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Patient _________________________________________ DOB _____ / _____ / _____ MRN _____________________
Date Time Chief complaint/Reason for consult Referring MD
Yes No
Constitution Reset
Fatigue History of Present Illness Patient is Nonverbal. History obtained from Family Medical records
Malaise Elements of HPI: Location, quality, severity, timing, duration, context, modifying factors, associated signs and symptoms
Fever or chills
Appetite changes
Eyes Reset
Vision changes
New pain
Scotomas
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ENT/mouth Reset
Nose bleed
Dental caries
Dental abscesses
Jaw pain
Respiratory Reset
Myalgias
Arthralgias Social History / Risk factors
Joint swelling Denies Yes Ever smoker ___ # Packs X ____ # Yrs Denies Yes Patient has tried smoking cessation aids
Recent trauma Denies Yes Chews tobacco Nicotine replacement
Skin/Breasts Reset Denies Yes Quit tobacco use Quit date _________ Buproprion or nortriptyline
Masses Patient is unwilling to quit Nicotine receptor blockade
New skin lesions Patient willing to consider quitting
Patient quit, but resumed smoking
Rashes
Patient willing to quit within 1 month
Sensitivity to sun
Neurologic Reset
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Denies Yes Feels safe at home or work Denies Yes Alcohol use ___ Drinks per day week
Headaches
Denies Yes Tattoos Denies Yes Felt the need to cut down on drinking?
Seizures Denies Yes High risk sexual behavior Denies Yes Annoyed by others criticizing drinking?
Muscle weakness Denies Yes Recreational drug use Denies Yes Guilt associated with drinking?
Endocrinologic Reset
Inhalational Injectable Ingestible Denies Yes Eye opener needed?
Hair loss Denies Yes Drug dependence
Polydipsia Narcotics Benzodiazepines
Tremors
Neck pain Occupational and Exposure History
Heme/Lymph Reset Inorganic dusts i.e., quarries, sandblasting, cement, stone carving, welding, plumbing, shipyard work, firefighter
Organic dusts i.e., farming, building inspection, woodworking, remodeling, handling vegetable matter or animals
Bleeding gums
Unusual bruising
Swollen lymph nodes
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Noxious fumes i.e., spray painting, autobody work, working with dyes or glues, manufacturing plastic
Hot tub or Jacuzzi or High Pressure washings
Pets or feathers
Allergy/Immunology Reset
Chemicals or fires
Sinus problems
Recurrent infections Family Medical History
Psychologic Reset
Asthma CHF COPD Coronary Artery Dis Pancreatitis Peripheral Artery Disease Renal Dysfunction
Mood changes
Thrombotic disorder Thyroid Disease
Agitation
Malignancy in first degree relatives, specify
Hallucinations
©MB and RR 2006-2008 Revised 31Oct08 e-medtools.com Indicates Physician Quality Reporting Initiative (PQRI) Physician Quality Measures
Completion of this form meets or exceeds the documentation requirements in the 1997 Guidelines for Evaluation & Management Services
Pulmonary Evaluation www.e-medtools.com
Patient _________________________________________ DOB _____ / _____ / _____ MRN _____________________
Exam To qualify as a comprehensive exam: General Multisystem requires performing ALL of ≥9 organ systems, AND ≥2 elements documented in each organ system
Respiratory Single Organ System Exam requires documentation of ALL highlighted organ system elements, AND ≥1 element in every other organ system is expected
Ventilator, IV Medications & Labs Constitutional (≥ 3 vitals) Body habitus and Grooming required of General Multisystem but not Organ System Exam
Mode AC SIMV PC Temperature __________ Pulse Rate __________ AND Rhythm Regular Irregular
PRVC Other ____________
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Blood Pressure sitting __________ / __________ OR standing __________ / __________
Rate __________
Blood Pressure lying __________ / __________
Tidal Vol __________
Respiratory Rate__________ Optional Sats _____ % Cardiac Output _____ SVR _____
PEEP __________
Body habitus wnl Cachectic Obese
PS __________
Grooming wnl Unkempt
ENT
FiO2 __________
Nasal mucosa, septum, and turbinates wnl
PO2/FiO2__________ Dentition and gums wnl Dental caries Gingivitis
____________________________
Lymph node exam wnl Areas examined Neck Axilla Groin Other ___________________
Steroids
____________________________ Lymphadenopathy noted in Neck Axilla Groin Other ___________________
Musc
Paralytic
____________________________ Muscle tone within normal limits, and no atrophy noted
Thrombolytic Tone is Increased Decreased Atrophy present
____________________________ Gait and station wnl
TPN Ataxia Wide based gait Shuffle Patient leaning Rt Lt Front Back
Labs www.e-medtools.com
Extrem
Exam wnl Clubbing Cyanosis Petechiae Synovitis Rt Lt ________________________
\____/ Skin
/ \ No rashes, ecchymoses, nodules, ulcers Periungual telangiectasias Splinter hemorrhages
Neuro
____ / ____ / ____ /
Oriented 58(Pts with Community Acquired Bacterial Pneumonia) NOT oriented to Person Time Place
\ \ \
Affect is within normal limits OR Patient appears Agitated Anxious Depressed
©MB and RR 2006-2008 Revised 31Oct08 e-medtools.com Indicates Physician Quality Reporting Initiative (PQRI) Physician Quality Measures
Completion of this form meets or exceeds the documentation requirements in the 1997 Guidelines for Evaluation & Management Services
Pulmonary Evaluation
Data Reviewed
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Patient _________________________________________ DOB _____ / _____ / _____ MRN _____________________
Impression
ER Notes Code Status Patient is a FULL CODE DO NOT ATTEMPT RESUSCITATION
Old medical records Patient has completed advanced health care directives 47
Labs HCPOA is _______________________________________
Radiology data
ECHO
ECG
Stress Test
Pulmonary Function Test
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Nursing Notes/Vitals log
Recommended Actions
Aggressive pulmonary toilet
DVT prophylaxis
Stress ulcer prophylaxis
Daily sedation vacation and
neurologic assessment
Head of bed elevated > 30 Degrees
at all times
Intense glycemic control
Insulin infusion
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Central line change or removal
(send tip for culture)
Physical therapy
Enteral/Parenteral feeds
Smoking cessation aids
Pneumonia vaccine prior to discharge
Influenza vaccine prior to discharge
Recommended Diagnostics
PPD Testing
12-lead EKG www.e-medtools.com
Echocardiogram
Sputum culture
Bacterial Fungal AFB
Blood culture
Urine culture
CSF culture
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CBC with differential
PT, PTT, INR
BMP (with calcium)
HIV
Hepatitis panel
Signature ________________________________________ cc __________________________________
©MB and RR 2006-2008 Revised 31Oct08 e-medtools.com Indicates Physician Quality Reporting Initiative (PQRI) Physician Quality Measures
Completion of this form meets or exceeds the documentation requirements in the 1997 Guidelines for Evaluation & Management Services
Pulmonary and Critical Care New Patient Evaluation Template
Definitions
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Date Start time Stop time
Physiologic Score
APACHE II Score - To be obtained within first 24 hours of ICU Admission
Sepsis APACHE II: a severity of disease classification system Crit Care Med 1985 13(10):818-29 Temp ______
Positive blood culture AND An evaluation of outcome from intensive care in major medical centers Ann Intern Med 1986 104(3):410
Heart rate >⁄= 90 Prediction of outcome from intensive care: a prospective cohort study comparing Acute Physiology and Chronic Health Evaluation II HR ______
and III prognostic systems in a United Kingdom intensive care unit Crit Care Med 1997 25(1):9-15
Temp <⁄= 36 C or >⁄= 38 C
Physiologic Variable 0 1 2 3 4
Resp rate >⁄= 20 OR MAP ______
Temperature 96.8-101.2 101.3-102.1 89.6-93.1 102.2-105.7 >105.7
PCO2 <⁄= 32 on ABG 93.2-96.7
WBC <⁄=4000 OR Heart Rate 70-109 n/a 110-139 140-179 >161 RR ______
>⁄= 12000 OR 55-69 40-54 < 50
>⁄= 10% Bands Oxygenation ______
Resp Rate
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(2 x DBP + SBP)/3
70-109
12-24
n/a
25-34
110-129
50-69
6-9
130-159
35-49
>181
<40
>49
Serum Na ______
©MB and RR 2006, 2007 Revised 13Nov07 www.e-medtools.com Indicates 2007 Physician Quality Reporting Initiative (PQRI) Physician Quality Measures