Please enable JavaScript in your browser to complete this form. How Symptoms and Individual's Name *Date of Hospitalization *Name of Person Completing Form *Title *Contact Information *Date Form Completed *MUI Number *Provider: *History/Antecedents *Please list what led to the hospitalization and the medical history of the individual. Have there been recent similar illnesses? What was the health of the individual in the 72 hours leading up to the hospitalization?Type of Hospitalization *MedicalPsychiatricHow many days was the individual in the hospital? *Reason for Hospitalization (Mark all that apply) *Abdominal PainsAbnormal Blood LevelsAbsent PulseAllergic ReactionAltered StateBaclofen Pump Issues BloodPressureBlood Sugar LevelsBody Temperature VariationsBowel ObstructionCancerChest PainsDebucitus UlcerDehydration/Volume DepletionEdemaEmesis (vomiting/diarrhea)GallbladderGeneralized PainHeart ProblemsImpaired RespirationInfectionIngestion- PICAKidneyMedical ErrorObservation/EvaluationPlaced item in OrificePneumonia and InfluenzaSeizuresShuntStrokeSyncope UncontrollableBleedingOther (explain below)Reason for HospitalizationIf you selected “other” in the question above, please explain here.Symptoms and Response *What were the individual’s symptoms – over what length of time – and what was the response?Diagnosis & Discharge Summary *Please describe in detail the individual’s diagnosis and discharge summary. Please attach discharge summary.Follow-Up Appointments/Changes to Medications/Continuing Care *Please list the changes and the continuing needs of the individual along with the person responsible for these. Please attach discharge paperwork and follow-up appointment outcomes.Cause and Contributing Factors *Medication ChangeChoked on FoodMedication ErrorFall-Due to Environmental FactorsFall- Due to Mobility IssuesAspiration Due to Improper Diet TextureFailure to Provide Timely Medical CareStaff Did Not Monitor Input/Output of FluidsOther (explain below)Cause and Contributing Factors – OtherPlease explain “other” if applicableInvestigative Agent Review *Comments & QuestionsIA Name *Review Completed Date *Submit
