Documentation

Question 1

HPI/ROS

Answer 1

Document any unique findings that need to be documented.

-Example: Presence or absence of neuropathies in diabetics; status of routine screenings

Question 2

Constitutional ROS

Answer 2

Abnormal: Fatigue, weakness, dizziness, syncope/presyncope, decreased tolerance to exercise, fever

Question 3

Cardiovascular ROS

Answer 3

Abnormal: Palpitations, chest pain, chest pressure, edema, left upper extremity discomfort, lower extremity pain

Question 4

Respiratory ROS

Answer 4

Abnormal: SOB, dyspnea at rest, dyspnea on exertion, PND, orthopnea, cough

Question 5

Neurological

Answer 5

Abnormal: Blurred vision, headache

Question 6

GI/Abdomen

Answer 6

Abnormal: Nausea, abdominal distension

Question 7

Cardiovascular

Answer 7

• Normal: Regular rate and rhythm. No murmurs, rubs, or gallops.
• Abnormal: Abnormal heart sounds; slow, fast or irregular rate, murmurs, gallop, elevated JVP, claudication

Question 8

Respiratory

Answer 8

Normal: Clear to auscultation bilaterally; no wheezes, no rales, no rhonchi
Abnormal: Dyspnea, wheezes, rales, rhonchi

Question 9

Abdominal

Answer 9

Normal: Soft, nontender
Abnormal: Ascites

Question 10

Extremities

Answer 10

Normal: No edema
Abnormal: Edema

Question 11

Neurological

Answer 11

Normal: CN II-XII grossly intact
Abnormal: Focal dysfunction, transient monocular blindness