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How to Use the Medical Form Template
All <enclosed> words are entry fields- where you enter your patient information.
Diagnosis: In this section list out all medical diagnosis the patient has been given. This list will very with each patient. A lot of times when asked this on the spot it is hard to come up with everything (or the correct name). This will help to be sure you get them all.
| Cerebral Palsy |
| Seizure Disorder |
| Incontinence |
| Blind |
| Autistic |
Allergies: Your doctor will go over the details of the allergic reaction, all you need to do here is indicate if there are any drug allergies and if so, the drug/medication that the patient is allergic to.
| Depakote |
| Penicillin |
| Latex |
MAJOR Medical History: This is MAJOR Medical, not ALL medical (Hospital Stays, Procedures, Special Treatments, etc). The date may be a single date is if was an outpatient procedure or it may need to be a date range if it was a hospital admitition.
| Date | Location | Summary |
|---|---|---|
| 01/01/10 | Dell Children’s Hospital | Ear tubes placed |
| 2/1/10-2/3/10 | Seton Main | Sleep Study |
| 3/1/10-4/5/10 | Austin HBOT | Hyperbaric Treatments (40-1 hour sessions) |
Nutrition: You may not need this section at all if you are not on a special diet or G-Tube. If so just enter N/A and move on to the next section.
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Medications: Be sure to include all prescription as well as over the counter medications.
Some helpful abbreviations for frequency:
- PRN indicates you take the medication as needed
- BID is twice a day
- TID is three times a day
- QID is 4 times a day
- Q# is every # hours ie: Q6 is every 6 hours.
| Name | Strength | Dose | Frequency |
|---|---|---|---|
| Motril | 20/5MG | 5ml | PRN |
| Prevacid | 15MG Solutab | 1 tab | BID |
| Keppra | 100MG/ML SOLN | 8ml | Q8 |
Medical Providers: This area can cover many areas (doctors, therapists, DME, Pharmacies, etc). Depending on the patient you may have a lot of entries for this section.
| Name | Specialty | Phone | Notes |
|---|---|---|---|
| Dr. Jones | Pediatrics | (512)555-1234 | RN-Jenny |
| CVS | Pharmacy | (512)555-2345 | |
| DCMC | Outpatient Rehab | (512)555-3456 | PT – Joe |
| Travis Med | DME | (512)555-4567 | Enteral Supplies |
| PSA | Nursing | (512)555-5678 | Case Manager- Lynn |
Equipment: In this section list out any medical equipment the patient uses. This can be a variety of things.
| Name | DME/Supplier |
|---|---|
| SuperStand | Owned/Purchased |
| Zevex Infinity Pump | ABC Medical Supply |
| DeVilBiss | ABC Medical Supply |
| 8french caths. | Walgreens Home Health |
Recent Labs, Imaging, Illnesses: In this section list out any recent labs, images and/or illnesses your child may have had. This really should just cover the past 6 weeks or less. This box my be better left blank and one you just write in on each visit if the rest of these sections are fairly stable for your child.
| Labs drawn at Pedi request on 2/12/16 at American Labs, Chest Xray done in ER on 4/4/16 at Dell Childrens…. |