Chief Complaint/Reason for Visit

Name DOB

DOV

SUBJECTIVE

Chief Complaint/Reason for Visit

History of Present Illness

[ ] dictated separately

Review of Systems

Past Medical History [ ] reviewed on IS

Family History [ ] reviewed on IS

Social History [ ] reviewed on IS

Allergies [ ] reviewed on IS

OBJECTIVE

Vital Signs BP______HR______T______RR______WT______HT______

Physical Exam Check for normal exam, indicate abnormals and describe Abnormals/pertinent negatives

Eyes / [ ] conjunctiva clear [ ] PERRLA [ ] fundi benign
ENT / [ ] TMs clear [ ] ext. canals clear [ ]nose clear [ ] throat clear
Neck / [ ] no thyroid abnorm. [ ] no masses [ ] no bruits
CV / [ ] RRR [ ] no murmurs, rubs, gallops [ ] no JVD
Lungs / [ ] CTA bilat. [ ] clear to perc. [ ] nl resp. effort
GI / [ ] soft [ ] NT [ ] ND [ ] no HSM [ ] nl bowel sounds [ ] no CVAT
Lymphatics / No enlarged nodes: [ ] neck [ ] axilla [ ] groin [ ] supraclav.
GU Male / [ ] no scrotal masses [ ] nl penis [ ] no discharge [ ] nl prostate
GU female / Breast: [ ] no masses; Pelvic: [ ] nl cervix [ ] nl vag [ ] nl uterus [ ] nl adnexa
Extr./MSK / [ ] no edema [ ] no joint swelling or abn. [ ] symm., palp. distal pulses
Skin / [ ] no rashes, lesions, [ ] no subcutaneous nodules
Neuro / [ ] CN I-XII intact [ ] DTRs nl [ ] nl strength [ ] nl sensation
Psych / [ ] A&Ox4 [ ] memory intact [ ] nl mood [ ] nl affect
Laboratory / U/A: _____leuk _____nitrites _____glu _____ketones _____prot _____blood
RST:______uHCG:______

ASSESSMENT [ ] dictated separately PLAN [ ] dictated separately

nurse time in______MD/NP time in______time out______

[ ] >50% of time spent counseling patient on illness, treatment options, diagnostic tests, and/or follow-up instructions

______

Gloria Gasnarez, MS, APRN J. Greg Hinson, MD