-
PATIENT FACESHEET
Camp 'Health System
Hill, PA 17011
MEDICAL RECORD#
145831 SURGERY DATE SOCIAL SECURITY NO
161-46-2179
NURSE STA ROOM/BED ADM DATE / TIME
01/28/06 21:03
HOSP SRV
ER1
PT TYPE
E
CLINIC CODE
ER1
PATIENT ACCT #
' 27106566 F IN CLASS
B
AGE
44
DATE OF BIRTH
04/24/1961
RACE
1
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M
CHURCH / R. PREF UNITED METHODIST-FIRST
AMBULANCE
1g4gtER SPRING AMB ASSN
ADM
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REG DATE / TIME
01/28/06 21:03
CONFID
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HOLLAND BINGAMA ,KELLY L 2250 CANTERBURY DRIVE MECHANICSBURG, PA
17055
717 - 697-6698
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PLAN CODE B09 INS CO BLUE CROSS
POLICY # YWU189448052 GROUP # 027041021
AUTHORIZATION #
ADDRESS PO BOX 779503 HARRISBURG PA 17179 PHONE # SUB NAME
BINGAMAN JR , ROBERT MI E REL TO PT 4 PRIORITY 1
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ACCIDENT DESCRIPTION ACC. DATE / TIME / IND. PRIVACY NOTICE
09 18 05 01 ER1 LML
COMMENTS
Exp-UNKNOWN ADMITTING DX. ADMITTING DR.
180018 ED GROUP
ATTENDING DR. ) e)
180018 ED.-GRU , I
REFERRING DR.
t-- ADMITTING COMPLAINT
RIB PAIN
BROUGHT BY: AMBULANCE
NCE SERVIC WEST SHORE
:
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MR #
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PT ACCT #
145831 27106566 ER1
ER MEDICAL RECORD HOLLAND BINGAMA ,KELLY L 44 F
-
Name' ktb 1 6`e) - ke (14-c. Date: TRIAGE ACUITY: - 1 2 4 5 Mode
of Arrival: ['ALS 2/11CS ❑ C ❑ POLICE ❑WALKED
Primary Language:-Per L3WigC lish OCARRIED 00THER
❑ Hard of hearing ❑0ther: Interpreter:
Log in -
Triage' Age . l , f l
male ______H_n ,...)
PCP . ❑ unknown Room: 7 :13.76
CHIEF COMPLAINT /WHAT BROUGHT YOU INTODAY? • 1• 55c) 1 le.)
ic.t-S I - -e- - PAIN HISTORY 0 pt. denies pain ❑ Can't Assess due
to severity of pts condition/unable to answer 0 Baby Location:
Onset (Date/Time for accident) ❑hours ❑days ❑weeks
1/3 .
HPI• L(6 OL‘A-' .re) C. 1^e,S4- t A PEA)/ / CLAP- ILeAi' ec
Intensity: 0 1 2 3 4 5 6 7 8 9 10 (g) 1) (Y) (!) (t) ®
, .. ... .... .,,.
Du .,
ration'' ,,,..
'. '. s'' ' '" wh''' W-'
rtr--...
-
Radiology ] Abd./Obstr. Series ] Ankle R L ] Clavicle R L ]
Cerv. Spine--Routine (3 view)
Cerv. Spine--AP/Lat ] Cerv. Spine--Portable Lat ] Chest--Routine
or Portable ] Elbow
R L ] Facial ] Femur
L ] Finger
R L ] Foot
L ] Forearm
R L Hand
R L ] Hip
R L ] Humerus
L
] Other: REASON: Special Procedures:
] Knee R L ] KUB ] US Spine ] Mandible ] Nasal ] Orbit R L ]
Pelvis
yelogram IVP Ribs 6:9 L
] Shoulder R L ] Skull ] Sternum ] T/Spine ] Tib i Fib R L ] Toe
R L ] Wrist R L
Time/CRT/Int
Initials:
Initials:
CRITICAL C
Signatur,e•
Date: t r 7 C I 01)
MD/DO/CRN
Time:
Signature- RN/MA
Signature- 1 RN/MA
Initial Lab & X-Ray Orders: Labs
] Acetaminophen [ ] ESR [ ] Theophylline I Acetone (SACE) [ ]
Glucose [ ] Thrombolytic Labs ] Alcohol (ALCO) [ HOGS [ ] Tox
Screen ] Amylase/Lipase [ ] Quantitative [ Urine Tox (DOAS)
APTT HOGS [ ] TSHR ] BBH [ ] HIV [ ] Type&Cross_# of units ]
Blood Cultures [ ] Lithium (BOR) ] BMP [ ] Liver profile [ ),Type
& Screen ] CBCP [ ] Lytes [ ] DIP AG.
] CMP [ ] ProBNP [ ] Urine C & I CK,CKMB,TNT [ ] Phenobarb [
] Urine HCG
] Depakote [ ] PTP [ ] WC Breath Alco Test ] Digoxin [ ]
Salicylate [ ] WC Drug Screen ] Dilantin [ ] Tegretol [ Other
Ultrasound: CT: (W=With contrast; WO=Without) ] Abdomen
[ Abdomen/Pelvis W WO [ ] VQ Scan ] Duplex Doppler [ ]
Brain/Head ] Gallbladder [ ] Chest ] Pelvis [ ] Spiral chest for PE
] Transvaginal [ Other ] MRI Scan
REASON:
Specimens/Cultures: ] Beta Strep AG Rapid
[ ] Stool C & S ] Cervical/Genital
[ ] Stool 0 & P ] Chlamydia
[ ] Stool C. Difficile ] GC Culture
[ ] Trichomonas ] Monospot (rapid)
[ ] Wound C & S ] Sputum C & S
[ ] Other:
Billing Classification:
Cardiac Respiratory [ ] Monitor [ ABG's [ EKG [ ] Peak Flows
Before/After Resp. Tx. [ 02____Umin. [ ] Respiratory Tx [ ] 02
Saturation
Medications / IV's / Additional Orders
ror ORDERS NURSE Caw
Time
IV: NSS/ D5W/ LR/ D5/ .45NS/ D5.9NS
WO/KVO/infuse at mis/hr
[ ] Obtain old records [ ] Td
[ ] Protocol initiated for: .
2:7A0 i r . V « C k,44/1 2 --rz_t)s- LO(tti
(4(( lc- bd tae1 -
,
063(0 c01) cly.,-,0 fo ,0 1 I i (.0_4.,--z_e___ I
Dv .o. read back
Time: [IDISCHARGE [ ] ADMIT [ 1 OBSERVATION [ ] REGULAR [ ]
TELEMETRY [ ] CRITICAL CARE ADMITTING PHYSICIAN / GROUP:
DIAGNOSTIC IMPRESSION: c.. ,
WO [ ] Echo- WO cardiogram
Time/CRT/Int
PHYSICIAN CHARGE ] Level I ] Level II
] Level III
] Level IV
] Level V
FACILITY CHARGE [ ] Level I [ ] Level II
] Level III
] Level IV
] Level V
[ ] Accident [ ] Medical
[ ] Case 1
[ ] Extended Hrs.
Holy Spirit Hospital Camp Hill, PA
John R. Dietz Emergency Center Physician Order Sheet
HOLLAND BINGAMA ,KELLY L44 F 04/24/1961
ED GROUP ER1 145831 01/28/06 27106566
206-ECU 12/04 REV. LLW CHART COPY
-
7110/ BEHAVIOR CHILD perative — Awake - Alert ❑ Appropriate
nted-Person words/ response
Oripted-Place 0 Consolable, jlefiented-Time inappropriate 0
Agitated words E Uncooperative 0 Persistent ❑ Verbally Abusive ❑
Combative inappropriate 0 Anxious 0 Crying crying/ screaming Ill
Conf used 0 Moans to pain
SKIN., __ _... 2Warm ip.rry.21qorm. Color ❑Skin Intact (visible)
❑ Cool ❑ Diaphoretic 'Abrasion ❑ Rash ❑ Hot ❑Tenting 0 Ecchymosis ❑
Bum ❑ Pale ❑Flushed ❑ Puncture Wound
❑ Dusky ❑ Mottled ❑ Laceration/ Avulsion ❑ Cyanotic ❑Jaundice
MUSOUS MEMBRANES ❑Bleeding ❑n/a ZPink / Moist ❑ Controlled ❑ Pale ❑
Cyanotic ❑ Not Controlled ❑ Dry ❑ Cracked Location:
R
❑clear 0 labored
❑cough
D02
%Sat
symmetrical/
❑wheezing LI rales/rhonchi
a productive
TORY unlabored
❑stridor LI retractions L / R
L / R
NIUSCULO,SKELETAL ,ERTA Extremity:
Extremity color: 0 WNL ❑ Mottled ❑ Cyanotic
Skin Temp ❑ Warm ❑ Cool Distal Pulses0Present ONot palp. Edema ❑
Yes ❑ No Deformity ❑Yes 17 No Ecchymosis ❑Yes E No
Umin via
NEURO ❑ headache rr*PERL D stiff neck Size ❑ neck pain ❑ tacial
droop ❑ numbness:
❑ weakness:
❑ „,,,An GLASGOW COMA OAF
, EYES MOTOR mm / '
SCALE 1"- Score
words
sounds 1 No Response
Gy GYN GM /61 denies s/s 0 urethral
❑ frequency discharge
❑urgency 0 vaginal D Dysuria J vaginal ❑ Hematuria ❑ foley ❑
retention present ❑Other: LMP
A
discharge
bleeding
#
CARDIOVASCULAR Legnies ❑ Monitor/rhythm: ❑ Chest pain
area: RESPONSE VERBAL Obeys 5 Oriented Localizes pain 4
Disoriented Flexion -withdrawal 3 Inappropriate Abnormal Flexion
Abnormal Extension 2 Incomprehensible No response
4 Spontaneous 6 Pinpoint ❑ • 3 To verb command 5 Dilated ❑ ❑ 2
To pain 4 Fixed ❑ ❑ 1 No response 3 Sluggish ❑ ❑ 2
non-reactive ❑ ❑ 1
Severity D constant ❑ intermittent ❑ burning ❑SOB ❑nausea ❑
non-radiating ❑ radiating
/10 ❑ pacer D edema .
❑sharp ❑dull
❑ pressure D heavy D pleuritic
❑JVD ❑capillary refill:
LI rapid D delayed
Dealt tender R / L
❑ N/A
GASTROINTESTINAL D Denies pain /symptoms ❑ nausea ❑ diarrhea
UN/A ❑ Duration/ intensity Last BM
Bowel Sounds D Abdomen tender
Winn ❑vomiting ❑ constipation ❑ Hematemesis ❑ distended
❑soft
EENT ❑denies s/s EYES ❑ Pain L / R Acuity: ❑ blurred vision L /
R ❑ double vision L / R 0 Photophobia L / R
UN/A L / Ears Nose Throat
UR ❑ congestion D sore ❑drainage ❑ drooling D Epistaxis L / R ❑
dysphasia
NURSING
Co CII bell
ArR up
ASS T,
ed by RN Time:Z-10.6 R / Li Pain ❑ with lenses ❑ discharge
❑Other: w in each ❑ Companion with patient
x2 DER procedure explained
IV condition: 0=noinflammation/complication 1=edema 2=erythema
3=ecchymosis 4=pain 5=hardness 6= arm h Neaking MEDICATIONS Time
Amt Solution Sz. Site Rate Attpt Cond Initial Time Drug / Dose
Route Site Initial
ti4:•• •-, ti— Wifill IE.,.
ta. - . ,z,„:„..1 ,-.1 ,...
Notes _
— _. mil A l_A it __ PaPIV.111..4 .,..■ II. arlirffEW4
111,11.112... _Ai" .!-
• C-4.0•4 4, c Milling t.......411 .._...... •
ak! . ...... . c) AilliWillerin witzu Initial Signature Initial
... vs6,
if • Ap . - .
. 11-dik.a. .—.......... .... —
J.> IV 4 0 r.
Via: To:
/
, IC -
ADMIT
TRANSFER Condition:
DISCHARGEDjaccompanieci
DISCHARGE
Discharge
Room#
C3ADMIT
d'crnlyJatory ❑ w/c .114-me ❑ nursing home
❑ other: jastructions given
'atient ❑ Family
OBS Report called
by;ier
-
) Thomas Aldous, MD 017075E ( ) ( ) Salvatore Alfano, MD 025502E
MD ( ) Ramesh Arora, MD 016727E ( ) ( ) Jon Dublin, DO 00699IL ( )
Amy Fajardo, MD 420942 ( ) Katarzyna Ferraro, MD 417936E ( )
Maripat Ganef -. MD 046724L ( ) Marlys Hasso , MD 072553L
DATE
HOLY SPIRIT HOSPITAL JOHN R. DIETZ EMERGENCY CENTER 503 NORTH
21ST STREET CAMP HILL, PA 17011-2288 (717) 763-2316
( ) David Zimmerman, MD 005636E ( ) Patricia Millner, NP
VP001553D ( ) Barbara Strong, NP VP003617B ( ) Teresa Williams, NP
TP006126B ( ) Nikki Wallace, NP TP006718B ( ) Jane Wenger, NP
SP005927B
( ) Pam Darden, NP SP006066B ( ) Selena DiPaolo, NP VP005264B (
) Natalie Gillis, NP TP006082B ( ) Michelle Hale, NP VP005355B ( )
Beverly Haney, NP SP001018B ( ) Susan Miller, NP SP00762413
) John P. Judson, MD 038368E ) Philip Maguire, MD 015063E ) Pu
Mnrinn 1514L
aron Palmer, MD 423 Paul, MD 0395 4L
) Howard Rudnick, MD 040862L ) Ranjana Sharma, MD 031265E )
Christine Sheridan, DO 009537L ) Alan Teplis, MD 03 8E
ats, 3D ett,
( )
-r721Ll . /168 t c.tt;r7xe--1...
SIGNATURE .O./NP DEA# P e(12-4-( REFILL TIMES IN ORDER FOR A
BRAND NAME PRODUCT TO BE DISPENSED, THE PRESCRIBER MUST HAND WRITE
"BRAND NECESSARY" OR "BRAND MEDICALLY NECESSARY" IN THE SPACE
BELOW.
0 LABEL 0 SUBSTITUTION PERMISSIBLE
178 (12/04)
HOLLAND BINGAMA ,KELLY 144 F 04/24/1961
ED GROUP ER1 145831 01/28/06 27106566
-
Holy Spirit Hospital Department of Radiology and Diagnoetir,
imaging
Camp Hill, Pennsylvania 17011 (717) 763-2600
PATIENT: HOLLAND BINGAMAN, KELLY L DICTATION DATE: Jan 30 2006
9:29A MR#: 145831 TRANSCRIPTION DATE: Jan 30 2006 9:29A SOC SEC:
161-46-2179 ORD DR: SELENA DIPAOLO,CRNP M.D. ADM DATE: 01/28/2006
PT TYPE: E ARRIVAL DATE: 01/29/2006 DOB: 04/24/1961 HOSP SERVICE:
ER1 LOCATION: ER1 D- ACCESSION: 2823079
***Final Report***
EXAMINATION: UNILAT RIGHT RIBS 71101 - 01/29/2006
COMMENTS: One View Chest with Right Rib Series:
History: Fall. Pain.
Findings: Comparison is made with prior chest radiograph of
October 16, 2003. When compared to this exam the old rib fracture
of the right posterolateral rib is again seen. No sign of acute
fracture is noted. No pneumothorax. The lungs are clear.
Cardiac size is normal.
CONCLUSION: Impression: Old right rib fracture. No sign of acute
rib fracture. No pneumothorax.
DICTATED BY: PAUL LICATA M.D. / PSC DATE OF EXAM: 01/29/2006
SIGNED BY: PAUL LICATA M.D. DATE/TIME: Jan 30 2006 9:32A
1 , 3
CONFIDENTIAL: This report contains private patient information.
If you have received this report in error, please call 717-972-4941
immediately.
Confidentiality Disclaimer: The information contained in this
communication may be confidential, is intended for the use of the
recipient named above, and may be legally privileged. If the reader
of this message is not the intended recipient, you are hereby
notified that any dissemination, distribution, or copying of this
communication, or any of its contents, is strictly prohibited. If
you received this communication in error, please resend this
communication to the sender
and delete the original message and any copy of it from your
computer system. Thank You.
Imaging Services Consultation Page 1
-
Witn ss
Time Date t el&
CONSENT TO MEDICAL TREATMENT I HEREBY CONSENT AND AUTHORIZE Holy
Spirit Hospital, its agents, and employees, to the rendering of
medical care, which may include routine diagnostic procedures and
such medical treatment as my attending or consulting physician
considers to be necessary. I also understand it is customary,
absent emergency or extraordinary circumstances, that no
substantial procedures will be performed upon me unless or until I
have had an opportunity to discuss them with a physician or other
health care professional to my satisfaction. If I am a competent
adult, I have the right to consent or refuse to consent. I
understand that the practice of medicine and surgery is not an
exact science and that diagnosis and treatment may involve risks of
injury or even death and acknowledge that no guarantee has been
made to me as to the results of any examination or treatment in
this Hospital.
I understand many of the physicians on the staff of Holy Spirit
Hospital are not employees or agents of the Hospital, but rather
are independent contractors who have been granted the privilege of
using these facilities for the care and treatment of their
patients. Further, I realize this Hospital is a teaching Hospital
and at the Hospital are health care personnel in training who,
unless expressly requested otherwise, may participate or may be
present during my care as part of their education. Still or motion
pictures and closed circuit monitoring of patient care may also be
used for educational purposes, unless I expressly request
otherwise.
I understand that in order to ensure a safe environment for
patients, visitors and staff all property on the premises of Ho
pirit Hospital is subject to reasonable search and/or seizure at
any time without further notice.
Initials
RELEASE OF MEDICAL INFORMATION I authorize Holy Spirit Hospital
to release to requesting health insurance carrier(s), their
representatives and auditors, and any referring health care
providers, such diagnostic and therapeutic information ( including
and information relating to treatment for alcohol and substance
abuse and/or treatment of psychiatric disorders. and/or
confidential HIV related information, as may be necessary for them
to determine benefit entitlement; to process payment claims for
health care services provided during this hospitalization/treatment
episode, for continuing care/treatment, and hospital operations. A
photocopy or carbon copy of this authorization shall be considered
as effective and valid as the original. The undersigned also
authorizes Medicare, when applicable, to release to another
insurance carrier, upon their request, medical information needed
to make payment upon that claim. I understand and consent that the
manufacturer of any implantable device inserted by my physician
during the course of my surgery/procedure may be provided with my
identification information, including social security number, as
mandatj j ege l Law. ACKNOWLEDGEMENT OF RECIEPT OF NOTICE OF
PRIVACY PRACTICES
Initials
I have received a copy of the Notice of Privacy Practices. The
Notice describes how my health information -may be used or
disclosed. I understand that I should read it carefully. I am aware
that the Notice may be changed at any time. I may obtain a r9vised
copy of the Notice by contacting this Organization's offices or on
this Organization's website at www.hsh.org .
Initials ) INSURANCE ASSIGNMENT OF BENEFITS I authorize payment
directly to Holy Spirit Hospital and my treating physicians of all
benefits payable under instlr ce policies. I understand I am
responsible to the Hospital and physicians for all charges not
covered by this assignment. Initial
STATEMENT TO PERMIT PAYMENT OF MEDICARE BENEFITS TO PROVIDERS,
PHYSICIANS AND PATIENT I request payment of Authorized Medicare
benefits to me or on my behalf for any services furnished me by or
in Holy Spirit Hospital including physician services. I authorize
any holder of medical and other information about me, to release to
Medicare and its agencies any information needed to determine these
benefits for related services. Initials
MEDICAL ASSISTANCE RECIPIENT My signature certifies that I
received a service or items from Holy Spirit Hospital and Dr. on
the date listed below. I understand that payment for this service
or item will be from Federal and State funds, and that any false
claims, statements, or documents, or concealment of material may be
prosecuted under applicable Federal State Laws. I understand that
certain tests and procedures may not be reimbursed by Federal and
State funds and that I may be responsible for non covered charges.
Also, I agree that if at the time of service, if I am not eligible
for Medical Assistance, I will be responsible for balances owed to
Holy Spirit Hospital.
Initials I have read and understand each of the sections
contained above. I understand that by signing this document, I am
agreeing and providing the authorization/consent contained in each
of the above sections where my initials are located. I have had the
opportunity to ask questions regarding each of these sections and
all such questions have been answered to my satisfaction.
Signature
Relationship to Patient
6wytf-pho
HOLY SPIRIT HOSPITAL CAMP HILL, PA.
CONSENT FOR TREATMENT/RELEASE OF INFORMATION INSURANCE
ASSIGNMENT
MED REC 165 (03/03)
MR#: 145831
PT#: 27106566
NAME: HOLLAND BINGAMA ,KELLY L
-
especially if
( ) Your blood pressure was elevated. Check with your
physician.
A copy of your dictated Emegency Room Report is available to
your Physician from Medical Records (763-2660), if not already
sent.
Clinical Impressions.
1
(717) 763-2316 (717) 763-2424
The examination and treatment you have received in the Emergency
Center have been rendered on an emergency basis only, and are not
intended to be a substitute for or an effort to provide complete
medical care. If you develop new problems or complications contact
your physician or the Emergency Center. FOLLOW THE INSTRUCTIONS
CHECKED BELOW.
Patient Information: Patient Information Sheets Contain
Important Information to Review and Keep. ( ) Abdominal pain ()
Alcohol reaction
)Allergic reaction
( )Corneal abrasion I I Croup/bronchitis ( I Crutch walking
( ) Headache ()Head Injury ( ) Hypertension
( ) Pain Management ( ) Pediatric Head Injury ( ) Pediatric
URI
( ) Threatened Miscarriage ( )Toothache ( ) URI and Colds
( ) Asthma ( ) Diarrhea and Vomiting/Ped. Vomiting (
)1mmunizationiTetanus ( )PID/STD t*UTI and Pyelonephritis ( ) Back
pain ( ) Dislocation ( ) Kidney Stones ( ) Pneumonia : I \hi A Is
3,./..yx.ounu:Reorteck - — () Bites-Human/Animal/Insect ( )
Drug/Alcohol abuse/addiction ( ) Lablynthitis ( ) Rash ( ) 24 Hr.
Pharmacies ( ) Burn ( ) Febrile Convulsion ( ) Laceration ( )
Seizure ( ) Other ( )Chest Pain ( ) Fever/Ped. Fever ( ) Neck
Strain ( ) Sore Throat ( ) High potassium containing food: (
)Conjunctivitis ( ) Flu ( ) Nosebleed ( ) Sprains and Strains ( ) (
I COPD ( ) Fracture ( )Otitis Media ( )Suture Care &
Removal
WOUND CARE MEDICATIONS
( ) May gently wash over wound in 24 hours with soap and water
or peroxide.
( ) Change dressing _times daily. Redress with
Bacitracin/Neosporin and sterile dressing or leave it open if
advised.
( ) Keep wound clean, dry ( ) covered ( ) uncovered
SPRAINS, STRAINS, BRUISES, FRACTURES ( ) Elevate the injured
part for_ days to reduce swelling. ( ) Apply ice packs
intermittently for _days to reduce swelling.
) Ace wrap for support for_days. ( ) Wear splint ( ) At all
times until follow-up. ( ) For activity as needed.
) Use sling for support. ( ) Use crutches: ( )As needed, weight
bearing as tolerated.
( ) At all times. NO WEIGHT BEARING
NECK/BACK ( ) Wear cervical collar for support for _days. ( )
Rest, avoid bending, lifting, strenuous activity for_days. ( )
Apply moist heat for minutes times daily
beginning in hours.
ADDITIONAL INSTRUCTIONS ( ) Encourage fluid intake ( ) Clear
liquid diet. Advance to regular diet as tolerated ( ) Off
work/school from to ( ) Return to work on ( ) Light Duty until:
Restrictions: ( ) No gym/sports until ( ) Follow instructions on
Workmen's Compensation Form. ( ) Wear eye patch for hours. ( ) If
nose bleed recurs, pinch nose firmly for 5 minutes
continuously, retum if bleeding not controlled. ( ) The
prescribed antibiotic/medication, may reduce the effectiveness
of medication you are currently taking. Check package
instructions or consult with Pharmacist.
(... fq
' ) / P. \---h_ A....1 7.
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