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Download and use this form to maintain a Health Progress Report for your Patient.


Adult Progress Note Form

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 _________________________________________

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