Downtime Form
IHS PHYSICIAN & CLINIC SERVICES TOUCHWORKS ENCOUNTER FORM
VITALS TPR WT KG LBS HT CM IN BP
TIME___________ PAIN SCALE _______________________________ INTERVENTION(S): SCORE / 10 ALLERGIES/REACTIONS
CHIEF COMPLAINT
CURRENT MEDICATIONS
NURSE SIGNATURE DATE Active, PSH, Family Hx, Personal Hx
HISTORY OF PRESENT ILLNESS
Tobacco Use/Exposure Y/N
Alcohol Use: Y/N
CHIEF COMPLAINT
REVIEW OF SYSTEMS EXAMINATION NORMAL AB-NORMAL SIGNIFICANT FINDINGS
FEVER - HEAD
EYES - EYES ENT/MOUTH - EARS CARDIOVASCULAR - NOSE RESPIRATORY - THROAT GI - MOUTH/TEETH GU LMP - NECK MUSCULOSKELETAL - LYMPH SKIN - LUNGS NEUROLOGICAL - HEART PSYCH/DEVELOPMENT - GI ENDOCRINE - BACK HEMATOLOGY - GENITALIA ALLERGY/IMMUNO - RECTAL MUSCULOSKELETAL SKIN NEURO/PSYCH ASSESSMENT:
RETURN VISIT:
F/U VISIT: ___________________ NEXT HME: _________________
PLAN/DISCUSSION:
ORDERS:
IMMUNIZATIONS GIVEN:
Pediarix / Dtap / IPV / Hib / Hep B / PCV / MMR / MMRV / Varicella / Influenza / Rota Teq / Hep A/Pneumovax HPV / Tdap / Menactra / Td
NEW MEDICATIONS/ MEDICATION REFILL:
PROVIDER SIGNATURE RESIDENT SIGNATURE