HISTORY OF PRESENT ILLNESS:



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Transcription:

Always document chief complaint. HPI: CHP1=4+elements or status of 3 chronic conditions; CHP2&3=4+ elements DATE: / / CHIEF COMPLAINT: HISTORY OF PRESENT ILLNESS: PCP Location Contacted Page 1 of 6

PMH, Family, Social History: CHP1=1 of 3 CHP 2 & 3 = 3 of 3 PAST MEDICAL HISTORY: (include health maintenance & vaccines) Last influenza vaccine (month/year) / Pneumococcal vaccine (month/year) / SURGICAL HISTORY: FAMILY HISTORY: SOCIAL HISTORY: Occupation: Alcohol: HIV risk factors: Tobacco: Travel: Counseled about cessation Pets: Illicit drugs: Hobbies: Lives with: Housing: Urban house Trailer Farm Homeless MEDICATIONS: Please see medication reconciliation form on pages 5-6 ALLERGIES: ROS: CHP 1 = prob. pertinent + 2; CHP 2 & 3 = 10+ elements REVIEW OF SYSTEMS: (check if done, circle abnormal) General Skin rash, pain, abscess, mass Eyes - poor vision, pain Psych - fatigue, insomnia, mood problem, crying, depression ENT - sore throat, pain, coryza, acuity, dysphagia Endocrine - hot flashes CV - pain, palpitations, hypo/hypertension Hem/Lymph fevers, chills, swelling, night sweats Resp dyspnea, cough, tachypnea Neuro: numbness, tingling, weakness, headache, loss of GI pain, nausea, vomiting, diarrhea, constipation consciousness GU - pain, bleeding, incontinent, nocturia, foul smell Immunologic/Allergies: Muscle pain, weakness Exam: CHP 1 = extended; CHP 2 & 3 = 8+ organ systems PHYSICAL EXAMINATION: (if normal: ; if abnormal: & describe) Vitals BP / P R T Pain /10 SaO2 % Ht W General Abnormal Findings Descriptions Eyes Conjunctivae, lids, pupils & irises Fundi: Y N Y N Disc edges sharp Hemorrhages Venous pulses seen Exudates A-V nicking Cup:disc ratio Page 2 of 6

ENT, Neck, Breast Resp Cardiovascular External canals, TMs Nasal mucosa, septum Lips, gums, teeth Oropharynx, mucosa, salivary glands Hard/soft palate, tongue, tonsils, posterior pharynx Thyroid Neck (note bruit, JVD) Breasts (note dimpling, discharge, mass) Respiratory effort (note use of accessory muscles) Lung percussion & auscultation Auscultation: Y N Regular rhythm Palpation of heart S1 constant Abdominal aorta S2 physiologic split Femoral arteries Murmur (describe) Pedal pulses GI GU Lymph,skin musc/skel Abdomen: Y N Bowel sounds: Scars normal Bruit Mass absent Tenderness Stool: Hepatomegaly Heme positive Splenomegaly Heme negative Anus, perineum, rectum, sphincter tone Male: Penis Testes Prostate Lymph nodes Female: External genitalia Cervix Uterus/adnexa Skin & SQ tissue (describe any rash) Gait & station Digits, nails ROM, stability Joints, bones, muscles Muscle strength & tone Neuro Cranial nerves (note deficits) Motor DTRs Sensation Psych Judgment & insight Mood & affect Oriented to time, place, person Memory LABS Na ALT PT WBC K AST PTT % Bands Cl ALP Hgb % PMNs CO2 Albumin Platelet % Lymphs BUN d-bili % Monos Cr i-bili % Basos Glu Amylase % Eos Lipase EKG: CXR: UA: Page 3 of 6

Decision Making (meet 2 of the following 3): No. of diagnoses: CHP1 = 1 CHP2 = 3 CHP3 = 4+ Data reviewed &/or Ordered: CHP1 = 0-2 CHP2 = 3 CHP3 = 4+ Labs review/order Radiology tests review/order Medicine tests review/order (EKG, echo, cath, vasc tests, PFTs) Discuss results w/ performing MD Independent review of image, tracing or specimen Obtain old records &/or history from person other than pt Review/summarize old records &/or obtain hx from person other than pt Risk: CHP1=Min-low CHP2=Mod. CHP3=High IMPRESSION & PLAN Discharge Planning: Estimated length of stay: days. Likely disposition: Home Nursing home Correctional facility Resident Signature: Date: I was present with the resident during the entire interview & examination of the patient. I repeated the key portions of the exam in the presence of the resident. I confirmed/revised the resident s history, exam, assessment & plan as noted in the margin. See resident s notes for details. I was NOT present with the resident during the entire interview & examination of the patient. I personally interviewed the patient & repeated the exam. I confirmed/revised the history, exam, assessment & plan as noted in the margin. See resident s notes for details. Teaching/Attending Physician Signature Date Level of Service Page 4 of 6

Interdisciplinary Admission Medication History Each healthcare provider who adds information to this document must initial and sign his/her name. The admitting physician will review listed medications, determine the admission medication plan, and sign this page. Key for source(s) of information: Patient Family Transfer records Rx vials Pharmacy (phone # ) Cerner Info System Other Home/Prior to Admission Prescription Medications (List Below) 1 NONE Physician Review & Admission Medication Plan Date Initials Source of Info Medication Name Dose Route Frequency Date/Time Last dose Order Modify Do not order Prescription medications are continued on back of form Home/Prior to Admission OTC, Herbal & Homeopathic Preparations (List Below) 1 NONE OTC, herbal, and homeopathic medications are continued on next page Each healthcare provider who adds information to this document must initial and sign his/her name: *Admitting Physician Review: Signature: Printed Name: Date & Time: Pager #: Page 5 of 6

Each healthcare provider who adds information to this document must initial and sign his/her name. Key for source(s) of information: Patient Family Transfer records Rx vials Pharmacy (phone # ) Cerner Info System Other Date Initials Source of Info Home/Prior to Admission Prescription Medications and OTC, Herbal & Homeopathic Preparations (List Below) Medication Name Dose Route Frequency Date/Time Last dose Physician Review & Admission Medication Plan Do not Order Modify order Each healthcare provider who adds information to this document must initial and sign his/her name: 58-354 Form H-MR 717 Revised 09/2006 Medical Records Committee Medical Record Copy Page 6 of 6

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