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Admission Date
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Discharge Date
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Discharge Diagnosis
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Brief History/ HPI
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Rehabiltation Summary
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Meds on discharge, refer to MAR
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Other instructions upon discharge
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Code discussed with
• • •
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Code Status
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Functional status on discharge
• • •
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Functional status comments
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Pertinent Physical and laboratory findings
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Follow up with PCP
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Other Follow ups
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Transitional Care with Zumedic
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Dispostion
• • •
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Plan of care on Discharge
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Condition on discharge
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Discharge medical equipment
• • •
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Comments
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Education
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Physical Exam, Normal
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General [-]
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Other findings
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General Comments
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General Abnormal
• • •
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HEENT WNL
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HEENT Comments
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HEENT Abnormal
• • •
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Skin WNL
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Skin Comments
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Skin Lesion
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Neck WNL
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Neck Comments
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Neck Abnormal
• • •
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Cardiovascular WNL
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Cardiovascular Comments
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Cardiovascular Abnormal
• • •
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Lungs WNL
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Lungs Comments
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Lungs Abnormal
• • •
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Abdomen WNL
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Abdomen Comments
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Abdomen Abnormal
• • •
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MSK WNL
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MSK Comments
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MSK Abnormal
• • •
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Neuro WNL
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Neuro Comments
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Neuro Abnormal
• • •
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Extremities WNL
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Extremity Comments
|
Extrem Abnormal
• • •
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Face to Face Minutes
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