Resources
HPForm – Short Form with faculty verbiage 2013
HPForm – Long Form with faculty verbiage 2013
Family Medicine Program Comparison Worksheet
Family Medicine Program Comparison checklist in Excel
BINDING LINE _
|
|
|
PATIENT IDENTIFICATION
|
Via Christi Adult Medicine
HISTORY AND PHYSICAL EXAMINATION
| Admit History & Physical / Family Medicine Resident | |
| Attending Physician: Primary Care Physician: | |
| CC: Information Source: Patient Other: | |
| History of Present Illness: | |
| Past Medical History: Past Surgical History: | |
| Medications on Admission: | |
| Imunizations: Pneumovax Influenza Tetanus < 10 y | |
| Allergies: | |
| Family History: DM HTN CAD CVA Asthma TB COPD CA ______________ Same as CC: | |
| Social History: Tobacco: EtOH: ILDU: | |
| Marital/Family Status: Religion/Cultural: | |
| Occupational History: OBHistory: G__P__LC__ | |
| Review of Systems: gained/lost weight, f/c/ns, insomnia, fatigue, weakness, HA, vision change, nasal d/c, epistaxis, congestion, | |
| dec. drinking/eating, ear pain, sore throat, chest pain, palpitations, dyspnea, wheezing, syncope, hemoptysis, cough: dry, sputum | |
| n/v/d, constipation, dysphagia, reflux, hematemesis, abd pain, melena/hematochezia, jaundice, last BM _____, last urination: _____ | |
| dysuria, hematuria, polyuria, polydipsia, polyphagia, nocturia, rash, pruritus, bruise/bleed, back pain, pain____________________ | |
| All other systems negative (continued next page) Signature: |
_______________________________________________________BINDING LINE______________________________________________________
PATIENT IDENTIFICATION
|
Via Christi Adult Medicine
HISTORY AND PHYSICAL EXAMINATION
| History & Physical / Family Medicine Resident – continued | |
| VS: T BP P R SaO2 Wt Pain /10 | |
| PE: Gen – Alert and oriented, NAD | |
| HEENT – NCAT, PERRLA, EOMI, TM Intact B, MMM, OP Clear | |
| Neck – Supple, No LAD | |
| Pulm – CTAB | |
| CV – RRR without Murmur | |
| Abd/GI – Soft, NT, ND, + BS, No HSM, No guarding or rebound | |
| Rectal – Heme +, Heme - | |
| GU - | |
| Ext – No c/c/e, strong periph pulses, cap refill < 2 sec | |
| Skin – No rashes noted, warm, dry | |
| Neuro – CNII-XII grossly intact, no focal deficits, strength/sensation equal B | |
LAB Ca AST Protein TroponinT. Bili ALT Albumin CPK Alk Phos Globulin CKMB |
|
| Radiology: | |
| Assessment/Plan: | |
| Code status: Proph: DVT GI | |
| Discussed with: Dictation # Signature: | |
| Date/Time | I personally examined and interviewed the patient. I reviewed the chart, imaging, and labs. I discussed the patient with the family medicine resident, reviewed the note as above, and agree with the history, physical exam, assessment and plan of care as above, with the following additions or corrections:
Preceptor Signature: |
