PDF AMBULATORY SURGERY / SHORT STAY HISTORY & PHYSICAL - Cedars-Sinai

AMBULATORY SURGERY / SHORT STAY HISTORY & PHYSICAL

(To be used only if planned admission is less than 48 hrs.)

DATE:

SEX MALE FEMALE

PRESENT ILLNESS (Onset-Complaint):

AGE:

SINGLE MARRIED

PATIENT I.D. DIVORCED OCCUPATION WIDOWED

RELEVANT FAMILY HISTORY: ALLERGIES: MEDICATIONS:

IMMUNIZATIONS: PAST MEDICAL HISTORY/ REVIEW OF SYSTEMS:

PHYSICAL EXAMINATION: VITAL SIGNS: BP______________ TEMP______________ PULSE______________ RESP.______________

DX/PLAN OF CARE:

DATE:

TIME:

RESIDENT SIGNATURE: PHYSICIAN SIGNATURE:

(OVER)

M.D. Form No. 4296 (Rev. 7/99) Page 1 of 1

PROGRESS RECORD

Date

Note progress of case, complications, change in diagnosis, condition on discharge, instruction to patient, etc.

PROGRESS RECORDS

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