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DATE: |
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ROLE: □ Attending □ Fellow □ RN □ APRN |
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| CONTACT # |
IN/OUT |
START TIME |
CALLER |
AGE |
DIAGNOSIS |
PHONE CALL |
E-MAIL |
E-MESSAGING |
REASON |
LANGUAGE |
END TIME |
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□ Parent □ Patient □ Insurance □ School □ Clinic □ VNA □ Floor □ Outside Provider □ Resp Provider □ Other: |
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□ Asthma □ BPD □ CF □ Sleep □ Other: |
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□ |
□ |
□ Sick □ Refill □ Scheduling □ Insurance/Prior Auth □ Update □ Results □ Other: |
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□ Parent □ Patient □ Insurance □ School □ Clinic □ VNA □ Floor □ Outside Provider □ Resp Provider □ Other: |
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□ Asthma □ BPD □ CF □ Sleep □ Other: |
□ |
□ |
□ |
□ Sick □ Refill □ Scheduling □ Insurance/Prior Auth □ Update □ Results □ Other: |
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□ Parent □ Patient □ Insurance □ School □ Clinic □ VNA □ Floor □ Outside Provider □ Resp Provider □ Other: |
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□ Asthma □ BPD □ CF □ Sleep □ Other: |
□ |
□ |
□ |
□ Sick □ Refill □ Scheduling □ Insurance/Prior Auth □ Update □ Results □ Other: |
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□ Parent □ Patient □ Insurance □ School □ Clinic □ VNA □ Floor □ Outside Provider □ Resp Provider □ Other: |
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□ Asthma □ BPD □ CF □ Sleep □ Other: |
□ |
□ |
□ |
□ Sick □ Refill □ Scheduling □ Insurance/Prior Auth □ Update □ Results □ Other: |
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□ Parent □ Patient □ Insurance □ School □ Clinic □ VNA □ Floor □ Outside Provider □ Resp Provider □ Other: |
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□ Asthma □ BPD □ CF □ Sleep □ Other: |
□ |
□ |
□ |
□ Sick □ Refill □ Scheduling □ Insurance/Prior Auth □ Update □ Results □ Other: |
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□ Parent □ Patient □ Insurance □ School □ Clinic □ VNA □ Floor □ Outside Provider □ Resp Provider □ Other: |
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□ Asthma □ BPD □ CF □ Sleep □ Other: |
□ |
□ |
□ |
□ Sick □ Refill □ Scheduling □ Insurance/Prior Auth □ Update □ Results □ Other: |
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□ Parent □ Patient □ Insurance □ School □ Clinic □ VNA □ Floor □ Outside Provider □ Resp Provider □ Other: |
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□ Asthma □ BPD □ CF □ Sleep □ Other: |
□ |
□ |
□ |
□ Sick □ Refill □ Scheduling □ Insurance/Prior Auth □ Update □ Results □ Other: |
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□ Parent □ Patient □ Insurance □ School □ Clinic □ VNA □ Floor □ Outside Provider □ Resp Provider □ Other: |
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□ Asthma □ BPD □ CF □ Sleep □ Other: |
□ |
□ |
□ |
□ Sick □ Refill □ Scheduling □ Insurance/Prior Auth □ Update □ Results □ Other: |
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