WLAVA:Enhanced Screening Tent Template

CC: |PATIENT AGE|

HPI:

REFERRED BY:
[ ] Self
[ ] Failed primary screen
[ ] Primary care provider
[ ] Other: (free text box)

SYMPTOM SCREEN (select all that apply):
[ ] Subjective fevers/chills or T > 99.9F
[ ] Cough (new or worse than usual)
[ ] Sore throat (new or worse than usual)
[ ] Shortness of breath or trouble breathing (new or worse than usual)
[ ] Body or muscle aches (new or worse than usual)
[ ] Diarrhea (new or worse than usual)
[ ] Severe fatigue
[ ] Other: (free text box)

EXPOSURE SCREEN:
[ ] Close contact with CONFIRMED COVID19 case (within 14 days of Sx onset)
[ ] Close contact with patients of a respiratory illness outbreak in last 3 days
[ ] Healthcare worker (including EMT, paramedic, etc)
[ ] Lives in a long-term care facility (CLC, CalVet, New Vista, community SNF, etc)
[ ] Lives in a group living facility (homeless shelter, board & care, DOM, New Directions, US Vets, etc)
[ ] Patient gets chronic care in healthcare facility (i.e., dialysis or chemotherapy patient)

SOCIAL HISTORY:
[ ] Domiciled in private residence
[ ] Undomiciled (includes living in tent, car, etc)
[ ] Domiciled in long-term care facility (auto populate if selected above in exposure screen?)
[ ] Domiciled in group living facility (auto populate if selected above in exposure screen?)

PMHx:
ACTIVE PROBLEMS
|ACTIVE PROB LIST-SHORT|

ALLERGIES:
|ALLERGIES|

VITALS:
T: |TEMPERATURE|
P: |PULSE|
R: |RESPIRATION|
BP:|BLOOD PRESSURE|
Pain: |PAIN|
Pulse Ox: |PULSE OXIMETRY|

PHYSICAL EXAM:
GEN: Well-appearing, No apparent distress
Resp: Normal work of breathing, speaking in complete sentences
Neuro: A&Ox3, Gait: steady, moving all extremities, no gross focal deficits

ASSESSMENT:
Patient is afebrile and with unremarkable respiratory vital signs. Patient at baseline ambulatory status,
non-toxic appearing, and speaking in full sentences. Based on the limited examination there is a low
suspicion for serious bacterial infection or systemic illness.
[ ] COVID-19 suspected, met testing criteria.
[ ] COVID-19 suspected, did not meet testing criteria.
[ ] COVID-19 suspected, testing refused.
[ ] COVID-19 not suspected.
[ ] Other: (free text box)

PLAN: [ ] Encouraged patient to continue with symptom alleviation.
[ ] Encouraged to return if has significant worsening of symptoms including chest pain, shortness of
breath, or inability to care for self.

DISPOSITION:
[ ] If no concern for COVID, allowed to enter medical center
[ ] Home
[ ] Long-term care facility (i.e., CLC, CalVet, New Vista, community SNF, etc)
[ ] Building 214 “COVID” DOM
[ ] VA Homeless Housing Program (i.e., Grant Per Diem, DOM, New Directions, etc.)
[ ] Other group living facility (i.e., shelter, board & care, assisted living facility etc.)
[ ] ED attending consult for help with disposition: (text box for name)
[ ] Escorted to ED (critically ill)
[ ] Directly Admitted
[ ] Other: (free text box)

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