Clinic History and Physical MedicalTemplate
New Outpatient Evaluation Review of Systems DOB Chief complaint/Reason for consult No History of
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New Outpatient Evaluation Review of Systems
DOB
Chief complaint/Reason for consult No
History of Present Illness
©MB and RR 2011
MRN
Start Time
Patient is Nonverbal.
Encounter Date
Stop Time
History obtained from
Family Medical records
PL
E
Yes
Allergies and Medications
Allergy List reviewed No drug allergies No food allergies History of life threatening allergic response to Medications reviewed Medications reconciled with Nursing Home data Past Medical History, Social History and Family History
M
Asthma Diabetes COPD Hepatic Dysfunction Congestive Heart Failure(CHF) HIV/AIDS Coronary Artery Disease Hypertension
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Obstructive Sleep Apnea Other Seizure Disorder Thyroid disease Hyper Hypo Tuberculosis Treatment
Malignancy
Adrenal Colon Leukemia/Lymphoma Melanoma Renal cell Thyroid Breast Lung Pituitary Prostate Testicular Stage Treatment Surgical Resection Radioablation Chemotherapy Last Tx Radiation Last Tx Surgeries CABG Cardiac valve replacement Splenectomy Organ transplant Joint replacement Other
SA
Constitution Fatigue or Malaise Fever or chills Appetite changes Eyes Conjunctivitis New eye pain Blurred vision ENT/mouth Sore throat Swollen uvula Jaw pain Respiratory Dyspnea Cough Phlegm Hemoptysis Wheeze Cardiovascular Chest pain Diaphoresis Ankle edema Syncope Palpitations Gastrointestinal Nausea or vomiting Weight changes Diarrhea Abdominal pain Genitourinary Hematuria Dysuria Urethral discharge Musculoskeletal Myalgias Arthralgias Joint swelling Recent trauma Skin/Breasts Masses New skin lesions Rash Neurologic Headaches Seizures Muscle weakness Paresthesias Endocrinologic Hair loss Polydipsia Tremors Neck pain Heme/Lymph Bleeding gums Unusual bruising Swollen lymph nodes Allergy/Immunology Nasal congestion Rhinorrhea Psychologic Agitation Hallucinations
Patient Name
Social History / Risk factors
No Yes No Yes
Tobacco use Number Pack-Years __________ Quit tobacco use Quit date __________ Willingness to Quit Unwilling Considering Quit but resumed Within 1 month Patient has tried smoking cessation aids Nicotine Replacement Receptor blockade
No Yes No Yes
Recreational drug use Route Inhalation Injection Ingestion Drug dependence Type Narcotics Benzodiazepines
No Yes
Alcohol use ___ Drinks per Day Week
Ability to Perform Activities of Daily Living Able Unable Eating
Bathing Dressing Toileting Transfers
Family Medical History
Asthma Coronary Artery Disease CHF Pancreatitis COPD Peripheral Artery Disease Revised 1Feb2011
Vaccines
No No No No
Yes Yes Yes Yes
Influenza Pneumococcal Pertussis Varicella
Renal Dysfunction Malignancy Thrombotic disorder Other Thyroid Disease Health Care Provider Signature
Buproprion or nortriptyline
New Outpatient Evaluation
Patient Name
DOB
Exam NonInvasive Ventilator
Constitutional Height
CPAP BiPAP Expiratory Pressure
_______
Blood Pressure
Medications
Encounter Date
________
Weight
lb kg
________
Pulse Rate ________
Sitting Standing Lying
AND Rhythm Regular
Irregular
__________ / __________
Respiratory Rate__________
E
Optional Oxygen Saturation _____ % Cardiac Output _____ Systemic Vascular Resistance _____
Body habitus wnl Cachectic Obese Grooming wnl Unkempt ENT
Within normal limits Edema or erythema present Dental caries Gingivitis Oropharynx Within normal limits Edema or erythema present Oral ulcers Oral Petechiae Mallampati I II III IV Nasal mucosa, septum, and turbinates
Neck
PL
Dentition and gums Within normal limits
Within normal limits Erythema or scarring consistent with recent or old radiation dermatitis Thyromegaly Nodules palpable Neck mass _____________________ Jugular Veins Within normal limits JVD present a, v or cannon a waves present
Neck
Thyroid Within normal limits
Resp
Labs ____ / ____ / ____ / \ \ \
Chest is free of defects, expands normally and symmetrically Erythema consistent with radiation dermatitis Scarring consistent with old, healed radiation dermatitis Resp effort Within normal limits Accessory muscle use Intercostal retractions Paradoxic movements Chest percussion Within normal limits Dullness to percussion Lt Rt Hyperresonance Lt Rt Tactile exam Within normal limits Tactile fremitus Increased Decreased ________________________ Auscultation Within normal limits Bronchial breath sounds Egophony Rales Rhonchi Wheezes Rub present
M
\____/ / \
in cm
Temperature C F ________
Inspiratory Pressure _______
MRN
WNL = Within Normal Limits
Clear S1 S2 No murmur, rub or gallop Gallop Rub Murmur present Systolic Diastolic Grade I II III IV V VI Peripheral pulses palpable No peripheral edema Peripheral pulses Absent Weak
SA
CV
GI
Radiology
CXR CT scan Other
Within normal limits Mass present LUQ RUQ LLQ RLQ ______________ Pulsatile Liver and spleen palpation wnl Unable to palpate Liver Spleen Enlarged Liver Spleen Abdomen
Lymph (2 areas must be examined)
Lymph node exam wnl
Musc
Extrem Skin Neuro
Neck Axilla Groin Other ___________________ Neck Axilla Groin Other ___________________
Areas examined
Lymphadenopathy noted in
Muscle tone within normal limits, and no atrophy noted Tone is Increased Decreased Atrophy present Gait and station wnl Ataxia Wide based gait Shuffle Patient leans Rt Lt Front Back Exam wnl Clubbing Cyanosis Petechiae Synovitis Rt Lt No rashes, ecchymoses, nodules, ulcers Oriented NOT oriented to Person Time Place Affect is within normal limits OR Patient appears Agitated Anxious Depressed
Additional Findings
©MB and RR 2011
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________________________
Revised 1Feb2011
Health Care Provider Signature
New Outpatient Evaluation Medical Decision Making
Patient Name
DOB
MRN
Data Reviewed
I have personally discussed Code Status with this patient, and believe that this patient (or their surrogate decision maker) understands their medical condition, their prognosis and the consequences of their Code Status decision. Code Status Patient is a FULL CODE DO NOT ATTEMPT Cardiac Resuscitation DO NOT Intubate
ER Notes Old medical records Labs Radiology data Pathology Echocardiogram (ECHO) Electrocardiogram (ECG) Stress Test Pulmonary Function Test Operative/Procedure Notes
E
This patient has advanced health care directives. Their HCPOA is
Care Coordinated with
PL
Patient HCPOA / Surrogate Consultant(s)
Recommended Actions
Smoking cessation aids Pneumonia vaccine Influenza Vaccine Recommended Diagnostics
SA
M
12-lead Electrocardiogram (ECG) Echocardiogram (ECHO) Chest X-ray Computed Tomography (CT) Magnetic Resonance Imaging (MRI) CBC with differential PT, PTT, INR Basic Metabolic Panel Complete Metabolic Panel TSH HIV Hepatitis panel Toxicology screen
Urinalysis Urine electrolytes Nasal or nasopharyngeal swab/wash PPD Quantiferon test Serum Mycoplasma Urinary antigen Histoplasma Legionella Culture
Sputum Blood Urine CSF Consult
Follow Up Planned
Physician Signature cc
©MB and RR 2011
Encounter Date
Impression
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Revised 1Feb2011
Health Care Provider Signature