20 Park Avenue, Suite 1A (@35th St.), New York, NY 10016 - Tel.: 646.957.5444 (Please note: No insurances, Medicare, or Medicaid accepted)

The First Public Demonstration of Surgical Anesthesia
(Boston, October 16, 1846)

NURSE AND MEDICAL ASSISTANT NOTE

Patient Name:

Patient Date of Birth:

Purpose of Visit:

Allergies to Medicines

Vital Signs Before Procedure: :

Temp:

Pulse

Height

Weight

Treatment Note: The procedure or test I am performing has been reviewed with this patient by a physician and has been consented to by the patient of their health care proxy or their guardian. Any procedures performed when medically necessary are under the direct supervision of a physician. CHECK BELOW

Yes:

Procedure Performed:

Vital signs after procedure:

Temp:

Pulse

Height

Weight

Medication (s) Dispensed &/or Injected (include Name of Medication, Lot #, Expiration Date, Quantity):

	ICD-9 Codes (check all that apply): Back Pain (724.5) Bronchitis, Acute (466.0) Cough (786.2) Diarrhea (787.91) Dizzyness/Vertigo (780.4) Fatigue (780.79) Fever (780.6) Nausea (787.01) Pharyngitis (462) UTI (595.0) Other ICD-9: CPT Codes (Check all that apply): Blood Draw (36415) IV for dehydration-up to 1 hour (90760) IV for dehydration more that 1 hour (90761) IV for medicine or vitamin administration-up to 1 hour (90765) IV for medicine or vitamine administration - more than 1 hour (90766) Home visit for injection (99506) Urine Bladder Catheder Insertion (5172) Other: Please specify below:
	Medical Provide Name:
	Medical Provider Signature: (Please put slashes to verify signature, f or example: /Natan Schleider, M. D. /)
	Date of Medical Service:
	Today's Date:

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