Constipation - American Health Care Association
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Patient Name: ___________________________ Date of Birth: ___________________________ Medicaid Record Number: _________________ CHAT: Constipation History When was the patient’s last bowel movement? Tell the story: ____________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Is the patient on any narcotic pain medicines? Tell the story: _____________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Does the patient’s medicine list include any stool softeners or laxatives? Tell the story: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Associated symptoms: □ Nausea □ Decreased appetite □ Abdominal pain or cramps Exam Current vital signs: ______________________________________________________________ Abdominal exam: □ Is the abdomen distended? □ Are bowel sounds present? □ Is the abdomen tender to palpitation? If patient has not had a bowel movement for 3 days or more, consider performing a rectal exam to check for impaction. ***Do NOT perform rectal exams on patients who are undergoing XRT to the prostate or rectum, OR have a diagnosis of proctitis OR if the patient has neutropenia (low white blood cell count). If you are not sure, check with the doctor first. If you do perform a rectal exam: □ Was the patient impacted? □ Was disimpaction successful? 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)
