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