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    Last Modified 1/6/2009

    Pulmonary Clinic H&P Medical Note Template  

    The pulmonary new clinic patient evaluation MedicalTemplate is suitable for pulmonologists and other health care providers.

    How to use MedicalTemplates

      Read this document on Scribd: Pulmonary Clinic History and Physical

      Outpatient Pulmonary Evaluation Date Start time Stop time Patient Name Pt DOB Referring MD Chief complaint/Reason for consult Medications History of Present Illness ‰Patient is Nonverbal. History obtained from ‰ Family ‰ Medical records ‰Medications reviewed ‰Medications reconciled Changes as follows with Nursing Home or Hospital discharge Information œ46 Allergies ‰ Allergy List reviewed ‰ No drug allergies ‰ No food allergies Social History ‰Never Smoker ‰Tobacco ____ # Packs X ____ # Yrs ‰ Quit ‰Patient is unwilling to quit ‰Patient willing to consider quitting ‰Patient quit, but resumed smoking ‰Patient willing to quit within 1 month Patient has tried ‰Nicotine replacement ‰Buproprion or nortriptyline ‰Nicotine receptor blockade Daily, occasional and ex-smokers are more likely to be hazardous drinkers Review of Systems ‰ Constitutional ‰Fatigue ‰Malaise ‰Fever/chills ‰Change in appetite ‰Weight changes ‰ Eyes ‰Vision changes ‰New pain ‰Scotomas ‰Discharge ‰Dryness ‰Gritty sensation ‰ ENT/mouth ‰Nose bleeds ‰Dental caries ‰Dental abscesses ‰Jaw pain ‰ Resp ‰Dyspnea ‰Cough ‰Phlegm ‰Hemoptysis ‰Wheeze ‰Chest tightness ‰ CV ‰Chest pain ‰Diaphoresis ‰Ankle edema ‰PND ‰Syncope ‰ GI ‰Nausea ‰Vomiting ‰Constipation ‰Diarrhea ‰Abdominal pain ‰ GU ‰Change in urinary habits ‰Hematuria ‰Dysuria ‰ Musc ‰Myalgias ‰Recent trauma ‰Bony fractures ‰Arthralgias ‰Joint swelling ‰ Skin/breasts ‰Rashes ‰Masses or skin lesions ‰Increased sensitivity to sun ‰ Neuro ‰Seizures ‰Episodic or chronic muscle weakness ‰Headaches ‰ Endo ‰Hair loss ‰Polydipsia ‰Tremors ‰Neck pain ‰Hirsutism ‰ Heme/lymph ‰Bleeding gums ‰Unusual bruising ‰Swollen lymph nodes ‰ Allergy/Immun ‰Sinus probs ‰Recurrent infections ‰ Psych ‰Mood changes ‰Agitation ‰Psychosis ‰Delirium ‰Dementia Notes Occupational and Exposure History ‰Inorganic dusts i.e., quarries, sandblasting, cement, stone carving, welding, plumbing, shipyard work, firefighter ‰Organic dusts i.e., farming, building inspection, woodworking, remodeling, handling vegetable matter or animals ‰Noxious fumes i.e., spray painting, autobody work, working with dyes or glues, manufacturing plastic ‰Hot tub or Jacuzzi ‰High Pressure washings ‰Pets or feathers ‰Chemicals or fires WNL Drinks per ‰day ‰week Hazardous drinking NIAAA (National Institute on Alcoholism and Alcohol Abuse guidelines) ‰Alcohol use Men > 14 drinks per week OR > 4 drinks per day Women > 7 drinks per week OR >3 drinks per day ‰Recreational drug use ‰Inhalational ‰Injectable ‰Ingestible ‰Drug dependence ‰Narcotics ‰Benzodiazepines Family Medical History ‰ Asthma ‰ Congestive Heart Failure ‰ COPD ‰ Coronary Artery Disease ‰Premature Onset ‰ Malignancy ‰ Pancreatitis ‰ Peripheral Artery Disease ‰ Renal Dysfunction ‰ Thrombotic disorder ‰ Thyroid Disease Past Medical and Surgical History ‰ Asthma ‰ Cerebral Artery Disease ‰ Bronchiectasis ‰ Congestive Heart Failure ‰ COPD ‰ Coronary Artery Disease ‰ COP (BOOP) ‰ Diabetes ‰ Cystic Fibrosis ‰ GERD ‰ Histiocytosis ‰ Hepatic Dysfunction ‰ Tuberculosis ‰ HIV/AIDS ‰ PAH ‰ Hypertension ‰ Sarcoidosis ‰ Inflam bowel disease ‰ Tuberculosis ‰ Malignancy ‰ Wegener’s ‰ Obstructive Sleep Apnea ‰ CPAP ‰ BiPAP ‰ Neuromuscular weakness ‰ Occupational exposures ‰ Pancreatitis ‰ Peripheral Artery Disease ‰ Scleroderma ‰ Seizure Disorder ‰ Sjogren ‰ Renal Dysfunction ‰ Rheumatoid arthritis ‰ Thrombotic Disease ‰ Thyroid Disease ‰ Chemotherapy Surgeries ‰ Colonoscopy ‰ ECHO/Stress Test ‰ Mammogram ‰ PFTs ‰ PapSmear ‰ Prior Intubations ‰ Radiation exposure ‰ Sleep Study ‰ Steroid use Vaccines İMB and RR 2006 -2008 Revised 20Mar08 ‰Flu ‰Pneumo ‰BCG ‰Tetanus ‰Pertussis ‰Varicella e-medtools.com œIndicates Physician Quality Reporting Initiative (PQRI) Physician Quality Measures Outpatient Pulmonary Evaluation Prior Diagnostic Data \____/ / \ ____ / ____ / ____ / \ \ \ Patient Name Pt DOB Exam ENT ‰Alert Vitals T P R BP Sats % ‰Nasal mucosa ‰Dentition ‰Oropharynx Mallampati ‰I ‰II ‰III ‰IV Neck ‰Normal to palpation ‰Thyroid ‰No JVD Resp ‰Clear to auscultation ‰Dullness to percussion ‰No respiratory distress ‰No chest wall defects ‰Decreased fremitus ‰Bronchial breath sounds ‰Absence of intercostal respiratory retractions ‰Egophony (E to A change) CV ‰Clear S1 S2 ‰No murmur ‰No gallop ‰No rub ‰Peripheral pulses ‰No peripheral edema GI ‰No palpable masses ‰Liver and spleen not palpable ‰No hepatojugular reflux Lymph ‰No lymphadenopathy Musc ‰Tone ‰Gait Extrem ‰No clubbing ‰No cyanosis Skin ‰No rashes, ecchymoses, nodules, ulcers Neuro ‰Oriented œ58(Pts with Community Acquired Bacterial Pneumonia) ‰Affect General Impression and Plan Diagnostic Evaluation ‰Sputum culture ‰Bacterial ‰Fungal ‰AFB ‰Sputum Cytology ‰CBC with differential ‰PT, PTT, INR ‰BMP (with calcium) ‰CMP ‰Alpha-1 Antitrypsin level ‰Serum ACE level ‰Serum LDH ‰HIV ‰Hepatitis panel ‰Antibodies ‰ANA (SLE) ‰ds-DNA (SLE) ‰ANCA (vasculitis not PAN) ‰RF ‰Anti-CCP (RA) ‰Jo (PM/DM) ‰Topoisomerase (Scl-70) ‰anti-RNP (Scleroderma and SLE) ‰GM-CSF (Pulm Alveolar Proteinosis) ‰Ro, La (Sjogren) ‰Cryoglobulins ‰Complements (C3, C4) ‰Other labs ‰ Patient has completed advanced health care directivesœ47 HCPOA is Code Status ‰ Patient is a FULL CODE ‰ DO NOT ATTEMPT RESUSCITATION ‰12-lead EKG ‰Echocardiogram ‰CXR ‰CT of Chest ‰High Resolution CT Chest ‰Pulmonary Function Testing ‰Overnight Polysomnography ‰Cardio Pulmonary Exercise Test ‰6 Minute Walk Test İMB and RR 2006 -2008 Follow Up Signature Cc ‰Pneumonia vaccine ‰Influenza vaccine e-medtools.com ‰PPD Testing ‰Physical therapy ‰Smoking cessation aids ‰Pulmonary Rehabilitation œIndicates Physician Quality Reporting Initiative (PQRI) Physician Quality Measures Revised 20Mar08


      Template updated 3/20/2008

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    E & M Documentation Template

    The pulmonary new clinic patient evaluation MedicalTemplate contains prompters and space for all the required elements for a E&M encounter.  

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    Digital Health Record

    The pulmonary new clinic patient evaluation MedicalTemplate functions like all other PDF files, but they have editable text fields and working checkboxes.  This allows information to be typed in or pasted from other applications to fill out the template.

    Filled pulmonary new clinic patient evaluation MedicalTemplates can be printed and saved to a computer, USB drive, CD, DVD, or other storage device to create a digital health record for your patients.

    To learn more about how MedicalTemplates can be used as a digital health record, click here.

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    Digital Signature Enabled

    Pulmonary new clinic patient evaluation MedicalTemplates can be signed with a digital signature, instead of a handwritten signature, if the use of a digital signature is acceptable at your practice location.   Adobe PDF digital signatures require the creation of a digital ID that is used to sign the PDF.  

    To learn more about Adobe PDF digital signatures, click here.

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    MedicalTemplates are in the Adobe PDF format, which requires the free Adobe Reader.  With Adobe Reader, these templates can be printed as many times as needed on paper meeting your specifications or the specifications of any clinic, hospital, or other health care facility.