Patient Name: _________________________
Date of Birth: __________________________
Medicaid Record Number: ________________
CHAT: Urinary Complaints/Positive Urine Culture or UA
History
How long have the urinary symptoms been present? Tell the story: ______________________
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Does the patient have a foley catheter? ______________________________________________
Has the patient been on antibiotics this week? ________________________________________
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Current symptoms or complaints:
□ pain with urination
□ urinary frequency
□ blood in urine
□ foul-smelling urine
□ inability to urinate or difficulty passing urine
□ urinary incontinence
□ decreased amount of urine
Exam
Temperature, blood pressure, pulse _________________________________________________
Staff Name: _______________________________________________________(RN/LPN) __________
Reported to:
Name: _______________________________ (MD/NP/PA) Date: _________ Time: _____am __ pm __
If to MD/NP/PA, communicated via: ______________ Phone
_______________ In person ______
(This CHAT has been modified by AHCA. The original CHAT is a product of Duke University.)
Patient Name: ___________________________
Date of Birth: ___________________________
Medicaid Record Number: _________________
CHAT Progress Note
Progress Note (complete and place CHAT/progress note in medical record)
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__ Family or health care proxy notified
Return call/new orders from MD/NP/PA
Date___/___/___ Time___/___AM/PM
Signature________________________________RN/LPN
Date___/___/___ Time___/___AM/PM
(This CHAT has been modified by AHCA. The original CHAT is a product of Duke University)