Progress Note Draft Template (Page 2 of 4) in pdf

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:

Progress Note Draft Template Page 2

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