MEDICAL RECORD - SUPPLEMENTAL MEDICAL DATA
For use of this form, see AR 40-66; the proponent agency is the office of the Surgeon General
EMERGENCY DEPARTMENT DISCHARGE INSTRUCTIONS - ADULT
The examination and treatment you received has been rendered on an emergency basis and is not intended to substitute or provide complete medical care. Often
additional care is needed and this will be provided by the general or specialty clinic to which you have been referred. All tests will be reviewed by doctors who
specialize in their interpretation at a later date and you will be contacted if there are findings different from the emergency department.
Discharge instructions provided (check/circle one)
Wound care/burn care: Keep the wound clean. Apply the ointment and
change the dressing ____ times per day. If you note swelling, pus, foul
oder, fever, redness, increased pain, or have any concerns return to
PCM or ED.
Stitches/staples removed in ____ days by PCM/ED.
Wound checked in ____ days by PCM/ED
Upper back/neck pain
Packing changed in ____ days by PCM/ED
Low back pain
Metformin and IV contrast: Your medication list includes metformin.
(Glucophage). During your stay in the ED you received intravenous
contrast for a CT scan. You should stop your metformin for 48 hours and
follow-up with your primary care provider to prevent possible interactions
between the metformin and the IV contrast. Continue to monitor your blood
Urinary tract infection
glucose as normal. If you notice that your glucose is running high or you have
Viral upper respiratory infection
symptoms of low blood sugar call yout PCM or return to the ED.
* PCM is primary care physician
** ED is emergency department
Additional Instructions: _________________________________________________________________________________
Medication reconciliation completed by ED provider and list given to patient.
Medication reconciliation NOT indicated.
Please make the following changes to your home medications:
Your provider has prescribed the following medications:
All medications have potential side effects and medications can interact with each other. After you review your medications, notify an ED staff
member or the pharmacy if you have questions.
You have been prescribed medications which decrease your alertness. Do not drive or perform activity where alertness is
Make an appointment in _____ days at your primary care managers clinic, or sooner if you become worse.
A physician was consulted to continue your care in the _________________________ clinic. Please call for an appointment.
TRICARE appointment number 1-866-299-4234 or 573-596-1490
Front Desk 596-0035
Family Practice 596-1765
Internal Med 596-1600
Ozark St Robert 596-0064
Gen Surg 596-1769
Phy Therapy 596-1707
Behavioral Med 596-0522
Social Work 596-0521
The patient and/or the representative verbalizes/demonstrates understanding of medications, treatment plans, pain management
and follow-up care. I understand and have received a copy of my instructions regarding my medical care and follow-up care as
noted above. I understand that if there is a serious change in my condition I should contact my regular clinic or return to the ED.
Patient/Representative Signature: _____________________________________ Date: __________________
ACCIDENTAL INGESTION? Call 911 or Poison Control 1-800-222-1222
SUICIDE ON YOUR MIND?
Help is available. Notify ED staff member, Military Police, or Military One Source 1-800-342-9647
YOUR FEEDBACK IS IMPORTANT TO US! Please complete and return the survey you receive in the mail regarding your ED visit.
(Signature & Date)
(For typed or written entries give: Name- Last, First, Middle; grade; date;
hospital or medical facility)
DA FORM 4700 FEB 2003
EDITION OF MAY 78 IS OBSOLETE
USA MEDDAC OP 485 (FLWMO)(1 Mar 2012)