adult encounter form - USAFP Home Page by qingyunliuliu


									                                                       Encounter Intake Form
Staff conducting                               Physician/NPP (signature indicates
initial intake                                 review/notation of pertinent findings)
Date                            Patient Name                                                   DOB                      Sex
Patient Assessment Form Updated                                           Date of last visit
Language or other communication barriers
Interpreter or other accomodation provided
Allergies                                                          LMP                         Gravida/Para
Vital Signs            H      W/BMI            P/R                 BP              T
Last Immun.            Flu    Meningococcal    Pneumococcal        HepB            Td/Tdap     Varicella                MMR

Vaccines Administered Today   Vaccine type/method & site of administration
(complete vaccine
administration record also)
Patient Social History
Tobacco             Current   Type:            Freq:               2nd hand      Never         Quit date:
ETOH                Never     Occasional       Daily               History of ETOH:
Occupation                                                         Exercise type/frequency
Home Environment              Private Home     Assisted Living     Other
Family History      Father    Mother           Sisters (#)         Brothers (#) Aunt           Uncle                    Children
(Indicate positive                                                                                                      # Female
with Ö )                                                                                                                # Male
Heart Disease
Kidney Disease
Genetic Disorder
Liver Disease
Depression or
manic depressive
Colon or rectal
Breast Cancer
Other Cancer
Dates hospitalized/ ER since Facility          Attending           Past Surgeries/Dates        Notes:
last visit/reason                              Physician

Reviewed & Negative (Initial) Positive ROS Findings
(Circle/Note Findings)
Constitutional                 Fever Chills Diaphoresis            Cardiovascular              Chest Pain Dyspnea on Exertion
                               Weight Change Loss of Appetite                                  Edema Palpitations Fainting
Eyes                          Visual changes Pain Discharge        Respiratory                 Cough Hemoptysis Snoring
                              Sensitivity Blurring                                             Shortness of Breath Wheezing
Ears, Nose, Mouth, Throat     Earache Ringing Sore Throat          Gastrointestinal            Nausea Vomiting Diarrhea
                              Mouth Sores Hoarseness                                           Constipation Melena Jaundice
Psychiatric                   Depression Anxiety Insomnia          Genitourinary               Frequency Burning Pain Retention

Endocrine                     Thirst Weight Change                 Musculoskeletal             Joint Pain Muscle Aches Stiffness
                              Facial Hair (female)
Hematologic/Lymphatic         Swollen glands                       Integumentary (skin/breast) Rash Itching Cyst Mole Sores Mass
                                                                                               Discharge Pain
Allergic/Immunologic          Hives Rashes Food/Drug Concerns Neurological                     Headache Seizures Dizziness
                                                                                               Syncope Numbness Tingling

                                                                                                            Last Updated 08/04/08
                                                           Clinician Encounter Form

Date                            Patient Name                                                   DOB            Sex
Physician face-to-face time     Total        Counseling                                Counseling - tobacco
Chief Complaint Today:

I reviewed the patient medications including supplements and OTC - no changes (Initial if done)
Medication list reviewed with changes as noted on medication log (Initial if done)
History of Present Illness (Note findings: location, quality,           Reports/Records Reviewed
severity, duration, timing, context, modifying factors and assoc.
signs & symptoms)

Examination - Indicate negative or document pertinent negative              Notes/Counseling (indicate if further documentation is
and positive findings for each system examined                                      available elsewhere in patient chart):
Constitutional (vitals, general appearance)

Eyes (conjunctiva, lids)

Ear, Nose, Mouth, Throat (teeth, gums, palate, oral mucosa)

Neck (jugular veins, thyroid)

Respiratory (respiratory effort, auscultation of lungs)

Cardiovascular (palpation, auscultation, carotid, abd. aorta, peripheral
pulses, edema, varicosities)

Chest (breasts)

Gastrointestinal (abd. mass/tenderness, liver, spleen, rectal)

Genitourinary (inspection, collection of specimens as indicated, digital

Lymphatic (neck, axillae, groin, other)

Musculoskeletal (gait, station, digits, nails, ROM, stability,
strength, tone)

Skin (Inspection, palpation)

Neurologic (test cranial nerves, reflexes, sensation)

Psychiatric (judgement, insight, orientation, memory, mood,                Care plan completed/updated

Orders (tests, consults, next appointment)

Diagnoses                                                                  Physician/NPP Signature(s)

                                                                                                           Last updated 08/04/08
                                                                Patient Care Plan

Date                           Patient Name                                     DOB            Sex
Patient care plan for management of: Diabetes
Physician/Healthcare Service Plan
Date                Next visit Microalbumin Creatinine    A1C         Eye exam Foot Exam       Lipids    ECG          Other

Patient goals
Date                 Current   Goal/Ideal   Date          Current     Goal/Ideal Date          Current   Goal/Ideal
Weight                                      Weight                               Weight
BMI                                         BMI                                  BMI
BP                                          BP                                   BP
A1C                                         A1C                                  A1C
Cholesterol                                 Cholesterol                          Cholesterol
LDL                                         LDL                                  LDL
HDL                                         HDL                                  HDL

                                              Patient self-management plan                                            Date plan updated
Monitor blood
sugars (frequency)
Schedule eye

Exercise plan
Flu vaccine
Dental exam
Dietary plan

Patient signature:

Physician signature:

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