Patient Demographics
Name:
Age:
Sex:
Date of Birth:
Attending Physician:
Reason for Hold
Clearly state the medical reason(s) for placing the patient on hold. Be as specific as possible, citing relevant findings from the history, physical examination, or diagnostic tests.
Include the date and time the decision for hold was made.
Impact on Planned Procedure/Discharge
Specify the planned procedure or discharge that is being delayed.
Indicate the anticipated duration of the hold, if known. If the duration is uncertain, state that the hold will be reassessed on a specific date or based on the fulfillment of certain criteria.
Plan
Outline the next steps in the patient’s care plan.
Include any additional investigations or monitoring required before proceeding with the originally planned procedure/discharge.
Mention any medications or treatments initiated as part of the management plan for the reason for hold.
Communication
Briefly document who has been informed about the hold, such as the patient, family members, and other healthcare providers involved in the patient’s care.