Blank Clinical Log for My Evaluations (1) PDF

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Summary

This is a log that can be used for logging practicum...

Description

Date:

Physical Exam:

Client complexity:

Initials:

Cardiac Constitutional/VS Dermatology Development Endocrine GI Genitalia GU Gynecology HEENT Lymphatic/Immunological Medical Reconciliation Musculoskeletal Neurological OB Other Pain Assessment Psych Respiratory

Comfort assessment Episodic (acute condition) Multiple/chronic/controlled Multiple/chronic/uncontrolled Single/chronic/controlled Single/chronic/uncontrolled Wellness screening/HPDP Immunizations

Type of visit:

Procedures performed:

Medications:

Acute (episodic) Chronic illness management DOT physical Family planning visit Health maintenance Immunizations IUD placement/check Menopause counseling New OB visit Other Postpartum visit Pre-employment physical Prenatal visit School physical STD/STI visit Well child exam Well woman exam

Refers only to the procedures that YOU did. Some of the options you. Examples: You do a blood draw, cautery, Liquid nitrogen, excision biopsy, wart destruction, etc.

Acne Tx Analgesic (narcotic/non-narcotic) Anti-anxiety Anti-arrhythmia Anti-infective/inflammatory Anti-hypertensive Anti-viral Chemotherapy Coagulants Contraceptives Depressants Diuretics Dopamine agonist/antagonist GI agents Glucocorticoids Hormones Hypoglycemic agents Insulin/other diabetic Lipid agents Platelet aggregation Psychotropic Respiratory Serotonin Vasoconstrictors Vasodilators Vitamins/herbs

Age: Gender:

F/M/T

Ethnicity:

Chief Complaint:

S:

N: A:

P:

P: S: Allergies:

LAB ORDERS:

Therapeutics: Addiction screening Age/Gender specific screening Aromatherapy Behavioral modification Behavioral skills management Care coordination Caregiver support Case management Cognitive Behavioral Therapy Complementary therapy Consultation feedback Crisis intervention Diagnostic testing understanding Dialectical behavioral therapy Discharge instructions

Disease specific screening Disease specific teaching Disease understanding Emotional support End-of-life decisions Exercise management Exercise/activity Family counseling Family planning Fluid management Gender health promotion Grief counseling Growth and development Immunizations Infection prevention Initiate medication Initiate/modify treatments

Referrals: Allergy Audiology Cardiology Dermatology ER Endocrinology Family Practice Gastroenterology Geriatric Medicine Hand surgeon Hematology Immunology Infectious disease Neo/Peri Medicine Nephrology Neurologic Surgery Neurology Nutritionist OB Oncology Ophthalmology

Minutes:

Injury prevention Insight therapy Interdisciplinary meetings Medication management Meditation Modify medication Music therapy Nutrition counseling Nutrition therapeutics Other Other self-care management Pain management Parenting guidance Play therapy Psychoeducation Referral to community resource Referral to health professional REIKI

Relapse counseling Relaxation Relaxation/imagery Reminiscence therapy Safety/environment management Self-responsibility facilitation Spiritual support Staff education STD prevention Stress management Suicide prevention Symptom management Technology management Therapeutic touch Tobacco cessation Violence prevention Weight management Wound care

CPT visit code: Orthopedics Otolaryngology Pain Management Pediatrics Plastic Surgery Podiatry Psychiatry Psychology Pulmonary Rheumatology Sleep medicine Sports medicine Surgeongeneral Thoracic surgeon Transplant Urology Vascular Surgery

OFFICE VISITS: New Patient: 99202-99205 Est Patient: 99212-99215 WELLNESS PHYSICALS: New Patient Preventative Visit: 99381-99387 Est Patient Preventative Medicine Visit: 99391-99397 Physicals should have a wellness visit ICD-10 code also (Z00.00, Z00.01, etc) Diagnoses/ICD-10: (Only DX addressed this visit)

Follow up:...