Healthcare Monitoring Report

HEALTHCARE MONITORING REPORT

Patient Information

Patient Name:     Date of Birth:     Gender:

Primary Phone:     Email:

Emergency Contact

Insurance & Coverage

Policy Number:     Group Number:     Subscriber Name:

Monitoring Assignment

Facility / Service Location:     Contact Phone:

Monitoring Start Date:     Expected End Date:     Frequency:

Vital signs     Glucose     ECG / Cardiac rhythm     Activity / Fall monitoring     Respiratory     Other:

Clinical Observations (Documented Entries)

Observation 1 — Date: Time:

Observation 2 — Date: Time:

Observation 3 — Date: Time:

Incident / Adverse Event Occurred:

Medications & Clinical Status

Assessment, Plan & Notifications

Notifications Sent To (name and role):     Notification Date/Time:

Legal Acknowledgments & Authorization

By signing below, the patient or authorized representative certifies that the information contained in this Healthcare Monitoring Report is true and accurate to the best of their knowledge. The patient authorizes the healthcare provider and their agents to collect, record, transmit, store, and disclose monitoring data for treatment, care coordination, and quality assurance consistent with applicable law. The patient understands that monitoring devices and transmissions may be subject to technical limitations and that urgent or emergent changes in condition should be reported directly to emergency services or the treating clinician.

The patient acknowledges receipt of privacy information and understands the rights to revoke authorization in writing, except to the extent that actions have already been taken in reliance on this authorization. Revocation does not affect disclosures already made. The patient further acknowledges that refusal to consent to monitoring may limit the ability of the provider to remotely assess condition and may result in modification of the care plan.

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