Fillable OMH PC COVID-19 Screening Admissions Form - March 23, 2020

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NOVEL CORONAVIRUS (COVID-19) SCREENING FORM - March 23, 2020

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The OMH PC COVID-19 Screening Admissions Form - March 23, 2020 form is 5 pages long and contains:

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1
NOVEL CORONAVIRUS (COVID-19) SCREENING FORM
For Admi
ssion to NYS OMH Adult, Forensic, and Child Psychiatric Center's Inpatient Services
Please fill out the screening form below and sign at the bottom once completed. PLEASE e-mail a copy of this
PDF to the PC through the Health Commerce System as you do with other clinical and administrative referral
documentation
Pati
ent Name:
Patient’s Date of Birth: ____________________________________________________________
1. Has the patient traveled internationally to a CDC-designated Level 2 or Level 3 country
within the last 14 days?
Yes No
If yes, please indicate where the patient traveled, whether the patient has been tested and
results (i.e., pending, COVID negative), and other pertinent information:
`
OMH Novel Coronavirus (COVID-19) Screening Form
2
2. Has the patient been in a domestic area of focus where COVID-19 prevalence is high within
the last 14 days? (e.g., New Rochelle, NY was designated for high focus on 3/10/20)
Yes No
If yes, please indicate where the patient traveled, whether the patient has been tested and
results (i.e., pending, COVID negative), and other pertinent information:
3. Has t
he patient had direct contact with a person confirmed to be positive for COVID-19?
Yes No
If yes,
please indicate what, if any, testing has been done to date:
OMH Novel Coronavirus (COVID-19) Screening Form
3
4. Is the patient experiencing any of the following symptoms?
Fever Yes No
If yes, please detail the last 36-hours of temperature recordings and current management
Sore throat Yes No
If yes, please detail symptom history and management:
OMH Novel Coronavirus (COVID-19) Screening Form
4
Cough Yes No
If yes, please detail symptom history and management:
Shortness of breath? Yes No
If yes, please detail symptom history and management:
OMH Novel Coronavirus (COVID-19) Screening Form
5
If yes, does the patient have comorbid pulmonary conditions? If so, please detail:
Name of the Referring Facility: ______________________________________________________
Name of the Referring Physician/Nurse Practitioner: _____________________________________
_______________________________________________________________________________
Contact Number of Referring Physician / Nurse Practitioner: _______________________________
Referring Physician/Nurse Practitioner Signature: _______________________________________
Date of Completion: ______________________________________________________________
Time of Completion (Please use military time, e.g., 14:06): ________________________________
Version 3.23.2020
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OMH PC COVID-19 Screening Admissions Form - March 23, 2020

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Completed 26 March 2020

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