8/10/2019 Ambulatory Clinic Note

1/4

AMBULATORY CLINIC NOTE

PATIENT INITIALSI: -

VISIT DATE: / /

PATIENT DIAGNOSIS:

PRINAMRY:

OTHER:

ANY RECENT SURGERY:

ALLERGIES:

REASON FOR TODAYS VISIT:

Medication and Related Patient EducationMedication Name(Brand & Generic)

Classification & Reasonit is prescribed

Dose & Route Important Patient Teacin! Point(s)

TEMP PULSE RESP BP LUNG SOUNDS EDEMA Y N PTITTING Y N

O R AA:_____reg/irreg

R:_____reg/irreg

L/R_____/____

Sitting

Anterir:RUL LULRMLRLL LLLP!terir

C"#$ R %& L %&

An'#e R %& L %&

In!te( R %& L %&WT PEDAL

PULSE

MEDS

Me)! T"'en "! Dire%te) Y N Me) C*"nge!:Me) Inter+entin/In!tr,%tin

Pt/SO Re!(n!e:

8/10/2019 Ambulatory Clinic Note

2/4

PPM _____

AICD ____

Other_______

Supine

Standing

L/R_____/____

RUL LULRLL LLL

L"ter"#

RUL LULRML

Scale for grading pitting edema1 + = 0 inch. Trace. Disappears rapidly2 + = - inch. Mod. Disappears in 10-45 sec3 + = - 1 inch. Deep. Disappears in 1-2 min!es.

4+ = " 1 inch. #ery dep. Disappears in 3-5 min!es

R

L

PAIN

P"in Ye! N L%"tin $ P"in:

A!!e!! (re!ent ("in: n ("in. 0 1 2 3 4 5 7 8 9 10 (severe)

A!!e!! ("in "t it! 6r!t: n ("in. 0 1 2 3 4 5 7 8 9 10 severe)T7(e: In%i!in"# Art*riti% Ne,r("t*i% Ot*er:

C*"r"%teri!ti% $ ("in: S*"r( D,## A%*e 8,rning S*ting

St"99ing Ot*er:

Fre,en%7: Le!! $ten t*"n )"i#7 D"i#7; 9,t nt %n!t"nt A## t*e ti&e

Pre%i(it"ting $"%tr!: M+e&ent/A%ti+it7 B g#"!!/)"7 N,tritin"# Int"'eS,((#e&ent Y N T,9e Fee)ing Y NInter+entin!:Ot*er:

SIN

8/10/2019 Ambulatory Clinic Note

3/4

S'in Int"%t Y N C#r T,rgrTe&(

P"tient/SO Re!(n!e:

8/10/2019 Ambulatory Clinic Note

4/4

Disease #anage#ent:MDI / !e&u$i.ers / O"gen:

Medications:

$I #ID"S"#pto# #anage#ent:

La&s:

Re%erra$s:

Disease #anage#ent:!utrition:

Medications:

*at important referrals+ p,sician appointments or lab follo- up is important+ and does patient a.e tis in place/

Does patient 0no- for -at and -en to call p,sician+ nurse+ or 122/

I+,er-D$s$%$+'r. C//r$+',$/+ Y N W$,& W&/:

2222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222

Patient Problems #bnormal %indin!

Inter.entions Teacin! Response to Teacin!$o- and -en -ill ,oue.aluate inter.entions

E3pected Result

24

54

64

74

84

94

Date of Ne3t isit%ocus of Ne3t isit

S,*e+, N'e D',e: " "