Progress Note
The use of this document is entirely voluntary/optional.
Patient:
First Name: ______________________ Last Name: _________________________Date of Birth: __/__/____
Name of physician/Medicare allowed non-physician practitioner (NPP)* who performed the encounter:
____________________________
Date of encounter: __/__/____
Is this encounter with the patient related to the primary reason the patient requires Home Health Services?
Yes No
(Please check one :)
Subjective:
Patient’s Chief Complaint:
________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________
Check if not completing a history and physical during the encounter.
[In the e-clinical template, the “History of Present Illness” and “Review of Systems” will not appear if
checked.]
History of Present Illness:
Pain Assessment:
______________________________
Location:
radiating other: _____________________________________________________________________________________
aching
burning
Quality:
1
2
3
4
5
6
7
8
9
10
Severity:
1day 2days 3days other: _______________________________________________________________________________________________
Duration:
time of day? _________________________________________________________________________________________
constant intermittent
Timing:
other: ______________________________________________________________________________
Context:
at work
rest
sleep
better/worse
other: ________________________________________________________________________
Moderating Factors:
heat
ice
better/worse with
______________________________________________________________________________________________________________
Associated Signs/Symptoms:
Medical History: ____________________________________________________________________________________
__________________________________________________________________________________________________
___________________________________________________________________
Surgical Procedure(s) History:
__________________________________________________________________________________________
Allergies:___________________________________________________________________________________________
Current Medications: _________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Review of Systems:
visual changes other____________________________________________________________________________________________________________________
Eyes:
sore throat rhinitis other____________________________________________________________________________________________________________
ENT:
chest pain other ______________________________________________________________________________________________________________________
CV:
Resp:
SOB cough hemoptysis other_____________________________________________________________________________________________________
nausea vomiting diarrhea abd pain other_______________________________________________________________________________________
Gastro:
GenitoUr:
dysuria frequency
urgency other__________________________________________________________________________________________
other ____________________________________________________________________________________________________
back pain joint pain
Musc/Skel:
rash itching other _________________________________________________________________________________________________________
Skin/Breast:
numbness dizziness other __________________________________________________________________________________________________
Neurologic:
other _________________________________________________________________________________________________________
anxiety depression
Psych:
hypoglycemia thirsty other ___________________________________________________________________________________________________
Endocrine:
anemia bleeding other ____________________________________________________________________________________________________
Hem/Lymph:
deficiency other __________________________________________________________________________________________________________
Allergy/Immune: