Professional Documents
Culture Documents
MRN / DOB:
DATE / TIME:
SOURCE:
PCP:
CHIEF COMPLAINT:
(age, pertinent PMH, chief complaint, duration)
MEDICATIONS:
(admission medications, including doses; cross check any chart information with patient)
1.
IMMUNIZATIONS:
(include Pneumovax, influenza, Hep A, Hep B, and tetanus)
SOCIAL HISTORY:
(current living situation [support at home, presence of threatening environment])
(occupation, interests)
(cultural background [origin, language, spiritual beliefs, complementary medicine, health literacy])
FAMILY HISTORY:
(conditions related to patient)
(common disorders [breast CA, colon CA, HTN, CAD, hypercholesterolemia, HH])
REVIEW OF SYSTEMS:
(circle positives and elaborate, cross out negatives)
general:
skin:
musculo:
head:
headache, dizziness
eyes:
ears:
nose:
oropharynx:
neck:
pain
nodes:
enlargement, tenderness
breasts:
respiratory:
cough, wheezing, sputum, hemoptysis, SOB, pleuritic CP, snoring, daytime somnolence
CV:
GI:
GU:
gynecologic:
neurologic:
paralysis, weakness, paresthesia, transient loss of speech or vision, memory loss, vertigo
psychiatric:
PHYSICAL EXAM:
(pertinent positives and negatives; items with an * should be explained if not performed)
(for vitals, be sure to include weight, BMI, SpO2, and whether pulse is regular or irregular)
general:
vital signs:
skin:
HEENT:
neck:
nodes:
breasts*:
chest:
heart:
abdomen:
extremities:
musculo:
neurologic:
genital*:
rectal*:
LABORATORY:
PROBLEM LIST:
(list ALL problems identified via Hx, PE, testing; group problems, but only when diagnosis is certain)
1.
SUMMARY:
(brief restatement of CC and pertinent history / findings, along with suspected diagnosis)
ASSESSMENT:
(list of active problems and likely causes, ordered by relative importance in hospitalization)
1.
PLAN:
(outline of what is being done for the patient)
1.
REFERENCES:
(those read to learn about patients symptoms, diagnoses, diagnostic tests, and/or therapies)
Signature:
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