Generic Hospital Admission Notes

Hospital Information Referring Facility: [name of referring facility] Phone: [contact phone number] Fax: [fax number] Contact Person: [name of contact person] Date of request: [date of request] Patient Medical Record Number: [medical record number] Patient Data Patient Name: [patient's full name] Date of Birth: [patient's date of birth] Gender: [Male/Female] Social Security Number: [social security number] Marital Status: [Married/Single/Widowed/Divorced] Address: [patient’s full address] Home/Cell Number: [patient’s phone number] Other contact Number: [alternate phone number] Mother’s First Name: [mother’s first name] Father’s First Name: [father’s first name] Insurance Details Insurance Plan: [insurance provider name] Plan ID/Group Number: [insurance plan ID/group number] Medicaid CIN Number: [Medicaid CIN number] Medicare Number: [Medicare number] Is the patient on an HMO plan?: [Yes/No] Plan name: [HMO plan name] (Please remind patients to bring their referrals on the date of appointment.) Admission Notes Referring Physician Name: [name of referring physician] UPIN Number (for diagnostic services): [UPIN number] Clinic Referred: [name of clinic] Diagnosis: [diagnosis] ICD 9 Code: [ICD 9 code] Request to rule out/evaluate patient for: [reason for referral] Time frame physician is seeking for appointment: [preferred appointment time frame] Additional Information: (attach reports/lab results, medications taken/exams done/history etc. pertinent to patient care) [relevant medical history, test results, medications, or other pertinent clinical details] Patient appointment day/time preference: [preferred appointment day/time] (Please send completed admission notes back - any incomplete detail will not be accepted) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information to include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely. Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)