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  • Bed Reservation Form: Reservation Date: Time: Room Requests: NO: Surgical: Medical

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    BabyNewts
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    This bed reservation form provides information about reserving a bed for a patient, including their admission details, medical history, insurance information, and discharge plans. The form requests the patient's name, date of birth, admitting diagnosis, treatment plan, physician details, insurance coverage, and intended length of stay and discharge disposition. Additional notes sections allow documentation of preexisting conditions, infectious disease precautions needed, and any relevant social details like living situation. The multi-page form is used to coordinate a patient's admission and plan their inpatient care.

    Original Description:

    This PDF document is a Hospital bed reservation form.

    Original Title

    Bed Reservation Form

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    This bed reservation form provides information about reserving a bed for a patient, including their admission details, medical history, insurance information, and discharge plans. The form requests the patient's name, date of birth, admitting diagnosis, treatment plan, physician details, insurance coverage, and intended length of stay and discharge disposition. Additional notes sections allow documentation of preexisting conditions, infectious disease precautions needed, and any relevant social details like living situation. The multi-page form is used to coordinate a patient's admission and plan their inpatient care.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    12 views1 page

    Bed Reservation Form: Reservation Date: Time: Room Requests: NO: Surgical: Medical

    Uploaded by

    BabyNewts
    This bed reservation form provides information about reserving a bed for a patient, including their admission details, medical history, insurance information, and discharge plans. The form requests the patient's name, date of birth, admitting diagnosis, treatment plan, physician details, insurance coverage, and intended length of stay and discharge disposition. Additional notes sections allow documentation of preexisting conditions, infectious disease precautions needed, and any relevant social details like living situation. The multi-page form is used to coordinate a patient's admission and plan their inpatient care.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    BED RESERVATION FORM

    RESERVATION DATE:

    ROOM REQUESTS:

    TIME:

    NO:

    MEDICAL:

    SURGICAL:

    Yes

    Admission Date: _______________

    Type of Admission:

    ER

    Urgent

    Patients Name: _____________________________________________


    LAST

    FIRST

    Elective

    No

    NT

    IC

    Medical Record #: _____________________

    DOB: ________________

    Age: _________

    Sex:

    MIDDLE

    Address: _________________________________________________________________________________________________________________
    Patients Phone Number:
    Physicians Name:

    Home: _______________________

    Work: __________________________

    Attending: _________________________________________

    Time Last Ate: __________

    SSN: __________________________

    Referring: _________________________________________

    Admitting Diagnosis: ________________________________________________________________________________

    _________________________________________________________________________________________________________________________
    Coexisting Conditions: _______________________________________________________________________________________________________
    Does patient have any draining areas?
    Is the patient confused?

    Yes

    Yes

    No

    Does patient need a private room for any infectious disease?

    No

    If YES, is patient noisy and / or agitated?

    Yes

    Yes

    No

    No

    Treatment Plan: ____________________________________________________________________________________________________________


    _________________________________________________________________________________________________________________________
    Last Hospitalization: _________________________________________________________________________________________________________
    HOSPITAL

    DISCHARGE DATE

    LENGTH OF STAY

    DATE:

    Surgical Procedure (Description) ___________________________________________________________________________


    TIME:

    _______________________________________________________________________________________________________

    INSURANCE:

    DISCHARGE INFORMATION:

    1. ___________________________________________________________________
    INSURANCE

    POLICY #

    Probable Length of Stay: ________________________

    GROUP NUMBER

    _____________________________________________________________________
    SUBSCRIBERS NAME

    Disposition: __________________________________

    SUBSCRIBERS EMPLOYER

    2. ___________________________________________________________________
    INSURANCE

    POLICY #

    _____________________________________________
    Was patient
    admitted from Nursing Home?
    Yes
    No

    GROUP NUMBER

    _____________________________________________________________________
    SUBSCRIBERS NAME

    SUBSCRIBERS EMPLOYER

    Insurance Phone #:

    Precertification Phone #:

    If yes, what Nursing Home: ______________________

    ________________________________

    __________________________________

    _____________________________________________
    Does patient live alone?

    Yes

    No

    P.A.T.

    Yes

    No

    FORT LINCOLN:

    Yes

    No

    ATTACHED:

    Yes

    No

    Reservation Taken by: _____________________ Preadmission Review: __________


    HOSPICE:

    Yes

    No

    PATHWAY:

    Yes

    No

    (if yes, secure information below)

    NOTES:

    WHITE = Admitting Office


    8850077 Rev. 02/05

    YELLOW = Preadmission Office


    Bed Reservation Form_ADMITTING

    PINK = Insurance Verification


    Page 1 of 1

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