Generic Hospital Admission Notes

Hospital Information Referring Facility: St. Mary's Hospital Phone: 020 7946 0958 Fax: 020 7946 0959 Contact Person: Dr. Emily Carter Date of request: 1 November 2024 Patient Medical Record Number: 123456789 Patient Data Patient Name: John Doe Date of Birth: 15 March 1980 Gender: Male Social Security Number: 987-65-4321 Marital Status: Married Address: 123 Elm Street, London, SW1A 1AA Home/Cell Number: 07123 456789 Other contact Number: 07123 987654 Mother’s First Name: Mary Father’s First Name: Robert Insurance Details Insurance Plan: HealthFirst Plan ID/Group Number: HF123456 Medicaid CIN Number: AB123456C Medicare Number: 1234-567-890 Is the patient on an HMO plan?: Yes Plan name: HealthFirst HMO Admission Notes Referring Physician Name: Dr. Thomas Kelly UPIN Number (for diagnostic services): A12345 Clinic Referred: City Health Clinic Diagnosis: Hypertension ICD 9 Code: 401.9 Request to rule out/evaluate patient for: Cardiovascular assessment Time frame physician is seeking for appointment: Within 2 weeks Additional Information: Patient has a history of high blood pressure and is currently on Lisinopril. Recent lab results show elevated cholesterol levels. No known allergies. Patient appointment day/time preference: Monday mornings