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Demographics
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Date of Onset/Duration
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Vitals
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H&P Notes
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H&P Notes Allergic Rhinitis Standard
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Notes
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MEDICATION
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Medication
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Medication Allergies
• • •
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Medication:
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Past Medical Hx
• • •
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Past Medical History Comments
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Past Surgical History
• • •
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Past Surgical History Comments
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Past Surgical History
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Past Surgical History
• • •
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Family Hx
• • •
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Family Hx Comments
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SOCIAL History
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Patient Education
• • •
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Marital Status
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Drink socially?
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How long?
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Former Alcohol Abuse?
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When did you stop drinking?
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Drug/Narcotic use?
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When did you stop?
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Current Tobacco Use
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How many packs per day
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Former Tobacco Use
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How many packs per day
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REVIEW OF SYSTEMS
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ROS Negative
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ROS
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PHYSICAL EXAM
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PHYSICAL EXAMINATION
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MA initialed
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General: WNL
|
General Abnormal
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General comments
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General Abnormal
• • •
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HEAD
|
HEAD Abnormal
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HEAD comment
|
HEAD: Abnormal
• • •
|
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ENT
|
ENT Abnormal
|
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ENT comment
|
ENT: Abnormal
• • •
|
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EYES
|
EYES: Abnormal
|
|
EYES comment
|
EYES: Abnormal
• • •
|
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NOSE
|
NOSE Abnormal
|
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NOSE comment
|
NOSE: Abnormal
• • •
|
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NECK
|
NECK Abnormal
|
|
NECK comment
|
NECK: Abnormal
• • •
|
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THROAT
|
THROAT Abnormal
|
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THROAT Comment
|
THROAT: Abnormal
• • •
|
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Lymph: WNL
|
Lymph: Abnormal
|
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Lymph: comments
|
Lymph: Abnormal
• • •
|
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Cardiovascular WNL
|
Cardiovascular Abnormal
|
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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
• • •
|
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Female GU WNL
|
Female GU Abnormal
|
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Female GU Comments
|
Female GU Abnormal
• • •
|
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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
• • •
|
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Psych: WNL
|
Psych Abnormal
|
|
Psych: Comments
|
Psych Abnormal
• • •
|
|
Neurologic WNL
|
If Neurologic Abnormal
|
|
Neurologic Comments
|
List Neurologic abnormalities
• • •
|
|
Rectal WNL
|
Rectal Abnormal
|
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Rectal Comments
|
Rectal Abnormal
• • •
|
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TREATMENT
|
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Nebulizer Albuterol Treatment
|
|
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Nebulizer ipatropium Treatment
|
Nebulizer comments
|
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Radiology ordered
|
Radiology Comments
|
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X-RAY/MRI
• • •
|
Anatomical Location
• • •
|
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EKG ordered
|
EKG comments
|
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Labs
|
Lab Orders
• • •
|
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Lab Comments
|
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Injection type
• • •
|
Injection Site
• • •
|
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Patient Education
• • •
|
Care Plan
• • •
|
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Dx Treatment Plan Side Effects Reviewed
|
Treatment plan comments
|
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Keep well hydrated nourish rested
|
Precautions comments
|
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If symptoms not improve in 1 week or high fever
|
If symptoms not improve in 1 week or high fever
|
|
Patient report immediately to Ed.
|
Patient to PCP in 2-3 days
|
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DIAGNOSIS
|
|
|
Diagnosis
|
|
|
Signature
|
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