Week06 Jane Dare
Sundance HealthCare Systems
Painted Valley, USA
Street Address
Patient's Name
Dare, Jane V.
Hospital Number
8032 Hao Jung Street
Birth Date
Age
10/31/xx
City
73
Sex
Phone Number
San Francisco
Marital Status
F
# 822999
823 762-3673
State
Married
Zip
California
Soc. Sec. #
County
85321-9626 Calaveras
773
Race
Religion
101-87-3546
Room
Taoism
Asian
Ethnicity
Patient's Occupation
Retired
Non-Hispanic
Notify In
Emergency
Name
Relationship
Jade Dare
Responsible for Account
Daughter
Address
Self
Phone No.
2102 Fillmore
Los Angeles
Date Admitted
Time
6/13/xx
1415
538
AM
PM
322-7734
Date Discharged
6/18/xx
Time
1025
AM
PM
Name & Address of Any Institution From Which Discharged in Last 60 Days
Date of Last Admission
05/22/xx
N/A
Admitting Physician
Dr. Archibald M. Graham
Consultant
Aitemding Physician
Dr. Archibald M. Graham
ICD-9-CM CODES
Admitting Diagnosis (Within 24 Hours)
Congestive heart failure, left pleural effusion, pneumonia.
Principal Diagnosis
Congestive heart failure, left pleural effusion, pneumonia.
Secondary Diagnoses
Complications
Operative Procedures (Date & Title)
ü
Discharged Alive ____
Died ____
Autopsy Yes ____
No ____
Archibald M. Graham
Physician Signature
ADMISSION SUMMARY SHEET
This is a simulated health record created and intended for educational purposes only. All scenarios, names, demographic information, medical events, and data portrayed herein are fictitious. No identification with or similarity to actual persons, living or dead, or to actual events or entities is intended or should be inferred. Any similarity to actual persons or events is purely coincidental.
© 2003. American Health Information Management Association. All rights reserved.
CONDITIONS OF ADMISSION
1. CONSENT TO HOSPITAL CARE
I am presenting myself for admission to Sundance HealthCare Systems. I voluntarily consent to the rendering of medical care which is determined to be necessary or beneficial in
Painted Valley, USA
Street Address
Patient's Name
Dare, Jane V.
Hospital Number
8032 Hao Jung Street
Birth Date
Age
10/31/xx
City
73
Sex
Phone Number
San Francisco
Marital Status
F
# 822999
823 762-3673
State
Married
Zip
California
Soc. Sec. #
County
85321-9626 Calaveras
773
Race
Religion
101-87-3546
Room
Taoism
Asian
Ethnicity
Patient's Occupation
Retired
Non-Hispanic
Notify In
Emergency
Name
Relationship
Jade Dare
Responsible for Account
Daughter
Address
Self
Phone No.
2102 Fillmore
Los Angeles
Date Admitted
Time
6/13/xx
1415
538
AM
PM
322-7734
Date Discharged
6/18/xx
Time
1025
AM
PM
Name & Address of Any Institution From Which Discharged in Last 60 Days
Date of Last Admission
05/22/xx
N/A
Admitting Physician
Dr. Archibald M. Graham
Consultant
Aitemding Physician
Dr. Archibald M. Graham
ICD-9-CM CODES
Admitting Diagnosis (Within 24 Hours)
Congestive heart failure, left pleural effusion, pneumonia.
Principal Diagnosis
Congestive heart failure, left pleural effusion, pneumonia.
Secondary Diagnoses
Complications
Operative Procedures (Date & Title)
ü
Discharged Alive ____
Died ____
Autopsy Yes ____
No ____
Archibald M. Graham
Physician Signature
ADMISSION SUMMARY SHEET
This is a simulated health record created and intended for educational purposes only. All scenarios, names, demographic information, medical events, and data portrayed herein are fictitious. No identification with or similarity to actual persons, living or dead, or to actual events or entities is intended or should be inferred. Any similarity to actual persons or events is purely coincidental.
© 2003. American Health Information Management Association. All rights reserved.
CONDITIONS OF ADMISSION
1. CONSENT TO HOSPITAL CARE
I am presenting myself for admission to Sundance HealthCare Systems. I voluntarily consent to the rendering of medical care which is determined to be necessary or beneficial in