Patient Information Patient Name Date of SME SME Clinician Phone Obstetric Hemorrhage Severe Hypertension/Preeclampsia SME Type Venous Thromboembolism Other: List Pregnancy Outcome Postpartum Discharge Weight Mom Live Birth Stillbirth NICU Baby GA (in weeks) Birthweight Length Clinical Summary Date Type Surgery Organs removed List Yes No Date Interventional Type Radiology Result Yes No Date Imaging Tests Type Result Red Blood Cells Platelets Plasma Type of Blood Products Blood Transfusion # of units #___ Red Blood Cells #___ Platelets #___ Plasma Medical Treatments List Follow-up Clinician Name Phone Pathology/Autopsy Phone For further information, please contact the Hospital Medical Record Office to request your complete medical record. Medical Record Office Phone Notes Reference:
Patient Information Patient Name Date of SME SME Clinician Phone SME Type Obstetric Hemorrhage Severe Hypertension/Preeclampsia Venous Thromboembolism Other: List Mom Pregnancy Outcome Live Birth Stillbirth NICU Postpartum Discharge Weight Baby GA (in weeks) Birthweight Length Clinical Summary Surgery Date Type Organs removed List Interventional Radiology Yes No Date Type Result Imaging Tests Yes No Date Type Result Blood Transfusion Type of Blood Products Red Blood Cells Platelets Plasma # of units #___ Red Blood Cells #___ Platelets #___ Plasma Medical Treatments List Follow-up Clinician Name Phone Pathology/Autopsy Phone For further information, please contact the Hospital Medical Record Office to request your complete medical record. Medical Record Office Phone Notes Reference:
SME-Patient-Clinical-Summary_v2-17-2016.docx