Patient Information Data Sheet

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					                                    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:


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):