ALFRED STATE MEDICAL CENTER INPATIENT FACE SHEET 100 MAIN ST, ALFRED NY 14802 (607) 555-1234 HOSPITAL #: 000999 PATI

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ALFRED STATE MEDICAL CENTER INPATIENT FACE SHEET
100 MAIN ST, ALFRED NY 14802
(607) 555-1234
HOSPITAL #: 000999
PATIENT NAME AND ADDRESS
GENDER
RACE
MARITAL STATUS
PATIENT NO.
PAULSON, Paula P.
49 Hillbottom Way
Alfred, NY 14802
F
W
M
IPCase010
DATE OF BIRTH
MAIDEN NAME
OCCUPATION
01-20-YYYY
King
Waitress
ADMISSION DATE
TIME

DISCHARGE DATE
TIME
LENGTH OF STAY
TELEPHONE NUMBER
04-26-YYYY
16:00
05-01-YYYY
09:30
05 DAYS
(607) 555-2836
GUARANTOR NAME AND ADDRESS
NEXT OF KIN NAME AND ADDRESS
PAULSON, Patrick 49 Hillbottom Way Alfred, NY 14802
PAULSON, Patrick 49 Hillbottom Way Alfred, NY 14802
GUARANTOR TELEPHONE NO.
RELATIONSHIP TO PATIENT
NEXT OF KIN TELEPHONE NUMBER
RELATIONSHIP TO PATIENT
(607) 555-2836
Husband
(607) 555-2836
Husband
ADMITTING PHYSICIAN
SERVICE
ADMIT TYPE
ROOM NUMBER/BED
Thompson MD, Donald
Medical
2
0367/01
ATTENDING PHYSICIAN
ATTENDING PHYSICIAN UPIN
ADMITTING DIAGNOSIS
Thompson MD, Donald
100B01
Congestive Heart Failure
PRIMARY INSURER
POLICY AND GROUP NUMBER
SECONDARY INSURER
POLICY AND GROUP NUMBER
BCBS
432763201 77690
Empire Plan
5739057512
DIAGNOSES AND PROCEDURES
ICD CODE

PRINCIPAL DIAGNOSIS
Acute Bronchitis
466.0
SECONDARY DIAGNOSES
Chronic obstructive pulmonary disease 496
Restrictive Lung Disease 518.89
Congestive heart failure
428.0
PRINCIPAL PROCEDURE

SECONDARY PROCEDURES

TOTAL CHARGES: $ 7,236.95
ACTIVITY: r Bedrest þ Light r Usual r Unlimited r Other:
DIET: r Regular r Low Cholesterol r Low Salt r ADA r _____ Calorie
FOLLOW-UP: þ Call for appointment þ Office appointment in 2 wks Other:
SPECIAL INSTRUCTIONS: Go to Pulmonary lab for blood test 1 hr before appt.
Signature of Attending Physician:
Donald Thompson, MD
Permission to reuse granted by Alfred State College and Michelle A. Green
PAULSON, Paula P. Admission: 04-26-YYYY
IPCase010 DOB: 01-20-YYYY LABORATORY DATA
Dr. Thompson ROOM: 0367
SPECIMEN COLLECTED: 04-26-YYYY SPECIMEN RECEIVED: 04-26-YYYY

CBC S DIFF
TEST RESULT FLAG REFERENCE
WBC 7.4 4.5-11.0 thous/UL
RBC 5.02 **L** 5.2-5.4 mill/UL
HGB 15.0 11.7-16.1 g/dl
HCT 45.8 35.0-47.0 % MCV 91.2 85-99 fL.
MCHC 32.8 **L** 33-37
RDW 15.2 **H** 11.4-14.5
Platelets 165
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