|
Historian
• • •
|
|
|
HPI: duration of symptoms (hours) *
• • •
|
Severity:
• • •
|
|
Course:
• • •
|
|
|
Exacerbating Factors:
• • •
|
Mitigating Factors
• • •
|
|
Associated Symptoms
• • •
|
Notes:
|
|
|
|
|
ROS: *
|
|
|
Respiratory (positive)
• • •
|
Respiratory (negative)
• • •
|
|
Additional
|
All systems otherwise negative.
|
|
|
|
|
PHYSICAL EXAM*
|
|
|
Respiratory: CTAB. nonlabored respirations.
|
|
|
Respiratory (positive)
• • •
|
Respiratory (negative)
• • •
|
|
Additional
|
|
|
PE: Superficial
|
PE: Head to toe exam
|
|
PE Notes:
|
|
|
|
|
|
PMFSHx: Negative. No tobacco
|
|
|
Medical History:
• • •
|
Free Text Medical History:
|
|
Surgical History:
|
Family History:
|
|
Social History
• • •
|
|
|
|
|
|
Orders
|
|
|
Treatment Includes:
• • •
|
|
|
CXR: results show CHF
|
CXR Results:
|
|
EKG __BPM.NSR.Nml axis/intervals.No ST changes
|
EKG:
|
|
|
|
|
Medication Attestation
|
|
|
# of mg or mL
|
Medication
|
|
Route
|
Site of Administration
|
|
# of mg or mL
|
Medication
|
|
Route
|
Site of Administration
|
|
Med, Dosage, Route, Lot#, Exp. Date, Site
|
|
|
|
|
|
MDM Notes
|
CHF decompensation secondary to:______
|
|
Dx: Acute CHF exacerbation
|
|
|
Status
|
Diagnosis:
• • •
|
|
Status
|
Diagnosis:
|
|
|
|
|
|
|
|
POC Meds:
|
Plan Notes
|
|
Discharge Note: ERD ONLY
|
|
