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SepsisEvaluation
Patient Name DOB MRN Encounter Date
©MB and RR 2011 e-medtools.com Revised18Jan2011 Health Care Provider Signature
Review of SystemsChief complaint/Reason for consult
Start Time Stop Time
YesNoConstitution
Fatigue or Malaise
Fever or chills
Appetite changes
Eyes
Conjunctivitis
New eye painBlurred vision
ENT/mouth
Sore throatSwollen uvulaJaw pain
Respiratory
DyspneaCoughPhlegmHemoptysisWheeze
Cardiovascular
Chest painDiaphoresis Ankle edemaSyncopePalpitations
Gastrointestinal
Nausea or vomitingWeight changesDiarrhea Abdominal pain
Genitourinary
HematuriaDysuriaUrethral discharge
Musculoskeletal
Myalgias ArthralgiasJoint swellingRecent trauma
Skin/Breasts
MassesNew skin lesionsRash
Neurologic
HeadachesSeizuresMuscle weaknessParesthesias
Endocrinologic
Hair lossPolydipsiaTremorsNeck pain
Heme/Lymph
Bleeding gumsUnusual bruisingSwollen lymph nodes
Allergy/Immunology
Nasal congestionRhinorrhea
Psychologic
AgitationHallucinations
History of Present Illness
Patient is Nonverbal. History obtained from
Family
Medical records
Risk factors
Dialysis
Hemodialysis
Peritoneal dialysisDrug abuse
Alcohol
Prescription drugs
Recreational drugsContacts
Children/college students
Nursing Home resident
Public transit
TravelMedical
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 reconciledwith Nursing Home data
Past Medical History, Social History and Family History
Asthma
Diabetes
Obstructive Sleep Apnea
Other
COPD
Hepatic Dysfunction
Seizure Disorder
Congestive Heart Failure(CHF)
HIV/AIDS
Thyroid disease
Hyper
Hypo
Coronary Artery Disease
Hypertension
Tuberculosis
Treatment
Malignancy
Adrenal
Colon
Leukemia/Lymphoma
Melanoma
Renal cell
Thyroid
Breast
Lung
Pituitary
Prostate
Testicular
Stage Treatment
Surgical Resection
Radioablation
Chemotherapy Last Tx
Radiation Last Tx
Surgeries
CABG
Cardiac valve replacement
Splenectomy
Organ transplant
Joint replacement
Other
Social History / Risk factors
No
Yes
Tobacco use
Number Pack-Years __________
No
Yes
Quit tobacco use
Quit date __________
Willingness to Quit
Unwilling
Considering
Quit but resumed
Within 1 month
Patient has tried smoking cessation aids
Nicotine
Replacement
Receptor blockade
Buproprion or nortriptyline
No
Yes
Recreational drug use
Route
Inhalation
Injection
Ingestion
No
Yes
Drug dependence
Type
Narcotics
Benzodiazepines
No
Yes
Alcohol use
___ Drinks per
Day
Week
Ability to Perform Activities of Daily Living VaccinesAble Unable
Eating
No
Yes
Influenza
Bathing
No
Yes
Pneumococcal
Dressing
No
Yes
Pertussis
Toileting
No
Yes
Varicella
Transfers
Family Medical History
Asthma
Coronary Artery Disease
Renal Dysfunction
Malignancy
CHF
Pancreatitis
Thrombotic disorder
Other
COPD
Peripheral Artery Disease
Thyroid Disease
S A M P L E
SepsisEvaluation
Patient Name DOB MRN Encounter Date
©MB and RR 2011 e-medtools.com Revised18Jan2011 Health Care Provider Signature
Exam
WNL = Within Normal Limits
Ventilator Mode
AC
SIMV
PC
PRVC
Date of Intubation ________________
Endotracheal Tube Size_____
Tracheostomy Tube Size _____ Rate
____
Tidal Vol
____
FiO2
____
PEEPlevel
______
Pressure Support level
______
Peak Inspiratory Pressure
______
Plateau Pressure
______
ARDS ALIPO2/FiO2
<200
201-300
>300
NonInvasive Ventilator
CPAP
BiPAP
Ins
____
Exp
____
IV Medications
Antiarrhythmics
Narcotics
Antihypertensives
Pressors
Diuretics
Sedation
Drotrecogin alfa
Steroids
Heparin
Thrombolytic
Insulin
TPN
Antibiotics / Day #
1.2.3.4.
Lines & Monitors
Telemetry
Chest tube
Left
Air leak
Present
Absent
Right
Air leak
Present
Absent
NG/ND tube
PEG/PEJ tube
Foley catheter
Ostomy
Central line/PICC
Site
No sign of infection
Peripheral venous access
Site
No sign of infection
Port access
No sign of infecti
on
Labs
\____/ ____ / ____ / ____ // \ \ \ \
Radiology
CXR
CT scan
Other
ConstitutionalHeight
in
cm
________
Weight
lb
kg ________
Temperature
C
F________
Pulse
Rate
________ AND
Rhythm
Regular
Irregular
Blood Pressure
Sitting
Standing
Lying __________ / __________
Respiratory Rate
__________
Optional
Oxygen Saturation
_____
% Cardiac Output
_____
Systemic Vascular Resistance
_____
Body habitus wnl
Cachectic
Obese
Grooming wnl
Unkempt
ENT
Nasal mucosa, septum, and turbinates
Within normal limits
Edema or erythema presentDentition and gums
Within normal limits
Dental caries
GingivitisOropharynx
Within normal limits
Edema or erythema present
Oral ulcers
Oral PetechiaeMallampati
I
II
III
IV
Neck
Neck
Within normal limits
Erythema or scarring consistent with
recent or
old radiation dermatitisThyroid
Within normal limits
Thyromegaly
Nodules palpable
Neck mass _____________________ Jugular Veins
Within normal limits
JVD present
a, v or cannon a waves present
Resp
Chest is free of defects, expands normally and symmetrically
Erythema consistent with radiation dermatitis
Scarring consistent with old, healed radiation dermatitisResp effort
Within normal limits
Accessory muscle use
Intercostal retractions
Paradoxic movementsChest percussion
Within normal limits
Dullness to percussion
Lt
Rt
Hyperresonance
Lt
RtTactile exam
Within normal limits Tactile fremitus
Increased
Decreased
________________________ Auscultation
Within normal limits
Bronchial breath sounds
Egophony
Rales
Rhonchi
Wheezes
Rub present
CV
Clear S1 S2
No murmur, rub or gallop
Gallop
Rub
Murmur present
Systolic
Diastolic
Grade
I
II
III
IV
V
VI
Peripheral pulses palpable
No peripheral edema Peripheral pulses
Absent
Weak
GI
Abdomen
Within normal limits Mass present
LUQ
RUQ
LLQ
RLQ ______________
Pulsatile
Liver and spleen palpation wnl Unable to palpate
Liver
Spleen Enlarged
Liver
Spleen
Lymph
(
2 areas must be examined)
Lymph node exam wnl Areasexamined
Neck
Axilla
Groin
Other ___________________ Lymphadenopathy noted in
Neck
Axilla
Groin
Other ___________________
Musc
Muscle tone within normal limits, and no atrophy noted Tone is
Increased
Decreased
Atrophy present
Gait and station wnl
Ataxia
Wide based gait
Shuffle Patient leans
Rt
Lt
Front
Back
Extrem
Exam wnl
Clubbing
Cyanosis
Petechiae
Synovitis
Rt
Lt ________________________
Skin
No rashes, ecchymoses,nodules, ulcers
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
S A M P L E
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