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Intro
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Medications
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Other Drug Information
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Allergies?
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Non-drug allergies
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Normal past med || New Patient?
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YES Past Med History
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Otherwise no PMHx
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Family History Normal
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YES Family History
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Social History
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Grade in school
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Other History
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ROS
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PA START - Height
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Height Percentile
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Length
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Length percentile
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Weight
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Weight Percentile
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BMI
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BMI Percentile
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Along growth curve
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Blood Pressure
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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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Normal Exam / No Murmur
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PE 1 Macro / Type
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Normal Exam - First half
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Precordium
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Surgical scar
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Scar description
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Chest wall Pain
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Pectus
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Rhythm
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S1 - S2
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Ejection Click
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Systolic Murmur - Grade
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Systolic Murmur - Location
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Systolic Murmur - Radiation
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Other Cardiac findings
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Diastolic Murmur - Grade
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Diastolic Murmur - Quality / Location
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Continuous Murmur
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PE 2 Macro / Type
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Normal Exam completion
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ECG - Rhythm
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ECG - BPM - #
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ECG - Axis
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ECG - Axis Degrees +/- w #
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ECG - PR interval - #
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ECG - QTc - #
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ECG - No Hypertophy or ST changes
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ECG - Other
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ECG - Additional findings
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Outside ECG Results
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Normal Chest xray?
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Abnormal CXR Findings - Select
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Abnormal / Other CXR - Type/Dictate
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Wire / Coils / Devices
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No CXR performed.
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Holter - Yes = 24-hr No = 48-hr
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Enter Holter Date
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Holter Results
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Normal Echo
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Additional Info to Normal
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Echocardiogram Report
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No echo
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Labs - other testing results
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Impression/Plan
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Pre-Chordial Catch
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Dx - Functional Murmur
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Dx - Syncope / Fluid Therapy
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Activities / Restrictions
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Isometric Restriction
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Other Activity Recommendations
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Other closing information
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SBE
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Follow up?
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<--IF YES follow up time.
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Dr. Laughrun Y- Our office N -Ia Heart
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follow-up timing
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Testing at next visit
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Other
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launguage line - # of minutes
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Closing
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Enclosures - Type
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Enclosures - List
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