emergency room record, Morton Plant Hospital

Home
Date:November 18, 1995
Pages:1


View the page scan

       ECM     ER PATIENT      MORTON PLANT HOSPITAL

PATIENT INFO

T#: 3804191494 MR#: 718248     ADMT: 11/18/95     TIME: 18:5
MCPHERSON , LISA               ROOM:         RELEASE INFO:
                                           SS#: 461-94-200
901 OSCEOLA AV #205             STA:                 ORIG:
CLEARWATER     FL 34616-        SVC: ECC              SMK:
831-559-9858                   TYPE: E                F/C:
DOB: 02/10/1959   AGE:  36   SEX: F   ARR:       MARITAL:
MAIDEN:                        SURG:
RELIGION: NO PREFERENCE          PREV:          VIP:

EMER

l: SLAUGHTER , BENETTA       OTHER          2: NONE          OTHER
XXXXX XXXXXXXXXXXXX     CLEARWATER
FL          813-XXX-XXXX

GUAR

MCPHERSON , LISA             PATIENT              SSN: 491-94-2009
901 OSCEOLA AV #205          CLEARWATER     FL         34616-
813-559-9856

EMPL

PT: AMC PUBLISHING                  GUAR: AMC PUBLISHING
XXXXX XXXXXXXXXXXXX    CLEARWATER   XXXXX XXXXXXXXXXXXX    CLEARWATER

INS

INS #1: SELF PAY        997      PRIORITY: 1        REL: P   GRP IND: N
                                                  PHONE:
                                                   POL#: NA
   SUBSCR: MCPHERSON , LISA                       GRP #: NA
   BLUE CROSS #:                                 GRP NM: 
NA
INS #2:                          PRIORITY:          REL:     GRP IND:
                                                  PHONE:
                                                   POL#:
   SUBSCR:                                         GRP#:
   BLUE CROSS #:                                 GRP NM:

MED

ADMT DR: 00000     UNASSIGNED DOCTOR            ANESTHESIA:
PRIM DX:                                         MEDIC STS: PSYCH EVAL

TESTS:

PROCEDURES:

ASSEMBLE: ____ ANALYZE: ____  ABSTRACT: ____  CODE: ____ FINAL CHECK:

PRINCIPAL DIAGNOSIS: ________________________________________________

SECONDARY DIAGNOSIS: ________________________________________________

OPERATIVE PROCEDURES: _______________________________________________

COMPLICATIONS: ______________________________________________________

CONSULTATIONS: ______________________________________________________

DISCHARGE STATUS:  ALIVE___  EXPIRED ___   DATE OF DISCHARGE: _______

    OVER 48 HOURS ____       AUTOPSY ___   TIME OF DISCHARGE: _______

   UNDER 48 HOURS ____  MED EXAMINER ____                LOS: _______

DISCHARGE DATE _________  LOS: __________ ATTENDING PHYSICIAN RECORDS