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Yes - Familiar / No - Salutation
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Familiar - First Name
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History
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Medications
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Other Drug Information
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Allergies?
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Non-drug allergies
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Negative Past Med History: Yes = New No = F/U
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Past medical history is significant for...
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Otherwise no PMHx
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Negative Family History Cardiac Dz
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Family history is significant for...
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Social History
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Grade in school
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Other History
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ROS
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Wt / Ht - No %'ile
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Weight %'ile
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< 2 years - Length %'ile
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> 2 years - Height %'ile
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Along growth curve
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On Trisomy 21 growth chart
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Add BMI - Input %'ile
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Pulse oximeter
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Blood Pressure
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No BP performed
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Orthostatic Changes
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<-- If Yes - BP / HR changes
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Normal Exam / No Murmur
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Functional murmur
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Normal Exam - First half
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PE 1 Macro / Type
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Additional information
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Precordium
• • •
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Surgical scar
• • •
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Scar description
• • •
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Chest wall Pain
• • •
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Pectus
• • •
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Rhythm
• • •
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S1 - S2
• • •
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Ejection Click
• • •
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Continuous Murmur
• • •
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Systolic Murmur - Grade
• • •
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Systolic Murmur - Location
• • •
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Systolic Murmur - Radiation
• • •
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Other systolic murmur info
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Diastolic Murmur - Grade
• • •
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Diastolic Murmur - Quality / Location
• • •
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Other Cardiac findings
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PE 2 Macro / Type
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Normal Exam completion
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ECG - Rhythm
• • •
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ECG - BPM - #
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ECG - Axis
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ECG - Axis Degrees +/- w #
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ECG - PR interval - #
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ECG - QTc - #
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ECG - No Hypertophy or ST changes
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ECG - Other
• • •
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ECG - Additional findings
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An outside ECG demonstrated...
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Normal Chest xray?
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Abnormal CXR Findings - Select
• • •
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Abnormal / Other CXR - Type/Dictate
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Wire / Coils / Devices
• • •
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Unchanged from previous
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No CXR performed.
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Holter - Yes = 24-hr No = 48-hr
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Enter Holter Date
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Holter Results - This study demonstrated...
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Normal Echo
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Additional Info to Normal
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Echocardiogram Report
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No echo
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Labs - other testing results
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Diagnosis and Procedures List
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Impression/Plan
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Pre-Chordial Catch
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Dx - Functional Murmur
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Dx - Syncope / Fluid Therapy
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Activities / Restrictions
• • •
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Isometric Restriction
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Other Activity Recommendations
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Other closing information
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SBE
• • •
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Continue current meds
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Follow up?
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<--IF YES follow up time.
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Testing at next visit
• • •
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Other
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ACHD Clinic Y- Our office N -Ia Heart
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follow-up timing
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Language line - Language
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Language Line - # of minutes
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Closing
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CC
• • •
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CC - Type
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Enclosures - List
• • •
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Enclosures - Type
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Scribe
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Scribe Attest
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