|
Standard
|
Hospice
|
|
GENERAL (alert, baseline orientation, NAD, good personal hygiene )
|
General Comments
|
|
negatives
• • •
|
General Abnormal
• • •
|
|
HEENT (no gross deformity, sclerae anicteric, EOMI, normal conjunctivae, PERRLA, no sinus tenderness, no erythema throat)
|
HEENT Comments
|
|
negatives
• • •
|
HEENT Abnormal
• • •
|
|
SKIN (no lesions, no rashes, no ulcers)
|
Skin Comments
|
|
negatives
• • •
|
Skin
• • •
|
|
NECK (Supple. No lymphadenopathy/tenderness (-) thyromegaly, FROM)
|
Neck Comments
|
|
negatives
• • •
|
Neck Abnormal
• • •
|
|
CARDIOVASCULAR (RRR, no JVD, no carotid bruits, no murmurs, no rubs or gallops, S1 S2 present, no S3, no S4)
|
Cardiovascular Comments
|
|
negatives
• • •
|
Cardiovascular Abnormal
• • •
|
|
LUNGS (CTA, no adventitious sounds)
|
Lungs Comments
|
|
negatives
• • •
|
Lungs Abnormal
• • •
|
|
ABDOMEN ( soft, non-tender, non-distended, normal bowel sounds all 4 quadrants, no masses, no tenderness, no rebound tenderness)
|
Abdomen Comments
|
|
negatives
• • •
|
Abdomen Abnormal
• • •
|
|
GU (negatives)
• • •
|
GU (positives)
• • •
|
|
MSK (normal muscle tone, no deformities, normal range of motion)
|
MSK Comments
|
|
negatives
• • •
|
MSK Abnormal
• • •
|
|
BREASTS (no masses noted, no lymphadenopathy, no tenderness)
|
Breasts Comments
|
|
negatives
• • •
|
Breasts Abnormal
• • •
|
|
NEURO (muscle strength at baseline in all major muscle groups, cranial nerves II-XII intact, finger to nose intact, sensation)
|
Neuro Comments
|
|
negatives
• • •
|
Neuro Abnormal
• • •
|
|
EXTREMITIES (no abnormal movements, no tremor, no rigidity, normal alignment)
|
Extrem Comments
|
|
negatives
• • •
|
Extrem Abnormal
• • •
|
|
|
|
|
Alzheimer's
|
|
|
GENERAL:
|
General Comments
|
|
negatives
• • •
|
General Abnormal
• • •
|
|
HEENT:
|
HEENT Comments
|
|
negatives
• • •
|
HEENT Abnormal
• • •
|
|
SKIN:
|
Skin Comments
|
|
negatives
• • •
|
Skin
• • •
|
|
CARDIOVASCULAR (AFIB)
|
CARDIOVASCULAR (WNL)
|
|
negatives
• • •
|
Cardiovascular Abnormal
• • •
|
|
LUNGS:
|
Lungs Comments
|
|
negatives
• • •
|
Lungs Abnormal
• • •
|
|
ABDOMEN
|
Abdomen Comments
|
|
negatives
• • •
|
Abdomen Abnormal
• • •
|
|
MSK:
|
MSK Comments
|
|
negatives
• • •
|
MSK Abnormal
• • •
|
|
Cardiac
|
|
|
GENERAL:
|
General Comments
|
|
negatives
• • •
|
General Abnormal
• • •
|
|
HEENT:
|
HEENT Comments
|
|
negatives
• • •
|
HEENT Abnormal
• • •
|
|
SKIN:
|
Skin Comments
|
|
negatives
• • •
|
Skin
• • •
|
|
CARDIOVASCULAR (AFIB)
|
CARDIOVASCULAR (WNL)
|
|
negatives
• • •
|
Cardiovascular Abnormal
• • •
|
|
LUNGS:
|
Lungs Comments
|
|
negatives
• • •
|
Lungs Abnormal
• • •
|
|
ABDOMEN
|
Abdomen Comments
|
|
negatives
• • •
|
Abdomen Abnormal
• • •
|
|
MSK:
|
MSK Comments
|
|
negatives
• • •
|
MSK Abnormal
• • •
|
|
Vascular Dementia
|
|
|
GENERAL:NAD, good personal hygiene (attended to by caregiver); weight down to ___ , MAC down to___)
|
General Comments
|
|
negatives
• • •
|
General Abnormal
• • •
|
|
HEENT (no gross deformity, normal conjunctivae)
|
HEENT Comments
|
|
negatives
• • •
|
HEENT Abnormal
• • •
|
|
SKIN (no lesions, no rashes, no ulcers)
|
Skin Comments
|
|
negatives
• • •
|
Skin
• • •
|
|
CARDIOVASCULAR (AFIB) (HR Irregular, + for murmur; no JVD, no carotid bruits)
|
CARDIOVASCULAR (WNL) ( RRR, no JVD, no carotid bruits, no murmurs, no rubs or gallops, S1 S2 present, no S3, no S4)
|
|
negatives
• • •
|
Cardiovascular Abnormal
• • •
|
|
LUNGS (CTA, no adventitious sounds)
|
Lungs Comments
|
|
negatives
• • •
|
Lungs Abnormal
• • •
|
|
ABDOMEN (soft, non-tender, non-distended, normal bowel sounds all 4 quadrants, no masses, no tenderness, no rebound tenderness)
|
Abdomen Comments
|
|
negatives
• • •
|
Abdomen Abnormal
• • •
|
|
MSK (poor/worsening muscle tone, poor/worsening muscle strength, worsening stiffness/rigidity, no deformities)
|
MSK Comments
|
|
negatives
• • •
|
MSK Abnormal
• • •
|
|
Parkinson's
|
|
|
GENERAL:NAD, good personal hygiene (attended to by caregiver); weight down to ___ , MAC down to___)
|
General Comments
|
|
negatives
• • •
|
General Abnormal
• • •
|
|
HEENT (no gross deformity, normal conjunctivae)
|
HEENT Comments
|
|
negatives
• • •
|
HEENT Abnormal
• • •
|
|
SKIN (no lesions, no rashes, no ulcers)
|
Skin Comments
|
|
negatives
• • •
|
Skin
• • •
|
|
CARDIOVASCULAR (AFIB) (HR Irregular, + for murmur; no JVD, no carotid bruits)
|
CARDIOVASCULAR (WNL) ( RRR, no JVD, no carotid bruits, no murmurs, no rubs or gallops, S1 S2 present, no S3, no S4)
|
|
negatives
• • •
|
Cardiovascular Abnormal
• • •
|
|
LUNGS (CTA, no adventitious sounds)
|
Lungs Comments
|
|
negatives
• • •
|
Lungs Abnormal
• • •
|
|
ABDOMEN (soft, non-tender, non-distended, normal bowel sounds all 4 quadrants, no masses, no tenderness, no rebound tenderness)
|
Abdomen Comments
|
|
negatives
• • •
|
Abdomen Abnormal
• • •
|
|
MSK (poor/worsening muscle tone, poor/worsening muscle strength, worsening stiffness/rigidity, no deformities)
|
MSK Comments
|
|
negatives
• • •
|
MSK Abnormal
• • •
|
|
Generic
|
|
|
GENERAL (NAD, good personal hygiene, weight is at {{weight}}, MAC currently at {{cvt_MAC}})
|
General Comments
|
|
negatives
• • •
|
General Abnormal
• • •
|
|
HEENT (no gross deformity, normal conjunctivae)
|
HEENT Comments
|
|
negatives
• • •
|
HEENT Abnormal
• • •
|
|
SKIN (no lesions, no rashes, no ulcers)
|
Skin Comments
|
|
negatives
• • •
|
Skin
• • •
|
|
CARDIOVASCULAR (WNL) (HRR, no murmur, S1, S2, no S3 or S4)
|
CARDIOVASCULAR (AFIB) (irregulary regular HR, no JVD, no carotid bruits, no murmurs, no rubs or gallops, + for murmur)
|
|
negatives
• • •
|
Cardiovascular Abnormal
• • •
|
|
LUNGS (LS diminished, no wheezing, CTA, no adventitious sounds)
|
Lungs Comments
|
|
negatives
• • •
|
Lungs Abnormal
• • •
|
|
ABDOMEN (soft, non-tender, non-distended, normal bowel sounds all 4 quadrants, no masses, no tenderness, no rebound tenderness)
|
Abdomen Comments
|
|
negatives
• • •
|
Abdomen Abnormal
• • •
|
|
MUSCULOSKELETAL (poor strength, poor endurance, no deformities)
|
MSK Comments
|
|
negatives
• • •
|
MSK Abnormal
• • •
|
