ASSESSMENT / PATIENT SUMMARY

Transcription

1 Patient Name: Primary Care Physician: Reason for Consultation: ASSESSMENT / PATIENT SUMMARY Referring Physician: Nursing Assessment: Prior Radiation Therapy: No Yes Name of Facility: Radiation Oncologist: Primary Language Cardiac Pacemaker or AICD: No Yes If Yes, complete the following information: Cardiologist: Manufacturer: of Implant: Model Number: Serial Number: Family History of Cancer: No Yes If Yes, list: Vital Signs: Temperature: Respirations: Height: Weight: Pulse: Blood Pressure: Social History: Occupation: Tobacco use: No Yes # packs per day # of years Alcohol use: No Yes # of drinks per day Marital Status Children Do you live with Family Spouse Other Current Pain: No Yes Pain Level Scale If Yes, rate on scale 0-10 Pain Level: Pain Goal: Reproductive Female only: Age at onset of period: of last period: Periods Regular: No Yes Age at time of menopause: # of children: # of pregnancies: Have you ever taken hormones? No Yes If Yes, explain No Pain Worst Pain Fall Risk Screening: (Any response=high risk for falls) No Yes If Yes, Explain: Are you currently feeling weak or dizzy? Do you have difficulty getting out of a chair or bed? Do you have any difficulty walking without holding onto furniture or walls? Do you use an assistive device for walking? Have you fallen in the last 3 months? Patient Summary List: Significant Medical Diagnoses and Conditions: Onset Past Operative or Invasive Procedures: Nurse/MA Signature: /Time: Assessment / Patient Summary

2 Review Of Systems - PLEASE CHECK EACH ITEM OR AS THEY RELATE TO YOUR HEALTH CONSTITUTIONAL RESPIRATORY HEMATOLOGIC/LYMP Weight Loss Cough Easy Bruising Fatigue -Productive Gums Bleed Easily Fever -Nonproductive Enlarged Glands Sweats Coughing Blood Blood Transfusion Wheezing E Short of breath MUSCULOSKELETAL Glasses/Contacts -At Rest Joint Pain/Swelling Pain -With Exertion Stiffness Double Vision Use of O2 Muscle Pain Blind Spots GASTROINTESTINAL Neck/Back Pain Blind Colostomy Glaucoma Nausea/Vomiting Cataracts Constipation Change in BMs SKIN EAR, SE, THROAT Diarrhea Rash/Sores Difficulty Hearing Diff. Swallowing Lesions Ringing in Ears Jaundice Itching/Burning Ear Pain Abdomen Pain Vertigo Pain w/ BMs NEUROLOGICAL Sinus Trouble Rectal Bleeding Seizures Nasal Stuffiness GENITOURINARY Weakness/Paralysis Freq. Sore Throat Pain Urinating Numbness/Tingling Hoarseness Burning Tremors Frequency Memory Loss CARDIOVASCULAR Nighttime Speech Murmur Blood in Urine Headaches Chest Pain Diff. Urinating Heart Attack Stream ENDOCRINE Palpitations His. Kidney Stones Loss of Hair Dizziness History STD Heat/Cold Intolerance Fainting Spells Abn. Discharge Change in Nails Hypertension Diff Lying Flat PSYCHIATRIC ALLERGIC/IMMULOGIC Swelling Ankles/Other Anxiety/Depression Hay Fever/Asthma Pace Maker/Defib. Difficult Sleep Hives/Eczema Mood Swings PROTECTIVE MECHANISMS Skin intact? If no, Incision Skin? Cool Cold Warm Hot Pressure sore Dry Flushed Moist Pale Other Ashen Cyanotic Jaundice ADVANCED DIRECTIVES REFERRALS Living Will Yes No Oncologist Health care surrogate Yes No Social Service/Pastoral Power of attorney Yes No Enterostomal Therapist Require more information Yes No Dietitian Registered w/ ACS Yes No Skin/Wound Nurse/MA Signature: MD Signature: NURSING ASSESSMENT CHECKLIST

3 KWN ALLERGIES Allergies, adverse or allergic reactions: MEDICATION RECONCILIATION LIST INFORMATION FROM: Patient Family / Legally / Authorized Person Other: No known current medications Unable to obtain medication list Incomplete List CURRENT MEDICATIONS Herbals and supplements are for information only Reviewer Signature Medication Discontinued Prescription / OTC / Vitamins / Supplements / Herbal Preparations Include Dose / Route / Frequency DATE DISCHARGE: NEW AND/OR CHANGES TO MEDICATIONS Medication Name Include Dose / Route / Frequency Reviewer Signature Prescription Given Instructions Next Provider of Care: Physician Name: Tel#: Fax#: Physician Name: Tel#: Fax#: Physician Name: Tel#: Fax#: Medication Reconciliation Summary

4 AUTHORIZATION FOR USE AND/OR DISCLOSURE AND REQUEST FOR ACCESS TO PROTECTED HEALTH IRMATION FORM Patient Name: of Birth: MR#: Address: Phone #: SS#: City: State: Zip Code: To be completed by requestor: Pick Up Mail Other: The following individual or organization is authorized to make the following disclosure: Name: Phone: Address: Fax: City: State: Zip Code: Admission/Discharge (s): Records Requested: *Abstract Discharge Summary Operative Report Emergency Room Report Pathology Report History & Physical Laboratory Report Radiology Report Consultation Other (specify): Reason for requesting information: Requests may be subject to copying fee This information may be disclosed to and used by the following individual or organization: Name: FHMMC- Phone: Address: 301 Memorial Medical Parkway Fax: City: Daytona Beach State: FL Zip Code: I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to the Health Information Management Department. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire on the following date, event or condition (not to exceed 90 days):. If I fail to specify an expiration date, event or condition, this authorization will expire 90 days from the date signed. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that I may inspect or obtain a copy of the information to be used or disclosed, as provided in CFR I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure and that information may not be protected by Federal confidentiality rules. If I have questions about disclosure of my health information, I can contact the authorized individual or organization making disclosure. I understand the information in my health record may include psychiatric, alcohol or drug abuse/testing information which may be protected by Federal and State Regulations. I also understand that my health record may include information relating to AIDS, HIV, and/or sexually transmitted disease. Patient Signature: : Authorized Representative/Parent: : Printed Name of Authorized Representative/Parent: Relationship to Patient: Address and Phone # of Authorized Representative/Parent: *Abstract consists of facesheet, discharge summary, history & physical, consults, operative notes, emergency record, lab, radiology, EKG reports, and pathology (if available). AUTHORIZATION FOR USE AND/OR DISCLOSURE AND REQUEST FOR ACCESS TO PROTECTED HEALTH IRMATION

5 ACKWLEDGEMENT OF RECEIPT Notice of Patient Privacy Practices By signing this Written Acknowledgment of Receipt of (Florida Hospital Ormond Memorial FH-OM), Florida Hospital Oceanside (FH-O), Florida Hospital Flagler (FH-F), the Medical Staff of FH-OM, the Medical Staff of FH-O, and the Medical Staff of FH-F Notice of Patient Privacy Practices ( Acknowledgment ), I hereby acknowledge my receipt of Florida Hospital Ormond Memorial ( FH-OM), Florida Hospital Oceanside (FH-O), Florida Hospital Flagler (FH-F), the Medical Staff of FH-OM, the Medical Staff of FH- O, and the Medical Staff of FH-F Notice of Patient Privacy Practices Patient, or Legal Representative, Signature Patient Account Number Printed Patient, or Legal Representative, Name (or label) Patient Medical Record Number Acknowledgment T obtained because: Patient, or legal representative, declined Notices of Patient Privacy Practices; Patient treated in Emergency Room and discharged before obtaining Acknowledgment; Other (Briefly describe) Employee Signature Employee Printed Name REQUEST/AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION 1. I authorize Florida Hospital Memorial Systems Cancer Institute to release information from the medical records of: Patient s Name of Birth 2. Information to be released includes: (please check one section) All medical information including psychiatric, alcohol and or drug treatment, HIV and/or AIDS (if present) Only the following information: 3. Information is to be released to (one designee): Name: Relationship: Phone # 4. I understand this consent can be revoked at any time except to the extent that disclosure made in good faith has already occurred in reliance on this consent. Patient s or legal representative s signature Relationship Witness Acknowledgement of Receipt of NPPP

6 MEDICARE SECONDARY PAYOR QUESTIONAIRE I am entitled to Medicare Benefits: Yes (Complete remainder of form) No (return form to Front Desk) PART I Are you receiving Black Lung benefits? Yes No Are services related to this visit to be paid by Government Program, Research? Has the Department of Veterans Affairs (DVA) authorized and agreed to pay for your care at this facility? Was the illness/injury due to a work-related accident/condition? Yes No PART II Was the illness/injury due to a non-work related accident? Yes No PART III Are you entitled to Medicare benefits based on (check all that apply) Age? Yes No Disability? Yes No Yes Yes No No Effective : of injury/illness: of accident: of retirement: of disability: End Stage Renal Disease (ESRD)? Yes No PART IV & V AGE & DISABILITY Are you currently employed? Yes No Do you have a spouse that is currently employed? Yes No Do you have group health plan (GHP) coverage based on your own or a spouse s current employment? Yes No Does the employer that sponsors your or your spouse s GHP employ 20 or more employees? Yes No PART VI END STAGE RENAL DISEASE Do you have group health plan (GHP) coverage? Yes No Have your received a kidney transplant? Yes No Have you received maintenance dialysis treatments? Yes No Is patient participating in a self dialysis training program? Yes No of spouse s retirement: of transplant: dialysis began: training started: Information obtained from: (Please check one): Patient Spouse Parent Other Patient/Guarantor signature: : Medicare Secondary Payor Questionnaire

7 Printed Name: MEDICARE SECONDARY PAYOR QUESTIONAIRE of Birth: Appointment To be completed by the patient at each appointment: I have reviewed the information on the Medicare Secondary Payor Questionnaire that I completed at a previous visit. I attest that all information is correct or I have indicated changes to my health insurance coverage to the best of my knowledge. Please return this form, your insurance cards and your driver s licenses to the front desk personnel. This section is to be completed by the medical practice personnel only. I have obtained a legible copy of each insurance card and a driver s license. I have determined whether Medicare is the primary or secondary payor for today s visit. Medicare Secondary Payor Questionnaire