Professional Documents
Culture Documents
Medications Reviewed
HPI Reviewed and Unchanged R ROS: Reviewed R Form Reviewed
PMH: HEENT:
Respiratory:
FH: CV / Chest:
GI / Abd:
SH: GU:
Musc. / Skel:
Skin / Lymph:
Neuro / Psych:
Smoking Hx: ppd x yrs
None Pt Household Counseled >3 minutes Precontemplative
Gen Appearance / Mood / Affect / Orientation: WNWD/AAO/NAD Labs / Test / Diagnostic Procedures
HEENT: nml eye movement, conjunctivae & lids, perrl, thyroid, external ears,nose, lips Urine Dip Holter Monitor
Respiratory: nml rhythm, deep & even, symetrical, BBS clear Rapid Strep PFT
Heart: S1/S2, w/o murmur, edema, strong/= pulses BUE Influenza EKG
Abdomen: No masses, tenderness, hernias Urine HCG Ear Irrigation R / L
Musc/Skel: Nml steady gait, station, overall strength and tone Mono-Spot Typmanogram
Skin: p/w/d, free of concerning rashes, bruises, lesions HgA1C Lipid Panel
Neuro: Nml facial symetry, DTRs, sensation, H. Pylori Old Records
Lymp: No palpable nodes, cervical, submental, subclavicular Other X-ray
Additional: Neb Tx FS Blood Glucose
Injection _____Toradol ______ Rocephin
Injection
Send out labs
CBC CMP BMP TSH PT/PTT INR
Assessment: Plan:
Instructed on typical course of illness / injury and potential further workup. Weight / Exercise / Nutrition Counseling
Side effects discussed Diabetic Counseling
Pt instructed to return if worse or if further symptoms develop ER Instructions given Discussed age appropriate medication use for
Information sheets given symptomatic relief
Discussed Smoking Illicit Drugs ETOH High Risk Sexual Behavior Breast Self Exam Discussed appropriate use of narcotic meds
Labs / Test Result Reviewed Discussed Return Appt. in__________ days / wks / month
Plan Discussed with patient and verbal consent obtained
Patient (Caregiver) verbalized understanding Date:
Greater than 50% of minutes spent in counseling /coordinating re: