ANSWER
In order to analyse and manage a patient’s health, this seems to be a thorough clinical examination and recording template. To utilise this template efficiently, take the following actions:
1. Patient Data
Enter the patient’s age, date, and name (initials).
2. Over-the-counter, nutritional, herbal, and complementary therapies
Any over-the-counter drugs, dietary supplements, herbal cures, or complementary therapies that the patient takes should be noted.
3. Substance Abuse Document substance use in detail:
Substance (such as marijuana, alcohol, etc.)
quantity consumed
Use frequency
Use duration (Length of Use)
4. Psychiatric History in the Family
Describe any family history of mental illnesses, such as schizophrenia, anxiety, sadness, etc.
5. Social History Document: Living arrangement (e.g., marital status and kind of home)
Level of education
Work status and occupation
Exposures to substances (such as smoking, drinking, and using drugs recreationally)
Use of contraception, sexual orientation, and sexual activity
The makeup of a family
Additional relevant social history, such as birthplace, trauma, aggression, and social network
6. Maintenance of Health
Provide details about: Screening procedures (such as colonoscopies and mammograms)
History of vaccinations
Exposures to the environment
7. System Review (ROS)
For every system—general, heent, cardiovascular, gastrointestinal, neuro, etc.—complete a systematic review.
Add relevant advantages and disadvantages.
8. Physical Examination
Note the following vital signs: height, weight, BMI, TPR, HR, RR, and BP.
Record the results for every system that was analysed.
9. Assessment of Mental Status
Evaluate the following: appearance, conduct, speech, mood, thought process, insight, and judgement.
10. Important Information and Contributing Diagnoses
Emphasise the main conclusions and important diagnoses.
11. Make plans
Add the major and differential diagnosis.
Describe the strategy for every diagnosis:
Screening and Diagnostic Testing
Pharmacological Intervention
Non-Medical Intervention
Referrals for Patient Education
Plan of follow-up
Predictive Advice
12. Guidelines Based on Evidence
Give examples of current recommendations that were used to inform the care plan, such as the APA, DSM-5, and USPSTF.
13. Medicines
Keep track of all prescribed drugs, including the RX information (dosage, amount dispensed, and refills).
14. Credentials and Signature
Make sure your contact details and credentials are signed on the form.
Please let me know if you need assistance developing a presentation of this workflow or filling out this template for a particular patient circumstance.
QUESTION
_________________________________________ ________________________________
_________________________________________ ________________________________
OTC/Nutritionals/Herbal/Complementary therapy:
_________________________________________ ________________________________
_________________________________________ ________________________________
Substance use : (alcohol, marijuana, cocaine, caffeine, cigarettes)
| Substance | Amount | Frequency | Length of Use |
Family Psychiatric History: _____________________________________________________
Social History
Lives: Single family House/Condo/ with stairs: ___________ Marital Status:________
Education:____________________________
Employment Status: ______ Current/Previous occupation type: _________________
Exposure to: ___Smoke____ ETOH ____Recreational Drug Use: __________________
Sexual Orientation: _______ Sexual Activity: ____ Contraception Use: ____________
Family Composition: Family/Mother/Father/Alone : _____________________________
Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx):_________________________________
________________________________________________________________________
Health Maintenance
Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____
Exposures:
Immunization HX:
Review of Systems:
General:
HEENT:
Neck:
Lungs:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Activity & Exercise:
Psychosocial:
Derm:
Nutrition:
Sleep/Rest:
LMP:
STI Hx:
Physical Exam
BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI ( percentile) _____
General:
HEENT:
Neck:
Pulmonary:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Derm:
Psychosocial:
Misc.
Mental Status Exam
Appearance:
Behavior:
Speech:
Mood:
Affect:
Thought Content:
Thought Process:
Cognition/Intelligence:
Clinical Insight:
Clinical Judgment:
Significant Data/Contributing Dx/Labs/Misc.
Plan:
Differential Diagnoses
1.
2.
Principal Diagnoses
1.
2.
Plan
Diagnosis #1
Diagnostic Testing/Screening:
Pharmacological Treatment:
Non-Pharmacological Treatment:
Education:
Referrals:
Follow-up:
Anticipatory Guidance:
Diagnosis #2
Diagnostic Testingg/Screenin:
Pharmacological Treatment:
Non-Pharmacological Treatment:
Education:
Referrals:
Follow-up:
Anticipatory Guidance:
Signature (with appropriate credentials): __________________________________________
Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________
DEA#: 101010101 STU Clinic LIC# 10000000
Tel: (000) 555-1234 FAX: (000) 555-12222
Patient Name: (Initials)______________________________ Age ___________
Date: _______________
RX ______________________________________
SIG:
Dispense: ___________ Refill: _________________
No Substitution
Signature: ____________________________________________________________
Rev. 10162021 LM
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