Community COVID19 Ward Monitoring

Risk Level

See Guide to Risk Assessment
High	Average	Low
MONITOR Daily for at least 14 days	MONITOR Every 2 days x 8 days; then recommend self-monitor for additional 7 days depending on progress	MONITOR Consider self-monitoring only; check-ins determined by individual patient. (Consider at 7 days)

Isolation and Contact Tracing

Test Data and Isolation Period

Date of Positive Test

Date of First Symptom OR No Symptoms

End of Isolation Period

Data Checklist

Download lab from OLIS to chart

Add COVID code to Disease Registry (080)

Add "COVID19 [month/year]" to medical history

Add COVID code to billing (080)

Patient Isolation/Contact Tracing Education Checklist

Patient was contacted by Public Health after positive test result OR

❓ Used Public Health Guide to provide or reinforce Public Health's direction on self isolation and identifying/contacting contacts *

Home Equipment Inventory

Patient has or can borrow:

BP cuff

Thermometer

❓ Pulse oximeter (NOTE: May direct to YouTube video on using pulse oximeter at https://www.youtube.com/watch?v=ghUTSH-PYio)

(*NOTE: Recommend directing patients to Hamilton Public Health (https://www.hamilton.ca/coronavirus/covid-19-have-symptoms-or-been-exposed) and HFAM Patient Resources (https://hfam.ca/patient-resources/) for more information. These may be provided verbally and/or sent electronically through VirtualClinic+.)

COVID-19 Monitoring Visits

IMPORTANT: To access a new row for data entry, save the form, exit, refresh the patient's OSCAR eChart and open this form again from the eChart's left menu.

Please follow specific history and exam details per HFAM Monitoring Template. Also see tips for assessing Dyspnea and Vitals virtually.
Date	Symptom Presence (and Relative Change) or Absence						Vitals
Date	Dyspnea	Cough	Fever	Loss of Taste/ Smell	GI Upset	Other	RR	HR	BP	T	O2 Sat (%)	Hydration	Red Flags	Safe to Continue?
	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Note	Note	Note	Note	Note	Concern Satisfactory Note	Y N Note	Y N Note
	Notes
	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Note	Note	Note	Note	Note	Concern Satisfactory Note	Y N Note	Y N Note
	Notes
	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Note	Note	Note	Note	Note	Concern Satisfactory Note	Y N Note	Y N Note
	Notes
	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Note	Note	Note	Note	Note	Concern Satisfactory Note	Y N Note	Y N Note
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	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Note	Note	Note	Note	Note	Concern Satisfactory Note	Y N Note	Y N Note
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	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Note	Note	Note	Note	Note	Concern Satisfactory Note	Y N Note	Y N Note
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	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Note	Note	Note	Note	Note	Concern Satisfactory Note	Y N Note	Y N Note
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	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Note	Note	Note	Note	Note	Concern Satisfactory Note	Y N Note	Y N Note
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	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Note	Note	Note	Note	Note	Concern Satisfactory Note	Y N Note	Y N Note
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	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Note	Note	Note	Note	Note	Concern Satisfactory Note	Y N Note	Y N Note
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	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Note	Note	Note	Note	Note	Concern Satisfactory Note	Y N Note	Y N Note
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	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Note	Note	Note	Note	Note	Concern Satisfactory Note	Y N Note	Y N Note
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	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Note	Note	Note	Note	Note	Concern Satisfactory Note	Y N Note	Y N Note
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	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Note	Note	Note	Note	Note	Concern Satisfactory Note	Y N Note	Y N Note
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	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Note	Note	Note	Note	Note	Concern Satisfactory Note	Y N Note	Y N Note
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	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Note	Note	Note	Note	Note	Concern Satisfactory Note	Y N Note	Y N Note
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	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Note	Note	Note	Note	Note	Concern Satisfactory Note	Y N Note	Y N Note
	Notes
	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Note	Note	Note	Note	Note	Concern Satisfactory Note	Y N Note	Y N Note
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	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Note	Note	Note	Note	Note	Concern Satisfactory Note	Y N Note	Y N Note
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	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Y N Better Worse Stable Note	Note	Note	Note	Note	Note	Concern Satisfactory Note	Y N Note	Y N Note
	Notes

Next Visit Date On Call Notified if Visit on Weekend

Discharge Date

Note

Other Areas of Assessment/Support

Area	Concern?	Referral?
Mental Health	Y N ❓	Y N ❓
Access to Food	Y N	Y N ❓
Access to Caregiver(s)	Y N	Y N ❓
Access to Needed Supports	Y N	Y N ❓
Financial Health	Y N	Y N ❓
Housing	Y N	Y N ❓

Patient Advice/Education Checklist

Please refer to "Patient Advice Guide"

Illness course explained

Information about hydration and comfort medications given:

Direction given to limit exertion and education provided about breathing position:

Return to care instructions given

Advice given about regular medications (SADMAN): N/A OR Notes:

Management of comorbidities discussed:

Summary of Goals of Care Conversation (if relevant and appropriate)

This form was developed by the McMaster University Department of Family Medicine and may be modified and used as needed, subject to retaining this acknowledgement in all versions. In the spirit of collaborative improvement, we welcome your feedback. Thank you v1.3