Saudi Electronic University Bacterial Meningitis Patient Worksheet

Please fill out the attached report for an inpatient medical record report for a patient who has been infected with bacterial meningitis

Neurology department Registration Form Patient Name: Nouf Alharbi MRN: DOB: Age: Gender: Telephone Number: Address: 1119630042 1-3-2003 19 F 0535683176 Dhahran Insurance company information (IF ANY) Company Name: Method Of Pay: Class: Date Of Expiry: Bupa Company Insurance Gold 1-3-2025 Neurology department Consent To Admission I voluntarily consent to the procedures and services that may be performed for me on an inpatient basis under the general and special instructions of my physician, and/or his/her assistant or designee. I understand that these procedures and services may include but are not limited to emergency treatment or services, laboratory procedures, imaging services, medical or surgical treatment or procedures, anaesthesia or hospital services. I understand that other conditions may be diagnosed which may require additional treatment. I authorize and consent to use of recordings, films, or other images of me (i.e., any photographic, video, electronic or audio media) for purposes of identification, diagnosis, or treatment in connection with the care provided to me. I am aware that the practice of medicine is not an exact science, and I acknowledge that no guarantees have been made to me as to the result of any treatment or examinations provided by UT Southwestern. I acknowledge that any supplies, medical devices, or other goods sold or given to me are provided “as is”, and that UT Southwestern disclaims any express or implied warranties related thereto. Patient Name: Nouf Alharbi Patient Relative: Amnah Alharbi signature: Signature: Health Care Provider: Khalid Alharbi Signature: Neurology department Discharge Summary Room:123 Admission Date: 16-11-2022 Discharge Date : 17-11-2022 Admission Diagnosis: Blood Cultures Discharge Diagnosis: Spinal Tap Summary Physician authentication : Neurology department History And Physical Chief complaint: Present Of Illnesses: Family History: Social History: Physician Authentication: Neurology department Progress Note Date: Time: Chief complaint: left flank pain; fever. Diagnosis: pyelonephritis; rule out renal calculus Plan of Treatment: Admit. Hydration with intravenous Ancef. Reviewed and Approved: John Black MD ATPB-S:02:1001261385: John Black MD (Signed: 4/27/YYYY 2:50:55 PM EST) Neurology department Laboratory Report Test Result Physician Authentication: Neurology department Radiology Report Neurology department Medication List