general information patient database
Post on 03-Dec-2021
2 Views
Preview:
TRANSCRIPT
PATIENT DATABASE Version 12.09 Copy to Chart
Each page must have pt. ID label
GENERAL INFORMATION PATIENT DATABASE
Preferred Name:
Why are you in the hospital (chief complaint)? _____________________________________
How can we provide “Very Good” care for you during your hospital visit? ______________________________________
If you have been hospitalized before, did you determine a specific Resuscitation/Code status ?
Full resuscitation/code No resuscitation/code Other
Do you have an Advanced Directive (living will, etc.)? Yes No
If yes, is it an Advance Directive Living Will Durable Power of Attorney Other
Location of Legal Healthcare Directive: Copy obtained from previous record Copy placed on paper chart
Family to bring in copy from home Scanned into EMR Unable to obtain copy
If you do not have an advanced directive, would you like assistance in developing one?
Yes No
Information Given By: ___________________________________
Name of information source (if not patient): ______________________________________
Primary Language Spoken: _______________________________________________
Do you have a good understanding of the English language? Yes No
Do you need an interpreter? Yes No Name of interpreter:
Interpreter: Offered Refused Patient Request Family / friend as interpreter Unable to Provide appropriate interpreter
Unable to provide appropriate interpreter reason:
Family Information:
Emergency contact / spokesperson: __________________________ Relationship: ___________________________
Preferred phone number: ( ) ______________ Alternative phone number: ( ) ____________
Legal Guardian: ____________________________________
Legal guardian relationship to patient: ___________________________________
Child resides with whom: _____________________________________________
Provider Information:
Who is your primary care physician? ______________________ Non-Sharp affiliated PCP: _______________________
Date of last visit / exam: _____ / _____ / ______Other Provider/Specialty:_________________________________
Special Requests:
Do you have any special requests regarding visitors? Yes No
If so please describe: __________________________________________________________________________
ALLERGIES
Are you allergic to latex or rubber? Yes No
Are you allergic to iodine, X-ray dye, or shellfish? Yes No
Do you have a tape allergy? Yes No
Height: Patient stated body weight:
MEDICAL HISTORY: Please check all that apply to your past medical history Check the None box if you have no problems in that area.
*Anesthesia Comment
Have you had any problems with previous anesthetics? If so, please describe:
Yes No
Have any of your blood relatives had unusual reactions to anesthesia? If so, please describe:
Yes No
Have you had any problems with difficult intubation? If so, please describe
Yes No
Nausea/Vomiting Yes No
Other anesthesia issues Yes No
Airway / Head/ & Neck None Airway note
Chronic ear infections Yes No
Dentures / partials Yes No
Difficulty fully opening mouth Yes No
False eye Yes No
Loose or chipped teeth Yes No
Permanent crowns/veneers / caps Yes No
Other airway/head & neck issues Yes No
*Cardiac / Heart Cardiac note If patient answers yes to “chest pain / angina” complete the chest pain algorithm section Aneurysm (where)
None
Yes No
Cardiac note
*Angioplasty (date) Yes No
Blood vessel clots (where/date) Yes No
*Chest pain or angina (date) Yes No
Congestive heart failure Yes No
Gestational hypertension Yes No
*Heart attack (date) Yes No
*Heart bypass (date) Yes No
Heart failure (date) Yes No
Heart murmur Yes No
Heart valve problem Yes No
*High blood pressure Yes No
High cholesterol Yes No
Palpitations/irregular heart beat Yes No
Each page must have pt. ID label PATIENT DATABASE Version 12.09 Copy to Chart
2
PATIENT DATABASE Version 12.09 Copy to Chart
3 Each page must have pt. ID label
Poor circulation Yes No
Short of breath at rest – cardiac Yes No
Short of breath with exertion Yes No
*Stent (date) Yes No
*Other cardiac/heart issues Yes No
*Do you have a Pacemaker or AICD both?
Pacemaker Information available? Yes Unknown Asked patient to bring in Other
When was Pacemaker/AICD last placed? ___________________
Date last Interrogated______________Make___________ Model_____________Cardiologist____________________
*Exercise tolerance – Do you get short of breath after walking?
Yes No Exercise note
Up one flight of stairs? Yes No
*Up two flights of stairs? Yes No
One level block? Yes No
*Do you exercise regularly? (what / long / often) Yes No
Has there been a recent change in exercise ability? Yes No
Other exercise tolerance issues Yes No
*Pulmonary / Lungs None Pulmonary note
*Asthma Yes No
*Bronchitis or Emphysema Yes No
*COPD Yes No
*CPAP machine Yes No
*Do you currently smoke? Yes No
Do you snore? Yes No
Lung blood clots (date) Yes No
Lung mass/surgery Yes No
*Oxygen dependent Yes No
Pneumonia (date) Yes No
Recent flu or productive cough Yes No
Short of breath at rest – pulmonary Yes No
*Sleep apnea Yes No
Tuberculosis Yes No
Other pulmonary/lung issues Yes No
*Metabolic / Endocrine None Metabolic note
Adrenal or pituitary gland problems Yes No Gestational diabetes Yes No Gout Yes No *Insulin dependent diabetic Yes No
*Non-insulin dependent diabetic Yes No
Is patient last Hgb A1C >7.5? Yes No *Is patient’s average fasting BG > 100? Yes No
Prednisone/steroid use within last 6 months Yes No
Thyroid disease Yes No
Other metabolic issues Yes No
Does the patient have an insulin pump? Yes No
*Gastrointestinal None GI note
Frequent diarrhea Yes No
GI bleeding Yes No
*Heartburn/acid reflux (GERD) Yes No
Hiatal hernia Yes No
Irritable/inflammatory bowel disease Yes No
Pancreatitis Yes No
Rectal bleeding; black/bloody stool Yes No
Stomach surgery Yes No
Ulcers Yes No
Other gastrointestinal issues Yes No
Gentourinary None GU note
Incontinence – urine Yes No
Other genitourinary issues Yes No
*Renal / Kidney None Renal note
*Dialysis Yes No
*Kidney disease or infection Yes No
Kidney failure Yes No
Kidney transplant Yes No
*Other renal/kidney issues Yes No
Hepatic / Liver
None Hepatic note
Cirrhosis Yes No
Current /former alcoholic Yes No
Hepatic Yes No
Liver disease Yes No
Other hepatic/liver issues Yes No
Hematology / Blood None Hematology note
Anemia Yes No
Easy bruising or bleeding Yes No
Hemophilia Yes No
Sickle cell anemia Yes No
Thalassemia Yes No
Unusual or prolonged bleeding Yes No
Each page must have pt. ID label PATIENT DATABASE Version 12.09 Copy to Chart
4
PATIENT DATABASE Version 12.09 Copy to Chart
5 Each page must have pt. ID label
Other hematology/blood issues Yes No
Muscle / Skeletal None Muscle/Skeletal note
Chronic back pain Yes No
Joint replacement Yes No
Joint stiffness Yes No
Lupus Yes No
Muscular dystrophy Yes No
Myasthenia gravis Yes No
Rheumatoid arthritis Yes No
Other muscle/skeletal issues Yes No
Neurological None Neurological note
Brain injury Yes No
Brain surgery Yes No
Brain tumors Yes No
Dementia/Alzheimer’s disease Yes No
Fainting/loss of consciousness (date) Yes No
Headaches/migraines Yes No
Multiple sclerosis Yes No
Parkinson’s disease Yes No
Prolonged nerve paralysis or numbness Yes No
Spina Bifida Yes No
Spinal cord injury/tumor Yes No
Stroke (date) Yes No
Other neurological issues Yes No
Integumentary None Integumentary Note
Rash/itching Yes No
Severe burn in the last 2 years Yes No
Skin problem Yes No
Other Integumentary issues
*Infectious Disease None
Infectious Disease Note
HIV Yes No
*Resistant bacterial infection (MRSA/MSSA/VRE) Yes No
Acinetobacter baumannii Yes No
Clostridium difficile (C Difficile) Yes No
Cytomegalovirus (CMV) Yes No
Extended spectrum beta-lactamase Yes No
Group B strep Yes No
Other infectious disease issues Yes No
PATIENT DATABASE Version 12.09 Copy to Chart
6 Each page must have pt. ID label
Cancer None Cancer note
Cancer type Cancer treatment
Females only N/A Female Note
Currently breast feeding Yes No Last menstrual period (date) Yes No Currently/possible pregnant Yes No Other female issues Yes No Currently / Possibly pregnant Yes No Behavioral Health None Behavioral Health Note
Anxiety Yes No
Depression Yes No
Schizophrenia Yes No
Other behavioral health issues Yes No
Have you had any previous operations? If numerous please list last 6 only
None
Surgery date Description Previous Surgery Comment
1.
2.
3.
4.
5.
6.
Visual Aids Vision Impaired Hearing Aids Hearing Impaired
Yes Blind left eye Yes Profoundly deaf left ear No Blind right eye No Profoundly deaf right ear Eye glasses Impaired left eye Right Hard of hearing left ear Contacts Impaired right eye Left Hard of hearing right ear Other Bilateral
Other Implanted devices Yes No
*Additional Medical History
Communicable Diseases
Exposure to Chicken Pox in last 3 weeks Yes No
TB screening Cough and night sweats lasting longer than 2 weeks No prenatal care Positive PPD without CXR and/or symptomatic Pulmonary symptoms (productive cough, fever > 2 weeks) None of the above; (next section not necessary
PATIENT DATABASE Version 12.09 Copy to Chart
7 Each page must have pt. ID label
SCREENING QUESTIONS
Do you have any special diet request based on religious / cultural practices or and preferences that need to be part of your care?
Yes No
Describe food preferences or special diet:
Have you been eating less than all of your meals during the last week? (other than a doctors order not to eat)
Yes No
Do you have difficulty eating or do you cough or choke while swallowing food/liquids
Yes (discuss with physician) No
Do you have a new problem with understanding, communicating, or talking?
Yes (relates to current admission) No Yes ( discuss with physician)
Have you had recent decrease in your ability to do your self care activities?
Yes (relates to current admission) No Yes (discuss with physician)
Are there any religious/cultural practices that will affect your care?
Describe:
Yes No
Would you like a spiritual advisor (Priest, Rabbi, etc) to visit you? Yes No Request to see personal advisor Request a pastoral care consult
Do you have objections in receiving blood products?
Describe objection to receiving blood:
Yes No
Do you use or are you interested in receiving integrative therapies during this hospitalization? Describe:
Yes No (Reiki, acupuncture, etc.- may not be available in all facilities)
Do you currently have an intravenous device (PICC line, mid line port) in your arm or chest; or any other catheter in your chest or neck?
Yes No
Do you currently have Home Health Services visiting you? Yes No Name of Agency:
Do you live anywhere other than a private residence? Yes No Name of Facility:
# SOCIAL HABITS Do you have more than 10 alcoholic drinks per week? If so, what type, frequency, amount, and last use?
Yes No
If you are pregnant, have you consumed alcohol during your pregnancy? Yes No N/A
Have you smoked within the last 12 months? If so, what type, cigarette use (packs per day), other tobacco frequency, and last use?
Yes No
Exposure to tobacco smoke: Exposed at work Live with someone who smokes Patient smokes Other
Do you use illicit (street) drugs? If so, what type, frequency, amount, and last use?
Yes No
If Patient is pregnant, and above screening questions are checked; complete the following: Bloody sputum Yes No History of exposure to TB Yes No History of positive TB skin test Yes No History of positive chest x-ray for TB Yes No Treated for TB Yes No PPD result non screened
or not available negative positive
Chest X-Ray results neg pos none
top related