COY. CODE 11Ft PD Fl KED EXP Fl Ut lOSS FL FUN EXP FL lCC DEA fl UBI FI- Sf UIH FL ST PA PLUS fL COHP FL COlL Fl 11 00001 tli toOtH 1110llGl 11110001 0100001 0110001 01 DOOOl 02 00002 112 00(102 02 00002 02 10002 02 18002 RATED PREMIUM 18.00 TERM PREMIUH 18.01 REF PRO- COMH lNCEP DATE CREDIT R~TA EX? CODE HD/VR CODE MISC. USE 1.000 16 B S/DS 140 CAP Al'tOUNl "06.00 60.00 53.00 13.00 11.00 ~6.00 11'18.00 "06.00 60.08 53.00 13.00 11.00 46.00 148.GB 41.00 55.00 "09.01) 13.00 1l.00 43.011 55.00 49.00 13.00 11.00 56o/'i.00 STATUS 1.000 1.000 1. OIl 0 1.0n 1.010 1.000 1.91111 1.0110 1.000 1.010 1.000 I. 010 LABElS LOAN NUMBER .. .A 'A .. 'A 'A 16 .. 'A 'A DA 'A o o o . o o . 5/115 5/05 5/l!i 5/05 5/05 5/05 5/1S 04' ." 1<, 16' '40 ." '4' o o o 8 o 5/IIS 5/IS 511S !i/a5 5115 '4' 14. '4' '4' .4. PATIENT NAME Ap, .-.-ACHIAN ORTHOPE:OlC CEN" ( Thomas 1. Green, M.D. Daniel P. Hely, M.D. Michael 1. Oplinger, M.D. Robert P. Baran, Jr., M.D. OFFICE RECORDS DATE OF BiRTI! PAGE jf Macnamara, Susan M DOB:ll/2111954 06/09/05 CRMC ER CONSULT & ADMISSION: By Dr. Green. DIAGNOSIS: Bilateral hip fractures, stable with acetabular involvement on the left. I Macnamara, Susan M DOB:l112111954 06/28/05 OFFICE VISIT: The patient is now almost 3_weeksjlostJ<lilitlgdown the stairs at home on 6/9/05 at which time she had a fracture of her right pelvis through the acetabular dome but nondisplaced and stable and a fracture. through the inferior and superior pubicianiiis on ilie lettslde. ThepatletJt was admitted to the hospital and treated in the hospital until she was able to get around on her walker. She returns for examination. . On examination, she walks very nicely with the walker. Good fluid gait and protecting the weight on both sides. Her pain and tenderness remains primarily on the right and I reviewed the films today especially the cervical spine which is negative for trauma but positive for spondylosis and the lumbar spine which is negative for trauma and positive for lumbar spondylosis as well as her pelvic fractures. Femur was not fractured and does not appear to be both clinically and roentgenographically. . DIAGNOSIS: 1. Bilateral pelvic fractures, nondisplaced, stable including the acetabulum on the right. 2. Lumbar spondylosis. 3. Cervical spondylosis. 4. Multiple trauma. PLAN: Continue with current treatment using the walker. Recheck in 3 weeks at which time we can decide if she's ready to get on a cane and she would like to get back to work. Thomas J. Green, M.D./dmg CC:_S~dlerC~lnic _ ~/ Macnamara, Susan M DOB:I1/21!1954 07/26105 OFFICE VISIT: She's in here with a cane using it in the incorrect hand. However she gets along pretty well that way and I tried to switch her over. She was unable to do so. She had a lot of confusion. Had a list of questions to ask. I tried to straighten out her confusion. I've asked her to come back in one month for follow up x-rays. I expect them to demonstrate healing and-shecancontinlle__ totltr1ttiltleolt more. Sfie'SIiot ready to do anyfiard work but she's-r-eady to drive and do a light duty job. Thomas J. Green. M.D./dmg cc:SadlerClinic --- -. .~- . -- - ------ CARLISLE REGIONAL MEDICAL CENTER RADIOLOGICAL INTERPRETATION PATIENT NAME: MACNAMARA SUSAN X-RAY#: 825381 EXAM DATE: 6/09/2005 ORDERING: ROBERT W LASEK,MD 245-5500 ATTENDING: THOMAS GREEN,MD 243-1414 CONSULTING: HAROLD G KRETZING,MD- HISTORY: MVA--MINOR INJURY MVA--MINOR INJURY MED REC ACCOUNT D.O.B. : ROOM: #: 825381 #: 9312840 11/21/1954 IP LUMBAR SPINE, PELVIS, LEFT FEMUR, CT OF THE ABDOMEN AND PELVIS 06/09/05 LUMBAR SPINE: There is scoliosis to the right. Otherwise there is no acute abnormality. There is mild narrowing of the disks at L4-5 and L5-S1. Foreign bodies overlying the right pelvic wing could be within the bowel or in the patient's skin or external to the patient, such as glass. CONCLUSION: NARROWED DISKS AT L4-5 AND L5-S1 WITH SCOLIOSIS, BUT THIS IS NOT AN ACUTE ABNORMALITY. PELVIS THREE VIEWS: There are nondisplaced fractures through the left pubis, the left inferior pubic ramus, the right superior pubic ramus and perhaps even extending vertically into the left acetabulum. None of these fractures is displaced. CONCLUSION: Multiple fractures of the even the left acetabulum. pubic bones, pubic rami, and perhaps Sacroiliac joints appear normal. LEFT FEMUR TWO VIEWS: Femur itself is normal with no fractures, but again seen are fractures of the left pubic bone and inferior pubic ramus. CONTINUED ON PAGE 2 REPRINT CARLISLE REGIONAL MEDICAL CENTER RADIOLOGICAL INTERPRETATION PATIENT NAME: MACNAMARA SUSAN X-RAY#: 825381 EXAM DATE: 6/09/2005 ORDERING: ROBERT W LASEK,MD 245-5500 ATTENDING: THOMAS GREEN,MD 243-1414 CONSULTING: HAROLD G KRETZING,MD- HISTORY: MVA--MINOR INJURY MVA--MINOR INJURY MED REC ACCOUNT D.O.B. : ROOM: #: 825381 #: 9312840 11/21/1954 IP CT OF THE ABDOMEN AND PELVIS: CT of the abdomen shows two separate low attenuation lesions of the liver, the largest being 14 mm in size in the inferior right lobe. These are most likely hemangiomas, but further evaluation with multiphase imaging of the liver is recommended. There is no evidence for laceration of the liver, spleen or kidneys. Gallbladder is normal and the retroperitoneum is normal. There is no abnormality of the bowel found. The uterus appears to have fibroids. Bladder is normal. Fractures of the left inferior pubic ramus and superior pubic rami along with the pubis itself are seen, and there is a fracture of the anterior column of the left acetabulum. Nondisplaced fracture of the right sacral ala is also seen. There appears to be glass or gravel imbedded in the soft tissues of the right buttocks. CONCLUSION: pelvic fractures as discussed, most of which were seen on previous radiographs. No evidence for acute abnormality of the abdominal viscera, but probable liver hemangiomas which need confirmation as discussed above. REVIEWED AND SIGNED ERNEST CAMPONOVO, M.D. INTERPRETING PHYSICIAN DATE DICTATED: 6/10/2005 DATE TRANSCRIBED: 6/10/2005 22:32 DATE SIGNED: 6/13/2005 8:25:00 TRANSCRIPTIONIST: MW 6019088 REPRINT PAGE 2 OF 2 SPINE LUMBAR COMP WIOBLlQ FEMUR AP & LATERAL PELVIS COMPLETE 3 VIEWS CT ABDOMEN P.82 /~" \ ,~j) 1'\ 0\ 6\~ PATIENT NAME; MACNAMARA SUSAN X-RAYU: 825381 EXAM DATE; 6/09/2805 ORDERING; ROBERT W LASEK.MD 245-5500 ATTENDING; THOMAS GREEN.MD 243-1414 CONSULTING HAROLD G KRETZING.MD- HISTORY; MVA--MINOR INJURY MVA--MINOR INJURY CARLISLE REGIONAL MEDICAL ~L~TER RADIOLOGICAL INTERPRETATION MED REC U; B25381 ACCOUNT II: 9312848 D.O.B.; 11/21/1954 ROOM; I P LUMBAR SPINE. PELVIS. LEFT FEMUR. CT OF THE ABDOMEN AND PELVIS 06109/05 LUMBAR SPINE; There is scoliosis to the right. Otherwise there is no acute abnormality. There is mild narrowing of the disks at L4-5 and lS-Sl. Foreign bodies overlying the right pelvic wing could be within the bowel or in the patient's skin or external to the patient. such as glass. CONCLUSION; NARROWED DISKS AT l4-S AND LS-S1 WITH SCOLIOSIS. BUT THIS IS NOT AN ACUTE ABNORMALITY. PELVIS THREE VIEWS; There are nondisplaced fractures through the left pubis. the left inferior pubic ramus. the right superior pubiC ramus and perhaps even extendin~ vertically into the left acetabulum. None of these fractures 1S displaced. CONCLUS ION; Multiple fractures of the pubic bones, pubic rami. and perhaps even the left acetabulum. Sacroiliac joints appear normal. LEFT FEMUR TWO VIEWS; Femur itself is normal with no fractures. but again seen are fractures of the left pubic bone and inferior pubic ramus. CONTINUED ON PAGE 2 P.83 CARLISLE REGIONAL MEDICAL CENTER RADIOLOGICAL INTERPRETATION PATIENT NAME: MACNAMARA SUSAN X-RAYH: 825381 EXAM DATE: 6/09/2805 ORDERING: ROBERT W LASEK.MD 245-5588 ATTENDING: THOMAS GREEN.MD 243-1414 CONSULTING HAROLD G KRETZING.MD- HISTORY: MVA--MINOR INJURY MVA--MINOR INJURY MED REC H: 825381 ACCOUNT #: 9312840 D.O.B.: 11/21/1954 ROOM: IP CT OF THE ABDOMEN AND PELVIS: CT of the abdomen shows two separate low attenuation lesions of the liver. the largest being 14 mm in size in the inferior right lobe. These are most likely hemangiomas. but further evaluation with multiphase imaging of the liver is recommended. There is no evidence for laceration of the liver, spleen or kidneys. Gallbladder is normal and the retroperitoneum is normal. There is no abnormality of the bowel found. The uterus appears to have fibroids. Bladder is normal. Fractures of the left inferior pubic ramus and superior pubic rami along with the pubis itself are seen. and there is a fracture of the anterior column of the left acetabulum. Nondisplaced fracture of the right sacral ala is also seen. There appears to be glass or gravel imbedded in the soft tissues of the right buttocks. CONCLUSION: Pelvic fractures as discussed. most of which were seen on previous radiographs. No evidence for acute abnormality of the abdominal viscera. but probable liver hemangiomas which need confirmation as discussed above. REVIEWED AND SIGNED ERNEST CAMPONOVO. M.D. INTERPRETING PHYSICIAN DATE DICTATED: DATE TRANSCRIBED: TRANSCRIPTIONIST: 6819088 6/10/2005 6/10/2005 22:32 MW ATTENDING FAX PAGE 2 OF 2 ~~ 6/2~ Carlisle Regional Medical C~ater Laboratory, 246 Parker St. Carlisle, PA 17013 Duckkyu Chang, M.D., pathologist Henry S. Crist, M.D., Pathologist NEW AFTER DISCHARGE MACNAMARA, SUSAN MRN:0000825381 Location:MS3-0307-W DOB:11/21/1954 Age:50 Sex:F Physician: GREEN, THOMAS J Admitted: 06/09/05 Discharged: DISCH.: 06/10/05 HEM A T 0 LOG Y ------------------+---54100078----+--------------- COLLECTIID 106/10/05 06,10 IREFERENCE RANGE ------------------+---------------+--------------- BLOOD CELL COUNT WEC 1 9.3 13. a-11. 0 x10^3 RBC 1 4.26 13.40-5.30 x10^6 HGB I 12.4 110.9-14.7 g/d1 HCT I 37.5 133.0-43.0 % MCV I 8a.1 lao.0-96.0 f1 MCR I 29.0 126.0-34.0 pg MCHC I 33.0 131. 0-36.0 g/dl ROW I 11.5 111.0-16.0 % PLT I 334 1140-400 x10^3 AUTOMATED DIFFERENTIAL Neut% 1 79.5 140.0-ao.0 % Lymph% I 11.1 L 115.0-50.0 % Mono% I a.6 B 11.0-a.0 % Eas% 1 0.1 10.0-6.0 % Baso%" I 0.7 10.0-2.0 % Neut# I 7.42 11.3o-a.ao x10^3 Lymph# I 1. 03 11.00-4.20 x10^3 Mano# I o.ao B 10.00-0.60 x10^3 Eos# I 0.01 10.00-0.40 x10^3 Baso# I 0.07 10.00-0.20 x10^3 .. Key for Abnormal ColU1'\U\ {L-Low }i-Hiqh AB-Annormal C-Critical T-Toxic) MACNAMARA, SUSAN MS3-0307-W 1 of 1, 77 of 93 continued HEM A T 0 LOG Y PRINTED 06/11/2005 00:20 Page: 1 of 1 (\~ ~CARilstE v\JJ ",f.!ft~ 246 Parker SI. Carlisle, PA J70l) Ph;7 [7-249-12]2 \! 7 T I E N T o IT DATE I TIME 06/09/2005 22:45 ROOM NO. 0307 W PATiENT; N Me& ADDRESS MACNAMARA, SUSAN 312 N WEST ST CARLISLE US G U A R RE NSIBL PA Y &. A ESS MACNAMARA, SUSAN 312 N WEST ST CARLISLE PA 17013 US EMERGENCY CONTACT NAME HATT, DIANE COMMENTS ER TO INP 22:45 6/9 KAB PRIVACY M DR. ATTENDING I ADMITTING I S C GREEN, THOMAS DIA NO I, l51 N & SYMPT M PELVIC FX PT II PHONE NUMBER (717) 243-2098 NU BEA 210-44-3603 PHONE NUMBER (717)243-2098 EMERGENCY CONTACT PHONE (717)243-6650 PRINCIPAL DIAGNOSIS (The condition established after study to be chiefly respCfViible tor occasioning the admission of the patient to the HOSPITAL for carel. COMPLICATIONS COMOR810lTY(IESl PRINCIPAL PROCEDURE AD001A 9312840 111111111111111111111111I111111111111111 111I111111lI1111111111~1I1111111111111111111 ADMISSION RECORD DATE OF BIRTH 11/21/1954 PROGRAM MEDI Al REC RD NO. 0000825381 PA lENT EMPLOY R RITE AIDE EMPLOYER PHONE NO. (717) 691-6200 COUNTY CUMBERLAND RE N BlE PAR Y PLOY 1'\ RITE AIDE 5280 SIMPSON FERRY RD MECHANICSBURG PA 17055 EMPL YER PHONE (717) 691-6200 RELATIONSHIP TO PATIENT PATIENT IS EMERGENCY CONTACT RELATIONSHIP TO PATIENT FRIEND MSP Dv cgN NPP ADMIT. BY MED. KEY DY I3IN PRIVACY Y KAB OAE I 00/00/0000 INSURED'S NAME ROUP NUMBER UP NAME AUTHORIZATION IN URED' NAME GROUP NUMBER GROUP NAME AUTHORIZATION NAME GROUP NUMBER GROUP NAME AUTHORIZATION DR. FAMILY I PRIMARY CARE KRETZING, HAROLD G A I T NO FAULT A ID NT DATE 06/09/2005 0000826381 nnrTnO/~ rnov 1111/1111111111111111111I111111111I111111I1111I11111111111I1 86/17/85 14:42;38 ~ightFAX-> 71724%23C \lig. .lX 825381 MACNAMARA, SUSAN MS3 DIAGNOSIS - Stable fractures of the pelVIS. PLAN - Teach her four-point reciprocating gait, give her analge5i~ to take home. Getthe laceration of the ear fixed and see her In the office In one week. She Is to take asplrtn as an anticoagulant measure and sIle 1510 get up and walk as mUCh as sIle cen tolerate, also as anticoagulation stralegy. T JG/jrs D: 06/09/2005 21 :15:09 T: 08/10/2005 11 ;20:38 This document 'MIS 8uthentlcated by Thomas J. Green, M.D. on 08117/200514:45:35. TtlOmas J. Green, M.D. c: Thomas J. Green, M.D. Page 2 of 2 DICTATING PHYSICIAN COpy CARLISLE REGIONAL MEDICAL CENTER EMERGENCY ROOM CONSULTATION 9312840 P'IE 8DZ ./ RightFAX-> 717249623~ ~ig. .AX B6/17/85 14:42:B9 ~ . ~t\OfJ j \,l,) i(\J\9 MACNAMARA,SUSAN DATE OF SERVICE~ 0610911004 Msa 82sa81 CONSULTATION DIAGNOSIS: Bilateral hip fractures, stable wnh acetabular involvement on the Iell. CHIEF COMPLAINT: Auto accident. HISTORY OF PRESENT ILLNESS: thiS Is a 50-year-Old woman WI'Io was In a small car w~h her three children and a truck ran Into her at a rapid rate of speed. Into to drlve~s side of her car. There was slgnlficant pain In her back and pelvis and then later on In her hips and WI'Ien they came \0 get ller, the emergency crew told her not to walk 8lthough that Is what she wanted to do. upon adVIce Of the emergency crew she did not. She subsequently was brought to the Emergency Room WI'Iere She was examined and prlmary survey was undertaken. Aller !he primary survey the neck collar was removed. Sha was taken off the bed board and then underwent examlnallon of the pelvis and lower back. The ftndlngs were that, on mU~lple VIews, of a bilateral hip fracture, which was stable wnhoUl any evidence of transverse process fracture oHIIe lumbar spine, no eVIdence of 51 pint disruption, iliac disruption or disruption oHhe sacrum. A CT scan was also performed that showed no Internal organs and no Instability on the CT scan by observation of the pelvis. The patient remained stable without blood In the urine and without symptoms of abdominal distress or distress In her chest PAST MEDICAL HISTORY: The past history was reviewed and is of no significance or pertinent to the current problem. PHYSICAL EXAMINATION: General: Physical examination reveals a the patient is completely lucid, more concerned about her children going home today without her tonight than she is about herself and would prefer going home as opposed to staying in the hospital. HEENT: Her pupils responded. The upper airway was clear. There was no evidence of significant facial trauma. There was a laceration, around and about the aer, which would require suturing. Neck: Range of motion in the neck was full without crepitus, tenderness or muscle spasm. Range of motion of the shoulders are nOl1Tlal. Palpation of the clavicle is intact. Chest: No tenderness of the chest wall, Lungs: Full inspiration, expiration and coughing did not produce pain in the chest or abdomen. Back: Palpation of the back and percussion of the back from the neck all the way down to the Sllcrum was nontender. Palpation of the para lumbar areas was also nomender, without swelling. Abdomen: There was no evidence of blunt trauma to the abdomen. Palpation of the internal organs of the abdomen were nontender and compatible with a CAT scan. Pelvis: Palpation of the pelvic region was tender and we didn1 force that. Neurologic: She had abiltty neurologically to move all the muscles of the lower exlremtty and had intact sensation and pluses. LABORATORY STUDIES - X-rays were reviewed, Lumbar spine is clear. The hips are clear, femur clear and knees clear. The pelviS has supenor and Infanor pubic ramus fractures on the right and no Involvement with the acetabulum. On \he left, pUbiC fr8ctures with Involvement of the acetabUlar area, nonwelghtbearlng side and the anterior column 15 not complel8ly VIolated. So, this Is a nondlsplaced fracture although It does Involve the articular surface there Is absolutely no displacement. Page 1 of 2 DICTATING PHYSICIAN COPY CARLISLE REGIONAL MEDICAL CENTER EMERGENCY ROOM CONSULTATION ga12640 Page BB1 ~1~Y y Diet: . Activity: Dressing/Personal Care Instructions: Follow-up appointment with Physician: Other follow.up appointments: Supplies $htttwlflthatient: U_'..:l!-j cC. d'. , _ .>-. ( ,,): , . .,' ,,( D VNS (Order on chart required) DOther SERVICES: 0 Skilled Nursing 0 Home Health Aide 0 P,T. 0 a.T. MEDICATIONS: (LIST BELOW) . _LLlc~_._~; , i"j:.. ...... ,.,j .;J,)jq:",i ')_~: I DS.T. NAME DOSAGE INSTRUCTIONS . , - '" -~ . ," .,' ./. ," I have received and understand the instructions on my medications and on food/drug interactions for these medications. This information is provided for educational purposes. Any recommendations from my physician will supercede this information. i t Patient or Responsible Party Signature: /. RN Signature:__ " ..J___,;.i! Date: ,I Physician Signature: PATIENT IDENTIFICATION MEDICAL CENTER MACNAMARA, SUSAN Acct#9312840 MR# GREEN, THOMAS 0000825381 06/0912005 CARLISLE REGIONAL M 008:11/21/1954 050 f 111/1/11111/ 1II/IIIIIIIil/ll/lllllllllViJ1yL CTR 0307W /1 246 PARKER ST.. P.O. BOX 310 CARLISLE. PA. 17013.0310 DISCHARGE INSTRUCTIONS 10 (11/01) ......,............ a~ 246 Parker St. Carlisle, PA 1701) Ph:7/7-249-1212 P A T 1 E N T ADMIT DATE !TIME ROOM NO 06/09/2005 22:45 0307 W PATIENT AME. & [lDRESS MACNAMARA, SUSAN 312 N WEST ST CARLISLE PA 170 US G U A R RESPONSIBLE PARTY ADDRESS MACNAMARA, SUSAN 312 N WEST ST CARLISLE PA 17013 US EMERGENCY CONTACT NAME HATT, DIANE COMMENTS ER TO INP 22:45 6/9 KAB PRIVACY N s 6/dJ'jo\' We- '7.0- ADMISSION RECORD PATIENT EMPLOYER RITE AIDE 0000825381 PT DATE OF BIRTH II 11/21/1954 PHONE NUMBER (717) 243-2098 58 NUMBER 210-44-3603 PHONE NUMBER (717) 243-2098 EMERGENCY CONTACT PHONE (717) 243-6650 u R A N IN URANCE M DR. ATTENDING I ADMITTING 1 GREEN, THOMAS S DIA NOSIS! I N & SYMPTOMS C PELVIC FX PRINCIPAL DIAGNOSIS (The condition established after study to be chiefly responsible fOI occasioning the admission of the patient to the HQSPIT AL for care) COMPLICATIONS CQMORBIDITY(IESI PRINCIPAL PROCEDURE AD001A 9312840 1111111111111111111111111111111111111111 111111111111111111111111111111111111111111111 PROGRAM COUNTY CUMBERLAND RESP NSIBLE PARTY EMPLOYER RITE AIDE 5280 SIMPSON FERRY RD MECHANICSBURG PA 17055 EMPL YER PHONE (717) 691-6200 RELATIONSHIP TO PATIENT PATIENT IS EMERGENCY CONTACT RELATIONSHIP TO PATIENT FRIEND MSP Dy QgN MED. KEY DY QgN PRIVACY NPP ADMIT. BY Y KAB P A E IRTH 00/00/0000 INSURED'S NAME ROUP NUMB UP NAME AUTHORIZATION INSURED'S NAME GROUP NUMBER GROUP NAME AUTHORIZATION DATE:OF,BIRTH / / IN URED'S NAME GROUP NUMBER GROUP NAME AUTHORIZATION DR. FAMILY I PRIMARY CARE KRETZING, HAROLD G ACCIDENT NO FAULT A IDEN A E 06/09/2005 0000825381 DOCTOR'S COPY '"11/11111111111111111111I"11I11111111111111111"11111111I Thomas J. Green, MD. Daniel P. Hely, M.D. Michael J. Oplinger, MD. James A. Oliverio, M.D. Appalachian Orthopedic Center I tunwoody Drive Carlisle. PA 17013 Telephone:(717) 249.0112 Fax:(717) 249.0235 Medical History and Screening Form . Reason for visit? RechUj( ';:;ikecL llv,'c be"", Is this the result of an injW')'? es 0 No Date of InjW')': l.JJ-q - 05 When did the problem sl1lrt? & _ 9 _ oS- If Yes then how and where did it occur? When did the problem sl1lrt? Evaluation of Pain I Discomtim . AA.fv iJ...code.n~ & -1-05" What activities are you unable to do because of the pain? ~- -05' Does the pain keep y9l" awake at night? DYes I!1'No What makes it feel better? What makes it feel wone? Pain Scale (circle one number) Which other Docton; have you seen for this robIem? What medications have you tried? Any Physical Therapy? As !nv'. YY\Ov*'rV\ent I J 0.. on .s,de 0( :5 bY\CLc.he: 1(1 (\ Other treatments? I I Is this being covered by Worker's Compensation? 0 Yes Is there a lawsuit or litigation pending in regard to your injwy? 0 Yes 0 No J hWJ e efet-(ed 1--0 G-.fhfnrn Past \1edical History (plea,e check 0111 thai appl) I Last date worked? Current work restrictions? o Diabetes o High Blood Pressure o Thyroid (Hyper or Hypo) o Parathyroid o Tuberculosis o Stroke o Seizure Disorder o AIDS I HlV o Current Pregnancy ~. -0'1 o Parkinson's Disease o Multiple Sclerosis o Heart Disease o Heart AttrJck o Irregular Heart Beat o Asthma o Bronchitis o Hepatitis o Sromach Ulcers o GastromtestinalDlSease o Liver Disease o Prostate o Kidney Disease o Vascular Disease (circulation) o Bladder Disease o Skin Disorder o Bleeding Disorder o Rheumaroid Arthritis o Osteoarthritis o Gout o Osteoporosis o E:ancer o Other ( describe) Page 1 of2 APPALACHIAN ORTHOPEDIC CENTER, L TD M D THOMAS J. GREEN. MD. 1 DUNWOODY DRIVE DANiel P HOE2l;(118.E MD # 012191-E CARUSlE, PA 17013 MD.# MICHAElJ. QpUNGER, MD. TELEPHONE: (717) 249-6112 ROBERl P BORAN:JR,~. M~J D MD#419117 Fax: (717)249-6235 MD#022 01- () <: vrnvn, - Zo \ C7 65'" NAME ...J vt .,,)C\ h '. r\O\ I'<)C~ r<A...- AGE DAlE ADDRESS ~OYY'\~G~ -\}/ ' i, \~T- WhL>L\.(~ ~Q...Q...\.Lv\. ti/"f- . e!!-.J\\...> 'AI '0e..Q.....\ Ch('~ .J(OJ.:tw~ Label Refill times' r"_((lJl? SU8SJTUTION PERM1SSI~ \J '<., l. j ,M ,D. IN ORDER FOR A BRAND NAME PRODUCT TO BE DISPENSED, THE P ESCRISfR MUST HAND WRt1E "BRAND N9cESSARY" OR "BRAND MEDICALLY NECESSARY" IN THE SPACE BELOW. ~ DEA # __ ~ 'l:- ~ ~ ~. Q-/,^ ~ _ '\7J'~9 \ry...JJ---- lYG3 CD @ 1(", 209 State Street Harrisburg, Pennsylvania 17101 7t7.232.6300 FAX 717.232.6467 www.srklaw.com 1528 Walnut Street, 3rd Floor Philadelphia, PA 19102 215.790.7303 VOICE 215.546.0942 FAX Schmidt, Ronca & Kramer PC INJURY LAWYERS PLEASE ~.~PO!lQ TO I-IARRISBlj!l.G Ol'EIYj:,_.____........ Affiliated Law Firm - Sheller, Ludwig & Badey, P.C. Philadelphia, PA June 29, 2005 Sadler Health Center Attn: Medical Records Department 100 North Hanover Street Carlisle, PA 17013 Re: Patient: Susan M. MacNamara DOS: 11/21/1954 SSN: 210-44-3603 Treatment dates: complete me Dear Sir or Madam: Please be advised this firm represents the above-referenced patient. Please forward to me copies of all medical records and itemized billing statements relating to the care and treatment of the patient for the above-referenced dates of treatment. I have enclosed an executed medical authorization permitting the release of this information. If you have any questions, please feel free to call me at any time. Very truly yours, SCHMIDT, RONCA & KRAMER, P.C. .._e."'. -- yman TSH/ jss Enclosure HIPAA AUTHOt<..lZATION TO DISCLOSE HEALTH INFORMATION Lfadk/lJ /k,J0}u CtfJhU To: From: Date of Birth: /1 /d.-1/54 , /fpA/lfl/ ) l.l'~A" ~<, Social Security Number: 02/Q-if.t./-3('03 -d"'-' v ..,,~ 0 ,- ~ /Y4-"v- r {f " 1. I authorize the use or disclosure of the above-named individual's health information as described below: 2. The above individual or organization is authorized to make the disclosure. 3. The type and amount of information to be used or disclosed is as follows: the entire chart concerning the above-named individual. 4. I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDSI, or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse. 5. This information may be disclosed to and used by the following individual or organization: Schmidt, Ronca, & Kramer. P.C. 209 State Street, Harrisburg. PA 17101 for the purpose of: potential legal proceeding. 6. I understand that I have the right to revoke this authorization at any time. I understand if I revoke this authorization I must do so in writing and present my written revocation to the health information management department. I understand the revocation will not apply to information that has already been released in response to this authorization. I understand the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire on the following date, event or condition: If I fail to specify an expiration date, event or condition, this authorization will expire in six months. 7. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand I may inspect or copy the information to be used or disclosed, as provided in CFR 164.524. I understand any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal confidentiality rules. If! have questions about disclosure of my health information, I can contact Schmidt, Ronca, & Kramer, P.C., 209 State Street, Harrisburg, PA 17101 (717) 232-6300. 8. I also authorize my attorneys or their delegate to photograph my person while I am present in any hospital. 9. I agree that a photostatic copy of this authorization shall be considered as effective and valid as the original. Date: (,I ,...1 _ 'i/ C ~ ~ J ".';.) j ~ ." . .... {;liN1U JJL(Lt /:.U'ltl<:Ua,.U' Signature of Patient or Legal Representative If signed by Legal Representative, Relationship to Patient MEDiCATION FLOW SHEET Name: . ~ll.M.l. (\ f\\l\.tX\CL tV" 6. V 0-...; ~ Dates: \1. U L\I \ee;- ~ CfS Medications: A~\rl \ \J '\\~\ V'0 Vi}J \/ V J . . CL ~309 t\\lOO) ~adl~r Health Center Corporation 10\ rth Hanover Street Carlisle, P A 17013 l'auent 'Name ?) )Cfl {\ (Y\C\C:f't lY\Cd"C\ Date 7-1'-1-05 Date ofBirth Age z:;n I J - ZI -S'V Vital Signs: WT lIT Temp Pulse Resp _DP: (need3min) Vision: L201_ R201_DoIh2.01_ Color: 'Hearing: Leftear SOO 1000 2000 4000 lUghtear 500 1000 2000 4000 . 01 ',w IIUSS or tenderness - 1iverIspteen . hemia . -:- am1S and reWm. . -h<:moeWlt OU.mates: . - temsfs<:lOlUm. .J=ls JtOSb.to . enemal vat;iJla' -um\n - b1.a<l.<<t cernx u\.<<IIS . adnW. -\' parameIria nod:. . . uilla' . --troin !:1IPtac1a~cu1ar 0IheC - mnialn= . -J)'IR . ieo$t.tiOll. . . judgtment + insi&bl odented X) -,- new -I-<>1d memory - ~an.deffe<:t S\:in:+ Sub Q ~ .Ja1pate ." .>tCbecl:ihysteminn<irm.a1. if al,notmalptease elCp1ain GenecaC_av.-alce, elert,1)ad.' . Byes: _coDj and lids _PERll.LA. Fundi J3ttll,{ extcm andnoso _canals . _heacin& .' '. _n=l.mucosa,tuW,ceptum . '. ",---Ups.~gumS . -oiop~ Ned:. ._thyroid. _trad1ea. Resp _au=ltatiOtl ~iotl ~ta\iOtl _effort . (N' ~tiOtl " t}alpataiion. e3rotids -::- M aorta " fem e.rtety : ~pulses . . ; atl:cmi1ies for e4ema: " . - {YUioosilies . . . J3tWts~~Oll. --palpatatiOll. Qfbreasts ana uiUae Psych: au females: L)'Illpb: (2 miD) 'Neuro: ME --..r;ait and staliOll. _inspe<:Ilpalp~te di&lls and m.iIs .123456-~oofpalpation. 1~456-ROM 1234S6-stal,Uity 123456-m1lSC1e sI!eng\h and tone X-ray: DS:_ minltopio ". " ' of~ following uea _1 head, noc\:..J spine, nos, + pelvis 3 RUB 4LUB 5lU..B =6UE UkpB: EK.G: SG:_ Oth~ Twe based Visit: To\a1.1im.e . . Assessment and.plan: tninloounseled time :Patient N:une: 5--1S:'v'\ r I {(~c..!'\Ci M (ii'Cr Date: 7-;=;:r:o:;- DateofBirtb:JJ - Il-:;;'l- Age: 5D . CC and lIP! (lOc, mod factQr3, duration, quality, severity, liming, context, sigrdsx) CC: '.' '. . \> \- \=0 k-- sc.eV'\. Coy ~9cl 'fCQcj c&. ~('1i.,c st,\\:J. I,! cD S"00~~r .~/tP;:L; RmewedpMt: nw_ NOIM--:-- X-rays OIher . .' ROS: ~o()bWnedfrom: l'alient:_ 1':Irent/G-=dian~ Careti=:_ Oth<<: . Cheek if system h nomul, eirel~ if system is a\notmai Conslibltional-fevtr, wealcnw, wr lo$$/tain, ~.!a1izn(l, ellills _ OU:polyuda. ~n:ocl\lrla, 'IlI!;eney, freq, he.wdwia, genlesio~ :=.d:;s _~~~het:ziilg. c<>"C!tb;hetrq>hysi.s orthopnea G1-abdl'ain, eramplnt, anorexia, nausea, ~ting - .Jianhe", constipation, hemonh>go, tee1al bleeding HemeJLympli-adenopathy, anemia, inc bleeding. - blood disorder, frtqUellt sitl::ness _MS-arthraitla,ll\yalgia, pain, swelling, . baek pain. stiffuess _3mti$h, IllIlle cWlgt$, j:mndiee, itch. lmlising,lromp3, tWn=, ksi0D3 _NeIlro-tintling, nom\>=, tOe, pain, sel=t$, ataili, memory, dizzy, radicn\:ltsx. . _l'S}'eh-h)'pttS6.mnia, anxiety, S\liei4al, insomnia, pbcbi:l, depression. _l!Jido-nl~sweau, hair losdgain, irMl ~ heat/cold _AIlergyiIrl>mun-ha~ever, foOdldrog illergy .- _Eye-mill change3, die, cataracts ENT.he:uing loS3, pain,ho3IllCS3, ~istaxis - congestion, n=1 die, tinni.lu!, dixt1 CV-cl>esl pain, syneope, palpitatioD.3, e.lema, - c1a~iicn ; " Allergies and Reactiol!3: See inside cover or ehart . Mcllli: . . Sxlci: Meds: (mod list was te'liewcd l'aro,ily. and-opda~ Social: Sm.ok~ EtOH: . l;)rult,s: Sex: OeoJpation: :'~~'cr Health Center Corporation . North Hanover Street Carlisle, PA 17()B h\knt Rame ~ )C:[~ 1\ m tcC:Jl\iu'h0,^C\ Date 1/ I Z. - 0 c:;; Dat~omklb. II-zi - <;LJ /\go 50 Vi~Signs:WT lIT Temp l'ulse_Rtsp---1ll': (need 3 min) Vision: L2QI_ F.2ot_ Both2.01_ C<lloi: .Hearing: Leftw SOO 1000 2000 4000 Rightw SOQ 1000 2000 4000 . 01 'aMwassoctende=s . lli'aIsp1-. . heroia . ~ = andtetum. '-h~ te;t='~ ...J=is . JtO$b.lo . c:xtema1 Vl.tina. - uteI1n blaM<< _cenix ut=s. . -~-t~ ~ ned;:. . - uilla . : -.r;roln . _,_. '_'__ . _GI1l?ra_\'lOUl4' Other . - mnialn= . -IJ'I.K . . ieQsWOD.' ~ent -t lnsi&\il odentc:d 'X 3 - m,w-l-oldmem.oty - moodandeffe<;t Slin:+SubQ ~ ~te '~Chec1c. if &ystem in. nOrmal, ihbll.Qcmal pl=~ er;p\ain. Geneca1:_e.wake, alert,Dad . B~: _conj and lids _l'EI1.l1U-. Fundi. l3N'I'M . m ~arnlldno$O . _=Is _hearin& , . _nasal mucosa, turo, septum " . ._Ups, toetb,'&=s -ot'op~ Necl<: ,_thyroid. _tra<;1= Resp _e.u=1\!.\iou ~on. j3.lpata\ion tIiort 0/' , -auscultation . ~a1pataiiOll. =tids --::- e.bd e.om. . fem. e.rtecy . ~puhes ; t.lctccIul1ies for cd= . .' Harloosilies . JJtCasts~jllspeottOI\. ---.Pa\p~ouofb=ts aM. uiI1ae GU.ma1es: GU females: . Lymph: (2. tnin) Ncuro: 'l'~ MS --tai\ e.nd slallon _inspcollpalpite digiIs and. nails 1"3-\S6-inspecti.oDlpalpw.oll 1~4S(j-ROM 123-\S6-stabUity l?.3-\S~e &lreDg\hand lone . 'X-ny: BS:_ of the following area -.1 h~d, ne<:\:. .......J.. spine, ribs, + pelvis 3 RUB "WE 5 1ill3 = 6lLB Uk pH:----:, SG:_ Other: BKG: . . millItopie Tune based Visit: Total. tllne Asse<:sment and.p\an: minlOOI1llS<:\ed time Yatien.tN=e:,S ,cr'"" n .....\..A\CllY1(:~ .---. Date: 7- )'7_ - 0 '5: Date ofBirfu: 11 - 2/- 01 .. Age: .r-;O - CC and 111'1 Q60, mod factors, duration, qoality, Wletily, timing. cOlltext, sign1:sx) co. .~\- \-.,~f'G. ~r -pPd, [hi Sc.}.o0L. -' ~9c\ ~"e.", Q ~fCO-(""'" lc,.\-tt60~l\:l''i r . -IJ11~'.. .' t /?JC(CCLy Revicweclp:lSt nw_ Notcs_ X-rays Other '. :. ROS: info obbineafrom: l'atien\:_ l'arentlGuardian_ Carer,i=:_ O\her. Cheek if sy.slem is nonll'll, eirele if sy.slem is abnottn:l1 CollSlitnuona1-f=r, ~ WT ~gain, ~.faligl1e, el).i1ls Jyc-visualchanl!,cs, ~e, eabracts 'EN!.}.eating loS3, pain, hoan=,epistaxis - toll&cslion,nasa1 ~e, tinnitu3, dizzy C'l-ehut pain, syn<<>pc, palpltatioM, tdema, - cla'lidie;liion . ~ OU:polyuria, dy.rorla, nocturia, 'IlIteney, freq, he1;natnria, gen1esions, sex. clys _MS-arlhtaig\a, mya\gla;pain, swclling, . back pain, slifi'nts! _Skin-rash, ~1c chailgcs,j:rondice, itch bnlising. b1nnP.s, ttdneS3, ~01l3 _Neuro-tint1ing.llIl1llb=, LOc, pain., sei:zures, ataxio,memory, <liny, zadicubr sx. . . .' ; R~nea, wheezing. COI!r,b,hemophysis - orthopnea . . G1-aMpain, mmping, anorexia, tIl\'O$es, vomilillg . - dimhe3, C01l$tipation, hemonhagc, Ittt>1bleeding nemtJL)'Xtlph-ad~JlQpat1ly, =ia,inc bleeding, - blood disoIder, fteqnent sickness _l'syeh-h~mnia, anxiety, :roici4aJ, insomnia, poobia, depression. _1!Jido..Dir,ht sweaU, hair Ioss/gain. intol . ~ heal/cold _Aller&)'Jlrmxran.hayfever, rood/drug . oller&)' Allerr,ies m1 Reactions: See inside C4"1Cf o{ chart . MedHx:. . sx hi: Mods: {mod list was reviewed l'amjIy: Socim: and1lpda~ Smoke: BiOH: . Prol?~ Sex: Oc~pation: ............."'....... ~.&........u"u ......"'11.\."'1 vVl.}!\JliiUUll .. ~'l North Hanover Street .-dTlis1e, P A 17013 l'atient'Name Su."{\{"\ f1\G.C.W~("(\ Date (, - ~ - 05" Of' '''"J(r ,0- I/Gir_ VitalSigns:WT lIT Temp (. :....)pulse.LlL-..Resp~BP: 7by (n=i3roin) Vision: L201_ F.2.01_llotD201_ O:Itor. Rearing: Lefteat' SOO 1000 2000 <\OW 'Right= SOO 1000 2000 <\000 . "~k if &y.;tcm in normal, if abllotlIlal please explain Genecal:_avn.ke, alert,nad Byes: _c:oo.i and lids _l'ERmA F\Uldi. BN'IN ~ea[ull.l1noze _c:=1s hi . -~. nasal. tlll100Z8., tilth, sqrtum '.. ---:1ips, teeth. gums - aropbarytpt. 'Ned: ._thywid. trachea Rezp ~ution ~on. ~ta\lon effort CV .. ~~uon :....Jlalpautioll. earotids ~ abd aorta . fem U\ety -.PCdalpu.lses ; cxtn:ml.ties for edema _ . - N1rlOQ$ities . ~rfasts:__jnspecQoll ~atatiOIl ofb~ and uillae . . MS --tail and slatioo. _inspec1lpalpato digits and nails 123<\S6-inspectioolpalpation 12.34S6-ROM c 113456-~ollily 12.34S6-muscle slmlgthand tone . BK.G: X-ray: B8:_ eM massoc t~=~z . 1ivedspleea. hernia -:- anus and retwn - hemooe1l1.t - ~;erobUll. ..~. -prostate GU female$; mew! vatiM. - urelln bladd<< _<<Mx WtUS' . - adnW. +param.etria -~ ui1I.a. . . -&TOin supraelavicular Olhef - wnial netYCS . --:1J1'R -,cosatioo. . lud&em~ + insiglit odented X 3 - Mw-l-oldmemotY - tlloodt.l\.hfl'~ Sldn:+ S\1b Q !lIspCQt ~to .01 GU .males: L)'Illph: (2 min') Ncuro: l'syclc of the following area _1 heid, ned: _2 spine, nos, + pelvis 3 RUE 4LUB S RIB - 6lLE UA:pH:_ SG:_ Other: Tune based VISit: Totallitne Assesztllen.t rod.plan: minleounseled time minltopio patientName:S ).Q;;.)Y~crLW1I)D(l.,\ b of /' Date: --.") - oS Date of Birth: [1- D ~ Age: 5h CC:wd ill! (lee, mod factors, duration, quality. severity, timing, context, signslsx) CC: .' . ~ ~~ ~ fPD ~ - ,;;trlC;~ ~~ 6 c\\~c-" Cb> bCd-l\"I ~I,;- H..- 0031'-''-1 r '1- 00' ";:::. P1C'~ Reviewedpast BW_ Notes_ X-rays OIher ROS: iJUo obtained from: l'atient_ l'arenVGua.tdi:m._ Categivet:_ Other. Cheek if system is no.rmal, citele if:system is a~ Constill1tional-fever. wemess, W'l'loWtain, ~.fatiguc, chilI$ Ey~vis1Ia1 changes, dlc, eatmcb wr-hearing loss, pain, hoamess, epistaxis - eonlr,cst1011, nasal die, tinnitus, di7:zy CV-eh~ pain, synwpe, palpitations, e<Iema, - e1a1idicaUon _ OU:potyoda, ~ nocturia, UtJ:eney, frcq, htlnalllria, gen lesions. sex. d~ _MS-a.tthnitia, myallr,ia. pain, ~e1ling. . back paiD, stifl'ness .< _Skin-r.lsh, mo1ecWltC3.jaundice, itch \mUsing, hllmps, redness, lesi01l3 . . ; _NCIlro-tintliDr.lIll.lnbness, LOC, pain, sei2urC3. atni., memoty, dmy, tadiellbt sx. . . R~" wheeziiIg.COI!gh,heioophysis - orthopnea Gl-abc1 pain, cmnpillg, anorexia, nausea, vomi1iDg . - di3nhe., constipation, hemonh1t;e. reelal bleeding HCIIldL~h-adenopathy, anemi.,lne bleeding, - blood disorder, freqoentslelcness _Psych-hypersOmnia, anxiety, Slliek1al. insomnia, phobia, depression. _~ni&1it sweat!, hair loss/tain, intol to heal/cold _AllergyJtrnnnm.hayfe'l'er, foodJdtug allergy AllCIti~ and Reactions: See inside <:0= of chart . Medlh: . . Sxlri: Meds:. (mod list was reviewed PalI\i1y: andupdated) Social: Smoke: EtOH: . Drugs: Sex: Occupation: _.___ _..__~~ .....,,,............ .......v1.pvlallVll ')0 North Hanover Street _ar1is1e, PA 17013 l.'atientNamc Sl.lIbQ.\\ Date I,p - d OS n\lJ\Q.n(\m()J~ DatcofBhth \ \ <l\ ^ 5-Y Atc50 VitalSif,ns:WT/J 1 'k Tempq)f);~ILRespliDP:~~ 0/ (need3min) Vision.: L201_ F.201_Both201_ Ollor: .Rearing: Left ear 500 1000 2000 <\000 lUglrt ear 500 1000 2.000 <\QQO . .Ch~ if ~ in normal, ifabllocmalpleasc explain Genera1:.J::j.wake, tlert,nad . Byes: 00ni e.M lids ~ ENTM ~eanI e.Mnose . ?l)~$ ~UCosa, tutb, septum '~~gums . , _ aropbarrt!x N~ - .....1hyroid . Resp ~~~tiQll. ~Qn. ~talion . .... -iLeffort '. C'V' JL8l1SI;>.1\~tiQn ~alpatalion _carotids -.:...e.b<:1 aorta . _feme.rt<<y . --I>Cda1 pulses i ClctreIlll1ies for edema . . - Nadoosities J3~~.Jnspeotion --palpalallon ofbteas\$ and uillae OU .wl.cs: . 01 .~ mass or teodem~s i2:1iver/sple<<> . h=ia ~ anus and retam. - hemoewl.t tested sct\lt1ml. ~ ----.Prostalc GUfema1es: _~~ =On -\>ladder o:rnx ut=. . ~+parametda - e.xillA . . ~ ~C1avicu1ar Other - cr:aaialneeves . </UIR l./'i<:ll$ltioll . </'iudgeo=\. + insig1i1 V'"OrlCllted X 3 <:7 MW-l1lldm=ory ~1l1OOd and cffeQt Skin:+SubQ ~ ~a1pate Lymph: (2. min) Neuro: r~ . . MS v{ait and S~tiOl1 _~pa1patecligits and Il3i1s 12.3456-inspeotioolpalpatioll 12.345(j-ROM 123<\5(i-stabllily 12.3456-mus<:le slmlgfue.lld tone . X-ray. 118:_ of the following uca /' _1 head, n~ ~7. $pine, nils, +pelvis 3 RUE 4LUE -SlU.B =6W3 UkpR:_ 8G:_ Other: BKG: Time based VISit: Total fune mioloo\ltlSeled time Assessmen.t and.plan: r p ,,~~~ f~ (fD'~ \~ &/~ 1..' "I-~~"'" C'10~) , em' ~ minllopic rAt-..u,? DPI]) l'atien.tNmne: SU)'\,l\h \\\'\~\\(\l'0(ln'- DaleofBirtb: \ \- ~\-M D:>te: l:, -705 ,. Age: 3.. j -"\ CCM)d}IPIOOo,modfacto~,duration,quility,severity,timing,conle:xl,sjgn.!/sx)CC: ..... "."" . '-7\':-'" ':p-\-' k(L. (01' yf-- . :..:.\1 \\A.JLU~~ v'\-t?tAe1 W @'Pf D; sbw\.tl ~ t> b u..+- ~ (fu5h.; w,+- klvuis_ 5M '^- ~ hrx..i 01J0 'j ~) r-ol \-ra.~ O>d-' t>-(; ~ /J1 Last- :~.~. kelj'~ ~Jl . Reviewed past nw _ Notes X.ta~ Other . . I> ROS: jnfoobtainedfrom: l'atient"/ l':u:ent/01l:Itdi:m~ Categiver:_ Other: Cheek if system. is normal, circlo if system is al>norma1 _Eyo-visual ebanges, die, calataeu ENl'-hearlng loss, pain, hoamess, epistaxis - congestion, nasal Ole, tinnitu3, dmy CV~tpain, ~ palpitations, edema, - cla\idlcaiion _ QU:polyurla, dysnria, Meroria, mgeney, freq, henIalutia, gen lesionJ, S~ d:p _MS-artbtaigla, myalgia, pain, swelling, . back pain, stiffness . Jkin-rash, ~le ch:lnges, jaundice, itch bluising, bomp:s, redness, l~oll3 _Nt.Utl>-\ingling. numbness, LOC, pain, seizures, .luia, memory, dizzy, nWiC'Olar $X . . ; Con.sti\\ltional-fever, wealcnw, wr lwlgain, ~ .fatigue, chills Resp..iyspnea, wheezing. C01?th. hernophysis - orthopnea Gl-M pain, crampIng, anorem, nausea, vomiting - dianhea, constipation, hemonb1ge, teeta1 bleeding lIemeJLymph-adenop.1hy, M'eIllia,!no bleeding, - blood disorder, freqoentsicl:ness _l'syeh-hypersOmn.ia, anxiety, suici4aJ. insomnia, phobia, depression _~ni&1it sweats, bait lossIgain, intol to heatleold ~All~gyJImnum.b1yfever, rood/dtug olletgy Allergies and Reactions: _.~C- ---:::....-.. See inside CO'lef or chart ~ Fatl\i1y: Social: Smoke: . Medfu: . . SxbX: Meds:. (mod list was reviewed and updated) ErOll: . Drugs: Sex: Occupation: PatientNameSUbf\.f\ r\\QQXCU'Y\Cll{~ Dateo[Birth \\\2...1 \6)4 Date i L: \ ~ - () \1 Age r"'l) Vi\alSigns:WT B'-/,qm 5::1 I~emp q~S' PU1seLRespKBP:lli) lLj (need3min) Visi<>n: L201_ IUOI_ B<>tb201_ Col<>r: Hearing: Leftear 500 1000 2000 4000 Righteac 500 1000 2000 4000 GI ~~Ql'tend= GCUl1 k~'V-4<) _livWspleeo. hemia - anus and retum. _hemo<x:ult _testeslsorotum .....Jl<Ws ~te GU females: _ext<:ma1......giM _URthn. _btadder _cervU utecus adnexa + panmetria . ~ uilla ----P'Oin _ suprac1aviCll1ar Other cruia1 nef\'t$ -PTR sensation ~udgement + insigh( <>dented X 3 -new +old memory - tn<><>d and effect Sldn + Sub Q inspect ---palpate "Ch<<k if system in 1lQnnal, if aboorm:Jl. please exp1ain. G=al.:_awake, alert,nad Eyes: _cooj and lids _PERRLA Fundi EN"IM --;xt cali and MSe _eana.ls -b.earing _nasal mucosa, turo, septum. .. _lips, teeth, gums -<l<Opbarynx Neclt _thyroid _noMa Resp _auscultation -.J>=USSioo. --.l'alpatation _effort _auscultation -.Jlllpatation _carotids _abd aorta _fem e.rtery ~ pulses _extremities for edema . .fvaricosities llRaSts_inspection --"palpatation of breasts and uillae GU males: Lymph: .. (2 min) cv N=: Psych: MS ---1;ait and station ,-..........., -'--le d" its and nails _"""Y'^'vp....- tg 123456-inspectioolpalpalion 123456.ROM 123456-stability 1234 56.muscle strength. and tone EKG: X-ray: liS: of the following area 1 head, neck 2 spine, ribs, + pelvis - - 3 RUE 4 WE -5RLE -6lLB UA: pH:_ SG:_ Other: ,,-.. ----------,,-- Time based Visit: Total time' minI=led time mioltopic Assessment and plan: J}; /hcdofCXAA..JG f,' frlrL~ Schpckd.e ftLf: ()1L4..t'YL/YLo '/iAl;)'-!5AF~~. ilea.1..fI'O Jf)mW../1 H~fd: a-i &-11 IX ;tl et'l( e.. UILA.A.i! dJ..! .s/X.10 - ... v..UiU- ~/":~ ~ f'(~l)~{,k~ ~<dl\ 5fRUi,....~1 V\ hL_iII. r~ ,/,\ c:; ,r Patient Name: 0\..\...1:x:\. '\\ _ I. i\C'fUJ,'\'\.t,YC"-.J!ateofBirth: \ \ \ 2..\ \..! ~ he-''', Age: c.l ....., \.c. C',U Date: \ L,.:' :_)- .. \ CC and liPl (lee, mod factors, duration, quality, severity, timing, conte>.t, signs/sx) CC: \\(,(t~\.,<\~'y '0'\9X'u~.~":> \ \:)\()(jC\ (VI V\..v~vu..0:~~\o'v\'\B\'V"q~~ \~().\ \~ OCu1SI,""'-.l bloo). 1(\ Lui.J../\f.!..,..j." lF~' ~ ~5 o.s;.p {j..!as {..old. ,~ u..?I..<, (haW P(.i..LLoe.. H<l.S "A !w 0 f'2"u.C:d .f-Lull. e I c.r.z{. ~U\h. i. ".1 z I - [.'{;'1. lviU/lt J<A.({id..,(~ /mw c2 ~ hvJ boc1:. ~"'1:.5 Since f-A.(J} +'M.e Iv:<.:> /--..:Jd.. eM. ~ P /J.1) b/(ec/J.f.. 1JJ.ct'TI ~'V)) ~Lu..i'I4[J c t~ SL:/J bU/LA-.Ut;,) ~)~ Iud... Qfiq .. ()/Reviewed~ BW_ Note, X.n)'$ Other f~' <ikoer: ROS: info obtained from: Patient:_ Parenl/Guardian_ C>Iegiver.~ Other: Check if s)'Stem is nonnal, circle if s)'Stem i. abnormal Constitutional-fever, weal:ness, wr loss/gain, - fatigue, ehilli _Eye-visua1changes, die, eatarac~ ENT -bearing 10$$, pain, hoarness, epistaxis . -c- congestion, nasal die, tinnihl3, dizzy cv<hest pain, syncope, palpitations, edema, - claudication Resp-d)'spnea, wheezing, <:<>ugh, hemoph)'Sis - orthopnea Gl-ahd pain, cran>ping. anorexia, nausea, vomiting - diarrhea, constipation, hemonhage, rec1al blcedillg HttnelLymph-adenopathy; anemia, inc bleeding. - blood disorder, frequenuiekness _ au-polyuria, dysuria. noelnria, urgency, freq, hematuria, gen lesion>, sex d:is _M3-arthralgia, myalgia, pain, swelling, back pain, stiffness _ Slcin-rash, mole changes, jaundice, itch bruising, bumps, redness, lesions _Neuro-tingling, numbness, LOC, pain, scUmes, abxia, memory, dizzy, radicular $X _Psych-hypersomnia, anxiety, suicidal, insomnia, phobia, depression _Endo-night sweats, hair \osoIgain, into1 to heal/cold _AIIergyllmmun-hayfever, CoodIdrog allergy Allergic> and Reactions: . N KA Med Hx: Sx 1u: Mods: (mod list was reviewed and updated} See inside cover of chart Family: Social: Smoke: . E'IOH: Drugs: Sex: Occupation: ~ ~ Sadler i He"Ith Center Corporation Page Number PROGRESS NOTES Name: 5( pc.,OJ\ r{\'Q c. r(.LN\.cU~ DATE l d..'l/ <SLf G -G D'i- . , J ui :. I~JI'" 'J, . I 'I Ld 10, cIs. g:J(\t.+O (,)L~+- feJ.)~d;'n ~2J,(,'r'nnY\ -fl~C\ i~(.;t:l,Lt:L, _ PbAJV\.9,1C -. jO~ _P. r\A WI-ctr.nri I.~J -",Ah 11' ll'rl) ~ Carlisle Hospital and ~, Health Services. CLINIC SERVICE PROGRESS NOTES Name:,C); lfY.yUr> m Illtlt.,j7(Jp;Yl~ - Page Number: 0 DATE -1;;;~{)J 1/;J'I/(j';< Wt It/G. 7 BP {(fO)(j;r T 1z'7 PR 7~ RR I~ kt &JJ-i' CL1630 (4198) R. /t'7}t/??ik/C/ 5r She is to tell the Encore Program that she has the order and they go ahead and have it scheduled without repeat exam. Will notify Susan by telephone of results of mammogram and Pap smear. If unable to reach by telephone will send a letter. Susan is agreeable to the above treatment p~an an ffers no further questions. ~lolc 1 f1ff LOlvld D: 07/25/2001 T: 08/03/2001 ois OrndOrf,~ / PPR ~CV\ - &M"..ut-- r-{J C.Uy/r!-u.r . cl . c:k-~d l./~O~ - \" . ________.-------=~(!J~~ ~~Z-- DATE I '.;l~'D I 11- J-(J} il;;-s-!o ( Wt I_~,g BP 110/70 T 9g3 PR "7J..... RR /4' '-ILi 0;)" CL 1630 (4198) ~ Carlisle Hospital and Health Services,. Page Number: 6' CLINIC SERVICE PROGRESS NOTES ~)crJ)O 41J{PA.A I ~I J---------- [CO). A ril because of inadequate 3. Will repeat Pap smoeaner nl~ a~d because of comment of endocervical comp . cytolysis with bactena present. as needed basis. Letter is Will follow-uP with Susan on an h Share . ( 4. dictated to the physician through ~~,,;;(<Y"(J f . O' 01/22/2001 T: 01/23/2001 .::(201S Orndo ,CRNP Lf;>N!cH-9x'~~~ I 1%i:/iiJ;~ Name:..:::iJ MJ) ---- R SUSAN MACNAMARA WOMEN'S HEALTH CLINIC 07/25/2001 SUBJECTIVE: Susan is a 46-year old Caucasian female presenting for repeat Pap smear. Pap smear from Jan. B, 2001 was inadequate because of inadequate endocervical component. At that time there was also a lot of bacteria present although GC and Chlamydia were negative. Susan reports no new problems, no recent illness. She did see the orthopedist through the Healthshare Program for her right shoulder. Susan states that the "lump' under her right arm is still present but does not bother her. It was examined by the orthopedist as well who felt that it was not an abnormality. Susan is also interested in getting the mammogram that was offered January B at this point. OBJECTIVE: Exam of the right axilla reveals a soft, compressible one em. mass that feels like a prominent axillary vein. It has not increased in size and is nontender. EXAM: Today is limited to pelvic exam to repeat the Pap smear. External genitalia is that of a normal appearing female. There is some atrophy of the labia majora. Vaginal vault has white mucoid discharge. Long Peterson speculum is used and the cervix is visualized. Cervix is pink and moist. Cervical os is small, round. Susan's children were all delivered via C-section. Vaginal Ph is less than 4.5. Bimanual Exam: The uterus is small, firm, anteverted and anteflexed. There is no cervical motion tenderness. There is no adnexal tenderness. ASSESSMENT: Repeat Pap smear prominent axillary vein. PLAN: 1. Pap smear is obtained. 2. Wet prep is within normal limits. 3. New order for a mammogram is given. She is advised to contact the YWCA to have that scheduled through the Encore Program. CCL<JfL{-t flttt~ DATE I tt?,; ()/ ! L' ! 'o-o-DI Wt -toLl BP- IOO'/JeO T ~ IIq(!) PR-'6'iS RR-OV. ~, Carlisle Hospital CLINIC SERVICES PROGRESS NOTES NAME :-, ( ((;,-1'11 \\AdJ )--- rhythm. Lungs are clear to ASCU. There is no CVA tenderness. The left shoulder is nq,tender, when tested for range of motion. Right shoulder is limited with external rotation due to pain. She does not have a thoracic outlet syndrome. The radial pulse does not diminish with external rotation. Breast are symmetrical. Both nipples are everted. There is no skin dimpling or puckering. Axillary nodes are not enlarged. I am able to palpate prominent axillary vein, which is soft. There are no nodules palpable. This axillary vein is in the right axilla. Abdomen is flat, soft and non-tender. Liver and spleen are not enlarged. Femoral pulses are palpable bilaterally. External genitalia is that of a normal appearing female, without lesions. Cervix is very posterior; uterus is anteverted, smooth and non.tender. There is no cervical motion tenderness. Adnexa are non-tender. Hemocult is negative. Vaginal pH is less than 4.5. Wet prep is within normal limits. A: Right shoulder pain. Annual exam with Pap smear. P: 1. Discussed STD testing and did collect GC AND CHLAMYDIA. 2. Patient is advised to get a mammogram. Patient does refuse the mammogram today and she will consider it at a later time. Importance of regular mammogram was discussed. 3. Susan is given Family and Children Service phone nSuhmber and hand out for counseling and parenting Issues. e IS also given the Helen Stevens number for Tipps program. . Susan voices understanding of the above instructlo~s and Will follow up in approximately two weeks for re-evaluatlon of the shoulder and lab results. rtO'L.~~ N!lff LO/ks D: 118/01 T: 1/9/01 cLois Orndorf, 'C.R.N.P SUSAN MACNAMARA ADULT HEALTH CLINIC 01/22/01 S: Susan is a 46-year-old Caucasian female presenting to clinic services for follow-up of lab studies that were collected January 8, 2001 and to re-evaluate the right shoulder. Susan states that discomfort in her right shoulder has basically unchanged, or is intermittent in nature and occurs with movement of the shoulder, for instance activity such as combing the back of her hair or reaching behind the car seat. She has not found any medicines, which were effective. She had tried Advil, but seemed to have no relief. She states that the pain in her shoulder has been there since July 1999. She also is concerned about the lump under her arm, which she is still able to palpate. Susan, again, does refuse the mammogram, stating that the pain in her shoulder started a month after her previous mammogram. 0: Please see the margin for vital signs and the lab section for lab results. A: Follow-up of lab report and right shoulder pain. P: 1. Discussed ideology of the "lump" under her right axilla and the importance of having the mammogram to ascertain if the lump is resulting from something in the breast tissue. She again does not want to have mammogram done. 2. Referral through Health Share to orthopedic office for evaluation of the right shoulder. C ((11 ~'I MUC\~---------- ~---------~ R , ~. cu.J;ho/JCcJ ~l" ~ r, '21 ~ (- #tLt!tIt~OdC tJ,l.J..wrJ/j .1 , (j . j., ,JhLkJIa .x.{)&. Cued,,;'!' '\ - , A" It' U, /",' ,/lP," - , . Vi I \/Ule v c/ Llt.LJ'IU0-{/ CL 1630 (4/98) ~ Carlisle Hospital CLINIC SERVICES PROGRESS NOTES Page Number: ~ NAME: ~,,~7J~ ) LA..n~ DATE R 'Lr.lfU /d !I,:;;'!O(.) /7. (tt..lt50 I !-a:i!Gi w t I,)f,.(l lief (1'''' BI;,~ I :J T 'icr - PRJV RRi~ Ti> i.Lp JUyYi-R-- OJ)) ,-fiz y" fJ~i: dL~d #t~Lz.~fJJ-. ~ / , , Jfh., i/ J oJ f?'CO am ~ /1 {j':.,2.Y- ( f{ (0 I IJ' \.SJlcJ.jf. '! .4- (to?. QJtJ '5 ../i70/e..o 02- OL . :!)' ~,-' ~OL-~~~~ ~~ 'J t.#_~/~W~~/ ~ 1t-frW. ~ Qll tc..LL pa~ t1-I: V'-t/ A. A ~ ,Q . ~ QJ<..t- -/e.--t.-U> ~ ~C' ~ . ~I~ -h tJU~~- t1kW CL !3~. 'L__' trCIJ fJ ~ ~ ~, ~ fYl IY\.T"" ,m /YI. ~tiJ... pr-crt-v t1.. hod- [ (pttL M, !5u i!A- aLJ ~OL. .~~ ~.~ tU'if'O ./-c t3ilU... tJhyu"C- If ~ ~~_!:;r ~U7;rtf-. t/.U----- C?~. 1/8/01 MACNAMARA"" SUSAN AHC VISIT S: Susan is a 46-year-old Caucasian female presenting for annual exam. For exam of lump that she has been aware of in her right axilla and painful right shoulder. She also slates that she had some intermittent episodes "light headiness" maybe once or twice a year, she believes it to be related to using a computer screen. Susan's last complete exam was in October of 1998. Susan is divorced; she is a G7P3 with two miscarriages and two abortions. She has been single since 1994. She has three children ages 10, 9 and 4. CHIEF COMPLAIN: Lump that has noted under her right axilla. She states it has been present for years it is not particularly tender. She notices is occasional when she is showering. She has no know injury. She wonders if it is any way associated with the mammogram that she had done several years ago. She is also complaining ot shotting pain in her right shoulder that begins at the clavicle and extends down to the mid humoos. This pain is also intermittent: she is not taking any medication for it. She has no known injury. She states that the pain occurs with particularly types of movement; for instance if she were to reach over the back seat of the car that produces the pain. Slates pain will go away without intervention. Last menstrual period was 12/18/00. Her interval is 30 days. Periods usually last about 5 days. She was last sexually active approximately two years ago. She has nd"had any STO testing since that time. She states that she does feel stressed out at times. she drinks a glass of wine or beer mostly every day. She is currently working at Rite Aid from 8:30 to 2:30. She is interested in connecting with some counseling to help her dealing with her children. She states she is trying no to yell quite so much at them. She does not smoke. 0: Skin is fair complicated. She has light reddish hair. Thyroid is not enlarged. There are no cervical lymph nodes palpable. Supraclavicular nodes are not enlarged. Heart is regular rate and r (~_ ,(J~'", , //}wrnm) f).{ ~ I {liP u ~~c a [' ~ {!jJCl.-Jd((( .::i~dcur (!KttfP CL 1630 (4/98) DATE 9/dr)q7 toltc{ It{ y. wt/c?.1 BP 110170 T qq.!." PR 70 RRdO F-/-t 5' I t" (II I<A L '" P j,,\q\~1 ...\,(h"~,,lL. /IIJ ( If? Page Number: eX ~ Carlisle Hospital CLINIC SERVICES PROGRESS NOTES NAME: "(!I?7tz;ni-<LC~ // pill. She is unsure. I gave her literature. She might be interested in the diaphragm. PMS counseling and written material given. Advised Tums 500 one tablet b.Ld. with meals for calcium supplementation and a daily multivitamin. Needs baseline mammogram which we will arrange at her next visit. Also needs lipid levels (she has never had that done) and glucose fasting. We will see her when she comes in on 10/14/98 for her exam. J1~ RS/bks D: 09/28/98-1639 T: 09/29/98 Rita SChlansky, [R.N.P. Susan MacNamara WHC 10/14198 S: Susan is here today for her examination, Previously had enrollment visit. Weil-developed 43-year-old white female, no acute distress. G 7, P3043. 0: SHEENT - WNL. Neck - Supple. Thyroid not enlarged, no nodules or bruits. Breasts are symmetrical, mild fibrocystic changes. no dom- inant masses, nodes, or discharge. There are skin lags on her chest which are very pruritic. Heart - RRR. Lungs - Clear. Abdomen - Soft. No organomegaly, masses, or tenderness. Weil healed scar from cesar- ean. No lymphadenopathy. Pulses symmetrical and intact. Extremities symmetrical. Pelvic Exam - External genitalia normal adult female with- out lesions or clitoromegaly. Vagina - Adequate support with normal mucosa. Cervix - Parous. Os - Bled easily with exam. No lesions. Corpus - Irregular contours top normal size. Firm, nontender. Ques- tionable fibroid. Adnexa - Benign. Rectovaginal wall intact. No hemoc- cult done due to excessive bleeding per cervix. Impression: 1. PMS. 2. Pruritic skin tags on chest area. 3. Unreliable contraception. Plan: Pap test obtained, will nolify of results. Breast self-examination reviewed. Osteoporosis prevention discussed. Is interested in the oral contraceptive but was unable to start this today because the patient was pressed for time since children were coming home from school, will return. Decided against diaphragm. Needs baseline mammogram through Encore Plus, will arrange next visit. Also needs the following labs, lipids, fasting blood sugar, and pelvic ultrasound for enlarged uter- us. possibly fibraids and will start the oral contraceptive when she re- turns. Her next visit is on November 14th at 12:45 p.m. J ~. RS/ar D: 10/14/98 - 3:12 T: 10/14/98 Rita Schlansky. CRN.P. .~ ~ tV.' ^-< 1'7" /%.P ,-"'--"'"" ./ "" ~/ "- ~_/-.~.. R p~ /,.,- CL 1630 (4/98) DATE 9#8'/9 r ~ Carlisle Hospital CLINIC SERVICES PROGRESS NOTES I Page Number: NAME: L I /YJ~ \.../' ~o/n '/,/ ~Jf' /fl/777()/l(){ MacNamara, Susan Enrollment. WHC 09/28/98 Susan MacNamara was referred here by Susie Studdard. She has sev- eral concerns. She needs a reliable form of contraception and she is concerned about several nevi on her chest which she would like to have evaluated. She is a 43-year-old divorced white female, G7 P3043. She has a significant other who she sees occasionally. He is the father of her youngest child. She had been married for seven years and that was her first marriage. Method of birth control currently - usually abstention but she has been taking some risks. She does not want a pregnancy. Denies dyspareunia. Number of past sexual partners are one to five male. Menstrual History - Menarche age 15. LMP 09/11/98. 28 days cycles. 6 days of bleeding. Periods are regular. No clots. Moderate cramps relieved by Advil. No 1MB. Flow is heavy. Uses pads and tam- pons on her first and second days. PMS symptoms of irritability one week prior to menses. Douches once per month. Douching was dis- couraged. No unusual vaginal discharge. No bladder or bowel prob- lems. OB History: She has had seven pregnancies. Two were SABs, one requiring a D&E and she had two VIPs, one in Philadelphia in 1973 and one more recently at the Hillcrest in Harrisburg. OB record--In 1990, delivered a female in Harrisburg Hospital, Dr. Halbert, cesarean delivery for failure to progress. Daughter's name is Erin. In 1991, male, Harris- burg Hospital, Dr. Dorko, scheduled cesarean. This child, Markus, has had problems with bronchial asthma. In 1996, female, Holy Spirit Hospi- tal, Dr. Manning, scheduled cesarean although patient was offered a VBAC. Daughter's name. Molly, has had many URis since birth. Children are ages 8, 7, and 2, otherwise, healthy. Medical History: No known allergies with the exception of mild envi- ronmental. No past history of blood transfusions. Present medications- multivitamin with iron taken sporadically. Occasional Advil for dysmen- orrhea and < V <f I, r, q ~ at h.s. No history of mammogram. She is due for at least her baseline. She does not do BSE. History of chicken pox. Had gestational diabetes with all three pregnancies and has not had a glucose drawn since and we will take care of that through the clinic. Tested for HIV during pregnancy. Satisfied with her current weight. No history of eating disorder or any type of abuse, living in a safe environment. Family Health History: Maternal side - mother had an MI at age 67. Father died of lung cancer. Has two brothers and two sisters. One sister with bipolar disorder. One nephew died of leukemia. Social History: Finished high school. Nonsmoker. Alcohol use is occasional and social. Does not garden or use recreational drugs. No cats at home. Caffeine intake per day is three cups of coffee. Her hob- bies are being with her children, camping and reading. Impression: Unreliable contracpetor undecided about what choice of contraception. We reviewed this in detail. I gave her literature. She has had moles on her chest since 1995. Would like these evaluated during her exam. They have not changed in size, shape or color but they are pruritic. Ongoing problems with PMS..irritability, gestational diabetes. Plan: She is to return on 10/14/98 at 1 :15 p.m. for her Women's Health Clinic visit with me. Discussed the possibility of starting the birth control /{ -/-. J I //Vl/ / dl/ /" /I R CL 1630 (4/98) MACNAMARA, SUSAN AHC 07124/2002 SUBJECTIVE: Susan is a 46-year-old Caucasian female presenting for annual exam. She has noted that her menstrual periods have become irregular over the last year, where she has a period every one to two months. Last menstrual period was May 23, 2002. States that the beginning of July she did have some spotting but not flow that would be consistent with any menstrual period. She is not currently sexually active and does not use anything for birth control. She has three children, ages 5. 10 and 12. OBJECTIVE: There is no lymphadenopathy, thyroid is not palpably enlarged. Supraclavicular nodes are not enlarged. Heart is regular rate and rhythm and lungs are clear to auscultation. There is no c.v.a. tenderness. Breasts are symmetrical. There is no skin dimpling or puckering. There are no fixed masses in either breasts. Axillary nodes are not enlarged. Abdomen is soft. Bowel sounds are present in all four quadrants. Liver and spleen are not enlarged. Femoral pulses are palpable bilaterally. External genitalia is that of a normal appearing female. Vaginal vault is long. used a long Petersen speculum. Cervix is only partially visible. Specimen for Pap smear is obtained. Vagina pH is less than 4.5; wet prep is within normal limits. There is cervical motion tenderness. Uterus is small and anteverted with the cervix quite deep in the vaginal vault. There are no adnexal masses or tenderness. ASSESSMENT: Annual exam. PLAN: Discussed the importance of doing monthly self-breast exams, encouraged her to get a mammogram which she declines at this time. Discussed the importance of earty diagnosis with a mammogram. Will notify by mail results of the Pap smear. Susan is encouraged to call the Clinic at any time she wishes to schedule a mammogram and will do so based on today's Clinical exam. She is also given information on hormone replacement therapies as well as a booklet on menopause. Susan voices understanding and offers no further questions. La/jrs D: T: 07/24/200212:36:54 07/27/200209:20:53 ~~(!RtJfJ Lois Orndorf,(tRNP Page 1 of 1 7186102 MACNAMARA. SUSAN 825381 07/24/2002 11/21/1954 ORNDORF. LOIS CARLISLE REGIONAL MEDICAL CENTER CLINIC SERVICES PROGRESS NOTES ,,<fft.. Quest ~t.:::i3 Diagnostics ~ 'JY QCSS7 Di,"\GNOSTlCS INCORPORATED CL1E!,T S?RVICE 800.825.7330 SPECIMEN INFORMATION SPECIMEN: NE669812M REQUISITION: 6534160 COLLECTED: RECEIVED: REPORTED: 12(17(2004 12(18(2004 12(18(2004 09:30 ET 02:18 ET 08:11 ET Quest on Dcmand™ PATIENT INFORMATION MACNAMARA,SUSAN DOB: 11(21/1954 AGE: 50 GENDER: F FASTING: U SSN: 210-44-3603 ID: PHONE: 717.243.2098 i -OR7 STATUS FINAL I ORDERING PHYSICIAN SHADLE, CATHY CLIENT INFORMATION N17013089 CH02 SADLER HEALTH CENTER 100 N HANOVER ST CARLISLE, PA 17013-2421 COMMENTS: LAB REF NO: 6534160 Test Name URINALYSIS, COMPLETE W(REFLEX TO CULTURE COLOR APPEARANCE SPECIFIC GRAVITY PH GLUCOSE BILIRUBIN KETONES PROTEIN NITRITE LEUKOCYTE ESTERASE WBC SQUAMOUS EPITHELIAL CELLS BACTERIA HYALINE CAST REFLEXIVE URINE CULTURE In Range Out of Range Reference Range Lab YELLOW CLEAR 1. 007 6.5 NEGATIVE NEGATIVE NEGATIVE NEGATIVE NEGATIVE NEGATIVE 0-5 QHO YELLOW CLEAR 1. 001-1. 035 5.0-8.0 NEGATIVE NEGATIVE NEGATIVE NEGATIVE NEGATIVE NEGATIVE < OR 5 (HPF < OR = 5 NONE SEEN NONE SEEN (HPF /HPF (LPF 0-5 NONE SEEN NONE SEEN NO CULTURE INDICATED QHO PERFORMING LABORATORY INFORMATION QHO QUEST DIAGNOSTICS-HORSHAM, 900 BUSINESS CENTER DRIVE, HORSHAM, PA 19044, Laboratory Director: MACNAMARA,SUSAN - NE669812M ;] IJt/UI ~1:' ~(+ rHQ:JJI8e '(')l!a.-)JULt I (~ L (\/\ ,~J?;J ~-ct{ ,... il- ~ ~~. "f:.~~l"Sl ~^r' ~ 'v \Y '\ ~f ~".s:_ O,,"<t O;"Q"o$\ic'. the lssooi"!~d loao ~od all.S5(lcial~d Q"",tOia~"o<\',"s,'i\1,h"p. '.het,-"!"".,,, r~ 'J"~,, fho;'"";c< ',< ,.,"" ;1,.","."':.,, 1""0,'''''''''' '" HERMAN HURWITZ, MD, peAP ,,,\Mhq . i di 0-+" (..d ~W-'J "I,/\0-h\'\J..I-' [J\ "/'Pf' \- \\"5\05> Page 1 - End of Report \J.. J. c.: \..:'--( ?L "",,,., ""","'M.^"" ;......0"" MACNAMARA, SUSAN MRN: 0000825381 Location: CLINIC DOB:11/21/1954 Age:47 Sex:F Physician: ORNDORF, LOIS Order#: 19240475 Date&Time Ordered: 07/26/02 12:47 Requested by: ORNDORF, LOIS C00315 Duckkyu Chang, M.D., Pathologist Henry S. Crist, M.D., pathologist FINAL REPORT SERVICES (PAdmitted:07/24/02 Carlis~e Regional .~ .kcal Center Laboratory, 246 Parker St. Carlisle, PA 17013 ORNDORF, LOIS sfilbi- 61 FINAL CYTOLOGY TEST-NAME RESULT Pap Smear see below GYN CYTOLOGY REPORT AB REF-RANGE UNITS TESTS: CYTOLOGY REPORT PAP 1 SLIDE (1) CLINICAL HISTORY/INFORMATION: LMP DATE: OS/23/2002 SOURCE: Cervix CLINICAL INFO: Not Provided COMMENTS: 7/25/01 WNL HORMONES: NOT PROVIDED SPECIMEN ADEQUACY: Satisfactory for Evaluation No endocervical/transformation g,q,CJ;j. -~ ------------------- FINAL INTERPRETATION ------------------- NEGATIVE FOR INTRAEPT'I'HF.T.T~T, LESION OR MALIGNANCY , zone component identified ~ Screener STF CT(ASCP) ELECTRONIC SIGNATURE ON FILE STF CT (ASCP) * The pap smear is a screening test used as an aid in detecting cervical cancer and its precursors. published con tin u e don n e x t p age Kev for Abnormal Column (L-Low H-Hiqh AB=Abnormal C-Critical T=Toxic) MACNAMARA, SUSAN CLINIC SERVICES (PT) ') of 7, 456 of S16 PRINTED 08/02/20Q2 00:1.5 Page: 1 of 2 COO315 6f9S C00315 Duckkyu Chang, M.D., Pathologist Henry S. Crist, M.D., Pathologist FINAL REPORT SERVICES (PAdmitted:07/24/02 Carlis~e Regional .cal Center Laboratory, 246 Parker St. Carlisle, PA 17013 MACNAMARA, SUSAN MRN: 0000825381 Location: CLINIC DOB:11/21/1954 Age:47 Sex:F Physician: ORNDORF, LOIS Order#: 19240475 Date&Time Ordered: 07/26/02 12:47 Requested by: ORNDORF, LOIS FINAL . ~fiA1of~ 61 ORNDORF, LOIS con tin u e d CYTOLOGY TEST-NAME RESULT AB REF-RANGE UNITS data indicates that pap smear testing is subject to false negative and false positive results. For this reason, periodic repeat testing and follow-up of any unexplained clinical signs and symptoms are recommended. RESULTS RECEIVED 08/01/02 ref:GY02249825EC Test Performed by AML, Chantilly, American Medical Laboratories, Inc., 14225 Newbrook Drive, Chantilly, VA 20153 (703) 802-6900 Key for Abnormal Column (L-Low H=Hiqh MACNAMARA, SUSAN AB=Abnormal C-Critical CLINIC SERVICES Page: 2 of 2 T-Toxic) (PT) 4 of 7, 457 of 516 PRINTED 08/02/2002 00:15 C00315 6/96 Carlisle Regional A-.l~llH:al Center Department of Pathology 246 Parker Street, Carlisle, P A 17013 Duckkyu Chang, MD., Pathologist Henry S. Crist, M.D., Pathologist MACNAMARA, SUSAN MRN: 0000825381 Ward/Clinic: CLINIC SERVICES (SPEC) DOB: 11/2\/1954 Age: 46 Y Sex:F Procedure Date: 07/25/200 I Received Date: 07/26/2001 Requesting: ORNDORF, LOIS Page I of I GY-Ol-955 Gynecologic Cytology Report SPECIMEN: CERVICAL PAP SMEAR, SCREENING CLINICAL INFORMATION: LMP ~ 7/4/2001 Previous smear date = 11 8/200] Comment = PREVIOUS SMEAR: CYTOLYSIS, INADEQUATE ENDOCERVICAL COMPONENT SPECIMEN ADEQUACY The specimen is satisfactory for evaluation. GENERAL CA TEGORIZA nON Within Normal Limits Screened By: ESW Signed Out/Reported: 0713012001 ELLEN S. WRIGHT, CT(ASCP) ()\ 1.9 !&'to .~ )~^p MACNAMARA, SUSAN Ward/Clinic: CLINIC SERVICES (SPEC) Printed: 07/31/01 11 :47 AM GY-Ol-955 Page I of 1 COO:J14 SIBS C00314 ~ COD CENTER FOR DISEASE DETECTION 4710 Perrin Creek Dr., San Antonio, TX 78217 CLIA #: 45D0660475 SADLER CLINIC SERVICES OF CARLISLE HOSPITAL 117N. HANOVER ST. CARLISLE, PA 17013 PATIENT NAME SSN PATIENT ID ACCESSION # DATE OF BIRTH DATE OF COLLECTION DATE OF RECEIPT IN LAB 12660 MACNAMARA, SUSAN M 210-40-3603 126808426 11-21-1954 01-08-2001 01-16-2001 01-16-2001 DIAGNOSIS: DATE OF REPORT TEST: CT-DNA GC-DNA Negative for C. trachomatis by DNA probe Negative for N. gonorrhoeae by DNA probe R~v'ie",J"" /0 pk, /' d-d' 0 / lIo TEST PERFORMED BY TRP MACNAMARA, SUSAN DOB:11/21/1954 AGE 46 YRS F (036) 825381 210-44-3603 (717) 243-2098 DR ORNDORF, LOIS S. OUTPATIENT REPORT OUTPATIENT REPor:r',,~> ',-:,',y % CLINIC SERVICES: :c:.tt!fl(!;,Y"j CARLISLE PA Collection Date: 01/08/01 SPECIMEN: CERVICAL SMEAR Received: 01/09/01 Access ion No,; CLINICAL INFORMATION: LMP: Prior History: 12/18/00 NONE GIVEN SPECIMEN ADEQUACY: The specimen is satisfactory for interpretation but limited because of an inadequate endocervical component. COMMENT: Cytolysis with many bacteria is present. INTERPRETATION: WITHIN NORMAL LIMITS. ESW:ESW 01f11f01 ELLEN S. WRIGHT (electronic signature) '\ 01 i,I.7" ....' l ,,;;::,'v( /..{l::.., vite. t' '~/)l...-- v PRINTED TIME ADMITTED PAGE P-01-00078 12JANOl 0730 08JAN01 1 GYN-CYTO PAP MACNAMARA, SUSAN Continued... 1 PAGE .~. MACNAMARA, SUSAN DOB:11/21/1954 AGE 46 YRS F (036)825381 210-44-3603 (717) 243-2098 DR ORNDORF, LOIS S. OUTPATIENT REPORT OUTPATIENT REPORT % CLINIC SERVICES t/:J 'oj PRINTED TIME ADMITTED CARLISLE, PA PAGE Collection Date: 01/08/01 Access ion No.: P-01-00078 SPECIMEN: CERVICAL SMEAR SPECIMEN ADEQUACY: The specimen is satisfactory for interpretation but limited because of an inadequate endocervical component. COMMENT: Cytolysis with many bacteria INTERPRETATION: WITHIN NORMAL LIMITS. is present. ESW:ESW 01111101 ELLEN S. WRIGHT (electronic sianatuiel Collection Date: 10/14/98 Accession No.: P-98-08508 SPECIMEN: CVVS CERVICAL/VAGINAL SPECIMEN ADEQUACY: The specimen is satisfactory for interpretation. COMMENT : Reactive and metaplastic changes noted. INTERPRETATION: NO DIAGNOSTIC CHANGES OF CONDYLOMA, DYSPLASIA, OR NEOPLASIA. DKC:DKC 10/22/98 DUCKKYU CHANG M.D. (electronic signature) 12JANOl 0730 08JAN01 2 Copies sent to the following offices: 2 GYN-HISTORY MACNAMARA, SUSAN End of Report PAGE MACNAMARA., SUSAN OUTPATIENT REPORT PRINTED 230CT98 00B:11121/1954 AGE 43 YRS F OUTPATIENT REPORT TIME 0700 (036) 825381 % CLINIC SERVICES ADMITTED 140CT98 210-44-3603 (999) 999-9999 DR SCHLANSKY, RITA COHaN CARLISLE, PA PAGE 1 Collection Date: 10/14/98 SPECIMEN: CVVS CERVICALNAGINAl Received: 10/19/98 Accession No. : P-98-08508 CLINICAL INFORMATION: LMP: Prior History: 10/19/98 SEVERAL YEARS SPECIMEN ADEQUACY: The specimen is satisfactory for interpretation. COMMENT: Reactive and metaplastic changes noted. INTERPRETATION: NO DIAGNOSTIC CHANGES OF CONDYLOMA, DYSPLASIA, OR NEOPLASIA. DKC:DKC 10/22/98 DUCKKYU CHANG M.D. (electronic signature) .; fAJ /,'(L:t;kc---t .~( /D/~-6/7P GYN-CYTO PAP MACNAMARA, SUSAN Continued... PAGE 1 ~ CARLISLE REGIONAL MEDICAL CENTER RADIOLOGICAL INTERPRETATION PATIENT NAME: MACNAMARA SUSAN X-RAY#: 825381 EXAM DATE: 6/09/2005 ORDERING: ROBERT W LASEK,MD 245-5500 ATTENDING: THOMAS GREEN,MD 243-1414 CONSULTING: HAROLD G KRETZING,MD- HISTORY: MVA--MINOR INJURY MVA--MINOR INJURY MED REC ACCOUNT D.O.B. : ROOM: #: 825381 #: 9312840 11/21/1954 IP LUMBAR SPINE, PELVIS, LEFT FEMUR, CT OF THE ABDOMEN AND PELVIS 06/09/05 LUMBAR SPINE: There is scoliosis to the right. Otherwise there is no acute abnormality. There is mild narrowing of the disks at L4-5 and L5-S1. Foreign bodies overlying the right pelvic wing could be within the bowel or in the patient's skin'or external to the patient, such as glass. CONCLUSION: NARROWED DISKS AT L4-5 AND L5-S1 WITH SCOLIOSIS, BUT THIS IS NOT AN ACUTE ABNORMALITY. PELVIS THREE VIEWS: There are nondisplaced fractures through the left pubis, the left inferior pubic ramus, the right superior pubic ramus and perhaps even extending vertically into the left acetabulum. None of these fractures is displaced. CONCLUSION: Multiple fractures of the even the left acetabulum. pubic bones, pubic rami, and perhaps Sacroiliac joints appear normal. LEFT FEMUR TWO VIEWS: Femur itself is normal with no fractures, but again seen are fractures of the left pubic bone and inferior pubic ramus. ~ ':\'~ ~J\ W CONTINUED ON PAGE 2 CONSULTING .~) l: \:J' \. .. \: ()I , '0 \\./ ---' CARLISLE REGIONAL MEDICAL CENTER RADIOLOGICAL INTERPRETATION PATIENT NAME: MACNAMARA SUSAN X-RAY#: 825381 EXAM DATE: 6/09/2005 ORDERING: ROBERT W LASEK,MD 245-5500 ATTENDING: THOMAS GREEN,MD 243-1414 CONSULTING: HAROLD G KRETZING,MD- HISTORY: MVA--MINOR INJURY MVA--MINOR INJURY MED REC ACCOUNT D.O.B. : ROOM: #: 825381 #: 9312840 11/21/1954 IP CT OF THE ABDOMEN AND PELVIS: CT of the abdomen shows two separate low attenuation lesions of the liver, the largest being 14 mm in size in the inferior right lobe. These are most likely hemangiomas, but further evaluation with multiphase imaging of the liver is recommended. There is no evidence for laceration of the liver, spleen or kidneys. Gallbladder is normal and the retroperitoneum is normal. There is no abnormality of the bowel found. The uterus appears to have fibroids. Bladder is normal. Fractures of the left inferior pubic ramus and superior pubic rami along with the pubis itself are seen, and there is a fracture of the anterior column of the left acetabulum. Nondisplaced fracture of the right sacral ala is also seen. There appears to be glass or gravel imbedded in the soft tissues of the right buttocks. CONCLUSION: Pelvic fractures as discussed, most of which were seen on previous radiographs. No evidence for acute abnormality of the abdominal viscera, but probable liver hemangiomas which need confirmation as discussed above. REVIEWED AND SIGNED ERNEST CAMPONOVO, M.D. INTERPRETING PHYSICIAN DATE DICTATED: 6/10/2005 DATE TRANSCRIBED: 6/10/2005 22:32 DATE SIGNED: 6/13/2005 8:25:00 TRANSCRIPTIONIST: MW 6019088 CONSULTING PAGE 2 OF 2 SPINE LUMBAR COMP W/OBLIQ FEMUR AP & LATERAL PELVIS COMPLETE 3 VIEWS CT ABDOMEN rrom; ~arllSle Reg.Med,Ctr. (1l7) 24q-1212 89/11/01 09;34 P,Oi/Gl \'.,.._ISLE REGIONAL MEDICAL CEN,_R RADIOLOGICAL INTERPRETATION PATIENT NAME: X-RAYII: EXAM OATE: ORDERING: ATTENDING: CONSULTING RODNEY K HOUGH.MD MED HISTORY: MAB SCREENING XR #27417 MAM MAB SCREENING MAMMOGRAM XR#27417 PREV FILMS HMC MACNAMARA SUSAN 8253Bl B/15/2001 LOIS ORNDORF,CRNP lAB MED REC If: ACCOUNT II: D.O.B.: ROOM: 825381 7058713 11/21/1954 OP MAMMOGRAM The bilateral film-screen mammogram is compared with the previous study performed 06/14/1999 from Harrisburg. Pennsylvania. Today's examination again reveals benign findings unchanged when compared with the previous examination consisting of symmetric and dense fibroglandular thickening with benign-appearing calcifications in each breast. IMPRESSION: There is no radiographic evidence of malignancy. Benign findings noted previously appear unchanged when compared with the previous examination. A routine follow-up examination is advised. This is a category 2 mammogram: Benign. ~ /\ .Ah.J. 0 I ~q.\B' -jO REVIEWED AND SIGNED KEITH S. PUMROY.MD MED INTERPRETING PHYSICIAN PAGE 1 OF 1 DATE DICTATED: DATE TRANSCRIBED: TRANSCRIPTIONIST: 8887655 9(1(:)(2001 9(1(:)/2001 KW ORDERING FAX 06/29/05 DO: ~5 Appalachion Orthopedic Cen Fax# (717)-1q9-6235 Page 2 of 2 #6620~} Macnamara, Susan M DOB: I 1/2111954 06/28/05 OFFICE VISIT: The patient is now almost 3 weeks post falling down the stairs at home on 6/9/05 at which time she had a fracture of her right pelvis through the acetabular dome but nondisplaced and stable and a fracture through the inferior and superior pubic ramus on the left side. The patient was admitted to the hospital and treated in the hospital until she was able to get around on her walker. She returns for examination. On examination, she walks very nicely with the walker. Good fluid gait and protecting the weight on both sides. Her pain and tenderness remains primarily on the right and I reviewed the films today especially the cervical spine which is negative for trauma but positive for spondylosis and the lumbar spine which is negative for trauma and positive for lumbar spondylosis as well as her pelvic fractures Femur was not fractured and does not appear to be both clinically and roentgenographically. DIAGNOSIS: 1. Bilateral pelvic fractures, nondisplaced, stable including the acetabulum on the right. 2. Lumbar spondylosis. 3. Cervical spondylosis. 4. Multiple trauma. PLAN: Continue with current treatment using the walker. Recheck in 3 weeks at which time we can decide if she's ready to get on a cane and she would like to get back to work. Thomas 1. Green, M. D.fdmg cc: Sadler Clinic .~ of_.D :VU ~ ~~ 246 Parker St. Carlisle. PA 17013 Ph:7J7-249-1212 s~~~ DATE OF BIRTH SEX RA MS 11/21/1954 F 1 S ADMISSION RECORD RO ADMIT DATE I TIME ROOM NO. 06/17/2005 12:06 0000 0000825381 LOCATION PROGRAM PATIENT EMPLOYER RITE AIDE EMPLOYER PHONE NO. (717)691-6200 PHONE NUMBER (717)243-2098 SUSAN WEST ST CARLISLE PA 17013 US EMERGENCY CONTACT NAME N C UNTY CUMBERLAN 210-44-3603 P I L M L VE RITE AIDE 5280 SIMPSON FERRY RD MECHANICSBURG PA 17055 PAN PHONE NUMBER (717)243-2098 EMERGENCY CONTACT PHONE (717) 691-6200 HATT, DIANE (717)243-6650 RELATIONSHIP TO PATIENT PATIENT IS EMERGENCY CONTACT RELATIONSHIP TO PATIENT COMMENTS FRIEND PRIVACY M P Dv Il!lN MED. KEY Dv Il!lN PRIVACY NPP ADMIT. BY Y CLC ROUP NUMBER GROUP NAME AUTHORIZA TI N RANDOLPH J DR. FAMILY I PRIMARY CAAE KRETZING, HAROLD G PRINCIPAL DIAGNOSIS rrhe condition established after study to be chieflV responsible for occasioning the admission of the patient to the HOSPITAL for carel. REMOVAL NO FAULT N A 1M COMPLICATIONS COMORSIDITYUESI (" N f~ \Si PRINCIPAl PROCEDURE ADOO'A 9313457 1111111111[[11111111111111[1111111111111 111111I1111I111111111111111111111111111111111 000082638' MEDICAL RECORDS COpy 11111111111111111111111111I111111111I11I111111111I1111111111 _.."9'~- l" .CARlISIE RECIONAL ME 0 I C A.L CE.N T.E R Patients Presenting to the Emergency Department for Procedures Not Requiring a Medical ScreenIng 'Examination You have presented to the Emergency Department for thefol1owingprocedure(s): o Blood Pressure Check o Ongoing Immunization .0 Employer,Requested DrineDrugScreen ~::::~;:: Removal OForensicCollection . .' - '.. .' , , ..- . '--.' .-. ........ . ....... ....... ..'- You are also entitled to a rnediealscreeni11gexarninatiollbyaphysicianorphysician assistalltin our EmergencyDepartment. . By.signing below youare.declinmg theoptionofa rnedica1screeningexamiriationhecause you have come only fortheabovecheckedprocedure(s). Should you d~cide that youwishto '.hav.eam.e..dicalsc.reening.' examination.aloilg......withthea.bo. vellroc. edure(s) .1.'twil1..b.epr.o.vided. YOllalso agree to wait 30 minutesafteryourinjection;to'be rnonitoredfo~complicati~ns. C"",, c. ,',: .,.....:....J. ,', ,',-,': ',:,. I, S \,cSC,N ~ki:.:U<A.m1i1CL- ';havedeclineda medical screening examination. '_',:' ~::_,_,._Pat~(R'\l'sNameJ .'_'. _,-i--_:'_',',,"_ _;-;'_,.,':t::_:;_,_-",-,<,,~':.. .. _ ':::: .. ,,' I am decliriing the medical screenlng.examination because I have presented to the' . ,':",-,':.: -- ,:'- Emergency DepartmentJor only the above checkedpro~edure(s) anddoilOt require :any additional medica] screenings. I understand thatJam .entitled tOea medical screening examination when presenting to the . Emergency Department.and.itwill beprovidedupon my request. 't '~AMIY'J n111 t,!I/M1W 11 /J , (Palient's Name) ^.&~ i} (Witness) 0/17/0:; (Date} ER 1690 (04ff14) .:..sle Regional Medical .:,..er Instructions: circle ositive - backslash ne ative, rovide additional ertinent information. '~~~~~_ ~firt Patient Family EMS NH Translator ~!mi't~~~] ALOC Intoxication Severity Dementia C I C~~-"-"-J~~r-,~vej:-='-'-_-=:::'=-:-~J)lJ'~~ld~~,~g~~A~-E~~~;;3i[::::[N~~-",i~ge~;:Ji;J-==::-:::__::-=::-:=.-=-':== _m._.___."_.._.__...._,_._..,_____."."__.,.......,_~'"...._,_m_.__...._..-'._n___.._.-."...._,..___...._n__..".___m....__...___............__._..,......_c......._ __ _____n....________.__._________ ____.__..__._________~,__._.__._._~~___.__,.________,_.._______._____'_._____________.___,..~______~_~____ ...._m___....____., m..."____.n.._.__._,...____._.'_m. .. .___..__....._ "._...._ _.__._m...._____...__.....____..._____..___..~____...~_.._...._._.~_..__ _... ...-...--..__.__...___........__.._..._.........m.___.._ _ ___._..._..._.._~_..___. _ ,.________ .--..---.....-.----...-....-.----.--...--...-----..-----------.-.------_..._._~_.-.__.._--------._-_.._--...__.._._._-_.---..__.----.'-.--....-...----...---..--"..--.-..-------....-...--..-...------...--...---- .--...-.-.-------..-.-------.-..------ - --...--.---.-......----..--..-..-..--..-.----.-...--..-----...-.---.-..----.-..------.......-..------ --....."---.....-..---.--...-.---.-.. ..---... ... .------.-,-..-.- .... .---.......----.-...-.----......--.- ..---........----,--..-...---..--.......--..-. .._-_...._--_...._~----.__._-_."._...-._--_...- -...-..----.....,...-......--.-...-.-----....------.----....--.-..-----...-.----....-..--.-...- .."-'-.'''-.'---'''-'.---.''.''''---...--..... -----.---....----.-..--- ..-.-.-....-----.--..--------- . -...-....--..----..-,..---...-......-.....-..-------..-- ......__....._._.____....__..._,,_._..._______"..____n_...____...._..____........ . _ . .___.._..__......_...____.._....._."._......_m_ ---------_.._.._-_._...~-_._.__.._._.._----~_._------_._-_._.---_._-_._-_._...._-~._----_.~..._---_.....__..._._--~._------...---.-...-....---------------.-.----.-...---..-....-...-.---.---.-"--.---------.-.. tji!1!lIi1Jl Sx started suddenly I gradually _ min. I hrs. I days I wks. ago : continuous I intermittent p1ii'iil@iiil-Sxi8s1-----;;;in~.thr~~1 daysl;ks:-at. ~rr;;;-~pres-;;-niTabseni-------------------.-----.-.----.-.------ ~~qn;1 8~l.fJ-ca;:;not-describe .----s.tab-le--j~pro;lng-..- wo~~ening-.'---.------...--'-------------'_.-----.-".-.' ....------ .--.-.--.-.~-..-,,----...------...-...~--.-,,--.-...-...- ~~ mild moderate severe 1-10 scale [OJi~1 ~t--~est~..-..---acti~ity.~. .----....---.--.----..-..---."---....--...------....- --.----.-.---.-".---.--.~.--------~.--.".~-.-.-,,-._---------.--.--...~.-_.-- ~i68tilllll'~ nothing _______________~~_.."-"~ing.___________.___._____._____.______. ~~if!'f&~"""'RiQffis1----.- C.P. ~il1liitilll ALOe Intoxication Severity oem.mtia ~P'riit6lii'2~.fuver-chTijs- weakness -- diaphOl:esis .---'.'-.--INiUf9~ HA--.-Selzures---' weakness-confusioo.------- '~Jj sore throat ear pain facial pain R..iY~aa1~ anxious depressed .. ~y~ p;,;----;;isuaIChanli..--.---.-------.-.--.--------.----. j;~IDi;l polyuria poiydlpsi.----.---------------- [~!l~~\fc::p:----paiPitalions DOE PND-' ~!!!l!~ii!] rashes pruritis lesions- ~fiffjf~--s:O:B.-.-OOU9h.--OOngesti~n---------.-.-..--T~~~~fa;;-;;;;;i~:-bieedi,;gdis;;rde;S-tr~nsiusio,;--.--.-- Gla N I V diarrhea I constipation pain melena hematemesis 1 ~tQE~ frequent infections allergies hives ~....,,--:-..._._--._-_._._--_.__.._-"._--_......__._.~_...__..-_._---_._.._--_.._--.__._-"---_...._~::,:-"._-.----------._._._--~......_--.._-----_......._------..._._---_.__.__....'"-_._~-_._-_.._.__...._...._-_.- Gyri] flank pain dysuria hematuria frequency Other:ll ~\9a~(!@~--.jOinipai~------neck I back pa~Xt. pain~=:1"'~-~ - ,---,--,c-'---LifAii-Oih"r Systems'Reviewed-AndAre-Negalive-- LEf Agree -Wiii) Nursinii-As.sessment--.----.-.---.--..--.-----.- MEDICAL AND SOCIAL HISTORY Mm~. none CAG HTN loDM { NloDM COPo P1iS1':Mijjjiii~~"MVA'--- ... ------.--.----------...-......-.--.-------..---------- "'!!_..."'''''',;JJ......, MeaijfAov;i:- .....-.-.- .... ... ..-----. ...-------...----- -----.-- ---......-.- .,~~d ..__E;l_~."~i"v.:e_~. ~l~t'iil2j;~--NoNE----- .-.-----.--------. o Reviewed ~HtPli!ii4 - none - Appy.. Chole Hyster F~m"fW,;ilX:'l;;egatiVe.cAO---ID-DMTNID[)r;r-CA- -----.--.-----------.-..--R/L-Handed----Li~es AI~n..-YtN---' ,,1'..,"''''~~1>., . s'oclWlltl~~ -,.obacoo:--yTi\i--.-PackSiDay.----years.-------.-.ETOH:yTi\i-'-l:irlnksIWK-Drugs: "Y/N--'~-'--- .....,....~......~ - - - g&SilI~~'2!11r-....-.....-...--------.....~---.._-..---.----.....--.-----.-.,,--.~--.__....-,.-..--..._,,--- ..... .-.-.-.~--.......__.-------..-------..-.,,---.....---.....--.-...----.-..-----....-----...---.-.--.-......-----..-...-------......-.- ~m!IDW\iittID:!1'tr~up-=to=date:--y7N-~.--~-~~--~---~--- Tetanlis:------------------~--- fi~~.tg:~q?1!Y:~~:tijr.-...-----..LM-P.:-.. .. .. -...- ......" ......---.-(;-....----.. ..----..p-~.._-..-.-AB...----- --''''-.--.'--.''''. ..- ."__..._____..________._._..."._......___c_..__..._. -- ._m_____._..m___..._..~__..._.._,,_ [J Reviewed Pro-MED Maximus ClClIpyrlghl2001 Pro-MEO C1inlcal SylIlems. LL,C. General Adult - Page 1 of 2 Rev.03lO~04 Carlisle Regional Medical Center NAME:. MACNAMARA, SUSAN (Instructions: circle positive - backslasn ne~~ _Ie, provide additional pertinent information.) (fE:NE:RAC:'. NAD "'~"e~::..:,,"_;'''.::::::c::.'_c'_'.'.:_,,,._._.__...,.._,._._.__ HEl;NT:: NC I AT PERRLA EOMI JVD Bruils '_""-""~"-C''''3:':':'_____.__________..,.~___,._~_____.____~______.____"_.___'__.._,..____,~,_~._..__.____.______..__.~_..___~,_.,___.___.____ ~\I{ ..~~.~.. . .... ~.r.1~~~..murmurs .16~ys I dys .... .......___.___..._...... ...__._.... ...... _......... _ rubs clicks gaUops 831 84 Location/Description of Symptoms: mild ( moderate I severe distress ...yi.J:~:s,It!t{~:- T 97.2 P67 R16 BP 1271078 lungs clear I equal resp. effort NL I distress raJes rhonchi wheezes t~) .~~ ~ ~ ,.-.1.'-', tlF soft flail dislended -0-'" ..___.____ tender I non-tender bowel sounds NLI ABN guarding rebound rigidity Ml!E--ROMNC-'.Ciubbi;;g-~c;:~~O;i"-'-ede;;;~---.:::'_:=':::.=~=:-.---.-.---.- ~!$.\~\~~i~::~'i.:~aph_o;~I~::~~ii"s::._.__...____.__ .._____.___ .. _____ Hiillg2a,; CN 2-12 inlacl DTRs equall symmelric R.~t9!{~o~:'::~()o~Taff~ci:~C:-=::::..:=:::.=:::=:'::=':::::::==::=::_:::: ~~~,~~ adenopa~y G'O'~'.NLTdefe!ITe-ci--.-..-.--,"..-n..--.... ." _......___.....__.._...._._......____....__...___._..._.m.__-..-.--..-.---.-.~-....--.---.-._--~---""--- ~~~-~_.______.._n______~______..__._"._______~__..__ ".________.__~_n____..____m~.__..______._~__..___.._.__.~_____~~______ ~!i~fL.__ ...._____. ..__._..___._.....___...___________ , 1..- " , . , D Labs reviewed and are negative X-Ray: MEDS: --E~:-::::==B:::::::::=-:::=~~=:::::::-::=.::=:=:.:::--.-=~:---==::::.=~:-====-:=-:::::= CXR: NL infiitrates IVF: NL I ABN NLI ABN --_..~._~------._~---~~----- DIFF _....____..______...______.._.._._.__n~"_.._..__..___._n__...__._______..______.___...._.__..__........__._____..__.___~..___..._______.___.._ 5_ ~.~.=:=..=..~~~.~-.~=~.__.~.~~~:=.=..~=~~~~=.~_~~_~~~_~~=~:=.-..~~.=~..~~~~~_~~.~~~.~~=:=:.~.=~~_~~~~~~~.~.._.~..:~m_~.:.: L --...... ---.---.------.-.--- .......--..PulSe-Ox'-.--.-%NLThyi>oXia--- UA:SC;----prc>i--RS.Cs.-WBCs.---..-----.--...--------.--...-----. ________.o.___~____________....__~_~__~_~.___.___.________~__~_ UCG/HCG: +/- ABG: pH 02 C02 .~-_...._-~-~--_..'"._----_._-~._.~._..-----_._-"_......_-._._--_..._._._._------_.._-_._...._--_._~.---_....__.._-.-.__._.._._._--_._.._._---~-----._.__..--- RE-EVAL: Time: Improved Same Worse .---....-.--.-.-.--..-~--------......-----....-.....---..-.--..."___..__._~__......___._.....____~n_..._.....____._..___.._.___.._...._.__....___.__~__......._.....___..__._._~..__u__._..____.._.___...____..._.___.__.._.__m_..______..___..._ ~.Q~L Critical Care: 30-74/75-90 /91-104/105-120 ..-----~-- 121-134/135-164 Minutes Excl. biUable proc. 1. Discharged to: Home Nursing Home Family .-._-"-"_.--.....__.._.....__....._...~_......_-...._.._.-...-..----..-.-----..-.--..-... ...-.--.-...-.-.---....--.-..-----.----.-.-..."..-.-..---.-.--........--....--.,,-.-...- ----- Follow-up with Patlent's Dr. in days. .m_ _._'''''_''''n_.___'.'_n._... . _ ...._...__...._____._.______._...... _ .._.._ ... "_.. __.____.....___........._.m..___~____._._.."._n__."___n__..._....._... Other Instructions: 2. ~~n__'''_''._._..__' 3. CONSULTATION DISPOSITION otscussed with Or. Discharge Time Out: m - ._.___.n~_...._._ _."....__.___......._~__._....._____._..__._..... __.~.____ .. ..____...__ __ _.._.... ..._u._.__.~"'...... _....__~"~._._,,__,,..... Admit Admit: OBS ICU PCU Floor Tele. OR Prescriptions Given: _..._-'__._m .._.__....______~.m. __,,_.. n...__ _.._.__"......._._.__."._..~__.._.__...__...,,______.__.._...._._ _.. . ....__._ _.".....__........_____._. Follow.up in Office Transfer: OldRecords-Reviewed-yTN . "--'- AMA:---n--.-_- -- .... .--.----. Reviewed 'DiWnR~"djoIogisf."Y.i...N-- - -..---...-.. -i:)"C)'A:-...om----. - --"----....--.~,,..,,--~.-""- _.....______.....______.....______..______~.._______...o Case OIW patlentTF-amily'y , N .. -~-.-.---"- CondiiIo'-;-;---improved--Sii6Ie-Oeceasecr--- -~--~ffETUFft{T(fE'jfiF-coN'D~lff6N WORS-ENS-,- See procedure form attached 0 MDIDO Record Complete 0 General Adult. Page 2 of 2 Rev.Q3IU5J04 Signatures: PAlARNP Pro-MED Maximus It>COPYrillht 2001 Pfo.MEO Clinical Systems, L.LC. Date tn: 6/1712005 Time: lisle Regional Medical Center Name:MACNAMARA, ",..,SAN Pt#:9313457 Age: 50YRS DOB: 11/2111 954 Sex: F MRII:0000825381 EDP: CORDLE, RANDOLPH PCP: KRETZING, HAROLD G ORDER PROCEDURE FORt MEDICAL EMERGENCIES '-sm:I"'~ @"~qr>~tQ.All.. _..' . OrCJerimroQ Q", ,'0. a r , CBC CXR PNLAT - Portable\ BMP CMP Amvlase Abd. (flat & upright) Drug screen (serum), {urine} ETOH Liver orofile Magnesium Glucose (bedside), (serum) clmuo ulm&na:r:O UA "'1<'" ABG 02 LPM j c Q 1'la<lrca:l: - ;n e Previous Medical Records Physical Therapy. Eval & Tx 0 o tmproved a Worse a Unchanged 0 o Improved 0 Worse o Unchanged 0 ~lmproved 0 Worse o Unchanged 0 J Improved 0 Worse a Unchanged 0 ] Improved 0 Worse a Unchanged 0 ] Improved 0 Worse o Unchanged 0 ] Improved 0 Worse 0 Unchanged e rJ!j !ll- 'Z:Ollllm"Qll_ ' ~, a KVO Device: o IV Fluid: o Cardiac Monitor: Rate Rhythm: o NGT Insertion II Fr. o Endolracheallntubation o NIBP Monitor o Gastric Lavage o Cardioversion o Pulse Oximetry o Central Line Placement o Oral Airway Insertion o Urinary Catheter Insertion: #_ Fr. o CVP Monitoring o Oropharyngeal Suclioning a CPR :9!"~ffa~11t Initials/Signature: IlnitiaIS/Signature: nitials/S\gnature: li~~ig"fi'f"a1^---- PNARNP: Physician's Signature: Rev.09/l4f04 EMERGENCY DEPARTMENT ONGOING NURSING ASSESSME,y r Date: 611712005 ~~I Name:MACNAMARA, SUSAN Age:50YRS DOB:11/21/1954 EDP: CORDLE, RANDOLPH 'e Regional Medical Center Pl#:9313457 Sex: F MR#: 0000825381 PCP: KRETZING, HAROLD G t!!lB.l;JN9"D~GNPJiI~ .:' ;~~jl@"~~!i ti~. iP' iIIJlta .. .~~ . Airway Clearance, Ineffective Communication Impaired Infection, Potential Self Care Deficit -Anxiety --Coping, Ineffective Injury. Potential -Skin Integrity Impairment =Sreathing Patterns, Ineffective -Fluid Volume, Alteration in Knowledge Deficit Thought Processes, Impaired ~rrdiac Output. Decreased Gas Exchange. Impaired _Mobility Impaired _Thought Processes, Alteration in Comfort, Alteration in _Hyperthermis (Fever) _Non-Compliance _Tissue Perfusion I Alteration in Other Other The:GGA . ;llm~r;tlii~datr~l~asSl~\;I~ilQmI~tiilifeti:~h"a1jrm!are-'!fnrewealllmS'fOt1i:\6~.. .. .. . . "'~~~'i.r. .. '.... '''' " ! Not Not No' Met Met I.t Met Met I., Met Met I., o FB REMOVAL o IMMOBILIZATION I PROPER ALIGNMENT (lIMPROVEMENT OF BREATHING (l BLEEDING CONTROL o DECREASE I PREVENT SWELLING (l STABiLIZE PATIENT IN DISTRESS o PAIN CONTROL o MAINTAIN STABLE HOMEOSTASIS o meet ENVIRONMENTAL NEEDS o ALLEVtA TE NN (l MAINTAIN SKIN ITISSUE INTEGRITY o meel PSYCHOSOCIAL NEEDS (l FEVER CONTROL o PREVENT FURTHER INJURY [:] meet SELF CARE ABILITY NEEDS o DECREASE ANXIETY o MAINTAIN I IMPROVE CIRCULATION o meet EDUCA TlONAL NEEDS (l SAFETY IN THE ED o INFECTION CONTROL o Other I lnt: N = documentation in nurses noles, other 'codes' per Hospital Policy. "','.- .. ~f . , I J' 8", I ~. to /3:JO ti"c.t.. J~ /J) A Jvt'U!....- /1[.11'/ ho, th/ 71 " ,. " '- AI' I (-?VI\. .. , "e" -1.0 ;2fJ 't"--L v - /lJth0 ~~s ,J ...ftIA,.j Afi.h <..cd 7.' & ""I, e -1.(.1 t"'JV~. Jl-I ~/llA' ~ , ( /; /, if) i2A fl.. /U) dA..A-YL~~ 3 ~. ./..".' A 1 A . n i I., I /~vt!... .. /. ~ ]"dl/J. / ..l<'<' If /", ~Il ~ ; {/ V/"'/ I~. I '. I';~ AJrL.l.<.A-L.. A / .{. Uk' A{/}-z, /,0 ' 1.,A/).'J (U -<.~c/J /J ~/J .fi../l~ - f-- tf..li-e AAA ~ I,,, k:n I" IN. ../'I d ~. A. /1, e, J 'f' /... " ' / k- I IU A /h..L, <" de.. I" , /I /)1 hr-.e'. dUJJ.. d I, t) hl4/l..t... ;; L- .J?A ~ , 1'> I ,..^ I' / ft , j ,;... ", ..J I ~ t, "It J. 11, " l,!.. I), I 11 ",. .( ~ / .t..,d-, I. I I (hC1;!..4I,j ill J .,1"_ 1.././/1" "'/1. .,4r/l.-1 .'/ /A 7 ~ 1)..4 VJ<.L .. AI L'j ~ IJ.,'A~ ,\;;:x r fAA'/..:}...! , ' a / 0 A A/I. 1- .A. ~ I,v L</. rt-'l-r::... .- U o tI I . ~liR9'~ Discharged in care of: n ,J' mb 0 W Ie 0 Slret 0 Carried Discharge instructions given \0 U f ~erbaliZed understanding Admit: Room #:_10 Dr. Ready for Room Time:_ Reporl called at and given to Transfered to o Transfer Verified Reporl called at and given to o Left without treatment o Left Against Medical Advise Condition at ~ilion: 0 improved 0 Stabie o Serious o Expired Pain Scale: Pain Location: -- Patient reports that pain is: o Improved o Unchanged DWorse Disposition VJtals: T P R - BP 02 - Oisposition Date:li!LTime: 13./0 Nurse: jV1 {/'--" D.." ,....,,,,,,,N"\A EMERGENCY DEPARTMEf PRIMARY NURSING ASSE~~,v,~,JT Time: I d.-em Name:MACNAMARA, SLJv"N Age: 50YRS DOS: 11121/1954 EDP: CORDLE, RANDOLPH -lisle Regional Medical Center Pl#: 9313457 Sex: F MR#: 0000825381 PCP: KRETZING, HAROLD G Date In:6/17/2005 Subjective Notes: j~~y9Ji..~!6.Sii! . .. Appearance: Mood I Affect I B oAppropriate oDepressed oAnxious OT~rfUI oOther Caregiver: If oFamily member oSignificant Other oGroup home Activity level: bulates independently oRequires assistance aNon-ambulatory Performs ADL's independently ORequires assistance with ADL's Ii"" Abdomen: 0 Soft 0 Flat o Non-Tender o Tender (Area) Bowel Sounds: 0 Present 0 Decreased 0 Absent Elimination: 0 Normal 0 Constipation 0 Diarrhea # of Stools: o Few steps 0 Many steps Nutr1t1onal status: ONormal 0 Cachetic 0 Obese Religious I Cultural preference: aNone {spec\fYI Best learn by: oVerbal OWritten oRetum demo Learning Barriers: OTDD phone olnterpreter oNe DYes o Other: Extremities: RUE LUE RLE LLE Urine: D Colorless 0 Yellow 0 Red o Anuria 0 Dysuria 0 Hematuria Vaginal DIC D No LMP: Penile DIC 0 Yes Type: o Srown oCloudy D Frequency [J Urgency ,;~~~,~~ "'C"pllla Turgor: Pulses: R Carotid Brachial Radial Femoral PopUtea Dorsalis Pedis S=Strong W=Weak L~~ilr'li:'- L 'M . Laceratlons I Abrasions I Contusions L~cation: rJ-t,( 1"1),1< ,<tW JA K.I' f Iv./'.L rl .s Size: A.I dl::.~ Uk!. IV -.U.dVh;;J. Bieeding: o'Absent 0 Present 0 Scant 0 Moderate 0 Heavy D Pulsating ROM: 0 WNL 0 Decreased 0 Absent Edema DAbsent 01+ 02+ 02+ DeformityoYes oNo Scars: 0 Yes 0 No Distal pulses: 0 Absent IJ Present ASGD Not Inflated o Legs Inflated OAbd Inftated DC-Collar o Backboard o Traction o Splint Medication Amt Rout Lung Sounds: Clear Wheezing Crackles Rhonchi Decreased Absent R L Vila I Signs: T: 97.2 P: 67 Regular R: 16 BP: 127/078 Nurse Signature: Rev.03/05f04 INITIAL ASSESSMENT FORM 4 Non-Urgent PRIORITY: / " 'e Regional Medical Center Pl#: 9313457 MR#: 0000825381 DATE: 06/17f2005 DOB: EDP: PCP: MACNAMARA, SUSAN 11f21f1954 AGE: CORDLE, RANDOLPH KRETZING, HAROLD G 50YRS Sex: F Patient: Worke~s Camp: Emp. Referred: Presentation Time: 12:Q6 Triage Time: 12:27 Arrival Mode: WALKED Height: Chief Complaint: . Weight: 127.0 Ibs. 57.7 kgs. LMP: SUTURE OR STAPLE REMOVAL Last Tetanus: Acc By: Vital SiQns T: 97.2 PO P: 67 Regular R: 16 Unlabored BP: 127/078 02: % RA Pain Intensity Scale: 0 /10 Pain Location: Denies Pain Brief Assessment: SEEN HERE TURSDAY AFTER MVA, HERE FOR SUTURE REMOVAL. ORTHO FOLLOW -UP 6128 NIGHT SWEATS WEIGHT LOSS ANOREXiA SAFETY NO NO NO HEMOPTYSIS FEVER NO NO NO Sudden Onset: Pre-Hospital NONE Treatment: pedialric NIA Assessment: Past Medical MV A History: Allergies: NONE /J J 11 L:vI 1-/ (l.v__)</~ 'j () ;n/1tl~ Jr1~ ~~~ Medicines: ADVIL Nurse Signature: ~. tk/-u-~ MCO J~ ZlQ --h0 II~ iL7 t","SK Additional Notes: a;~ 246 Parker SI. Carlisle, PA 1701) Ph:717-249-1212 ," .~'1__~ -'_ ~\ ADMISSION RECORD DATE OF BIRTH 11/21/1954 AL S N . 0000825381 ADMIT DATE ! TIME ROOM NO. 06/09/2005 16:35 0000 PROGRAM PATIENT EMPLOYER RITE AIDE PHONE NUMBER (717) 243-2098 COUNTY CUMBERLAND B N RITE AIDE 5280 SIMPSON FERRY RD MECHANICSBURG PA 17055 (717) 691-6200 l YE H , WEST CARLISLE US EMERGENCY CONTACT NAME HATT, DIANE COMMENTS PRIVACy 210-44-3603 PA 17013 PHONE NUMBER (717)243-2098 EMERGENCY CONTACT PHONE RELATIONSHIP TO PATIENT PATIENT IS EMERGENCY CONTACT RELATIONSHIP TO PATIENT (717)243-6650 FRIEND MSP Dv Il!IN MEO. KEY Dv Il!IN PRIVACY NPP ADMIT. BY KAB U A AUTHORIZATION GROUP NUMBER GROUP NAME AUTHORIZA nON GROUP NUMBER GROUP NAME AUTHORIZATION DR. ATTENDING I ADMITTING LASEK, ROBERT W MD DR. FAMILY I PRIMARY CARE KRETZING, HAROLD G A I NO FAULT A lME MVA--MINOR INJURY PRINCIPAL DIAGNOSIS [The cOndition established after study to be chiefly responsible for occasioning the admission 01 the patient to the HOSPITAL for carel. COMPUCATIONS COMORBIDITYUESI PRINCIPAL PROCEDURE ADOO'A 111111I11111111111111111I11111111111111I I E A 06/09/2005 I '''l II) 10 xi 'J 9312840 //11I/1111/1111111111111111111111111111111111 0000825381 MEDICAL REcnRn~ rnpv IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII~IIIIIIIIIIIIIIII C(.. . 'Ie Regional Medical Ce or (Instnictions: circle positive - backslash ne.. ,e, provide additional pertinent information.) NAME: MACNAMARA, SUSAN DOB: 11/21/1954 Age: 50 Yrs 0 Mos Se" F Wt: 57.7 KG Ht: Chief Complaint: MV A--MINOR INJURY Medicines: NONE o Wks " Allergies: NONE EOP: LASEK, ROBERT W MD PCP: KRETZING, HAROLD G Pt#: MR#: 9312840 0000825381 DATE OF SERVICE: 6/912005 Pres Time: 16:35 Triage Time: 16:35 T: 99 PO P: 88 Re9ular R: 18 Unlabored BP: 124/086 Sa02: 97 % Nonnall Hypoxia Pain Scale: 5 Arrival Mode: AlS HISTORY OF PRESENT ILLNESS Translator limited by: ALOe Intoxication Severity Dementia EMTA~"'~dic..1 Scr~.eri:, Emergent 0 Non-Emergent 0 Exam Tim., I? (0 Hxby: ~ Family EMS NH C I C I HPI: (Narrative)~r I~ PTA Y I N l^'\vA- ro ~(< f. 1,~.:f. "-'\or @ <; ~ G ,L.lo&--, ~ kJ ~\v ~ ~ ~ " f-t..- '^" , l1'"'''eaO'ue?toa: ,,,:;.,I:~M:~,,,.,,,;;;,'-W,,;."T"'h>'~ eakness d7'aPhores cial pain . DOE ." P Sur ~y Chole Hyster Family Hx: negative Colon CA Po~ps-- IDDM I NIDDM Social Hx: Tobacco: Y I N '""7'""packs/Day _ Years Qccupati,cm: ~ Irrlmunliations: Up-to-date: Y I N Reproductive Hx: LMP: G P Pro-MED Max;mus ltlCopyriQht 2001 PnrMED Clinical System&.l-.L.C. J"..:~<-r \ de . ;f.,~_,^- {lA L. ,"<. ?" ""- -lo- I......... I ,,-,<-J-- I c:~ j / ~CI 0..'- ~, continuous J intermittent ~'weari~-'" ~II : d, 09.--.... Intoxication Severity Dementia :~::~:~:~~ ~::;'i::::kness In~lJQm9h' rashes pruritis lesi s Hemat glc: anemia bleeding Aile yllmm.: frequentinfections Other, P"-~"-"- transfusion hives ~ ~wed ~wed' "{1.... v~_. RILHanded Live~ne:Y/N ET/. .. DrinkslWk. Drugs: ~ Tetanus: unknown AB MV A - Trauma Page 1 of 2 ,,~u ""',M"" Carlisle Regional Medical Cer' NAME: MACNAMARA, SUSAN (Instructions: circle positive - back! Pt#: 9312840 _ ative" rovitle",aciillhMI ertineilt information. MR#: 0000825381 GENERAL(NAD-:> mHd I IilOderate I severe distress HEENT~/@. PElJ. LA I Rlils-.- facj~AtusleA5--laceFatj(:>ns ~h!";1~ions 9I~-'RRR"'"PMI'Ni::) murmurs 16 sys / dys '--."~O c\~gallops 53/54 RESP:; ungs clear ~ qual bilateral resp. eff~tress r onchi wheezes G~.. t I distend".d bowet sounds ~ ABN ~~~n~_ ~S;( ROM_.L clubbing cyan~ edema (-" cervical tene s.._~_,_ L-S tenderness. thoracic tend~ ~KI~: warm - dry') diaphoretic rashes . !:lEUR():~_2:i2f,;1aCt <:?!"RS.;;;I;ymm6tric ~~X~: X3~ moo~ NL ~. LYMPI-/: adenopathy GU:. NL / deferred 9th"r: VITALSIGN5: T99 pa8 R18 . BP 1241086 Location/Description of Symptoms: be... 't.c.~ 1,- U:fC:-';. '\ '2 (...r- (~ "("~f \ ~ ,,," ,-~ ~~g : . , FA- v.- " ~ I --~..- MEDS: "''''''- , . z.~ . V-- -Z-Y-;",_ hvr" vr. pneuma IVF: NLI ABN NLI ABN ETOH: UDS:+I- RE-EVAL: Time: / Pulse Ox: % NL / hypoxia Improved Same Worse UA: SG prot RBCs WBCs ABG: pH 02 C02 UCG IHCG: +/- q.~~:; cervical strain L-S strain closed head injury fracture laceration pneumothorax cardiac contusion liver I spleen laceration contusion Critical Care: 30-74 f 75-90 /91-104/105-120 121.134 I 135-164 Minutes D Exc\. billable proc. CLINICAL IMPRESSION(S) DISCHARGE INSTRUCTIONS CD Gi t"lvA- p.LI..-C _ ,=..... 'i 1."4--~ ~<-L~Gj ~c;~v,-lL P'1 ~ e::::: dV\...---. Discharged to: Home Nursing Home Family Follow-up with Patient's Dr. In days. Other Instructions: 0/_G~ , [?.r(k-- ~. Old Records Reviewed Y / N Reviewed DIW Radiologist Y f N Case DIW Patient I Family Y I N Discussed with Dr. Admit Follow-up in Office Discharge Time Out: Admit: OBS ICU PCU Floor Tele. OR Prescriptlons Given: Transfer: AMA: DOA: Condition: Improved Stable Deceased RETURN TO ER IF CONDiTION WORSENS. Signatures: \ .~RNP See procedure form attached 0 MDIDO Record Complete 0 MVA - Trauma Page 2 of 2 Rev.03lQSl04 Pro-MED C.. NAME: MACNAMARA. SUSAN OOB: 11121/1954 Age: 50 Yrs 0 Sex: F Wt: 57,7 KG Chief Complaint: MVA--MINOR INJURY Medicines: NONE Mas 0 Wks Ht: Ie Regional Medical Ct "r lnstructi9ns: circle ositive - backslash n... ...dve, rovide additional ertinent information. Pt#: 9312840 DATE OF SERVICE: 6/9/2005 MR#: 0000825381 Pres Time: 16:35 Triage Time: 16:35 T: 99 PO P: 88 Regular R: 18 Unlabored BP: 1241086 Sa02: 97 % Normal I Hypo.ia Pain Scale: 5 Arrival Mode: ALS Allergies: NONE EOP: LASEK, ROBERT W MD PCP: KRETZING, HAROLD G LACERATION REPAIR Wound Location: (!) , t........lc1...-- ~~;{::~Jr:~::~Y:~;~tUS~~Qti:~~~~a~ ~sensm~ Shap linea . regular flap stellate avulsion CO.Htaminatioll: e foreign body ~ne~thesi,,: ~ digital block ~cc's .5% marcaine w f epi w I bicarb Wound Prep: betadine hibiclens debridement ~tion~ ~ ~ Repair Closur,,: ski staples Dermabond steri-strips Ie interrupted horiz I vert neous # __ silk simple interrupted running horiz I vert fascia f muscle I tendon # _ _ vicryl simple interrupted running horiz I vert St~rilfPre~",@j"ppli~#: & Other: SECONDARY LACERATION: e ~ WouridLoc::atiOtj: Ilacer~tl~n.$i.z:e.: -z.-- cm 6~~~:?~U(:S::~:i~~~ct =~:t sensatiorr1m~ S~~p~linea Jlgular flap stellate avulsion Co.". ... ... .'39' cl' foreign body A"esthe~la( local digital blOCk:t Cc's[1% ~ 2% lido .5% marcaine w f epi . w I bicarb betadine hibiclens saline irrigation debridement skin #. - 0 prolene nylon staples s' e interrupte running mattress horiz I vert s - 0 vicryl silk simple interrupted running mattress horiz I vert fascia f muscle I tendon # _ _ - 0 vicryl simple interrupted running mattress horiz I vert Wound Prep: RejJaitqIClfi~re: exploration Dermabond steri-strips sterile Dressing Applied: Y / N Other: P~tlenttolet~~ed-;proc~du.. Y/N Qi~~h*9l:)Jfl;~trlr-c;~iqli~gly~~-: Y / N Signatures: MD/DO Laceration Re Rev. Pro-MED Ma O:Opyrtght 2001 Pro-MEO CI ('-"isle Regional Medical Center Name:MACNAMARA, S ... Pt#:9312840 Age: 50YRS 006: 1112111954 Sex: F MR#:0000825381 EDP: LASEK, ROBERT W MD PCP: KRETZING, HAROLD G .~~ ~ CXR'PAlLAT-portablel ORDER PROCEDURE FORM ORTHOPEDIC EMERGENCIE Date In: 6/9/2005 Time: ~~ II ~ Sed Rate \ Uric Acid RA Factor ~ CMP 177'f Drug screen (serum), (urine) ETOH Type & Screen or Cross # 171'1 l){~ Units I J /0 " f UA Beta HCG P'V1 M1~~ r t;."~i~Jl~r~~,,..'1l' Previous Medical Records Physical Therapy - Eval & Tx )():~ (n., /,) '--' C-Spine (x.table) (Complete) /' f V-rA<.< "/ \. r A,......... / , y.- r h'GI 3 <-" .e-- lr./rAl ~ I L) I.~ '-alllrc5ll'u~oi\'anl L./ EKG ABG 02 ""7 ,+ Iff!.: -h--- ~ "'1- / ,I ""Hf ~~,'ill....tili r--' LPM .. " . IDJ\ ~ ~s!.\J!.!lCi~!JWil\tD~m IR"'Y c..,/M.d -- .(' I~..~ ..~~- . ,m'1i".'h, 01: h~ '1'4 ..--J L ~. '1. . J-;l;c.L;O \rJ f\.") r..1.. 'j-/)Vg"",w,:,:":,,,~+,"l" lOOl..\...5,,-\ L~ o Improved o Worse OUnchanged ~"-;':;~'-:;, ~'. ~:::~:: ~= . ~~~.J.:I:~;~~ 1/ ll;)"':~1"'lll~r . 'dlle"ll~~1!@'!l:U . .'" . all. 'II f" ,... ~l! ...., ~' ~~ '" ,~g~ ~ 'c~!"~" ,~,"" '~'~"'. ~. '. ~ t"~-tG ~VODevice: LQT U1211DA :,f1fJ( t) ~1X't-~ ~1.J. ' ; 1 0 IV Fluid: ?,'{\(/V 171'1 \k.c \c.........'J .is_'76 7.- 'L....<> Ill'" e-dli'''!'..U'''ln:........IIl.!lil'c ;.;_.g_;.~;",,'__!~__Ill''''''''..'''_._. o Cardiac Monllor Rate Rhythm o Splint Application o NIBP Monitor o Ace Bandage Application o Sling Application o Pulse Oximetry o (Cold), (Heat) Application o Wound Irrigation DC-Spine Immobilization o Dressings o Foreign Body Removal 91~~l)a(9'li1!i)~tt(j~!Itl'@,. ~ ~ 'I (JIL~ W 6k11u4~411t I'nliti'lo/~~~a~r';.:. ^ ~ I CP")(' I J ~ \ \\1 [\J'). :JP~ <...----' .-~;tialsfSignature: ",~ ~ I,/, IVV /'f -_ 77 (I'v, , I (Z-(-.'v t1 '- - f........\,M..... i= ~ - ;l:'v.,4~ i'" l3A o Improved 0 Worse 0 Unchanged : o (Local), (Regional) Anesthesia o Conscious Sedation o Laceration Repair o Cast Application o Fracture Care (open), (closed) \ \ --,,~, , ,~ (l{fA Ct, Inltialsl:gnature: ~ Physici t e: ./ 11.7 r~:~~u;e;, f.\CUU Rev,09! EMERGENCY DEPARTMENT ONGOING NURSING ASS'ESSNk. Ii , "Isle Regional Medical Center Name:MACNAMARA, SUSAI Pt#:9312840':' ", . Age:50YRS 008:11/21/1954 Sex: F MR#:0000825381 EOP: LASEK, ROBERT W MD PCP: KRETZING, HAROLD G Dale: 6/9/2005 ~VflSJ.IjG DIAGNOSIS .(Number;JJ)-:brder 9tRli9[1\~r:-'!;jlch.Rjltie.l'\:rn~~t~ave at )~~~1.9Plt.;$~.cted.'} ("iixi\:j:((t,,;., ;-::;;1f~'i:l\;1!ll.;':iil~~,'l!';r:I,:~~':;'i') Airvvay Clearance, Ineffective -Anxiety -Breathing Patterns, Ineffective _Cardiac Output, Decreased Comfort. Alteration in -Other Communication Impaired --Coping, Ineffective -Fluid Volume, Alteration in Gas Exchange, Impaired _ Hyperthermis (Fever} Infection, Potential Injury, Potential -Knowledge Deficit Mobility Impaired Non~Compliance -Olher Self Care Deficit --Skin tntegrity Impairment -rhought Processes, Impaired -Thought Processes, "Iteration in Tissue Perfusion, Alteration in The~GOALl'l!pIoAN "fa" thiS.natiOn! IS-Icr aSslsl')n riie<lllffa'lOel1I1f.ed 'nooaS' and llii\\.f.1J\terv....ntIOiis.lonio:.~.:!'t;.,~)~tl,t :":~l:c~~'):,~~l'J\j~"?~;:il":!:' Not Met Met 1m Not Met Met lnt Not Met Met Int o IMMOBILIZATION I PROPER "L1GNMENT 0 IMPROVEMENT OF BREATHING o OECREASE I PREVENT SWElliNG 0 STABILIZE PATIENT IN DISTRESS o MAINTAIN STABLE HOMEOSTASIS 0 meet ENVIRONMENTAL NEEDS o MAINTAIN SKIN I TISSUE INTEGRITY 0 meel PSYCHOSOCIAL NEEDS o PREVENT FURTHER INJURY 0 meet SELF CARE ABILITY NEEDS o MAINTAIN I IMPROVE CIRCULATION Omeel EDUCATIONAL NEEDS o INFECTION CONTROL o Other Int: N:: documentation in nurses notes, other 'codes' per Hospital Policy. 'i~,~,\l1~,t1..~~~flt~_y~!:T@S~;~.~~.i~~t\1,.~'i.t'.ltrlt!~~~ .~~,.,,,,,.,,_ ~f~lt/;~~~-~~ -.",-jf"J''''C,-,<!" __-_..._.~i ~m~~_I~~}J'9RI9rr!t'JJ- 'I<~ .,,)s.,\9,Cj'1l /7/5 '?A S-\\aI..D In -\--0 ey'OJY...-UtJl.. ---SV [1'60 c.Jo odvl-;:) r-Y1. "1\_ 0.. $lrlo <: \C.."\".9-.lL'5 <;-\e:.,><< d. - ),( -- , o FB REMOVAL o BLEEDING CONTROL o PAIN CONTROL o ALLEVIATE NN o FEVER CONTROL o DECREASE ANXIETY o SAFETY IN THE EO i ']g; ,0 X. ,r' - SfJ n J8-~ 'hn de -+n Bi<.CLr,,, I h- , 'u 1'100 PA ~U\) In --\-a ev r ~lS $J Lt sc.~"'JU lLiDO eo..c..\c +n ~Cl.f\.-') \ \-- - ~'\~ ' 'AC2f) l--\O~ \~ ' ""- ~ --t. '$,. :;ve..c.-,'-\-'~ Cor t.J2.... "" ~ IlOLIS \f 01 df'_cl roo" 10 \, - ...., 0A c: [0/1...( -I-- c:: I 2lcD Dr Gre.en \~ --In E^?CL--v\....LIA 0 rD-1- - Sf,. I /'l?f:J In ~tnf. CLJcJ ~ . rY' . 1 n ~ J ou..d I-2:l ~\'LLf ,) ?>f ~. 'f 4 :-c::: I l "','+,,^' c... __I l.\'30 ~L"'",", ';."","" 'y,.... cl., YQ..fY'>\ ~\j Discharged in care of: ,--..J 1 Discharge instructions qiven to ,de \::""d~~ c:: 1 - "<.1\1JtJ.,.... 'J'1 . Admit: Room #:~to Dr.err. ~eady for Room Time:_ ZZ\S A.\-\eJ,'lO.\e.d ~ cvn\J0\c::-hon Reportcalledat()Olf andgivento-f/I""-" 1=", \ \ \-" \ t \ Transfered 10 0 Transfer Verified L~. e.. \ ~ 0-'>, .The.:>\...., Report called at and given to ~ ...-.....;, \ _ r--. \ I \._ o Left without treatment o Left Against Medical Advise C"O t' "--'\ ~ \ --> CI--'S.S: 00'"\ .::'"C'.d-e)'; > _-=:;:! U "-' Condition at D~!~DlmprOVe~\)lable DSerious DExpired \ ,no.!" I .. .--\-C ~ \..J..J -\: Pain Scale: ~ Pain Location: ~ Patient reports that pain is: ....ra1filproved ClUnchanged tJWorse 6Vi CL') ~-eY C\' 0 -\-u n( ./l. Dlsposl\;onVilals: T qr'l p ~ RiL8PIlc/?D~~'!!.Tt.,j As?,\'S ~A-J\;:::c:..J::::~.~ -\u::::tR.d OisPosilionDate:~JD Time.COi'6 Nurse: Nr.~ ,\K1 - ...vvU.k.J? C <. A:rC. ^ h s\ 101)\rlOj) -)((( )..\... -5/-1 - ~~ o Amb 0 WIC 0 Stret 0 Carried o Verbalized understanding EMERGENCY DEPARTMENT ADDfTlONAL NURSING NOn Date Hour . ~ . .' ",arlisleRegional Medical Center Name:MACNAMARA, SUSAN Pt#:9312840 Age: 50YRS 00B:11/21/1954 Sex: F MR#:0000825381 EOP:LASEK. ROBERT W MD PCP:KRETZING. HAROLD G Notes The signature of a nurse shall accompany each entry. Date In: 61912005 (pig 22.\<:) PA s--\-<bCJo \'" C0.J,.ln^ n \n --\-0 ~ G""'r-l-.?+ -to be. C.drY1l+F.-1 , nz.S P-\- CL-tt:Q:''''-P-kd -Iv <.->-ledL c:.. ~'-' :;, ,;,::.-\-o,w 'v"\ (OOI-n, 0-1 an~ ~c .~ - ,,\.-:;>7" ~ V\,-.c.,~c \...'> eQ/\S PI Q.C ~J,.--.\ h oJ Ir ,.~ h n r-l. 0,-0 Let rv'\ 4- 0 --l-o.J ,. 11+ ",e-..'\( .vcn ~.A _rY1~,..-- -+O.....'nh+" - -:'W( '2IL<.fS '\!(',ded ~Y> \::::e~~. pta.c.2d bcce...L In oc:?l...lH, \r: " ) dA-l--e.r- gr. ' ....... "- ~ too r\.sc.de... _ Al.-W U ..,h ~- ,~;{-., o.-'SS ton ,'YLQf1--\-- ---5,U --.-J ZZc,:o \\---l\ ~c<"/,"~~:----'KE:-s::.u<s(O'\ 0:-............... ~. :::,-\=-~ ,..-1,,><<"-. (>6+ \ro. -..J e..... n.---, -""' F!.. VY"\(1"V "",~ ^ ....... + ~SiV. rom ,/,-\7, h nl {fllQ.. ~ v<<(- +.. verl-lY.J./ I J Rev.03/0SJQ4 EMERGENCY DEPARTMENT/is/e Regional Medical Center MUSCULOSKELETAL NURSING ,.,.)sEssMEM.Name:MACNAMARA,::;\ N Pl#931284o Age:50YRS 008:111211',.54 Sex: F MR#:0000825381 Date In: 61912005 Time: /7150 EDP: LASEK, ROBERT W MD PCP:KRETZING, HAROLD G SUbjective Notes: Location: yvl............\~p\e c.<...1\.fK-.t..J2:uality: OSharp ODull OCramping OBurning DAching Provocation: 0 Other: Radiating: DNa DYes (specify) o Constant o Intermittent Appearance: .J4<:1ean 0 Unkempt 0 Other Mood I Affect I Behavior: pAppropriate 0 Depressed oAnxious oTearful oOther Caregiver: l3Self o Family member OSignificant Other OGraup home Activity level: ~mbulates independently oRequires assistance oNon.ambulatory o Performs ADL's independently oRequires assistance with ADL's Severity scale: Sf {O Aggravating factors: Relieving factors: Onset: "Mecl","'s +'~''"''''''&,i..,\MJ" Direction and amount of force: Environment: 0 No steps 0 Few steps 0 Many steps Nutritional status: ~rmal 0 Cache tic 0 Obese Religious I Cultural preference: oNone (specify) Best learn by: oVerbal o Written oReturn demo Learning Barriers: OTDD phone olnterpreter oNo oYes o Other: What was felt or heard upon injury: Use numbers to Indicate Injury location and type Pre.hospital treatment: 0 Full spinal immobilization 0 C.Collar OSplint o Pr~ssure dressing 0 Ice 0 Heat 0 Ace wrap RIght Left Left 1.Abrasion 2.Amputation 3.Avulsion ..Bum 5. Closed Fxl Dis. 6. Contusion T.Crepilu5 a,Deformity '.Edema 10.GSW 11.lacerallon 12.0pen Fx. 13.Slab 14. 15. Right PMH from triage: o Previous Sx involving musculoskeletal system and date: oDiabetes oArthritis oOsteoporosis o Hemophiliao Cancer: o Anticoagulant medicine: 0 ASA 0 Coumadiro Other: Lacerations I Abrasions I Avulslons I Contusions Location: (see graph.) Size: Bleeding: 0 Absent 0 Present 0 Scant 0 Moderate 0 Heavy 0 Pulsating Immunization:unknown Scars: Edema: Extremity Assessment RUE Pulses: DYes ONo LUE Pulses: 0 Yes 0 No RLE Pulses: 0 Yes 0 No . LLE Pulses: 0 Yes 0 No !;S iN 0<2s.0>2s. 0<2s.0>2s. 0<2s.0>2s. 0<2s.0>2s. Molion: 0 Yes 0 No Motion: DYes 0 No Molion: DYes 0 No Motion: DYes 0 No Sensation: 0 Yes 0 No Sensalion: 0 Yes 0 No Sensation: 0 Ves 0 No Sensation: 0 Yes 0 No Temp.OW DC Temp.OW DC Temp.oW DC Temp.ow DC DATE: 06/09/2005 ~nt: DOB: EDP: PCP: MACNAMARA, SUSAN 11/21f1954 AGE: LASEK, ROBERT W MD KRETZING, HAROLD G -lisle Regional Medical Center Pt#: 9312840 Sex: F MR#: 0000825381 INITIAL ASSESSMENT FORM PRIORITY: 4 Non-Urgent 50YRS Worke~s Comp: Emp. Referred: Presentation Time: 16:35 Triage Time: 16:35 Arrival Mode: ALS Height: Chief Complaint: " Weight: 127.0 Ibs. 57.7 kgs. LMP: MVA-MINOR INJURY Last Tetanus: unknown NIGHT SWEATS WEIGHT LOSS ANOREXIA SAFETY RESTRAINED DRIVER AIRBAG DEPLOYED UNK UNK UNK HEMOPTYSIS FEVER UNK UNK Ace By: DAUGHTERS Vital SIQns T: 99.0 PO P: 88 Regular R: 18 Unlabored BP: 124/086 02: 97%RA Pain Intensity Scale: 5 f 10 Pain Location: Multiple Areas Brief Assessment DRIVER OF DRIVERS IDE FRONT IMPACT. PAIN IN PELVIC AREA, UNABLE TO LIFT LEGS, POSITIVE FEELING. UNK YES YES NO Sudden Onset: Pre-Hospital 20G RF A, C-COLLAR, BOARD Treatment: Pediatric NIA Assessment: Past Medical NONE History: Allergies: NONE Medicines: NONE Nurse Signature: /) KLA Additional Notes: Rev 05/" rlVIII. VVV,,"\J1 1-.l1..J r...'I:l~. " L..td-~O. 'V/VVIIl..VV,"", '''''0. .\J............ n.y1>\VI'lon Mon-F,!: 8"".1 lan, 5pm.8pm (EST) SBJ:-Sun: Kam-Kpm (EST) Phon" 8663%94295 Fax: 877 899 4295 ~>~ NightHawk Radiology SerViceS Night Dlvl,lon Mon'Pr;: 8pm.8an (EST) SoI.Sun: 8pm.8am (EST) Phono: 866 241 6635 Fox: 866287 1373 PRELIMINARY RADIOLOGY REPORT PATIENT NAME: PATIENT ID: MACNAMARA, SUSAN 825381 INSTITU'I'ION NAME: CARLISLE REGIONAL 11EDICAL CENTER - CARLISLE, PA 17013 DATE: 9th June, 2005 EDC; STUDY TYPE: CT AEDOMEN / CT P1LVIS This interpretation is based upon tl':e receipt of 111 images. CLINICAL HISTORY / INDICATION FOR EXAM: MV A HX OF PELVIC FX FINDINGS: CT of the abdomen and pelvis demonstrates a 14 mm hypodense nodule in the inferior right lateral liver, with some peripheral enhancement, and a smaller, subcentimeter lesion at the dome ofthe liver with a similar appearance. These may represent hemangiomas, although other etiologies arl: mt excluded, Ultrasound may be helpful in further evaluation. There is no evidence of liver laceration however. The spleen, pancreas, adrenal glands and kidneys are normal. The gallbladder is present. The abdominal aorta is normal in caliber and there is no retroperitoneal lymphadenopathy, There is no free peritoneal fluid. Bowel is nondilated. The uterus is somewhat prominent and irregular, suggesting fibroids, with the largest measuring 4 em. The bladder is relatively well distended but otherwise unremarkable. There is a fracture of the left inferior pubic ramus and superior pubic ramus laterally involving the anterior acetabulum and acetabular roof. There is a fiacture also seen in the right sacral ala. Impression: 1. Pelvic fracture, consistent with the reported history, 2. No other traumatic intra-abdominal orpehic injury is demonstrated. P.g,1 c. (RlnOEN'TTAL; nlfl 4JWmglllY tlct:otnlK110'111J! Ihls mm.vml,YJIUrl "","'1/11 illH1fldll/l/1ti( Ilif,;!llrlllfimmIlIJHllht# I.r 11/!f(l11y prMflJll!ld. TIt/,Y /I{ill'mLllllJ/l ~ 11111I/ldQd 1II11y/or I/rllll,\'a !I{th<: illdi~idll,.lllrc'Jlity IUJ/I1=ll.lmw:. nl~ ffuillllri:lfd fC:r:ipil!I1/lI/lhilf i'1/1lml<lliml i.. pmlllbil;d.frr/f1l di.,drMill!C 11i;.~ il!/ilr'mnfilllllll "'l.1' IIlhtr ptu'ty 1I/llc~ fT:l(UiniJ If! rill ~(/ hy law /If ragul,Ii/IHl (II'" /.1 rtlqulrwJ 11/ t!lJSlroy lha ItlfiJl'wUJlhlll ,1fI1I/-II.v .V{(IIr:d III/Ita I!'~I h;':/!/IiIfl/IJd.l{YUll <<1"11 nul Ihl1/rucl'.dtd rllClpIWll.YU\l (I1't/ /zWllby IIUl/ll"rJ Ihm {lilY di~llIIlln:. (l>lQ'i"Jr:. Ji.!lrihut;lI>l. (fI.trr;/imll"J.C'1 in rc1illl1l:C!II1 Il,e: mlll,ml., ri/l/".IC d'''I<f''~''11f i.I .<In",'IO, /lrtlMhifr:;J./f)'lIU hell'" ,,"r:i~r:d IIli,< illfill7fl'!lil/OJ illl:fmr, p[lm..1:: m/li{y 11111 ,Ylmdm'/lPlmudlll/a/)l mid tmWlgif.!;"./lw /';'1:.111 rW dU,\'II'I,1hI/lIYIl!rwl d/lCUmlJ/U,I, , 'V",. v'"'........., ,.." "" 'CO!!!",...... ........g. ,.."......,_......... "",.... ...............- Day Dlvltlod Mon-fri: hm.ll1lm, Spm-%pm (EST) Sa1-Sun: Ham-Mpm (EST) Phon,; 1663294295 fax' 1778994295 ~~, ~ NightHawk Radiology ,SerVices Night Dlvtllon Mon-Fri: 8pm.8am (EST) Sat-Sun.: Hpm-Mam (EST) Phone: %662416635 ,ax: 866 2871373 PRELIMINARY RADIOLOGY REPORT PATIENT NAME, PATIENT ID: MACNAMARA, SUSAN 825381 INSTITUTION NAME, CARLISLE REGIONAL MEDICAL CENTER - CARLISLE, PA 17013 DATE, STUDY T'll'E: 9th June, 2005 8D'1 CT ABDOMEN / CT PELVIS This interpretation is based upon ~ne receipt of III images. 3, There are two hypodense lesions in the liver, the larger measuring 14 mm. There is some peripheral enhancement suggesting hcmangiomas, but other etiologies not excluded by this study alone. Comparison to prior studies or correlation with ultrasound may be helpful. 4. Uterine fibroids. Preliminary report created by: John Boardman MD Pa~,1 2 Lut Page C,G~nDEN1TAc.,' ,"111 dtJr:t/1I'Wlf.'lll~'C.I{Hl1p<II~IIJH flrls 1,.(Jr~'lmf.y.tll}I/ tYIIIW!/1 cfllrjldllllll(lIIt~,,f'!1 ilr/imrwlllHI rlullu lage/ffy pl'N/lagad. Th/$/IIf(/f'rrl(<</(I11 b ItWtnch<l !Jllt\I ft/f' 111(1 \l${J "[1111: illdividl.1l1l w'I:IltiO' '"1M", tim/v.:. n'e 1IUIItr!>'i:ed f'l:c;pie'll r{llli~ i'lfimtulli,1Il i,. pYl;Il,biltdfh/lll w"c{lIolilW (fi~ i'l/ill7I'UlIillll IlIllIl)' 11th;,. pll/'ty 1l1l1l:M f'l:f{lAlf'l:U II/ dr/.~r/ by l<<w fir N/lJIIf<IlIIHf (rill! I.' r'/Il(Ylrad IlIdtJ.tlNI)' 1/1lI lWilmllltllllllfllal' Il.t .'UIlIJd IIIIU/l IldX b;';11./ill/lflQd. f/)IlIllllI'lI Iltl/ IIIII/lUonlllld l'rrc/pJI1IU,YIIU lll'llllllNhy 1Irlt/jllld Ihm (1/1)1 . Ji~,lr"I'~' ,IIP)'i,W. diol/ribuli/m. IIrtrdirlll uk'! i,lllIlulllce IIIllHe ccmll:>/I.f 1IIII'I!.~l; JII'lfrn""~ i~ .<Iri/;Ily pnlJ,ibiled f/)'UlA kllll:t rc,eiv=llhi.< i,rjimn'llill'l ill ;rrur, pll:lU<1! ,wlifj' IhQ $(JI!d'lf' Immoolflluly mid Ill'l'll>>yujht llw r.li\lm ,II'Ja.m'l{cl)(1Il lI!ihll.trI dlK:umIlIU,Y. ..". " "', EMERGENCYSERVlCES '. ..,. ,;J,'oi'lltQtOareLaboratory Testing'RepotfForm:,'" LABF 168-01 Issued'Date: 02-04 .' ,.> , PAl MACNAMARA, SUSANDATE/Ti~e: if) / q / ()5 120.1/5 Atct#9312840 MR#0000825381 06/0912005 II '. . lASEK, ROBERT 00B:1112111954 050 F ME: CARLISLE REGIONAL MEDICAL eTR FINAN CIAL# . . IIIIllllIlumllmllllllllllllmmlllll1 0000. El . /1_ . A.'- / / . . Employee Name (Performing testing): LafUiG ~ URINE CHEMSTRIP 7 Glucose 3- mroxd tt.J1lWtmte pH Ketones Leukocytes* .:Uolt Nitrite ~\ Ve Protein ~tl 'It.. Blood/Hgb utfu.r 50 (Read all results at 1 minute, except ij'Leukocyte pud indicates a trace result, then it should be read again at 2 minutes.) Reference values: Ail results negativ.e except for pE; that is normally around 6.0 but may range from 5.0-B..O. . URINE PREGNANCY TEST Patient result is (circle one): Positive' Negative Reference value is negative. pH' PAPER TESTING - q Result: Ranges: pH of the eye is neutral, around 7.0. . Normal vaginal pH is 4.5-5.5 Amniotic fluid is 7.0 or greater. \(", a;~ 246 ParkerSI. Carlisle. fA 17013 PIl:717-249-1212 HIPAA FORM 20 ACKNOWLEDGEMENT: RECEIPT OF PRIVACY NOTICE Purpose: This form is used to document (al an individual's acknowledgement of receipt of our Privacy Practices Notice or (b) when we have not obtained this acknowledgement, our good faith effort to obtain the acknowledgement. Patient Name: MACNAMARA, SUSAN Date of Admission: 0000825381 Social Security Number: 210-44-3603 06/09/2005 Notice Version (Date): 4/1412003 Medical Record Number: Acknowledgement of receipt of Privacy Practices Notice I, MACNAMARA, SUSAN Notice from: CARLISLE REGIONAL , acknowledge that I have received a Privacy Practices MEDICAL CTR Further, by signing below I provide my permission for this facility to use and disclose my medical information for the permitted purposes of treatment, payment and health care operations as discussed in the Notice of Pri~acy Iracti~es. . 9vl . . tl. _.. _ _ _ Patient Signature: ~ ~ ~Date: 06/09f2005 // o Notice has previously been distributed by another location in our OHCA (except for physicians): List location that distributed the Joint Notice: If a personal representative on behalf of the individual signs this authorization, complete the following: Personal Representative's Name: Relationship to Individual: IF NOT SIGNED:(Good faith effort to obtain acknowledgement of receipt) Describe your good faith effort to obtain the individual's signature on this form: Describe the reason why the individual would not sign this form: SIGNATURE: (Hospital Representative) I attest that the above information is correct. Signature: ~ru? f/l. Print Name: Bethea, K yuati - Admitting Data: 06/09f2005 Title: iALJw1 Include this acknowledgement form in the individual's records. Hospital Copy ~~ 246ParkerSt. Carlisle. PA 11013 Ph=717.249-[212 CONDITIONS OF TREATMENT AND ADMISSION PATIENT'S NAME ACCOUNT NO. MACNAMARA, SUSAN 9312840 ATTENDING PHYSICIAN LASEK, ROBERT W MD DATE & TIME OF ADMISSION 06/09/2005 16:35 CONSENT TO HOSPIT At. CARE AND THEA TMENT I AM PRESENTING MYSELF FOR EMERGENCY SERVICES OR ADMISSION TO THE HOSPITAL AND \ VOLUNTARilY CONSENT TO THE RENDERING OF SUCH CARE.. INCLUDING DlAGNOST1C TESTS AND Me:OICAL TREATMENT, BY AUTHORIZED AGENTS AND EMPLOYEES OF THE HOSPITAL, AND BY ITS MEDICAL 5T AFF I OR THEIR DESIGNEES, AS MAY IN THErA PROFESSIONAL JUDGEMENT BE DEEMED NECESSARY OR BENEFICIAL TO MY WELL BEING. I ACKNOWLEDGE AND UNDERSTAND THAT MANY OF THE PHYSICIANS ON THE STAFF OF THIS HOSPITAL. INCLUDING THE ATTENDING PHYSICIAN(SI NAMED ABOVE. AND RADIOLOGISTS. ANESTHESIOLOGISTS, PATHOLOGISTS AND EMERGENCY PHYSICIANS, ARE NOT EMPLOYEES OR AGENTS OF THE HOSPITAL, BUT RATHER ARE INDEPENDENT CONTRACTORS WHO HAVE BEEN GRANTED THE PRIVILEGE OF USING THE HOSPITAL FACILITIES FOR THE CARE AND TREATMENT OF THEIR PATIENTS. I AGREE TO ACCEPT THEIR CARE EVEN THOUGH THEY ARE NOT EMPLOYED BY THE HOSPITAL. I UNDERSTAND THAT THE EXAMINATION AND TREATMENT THAT I RECEIVE ON AN EMERGENCY BASIS IS NOT INTENDED AS A SUBSTITUTION OR REPLACEMENT FOR COMPLETE MEDICAL CARE, CONSENT TO REI..EASE INFORMATION I HEREBY AUTHORIZE THE HOSPITAL TO DISCLOSE TO INSURANCE COMPANIES, INCLUDING WORKERS COMPENSATION CARRIERS, OR OTHER PARTIES THAT MAY BE LIABLE fOR ALL OR PART OF THE HOSPITAL CHARGES, ALL OR PART OF MY HOSPITAL RECORDS AS MAY BE NECESSARY (INCLUDING ANY TREATMENT FOR ALCOHOL OR DRUG ABUSE OR DEPENDENCE), TO DETERMINE BENEFITS ENTITLEMENT AND PROCESS PAYMENT CLAIMS FOR HEALTH CARE SERVICES PROVIDED. MEDICARE CERTIFICATION RELEASE , CERTIFY THAT THE INFORMATION GIVEN BY ME IN APPLYING FOR PAYMENT UNDER THE TITLE XVIII AND TITLE XIX OF THE SOCIAL SECURITY ACT IS CORRECT. I AUTHORIZE ANY HOLDER OF MEDICAL OR OTHER INFORMATION ABOUT ME TO RELEASE TO THE SOCIAL SECURITY ADMINISTRATION OR ITS INTERMEDIARIES OR CARRIERS ANY INFORMATION NEEDED FOR THIS OR A RELATED MEDICARE CLAIM. I REQUEST THA T PAYMENT OF AUTHORIZED BENEFITS BE MADE ON MY BEHALF TO THE HOSPITAL OR TO THE PHYSICIAN WHO ACCEPTS ASSIGNMENT. PERSONAL EFFECTS AND VALUABLES I UNDERSTAND THAT THE HOSPITAL SHAll NOT BE LIABLE FOR THE LOSS OR DAMAGE OF ANY PERSONAL EFFECTS OR VALUABLES (MONEY, JEWElR.Y, GLASSES, DENTURES. DOCUMENTS, CLOTHING, ETC.} UNLESS SUCH ITEMS ARE DEPOSITED IN THE HOSPITAL SAFE. THE HOSPITAL WILL NOT BE LIABLE IN EXCESS OF $50 FOR THE lOSS OR DAMAGE OF ANY PERSONAL EFFECTS OR VALUABLES DEPOSITED WITHIN THE HOSPITAL SAFE. ABOUT YOUR BilL I UNDERSTAND THAT I WILL RECEIVE A BILL FROM THE HOSPITAL FOR PROVISION OF THE HOSPITAL SERVICES, INCLUDING STAFF AND EQUI?MEN1, AND FOR ANY SUPPLIES OR MEDICINES UTILIZED. I WILL ALSO RECEIVE A BILL FROM ANY PHYSICIAN WHO PROVIDES PROFESSIONAL CARE TO ME. FOR EXAMPLE, I MAY RECEIVE A SEPARATE BILL FROM ONE OR MORE OF THE FOLLOWING TYPES OF PHYSICIANS WHO RENDER SERVICES TO ME: MY ATTENDING PHYSICIAN OR PERSONAL PHYSICIAN, EMERGENCY ROOM PHYSICIAN, RADIOLOGIST, ANESTHESIOlOGIS1', PATHOLOGIST, OR ANY OTHER SPECIALIST. INSURANCE ASSIGNMENT I HEREBY ASSIGN TO AND AUTHORIZE THE HOSPITAL AND PHYSICIANS INVOLVED IN CARE DURING THIS PERIOD OF IllNESS OR TREATMENT (HEREINAFTER "PHYSICIANS"), OR THEIR OUl Y AUTHORIZED ASSIGNS TO TAKE ALL NECESSARY STEPS, WITHOUT LIMITATIONS, TO ENSURE THAT ANY INSURANCE BENEFITS OTHERWISE PAYABLE TO ME OR MY ESTATE ARE PAID DIRECTLY TO THE HOSPITAL OR PHYSICIANS. THIS ASSIGNMENT OF INSURANCE BENEFITS INCLUDES aUT IS NOT LIMITED TO BILLING INSURANCE, FILING PETITIONS, FILING SUIT, IN MY NAME OR ON BEHALF OF THE HOSPITAL OR PHYSICIANS, FlUNG PROOFS OF CLAIM, FlUNG PROBATE CLAIMS AND FlUNG GRIEVANCES AND ALL OTHER SIMILAR PROCEDURES, AS MAY 8E AMENDED FROM TIME TO TIME WITH THE STATE DEPARTMENT OF INSURANCE. I ALSO AGREE TO PROVIDE AND SIGN ANY OTHER DOCUMENTS THAT MAY BE REASONABLY NECESSARY TO ACCOMPLISH ANY OF THE OTHER PURPOSES. STATEMENT OF FINANCIAL RESPONSIBILITY I UNDERSTAND THAT I AM FINANCIALLY AND LEGALLY RESPONSIBLE FOR CHARGES NOT COVERED IN FUll BY ANY THIRD PARTY. I FURTHER AGREE THAT SHOULD I NOT PAY THE BALANCE WITHIN THIRTY (30) DAYS AFTER THE DATE OF DISCHARGE, MY ACCOUNT WILL BE CONSIDERED DELINQUENT. I AGREE TO PAY COSTS OF COLLECTION, INCLUDING REASONABLE ATTORNEY'S FEES AND COSTS, COLLECTION AGENCY FEES AND COSTS, AND INTEREST WHICH SHALL ACCRUE A1' THE MAXIMUM RATE ALLOWED BY LAW. ~ ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURANCE COMPANY, OR FILES A STATEMENT OF CLAIM CONTAINING FALSE, INCOMPLETE OR MISLEADING INFORMATION MAY BE SUBJECT TO PROSECUTION UNDER APPLICABLE LAW. ADVANCE DIRECTIVE {FOR ADMISSION TO HOSPITAl.. ONLYI IF \ AM 1'0 BE ADMlTTED TO THE HOSPITAL, I HAVE BEEN GIVEN WRITTEN MATERIALS ABOUT MY RIGHT TO ACCEPT OR REFUSE MEDICAL TAEATMENT. I HAVE BEEN INFORMED OF MY RIGHTS TO FORMULATE ADVANCE DIRECTIVES. I UNDERSTAND THAT I AM NOT REQUIRED TO HAVE AN ADVANCE DIRE:CTIVE IN ORDER TO RECEIVE MEDICAL TREATMENT AT THIS HOSPITAL. I UNDERSTAND THAT THE HOSPITAL AND MY CAREGIVERS WILL FOL.lOW THE TERMS OF ANY ADVANCE DIRECTIVE THAT I HAVE EXECUTED TO THE EXTENT PERMITTED BY LAW. (INITIAL THE FOLLOWING OPTION THAT APPUESI -I HAVE EXECUTED AN ADVANCE DIRECTIVE AND WILL PROVIDE A COpy OF THIS FOR MY MEDICAL RECORD WITHIN A REASONABLE AMOUNT OF TIME. -1 HAVE NOT EXECUTED AN ADVANCE DIRECTIVE AND 00 NOT WISH TO DO SO. INIT. INIT. (FOLLOW-UP DONE BY - I WISH TO COMPLETE AN ADVANCE DIRECTIVE DURING THIS HOSPITAUZATION. INIT. I CERTIFY T T I HAVE READ lOR HAVE BEEN READI THE ABOVE CONSENTS AND CERT1F CATIONS AND UNDERSTA -L~ ~ t)~A~rYn. 1'\ YEAR ~PA WITNESS DATE DATE: PRINT NAME OF PERSON ABOVE AD001B 9312840 0000825381 111l\111\llllllllllmlllll~~\\II\lIl IIIIIIIIIIIIIIIIIIII~IIIIIIIII\IIIIIIII\\III 1IIIIIIIImllllllllllllllllllllllllllllllllllllllllllllllll - <6d5'~ I 209 State Street Harrisburg, Pennsylvania 17101 717.232.6300 FAX 717.232.6467 www.srklaw.com 1528 Walnut Street. 3rd Floor Philadelphia, PA 19102 215.790.7303 VOiCE 215.546.0942 FAX Schmidt, Ronca & Kramer PC . INJURY LAWYERS PLEASE RESPOND TO HARRISBURG OFFICE. . Affiliated Law Firm - Sheiier, Ludwig & Badey, P.C. Philadelphia, PA June 29,2005 JUL 0 1 2005 Carlisle Regional Medical Center Attn: Medical Records Department 246 Parker Street P.O. Box 4100 Carlisle, PA 17013 Re: Patient: Susan M. MacNamara DOD: 11/21/1954 SSN: 210-44-3603 Treatment dates: 06/09/05 to present (.,-q-05' (p.-fO-OS' X I G. 'Il-Or E.. R Dear Sir or Madam: Please be advised this firm represents the above-referenced patient. Please forward to me copies of all medical records and itemized billing statements relating to the care and treatment of the patient for the above-referenced dates of treatment. I have enclosed an executed medical authorization permitting the release of this information. ".",' If you have any questions, please feel free to call me at any time. - ,1~ . .; ",; i , .very truly yours ,I, . C,.:, ' TSH/ jss Enclosure COPIED BY @~;JUL 0 8 2005 QW!:ONf! I ~O :sa-I .\ ~O,./'~. c.... 07/01/0', PAGE 001 HEALTH MANAGEMENT ASSOCIATES CARLISLE REGIONAL MED CENTER PATIEN": MACNAMARA, SUSAN F /e: F P /T: I A/C: 93~2840 ADMISSION: 06/09/05 DA17 COlD: 858 AS OF 06/30/05 DSC CODE: 01 DISCHARGE: 06/10/05 CHG DATI: OPT REV BAT# HCPC M1M2 CHGCD DESCRIPTION QTY AMOUNT -------------------------------------------------------------------------------- 06/09/0!J 311 121 4 00018 0307WSEMI PRIVATE RO 1 650.00 06/09/0', 412 250 5203 90718 36300 TET DIP TOX ADULT O. 1 76.66 06/09/0', 418 270 5400 26890 TRAY LACERATION 5288 1 52.74 06/09/0~i 428 320 8 72110 72110 SPINE LUMBAR MIN 4V 1 505.92 06/09/0:; 428 320 8 72190 72190 PELVIS MIN 3V 1 308.56 06/09/0!J 428 320 8 73550 LT 73550 FEMUR MIN 2V 1 292.65 06/09/0'; 429 352 8 72193 72193 CT PELVIS W/CONTRAST 1 1,119.56 06/09/0', 429 352 8 74160 74160 CT ABDOMEN W/CONTRAS 1 1,119.56 06/09/0!; 436 300 30 36415 36111 VENIPUNCTURE ROUTINE 1 9.00 06/09/0 '; 436 305 30 85025 85028 CBe COMPLETE AUTOMAT 1 57.66 06/10/0'; 412 250 5203 10642 CELECOXIB 200MG CAP 1 15.55 06/10/0!, 412 250 5203 11188 OXYCODONE ER 10MG TA 1 8.82 06/09/0'; 412 250 5202 17800 HYDROMORPHONE 4MG/ML 1 9.49 06/09/0'; 412 250 5202 17800 HYDROMORPHONE 4MG/ML 1- 9.49- CONTINUED.. . SELECT: REV= * DEPT= * CHGCD= * DATE/MDCY= * TO/MDCY= * CMD: l~Di\R, 2=PAT 4~SUMMARY,5=TOP,6=END,7=RETURN,8=BACKWARD ENTER~FORWARD 07/01/0', PAGE 001 HEALTH MANAGEMENT ASSOCIATES CARLISLE REGIONAL MED CENTER PATIEW': MACNAMARA, SUSAN F/C: F PIT: E A/C: 93 _3457 ADMISSION: 06/17/05 DA17 COlD: 858 AS OF 06/30/05 DSC CODE: 01 DISCHARGE: 06/17/05 -------------------------------------------------------------------------------- CHG DAT~ DPT REV BAT' HCPC MIM2 CHGCD DESCRIPTION QTY AMOUNT -------------------------------------------------------------------------------- 06/17/0', 418 272 5400 06/17/0') 418 272 5400 06/17/0') 480 450 6 99281 12845 STERI STRIP 1/2X4 30793 SET SUTURE DISP 33669 ER TRIAGE 1 1 1 16.88 10.56 75.46 -------.------------------------------------------------------------------------ TOTAL: (:ASH > SELECT: REV~ * CMD:1~Di\R,2~PAT TOTAL CHARGES 102.90 0.00 ADJUSTMENTS> 0.00 BALANCE> 102.90 DEPT= * CHGCD= * DATE/MDCY= * TO/MDCY= * 4~SUMMARY,5=TOP,6=END,7=RETURN,8=BACKWARD ENTER=FORWARD aRfC~ ADMISSION RECORD WEOICAL (;INTIIl. I ACCOUNT NO. Mtl>l\,;AL Rt:\.,;uRu:i Nu. 246 Parker St. Carlisle. PA 17013 Ph:717-249-1212 9312840 0000825381 ADMIT DATE I TIME I ROOM NO. PT rc I AGE I DATE OF BIRTH I SEX I RA I MS I LOCATION I PROGRAM P 06/09/2005 22:45 0307 W 11 P 50 11/21/1954 F 1 S MS3 A T PATIENT NAME~lSt _AODRE::>>S SS NUMBER PATIENT EMPLOYER EMPLOYER PHONE NO. I MACNAMARA, SUSAN 210-44-3603 RITE AIDE (717) 691-6200 E 312 N WEST ST N CARLISLE PA 17013 PHONE NUMBEA COUNTY T US (717) 243-2098 CUMBERLAND I ,:,~~~N_::>>JB,L:: ~ ~~ '(. co AI..II.I.!:'';~~ SS NUMBER Lc: !,A~, Y I::M LUYER <;M~L " G MACNAMARA, SUSAN RITE AIDE U 312 N WEST ST 210-44-3603 5280 SIMPSON FERRY RD (717)691-6200 A MECHANICS BURG PA 17055 RELATIONSHIP TO ?ATIENT CARLISLE PA 17013 PHONE NUMBER R US (717) 243-2098 PATIENT IS G EMERGENCY CONTACT NAME EMERGENCY CONTACT PHONE EMERGENCY CONTACT RELATIONSHIP TO PATIENT HATT, DIANE (717)243-6650 FRIEND COMMENTS MOP MED. KEY j I PRIVACY INP~1 ADMIT, BY ER TO INP 22:45 6/9 KAB DY Il!lN DY Il!lN Y KAB PRIVACY 1 . I ""H .1f'LAN puLl I UAlI:LJ":' ;:,lMIH 000 00/00/0000 I INSURANCE CO. NAME & ADDRESS INSURED'S NAME N CRUUP NUM"H l.liHUUI-' NAMI; AUTHuRIZATluN S 2 I PAYER .IP~AN POLl.... Y NUMBER IDATEO!" ~IATH U / / IN . NAME' ADDRESS IN::;URI;D'::; NAMt:; R GROUP NUMBER I GROUP NAME A AUTHORIZATION N .IPAYER IPLAN POLICY NUMBER . fDATEOFtRTHj 3 II'tI:.unAl'Il.c ....u. NAME at AOuRc:." IN::;UHI;U'::; NAMI; C GROUP NUMBER I GROUP NAME E AUTHORIZATION M DR. ATTENDING I ADMITTING DR, FAMILY I PRIMAAY CARE I GREEN, THOMAS KRETZING, HAROLD G S uIAl.>Nu::;l::; I ::.1l.>N::. &. ::.YMt'1 uM::. I Al.....luo::r..' uATI; C PELVIC FX NO FAULT I 06/09/2005 PRINCIPAL DIAGNOSIS IThe condition established after study to be chiefly responsible 101 I ID,>cHAR07;;' /05 occasioning the admission of the patient to the HOSPITAL lor carel. COMPLICATIONS COMORBIDITYUES) PRINCIPAL PROCEDURE AC001A 9312840 0000825381 \\11111111111111111111111111111111111111 1I111I111111111111111111111111111111111111111 MEDICAL RECORDS COpy 1111111111111111111111111I11111111111111111111111111111111II Diet: ! Activity: Dressing/Personal Care Instructions: , , """ /,'...../ (' L." rL-.~ , '-'"-~ - /' /j " :' --"..'- // .2. ;) Follow-up appointment with Physician: ,,' .' Other follow-up appointments: Supplies1~~i1T'batient: fA '1.".1.::1 ',V~, ik.:;.' " I,- D VNS (Order on chart required) D Other SERVICES: D Skilled Nursing 0 Home Health Aide MEDICATIONS: (LIST BELOW) , ) iI,,; ( i," "'.' ."--.._---,f. 1....7.L 'l .~ !~-t~n 'J.' i ~,10/' ('tf -.:::. i.;(1--~SI o P.T. OO.T. OS.T. NAME DOSAGE INSTRUCTIONS . ,- '. .c. / /-~ . . ' , .. . . -. , . , .' , , , - , .- . "i-'_ '-Y"",-- I have received and understand the instructions on my medications and on food/drug interactions for these medications. This information is provided for educational purposes. Any recommendations from my physician will supercede this information. Patient or Responsible Party Signature: \- ! ! RN Signature: .,,:\ . " v -1 All / I~'l-, -,,' , ~ (t'-!.i..I rite /-' , t}t:) ::':1 Date: I ,_' /.., _.::- 1,1 v Physician Signature: PATIENT IDENTIFICATION MEDICAL CENTER MACNAMARA, SUSAN Accth9312840 MRh0000825381 06/09/2005 GREEN. THOMAS OOB: t 1/2 t!t 954 050 F CARliSLE REGIONAL MEOICAl CTR 1/11I1111111I11/1111111111I1111I1111111I1111I 0307W It 246 PARKER ST., P.O. BOX 310 CARLISLE, PA. 17013-0310 DISCHARGE INSTRUCTIONS MR04iO(11!Oi) **FOR DISCHARGE SUMM4RY, PLEASE SEJ!P~kROGRESS NOTE** MACNAMARA, SUSAN Acct#9312840 MR#0000825381 06109/2005 GREEN. THOMAS 008:11121/1954 050 f CARLISLE REGIONAL MEDICAL CTR 111111111111111111111I111111111I1111111I1111' 0307.W 11 Carlisle Regional Medical Center DISCHARGE SUMMARY MACNAMARA, SUSAN MS3 825381 DATE OF SERVICE: 06/09/1004 CONSULTATION DIAGNOSIS: Bilateral hip fractures, stable with acetabular involvement on the left. CHIEF COMPLAINT: Auto accident. HISTORY OF PRESENT ILLNESS: This is a 50-year-old woman who was in a small car with her three children and a truck ran into her at a rapid rate of speed, into to driver's side of her car. There was significant pain in her back and pelvis and then later on in her hips and when they came to get her, the emergency crew told her not to walk although that is what she wanted to do. Upon advice of the emergency crew she did not. She subsequently was brought to the Emergency Room where she was examined and primary survey was undertaken. After the primary survey the neck collar was removed. She was taken off the bed board and then underwent examination of the pelvis and lower back. The findings were that, on multiple views, of a bilateral hip fracture, which was stable without any evidence of transverse process fracture of the lumbar spine, no evidence of SI joint disruption, iliac disruption or disruption of the sacrum. A CT scan was also performed that showed no internal organs and no instability on the CT scan by observation of the pelvis. The patient remained stable. without blood in the urine and without symptoms of abdominal distress or distress in her chest. PAST MEDICAL HISTORY: The past history was reviewed and is of no significance or pertinent to the current problem. PHYSICAL EXAMINATION: General: Physical examination reveals a the patient is completely lucid, more concerned about her children going home today without her tonight than she is about herself and would prefer going home as opposed to staying in the hospital. HEENT: Her pupils responded. The upper airway was clear. There was no evidence of significant facial trauma. There was a laceration, around and about the aer, which would require suturing. Neck: Range of motion in the neck was full without crepitus, tenderness or muscle spasm. Range of motion of the shoulders are normal. Palpation of the clavicle is intact. Chest: No tenderness of the chest wall. Lungs: Full inspiration, expiration and coughing did not produce pain in the chest or abdomen. Back: Palpation of the back and percussion of the back from the neck all the way down to the sacrum was nontender. Palpation of the paralumbar areas was also nontender, without swelling. Abdomen: There was no evidence of blunt trauma to the abdomen. Palpation of the internal organs of the abdomen were nontender and compatible with a CAT scan. Pelvis: Palpation of the pelvic region was tender and we didn't force that. Neurologic: She had ability neurologically to move all the muscles of the lower extremity and had intact sensation and pluses. LABORATORY STUDIES - X-rays were reviewed. Lumbar spine is clear. The hips are clear, femur clear and knees clear. The pelvis has superior and inferior pubic ramus fractures on the right and no involvement with the acetabulum. On the left, pubic fractures with involvement ot the acetabular area, nonweightbearing side and the anterior column is not completely violated. So, this is a Page 1 of 2 THIS DOCUMENT IS NOT A LEGAL COPY UNLESS SIGNED. CARLISLE REGIONAL MEDICAL CENTER EMERGENCY ROOM CONSULTATION/ /-I-.,I~ 9312840 MACNAMARA, SUSAN MS3 825381 nondisplaced fracture although it does involve the articular surface there is absolutely no displacement. DIAGNOSIS - Stable fractures of the pelvis. PLAN - Teach her four-point reciprocating gait, give her analgesics to take home. Get the laceration of the ear fixed and see her in the office in one week. She is to take aspirin as an anticoagulant measure and she is to get up and walk as much as she can tolerate, also as anticoagulation strategy. TJG/jrs D: 06/09/200521:15:09 T: 06/10/2005 11 :20:38 Thom c: Thomas J. Green, M.D. Page 2 of 2 THIS DOCUMENT IS NOT A LEGAL COPY UNLESS SIGNED. CARLISLE REGIONAL MEDICAL CENTER EMERGENCY ROOM CONSULTATION / /-Iv? 9312840 a~ 246 Parkcr$t. Carlis]e,PA 17013 Ph;717-249-1212 P A T I E N T ADMIT DATE I TIME ROOM NO. 06/09/2005 16:35 0000 PATIENT NAME & ADDRESS MACNAMARA, SUSAN 312 N WEST ST CARLISLE PA 17013 US G U A R N lBL PAR Y ADOR MACNAMARA, SUSAN 312 N WEST ST CARLISLE PA 17013 US EMERGENCY CaNT ACT NAME HATT, DIANE COMMENTS PRIVACy 1 A 000 INSURANCE co. NAME &. ADDRESS N S 2 PAYER U IN U AN E .NAM A 0 R A N 3 PAYER IN URAN E .NAM DR C E M DR. ATTENDING I ADMITTIN I S C LASEK, ROBERT W MD IA N I I I N v M MVA--MINOR INJURY PT DATE OF BIRTH E1 11/21/1954 PATIENT EMPLOYER RITE AIDE PHONE NUMBER (717) 243-2098 Qt0\ NO. 210-44-3603 R N IBLl: AR Y M l Y RITE AIDE 5280 SIMPSON FERRY RD MECHANICSBURG PA 17055 NUM PHONE NUMBER (717)243-2098 EMERGENCY CONTACT PHONE ADMISSION RECORD 0000825381 PROGRAM EMPLOYER PHONE NO. (717) 691-6200 COUNTY CUMBERLAND MlYRPHN (717) 691-6200 PATIENT IS EMERGENCY CONTACT RELATIONSHIP TO PATIENT RELATIONSHIP TO ?ATIENT (717)243-6650 MSP Dv t;gN LI INSURED'S NAME U NUM AUTHORIZATION PLAN P LI Y NUMB A INU 'NAM GROUP NUMBER AUTHORIZATION PLAN POLICY NUMBER IN UR Q' NA GROUP NUMBER AUTHORIZATION OR. FAMILY f PRIMARY CARE FRIEND MEO. KEY Dv t;gN PRIVACY NAM GROUP NAME GROUP NAME KRETZING, HAROLD G A 10 N PRINCIPAL DIAGNOSIS IThe I:;onditlon established after study to be I:;hieftv responsible for occasioning the admission of the patient to the HOSPITAL for carel. COMPLICATIONS COMORBIOITYIIESI PRINCIPAL PROCEDURE ACOO 1 A 9312840 IIIIII\\IIIIIII\\IIIIIIIIIIIIIIII!IIIIII 111111111111111111111111111111111111111111111 MFf1Ir.AI RFr.ORf1c; r.OPY NO FAULT 0000825381 NPP ADMIT. BY KAB I 00/00/0000 A 0 BIRH / I DATE OF BIRTH / / A I N A 06/09/2005 A E 1M 111111I11I1111I111111I11I11111111111111111111I1111111111111I MACNAMARA, SUSAN MS3 825381 J.oe./' DATE OF SERVICE: 06109/1-&&t;. _ ~-,n-,)~ CONSUL TA TION DIAGNOSIS: Bilateral hip fractures, stable with acetabular involvement on the left. CHIEF COMPLAINT: Auto accident. HISTORY OF PRESENT ILLNESS: This is a 50-year-old woman who was in a small car with her three chiidren and a truck ran into her at a rapid rate of speed, into to driver's side of her car. There was significant pain in her back and pelvis and then later on in her hips and when they came to get her, the emergency crew told her not to walk although that is what she wanted to do. Upon advice of the emergency crew she did not. She subsequently was brought to the Emergency Room where she was examined and primary survey was undertaken. After the primary survey the neck coilar was removed. She was taken off the bed board and then underwent examination of the pelVis and lower back. The findings were that, on multiple views, of a bilateral hip fracture, which was stable without any evidence of transverse process fracture of the lumbar spine, no evidence of SI joint disruption, iliac disruption or disruption of the sacrum. A CT scan was also performed that showed no internal organs and no instability on the CT scan by observation of the pelvis. The patient remained stable without blood in the urine and without symptoms of abdominal distress or distress in her chest. PAST MEDICAL HISTORY: The past history was reviewed and is of no significance or pertinent to the current problem. PHYSICAL EXAMINATION: General: Physical examination reveals a the patient is completely lucid, more concerned about her children going home today without her tonight than she Is about herself and would prefer going home as opposed to staying in the hospital. HEENT: Her pupils responded. The upper airway was clear. There was no evidence of significant facial trauma. There was a laceration, around and about the aer, which would require suturing. Neck: Range of motion in the neck was full without crepitus, tenderness or muscle spasm. Range of motion of the shoulders are normal. Palpation of the clavicle is intact. Chest: No tenderness of the chest wall. Lungs: Full inspiration, expiration and coughing did not produce pain in the chest or abdomen. Back: Palpation of the back and percussion of the back from the neck all the way down to the sacrum was nontender. Palpation of the paralumbar areas was also non tender, without swelling. Abdomen: There was no evidence of blunt trauma to the abdomen. Palpation of the internal organs of the abdomen were nontender and compatible with a CAT scan. Pelvis: Palpation of the pelvic region was tender and we didn't force that. Neurologic: She had ability neurologically to move all the muscles of the lower extremity and had intact sensation and pluses. LABORATORY STUDIES - X-rays were reviewed. Lumbar spine is clear. The hips are clear, femur clear and knees clear. The pelvis has superior and inferior pubic ramus fractures on the right and no involvement with the acetabulum. On the left, pubic fractures with involvement of the acetabular area, nonweightbearing side and the anterior column is not completely violated. So, this is a nondlsplaced fracture although It does involve the articular surface there is absolutely no displacement. DIAGNOSIS - Stable fractures of the pelvis. Page 1 of 2 THIS DOCUMENT IS NOT A LEGAL COPY UNLESS SIGNED CARLISLE REGIONAL MEDICAL CENTER EMERGENCY ROOM CONSULTATION 9312840 MACNAMARA, SUSAN MS3 825381 PLAN - Teach her four-point reciprocating gait, give her analgesics to take home. Get the laceration of the ear fixed and see her in the office in one week. She is to take aspirin as an anticoagulant measure and she is to get up and walk as much as she can tolerate, also as anticoagulation strategy. TJG/jrs 0: 06109/200521:15:09 T: 06/10/2005 11 :20:38 This document was authenticated by Thomas J. Green, M.D. on 06/17/2005 14:45:35. Thomas J. Green, M,D. C: Thomas J. Green, M.D. Page 2 of 2 THIS DOCUMENT IS NOT A LEGAL COPY UNLESS SIGNED CARLISLE REGIONAL MEDICAL CENTER EMERGENCY ROOM CONSULTATION 9312840 C; sle Regior . Medical C er (Instructions: circle positive - backslash negative. provide additional pertinent information.) NAME: MACNAMARA, SUSAN DaB: 11121/1954 Age: 50 Yrs 0 Mos 0 Wks Sex: F Wt: 57.7 KG HI: Chief Complaint: MVA-MINOR INJURY Medicines: NONE Allergies: NONE EOP: LASEK, ROBERT W MD PCP: KRETZING, HAROLD G Pt#: MR#: 9312B40 0000B25381 DATE OF SERVICE: 6/9/2005 Pres Time: 16:35 Triage Time: 16:35 T: 99 PO P: BB Regular R: 1B Unlabored BP: 124/0B6 Sa02: 97 % Normal I Hypoxia Pain Scale: 5 Arrival Mode: ALS Exam Time: I?!() Hx by: ~ Family EMS C I C I HPI: (NarratiVe)~r '~ PTA Y I N {.fV\v4- W ~(~ , ,...L.- A- NH Translator Limited by: ALOe Intoxication Severity Dementia EMTALA Medical So",en: Emergent D Non-Emergent D (.<- <> -<- e<;~ "L Co&--, 0:......... G ~ ~ f-t-- ~ \v r<-_ c1,."VLr do ,/.. ~_t~ - ........ ') 0.. (1A.. ('-,,-0:- j ",<-,L --- 1",",- I ~cI <~ l.........-,} ~~ ?""".....'- I c.Lw /- Timing: Sx starte~y I gradually .// min. I hrs. I days I wks. ago continuous I intermittent Duration: Sx last _ min. { hrs. I days' wks. at a time : present I absent Location of Injury: head neck back ches~ en upper ext R I L lower ext R I L Quality: cannotdescrib A MeA r~stT;ineddriver restrain~rrger"... fr~~ ~'weari~. Severity: mild severe 1 ~ 1 C scale ~ threatening Context: none u~le vehicl~.' side impact'~iver I passenger . airb~r~_-speed at ~ct E;l=€)11 / d,u!::!" Exacerbated by: nothing . a . Relieved by:. ~ rest pain meds Assoc. Signs & Symptoms: ~eck . .. .. pain N I Constitutional: Limited Due To: eakness d7 DOE ENT: congestion diarr: ea I constipation pain hematemesis flank pain dysuria hematuria f uency Musculoskeletal: 19fD1-Pain neck I ack pa~~ '~ .- ;(J All Other Systems Revie~e . . n ppy Chole Hyster negative Colon CA Polyps 100M I NIDDM ...-/ Tobacco: Y I N ~P;;icks/Day _ Years Occupation: . ~ Immunizations: Up-to~date: Y I N Reproductive Hx: LMP: G P Pro-MED Maximus 'OCQP~rl\lhl ::001 Pro-MEO ClInIcal Svslems. L,L,C Severity Neurological: HA weakness Psychological: depressed Endocrine: polydipsia Integume~ rashes pruritis Hema~6giC: anemia bleeding A1Ief9y/lmm.: frequent infections I allergies Other: p<--~'--"--- transfusion hives ~ Agree With Nursing Assessment ~wed ~~wed n.... y~/ R/LHanded E~/... DrinkslWk. Drugs: Tetanus: unknown Lives AIQne: Y I N ~ AB MVA - Trauma Page 1 of 2 Re~ 03105i04 Carlisle Re~ lal Medical Cen NAME: MACNAMARA, SUSAN (Instruct. . circle positive - backs. a ative, rovide additic. ertinent information. GENERAL@::, mild I moderate / severe distress HEENT~I@.(PERRLA~JVEJ BRJits faci~acetatl€Jns ::thr;:J!';inns C.\t,- RRR"'"'PM~ murmurs /6 sys I dys C ,uL" ~lICKS gallops 83/84 RESP.' ungs clear" qual bilateral resp. eff~tress r onchi wheezes G~t I diste~d:d bowel sounds ~ ABN ~~ ~f'\~ It::DuuI'<.I rigirfitv ~-:- ROM _~ clubbing Cyan~edema cervical ten e ___. L-S tenderness" thoracic ten~ SKIN: warm - dry ) diaphoretic ~-----.. NEURO:cCN2.i:i: in.tiCt ~qual/ symme'lric ?r~ - cS-- PSY~: AAO X3" mood I ~t NL ' LYMPH: adenopathy GU: NLI deferred Other: VITAL SIGNS: T99 P88 R18 BP 124/086 Location/Description of Symptoms: " --,~ - 7- c..........- /~-;'" j....,,..--- ~ )=.( '1--/ k'!,,"- ~~\-' \,\:>;[ <-~-! p..( (\! t /?A-v- i! . . .tl'-)'j ''f . Y \. , I p. \1 I' \\{ 1~ U'; NL pneuma Fx IVF: Co< l- . z-v V- ~;;--;"" h~ err. NL alignment Fx t- J;.., &.' d ()-\.. '" ./~ NLI ABN FOLEY: ETOH: UDS: +/- --.. <. RE-EVAL: Time: Pulse Ox: % NL I hypoxia Improved Same Worse UA: SG prot RBGs WBCs UCG / HCG: +/- cox; cervical strain L-S strain closed head injury fracture pneumothorax cardiac contusion liver I spleen laceration ABG: pH 02 C02 laceration contusion Critical Care: 30-74/75-90/91-104/105-120 121-134/135-164 Minutes o Excl. billable proc. k~Gj cz.~,v~(1L "'1 ~ t::= dvv--- Discharged to: Home Nursing Home Follow-up with Patient's Dr. in Other Instructions: 0/.G.~ '. Discussed with Dr. b/I.A.-- Admit (.r)crr2--- Follow-up in Office 7 Old Records Reviewed Y I N Reviewed OIW Radiologist Y I N Case OIW Patient I Family Y f N Discharge Time Out: Admit: OBS ICU PCU Transfer: Floor Tele. OR Prescriptions Given: AMA: DOA: Condition: Improved Stable Deceased I' RETURN TO ER IF CONDITION WORSENS. Signatures: ~RNP See procedure form attached 0 MD/DO Record Complete 0 MVA - Trauma Page 2 of 2 R.ev OJI05/0~ Pro- MED C .sle Regior ,Medical C .er Instructions: circle Dositive - backslash ne ative, rovide additional rtlnent information. LACERATIO~ REPAIR EDP: LASEK, ROBERT W MD PCP: KRETZING, HAROLD G Arrival Mode: ALS DATE OF SERVICE: 6/9/2005 Pres Time: 16:35 Triage Time: 16:35 T: 99 PO P: 88 Regular R: 18 Unlabored BP: 124/086 5a02: 97 % Normal! Hypoxia Pain Scale: 5 NAME: MACNAMARA, SUSAN DOB: 1112111954 Age: 50 Yrs 0 Mos Sex: F Wt: 57.7 KG HI: Chief Complaint: MVA--MINOR INJURY Medicines: NONE o Wks Pt#: 9312840 MR#: 0000825381 " lIergies: NONE Wound Location: (!) , !.....-l cL..- Laceration Size: em 'Z... c. ~ \ ~' Distal neurovascular status: en~ctiori'iiifa; ascu!arin1act '.Jsensal~ Depth: ~eIQcial s ", endon bone 5haPeC:!iI1~~~gular flap stellate avulsion Contamination: ~) foreign body Anesthesia: ~ digital block ~cc's .5% marcaine w f epi w I bicarb Wound Prep: betadine hibiclens Ine irrig on debridement ~tion.-/ ~ ~ Repair Closure: skin prolene nyl n staples Dermabond sterl-strips simple interrupted unning mattress horiz 1 vert neous # _ _ - 0 vicryl silk simple interrupted running mattress horlz f vert fascia f muscle f tendon # _ _ - 0 vlcryl simple interrupted running mattress horiz 1 vert Sterile Dressing Applied: & Other: SECONDARY LACERATION: /<--) ~' ~ Wound Location: L.aceration Size: "'Z--- em Distal neurovascular status: on function jntact-~~~ifl~et J,-=II~Cl.liulllll[j:lct'-:::- Depth: subcut muscle tendon bone Shape'~ linea Slgular flap stellate avulsion 09: cl' foreign body B ocal digital blOCk:t cc's 1 % lido 2% lido w 1 epi w f bicarb betadine hibiclens saline Irrigation debridement skin #... - 0 prolene nylon staples s e interrupted running mattress horlz f vert s - 0 vicryl silk simple interrupted running mattress horiz 1 vert fascia f muscle f tendon # _ _ - 0 vicryl simple interrupted running mattress horiz 1 vert .5% marcaine Wound Prep: Repair Closure: exploration Dermabond steri-strips Sterile Dressing Applied: Y I N Other: Patient tolerated. procedur Y/N Discharge instructions given: Y I N MD/DO Laceration R~ R.. Signatures: ARNP sr- I . Pro-MED Ma oeapyn\jn\2001 P!o-Ml:DC" ORDERPRr~~DUREFORM ORTHOPEDI~ EMERGENCIES ,. .isle Regional"~d;cal Center Pt" .,12840 Sex: F MR#:0000825381 PCP: KRETZING, HAROLD G ..,..,... Order Sent By Date In: 61912005 Time: Nah. ,v'IACNAMARA, SlJ_ .4 Age: 50YRS DOS: 11/21/1954 EDP: LASEK, ROBERT W MD Laboratory Tests . ,> . '. ... Order Time ~---r--.. 1 "'r C ~ III P CMP Sed Rate Uric Acid RA Factor Order Sen BY ,'j 7'-1 j,.','." Other Diagnostic Tests prderTim. Radiology CXR IPAlLAT. Portable /7 '" C-Spine ()(.table) (Complete) /' i ~~ '-1'- r",......-<- / T T y.rh!; 3 V',...._ Y/~N-... 7,', r'. CardioDul amI'" L/ EKG ASG 02 '17 '-I t<.. -, Drug screen (serum), (urine) ETOH Type & Screen or Cross # I) 14 1/''1 -fy_.i.-- "" ./ /1-;-'(,-",,"5 1 ~) cl I i._ Il.::' r ~ Units UA Seta HCG LPM 17/t, , I Lv~ P,VJ -"':~(,11!J) Misc. Orders ,., '-..... Medical Nece.sity InfDnnatlon: , Previous Medical Records Ie I.f'-{ e...r//.4i.d /rz<-f...... ,'e...... - f,A.V"'''' PhysicaITherapy-Eval&Tx - t" ...... l"".t- .=~< - .LV Weight: s; NUNc .' ... _: r~ ' . Ibs: 127 kgs: 57.7 . '. . . .' . Order Time Medication / Dosage I. Route VO Read Sack Adm tim Adm by Site Time Reassessment \l.<...,.\,,,,-- ' 0 0 I -.u.......:_::. _-....-1.-...-..:: Iv" . ,rl ,\.') rL '1-1/V.G~'''' ZOOLl..5/--..1 U\ , . ,I """..",.",.10 ,. f). ~,'<y I...... ~1.....ndDl......... ,- ';:l (/\f8.Cr-.o [flw!'-u.e \ t"" .)\ 1o.J r f1, . . . :.' Pain Initials 171'1 o Improved 0 Worse 0 Unchanged W5.,,1i -z.-z.'"t,c.. o Improved 0 Worse 0 Unchanged o Improved 0 Worse 0 Unchanged o Improved 0 Worse 0 Unchanged ,. Order Time . IVlS9lwtilln I Added Medication i 'i 14 ,a<vo Device: I ' I 0 IV Fluid: ,>,;;r--........ "Mhl",: AWfttlshlteurtnc. 0 Improved 0 Worse 0 Unchanged .S~T1meDe\lic:& I Size. Location # AttemptsAmount Start by DIC Time Am! Infused .. lJlC b~ LOT U1211DA .J;:I1C C...(C) (p. 't-\ "7IJ c-,'(1.CV Procedures INursingAssistance ',.,' ',' <<, o Cardiac Monitor Rate Rhythm . o Splint Application . o (Local). (Regional) Anesthesia o NISP Monitor o Pulse Oximetry o Ace Bandage Application o Conscious Sedation o (Cold). (Heat) Appiication o Sling Application o Laceration Repair o Wound Irrigation DC-Spine Immobilization o Cast Application o Dressings 0 Foreign Body Removal 0 Fracture Care (open), (closed)" Dlschargeln.tructlDn.... .. ..' .... ... ..... ..... ... .. .';.. ----;- ....:. eu.~/ \;l.-.L-(U-[/' ~ yJ Iu;j ,au)! (J(tiZt~ lLJ & 4/U~MJ{110 Init~aIS/Sjgnat,ur~; IlnitiaJS/S!9. nature: -<:.1 ",1 I ,.r\. .\.,.., J1"L ,~ t..~, ;' ~ \ \ \'. PAlARNP: ' () n /'/ I.v(.)- 7""<\ '-- \ '. \ . . J InitiaISJ:gnature: x ~ Physici' t' .fe: ~ \ 11~:~n~:u;eU..JCCiJ \~/ ^ Ii. / I ...., IIII'--- /1 (j Y v Rev. 09/14104 EMERGEN"" DEPARTMENT ONGOING ..JRSING ASSES~",cNT Date: 6/912005 Name.IIIIACNAMARA, SUSAI~ Age:50YRS 008:11/21/1954 EDP: LASEK, ROBERT W MD lisle Regiana, 3dical Center Pt#:1l312840 Sex: F MR#:0000825381 pCP: KRETZING, HAROLD G NURSING DIAGNOSIS (Number In order of priortty. Eac~ patient must have at least one selected.) , .... ..( ....... ... '.. Airway Clearance, Ineffective Communication Impaired Infection, Potential . Self Care Deficit = Anxiety -Coping, Ineffective injury, Potential -Skin Integrity Impairment Breathing Patterns. Ineffective -Fluid Volume, Alteration in -Knowledge Deficit --rhought Processes, Impaired =Cardiac Output, Decreased Gas Exchange, Impaired Mobility Impaired _Thought Processes, Alteration in Comfort, Alteration in _ Hyperthermis (Fever) _Non~Compliance _Tissue Perfusion, Alteration in -Other Other The GOAL/PLAN.for this oatient i5>tO assist in meetiha identified, needs and initiate interventions for I to: . .. .... Not Not Not Met Met Int Met Met Int Met Met Int o FB REMOVAL o IMMOBiliZATION {PROPER ALIGNMENT o IMPROVEMENT OF BREATHING o BLEEDING CONTROL o DECREASE / PREVENT SWELLING o STABILIZE PATIENT IN DISTRESS o PAIN CONTROL o MAINTAIN STABLE HOMEOSTASIS o meet ENVIRONMENTAL NEEDS o ALLEVIATE NN o MAINTAIN SKIN f TISSUE INTEGRITY o meet PSYCHOSOCIAL NEEDS o FEVER CONTROL o PREVENT FURTHER INJURY o meet SELF CARE ABIU1Y NEEDS o DECREASE ANXIE1Y o MAINTAIN {IMPROVE CIRCULATION o meet EDUCATIONAL NEEDS o SAFETY IN THE ED o INFECTION CONTROL o Other Int: N = documentation in nurses notes, other 'codes' per Hospital Policy. I.... ',. ,::,' ',<;.~u~esprogress NotEts ..,...i. .... Ip . 02 NGI C~rdiac .. I..... ~a;n , .Time ..:.<'& Reassessment Signature Time T R '.BP ... Sat Emesi Monitor Urtne GCS ee; 17;5 vA Sf\-o,-'O In +-0 "" '>( 0... '" -crL<<-.. --<'- rv I --:> 0'60 c.Jo 0<::-1 VI;:) 0"'- SlcL.,;, c: Ic ,,--,,- S;k '>c< d. ~ B) r-::c.u....l'\ .. - "-'5 . A.. 1'7f];; --;-0 X ,c -5U 18:0 u "D:Lc_k... -+0 e xo....rn Iv.:, c u , 1'40D PA ~\.Jf) In +0 e',(c Vl u A~ .C c ~ <: , \- t \ <- S\ "10, lc:lr2 '\ t;;(, \ I : IC\\S 10 C\ S C eLf') S 1\..1 I I I~OO fuc..\c +n \I.r -S~ / i ~yC G_ r.-, I AC:::O Her.... In ~ ""'-\' \),-- ..., ,-h :.) ( on '\.....Q.. ,""a >-\- -Sf. II ::>ye.c leLIS \jclded. on \:x~ri.oo..n .. vA c- OrD -c;: 'I 2lCO Dr. G ...-e..e.n l LQ...~ -to e..\lLL '>IJ.. l( JL ( >+ - Sf. ) 7.(:<0 oMenLDf c..Lo...\ t Ln::: (0. ~ nd b .~ -- ~ 'To ~ 00 Q \-t , e( '\. -f :-C I, : s.u::b...L \ 0.. I *-1 , I S;", 'S 'ne d . - ...' >. ..'.. Disposition,: '.. .... Z.ISO ~'""\C "-0."",\" Discharged in care of: oAmb o WIC 0 Sire! 0 Carried -' I Discharge instructjOn~iVen ~ o Verbalized understanding 1,...+ ~c\. :'S.t...cl....... <:; 1 Admit: Room #:~to Dr. I Ready for Room Time:_ 22IS A\Aenw-\ed G...."*-- Ofl'> \::>0 \ C f1cn Report called atnO! f and given to I (J }<.: Transfered to / o Transfer Verified ~ "L...lc....d . ,..... \, rc\+ c....", H,c'-...: Report called at and given to ..... C,C, '"""'\C" +u Dc....:.: cu\ ... AeJ--c, o Left without treatment o Left Against Medical Advise ',""" ......, Condition at~ Olmproved~e OSerious o Expired l'nc~td lL.. .-\-C ~,_ '-.lL LG -\: Pain Scale: Pain Location: ---- (, I '\ ('C) Patient reports that pain is: ...t3'1iTiproved DUnChangel-1IDworse \-ee, r\ ~'--'l -\-0 C), -L....-'l Disposition Vitals: T 9..f!..... P S?8"" R JL BP 110. 0' 02 ~ 1--\0- - ~ -\eA::..J \. c.. \c..... ' \ ::l.Q c \ Disposition Date: "It 0 Time: COI il Nurse: Nr1.itJlzuJ I",h ':.:. -~ \ .:) r: \ __r-,,-, ' +c- 0~- Rev. 03/05104 EMERGEN,'DEPARTMENT ADDfT/ONA_ ,1JURSING NOTE:~ The signature of a nurse shall accompany each entry. Date In: 6/912005 ......rlisle RegionallVledical Center Name:MACNAMARA, SUSAN Pt#:9312840 Age: 50YRS 008:11/21/1954 Sex: F MR#:0000825381 EOP:LASEK, ROBERT W MD PCP:KRETZING, HAROLD G Date Hour Notes (pIC! Z2.lS PA S-\-no,-,~ (Y)C.r\e. CLu-JCl.-^ 0 In -\-c ~ ~ p+ +0 he odm '+fr .nz.c. p-+- Ci:tb2,'\.<...O-kc~ -Iv c..J0--\'c c-~-,v<...-<....l,--, "S ?~-\-cw 'Y, lCO,\-; -r ':--1 ()+-o.nc~ ~Co...vV--" '--'\'-:>7'. ~ V\"C'~C I"~ eO./'c; DI Qr-:;,-\ (~c_cl, . _ \r.... ~.-l Cl,-o ld r-,r, -1- J -h., )~,. '/ "'+- . 0-\~V\..O CL-vLu-~1.~Y- --+c,,,,nh+o - -:vt( ?;!<.fS Y'>,de....c\ 9,,.., tec'::{~J" PICLCC6 bc<..L In 00<....0(\ \'r LJOC'\.-ie., rc:.rv,,..-;, A'" o...X- b" AScde.... _ AL-G ~"-<:.> ,~ r?-., O-c,S \Oh n l.Q..,-,+ -:') s....i ---.J ZZ~ \t--S\ ~\CL,,~JKe.-~~ f.X---'--"..-Y'\. y~ 5-\c-~"- ,-Ioce< ,'C'-\- \'\c',"c... ~~ ~ ~ """0\!""~~.,.,+ Si\.1 (YJ/P, \M7Ih rlrrno ,/<O f),yt- -h v(JA-I'vv ,. J I Rev. 03/05104 EMERGEN('" DEPARTMENT MUSCULO~. .ELETAL NURSIf-.... ASSESSMEN7 Date In: 619/2005 Time: /700 Subjective Notes: .isle Regional '~edical Center .ame:MACNAMARJ.-, _ JSAN .19312840 Age:50YRS D08:1112111954 Sex: F MR~0000825381 EDP: LASEK, ROBERT W MD PCP: KRETZING, HAROLD G Pain ,'oPatient denies pain Location: ".......'-'--\~~\e C<.-~~~uality: oSharp oDull o Cramping o Burning oAching Provocation: oOther: Radiating: oNa DYes (specify) oConstant o Intermittent Psychosocial Appearance: ~ean oUnkempt oOther Mood I Affect / Behavior: p.Appropriate 0 Depressed oAnxious oTearful oOther Caregiver: eSelf 0 Family member oSignificant Other 0 Group home Activity level: ,.aAmbulates independently o Requires assistance oNon-ambulatoiY o Performs ADL's independently o Requires assistance with ADL's Mechanism of Injury Direction and amount of force: What was felt or heard upon injury: Pre-hospital treatment: 0 Full spinal immobilization 0 C-Collar oSplint o Pressure dressing 0 Ice 0 Heat 0 Ace wrap Severity scale: 'SIlO Aggravating factors: Relieving factors: Onset: Environment: 0 No steps 0 Few steps 0 Many steps Nutritional status: ~rmal 0 Cachetic 0 Obese Religious I Cultural preference: 0 None (specify) Best learn by: oVerbal o Written oReturn demo Learning Barriers: OTDD phone olnterpreter oNo oYes o Other: U$8 numbers to indicate Injury locatIon and type !3{ h RIght Left Past Medical History and. Risk Factors PMH from triage: NONE o Previous Sx involving musculoskeletal system and date: o Diabetes 0 Arthritis 0 Osteoporosis 0 Hemophilia 0 Cancer: o Anticoagulant medicine: 0 ASA 0 Coumadino Other: Muscle strengh: 0= no strengh 5= normal RUEoO 01 02 03 04 05 LUE 00 01 02 03 04 05 RLE 00 01 02 03 04 05 LLE 00 01 02 03 04 05 Loft Right 1.Abra~on 2. Amputation 3. Avulsion 4.8um 5. Closed Fx IDis. 6. Contusion 7.Crepilus a.Deformity 9. Edema 10.GSW 11.Laceralion 12.QpenFx. 13.Srab 14. 15. Lacerations I Abrasions I Avulsions I Contusions Location: (see graph.) Size: Bleeding: 0 Absent 0 Present 0 Scant 0 Moderate 0 Heavy 0 Pulsating Immunization:unknown Scars: Extremity Assessment RUE Pulses: 0 Yes 0 No LUE Pulses: 0 Yes 0 No RLE Pulses: 0 Yes 0 No LLE Pulses: 0 Yes 0 No S stem Review Neurologic.al, GAier! .-oOriented X S prCooperative . o Awake but confused Cap. Ref.: 0 < 2 s. 0> 2 s. Cap. Ref.: 0 < 2 s. 0> 2 s. Cap. Ref.: 0< 2 s. 0> 2 s. Cap. Ref.: 0 < 2 s. 0> 2 s. Motion: 0 Yes 0 No Motion: 0 Yes 0 No Motion: 0 Yes 0 No Motion: 0 Yes 0 No Edema: Sensation: 0 Yes 0 No Sensation: 0 Yes 0 No Sensation: 0 Yes 0 No Sensation: 0 Yes 0 No q L1ocooperative oConibative oAgitated o Restrained Cardiovascular Skin>-aWam, O-Elry OMoist oDiaphoretlc Color:Of'lIik 0 Pale oAshen oFlushed oCyanotic oJaundiced Vital Signs: 16:35 T: gg P: 88 Regular R: 18 BP: 124/086 Temp.OW DC Temp.OW DC Temp.OW DC Temp.OW DC Color Color Color Color Respiratory Airway: oClear oOther: Effort: .Qth1labored OMildly oSeverely o Retractions,'. 0 Strido r 0 Nasal Flaring Lung: pclearOWheezing oCrackles oRhonchio Decreased Nurse Signature~ ) '- -=<~ Rev. 03/05/04 INlnALAS~~~SMENTFORM PRIORITY: ~ Patient: DOB: EDP: PCP: MACNAMARA, ::.LlSAN 11/21f1954 AGE: LASEK, ROBERT W MD KRETZING, HAROLD G rlis/e Regiona' "'edical Center Pt#: 9312840 Sex: F MR#: 0000825381 Non-Urgent 50YRS DATE: 06f09/2005 Worker's Camp: Emp. Referred: Presentation Time: 16:35 Triage Time: 16:35 Arrival Mode: ALS Height: Chief Complaint: . Weight: 127.0 Ibs. 57.7 kgs. LMP: MVA--MINOR INJURY Last Tetanus: unknown Acc By: DAUGHTERS Vital Siqns T: 99.0 PO P: 88 Regular R: 18 Unlabored BP: 124/086 02: 97 % RA Pain Intensity Scale: 5 f 10 Pain Location: Multiple Areas Brief DRIVER OF DRIVERS IDE FRONT IMPACT. PAIN IN PELVIC AREA, UNABLE TO LIFT LEGS, Assessment: POSITIVE FEELING. NIGHT SWEATS WEIGHT LOSS ANOREXIA UNK UNK UNK HEMOPTYSIS FEVER UNK UNK SAFETY RESTRAINED DRIVER AIRBAG DEPLOYED UNK YES YES NO Sudden Onset: Pre-Hospital 20G RFA. C-COLLAR, BOARD Treatment: Pediatric NIA Assessment: Past Medical NONE History: Allergies: NONE Medicines: NONE Nurse Signature: 'i I KLA Additional Notes: Rev 05/" ~~ 246 Parker St. Carlisle. PA 170\3 Ph:717.249-i212 HIPAA FORM 20 ACKNOWLEDGEMENT: RECEIPT OF PRIVACY NOTICE Purpose: This form is used to document (a) an individual's acknowledgement of receipt of our Privacy Practices Notice or (b) when we have not obtained this acknowledgement, our good faith effort to obtain the acknowledgement. Patient Name: MACNAMARA, SUSAN Date of Admission: 0000825381 Social Security Number: 210-44-3603 06/09/2005 Notice Version (Date): 411412003 Medical Record Number: Acknowledgement of receipt of Privacy Practices Notice I, MACNAMARA, SUSAN Notice from: CARLISLE REGIONAL , acknowledge that I have received a Privacy Practices MEDICAL CTR Further, by signing below I provide my permission for this facility to use and disclose my medical information for the permitted purposes of treatment, payment and health care operations as discussed in the Notice of Privacy Iracti~es. . ~ . _ 11 h _.. ~ _ _ . Patient Signature: X ~ ~Date: 0610912005 / ./ D Notice has previously been distributed by another location in our OHCA (except for physicians): List location that distributed the Joint Notice: If a personal representative on behalf of the individual signs this authorization, complete the following: Personal Representative's Name: Relationship to Individual: IF NOT SIGNED:(Good faith effort to obtain acknowledgement of receipt) Describe your good faith effort to obtain the individual's signature on this form: Describe the reason why the individual would not sign this form: SIGNATURE: (Hospital Representative) I attest that the above information is correct. Signature: ~tf1J?(!\ Date: 06109/2005 CZf, 12u1 Print Name: Bethea, Kyuati - Admitting Title: Include this acknowledgement form in the individual's records. Hcsp1tnl COP'! 05/11/2005 20:51 972407' ,:EST SHORE EMS '. ~~ C?).~:S ~I PAGE 01 Pennsylvania EMS Report - DoU Senke Nanw staUon Unir Nane. No. PCR No. West Shcn EMS C Station C Sblica -1102204 31145391 ~1200S Incldmi L_ M\IIIldpoJIlyA._ZIp I P9AP iJldd. No. MONTOUR RD Tvroo~ TOWDWV I LD)T';U. P'1491 ,... NanM: I Pt. woqIU PhDne iVo. T R-.mc Accn<l' .s SUSAN MACNA!,fARA 1717\ 243-2098 ClI\lal. R>.;llIIIl Modi<al C_ = Street A'_ AC' AMI _, Randall P oo160S - 306 N. WIlST ST 50, Years - Clly Slo" zq. DCB AIZ = CARLISLE PA 11013 I: 21/19S4 AIfJ ~ Patient NtIII1IJ.er Sodal Sec. No. Sot:;;: AM .- - 210-44.3603 Fnale /lIS Prt9a101'llJ*ltm Dnver', IJc:ernt. Oul On-Scent IleIt In '11 ~ 1lIIpa1dl IS,21 EnroaU IS,26 TnnJPO'Ung AJoIot Unlb A.-.. OS ArIm SeeK 15:45 C..... 15:46 RetpoDM Oatcome M.nbI .:........,.\ PhyIldan Me Tlmo Deport s.... 15:S9 Tholl".,.,... _ r.dIIIy 16:31 AnlIablo 11:S0 In 11:S0 Odd : PAIN IN LOWER BAI AND LOWER EXTRllMITlES eon.. Malo: I NONE - : A ~ o ~ ~ \C .... Narrative -...I N ~ .... \C .... N -...I PMHx: Not Stated, NO PMH DID CLASS 1 FOR MVA, ADVISED fC ENTRAPMENT, RESPONDED IMMEDIATELY. AOS TO FIND 3 PTS REMAINING OIS, 2 FEMALE CHILDREN AND ADULT FEMALE WHO I AM DIRECTED TO. PT IS A 50 Y/O FEMALE STILL iN VEHICLE, QUESTIONED WHY PT WAS STILL IN VEHICLE 30 MINUTES INTO INCIDENT, ADVISED F'T IS CONFINED, RAPID ASSESS SHOWS PT OBVIOUSLY NOT CONFINED, FD CUTIING ROOF FROM VEHICLE, ADVISED RESCUE PERSONEL THEY WILL MOVE PT MORE IC VERTICAL EXTRICATION THAN LATERALLY IN LINE, PT HAS C-COLLAR IN PLACE AND C-SPINE STABILIZED. LBB PLACED ON SEAT AT DIRECTION OF THIS PROVIDER AND PT IS EXTRICATED IN-LINE, SECURED TO LBB IC STRAPS AND CIDS AND TAKEN TO AMBULANCE. PT CIO PAIN IN LOWER BACK AND LOWER EXTREMITIES. THERE IS CONFUSION OIS AS TO WHO WILL TRANSPORT THE 2 REMAINING CHILDREN, RAPID ASSESS INDICATES NO VISIBLE INJURY, NO COMPLAINTS, SISTERS AND CHILDREN OF MY PT. BEING TRANSPORTED BLS FOR EVALUATION. BLAIN AMBULANCE AOS AND REFUSES TO TRANSPORT BOTH PTS. THIS UNIT HAVING FULL STAFF TRANSPORTS FEMALE DRIVER AND CHILD, CARE OF CHILD DONE BY BLS STAFF. THIS PT A 50 YIO FEMP,LE STATES SHE WAS RESTRAINED DRIVER, WITNESSES 01S ADVISE NO ONE WAS WEARING SEATBEL TS. PT C/O PAIN AS NOTED, APPEARS IN NO DISTRESS, ABLE TO MOVE ALL EXTREMITIES fC + SENSATION x4,. DEFORMITIES TO NECK OR BACK. DENIES CP, SOB, NN, DIZZINESS, - LOSS OF CONSCIOUSNESS. AMBIENT SP02 98%. NO PMH, MEDS OR ALLERGIES. PE FINDS PT TO BE CAOx4, SKIN WON, PERRL, ENT CLEAR OF BLOOD OR FLUIDS, SMALL AMMOUNT OF DRIED BLOOD COMING FROM L T FACE BES!OE NOSE, SUPERFICIAL LAC. C-SPINE AND BACK IS SIGNIFICANT FINDINGS, SMAL LAC TO L T POSTERIOR SHOULDER, MINIMAL /-7 BLEEDING. CHEST ATRAUMATIC, LUNGS CLEAR=, ABD ATRAUM~ , . PrOVIder Printed On: 06/11/2005 21 :48 EMStat RepMine(c) 1991-2QO', Mcd~Media" Inc. All Righb Reler.cod Page: 1 of 2 05/11/2005 20:51 9724'a77 :)JES T ShOPE EMS P~GE 3~ Pennsylvania EMS Report Sonico 1'1..... UlIIlNo. PClIl'lo. l~iZOOl Weat S....1!Mll C S1atiOll . 2102211' 3045391 1'11_1'1..... !DoI.or_ _ S,,"uiIy l'hunber I MCC M_ C_l'h1tldm S1.JSAN MACNAMARA 111111195' 210~"O3 PRESSURE 2. HAVING TO URINATE. PELVIS STABLE, MAEx4, - DEFORMITiES NOTED, CfO ~ PAIN IN LEGS AND LOWER BACK WHEN SHE MOVES, + SENSATION x4. + DISTAL PUl.SES oIil. x4. EKG NSR. IV ACCESS ESTABLISHED RT FOREARM, #20 ANGlO NSS @ KVO. ENROUTE ~ PT is REASSURED THAT HER CHILDREN ARE FINE AND SHE BECOMES VERY ~ CONVERSIVE ONLY CIO HAVING TO URINATI: AND HAVING BROKEN GLASS IN HERE ~ PANTS. VS REMAIN STABLE, EKG REMAINS ~ISR. ALSN CALLED TO RECEIVING FACILITY UPON ARRIVAL AT ER REPORT TO RNf Toe ~~,~~:2:t:t?~:,,:. :~,'" ':,^:;.-~~'j ':,~(:-; ~.~:~:~;'~",;,:;:: ~r~ ';!t. :;~; ,~:: ~, ,', ' '- . : '" , ....I:'-m " "'::;..-' .. .. .. . . ,.':"r",,~ Jj::"S I 1/ RAP - AI 15:" / 1/ .-., ASS1.JMI! .unRVlSlON AI OFllXTlUCATION 15:50 16 16 120110 98 415/6 NSR A88ESS Al lnilIoI vs; ""'Po ElIbr< NomW; P_ N_ 1':S' / 1/ AIUlANGl! AI TIlANSFORTATION FOil FIlIAL PT, 16:00 / 1/ IV ACCI!S8 16:15 96 16 11611' 41'16 NSR .. RMB8E8S AI !loop. I!lI'ort: Naaaal; P_' N_ 16:30 / 1/ Al.SN Al 1637 91 16 1201P 41S/6 SSP. AlUUV AL AT BR AI ...../TOC; R.... , _: N"";"":: '. NcnnaI -..l N ~ .- \l:) .- N -..l Printed On: 06/11"005 21 :48 E.\lSIa'RoponiIlg(<) 199I-:IOOl, Mod.Modi&, lno. All Riib1> R<OCNod P/;l:/~ Provider Page: 201'2 05111/2005 20:51 972407' or f\ CI.'- " e,., I'-<J... ('; L 5 1.....') ~ '- . '"E3T 3r;ORE EMS P,GE B 3 c ~ - 0 ( 50 y {s9( -.---------'T~ , ,,~ .:';~~ --- 'tJ.,'.,~814, it .':114:39 11I:98 'M'." .... L-IL.,.J~:--~'lcr'-- '.'. i, , " ' at':''''-''' 'i'^~'l' ' , ., " !. . .-, 'I 1- ""-'1"-1 .,. : : '"" ,,' , ' I , I" : 1-; I, . I' .. ,\1 I " . Ii ::'11 . i 'j I ' fQ...:;"'}..-/'--J~l-^-.~~~~'~~ Ii'''' -, -, ,- , ":: I :- ': ~ '; .."t".....:. ' 1 , ' I I ", i! I ::.=: -';-1 .' I' ! I': Il 1-';-:" :-!---! r- : t'l ;,' i' .! --j '-,--i "1'-"" ill. ,1_, +-0 -'...A,IA" H/'--^J'~lIll!", ,.-+l~ .!ikffr' - h./t:: ~._ __,..ri~'!"V ,-"","-j\ r ,--'t<Ir(~lVp--. "'I.r:.~ 1--- ____ "' .~. ,1- ,I , I 1 I I) I I I I ' , -r .-.....1 -- ~ _ I -,.. I L - I I' , ,I I' I I .' , , I Ii: : ~i, : T', ; "I: '. , " I Ii : HT ,-.- ~~1~i ,~,. , ' -' ..j-.. 1'--+'-'- , '!-'--~': ,-,-,-+ i---1i----+-I.-.+ - I : _ : _ ," I II II! ( -iI~~~25mnJsecf-. ~. '-'. ~l mA[I~-p~1- ~11S11l1811~1JiJj~i -------------,--..' ..--...,........ , ,r; 1:"'1, .-~16eI4~~lS;:I:!III;IIl:9Z !_ I l ~-_ .__ 'i-'U! -~-~. _Li,'i . I : , 1- - riM. r<L \io....~ I \M--~C I'\. ---.: II! I ,.', i 'I ! 'f- '...~.. I +L_l~! '. iI.: '~Ii . :Ii! ,I ~1"1'l-f'-lJ .. ,. ,! ~ -'.-"'--r'~ _ I, ;- -'r- . -,' 1- - I'" ., II I I -tt'~ _I -;- I _-1.~_, i ' ' , ,. T' 1..1 It... ""1' Jj~.- J i; I '~. I I r -],. ,. 1--, 1-; 111. ...-.t... I -t .._.L i -.jj ''',-" -':;":' , m;: ii, - ,'" J '. f_ _ : -~t.~r .(''-'w, 1 ~" r-" .-J " 1 I ' ,I , r -, ___,__...._.1 -- --- i -- I : ; I I I .' , ~j~'F i:! I : : \1 ' , ' II i-I--_; -~ _F:~t~:;~:j ~~hl--~'-i'Jt---w...,~hJr~~J, T 1_: ~~- ~i~~.c! P8ICSTAililirp-3138i1~HI1:'--;'---' -----==-..~ 'Ii: - Q~ 246 Park:erSt. Carlisle. PA 17013 Ph;717-249-1212 CONDITIONS OF TREATMENT AND ADMISSION PATIENT'S NAME ACCOUNT NO. MACNAMARA, SUSAN 9312840 ATTENDING PHYSICIAN LASEK, ROBERT W MD DATE 8. TIME OF ADMISSION 06/09/2005 16: 35 CONSENT TO HOSPITAL CARE AND TREATMENT I AM PRESENTING MYSELF FOR EMERGENCY SERVICES OR ADMISSION TO THE HOSPITAL AND! VOLUNTARilY CONSENT TO THE RENDERING OF SUCH CARE, INCLUDING DIAGNOSTIC TESTS AND MEDICAL TREATMENT, BY AUTHORIZED AGENTS AND EMPLOYEES OF THE HOSPITAL, AND BY ITS MEDICAL STAFF. OR THEIR DESIGNEES, AS MAY IN THEIR PROFESSIONAL JUDGEMENT BE DEEMED NECESSARY OR BENEFICIAL TO MY WELL BEING. I ACKNOWLEDGE AND UNDERSTAND THAT MANY OF THE PHYSICIANS ON THE STAFF OF THIS HOSPITAL. INCLUDING THE ATTENDING PHYSICIANtS) NAMED ABOVE, AND RADIOLOGISTS, ANESTHESIOLOGISTS, PATHOLOGISTS AND EMERGENCY PHYSICIANS, ARE NOT EMPLOYEES OR AGENTS OF THE HOSPITAL, BUT RATHER ARE INDEPENDENT CONTRACTORS WHO HAVE BEEN GRANTED THE PRIVILEGE OF USING THE HOSPITAL FACILITIES FOR THE CARE AND TREATMENT OF THEIR PATIENTS.' AGREE TO ACCEPT THEIR CARE EVEN THOUGH THEY ARE NOT EMPLOYED BY THE HOSPITAL. I UNDERSTAND THAT THE EXAMINATION AND TREATMENT THAT I RECEIVE ON AN EMERGENCY BASIS IS NOT INTENDED AS A SUBSTITUTION OR REPLACEMENT FOR COMPLETE MEDICAL CARE. CONSENT TO RelEASE INFORMATION I HEREBY AUTHORIZE THE HOSPITAL TO DISCLOSE TO INSURANCE COMPANIES, INCLUDING WORKERS COMPENSATION CARRIERS, OR OTHER PARTIES THAT MAY BE LIABLE FOR ALL OR PART OF THE HOSPITAL CHARGES, ALL OR PART OF MY HOSPITAL RECORDS AS MAY BE NECESSARY (INCLUDING ANY TREATMENT FOR ALCOHOL OR DRUG ABUSE OR DEPENDENCE), TO DETERMINE BENEFITS ENT1TLEMENT AND PROCESS PAYMENT CLAIMS FOR HEALTH CARE SERVICES PROVIDED. MEDICARE CERTIFICATION RELEASE I CERTIFY THAT THE INFORMATION GIVEN BY ME IN APPLYING FOR PAYMENT UNDER THE TITLE XVII! AND TITLE XIX OF THE SOCIAL SECURITY ACT IS CORRECT. I AUTHORIZE ANY HOLDER OF MEDICAL OR OTHER INFORMATION ABOUT ME TO RELEASE TO THE SOCIAL SECURITY ADMINISTRATION OR ITS INTERMEDIARIES OR CARRIERS ANY INFORMATION NEEDED FOR THIS OR A RELATED MEDICARE CLAIM. r REQUEST THAT PAYMENT OF AUTHORIZED BENEFITS BE MADE ON MY BEHALF TO THE HOSPITAL OR TO THE PHYSICIAN WHO ACCEPTS ASSIGNMENT. PERSONAL EFFECTS AND VALUABLES I UNDERSTAND THAT THE HOSPITAL SHALL NOT BE LIABLE FOR THE LOSS OR DAMAGE OF ANY PERSONAL EFFECTS OR VALUABLES (MONEY, JEWELRY, GLASSES, DENTURES, DOCUMENTS, CLOTHING, ETC.) UNLESS SUCH ITEMS ARE DEPOSITED IN THE HOSPITAL SAFE. THE HOSPITAL WILL NOT BE LIABLE IN EXCESS OF $50 FOR THE LOSS OR DAMAGE OF ANY PERSONAL EFFECTS OR VALUABLES DEPOSITED WITHIN THE HOSPITAL SAFE. A: OUT YOUR BILL I UNDERSTAND THAT I WILL RECEIVE A BILL FROM THE HOSPITAL FOR PROVISION OF THE HOSPITAL SERVICES, INCLUDING STAFF AND EQUIPMENT, AND FOR ANY SUPPLIES OR MEDICINES UTILIZED. I WILL ALSO RECEIVE A BILL FROM ANY PHYSICIAN WHO PROVIDES PROFESSIONAL CARE TO ME. FOR EXAMPLE, I MAY RECEIVE A SEPARATE BILL FROM ONE OR MORE OF THE FOLLOWING TYPES OF PHYSICIANS WHO RENDER SERVICES TO ME: MY ATTENDING PHYSICIAN OR PERSONAL PHYSICIAN, EMERGENCY ROOM PHYSICIAN, RADIOLOGIST, ANESTHESIOLOGIST, PATHOLOGIST, OR ANY OTHER SPECIALIST. INSURANCE ASSIGNMENT I HEREBY ASSIGN TO AND AUTHORIZE THE HOSPITAL AND PHYSIClANS INVOLVED IN CARE DURING THIS PERIOD OF ILLNESS OR TREATMENT (HEREINAFTER ~PHYSICIANS~), OR THEIR DULY AUTHORIZED ASSIGNS TO TAKE ALL NECESSARY STEPS, WITHOUT LIMITATIONS, TO ENSURE THAT ANY INSURANCE BENEFITS OTHERWISE PAYABLE TO ME OR MY ESTATE ARE PAID DIRECTLY TO THE HOSPITAL OR PHYSICIANS. THIS ASSIGNMENT OF INSURANCE BENEFITS INCLUDES BUT IS NOT LIMITED TO BILLING INSURANCE, FILING PETITIONS, FILING SUIT, IN MY NAME OR ON BEHALF OF THE HOSPITAL OR PHYSICIANS, FlUNG PROOFS OF CLAIM, FILING PROBATE CLAIMS AND FILING GRIEVANCES AND ALL OTHER SIMILAR PROCEDURES, AS MAYBE AMENDED FROM TIME TO TIME WITH THE STATE DEPARTMENT OF INSURANCE. I ALSO AGREE TO PROVIDE AND SIGN ANY OTHER DOCUMENTS THAT MAY BE REASONABLY NECESSARY TO ACCOMPLISH ANY OF THE OTHER PURPOSES. STATEMENT OF FINANCIAL RESPONSIBILITY I UNDERSTAND THAT I AM FINANCIALLY AND LEGALLY RESPONSIBLE FOR CHARGES NOT COVERED IN FULL BY ANY THIRD PARTY. I FURTHER AGREE THAT SHOULD I NOT PAY THE BALANCE WITHIN THIRTY (3D) DAYS AFTER THE DATE OF DISCHARGE, MY ACCOUNT WILL BE CONSIDERED DELINQUENT. I AGREE TO PAY COSTS OF COLLECTION, INCLUDING REASONABLE ATTORNEY'S FEES AND COSTS, COLLECTION AGENCY FEES AND COSTS, AND INTEREST WHICH SHALL ACCRUE AT THE MAXIMUM RATE ALLOWED BY LAW. FRAUD ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUO, OR DECEIVE ANY INSURANCE COMPANY, OR FILES A STATEMENT OF CLAIM CONTAINING FALSE, INCOMPLETE OR MISLEADING INFORMATION MAY BE SUBJECT TO PROSECUTION UNDER APPLICABLE LAW. ADVANCE DIRECTIVE IFOR ADMISSION TO HOSPITAL ONt YI IF I AM TO BE ADMITTED TO THE HOSPITAL, I HAVE BEEN GIVEN WRITTEN MATERIALS ABOUT MY RIGHT TO ACCEPT OR REFUSE MEDICAL TREATMENT, I HAVE BEEN INFORMED OF MY RIGHTS TO FORMULATE ADVANCE DIRECTIVES. I UNDERSTAND THAT I AM NOT REQUIRED TO HAVE AN ADVANCE DIRECTIVE IN ORDER TO RECEIVE MEDICAL TREATMENT AT THIS HOSPITAl. I UNDERSTAND THAT THE HOSPITAL AND MY CAREGIVERS WILL FOLLOW THE TERMS OF ANY ADVANCE DIRECTIVE THAT I HAVE EXECUTED TO THE EXTENT PERMITTED BY LAW. (INITIAL THE FOLLOWING OPTION THAT APPLIES) . I HAVE EXECUTED AN ADVANCE DIRECTIVE AND WilL PROVIDE A COPY OF THIS FOR MY MEDICAL RECORD WITHIN A REASONABLE AMOUNT OF TIME. . I HAVE NOT EXECUTED AN ADVANCE DIRECTIVE AND DO NOT WISH TO DO SO. INIT. INIT. (FOLLOW-UP DONE BY DATE .1 WISH TO COMPLETE AN ADVANCE DIRECTIVE DURING THIS HOSPITALIZATION. INIT. I CERTIFY T T I HAVE READ lOR HAVE BEEN READ) THE ABOVE CONSENTS AND CERTlF CATIONS AND UNDERSTA .t<-L- ---L J.l'r'f) ~ ! MONTH 'k6~(" YEAR WITNESS DATE: PRINT NAME OF PERSON ABOVE A.D001S 9312840 0000825381 \\11\11111111111111111111111111111111111 111111111111111111111111111111111111111111111 1111I1111111111111111111111111111111I11I11111111111111111111 Carlisle Regional Me_~cal Center Laboratory, 246 Parker St. Carlisle, PA 17013 Duckkyu Chang, M.D., Pathologist Henry S. Crist, M.D., Pathologist MED-REC-DISCHARGE-REPORT MACNAMARA, SUSAN MRN:0000825381 Location:MS3-0307-W DOB:11/21/1954 Age:50 Sex:F Physician: GREEN, THOMAS J Admitted: 06/09/05 Discharged: DISCH.: 06/10/05 HEM A T 0 LOG Y ------------------+---54100078----+---54090472----+--------------- COLLECTED 106/10/05 06,10 106/09/05 17,38 IREFERENCE RANGE ------------------+---------------+---------------+--------------- BLOOD CELL COUNT I 9.3 I 4.26 1 12.4 1 37.5 I 88.1 I 29.0 1 33.0 1 11. 5 I 334 DIFFERENTIAL 1 79.5 1 11.1 1 8.6 I 0.1 I 0.7 I 7.42 1 1.03 1 0.80 1 0.01 1 0.07 WBC RBC HGB HCT MCV MCH MeHe RDW PLT AUTOMATED Neut%" LympM Mono%- East Baso%" Neut# Lymph# Mano# Eos# Baso# 14.2 4.33 13 .1 38.1 88.1 30.3 34.4 11.2 338 L H 84.5 8.7 5.5 0.4 0.8 12.00 1.24 0.78 0.06 0.12 H 13.8-11.0 x10^3 13.40-5.30 x10^6 110.9-14.7 g/dl 133.0-43.0 % 180.0-96.0 fl 126.0-34.0 pg 131.0-36.0 g/dl Ill.0-16.0 % 1140-400 x10-3 H 140.0-80.0 % L 115.0-50.0 % 11.0-8.0 % 10.0-6.0 % 10.0-2.0 % H 11.30-8.80 x10^3 11.00-4.20 x10^3 H 10.00-0.60 x10^3 10.00-0.40 xlO^3 10.00-0.20 x10^3 . Key for Abnormal Column (L-Low H-Hiqh AS-Abnormal C-Critical T-ToxicJ MACNAMARA, SUSAN "'7 of 119 H MS3-0307-W continued HEM A T 0 LOG Y PRINTED 06/11/2005 02: 34 Page: 1 of 1 Authorization is her... , Jiven to dispense the gel h.., ,e equivalent uniess othe('.. Jdicated by the physicia, Date Time Complete top portion with each Level of Care change. Indicate order with a Check Mark. o Outpatient Procedure: (procedure) for (medical reason). o Place in Outpatient Observation Services for _..Q-:zIdmit as Inpatient for (medical reason). (medical reason). Physician Signature: , I' Date Time Additional Orders: (Dates/Times required) I / - ".., " 'F;, . .. _lJ1141 c',,_ Q/f/) J:1.dt.J>",d- '--Jf.:\..... ,.._'_ ... ..-- . ~Y~0tl~~~~~ '-' I", c...d c.., v,..-v8 IY).,..-\IL/ .. ,. (2XlC:~~ IOrv-v.{_ .,,<~ .@j.~'1~J. ~ /-'--,-" 'j)C:-/? bt:.~)('_ de '-'f) ';["f;8Lq{'1-n&>V-.- -re: C~y. -,~-~.. .. Jel C(.fQ-f-.e.I....._-.dLJR . .-,/,1::/3 .(__,l[,):~.___.__ .. m...__ . ...... -. _______. -~1:'':'00\:;~L -!l[L~'-&uu-YL--j . ''''~,,&~I!...2\.L__ .Lf- 0"=-:.----.--, - ;7; '/' .'- ------ u______ -' - .---- --- -" ---.----. -- -- ---=--- -- - ( n1';,'~Y'-f.-:".~-" 6;~/t1> lJd-'L.ik1-Aj~__~ ~ 15<./- dA.JJv -:;t:k~,j{J(:!-<,tu -~_:- - /f/K 1-0 ~1 ~ uJ- I Iii {/ I. 1). .t-({ .;-:...J LJ.~.:.!r,L c It-L .. I I 1- J ~_u__.\::) \'0.C\>~ej~lp< <-L_..... . rt:;. ____,___..._ .m..____.o___'_.o_.__.o_.o___.._.o_ ___.o,__,.o~'~__.".o.o .o"_,_ ___.o __,_,,,___ ~...o_..o.,_.o_. m.__'_ ...m\ ~a~~-f;b tk~/... "--~------==--- .-. (r I / ~?'-/l(C-T_.ti-jJC:._ / ~--- (, / / IJ / C: C- l~ 9:- Allergies & Sensitivities IZJ.NKA T PATi::::~, iD "1 I I Weight Height Diagnosis MACNAMARA, SUSAN Acct#9312840 MR#0000825381 06i09/2005 GREEN. THOMAS CARLISLE REGIONAL MEOICA~~~~ 1/2111954 050 f 1IIIIIIIIIIIIIIIfIIIIIIIIIIIIIIIIIIIIIIIIIIII O:J07W II Physician's Orders NO 161310/04 N6302 Date I Time Each Entry Requires Physician's Signature I I , I I I I i , , , - I I , . i i I I I i , ! , f , I I I i , , , I , i I , I i I , I i I I I I ) I I , i I , i ... I PATiENT IDElHlF:CAT!QN ~ =J MACNAMARA, SUSAN Acct#9312B40 MR#0000B253B1 06/09/2005 GREEN. THOMAS 008:1112111954050 F CARLISLE REGIONAL MEDICAL eTR 1111I11111111111I1111111111111111111111111111 0307.W 11 Physician's Progress Notes N6302-T 11;98 DATE ( Y mp C\, 2cr:6 10 II 12... I-'J HOSP/POST OP Cld nc; \- ANTIBIOTIC 1 2 o).P 40' 04 08 12 16 20 I 14' 04 08 12 16 20 24 04 08 12 16 20 24 04 08 12 16 20 24 04 08 12 16 20 24 ? 250 U 240 L , 230 5 220 E 39' 210 - 200 T 190 E. 180 M 110 P 38' 160 - 150 140 /' '\ 130 120 LJ 110 3r , .;.- - 100 .... "" 90 // ~) .' 60 ., l.' 70 -36' 60 - 50 40 / 30 .8 I' Dl . 3Ji' p .)":" RESP,AATE ~ 17 TIME f5BS I RESULT I WEJGHTJSCAlE SHIFT 07 -15 1S - 23 23 -07 07-15 15- 23 23 -07 07 -15 15 - 23 23 - 07 07 -15 15 -23 23 - 07 07 -15 15-23 23 -07 PO TUBE fEEO w " IV '" ;;: B HR. TOTAL 24 HR. TOTAL VOIDED URINE FOLEY .~ I :l "- ~ :l :l DRMNS I B HR. TOTAL 24 HR. TOTAL <D ACTUAL I U qENAlOUTPUT ~~SlE MACNAMARA, SUSAN . RECIONAL A 1#9312840 MR#0000825381 06/0912005 \lll'I,:\I. (.[:""-;"[:11.. cc 00B'1112111954050f GREEN, THOMAS . CLINICAL RECORD CARLISLE REGIONAL MEDICAL CTR 0307.W 11 1111I11111111111I1111111111111111111111\\\111 NO CJ32':i <~ 011 250~ 240 230 220 210 39~ 200- 190 180 170 160 3B' 150- 140 130 120 110 37w 100- 90 80 70 60 36~ 50- 40 30 35' ru . CARUSlE REtI6NtJ.. . .'Mfl.:tl'TC,*oC t::[,,'N:Y'I!jJI. Medication Administration Record inane/al #: Phvsie!an: Alleraies: .', .' --, , From ~/, 0 al'i70lto Clft I at OlD!) DAY SHIFT EVENiNG SHIFT NIGHT SHIFT NO DOSE ROUTE FREQUENCY START STOP 0701-1 SUO 1501-2300 2301-0700 Oy. Llc.Dntln IOl"N. VO C% (jq [5...:,('(1-.1'-'., dlC0 ~') ~,\2.0 /0 Nf>>'" Ce lebrev: d!:D('!.Lpt) ~ OC]I)' (/ijj') dlOO . l 70 j' ,) cJ ~s -tc.') Ql-Zo , 01 l:~o..( J ()( et O~o '10 10 o'6SO~C} je\1S 1.-0 ! 'i}-DO 10' -.\vo ?e. "-I . \ Name: Age: F Glureral L VC -left vent RVe - ~ht vent LOC - ~ft dorsal ROC - ~ht dorsal AdmissiOfl Date: Sex: nmn LIlT -1elt onl \I1igh RAT -righlont1high LLT -Ielllatthigh RLT -rightlot1hlgh LVL-leftvu lot RVL - righl vas lot HI. Bl!lJ LD -loft deltoid RD -right delto~ RtA - rilht lat arm ill - h3ft lateral arm N - N,P.O, P -On Po.. T-Teslli'PJ Room # WI: MACNAMARA, SUSAN Acct#9312840 MR#0000825381 06/09/2005 GREEN. THOMAS 008:1112111954050 F CARLISLE REGIONAL MEDICAL eTR 11111111111111111111111111I111111111I11111111 0307.WII \ :/ :'.:..- Abdomen LLQ-loftloworquad RLQ - right klwer quad LUa -left upper Quad RUO - rght upper quad t Ii. " R - Refused NN - NouoeofJomitin<.l Litb pt, Nama: MR~: 1tf!1 'lllf' 1ll"l4' ~'?7CAAustE REtiSNt\L - ':r.f..:t11C....e t:::.r.'N:"f"f.;']'l Medication Administration Record Financial #: PhySician: Allslllies: //, ./ i~~' From/'?"k}- at1ff)r;;(jlcl,'~at 010D DAY SHIFT EVENING SHIFT NIC-HT SHIFT NO DOSE ROUTE FREQUENCY START STOP 0101.1500 1501.2300 2301-0100 OXfC<,.,T;A /J/~r 1.0 cY {').J, &/1"S> ~b r~ / ~/( ./IHrh " /7/2-,' I C c-- Ie.- b'lex. JUDO /2(J, c~l:}'';' {) /I..fS-uJ C/:J Hw") flit rv'QC (2,{ . . prr, . &b Ai icc' cO , Ca /-Itr;::, , I I Name: Aga: ~ l VC - feft vent Rve - right vent (DC - ~ft dorsal RDC - right do"",1 Admission Dater Se:c I!J!lll LAT -Ie/t anllh.igh RAT -righlanlthlgh LLT-leftlalll1lgh RLT -righllatll1lgh LVL-laftvaslat RVL - ri;lht vas lal HI. /\!!ll LO-leltd~1d RO-rightdello~ RIA - right Iat arm LLA -left lateral arm N - N.P.O. P-OnPass T - Testing Room # WI: MACNAMARA, SUSAN Acct#9312840 MRII0000825381 06/09/2005 GREEN, THOMAS 008:11/21119540,0 F CARLISLE REGIONAL MEDICAL CTR /111I111111111I1111111111111111111111111111/1 03D7-W 11 !' Abdomen LLO -Iefllower quad RLQ - right lower quad LUQ -left upper Quad RUQ - right UJllle' 'It/ad R - Relused NN - N.useaJ\lom~ng INITIALS SIGNATURE NITIALS SIGNATURE Ycb ',(6 Pt. Name: MR#: ltt.:1.1C{ I9"W . , .J . ~ / lpl c! . COMA SCALE EXTREMITY MOVEMENT TIME ",,'Ii.' ;' (~...."t HEARTRATEIWNl 'iJi? ,,-/'0 , 1 2 3 4 5 6 +1 +2 +3 +4 C IRREGULAR" ; EYES TO TO SPONTA. PUPIL REACTION A TACHYCARDIA:> 100 NEVER I OPEN PAIN SOUND NEGUS , SLUGGISH R BRADYCARDIA < 60 , INAPPRO. CON. + REACTIVE 0 INCOMP. FUSED TELEMETRY iVERBAL NONE SOUNDS PRIATE CONVER- ORIENTED - NON-REACTIVE I '1'(\ t--/'J WOROS SAllON PERIPHERAL PULSESfWNL ;.uP'iitm~. 4. 0 DIMINISHED EX11'N. FLEXlON FLEXlDN LOCAL- OBEYS 5.6.7.8. I ABSENT" MOTOR NONE WITH. IZES COM- - SIDN ABNOR. DRAW PAIN MANOS V CAPILLARY REF1LUWNL "):.) t-(-:; TIME r.7 <fj rloCC A ANTI-EMBOLISM STOCKINGS N -"I S HOMANS SIGN .o.j. EYES OPEN L-1 INTERMITTENT COMPo DEV. E BEST VERBAUMOTOR ~ fr ~ i..J U QUALlTYIWNL ilry;) /.-0 EXT. MOVEMENT R SHALLOW R (ARM/LEG) L DYSPNEA- 0 PUPIL R R ORTHOPNEA' SI2E / REACTION L E DIMINISHED I B COMPLIANT rw1I L.(? S CLEAR An 1.-,'-:/ , I E NONCOMMUNICATIVE' r P CRACKLES" I ~ ANXIOUS' I RHONCHI* NON-COMPLIANT' R WHEEZES" SLEEPSIWNL A COUGH/NON PRODUCTiVE I TEMPERATUR8VVARM i IJ-.c\ i-r..J T PRODUCTIVE' I COOL 0 LOOSE HOT R TIGHT TURGOR/WNL i.M M y COUGH & DEEP BREATHE EDEMA' 158 COLOR/WNL I'll Wi) 02 Urnin. PU LSE OX ::Vl I PALE TRACHEOSTOMY CARE FLUSHED A N ABDOMENIWNL '11 1....(>:; ASHEN' B T DISTENDED' CYANOTIC' 0 E FIRM* JAUNOICED' 0 .Ov, /.f?: G BOWEL SOUNDS/WNL MUCOUS MEMBRANE'WNL 1)(,:1 HI] M HYPERACTIVE U DRY E HYPOACTIVE M SENSATIONIWNL 11(\ LtJ N ABSENT* , E N TINGLING' NAUSEA' T NUMBNESS' VOM1TlNG* A INTEGRITYIWNL IK:I /..1?J FEED TUBE ASP!RATE AMI. ECCHYMOSIS' DIARRHEA' R PRESSURE ULCER STAGE CONSTIPATION' Y BRADEN SCALE 1&\ STOOUCOLOR INCISIONIWNL CONSISTENCY/SIZE DRESSING DRY & INTACT G NG PLACEMENT CHECK IV SITElWNL I NG DRAINAGE COLOR I DIVERSION G BLADDERlWNL U BLADDER PALPABLE' FREQUENCY' . REFLECTED IN PATIENT OUTCOME/EVALUATION AREA: SEE BACK DYSURIA* URINE COLOR/APPEARANCE LlII / MALODOROUS' / MACNAMARA, SUSAN GU DISCHARGE"/AMTICOlOF FUNDUS Acct#9312840 MR#0000825381 06/09/2005 GREEN. THOMAS 008:11/21/1954 050 F 0 BREASTS CARLISLE REGIONAL MEDICAL CTA T 1/1111111111111111111111111111111111111I11111 H 0307.W 11 E R DATE' ..-- ~ o......~.. ...,., cr~ NURSING DOCUMENTATION FORM . r EXPLANATIONS I MEANINGS I CODES URO: EXT. MOVEMENT +4=Normal Strength +3=Mild Weakness +2=Severe Weakness + 1 =No Response K - Within Normal limits :HAVIOR: SLEEPSIWNL - Able to fall asleep unaided between periods of care and does not display signs of sleep deprivation. iEGUMENTARY: TURGORIWNl- When skin pinched, returns to original position without leaving peak. EDEMA - +1 =2mm, small pit not retained +3=6mm, pit retained +2=4mm, pit - some retained +4=8mm, pit retained COLOR/WNL - Pink nail beds & mucous membranes MUCOUS MEMBRANESIWNL - Moist and pink SENSATION/WNL - Able to feel light touch & locate with eyes closed. ,-EGRITYIWNL - No opened or reddened areas ik ~ See Braden Scale ESSURE ULCER STAGE STAGE 1- Reddened area that does not resolve within 30 min. of pressure relief. STAGE II ~ Skin blister or superficial break in skin with surrounding redness. STAGE 11I- Skin break with deep tissue involvement (Notify Physician). STAGE IV. Deep ulceration with involvement of tissue, muscle and bone. :ISIONIWNL. Wound edges well approximated with no ecchymosis, edema. redness or drainage. RDNAS: HEART RATElWNL. Regular rate between 60 - 100. PERIPHERAL PULSES - Pedal and Radial CAPILLARY REFILL. Return of blood within 5 seconds HOMANS SIGN - +Pain in the calf on dorsiflexion. SPIRATORY: aUAlITYIWNL . Even chest excursion & unlabored pattern. DYSPNEA. Labored or difficult breathing. may be painful. ORTHOPNEA - Comfortable breathing at angle of 450 or greater. CRACKLES - Heard chiefly on inspiration' produced by fluid in alveoli. ::>NCHI . Head on inspiration & expiration; produced by air passing through mucous in larger airway. EEZE - Noisy whistling - may be heard on inspiration but more common on expiration. . . ( ABDIWNL. Soft, non-distended, non-tender. BOWEL SOUNDSIWNL . 5 . 12 gurgles per minute. BLADDER: WNL. Voiding at least lX/shift, clear pale to amber urine with faint aromatic odor at least 30 ccJhr or 240 cc/shift. PALPABLE - Bladder distended and felt as smooth firm mass above the symphysis pubis. FREQUENCY - Voiding more than once q 3.6 hours. DYSURIA. Painful or difficult urination. MALODOROUS. Unpleasant or foul odor. GU DISCHARGE - Vaginal, penile or urethral. SAFETY: See Falls Risk Assessment BODY SECRETION CODES COLOR: G.green Y=yellow T=tan B=brown BL=black WH=white MA=maroon R=red CG=coffee ground ST=straw LY=light yellow DY=dark yellow LA=light amber DA=dark amber TE'=tea CR=cranberry P=pink GR=grey BD=bloody DR=dark red SE=serosa RU=Rubra CONSISTENCY: W=watery S=soft M=mucousy F=formed L=toose P=pasty MS=mushy H=hard TH=thick FR=frothy APPEARANCE: C=c1ear M=mucousy CD:::cloudy CL==c1ots S=sediment SD:::seedy F=f1ecks T=tarry SIZE: SM=smears S=small M=moderate L=large BREASTS: S=soft F=filling FU=full E-engorged SITE CONDITION I TUBING TYPES 1 = NO COMPLICATION P - Prima" 2 TEND"'RNESS 1<: - SecondarY Med 3 - PHLEBITIS' Bid - Blood 4 INFILTRATION' V - Vented 5 = IV OUT PCA - PCA Fit Tub Site Site Cath Rate SITE. # OF STICKS. CI DIFFICULTY. SOLUTIONIHEP LOCK, Date Time Chg Chg Care Cond GA CC COMMENTS In it ~ltok I J /':: IJ-r...- .fu.M.., 1&-,.,,--,, d.. L-1A.Y(j"t ~ , I I i MACNAMARA, SUSAN em Acct#9312B40 MR#0000825381 06/09/2005 "'~ GREEN. THOMAS 008:t 112111954050 f CARLISLE REGIONAL MEDICAL CTR NURSING DOCUMENTATION FORM 1111I111111111111111111111111I111111111I11111 0307.W 11 ...",uJCI Page20f4 .....::- :..w.0 ,REV 11104\ I TIMES H COMP' ~TICjPARTIAUSa.F ~ y ~HOWEBPtU~ 'G ORAL CARE I E H.S. CARE N SKIN CARE E FOLEY CARE BLADDER IRRIGATION A BEDREST C TURN Q HRS T OOB I V BRP I Bse T AMB WITH ASSIST Y UPAD LIB E VOIDING L HNV I STRAIGHT CATHIFOLEY M DATE LAST BM ISTOOL SIDE RAILS UP S LOW BED POSITION A CALL BELL IN REACH F FALLS RISK (L / H) E T TRANSFER CATEGORY Y ASSIST/DEVICE 1500 - 2300 230040700 0700 - 1500 (J.",,- j..{'~ f>'{- \ I/I"'? M '('," ,. ()"ro( ,. ,;., '1.:7_ f).(\ nr:.), L . I;' ,_,1, l...r:) l- ..;- ,-,.,., TIMES 0700 -1500 1500 - 2300 2300 - 0700 o OVERHEAD TRAPEZEfTX CHECKS T SITZ BATH ~ SPECIAL CARE BED R e DIET: FILL IN DIET. NOTE ANY CHANGES. CIRCLE APPROPRIATE 0 0 DESCRIPTIONS. FEEDING TUBE CODES: P=PEG G~GASTROSTOMY E NG=NASO GASTRIC PPN=PERIPHERAL PARENTERAL NUTRITION S N DIET v'LP fA %AMT. TPN PPN U BREAKFAST tI' (j SELF,ASSIST FEEO T R LUNCH '-.j U "tJICORIE COUNT I SUPPER li'O RESTRICT FLUIDS T SUPPLEMENT FORCE FLUIDS I ENTERAL FORMULA SNACK 0 N RATE FDG!TUSE P G NG T FROM TO MODE INIT. RETURN TO INIT. R A N S P 0 R T INIT. SI\3NATURE 'j INIT. SIGNATURE S ,A,q {;/. 'lid ~ <I:.i / I G t/iiul)/'" ~ t Jh.. N tl:J... A ,. , T U R E o PAIN SCALES 5 10 NO PAIN WORST ,PAIN Wong-Baker Faces Pain Rating Scale @oo@oo@oo@oo-@"""@ ,-, - - - - ,_. ____ "--' - --- r--"' r\. o 2 4 5 3 PAIN MANAGEMENT _ Intervention' (M)edicate (P)osition change (N/A) None - continue to assess (R)elaxation technique (E)pidural (PCA) PCA (D)rip (') Other - specify in Notes PATIENT GOAL: SCALE USED: (F) = Faces (#) = Numbers TIME: I/ircC Location '(-Y:9~ Pain Level 'f Scale Used: F Intervention: rv1, Pt states Pain "'"'u ;;:) controlled: (time/level) I~ Initials Ai- ~ MACNAMARA, SUSAN .J CARuSIE Acct#9312840 MR#0000825381 06109/2005 ME ~?9.~~ GREEN. THOMAS 006:1112111954 050 f CARLISLE REGIONAL MEDICAL CTR 1111I111111I111111111I111111111I111111111111I 0307.W 11 NURSING DOCUMENTATION FORM Label Pa e3o!4 4 REV 11/04\ . - 9 NOQ4 Q( . - . . , .J . c, . PATIENT/FAMILY DISCHARGE PLANNING JISCHARGE INSTRUCTIONS: }' Physician's instructions reviewed with Patient/Significant Other, signed, copy given. "0 Prescriptions given. 0 Patient's own medications returned. J' Patient/Significant Other accurately restates all instructions. Does not request any further Health Ed. t Instructed to call Physician/Hospital 7 any f"Ob~s/questions develop. . DISCHARGED' Date I Time: ~ 1/1) f...9 :i ( q d 0 To: 0/ Home 0 Other: ] Ambulatory I!I we ~ Ambulance/" With: cr Family 0 Other: Signature: c4"~ cl rJo.- '-0 f-u.LlLJ -r; h, DATEITIME: 8/'. -, MACNAMARA, SUSAN Acct#9312840 MR#0000825381 06/09/2005 GREEN. THOMAS ODS: 11121 /1954 050 F CARLISLE REGIONAL MEDICAL eTR 1111111111111111I111111111111111111111111111I 0307.W 11 r/~ 0.~SlE .ME~~I~~ NURSING DOCUMENTATION FORM Page 4 of 4 N0044Q (REV) 11/04 . '-.J . t, / /. . - DATE: !,;>/ / {) Cb COMA SCALE EXTREMITY MOVEMENT TIME ~I d't) HEARTRATE/INNL (.<J 1 2 3 4 5 6 +1 +2 +3 +4 C IRREGULAW EYES TO TO SPOIfTA- PUPIL REACTION A TACHYCARDIA> 100 OPEN NEVER PAIN SOUND NEOUS " SLUGGISH R BRADYCARDIA < 60 CON. + REACTIVE D INCOMP. INAPPRO- FUSED TELEMETRY VERBAL NONE SOUNDS PAlATE CQNVER- ORIENTED - NON-REACTIVE I PERIPHERAL PULSESIWNL L.# WORDS SATION i.UP1ii m~. 4. 0 DIMINISHED EXTEN. FLEXION FLEXION lOCAL. OBEYS 5.6.7.'. I ABSENT- MOTOR NONE SION ABNOR. WIlH. IZES COM- ORAW PAIN MANOS V CAPILLARY REFILUWNL LO TIME r"\()cp A ANTI-EMBOLISM STOCKINGS N S HOMANS SIGN +1. EYES OPEN '1 INTERMITTENT COMPo DEV. E BEST IJERBAUMOTOR :;, u QUALlTYfWNL r,/I U EXT MOVEMENT R q 1 SHALLOW R (ARM/LEG) L ''f1J, DYSPNEA' 0 PUPIL R R ORTHOPNEA" SIZE I REACTION L E DIMINISHED B COMPLIANT W S CLEAR I (,J E NONCOMMUNICATIVE' P CRACKLES' H ANXIOUS' -r I RHONCHI' A NON.COMPLlANT' R WHEEZES' V SLEEPSIWNL A COUGH/NON PRODUCTIVE TEMPERATUR~1NARM 0' T PRODUCTIVE' COOL 0 LOOSE HOT R TIGHT TURGORlWNL U y COUGH & DEEP BREATHE EDEMA' 158 W 02 Umin. Ci~ COLORlWNL R-iIJ. PULSE OX I PALE TRACHEOSTOMY CARE A N FLUSHED ABOOMENIWN"l c-u ASHEN' B T D DISTENDED* E CYANOTIC' FIRM* JAUNDICED' 0 (/-' G BOWEL SOUNDS/WNL MUCOUS MEMBRANE'WNL (,.1 M HYPERACTIVE U DRY E HYPOACTIVE M SENSATIONIWNL '/1 N ABSENT' . E N TINGLING' NAUSEA" Y T NUMBNESS' VOMITING' .A:r INTEGRITYIWNL ~ FEED TUBE ASPIRATE AMT. A ECCHYMOSIS' DIARRHEA" R CONSTIPATION" PRESSURE ULCER STAGE y STOOUCOLOR BRADEN SCALE INCISIONIWNL CONSISTENCY/SIZE DRESSING DRY & INTACT G NG PLACEMENT CHECK IV SITEIWNL I NG DRAINAGE COLOR I / DIVERSION G BLADOERiWNl CO U BLADDER PALPABLE' FREQUENCY' i . REFLECTED IN PATIENT OUTCOME/EVALUATION AREA: SEE BACK DYSURIA" ! URINE COLOR/APPEARANCE 'IIG i MALODOROUS' , GU DISCHARGPIAMTICQLOR ! MACNAMARA, SUSAN FUNDUS Acct#9312840 MR#0000825381 06/09/2005 GREEN, THOMAS 006:111Z111954 050 F 0 BREASTS CARLISLE REGIONAL MEDICAL CTR T 11111111111111111111111111111111111111111111I H 0307.W 11 E R ~In ,'1.1....\ to"'" ",," , p~-~ , ~. , ~. / C'\RLL9.E ( RECIONAL NURSING DOCUMENTATION FORM . " l" EXPLANATIONS I MEANINGS I CODES URO: EXT. MOVEMENT +4=Normal Slrength +3=Mild Weakness +2=Severe Weakness + 1 =No Response IL - Within Normal Limits HAVIOR: SLEEPS/WNl- Able to fall asleep unaided between periods of care and does not display signs of sleep deprivation. "EGUMENTARY: TURGORlWNL - When skin pinched, returns to original position without leaving peak. EDEMA - +1=2mm. small pit not retained +3=6mm, pit retained +2=4mm. pit - some retained +4=8mm. pit retained COlORIWNL . Pink nail beds & mucous membranes MUCOUS MEMBRANESIWNL . Moist and pink SENSATIONIWNL - Able to feel tight touch & locate with eyes closed. EGRITYIWNL - No opened or reddened areas k - See Braden Scale :SSURE ULCER STAGE STAGE I . Reddened area that does not resolve within 30 min. of pressure relief. STAGE 11- Skin blister or superficial break in skin with surrounding redness. STAGE 11I- Skin break with deep tissue involvement (Notify Physician). STAGE IV - Deep ulceration with involvement of tissue, muscle and bone. ISIONIWNL - Wound edges well approximated with no ecchymosis, edema, redness or drainage. ~DNAS: HEART RATEJWNL- Regular rate between 60 - 100. PERIPHERAL PULSES. Pedal and Radial CAPILLARY REFILL - Retum of blood within 5 seconds HOMANS SIGN - +Pain in the calf on dorsiflexion. iPIRATORY: QUALITYIWNL. Even chest excursion & unlabored pattern. DYSPNEA - Labored or difficult breathing - may be painful. ORTHOPNEA - Comfortable breathing at angle of 450 or greater. CRACKLES - Heard chiefly on inspiration produced by fluid in alveoli. )NCHI - Head on inspiration & expiration; produced by air passing through mucous in larger airway. ::ezE . Noisy whistling - may be heard on inspiration but more common on expiration. . , . ABOIWNl- Soft, non-distended, non-tender. BOWEL SOUNDSIWNL - 5. 12 gurgles per minute. BLADDER: WNL - Voiding at least 1 X/shift, clear pale to amber urine with faint aromatic odor at least 30 cc/hr or 240 cc/shift. PALPABLE - Bladder distended and felt as smooth firm mass above the symphysis pubis. FREQUENCY - Voiding more than once q 3 - 6 hours. DYSURIA - Painful or difficult urination. MALODOROUS - Unpleasant or foul odor. GU DISCHARGE. Vaginal, penile or urethraL SAFETY: See Falls Risk Assessment BODY SECRETION CODES COLOR: G-green Y=yellow T=tan B=brown BL=black WH=white MA=maroon R=red CG=coffee ground ST=straw LY=light yellow DY=dark yellow LA=light amber DA=dark amber TE=tea CR=cranberry P=pink GR=grey BO=bloody DR=dark red SE=serosa RU=Rubra CONSISTENCY: W=watery S=soft M=mucousy F=formed L=toose P=pasty MS=mushy H=hard TH=thick FR=frothy APPEARANCE: C=dear M=mucousy CD=doudy CL=dots S=sediment SO=seedy F=f1ecks T=tarry SIZE: SM=smears S=small M=moderate L=large BREASTS: S=soft F=filling FU=full E.engorged SITE CONDITION f TUBING TYPES 1 NO COMPLICATION P - Priman, 2 TENDERNESS S - SecondaN M"d 3 - PHLEBITIS' Bid - Blood 4 INFILTRATION' V - Vented 5 - IV OUT PCA - peA Fit Tub Site Site Cath Rate SITE. # OF STICKS. Cf DIFFICULTY. SOlUTION/HEP LOCK. Date Time Chg Chg Care Cond GA CC COMMENTS Init U/do ~ Ci.J 'P tfl. .J' d. .~ ~A. -C /1-./ c:.. iK)fAif tY I MACNAMARA, SUSA C,(;WllSLE Acct#9312840 MR N M ,fcE~Ig~N. GREEN. THOMAS #0000825381 06/09/2005 CARLISLE REGIONAL ME 008:11/21/1954050 F 111/1/111/11 11I1/1/111 1ll/IlllIIllI/llnil/Ul eTR NURSING DOCUMENTATION FORM La 0307.W II I Pa e2014 ~,,-,,,., 'f' . "''''' , ,. ..".,. be 9 " I " I " " " IHI/II') 0700 . 1500 1500.2300 2300 . 0700 , IIMI'lJ:TE/PART1AUSELF 1111 )WIJ~ITUB ,ltll'!. C^I~E II 'j (;^I~E 11.II'II;AnE 11111 '(CARE 1111\I)UI.:r~ IRRIGATION HillIn-Sf 0') !11I1f'IIJ HRS. .11111 lUll' 1\:,4; "Mil WITH ASSIST III'A{)LIB 111)11)11'1<.) '....' IINV 111~^I(jHT CATHIFOLEY I)I\IE LASTBM ( . I "I 15TOOL ill U: IMILS UP . \ .. " ; ~ IW oED POSITION ,"/1 , :J\I.L BELL IN REACH I A t ALLS RISK (L I H) i-I 11(ANSFER CATEGORY ~ 1\:i~~JST/OEVICE (' "iC+-c-L IIM!:3 0700 . 1500 1500 . 2300 2300 . 0700 , IVU?HEAD TRAPEZEITX CHECKS 'illt IlATH 'il'I:CIAL CARE BED - 1\ I I V I I I " I I Nt ~ i\ I' ~ I 1 " I II t~ " C DIET: FILL IN DIET. NOTE ANY CHANGES. CIRCLE APPROPRIATE 0 0 DESCRIPTIONS. FEEDING TUBE CODES: P=PEG G=GASTROSTOMY E NG=NASO GASTRIC PPN=PERIPHERAL PARENTERAL NUTRITION 5 N DIET %AMT TPN PPN U BREAKFAST SELF ASSIST FEED T R LUNCH CALORIE COUNT I SU PPER RESTRICT FLUIDS T SUPPLEMENT FORCE FLUIDS I ENTERAL FORMULA SNACK 0 N RATE FOGITU8E P G NG T FROM TO MODE INIT. RETURN TO INIT, R A N S P 0 R T INIT. SIGNATURE INIT. SIGNATURE S i/_'7_..__k'v-J.-Il-V I Co G , N A T U R E o PAIN SCALES 5 10 NO PAIN WORST PAiN Wong~Baker Faces Pain Rating Scale @~ @_.@- @, ~' @ G0 00 00 00 /0S) 'WY'" ,-, .. - - .. ,'" '--""--"--- r--..r\ o 4 5 2 3 'AIN MANAGEMENT - Intp.I'Vp.ntion. (M)edicate (P)osition change (N/A) None - continue to assess (R)eJaxation technique I (E)pidural (PCA) peA (D)rip (') Other - specify in Notes I'A r1ENT GOAL: SCALE USED: (F) = Faces (#) = Numbers TIME: I tll:dllon f 'dIll Lt:tvel ')' .lId Used: II 111llVantion: I 'I :;Iult:ts Pain 1.IJlllrnUed: (time/level) 1lllUdls MACNAMARA, SUSAN ~ / CARuStE Acct#9312840 MR#0000825381 06/09/2005 ...M E ~~I9,~ GREEN. THOMAS 008:11121/1954 050 F CARLISLE REGIONAL MEDICAL CTR 111111111111111111111111111111111111111111111 OJ07.W 11 NURSING DOCUMENTATION FORM I Pa e 3 014 NO 0440 (REV 11/04) Labe . - 9 . - . . ,. -....I . ~ . PATIENT/FAMILY DISCHARGE PLANNING JISCHARGE INSTRUCTIONS: ] Physician's instructions reviewed with PatienUSignificant Other, signed, copy given. ] Prescriptions given. 0 Patient's own medications returned. ] Patient/Significant Other accurately restates all instructions. Does not request any further Health Ed. ] Instructed to call Physician/Hospital if any problems/questions develop. I)ISCHARGED: Date' Time: ] Ambulatory 0 we 0 Ambulance To: 0 Home 0 Other: With: 0 Family 0 Other: Signature: OATEITIME: 0.),-/0' "'- r {" :r j.,L. .r:- e:,... '-d. ~, --.- c--- C/?-z..~ ------- . c.;.. MACNAMARA, SUSAN Acct#9312840 MR#O000825381 0610912005 GREEN, THOMAS 008:11/21/1954 050 f CARLISLE REGIONAL MEDICAL CTR 11111111111111111111111111I111111111111111111 r /'l"F 0e~SlE .. M E ~yI~f:I, NURSING DOCUMENTATION FORM 0307.W 11 Pace 4 of 4 NO 0440 (REV) 11/04 PATIENT ASSESSMENT FORM Page 3 PAIN: ACUTE' Location Cause of Radiating: 0 No 0 Yes Specffy o Causes lifestyle changes in ADL's: CHRONIC: 0 Vas 0 No Location What brought it on? Radiating: 0 No 0 Ves Specify o Causes lifestyle changes in AOL.'s: 0 Yes 0 No NOTE: if pain Is Identified, please re1er to nursing policy on pain asseument QUality:~ 0 Dull . 0 Other Severity Scale:_ Onset Aggravating Factors Relieving Factors o Cramping 0 Buming o Aching o Constant 0 Intermittent OVos ONo Qusl~y: 0 Sharp 0 Dull 0 Cramping 0 Burning o Other o Aching Severity Scale:_ Onset Aggravating Factors Relieving Factors Dentures: 0 Upper 0 Lower one Brought to hospital: 0 Yes 0 No Vision: ~asses2Contacts 0 None (!;. ~ r- Brought to hospttal: .....a'f"es 0 No _ u Hearing Aid: 0 Rt 0 U 0 Both ~e Brought to h01lP~sI: 0 Yas 0 No F.n , Safety Risk _.ment. Guideline: Patients with W applicable araas of the tool or with one or more asterisked areas are considered to be at high risk for falls. The decision of whether or not a patient is at risk for falls is based on the nurse's professional judgement. Ge......1 Data _Age <50r >70 _ History of fall prior to admission* _ Postoperative or admission for surgery Medlcallons Diuretics or Laxatives = Hypotensive or eNS Suppressants (narcotics, sedatives, psychotropics. hypnotics, tranquil1zers. anti- hyperten~ves,antide~s~. anesthetics, muscle relaxants) Substances of Abuse o Constant 0 Intermittent Valuables to Safe: . Sight 0 Blind o Ves No o Diminished Hearing: 0 Deaf o Diminished Phyaical Condlllon _ Dizziness I Vertigo I Ughtheadedness _ Syncope _ Unsteady Ga;t I Poor Coordination _ Diseases I Problems affecting weight- bearing joints Weakness = Paresis I Hemi.neglect Anemia I Blood loss - Seizure disorder = Impairment of Vision _Impainnent of Hearing _ Urinary frequency Mental Slatu. Confusion I Disorientatlon* = Impaired me~ory _Inability to understand or follow directions Delirium HaJlucinations High Risk ~ _ Ves If Yes, Falls Risk Protocol Initiated Date: Time: Ambulatory Devices Cane I Walker Wheelchair OrthOSIS I Prc6theSls Crutches Signature: safe UYlng I Transfer Asseaement: Guideline: Aasign patient to appropriate category. Determine the number of assistants needed; Write initial category and number of assistants on Kardex and on dry-erase board in room. This information is to be updated daily. _ Independent: Can ambulate and transfer without assistance Minimum: Assist with ambulation and transfer. Number of assistants; Moderate: More than one assistant for transfer. Number of assistants:- Maximum: Patient unable to assist in transfer. Number of assistants: = Do Not Move: Only transport via bed, without changing position. Catagory: Aaalalanto:- On Kardex: On Board: Signature: RN Slgnatura: Datomme ~f2tV Oalemme tf>,I;-O /0-6- Reviewing RN: Patient unable to answer questions for the following reasons: o No family present o Medical condmon . Explain; RN Signature: Datemme Patient unable to answer questions for the following reasons: o No family pr968nt o Medical condition - Explain: AN Signature: Datemme PATIENT IDENTIFICATION ~ M'~ PATIENT ASSESSMENT FORM MACNAMARA, SUSAN AcctU9312840 MRU0000825381 ()6109/2005 GREEN, THOMAS 00B:11I2111954 050 F CARLISLE REGIONAL MEOICAL CrR 11111111111I11111111111111I111111111111I11111 0307W 11 NO 0110C 1/05 '" AT .,SMENTFORM Pae1of4 Name '., ".5 t.l." /vl., r q I d ma.rl" Date: r.; /1_ /. j Time: 00'1' MEDICAL HISTORY I PSYCHIATRIC HISTORY: 0 NONE Likes to be caJJed Age o Anxiety o Depression o Pregnant EscortlOrivef o Arthritl.: o Diabetes . LMP Height Weight: Present ,H Usual o Aslt1ma o Dyspnea o Seizures VItal Signs:. T. 'IS P R o Bleeding Tendencies 0 Emphyseme o Transfusion Reaction BP 10 4, /4,., Sa02 1f"7. ,L (,*",ead Circ < 2 yrs IV ( rr- DCA o Glaucome DYes DNa ALLERGIES/SENaITlVITIES' (Describe Reaction} o Cardiac Disease o Home Oxygen o Ulcer Medication Q.bIGNE o Chest Pain o Hypertension o Other: -E.TNONE o COPD o \Jver Disease Food o Cough OMI Environmental (latex, tape) Q-NoNE OCVA Exposure to lntectious Disease: i:J Yes -81'fo; If yes, l~t Implanted Oevlces: ~ 0 Yes Explain: Surgical History: {"....i" ~~~.. ':_1""-, .21~ (' ,r 1 ~ A" ....".L, > Immunizations Current: 0 Yes 0 No IV .4 ~ b , / . Reason for Admission: .NIt/fI- l/i' '1,/' c. ,:"A TETANUS. s'TAruS: a Within 5 Vrs o 5-10 'Irs o More than 10 Yrs l:IldlI:m: o Unknown TobaCCO Use Alcohol Intake CURRE.NT MF..nlCAT10NS: (Ax, OTC, Herbs, Vitamins) ~er Smoked 0 Chew 0 Snuff ~ne Mllll l&ill last Oosemme ;.Smoker (Date Stopped ) 0 Occasional /; I, o Smoke. (AmI. per day } o Daily (Amt. \ 1. ( J 'r I <.<..ir- Smoldng cessatio~ation: 0 Accepted o Declined 2. flY.. ; /('; STREET DRUGS' No 0 Yes Type(s) REVIEW OF SYSTEMS 3. Has patient evidenced any of the foUow\ng now or in the past 30 days~ 4. NeurologlcaJ;r9 NONE 5. o Headl\Che ~ne.. o Seizures Q Numbne..rnngllng o Tinnitus it Problems o Diplopia Q Sensi1ivity to Light 6. CommentS 7. R..plratorylCardlo Vascular. ~E o Cough o SI10rt of grlllllh Q Snoring/Sleep Apnea 6. OTx for TB o Night Sweats OEdema 9, Q Chest Pain o Palpitation. Q TB Screen Sheet Needed Cornmants 10. G80tr0ln_...I: ~E 11. o Painlfendemess 0 Vomiting o Nausea o Diarrhea 12. o Constipation 0 T.ny StooJs, Q.Bleedlng o Incontinent Q Last Bowel Movement 'il If! tJ j 13. Comments I 14. GenltourtnarylReproductlve: ~ Q Dribbling MEDICATIONS, ~e o Home o To Pharmacy o Pain/IlUminglltching o Discharge o Blaeding o @ Bedside o Frequency o Nocturia o Oliguria o Incontinent PSYCHOSOCtAL a Menopause o Bre... Chonge o Prosta1:e Problems Caregiver: Q Self 0 Family Member 0 Signlllcant Other o Nursing Home* o Last Menstrual Period Olives .Ione ~ with 'A f,,.i,l Comments - Help was needsd with the following: 0 Shopping 0 MeeJ prep 0 Chores o None Q Laundry Employment: ~Ioyed 0 Unemployed 0 Retired Environment: 0 No Steps 0 Few Steps 0 Many Steps Development Age: (Check onfy tho.e that apply) o Infant 0 Eariy..Dliidhood 0 MIddle Childhood 0 \..ate Childhood o Adolescent ...c:r Adult 0 Geriatric 1. Ha.;.aomeone you cared about threatened or harmed you? ...e:fDenies 0 Yes* 2. Do ~el safe in your home? ~es 0 No'" 3. ~ou~eneflt from discharge planning: ~s 0 No, not apparent at this time If you have checked any of the (*) boxes, please contact case Management Services at Ext. 5290. I I Inil:iallf consulted Q Copy to Pharmacy ~ have any religiolls orcutturat issues that would affect your care? ~NO OYes Specify Highest Grade 01 Sc~1 Complated Read: Q No .,A:J"Y.... ~e: How do you learn be Reading Communication Barriers ne a Cyraphone CI TOO Phone 0 Dementia Preoperative InstruCtions received 0 Yes 0 No AN Signature: J~;$;;...."r-lc.:~ "vv/ Aevi "og AN: o Visua Oate/Time6' fch ,- o""IJ- t ' Oate!Time PATIENT IDENTIFICATION r~ '-/.~ . ..Nfi~ ~~;i~~t:..~ MACNAMARA, ~0~~~~81 061D912DG5 Acct#9312840 MR#D 006:1112111954 050 F GReEN. THOMAS C1R CARum REGIONAL MCOICAl \\1\\\\\\\\\\\\\\\\\1\\\\\\\\\1\111\\\1\\\\11 0307 -w 11 PATIENT ASSESSMENT FORM NOOllOA 1105 '" PATIENT ASSESSMENT FORM _DI_ Do you have an Advance Oirectlve/Uving Will? CJ Y.. ~ Patient is unable to answer: 0 Unable to communtcate Cl No family present o If "Yes", do you have a copy of your Advance Directive .w1th you? OV.. ONo If -Yes", p4ace a copy on chart. If "No.. does the hospttal have your Advance Directive on file? 0 YH 0 No If 'Y.." contact H.I.M. Depl (Ex!. 2164) for copy If "No., can family member provide a copy? 0 V.. 0 No If .No~. do you want to complete a new Advance Directive? OV.. 0 No ~ 'Yea". contact Case Management. (Ex!. 5290) If you 00 NOT haV8:E\1 Directive, do you wish to complete one7 0 CI V.. ~ 'Y.... con ass'Menagement. (Exl. 5290). InftIaI' It consulted Family to bring copy: Date H,I.M. contacted to obtain copy: Date Case Management consulted: Dete Status of Advance Directive on Kardex: Slgml1ure: Advance Directive on chart: Date SIgnature: NutrtlIon 5_ 5CNe1l1ng: Note: tt 17 Year3 at age or under, complete Part A by clrcUng any that apply and Consult Nutrition Servtces. Part A: V..: (') Pregnant or lectallng . 2 pia; (2) Fellu'" to Thrive dlagnosl. ' 4 pia; (3) TFITPN . 6 pia; (4) New dx DM . 3 pts; (5) Feeding problems/prolonged NN/D >5 days . 3 pts. PoInt TotlII ---------------------------------------------------------- Part B (Adults): 1. Are you on TPN or tubefeedlng? 2. Do you have a pressure ulcer with impaired healing? 3. . Do you. have an illness or condition that has made you change the amount/ldnd of foods you usually eat? (NN/O > 5 days, Cancer Therapy) 4. Have you had recent unln18ntlonal weight 1088 (> 10 1b812 mos.)? 5. N8 you pregnant or lactating? 6. . Non-electlve ."'gIoeI petient > 75 y~ old? 2 '2 1 Point Total V.. 6 4 3 No JY'7 .....rr- > ....e- -if ..v-- icons . If score Ja 3 or more, COMUtl CUnlC81 Nutrttton via the computer (NUb1tIon eon.utt Phyolc:a/ 7lIe_ 5_"'11: (New..llllUl in month prier to admlsaion) 0 Voo ~ o History of f8tls o Unable to .tt _ .upport o Dependency upon assIttlve device for ambufatlon prior to admission Q W~chalr Q Walker [J Cane o Inabill1)' to change bed position Q-Recent discharge from rehab unit or center NOTE: If ""y .... prNlIRt, p_ nolIIy phyeIcIan lor coneuft. Initial If consulted 5jHH1Ch TIwepy -"'11: (New llIlIlIIln month poor 1D admlsaton) 0 V~ o DIlflcuI1)' with chewing/swallowing 0 Slurred speech o DffficuI1)' with understanding simple directions 0 DltflcuJ1y sp_lng NOTE: If ony .... pnt88nt, p1u.. notify physlchln lor coneull. Initial if consulted Occupdorra/71l....py: (New__ within month prior to admission) 0 V..~ o Needs assistance with bathroom sldlls o Uneble to feed sell o Unable to groom .e~ o Needs assistance with ADL's NOTE: If any of th... .. p,...nt., pi... notify physlclen for conautt. initial It coneutted AN Slgnetu... ,ap.,y--{~rC-J / It,.-- <,IJ '13 . Detemm6//o P.> A_II RN: Dalem",. . '7/; ~~ PATIENT ASSESSMENT FORM NO OllOB 1105 MACNAMARA, SUSAN Acct#9312840 MR#0000825381 06/09/2005 GREEN. THOMAS 008:11/2111954050 F CARLISLE REGIONAL MEDICAL CTR 1111I111111I11111111111111I1111111I1111I1111I '14 0307.Wll SKIN ASSESSMENT FORM Pa e4 SENSORY ACTIVITY MDBIUTY NUTRITION MOISTURE FRICTION AND PERCEPTION SHEAR Completely Completely Very Constantly Umned Bedfast Immobile Poor Moist Problem Very Chair Very Probably Potential Umited 2 Fast 2 Umited 2 Inadequate 2 Moist 2 Problem 2 Slightly Walk Slightly Occasionally No Apparent Limited 3 Occasionally 3 Limited 3 Adequate Moist Problem No Walk No Rarely Impairment Frequently 4 Limitation 4 Excellent 4 Moist SolXce: BarDa/'8 Braden ami Nancy Bergstrom, COP't'igl1t 1988 If Admission Score is 12 or below, consutt Wound/Ostomy/Continence Nurse st Ext. 5283 Initial it consult SKIN ASSESSMENT Characteristics: O~...P-ll1'Y 0 Warm Wound Type: ~asion o Bruise o Skin Tear o Burn o Laceration OScar o Rash o Other o None o Paie 0 Jaundiced o Flushed 0 Dusky 0 Diaphoretic 0 Cool Surgical Wound(.): #1 None ~I~ ) #2 "' , \ I V #3 R L L )1 II SITE CONDITION SIZE - em lxWxD f'''J "--.l R R Note area by drawing line to figure ODOR STAGE Y or (Pressure Ulcer Stage) BASE COLOR DRAINAGE Amount T TUNNEUNG YarN TYPES OF DRAINAGE: N NONE S SEROUS P PURULENT T/G TAN/GREEN SS SEROSANGUINOUS DRAINAGE: N NONE SM SMALL M MODERATE L LARGE COLOR: P = R Y B W BR STAGES: I II III IV PINK RED YELLOW BLACK WHITE BROWN NONBLANCHABLE ERYTHEMA PARTIAL THICKNESS SKIN LOSS FULL THICKNESS SKIN LOSS FULL THICKNESS TISSUE LOSS INVOLVING DAMAGE TO MUSCLE, BONE, OR SUPPORTING STRUCTURES Date: ? 0.5 Signature: PATIENT IDENTIFICATION MACNAMARA, SUSAN Acct#9312840 MR#0000825381 06/09/2005 GREEN, THOMAS 008:11121/1954050 f CARLISLE REGIONAL MEDICAL CTR 111111111111I1111111111111111111111111I111111 0307- W 11 rn~ , C\RusIE ..'",W~ PATIENT ASSESSMENT FORM NO 01100 1/05 '" INTERDISCIPLINARY PROGRESS NOTES Date: l, /o,,~ s: 0: f'r Discipline: 1<""- Time: '5'15:"-"( " Visit Duration: Treatment & I Code.a 0.. . i (.[ , . ~ '." I/,J v ",_ c,."'/') Il, /"'-'-' -r/{'-'""> :.ji~ JI'~.-:. Irl/" -I- I) /..~t.-' .rJla '- A: P: .' /' 7 . Therapi~ /lJ<!rl2-.f! r; L---'" Date: Discipline: o. c. r v Treabnent & Code C- T Time: /l:rr- 1'-/ Visit Duration: ' P: /~J1~/J...... /'/' </,If ,~;.,,;;., .;/ Therapist;/'~ (~71...d- f:'r Date: I Discipline: Time: Visit Duration: Treatment & Code S: 0: A: . P: Therapist: .-PATII=NT Ir\CMTIClr""-r',...... (~RJJSIE .!l "' RECIONAL '-/M t:OIC"l CENTtR. MACNAMARA, SUSAN Acct#9312840 MR#000082538' 0510912005 GREEN, THOMAS 008:1112111954050 F CARLISLE REGIONAL MEDICAL CTR 111111111\\1111\11111111111111111111111111111 Q307W 11 INTERDISCIPLINARY PROGRESS NOTES PT 09018 (08/01) r'" . ~ . ~ .., . ./.E ua ';'.ATMENT "rjNOSIS , U;AUTIONS BACKGROUND: SO 'j'v ~. lit' /'1lJjI) e ;u1V/L ,,f;. 6:Jw.,ijb~l jP..(jj/J,.., @ ;ttLIJ_ t. h. DATE 6/ Id1>f' AGEf'U DATE OF ONSET 0 - "'"Or J "")O)Fy j/i.h L ;?fvJJ) fYv'VL 9-r ,j<)ME ENVIRONMENT: ,,/ J ,,,,-,.>>1 J,.M.... .7'i./~ c- 'pC PLANS: ');H U)lJIPMENT NEEDS: .1'<1",11, k-p1"'7'--L.. uhJd. S: 1Jyw.....l)t j, ()- ". J.f'"1 !' /}/J1 />1' J., lA/I.. MENTAL STATUS: A+Ox3 CJ A + 0 x time, person, place unresponsive N COMMUNICA nON: Speech: . M WFL Comprehension: ~ WFL Other: INSPECTION: ----- " -fHIN/A VG/OVERWEIGHT IV o~ L/R OXYGEN SKIN CATHE RESTRAINTS? 'UAMOBILIZER or BRACE PLEXIPULSE BOOTS OTHER yOSTURE ~,)JTTING- WNL UIfItvI1 J.. STANDING- COMMENTS- TRANSFERS ROLLING- L R tfdl (l.. M'.;,(i; CI.r- IN=OUT OF BE,9,;: lY1,..0 ON=OFF COMMODE fi.; t: (~ ""y' LIE SIT SIT STAND OTHER ltOM .-----.. STRENGTH GENERAL- WNL (WFL) GENERAL- 5\ 4 3 2 1 0 UE'S- WNL WFL UE'S- 5) 4 3 2 I 0 -- LE'S- WNL WFL LE'S- 5 ,4) 3 2 I 0 COMMENTS- , COMMENTS- .... n: MACNAMARA, SUSAN a;~ Acct#9312840 MR#0000825381 0610912005 GREEN. THOMAS 008:11/21/1954 050 F CARLISLE REGIONAL MEDICAL CTR PHYSICAL THERAPY DEPARTMENT 111111111111111111111111111111111111111I1111I 0307.W 11 1"o<i1~fI'I',,). EVAL.ION . . . r ".c_,.~ BALANCE SITTING ?to requires (;> @ l..r-.o %oftime STANDING PI. requires cy<-y IV'-> % of time Comments: with '-^&.:!:Ot device Comments: NEUROLOGICAL Sensation Reflexes WNL WNL Coordination WNL WF AMBULATION RLE LLE PWB TTWB NWB CRUTCHES WALKER HEMIW ALKER ~jjD WA!$BR HHA CANE NONE INDEPENDENT SUPERVISION ~CT~ MlNA MOD A MAX A STAIRS STANDING ONLY M a /""1: v)u.~&ol Vvl.cLh.v-.- T: (t-.g;vl) ASSESSMENT: cui . /.l. ) A / rr ~.J1rJ, -C- Uh-pAN1.t.vJ /,,"'mil0J /7h:'Pt..l.,~S P JuvI '2" ~ ~ /,...JVI'- ~'J;J";- M/{ I:UJl~Jt f1"-- /J. j:, ur:A~ ).:Jh..P{I) lL/ 5rD~ REHAB POTENTIAL: c~ TREATMENT: -ev< if" - j-r-lL/Yl/<-, . ~"c1- Plan or Care (POC):~ 1idL& tr...Neuro re-ed,~ swrs - J. 'to L0 ~.../ WThe above Plan of Care has been discussed and agreed upon with the patient and/or family (as available): -L Yes No Comments: THHRAPIST: Gc~ PATIENT IDENTIFICATION "/'f." r':rC\RusrE ~EN:?~ PHYSICAL THERAPY DEPARTMENT EVALUATION PT05/IB(10i02) . . . . . . "" . ., . GOALS Transfers: ~i11 transfer supine < -<-- > dangle with S' assist to allow for functional activities in sitting in '] .J- sessions. ~atient will transfer sit < ----- > stand with -L-assist to allow for initiation of gait and toileting activities in ~ sessions. 6)atient will transfer bed < ----- > chair with -L- assist to allow for functional activities in sitting in ~ sessions. 4. Patient will transfer floor < ----- >stand with _ assist to allow for knowledge of safe technique in _ sessions, Ambulation: 1. Patient will ambulate distance with with _ assist in _ sessions. ~atient will achieve inqependent ambulation with appropriate assistive device on level surfaces and stairs as necessary .--- Vve days plus. . Steps: 1 . Patient will ascendfdescend steps with _ with _ assist in 2. Patient will ascendfdescend one step/or curb with _ with _ assist in sessions. sessions. Balance: . 1 . Patient will demonstrate _ balance with _ to ensure safety with transfers and ambulation in _ sessions. 2. Patient will be able to sit with _ support in _ sessions. Therapeutic Exercise: 1 . Patient will be independent with a home exercise program in _ sessions. Endurance: 19atient will tolerate "2/0 repetitions of exercises to increase endurance necessary for ADL's in 1'-' sessions. Other: 1)' . hysical Therapy Department will assist with discharge planning. 2. atient andlor family in agreement with above goals U yes _ no . . THERAPfST~ f1~J /.,; DATE: b )Q.u,. PATIENT IDENTIFICATION .",~ /r, . . O\RuSLE REGiONAL MED1CAl CENTER MACNAMARA, SUSAN Accth9312840 MRh0000825381 06109/2005 GREEN. THOMAS 008:1112111954050 f CARLISLE REGIONAL MEDICAL CTR 1111I1/111111111I111I11111I111111111111I1111I 0307.W II GENERAL PATIENT GOALS PT nt;11r (-:tln?\ ~ ~ '0 ~ Il3 I'" ~.\:'\~ ~ ?~:!- o 0.. z!: ~ Q. (tl a). UI , Q.. ~." ,... S - <0 a:l~ , ~O~~ ~ ~ aroa d) c ~ar~ I'!'. g..?<a~ "0 g ",;;!.' <o"Ol II (1.:"<0", . -0 0 ('}.-;:;::=. ~_ o.c.....-. ) 9.. \~;:; s: ~ i~. \!'! ,,0.'" :J3 md<=:: ~$:r cc:. ~(j;'1I 9.\\\% -6 ~ 3 0 ..,z: -- 0.- ~~ -g,.\\::;" ~~~ -.c d) 0...... '9 s.~ ~~ ~_.~ ';;..~< ~:J"-1-C::~~' cO(OC') ~~(f)nCCO ro~o \c,r II .\7, II cr- " \, ~6@O'0l ",g9: c. C 5"::\ 0 3.tO '; <j 5 (Q. 0 co::1:J \, ,;:. ':J' - ". j\;;; ~ , 0 ~:3 ..:::;:: - .... :j s. ~ .;. 9:. Q) S. ~ ~5' "'t 0 0.0- :3 -, -0 tl) co ~uJ$.2. (J) ~ S~ ~~~ \\ ()~(O ~. C) g. -\ g.(') ~ :0 d) mOCD "~ Q.l 0 aU) \\ ,." 9.. g. c 9- :1JW;s. 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'(ij '2.9 ~Q)13 iii~~ ~~U> 0" ~Q)O,I ._- u<( ~ai~ .::"n;.3f: ::;;<0 u <= " " Q. _<n .6:g, 0< <: o ~ ~ ~ .!!! :E "5 ~ ~ 0> ';; o ~ ~ ~ 00 =..c: e~ g:g ~ ~ ~ .2 '='~ u.9c: "cO :s "5. 1: E V,I Q) {) _o~.6=G O';:~UlIJ) -:E!2Q)"~ '-J::: <3.5 [!) .!!!"O; C>> E:o'E o_.2:~ 7" ~us~<;! .~-o~<3 ~8 u3 - 20 ~oooo o . ~ . a;Qi' <D c.S .5 ~~ 'ii a:llU- g} .a.o~ .0 00= g ~~~ E .a.3~ .3 a) ,g.g.g g. i! ... as c: !DC j~a C' :g;2 0-0 ~ g 'U;.2 ~~-;-Q ~i 5o~r; O)~ ~B=~ ~ a'1Il oaiaffi ..=mlDr;nc<n'Q)_ ~5;e8.3~3~ :::16' ,~ 015 a u... u... ~ "'0 0 o " " > - ll~ en ~ - '" '" 5: '" ~ ,.;. ~ '" a: on '" II ... M '" ~ '" .. '" 0> " '" 0: "" :2: ;;; ;: c= M c; ,.... <t en '" u en ~ '" <t= '" " 9 :=) '" u= .. en '" 0_ ::J '" ~- .5 ,'" :E~ 'E <t~ ~= a:: :;; <<= 0 ~ " <t '" ~ ~ ::2 ... << 5 '" '" "'- ~= <t ~ '" c== II M '" ~= 0 :2: ,.... ~ U 0> ,,; a <t ~ ~ u ~ c== ::2 u c= <3 <C '" ,.. .Q '0 ~ ~ " ;; ~ .. ~ a: J' C a: " ~~ 2: " s !J o - ;: '" 0. !- II -;. 0. u '" '0 " Q. '" 8, < ~OOOO o '" " 0> c 0. ~ c ~ " ~ E ~ 1ii ~ "C ~ " " > 15- ,,; 0> ~ ~ E " .Q " 'iij u :g 0 ;; ::J a. E '" ~ c " 2:- i5 " ::;; ~ .. :E ~ " " E " '" " ~ :; .. '" 1;; '5 .. E " - ~- ~ ci 0<:0 c C).2 C1 iii .; ~ - ~ ::. _ CC1__ " C " u" 1;; -" ~.- ~ ".. () 'iij -0)_0 0- ~E~= ~ :; M Q)... 0) C..l " "00"0(1) '3 g c_cc. ~ :2::3-g::.cn 0. D M III en ~ ((J CD ~ > lDc:CUcn .Q D W ~ = eo. .~ Q).!:::! <( 0 g cu-;;Ea;":: D "O.e--e~ ::;; 0 '" Q) cu g>Q) 5 iri ~ "" "3:>.....> u :;; <( ~ ~ 0 m 0 '- " '" .,. ~O DO opo ",000 &! DODO Ii; c 0 ;; ~ w D' 0 0 c: 0: a. ADMIT DATE I TIME ROOM NO. ?T DATE OF BIRTH ADMISSION RECORD rr~ 24" Parker St. Carlisle. PA 17013 Ph;717-249-12] 2 N . 0000825381 06/17/2005 12:06 0000 E1 11/21/1954 PROGRAM P A T PA.TIEN NAME ADORE I MACNAMARA, E 306N WEST N CARLISLE T US SUSAN ST SS NUM ER PATIENT EMPLOYER 210-44-3603 RITE AIDE PA 17013 PHONE NUMBER (717)243-2098 COUNTY CUMBERLAND R NILe A A G MACNAMARA, U 306 N WEST A R UM NILeAYMLY RITE AIDE 5280 SIMPSON FERRY RD MECHANICSBURG PA 17055 L H SUSAN ST 210-44-3603 (717) 691-6200 CARLISLE US EMERGENCY CONTACT NAME PA 17013 PHONE NUMBER (717) 243 -2098 EMERGENCY CONTACT PHONE RELATIONSHIP TO PATIEN PATIENT IS EMERGENCY CONTACT RELATIONSHIP TO PATIENT HATT, DIANE (717) 243-6650 FRIEND C MMENTS MS? Dv Il'IN MED. KEY Dv Il'IN PRIVACY NPP ADMIT. BY Y CLC PRIVACY I 1 917 INSURANCE CO. NAME &. ADDRESS USAA - AUTO INS PO BOX 659466 SAN ANTONIO (800)531-8222 ATO U CLAIM 6209823 INSURED' NAME MACNAMARA, SUSAN I 11/21/1954 N TX 78265 NU NONE NA AUTHORIZA ION s U 2 IN U AN .NA R A N I URAN C E A R PLAN LI NV o IR / / IN U NAM ROUP NUMBER GROUP NAME AU HORIZATlON ?lAN P 1I Y NUMBER DATE Of BIRTH / / "", " " , '""'" GR UP NUMBER R U NAME AUTH IZA nON M DR. AT ENDING j ADMITT1N I S C CORDLE, RANDOLPH J " \ ". DR. AMILY { PRIMARY ARE M ( / / KRETZING, HAROLD G IA A N NO FAULT A 1M N A I N A 06/09/2005 SUTURE OR STAPLE REMOVAL PRINCIPAL DIAGNOSIS (The condition established after study to be chiefly resjmnsible for occasioning the admiSSion of the patIent to the HOSPITAL for carel. COMPLICATIONS CQMORBIDITY(lES) PRINCIPAL PROCEDURE A0001A 9313457 0000825381 11111111111111111111111111I1111111111111 1111I111111111111111111111I1111I1111111111111 MEDICAL RECORDS COPY 1[11111111111111111111111111111111111111111111I11111111111II CARuSIE RECIONAl MEDICAL CENTER Patients Presenting to the Emergency Department for Procedures Not Requiring a Medical Screening Examination You have presented to the Emergency Deparonent for the following procedure(s): o Blood Pressure Check o Ongoing Immunization o Employer Requested Urine Drug Screen o J"ergy Shoes ~uture/Staple Removal o Forensic Collection You are also entitled to a medical screening examination by a physician or physician assistant in our Emergency Department. By signing below you are declining the option of a medical screening examination because you have come only for the above checkedprocedure(s). Should you decide that you wish to have a medical screening examination along with the above procedure(s) itwill be provided. You also agree to wait 30 minutes after your injection to be monitored for complications. I, S I,cSc- '" ('\GcL'u~~JY'\~'\..r(L. , have declined a medical screening examination. (PatICTIrsName) I am declining the medical screening examination because I have presented to the Emergency Department for only the above checked procedure(s) and do not require any additional medical screenings. I understand that I am entitled to a medical screening examination when presenting to the Emergency Department and it will be provided upon my request. (Parient'~ Name) ^ . Me}'- re~ (Witness) 6/17/0)- (Dale) ER 1640 (114/11&) Carlisle Regional Medical Center Instructions: circle ositive - backslash oe ative. rovide additional ertinent information. NAME: MACNAMARA, SUSAN DOB: 11/2111954 Age: 50 Yrs 0 Mos 0 Sex: F Wt: 57.7 KG Ht: Chief Complaint: SUTURE OR STAPLE REMOVAL Medicines: ADVIL Wks pt#: MR#: 9313457 0000825381 DATE OF SERVICE: 611712005 Pres Time: 12:06 Triage Time: 12:27 T: 97.2 PO P: 67 Regular R: 16 Unlabored BP: 1271078 Sa02: % Normal I Hypoxia Pain Scale: 0 " Allergies: NONE EDP: CORDLE, RANDOLPH PCP: KRETZING, HAROLD G Arrival Mode: WALKED HISTORY OF PRESENT ILLNESS Exam Time: Ii~by:. Patient Family EMS NH Translator l.irni.te~bY:J ALOe Intoxication C I C I HPI: (Narrative): EMTALA Me~l~~_~_~c!~en~___ _~~~.~_~~~-O~::'~~~.~_~_~~~'~~~]:l~_.._. __" Severity Dementia Ti~ing: Sx started suddenly I gradually _ min. I hrs. I days I wks. ago ; continuous / intermittent Du~ti~n(,---'Sx last _ min. I hrs. I days I wks. at a time : present I absent Lo~tio~n:~;---- --'-' .---------- QlIality:-" cannot describe se~~ritY~-.'.mild---moderate c:o~te~t:; at rest activity Exa:~~~1~_~~~_~~/-~~~0,i.ng -- Assoc. Signs & Symptoms: stable improving worsening - ----_.._._-_..._-----~~------ severe 1-10 scale . -----Rell..~ed by:'--nolhing--- - ------.. -- none C.P. S.0.8. N I V F I C REVIEW OF SYSTEMS ~i~(,t":(tQlJeT~: ALoe Intoxication Severity Dementia co~stj'~ji:~~'~IL'~__f~~e~~___~~~~ ,_,_~~~~_e=-s ....._._~~E_~?!::!~_ _.._=~~:~!~eJP_~t~fD"'.""HA-- ,_~eizure~ak~~s confusion ENT:i sore throat ear pain facial pain Psy,~tl~Io,9h:;a'::. anxious depressed --- E)ie'5j:::' pain visual changes __ _.__~~.~,g~~tth~.~__E.?~Uri~___~~~~_i~~~....._._______~ Car~i'~X~;C'Ulat-.-c:p~-----pa'lpTtations DOE PND ! !ri~e'g~men~::; rashes pruritis lesions --~------.-------- Res_~Lrat-orY':.; S.0.8. ~~gh ___~~_~n~!:_~~_~~.,~~. _ _ _____.._m. __~__j~~!.B~J~;t~,~lsL" _anemia ___ bleedi~ ~jsord:':.~ _ ~ ~~nsfu~~~~~_ ____ GI~;" N I V diarrhea I constipation pain melena hematemesis i ~I~t~Wlrii:m:;; frequent infections allergies hives GU: flank pain dysuria hematuria frequency 9:t~t'-r: M u~cUIO~k~i;rtal:f --join't' pain neck / back pain e~t: pai'n----".'- '''----------.,-''--..-----,,--------~- . . . O-Aii.'Oth'er-Syste'm's"-Reviewed' A'nd'-Are---Neg.aiive"'.. O-.Agre'e"iAijih--Nurs-ing-'As'sess'ment MEDICAL AND SOCIAL HISTORY MEid. Hx: none ..............................-. Past Med. Hx: Meds: ADVIL CAD MVA HTN IDDM I NIDDM COPD o Reviewed Allergies: NONE o Reviewed Surg:Hx: none Appy Chole Hyster Family Hx: negative CAD 100M I NIDDM CA Social Hx: Tobacco: Y / N _ Packs/Day _ Years Occu'patlon: Immunizations: Up-to.date: Y I N __ _ "._.l:L~~:!:.~e~" R I L Handed Lives Alone: Y I N ETOH: Y I N DrinkslWk. Drugs: Y I N Tetanus: Reproductive Hx: LMP: G P AB Pro-MED Maximus QC,Jpynght 2001 PrO-MEO Clinical S~Slems, LL.C General Adult - Page 1 of 2 Rev_Cl3l05J04 Carlisle Regional Medical Center NAME: MACNAMARA, SUSAN (Instructions: circle positive. backslash negative, provide additional pertinent information.) GENERAL: NAD mild I moderate I severe distress HEENT: NC / AT PERRLA EOMI JVD Bruits -------------- ---------------...--..-..------..-..---.--- CV: RRR PMI NL murmurs /6 sys / dys rubs clicks gallops S3/ S4 VITAL SIGNS: T 97.2 P67 R16 BP 127/078 Location/Description of Symptoms: RESP: lungs clear I equal bilateral rales rhonchi wheezes rasp. effort NL / distress r---\ ,r::::.,l,' ..;:...l ,-!.. --, . .( , (I GI: soft flat I distended bowel sounds NL I ABN tender I non.tender guarding rebound rigidity MS: ROM NL clubbing cyanosis edema SKIN: warm - dry diaphoretic rashes NEURO: CN 2-12 intact DTRs equal/symmetric PSYCH: AAO X3 mood I affect NL LYMPH:' adenopathy NL I deferred )~ C-~ " " MEDICAL DECISION MAKING +-< ~;~f':,h~t~~::~:i:i;',..';;;!*".f}_o~'FK;~;H,;;i1Hf'l;i);;:8J;;ABS:'AND' STUDIES ':';~:;';":f:'::;; o Labs reviewed and are negative X-Ray: 'U 2--< . ._____ ~>f.;;' ;, ,;'.,hnv4~.:~r:;~-.,::;f!+~~.:~:.:~i[~,:~;!rJ\tP~.;.'.{.f~~A;,~:_l:D._COURSE' AN[)-i,TX:;'Ji:~_,:~~;j8~;:. '~~i'."i-' MEDS: CXR: NL infiltrates IVF: NL/ ABN NL/ ABN DIFF s EKG: NSR no acute disease RE-EVAL: Time: L Pulse Ox: '%"r;.iC""T 'h'ypoxla Improved Worse ABG: pH 02 C02 Critical Care: 30-74/75-90 I 91-104/105-120 ---------~--,,--,._------~----""-------- 121-134/135-164 Minutes Excl. billable proc. 1. 2. 3. 4. 5. Discharged to: Home Nursing Home Follow-up with Patient's Dr. in Other Instructions: Family days. CONSULTATION DISPOSITION Discussed with Or. Admit Follow-up in Office Old Records Reviewed Y I N Reviewed OIW R~diologist Y , N Case OIW Patient I Family Y I N Discharge Time Out: Admit: aBS ICU PCU Floor Tele. OR Prescriptions Given: Transfer: AMA: DOA: Condition: Improved Stable Deceased RETURN TO ER IF CONDITION WORSENS. - See procedure form attached 0 MD/DO Record Complete 0 General Adult - Page 2 of 2 Rli!v03IQ5J()4 Signatures: PAlARNP Pro-MED Maximus QCoPvngh12001 Pro-MEO CIi,,"cal Systems. LLC -:;-- ~ "; Order Time rder; San Bv Drder;Iim Radlolog~ Order Sent B~ CBC CXR IPAlLAT- Portable' BMP CMP ArT1VIase Abd. (ftat & upright) Drug screen (serum), (urine) ETOH Liver orafile Magnesium Glucose (bedside). (serum) Ciii"dl()oulirioniiiii UA "Kr: ABG 02 LPM Mlsc;' Orders Medical. N.c~~sitYlrifoirl1atiori: , Previous Medical Records Physical Therapy - Eval & Tx :ij'(~"ij!_ .1~~~13?';$!::_~ kg$';57:7.,., ~rd~f;';;;~:~;ci.donl'PQsagel: Rou18@'i! Vp :!,Read BaCk"lAdiritim.Ailiriiby <<S1~1'iirie'''',;!i:,:i!N,ReaSSes$rn''l)t;:!l;',-1~~F'ell); Il)iti~I$ 0 b Improved 0 Worse o Unchanged 0 b Improved 0 Worse o Unchanged 0 ::J Improved 0 Worse o Unchanged 0 :J Improved 0 Worse o Unchanged 0 :J Improved 0 Worse o Unchanged 0 :J Improved o Worse o Unchanged 0 :J Improved 0 Worse o Unchanged Order;Tirr'1e .'::'I'WlSollJtion.'(Md~' MedicatiOn;'" SlattIime Oevfc:e(SlzeiLocation.AllernptS !Iil1(llJnl 'start bY,; ;OIC Time <!~'Arnlll1fusedJ~'~, O(Cby OKVO Device: OIV Fluid: ~ ~ 0 Cardiac Monitor: Rate Rhythm: 0 NGT Insertion # Fr. 0 Endotracheal Intubation 0 NIBP Monitor 0 Gastric Lavage 0 Cardioversion 0 Pulse Oximetry 0 Central Line Placement 0 Oral Airway Insertion 0 Urinary Catheter Insertion: #- Fr. 0 CVP Monitoring 0 Oropharyngeal Suctioning 0 CPR , "'"o"org" ":i ,:,',.~ ~ ~ Initials/Signature: I Initials/Signature: nitials/Signature: II;YJ}a~ig'fi'r"(} y"- PAlARNP: Physician's Signature: ORDER PROCEDURE FORM MEDICAL EMERGENCIES (. lisle Regional Medical Center Name:MACNAMARA, SUSAN Pt#:9313457 Age: 50YRS DDB: 11/21/1954 Sex: F MR#:0000825381 EDP: CORDLE, RANDOLPH PCP: KRETZING, HAROLD G Date In: 6(1712005 Time: Rev,09/14104 l..drlisle Regional Medical Center Name:MACNAMARA, SUSAN Pt#:9313457 Age:50YRS 008:11/2111954 Sex: F MR#:OOOOB25381 EDP: CORDLE, RANDOLPH PCP: KRETZING, HAROLD G EMERGENCY DEPARTMENT ONGOING NURSING ASSESSMENT Date: 6117/2005 NURSING DIAGNOSIS.(Numbe( in oederof priOlily.Eac~. palj~ntl11ust~ave at leastpne,selected.I;:t'I:, ":.;"\,;,;'o":!"::,:,.".. Airway Clearance, Ineffective Communication Impaired Infection, Potential Self Care Deficit Anxiety -Coping, Ineffective InjUlY. Potential -Skin Integrity Impairment Breathing Patterns, Ineffective -Fluid Volume, Alteration in -Knowledge Deficit Thought Processes, Impaired ~gardiaC Output. Decreased Gas Exchange, Impaired Mobility Impaired _Thought Processes, Alteration in Comfort, Alteration in ~yperthermi5 (Fever) _Non-Compliance _Tissue Perfusion. Alteration in Other Other The GOAL! PLAN: 'for thisoatie'nt is' to assist in meeting'rdentified needs'and initiate iriterJentionsfor I to:' ,<,',,:",,';C"~':'f'>' Not Nol Nol Met Met Inl Met Mel Int Met Met Int o FB REMOVAL o IMMOBILIZATION I PROPER ALIGNMENT o IMPROVEMENT OF BREATHING o BLEEDING CONTROL o DECREASE I PREVENT SWELLING o STABILIZE PATIENT IN DISTRESS o PAIN CONTROL o MAINTAIN STABLE HOMEOSTASIS o meet ENVIRONMENTAL NEEDS o ALLEVIATE NN o MAINTAIN SKIN I TISSUE INTEGRITY o meet PSYCHOSOCIAL NEEDS o FEVER CONTROL o PREVENT FURTHER INJURY o meet SELF CARE ABILITY NEEDS o DECREASE ANXIETY o MAINTAIN f IMPROVE CIRCULATION o meet EDUCATIONAL NEEDS o SAFETY IN THE EO o INFECTION CONTROL o Other Int: N = documentation in nurses notes, other 'codes' per Hospital Policy. I'.'~.":'.;< r;1i;~llir.:' "i:"""'i";~'Hi::i "i"'",,,,.,;,,, ":,Hi,: ;, f"p:\ r'~' :0'6;;!I, 02' N(3I' ::Cardia~ :i "'tSc""*' ~ ~~ '<" "Ii .'i' [;rime 'J;, sat Emel?l~ : MonitOr~ O~(,~ /3& /ll.I...{ ,/,,- /'1J ,,4eLL- /1.{., 11... - ' tn, hip,) " J '- A" ;::'''It''\. IL.\.... r-lAc -/.0 J4 ~.( <- , ~ uk,' I.~ ' \ (.,ui 7- ~ 't Vu.. 'J J"'JI,dZ . kht-I tl..W t<-- 4lh<.f/JS o JI.{.IJ.......! Iu'-!.. C , f ~kJ L v:, (f)--t a.u2.w C..lLl{/flA-<..L _ .3 muL,; L Le.- II /l / ,., I. ,; y .tvL I.:.ut.. ? c(j JJ. .. f ,l.- I ..(.~ rl1 ;, , ,iJ ~ I.t C' VkltL L- ..i ..<JO..!..LA-1 .(. "iL U.oJ /I t/).t [.,L 11", " (2 ---<'(]c/}/,It/i)..r.'v,J- 'nryj.t l-1d II -?11, I L., ;; - V)U I fA' .t'>i /1. V 1./1, .s .../ r (' 4,,,,-- fi- I / h-" L U .cJtd...-l..Uu:' --e.'-L- de. 1/4. /I. -'Yl' 1/"'-"-- /1..LL ,,~ . . , 0 ;;: I- ..iJ , It\ / f.^ J ~"L ' . .' Co ..:)j.(v.. J).:7 Ii' ...J I ~ c: /I J It L~') oL ;)"fl- "'I .( .L, ~. i/l-vL ~ f /hClAL-f...) ; .l .t.1/ _, .I; .1, 1.11. ,,{ '/},1 'Yh -If 1l.L 1.1 J J.( z./-t.C'C,>,.) ';y A..",l,c, . (.....t.<....,-.J...J, .0- / 1'J'vC '~<./ .:;1 f-rJ~ U () f I '), i~, ~ Discharged in care of: /1" j ~mb 0 W/C 0 Stret 0 Carried Discharge instructions given to II (c '\. . yerbalized understanding Admit: Room #:_to Dr. Ready for Room Time:_ Report called at and given to Transfered to o Transfer Verified Report called at and given to o Left without treatment o Left Against Medical Advise Condition at Disposition: 0 Improved OStable o Serious o Expired Pain Scale: E- Pain Location: -- Patient reports that pain is: o Improved o Unchanged o Worse Disposition Vitals: T P R BP 02 - Disposition Dale: ";f '7 Time: 13/0 Nurse: fL--f {./'-- Rev. ()Jj05,04 EMERGENCY DEPARTMENT PRIMARY NURSING ASSESSMENT /<,.,:::;1 Oaleln:611712005 Time: (0-<..' V t;arlisle Regional Medical Center Name:MACNAMARA, SUSAN Pt#: 9313457 Age: 50YRS 00B:11121/1954 Sex: F MR#:0000825381 EOP: CORDLE, RANDOLPH PCP: KRETZING, HAROLD G Subjective Notes: { /.li. .(71.. ,U~ A ltu;'tL Pain . !:lP'atienldenieS painy.:},.',::::....:I't:,.:.:,ii':::.....,,: ."i:" ":"':::.",':::! Localion:'V Qualily: oSharp ClOuil ClCrampingJBuming ClAching Provocation: oOther: Radiating: oNa aYes (specify) oeonstant [JlntermiUent ": .' ...,....:. '" ,'.0 ,,'.':>,'.: Severity Scale: Onset: Aggravating Factors: Relieving Factors: Psychosocial.":"" :c:W" . "',"'..;...'"",:::' . "'::",:;.,' '. ..:>! . ',':.,:::.\.,/'.,,!:'... . ,:."':"...,H , ':':';:". Appearance: dqean oUnkempt o Other Envi(onment: ClNa steps 0 Few steps 0 Many steps Mood I Affect I Beh'ivior: o Appropriate 0 Depressed oAnxiou5 Nutritional status: 0 Normal 0 Cacl1etic 0 Obese ClT~rfUl oOther Religious I Cultural preference: oNone (specify) Caregiver: elf o Family member oSlgnificant Other o Group home Best learn by: o Verbal o Written o Return demo Activity level: . bulates independently o Requires assistance aNon-ambulatory Learning Barriers: oTDD phone olnterpreter oNo oYes Performs ADL's independently o Requires assistance with AOL's oOther: ...,,,,.,,',iir. 9astr~i~t~tinal ,""c;:;/""':.'" ~Iert Cl)lliented X 3 O!;toperalive Cl Awake but Confused Abdomen: Cl Soft Cl Flat b Uncooperative ClComba,ri~ Cl Agitated Cl Restrained Cl Non-Tender ClTender (Area) Responds: 0 To Verbal 0 To Pain 0 Unresponsive Bowel Sounds: 0 Present 0 Decreased 0 Absent Posturing: 0 No 0 Decorticate 0 Decerebrate Elimination: 0 Normal oConstipation oDiarrhea # of Stools: Pupils: I Brisk I Sluggish I Fixed I Pinpoint I Oilaled I " ;:: ClRigid o Distended Extremities: RUE LUE RLE LLE ("}i....(:..':::'/".", ~ Urine: 0 Colorless 0 Yerrow 0 Red o Anuria 0 Dysuria 0 Hematuria Vaginal OIC Cl No LMP: Penile OIC Cl Yes Type: 0; o Brown oCloudy oFre,C1uency 0 Urgency I,.;' Movement: Q=None 1=Barely Breaks Gravity 2=Weak 3=Strong Sensation: NR=No response DP=Deep pain MP=Mod pain L T:::Ught touch ~'~:,~i.f.~=?illli .1:~?~~~::;7;~:~7" Turgor: 0 Normal 0 Decreased Bleeding: o"Absent a Present 0 Scant 0 Moderate 0 Heavy 0 Pulsating Pulses: R L ROM: 0 WNL 0 Decreased 0 Absent Carotid Edema 0 Absent 0 1 + 02+ 02+ Deformity [] Yes 0 No Brachial Scars: DYes oNo Distal pulses: C)Absent a Present Radial Femoral Popliteal Dorsalis Pedis S=Slrong W=Weak O=Ooppler A=Absent RespiralQlJ ':,; Airway: . q;ciear Cl Other Effort: ~;abored 0 Labored Cl Mildly Cl Severely I 0 Retractions 0 Stridor 0 Nasal Flaring o None 0 Productive 0 Non-Productive ~re,HosllltaICar..:ji oCPR o Intubated o Ambu-Assist o Mask o Nasal Cannula o02@_lpm_% ,:\;,::.:::l;;t;kbil2~~;r::i;~',;.i:~~ifJ;:um,';~~\i~:,~;;~fPI~n~PClKtjgvly(t~ PASGClNollnflaled IV I ype Aml musea ClLegs Inflated ClAbd Inflaled Cough: DC-Collar Cl Backboard o Traction oSplinl Medication AmI Roule Lung Sounds: R L t Comments '. ..~:;;.,,;'-,-,.. Clear Wheezing Crackles Rhonchi Decreased Absent Vital Signs: T: 97.2 P: 67 Regular R: 16 BP: 127/078 Nurse Signature: )/11 (/ '-- . ,"',,)Z,N.~'" INITIAL ASSESSMENT FORM 4 Non-Urgent / ~arlisle Regional Medical Center Pt#: 9313457 Sex: F MR#: 0000825381 DATE: 06/17/2005 DOS: EDP: PCP: MACNAMARA, SUSAN 11f21/1954 AGE: CORDLE, RANDOLPH KRETZING, HAROLD G 50YRS PRIORITY: Patient: Worker's Camp: Emp. Referred: Presentation Time: 12:06 Triage Time: 12:27 Arrival Mode: WALKED Height: Chief Complaint: Weight: 127.0 Ibs. 57.7 kgs. LMP: SUTURE OR STAPLE REMOVAL Last Tetanus: Ace Sy: Vital Siqns T: 97.2 PO P: 67 Regular R: 16 Unlabored SP 127/078 02: % RA Pain Intensity Scale: 0 f 10 Pain Location: Denies Pain Srief SEEN HERE TURSDAY AFTER MVA, HERE FOR SUTURE REMOVAL. ORTHO FOLLOW -UP 6128 Assessment: NIGHT SWEATS WEIGHT LOSS ANOREXIA NO NO NO HEMOPTYSIS FEVER NO NO SAFETY NO Sudden Onset: Pre-Hospital NONE Treatment: Pediatric N/A Assessment: Past Medical MV A History: Allergies: NONE /J t lu:vJ! t( (I'\.U,(C 0-( 'I u /)'7//1. ULd ..J r11t j ift~ ~LJ Medicines: AOVIL Nurse Signature: 'fM. {)~_ MCO /~ 3:{] '-f,r; /:/bJ C", L. /) 1i\..Si\ I I ~' Additional Notes: Rev 05/18/04 cz-~ 246?!ltlceiSr. C.:ltlisle, PA 17013 Ph;717-249-1212 CONDITIONS OF TREATMENT AND ADMISSION PATIENT'S NAME ACCOUNT NO. MACNAMARA, SUSAN 9313457 ATTENDING PHYSICIAN CORDLE, RANDOLPH J DATE & TIME OF ADMISSION 06/17/2005 12:06 CONSENT TO HOSPITAL CARE AND TREATMENT 1 AM PRESENTING MYSELF FOR EMERGENCY SERVICES OR ADMISSION TO THE HOSPITAL AND I VOLUNTARilY CONSENT TO THE RENDERiNG OF SUCH CARE. INCLUOING DIAGNOSTIC TESTS AND MEDICAL TREATMENT, BY AUTHORIZED AGENTS AND EMPLOYEES OF THE HOSPITAL. AND BY iTS MEDICAL STAFF, OR THEIR DESIGNEES, AS MAY IN THEIR PROFESSIONAL JUDGEMENT BE DEEMED NECESSARY OR BENEFICIAL TO MY WELL BEING. I ACKNOWLEDGE AND UNDERSTAND THAT MANY OF THE PHYSICIANS ON THE STAFF OF THIS HOSPITAL. INCLUDING THE ATTENDING PHYSICIANISI NAMED ABove. AND RADIOLOGISTS. ANESTHESIOLOGISTS. PATHOLOGISTS AND EMERGENCY PHYSICIANS, ARE NOT EMPLOYEES OR AGENTS OF THE HOSPITAL, BUT RATHER ARE INDEPENDENT CONTRACTORS WHO HAVE BEEN GRANTED THE PRIVILEGE OF USING THE HOSPITAL FACILITIES FOR THE CARE AND TREATMENT OF THEIR PATIENTS. I AGREE TO ACCEPT THEIR CARE EVEN THOUGH THEY ARE NOT EMPLOYED BY THE HOSPITAL I UNDERSTAND "tHAT THE EXAMINATION AND TREATMENT THAT I RECEIVE ON AN EMERGENCY BASIS IS NOT INTENDED AS A SUBSTITUTION OR REPLACEMENT FOR COMPLETE MEDICAL CARE. CONSENT TO RELEASE INFORMATION I HEREBY AUTHORIZE THE HOSPITAL TO DISCLOSE TO INSURANCE COMPANIES, INCLUDING WORKERS CQMPENSAnON CARRIERS, OR OTHER PARTIES THAT MAY BE LIABLE FOR AllOR PART OF THE HOSPITAL CHARGES, ALL OR PART OF MY HOSPITAl RECORDS AS MAY BE NECESSARY (INCLUDING ANY TREATMENT FOR ALCOHOL OR DRUG A!3USE OR DEPENDENCE), TO DETERMINE BENEFITS ENTITLEMENT AND PROCESS PAYMENT CLAIMS FOR HEALTH CARE SERVICES PROVIDED_ MEDICARE CERTfFICA TlON RELEASE I CERTIFY THAT THE INFORMATION GIVEN BY ME IN APPL YtNG FOR PAYMENT UNDER THE TITLE XVIII AND TITLE XIX OF THE SOCIAL SECURITY ACT IS CORRECT, I AUTHORIZE ANY HOLDER OF MEDICAL OR OTHER fNFORMATJON ABOUT ME TO RELEAse TO THE SOCIAL SECURITY ADMINISTRATION OR ITS INTERMEDIARIES OR CARRIERS ANY INFORMATION NEEDED FOR THIS OR A RELATED MEDICARE CLAIM. I REOUEST THAT PAYMENT OF AUTHORIZED BENEFITS BE MADE ON MY BEHALF TO THE HOSPITAL OR TO THE PHYSICIAN WHO ACCEPTS ASSIGNMENT. PERSONAL EFFECTS AND VALUABLES t UNDERSTAND THAT THE HOSPITAL SHALL NOT BE L1A8LE FOR THE lOSS OR DAMAGE OF ANY PERSONAL EFFECTS OR VALUABLES lMONEY, JEWELRY, GLASSES, DENTURES, DOCUMENTS, CLOTHING, ETC,) UNLESS SUCH ITEMS ARE DEPOSITED IN THE HOSPITAL SAFE. THE HOSPITAL WILL NOT BE LIABLE IN EXCESS OF $50 FOR THE LOSS OR DAMAGE OF ANY PERSONAL EFFECTS OR VALUABLES DEPOSITED WITHIN THE HOSPITAL SAFE, ABOUT YOUR BilL I UNDERSTAND THAT I WILL RECEIVE A BILL FADM THE HOSPITAL FOR PROVISION OF THE HOSPITAL SERVICES, lNCLUOING STAFF AND EQUIPMENT, AND FOR ANY SUPPLIES OR MEDICINES UTILIZED, I WIll ALSO RECEIVE A BilL FROM ANY PHYSICIAN WHO PROVIDES PROFESSIONAL CARE TO ME. FOR EXAMPLE, I MAY RECEIVE A SEPARATE BilL FROM ONE OR MORE OF THE FOLLOWING TYPES OF PHYSICIANS WHO RENDER SERVICES TO ME: MY ATTENDING PHYSICIAN OR PERSONAL PHYSICIAN, EMERGENCY ROOM PHYSICIAN, RADIOLOGIST, ANESTHESIOLOGIST, PATHOLOGIST, OR ANY OTHER SPECIALIST. INSURANCE ASSIGNMENT I HEREBY ASSIGN TO AND AUTHORIZE THE HOSPITAL AND PHYSICIANS INVOLVED IN CARE DURING THIS PERIOD OF ILLNESS OR TREATMENT {HEREINAFTER "PHYSICIANS"}, OR THEIR DULY AUTHORIZED ASSIGNS TO TAKE ALL NECESSARY STEPS, WITHOUT UMrTATCONS, TO ENSURE THAT ANY INSURANCE BENEFITS OTHERWISE PAYABLE TO ME OR MY ESTATE ARE PAID DIRECTLY TO THE HOSPITAL OR PHYSICIANS. THIS ASSIGNMENT OF INSURANCE BENEFITS INCLUDES aUT IS NOT LIMITED TO BllLJNG INSURANCE, FILING PETITIONS, FILING SUIT, IN MY NAME OR ON BEHALF OF THE HOSPITAL OR PHYSICIANS, FILING PROOFS OF CLAIM, FILING PROBATE CLAIMS AND FlUNG GRIEVANCES AND ALL OTHER; SIMILAR PROCEDURES, AS MAYBE AMENDED FROM TIME TO TIME WITH THE STATE DEPARTMENT OF INSURANCE. I ALSO AGREE TO PROVIDE AND SIGN ANY OTHER DOCUMENTS THA T MAYBE REASONABLY NECESSARY TO ACCOMPLISH ANY OF THE OTHER PURPOSES, STATEMENT OF FINANCIAL RESPONSIBILITY \ UNDERSTAND THAT I AM FINANCIALLY AND LEGAllY RESPONSIBLE FOR CHARGES NOT COVERED IN FULL BY ANY THIRD PARTY. I FURTHER AGREE THAT SHOULD I NOT PAY THE BALANCE WITHIN THIRTY (30) DAYS AFTER THE DATE OF DISCHARGE, MY ACCOUNT WILL BE CONSIDERED DELINQUENT. I AGAEE TO PAY COSTS OF COLLECTION, INCLUDING REASONABLE A nORNEY'S FEES AND COSTS, COLLECTION AGENCY FEES AND caSTS, AND INTEREST WHICH SHAll ACCRUE AT THE MAXIMUM RATE ALLOWED BY LAW. ~ ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURANCE COMPANY. OR FILES A STATEMENT OF CLAIM CONTAINING FALSE, INCOMPlETE OR MISLEADING INFORMATION MAY BE SUBJECT TO PROSECUTION UNDER APPLICABLE LAW. ADVANCE OlRECTIVE IFOR ADMISSION TO HOSPITAL ONLY) IF I AM TO BE ADMITTED TO THE HOSPITAL, I HAVE SEEN GIVEN WRITTEN MATERIALS ABOUT MY RIGHT TO ACCEPT OR REFUSE MEDICAL TREATMENT. I HAVE BEEN INFORMED OF MY RJGHTS TO FORMULATE ADVANCE DIRECTIVES. I UNDERSTAND THAT I AM NOT REQUIRED TO HAVE AN ADVANCE DIRECTIVE IN ORDER TO RECEIVE MEDICAL TREATMENT AT THIS HOSPITAL. I UNDERSTAND tHAT THE HOSPITAL AND MY CAREGIVERS WILL FOLLOW THE TERMS OF ANY ADVANCE DIRECTIVE THAT I HAVE EXECUTED TO THE EXTENT PERMITTED BY lAW. !INITIAL THE FOLLOWING OPTION THAT APPLIES} - I HAVE EXECUTED AN ADVANCE DIRECTIVE AND WILL PROVIDE A COpy OF THIS FOR MY MEDICAL RECORD WITHIN A REASONABLE AMOUNT OF TIME, -I HAVE NOT EXECUTED AN ADVANCE DIRECTIVE AND DO NOT WISH to 00 SO, INIT, INIT, (FOllOW-UP DONE BY DATE - I WISH TO COMPLETE AN ADVANCE DIRECTIVE DURING THIS HOSPITALIZATION. INIT. I CERTIFY THAT I HAVE ~EAD lOR ~VE SEEN RE~~!.2-HE ABOVE CONSENTS AND CE~:IFICA IONS AND. U~~J:~STAND,M~ AGREE WITH THEM. DATE, 0 ~ 0, ' '/Y'./ ,lLe / W;Y'i'. '. MONTH ("') JAY YEAR SJ~ RE OF PATIENT OR LEGALlY AUTHORIZED REPRESENTATIVE '--- L-f' 7 GF1Aifj I WITNESS PFlINT NAME OF PERSON ABOVE AD001B 9313457 0000825381 \\11\1\\\1\\111\\11\\11111I1111111111111 111111111111111111111111111111111\\11111I111I 1111111111111II~11111111'llIllilIllll~llmlllllllllllll 209 State Street Harrisburg, Pennsylvania 17101 717 .232.6300 FI'.x 717.232.6467 www.srklaw.com i 528 Walnut Street, 3rd Floor Pr.iladelphia, PA 19102 215.790.7303 VOICE 215.546.0942 FAX Sch' . 'dt R.'~ & K"'l' "'- ",~ ' . ,fill a..JJ.lCa . .L........(::~.L:lI.....~________ 'INJURY LAWYERS PLEASE RESPOND TO HARRISBURG OFFICe._____.__< Affiliated Law Firm - Shener, Ludwig & Badey, PC. Philadelphia, PA June 29, 2005 h/A-- /' ~\t\<:>\ Carlisle Pediatric Associates Attn: Medical Records Department 804 Belvedere Street Carlisle, PA 17013 Re: Patient: Markus R. MacNamara DOB: 10/28/1991 SSN:' 205-72-5653 Treatment dates: complete file Dear Sir or Madam: Please be advised this firm represents the above-referenced patient. Please forward to me copies of all medical records and itemized billing statements relating to the care and treatment of the patient for the above-referenced dates of treatment. I have enclosed an executed medical authorization permitting the release of this information. If you have any questions, please feel free to call me at any time. Very truly yours, SCHMIDT, RONCA & KRAMER, P.C. ~ ~- ./TerrySJ1Yman TSH/ jss Enclosure ,rlisle Pediatric Associates Vaccinatior ;r.:j Name I1lorku'> mll[/l/a,.n,',rt'~ Parent Name Address Birth Date lo"d'~-{il Da,e First Seen Sex t<\ Insurance Phone Number I have read or have had expl2.1.ied to me the infonnation regarding the diseases and vaccines listed below. I have had a Chfu"1Ce to e.sk questions tnal Yiere aXLS\{erad ~o il-L: satisfaction. I "veliev.; I llilG.;Tstand tll.<e b~D.eTIt5 2.I1.d Tis}: of ili~ -v'asGines chen fu""!.d ask ~\2.~ t'le vaccines liSled be given to me or iO tb.~ person TIaJ.-ned abl'JY"t for whom I am aTIt.IJomed to m~ice D."1is reGuest. Vaccine I Data 1 Ace I Sr.:~ I Giv.n I .. I Des:: GiVS:il SaUTe::! 0' Vaccine I Let i'vl~T']uf~urcr ! Nurnbei E.::?ir. Date 1Ja:::dnc !n:o Sig;;atu,a Of\)~C"'II'l" S!~!'!=:!.!;:: n, i i i ... -- ~.+.- - \ Vac:::r.e P:.:l:;!;s!'; . A::;-;-;.j;;;s~';,Q~ ~j I ranmt' I I I I I ~2t2 G;':Cij"~L=:, , I Dla? 1 or DT I CTaP 2 c: DT I DTaP J or DT I l----r-l OTaP 4 Qr DT i I I I DTaP 5 or DT I IPV1 IPV2 I I I r-T-1 I I I I IP\lJ I I I IP" 4 j I I _._~ - .... Hib1 Hib2 "Hm:;"-"" I [ Bib4 MMR1 MMR2 Hep 81 , Hep S 2 Hep 8 J VariviiJt i V<lriv<:i;; 2 Prevnar 1 Pr~vr.ar 2. ! prevnar :3 I Pr~vnar 4 I I i i I i I I I I f.-t.p./'I'J) I , , ("'~,..-. ......"lJt;"1 trd1:O~~ ?-I I I I , ' I ' , I I I 1;J 1"'- .v~) I I I I , : p Ipr;~:t q!lr~~J!.h"tl716-'1Lf 16S I I I I I ~ i ! ! r t I ) J i I I I I I Iii i i R"t~~ I , I I I ether , -. I,C", i-' , ;.- " 1;- , '.1 ,). . '-\\ i ,n..,;;:"""" ~:.., J.,,~ l \ h ---t:.::.-: r~_j i ",Ii }11J1 i ,J,. "-I ( "./ti i - (j '-..' / /",", !: '" --~ ~ \/,'~ j"""": f, i 1 "V', tI. ( , " ",r ,...' ~, t 1..1 " I , " 1 '~" I V.! ;'1./1> J..--.;; /~ , ... ~,,. ( , '''''', .(:':- ft, _ i~' ~ .'.~ '; '-....ir.~(..-:,71Vl.',-'.::; ~ () \J If-. ----- / )" I--' lCt c.d , ! h~l I ( , ~. r /, / /'0 -f' -; CLU----r [ I 'L' +---ft ~ /\r(; h I 0~'-k k I V ~"%-rr f/\J..o1-, l /'j ,,.. I. t1 ~ ' i-)INL /(l'yNb C1rCo, l':~" -I I L- .0 0'1: }7 m 'Zl '}::\D \" rl-.'f I ~'o' c.h:-- [) 5 Ik--nP2/l rr-'? f'C->-'<.<.l, '. I :) <<.-.~ I~ 1'1-- e-rlJ..,/ I c I 0 I' \ s.....l.,~ rc r'X-~. V -t',~,.t. ~, o -J (:. 4C ;-C\.1't:..-') (- \~. OC)t0 u0lld l I "'1 eM} 7- (~ ~ I ',rr""" ~.~,~ Cv '/~ 1,1 '.[, ",~fi., 1.< cl- "" b tl-rL J 'J'L.." f-c;~ ./ .J '.A ;?'I.-f' (L.~ J...Cr:;,j- tA; (,;,,..,1 I!U{f. r:J I- J' I ~ <I.. {.,ccl., Ka ,-;{"...."., --,. - (,.>!-! t?J_v,/'.D ~)lr-("~A ,r Ie.. , . ~ ..... ,. ./ .1.-11:(/./11-:. t./vu..~ /,,,-,,,.4,0."'/ fJ d,~- ) , I /1;-;) (f.I"""',~; .f-I;, (, ",.L<-<.I y/'''''' /'Ir!!,"""./. ,.14":-1 ~ "vli- ,;;-~jA (1m ....<; ,. ()_llll..J (', ,.1{!. I., etA- i ./.-1 r I, i- n d~' . i if! ! I / <';:).). c-L/( le7 L~ Lv. ; "" ,? .'"'2./ 1--;:). I)~(i .'J- /;1/) / ..../1...L ./ ___ , "I ~r.....-~, _ _ .-fLy /r ~j .~. (fl...f> ~ \.nrl.t.~/,..t ~1/v....Av ,.; --!,~-;'-, ,../ C ",// J . " / r::{{(...-.LCL.""~ ,....'v';J.c. ,~ id,. , C ,-llu'~''''<'_1 ....;iLl-..... 'fi.c..-, '\../ :v . j , 13.:.v <A.M-:t/ ~ ~,'~!~(L.- I J;(. ,..:. "J ~,_..__l I ~.Lvu,I__. /LA~J / <--7 'q . ~, / ""'''- ...:,....,.lA.... " ...CI. .t. (.uvc~ 'I " / . <e.G.1 ..4 v,) Patient Progress Notes Patient: Markus R. Macnamara ! Birthdate: 10/2811991 Provider: Neil A. Flenniken DOS Phone: (717)249-7777 Office: 30 State Avenue Carlisle, PA 17013 Chart #: MA0242 Date: 07/05/2005 55#: 205-72-5653 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 , ' ('.". , " ( , , , ~ ( l__ ~ ~', iJ l ,; , , '. ., , '---,' , , , 27 26 25 24 23 22 21 20 19 18 17 32 31 30 29 28 Progress Notes Date Tooth Surf Proc Prov Description Stat 0612112005 Clinical Note --------------- Tue - Jun 21, 2005 ----------.----patient was in car accident 6/1812005.-hit both upper and lower teeth; xrays can't rule out tracture of 8,9 but remaninder of teeth show no visible fracture--affected teeth show craze lines and thre are clinical fx extendin9 into dentin on # 8, 22, 23, 24 which can be restored with composite restorations-- recommend case not be closed for several years so we can cover pulp vitality and any distant remifications caused by the accident (at least 5 years recommended) will schedule to restore fractures at this time and recommend yeariy radiographs and pulp testilng--JMT 06/21/2005 00140 OR06 Limited oral evaluation C 0612112005 7 00220 OR01 Intraoral-periapical-1stfilm C 06/2112005 8 00230 OR01 Intraoral.periapical.each add C 06/21/2005 10 00230 OR01 Intraoral-periapical-each add C 06/21/2005 24 00230 OR01 Intraoral-periapical-each add C 06127/2005 8 10LF 02335 OR01 Resin-4+ w/incis angle-anterio C 0612712005 23 MILF 02335 OR01 Resin-4+ wlincis angle-anterio C 06/27/2005 24 10LF 02335 OR01 Resin-4+ wlincis angle-anterio C 0612712005 25 10LF 02335 OR01 Resin-4+ w/incis angle-anterio C 1> \cr>~1 209 State Street Harrisburg, Pennsylvania 17101 717.232.6300 FAX 717 .232.6467 www.srklaw.com 1528 Walnut Street. 3rd Floor Philadelphia. PA 19102 215.790.7303 VOICE 215.546.0942 FAX Schmidt, Ronca & Kramer PC INJURY LAWYERS PLEASE RESPOND TO HARRISBURG OFFICE. . Affiliated Law Firm - Sheller, Ludwig & Badey. PC. Philadelphia, PA June 29, 2005 .I!JL 0 1 2005 Carlisle Regional Medical Center Attn: Medical Records Department 246 Parker Street P.O. Box 4100 Carlisle, PA 17013 Re: Patient: Markus R. MacNamara DOB: 10/28/1991 SSN: 205-72-5653 Treatment dates: 06/09/05 to present ~_ 'I - O~ C-R.:" / (" - fO -as' t.~ Dear Sir or Madam: Please be advised this firm represents the above-referenced patient. Please forward to me copies of all medical records and itemized billing statements relating to the care and treatment of the patient for the above-referenced dates of treatment. I have enclosed an executed medical authorization permitting the release of this information. If you have any questions, please feel free to call me at any time. Very truly yours, TSH/ jss Enclosure (J)\?" @~. CO?E~D BY JUL 0 5 2005 C _"'l."_ '\.. ~ -- ..'-'" .. .l ~-"-_, '\,#~"'-- \d6~\9 -\ ~ 07/01/0:, PAGE 001 HEALTH MANAGEMENT ASSOCIATES CARLISLE REGIONAL MED CENTER PATIEN": MACNAMARA, MARKUS R F/C: P PiT: E A/C: 93.2838 ADMISSION: 06/09/05 DA17 COlD: 858 AS OF 06/30105 DSC CODE: 01 DISCHARGE: 06/09/05 ---------------------------------------------------------------- CHG DATJ: DPT REV BAT# HCPC MIM2 CHGCD DESCRIPTION QTY AMOUNT -------.------------------------------------------------------------------------ 06/09/0', 412 250 5203 18160 IBUPROFEN 400MG TAB 1 3.80 06/09/0', 412 250 5203 97063 LET SOLUTION 5ML 1 5.57 06/09/0', 418 270 5400 26890 TRAY LACERATION 5288 1 52.74 06/09/0', 428 320 8 73590 LT 73590 TIBIA & FIBULA MIN 2 1 362.62 06/09/0', 428 320 8 73590 RT 73590 TIBIA & FIBULA MIN 2 1 362.62 06/09/0', 429 350 8 76375 10036 RECONSTRUCT CT 1 756.12 06/09/0', 429 351 8 70450 70450 CT HEAD/BRAIN WIO CO 1 1,006.32 06/09/0:> 429 352 8 72125 72125 CT CERVICAL W/O CONT 1 1,048.33 06/09/0~, 418 270 6 25167 SUTURE TYPE I 1 27.90 06/09/0', 480 450 6 9928:3 00515 ER DEPT INTERMEDIATE 1 573.55 06/09/0', 480 450 6 97001 ER PROCED INTERMED 1 979.51 06/09/0'; 412 250 5200 21 030 LIDOCAINE HCL/EPI 1% 1 52.82 06/09/0', 428 320 2441 73590 LT 73590 TIBIA & FIBULA MIN 2 1- 362.62- 06/09/0', 428 320 2441 73590 RT 73590 TIBIA & FIBULA MIN 2 1- 362.62- CONTINUED. . . SELECT: REV~ * DEPT= * CHGCD= * DATE/MDCY= * TO/MDCY= * CMD: l=Di\R, 2~PAT 4=SUMMARY,5=TOP,6=END,7=RETURN,8=BACKWARD ENTER=FORWARD 07 /01/0~l PAGE 002 HEALTH MANAGEMENT ASSOCIATES CARLISLE REGIONAL MED CENTER PATIEN": MACNAMARA, MARKUS R F/C: P PiT: E A/C: 93.2838 ADMISSION: 06/09/05 DAl7 COlD: 858 AS OF 06130/05 DSC CODE: 01 DISCHARGE: 06/09/05 CHG DATB DPT REV BAT# HCPC M1M2 CHGCD DESCRIPTION QTY AMOUNT 06/09/0" 428 320 2441 73590 50 76522 TIBIA & FIBULA MIN 2 1 265.65 TOTAL: CASH> SELECT: REV~ * CMD: l=Di\R, 2~PAT TOTAL CHARGES 4,772.31 0.00 ADJUSTMENTS> 0.00 BALANCE> 4,772.31 DEPT= * CHGCD= * DATE/MDCY= * TO/MDCY= * 4=SUMMARY,5=TOP,6=END,7=RETURN,8=BACKWARD ENTER=FORWARD 07/01/0'; PAGE 001 HEALTH MANAGEMENT ASSOCIATES CARLISLE REGIONAL MED CENTER PATIEN": MACNAMARA, MARKUS R F'/c: P PIT: E A/C: 93_2903 ADMISSION: 06/10/05 DA17 COlD: 858 AS OF' 06/30/05 DSC CODE: 01 DISCHARGE: 06/10/05 -------------------------------------------------------------------------------- CHG DATI: OPT REV BAT# HCPC MIM2 CHGCD DESCRIPTION QTY AMOUNT 06110/0~; 480 450 6 99281 00001 ER DEPT BASIC VISIT 1 377.34 ------------------------------------------------ TOTAL: CASH> SELECT: REV= * CMD: l=D,IR, 2=PAT TOTAL CHARGES 377.34 0.00 ADJUSTMENTS> 0.00 BALANCE> 377.34 DEPT= * CHGCD= * DATE/MDCY= * TO/MDCY= * 4~SUMMARY,5=TOP,6=END,7=RETURN,8=BACKWARD ENTER=FORWARD P A T I E N T ADMIT DATE { TIME 06/10/2005 10:25 cr~ 246 Parker Sl. Carlisle, PA 170lJ Ph:717.249-1212 N .N MEA DR S MACNAMARA, MARKUS R 306 N WEST ST CARLISLE PA 17013 US PHONE NUMBE (717)243-2098 G U A R N A A MACNAMARA, SUSAN 306 N WEST ST CARLISLE PA 17013 US EMERGENCY CONTACT NAME PHONE NUMSE (717) 243-2098 EMERGENCY CONTACT PHONE u 210-44-3603 HESS, DIANE e ~ ADMISSION RECORD 0', TE OF BiRTH 10/28/1991 PROGRAM A R 0000810047 PATIENT EMPLOYER STUDENT WILSON MIDDLE EMPL YER PHONE NO. COUNTY CUMBERLAND L A RITE AID 5280 SIMPSON FERRY RD MECHANICSBURG PA 17055 RELATlQNSHIPTO PATIENT MOTHER RESPO EMERGENCY CONTACT RELATIONSHiP TO PATJfNT (717)243-6650 P IVA Y NPP ADMIT. BY Y SSS C MMENTS RECHECK PRIVACY A N c E M-. DR.ATTENDIN 1ADMITTING f' CLOONAN, CLIFFORD SAN I I ,C_ weUNB-'RE-€HEeK ,---- PRINCIPAL DIAGNOSIS (The conditio" established after study to be chiefly responsible lor occaSioning the admissIon of the patient to ttla HQSP!T AL for Cafe>. COMPLICATIONS CQMQRBIQITYIIESI f'RINCIPAl PROCEDURE AOO01A 9312903 MEDICAL RECORDS COPY 1~1I11111111l1l111'"I1I~11I11I1I11111II1I1111I11111111 111111111111111111111111111111111111111I 1111111111111111111111111111111I111111111111I FRIEND MSP Dy Jl[N MED. KEY Dy Il'lN INSURED'S NAME / u B N M AUTH AIZATI N A GR UP NUMBE GR UP NAME A THORIZATION IN NA G OU NUMBER GROUP NAME AUTHQRIZA TI N D . FAMII.. Y I PRIMARY ARE NONSTAFF, FAMILY PHY A -NO-FAl:Jf;T- A --0 6-to g-j-2-Dj) 5-- I HA A 0000810047 Carlisle Regional Medical Center Instructions: circle ositive ~ backslash ne alive, NAME: MACNAMARA, MARKUS R DOB: 10/28/1991 Age: 13 Yrs 0 Mas 0 Wks Sex: M ',' Wt: 35.5 KG Ht: . Chief Complaint: WOUND RECHECK Medicines:' INHALER ' , ~>,' "_::"',':.::' PCp;' NON-STAFF, FAMILY, Allergies, NKDA <.,....'..- -"", ." EDP: CLOONAN, CLIFFORD Exam'Tlme;;! '___'''.:::'.''-,,!.':...~:,:::;;;;O, C I C I HPI: (Narrative): ~i)>y,; Patient Family.. EMS NH Translator. , ~1i]j1(!~J)Yfj ALoe. IntoXi"".tIo.."..._~!.verity___~_~eliabl~_ --- -- ----~M1AO:Mitdjc';,[S~iJ,JjYl. '-Eme,genitJ --Noil-'Emergent 0 - - - -- ----- .__.._--~-----~-_._---_."_..,_.--..,.,..,.._..,.._.._----------.---- .____.._____.__.m.____...............__._.._....__.m__.__u._........______.._____.______________________........_....__.____._.___________.._._ .._______m.___.____......_.__._____...___..__..__. _____.____.,_,___.,__.__.,._,__________...____~._.____..-.-".--.,.--.-..... -..-..-..--..~-----..-----".----.---------.---...---.-------....- .....-.----~---.--.-------...--.- ._..____________..________._.__._....._....._.__..._____._ _______m__....._..._...._ ..__..,,________....__.__..____________.._..___________.._._.._ --.-.-..-....------..---.---..--.------.-------------....-- ..........-...-....--.-------------......-..-..----~-... .....-----..-....-.-,--...---...--.----,-..---....---...--.....-..-.-----,._---_._..__._.._...._...__._--~_...._-----_.~..__....__..---------.._--_._...._-~-_..._-------_.__._._---_._.__._.__._-----------------------.---.-...------...-..--- ...._...___~__._....___....__.___________......_._..___m...._....._..__._____________._..._..____.....____._____..._______.__...__..__----.-.--.---.---.----..----------.--.----..-------..-.-.-.-..-,~----..-.-..--~--.-- _____.__.._._.__.._______..___________.______...__......______....m__..~_____.__..__._._....______._..._____'"________ . _ _ _ _ .___..._'"__________ .--..--.--.--- !I!!JJ~Q~ Sx started suddenly J gradually _ min. J hrs. J days J wks. ago : continuous J intermittent R~~,tiafi]r Sx las-t-----..--min~-Thrs.:..Tdaysi"Wks~-~t'a-time:-p;esent jab~ent...--n---------.-.---..-.------.------.---------..---------.-~--- Q~!'l~11 cannot describe cough sore throat ear pain abd pain N I V diarrhea irritable ~.~~~~~!YTI -ri1ild-'-- m.ode-rai"e-...-..-seve;e-----1.:iO-s.cale.--.-n-----.-----.te~-p-max->.1-00~4-..-....-----.._.-.--.-.--.---. .------.-.--.-.----.-----------.--..- g,.o.~i~]___~~..e <~._~~~_~~...._...._.~~~_:?~.tac~__.__.~...~~ sy.~?toms _____ ~S!!!W."!!.~y:i nothing non-compliance n--R~I,!~a-6~r nOth;;;g--Tylenol-MOtri~----ti,;;~-------- 1\S~~9~1~~~~~SjjfiR!.~'1'~~_.n".~:___~~~.~.n"'s~ratOry~i~~e~...__I~.t~~rgi"-__..cl~creas:_d~~?. in~~~_",________________ REVIEW OF SYSTEMS !i!i!I!!dAi!~.$l ALOC IntOJdcation Severity Unreliable co~titoti"onal~r fever--chms---weakness-diaphores.is~--N.euroiag"i'taf~f-HA ---selZures--Weakness'--confusion -'---'-- <."," "",,,,,,''''''A-.,.,.,,,... "'q".'..'d".'~."..'.. .'..~.....,,_ Ei~til sore throat ear pain facial pain ",iiic;tii!(!igl.!'!il;:; anxious depressed ~~Jrp~~s"UaIChanges....-....--._...----.--..---------..---.--..-----..----~---.-gn~9.~ff[!jI-polyuria---.POlYdiPsia-------.--.---..-------.---- ~~.fii~f9J~LC~:_~~~i~ti~""__ DOE PND______.__._ Jtj~m~!\t:; _ras~:~___~":'~~~__~~i<l~~______ ____________ ~~el~fm S.O.B. cough congestion tf~~m~,,gt~g(~2 anemia bleeding disorders transfusion ~._...~_~_~~~~!L~~~_~.~~~.~____~~~~_______~~!~_~_.___._~.~mate~.!~~_ ._~~!'!~~m;m_~~_ fr~.~.~:.~~~!:ction~.__...~~~.~_~~~____~.ive~._____.__.___._ gQ:~ flank pain dysuria hematuria frequency ~h!t;] -..- MU~I.IIOikel~~~:l joint pain neck I back pain ex!. pain .. ....... ........ . . " D Ail Other Systems Reviewed And Are Negative ..__.._.._ . ~-'===."'==.'~.="'"_;;::;-.=..~;;;;;;;;.-::c__.. ---=,,-,,-,,~_;~;;;.=.;;;c;;...;';;:';;';;"---;;;;;::--- D Agree With Nursing Assessment -.-..-. MEDICAL AND SOCIAL HISTORY ~.!~;!!!:~ none 100M I NIDDM asthma ~!!f.~!~tJi~r'AsiHMA--------'---""'" ~!d~~-INHALER----' .. --- ear infections birth related illness D Reviewed ._____,,__._____._._...__.._._ .__ _. __...._._______.._... ._.__.____,..__.____ _________._________.__e..____.....___________._________.___.-.---- Aller9leSi.. NKDA o Reviewed o Reviewed SLi:ra~J~~it none Appy Tonsillectomy F~m.iiyij~ir-';egative' .. So~~~,~.~~:~_~__..~~~_~~_ . .._~~.~~_~.~~..._m__~~~E.ation: Tobacco: Y I N Packs I Day Iminug~lI"~:. Up-to-date: Y I N Reproductive Hx; LMP R I L Handed Lives Alone: Y I N Years Eiof.i'Y!N='oiinkslWk:' Tetanus: Drugs: Y I N G p AB Pro-MED Maximus CCopyngnc 2001 Pm-MEO Clinical S~eml, L.L.C General Pediatric - Page 1 of 2 Rev.03I05/OA ,:> .-,i<..,..:..\,;;,z.'JMr.;' " ..,...Y-G1 ;JJ I#>~" ' .~ ;i" .,.: ~ ~-;, .... " ;t.,~ .... .. ...-r_ .,~;;.>j },:.;:".:t::;; p ;-' )'.-;l: t::~; ;'f~)>{, ~~J~ m-:msmm L,_ <i->';,;J~,,;-': .'r ;' ~:5;~q-i'~J1'~" ~~':,L~:i;1~.. :~/~~_lf'-.',--:'~:<,,-Jl~~;Wti:t/,.tJ.o '-~',-.' ~:".\ ,,;,t!.t::A~',;;~:i":",;;, ':1.'~' :~':'~t c, ;.;, -ii ",-'-" ,):' .. munnurs . gallops e!)1hema I exudates sys I dys :'; ,.;. . , cap refill < 2 see -. ;'i; ; :~ f ' ..: ::_ .};:.:~' \., '~" "<:~'-',( \;J~~li~i.;::'~~:"'''~ ".;:~,' '-- ,,:~_'r :.- ~,,~,;",,-, ;;j', ;,,-,.:> ~ .; ~ .. ,," i",'_'" ;--, ~ ':'1' ','~ ~~" ',,'.:' ,-" '".,; "',,i',', .. '." ':.' , ::-'7.',' .-, . "'(-,. -;/,'., . .!'~' (.:"'-, . ~~ '"<. ,- "'. I{E'S~ lungs clear I equal bilateral ',:' rales rhonchi wheezes , accessory muscle use ~ soft flat I distended ,. : tender I non-tender resp. effort NL I distress sbidor retractions " "",-. ",', ,- , \-,-" ,'; ~-' ",t p bowei sounds NLI ABN guarding rebound rigidity cyanosis edema rashes turgor erythema equal I symmetric , appropriate for age: "', Discussed with Dr. Admit Follow-up In Office Old Records Reviewed Y I N Reviewed OIW Radiologist Y I N Case DIW Patient I Family Y I N Discharge Time Out: Admit: OBS ICU PCU Floor Tele. OR Prescriptions Given: Transfer: AMA: DOA: Condition: Improved Stable Deceased RETURN TO ER IF CONDITION WORSENS. Signatures: Prn_ Mc:n M~virnllC!' PAlARNP ~ . See procedure fonn attached EiI ~ UJ:k-v...~ ~~O Record Complete OJ ~Dno.r~1 Dft,.(;~+ri,.. _ D~"c?,....f? Carlisle Regional Medical Center NAME: MACNAMARA, MARKUS R ositive ~ backslash ne alive rovide additional ertinent information. GENEflAr:~ NAD mild/moderate/severe distress 'Yl!~:!!Ci~.l!:l T97.4 P77 R20 BP104/081 ~~~~!I~~Aj ~t;RHLA EOMI ....,f!~~-~:-=-~1~1.-~\--_.--------- TM's erythema pharyngeal erythema I exudates 1_..__ ~y:; :~:-:~sNL-g~;o::u;SS3 /:4's:~ ~:II <~ se:----.----.--.-------io~~DescriPtl~1f~m:: -------.------.---.------.--------.---.--'.---.--.--.--.-....-.--..--------- I~ ~ ~', t J IlE~~:'.I~~~~.s:~:::~~~::!~s .r~;~o:~:~~~~n:istr.e:'=--------(.,~~-~-~-- ? \'-11' ..-."::::=~"';.,-=----- -.. :' I (I I Sl,<l~::~ diaphoretic rashes turgor erythema ~ NE~RO~J CN2:i 2 i~i3ct-DTRs-..equai/symmetr;;;---.-------- ..---.--~S~ ~l!yg~~~I~}'f1JI~r~Pri~tefCll'~--@-.~--.~---- !:'Y.'!IP',H;i: adenopathy gg,j; NL / deferred 9!fj~?r------.---------------- -------- :::: 'J o Labs reviewed and are negative X-Ray: CXR: R-::::::R-:::-:::::::::::.-:m.::-::-:----- MEDS: _._---,._-~- --.---_._--- ........-..-----......---.---------.--------.---..-.----.--.-----.. IVF: .m___.__.___________..__.__._...__,______....__.____.._.._...._._._.____.___.___..__....._._________..____.._____.----.--.---- NLI ABN NLI ABN DIFF ...._._----~--_._-_.._-_..._._---- ----_.._-_.._._.....__._..._.._----~---_._----_.._.__.__._- .-..--.------------.-....-.----.---.-....---.---- .-.-.--.---------.-------...-.-..------------.--------- :~~-~t~f~.:~~-=-==:-:=i===:-=:=:=:=====__=:==::=:=.===:==~ :~~~~~~:==_=-==.:=::_ ll~~=~-- L ------...----..-...--....--.---.--.-- - --- - ---- -- ----------------- -..- - - ------- ---------~ - --- -- --------------- - --- - - ---------- -- ----- Improved Same Worse UA:-...-------.------ --...-.-.--.-....-.----Puise.Ox:-.-%i'iC"Tiiypoxi.-------- CSF (see procedure): !2P-.!J febrile illness URI viral syndrome bronchitis pneumonia pharyngitis otitis media meningitis UTI sepsis gastroenteritis other: Critical Care: 30-74/75-90/91-104/105-120 121-134/135-164 Minutes ----.-------,--..--.---.-.-.-.--------------....-..--.---.---.---.---.-------..---.--.--.-.--------------...-----.~_.--------------------_.._----~--_.._-------- Excl. billable proc. Discharged to: Home Nursing Home Follow-up with Patlent's Dr. In ..-...---------..- --------------..---..---.-.------ Other Instructions: CONSULTATION DISPOSITION 5. Discussed with Dr. Admit Foi'low~l"p--i"nOffi'ce-- Old...Rec-ords-Re."I-ewetj"-----y"j'-N- Reviewed[)/W-Radfologfsi'y/ N Case-Om -Patient I Family iTN----.- Discharge Time Out: -... ---.....--...----".--. ----- Admit: OBS ICU PCU Floor Tele. OR Prescrlptlons-G'iven:--"-'---- Transfer: AMA: Condition: Improved Stable Deceased- --RETURN TO ERlFCONDITIONWORSENS-:- Signatures: PAlARNP See procedure form attached 0 ~ U~__ )t;i[1;h0 Record Complete 0 General Pediatric - Page 2 of 2 R"",.03lO5l04 Pro-MED Maximus CCopynghl2001 Prc-MEO CllniCilI System.. LLC. Carlisle Regional Medical Center Instructions: circle ositlve. backslash ne alive rovide additional NAME: DOB: 10/28/1991 ex: M Chief ~;fi~~~~~1te r:1:c~le~ov~RVu~r~~;~a~-=:~~I~~~V::::~=J'- \;d;;:;@- ~ +~ .. .~~-t.,?~;;:;",:~...~;&~ .. . .f*=-~::r~'1:;- . . ~t.' ." . _'-~~:zij5:: :___.LP_~.. .. k!t::._ .---- . {. 5. .... ~3e"'~~NI\t! mild I erate I severe distress VITAL SIGNS: T R P B I P S~~:i.:~:0~!=~~~~~__ i~;~~~;::~~~~i~~-~~~'~~~~ftl..=I.~t~ l, ~ ;~ ~i~'~:--"'"';.,'j~C . .I-h~ ~ ~ll' . ' M;~n~bel:,,"~~:IOf~..---:@j)BN_ . '.". . .... .. .~_~: _I__j~.~~'t.!f .:.__ ~~~~~~~~~=--=.= ~~!!_-_. MEDICAL DECISION MAKING ~=----------------;~._..,_.._-_._-=~ ~-~.,~~;,;j~':","-,j~~;'I':...lL~.:.cAJ--:'::":',;;',;... ~"" ^ ._~__~." ~ ~'...':l..:fl....::e.::J:J~~~,~:~,~~~~;:>::'~,....~:~~..:.J sutures I staples removed ....---.--...."--.".."...........-.,.-..---.."-.---------.----------....---------------..,--. ---'________,,__.__.__.__._.____.__..__..,_____,_~ _.._.m_..._.~.._..___..._...______..__ bum dressings changed silvadene other: . ...___..n.._........______._~_..__...._____m._.._...__.______m.._._.___.._.. ________._m..___...________..___._n__.._......._..._ .._...._____._.___..___~ abscess repacked iodoform other: ...-----...........-.---~-..-.-------.--.----.--._.-.-.------...----.-.-~--.-..--....-...-.-----.....-..__.__....__.._.._.___.__m..__m......_..........._..._.___.mm__._._._._._...m......._.____.....__ antibiotic given: IV 11M .~n_...m._...~m..__....____..__,,__...._.._._.___.___.~_._._..._._____._.______.__...______.__._.___._._._.._..__...__._.m_______._..._.___._..~ ._~_...n....__~___.___.._.___________....___._..______..____.._~._...___n____.___.._____.,_.___..._._____.________. CLINICAL IMPRESSiONiSj 1. 2. 3. 4. --...____.___~_.__..___m___._____m__._____.__.__________.__.__~__.__..__..m__....__________..._._____._._.__.______..._.___.__.__.__.,..____.._. 5. ..-...-.......--~--.-..-----....._. ..m_._____....._______..__.______m_..._~_...._.._._...___....___...._.__..__._____.m_.__. __.............._..___.~_........_.._.....__~___.m._ . ... _.......__._m..__...~_..._ ___..______.......__ 6. CONSULTATION DISPOSITION INSTRUCTIONS Discussed with Dr. Discharge Time Out: Discharged to: Home Nursing Home Family Admit Admit: ICU PCU Floor Tele. OR Follow.up with Patient's MDln _ days. .__m'''n___.''_.'''__.__ _mm._......_ ...__..m_m__m___. ...._.".._..n..__............_... ......-.-----...---."..- ___..._..,..._._n_ ..._..~- ...-...... ~_...._._....._-_. .._.__...m.____..m_........,..._.._._.__ _._...__....._.._.._._.________.n...._. --.--....-.-.---- Follow.up in Office Transfer: Recheck in ER In days. Old Records Reviewed YIN AMA: Suture removal in days. .......-....--..-........-..-.-.---..-----...---- ..--.---- -..-- .............. ---"._- ...___m__.__....__._ ..____ --....--- ..-. n.._...n___._...._.....__._.. .....______mnm.___...'-_.n._......._ m__. .. .-..-..... .._.m.".._._ ..--....--....---.--...- Reviewed DIW Radiologist Y I N DOA: Burn dressing changed in days. Ca.e DIW Patient I Family Y/N Condition: Improved Stable Deceased RETURN TO ER IF CONDITION WORSENS. Signatures: PAlARNP (~c.a/~____~ Wound Re~ ROJv.03lQ5KW Pro-MED Maximus ICCopyOgrrt2001 Pro-MEDClln'calSyslOJIT\I,L.LC. ORDER PROCEDURE FORM .MEDICAL EMERGENCIES Date In: 6/10/2005 Time: , .rlisle Regional Medical Center Name:MACNAMARA. MARKUS R Pt#:9312903 Age: 13YRS DOB: 10/28/1991 Sex: M MR#:OOD0810047 EDP: CLOONAN, CLIFFORD PCP:' NON-STAFF,FAMILY, PHY' . . . . CBC i'iIi. -jj roe CXR :AlLAT _ Portable' 0" If BMP CMP Amvlase Abd. (flat & upright) Drug screen (serum). (urine) ETOH Liver nrofile Magnesium Giucose (bedside), (serum) t 0 mona UA ,,,a:: ABG 02 LPM .. . tI~!"'F~"ceii\!iJ~ ~vious Medical Records ~ \C'~ l~ ....I I~ E.Q.r~ _ .., ' ".,apy - Eval & Tx \ , .. . . .. - 0 b Improved 0 Worse o Unchanged L- 0 b Improved 0 Worse o Unchanged 0 o Improved 0 Worse o Unchanged 0 o Improved 0 Worse o Unchanged 0 o Improved 0 Worse o Unchanged 0 :J Improved 0 Worse o Unchanged 0 :J Improved 0 Worse o Unchanged ~l! :.II!. ., ..11 , .. o KVO Device: o IV Fluid: ~. o Cardiac Monitor: Rate Rhythm: o NGT Insertion # Fr. o Endotracheai Intubation o NIBP Monitor o Gastric Lavage o Cardioversion o Pulse Oximetry o Central Line Placement o Oral Airway Insertion o Urinary Catheter Insertion: #_ Fr. o CVP Monitoring o Oropharyngeal Suctioning o CPR P,1~." PAiARN : Rev,09/14/04 Initials/Signature: nifials/Signature: ;~!!Ill lJe.["'Qf!aMle,~jj~1 Location: Quality: OSharp OOull OCramping OBuming OAching 0 Mode of Onset: 0 Sudden 0 Gradual 0 Intermittent Onset: Date: Time: Duration: Onset> 24 hrs. medical attention was sought? oNa aYes Date: Radiating: DNa DYes (specify) Carlisle Regional Medical Center Name:MACNAMARA, MARKUS R Pt#:9312903 Age: 13YRS DOB: 10/28/1991 Sex: M MR#: 0000810047 EDP: CLOONAN, CLIFFORD PCP:' NON-STAFF, FAMILY, PHV' EMERGENCY DEPARTMENT PEDIA TRIC NURSING ASSESSMENT Date In:6/1 0/2005 Subjective Notes: P~ychOS:ocla Rating Scale: WCIDO:BAKCIDE~ ~ACE@S :TING@SCALE@ .. ~ .... - -..=J .......... - - r-""1 r, 2 4 6 8 10 Caregiver: oParents oMother oFather oather: Accompanied by: Appearance: Delean oUnkempt Activity levei: oAwake o Playful o Other oOther o Smiles I Laughs Environment: 0 No steps 0 Few steps 0 Many steps Nutritional status: 0 Normal 0 Cachetic 0 Obese Religious I Cultural preference: 0 None (specify) Besllearn by: (pll caregiver> oVerbal oWnUen o Retum demo Learning Baniers: Voiding: oContinent o Dysuria Other findings: o Incontinent a Frequency o Diaper Color: o Potty trained .1'tH.Pl. Airway: ,..er6earOOthe,-. ",.:;.::',Yt,,'.:" , iiffort:"; ;!~Ia;;o,;,d';'. 0 ~bofed 0 ~i1dIXO Severely, F "''f:',:; ;,j:j/:':'~"Y":' '.", -":".', -, '''. .-;;,--,,:;:,;-_jY;;)!!V;~ ,;- ~- ; f;';-;'-.~,o ":. ..,.1.....'.. ,./ :(';"i: ;.'ORetractions o Stridor' 0 NaSal F1a ng ;, ,";, ". ;,>)">.,, \',.""":),"f<;~i,b;;;,,,,:;_i,",>""'" ,-;"",..,.~.>",._~,;_j";r.,'":"",-_-~;;;,,;,,,;~....;_c. Cough: Cl None a Productive 0 Non-Productive lung Sounds: ClClear DWheezes o Rhonchi o Crackles ODiminished DAbsent DR OL DR OL DR OL DR OL DR OL DR OL ... Abrasions I Contusions : Q"in.,r>d <<-7"#.001> ~~t~~~~~-.--1t~J~1--"'---r~fU';;-r.:-itf,1i7;'~fzr" ---~--:71~ --- , L.iii1:~.l~~~\::_ _~ ,,:4t-2i.:L....L, ~k ~~_ _ ~_ ~t", _;...;, _ ' ..'" ~~ ,i4;.: >',- .1 j Size: Bleeding: 0 Absent 0 Present 0 Scant 0 Moderate 0 Heavy 0 Pulsating ROM: 0 WNL 0 Decreased 0 Absent Edema: DAbsent 01+ 02+ 02+ DeformityDYes ONo Scars: 0 Yes 0 No Distal pulses: 0 Absent 0 Present DNEW BORN Ago"1 Month DINFANT 1.12 Months Language: DCnes Often DSmlles DCoos I Gurgles DBabbles __~?~_~tTerm:~~s D~~__ _ DeJ!.ve_~ DVagi~g_9-=Sec~_()-'L___.___m__ Diet: D Breast Feed DFormuia type: Elimination: 0 3 - 8 stools a day Other: Activity: Lifts Head: DYes DNo Sits up: Owith help D without help Crawis: DYes D No Teething: DYes D No Observation of interaction with caregiver Is 0 Appropriate OSee Nursing Assessment Uses: DBoUle DSpoon DCup DTOODLER Age 1. 2 Yeart 0 Pre..school Age 3.5 Years Language: DFew Words DSentences 0 Easily Understood Diet: OFinger Foods DRegular Diet DFeeds Self Uses: OBottle D Cup Teething: DYes DNo Elimination: 01 - 2 Stools per day DDiapers DToilet trained DWets bed: D Rarely D Occasionally Activity: Walks: 0 Yes 0 No DWalks with assistance DWalks Independently Observation of interaction with caregiver Is 0 Appropriate OSee Nursing Assessment OSCHOOL AGE Age a .11 Vears OLESCENT Age 12 .18 Vears Reached Puberty: 0 Yes ONo Diet ~ats 3 meals/day 0 Eating disorder: (specify) Elimination: ~ problem reported 0 Wets bed: DRarely OOccasionally Social Habits: Smokes 0 Yes ~o Uses Alcohol: 0 Yes ~o Observation of interaction with caregiver Is propriate OSee Nursing Assessment DFrequentiy Learning disability: 0 Yes Wears Braces OFrequently Uses Drugs: 0 Yes ONo School grade: DYes DNo Vital Signs: 10:40 T: 97.4 P: 77 Regular R: 20 BP: 1041081 Nurse Signature: Rev. 03/05104 EMERGENCY DEPARTMENT ONGOING NURSING ASSESSMENT Date: 6/10/2005 .NIJJ.tfl ~u:! Airway Clearance, Ineffective -Anxiety -Breathing Patterns, Ineffective _ Cardiac Output, Decreased "?""Comfort. Alteration in -Other <<: .. j'- "' .,.!~~~r~mr-~~-~-----r~..,..,......... . ~..:& -. x__tJ}.l", ,_,:":d:;E&LI~'~;:H';m,f;'>~,,r,1};irJ.) ~~A~ >.r~lV>;ht.L,_t~~.....", ld.~........,_, __ ,,""~~~. M' ~." _..~;;.,;),~ Carlisle Regional Medical Center Name:MACNAMARA, MARKUS R Pl#:9312903 Age: 13YRS DOB:l0/28/1991 Sex: M MR#:OOOO810047 EDP:CLOONAN, CLIFFORD PCP:' NON-STAFF, FA.MIL Y, PHY. Communication Impaired --Coping, Ineffective -Fluid Volume, Alteration In Gas Exchange. Impaired _ Hyperthermis (Fever) Infection, Potential Injury, Potential I<nowledge Dencit Mobility Impaired Non-Compliance -Other Self Care Dencit --Skin Integrity Impairment Thoughl Processes, Impaired Thought Processes, Alteration in _Tissue Perfusion, Alteration in Th'itGoXl"l;'P '" . , ----~-:;~~~~~~....-"....-.......~- ,.~ :W!Jl'~~w.;l}~~~"""""_","-,~_~,,,,~__.......w.~--..--.._...._;, ..... _~"_1 o FB REMOVAL o BLEEDING CONTROL o PAIN CONTROL o ALLEVIATE NN o FEVER CONTROL o D;cREASE ANXIETY ~AFElY IN THE ED Not Met Met lot o IMPROVEMENT OF BREATHING o STABILIZE PATIENT IN DISTRESS CJ meet ENVIRONMENTAL NEEDS CJ meet PSYCHOSOCIAL NEEDS CJ meet SELF CARE ABILITY NEEDS CJ meet eDUCATIONAL NEEDS CJother Not Met Met lnl o IMMOBILIZATION / PROPER ALIGNMENT o DECREASE / PREVENT SWELLING o MAINTAIN STABLE HOMEOSTASIS o MAINTAIN SKIN I TISSUE INTEGRllY o PREVENT FURTHER INJURV o MAINTAIN / IMPROVE CIRCULATION o INFECTION CONTROL No' Met Met Int Int: N = documentation in nurses notes, other 'codes' per Hospital Policy. ,~~_._... n- .. ~.. "-;;)'P;~1:f.7~ ,.-. .." ,- ':71 ~..".."" 4~ " , . ~ ,~" ._.~ "n~~'Y;:~ =....., ,_ ~ 'r, _.~!.I Discharged in care of: Discharge instructions given to Admit: Room #:_to Dr. Report called at and given to Transfered to 0 Transfer Verified Report called at and given to o Left without treatment oLeft Against Medical AdVise Condition at Disposition: Dlmproved DStaDJe OSerious CJExpired Pain Scale: Pain Location: Patient reports that pain is: 0 Improved 0 Unchanged DWorse DAmb DW/C DStretDCarried o Verbalized understanding Ready for Room Time:_ Disposition Vitals: T P R BP 02 Disposition Date: Time Nurse: DATE: 06/10/2005 DOB: EDP: PCP: MACNAMARA, MARKUS R 10/28/1991 AGE: 13YRS CLOONAN, CLIFFORD . NON-STAFF, FAMILY, PHY* {lisle Regional Medical Center Pt#: 9312903 Sex: M MR#: 0000810047 INITIAL ASSESSMENT FORM 4 Non-Urgent PRIORITY: Patient: Worke(s Compo Emp. Referred: Presentation Time: 10:25 Triage Time: 10:40 Arrival Mode: WALKED Height: Chief Complaint: . Weight: 78.0 Ibs. 35.5 kgs. LMP: WOUND RECHECK Last Tetanus: Acc By: Vital Siqns T: 97.4 T P: 77 Regular R: 20 Unlabored BP: 104/081 02: % RA Pain Intensity Scale: 1 /10 Pain Location: Multiple Areas Brief Assessment: PT HERE FOR RECHECK POST MVC YESTERDAY LEFT EYE SWOLLEN SHUT WITH BRUISING SUTURED LACERATION NOTED IN EYEBROW AND UNDER LEFT EYE NIGHT SWEATS WEIGHT LOSS ANOREXIA NO NO NO HEMOPTYSIS FEVER NO NO SAFETY NO Sudden Onset: Pre-Hospital Treatment Pediatric Assessment: Pasl Medical History: Allergies: . G&D App. for Age. N/A, Immunization UTD . N/A, Height ft. in., Head Clre. - Grade., with ASTHMA NKDA Medicil1""'-__lN.H!-~_ Nurse Signature: ~iW ~9~ . MAJ Additional Notes: (L7Y7 r Rev 05/18/04 :arlisle Hospital -- EmerQencv Departmp '46 Parker St. Carlisle. P A 17013 -- (717, ;;-5500 mACr \RA. mARKUS r 6/1 OIL .1 :46am 0000810047 llSPOSITION SUMMARY Patient: mACnAMARA. mARKUS r SS#: CURRENT Address: City: AQe/DOB: Current Ph: Medical Record: 000081 0047 Zip: Arrival: 6/1 0/05 11 :46am Disch: 6/10/05 11 :51 am Disposition: MD ED: Cliff Cloonan. MD Res/PNNP: Dx #1: MVA (Unspecified) - FOLLOW UP EXAM ICD-9 #1: E819.9 #1 Dx EnQI: MOTORV A.ESW Dx #2: Laceration. Face -WOUND CHECK. NO EVIDENCE OF INFECTION ICD-9 #2: 873.40 #2 Dx EnQI: LACERATS.ESW Rx #1: Motrin (Ibuprofen) 400 mQ 1 tablet by mouth every 4 to 6 hours as needed, with food #60 tablets Rx #2: Tylenol (Acetaminophen) 325mQ 1 or 2 capsules by mouth every 4 to 6 hours as needed #50 capsules PMD: PMD Ph: #1 Dx Span: MOTORVA.SSW #2 Dx Span: LACERATS.SSW .~ Follow-up: EMERGENCY DEPARTMENT CARLISLE REGIONAL MEDICAL CENTER 246 PARKER ST CARLISLE, PA FlU MD Ph: 717-245-5500 FlU Dff: 5 Davs Other Instr: Suture removal in 5 - 6 days. Keep wounds clean and dry - return to ED if any evidence of infection - increasinQ redness. swellinq. pain. drainaQe of pus or fever. Return to ED if any faintinQ/near faintinQ. abdominal pain, or as needed. MY SIGNATURE BELOW INDICATES: > I have received and understood the oral instructions reQardinQ my current medical problem. > I will arranqe follow-up care as instructed above. > I acknowledQe receipt of the written instructions as outlined on this and xanZUSpaQ8ts): !wilfreao a; rl:lVlew::;siructions. Patient (or LeQal Guardian) iQnature Staff ( cz~ 246 Parker St. Carlisle. PA 17013 Ph:717.249-1212 ~ CONDITIONS OF TREATMENT AND ADMISSION PATIENT'S NAME ACCOUNT NO. MACNAMARA, MARKUS R 9312903 ATTENDING PHYSICIAN CLOONAN, CLIFFORD C DATE & TIME OF ADMISSION 06(10(2005 10:25 CONSENT TO HOSPITAL CARE AND TREATMENT I AM PRESENTING MYSELF FOR EMERGENCY SERVICES OR ADMISSION TO THE HOSPITAL AND I VOLUNTARilY CONSENT TO THE RENDERING OF SUCH CARE, INCLUDING DIAGNOSTIC TESTS AND MEDICAL TREATMENT, BY AUTHORIZED AGENTS AND EMPLOYEES OF THE HOSPITAL. AND BY ITS MEDICAL STAFF, OR THEIR DESIGNEES, AS MAY IN THEIR PROFESSIONAL JUDGEMENT BE DEEMED NECESSARY OR BENEFICIAL TO MY WELL BEING. I ACKNOWLEDGE AND UNDERSTAND THAT MANY OF THE PHYSICIANS ON THE STAFF OF THIS HOSPITAL. INCLUDING THE ATTENDING PHYSICIANtSJ NAMED ABOVE. AND RADIOLOGISTS, ANESTHESIOLOGISTS, PATHOLOGISTS AND EMERGENCY PHYSICIANS, ARE NOT EMPLOYEES OR AGENTS OF THE HOSPITAL, BUT RATHER ARE INDEPENDENT CONTRACTORS WHO HAVE BEEN GRANTED THE PRIVILEGE OF USING THE HOSPITAL FACILITIES FOR THE CARE AND TREATMENT OF THEIR PATIENTS. I AGREE TO ACCEPT THEIR CARE EVEN THOUGH THEY ARE NOT EMPLOYED BY THE HOSPITAl. I UNDERSTAND THAT THE EXAMINATION AND TREATMENT THAT I RECEIVE ON AN EMERGENCY BASIS IS NOT INTENDED AS A SUBSTITUTION OR REPLACEMENT FOR COMPLETE MEDICAL CARE. CONSENT TO RelEASE INFORMATION I HEREBY AUTHORIZE THE HOSPITAL TO DISCLOSE TO INSURANCE COMPANIES, INCLUDING WORKERS COMPENSATION CARRIERS, OR OTHER PARTIES THAT MAY BE LIABLE FOR ALL OR PART OF THE HOSPITAL CHARGES, ALL OR PART OF MY HOSPITAL RECORDS AS MAY BE NECESSARY (INCLUDING ANY TREATMENT FOR ALCOHOL OR DRUG ABUSE OR DEPENDENCE), TO DETERMINE BENEFITS ENTITLEMENT AND PROCESS PAYMENT CLAIMS FOR HEALTH CARE SERVICES PROVIDED. MEDICARE CERTIFICATION RelEASE I CERTIFY THAT THE INFORMATION GIVEN BY ME IN APPLYING FOR PAYMENT UNDER THE TITLE XVIII AND TITLE XIX OF THE SOCIAL SECURITY ACT IS CORRECT. I AUTHORIZE ANY HOLDER OF MEDICAL OR OTHER INFORMATION ABOUT ME TO RELEASE TO THE SOCIAL SECURITY ADMINISTRATION OR ITS INTERMEDIARIES OR CARRIERS ANY INFORMATION NEEDED FOR THIS OR A RELATED MEDICARE CLAIM. I REQUEST THAT PAYMENT OF AUTHORIZED BENEFITS BE MADE ON MY BEHALF TO THE HOSPITAL OR TO THE PHYSICIAN WHO ACCEPTS ASSIGNMENT. PERSONAL EFFECTS AND VALUABLES I UNDERSTAND THAT THE HOSPITAL SHALL NOT BE LIABLE FOR THE LOSS OR DAMAGE OF ANY PERSONAL EFFECTS OR VALUABLES (MONEY, JEWELRY, GLASSES, DENTURES, DOCUMENTS, CLOTHING, ETC.! UNLESS SUCH ITEMS ARE DEPOSITED IN THE HOSPITAL SAFE. THE HOSPITAL WilL NOT BE LIABLE IN EXCESS OF $50 FOR THE LOSS OR DAMAGE OF ANY PERSONAL EFFECTS OR VALUABLES DEPOSITED WITHIN THE HOSPITAL SAFE. ABOUT YOUR BILL I UNDERSTAND THAT I WILL RECEIVE A BILL FROM THE HOSPITAL FOR PROVISION OF THE HOSPITAL SERVICES, INCLUDING STAFF AND EQUIPMENT, AND FOR ANY SUPPLIES OR MEDICINES UTILIZED. I WilL ALSO RECEIVE A BILL FROM ANY PHYSICIAN WHO PROVIDES PROFESSIONAL CARE TO ME. FOR EXAMPLE, I MAY RECEIVE A SEPARATE BilL FROM ONE OR MORE OF THE FOLLOWING TYPES OF PHYSICIANS WHO RENDER SERVICES TO ME: MY ATTENDING PHYSICIAN OR PERSONAL PHYSICIAN, EMERGENCY ROOM PHYSICIAN, RADIOLOGIST, ANESTHESIOLOGIST, PATHOLOGIST, OR ANY OTHER SPECIALIST. INSURANCE ASSIGNMENT I HEREBY ASSIGN TO AND AUTHORIZE THE HOSPITAL AND PHYSICIANS INVOLVED IN CARE DURING THIS PERIOD OF ILLNESS OR TREATMENT (HEREINAFTER "PHYSICIANS"}, OR THEIR DULY AUTHORIZED ASSIGNS TO TAKE ALL NECESSARY STEPS, WITHOUT LIMITATIONS, TO ENSURE THAT ANY INSURANCE BENEFITS OTHERWISE PAYABLE TO ME OR MY ESTATE ARE PAID DIRECTLY TO THE HOSPITAL OR PHYSICIANS. THIS ASSIGNMENT OF INSURANCE BENEFITS INCLUDES BUT IS NOT LIMITED TO BILLING INSURANCE, FILING PETITIONS, FILING SUIT, IN MY NAME OR ON BEHALF OF THE HOSPITAL OR PHYSICIANS, FILING PROOFS OF CLAIM, FILING PROBATE CLAIMS AND FILING GRIEVANCES AND ALL OTHER SIMILAR PROCEDURES, AS MAY BE AMENDED FROM TIME TO TIME WITH THE STATE DEPARTMENT OF INSURANCE. I ALSO AGREE TO PROVIDE AND SIGN ANY OTHER DOCUMENTS THAT MAY BE REASONABLY NECESSARY TO ACCOMPLISH ANY OF THE OTHER PURPOSES. STATEMENT OF FINANCIAL RESPONSIBILITY I UNDERSTAND THAT I AM FINANCIALLY AND lEGALLY RESPONSIBLE FOR CHARGES NOT COVERED IN FULL BY ANY THIRD PARTY. I FURTHER AGREE THAT SHOULD I NOT PAY THE BALANCE WITHIN THIRTY (30) DAYS AFTER THE DATE OF DISCHARGE, MY ACCOUNT WILL BE CONSIDERED DELINQUENT. I AGREE TO PAY COSTS OF COLLECTION, INCLUDING REASONABLE ATTORNEY'S FEES AND COSTS, COLLECTION AGENCY FEES AND COSTS, AND INTEREST WHICH SHALL ACCRUE AT THE MAXIMUM RATE ALLOWED BY LAW. FRAUD._ ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURA~CE COMPANY, OR FILES A STATEMENT OF CLAIM CONTAINING FALSE, INCOMPLETE OR MISLEADING INFORMATION MAY BE SUBJECT TO PROSECUTION UNDER APPLICABLE LAW. ADVANCE DIRECTIVE IFOR ADMISSION TO HOSPITAL ONL YI IF I AM TO BE ADMITTED TO THE HOSPITAL, I HAVE BEEN GIVEN WRITTEN MATERIALS ABOUT MY RIGHT TO ACCEPT OR REFUSE MEDICAL TREATMENT. I HAVE BEEN INFORMED OF MY RIGHTS TO FORMULATE ADVANCE DIRECTIVES. I UNDERSTAND THAT I AM NOT REQUIRED TO HAVE AN ADVANCE DIRECTIVE IN ORDER TO RECEIVE MEDICAL TREATMENT AT THIS HOSPITAL I UNDERSTAND THAT THE HOSPITAL AND MY CAREGIVERS WILL FOLLOW THE TERMS OF ANY ADVANCE DIRECTIVE THAT I HAVE EXECUTED TO THE EXTENT PERMITTED BY LAW. (INITIAL THE FOLLOWING OPTION THAT APPLIES) _ I HAVE EXECUTED AN ADVANCE DIRECTIVE AND WILL PROVIDE A COpy OF THIS FOR MY MEDICAL RECORD WITHIN A REASONABLE AMOUNT OF TIME. INIT. _I HAVE NOT EXECUTED AN ADVANCE DIRECTIVE AND DO NOT WISH TO DO SO. IN1T. (FOLLOW-UP DONE BY DATE _I WISH TO COMPLETE AN ADVANCE DIRECTIVE DURING THIS HOSPITALIZATION. INlT. I CERTIFY THAT I HAVE READ lOR HAVE BEEN READ I THE ABOVE CONSENTS AND CERTIFI ATIONS AN~DERSTANp AND AGRE~ WITH THEM. OATE, l.c \ C ~ ::. )': .~ .~V'~ +,r '/\ MONTH DAY YEAR SIG URE OF PATIENT OR l.EGALLY HORIZED REPRESENT TIVE '---"'~\"9"~"("~'--J i)1I ft-(LC l.\ <:: /hA ( 4 (hI) f. J4- WITNESS pAIN NA E OF PERSON AEl'OVE I ' AC001S 9312903 0000810047 1[11111111111111111111111111111111111111 11111111111111111111111[111111111111111111111 111111111111111111111111I11111111111111111111111111111111111 P A T I E N T ~.,~ ".'1 . CAR1..ISU: Mt~~ 246 Parker St. Carlisle. PA 1701) Ph;717.249-1.: ~s ~ PATI NT EMPLOYER STUDENT WILSON MIDDLE ADMISSION RECORD 0000810047 D.~,TE OF BIRTH 10/28/1991 PROGRAM PHONE N . PHONE NUMBER (717)243-2098 COUNTY CUMBERLAND IBl. A AD MACNAMARA, 312 N WEST UM N L A RITE AID 5280 SIMPSON FERRY RD MECHANICSBURG PA 17055 RELATIONSHIP TO PATIENT MOTHER RESPO EMERGENCY CONTACT RELATIONSHIP TO PATIENT G U ~ CARLISLE US EMERGENCY CONTACT NAME SUSAN ST 210-44-3603 PA 17013 PHONE NUMBER (717)243-2098 EMERGENCY CONTACT PHONE COMMENTS MSP Dy Il!lN MED. KEY Dy Il!lN PRIVACY NPP ADM!T. BY KAB PRIVACY INSURED' NAME U NU U A AUTHORIZATION s u IN U NAM N R GROUP NUMBER ROUP NAME AUTHQRIZA liON ROUP NUMBER R UP NAME AUTH RllATJQN M DR. A TENDING I ADMITTING I LASEK, ROBERT W MD S I IN C -MVA" "MINOR-I.NJURY - DR. FAMIl.Y f PRIMARY CARE CARUSO, KELLY D. A NO-FAULT -. A -o61ll9/2005 PRINCIPAL DIAGNOSIS (The condition established after study to be chiefly responsible for occasioning the admission of the pattent to the HOSPITAL for care). COMPUCATIONS COMOR610ITY(IES) PRINCIPAL PROCEDURE AD001A 9312838 0000810047 1111111111111111111111111111111111111111 11111111111111111111111111I1111I111111111111I MEDICAL RECORDS COPY 1111111111111111111111111111111111111111~1I111111111111111I Carlisle Regional Medical Cehler Instructions: circle ositlve. backslash ne ative, rovide additional ertinent infonnation. Pt#: 9312838 DATE OF SERVICE: 6/912005 MR#: 0000810047 Pres Time: 16:21 Triage Time: 16:21 T: 97.6 PO P: 88 Regular R: 18 U nlabored BP: 118/075 Sa02: 100 % Nonmall Hypoxia Pain Scale: 6 NAME: MACNAMARA, MARKUS R DOB: 10/28/1991 Age: 13 Yrs Sex: M Wt: 56.8 KG Chief Complaint: MVA--MINOR INJURY Medicines: INHALER o Mos 0 Wks Ht: " Allergies: NKDA EDP: LASEK, ROBERT W MD PCP: CARUSO, KELLY D. Arrival Mode: ALS "^ J~ C I C I HPI: (Narrative): Family EMS NH Translator Limited by: ALOC A Y / N EMTALAMedlcalScr.en: Emergent 0 Non-EmergentD I~~ ~'-( 5;+6- -- 1<-.." _LI'^'- h..-- +' Timing: Sx starte~ I gradually _ min./ hrs./ days 1 wks. ago : continuous 1 intenmittent r ."'11>, Duration: Sx last min. 1 hrs. I days I wks. at a time : presenll absent 0 ~JI> ..... \J-- Location of Injury: ~~(n~ c~~ a~erextR/L . lower~ (;:).............'-.,\v- QUality.: _~nbe fall I he,gl1f _ It crus" "'Ju,y puriCRea- k'c~GSW Slatrwound-__ P SE!V'erlty~oderate sev~ 1-10scae_ life threatening L ::;::at~S:~~~;:~~:' '1t~4;~ :Z!!t- found unres~eved by: n~ rest ice OT:::S. --r '-- ") , Assoc. Signs & Symptoms: none WL ~.abdo~ bleeding- defonmrnes-- HEH ,-,"') JJ"",I.-"f~ ......' -I- c.^- !:of.. L..--J c-'-,vr ( ;/ '" ~~ O~'-'-'- ~ s:L~ \.J">'> dr:,(,'" C:..> --<.. C- . REVIEW OF SYSTEMS L1l1lltedDu~To: ALOC Constitutional: fe';~iIIS'-weakness ~ ENT:.~e throat .. ea~al pa~ Eyes: / paTn---vts'ual changes Cardiovascular: ~lpilatio~P~ Respiratory: ~_c.ouflh--<:JJngestio~ GI:!; ~_ms!lhea.t.a5nsnpattorr- pafii- melena hematemesis GU' flankDain dysur.i3-.... oc...*....i.-; . -rre=:--.qu~ncy. . Musculoskeletal: .. J~~I_~_~:~_~~__~~I~_~ I::2fAll:Q.ther Systems Reviewed 'fiJ,u -;. t: Negative . .. I DD..M.t.W1DDM Past Med. Hx:(""ASTHMA MedS~AtEF/ Allerg~ fV^I.Jr. --.-- Surg. ~-~f1'- AIJP9--- - Tonsillectomy Family Hx: negative Social Hx: day care student occupation~._ Tobacco: Y I ~;~ Years Immunizations: Up-to-date: Y I N Reproductive Hx: LMP: G P Pro-MED Maximus CCopyrighl2001 Pro-MED Clinical Systems. L.LC weakness confusion Integument: Hematologic: Allergy/lmm.: Other: lesions alltllll:... rs transfusion hives R / L Handed /eviewed ~eviewed ~iewed Lives Alone: Y I N ETOH~. Tetanus: Dru9~ AB Pediatric - Trauma - Page 1 of 2 Rev,03l0Sl04 Carlisle Regional'Medical Centl>. NAME: MACNAMARA, MARKUS R Instructions: circle ositive - backslasll ne ative rovide additional ertinent information. GENERA~A'o HEENT: AT CV: I VITAL SIGNS: T97.6 P88 .....~ vt.,......~ distress '-...... - R18 ;:)~ BPl18/075 location/Description of Symptoms: X-Ray: C-spine: MEDS: C-T ~ l-Jo ,0....0 CXR: -, 'ZC( .....-, <9 IVF: ~(,- pelvic C. -<; I'Wo.. (;? !-<- FOLEY: Improved Same Worse Critical Care: 30-74/75-90 191-104/105-120 121-134/135-164 Minutes D Excl. billable proc. RESP~S clear I ual bilatera-,-. resp. effort8-tress r ...._Ahunchi ~es -- GI:~; flat I' / bowel soundS~ . r 1 non-tend guarg rebol:':"'1 rigi<iil(" MS: c ubbing cyanosis edema SKIN: wa~ diaphoretic rashes NEURO: C~tact DTRs equal 1 symmetric PSYCH: ~ pi~ppro~ LYMPH: adenopathy GU: NL I deferred Other: o I..e::") ;1 ~i I'" .~ '2, "") ~-i \ A-<O- ? . (j. . t\ ~ '5 t..-.\-.- J..l D Labs reviewed and are negative NLI ABN NLI ABN DIFF S B L WBCs RE-EV AL: C.T.: head 1 abd 1 pelvis EKG:NSR no acute disease NG: UA: SG Prot RBCs UCG: +1- Other: % NL I hypoxia Pulse Ox: ABG: pH 02 C02 COX: concussion cervical strain Fx laceration hematoma skull Fx pneumothorax shock spleen injury contusion child abuse other. ~--'\ I' , I, ~ <;0, /! r)l~ (~~ <- ~\ ~I'l~- t~ Time: CLINICAL IMPRESSION(S) DISCHARGE INSTRUCTIONS c:t d.- el.-- ~ 5. vY' \"...,.. . r--.:...' h-"'fw-, ~ \~. "). c..-.."-'-1" 'tJ Discharged to: Home Nursing Home Family Follow-up with Patient's Or. in days. Other Instructions: -F~ URN TO ER IF CONDITION WORSENS. CONSULTATION DISPOSITION Discussed with Or. Admit Follow-up in Office Old Records Reviewed Y I N Reviewed OIW Radiologist Y I N Case OIW Patient I Family Y I N Discharge Time Out: Admit: OBS leu PCU Floor Tele. Transfer: AMA: DOA: OR Prescriptions Given: lJ.-(.\ l5 d4 o ee procedure form attached MD/DO Record Complete D Pediatric - Trauma - Page 2 of 2 Ruv03l06104 Signatures: Pro-MED Maximus <!:lCopynghl2001 Pro..MED Clinical Syslems. LL,C. Carlisle Regional Medical Cel.Ler Instructions: circle ositive - backslash os alive rovide additional rtlnent information. Pl#: 9312838 DATE OF SERVICE: 6/912005 M~#: 0009810047 Pres Time: 16:21 Triage Time: 16:21 T: 97.6 PO P: 88 Regular R: 18 Unlabored BP: 118/075 Sa02: 100 % Normal I Hypoxia Pain Scale: 6 NAME: MACNAMARA, MARKUS R DOB: 10/28/1991 Age: 13 Yrs Sex: M Wt: 56.8 KG Chief Complaint: MVA-MINOR INJURY Medicines: INHALER o Mos 0 Wks Ht: " nergies: NKDA EDP: LASEK, ROBERT W MD PCP: CARUSO, KELLY D. Arrival Mode: ALS LACERATION REPAIR Wound Location: F-c./'-L Laceration Size: '/ cm Distal neurovascular status: tendon function intact vascular intact sensation intact Depth: utan ou muscle tendon bone Shape: rregul a stellate avuision Contamination: leB foreign body Anesthesia: ~ digital block ~ cc's /'r%iidcl 2% lido .5% marcaine ~ w/bicarb ~ Wound Prep: '---oeraaine hi!j!clens~rreTrrigati~. debridement exploration Repair Closure; ~kin #. --"'-~lt"re---6D> staples Dermabond ~~rupte~ing mattress horiz I vert s neous # _ _ - 0 vicryl silk simple interrupted running mattress horiz I vert fascia I muscle I tendon # _ _ - 0 vicryl simple interrupted running mattress horiz I vert Sterile Dressing Applied: ~ Other: SECONDARY LACERATION: c..\........k, .y steri-strips Wound Locatio.,: Laceration.Size: em Distal neurovascular status: te n function intact vascular intact sensation intact Depth: superficial bcutaneous muscle tendon bone Shape: linear If gu ap stellate avulsion Contamination: oreign body ~ Anesthesia: . ital block -L cc's ~ 2% lido .5% marcaine epi w I bicarb Wound Prep: adine n hibiclens - saline irrigatiori.-aebridemenl .ejf~lorafion. Repair Closure: ski - 0 prolene~ staples Dermabond steri-strips simple inter running m~ horiz I vert - 0 vicryl silk simple interrupted running mattress horiz I vert fascia I muscle I tendon # _ _ - 0 vicryl simple interrupled running mattress heriz I vert Sterile Dressing APPlled:~ Other: Patient tolerated procedure well: Y/N Discharge instructions given: Signatures: <IJ.-- fjARNP Pro-MED Maximus O::Opy~trt 2001 Pro-MED Cllmcal SY'ltems, LL.C MD/DO Laceration Repair Rev03ro5/Q.4 ORDER PROCEDURE FORM ORTHOPEDIC EMERGENCIES lisle Regional Medical Center Name:MACNAMARA, MARKUS R Pt#:9312838 Age: 13YRS DOB: 10/28/1991 Sex: M MR#:0000810047 EDP: LASEK, ROBERT W MD PCP: CARUSO, KELLY D. Date In' 6/9/2005 Time: ?e,;: , cc;.. ;" ";C;b...;H~ .,. ... Order Time Ord"'Sen By (derTjmE R;ld1Q199Y O,"",rSent BY CBC CXR IP A1LA T - Portable' BMP CMP -~ .~ Sed Rate y, Uric Acid I L z:;7 t":o '^-"-c~ ) A RA Factor '-;:z7 '" ;'1.." 1 H:f.-. }l.':>\ -"N I r Drug screen (serum), (urine) I ETOH ((, <c;; y-~ L;I.... 'L . ".....:'<;: 1<.\-..( Type & Screen or Cross # Units CardloDul on"'" +-,.11 L.'{. EKG UA ABG Bela HCG 02 LPM . (6'" J - r -r-- c-<:rv"L.,,-l <;r, ..-z..'-t Mls",'pi-ders M~~lq~I,Ne.~~~~Ltyl~fonn.~t1e~; I I - -0' Previous Medical Records ./ ~" !?rv Physical Therapy - Eval & Tx lIVlIlg' Ills:: ~gS:t;S6. ,.......,....:d.."_}..: Orderc:Time c, Medt<;ationf D.O$ageLI'l"uteCVO : Read aacl<f A M\ Adrnby cS1le Tim :'0 PaW riillals \I)~ (Yl o\r\ Y') LtCO VVtl kt D \J,o \12,)" ~ IOD o Improved o Worse o Unchanged ...j 0 o Improved o Worse o Unchanged 0 o Improved o Worse o Unchanged 0 o Improved o Worse o Unchanged 0 o Improved o Worse o Unchanged Order Time. clV! lioluliQ.~IAdded Medication.' lilertTimeDevice I Siz" Location #i\ttempI$AmOunt 'StartW D/QTime ,AlnUnfUSed ... DlCby o KVO Device: o IV Fluid: ........ .Y....c...: ...c,.. .'\..c'.'.,.:c,,,,,,\...;..c .\c......'.c :,..;"C Yi "',:,,,5;~ ':C. o Cardiac Monitor Rate Rhythm o Splinl Application o (Local), (Regional) Anesthesia o NiBP Monitor o Pulse Oximetry o Ace Bandage Application o Conscious Sedation o (Gold), (Heat) Application-. [] Sling Application ... 0 Laceration Repair - o Wound Irrigation o C~Spine Immobilization o Cast Application o Dressings o Foreign Body Removal 0 Fracture Care (open), (closed) Discharge1nstrucUons.. .. ((.. ."( ..... ...... ..,').H.,c( .........(.,\ ... ., '....:.'7 .,," '("i;(; ~~sISist~) ~ Initials/Signature: Initials/Signature: A~S}i9~~ 1 , , PAlARNP: // ----- Physician's Signature: vr --..::.. - ;/ Rev. 09114104 EMERGENCY DEPARTMENT ONGOING NURSING ASSESSMENT " lisle Regional Medical Center Name:MACNAMARA, MARKUS R Pl#:9312838 Age: 13YRS DOB: 1 0/28/1991 Sex: M MR#:0000810047 EDP: LASEK, ROBERT W MD PCP: CARUSO, KELLY D. Date: 6/9/2005 NU~SINGDIAGNOSIS.'(NlJrnb$rJ~.pr~erof'prlolitYiiEac:l)pab~n\.l1)uSI.~ala.allea.~~..oh...~I"l'l~d,);;;i" . ;~0IB~C:~rri q0.rL;~i:,ji;;;i(i;i:i;;;;:yYlil'l~j['Hv0:1~<if;~i/%itij;~!I:~tr~~#':r(:;(' .. Airway Clearance, Ineffective Communication Impaired Infection, Potenbal Self Care Deficit -Anxiety -Coping, Ineffecbve Injury, Potential --Skin Integrity Impainment -Breathing Patterns, Ineffective -Fluid Volume, Alteration in -Knowledge Deficit -----rhought Processes, Impaired Cardiac Output, Decreased Gas Exchange, Impaired Mobility Impaired _Thought Processes, Alteration in _Comfort, Alteration in _ Hypertl1enmls (Fever) Non-Compliance _Tissue Perfusion. Alteration in Other -Other The GOAL: II>I.AN (o(lhiSballehliStoassisl inTT1~e\ln"'derilified llei>ils"nainitlat~rnt~i'lenliOnS fortID:Y.~\;;i!r :'?'\iO::/;\<<':" <<~?j:t: ~~ilfiif:~gPi;; ;r~ity:':,~~{~:,y; -: Not Not Not Mot Mot Int Mot Mot Int Mot Mot Int o FB REMOVAL o IMMOBILIZATION I PROPER ALIGNMENT o IMPROVEMENT OF BREATHING o BLEEDING CONTROL o DECREASE I PREVENT SWELLING o STABILIZE PATIENT IN DISTRESS o PAIN CONTROL o MAINTAIN STABLE HOMEOSTASIS o meet ENVIRONMENTAL NEEDS o ALLEVIATE NN o MAINTAIN SKIN I TISSUE INTEGRITY o meet PSYCHOSOCIAL NEEDS o FEVER CONTROL o PREVENT FURTHER INJURV o meet SELF CARE ABILITY NEEDS o DECREASE ANXIETY o MAINTAIN I IMPROVE CIRCULATlON a meet EDUCATIONAL NEEDS o SAFETY IN THE ED o INFECTION CONTROL COther Int: N = documentation in nurses notes, other 'codes' per Hospital Policy. '~1r.~~r >;,..' .,e~~ >,.......,... ~ hI; ......;... 02; ,::,NGJli: CardiaC., ibi;; Pain T!;>; -<'c- 'Time .f>,i; .Sat Emeii. MQnhOr; ~hh! qcs s8alE 1(P~S Qe.e.. 0 . ""'C\ ~ EmS 0" ' ~ _\ So n\"- \~ , \"Y\ \r 0\ ,,,,,0- ~o"" ) ~ D\ "'" u O~ ~[ ()~ Q ct'V....S'3.. Y\C1 o ue...'l reJ.1 ~, c.J' o ^, ~ n r " \'€... '\ 0- :::J, U-I., a (fh ~ -::. " ~c t. p+- lr ILl: a....b"ClJ.. S \ IW, <: (Y'-C ~ So .., - -> . - OJ>e ,,-1. >, S, 0\s"" .. - =h,,,, h_ - b \.]1 , ..:: -x.. - - Il,;3{p rA 'S-\:ru, "" \'0 --\-c:, .~ ~ !u . oA ^ ;S" I - , ILo4S 10 L"\ d \X-'(""W, - e.c. v-.. 1;::- ( ~ ~ f-S <J - illS Dc:?...C..Y ' ~ In _.4., +a p.A({) rY' . Co.->-\-t h., '" G lr_ ,I-( <::. """"0 D~ S, J /l~ AI'Y'I~-kr-\ -h--. Y75C. '" \ .l -e,\- 0 I. lri-\ \ VYl 6-t 1~'lo/1. (' .3- ~u 0<:::' -\-0 ~ 'VIm P . ,) VV-' -t- ( ~~. "' . r + b ,.., , '" .x'l-\-'< b+- YY'\'IJ - G~ ~\. . t Ilif:, ('Yt.QJ1 C c--k..~ ~, ~In .< ~'f - - ..... . -. . 4-. . ^ , J. b t?;'50 S\e. - _Y'O. <4- ~y JJ.c. ff!\ ' , \J ::S J 0""' SH' - l) IA(CL 'S\p, B lC/3D Col"'\+-"'~ c '" l r-r. Discharged in care of: mo+tcR. .- t:r1\fnb OW/C oSlret 0 Carried T -;:) Discharge instructions given to I"Y"C-\-Lu.V' ~rbalized understanding \ '" '<<m~, Sn Admit: Room #: to Dr. Ready for Room Time:_ Amb. Orth ('Q ~ d L-U:; c..u.: -L..." - ?a:t:J . Report called at and given to U C\ Transfered to [J Transfer Verified S/J Report called at and given to 2J'FcD DL:;'ch~~ l'LoY'lLe. . s+ Lk o Left without treatment o Left Against Medical Advise Ur-rJr:/ Condition at Disposition: Dlmproved ..astable o Serious o Expired UV\,d,.QAS ~vvL"",,-c c;~ Pain Scale: ~ Pain Location: 1y, ~ ..-.. ....I -.) / Patient reports that pain iS~tZImproved o Unchanged DWorse IY/S+Vc-HOY75 l&-t- - Disposition Vitals: T q I P ~ R I Lt BP 117 h () 02 m 6 lV\.e>-\-t \..u\ OiC /. Disposition Date: (g 19 Time:2cRJ Nurse: S7 A . u Rev. 03/05/04 EMERGENCY DEPARTMENT PEDIA TRIC NURSING ASSESSMENT Date In:6/9/2005 Time: Y Subjective Notes: "lisle Regional Medical Center Name:MACNAMARA, MARKUS R Pt#:9312838 Age: 13YRS DOB: 10/28/1991 Sex: M MR#: 0000810047 EDP: LASEK, ROBERT W MD PCP: CARUSO, KELLY D. Pain i>iAJPatiel1t,del1ies Location: {\U.>.\\-'~I.::. ().ACD.."!:luality: OSharp ODull Mode of Onset: 0 Sudden 0 Gradual 0 Intermittent Onset: Date: Time: Duration: Onset> 24 Mrs. medical attention was sought? oNa aYes Radiating: DNa DYes (speCify) Psychosocial,:;', OCramping OBuming oAching 0 Rating Scale: MW~A~E~ME~ ~~: ~~~~~~ o 2 4 6 8 10 Caregiver: ...JaParents oMother oFather DOther: Accompanied by: V"'C\~ Appearance: Delean o Unkempt Activity level: o Awake o Playful oOther oOther oSmiles I Laughs Environment: DNa steps 0 Few steps OMany steps Nutritional status: o Normal 0 Cachetic 0 Obese Religious I Cultural preference: 0 None (specify) Best learn by: (pt I caregiver) oVerbal oWritten oRetum demo Learning Barriers: Neur Awake. ORestless :: ,>:;; ;; ':!<;'~:>,;;"'>'(~ ;"': pup~lsiiZe and i'e Cardiovascular . Skin:".'" .......,-arm ,."""'-'oCool. :;oMo ." ",*,'s<,:,'!>,~:.,r,:;:..;!:;;:;i:~n.~;0;",;>;,:;,:;,' ,'\',"'r :'.:,. .,:.' .. .Color...OPink o Pale. OA~..n' OFIU,\h~. aund. 'd"""',"',-"""".'." '..",',',Q;,.,,;''i.;/;.,.' ",,,,,,;C;"''''.'"'''':;''''';'''''':'''4::.>/...::~;,;.:,h, .;" Capillary Refill: 0 <2 Secs (Normal) 0 >2 Secs (Delayed) Turgor: 0 Normal 0 Decreased Pulses: L Radial: 0 Present 0 Absent L Pedal: 0 Present 0 Absent Abdomen: 0 Soft 0 Flat 0 Rigid 0 Distended o Non-Tender o Tender (Area) Bowel Sounds: 0 Present 0 Decreased 0 Absent Elimination: o Normal DConstipation DDiarrhea #ofStools: Voiding: o Continent o Dysuria Other findings: o Incontinent o Frequency o Diaper Color: o Potty trained R Radial: 0 Present 0 Absent R Pedal: 0 Present 0 Absent Cough: 0 None Lung Sounds: o Clear 0 Wheezes OR OL DR OL o Non-Productive MusculoskefetalA ;;h:)H~~~:H;,t'('-2'<:>-;; ;;;:;;,<:';;;;i!':?.J#fjii'\~;;~;;:;: ;;;!;,;;<;iONot Assessed Lacerations I Abrasions I Contusions Location: Size: Bleeding: DAbsent o Present DScant DModerate o Heavy 0 Pulsating ROM: 0 WNL 0 Decreased 0 Absent Edema: o Absent 01+ 02+ 02+ DefonnityOYes ONo Scars: DYes 0 No Distal pulses: 0 Absent 0 Present DRhonchiCCrackles o Diminished DAbsent OR OL OR OL OR OL DR OL DNEW BORN Age 0.1 Month DINFANT 1.12 Months Language: DCnes Often DSmiles DCoos I Gurgles ElBabbles Born at Tenn:DYes DNo Delivery: DVaginal DC-Section Diet: D Breast Feed DFormula type: Uses: DBottle DSpoon DCup Elimination: 03 - 8 stoots a day Other: Activity: Lifts Head: DYes ONo Sits up: Dwith help 0 without help Crawls: 0 Yes 0 No Teething: 0 Yes 0 No Observation of interaction with caregiver is 0 Appropriate OSee Nursing Assessment DTODDLER Age 1.2 Years 0 Pre-5chool Age 3.5 Years Language: DFew Words oSentences 0 Easily Understood Diet: OFinger Foods ORegular Diet OFeeds Self Uses: DBottle 0 Cup Teething: DYes ONo Elimination: 01 - 2 Stools per day DDiapers DToilet trained oWets bed: 0 Rarely 0 Occasionally Activity: Walks: 0 Yes 0 No DWalks with assistance OWalks Independently Observation of interaction with caregiver is 0 Appropriate OSee Nursing Assessment OSCHOOL AGE Age 6 .11 Years .;:tA.DOLESCENT Age 12 -18 Years Reached Puberty: Yes oNo Diet: ~ats 3 meals/day 0 Eating disorder: (specify) Elimination: 0 No problem reported 0 Wets bed: DRarely OOccasionally Social Habits: Smokes DYes ~ ~AICOhol: DYes DNa Observation of interaction with caregiver is p1'-ppropriate OSee Nursing Assessment Vital Signs: 16:21 T: 97.6 P: 88 Regular R: 18 BP: 118/075 DFrequently Learning disability: 0 Yes Wears Braces oFrequently Uses Drugs: 0 Yes oNo School grade: DYes ONo Nurse Signature: Rev. 03105104 DATE: 06/09/2005 DOB: EDP: PCP: MACNAMARA. MARKUS R 10/28/1991 AGE: LASEK, ROBERT W MD CARUSO, KELLY D. rlis/e Regional Medical Center Pt#: 9312838 Sex: M MR#: 0000810047 INITIAL ASSESSMENT FORM PRIORITY: 3. ' Patient: Urgent 13YRS Worker's Camp: Emp, Referred: Presentation Time: 16:21 Triage Time: 16:21 Arrival Mode: ALS Height: Chief Complaint: Weight: 125,0 Ibs, 56,8 kgs. LMP: MVA-MINOR INJURY Last Tetanus: Acc By: Vital Sians T: 97.6 PO P: 88 Regular R: 18 Unlabored BP: 118/075 02: 100 % RA Pain Intensity Scale: 6 110 Pain Location: Multiple Areas Brief Assessment: BACK SEAT PASSENGER IN 2 CAR MVC, DAMAGE ON DRIVER SIDE, NO SEAT BELT, REPEATIVE TALKING, LAERATION ABOVE L EYE. R SHIN PAIN, ABRAISIONS ON L SHIN, NIGHT SWEATS WEIGHT LOSS ANOREXIA NO NO NO HEMOPTYSIS FEVER NO NO SAFETY RESTRAINED DRIVER AIRBAG DEPLOYED NO NO NO NO Sudden Onset: Pre~Hospitar Treatment: Pediatric G&D App, for Age - N/A, Immunization UTD - N/A, Height ft in., Head Circ, - Grade - , with Assessment: Past Medical ASTHMA History: Allergies: NKDA Medicines: INHALER Nurse Signature: ~ --.. SEN Additional Notes: "Tb oa VY) ( (" 2.0 s^/ Rev 05/18/04 :arlisle Hospital -- EmerClencv Deparlmr !46 Parker 51. Carlisle. PA 17013 -- (717) _ .5-5500 -. Macn 6/9/05 3ra. Markus 17pm 0810047 JISPOSITION SUMMARY Patient: Macnamara, Markus SS#: CURRENT Address: City: AQe/DOB: Current Ph: Medical Record: 081 0047 Zip: Arrival: 6/9/05 6:17pm Disch: 6/9/05 8:16pm Disposition: MD ED: Robert Lasek MD Res/PNNP: Duane Stroup, PA-C Dx #1: Concussion (Unspecified) ICD-9 #1: 850.9 Dx #2: Head Injury, Superficial (Unspecified) ICD-9 #2: 910.8 Dx #3: Facial Laceration (Unspecified Site) ICD-9 #3: 873.40 PMD: PMD Ph: #1 Dx EnQI: HEADINJ.ESW #1 Dx Span: HEADINJ.SSW #2 Dx EnQI: HEADINJ.ESW #2 Dx Span: HEADlNJ.SSW ~ #3 Dx EnClI: LACERATS.ESW #3 Dx Span: LACERATS.SSW Follow-up: EMERGENCY DEPARTMENT CARLISLE REGIONAL MEDICAL CENTER 246 PARKER ST CARLISLE, PA FlU MD Ph: 717-245-5500 FlU DfT: Tomorrow after 9 am Other Instr: rest, ice packs, Motrin 200mQ 2 tabiets every 8 hours as needed, sutures to be removed in 5 days, return to the ER sooner if problems. MY SIGNATURE 8ELOW INDICATES: > I have received and understood the oral instructions reQardinQ my current medical problem. > I will arrBnQe follow-up care as instructed above. > I acknowledQe receipt of the written instructions as outlined on this and any previous paQe(s). I will read and review these instructions. ~ X .& A DlJ;yV r~u 7leVYYlJt'leG x~,<J - Patient (or LeQal Guardian) SiQnature aft (Witness) SiQnature CARLISLE REGIONAL MEDICAL CENTER RADIOLOGICAL INTERPRETATION PATIENT NAME: MACNAMARA MARKUS R X-RAY#: 810047 EXAM DATE: 6/09/2005 ORDERING: ROBERT W LASEK,MD 245-5500 ATTENDING: DUANE A STROUP,MD 717-4977 CONSULTING: KELLY D. CARUSO,DO 789-3553 HISTORY: MVA--MINOR INJURY MVA--MINOR INJURY MED REC ACCOUNT D.O.B. : ROOM: #: 810047 #: 9312838 10/28/1991 ER ~/ RIGHT TIB FIB - TWO VIEWS HISTORY: Trauma. No fracture or other bony abnormality is seen. No soft tissue abnormality is noted. IMPRESSION: Negative right tib fib. REVIEWED AND SIGNED ERNEST CAMPONOVO, M.D. INTERPRETING PHYSICIAN DATE DICTATED: DATE TRANSCRIBED: DATE SIGNED: TRANSCRIPTIONIST: 6019290 TmIA & FmVLA AP & LAT 6/10/2005 6/10/2005 11:01 6/10/2005 11:48:44 JND E.R. PAGE 1 OF 1 CARLISLE REGIONAL MEDICAL CENTER RADIOLOGICAL 1NTBR2RETATION PATIENT NAME: MACNAMARA MARKUS R X-RAY#: 810047 EXAM DATE: 6/09/2005 ORDERING: ROBERT W LASEK,MD 245-5500 ATTENDING: DUANE A STROUP,MD 717-4977 CONSULTING: KELLY D. CARUSO,DO 789-3553 HISTORY: MVA--MINOR INJURY MVA--MINOR INJURY MED REC ACCOUNT D.O.B. : ROOM: #: 810047 #: 9312838 10/28/1991 ER ;( CT SCAN OF THE CERVICAL SPINE - UNENHANCED - WITH SAGITTAL AND CORONAL REFORMATIONS HISTORY: Pain post trauma. CT scan of the cervical spine shows normal alignment and prevertebral soft tissues. The disc heights are normally maintained. There is no evidence of bony stenosis. The study shows no evidence of a fracture or of a pathologic subluxation. CONCLUSION: Normal CT scan of the cervical spine, unenhanced with reformations. REVIEWED AND SIGNED ERNEST CAMPONOVO, M.D. RICHARD KRAUS DICTATED BY DATE DICTATED: DATE TRANSCRIBED: DATE SIGNED: TRANSCRIPTIONIST: 6019292 CT CERVICAL W/O CONTRAST 6/09/2005 6/10/2005 16:46 6/13/2005 8:30:39 JND E.R. PAGE 1 OF 1 CARLISLE REGIONAL MEDICAL CENTER RADIOLOGICAL INTER~RETATION PATIENT NAME: MACNAMARA MARKUS R X-RAY#: 810047 EXAM DATE: 6/09/2005 ORDERING: ROBERT W LASEK,MD 245-5500 ATTENDING: DUANE A STROUP,MD 717-4977 CONSULTING: KELLY D. CARUSO,DO 789-3553 HISTORY: MVA--MINOR INJURY MVA--MINOR INJURY MED REC ACCOUNT D.O.B. : ROOM: #: 810047 #: 9312838 10/28/1991 ER ~o~ . CT SCAN OF THE CRANIUM - UNENHANCED HISTORY: Pain post trauma. The bony calvarium shows no evidence of a fracture. There is prominent soft tissue swelling and a laceration of the left supertemporal and frontal region. Underlying bony structures are intact. Intracranially, there is normal ventricular size without compression. The cortical sulci and subarachnoid cisterns are normal and there is normal gray matter/white matter attenuation. There is no evidence of edema or hemorrhage. No compressive lesions are seen, either intra-axial or extra-axial. There is no orbital abnormality seen and the paranasal sinuses are normally aerated. CONCLUSION: Cranial CT scan unenhanced shows no intracranial abnormality. There is prominent extracranial soft tissue swelling and laceration in the left frontal region. REVIEWED AND SIGNED GEORGE BRODER, MD RICHARD KRAUS DICTATED BY DATE DICTATED: DATE TRANSCRIBED: DATE SIGNED: TRANSCRIPTIONIST: 6019294 CT HEADiBRAIN W/O CONTRAST 6/09/2005 6/10/2005 16:45 6/14/2005 16:18:09 JND E.R. PAGE 1 OF 1 '- Pennsylvania EMS Report _1'1_ l!'- lU"'-A~ ItcaN.. 1~l2oe5 W_ Sllonl EM!! ISOOlioa '_-21_ _376 -~ .........., A _ ZIp ! PSAP IMl/. ~ .....__ofW_er"MIl RoM &_ Tyooao TOWIIllIlip I LoymIo, 11007 CC8Q99I _1'1_ Irt-W'" "'-1'1.. - .........,. ~ MtrkusR.MIc_ ~71 n ~'3-Z"" f'~~_c- = _A_ ~p "'JI~T""l' P _37 ~ 312 N. W... S..... BY..,. .... ClOy - Zip BOa ",n 1:1 c_ I'A 17013 111/28/1991 "n ~ ..... 1"_" _Set. ~ ~. ...04 :d 0000I1 ()(M 7 205. n-SfS) F_ ""- II ..........,.." 11:1.. _.....u.- o.c Oo-Saw -. .. "' =- ....... 15;22 . - lS;22 T=.........._ u.. "'_os -- 15042 Ic:t 1\-1.. . .l IBll c_ IN) ....... o.-_e -..c_""_ Me TiIH ...... Set.. INS Tr A__ l'oJO ...- )6;17 "" 16017 QieI' C - .... . C__ ....- -. .u.. In_ ICCI narntiY~ Narrative PMHx: see narrative Medications: a/butero/ inhaler Allergies: nkda PMH: asthma Dispatched for: mva with Perry Amb's 48,39; 89,19, & Perry Medic 81-c1ass 1 response. Medic 163 responded immediately. No information was given by Perry County EOC. Arrived to find: this 13 year old white male fully immoblized laying supine on the ambulance stretcher. pt in attendance of the BLS Crew. HPI: !Iccording to the BLS Crew, there was a 2 vehicle mvc apparently head on. They stated this 13 year old white male was apparently a back seat passenger behind the passenger seat. They stated up their arrival to the scene, they encountered the pt already packaged fortranspQrt. 8LS stated that ttle pt was apparently !I unrestrained passenger, stl'\lck hIs head and legs. ALS is called. Upon ALS arrival, pt is found in no acute distress clo a headache & R-Ieg pain. He denies any chest pains, sob, n/v, diaphoresis, weakness, dizziness, or blurred vision. BLS staled there was minimal fronl end damage noted to the vehicle lhe pt was riding in and no interior damage was noted. There is +repetitive speech note.>d. PE: pt Is CAOX3, skin is pink, warm, & dry, there is +smalllaceratlon noted above the L-eye with bleeding noted, controlle<l by bandages, no other head trauma noted, there is no blood or fluid noted from the ears, nose, or mouth, pupilS are pearl, there is no jVd n trachea i . - n J>rinted On: 06/09/200S 17;S9 Provider 0..-. '._..:-.. ~ e .... VI ~ -...J 0\ -...J N 0\ i-" -...J ~ -4 \(> Pennsylvania EMS Report Senke Na..e UaitN... fCKl'I.. IDoft W~1Jt Shere EMS I S";cn - 2102266 3&4S376 06I091200~ ',uut N.-.e '1-........ Social Sec.rtty N.."" I*=c ....... c- . ...,... Matkus R. MacN...... 100111991 205-72-56l3 there is no trauma noted to the c-spine area, chest is symmetrical with equal rise, there is no paradoxa I movement noted to the chest, lungs are clear bilaterally, abd is soft & non-tender, peNis is stable & intact, there is +pain, abrasiOns, bruising & swelling noted to the R-Iower extremity, there is +sensatlon & pedal pulses noted, therE; is +abrasion noted to the L-Ieg, however, no deformities are noted, there is no trauma natee' to the upper extremities, there is no trauma noted to the back area. ~ = .&:0. l.II ~ ..... =" Treatment: see detailed flow chart. Outcome: pt remained stable throughout transport. PI transported class 3 to CRMC ED, report given to staff at bedside. HIPPA form signed ty the pt's mother. ET ~w ,. Ti,. P It B.P. '10><. cO! ~ T_t - ....,...,c- 15030 C..sDillc~ /OJ) 15:31 c.m..I e_ N) 15;33 _...... _.1- AC 15:35 co! - /OJ) Il:" 86 20 10216a 4/l/6 ~ VS: II.,. E""'" NOIll1Il, _.100: _I l!:42 I " ... ~ 15:43 I " _t 044037 .... . eo... ditVeW INS I " _CI<MCED c.... , 15:46 _I EKO AI ~iftus IH7 I 100 " DdtMOk Q4.to ItA 15;50 I " ............' M4Ol7 '''_",oR 1l:11 I " .... ..... _37 ,..- 15;51 84 20 116n4 413(6 vital_ BLS .... E_: _ Ptrt\nIioa; Normal 16:00 I " w~ - _'7 1.._- I: 1 " ALS_ 0441137 .._- 16:0:5 , " -...... _37 1._- 16:07 - EKO AI SiIlLlS 16:08 80 20 118/80 100 4/5/6 vi"'l BLS II..,. E_ N_; NOIll1Il 16,10 I " arrived CkMC ED C.... ..--.......-.. - ...... N =" ~ -..J N -..J \Q Printed On: 06/0912005 J 7:59 --.." ..;. ....... r11Cfc~~a(!!1a{-.;j ~ jt.'-:;,' t2. . 55 <:t dJs--1~-5Y;-3 ,~/ r; (t)s IYtsU-cc.. d13a 30453?~ :J i ., , 1 , f.. i ,.1 I 1 MI I L , ! !'. ! i . I i I I . _.; i..L ,'+i! : ....1.. : ; :..J_1i_J i . I: : I. I...' 1'."1 r, .' ;, ~~ '--, J.., ._._.1 ,. . I," '1 !~ ---1-- ' . ': , I' , [. .' . ~ ! ! : : ii, I I : t5v?fi!!: I. ... IiITFSTiTllllJi3l113t'it~Mi~~ , . I . i I I .i i . ! : : i I : 11.8 ~_ ~~:u.; , , In ji 'eI:Z2\l:n. .:--' I! f .1 i. ( I , I I , , I , I .0 ." , . ... ~ I [,.,J ~ i..+ i : I . I -;-1 ,", iT ; +"--r I._.~_....I. ..i.!-. .-.: ! j , .".. ft. '~l' T I;. .: I .djl1_ J-J i. 1 1.1 .1 '- rn~C'DI;CI.I:: REC~ I.uOIC'^I.~ 246ParkerSI. Carlisle, PA 17013 Ph:717-249-1212 CONDITIONS OF TREATMENT AND ADMISSION PATIENT'S NAME ACCOUNT NO. MACNAMARA, MARKtJS R 9312838 ATTENDING PHYSICIAN LASEK, ROBERT W MD DATE & TIME OF ADMISSION 06/09/2005 16 :21 CONSENT TO HOSPITAL CARE AND TREATMENT I AM PRESENTING MYSELF FOR EMERGENCY SERVICES OR ADMISSION TO THE HOSPITAL AND I VOLUNTARILY CONSENT TO THE RENDERING OF SUCH CARE. INClUDING DIAGNOSTIC TESTS AND MEDICAL TREATMENT. BY AUTHORIZED AGENTS AND EMPLOYEES OF THE HOSPITAL. AND BY ITS MEDICAL STAFF. OR THEIR DESIGNEES, AS MAY IN THEIR PROFESSIONAL JUDGEMENT BE DEEMED NECESSARY OR BENEFICIAL TO MY WELL BEING. I ACKNOWLEDGE AND UNDE:RSTAND THAT MANY OF THE PHYSICIANS ON THE STAFF OF THIS HOSPITAL. INCLUDING THE ATTENDING PHYSICIANISI NAMED ABOVE, AND RADIOLOGISTS, ANESTHESIOLOGISTS, PATHOLOGISTS AND EMERGENCY PHYSICIANS, ARE NOT EMPLOYEES OR AGENTS OF THE HOSPITAL, BUT RATHER ARE INDEPENDENT CONTRACTORS WHO HAVE BEEN GRANTED THE PRIVILEGE OF USING THE HOSPITAL FACILITIES FOR THE CARE AND TREATMENT OF THEIR PATIENTS. I AGREE TO ACCEPT THEIR CARE EVEN THOUGH THEY ARE NOT EMPLOYED BY THE HOSPITAL. I UNDERSTAND THAT THE EXAMINATION AND TREATMENT THAT I RECEIVE ON AN EMERGENCY BASIS IS NOT lNTENDED AS A SUBSTITUTION OR REPLACEMENT FOR COMPLETE MEDICAL CARE. CONSENT TO RELEASE INFORMATION I HEREBY AUTHORIZE THE HOSPITAL TO DISCLOSE TO INSURANCE COMPANIES, INCLUDING WORKERS COMPENSATION CARRIERS, OR OTHER PARTIES THAT MAY BE LIABLE FOR ALL OR PART OF THE HOSPITAL CHARGES, ALL OR PART OF MY HOSPITAL RECORDS AS MAY BE NECESSARY (INCLVDJNG ANY TREATMENT FOR ALCOHOL OR DRUG AaUSE OR DEPENDENCE), TO DETERMINE BENEFITS ENTITLEMENT AND PROCESS PAYMENT CLAIMS FOR HEALTH CARE SERVICES PROVIDED. MEDICARE CERTIFICATION RELEASE I CERTIFY THAT THE INFORMATION GIVEN BY ME IN APPLYING FOR PAYMENT UNDER THE TITLE XVfH ANO TITLE XIX OF THE SOCIAL SECURITY ACT IS CORRECT. I AUTHORIZE ANY HOLDER OF MEDICAL OR OTHER INFORMATION ABOUT ME TO RELEASE TO THE SOCIAL SECURITY ADMINISTRATION OR ITS INTERMEOIARIES OR CARRIERS ANY JNFOAMA TION NEEDED FOR THIS OR A RELATED MEDICARE CLAIM. I REQUEST THAT PAYMENT OF AUTHORIZED BENEFITS BE MADE ON MY BEHALF TO THE HOSPITAL OR TO THE PHYSICIAN WHO ACCEPTS ASSIGNMENT. PERSONAL EFFECTS AND VALUABLES I UNDERSTAND THAT THE HOSPITAL SHALL NOT BE LIABLE FOR THE lOSS OR DAMAGE OF ANY PERSONAL EFFECTS OR VALUABLES {MONEY, JEWELRY, GLASSES, DENTURES, DOCUMENTS, CLOTHING, ETC.} UNLESS SUCH ITEMS ARE DEPOSITED IN THE HOSPITAL SAFE. THE HOSPITAL WILL NOT BE LIABLE IN EXCESS OF $50 FOR THE lOSS OR DAMAGE OF ANY PERSONAL EFFECTS OR VALUABLES DEPOSITED WITHIN THE HOSPITAL SAFE. ABOUT YOUR Bill I UNDERSTAND THAT I WILL RECEIVE A BILL FROM THE HOSPITAL FOR PROVISION OF THE HOSPITAL SERVICES, INCLUDING STAFF AND EQUIPMENT, AND FOR ANY SUPPLIES OR MEDICINES UTILIZED. I WILL ALSO RECEIVE A 81LL FROM ANY PHYSICIAN WHO PROVIDES PROFESSIONAL CARE TO ME. FOA EXAMPLE, I MAY RECEIVE A SEPARATE BILL FROM ONE OR MORE OF THE FOLLOWING TYPES OF PHYSICIANS WHO RENDER SERVICES TO ME: MY ATTENDING PHYSICIAN OR PERSONAL PHYSICIAN, EMERGENCY ROOM PHYSICIAN, RADIOLOGIST, ANESTHESIOLOGIST, PATHOLOGIST, OR ANY OTHER SPECIALIST. INSURANCE ASSIGNMENT I HEREBY ASSIGN TO AND AUTHORIZE THE HOSPITAL AND PHYSICIANS INVOLVED IN CARE DURING THIS PERIOD OF ILLNESS OR TREATMENT lHEREINAFTER "PHYSICIANS"), OR THEIR DULY AUTHORIZED ASSIGNS TO TAKE ALL NECESSARY STEPS, WITHOl,JT LIMITATIONS, TO ENSURE THAT ANY INSURANCE BENEFITS OTHERWISE PAYABLE TO ME OR MY ESTATE ARE PAID DIRECTLY TO THE HOSPITAL OR PHYSJC1ANS. THIS ASSJGNMENT OF INSURANCE. BENEFITS INCLUDES BUT IS NOT LIMITED TO BILLING INSURANCE, FILING PETITIONS, FILING SUIT, IN MY NAME OR ON BEHALF OF THE HOSPITAL OR PHYSICIANS, FILING PROOFS OF CLAIM, FILING PROBATE CLAIMS AND FILING GRIEVANCES AND ALL OTHER SIMILAR PROCEDURES, AS MAY BE AMENDED FROM TIME TO TIME WITH THE STATE DEPARTMENT OF INSURANCE. r ALSO AGREE TO PROVIDE AND SIGN ANY OTHER DOCUMENTS THA T MAY BE REASONABLY NECESSARY TO ACCOMPLISH ANY OF THE OTHER PURPOSES. STATEMENT OF FINANCIAL RESPONSIBILITY 1 UNDERSTAND THAT I AM FINANCIALLY AND LEGALLY RESPONSJBLE FOR CHARGES NOT COVERED IN FULL BY ANY THIRD PARTY. I FURTHER AGREE THA T SHOULD I NOT PAY THE BALANCE WITHIN THIRTY (30) DAYS AFTER THE DATE OF DISCHARGE, MY ACCOUNT WILL BE CONSIDERED DELINQUENT. I AGREE TO PAY COSTS OF COLLECTION, INCLUDING REASONABLE ATTORNEY'S FEES AND COSTS, COLLECTION AGENCY FEES AND COSTS, AND INTEREST WHICH SHAll ACCRUE AT THE MAXIMUM RATE ALLOWED BY LAW. ~ ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURAblCE COMPANY, OR FILES A STATEMENT OF CLAIM CONTAINING FALSE, INCOMPLETE OR MISLEADING INFORMATION MAY BE SUBJECT TO PROSECUTION UNDER APPLICABLE LAW. ADVANCE DIRECTIVE (FOR ADMISSION TO HOSPITAL ONLY) IF I AM TO BE ADMITTED TO THE HOSPITAL, I HAVE BEEN GIVEN WRITTEN MATERIALS ABOUT MY RIGHT TO ACCEPT OR REFUSE MEDICAL TREATMENT. I HAVE BEEN INFORMED OF MY RIGHTS TO FORMULATE ADVANCE DIRECTIVES. I UNDERSTAND THAT I AM NOT REQUIRED TO HAVE AN ADVANCE DIRECTIVE IN ORDER TO RECEIVE MEDICAL TREATMENT AT THIS HOSPITAl. I UNDERSTAND THAT THE HOSPITAL AND MY CAREGIVERS WILL FOLLOW THE TERMS OF ANY ADVANCE DIRECTIVE THAT I HAVE EXECUTED TO THE EXTENT PERMITTED BY lAW. f]NITlAl THE FOLLOWING OPTION THAT APPliES) . I HAVE EXECUTED AN ADVANCE DIREC1WE AND WILL PROVIDE A COpy OF THIS FOR MY MEDICAL RECORD WITHIN A REASONABLE AMOUNT OF TIME. . I HAVE NOT EXECUTED AN ADVANCE DIRECTIVE AND DO NOT WISH TO DO SO. INIT. INIT. lFOLLDW.UP DONE BY DATE DATE: WITN 55 ACOOla 9312838 00008 T 004 7 1111/1111111111111111111I11111111111111I 1111/1111111111111111111111111111111111111111 IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII~III~IIIIIIIIIIIII ~CARustE . .' RftKJNAL . "HDICAL CINTIU, 246 ParJcerSI. Carlisle. PA J701) Ph:717-149-1211 H1PAA FORM 20 ACKNOWLEDGEMENT: RECEIPT OF PRIVACY NOTICE Purpose: This form is used to document (a) an individual's acknowledgement of receipt of our Privacy Practices Notice or (bl when we have not obtained this acknowledgement, our good faith effort to obtain the acknowledgement. Patient Name: MACNAMARA, MARKUS R Date of Admission: 0000810047 Social Security Number: 205,72-5653 06/0912005 Notice Version (Datel: 4114/2003 Medical Record Number: Acknowledgement of receipt of Privacy Practices Notice I, MACNAMARA, MARKUS R Notice from: CARLISLE REGIONAL , acknowledge that I have received a Privacy Practices MEDICAL CTR Further, by signing below I provide my permission for this facility to use and disclose my medical information for the permitted purposes of treatment, payment and health care operations as discussed in the Notice of Privacy Practices. Patient Signature: Date: 06/09/2005 o Notice has previously been distributed by another location in our OHCA (except for physiciansl: List location that distributed the Joint Notice: If a personal representative on behalf of the individual signs this authorization, complete the following: Personal Representative's Name: ( .-<t d-Q/'rtJ 9>tM ~~ , /... Relationship to Individual: ~JA.R/v1A- . IF NOT SIGNED:(Good faith effort to obtain acknowledgement of receipt I Describe your good faith effort to obtain the individual's signature on this form: Describe the reason why the individual would not sign this form: SIGNATURE: (Hospital Representative) I attest that the above information is correct. Signature: ~~0 Date: 06/0912005 4t- ~6 Print Name: Bethea, Kyuati - Admitting Titie: Include this acknowledgement form in the individual's records. Hospital Copy ~f\ - 6'- ~ "<' ...0 lJ" ~ '-I '0<J ~ <) ~~ ~\ , \ l..t ~ , C? .) -, ...., {;::;, i.;:,.::) c..'1 o -" .-1 I-'n rl1 ":-C::~ ~ ;t.". ,.....- 2::; {'--' 0' ~~{ j j',.) I :~? \ ~l r_ IN RE: MARKUS R. MACNAMARA, IN THE COURT OF COMMON PLEAS OF ERIN G. MACNAMARA, AND CUMBERLAND COUNTY, PENNSYLVANIA MOLLIE M. GOODLING, MINORS BY SUSAN M. MACNAMARA, PARENT AND NATURAL GUARDIAN 05-4386 CIVIL TERM ORDER OF CaUR1: AND NOW, this -z..OI day of August, 2005, IT IS ORDERED that a hearing on the within petition to settle a minor's action shall be conducted in Courtroom Number 2, Cumberland County Courthouse, Carlisle, Pennsylvania at 4:00 p.m., Wednesday, September 7,2005. Edgar B. Bayley, J. Terry S. Hyman, Esquire For Petitioner :sal ~h ~ 1.30.0~' C}-. >- 0;; ~ (") w.,. ~2f~' ~1- '::i'~' OF I C) oc: UJQ_ ~tu u..~ l- lL. o C) <'") e,.,> ::::> "'" <.r.> = c::> c'" a <'J O::i ~~ -3 .,'.':,~ t.:.::: ~.2 .::J () m IN RE: MARKUS R. MACNAMARA, ERIN G. MACNAMARA, AND MOLLIE M. GOODLING, MINORS BY SUSAN M. MACNAMARA, PARENT AND NATURAL GUARDIAN IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA 05-4386 CIVIL TERM AND NOW, this ORDER OF COURT \""2..---- day of September, 2005, IT IS ORDERED: (1) Approval of settlement for three minors in the total amount of $25,000, allocated to Erin G. MacNamara, born March 29,1990, of $3,750, Markus MacNamara, born October 28, 1991, of $11 ,250, and Mollie Goodling, born October 25, 1996, of $3,750, IS GRANTED. (2) From the total settlement, an attorney fee of $6,250 to Schmidt, Ronca, & Kramer, P.C., IS APPROVED. (3) The allocated proceeds to each minor shall be placed in a federally insured investment through Fidelity Investments in the individual name of the minors. (4) Each account shall contain the following notation: "NO WITHDRAWAL CAN BE MADE PRIOR TO [THE NAMED MINOR). OBTAINING MAJORITY EXCEPT BY AN ORDER OF A COURT OF COMPETENT JURISDICTION." (5) Susan M. MacNamara, a parent and natural guardian of the three minors, is authorized to sign any releases necessary to effectuate this settlement, and then to settle and satisfy the docket (6) Terry S. Hyman, Esquire, shall file with the Prothonotary, and forward a copy to this chambers, proof of compliance with this order. / By the Court " ' '" .. G(' Edgar B. Bayley, J. ~s.Hm For petitio~eran, Esquire :sal C' ~o? 09' I~' / 1,--,- .- '(": '.---~ .;c.' C"" - ,.:...r.: C') '::~~:\ Ci) ~_D (:-:', ~,;~ , IN RE: Markus R. MacNamara, Erin G. MacNamara, and Mollie M. Goodling, Minors, By Susan M. MacNamara, parent And Natural Guardian IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO: 05-4386 CIVIL TERM ORPHAN'S COURT DIVISION PETITION FOR APPROVAL OF MINOR COMPROMISE SETTLEMENT AND DISTRIBUTION OF PROCEEDS PROOF OF COMPLIANCE WITH COURT ORDER AND NOW, this 27th day of October, 2005, attached for filing is a copy of the Certificate of Deposit Terms and Conditions from Wachovia Bank verifying that the restricted accounts have been opened for Mollie M. Goodling, Erin G. MacNamara, and Markus R. MacNamara, minors, in accordance with the Order signed by Judge Edgar B. Bayley on September 12, 2005. Respectfully submitted, SCHMIDT, RONCA & KRAMER, P.C. /~~o y Terry Attor Law Attorney 1.0. No. 36807 209 State Street Harrisburg, PA 17101 (717) 232-6300 . WACHOVIA TIME DEPOSIT AUTOMATICALLY RENEWABLE PERSONAL CD 24 MONTH STEP RATE Opening Date Account Number Taxpayer ID Number OCTOBER 24, 2005 247402302409024 197767058 This Receipt Acknowledges That The Depositor Named Below Has Deposited With This Bank The Sum Of $ ****"'*****3,750.00ilh1o"l< Depositor Name And Address MOLLIE M GOODLING SUSAN M MACNAMRA GUARDIAN NO WID ALLOWED WIO COURT ORDER 306 N WEST ST CARLISLE PA 17013 Tenn Maturity Date OCTOBER 24, 2007 Interest Rate Per Annum 03.92% Annual Percentage Yield Interest Payment Frequency/Period 24 MONTHS 04.00% 1 MONTH(S) Interest Payment Disposition CAPITALIZE Account to Credit PROD-TYPE: 230 PROMO CD: Issued by WACHOVIA BANK, N.A. NE C PA I HARRISBURG CPTL PA dd 1M . .fA PAl. .I. 1>>" ulho zed Signature -.... x Iqz It{() ~-) Date Member FDIC NOT TRANSFERABLE 5S659~ (Rev G3 Page' 012) CUSTOMER RECEIPT AMS3 A372939 BPZ78105 , Customer: Org: 075 Serv: CDA Aeet: 247402302409024 Name: MOLLIE M GOODLING SUSAN M MACNAMRA GUARDIAN NO WiD ALLOWED wlo COURT ORDER Aeet Maint - Comments CZ663001 Cust Tax Id: State: PA Merger: Address: Bank: 024 Status: 306 N WEST ST CARLISLE PA 17013 10/24/05 16:55 OPEN Sel Comm Typ: IN Br: 85396 Sre: A372939 Comm Typ: Br: Sre: Comm Typ: Br: Sre: Comm Typ: Br: Sre: Comm Typ: Br: Sre: Comments: Eff: 10242005 NO WiD CAN BE MADE PRIOR TO MOLLIE OBTAI Exp: 04242006 NING A MAJORITY EXCEPTION BY COURT ORDER Eff: Exp: Eff: Exp: Eff: Exp: Eff: Exp: NO DATA CHANGED Command: AMS4 PF1;Hlp 3;Exit 4;Next 5;Refresh 7;Bkwd 8;Fwd WACHOVIA TIME DEPOSIT AUTOMATICALLY RENEWABLE PERSONAL CD 24 MONTH STEP RATE Opening Dale Account Number Taxpayer 10 Number OCTOBER 24, 2005 247402302409023 205725653 This Receipt Acknowledges Thai The Depositor Named Below Has Deposited With This Bank The Sum Of $ *********11,250.00***** Depositor Name And Address MARKUS R MACNAMARA SUSAN M MACNAMARA GUARDIAN NO WID ALLOWED WIO COURT ORDER 306 N WEST ST CARLISLE PA 17013 Term Maturity Date OCTOBER 24, 2007 Interest Rate Per Annum Annual Percentage Yield Interest Payment Frequency/Period 24 MONTHS 03.92% 04.00% 1 MONTH(S) Interest Payment Disposition CAPITALIZE Accour\t to Credit PROD-TYPE: 230 PROMO CD: Issued by WACHOVIA BANK, N.A. NE C PA I HARRISBURG CPTL PA ci ~ I . X'MUA~ .~ Authonzed Signature '"' x 1t''\Jll4/m Date I , Member FDIC NOT TRANSFERABLE 566591 (Rev 03 Page 1 of 2) CUSTOMER RECEIPT AMSs A372939 BPZ78105 Customer: Org: 075 Serv: CDA Aeet: 247402302409023 Name: MARKUS R MACNAMARA SUSAN M MACNAMARA GUARDIAN NO W/D ALLOWED W/O COURT ORDER Aeet Maint - Comments CZ6630 0 1 Cust Tax Id: State: PA Merger: Address: Bank: 024 Status: 306 N WEST ST CARLISLE PA 17013 10/24/05 16:49 OPEN Sel Comm Typ: Sre: Comm Typ: Sre: Comm Typ: Sre: Comm Typ: Src: Comm Typ: Src: IN Br: 85396 A372939 Br: Comments: 10242005 NO W/D CAN BE MADE PIROR TO MARKUS OBTAI 04242006 NING MAJORITY EXCEPTION BY COURT ORDER Br: Eff: Exp: Eff: Exp: Eff: Exp: Eff: Exp: Eff: Exp: Br: Br: NO DATA CHANGED Command: AMS4 PF1=Hlp 3=Exit 4=Next 5=Refresh 7=Bkwd 8=Fwd WACHOVIA TIME DEPOSIT AUTOMATICALLY RENEWABLE PERSONAL CD 24 MONTH STEP RATE Opening Date Account Number Taxpayer 10 Number OCTOBER 24, 2005 247402302409021 168726794 This Receipt Acknowledges That The Depositor Named Below Has Deposited With This Bank The Sum Of $ **********3,750.00***** Depositor Name And Address ERIN G MACNAMARA SUSAN M MACNAMARA GUARDIAN NO WID ALLOWED WID COURT ORDER 306 N WEST ST CARLISLE PA 17013 Term Maturity Date OCTOBER 24, 2007 Interest Rate Per Annum 03.92% Annual Percentage Yield Interest Payment Frequency/Period 24 MONTHS 04.00% 1 MONTH(S) Interest Payment Disposition CAPITALIZE Account to Credit PROD-TYPE: 230 PROMO CD: Issued by WACHOVIA BANK, NA NE C PA I HARRISBURG CPTL PA ~f(;'- i)~, x D,(,()! z L!l~~ Member FDIC NOT TRANSFERABLE 566591 (Rev 03 Page tof2) CUSTOMER RECEIPT AMSJ A372939 BPZ78105 Customer: Org: 075 Servo CDA Acct: 247402302409021 Name: ERIN G MACNAMARA SUSAN M MACNAMARA GUARDIAN NO WiD ALLOWED W/O COURT ORDER Acct Maint - Comments CZ663001 Cust Tax Id: State: PA Merger: Address: Bank: 024 Status: 306 N WEST ST CARLISLE PA 17013 10/24/05 16:44 OPEN Sel Comm Typ: Src: Comm Typ: Src: Comm Typ: Src: Comm Typ: Src: Comm Typ: Src: IN Br: 85396 A3 72 93 9 Br: Comments: 10242005 NO WiD CAN BE MADE PRIOR TO ERIN OBTAINI 04242006 NG MAJORITY EXPECT ION BY A COURT ORDER Br: Eff: Exp: Eff: Exp: Eff: Exp: Eff: Exp: Eff: Exp: Br: Br: CHANGE COMPLETED - NAME/ADR/TAXID CHG MAY APPLY TO CDC Command: AMS4 PF1~Hlp 3~Exit 4~Next 5~Refresh 7~Bkwd 8;Fwd --------------- () ~~--: ~....:' , ( . ~~ ", = C:::-:l c.n c:::> n -l w o ." =:rJ rn11 :qm ..,.10 (j ,~. - n-{ '..) ;~\:ri ":~ C) CSn"l :::-"' ~. .', ::< ~ '>:> (}1 '"