The Simple Admit form
Accident: Patients may be treated for injuries or conditions due, in part or in full, to an accident, such as a motor vehicle accident, an accident at home, an accident involving third parties, or a job-related accident.
Admitting Physician: The name of the doctor responsible for admitting the patient to a hospital or other health facility.
Advance Directive: Written ahead of time, a health care advance directive is a written document that says how the patient wants medical decisions to be made if they lose the ability to make decisions for themselves. A health care advance directive may include a Living Will and a Durable Power of Attorney for health care.
Angina: Angina is chest pain or discomfort that occurs if an area of your heart muscle doesn't get enough oxygen-rich blood. Angina may feel like pressure or squeezing in your chest. The pain also can occur in your shoulders, arms, neck, jaw, or back. Angina pain may even feel like indigestion.
Beneficiary: The name for a person who has health insurance through Medicare or an insurance plan.
Birth Date: Enter the patient's, guarantor's, or subscriber's birth date in MM/DD/YYYY format, where MM is the birth month, DD is the birth day, and YYYY is the birth year. Insurance priority is sometimes determined by birth date order in the calendar year.
C. Diff A species of bacteria that causes severe diarrhea and other intestinal disease when competing bacteria in the gut flora have been wiped out by antibiotics.
Colitis Refers to an inflammation of the inner lining of the colon.
COPD (Chronic Obstructive Pulmonary Disease): is a term used to describe a disease that interferes with normal breathing and gets worse slowly over time. COPD includes chronic bronchitis and emphysema. Often, people have both.
Description of Accident: Describe the accident in a written account. Include information about what happened, what part(s) of the body was/were injured, and where the accident happened.
Diagnosis or Complaint: The reason the patient is being treated. Include the name that describes the health problem for which the patient is being admitted. Include the body site that is affected (e.g. left forearm or right side of lower back).
Drug-eluting stent: A drug-eluting cardiac stent is a regular metal stent that has been coated with a type of medication that is known to decrease the process of restenosis (blockage) in the artery.
Employment Status: Identify the employment status of the patient, the subscriber, or the guarantor. Options may include: Employed Full Time, Employed Part Time, Unemployed, Self-Employed, Retired, Active Military Duty; Student.
End-Stage Renal Disease (ESRD): Permanent kidney failure that is severe enough to require lifetime kidney dialysis or a kidney transplant.
Ethnicity: Ethnic character, background, or affiliation; an ethnic group; of or relating to a sizable group of people sharing a common and distinctive racial, national, religious, linguistic, or cultural heritage.
Group Name: Enter the name of the insurance group or plan defined for the patient's account. Please refer to the insurance card for this information. Group name may include letters, numbers, and spaces.
Group Number: Enter the identification number or code used for group coverage by the carrier or administration to identify the patient's insurance group. Please refer to the insurance card for this information. The group number may include letters, numbers, and spaces.
Guarantor: The person who ultimately accepts financial responsibility to pay the patient's bill. In most cases it is the adult patient receiving the service. If the patient is a child, the responsible party may be the child's parent or legal guardian. The guarantor should not be confused with the subscriber of the insurance policy. This may or may not be the same person.
Health Care Proxy: A legal document in which an individual designates another person to make health care decisions if he or she is rendered incapable of making their wishes known.
Inpatient/Outpatient Service: The patient is considered an inpatient if his/her doctor has indicated the patient will be admitted to remain in a hospital bed for one or more days. Outpatients require a stay of less than 24 hours and procedures are typically done in an outpatient department.
Insurance Information: Policy/Claim Number, Plan Group Number, and Group Name may be found on the subscriber's insurance card.
Insurance Name: Enter the name of the insurance company that issued the policy. Please refer to the insurance card for this information. This information is generally found on the back of the insurance card near the claims mailing address. Materials you may need to complete the insurance registration: All applicable Health Insurance cards or documents that include the insurance company name, insurance policy number, and insurance billing address, and insurance phone numbers; Birth dates, names, resident mailing addresses and phone numbers of the patient, subscriber, and guarantor; Employer names, employer addresses and employer phone numbers for the patient, subscriber and guarantor; Name and address and phone number of person who is the Emergency/Primary contact for the patient.
Malignant Hyperthermia: Malignant hyperthermia is a disease passed down through families that causes a fast rise in body temperature (fever) and severe muscle contractions when the affected person gets general anesthesia.
Medicare: A federal program of healthcare insurance for the aged, totally disabled, and those with end-stage renal disease. Medicare Part A pays for hospital services. Medicare Part B is the voluntary part of Medicare that pays a percentage of reasonable and customary costs for physician and ancillary services.
MRSA: Methicillin-resistant Staphylococcus aureus (MRSA) is a type (strain) of staph bacteria that does not respond to some antibiotics that are commonly used to treat staph infection
Occupation: Enter the patient's, guarantor's, or subscriber's occupation or job title, as requested. Enter a specific occupation, such as teacher, doctor, carpenter, etc. Homemaker and student are valid occupations. Enter the name and address of the student's school in the Employer field. Self-employed people should include their type of work.
Primary Care Physician/Personal Care Physician: In an HMO plan, the PCP is responsible for providing covered healthcare services and for coordinating referrals to other network providers when specialized care is required. The PCP may be trained in family practice, internal medicine, pediatrics, or general practice.
Pedal Edema: Swelling of the feet and ankles.
Policy Number: Enter the policy number for the patient's insurance plan. Please refer to the insurance card for this information. For Medicare plans, enter the patient's Medicare number. For all other plans, enter the insurance plan policy number. The answer can include letters, numbers, and spaces.
Pre-registration: The process of collecting paient information before the time of service. This allows for more accurate insurance billing and shorter wait times at the medical facility.
Primary Insurance or Primary Payer: An insurance policy, plan, or program that pays first on a claim or bill from the hospital for medical care. This could be Medicare or other commercial health insurance.
Prior Admission Date: Enter the admission date of the patient's last hospital stay; the day the patient began their last hospital inpatient stay.
Prior Discharge Date: Enter the discharge date of the patient's last hospital stay; the day the patient went home from their last hospital inpatient stay.
Prior Stay: Has the patient been admitted to a hospital previously? If yes, provide the name of the most recent facility and dates of admission and discharge from that facility.
Procedure: Something done to fix a health problem or to learn more about it; for example, surgery, tests, and putting in an IV (intravenous line) are procedures.
Provider: A doctor, hospital, health care professional, or health care facility.
Pseudocholinesterase Deficiency: A condition that results in increased sensitivity to certain muscle relaxant drugs used during general anesthesia. People affected by this condition may not be able to move or breathe on their own for a few hours after the drugs are administered, and they generally require the assistance of mechanical ventilation devices to help them breathe until the drugs are cleared from the body.
Referral: Approval from the patient's primary care doctor for the patient to see a specialist or get certain services. In many managed care plans, the patient needs to get a referral before he/she gets care from anyone except their primary care doctor. If they do not get a referral first, the plan may not pay for their care.
Relationship to Patient: Enter the emergency or primary contact's relationship to the patient. The selections may include: Mother, Sibling, Father, Friend, Spouse, Grandparent, Emancipated Minor, Child, Legal Guardian, Grandchild, Other.
Religion: Enter the patient's religious preference.
Required Answers: Required fields are indicated by an asterisk to the left of the field description. An answer must be entered for each of these fields. The information is necessary for on-line pre-registration. If you do not have the required information, please gather the information before proceeding. The computer will not submit the registration without this data.
Secondary Insurance or Payer: An insurance policy, plan, or program that pays second on a claim or bill from the hospital for medical care. This could be Medicare, Medicaid, or other health insurance depending on the situation.
Sleep Apnea: Abnormal pauses in breathing or instances of abnormally low breathing during sleep.
Sexually Transmitted Disease (STD): Sexually transmitted diseases (STDs) are infections that you can get from having sex with someone who has the infection. The causes of STDs are bacteria, parasites and viruses. Most STDs affect both men and women, but in many cases the health problems they cause can be more severe for women. If a pregnant woman has an STD, it can cause serious health problems for the baby. If you have an STD caused by bacteria or parasites, your health care provider can treat it with antibiotics or other medicines. If you have an STD caused by a virus, there is no cure. Sometimes medicines can keep the disease under control. Correct usage of latex condoms greatly reduces, but does not completely eliminate, the risk of catching or spreading STDs.
Subscriber: The individual who signs and is responsible for a contract with a health insurance plan. The subscriber is the person subscribing to the insurance plan for the patient. The subscriber is different from the enrollee, who is defined as anyone covered under the contract.
Temporomandibular Joint Syndrome(TMJ): A disorder of the jaw muscles and nerves caused by injury to the temporomandibular joint.
Type of Outpatient Service: Select the type of procedure for which the patient is seeking services, whether inpatient or outpatient care.
Vancomycin-Resistant Enterococci (VRE): Vancomycin-resistant enterococci (VRE) are a type of bacteria called enterococci that have developed resistance to many antibiotics, especially vancomycin.
Worker's Compensation: Insurance that employers are required to have to cover employees who get sick or injured on the job while performing job-related duties.
Carbapenem-resistant Enterobacteriaceae (CRE): CRE are a part (or subgroup) of Enterobacteriaceae that are difficult to treat because they are resistant to commonly used antibiotics. Occasionally CRE are completely resistant to all available antibiotics. CRE cause a variety of diseases, ranging from pneumonia to urinary tract infections, to serious bloodstream or wound infections. The symptoms vary depending on the disease.
Cirrhosis: A chronic disease of the liver marked by degeneration of cells, inflammation, and fibrous thickening of tissue. It is typically a result of alcoholism or hepatitis.
Hiatal Hernia: The term hiatal hernia describes a condition where a part of the stomach that normally is located in the abdominal cavity pushes or protrudes through the esophageal hiatus to rest within the chest cavity.
Congestive Heart Failure (CHF): Congestive heart failure (CHF) is a chronic progressive condition that affects the pumping power of your heart muscles. While often referred to simply as "heart failure", CHF specifically refers to the stage in which fluid builds up around the heart causing it to pump inefficiently.
Peripheral Vascular Disease (PVD): Peripheral vascular diseases (PVDs) are circulation disorders that affect blood vessels outside of the heart and brain. PVD typically strikes the veins and arteries that supply the arms, legs, and organs located below your stomach. These are the blood vessels that are distant from the heart. They are known as peripheral vessels.
In PVD, blood vessels are narrowed. Narrowing is usually caused by arteriosclerosis. Arteriosclerosis is a condition where plaque builds up inside a vessel. It is also called "hardening of the arteries." Plaque decreases the amount of blood and oxygen supplied to the arms and legs.
Coronary Artery Disease (CAD): Coronary heart disease is a common term for the buildup of plaque in the heart�s arteries that could lead to heart attack.
Atrial Fibrillation: Atrial fibrillation is an irregular heartbeat that increases the risk of stroke and heart disease. Signs include dizziness, weakness, and fatigue. Treatment involves medication and lifestyle changes, and sometimes procedures such as cardioversion, ablation, pacemakers, or surgery.
Barrett's Esophagus: Barrett's esophagus is a serious complication of GERD, which stands for gastroesophageal reflux disease. In Barrett's esophagus, normal tissue lining the esophagus -- the tube that carries food from the mouth to the stomach -- changes to tissue that resembles the lining of the intestine. About 10% of people with chronic symptoms of GERD develop Barrett's esophagus.
Esophageal Stricture: An esophageal stricture is a narrowing of the esophagus, the passageway from the throat to the stomach. Stomach acid, accidentally swallowed harsh chemicals, and other irritants may injure the esophageal lining, causing inflammation (esophagitis) and the formation of scar tissue.
What is Latex? Latex can be natural or synthetic. It is found in the milky fluid that exists in about 10% of angiosperms (flowering plants). Latex is a complex emulsion (mixture of at least two liquids that are normally unblendable), consisting of resins, tannins, oils, sugars, starches, alkaloids, proteins and gums that go hard when exposed to air. Plants usually exude latex after there are injured, rather like a human bleeds after a skin lesion. Natural latex is usually white, but can be scarlet, orange, and yellow. Plants use latex as a defense against insects.
What is a Latex Allergy? Latex allergy is a term that describes the range of allergic reactions to substances in natural latex. An allergy is a hypersensitivity disorder of the immune system. Allergic reactions appear when a person's immune system reacts to nontoxic substances in the environment, in this case latex.
Atherosclerotic Cardiovascular Disease Atherosclerosis is characterized by thickening of the walls of the arteries, a process that occurs slowly and 'silently' over decades. This prolonged course of disease provides a window of opportunity for diagnosis before symptoms occur. But, until recently, only advanced atherosclerotic disease could be observed. Now, developments in imaging technology offer many enticing prospects, including detecting atherosclerosis early, grouping individuals by the probability that they will develop symptoms of atherosclerosis, assessing the results of treatment and improving the current understanding of the biology of atherosclerosis.
Angioplasty Angioplasty and related techniques are known as percutaneous coronary intervention (PCI). Angioplasty is a procedure in which a narrowed section of the coronary artery is widened. Angioplasty is less invasive and has a shorter recovery time than bypass surgery, which is also done to increase blood flow to the heart muscle but requires open-chest surgery. Most of the time stents are placed during angioplasty.
An angioplasty is done using a thin, soft tube called a catheter. A doctor inserts the catheter into a blood vessel in the groin or wrist. The doctor carefully guides the catheter through blood vessels until it reaches the narrowed or blocked portion of the coronary artery.
Cardiac catheterization, also called coronary angiography, is done first to find where the artery is narrowed or blocked.
Cardiac Dysrhythmia A cardiac dysrhythmia is an abnormal heart beat: the rhythm may be irregular in its pacing or the heart rate may be low or high. Some dysrhythmias are potentially life threatening while other dysrhythmias (such as sinus arrhythmia) are normal.
Stomach ulcers Stomach ulcers are painful sores that can be found in the stomach lining or small intestine. Stomach ulcers are the most visible sign of peptic ulcer disease. They occur when the thick layer of mucus that protects your stomach from digestive juices is reduced, thus enabling the digestive acids to eat away at the lining tissues of the stomach.
Stomach ulcers aren�t necessarily caused by one single factor. The decrease in the stomach�s mucus lining that leads to an ulcer is usually caused by one of the following:
GERD/Acid Reflux Gastroesophageal Reflux Disease, or GERD, is a digestive disorder that affects the lower esophageal sphincter (LES), the ring of muscle between the esophagus and stomach.
In normal digestion, the lower esophageal sphincter (LES) opens to allow food to pass into the stomach and closes to prevent food and acidic stomach juices from flowing back into the esophagus. Gastroesophageal reflux occurs when the LES is weak or relaxes inappropriately, allowing the stomach's contents to flow up into the esophagus.
Many people, including pregnant women, suffer from heartburn or acid indigestion caused by GERD. Doctors believe that some people suffer from GERD due to a condition called hiatal hernia. In most cases, GERD can be relieved through diet and lifestyle changes; however, some people may require medication or surgery.
Deep Vein Thrombosis (DVT) Deep vein thrombosis (DVT) occurs when a blood clot (thrombus) forms in one or more of the deep veins in your body, usually in your legs. Deep vein thrombosis can cause leg pain or swelling, but may occur without any symptoms.
Deep vein thrombosis can develop if you have certain medical conditions that affect how your blood clots. Deep vein thrombosis can also happen if you don't move for a long time, such as after surgery, following an accident, or when you are confined to a hospital or nursing home bed.
Deep vein thrombosis is a serious condition because blood clots in your veins can break loose, travel through your bloodstream and lodge in your lungs, blocking blood flow (pulmonary embolism).
Pulmonary Embolism (PE) Pulmonary embolism symptoms can vary greatly, depending on how much of your lung is involved, the size of the clots, and whether you have underlying lung or heart disease.
Common signs and symptoms include:
Shortness of breath. This symptom typically appears suddenly and always gets worse with exertion.
Chest pain. You may feel like you're having a heart attack. The pain may become worse when you breathe deeply (pleurisy), cough, eat, bend or stoop. The pain will get worse with exertion but won't go away when you rest.
Cough. The cough may produce bloody or blood-streaked sputum.
Gastritis Gastritis is an inflammation, irritation, or erosion of the lining of the stomach. It can occur suddenly (acute) or gradually (chronic). It can be caused by irritation due to excessive alcohol use, chronic vomiting, stress, or the use of certain medications such as aspirin or other anti-inflammatory drugs. It may also be caused by any of the following:
Diverticulosis Diverticulosis happens when pouches form in the wall of the colon. If these pouches get inflamed or infected, it is called diverticulitis. Diverticulitis can be very painful.
Doctors aren't sure what causes diverticula in the colon (Diverticulosis). But they think that a low-fiber diet may play a role. Without fiber to add bulk to the stool, the colon has to work harder than normal to push the stool forward. The pressure from this may cause pouches to form in weak spots along the colon.
Symptoms of diverticulitis may last from a few hours to a week or more. Symptoms include:
Ulcerative Colitis Ulcerative colitis is an inflammatory bowel disease (IBD) that causes long-lasting inflammation and ulcers (sores) in your digestive tract. Ulcerative colitis affects the innermost lining of your large intestine (colon) and rectum. Symptoms usually develop over time, rather than suddenly.
Ulcerative colitis can be debilitating and sometimes can lead to life-threatening complications. While it has no known cure, treatment can greatly reduce signs and symptoms of the disease and even bring about long-term remission.
Irritable Bowel Syndrome Irritable bowel syndrome (IBS) is a common disorder that affects the large intestine (colon). Irritable bowel syndrome commonly causes cramping, abdominal pain, bloating, gas, diarrhea and constipation. IBS is a chronic condition that you will need to manage long term.
Even though signs and symptoms are uncomfortable, IBS � unlike ulcerative colitis and Crohn's disease, which are forms of inflammatory bowel disease � doesn't cause changes in bowel tissue or increase your risk of colorectal cancer.
Only a small number of people with irritable bowel syndrome have severe signs and symptoms. Some people can control their symptoms by managing diet, lifestyle and stress. Others will need medication and counseling.
Sickle Cell: Sickle cell disease: A genetic blood disorder caused by the presence of an abnormal form of hemoglobin. These hemoglobin molecules tend to aggregate after unloading oxygen forming long, rod-like strictures that force the red cells to assume a sickle shape. Unlike normal red cells, which are usually smooth and malleable, the sickle red cells cannot squeeze through small blood vessels. When the sickle cells block small blood vessels, the organs are deprived of blood and oxygen. This leads to periodic episodes of pain and damages the vital organs. Sickle red cells die after only about 10 to 20 days. Instead of the usual 120 days or so. Because they cannot be replaced fast enough, the blood is chronically short of red cells, causing anemia. The gene for sickle cell anemia must be inherited from both parents for the illness to occur in children. A child with only one copy of the gene may have sickle-cell traits but no symptoms of illness.
HIV: HIV stands for human immunodeficiency virus. It is the virus that can lead to acquired immunodeficiency syndrome, or AIDS, if not treated. Unlike some other viruses, the human body can�t get rid of HIV completely, even with treatment. So once you get HIV, you have it for life.
HIV attacks the body�s immune system, specifically the CD4 cells (T cells), which help the immune system fight off infections. Untreated, HIV reduces the number of CD4 cells (T cells) in the body, making the person more likely to get other infections or infection-related cancers. Over time, HIV can destroy so many of these cells that the body can�t fight off infections and disease. These opportunistic infections or cancers take advantage of a very weak immune system and signal that the person has AIDS, the last stage of HIV infection.
Information in part from St. Joseph's Hospital and Medical Center.