Date Asthma Clinic Followup Chief Complaint or Quality Reporting Initiative (PQRI) Physician Quality Measures Indicates 2007

Physician Reason For Visit Time ROS
Constitutional Eyes ENT/mouth Resp CV GI GU Musc Skin/breasts Neuro Endo Heme/lymph Allergy/Immun Psych Allergies

WNL

See HPI

HPI

             

                 

Asthma Symptom Frequency

 64

 1+ days per week
OR 1+ nights per month

 2+ days per week
OR 2+ nights per month

 Daily
OR 2+ nights per week  Antibiotic use  ER visit for asthma  Oral steroid use  Hospital admission for asthma

 Continual
OR Frequent

 Discharge Medications from hospital/ER visit reconciled 46

Physical Exam Checked box indicates findings are within normal limits
General

 Alert

Vital signs

Temp

Pulse

BP

RR

Sats

ENT Neck Resp CV GI Lymph Musc Extrem Skin Neuro

History No changes See HPI

 PMSH  Social  Family  Asthma Severity
Mild Intermittent Mild persistent Moderate persistent Severe persistent

 Mucosa  Dentition  Oropharynx Mallampati  I  II  III  IV  Palpation  Thyroid  No JVD  Auscultation  Percussion Respiratory effort Palpation Chest wall  Clear S1 S2  No murmur  No gallop No rub  Peripheral pulses  No peripheral edema No palpable masses  No hepatosplenomegaly  No hepatojugular reflux  No lymphadenopathy Tone  Gait  Digits without clubbing or cyanosis  No rashes, ecchymoses, nodules, ulcers  Oriented (person, time, place) Affect
Tests to be ordered Bronchoscopy Pulmonary Function Testing Sleep study CXR Chest CT with contrast Echocardiogram with
Bubble study PA pressures Cardiopulmonary Stress Test

Impression and Plan

Asthma Therapy Current New Short-acting beta 
agonist “Rescue Agent” Inhaled steroid 53 Long-acting beta agonist Theophylline Omalizumab Oral steroids Antibiotics Leukotriene inhibitor Oral antihistamine Intranasal steroids Intranasal antihistamine Smoking cessation aids

             Patient has completed advanced health care directives 47
HCPOA is

          

Follow Up
©MB and RR 2006, 2007
Data Reviewed

Signature

Care Coordinated With

 ER Notes  Old Chart EMS Note ECG Nursing Notes & Vitals log  Labs  X Rays MRI ER MD HCPOA Primary Care MD Case Management Social Worker Pharmacy

Pulmonary Rehabilitation Pneumococcal vaccine Influenza vaccine PPD Testing Allergy skin testing Labs Instruction & Education Asthma action plan Smoking cessation Peak flow meter use Inhaler use Importance of vaccinations Medication side effects Advanced care directives explained  Form offered to patient US CT

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