|
Date of Onset/Duration
|
|
|
Vitals
|
|
|
H&P Notes
|
|
|
Notes
|
|
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MEDICATION
|
|
|
Medication Allergies
• • •
|
Medication:
|
|
MED & FAM Hx
|
|
|
Past Medical Hx
• • •
|
Past Medical History Comments
|
|
Past Surgical History
• • •
|
Past Surgical History Comments
|
|
Family Hx
• • •
|
Family Hx Comments
|
|
SOCIAL History
|
|
|
Marital Status
|
Patient Education
• • •
|
|
Drink socially?
|
How long?
|
|
Former Alcohol Abuse?
|
When did you stop drinking?
|
|
Drug/Narcotic use?
|
When did you stop?
|
|
Current Tobacco Use
|
How many packs per day
|
|
Former Tobacco Use
|
How many packs per day
|
|
REVIEW OF SYSTEMS
|
|
|
ROS Negative
|
ROS
|
|
PHYSICAL EXAM
|
|
|
PHYSICAL EXAMINATION
|
MA initialed
|
|
General: WNL
|
General Abnormal
|
|
General comments
|
General Abnormal
• • •
|
|
HEAD
|
HEAD Abnormal
|
|
HEAD comment
|
HEAD: Abnormal
• • •
|
|
ENT
|
ENT Abnormal
|
|
ENT comment
|
ENT: Abnormal
• • •
|
|
EYES
|
EYES: Abnormal
|
|
EYES comment
|
EYES: Abnormal
• • •
|
|
NOSE
|
NOSE Abnormal
|
|
NOSE comment
|
NOSE: Abnormal
• • •
|
|
NECK
|
NECK Abnormal
|
|
NECK comment
|
NECK: Abnormal
• • •
|
|
THROAT
|
THROAT Abnormal
|
|
THROAT Comment
|
THROAT: Abnormal
• • •
|
|
Lymph: WNL
|
Lymph: Abnormal
|
|
Lymph: comments
|
Lymph: Abnormal
• • •
|
|
Cardiovascular WNL
|
Cardiovascular Abnormal
|
|
Cardiovascular Comments
|
Cardiovascular Abnormal
• • •
|
|
Respiratory WNL
|
Respiratory Abnormal
|
|
Respiratory Comments
|
Respiratory Abnormal
• • •
|
|
Abdomen WNL
|
Abdomen Abnormal
|
|
Abdomen Comments
|
Abdomen Abnormal
• • •
|
|
Breast WNL
|
Breast Abnormal
|
|
Breasts Comments
|
Breast Abnormal
• • •
|
|
Female GU WNL
|
Female GU Abnormal
|
|
Female GU Comments
|
Female GU Abnormal
• • •
|
|
Male GU WNL
|
Male GU Abnormal
|
|
Male GU Comments:
|
Male GU Abnormal
• • •
|
|
Extremities WNL
|
Extremities Abnormal
|
|
Extremities Comments
|
Extremities Abnormal
• • •
|
|
Skin WNL
|
Skin Abnormal
|
|
Skin Comments
|
Skin Abnormal
• • •
|
|
Psych: WNL
|
Psych Abnormal
|
|
Psych: Comments
|
Psych Abnormal
• • •
|
|
Neurologic WNL
|
If Neurologic Abnormal
|
|
Neurologic Comments
|
List Neurologic abnormalities
• • •
|
|
Rectal WNL
|
Rectal Abnormal
|
|
Rectal Comments
|
Rectal Abnormal
• • •
|
|
IMPRESSION
|
|
|
Diagnosis
|
|
|
TREATMENT
|
|
|
Nebulizer Treatment
|
Nebulizer comments
|
|
Dx Treatment Plan Side Effects Reviewed
|
Treatment plan comments
|
|
Precautions & Prevention Reviewed
|
precautions comments
|
|
If worsen see MD immedidately
|
if worsen comments
|
|
Keep well hydrated nourish rested
|
Keep well hydrated nourish rested
|
|
If symptoms not improve in 1 week or high fever
|
If symptoms not improve in 1 week or high fever
|
|
EKG ordered
|
EKG comments
|
|
Labs
|
Lab Orders
• • •
|
|
|
Lab Comments
|
|
Radiology ordered
|
Radiology Comments
|
|
Type of Scan
• • •
|
Anatomical Location
• • •
|
|
Injection type
• • •
|
Injection Site
• • •
|
|
Plan
• • •
|
Care Plan
• • •
|
|
Patient Education
• • •
|
|
|
Return to PCP in 2-3 days
|
|
