|
Admission Date
|
Discharge Date
|
|
Dispostion
• • •
|
Discharge Diagnosis
|
|
Brief History/ HPI
|
Course of Treatment
|
|
Plan of care on Discharge
|
Pertinent Physical and laboratory findings
|
|
Rehabiltation potential
|
Condition on discharge
|
|
Code Status
|
Code discussed with
• • •
|
|
Follow up with PCP
|
Follow up
|
|
Meds on discharge, refer to MAR
|
Education
|
|
Other instructions upon discharge
|
|
|
|
|
|
Physical Exam, Normal
|
|
|
General [-]
|
General Abnormal
• • •
|
|
General Comments
|
|
|
HEENT WNL
|
HEENT Abnormal
• • •
|
|
HEENT Comments
|
|
|
Skin WNL
|
Skin Lesion
|
|
Skin Comments
|
|
|
Neck WNL
|
Neck Abnormal
• • •
|
|
Neck Comments
|
|
|
Cardiovascular WNL
|
Cardiovascular Abnormal
• • •
|
|
Cardiovascular Comments
|
|
|
Lungs WNL
|
Lungs Abnormal
• • •
|
|
Lungs Comments
|
|
|
Abdomen WNL
|
Abdomen Abnormal
• • •
|
|
Abdomen Comments
|
|
|
MSK WNL
|
MSK Abnormal
• • •
|
|
MSK Comments
|
|
|
Breasts WNL
|
Breasts Abnormal
• • •
|
|
Breasts Comments
|
|
|
Neuro WNL
|
Neuro Abnormal
• • •
|
|
Neuro Comments
|
|
|
Extremities WNL
|
Extrem Abnormal
• • •
|
|
Extrem Comments
|
Other findings
|
|
Demographics
|
Demographics
|
|
MAR
|
MAR
|
|
MAR
|
MAR
|
|
MAR
|
MAR
|
|
MAR
|
MAR
|
|
Diagnostics
|
Diagnostics
|
|
Diagnostics
|
Diagnostics
|
|
Diagnostics
|
Diagnostics
|
|
Diagnostics
|
Diagnostics
|
|
Diagnostics
|
Diagnostics
|
