Templates file 1
This is a text file with a number of chart Templates in it. Go to Templates in Admin and copy and paste in templates __separately__ Remeber to put a name in for each one - you will see that I have put a name above each one. I set the names to start with aa so that they appear at the top of the template list. The templates are miracles of modern medical care. Please feel free to edit and add to them, send me your work, and I will post it here. Contributed by Jel Coward jel@OSCARwest.com http://www.OSCARwest.com
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aaURTI Adult URTI, Afebrile Ears NAD, Throat NAD, Snuffly Chest clear. Advised fluids, tylenol - Rv sos aaURTI Child URTI, Afebrile Ears NAD, Throat NAD, Snuffly Chest clear, no tachypnoea/recession, Abdo soft, non-tender. No rash no meningism. Advised - fluids, tylenol - Rv if any concerns aaComplete Physical History PMH - PUT ABOVE Family History- PUT ABOVE MedicationsPUT ABOVE OE Looks well. No An/Cy/J/Nodes/Clubbing CVS – Pulse 80 reg, BP / HS normal, no ankle oedema, JVP not elevated. Apex beat not displaced RS – RR No recession, Trachea central, PN Res all areas, BS vesic + nil Abdo – soft, non-tender, no masses, no LKKS, HOs intact BS normal NS – Cns II-XII intact. PERL, Discs flat. UL – Tone, Power, Co-ord – normal. Sensation grossly normal. LL - Tone, Power, Co-ord – normal. Sensation grossly normal. Plantars downgoing ENT – Ears – NAD, Throat – NAD, Nasal mucosa – not inflamed aaCVS exam CVS - Pulse 80 reg, BP / Peripheral pulses normal. JVP not elevated. Apex beat not displaced HS normal, no peripheral oedema aaDepression Screen. In the last month: Lost interest/pleasure in things you usually enjoy? Felt sad, low, down, depressed or hopeless? If yes to either then use SIGECAPS - 5 for most days for at least 2 weeks for diagnosis of MDD (must include depressed mood or loss of interest) Sleep disturbance? Interest loss (reduced pleasure)? Guilt? Energy loss/fatigue? Concentration problems? Appetite change? Psychomotor changes? Suicidal thoughts? Consider using Patient Depression Questionnaire-9 see Intranet aaENT exam ENT - Ears - NAD, Throat - NAD, Nasal mucosa - not inflamed aaFull exam OE Looks well. No An/Cy/J/Nodes/Clubbing CVS – Pulse 80 reg, BP / HS normal, no ankle oedema, JVP not elevated. Apex beat not displaced RS – RR No recession, Trachea central, PN Res all areas, BS vesic + nil Abdo – soft, non-tender, no masses, no LKKS, Hos intact BS normal NS – Cns II-XII intact. PERL, Discs flat. UL – Tone, Power, Co-ord – normal. Sensation grossly normal. LL - Tone, Power, Co-ord – normal. Sensation grossly normal. Plantars downgoing ENT – Ears – NAD, Throat – NAD, Nasal mucosa – not inflamed aaHayfever Allergic rhinitis Flonase 1 puff each side bid x1 bottle Sodium cromoglycate eye drops qid 1 bottle Cetirizine 10mg od x30 Use regularly – advised re avoidance . Rv sos aaNeuro exam NS - CNs II-XII intact. PERL, Discs flat. UL - Tone, Power, Co-ord - normal. Sensation grossly normal. LL - Tone, Power, Co-ord - normal. Sensation grossly normal. Plantars downgoing. aaPSA screen Asking re PSA screening. No FH of prostate Ca. No prostatic symptoms. Advised that jury is still out on this. Can have test but made aware of false positives and negatives discussed with pros and cons. Will think about it/wants done/doesn't want aaResp exam RS - RR No recession, Trachea central, PN Res all areas, BS vesic + nil aaStrep throat Sore throat. Red, pus. Nodes++ Fever symptoms. Temp No quinsy. PenV 600 bid 10d, fluids, tylenol - Rv sos. Swabbed
