Admit Over 21 Form - CHCO Web Forms

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Request to Admit Patient Over 21 Years of Age

Complete all fields. The fields marked with * are required. This secure form will be used to request admission of a patient over 21 years of age to Children's Hospital Colorado.

Requesting Provider: *

You must enter the name of the requesting provider in the 'Requesting Provider' field.

Requesting Service: *

You must enter the requesting service in the 'Requesting Service' field.

Patient Name: *

You must enter the patient's full name in the 'Patient Name' field.

Medical Record Number: *

You must enter the patient's medical record number in the 'Medical Record Number' field.

Date of Birth: *

You must choose a date for the 'Date of Birth' field.

Age:

Anticipated Admission Date: *

You must choose a date for the 'Date of Admission' field.

Is this an elective admit for a procedure/operation? *

Yes

Other (add comments)

You must specify if this is an elective admit for a procedure/operation

Elective Admit Comments: *

You must enter comments about the elective admit in the 'Elective Admit Comments' field.

Anticipated Length of Stay: *

You must enter the patient's anticipated length of stay in the 'Anticipated Length of Stay' field.

Patient Diagnosis: *

You must enter the patient's diagnosis in the 'Patient Diagnosis' field.

Purpose of Admission/Planned Procedure: *

You must enter the purpose of admission/planned procedure in the 'Purpose of Admission' field.

Please choose/explain how CHCO offers a quality or safety advantage to the patient:*

Technology not available at adult/community hospital

Provider and/or care team expertise only available at CHCO

Other (add details)

You must choose/explain how CHCO offers a quality or safety advantage to the patient

Quality/Safety Advantage Details: *

You must enter details about why CHCO offers a quality or safety advantage to the patient in the 'Safety Advantage Detais' field.

Will other medical/surgical services be asked to consult on or care for the patient, including critical care?*

Yes (list services)

You must choose whether other medical/surgical services will be asked to consult

Medical/Surgical Services List: *

You must list the other medical/surgical services which will be asked to consult in the 'Medical Services' field.

Best practice at CHCO is for the primary admitting service to notify consulting services in advance of elective admissions of adult patients when those consults are anticipated and, where possible, arrange for outpatient consultation prior to admission. When post-operative critical care admission is requested, notify PICU medical staff in advance of admit.

Is an anesthesia preoperative visit indicated? *

Yes

You must choose if an anesthesia preoperative visit is indicated

For Patients requiring anesthesia either with complex disease or for any patient > 25years old, consultation with anesthesiology is strongly recommended.

To speak with anesthesia about utility of anesthesiology preoperative clinic for your patient, call 720-777-5337 between 0700-1600 Mon-Fri. To schedule a preoperative clinic visit, call 720-777-3001.

Requesting Provider Name: *

You must enter the requesting provider's full name in the 'Requesting Provider Name' field.

Requesting Provider Phone: *

You must enter the requesting provider's phone number in the 'Requesting Provider Phone' field.

Requesting Provider Email: *

You must enter the requesting provider's email address in the 'Requesting Provider Email' field. Requesting provider email address is invalid

Chief Medical Officer:

Date:

Chief Nursing Officer:

Date:

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