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MINUTES - 07111995 - C30
AMENDED , CLAN C � 3� BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA July 11, 1995 Claim Against the County, or District governed by) BOARD ACTION the ooard of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board. Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $27,500.00 Section 913 and 9.15.4. Please-note-all "Warnings", IC CLAIMANT: Dormesha Turner .�U N 19 10495 ATTOPNEY: Elizabeth M. Guagenti COUNTY COUNSEL, Jacoby and Meyers Law Offices Date received MARTINEZCAUF. ADDRESS: 100 Bush St. , #700 BY DELIVERY TO CLERK ON June 19, 1995 San Francisco, CA 94104 BY MAIL POSTMARKED: June 15, 1995 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. pp DATED: June 1 A� 1 qQ5 BalO �eputylOR, Clerk ll. FROM- County Counsel TO: Clerk of the Board of Supervisors (1� This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Clair is not timely filed. The Clerk should return claim on ground that it was filed late and seed warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: �/ Attuft&.,-f6 !/§W (/yk Dated: X0 BY: Deputy County Counsel Ill. FRC"': Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BG^ - .ER: By unanimous vote of the Supervisors present (✓) This Claim is rejected in full. ( ) Otrer: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: 11 IckCIS PHIL SATCbiELOR, Clerk, By .ap . _l hw. 1LDJ , Deputy Clerk WARNING (Gov. code section 913) S;:tject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a coirt action on this claim. See Government Code Section 945.6. Y:4J T:3v Seek tr•e acv�ce of ar, attorney of your choice in connection with this matter. If you want to consL'lt an attcr-.e,, y::, s�,c.+lc do s: immediately. * For Additional Warning See Reverse Side Of This 'notice. AFFIDAVIT OF MAILING 1 ce:ia-e under penalty of perjury that I ar, now, arc at ail times herein mentioned, have been a citizen of •ne Lri%ed S:a:es, over age lc; and that today I ce:ositec in the Urited •States Postai Service in Martinez, Cx_ '.farniE, pcstace fully prepaid a ce-:'free :::)y Oj tris E:ard Order and Notice to Claimant, addressed to .re cla�7ar: as sho«r at:ve. C195 BY: PHIL E�?CSE:Gh :y De;uty Clerk [:.*•:y a.oniristrat:r • DECEIVE® JUN 19 1995 CLERK BOAR CON3RA.D OF SUNSRUESORS CO. -CO. DORMESHA TURNER I. Settlement Letter - with attorney designation II. Claim Form III. Witness Statement IV. Medical Providers A. Brookside Hospital B. Richmond Pediatrics V. Medical Specials A. Brookside Hospital B. Richmond Pediatrics C. Robert Brink, M.D. VI . Color Photocopies 1 • JACQIBY& MEYE S LAW OFFICES PERSONAL INJURY UNIT 100 Bush Street,Suite 700,San Francisco,CA 94104 415/399-8951; FAX:415/399-1939 June 16, 1995 Clerk of the Board of Supervisors County Administration Building 651 Pine Street, Room 106 Martinez, CA 94553 Re: Our Client Dormesha Turner (minor) Date of Loss: 12-09-94 Dear Sir or Madam: Our office represents Dormesha Turner, five years of age, who was injured by the County of Contra Costa' s negligent maintenance of property. Enclosed please find our settlement documents. Liability On December 9, 1994, at approximately 12 : 15 p.m. , Dormesha was walking home from school accompanied by her sister, Ranesha Moore, when a chain-linked fence structure, located on the County of Contra Costa's premises, suddenly fell on her small body. As the fence fell, it struck Dormesha on the left side of her face. She was not able to get out of the way in time. A female teenager, who was near the site of the accident, assisted Dormesha, by taking her home and informing her mother, Doris Jackson, that she was injured in an accident. As a result, Dormesha's mother took her to the hospital immediately by taxi cab, as her face was bleeding, in pain, and extremely swollen. Dormesha was also crying and experiencing extreme pain. Landowners and Possessors Liability - As you are well aware, a landowner or possessor owes certain affirmative duties of care as to conditions of activities on the land, to persons who come on the land, and sometimes, to persons outside the land. An owner or possessor is liable for creating or maintaining dangerous artificial conditions, or for permitting dangerous disrepair. In the case of a defective structure, the owner's freedom from liability for conditions on the sidewalk or street disappears when he builds something there, in this case, a fence. Thus, the County of Contra Costa was under a duty to keep it in repair. We use recycled paper. I V As you are also aware, the duty to maintain such structures or artificial conditions "runs with the land" . In addition, a young child has been injured as a result of the County pf Contra Costa's failure to repair this fence. A landowner is liable for harm to young trespassing children caused by "an artificial condition" if " (a) the place where the condition exists is one upon which the possessor knows or has reason to know that children are likely to trespass, and (b) the condition is one of which the possessor knows or has reason to know and which he realizes or should realize will involve an unreasonable risk of death or serious bodily harm to such children, and (c) the children because of their youth do not discover the condition or realize the risk involved in intermeddling with it or in coming within the area made dangerous by it, and (d) the utility to the possessor of maintaining the condition and the burden of eliminating the danger are slight as compared to the risk to young children involved, and (e) the possessor fails to exercise reasonable care to eliminate the danger or otherwise protect the children. In the case before us, my client was not trespassing upon the County of Contra Costa' s property, rather she was merely walking home from school on the sidewalk adjacent to the defective fence. Damages Brookside Hospital Dormesha was immediately taken by her mother to the hospital by a taxi cab. She was examined and found with the following objective injuries: left eye contusion, abrasion, facial abrasions, forehead lacerations, head trauma, chest wall contusion, and severe emotional distress. The doctor diagnosed her with head injury and facial lacerations. She was treated by having her wounds cleaned first. She was given an instruction booklet for head injuries, abrasions, and contusions, and was also advised to follow up with Dr. Jenkins in three days, and to take Tylenol for the pain. Richmond Pediatrics On December 12 , 1995, three days after the accident, Dormesha was taken to Dr. Jenkins at Richmond Pediatrics for a follow up examination. After her examination, he found an infection to the laceration of the forehead. The doctor prescribed her facial cream as an antibiotic. As a result of the accident, Dormesha's left eye was badly bruised and swollen shut. She was not able to see for a period one of month. c Y Future Medical Expense Robert Brink, M.D. On April 12 , 1995, Dormesha Turner was taken to Dr. Brink for evaluation of her facial scar, arising out of this accident. She was examined and the doctor determined that two scar revisions were necessary, which would include medical tattoos, skin pigmentation to camouflage the scars. Dr. Brink has determined that the estimated future cost of these revisions will be $ 1,850. 00. Medical Specials Brookside Hospital $ 291.48 Richmond Pediatrics $ 40. 00 Future Medical Expense $ 1,850. 00 Total Medical Expense $ 2, 181.48 Negligent Infliction of Emotional Distress At the time of accident, eight-year old Ranesha Moore, Dormesha's sister, was accompanying Dormesha from school when a chain linked fence fell on top of her. Ranesha and Dormesha were very close, as they shared special times and moments, as sisters do. Upon witnessing such a horrid accident, she became very frightened and concerned for her sister' s condition. In the days and weeks that followed, she was often panicked and would often cry, wondering if Dormesha would be alright by asking her mother, Doris Jackson, questions on Dormesha's injury. As a result, Ranesha had difficulty sleeping, eating, playing, and interacting with other people. Therefore, considering the damages that she has sustained, we recommend that Ranesha Moore accept $ 5, 000. 00 to settle her damages for negligent infliction of emotion distress against the County of Contra Costa. Persons who witness injury inflicted upon someone with whom they have a "close relationship" have a right to recover damages on their own behalf for the resulting emotional trauma. Loss of Consortium As a result of this terrible accident, Dormesha's mother, Doris Jackson, has been denied her daughter' s love, affection and companionship. Ms. Jackson's only concern was to heal Dormesha's injury and, hope that her daughter's physical and emotional scars will eventually heal. Sometimes, an injury is so severe that the family unit, as it was prior to the accident, will never be the same. E.g. members of the household suffer their own "detriment" when an injury renders another member incapable of engaging in routine activities and contributing to a family's financial and moral support. i Y Therefore, considering the damages that she has sustained, we recommend that she accept $ 5, 000. 00 to settle her damages for loss of consortium against the County of Contra Costa. Conclusion Dormesha Turner has suffered the consequences of an accident for which she was not at fault. Dormesha sustained a swollen left eye for one month, which had impaired her eyesight. As a result, she stayed at school for that month until her condition improved. When she returned to school, she became very frightened to walk past any chain-linked fences or gates, as it reminded her of the accident. She also felt embarrassed as her school mates constantly stared at her face and ridiculed her. Although her physical scars may heal, her emotional scars may linger for some time. Considering the nature and extent of our client's injuries, we are prepared to recommend that Dormesha Turner accept $ 27, 500. 00 to settle her claim for bodily injury against the County of Contra Costa. Please contact the undersigned after you have had an opportunity to review the enclosed documentation. Very truly yours, JACOBY & MEYERS LAW OFFICES E abe M. Guag ti Attorne at Law EMG:whh BY Y W OFFICES PERSONAL INJURY UNI i 100 flush Street.Suit_7CC,San Francisco.CA 941C4 _ 4151399-8951; rFAX:<t�r�co_togo Pursuant to Section 2695 . 2 (c) of the .Cali=ornia Code of Regulations, Title, 10, chaDter 5 ; 1 authorize the Law Offices of jacobv & Meyers to handle my clam for the loss which occurred on t This authorization shall be Valid for only one vear fro--a the below date unless renewed or revoke, by the urdersigned. Any and all prior authorization are hereby =evoked by the undersicned as of the date of this authorization. Date JA��BY& NEY& 1 'LAW OFFICES PERSONAL INJURY UNIT 100 Bush Street,Suite 700,San Francisco,CA 94104 415/399-8951; FAX:415/399-1939 Persuant to Section 2695 . 2 (c) of the California Code of Regulations, Title, 10, chapter 5; I authorize the Law Offices of Jacoby & Meyers to handle my claim for the loss which occurred on December 9 , 1994 This authorization shall be valid for only one year from the below date unless renewed or revoked by the undersigned. Any and all prior authorization are hereby revoked by the undersigned as of the date of this authorization. �Szg r�iature `' Doris Jackson for Ranesha Moore Printed Name Date' _ -We use recyded paper. - - - n 1 + Page One STATEMENT OF ACCIDENT Re: our Client(s) : ljolwe5j-a- 12 . Accident Date: 12-09-94. Location 4th Street (between Silver & Market) Richmond, CA 1. Your Name:— Your ame:Your Address : Home Phone: (j iCi� S(� 1-2 - 97 2 . Your occupation: G� _ /Gid✓ Cr✓ ✓� Business phone: Relationship to our client: 3 . Date of accident/time: Place: City: 4 . Where were you when you cs the accident that took place? Was anything blocking your view? 5 . Description of what you saw: i 3 Page Two What happened after the accident (e.g. what did witness, client, defendant, etc. do?) 6 . Diagram of what you saw: Description of surrounding conditions: Weather: Rain Snow Fog Sleet Other Road: Icy Wet Oily Muddy Snowy Road construction blocking part of the road Other 7 . Nature of injuries witnessed and to whom: 8 . Nature of -property damage witnessed and to whom ( if auto accident only) : t � Page Three 9 . Medical and other remedial care on the scene (ambulance, paramedics, vehicle tow trucks ? specify) : ��61b' 10. Police, CHP or Sheriff on the scene ? (specify) : 11. Television reporters, cameras, newspaper reporters, photographers on scene ? (specify) : 12 . Other witnesses, names, addresses and phone numbers : Ja 13 . Did you hear any of the parties or witnesses make any la statements about the accident? Specify all statements heard made: �O 14 . Have you been contacted by anyone else about the accident? (please specify who contacted you, nature of the contact, date, and what was said) : �C I DECLARE UNDER PENALTY OF PERJURY IN ACCORDANCE WITH THE LAWS OF THE STATE OF CALIFORNIA THAT THE ABOVE STATEMENTS ARE TRUE AND CORRECT AND IF CALLED AS A WITNESS I WOULD AND COULD TESTIFY COMPETENTLY THERETO. Dated — �\ 19 1� Signature �, �U, vaC��� Printed Name)(715 Vic'Z nle�'N�' `��e� Page One STATEMENT OF ACCIDENT Re: Our Client (s) : Dormesha Turner Accident Date: 12-09-94 Location 4th Street (between Silver &' Market) Richmond, CA 1. Your Name: Your Address : �7�C/ Home Phone - 1�7 2 . Your occupation: Business phone: Relationship to our client: Si SC✓'/� 3 . Date of accident/time: / 1 `� Place: G I` �Sl/ City: 4 . Where were you when you witnessed the accident that took place? 7Z/6 Was % Was anything blocking your view? / �G 5 . Description of what you saw: �i,v�✓ ��.�,�, �/ter � ���v��' Page Three 9 . Medical and other remedial care on the scene (ambulance, paramedics, vehicle tow trucks ? specify) : 10. Police, CHP or Sheriff on the scene ? (specify) : 11. Television reporters, cameras, newspaper reporters, photographers on scene ? (specify) : /vim 12 . Other witnesses, names, addresses and phone numbers: 13 . Did you hear any of the parties or witnesses make any statements about the accident? Specify all statements heard made: 14 . Have you been contacted by anyone else about the accident? (please specify who contacted you, nature of the contact, date, and what was said) : I DECLARE UNDER PENALTY OF PERJURY IN ACCORDANCE WITH THE LAWS OF THE STATE OF CALIFORNIA THAT THE ABOVE STATEMENTS ARE TRUE AND CORRECT AND IF CALLED AS A WITNESS I WOULD AND COULD TESTIFY COMPETENTLY THERETO. Dated 19 `1 Signature Printed Name,-a- Claim to: BOARD , IIPERVISORS OF CONTRA COSTA CCA IN UCTIONS TO.CLAIMANT A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code §911.2. ) B. Claims must be filed with the Clerk of the Board of Supervisors at its office. in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553. C. If claim is against a district governed by the Beard of Lup'e'l .,3013, .at..... the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the. end of this form. RE: Claim By:Doris Jackson, Guardian ) Reserved for Clerk's filing stamp for Dormesha Turner, minor ) ) Against the County of Contra Costa ) or ) District) Fill in name ) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ An amount to and in support of this claim represents as follows: exceed $ 25 , 000 . 00 1. When did the damage or in jur-y occur? (Give n=c'C, C, and h^^' 12-09-94 (12 : 15 p.m. ) 2. Where did the damage or injury occur? (Include city and county) Vacant lot on 4th Street between Silver ane'. Market Streets , located in: Richmond, Contra Costa County. 3. How did the damage or injury occur? (Give full details; use e paper if required) s Dormesha Turner, a minor of 5 years old, was walking past a vacant lot on 4th Street when the chain-linked fence fell on top of her entire body, striking her in the head and face. 46 What particular-act or emission on the part of county or district officers, servants or employees caused -the injury or damage? 1 . Premises Liability-negligent maintenance of property. 2. General negligence .- _ _ (over) 5. What are the names of cu.� es lty or district officers, serv , or employees causing the damage or injury? N/A 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. General Damages . Special Damages : left eye contusion and abrasion, facial abrasions , forehead lacerationshead ion, 7. h411 cT-emo T-nal--'-- ow was M amouE4%c Ea i' above computed? (Include the estimated amount of any prospective injury or damage.) Medical Specials 8. Names and addresses of witnesses, doctors and hospitals. (Witness) : Ranesha Moore, 7709 Ney Avenue , Oakland, CA (Doctors/Hospitals) : Brookside Hospital, 200 Vale Road, San Pablo, CA Richmond Pediatrics , 3619 Cutting Blvd. , Richmond, CA Robert Brink, 490 Post Street, San Francisco, CA ------------------------------------------------------------------------------------ 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT 12-09-94 Brookside Hospital $ 291 . 48 12-12-94 Richmond Pediatrics 40 . 00 FUTURE MEDICAL EXPENSE 1 , 850 . 00 Gov. Code Sec. 910.2 provides: "The claim must be signed by the claimant SEND NOTICES TO: (Attorney) . or bx qmeperson-cm his behalfr"---, Name and Address of Attorney Elizabeth M. GuagentiClaimari.�Is-\Signature) Jacoby and Meyers Law Offices Atto ney' ClaimantG» 100 Bush Street, #700 c� ,-��('(, ,t San Francico, CA 94104 Address CA— Telephone No. (415) 399-8951 Telephone No.( N O T I C E Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent: claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand ($1,000), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or by both such imprisonment and fine. BROOSDE"HOSPITAL • 2000 VALE ROAD L =„ SAN PABLO, CA 94806 '90536Q (510) 235-7000 �� 9 r s. �<ADMs �sf' 13x2�, E'T RSADt � #: �. b8'0 t-0 GDS 13 :23 12/ 19/94 ACTIVE OUTPATIENT DEARE � as ���,. Pis PATIENT INFORMATION n -+n �.`�!tt .�'...rro-�,�•.y�. .e�� .. •,•� #^ ,r ..y.s.fs �.rM��r " .cam• [-t. '•_ .1Irz8HA, �F �f 'J 1y x bRlt3fiLz;� fIDIINt' ID�-q. 'EERiVG r PHYSICIAN l 4�Nn •:=ry �''j�•` 4.fi �F MV23 10 t �4r^rT`o='�''mF'�'q'y. Fes,, • h �.+•- �. mfll., TIENT EMPLOYER NEAREST RELATIVE EMERGENCY CONTACT y. ms`s 'A`r� ' s � k ,i zMDThERs ACKSON� 00-0 �� m. 1141 -.�- `.z' ,- r Atir -i" KRiI# ,. 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'J-F'h'v` +rs �&.�•.�� �� _ �:'r'�.` S��,�'d�i� �1 7,[y`r�n"�Ya.'� ✓ "`�"c �r' � R-h�Q � �� '.'�.�•a r-;'CS- `f.n- ""5s+•z+' rr'^a T 2 F '#rte�� 4 it t � ` - � � �•�, � > rhl r ''iL C y ..c 3-,. L _t >. rj•�, 4 F �7"i i h a �). ;r 4"+•s r. .> - .� t!9�ino. _ ....�-:`.# t`.,� -�'?ae t,r�'�g�x.��. -n.;sa?•x r'.-.z.�;.,�"�" �*�t,n.?:(,�i .. ..y ADMIT DIAGNOSIS TT— CM.-ra-'.�NY�a.{'.�`�". '- � '_-�.-"'�r i`�"ix-"•-t �.� a° Lei �h�, t __°�s � �. BOUGHT DIY OLi�S Y bEr�`WALI I NG 1`10 E` RM SCHO[ ; , nY xr, IN By, s >' r - ,rs�t�.s;'_•..t•,� ..r., �3��..:,t'az� c �s+.;"�*'.s`.�..>nu:`,����'' �t s. ^4� .��� s REIATIVENERE� NE ACCIDENT DATE TILIF.. ONS.T DOCTOR WILff. HISTORY/COMMENTS WIL1:RENDER 7REATTv1ENT PAC`3Q )"REFERRED O ED��' "{ sr�� _ _ :'� ra ti ,..r<'its _t::4 r C�,.t �jr, 2. ''" ' Y1-•1 �ai. OLICE;OFFICER NAME` D NO, mg LVS CLERK INITIALS 8560300(7/93)SEQ.1399 ORIGINAL-DO NOT REMOVE FROM CHART - - TURNER, DORNESHA 83-31-70 IAN AHWAH, M. D. 12/9/9.4 HISTORY OF PRESENT- ILLNESS : The patient is essentially a five year old who was playing with her sister, who was pushed by her sister, falling, and supposedly a gate fell and hit her in the face, on the left side of her face . There was no loss of consciousness . She now presents for evaluation, acting appropriately as per the mom. There .is no chest wall tenderness . The child is alert and oriented at present without any complaint of pain other than her face . PAST MEDICAL HISTORY: None . MEDICATIONS : None . ALLERGIES : No known allergies . SOCIAL AND FAMILY HISTORY: Not pertinent. PHYSICAL EXAMINATION: Reveals a well-developed, well-nourished, black female in no acute distress with normal vital signs . HEENT: Normocephalic, atraumatic . There is a positive bump on the right posterior aspect without any stepoff . There is no C-spine tenderness . Neck was supple : The patient' s left face : There is a large abrasion of her forehead on the left side of her face with a small avulsion of skin just lateral to the epicanthal fold of the eye . Again, there is no stepoff here . In terms of fracture , it was nontender . Pupils were equal, round, and reactive to light. Extraocular motions are intact. Pharynx is clear. Chest: Breath sounds full and equal , no rales, rhonchi , wheezing, stridor or chest wall tenderness . Cardiovascular exam: Regular rate and rhythm, no murmurs, rubs or gallops . Abdomen: Soft, nontender, nondistended . Skin : There is no rash . Neurological exam: There was no focal deficit, good muscle tone . EMERGENCY DEPARTMENT COURSE : The patient will have the wound cleaned and Steri-Strips placed . DIAGNOSES : i 1 . Head injury. 2 . Facial laceration . PLAN: She will be given an instruction sheet for head injury, abrasion and contusion . She is to followup with Dr. Jenkins in three days for recheck. She is to ke Tyleno for pain. IAN AHWAH, M.D. IA: ase/lw DD: 12/9/94 1354 DT: 12/9/94 ,Doc. #E343LWO2 . BRK [ 4.3828 ] - EMERGENCY DEPARTMENT REPORT Page 1 J SPIT 200GVi.�.LER AID,-SANPABLID.CALIF.,94806, ...y.. �.v.ui i ici nuuvDail rauw;vn aVow .. - DATE: - ❑ Unschedul return Within 72 Hours — - L7 p 0 6 Name at,First,M.I.) r Se A'a DOB s Carrier Pn I/ET � III' 619OS360METH83-31 ARRIVAL El OF Ambulatory ❑EMT ❑W/C PMD TURNER, 04PM E.SMA R El PM El Other TRIAGE TIME EXAM RM TIME POLICE N T FIED? SOCIAL SERVICES J E N K I N S,Y—E R MDS ❑YES ❑YES 120954 ;F X Chief Complaint VA G� D—OS— t - PMH MED ATIO one LNMP — AB— LAST TD ALLERG S NKA BP P Tom\ B ATA `�., a, Ilk \ �- v� M.D.TIME rRICTATED ' INTERPRETER LANG Irb FGLLOW-U HISTORIAN FAMILY/FRIEN S ❑YES IN WAITING RM ❑NO Si natur . R.N. H+P SH: `` i`' !•I ` FH: PMH: v 1 14 PROCONTERP. ;L l l� ❑ SEE PROGRESS NOTE: ('' 1 Consulting Physician's Name Time Called Time Responded" Time Arrived "` IAB TIME X-RAY TIME MD 0t7DERS INSYPANCE AUTH TI E ROUTE SIT SI URE ORD INITIAL ORD INITIAL ! ❑ER Panel — ❑Cx R �.(. ❑BC ❑Abd X-R - — ❑Lytes ❑C-Spine — ❑PT/PTT ❑Cl ABG ❑ — ❑U/A ❑ — ❑U/A PREG ❑Old Record — ❑BICX ❑EKG = — ❑- ❑ Condition: ❑Improved ❑Stable ❑Critical ❑Expired DISP: ❑ADMIT SERV RM TIME DX 1. PMD ACCEPTING ❑ TRANS TO: MD 3. TRANSPORT BY: ❑ BLS ❑ ALS - ED/DC TIME E)IOME MD/SIG - -MART COMPLETE - 7015-103A(1193LSEQ.1.354 - MEDICAL RECORDS. - - ED NURSING FLOW SHEET - DATE: • 019 Q S 3 b Q NAME: Tt;F:srER , QOaNf5Na g 31 - 10 Ora Umin ❑Cannula ❑Mask [ ?IDS Cardiac Rhythm ;�q 1 2 3 4 5 6 7 8 9 x Pupil Guage(mm) j 1 Z Q g s LV PEDIATRIC START AMOUNT RN HYDRATION/MUCOUS COLOR ACTIVITY LEVEL TIME AMT PARENTAL FLUIDS/BLOOD SITE ABSORBED SIG. MEMBRANE ❑Pink DPfayful ❑Moist ❑Pale ❑Irritable ❑Dry ❑Cyanotic ❑Dull ❑Poor Skin Turgor GENERAL ASSESSMENT CARDIAC RESP EENT TRAUMA ❑HR Reg. ❑Qua[.Normal ❑No Deficit ❑Nothing Visible ❑HR Irreg. ❑Clear Bilat ❑Deficit ❑Laceration) ❑Chest Pains ❑Labored SKIN 0i ❑Palpitations ❑Rhonchi 'karrh ❑Edema ❑Rates l r�ry ❑Retractions ❑Cool ❑Bur& ❑Wheezes ❑Diaphoretic puncture ❑JVD ❑Pale GSW GI ❑Rash ❑N/A ❑ fortuity ❑Soft Swelling ❑Bowel Sounds' �ruising GLASGow coSCALE Activity re Infants Children and Adults ❑Tender INPUT OUTPUT ❑ROIv1/"Decr ase / EYE / a� Spontaneous Spontaneous / li OPENING --L To speech or sound To speech ❑Distended ❑ / ( 2 To painful stimuli To pain IV URINE 1 None None ❑Riged i VERBAL �5 Appropriate words or sounds; Oriented PO EMESIS social smile;fixes and follows 4 Cries but consolable Confused 3 Persistently irritable Inappropriate words OTHER OTHER 2 Restless;agitated Incomprehensible words None None MOTOR % Spontaneous rlovement Obeys commands �5 Localizes to pain Localizes to pain 4 Withdraws to pain Withdraws to vain 3 Abnormal llexron(decorticate) Abnormal flexion (decorticate) 2 Abnormal extension(decerebrate) Abnormal extension (decerebrate1 1 None(flaccid) None(flaccidl Adapted Iron Teasdale.G..d Jennetl.B.(1974).L-4.2.81-84;and James. TOTAL / N F r Annals,15(1).17. � SIGNATI E - TIME: PUPILS: Size R NR fz� Size R NR PULSE TIME BP P RESP T OX GCS NURSING PROGRESS NOTES to e7 _ METHOD OF DISCHARGE: _ 01I66AR E DISPOS4T1 N TIME: p AMBULATORY ❑WIG ❑CARRIED ❑CRUTCHES ❑CRUTCH WALKS WELL ❑AMBULANCE ADMIT PT.BELONGINGS: ❑PATIENT ❑FAMILY SAFE LIST ITEMS: ❑MEDS TO PHARMACY - RN SIGNAT g;� � 7015-105(6194)SEQ.1426 BROOKSIDE HOSPITAL EMERGENCY DEPARTMENT NURSING 7U> >wE VORhESNA R E If Ir FLOW SHEET #7015-105(9/92) `"x bNS •V—ER RIDS G/ �t�Ot�3�9 p� Lats DATE/c,2— / NAME TIME MEDICATIONS ROUTE SITE RN TIME MEDICATIONS ROUTE SITE RN SIGN. SIGN. TIME BP P RES T P OX E GCS NURSING PROGRESS NOTES J- _ c�L BROOKSIDE HObPITAL CONDITIONS OF SERVICE , SAN PABLO,CALIFORNIA I " 1.CONSENT TO MEDICAL AND SURGICAL PROCEDURES J The undersigned consents to the procedures which may be performed during this hospitalization or. 1 =.`l 2 on an outpatient basis,including emergency treatment or services,and which may include but are not limited to laboratory procedures,x-ray examination,medical or surgical treatment or procedures,x- ray examination, medical or surgical treatment or procedures, anesthesia, or hospital services rendered the patient under the general and special instructions of the patient's physician or surgeon. 2.NURSING CARE This hospital provides only general duty nursing care unless,upon orders of the patient's physician,the patient is provided more intensive nursing rare.If the patient's condition is such as to need the service of a special duty nurse,it is agreed that such must be arranged by the patient or his/her legal representative.The hospital shall in no way be responsible for failure to provide the same and is hereby released from any and all liability arising from the fad that said patient is not provided with such additional care. 3.LEGAL RELATIONSHIP BETWEEN HOSPITAL AND PHYSICIAN All physicians and surgeons furnishing services to the patient,including the radiologist,pathologist,anesthesiologist and the like,are independent contractors with the patient and are not employees or agents of the hospital.The patient is under the care and supervision of his/her attending physician and it is the responsibility of the hospital and its nursing staff to carry out the instructions of such physician.It is the responsibility of the patient's physician or surgeon to obtain the patient's informed consent,when required,to medical or surgical treatment,special diagnostic or therapeutic procedures,or hospital services rendered the patient under the general and special instructions of the physician. 4.RELEASE OF INFORMATION Upon inquiry,the hospital may make available to the public certain basic information about the patient,including name,address,age,sex,general description of the reason for treatment (whether and injury, bum, poisoning, or other condition), general nature of the injury, bum, poisoning or other condition, and general condition. If the patient or the patient's legal representative does not want such information to be released,he/she must make a written request for such information to be withheld.The patient or the patient's legal representative may obtain a separate form for this purpose upon request. The hospital will obtain the patients consent and his/her written authorization to release information,other than basic information,concerning the patient,except in those circumstances when the hospital is permitted or required by law to release information. The undersigned agrees that,to the extent necessary to determine liability for payment and to obtain reimbursement,the hospital may disclose portions of the patient's record,including his/her medical records,to any person or corporation which is or may be liable,for all or any portion of the hospitars charges,including but not limited to insurance companies,health care service plans,or workers'compensation carriers.Special permission is needed to release this information where the patient is being treated for alcohol or drug abuse. 5.PERSONAL VALUABLES It is understood and agreed that the hospital maintains a safe for the safekeeping of money and valuables,and the hospital shall not be liable for the loss or damage to any money,jewelry, eyeglasses,dentures,hearing-aides,documents,furs,fur coats and fur garments or other articles of unusual value and small size,unless placed therein,and shall not be liable for loss or damage to any other personal property,unless deposited with the hospital for safekeeping.The liability of the hospital for loss of any personal property which is deposited with the hospital for safekeeping is limited by statute to rive hundred dollars ($500.00) unless a written receipt for a greater amount has been obtained from the hospital by the patient. I do not have itemslvaluables to lock in the safe 6.FINANCIAL AGREEMENT PatienwarenVGuardianCa mer,-ator fats The undersigned agrees,whether he/she signs as agent or as patient,that in consideration of the services to be rendered to the patient,he/she hereby individually obligates himseff/herse`f to pay the account of the hospital in accordance with the regular rates and terms of the hospital. Should the account be referred to an attorney or coilection agency for collection, the undersigned shall pay actual attorney's fees and collection expenses.All delinquent accounts shall bear interest at the legal rate. 7.ASSIGNMENT OF INSURANCE BENEFITS The undersigned authorizes,whether he/she signs as agent or as patient,direct payment to the hospital of any insurance benefits otherwise payable to or on behalf of the undersigned for this hospitalization or for these outpatient services,including emergency services if rendered,at a rate not to exceed the hospital's regular charges.It is agreed that payment to the hospital, pursuant to this authorization,by an insurance company shall discharge said insurance company of any and all obligations under a policy to the extent of such payment.It is understood by the undersigned that he/she is financially responsible for charges not covered by this assignment.The undersigned assigns to providers of care or hospital based physicians any insurance or health plan benefits as described above. 6.HEALTH CARE SERVICE PLAN OBLIGATION This hospital maintains a fist of the health care service plans with which it has contracted.A list of such plans is available upon request from the financial office.The hospital has no contract express or implied,with any plan that does not appear on the list.The undersigned agrees that he/she is individually obligated to pay the full cost of all services rendered to hirvher by the hospital if he/she belongs to a plan which does not appear on the above mentioned list 9.NOTIFICATION OF BILLING Services provided(either inpatient or outpatient)at this hospital may generate more than one bill.One bill will cover your hospital charges.Other bills may come from:Anesthesiologist, Pulmonologist,Cardiologist,Pathologist,Radiologist or any other physician,or reference laboratory services.If you are being'Admitted to Observation',please know your physician has ordered an outpatient service.Although you will be in a'regular hospital bed',you will be considered an outpatient(by Medicare regulations).You may be responsible for a 20°o co-pay. The undersigned certifies that he/she has read the foregoing, received a copy thereof,and is the patient,the patient's legal representative,or is duly authorized by the patient as the patent's gene agent to execute the above and accept its terms. If other than patient,indicate relationship: —'tone rl i�l - Financial Res '_tAQreement by P9rson Other than the Patient,or the Patient's Legal Representative:I agree to a al responsibility for services rendered to the patient and - to accept the terms of the Financial Agreement,Assignment of Insurance Benefits,and Health Care Service Plan Obligation Provisions above. REASON FOR NOT SIGNING(Document dateibme/signature/reason not obtained): - F-maly p-p-abla parry ' A COPY OF THIS DOCUMENT IS TO BE DELIVERED TO THE PATIENT AND ANY OTHER PERSON WHO SIGNS THIS DOCUMENT. asw-1o6(10M)MO.829 i; f;fi-;nl_. nEconDS - - PLEASE NOTE: The examination and treatment that you have received in the Emergency Department has been given on an emergency basis only, and is not intended to be a substitute for complete medical care. It is important that you be checked again as instructed. If you notice any worsening of your symptoms, promptly call your referral doctor or return to the hospital. If an x-ray or EKG has been performed, it has been read on a preliminary basis only, and will be reviewed by a radiologist or internist within 24 hours. You will be notified if additional findings are noted. YOUR DIAGNOSIS IS: TRAUMA ADULT PEDES GYN-GU Laceratiorv?unctureead Injury Yiral URI Pneumonia/Bronchitis Fever Control Otitis Media Miscarriage,Spont. PID SprairdStrain Concu Gastroenteritis Asthma Viral URI Otitis/Extema Miscarriage,Threaten Ovarian Cyst Bu asro Neck/Back Pain Ulcer/Gastritis COPD Flare' Gastroenteritis Pneumonia/Bronchitis Irregular Vag.Bleed Curettage ntuston Corneal Abrasion' Esophagitis' Tension Headache Pharyngitis,Viral' Asthma' Vaginitis' Menstrual Pain' ra Abscess' Chest Wall Pain' Hypertension,New Pharyngitis,Strep' Poisoning,Pedes' Cystitis,Fem. Kidney Stone' Cast and Splint Care Cellulitis' Seizure,Recurrent' Dehydration' Pharyng,Strep Pend'g' Febrile Seizure' Pyelonephritis' GC/Chlamydia' Suture Removal- Animal Bite' Abdominal Unknown Overdose' Hives' Croup' Scabies No Complications Alcohol W/D Syndrome Biliary Colic Chicken Pox Conjunctivitis' PRINTED INSTRUCTIONS PROVIDED: Q indicated above ❑ other: ❑ PARENTS/GUARDIAN INFORMED OF CAR SEAT LAW. ADDITIONAL INSTRUCTJIONS: ❑ Call 235-7006 x 2100 on for the results of your test: YOUR EMERGENCY DEPARTMENT .HY IAN HAS BEEN: P. Kivela D.Mendelson E. Nipomnick,I.Ahw J. Rampulla M.Gibson R.Turner B.Gustin R.Mandiberg L.H.Hodgson T.Smith I have received and understand the instructions outlined above. Patient or Representative ' Staff ' Date D/C Time ------------------------------------= C_- q HOSPITAL WORK/SCHOOL NOTIFICATION FORM was seen in the Emergency Department on He/She should be able to return to work/school on with the following restrictions: _____ --------- X • ,`M.D. -------------------------------- EMERGENCY DEPARTMENT PRESCRIPTION Drug Name Mn. Dis Sig. ❑ Do not drive while Physician Printed taking medication. Signature Name ❑ Do not substitute. M.D. • ❑ Spanish Instructions. P.Kivela D.Mendelson E.Nioomr"CR'I.AhwahVJ.RarSpullaI M.Gibscn P..Turner B.Gustin R.Mandiberg L.H.Hodgson T.Smith b ' SOW b3-11 ` SNINN3r � N3 - V YH93WVCO 1 �13NNnL - ED BROOKSIDE HOSPITAL .� ED Vale Road OL —TE g n ? E S � b T 9 San Pablo,CA 94806 EMERGENCY DEPARTMENTfi b b 2 T DISCHARGE INSTRUCTIONS 7015-107 SEQ.790(9/93) - P,rlFtllr :Al PATIENT'S NAME AGE D� MONDAY DEC 121994 CHIEF COMPLAINT: HISTORY PRESENT ILLNESS: } t , SIGNIFICANT A TIST Y: / PHYSICAL.EXAM TEMP: �j WT HT, BP. GENERAL APPEARANCE_�� SKIN: HEENT:" NECK: -� CHEST: LUN HEA ABDOME GENATALIA: EXTREMETIE REFL . _ - - / IMPRESSION: DISPOSITION. 04—'2i-1995 12: 24 .235b5B7 - BH PATIENT ACCOUNTS - P. 03- -_ FINAL 12/'14/917 BROOKSIDE HOSPITAL I to - = r l 2000 Vale Road San Pablo, CA 94806 ® N 1 • � 9 UORME5r1A R TURNFK 61905360 � 83114 X F u 1 • f • • 12/(1N/y4 [0 12/09/94 13 :24 02/ 10/bc) 61322645b AHWAHy IAN 027° DORIS JACKSON 361 uRUVE AVN #B MEDT—CAL ' OUTPATI�ly7 • KICHMOND LA 94ts01 MCALC}P o1 �2Z645b9 2 /Ud 1 ED FACILITY tIi 40.259039 145.00 145.x0 EMERGENCY ROOM 145. OU 145. v0 2 /09 1 INTEKMED F/R EXAM 4:8•?27108 100.00 1_(}0100 FR kM—PRnF FEE 100.Ou iou.Un 4 /00 1 FIILYSPORIKI PACKET 47163040 2.9b [ . y� PHARMACY ?. 9b 1/OP 1 STER1 STRIP 1/1 1^1 4470497.7 11 . 0u 14. 1;0 2 /09 1 5p(JN6FS 4X4 I()—Pr, 44700993 10.00 IU. U^ LNq 1 CHJX EACH 44700910 6. 5U 6.50 e109 1 LINEN PACK 40158502 13.00 13.00 CENTPAL SUPPLIES 43.5p . 43 .50 hi is:l NEFEi:11)Ph I1FNT auLt'u.4 t:AL I �C]I,IF=n St.n ALDITIONAL PATI-N ._'nnF;:ivu;i'L•VCF w t� °:I I' ' `Y H NOT Fi.. ten; Tfl., I'! ''OA,, NF- CA R k,1-9 5,Dn r:!!I 1'A i! A; L i _1 31 PLEASEj'LQt3lc?:.GG2�f'• /�� ANO • • , ' , .G t t'' REMIT TO r7 QX{j�0. N PROFI f t]RrAP11ZATION r Hlil I; —-- :i r: :•, .,'•r ::T:. D PT.7,7?P.O.m:>,x,Gtnccr _�NFrinn:r.!cr^I^.-r•e..•r_ IAC niri r.. . �.,.,.._... •iil �,,:I•,:YQ, _ _1 "t :r — 04-27.-1555 .12;23 235.69-E7 - BH PATIENT ACCOUNTS P. 0'2- FINAL 12/14!94 BROOKSIDESPITAL 1 9 I L L` �-�..) 2000 Vale Fuad • San Pablo; CA 94806 4*SU1jMARY HILLY N DORMESHA R TURNER 61905360 1333170 X E III mill mmeNommurm: • lam 91111rMWIPPA .- 12/^9/94 13 40 12/ 09/94 13 24 02/10/89 6.132Z645d AHWAH, IAN 0275 UnRIS JACKSON •' 361 URUVE AVN X8 rME!D?1�-�CAL 'OUTPATTENT KICHMOND LA 94b0.1 MCLU+' o13Tt645$9. EMERGkNCY RUOM 145.00 14b•UO FR RM-PROF FEE 100.00 100.00 PKAKMACY 2.9d 2098 CENTRAL SUPPLIES 43 .50 43 ._50 TOTAL . CURRENT CHARGES 291. 48 [91 .48 BALANCE FORWARD CHARGES TO-DATE PAYMENTS AUJS . DEDUCTIBLE AMOUNTS ACCOUNT BALANCE 291.. 48 1=1 9 In 0 111r 1 Afa III;I N-1:;rnw ry 1 NU411}=" Af)1):I H"NA I w I II 1•Ji46d.m5 Y M ht:(.f :d:i l::N..-.!iYi;l r.::• I fHi}: FIR I D.'A'i ✓H!r:?,I i=1: .iii ! I!,li•a[+i=):.'.r CU�:FESPU'SeN�e. C:aHH;Fhg lx)>Jtr f-'?'t AtJ�'rANI(7'r lei .:G4 glP.1; ' •; "YI s • • • i , • • 11 ;'Jf PLEASE . ANON PRORORGANIZATION I*•moi.;PF af:; n.3.7,- s::0.14'!E :REMIT TO BOX SAN rR NCI:CO.CA 1kN0.9':-FG031:1;4V .A 1479 1 X41 c:. 04-27=1955 12:24 235E9E7 - gl{ PAT-1ENT At, UtJTS P. 04 OREM fTNAta J i BROOKSID.E HOSPITAL BILL r'-U7U 2000 Vale Riad • San Pablo, CA 94806 Z N .. .. i30RMkSHA R Tt1RHEk 6190 6U 83. 1Z� X f 12/^y/94 13 ,ZO 12/ 09/94 13 :24 U2/10/89 613226456 AHWAH, IAN 027ti DORIS JACKSON • .161 GPOVE AVN 98 MLOT—CAL ...'O�VTPATTENT: KT.CHMOND GA 94b01 MCALOP bl:s2464589 TOTAL CURRENT CHARGES 91 .hA BALANCL- FOkWARU CHARGES TO•-GATE PAYMENTS AUJS . UFOUCTIFLE AMOUNT'S ACLOUNT 8ALANCE 2n5iE F.-OP"ftitraw t;i niatp!:y .•.- .._..--- i[N a! itJU!.'P,L':1041 gnb;TiONA_�',.1 iLid :!tl I!IJ[•.LUY M1.'(.`J"c?','11'1 I( '. •., ,.•+ ' !:'rn❑a r+t:i. 1.1I SCM I H; r:u I vv;.. 1'R'i'i,r4 l :7 r;:.;;s.tt`, j L Q 1• 4 R — — r:a�r3ler,'s.:or•:c� ar,r•r;�l ............. i'C Hha e - 11'93' PLEASE /{ J n/ - 1•:'Ka REMIT Tfl 'Z44k14'j1cdE r7"'Jdhacze A NON PHOFrr ORGAN1ZnTON RICHMOND PEDIATRIC MEDICAL GROUP, INC. WILLIAM M. JENKINS, JR., M. D. ROBERT E. MINES, JR., M. D. 3619 CUTTING BOULEVARD RICHMOND.CALIFORNIA 94804 TELEPHONE:(415)5291271 January 12, 1995 To whom it may concern: Re: Au, DIEDI-CAI, PATIENTS OUR FEE FOR EVERY OFFICE VISIT IS $40.00 MEDI-CAT, REIMBURSEMENT IS $ 16,56 PER OFFICE VISIT, Surgery Evaluation To: From: Date of Loss: Client/Patient: ( Dear Please provide the following information re,;arding the above referenced client: i. Is surgery required arising out of injury sustained in this accident? Yes _ No 2 . 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