Clinic Locations
Allergy: UCLA-Harbor
Breast: 2B156
Cardiology: 2C121
Clinic A: 2C138
Clinic B (anticoagulation): 6D101, Fax 4747, Ext 4418, Attn: Paula, NP
Continuity Clinic A: Dr. Alder, General Medicine
Coumadin - Penny Luc: 2D152
Diabetes - Penny Luc: 2B182 (Dept of Medicine)
Dietary: 1C112
ENT/Optho: 2C101
Gyn: Clinic D: 2A167
Neurology: 2C136
Neurosurgery: County USC Medical Center
Physical Therapy: 1D122
Plastic Surgery: 2B156
Podiatry: 2B156
CCC: Clinic A
Proctology: 2B156
Psychiatry: 2B131
Skin Bx: Nowfar Radiology
Stroke Clinic: 2C136
Surgery: 2B156
Referral Center: 2D152, x3610
Pulmonary Lab: 6B102, x4428
TB Control: Education Bldg, Rm 241
Urology: 2B156
Valley Care: Referral Center
Vascular Surgery: 2B156
Clinic P: Primary Care - x4990
Palliative Care: Clinic A
Dept Of Medicine (Room 2B182)
Ambulatory Medicine, Derm, Endo, GI, Hem/Onc, PCP, ID, Primary Care, Pulmonary, Renal, Rheum
Monday, February 9, 2015
Sunday, February 8, 2015
OV Phone Numbers
Admissions: 3939
Appt Desk: 3184/5100
Bed Control: 5959
ER Finance 4802
ER Registration 3942
ER Main: 4320
Triage Nurse: 5658
PEDS Room: 4331
Lab 3476 or 4038 (stat)
MAC: 866-940-4401
Dental USC 323-226-5013
Computer Help Desk: 4522
Psych ER (consults) 4341
IR 5906
Radiology 4086 or 6516
Appts 4086
Dr. Chawla 4863
In-house Radiology at night 6055 or 4089
CT 4089
CT body reading room 6078
MRI 3535
MRI reading room 6094
u/s 4075 or 6055
XRAY 4059
XRAY ER or portable tech 4540 or 6118
Respiratory Therapy 4422
Social Work
Operators
OV 3055
LAC-USC 323-226-2622
CHLA 323-660-2450
Harbor UCLA 310-22-2345
Cardiology: 4287
Cath Lab: 5906
Echo Lab: 6188
Central Processing: 5945/5946
Clinics
A (CCP/PCC/MFU) 3125
B (Surgical/Derm): 3129/3132
C (Cardiology/ID Clinic): 3133
D (GYN): 3137
E (Ortho/Podiatry): 3676
ENT/Optho: 3538
Peds Clinic: 3141
Special Treatment Center: 6346/4340
Chemo Clinic: 3540
Neurology: 3104
Urology: 3129
Physical Therapy 4245
MAC Ph: 866-940-4401
MAC Fax: 323-890-7643
Continuity of Care (Home Health): 3352
Coumadin Referrals: 4418
Coumadin Fax: 4747
County Transportation: 866-941-4401
Radiology
Night Hawk: 866-448-7762
Night Reads: 4971/4969
XR Read: 5145/4863
CT Body Read: 4791/6078
US Read: 3470/4543
Neuro Read: 4082/6094
XR/CT/US Schd: 4086/4474
XR Main (Tech): 4059
XR ED/after hrs: 5496/4327
CT Main (tech): 4089/4080
CT ED/after hrs: 4968
US Main (tech): 6082/4084
US ED: 4940
MRI Main: 3535
Nuc Med Schd: 4094/
ER CT: 4968
Floor CT: 4474
CT
Scheduling: 4075
Reading: 4089
Dental: 3145
Dept Med: 3205
Dept OB/GYN: 3222
Dept Surgery: 3194
EM ROOM: 4323/4324
Pysch ER: 4340/4343
Urgent Care: 4311/4312
Lab
Blood Bank: 4062
Chemistry: 3476
Lab day: 4025
Lab Night: 6033
Stat Lab: 3476
Financial Services
Inpatient: 4182 (ER 5094)
Outpatient: 4262
GI Lab-2C175: 6186
Help Desk: 4522
Human Resources: 3311
Infectious Room: 3624/4216
Oxygen Tank Refill
Respiratory Therapy: 4422
Operating Room: 4364
Floors
4BN (Step Down) 4390
4BS (Step Down): 3456
4D: 4578
5A: 4400
5BN (ICU): 4414
5BS (ICU): 4409
5C: 4406
5D (step down): 4403
6A (Psych) 3760
L&D: 6110/6589
Operating Room: 4364
Appt Desk: 3184/5100
Bed Control: 5959
ER Finance 4802
ER Registration 3942
ER Main: 4320
Triage Nurse: 5658
PEDS Room: 4331
Lab 3476 or 4038 (stat)
MAC: 866-940-4401
Dental USC 323-226-5013
Computer Help Desk: 4522
Psych ER (consults) 4341
IR 5906
Radiology 4086 or 6516
Appts 4086
Dr. Chawla 4863
In-house Radiology at night 6055 or 4089
CT 4089
CT body reading room 6078
MRI 3535
MRI reading room 6094
u/s 4075 or 6055
XRAY 4059
XRAY ER or portable tech 4540 or 6118
Respiratory Therapy 4422
Social Work
Operators
OV 3055
LAC-USC 323-226-2622
CHLA 323-660-2450
Harbor UCLA 310-22-2345
Cardiology: 4287
Cath Lab: 5906
Echo Lab: 6188
Central Processing: 5945/5946
Clinics
A (CCP/PCC/MFU) 3125
B (Surgical/Derm): 3129/3132
C (Cardiology/ID Clinic): 3133
D (GYN): 3137
E (Ortho/Podiatry): 3676
ENT/Optho: 3538
Peds Clinic: 3141
Special Treatment Center: 6346/4340
Chemo Clinic: 3540
Neurology: 3104
Urology: 3129
Physical Therapy 4245
MAC Ph: 866-940-4401
MAC Fax: 323-890-7643
Continuity of Care (Home Health): 3352
Coumadin Referrals: 4418
Coumadin Fax: 4747
County Transportation: 866-941-4401
Radiology
Night Hawk: 866-448-7762
Night Reads: 4971/4969
XR Read: 5145/4863
CT Body Read: 4791/6078
US Read: 3470/4543
Neuro Read: 4082/6094
XR/CT/US Schd: 4086/4474
XR Main (Tech): 4059
XR ED/after hrs: 5496/4327
CT Main (tech): 4089/4080
CT ED/after hrs: 4968
US Main (tech): 6082/4084
US ED: 4940
MRI Main: 3535
Nuc Med Schd: 4094/
ER CT: 4968
Floor CT: 4474
CT
Scheduling: 4075
Reading: 4089
Dental: 3145
Dept Med: 3205
Dept OB/GYN: 3222
Dept Surgery: 3194
EM ROOM: 4323/4324
Pysch ER: 4340/4343
Urgent Care: 4311/4312
Lab
Blood Bank: 4062
Chemistry: 3476
Lab day: 4025
Lab Night: 6033
Stat Lab: 3476
Financial Services
Inpatient: 4182 (ER 5094)
Outpatient: 4262
GI Lab-2C175: 6186
Help Desk: 4522
Human Resources: 3311
Infectious Room: 3624/4216
Oxygen Tank Refill
Respiratory Therapy: 4422
Operating Room: 4364
Floors
4BN (Step Down) 4390
4BS (Step Down): 3456
4D: 4578
5A: 4400
5BN (ICU): 4414
5BS (ICU): 4409
5C: 4406
5D (step down): 4403
6A (Psych) 3760
L&D: 6110/6589
Operating Room: 4364
Friday, February 6, 2015
OV Templates
Subjective
No Acute Events overnight. Pt denies CP, SOB, ABD pain, N/V/F/C.
Objective
Vital Signs
Temp / HR / RR / BP / O2 Sat
/ / / /
24 hour I/O: /
Normal Physical Exam
GEN: NAD, Laying Comfortably in bed
HEENT: PERRLA, no jaundice
CV: rrr, no mrg, +S1, S2
PULM: CTAB, no crackles, wheezing, rales
ABD: soft, NTND, no rebound, no guarding
EXT: 2+ peripheral pulses. No edema b/l.
SKIN: no petechiae, no rash
NEURO: A&O x 3.
Normal Neuro Exam
CN2-12 intact b/l. EOMI. 5/5 strength in UE and LE. Intact sensation b/l. No dysmetria, no dysdokinesia. Neg protanator drift, neg romberg. Gait nl.
Labs
BMP
Na / K / Cl / HCO3 / BUN / Cr < Glu
/ / / / / <
Ca / Mg / Phos
/ /
CBC
WBC > Hgb / Hct < Plts
> / <
LFTs
Albumin / Tot Protein / D. Bili / T. Bili / AST / ALT < Alk Phos
/ / / / / <
A/P
yo M/F with PMH * presents with
# FEN/GI: regular diet
# DVT PPX: heparin Subq
# Code Status: FULL CODE
# Dispo: Pending medical work-up
# Emergency Contact:
Brian Truong, p0503
Plan discussed with attending physician: Dr. *
Discharge Summary Template
Date of Admission:
Date of Discharge:
Service: Medicine Team H
Attending: Mark Richman
Resident: Patrick Poquiz
Intern: Brian Truong
Discharge Diagnoses (no abbreviations; list all conditions from past medical history and that developed during hospitalization):
Procedures:
Imaging
History of present illness:
Hospital Course:
Disposition: Discharge to home
Code Status: Full
Discharge Condition: Good
Pending Studies:
Discharge Activity: Ambulating
Discharge Diet:
Discharge Medications:
Follow-up Instructions: Follow-up with PCP in 2-3 days.
[ ] Central line, PICC line, or dialysis catheter present and indicated
Discharge plan discussed with attending who concurs with plan.
Date of Discharge:
Service: Medicine Team H
Attending: Mark Richman
Resident: Patrick Poquiz
Intern: Brian Truong
Discharge Diagnoses (no abbreviations; list all conditions from past medical history and that developed during hospitalization):
Procedures:
Imaging
History of present illness:
Hospital Course:
Disposition: Discharge to home
Code Status: Full
Discharge Condition: Good
Pending Studies:
Discharge Activity: Ambulating
Discharge Diet:
Discharge Medications:
Follow-up Instructions: Follow-up with PCP in 2-3 days.
[ ] Central line, PICC line, or dialysis catheter present and indicated
Discharge plan discussed with attending who concurs with plan.
Discharge Instructions Template
Discharge Service: Medicine Team H
Discharge Attending: Mark Richman
Discharge Resident: Patrick Poquiz
Discharge Intern: Brian Truong
Date of Admission:
Date of Discharge:
Admission Diagnosis:
Primary Discharge Diagnosis:
Secondary Discharge Diagnoses:
[ ] MRSA-positive; patient notified and educated
Disposition: [ ] Home[ ] Home with Home Health[ ] Nursing Home [ ] Other:
Labs/Tests prior to discharge:
[ ] MRSA-negative chronic dialysis patient: perform MRSA nasal swab
Labs/Tests after discharge:
Follow-up in / Make referrals to (Doctor: please fill in consult/referral form):
1. Location: Date: Time: Bldg/Room#:
2. Location: Date: Time: Bldg/Room#:
3. Location: Date: Time: Bldg/Room#:
4. Location: Date: Time: Bldg/Room#:
Additional Instructions / Treatment at Home (e.g., return precautions, wound care, injections):
Medications (keep a list of ALL medications you take and bring it with you whenever you see a healthcare provider)
Your new medications are:
Continue your home medications:
Stop these medications:
Diet:[ ] Heart Healthy [ ] 2 gm sodium [ ] Diabetes [ ] Other:
Activities:[x]As tolerated [ ] Restrictions: [ ] Return to Work in: ____ days
[x] Discussed with Attending, who agrees with discharge plan
_____________________________________________________________________ _____________________________________________________________________
Patient Instructions BRING THIS FORM AND YOUR OLIVE VIEW IDENTIFICATION CARD (PLASTIC CARD) WITH YOU TO YOUR FOLLOW-UP CLINIC APPOINTMENT.
General Instructions If your symptoms recur or persist, return to the Emergency Room/Medical Walk-In; if life-threatening, call 911.
Additional Instructions:
For Patients Diagnosed with Heart Failure 1. Low salt, low cholesterol/fat diet, and restrict fluid intake as directed by your doctor. 2. Gradually increase your activity, as directed by your doctor; schedule rest breaks as needed. 3. Weigh yourself daily on same scale in the morning; bring your weight record to your follow-up appointment. 4. If you experience any chest pain, increased bleeding or bruising, swelling in your legs or ankles, difficulties in breathing, or gain 2 or more pounds in one day or 5 or more pounds in one week, return to the hospital.
For Patients Diagnosed with a Heart Attack 1. Low salt, low cholesterol/fat diet, as directed by your doctor. 2. Gradually increase your activity, as directed by your doctor. 3. If you experience chest pain that does not go away, call 911.
For Patients Diagnosed with Stroke 1.Call 911 if you have a SUDDEN: numbness or weakness of the face, arm or leg, especially on one side of the body, confusion, trouble speaking, understanding, seeing, walking, or feeling dizzy, loss of balance or coordination, or a severe headache without cause. 2. Keep all doctor and test appointments. 3. Take all medications prescribed to you at discharge. 4. Be aware of risk factors for Stroke, such as: Cigarette smoking, alcohol abuse, being overweight, poor diet, not being active.
Outpatient Clinic Appointments 1. To make, change or cancel a clinic appointment, call (818) 364-3184. 2. Be prepared to tell the appointment clerk: medical record number, patient's name, birth date, telephone number and address. 3. Please arrive 15 minutes prior to your scheduled appointment time. 4. If you arrive later than 15 minutes after your scheduled appointment time, your appointment may be rescheduled or you may be referred to Emergency Room/Medical Walk-In if your condition warrants such. 5. If you are expecting to be late, you must call the clinic to find out if you can be accommodated.
Postoperative Discharge Instructions 1. Nausea and/or vomiting may occur in the immediate postoperative period. 2. If breathing difficulties, excessive bleeding, fever, or other disturbing problems should develop after leaving the hospital, return to the Emergency Room. 3. Do not drive a car or make any important decisions for the next 24 hours. 4. You must follow up with your primary doctor after discharge for instructions on the medications you took prior to surgery. 5. If you have been instructed to change your dressing, wash your hands before and after touching your wound/dressing.
Infection Prevention Strategies To prevent the spread of infections and multi-drug resistant organisms (MDROs) such as: 1. Methicillin Resistant Staphylcoccus Aureus (MRSA) 2. Vancomycin Resistant Enterococcus (VRE) 3. Extended Spectrum Beta Lactamase (ESBL) 4. Clostridium difficile (CDI) Wash hands frequently with soap and water for at least 15 seconds. Keep wounds covered. Regularly wash clothing, bedding and areas in your home that can become contaminated such as bathrooms and kitchen. Do not share personal items like towels, washcloths, bars of soap or razors.
Blood clot prevention: If you started on an anticoagulant (also called a ?blood thinner?) by mouth (for example, warfarin [COUMADIN]) or by injection (for example, enoxaparin [LOVENOX]), the anticoagulation handouts given to you by your Registered Nurse, summarize the education given to you in the hospital. For patients discharged on Warfarin [COUMANDIN], the hand out given & reviewed is '?What I Should Know about Warfarin?. It is important that you take your Warfarin as instructed, follow-up with your doctor and keep all blood test (PT/INR) monitoring appointments, follow your diet (consistent amount of foods that contain vitamin K) and avoid major dietary changes. As changes in diet or medication will affect your PT/INR level, inform your doctor of changes in your medications or over-the-counter medications, diet, or use of alcohol to avoid adverse drug reactions or interactions. Be aware of risks such as signs of bleeding or clotting; seek urgent/emergent care for any bleeding that is continuous or excessive. Wear a ?medic alert? bracelet.
RECEIPT FOR THIS PATIENT, IF CHILD OR WARD OF COURT Before permitting a child to leave the hospital, the responsible nurse will require the parent or legal guardian to sign below. When parent or guardian cannot be reached, the RESIDENT PHYSICIAN ON DUTY may authorize a relative or friend to sign the receipt when circumstances warrant. Receipt is not required for a minor deemed sufficiently responsible to look after himself. I have received ___________________________________ from the Los Angeles County Olive View-UCLA Medical Center, who is my __________________________ for whom I acknowledge full and complete responsibility.
Signature Printed Name Date
Address _______________________________________________________ Phone __________________________
Discharged with whom:
Discharge via:[ ] Ambulatory[ ] Stretcher[ ] Wheelchair
Discharge to:[ ] Ambulance[ ] County sedan[ ] Private car
Valuables/personal belongings returned?[ ] Yes[ ] No[ ] None
Supplies/equipment to send with patient:
Child Safety Info Given: [ ] Yes [ ] No [ ] N/A
Crisis Hotline Info: 1-877-727-4747
Smoking causes many health problems and can shorten your life. We advise you not to smoke. For free help with quitting, call 1-800-NO-BUTTS
(1-800-662-8887).
SIGNATURES
Clerk:
Printed Name Signature Date Time
Patient or responsible person: I hereby acknowledge the receipt of these instructions and understand them.
Printed Name Signature Date Time
Discharge Nurse/RN: I have verified that the Influenza/Pneumococcal vaccine(s) have been offered and administered to patient if criteria were met.
Printed Name Signature Date Time
Discharge Attending: Mark Richman
Discharge Resident: Patrick Poquiz
Discharge Intern: Brian Truong
Date of Admission:
Date of Discharge:
Admission Diagnosis:
Primary Discharge Diagnosis:
Secondary Discharge Diagnoses:
[ ] MRSA-positive; patient notified and educated
Disposition: [ ] Home[ ] Home with Home Health[ ] Nursing Home [ ] Other:
Labs/Tests prior to discharge:
[ ] MRSA-negative chronic dialysis patient: perform MRSA nasal swab
Labs/Tests after discharge:
Follow-up in / Make referrals to (Doctor: please fill in consult/referral form):
1. Location: Date: Time: Bldg/Room#:
2. Location: Date: Time: Bldg/Room#:
3. Location: Date: Time: Bldg/Room#:
4. Location: Date: Time: Bldg/Room#:
Additional Instructions / Treatment at Home (e.g., return precautions, wound care, injections):
Medications (keep a list of ALL medications you take and bring it with you whenever you see a healthcare provider)
Your new medications are:
Continue your home medications:
Stop these medications:
Diet:[ ] Heart Healthy [ ] 2 gm sodium [ ] Diabetes [ ] Other:
Activities:[x]As tolerated [ ] Restrictions: [ ] Return to Work in: ____ days
[x] Discussed with Attending, who agrees with discharge plan
_____________________________________________________________________ _____________________________________________________________________
Patient Instructions BRING THIS FORM AND YOUR OLIVE VIEW IDENTIFICATION CARD (PLASTIC CARD) WITH YOU TO YOUR FOLLOW-UP CLINIC APPOINTMENT.
General Instructions If your symptoms recur or persist, return to the Emergency Room/Medical Walk-In; if life-threatening, call 911.
Additional Instructions:
For Patients Diagnosed with Heart Failure 1. Low salt, low cholesterol/fat diet, and restrict fluid intake as directed by your doctor. 2. Gradually increase your activity, as directed by your doctor; schedule rest breaks as needed. 3. Weigh yourself daily on same scale in the morning; bring your weight record to your follow-up appointment. 4. If you experience any chest pain, increased bleeding or bruising, swelling in your legs or ankles, difficulties in breathing, or gain 2 or more pounds in one day or 5 or more pounds in one week, return to the hospital.
For Patients Diagnosed with a Heart Attack 1. Low salt, low cholesterol/fat diet, as directed by your doctor. 2. Gradually increase your activity, as directed by your doctor. 3. If you experience chest pain that does not go away, call 911.
For Patients Diagnosed with Stroke 1.Call 911 if you have a SUDDEN: numbness or weakness of the face, arm or leg, especially on one side of the body, confusion, trouble speaking, understanding, seeing, walking, or feeling dizzy, loss of balance or coordination, or a severe headache without cause. 2. Keep all doctor and test appointments. 3. Take all medications prescribed to you at discharge. 4. Be aware of risk factors for Stroke, such as: Cigarette smoking, alcohol abuse, being overweight, poor diet, not being active.
Outpatient Clinic Appointments 1. To make, change or cancel a clinic appointment, call (818) 364-3184. 2. Be prepared to tell the appointment clerk: medical record number, patient's name, birth date, telephone number and address. 3. Please arrive 15 minutes prior to your scheduled appointment time. 4. If you arrive later than 15 minutes after your scheduled appointment time, your appointment may be rescheduled or you may be referred to Emergency Room/Medical Walk-In if your condition warrants such. 5. If you are expecting to be late, you must call the clinic to find out if you can be accommodated.
Postoperative Discharge Instructions 1. Nausea and/or vomiting may occur in the immediate postoperative period. 2. If breathing difficulties, excessive bleeding, fever, or other disturbing problems should develop after leaving the hospital, return to the Emergency Room. 3. Do not drive a car or make any important decisions for the next 24 hours. 4. You must follow up with your primary doctor after discharge for instructions on the medications you took prior to surgery. 5. If you have been instructed to change your dressing, wash your hands before and after touching your wound/dressing.
Infection Prevention Strategies To prevent the spread of infections and multi-drug resistant organisms (MDROs) such as: 1. Methicillin Resistant Staphylcoccus Aureus (MRSA) 2. Vancomycin Resistant Enterococcus (VRE) 3. Extended Spectrum Beta Lactamase (ESBL) 4. Clostridium difficile (CDI) Wash hands frequently with soap and water for at least 15 seconds. Keep wounds covered. Regularly wash clothing, bedding and areas in your home that can become contaminated such as bathrooms and kitchen. Do not share personal items like towels, washcloths, bars of soap or razors.
Blood clot prevention: If you started on an anticoagulant (also called a ?blood thinner?) by mouth (for example, warfarin [COUMADIN]) or by injection (for example, enoxaparin [LOVENOX]), the anticoagulation handouts given to you by your Registered Nurse, summarize the education given to you in the hospital. For patients discharged on Warfarin [COUMANDIN], the hand out given & reviewed is '?What I Should Know about Warfarin?. It is important that you take your Warfarin as instructed, follow-up with your doctor and keep all blood test (PT/INR) monitoring appointments, follow your diet (consistent amount of foods that contain vitamin K) and avoid major dietary changes. As changes in diet or medication will affect your PT/INR level, inform your doctor of changes in your medications or over-the-counter medications, diet, or use of alcohol to avoid adverse drug reactions or interactions. Be aware of risks such as signs of bleeding or clotting; seek urgent/emergent care for any bleeding that is continuous or excessive. Wear a ?medic alert? bracelet.
RECEIPT FOR THIS PATIENT, IF CHILD OR WARD OF COURT Before permitting a child to leave the hospital, the responsible nurse will require the parent or legal guardian to sign below. When parent or guardian cannot be reached, the RESIDENT PHYSICIAN ON DUTY may authorize a relative or friend to sign the receipt when circumstances warrant. Receipt is not required for a minor deemed sufficiently responsible to look after himself. I have received ___________________________________ from the Los Angeles County Olive View-UCLA Medical Center, who is my __________________________ for whom I acknowledge full and complete responsibility.
Signature Printed Name Date
Address _______________________________________________________ Phone __________________________
Discharged with whom:
Discharge via:[ ] Ambulatory[ ] Stretcher[ ] Wheelchair
Discharge to:[ ] Ambulance[ ] County sedan[ ] Private car
Valuables/personal belongings returned?[ ] Yes[ ] No[ ] None
Supplies/equipment to send with patient:
Child Safety Info Given: [ ] Yes [ ] No [ ] N/A
Crisis Hotline Info: 1-877-727-4747
Smoking causes many health problems and can shorten your life. We advise you not to smoke. For free help with quitting, call 1-800-NO-BUTTS
(1-800-662-8887).
SIGNATURES
Clerk:
Printed Name Signature Date Time
Patient or responsible person: I hereby acknowledge the receipt of these instructions and understand them.
Printed Name Signature Date Time
Discharge Nurse/RN: I have verified that the Influenza/Pneumococcal vaccine(s) have been offered and administered to patient if criteria were met.
Printed Name Signature Date Time
H&P Template
Date of Note:
Chief Complaint:
History of Present Illnesses:
Past Medical History:
Allergies:
Medications:
Past Surgical History:
Social History:
Review of Systems: as above
Family History:
Physical Examination:
GEN: NAD, Laying Comfortably in bed
Test Results:
Labs
IMAGING
Assessment and Plan:
[ ] Central line, PICC line, or dialysis catheter present and indicated
PLEASE SEE ATTENDING ADDENDUM
DISCUSSED WITH DOCTOR: Dr. Richman
Used Interpreter - Name:
Used HCN - Interpreter ID #:
Interpretation language:
Chief Complaint:
History of Present Illnesses:
Past Medical History:
Allergies:
Medications:
Past Surgical History:
Social History:
Review of Systems: as above
Family History:
Physical Examination:
Vital Signs
Temp / HR / RR / BP / O2 Sat
/ / / /
HEENT: PERRLA, no jaundice
CV: rrr, no mrg, +S1, S2
PULM: CTAB, no crackles, wheezing, rales
ABD: soft, NTND, no rebound, no guarding
EXT: 2+ peripheral pulses. No edema b/l.
SKIN: no petechiae, no rash
NEURO: A&O x 3.
GU/Pelvic/rectal: deferred
GU/Pelvic/rectal: deferred
Test Results:
Labs
BMP
Na / K / Cl / HCO3 / BUN / Cr < Glu
/ / / / / <
CBC
WBC > Hgb / Hct < Plts
> / <
LFTs
Albumin / Tot Protein / D. Bili / T. Bili / AST / ALT < Alk Phos
/ / / / / <
IMAGING
Assessment and Plan:
yo M/F with PMH * presents with
# FEN/GI: regular diet
# DVT PPX: heparin Subq
# Code Status: FULL CODE
# Dispo: Pending medical work-up
# Emergency Contact:
[ ] Central line, PICC line, or dialysis catheter present and indicated
PLEASE SEE ATTENDING ADDENDUM
DISCUSSED WITH DOCTOR: Dr. Richman
Used Interpreter - Name:
Used HCN - Interpreter ID #:
Interpretation language:
Progress Note Template
Progress note Template
Reason for Continued Hospitalization:
Subjective:
Objective:
GEN: NAD, Laying Comfortably in bed
Meds:
Studies:
Labs:
A/P:
[ ] Central line, PICC line, or dialysis catheter present and indicated
Plan discussed with Attending: Mark Richman
Reason for Continued Hospitalization:
Subjective:
Objective:
Vital Signs
Temp / HR / RR / BP / O2 Sat
/ / / /
24 hour I/O: /
GEN: NAD, Laying Comfortably in bed
HEENT: PERRLA, no jaundice
CV: rrr, no mrg, +S1, S2
PULM: CTAB, no crackles, wheezing, rales
ABD: soft, NTND, no rebound, no guarding
EXT: 2+ peripheral pulses. No edema b/l.
SKIN: no petechiae, no rash
NEURO: A&O x 3.
GU/Pelvic/rectal: deferred
GU/Pelvic/rectal: deferred
Meds:
Studies:
Labs:
BMP
Na / K / Cl / HCO3 / BUN / Cr < Glu
/ / / / / <
Ca / Mg / Phos
/ /
CBC
WBC > Hgb / Hct < Plts
> / <
LFTs
Albumin / Tot Protein / D. Bili / T. Bili / AST / ALT < Alk Phos
/ / / / / <
A/P:
[ ] Central line, PICC line, or dialysis catheter present and indicated
Plan discussed with Attending: Mark Richman
Thursday, February 5, 2015
OV Templates
Subjective
No Acute Events overnight. Pt denies CP, SOB, ABD pain, N/V/F/C.
Objective
Vital Signs
Temp / HR / RR / BP / O2 Sat
/ / / /
24 hour I/O: /
Normal Physical Exam
GEN: NAD, Laying Comfortably in bed
HEENT: PERRLA, no jaundice
CV: rrr, no mrg, +S1, S2
PULM: CTAB, no crackles, wheezing, rales
ABD: soft, NTND, no rebound, no guarding
EXT: 2+ peripheral pulses. No edema b/l.
SKIN: no petechiae, no rash
NEURO: A&O x 3.
Normal Neuro Exam
CN2-12 intact b/l. EOMI. 5/5 strength in UE and LE. Intact sensation b/l. No dysmetria, no dysdokinesia. Neg protanator drift, neg romberg. Gait nl.
Labs
BMP
Na / K / Cl / HCO3 / BUN / Cr < Glu
/ / / / / <
Ca / Mg / Phos
/ /
CBC
WBC > Hgb / Hct < Plts
> / <
LFTs
Albumin / Tot Protein / D. Bili / T. Bili / AST / ALT < Alk Phos
/ / / / / <
A/P
yo M/F with PMH * presents with
# FEN/GI: regular diet
# DVT PPX: heparin Subq
# Code Status: FULL CODE
# Dispo: Pending medical work-up
# Emergency Contact:
Brian Truong, p0503
Plan discussed with attending physician: Dr. *
Progress note Template
Reason for Continued Hospitalization:
Subjective:
Objective:
GEN: NAD, Laying Comfortably in bed
Meds:
Studies:
Labs:
A/P:
[ ] Central line, PICC line, or dialysis catheter present and indicated
Plan discussed with Attending:
Used Interpreter - name:
Used HCIN - Interpreter ID #:
Interpretation language:
H&P Template
Date of Note:
Chief Complaint:
History of Present Illnesses:
Past Medical History:
Allergies:
Medications:
Past Surgical History:
Social History:
Review of Systems:
Family History:
Physical Examination:
GEN: NAD, Laying Comfortably in bed
Test Results:
Labs
Assessment and Plan:
[ ] Central line, PICC line, or dialysis catheter present and indicated
PLEASE SEE ATTENDING ADDENDUM
DISCUSSED WITH DOCTOR:
Used Interpreter - Name:
Used HCN - Interpreter ID #:
Interpretation language:
Progress note Template
Reason for Continued Hospitalization:
Subjective:
Objective:
Vital Signs
Temp / HR / RR / BP / O2 Sat
/ / / /
24 hour I/O: /
GEN: NAD, Laying Comfortably in bed
HEENT: PERRLA, no jaundice
CV: rrr, no mrg, +S1, S2
PULM: CTAB, no crackles, wheezing, rales
ABD: soft, NTND, no rebound, no guarding
EXT: 2+ peripheral pulses. No edema b/l.
SKIN: no petechiae, no rash
NEURO: A&O x 3.
GU/Pelvic/rectal: deferred
GU/Pelvic/rectal: deferred
Meds:
Studies:
Labs:
BMP
Na / K / Cl / HCO3 / BUN / Cr < Glu
/ / / / / <
Ca / Mg / Phos
/ /
CBC
WBC > Hgb / Hct < Plts
> / <
LFTs
Albumin / Tot Protein / D. Bili / T. Bili / AST / ALT < Alk Phos
/ / / / / <
A/P:
[ ] Central line, PICC line, or dialysis catheter present and indicated
Plan discussed with Attending:
Used Interpreter - name:
Used HCIN - Interpreter ID #:
Interpretation language:
H&P Template
Date of Note:
Chief Complaint:
History of Present Illnesses:
Past Medical History:
Allergies:
Medications:
Past Surgical History:
Social History:
Review of Systems:
Family History:
Physical Examination:
Vital Signs
Temp / HR / RR / BP / O2 Sat
/ / / /
24 hour I/O: /
GEN: NAD, Laying Comfortably in bed
HEENT: PERRLA, no jaundice
CV: rrr, no mrg, +S1, S2
PULM: CTAB, no crackles, wheezing, rales
ABD: soft, NTND, no rebound, no guarding
EXT: 2+ peripheral pulses. No edema b/l.
SKIN: no petechiae, no rash
NEURO: A&O x 3.
GU/Pelvic/rectal: deferred
GU/Pelvic/rectal: deferred
Test Results:
Labs
BMP
Na / K / Cl / HCO3 / BUN / Cr < Glu
/ / / / / <
Ca / Mg / Phos
/ /
CBC
WBC > Hgb / Hct < Plts
> / <
LFTs
Albumin / Tot Protein / D. Bili / T. Bili / AST / ALT < Alk Phos
/ / / / / <
Assessment and Plan:
yo M/F with PMH * presents with
# FEN/GI: regular diet
# DVT PPX: heparin Subq
# Code Status: FULL CODE
# Dispo: Pending medical work-up
# Emergency Contact:
[ ] Central line, PICC line, or dialysis catheter present and indicated
PLEASE SEE ATTENDING ADDENDUM
DISCUSSED WITH DOCTOR:
Used Interpreter - Name:
Used HCN - Interpreter ID #:
Interpretation language:
Discharge Summary
Date of Admission:
Date of Discharge:
Service:
Attending:
Resident:
Intern:
Discharge Diagnoses (no abbreviations; list all conditions from past medical history and that developed during hospitalization):
Procedures:
History of present illness:
Hospital Course:
Disposition:
Code Status:
Discharge Condition:
Pending Studies:
Discharge Activity:
Discharge Diet:
Discharge Medications:
Follow-up Instructions:
[ ] Central line, PICC line, or dialysis catheter present and indicated
Discharge plan discussed with attending who concurs with plan.
Used Interpreter - name:
Used HCIN - Interpreter ID #:
Interpretation language:
Discharge Instructions
Discharge Service: Date of Admission:
Date of Discharge:
Service:
Attending:
Resident:
Intern:
Discharge Diagnoses (no abbreviations; list all conditions from past medical history and that developed during hospitalization):
Procedures:
History of present illness:
Hospital Course:
Disposition:
Code Status:
Discharge Condition:
Pending Studies:
Discharge Activity:
Discharge Diet:
Discharge Medications:
Follow-up Instructions:
[ ] Central line, PICC line, or dialysis catheter present and indicated
Discharge plan discussed with attending who concurs with plan.
Used Interpreter - name:
Used HCIN - Interpreter ID #:
Interpretation language:
Discharge Instructions
Discharge Attending:
Discharge Resident ([ ] licensed [ ] unlicensed):
Discharge Intern:
Date of Admission:
Date of Discharge:
Admission Diagnosis:
Primary Discharge Diagnosis:
Secondary Discharge Diagnoses:
[ ] MRSA-positive; patient notified and educated
Disposition: [ ] Home[ ] Home with Home Health[ ] Nursing Home [ ] Other:
Labs/Tests prior to discharge:
[ ] MRSA-negative chronic dialysis patient: perform MRSA nasal swab
Labs/Tests after discharge:
Follow-up in / Make referrals to (Doctor: please fill in consult/referral form):
1. Location: Date: Time: Bldg/Room#:
2. Location: Date: Time: Bldg/Room#:
3. Location: Date: Time: Bldg/Room#:
4. Location: Date: Time: Bldg/Room#:
Additional Instructions / Treatment at Home (e.g., return precautions, wound care, injections):
Medications (keep a list of ALL medications you take and bring it with you whenever you see a healthcare provider)
Your new medications are:
Continue your home medications:
Diet:[ ] Heart Healthy [ ] 2 gm sodium [ ] Diabetes [ ] Other:
Activities:[ ]As tolerated [ ] Restrictions: [ ] Return to Work in: ____ days
[ ] Discussed with Attending, who agrees with discharge plan
_____________________________________________________________________ _____________________________________________________________________
Patient Instructions BRING THIS FORM AND YOUR OLIVE VIEW IDENTIFICATION CARD (PLASTIC CARD) WITH YOU TO YOUR FOLLOW-UP CLINIC APPOINTMENT.
General Instructions If your symptoms recur or persist, return to the Emergency Room/Medical Walk-In; if life-threatening, call 911.
Additional Instructions:
For Patients Diagnosed with Heart Failure 1. Low salt, low cholesterol/fat diet, and restrict fluid intake as directed by your doctor. 2. Gradually increase your activity, as directed by your doctor; schedule rest breaks as needed. 3. Weigh yourself daily on same scale in the morning; bring your weight record to your follow-up appointment. 4. If you experience any chest pain, increased bleeding or bruising, swelling in your legs or ankles, difficulties in breathing, or gain 2 or more pounds in one day or 5 or more pounds in one week, return to the hospital.
For Patients Diagnosed with a Heart Attack 1. Low salt, low cholesterol/fat diet, as directed by your doctor. 2. Gradually increase your activity, as directed by your doctor. 3. If you experience chest pain that does not go away, call 911.
For Patients Diagnosed with Stroke 1.Call 911 if you have a SUDDEN: numbness or weakness of the face, arm or leg, especially on one side of the body, confusion, trouble speaking, understanding, seeing, walking, or feeling dizzy, loss of balance or coordination, or a severe headache without cause. 2. Keep all doctor and test appointments. 3. Take all medications prescribed to you at discharge. 4. Be aware of risk factors for Stroke, such as: Cigarette smoking, alcohol abuse, being overweight, poor diet, not being active.
Outpatient Clinic Appointments 1. To make, change or cancel a clinic appointment, call (818) 364-3184. 2. Be prepared to tell the appointment clerk: medical record number, patient's name, birth date, telephone number and address. 3. Please arrive 15 minutes prior to your scheduled appointment time. 4. If you arrive later than 15 minutes after your scheduled appointment time, your appointment may be rescheduled or you may be referred to Emergency Room/Medical Walk-In if your condition warrants such. 5. If you are expecting to be late, you must call the clinic to find out if you can be accommodated.
Postoperative Discharge Instructions 1. Nausea and/or vomiting may occur in the immediate postoperative period. 2. If breathing difficulties, excessive bleeding, fever, or other disturbing problems should develop after leaving the hospital, return to the Emergency Room. 3. Do not drive a car or make any important decisions for the next 24 hours. 4. You must follow up with your primary doctor after discharge for instructions on the medications you took prior to surgery. 5. If you have been instructed to change your dressing, wash your hands before and after touching your wound/dressing.
Infection Prevention Strategies To prevent the spread of infections and multi-drug resistant organisms (MDROs) such as: 1. Methicillin Resistant Staphylcoccus Aureus (MRSA) 2. Vancomycin Resistant Enterococcus (VRE) 3. Extended Spectrum Beta Lactamase (ESBL) 4. Clostridium difficile (CDI) Wash hands frequently with soap and water for at least 15 seconds. Keep wounds covered. Regularly wash clothing, bedding and areas in your home that can become contaminated such as bathrooms and kitchen. Do not share personal items like towels, washcloths, bars of soap or razors.
Blood clot prevention: If you started on an anticoagulant (also called a ?blood thinner?) by mouth (for example, warfarin [COUMADIN]) or by injection (for example, enoxaparin [LOVENOX]), the anticoagulation handouts given to you by your Registered Nurse, summarize the education given to you in the hospital. For patients discharged on Warfarin [COUMANDIN], the hand out given & reviewed is '?What I Should Know about Warfarin?. It is important that you take your Warfarin as instructed, follow-up with your doctor and keep all blood test (PT/INR) monitoring appointments, follow your diet (consistent amount of foods that contain vitamin K) and avoid major dietary changes. As changes in diet or medication will affect your PT/INR level, inform your doctor of changes in your medications or over-the-counter medications, diet, or use of alcohol to avoid adverse drug reactions or interactions. Be aware of risks such as signs of bleeding or clotting; seek urgent/emergent care for any bleeding that is continuous or excessive. Wear a ?medic alert? bracelet.
RECEIPT FOR THIS PATIENT, IF CHILD OR WARD OF COURT Before permitting a child to leave the hospital, the responsible nurse will require the parent or legal guardian to sign below. When parent or guardian cannot be reached, the RESIDENT PHYSICIAN ON DUTY may authorize a relative or friend to sign the receipt when circumstances warrant. Receipt is not required for a minor deemed sufficiently responsible to look after himself. I have received ___________________________________ from the Los Angeles County Olive View-UCLA Medical Center, who is my __________________________ for whom I acknowledge full and complete responsibility.
Signature Printed Name Date
Address _______________________________________________________ Phone __________________________
Discharged with whom:
Discharge via:[ ] Ambulatory[ ] Stretcher[ ] Wheelchair
Discharge to:[ ] Ambulance[ ] County sedan[ ] Private car
Valuables/personal belongings returned?[ ] Yes[ ] No[ ] None
Supplies/equipment to send with patient:
Child Safety Info Given: [ ] Yes [ ] No [ ] N/A
Crisis Hotline Info: 1-877-727-4747
Smoking causes many health problems and can shorten your life. We advise you not to smoke. For free help with quitting, call 1-800-NO-BUTTS
(1-800-662-8887).
SIGNATURES
Clerk:
Printed Name Signature Date Time
Patient or responsible person: I hereby acknowledge the receipt of these instructions and understand them.
Printed Name Signature Date Time
Discharge Nurse/RN: I have verified that the Influenza/Pneumococcal vaccine(s) have been offered and administered to patient if criteria were met.
Printed Name Signature Date Time
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