Attachment_1_Templates.pdf

MIKE O'CALLAGHAN FEDERAL MEDICAL CENTER

NELLIS AIR FORCE BASE, NEVADA

HISTORY AND PHYSICAL EXAMINATION

DATE OF ADMISSION:

CHIEF COMPLAINT:

HISTORY OF THE PRESENT ILLNESS:

PAST MEDICAL HISTORY:

REVIEW OF SYSTEMS:

PHYSICAL EXAMINATION:

GENERAL:

HEENT:

NECK:

LUNGS:

HEART:

ABDOMEN:

BACK:

PELVIC:

RECTAL:

EXTREMITIES:

SKIN:

LYMPHATICS:

IMPRESSION:

PLAN:

JANE A DOE, MAJ, USAF, MC

STAFF PHYSICIAN, *********** Department

Pt Name:

SS#

MR#

DOD & Time DOT & Time Transcriptionist ID:

Replaces SF 504 Personal Data-Privacy Act of 1974 (PL 93-579)

CLINIC NOTE

DATE OF SERVICE:

HISTORY OF PRESENT ILLNESS:

PHYSICAL EXAMINATION:

GENERAL:

HEENT:

SKIN:

LUNGS:

HEART:

ABDOMEN:

VASCULAR:

EXTREMITY:

DIAGNOSTIC DATA:

ASSESSMENT:

Pt Name:

SS#

MR#

DOD & Time DOT & Time Transcriptionist ID:

NARRATIVE SUMMARY

DATE OF ADMISSION:

DATE OF DISCHARGE:

HISTORY OF THE PRESENT ILLNESS:

PAST HISTORY:

PHYSICAL EXAMINATION:

HEENT:

NECK:

LUNGS:

HEART:

ABDOMEN:

EXTREMITIES:

HOSPITAL COURSE:

Pt Name:

SS#

MR#

DOD & Time DOT & Time Transcriptionist ID:

OPERATIVE REPORT

DATE OF OPERATION:

PREOPERATIVE DIAGNOSIS:

POSTOPERATIVE DIAGNOSIS:

PROCEDURE OBTAINED:

STAFF SURGEON 1:

STAFF SURGEON 2:

ANESTHESIA:

ESTIMATED BLOOD LOSS:

SPECIMENS SUBMITTED

OPERATIVE COMPLICATIONS

OPERATIVE INDICATION:

OPERATIVE DESCRIPTION:

Pt Name:

SS#

MR#

DOD & Time DOT & Time Transcriptionist ID:

ORTHOPEDIC CLINIC NOTE

DATE OF SERVICE:

CHIEF COMPLAINT:

HISTORY OF PRESENT ILLNESS:

PAST MEDICAL HISTORY:

PAST SURGICAL HISTORY:

CURRENT MEDICATIONS:

1.

2.

ALLERGIES:

1.

2.

SOCIAL HISTORY:

FAMILY HISTORY:

REVIEW OF SYSTEMS:

PHYSICAL EXAMINATION:

GENERAL:

HEENT:

LUNG:

HEART:

SKIN:

NEURO:

EXTREMITY:

DIAGNOSTIC DATA:

1.

2.

ASSESSMENT:

Pt Name:

SS#

MR#

DOD & Time DOT & Time Transcriptionist ID:

CONSULTATION

NARRATIVE:

PAST MEDICAL HISTORY:

SOCIAL HISTORY:

CURRENT MEDICATIONS:

ALLERGIES:

REVIEW OF SYSTEMS:

FAMILY HISTORY:

PHYSICAL EXAMINATION:

VITAL SIGNS:

GENERAL:

ENT:

NEUROLOGIC:

MOTOR:

SENSORY:

COORDINATION:

IMPRESSION:

Pt Name:

SS#

MR#

Transcriptionist ID:

DOD & Time DOT & Time

MEDICAL EVALUATION BOARD SUMMARY

1. Chief Complaint.

2. History of Present Illness.

3. Past Medical History.

4. Review of Systems.

5. Pertinent Family History.

6. Full Physical Exam to Include Right or Left Handed. See also DoDI

1332.38, paragraph E4.A1.1.3.

7. Laboratory and Radiology Findings.

8. Hospital Course.

9. Operations and Procedures.

10. Current Medications.

11. Other Diagnoses.

12. Referring provider’s name, duty title, AFSC, and phone number.

13. Administrative LOD.

14. Worldwide Qualification.

15. Current Profile.

16. Final Diagnosis/Recommendation.

17. Prognosis, follow-up, restrictions and/or limitations involving current assigned military duties, without stating fitness for duty.

Pt Name:

SS#

MR#

Transcriptionist ID:

DOD & Time

PROGRESS NOTE

24h/Subjective:

Vitals:

HR:

BP:

RR:

Temp max:

Exam:

Gen:

HEENT:

Neck:

Lungs/chest:

Heart:

Extremities:

Labs:

Studies:

Assessment/Plan:

Prevention/PRN:

DVT/PE:

Pain/Fever:

Estimated length of stay:

Pt Name:

SS#

MR#

Transcriptionist ID:

DOD & Time