|
Subjective
|
|
|
Complaint
• • •
|
|
|
Pain Sx
• • •
|
Pain Comments
|
|
Pain Exacerbating Factors
|
Pain Relieving Factors
|
|
Association w/ Meals
|
Meals Comments
|
|
Meds Tried
• • •
|
Meds Comments
|
|
|
|
|
Other Sx
• • •
|
Other Comments
|
|
Diarrhea Frequency
|
Diarrhea Comments
|
|
Constipation
• • •
|
Constipation Comments
|
|
Urinary Sx
• • •
|
Urinary Comments
|
|
|
|
|
Hx
• • •
|
Hx Comments
|
|
Family Hx
• • •
|
Family Hx Comments
|
|
|
|
|
LMP
|
Rash
|
|
Discharge Character
|
Odor
|
|
Dyspareunia
|
|
|
Objective
|
|
|
Vital Signs WNL
• • •
|
Vitals Abnormal
|
|
HEENT WNL
• • •
|
HEENT Abnormal
|
|
Lungs WNL
• • •
|
Lungs Abnormal
|
|
Cardiovascular WNL
• • •
|
Cardiovascular Abnormal
|
|
Abdomen WNL
• • •
|
Abdomen Abnormal
|
|
Rectal WNL
• • •
|
Rectal Abnormal
|
|
Rectal Deferred
|
|
|
Female Genitals WNL
• • •
|
Male Genitals WNL
• • •
|
|
Genitals Abnormal
|
|
|
Extremities WNL
• • •
|
Extremities Abnormal
|
|
General WNL
• • •
|
General Abnormal
|
|
Urinalysis
|
Wet Prep
|
|
Assessment
|
|
|
Abd Pain Assessment
• • •
|
Assessment Comments
|
|
Plan
|
|
|
Labs
• • •
|
Lab Comments
|
|
Tests
• • •
|
Tests Comments
|
|
Antibiotics
• • •
|
Antibiotics Comments
|
|
Medications
• • •
|
Medications Comments
|
|
Pt. instructed on Meds
|
Teach disease process
|
|
Increase fluids/dietary fiber
|
F/U
|
