Short Stay H&P Form - Cedars-Sinai

AMBULATORY SURGERY / SHORT STAY
HISTORY & PHYSICAL
(To be used only if planned admission is less than 48 hrs.) PATIENT I.D.
DATE: SEX ❐ MALE AGE: ❐ SINGLE ❐ DIVORCED OCCUPATION
❐ FEMALE ❐ MARRIED ❐ WIDOWED
PRESENT ILLNESS (Onset-Complaint):
RELEVANT FAMILY HISTORY:
ALLERGIES:
MEDICATIONS:
IMMUNIZATIONS:
PAST MEDICAL HISTORY/ REVIEW OF SYSTEMS:
PHYSICAL EXAMINATION: VITAL SIGNS: BP______________ TEMP______________ PULSE______________ RESP.______________
DX/PLAN OF CARE:
RESIDENT SIGNATURE:
DATE: TIME: PHYSICIAN SIGNATURE:
(OVER)
M.D.
Form No. 4296 (Rev. 7/99) Page 1 of 1

PROGRESS RECORD
Date Note progress of case, complications, change in diagnosis, condition on discharge, instruction to patient, etc.
PROGRESS RECORDS