Template for Dictating a History and Physical Physical Exam
Date:
Patient Name:
Chief Complaint: Reason for Admission:
History of Present Illness:
Template for Dictating a History and Physical Ext 2-9007, work type #09: Enter FIN (not MRN) State your name, Patient Name, Patient MRN and FIN,
Admitting Attending, Date of service
Patient MR/FIN:
PCP: Code Status: Surrogate Decision Maker:
(Location, Severity, Timing, Quality, Duration, Context, Modifying factors, Associated signs & symptoms--minimum 4 of 8)
Physical Exam:
Vital signs: Temp
HR
BP
RR
Ht
Wt
Organ Systems / Body Areas (8+ systems with 2 items each)
O2sat
Nml Abnml Findings
Nml Abnml Findings
General
Obese?
Skin
Breakdown, Ulcers?
Appearance
HEENT
Moist? EOMI?
MSK/
Extremities
Neck
Neuro
Respiratory Cardiac GI
Psych
GU/Genital Rectal Other
Lines/Foley
Labs/Studies
Past / Family / Social History (must include all 3) Past Medical / Surgical Hx/Chronic Medical Issues:
(if unable to obtain any of these sections, state why)
Review of Systems: (need 10+ or reason not done) Constitutional - Fever, chills, malaise
Eyes
- Vision, pain
ENT/mouth
- Teeth, sore throat
Cardiovascular - CP, palpitations, orthopnea
Respiratory
- SOB, cough, pleuritic CP
GI
- N/V/D, abd pain
GU
- Dysuria, hematuria
Musculoskeletal - Myalgia, arthralgia, weakness
Integumentary - Rashes, lesions
Neurological
- Focal weakness, numbness
Psychiatric
- Delusions, depression
Endocrine
- Polyuria, polydipsia
Heme / lymph - Bruising, bleeding, LAD
Allergy / immune
- Seasonal, frequent infections
Social History: Tobacco, ETOH, recreation drugs Functional status/ambulation Home, support system Family History:
Allergies:
Medications:
State if Radiology ordered / reviewed, Old / electronic chart reviewed
Assessment/Plan by Problem (all admitting diagnoses, pertinent chronic problems. State reason for admission and what level of care):
Hospital issues: DVTp Diet Ambulation Status Dispo
Bed Request Admit Orders Med Rec Code Status Note H&P or MRAN Update Cache Team Color ____
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