patient chart - e

TEAM (CIRCLE ONE):
ALPHA
PATIENT CHART
SEX: Male
AGE: 8
PATIENT NAME: Abelena Abrillo
BRAVO
CHARLIE
DELTA :
Female
Patient Status: Check one before giving chart to Case Manager
 Initial Diagnosis
 Results In
Treatment Plan
 Test Ordered
 Final Diagnosis
Trial Selected
Key Symptoms: (from Medical Chart)
DIAGNOSTIC SPECIALISTS
Itching, blistering sores on back , chest, stomach , face , arms, and legs. Nausea and loss of appetite .
Selected in Medi-Net : YES
Initial Diagnosis :chickenpox
Test ordered (list below)
Physical exam diagnosis
() when ordered
in Medi-Net
NO
Test ordered (list below)
() when ordered
in Medi-Net

Signature: c. Rogers
MED-SURGE SPECIALISTS
Test ordered (list below)
Physical exam diagnosis
Date:
Reviewed Key Symptoms and Initial Diagnosis:
Results:
(Circle one)
YES
NO
Observation/Conclusion/Explanation
Normal / Not Normal
Normal / Not Normal
Normal / Not Normal
Normal / Not Normal
Normal / Not Normal
Final Diagnosis:
chickenpox
Selected in Medi-Net : YES
NO
Signature: M. Calinger
CLINICAL INTERVENTION SPECIALISTS
Treatment Plan:
Signature:
Date:
Reviewed Test Results and Confirmed Final Diagnosis:
YES
NO
Recommended Clinical Trial:
Date:
TEAM (CIRCLE ONE):
ALPHA
PATIENT CHART
SEX: Male
AGE: 15
PATIENT NAME: Josefina Consuelo
BRAVO
CHARLIE
DELTA :
Female
Patient Status: Check one before giving chart to Case Manager
 Initial Diagnosis
 Results In
Treatment Plan
 Test Ordered
 Final Diagnosis
Trial Selected
Key Symptoms: (from Medical Chart)
DIAGNOSTIC SPECIALISTS
Difficulty with breathing. Wheezing and coughing a lot. Has gotten much worse
Selected in Medi-Net : YES
Initial Diagnosis :asthma
Test ordered (list below)
() when ordered
in Medi-Net
Peak flow measures

Chest x-ray

NO
Test ordered (list below)
() when ordered
in Medi-Net
Signature: C. Rogers
MED-SURGE SPECIALISTS
Test ordered (list below)
Date:
Reviewed Key Symptoms and Initial Diagnosis:
Results:
(Circle one)
YES
NO
Observation/Conclusion/Explanation
Peak flow measures
Normal / Not Normal
Severe asthmatic conditions with constricted airways
Chest x-ray
Normal / Not Normal
Very low
Normal / Not Normal
Normal / Not Normal
Normal / Not Normal
Final Diagnosis:
asthma
Selected in Medi-Net : YES
NO
Signature: M. Calinger
CLINICAL INTERVENTION SPECIALISTS
Treatment Plan:
Signature:
Date:
Reviewed Test Results and Confirmed Final Diagnosis:
YES
NO
Recommended Clinical Trial:
Date:
TEAM (CIRCLE ONE):
ALPHA
PATIENT CHART
CHARLIE
SEX: Male
AGE: 32
PATIENT NAME: Kathleen Danieles
BRAVO
DELTA :
Female
Patient Status: Check one before giving chart to Case Manager
 Initial Diagnosis
 Results In
 Test Ordered
Treatment Plan
Final Diagnosis
Trial Selected
Key Symptoms: (from Medical Chart)
DIAGNOSTIC SPECIALISTS
Mild soreness of right, front, lower let. Increase pain level and frequency of pain after one week . Itching, nausea ,
vomiting and diarrhea .
Selected in Medi-Net : YES
Initial Diagnosis : infection
Test ordered (list below)
X-ray
Signature:
() when ordered
in Medi-Net
NO
Test ordered (list below)
() when ordered
in Medi-Net

Date:
M. Callinger
MED-SURGE SPECIALISTS
Test ordered (list below)
Reviewed Key Symptoms and Initial Diagnosis:
Results:
(Circle one)
YES
NO
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:
CLINICAL INTERVENTION SPECIALISTS
Treatment Plan:
Signature:
Date:
Reviewed Test Results and Confirmed Final Diagnosis:
YES
NO
Recommended Clinical Trial:
Date:
TEAM (CIRCLE ONE):
ALPHA
PATIENT CHART
CHARLIE
SEX: Male
AGE: 36
PATIENT NAME: Kelly Murdock
BRAVO
DELTA :
Female
Patient Status: Check one before giving chart to Case Manager
Initial Diagnosis
Results In
Treatment Plan
Test Ordered
Final Diagnosis
Trial Selected
DIAGNOSTIC SPECIALISTS
Key Symptoms: (from Medical Chart)
Selected in Medi-Net : YES
Initial Diagnosis :
Test ordered (list below)
() when ordered
in Medi-Net
NO
Test ordered (list below)
() when ordered
in Medi-Net
Signature:
MED-SURGE SPECIALISTS
Test ordered (list below)
Date:
Reviewed Key Symptoms and Initial Diagnosis:
Results:
(Circle one)
YES
NO
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:
CLINICAL INTERVENTION SPECIALISTS
Treatment Plan:
Signature:
Date:
Reviewed Test Results and Confirmed Final Diagnosis:
YES
NO
Recommended Clinical Trial:
Date:
TEAM (CIRCLE ONE):
ALPHA
PATIENT CHART
CHARLIE
SEX: Male
AGE: 22
PATIENT NAME: Stephanie Holstein
BRAVO
DELTA :
Female
Patient Status: Check one before giving chart to Case Manager
 Initial Diagnosis
 Results In
 Test Ordered
Treatment Plan
Final Diagnosis
Trial Selected
Key Symptoms: (from Medical Chart)
DIAGNOSTIC SPECIALISTS
Headache , sore throat, tired all of the time . Has no appetite , muscles ache and general weakness all over.
Selected in Medi-Net : YES
Initial Diagnosis : mononucleosis
Test ordered (list below)
() when ordered
in Medi-Net
CBC (complete blood count)

Liver function test

Monospot test

Strep test

Signature:
NO
Test ordered (list below)
() when ordered
in Medi-Net
Date:
M. Calinger
MED-SURGE SPECIALISTS
Test ordered (list below)
Reviewed Key Symptoms and Initial Diagnosis:
Results:
(Circle one)
YES
NO
Observation/Conclusion/Explanation
CBC (complete blood count)
Normal / Not Normal
Liver function test
Normal / Not Normal
Monospot test
Normal / Not Normal
Strep test
Normal / Not Normal
WBC 15,000
Positive for mononucleosis
Normal / Not Normal
Final Diagnosis:
mononucleosis
Signature:
J. Schraml
CLINICAL INTERVENTION SPECIALISTS
Treatment Plan:
Signature:
Selected in Medi-Net : YES
NO
Date:
Reviewed Test Results and Confirmed Final Diagnosis:
YES
NO
Recommended Clinical Trial:
Date: