Family Oriented Medical Record
Family Oriented Medical Record
Family Oriented Medical Record
CHART
[Adopted from PAFP Quality, standards and Competencies Manual
2008 ]
NAME OF RESIDENT-IN-CHARGE:
PROBLEM(S) / ASSESSMENT
DIAGNOSTICS
THERAPEUTICS
Review of Systems:
HEENT
blurring of vision
ringing of ears
hearing loss
eye redness
others, list _________
______________________
Respiratory
difficulty of breathing
wheezes
cough
hemoptysis
others, list _________
______________________
Cardiovascular
chest pain
orthopnea
paroxysmal nocturnal dyspnea
easy fatigability
edema
others, list _________
Past/Medical History:
Illnesses, please list:
_______________________________
_______________________________
Hospitalizations, please list
_______________________________
_______________________________
Allergies, please list
______________________________
_______________________________
Immunization History:
_____________________________
_____________________________
_____________________________
Gastrointestinal
Neurologic
abdominal pain
weakness
jaundice
numbness/paresthesia
nausea/vomiting
headache
diarrhea
dizziness
melena/hematochezia
gait disturbances
others, list _________
others, list _________
Genitourinary
Musculoskeletal
frequency/intermittency
muscle pain
hematuria
bone pain
passage of sandy material
sprain/strain
dribbling
joint pains
hesitancy
others, list _________
others, list _________
Metabolic/Endocrine
Skin/Integument
polyuria
pallor
polyphagia
cyanosis
polydipsia
rashes
tremors
mottling
unexplained weight loss/gain others, list ____
others, list _________
Personal/Social History
Smoker
yes
no
pack years? ___________
quit, when? _______
Alcohol Beverage Drinker?
yes
no
Frequency? ____________
Duration? ______________
Type of drink? __________
Drugs or other substance used/abused?
________________________________
Obstetric/Menstrual History:
G ___ P ____ ( , , , )
age of menarche?
age of menopause?
Age at first coitus?
Operations?
Birth/Maternal History:
born _________ via ________________
to a G ___ P ___, ____-year old mother
birth complications? ________________
Developmental Milestones:
_________________________
_________________________
_________________________
HR=
RR=
Temperature=
Weight=
Height=
BMI*=
General Survey:
no significant findings
noted the following:_____________________________________________________________________
Skin/Integument:
no significant findings
noted the following:_____________________________________________________________________
HEENT:
no significant findings
noted the following:_____________________________________________________________________
Respiratory:
no significant findings
noted the following:_____________________________________________________________________
Cardiovascular:
no significant findings
noted the following:_____________________________________________________________________
Gastrointestinal:
no significant findings
noted the following:_____________________________________________________________________
Genitourinary:
no significant findings
noted the following:_____________________________________________________________________
IE:
no significant findings
noted the following:_____________________________________________________________________
DRE:
no significant findings
noted the following:_____________________________________________________________________
Neurologic:
no significant findings
noted the following:_____________________________________________________________________
Plan:
Diagnostics:
Follow-up:
Therapeutics:
Referral:
IBW**=
B. FAMILY MAP
C. ECOMAP
D. FAMILY APGAR
Areas of the APGAR
Family
Member 1
Family
Member 2
Over-all assessment
Score: 0-hardly ever (halos hindi)
1-some of the time (minsan)
2-almost always (palagi)
Interpretation: 0-3 severly dysfunctional, 4-6 moderately dysfunctional, 7-10 highly functional
Average
Age/Sex: _______________
*include symptom progression or improvement and medications on board and lab results for chronic illnesses
**put symptoms and interventions done for new complaints
C:
O:
no significant findings
noted the following:_____________________________________________________________________
HEENT:
no significant findings
noted the following:_____________________________________________________________________
Respiratory:
no significant findings
noted the following:_____________________________________________________________________
Cardiovascular:
no significant findings
noted the following:_____________________________________________________________________
Gastrointestinal:
no significant findings
noted the following:_____________________________________________________________________
Genitourinary:
no significant findings
noted the following:_____________________________________________________________________
IE:
no significant findings
noted the following:_____________________________________________________________________
DRE:
no significant findings
noted the following:_____________________________________________________________________
Neurologic:
no significant findings
noted the following:_____________________________________________________________________
A:
P:
Screening Tests
Immunizations
10
Lifestyle
Changes
Counseling Needs