East Valley Internal Medicine SNF Progress Note

Patient Name: DOB: DOA:

CC/HPI/FOLLOW-UP CHRONIC PROBLEMS:

[]Location []Severity []Timing []Quality []Duration []Context []Modifying Factor(s) []Assoc Signs/Symptoms
History Form of ____/____/____ reviewed.

(PF/EPF requires 1-3 elements or 1-2 chronic conditions Detailed/Comprehensive require 4 elements or >3 chronic conditions)

Review of Systems
Constitutional Y N Respiratory Y N Heme/lymph Y N
Appetite change Shortness of breath Bleeding/ Easy bruising
Weight change Chronic cough Enlarged glands
Night sweats/fever Wheezing/asthma Anemia
Fatigue Coughing up blood Phlebitis
Sleep Cardiovascular Musculoskeletal
Psychiatric Chest pain/angina Joint pain/stiffness/swelling
Confusion/Memory loss Palpitations Muscle weakness
Depression Heart trouble Difficulty walking
Nervousness/Anxiety Swelling hands/feet Back pain
Eyes SOB/orthopnea Cold extremities
Glaucoma GI Neurological
Glasses/contacts Nausea/vomiting Freqnt/recurrent headache
Blurred/double vision Change in BM Light headed/dizzy
Ears/nose/throat/mouth Diarrhea/constipation Seizures
Hearing loss/ringing Rectal bleeding Tremors/paralysis
Rhinitis Heartburn/ulcer disease Numbness or tingling
Mouth sores/bleeding gums Stool incontinence Stroke
sore throat/hoarseness Abdominal pain Endocrine
Skin/hair/nails/breasts Trouble swallowing Thyroid disease
Rash GU Diabetes
Itching Blood in urine Increased thirst/urination
Change in skin color Urgency Heat/cold intolerance
Change in hair or nails Frequency Dry skin
Breast pain/lump Urinary incontinence

Allergies: List:
ROS: EPF requires positives and pertinent negatives of symptom(s) related to HPI (1)
Detailed requires positives and pertinent negatives of problem system and at least one other related system (2-9)
Comprehensive requires positives and pertinent negatives for 10+ systems or some systems w/ statement “all other negative”
PFSH (Past Medical, Family, Social History)
Past Medical: (Illnesses, Surgery, Hospitalization)

Initials ______ Date ______

 East Valley Internal Medicine SNF Progress Note
Family:

Social:

EPF requires no documented history. Detailed requires 1 specific item from 1 of the 3 areas (past, family, social) Comprehensive requires at
least 1 item from each of the 3 areas. 3 areas for all new patients/2 areas for all follow-up/established visits
Vitals/Appearance/:

Ht: Wt: BP: TEMP: HR: RR:

NL ABNL

WD/WN Other _____________________________________

General
Obese mild moderate severe
Appearance General habitus

Eyes Conjunctiva & lids

Pupils/irises/EOM

Fundus exam
Ear, Nose, Mouth,
Throat Appearance

Canals/TM’s

Hearing

Oropharynx oral mucosa, hard-soft palate, tongue, tonsils

Lips, Teeth, gums

Appearance,
Neck symmetry masses, overall appearance, tracheal position
Thyroid enlargement, tenderness, nodule
Respiratory
Respiratory effort intercostal retractions, use of accessory muscles
Palpation of chest

Auscultation rales, rhonchi, wheezes, rubs

Cardiovascular Auscultation S3, S4, SEM, holosystolic murmur

Carotid arteries

Abdominal aorta

Pedal pulses

NL ABNL

edema, varicose veins

Extremities

Initials ______ Date ______

 East Valley Internal Medicine SNF Progress Note

Palpation,
GI Auscultation normal = soft, nontender, BS present
Hernia umbilical, ventral, incisional
H/S, masses

Rectal exam Sphincter tone, hemorrhoids, masses

GU External genitalia

Hernia
Musculoskeletal
Gait, Station

Joints

Strength

Digits, nails Clubbing, cyanosis, nail biting

Skin/Breasts Inspection breast/chest
wall

Inspection
rashes, lesions, ulcers, jaundice, spiders

Palpation
induration, SQ nodules, tightening
Neurological
Speech

Cognition

Sensation/Strength

Psych Judgment/insight

Orientation/memory time, place, person

Mood, affect depression, anxiety, agitation
Lab/X-ray: Results:

Physical Exam: PF requires only 1 system(1-5 items) , EPF requires 2-4 systems(6-11) Detailed requires 5-7 systems (12-17 from 2+
systems) Comprehensive requires18+ items for 9+ systems
Patient Name: Date:

Initials ______ Date ______

 East Valley Internal Medicine SNF Progress Note

Assessment and Plan (Diagnosis, Risk, Order/review of Data)

Review lab ___________ Review & summarize previous records ___________
Review radiology/tests ___________ Consult/review Rehab notes ___________
Consult with other provider/MD ___________
PROBLEM PLAN
1. 1.

2. 2.

3. 3.

4. 4.

5. 5.

6. 6.

Established visit requires 2 of the 3 (History, Exam and/or Medical Decision Making)
NP/MD Signature: Date:

Initials ______ Date ______