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 eds 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
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