HomeMy WebLinkAbout94-07176
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IRfMIUM TRANSMITTAL FORM
"-L'II ~
Prlmi.m:S 15,000.00 c..Nlme: Krvsta
~ Brakll'l Nlme: W. Ross Duncan
Co~ R1n!ller Associates ~JpA
Hoffman 0.: 02108/95
BrokwPllol>>t: (610) 834-5553
BroltwFat: (610) 834-5442
T~.: IUI CHECK DWIRE TRANSFER
<_-I "'-_ {JIrlort'tl.... ~,...._IIld~
... ....... .....1Ild_1II: """"-11I:
SheIy HlOIflo (.02) 471-72~ SheIV HI"",
AIIlalII s.tIIIment eo. jIOIllIon (402l471-72~
20S SoUh 13111 SlrMt - SIil8 200 (402) ..71-7eall Fa
LrIc:M. PWlrIIkI ea506-201 0
o CIledc hefllf ~ cae -1*1WY fInIod ...... nl ~ II .ddtIonal p""nilm.
ia-- __ Mike Checb P8YlIble 10: S<<ld Wlree to:
rm AIeIpd AIIlIlII SetIlement NCll'NMt Bank Nebfnlul, NA.
AIIlIte ute Am.iIri COlJlOI allon c:enten::one ElliIdklg, 1200 0 Str",
~,Nebrnk.I easoa
ABA . 1 ()40..()00.58
Aktate SalIIement CoIp.-
AUC a-raI Deposit Aceot.rll
Acd.. . 11 550S5430
o AasilJled ADstale Selllemen! NClIWeSt Bank Nebrau, N.A.
Aklatl ute of COlpOf'8Uan Centerltane ElliIdklg, 1200 0 S1reet
New York Annuity ~,Nebrnu 6850S
ABA .,040-000-SS
AJstalll SalIIement Carp,o
AJ.Nf G<<MraI 0epaeIt Account
A=- ." 550SSlI22
o U.l4mgned AIstIte ute IIlSlnI1C8 NOIWIlSt Bank Nebrew, NA
AIstate ute Annuity Company Centerstane BuIci1g, 1200 0 Street
~. NebraakI eases
ABA . 1 040-000-SS
AIIItate Ute 1nI. Company-
GenefaI DepOIit Accawrt
Acd. . 11550S5449
o UnaAigned AiIItlIte Ure Insurance Chase Mamattan Bank, NA
AIstate Ufe of Company or New York One ChaSe Manhallan Plaza
New Yor1t Annuity NewYOI1l,NewYork 10091
ABA.0210-0002.1
Alstate Ute of New YOlk
General Oepoelt Acc:a\.I1t
Acd. . 91 0-2.e3M49
o AAlgned to Slructured Structured Selllement Trust Norwes1 Bank Nebraska, NA
Setllement Trust Cententone Btildlng, 1200 0 Street
llncaln, Nebraska essos
M3A .,040-000.sa
S1ructured Settlement Trust-
General Deposit Account
Acc1. . 11 5S0SS930
Far Ofllce Use Only:
Invoice t: Accepted by: Date:
"'"
PREMIUM TRANSMITTAL FORM
I'UAII ".".
~mUn:S 20,000.00 c..Nlme: Jennifer Orlouskv o.tI: 02/08/95
IncIIIicUIBrokll'.Nlme: W. Ross Duncan Brok<<PIlonef: (610) 834-5553
~ R1nder Associates ~~Hr- Brok<<Faf: (610) 834-5442
T~.: [Xl CHECK DWIRE TRANSFER
(--I __ (p1crIy) mol __"",""Ind~
.........~Ind_..: ..,*t"'''-'':
SIleIy HIQIlI- (402) "7~72'" SheIy HI~
AllIn SelIlIment Coqlollllan (402) "7~72'"
20lS SculII131h Slrltt . SIillI 200 (402) "7~7eU Fa
1.ilclWl, N4brIIka saS08-2010
o Chedl llefe if ttW ClIM _ pII1IaIy f\nled ellt<< and ttW Ie .ddtIonlII premium.
a;;,."....tm_ Mike CllecQ plI'{lIble to: Send Wlr.. to:
~AaV1ed AIslallt SeIllemenl NOIWMt 8Inlc Nebc'8aU, NA
AIstate ute Arnrity CoIponItlon ~ BuIIc*lg, 1200 0 Street
Lnc:oln, Nebc'8aU ~
ABA, 1 04G-000-58
AIItate SellIement Corp,.
AUC Geoet'al Oepoeil ACCOl.r1t
kd. '11~~5430
OAsslpd ADstate Selllemenl NOIWMt Bank Nebraska, N.A.
AIslate ute of COfJlOf'8Uon Centenlone BuIIc*lg, 1200 0 Street
New York Annuity LJncoIn, Nebl1llka 68~Oa
ABA '1G4lHlOO-S3
Alstate SellIement COIp.-
/IoUl'f Geoet'al Oepoeil Account
ACd.' t1560S3922
o Unassigned AIstate ute Insurance NOlW'at 8Inlc Nebraaka, NA
AIsl3te ute Annuity Company Cenlerstone Eli*Jng, 1200 0 Street
Lnc:oln, Nebc'8aU 68503
ABA, 1G4lHlOO-S3
AIatate ute n. Company-
General DepoIit Acccu1t
kd. '115S0~5449
o UnaS$lgned Allstate Ure Insurance ChaSe Manhattan Bank. NA
AJIstate ute of Company of New Yorll One ChaSe Meri1attan Plaza
New York Annuity New York. New York 10091
ABA'0210-0002.1
Alstale ute of New York
General Oepoeit Account
kd.'91G-2~9
o AssIgned to Structured S1ructured SeUlement Trust NOIWeSt Bank Nebraska, NA
SeUlement TI\J!Il Centerstone 8liIdIng, 1200 0 Street
lilcoln, Nebraska 68S0a
ABA, 1040-000-S3
Structured Selllement Trust-
Genel1ll Deposlt Account
Acct. , 115~0~a930
IFOI' Olfic:e Us. Only:
Invoice t:
Accepted by.
Date:
000'
PREMIUM TRANSMITTAL fORM
I'UAII PMf1'
PremILm: S 10 , 000 . 00 c.. Narne:
InctvkllII Bruk.... Nam.: W. Ross Duncan
Jllue_\l.e_l1
Comparty Ringler Associates ~.. PA
Melissa Hoffman o.tII: 02/08/95
BroklltPllcnet:(610) 834-5553
BroklltFat: (610) 834-544'
~
Trarwmllled via: GJ CHECK DWIRe TRANSFER
(dlodl....) ---(jr1orIyJ.... _ """lIlrm ond <p*
IlilIaml. quole ond -..: ....,.,...- ..:
SheIy Hagen. (402) 47$-7244 SheIy Hagen
AIIlala Selllel11<<lt CoipoI.lIon (0402)47$07244
:zoe ~ 13th SlrHt. S\ile 200 (402)47$07888 Fa
I..ilcm, NebrIIka ea5O&-201 0
D Check lief. If It* cne wn pIl1IaIy fu1ded ellltef and It* II addtlonal premium.
~-bQl- Meke Checb PlVlIble to: Send wne to:
[Xl AAV1ed AIslale Se1llement Nocwesl Bank NeIxnluI, NA
AIIl8tlI Ufe Anxitty CoIpot a1lon Centeratone BuIdng, 1200 0 Street
t.r.cOO, Nebraka ~
ABA . 1 ()4O-OC)O-lla
Ahta1e Selllement Corp,.
ALIC General Oeposit Ac:cooot
Acct. . 11550S5430
DAssllJled ADstate SelUement NOIWftt Bank Nebraska, NA.
Alltate ute ot Corporation eentemone BuIdng, 1200 0 Street
New York Annuity Ulcoln, Nebralka ea508
ABA . 1 ()4O-OC)O-lla
AIstIIle Setllement Corp.-
PJ.NY General Oeposit Account
Acd. .1155058922
D Unaalgned Aastat.e Ufe Il'lSlI'ance Norwest Bank Nebnttka, NA
AJIstate Ufe Annuity Company Cenlerstone Ektilg, 1200 0 Street
Li1c:oln, Nebraka ea508
ABA' 1040-000-58
AIIlate Ute n. Company.
General DepoIit Acc:owlt
Acct. . 115501l5448
D UnaS$lgned Allstate ute IlllU'Ince Ch.Iae Manhallan Bank, NA
AIIlate Ufe ot Company at New York One Chaie Manhatbln Plaza
New York Annuity New York. New York 10091
ABA, 021 Q.OOO2-1
Alstale Ute of New York
General Oepoelt Account
Acct. . 91 G-2-638&49
D Asslgned to Structured S1nJclured Selllement Tr<lSt Norwest Bank Nebralka, NA
Selllement Trust Centenrtone BuldIng, 1200 0 Street
1.i1co1n, Nebraska 68508
ABA . 104(}'o()()'58
Structured Selllemem Trust.
General Deposit Account
Acct. . 1155058930
IFor Ol'lk:e Use Only:
Invoice t:
Accepted by.
Oale:
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PREMIUM TRANSMmAL FORM
~PMfl'
Premiln:S 20,000.00 c..N.me; Jennifer Orlouskv 0ftI: 02/08/95
IncNcbIIBnlk....N..".; W. Ross Duncan BnlkIl'Phonet: (610) 834-5553
ComptI\'f Rinder Associates ~~Hr- 8IoIlll'fa-= (610) 834-5442
Tranamltled'ila; [Xl CHECK DWIRE ~SFER
(..-onol - - (Jrlortylmol --...-.....,..,..
INI....... .,..,...... _ ,,, ..._01_'"
SheIy Hagen . (~ 478-7244 SIlIIy H.gen
AIIlnI SelIIement COIpOlI1lon (402) 478-7244
208 Souh 13111 Shet . SUIlt 200 (402) 47i-7ea8 fa
~.NebrMka ~2010
o Checll het'alf ltia _ _ parWy fII1dad aliiiil' and ltia Ie .ddltlonaI pramiJm.
p-ono...- Make Cl1eckJ Pavable to: Send wn. to;
@AIaV1ed AIIlalll Selllemen! Norwell Banll Nebtuka, N.A.
Allstate ute AtnJlrt Corpore1lon CcntenlllnIl3I.ti1g, 1200 0 Street
Lnc:OO, NeInIlla G4S04
ABA"~
AIItalII SeIlIement Corp,.
AUC General Oepoeit ACCOIrt
Ar.d. ., t 550S5430
DAssigled Aaslate SetUemen! NocwetI Bank NebrnU, N.A.
AAstale ute ot COfIlOnIUon CentenlOM Bulldng, 1200 0 Street
New York Annuity ~,Nebraaka 68508
ABA ., 04G-00Q..5a
Alstate Setllement Corp,.
I>J.N'f General Depoell Account
Acct. . 115S05a922
o Unassigned A!state ute IrlSlnnce NOlWllIt Banll Nebraaka, N.A.
AAslate ute Annuity Company Centerslone BWdk1g, 1200 0 Street
~,Nebraaka 68504
ABA . 1 04G-00Q..5a
AIIstalII ur. n. Company.
Genen/ Oepod ACCOW1t
Ar.d. . 1155055449
o Unasalgned AlIsllIte Ute Insurance Chaae Mamaltan Bank, N.A.
AIslate ute ot Company 01 New York One Chaie Manhalllln PIlWI
New York Annuity New York. New York 10091
ABA U210-0002.t
Alstale life ot New York
Gene,.) 0ep0Ilt AccoIr1t
Ar.d. . 91 ()"2-83S849
o AssIgned to Slruc1lJred StruclJJred Selllement Trust Norwest Bank Nebrnka, N.A.
Selllement Trust Centem- Building, 1200 0 Street
~,Nebra.ka 68508
ABA .,CMC).QOO.5a
StrlJ<:Ued Selllement Trust-
Genensl Depoalt Account
Acc;t. , t 155058930
For Ol'lice Use Only:
Invoice t: Accepled by: Date:
""
I
PREMIUM TRANSMmAJ. FORM
~ I'Mf1'
""mUll: S 10 , 000 , 00 CaN Name:
~ Broka(a Nam.: W. Ross Duncan
1I1ue_~,,11
CompclY RlnRler Asaoc1ates qftIceIOI'f.' PA
~ell..a Hoffman 0..: 01/08/95
BtokltPhonlI: (610) 834-5553
IlrokltFal: (610) 834-5441
TI8IlI/IIilIed Wi: GJ CHECK DWIRE TRANSFER
<_-I _ __ (p1arWy) mol _,.. INI_""" ""*
tNIlarm. ""* IIld _10: ..,."'''-10:
SheIy Hagan. (402) ..79-72404 SheIy Hagan
AIDlII s.tlIament Coo)l<llallon (402) ..7e-72....
20lI SoUtI13lh SlrHt - &illI 200 (4O:Z) .. 7e-7sai Fa
Lilc:OO. Nelntka 68S(l&.2010
D Chedt her. If tIia case _ partWv fu1ded .uter end tNllI Id<ItlonII premklm.
0-... -- Mlk. Cheeks PlVlIbIe 10: Send Wlrve to:
Ul~ AIslIIle SetlIement N~ Bank NebnnkI, NA.
AIItate ute Arn.itf Colpot lItlon Ceta. alilOI BuIIdk1g, 1200 0 Street
l.ilc:OO, NIbnIelta ~
ABA'l~
AIIlate Selllemenl Corp,-
AUC G4lnefaI Oepoeit ACCOlI1t
Acd. '115~30
DAasigMd AAIlate Selllement Ncxwest Bank Nebnlskl, N.A,
Aktal. ute of COfJl<<lIUon CenlIrslone BuIIdk1g, 1200 0 S1reet
New Yorll AnnuitY UlecWI, Nebrukl 118508
ABA, 1 04G-000-58
AIstIte SeIlIement COlJI.-
p.u('( G4lnefaI Oepoeit Accolmt
Acd. . 11550lI8922
DUo usl:llled AIstale ut. Inst.nnee NOIWIlSt Bank Nebruka, NA.
AIstate ute Annuity Company CententoM 1luIcIng, 1200 0 S1reet
l.ilc:OO, NebnnkI 118508
ABA'l~58
AIItate Ute I~. Complny-
General DepoIil Acc:ou1l
Acd. . 1155OS5448
D Unassigned AlIstale ure Il1lIInI1Ce Chase Manhallan Bank, NA.
AIItate ute of Company of New Yorll One Chase ManhlIlIan P11WI
New Yor\( Annuity New York, New YorlI 10091
ABA.0210-0002.1
AIslale Ute of New YorlI
General Depollt Account
Acd. . 91G-2-638849
D AssIgned to StnJctured S1ructured Selllement Trust NolWest Blnk Nebraska, NA.
Selllement Trust Cenlerstone Building, 1200 0 Street
Li1eoIn, Nebfeska 68508
ABA . l040-00G-lI8
S1ruclured Selllement Trust-
General Deposit Account
Acct. . 1155058930
For Ofllce Us. Only:
Invoice t: Accepted by: Oate:
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CALDWELL 0. KEARNS
A PAOr["IO"''''' CORPORATION
THOM"S D. CAL.DWELL. oJ"
RICHARD 1.,. KIA"HS
CAAL 0 WAS!!
.JAMES A CLII'PIHGlA
CHARl.ES oJ O<<HAAT. HI
.J...~tS D. ,,,"'P8EI.I.,..I"
.JA",ES L GOLDSMITH
TIMOTH.... l. ......AM.
,''''IotItS G NI:ALC~. III
MATTHlW ... OOV1A
DIBORAH A CAVACINI
KEVIN C. ELLIOTT
ATTORNEYS AT LAW
3e31 NORTH F'AONT STREET
HARRISBURG, PENNSYLVANIA 17110-1533
117.i3" 'eel
'A'" 117.2:U.llee
April 3, 1995
Honorable Edgar B. Bayley, Judge
CUMBERLAND COUNTY COURTHOUSE
1 Courthouse Square
Carlisle, PA 17013
Re: Roger L. Hoffnsn and Diane Hoffman, Individually and
as Parents and Natural Guardians of Nicole D. Orlousky,
Jennifer E. Orlousky, Krysta E. Hoffman and Melissa C.
Hoffman, Minors v. John W. Snyder, Deceased
C~mberland County C.C.P. No.: 94-7176
Dear Judge Bayley:
Enclosed please find a proposed Order regarding the Petition to
Settle the Claims of Minors filed to the above-referenced docket
number. You will note that the parents confirmed their original
decision to invest in the annuities for the three children with
larger settlements. At the time of the hearing, you had also asked
that I provide you with the name of the company through which the
annuities would be purchased. In this instance, the annuities will
be purchased from the Allstate Life Insurance Company. The
proposed Order reflects this information as well. If this proposed
Order is acceptable, I would ask that a time-stamped signed copy be ",-
forwarded to me in the enclosed stamped, self-addressed envelope.
If this is not convenient, I could also have the Order picked up
the next time someone from my office is in Carlisle.
If you have any further questions or concerns, please contact me.
(' Very t~rUiY'_YO
J fl ~J''' N
Debora . C
~L~
DAC:sml:48234
Enclosures
THOMAS D. CALDWELL, JR
RICHARD L. KEARNS
CARL G. WASS
JAMf.S R. CUPPINGER
CHARLES J. Dt:HART. III
JAMES D. CAMPBELL. JR
JAMES L. GOLDSMITH
TIMOTHY I. MARK
JAMES G. NEALON, III
MATTHEW R. GOVER
DEBORAH A. CAVACtNI
KEVIN O. ELUOTT
A PROFESSION,tt. CORPORATION
AlTORNEYS AT LAW
0~;"~D$
~~32-7881 611"1../
FAX, 717,232-2786 '7'"
CALDWELL Be KEARNS
3631 NORTH FRONT STREET
HARRISBURG. PENNSYLVANIA 17110,1533
June 9, 1995
Honorable Edgar B. Bayley, Judge
CUMBERLAND COUNTY COURTHOUSE
1 Courthouse Square
Carlisle, PA 17013
Re: Roger L. Hoffman and Diane Hoffman, Individually and
as Parents and Natural Guardians of Nicole D. Orlousky,
Jennifer E. Orlousky, Krysta E. Hoffman and Melissa C.
Hoffman, Minors v. John W. snycier....Deceased
Cumberland County C.C.P. NO~ 94-7~~~~ '
Dear Judge Bayley:
Enclosed please find proof of the purchase of a Certificate of
Deposit which complies with your Order dated April 12, 1995 and
your letter of May 10, 1995. Please note that the Certificate of
Deposit was purchased in the name of Nicole D. Orlousky and the
Certificate bears a notation that no withdrawal can be made until
Nicole reaches her majority, except as authorized by Court Order.
This documentation has been filed with the Prothonotary on this
date.
I do want to draw your attention to the fact that both the petition
and the testimony at the hearing confirmed that I did not act as
attorney for the Petitioners, but rather was hired by Allstate to
facilitate the Court approval of the settlement reached between the
Hoffmans with Allstate. Your Order of April 12, 1995 refers to
"counsel for Plaintiffs/Petitioners" in both paragraphs 1 and 6.
If you need anything further
from me, please advise.
--------
"~efY s-~y you\rr' )~
\1/ /, ,
( Q.,~)8 }.J-j' / .
C DWELL & S.
DAC:sml:52379
Enclosures
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IN RE: ROGER L, HOFFMAN AND
DIANE HOFFMAN, Individually
and as Parents and Natural Guardians
of NICOLE D, ORLOUSKY,
JENNIFER E, ORLOUSKY, KRYSTA
E. HOFFMAN and MELISSA C,
HOFFMAN, Minors,
Petitioners
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION.LAW
94-7176 CIVIL TERM
ORDER OF COURT
AND NOW, this 12th day of April, 1995, the petition to settle the minors' claims
arising out of an accident of October 17, 1993, Involving a vehicle operated by John
W, Snyder, deceased, and Insured by Allstate Insurance Company, IS APPROVED.
Distribution shall be as follows:
(1) The sum of $3,000 for Nicole D, Orlousky, bom August 7, 1961. Counsel
for plaintiffs shall open a federally Insured account at the highest Interest rate
available In the Dauphin Deposit Bank IN THE NAME OF NICOLE D. ORLOUSKY.
The account shall contain the provision that NO WITHDRAWAL CAN BE MADE
UNTIL THE MINOR ATTAINS HER MAJORITY, EXCEPT AS AUTHORIZED BY A
PRIOR ORDER OF A COURT OF COMPETENT JURISDICTION.
(2) The sum of $20,000 for Jennifer E. Orlousky, born July 14, 1983, Allstate
Insurance Company shall purchase for $20,000 an annuity from Allstate Life Insurance
Company IN THE NAME OF JENNIFER E. ORLOUSKY to provide a structured
settlement as follows: $7,500 to be paid to Jennifer E, Orlousky on July 14, 2001;
$12,500 to be paid to Jennifer E, Orlousky on July 14, 2004; and $21,635 to be paid
to Jennifer E, Orlousky on July 14, 2008,
.
(3) The sum of $15,000 for Krysta E, Hoffman, born February 25, 1987,
Allstate Insurance Company shall purchase for $15,000 an annuity from Allstate Life
Insurance Company IN THE NAME OF KRYSTA E. HOFFMAN to provide a
structured settlement as follows: $7,500 to be paid to Krysta E, Hoffman on February
25, 2005; $12,500 to be paid to Krysta E. Hoffman, on February 25, 2008; and
$21,256 to be paid to Krysta E, Hoffman on February 25,2012,
(4) The sum of $10,000 for Melissa C, Hoffman, born July 25, 1991.
Allstate Insurance Company shall purchase for $10,000 an annuity from Allstate Life
Insurance Company IN THE NAME OF MELISSA C. HOFFMAN to provide a
structured settlement as follows: $7,500 to be paid to Melissa C, Hoffman on July 25,
2009; $12,500 to be paid to Melissa C, Hoffrnan, on July 25, 2012; and $17,828 to be
paid to Melissa C, Hoffman on July 25, 2016,
(5) Roger L. Hoffman and Diane Hoffman, the parent and parents of the
aforesaid minors are authorized to execute a release I" favor of the estate of John W,
Snyder and Allstate Insurance Company, and are further authorized to execute any
other documents necessary to effectuate this settlement.
(6) Counsel for petitioners shall forthwith file with the Prothonotary, and have
forwarded a copy to this judge, proof of the deposit for Nicole D. Orfousky and the
purchase of the ann\,;ities for the other three minors,
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IN RE:
ROGER L. HOFFMAN and DIANE
HOFFMAN, Individually and as
Parents and Natural Guardians
of NICOLE D. ORLOUSKY,
JENNIFER E. ORLOUSKY, KRYSTA
E. HOFFMAN and MELISSA C.
HOFFMAN, Minors,
Petitioners
..
~
* IN THE COURT OF COMMON PLEAS
* CUMBERLAND COUNTY, PENNSYLVANIA
*
* No.:
*
*
*
*
*
*
PETITION TO OBTAIN COURT APPROVAL
TO SETTLE THE CLAIMS OP MINORS
The Petitioners, Roger L. Hoffman and Diane Hoffman,
individually and as parents and natural guardians of Nicole D.
Orlousky, Jennifer E. Orlousky, Krysta E. Hoffman and Melissa C.
Hoffman, Minors, respectfully represent:
1. The Petitioners, Roger L. Hoffman and Diane Hoffman,
husband and wife, are adult individuals who currently reside at
RD#l, Box 431H, Palmyra, Pennsylvania, 17078.
2. The Petitioners are the parents and natural guardians of
the following minors:
(a) Nicole D. Orlousky; d/o/b August 7, 1981.
(b) Jennifer E. Orlousky; d/o/b July 14, 1983.
(e) Krysta E. Hoffman; d/o/b February 25, 1987.
(d) Melissa C. Hoffman; d/o/b July 25, 1991.
...
.
.
.
The minors reside with their parents and natural guardians,
Roger and Diane Hoffman.
3. The circumstances giving rise to the instant Petition
occurred on October 17, 1993 at approximately 5:00 p.m. on north
bound Route 81 in Carlisle, Cumberland County, Pennsylvania.
4. At that time and place, Roger L. Hoffman was operating a
1993 Ford Aerostar minivan owned by his employer, Rite Aid
Corporation. The minors were passengers in this vehicle. The
accident occurred when John W. Snyder, deceased, rear-ended the
vehicle driven by Hoffman, which was slowing down for a traffic
jam. This impact caused the Hoffman vehicle to spin and hit a
third vehicle operated by Casey S. Lamb, which third vehicle was
stopped at the time of impact. A true and correct copy of the
police accident report is attached hereto and incorporated herein
by reference as Exhibit "A".
5. John W. Snyder sustained fatal injuries as a result of
this accident. At the time of the accident, he was operating a
1987 Oldsmobile Delta 88. This automobile was insured under a
policy written by the Allstate Insurance Company. Attached hereto
and incorporated herein by reference as Exhibit "B" is a true and
correct copy of the Allstate policy limits verification.
6. As a result of the subject accident, the minor, Nicole D.
Orlousky, suffered an abrasion and contusion to her right leg.
2
..
.
.
..
Attached hereto and incorporated herein by reference as Exhibit "e"
are copies of the pertinent medical records of Nicole D. Orlousky.
7. As a reeult of the subject accident, the minor, Jennifer
E. Orlousky, suffered a closed head injury and left humerus
fracture. Attached hereto and incorporated herein by reference as
Exhibit "D" are copies of the pertinent medical records of Jennifer
E. Orlousky.
8. As a result of the subject accident, the minor, Krysta E.
Hoffman, suffered a closed head injury, a mandibular contusion and
a left shoulder contusion. Attached hereto and incorporated herein
by reference as Exhibit "E" are copies of the pertinent medical
records of Krysta E. Hoffman.
9. As a result of the subject accident, the minor, Melissa
C. Hoffman, suffered an abrasion to her face and abdominal pain.
Attached hereto and incorporated herein by reference as Exhibit "F"
are copies of the pertinent medical records of Melissa C. Hoffman.
10. The following sums have been agreed upon by the
petitioners and Allstate Insurance Company for the settlement of
the minora' claims:
(a) Nicole D. Orlousky - $3,000
(b) Jennifer E. Orlousky - $20,000
(c) Krysta E. Hoffman - $15,000
(d) Melissa C. Hoffman - $10,000
11. The Petitioners believe that the settlement enumerated
in this Petition is fair and equitable and in the best interest of
3
.
.
.
the minors. The petitioners are unrepresented. They understand
and waive their right to obtain counsel to advise them regarding
the appropriateness of the settlement.
12. The Allstate Insurance Company has offered to pay the
sums set out in paragraph 10 above toward an amicable solution of
the claims and in exchange for Court approval and a Release of all
claims.
13. The Petitioners, the minors and the Allstate Insurance
Company agree that the sum of $3,000, payable on behalf of Nicole
D. OrlouskYi $20,000, payable on behalf of Jennifer E. Orlousky;
$15,000 payable on behalf of Krysta E. Hoffman; and $10,000,
payable on behalf of Melissa C. Hoffman, minors, shall be deposited
in a federally-insured savings bank in the name of the minors, with
the provision that no withdrawals can be made from such accounts
until each minor reaches her majority, except as authorized by
prior Order of this Court.
WHEREFORE, the Petitioners respectfully request that this
Court enter an Order approving the foregoing compromise settlement,
directing the distribution of proceeds thereof as set forth above,
authorizing the Petitioners, upon payment of the aforesaid sums, to
discontinue the action brought and to execute a good and sufficient
Release of any and all claims arising from or as a result of the
4
~
EXHIBIT A
.
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EXHIBIT B
"'.''''\
Exhibit C
.
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---.-------- -
( 0D
(717) 245-5500 EMERGENCV
REGISTRAnO~
697,6192
246 Park.r Sir...
earlhl., PA 17013.0310
18:29
Mlf.",!IO t.(I4(WI'\.O'l'IA
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183-16-9802
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(717) '169-78'16
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H~FFHAN, ROCER L. 18
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AUTO
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TO BE EVALUATED
DI
WILLARD, WILLIS W
EMERa VISIT D005 26600 CAST ROLL. SCOTCH 26061 ALL ADDInONAL CHARGES
EMERa VISIT 0610 26605 EKG MONITOR 26042 r-- -..... r .....
I II I
EMERa VISIT 1115 28610 EXTERNAL PACER 26045 L Q?(Q CJ II I
II I
EMERa VISIT' 1625 26615 PACER PADS 79064 J\. J
EMERa VISIT 2640 28620 GASTRO/HEMO SUDE 28060 r-- .....r .....
EMERa VISIT I II I
4155 26625 KIDOE TOURNIOUET 26046 I II I
EMERa VISIT 5685 26630 OCL PER fOOT 79670 I II I
\. ____J \. J
EMERG VISIT CLASS 6 26635 f,S,B,S. 600Bl r- .....r .....
OBSERVATION, EACH HR 26017 SUTURE PER PACK 26073 I II I
I II I
26010 TUBE GAUZE PER FOOT 26074 I II I
\. _J \. J
EMPLOVEE HEAl.TH VISIT 28018 ALL AODInONAL CHARGES r -..... r .....
LIGHT SOURCE fOR SPECULUM 26645 I I II I
I I II I
ALL VAGINAL SPECULUM 80068 I II II I
INJECTlON fEE 26009 \. _ J \. J\. J
r- ..... r .....r .....
B/P MONITOR 26037 I I I II I
CAST. SCOTCH SHORT ARM 26031 I I I II I
I I I II I
CAST, SCOTCH LONG ARM 28032 \. J \. J\.____ ___J
CAST, SCOTCH SHORT LEG 20033 r ..... r .....r .....
I I I II I
CAllT. SCOTCH LONG LEG 26034 I I I II I
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CAST, CYLNDR LEG 26030 \. .J \. J\. J
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CARLIf ~E HOSI__AL 248 PARKt.. STREET CARLISLE, ..' 17013'03'0 ., EMERGI:.--,Y REGISTRATION
~'1 '51.1 I'~{) I' \&11.p~. I il~1'ri1\ I fen ' , ,
,
....,
FOR NURSING ASSESSMENT
SEE NURSING DOCUMENTATION SHEET
,~I "'TORY
,'- IORO<" L
,
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NURSING DOCUMENTATION - EMERGENCY DEPARTMENT
fR 2010 (llI9ll
NAME () 1L L6U-~~ '-17 I C ~
ROOM 8 AG~ ~ WT,
VITALsf1;; :~~ T I
P R Bp IOt.J11Jl,
ALLERGI 5: .) ,
CURRENT MEDICATIONS.
N d'U-
TETANUS STATUS.
o Wllhln S Vea" "T (~
o S,10 Vea" '-""..)
o Mere than 10 Years
o Never
. TREATMENT IN PROGRESS ON ARRIVAL:
o CPR Down Time min.
o Airway - 0 Oral, 0 Na.al Size
o Airway, Ende"acheal- Size
o Airway, Nasalracheal - Size
o IV Seluli... Sile
a GENERAL APPEARANCE
PUj.SE:
ErReguler 0 Irregular
o Full 0 Weak
RE;SP' 0 Shallew 0 Rapid
E1"'Normal 0 Deep 0 Slew
o Labered 0 Slrlder
Right: 0 Rat.. 0 Wheeze
o AhoneN 0 Abu"1
~Ur:!~nd.:
~p"
Len:
CRaie.
e Rhonchi
Pupil.: ,. .
Right . Size
Reaction _ z. .
~
o Reac:tlon_ 3- .
. INmAL NURSING INTIiRVIEW:
REASON FOR VISIT: "CJTR M
PAST MEDICAL HISTORV:
Size
o Olher
COLOR.
cad
Pale
IN.
Warm
Q'Dry
TRIAGE NOTE:
Tn.g. Slalul: Mode of Arrlyal:
o Prlerily I D ALS D BLS
D Prlerlly II .Q.-Il1i1bulalory
a-l'rlerlly III D Wll.elch.lr
o Fa" Trick 0 C.rrled
Ch~mpllln,. {--
(U~~:~ j,:C~ 5~~~
On.al el Symplems:
Nursing ""lion/Cemmonl'.
Chlldhcad Immunlzatlcn.. 0 UTD 0 Nevar 0
Treatment Prior to Arrival:
TRIAGE NURSE SIGNATURE
o Menllor - Rhythm Rale
o O'ygan - 0 Ma.k, 0 NC - UMln
D Splnallmmoblllzalien,
D Ma.I,
o Pressure Oressing a Other
o Flu.hed
o Jaundiced
o Ceel 0 Ecchyme.I.,
o Clammy 0 Ra.h,
Tho~
C""'CIi.tJSponlaneou.
o VagueJOisconnec:ttd
o OI50nenled
o Slow to Answer
C W1tn Ola,,"
o Without Ollss.,
TIME: D
o MEDICAL ,r O.PSVCHOSOCIAlJEMOTIONAL
" -.C-CLn-r
.ael,
_ Noncompliance
_ $en Car. a.llcit
.::::::: Comfort. Alterallonsln:
_ CommuniCation ImPAired
_ eopno, Inerroctlvl
_ Fluid Volume. Alleralions In:
_ au exchlnQlt. Impaired
nllue Perlulion, An. In:
SUBJECTIVE: Cau.a ellnjurylHlSlory ef Pre.anllllna., (Whallhe palienllell. yeu),
o WhHII
o Absent
,nlll A.....menl:
Mo<1!llAIlec1'
~ppropnlll
o Blunledifl;&l
o OelenliV'
o Appt'eh.nllV.
o ResUnSlComblUvl
PATIENT PROBLEM: Nursing Dlagne'l.
_ A1twlY CJelranc.. Ineffective
....<:::'An,Ie!)'
_ Breathlng Panems, In.ffecUvl
_ Cardiac Output. Decreased
Other
OUTCOMElGOAL: E'pecled by Dlscharg..
81
.2
83
"
4. .
S' .
I. .
Vllu.1 Activity:
00
OS
_ Skin Integrity Impairment
_ Thought Processes. Alt. In:
_ Hyperthermia (Fevlr)
_ Inlec1lon. Potlntial
_ InlulY. Pot.ntial
_ Knowfedg. Oollc:il
_ MobIlity Impaired
Oner
.ji:n....f.' 'i c::'i~IATIJPF
10 - /
Dlt~:
Arrived Wilh.
D Pellcl
..a-flrenl
D 5.11
o Frllnd
D Spau..
o Other
<:..
DRUGS:
D Du.ky
o Cyanetlc
o Nailbed.
o Clrcumeral
o Laeeratlon
D Edema
...
.
.
Speech:
g...HurmaVClear
o Sltlnl
o Talkatlvl
e Rlptliltve
o Mumbling
~~ftI'_
Int.et
o Impai,1d
o R.cent
o OllllnllP.'1
r
..
~
LMP:
..
~
o
PLAN OF CARE:
o Malnlaln Pallen' Airway
o Menilor Cardlevascular Slalu.
D IV D BP Menller
D EKG 0 Cardiac Monllor
o Salety Maa.ure,
D Ra,'ralnts 0 Sulclda Pracautlcn.
o SeIzure Precautions
D Side Rail. Up
Comfort Measures
o Pain Cenlral
o Peslllen lor Cemlo~
o Prepare for Ellam
D E'plaln Prccedure.
. D Emellenal Suppc~
Palenl Taaching
Discharge Inslrucllcnl
Other
Other
Other
. IV FLUID: . MEDICATIONS
Typo/AmL lit. c.rh. Ill. n... IllIMlure lIod, DON "au" n... Ilgntture
. TREATMENT/PROCEDURES: . INTAKE: . OUTPUT:
(J RESP, THERAPV TREATMENT IV PO
(J TIM" TIM" TIME TyPO amI, TY\lO AmI. Urine IIMl11 OI/W
(J OXYGEN UMIN
(J INTUBATION, SIZE TIME
(J A8O'S TIME. TIM" TIME
(J PULSE OX TIM" TIME
(J AIRWAV. TYPE- TIME
(J NASOGASTRIC TUBE. SIZ" TIME . NOTIFICATION OF:
(J GASTRIC LAVArJ" AMT c Hospll>' Sodal Wo"''' o Family Dodo<
o Family o Coronet
o Pollco o Conluftant
(J FOLEV CATHETER' SIZE TIME o Crilll Inllrvenllon o O\htr_
M'iT, OUT COLOR o NUll/no Home 0011,.,
(
TIme BP P R NOTES:
" .
-r.~~AJ~~N~... DISCH~~GE tl.O.!:E~:r'l1 U :L -::-1- ~.OI..-D" ~-i,~ '" J)J, ,,1.' fe-
r -
"...... -6.1 J~ A '17'1'1;:: no ' 'it ' A.! ,..,,'0::. Cs'""
'~ ~. "h.Af -v -V U
. VITAL SIGNS. 0 ON Bp MONITOR
o MANUAL
C For ObMf\llllon
10.
o Transl'ffltd 10:
DISCHARGE:
~
o Ambulatory c: ....Ii.lane.
o Wh..\chalr
o ,lmbu11l'lCa
O\har
o Soil
,P-f'Iffi1Iy
o Friend
o Police
o Valuable'
INSTRUCTIONS:
o en." 0 UTI
a CruW\t1 0 KIdney Slon.
o Abd. PrQtHm 0 P,Mc Inf.
o Wound Car. 0 Sp'alntBfulsl
o Clear uqukl 0 Asthma
o Fevlr 0 OCUCal'
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CJO\lIaf
CO\llaf
DISPOSITION:
O_odlO:
PA nENT'S NAME
N'-cu\c
'Crt ,Oll.~,I(1
HURSE'S SIGNA TU
O_QUO
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@/C'aIiiOO I-bspital
CDNIEVT TO 101.ITAL ADMIIIION AND
ICZDI c.u. TIlL\TICZHT
Name ot
Attendin~ Phy.ician (.)1
}V - I, -93 Timel
(AH)_____(PH)____
Date ot Admi..ionl
1. I, (or .cting on behalt ot)
NIae 01 ,UtMrUe4 ..,....~-'ltI"
-LV'lc" It' (1"")nu..s,e-'1 , .uttuin~ trOll\ a condition nquil'1n~ ho.p1tal car., hanby
N-. 01 r.. 1
con..nt to r.nderin~ ot .uch c.r., which may include rout in. di.gno.tic proc.dure. .nd .uch
medical tre.t..nt e. the n~d .ttendin~ phy.ici.n(.) or oth.r ot the ho.pit.l'. medical
.t.tt con.ider to be n.c....ry.
2. I und.r.tand thAt the pr.ctice ot medicine and .urgery i. not .n ...ct .cienc. .nd
th.t di.gno.i. .nd tre.tm.nt m.y involv. ri.k. at injury, or .v.n d..th. I acknowledge that
no ~u.r.nte.. h.ve be.n m.d. to me .. to the r..ult ot examin.tion or tre.tment during thi.
ho.pit.lia.tion.
3. I und.r.t.nd that,
(A) It i. cu.tom.ry, .b..nt .mergency or extr.ordinary circum.tance., th.t no
.ub.t.nti.l proc.dur.. .r. pertorm.d upon. pati.nt unle.. and until he or
.h. h.. h.d .n opportunity to di.cu.. th.m with the phy.ici.n or oth.r
he.lth prot...ion.l to the p.ti.nt'. ..ti.t.ction,
(B) E.ch pAti.nt h.. th. right to con..nt, or to retu.. con.ent, to .ny
propo..d proc.dure or th.r.peutic cour.., .nd
(e) No p.tient wUl b. involved in .ny r....rch or ..pel'1m.nt.l proc.dur.
without hi. or h.r full krowledge and con.ent.
4. I under.t.nd th.t m.ny of the phyeici.n. on the .t.tt ot thi. ho.pital, includin~
the attending phy.ici.n(.) named .bov., .re not employ... or .gent. at the ho.pital but,
rathel', are independent contr.ctora who h.v. b..n gr.nt.d th. privU.g. ot u.ing it.
t.cUitie. tor the c.re .nd traatm.nt of th.ir p.ti.nt.. Further, I r.alh. th.t aman~ tho..
who attend p.tient. .t thi. ho.pital .r. m.dic.l, nur.ing, .nd other he.lth car. per.onnel
in tr.ining who, unl... r.qu..t.d Dth.rwi.., may b. pre.ent durin~ p.ti.nt car. .. a p.rt at
thalr .ducation. StUl or motion pictun. .nd clo..d circuit t.l.viaion monitoring at
pati.nt car. .1.0 m.y b. u.ad tor .duc.tion.l purpo.e. or tor document.tion ot th. clinic.l
COur.. unl... . pati.nt expr..ely r.qu..t. oth.rwiB..
5. I r.l.... CARLISLE 10l'lTAL trom .11 r.Bpon.ibility for all .rticl.. which I am
r.t.ining'or will hav. with me during my .tay .t the ho.pital. I und.r.t.nd thi. includ..
clothin~, bridgework, tahe te.th, .y.gl....., j.w.lry, mon.y, radio, r.aor or .nr oth.r it_
k.pt in my po.Beuion. I under.tand 1 may depoBit valuable. in a .afe prov ded by the
ho.pital, only it thh h don. will the hOBpital auum. any r.Bpondbility tor the
.at.k..ping.
6. I hereby acknowl.dge that 1 have receivud written intorm.tion on the topic. at
P.ti.nt Right. .nd Adv.ne. Dir.ctiv..,
D.te of Signature I
i6 -/7 -q)J
(SIONATURE or PATIENT)
(SIONATURE or WITNESS)
(It patient ie unable to con Dent or iB . minor, complete the followingl)
P.tient [i. . minor ____ ye.r. of .gel [ie unable to con.ent becau.e)I
-)J~S;G;;"TURB ~~:::!;k~ , Q.~
J (J; t)..?-Q (7,~ ,,~
(s"IONATURE or LEGAL 0 IAH OR
CLOSEST AVAILABLE RELATIVE)
An 0115 110/91 \
, .'
o () 0, ()
. @) Carlisle Hospital
PATIENT'S NAME: ~~.L~_ cO/2/~ ':f'-4-
INSURANCE CO,: .;.1?f.'f;:~/tL/l--:vY'l <-/~ Comm e,y-C 10...1
o
.
~u-to
i
Statement to Permit the Release of Medical InFormaticn and Pavment of Medicare and lor
Other Health Insurance Benefits andlor Physician,
./
-' "'.
I authorize Carlisle Hospital as the holder of medieal information pertaining to me to
release the necessary and appropriate medieal information to the fiscal intermediary of the
Soeial Security Administration and/or to my primary or supplemental health insurance
company or it's designated review ageney for payment for services rendered,
'\'
'.. "
, .
I authorize the Carlisle Hospital's and/or the physician's billing agent to submit a
,- claim to Medicare or other health insuranee on my behalf. or to request, on a one lime
only basis. fr"m the Social Seeurity Administration, such information necess'ary to complete
the claim submission process.
I 8m the individual to whom the information/reeord pertains, or am authorized to
eonsent, on behalf of the Individual, to the release of the informatlonJreeord, I understand
that any false statement or representation knowingly and willfully made or caused to be
made for use in determining rights to Medicare benefits or payments may be punishable by
a fine of not more than $10.000.00 or one year in prison. or both,
I request that payment of authorized benefits be made on my behalf.
I assign the payment of inpatient or outpatient hospital benefits to Carlisle Hospital
for those services provided by Carlisle Hospital and/or I assign the benefit payable for phy-
sician services to the physieian.
I certify that the information given by me in applying for payment of services under
Tille XVIII of the Social Security Act or for any/all other health insurance is eorrect.
PatJenl's Signature
SSN
Date
Responsible Party if Patient Unable to Sign
Relationship
Date
J...OiCUru (l, /.oJ.. J,/
, lneured Parson's Signature 'r( T-"' -------
(If dlf'erent lrom patient 0/' il patient Is a minor,)
I (j- 17. '1 -~
Date -
Reason Patient eould not sign.
Witness
VL
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,It. Copy - Heallhear. BlIIlng
. 10' .' "~., . :' t ~ ~....:
...,.d:......;. t t 1!! ""
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Canary Copy - Modlcal Rocords 1 Ancillary Departments
.)~":"""".
. .
AD 1825 (10192)
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NN4B1 Orlousky, Jennifer
HRlI 697644
DM'EI 10-17-93
DmlGEmlr JlOCJ( JUXXIU)
aIIEI' CX'IfPIAINl'I ItJtar vehicle aocident.
RIBlalY 0'Il'Rmmr ILUmlSI 'lhis 10-year-old child was a rear l"'''''erqer in a
van probably unrestrained when the van was struck tran tlehind by another car.
'!he children in the back of the van were thrown out onto the highway and this
child may have been unoonscioos briefly. She was brought fully ilTInobilized by
paramedics because she appeared to have a dislocated elbow. '!here was no
awarent past history of serious medical problems. M.1ltiple victins 1'ran this
acx:ident were evaluated and this child was the wrst hurt in the wn.
l'BYBICAL EIl\KINl\TIOOI Revealed an alert and oriented white female who was in
moderate to severe distress with pain about the left elbow region. She was
holdinq the el.bolo1 in aJ:xIuction and external rotation and I felt that she had a
supraccn:iylar fracture of the humerus. '!he el1:at itself appeared to be in
normal anatanic alilJl1lllBllt and the wrist was withoot awarent trauma. 'lhere
was sane minor abrasions of the left chin an:! of the head, tA1t otherwise,
there was no significant areas of tendernP.SS a.rourxl the head, chest, neck, or
al:danen.
'DU:l'd'ME2fr1 We did x-ray her cervical spine prior to removal of the devices
for ilrIoobilization and this was nonnal in my opinion. Dr. Hely was called
early on because of he was the orthopedic doctor on call an:! he came ~""t'Lly
to the department and OCIIpleted the secordary survey of the patient. ~ of
the sullsequent examination was at his direction. I did re-evaluate the
patient several times and she was in stable condition each tiJre. She was
qiven Haq:hine for pain and it was easier to examine follcwi.n;J this l:ut still
required a lot of ooaxi.rq to qet her arm back into a normal anatanic position.
Exl:ensive x-rays were taken and there was no aI:I1ormality of cervical spine,
chest, pelvis, el.bolo1 or the cr of the head all of which were read by the m
doctor exceptin:J the cr by Dr. Loh. 'l11e left humeral film did shows a m0der-
ately displaced fracture of the proximal humerus. I was able to J:'E!IOOVed the
child fran her lorq board and get the arm back into almost normal alignment
and eventually a s slin:J was placed at Dr. Hely's direction. We plan to admit
the child to this hospital tA1t because the patient's family was fran Palmyra,
they prefer to have her a Hershey. I did speak with Milton Hershey with bIo
of the doctors on the telephone and they will resume their care as a cllrect
admission to the intermediate care unit. 'lhe patient was stable after her cr
scan an:! was cUscharged by BlS aml::ulance to be admitted at Milton Hershey.
I'DlI\L DDIoGN:lSIBI M:ltor vehicle aocident with left humerus fracture an:!
cerebral concussion.
JGC/'r:ks
0: 10-17-93 2048 T: 10-19-93
CARLISLE HOSPITAL
EMERGENCY ROOK RECORD
@I~ l-bspital
Copyllghl 1992
NAME
ROOM'
VITAL SI
P
ALLERGIES:
CURRENT MEDICATIONS.
NURSING DOCUMENTATION - EMERGENCY DEPARTMENT
"~~ ::
BpI tp(
.
o Wilhln 5 Voa,.
o 5,10 Yea,.
o Morolhan 10 Vears
o Nevtr
.. TREATMENT IN PROGRESS ON ARRIVAL:
o CPR Down Tlmt min.
o AIrway - 0 Ofal, 0 ar:::1lze
o Airway, E eal Size
o Ai ,asolrache.1 Size
Solullon Sile Size
TETANUS STATUS:
LUnG 50._:
e NOrmal
e N1A
o Aal..
C Rhonchi
Pupil", ,. .
Righi. Sill
R,actlon _ 2, .
Lalt . Siz.
e N1A Reaction _ 2. .
.. INmAL NURSING INTERVIEW:
REASON FOR VISIT: [J T AUM
PAST MEDICAL HISTORY: 0
NT PROBLEM: Nursing Diagnosis
_ AlIW11 CSearance, IntnlKtNl
_Analoly
_ Ste.thing: Pan.ml. IntllKtivI
_ Cardiac Oulput. OKrauld
OthOt
OUTCOMEiGOAL: Eapeeled by Oiseha~e.
4. .
s. .
eo.
VI.u.1 Actl'4lty:
00
OS
TRIAGE NOTE:
Trl'OI Slalus: Mode of Arrival;
o Pnotlly I [J ALS [J BLS
o Prlorlly II a Ambulatory
o Prlorltv 111 0 WhOtllcl'lBlf
o Fill Trael< [J Carried
Chief Complaint ~ A
1illn
Onsal of Symploms.
Nursing Acllan/Comments:
Childhood Immunizallons. 0 TO
Trealment Prior 10 Arrival:
TRIAOE HURSE SIOHATUR
o Monilor - Rhythm Rail
~ .Oaygon - [J Mask, [J NC - UMin
ltV'Spinallmmobill:atlon,
o MaS!,
o Pressure Dressing 0 Other
[J Flushed
o Jaundiced
o Cool [J Ecchymosis,
o Clammy [J Rash,
ThoU9""
o Clu,/Spontaneous
a VagutlOilConnecltd
o OilOrienfed
o Slow 10 An.......r
o With Glas...
C Wllhout Qt.....
TIME:
[J PSVCHOSOCIAUEMOTIONAL
, .
NoncompUance
Self C.,a OerlOl
~lotI.AIleration'ln:
_ Communicallon Impaired
_ Copnq. Inetlectrve
_ FlUId Volume. Alleratlons In'
_ 0.. eachange, Impalrld
Ti.sue p,rlulion. All. In:
-
(l,~.
you)
_ Skin Inleorlty Impalrmenl
_ Thoughl Procu.... Alt In:
_ Hyperthermia (FI"''')
_ Inlettlon, Pollnlial
_ I"jury. PotenUaI
_ I<nowtedgl OIrlCit
_ Mobility Imp&lred
Oth,r
"l' .n"'r r: r.r.:.,"" .n~
o Dusky
Spoodl:
e NormaVCI..,
e 5.11"1
e Talkalive
e R.petltive
e Mumbtino
o HlA
LMP:
Data:
Arrived Wllh.
o Polico
o Parenl
o Self
o
M
DRUGS:
o Cyanollc
o Nailbods
o Clrcumo,aJ
(] Lac8ralion
o Edoma
Mlmory:
C InlKt
C Impaired
o Reclnt
o Dill.nI/Pa.1
8eJW
'ER~1f
~
o Friend
o Spouse
[J Othor
..
...
.
r
..
..
-
o
N OF CARE:
alnlaln Patlonl Airway
Monitor Cardiovascular Status
o IV [J BP Monitor
o EKG [J Cardiac Monllor
[J Saloly Moasures
o Rostralnts [J Suicide PI,"",utlon.
a Seizure P,ecaulions
o Side Ralls Up
[J Comfort Mo..uros
o Pain Control
o Posllion for Comlort
~ Propare lor Exam
.l'l Eaplain Procedures
j2I Emotional Support
./1 Palen! Teaching
2t Discharge Inslructlt.ns
[J Other
[J Other
o Olher
.- "'If'....
"
(
" IV FLUID: L- MEDICATIONS
Typo/AmI, IU, C.th. SI.I 11.... """""",, lied. 00.. floul. Time '~ Ilgn.lure
~ I?!f.s, I<;/'....... I 'In II P/(" RN1
/
/"
./
./
/
~EATMENT/PROCEDURES: " INTAKE: . OUTPUT:
o RESP. THERAPY TREATMENT IV PO ~
0 TIME TIM~ TIME Typo Ami. Typo AmI, Urine Em..l.
o OXYGEN LJMIN ~
o INTUBATION. SIZE T.......... ..,/"
o ABG'S TIME TIME ~TIME ......
o PULSE OX TIME ./ TIME ~
o AIRWAY, TYP~ /" TIME -/
o NASOGASTRI:~IZE TIME " NOTIFICA~~
o GASTRIC LAV' AMT o HOlpllal Social II o Family Doctor
'/ o Family C Coroner
- ~ATHETER' SIZE o PolICI ./ o Conluttant
TIME ~nl.rv.nl)on o Oth.,
A .OUT COLOR u,tlnog Home o 0Iht,
.. VITAL SIGNS. 0 ON Bp MONITOR
TIme UP P R NOTES:
o MANUAL
1~~m~N~i.r;r7~E
~
DISPOSITION: DISCHARGE:
o Adminld 10:
INSTRUCTIONS:
o FOI Obt,tvahon
"'.
~ T'.n.t.~ 10;
0"":: ~
PA~~E~T'S NAME1 .
o AmbuIalory
o Ambul.aIOry c Assislane.
e Whe,lchait
o Ambulanco
01"'"
o Sell
~Fam,ly
o Fri,nd
o Poilu
~ V luab! ,
o UTI
o Kidney 5100e
e Pelyiclnl.
a Sp,l.inIBruis.
o "'Ihm.a
o Other
o Other
NURSE'S SIGNATURE
. . '.
:
(
DEPARTMENT OF RADIOLOGY
. .
d:, Carlisle I-bspita1
~ 246 Parker Street. P.O. Sox 310. Ca,lislfl. Pennsylvania 17013-0310. 1-800-346-4769. (717)249'1212
CARLISLE IMAGING ASSOCIATES, P.C.
ORLOUSKY, JENNIFER E, (10)
ROU BOX 431A
PALMYRA, PA
10/17/93
110521
OR. WILLARD (8R)
DR. HBLY
M. R, '697644
CERVICAL SPINE, CHEST, LBPT SHOULDER AND PBLVIS
AP and cross table lateral views of the cervical Ipine are
performed only. The study is limited because of motion on the
lateral view. The vertebral alignment i8 normal. The vertebral
bodies and interspaces are normal and the associated appendage.
show no abnormality. The soft tissue in the neck il normal Ind
there are no cervical ribs.
Single supine examination of the chest showl thlt the heart i.
normal in size and configuration. The pulmonary va.cularity i.
normal. There is no active parenchymal or pleural di..I.e. The
bony thorax is within normal limits. AP and aXillary viewl of
the left shoulder show comminuted displaced fracture through the
proximal humeral meta-diaphysis. The fractured major diltal
fragment is slightly displaced anteriorly. No additional
fracture or dislocation is noted. No significant loft tis.ut
abnormality is seen.
Single AP view of the pelvis and hips reveal no fracture,
dislocation or other bony abnormality. ~he joint. appear normal
and no significant soft tissue abnormality is noted.
IMPRESSION:
Negative limited views of the cervical spine.
Negative supine chest,
Comminuted displaced fracture, left proximal
humeral meta-diaphysis,
Negative AP pelvis and hips,
CKL/cc
0-10/17/93 2028
T-10/18/93 0913
Charles K, Loll, M,O.
~
r~^n~ rll,',('lr,..,
.
"
,-
(
-
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'-
-'
@Carlise I-mpital
CON.~ TO BOIPITAL AnNIIIION AND
Ill!iDICAL TIUATMIMT
Mame of Att.ndin~ Phy.ici.n (.).
D.t. of AcSl1liuion. JD-/7-q3
Time.
(P.H)_(PK)_
1. I, (or .cUn9 on b.h.lf of)
J N.-. Of AutMrIMoI ..... ,,-..""
.enn/-k-r 0 (' JoUS)C 'f ' .uft.dn~ troaa a condition nquir1n~ hOlpital car., har.b:
N.-. 01 ~
con.ent to r.nd.rln~ ot .uch c.r., whlch m.y includ. routine dl.9no.tlc proc.dur.. .nd .uc:
..dlcal tr..tment .. the nam.d .tt.ndin~ phy.lcl.n(.) or oth.r ot the ho.plt.l'. ..die.
.t.tf con.id.r to b. n.c....ry.
2. I und.r.t.nd that the practlc. of m.dicin. .nd .ur~.ry i. not .n ...ct .ciance an.
th.t dl.~no.i. .nd tr.atm.nt lII.y involve riek. ot injury, or .ven de.th. I .clulowlad9. the
no ~u.r.nte.. have b..n m.de to me .. to the r..ult of .xamin.tion or tr..tment durin~ thi
ho.pltali.ation.
3. I und.r.t.nd that.
(A) It i. cu.tomary, ab..nt emerg.ncy or .xtraDrdin.ry circum.t.nc.., th.t n
.ub.t.nti.l proc.dur.. .1'. pertorm.d upon . pati.nt unl... and until h. 0
.h. h.. had an opportunity to di.cu.. th.m with tha phy.ician or oth.
h..lth prot...ional to the pati.nt'. ..ti.taction,
(S) Z.ch pati.nt h.. the right to con.ant, or to r.fu.. con.ant, to .n
propo.ad proc.dur. or th.r.peutic cour.a, .nd
Ie) 110 pati.nt will b. involv.d in .ny r....rch or .xp.rimant.l proc.dur
~ithout hi. or h.r tull knowl.d9a and con..nt.
4. I undar.t.nd th.t m.ny of th. phy.ici.n. on the .t.ff of thi. ho.pit.l, includin
the att.nding phy.lcian(.) named .bov., ar. not .mploy.a. or a9.nt. of the ho.pit.l but
rath.r, ar. ind.pendent contractor. who h.v. b..n gr.nt.d the privil.g. of udng it
f.ciliti.. tor the car. and tr.atm.nt of their patiant.. rurther, I raali.. th.t amon~ tho.
who attend patient. .t thi. ho.pital .1'. medic.l, nur.ing, and oth.r ha.lth c.r. par.onn.
in tr.ining who, unl... r.qu..t.d oth.rwi.., m.y b. pr...nt during p.ti.nt c.r. .. . p.rt 0
th.ir .duc.tion. Still or motion picture. .nd clond circuit tDl.vhion monitoring 0
pati.nt c.re .1.0 may b. u.ad tar .duc.tion.l purpoI.. or far documentation of the clinica
cour.. unl... . pati.nt .xpr...ly r.qu..t. oth.rwi...
5. I 1'.1.... CARLIILI .OIPI~AL from all r..ponlibility tor all .rticl.. which I I
r.taining' or will have with m. during my .tay at the ho.pitll. I und.r.tand thi. includl
clothing, bridg.work, fal.. t..th, .y.gl....., j.w.lry, mon.y, r.dio, ra.or or .ny oth.r ita
k.pt in my po.....ion. I und.r.t.nd I may depodt v.lu.bl.. in a .at. provid.d by th
ho.pital, only it thh ia don. will the hoapit.l ...um. any r..pondbility tor th
.at.k..ping.
6. I h.r.by acknowledge that I have receiv.d writt.n intor1llation on the topic. e
pati.nt Right. and Adv.nc. ~ir.ctlve..
Dat. of Signatur.. 1 0 -I -, ~ q ~
(SIOIIATURE or PATIENT) (SIGNATURE or WITNESS)
(If pati.nt i. unable to eonaent or i. a minor, complete the tollowing.)
Patient (i. . minor ____ yell'. ot age) (i. unable to eon.ent becau.. I
.x iOo/).} .~~
" (SIGNATIfRB or LEGAL GU AM OR
CLOSEST AVAILABLE RELATIVE)
M' n115 f1(l/911
/ . MARl~ ClAIM omc! I.
_'<_.' ' 04SnANltDRIYIIUITIIOOO
, IIARlbRUIO fA 11/1J
PIIONE NUMBER, 111.5411-1500
OffiCE 1I0URS, MONDAY.FRIDAY ':00-4:30
November 16, 1993
(
'A II state" "
You're InPMI~.
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S7y
S$'()
HEDICAL RECORDS DEPARnlENT
UNIVERSITY HOSPITAL
PO BOX 850
HERSHEY PA 17033
. Claim Nwnbor:
Loss Date:
Our Insured:
Location:
Claimant:
1551/.29903 B26
OCTOBER 17. 1993
JOHN Ii SNYDER
I 81, CARLISLE
JENNIFER ORLOUSKY
Dear Roeords Dopt,:
P~~,,/t1
/'
Please send me copies of roeords on Jonnifer Orlousky, Ploase include face
sheets, e.r. reeords, radiology, lab, consultation, & operative reports,
historY/physieal exams, & hospital & diseharge summaries. A signed
authorization is enclosed, Thank you in advance for your cooperation,
Sineerely,
ptJJ I ~
HICHAEL DONAHUE
Claim Department
SHOO:Ol/O/Ol/l
1 Enclosure
~
~~~~
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~~~
~~ <k <:>
~~ 'B>
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'PENNSTATE
. ~~:i::'I ColI~g~ of M~dicin~
. Univ~rsily Ilmpilal'Children's Illlspilal
The Milton S. lIershey Medil:al Celllcr
P.O, BOX 850 HERSHEY. PENNSYLVANIA 17033
RE: ORLUSKY, Jennifer
NARRATIVE SlIHNARY
PATIENT NUMBER: '594550
DATE OF AOMISSION: 17 October 1993
AOMISSION OIAGNOSIS:
1. Closed head Injury,
2. Left humerus fracture,
DATE OF DISCHARGE: 18 October 1993
I
DISCHARGE DIAGNOSIS:
1. Closed head Injury.
2, Left humerus fracture,
OPERATIONS OR PROCEDURES:
None.
BRIEF HISTORY: This Is a 10-year-01d white female who was the unrestrained
passenger In a van which was rearended by a car on an interstate highway,
The patient was reportedly ejected and suffered loss of consciousness at the
scene. She was evaluated at Carlisle Hospital and transferred to The Milton
S, Hershey Medical Center for further evaluation.
On physical exam here at Hershey Medical Center, she was found to be
neurologically intact, alert, and appropriate, Her vital signs were stable.
Physical exam revealed evidence of a left proximal humerus fracture with
normal neurovascular exam. The patient had x-rays done at this hospital
including a chest x-ray, cervical spine series, and pelvis x-rays. These
were all within normal limits. Her CAT scan of the head which was performed
at Carlisle Hospital was negative for intracerebral bleeds or edema and her
laboratory work Included coagulation parameters, liver function tests,
amylase, and lipase, a hematocrit of 35, and a white count of 17 with normal
electrolytes.
HOSPITAL COURSE: The patient was admitted to the Intermediate Care Unit and
observed overnight. She did well without any evidence of neurologic
disease. She had minimal pain in her arm controlled with oral pain
medication. On hospital day number two, she was able to eat a regu1ar,diet
and ambulate without difficulty, The pediatric orthopedic physicians were
consulted and recommend a slin9 or swath to the patient's left arm. She will
be discharged to the care of her family with instructions to return to the
Orthopedic Surgery as well as the Pediatric Surgery Clinic within the next
few weeks.
Her discharge medications Include only Tylenol on a p.r,n, basis and a
prescription for Tylenol with codeine elixir will be given to the patient's
rQUAl OPPOIU'..ljlt, ""IAU,HI'I( "C'IO'4 rMltlOUR
.
. ,
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PEN NSTATE
,
(
;; College of Medicine
UnivmilY Hospilal' Children's Hospilal
The Millon S, Hershey Medical Celller
00594550
1260-101793
ORLOUSKI,JENNIFER
14-Jul-83
EMER
R.llhlllngy S~r\"lP.:~'i
I',(). OU\ MSIl
Her,hey, Penn\ylvania 17033
Date of Exam: 17-0ct-93
MARK A BATES MD
EMERGENCY DEPARTMENT
HMC,
Exam: OX PORT CHEST - AP , SEMIER, INSP, PORT,
Exam: OX C-SPINE 2-3 VIEWS - LAT, XTAB, SUPINE, AP , POR
AP PORTABLE CHEST AT 2215 HOURS AND CERVICAL SPINE
CLINICAL HISTORY: Motor vehicle accident.
DISCUSSION: There are no prior films for comparison.
AP PORTABLE FILM OF CHEST AT 2215 HOURS: The cardiomediastinal
silhouette is within normal limits. The lungs are clear. The soft
tissues are normal. There is an undisplaced transverse fracture of
the left humerus. The remainder of the bony structures are within
normal limits.
CERVICAL SPINE: All seven cervical vertebrae are well seen. The
alignment of the cervical spine is normal. There is no evidence of
fracture or dislocation. The soft tissues are within normal
limits. The visualized calvarium and mandible are within normal
limits.
IMPRESSION:
1. Normal chest.
2. There is an undisplaced fracture of the proximal left humerus.
3. Normal cervical spine.
MTD/djr
Dictated: MARIA T. DEVER, M.D.
Reviewed & Signed: THELMA QUIOGUE, M.D.
DICTATED:
TRANSCRIBED: 19-0ct-93 SIGNED: 20-0ct-93
OC120 -
An EquJI OpplJr'lunuy Um",cI"lll)'
.
PENNSTATE CI ~t ov. -sk.. i I'~ J(.(' ~ J'R..{
. . " Colk~o or M~" 'no
Univo"ilY Hu,pllal' Ch, ,n', Hmpilal
I Tho Milton S, llo"hoy ~kdi"al Conlor -# '5Q ((5$ 0
~ PROGRESS REPORT
DATE TIME PROGRESS NOTES 0 INPATIENT o OUTPA T1ENT NAME. TITLE
.Y'/.?a-123 ;5, II. 4},~t1 h J.,,/lCvJ ., J .tf"V/>f
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PROGRESS REPORT
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-~'. (: ..:,....
to . .. I" t- ... ~ .. ~ ,. t: -.'" ... .....
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... .. .. .... .." ;... ,... ,,4., .. I'."
..~...J.-:::PJ- MEt-I
'"
.' .
;:'~GE
o::~:c:~: :c:
PENNSTATE
. L'ull"~. uf 1'1 ',,,.
Uni.."ily Hu'pilal' C. "en', Hospilal
The M,ll"" S, Hmhey M.d,cal Cenler
AMBULATORY HEALTH VISITPLD3 SURGERY
=t ';", L\S ~ . . CjtQ5U
\-\ ch<T lY\ a () '" \,\'0 -'c -a
I ~.)).'~-%-E
1\'
o Health Maintenance
Referred by' Addr8ss:
Nunlng
o Consultation
o Acute Care
o Follow.up
Medlcallons'ODsage
1,
2,
3,
4,
5,
:,.
a",\,...... ,..,..c.. ."'b
51:? 7 .s, a....c...._~t.~ CL4 .
~ll'>'i)' . "''''',
-ne AlL/ll~
c.f/:l
C. SUbJective
1. t.j~ .............
2, hI..., l A :i!~- ...........
.
3, F' b...-J.-
u- .........rk'
4.
C 5. ,..LL u.....
-r. GIIHN 111
Signature
~(. I, f......'- <::) 4.J.. - ............ c!-(:L. .
~ J....
.2., u.~ es,..;.J.. ~_w
r1 "'-- ....-~ ..J
ObJective:
Vital Signs:
Measurements:
00 RO AlIO
em, %
(
~t.L.L .
.j., ;..,J Jl ''d
4 L" - .......:L
. .
~.......~l.
..........l--.L
I~
l-_
,j
(!;;) &- J... J,.....'_ .
,..J,J..- ~,
l
Lab
AssessmenllDlagnosls'Plan J
'4~ ,_.
1, ~~~_ I I-- J.-
2, 'J
3,
4.
5,
Next visit:
SIGNAT
)...A,/,I....-.-.......i..n-.",~
e/,. t..J........
ATTENDING
,
J.,.)I &-....~...J
OSee dictallon I 0 Lener!o M.O,
DATE _~.l-lgIME
MAlS7 4185
AMBULATORY HEALTH VISIT
@/ carlisle lb.1>ita!
'L~I
(
246 Park.r 51,..1
C..II.I., PA 17013.0310
(717) 245-5500 EMERGEN'
REGISTRATI
6976181
,
10/17/93
,
,.. CI."T NO
,w
E.
JllIoI'l",IIO'H,AIW'\O.lA
6Y F W S
02125/87
000-00-0000
PALYtlRA, PA
'. '1.~ "i<i". ., .;. .
, , I LA ION I .,
HOFFHAN. ROGER L.
RD 1 131A
17078
183-16-':>802
GUAAAN S 1IrMo\.000IA
RITE AID COF:F'
HILL, f'A 170911
,,.
17078
I PHOfC ~ Rt'LATlO"" $OC.Me.NO
(loll (HeY NO".
HOFFMAN, DIANE
(717)'16':>-78'16
. 18
~
L.
18
"""""HI
, WILLIS W
EMERG VISIT 0005 28800 CAST ROLL. SCOTCH 28081 ALL ADDITIONAL CHARGES
EMERG VISIT 0610 28805 EKG MONITOR 28042 :- ~J:--
EMERG VISIT 1115 28810 EXTERNAL PACER 28045
I II
EMERG VISIT 182~ 28815 PACER PADS 79064 "----- -.) "--
EMERG VISIT 2640 28620 GASTRO/HEMO SUDE 26060 r -"'I r
EMERG VISIT KIDDE TOURNIOUET 26046 I II
4155 28625 I II
EMERG VISIT 5865 28830 OCL PER FOOT 79670 I II
"- -')"--
EMERG VISIT CLASS 8 28635 F,S,B5. 80061 r -"'I r
06SERVATION, EACH HR 26017 SUTURE PER PACK 28073 I II
I II
PRIVATE EXAM CHARGE 28010 TUBE GAUZE PER FOOT 28074 I II
EMPlOYEE HEALTH VISIT "- -.) "-
28018 ALL ADDITIONAL CHARGES r ---"'Ir--
LIGHT SOURCE FOR SPECULUM 28845 I 1 11
I I II
ALl. VAGINAL SPECULUM 80088 I II 11
INJECTION FEE 28009 I... .)"- -.)"-
f" "'Ir -"'I f" -- --
BIP MONITOO 28037 I 11 II
CAST, SCOTCH SHORT ARM 28031 I II II
I 11 II
CAST. SCOTCH LONG ARM 28032 I... .)"- -.)"-
f" "'If" "'Ir - - --..
CAST, SCOTCH SHORT LEG 28033
1 II II
CA$T, SCOTCH LONG LEG 28034 I II II
I II II
CAST, CYLNDR LEG 28030 \.. .)"- ')"--
ER.O~06IREV 8/9
JWlZI 1klrtrMn, J(iysta E.
MIll I 032295
Dlftl 10-17-93
-'
(
~ IOJ( IlIXXIlD
ou.d' CCIG'IJUNl'I Hctar vehicle aocident.
JWnUtY 011 ~ nua:ssl 'l1Us 6-year-old ferale was the ~ in a van
with JII1ltiple sibli.n:]s. '1110 van was struek in the rear ard the children wre
catap.1lted cut the back door onto the grass am pavement. '!be child was not
unconscious, probably alt:hcO:lh she was not closely ol:;serWd ol:Niously. She
aw""red to have Mly minor injurielJ at the time or arrival in the ~
oepartment b1t by the time I evaluated her, she was OCITPla~ or nausea ard
vanited Q'lOB.
1'IMJXCM. J!lDKDlM'IClU 'l1Us is an alert white remale wtv;) is 0:.. "..., ative ani
not in ao..rt:a disL.. ~.. alt:hcO:lh she is nauseated, pale, ard~' '!be
heart ani lW"l;lS are clear. '!be al:xlaneJl is soft ard totally ~. '!be
d'IeSt is ~. 'lbere is no visible injury with the eio::eptia'\ of a slight
ccntused area un:ler the left sids of the chin. '!be neck is ei1t1rely lIURlle
am haS fUll painless rarge of tWtia'\ up to about 110' of rotatia'\ left ani
right. She haS no aI::n:lrlIli!lity of the eXtremities. 'lbe neurological exam is
withcA1t focal firdJ,rq. '1110 t}onpanic l\'IE!INJral'll are normal bilaterally. 'lbe
plPils are equal, J;O.Jni, an:! reactive.
~I No tliagncGtic sbJd,ies were done b.1t the patient vanited Q'lOB again
ani was given a ~ SlW""itory. She 0()Iltinued to vanit al8 IIm'8 time.
BeCause or concern for possible intracranial injury, a cr scan of the he8d was
orderEd. 'l1Us was reported as normal by Dr. Lch. 'lbe family lives in Pa]myra
and this child haS siblin;J wtv;) will be hoSPitalized follCMin;J a fractured arm
and possible loss of c:onsci~ also. I felt that this child warranted
oI:l6eI'Vl\tia'\ in the hoSPital for c;erebral ooncussia'\, b1t be"""'" the children
were not stayin;J at this institutia'\, I spoke with Dr. BurIchArt at HerSheY to
obtain wmiA..ion there for the children. At this time, 10/9 are waiting for a
call back fran h.illl ard the child is stable.
rnw. DDQUlISI Hctar vehicle aocident. Cerebral CCJI'OlSSia'\.
JGC/'tj{S
D: 10-17-93 2023
T: 10-19-93
CARLISLE HOSPITAL
EMERGENCY ROOK RECORD
@/~ Jbspital
Copy'lQhl .992
(
NURSING DOCUMENTATION - EMERGENCY DEPARTMENT
ER 2010 1"2)
TRIAGE NOTE:
Triage Status:
CJ Priorlly I
o Prlorlly II
50 Priority III
r 0 Fasl T'ack
Chial Complainl.
NAME y~ L~-
ROOM~EU U WT, 9
VI::L SIGNS ME R .at> TBP ~~~i
ALLERGIES..J..J (
CURRENT MEDICATIONS.
~Wilhln 5 Vaa,s
(0 5-10 Vura
o Mnre 'han 10 Vurs
o Naver
. TREATMENT IN PROGRESS ON ARRIVAL:
o CPR Down Time min.
o AIrway - 0 Oral. Nasal - Sin
o Airway, Endo',acheal Size
o Airway. Naso',acheal Iza
o IV Solullon
= GENERAL APPEARANCE
PULSE<"
8""'Ffegula,
o Full
RE$P:
~ormal
o Irregular
o Weak
o Shallow 0 Rapid 0 Audible
o Daap 0 Slow Wh.eze
o Labored 0 SI,ldor 0 Rel,acllona
Luna Sound.: FbQht; C R.les 0 Wh.,,, ....nl.1 A..nsmenl:
o tformaJ 0 Rhonchi 0 Abunl ~6Ct'
q".)efA Lift: top'i'"
o Aal.. 0 Wheeze
o AI\Ond\I 0 Absent 0 BlunledlF~1
o Oelensive
o Appt.henlMl
o AeaUlal/Combati.,,1
TETANUS STATUS.
Pupil.: 1- .
Righi, SIze
R.action _ 2. .
leh. Size
D NJA R..clion _ 3. .
= INmAL NURSING INTERVIEW:
REASON FOR VISIT: 0 TRAUMA
PAST MEDICAL HISTORV:
Mode 01 Amv.V
o ALS p1iLS
o Amtluialory
o Wheolchalr
o Carr'ad
,/ff}1 L:#i-
Onsel 01 Symploms.
Nursing ActlonlCommllntl:
Childhood Immunizations. 0 UTO
Treatment Prior 10 AmVI!:
TRIAOE NURSE SIGNATURE
10
Size
a Monitor-
o Oxygan - 0 k, 0 NC
~'
inallmmobllizatio ,
Mast,
a Pressurs Cressing 0 Other
o O'he,
COLOR:
lJ Good , i 0, Flushed
o-Pale ~ Jaundiced
o Cool 0 Ecchymosis,
o Clammy 0 Rash.
~
~
4- .
5. .
0- .
Tho h'
.11ISponlaneou.
Vagu8l0jlCOnnecl~
o OiSOfi,nled
o Slow 10 AnsWlr
Visual Activity:
00
OS
o Wilh GlalSotS
o Wilhou1 Gtusl.
TIME:
o MEDICAL 0 PSVCHOSOCIAUEMOTIONAL
Va:.;a~UrylHiSIOry 01 Pres.nlllln... (Whatlh. pali.n I.lls you).
,
PATIENT PROBLEM: Nursing Diagnosis
_ Airway CI.aranee, lnertecUvl
_Anxl.ty
_ Bllllh1no Panern., lnertectlv.
_ Cardiac Oulput, Decreased
Other
OUTCOME/GOAL. Expecled by Di.charga:
.1
.2
.3
18 to see).
_ NoncomplIance
_ Setf Care Deficit
_ Comlort. Altelations In:
_ Communicalion ImpUld
_ CoPno, lne"ectlv.
_ Fluid Volume. Allerabonsln;
_ aas exchange. Imparred
Tissue PerfUSIOn, An. '"
_ Skin Inlogrlly Impairment
_ ThoUOhl P,ocesses. M. In:
_J;typerthermla (FIVefI
L!nloclion, Pelef'ttial
_ Inlury. Pel.nli"
_ Knowledge DeOo1
_ Mobliry Impaired
Oth.r
Cl (I
~J"n"'~ ~ C ...,.....;"1"
Dlte:
Arrivod Wil
o Pollee
o Parenl
o Sell
o F,'and
o Spausa
o Orh.r
~"
.;'
. - t4J1~
o No....'
Ral.
Win
\
"-
'-
o Dusky
o Cyanollc
o Naiibed.
o ClrClJmoraJ
o lacerallon
OEdema
..
..
..
~.
o NQmlllfCI..r
o Siltnt
o Talk.lliv.
o A.pellIlV.
o Mumbling
r~l1t I" ----
o Intact
o Impaired
C Recent
o 01111nllP111
..
I.
..
~
LMP:
..
p
..
PLAN OF CARE:
o Malnlain Pallent Airway
Monilor Cardiovascular StatuI
o IV 0 BP Monllor
o EKG 0 Cardiac Monllor
o Salely Measur.a
o Res'ralnls 0 Suicide P,ecauliona
o Seizure Precaullons
o Side Raiis Up
o Comfort Measures
o Pain Conlrol
o Position for Comlar1
o P,opa,e lor Exam
o Ellplain Procedure.
o Emolional suppon
o Palanl Tuchlng
o Dlscharg. In,lNcllan,
o Olhe'
o Olh..
o Olhe'
~ fj.",H
~- (
. IV FLUID: . MEDICATIONS
- b.
TrP"Am.. III. C.'h, Sill TI9' Slgn,lurt Mod, 0... Roul. Tim. Slgn.lUr.
'I - /01, ~ .-; '1- /Y5d' IJrA? _
7 , .- ,
./
./ -
-,.,
./
./
~~ATMENT/PROCEDUAES: ... . INTAKE: . OUTPUT:
CJ A5SP. THERAPY TREATMENT / IV PO ;/
CJ TIME TIME TIME ./' Trpo Ami. Typo Ami. Urine ~ CIllo'
CJ OXYOEN WIN ./
CJ INTUBATION, SIZE Aj'ME ./
CJ ABO'S TIME TIME "/ TIME /
CJ PULSE OX TIME /TIME ./
CJ AIRWAY, TYpo ../ TIME
CJ NASOOASTRI~;:-~~ TIME = NOTIFICA~
CJ OASTRIC LA~ AMT o tiolplt.1 SOcIII It a Famlty Ooc1Of
o Flmlty o COrOMr
CJ FOl~HETER. SIZE C Pollc. ./ o Cantull."t
TIME ~~l.rv.nhon a ~h.,
~T COLOR o Ulli~ Hom. o Other
.. VITAL SIGNS. CJ
ON Bp MONITOR
A NOTES:
TIme
BP
P
.. EVALUATION AND DISCHA
DISPOSITION: DISCH GE:
a Admintd 10: 0 AmOOI.tory
o AmbulAtory c A..ill.nce
o Wheelchair
o Ambulaneo
CIllo.
o For Oburv.Uon
...
>' Tl/:.,.rttd 10<:
m
o Morgu. -f
PATIENT'S NAME 4~
CJ MANUAL
o Sell
a Family
o Friend
o POl~.
o Valuables
~
~
o Chill
o Crutch..
o Abd. Problem
o Wound ColI'
o Clea' llQOd
o Fev.,
o URI
o UTI
o Kidney Sian,
OP'lviClnl'j
o Sptlirva,u1se
o ",lhm.
o QCUCast
nc
CT
o Other
o Other
NURSE'S SIGNATURE
,
"
1 ,
. .
(
'-
@/ C'ariise I-bspital
COW'INT TO IO..ITAL ADMI..IOH AXD
IIEDICAL TRUoTKKH'r
Nam. at Att.ndlng Phy.lci.n (.)1
D.t. at Aclnlluiont I 6 - I r -9 <.,
Tlm.t
IAH)_IPH)_
1. I, lor .ctlng on b.halt at)
, J rJ'l N... 01 AoOon... 1....-IoU..
k r'-1 t;.-/. Q ~I:f()-""'~ ,.utt.ring trom. condltion requiring ho.pltal car., h.reby
N-. ot hd.I
con..nt to r.nd.rlng at .uch c.r., which m.y includ. rout In. di.gno.tlo proc.dur.. .nd .uch
medical tr..tment .. the n&m.d .tt.nding phy.lcl.nl') or oth.r at the ho.pltal'. m.dic.l
.t.tt con.ld.r to b. n.c....ry.
2. I und.r.t.nd th.t th. pr.ctlc. ot m.dlclne .nd .urg.ry 1. not .n .x.ct .cl.nce .nd
th.t dl.gno.l. and tr..tm.nt m.y lnvolv. rl.k. ot lnjury, or .v.n d..th. I acknowl.dg. th.t
no guarant... h.v. b..n mAd. to me .. to the re.ult ot examln.tlon or tr..tment durlng thl.
ho.pltallzatlon,
3. I und.r.t.nd th.t,
It 1. cu.tom.ry, .b..nt .mergency or extr.ordln.ry clrcum.tanc.., that no
.ub.t.nthl proc.dur.. .r. pertorm.d upon. p.tl.nt un 1... and untl1 h. or
.he h.. h.d .n opportunlty to dl.cu.. th.m wlth the phy.lcl.n or oth.r
he.lth prot...lon.l to the p.tlent'. ..tl.t.ctlon,
E.ch p.tl.nt h.. th. right to con.ent, or to retu.. con..nt, to .ny
propo..d proc.dur. or th.r.p.utlc cour.., .nd
No p.tient will b. lnvolved ln .ny re..arch or .xp.rim.ntal procedure
wlthout hi. or h.r full knowledge .nd con..nt.
.. I und.ratand that m.ny of the phy.icl.na on the .tatt ot thi. ho.plt.l, including
the .ttendlng phy.lc1.n(.) named Abov., are not employee. or ag.nt. of the hoap1t.l but,
rath.r, ar. lndapendent contractor. who have been grant.d the prlvil.g. at u.1ng it.
t.cilitl.. tor the c.r. .nd trutm.nt of th.lr patient.. Further, I reaUz. th.t among tho.e
who .ttend p.tlent. at thl. ho.pit.l .r. medlc.l, nur.ing, .nd other h.alth c.re per.onnel
ln trainlng who, unle.. r.qu..t.d oth.rwi.., may be pre.ent durlng p.t1.nt c.re .. a part at
thelr educ.tion. StLll or DIOtion picture. and cloeed clrcuit t.levldon IIlOnitoring at
patl.nt care alao m.y b. u..d tor .duc.tlonal purpo.e. or tor document.tion ot the olinic.l
courae unl... . p.tient .xpre..ly r.qu..t. otherwie..
IA)
(8)
Ie)
5. I releaa. CARLllLE IO'.ITAL trom all reepon.ibl1lty tor .11 .rticl.. which I am
r.t.ining'or will have with ma during my .tay at the ho.pit.l. I under.t.nd thi. includ..
Clothing, bridgework, talle te.th, .y.gl....., jewelry, money, r.dio, r.zor or .ny oth.r it"
kept in my po..eBdon. I underatand I may depoBit valuable. in . ufe provided by th.
ho.pital, only it thh h done will the hoopital a...ume any re.pondbility tor th.
.atekeeping.
6. I hereby acknowledge that I have recelved written intorm.tlDn on th. topic. ot
P.tient Right. and Adv.nce Dir.ctive..
D.te at Slgnature.
, () - II -q.3
I
(SIONATURE or PATIENT)
(SIONATURE or WITNESS)
lIt patient ie unable to conoont or io . minor, complote tho tollowing.)
P.tient [i. a minor ____ yoarB of ago) (i. unable to conoent becauBe).
u...A--
~-.
. ..
o () 0, () '0
~ Carlisle Hospital
/ .~
PATIENT'S NAME: ~f/;i-~ ~~C2
INSURANCE CO/" j~a~ ' -/ ;'A..~A (I ;~'l (y (' '(\ l A.; ~"
Slalemenl 10 Permit Ihe Release of Medical Information and Pavment of Medicare Bnd/or
Other Health Insurance Benefit~ a,ntlor phvsician,
. ,
" ~
"
I aUlhorize Carlisle Hospital as the holder oPmedieBI information perlaining to me 10
release the neeessary and appropriale medieal informalion to the fiscal intermediary of Ihe
Social Sceurity Adminislralion and/or 10 my primary or supplemenlal heallh insuranee
company or ii'S designaled rtview ageney for 'Paymenl for services rendered,
.,
I authorize Ihe Carlisle Hospital's and/or the physician's billing agent to submil a
claim 10 Medicare or other health insuran~e on my behalf, or 10 request, on a one time
only basis, from the Soeial SeeurilY Administration, such information necessary to complete
the claim submission proeess,
'-,
-
I am the individual to whom the information/record pertains, or am authorized to
consent, on behalf of the individual. to Ihe release of the information/record, I understand
that' any false statemenl or representation knowingly and willfully made or caused to be
made for use in determining rights to Medieare benefits or payments may be punishable by
a fine of not more Ihan S 10.000.00 or one year in prison, or both,
I request that payment of authorized benefits be made on my behalf.
I assign the paymenl of inpatient or outpalient hospital benefits 10 Carlisle Hospilal
for those services provided by Carlisle Hospital and/or I assign the benefil payable for phy-
sician services 10 the physician,
I certify that the information given by me in applying for payment of serviecs under
Title XVlII of the Social Security Aet or for any/all other health insurance is correct
Patient's Signature
SSN
Oats
Responsible Party It Palient Unable to Sign
./fl/ a~ (J . )j~ ..h--,
Insure~~on's Signature U Tf .' .
(It dillerent from patienl or if patient is a minor,)
Relationship
Date
/o~ / /. 73>
Date
Reason Pallent eould nol sign,
JL
Wilness
White Copy - Hcallhcare Billing
Canary Copy - Medical Reeords I Aneillary DepartmenlJ
AD 1825 ( 10/9;
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.......
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EMERGENCV CARE UrI l(ArMENT FQIlM ,".I'f'5ICtA~ AHORD 'ART l 0' 11
"I'\I"m", I 0", J,.m. ' ..To;; ["m. D.'''; -----ri."" ,,,.;;;;;;;- I
594579 I 10/10/93 1020 I 999-59-4579
;111'"' Herne Ol'e of .'"'" I Ai' IS..
HOrFMAN, MELISSA C 07/2S/91 1 ~r r
~'I,,1'l1 Add'I" N,_, o,c,,,
PRIMARY PHYSICIAN
200646
11m"II'''CY C... PlIo
W "'hu,on I "'1',1; 51th,. (I 7)0
r'
A.eI
I
r~OI (11);( 4:SIH
HOFFMM-l, I"\OGEr,
\:'ALMYf(':,
1 Add'...
PA 170701 RDl BOX 431H
51",ll,p
e""
rll"nl""OAtIHIol"'Mf
PALMiRA
Tlllphon, I
717-'169-7044
,..I5IHT MIDtCAnoH
717-469-7846
1I0loll"'ly'
FATHEr<
PA 17078
1""/111'10 I ,,.,,,.,y phytoC.,"
MOdI of "'"IIlO,"IIO"
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C..
Ch..ICor'I'Ip!.,nl
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coptl'
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09629 MeeO) , ANDREA C
HMC "U.ndlng M 0
.6030 BATES, M~RK A
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V,ltl II 1 VIIU,I
SllIn' 0 "eclll I I I I Acu,ty
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0ll,I01'l9,nOl
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T'I'O'~loltl,Slllnllloltl /
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Oun'bla
ToRlleh
TIME
DoeTDR'S ORDERS
TIME
NUASI~O ACTION, PAOOAESS NOTES. a. SIONATURE
D"d'
O C"dlac
MonItor
o Adlol11
/oJtJ -J" V II, W,,(O ~LP# ~ C"e ~ /.(. H<< -
~~mv// ./t'/?~.:I -~......- ~ ~
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t ~""''''A. ,1('\ -tflA, ~. ff, rl r' c: \0-. (fL
rlilM fl.-. TO -j,( };'-;::{.'1 f rWL c: ", ~&\ r1l
I A..... n, ~ c?rz) r{/ l.l.J^' 0 ....,,/
f\ (-?-A-n,-t.l.,~(fI'~
(
o.pl'lll'llf.'
TlllnlollO~elM
Tim,
01-1 Nloltlll'lO
Ou,'n. 0
CIS Amyl'l'
0:' D~:r Dlu.No
OU"
0'"
,n.
~.LJ
..t'_
t!-L ~..."4
IL~~ .., ~-
DOlucol.
O Chili
)C...,.,
Dcrll'inin'
Ai
OeBC
DItUB,
)C.R..,
DOlI!
0,,_11,0.
O",Q,
ICJ~
(f~O
./ ./
COI'Il\lll,no
5"""(1 CIUad'
Tima
A"'ved'
Ph.,ll(i,n
~Qn'lura
Continu.d on Prog"" RlCord DYES
N.urological 0
EVAlu'lion Check ll,. YES
C'rdi,c Arterl,l
Monllor lIn.
~1O'.d'" I
o hv.' 0 Impet'oo
o 0.,"",,,. 0 011111
Vom,,,"O 0 II", "'1'1
o PI" Cold 0 CMe"
o Abet, "In W...,no
CJ Uti""" 0 CII' C,"
Tlte''''' nlp'111I11
Tlma Timp ",,,I,, RIIP II ,
CVP
i
I
i NUl"
R "'altl.(h"9
I
o SO"ln,$oll
T,Uullnlloll'l'
o Hud Injury
o Wound C..,
o 1l1ol'" C.,.
Dh.
EMERGENCY CARE UNIT TREATMENT FORM cfim ~ck#~
~nh.Y
~
O"'114~r~J
'Hadle.l Centu,
Emergeney Room,
~
.
TRIAGE ASSESSHEHT
/4.j,{l,
c '_~ :::. Ci It C; ... q 3 2 q 1
lime;
. I
~ ': I f ~ l 'I. " ELI j ~ 1 C
: 7'.';11 HI r
z. r' t .. [ ';'
'I'
....left. NAmtI
,0 /;,..,....",
I?h_h '$ s",-, "'Y"I'
Patient Hospital Number
All....... Phy"c""
tutU d tn" /:
All.......
"pC/V- /hd.,.A~rj,
a//~ ':j"'t',
C..rtn. Medlcatlonll
;If I"?f-L. '
.Iy/"""'/ #dldrl.',S (j) dfro'
T...... I PUIMI I "up: , Blood Pr,uurel
VI tal Signs: I I l ~k~
d~~ ,(J )( I .a~
, / t1 J" I
, ,
aile' Ccamol,lnl:
~ay.J" " /! -6.t'. ,i1~ , r1 "
Tr lage Note: 0 Emergeney o Urgent o Routine
~ s- 4/-A~r
p-z,J "" ~
;ra
..r
A.'LeC my/? '/(I~7~.;i' - P/
s..:~'" r;; ~,...,I,.r/;' 4 "~:<./'
.,.Lfi ~""?f
7/.{, oS /1m
-
w,lLn
"PI- At:J..f
~ 6l!Jur.r
d- ..Ira S,.I->> s
dVLr C!.rfLS
k", n1
~fn
J"
-~~~"
Initial Treatment:
o lee 0 Elevation
o Other:
o I mmoblll zed
o Dre.sslng
r'II" NI.IM ~"l\Ih"':
~ ~4" 4',
~
I
246 Park.r SIrU'
Ca,II,la, PA 1701J.(1310
(717) 245-5500 EMERGE'
REGISTRA'
18:37
""
, , ,
HOFFHAN, HELlS SA C. 2Y F W S
~'~1~~~~X"'~~'~'~~ I., :.:.,<,..,~:" 007010~:5010~01 000
f\iP"11<J~~1"'~~ "'~rl'~.,"':'''' -; r....' '/ ::"\1.., ., ,.," .;,
F!'Al,.HYRA, PA.:'~; '.,> ':' 17078' , ..l.,
.' . . .;', .
I , ,.... IOHI 01' .$IC.
HOFFHAN, ROGER L.
RO 1 BOX "I31A
Pill,....., lJ...RI~ '.
.......Ovllll
RITE AID CORF'
183-"16-9803
CAMP HILL, PA
PALMYRA, PA 17078
. (C.HO 1El."'ACoC v NOT.,,,
HOFFMAN, DIANE C.
(717) 169-78'16
. 18
-r
HOFFMAN, ROGER L.
01
AUTO
EVALUATED
I JAJIlh()lNQ
WILLARD I WILLIS W
EMERG II1SIT 0005 26800 CAST ROLL. SCOTCH 26081 ALL ADDI110NAL CHARGES
EMERG VISIT 0610 26805 EKG MONITOR 26042 r "'I r-
I II
EMERG II1SIT 1115 26610 EXTERNAL PACER 26045 ~I/(j I I
I I
EMERG II1SIT 1625 26615 PACER PADS 79084 .J \.._
EMERG II1SIT 2640 26620 GASTRO/HEMO SLIDE 28060 r "'I r-
EMERG II1SIT I I I
4155 26825 KIDDE TOURNIQUET 2604B I I I
EMERG II1SIT 56B5 28830 OCLPERFOOT 79670 I I I
\.. _.J \..
EMERG II1SIT CLASS 8 26635 FS,B,S. 800Bl r- -"'I r
OBSER\lATION, EACH HR 26017 SUTURE PER PACK 26073 I I I
I I I
PRIVATE EXAM CHARGE 26010 TUBE GAUZE PER FOOT 26074 I II
\.. .J \.._
EMPLOYEE HE!lLTH VISIT 26018 ALl ADOITlONAL CHARGES r , r
UGHT SOURCE FOR SPECULUM 26845 I II II
I II I I
ALl VAGINAL SPECULUM 80068 I II I I
INJECTlONFEE 26009 \.. .J\.. .J\..
B/P MONITOR r ,r ,r
26037 I II II
CAST. SCOTCH SHORT ARM 26031 I II II
I II I I
CAST, SCOTCH LONG ARM 26032 \.. _.J \, _.J \..
CAST. SCOTCH SHORT LEG 26033 r ,r , r
I II I I
CAST, SCOTCH LONG LEG 26034 I II II
I II II
CAST, CYLNDR LEG 26030 \. .J \. _.J \..
ER.0506IREV I
ARLISLE HOSl-..,<AL
248 PARKtl fRUT eARUSL!;_, 17013.0310
(
(2)
EMERG~--,Y REGISTRATION
(fl
FOR NURSING ASSESSMENT
SEE NURSING DOCUMENTATION SHEET
MP:
NONE 0
0 0 0 0
"""" ceo """'. alliER
'1DU SAME o IMPROVED
. , HOlVlID NI. "IT. ftllPONOID
'5003
, '
,6976sie
. .' . .
HOFFMAN. MELISSA C.
"
0/17/':>3 18:37
2'(
A
..
ER.OS08 (REV, 819,
~CarlisIe ~
~ ' eop',.lQi.i uta
./
'---"
eR 2010 l""a,
NAME
ROOM ,
VITAL SI
P
ALLERGIES.
CURRENT MEDICATIONS.
NURSING DOCUMENTATION - EMERGENCY DEPARTMENT
DIle: /0-
Arrived Wilh:
o Polic.
~a(.nl
o S.II
J!"-
T -:J-1 :5
Bp
TRIAGE NOTE:
TI13ge SlaIUS:
o Prlonty I
o Pnorlly II
i:l"Pno,,1y III
o FUI Track
Ch t Com .,nt
Mode 01 Am~
o ALS Cf'BLS
o Ambulatory
o Wh.elchair
o Carrltd
o F"and
o Spouso
o OIhor
~
'-4
o Within 5 Voars
o 5.10 VOIrs
o Mor. than 10 Years
o NIver
. TREATMENT IN PROGRESS ON ARRIVAL:
o CPR Down Time
o Ai""ay - 0 Orol, 0 Nosal - Silt
o Ai""ay, Endo~achoaJ - Silt -
o Ai""ay, Naso~acheal Slzt...........
o IV Solullon LS,le
Onsel 01 Symptom..
Nursing Actlol'\lCommentl:
Childhood Immunlzallona. 0 UTD
Treatment PIlOt 10 Arrival:
TRIAGa NURSE SIONATUR~. ,m .r
o Never
o
TETANUS STATUS.
Size
o Monilor - Rhythm
o Oxygen - 0 Mask,
o Spinal Immobil'
o MaS!,
o Pressure Dressing
Ra..
C - Win
('x f..J
DRUGS:
min.
.......'
---
,
o Olher
. GENERAL APPEARANCE
PIJI<6E:
il'Rogutar
o FuN
RESP.
JOnIormaJ
o Flushed
o Jaundiced
o Cool Q-1;cchymosis,
o Clammy 0 Rash,
o Dusky
o Cyanollc
o Nailbeds
o Circumoral
o Laceration
OEdema
.
..
o Aa~. C Wheez.
o Rhonchi C AbI,nl
Pupil.: .' . .. .
RiQIlI' Sl.l.
R..cUon _ a, . S' .
L.n. SUI
o NlA Raaellon_ 3. . 3. .
-t Co I"frof'r' ..
Tho I: Speech:
o Crear/Spontaneous 0 Normal/Cleat
o VaQu,iOllConnlcl1d 0 S.llnl
o Olsori.nled 0 Talkaliv.
e SlaIN 10 Answer 0 R.ptllli'~.
a Mumbling
..
Mlmo!')':
e Inllct
(] Impaired
o Reclnt
o CtIslo1n\lPlsl
..
o With Gluses
o Wlthoul 0111581 (] NlA
nb"'d
~ I}v.....
I.
VIsusl Activity:
00
OS
"
. INmAL NURSING INTERVIEW: TIME.
REASON FOR VISIT: B"fRAUMA 0 MEDICAL 0 SVCHOSQCIAUEMOTlONAL
PAST MEDICAL HISTORV: nt)..... CCX'\ \'C",~u..'
LMP.
H
-
()'
o
PLAN OF CARE:
PATIENT PROBLEM: Nursing Diagnosis
_ Noncompliancl
_ Sell ea" oellClt
.....o=::"ComlOf1. All,rallons In
_ CommuniQllon Im~lIed
_ Copng. IntffeclNI
_ FlUld Volume, AII,'abonlln:
_ Ga, Elchangl, Impaired
TillUI P"h,tllOn. All. In
_ Skin Inlegrlly Imp.ilitmenl
_ Thought Proc.SlU, All. In:
_ HVpel1hermia (Fev.r)
_ Inlection, Potenlial
_ Inlury. Potential
_ KnowledOe Oelicll
_ Moblllly Impaired
Olher _
o Malnlaln Pallanl Ai....ay
&' Q:] Monitor Cardiovascular Sla1us
o IV 0 BP Monilor
o EKG 0 Cardiac Monllor
o Safely Measures
o Restraints 0 Suicide PreC3111l0nl
o Seizure Precautions
Sida Ralls Up
Cornfor1 Measures
o Pain Conuol
o Position fo' Comfort
o P,epare for e.-am
Explain Procedures
Emotional Support
o alent Toaching
Discharge Inslruclions
o Olhar
Othar
Other
',',f!' t '", (' r.~j_'''t'nr .., ("H"."
_ Anrl1 Clearance. lnQHectivl
~""'ll"ty
_ e.'athing Pan'mI. IneHoc,^,_
_ Cardiac Oulpul. Oecteased
0Iha<
OUTCOMElGOAL. Expecled by Discharge:
I'
.2
'3
"
aId J( r, , I....
.
(
. IV FLUID: o MEDICATIONS
Typo/Ami. SIlO C.'h. Slll TI_ Slgnalure II..., 00'. Route TI_ Blgn.lure
-
. TREATMENT/PROCEDURES: . INTAKE: . OUTPUT:
:J RESP, THEAAPV TREATMENT IV PO
:J TIME TIME TIME TyPO Ami, Typo Amt. Urlne 1m..'. 0U\0f
:J OXYGEN UMIN
o INTUBATION, SIZE TIME
o Aoo'S TIME TIME TIME
o PULSE OX TIME TIME
o AIRWAY, TYPE TIME -
o NASOQASTRIC TUBe, SIZE TIME . NOTIFICATION OF:
o GASTRIC I.AVAO. AMT o tiolpdal Soc;lal WOf1let o FamoIy lloCtDf
o FamIly o Con><*
o poliCe e CoftIuftlnl
o FOLEV CATHETER, SIZE TIME o enti' II\I.,....nllOn o 01....
AlofT. OUT COLOR -- o NutslOO Homt o 0\h0f
. VITAL SIGNS. 0
o MANUAL
n....
BP
P
,
E'tJIUATIO~D MAR OT
CAt . U\J.d. V(UC~,
o For ObHtvlhOn
10:
o Tranlf."ed IQ;
o Ambulatory
o ,\mbuIalOl"f C A'Slllanetl
o Whte~.I'
o /tmbulan(1
01....
o Sell
o FamIly
o F,..nd
o Polict
o "aluablet
INSTRUCTIONS:
o Chill 0 UTI
o Crutch.. 0 KIdney Slone
a Abet. problem 0 PeMe Inl.
o Wound Car. 0 SpfainIBruise
o Clt" lIQuid 0 Asthma
OF..." 0 ocuc...~
DUAl ~
-=====r Mis
o OIhIr
o 0\h0f
DISPOSITION: DISCHARGE:
o AdmIned 10:
o h4oroue
PATIENT'S N^"'E .fY'e ll~
M-D~U:::-.
HURSE'S SIGNATURE
~
r-
~
.
,....
r
....
e~ I-b5pital
CONIENT TO BOI.ITAL ADMI..ION AND
IIZDICAL TUlIo'I'Kl:HT
Nam. ot Att.nding Phy.lcl.n (.)1
D.t. of lIodmluionl /0 - 17 -93
Tim.,
(lIoK)_____(.K)____
1. I, (or .cting on b.h.lf ot)
(11'. N_. 01 ""~riM4 a.__lalh.
me j,'_s. Sa /);/.. \rn14" , .utt.ring from. condltion U'1'liring ho.pital cu., her.by
N_ 01 hlIoot
con..nt to r.nd.rlng of .uch c.r., whlch m.y includ. rout In. dl.gno.tlc proc.dur.. .nd .uch
medlc.l tr..t~nt .. the nam.d .tt.ndlng phy.lcl.n(.) or oth.r of the ho.pit.l'. medic.l
.t.ft con.id.r to b. n.c....ry.
2. I und.r.t.nd th.t the pr.ctlc. of m.dlcln. .nd .urg.ry i. not .n .x.ct .cl.nc. .nd
th.t di.gno.la .nd tr..tm.nt m.y lnvolv. rLak. of lnjury, or .v.n d..th. I .cknowl.dg. th.t
no gu.r.nt... h.v. b..n m.d. to me .. to the r..ult of .xamln.tlon or tr..tment durlng thl.
ho.plt.liz.tlon.
3. I und.r.t.nd th.tl
(A) It 1. cu.tom.ry, .b.ent .mergency or .xtr.ordln.ry clrcum.t.nc.., th.t no
.ub.t.ntl.l prDc.dur.. .r. performed upon. p.tl.nt unl... and untl1 h. or
.h. h.. h.d .n opportunity to dl.cu.. th.m wlth the phy.lcl.n or oth.r
he.lth prof...lon.l to the patlent'. ..tl.f.ctlon,
(S) E.ch p.tl.nt h.. the rlght to con.ent, or to r.fu.. con..nt, to .ny
propo.ed proc.dur. or ther.peutlc cour.e, .nd
(e) No p.tlent wlll b. lnvolved ln any r....rch or .xperlm.nt.l proc.dur.
without hl. or h.r full knowledge and con..nt.
4. I under.t.nd that many of the phyelclan. on the .taff of thi. hospit.l, includlng
the attendlng phy.lcl.n(.) named .bov., .re not employ... or .g.nt. ot the ho.plt.l but,
r.th.r, .r. lnd.pencl<lnt contrActors who have been gr.nt.d the prlvl1.g. ot uaLng It.
t.cl1itle. for the c.r. .nd treatment of th.lr patient.. rurther, I re.lize th.t among tho..
who attend p.ti.nt. .t thl. ho.plt.l Ar. medlc.l, nurelng, .nd other h.alth c.r. per.onn.l
in trainlng who, unl... raque.t.d oth.rwi.e, may be pra..nt durlng pati.nt c.ra .. . p.rt of
th.ir .ducation. Still or motlDn plcture. and clo.ad clrcult telavidon monitoring ot
p.tiant c.ra .1.0 m.y ba u.ad tor aduc.tional purpo.e. or for docum.nt.tion ot tha clinlc.l
cour.. unle.. a patient expr...ly reque.t. otherwi...
5. I rel.a.e CARLISLE BOI.ITAL from .11 reepon.ibllity for .11 .rtlcl.. which I am
rat.ining-or will have wlth me durlng my .t.y .t the ho.plt.l. I und.r.t.nd thi. lnclud..
clothing, bddgework, fal.e t.eth, .y.gla...., jewelry, mon.y, r.dlo, r.zor or .ny oth.r It....
kept in my poeeeulon. I underatand I may depoeit valuable. ln . .afe provided by tha
ho.pital, only it thl. 1. done w1l1 the hosplt.l .seume any re.pon.lb1l1ty tor tha
..fekeeping.
6. I hereby acknowlsdge that I have recelved wrltten lnformatlon on tha toplc. of
Patlent Rlght. and Advance Dlrectlve.,
Data of Signature. ? () -17 -9 .3
(SIGNATURE or PlIoTI~NT) (SIGNlIo~ or WITNESS)
(If patlent ls unable to eonsent or ls a mlnor, complete the fOllowlng')
Pat lent [i. . mlnor ysare of age) (le unable to consent because).
;~ p- I.
(SIONlIoTUJU: or LEGAL GUM
~
OR
-....--..- ............- "'......-.......