FINAL PROJECT - TERRY ROBERTS

1 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green.

Global Care Medical Center

100 Main St, Alfred NY 14802

(607) 555-1234

Hospital No. 999

: Bed rest Light Usual Unlimited Other:

Regular Low Cholesterol Low Salt ADA _____ Calorie

Follow-Up: Call for appointment Office appointment on Other:

:

2 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green.

I, hereby consent to admission to the Global Care Medical Center (ASMC) , and I further consent to such

routine hospital care, diagnostic procedures, and medical treatment that the medical and professional staff of ASMC may deem necessary or advisable. I authorize the use of medical information obtained about me as specified above and the disclosure of such information to my referring physician(s). This form has been fully explained to me, and I understand its contents. I further understand that no guarantees have been made to me as to the results of treatments or examinations done at the ASMC.

Signature of Patient

Signature of Parent/Legal Guardian for Minor

Relationship to Minor

WITNESS: Global Care Medical Center Staff Member

CONSENT TO RELEASE INFORMATION FOR REIMBURSEMENT PURPOSES In order to permit reimbursement, upon request, the Global Care Medical Center (ASMC) may disclose such treatment information pertaining to my hospitalization to any corporation, organization, or agent thereof, which is, or may be liable under contract to the ASMC or to me, or to any of my family members or other person, for payment of all or part of the

any release of information is to facilitate reimbursement for services rendered. In addition, in the event that my health insurance program includes utilization review of services provided during this admission, I authorize ASMC to release information as is necessary to permit the review. This authorization will expire once the reimbursement for services rendered is complete.

Signature of Patient

Signature of Parent/Legal Guardian for Minor

Relationship to Minor

WITNESS: Global Care Medical Center Staff Member

3 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green.

GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234

Your answers to the following questions will assist your Physician and the Hospital to respect your wishes regarding your medical care. This information will become a part of your medical record.

YES NO PATIENT S INITIALS

1. Have you been provided with a copy of the information called

2. Have you Hospital 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 medical record.

4. Have you provided this facility with an Advance Directive on a prior admission and is it still in effect? If yes, Admitting Office to contact Medical Records to obtain a copy for the medical record.

5. Do you desire to execute a Living Will/Durable Power of Attorney? If yes, refer to in order: a. Physician b. Social Service c. Volunteer Service

HOSPITAL STAFF DIRECTIONS: Check when each step is completed.

1. Verify the above questions where answered and actions taken where required.

2.

Name of Individual Receiving Information Relationship to Patient

3. 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 the Advanced 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 Patient

Signature of Patient Date

4 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green.

Signature of Hospital Representative Date

GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234

ALLERGY TO ASPIRIN

Physician Name

5 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green.

DD: 06/30YYYY

DT: 07/01/YYYY Physician Name GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234

6 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green.

Physician Name GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234

7 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green.

Date Time

8 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green.

GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234

9 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green.

Date Time

10 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green.

GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234

Date Time

11 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green.

GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234

12 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green.

Date Time

GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234

13 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green.

14 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green.

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Date Time

GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234

15 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green.

’

Date Time

GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234

16 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green.

DD: 07/05/YYYY

DT: 07/06/YYYY

GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234

17 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green.

DD: 06/30/YYYY

DT: 07/01/YYYY

GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234

18 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green.

SPECIMEN COLLECTED:

IN: 06/30YYYY

1614

SPECIMEN RECEIVED

OUT: 06/30/YYYY

1749

ACID PHOSPHATASE

ALKALINE PHOSPHATASE

AMYLASE

LIPASE

GLUCOSE FASTING

GLUCOSE

BUN

SODIUM

POTASSIUM

CARBON DIOXIDE

CHLORIDE

CHOLESTEROL

SERUM GLUTAMATE

PYRUVATE TRANSAMINASE SERUM GLUTAMIC

OXALOCETIC

TRANSAMINASE

CREATININE KINASE

LACTATE DEHYDROGENASE

CREATININE

CALCIUM

PHOSPHORUS

BILIRUBIN-DIRECT

BILIRUBIN-TOTAL

TOTAL PROTEIN

ALBUMIN

URIC ACID

TRIGLYCERIDE

GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234

19 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green.

20 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green.

SPECIMEN COLLECTED:

IN: 06/30YYYY

2322

SPECIMEN RECEIVED

OUT: 07/01/YYYY

1032

ACID PHOSPHATASE

ALKALINE PHOSPHATASE

AMYLASE

LIPASE

GLUCOSE FASTING

GLUCOSE

BUN

SODIUM

POTASSIUM

CARBON DIOXIDE

CHLORIDE

CHOLESTEROL

SERUM GLUTAMATE

PYRUVATE TRANSAMINASE SERUM GLUTAMIC OXALOCETIC

TRANSAMINASE

CREATININE KINASE

LACTATE DEHYDROGENASE

CREATININE

CALCIUM

PHOSPHORUS

BILIRUBIN-DIRECT

BILIRUBIN-TOTAL

TOTAL PROTEIN

ALBUMIN

URIC ACID

TRIGLYCERIDE

GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234

21 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green.

URINALYSIS

DIPSTICK ONLY

COLOR

SP GRAVITY

ALBUMIN

BILIRUBIN

SUGAR

BLOOD

PH

ACETONE

UROBILINOGEN

NITRITES

LEUKOCYTE

W.B.C.

R.B.C.

BACT.

URINE PREGNANCY TEST

GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234

22 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green.

TIME IN: TIME OUT:

WHITE BLOOD CELL

RED BLOOD CELL

HEMOGLOBIN

HEMATOCRIT

MEAN CORPUSCULAR

VOLUME

MEAN CORPUSCULAR

HEMOGLOBIN

MEAN CORPUSCULAR

HEMOGLOBIN

CONCENTRATION

RED CELL

DISTRIBUTION WIDTH

PLATELETS

SEGMENTED CELLS %

LYMPHOCYTES %

MONOCYTES %

EOSINOPHILS %

BAND CELLS %

COMMENTS:

GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234

23 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green.

TIME IN: TIME OUT:

WHITE BLOOD CELL

RED BLOOD CELL

HEMOGLOBIN

HEMATOCRIT

MEAN CORPUSCULAR VOLUME

MEAN CORPUSCULAR HEMOGLOBIN

MEAN CORPUSCULAR HEMOGLOBIN

CONCENTRATION

RED CELL DISTRIBUTION WIDTH

PLATELETS

SEGMENTED CELLS %

LYMPHOCYTES %

MONOCYTES %

EOSINOPHILS %

BAND CELLS %

COMMENTS

GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234

24 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green.

SPECIMEN COLLECTED: 07-02-YYYY SPECIMEN RECEIVED: 07-06-YYYY

BACTERIOLOGY

SOURCE: Sputum

SMEAR ONLY:

CULTURE

1st PRELIMINARY

2nd PRELIMINARY

OTHER ROUTINE

CULTURES

FINAL REPORT

SENSITIVITIES

GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234

25 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green.

Time of EKG

GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234

26 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green.

SPECIAL INSTRUCTIONS:

MEDICATION (dose and route) DATE: DATE: DATE: DATE

TIME INITIALS TIME INITIALS TIME INITIALS TIME INITIALS

Single Orders

PRN Medications

INITIALS SIGNATURE AND TITLE INITIALS SIGNATURE AND TITLE INITIALS SIGNATURE AND TITLE

GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234

27 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green.

SPECIAL INSTRUCTIONS:

MEDICATION (dose and route) DATE: DATE: DATE: DATE

TIME INITIALS TIME INITIALS TIME INITIALS TIME INITIALS

PRN Medications

INITIALS SIGNATURE AND TITLE INITIALS SIGNATURE AND TITLE INITIALS SIGNATURE AND TITLE

GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234

28 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green.

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DATE TIME TREATMENTS & MEDICATIONS TIME

LOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234

29 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green.

’

DATE TIME TREATMENTS & MEDICATIONS TIME

GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234

30 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green.

’

DATE TIME TREATMENTS & MEDICATIONS TIME

GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234

31 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green.

’

DATE TIME TREATMENTS & MEDICATIONS TIME

32 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green.

GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234

’

DATE TIME TREATMENTS & MEDICATIONS TIME

33 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green.

GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234

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DATE TIME TREATMENTS & MEDICATIONS TIME

34 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green.

GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234

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DATE TIME TREATMENTS & MEDICATIONS TIME

35 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green.

GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234

’

DATE TIME TREATMENTS & MEDICATIONS TIME

36 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green.

GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234

1. AFEBRILE: No

2. WOUND: Clean/Dry Reddened Infected NA

3. PAIN FREE: Yes No

4. POST-HOSPITAL INSTRUCTION SHEET GIVEN TO PATIENT/FAMILY: Yes No

If NO, complete lines 5-8 below.

5. DIET: Other (Describe):

6. ACTIVITY: Normal Light Limited Bed rest

7. MEDICATIONS:

8. INSTRUCTIONS GIVEN TO PATIENT/FAMILY:

9. PATIENT/FAMILY verbalize understanding of instructions: Yes No

10. DISCHARGED at Via: Wheelchair Stretcher Ambulance Co.

Ambulatory

Accompanied by: to

COMMENTS:

DATE:

SIGNATURE:

GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234

37 | P a g e Permission to reuse granted by Alfred State College and Michelle A. Green.

I understand that while the facility will be responsible for items deposited in the safe, I must be responsible for all items retained by me at the bedside. (Dentures kept the bedside will be labeled, but the facility cannot assure responsibility for them.) I also recognize that the hospital cannot be held responsible for items brought in to me after this form has been completed and signed.

Signature of Patient Date

Signature of Witness Date

I have no money or valuables that I wish to deposit for safekeeping. I do not hold the facility responsible for any other money or valuables that I am retaining or will have brought in to me. I have been advised that it is recommended that I retain no more than $5.00 at the bedside.

Signature of Patient Date

Signature of Witness Date

I have deposited valuables in the facility safe. The envelope number is .

Signature of Patient Date

Signature of Person Accepting Property Date

I understand that medications I have brought to the facility will be handled as recommended by my physician. This may include storage, disposal, or administration.

Signature of Patient Date

Signature of Witness Date

GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234