WLAVA:Enhanced Screening Tent Template/it

Machine-translated from the English original. Only the English page can be edited.

CC: |PATIENT AGE|

HPI:

RIFERITO DA: [ ] Self [ ] Failed primary screen [ ] Primary care provider [ ] Other: (free text box)

SCREEN DEI SINTOMI (selezionare tutti quelli applicabili): [ ] Subjective fevers/chills or T > 99.9F [ ] Cough (new or worse than usual) [ ] Sore throat (new or worse than usual) [ ] Shortness of breath or trouble breathing (new or worse than usual) [ ] Body or muscle aches (new or worse than usual) [ ] Diarrhea (new or worse than usual) [ ] Severe fatigue [ ] Other: (free text box)

SCREEN DI ESPOSIZIONE: [ ] Close contact with CONFIRMED COVID19 case (within 14 days of Sx onset) [ ] Close contact with patients of a respiratory illness outbreak in last 3 days [ ] Healthcare worker (including EMT, paramedic, etc) [ ] Lives in a long-term care facility (CLC, CalVet, New Vista, community SNF, etc) [ ] Lives in a group living facility (homeless shelter, board & care, DOM, New Directions, US Vets, etc) [ ] Patient gets chronic care in healthcare facility (i.e., dialysis or chemotherapy patient)

STORIA SOCIALE: [ ] Domiciled in private residence [ ] Undomiciled (includes living in tent, car, etc) [ ] Domiciled in long-term care facility (auto populate if selected above in exposure screen?) [ ] Domiciled in group living facility (auto populate if selected above in exposure screen?)

PMHx: PROBLEMI ATTIVI

ACTIVE PROB LIST-SHORT

ALLERGIE:

ALLERGIES

SEGNI VITALI: T: |TEMPERATURE| P: |PULSE| R: |RESPIRATION| BP:|BLOOD PRESSURE| Pain: |PAIN| Pulse Ox: |PULSE OXIMETRY|

ESAME FISICO: GEN: Well-appearing, No apparent distress Resp: Normal work of breathing, speaking in complete sentences Neuro: A&Ox3, Gait: steady, moving all extremities, no gross focal deficits

VALUTAZIONE: Patient is afebrile and with unremarkable respiratory vital signs. Patient at baseline ambulatory status, non-toxic appearing, and speaking in full sentences. Based on the limited examination there is a low suspicion for serious bacterial infection or systemic illness. [ ] COVID-19 suspected, met testing criteria. [ ] COVID-19 suspected, did not meet testing criteria. [ ] COVID-19 suspected, testing refused. [ ] COVID-19 not suspected. [ ] Other: (free text box)

PIANO: [ ] Encouraged patient to continue with symptom alleviation. [ ] Encouraged to return if has significant worsening of symptoms including chest pain, shortness of breath, or inability to care for self.

DISPOSIZIONE: [ ] If no concern for COVID, allowed to enter medical center [ ] Home [ ] Long-term care facility (i.e., CLC, CalVet, New Vista, community SNF, etc) [ ] Building 214 “COVID” DOM [ ] VA Homeless Housing Program (i.e., Grant Per Diem, DOM, New Directions, etc.) [ ] Other group living facility (i.e., shelter, board & care, assisted living facility etc.) [ ] ED attending consult for help with disposition: (text box for name) [ ] Escorted to ED (critically ill) [ ] Directly Admitted [ ] Other: (free text box)

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Autori

Jonie Hsiao MD, Daniel Ostermayer, MD

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