Georgia College and State University

School of Nursing
Episodic Document
Patient Information:
Initials:__LM_______ Age:__29____
visit:__02/03/2015_

Sex:__F_____

Date of

Chief Complaint(s) or Reason for Visit: _3 month follow-up and

medication refill_________
o

HPI: Subjective Information about each major area or

complaint addressed (repeat as needed):
Onset _Patient was diagnosed a year ago. She
reported not going to see a PCP regularly due to her
lack of illness.____________________________ _
Location of problem _Cardiovascular_______________
_______________
Duration of problem _1 year (possibly going on prior
to diagnosis). Ongoing problem with HTN.
Character of problem _Currently uncontrolled
______________________
Intensity rating: N/A /10 or
other:___________________________
Aggravating Factors _poor diet, high salt intake, lack
of physical exercise, weight gain
____________________________________________
Relieving Factors _low salt diet, regular physical
activity, weight loss, taking medications
Treatments Tried _Diltiazem
HCL___________________________________
Smoking: _Nonsmoker __________________
______________________
Additional information__Patients blood pressure is
currently not under control. The patient reported not
taking her medication this morning._ __

Current Medications and how patient takes the medications:

Diltiazem HCL Capsule Extended Release

GCSU Revised Fall 2014

The patient takes one capsule in the am

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12 hour, 120 mg, 1 capsule, Orally, Twice

a day, 30 days, Disp:60, Refills 2

and one capsule in pm.

Additional Information:
Allergies:
_N.K.D.A._____________________________________________________________________
Current Immunizations: _Up-to-date on immunizations. Received influenza
shot in 2014 ____________
PMH, Chronic Problems, Significant birth history (NNICU admission, apgar
scores, bilirubin, other complications of birth):
__HTN_______________________________________________________________________________
___________________________________________________
______________________
Past Surgical Hx:_Tubal Ligation 2010
_
Substance use/amount: Alcohol Y/N amount
None
__
Tobacco (smoke any form, smokeless any form) Y/N Type/amount/how
long:_N/A___________________________________________________________________________
___
Illicit drugs Y/N amount
N/A
__
Family Hx: Heart disease, DM, cancer, HTN, COPD, strokes, other
(HTN,
Asthma)
_________
o Mother:_Alive 49, Diagnosed with HTN
______________________________________
o Father:__Alive 50s, Unknown history
_______________________________________________
o Siblings:_1 Sister 20s, Alive, Diagnosed with Asthma
__________________________________
o Children: 1-son and 1-daughter, Alive and healthy

INTERVAL HISTORY: Have they been to the ER, seen other providers, any
procedures (mammograms, etc.) since their last visit to the practice? What was
done and why? Have those records been sent to the practice? _Has not been seen

by any other provider since last visit. ______________________

GCSU Revised Fall 2014

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Review of Systems: Only those specifically assessed at this visit.

Neg.

Neg.

Neg.

Neg.

Constitutional
Pos.
Chills
Decreased activity
Weight Gain
Weight Loss
Fussiness
Irritability
Lethargy
Fever: duration___
Tmax:____
Other: _____________
Metabolic
Pos.
Polydipsia
Polyuria
Polyphagia
Brittle Nails
Cold intolerance
Heat intolerance
Hirsute
Thinning Hair
Other:_________

Gastrointestinal
Pos.
Abdominal Pain
Constipation
Diarrhea
Nausea
Reflux
Vomiting
Other: _____________

Female Reproductive
Pos.
Dysmenorrhea
Dyspareunia
Menorrhagia
Vaginal Discharge
Vaginal itching
Foul vaginal odor
Other:_____________

GCSU Revised Fall 2014

Neg.

Neg.

HEENT
Pos.
Dysphagia
Ear Discharge
Esotropia
Exotropia
Eye Discharge
Eye Redness
Headache
Hearing loss
Nasal Congestion
Otalgia
Pharyngitis
Rhinorrhea
Sneezing
Tearing
Vision changes
Vision loss
Other: ____________

Urinary
Pos.
Decreased Urine Output
Dysuria
Enuresis
Flank Pain
Foul urine odor
Hematuria
Other: ____________

Male Reproductive
Neg.
Pos.

Straining to urinate

Urinary hesitancy

Urinary Retention

Erectile dysfunction
Hematospermia
Penile discharge
Premature ejaculation

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Neg.

Respiratory
Pos.
Accessory muscles use
Dyspnea
Stridor
Sputum Production
Wheezing
Cough:
Quality_______
Freq:_________

Exposure to TB
Other: _________

Cardiovascular and
Vascular
Neg.
Pos.

Chest Pain

Irreg. Heart Beat

Palpitations

Syncope

Neg.

Immunological
Pos.
Allergic Rhinitis
Environmental Allergy
Food allergy
Seasonal allergy
Urticaria
Other: __________

Neg.

Hematologic
Pos.
Easy bleeding
Easy bruising
Lymphadenopathy
Petechiae
Other:_________

Neg.

Musculoskeletal
Pos.
Back pain
Bone pain
Joint pain
Joint swelling
Muscle weakness
Myalgia
Other: _________

Cool extremities
Cyanosis
Edema
Other: _________

Menarche age:
Last Menses: 1/19/15
Regular Irregular
Frequency:
Flow:

Neg.

Skin
Pos.
Acne
Eczema
Pruritus
Psoriasis
Skin lesion
Other:_____________

Neg.

Scrotal mass
Scrotal pain
Other: _______________

Neurological
Pos.
Aphasia or dysarthria
Agnosia
Balance disturbance
Confusion
Paraesthesia
Seizure
Tremor
Memory loss
Other: _______________

Neg.

Psychiatric
Pos.
Appropriate interaction
Behavioral changes
Difficulty concentrating
Distorted body image
Obsessive behaviors
Self-conscious
Other: ____________

Objective Findings:
Vital Signs:
o Blood Pressure: __158/102__ Pulse: _86_________ Respirations:
_18__________
o Temperature:__98.2 F______ Pulse Ox: _98%_______
Head Circ
(percentile): ______
o Weight (%): __240.8_________
Height (%): _64 inches_______
BMI (%):
_41.33_______
Physical Exam: If you need more than one entry from the drop down boxes, please
right click on the box, copy it and paste it into the assessment.
Physical Exam - Mark only those assessed during the exam
Constitutional: Show
Level of Distress

No acute distress

___________
Nourishment

Obesity Class III - BMI >40

Overall Appearance

Age Appropriate

Other: ___________
Other:_________________________________________________

GCSU Revised Fall 2014

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Other:

Other: ___________

Head/Skull: Show
Appearance

Normocephalic

Fontanels

Choose an item.

an item.

Other: ______________

Choose

Other:________________

Facial Features

Normal stucture alignment

Other:

______________
Hair Distribution

Normal Distribution

Other:______________

Other:___________________________________________________
Eyes: Show
Surrounding Structures OS

Normal Structures

Other:___________

Surrounding Structures OD

Normal Structures

Other:___________

External Eye OS

Normal

Other:___________

External Eye OD

Normal

Other:___________

Eye Lids OS

Normal

Other:___________

Eye Lids OD

Normal

Other:___________

Pupil OS

PERRLA

Other:___________

Pupils OD

PERRLA

Other:___________

Conjunctiva OS

Clear

Other:___________

Conjunctiva

Clear

Other:___________

OD

Sclera

OS

Normal

Other:___________

Sclera

OD

Normal

Other:___________

Iris OS

Normal

Other:___________

Iris OD

Normal

Other:___________

Cornea OS

Choose an item.

Other:___________

Cornea OD

Choose an item.

Other:___________

Fundoscopy OS

GCSU Revised Fall 2014

Normal stuctures and sharp disc margin

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Other:___________
Fundoscopy

Normal

OD

Other:___________

Lens OS

Clear

Other:___________

Lens OD

Clear

Other:___________

Normal cardinal gaze

Ocular Muscles
Red Reflex
Vision Screen:

Other:___________

Present Bilaterally
Abnormal:_____________________
OS:________ OD:_________ OU:__________________

Ears: Show
Normal structure/placement

Auricle Right
Other:____________

Normal placement/structure

Auricle Left
Other:____________
Canal Right

Normal

Other:___________

Canal Left

Normal

Other:___________

TM Right

Light reflex present/TM clear

Other:___________
Light reflex present/TM clear

TM Left
Other:___________

Normal Bilaterally

Hearing

Other:___________

Nose and Sinus: Show

Naris Right

Normal patency

Naris Left

Normal patency

Other:________________
Other:________________

Turbinates Right

Choose an item.

Other:________________

Turbinates Left

Choose an item.

Other:________________

Frontal Sinus Right

Non-tender

GCSU Revised Fall 2014

Other:________________

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Frontal Sinus Left

Non-tender

Other:________________

Maxillary Sinus Right

Non-tender

Other:________________

Maxillary Sinus Left

Non-tender

Other:________________

Mouth/Teeth:
Lips

Normal fullness and symmetry

Teeth

Normal dentation

Other:__________________

Other:__________________
Buccal

pink and moist

Other:__________________
Tongue

Normal

Other:__________________
Palate

Cleft Hard Palate

Uvula

Normal configuration

Oropharynx

pink and moist

Tonsils

+1

Other:__________________
Other:__________________
Other:__________________
Other:__________________

Neck:
Palpation of Thyroid: Normal

Describe

Abn:___________________________________
Other:____________________________________________________________________________

Lymphatic: Show
Overview: No noted abnormal swelling/tenderness

Location of Abn:

Choose an item.

Choose an item.

Description of Abn:

Choose an item.

Choose an item.

Size: ______________________

GCSU Revised Fall 2014

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Other
Findings:__________________________________________________________________________
Respiratory: Show
Normal anatomical configuration

Chest
Other:_______________
Inspection
Other:_______________

Normal respiratory effort

Auscultation

Clear Breath Sounds Bilaterally

Location

Bilateral
Choose an item.

Cough

Other: ___________________________________________________________________
Cardiac: Show
Morbid Obesity Limits Exam Accuracy: Yes or No
Regular Rate and Rhythm

Rate/Rhythm
Murmur

Timing:

Other:________________

Choose an item.

Intensity:

Choose an item.

Location: Choose an item.

Quality:

Choose an item.

Radiation: ____________
Edema: __No edema present___________________________________
Location:____________________________
Capillary Refill__1 second______________________________
Pedal Pulses:__2+ edema___________________________
Carotid Bruits:__Negative_____________________________________
Other Findings:_______________________________________
EKG Results:__________________________________
Abdomen: Show

Morbid Obesity Limits Exam Accuracy: Yes or No

Inspection

Obese

Auscultation

Normal Bowel Sounds

All four quadrants

GCSU Revised Fall 2014

Location:
Other:________

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Normal

Palpation
All four quadrants

Associated Findings

Location:
Other:________

Choose an item.

Hernia _____________________
CVA Tenderness _____________
Other:______________________
Female Exam Show
Male Exam

Show

Musculoskeletal Show
Overview: Normal ROM, muscle strength, and Stability
Posture: No structural abnormalities
ROM: Normal ROM all extremities

Describe

Abn:_______________________________
Muscle Strength: Normal all extremities

Describe

Abn:_______________________________
Joint Stability: Choose an item.

Describe

Abn:_______________________________
Assessment of problem area:___________________________________________________
___________________________________________________________________________
Neurological Show
Mental Status: Alert, Oriented to Time, Place, Person

Describe

Abn:_______________________________
Appearance: Good Hygiene

Describe

Abn:_______________________________
Thought Process: Follows conversation and engages appropriately
Describe Abn:_______________________________
MMSE Score:_______
Gait: Smooth, active gait

Describe

Abn:___________________________________

GCSU Revised Fall 2014

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CN II-XII: Choose an item.

Describe

Abn:___________________________________
DTRs: upper Choose an item.

Lower:

Choose an item.

Muscle Bulk, Tone and Strength: Grossly normal

Describe

Abn:_______________________________
Sensory: Grossly normal
Body Position: Grossly normal

Describe Abn:_______________________________
Describe Abn:_______________________________

Other
findings:_________________________________________________________________________
Skin Show
Overview: Normal overview but detail exam not done

Describe

Abn:___________________________________
Lesion Description:
Mole Description:
Rash Description:
Other:___________________________________________________________________________
Results of labs done today: __N/A_________________________________________________
Other labs: __CBC, Lipid Panel, BMP ordered for
5/6/15__________________________________

Assessment/Plan: Please enter each ICD-9 Code with the diagnosis followed by
corresponding teaching and comments that you may have. Repeat as needed.

First Diagnosis:________________ ICD-9:_________________

o Additional teaching or comments:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Second Diagnosis:________________ ICD-9:_________________
o Additional teaching or comments:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

GCSU Revised Fall 2014

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Third Diagnosis:________________ ICD-9:_________________

o Additional teaching or comments:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Medications Added This Visit

Medication Name
Diltiazem HCL
Capsule Extended
Release 12 hour

Quantity
60 tablets

Dose
120 mg

Sig
Take one capsule in
am and in pm (1
capsule every 12
hours)

Office Code for Visit: Please Highlight

Est. Pt.
Office

New Pt.
Office

Est. Pt.
Health Check

New Pt.
Health Check

99211
99212
99213
99214
99215

------99201
99202
99203
99204
99205

99391 (<
1yr)
99392 (1-4yr)
99393 (511yr)
99394 (1217yr)
99395
(18yr>)

99381 (<
1yr)
99382 (14yr)
99383 (511yr)
99384 (1217yr)
99385
(18yr>)

GCSU Revised Fall 2014

Additional Procedure Codes,

Immunization, Lab, etc.

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