Professional Documents
Culture Documents
Time
ROS WNL See HPI HPI Asthma Symptom Frequency 64
Constitutional
Eyes 1+ days per week
ENT/mouth OR 1+ nights per month
Resp 2+ days per week
CV OR 2+ nights per month
GI Daily
GU OR 2+ nights per week
Musc Antibiotic use Oral steroid use Continual
OR Frequent
Skin/breasts ER visit for asthma Hospital admission for asthma
Discharge Medications from hospital/ER visit reconciled 46
Neuro Physical Exam Checked box indicates findings are within normal limits
General Alert Vital signs Temp Pulse BP RR Sats
Endo
Heme/lymph ENT Mucosa Dentition Oropharynx Mallampati I II III IV
Allergy/Immun Neck Palpation Thyroid No JVD
Psych Resp Auscultation Percussion Respiratory effort Palpation Chest wall
History No changes See HPI CV Clear S1 S2 No murmur No gallop No rub Peripheral pulses No peripheral edema
Allergies GI No palpable masses No hepatosplenomegaly No hepatojugular reflux
PMSH Lymph No lymphadenopathy
Social Musc Tone Gait
Family Extrem Digits without clubbing or cyanosis
Asthma Severity Skin No rashes, ecchymoses, nodules, ulcers
Mild Intermittent Neuro Oriented (person, time, place) Affect
Mild persistent Impression and Plan Tests to be ordered
Moderate persistent Bronchoscopy
Severe persistent Pulmonary Function Testing
Asthma Therapy Sleep study
Current New CXR
Short-acting beta Chest CT with contrast
agonist
“Rescue Agent” Echocardiogram with
Bubble study PA pressures
Inhaled steroid 53
Long-acting beta
Cardiopulmonary Stress Test
agonist Pulmonary Rehabilitation
Theophylline Pneumococcal vaccine
Omalizumab Influenza vaccine
Oral steroids PPD Testing
Antibiotics Allergy skin testing
Leukotriene Labs
inhibitor Instruction & Education
Oral antihistamine Asthma action plan
Intranasal steroids Smoking cessation
Intranasal Peak flow meter use
antihistamine Inhaler use
Smoking
cessation aids Importance of vaccinations
Patient has completed advanced health care directives 47 Medication side effects
Follow Up HCPOA is
Signature Advanced care directives explained
©MB and RR 2006, 2007 Form offered to patient
Data Reviewed ER Notes Old Chart EMS Note ECG Nursing Notes & Vitals log Labs X Rays MRI
US CT
Care Coordinated WithER MD HCPOA Primary Care MD Case Management Social Worker Pharmacy