patient chart alpha bravo charlie delta - … · patient chart alpha bravo charlie delta patient...
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PATIENT NAME: Janice Stingley SEX: Male Female
DIAGNOSTIC SPECIALISTS
AGE: 28
Reviewed Key Symptoms and Initial Diagnosis: YES NO
Key Symptoms: (from Medical Chart)
.
Initial Diagnosis :
Recommended Clinical Trial: Treatment Plan:
PATIENT CHART
Patient Status: Check one before giving chart to Case Manager
TEAM (CIRCLE ONE):
ALPHA BRAVO CHARLIE DELTA :
Selected in Medi-Net : YES NO
Test ordered (list below) () when ordered
in Medi-Net
Test ordered (list below) () when ordered
in Medi-Net
MED-SURGE SPECIALISTS
Test ordered (list below) Results:
(Circle one)
Observation/Conclusion/Explanation
Normal / Not Normal
Normal / Not Normal
Normal / Not Normal
Normal / Not Normal
Normal / Not Normal
Final Diagnosis:
Selected in Medi-Net : YES NO
Signature: Date:
CLINICAL INTERVENTION SPECIALISTS Reviewed Test Results and Confirmed Final Diagnosis: YES NO
Signature: Date:
Initial Diagnosis Results In Treatment Plan
Test Ordered Final Diagnosis Trial Selected
Signature: Date:
PATIENT NAME: Lucia Merano SEX: Male Female
DIAGNOSTIC SPECIALISTS
AGE: 19
Reviewed Key Symptoms and Initial Diagnosis: YES NO
Key Symptoms: (from Medical Chart)
General feeling of sickness, tired. No appetite . Yellowish color of skin and eyes..
Initial Diagnosis : internal injuries
Recommended Clinical Trial: Treatment Plan:
PATIENT CHART
Patient Status: Check one before giving chart to Case Manager
TEAM (CIRCLE ONE):
ALPHA BRAVO CHARLIE DELTA :
Selected in Medi-Net : YES NO
Test ordered (list below) () when ordered
in Medi-Net
Test ordered (list below) () when ordered
in Medi-Net
Liver enzymes
Serological test: Hepatitis A
Urine bilirubin
MED-SURGE SPECIALISTS
Test ordered (list below) Results:
(Circle one)
Observation/Conclusion/Explanation
Liver enzymes Normal / Not Normal High values
Serological test: Hepatitis A Normal / Not Normal Positive for hepatitis
Urine bilirubin Normal / Not Normal High values
Normal / Not Normal
Normal / Not Normal
Final Diagnosis: hepatitis Selected in Medi-Net : YES NO
Signature: R . Moore Date:
CLINICAL INTERVENTION SPECIALISTS Reviewed Test Results and Confirmed Final Diagnosis: YES NO
Signature: Date:
Initial Diagnosis Results In Treatment Plan
Test Ordered Final Diagnosis Trial Selected
Signature: B. Shaw Date:
PATIENT NAME: Pedro Lugo SEX: Male Female
DIAGNOSTIC SPECIALISTS
AGE: 2
Reviewed Key Symptoms and Initial Diagnosis: YES NO
Key Symptoms: (from Medical Chart)
Cries constantly. Appears to be in pain . Tugs at right ear.
Initial Diagnosis : ear infection
Recommended Clinical Trial: Treatment Plan:
PATIENT CHART
Patient Status: Check one before giving chart to Case Manager
TEAM (CIRCLE ONE):
ALPHA BRAVO CHARLIE DELTA :
Selected in Medi-Net : YES NO
Test ordered (list below) () when ordered
in Medi-Net
Test ordered (list below) () when ordered
in Medi-Net
Culture & sensitivity-ear discharge
Hearing test
X-ray mastoid
MED-SURGE SPECIALISTS
Test ordered (list below) Results:
(Circle one)
Observation/Conclusion/Explanation
Culture & sensitivity-ear discharge Normal / Not Normal Resistance to broad spectrum antibiotics
Hearing test Normal / Not Normal Mild hearing loss –result of reoccurring infections
X-ray mastoid Normal / Not Normal Presence of fluid beyond middle ear
Normal / Not Normal
Normal / Not Normal
Final Diagnosis: ear infection Selected in Medi-Net : YES NO
Signature: L. Flynn Date:
CLINICAL INTERVENTION SPECIALISTS Reviewed Test Results and Confirmed Final Diagnosis: YES NO
Signature: Date:
Initial Diagnosis Results In Treatment Plan
Test Ordered Final Diagnosis Trial Selected
Signature: B. Shaw Date:
PATIENT NAME: Ramon Medina SEX: Male Female
DIAGNOSTIC SPECIALISTS
AGE: 28
Reviewed Key Symptoms and Initial Diagnosis: YES NO
Key Symptoms: (from Medical Chart)
Persistent cough , fever and night sweats. Difficulty breathing and chest pain when coughs; occasionally coughs up blood and phlegm.
Initial Diagnosis : tuberculosis
Recommended Clinical Trial: Treatment Plan:
PATIENT CHART
Patient Status: Check one before giving chart to Case Manager
TEAM (CIRCLE ONE):
ALPHA BRAVO CHARLIE DELTA :
Selected in Medi-Net : YES NO
Test ordered (list below) () when ordered
in Medi-Net
Test ordered (list below) () when ordered
in Medi-Net
Culture & sensitivity-sputum
Chest x-ray
MED-SURGE SPECIALISTS
Test ordered (list below) Results:
(Circle one)
Observation/Conclusion/Explanation
Normal / Not Normal
Normal / Not Normal
Normal / Not Normal
Normal / Not Normal
Normal / Not Normal
Final Diagnosis:
Selected in Medi-Net : YES NO
Signature: Date:
CLINICAL INTERVENTION SPECIALISTS Reviewed Test Results and Confirmed Final Diagnosis: YES NO
Signature: Date:
Initial Diagnosis Results In Treatment Plan
Test Ordered Final Diagnosis Trial Selected
Signature: B. Shaw Date:
PATIENT NAME: Richard Kascory SEX: Male Female
DIAGNOSTIC SPECIALISTS
AGE: 26
Reviewed Key Symptoms and Initial Diagnosis: YES NO
Key Symptoms: (from Medical Chart)
Heartburn , indigestion , slight chest pain and burning feeling in stomach . Worse at night, not eating spicy foods has not helped.
Initial Diagnosis : heartburn , possible hiatal hernia
Recommended Clinical Trial: Treatment Plan:
PATIENT CHART
Patient Status: Check one before giving chart to Case Manager
TEAM (CIRCLE ONE):
ALPHA BRAVO CHARLIE DELTA :
Selected in Medi-Net : YES NO
Test ordered (list below) () when ordered
in Medi-Net
Test ordered (list below) () when ordered
in Medi-Net
Barium swallow x-ray
MED-SURGE SPECIALISTS
Test ordered (list below) Results:
(Circle one)
Observation/Conclusion/Explanation
Barium swallow x-ray Normal / Not Normal Hiatal hernia present
Normal / Not Normal
Normal / Not Normal
Normal / Not Normal
Normal / Not Normal
Final Diagnosis: Hiatal hernia Selected in Medi-Net : YES NO
Signature: G. Michaels Date:
CLINICAL INTERVENTION SPECIALISTS Reviewed Test Results and Confirmed Final Diagnosis: YES NO
Signature: Date:
Initial Diagnosis Results In Treatment Plan
Test Ordered Final Diagnosis Trial Selected
Signature: K.K. May Date: