NURS 550 - Focused Note Template

Necessary Components for the Subjective information: Date of encounter: Patient Name or initials: Informant: (Source of history/Reliability) Chief Complaint (CC): History of present illness (HPI): include 7 attributes of principle symptoms (OLDCART) Allergies: (Medication, food, over the counter meds, environmental, latex) Medications: (dose, frequency, indication) ie. Lisinopril 10 mg daily HTN (prescription, over-the-counter, vitamins/herbal supplements) Smoking/Recreational drugs: Drink Alcohol: Past History: childhood illnesses, medical problems (state top diseases), surgical history, trauma, OB/GYN, psychiatric had general anesthesia or family history of anesthesia issues? Year born, full term, preterm weeks, vag or c/s, sex, weight, complications. Gyn history-first menstrual cycle, cycle length, flow days? Light-med or heavy flow. Any major Gyn problem, sex active, type of birth control. Family History: Review a family health history of parents, grandparents, siblings, and children. Include: 1) current age or age of death, 2) current health status with PMH or cause of death. Any sudden cardiac death on either side of the family? Personal and Social History: Live alone? With someone, insurance? _______________________________ You can narrow down your personal and social history based on the complaint. For instance in a focused note, I usually do not document Health Promotion/Maintenance Activities: screenings, immunizations, sleep, and exercise. I do however usually narrow down the personal and social history to tobacco use, alcohol use, and drug use! Health Promotion/Maintenance Activities: screenings, immunizations, sleep, exercise Tobacco Use: (never, quit, or current; amount) [Type – ie. cigarette, e-cigarette, smokeless tobacco, etc.) Alcohol and Drug use: (never, quit, current; type) Pertinent Review of systems (ROS): (See Pages 12-13 in Bates’ for the information to include in this section): You do not need to complete a full head to toe ROS. Based on the chief complaint, you will determine what systems are likely related to the chief complaint of chest pain. For example, if I have a patient who presents with syncope – I would consider all of the body systems that could cause the syncope and I would complete a ROS on those body systems. In the example of syncope, I would do a neurological ROS, cardiovascular ROS, respiratory ROS, and possibly endocrine ROS and peripheral vascular ROS. That is it! You can delete the systems from the template that you do not feel are necessary. Make sure you list pertinent positives and negatives (see page 12-14 of your Bates’ text). If positive, expand upon with the 7 attributes in the HPI. Always include “General” in your ROS