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20 Park Avenue, Suite 1A (@35th St.), New York, NY 10016 - Tel.: 646.957.5444 (Please note: No insurances, Medicare, or Medicaid accepted)

 

The First Public Demonstration of Surgical Anesthesia
(Boston, October 16, 1846)

PROGRESS NOTE

 

Patient Name :

 

Patient's Date of Birth:

 

Chief Complaint & History of Present Illness:

 

Past Medical History:

 

Family Hx:
 

Allergies:
 

No Known Drug Allergies:
 

Social Hx:

 

Gen/HEENT

 

CV/PULM

 

F/C/S

Y

N

Chest Pain

Y

N

Fatigue

Y

N

Dyspnea

Y

N

Itchy Eyes

Y

N

Pleuritic Pain

Y

N

Ear Pain L&/or R

Y

N

Cough

Y

N

Runny Nose

Y

N

Orthopnea

Y

N

Sore Throat

Y

N

PND

Y

N

Sinus Pain or Pressure

Y

N

Leg Edema

Y

N

Tooth Pain

Y

N

Nocturnia

Y

N

 

GI/GU

 

MSK/NEURO/PSYCH

 

Nausea

Y

N

Joint Pain

Y

N

Vomitting

Y

N

Joint Swelling

Y

N

Diarrhea

Y

N

Myalgias

Y

N

Melena/Hematochezia

Y

N

Paresthesias

Y

N

Abd Pain

Y

N

Depressed Mood

Y

N

Dysuria

Y

N

Suicidality

Y

N

Hematuria

Y

N

Anxiety

Y

N

Urinary Frequency

Y

N

 

 

 

Other

 

Weight Loss

Y

N

Weight Gaim

Y

N

 

Vitals: T

 

Pulse

BP

R

02 Sat

HT

WT

 

Physical Exam

Normal

Comment here on abnormal findings

HEENT

CV

LUNGS

ABD

EXT

NEURO

PSYCH

LYMPH

SKIN

GU/RECTAL

 

LAB AND SPOT DIAGNOSTIC TESTING

 

UA Not Done Negative Positive

Rapid Strep Test: Not Done Negative Positive


Other:


Diagnosis / Impression / Plan:

 

My differential diagnosis and working diagnosis were explained to the patient. Treatment and alternative treatment options were reviewed. Risks, benefits, and potentially adverse effects of treatment were explained. Verbal and written information on diagnosis and treatment was provided. Follow-up within 24 hours advised if no improvement. Patient demonstrated understanding.

 

Yes No

 

Medication(s) Dispensed &/or Injected (include Name of Medication, Lot #, Expiration Date, Quantity):

 

 

ICD-9 Codes (check all that apply): Back Pain (724.5)
Bronchitis, Acute (466.0) Cough (786.2)
Diarrhea (787.91) Dizzyness/Vertigo (780.4) Fatigue (780.79) Fever (780.6) Nausea (787.01)
Pharyngitis (462) UTI (595.0)


Other ICD-9:


CPT Codes: Physician House Call New Patient (99345) Physician House Call Established Patient (99350)

 

Medical Provide Name:
 

Medical Provider Signature:

(Please put slashes to verify signature, f or example: /Natan Schleider, M. D. /)
 

Medical Provider's Email:
 

Date of Medical Service:

 
 

Today's Date:

 



 


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