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Date

Asthma Clinic Followup Chief Complaint


Indicates or Quality
2007 Physician Reason For Initiative
Reporting Visit (PQRI) Physician Quality Measures

Time
ROS WNL See HPI HPI Asthma Symptom Frequency  64
Constitutional  
Eyes    1+ days per week
ENT/mouth   OR 1+ nights per month
Resp    2+ days per week
CV   OR 2+ nights per month
GI    Daily
GU OR 2+ nights per week
 
Musc  Antibiotic use  Oral steroid use  Continual
  OR Frequent
Skin/breasts  ER visit for asthma  Hospital admission for asthma
 
 Discharge Medications from hospital/ER visit reconciled 46
Neuro   Physical Exam Checked box indicates findings are within normal limits
General  Alert Vital signs Temp Pulse BP RR Sats
Endo  
Heme/lymph   ENT  Mucosa  Dentition  Oropharynx Mallampati  I  II  III  IV
Allergy/Immun   Neck  Palpation  Thyroid  No JVD
Psych   Resp  Auscultation  Percussion Respiratory effort Palpation Chest wall
History No changes See HPI CV  Clear S1 S2  No murmur  No gallop No rub  Peripheral pulses  No peripheral edema
Allergies   GI No palpable masses  No hepatosplenomegaly  No hepatojugular reflux
PMSH   Lymph  No lymphadenopathy
Social   Musc Tone  Gait
Family   Extrem  Digits without clubbing or cyanosis
Asthma Severity Skin  No rashes, ecchymoses, nodules, ulcers
Mild Intermittent Neuro  Oriented (person, time, place) Affect
Mild persistent Impression and Plan Tests to be ordered
Moderate persistent Bronchoscopy
Severe persistent Pulmonary Function Testing
Asthma Therapy Sleep study
Current New CXR
Short-acting beta   Chest CT with contrast
agonist
“Rescue Agent” Echocardiogram with
Bubble study PA pressures
Inhaled steroid 53  
Long-acting beta
Cardiopulmonary Stress Test
 
agonist Pulmonary Rehabilitation
Theophylline   Pneumococcal vaccine
Omalizumab   Influenza vaccine
Oral steroids   PPD Testing
Antibiotics Allergy skin testing
 
Leukotriene Labs
 
inhibitor Instruction & Education
Oral antihistamine   Asthma action plan
Intranasal steroids   Smoking cessation
Intranasal   Peak flow meter use
antihistamine Inhaler use
Smoking  
cessation aids Importance of vaccinations
 Patient has completed advanced health care directives 47 Medication side effects
Follow Up HCPOA is
Signature Advanced care directives explained
©MB and RR 2006, 2007  Form offered to patient
Data Reviewed  ER Notes  Old Chart EMS Note ECG Nursing Notes & Vitals log  Labs  X Rays MRI
US CT
Care Coordinated WithER MD HCPOA Primary Care MD Case Management Social Worker Pharmacy