kidSTOP at C.O.P.S. - Outpatient Physician Order

kidSTOP at C.O.P.S. - Outpatient Physician Order

kidSTOP at C.O.P.S. - Outpatient Physician Order
Phone: 210.704.2587 • Fax: 210.704.2868 • Monday through Friday • 8:00 a.m. to 8:00 p.m.
Patient Name:
Date of Birth:
Allergies:
Diagnosis:
Weight:
Date of Surgery/Procedure:
Lab: 210.704.2302
CBC w/diff
CBC w/man diff
BMP/CMP
T4F TSH
kg
Central Scheduling: 210.704.4100
Urinalysis
Urine Culture
I/Ocath
Clean Catch
Blood Culture
RSV Ag
Influenza A/BAg
Culture of
Medications and Interventions
IV Hydration for
IV fluids:
Discharge Instructions
hours (maximum 2 hours)
* These exams may require prior authorization and
scheduling, depending upon insurance coverage.
Radiology: 210.704.2372
CXR
KUB
Abd Flat & Upright
*CT Scan of
*MRI of
*US of
Contrast
Reason
Yes or
No
Cardiopulmonary: 210.704.2264
EKG
Discharge Criteria
Physician’s Information
Physician Office Number:
Physician Fax Number:
Physician (print name):
Signature:
Date:
Vital signs within normal limits
Void x1
Tolerates clear liquids w/o emesis
LOC appropriate for development age
Respiratory d/c criteria
Good air exchange
If Discharge Criteria Not Met
Call Office Cell/Pager:
Other:
Patient Label
Scheduled Procedures
Direct Admissions
• Some exams may require pre-certification depending
on insurance coverage. The referring physician’s
office is responsible for obtaining that authorization
• Fax Admission Orders to 210.704.3010
• Notify Central Scheduling at 210.704.4100
Directions
• From 1604 and IH 35 (North
East San Antonio): Take IH
35 South to downtown. Take the
Houston Street exit. Turn left on
Martin. Turn right on Santa Rosa
Street to patient/visitor parking.
• From 1604 and U.S. Highway
281 (North Central San
Antonio): Take U.S. Highway
281 South to downtown. Take IH
35 South exit. Take the Houston
Street exit. Turn left on Martin.
Turn right on Santa Rosa Street
to patient/visitor parking.
• From 1604 and IH 10 (North
West San Antonio): Take
IH 10 East to downtown. Exit
Santa Rosa Street and follow
to patient/visitor parking.
• Notify Patient Intake Center
at 210.704.3292
• From U. S. Highway 90 and
IH 35 (West San Antonio):
Take U.S. Highway 90 East to
downtown. Take IH 35 North.
Exit Cesar Chavez to Santa
Rosa Street. Take a right on
Santa Rosa Street and follow
to patient/visitor parking.
• From 1604 and IH 35 (South
West San Antonio): Take IH
35 North to downtown. Take IH
35 North. Exit Cesar Chavez to
Santa Rosa Street. Take a right
on Santa Rosa Street and follow
to patient/visitor parking.
• From Loop 410 and IH 37
(South San Antonio): Take IH
37 North to downtown. Take IH 10
West to IH 35 North. Exit Cesar
Chavez to Santa Rosa Street. Take
a right on Santa Rosa Street and
follow to patient/visitor parking.
• From 1604 and IH 10 (East San
Antonio):
Take IH 10 West to downtown.
Take IH 35 North. Exit Cesar
Chavez to Santa Rosa Street. Take
a right on Santa Rosa Street and
follow to patient/visitor parking.