HomeMy WebLinkAbout06-2372
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In re: Petition ofNigerie Butler, as parent and
natural guardian of Ingrid Lee, a minor
Plaintiff,
COURT OF COMMON PLEAS
CUMBERLAND COUNTY
NO: Ol, - ;L.Y7~ l2i u,l '-T 82..YY'\
PETITION FOR LEAVE TO COMPROMISE MINOR'S ACTION
This Petition ofNigerie Butler, as parent and natural guardian oflngrid Lee a minor,
respectfully states:
1. The petitioner is Nigerie Butler, the mother and natural guardian of Ingrid Lee, a
mmor.
2, Ingrid was born on February 3,1998. She currently resides with her mother at
1750 L. Wisteria Drive, Charnbersburg, PAl 7201,
3, On or about May 10, 2004, Ingrid was involved in a single vehicle-pedestrian
accident with an automobile operated by Jason E, Boyce, who pulling out of a parking space on
Arbor Way in Martinsburg, West Virginia" As Mr. Boyce was leaving the parking space, a large
truck blocked his view of a dirt embankment. After he pulled out he traveled approximately
thirty (30) feet when a child on a bicycle came off the dirt embankment and in front ofMr.
Boyce's vehicle. Before he had time to react, another child (Ingrid Lee) came over the
embankment and struck Mr. Boyce's vehicle. A true and correct copy of the West Virginia
Uniform Traffic Crash Report is attached hereto as Exhibit "A."
4. Ingrid was transported from the scene, via ambulance, to the hospital. As a result
of the incident, Ingrid suffered injuries, including a left femur fracture and head contusion, She
was hospitalized for a total of 2 days and during her stay underwent a dosed reduction with
.
Nancy nail fixation for the left femur fracture. Copies oflngrid Lee's medical records are
collectively attached hereto as Exhibit "B."
5. Upon discharge from the hospital, Ingrid's left leg was in a cast and she had to
learn to ambulate with a pediatric walker. See Exhibit B. Within two months, Ingrid was able to
jump rope without pain and was ambulating welL See Exhibit B.
6. On October 13, 2004, Ingrid underwent a second procedure, without incident, to
remove the Nancy Nails, See Exhibit B, Two weeks after the surgery, Ingrid was almost fully
active. Her last medical visit, relative to the femur fracture, was on October 28, 2004,
7. At the time of the accident, Agency Insurance Company of Maryland issued a
policy of insurance numbered AU 0027198 to Jason Boyce, Said policy provides Bodily Injury
coverage in the amount of $50,000 per person/$I 00 per occurrence. A copy of the Declarations
page for policy AU 0027198 is attached hereto as Exhibit "c."
8, An agreement has been reached between Agency Insurance Company and
Petitioner whereby Petitioner, as the parent and natural Guardian of Ingrid Lee, a minor, has
agreed to settle any and all claims Ingrid Lee, a minor, has or may have for $5000.
9. Counsel preparing this petition has been retained by Agency Insurance Company
to file the pleadings and documents necessary for court approval of the parties' settlement
agreement.
10. In telephone calls and by letter dated March 22, 2006, counsel specifically
informed Nigerie Butler of the nature of counsel's involvement in this matter and that counsel
preparing the petition is not her attorney in this matter. A true and cOn'ect copy of the letter is
attached as Exhibit "D."
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11. Petitioner understands that if the Court approves this settkment, pursuant to the
terms of the Settlement and Release Agreement, no further action or recovery may be had by
either Petitioner or Ingrid Lee, a minor.
12. Petitioner, Nigerie Butler, as parent and natural guardian oflngrid Lee, believes
the settlement oflngrid's claim for $5000 is in the best interest of her daughter and requests
court approval of the above settlement as well as authority to execute any documents necessary
to affect the actual settlement, including the proposed Settlement and Release Agreement
attached hereto as Exhibit "E".
WHEREFORE, Petitioner, Nigerie Butler as parent and natural guardian of Ingrid lee,
requests this Honorable Court to enter an Order authorizing the proposed settlement as has been
set forth,
Respectfully submitted:
Dated:
By:
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Nigeri utler, as parent and natural
guardian ofIngrid Lee
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Re: Butler
VERIFICATION
I HEREBY VERIFY that the statements made in the foregoing document are true and
correct to the best of my knowledge, information and belief. I understand that any false
statements contained herein are subject to the penalties of 18 Pa. C,S, Section 4904 relating to
unsworn falsification to authorities,
BY:
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Nigerie tier, as parent andnatural guardian of
Ingrid Lee; a minor
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REVISED 5/97
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CRASH 10St* PdQ 3 .
REPORTID8Y:2ecityPolioe 4C)Olher
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HIGHWAY ClASSIACATION
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2 U.S. cC)County 6. Other
MAXIM SPEED UMIT ADVISORY SPEED IF ON CONTROLLED AcceSS HIG
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MAXIMUM SPEED LIMIT ADVISORY SPEED 2(:) Main Road lIIlnterchange .
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SPECIAL REFERENCE
OR GISlGPS COORDINATES
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5 8 FolloWng Too Closely
8 Oisr.g8rded TI'lIffic Control
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INJURED TAKEN TO I INJURED TAKEN BY; EMS/AMeS UNIT HUMBER EMS RUN FORM NUMBER
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PEDESTRIAN ACTION: I[J;, 8 Crossing at intersection . 38 WIIdng on PaYMMI'lI \r\Wl Tr1Iffic 58 Standing on Pavement 78 WxtUng on P.V'III'Mf'II. 90 Not on PavenMlnt
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NAME OF YVITNESS ADDRESS MAAT.DI~ LAN urN b CITY STATE lJP
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6 Sleeting 5 M~_. 6 CUlW-.HiIaMt 5 0i1 6 ean.tructionZcne 3~~ r,.....BuIhM 10~~__
7 Halling 6 Haz._ 7 ~ ~~andRok1g 6 Other: 7 Sd1ooIZoM .. Building(1) 11 BIindi1g&nighl:
NUMBER 8 Cro.~ 7 Ottw 8 J Ran Curw . , 8 v.. 5 ~ 12 Other
QFlANES: \ \\ERElANESCLEARlYMARKED1 DYES NO FUNCTIONING? No 6 SIgnbon 13 Unknown
MANNEROFCOlLIStON: lEFT&fUQHT1\JRN VEH. SEQUENCE OF EVEHTS (UMCodN8tRIgN 01 CcIIlnII 1............... 32~1IUllPlIrt
;Q=~ c;t~ O;u 1JlElrnrnrn~;~l:!::.- =
3(:)s.m.Oirection 10r 0"]""'"' 0 VEH. ~........ >>PMIIll__whldIt 3I-CwtI
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5~Re8r~ 0..4- o.b: oi fhte-le-.d..,..."...e-l"-lfllI!Wlll.,............ 2+10,. Llllmvt ~
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'!eAEENING INFORIIIAl1ON: VEHICLE NUMBER CARRIER INFORMATION SOURCE: VEHICLE CONFtoURATlON COL TYPE ENOORS.
000000 10_P__ 20-.... ~A ~~:H
NUMBEROFOUAL HICLES 1 2 3 .. 5 IS 30 Log Book ..ODfMr sOOth<< ~ =:4-tn....... B
INVOLVED: ~ CARRIERNAME 3 SlngIIl.ftttndt(2M1Mt1ormcntirM. C
TNCbwilh6ormoreti'el ~ : =-=::(3 Gr mcn...) 0 NoM
Of. He..... P-..rn _~ ____ e Trudtnearrit(BotMI) Cot RESTRICTIONS
7 T'**-"wIIh......... ~ 8
Buset designed to carry 8 Tr<<:I<< wilh doIA* n/Ien; K~ ~__
16ormc:reptnON _ CITY ~1E I ZIP .9_ T.-.ctorwW'l1riPe____ .......
I ~ 1u Olher.lIMtMlDdMItlfy
ICCMC ____ CARGO BODY TYPE
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6 Conc::rN MbrM
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8 >-: ~orlWwe
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NUMBER OF
PersotuISuataining
fetal .....
P..-.onslr'8llSp(lrtedfOl'
IMMEDIATE medlc::8l
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NUMBER OF AXlES PER UNIT '.:
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scene dull to dMl.p or
provided ~
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O.R.I. NUMBER
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CRAW SCENE AS OBSERVED, INClUDING F/OI>DNAY LAYOUT, VEHIClE, PEDESTRIAN OR OBJECT CRAW ARROW POINTING t
STRUCK, TRAFFIC CONTROlS: SKIDMARKS, ETC. NORTH IN CIRCLE 1
IMPORTANT; NUMBER THE VEHClES ACCORDING TO THE VEHla...E NlNBERS ON THE FRONT PAGE. ;
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DESCRIBE WHAT HAPPENED (Refer to Vehicles by Number)
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Complaint: Vehicle Accident
May 10, 2004
Case No, 0405-08754
Page 1 of'l-
Vehicle one was leaving the third west side parking space on Arbor Way, Martinsburg WV. As vehicle one
traveled approximately 30 feet south on Arbor Way a child on a bicycle came off a dirt embankment and in
front off vehicle one's path, Before vehicle one could react, a second child on a bicycle came off the
embankment and struck the front of vehicle one.
According to vehicle one driver, Jason E. Boyce, he had just left his parking space, Boyce stated a large
truck blocked his view of the dirt embankment. According to Boyce, a child on a bicycle came off the
embankment and barely missed his car, Boyce informed before he could react another child on a bike came
off the embankment and struck his vehicle,
A large white truck was blocking the view of the embankment. The embankment appeared to be worn
down from possibly pedestrian and bicycle traffic, On the top of the embankment was a dirt trail, It appeared
the children came off the dirt trail and down the embankment. At the end of the embankment was a parked
vehicle that made it difficult to see up Arbor Way, It appeared the children came off the embankment onto
Arbor Way without stopping, There were no skid marks present or acceleration marks coming from the parking
space,
The child was identified as Ingrid Lee (age 6), Ingrid Lee was transported to Martinsburg City Hospital by
rescue ambulance. Lee suffered an injury to her left leg (possible fracture) and a bump on her head,
The only witness to the incident was Paul Lopez, Mr, Lopez gave the same account of the incident as
Boyce.
Patrolman M,M, Usack
Pr,-,^". /iII,tffI,tt/
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STATEMENT OF:
N8IIII: ,PI\IJL Lo f'
Telephone ,: (Bome) 3 eM-
Dare M.A-) 10 ;:;l00'-1
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MP.RTDIIS6URb WII
Address: a a IVlI\R.T1' CI
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Drivel."sLicense :
Dl.".L1c.State
Date of Birth:
o Soci81 Security':' UN\(NQ M
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Height: CD 0'\ Weight: 310
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Age: 3 L\
Hair: 6lK
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I afflrll that the informotLon {n this stotement is trlll.l ond cori'I.Ict. if so 51an bl.l{""':
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STATEMENTS OF INVOLVED DRIVERS AND WITNESSES (IF AVAILABLE)
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ATTAOi ADIJIT10NAL STA~UT C:1oICC'T'C!' Af!' ..-..........-
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.. CAD Operations Report
Call N~mber
0405-08754
MARTINSBURG POLICE DEPARTMENT
Prinled ,05/10/2004 09:57 PM '
Call Detail Information
Gall Num~r '
0405-08754
ComJll;:lint
VEH ACC
D"'~~Jime R~iv,~ ,'. . lnj
Man 05/1012004 20:38.26 ! 0
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()():()():OO : 20:38:26 .." 20:39:01 . 20:42:53
."...."n....'-,.,.,',..-.. ','_ .,.-....',....... ".,-...., ," _."_,,,<,"," ";,'_-__,'s~,-_--.
[5/10/2004 9:54:54 PM: mistyh]
SEE REPORT UNIT CLEAR FROM CHI AND LOCATION OF 10-50
[5110/2004 8:39:01 PM: mistyh]
PEDESTRAIN STRUCK
DeDartment Numbers
MPD 0405-08055
-
21
DepartmentlRMS OCA Numbers
-
MPD 0405-08754 WVOO20100
Call DisDositions
2004/05/) 0 2) :56:59 1024 SEE REPORT
Page 1 of 2
"
.
-:Y
. c I
,,'h"
f- 'I- Y"
"
CITY HOSPITAL, INC.
Martinsburg, WV,
EMERGENCY ROOM NOTE'
PATIENT,
LEE, INGRID
ACCT#, VOOOOl195795 AGE, 6Y
PHYSICIAN, PHILIP VAN DONGEN, MD
MR#, M000170563
ROOM#, 424
DATE OF SERVICE, 05/11/2004
ADMISSION
CHIEF COMPLAINT, Pedestrian struck by a vehicle,
HISTORY OF PRESENT ILLNESS, This 6-year-old black female who was riding
her bicycle without a helmet when she apparently went into the road and
was struck by a vehicle. She was knocked from the bicycle. It is unknown
whether there was any loss of consciousness although when I spoke with
the child she seemed to recall getting struck by the car and said that
the remained on the ground after she was struck. She seems to have good
recollection of the events, When brought in by EMS they noted that she
had a possible injury to the left upper leg and that she seemed to be
lldrifting in and outll a little bit. The rest of the review of systems
was negative as best as can be determined.
PAST MEDICAL HISTORY, None,
ALLERGIES, None,
MEDICATIONS, Zyrtec,
Prior treatment with a Hare traction, C collar and long board.
PHYSICAL EXAMINATION, This is a well appearing, alert, chubby black
female with a stated weight of 86 pounds, Afebrile, Heart rate 130,
other vital signs stable,
PSYCH: For me she is awake, alert, answering my questions appropriately
and appropriately scared,
HEENT, There was a cephalohematoma on the left side of the forehead with
an associated minor abrasion. No other cephalohematomas or other outward
evidence of any head or facial trauma was noted. Trachea midline.
Cervical spine seems to be non-tender but the collar was left in place.
LUNGS, Clear to auscultation anteriorly with full and equal breath sounds
bilaterally. No accessory muscle use or intercostal retractions.
CHEST, Chest wall was non-tender to palpation with no crepitus and no
outward evidence of any trauma.
ABDOMEN, Soft, She seemed to be exhibiting some discomfort with
palpation but when asked where it was hurting her, she said it was
hurting her left upper leg. Bowel sounds were present but diminished.
There was no rebound, no guarding and no palpable mass. There was a
slight abrasion on the far lateral aspect of the left lower abdomen and
another slight abrasion in the left upper quadrant region anteriorly.
PELVIS: Pelvis was non-tender to compression and pelvic rock. The left
upper leg seemed to be slightly swollen when compared to the right upper
LEE,INGRID
MT REP #: 0511-0007
Page 1 of 3
EMERGENCY ROOM NOTE
Medical Records' copy
"
CITY HOSPITAL, INC
MARTINSBURG, WV
EMERGENCY ROOM NOTE
LEE,INGRID V00001195795 M000170563
leg. There also were some minor abrasions on the left upper leg. The
knee appears unremarkable with no evidence of effusion and the remainder
of the left lower leg and foot as well as the entire right lower
extremity showed no outward evidence of any trauma with no t:enderness
with palpation,
SKIN: Cool and dry. No rash or ulcerations noted. Just the abrasions as
previously noted.
NEUROLOGIC: The child was alert. She was responding appropriately for a
child in her situation. She was moving her extremities without difficulty
with the fourth being in the traction device.
The patient had a peripheral IV initiated and labs were sent, She was
then sent for CT scan of the head, abdomen and pelvis as well as a
variety of plain films, Glucose 195, potassium 3.2, chloride 112,
alkaline phosphatase 284, The rest of the comprehensive metabolic
profile and CBC were normal, X-rays of the cervical spine were
unremarkable with no evidence of fracture, subluxation, or prevertebral
soft tissue swelling, The open mouth view of the odontoid was
inadequate. Chest x-ray showed a normal mediastinum with no evidence of
pneumothorax or other lung injury. x-ray of the pelvis showed no
evidence of fracture, X-ray of the left femur showed a simple mid shaft
fracture. CT scan of the head was negative with no sign of intracranial
injury and CT of the abdomen and pelvis also was unremarkable with no
evidence of any intraperitoneal injury. The child remains appropriately
responsive tome in the Emergency Department. She was takenDff the long
board. Her cervical collar was also removed. I spoke with Dr. Knutson,
the on call orthopedist, who kindly agreed to admit the patient for
ongoing orthopedic care.
IMPRESSION:
1, Left femur fracture,
2. Forehead contusion.
3, Hyperglycemia,
4, HypOkalemia.
Condition on admission is stable.
PHILIP VAN DONGEN, MD
DD: 05/11/2004
JOB: 775728 ID: 000189348 DT: 05/11/2004
cc: KNUTSON DO,THOMAS E JR (00261)
LOBATON MD,CHERRY (00066)
fx: VAN DONGEN MD,PHILIP C (00252)
> TRANS:
TD: Ol~,8
0723 '
LEE,INGRID
MT REP #: 0511-0007
Page 2 of 3
EMERGENCY ROOM NOTE
Medical Records' copy
"
LEE, INGRID
cc:
KNUTSON DO,THOMAS E JR
LOBATON MD,CHERRY
CITY HOSPITAL, INC
MARTINSBURG, WV
EMERGENCY ROOM NOTE
V00001195795 M000170563
LEE,INGRID
MT REP #: 0511-0007
EMERGENCY ROOM NOTE
Page 3 of 3
Medical Records' copy
CITY HOSPITAL, INC
MARTINSBURG, WV
M4y J
9 2001
HISTORY AND PHYSICAL
PATIENT: LEE, INGRID
ACCT#: VOOOOl195795
ROOM#: 424
ATTENDING: THOMAS E KNUTSON JR, DO
MR#: M000170563
DATE OF ADMISSION: 05/11/2004
IMPRESSION:
1. Left femur fracture, displaced.
2. Closed head injury.
PLAN:
1. To the operating room this evening for closed reduction" possible
open reduction with flexible nail fixation.
2. Admit for pain control, neurovascular checks and physical therapy.
HISTORY: This is a 6-year-old black female who was struck by a car this
evening, where she was hit in the thigh. She had acute .onset of pain in
the thigh and also did suffer a contusion to her head, Throughout her
stay in the Emergency Room, even though she was somewhat somnolent, she
aroused to her name and was very cooperative and followed instructions.
She was evaluated per the Emergency Room physician and did have a head CT
and abdomen and pelvis CT which were all negative, She did complain of
pain in her left thigh and this was her only extremity pain.
PAST MEDICAL HISTORY: None,
PAST SURGICAL HISTORY: None,
ALLERGIES: None,
MEDICATIONS: Zyrtec.
REVIEW OF SYSTEMS: HEENT - she does have a head contusion. She denies
any history of blurred vision, dizziness.
Lungs: Denies history of cough, hemoptysis or wheeze,
Heart: Denies any history of chest pain or palpitations.
Extremities as per above.
PHYSICAL EXAMINATION: The patient is awake, alert, pleasant on exam and
in a moderate amount of distress because of her left thigh pain. She has
no cervical, thoracic or lumbar tenderness.
HEENT:
Within normal limits with the exception of a head
contusion.
HEART:
Regular rate and rhythm.
LUNGS:
ABDOMEN:
0,.<:-
Clear to auscultation.
Soft and nontender. positive bowel sounds in upper
quadrants.
EXTREMITIES:
Within normal limits with the exception and attention to
her left thigh. She does have a superficial abrasion to
her left thigh with a mild to moderate amount of swelling.
LEE,INGRID
History and Physical MT REP #: 0512-0029
Dictating Physician's copy
"
CITY HOSPITAL, INC.
MARTINSBURG, WV
HISTORY AND PHYSICAL
however,
intact.
V00001195795 M000170563
her thigh is soft. She is neurovascularly
Pulses are +2 and symmetric.
LEE,INGRID
X-rays of her left femur do show a displaced, essentially transverse
fracture of the distal middle third of the left femur fracture.
IMPRESSION: As per above.
PLAN: Discussed with the parents recommendations were for closed
reduction, possible open reduction with flexible nail fixation. All
risks, benefits, complications, as well as postoperative care were
discussed, questions and concerns answered to her satisfaction. They
were in agreement with the above recorr.mendations. will plan on going to
surgery this evening.
THOMAS E KNUTSON JR, DO
JOB: 775713
ID: 000189752
DD: 05/11/2004 TD: 1231
DT: 05/12/2004 0910
cc: KNUTSON DO,THOMAS E JR (00261)
> TRANS:
CC:
KNUTSON DO,THOMAS E JR
LOBATON MD,CHERRY
LEE,INGRID
History and Physical MT REP #: 0512-0029
Dictating Physician's copy
" ,
CITY HOSPITAL, INC,
Martinsburg, WV,
OPERATIVE NOTE
LEE, INGRID
ACCT#: VOOOOl195795
PATIENT:
PHYSICIAN: THOMAS E KNUTSON JR, DO
MR#: M000170563
ROOM#: 424
DATE OF OPERATION: 05/11/04
PREOPERATIVE DIAGNOSIS: Displaced left femur fracture.
POSTOPERATIVE DIAGNOSIS: Displaced left femur fracture,
PROCEDURE: Closed reduction with Nancy nail fixation, left: femur,
SURGEON: Dr, Knutson,
FIRST ASSIST: Dave Wagner, SA,
ANESTHESIA: General.
COMPLICATIONS: None. Sponge count was correct, Patient tolerated the
procedure well and was taken to recovery room in stable condition.
HISTORY/INDICATIONS: This is a 6-year-old female who was hit by a car
where she suffered a isolated left femur fracture. Because of her size,
recommendations were for the above. After the risks, benefits,
complications, and alternatives were discussed with her parents,
questions and concerns were answered to their satisfactory.. They was in
agreement with the above recommendation.
PROCEDURE: Patient was taken to the operating room suite. After general
anesthesia was administered, she was placed on the Chick fracture table.
Her leg was placed in traction and the reduction was made prior to
prepping and draping her left thigh. Once happy with our position, the
left lower extremity was then sterilely prepped and draped in a normal
sterile fashion. We evaluated the area of the physis of the distal
femur, We then picked a spot approximately 2 cm proximal to this,
Incision was made along the lateral aspect of her thigh at this area with
a 10 blade down through the skin, also through the fascia, Hemostasis
was controlled with electrocautery as we went from superficial to deep.
We then split the vastus lateralis down to the bone. Once down to the
bone, we assessed our placement and our lateral drill hole was made.
Once this was complete, this was done on similar fashion along the medial
side. Once this was complete, we then placed two Nancy nails, one in the
lateral hole, one in the medial hole measuring 3 mm each. The Nancy
nails were then advanced intramedullary to the fracture site. The
fracture was held reduced. Intramedullary nails were then advanced past
the fracture site up to the area of the less trochanter. The nails were
cut and then buried, We evaluated our placement in both the AP and
lateral views. We also checked our placement both at the knee and the
hip. Once happy with our position, again the pins were cut, buried. The
wounds were copiously irrigated. The fascia was closed with 0 Vicryl.
The subcutaneous tissues were then closed with a 3-0 subcuticular.
Steri-Strips were then applied, A sterile dressing was then applied.
She was then placed in a long leg cast from ankle to groin. She was
successfully extubated and taken to recovery room in stable condition.
She tolerated the procedure well without complications. Sponge count was
correct.
PAGE 1 of 2
OPERATIVE NOTE
LEE,INGRID
MT REP #: 0511-0067
Patient Location's copy
"
CITY HOSPITAL, INC.
MARTINSBURG, WV
LEE,INGRID
OPERATIVE NOTE
VOOOO 1195795 M000170563
/l.
I
THOMAS E KNUTSON JR, 00
JOB, 775746 10, 000189453
00, 05/11/2004 TO, 0259
OT, 05/11/2004 1114
cc, KNUTSON OO,THOMAS E JR (00261)
> TRANS:
CC:
KNUTSON DO, THOMAS E JR
LOBATON MD,CHERRY
LEE,INGRID
MT REP #: 0511-0067
PAGE2of2
OPERATIVE NOTE
Patient Location's CODY
'.
.
CITY HOSPITAL,INC.
Martinsburg, WV.
CONSULTATION REPORT
PATIENT, LEE, INGRID
ACCT#, VOOOOl195795
AGE, 6Y
ATTENDING, THOMAS E KNUTSON JR, DO
MR#, M000170563
ROOM#, 424
CONSULTANT,
PAUL SPILSBURY, MD
DATE OF CONSULT,
05(11(2004
INPATIENT NEUROLOGIC CONSULTATION
This six year old black girl, kindergartner, is seen because of l1in and
Dutil behavior since suffering an apparently minor closed hear injury when
hit on her bicycle by a car this morning.
Details of the accident were not available and specifically it is not
known at this time whether there was any loss of consciousness but if so
it was brief and though EMS said that she was Ildrifting in and out" on
recovery, in the Emergency Room, Dr. Van Dongen found her quite alert and
communicative, able to teel him a bit about the accident and other
circumstances. She had a little bump on her left forehead but no
evidence of deeper injury and normal neurologic exam and CT scan. She
had suffered a displaced fracture of her left fibula which Dr, Knutson
has nailed.
PAST MEDICAL HISTORY, Negative save for a sleep disordered breathing due
to apnea from hypertrophied tonsils which were removed in December to
good effect. The obstructive apnea was not associated with oxygen
desaturation and her sleep architecture was reportedly normal. She has
multiple allergies for which she takes Zyrtec and a history of otitis
media associated with the tonsils.
CURRENT MEDICATIONS, Include only cefazolin IV.
PHYSICAL EXAMINATION, In Room 424 reveals a very well-developed, husky,
young black girl lying propped up in bed, her left leg freshly casted.
She seems fairly alert and interactive though shy and soft-spoken and
difficulty to get much information out of at present though she will
follow all my simple commands and will tell me her name and hometown and
a little bit about what happened to her today, the speech fluent and
coherent without dysphasic errors. She denies even a headache at this
point. However, she does not seem much interested in her full liquid
diet,
HEAD: Normocephalic with a modest swelling and superficial abrasion over
the left forehead consistent with hematoma though it is not really tender
and there are no signs or bony injury.
EYES, Without deformity, I could not get a look at her fundi,
EARS, NOSE AND THROAT: Clear without drainage.
NECK: Supple,
NEUROLOGIC: Mental status minimally abnormal as above. Cranial nerves
II through XII were intact including fields to finger counting and
confrontation. Pupils are normal size and reactivity.. Extraocular
movements full and conjugate without nystagmus. Face strong and
symmetrical. Hearing intact to whisper bilaterally and no bulbar signs.
LEE,INGRID
MT RI=P H. f\/:;1?_n1'J.1
Page 1 of 2
CONSUL T A TION REPORT
P::;:Itipnt I nr.~tinn'~ r.nnv
"
,
CITY HOSPITAL, INC.
MARTINSBURG, WV
CONSULTATION REPORT
LEE,INGRID V00001195795 M000170563
Motor system is unremarkable as to gross strength, tone and coordination
in all but the left leg where testing is limited to the foot and toe
muscles which seem intact. Gross sensation to touch is intact
throughout. Deep tendon reflexes are 1-2+ throughout save cannot be
tested in the left leg at this time. Plantar responses are flexor
bilaterally,
Laboratory data has included CBC and comprehensive metabolic profile, all
unremarkable save she may be diabetic with a sugar of 195 and potassium
3.2 on entry. Review of her non-contrast CT scan of the brain reveals it
to be somewhat suboptimal in quality and canted to the right but grossly
within normal limits with no indication of a parenchymal lesion or extra-
axial hematoma and intact skull with no fluid in the sinuses or mastoids.
IMPRESSION: closed head injury with minor post-concussion syndrome but
no findings to suggest any likely residual,
DISPOSITION: Observe overnight. If she is perky in the morningt she can
be cleared to go me neurologically.
PAUL SPILSBURY, MD
JOB: 776283
cc: KNUTSON
SPILSBURY
> TRANS:
DD:
ID: 000189938 DT:
DO,THOMAS E JR (00261)
MD,PAUL (00156)
05/11/2004
05/12/2004
TD: 1924
1451
CC:
KNUTSON DO,THOMAS E JR
LOBATON MD,CHERRY
SPILSBURY MD,PAUL
LEE,INGRID
Page 2 of2
CONSULTATION REPORT
....... .....-~.. ..._~~ ...~...~
- - ~ ," - -~.- - ~ --
CITY HOSPITAL, INC,
Martinsburg, WV,
MAr 2
42004
<&
DISCHARGE SUMMARY
PATIENT:
LEE, INGRID
ACCT#:V00001195795
PHYSICIAN: KNUTSON DO,THOMAS E JR
MR#:M000170563 ROOM#: 424-A
DATE OF ADMISSION: 05/11/04
DATE OF DISCHARGE: 05/12/04
ADMITTING DIAGNOSIS:
Left femur fracture,
SECONDARY DIAGNOSIS:
Post concussive syndrome,
CONSULTANTS:
Paul Spilsbury, M.D,
SURGICAL PROCEDURES:
On 05/10/04 was closed reduction with flexible nail fixation left femur,
COMPLICATIONS:
None,
HISTORY:
This is a 6-year-old female who was struck by a car, where she suffered left femur fracture, and also did suffer a
concussion, Her CT scans of the head, pelvis and belly were all negative, Because of the injury,
recommendations were for the above. After the risks, benefits, complications, and alternatives of surgery
discussed with the parents, questions were answered to their satisfaction, and they agreed with above
recommendations. Patient underwent the above procedure that evening, she tolerated it welL She was placed
on long leg casts, On postop day number 1, the patient is still somewhat drowsy, however she did answer
questions appropriately, Because ofthe continued drowsiness, I did consult Dr. Spilsbury for evaluation, On
post op day number 2, the patient was much more alert, She tolerated her therapy welL She remained
neurovascularly intact and was discharged home with discharge instructions, She is to follow up in the office in
2 weeks.
City Job ID: 776777
,----<-
i
THOMAS E KNUTSON DO JR
Dictated date/time: 05/12/04 1656
Tra~cribed dale/time: 05/17/041641
'0
LEE, INGRID Page 1 of 2 DISCHARGE SUMMARY
MT REP #: 0517-0163 Dictatina Physician's CODV
"
,
CITY HOSPITAL, INC.
MARTINSBURG, WV
DISCHARGE SUMMARY
LEE, INGRID
Transcriptionist:
V00001195795 M000170563
Sara Sargent
cc:
KNUTSON DO,THOMAS E JR
LOBATON MD,CHERRY
LEE, INGRID Page 2 of 2
MT REP #: 0517-0163
DISCHARGE SUMMARY
Dictating Physician's copy
"
City Hospital
Radiology Services
Martinsburg, WV 25401
CAT SCAN REPORT
Patient Name: LEE,INGRID
DOB: 02103/1998
Age: 6 Sex: F
Unit#:
Req#:
Acct#:
M000170563
04-0025912
V00001195795
Ordering Physician: VAN DONGEN MD, PHILIP C
Family Physician: LOBATON MD,CHERRY
Technologist: Amanda Stoner
Location:
Room # :
Auth#:
4P
424-A
Report Status: Signed
Exam: CT AbdomenlPelvis wI Contrast
Exam Date: 05/10104
CLINICAL HISTORY: TRAUMA,
CT SCAN OF THE ABDOMEN AND PELVIS WITH IV CONTRAST: This is a slightly limited study as the very
anterior abdomen was excluded from the scanning field, The liver, spleen, adrenals, kidneys, and pancreas
are unremarkable, There is no evidence for bowel injury, There is no free fluid in the pelvis. There is mild
subcutaneous stranding in the left lateral pelvis,
IMPRESSION:
1. No CT evidence for acute intracranial injury or fracture,
2, Mild subcutaneous contusion in the left lateral pelvis.
<Electronically signed by HOJOON JUNG MD >
HOJOON JUNG MD
Dictated by:
Signed by:
Trans:
HOJOON JUNG MD
HOJOON JUNG MD
PJS
Diet dUtm: 05/11/04 0805
Signature dUlm: 05/11/04 1040
Trans dUtm: 05/11/040847
cc:
LOBATON MD,CHERRY
VAN DONGEN MD,PHILlP C
L
,.
Reprt #: 0511-0024
1 of 1
Patient Location's copy
.
City Hospital
Radiology Services
Martinsburg, WV 25401
DIAGNOSTIC RADIOLOGY REPORT
Patient Name: LEE,INGRID
DOB: 02/03/1998
Age: 6 Sex: F
Ordering Physician: VAN DONG EN MD, PHILIP C
Family Physician: LOBATON MD,CHERRY
Technologist: Jennifer Fincham
Unit#:
Req#:
Acct#:
M000170563
04-0025908
V00001195795
Location:
Room # :
Auth# :
4P
424-A
Report Status: Signed
Exam: DX CHEST 1 VIEW
CLINICAL HISTORY: Trauma.
Exam Date: 05/10104
CHEST (1 view): The cardiac silhouette is within normal limits, The lungs are clear. There are no displaced
rib fractures, pneumothorax, or pleural effusion.
IMPRESSION: Unremarkable chest radiograph,
<Electronically signed by HOJOON JUNG MD >
HOJOON JUNG MD
Dictated by:
Signed by:
Trans:
HOJOON JUNG MD
HOJOON JUNG MD
BJW
DictdVtm: 05/11/040810
Signature dVtm: 05/11/041040
Trans dVtm: 05/11/040851
cc:
LOBATON MD,CHERRY
VAN DONGEN MD,PHILlP C
Reprt #: 0511-0026
1 of 1
Patient Location's copy
" .
City Hospital
Radiology Services
Martinsburg, WV 25401
DIAGNOSTIC RADIOLOGY REPORT
Patient Name: LEE,INGRID
DOB: 02/03/1998
Age: 6 Sex: F
Ordering Physician: VAN DONG EN MD, PHILIP C
Family Physician: LOBATON MD,CHERRY
Technologist: Jennifer Fincham
Unit#:
Req#:
Acct#:
M000170563
04-0025914
V00001195795
Location:
Room # :
Auth# :
4P
424-A
Report Status: Signed
Exam: DX SPINE, CERVICAL AP/LAT
Exam Date: 05/10104
CLINICAL HISTORY: TRAUMA.
CERVICAL SPINE - FIVE VIEWS: There is loss of normal cervical lordosis. The odontoid view is very limited
due to rotation, No definite fractures are identified, The prevertebral soft tissue is within normal limits for age,
IMPRESSION: Limited study, No definite fracture is seen,
<Electronically signed by HOJOON JUNG MD >
HOJOON JUNG MD
Dictated by:
Signed by:
Trans:
HOJOON JUNG MD
HOJOON JUNG MD
PJS
Dict dUtm: 05/11/040809
Signature dUtm: 05/11/041040
Trans dUtm: 05/11/040850
cc:
LOBATON MD,CHERRY
VAN DONGEN MD,PHILlP C
"
Reprt #: 0511-0030
1 of 1
Patient Location's copy
" ,
City Hospital
Radiology Services
Martinsburg, WV 25401
DIAGNOSTIC RADIOLOGY REPORT
Patient Name: LEE,INGRID
DOB: 02/03/1998
Age: 6 Sex: F
Unit#:
Req#:
Acct#:
M000170563
04-0025910
V00001195795
Ordering Physician: VAN DONG EN MD, PHILIP C
Family Physician: LOBATON MD,CHERRY
Technologist: Jennifer Fincham
Location:
Room # :
Auth#:
4P
424-A
Report Status: Signed
Exam: OX PELVIS, < 2V
CLINICAL HISTORY: Trauma.
Exam Date: 05/10104
PELVIS (1 view): The hips bilaterally are anatomically aligned, No fracture is seen.
IMPRESSION: Unremarkable pelvis radiograph,
<Electronically signed by HOJOON JUNG MD >
HOJOON JUNG MD
Dictated by:
Signed by:
Trans:
HOJOON JUNG MD
HOJOON JUNG MD
BJW
Dict dt/lm: 05/11/040808
Signature dUtm: 05/11/04 1040
TransdUtm: 05/11/040849
cc:
LOBATON MD,CHERRY
VAN DONGEN MD,PHILlP C
Reprt #: 0511-0025
1 of 1
Patient Location's copy
"
,
City Hospital
Radiology Services
Martinsburg, WV 25401
DIAGNOSTIC RADIOLOGY REPORT
Patient Name: LEE,INGRID
DOB: 02/03/1998
Age: 6 Sex: F
Unit#:
Req#:
Acct#:
M000170563
04-0025913
voooa 1195795
Ordering Physician: VAN DONGEN MD, PHILIP C
Family Physician: LOBATON MD,CHERRY
Technologist: Jennifer Fincham
Location:
Room # :
Auth#:
4P
424-A
Report Status: Signed
Exam: DX FEMUR, L T 2V
CLINICAL HISTORY: Trauma.
Exam Date: 05/10104
LEFT FEMUR (two views): Evaluation of the left femur demonstrates a transverse fracture through the distal
diaphysis of the femur with 1 cm lateral displacement of the distal fragment.
IMPRESSION: Transverse fracture through the distal diaphysis of the left femur.
<Electronically signed by HOJOON JUNG MD >
HOJOON JUNG MD
Dictated by:
Signed by:
Trans:
HOJOON JUNG MD
HOJOON JUNG MD
BJW
Dict dtltm: 05/11/040807
Signature dtltm: 05/11/041040
Trans dtltm: 05/11/040847
cc:
LOBATON MD,CHERRY
VAN DONGEN MD,PHILlP C
Reprt #: 0511-0023
1 of 1
Patient Location's CODY
PATIENT NAME: Lej?~)
,.,OR''''O' "k"" "'''''' CO""O"
1, YES' NO Have you had a previoUs injection of contrast material?
If yes, what ex did you have? IVP CT Venogram
YES ~. NO Have you ever had a reaction to contrast material?
If yes, what kin 0' eaction? .
YES NO Did you require medication? What kind?
YES Y.,,- NO Do you have any allergies to iodine, seafood, or other medications?
If yes, what?
YES V NO Are you a diabetic? If yes, are you taking GLUCHOPHAGE?
When was you~se?
(Those on GLUCHOPHAGE should discontinue use after IV contrast administration and have blood test 48 hours
past procedures to determine resumption of GLUCHOPHAGE,I
cITY HOSPITAL
RADIOLOGY SERVICES
CONSENT TO ADMINISTER IV CONTRAST MEDIA
'1,(\3(-1 d
FILE NUMBER: i\A noo 1-1 rF:>lr-3
cP--
MRI
2.
3.
YES
NO
4,
PATIENT INFORMATION:
1, Most patients experience no unusual effects from this Injection. It is used to show the blood vessels and parts
of the body, like the kidneys, brain, abdomen and pelvis, This gives the Radiologist (doctor trained to interpret
images) more information about you that can be sent to your physician,
2. This procedure generally consists of injecting an appropriate amount of fluid that contains iodine in a vein in
either your arm (IVP/CT) or foot (Venogram). This will allow us to take pictures of the areas that your doctor is
interested in having us check.
3. There can be some common side effects and risks involved with these procedures. These can include:
flushing/warm feeling, metallic taste, nausea, vomiting, mild allergic reactions such as hives or skin rashes. TherE
can also be burning at the site of the Infection and, in rare instances, more serious complications that could
Include shock, kidney failure, and cardiac arrest. City Hospital has the facilities to treat all these reactions
Immediately.
4, Other exams that could be used to help diagnose your condition are Nuclear Scans and lor Ultrasound, They haVE
not been recommended at this time,
5. Although there are no guarantees, we want to again state that most patients experience no unusual effects from
this Injection.
6, Do you have any questions? Please ask the technologist for more information before the test.
I have reviewed the above information and understand it. Any questions I may have had have been answered to my
satisfaction and I consent to proceeding with the injection and the test that has been ordered by my doctor,
Y I'
Date & Time Ia~t's Signature
Date Time
The patient is a minor/unable to sign, I have read
oq'.ZO
~{
Date Tim
RAD-QQ
PAGE 2
10
LEE, INGRID
VOO1l95795 REG ER
0?/0311998 6/F
VAN OONGEN MD.PHILIP C
L08ATON MO.CHERRY
MG,170'i63 05110/04
;
LABEL
SOCIAL HISTORY: Smoki';g ~dY Alcohol .OY RecrealionalDrugs- OY
NUTRITIONAL SCREEN: Unplanned loss/gain 10lbs in 6 mos. ON DY Any problems swallowing lasting> 3 days 0 N OY Dietary Referra. N OY
DOMESTIC VIOLENCE: Have you ever been injured, verbally abused, or harmed by a member of your household or intimate partner? PNJ 0 Y
o Declines to answer [If yes, complete referral form] "--"
LIMITED MOBILITY: 0 Assisted ride ndent Safet OY
tMPAIRMENTS: ONIA 0 Visual 0 AUditory 0 Other:
BARRIERS: 0 NIA 0 Language 0 Physical 0 Developmental 0 Live,sftlone
Do you have any cultural/religious beliefs practices the staff need to be aware of? ~ 0 y
~ I n 'I I SUMMARY PRESENT PROBLEM (subjective assessment)
rl"'/',: _ }..,,'C,- efr '''h (.(r l-,i t..e{,.'t:<p
:7 '
kl? 1",,,.;.1 't I 0 I.€-t; .<Y: I)~
o Adult Home ~amily 5/0
'-')
.
,
/\.-.J...-.- i"'.'- c:."",&.. i ::"
U
J,J)C_
PERTIN}iNT PHYSICAL ASSESSMENT ,(objective as~essment)_
~C!.I9'":t (Sri -fl (" '?'" 4t- j+<--"".&2 cl, 0:";(' -I, I
EtJ dt-f71(',.,..,;-~'l (l::-Y'{fb"A"'- /;""N~, ( ,0"; ~,- S'
i I'" Assessing Nurse Signature: ), i.'-(j;>t.<. -"': /J,--:,
ORDERS ..~ TIME ORDERS ~ TIME
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Medical Records
1(\.-\..6
SIGNATURE r',
Kt It ~&I :::l'r C.<'.v h /1
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INITIAL
<' --y
( ~::'>
SIGNATURE
J,., "1 .0/
(_'.)\1 .'.-"_4.J ,t? . <~._r>,_,...~_("' ~ _.. l'
INITIAL
__."_h...__~_ _ ___ ______
ICUII:'Dnl:'''~V nl:Df TUi:NT
~ITV LlOSPITAL INC.
PHYSICIAN'S
PROGRESS NOTES
DATE
ALL PROGRESS NOTES MUST BE SIGNED BY PHYSICIAN
(.U1'\...
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3610 (4-98)
CITY HOSPITAL, INC.
PHYSICIAN'S
PROGRESS NOTES
LEE,INGRID
VOOOOl195795 ADM IN
02/03/1998 6/F 424A
KNUTSON DO, THOMAS E JR
lOnrrSQN DO, THOMAS E J.~
" ,
.
.
.
"
.
I
THIS PAGE FOR DOCUMENTATION OF FORMAL TEAM REVIEW ONLY
Plan of Care
In_/ Problem Desired Outcome Plan of Care / Intentention or Problem
Reviewed Interv..-n Resolution
Dele . (Circle tho... (Circle tho... (Circle those applicable) No longer
Initials .ppiicllble) .ppiicllble ) Applicllble Dele/Inltlal
Dele/Initial
7. Oxygenation Patient wtll maintain patent 0 Assess resplratXlry status 0
alrway# ease of respiration <L-hr
Olfficulty breathing. &. slgns of .dequabo 0 Montor diagnostic resutts 0
shortness of breath, atrway oxygenatton and 0 Encourage post-op coughing &. 0
obstruction, Inadequate draJlatton. deep breathing
oxygenation or Isdlemla. 0 Bevate head of bed for ease of 0
breathing
0 Endob'acheal or trach tube care 0
0 0
0 0
0 D
)tJ <; (t o'-f 8, Actlvtty Patient wtll maintain or g-' ActIve range of motion 0
('~A ,t;'/J;.L Improve pre-hospital er PassIve range of motton 0
AI_on In ability to mobility slatus, if AssIst to chair transfer or 0
.mbuI..... turn from slde L'f ambulate
to side, or actively move Involvement of Teach use of walker/cane 0
ext:refTOties IamUy/slgnlftcant other' 0 Iledrest 0
whenever possible. 0
9, COpIng 1 Patient/filmlly/slgnlftcant 0 ObtaIn Inte,.".-... hearing aid 0
Communlcatlon 1 SpIritual other wtll express tI10ughts 0 Consult Sod.1 5enllces
Needs and IIoeIlngs, 0 Facilitate dergy Ylslt as de5I~ 0 -
0 SUldde precautloos
Problem coping wtth Pallent wtll be able to 0 0
disease process, communicate effectlvety. 0 0
communtcatlon banters, or 0 D
spiritual distress RedllCtton or management 0 0
of__, 0 0
.~il' ., 10. Iqe Spedftc Care care and education based I~nfant 0
'ifla 5'" on age and developmental O\Ild D
ConsIdenltton of age and level, D Adolescent D -
developmenl3Ily 0 Adult 0 -
-"Pr1- _Ies 0 Ger1ab1c D -
0 D
0 0
D 0
11, Terminally DII DyIng Respe<t ,.,.. dedsloos, D Honor advance directives I DNR D
0 HospIce memo! 0
Management of pain. other 0 Pall1allve Care refl!rnl 0
~ms. 0 0
D 0
II 12, lnl\!cUon Mlnlml"" the development 0 Assess for S1gns/sx of Infection D
.
c or spread of InIectlon, 0 SI8I1~ aseptic technique when D
PnIlenIJall Ad1Ja/ rf" .pproprlate
Promote healing, AnUblotlcs &. dlagnosllcs as 0
ordered
0 0
.
13. canllovascular PlItient wtn _rUIn or 0 Assess vttal signs q hr 0
Improve canllac-'" 0 cardiac monItof1ng; docu~ &. 0
Altered carnlac status _ dysr1Iythmlas as ~
0 cardiac rehab as onte~ 0
0 MedIcations and diagnostics as D
, OJ ordered
D
..;I 14, Olscharve Plannlng Anlldpall!! and plan needs rs::-. c- ~ Inwlvement 0
post-hospllall:ratlon IrMllvement of other 0
0 disci"""",,
~_on aaoss 0 __ expIanallons 0
the contImun of care 0 DIet expIanalIon 0
0 AcIMty expIonotlon 0
0 -- 0
Interdisciplinary Care Plan - Page 2
City Hospital, Inc.
Martinsburg, WV
LABEL
LEE,INGRID
VOOOOl195795 ADM IN
02/03/1998 61F 424A
KNll'T'<::/"lM nA ........"..~_
,
".
.
.
'-
.
Plan of CllI'e
nltlllCl8d/ Problem Desired Outcome Plan of Care / Intervention or Pn>blem
_wed Intervention Resolution
-. No 1.0_
.1IIa.. Appllalble Dete/Initl81
Dete/In_1
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Initials
Signature / Title
~fl
c
'->
.1-.1//1
L.--~
LABEL
Interdisciplinary Care Plan - Page 3
City Hospital, Inc.
Martinsburg, WV
LEE;J:NGRIn
VOOOOl195795 ADM IN
02/03/1996 6/F 424A
KNUTSON DO, THOMAS E JR
KNUTSON DO,THOMAS E JR
M000170S~1 n~/'l InA
,151 Rev. 03/02
,
.
.
.
.
.
I
THIS PAGE FOR DOCUMENTATION OF FORMAL TEAM REVIEW ONLY
Patient Problems List - Circle those applicable
1. Protection
2. Patient Education
3. Management of Health
4. Comfort
S. Nutrition
6. Elimination
7. Oxygenation
8. Activity
9. Coping/Comm./Spirit.
10. Age Specific Care
11. Terminally III
12. Infection
13. CardlovasaJlar
14. Discharge Planning
1S.Other
TEAM MEETING DATE:
Nursin
Education
Pharma
Nutrition
Res irato Tx
Rehab
Social Service
Case M t
TCU
, jlt~!';'\ ~
Interdisdplinary Care Plan
Team Meeting Notes
City Hospital, Inc.
Martinsburg, WV
lABEL
..
-.. - -- . - --
,'"- - -, --, -.
56151
LEE,INGRJ:D
VOOOOl195795 ADM IN
02/03/1998 6/F 424A
KNUTSON DO,THOMAS E JR
KNUTSON DO, THOMAS E JR
M000170S61 O~/ll 104
"
,
Date: s-I, ,I oj it7V1
Discharge needs:
Barriers to learning:
Subjective:
Numeric Pain Scale:
Objective.
Cognition: t
General Observations'
ROM:
oJt (A,,{,{Pl,(/n(t ir) MJ)
- 7 - 8 - 9 - 10 nbearab ~
STRENGTH:
(L) LE JE?,.yw tVT w,-
(\ CWt- c\J1 LVlAA/iAV-
(L) UE i~Fi-
(L)LE ,
(R)LE
tuFL
(R)UE
(R) LE
Sensation:
Neurologica .
Impaired
MIN MOD MAX Assist of All
MIN Assist of d-,
MIN Assist of ~
Fair Normal
G) MOD MAX Assist of ~
Fair
SBA MIN MOD MAX Assist of ;J,
r <;1- IA )('J, Q Jt.-e.",
Rolling: SBA
Supine-Sit: SBA
Sit-Supine: SBA
Sitting Balance: Poor
Sit-Stand: SBA
Standing Balance: Poor
Bed-Chair/Chair Bed:
4..
INPATIENT
PHYSICAL THERAPY TREATMENT PLAN
CITY HOSPITAL,INC
MARTINSBURG, WV
PATIENT IDENTIFICATION
Revised 10f18100
LEE, INGRID
VOO~01195795 ADM IN
02/03/1998 6/F 424A
KNUTSON DO, THOMAS E JR
KNUTSON DO,THOMAS E JR
-_ ~r 11 1 'fI"
CONSENT FOR MEDICAL OR SURGICAL PROCEDURES
I, ---c-'""'~ L:.<..- have received information from
Dr.. ~'t;'""""" about my diagnosis, the proposed treatment, alternative
and related risks. I have received all the information and a satisfactory explanation of the procedure and
all of my questions have been answered to my satisfaction, J understand that I may refuse to consent.
I give my consent to the proposed procedures and other matters shown below.
I understand my condition to be:
4
r:-~ C....,.-<;~
I understand the proposed procedure/operation to be: C<-.."'-<.R. ~~ '7t~
'y<-- /'L<~~ .~ ~ ""'<-..A. ~.:L....V' l.. , rl' , .-.--
I hereby certify that I have read and fully understand the reasons why the operation/procedure is
appropriate. its advantages, and I also certify that the risks associated with the proposed procedure(s)
and possible complications were fully explained.
I also understand that there may be other unforeseen risks of complications, serious injury or even
death from both known and unknown causes.
I understand the alternatives (including refusal to have the procedure) to the proposed procedure(s).
If an exploratory operation is proposed, I consent t,,) performance of any additional procedures
determined in the course of a procedure to be in rr,{ best interest where delay might impair my health.
I also consent to photographing or video taping of the procedure including appropriate portions of my
body. and to the agmi!ta.m:e of 0I!sef\Le.rl;!9 the operatil!g rOQIJ'IJQr!TIedic_aJ.scientific. or educational
purposes.
I hereby authorize Dr. ~
and such assistant(s) as (s)he may select to treat my condition.
I am aware that the practice of medicine and surgery is not an exact science and I acknowledge that no
guarantees have been made to me concerning the results of the operation, or other procedures.
I understand and agree that any tissue or parts, including fetal remains removed maybe disposed of by
the hospital in accordance' with customary practice.
3721 (REV. 1/95)
CITY HOSPITAL INC,
MARTINSBURG. W.VA.
CONSENT FOR MEDICAL
OR SURGICAL PROCEDURES
LEE, INGRID
VOOl195795 REG ER
02/03/1998 6/F
VAN DONGEN MD.PHILIP C
LOBATON MD,CHERRY
M0170563 05/10/04
F3721
,
I HAVE READ AND UNDERSTAND THiS CONSENT FORM AND i GIVE MY CONSENT AS
DESCRIBED IN THIS FORM.
Patient
Date and Time
Witness
Date and Time
***w~******************.*******~*******************.************
This patient is unable to consent for the following reasons:
I therefore consent for the patient:
~
.d(;{~
S.1/-o'f~JOO'lJ
,(i,:J,. y:'o/~ '1
Date and Time
, fJ
II: i~
t\..c~
Relationship to Patient
Witness
Date andfime
* * * * * * * ** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
I certify that the above named patient (or
informed consent as explained by myself on this date,
) has received an
-;L
Physician
0.-61
Date
CITY HOSPITAL INC.
MARTINSBURG, W.VA
CONSENT FOR MEDICAL
OR SURGICAL PROCEDURES
LEE, INGRID
VOOl195795 REG ER
02/03/1998 6/F
VAN DONGEN MO.PHILIP C
L08ATON MD,CHERRY
MOL 70563
05/10/04
,
I, , acknowledge that my doctor has explained to me that I will have an
operation, diagnostic or treatment procedure. My doctor has explained the risks of the procedure, advised me of
alternative treatments and told me about the expected outcome and what could happen if my condition remains untreated.
I understand that anesthesia services are needed so that my doctor can perform the operation procedure.
It has been explained to me that all forms of anesthesia involve some risks and no guarantees or promises can be made
concerning the results of my procedure or treatment. Although rare, unexpected severe complications from anesthesia
can occur and these include the remote possibility of: infection, bleeding, awareness, drug reactions, blood clots, loss of
sensation, loss of limb function, paralysis, stroke, brain damage, heart attack or death, The overall risk of dying directly
related to complications from anesthesia is reported to be between 1 in 100,000 to 200,000. I understand that the
anesthetic technique to be used is determined by many factors including my physical condition, the type of procedure my
doctor is to do, his or her preference, as well as my own desire.
I acknowledge that I have read and understand the description of the anesthetic techniques listed below. I also
unde.!:s.tand that depending upon the clinical situation, an anesthetic technique may need to be altered or changed for my
ber'lefiL)
c9~vAnesthesia Expected Result Total Unconscious State,
Technique Drugs injected into bloodstream, breathed into lungs, or by other routes,
possible placement of a tube into windpipe when asleep,
Other Risks Mouth or throat soreness, hoarseness, injury to mouth or teeth,
awareness under anesthesia, injury to blood vessels, aspiration,
pneumonia.
Spinal or Epidural Expected Result Temporary decrease or loss of feeling and/or movement to affected
Analgesia/Anesthesia parts.
With sedation
Without sedation Technique Drug injected through a needle and/or a catheter placed either directly
into the spinal canal or just outside of the spinal canal.
Other Risks Headache, backache, buzzing in ears, convulsions, infection, persistent
weakness, numbness, residual pain, injury to blood vessels, "total
spinal".
Major/Minor Nerve Expected Risk Temporary loss of feeling and/or movement of a specific limb or area,
Block
With sedation Technique Drug injected near nerves causing loss of sensation to the area of
Without sedation operation.
Other Risks Infection, convulsions, persistent numbness, residual pain, injury to
blood vessels.
Intravenous Expected Risk Temporary loss of feeling and/or movement of a limb.
Anesthesia Care Technique Drug injected into veins of arm or leg while using a tourniquet
With sedation
Other Risks Infection, convulsions, persistent numbness, residual pain, injury to
blood vessels.
Monitored Anesthesia Expected Result Reduced anxiety, pain, and partial or total temporary amnesia,
Care Technique Drug(s) injected into bloodstream, breathed into lungs or by other
With sedation routes to produce a semi-conscious state.
Other Risks An unconscious state, depressed breathing, injury to blood vessels,
Monitored Anesthesia Expected Result Measurement of vital signs, availability of anesthesia provider for
Care further intervention as needed,
Without sedation
Technique Continuous monitoring of vital signs,
Other Risks Awareness, anxiety and/or discomfort,
FJ995
,
City Hospital
Radiology Services
Martinsburg, WV 25401
DIAGNOSTIC RADIOLOGY REPORT
A14r ])5
1 J 2004
Patient Name: LEE,INGRID
DOB: 02/03/1998
Age 6 Sex: F
Ordering Physician: KNUTSON DO, THOMAS E JR
Family Physician: LOBATON MD,CHERRY
Technologist: Jennifer Fincham
Unit#:
Req#:
Acct#:
M000170563
04-0025938
V00001195795
Location: 4P
Room # : 424-A
Auth#:
Report Status: Signed
Exam: DX FEMUR, L T 2V
CLINICAL HISTORY: Fracture.
Exam Date: 05/11/04
LEFT FEMUR: There are two intramedullary rods in place aligning the mid femoral shaft fracture. There is
anatomic alignment noted in orthogonal projections. The tip of the rod is noted proximally below the level of the
lesser trochanter and distally projecting over the distal third segment of the femoral diaphysis,
IMPRESSION: There is anatomic alignment of the femoral fracture as discussed above.
<Electronically signed by DIMITRI MISAILlDIS MD >
DIMITRI MISAILlDIS MD
Dictated by:
Signed by:
Trans:
DIMITRI MISAILlDIS MD
DIMITRI MISAILlDIS MD
BJW
Diet dtltm: 05/11/04 1516
Signature dtltm: 05/12/04 1033
Trans dtltm: 05/11/041559
cc:
KNUTSON DO,THOMAS E JR
LOBATON MD,CHERRY
--,
Of
Reprt #: 0511-0184
1 nf 1
Ordering Physician's copy
,
CITY HOSPITAL, INC,
MARTINSBURG, WV
DISCHARGE SUMMARY
LEE,INGRID
Transcriptionist:
V00001195795 M000170563
Sara Sargent
cc:
KNUTSON DO,THOMAS E JR
LOBATON MD,CHERRY
LEE, INGRID Page 2 of 2
MT REP #: 0517-0163
DISCHARGE SUMMARY
Medical Records' copy
"
,
City Hospital
Radiology Services
Martinsburg, WV 25401
CAT SCAN REPORT
Patient Name: lEE,INGRID
DOB: 02103/1998
Age: 6 Sex: F
Unit#:
Req#:
Acct#:
M000170563
04-0025911
V00001195795
Ordering Physician: VAN DONGEN MD, PHILIP C
Family Physician: LOBATON MD,CHERRY
Technologist: Amanda Stoner
Location:
Room # :
Auth #:
4P
424-A
Report Status: Signed
Exam: CT HEAD WO/CONTRAST
CLINICAL HISTORY: Trauma.
Exam Date: 05/10/04
CT OF THE HEAD WITHOUT CONTRAST: The ventricles are normal. There is no acute intracranial
hemorrhage, Normal gray-white differentiation is seen, There are no extra-axial collections. There is no
mass effect. There is no fracture,
IMPRESSION: Unremarkable head CT,
<Electronically signed by HOJOON JUNG MD >
HOJOON JUNG MD
Dictated by:
Signed by:
Trans:
HOJOON JUNG MD
HOJOON JUNG MD
BJW
Dict dVtm: 05/11/040800
Signature dVtm: 05/11/041040
Trans dVtm: 05/111040845
cc:
LOBATON MD,CHERRY
VAN DONGEN MD,PHILlP C
Reprt #: 0511-0020
1 of 1
Patieni Location's copy
i
,rom. Or'lOLO/ 1':>1,,)
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NightHa\vk
RCldiologyservices
Phone 866.24106635
Fax 888-287-1373
PRELIMINARY RADIOLOGY REPORT
PATIENT NAME:
PATIENT ID:
LEE, INGRID
MOOOl70563
INSTITUTION NAME: CITY HOSPITAL - MARTINSBURG, WV 2540l
DATE:
STUDY TYPE:
lOth May, 2004 CDT
CT BRAIN / CT ABDOMEN I CT PELVIS
This interpretation is based upon the receipt of l22 .images.
CLINICAL HISTORY / INDICA nON FOR EXAM:
TRAUMA. RIO ICB OR INTRABDOMINAL BLEEDING.
FINDINGS:
CT BRAIN.
The brain is unremarkable in appearance,
No fractures are identified,
Mild left frontal scalp soft tissue swelling appears to be present,
CT ABDOMEN/PEL VIS.
Portions of the anterior abdomen are excluded from the field of view,
There is no evidence for visceral injury, No pneumoperitoneum or free fluid is seen in
the abdomen or pelvis.
No fractures are identified,
Pagel
CONFTDlil'lTTAf-: tha a,cumUlI!f t/tcllmptf'O'ltll! Orb Irtllt.'lPfls.1hm crill/it/if CfHl!1rJlMI/tJ hatd/h 1'l/i1f'7PUlllon tlu" Lf 1f!JPlll,y prMfagtrd. 711/.1 ItVilf'ml.llh,1l J:t Irt'rJlldud IItIIy irK""/! k:fa
ulthe i..&viJunlurc.'t/i(y >CI:<nK:J"buw:. n.Cau~fI";:cJ r<<ipicOll rut"" injj,,,,,,,,,lIiflOl if p",hihi,cJ/flJIN c:..clIlN"~ 11f" iHJ"unwlli,,,,," dOO'tKhupnrty Iffl/cM ~iTl;Jftl ""JIl' b;-
kM",. rvguflllJrHt fInd I:t raqlLJrtId III ..111''')' tlufl'r/imr""/rHt (fila,. JI:t .f/,IIqd Ilwd hi.., hDm/ltlflllvd. Vyr,14 ,,,.a ""11"" 1,II"dad f'IIClpltMi"JIlAi {Ira hl1fTlby ""llf1vd 111l1l tl'O'
di~/'MUrr:. {;1'P]'i...~. ~/rjhut;f"'. IIrtlClilll1.lakC... il1. rr:lilllfl:l: 11II,he: I:llIItl:"'~ lifllw:..r: JIIClInu:otU ilI.,riclfy ,rohibiteA Tf)'llll _'lIC' "Q:~~r;J IIrUr ;";'"*lIil/O( i... ~'. pllZ'-"'i: If'"i/Y
Iha saNler Immudlllllrly {Ittd um",!/afi,r {ha 1'D'IJm. or dllfll'Jlclhm Ilflhl:sa ducuMl1llls.
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NightHa",rk
Badiologyscrvices
Phone 866-241-6635
Fax 888-287-1373
STUDY CONFIRMATION
PATIENT NAME:
NO OF lKAGES:
INSTITUTION NAME:
STUDY TYPE:
LEE, INGRID
122*
CITY HOSPITAL - MARTINSBURG, WV 25401
CT BRAIN / CT ABDOMEN / CT PELVIS
The above patient details have been accepted into our
system. We have received both the images and the
requisition form. The study is now ready for
interpretation.
.Should the number of Images differ from the above, please contact us
IMMEDIATELY.
Acceptance Time (Sydney):
12:29
COWFTlJENTTAL' 1h" dnClltflNlt.T cu:cn~QlIloj'W this lfTJftTmi.T.TifUl can.(ain co'!fid",,(iaJ Itealrh injnrrrJQ(inn ,hat u l~alh'prillil~&J 'IN., infn,.",atirM i.T il'l/sndtJd
,"*/or tht.. u.<<'! qf 1M InJM4Ial or tnt/tl' MmtJ ahaI'(!. Th~ flldMrkN redp/t.1I1 oflhLt lnj'armOfJt'HI Lf prohlbhNl froM QCfd()SJM ,1ft, /liforMflf/tlll If) 11111' "fht!/"
party I.m/&T;r fYlqu.irlJd In "':to ~l"aw of"',.ttgulatioll afld is t"ef/u.il"&1tn ds.lf~l' ,I", iiVnrmatiml after it,T xtattJd 1If1a:i1aa.r h&Jflju.IfUTed. .
lfyoll art. /Jot the. llllt.",*.d r<</pIM/, 1'\?II11re herdJv not!fltJ rhat alii' dLn:los"'~, oopylllg, dJ.flrlbwllon, or oct/lln takn In reliance ()IJ the contents O/the..ft.
i1iJcLl'fUJfJt~ is #"kt~l' pmhihi(M. If,W;ll haWJ fYJCf!;v'iHJ IJ", i'!f(}l'MQtinll ;11 tJrm,., pltJa.TtJ nntW.thf! .rf!NUr ilfUftfJa/Qtw,t' aNi arrQ"8f!jn,.thf! I"fJtlVn n,. a.artl'Udinn
oftht.'Ct. doCMMMt.f.
,
DATE
II~r
TIME
v 1, ~'G.
(Orders Written)
PACU
1 . Respiratory Therapy
.l1J 02 therapy via nasal-cannula, mask or T-piece as needed to maintain 8a02 90% or above in PACU.
o Ventilator settings PS _ TV Fi02 peep __ rate
o Aerosol treatment: Albuterol 2,5 mg/NS 3 ml _
Other
2. Analgesics ,
:li3 Morphine 2 ( IV q 5 min. pm to maximum dose of ,<> '(
o Meperidine 25 mg IV q 5 min, pm to maximum dose of
o Hydromorphone _mg IV q5 min pm to maximum dose of _ mg
o Ketorolac 15 mg IV x 1 dose pm
o Ketorolac 30 mg IV x 1 dose pm
o Other
3. Antiemetic
o Promethazine 12.5 mg IV x 1 dose pm
o Ondansetron 4 mg IV x 1 dose pm
4. Sedatives
o MidazoJam _mg IV q5 min prn up to _mg
5, 0 Other
))./)/I1...)m~
NURS,'NG UNIT
1, 0 Maintain 02 therapy until room air Sp02 is >90%
2, 0 Post spinal activity orders:
o a.Bedrest in any comfortable position until sensation and movement has returned,
o b.OOB with assistance until able to bear full weight
3. 0 NPO until
4.0 Other
DRUG ALLERGIES
1
Orders Per
(6.- )~ ~___
AJ~l
POST-OP ANESTHESIA
CARE ORDERS
PHYSICIANS ORDERS
CITY HOSPITAL
--4DORESSQGRAPH
M000170563 - - 05/10/04
LEE,INGRID
VOOOOl195795 REG ER
02/03/1998 6/F
VAN OONGEN MD,PHILIP C
LOBATON MD. CHERRY
Nursing>Chart fonns>OR>Physidans Orders PACU
Revised: 02104/04
F3941
,
AFfER DOCTOR WRITES A MEDICATION ORDER
1. Remov.rvellowandp;nkcopies
2. ~tchyellowcopylolhePhannacyandlhepjnkoopy
IOltieMedicatior'l N<.JI'Se
3. AIIercopy3Isused'X"0UI'8'I1"IiIIningunusedl;"""
36271 (10-95)
Another brand of generically equivalent product
identical In dosage form and content of active ingredi-
ents(s) may be adminisl9l9d if column is not checked
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AUEAGIES
PATIENT INFORMATION
._J.....:.,,"""~ ..'>
M000170563'- '-"'05/10/04
CITY HOSPITAL, INC.
l'
lEE. INGRID
VOOOO1l95795 REG ER
02/03/1998 6/F
IV~A~~Gm ~RF' PHI LI P C
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CITY HOSPITAL, MARTINSBURG WV
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ALLERGIES
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PATIENT INFORMATION
PHYSICIAN'S ORDERS
CITY HOSPITAL, INC.
MARTINSBURG, WV 25401
LEE. INGRID
VOOOOI195795 REG ER
02/03/1998 6/F
VAN DONGEN MD. PHILIP C
,,,.......,...,,., .,,.,. .....,..............."
CG-D001
". '.
AUTOMATIC STOP ORDERS
Control Drugs Schedule II-V...... .....6 days
Hynotics ._... ..... .___.. ...._ ....... _ ...10 days
Antibiotics.. .__... ._.... .......10 days
Anticoagulants ............ _ __......... ....3 days
An other medications .._......__... ..._...30 days
Allergies
Nkff
Year:
'd-oD4
-:-:::::>'
SCHEDULED MEDICATIONS/IV FLUIDS DATE
~
INITIALS IV FLUIDS. AMOUNT. RATE SITE If 5.;
... . . ... .. .
111 n n. I 8m.-XII f.)J'" o,H"]: ,)!?/){) I ", 1\
I '/,^~ 'X
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,
till LR (i) infJ crLAr 110001'
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MEDICATION ADMINISTRATIONI PATIENT IDENTIFICATION
IV RECORD
LBB,INGRIn
CITY HOSPITAL, INC VOOOO1l95795 ADM IN
MARTINSBURG, WV 25401 02/03/1998 6/F 424A
KNuTSON DO,THOMAS E JR
Rev (10/00) KNuTSON DO, THOMAS E JR F3813
"'1'l1"l1'l1 "1"11:1:1 I'lC I
111(\/1
~. "
I
OR DATE MEDICATION. DOSAGE PRN MEDICATIONS:
INITIALS FREQUENCY. RT. OF ADM,
sJl!
oJ/I
5)/1
5)1/
5/1/
Dale
Time
Site
lnit.
Pain
Time
Eft.
Date
Time
Site
Init.
Pain
Time
Eft.
Date
7'jUru-l c CrdR,ii-/bIJTime
eJlK'Pr f .~ tf'o ~Ii~e
rv <> pl<J/ Pun. Pain
c.....tt"" Time
Eft.
Date
Time
Site
Init.
Pain
Time
Eft.
Date
Time
Site
Init.
Pain
Time
Eft,
Date
Time
Site
Inil
Pain
Time
Eft.
II? e;rrphlnL5v./{d.k
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STAT - NOW - ONE TIME MEDICATIONS -IV BOLUS
OR DATE MEDICATION. DOSAGE. RT. OF ADM. TO BE GIVEN NURSE ~~" MEDICATION. DOSAGE. RT. OF ADM. TO BE GIVEN NURSE
N FLUID. AMT. RATE DATE TIME INITIALS N FLUID. AMT . RATE DATE TIME INITIALS
Epidural/IV peA meds. Documented on Pain Management Flowsheet
INITIALS FULL SIGNATURE INITI!li,S " FULL SIGNAIURE INITIALS FULL SIGNATURE
5~'J :-;, 1:')/'\)_iY\ rl 0 I' A ~ ) /f1>.. . )i<ll-?/<(N
/ .-
-=:J
LEE, INGRID
VOOOO1l95795 ADM IN
02/03/1998 6/F 424A
KNUTSON DO,THOMAS E JR
KNUTSON DO,THOMAS E JR
" -
I
DATE 5 /I 8\1d-.IO'1 51 {2:- (:>0./
,
A-O-R-T HOSPITAL DAY PO-PP DAY HOSPITAL DAY PO-PP DAY HOSPITAL DAY PO-PP DAY
TEMP TEMP ~ ~ I.. '1/ cwI rAn .kO) 1la:D
FO Co
105,8 41
104,0 40
102,2 39
100.4 38
f, ~ :/-
"'( .~
98,6 37 Jl: jt
~ "1IIS' 1"- .Ii'. ~v
....
96.8 36
35,5
PULSE )~).... \1 't Wi La fez 12~ ! 1'1 lit
RESP, ~,9-0 b.o ,.;}0 /~ 18' lr.c do'? at
BLOOD 5 (4'D 1:5\ Hi) --- 117 Cf1
PRESSURE 0 lvS \0 t[b - R/ <iq
Initials "b.J <;J Ot-lJ f~ .---- ~, 1kM. 17~
IUV (]I cr
FREQUENT MONITORING RECORD
Date: Time ~'Jj) b:ilS p~tb ellls [)IJo DyY. OS>
BP S IY1 1(,;7 1:0 150 1./.3 12'( 1317
0 ).:, '>'l y,}- In' H 12 75
HEART RATE 16"!J /I~ /O~ /I'! z.~ IvI 1~5
RESP, RATE I'! /1 l't Jb
TEMP (A-O-R-T) 'ifl
CVP READINGS
Initials -M :t.2, ;fJ (P' XJ jJ I:U
V'"
PATIEuT Inc"lT.!c;;lt'~"'Vro.! "oil "'.J "'''
GRAPHIC RECORD -" .;..:,;,,~
LEE,J:NGRID
3854 (O''()3) VOOOO1195795 ADM IN
CITY HOSPITAL, INC 02/03/1998 tifF 424A
KNUTSON DO,THOMAS E JR
MARTINSBURG, WV 25401 KNUTSON DO, THOMAS E JR
Mnnnl1nc;~,
or; /11/04
fO",,, n1.,-:I\ C':IQ.c:;A
" ,
I
DATE ,") /I S\ I'd- I F1 51 (~;., i "0./
A-O-R-T HOSPITAL DAY PO-PP DAY HOSPITAL DAY PO-PP DAY HOSPITAL DAY PO-PP DAY
TEMP TEMP D~D ~ It(,-,,'b ".~ ccoI InUi I-:Ron Ila::O
-.IlD'>
F" Co
105,8 41
104,0 40
102,2 39
100.4 38
A ~
~ /, K ~ ;~
98,6 37 n : ;~ :,/
~ ~ " ,'Y
-
96,8 36
35,5
PULSE }l.\':L , \li~ to let 12C It! /lL
\\9;
RESP, ,!ID 1.lO )J0 liP )8' [&0 ,)'1- C}t
BLOOD S (4'0 1;:5 l"fu ----- 1\1 t.t1
PRESSURE D l/os II\-') <:{2> - IRI Io./q
Initials );-J I<;:;:J Ol+! f~ i.J ~ lk'lA 11
IUI/
FREQUENT MONITORING RECORD
Date: Time bw b-zJJs pm lolls :Jj,l'> ID5& O';{)
BP S 114i 1<<7 150 150 1./.5 /2'( J3b
0 53- 'O'l ,'J.' IW' IN '1Z 75
HEART RATE loS II~ IO~ (/1 },"6 Iv-! Jt'S
RESP, RATE I~ /1 11 JO
TEMP (A-O-R-T) 31
CVP READINGS
Initials .~ :f,J, -f!J L:RY W -PI 1;1(,(
PATIE"'T Inc"ITJ~t.r~A,"tJro!. .......,......,"'.
GRAPHIC RECORD LEE. INGRID
3854 /01-<13) VOOOO1l95795 ADM IN
CITY HOSPITAL, INC 02/03/1998 6/F 424A
KNUTSON DO,THOMAS E JR
MARTINSBURG, WV 25401 KNUTSON DO,THOMAS E JR
Mflnn17nt;k"'l
or:: I' l/nd
" ".
DATE 61 )( 5/ /d--,
,
WEIGHT
SHIFT -
INTAKES
\oJ I'btl I~
~ yltl& 1'8--
:;1b . ~
P,O& I 0"-\
FEEDINGS
Intra..operative or
Procedural intake
PARENTERAL 4~ 5(.'1 ~ ~
IRRIG,G.I,
&G,U,
80 TOTAL SO;; c{(J
INTAKE
OUTPUT
URINE \\~\l e\ €I ~
Intra--operative or
Procedural urinary
output
Other Intra-
operative output
lincludina EBll
NG
JP/HEMOVAC
EMESIS
STOOL
IRRIG G.I. & G,U,
8OTOTAL W
OUTPUT
Init Signature In it ~ignature I , Init Signature. (
( t> I J,JJ..., (6- ./ mV l )G/\.Q. , ItJ d \hI- nJ ;y ~,,>'\,a. ~.:!J hil ~, ,
- t--r. },(l (\ " I 0 , 1'7lt7 . yf.., IllLkt\\ ~
0 .
....._, __L ~~, ~., v ~
LEE, INGRID
V00001195'1~-
ADM IN
'. '.
ADMISSION DATA VITAL STATISTICS MEDICAL HISTORY
Nickname: Jonm"--' ~J:-'{ Symptoms / Complaint:
O/AxI~ '--f'" !J~ nwv
Temp < ,J
Pulse 103 Radial/~Ical
Emer~~llnt~~e & #) Resp 11 B/P 14. /?3 UR
HtlLen(l,th /)'0 Actual/ Stated Has child been a~d anyone sick?
) I tp'3 m7/ Wt 't'oG Actual/ Stated o Y. N
From: Scale Used 1-:(1\ <JQ.. .Explain:
Head circ cm (under 2 yr) {~3 y~ft,
0 Home BROSELO~ Water source
0 ED Heat source ( J ./
g; g~h~ffi1"Vt(,L\ Birth Status: (for pts < 5 yrs) M~ Illnesses:
Via: Delivery: o Vaginal o C-Sect None
0 Ambulatory o Full term o Premature 0 Arthritis pt M F Sib GP
~ W/C Birth weight 0 Asthma pt M F Sib GP
Stretcher Complications: 0 Bleeding pt M F Sib GP
0 Carried Anomalies: 0 Bronchitis pt M F Sib GP
Informant: Other: 0 Cancer pt M F Sib GP
0 Patient ALLERGIES (Meds, Food, Contact, 0 CP pt M F Sib GP
0 Family 0 CF pt M F Sib GP
0 Other ~KA 0 Diabetes pt M F Sib GP
0 Unable to obtain info 0 Down's pt M F Sib GP
(unresponsive &/or unaccompanied) o Allergen Symptom 0 Heart Px pt M F Sib GP
Oriented to: 0 Hepatitis pt M F Sib GP
0 Surroundings 0 High BP pt M F Sib GP
0 Siderails/calllightfTV 0 HIV/AIDS pt M F Sib GP
0 Telephone 0 Kidney Px pt M F Sib GP
0 Visiting hours 0 Liver Px pt M F Sib GP
0 Smoking policy Latex screen 0 Pneumonia pt M F Sib GP
0 Electrical equipment o NO KNOWN LATEX ALLERGY 0 Rheumatic fever
0 ID/Allergy bands o Allergy to bananas, avocados, pt M F Sib GP
0 Admission type: chestnuts 0 Seizures pt M F Sib GP
Inpatient / Observation o Known allergy to latex 0 Sickle cell pt M F Sib GP
0 Cots o Multiple allergies 0 SIDS pt M F Sib GP
Equip/Aids brought in: o Swelling/itching/hives after blowing up 0 Stroke pt M F Sib GP
0 None balloons or being examined by 0 TB pt M F Sib GP
Pt, Home someone wearing gloves 0 Ulcers pt M F Sib GP
0 Glasses - - OSpina Bifida 0 Other
0 Contacts - - 0
0 Hearing aid - - IMMUNIZATIONS
0 Walker/ UTD ~mmunizationS? Major Surgeries / Procedures
CrutcheslWC - - Y OW 0 None
0 Dental .List missed immunizations 0 Appendectomy
Apparatus - - 0 Cleft lip/palate
0 Security o Hemia ~/Uf
object - - Date of last: orT&A
0 Jewelry - - Flu vaccine 0 PET
Describe W Other ('),f)~jcr1 Af[W~L
Pneumococcal vaccine /
0 Other
o IMZ schedule give to care provider
.Valuab/es kept at patient risk,
Signatur~t~-/L--
Nursing Admission Assessment Page 1
Pediatrics
City Hospital, Inc.
Martinsburg, WV
rev. 5102
DateAr
Time
03?0
'"'VVV"1; IlTJtl"J
"'--(j"J/l'J:Y~N
LEE,XNGRXn
V00001195795 ADM IN
02/03/1998 6/F 424A
KNUTSON DO,THOMAS E JR
KNUTSON DO. 'T'H()M.a"~ '" .TO
C4P..oOO1
'.
HOME MEDICATIONS Include Prescription, Over-the-Counter, Notify Pharmacy of any alternative
o None and alternative meds such as herbs or meds being used.
o Sent home with home remedies,
o To Pharmacy
Medication DoselFrequency Last Dose
/J'u^-fif' )
Uf/
PSYCHOSOCIAUCUL TURAL P~ry Care giVer~).& EDUCATION I TEACHING
Be~ior: Parents - (Y1.6 v ASSESSMENT
Calm/cooperative/playful 0 Grandparents Barriers to learning
0 Anxious/restless/tearful/clinging 0 Other EYNone
0 Irritable/angry ~~qY 0 Legal custody [] Age
0 Combative Stressors: [] Auditory / Visual
DruglAlcohol use 0 Divorce o Death [] Cultural
0 No 0 Illness o Moving [] Emotional/ Cognitive
0 Yes: Type 0 Birth o Other 0 Financial Concerns
Amount [I Language
Tobacco use Child's rx;;~ parental separation: D Religious Beliefs
(i -~- lot
0 No D Physical Limitations
0 Yes: Type Parents rxn to separation from 0 Difficulty Reading 1 Writing
Amount daily child: Describe any positive item above
# years Child's rxn to strangers:
"naf pert"
Relig~S/$Piritual Affiliation Special fears:
R~iness to learn
,~1 ,1:fto..n Suicidal thoughts o Y' ON
B Eager
Can we contact anyone for you? 'Describe 0 Accepting
o Y' ON 0 Denies Need
, 0 Refuses
PAIN ASSESSMENT ~ ~f!j Educational Needs
List any treatments that are o No Known Problem Jt -, '- trJDiph U/ Disease Process
unacceptable to you o Location /711 o ,..--ADL's & Discharge
o Duration j Y1 OJ( IT Treatments / Procedures
S~I Grade 0'rdlADft ft;/fl 0 Intensity (0-10) 0 Equipment
0 Relieved by 0 Medications
Like 0 Dislike ' 0 Diet (enter Nutrition Consult)
If multip/e sites of pain, detail in narrative 0 Other
Future plans notes
How does patient/family report
Hobbies /Interests: ~VIOUS BLOOD TRANSFUSION ~ learning?
No 0 Yes; date Visual
o Reaction: o Y' ON 0 Verbal
'Describe 0 Written
Signature c:;fJI;xLZ&O::CC~
Nursing Admission Assessment -- Page 2
Pediatrics
City Hospital, Inc,
Martinsburg, WV
Rev. 5/02
RN/LPN
Date
s/;/
T. 030
Ime
LEE, INGRID
VOOOOl195795 ADM IN
02/03/1998 6/F 424A
KNUTSON DO, THOMAS E JR
KNUTSON DO.~QOMAS E JR
A_ /11 /"A
'.
NEURO I SENSORY I COGNITIVE
~ No Known Problems
o Fontanel: 0 WNL 0 Closed
o Bulging 0 Sunken
o Hearing Impaired
Describe
o Vision Impaired
Describe
o Speech Impaired
Describe
level of Consciousness
0/' Alert (\JUt~o
o Oriented x 3 r~ tJ " n
o Disoriented to ('( , (J\ LillJl.W-t
o Lethargic
o Unresponsive
o Inappropriate response to questions
o Does not follow commands
Pupils
o Equal
o Reactive
o Unequal: larger 0 R 0 L
o Pinpoint
o Blown
Eyys
[2( Moist
o Dry, not tearing
O~I Mucous Membranes
0' Moist
DOry/cracked
o Tongue swollen
ReSPIRATORY
Ei' No Known Problems
o SOB: 0 at rest 0 on exertion
o Labored
o Flaring
o Stridor
o Retractions
o Cough: 0 NP 0 Productive,
describe
B~ath Sounds
rzf Clear throughout
o Wheeze: 0 inhale 0 exhale
o Decreased: 0 right 0 left
o anterior 0 posterior
o Rales / rhonchi: 0 right 0 left
o anterior 0 posterior
o Trach: type
o 02 at home L / min
02 Sat % if known
Signature }lido[ ('/./ lLoca:/z-
~
Nursing Admission Assessment - Page 3
Pediatrics
City Hospital, Inc.
Martinsburg, WV Rev 5/02
TB Screen
If the first item is positive along
with any other item(s), place in
negative airflow unless other
diagnosis has been confirmed,
o Significant productive cough >2 weeks
o Cough up blood
o Fever recent or on admission
o Night sweats
o Recent unplanned weight loss> 5 Ibs,
CIRCULATORY
H~ Sounds
0' WNL
o Abnormal
Describe
Rhythm
(2('Regular
o Irregular
Describe
P~ipheral Pulses x 4
0' WNL
o Decreased
Describe
Other
o j\lo known problems
~Pedal.edema @ iro:t
Descnbe -i:b L..
/
o Other ,
Describe
DIETARY HABITSIPREFERENCES
Food likes
Food dislikes
Diet taken at home:
o Fonnula
o Baby food
Other flUlr'
R.N.
Date ..:s,J / /'
...-'V"..I".tT!'iJ&.t..
GIj GU
if No Known Problems
o Potty trained
S!!Cking
rf N/A
o Strong/normal
o Weak/impaired
Ab~omen
r;;r' Soft
o Firm
o /Distended
D Nontender
o Tender
o G-tube
o Ostomy
BO)llel Sounds
cr Present x 4 quadrants
o Decreased
Describe
B9Wel Habits
I3' Regular
o Irregular
o Diarrhea
'0 Constipation
~./ Laxative Use . {
t;r Color hOYYt1Q(
Ii!' Last BM .f5J.ly
o Incontinence
GI Symptoms
o Nausea
o Vomiting
o Bleeding
Uyine
~ Appearance WNL
o Altered appearance
Describe
o Frequency
o Dysuria
o Foley
o Ostomy
o Incontinence
Menses ~
e-None/ t applicabl
IJ Regula
o Irregular
lJ Date of onset
[J LMP
[J Pregnant
Discharge
[J Vaginal
[J Penile
Time 03.3?O
..\,I"......, 'J.JU"'.
LEE,INGRIn
VOOOOl195795 ADM IN
02/03/1998 6/F 424A
KNUTSON DO, THOMAS E JR
~~~N_ DO,THOMAS E JR
INTEGUMENTARY
o ~ool
~ Warm
ICJ Dry
O/Diaphoretic
E:J Color WNL
o Pale
o Ashen
o Flushed
o Cyanotic
o Jaundiced
o Intact
Altered: Describe alterations and note locations
on diagram
Braden Score
Total c9 I
Sens,pry
l3'No' impairment" 4
o Slightly limited = 3
o Very limited = 2
o Completely limited = 1
Moist!,lre
l:af{arely =4
o Occasionally = 3
o Moist = 2
o Constantly = 1
Activity
o lJyalks frequently = 4
li:rWalks occasionally = 3
o Chair fast = 2
o Bed fast=1
Mobility
o No limitations =4
a-Slightly limited =,3
o Very limited = 2
o Completely immobile = 1
Nutrition
g-6cellent " 4
EI Adequate = 3
o Probably inadequate = 2
o Very poor = 1
Fri,ctieh & Shear
f:f No problem = 3
o Potential problem = 2
o Problem 1
Signature
RN,
Uff~
Nursing Admission Assessment - Page 4
Pediatrics
City Hospital, Inc.
Martinsburg, WV
REV 5/02
o .
~ '-
/'-
-I -I
(
)(~
,/
1.!..11
lit
A = Abrasion
B = Bruise
R = Rash
S = Scar
W = Wound
D = Decubitus
SU = Stasis Ulcer
S}t) 7'\.,_;;r2 / '\
Date' Time LA <..-.-'U
,
nv".......'..r-...t.I7"""':.,--;-
i ""
-..,.,....,."...'J.,"~
LEE, INGRID
VOOOOl195795 ADM IN
02/03/1998 6/F 424A
KNUTSON DO ,'rHOMAS E JR
KNUTSON DO. mOMAS E JR
Mnnn1 "'lnl;j:;"); (IE; I' 1 Inl1
"
FUNCTIONAL SCREEN
Developmenta!!Jvappropriate for stated
age? ~ ON'
'Explain:
Assistance Needed For
o None
o Feeding
o )>lygiene
GY Activity
Balance I Gait
o Steady
o ,)Jnsteady
ff Unable to assess
o Other:
Any * items require Functional
Screen
~Moves all 4 extrem' ies
equally 0 Y N* t1.C;
Explain: t6 L '"-G
~ Reflexes WNL 0 Y 0 N*
~xplain:
IT Rolls/Turns / Sits /CsawlslWalks
WNL for age 13 Y 0 N*
'Explain:
o 'Fracture in last 30 days affecting
ADL
o 'Other anticipated Rehab need;
specify_
NUTRITIONAL SCREEN
Diet prior to admission
o No needs identified
High Risk items (*J require
Nutrition Screen
o . NPO (other than preps/tests)
o . Breast feeding
o . TPN/Tube feedings
o . Impaired chewing or
swallowing
o . Unintentional weight loss/gain
> 10% in two months
o . Chronic N N /0
o * Multiple food allergies/aversions
o * Any trouble following special diet
o . High risk diagnosis: Cancer,
Burns, HIV/AIDS,
Developmental delay (affecting
intake), Major surgery/trauma,
Inborn error of metabolism /
malabsorption, Sepsis /
Infection; Diabetes; chronic
renal, liver, lung disease;
cardiac disease, Cerebral palsy
pregnancy, FIT
o Other
DISCHARGE PLANNING
SCREEN
8 No needs identified
ANY ITEM checked below
requires Clinical Care
Coordinator Consult
o Admitted from Nursing
Home/Group home/Sheltered
workshop;
Specify
o Receiving Home Health prior to
admission; agency
o Chronic disabling illness or
complex physical needs;
specify
o Discharge with equipment (apnea
monitor, etc.)
o Signs or symptoms of abuse or
neglect
o Readmitted within 30 days of prior
discharge
o Hx of home injury/falls
o Financial needs
o Needs support for ADL's (meals,
transportation, etc.)
o Discharge planned to place other
than home
o Teen pregnancy with
familylfinancial difficulties
o Homebound teacher - anticipated
absence from school? 5 days
INTERDISCIPLINARY REFERRALS
0 None Indicated PATIENT PROBLEMS LIST
0 Functional Screen 7 Rehab Circle all applicable. Complete
Notified date time by Interdisciplinary Care Plan.
0 Nutritional Screen 7 FNS
Notified date time by Protection ~ CopinglComm/Spirit
0 Discharge Planning Screen 7 Clinical Care Coordinator 2 Patient Education 10, 'Age Specific Care
Notified date time by 3, Mgt of Health : Tenninally III/Dying
0 Patient Education 4, Comfort 12, nfection
Notified date time by Nutrition 13, Cardiovascular
0 Cardiopulmonary 6. Elimination 14. Discharge Planning
Notified date time by . Oxygenation 15, Other
0 Other 8, Activity
Notified date time by
I have been advised to send all valuables home or to the hospital security safe. I accept responsibility for valuables,
money, and personal devices, including dentures, that I bring to the hospital and keep at my bedside. I have received
inf rmation about Advance Directives and organ donation, and the Patient Information Guide. The nurse has reviewed
n f r for his s' , tion with me and/or my family,
Nursing Admission Assessment Page 5
Pediatrics
City Hospital, Inc.
Martinsburg. WV rev 5/02
R.N.
:;,!//
.
Date
Patient/Family signature
Time Q~v
LEE,XNGRXn
V00001195795
02/01/1 QOD ,. 1_
ADM IN
" '-
DATE
DfJ,n
/<1-4:5
\\Q3,-o
TIME
NOTES
PATIENT PROGRESS NOTES
NURSING
CITY HOSPTIAL, INC
MARTINSBURG, WV 25401
3851 (REV. 01-95)
LEE,rNGRID
VOOOOl195795 ADM IN
02/03/1998 6/F 424A
KNUTSON DO,THOMAS E JR
KNUTSON DO,THOMAS E JR
M000170563 05/11/04
", '.
DATE
51, ,
TIME
NOTES
ao~~.-pl.
~" :J..(S
Rr--J ~
PATIENT NAM
LEE,INGRID
VOOOOl195795 ADM IN
02/03/199B 6/F 424A
KNuTSON DO,THOMAS E JR
KNuTSON DO.THOMAS E JR
Mono, "o~c. ....... J~ ~ ,~.
"
\ I
DATE: MO-DAY-YEAR . ") II J I OLI
Patient Activities Codes (PAC) I '
o - no set up or physical help 1 = Set up help only
2 = One person physical assist 3 = Two + persons physical assist
. indicates placing PAC with initials in appropriate space, Initials indicate affirm NIGHTS DAYS EVENINGS
FUNCTIONAL ACTIVITIES TIME b'1?}.: Inlio 1I(03~
BATH .5J V
C=COMPLETE A=AssrST H=HS CARE S=SELF /'~ V
S=SHOWER T=TUB ~
LINEN CHANGED ~
PERINEAL CARE 1.;,( /'
ORAL CARE/DENTURE CARE' ~ ,/
RANGE OF MOTION P=PASSIVE A=ACTIVE It 1/
BED TO CHAIR' ----
BATHROOM PRIVILEGES' - ~,
AMBULATORY' - /'
POSITION CHANGED (q2h)' 0 0 .0
BED REST ',Z IlV I" tV
SLEEPING U=UNINTERRUPTED 1=INTERRUPTED LA --r 1-
SPECIAL BED I TYPE:
ASSISTIVE DEVICES (Iisl)
DIET B L 0 -
% OF DIET CONSUMED ' j(\C1j.. 1kY1J ,
F=FEED S=SETUP C=CUE
SAFETY
SIDE RAILS RAISED X2-X4 'l 'X2 L
CRIB RAILS UP - ----
~
BED FRAME D=DOWN J. 17"-. D
CALL BELL IN REACH -1 ::N i)!b.J
FAMILY I S,O. PRESENT JYVJ}1\ (liLl\ rrm,
ISOLATION: TYPE 5 <) <:,
TRACTION FRAME SAFETY CHECKED I
BED CHECK FOR l' FALL RISK
ELIMINATION TIME D
BOWEL MOVEMENT Y=YES N=NO 1'\ i'--) i"
- -, .:.----
VOIDING Q SHIFT Y=YES N=NO tJ y
CATHETER CARE I -
c/
OV J
PATIENT CARE RECORD Patient Infonnatlon ,
"""""~' ............... "-',......,...."
CITY HOSPITAl,INC.
MARTINSBURG, WV 25401 LEE,INGRID
VOOOO1195795 ADM IN
02/03/1998 6/F 424A
KNUTSDN DO,THOMAS E JR
,
(This side to completed by RN or LPN only)
IV THERAPY
TYPE: P-Peripheral C=Central Venous line
PIC - PICLlNE
NIGHTS DAYS
TIME ~ J \?'cu
.olU
(
I I
I I
-lI"! \:v
~ EVENINGS
SITE CHECKED
TUBING CHANGED
Jl{j
MISCELLANEOUS:
I
\
\
FALL I BED RAIL ENTRAPMENT RISK
Completed on all patients @J admission
Time
1C onf U'slo'~n'I"'ls"O~f'I"e"n..ta' .'lo....n.' "," ;~;" 1),Ii': "-'''',' . ..""" ,." ~
.;?~ ,', '",.,,- -, \1,._,.,;" JL.;,,+:;}8;!:m':~;"i;,~;v'~',~"~ii;f,i:v,ifii.'r<,t;~
o - oriented at all times or comatose
2 - confused at all times
6 - intermittent confusion
2, it Davs in'Cun'ent'BildtAssiofnilent, ,'?, r"'~:'}~
o - over 3 days
2 = up to 3 da s
BRADEN SCORE
(enter # in box) "Score < 18 see Decision Tree"
3,
~
1- completely limited 2= very limited /I
~ 4=no.ent ~~
1= constantly 2- moist 11
tl\i.'i',;,;I~i#- 3 occasionally ~rarelY ~
"'L\"I !.!:l:i.'. ~
1- bed fast 2- chair fast I n
3 walks occasionally ~= walks fr uentl
~~~Mril:lm' .
~mobiie 2- very limited -,
j 3- *~~;illfJt~P7i~= Ml'
1 very poor 2= probably Inadequate
3= adequate 4- excellent
""..',,':,...t'!(.,,".' '''''";''~..,r't'''c.t't..Q... 'n. ."a.'n..d'S.h.'..e....a"...."'.",".","'.'"t.t.,"'''.'"",fu,' t"_,'"' '.'"
~\j.:"(.i.h'ik!,;;:<1\-1:}-b~t\s;r;r1.~!~JT, ,: _ ,,> - _ ,'.' L'_.-. _ -'j*'~'*'B~,,~ty.;'~!;ir#~illlij~1~ii~);t
1- problem 2= potential problem f7
3- no problem ---J
o = Independent
1 = catheter andlor ostomy
3 - elimination with assistance
5 - incontinence
4:;~:Q:~i~~~~(/a$(',Q'~i'iPn\l!l~
6 = hlstor of falls
5..i\tj~t;a'''*''
6:jOij'Q
eal'iri'
airm:erjt~i1
',' !)tlt
.. n
.,"""",..
''''::';'(3:'''''' >'f'ij" :"_-,~",,..,,;;-
.,.', al ..l!'f<l
1 = wide base of support
1 - loss of balance while standinQ
1 = balance problems when walking
1 = decreased muscle coordination
1 = use of assistive devices
6 unable to et out of bed
l\.,MElClltati01' $~
"'Jlantl '" -.
) ,,:~a'iili
".'''M''~o'
.
o = no medications
1 - 1 medication
2 - 2 or more medications
1 = with chanoe In med or dose Dast
~
~ ',.~"
Initiate Fall Protocol Intervention
SCORE: 6 - 9 = Moderate risk
10 or > - High risk
,
TOT ~ SCORE CJ, I
Inltials:?ftJ I Signature:H:d; 1Ul j) '''''' rl" A.
INIT SIGNATURE INIT SIGNATURE
1\ ,,(, /
II'>>/ J I lilY! L\\.Il~ I2L, lU
'"
tiC"
:',,,,
f\/ fI/
ffi\{1 '7/r.U/ .. nilVr'L
t/
,
I . '.', " ,'.. Patient Information
LEE, INGRID
V00001195795 ADM IN
02/03/1998 6/F 424A
KNUTSON DO, THOMAS E JR
KNUTSON 00. THOMAS E JR
M000170563 05/11/04
"
'INDICATES COMMENT REQUIRED IN NARRATIVE NOTE. INITIAL APPROPRIATE BOX.
DRAW A LINE IN BOX NOT USED.
DATE: MO-DAY-YEAR
ii~,~(tl."",:!~,
ALERT
ORIENTED TO PERSON, PLACE, TIME
COOPERATIVE
, LISTLESS AND LETHARGIC
, CONFUSED
, UNRESPONSIVE
, ANXIOUS
, MOOD ALTERED
, RESTRAINTS
, PAIN SCALE
~~!:m:~"~--'~'~~-~~~-' ''''''''''-'-'-~'-~
",> 0- , ' "<<<"
~1( _~,,",..l ~_ ~,_".J:""'.__'<L!V~"~~_~""""'-~~4"',""",~'
RESPIRATIONS R=REGULAR 'I=IRREGULAR
LUNG SOUNDS C= CLEAR 'A=AL TERED
, REQUIRES SUCTIONING
, REQUIRES 02
COUGH 'P=PRODUCTIVE N=NON,PRODUCTIVE
ABDOMEN APPEARANCE N=NORMAL 'A=ALTERED
BOWEL SOUNDS N=NORMAL 'A-ALTERED
, NN, EPIGASTRIC DISTRESS
FLATUS Y=YES N=NO
TUBE TYPE:
P-PATENT
PL=PLACEMENT CHECKED
OSTOMY TYPE:
BLADDER DISTENTION 'P-PRESENT A=ABSENT
GENITAL APPEARANCE N-NORMAL 'A=ALTERED
CATHETER PATENT
'ALTERATION IN CATHETER DRAINAGE
'VAGINAL DRAINAGE
SKIN N=NORMAL
'A=AL TERED (Refer to 'Wound and Skin Documentation Tool")
INIT.
SIGNATURE
Patient InformatJon
- -, - -, ~ -
24 HOUR SYSTEMS REVIEW
CITY HOSPITAL, INC.
MARTINSBURG, WV
LEE,XNGRXn
VOOOO1l95795
02/03/1998 6/F ADM IN
KNUTSON DO, THOMAS 424A
KNUTSON DO E JR
M000170S61 ,THOMAS E JR
. , 05/]]/04
F4288
Rev. 05/02
'. ~.
.
NURSES NOTES
(This 24 hours only)
Time 511 ~/ 04-- Time
lJ4J: iUfPA1.l:C c. ..1 '".,n) p;JiV-Jr an9/n
J)W. I^YJ;ML Dlll11 ',1/1~ laY hd. }fS}/
U ;?Ll/: ,/ ,. I1V.'..L ,/v /..LIJ), /
'7i. f)p Ii y -/f-, ia J
(f/DD Ibs \5.1. \kYJ..rchiYLo.. r Vf'CLhY'C\blCMw'i
mDrn n1 n." /It. nu::lco (,\'VOA. cfl. u
W/IIL r\l(;n"v, "" dru- -hl("(\l'<.~;;D~ {'nO
11\tl;.k2.",,<- VuL'liA A'1I-JJ'''';,r t,./i. fllWL.
~Iln OOi.n(Ci),M.O.f\of\1- ~v~ ~cc
I1lltr.n[)./'c 0Mfp/ni hJd rnllUuIJ...,d'/!1l-orl
1.J:'e IAVliJ-; hll [b'-)t O-r"K..l'Jr ''Lid I\.Jf
Ir)Q30 I mo rl;;, (I,.. .oi..hJj '" I'r'd 0 ; rfJ ~'f;:'o
Po. /") . < 0~..irl.:J..O ,""", Cfo (i;)
;1"" Ai.,) /lrrY'YlJ,,,,,t A7-l-.-Uri JollO
/"mil, .rv>L~ ,f),(o':r,,6 ' J1fU rnJ1f!. (0
.0l11 '0'- I'1Y1 .1\, 'u 6"" ,). (".Ai" ,r/j, ,
uCvy,rl .1M fn~'f. Q u,,,1- [)p l'"hfO, ,
VlI LI. J OJ hu..}; . L U fl. 1>1., B '1JJ.,LU,;,.
{/) vvp,:""J, LkJL) .:; ~I f'Y'n,",~,,,,,.~r
I'l/YlI'IL .l\O r,. 4-; ~'\'YJ~ dN i'mJ t h,
1.:J .OM. .c", /Jv";,.,,,./UoR.u -
1700 IV De'd, .Ad~/llll, d.. ,~Bf".
IV f'.n#1 -1,.0 J.;"h,j.t.. '0. f!y)j. j~,,1.)
,
.
Int.:SI:S Sianature:.s, fJ.,. '.{I. RI\\
Int.: Signature:
Int.: SiQnature:
24 Hour Systems Review
City Hospital, Inc.
Martinsburg, WV 25402
Int.: Sionature:
Int.: Sianature:
In' . '" .Siona\lJre:
..~,
LEB,INGRID
VOOOOl195795 ADM IN
02/03i199B 6/F 424A
KNUTSON DO,THOMAS E JR
KNUTSON DO,THOMAS E JR
Mnnn17n~~l n~/l1/n4
I I .
DATE: MO-DAY-YEAR <.. ~ fT:J Ill'!
Patient Activities Codes (PAC) 1
o ::: no sel up or physical help 1 ::: Set up help only
2 = One person physical assist 3::: Two -t persons physical assist
. indicates placing PAC with initials in appropriate space, Initials indicate affinn NIGHTS DAYS EVENINGS
FUNCTIONAL ACTIVITIES TIME OJ{) I be<l') i /q-{)
BATH -. /
C=COMPLETE A=ASSlST H=HS CARE S=SELF F\ ,/
S=SHOWER T=TUB ~ ./
LINEN CHANGED -- ./
PERINEAL CARE -..... 1-;1
ORAL CARE/DENTURE CARE' -I 1 I
RANGE OF MOTION P=PAS$IVE A=ACTlve 1 A /
BED TO CHAIR' 'l ;2 }.
BATHROOM PRIVILEGES' Q. a :J...
AMBULATORY' ;..---- ~-3 !)...
POSITION CHANGED (q2h) . :2 Q 0
BED REST ~ I {u.... S6
SLEEPING U=UN1NTERRUPTED I=INTERRUPTED - '- T ~,IO
SPECIAL BED / TYPE:
ASSISTIVE DEVICES (list)
DIET B l 0
% OF DIET CONSUMED 5fft ::;:;:-1" ."'\
F=FEEO S=SETUP C=CUE -
\.
"----
SAFETY i--
SIDE RAILS RAISED X2-X4 '~ XI.. X;).
CRIB RAILS UP /' ~ --------
BED FRAME D=DOWN .J t> ])
CALL BELL IN REACH , ~ VB ~
FAMILY/ S.O. PRESENT ^,- rrorfl
ISOLATION: TYPE ( J I <1. ~
TRACTION FRAME SAFETY CHECKED
BED CHECK FOR l' FALL RISK
ELIMINATION TIME ~.
BOWEL MOVEMENT Y=YES N=NO /lJ ./J N
/' -- ./
VOIDING Q SHIFT Y=YES N=NO yo V Y
CATHETER CARE I I /
I /
PATIENT CARE RECORD Patient Information
CITY HOSPITAL, INC.
MARTINSBURG, WV 25401 LEE,INGRID
VOOOO1195795
ADM IN
02/03/1998 6/F 424A
KNUTSON DO,THOMAS E JR
v""......."n __
,
(This side to completed by RN 0' LPN only)
IV THERAPY
TYPE: P=?eripheral C=Central Venous Line
PIC - PICLlNE
NIGHTS
DAYS
EVENINGS
>;TN..
OlI45
"P
(
/
{
ILL.~
/
(
4'-'
1500
1-'
TIME ,00
~
SITE CHECKED
TUBING CHANGED
S,~
MISCELLANEOUS:
Tee To (I";; Jec:v-
5P.,
FALL l BED RAIL ENTRAPMENT RISK BRADEN SCORE
Completed on all patients la) admission ("nt", # in box) 'Score < 18 see Decision Tree"
Time ;', ;;
1. Confusion/diso(ientatidn ~.':','.<:.;: ':';. "0 ;.tI=.:.'; . J:", ".,'1 1 completely limited 2- very limited
o oriented at all times or comatose 3 sl~ limited 4- no impairmer
2 confused at all times ~ ~
6 _ intermittent confusion 1 = constantly 2= moist
2. # Davs'iil'CtirrentBed 'Assiahme\10A:F;:~;.j!:y~ ~ 3 occasionallY s 4 rarely
o over 3 days H,'.'"..2.:J
2 = UP to 3 days 1 = bed fast 2- chair fast
, ,...".; ~ccaSiOnallY 4- walks freauentlv
0- indeoendent ~
1 _ catheter andlor ostomy 1- completely immobile 2= verY limited
::==:.'~;"M~ l~ ,~~~
4. Histoni oftatls Ilas'f6~ 1= verY poor 2= probablY in~
0= no historY ~ 1'3- ade uate 4= excellent I
5.V~:a~I~~~~~:~~'6Ei'<lill)llr " i(m!lii~' 1= problem 2= ootential problem ~.;
6. Chronic:disease r06ess'siJ 3- no problem I
neurOlQg'i~1 im
(3 plsY: i~';o
7. GaiVbalan .
1 = wide base of support
1 = loss of balance while standinq
1 balance oroblems when walking
1 - decreased muscle coordination
1 - use of assistive devices
6 - unable to eet out of bed
8. MedicatiQns Isoote;all tl1a"l
(antitiista1n1ne,'antlh .'H
8I1tici)n'-llJ!sant:tijhlref
twpo!'live,emics;
seaa!iyesthVnnpt
cathartiCS. ariceDtl ':> .
o - no medications
1 - 1 medication
2 - 2 or more medications
1 - with chanae in med or dose past
5 days ~
;nitiate Fall prot:collnt~ntion
SCORE: 6 - 9 - Moderate risk
10 or > - High risk
s, -:
.. :,';') ',:'C,'
3.
TOTAL SCORE
Initials: I Sianature:
INrt SIGNATURE
>f-A <A UJl JlIHr I( A I
I'll, I W~' ~ ^,i.j AJT'
v
INIT SIGNATURE
SP, 5 f'y-,,,:,,..ilo RA,}
Patient Information
LEE. INGRID
VOOOOl195795 ADM IN
02{03/1998 6/F 424A
KNUTSON DO,THOMAS E JR
KNUTSON DO,THOMAS E JR
M000170563 05/11/04
,
NURSING DISCHARGE RECORD
Date & Time of Discharge: S},LIO'-I 1'7/0
Condition on Discharae (check all that aDDlvl
'-J Alert IV Status: Foley Catheter: Other Equipment:
-
'-' Oriented Intact Intact Intact
- - - -
~ Vital signs stable "'-i Discontinued - Discontinued - Discontinued
- Confused _Not Applicable ::::::!- Not Applicable _ Not Applicable
_ Lethargic _ Specify Equipment:
- Comatose ."'-....J Ik. Dl..J.Jo^\Q d lNCLtl:.l,.-
Deceased
Valuables/Personal Belongings:
_ Returned to patient/family/taken home before dc Medications returned to patienUfamily:
- Sent to funeral home _ Returned to patienUfamily
----, Not Applicable ~ Not Applicable
Discharged: Via: To: Accompanied by:
~ Ambulatory ~ Auto/Cab '-.....J Home "-i Family
~ Wheelchair - Ambulance - Transitional Care Unit Friend
-
- Stretcher - Funeral Home Staff
-
- AMA Name Volunteer
-
_ Child carried by - Other
mother
Nursing Diagnosis: '" PatienUFamily verbalizes understanding of
- All Resolved discharge instructions given by physician
- Active Referrals: ~ Physician written instructions given
_ Dressing Change:
~ Activity/Limitation: Co.'l fCru.<n Th Sthoo I
Miscellaneous Comments: ;3 P.e::
_ Signs/Symptoms of Infection:
_ Medication Regime per physician
~ Prescriptions: J;-~I(nol f CodeiN '1,Ii'(I<-
, Po Cillo"
_ Food & Drug Interaction (instructions given)
~ PatienUfamily instructed to contact physicians
regarding concerns/questions.
\.~J\'J\10-. "111n?CW6 NT
Sionature of Discharaina RN
PATIENT IDENTIFICATION
NURSING DISCHARGE RECORD ,
CITY HOSPITAL,INC LEE. INGRID ADM IN
VOOOO1l95795
MARTINSBURG, WV 25401 Rev(Oa.g8) 02/03/1998 6/F 424A
KNUTSON DO,THOMAS E JR
KNUTSON DO,THOMAS E JR
M000170563 05/11/04
F3520
"
EDUCATION CODES
A. Questions answered
B. Verbal information provided
C. Written information provided
D. Task Demonstrated
E, Audiolvisual teaching tool used
F. Referral to outpatient education
G, Not applicable
PATIENTlFAMIL Y EDUCATION RECORD
FRACTURE
LEARNING CODES
1. Needs further instruction
2. Stated understanding
3. Return demonstration, with help
4. Return demonstration, independent
5, Unable to understand
6. Refuses information
Information Taught (to Patient or Support) Educ. Learn. Comments
Code Code Initials/Date
I. Definition - Fracture 'iiJs )'(J::, '? LVX' "1 II
II. Exolanation of Procedure Completed p [;L, 'J- 01'7:' ,
S .)1 I
III. Pain Mana!!ement PIS
A. Site PIS
B. Severitv PIS
C. Duration PIS
D. Use of oain scale PIS
E. Medication use PIS
F. Other oain relief measures PJS
IV. Post-Oo Care i-~
A. Neurovascular assessment ~ W L I'
B. Elevation " , .< "
C.lce S h ..., , c' "
D. Medications IV~ /) < II
1. Pain ). ..: c /I
2. Antibiotics S)W 1- '71, .S) 11
E, Cast care or dressi.,!! chanaes PIS v
F. Complications PIS
1. Infection PJS
2. Loss of mobilitv PIS
G. Education PIS
1. Anticoaaulation theraov with PIS
Lovenox, Heparin or Coumadin. PIS
a. Avoid OTC meds without ohvsician PIS
knowled!!e. PIS
b. Avoid herbs without physician PIS
knowled!!e. ~
H. Rehab - physical theraov S) \-'> ':) Wy J II
1. Exercises (2 'd ' A C II
2. Gait trainin!! P , ;) jt<! ---z;' '1
3. Wheelchair transfers "f>/S
4. Walkerlcane use PIS
I. Rehab occupational theraov PIS
1. ADL's PIS
2. Strenothenina exercises PIS
3. Assistive devices PIS
Initials Name Patient Label
( /\ .. 1(,"" A
c'j{/] ( ''-kI'1n'[CU .I.U 'iYcf---
, J LEE,INGRID
VOOOO1l95795
02/03/1998 6/F ADM IN
KNu 424A
TSON DO. THOMAS E JR
CITY HOSPITAL, INC.
MARTINSBURG, WV 25401
KNUTSON DO THOM
M000170563' ~ 1~1~~4
,
~ ,.J ~
PATIENT/FAMIL Y EDUCATION RECORD
A. Questions answered 1. Needs further instruction
B. Verbal information provided 2. Stated understanding
C. Written information provided 3. Return demonstration, with help
D. Task demonstrated 4. Return demonstration, independent
E. Audiolvisual teaching tool used 5. Unable to understand
F. Referral to outpatient education Refuses information
G. Not aoplicable
Information Taught (to Patient or Support) Educ. Learn. Comments
('''''. ('''''. Initials/Date
PIS
REHABILITATION SERVICES: PiS
Exercises PIS .
m
Gait Training (p., 1'1' ill iOO f\U'*-- i2J. rll fLtn r <;i0 .<)/1/ I
'i>/S I1JOO(Jr" I
Weight Bearino Status PIS
PJS i
Precautions PIS \
ri ~
Bed Mobilitv f'J .:.j 90<;-{uIO
PIS
Home Safetv PiS
PIS
Energv Conservation PIS
PIS I
Joint Protection PIS I
PiS
Adaptive Device Use PIS
PIS
ADL Retrainina (Bathing, Dressino, etc.) PIS
PIS
Positionina PIS
PIS
Toilet I Tub Transfers PJS
PIS
T"+.v i S'f-f.fJ (elS . 13, 2- <;0 01dD
I PIS
Initials Name Addressograph
C;r0 ",,",. Y'rlVu.--, P-r--'
LEE/INGRID
VOOOO1195795 ADM IN
02/03/1998 6/F 424A
CITY HOSPITAL, INC. KNUTSON DO, THOMAS E JR
KNUTSON DO, THOMAS E JR
MARTINSBURG, WV MOOO170563 05/11/04
EDUCATION CODES
LEARNING CODES
()~
if
't
~
City Hospital
Radiology Services
Martinsburg, WV 25401
DIAGNOSTIC RADIOLOGY REPORT
Patient Name: LEE,INGRID
DOB: 02103/1998
Age: 6 Sex: F
Ordering Physician: KNUTSON DO, THOMAS E JR
Family Physician: LOBATON MD,CHERRY
Technologist: Jennifer Fincham
Unit#:
Req#:
Acct#:
M000170563
04,0025938
V00001195795
Location:
Room # :
Auth#:
4P
424-A
Report Status: Signed
Exam: OX FEMUR, L T 2V
CLINICAL HISTORY: Fracture.
Exam Date: 05/11104
LEFT FEMUR: There are two intramedullary rods in place aligning the mid femoral shaft fracture. There is
anatomic alignment noted in orthogonal projections. The tip of the rod is noted proximally below the level of
the lesser trochanter and distally projecting over the distal third segment of the femoral diaphysis.
IMPRESSION: There is anatomic alignment of the femoral fracture as discussed above.
<Electronically signed by DIMITRI MISAILlDIS MD >
DIMITRI MISAILlDIS MD
Dictated by:
Signed by:
Trans:
DIMITRI MISAILlDIS MD
DIMITRI MISAILlDIS MD
BJW
Diet dUtm: 05/11/041516
Signature dUtm:05/12/04 1033
Trans dUtm: 05/11/041559
cc:
KNUTSON DO ,THOMAS E JR
LOBATON MD,CHERRY
Reprt #: 0511-0184
1 of 1
Patient Location's copy
c,
(Y)
to
N
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CITY HOSPITAL, INC.
- MONITOR RECORD -
LEE INGRID
VOOOOl195795 REG ER
02/03/1998 6/F
VAN DONGEN MO.PHILIP C
. "'n.T.....' oAr> t"',...-nn\1
TIME: NURSES' NOTES
AATE:
RHYTHM:
P WAVES:
P-A:
QAS:
Q-T:
RATE:
RHYTHM:
P WAVES:
P-R:
QAS:
Q-T:
RATE:
RHYTHM:
P WAVES.
P-A:
QRS:
Q-T:
RATE:
AHYTHM:
P WAVES:
P-A:
QRS:
F<HYTHM:
P WAVES:
P.A:
I
QRS:
,
I hereby consent to the administration of anesthesia and authorize that administration by
or his/her associate, all of whom are credentialed to provide anesthesia services at City Hospital, Inc and consent to an
alternate type of anesthesia if deemed necessary by them. I expressly desire the following considerations be observed
or write "none"
I certify and acknowledge that I have read this from or had it read to me, that I understand the risks, alternatives and
expected results of the anesthesia service and that I have had ample time to ask questions and consider my decision.
DATE & TIME
pL~ .J~t~
WITNESS
PATIENT'S SIGNATURE
~
.f.wUI2 1\
RELATIONSHIP TO
PATIENT
..-
~
REASON
~^"A"A"^"AY^YA"A"A"A"^"A"A"AY^"K'^"A"^"^"A"A"^"A"A"'AYAYA"A"A"A"^"A"^"-t,..:~A"A"AYA"^YA"^"A"A"AYAVA"A"^"A"'AvA"'^"A"A"A"A""'''A''A''A''A'''^''.f.,.''A''A''.i;<..''A''A....<\.....
I certify that the above named patient (or
to anesthesia as explained by myself on this date.
/
) has received an informed Consent relating
II' .:J tr
DATE
MOOO 17 0563
05110 I 04
CONSENT FOR ANESTHESIA
CITY HOSPITAL, INC.
MARTINSBURG, WV 25401
LEE INGRID
V0000l195795 REG ER
~U05b~~~~M~.FpHIL1P C
LOBATON MO.CHERRY
F3995
'.
c
h
.~
Anesthesia Preoperative Evaluation
Name: Ar/
Planned SurgerY:
Preop Diagnosis:
Age: lJ HT:
Allergies: /1/ t<:-cJ 1,
Medications 2. ~~
,c,
Surgeon: ~-..,v-~-c;'--"'l.--
~{ Akrl::.-..
(1J f..,c,Uc'--- <, '
t WTi. fLit.- BP '~"II"t,}
:Jlhr
-/"1 I~j"r
Surg. Date: J I tyt"J"Ot
Room:
Pulse: /1.1 R:
SP02: no ~
Cardiac:
JV-q~ i-f-x.
/ .
Pulmonary:
l'J iI-x,
It",
~.~~.1
fr\.vA- v~ ~ .~
J;.JA (;4
Renal:
GI/Hepatic:
Neuro:
Metabolic/Endocrine:
Dentition: t!l'L
Familial Anesthesia Problems:
Surgical 1 Anesth History
-r+-IJ-
Yes 10
o~ rfto~4 IL4t~_
LMP: ~~-
Other Medical Problems:
Date
Anesth Type Complications
Labs: HGB: ' HCT: > <.( Lyles:
Other Labs:
EKG:
Chest X-Ray:
Remarks:
Signed:
C rbl -
Interviewed: ~o
Preoperative Evaluation:
Physical Assessment: /1'
Airway: .'\r. f t (
Cardiac/t.L-j
Respiratory:
ASA Statu~~ 1 ~ 3
S9ned: C. f, .
t. o'i1k-iv.f . .\..<. i:v ~.;t-~
NPO Status: :Y /J1'f\.
Proposed Anesth: ~ 0 If IT
Postoperative Evaluation: "
Vital Signs: j ~_, \', I;) <~ \ -S I." 11 :>
Cardiorespiratory Status: /' L '''1/.
Neurological Status: II \'..'S . ,~. C. U j ... i l ..}
~neSthetic Comp'icationr hi ~,' j... i ~ f~I\-' i '-. L)
~ l j t f " I.f ,j, ,;
- ,f
/ Date: II Ii
lime: 'Do I J
<.if i(",,' j) i-\ k t,J
t 'ok' r d\ I~C 1~:L'14
M000170563
05/10/04
,.; j'\Lnl-:;)Cj(;'(I)
LEE, INGRID
VOOOOl195795 REG ER
02/03/1998 6/F
IV~A!1)liG&~ w.~e~iLIP c
t) V.I i t ~ L 1.( {
<::. I j _ ,~
'. ",
RUN DATE, 05/13/04
RUN TIME, 1402
'--'
LABORATORY CITY HOSPITAL, INC. PAGE 1
***SUMMARY DISCHARGE REPORT*** MARTINSBURG,WV
Patient: LEE, INGRID Age/Sex: 6/F Attend Dr: KNUTSON DO,THOMAS E f:J1
Acct#: VQQOO1195795 Unitt: MOOO170563 DOB: 02/03i1998 Location: 4P 424 ~A
Reg: 05/11/04 Disch: 05/12/04 Status: DIS INo
***** CHEMISTRY *****
Date MAY 10
Time 2115 Refe:cence Units
GLUCOSE 1.95 H (70,:110) mg/dL
BLOOD UREA NITROGEN 16 (6-22) mg/dL
CREATININE 0.5 (0.5,1.. 3) mg/dL
SODIUM 138 (13 6,14 5) mEq/L
POTASSIUM 3.2 L (3.5'5. ()) mEq/L
CHLORIDE 1.1.2 H (101..111) mEq/L
CARBON DIOXIDE 23 (22 -32) lnEq/L
CALCIUM 9.2 (8,5.-10,5) mg/dL
TOTAL PROTEIN 6.5 (6.0.-8.0) g/dL
ALBUMIN 3.6 (3.2-'5.0) g/dL
BILIRUBIN TOTAL 0.5 (0.0--1..3) mg/dL
AST 21 (Q-4S) U/L
ALT 19 (O-5~5) U/L
ALK PHOSPHATASE 284 H (35,:l20) U/L
Patient: LEE, INGRID Age/Sex: 6/F Acct#VOOOO1195795 Un:l.t#MOOO170563
R
RUN DATE, 05/13/04
RUN TI..-~E: 1402
LABORATORY CITY HOSPITAL, INC, PAGE 2
***SUMMARY DISCHARGE REPORT*** MARTINSBURG,WV
Patient: LEE, INGRID IIVOOOOll95795 (Continued)
***** HEMATOLOGY *****
Date MAY 10
Time 2115 Reference Units
WBC 6.7 (5,5-14,5) K/uL
RBC 4.45 (3.80,5,30) M/uL
HEMOGLOBIN 11. 6 (10.2-15.0) g/dL
HEMATOCRIT 34,8 (31.7'41.3) %
MCV 78,0 (71. 0-87.0) fL
MCH 26,1 (24,0,30,0) pg
MCHC 33.5 (32.5.35.7) g/dL
RDW 12.8 (11.2-14.6) %
PLATELET COUNT 319 (150-450) K/uL
MPV 6.8 L (7.4-10.2) fL
NEUTROPHIL % 54.6 (36.0-66.0) %
LYMPHOCYTE % 35.6 (28.0-56.0) %
MONOCYTE % 7.1 (3.0-9,0) %
EOSINOPHIL % 2,3 (0.0-5,5) %
BJ>.SOPHIL % 0.4 (0.1-0.8) %
NEUTROPHIL # 3,7 (1,5-8.0) K/uL
LYMPHOCYTE II 2.4 (1,5-7.0) K/uL
MONOCYTE II 0.5 (0.0-0.8) K/uL
EOSINOPHIL # 0.2 (0.0-0.7) K/uL
BASOPHIL 1/ 0.0 (0.0-0.2) K/uL
Patient: LEE,INGRID Age/Sex: 6/F Acct#VOOOOl195795 UnitllMOOO170563
DATE ..
/'1
1! h'1.0'i
DIAGNOSIS:
PAE.MEO:
PRE-OP ANTIBIOTICS
TIME OF ANESTHESIA
STAAT 0/0;J
TIME OF SURGERY
o t]C
Start:
OPERATION
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ANESTHESIA SERVICE DOCUMENT
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M000170563 05/10/04
1'7
it: / ) 1./
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VOOOOl195795 REG ER
02/0311998 6/F
VAN DONGEN MO.PHILIP C
I nO^Tml f.An rUCODV
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, Precaution/Safety
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Learning Goals: Exercise
TransferslMobility
Other
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for
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The patient has been advised of his/her Physical Therapy Diagnosis, Goals, Prognosis.
The patient has given Verbal Consent for evaluation and treatment.
\5: fl~ p-J-
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Y
N
Physical Therapist Signature:
The Patient is not appropriate for skilled physical therapy intervention at this time.
Physical Therapist Signature:
P A TlENT IDENTIFICATION
INPATIENT
PHYSICAL THERAPY TREATMENT PLAN
.'~ WU ~. w___ ,
.. ....~.....,.'1 v .
',.,'."
',oJ'
CITY HOSPITAL, INC
MARTINSBURG, WV
LEE,INGRID
VOOOOl1957!l5 ADM IN
02/03/1998 6/F 424A
KNUTSON DO, THOMAS E JR
KNUTSON DO, THOMAS E JR
MonOliOc:.I>.. 0':;/11/04
Revised 10118/00
CITY H(,)SP~'1' AL, INC.
IL.iABILlTATION ~~RVICES PROGRl NOTES
tS)L.R. 0<:> 02h. ~1c iv1fjf
2 (> 10 It IiJ tMJ-L'.
T C. u~
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LEE,I.NGRID
VOOOOl195795 ADM IN
02/03/1998 6/F 424A
,,~..__C'n'" nO THOMAS E JR
F3853
RUN DATE' o5i~4/04
RUN TIME; 1713
cy Hospital ABS *L~VE* Database
ATTESTATION STATEMENT
PAGE 1
NAME: LEE, INGRID
ACCT# ,
FORM:
VOOOO~195795
ADM DATE, 05/~~/04
ATTEND PHYS: KNUTSON DO, THOMAS E JR
DIS DATE' 05/~2/o4
DIS DISP: 01 +HOME, SELF-CARE
LOS: 1
PT~CLASS, ER/SDC/INO
UN'IT#'
SEX:
AGE:
DOB:
FIN CLASS:
AB S STATUS:
MOOO~70563
F
6
02/03/:l998
MCD
FINAL
DIAGNOSES
ADMIT
PRINe
729.5
82~.01
E813 .6
310.2
850.0
FX FEMUR SHAFT,CLOSED
MV-OTH VEH COLL-PED CYCL
POSTCONCUSSION SYNDROME
CONCUSSION W/O COMA
C
OPERATIONS
DATE PROe CODE & NAME
05/~~/04 79,~5 CLOSED RED-INT FIX FEMUR
SURGEON ANESTHESIOLOGIST
KNUTSON DO,THOM MENON DO,SATISH
CPT CODES
27507
TREATMENT OF THIGH FRACTURE
DRG,
STATUS
$REIMB
KIN-LOS
STD-LOS
GRP VERS
2~
GRP FC
MCD
~3 HOUR
OBSERVATION
Dry Run F
.
City Hasp..
MartinBburg~ ~
~
;540J. (304):;:
.::LOOO
V00001195795
_ Patient Demographics
ADM ]:Na
Patient's Narne
Admit/Service Date
Time
Maiden/Other Name
Newborn Mother t
Date of Birth
Race
VIP
-o(e..
>1.n../bd
Medi a1 Re;tr'd ,
LEE ~ :INGRID
05/11/04
0319
social Security Number
Age Sex
Religion
Marital Status
Patient
134-86-9199
02/03/1998
6
F
AA
s
M000170563
_ Patient -
_ Employer
2452 MARTINS LANDING C:IR
NO EMPLOYER
Occupa tiOD:
MART:INSBURG~WV 25401
(304)267-9398
_ Next of Xin -
_ Person to Notify -
BUTLER~N:I:GERIE
Relationship to pt PA
BOTLER~N:J:GER:J:E
Relationship to pt PA
2452 MARTXNS LAND:I:NG CrR
2452 MART:I:NS LANDING CrR
MARTINSBURG,WV 25401
(304) 267-9398
MARTINSBURG,WV 25401
(304) 267-9398
_ Guarantor
Alternate Address -
_ Guarantor's Employer -
Relationship to pt PA
BUTLER,NIGERIE OUTLOOK POINT
Social Security *
2452 MARTINS LANDING CIR 116-60-6910
UNKNOWN
MARTINSBURG,WV 25401
(304)267-9398
MARTINSBORG,WV 25401
(304) 267-5800
_ Insurance Information -
IPC 1
Insurance Company
Subscriber
Social Security Number
DOB
MCDWV MEDICAID WEST V:IRGINIA
LEE~INGRID
134-86-9199
02/03/1998
FC-l
POBOX 3766
Relationship to pt SP
Me
CHARLESTON
wv 25337
(800)982-6334
poHcy It
Authorization .
Co/Org Name
c%rg I
00101682620
MFAX RAN PAAS
5630394000
IPC 2
Insurance Company
Subscriber
social security Number
DOB
FC-2
cjjU~lil
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RelatielDship to pt
Policy .
Authorization'
Co/Org Name
Co/Org #
VOOOOJ..195795
_ Specific Visit Information
Attending Physician
Physician's Phone
Adm By
Adm Source
Adm priority
Adm Service oX" Op Loc
KNUTSON DO, THOMAS E JR
(304)263-5129
LECKMAN
EMR
ER
OBV4P
Admitting Physician
OCcurence
Date
Time
Room/Bed
.0
KNUTSON DO, THOMAS E JR
(304)263-5129
05
05/10/04 2045
424-A
Da.te of Service
05/i51'/04
Arrived By
AM
Dir DiscI
NONE
NPP (date I
Y 20031103
Confidential Communication
Alt Phone/Address:
&)/JSU L-- T
51" .5 6 ill
Family Physician
Reason For Visit/Chief Complaint
LOBATON MD,CHERRY
(304)262-2538
STRUCK BY CAR// PAIN CONTROL
City HOspltal
Martinsburg, WV 25401
LEE. INGRID
V001195795 REG ER
02/03/1998 6/F
VAN OONGEN MD.PHILIP C
L08ATON MD,CHERRY
M0170563 05110/04
_ CONSENT TO TREAT AND RELEASE OF INFO
1_ I have consented to an examination and necessary medical treatment. I have been made aware of the
hospital's duty to me under federal law to provide. without regard to my ability to pay. an appropriate
SCREENING EXAMINATION and STABILIZING TREATMENT of any medical emergency "including labor contractions
2. In the event that 1 am admi tted. I hereby vol untari ly present mysel f for admi 55; on to C; ty Hospi ta 1 and
hereby consent to hosp; tal and/or Hospita 1 Based Nurs i n9 Faci 1 i ty servi ces and to such di agnost i c
medical. surgical or x-ray treatment as performed by VAN DONGEN MO.PHILIP (physician) or by his
consultants. assistants. or designees as are necessary ~n his judgement.
3. I am aware that the practice of medicine and surgery is not an exact science and I acknowledge that no
guarantees have been made to me as to the results of treatment or examina<tion in the hospital.
4. I hereby authorize City Hospital to retain, photOgraph. preserve and use 'for scientific or teaching
purposes. or dispose of at their own convenience. any specimens or tissues taken from my body
duri ng treatment.
5. I further authorize City Hospital to release to my insurance company and/or other reimbursing agency
whatever information is required in connection with this treatment or Hospital Based Nursing Facility
service_ I understand this may include results of HIV testing and/or ment,:Il health and/or drug/alcohol
abuse records. as applicable.
6. I understand that for the convenience of patients. a safe is maintained w'ithout charge. Therefore.
I release City Hospital from any responsibility for the loss of damage of valuables, money and/or other
personal possessions brought into the Hospital by me unless they are deposited in the safe for
sa fekeepi ng_
7. agree that if I leave the hospital and/or Hospital Based Nursing Facility without physician consent.
do so at my own risk.
8. I understand that the treatment rendered is emergency treatment only and I am advised to contact my
family physician or assigned physician for follow-up care if necessary, unless I am admitted to the
hospital and/or Hospital Based Nursing Facility under the care of an attending physician.
9. I understand that City Hospital serves as an educational setting for a variety of health occupations
students. Unl ess subsequently speci fi ed. I consent to such students' i nvo 1 vement in my care_
10 The above consents and releases have been fully explained to me and I certify I understand the
explanation.
_ AUTHORIZATION. RELEASE AND AGREEMENT TO PAY FOR SERVICES -
11. 1 hereby assign and transfer unto City Hospital and Associates (Lab & Phys.. ANES.. Rad., Hospital
Based Nursing Facility) (hereinafter collectively 'hospital') all hospital benefits now due and to
become due to me from the insurance companies by virture of admission to said hospital on the below
date and hereby direct the insurer(s) to pay such benefits directly to said hospital, in consideration
of the professional care rendered to me unsured dependent. I authorize the said insurer(s) to deduct
such payments from its obligations to me for hospital benefits under the above numbered policy(s).
12. I further authorize City Hospital to release to my insurance company and/or other reimbursing
agency whatever information is required in connection with this hospitalization or Hospital Based
Nursing Facility service. I understand this may include results of HIV testing and/or mental health
and/or drug/alcohol abuse records as applicable.
13. I (as patient or responsible party) understand that I remain financially responSible to the hospital and
I agree to pay hospital for any and all charges not met by the proceeds of this assignment, and for all
charges Should said proceeds not be paid within a reasonable time after charges are filled with
insurer(s), or should carrieres) or insurer(s) deny payment retroactively. If I am providing this
authorization for services of the Hospital Based Nursing Facility, as the individual who has legal
access to the patient's income or funds. my financial liability is limited to the income or funds of
the patient
14. I certify that the information given by me in applying for payment under Title XVIII or Title XIX of the
Securi ty Act is correct. I request. that. payment of author i zed benefi ts be made in my behal f.
15. The above authorizations. releases and agreements have been fully explained to me and I understand
the explanation.
16.
Is the patient covered under any other health insurance plan. program, or policy?
Yes
No
\lnnnn1,QI:\7Qt;
Pilaf> 1 of?
17.
/
/18,
City Hospital
Martinsburg. WV 25401
LEE. INGRID
VOOl195795 ,EG ER
02/03/1998 6/F
VAN OONGEN MO.PHILIP C
LOBATON MO,CHERRY
M0170563 05/10/04
- NOTICE OF PRIVACY PRACTICES (HIPAAl -
(con"t)
Was Notice of~Privacy
/,J'//'"
_<,1 do -===- I do not
Hasp; ta 1 . spat i ent
patient directory.
able to contact me.
Practice offered and signature obtained below?
Yes/No
Date: 20031103
y
want my name. location. and general condition released as part of City
directory. I understand that if thi s information is not a part of City Hospital's
visitors such as family and friends. outside phone callers. and florists will not be
1 do
(any
City
L--;-dO not want my name released as part of City Hospital's rel igion patient directory
el"'ergy who may inquire about me). I understand that if this informa'tion is not a part of
Hospital's religion patient directory. members of the clergy will not be able to contact me_
1
,
19. Has patient requested confidential communications (alternate address)?
Yes/No
~;- /r: / '(
-------/ (> DATE/TIME
--;; ~:#-~-Z-L"--
SIGNATURE OF WITNESS
SIGNATURE OF PATIENT
/) ."JI
<::: f I, , V )~
(IF PATIE IS A ~INOR. INCOM ETENT OR UNABLE TO
SIGN. SIGNATURE bF NEAREST RELATIVE OR GUARDIAN)
.1-" T\ \\.r\\A \"'__
RELATIONSHIP TO PATIENT
SIGNATURE OF WITNESS
VOOOO1l95795
Page 2 of 2
Center for Orthopedic
1004 Tavern Road
Martinsburg, WV 25401
304-263-5129 or 304-263-5200
:cellence
Ho~pital Discharge
Instructions
RETURN APPOINTMENT #2
RETURN APPOINTMENT #1
~. /' .~,
OMON
o TUES
OWED
o THURS 0 FRI
AM
AT PM
o MON
b TUES
OWED
o THURS 0 FRI
AM
AT "'PM
DATE
WITH DR.
FOR
"/
DATE
WITH DR.
FOR
/
(,(,~ -", }'<'
TELEPHONE 263-5129 OR 263,5200
IF UNABLE TO KEEP THIS APPOINTMENT
KINDLY GIVE 24 HOURS NOTICE
TELEPHONE 263,5129 OR 263-5200
IF UNABLE TO KEEP THIS APPOINTMENT
KINOL Y GIVE 24 HOURS NOTICE
_, .. ~:t'
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RESUME YOUR PREOPERATIVE DIET UNLESS OTHERWlSEINSTRUCTED. CALL THE OFACE WITH ANY QUESTIONS OR CONCERNS.
Medications: You should resume the medtcations prescribed by your family doctor or medk:al specialist. Be sure to report all allergies. The medication(s)
below should be taken as directed. Please read the following instructions to be sure you understand them prior to discharge. A representative of this office
is on call at all times and can be reached at this office or through City Hospital to assure your continuing care. Orthopedic care is a speciatty and does not
replace the treatment from your family doctor.
I have read and understand all of the above instructions. I have also had the opportunity to have any additional questions answered and/or clarified for
me. 1 also understand these instructions are not all inclusive and it is my responsiblity to contact my doctor if I have any further problems or questions.
Referring Doctor
Patient Signature'
Witness
Date and Time
.........................................__.............._................................... PRESCRIPTION BLANK - TEAR ALONG DOTTED LINE ......................-...............-..................:.............-.-....-....-..........-....-...
Name
#2
Center for Orthopedic Excellence
Joseph P. Cincinnati, D.O.
Troy D. Foster, D.G.
Thomas E. Knutson, Jr., D.O.
1004 Tavern Road. Martinsburg, WV 25401
304-263-5129 or 304-263-5200
"1'".
".,........ ~
)0
t.A.."oL
Street.
City
Date
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o LABEL ALL DRUGS UNLESS CHECKED OMAY SUBSTITUTE JOSEPH P. CINCINNATI 0.0. DEA' BC3731177
o DO NOT SUBSTITUTE 0 REFER PRESCRIBING TROY,.D, FOSTER-D.O.' DEA t, BF3ea7049
INFQAMATKJ'.I TO PHYSIClAN,TH,QMA$,E,t<NU1"~ON. ..R.. D.O. DEA' BK6022393. -
.........................................._.._........ ...m................._____....__.._ pRESCRlPTJON ~~NK - TEAR ~LONG DOTTED lINE .__.._....._._..._........~_......_..............................................._..-......~:?
#1
Center for Orthopedic Excellence
Joseph P. Cincinnati, 0,0,
TroyD. Foste" 0,0.
Thomas E. Knutson, Jr" 0,0.
1004 Tavern Road. Martinsburg, WV 25401
304,263-5129 or 304-263-5200
Name
Street
.,
City
Date
f'
I .
I
I
I
o LABEL ALL DRUGS UNLESS CHECKED DMAY SUBSTITUTE
o 00 NOT SUBSTITUTE OREFER PRESCRIBING
INFORMATICl'l 10 PHVSICtAN
WHiTE. - PA nENT copy
JOSEPH P. CINCINNATI 0.0. DEA' BC3731177
TROY D. FOSTER D.O. DEA I SF3887049
THOMAS E. KNUTSON...R, DD. OEA I SK6022393
CANARY _ CHART COPY PINK - 0FF7CE copy
0,0.
Dr. Knutson
Ingrid Lee
May 14, 2004: Spoke with mother who is concemed about pt not wanting to walk on her leg.
She did get the walker but pt is not willing to walk on her leg. Wants to know if she should
push the issue. Dr. Knutson states no just give it time. Attempted to call back and had to LM.
T. Smoot, RN
J~
.~ ...
,
h
Ingrid Lee
023/03/1998
Dr. Knutson
OS/27/2004: This is a 6'year-old female who is 2 weeks status post-Nancy nail
fixation to a femur fracture. She is here for follow up. On physical exam, cast is a little
loss both around her thigh and around her ankle. She is neurovascularly intact. We did
do x-rays which show a healing femur fracture. On AP view, it is in good alignment. On
lateral view, she does have approximately 5 degrees of flexion. There is early callus
appreciated. The hardware is intact, We did remove her cast. Her skin is intact. Her
incisions are well approximated. There is no erythema, no drainage.
Impression: 2 weeks status post-Nancy nail fixation, L femur fracture.
Plan: Again her cast is removed. I did stress with both her mom and her that she is
not close to being active on this leg, I want her to start working on some gentle range
of motion. I still want her to use a walker for 2 weeks. We will see her back in 2
weeks, repeat x-rays. If everything is looking good and she is doing well, will progress
her to partial weightbearing at that time.
TEK/bab
DICTATED BUT NOT READ 'l'
]OO4TAVEr-NROAD
MARTINSBURG, WV 2540]
(304) 263-5]29
(304) 263-5200
(304) 263-3726 FAX
Ingrid Lee
Dr. Knutson
June 17, 2004
History: This is a six-year-old female who is about a month out from Nancy nail fixation to a
left,~.tm .EI III fracture. She is here for follow up.
~.-u
Physical Exam: She has near full extension. With flexion she only goes to about 100
degrees. She has no tenderness at the fracture site, No tenderness with varus valgus stress.
X-ray Findings: X-rays were taken which shows approximately 5 degrees of varus. She is also
in approximately 10 degrees of flexion. She has abundant callous at the fracture site. Her
hardware is intact.
-f<--..:>n..1
impression: Status post Nancy nail left hw..ellll fracture.
Plan: I did tell her that she can start weightbearing with the walker and then once she is not
having any pain she can DC her walker at that point. I did tell her that she is not to run or
jump on this leg. I also considered physical therapy but right now financially they can't afford it
so I did go through some exercises with them. We will see them back in one month and repeat
her x-rays at that point.
TEK/kph
DICTATED BUT NOT READ
,,---L--
I
.'.il l.~~b~
INGRID LEE
02103/1998
Dr. Knutson
07/15/2004: This is a 6-year,old female who is two months out from internal fixation to the left
femur fracture, She has been ambulating and actually states she has been jump roping without
any pain. Still does walk with a mild limp. We were going to get her into physical therapy,
however, because of some social reasons, she has been unable to do so,
Physical Examination: She does have full extension, flexion at the knee to 125. She does
tend to hold her hip out a little bit more to external rotation than internal rotation. However,
when I get her to relax, I am able to get her to full internal rotation, We did get x-rays, which
shows abundant callus at the fracture side, She does have mild amount of varus deformity at
the fracture; however, it is only approximately 5 degrees as well as mild amount of flexion at the
fracture site as well and this measured approximately 5 degrees as well. She is also
approximately a half thumb breadth shorter on the left compared to the right.
Impression: Healing left femur fracture.
Plan: We are going to see her back in two months with repeat x-rays, I did tell her the benefit
of getting the physical therapy, but however, right now they are unable to do so, Her
grandmother is going to work with her on some exercises not only for improving her extension
but also to improve her internal rotation and again we will see her back in two months with
repeat x-rays of her femur.
TKldlp/smp/qc3mlw
DO: 07/15/2004 DT: 07/16/2004 Job #: 632528
DICTATED BUT NOT READ
Electronically Signed and Finalized by
Thomas E. Knutson Jr., DO 7/1612004 3:51:59 PM
1004 Tavern Road
Martinsburg, WV 25401
(304) 263-5129
(304) 263,5200
(304) 263-3726 FAA
INGRID LEE
02/03/1998
Dr. Knutson
09/16/2004: A 6-year-old female who is status post Nancy nail fixation for a left femur fracture,
is here for followup, Has full range of motion, Denies any complaints,
Physical Examination: Again, she has full range of motion, Her leg lengths are near
symmetric,
X-Ray Findings: X,rays were taken, which shows a healed left femur fracture in good
alignment.
Impression: Healed left femur fracture.
Plan: I did tell mom recommendations at this point were for removal of her Nancy nails, All
risks, benefits, complications, as well as postoperative care was discussed. Questions and
concerns were answered to their satisfaction. They are in agreement with the above
recommendations, I did tell them afterwards we are going to have to protect her weightbearing
for a period of about 4 weeks, We will proceed with surgery at City Hospital.
TKfdlp/shr
DO: 09/16/2004 DT: 09/17/2004 Job #: 701200
DICTATED BUT NOT READ
Electronically Signed and Finalized by
Thomas E. Knutson Jr., DO 9/17/2004 I :48:48 PM
1004 Tavern Road
Martinsburg, WV 25401
(304) 263-5129
(304) 263-5200
(304) 263-3726 FAX
CITY HOSPITAL, INC.
Martinsburg, WV.
HISTORY AND PHYSICAL'
PATIENT, LEE, INGRID
ACCT#, V00001249116 AGE, 6Y
ATTENDING, THOMAS E KNUTSON JR, DO
MR#, M000170563
DATE OF ADMISSION, 10/13/2004
HISTORY, This is a 6'year,old female who was struck by a car back in May
where she suffered a left femur fracture. Nancy nail fixation was
performed. She has done well postoperatively, but is essentially four
months out from surgery, and her femur is healed and recommendations are
for hardware removal.
PAST MEDICAL HISTORY, None.
PAST SURGICAL HISTORY, Significant for that Nancy nail fixation to her
left femur.
MEDICATION, Zyrtec,
ALLERGIES, None,
REVIEW OF SYSTEMS, HEENT' within normal limits.
Heart: No history of chest pain or palpitations.
Lungs: Denies history of cough, hemoptysis and wheeze.
Extremities: As per above.
PHYSICAL EXAMINATION, Vital signs reveal blood pressure of 120/81, pulse
89, respirations 89, respirations 20, temperature 96.9.
HEENT,
Within normal limits.
HEART,
Regular rate and rhythm,
LUNGS,
Clear to auscultation.
ABDOMEN,
Soft and nontender. There are positive bowel sounds in
upper quadrants,
EXTREMITIES,
Within normal limits. She essentially has full range of
motion to her left knee. Her leg lengths are near
s)'TTlmetric.
X-rays of her left femur do show a healed femur fracture in good
alignment with retained hardware.
IMPRESSION, Retained hardware of left femur.
PLAN: Discussed with mom and patient that recommendations are for
hardware removal. All risks, benefits, complications as well as
postoperative are were discussed, questions and concerns were answered to
DF
CITY HOSPITAL, INC.
LEE, INGRID D
Page 1 of 2
HISTORY AND PHYSICAL
Dictating Physician's copy
CITY HOSPITAL, INC.
Martinsburg, WV.
OPERATIVE NOTE
PATIENT:
LEE, INGRID
ACCT#: V00001249116
PHYSICIAN: THOMAS E KNUTSON JR, DO
MR#: M000170563
ROO~l#: ASU
DATE OF OPERATION: 10/13/2004
PREOPERATIVE DIAGNOSES:
Retained hardware left femur status post Nancy nail fixation for left
femur fracture.
POSTOPERATIVE DIAGNOSES:
Retained hardware left femur status post Nancy nail fixation for left
femur fracture.
OPERATION:
Removal of Nancy nails.
SURGEON:
Thomas E Knutson Jr, DO.
FIRST ASSISTANT:
David Wagner, Certified Surgical Assistant.
ANESTHESIA:
General.
COMPLICATIONS:
None.
DISPOSITION:
Patient tolerated the
in stable condition.
procedure well and was taken to the recovery room
Sponge count correct.
HISTORY/INDICATIONS:
This is a 6-year-old female who suffered a left femur fracture about four
to six months ago, she went on to heal and has been ambulating. Because
pi retained hardware, recommendations were for removal. After the risks,
benefits, complications, and alternatives were discussed, all questions
and concerns were answered to their satisfaction. They are in agreement
with the above recommendations.
DESCRIPTION OF PROCEDURE:
Patient was taken to the operative suite and after general anesthesia was
administered, her left leg was sterilely prepped and draped in normal
sterile fashion. We used our initial incisions and incisio~ was made
with a #15 blade and dissected down bluntly first starting medially down
to the vastus medialis palpating the nail. Once this was palpated, it
was removed with a pair of pliers. A small stab incision was made just
distal to the incision in order to remove the nail out atraurnatically,
this was removed in toto. We then went to the lateral side and again,
incision was made with a #15 blade dissecting down to the iliotibial
band. This was split with cautery, the nail was palpated, and then
DFemoved with a pair of pliers. The wounds were then copiously irrigated
.. and no active bleeding is noted. The subcutaneous tissues are closed
with 0 Vicryl and skin then closed with 3-0 nylon. A sterile dressing
LEE, INGRID D
MT REP #: 1013-0076
PAGE 1012
Dictating Physician's copy
OPERATIVE NOTE
CITY HOSPITAL, INC.
MARTINSBURG, WV
OPERATIVE NOTE
LEE,INGRID 0 V00001249116 M000170563
was applied. The wound was infiltrated with a total of 10 cc of 0.5%
Marcaine plain for postoperative pain control. Patient was successfully
extubated and taken to the recovery room in stable condition.
THOMAS E KNUTSON JR, DO
JOB, 850154
ID, 000222489
cc, KNUTSON
> TRANS:
DD, 10/13/2004
DT, 10/13/2004
DO,THOMAS E JR (00261)
TD, 0849
1530
cc:
KNUTSON DO,THOMAS E JR
LOBATON MD,CHERRY
LEE, INGRID D
MT REP #: 1013-0076
PAGE 2 of 2
Dictating Physician's copy
OPERATIVE NOTE
INGRID LEE
02/03/1998
Dr. Knutson
10/28/2004: This is a 6,year,old female who is 2 weeks out from removal of Nancy nails to her
left femur. She was on some weightbearing restrictions. Mom states she has been pretty much
full activity.
Physical Examination: On physical exam, she has got full range of motion, Her incisions are
healed.
Impression: Status post Nancy nail removal.
Plan: I discussed with her she really needs to take it easy for about 3 more weeks, I did give
her some restrictions for PE for another 2 weeks, We will see her back at that time if needed.
Otherwise, we will see her back on a p,r.n, basis,
TK/dlp/sat
DO 10/2812004 DT: 10/29/2004 Job #: 749911
DieT A TED BUT NOT READ
Electronically Signed and Finalized by
Thomas E. Knutson Jr., DO 10/29/20048:22:16 AM
1004 Tavern Road
Martinsburg, WV 25401
(304) 263-5129
(304) 263-5200
(304) 263-3726 FAX
- Center fOT
Orthopedic ~?(ce{rence
JOSEPH p, CINCINNATI, D,O,' TROyD. FOSTER, D.O.
THOMAS E. KNUTSON,]R" 0.0,
1004 TAVERN ROAD
MARTINSBURG, WV 25401
(304) 263-5129 . (304) 263,5200
(304) 263-3726 FAx
SCHOOL EXCUSE
Patient Name ;c:~~ G.......
Date 'y-c. -yo--,
,/ The above patient was seen in my office this date.
The above patient was under my care
from school for this time period.
. Please excuse
Please allow to leave class 5-10 minutes early with a buddy to carry books.
Please allow to use elevator.
ACTIVITIES
./ The above patient m~i ~articiPate in gym/sports activities for the
period of '> . ~ ~
The patient has been released to participate in sports activities effective
r
Joseph P. Cincinnati, D.O.
Troy D. Foster, D,O,
Thomas E, Knutson, Jr., D.O.
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'* AMENDED ** 04/16/2004
, f (/ Agency lnsunmce Company
~~' of lVim'yland, Inc.
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P.O. BOX 17071' BALTIMOr,[, MD 21297-0388' (800) 492.5629
AUTOMOBILE POLICY DECLARATION
POLlCY NUMBER: AU 0027198
INSURED
,Jasen Boyce
1109 Beecllwood Drive
HClgcrstowlI, "1fJ 21'742
;,~r
513
SS.c-~
AGENT (301) 733,1234
Wright-Gardner Ins. Inc
100 W Antietam Street
Hagerstown, MD 21740
ISSUE DATE
08/30/2004
POLICY TERM
11/20/2003 ' 11!20/2004
Thispohcy,ncCl'lsthclali.:ro(
A. 12:01 AM on Ih~ C.rsl dny oClhe pol;~y period; or
Fl. (h~ hintl,,,!! ILI11C on lhc ~igncd ~ppli~ill ion on (he forst day or 1I1C policy period
TI1isl'olicyshallcxI'il'cJI12cOl AMoL1thcl"'ldny()rlll~pOli(ypcriod.
VEH YR
I I 'N5
MAKE
FOIUJ
~'iODEL
I'IWfJE/SE
VIN
I ZVLT20A 7S5144589
GARAGE COMP COLL
USE ZIP DED DED
W 21742 None None
Bodily Ill,lury - 50000/100000 each persoll/each aCCldc,ll(
Property l)<lllHlgc - 25000 c,jeh accidel1t
Economic Loss - Full ~ 2500
PREMIUMS
VEH I
445.00
329,00
134.00
COVFI<..\C; ES/iJI1\IITS
Unillsured ivlolmist
50000/1 iJO{)(JO....25000 each pcrsoli/Ci1cll accidclll
~ 1.00
TOT,~L VEHICLE PREMIUM
9~9.00
TOTAL POLlCY I'R[cMIU~J $989,00
Amended Premium
$0.00
,^,'JU0:"~ (~,'0l)
INSURED COPY
Page 1 of 2
H AMENDED ** 04/16/2004
, -( r> Agency Insurance Company
11!''''(i0 of Maryland, Inc.
j. -
P,O, BOX 17071 . BALTIMORE, MD 21297-0388' (800) 492-5629
AUTOMOBILE POLICY DECLARATION
POLICY NUMBER: AU 0027198
ii, (:!'-::r-'~ l;Y'I,nl, :\1D
~ 17 <-17.
AGENT
Wright-Gardner
}Or) (II] Antietam
Hagerstown, tv'JD
(301) 733-]234
Ins. Ine
Street
21740
INSURED
cJil son EO'/ce
11. C C) L:-;c;Cli-,.\TOC)d
DrIve
ISSUE DATe
08/30/2004
POLICY TERM
11/20/2003 ' 11/20/2004
rhh pollt} LlIC~l'h Ihc I~h" of
^. 12:01 ;\M on the flfS! <In). orlh~l'ohcY PCI;,"!. GI
n tile binding lil11e C\1l111C sigll~(1 'Pl'li~JlioLl On lh~ r-"sl dny or (11~ policy period
TI,;, poli9 shall L~P;"C at 12[)] AM 01\11,,; la>l,b)' of the policy pCl1od.
DRV
1
DlnveR NAME
L\SCll1 Boyce
EXCLUDED
NO
DATE OF
BIRTH
0811411980
MARITAL
STATUS
SINGLE
SEX LICENSE NUMBER PTS
M B200373189635 0
FOR~lS Ai'D E"IlOHSEMENTS
DISCOUNTS AND SURCHARGES
AgcI1C) ['hlll'"1lT C()Il1!1;II1Y of Ivlaryl,ll1d, Inc. will consider your claims bistory for purposes of determining
whether to e'1llct'[ Ollcl'lISC 10 rcnew your policy.
A.U-D03? (4!!'l7)
INSURED COPY
Page 2 of 2
~[GYCLEO@
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SCHEIL"
ATTOIlNEYS AT LAW
1857 William Penn Way
P.O, Box 10248
Lancaster, PA 17605,0248
717-291-4532 Main
717,291-1609 Fax
www.postscheU.com
Dana C. Panagopoulos
dpanagopoulos@postschell.com
717-391-1167 Direct
717.291,1609 Fax
File #: 968/12837
March 22, 2006
Nigerie Butler
1750 L. Wisteria Lane
Chambersburg, P A 17201
RE: In re: Petition of Nigerie Butler, as parent and natural guardian of
Ingrid Le
Dear Ms, Butler:
As you know, in order to complete the settlement of the above matter, I have been retained by
Agency Insurance Company to draft the documents necessary for court approval of the
settlement for the claims of Ingrid Lee. Please keep in mind that I am not your attorney and you
will have to submit the Petition to Compromise Minor's Action which I have drafted to the Court
and explain to the Court why you believe the settlement agreement is in Ingrid's best interest.
Enclosed you will find the Petitions for Leave to Compromise Minor's Action with attachments
and a verification. Please review the information contained in the Petition to ensure that it is
completely accurate, Please also review the Release and Settlement Agreement that is attached
as an exhibit to the Petition, If you are satisfied with the contents ofthe Petition and Release and
Settlement Agreement, kindly sign and return them, along with the signed verification in the
envelope I have provided.
After receipt of these documents from you, I will forward them to the court and schedule a
hearing, Upon receipt of the hearing date, I will notify you of the hearing, which your presence
will be required, as well as Ingrid's presence, At the hearing, the judge will review these
documents and ask any questions he may have,
Please contact me if you have any questions or concerns, Thank you,
Very trul y yours,
Dana C. Panagopoulos
~
DCP:dcp
Enclosure
ALLENTOWN HARRISBURG LANCASTER PHILADELPHIA PITTSBURGH PRINCETON WASHINGTON, D,C.
A PENNSYLVANIA PROFESSIONAl. CORPORATION
tli I.;b,t
1;1''''':..,,,
f
RELEASE AND SETTLEMENT AGREEMENT
KNOW ALL THESE MEN THAT, Nigerie Butler. as parent and natural guardian of
Ingrid Lee, for and in consideration of Five Thousand Dollars ($5,000.00), the receipt and
sufficiency of which are hereby acknowledged, do hereby remise, release and forever discharge,
Jason Bovce and Agencv Insurance Companv of Marlvand, (hereinafter referred to as
Releasees), their heirs, executors, administrators, insurers, employees, successors, and assigns of
and from all, and all manner of actions and causes of action, suits, debts, dues, accounts, bonds,
covenants, contracts, agreements, judgments, claims and demands whatsoever in law or equity
presently existing or subsequently discovered by us, stemming from the mot.9fyehiclei,%\ccident
.\.:'. "',o;t
that occurred 0
',>,;1/:$;;
"y'
!them, hereafter
,
agreeing to this compromise payment, neither
admit liability but all expressly deny liability of any sort, and said Releasees have made no
agreement or promise to do or omit to do any act or thing not herein set forth and we further
understand that this Release is made as a compromise to avoid expense to terminate all
controversy and/or claims for injuries or damages of whatsoever nature, known or unknown,
including future developments thereof, in any way growing out of or connected with said
incident or accident.
We admit that no representation of fact or opinion has been made by the said Releasees
or anyone on his, her, or their belief to induce this compromise with respect to the extent, nature
or permanency of said injuries or as to the likelihood of future complications or recovery
I.
therefrom and that the sum paid is solely by way of compromise of a disputed claim, and that in
determining said sum there has been taken into consideration the fact that serious or unexpected
consequences might result from the present injuries, known or unknown, from said incident,
accident or medical treatment, and it is therefore specifically agreed that this Release shall be a
complete bar to all claims or suits for injuries or damages of whatsoever nature resulting or to
result from said incident or accident.
We represent and warrant that no other person or entity has, or has had, any interests in
the claims, demands, obligations, or causes of action referred to in this General Release, except
as otherwise set forth herein; that we have the sole right and exclusive :,
'ty to Te this
t fl, assigned,
i
ration o~~ said pa . armless from any and all expenses and
, ..."f":?? ,',~~'
ar1.~i;~g from subrogation claims under any payments due or claimed to be due under the
law, state or federal, regulation or contract.
It is further understood and agreed and made part hereof, that neither we, nor our heirs,
executors, administrators, successors or assigns nor my Attorneys or other representative, will in
any way publicize in any news or communications media, including but not limited to
newspapers, magazines, radio or television, the facts or terms and conditions of the settlement.
All parties to this agreement expressly agree to decline comment on any aspect of this settlement
to any member of the news media, This paragraph is intended to become part of the
consideration for the settlement of this claim.
2
I.
IN WITNESS WHEREOF, we have hereunto set my hand and seal this
day
of
,2006.
SIGNED, SEALED AND DELIVERED
in the presence of
(SEAL)
Nigerie Butler, as parent and natural guardian of
Ingrid Lee,
L RELEASE
3
po@
SCHEIL,,,
ATTOI\N[;"iS AT L-I\.W
1857 William Penn Way
P.O, Box 10248
Lancaster, PA 17605-0248
717,291-4532 Main
717-291,1609 Fax
"WWW.postschell.com
Dana C. Panagopoulos
dpanagopoulos@postschell,com
717,391,1167 Direct
717-291,1609 Fax
File # 968/12837
March 22, 2006
Nigerie Butler
1750 L. Wisteria Lane
Chambersburg, P A 17201
RE: In re: Petition of Nigerie Butler, as parent and natural guardian of
Inl!rid Le
Dear Ms, Butler:
As you know, in order to complete the settlement of the above matter, I have been retained by
Agency Insurance Company to draft the documents necessary for court approval of the
settlement for the claims of Ingrid Lee, Please keep in mind that I am not your attorney and you
will have to submit the Petition to Compromise Minor's Action which I have drafted to the Court
and explain to the Court why you believe the settlement agreement is in Ingrid's best interest.
Enclosed you will find the Petitions for Leave to Compromise Minor's Action with attachments
and a verification, Please review the information contained in the Petition to ensure that it is
completely accurate, Please also review the Release and Settlement Agreement that is attached
as an exhibit to the Petition, If you are satisfied with the contents of the Petition and Release and
Settlement Agreement, kindly sign and return them, along with the signed verification in the
envelope I have provided,
After receipt of these documents from you, I will forward them to the court and schedule a
hearing, Upon receipt of the hearing date, I will notify you of the hearing, which your presence
will be required, as well as Ingrid's presence. At the hearing, the judge will review these
documents and ask any questions he may have,
Please contact me if you have any questions or concerns. Thank you.
Very truly yours,
Dana C. Panagopoulos
DCP:dcp
Enclosure
ALLENTOWN HARRISBURG LANCASTER PHILADELPHIA PITTSBURGH PRINCETON WASHINGTON, D.C
A PENNSYLVANIA PROFESSIONAL CORPORATION
Nigerie Butler
March 22, 2006
Page 2
bcc: Jim Martin
Agency Insurance Company
Claim # 21760
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In re: Petition ofNigerie Butler, as parent and
natural guardian of Ingrid Lee, a minor
Plaintiff,
COURT OF COMMON PLEAS
CUMBERLAND COUNTY
NO: 06-2372
PRAECIPE TO WITHDRAW PETITION FOR
LEAVE TO COMPROMISE MINOR'S ACTION
TO THE PROTHONOTARY:
Please withdraw the Petition for Leave to Compromise Minor's Action in the above
matter docketed at No. 06-2372, filed of record on or about April 25, 2006.
POST & SCHELL, P.C.
BY:~ C. r 0- ---......
D A C, PANAGOPOULOS, ESQUIRE
Attorney J.D. No. 89491
DATE: ...i..1 S; I D LP
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