Home Medical Chart

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Readymom
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Joined: Tue Nov 21, 2006 2:42 pm

Home Medical Chart

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Necessary for tracking your patient cared for at home, will be a Patient's Medical Sheet. Designed by Fla_Med, of Avian Flu Diary, he originally posted this chart at Plan For Pandemic. He stated that it is 'easier to use, allows for multiple ( 8 ) entries on one page, and is easier to spot trends at a glance. .His original post is no longer available. * Link Unavailable. This site is no longer active and available to view on line. But the info was good and we wanted to keep sharing it!

WHAT NEEDS TO BE ON THE CHART?

I’ve divided my chart into two sections. The top section is basic patient information. The bottom section is for charting the patients condition over time.

TOP SECTION

Obviously, the patient’s name, age, gender and approximate weight. Sure, you know your kid’s name, but if your child is transferred to another caregiver, having this identifying information at the top of the chart will be important. Additionally, an address or contact information, along with the DATE should be noted. Some way of noting the page number is also important, as most patients will require several pages of notes.

Next come the Patients Symptoms and Complaints. Symptoms are things like Fever, Nausea, vomiting, muscle aches, or shortness of breath. These are things the patient tells you about how they are feeling.

Following that I have room for Clinical Examination. Skin Color, Texture, heart and lung sounds, states of consciousness, etc. These are the things you observe about the patient.

Allergies, and a list of current Meds are next. Allergies are to meds, or severe food allergies. It would be important to note a penicillin allergy, or an allergy to Corn. If the patient is on meds, they can be listed.

Medical History (Hx) and Initial Diagnosis are next. If the patient is an asthmatic, or has diabetes, or a heart condition, it would be important to note that. While you are not a doctor, you will have to make an assumption of what is wrong with the patient. Just like doctors, you may need to put down more than one thing. In the ER, doctors routinely list 2 or 3 possible diagnoses. FLU is fine. Doesn’t have to be fancy. If you don’t know, the standard in most Emergency rooms is to write down: GOK, which stands for God Only Knows.

And Lastly, a Treatment Plan. This may be as simple as Push ORS, Tylenol every 6 hours. Monitor Fluid In/Out.

BOTTOM SECTION

Here I’ve placed 8 charting notes to be filled in. It is customary to check the patient’s vital signs and notate them on a regular basis. Every 2 hours, or 3 hours or 6 hours. How often depends on how ill the patient is. With 8 slots, one page will handle 24 hours worth of charting every 3 hours.

Each slot has the following line items:

Time Date Vitals Observations

___:__ __/___ BP ___/___ P ___ R___ T____ ______________________________

Treatment:_________________________Fluid In: ______cc Out: ______cc Init ___


These items are pretty much self-explanatory, but in the interest of verbosity, I’ll go into them further.

Time is easiest if entered in Military time, but only if you are comfortable with the format. Otherwise append an A or P after the time to indicate morning or evening.

Date is Month/Day format.

B/P is blood pressure. If you don’t have a blood pressure cuff, consider getting one.

P is pulse rate.

R is respiration rate.

T is temperature.

Observations can be as simple as improving, worsening, fever broke, or dark urine. Just a few descriptive words about how the patient is doing.

Treatment should indicate what you’ve done for the patient since the last notation. Ie. 1 quart of ORS, or Tylenol 1000mg @ (time).

FLUID IN/OUT charts the amount of fluid ingested (or administered IV), and the amount of urine voided since the last chart notation. Keeping track of this is very important in patients. Normally, we note these in cc’s, but you can use ounces, or cups, or whatever. While a patient should take in more fluid than they put out, a wide discrepancy in the two can indicate kidney failure.

And lastly, INIT: a place for the person doing the charting to place their initials.

MEDICAL ABBREVIATIONS

Abbreviation Meaning Latin Term

ac before meals ante cibum
bid twice a day bis in die
cap capsule capsula
gt drop gutta
hs at bedtime hora somni
od right eye oculus dexter
os left eye oculus sinister
po by mouth per os
pc after meals post cibum
pil pill pilula
prn as needed pro re nata
q2h every 2 hours quaque 2 hora
qd every day quaque die
qh every hour quaque hora
qid 4 times a day quater in die
tab tablet tabella
tid 3 times a day ter in die

Additionally, SOB is not a comment upon the parentage of a patient, it stands for Short of Breath. IOU is often used for Incontinent of Urine, and IOF for Incontinent of Feces.

While formatting using PFP's text editor leaves something to be desired, an approximation of what my chart looks like follows:


PATIENT MEDICAL SHEET

Name _______________________ Age _______ Gender ____ Weight ______

Address/Contact Info _______________________________ Date _____/____/_______

Symptoms/Complaints ____________________________________________________

Clinical Examination ______________________________________________________

Allergies: _____________ Meds : ___________________________________________

Medical Hx _____________________________ Initial Diagnosis __________________

Treatment Plan __________________________________________________________

==============================================================

Time Date Vitals Observations


___:__ __/___ BP ___/___ P ___ R___ T____ ______________________________

Treatment:__________________________Fluid In: ______cc Out: ______cc Init ___

___:__ __/___ BP ___/___ P ___ R___ T____ ______________________________

Treatment:__________________________Fluid In: ______cc Out: ______cc Init ___

___:__ __/___ BP ___/___ P ___ R___ T____ ______________________________

Treatment:__________________________Fluid In: ______cc Out: ______cc Init ___

___:__ __/___ BP ___/___ P ___ R___ T____ ______________________________

Treatment:__________________________Fluid In: ______cc Out: ______cc Init ___

___:__ __/___ BP ___/___ P ___ R___ T____ ______________________________

Treatment:__________________________Fluid In: ______cc Out: ______cc Init ___

___:__ __/___ BP ___/___ P ___ R___ T____ ______________________________

Treatment:__________________________Fluid In: ______cc Out: ______cc Init ___

___:__ __/___ BP ___/___ P ___ R___ T____ ______________________________

Treatment:__________________________Fluid In: ______cc Out: ______cc Init ___

___:__ __/___ BP ___/___ P ___ R___ T____ ______________________________

Treatment:__________________________Fluid In: ______cc Out: ______cc Init ___



While all of this may seem like extra work, I can assure you, it will pay many dividends in the end. Charting helps avoid costly mistakes, and can truly be one of the most important steps you can take when caring for someone who is ill.
Readymom
Site Admin
Posts: 4658
Joined: Tue Nov 21, 2006 2:42 pm

Home Care Patient Chart

Post by Readymom »

Health Care Record Sheet-Free Download

Adult health assessment FORM
by Cynthia J. Koelker, MD

http://armageddonmedicine.net/wp-content/uploads/2011/04/Adult-health-assessment-FORM.pdf

If no physician is available, and you become responsible for the health care of your family or group, what should you know about a patient?

No doubt you’ve completed health assessment forms yourself upon visiting a medical office, emergency room, or your friendly family dentist. What was it they asked? And why did they want to know?

Medical students are taught to ask the correct questions before learning the correct answers. As potential future health care providers, you, too, might want to know the important aspects of a patient’s history.

Today’s free download will help guide you in your information gathering and record keeping. Below you can download a modified copy of the Adult Health Assessment Form I used in my own office. On a single page you’ll have before you the highlights of a patient’s history. Enjoy!

Adult health assessment FORM Click on LINK, above ...
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