Fillable Da Form 4700 - Medical Record - Supplemental Medical Data printable pdf download

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MEDICAL RECORD - SUPPLEMENTAL MEDICAL DATA

For use of this form, see AR 40-66; the proponent agency is the office of the Surgeon General

(Date)

REPORT TITLE

OTSG APPROVED

EMERGENCY DEPARTMENT DISCHARGE INSTRUCTIONS - ADULT

(YYYYMMDD)

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.

Diagnosis:

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

Abdominal pain

Headache

oder, fever, redness, increased pain, or have any concerns return to

PCM or ED.

Allergic reaction

Head injury

Stitches/staples removed in ____ days by PCM/ED.

Asthma

Heat exhaustion

Wound checked in ____ days by PCM/ED

Upper back/neck pain

Influenza

Packing changed in ____ days by PCM/ED

Low back pain

Kidney stone

Metformin and IV contrast: Your medication list includes metformin.

Behavioral

Seizure

(Glucophage). During your stay in the ED you received intravenous

Chest pain

Sprains/strains/bruises/fractures

contrast for a CT scan. You should stop your metformin for 48 hours and

Conjunctivitis

Threatened miscarriage

follow-up with your primary care provider to prevent possible interactions

between the metformin and the IV contrast. Continue to monitor your blood

Dehydration

Urinary tract infection

glucose as normal. If you notice that your glucose is running high or you have

Vomiting/diarrhea

Viral upper respiratory infection

symptoms of low blood sugar call yout PCM or return to the ED.

* PCM is primary care physician

Other (specify):_________________________________

** ED is emergency department

Additional Instructions: _________________________________________________________________________________

______________________________________________________________________________________________________

Medications:

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

required.

Follow-up:

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

CTMC 596-1680

Victory 596-1760

OB/GYN 596-1770

Ortho 596-1764

Podiatry 596-1767

EENT 596-0048

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.

PREPARED BY

(Signature & Date)

DEPARTMENT/SERVICE/CLINIC

Date (YYYYMMDD)

GLWACH ER

(For typed or written entries give: Name- Last, First, Middle; grade; date;

Patients Identification

HISTORY/PHYSICAL

FLOW CHART

hospital or medical facility)

OTHER EXAMINATION

OTHER

PIXIS

OR EVALUATION

(Specify)

DIAGNOSTIC STUDIES

TREATMENT

DA FORM 4700 FEB 2003

EDITION OF MAY 78 IS OBSOLETE

USA MEDDAC OP 485 (FLWMO)(1 Mar 2012)

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Da Form 4700 - Medical Record - Supplemental Medical Data

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