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Admission & Transfer
Patient name
Date of transfer
Date of birth
Referring Hospital
Referring physician
Phone number
Reason of Admission and history
Length of stay
Social & Family Conditions
Family members not available
Widow
Married
Living away from town
Others
Complications and courses
(Delirium- CVA-Bleeding (wound or GI)- Afib.-Bed sore- Urine retention-Aspiration Pneumonia- Nosocomial infection. etc…)
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Progression +Actual Situation and Needs
Mobility
Bedsores
No
Yes
Water/air Mattress
Feeding and Diet
Mouth Hygiene
Bowel Movement
Sleep Pattern
Mental Status
Mouth Hygiene
Nasal Cannula
Bipap
Others
Indwelling catheter
Urinary
NGT
Stomy
Precaution & Preventions
Risk of Aspiration
Risk of Bedsores
Type of Isolation
Last Test Result
(Blood; Urine; EKG; Others)
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Last culture Results
Wound Care
(Surgery or Bed Sore)
Dressing
Physical Therapy
Yes
No
BROWSE
Type
Frequency
Weight Bearing
Full WB
Partial WB
No WB
Control Test
(Prescription and date)
Imaging
Blood & Urine Test
Care Plan
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Treatment upon discharge
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Date
Full Name
Telephone / Beeper
