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Medication
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Continue Medication Rationale
• • •
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New Medication Rationale
• • •
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Taper Medication Rationale
• • •
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Sample Medications Provided
• • •
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Med Change Comments
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Labs
• • •
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Lab Comments
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Referrals
• • •
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Referral Comments
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Diagnostics
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Mammogram
• • •
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DEXA-Bone Density
• • •
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X-Ray
• • •
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Ultrasound
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CT
• • •
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PET
• • •
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MRI
• • •
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Nuclear Medicine
• • •
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Diet
• • •
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Diet comments
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Education
• • •
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Education Comments
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Release of Information/Medical Records
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Release of Information / Obtain Records
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General Instructions
• • •
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Follow-Up / Return to Clinic
• • •
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Emergency Care Recommendation
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EMS/911 Activated
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Patient Declined
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Patient Transported Successfully
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Self / Family / Other Attendee Transported to ED
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Patient Declined
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Self Transported
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Family/Friend/Attendee Transported
• • •
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AMA Form
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AMA Signed/Obtained
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AMA FORM- Patient Signed
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AMA Refused/Left Office
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AMA FORM- Refused to Sign
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