Koppma Posted October 6, 2013 Share Posted October 6, 2013 Does anyone know a good site that has any good template for H&P's that is good for the beginner? Thank you very much for your help. Link to comment Share on other sites More sharing options...
PYRITE Posted October 6, 2013 Share Posted October 6, 2013 this site has some decent templates to download: http://www.medfools.com (go to downloads tab) Link to comment Share on other sites More sharing options...
winterallsummer Posted October 9, 2013 Share Posted October 9, 2013 Here is what I used when we first started doing these in school. Nothing special but you can use it if you like or use it to get an idea of how you want of make your own. This is obviously not practical for real life practice. Date & Time: Name:DOB: CC: OPQRST Onset: Palliative (worse/better): Quality: Region/radiate: Severity: Time: Assoc sx (& OPQRST) PMH Medical (MI, CAD, HTN, valvular heart disease, stroke, migraine, mental health, substance abuse, asthma, chronic bronchitis, emphysema, cancer liver disease, hepatitis, renal disease, diabetes peptic ulcer, arthritis, glaucoma, thyroid disorder) Childhood Adulthood (seasonal allergies go here) Past blood transfusions (*hematologic section*): Surgeries (type, date, where, complications, C sections, eye) Hospitalizations (where, dx, tx) Injury Immunizations (when) Health screening (when + result) TB test pap smear mammogram metabolic panels & blood work Family History: alive, dead & cause of death, diabetes, cancer, heart, HTN, cholesterol, cancer Social History: Born where: Live where: Education/job: Ethnicity: Support system: Sleep: Diet: Tobacco: Alcohol: Street drugs (cost or quantity): Exercise: Relationship status (& kids): Drug allergies Food allergies Medication Prescription: OTC: ROS (!!! PAST 6 MONTHS!!!) General Weight: Weight changes (if unintentional, details): Weakness: Fatigue: Fever: Chills: Skin Lesions: Rashes: Pruritus (itching): Bruise easily (*hematologic section*): Dry/moist skin: Changes in skin color: Hair or nails abnormally brittle: Change in size/color of moles: Jaundice (yellow skin/eyes): Head New/unusual headache: Trauma: Lightheadedness Dizziness: Eyes Vision: Glasses/contacts (why needed?): Last eye exam & results: Pain: Diplopia (dbl vision): Blurred vision: Scotomata (marks/blocks in field of vision): Photophobia: Excessive lacrimation: Injection (redness): Discharge: Field cut: Injury: Ears Pain/earache: Discharge: Vertigo (room spinning): Tinnitus: Hearing issues: Past or recurrent infections: Noses/Sinuses Frequent colds: Pain: Discharge: Injury: Epistaxis (nosebleed): Congestion: Throat/Mouth/Pharynx Condition of teeth/gums: Dentures (& fit): Last dental exam (& results): Sore tongue: Dry mouth: Frequent sore throats: Hoarseness: Neck Pain/stiffness: Limitation of movement: Goiter: Lumps: Swollen glands: Respiratory Cough: Sputum (quality, color, odor): Hemoptysis (cough up blood): Wheezing: Dyspnea (SOB): Pleuritic chest pain:Exposure to TB: Cardiovascular Chest pain: Orthopnea (hard to breath when lying down): Paroxysmal nocturnal dyspnea (wake up gasping for air & coughing): Palpitations/irregular heartbeat: GI Dysphagia (hard to swallow): Heartburn (relation to meals, use of antacids): Appetite: Nausea: Vomiting (frequency, last time ingested foods, color, amount) Hematemesis (vomiting blood): Abdominal pain: Excessive belching or gas: Frequency of bowel habits: Changes in bowel movements: Stool color & frequency: Tarry stools: Painful defecation: Rectal bleeding: Hemorrhoids: Tenesmus (frequent urge to pee or poop but nothing comes out): Peripheral vascular Intermittent claudication (tingling, pain, numbness in legs that comes & goes): Leg cramps: Varicose veins: Edema/ulceration/hair loss/color change/coldness of calves, legs or feet: Color changes in fingertips/toes: Musculoskeletal (if positive - what muscle/joint area, any swelling, erythema, stiffness, weakness, limitation of movement, timing and duration of sx) Trauma/injury: Muscle or joint pain: Stiffness: Backache: Redness: Swelling: Neurological: Changes in mood, attention or speech: Changes in orientation, memory or judgement: Blackouts: Paralysis: Numbness/loss of sensation: Tremor: Clumsiness/balance problems: Loss of coordination: Paresthesia (tingling, numbess anywhere on body): Gait changes: Psychiatric Nervousness: Tension: Depressed mood: Anxiety: Hallucinations: Suicidal (thoughts to hurt self): Homicidal (thoughts to hurt others): Endocrine: Heat or cold intolerance: Changes in glove/shoe size: Excessive perspiration (sweating): Hirsutism (girls getting lots of hair on arms, legs etc): Increased thirst/hunger: Genitourinary - both Lumbar/flank/suprapubic (think kidneys) pain: Frequency of urination: Polyuria (excess urine): Nocturia (awake to pee at night often): Urgency: Changes in the force of the urinary system: Incontinence: Hesitancy: Calculi (kidney stones): Dysuria (painful peeing): Hematuria (blood in pee): MEN ONLY! Dribbling: Hernias: Penile lesions or discharges: Testicular pain/masses: Prostate disease: Scrotal pain: Erection (achieve/maintain): Ability to ejaculate: WOMEN ONLY! Breasts (female patients only!) Breast self exam: Masses: Tenderness: Nipple discharge/changes in areolar skin Menarche (first one / any problems with): Regularity/frequency/duration of menses (period): Bleeding between menses or after intercourse: Last menstrual period (LMP): If menopausal → age at LMP, hormone replacement therapy, history of post-menopausal bleeding) Dysmenorrhea (painful period): Dyspareunia (painful sex): Vaginal discharge/pruritus/lesions/lumps: Vulvar lesions/pruritus/pain: # of pregnancies (gravida): # of viable births (para): # of abortions & miscarriages: Type of deliveries: Complications during pregnancy/labor/delivery OR postpartum: C sections → surgical; Deliveries → hospital Sexual history History and activity (men/women; oral/vaginal/anal): Protection (condoms and/or BC): HIV/STIs concerns; ever tested: Frequency: Satisfaction: WASH HANDS!!! Link to comment Share on other sites More sharing options...
Guest Posted October 16, 2013 Share Posted October 16, 2013 Can you make your own? When we started we just used word to edit the packet with directions on how to do H&P. We just left a bunch of spaces after each field, and circled ROS and PMH stuff. Of course you have o elaborate on those but can always use the back of the page. Link to comment Share on other sites More sharing options...
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