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Common dot phrases

Page history last edited by kmccalmont@salud.unm.edu 1 year, 11 months ago

Return to Southeast Heights Main Page

 

Link to Word Document with Pediatric Note Templates:    Peds_Clinic_Templates.docx   

 

 

Prenatal Note HPI

Ms. _ is a _ yo G_ P_ at _ with an EDD of _ by _ who presents for prenatal care.

Interim history:

Contractions:
Leaking of fluid:
Vaginal bleeding:
Fetal movement:
Dysuria/abnormal discharge:

Problems this Pregnancy:
1._

PrenatalCare:
The patient is seen at the Southeast Heights Clinic by _.
Initiated prenatal care at _ weeks.
Number of visits: _
Pre-pregnancy weight: _, Recommended weight gain in pregnancy: _
First trimester BP: _.
Tdap vaccination (week 27-36): _
Influenza vaccination: _
TOLAC: _ Op Note Reviewed: _

Plans for Current Pregnancy:
Genetic screen desired?:_
FOB/support person: _
Preferred provider for delivery: _
Labor preferences/Pain control in labor: _
Infant feeding preference: _
Custody issues: _ 
Circumcision preference: _ 
Infant medical care plans: _
Postpartum contraception: _
Would accept blood transfusion in emergency?: _ 

OB History:
G1 _

Gynecological History:
LMP: _ Certain?: _
Abnormal paps?: _
Last pap?: _
STIs?: _


PMHx:
_

PSHx:
_

Social History:
Desired pregnancy?: _
Partner: _
Living situation: _
Employment: _
Education: _
IPV or other abuse/neglect/assault? _
Eating disorder?: _
Tobacco use disorder?: _ 
Alcohol/other substances?: 4 P's: 
Have you used alcohol or substances in the current Pregnancy?: _ 
Have you had a problem with drugs or alcohol in the Past?: _ 
Does your Partner have a problem with drugs or alcohol?: _ 
Do you consider one of your Parents to be an addict or alcoholic?: _

Family History:
Family members with congenital anomalies, deafness, cognitive disability?: _
Family members with hypercoagulable disorders or thromboembolic events? _
Mother: _
Father: _
Siblings: _
Children: _
Others: _
Partner’s pertinent medical history: _

Prenatal Labs:
Blood type: _
AST: _
Hct: _
GC/CT: _
Urine culture: _
Tpab: _
HepB SAg: _
HIV: _
Rub: _
Varicella: _
Genetic screening: _
HgbA1c: _
Pap: _

24-28 week labs:
Repeat Hct: _
1 hour GTT: _

35-37 week labs:
GBS: _

Ultrasounds:
1. _

 

 

Controlled Substances

UDM: Has been done within last 6 months. Last done _; Significant results: _

NM PMP: Reviewed _. Appropriate

Last time medication was taken by patient: _

 

Prescription: _

Frequency of prescription: _

Initial date of current prescription: _

Date opioid first prescribed: _

MME: _ (For MME/day >90, justification for ongoing use: _).

Condition requiring chronic opioid: _

Previous work-up of this condition: _

Other modalities used to treat this condition: _

There has been clinically meaningful improvement in pain and/or function with this use of this chronic opioid: _

Side effects/complications reviewed/discussed with patient.

High Risk Conditions:

_ None

_ Previous substance use disorder

_ Previous overdose on opiates

_ Aberrant behavior

_ Concurrent benzodiazepine use

_ Concurrent pulmonary disease, sleep-disordered breathing, renal impairment or hepatic impairment

_ Naloxone discussed _ prescribed.

 

Date last contract signed: _

Recommendations for lost Rx, missed appointment, etc.: _ 

 

 

Buprenorphine

Buprenorphine dose: _

Frequency of prescription: _

Initial date of current prescription: _

Recommendations for lost Rx, missed appointment, etc.: _

Buprenorphine Start date: _

 

UDM: Has been done within last 6 months. Last done _; Significant results: _

Urine buprenorphine metabolites: _

NM PMP: Reviewed _. Appropriate (Checked at minimum Q 3 months)

Last relapse: _

Naloxone Rx and/or education: _

Counseling: _

 

Date last contract signed: _

 

 

FOCUS adult HPI

This is a __ yo patient with history of (hepatitis C, opiate use disorder, etc) who presents for follow up with the FOCUS clinic.

 

1. Opiate use disorder, in remission, on MAT with Suboxone.  

- Current dose (desire to go up or down)

- Symptoms (note patient’s rating for each: craving, withdrawal, anxiety, depression, difficulty 

sleeping)

- Recent relapses reported

- Last UDM and today’s POC UDM

- Review of PMP (when last Rx was filled and any other controlled substances filled)

- Engagement with counseling

 

2. Psychiatric diagnoses (if relevant).

- Current medications and symptoms.

 

3. Hepatitis C status.

- Hep C antibody: (reactive or nonreactive and date)

- If reactive antibody, do Hep C PCR: 

- If PCR +, needs CBC/LFTs and abdominal US:

- If evidence of cirrhosis on US, needs US every 6 months, MELD score (Chem7/LFTs/INR), EGD to screen for varices 

-  Assess interest in Hep C treatment:

 

4.  Other health conditions (hypertension, hypothyroidism, musculoskeletal concerns, etc)

 

5. Contraception.

 

6. HCM:

- Last pap:  (and when next is due)

- Immunizations:

- Lipid panel (if > 35), mammogram/colon cancer screening (if > 50)

 

 

Referral to Dr. Caro

 

PCP: _ 

Reason for Behavioral Health Referral:   _Individual/Couples counseling      _ Stress management           _ Pain Management          _ Diagnostic evaluation         _ Behavioral change           

  _ Insomnia         _ Other: 

Clinical question to be addressed/answered: _ 

What does the client hope to achieve through counseling?: _ 

Does the patient understand why they are being referred? _ 

Level of motivation for change/therapy: _ 

Urgency:              _ Urgent (discuss directly with Dr Caro)                                 _ Routine 

Patient's preferred language: _ English, _ Spanish, _ Other: _

 

Reminders:

- Dr Caro is available for warm hand-offs, will pause current session to meet with new patients

- Send above referral in PCO message to Betty A Vigil and Blanca Caro for scheduling

- Be sure that patient is wanting to have referral to Dr Caro (if not, this should be specified on referral)

- Dr. Caro works with clients presenting with a broad range of problems including sexual and gender identity, diabetes management, and sexual dysfunction (among others)

 

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