NAME:
[ Name (First, Last) ] [ Age ] [ Gender ]_ #[ Encounter Type ] [ Assigned Room ]-[ Assigned Bed ]@[ Assigned Facility ][ Body Mass Index ]
ARRIVAL: [ Arrival Date and Time ] FROM [ Admit Source ] VIA [ Admit Mode ]
DISCHARGE: [ Discharge Date and Time ]
LOS: [ Encounter LOS ] hrs
DESTINATION: [ DC – Follow-Up Care ]
DISCHARGE INFO:
[ DC – Follow Up Information ]
DISCHARGE MEDS:
[ DC – Summary Medications ]
PHYSICIANS:
[ Primary Care Provider (PCP) ]ATTENDING:[ Attending Physician ]
CONSULT (S):[ Consulting Physician ]
CHIEF COMPLAINT:
[ Ophth PN Chief Complaint ]
PAST MEDICAL HISTORY:
[ Diagnosis List ][ Problem List ]
PAST SURGICAL HISTORY:
[ Procedure History ]
FAMILY HISTORY:
[ Ophth PN Contacts Info ST ]
[ Family History ]
SOCIAL HISTORY:
[ Social History ]
ALLERGIES:
[ MU Allergies ]
HOME MEDICATIONS:
[ Home Medications ]
LATEST VITALS:
[ Vital Signs – Outpatient (Adult) ]
PAIN SCALE:
[ Pain Assessment ]
INPUT AND OUTPUT:
[ Intake and Output (Last 24hr/8hr) ]
[ Intake and Output – ICU ]
LINES, DRAINS AND TUBES:
[ DC – Lines, Drains, and Tubes ]
[ Cardiac Implant Electronic Device (CIED) ]
LAST 24HR LAB RESULTS:
[ Lab Results – Last 24hrs ]
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ID LAB RESULTS:
[ Lab Results – Infectious Disease ]
CULTURES:
[ Sepsis Culture/Lactate ]
[ Microbiology W/O Suscept Last 48 Hours ]
[ Sepsis Alert Criteria ]
ONCOLOGY AND CRITICAL CARE LABS:
[ Oncology Labs ]
[ Critical Care Labs ]
[ Oncology Inpatient Diagnostics ]
INPATIENT MEDICATIONS:
[ Active Inpatient Medications ]
WARFARIN HISTORY:
[ DC – Warfarin Monitoring History ]
VITALS RANGED:
[ Vital Signs – Ranged ]
GIVEN
[ Medications Given ]