Geriatrics
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This is [checkbox name="encounter" value="a new patient|a monthly follow up visit to review chronic conditions|an episodic visit to address change of status|a telephone encounter|an email communication"]

HISTORIAN:
[textarea cols=40 rows=2][checkbox name="historian" value="resident|facility staff|SO/family member|complete history unobtainable d/t cognitive changes|complete history unobtainable d/t HOH"]

NURSING:
[textarea cols=40 rows=2][checkbox name="nursing" value="unable to verify d/t cognitive changes|none|hospice|HH"]

PLANNING: [textarea cols=40 rows=2][checkbox name="planning" value="unable to verify d/t cognitive changes|full code|DNR|advanced directive on file|no advanced directive|POA"]

CURRENT MEDICATIONS:
[textarea cols=40 rows=2][checkbox name="medications" value="administered by staff|self-administered|MAR available for review|insulin|BS log available for review|warfarin|INR results available for review|opioids|sedatives|blood thinners/anticoagulants"]

IMMUNIZATION:
[textarea cols=40 rows=2][checkbox name="iz" value="unable to verify d/t cognitive changes|up to date|not up to date|declined|per facility policy"]

FUNCTIONAL STATUS:
[textarea cols=40 rows=2][checkbox name="functional" value="resident at assisted living facility|lives at home|requires assistance with most ADLs|incontinent|O2 use|smoker|hard of hearing"]

MOBILITY:
[textarea cols=40 rows=2][checkbox name="mobility" value="unable to verify d/t cognitive changes|ambulates unassisted|difficulty with mobility|ambulation requires walker|ambulation requires cane|ambulation requires assist|uses wheelchair|uses motorized scooter/wheelchair"]

PATIENT/CAREGIVER/STAFF REPORTS:

INTERVAL HISTORY/CC:
[checklist name="recent" value="patient complains|concerns by staff|concerns by family|ER/UC visit| hospitalization|surgery/procedure|diagnostic/laboratory studies|specialty consults|new medications|infection|falls|wounds|behavioral changes|wt loss"]
[textarea cols=60 rows=3]

ROS:
[+] reported
[-] not reported

CONSTITUTIONAL:
[textarea cols=40 rows=2][checklist name="constitutional_symptoms" value="fever|malaise|fatigue|deconditioning|night sweats|weakness|wt loss"]
HEAD/FACE:
[textarea cols=40 rows=2][checklist name="head_symptoms" value="headache|scalp swelling|facial pain|facial swelling|facial numbness"]
EYES:
[textarea cols=40 rows=2][checklist name="eye_symptoms" value="decrease in vision|requires glasses for reading|dryness|irritation|lid swelling|discharge"]
EARS:
[textarea cols=40 rows=2][checklist name="ears_symptoms" value="pain|pressure|discharge|bleeding|wax|hearing loss|ringing|hearing aids"]
NOSE:
[textarea cols=40 rows=2][checklist name="nose_symptoms" value="discharge|PND|congestion|sinus pressure|snoring|bleeding"]
MOUTH:
[textarea cols=40 rows=2][checklist name="mouth_symptoms" value="sores|dryness|drooling|tongue pain/swelling|toothache|infection|odor|swelling|jaw pain|clicking|loose dentures"]
THROAT:
[textarea cols=40 rows=2][checklist name="throat_symptoms" value="sore throat|dysphagia|choking|hoarseness|globus"]
NECK:
[textarea cols=40 rows=2][checklist name="neck_symptoms" value="pain|swelling|limited motion|swollen glands"]
CV:
[textarea cols=40 rows=2][checklist name="cv_symptoms" value="chest pain/pressure|SOB|palpitations|lightheartedness|fainting|exertional dyspnea|orthopnea|rapid wt gain|ankle swelling|ankle discoloration|varicose veins|leg cramps"]
Respiratory:
[textarea cols=40 rows=2][checklist name="chest_symptoms" value="former smoker|current smoker|cough|phlegm|wheezing|pain w/ breathing|rib pain|breast swelling/lump"]
GI:
[textarea cols=40 rows=2][checklist name="gi_symptoms" value="constipation|laxative use|poor appetite|nausea|vomiting|early satiety|bloating|heartburn|gas|generalized abdominal pain|epigastric pain|diarrhea|melena|rectal pain/itching|rectal bleeding"]
GU:
[textarea cols=40 rows=2][checklist name="gu_symptoms" value="dysuria|burning|frequency|urgency|odor|hematuria|hesitancy|retention|nocturia|oliguria|CKD|discharge|itching|skin lesion(s)/rash"]
MSK:
[textarea cols=40 rows=2][checklist name="msk_symptoms" value="joint pain/deformity|neck pain|back pain|shoulder pain|hip pain|knee pain|chronic pain/meds"]
NEURO:
[textarea cols=40 rows=2][checklist name="neuro_symptoms" value="dizziness|vertigo|poor balance|abnormality of walk|focal weakness|blackouts|tingling/numbness|speech difficulty|tremor|seizures"]
PSYCH:
[textarea cols=40 rows=2][checklist name="psych_symptoms" value="irritability|confusion|dysinhibition|aggression|withdrawal|wandering|repetitive activities|suspiciousness|depression|apathy|anxiety|mood swings|elation|delusions|hallucinations|memory loss|insomnia|excessive naps"]
ENDO:
[textarea cols=40 rows=2][checklist name="endo_symptoms" value="cold intolerance|skin dryness|hair loss|polyuria"]
LYMPH/HEMA:
[textarea cols=40 rows=2][checklist name="hem_symptoms" value="gland swelling|bruising|anticoagulation|h/o DVT|anemia"]
ALLERGIES/IMMUNE:
[textarea cols=40 rows=2][checklist name="allergy_symptoms" value="atopy|environmental allergies|food allergies|autoimmune dz|h/o cancer"]
DERM:
[textarea cols=40 rows=2][checklist name="derm_symptoms" value="dryness|pruritus|rash|hives|redness|swelling|wounds"]

------------------------------------------------------------------------------------

Appearance: [textarea cols=40 rows=2]
[checkbox name="appearance" value="well-appearing|no signs of discomfort visible|normal built|clean-shaven|good hygiene||heavy built|emaciated|frail|ill-appearing|tired-looking|short of breath|diaphoretic|slumped in wheelchair|disheveled|unshaven|body odor"]
Head/Face: [textarea cols=40 rows=2]
[checkbox name="head" value="normocephalic, atraumatic|symmetrical face|CN grossly intact||alopecia|facial droop"]
Eyes: [textarea cols=40 rows=2]
[checkbox name="eyes" value="clear conjunctiva w/o exudates or hemorrhage, anicteric sclera, EOM intact without nystagmus|visual acuity grossly intact|red reflex present|cornea(s) clear||ptosis|glasses|periorbital swelling|conjunctival injection|epiphora|conjunctival exudate|palpebral edema|palpebral exudates|chemosis|hyphema|dysconjugate gaze"]
Ears: [textarea cols=40 rows=2]
[checkbox name="ears" value="symmetrical & intact auricles bilaterally|hearing to conversation intact|very HOH|hearing aid(s)|clear canals without erythema or discharge|TMs normal in appearance||large amount of wax"]
Nose: [textarea cols=40 rows=2]
[checkbox name="nose" value="nares patent bilaterally, no facial swelling or discoloration|septum midline|no facial tenderness|mucosa pink & moist||allergic salute|maxillary tenderness|frontal tenderness|deviated septum|swollen & boggy mucosa|mucosal ulceration|mucosal congestion|clear discharge|yellow discharge|crusty discharge|active septal hemorrhage|dried up blood"]
Mouth: [textarea cols=40 rows=2]
[checkbox name="mouth" value="tongue normal in appearance w/o lesions and with good symmetrical movements|moist oral mucosa without lesions|upper denture|lower denture|teeth absent|some teeth present"]
Throat: [textarea cols=40 rows=2]
[checkbox name="throat" value="normal voice|patent pharynx w/o swelling or exudates|uvula midline|clear pharynx w/o exudates||pharyngeal erythema w/o exudates|hoarseness|vesicles on soft palate|petechiae on soft palate|pharyngeal crowding|tonsilar exudates|tonsilar pustules"]
Neck: [textarea cols=40 rows=2]
[checkbox name="neck" value="symmetric with free painless ROM and no masses|supple|no LAD|no bruit or JVD|thyroid enlargement|nuchal tenderness"]
Lungs: [textarea cols=40 rows=2][checkbox name="lungs" value="normal work of breathing, symmetrical chest expansion, no stridor|clear and equal breath sounds bilaterally||SOB|decreased bilaterally|wheezing|crackles"]
CV: [textarea cols=40 rows=2]
[checkbox name="cv" value="regular rhythm|no murmurs||tachycardia|irregular heart rhythm|systolic murmur"]
Abdomen: [textarea cols=40 rows=2]
[checkbox name="abd" value="not examined|normal visual inspection, no distension|normal active bowel sounds|soft non-tender|no bruit auscultated over AA and renal arteries||protruding|surgical scar|diffuse tenderness over entire abdomen w/o RRG|umbilical hernia|hypoactive bowel sounds|hyperactive bowel sounds|direct non-rebound tenderness|colostomy in situ"]
GU: [textarea cols=40 rows=2]
[checkbox name="gu" value="not examined|no suprapubic tenderness|no smell of urine||Foley in situ|normal external genitalia|"]
MSK: [textarea cols=40 rows=2]
[checkbox name="spine" value="no gross deformities, moves all extremities with good ROM for age||kyphosis|paraspinal muscle spasm"]
Upper extremity(s): [textarea cols=40 rows=2]
[checkbox name="upper_extremity" value="atraumatic w/o swelling or deformity|good ROM for age|equal power and tone bilaterally|able to make tight grips|no vascular compromise||ecchymoses|clubbing"]
Lower extremity(s): [textarea cols=40 rows=2]
[checkbox name="lower_extremity" value="atraumatic|strength, tone & bulk symmetrical & grossly intact|able to stand up|no vascular compromise|compartments soft w/o tension|pedal skin warm with good & equal pulses|no edema||xerosis|calf tenderness|ankle edema|varicosities|loss of hair|ecchymoses|stasis discoloration|varicose veins"]
Neuro: [textarea cols=40 rows=2]
[checkbox name="neuro" value="balance & coordination grossly intact|no involuntary movements|normal speech|sensation symmetrical & grossly intact|full weight bearing||wide gait|shuffling gait|tremor|dystonia|dyskinesia"]
Behavior: [textarea cols=40 rows=2]
[checkbox name="behavior" value="pleasant, cooperative|engaged||withdrawn|hostile|defensive|argumentative|suspicious|ingratiating|demanding"]
Psych: [textarea cols=40 rows=2]
[checkbox name="psych" value="alert|oriented to self and place|appropriate to situation|normal concentration and attention|memory grossly intact|good eye contact|speech normal rate & rhythm|organized thought process||drowsy|poor eye contact|confused|agitated|anxious|irritable|indifferent|guarded||expansive affect|flat affect|labile affect||speech slurred|hypoverbal|hyperverbal|speech loud|speech slow|speech rapid||tangential thought|circumstantial thought|aberrant thought|flight of ideas|poor judgment & insight"]
Skin: [textarea cols=40 rows=2]
[checkbox name="skin" value="grossly intact, no rashes|no bruises|normal turgor||multiple tattoos|body piercings|poor turgor|dry|sweaty"]

--------------------------------------

ORDERS:
[textarea cols=40 rows=2][checkbox name="orders" value="none|Rx electronic|Rx paper left at facility|Rx faxed to pharmacy|laboratory studies|diagnostic studies|referrals"]

REVIEWED:
[textarea cols=40 rows=2][checkbox name="reviewed" value="MAR|chart|previous visits|PMP|laboratory studies|diagnostic studies|specialty reports|hospital discharge|facility communication"]

DISCUSSED/COMMUNICATED FINDINGS/POC WITH:
[textarea cols=40 rows=2][checkbox name="discussed" value="patient|staff|family|MA"]

PATIENT/SO/STAFF INSTRUCTED ON:
[textarea cols=40 rows=2][checkbox name="instructions" value="vital signs|office tests|exam findings|recommendations||outside laboratory/diagnostic studies|specialty consults|importance of controlling chronic conditions|age-appropriate screening and immunization|diet, exercise|smoking cessation|alcohol/substance use"]

ADVISED ON PREVENTATIVE CARE:
[checkbox name="preventative" value="colonoscopy|DEXA|mammogram|dental exam|eye exam|foot exam|patient declined|appropriate referrals to be generated"]

FOLLOW UP: [textarea cols=10 rows=1][checkbox name="fu" value="1 week|2 weeks|3 weeks|4 weeks|discharged"]

TOTAL TIME: [textarea cols=10 rows=1][checkbox name="time" value="15 min|30 min|45 min|60 min|75 min|visit dominated by counseling"]

-------------------------------


Depression Screening:
[checklist name="depression_screeming" value="over the past two weeks, have you felt down, depressed, or hopeless?|over the past two weeks, have you felt little interest or pleasure in doing things?|over the past 2 weeks, have you felt suicidal?"]

Patient/Caregiver Support:
[checklist name="caregiver_support" value="do you feel unsafe at home?|Do you live alone?"]

Functional Ability Screen (needs help with):
[checklist name="functional_ability" value="phone|transportation|shopping|preparing meals|housework|laundry|medications|managing money"]
This is

HISTORIAN:


NURSING:


PLANNING:

CURRENT MEDICATIONS:


IMMUNIZATION:


FUNCTIONAL STATUS:


MOBILITY:


PATIENT/CAREGIVER/STAFF REPORTS:

INTERVAL HISTORY/CC:



ROS:
[+] reported
[-] not reported

CONSTITUTIONAL:

HEAD/FACE:

EYES:

EARS:

NOSE:

MOUTH:

THROAT:

NECK:

CV:

Respiratory:

GI:

GU:

MSK:

NEURO:

PSYCH:

ENDO:

LYMPH/HEMA:

ALLERGIES/IMMUNE:

DERM:


------------------------------------------------------------------------------------

Appearance:

Head/Face:

Eyes:

Ears:

Nose:

Mouth:

Throat:

Neck:

Lungs:
CV:

Abdomen:

GU:

MSK:

Upper extremity(s):

Lower extremity(s):

Neuro:

Behavior:

Psych:

Skin:


--------------------------------------

ORDERS:


REVIEWED:


DISCUSSED/COMMUNICATED FINDINGS/POC WITH:


PATIENT/SO/STAFF INSTRUCTED ON:


ADVISED ON PREVENTATIVE CARE:


FOLLOW UP:

TOTAL TIME:

-------------------------------


Depression Screening:


Patient/Caregiver Support:


Functional Ability Screen (needs help with):
Result - Copy and paste this output: