Enter An Inpatient Record for {{ client.fname }} {{ client.lname }}
Select Client:
{{ client.client_id }} {{ client.lname}}, {{ client.fname}}
Reporting Unit:
{{ place_str }}
{% for unit in units %}
{{unit.unit_id}} -- {{ unit.unit_lname }}
{% endfor %}
Inpatient Admission:
Discharge (If Applicable):
Hospital Name:
Hospital Address:
State Hospital:
No
Yes
Hospital Type:
Psychiatric
Medical
Other
Staff Name:
Staff Shift:
Time Of Day:
Specific Complaint:
Abdominal Pain
Agitation
Alcohol Intoxication
Allergic Reaction
Anxiety
Asthma
Back Pain
Bizarre Behavior
Breathing Issue
Cellulitis
Chronic Obstructive Pulmonary Disease (COPD)
Chest Pain
Coronary Artery Disease (CAD)
Congestive Heart Failure (CHF)
Congestion
Cough
Depression
Diabetic ulcer
Dizziness
Ear Infection
Emphysema
Evaluation
Fainting
Fall
Fever
Flu
Fracture
Gastrointestinal Illness
Glucose Levels
Gout
Hallucination
Headache
Homicidal Ideation
Infection
Irritable Bowel Syndrome (IBS)
K2
Medication Error
Nausea
Pneumonia
Rash
Rectal Bleeding
Respiratory Failure
Seizure
Sickle Cell
Sore Throat
Stomach Pain
Substance Abuse Relapse
Suicidal Ideation
Unconscious
Upper Respiratory Infection
Urinary Tract Infection (UTI)
Vomiting
Weakness
Wound
Other - Specify In Reason For Visit
Reason For Visit (Detail):
EOB Visit:
No
Yes
Admission / Visit Type:
Voluntary
Non-Voluntary
Escort Type:
EMT
Police
Self
Staff
Transportation Type:
Agency Vehicle
Ambulance
Ambulette
Police Vehicle
Public Transportion
Staff/Agency Vehicle
Client Age At Time Of Visit:
Client Sex:
Diagnosis:
Outcome (If Applicable):
Comments:
Submit
{% include '_footer.html' %}