(Sample)
Patient name: | Today's date: | |||||
Date of birth: | Time call received: | |||||
Telephone number: | Time call returned: | |||||
Primary Provider: | Time call finished: | |||||
Gender | M | F | Weight | kg. | Attempted call-backs: | |
lb. | ||||||
Meds: | Caller name: | |||||
Allergies: | Relationship: | |||||
PMH: | Immunizations: | |||||
LNMP: | ||||||
Presenting Symptom or Concern: | ||||||
Nursing Assessment: | ||||||
Fever: | oral | rectal | Fluid intake: | |||
axillary | other | |||||
Urine output: | Vomiting X: | Diarrhea X: | ||||
HEENT: | ||||||
NEURO/Activity Level | ||||||
Chest/Lungs/Heart | ||||||
GI/GU | ||||||
Musculoskeletal | ||||||
Skin: | ||||||
Disposition: | EMS (911) | See Immediately | See w/i 4 hrs | See w/i 12-24 hrs | Home care | |
Call referred to: | Poison Control Center | Mental Health Crisis Center | ||||
Protocol (s) used for Assessment: | ||||||
Protocol (s) use for Home Care Advice: | ||||||
Additional comments or advice: | ||||||
Caller verbalizes understanding of instructions given? | yes | no | ||||
Caller agrees with action taken? | yes | no | ||||
Caller agrees to call back if symptoms worser or caregiver concern increases? | yes | no | ||||
Caller disagrees w/advice given, caller preference is: | ||||||
Signature: | RN | NP | MD | |||
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