FAMILY-ORIENTED

CHART
[Adopted from PAFP Quality, standards and Competencies Manual
2008 ]

DEPARTMENT OF FAMILY MEDICINE

SEAMENS HOSPITAL MANILA

NAME OF RESIDENT-IN-CHARGE:

EPISODIC CONSULTS SUMMARY (ECS) SHEET

(ECS contains information on clinic visits.)
FAMILY NAME: _________________________________________
DATE

PROBLEM(S) / ASSESSMENT

DIAGNOSTICS

THERAPEUTICS

RECORD FOR INITIAL CONSULT (RIC)

Name: _____________________________________________________________________
Date of Consult: ____________________________________________________________
History:

Review of Systems:
HEENT
blurring of vision
ringing of ears
hearing loss
eye redness
others, list _________
______________________
Respiratory
difficulty of breathing
wheezes
cough
hemoptysis
others, list _________
______________________
Cardiovascular
chest pain
orthopnea
paroxysmal nocturnal dyspnea
easy fatigability
edema
others, list _________
Past/Medical History:
Illnesses, please list:
_______________________________
_______________________________
Hospitalizations, please list
_______________________________
_______________________________
Allergies, please list
______________________________
_______________________________
Immunization History:
_____________________________
_____________________________
_____________________________

Gastrointestinal
Neurologic
abdominal pain
weakness
jaundice
numbness/paresthesia
nausea/vomiting
headache
diarrhea
dizziness
melena/hematochezia
gait disturbances
others, list _________
others, list _________
Genitourinary
Musculoskeletal
frequency/intermittency
muscle pain
hematuria
bone pain
passage of sandy material
sprain/strain
dribbling
joint pains
hesitancy
others, list _________
others, list _________
Metabolic/Endocrine
Skin/Integument
polyuria
pallor
polyphagia
cyanosis
polydipsia
rashes
tremors
mottling
unexplained weight loss/gain others, list ____
others, list _________
Personal/Social History
Smoker
yes
no
pack years? ___________
quit, when? _______
Alcohol Beverage Drinker?
yes
no
Frequency? ____________
Duration? ______________
Type of drink? __________
Drugs or other substance used/abused?
________________________________

Obstetric/Menstrual History:
G ___ P ____ ( , , , )
age of menarche?
age of menopause?
Age at first coitus?
Operations?

Birth/Maternal History:
born _________ via ________________
to a G ___ P ___, ____-year old mother
birth complications? ________________

Developmental Milestones:
_________________________
_________________________
_________________________

Physical Examination: BP=

HR=

RR=

Temperature=

Weight=

Height=

BMI*=

General Survey:

no significant findings
noted the following:_____________________________________________________________________

Skin/Integument:

no significant findings
noted the following:_____________________________________________________________________

HEENT:

no significant findings
noted the following:_____________________________________________________________________

Respiratory:

no significant findings
noted the following:_____________________________________________________________________

Cardiovascular:

no significant findings
noted the following:_____________________________________________________________________

Gastrointestinal:

no significant findings
noted the following:_____________________________________________________________________

Genitourinary:

no significant findings
noted the following:_____________________________________________________________________

IE:

no significant findings
noted the following:_____________________________________________________________________

DRE:

no significant findings
noted the following:_____________________________________________________________________

Neurologic:

no significant findings
noted the following:_____________________________________________________________________

*BMI = weight in kg/height in meters squared or weight in lbs x 705/inches

**IBW quick estimate for females is 105 lbs for first 5 feet + 5 lbs for every inch above five feet
For males is 106 lbs for first 5 feet and 5 lbs for every inch above five feet
Assessment:

Plan:
Diagnostics:

Follow-up:

Therapeutics:

Referral:

Health Education and Advice:

Family Interventions if needed:

IBW**=

FAMILY ASSESSMENT TOOLS (FAT)

A. GENOGRAM

B. FAMILY MAP

C. ECOMAP

D. FAMILY APGAR
Areas of the APGAR

Family
Member 1

Family
Member 2

A I am satisfied I can turn to my family for help when something is

troubling me. (Akoy nasisiyahan dahil sa nakakaasa ako ng tulong sa
aking pamilya)
P - I am satisfied with the way my family talks over things with me and
shares problems with me. (Akoy nasisiyahan sa paraang
nakikipagtalakayan sa akin ang aking pamilya tungkol sa aking
problema)
G I am satisfied that my family accepts and supports my wishes to take
on new activities or directions. (Akoy nasisiyahan at ang aking pamilya
ay tinatanggap at sinusuportahan ang aking mga nais gawin patungo sa
mga bagong landas para sa aking ikauunlad)
A I am satisfied with the way my family expresses affection and
responds to my emotions, such as anger, sorrow or love. (Akoy
nasisiyahan sa paraang ipinadadama ng aking pamilya ang
kanilang pagmamahal at nauunawaan ang aking damdamin
katulad ng galit, lungkot at pag-ibig)
R I am satisfied with the way my family and I share time together.
( Akoy nasisiyahan na ang aking pamilya at ako ay nagkakaroon ng
panahon sa isat isa).

Over-all assessment
Score: 0-hardly ever (halos hindi)
1-some of the time (minsan)
2-almost always (palagi)
Interpretation: 0-3 severly dysfunctional, 4-6 moderately dysfunctional, 7-10 highly functional

Average

FOLLOW-UP PATIENT RECORD (FPR)

Name: _______________________________________________
Date of Follow-up:
Reason for follow-up: continuing care from previous visit new complaint
S:

Age/Sex: _______________

*include symptom progression or improvement and medications on board and lab results for chronic illnesses
**put symptoms and interventions done for new complaints

C:

* Psychosocial Context of the disease

O:

BP= ________ HR= _________

RR= _______
Temperature= ________Weight= _____
Height = _______ BMI = ______
General Survey:
no significant findings
noted the following:_____________________________________________________________________
Skin/Integument:

no significant findings
noted the following:_____________________________________________________________________

HEENT:

no significant findings
noted the following:_____________________________________________________________________

Respiratory:

no significant findings
noted the following:_____________________________________________________________________

Cardiovascular:

no significant findings
noted the following:_____________________________________________________________________

Gastrointestinal:

no significant findings
noted the following:_____________________________________________________________________

Genitourinary:

no significant findings
noted the following:_____________________________________________________________________

IE:

no significant findings
noted the following:_____________________________________________________________________

DRE:

no significant findings
noted the following:_____________________________________________________________________

Neurologic:

no significant findings
noted the following:_____________________________________________________________________

A:

P:

FAMILY WELLNESS PLAN (FWP)

List down specific wellness plan and put a check mark after when completed.
Family Member

Screening Tests

Immunizations

10

Lifestyle
Changes

Counseling Needs