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Culture Documents
m
Dental caries
ol E
Dental abscesses
Jaw pain Recent Antibiotic use Recent ER visits Recent
cent Weight loss
lo
los or decreased appetite
Respiratory Recent Oral steroid use Recent Hospital
al admissions
admis Planned
ed air travel
tra in near future
co
Dyspnea Spirometry evaluation performed within
thin
in previous 12 months
Cough
Phlegm
Hemoptysis
Wheeze
Cardiovascular
to L P COPD Symptoms
Asymptomatic with usual activity
Chest pain
s.
<70%
70% <30% Very
ry Severe
S
Diaphoresis
Medications Allerg
Allergies
ed M
Ankle edema
Medications reviewed
eviewed Aller
Allergy List reviewed
Syncope Medications reconciled 6 N
tion 46
nciled with Nursing Home or Hospital discharge Information No food or drug allergies
Palpitations
Gastrointestinal Past Medical, Family S
Social History
Nausea or vomiting
Asthma
ma Inflammatory
mmatory Bowel Disease
Dise Chemotherapy Notes
m A
Hematuria Peripheral
ipheral Artery Disease
Dise
Dis
Dysuria Coronary
ronary Artery Disease Pituitary infarct oor hemorrhagePFTs
Urethral discharge Cystic Fibrosis Protein deficie
deficiency C S Pap Smear
Musculoskeletal Dia
Diabetes 1 2
Renal
nal dysfu
dysfunction
dy ESRD Prior intubations
Myalgias Endocarditis Hemodi
Hemodialysis
emod Peritoneal dialysis Radiation exposure
Arthralgias GERD Sarc
Sarcoidosis Sleep study
Joint swelling Gout SSeizure disorder Steroid use, chronic
Claudication symptoms Hemolytic
lytic anemia Sleep Apnea CPAP BiPAP
Skin/Breasts Hepatic
patic dysfunction
sfunction Systemic Lupus Erythematosis Tuberculosis
Masses HIV/AIDSS Thrombocytopenia ITP TTP PPD Result Positive Negative Date
New skin lesions Hype
Hypertension
ertension Thyroid disease hypo hyper Tuberculosis Treatment
Sensitivity to sun
Malignancy
ignancy
Neurologic
Adrenal
renal Colon
on L
Leukemia/Lymphoma Melanoma Renal cell Thyroid Breast Lung Pituitary Prostate Testicular
Headaches Stage
ge Treat
Treatment
T Surgical Resection Radioablation Chemotherapy Last Tx Radiation Last Tx
Seizures
CABG Splenectomy Organ transplant Lung resection Pleurodesis Other
e-
©MB and RR 2006-2009 Revised 16Sep09 e-medtools.com Health Care Provider Signature
COPD Evaluation Patient DOB MRN
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 highlighted 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 ACSIMV PC PRVC Height ___________ in cm Weight ___________ lb kg
Intubation date ____ / ____ / ____ Temperature __________ Pulse Rate __________ AND Rhythm Regular
egul Irregular
Blood Pressure sitting _____ / _____ OR standing _____ / _____ OR lying
ng _____ / _____
__
___
ETT size _____ PS ______ Respiratory Rate__________ nal Sa
Optional
onal Sats _____ % Cardiac Output _____ SVR _
S _____
Rate ______ Tidal Vol ______
Body habitus wnl Cachectic Obese
bese
ese
m
Grooming wnl Unkempt
PEEP ______ Plateau ______ ENT WNL = Within Normal Limits
ol E
FiO2 ______ PO2/FiO2 ______ WNL Edema
Nasal mucosa, septum, and turbinates
rbinates Edem or erythema presentt
Dentition and gums WNL
L D Ging
Dental caries Gingivitis
co
NonInvasive Ventilator
Oropharynx WNL Edema or erythema pre
present Oral ulcers
pres cers Oral Petechiae
CPAP BiPAP IE ____ to L
EE ____
Mallampati I II III
II IV
V
IV Medications Neck WNL = Within Normal Limits
imits
s. Resp WNL
ular Veins WNL JVD p
Jugular
ula
L = Within Normal Limits
present a, v or cannon a waves presen
present
ed M
Heparin Thrombolytic Chest
hest is free of defects
de
defects, expands normally nd symmetrically Erythema consistent with radiation dermatitis
rmally and
Insulin TPN Scarring consistent with old, healed radiation dermatitis Surgical scar present Scar, other
carring consis
consi
Antibiotics Resp effort WN WNL Accessory
W ory muscle use Intercosta
Intercostal
erco retractions Paradoxic movements
percussion WNL Dullness o percussion Lt Rt Hyperresonance Lt Rt
m A
Chest percus
percuss ness tto
Lines & Monitors
Telemetry Tactile fremitus
Ta fre WNL Increased rea Decreased
De
Decreas __________________________________
Chest tube Auscultation WNL
Aus
Auscu L Bronchial breath sounds
sound Egophony Rales Rhonchi Wheezes Rub present
soun
present absent CV
e- S
Right Air leak present absent Clear S1 S2 No murmur, rub or ga gallop Gallop audible Rub audible
Trach present Size Murmur nt Systolic
ur present ystolic Diastolic Grade I II III IV V VI
Endotracheal tube Size Peripheral
al pulses palpable No peripheral edema Peripheral pulses Absent Weak
eripheral
NG/ND tube GI WNL = Within Normal Limits
©MB and RR 2006-2009 Revised 16Sep09 e-medtools.com Health Care Provider Signature
COPD Evaluation Patient DOB MRN
Recommendations Impression
Aggressive pulmonary toilet I have personally discussed Code Status with this patient, and believe that this patient (or their surrogate
DVT prophylaxis decision maker) understands their medical condition and the consequences of their Code Status decision.
Stress ulcer prophylaxis Code Status Patient is a FULL CODE
Daily sedation vacation and DO NOT ATTEMPT RESUSCITATION, Cardiac or Pulmonary
neurologic assessment
Head of bed elevated > 30 Degrees This patient has advanced health care directives.
s. Their
T HCPOA is
Intense glycemic control 100-150
Central line change or removal
m
(send tip for culture)
Physical therapy
ol E
Enteral/Parenteral feeds
Supplemental IV Fluids
co
Smoking cessation aids
to L
Pneumonia vaccine prior to discharge
Influenza vaccine prior to discharge
Antiviral Treatment Prophylaxis
P
Oseltamivir
Zanamivir
Amantadine
s.
ed M
Ramantadine
Antibiotics
Diagnostics
m A
HIV
Hepatitis panel
BNP
Cardiac Enzymes
Nasal or nasopharyngeal swab
Nasal wash or aspirate
Cultures
Sputum Blood Urine CSF
Bacterial Fungal AFB
PPD Testing
Quantiferon for TB
Urinary Antigen
e-
Histoplasma Legionella
Serum mycoplasma
12-lead EKG
Echocardiogram
Chest x-ray
PA and Lateral Decubitus Signature
CT of chest cc
Other
©MB and RR 2006-2009 Revised 16Sep09 e-medtools.com Health Care Provider Signature