Influenza Like Illness Medical Documentation Template

Influenza Like Illness Evaluation Patient Name DOB MRN
Review of Systems Chief complaint/Reason for consult Start Time Stop Time Date
Review of Systems Yes No
Constitution
Fatigue or Malaise
Fever or chills History of Present Illness Patient is Nonverbal. History obtained from Family Medical records
Appetite changes 4 or more: Location Quality Severity Duration Timing Context Modifying factors Associated Signs/Symptoms OR status of 3 chronic conditions
Eyes
Conjunctivitis

New eye pain
Blurred vision
ENT/mouth
Sore throat
Swollen uvula

Jaw pain
Respiratory
Dyspnea
Cough

m
Phlegm

ol E
Hemoptysis
Wheeze
Pleuritic Symptoms
Cardiovascular
co
Chest pain
to L
Diaphoresis
Ankle edema
Syncope Cough
P
In the
e past 1 month this patient has had close contact with others
Palpitations Dyspnea With similar sympto
symptoms
Gastrointestinal
Decreased appetite While
Nausea or vomiting
s.
Fever or chills
ile hospitalized or a
Through
as a Nursing Home
ugh travel (Airline,
(A
e or Rehab resident
Cruise, Train, Public
ublic transport)
ed M
Weight changes
Diarrhea Malaise Children in daycare,
dayc secondary school or adults
ults in college
Abdominal pain Myalgias While incarcerated

incar
Genitourinary Nausea/vomiting
vomiting This
is patient
pati has received a
Hematuria Sore throat
at CCurrent influenza vaccine H1N1 influenza vaccine Pneumococcal vaccine Other recent vaccination
m A
Dysuria Sputum production

Urethral discharge
Musculoskeletal Allergies and Medications
M
Myalgias
Allergy List rev
reviewed No drug
revi rug allergies No food allergies History of life threatening allergic response to
S
Arthralgias
Joint swelling
Medications
tions reviewed Medications
cations reconciled with
w Nursing Home data
Recent trauma Past
st Med
Medical History, Social
al History and Family
F History
Skin/Breasts Asthma Diabetes
etes Obstructive Sleep Apnea Other
Masses COPD Hepati
Hepatic Dysfunction Seizure Disorder
New skin lesions Congestive Heart
eart Failure(CHF)
e(CHF) HIV
HIV/AIDS Thyroid disease Hyper Hypo
Rash
Coronary Artery Disease
Disea
Disease Hypertension Tuberculosis Treatment
Neurologic
Headaches
Malignancy
gnancy
y Y es No
Yes
Seizures
Muscle weakness
Adrenal
al Colon
on Leukem
Leukemia/Lymphoma
m Melanoma Renal cell Thyroid Breast Lung Pituitary Prostate Testicular
Numbness Stage Treatment Surgical Resection Radioablation Chemotherapy Last Tx Radiation Last Tx
Paresthesias
Endocrinologic i able to perform the following independently Eating Bathing Dressing Toileting Transfers
ADLs This patient is
Hair loss is current on the following Seasonal Influenza H1N1 Influenza Pertussis Pneumococcal Varicella
e-
Vaccine This patient

Vaccines p
Polydipsia
Tremors Surgeries CABG Splenectomy Organ transplant Lung resection Other
Surgeri
Neck pain
Heme/Lymph
Bleeding gums Social History / Risk factors
Unusual bruising Denies Yes Ever smoker ___ # Packs X ____ # Yrs Denies Yes Recreational drug use Inhalation Injection Ingestion
Swollen lymph nodes Denies Yes Chews tobacco Denies Yes Drug dependence Narcotics Benzodiazepines
Allergy/Immunology Denies Yes Quit tobacco use Quit date _________ Denies Yes Alcohol use ___ Drinks per Day Week
Nasal congestion Willingness to Quit Unwilling Considering Quit but resumed Within 1 month
Rhinorrhea Patient has tried smoking cessation aids Nicotine replacement Buproprion or nortriptyline Nicotine receptor blockade
Psychologic
Agitation Able to perform the following ADLs Eating Bathing Dressing Toileting Transfers
Hallucinations
Other Family Medical History
Asthma CHF COPD Coronary Artery Dis Pancreatitis Peripheral Artery Disease Renal Dysfunction
Thrombotic disorder Thyroid Disease Malignancy Other
©MB and RR 2006-2009 e-medtools.com Revised 2Oct09 Health Care Provider Signature
Exam To qualify as a comprehensive exam: General Multisystem requires performing ALL of 9 organ systems, AND 2 elements documented in each organ system
Respiratory Single Organ System Exam requires documentation of ALL organ system elements, AND 1 element in every other organ system is expected
Ventilator Constitutional ( 3 vitals) Body habitus and Grooming required of General Multisystem but not Organ System Exam
Mode ACSIMVPCPRVC Height ___________ in cm Weight ___________ lb kg
Date of Intubation ____ / ____ / ____ Temperature __________ Pulse Rate __________ AND Rhythm Regular Irregular
Blood Pressure sitting __________ / __________ OR standing __________ / __________
Endotracheal tube size _____ Blood Pressure lying __________ / __________
Respiratory Rate__________ Optional Sats _____ % Cardiac Output _____ SVR _____
Rate ______ Tidal Vol ______
Body habitus wnl Cachectic Obese Grooming wnl Unkempt
PEEP ______ PS ______ ENT
Within normal limits Edema or erythema presen
Nasal mucosa, septum, and turbinates present
FiO2 ______ PO2/FiO2 ______
Dentition and gums Within normal limits
DDental caries Gingivitis
Plateau _______ Oropharynx Within normal limits Edema or eryt
erythema present Oral ulcers
cers Oral Petechi
Petechiae
m
NonInvasive Ventilator Mallampati I II III IV V
CPAP BiPAP IE ____ Neck
ol E
EE ____
Neck Within normal limits Erythema or scarring cconsistent withh recent
cent or oldd rad
radiat
radiation dermatitis
IV Medications Thyroid Within normal limits
its Thyromegalyy Nodules palpable
alpable Neck mass _____________________
__
co
Antiarrhythmics Narcotics to L Jugular Veins Within
hin normal limits JVD present a, v or cannon a waves pre present
Antihypertensives Pressors Resp
Diuretics Sedation Chest is free
ee of defects, expands norm
normally
nor mmetrically Erythema cconsistent with radiation dermatitis
and symmetrically
Drotrecogin alfa Steroids
P
Scarring
carrin consiste
consistent with old, healed
ealed radiation dermatitis
Heparin Thrombolytic
Resp effort Within normal limlimits Accessory ory muscle use Intercos retractions Paradoxic movements
Insulin
Antibiotics / Day #
TPN
s. est percussion Withi

Chest
hest Within n
limi
normal limits Dullness
Intercostal
erco
percussio Lt Rt Hyperresonance Lt Rt
ullness to percussion
ed M
1. Tactile
e exam wnl Tactile
Tactil
Ta fremitus Increased Decreased _____________________________________
2. Auscultation With
Within
h normal limits ts
3.
4.
Bronchial breath soundss Egophony hon RalesRal Rhonchi Wheezes Rub present
m A
CV
Lines & Monitors Clear SS1 S2 No murmur, rub or gallo
gallop Gallop Rub
Telemetry Mu
Murmur present Systolic Diastolic
M stoli Grade I II III IV V VI
Chest tube Peripheral pulses
ulsess palpable No peripheral edema Peripheral pulses Absent Weak
e- S
per
pe
Left Air leak present absent GI
Right Air leak present absent Abdomen
n Within limits Mass present LUQ RUQ LLQ RLQ ______________ Pulsatile
hin normal limit
Trach present Size Liver
iver and
nd spleen palpation wnl
w Unable to palpate Liver Spleen Enlarged Liver Spleen
Endotracheal tube Size Lymph (2 areas must be examined)
NG/ND tube Lymph
ymph node exam wnl
w Neck Axilla Groin Other ___________________
Areas examined
PEG/PEJ tube Lymphadenopath
Lymphadenopathy noted in Neck Axilla Groin Other ___________________
Foley catheter Musc
Ostomy Mus
Muscle totone within normal limits, and no atrophy noted Tone is Increased Decreased Atrophy present
Central line/PICC Gaitit and
a station wnl Ataxia Wide based gait Shuffle Patient leans Rt Lt Front Back
Site Extrem
em
No sign of infection
Peripheral venous access Exam wnl Clubbing Cyanosis Petechiae Synovitis Rt Lt ________________________
Site Skin
No sign of infection No rashes, ecchymoses, nodules, ulcers Rash Bullae Pressure Ulcer Stage 1 2 3 4
Port access Neuro
Neu
No sign of infection Oriented 58(Pts with Community Acquired Bacterial Pneumonia) NOT oriented to Person Time Place
Labs 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/Chest Other
Impression and Plan
Data Reviewed I have personally discussed Code Status with this patient, and believe that this patient (or their surrogate
ER Notes decision maker) understands their medical condition and the consequences of their Code Status decision.
Old medical records Code Status Patient is a FULL CODE
Labs DO NOT ATTEMPT Cardiac Resuscitation
Radiology data DO NOT Intubate
Pathology
ECHO This patient has advanced health care directives. Their HCPOA is
ECG
Stress Test
Pulmonary Function Test
Care Coordinated with
Patient
HCPOA / Surrogate
om
PCP
Consultant
Case Management or Social Worker
Pharmacy
Nursing
Recommended Actions
.c
Aggressive pulmonary toilet
DVT prophylaxis
Stress ulcer prophylaxis
Daily sedation vacation and
neurologic assessment
Head of bed elevated > 30 Degrees
Insulin infusion Goal: 100-150
Central line change/removal culture tip
o ls
Physical therapy
Enteral/Parenteral feeds
to
Smoking cessation aids
S
Pneumonia vaccine prior to discharge

Influenza vaccine prior to discharge
Antiviral Treatment Prophylaxis
ed
Oseltamivir Zanamivir
Amantadine Ramantadine
Antibiotics
Recommended Diagnostics
Sputum culture
m
Bacterial Fungal AFB

Blood culture
Urine culture
CSF culture
e-
Nasal or nasopharyngeal swab

Nasal wash or aspirate
PPD Testing
Quantiferon test for Tuberculosis
Serum Mycoplasma
Urinary antigen
Histoplasma Legionella
CBC with differential C-FNP or PA-C Signature
PT, PTT, INR
Basic Complete Metabolic Panel I have examined this patient, reviewed the history, labs and radiographs relevant to this patient, have discussed this patient with the NP or PA above
HIV
and I agree with the assessment and plan as outlined.
12-lead EKG Echocardiogram Physician Signature

BNP Cardiac Enzymes cc

Influenza Like Illness Medical Documentation Template

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Influenza Like Illness Medical Documentation Template

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Influenza Like Illness Evaluation Patient Name DOB MRN

Abdominal pain Myalgias While incarcerated

Dysuria Sputum production

Vaccine This patient

s. est percussion Withi

Pneumonia vaccine prior to discharge

Bacterial Fungal AFB

Nasal or nasopharyngeal swab

12-lead EKG Echocardiogram Physician Signature

You might also like

Influenza Like Illness Medical Documentation Template

Uploaded by

Document Information

Copyright

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Influenza Like Illness Medical Documentation Template

Uploaded by

Copyright:

Influenza Like Illness Evaluation Patient Name DOB MRN

Abdominal pain Myalgias While incarcerated

Dysuria Sputum production

Vaccine This patient

s. est percussion Withi

Pneumonia vaccine prior to discharge

Bacterial Fungal AFB

Nasal or nasopharyngeal swab

12-lead EKG Echocardiogram Physician Signature

You might also like

Abdominal pain Myalgias While incarcerated

Dysuria Sputum production

s. est percussion Withi

Pneumonia vaccine prior to discharge

Bacterial Fungal AFB

Nasal or nasopharyngeal swab

12-lead EKG Echocardiogram Physician Signature