Title Page
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Site conducted
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Conducted on
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Prepared by
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Provider
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Patient MRN
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Services
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Admission Date
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Discharge Date (if applicable)
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Consent to Treatment
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Intake Documentation
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Care Team
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Problem List
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Vital Signs
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BMI
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Nutrition Assessment
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Depression/Suicide Screening
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Safety Plan
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BH: Annual Family History Documented
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Medications
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Immunizations
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Allergies
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Condition History
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Pain Management
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Service/Treatment Plan
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Goals
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SDOH considered
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Laboratory Testing
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Physical/Psychiatric Exam
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Tobacco Use
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Pregnancy
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Spiritual Needs Assessment
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Preventative Screenings
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Diabetes
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Asthma
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CV Risk Assessment
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Hypertension
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Hepatitis C Screening
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Advanced Directives
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Referrals
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Discharge from Services
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Documentation Timely
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HPI
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Medical Decision-Making
