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:
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:
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