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: ___________________________
______________________________________________________________________________
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□ 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? ___________________________________
______________________________________________________________________________
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______________________________________________________________________________
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)
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__ 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)
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