New Inpatient Evaluation

Review of Systems
Review of Systems Constitution Fatigue or Malaise Fever or chills Appetite changes Eyes Conjunctivitis New eye pain Blurred vision ENT/mouth Sore throat Swollen uvula Jaw pain Respiratory Dyspnea Cough Phlegm Hemoptysis Wheeze Pleuritic Symptoms Cardiovascular Chest pain Diaphoresis Ankle edema Syncope Palpitations Gastrointestinal Nausea or vomiting Weight changes Diarrhea Abdominal pain Genitourinary Hematuria Dysuria Urethral discharge Musculoskeletal Myalgias Arthralgias Joint swelling Recent trauma Skin/Breasts Masses New skin lesions Rash Neurologic Headaches Seizures Numbness Paresthesias Endocrinologic Hair loss Polydipsia Tremors Neck pain Heme/Lymph Bleeding gums Unusual bruising Swollen lymph nodes Allergy/Immunology Nasal congestion Rhinorrhea Psychologic Agitation Hallucinations Yes No

Patient Name Chief complaint/Reason for consult

Start Time

Stop Time Date

History of Present Illness

‰Patient is Nonverbal.

History obtained from

‰Family ‰Medical records

‰Ambulatory ‰Bedridden ‰Pain present Level (1-10 Scale) ‰1 ‰2 ‰3 ‰4 ‰5 ‰6 ‰7 ‰8 ‰9 ‰10

Allergies and Medications

‰Allergy List reviewed ‰No drug allergies ‰No food allergies ‰Medications reviewed ‰Medications reconciled with Nursing Home data

Past Medical, Family Social History (PFSH)
Past Medical History

‰Asthma ‰Diabetes ‰COPD ‰Hepatic Dysfunction ‰Congestive Heart Failure(CHF) ‰HIV/AIDS ‰Coronary Artery Disease ‰Hypertension

‰Obstructive Sleep Apnea ‰Other ‰Seizure Disorder ‰Thyroid disease ‰Hyper ‰Hypo ‰Tuberculosis

‰Yes ‰No ‰Adrenal ‰Breast ‰Colon ‰Leuk/Lymph ‰Lung ‰Melanoma ‰Renal cell ‰Skin ‰Pituitary ‰Prostate ‰Testicular ‰Thyroid Treatment ‰Surgical Resection ‰Radioablation ‰Chemotherapy ‰Radiation

ADLs This patient is able to perform the following independently ‰Eating ‰Bathing ‰Dressing ‰Toileting ‰Transfers Vaccines This patient is current on the following ‰Seasonal Influenza ‰H1N1 Influenza ‰Pertussis ‰Pneumococcal ‰Varicella ‰Tetanus

‰Appendectomy ‰Arterial bypass ‰Coronary Artery Bypass ‰Cardiac valve repair or replace ‰Carotid Endarterectomy
Social History Risk factors


‰Cholecystectomy ‰Colon resection ‰Hysterectomy ‰Nephrectomy ‰Splenectomy

‰Pacemaker ‰Defibrillator ‰Hip replacement ‰Knee replacement

‰Organ transplant ‰Other

‰Denies ‰Yes ‰Denies ‰Yes

Tobacco use Number Pack-Years ______ Quit tobacco use Quit date _________ Willingness to Quit ‰Unwilling ‰Considering ‰Quit but resumed Patient has tried smoking cessation aids Nicotine ‰Replacement

‰Within 1 month ‰Receptor blockade ‰Buproprion or nortriptyline

‰Denies ‰Yes ‰Denies ‰Yes ‰Denies ‰Yes
Family History

Recreational drug use Route ‰Inhalation ‰Injection ‰Ingestion Drug dependence Type ‰Narcotics ‰Benzodiazepines Alcohol use ___ Drinks per ‰Day ‰Week

‰Asthma ‰Coronary Artery Disease ‰CHF ‰Pancreatitis ‰COPD ‰Peripheral Artery Disease Revised 12Jan2010

‰Renal Dysfunction ‰Thrombotic disorder ‰Thyroid Disease

‰Malignancy ‰Other

©MB and RR 2006-2010

Health Care Provider Signature

New Inpatient Evaluation
Ventilator Mode

Patient Name Exam



Size _____ Size _____

Constitutional WNL = Within Normal Limits Height _______ ‰in ‰cm Respiratory Rate _______

Weight _______

‰lb ‰kg

Temperature _____

Date of Intubation ________________

Pulse Rate _______

‰Endotracheal Tube ‰Tracheostomy Tube
PEEP ____

AND Rhythm ‰Regular


Blood Pressure Sitting __________ OR Standing __________

OR Lying __________

Rate ____ Tidal Vol ____ FiO2 ____ PS ______ Plateau _____ ARDS ALI

Optional Sats _____ % Cardiac Output _____ SVR _____


‰<200 ‰201-300 ‰>300
Exp ____


‰WNL ‰Unkempt
Nasal mucosa, septum, and turbinates

Body habitus ‰WNL

‰Cachectic ‰Obese

NonInvasive Ventilator

‰CPAP ‰BiPAP Ins ____
IV Medications

Dentition and gums ‰WNL ‰Dental caries

‰ Antiarrhythmics ‰ Antihypertensives ‰ Diuretics ‰ Drotrecogin alfa ‰ Heparin ‰ Insulin ‰ Antibiotics

‰ Narcotics ‰ Pressors ‰ Sedation ‰ Steroids ‰ Thrombolytic ‰ TPN


‰WNL ‰Edema or erythema present ‰Gingivitis Oropharynx ‰ WNL ‰Edema or erythema present ‰Oral ulcers ‰Oral Petechiae Mallampati ‰I ‰II ‰III ‰IV
Thyroid ‰ WNL ‰Thyromegaly



‰ WNL ‰Erythema or scarring consistent with ‰recent or ‰old radiation dermatitis ‰Nodules palpable ‰Neck mass Jugular Veins ‰ WNL ‰JVD present ‰a, v or cannon a waves present
Scarring consistent with

Lines & Monitors

‰Telemetry ‰Chest tube

‰NG/ND tube ‰PEG/PEJ tube ‰Foley catheter ‰Ostomy ‰Central line/PICC

‰Present ‰Absent Right Air leak ‰Present ‰Absent
Left Air leak


‰Free of defects, expands normally and symmetrically ‰Erythema consistent with radiation dermatitis ‰Old, healed radiation dermatitis ‰Prior surgery ‰Trauma ‰Other Respiratory effort ‰WNL ‰Accessory muscle use ‰Intercostal retractions ‰Paradoxic movements Chest percussion ‰WNL ‰Dullness to percussion ‰Lt ‰Rt ‰Hyperresonance ‰Lt ‰Rt Tactile fremitus ‰WNL ‰ Increased ‰ Decreased Auscultation ‰WNL ‰Bronchial breath sounds ‰Egophony ‰Rales ‰Rhonchi ‰Wheezes ‰Rub present
Chest Heart sounds


‰Clear S1 S2 ‰No murmur, rub or gallop ‰Gallop audible ‰Rub audible ‰Murmur present ‰Systolic ‰Diastolic Grade ‰I ‰II ‰III ‰IV ‰V ‰VI Peripheral pulses ‰Palpable and symmetric ‰Absent ‰Weak Peripheral edema ‰Absent ‰Present
Abdomen ‰WNL ‰Mass present ‰LUQ

‰No sign of infection Site

Liver and spleen ‰Palpable and WNL Unable to palpate ‰Liver Lymphatics (•2 areas must be examined) Lymph node exam ‰WNL Areas examined Lymphadenopathy noted ‰Neck

‰RUQ ‰LLQ ‰RLQ ‰Pulsatile ‰Spleen Organomegaly ‰Liver ‰Spleen

‰Peripheral venous access
‰No sign of infection Site


‰Neck ‰Axilla ‰Groin ‰Other ‰Submental ‰Axillary ‰Epitrochlear ‰Inguinal ‰Other

‰Port access

Muscle tone ‰WNL, and no atrophy noted Gait and station ‰WNL

‰No sign of infection

Extremities Skin

‰Increased ‰Decreased ‰Atrophy present ‰Ataxia ‰Wide based gait ‰Shuffle Patient leans ‰Rt ‰Lt ‰Front ‰Back ‰Cyanosis ‰Petechiae ‰Synovitis ‰Rt ‰Lt

Exam ‰WNL ‰Clubbing Exam ‰ WNL ‰Rash Orientation ‰Oriented

\____/ / \

____ / ____ / ____ / \ \ \


‰Ecchymosis ‰Nodules ‰Ulcer


Affect ‰WNL Additional Findings

NOT oriented to ‰Person ‰Time ‰Place ‰Agitated ‰Anxious ‰Depressed

‰CXR ‰CT/Chest ‰Other

©MB and RR 2006-2010

Revised 12Jan2010

Health Care Provider Signature

New Inpatient Evaluation
Data Reviewed

Patient Name Impression and Plan



‰ER Notes ‰Old medical records ‰Labs ‰Radiology data ‰Pathology ‰ECHO ‰EKG ‰Stress Test ‰Pulmonary Function Test
Care Coordinated with

‰ I have personally discussed Code Status with this patient, and believe that this patient (or their surrogate
decision maker) understands their medical condition, their prognosis and the consequences of their Code Status decision. Code Status ‰Patient is a FULL CODE ‰DO NOT ATTEMPT Cardiac Resuscitation ‰DO NOT Intubate

‰ This patient has advanced health care directives. Their HCPOA is

‰Patient ‰HCPOA / Surrogate ‰Other physician or Consultant ‰Case Management or Social Worker ‰Pharmacy ‰Nursing ‰Aggressive pulmonary toilet ‰DVT prophylaxis ‰Stress ulcer prophylaxis ‰Daily sedation vacation and ‰Head of bed elevated > 30 Degrees ‰Insulin infusion Goal: 100-150 ‰Central line change/removal culture tip ‰Physical therapy ‰Enteral/Parenteral feeds ‰Smoking cessation aids ‰Pneumonia vaccine prior to discharge ‰Influenza vaccine prior to discharge ‰Antibiotics
Recommended Diagnostics
Cultures ‰Sputum ‰Blood ‰Urine ‰CSF neurologic assessment

Recommended Actions

‰Influenza swab, wash or aspirate ‰PPD ‰Quantiferon ‰Serum Mycoplasma ‰Urine for Histoplasma and Legionella ‰CBC with differential ‰PT, PTT, INR ‰Metabolic Panel ‰BNP ‰Cardiac Enzymes ‰HIV ‰DIC Panel ‰Thyroid function studies ‰EKG ‰ECHO ‰Other

C-FNP or PA-C Signature
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 and I agree with the assessment and plan as outlined.

Physician Signature cc

©MB and RR 2006-2010

Revised 12Jan2010

Health Care Provider Signature