FINAL PROJECT - TERRY ROBERTS

1 | P a g e Permissi on to reu se g ranted b y Alfred State College and Mic helle A. Green. Glob al Care Medical Cent er 100 Main St, A lfred NY 14802 (607 ) 555 -1234 Hospital No. 999 : Bed rest Light Usual Unlimi ted Othe r: Regular Low Cholesterol Low Salt ADA _____ Calorie Follow-U p: Call for appo intment Off ice appo intment on Othe r: : 2 | P a g e Pe rmissi on to reu se g ranted b y Alfred State College and Mic helle A. G reen. I, he reb y con sent to ad missi on to the Globa l Care Med ical Cente r (AS MC) , and I fu rthe r con sent to such rout ine ho spital care, d iagno stic procedu res, and med ical treat ment that the med ical and p rofe ssi ona l staff of AS MC may dee m ne cess ary or ad vis ab le. I autho riz e the u se of med ical info rm ation obta ined about me a s spe cified abo ve and the d iscl osure of such info rm ation to my refe rring ph ysici an (s) . This fo rm ha s been fu lly explained to me, and I unde rstand its content s. I fu rthe r unde rstand that no gua rantee s ha ve been made to me a s to the results of t reat ment s or exami nat ion s done at the AS MC . Signatu re of Pat ient Signatu re of Pa rent/Lega l Gua rdian fo r Mi no r Relat ion ship to Mi no r W ITN ESS: G loba l Care Med ical Cente r Staff Mem be r C O NSE NT TO R ELEASE INF ORM ATIO N FO R R EI M BUR SE M ENT P UR POSES In o rde r to pe rmi t reim bu rsement, upon reque st, the G loba l Care Med ical Cente r (AS MC) may discl ose such t reat ment info rm ation pe rtaining to my ho spitalization to an y corpo ration, o rgan ization, o r agent the reof, which is, o r may be liab le unde r cont ract to the AS MC or to me, o r to an y of my fa mily membe rs or othe r pe rson, fo r pa ym ent of a ll or pa rt of the an y relea se of info rm ation is to fa cili tate reim bu rsement fo r servic es rende red. In add ition, in the e vent that my hea lth insuran ce p rog ram include s ut iliz ation review of servic es p rovided du ring th is ad missi on, I autho riz e AS MC to relea se info rm ation a s is ne cessary to pe rmi t the review. This autho riz ation will e xpire on ce the reim bu rsement fo r servic es rende red is complete. Signatu re of Pat ient Signatu re of Pa rent/Lega l Gua rdian fo r Mi no r Relat ion ship to Mi no r W ITN ESS: G loba l Care Med ical Cente r Staff Mem be r 3 | P a g e Pe rmissi on to reu se g ranted b y Alfred State College and Mic helle A. G reen. GLOBAL CARE MEDICAL CENT ER 100 MAIN ST, ALFR ED NY 14802 (607 ) 555 -1234 You r an sw ers to the fo llowing que stion s will assis t you r Ph ysici an and the Hospital to respe ct you r wis he s rega rding you r med ical care. This info rm ation will be come a pa rt of you r med ical record. Y ES NO P ATIENT S INITIALS 1. Have you been p rovided with a cop y of the info rm ation called 2. Have you Hospital with a cop y fo r you r med ical record. 3. Have you p repa red a Durab le Po wer of Atto rne y fo r Hea lth Care? If yes, p lea se p rovide the Hospital with a cop y fo r you r med ical record. 4. Have you p rovided th is fa cili ty with an Ad van ce Dir ective on a p rior ad missi on and is it still in effe ct? If yes, Ad mi tting Off ice to conta ct Med ical Records to obta in a cop y fo r the med ical record. 5. Do you de sir e to e xecute a L iving Will /Durab le Po wer of Atto rne y? If yes, refe r to in o rde r:

a. Ph ysici an b. So cial Se rvic e c. Vo luntee r Se rvic e HOSP ITAL STAFF DIRECT IONS: Ch eck when eac h step is c ompleted. 1. Ve rify the abo ve que stion s whe re an sw ered and a ction s ta ken whe re requ ired. 2. Name of Ind ividua l Receiving Info rm ation Relation ship to Pat ient 3. If info rm ation was provided in a language othe r than Eng lish, spe cify language and method. 4. Ve rify pat ient was ad vis ed on ho w to obta in add itiona l info rm ation on Ad van ce Dir ectives. 5. Ve rify the Pat ient/ Family Membe r/Lega l Rep resentat ive was ask ed to p rovide the Hospital with a cop y of the Ad van ced Dir ective which will be reta ined in the med ical record. File this form in the medical record, and give a copy to the patient. Name of Pat ient Name of Ind ividua l giving info rm ation if d iffe rent f rom Pat ient S ignatu re of Pat ient Date 4 | P a g e Pe rmissi on to reu se g ranted b y Alfred State College and Mic helle A. G reen. S ignatu re of Hospital Rep resentat ive Date GLOBAL CARE MEDICAL CENT ER 100 MAIN ST, ALFR ED NY 14802 (607 ) 555 -1234 ALLERGY TO ASPIRIN Phy sician Na me 5 | P a g e Pe rmissi on to reu se g ranted b y Alfred State College and Mic helle A. G reen. DD : 06 /30YYYY DT : 07 /01 /YYYY Phy sician Na me GLOBAL CARE MEDICAL CENT ER 100 MAIN ST, ALFR ED NY 14802 (607 ) 555 -1234 6 | P a g e Pe rmissi on to reu se g ranted b y Alfred State College and Mic helle A. G reen. Phy sician Na me GLOBAL CARE MEDICAL CENT ER 100 MAIN ST, ALFR ED NY 14802 (607 ) 555 -1234 7 | P a g e Pe rmissi on to reu se g ranted b y Alfred State College and Mic helle A. G reen. Date Tim e 8 | P a g e Pe rmissi on to reu se g ranted b y Alfred State College and Mic helle A. G reen. GLOBAL MEDICAL CENT ER 100 MAIN ST, ALFR ED NY 14802 (607 ) 555 -1234 9 | P a g e Pe rmissi on to reu se g ranted b y Alfred State College and Mic helle A. G reen. Date Tim e 10 | P a g e Pe rmissi on to reu se g ranted b y Alfred State College and Mic helle A. G reen. GLOBAL MEDICAL CENT ER 100 MAIN ST, ALFR ED NY 14802 (607 ) 555 -1234 Date Tim e 11 | P a g e Pe rmissi on to reu se g ranted b y Alfred State College and Mic helle A. G reen. GLOBAL MEDICAL CENT ER 100 MAIN ST, ALFR ED NY 14802 (607 ) 555 -1234 12 | P a g e Pe rmissi on to reu se g ranted b y Alfred State College and Mic helle A. G reen. Date Tim e GLOBAL MEDICAL CENT ER 100 MAIN ST, ALFR ED NY 14802 (607 ) 555 -1234 13 | P a g e Pe rmissi on to reu se g ranted b y Alfred State College and Mic helle A. G reen. 14 | P a g e Pe rmissi on to reu se g ranted b y Alfred State College and Mic helle A. G reen. ’ Date Tim e GLOBAL CARE MEDICAL CENT ER 100 MAIN ST, ALFR ED NY 14802 (607 ) 555 -1234 15 | P a g e Pe rmissi on to reu se g ranted b y Alfred State College and Mic helle A. G reen. ’ Date Tim e GLOBAL CARE MEDICAL CENT ER 100 MAIN ST, ALFR ED NY 14802 (607 ) 555 -1234 16 | P a g e Pe rmissi on to reu se g ranted b y Alfred State College and Mic helle A. G reen. DD : 07 /05 /YYYY DT : 07 /06 /YYYY GLOBAL CARE MEDICAL CENT ER 100 MAIN ST, ALFR ED NY 14802 (607 ) 555 -1234 17 | P a g e Pe rmissi on to reu se g ranted b y Alfred State College and Mic helle A. G reen. DD : 06 /30 /YYYY DT : 07 /01 /YYYY GLOBAL CARE MEDICAL CENT ER 100 MAIN ST, ALFR ED NY 14802 (607 ) 555 -1234 18 | P a g e Pe rmissi on to reu se g ranted b y Alfred State College and Mic helle A. G reen. SPE CIMEN COLLE CT ED:

I N: 06/30YYYY 1614 SPE CIMEN RECEIVE D O UT : 06/30/YYYY 1749 ACID PHOSPHATASE ALKALINE PHOSPHATASE AMYLASE LIPASE GLUCOSE FASTING GLUCOSE BUN SODIUM POTASSIUM CARBON DIOXIDE CHLORIDE CHOLESTEROL SERUM GLUTAMATE PYRUVATE TRANSAMINASE SERUM GLUTAMIC OXALOCETIC TRANSAMINASE CREATININE KINASE LACTATE DEHYDROGENASE CREATININE CALCIUM PHOSPHORUS BILIRUBIN-DIRECT BILIRUBIN-TOTAL TOTAL PROTEIN ALBUMIN URIC ACID TRIGLYCERIDE GLOBAL CARE MEDICAL CENT ER 100 MAIN ST, ALFR ED NY 14802 (607 ) 555 -1234 19 | P a g e Pe rmissi on to reu se g ranted b y Alfred State College and Mic helle A. G reen. 20 | P a g e Pe rmissi on to reu se g ranted b y Alfred State College and Mic helle A. G reen. SPE CIMEN COLLE CT ED:

I N: 06/30YYYY 2322 SPE CIMEN RECEIVE D O UT : 07/01/YYYY 1032 ACID PHOSPHATASE ALKALINE PHOSPHATASE AMYLASE LIPASE GLUCOSE FASTING GLUCOSE BUN SODIUM POTASSIUM CARBON DIOXIDE CHLORIDE CHOLESTEROL SERUM GLUTAMATE PYRUVATE TRANSAMINASE SERUM GLUTAMIC OXALOCETIC TRANSAMINASE CREATININE KINASE LACTATE DEHYDROGENASE CREATININE CALCIUM PHOSPHORUS BILIRUBIN-DIRECT BILIRUBIN-TOTAL TOTAL PROTEIN ALBUMIN URIC ACID TRIGLYCERIDE GLOBAL CARE MEDICAL CENT ER 100 MAIN ST, ALFR ED NY 14802 (607 ) 555 -1234 21 | P a g e Pe rmissi on to reu se g ranted b y Alfred State College and Mic helle A. G reen. URINALYSIS DIPSTICK ONLY COLOR SP GRAVITY ALBUMIN BILIRUBIN SUGAR BLOOD PH ACETONE UROBILINOGEN NITRITES LEUKOCYTE W.B.C.

R.B.C.

BACT.

URINE PREGNANCY TEST GLOBAL MEDICAL CENT ER 100 MAIN ST, ALFR ED NY 14802 (607 ) 555 -1234 22 | P a g e Pe rmissi on to reu se g ranted b y Alfred State College and Mic helle A. G reen. TIME IN: TIME OUT : WHITE BLOOD CELL RED BLOOD CELL HEMOGLOBIN HEMATOCRIT MEAN CORPUSCULAR VOLUME MEAN CORPUSCULAR HEMOGLOBIN MEAN CORPUSCULAR HEMOGLOBIN CONCENTRATION RED CELL DISTRIBUTION WIDTH PLATELETS SEGMENTED CELLS % LYMPHOCYTES % MONOCYTES % EOSINOPHILS % BAND CELLS % COMMENTS: GLOBAL CARE MEDICAL CENT ER 100 MAIN ST, ALFR ED NY 14802 (607 ) 555 -1234 23 | P a g e Pe rmissi on to reu se g ranted b y Alfred State College and Mic helle A. G reen. TIME IN : TIME OUT: WHITE BLOOD CELL RED BLOOD CELL HEMOGLOBIN HEMATOCRIT MEAN CORPUSCULAR VOLUME MEAN CORPUSCULAR HEMOGLOBIN MEAN CORPUSCULAR HEMOGLOBIN CONCENTRATION RED CELL DISTRIBUTION WIDTH PLATELETS SEGMENTED CELLS % LYMPHOCYTES % MONOCYTES % EOSINOPHILS % BAND CELLS % COMMENTS GLOBAL CARE MEDICAL CENT ER 100 MAIN ST, ALFR ED NY 14802 (607 ) 555 -1234 24 | P a g e Pe rmissi on to reu se g ranted b y Alfred State College and Mic helle A. G reen. SPECIMEN COLLE CTED: 07 -02 -YYYY SPE CIMEN RECEIVE D: 07 -06 -YYYY BACTERIOLOGY SOURCE: Sputum SMEAR ONLY:

CULTURE 1st PRELIMINARY 2nd PRELIMINARY OTHER ROUTINE CULTURES FINAL REPORT SENSITIVITIES GLOBAL MEDICAL CENT ER 100 MAIN ST, ALFR ED NY 14802 (607 ) 555 -1234 25 | P a g e Pe rmissi on to reu se g ranted b y Alfred State College and Mic helle A. G reen. Tim e of EKG GLOBAL CARE MEDICAL CENT ER 100 MAIN ST, ALFR ED NY 14802 (607 ) 555 -1234 26 | P a g e Pe rmissi on to reu se g ranted b y Alfred State College and Mic helle A. G reen. S PECIAL INSTRUCTIONS :

MEDICAT ION (do se and route ) DAT E: DAT E: DAT E: DAT E TIME INITIALS TIME INITIALS TIME INITIALS TIME INITIALS Single Orders PRN Medications INITIALS SIGNATUR E AND TITLE INITIALS SIGNATUR E AND TITLE INITIALS SIGNATUR E AND TITLE GLOBAL CARE MEDICAL CENT ER 100 MAIN ST, ALFR ED NY 14802 (607 ) 555 -1234 27 | P a g e Pe rmissi on to reu se g ranted b y Alfred State College and Mic helle A. G reen. S PECIAL INSTRUCTIONS :

MEDICAT IO N (do se and route ) DAT E: DAT E: DAT E: DAT E TIME INITIALS TIME INITIALS TIME INITIALS TIME INITIALS PRN Medications INITIALS S IGNATUR E AND TITLE I NITIALS S IGNATUR E AND TITLE I NITIALS S IGNATUR E AND TITLE GLOBAL CARE MEDICAL CENT ER 100 MAIN ST, ALFR ED NY 14802 (607) 555-1234 28 | P a g e Pe rmissi on to reu se g ranted b y Alfred State College and Mic helle A. G reen. ’ DATE TIME TR EA TM ENT S & MEDICATIO NS TIME LOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607 ) 555 -1234 29 | P a g e Pe rmissi on to reu se g ranted b y Alfred State College and Mic helle A. G reen. ’ DATE TIME TR EA TM ENT S & MEDICATIO NS TIME GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607 ) 555 -1234 30 | P a g e Pe rmissi on to reu se g ranted b y Alfred State College and Mic helle A. G reen. ’ DATE TIME TR EA TM ENT S & MEDICATIO NS TIME GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607 ) 555 -1234 31 | P a g e Pe rmissi on to reu se g ranted b y Alfred State College and Mic helle A. G reen. ’ DATE TIME TR EA TM ENT S & MEDICATIO NS TIME 32 | P a g e Pe rmissi on to reu se g ranted b y Alfred State College and Mic helle A. G reen. GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607 ) 555 -1234 ’ DATE TIME TR EA TM ENT S & MEDICATIO NS TIME 33 | P a g e Pe rmissi on to reu se g ranted b y Alfred State College and Mic helle A. G reen. GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607 ) 555 -1234 ’ DATE TIME TR EA TM ENT S & MEDICATIO NS TIME 34 | P a g e Pe rmissi on to reu se g ranted b y Alfred State College and Mic helle A. G reen. GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607 ) 555 -1234 ’ DATE TIME TR EA TM ENT S & MEDICATIO NS TIME 35 | P a g e Pe rmissi on to reu se g ranted b y Alfred State College and Mic helle A. G reen. GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607 ) 555 -1234 ’ DATE TIME TR EA TM ENT S & MEDICATIO NS TIME 36 | P a g e Pe rmissi on to reu se g ranted b y Alfred State College and Mic helle A. G reen. GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607 ) 555 -1234 1. A FEB RILE: No 2. WOUND : Clean/ Dry Reddened Infe cted NA 3. PAI N FR EE: Ye s No 4. POS T-H OSPI TAL I NSTRUCT IO N SHEE T GIVE N TO PA TIENT /FAMILY: Ye s No If NO, complete line s 5-8 be low. 5. DIET: Othe r (D escri be ): 6. A CT IVI TY: Norm al L ight L imi ted Bed rest 7. MEDICATIO NS: 8. I NSTRUCT IO NS GIVE N TO PA TIENT /FAMILY: 9. PA TIENT /FAMILY verba lize unde rstand ing of instruction s: Ye s No 10. DISCH ARGE D at Via: Whee lcha ir Stretche r A mbu lan ce Co. A mbu lato ry A cc ompan ied b y: to COMM ENT S: DATE: SIG NATUR E: GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607 ) 555 -1234 37 | P a g e Pe rmissi on to reu se g ranted b y Alfred State College and Mic helle A. G reen. I unde rstand that while the fa cili ty will be respon sible fo r items depo sited in the safe, I must be respon sible fo r all items reta ined b y me at the bed side. (D entu res kept the bed side will be labe led, but the fa cili ty cannot a ssure respon sibility fo r the m.) I a lso recogn ize that the ho spital cannot be he ld respon sible fo r items brought in to me afte r th is fo rm ha s been completed and signed. Signatu re of Pat ient Date Signatu re of Witne ss Date I ha ve no mone y or valuab les that I wis h to depo sit fo r safe keep ing. I do not ho ld the fa cili ty respon sible fo r an y othe r mone y or valuab les that I a m reta ining o r will ha ve b rought in to me. I ha ve been ad vis ed that it is recomm ended that I reta in no more than $5.00 at the bed side. Signatu re of Pat ient Date Signatu re of Witne ss Date I ha ve depo sited valuab les in the fa cili ty safe. The en velope nu m be r is . Signature of Patient Date S ignatu re of Pe rson A ccept ing P rope rty Date I unde rstand that m ed icat ion s I ha ve b rought to the fa cili ty will be hand led a s recomm ended b y my ph ysici an. This m ay include storage, d ispo sal, o r ad mi nistration. S ignatu re of Pat ient Date S ignatu re of Witne ss Date GLOBAL CARE MEDICAL CENT ER 100 MAIN ST, ALFR ED NY 14802 (607 ) 555 -1234