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