Revised 11/07/00

New York Presbyterian Hospital New York Weill Cornell Center

Urgent Care Encounter Form Pediatric Primary Care

IF NO PLATE, PRINT NAME, SEX AND HISTORY NO.

DATE ______________ TIME ____________ PRIMARY PROVIDER _________________________________

DOB________________AGE_____________HISTORIAN________________PHONE# ___________________

NURSING ASSESSMENT

CHIEF COMPLAINT _________________________________________________________________________ __________________________________________________________________________________________ MEDICATIONS ________________________________ ALLERGIES___________________________ _____________________________________________ _____________________________________ __________________________________________________________________________________________ VITALS T_______ OC P_________ R_______ BP__________ Ht_______cm Wt _____kg O2Sat_______%

RN/LPN

NURSING SIGNATURE/TITLE PHYSICIAN ASSESSMENT

CC/HPI

PMH ______________________________________________________________________________________

PERTINENT PHYSICAL FINDINGS ____________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ASSESSMENT _____________________________________________________________________________

PLAN 1.__________________________________________________________________________________ 2.__________________________________________________________________________________ 3.__________________________________________________________________________________ 4.__________________________________________________________________________________

ATTENDING NOTE _________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Provider Signature MD/NP Date __________Provider Code___________

Attending Signature MD Date __________Provider Code___________

IMMUNIZATIONS

Up To Date

Documented

By Report Only

Delayed (explain)