HISTORY & PHYSICAL/ADMISSION ASSESSMENT – INPATIENT

 
          HISTORY & PHYSICAL/ADMISSION ASSESSMENT - INPATIENT
                        (Revised:  MRC 01/2004)
                                                                                                                       
                      PLEASE ADDRESS ALL SECTIONS.
      DO NOT ALTER OR DELETE ANY SECTION OF THIS ADMISSION ASSESSMENT
                (DUE TO REQUIRED VHA & JCAHO COMPONENTS)
 

PATIENT NAME		|PATIENT NAME FIRST,LAST|
DATE OF BIRTH		|PATIENT DOB|
ETHNICITY		|PATIENT ETHNICITY|
SEXUAL ORIENTATION	|VA-SEXUAL ORIENTATION|
INPATIENT PROVIDER	|INPATIENT PROVIDER|
INPATIENT ATTENDING	|INPATIENT ATTENDING|
ADMISSION DATE	|ADMISSION DATE|

ADMISSION DIAGNOSIS	|ADMITTING DX|


HISTORY OF PRESENT ILLNESS

|PATIENT NAME FIRST,LAST| is a |PATIENT AGE| year old |PATIENT SEX| who presented with @@@

ED COURSE
@@@

REVIEW OF SYSTEMS

OBJECTIVE

PAST MEDICAL HISTORY
|PROBLEM LIST BRIEF|

 
CHIEF COMPLAINT/SUMMARY OF INDICATIONS FOR ADMISSION: (MD, NP, PA to
     complete)               
 
2.)  HX OF PRESENT ILLNESS:
 
 
3.)  PAST MEDICAL HISTORY & REVIEW OF SYSTEMS:
 
4.)  PHYSICAL EXAM
 
PAST SURGICAL HISTORY
|HS:MEDB;100;15Y|

PCP		
|PCMM PRIMARY CARE PROVIDER|

LAST ADMISSION	
|PREVIOUS ADMISSION|

APPOINTMENTS FOR LAST SIX MONTHS
|VA-APTS PAST 6M|
			
SOCIAL HISTORY

FUNCTIONAL STATUS: 	
ABLE TO PERFORM ADLS WITHOUT ASSISTANCE
@@@

LIVES WITH		
@@@

FAMILY HISTORY	
@@@

MILITARY HISTORY

SERVICE CONNECTED %	|SERVICE CONNECTED %|
DISABILITY		|SERVICE CONNECTED DISABILITY|
COMBACT SERVICE	|COMBAT SERVICE|
BRANCH			|SERVICE BRANCH|
ENTRY			|SERVICE ENTRY DATE|
SEPARATION		|SERVICE SEPARATION DATE|

TOXIC EXPOSURE
|VA-TOXIC EXPOSURE|

SOCIAL HISTORY

TOBACCO USE		|HS:SHF-TOBACCO;1;5Y|
ALCOHOL USE		NO @@@
OTHER SUBSTANCES	NO @@@

ALLERGIES		
|ALLERGIES/ADR|			

PHQ9
|HS:PHQ2 PHQ9|
|HS:PC-PTSD PCL|
	
		
MEDICATIONS
|ACTIVE MEDICATIONS|
|REMOTE ACTIVE MEDICATIONS|
|ACTIVE OUTPT MED|

VITALS

|VITALS 48H|

Pain:
|PAIN|

WEIGHT
|WEIGHT-LAST 3|
 
PHYSICAL EXAM

General: NAD
Neck: Supple, NO JVD, NO LAD
HEENT: NCAT, EOMI, PERRLA, MMM, OP clear
CV: S1, S2, RRR, NO MRG
Resp: CTAB
Abd: Soft, NTND, BS+, NO HSM
Ext: WWP, NO edema, NO cyanosis
Skin: NO rashes, NO bruising
Msk: NORMAL tone/bulk, NO joint swelling, NO joint redness
Neuro: A&Ox4, NO focal deficits, NORMAL CN2-12 motor, NORMAL CN2-12 sensory 

DIAGNOSTICS

LABS

IMAGING

ASSESSMENT AND PLAN

|PATIENT NAME FIRST,LAST| is a |PATIENT AGE| year-old |PATIENT SEX|

|PROBLEM LIST BRIEF|

#

- diagnostics
- tx
- consults:

#

- dtx
- tx
-

#
-
-
-

#
## D/Dx
Dx
- ctm
- f/u  
- not clinically neccesary atm

Tx
- c/w 
- not clinically neccesary atm

Con
- c/w 
- prn
- consider 
- not clinically neccesary atm

ADVANCE DIRECTIVE STATUS: 
@@@


CHECKLIST
#Diet		@@@
#VTE ppx	HEPARIN @@@
#GI ppx	PPI
#Bowel Reg:	PEG
#Analgesia	TYLENOL
#Glycemic	SSI
#Abx		N/A
#Lines		PIV
#Contact:	|PATIENT EMERGENCY CONTACT NAME|
		|PATIENT EMERGENCY CONTACT NUMBER|
		|PATIENT EMERGENCY RELATIONSHIP|
#Dispo:	STABLE
#Code Status	FULL @@@