Evaluation and Management Template

Ó GENERAL MULTI-SYSTEM


PT TYPE: OFC/NEW_____ OFC/EST _______
Hosp Obs____ Hosp Obs w/ Adm & DC ______ ER ________ CONSULT OFC/OP _________Consult Initial IP______
Consult FU IP______ Consult Confirm_______
Nursing facility Initial Comprehensive Assessment_____
Nursing facility Subsequent______

CC_____________

HISTORY

HISTORY of Present Illness:
____Location diffuse/localized, unilateral/bilateral, fixed/migratory
____Duration How long? 20 min, onset 3 yrs ago, since last Friday, for approx 2 months, since yesterday
____Quality sharp, dull, burning, gnawing, fullness, aching, throbbing, stabbing, radiating, color of sputum, non-productive, asymptomatic etc. Laceration jagged/straight. Sore throat scratchy
____Context What was going on at time symptoms occurred, exercise, big meals, dairy products, spicy foods, etc. What were they doing when it occurred, MVA, running down steps, sitting in chair, playing sports.
____Severity Rank of pain on pain scale 0-10, severe, slightly, worst I’ve ever had, mild, moderate, 0 pain, increase, decrease, progressive, well, major, poor, significant, complicated (must be ranked; can’t just say “pain in my leg”
____Modifying Factors What makes better or worse, any meds helping, rest or eating, affected by spicy foods, ice pack or quiet room for MHA, coughing irritates the pain, OTC or prescribed meds have been attempted, etc What were the results?
____Timing Onset, night, day, continuous, occasional, episodic, AM, PM, constant, recurrent, seldom, frequently, off and on, morning, evening, intermittent, transient.
____Signs/Symps Associated with…, Negative Responses will count

Document of at least 3 chronic/inactive conditions_____

REVIEW OF SYSTEMS:
Negative, Normal, WNL can count in any/all systems
_____Constitutional – Activity, appearance, appetite, exercise, fatigue, fevers, mood, sweats, weakness, wt change, chills
_____Eyes - Blurred vision, drainage, dryness, flashing, pain, photophobia, redness, tearing, vision change
_____ENT & Mouth - Airway, balance, bleeding, discharge, hearing, pain, ringing, smell, swallowing, taste, voice
_____CV - Chest pain, diaphoresis, dizziness, exertional pain, irregular beats, leg cramps, orthopnea, palpitations, peripheral edema, radiation, SOB
_____Respiratory - Allergies, cough, dyspnea, hemoptysis, pain, SOB, sputum, wheezing
_____GI - Appetite, Change in bowel habits, constipation, diarrhea, heartburn, hemetemesis, indigestion, nausea, pain, rectal bleed, swallowing, thirst, vomiting
_____GU – Burning, discharge, dribbling, frequency, hematuria, incontinence, menopause, nocturia, odor, pain, pregnancies, starting, stopping, urgency, dyuria
_____All/Imm – Allergies to meds, chemo, hay fever, HIV/AIDS, hives, immune suppression, immunizations, sweating
_____MS - Limitation of activity, pain, redness, stiffness, swelling, weakness
_____Skin – bleeding, color change, cyanosis, dryness, growths, jaundice, rash
_____Neuro – blackout, HA, memory loss, numbness, seizure, syncope, tingling, tremors
_____Psych – Anxiety, delusion, depression, hallucination, insomnia, nervous, panic, personality, phobia, suicidal
_____Endocr – Change hair pattern, heat/cold intolerance, polydiipsia, polyphagia, polyuria, sweating
_____Hem/Lym – bleeding, bruising, gland swelling, menses, nodes
_____Documentation of adequate ROS & all others negative


PFSH
_____Past Medical History
Surgeries
Any item labeled as PMH may only be used for that. This is true for even chronic problems. Don’t try to count them for HPI or ROS elements
Diagnostic tests, even when they appear in the HPI area, can only be used as PMH. Don’t try to count them as something else
_____Family History
_____Social History
Smoking, Alcohol, Marital status
____Unable to do comprehensive history due to patient condition






PHYSICAL EXAM

CONSTITUTIONAL (2) –
____BP, Pulse, Respiration, Temp, Ht, Wt Measurement of any 3 of
the above VS. (May be measured/recorded by staff person)
____GENERAL APPEARANCE – Development, Nutrition,
Body habitus, Deformities, Grooming
EYES (3)–
____ Conjunctivae, Lids
____ Pupils and Irises PERRLA
____ SCOPE EXAM, Optic discs, C/D ratio (Cup to Disk
Ratio), Size, Appearance
Posterior segments,Vessel changes, Exudates,
hemorrhages
EARS, NOSE, MOUTH, THROAT (6)
____External auditory canals, TM’s
____EARS & NOSE – Appearance, Scars, Lesions, Masses
____Hearing, Whispered voice, Finger rub, Tuning Fork
____NOSE - Mucosa, Septum, Turbinates
____MOUTH – Lips, Teeth, Gums
____THROAT/OROPHARYNX – Oral mucosa, Salivary glands,
Hard and soft palates, Tongue, Tonsils, Posterior pharynx
NECK (2)
____NECK – Masses, Appearance, Symmetry, Tracheal
position, Crepitus
____THYROID – Enlargement, Tenderness, Mass
RESPIRATORY (4) –
____Effort, Retractions, Muscles, Movement
____Percussion, Dullness, Flatness, Hyperresonance
____Palpation, Fremitus,
____Auscultation, Breath sounds, Rubs
CARDIOVASCULAR (7) –
____Palpation, Location, Size, Thrills
____Auscultation, Abnormal sounds, Murmurs
ARTERIES –
____Carotid, Pulse, Bruits
____Abdominal Aorta,Size, Bruits
____Femoral, Pulse, Bruits
____Pedal Pulse
____Extremities, Edema, Varicosities
CHEST/BREASTS (2)–
____Breasts, Symmetry, Nipple discharge
____Breasts and axillae, Mass, Lump, Tenderness
GI/ABDOMEN (5) –
____Abdomen, Mass, Tenderness
____Liver, Spleen
____Hernia
____Anus, Perineum, Rectum, Sphincter tone, Hemorrhoids,
Rectal mass
____Occult blood


GU, FEMALE (6)–
____External genitalia, Appearance, Hair distribution, Lesions,
____Vagina, Appearance, Estrogen effect, Discharge,
Lesions, Pelvic support, Cystocele, Rectocele
____Urethra, Mass, Tenderness, Scarring
____Bladder, Fullness, Mass, Tenderness
____Cervix, Appearance, Lesions, Discharge
____Uterus, Contour, Position, Mobility, Tenderness,
Consistency, Descent or Support
____Adnexa/Parametria, Mass, Tenderness, Organomegaly,
Nodules
GU, MALE (3)–
____Scrotum, Hydrocele, Spermatocele, Tenderness of cord,
Testicular mass
____Penis, phallus
____DRE of prostate for Size, Symmetry, Nodules, Tenderness
LYMPHATIC (4) - Nodes, ____Neck, ____Axillae
____Groin, ____Other
MS (26) –
____Gait, Station, Romberg, Ambulatory??
____Nails/Digits, Clubbing, Cyanosis, Inflammation,
Petechiae, Ischemia, Infection, Nodes
HEAD AND NECK
____Misalignment, Asymmetry, Crepitation, Defects,
Tenderness, Mass, Effusion, EOMI
____ROM, Pain, Crepitation, Contracture
____Stability, Dislocation, Subluxation, Laxity
____Muscle strength, Tone, Atrophy, Abnormal movements
SPINE, RIBS, AND PELVIS
____Misalignment, Asymmetry, Crepitation, Defects,
Tenderness, Mass, Effusion
____ROM, Pain, Crepitation, Contracture
____Stability, Dislocation, Subluxation, Laxity
____Muscle strength, Tone, Atrophy, Abnormal movements
EXTREMITIES,
RUE
____Misalignment, Asymmetry, Crepitation, Defects,
Tenderness, Mass, Effusion
____ROM, Pain, Crepitation, Contracture
____Stability, Dislocation, Subluxation, Laxity
____Muscle strength, Tone, Atrophy, Abnormal movements
LUE
____Misalignment, Asymmetry, Crepitation, Defects,
Tenderness, Mass, Effusion
____ROM, Pain, Crepitation, Contracture
____Stability, Dislocation, Subluxation, Laxity
____Muscle strength, Tone, Atrophy, Abnormal movements
RLE
____Misalignment, Asymmetry, Crepitation, Defects,
Tenderness, Mass, Effusion
____ROM, Pain, Crepitation, Contracture
____Stability, Dislocation, Subluxation, Laxity
____Muscle strength, Tone, Atrophy, Abnormal movements
LLE
____Misalignment, Asymmetry, Crepitation, Defects,
Tenderness, Mass, Effusion
____ROM, Pain, Crepitation, Contracture
____Stability, Dislocation, Subluxation, Laxity
____Muscle strength, Tone, Atrophy, Abnormal movements

SKIN (2) –
____Inspection, Rash, Lesion, Ulcer
____Palpation, Induration, Nodule, Tightening

NEURO (3) –
____Cranial deficits
____DTR, Babinski
____Sensation, Touch, Pin, Vibration, Proprioception

PSYCH (4) –
____Judgement, Insight
____AO x 3
____Memory, recent and remote
____Mood and affect, Depression, Anxiety, Agitation





MEDICAL DECISION MAKING:

Dx: Types of problem:
_____Self-limited or minor
_____Established same/improving ____ Established, worsening
_____New, no additional workup ____New, with additional workup

_____Are any of the above illnesses a severe exacerbation, progression or side effect of treatment?

Management Options:
_____OTC Meds ____Phys/Occ Therapy
_____Prescrip/IM meds ____Closed Fx/dislocation w/o
_____IV meds manipulation
_____IV meds w/ additives ____Minor surg w/o risk factors
_____High Risk meds ____Minor surg w/ risk factors
_____Telemetry ____Major surg w/o risk factors
_____Respiratory treatments ____Major surg w/ risk factors
_____Nuclear Medicine ____Major emergency surger
____Decision not to resuscitate
----------------------------
_____Decision to obtain old medical records and/or obtain Hx from someone other than patient
_____Review and summ of old records and/or obtain Hx
from someone other than patient
_____Discussion of case with another health care provider

Time spent in minutes w/ patient or family_____________


Labs:
_____CBC/UA ____Cardiac enzymes
_____Flu/Strep/Monospot ____ABG
_____PG test _____PT/PTT
_____Amylase _____T&C
_____BUN/Creat _____Superficial Bx
_____Electrolytes _____Deep/incisional Bx
_____ETOH/Drug screen ____Other labs 0-9
_____Chem profile
----------------------
_____Independent visualization of test
_____Discussion w/ performing
physician

X-ray/Radiology
_____Chest ____GI/Gallbladder series
_____Extremities ____IVP
_____Abdomen ____CAT scan
_____Hip/Pelvis ____MRI
_____C-spine ____Vascular studies w/o risk
_____Diagnostic US ____Vascular studies w/ risk
_____Discography ____Other X-ray 0-9
_____T/L spine
--------------------------
_____Independent visualization of test
_____Discussion w/ performing physician

Other diagnostic tests:
_____EKG ____Nuclear scan
_____Holter ____Lumbar puncture
_____Treadmill/stress ____Thoracentesis
_____EEG/EMG ____Culdocentesis
_____Vectorcardiogram ____Endoscope w/o risk
_____Doppler flow ____Endoscope w/ risk
_____Pulmonary
---------------------
_____Independent visualization of test
_____Discussion w/ performing
physician


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