Brown County Hospital
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Admitting Worksheet for Skilled Patients Date & Time Patient Name: Current location: Situation ETA: Recent medical diagnosis/surgical procedure:
Background Date of onset: PMH:
Age: Sex: M F Allergies:
Documents Received: History and Physical Assessment Discharge summary All therapy notes Discharge provider’s orders All labs and x-rays (EKG, echo, catscan, etc. as applicable) Discharge medication list/orders Assistive Device: platform walker 4-wheeled rollator FWW Quad cane Recommendations single-point cane BSC Wheelchair Other needs: Air mattress Trapeze bar Supplemental O2 Other: ______
Services Ordered: PT OT ST RT
Other considerations:
All necessary staff notified: nursing therapy office AFC Follow-Up respiratory radiology lab pharmacy
Form seen by: Admitting Physician ______ ______