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  • Hospital Follow Up Progress Note MedicalTemplate

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    e-MedTools
    14K views1 page
    The hospital follow up visit MedicalTemplate is suitable for hospitalists, internal medicine physicians, family practice physicians, and other health care providers working in hospitals. The hospital follow up visit MedicalTemplate contains prompters and space for all the required elements for a E&M encounter. * History o Chief complaint o History of present illness o Past medical and surgical history o Social history o Family history o Review of systems * Examination * Medical Decision Making o Review of data (labs, tests, imaging, old records) o Assessment and plan

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    The hospital follow up visit MedicalTemplate is suitable for hospitalists, internal medicine physicians, family practice physicians, and other health care providers working in hospitals. The hospital follow up visit MedicalTemplate contains prompters and space for all the required elements for a E&M encounter. * History o Chief complaint o History of present illness o Past medical and surgical history o Social history o Family history o Review of systems * Examination * Medical Decision Making o Review of data (labs, tests, imaging, old records) o Assessment and plan

    Copyright:

    © All Rights Reserved
    Flag for inappropriate content
    14K views1 page

    Hospital Follow Up Progress Note MedicalTemplate

    Uploaded by

    e-MedTools
    The hospital follow up visit MedicalTemplate is suitable for hospitalists, internal medicine physicians, family practice physicians, and other health care providers working in hospitals. The hospital follow up visit MedicalTemplate contains prompters and space for all the required elements for a E&M encounter. * History o Chief complaint o History of present illness o Past medical and surgical history o Social history o Family history o Review of systems * Examination * Medical Decision Making o Review of data (labs, tests, imaging, old records) o Assessment and plan

    Copyright:

    © All Rights Reserved
    Flag for inappropriate content
    of 1

    Daily Progress Note Code Status ‰Full Code ‰Do Not Attempt Resuscitation ‰Comfort Care Patient Care

    t Care Patient Care Time


    Date Chief Complaint/Reason For Visit Start time
    Stop time
    Review of Systems History of Present Illness ‰ Patient is Nonverbal Data Reviewed
    See HPI WNL  ‰Past Medical History
    ‰‰ Constitutional 
    ‰‰ Eyes  ‰Social History
    ‰‰ ENT  ‰Family Medical History
    
    ‰‰ Cardiovascular  ‰Allergy list
    ‰‰ Respiratory  www.e-medtools.com ‰Medication list
    ‰‰ Gastrointestinal 
    
    ‰Labs/Tests
    ‰‰ Genitourinary
    ‰‰ Musculoskeletal  ‰Old Chart
    ‰‰ Skin ‰ECG
    
    ‰‰ Neurologic  www.e-medtools.com ‰Nursing Notes & Vitals
    ‰‰ Endocrine ‰Radiology studies
    ‰‰ Psych ‰Pain present Location Quality Duration
    ‰‰ Heme/Lymph Level (1-10 Scale) ‰1 ‰2 ‰3 ‰4 ‰5 ‰6 ‰7 ‰8 ‰9 ‰10
    ‰‰ Allergy/Immun ‰Ambulating ‰Bedridden ‰Oral intake appropriate ‰Moving bowels (BM in last 24hr )
    Lines and Monitors Physical Exam ‰
    ✔ Check indicates findings are within normal limits, or trait is present Labs & Radiographics
    ‰Telemetry Vitals T P www.e-medtools.com
    R BP / Sats Wt
    ‰Chest tube \____/
    ‰Trach Size Vent Mode Rate Tidal Volume %FiO2 PEEP PS / \
    ‰Endotracheal tube
    ‰NG/ND tube Const ‰General ‰Sedated but arousable ____ / ____ / ____ /
    ‰PEG/PEJ tube Eye ‰Conjunctivae ‰Pupils ‰Discs \ \ \
    ‰Foley catheter www.e-medtools.com
    ENT ‰Pharynx ‰Nasal mucosa ‰External ears 
    ‰Ostomy 
    ‰Central line/PICC Resp ‰Auscultation ‰Effort ‰Percussion ‰Palpation
    Site CV ‰Ausc ‰Palp ‰Edema ‰Carotids ‰Aorta ‰Fem pulses ‰Pedal pulses
    ‰No evidence infection GI ‰Abdomen ‰No hepatosplenomegaly ‰No hernias ‰Rectum ‰Guaiac
    ‰Peripheral venous access Musc ‰Gait ‰Digit ‰Inspection ‰ROM ‰Stability ‰Strength
    Site
     ‰No evidence infection Skin ‰Inspection ‰Palpation
    www.e-medtools.com
    Neuro ‰Cranial Nerves ‰Deep Tendon Reflexes ‰Sensation ‰Orientation
    Psych ‰Affect ‰Insight ‰Memory
    Abnormal Findings ‰Lethargic ‰Obtunded ‰Combative

    www.e-medtools.com
    Care Coordinated With Impression Plan
    ‰HCPOA ‰Labs
    ‰PCP ‰Cultures
    ‰Consultants ‰Blood‰Sputum‰Urine
    ‰Case Management ‰Radiographs
    ‰Social Worker ‰Cardiac Stress Testing
    ‰Pharmacy ‰ECHO
    ‰Nutrition team ‰PFTs
    ‰Physical therapy ‰Aggressive pulm toilet
    ‰Respiratory therapy ‰DVT prophylaxis
    ‰Speech Therapy ‰Stress ulcer prophylaxis
    ‰Nursing staff ‰Daily sedation vacation
    Estimated Day of Discharge
    ‰Head of bed elev > 30°
    ‰Intense glycemic control
    ‰Changing central lines
    Plan to discharge to
    C-FNP or PA-C Signature
    ‰Physical/Occupation Tx
    ‰Hospital I have examined this patient, reviewed the history, labs and radiographs relevant to this patient, have discussed this ‰Swallow evaluation
    ‰Home patient with the NP or PA above and I agree with the assessment and plan as outlined.
    ‰Pneumo vac before d/c
    ‰Nursing Home Physician Signature
    ‰Flu vac before d/c
    Nature of presenting problem ‰Minimal ‰Self-limited or minor ‰Low severity ‰Moderate severity ‰High severity
    Exam ‰Problem focused ‰Expanded problem focused ‰Detailed ‰Comprehensive
    Complexity of Medical Decision Making ‰Straightforward ‰Low ‰Moderate ‰High Encounter Code

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