Date Case Referred:
Case Manager: / Case Manager contact #:
Last Name: / First Name:
DOB/Age: / Gender:
Start of Service Date and Time: / D/C Date and Time:
Admitting Dx:
Admit Date and Time:
Location on Chart: / Physician Order (inpatient or obs):
Estimated Length of stay and location on chart:
Review Type: / Payer/Member ID:
Attending: / Attending Contact #:
Chief Complaint:
Location of Pain:
Location of radiation of pain:
Nausea:
Vomiting:
Diarrhea:
Tolerating po:
PMH list:
Outpatient workup/ treatment
Date and Time
Physical Exam:
Vital signs:
Repeat Vital signs(looking for changes):
Abdominal Findings:
Tenderness, location:
Rebound: / Rigidity:
Guarding:
Stool heme positive or negative?
LABS:
WBC:
H/H:
BUN/Cr:
LFTs:
Na: / K:
Cl:
CO2:
Amylase(& Range):
Lipase (& Range):
Studies:
Obstruction series:
CT scan of abd:
Ultrasound:
CXR:
EKG:
ED treatment:
Pain meds, drug, dosage, route, frequency:
Antiemetic drug, dosage, frequency, route:
Plan of care with orders:
NPO:
IVF w rate:
Consults ordered:
Pain meds:
Anti-emetics:
Studies ordered:
What is the physician’s concern (Impression)?
Additional Information:
Client Version Page 1 Updated - 9/5/2014