Download Short Stay Admission Form

EXTENDED EMERGENCY CARE UNIT ADMISSION FORM
Date:
Time:
Stream:
Insert Patient Sticker Here
SSU / AAU
SMO:
RMO:
PRESENTING COMPLAINT
RELEVENT HISTORY
RELEVENT EXAMINATION FINDINGS
Vital signs:
□ See EDIS notes (do not re-write hx and exam)
□ Vital Signs NAD
HR ____ BP ____/____ RR ____ Sats ____% Temp ____
INVESTIGATIONS:
Test
Not
performed
BEDSIDE TESTS
ECG
NAD
Pending *
Abnormal results
(detail)
MEDICAL IMAGING
Test
Not
performed
CXR
Urine
NAD
Pending *
Abnormal results
(detail)
CT
Head
CT
abdo
CSpine
Pelvis
ABG/
VBG
PATHOLOGY
FBC
UEC
Other investigations:
cTnI
Lact
Coags
Other
* Pending investigations include those which are to be performed from EECU
CLINICAL IMPRESSION
MANAGEMENT PERFORMED IN ED
EECU PATHWAY COMMENCED (IF APPLICABLE)
□ Analgesia □ IV Fluids □ IV Antibotics
PROPOSED MANAGEMENT IN EECU
□ 2nd cTnI at _____
Other Management:
□ IV Antibiotics
□ Observation until _____
ORDERS
Observations: □ Routine □ Every _____ hours
Diet:
□ Normal Diet □ NBM □ Diabetic
□ Neuro Obs every _____ hours
Telemetry:
□ Yes □ No
□ Limb Obs every _____ hours / minutes.
Other orders:
Specify limb / injury:______________________
EECU checklist:
Yes
Analgesia charted
IV Antibiotics charted
Anti-Emetics charted
DVT Prophylaxis
N/R
Yes
IV Fluids charted
Med Img forms
Path forms completed
EDIS Notes printed
N/R
Yes
EECU SMO informed
EECU PHO informed
THIS ADMISSION FORM CAN BE USED AS YOUR CLINICAL NOTES
N/R