|
Review of Systems
|
|
|
Constitutional - Negative Observations
|
Constitutional
|
|
Eyes - Negative Observations
|
Eyes
|
|
ENMT - Negative Observations
|
ENMT
|
|
Respiratory - Negative Observations
|
Respiratory
|
|
Cardiovascular - Negative Observations
|
Cardiovascular
|
|
Gastrointestinal - Negative Observations
|
Gastrointestinal
|
|
Genitourinary - Negative Observations
|
Genitourinary
|
|
Hema/Lymph - Negative Observations
|
Hema/Lymph
|
|
Endocrine - Negative Observations
|
Endocrine
|
|
Immunologic - Negative Observations
|
Immunologic
|
|
Musculoskeletal - Negative Observations
|
Musculoskeletal
|
|
Integumentary - Negative Observations
|
Integumentary
|
|
Neurologic - Negative Observations
|
Neurologic
|
|
Psychiatric - Negative Observations
|
Psychiatric
|
|
All Other - Negative Observations
|
All Other
|
|
Physical Exam
|
|
|
General
|
Eye
|
|
HENT
|
|
|
Respiratory
|
Right Lung Other
|
|
Left Lung Other
|
|
|
Cardiovascular
|
Gastrointestinal
|
|
Genitourinary - Male
|
Genitourinary - Female
|
|
Lymphatics
|
Musculoskeletal
|
|
Integumentary
|
Psychiatric
|
|
Mobility
|
Additional Exam Notes
|
|
Chief Complaint
|
|
|
Unable to obtain Vitals BP, P, O2, T
|
Patient refused Vitals
|
|
HPI
|
Associated Symptoms
|
|
Basic Information
|
|
|
Accompanied By
• • •
|
Source of History
• • •
|
|
History of Limitation
• • •
|
|
|
Living Arrangement
• • •
|
|
|
Foot Care
• • •
|
|
|
Eye Chart - Snerlen chart
|
|
|
Deffered
|
|
|
Both eyes
/
|
Right
/
|
|
Left
/
|
|
|
With Glasses
|
Without Glasses
|
|
With Contacts
|
Without Contacts
|
|
Patient Health Maintenance
|
|
|
Diabetes/A1C Assessment
|
|
|
Patient Currently Refuses
|
|
|
Plan of Care Discussed with Patient/Family/Medical Personnel
|
|
|
Other
|
|
|
Hypertension Assessment
|
|
|
Patient Currently Refuses
|
|
|
Plan of Care Discussed with Patient/Family/Medical Personnel
|
|
|
Other
|
|
|
Urinary Incontinence Assessment
|
|
|
Patient Currently Refuses
|
|
|
Plan of Care Discussed with Patient/Family/Medical Personnel
|
|
|
Other
|
|
|
Influenza Assessment
|
|
|
Patient Currently Refuses
|
|
|
Plan of Care Discussed with Patient/Family/Medical Personnel
|
|
|
Other
|
|
|
Immunizations
|
Flu Vaccine
|
|
Shingles Vaccine
|
Pneumonia Vaccine
|
|
Immunization Schedule
|
|
|
Regular Exams
|
|
|
Mammogram
|
Colonoscopy
|
|
FOBT
|
Eye Exam Diabetes
|
|
Foot Exam Diabetes
|
|
|
Fall Assessment
|
Notes
|
|
Depression Assessment
|
Notes
|
|
Living Will/Advanced Directive
|
Notes
|
|
POLST
|
Notes
|
|
DNR
|
Notes
|
|
Assessment and Plan
|
|
|
Follow up
|
|
|
PRN / Days/Weeks/Months/Years
• • •
|
|
|
Time
|
Other
|
|
Individuals
• • •
|
Other
|
