DATE: ______ /______ /______ PCP ________________ Location ________________ Contacted CHIEF COMPLAINT:
Teaching / Attending MD Key Findings:
Always document chief complaint. HPI: CHP1=4+elements or status of 3 chronic conditions; CHP2&3=4+
PAST MEDICAL HISTORY: (include health maintenance & vaccines) Last influenza vaccine (month/year) ______/______
Pneumococcal vaccine (month/year) _____/______
SURGICAL HISTORY:
FAMILY HISTORY:
SOCIAL HISTORY: Occupation: ________________________________
Alcohol:_____________________________ HIV risk factors: ___________________________ Tobacco:____________________________ Travel: __________________________________ Counseled about cessation Pets: ____________________________________ Illicit drugs: __________________________ Hobbies: _________________________________ Lives with:___________________________ Housing: Urban house Trailer Farm Homeless MEDICATIONS: Please see medication reconciliation form on pages 5-6
Teaching / Attending MD Key Findings:
PMH, Family, Social History: CHP1=1 of 3
CHP 2 & 3 = 3 of 3
ALLERGIES
:
REVIEW OF SYSTEMS: (check if done, circle abnormal) ROS: CHP 1 = prob. pertinent + 2;
CHP 2 & 3 = 10+ elements General
Eyes - poor vision, pain
ENT - sore throat, pain, coryza, acuity, dysphagia CV - pain, palpitations, hypo/hypertension Resp – dyspnea, cough, tachypnea
GI – pain, nausea, vomiting, diarrhea, constipation GU - pain, bleeding, incontinent, nocturia, foul smell Muscle – pain, weakness
Skin – rash, pain, abscess, mass
Psych - fatigue, insomnia, mood problem, crying, depression Endocrine - hot flashes
Hem/Lymph – fevers, chills, swelling, night sweats Neuro: numbness, tingling, weakness, headache, loss of consciousness
Immunologic/Allergies:
PHYSICAL EXAMINATION: (if normal: ; if abnormal: & describe) Abnormal Findings Descriptions
Vitals BP_____/_____ P_____ R_____ T______ Pain _____/10 SaO2 ______% Ht_______ W_______ General_______ Teaching / Attending MD Key Findings: Exam: CHP 1 = extended; CHP 2 & 3 = 8+ organ systems
Eyes
Conjunctivae, lids, pupils & irises
Fundi: Y N Y N
Disc edges sharp Hemorrhages
Venous pulses seen Exudates
ENT, Neck, Breast
External canals, TMs Nasal mucosa, septum
Lips, gums, teeth Oropharynx, mucosa, salivary glands Hard/soft palate, tongue, tonsils, posterior pharynx
Thyroid Neck (note bruit, JVD) Breasts (note dimpling, discharge, mass)
Resp
Respiratory effort (note use of accessory muscles) Lung percussion & auscultation
Cardiovascular
Auscultation: Y N
Regular rhythm Palpation of heart
S1 constant Abdominal aorta
S2 physiologic split Femoral arteries
Murmur (describe) Pedal pulses
GI
Abdomen: Y N Bowel sounds:
Scars normal
Bruit ↑ ↓
Mass absent
Tenderness Stool:
Hepatomegaly Heme positive
Splenomegaly Heme negative Anus, perineum, rectum, sphincter tone
GU
Male: Penis Testes Prostate
Female: External genitalia Cervix
Uterus/adnexa
Lymph nodes Skin & SQ tissue (describe any rash)
Lymph,skin musc/skel
Gait & station Digits, nails ROM, stability Joints, bones, muscles Muscle strength & tone
Neuro
Cranial nerves (note deficits) DTRs Motor Sensation
Psych
Judgment & insight Mood & affect Oriented to time, place, person Memory Teaching / Attending MD
Key Findings: LABS Na ALT PT WBC
K AST PTT •% Bands
Cl ALP Hgb •% PMNs
CO2 Albumin Platelet •% Lymphs
BUN d-bili •% Monos
Cr i-bili •% Basos
Glu Amylase •% Eos
Lipase
Decision Making (meet 2 of the following 3): No. of diagnoses: CHP1 = 1 CHP2 = 3 CHP3 = 4+
Data reviewed &/or Ordered: CHP1 = 0-2 CHP2 = 3 CHP3 = 4+ Labs review/order Radiology tests review/order Medicine tests review/order (EKG, echo, cath, vasc tests, PFTs) Discuss results w/ performing MD Independent review of image, tracing or specimen Obtain old records &/or history from person other than pt Review/summarize old records &/or obtain hx from person other than pt
Risk:
CHP1=Min-low CHP2=Mod. CHP3=High
Teaching / Attending MD
Key Findings: IMPRESSION & PLAN
Discharge Planning: Estimated length of stay: ____ days. Likely disposition: Home Nursing home Correctional facility
Resident Signature: Date:
I was present with the resident during the entire interview & examination of the patient. I repeated the key portions of the exam in the presence of the resident. I confirmed/revised the resident’s history, exam, assessment & plan as noted in the margin. See resident’s notes for details.
I was NOT present with the resident during the entire interview & examination of the patient. I personally interviewed the patient & repeated the exam. I confirmed/revised the history, exam, assessment & plan as noted in the margin. See resident’s notes for details.
__________________________________________________________ ____________________________ __________________
Interdisciplinary Admission Medication History
Each healthcare provider who adds information to this document must initial and sign his/her name.
The admitting physician will review listed medications, determine the admission medication plan, and sign this page.
Key for source(s) of information: Patient Family Transfer records Rx vials Pharmacy (phone #____________________) Cerner Info System Other Home/Prior to Admission Prescription Medications (List Below) 1 NONE
Physician Review & Admission Medication Plan Date Initials Source
of Info Medication Name Dose Route Frequency
Date/Time
Last dose Order Modify
Do not order every every every every every every every every every every every every
Prescription medications are continued on back of form
Home/Prior to Admission OTC, Herbal & Homeopathic Preparations (List Below) 1 NONE
every every every every
OTC, herbal, and homeopathic medications are continued on next page
Each healthcare provider who adds information to this document must initial and sign his/her name:
Initials ___________ Print name ______________________________Signature __________________________ Initials ___________ Print name ______________________________Signature __________________________
*Admitting Physician Review:
Signature: ___________________________________________ Date & Time: ________________________
Each healthcare provider who adds information to this document must initial and sign his/her name.
Key for source(s) of information: Patient Family Transfer records Rx vials Pharmacy (phone #_____________________) Cerner Info System Other
Home/Prior to Admission Prescription Medications and
OTC, Herbal & Homeopathic Preparations (List Below)
Physician Review & Admission Medication Plan Date Initials Source
of Info Medication Name Dose Route Frequency Date/Time
Last dose Order Modify Do not order every every every every every every every every every every every every every every every every every
Each healthcare provider who adds information to this document must initial and sign his/her name:
Initials ___________ Print name ______________________________Signature __________________________ Initials ___________ Print name ______________________________Signature __________________________ Initials ___________ Print name ______________________________Signature __________________________ Initials ___________ Print name ______________________________Signature __________________________ Initials ___________ Print name ______________________________Signature __________________________
58-354
Form H-MR 717 Revised 09/2006 Medical Record Copy Medical Records Committee
