Sepsis Evaluation MedicalTemplate

Sepsis Evaluation Patient Name DOB MRN Encounter Date
Review of Systems Chief complaint/Reason for consult Start Time Stop Time
Yes No
Constitution
Fatigue or Malaise
Fever or chills
History of Present Illness Patient is Nonverbal. History obtained from Family Medical records
Appetite changes
Eyes
Conjunctivitis
New eye pain
Blurred vision
ENT/mouth
Sore throat
Swollen uvula
E
Jaw pain
Respiratory
Dyspnea
Cough
Phlegm
Hemoptysis Risk factors
Hemodialysis Peritoneal dialysis
Wheeze
Cardiovascular
Chest pain
Diaphoresis
Ankle edema
Syncope
Palpitations
Gastrointestinal
Nausea or vomiting
Weight changes
Diarrhea
Abdominal pain
Dialysis
Drug abuse
Contacts
Medical
PL
Alcohol Prescription drugs Recreational drugs
Children/college students Nursing Home resident Public transit Travel
Implanted medical device Long term IV access
Chronic steroid use Hospitalization Immunocompromised Infection Surgery Trauma
Allergies and Medications
Allergy List reviewed No drug allergies No food allergies History of life threatening allergic response to
Medications reviewed Medications reconciled with Nursing Home data
Past Medical History, Social History and Family History
Asthma Diabetes Obstructive Sleep Apnea Other

COPD Hepatic Dysfunction Seizure Disorder

M
Genitourinary
Hematuria Congestive Heart Failure(CHF) HIV/AIDS Thyroid disease Hyper Hypo
Dysuria Coronary Artery Disease Hypertension Tuberculosis Treatment
Urethral discharge
Musculoskeletal Malignancy
Myalgias Adrenal Colon Leukemia/Lymphoma Melanoma Renal cell Thyroid Breast Lung Pituitary Prostate Testicular
Arthralgias Stage Treatment Surgical Resection Radioablation Chemotherapy Last Tx Radiation Last Tx
Joint swelling
Recent trauma Surgeries CABG Cardiac valve replacement Splenectomy Organ transplant Joint replacement Other
SA
Skin/Breasts
Masses
New skin lesions
Social History / Risk factors
Rash No Yes Tobacco use Number Pack-Years __________
Neurologic No Yes Quit tobacco use Quit date __________
Headaches Willingness to Quit Unwilling Considering Quit but resumed Within 1 month
Seizures Patient has tried smoking cessation aids Nicotine Replacement Receptor blockade Buproprion or nortriptyline
Muscle weakness
Paresthesias No Yes Recreational drug use Route Inhalation Injection Ingestion
Endocrinologic No Yes Drug dependence Type Narcotics Benzodiazepines
Hair loss
Polydipsia No Yes Alcohol use ___ Drinks per Day Week
Tremors
Ability to Perform Activities of Daily Living Vaccines
Neck pain Able Unable
Heme/Lymph Eating No Yes Influenza
Bleeding gums
Bathing No Yes Pneumococcal
Unusual bruising
Swollen lymph nodes Dressing No Yes Pertussis
Allergy/Immunology Toileting No Yes Varicella
Nasal congestion Transfers
Rhinorrhea
Psychologic Family Medical History
Agitation Asthma Coronary Artery Disease Renal Dysfunction Malignancy
Hallucinations CHF Pancreatitis Thrombotic disorder Other
COPD Peripheral Artery Disease Thyroid Disease
©MB and RR 2011 e-medtools.com Revised 18Jan2011 Health Care Provider Signature
Exam WNL = Within Normal Limits
Ventilator Constitutional
Mode ACSIMVPCPRVC Height in cm ________ Weight lb kg ________

Temperature C F ________ AND Rhythm Regular Irregular
Date of Intubation ________________
Pulse Rate ________
Endotracheal Tube Size _____
Tracheostomy Tube Size _____ Blood Pressure Sitting Standing Lying __________ / __________
Rate ____ Tidal Vol ____ FiO2 ____ Respiratory Rate__________
PEEP level ______ Optional Oxygen Saturation _____ % Cardiac Output _____ Systemic Vascular Resistance _____
Pressure Support level ______
E
Peak Inspiratory Pressure ______ Body habitus wnl Cachectic Obese Grooming wnl Unkempt
Plateau Pressure ______ ENT
ARDS ALI
Within normal limits Edema or erythema present
Nasal mucosa, septum, and turbinates
PO2/FiO2 <200 201-300 >300 Dentition and gums Within normal limits
Dental caries Gingivitis
Oropharynx Within normal limits Edema or erythema present Oral ulcers Oral Petechiae
NonInvasive Ventilator
CPAP BiPAP Ins ____
IV Medications
Antiarrhythmics
Antihypertensives
Diuretics
Drotrecogin alfa
Heparin
Insulin
Antibiotics / Day #
Pressors
Sedation
Steroids
Exp ____
Narcotics
Thrombolytic
TPN
Neck
Resp
PL
Mallampati I II III IV
Neck Within normal limits Erythema or scarring consistent with recent or old radiation dermatitis
Thyroid Within normal limits Thyromegaly Nodules palpable Neck mass _____________________
Jugular Veins Within normal limits JVD present a, v or cannon a waves present
Chest is free of defects, expands normally and symmetrically Erythema consistent with radiation dermatitis
Scarring consistent with old, healed radiation dermatitis
Resp effort Within normal limits Accessory muscle use Intercostal retractions Paradoxic movements
Chest percussion Within normal limits Dullness to percussion Lt Rt Hyperresonance Lt Rt
M
1.
Tactile exam Within normal limits Tactile fremitus Increased Decreased ________________________
2.
3. Auscultation Within normal limits
4. Bronchial breath sounds Egophony Rales Rhonchi Wheezes Rub present
CV
Lines & Monitors
Clear S1 S2 No murmur, rub or gallop Gallop Rub
Telemetry
Chest tube Murmur present Systolic Diastolic Grade I II III IV V VI
Present Absent Peripheral pulses palpable No peripheral edema Peripheral pulses Absent Weak
SA
Left Air leak

GI
Right Air leak Present Absent
NG/ND tube Abdomen Within normal limits Mass present LUQ RUQ LLQ RLQ ______________ Pulsatile
PEG/PEJ tube Liver and spleen palpation wnl Unable to palpate Liver Spleen Enlarged Liver Spleen
Lymph (2 areas must be examined)
Foley catheter
Ostomy Lymph node exam wnl Areas examined Neck Axilla Groin Other ___________________
Central line/PICC Lymphadenopathy noted in Neck Axilla Groin Other ___________________
Site Musc
No sign of infection Muscle tone within normal limits, and no atrophy noted Tone is Increased Decreased Atrophy present
Peripheral venous access Gait and station wnl Ataxia Wide based gait Shuffle Patient leans Rt Lt Front Back
Site
No sign of infection
Extrem
Port access Exam wnl Clubbing Cyanosis Petechiae Synovitis Rt Lt ________________________
No sign of infection Skin
No rashes, ecchymoses, nodules, ulcers
Labs Neuro
\____/ ____ / ____ / ____ /

Oriented NOT oriented to Person Time Place
/ \ \ \ \ Affect is within normal limits OR Patient appears Agitated Anxious Depressed
Glasgow Coma Score E _____ V _____ M _____ APACHE II Score __________
Additional Findings
Radiology
CXR CT scan Other
Medical Decision Making Impression
Data Reviewed
ER Notes
Old medical records
Labs
Radiology data
Pathology
ECHO
ECG
Stress Test
Pulmonary Function Test
E
Care Coordinated with
Patient
HCPOA / Surrogate
PCP
Consultant(s)
Case Management or Social Worker
Pharmacy
Nursing
Recommended Actions
Aggressive pulmonary toilet
DVT prophylaxis
Stress ulcer prophylaxis
Daily sedation vacation and
neurologic assessment
Head of bed elevated > 30 Degrees
PL
Insulin infusion
M
Central line change or removal
Physical therapy
Enteral/Parenteral feeds
Smoking cessation aids
Pneumonia vaccine prior to discharge
Influenza vaccine prior to discharge
SA
Recommended Diagnostics
12-lead EKG
Echocardiogram
Sputum culture
Blood culture
Urine culture
CSF culture
Nasal or nasopharyngeal swab/wash
PPD Testing
Quantiferon test for Tuberculosis I have personally discussed Code Status with this patient, and believe that this patient (or their surrogate
Serum Mycoplasma decision maker) understands their medical condition, their prognosis and the consequences of their Code
Status decision.
Urinary antigen Code Status Patient is a FULL CODE
Histoplasma Legionella DO NOT ATTEMPT Cardiac Resuscitation
CBC with differential DO NOT Intubate
PT, PTT, INR
Basic Metabolic Panel This patient has advanced health care directives. Their HCPOA is
Complete Metabolic Panel
HIV
Hepatitis panel Physician Signature
Toxicology screen cc

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Sepsis Evaluation Patient Name DOB MRN Encounter Date

COPD Hepatic Dysfunction Seizure Disorder

Rate Tidal Vol FiO2 Respiratory Rate______

Left Air leak

\/ / / /

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Sepsis Evaluation MedicalTemplate

Uploaded by

Document Information

Copyright

Share this document

Share or Embed Document

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Did you find this document useful?

Is this content inappropriate?

Copyright:

Sepsis Evaluation MedicalTemplate

Uploaded by

Copyright:

Sepsis Evaluation Patient Name DOB MRN Encounter Date

 COPD  Hepatic Dysfunction  Seizure Disorder

Rate ____ Tidal Vol ____ FiO2 ____ Respiratory Rate__________

Left Air leak

\____/ ____ / ____ / ____ /

You might also like

COPD Hepatic Dysfunction Seizure Disorder

Rate Tidal Vol FiO2 Respiratory Rate______

\/ / / /