progress note

advertisement
Patient Name: ________________________________________
ADULT PROGRESS NOTE
Date of Birth: ________________________________________
Date: ____________________________
 New
 Return
Medical Record Number: _______________________________
 Periodic
 Chart Not Available  Interval ED Visit  Interval Admission
 Missed App’t(s)
 Needs Prescriptions
Allergies:  Yes (See Adult Summary Form)
 No
CC: _________________________________________________________________________________________________________
____________________________________________________________________________ Initial: ___________________________
HPI: (Location, Quality, Severity, Duration, Timing, Context, Modifying Factors, Assoc. Signs/Symptoms)
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Medications:  None
 See Updated Med List
Review of Systems:
+




- Constitutional




Change Wt
Fatigue
Temperature/Chills
Weakness
Skin


































Chng Color
Chng Hair/Nails
New Lesions
Pruritis
Rash
Xerosis
Eyes
Cataracts
Chng Vision
Glaucoma
Redness
ENMT
Bleeding Gums
Chng Hearing
Chng Voice
Dentures
Epistaxis
Hoarseness
Sinusitis
+
-
+
-
Asthma
Bronchitis
Cough
DOE
Hemoptysis
Pneumonia
SOB




















Cardiovascular
+
- Genitourinary
Angina
CAD
Chest Pain
Claudication
DOE
Edema
HTN
Orthopnea
Palpitations
PND






















  Tinnitus
  Ulcers
Respiratory


































Gastrointestinal
Constipation
Diarrhea
Dysphagia
Fecal Incontinence
GERD
Hematochezia
Hemorrhoids
Melena
N/V
PUD
Chng Stream
Hematuria
Hernia
Hesitancy
Impotence
Incontinence
Nocturia
Polyuria
Scrotal Masses/Pain
STD’s
Urgency
  BRBPR
  Chng Bowel Habits
+ - Musculoskeletal
+










  Breast Pain
  Breast Lumps
  Breast Discharge










Arthritis
Cervical Pain
Decreased Motion
Gout
Injuries
Joint Pain
Joint Stiffness
Locking Joints
Low Back Pain
Swelling
Psychiatric
























Depression
Homicidal Ideation
Substance Abuse
Suicidal Ideation
Time/Place Orientation
Recent/Remote Memory
Anxiety/Agitation
-
Endocrine


























Chng Concentration
Chng Memory
Dizziness
Headache
Imbalance
Numbness
Seizures
Tremor
Weakness








Anemia
Easy Bruisability
Enlarged LN’s
HxTransfusions
Neurologic
Female Reprod.
Abnormal Menses
Dryness
Dyspareunia
Sexual Abuse
Vaginal Discharge
Heat/Cold Intol.
Neck Enlargement
Polydipsia
Xerosis
Hematologic
Comments:
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
 PMH Reviewed – No Changes; See Adult Summary Form
 SHx Reviewed – No Changes; See Extended Hx Form
 FHx Reviewed – No Changes; See Extended Hx Form
 PMH Reviewed & Updated; See Adult Summary Form
 SHx Reviewed & Updated; See Extended Hx Form
 FHx Reviewed & Updated; See Extended Hx Form
Vital Signs:
Age: ____________
Weight: ____________BMI: _____________Temperature: _____________Blood Pressure: ______________Pulse: _______________
Respirations: ________ Fingerstick: _____________ LMP: _____________ Oxygen Saturation: _______________ Initials: _________
Physical Exam:
Nl


Ab General
 Appearance
 VS









 Conjunctiva/lids
 Pupils (Reactivity/Accom) 
 Disc/Fundi

 EOM

ENMT

 Ear Infection

 TMs & Canal

 Hearing (Whisper, Etc.) 
 Weber

 Rhinne

 Nasal Mucosa/Septum/

Turb.

 Lips/Gums/Teeth
 Oropharynx
Neck

 Appearance

 Symmetry

 Trachea

 Thyroid

 Lymph Nodes





Nl Ab
  Auscultation
  Percussion
  Palpation
Eyes








CV











PMI
Palpation
Auscultation
Rhythm
Rate
S1
S2
Carotid Art.
Abd. Aorta
Fem. Pulses
Extremities (Edema/
Varicose Veins)






Inspection
Palpation
Right Breast
Left Breast
Right Axillae
Left Axillae
Chest
Lungs
Nl





Ab








































 Neck
 Supraclavicular
Skin
GU – Male
Scrotum/Testes
Penis
Anus
Perineum
Rectal Area (Ext.)
Prostate (DRE)
Occult Blood
GU – Female
Abdomen

Resp. Effort
Rib Excursion
Nl Ab
  Axillary
  Inguinal
  Other ___________
Bowel Sounds
Palpation
Liver Span
Spleen
Inguinal Area
Ext. Genitalia
Urethra
Cervix
Adnexa
Uterus
Bladder
Saline/KOH
Rectal Exam
Occult Blood
Lymph Nodes
Inspection


 Inspection
 Palpation






































Neuro
Nl












Cranial Nerves
Tendon Reflexes
Biceps
Triceps
Patellar
Achilles
Brachioradialis
Motor Strength

Upper Ext. – Strength
Lower Ext. – Strength 
Sensory

Light Touch

Pin Prick

Vibration

Temperature

Proprioception

Romberg

RAM

Babinski Eval
Ab












MSK
Inspection
Exam of Joint
Head & Neck
Spine/Ribs
Pelvis
RUE Stability
LUE
ROM
RLL
Strength
LLE
ROM
Gait
Clubbing/Cyanos
Edema
Psychiatric
 Orientation
(Person, Place, Time)
 Mental Status
 Judgment
 Insight
 Short-Term Mem
 Long-Term Mem
 Mood
 Affect
 Concentration
 Speech
Comments: ____________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
Assessment & Plan: ___________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
 SF  L  M  H Medical Decision-Making
 See Continuation Sheet
Counseling

















Advance Directives
Alcohol
BSE
Dental Care
Diabetes
Domestic Violence
Exercise
Eye Protection
Foot Care
Firearms Risk
Hearing Conserv.
Hormone Replacement
Medication S/E
Noncompliance
Nutrition
Osteoporosis
Pregnancy Prevention







Seat Belts
Smoke Detectors
STD/HIV Counseling
Substance Abuse
Sun Protection
TSE
Tobacco Cess.
Labs Ordered
 BMP
 CBC
 Cholesterol Profile
 CMP
 Drug Level
 GC/Chlamydia
 Hb A1c
 Hepatic Profile
 Hepatitis Serology
 HIV














INR
PAP
Pregnancy Test
PSA
Rapid Strep
Renal Profile
RPR
Stool Cards
TFTs
Throat Culture
Urinalysis
Urine Culture
Urine Pregnancy Test
Other _______________
Tests Ordered










CXR
Echocardiogram
Electrocardiogram
Flex Sig
IVP
Mammogram
Stress Echo
Stress Test ________________
Ultrasound
Follow Up ________________
Follow Up
____ Day(s)
____ Week(s)
____ Month(s)
____ Prn
 BE
 Colonoscopy
 Pending Test(s) ___________
 CT/MRI _____________
BP Check In
____ Day(s)
____ Week(s)
____ Month(s)
Call Office
____ Day(s)
____ Week(s)
____ Month(s)
____ Prn
Labs to be Done In
____ Today
____ Day(s)
____ Week(s)
____ Month(s)
 Old Records Requested
Referred To ________________________________________________________________________ Time Counseling (Minutes) ______________________
Signature __________________________________________________________________________ Date _________________________________________
Download
Random flashcards
Arab people

15 Cards

Radiobiology

39 Cards

Pastoralists

20 Cards

African nomads

18 Cards

Ethnology

14 Cards

Create flashcards