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Intro / Major Symptoms
• • •
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History - Dicatate
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Fluid amount
|
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Carbonated / Caffeine
• • •
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Yes - Low Na No - Normal Na
|
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Medications
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Other Drug Information
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Allergies?
|
Non-drug allergies
|
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Normal past med || New Patient?
|
YES Past Med History
|
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Family History Normal
|
YES Family History
|
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Social History
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Grade in school
|
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Other History
|
ROS
|
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PA START - Height
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Height Percentile
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Weight
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Weight Percentile
|
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Blood Pressure
|
No BP performed
|
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BPM
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Pulse Ox
|
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Orthostatic Changes
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<-- If Yes - BP / HR changes
|
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Supine BP
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Supine Heart Rate
|
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Standing BP
|
Standing HR
|
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Normal Exam / No Murmur
|
PE 1 Macro / Type
|
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Normal Exam - First half
|
Precordium
• • •
|
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Chest wall Pain
• • •
|
Pectus
• • •
|
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Rhythm
• • •
|
S1 - S2
• • •
|
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Ejection Click
• • •
|
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Systolic Murmur - Grade
• • •
|
Systolic Murmur - Quality / Location
• • •
|
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Systolic Murmur - Radiation
• • •
|
Continuous Murmur
• • •
|
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Diastolic Murmur - Grade
• • •
|
Diastolic Murmur - Quality / Location
• • •
|
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Normal Exam completion
|
PE 2 Macro / Type
|
|
|
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ECG - Rhythm
• • •
|
ECG - BPM - #
|
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ECG - Axis
|
ECG - Axis Degrees +/- w #
|
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ECG - PR interval - #
|
ECG - QTc - #
|
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ECG - No Hypertophy or ST changes
|
ECG - Other
• • •
|
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ECG - Additional findings
|
Outside ECG Results
|
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Normal Chest xray?
|
Abnormal CXR Findings - Select
• • •
|
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Abnormal / Other CXR - Type/Dictate
|
Wire / Coils / Devices
• • •
|
|
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No CXR performed.
|
|
Holter - Yes = 24-hr No = 48-hr
|
Enter Holter Date
|
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Holter Results
|
|
|
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Normal Echo
|
No echo
|
|
Echocardiogram Report
|
|
|
|
|
|
Dx - Syncope / Fluid Therapy
|
Dx - Functional Murmur
|
|
Additional Impression/Plan
|
|
|
No restrictions / No SBE
|
Other Activity Recommendations
|
|
Follow up?
|
<--IF YES follow up time.
|
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Other closing information
|
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Closing
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