petition of private criminal complaint in lancaster county court of common pleas clerk of court v....
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Petition of Private Criminal Complaint in Lancaster County Court of Common Pleas Clerk of Court v. Lancaster City Police for 302 Warrant of July 9, 2015 Filed September 23, 2015TRANSCRIPT
Stanley J. Caterbone, Petitioner
IN THE COURT OF COMMON PLEAS OF LANCASTER COUNTY, PENNSYLVANIA
CRIMINAL DIVISION STANLEY J. CATERBONE : Docket No. __________
vs. :
KIETH SADLER, Chief, Lancaster City Police DepartmentLANCASTER CITY POLICE DEPARTMENTDETECTIVE CLARK BEARINGER, Lancaster City Police DepartmentOFFICER WILLIAMSOFFICER BINDERUP
ORDER
AND NOW, this __________ day of___________ , 2015, the Above named Defendants,
in part or in whole, shall be issued citations for violating 18 Pa. C.S.A. § 2901
KIDNAPPING ; and § 3503 CRIMINAL TRESPASS. The Issuing Authorities shall file the
appropriate citations for the Commonwealth of Pennsylvania.
AND NOW, this __________ day of___________ , 2015, Chief Keith Sadler and Stan J.
Caterbone shall enter into MEDIATION with a accredited local or state agency for violating 18 Pa.
C.S.A. § 2901 KIDNAPPING ; and § 3503 CRIMINAL TRESPASS.
AND NOW, this __________ day of___________ , 2015, I am ORDERING the
EMERGENCY PRELIMINARY INJUNCTION, Case No. 15-06985 in the Lancaster County Court of
Common Pleas, be hereby GRANTED AND the Matter before the Superior Court be hereby
WITHDRAWN, for violating 18 Pa. C.S.A. § 2901 KIDNAPPING ; and § 3503 CRIMINAL
TRESPASS.
BY THE COURT:
________________________J.
ATTEST:
___________________________Stanley J. Caterbone, Petitioner
1 of 9 Thursday, September 24, 2015
IN THE COURT OF COMMON PLEAS OF LANCASTER COUNTY, PENNSYLVANIA
CRIMINAL DIVISION STANLEY J. CATERBONE : Docket No. __________
vs. :
KIETH SADLER, Chief, Lancaster City Police DepartmentLANCASTER CITY POLICE DEPARTMENTDETECTIVE CLARK BEARINGER, Lancaster City Police DepartmentOFFICER WILLIAMSOFFICER BINDERUP
PETITION FOR REVIEW OF PRIVATE CRIMINAL COMPLAINT
TO THE HONORABLE, THE JUDGES OF THE SAID COURT:
Petitioner, Stanley Caterbone, hereby petitions the court for the review of the
decision issued by Chief County Detective Michael Landis, Office of the Attorney for the
Commonwealth issued on August 31, 2015, not to file criminal charges from the Private Criminal
Complaint attached hereto.
§ 2901. Kidnapping.(a) Offense defined.--Except as provided in subsection (a.1), a person is guilty of kidnapping if he
unlawfully removes another a substantial distance under the circumstances from the place where he is found,or if he unlawfully confines another for a substantial period in a place of isolation, with any of the following intentions:
(1) To hold for ransom or reward, or as a shield or hostage.(2) To facilitate commission of any felony or flight thereafter.(3) To inflict bodily injury on or to terrorize the victim or another.(4) To interfere with the performance by public officials of any governmental or political function.§ 3503. Criminal trespass.
(a) Buildings and occupied structures.--(1) A person commits an offense if, knowing that he is not licensed or privileged to do so, he: (i) enters, gains entry by subterfuge or surreptitiously remains in any building or occupied structure or
separately secured or occupied portion thereof; or (ii) breaks into any building or occupied structure or separately secured or occupied portion thereof. (2) An offense under paragraph (1)(i) is a felony of the third degree, and an offense under paragraph
(1)(ii) is a felony of the second degree. (3) As used in this subsection:
"Breaks into." To gain entry by force, breaking, intimidation, unauthorized opening of locks, or through anopening not designed for human access.
_____________________________ Date: September 23, 2015 Stanley J. Caterbone, Pro Se Litigant
1250 Fremont Street (717) 669-2163Lancaster, PA 17603 [email protected] www.amgglobalentertainmentgroup.com
2 of 9 Thursday, September 24, 2015
BRIEF IN SUPPORT OF PRIVATE CRIMINAL COMPLAINT
JURISDICTION:
The proper procedure for seeking approval of private criminal complaints is set forth in
Pa.R.Crim.P. 133 as follows:
(a) When the affiant is not a law enforcement officer and the offense(s) charged include(s) a
misdemeanor or felony which does not involve a clear and present danger to any person or to the
community, the complaint shall be submitted to an attorney for the Commonwealth, who shall
approve or disapprove without unreasonable delay.
(b) If the attorney for the Commonwealth
(1) Approves the complaint, the attorney shall indicate this decision on the complaint form and
transmit it to the issuing authority;
(2) Disapproves the complaint, the attorney shall state the reasons on the complaint form and
return it to the affiant. Thereafter the affiant may file the complaint with a judge of a Court of
Common Pleas for approval or disapproval;
(3) Does not approve or disapprove within a reasonable period of time, the affiant may file the
complaint on a separate form with the issuing authority, noting thereon that a complaint is
pending before an attorney for the Commonwealth. The issuing authority shall determine whether
a reasonable period has elapsed, and when appropriate, shall defer action to allow the attorney
for the Commonwealth an additional period of time to respond.
In determining whether to approve or disapprove a private criminal complaint, the district
attorney may rely on either a legal assessment of the complaint, or wholly discretionary matters
of policy. Commonwealth v. Benz523 Pa. 203, 565 A.2d 764 (1989). When thedistrict attorney
rests the disapproval of a private criminal complaint on wholly discretionary matters of policy, this
Court will not disturb that determination, absent a gross abuse of discretion. Commonwealth v.
Pritchard,408 Pa. Super. 221, 596 A.2d 827 (1991). See also In Re Wood, 333 Pa. Super. 597,
602, 482 A.2d 1033, 1036 (1985) (quoting Commonwealth v. Eisemann, 276 Pa. Super. 543, 419
A.2d 591 (1980)) (prosecutorial discretion may depend on policy matters wholly apart from the
existence or non-existence of probable cause; courts are wary of supervising exercise of such
discretion). When the district attorney bases a dismissal solely on a lack of evidence,however, this
Court will apply a de novo standard of review because such a decision is not entitled to the same
deference afforded a policy decision not to prosecute, even where a prima facie case exists.
Commonwealth v. Benz, supra at 208 n.4,565 A.2d at 767 n.4. The special deference extended to
a policy decision not to prosecute arises from the deference accorded the discretionary use of
executive powers conferred in the district attorney. Id. The power to approve or disapprove
private criminal complaints granted under Pa.R.Crim.P. 133 to the district attorney is consistent
with the authority which that office regularly exercises in deciding to initiate or discontinue
prosecutions. In re Petition of Piscanio,235 Pa. Super. 490, 494, 344 A.2d 658, 660 (1975). The
requirements for the issuance of process pursuant to a criminal complaint are provided in
3 of 9 Thursday, September 24, 2015
Pa.R.Crim.P. 134.
ARGUEMENT
“The proper procedure for seeking approval of private criminal complaints is set forth in
Pa.R.Crim.P. 133 as follows:
(a) When the affiant is not a law enforcement officer and the offense(s) charged include(s) a
misdemeanor or felony which does not involve a clear and present danger to any person or to the
community, the complaint shall be submitted to an attorney for the Commonwealth, who shall
approve or disapprove without unreasonable delay.
(b) If the attorney for the Commonwealth
(1) Approves the complaint, the attorney shall indicate this decision on the complaint form and
transmit it to the issuing authority;
(2) Disapproves the complaint, the attorney shall state the reasons on the complaint form
and return it to the affiant. Thereafter the affiant may file the complaint with a judge of a Court
of Common Pleas for approval or disapproval;”
The Petitioner's Private Criminal Complaint was dismissed by the following statement by
Michael L. Landis, Chief County Detective: “Pursuant to Rule 506 of the Pennsylvania Rules
of Criminal Procedure, the Private Criminal Complaint you submitted to our office
seeking to charge various police officers of the Lancaster Bureau of Police with criminal
offenses, has been reviewed by an Assistant District Attorney and has been
disapproved. The complaint is enclosed.”
The above clearly does not satisfy Pa.R.Crim.P. 134, and/or other statutes that
include the rules for Private Criminal Complaints.
The above named defendants did engage in the following:
A. An Act of Malice and Recklace Disregard for the false statements in the 303 Hearing by
both Dr. Silvia Gratz and Lt. Clark Bearinger.
B. Conspiracy and Collusion to Obstruct Due Process in the Lisa Michelle Lambert Case,
No. 5:14-cv-02559 in the U.S. District Court for Eastern Pennsylvania of which I am
named MOVANT, by not releasing medical records in a timely fashion. It has been
about 1 month and the staff continues to state that the invoice is on it's way.
C. Gross negligence in the manner in which psychiatric drugs were administered and the
misinformation with regards to dosage and strength.
D. Medical Malpractice in the lack of care when requesting help and treatment for illnesses
and ailments during the stay, with one incident when I begged to go to the emergency
4 of 9 Thursday, September 24, 2015
room for not being able to breath.
E. Assault and Battery in providing an environment for chemicals to be used
against me, such as chloroform or something similar.
1. Petitioner was named the MOVAN in the Lisa Michelle Lambert Habeus Corpus Case of 2014
on June 25, 2015 in the U.S. District Court for Eastern Pennsylvania Case No. 14-02559.
2. Petitioner has been formerly and officially making complaints for computer hacking,
harassment, threats to person and property, etc., to the Lancaster City Police, the
Lancaster County District Attorney's Office, the Pennsylvania Attorney General's Office, and
the FBI in Harrisburg prior to July 9, 2015.
3. Petitioner has filed civil complaints against the Lancaster City Police Department in both
federal (06-4650, 05-2288) and state (08-13373) courts since 2005.
4. Petitioner had formerly and officially attempted to engage Chief Kieth Sadler of the
Lancaster City Police Department into Mediation through the Lancaster Human Rights
Commission at 225 West King Street, Lancaster, Pennsylvania and worked with intake
person Linda Struass prior to the year 2010.
5. Petitioner had introduced legislation to the Pennsylvania General Assembly through Michael
Sturla, House of Representatives, regarding organized stalking and electronic weapons in
2009 and again in 2015 prior to July 9, 2015.
6. Petitioner was a Federal Whistleblower in 1987 with regards to International Signal &
Control, or ISC.
7. Petitioner has been receiving Social Security Disability Benefits since 2008 for symptoms
and illnesses related to U.S. Sponsored Mind Control, and was declared disabled in
December of 2005 by the Social Security Administration. There was no medical or
psychiatric evaluations performed for the application and approval process, nor were there
any medical/psychiatric professionals listed in any documentation.
The Following Address the Federal Whistleblower and ISC Issues
8. ISC was indicted in 1991 for illegal arms transfers to Iraq and a $1 Billion Fraud.
9. Petitioner has been claiming and proving with a preponderance of evidence of a vast
criminal and civil conspiracy to cover-up his allegations and his public and official
disclosures.
10.The False Arrests and Prosecutorial Misconduct that Stan J. Caterbone was subject to in
1987 was an effort to cover-up the allegations made by Stan J. Caterbone in the Spring
and Summer of 1987 after the Meeting of June 23, 1987 with ISC and United Chem Con
Executive Larry Resch.
11.The ISC Fraud and Sales of Arms to Iraq Story by the ABC News Nightline with Ted Koppel
and the Financial Times of London in May, July, and September of 1991 was most likely
5 of 9 Thursday, September 24, 2015
initiated by Lancaster Newspapers reporter Thomas Flannary.
12.Thomas Flannary's mysterious death in February of 2004 was either murder by poison or
was a cover story to hide the fact that he was a CIA operative used to control the flow of
information, disinformation, and propaganda. It is highly subject that he began his career
with Lancaster Newspapers in 1987 and is not a native Lancastrian.
13.The ISC merger was not completed until December of 1987, 3 months after the False
Arrests of Stan J. Caterbone.
14.The official meeting with the Pennsylvania Securities Commission Agent Howard Eisler in
September of 1987, which was solicited by Agent Eisler was an effort to illegally
interrogate Stan J. Caterbone without a legal subpoena.
15. In the months after the June 23, 1987 meeting with ISC Executive Larry Resch Stan J.
Caterbone had personally solicited a vast array of local, state, and federal officials,
including the FBI and Congressman Robert Walker, PA State Representative Gison
Armstrong for assistance in the retaliation and slander campaign that was in progress.
16.That there is credible linkage between the ISC Scandal, U.S. Sponsored Mind Control, Stan
J. Caterbone's family VICTIMIZATION, and LANCASTER COUNTY, PENNSYLVANIA.
17.The Zook Murder Appeal proves that Lancaster County Detective Michael Landis, Judge
James Cullen, and Judge Farina of the Lancaster County Court of Common Pleas were all
involved in U.S. Sponsored Mind Control before 2004 and before Stan J. Caterbone went
public with his VICTIMIZATION of U.S. Sponsored Mind Control.
18.Bobby Ray Inman, former director of the National Security Agency (NSA) was on the Board
of Directors of ISC and was involved in U.S. Sponsored Mind Control Technologies through
his company S.A.I.C. Corporation. Bobby Ray Inman would later be selected by Former
President Bill Clinton for his Director of Defense, but would later remove himself due to
allegations and public scrutiny for his role in the ISC scandal.
19. In the Fall of 1991 Robert Gates was nominated for Director of the Central Intelligence
Agency (CIA) and during his televised confirmation hearings the was subject to brutal
array of questions concerning his participation in the ISC scandal. He went on to be
nominated and later would serve both the Bush Administrations and the Obama
Administrations as Secretary of Defense until resigning in 2011.
20.The above finding of facts and evidence corroborates a vast conspiracy and criminal
enterprise that violates both civil and criminal RICO statutes and antitrust statutes.
21. The above would constitute treble damages for Stan J. Caterbone and Advanced Media Group in U.S. District
Courts, specifically in the Eastern District for Pennsylvania Case No. 05-2288, 06-4650, 14-02559; and
Case No. 08-13373 in the Lancaster County Court of Common Pleas.
22.Petitioner was taken into assaulted, arrested and taken into custody under the following
Pennsylvania Mental Health Laws and RegulationsPennsylvania Rules:
7301. Persons who may be subject to involuntary emergency examination and treatment
6 of 9 Thursday, September 24, 2015
(a) Persons Subject. -- Whenever a person is severely mentally ill and in need of
immediate treatment, he may be made subject to involuntary emergency
examination and treatment. A person is severely mentally disabled when, as a result
of mental illness, his capacity to exercise self-control, judgment and discretion in
the conduct of his affairs and social relations or to care for his own personal needs is
so lessened that he poses a clear and present danger of harm to others or to
himself.
23.Detective Clark Bearinger did engage in a fraud with Lancaster County Crisis
Intervention or the County Administrator when he changed to a 7301.(b)
Determination of Clear and Present Danger in the Stanley J. Caterbone Petition
Statement.
24.Defendant's did approach Petitioner outside his residence on Fremont Street while
Petitioner was mowing his front lawn.
25.Petitioner did immediately go directly inside his residence and lock his doors in fear for his
safety and in fear of physical harm.
26.Petitioner did immediately go directly to his front bedroom on the second floor and tried
desperately to communicate with the Defendant's and talk them down and did warn the
Defendant's of his legal and civil rights.
27.Petitioner did also make declaratory statements that the assault was retaliatory for the
Petitioner's active role in the Lisa Michelle Lambert Case.
28.Petitioner did throw out his window to Defendants to read his “Press Release” for the
Organized Stalking Bill containing the docket to prove his being named as MOVANT by the
Courts in the Lisa Michelle Lambert Case.
29.Defendant's did illegally and recklessly break the Petitioner's door down, physically assault
the Petitioner and engage in an act of KIDNAPPING in removing Petitioner from his locked
residence.
30.Defendant's did further violate the Petitioner's civil rights by not allowing Petitioner to take
his files that were on his person at the time of the illegal assault with him to the hospitals.
31. Defendants did maliciously and with specific intent physically assault and torture the
Petitioner en route to the Lancaster General Hospital resulting in the Lancaster General
Hospital performing an x-ray and examination of the Petitioner's left should, right groin,
and back.
32.Petitioner was also subject to a brutal array of harassment and torture at the hands of the
Lancaster General Hospital and the attending physicians, duty nurse, and aids.
7 of 9 Thursday, September 24, 2015
33. In Pederson v. South Williamsport Area School District, the courts interpreted due process,
as “Essentially fundamental fairness is exactly what due process means”. Furthermore, the
United States District Courts in Perry v. Coyler (1978, 524 F 2d. 644) have concluded the
following: “Even the probability of unfairness can result in a defendant being deprived of
his due process rights…”.
34.Hempfield Township v. Hapchuck 153 Pa. Commonwealth. 173620 A. 2d. 668 (1993) Pro
Se Brief failed to comply with Pa. Rules of Appellate Procedure, but the failure to comply
did not substantially impede the Courts ability to review the issues presented and therefore
considered the merits of the case.
_____________________________ Date: September 23, 2015 Stanley J. Caterbone, Pro Se Litigant
1250 Fremont Street (717) 669-2163Lancaster, PA 17603 [email protected] www.amgglobalentertainmentgroup.com
8 of 9 Thursday, September 24, 2015
CERTIFICATE OF SERVICE
Lancaster County District Attorney50 North Duke StreetLancaster, PA 17602
Service was executed on _______ day of September, 2015.
_____________________________ Date: September 23, 2015 Stanley J. Caterbone, Pro Se Litigant
1250 Fremont Street (717) 669-2163Lancaster, PA 17603 [email protected] www.amgglobalentertainmentgroup.com
9 of 9 Thursday, September 24, 2015
CLOSED,HABEAS,A/R
United States District Court
Eastern District of Pennsylvania (Allentown)
CIVIL DOCKET FOR CASE #: 5:15-cv-03984-JCJ
CATERBONE v. LANCASTER BEHAVIORAL HEALTH/ CRISIS INTERVENTION et al
Assigned to: HONORABLE J. CURTIS JOYNER
related Case: 2:06-cv-05138-JCJ
Cause: 28:2241 Petition for Writ of Habeas Corpus (federal)
Date Filed: 07/17/2015
Date Terminated: 08/25/2015
Jury Demand: None
Nature of Suit: 530 Habeas Corpus: (General)
Jurisdiction: Federal Question
Petitioner
STANLEY J. CATERBONE represented by STANLEY J. CATERBONE
1250 FREMONT STREET
LANCASTER, PA 17603
717-669-2163
Email: [email protected]
PRO SE
V.
Respondent
LANCASTER BEHAVIORAL HEALTH/ CRISIS INTERVENTION
TERMINATED: 08/19/2015
Respondent
CRAIG STEDMAN
TERMINATED: 08/19/2015
Respondent
LANCASTER COUNTY DISTRICT ATTY
TERMINATED: 08/19/2015
Respondent
DET. LT. CLARK BEARIWGER
TERMINATED: 08/19/2015
Respondent
LANCASTER CITY POLICE
TERMINATED: 08/19/2015
Respondent
FAIRMONT BEHAVIOR SYSTEM
TERMINATED: 08/19/2015
Respondent
SILVIA GRATZ
CHIEF MEDICAL OFFICER
TERMINATED: 08/19/2015
Respondent
DISTRICT ATTORNEY OF THE COUNTY OF LANCASTER
Respondent
ATTORNEY GENERAL OF THE STATE OF PA
Date Filed # Docket Text
07/17/2015 1 PETITION for Writ of Habeas Corpus, filed by STANLEY J. CATERBONE (NO IFP, NO FEE PAID). (Attachments: # 1 Civil Cover Sheet)(jwl, ) (Additional attachment(s) added on 7/20/2015: # 2
Envelope) (jwl, ). Modified on 7/21/2015 (afm, ). (Entered: 07/20/2015)
07/24/2015 2 APPLICATION to proceed in District Court without prepaying fees or costs filed by STANLEY J. CATERBONE. Cert. of Service. (pr, ) (Entered: 07/24/2015)
07/31/2015 3 ORDER THAT THE CLERK OF COURT SHALL FURNISH PETITIONER WITH A BLANK COPY OF THE COURT'S CURRENT STANDARD FORM FOR FILING A PETITION PURSUANT
TO 28 USC, SECTION 2254 AND BEARING THE ABOVE-CAPTIONED CIVIL ACTION NUMBER; PETITIONER'S APPLICATION TO PROCEED IN FORMA PAUPERIS IS DENIED; AND
PETITIONER SHALL SUBMIT THE FIVE DOLLAR ($5.00) FILING FEE TO THE COURT WITHIN THIRTY (30) DAYS OF THE DATE OF THIS ORDER OR THIS ACTION WILL BE
DISMISSED WITHOUT FURTHER NOTICE TO PETITIONER.. SIGNED BY HONORABLE J. CURTIS JOYNER ON 7/28/15. 7/31/15 ENTERED AND COPIES MAILED TO PRO SE
PETITIONER WITH A BLANK COPY OF A 2254 PETITION FORM AND INSTRUCTIONS.(pr, ) (Entered: 07/31/2015)
08/10/2015 Copy of Order dated 7/28/15, blank 2254 petition form and envelope returned from the U.S. Postal Service addressed to STANLEY J. CATERBONE for the following reason: Return to sender, not
deliverable as addressed, unable to forward.(Re-sending to STANLEY J. CATERBONE, 1250 FREMONT ST., LANCASTER, PA 17603) (pr, ) (Entered: 08/10/2015)
08/17/2015 4 NOTICE/MOTION of Change of Address by STANLEY J. CATERBONE(ti, ) (Entered: 08/18/2015)
08/19/2015 5 Revised Habeas Petition Forms returned filed by STANLEY J. CATERBONE. (Attachments: # 1 Envelope)(pr, ) (Entered: 08/20/2015)
08/25/2015 6 ORDER THAT THE PETITION IS DISMISSED FOR FAILURE TO EXHAUST CLAIMS; THE CLERK OF COURT SHALL CLOSE THIS MATTER; AND THERE IS NO CAUSE TO ISSUE A
CERTIFICATE OF APPEALABILITY.. SIGNED BY HONORABLE J. CURTIS JOYNER ON 8/25/15. 8/25/15 ENTERED AND COPIES MAILED TO PRO SE PETITIONER.(pr, ) (Entered:
08/25/2015)
09/04/2015 7 ORDER THAT PETITIONER'S REQUEST FOR PERMISSION TO REGISTER AS AN ECF FILING USER IS GRANTED AND THE CLERK OF COURT IS DIRECTED TO PROCESS
PETITIONER'S REGISTRATION PURSUANT TO PROCEDURE 4(b) UNDER L.R.C.P. 5.1.2.. SIGNED BY HONORABLE J. CURTIS JOYNER ON 9/2/2015. 9/4/2015 ENTERED AND
COPIES MAILED TO PRO SE.(sg, ) (Entered: 09/04/2015)
PACER Service Center
Transaction Receipt
09/23/2015 05:32:52
PACER Login: am6446:3514696:0 Client Code:
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United States District Court Eastern District of Pennsylvania https://ecf.paed.uscourts.gov/cgi-bin/DktRpt.pl?509947849302174-L_1_0-1
1 of 1 9/23/2015 5:33 AM
18 of 114 Thursday, September 24, 2015
LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record
CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015
Patient Demographics
ED Arrival Information
Expected Arrival AcuityMeans ofArrival Escorted By Service
AdmissionType
- 7/10/201517:46
2=Emergent Police - EmergencyMedicine
Emergency
Arrival Complaintpsych eval
Chief ComplaintPsych Evaluation [160478]
DiagnosisAcute psychosis
ED EventsDate/Time Event User Comments07/10/15 1746 Patient arrived in ED RODRIGUEZ-SOTO,
MELISSA07/10/15 1747 RODRIGUEZ-SOTO,
MELISSA07/10/15 1747 RODRIGUEZ-SOTO,
MELISSA07/10/15 1747 Patient roomed in ED RODRIGUEZ-SOTO,
MELISSATo room 15BHE
07/10/15 1747 Assign Nurse HUEHNERGARTH,GRETCHEN A
Huehnergarth, Gretchen A, RN assigned asRegistered Nurse
07/10/15 1748 Assign Attending HUEHNERGARTH,GRETCHEN A
McIntyre, Daniel, MD assigned as Attending
07/10/15 1748 Assign Doctor/Pt. evalbegins
HUEHNERGARTH,GRETCHEN A
07/10/15 1749 Triage Started HUEHNERGARTH,GRETCHEN A
07/10/15 1749 XR Ordered MCINTYRE MD, DANIEL P XR SHOULDER RIGHT MIN 2 VW07/10/15 1749 Imaging Exam
OrderedMCINTYRE MD, DANIEL P
Printed on 7/28/2015 11:44 AM Page 1
CATERBONE,STANLEY ENGLISH
Emergency Contact 1Refused
Name Patient ID SSN
Address Phone EMail Employer1250 FREMONT STREETLANCASTER PA 17603-9543
717-826-5354 (H)717-669-2163 (M)
Sex Birth Date
County RaceLANCASTER White
Caterbone, Stanley J 0542297 xxx-xx-0959
Reg Status PCPVerified Sullivan, Brian P, MD717-291-5991
Male 07/15/58 (57 yrs)
Marital Status Religion Alias LanguageSingle -
90 of 114 Thursday, September 24, 2015
LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record
CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015
ED EventsDate/Time Event User Comments07/10/15 1750 Vitals Assessment HUEHNERGARTH,
GRETCHEN A07/10/15 1801 Charting Complete MCINTYRE MD, DANIEL P07/10/15 1801 Transfer Disposition
SelectedMCINTYRE MD, DANIEL P ED Disposition set to Transfer
07/10/15 1801 Disposition Selected MCINTYRE MD, DANIEL P07/10/15 1824 Registration
CompletedGROFF, BARBARA A
07/10/15 1829 Xray Final Result INTERFACE, INCOMINGRAD RESULTS
(Final result) XR SHOULDER RIGHT MIN 2VW
07/10/15 1938 Lab Ordered HUEHNERGARTH,GRETCHEN A
CBC, POCT URINE PREGNANCY
07/10/15 1946 Admit DispositionSelected
ECHEVARRIA, MARIAN ER
ED Disposition set to Admit
07/10/15 1946 Disposition Selected ECHEVARRIA, MARIAN ER
07/10/15 1946 Transfer DispositionSelected
ECHEVARRIA, MARIAN ER
ED Disposition set to Transfer
07/10/15 1946 Disposition Selected ECHEVARRIA, MARIAN ER
07/10/15 2010 Lab Resulted INTERFACE, INCOMINGLAB RESULTS
(Final result) CBC
07/10/15 2034 Lab Resulted INTERFACE, INCOMINGLAB RESULTS
(Final result) BASIC METABOLIC PANEL(BMP)
07/10/15 2323 Assign Nurse YARNISH, THERESA M Yarnish, Theresa M, RN assigned asRegistered Nurse
07/10/15 2323 Remove Nurse YARNISH, THERESA M Huehnergarth, Gretchen A, RN removed asRegistered Nurse
07/10/15 2333 Triage Completed YARNISH, THERESA M07/11/15 0000 ED Census07/11/15 0040 Patient discharged YARNISH, THERESA M07/11/15 0040 Patient departed from
EDYARNISH, THERESA M
07/11/15 0114 YARNISH, THERESA M07/11/15 0114 YARNISH, THERESA M07/11/15 0114 YARNISH, THERESA M07/11/15 0114 YARNISH, THERESA M07/11/15 0119 Charting Complete YARNISH, THERESA M07/21/15 1520 Charting Complete HUEHNERGARTH,
GRETCHEN A07/10/15 1810 Imaging Exam Started MESKEY, ELIZABETH M XR SHOULDER RIGHT MIN 2 VW07/10/15 1812 Imaging Exam Ended MESKEY, ELIZABETH M XR SHOULDER RIGHT MIN 2 VW
ED Treatment TeamProvider Role From To Phone PagerMcIntyre, Daniel, MD Attending Provider 07/10/15 1748 07/11/15 0040 717-544-4978Huehnergarth,Gretchen A, RN
Registered Nurse 07/10/15 1747 07/10/15 2323
Yarnish, Theresa M,RN
Registered Nurse 07/10/15 2323 --
Printed on 7/28/2015 11:44 AM Page 291 of 114 Thursday, September 24, 2015
LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record
CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015
Discharge OrdersNone
Printed on 7/28/2015 11:44 AM Page 392 of 114 Thursday, September 24, 2015
LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record
CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015
ED Notes
ED Notes by Huehnergarth, Gretchen A, RN at 7/10/2015 5:49 PM Version 1 of 1Author: Huehnergarth, Gretchen A,RN
Service: (none) Author Type: Registered Nurse
Filed: 7/10/2015 5:50 PM Note Time: 7/10/2015 5:49 PM Status: SignedEditor: Huehnergarth, Gretchen A, RN (Registered Nurse)
Patient on 302 for psychosis and paranoia directed at a Lancaster Detective
Signed by Huehnergarth, Gretchen A, RN on 7/10/2015 5:50 PM
ED Provider Notes by McIntyre, Daniel, MD at 7/10/2015 5:58 PM Version 1 of 1Author: McIntyre, Daniel, MD Service: Emergency Medicine Author Type: PhysicianFiled: 7/10/2015 6:01 PM Note Time: 7/10/2015 5:58 PM Status: SignedEditor: McIntyre, Daniel, MD (Physician)
HISTORY:
Chief ComplaintPatient presents with•Psych Evaluation
HPI56-year-old male with a long psychiatric history presents to the emergency room in police custody on a 302petition. Apparently the patient has been contacting a detective and making threats of packing into policecomputers. The patient has been off of his medication for some time. The patient appears paranoid. He iscomplaining of right shoulder pain. He states that he was arrested while cutting his lawn today. He thinks thathis right arm was twisted in his shoulders been uncomfortable since. The patient denied any other injuries. Hedenies any homicidal or suicidal thoughts. No past medical history on file.
No past surgical history on file.
No family history on file.Not significantSocial HistorySubstance Use Topics•Smoking status: Current Every Day Smoker -- 1.00 packs/day
Types: Cigarettes•Smokeless tobacco: Not on file•Alcohol Use: Yes
Continues to smoke dailyProblem List
Diagnosis•Paranoid Schizophrenia
Printed on 7/28/2015 11:44 AM Page 493 of 114 Thursday, September 24, 2015
LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record
CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015
ED Notes (continued)
Review of SystemsI have reviewed and agree with the nursing notes as well as the social history.
Review of Systems both pertinent positive and negative findings of the review of systems, has beenthoroughly documented in the HPI (above in the chart) and all other systems are negative.
PHYSICAL EXAM:Vital SignsTemperaturePulse/Heart RateRespirationBP 132/74 mmHg (07/10/15 1750)MAP 93 MM HG (07/10/15 1750)SpO2O2 DeviceO2 Therapy Flow
Physical ExamConstitutional: He is oriented to person, place, and time. He appears well-developed and well-nourished. Nodistress.HENT:Head: Normocephalic and atraumatic.Eyes: Conjunctivae are normal. Pupils are equal, round, and reactive to light.Neck: Normal range of motion. Neck supple.Cardiovascular: Normal rate, regular rhythm and normal heart sounds.Pulmonary/Chest: Effort normal and breath sounds normal. No respiratory distress. He has no wheezes.Abdominal: Soft. There is no tenderness.Musculoskeletal: Normal range of motion. He exhibits no edema.Neurological: He is alert and oriented to person, place, and time. No cranial nerve deficit. He exhibits normalmuscle tone.Skin: Skin is warm and dry. He is not diaphoretic.Psychiatric: His mood appears anxious. His speech is rapid and/or pressured. Thought content is paranoid anddelusional. He expresses no homicidal and no suicidal ideation.
EKG RHYTHM:
EKG INTERPRETATION:
OXYGEN SATURATION INTERPRETATION:
Printed on 7/28/2015 11:44 AM Page 594 of 114 Thursday, September 24, 2015
LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record
CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015
ED Notes (continued)
LAB INTERPRETATION:
RADIOLOGY INTERPRETATION:
ED COURSE:Procedures
MDMPatient has been evaluated by myself and the mental health liason. Mental health liason has discussed thecase with the psychiatrist on call. We feel patient would benefit from inpatient psychiatric admission. Mentalhealth liason is arranging transfer to an inpatient bed.
The patients condition at the time of Disposition is Unchanged.
McIntyre, Daniel, MD07/10/15 1801
Signed by McIntyre, Daniel, MD on 7/10/2015 6:01 PM
ED Notes by Huehnergarth, Gretchen A, RN at 7/10/2015 8:31 PM Version 1 of 1Author: Huehnergarth, Gretchen A,RN
Service: (none) Author Type: Registered Nurse
Filed: 7/10/2015 8:31 PM Note Time: 7/10/2015 8:31 PM Status: SignedEditor: Huehnergarth, Gretchen A, RN (Registered Nurse)
Patient medical history and current status reviewed. Active medical problems: stable
Signed by Huehnergarth, Gretchen A, RN on 7/10/2015 8:31 PM
ED Notes by Huehnergarth, Gretchen A, RN at 7/10/2015 8:32 PM Version 2 of 2Author: Huehnergarth, Gretchen A,RN
Service: (none) Author Type: Registered Nurse
Filed: 7/10/2015 10:05 PM Note Time: 7/10/2015 8:32 PM Status: AddendumEditor: Huehnergarth, Gretchen A, RN (Registered Nurse)Related Notes: Original Note by Huehnergarth, Gretchen A, RN (Registered Nurse) filed at 7/10/2015 8:52 PM
Arrival Status:Police on 302 petitioned by Lancaster Detective
Chief Complaint:Patient was sending paranoid and harrassing emails to local detective(enclosed copies in 302)Printed on 7/28/2015 11:44 AM Page 6
95 of 114 Thursday, September 24, 2015
LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record
CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015
ED Notes (continued)
History of Present Illness:Patient denies he is suicidal or homicidal or psychotic. He denies he is paranoid and is invested inaseries of paranoid delusions regarding the government and FBIPatients petitioner is a local Detective who states that patient has sent him over 100 emails since midJune 2015, and to other police. He states the emails are more antagonistic One of them stating "Whyare you trying to kill me" the petitioner states that patients behavior is becoming alarming and that hefears patient will reach the paranoid state of 2010 when he stated cops should be beaten and killedTo this writers knowledge patient has never been violentPatient told this writer a lengthy statement of his making a legal petition in the case of MichelleLambert (convicted Lancaster murderer from 1990's), patient states he met with the attorney generalrecently about this case and that he also drove to the office of Mike Sturla in Harrisburg.Patient became very paranoid of nurse and said she had purposely given him a cold room, that shewas a liar. He stated he would sue the hospital "back to the courts" and demanded this writer writedown the number of the court case he had against LGH from the past.Patient believes the police and FBI are hacking his computerPatient lives with his brother and doesn't drink alcohol or use drugsHe denies he has been hospitalized since 2010 at Fairmount. He is requesting to return to Fairmount
General Appearance and Behavior:Appearance/Behavior: AgitatedEye Contact: GoodAppetite: no change from normalSleep: no change
Thought Processing and Cognitive Evaluation:Orientation: Time, Place, Person, Name and SituationAttention & Concentration: WNLMood: HostileAffect: AppropriateSpeech: Rate: normal Volume: normal Coherence: goodThought Process: Logical:noThought Association: Tangential
Abnormal Thought Content:Suicidal thoughts: noHomicidal thoughts: noHallucinations: noDelusions: yes
Printed on 7/28/2015 11:44 AM Page 796 of 114 Thursday, September 24, 2015
LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record
CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015
ED Notes (continued)
Insight: poorJudgment: poor
Substance Use:Alcohol use: no Type: Amount/Frequency: Last use: History of withdrawal symptoms:
Use of other substances: no Type/Route: Amount/Frequency: Last use: History of withdrawal symptoms:
History of Treatment for Substance Use: no
Past Psychiatric History and Current Treatment:Inpatient history: yesOutpatient services: no Psychiatrist: Therapist: Case Management: Other Services:Medication and treatment compliance: n/aHistory of Suicide Attempts: noFamily history of suicide: noActs of Self Harm: noActs of Violence: no
Social, Family and Developmental History:Current relationships/support system: brotherLiving situation: with brotherEducation:Employment: noLegal history and current charges, probation/parole: noCustody status/Child Service Involvement: noAbuse/Trauma: no
Printed on 7/28/2015 11:44 AM Page 897 of 114 Thursday, September 24, 2015
LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record
CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015
ED Notes (continued)
Functional Status:Independent for ambulation: yesIndependent in performing ADLs: yesSpecial equipment/environmental needs: noLanguage and Cultural Needs: no
Clinical Impression:psychosis
Plan for Disposition:Commitment Status: 302Physician recommendation: admit Psychiatrist is okay with patient request to transfer to Fairmount
Signed by Huehnergarth, Gretchen A, RN on 7/10/2015 10:05 PM
ED Notes by Huehnergarth, Gretchen A, RN at 7/10/2015 8:32 PM Version 1 of 2Author: Huehnergarth, Gretchen A,RN
Service: (none) Author Type: Registered Nurse
Filed: 7/10/2015 8:52 PM Note Time: 7/10/2015 8:32 PM Status: SignedEditor: Huehnergarth, Gretchen A, RN (Registered Nurse)Related Notes: Addendum by Huehnergarth, Gretchen A, RN (Registered Nurse) filed at 7/10/2015 10:05 PM
Arrival Status:Police on 302 petitioned by Lancaster Detective
Chief Complaint:Patient was sending paranoid and harrassing emails to local detective(enclosed copies in 302)
History of Present Illness:Patient denies he is suicidal or homicidal or psychotic. He denies he is paranoid and is invested inaseries of paranoid delusions regarding the government and FBIPatients petitioner is a local Detective who states that patient has sent him over 100 emails since midJune 2015, and to other police. He states the emails are more antagonistic One of them stating "Whyare you trying to kill me" the petitioner states that patients behavior is becoming alarming and that hefears patient will reach the paranoid state of 201 when he stateded cops should be beaten and killedTo this writers knowledge patient has never been violentPatient told this writer a lengthy statement of his making a legal petition in the case of MichelleLambert (convicted Lancaster murderer from 1990's), patient states he met with the attorney generalrecently about this case and that he also drove to the office of Mike Sturla in Harrisburg.Patient became very paranoid of nurse and said she had purposely given him a cold room, that shewas a liar. He stated he would sue the hospital "back to the courts" and demanded this writer writedown the number of the court case he had against LGH from the past.
Printed on 7/28/2015 11:44 AM Page 998 of 114 Thursday, September 24, 2015
LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record
CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015
ED Notes (continued)
Patient believes the police and FBI are hacking his computerPatient lives with his brother and doesn't drink alcohol or use drugsHe denies he has been hospitalized since 2010 at Fairmount. He is requesting to return to Fairmount
General Appearance and Behavior:Appearance/Behavior: AgitatedEye Contact: GoodAppetite: no change from normalSleep: no change
Thought Processing and Cognitive Evaluation:Orientation: Time, Place, Person, Name and SituationAttention & Concentration: WNLMood: HostileAffect: AppropriateSpeech: Rate: normal Volume: normal Coherence: goodThought Process: Logical:noThought Association: Tangential
Abnormal Thought Content:Suicidal thoughts: noHomicidal thoughts: noHallucinations: noDelusions: yes
Insight: poorJudgment: poor
Substance Use:Alcohol use: no Type: Amount/Frequency: Last use: History of withdrawal symptoms:
Use of other substances: no Type/Route: Amount/Frequency: Last use:
Printed on 7/28/2015 11:44 AM Page 1099 of 114 Thursday, September 24, 2015
LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record
CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015
ED Notes (continued)
History of withdrawal symptoms:
History of Treatment for Substance Use: no
Past Psychiatric History and Current Treatment:Inpatient history: yesOutpatient services: no Psychiatrist: Therapist: Case Management: Other Services:Medication and treatment compliance: n/aHistory of Suicide Attempts: noFamily history of suicide: noActs of Self Harm: noActs of Violence: no
Social, Family and Developmental History:Current relationships/support system: brotherLiving situation: with brotherEducation:Employment: noLegal history and current charges, probation/parole: noCustody status/Child Service Involvement: noAbuse/Trauma: no
Functional Status:Independent for ambulation: yesIndependent in performing ADLs: yesSpecial equipment/environmental needs: noLanguage and Cultural Needs: no
Clinical Impression:psychosis
Plan for Disposition:Commitment Status: 302Physician recommendation: admit Psychiatrist is okay with patient request to transfer to Fairmount
Signed by Huehnergarth, Gretchen A, RN on 7/10/2015 8:52 PM
ED Notes by Huehnergarth, Gretchen A, RN at 7/10/2015 10:26 PM Version 1 of 1
Printed on 7/28/2015 11:44 AM Page 11100 of 114 Thursday, September 24, 2015
LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record
CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015
ED Notes (continued)
ED Notes by Huehnergarth, Gretchen A, RN at 7/10/2015 10:26 PM Version 1 of 1Author: Huehnergarth, Gretchen A,RN
Service: (none) Author Type: Registered Nurse
Filed: 7/10/2015 10:28 PM Note Time: 7/10/2015 10:26 PM Status: SignedEditor: Huehnergarth, Gretchen A, RN (Registered Nurse)
Insurance
Insurance Company :humanaMH Managed by : lifesyncPhone Number :8665500027Staff talked with :heather HAuthorization # :noneDates Authorized :7/10-7/13 review 7/13Other Information :
Signed by Huehnergarth, Gretchen A, RN on 7/10/2015 10:28 PM
ED Notes by Huehnergarth, Gretchen A, RN at 7/10/2015 10:33 PM Version 1 of 1Author: Huehnergarth, Gretchen A,RN
Service: (none) Author Type: Registered Nurse
Filed: 7/10/2015 10:33 PM Note Time: 7/10/2015 10:33 PM Status: SignedEditor: Huehnergarth, Gretchen A, RN (Registered Nurse)
Patient requested and was given copy of 302
Signed by Huehnergarth, Gretchen A, RN on 7/10/2015 10:33 PM
ED Notes by Huehnergarth, Gretchen A, RN at 7/10/2015 10:37 PM Version 1 of 1Author: Huehnergarth, Gretchen A,RN
Service: (none) Author Type: Registered Nurse
Filed: 7/10/2015 10:37 PM Note Time: 7/10/2015 10:37 PM Status: SignedEditor: Huehnergarth, Gretchen A, RN (Registered Nurse)
Patient declined any anxiolytic or antipsychotic
Signed by Huehnergarth, Gretchen A, RN on 7/10/2015 10:37 PM
ED Orders
Start Status Ordering Provider07/10/15
1939Final result MCINTYRE, DANIEL
07/10/151939
Final result MCINTYRE, DANIEL
Printed on 7/28/2015 11:44 AM Page 12
Toxic Screen, Urine, No Confirmation ONE TIME
Alcohol, Serum ONE TIME
101 of 114 Thursday, September 24, 2015
LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record
CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015
ED Orders
Start Status Ordering Provider07/10/15
1939Final result MCINTYRE, DANIEL
07/10/151939
Final result MCINTYRE, DANIEL
07/10/151830
Last MAR action:Given - byHUEHNERGARTH,GRETCHEN A on07/10/15 at 1954
MCINTYRE, DANIEL
07/10/151750
Final result MCINTYRE, DANIEL
Lab Results (07/10/15 - 07/10/15)
CBC (For Transfers Only) [110835910] (Abnormal)Resulted: 07/10/15 2010, Result Status: Final
resultOrdering provider: McIntyre, Daniel, MD 07/10/15 1938 Resulting Lab: LANCASTER GENERAL
LABORATORY
Basic Metabolic Panel (BMP) (For Transfers Only) [110835909](Abnormal)
Resulted: 07/10/15 2034, Result Status: Finalresult
Ordering provider: McIntyre, Daniel, MD 07/10/15 1938 Resulting Lab: LANCASTER GENERALLABORATORY
Printed on 7/28/2015 11:44 AM Page 13
07/10/15 1948Comment: For Transfers Only.
XR SHOULDER RIGHT MIN 2 VW ONE TIME
Components
Value Ref Range Flag Comment LabWBC Count 11.4 4.8 - 10.8 K H - LG
LABRBC Count 5.12 4.60 - 6.20 M - LG
LABHgb 14.7 14.0 - 18.0 g/dL - LG
LABHct 42.5 42.0 - 52.0 % - LG
LABMCV 83.0 80.0 - 100.0 fL - LG
LABMCH 28.7 27.0 - 33.0 pg - LG
LABMCHC 34.6 32.0 - 36.0 % - LG
LABPlatelet Count 203 150 - 450 K - LG
LABRDW 14.4 12.2 - 14.6 % - LG
LAB
Basic Metabolic Panel (BMP) (For Transfers Only)ONE TIME
CBC (For Transfers Only) ONE TIME
ibuprofen (ADVIL,MOTRIN) tablet 600 mg ONCE
Comments: For Transfers Only.
Comments: For Transfers Only.
Specimen Collection
Specimen CollectionType Source Collected On
07/10/15 1948
Type Source Collected On
102 of 114 Thursday, September 24, 2015
LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record
CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015
Lab Results (07/10/15 - 07/10/15) (continued)
Basic Metabolic Panel (BMP) (For Transfers Only) [110835909](Abnormal)
Resulted: 07/10/15 2034, Result Status: Finalresult
Alcohol, Serum [110835908]Resulted: 07/10/15 2037, Result Status: Final
resultOrdering provider: McIntyre, Daniel, MD 07/10/15 1938 Resulting Lab: LANCASTER GENERAL
LABORATORY
Printed on 7/28/2015 11:44 AM Page 14
16 8 - 22 mg/dL - LGLAB
Sodium 137 135 - 145mmol/L
- LGLAB
Potassium 4.1 3.4 - 5.3 mmol/L - LGLAB
Chloride 105 98 - 107 mmol/L - LGLAB
CO2 Venous 28.0 21.0 - 31.0mmol/L
- LGLAB
Anion Gap 4 5 - 15 mmol/L L - LGLAB
Creatinine 0.8 0.7 - 1.2 mg/dL - LGLAB
BUN/CreatinineRatio
20 10 - 20 Ratio - LGLAB
OsmolalityCalculation(serum)
275 275 - 300mOsm/Kg
- LGLAB
Calcium 9.7 8.6 - 10.3 mg/dL - LGLAB
GFR >60 mL/min/1.73sqm
LGLAB
Comment: Notes for GFR:1. Multiply result by 1.21 if patient is black/African American.2. Chronic kidney disease: <60 mL/min/1.73 sq.m. Renal Failure: <15 mL/min/1.73 sq.m.
Comment: For Transfers Only.
Components
Value Ref Range Flag Comment Lab
Specimen CollectionType Source Collected On
07/10/15 1948
Glucose (serum) 95
Components
Value Ref Range Flag Comment LabAlcohol (serum) NONE DETECTED None Detected
mg/dLLGLAB
Comment: Intoxication Symptoms: 50-100 mg/dLComatose Level: 350-500 mg/dL
65 - 100 mg/dL - LGLAB
Blood UreaNitrogen
103 of 114 Thursday, September 24, 2015
LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record
CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015
Lab Results (07/10/15 - 07/10/15) (continued)
Alcohol, Serum [110835908]Resulted: 07/10/15 2037, Result Status: Final
result
Toxic Screen, Urine, No Confirmation [110835906]Resulted: 07/10/15 2301, Result Status: Final
resultOrdering provider: McIntyre, Daniel, MD 07/10/15 1938 Resulting Lab: LANCASTER GENERAL
LABORATORY
Printed on 7/28/2015 11:44 AM Page 15
Collected On07/10/15 2149
Components
Value Ref Range Flag Comment LabUrineAmphetamineScreen
NONE DETECTED None Detected - LGLAB
Urine BarbiturateScreen
NONE DETECTED None Detected - LGLAB
UrineBenzodiazepineScreen
NONE DETECTED None Detected - LGLAB
Urine CocaineMetabolite Screen
NONE DETECTED None Detected - LGLAB
Urine MarijuanaScreen
NONE DETECTED None Detected - LGLAB
Urine OpiateScreen
See Below None Detected LGLAB
Comment: NONE DETECTED -Hydrocodone and Methadone are not routinelydetected by the LGH Urine Toxic Screen. These drugsmust be ordered specifically.
UR OxycodoneScreen
NONE DETECTED None Detected - LGLAB
UrinePCP(Phencyclidine) Screen
NONE DETECTED None Detected LGLAB
Comment: Unconfirmed screening results MUST NOT be used fornon-medical purposes: (eg. employment testing, legal testing) CUT OFF CONCENTRATION FOR POSITIVE RESULTS: Amphetamines = 1000 ng/mL Barbiturates = 200 ng/mL Benzodiazepine = 200 ng/mL Cocaine = 300 ng/mL Opiates = 300 ng/mL Oxycodone = 100 ng/mL Phencyclidine = 25 ng/mL THC = 50 ng/mL
Concentrations above 400 mg/dL may be fatal.
Specimen CollectionType Source
104 of 114 Thursday, September 24, 2015
LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record
CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015
Lab Results (07/10/15 - 07/10/15) (continued)
Toxic Screen, Urine, No Confirmation [110835906]Resulted: 07/10/15 2301, Result Status: Final
result
Testing Performed ByLab - Abbreviation Name Director Address Valid Date Range6 - LG LAB LANCASTER
GENERALLABORATORY
Bruce King, M.D.,Director
555 N. Duke St.Lancaster PA 17602-2250
10/10/13 1035 - Present
Radiology Results (07/10/15 - 07/10/15)
XR SHOULDER RIGHT MIN 2 VW [110832753]Resulted: 07/10/15 1825, Result Status: Final
resultOrdering provider: McIntyre, Daniel, MD 07/10/15 1749 Resulted by: Smigocki, Gene C, MDPerformed: 07/10/15 1810 - 07/10/15 1810 Resulting Lab: LANCASTER GENERAL RADIOLOGYNarrative: Two-view right shoulder
History: Pain following injury
Comparison: None
Technique: Internal and external views were obtained
Findings:
No osseous abnormality is present. Minor degenerative changes are present in theacromioclavicular joint. Joint spaces and soft tissues are otherwise normal.
Impression:
No evidence of fracture
Dictating Workstation: HMINWKS2
Testing Performed ByLab - Abbreviation Name Director Address Valid Date Range7 - LG RADIOLOGY LANCASTER
GENERALRADIOLOGY
RobertLatshaw,MD
555 N. Duke St.Lancaster PA 17604-3555
08/08/12 1438 - Present
EKG ResultsNone
All Administrations of ibuprofen (ADVIL,MOTRIN) tablet 600 mg
User(s)ActionTime
RecordedTime
Dose/Rate Route Site Comment Action
Reason
Huehnergarth,Gretchen A, RN
07/10/151954
07/10/151955
600 mg Oral Given
Printed on 7/28/2015 11:44 AM Page 16
Specimen CollectionType Source Collected On
07/10/15 1810
105 of 114 Thursday, September 24, 2015
LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record
CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015
All Administrations of ibuprofen (ADVIL,MOTRIN) tablet 600 mg
ED Current OP MedicationsMedication Sig Dispense Start Date End Date Doc. ProviderNAPROXEN 500 MG ORAL TABS 1 TABLET
TWICE DAILYas needed forpain
60 9/23/2009 Sullivan, Brian P,MD
VICODIN ES 7.5-750 MG ORALTABS
1/2 to 1 tabletevery 6 hoursas needed forpain
30 tablet 5/10/2010 Sullivan, Brian P,MD
Medications not reviewed this encounter
Medication Comments** No Medication Comments Found **
Allergies (verified on: 05/25/10)Agent Severity CommentsNO KNOWN ALLERGIES
Follow-up InformationNone
Vitals from to
Date and Time BPPosition Pulse Resp Temp
Tempsrc SpO2
OxygenTherapyFlow(L/min)
Weight
Doppler/Fetoscope Rate
POCTCarboxyhemoglobin
Who
07/10/15 1750 132/74mmHg
-- 82 20 98 °F(36.7°C)
Oral -- -- -- -- -- GAH
Flowsheets (all recorded)
Printed on 7/28/2015 11:44 AM Page 17
AmbulanceArrived
Yes -TMYARNIS
Transfer Charting - Sat July 11, 2015
Transfer Checklist - Sat July 11, 2015
0043Transfer ChecklistReport toTransfer Team
Yes -TMYARNIS
0043Transport Request
106 of 114 Thursday, September 24, 2015
LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record
CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015
Flowsheets (all recorded)
Printed on 7/28/2015 11:44 AM Page 18
MAR MINI-FLOWSHEET DATA - Fri July 10, 2015
Custom Formula Data - Fri July 10, 2015
1750OTHERMean ArterialPressure
93 MM HG -GAHUEHNE
1954 1817
Triage Plan - Fri July 10, 2015
2333Triage Acuity CalculatorIsRESUSCITATION required?
No -TMYARNIS
Is this anEMERGENT(High Risk,Altered LOC,Severe Pain)situation?
Yes (2) -TMYARNIS
Patient Acuity 2 -TMYARNIS
ED Destination Behavioral Health-TMYARNIS
Vital Signs - Fri July 10, 2015
1954 1817 1750Vital SignsBP 132/74 mmHg -
GAHUEHNE
Pulse 82 -GAHUEHNE
Resp 20 -GAHUEHNE
Temp 98 °F (36.7 °C) -GAHUEHNE
Temp src Oral -GAHUEHNE
PainAssessment
0-10 -GAHUEHNE
Number Scale*Pain Rating 4 -GAHUEHNE 7 -GAHUEHNE
*Pain Location shoulder -GAHUEHNE
PainDescription -Quality
aching -GAHUEHNE
*Factors thatAggravate Pain
activity -GAHUEHNE
*Factors thatRelieve Pain
repositioning -GAHUEHNE
Number Scale
Transfer Charting - Fri July 10, 2015
2216
*Pain Rating 4 -GAHUEHNE 7 -GAHUEHNE
107 of 114 Thursday, September 24, 2015
LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record
CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015
Printed on 7/28/2015 11:44 AM Page 19
ETA ofAmbulance
2330 -GAHUEHNE
AmbulanceArrived
Yes -GAHUEHNE
Transfer Mode Gurney -GAHUEHNE
Type ofTransfer
BLS/ALS/CCTAmbulance -GAHUEHNE
AccompaniedBy
EMS Personnel -GAHUEHNE
Transport Request
Transfer Checklist - Fri July 10, 2015
2216Transfer ChecklistReason forTransfer
Patient Request -GAHUEHNE
AcceptingHospital
fairmount -GAHUEHNE
AcceptingPhysician
bridget bautista -GAHUEHNE
SendingPhysician
mcintyre -GAHUEHNE
Report toTransfer Team
Yes -GAHUEHNE
Report toReceivingFacility
Yes -GAHUEHNE
Spoke with tyree -GAHUEHNE
TransferConsentSigned
Yes -GAHUEHNE
Copy ofRecords and DIObtained
Yes -GAHUEHNE
Faxed Recordsto ReceivingFacility
Yes -GAHUEHNE
DispatcherCalled
Yes -GAHUEHNE
Travel Screening - Fri July 10, 2015
1824Travel ScreeningHas the patienttraveled toAfrica OR hadcontact withsomeone whohas traveled toAfrica in thelast 21 days?
No -BG017
Name ofDispatcher
jaimie -GAHUEHNE
108 of 114 Thursday, September 24, 2015
LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record
CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015
ED After Visit Summary
Diagnoses this visitYour diagnosis was ACUTE PSYCHOSIS.
You were seen byYou were seen by McIntyre, Daniel, MD.
ED PrescriptionsNone
Orders Completed During Your ED Visit
Start Status Ordering Provider07/10/15
1939Final result MCINTYRE, DANIEL
07/10/151939
Final result MCINTYRE, DANIEL
07/10/151939
Final result MCINTYRE, DANIEL
07/10/151939
Final result MCINTYRE, DANIEL
07/10/151830
Last MAR action:Given
MCINTYRE, DANIEL
07/10/151750
Final result MCINTYRE, DANIEL
Suture Information from toNone
Printed on 7/28/2015 11:44 AM Page 20
Automaticrestart vitalstimer
YES -GAHUEHNE
Arrival Documentation - Fri July 10, 2015
User Key(r) = User Recd, (t) = User Taken, (c) = User
Cosigned
Toxic Screen, Urine, No Confirmation ONE TIME
User ID Name Effective DatesBG017
Alcohol, Serum ONE TIME
Groff, Barbara A -GAHUEHNE Huehnergarth, Gretchen A, RN 03/23/11 -
Basic Metabolic Panel (BMP) (For Transfers Only)ONE TIME
TMYARNIS Yarnish, Theresa M, RN 03/23/11 -
CBC (For Transfers Only) ONE TIME
1749
ibuprofen (ADVIL,MOTRIN) tablet 600 mg ONCE
Triage StartTriage Start
XR SHOULDER RIGHT MIN 2 VW ONE TIME
Start -GAHUEHNE
Prehospital TreatmentPrehospitalTreatment
No -GAHUEHNE
Vitals Reassessment - Fri July 10, 2015
1750Vitals Assessment
109 of 114 Thursday, September 24, 2015
LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record
CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015
ED After Visit Summary (continued)
Information regarding the care you received at theLancaster General Hospital Emergency Department
You may receive a survey about your emergency department visit.Our goal is for our patients to receive very good care during their ED visit.Please take a moment to complete a survey if you receive one so we may continue to improve.
The examination and treatment you have received in the Emergency Department have been rendered on anemergency basis only, and are not intended to be a substitute for or an effort to provide complete medicalcare. Your primary care physician may request a copy of your records and all test results. It is important thatyou let him/her check you again, and that you report any new or remaining problems.
XRAYS/EKGSThe interpretation of EKG'S and/or x-rays at the time of the emergency visit may only be a preliminary report.You will be notified by telephone if there is a change in the interpretation when the tests are reviewed by thecardiologist and/or radiologist.
MEDICATIONS/PRESCRIPTIONSTake all medication as prescribed by the physician.
FAMILY PHYSICIAN If you are being referred to your own Primary Care Physician for follow up and do not have one, please callthe Physician Referral Line at 1-888-LGH-INFO (1-888-544-4636) and you will be assisted in locating aPrimary Care Physician.
REFERRAL TO SPECIALISTIf you are being referred to any doctor/specialist other than your own Primary Care Physician: Please contactyour doctor for a referral and any paperwork or referral forms that may be required. If you have anyquestions about whether you need such forms, contact your insurance company or doctor's office as soon aspossible.
The staff of the Lancaster General Hospital Emergency Department and Trauma Services strives to ensurequality care and customer service during your visit.Your Current Condition does not require hospitalization. Your condition can, however, change. If there areany concerns regarding your condition, you may return to the Emergency Department or contact yourPrimary Physician.
The Emergency Physicians of Lancaster Emergency Associates (LEA) are the exclusive providers ofEmergency Medical care at Lancaster General Hospital. We appreciate any comments or feedback you mayhave on your experience with us in the Emergency Department and invite you to visit us atwww.LancasterEmergencyAssociates.com
We constantly are looking for ways to improve your Emergency Department Experience.If you have any suggestions or concerns, please let us know.
Printed on 7/28/2015 11:44 AM Page 21110 of 114 Thursday, September 24, 2015
LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record
CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015
ED After Visit Summary (continued)
You may call any of the following ED Management Team:Jolyne Barnett, RN ED Nurse Manager 717 544-5125Penne Marino, RN, Days Assistant Nurse Manager 717 544-4582Amy Sechrist, RN Evenings Assistant Nurse Manager 717 544-7055Lisa Williams, RN Nights Assistant Nurse Manager 717 544-1776
Lancaster General Hospital Convenience Pharmacy 717 544-5929Hours of Operation: Monday through Friday 7am- 6pmSaturday 9am- 3pmSunday Closed
Procedures and tests performed during your visitAlcohol, SerumBasic Metabolic Panel (BMP) (For Transfers Only)CBC (For Transfers Only)Toxic Screen, Urine, No ConfirmationXR SHOULDER RIGHT MIN 2 VW
Scanned Information
Encounter-Level Documents - 07/10/2015:
Scan on 7/11/2015 8:21 PM (below)
Printed on 7/28/2015 11:44 AM Page 22111 of 114 Thursday, September 24, 2015
LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record
CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015
Scanned Information (continued)
Scan on 7/11/2015 5:38 PM (below)
Printed on 7/28/2015 11:44 AM Page 23112 of 114 Thursday, September 24, 2015
LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record
CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015
Scanned Information (continued)
Order-Level Documents:There are no order-level documents.
Code Documentation
No data selected in time range
Printed on 7/28/2015 11:44 AM Page 24113 of 114 Thursday, September 24, 2015
LANCASTER GENERAL HOSPITALHealth Information Management555 North Duke StreetLancaster PA 17604-3555ED Record
CATERBONE,STANLEY JMRN: 0542297DOB: 7/15/1958, Sex: MAdm: 7/10/2015, D/C: 7/11/2015
Scanned Information (continued)
Sedation Documentation
No data selected in time range
114 of 114 Thursday, September 24, 2015