e-Form

ent department
Patient Assesment

Patient's Name : Muhammad Ali

MR#: 12065354

Gender: Male

Age: 45

Nationality: Saudi

January

2021

Please Note :

If the answer is positive make tick

If the answer is negative leave it blank

If the answer is not accepted

Temp.:

Nurse ID & Sign : Noor Muhammad

Pulse: BP: O2 Sat: Weight:

I. Histoy

1.C/O / History of Present Illness

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2.Past Medical & Surgical History

Previous Admission(s):

Duration:

3. Family History ( including: Social / psychological factors)

4. Allergies:

Food Medications

Spacify:

Adverse Drug Reaction :

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Drug History :

Steroids Contraceptives Current Medication

MEDICATIONS :

Not Applicable Sent to Pharmacy Not brought with patient Sent home with family

Risk Of Fall :

Yes No

II. Examination

a. General

b. Systems Review

Titel 01	Titel 01	Negative	Positive	Comment
A	HEAD & NECK
B	CNS
C	CVS
D	RESP
E	GIT
F	GENITO-URINARY
G	SKIN
H	ENDOCRINE
I	Others: Please Specify

Please elaborate more if any System Review is Positive:

3. Local

a. EARS

01 Point 01
02 Point 02
03 Point 03

b. NOSE & SINUSES

01 Point 01
02 Point 02
03 Point 03

c. THROAT & LARYNX

01 Point 01
02 Point 02
03 Point 03

d. HEAD & NECK

01 Point 01
02 Point 02
03 Point 03

III. SPECIAL NEEDS

Functional Screening Criteria :

Patient cannot position himself in bed

Restricted ROM

Impaired Daily Living Activitie

Change in Muscle Power

Nutritional Screening Criteria :

Psychological Screening Criteria :

Non-compliance to offered treatment

Suspected drug abuse

Suicidal attempt

Emotional / behavioral problem ( Tearful, uncooperative)

Psychological Screening Criteria :

Living alone

Unable to assess due to lack of family.

Suicidal attempt

Spiritual / Cultural Screening :

Any spiritual belief or faith that help to cope with healing (prayer, meditation, reading Quran, attending religious activity .

Any spiritual leader to be involved in healthcare management .

Any conflicts between patient/caregiver beliefs and your medical situation / care / decisions .

Any specific spiritual needs to be fulfilled .

Any specific practice or restrictions patient/caregiver should know about providing his/her medical care (Dietary restrictions, use of blood products)

Cultural or religious background that would need to know for the plan of care .

* Choose any of the following options based on the above-mentioned criteria :

Screening Category	Positive Screening	Doctor will handle (Tick if YES)	Referred for further assessment (Tick if YES)	Patient refused referrals (Tick if YES)
Screening Category		Doctor will handle (Tick if YES)	Referred for further assessment (Tick if YES)	Patient refused referrals (Tick if YES)
Functional Screening
Nutritional Screening
Psychological Screening
Socio-economic Screening
Spiritual / Cultural Screening

Spiritual / Cultural Screening :

Pain Assessment :

Pain Score

IV. INVESTIGATIONS

Other :

V. DIAGNOSIS

Provisional Diagnosis :

Associated Condition Requiring Treatment & Monitoring :

VI. MANAGEMENT PLAN

VII. PRESCRIBED MEDICATIONS

Physician’s Name : Dr. Khaled Al JAber

ID #: 12065354

Date : 07-01-2020

Age : 10:35 AM

I. Histoy

1.C/O / History of Present Illness

2.Past Medical & Surgical History

3. Family History ( including: Social / psychological factors)

4. Allergies:

Adverse Drug Reaction :

Drug History :

MEDICATIONS :

Risk Of Fall :

II. Examination

a. General

b. Systems Review

Please elaborate more if any System Review is Positive:

3. Local

a. EARS

b. NOSE & SINUSES

c. THROAT & LARYNX

d. HEAD & NECK

III. SPECIAL NEEDS

Functional Screening Criteria :

Nutritional Screening Criteria :

Psychological Screening Criteria :

Psychological Screening Criteria :

Spiritual / Cultural Screening :

* Choose any of the following options based on the above-mentioned criteria :

Spiritual / Cultural Screening :

Pain Assessment :

Patient’s pain relief goal :

# Need for Additional Specialized Assessment:

IV. INVESTIGATIONS

V. DIAGNOSIS

VI. MANAGEMENT PLAN

VII. PRESCRIBED MEDICATIONS