ECM ER PATIENT MORTON PLANT HOSPITAL
PATIENT INFO
T#: 3804191494 MR#: 718248 ADMT: 11/18/95 TIME: 18:5
MCPHERSON , LISA ROOM: RELEASE INFO:
SS#: 461-94-200
901 OSCEOLA AV #205 STA: ORIG:
CLEARWATER FL 34616- SVC: ECC SMK:
831-559-9858 TYPE: E F/C:
DOB: 02/10/1959 AGE: 36 SEX: F ARR: MARITAL:
MAIDEN: SURG:
RELIGION: NO PREFERENCE PREV: VIP:
|
EMER
l: SLAUGHTER , BENETTA OTHER 2: NONE OTHER
XXXXX XXXXXXXXXXXXX CLEARWATER
FL 813-XXX-XXXX
|
GUAR
MCPHERSON , LISA PATIENT SSN: 491-94-2009
901 OSCEOLA AV #205 CLEARWATER FL 34616-
813-559-9856
|
EMPL
INS
INS #1: SELF PAY 997 PRIORITY: 1 REL: P GRP IND: N
PHONE:
POL#: NA
SUBSCR: MCPHERSON , LISA GRP #: NA
BLUE CROSS #: GRP NM:
NA
INS #2: PRIORITY: REL: GRP IND:
PHONE:
POL#:
SUBSCR: GRP#:
BLUE CROSS #: GRP NM:
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MED
ADMT DR: 00000 UNASSIGNED DOCTOR ANESTHESIA:
PRIM DX: MEDIC STS: PSYCH EVAL
TESTS:
PROCEDURES:
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ASSEMBLE: ____ ANALYZE: ____ ABSTRACT: ____ CODE: ____ FINAL CHECK:
PRINCIPAL DIAGNOSIS: ________________________________________________
SECONDARY DIAGNOSIS: ________________________________________________
OPERATIVE PROCEDURES: _______________________________________________
COMPLICATIONS: ______________________________________________________
CONSULTATIONS: ______________________________________________________
DISCHARGE STATUS: ALIVE___ EXPIRED ___ DATE OF DISCHARGE: _______
OVER 48 HOURS ____ AUTOPSY ___ TIME OF DISCHARGE: _______
UNDER 48 HOURS ____ MED EXAMINER ____ LOS: _______
DISCHARGE DATE _________ LOS: __________ ATTENDING PHYSICIAN RECORDS
