Cheat Sheet for Specific Visits

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Cheat Sheet for Specific Visits:
Acute Visits
(including colds,
flus, vomiting,
pain, etc)
Anxiety,
Depression &
ADHD (initial)
Asthma f/u
Birth control
Diabetes
Mellitus
Chest Pain
Chronic Pain
Diabetes
Dizziness
Deployers/TDY
clearance
Erectile Dysf
o
o
o
o
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Onset, duration, intensity, exacerbating and relieving factors
What has pt tried to help assist with sx
Localized/radiating
Loss of ROM
Document onset, previous history of same, counseling.
Ensure AUDIT screening is completed.
PHQ9/GAD7
Utilize ADHD screening tool from UpToDate or Vanderbilt.
Epworth and Stop Bang
Labs should be ordered by the technician prior to visit: TSH, Vitamin D, CBC, CMP and
A1C
o Document ACT, Peak flow x3 and average (document all 3), frequency of use of albuterol,
controller medication if applicable, when was the last time albuterol was used, and
identified triggers.
o GC urine if 24 or under
o Contact patient to ensure that patient will bring glucometer. Labs should be ordered if they
have not been ordered. Patient should be notified to attend lab if possible prior to visit as
this cuts down on T Cons.
o Update or document last foot exam and eye exam.
o Obtain an A1C if last A1c was over 7.0 or was greater than 6 months ago. Obtain lipids
and CMP if not completed in last 12 months.
o Perform EKG if patient age over 45 and chest pain is occurring at time of encounter.
o Perform EKG for anyone who reports chest pain since last visit if age over 55 and one of
the following: smoker, BMI over 30, history of HTN, hyperlipidemia, or diabetes, AUDIT
screener is positive, patient has history of MI or family history of MI before 55 years of
age. (Also order EKG in AHLTA.)
o Document if same/better/worse; pain medications, recent consults, any recent
imaging/radiology
o Previous treatment with ortho/chiro/physical therapy
o Lipid panel, CMP, micro/albumin (urine), A1c;q 3 months if not stable. Obtain an A1C if
last A1c was over 7.0 or was greater than 6 months ago.
o Complete orthostatic vitals.
 Document patient’s duties as an airmen, their projected deployment responsibilities and the
place the patient is deploying to.
 Review ASIMS tab for restrictions, fitness and quarters authorizations.
 Any names of the medication, # of remaining refills, dosage and frequency should be
documented.
 Medication reaction/adverse effects should be documented.
 Document specialist visits, hospitalizations and ER visits in the last 12 months in the HPI.
This includes phys therapy.
 Document any concerns patient has regarding deployment.
 SHIM score, PHQ9, GAD7
 Order labs: testosterone, FSH, and PSA, urinalysis, prolactin, lipids, CMP and A1c if first
visit.
Last Edited 12/1/2018 3:30 AM
1
Fatigue &
Insomnia
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Hyperlipidemia
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Obs Sleep
Apnea/Snoring
Pediatric
Patients
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PHQ9 and GAD7
Epworth and Stop Bang
Labs should be ordered by the technician prior to visit: TSH, Vitamin D, CBC, CMP and
A1C
Labs should be ordered yearly. (CMP, A1C and Lipid profile (patient must fast first)
Name of the medication, # of remaining refills, dosage and frequency should be
documented.
Medication reaction/adverse effects should be documented.
Contact patient to ensure that patient will bring BP log if available. Labs should be ordered
if they have not been ordered since last visit (CMP, Lipids, A1c, micro/albumin (urine)).
An EKG should be performed at baseline and q 2 years. An EKG should be performed if
patient reports any chest pain since last visit.
Chest pain, headache, sob, decreased urinary output should be documented.
Name of the medication, # of remaining refills, dosage and frequency should be
documented.
Medication reaction/adverse effects should be documented.
CMP, A1C and Lipid profile (patient must fast)
Name of the medication, # of remaining refills, dosage and frequency should be
documented.
Adverse reactions or change requests should be documented.
Appropriate documentation dependent on the type of medication. PHQ/GAD for
depression and anxiety. Stop bang/Epworth for OSA. ACT for asthma.
See fatigue & insomnia above.
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MCHAT and ASQ must be completed prior to pt being seen by provider.
Copy the growth chart into note.
Print out the entire Bright Futures fact sheet/anticipatory guidance for the appropriate age.
Physical
(annual)/Well
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Review labs prior to huddle.
Order screening labs every other year if BMI over 30 or age over 40 years: CMP, A1C and
Lipid profile (patient must fast).
Screen patient for medication and supplements, new complaints and new ER visits,
procedures or hospitalizations since last visit.
Print copy of previous profile.
Utilize RILO/MEB worksheet if possible.
Document improvement/deterioration of symptoms.
Document last specialist visit.
Labs should be ordered prior to clinic visit.
Hepatitis panel, RPR, HIV, RPR
Hypertension
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Hyperlipidemia
Medication
refills
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RILOs/MEBs
Sexually
Transmitted
Illnesses
Urinary Sx
Well Woman
Visits/Pap
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Order urinalysis and culture
Fill out Well Woman tab in its entirety including the type of birth control utilized.
Order labs per protocol. (No HPV before 30. Order cytology with reflex below 30, etc.
Always order KOH/Wet prep and GC if under 35. Ask if uncertain.)
Last Edited 12/1/2018 3:30 AM
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