Patient Information Data Sheet

Document Sample
Patient Information Data Sheet Powered By Docstoc
					                                    Patient Information Data Sheet
        Total Time on Case (time start chart review through time closing report to nurse):    Stop:
Patient consents to follow up:      Yes            No                                        Start :
Was this a telemedicine screening?             Yes         No                           Total Time:

Hospital:                                                          Unit:        ER or           Med        Floor or Room #
                Drop Down Box    Other Facility Type

                                                              Staff Dispo.
Staff Screen                                                     (if same)                                       Date:

Patient Name:
(or label)                                                                                             MRN#


DOB:                                   Age:                                   Sex:                      Loc Code:
Page notification:
Time seen:                                         Time complete:                                     Eval time in minutes:
Reason for delay:                None or Describe:

Diagnosis:

Current Situation:

ER/Med MD:                                                                              Psych MD:
                                                        (name)                                             (name of accepting &/or consulting Psych)

     Team                       Reeval                 Inpt      Outpt /DC               MD             Reeval        Inpt        Outpt/DC
   Recommendation                                                                    Recommendation


Result                                                                                                Transfer to:

1:1 ordered?                    Yes              No              Insurance:          Nonresource

Status:               Open               Closed               External Agency (pow, edw, cps/aps?):
Comments (list referrals or check):

Problems: