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VA Form 10-0137 Patient Instructions

The document appears to be a medical certificate template used to record patient information and vital signs. It includes fields to document details like date, time, age, gender, condition on arrival, allergies, weight, temperature and more. The certificate is multi-page and continues on the back as needed to further document history, physical exam findings, diagnostic impressions, treatment plan, discharge details and patient instructions.

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salazarrey24
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46 views3 pages

VA Form 10-0137 Patient Instructions

The document appears to be a medical certificate template used to record patient information and vital signs. It includes fields to document details like date, time, age, gender, condition on arrival, allergies, weight, temperature and more. The certificate is multi-page and continues on the back as needed to further document history, physical exam findings, diagnostic impressions, treatment plan, discharge details and patient instructions.

Uploaded by

salazarrey24
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

CONTINUE ON BACK WHEN NECESSARY

MEDICAL CERTIFICATE
1. DATE 2. TIME AM 3. AGE 4. SEX 5.ON ARRIVAL PATIENT WAS: 6. PHONE NUMBER 7. HOMELESS
PM M F AMBULATORY STRETCHER WHEELCHAIR YES NO
8A. ALLERGIES 8B. WEIGHT 8C. TEMPERATURE 8D. PULSE 8E. RESPIRATION 8F.B/P 8G. DUE TO INJURY
NO YES
9. CURRENT MEDICATIONS

10. TRIAGE

11. SIGNATURE

12. HISTORY AND PHYSICAL

13. DIAGNOSTIC IMPRESSIONS


14. PLAN

15A. ATTENDING OF RECORD 15B. EXAMINER’S SIGNATURE

SECTION II - FOR PATIENT


1. DISPOSITION/CLINIC APPOINTMENT 2. AFTER CARE SHEET GIVEN 3. FOLLOW UP - ACTIVITY - LIMITATIONS
YES NO
4. CONDITION 5. DATE/TIME OF DISCHARGE 6. SIGNATURE TO INDICATE INSTRUCTIONS GIVEN
IMPROVED SATISFACTORY UNCHANGED
IMPRINT PATIENT DATA CARD 7. PATIENT INSTRUCTIONS

I CERTIFY THAT I RECEIVED AND 8. PATIENT’S SIGNATURE


VA FORM
10-10M UNDERSTAND THESE INSTRUCTIONS
DEC 2016
SUPERSEDES VA FORM10-10M, MAY1990, WHICH WILL NOT BE USED.
VITAL SIGNS MD NURSE
TIME TIME ORDERS TIME EFFECTIVENESS
TEMP PULSE RESP B/P SIGNATURE SIGNATURE

CONTINUATION FROM FRONT/PROGRESS NOTE

STUDIES REQUESTED RESULTS

VA FORM
DEC 2016 10-10M PAGE 2
SECTION II - FOR PATIENT
1. DISPOSITION/CLINIC APPOINTMENT 2. AFTER CARE SHEET GIVEN 3. FOLLOW UP-ACTIVITY-LIMITATIONS
YES NO
4. CONDITION 5. DATE/TIME OF DISCHARGE 6. SIGNATURE TO INDICATE INSTRUCTIONS GIVEN
IMPROVED SATISFACTORY UNCHANGED
IMPRINT PATIENT DATA CARD 7. PATIENT INSTRUCTIONS

I CERTIFY THAT I RECEIVED AND 8. PATIENT’S SIGNATURE


UNDERSTAND THESE INSTRUCTIONS
VA FORM
MAR 1992 10-10M PAGE 3 PATIENTS COPY

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