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PMH
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Systemic
• • •
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Neuro
• • •
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Heart
• • •
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Lungs
• • •
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GI
• • •
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MS
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Psych
• • •
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Operations
• • •
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Additional comments
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Other
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FH
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FH
• • •
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Sudden death
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SH
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Smoke
• • •
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ETOH
• • •
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Illicit drugs
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Medications
• • •
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Medications Comments
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Allergies
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Allergies Comments
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HPI
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Source
• • •
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Mode of Arrival
• • •
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Timing
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Duration
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Symptoms started
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Duration
• • •
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Context
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Exposed to
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Other
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Developed
• • •
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Developed comments
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History of
• • •
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Location
• • •
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Severity
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SOB
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Difficulty Swallowing
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Rash
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Pruritus
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Modifying factors
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Improves
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Associated signs and symptoms
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Associated signs and symptoms: None
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Signs & Symptoms
• • •
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Other history
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Constitutional
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Distress
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Neck:
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Neck comments
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Eyes
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Eyes commens
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ENT
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Oropharynx
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Airways
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Airways comments
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Lips
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Lips comments
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Nose
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Respiratory
• • •
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Breath sounds
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Breath sounds comments
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Respiratory
• • •
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Respiratory comments
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CV
• • •
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VI
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Murmur comments
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GI
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Tenderness
• • •
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Tenderness Comments
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Skin
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Rash
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Rash Comments
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Location
• • •
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Lymphatics
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Adenopathy
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Adenopathy Comments
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Other exam
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Constitutional
• • •
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Eyes
• • •
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ENT
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Ears
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Nose
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Throat
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Respiratory
• • •
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CV
• • •
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GI
• • •
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GU
• • •
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GU Male
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GU Female
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Neurological
• • •
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Musculoskeletal
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Musculoskeletal Pain and Swelling in
• • •
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Integumentary
• • •
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Allergic / Immunologic
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Hematologic
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Easy
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Endocrine
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Weight
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Loss Comments
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Psychiatric
• • •
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MEDICAL DECISION MAKING
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Additional information obtained
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Old records Family Caretaker PCP
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Findings
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Differential Diagnosis
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Considerations may include
• • •
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Additional info
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Notes / Course
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Treatment: SQ epi X
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IV / IM
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Reevaluation 1st
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Reevaluation 2nd
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Reevaluation 3rd
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Consultation
• • •
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Other
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Called
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Call returned
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Findings
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Summary
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Patient Family Education Counseling Regarding:
• • •
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Was patient counseled?
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PROCEDURES
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Informed consent obtained
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Intubation by
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Placement confirmed by
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Critical Care time / Minutes
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Start time
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Stop time
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Procedure Note
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IMPRESSION
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DISCHARGE INSTRUCTIONS
• • •
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Discharge instruction sheet
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Disposition
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Transfer to
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Release Time
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Quarters
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Modified duty for
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Or until
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Condition
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Return to the ED if
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Follow up with Dr.
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Emergency
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DEPLOYMENT RELATED
|
Comments
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Time of order
|
Old Records
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INI
|
Time
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Time of order
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O2
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INI
|
Time
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Time of order
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IV
|
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INI
|
Time
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Time of order
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Pulse oximetry: spot continuous
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INI
|
Time
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Time of order
|
EKG Monitor
|
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INI
|
Time
|
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Time of order
|
LABS: ISTAT: CHEM CBC
|
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INI
|
Time
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Labs
• • •
|
Panels
• • •
|
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ETOH
|
T & S
|
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T & C
|
HCG
• • •
|
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UA
• • •
|
Additional Comments
|
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See Nurse Initiated Protocol Sheet
|
See Radiology Order Sheet
|
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REVIEW OF RESULTS
|
REVIEW of RESULTS
|
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URINALYSIS
|
Other
|
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OTHER
|
XR
|
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Interpreted by
|
XR Comments
|
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EKG
|
Interpreted by
|
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Reviewed
• • •
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Other Findings:
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Interviewed & examined pt & agree with resident
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With the following exceptions Noted
|
