H&P Checklist (Inpatient) Evaluator: Subject: Program:

Transcription

1 H&P Checklist (Inpatient) Evaluator: Subject: Program: PROFESSIONALISM 1) Introduces self/role and preceptor Did 2) Verbal and non-verbal language demonstrates respect for patient & family. Did 3) Respects patient modesty in child and adolescent Did 4) Washes hands before examining patient Did Communication Skills 5) Uses language that is understood by patient/parent Did 6) Approach to patient is compatible with developmental level Did 7) Includes patient in interview to whatever extent possible Did 8) Uses open-ended questions to elicit information Did (1 of 8) [2/25/ :31:22 AM]

2 9) Gathers information in a logical sequence Did 10) Clarifies responses that are unclear Did History 11) Elicits a chief complaint History: HPI 12) Thorough review of all events leading up to hospitalization 13) Includes pertinent positives and negatives 14) Includes pertinent information from past history, family history, social history and ROS that is relevant to HPI History: Past History 15) Birth history (prenatal complications, gestational age, type of delivery, birth weight, neonatal complications) 16) Illnesses/Hospitalizations (2 of 8) [2/25/ :31:22 AM]

3 17) Operations 18) Allergies (food and drugs) 19) Immunizations 20) Medications 21) Diet 22) Developmental Milestones/School Performance 23) Primary Physician 24) Pertinent elements of family history (3 of 8) [2/25/ :31:22 AM]

4 25) Pertinent elements of social history (primary caretaker, members of household, occupations, social support structure, HEADSS (home, education, activities, drugs, sex and suicide) for adolescents) 26) All elements of the review of systems 27) Observes general appearance for toxicity, distress, irritability, growth/ development 28) Head (fontanelles, shape, evidence of trauma) 29) Eyes (pupils, EOMs, red reflex, discs in older child) 30) Ears (canals and tympanic membranes) 31) Nose (cervical, axillary, inguinal) 32) Mouth/throat (mucous membranes, pharynx) (4 of 8) [2/25/ :31:22 AM]

5 33) Neck (thyroid, trachea, movement) 34) Nodes (cervical, axillary, inguinal) 35) Cardiac (rate, rhythm, first & second heart sounds, murmurs, gallops, rubs, symmetry of pulses, capillary refill) 36) Chest (symmetry, breasts, spine) 37) Lungs (respiratory rate, distress, retractions, air entry, wheezing, rales, rhonchi) 38) Abdomen (inspection, bowel sounds, palpation) 39) Genitourinary (inspection, palpation of testes) 40) Extremities (clubbing, cyanosis, edema, symmetry, hips in infants) (5 of 8) [2/25/ :31:22 AM]

6 41) Neurologic (LOC, cranial nerves, sensory, motor, cerebellar, DTR's, gait) 42) Skin (rashes, lesions) OVERALL EVALUATION 43) Professionalism Below expected level of At expected level of Above expected level of 44) Communication Below expected level of At expected level of Above expected level of 45) History Below expected level of At expected level of Above expected level of 46) Physical Examination Below expected level of At expected level of Above expected level of QUESTIONS IN THE NEXT SESSION ARE FOR EVALUATION OF WRITTEN COMMUNICATION ADMISSION NOTE 47) SIGNED YES NO 48) DATED YES NO 49) TIMED YES NO (6 of 8) [2/25/ :31:22 AM]

7 50) DOCUMENTS ATTENDING'S NAME YES NO 51) PATIENT'S IDENTIFYING INFORMATION PROVIDED YES NO 52) CHIEF COMPLAINT IN PATIENT/PARENT WORDS YES NO 53) HPI COMPLETE AND ACCURATE YES NO 54) PAST MEDICAL HISTORY - ALLERGIES YES NO 55) PAST MEDICAL HISTORY - MEDICATIONS YES NO 56) PAST MEDICAL HISTORY - NUTRITIONAL YES NO 57) PAST MEDICAL HISTORY - SURGICAL HISTORY YES NO 58) PAST MEDICAL HISTORY - GESTATIONAL/ PERIPARTUM YES NO 59) PAST MEDICAL HISTORY - DEVELOPMENTAL YES NO 60) FAMILY HISTORY YES NO (7 of 8) [2/25/ :31:22 AM]

8 61) SOCIAL HISTORY YES NO 62) REVIEW OF SYSTEMS YES NO 63) PHYSICAL EXAM ACCURATELY DOCUMENTED YES NO Overall Comments: Remaining Characters: 5000 Return to Questionnaire New Innovations, Inc (8 of 8) [2/25/ :31:22 AM]