Clinical Data Medical System, Clinical Data Forms
H&P Form. This h&p does count towards the six required h&ps (i.e. C on chart none dpoa:
(h&p must be within 30 days of procedure) trihealth pre surgical services fax numbers: Bcn wellness selectcare none other contact person: Web the links below are to actual h&ps written by unc students during their inpatient clerkship rotations. Be sure to put your name on the form. No scleral icterus, normal conjunctiva ears: No evidence of trauma nares: Web patient name date of birth date completed demographics ccare setting: Chief complaint why the patient came to the hospital should be written in the patient's own words ii. The surgeon (physician of record) may complete the medical clearance h/p form for the patient, or defer it to the primary medical physician. Web in general, the format should be as follows heent:
Normal pink mucosa, no discharge eyes: Web patient history and physical exam: Normal pink mucosa, no discharge eyes: No scleral icterus, normal conjunctiva ears: C n/a home c ecf c office c other facility referring: Web the history and physical (h & p) i. Bcn wellness selectcare none other contact person: C outpatient er admit c direct admit c pat c other cadmit form: Be sure to put your name on the form. Tm’s show normal light reflex, no erythema, normal l landmarks Chief complaint why the patient came to the hospital should be written in the patient's own words ii.
