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Tell A Nurse Patient Encounter Record

TRIAGE ENCOUNTER FORM

ID:

Name	PCP Name	On Call Physician Name
PRACTICE, GUY	, MD	, MD

Date of Birth	Age	Gender	SSN	Phone
1/1/45	55	Male	555-55-5555	(541)222-2222

Address
1000 CARDIAC LANE, MEDFORD, OR 97504

CALL:

Encounter Time
2000/03/13 20:37:32.98

Nurse ID
7

Caller

Call Charge
No Charge

SUBJECTIVE:

Presenting Problem
"I think I have a Sinus Infection"

Allergies
NKDA

Medication
DIGOXIN/ASA

Social History
SMOKES 1 PK/DAY, DRINKS 1 BEER/DAY, NO STREET DRUGS

Health History
HEART ATTACK (1998)
TRIPLE BYPASS (1998)

Review of Pertinent Systems
c/o OF SINUS HEADACHE, FULLNESS IN HEAD, THICK GREEN MUCUS, NO TEMP, NO COUGH

ASSESSMENT/PLAN:

TRIAGE DISPOSTION
Follow-up interval: 2-3 Days
PERTINENT POSITIVE: a throbbing pain above or below one or both eyes that intensifies when you bend forward or cough
PERTINENT POSITIVE: a thick or colored nasal discharge
Looking for Sinusitis....
HOME CARE FOR SINUSITIS: Blow nose regularly and gently / use warm compresses to face / ibuprofen for pain / steam vaporizer or cool mist / drink plenty of fluids / take decongestant only after doctor's approval.

Comments
NURSE NOTE: CALL PCP WITHIN 2-3 DAYS IF SYMPTOMS CONTINUE

Encounter ID
1,104

Home Benefits and Advantages The Service

DISCLAIMER: Patient (or caller) says instructions understood and can repeat them and says that all questions are answered. Patient or caller agrees to seek further medical attention if not content with patient condition, if patient changes for the worse, or does not improve within a reasonable time.