02-FM-ERD-007-00 Short Stay & Day Surgery

Short Stay & Day Surgery Date : ……………………………… Time : ………………………
HN : ……………………………….. Room : …………………….
Name : …………………………….. Gender : ………………...
Date of Birth : ………………...…… Age : ………………………
Physician : ………………………… MD code : ………………..
Allergies : …………………………………………………………..

Chief Complaint/Reasons for Admission: ............................................................................................................................. ...

Date of Surgery/Procedure: ...................................................................... N/A

History of Present Illness: ............................................................................................................................. ...............................

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Past Medical History: Hypertension No Yes Heart disease No Yes DM No Yes

Hematological disease No Yes Kidney disease No Yes

Past reaction to GA No Yes Other........................................................................................

Past Surgical History: ............................................................................................................................. ......................................

Current Medications: None Yes

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Allergy: Drug No Yes............................. Latex No Yes...........................................

Social History: Alcohol No Yes Tobacco No Yes Illicit Drug No Yes

Pertinent Review of System: (Check if present) : Active cough Fever Shortness of Breath

Chest pain Other ...............................................................

Physical Examination: Pulse .................... /min R .................... /min BP...................... mmHg
Vital Signs: Temp .................... oC

Mental status: Normal Abnormal ................................................................................................................... ........

Head and EENT: Normal Abnormal ................................................................................................................... ........

Neck: Normal Abnormal ................................................................................................................... ........

Chest: Normal Abnormal ................................................................................................................... ........

Heart: Normal Abnormal ................................................................................................................... ........

Abdomen: Normal Abnormal ................................................................................................................... ........

Extremities: Normal Abnormal ................................................................................................................... ........

Genitourinary: Normal Abnormal ................................................................................................................... ........

Neurological: Normal Abnormal ................................................................................................................... ........

Skin: Normal Abnormal ................................................................................................................... ........

Diagnosis/Pre-op Diagnosis: ...........................................................................................................................................................

Surgery/Procedures: ......................................................................................................... ..............................................................

Plan/Treatment/Hospital Course: ............................................................................................. .......................................................

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Physician's Signature.......................................................... MD Code.................... Date........../.. .........../........... Time...................

Discharge Status: Stable/improved Full Admission Room............... Transfer......................................... AMA

Discharge Date............................................................................................................... .................................................................

Physician's Signature.......................................................... MD Code.................... Date........../.. .........../........... Time...................

FM-ERD-007-00