MR# Time contacted: Time Evaluated: ____________ Team contacting: □ ED □ PALS □ MICU □ Team contacted :□ silver □ day call □ night float Pt admitted to: □ None □ IM □ MICU □ oncology □ other:___________ Pt admitted by: □ silver □ day call □ night float Room PCP One liner: MR# Time contacted: Time Evaluated: ____________ Team contacting: □ ED □ PALS □ MICU □ other:________________ Team contacted :□ silver □ day call □ night float Pt admitted to: □ None □ IM □ MICU □ oncology □ other:___________ Pt admitted by: □ silver □ day call □ night float Room PCP One liner: MR# Time contacted: Time Evaluated: ____________ Team contacting: □ ED □ PALS □ MICU □ other:________________ Team contacted :□ silver □ day call □ float Pt admitted to: □ None □ IM □ MICU □ oncology □ other:___________ Pt admitted by: □ silver □ day call □ float Room PCP One liner: MR# Time contacted: Time Evaluated: ____________ Team contacting: □ ED □ PALS □ MICU □ other:________________ Team contacted :□ silver □ day call □ night float Pt admitted to: □ None □ IM □ MICU □ oncology □ other:___________ Pt admitted by: □ silver □ day call □ night float Room PCP One liner:
MR# Time contacted: Time Evaluated: ____________ Team contacting: □ ED □ PALS □ MICU □ other:________________ Team contacted :□ silver □ day call □ float Pt admitted to: □ None □ IM □ MICU □ oncology □ other:___________ Pt admitted by: □ silver □ day call □ night float Room PCP One liner: MR# Time contacted: Time Evaluated: ____________ Team contacting: □ ED □ PALS □ MICU □ other:________________ Team contacted :□ silver □ day call □ night float Pt admitted to: □ None □ IM □ MICU □ oncology □ other:___________ Pt admitted by: □ silver □ day call □ night float Room PCP One liner: MR# Time contacted: Time Evaluated: ____________ Team contacting: □ ED □ PALS □ MICU □ other:________________ Team contacted :□ silver □ day call □ float Pt admitted to: □ None □ IM □ MICU □ oncology □ other:___________ Pt admitted by: □ silver □ day call □ night float Room PCP One liner: MR# Time contacted: Time Evaluated: ____________ Team contacting: □ ED □ PALS □ MICU □ other:________________ Team contacted :□ silver □ day call □ night float Pt admitted to: □ None □ IM □ MICU □ oncology □ Pt admitted by: □ silver □ day call □ float Room PCP One liner:
MR# Time contacted: Time Evaluated: ____________ Team contacting: □ ED □ PALS □ MICU □ other:________________ Team contacted :□ silver □ day call □ night float Pt admitted to: □ None □ IM □ MICU □ oncology □ other:___________ Pt admitted by: □ silver □ day call □ night float Room PCP One MR# Time contacted: Time Evaluated: ____________ Team contacting: □ ED □ PALS □ MICU □ other:________________ Team contacted :□ silver □ day call □ float Pt admitted to: □ None □ IM □ MICU □ oncology □ other:___________ Pt admitted by: □ silver □ day call □ night float Room PCP One MR# Time contacted: Time Evaluated: ____________ Team contacting: □ ED □ PALS □ MICU □ other:________________ Team contacted :□ silver □ day call □ night float Pt admitted to: □ None □ IM □ MICU □ oncology □ Pt admitted by: □ silver □ day call □ night float Room PCP One liner: MR# Time contacted: Time Evaluated: ____________ Team contacting: □ ED □ PALS □ MICU □ other:________________ Team contacted :□ silver □ day call □ float Pt admitted to: □ None □ IM □ MICU □ oncology □ Pt admitted by: □ silver □ day call □ night float Room PCP One liner:
MR# Time contacted: Time Evaluated: ____________ Team contacting: □ ED □ PALS □ MICU □ other:________________ Team contacted :□ silver □ day call □ night float Pt admitted to: □ None □ IM □ MICU □ oncology □ other:___________ Pt admitted by: □ silver □ day call □ night float Room PCP One liner: MR# Time contacted: Time Evaluated: ____________ Team contacting: □ ED □ PALS □ MICU □ other:________________ Team contacted :□ silver □ day call □ night float Pt admitted to: □ None □ IM □ MICU □ oncology □ other:___________ Pt admitted by: □ silver □ day call □ night float Room PCP One liner: MR# Time contacted: Time Evaluated: ____________ Team contacting: □ ED □ PALS □ MICU □ other:________________ Team contacted :□ silver □ day call □ night float Pt admitted to: □ None □ IM □ MICU □ oncology □ other:___________ Pt admitted by: □ silver □ day call □ night float Room PCP One liner: MR# Time contacted: Time Evaluated: ____________ Team contacting: □ ED □ PALS □ MICU □ Team contacted :□ silver □ day call □ night float Pt admitted to: □ None □ IM □ MICU □ oncology □ other:___________ Pt admitted by: □ silver □ day call □ float Room PCP One liner:
MR# Time contacted: Time Evaluated: ____________ Team contacting: □ ED □ PALS □ MICU □ other:________________ Team contacted :□ silver □ day call □ float Pt admitted to: □ None □ IM □ MICU □ oncology □ other:___________ Pt admitted by: □ silver □ day call □ night float Room PCP One liner: MR# Time contacted: Time Evaluated: ____________ Team contacting: □ ED □ PALS □ MICU □ Team contacted :□ silver □ day call □ night float Pt admitted to: □ None □ IM □ MICU □ oncology □ Pt admitted by: □ silver □ day call □ float Room PCP One liner: MR# Time contacted: Time Evaluated: ____________ Team contacting: □ ED □ PALS □ MICU □ other:________________ Team contacted :□ silver □ day call □ night float Pt admitted to: □ None □ IM □ MICU □ oncology □ other:___________ Pt admitted by: □ silver □ day call □ night float Room PCP One liner: