Georgia College and State University

School of Nursing
Episodic Document
Patient Information:
Initials:_AA_______
Age:_20_______
visit:_6/03/15______

Sex:_M_____ Date of

Chief Complaint(s) or Reason for Visit: _Yearly check-up___________

o

HPI:
Onset _Annual physical
_________________
Location of problem __Denies problems at this
time__________________
Duration of problem _Not applicable
_________________________
Character of problem _Not applicable
_________________
Intensity rating: 0/10
Aggravating Factors _Not applicable_________________
______________
Relieving Factors _Not
applicable__________________________________
Treatments Tried _Not
applicable__________________________________
Smoking:
_Smoker___________________________________________
Additional information: Patient works at a nearby
factory and is single. Denies any complaints at this
time and is here today for an annual physical exam.

Current Medications and how patient takes the medications:

NONE
Additional Information:
Allergies:
__N.K.D.A._____________________________________________________________________

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Current Immunizations: __Up-to-date on all immunizations. Declines

influenza vaccination at this time.
PMH, Chronic Problems, Significant birth history (NNICU admission, apgar
scores, bilirubin, other complications of birth): _No past medical history
_____________________________________________
Past Surgical Hx:___None
_
Substance use/amount: Alcohol Y/N amount The patient reported he is
drinks on the weekend and has a drink containing alcohol monthly. He
reported that one or more times in the past year he has drank 5 or more
beers at one time.
__
Tobacco (smoke any form, smokeless any form) Y/N Type/amount/how
long:_Has been smoking 1 pack of cigarettes daily for the last four years.
Currently has no desire to quit smoking.______________
Illicit drugs Y/N amount
N/A
__
Family Hx: Heart disease, DM, cancer, HTN, COPD, strokes, other
___________________________
o Mother:_Alive 40s; HTN
_________
_____________
o Father:_Unknown
___________________________________________
o Siblings:_3 sisters-healthy; 1 brother healthy_
___________________________________
INTERVAL HISTORY: Patient denies being seen by any other providers, ER

visits and receiving any recent

procedures.______________________________________________________________
Review of Systems:
Constitutional
Pos.

Neg.

HEENT
Pos.

Neg.

Respiratory
Pos.

Neg.

Chills

Dysphagia

Accessory muscles use

Decreased activity

Ear Discharge

Dyspnea

Weight Gain

Esotropia

Stridor

Weight Loss

Exotropia

Sputum Production

Fussiness

Eye Discharge

Wheezing

Irritability

Eye Redness

Lethargy

Headache

Cough:
Quality_______
Freq:_________

Hearing loss

Exposure to TB

Fever: duration___
Tmax:____
Other: _
__

Nasal Congestion

Other: _________

Otalgia

Pharyngitis

Metabolic
Pos.

Neg.

Polydipsia

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Cardiovascular and

Polyuria

Rhinorrhea

Polyphagia

Sneezing

Brittle Nails

Tearing

Cold intolerance

Vision changes

Heat intolerance
Hirsute

Vision loss

Other: ____________

Vascular
Pos.

Neg.

Chest Pain

Irreg. Heart Beat

Palpitations

Syncope

Thinning Hair

Cool extremities

Other:_________

Cyanosis

Edema

Other: _________

Gastrointestinal
Pos.

Neg.

Urinary
Pos.

Neg.

Immunological
Neg.

Abdominal Pain

Decreased Urine Output

Constipation

Dysuria

Diarrhea

Enuresis

Nausea

Flank Pain

Reflux

Foul urine odor

Vomiting
Other: _____________

Hematuria
Other: ____________

Allergic Rhinitis

Environmental Allergy

Food allergy

Seasonal allergy

Urticaria

Other: __________

Neg.

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Pos.

Hematologic
Pos.

Easy bleeding

Easy bruising

Lymphadenopathy

Petechiae

Other:_________

Neg.

Female Reproductive
Pos.

Male Reproductive
Pos.

Neg.

Neg.

Musculoskeletal
Pos.

Dysmenorrhea

Straining to urinate

Back pain

Dyspareunia

Urinary hesitancy
Urinary Retention

Bone pain

Menorrhagia

Joint pain

Vaginal Discharge

Erectile dysfunction

Joint swelling

Vaginal itching

Hematospermia

Muscle weakness

Foul vaginal odor

Penile discharge

Myalgia

Other:_____________

Premature ejaculation

Other: _________

Scrotal mass

Scrotal pain

Other: _______________

Menarche age:
Last Menses:
Regular Irregular
Frequency:
Flow:

Skin
Neg.

Pos.

Neurological
Pos.

Neg.

Eczema

Pruritus

Neg.

Psychiatric
Pos.

Appropriate interaction

Agnosia

Behavioral changes

Difficulty concentrating

Psoriasis

Confusion

Distorted body image

Skin lesion

Paraesthesia

Obsessive behaviors

Seizure

Tremor

Other: ____________

Memory loss

Acne

Other:_____________

Aphasia or dysarthria

Balance disturbance

Other: _______________

Objective Findings:
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Self-conscious

 Vital Signs:
o Blood Pressure: __128/74_______ Pulse: _69___________ Respirations:
__14_______
o Temperature:_98.8 F_______ Pulse Ox: _99 %________
Head Circ
(percentile): ______
o Weight : _180 lbs._________
Height : _72 inches_______
BMI :
_24.4__________
Physical Exam:
Physical Exam
Constitutional: Show
Level of Distress

Other:

No acute distress

___________
Nourishment

Normal Weight BMI 18.5-24.9

Overall Appearance

Age Appropriate

Other: ___________

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:___________

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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

Normal

Other:___________

Cornea OD

Normal

Other:___________

Fundoscopy OS

Normal stuctures and sharp disc margin

Other:___________
Fundoscopy

OD

Normal

Other:___________

Lens OS

Clear

Other:___________

Lens OD

Clear

Other:___________

Ocular Muscles
Red Reflex
Vision Screen:

Normal cardinal gaze

Other:___________

Present Bilaterally
Abnormal:_____________________
OS:_20/20_______ OD:_20/20________ OU:_20/20___

Ears: Show
Auricle Right

Normal structure/placement

Other:____________
Auricle Left

Normal placement/structure

Other:____________
Canal Right

Normal

Other:___________

Canal Left

Normal

Other:___________

TM Right

Light reflex present/TM clear

Other:___________
TM Left

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Light reflex present/TM clear

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Other:___________
Hearing

Other:___________

Normal Bilaterally

Nose and Sinus: Show

Naris Right

Discharge - Clear

Naris Left

Discharge - Clear

Other:________________
Other:________________

Turbinates Right

Other:________________

Turbinates Left

Other:________________

Frontal Sinus Right

Non-tender

Other:________________

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

Palate

Choose an item.

Uvula

Normal configuration

Other:__________________

Oropharynx

pink and moist

Tonsils

+1

Other:__Normal hard palate

Other:__________________
Other:__________________
Other:__________________

Neck:
Palpation of Thyroid: Normal

Describe

Abn:___________________________________
Other:____________________________________________________________________________

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Lymphatic: Show
Overview: No noted abnormal swelling/tenderness

Respiratory: Show
Chest

Normal anatomical configuration

Other:_______________
Inspection
Other:_______________

Normal respiratory effort

Auscultation

Clear Breath Sounds Bilaterally

Location

Choose an item.

Cough

Choose an item.

None

Other: ___________________________________________________________________
Cardiac: Show
Morbid Obesity Limits Exam Accuracy: Yes or N/A
Rate/Rhythm

Regular Rate and Rhythm

Edema: _None____________________________________
Capillary Refill_Less than 2 seconds in all four extremities___________
Pedal Pulses:__2+
____________
Carotid Bruits:_Negative_____________________
Other Findings:_______________________________________
Abdomen: Show

Morbid Obesity Limits Exam Accuracy: Yes or No

Inspection

Normal Contour Symmetry

Auscultation

Normal Bowel Sounds

Other:________

Choose an item.

Palpation

Location:

Location:

Normal

Choose an item.

Associated Findings

Other:________
Choose an item.

Hernia _Negative____________________
CVA Tenderness _Negative____________
Other:______________________

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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: Normal all extremities

Describe

Abn:_______________________________
Neurological Show
Mental Status: Alert, Oriented to Time, Place, Person

Describe

Abn:_______________________________
Appearance: Good Hygiene

Describe

Abn:_______________________________
Thought Process: Follows conversation and engages appropriately

Gait: Smooth, active gait

Describe

Abn:___________________________________
CN II-XII: Grossly intact

Describe

Abn:___________________________________
DTRs: upper 2+ Avg

Lower:

2+ Avg

Muscle Bulk, Tone and Strength: Grossly normal

Describe

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

Describe Abn:_______________________________
Describe Abn:_______________________________

Other findings:_Negative Depression

Screening________________________________________________

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Skin Show
Overview: Normal overview but detail exam not done
Lesion Description:
Mole Description:
Rash Description:
Other:___________________________________________________________________________
Results of labs done today: _CBC, CMP, Lipid
pending___________________________________________
______________________________________________________________________________________
__
SBIRT
Date of Alcohol Screening: _6/03/2015__________________
Alcohol Screening Instrument(s) Used: _AUDIT____________
Alcohol Screening done by: _Salena Barnes NPS___________
Alcohol Screening Results: Positive
Brief Interventions conducted: Yes (with patients consent to discuss results
to questionnaire)
Brief Intervention delivered by: _Salena Barnes NPS_______
Length of Brief Intervention: _15 minutes
_____________
Audit score: 5 Zone II: At Risk
Referrals to Treatment provided: Yes/No
Type of Referral to Treatment: _N/A_
___
Additional information: In discussing the issue, my medical advice was that
he cut back to no more than 4 drinks in one day and no more than 14 per
week. His readiness for change was 6 on a scale of 0-10. We explored why it
was not a lower number and discussed the patients own motivation for
change. He was unaware of effects excessive alcohol consumption had on
the body. He agreed to cut back to the advised daily and weekly limits. A
prescription for change was provided and the patient will contact the office
for any further questions or concerns.

Assessment/Plan:

First Diagnosis: Adult Physical Examination____________ ICD9:_V70.0________________

o Additional teaching or comments: Patient encouraged to maintain a
healthy diet of fresh fruits, vegetables and lean meats, as well as
engaging in regular physical activity. Patient verbalized understanding.

Second Diagnosis: Tobacco use disorder______________ ICD9:_305.1________________

o Additional teaching or comments: The patient was encouraged to quit
smoking or decrease amount of cigarettes smoked per day. Explained
increased risks associated with smoking such as cancer, strokes,

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respiratory, and cardiovascular disease. The patient reported he was

not ready to quit and declined information on the smoking cessation
program and nicotine medications to assist with smoking cessation.
The patient was encouraged to contact office if he decided to proceed
with the smoking cessation program. Patient verbalized understanding.

Third Diagnosis:_Counseling on substance use and abuse ICD9:_V65.42________________

o Additional teaching or comments: Patient educated on low-risk
consumption levels and the risks of excessive alcohol use. Verbalized
understanding and will contact office for additional information or if
there are any additional questions. ____________________

Medications Added This Visit

Medication Name
None

Quantity

Dose

Sig

Office Code for Visit:

Est. Pt.
Office

New Pt.
Office

Est. Pt.
Health Check

New Pt.
Health Check

Additional Procedure Codes,

Immunization, Lab, etc.

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>)

99408

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