Beruflich Dokumente
Kultur Dokumente
School of Nursing
Episodic Document
Patient Information:
Initials:_AA_______
Age:_20_______
visit:_6/03/15______
Sex:_M_____ Date of
HPI:
Onset _Annual physical
_________________
Location of problem __Denies problems at this
time__________________
Duration of problem _Not applicable
_________________________
Character of problem _Not applicable
_________________
Intensity rating: 0/10
Aggravating Factors _Not applicable_________________
______________
Relieving Factors _Not
applicable__________________________________
Treatments Tried _Not
applicable__________________________________
Smoking:
_Smoker___________________________________________
Additional information: Patient works at a nearby
factory and is single. Denies any complaints at this
time and is here today for an annual physical exam.
NONE
Additional Information:
Allergies:
__N.K.D.A._____________________________________________________________________
Page 1
Neg.
HEENT
Pos.
Neg.
Respiratory
Pos.
Neg.
Chills
Dysphagia
Decreased activity
Ear Discharge
Dyspnea
Weight Gain
Esotropia
Stridor
Weight Loss
Exotropia
Sputum Production
Fussiness
Eye Discharge
Wheezing
Irritability
Eye Redness
Lethargy
Headache
Cough:
Quality_______
Freq:_________
Hearing loss
Exposure to TB
Fever: duration___
Tmax:____
Other: _
__
Nasal Congestion
Other: _________
Otalgia
Pharyngitis
Metabolic
Pos.
Neg.
Polydipsia
Page 2
Cardiovascular and
Polyuria
Rhinorrhea
Polyphagia
Sneezing
Brittle Nails
Tearing
Cold intolerance
Vision changes
Heat intolerance
Hirsute
Vision loss
Other: ____________
Vascular
Pos.
Neg.
Chest Pain
Palpitations
Syncope
Thinning Hair
Cool extremities
Other:_________
Cyanosis
Edema
Other: _________
Gastrointestinal
Pos.
Neg.
Urinary
Pos.
Neg.
Immunological
Neg.
Abdominal Pain
Constipation
Dysuria
Diarrhea
Enuresis
Nausea
Flank Pain
Reflux
Vomiting
Other: _____________
Hematuria
Other: ____________
Allergic Rhinitis
Environmental Allergy
Food allergy
Seasonal allergy
Urticaria
Other: __________
Neg.
Page 3
Pos.
Hematologic
Pos.
Easy bleeding
Easy bruising
Lymphadenopathy
Petechiae
Other:_________
Neg.
Female Reproductive
Pos.
Male Reproductive
Pos.
Neg.
Neg.
Musculoskeletal
Pos.
Dysmenorrhea
Straining to urinate
Back pain
Dyspareunia
Urinary hesitancy
Urinary Retention
Bone pain
Menorrhagia
Joint pain
Vaginal Discharge
Erectile dysfunction
Joint swelling
Vaginal itching
Hematospermia
Muscle weakness
Penile discharge
Myalgia
Other:_____________
Premature ejaculation
Other: _________
Scrotal mass
Scrotal pain
Other: _______________
Menarche age:
Last Menses:
Regular Irregular
Frequency:
Flow:
Skin
Neg.
Pos.
Neurological
Pos.
Neg.
Eczema
Pruritus
Neg.
Psychiatric
Pos.
Appropriate interaction
Agnosia
Behavioral changes
Difficulty concentrating
Psoriasis
Confusion
Skin lesion
Paraesthesia
Obsessive behaviors
Seizure
Tremor
Other: ____________
Memory loss
Acne
Other:_____________
Aphasia or dysarthria
Balance disturbance
Other: _______________
Objective Findings:
GCSU Revised Fall 2014
Page 4
Self-conscious
Vital Signs:
o Blood Pressure: __128/74_______ Pulse: _69___________ Respirations:
__14_______
o Temperature:_98.8 F_______ Pulse Ox: _99 %________
Head Circ
(percentile): ______
o Weight : _180 lbs._________
Height : _72 inches_______
BMI :
_24.4__________
Physical Exam:
Physical Exam
Constitutional: Show
Level of Distress
Other:
No acute distress
___________
Nourishment
Overall Appearance
Age Appropriate
Other: ___________
Other: ___________
Other:_________________________________________________
Head/Skull: Show
Appearance
Normocephalic
Fontanels
Choose an item.
an item.
Other: ______________
Choose
Other:________________
Facial Features
Other:
______________
Hair Distribution
Normal Distribution
Other:______________
Other:___________________________________________________
Eyes: Show
Surrounding Structures OS
Normal Structures
Other:___________
Surrounding Structures OD
Normal Structures
Other:___________
External Eye OS
Normal
Other:___________
External Eye OD
Normal
Other:___________
Eye Lids OS
Normal
Other:___________
Eye Lids OD
Normal
Other:___________
Pupil OS
PERRLA
Other:___________
Page 5
Pupils OD
PERRLA
Other:___________
Conjunctiva OS
Clear
Other:___________
Conjunctiva
Clear
Other:___________
OD
Sclera
OS
Normal
Other:___________
Sclera
OD
Normal
Other:___________
Iris OS
Normal
Other:___________
Iris OD
Normal
Other:___________
Cornea OS
Normal
Other:___________
Cornea OD
Normal
Other:___________
Fundoscopy OS
Other:___________
Fundoscopy
OD
Normal
Other:___________
Lens OS
Clear
Other:___________
Lens OD
Clear
Other:___________
Ocular Muscles
Red Reflex
Vision Screen:
Other:___________
Present Bilaterally
Abnormal:_____________________
OS:_20/20_______ OD:_20/20________ OU:_20/20___
Ears: Show
Auricle Right
Normal structure/placement
Other:____________
Auricle Left
Normal placement/structure
Other:____________
Canal Right
Normal
Other:___________
Canal Left
Normal
Other:___________
TM Right
Other:___________
TM Left
Page 6
Other:___________
Hearing
Other:___________
Normal Bilaterally
Discharge - Clear
Naris Left
Discharge - Clear
Other:________________
Other:________________
Turbinates Right
Other:________________
Turbinates Left
Other:________________
Non-tender
Other:________________
Non-tender
Other:________________
Non-tender
Other:________________
Non-tender
Other:________________
Mouth/Teeth:
Lips
Teeth
Normal dentation
Other:__________________
Other:__________________
Buccal
Other:__________________
Tongue
Normal
Palate
Choose an item.
Uvula
Normal configuration
Other:__________________
Oropharynx
Tonsils
+1
Neck:
Palpation of Thyroid: Normal
Describe
Abn:___________________________________
Other:____________________________________________________________________________
Page 7
Lymphatic: Show
Overview: No noted abnormal swelling/tenderness
Respiratory: Show
Chest
Other:_______________
Inspection
Other:_______________
Auscultation
Location
Choose an item.
Cough
Choose an item.
None
Other: ___________________________________________________________________
Cardiac: Show
Morbid Obesity Limits Exam Accuracy: Yes or N/A
Rate/Rhythm
Edema: _None____________________________________
Capillary Refill_Less than 2 seconds in all four extremities___________
Pedal Pulses:__2+
____________
Carotid Bruits:_Negative_____________________
Other Findings:_______________________________________
Abdomen: Show
Inspection
Auscultation
Other:________
Choose an item.
Palpation
Location:
Location:
Normal
Choose an item.
Associated Findings
Other:________
Choose an item.
Hernia _Negative____________________
CVA Tenderness _Negative____________
Other:______________________
Page 8
Male Exam
Show
Musculoskeletal Show
Overview: Normal ROM, muscle strength, and Stability
Posture: No structural abnormalities
ROM: Normal ROM all extremities
Describe
Abn:_______________________________
Muscle Strength: Normal all extremities
Describe
Abn:_______________________________
Joint Stability: Normal all extremities
Describe
Abn:_______________________________
Neurological Show
Mental Status: Alert, Oriented to Time, Place, Person
Describe
Abn:_______________________________
Appearance: Good Hygiene
Describe
Abn:_______________________________
Thought Process: Follows conversation and engages appropriately
Describe
Abn:___________________________________
CN II-XII: Grossly intact
Describe
Abn:___________________________________
DTRs: upper 2+ Avg
Lower:
2+ Avg
Describe
Abn:_______________________________
Sensory: Grossly normal
Body Position: Grossly normal
Describe Abn:_______________________________
Describe Abn:_______________________________
Page 9
Skin Show
Overview: Normal overview but detail exam not done
Lesion Description:
Mole Description:
Rash Description:
Other:___________________________________________________________________________
Results of labs done today: _CBC, CMP, Lipid
pending___________________________________________
______________________________________________________________________________________
__
SBIRT
Date of Alcohol Screening: _6/03/2015__________________
Alcohol Screening Instrument(s) Used: _AUDIT____________
Alcohol Screening done by: _Salena Barnes NPS___________
Alcohol Screening Results: Positive
Brief Interventions conducted: Yes (with patients consent to discuss results
to questionnaire)
Brief Intervention delivered by: _Salena Barnes NPS_______
Length of Brief Intervention: _15 minutes
_____________
Audit score: 5 Zone II: At Risk
Referrals to Treatment provided: Yes/No
Type of Referral to Treatment: _N/A_
___
Additional information: In discussing the issue, my medical advice was that
he cut back to no more than 4 drinks in one day and no more than 14 per
week. His readiness for change was 6 on a scale of 0-10. We explored why it
was not a lower number and discussed the patients own motivation for
change. He was unaware of effects excessive alcohol consumption had on
the body. He agreed to cut back to the advised daily and weekly limits. A
prescription for change was provided and the patient will contact the office
for any further questions or concerns.
Assessment/Plan:
Page 10
Quantity
Dose
Sig
New Pt.
Office
Est. Pt.
Health Check
New Pt.
Health Check
99211
99212
99213
99214
99215
------99201
99202
99203
99204
99205
99391 (<
1yr)
99392 (1-4yr)
99393 (511yr)
99394 (1217yr)
99395
(18yr>)
99381 (<
1yr)
99382 (14yr)
99383 (511yr)
99384 (1217yr)
99385
(18yr>)
99408
Page 11