Nausea and/or Vomiting
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Patient Name: __________________________ Date of Birth: ___________________________ Medicaid Record Number: _________________ CHAT: Nausea and/or Vomiting History How long has the patient had nausea/vomiting? Tell the story: ___________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ □ Has the patient vomited? □ Any blood in vomitus? How many times in the last 24 hours? _______________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Other symptoms in the last 24 hours: □ Diarrhea □ Abdominal pain □ Constipation Any new medications in the last 48 hours, including PRN’s? ___________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Is the patient receiving chemotherapy or radiation? ___________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Exam Blood pressure, pulse, temperature _________________________________________________ Other pertinent information may include an assessment for impaction (rectal exam) or abdominal exam for bowel sounds, pain, distention) ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Staff Name: _______________________________________________________________(RN/LPN) ___________ Reported to: Name: _________________________________ (MD/NP/PA) Date: _________ Time: _______am ___ pm _____ If to MD/NP/PA, communicated via: ______________ Phone _______________ In person ______________ (This CHAT has been modified by AHCA. The original CHAT is a product of Duke University.) Patient Name: ___________________________ Date of Birth: ___________________________ Medicaid Record Number: _________________ CHAT Progress Note Progress Note (complete and place CHAT/progress note in medical record) _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ __ Family or health care proxy notified Return call/new orders from MD/NP/PA Date___/___/___ Time___/___AM/PM Signature________________________________RN/LPN Date___/___/___ Time___/___AM/PM (This CHAT has been modified by AHCA. The original CHAT is a product of Duke University)
