INPATIENT FACE SHEET

Global Care Medical Center100 Main St, Alfred NY 14802(607) 555-1234Hospital No. 999 WEST, KEITHM W S IPCase010417 RUSH ROAD ALMOND, NY 14804 05/23/YYYY 8 mo N/A N/A !02-09-YYYY 15:55 02-11-YYYY 1300 02 DAYS (607)000-8107 WEST, KEN417 RUSH ROADALMOND, NY 14804"# WEST, KELLY417 RUSH ROADALMOND, NY 14804 "# ! (607)000-8107 Father (607)000-8107 Mother $ !%Fred Moore, MD N/A N/A 331 John Black, MD BRONCHIOLITIS / CROUP & ! & !Blue Cross of WNY 76894567-900 N/A N/A Bronchiolitis with fever Croup tent with nebulizer &$ : Bed rest Light Usual Unlimited Other:' Regular Low Cholesterol Low Salt ADA SoftFollow-Up: Call for appointment Office appointment on Recheck in one week.&: 'Reviewed and Approved: John Black MDATP-B-S:02:1001261385: John Black MD(Signed: 02/09/YYYY 04:20:44 PM EST)

WEST, KEITHIPCase010Dr. BLACKAdmission:02/09/YYYYDOB: 05/23/YYYYROOM: 331I, Keith West hereby consent to admission to the Global Care Medical Center (ASMC) , and I further consent to suchroutine hospital care, diagnostic procedures, and medical treatment that the medical and professional staff of ASMC may deemnecessary or advisable. I authorize the use of medical information obtained about me as specified above and the disclosure of suchinformation to my referring physician(s). This form has been fully explained to me, and I understand its contents. I furtherunderstand that no guarantees have been made to me as to the results of treatments or examinations done at the ASMC.Signature of PatientReviewed and Approved: Kelly WestATP-B-S:02:1001261385: Kelly West(Signed: 02/09/YYYY 04:32:05 PM EST)Signature of Parent/Legal Guardian for MinorRelationship to MinorReviewed and Approved: Andrea WittemanATP-B-S:02:1001261385: Andrea Witteman(Signed: 02/09/YYYY 04:32:05 PM ESTWITNESS: Global Care Medical Center Staff MemberCONSENT TO RELEASE INFORMATION FOR REIMBURSEMENT PURPOSESIn order to permit reimbursement, upon request, the Global Care Medical Center (ASMC) may disclose such treatment informationpertaining to my hospitalization to any corporation, organization, or agent thereof, which is, or may be liable under contract to theASMC or to me, or to any of my family members or other person, for payment of all or part of the ASMC’s charges for servicesrendered to me (e.g. the patient’s health insurance carrier). I understand that the purpose of any release of information is to facilitatereimbursement for services rendered. In addition, in the event that my health insurance program includes utilization review ofservices provided during this admission, I authorize ASMC to release information as is necessary to permit the review. Thisauthorization will expire once the reimbursement for services rendered is complete.Signature of PatientReviewed and Approved: Kelly WestATP-B-S:02:1001261385: Kelly West(Signed: 02/09/YYYY 04:36:17 PM EST)Signature of Parent/Legal Guardian for MinorRelationship to MinorReviewed and Approved: Andrea WittemanATP-B-S:02:1001261385: Andrea Witteman(Signed: 02/09/YYYY 04:36:24 PM ESTWITNESS: Global Care Medical Center Staff MemberGLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234

WEST, KEITHIPCase010Dr. BLACKAdmission:02/09/YYYYDOB: 05/23/YYYYROOM: 331 Your answers to the following questions will assist your Physician and the Hospital to respect your wishes regarding your medicalcare. This information will become a part of your medical record.1. Have you been provided with a copy of the information called“Patient Rights Regarding Health Care Decision?”2. Have you prepared a “Living Will?” If yes, please provide theHospital with a copy for your medical record.3. Have you prepared a Durable Power of Attorney for Health Care?If yes, please provide the Hospital with a copy for your medicalrecord.4. Have you provided this facility with an Advance Directive on aprior admission and is it still in effect? If yes, Admitting Office tocontact Medical Records to obtain a copy for the medical record.5. Do you desire to execute a Living Will/Durable Power ofAttorney? If yes, refer to in order:a. Physicianb. Social Servicec. Volunteer ServiceHOSPITAL STAFF DIRECTIONS: Check when each step is completed.1. Verify the above questions where answered and actions taken where required.YES NO PATIENT’S INITIALS2. If the “Patient Rights” information was provided to someone other than the patient, state reason:XXXXXName of Individual Receiving InformationRelationship to Patient3. If information was provided in a language other than English, specify language and method.4. Verify patient was advised on how to obtain additional information on Advance Directives.5. Verify the Patient/Family Member/Legal Representative was asked to provide the Hospital with a copy of theAdvanced Directive which will be retained in the medical record.File this form in the medical record, and give a copy to the patient.Name of Patient Name of Individual giving information if different from PatientReviewed and Approved: Kelly WestATP-B-S:02:1001261385: Kelly West(Signed: 02/09/YYYY 04:35:05 PM EST)Signature of Parent/Legal Guardian for MinorDateReviewed and Approved: Andrea WittemanATP-B-S:02:1001261385: Andrea Witteman(Signed: 02/09/YYYY 04:35:47 PM ESTSignature of Hospital RepresentativeDateGLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234

WEST, KEITHIPCase010Dr. BLACKAdmission:02/09/YYYYDOB: 05/23/YYYYROOM: 331 ADMISSION DATE:02/09/YYYYDISCHARGE DATE: 02/11/YYYYADMISSION DIAGNOSIS: Bronchiolitis with hyperpyrexia; history of premature delivery withone hospitalization for lung immaturity at time of birth.DISCHARGE DIAGNOSIS: Bronchiolitis with fever and poor fluid intake.SUMMARY: This is an 8-month-old white male seen by Dr. White at the Lofty Pines HealthCenter for a viral-type syndrome. The mother states that the baby had a temperature overthe weekend, going up to 104 and 103 the night prior to admission. The baby hasprogressively gotten more worked up, more short of breath and has had respiratory disease.The patient was hospitalized for his respiratory distress and lower respiratory disease.Positive physical exam on admission included both lung fields filled with rhonchi andoccasional rales. There were no signs of consolidation. The patient was put in a crouptent during his hospital stay and was placed on Ampicillin four times a day for his twodaycourse. He tolerated the croup tent well and the antibiotics. His lungs progressivelycleared, and the patient was discharged on 02-11-YYYY. He was discharged on theinstructions to force fluids, saline nose drops and bulb suction as needed, Amoxicillin125 milligrams three times a day, and to return to the clinic in one week to see Dr.Swisher.Lab data – white count was 10.7, hemoglobin was 12.2, hematocrit was 37.7, 13 segmentedcells, 77 lymphocytes, 10 monocytes. Chest x-ray was within normal limits.DD: 02/11/YYYYDT: 02/20/YYYYReviewed and Approved: Fred Moore MDATP-B-S:02:1001261385: Fred Moore MD(Signed: 02/11/YYYY 04:14:44 PM EST)Physician AuthenticationGLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234

WEST, KEITHIPCase010Dr. BLACKAdmission:02/09/YYYYDOB: 05/23/YYYYROOM: 331 CHIEF COMPLAINT: Difficulty breathing and hyperpyrexiaHISTORY OF PRESENT ILLNESS: This is an 8-month-old white male seen by Dr. White at theLofty Pines Health Center for a viral-type syndrome. The mother states that the baby hada temperature over the weekend with it being 104 on Saturday night and 103 last night.The baby has progressively gotten more worked up, more short of breath and has had moreproblems with congestion. The baby was admitted for observation and evaluation of hisupper respiratory and lower respiratory disease. This is the first hospitalization forthis child.PAST MEDICAL HISTORY: This baby only has one other hospitalization besides that of birthand that was for admission to the hospital for respiratory distress syndrome and wastaken care of by Dr. Smith in the neonatal intensive care unit. He only stayed less thana week and did quite well and there was no need for follow up. The mother states that thepatient was born three weeks early and the doctors felt that this was secondary to herhaving a kidney stone. The child had a normal, spontaneous, vaginal birth. He was 19inches at birth and weighed 6 pounds 15 ounces.FAMILY HISTORY: There is a family history of diabetes, paternal great grandmother; heartdisease, grandfather. One brother has congenital heart disease, and an uncle hascongenital heart disease. There are 2 maternal aunts who died of myocardial infarction.There is no tuberculosis, hypertension, or cancer in the family. There also is a familyhistory of paternal grandfather with allergies and desensitizations. Mother and father donot have allergies.SOCIAL HISTORY: This is an only child.REVIEW OF SYSTEMS: Growth and development is within normal limits. Patient is a goodeater, nonfussy. Still takes occasional Prosobee but is not on a strict formula diet atthis time.GENERAL: This is an 8-month-old looking his stated age with respiratory problems with arapid rate and rather annoyed with a stuffed-up nose.TEMPERATURE: 101.3 PULSE: 158 RESPIRATIONS: 62DD: 02/09/YYYYDT: 02/10/YYYYContinued on next pagePhysician AuthenticationGLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234

WEST, KEITHIPCase010Dr. BLACKPage 2 continuedAdmission:02/09/YYYYDOB: 05/23/YYYYROOM: 331 EENT: Extraocular movements are full. Pupils are equal, round, and reactive to light andaccommodation – red reflexes within normal limits. Nose – stuffed up with clearrhinorrhea. Mouth – within normal limits.CHEST: Both lung fields are filled with rhonchi and occasional rales. There were no signsof consolidation.HEART: Regular rhythm. Without murmur, rub, or gallop that I can detect, but the patientindeed had a tachycardia at the time of examination.ABDOMEN: Within normal limits.GENITALIA: Circumcised male with testes descended. Good femoral pulses bilaterally. No hipclicks.RECTUM: Anus patent.EXTREMITIES: Within normal limits.LAB DATA: Complete Blood Count revealed: White count was 10.7, hemoglobin was 12.2,hematocrit was 37.7, 13 segmented cells, 77 lymphocytes, 10 monocytes. Urinalysis waswithin normal limits except for trace blood on dipstick; doubt whether that issignificant. Chest x-ray was within normal limits.IMPRESSION: 1. Bronchiolitis with hyperpyrexia. 2. History of premature delivery with onehospitalization for lung immaturity at time of birth.Patient will need forced fluids and close observation.DD: 02/09/YYYYDT: 02/10/YYYYReviewed and Approved: Fred Moore MDATP-B-S:02:1001261385: Fred Moore MD(Signed: 02/09/YYYY 04:14:44 PM EST)Physician AuthenticationGLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234

WEST, KEITHIPCase010Dr. BLACKAdmission:02/09/YYYYDOB: 05/23/YYYYROOM: 331Date Time Physician’s signature required for each order. (Please skip one line between dates.)02/09/YYYY 1600 Chief complaint: Fever and coughing.Diagnosis: Bronchiolitis with feverPlan of Treatment: Croup tent. FluidsDISCHARGE PLAN: Home. No services neededReviewed and Approved: Fred Moore MDATP-B-S:02:1001261385: Fred Moore MD(Signed: 02/09/YYYY 04:10:55 PM EST)02/10/YYYY 0800Bronchiolitis / Respiratory distressLungs – Rhonchi throughout- much looserTemperature lowerBreathing easier – Respiratory rate 30 a minute\Reviewed and Approved: Fred Moore MDATP-B-S:02:1001261385: Fred Moore MD(Signed: 02/10/YYYY 08:04:07 AM EST)02/11/YYYY 0800 Bronchiolitis / Respiratory distressLungs – Rhonchi throughout- much looserTemperature lowerIntake good.Reviewed and Approved: Fred Moore MDATP-B-S:02:1001261385: Fred Moore MD(Signed: 02/11/YYYY 08:10:32 AM EST)GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234

WEST, KEITHIPCase010Dr. BLACKAdmission:02/09/YYYYDOB: 05/23/YYYYROOM: 331 Date Time Physician’s signature required for each order. (Please skip one line between dates.)02/09/YYYY 1650 Admit to service Dr. BlackAdmitting diagnosis: BronchiolitisVitals every shiftCoup tent with oxygen continuous and while sleepingDaily weightComplete Blood CountUrinalysisChest x-ray to rule out pneumoniaMilk-free diet. Encourage fluids, Gatorade.Sudafed 2.5 centimeters 4 times a day as needed forcongestionAmoxicillin 125/5 centimeters 4 times a dayNasopharynx and throat culturesPlease call Dr. Moore when blood work and x-ray aredone.Reviewed and Approved: Mary Stanley RNATP-B-S:02:1001261385: Mary Stanley RN(Signed: 02/09/YYYY 04:54:07 PM EST)02/09/YYYY 1700 1 grain aspirin or 1 grain Tylenol by mouth orsuppository every 4 hours as needed.Reviewed and Approved: Mary Stanley RNATP-B-S:02:1001261385: Mary Stanley RN(Signed: 02/09/YYYY 04:54:07 PM EST)02/09/YYYY 2315 Please do nose irrigation with normal saline 2-3 dropsin each nostril – then suction with bulb syringe andneeded.Reviewed and Approved: Mary Stanley RNATP-B-S:02:1001261385: Mary Stanley RN(Signed: 02/09/YYYY 11:54:07 PM EST)GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234

WEST, KEITHIPCase010Dr. BLACKAdmission:02/09/YYYYDOB: 05/23/YYYYROOM: 331 Date Time Physician’s signature required for each order. (Please skip one line between dates.)02/11/YYYY 1300 Discharge.Force fluidsSaline nose drops and suctionAmoxicillin 125/5 centimeters three times a dayReturn to clinic one weekSummary dictated.Reviewed and Approved: Fred Moore MDATP-B-S:02:1001261385: Fred Moore MD(Signed: 02/11/YYYY 01:05:52 PM EST)GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234

WEST, KEITHIPCase010Dr. BLACKAdmission:02/09/YYYYDOB: 05/23/YYYYROOM: 331 02/09/YYYY 1630 02/09/YYYY 1634BACTERIOLOGYSOURCE:OTHER ROUTINE CULTURESThroatSMEAR ONLY:CULTURENormal flora1st PRELIMINARY2nd PRELIMINARYFINAL REPORTNormal floraSENSITIVITIES 1. AMIKACIN 1. NITROFURANTOINR = Resistant 1. AMPICILLIN PENICILLIN GS = Sensitive 1. CARBENICILLIN POLYMYXIN B› = greater than 1. CEFAMANDOLE 1. SULFISOXAZOLE1. CEFOXITIN 1. TETRACYCLINE1. CEPHALOTHIN 1. TRIMETHOPRIM1. CHLORAMPHENICOL VANCOMYCINCLINDAMYCINERYTHROMYCIN1. GENTAMICINKANAMYCINMETHICILLINNALIDIXIC ACIDGLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234

WEST, KEITHIPCase010Dr. BLACKAdmission:02/09/YYYYDOB: 05/23/YYYYROOM: 331SPECIMEN RECEIVED: 02/10/YYYY SPECIMEN RECEIVED: 02/10/YYYY URINALYSISDIPSTICK ONLYCOLORYellowSP GRAVITY 1.020 ≤ 1.030ALBUMIN Negative ≤ 125 mg/dlBILIRUBIN Negative ≤ 0.8 mg/dlACETONE Small ≤ 10 mg/dlBLOOD Trace 0.06 mg/dl hgbPH 6 5-8.0PROTEINSUGARNITRITESLEUKOCYTE≤ 30 mg/dlNEGNEG≤ 15 WBC/hpfW.B.C. 0 ≤ 5/hpfR.B.C. No intact RBC ≤ 5/hpfBACT. few 1+(≤ 20/hpf)URINE PREGNANCY TEST***End of Report***GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234

WEST, KEITHIPCase010Dr. BLACKAdmission:02/09/YYYYDOB: 05/23/YYYYROOM: 331TIME IN 02/09/YYYY 1634TIME OUT:02/09/YYYY 1815 WHITE BLOOD CELL 10.7 4.5-11.0 thou/ulRED BLOOD CELL 5.17 5.2-5.4 milliliter/ upper limitHEMOGLOBIN 12.2 11.7-16.1 grams per deciliterHEMATOCRIT 37.7 35.0-47.0 %MEAN CORPUSCULAR VOLUME 73.0 85-99 factor levelMEAN CORPUSCULAR HEMOGLOBIN 23.7MEAN CORPUSCULAR HEMOGLOBINCONCENTRATION32.4 33-37RED CELL DISTRIBUTION WIDTH 11.4-14.5PLATELETS 387 130-400 thou/ulSEGMENTED CELLS % 13LYMPHOCYTES % 77 20.5-51.1MONOCYTES % 10 1.7-9.3EOSINOPHILS %BAND CELLS %ATYPICAL LYMPHThou/ul= thousand upper limitCOMMENTS:N/A***End of Report***GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234

WEST, KEITHIPCase010Dr. BLACKAdmission:02/09/YYYYDOB: 05/23/YYYYROOM: 331Date of X-ray: 02/09/YYYYREASON: Rule out pneumonia.TECHNICAL DATA: Anterior-posterior and lateral elevated 72 inches Pigg-O-Stat pediatric immobilizer.REPORT02/09/YYYY CHEST Anterior-posterior and lateral views show that the lungsare clear. The heart and pulmonary vascularity are normal.DD: 02/10/YYYYDT: 02/10/YYYYReviewed and Approved: Randall Cunningham MDATP-B-S:02:1001261385: Randall Cunningham MD(Signed:02/10/YYYY 2:24:44 PM EST)Physician AuthenticationGLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234

WEST, KEITHIPCase010Dr. BLACKAdmission:02/09/YYYYDOB: 05/23/YYYYROOM: 331 SPECIAL INSTRUCTIONS: N/ADATE: 02/09 DATE: 02/10 DATE: 02/11DATE: MEDICATION (dose and route) TIME INITIALS TIME INITIALS TIME INITIALS TIME INITIALSAmoxicillin 125/5 centimetersfour times a day12:00 ---- 12:00 VS 12:00 VS18:00 ---- 18:00 OR 18:00 OR24:00 ---- 24:00 JD 24:00 JD06:00 JD 06:00 JD 06:00 ----Single OrdersPRN MedicationsPseudofed 2.5 centimeters 4times a day as needed forcongestionTylenol or Aspirin 1 grainby mouth or suppositoryevery 4 hours as needed1650 OR 1215 VS1720 ORINITIALS SIGNATURE AND TITLE INITIALS SIGNATURE AND TITLE INITIALS SIGNATURE AND TITLEVT Vera South, RN GPW G. P. Well, RN OR Ora Richards, RN PS P. Small, RN JD Jane Dobbs, RN HF H. Figgs, RN GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234

WEST, KEITHIPCase010Dr. BLACKAdmission:02/09/YYYYDOB: 05/23/YYYYROOM: 331DATE TIME TREATMENTS &MEDICATIONS02/09/YYYY1700 Temperature 101.3 Tylenol60 milligrams by mouthTIMENURSES’ NOTES1615 8-month old white male admitted to room331 in tent for possible pneumonia. Underservices of Dr. Black. Throat andNasopharynx culture done. Blood work andchest x-ray done. Parents in. Patient’sface flushed. Hot to touch. Taped forurinalysis.Reviewed and Approved: O. Richards, RNATP-B-S:02:1001261385: O. Richards, RN(Signed: 02/09/YYYY 04:20:32 PM EST)1630 Given bottle Gatorade. Took very smallamount of coup. In tent sleeping.Reviewed and Approved: O. Richards, RNATP-B-S:02:1001261385: O. Richards, RN(Signed: 02/09/YYYY 04:32:09 PM EST)1830 Sleeping. Respirations even/regular.Slightly rapid. Occasional congestivecough. Took small amount of Gatorade.02/10/YYYY2000 Temperature 99.3 Dr. Mooreis in.TuesdayTemperature 97Reviewed and Approved: O. Richards, RNATP-B-S:02:1001261385: O. Richards, RN(Signed: 02/09/YYYY 06:32:19 PM EST)2000 Evening care given. In tent. Patient is alittle fussy. Mother with patient.Reviewed and Approved: O. Richards, RNATP-B-S:02:1001261385: O. Richards, RN(Signed: 02/09/YYYY 08:07:33 PM EST)2230 Sleeping quietly. Respirations even andregular.Reviewed and Approved: O. Richards, RNATP-B-S:02:1001261385: O. Richards, RN(Signed: 02/09/YYYY 10:34:33 PM EST)2400 Sleeping in croupette. Awakened for vitalsigns and medicine. Respirationscongested, rate 36. Occasional congestedcough. Nose irrigated and suctioned asordered. Had yellow nasal drainage. Motherwith patient.0015 Sudafed 2.5 centimeters 0015Reviewed and Approved: J. Dobbs, RNATP-B-S:02:1001261385: J. Dobbs, RN(Signed: 02/10/YYYY 12:03:28 AM EST)Given for congestion. Back in tent.Reviewed and Approved: J. Dobbs, RNATP-B-S:02:1001261385: J. Dobbs, RN(Signed: 02/10/YYYY 12:17:28 AM EST)0100 Sleeping. Respirations remain slightlycongested.Reviewed and Approved: J. Dobbs, RNATP-B-S:02:1001261385: J. Dobbs, RN(Signed: 02/10/YYYY 01:03:28 AM EST)GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234

WEST, KEITHIPCase010Dr. BLACKAdmission:02/09/YYYYDOB: 05/23/YYYYROOM: 331DATE TIME TREATMENTS & MEDICATIONS TIME NURSES’ NOTES02/10/YYYY1830 In tent. Little fussy.Reviewed and Approved: O. Richards, RNATP-B-S:02:1001261385: O. Richards, RN(Signed: 02/10/YYYY 06:31:29 PM EST)2000 Evening care given. Took Gatorade. Intent sleeping.Reviewed and Approved: O. Richards, RNATP-B-S:02:1001261385: O. Richards, RN(Signed: 02/10/YYYY 08:04:19 PM EST)2230 Sleeping quietly. Respirations even andregular. Loose congestive cough.Reviewed and Approved: O. Richards, RNATP-B-S:02:1001261385: O. Richards, RN(Signed: 02/10/YYYY 10:33:33 PM EST)02/11/YYYY Wednesday 2400 Sleeping in croup tent. Respirationseasy and regular.0100-0500Reviewed and Approved: J. Dobbs, RNATP-B-S:02:1001261385: J. Dobbs, RN(Signed: 02/11/YYYY 12:02:16 AM EST)Sleeping.Reviewed and Approved: J. Dobbs, RNATP-B-S:02:1001261385: J. Dobbs, RN(Signed: 02/11/YYYY 05:00:46 AM EST)97.9 – 152 - 36 0600 Sleeping in croup tent. Respirationseasy and regular. Had moderate amount ofbrown, hard constipated stool.02/11/YYYY 0800 97.9 – 152 - 36Regular diet without milkReviewed and Approved: J. Dobbs, RNATP-B-S:02:1001261385: J. Dobbs, RN(Signed: 02/11/YYYY 06:02:36 AM EST)0800 Awake. 1 soft stool. Ate well atbreakfast. Bath given. Dr. Moore in toexam. Out of tent.Reviewed and Approved: V. South, RNATP-B-S:02:1001261385: V. South, RN(Signed: 02/11/YYYY 08:03:00 AM EST)1000 Content in crib. Tolerates out of tentwell. Clear nasal drainage.Reviewed and Approved: V. South, RNATP-B-S:02:1001261385: V. South, RN(Signed: 02/11/YYYY 10:11:48 AM EST)1200 Ate well at lunch. Parents here. Dr.Moore in to exam child and talked withparents. Patient to go home.Reviewed and Approved: V. South, RNATP-B-S:02:1001261385: V. South, RN(Signed: 02/11/YYYY 12:06:09 PM EST)1300 Discharge. Refer to discharge summarysheet.GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234Reviewed and Approved: V. South, RNATP-B-S:02:1001261385: V. South, RN(Signed: 02/11/YYYY 01:01:01 PM EST)

WEST, KEITHIPCase010Dr. BLACKAdmission:02/09/YYYYDOB: 05/23/YYYYROOM: 331 1. AFEBRILE: X Yes No2. WOUND: Clean/Dry Reddened Infected X NA3. PAIN FREE: X Yes No If “No,” describe:4. POST-HOSPITAL INSTRUCTION SHEET GIVEN TO PATIENT/FAMILY: Yes X NoIf NO, complete lines 5-8 below.5. DIET: X Regular X Other (Describe): 6. ACTIVITY: X Normal Light Limited Bed rest7. MEDICATIONS:8. INSTRUCTIONS GIVEN TO PATIENT/FAMILY:9. PATIENT/FAMILY verbalize understanding of instructions: Yes No10. DISCHARGED at 1300 Via: Wheelchair Stretcher Ambulance Co.Accompanied by:Reviewed and Approved: V. South, RNATP-B-S:02:1001261385: V. South, RN(Signed: 02/11/YYYY 01:07:03 PM EST)to Front deskCOMMENTS:GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234

WEST, KEITHIPCase010Dr. BLACKAdmission:02/09/YYYYDOB: 05/23/YYYYROOM: 331 I understand that while the facility will be responsible for items deposited in the safe, I must be responsible for all itemsretained by me at the bedside. (Dentures kept the bedside will be labeled, but the facility cannot assure responsibility forthem.) I also recognize that the hospital cannot be held responsible for items brought in to me after this form has beencompleted and signed.Reviewed and Approved: Kelly WestATP-B-S:02:1001261385: Kelly West(Signed: 02/09/YYYY 04:36:44 PM ESTSignature of Parent or Guardian of PatientReviewed and Approved: Andrea WittemanATP-B-S:02:1001261385: Andrea Witteman(Signed: 02/09/YYYY 04:37:00 PM ESTSignature of WitnessI have no money or valuables that I wish to deposit for safekeeping. I do not hold the facility responsible for any othermoney or valuables that I am retaining or will have brought in to me. I have been advised that it is recommended that Iretain no more than $5.00 at the bedside.Reviewed and Approved: Kelly WestATP-B-S:02:1001261385: Kelly West(Signed: 02/09/YYYY 04:36:59 PM ESTSignature of Parent or Guardian of PatientReviewed and Approved: Andrea WittemanATP-B-S:02:1001261385: Andrea Witteman(Signed: 02/09/YYYY 04:38:28 PM ESTSignature of WitnessI have deposited valuables in the facility safe. The envelope number is .Signature of PatientSignature of Person Accepting PropertyI understand that medications I have brought to the facility will be handled as recommended by my physician. This mayinclude storage, disposal, or administration.Signature of PatientSignature of WitnessGLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234