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Sepsis Evaluation MedicalTemplate

Sepsis Evaluation MedicalTemplate

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Published by e-MedTools
The sepsis evaluation MedicalTemplate is suitable for any health care provider that manages patients with known or suspected sepsis, SIRS, or septic shock.

The sepsis evaluation MedicalTemplate includes all required E&M documentation elements for even the highest levels of complexity, including critical care.

The sepsis evaluation MedicalTemplate contains prompters and space for all the required elements for a E&M encounter, including critical care encounters.

* 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
The sepsis evaluation MedicalTemplate is suitable for any health care provider that manages patients with known or suspected sepsis, SIRS, or septic shock.

The sepsis evaluation MedicalTemplate includes all required E&M documentation elements for even the highest levels of complexity, including critical care.

The sepsis evaluation MedicalTemplate contains prompters and space for all the required elements for a E&M encounter, including critical care encounters.

* 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

More info:

Published by: e-MedTools on Sep 06, 2008
Copyright:Traditional Copyright: All rights reserved

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02/07/2014

 
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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