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Physical Exam: Level: (1) N/A (2) affected area (3) affected area & related area (4):

area (4): affect in detail & related (5) 8 sys.


Weight_________________ Height_____________ Temp_________ Pulse______ Resp.________
BP_________________
General Appearance:

NL Description
NL Description
HEENT Musculoskeletal
Neck Skin & SQ
Cardiovascular GI/Rectal
Respiratory GU
Back Neuro
Breasts
Abdomen
Extremities Psych

Reviewed: O Old records / tests O labs O x-ray O other____________________________________


Comments:

Assessment/Plan:
T e s t s D o n e / O r d e re d :
(check all that apply &/or indicate
Visit based on time: Counseling over 50% of visit O: visit: ___________/minutes See comments below. results)
Established Pt: Level: (1) 5 mins., (2) 10 rmins., (3) 15 mins., (4) 25 mins., (5) 40 mins
O Metabolic panel-12
O Chem 7
O Electrolytes
O LFTs
O Glu-fingerstick_____________
O Cholesterol/Lipid Panel
O CBC

O Glu- serum
O HbA,C
O Hgb-Fingerstick

O TSH
O PSA
O Urine Dipstick
O Urine HCG__________________
O EKG
Imaging
O Mammogram
O CX R
OOther:_______________________________

Level 2 HPI (1-3) Level 3 HPI (1-3) ROS (1) Level 4 HPI (4+), ROS (2-9) PFSH (1) Level 5 (HPI 4+) ROS (10) PFSH (2 or 3)
I

Exam-affected area Exam-affected & related sys._________Exam (2-7 sys. ;l detailed) Exam -8 body areas/systems
MDM-straightforward MDM- low complexity_____________MDM-moderate complexity MDM- high complexity

Return Visit: Yr.______ Mo.__ Wk._____ Days___ PRN ___


_.
_________________________________________________
Signature

___________________________________________________________________________________________________________________________________________________
Additional Notes

________________________________________
Signature
J e ff e r s o n Fa m i l y DOB Chart No._________________
Medicine Page No.__________________

Progress Note
Chief Complaint/HPI:(location/quality/severity/duration/timing/context modifying fa ctors/associated
signs/symptoms)
Level 2&3 (1-3 elements) level 4 - 5 (4 or more) OR List the Status of3 Chronic Diseases:
Prob. Addressed Subjective Findings

Name___________________________________________ Date__________________________________

Counseling:

Past History: O No change from profile of___________ Family History: O Negative 0 No change from
profile
date
O Update
O Changes as follows
- circle all that apply: of_________________
DM, HTN, CAD, Ovarian breast/colon ca date

Social History: Medications: (update allergy profile, med list) O See med sheet
O No change from initial profile_______
date
O Update - circle all that apply & comment as indicated
Tobacco, Alcohol, Drugs, Abuse Screen

Review of Level: (2) none (3) pertinent -1 (4) extended - 2-9 (5) complete -10 or more
Systems: NL Descripti NL Description
Constitutional Symptoms MS
Eyes Integumentary
Ears, Nose, Mouth, Throat Neurological
Cardiovascular Psychiatric
Respiratory Endocrine
GI Hematologic, Lymphatic
GU Allergic, Immunologic

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