儿科保健检查英文病历规范

ChiefComplaint(1/1):This1year-oldfemalepresentstodayforahealthmaintenanceexam.Patientwasaccompaniedbymother.

Thechildeats3mealsadayplus2snacksandisoffthebottle.

Gabriellasleepsthroughthenight.Gabriellatakesmorningandafternoonnaps.

Motherisconcernedaboutchild'sred,mattedeyeandnotwalkingcompletelyaloneyet.Immunizationsneedtobeupdatedattoday'svisit.

Developmentalmilestones:1yeardevelopmentalmilestonesreached:bangsblockstogether,drinksfromcup,eatingfingerfoods,feedsself,givestoysonrequest,imitatesvocalizations,looksfordroppedorhiddenobjects,pointstodesiredobjects,pullstostandandcruises,releasescubeintocupafterdemonstration,says"mama"and"dada"withmeaning,saysoneortwootherwords,triestobuildtowerof2cubesandwavesbye.

Allergies:Noknownmedicalallergies.

Medications:None.

PMH:Pastmedicalhistoryisunremarkable.

PSH:Noprevioussurgeries.

FamilyHistory:Patientadmitsafamilyhistoryofcancerassociatedwithmaternalaunt,hypertensionassociatedwithpaternalgrandfather.

SocialHistory:Shelivesathomewithparents.Patientadmitsbeingindaycare.

ReviewofSystems:Nochangesincelastvisit

PhysicalExam:Temp:97.6Height:0ft.31in.Weight:28lbs.BMI:20

GrowthChartEntry:Weight:28lbs0ozsHeight:0ft31inHeadCircumference:18.50inPatientisa1year-oldfemalewhoappearsinnoapparentdistress,welldevelopedandwellnourished.

Inspectionofheadandfaceshowsanteriorfontanelnormal,posteriorfontanelnormalandheadisnormocephalicandatraumatic.

Eyes:Fundoscopicexamrevealsredreflexispresentbilaterally.Alignmentisnormal.

Scleraiswhitebilaterally.

Leftinferiorpalpebralconjunctivarevealsconjunctivitis.

Ocularmotilityexamrevealsgrossorthotropiawithfullductionsandversionsbilateral.

ENT:Pinna:normal.

Otoscopicexaminationrevealsnoabnormalitiesofexternalauditorycanalsandtympanicmembranes.

Inspectionofnoserevealsnoabnormalitiesandnaresthatarenormal.

Nasalmucosamoist,pink,andwithoutmassorexudatewithnoabnormalitiesoftheseptumandturbinatesnoted.

Inspectionoflips,gums,andpalaterevealsnoabnormalities.

Examinationoforopharynxrevealsnoabnormalitiesandtissuespinkandmoist.

Neck:Neckexamrevealsnomasses.

Respiratory:Assessmentofrespiratoryeffortrevealsevenandnonlaboredrespirations.Auscultationoflungsrevealclearlungfieldsandnorubsnoted.

Cardiovascular:Heartauscultationrevealsrateisregular,rhythmisregularandnomurmurs,gallop,rubsorclicks.

Femoralpulsesare2/4,bilateral.

Abdomen:Abdomensoft,non-tender,bowelsoundspresentx4withoutpalpablemasses.

Palpationofliverrevealsnoabnormalities.Palpationofspleenrevealsnoabnormalities.

Genitourinary:

Examinationofanusandperineumshowsnoabnormalities.

Musculoskeletal:

Inspectionandpalpationofbones,jointsandmusclesisunremarkable.Muscletoneisnormal.

Skin:Skinisnotpale,jaundice,orcyanotic.Skinturgor,hydration,andtextureisgood.Palpationofskinshowsnoabnormalities.

Neurologic/Psychiatric:Movesallextremities.

Test&X-RayResults:

Hb:12g/dl.

Impression:Routinewellchildcare.Acuteconjunctivitis.

Plan:Diagnostic&LabOrders:Orderedbloodlead.

ImmunizationsGiven:

VaricellaType:IMManufacturer:ABCDrugCoLot:abc123administeredon07/30/2003by

Ped,Nurseinthethigh,left.

AnticipatoryGuidanceforthe1yearold:Guidancegivenforinjuryandillnessprevention:keephomeandcarsmoke,drug,andalcoholfree,avoidorlimitTVviewing,usesafetyseatinbackseat;canfaceforward,checkhomeforleadhazards,supervisenearwater,emptytubs,buckets,pools,supervisenearpets,mowers,driveways,streetsandlimitsun;usesunscreenandhat.

Guidanceonnutritionprovidedincluding:provide3nutritiousmeals,2-3healthysnacksdailyandallowchildtofeedself,usecup.

Discussedoralhealth.

Guidanceprovidedonsocialcompetenceincluding:praisegoodbehavior,talk,sing,readtogether,encouragesafeexploration,setlimits(i.e.usedistraction),don'tallowhitting,biting,aggressivebehavior,delaytoilettrainingandexpectcuriosityaboutgenitals.

Discussedparent-infantinteractionandfamilyrelationships.Returntoofficein3month(s).

PatientInstructions:

Patientgiveninformationonconjunctivitis

Prescriptions:

TobramycinophthalmicDosage:0.3%ointmentSig:ApplytobotheyesQIDx5days

Dispense:1Refills:0AllowGeneric:Yes

_______________________________JohnSmith,M.D.

SamplePrescription

ChartingPlus™-ElectronicMedicalRecords

JohnSmith,M.D.

DEA#:

_____________________________________________________________

Name:GabriellaKraemerDate:07/30/2003

Address:

WDM,IA50266

_____________________________________________________________

Tobramycinophthalmic

0.3%ointment

ApplytobotheyesQIDx5daysX_____________________________________X_____________________________________

SubstitutionPermittedDispenseaswritten

Refills:0

Disp:1

AllowGeneric:Yes

SamplePatientInstruction

ChartingPlus™-ElectronicMedicalRecords

PatientInstructionsforGabriellaKraemeron07/30/2003

CONJUNCTIVITIS(PinkEye)PatientInformation

WhatisConjunctivitis?

Conjunctivitis,betterknownasPinkEye,isaninfectionoftheinsideofyoureyelid.Itisusuallycausedbyallergies,bacteria,viruses,orchemicals.

Whatarethesignsandsymptoms?

1.Red,irritatedeye.

2.Someburningand/orscratchyfeeling.

3.Theremaybeapurulent(pus)oramucoustypedischarge.

Howisittreated?

ItdependsonwhatcausedthePinkEye.Itmayormaynotneedmedicationfortreatment.Ifmedicationisgiven,followthedirectionsonthelabel.

WhatelsedoIneedtoknow?

Topreventthespreadoftheinfection:

1.Washhandsthoroughly

Beforeyouusethemedicineinyoureyes.Afterusingthemedicineinyoureyes.Everytimeyoutouchyoureyesorface.

2.Washanyclothingtouchedbyinfectedeyes.Clothes

Towels

Pillowcases

3.Donotsharemake-up.Iftheinfectioniscausedbybacteriaoravirusyoumustthrowawayyourusedmake-upandbuynewmake-up.

4.Donottouchtheinfectedeyebecausetheinfectionwillspreadtothegoodeye.IMPORTANT!!!

5.PinkEyeSpreadsVeryEasily!

_______________________________JohnSmith,M.D.

SampleBillingStatement

ChartingPlus™-ElectronicMedicalRecords

BillingStatement-Wednesday,July30,2003

Provider:JohnSmith,M.D.

Patient:GabriellaKraemer,Chart16881

1025AshworthRoad,Suite222

WestDesMoines,IA50265

Diagnoses

1.V20.2RoutineInfantOrChildHealthCheck

2.372.00AcuteConjunctivitis,Unspecified

Treatments

1.83655Lead

RelatedDiagnoses:V20.2

Modifiers:Units:

2.90396Varicella-ZosterImmuneGlobulin,Human,ForIntramuscular

Use

RelatedDiagnoses:V20.2

Modifiers:Units:

3.83020HemoglobinFractionationAndQuantitation;Electrophoresis

(eg,A2,S,C,And/OrF)RelatedDiagnoses:V20.2

Modifiers:Units:

4.99212Officeorotheroutpatientvisit-est.patient-10min.RelatedDiagnoses:V20.2

Modifiers:Units:

ReferringPhysician:MarcusWelby,M.D.

DateLastSeen:

SampleHistoryandPhysicalNoteChartingPlus™-ElectronicMedicalRecords

Subjective:ChiefComplaint(1/1):This3year-oldfemalepresentstodayforevaluationofearpainandfullnessintheearbilateral.

Associatedsignsandsymptomsforotitismedia:Associatedsignsandsymptomsinclude:speechandlanguagedelay,irritability,cough,runnynoseandlossofhearing.

Context:Priorhistoryofthisconditionexists,14thboutwithotitismedia.

Duration:Conditionhasexistedfor2years.

Modifyingfactors:Parentindicatespriortreatmentshavebeenineffective.Quality:Qualityofthepainisdescribedbythepatientasthrobbing.Severity:Severityofconditionisworsening.

Eatingispoor.

Childisupfrequentlyinthenight.Dateoflastexamwas7/22/2003.

PFSH:SocialHistory:Sheisinalargedaycare.

MedicationHistory:PatientiscurrentlyusingAugmentin.PatientisnolongerusingZithromaxoramoxicillin.

ReviewofSystems:Integumentary:(+)eczema,Gastrointestinal:(+)appetitepoororchanged,Ears,Nose,Mouth,Throat:(+)cough,productive,(+)difficultywithhearing,(+)runnynose,ConstitutionalSymptoms:(+)appetitedecrease,(+)sleepproblems,Allergic/Immunologic:(-)unremarkable,Cardiovascular:(-)unremarkable,Endocrine:(-)unremarkable,Eyes:(-)unremarkable,Genitourinary:(-)unremarkable,Hematologic/Lymphatic:(-)unremarkable,Musculoskeletal:(-)unremarkable,Psychiatric:(-)unremarkable.

Objective:Thephysicalexamisupdatedasfollows.Temp:99.8Weight:38lbs.Patientisa3yearoldfemalewhoappearswelldevelopedandwellnourished.

Inspectionofheadandfaceshowsheadthatisnormocephalic,atraumatic,withoutanygrossorneckmasses.

Conjunctivaandlidsrevealnosignsorsymptomsofinfection.Inspectionofbilateralearsrevealsnomassesorswelling.

Otoscopicexaminationrevealsbulgingtympanicmembrane,opaque,andwithpoormobilitybilaterally.Tympanicmembranemobilitywastestedbyapneumaticotoscope.

Inspectionofnasalmucosa,septumandturbinatesrevealserythema.Examinationoforopharynxrevealsnoabnormalities.

Neckexamrevealsnomasses.Necklymphnodesarenormal.

Auscultationoflungsrevealclearlungfieldsandnorubsnoted.

Heartauscultationrevealsrateisregular,rhythmisregularandnomurmurs,gallop,rubsorclicks.

Abdomensoft,nontender,bowelsoundspresentx4withoutpalpablemasses.

TestResults:Noteststoreportatthistime

Assessment:Chronicpurulentotitismedia.

Plan:TheplanistocontinuewithcourseofAugmentintreatmentfromlastvisit.Patientwasreferredtootolaryngology.

_______________________________JohnSmith,M.D.

SampleReferralLetter

ChartingPlus™-ElectronicMedicalRecords

08/01/2003

AndrewOtolaryngologist

1025AshworthRoad,Suite222

WestDesMoines,IA50265

DearDr.Otolaryngologist:

ElizabethOttenwasseeninmyoffice.IhaverequestedthatElizabethbeseenbyyouforfurtherevaluationofchronicotitismediaandpossibleinsertionofeartubes.Thefollowingisasummaryofmyfindings:

Subjective:ChiefComplaint(1/1):This3year-oldfemalepresentstodayforevaluationofearpainandfullnessintheearbilateral.

Associatedsignsandsymptomsforotitismedia:Associatedsignsandsymptomsinclude:speechandlanguagedelay,irritability,cough,runnynoseandlossofhearing.

Context:Priorhistoryofthisconditionexists,14thboutwithotitismedia.

Duration:Conditionhasexistedfor2years.

Modifyingfactors:Parentindicatespriortreatmentshavebeenineffective.Quality:Qualityofthepainisdescribedbythepatientasthrobbing.Severity:Severityofconditionisworsening.

Eatingispoor.

Childisupfrequentlyinthenight.Dateoflastexamwas7/22/2003.

PFSH:SocialHistory:Sheisinalargedaycare.

MedicationHistory:PatientiscurrentlyusingAugmentin.PatientisnolongerusingZithromaxoramoxicillin.

ReviewofSystems:Integumentary:(+)eczema,Gastrointestinal:(+)appetitepoororchanged,Ears,Nose,Mouth,Throat:(+)cough,productive,(+)difficultywithhearing,(+)runnynose,ConstitutionalSymptoms:(+)appetitedecrease,(+)sleepproblems,Allergic/Immunologic:(-)unremarkable,Cardiovascular:(-)unremarkable,Endocrine:(-)unremarkable,Eyes:(-)unremarkable,Genitourinary:(-)unremarkable,Hematologic/Lymphatic:(-)unremarkable,Musculoskeletal:(-)unremarkable,Psychiatric:(-)unremarkable.

Objective:Thephysicalexamisupdatedasfollows.Temp:99.8Weight:38lbs.Patientisa3year-oldfemalewhoappearswelldevelopedandwellnourished.

Inspectionofheadandfaceshowsheadthatisnormocephalic,atraumatic,withoutanygrossorneckmasses.

Conjunctivaandlidsrevealnosignsorsymptomsofinfection.Inspectionofbilateralearsrevealsnomassesorswelling.

Otoscopicexaminationrevealsbulgingtympanicmembrane,opaque,andwithpoormobilitybilaterally.Tympanicmembran