HISTORY AND PHYSICAL
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3 HISTORY AND PHYSICAL GENERAL INFORMATION Today s Date: Start of Care: Unit: Chart: Patient s Name: Admitting DX: Address: Date of Birth: Sex: M F City and State: Zip: Phone #: Directions: Marital Status: Single Married Widowed Divorced Separated ALLERGIES: Race: Caucasian Black Hispanic Other Hospital: Admitted: Discharged: Physician Office #: Lab Preferred: MD s Office Other: Primary Payer: Secondary Payer: Number: Number: ADMISSION ORDERS: Outside of Home Emergency Contact: Name: Number: Caregiver: Foley Catheter: Size: Feeding Tube: Size Type: VITAL SIGNS B/P: / Sitting Standing Lying PULSE Radial Apical RESPIRATIONS TEMPERATURE Oral Axillary Rectal HEIGHT Feet/Inches Actual Estimated WEIGHT Pounds Actual Estimated PROSTHESIS Dentures Removable Bridge Crown Braces Glasses Contact Lenses Lens Implant(s) Hearing Aid Pacemaker Artificial Limb(s): Right Left Upper Lower
4 HISTORY AND PHYSICAL PATIENT NAME: HISTORY MEDICAL HISTORY: SURGICAL HISTORY: PRIOR HISTORY: Comments on History: MUSCULOSKELETAL INSPECT & PALPATE EXTREMITIES Skin Smooth / Temp Warm Edema Pitting Non-pitting GAIT and MOVEMENT Coordinated Uses Assistive Person Uses Assistive Device JOINTS BILATERAL Pain ROK WNL Edema Crepitation Heat INTEGUMENT COLOR MOISTURE CAPILLLARY REFILL TIME TEMPERATURE Normal Pale Cyanotic Dry Clammy Almost Immediate Y N Warm Cool Hot Jaundiced SKING TURGOR CONTOUR OF NAIL PRESSURE RELIEVING DEVICES PROTECTORS Return Quickly to Place Tenting Convex Other Egg Crate Air Mattress Heel Elbow SKIN INTACT Yes No (if skin is not intact use Wound Care Flow Sheet)
5 HISTORY AND PHYSICAL FAMILY HISTORY YES NO DMR Diabetes Tuberculosis Heart Disease CVA Hypertension Cancer COPD Mental Illness CARDIOVASCULAR Heart Rhythm & Rate: Regular Slightly Irregular Very Irregular Chest Pain: Yes No Distended Neck Veins Yes No Peripheral Pulses: Strong Weak Not Present Other: NEUROLOGICAL Alert Oriented Forgetful Confused Agitated Comatose Depressed Paralysis Tremors Seizures Headaches Numbness Tingling Lethargic Memory Loss: Short Term Long Term Hallucinations Delusions Disoriented: Time Place Person Attention Span: Affect: Normocephalic Face Symmetric HEAD AND NECK Hearing Loss EYEBALLS CONJUNCTIVA SCLERA PUPILS CORNEAL LIGHT REFLEX Firm Soft Moist Dry White Moist Round Equal Equal Not Equal React to Light Sluggish CORNEA PERIORBITAL EDEMA LYMPH NODE Transplant Normal Yes No Within Normal Limits Other TOUNGUE LIPS GUMS Dry Moist Pink Teeth Dry Moist Lesions Ulcers Cracks Pink Pale Bleeding Ulcers OTHER: RESPIRATORY Regular Shallow Irregular Dyspnea Orthopnea Cough Production Oxygen Nasal Cannula Audible Breath Sounds URINARY Dysuria Frequency Burning Nocturia Hematuria Retention Incontinent Pampers Catheter: Texas Foley Character of Urine:
6 HISTORY AND PHYSICAL HOUSING AND FAMILY DYNAMICS LIVING QUARTERS: Single Dwelling Apartment Duplex Other: CONDITIONS OF DWELLING: Adequate Poor Inadequate Comments: FAMILY DYNAMICS: RELIGIOUS PREFERENCE: MISCELLANEOUS SLEEP PATTERN EMOTIONAL SUPPORT SPEECH Well Fair Poor Insomnia Patient Significant Other Normal Slurred Hardness R L SAFETY Side Rails Restraints Uses Assistive Devices Other: ADDITIONAL ASSESSMENT DATA SUBJECTIVE PHYSICIAN APPOINTMENTS: PHYSICIAN CONTACTS: NEW ORDERS:
7 HISTORY AND PHYSICAL GASTROINTESTINAL ABDOMEN: Flat Rotund Distended Rigid Rebound Tenderness Soft Masses Nausea Vomiting Difficulty Swallowing Diarrhea Constipation Incontinent Tarry Stools Change in Bowel Habits BOWEL SOUNDS: Present Absent Quadrant: APPETITE NUTRITIONAL STATUS HYDRATION Good Fair Poor Unchanged Good Fair Poor Good Fair Poor Task Wholly Independent Uses Assistive Devices Help of Another Assistive Device & Help Wholly Dependent Undetermined Eating Transferring Dressing Bathing Toileting Ambulation Finances Cleaning/Laundry Shopping SELF-CARE AGENCY (Ability to Perform ADL s) INSTRUCTIONS RENDERED TO : Patient Significant Other INTERVENTIONS INSTRUCTION A1 Skilled Observation/Assessment A16 Teach Nasogastric Feeding Adequate Hydration A2 Foley Catheter Insertion A17 Reinsertion Nasogastric Feeding Tube Prevention Constipation A3 Bladder Instillation A18 Teach Gastrostomy Feeding Dressing Changes A4 Open Wound Care/Dressing A19 Teach Parenteral Nutrition Decubitus Care A5 Decubitus Care-State 3, 4, 5 A20 Teach Care of Tracheostomy Catheter Care A6 Venipuncture A21 Adm. Care of Tracheostomy Irrigation A7 Restorative Nursing A22 Teach Inhalation Medication: Time, Dose, Route A8 Post Cataract Care A23 Adm. Inhalation RX Emergency Measures A9 Bowel/Bladder Training A24 Teach Adm. of Injection Safety Precautions A10 Chest Physiotherapy (includes postural drainage) A25 Teach Diabetic Care Adequate Nutrition A11 Adm. Of Vitamin B-12 A26 Disimpaction/F.U. edema A12 Adm. Insulin A27 Other (specify under orders) A13 Adm. Other IM/Subq. A28 Wound Care/Dressing-Closed Incision/Suture Line A14 Adm. IV s A29 Decubitus Care-Stage 1, 2, 3 A15 Teach Ostomy or Ileo Conduit Care A30 Teaching Care of Any Indwelling Catheter (V/S, Response to Meds, etc.) LEVEL OF COMPREHENSION REGARDING INSTRUCTION RENDERED Good (70-100%) Fair (35-70%) Poor (0-35%)
8 HISTORY AND PHYSICAL METHOD OF INSTRUCTION Written instructions left in the home (see attached) Verbal instructions rendered PROJECTION OF NEED FOR FUTURE INSTRUCTION Much teaching and reinforcement regarding patient s care Moderate teaching and reinforcement regarding patient s care Minimal teaching and reinforcement regarding patient s care ADDITIONAL INTERVENTIONS
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