Patient Care Report printable pdf download

Patient

Gender

Age

Doctor

Diagnosis

Diet:

Lab:

Other tests:

Treatments:

IV Orders:

MEDICATION ORDERS:

ALLERGIES:

Diabetes: Type I

Insulin:

Type II

Medication:

Blood sugar __________

Blood sugar__________

Medication/dose/route/frequency

reason for giving

Time(s) to give

CHIEF COMPLAINT/PRESENT ILLNESS

(why the patient is here)

HISTORY

(past illness, injuries, hospitalizations, surgery, sleep patterns, family)

GENERAL:

Normal Weight _____ B/P_______ Pulse_____ Respirations______ Temperature_____

SKIN

(rashes, itching, hives, bruising, eczema, dryness, skin color changes, hair texture

changes, nail texture changes, appearance of nails (including toes), previous skin disorders,

lumps, use of hair dyes)

EYES, NOSE, EARS

PERRLA_____

(eyeglasses, redness, problems with vision, eye discharge, glaucoma,

cataracts, last eye exam, eye injuries, nasal discharge, nosebleeds, sinus infections, hay fever,

nasal obstruction, frequency of colds, hearing aid, hard of hearing, deafness, ringing in ears,

dizziness, ear discharge, pain in ears)

MOUTH AND THROAT

(condition of teeth and gums, bad breath, problems with chewing

or eating, last dental exam, frequency of sore throats, changes in voice, persistent hoarseness,

thyroid problems, goiter, lumps, pain in neck, swollen glands)

BREAST

(lumps, discharge, pain, frequency of self exam)

CARDIOVASCULAR

HR regular irregular _____

(chest pain, palpitations, murmurs, high blood pressure, shortness of

murmur ____

breath with exertion or lying down, history of heart attack or rheumatic fever, varicose veins,

3 ____

4 ____

pain in legs or calves with walking, swelling in legs or feet, coolness of an extremity, loss of hair

on legs, discoloration of an extremity, ulcers)

RESPIRATORY

Pulse Ox____ O

____

(cough, wheezing, sputum amount and color, bloody sputum, shortness of

breath, asthma, pleurisy, bronchitis, TB, last chest X-ray, last TB skin test)

GASTROINTESTINAL

flat/round/distended

(recent weight loss, appetite, heartburn, belching, nausea,

bowel sounds? yes no

vomiting, abdominal pain, constipation, change in color or consistency of stool, frequency of

Pain location

stool, hemorrhoids, rectal bleeding, use of laxatives, jaundice, hepatitis, gallbladder problems)

GENITOURINARY

Last BM_____

(color and odor of urine, frequency, urgency, difficulty starting stream,

stress incontinence, excessive, painful or burning urination, blood in urine, flank pain, waking at

night to urinate, retention, kidney stones, UTIs, STDs, MALESprostate problems, self exam of

testicles, FEMALESonset of menses, frequency and length of periods, date of menopause,

pregnancies/miscarriages, use of birth control, date of last PAP)

MUSCULOSKELETAL

(pain or stiffness in joints, weakness, deformities, limitations in

ability to ambulate and transfer, joint clicking, muscle cramps or spasms, use of assistive

devices, use of prosthesis, problems with balance, history of gout, arthritis, bursitis or fractures,

ability to carry out ADLs)

NEUROLOGICAL

Orientation

(headache, fainting, dizziness, ataxia, blackouts, paralysis, numbness,

Hand grips? L R

tingling, burning, tremors, memory loss, mood changes, nervousness, speech problems, loss of

Facial symmetry

consciousness, hallucinations, visual disturbances, disorientation, history of brain injury or

stroke)

DISCHARGE PLAN:

Patient Care Report

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