Download and use this form to maintain a Health Progress Report for your Patient.
Text Version of the Form
Patient Name: ________________________________________
ADULT PROGRESS NOTE Date of Birth: ________________________________________
Date: ____________________________ Medical Record Number: _______________________________
- o New o Return o Periodic
- o Chart Not Available o Interval ED Visit o Interval Admission Allergies: o Yes (See Adult Summary Form)
- o Missed App’t(s) o Needs Prescriptions o No
CC: _________________________________________________________________________________________________________
____________________________________________________________________________ Initial: ___________________________
HPI: (Location, Quality, Severity, Duration, Timing, Context, Modifying Factors, Assoc. Signs/Symptoms)
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Medications: o None o See Updated Med List
Review of Systems:
+ – Constitutional + – + – + – Musculoskeletal + –
- o Change Wt o o Tinnitus o o Constipation o o Arthritis o o Breast Pain
- o Fatigue o o Ulcers o o Diarrhea o o Cervical Pain o o Breast Lumps
- o Temperature/Chills Respiratory o o Dysphagia o o Decreased Motion o o Breast Discharge
- o Weakness o o Asthma o o Fecal Incontinence o o Gout Endocrine
Skin o o Bronchitis o o GERD o o Injuries o o Heat/Cold Intol.
- o Chng Color o o Cough o o Hematochezia o o Joint Pain o o Neck Enlargement
- o Chng Hair/Nails o o DOE o o Hemorrhoids o o Joint Stiffness o o Polydipsia
- o New Lesions o o Hemoptysis o o Melena o o Locking Joints o o Xerosis
- o Pruritis o o Pneumonia o o N/V o o Low Back Pain Neurologic
- o Rash o o SOB o o PUD o o Swelling o o Chng Concentration
- o Xerosis Cardiovascular + – Genitourinary Psychiatric o o Chng Memory
Eyes o o Angina o o Chng Stream o o Depression o o Dizziness
- o Cataracts o o CAD o o Hematuria o o Homicidal Ideation o o Headache
- o Chng Vision o o Chest Pain o o Hernia o o Substance Abuse o o Imbalance
- o Glaucoma o o Claudication o o Hesitancy o o Suicidal Ideation o o Numbness
- o Redness o o DOE o o Impotence o o Time/Place Orientation o o Seizures
ENMT o o Edema o o Incontinence o o Recent/Remote Memory o o Tremor
- o Bleeding Gums o o HTN o o Nocturia o o Anxiety/Agitation o o Weakness
- o Chng Hearing o o Orthopnea o o Polyuria Female Reprod. Hematologic
- o Chng Voice o o Palpitations o o Scrotal Masses/Pain o o Abnormal Menses o o Anemia
- o Dentures o o PND o o STD’s o o Dryness o o Easy Bruisability
- o Epistaxis Gastrointestinal o o Urgency o o Dyspareunia o o Enlarged LN’s
- o Hoarseness o o BRBPR o o Sexual Abuse o o HxTransfusions
- o Sinusitis o o Chng Bowel Habits o o Vaginal Discharge
Comments:
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
- o PMH Reviewed – No Changes; See Adult Summary Form o PMH Reviewed & Updated; See Adult Summary Form
- o SHx Reviewed – No Changes; See Extended Hx Form o SHx Reviewed & Updated; See Extended Hx Form
- o FHx Reviewed – No Changes; See Extended Hx Form o FHx Reviewed & Updated; See Extended Hx Form
Vital Signs: Age: ____________
Weight: ____________BMI: _____________Temperature: _____________Blood Pressure: ______________Pulse: _______________
Respirations: ________ Fingerstick: _____________ LMP: _____________ Oxygen Saturation: _______________ Initials: _________
Physical Exam:
Nl Ab General Nl Ab Nl Ab Nl Ab Nl Ab MSK
- o Appearance o o Auscultation o o Bowel Sounds o o Axillary o o Inspection
- o VS o o Percussion o o Palpation o o Inguinal o o Exam of Joint
Eyes o o Palpation o o Liver Span o o Other ___________ o o Head & Neck
- o Conjunctiva/lids CV o o Spleen Skin o o Spine/Ribs
- o Pupils (Reactivity/Accom) o o PMI o o Inguinal Area o o Inspection o o Pelvis
- o Disc/Fundi o o Palpation GU – Male o o Palpation o o RUE Stability
- o EOM o o Auscultation o o Scrotum/Testes Neuro o o LUE ROM
ENMT o o Rhythm o o Penis o o Cranial Nerves o o RLL Strength
- o Ear Infection o o Rate o o Anus o o Tendon Reflexes o o LLE
- o TMs & Canal o o S1 o o Perineum o o Biceps o o ROM
- o Hearing (Whisper, Etc.) o o S2 o o Rectal Area (Ext.) o o Triceps o o Gait
- o Weber o o Carotid Art. o o Prostate (DRE) o o Patellar o o Clubbing/Cyanos
- o Rhinne o o Abd. Aorta o o Occult Blood o o Achilles Edema
- o Nasal Mucosa/Septum/ o o Fem. Pulses GU – Female o o Brachioradialis Psychiatric
Turb. o o Extremities (Edema/ o o Ext. Genitalia o o Motor Strength o o Orientation
- o Lips/Gums/Teeth Varicose Veins) o o Urethra o o Upper Ext. – Strength (Person, Place, Time)
- o Oropharynx Chest o o Cervix o o Lower Ext. – Strength o o Mental Status
Neck o o Inspection o o Adnexa o o Sensory o o Judgment
- o Appearance o o Palpation o o Uterus o o Light Touch o o Insight
- o Symmetry o o Right Breast o o Bladder o o Pin Prick o o Short-Term Mem
- o Trachea o o Left Breast o o Saline/KOH o o Vibration o o Long-Term Mem
- o Thyroid o o Right Axillae o o Rectal Exam o o Temperature o o Mood
- o Lymph Nodes o o Left Axillae o o Occult Blood o o Proprioception o o Affect
Lungs Abdomen Lymph Nodes o o Romberg o o Concentration
- o Resp. Effort o o Inspection o o Neck o o RAM o o Speech
- o Rib Excursion o o Supraclavicular o o Babinski Eval
Comments: ____________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Assessment & Plan: ___________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
- SF o L o M o H Medical Decision-Making
- o See Continuation Sheet
Counseling o Seat Belts o INR o CXR BP Check In
- Advance Directives o Smoke Detectors o PAP o Echocardiogram ____ Day(s)
- Alcohol o STD/HIV Counseling o Pregnancy Test o Electrocardiogram ____ Week(s)
- BSE o Substance Abuse o PSA o Flex Sig ____ Month(s)
- Dental Care o Sun Protection o Rapid Strep o IVP Call Office
- Diabetes o TSE o Renal Profile o Mammogram ____ Day(s)
- Domestic Violence o Tobacco Cess. o RPR o Stress Echo ____ Week(s)
- Exercise Labs Ordered o Stool Cards o Stress Test ________________ ____ Month(s)
- Eye Protection o BMP o TFTs o Ultrasound ____ Prn
- Foot Care o CBC o Throat Culture o Follow Up ________________ Labs to be Done In
- Firearms Risk o Cholesterol Profile o Urinalysis Follow Up ____ Today
- Hearing Conserv. o CMP o Urine Culture ____ Day(s) ____ Day(s)
- Hormone Replacement o Drug Level o Urine Pregnancy Test ____ Week(s) ____ Week(s)
- Medication S/E o GC/Chlamydia o Other _______________ ____ Month(s) ____ Month(s)
- Noncompliance o Hb A1c Tests Ordered ____ Prn
- Nutrition o Hepatic Profile o BE o Old Records Requested
- Osteoporosis o Hepatitis Serology o Colonoscopy o Pending Test(s) ___________
- Pregnancy Prevention o HIV o CT/MRI _____________
Referred To ________________________________________________________________________ Time Counseling (Minutes) ______________________
Signature __________________________________________________________________________ Date _________________________________________