☐ TELEPHONE RECORD PRIORITY PATIENT AGE MESSAGE CALLER TELEPHONE REFERRED TO TEMP ALLERGIES CHART # RESPONSE ☐ ☐ CHART ATTACHED YES NO DATE TIME REC’D BY PHY/RN INITIALS DATE / / TIME INITIALS / / ☐ TELEPHONE RECORD PRIORITY PATIENT AGE MESSAGE CALLER TELEPHONE REFERRED TO TEMP ALLERGIES CHART # RESPONSE ☐ ☐ CHART ATTACHED YES NO DATE TIME REC’D BY PHY/RN INITIALS DATE / / TIME INITIALS / / ☐ TELEPHONE RECORD PRIORITY PATIENT AGE MESSAGE CALLER TELEPHONE REFERRED TO TEMP ALLERGIES CHART # RESPONSE ☐ ☐ CHART ATTACHED YES NO DATE TIME REC’D BY PHY/RN INITIALS DATE / / TIME INITIALS / / FORM (3-6)
PRIORITY ☐ PATIENT AGE CALLER TELEPHONE REFERRED TO CHART # CHART ATTACHED ☐ YES ☐ NO DATE TIME REC’D BY / / TELEPHONE RECORD MESSAGE TEMP ALLERGIES RESPONSE PHY/RN INITIALS DATE / / TIME INITIALS PRIORITY ☐ PATIENT AGE CALLER TELEPHONE REFERRED TO CHART # CHART ATTACHED ☐ YES ☐ NO DATE TIME REC’D BY / / TELEPHONE RECORD MESSAGE TEMP ALLERGIES RESPONSE PHY/RN INITIALS DATE / / TIME INITIALS PRIORITY ☐ PATIENT AGE CALLER TELEPHONE REFERRED TO CHART # CHART ATTACHED ☐ YES ☐ NO DATE TIME REC’D BY / / TELEPHONE RECORD MESSAGE TEMP ALLERGIES RESPONSE PHY/RN INITIALS DATE / / TIME INITIALS FORM (3-6)
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