Community Health Aide/practitioner Patient Encounter Form
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1A-663 (ANC)
Medicaid: o AU o AY
rev. 5/05
COMMUNITY HEALTH AIDE/PRACTITIONER PATIENT ENCOUNTER FORM
Clinic Code ___________
HISTORY
Chief complaint: __________________________________________
Hx of Present Illness: _______________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Past Health Hx: __________________________________________________________________________________________
__________________________________________________________________________________ LMP: _______________
__________________________________________________________________________________ If Pregnant, # weeks: ___
Medicines: ______________________________________________________________________________________________
Allergies:
________________________________________ Immunization status: ______ PPD status: _____
(What & Reaction)
Other Hx: ______________________________________________________________________________________________
_______________________________________________________________________
Tobacco: None 2nd-hand Chew Smoke
_______________________________________________________________________
Thinking about quitting? Y N Already Quit
Habit Hx:
Referral: Yes No
Never Used
(ETOH, Drugs) ___________________________________________________________________
EXAM
General Appearance: ______________________________________________________________________________
Vital Signs: T ______ P __________ R ________ BP __________ SPO2 ________ WT ________ HT _________ HC ______
Head: __________________________________________________________________________________________________
Eyes: ____________________________________________________________ Snellen Test: (R) _____ (L) _____ (B) _____
Ears: (R) _______________________________________________________________________________________________
(L) _______________________________________________________________________________________________
Nose/Sinus: ____________________________________________________________________________________________
Mouth/Throat: ___________________________________________________________________________________________
Neck/Nodes: ____________________________________________________________________________________________
Back: __________________________________________________________________________________________________
Lungs/Chest: ___________________________________________________________________________________________
Heart: _________________________________________________________________________________________________
Breasts: _______________________________________________________________________________________________
Abdomen: ______________________________________________________________________________________________
Genital/Rectal: __________________________________________________________________________________________
Extremities: _____________________________________________________________________________________________
Nervous System: ________________________________________________________________________________________
Skin: __________________________________________________________________________________________________
Lab Tests/Results: _______________________________________________________________________________________
ASSESSMENT
_______________________________________________________________
Immunizations given:
_____________________________________________________________________________
Initials/Vaccine/Lot #
PLAN
(
) ___________ # ______
Pt. Education: __________________________________________________________
(
) ___________ # ______
_____________________________________________________________________________
(
) ___________ # ______
Medicines: ____________________________________________________________________
TB Skin Test
_____________________________________________________________________________
Special/Other Care: _____________________________________________________________
(
) PPD 0.1 ml ID LFA/RFA(circle)
Recheck/Follow-up: _____________________________________________________________
(
) PPD
00
mm (when read)
Date: ........... / ............../ ........... Time: .........................................
Doctor: __________________________ on: ___ / ____ / ____
Dr.’s Assessment: ___________________________________
Hospital #: ................................ SS #: .......................................
CHAM Plan Page # ____________________ Standing Order
o
Name: (L) .................................. (F) .............................. (MI) .....
CHA/CHP: ________________________________________
DOB: ............/ ........... / ............... Age: ............... Sex: ................
Village: ____________________________________________
Normal Clinic Hrs
After Clinic Hrs
Home Visit
ETOH Related Yes
No
o
o
o
o
o
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Parent category: Medical