INPATIENT FACE SHEET

More documents

Recommendations

Info

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 <strong>SHEET</strong> 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
Page 1 and 2: Global Care Medical Center100 Main
Page 3 and 4: WEST, KEITHIPCase010Dr. BLACKAdmiss
Page 15: WEST, KEITHIPCase010Dr. BLACKAdmiss

INPATIENT FACE SHEET

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?