EAMC DFCM OPD Charting Guidelines as of January 2020

DISCLAIMER: Please use this only as a guide during EAMC DFCM rotation. Good clinical judgement and updated knowledge supersedes this guideline.
There are 4 Clerks/ Interns posts:
1. Triage
2. Vital Signs
3. Consults
4. Census
Patient Care Flow Chart

Triage Vital Signs Team Consultation Team Census Encoding

• Brief HPI • Vital Signs and Anthropometrics • History and Physical Exam • Checking of chart completion
• Triaging of patients to different • Referring of patients with abnormal vital • Referring of patients to Residents on • Encoding of Patient Charts on the
departments. signs and red flag symptoms. Duty Computer
• ER referrals • Logging and charting of time recieved • Checking of chart completion • Checking of accuracy of orders:
and time interviewed • Takes note the Time referred to the spelling errors, correct prescriptions.
resident. • Logging of time referred and time
• Takes note the time discharged (time discharged.
when the resident is finished checking
the patient and the chart.
• Carrying out Corrected Resident's
Orders (prescription, Lab requests,
Clinical abstracts or medical
certificates)
• Checking of completion and correct
chart orders (prescription, Lab
requests, Clinical abstracts or medical
certificates).
• Discussing Patient discharge
instructions to the patient.
• Checking of chart completion prior to
encoding.
• Checks completeness of time stamps.
(time recieved, time interviewed, time
referred, time discharged.)
CENSUS ASSISTANTS RESPONSIBILITIES
Assistant 1
1. Checks the completeness of the Daily census every after OPD hours. (with the encoder of the day)
2. Uploads the Census file on the Google drive link.
3. Checks and corrects spelling errors, dosages, and other encoding errors.
4. Every Tuesday, Converts OPD Daily Census Document files to DOH CENSUS Format. See DOH Census Editing Guidelines.

Assistant 2
1. Compiles Daily Morbidity Tally Sheets and encodes it to the Morbidity Census Excel file.
2. Copies Daily Census Summary information to Daily Census Summary File.
3. Every Tuesday, copies all the census on the Daily OPD census to the Master Monthly Census.
4. On the last day of the rotation, copies the Master monthly Census to the Master Annual Census.

Files to be submitted at the End of the rotation.

Soft copy of OPD Daily Census Summary.
Soft and Hard Copies of OPD Daily Morbidity Tally Summary.

FOR EAST AVENUE MEDICAL CENTER DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE USE ONLY
EAMC DFCM OPD Charting Guidelines as of January 2020
DISCLAIMER: Please use this only as a guide during EAMC DFCM rotation. Good clinical judgement and updated knowledge supersedes this guideline.
HISTORY OF PRESENT ILLNESS
PRIMARY SYMPTOM Associated symptoms Pertinent negatives Medications/consults
Timing: Associated with: List your differentials Medical Consults if any
Previous episodes, Include RELEVANT symptoms only. Then pertinent negatives. Ex. Sought consult at <private clinic, ER,
Onset, Other unrelated symptoms should be in UTI hospital, government hospital/ OPD>
Frequency, the Review of Systems. No dysuria, frequency, urgency, fever, Diagnosed with <diagnosis>
Duration chills, flank or suprapubic pain. Diagnostics done were <Tests>
Location Gynecologic Prescribed with <drug>
Quality or Character No vaginal discharge, vaginal pruritus, Self-medicated with <drug>
Severity dyspareunia With relief/no relief of symptoms.
Radiation FOR PATIENTS SEEN AT THE ER,
Relieving factors ALWAYS START THE HISTORY
Precipitating factors PRIOR TO THE ER CONSULT.
Progression
Interim history: Progression, if episodic, frequency, Timing of symptoms, relieving and aggravating factors,
Reason for consult: persistence, progression, severity, of symptoms prompted consult.

Minimum “Normal” Physical Exam findings

Neuro PE (Normal)
General Conscious, coherent, not in cardiorespiratory distress
I Not assessed
Survey
II PERRLA
Skin Skin is brown moist with good skin turgor, no visible mass or III, IV, VI EOM- able to perform cardinal Eye ROM
lesions. V clenches teeth symmetrically, intact facial sensation
VII Symmetrical facie
HEENT Normocephalic, Pink palpebral Conjunctiva, anicteric sclera, VIII Intact audition
(Inspection, No Nasal nor aural discharge, no tonsillopharyngeal IX, X Uvula in midline, (+) gag reflex
Palpation) congestion, Neck is supple with no CLAD and no JVD XI Shrugs both shoulders symmetrically
XII Tongue protrudes in midline, no fasc.
Chest/Lungs No mass or lesions, Symmetrical chest expansion, no
(Insp, Palp, retractions, no chest lagging, vesicular breath sounds.
Perc, Ausc)

Heart Adynamic Precordium, PMI at 5th ICS Left Midclavicular line,

(Inspe, Normal Rate, Regular Rhythm, distinct S1 and S2, No
Ausc) murmurs

Abdomen Globular, no visible mass or lesions, normoactive bowel

(Insp, Aus, sounds , soft, non-tender, no CVA tenderness, Negative
Palp, Perc) Murphy sign, tympanitic

Extremities No gross deformities, full and equal pulses, capillary refill

time <2 secs, No edema.

Genitalia Grossly Male/Female Adult Genitalia, no visible mass or

lesions, no visible discharge.

Internal Patent vaginal canal, cervix is closed, soft, smooth and

exam nontender. uterus in midline, smooth, firm, and non- tender,
no palpable right and left adnexal mass. Whitish discharge
on examining finger upon withdrawal.
Rectal No visible mass or lesions, good sphincter tone, smooth
rectal walls, 2 fingerbreadths prostate, non-tender, full/empty
rectal vault, no palpable mass or lesions.
Spine Spine is in midline, no visible lesions, abnormal curvature,
Straight Leg raise negative.
Assessment Tools / Questionnaires Available for Printing
Cardiology: Heart Failure-Framingham Criteria, NYHA and Angina
Headache: Tension Type, Migraine, Cluster Diagnostic Criteria
Psychiatry DSM V criteria for MDD, GAD, Panic Disorder, Schizophrenia and
Mental Status Exam checklist.
Thyroid Disorders: Burch Wartofsky for Thyroid Storm, Wayne’s Index for
Hyperthyroidism, Billewics Scoring for Hypothyroidism
Birmingham Vasculitis Activity Score.

FOR EAST AVENUE MEDICAL CENTER DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE USE ONLY
EAMC DFCM OPD Charting Guidelines as of January 2020
DISCLAIMER: Please use this only as a guide during EAMC DFCM rotation. Good clinical judgement and updated knowledge supersedes this guideline.
CHARTING GUIDELINES

Assessment 1. With comorbidities (HTN, DM, CKD) “for HTN/DM/Workup: 12 L ECG,

1. Medical Assessment FBS, Lipid Profile, Blood Uric Acid, CBC with pc, UA, Na, K, Cl, BUN,
Primary diagnosis then from most significant (RELATED TO THE CHIEF Creatinine, SGPT SGOT”
COMPLAINT) For patients with comorbidities 3 Write “For HTN/DM workup: 12 L ECG, FBS, Lipid
to least significant diagnosis Profile, Blood Uric Acid, CBC with pc, UA, Na, K, Cl, BUN, Creatinine, SGPT SGOT
Example: CC cough for 5 days
PMH: Hypertension Stage II When writing Imaging tests, do it in LIV format Location, Imaging modality, View
Assessment: (what type of view or special views)
CAP-LR (since it is the Main Diagnosis) Ex. Chest Xray PAL, HBT UTZ, Lumbosacral MRI, Cranial CT scan with contrast, 2D
Hypertension stage II controlled Echo with doppler studies, Arterial, Venous, AV duplex scan etc.
Warning: Always write pertinent history and physical exam on the Imaging
2. Psychosocial Assessment request, failure to do so has corresponding consequences.
Here is the list of acceptable Psychosocial assessment For 2D Echo/AV duplex scan patients, aside from the 2D Echo Request, make sure to
Tobacco use [ Z72.0] fill up the 2D Echo Physical Exam Form.
Alcohol use [ Z72.1] For laboratory requests that is not available in our standard request form, write the
Drug use [ Z72.2] request on the prescription pad.
Abuse of non-dependent producing substances [F55]
Lack of physical exercise [ Z72.3] Preventive/Screening recommendations:
Inappropriate diet and eating habits [Z72.4] Chest X-ray PAL- smoking history (>10 pack years)
Non organic insomnia – inadequate quantity or quality of sleep for a prolonged Female, 21 years old and above or 3 years from coitarche: PAP smear and HPV
period [ F51.0] screening every 3 years
Sleep disorders [G47] Female, 40 years old and above - Screening annual Mammography
Insomnia [G47.0] Males, 50 years old and above, Do Digital Rectal Exam
Insomnia due to medical condition (G47.01) Anyone >55 Recommend PCV and influenza vaccine
High risk sexual behavior [Z72.5]
Gambling and betting [Z72.6] Pre-Employment Workup.
Self damaging behavior [Z72.8] Routine: students, office, sales, etc.: CBC with PC, UA, Chest Xray PA-L
Burnout [Z73.0] Food handlers: CBC with PC, UA, Chest Xray PA-L, FA, Anti-HAV
Lack of relaxation and leisure [ Z73.2] For strenuous jobs: CBC with PC, UA, Chest Xray PA-L, 12-L ECG
Stress Not elsewhere classified / Physical and mental strain [ Z73.3]
Type A behavior pattern (characterized by unbridled ambition, a need for high PHARMACOLOGIC MANAGEMENT
achievement, impatience, competitiveness, and a sense of urgency) [Z73.1] Use standard format:
Social role conflict [Z73.5] Generic name, stock dose, dosing, frequency, duration*.
Inadequate social skills [ Z73.4] USE OD, q8h for TID, q12h for BID, q6h for QID. NEVER USE, BID, TID, QID,
Problems related to life management difficulty [ Z73. 9] E.g. Co-amoxiclav 1 g/tab, 1tab q12 for 7 days
Limitation of activities due to disability [Z73.6] *No duration for maintenance medications
Problems related to care provider dependency [ Z74]
Problems related to medical facility and other health care – unavailable, inaccessible NON-PHARMACOLOGIC MANAGEMENT
[ Z76 ] SEE SAMPLE PLANS for other nonpharmacologic management
Malingering – person feigning illness with obvious motivation [ Z76.5] Smoker: Smoking cessation advised, patient in pre-contemplation stage, advised
Example of Psychosocial Assessment patient that he can come back anytime if decided to quit.
S: Main chief complaint, Medical HPI then Fluid intake:
Patient came in seeking clinical abstract for her labs/medications. For well adults: Increase oral fluid intake.
O: Income: less than 5000 per month. Breadwinner of 5. For CKD, CHF patients. Limit fluid intake to 1L/ day instead.
A: Psychosocial Assessment: Problems related to medical facility and other health care Activity: Moderate intensity physical activity 30 mins/day 5x per week as tolerated. (for
– unavailable, inaccessible [ Z76 ] due to financial constraints healthy patients who you think can tolerate exercise)
Plan: Usual medical plan. DIET PLAN (compute for all Obese, DM and Hypertensive patients)
Insert at nonpharmacologic management: “Clinical Abstract provided and was referred HOW TO COMPUTE FOR THE DIET PRESCRIPTION
to Social Services for further assistance.” 1. Ideal body weight using Tanhauser method.
(Height in cms – 100) X 0.9 =
Eg. (169 – 100) = 69 X 0.9 = 62.1 kgs
Plan 2. Total Caloric Requirement = IBW X Activity factor
Follow the format Activity factor
1. Diagnostics 25 for bedridden, 30 for sedentary, 35 for moderate activity, 40 for strenuous.
2. Pharmacologic management 3. Distribution:
3. Non-Pharmacologic management CHO: TC x 0.6, CHON: TC x 0.15, Fat: TC x 0.25
4. Referrals Sample Diet plan Order
5. Follow up Refer to Nutrition Clinic for a diet plan
Diet: E.g. Low Salt, Low Fat, and/or DM Diet (specific)
DIAGNOSTICS TC: 1539, CHO: 923, CHON: 231, Fat: 385
Laboratory/Imaging Request should be clustered in to: If the patient already had a diet plan from nutrition clinic write:
1. PRIORITY LAB WORKUP: Labs that are relevant to the diagnosis “Continue diet plan C/O Nutrition Clinic”
For any patients >40 years old and above with Abdominal or Chest pain do STAT 12L If the patient has previous diet prescription but still unable to go to Nutrition clinic write:
ECG to Rule out Ischemic Heart Disease, if the patient came back with Normal ECG “Still for Nutrition clinic referral”
results, Write Stat12 L ECG – DONE
If refused for any reason, fill up the “release of responsibility form” and indicate the Referrals:
primary reason for refusing, then write STAT 12 L ECG – Refused, waiver signed. Refer to <Department> for further evaluation and co-management.
LIST PRIORITY WORKUP FIRST BEFORE ROUTINE WORKUP. NEVER write refer to <department> for Clinical abstract.
2. ROUTINE LAB WORKUP: Refer to Ophthalmology for official fundoscopy (all New DM and Hypertensive patients)
12 L ECG, FBS, Lipid Profile, Blood Uric Acid, CBC with pc, UA, Na, K, Cl, BUN, Refer to Ophthalmology for annual fundoscopy (for previously screened old patients)
Creatinine, SGPT SGOT Refer to HACT for counselling and testing (all urethritis and other STI’s)
Indications for routine workup HACT means HIV-AIDS Core Team. But writing “HIV” or “AIDS” on patient’s charts or
1. Obese at any age requests is taboo so we use HACT instead.
2. 40 years old and above
For patients qualifying 1 and 2 Write “For Wellness: 12 L ECG, FBS, Lipid Profile,
Blood Uric Acid, CBC with pc, UA, Na, K, Cl, BUN, Creatinine, SGPT SGOT

FOR EAST AVENUE MEDICAL CENTER DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE USE ONLY
EAMC DFCM OPD Charting Guidelines as of January 2020
DISCLAIMER: Please use this only as a guide during EAMC DFCM rotation. Good clinical judgement and updated knowledge supersedes this guideline.
Same-Day Referrals Protocol
1. Confirm to the resident if the patient needs to be referred today. PATIENT FOLLOW UPS
2. If confirmed, complete the charting, prescriptions, laboratory or imaging request, Always review previous charting.
and referral letter for the department. SOAP format
3. Have the Census encoder take a picture of the chart.
4. Bring the patient and the chart to the receiving department and endorse the chart Subjective:
to the nurse/intern on duty. Review previous complaints if still existing, progressing, regressing or resolved.
5. Ask the patient to wait for his/her name to be called at the department. Ask for new symptoms/ Differential symptoms, Pertinent Negatives.
6. Ask the patient to come back to us once done with that department’s consultation. Ask for compliance to new/ current medications.

REFERRED FROM: THIS ARE PATIENT’S THAT WAS REFERRED TO OUR
DEPARTMENT FOR FURTHER EVALUATION AND MANAGEMENT:
Write: Patient was referred from, <department>, advised to continue follow up with
<department> for continuity of care. And always write SOAP on the Referral Letter
FOLLOW UP
for those in pain, infectious, started on antibiotics, (if you are not sure when to follow up
its safe to use 3 days) Follow up after 3 days
for Chronic diseases like DM, HTN, CKD: Follow up after 1 week
For follow up laboratories: “Follow up ASAP with results”
For Viral Exanthem T/C Varicella, Herpes zoster
Follow up after 2 weeks once lesions have DRIED
For patients referred to other departments write:
Follow up once seen by <department>
NEVER WRITE ON THE CHART “FF UP ONCE WITH RESULTS” or “To come
back”
NEVER FORGET TO GIVE A PATIENT A FOLLOW UP CARD.
Ask the patient to always bring the follow up card and his/her Hospital ID ”green”
Card.
IF IN DOUBT, USE 3 DAYS FOLLOW UP
ADVISED (always end your charting with it.)
AT THE END OF EVERY PLAN DO NOT FORGET THE FOLLOWING:
YOUR FULLNAME AND SIGNATURE
TIME INTERVIEWED
TIME REFERRED TO THE RESIDENT
TIME DISCHARGED: TIME THE RESIDENT WAS FINISHED SEEING THE PATIENT.
EXCLUDE THE TIME YOU USED TO CORRECT AND CARRY OUT CORRECTED
PATIENT PLANS.
Objective
PE as per previous charting. NOTE ANY CHANGES.
Patient came in with laboratory results.
Check for completion of laboratories, write the results legibly,
Use the mg/dl unit in writing lab results on the chart.
Use MDCALC app on Android/IOS device
if with Creatinine, always compute for EGFR using CKD-EPI calculator and if
EGFR is Less than 60, compute for BUN/Creatinine Ratio. (Normal 12-20)
if with Lipid profile, always compute for ASCVD risk score.
Assessment: note the NEW DIAGNOSIS if any, followed by the PREVIOUS
DIAGNOSIS.
Add RESOLVING if patient is clinically improving.
Add RESOLVED if patient’s symptoms have resolved.
Plan: Review previous and rewrite unless the resident in decides to change, shift, or
discontinue current medications.
Patients for Clinical Abstract/ Medical Certificate.
1. Write in a sheet of small piece of paper the document (Clinical Abstract or Medical
Certificate) the patient needs.
2. Ask the patient to proceed to the nurse’s station (in front of the elevator) to get the
order of payment.
3. Present Order of Payment and pay at the cashier.
4. Ask the patient to bring the receipt back to the nurse’s station.
5. Either the nurses or the Nurse assistant will bring the document to us.
6. Fill up the document as legibly as possible. Avoid erasures and spelling errors
particularly the patient’s name, address, and diagnosis. Use permanent ink in filling
up the form to prevent scammers from abusing the document.
7. Have the resident on duty sign the document.

FOR EAST AVENUE MEDICAL CENTER DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE USE ONLY
EAMC DFCM OPD Charting Guidelines as of January 2020
DISCLAIMER: Please use this only as a guide during EAMC DFCM rotation. Good clinical judgement and updated knowledge supersedes this guideline.
SAMPLE PLANS
Respiratory Disorders
Community Acquired Pneumonia-Low URTI prob Viral
Risk
For Chest Xray PAL
<Routine labs if indicated>
Co-amoxiclav 1g/tab 1-tab q12 for 7
days or
Cefuroxime 500 mg/tab 1-tab q 12 for
7 days
And or
Azithromycin 500 mg/tab 1-tab OD for
3 days
If with tenacious cough:
NAC 600mg/sachet dissolve 1 sachet
in 100 ml of water and drink ODHS or
Carbocisteine 500mg/tab 1-tab q8
PRN for tenacious cough
Proper cough etiquette, droplet
precaution
Increase oral fluid intake
Recommended pneumococcal and
influenza vaccines (age dependent)
Follow up after 3 days
Advised
Acute Tonsillopharyngitis prob
bacterial
Start Co-Amoxiclav 625 mg/ tab 1-tab
Q8 for 7 days
Paracetamol 500 mg/ tab 1-tab q4 PRN
for Fever > 37.8
May gargle with Chlorhexidine oral
solution 3x a day after meals.
Cold soft diet, Increase oral fluid intake hypoallergenic diet
Refer to ENT-OHNS for further
evaluation and management (If with
Hypertrophic tonsils)
Follow up after 3 days
Advised
FOR EAST AVENUE MEDICAL CENTER DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE USE ONLY
<Imaging/routine labs if indicated>
For non-hypertensive patients:
Phenylephrine + paracetamol 10
mg+500 mg/tab 1-tab q8 PRN for
colds.
For hypertensive patients:
Gentinae radix et al. 6 mg/ tab 1-tab
q8 PRN for colds.
If bacterial:
Co-Amoxiclav 625 mg/tab 1-tab q8 for
7 days.
If with allergic component:
Cetirizine 10 mg/tab, 1-tab ODHS for 1
week or
Loratadine 10 mg/tab 1-tab OD for 1
week
If with allergic component: Allergen
Identification and avoidance.
Proper cough etiquette, droplet
precaution, increase oral fluid intake
Recommended pneumococcal and
influenza vaccines (age dependent)
Follow up after 3 days.
Advised.
Allergy (Allergic Rhinitis, Allergic
Cough)
<Routine labs if indicated>
Cetirizine 10 mg/tab, 1-tab ODHS for 1
week or
Loratadine 10 mg/tab 1-tab OD for 1
week
Allergen Identification and avoidance.
Recommended pneumococcal and
influenza vaccines (age dependent)
Follow up after 3 days
Advised
PTB, R/O PTB, PTB Cat II T/C Relapse, Bronchial Asthma, controlled or
Presumptive PTB uncontrolled not in acute
For patients 15 years old and above, a exacerbation, or COPD not in acute
presumptive TB has any of the following: exacerbation
Cough of at least 2 weeks duration Spirometry with Bronchoprovocative test
with or without the following symptoms: <Imaging/routine labs if indicated>
Significant and unintentional weight loss; Reliever:
Fever; Bloody sputum (hemoptysis); Salbutamol 100 mcg/actuation MDI, 1-
Chest/back pains not referable to any 2 puffs Q8 for PRN 3 days.
musculoskeletal disorders; Easy Salbutamol nebules, nebulize with 1
fatigability or malaise; Night sweats; and, nebule as needed for shortness of
Shortness of breath or difficulty of breath, may nebulize up to 3 times 15
breathing. minutes apart for 3 days
(Initially) For Chest X-ray PAL Controller:
(Patient came back with CXR indicative Budesonide + Formoterol 160mg+4.5
of PTB) For DSSM and mcg MDI, 1 puff Q12 or
Chest Xray Apicolordotic view per Salmeterol + Fluticasone 50+250 mcg
radiologist recommendation, Do not write MDI, 1 puff Q12
APL view, it is totally different from Fluticasone furoate + Vilanterol
Apicolordotic view. trifenatate 100/200 mcg/25 mcg DPI, 1
(additional test for PTB Cat II: History of puff OD
previous PTB) Gene Xpert Identify potential allergens, allergen
<Routine labs if indicated> avoidance, hypoallergenic diet, proper
<Meds if any> cough etiquette, droplet precaution,
Proper cough etiquette, airborne increase oral fluid intake
precaution, Recommended pneumococcal and
Encouraged screening of household influenza vaccines (age dependent)
members Bring MDI on next follow up for proper
Refer to TB DOTS for DSSM inhaler technique assessment.
Follow up ASAP once with result Follow up after 3 days
Advised Advised
COPD, COPD suspect
Spirometry with Bronchoprovocative test.
<Routine labs if indicated>
Salbutamol + Ipratropium bromide
nebules, nebulize with 1 nebule up to
3 doses 15 minutes apart as needed
for shortness of breath then Q8 for 3-
5 days
Start Indacaterol + Glycopyrronium
110/50 mcg/actuation, 1-2 puffs once
a day
Identify potential allergens, allergen
avoidance, hypoallergenic diet, proper
cough etiquette, droplet precaution,
increase oral fluid intake
Recommended pneumococcal and
influenza vaccines (age dependent)
Bring MDI on next follow up for proper
inhaler technique assessment.
Follow up after 3 days
Advised
EAMC DFCM OPD Charting Guidelines as of January 2020
DISCLAIMER: Please use this only as a guide during EAMC DFCM rotation. Good clinical judgement and updated knowledge supersedes this guideline.
Cardiovascular disorders
Hypertension/HCVD
12 L ECG, FBS, LP, BUA, CBC with PC, UA, Na, K, Cl,
BUN, Crea, SGPT SGOT
2D echo with doppler studies for HCVD
Chest Xray PAL if indicated
Irbesartan 150 or 300 mg/tab, 1-tab OD
Telmisartan 40 or 80 mg/tab 1-tab OD
Losartan 50 or 100 mg/tab, 1-tab OD, q12
Amlodipine 5 or 10 mg/tab, 1-tab OD (watch out for
signs of edema)
Strict compliance with medications
Daily BP monitoring and record
Refer to Nutrition Clinic for a diet plan
Diet: Low Salt, Low Fat Diet
TC: 1539, CHO: 923, CHON: 231, Fat: 385
Refer to Ophthalmology for official fundoscopy
Follow up after 1 week
Advised
Hypertension suspect (single episode of BP >140/90 Refer to Nutrition Clinic for a diet plan
mmHg)
No meds for now
Daily BP monitoring and record
Refer to Nutrition Clinic for a diet plan
Diet: Low Salt, Low Fat Diet
TC: 1539, CHO: 923, CHON: 231, Fat: 385
Follow up after 1 week with BP monitoring record.
Gastroenterology Disorders
Dyspepsia w/o alarm features
(less than 40 years old without any comorbidities)
<Routine labs if indicated>
Omeprazole 40 mg/cap, 1 cap OD 30 minutes before
breakfast for 2-4 weeks
Avoid spicy, acidic, fatty, and caffeinated food and
beverages, small frequent meals, avoid skipping of
meals.
Follow up after 3 days
Advised
Dyspepsia with alarm features
Still follows ABDOMINAL PAIN PROTOCOL
CBC with PC, Fecal Immunochemical Test c/o
Gastro, T, H. pylori stool antigen test.
<Routine labs if indicated>
Omeprazole 40 mg/cap, 1 cap OD 30 minutes before
breakfast for 4 weeks
Avoid spicy, acidic, fatty, and caffeinated food and
beverages, small frequent meals, avoid skipping of
meals.
Refer to IM-Gastro for possible endoscopy
Follow up after 3 days
Advised
FOR EAST AVENUE MEDICAL CENTER DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE USE ONLY
Congestive Heart Failure NYHA Class I-IV
12 L ECG, FBS, LP, BUA, CBC with PC, UA, Na, K, Cl,
BUN, Crea, SGPT SGOT
2D echo with doppler studies
Chest Xray PAL
ARBS
Losartan 50 or 100 mg/tab, 1-tab OD, q12
Irbesartan 150 or 300 mg/tab, 1-tab OD
Telmisartan 40 or 80 mg/tab 1-tab OD
Betablocker
Carvedilol 6.25 mg/ tab half tab q12
If indicated: Atorvastatin 40mg/tab 1-tab ODHS
Antiplatelets
Aspirin 80 mg/tab 1-tab OD or
Clopidogrel 75 mg/ tab 1-tab OD
Strict compliance with medications
Daily BP monitoring and record
Limit Fluid intake to 1 L/ day
Diet: Low Salt, Low Fat Diet
TC: 1539, CHO: 923, CHON: 231, Fat: 385
(NYHA Class III-IV) Refer to IM-Cardiology for
further evaluation and management
Follow up after 3 days or once seen by IM
Advised
Dyspepsia without Alarm features,
if 40 years old and above ALWAYS
Rule out ACS if the setting of symptoms is acute
(days) warrants immediate ER referral
Rule out IHD if the setting of symptoms is chronic
(weeks to months)
ABDOMINAL PAIN PROTOCOL
FOR PATIENTS >40 YRS. OLD WITH ABDOMINAL
PAIN, DO NOT COMPLETE THE CHART YET AND
REFER THE PATIENT RIGHT AWAY TO THE
RESIDENT ON DUTY. THE ROD WILL DECIDE IF
PATIENT IS FOR STAT 12 L ECG OR IMMEDIATE ER
REFERRAL.
If patient came back with 12 L ECG strip photocopy
within the day, write STAT 12 L ECG done.
If patient refuses due to any circumstance, have the
patient signed Release of Responsibility Form and
indicate the reason for refusal. Then write
STAT 12 L ECG/ ER referral refused; waiver signed.
FBS, LP, BUA, CBC with pc, UA, Na, K, Cl, BUN,
Crea, SGPT SGOT
Omeprazole 40 mg/cap, 1 cap OD 30 minutes before
breakfast for 2-4 weeks
Avoid spicy, acidic, fatty, caffeinated food and
beverages
Small frequent meals, avoid skipping of meals
Follow up after 3 days
Advised
Acute Gastroenteritis without signs of dehydration
For Fecalysis (if indicated: hematochezia)
Racecadotril 100 mg/tab 1-tab q8 until 2 consecutive
formed stools
ORS sachet dissolve in 200 ml of clean water and drink
1 sachet for every bout of loose stool
Proper handwashing, proper food preparation.
WOF weakness, drowsiness, persistent vomiting,
decreased urination.
Follow up after 3 days.
Advised
Typical/ Atypical Angina Pectoris R/O Ischemic
Heart Disease
CHEST PAIN PROTOCOL
FOR PATIENTS >40 YRS. OLD WITH CHEST PAIN,
DO NOT COMPLETE THE CHART YET AND REFER
THE PATIENT RIGHT AWAY TO THE RESIDENT ON
DUTY. THE ROD WILL DECIDE IF PATIENT IS FOR
STAT 12 L ECG OR IMMEDIATE ER REFERRAL.
If patient came back with 12 L ECG strip photocopy
within the day, write STAT 12 L ECG done.
If patient refuses due to any circumstance, have the
patient signed Release of Responsibility Form and
indicate the reason for refusal. Then write,
STAT 12 L ECG/ ER referral refused; waiver signed.
For FBS, LP, BUA, CBC with PC, UA, Na, K, Cl, BUN,
Crea, SGPT SGOT
2D echo with doppler studies
Chest Xray PAL
ISMN 30 mg/tab 1-tab OD
ISDN 5 mg/ tab 1-tab sublingual PRN for chest pain,
may repeat up to 3 doses 15 minutes apart.
Clopidogrel 75 mg/tab 1-tab OD
Atorvastatin 40 mg/tab 1-tab ODHS
Watch out for chest pain not relieve by ISDN, advised to
go to ER if unrelieved after 30 minutes.
Watch out for severe headache may be a side effect of
nitrates. Follow up ASAP if with headache.
Daily BP monitoring and record
Fall precaution: Avoid sudden standing. Dangle legs at
the edge of the bed, if with no lightheadedness, may
stand up carefully.
Follow up after 3 days.
Advised
Gastroesopphageal Reflux disease
if 40 years old and above ALWAYS
Rule out ACS if the setting of symptoms is acute
(days) warrants immediate ER referral
Rule out IHD if the setting of symptoms is chronic
(weeks to months)
ABDOMINAL PAIN PROTOCOL
FOR PATIENTS >40 YRS. OLD WITH ABDOMINAL
PAIN, DO NOT COMPLETE THE CHART YET AND
REFER THE PATIENT RIGHT AWAY TO THE
RESIDENT ON DUTY. THE ROD WILL DECIDE IF
PATIENT IS FOR STAT 12 L ECG OR IMMEDIATE ER
REFERRAL.
If patient came back with 12 L ECG strip photocopy
within the day, write STAT 12 L ECG done.
If patient refuses due to any circumstance, have the
patient signed Release of Responsibility Form and
indicate the reason for refusal. Then write
STAT 12 L ECG/ ER referral refused; waiver signed.
FBS, LP, BUA, CBC with pc, UA, Na, K, Cl, BUN,
Crea, SGPT SGOT
Omeprazole 40 mg/cap, 1 cap OD 30 minutes before
breakfast for 8 weeks
Avoid spicy, acidic, fatty, and caffeinated food and
beverages, Small frequent meals, avoid skipping of
meals.
Maintain upright position 2-3 hours after meals.
Follow up after 3 days
Advised
Biliary cholic T/C Cholelithiasis
For HBT ultrasound,
<Routine labs if indicated>
Start Pinaverium 50 mg/tab 1-tab q8 PRN for pain
Avoid fatty food.
Watch out for fever, right upper quadrant pain.
Small frequent meals.
Follow up after 3 days
EAMC DFCM OPD Charting Guidelines as of January 2020
DISCLAIMER: Please use this only as a guide during EAMC DFCM rotation. Good clinical judgement and updated knowledge supersedes this guideline.
Genitourinary/ Nephrology Disorders
Acute Uncomplicated Cystitis
(pre-menopausal women, no prior history pyelonephritis
of UTI within 2x in 6 mos, or 3 in 1 year) UA, Urine GSCS
No need for Urinalysis
<Routine labs if indicated>
Offered Fosfomycin 3mg/ sachet
dissolve 1 sachet in ½ glass or water
and drink as a single dose but patient
preferred a cheaper drug.
Start one
Cefuroxime 500 mg/tab 1-tab q 12 for
7 days*
Cefaclor 500 mg/tab 1-tab q8 for 7
days
Cefixime 200 mg/tab 1-tab q12 for 7
days
Ofloxacin 200 mg/tab 1-tab q12 for 3
days
Ciprofloxacin 250 mg/tab 1-tab q12 for End-Stage Renal Disease secondary
3 days
Levofloxacin 250 mg/tab 1-tab q12 for
3 days
Co-Amoxiclav 625 mg/tab 1-tab q12
for 7 days
Increase oral fluid intake 2-2.5 L/day,
proper perineal hygiene, avoid delays in
voiding
Follow up after 3 days
Advised
Benign Prostatic Enlargement with
(Mild/Moderate/Severe Lower urinary
tract Symptoms.
For KUBP Ultrasound, PSA
<Imaging/routine labs if indicated>
Start Tamsulosin 0.4 mg/tab 1-tab OD
Or Tamsulosin + Finasteride 0.4/5
mg/tab 1-tab OD
Decrease oral fluid intake at bedtime.
Avoid delays in voiding
Refer to Urology for further evaluation
once with results.
Follow up after 1 week
Advised
Neurology Disorders
Benign Paroxysmal Positional Vertigo
<Imaging/routine labs if indicated>
Start Betahistine 24 mg/tab 1-tab q12 for 2
weeks
Avoid sudden head movements
May do Anti-vertigo exercise (Semont
maneuver) with caution.
Fall precaution:
Observe for spinning sensation prior to
standing up.
Betahistine may cause drowsiness so avoid
risky activities such as driving or handling
power tools and dangerous equipment.
Refer to ENT-OHNS for further evaluation
and management
Follow up after 3 days
Advised
FOR EAST AVENUE MEDICAL CENTER DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE USE ONLY
Complicated UTI, Acute UTI in male Urethritis
UA, Urine GSCS High risk sexual behavior [Z72.5]
<Routine labs if indicated>
<Routine labs if indicated> Start one Urethral Discharge GS/CS, UA, HBSAG,
Start one Ciprofloxacin 500 mg/tab 1-tab q12 for RPR, HACT
Ciprofloxacin 500 mg/tab 1-tab q12 for 7-10 days Ceftriaxone 250 mg TIM as a single
7-10 days* Levofloxacin 250 mg/tab 1-tab OD for dose ANST (-)
Levofloxacin 250 mg/tab 1-tab OD for 7-10 days PLUS
7-10 days Ofloxacin 400 mg/tab 1-tab OD for 5 Doxycycline 100mg/tab 1-tab q12 for 7
Ofloxacin 400 mg/tab 1-tab OD for 5 days days Avoid prolong sun exposure during
days Cefixime 400 mg/tab 1-tab OD for 14 doxycycline treatment <if will be taking
Cefixime 400 mg/tab 1-tab OD for 14 days doxycycline>
days Increase oral fluid intake greater than 2- OR
Increase oral fluid intake 2-2.5 L/day, 2.5 L/day Azithromycin 500 mg/tab 2 tabs as a
proper perineal hygiene (for women Avoid delays in voiding single dose
only), avoid delays in voiding Follow up after 3 days Avoid delays in voiding. Increase oral
Follow up after 3 days Advised fluid intake greater than 2.5 L/day,
Advised Counselling done: increased patient ‘s
awareness on high risk activities, sexual
to <insert etiology here> abstinence during treatment, encourage
Continue Hemodialysis (frequency)/ sexual partner screening, and use
week protective contraception (condoms)
Continue Medications: Refer to HACT for further counselling
<Insert maintenance medications here> and testing
Limit fluid intake to less than 1L/day Follow up after 3 days
Strict compliance with medications Advised
Daily BP monitoring and record
Refer to Nutrition Clinic for a diet plan
Diet: Low Salt, Low Fat Diet
TC: 1539, CHO: 923, CHON: 231, Fat: Nephrolithiasis (confirmed by UTZ) T/C CKD Stage III -V
385 For UA (EGFR less than 60 mL/min/1.73m2)
Refer to IM for further evaluation and Sambong tablet 1-tab q8h for 1 month Repeat Creatinine,
co-management. <NEVER write for K citrate 1080 mg/tab 1-tab Q8 for 1 Spot Urine Protein/Creatinine Ratio or
clinical abstract> month 24-hour urine protein
Follow up with attending Nephrologist. Increase oral fluid intake Na, K, Cl, Ca, Mg, Ph,
Advised Low salt diet KUB Ultrasound with Doppler studies
Refer to Urology for further evaluation Refer to Nutrition Clinic for a diet plan
and management (for stones greater Diet: Low Salt
than 5 mm) TC: 1539, CHO: 923, CHON: 231, Fat:
Follow up after 1 month or anytime if with 385
problems For possible referral to IM and
Advised Nephrology once with conclusive
results.
Follow up ASAP with results.
S/P Cerebrovascular accident / Transient Bell’s Palsy R/O Cerebrovascular Acute Headache T/C Tension or Migraine
Ischemic Attack accident Headache with/without aura
Limitation of activities due to disability For Plain CT scan Physical and mental strain [ Z73.3] if
[Z73.6] <Imaging/routine labs if indicated> there is any identifiable source of strain.
Start Prednisone 20 mg/ tab 1-tab q8h for 5 If with indication (Danger Signs):
Plain CT Scan/ MRI ask the resident in days then Cranial CT Scan with IV contrast
charge Prednisone 20 mg/ tab 1-tab q12h for 3 days <Imaging/routine labs if indicated>
<Imaging/routine labs if indicated> then Celecoxib 200 mg/ tab, 1-tab q12 for 5
Start Clopidogrel 75 mg/tab 1-tab OD Prednisone 20 mg/ tab 1-tab OD for 2 days days
Atorvastatin 40 mg/tab 1-tab ODHS Dextran+Hydroxypropyl methylcellulose Etoricoxib 60 or 90 mg/tab 1-tab OD for 5
Continue current medications (list down with eyedrops apply on affected eye every 3-4 days
correct prescription format) hours. Paracetamol + Orphenadrine 650+50
Strict compliance with medications Tape affected eye to close during sleep. mg/tab, 1-tab q8PRN for pain for 5 days
Daily BP monitoring and record Refer to Neurology for further evaluation or
Refer to Nutrition Clinic for a diet plan and management. Avoid triggers: lack of sleep, emotional
Diet: Low Salt, Low Fat Diet Refer to Rehab medicine for further stress, and fatigue or any other known
TC: 1539, CHO: 923, CHON: 231, Fat: 385 evaluation and co-management triggers mentioned in the HPI
Refer to Neurology for further evaluation Refer to Ophthalmology for further Counselling done. Proper stress
and management. evaluation and co-management. management.
Referral to LGU for possible Follow up after 3 days Follow up after 3 days
psychosocial disability certification. Advised Advised.
Follow up after 1 week
Advised
EAMC DFCM OPD Charting Guidelines as of January 2020
DISCLAIMER: Please use this only as a guide during EAMC DFCM rotation. Good clinical judgement and updated knowledge supersedes this guideline.
Psychiatry Disorders
Major Depressive Disorder/ Generalized Anxiety Disorder
Limitation of activities due to disability [Z73.6]
<Imaging/routine labs if indicated>
Escitalopram 10mg/tab ½ tab ODHS for first 4 nights
then 1-tab ODHS thereafter. <Always ASK the resident first>
Counselling done.
Deep breathing exercises, proper stress management.
Suicide precaution.
Refer to Psychiatry for further evaluation and management.
For possible referral to LGU for possible psychosocial disability certification once certified Advised
by psychiatry.
Follow up once seen by Psychiatry
Advised
Musculoskeletal Disorders
Musculoskeletal Disorder (MSD), <indicate location>
or Arthritic Group of Diseases (AGD) T/C
Osteoarthritis, <indicate specific joint>
For severe symptoms add
Limitation of activities due to disability [Z73.6]
NON HYPERTENSIVE, LESS THAN 40 YRS OLD
<Imaging if indicated>
Lumbar MRI if with radiculopathy symptoms
Scoliosis series if with scoliosis
Lumbosacral Xray APL if with visible spine deformity or
crepitus
Celecoxib 200 mg/ tab, 1-tab q12 for 5 days
Etoricoxib 60 or 90 mg/tab 1-tab OD for 5 days
Diclofenac 50 mg/tab 1-tab q8 for 5 days
Proper body mechanics, avoid prolonged <insert
potential risk factor here>,
adequate rest and sleep, warm compress affected area
for 15 minutes 3x a day or as needed.
Refer to Rehab Medicine for further evaluation and
management (If indicated: symptoms persist >6
weeks)
Referral to LGU for possible psychosocial disability
certification.
Follow up after 3 days
Infectious Diseases
Viral Exanthem T/C Varicella Zoster / Herpes Zoster
(Shingles)/ Herpes Zoster ophthalmicus
<Routine labs if indicated>
If within 48 hours from the onset of rash or vesicles.
Start Acyclovir 800 mg/tab 1-tab q4 hours (8 am, 12 nn,
4 pm, 8 pm, 12 mn) for 7 days,
<If in severe pain> Pregabalin 75mg/tab 1-tab q12
Keep lesions dry, proper handwashing, avoid scratching
affected areas.
Isolate from household members,
contact and droplet precaution.
For patients with Herpes Zoster ophthalmicus
Refer to Ophthalmology for further evaluation and
management
Follow up after 2 weeks or once all lesions have DRIED.
Advised
Viral Exanthem T/C Rubeola
CBC with pc, Measles IgM, IgG c/o Public Health Unit
Cetirizine 10 mg/tab 1-tab ODHS for 2 weeks for
pruritus
Loratadine 10mg/tab 1-tab OD for 2 weeks for pruritus
Proper body hygiene, proper handwashing, Keep
lesions clean and dry. Avoid scratching affected areas.
Airborne precaution: Isolate from household members,
wear mask if necessary.
Watch out for progressive cough, fever, difficulty of
breathing or shortness of breath.
Refer to PHU for surveillance and testing.
Follow up after 1 week.
Advised
FOR EAST AVENUE MEDICAL CENTER DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE USE ONLY
T/C Schizophrenia
Limitation of activities due to disability [Z73.6]
<Imaging/routine labs if indicated>
Counselling done with the family member.
Keep company at all times.
Refer to Psychiatry for further evaluation and management.
For possible referral to LGU for possible psychosocial disability certification once
certified.
Follow up once seen by Psychiatry
Musculoskeletal Disorder (MSD), <indicate location> Arthritic Group of Diseases (AGD) T/C Gouty
e.g. Plantar fasciitis, Low back pain> or Arthritic arthritis in flare
Group of Diseases (AGD) T/C Osteoarthritis <Imaging/routine labs if indicated except BUA, may do
<indicate specific joint> BUA when patient is no longer in flare>
For severe symptoms add Colchicine 500 mcg/tab 1-tab q8 until 6 days or
Limitation of activities due to disability [Z73.6] relief of symptoms or diarrhea occurs
>40 YRS OLD, HYPERTENSIVES, DIABETICS, CKD UNLESS THERE IS CONTRAINDICATION:
<Imaging if indicated> Uncontrolled hypertension, history of chest pain, MI,
Lumbar MRI if with radiculopathy symptoms stroke, Gastric or duodenal ulcers
Scoliosis series if with scoliosis Select one if without any contraindication.
Lumbosacral Xray APL if with visible spine deformity or Celecoxib 200 mg/ tab, 1-tab q12 for 5 days
crepitus Etoricoxib 60 or 90 mg/tab 1-tab OD for 5 days
Paracetamol + tramadol 325+37.5mg/tab, 1-tab q8 Diclofenac 50 mg/tab 1-tab q8 for 5 days
PRN for pain for 5 days or DO NOT START URICOSURIC AGENTS LIKE
Paracetamol + Orphenadrine 650+50 mg/tab, 1-tab FEBUXOSTAT DURING ACUTE GOUTY ATTACKS
q8PRN for pain for 5 days or On follow up see Hyperuricemia.
Eperisone 50 mg/tab, 1-tab Q8 for 5 days Rest affected area, Elevate affected area when at rest
Proper body mechanics, avoid prolonged <insert Cold compress for 15 minutes 3x a day or more as
potential risk factor here>, tolerated
adequate rest and sleep, warm compress affected area Refer to Nutrition Clinic for a diet plan
for 15 minutes 3x a day or as needed. Diet: Low purine Diet (if no other co-morbidities)
Refer to Rehab Medicine for further evaluation and TC: 1539, CHO: 923, CHON: 231, Fat: 385
management (If indicated: symptoms persist >6 Follow up after 3 days
weeks) Advised
Referral to LGU for possible psychosocial disability
certification.
Follow up after 3 days
Dengue Fever Syndrome w/o warning signs Leptospirosis, Mild (Moderate- Severe, send to ER)
For CBC with PC CBC PC, UA, BUN, Crea, SGPT, SGOT, Lepto-MAT
Fever for 3 days- Dengue NS Doxycycline 100 mg/tab 1-tab q12 for 7 days
Fever for >3 days- Dengue IgG, IgM Paracetamol 500 mg/tab 1-tab q4 for fever >37.8 C
Paracetamol 500 mg/tab 1-tab q4 for fever >37.8 C ORS sachet dissolve in 200 ml of clean water and drink
ORS sachet dissolve in 200 ml of clean water and drink every 3-4 hours as tolerated
every 3-4 hours as tolerated Increase oral fluid intake
Avoid dark-colored foods WOF: Urination less than 4-6x per day, tea colored
WOF: Urination less than 4-6x per day, Abdominal pain urine, Abdominal pain or tenderness, Persistent
or tenderness, Persistent vomiting, Mucosal bleed vomiting, or yellowing of the skin
(gums, urine, vomitus) Follow up today with results or at the ER if OPD is
Follow up today with results or at the ER if OPD is closed.
already closed. Advised.
Advised. Have the patient sign on the chart that he/she will come
Have the patient sign on the chart that he/she will come back today with results or at the ER if OPD is closed
back today with results or at the ER if OPD is closed Example “Ako ay babalik sa OPD or sa ER dala-dala
Example “Ako ay babalik sa OPD or sa ER dala-dala ang resulta ngayong araw na ito”
ang resulta ngayong araw na ito”
EAMC DFCM OPD Charting Guidelines as of January 2020
DISCLAIMER: Please use this only as a guide during EAMC DFCM rotation. Good clinical judgement and updated knowledge supersedes this guideline.
Routine Patients
ESSENTIALLY WELL ADULT AT THE TIME OF CONSULT (pre-employment)
For Chest X-ray PAL, CBC w/ PC, UA,
(for food handlers) add FA, Anti-HAV
(for strenuous occupation) add 12 L ECG
Well balanced diet
Adequate oral fluid intake
Moderate intensity physical activity 30 mins/day 5x per week as tolerated. (for healthy Prescribed with <drug>
patients who you think can tolerate exercise)
Follow up ASAP with result
Advised
Endocrine / Metabolic/ Hematology Disorders
Anterior Neck Mass T/C Multinodular Toxic/Non-
Toxic Goiter, Hyperthyroidism,
If mass is small, do Thyroid Ultrasound
If mass is large or with CLAD, do Neck Ultrasound
TSH, Free T4, Free T3, Calcium),
CBC with PC, SGPT, SGOT.
<then monitor TSH every 6 weeks (4-8 weeks)>
Antithyroid medications:
Methimazole 5mg/tab 1-tab q8h (then adjust accordingly
at increments of 5mg)
Propranolol 10/tab 1-tab OD for palpitations,
tachycardia.
Avoid goitrogenic food such as Brussel sprouts,
radishes, cabbage, and cauliflower.
Watch out for fever, sore throat, generalized body
malaise, chest pain, severe palpitations, nervousness,
fatigue.
For possible referral to ENT-OHNS once with results
Follow up ASAP with results.
Advised
Dyslipidemia
When to start?
1. All diabetics, Stroke (CVA), TIA or MI patients should
be started on a HIGH INTENSITY STATIN.
2. ≥40 years of age ASCVD score >7.5%
3. ≥ 45 years with LDL-C ≥ 130 mg/dL AND ≥ 2 risk
factors*
Risk Factors: male sex, postmenopausal women,
smoker, hypertension, obesity (BMI > 25 kg/m2), family
history of premature CHD, microalbuminuria,
proteinuria, left ventricular hypertrophy
Target: LDL-C level of < 70 mg/dL
Dyslipidemia
Diagnostics: Repeat Lipid Profile after 2 months
<Imaging/routine labs if indicated>
Start Rosuvastatin 10 or 20 mg/tab 1-tab ODHS
Atorvastatin 20 or 40 mg/tab, 1-tab ODHS
Simvastatin 40 mg/tab 1tab ODHS
Refer to Nutrition Clinic for a diet plan
Diet: Low Fat Diet
TC: 1539, CHO: 923, CHON: 231, Fat: 385
Follow up after 2 months
Advised
Psychosocial Assessment
Tobacco use [ Z72.0] (_____Pack years)
Counselling done; smoking cessation advised. Patient
in ______ stage
Stages:
For stages Pre contemplation and Contemplation.
Advised to come back anytime if decided to quit.
For Preparation and Action
Refer to Smoking Cessation Clinic for further
counselling and management.
For Maintenance
Continue smoking cessation, avoid temptations and
influences.
FOR EAST AVENUE MEDICAL CENTER DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE USE ONLY
Follow ups from ER (treat as NEW patient)
Take note of the history of present Illness before the ER consult.
Then: Sought consult at <private clinic, hospital, government hospital/ OPD>
Diagnosed with <diagnosis>
Diagnostics done were <Tests>
Results were as follows <results>
Self-medicated with <drug>
With Relief/no relief of symptoms
Patient came in today as follow up per ED instructions.
Anterior Neck Mass T/C Hypothyroidism sec to (RAI/
Hashimoto Thyroiditis/ Multinodular Non-Toxic
Goiter/ Total Thyroidectomy)
If mass is small, do Thyroid Ultrasound
If mass is large or with CLAD, do Neck Ultrasound
TSH, Free T4, Free T3, Calcium (if S/P total
Thyroidectomy), <then monitor every 6 weeks>
Hypothyroid medications:
Less than 65 yrs old:
Initial Low dose: Levothyroxine 50 mcg/tab 1-tab OD
Full-dose Levothyroxine (1.6 to 1.7 mcg per kg)
65 years and older or who have ischemic heart
disease, start with: Levothyroxine 25 to 50 mcg per day
Avoid goitrogenic food such as brussel sprouts,
radishes, cabbage, and cauliflower, iodine rich foods.
Watch out for lack of energy, sleepiness, weight gain, or
lethargy
For possible referral to ENT-OHNS once with results
Follow up ASAP with results.
Advised
Asymptomatic Hyperuricemia
Repeat BUA after 2 months
<Imaging/routine labs if indicated>
WHEN TO START URICOSURIC AGENTS?
If with history of gout or uric acid Nephrolithiasis
7 mg/dl (416 umol/L) in men
6 mg/dl (357 umol/L) in pre-menopausal women
If without history of gout or uric acid nephrolithiasis.
9 mg/dl
Febuxostat 40 mg/tab, 1-tab OD
Refer to Nutrition Clinic for a diet plan
Diet: Low Purine Diet
TC: 1539, CHO: 923, CHON: 231, Fat: 385
Follow up after 2 months
Anemia probably IDA
For CBC wit PC with Red cell indices, Reticulocyte
count, serum ferritin.
Once confirmed with IDA, may start
FeSO4 323 mg/tab 1-tab OD for 3 months
Monitor CBC with PC monthly for increase 1 g/4 weeks
Iron-rich Diet: green leafy vegetables, organ or red
meats.
Follow up after 1 month with CBC result.
Advised
Insomnia [G47.0] Primary
(see DSM V Criteria)
Melatonin 3 mg/tab 1-tab 30 minutes before bedtime.
Proper sleep hygiene: Avoid bright screens 1-2 hours
before bedtime.
Avoid caffeinated food and beverages and strenuous
activities 4-6 hours before bedtime.
Follow up after 1 week.
Diabetes Mellitus Type 2, Diabetes Mellitus Type 2
suspect
Priority labs: FBS, HBA1C (if known DM prior to consult)
FBS only (if for DM suspect) LP, BUN, Crea, UA, 12 L
ECG.
BUA, CBC with pc, Na, K, Cl, SGPT SGOT
Chest X-ray PAL if indicated
<insert current maintenance medications here>
Or Start Metformin 500mg/tab 1-tab q8h
Gliclazide 80 mg/tab 1-tab OD/Q12
For CKD patients (EGFR less than 60)
Glimepiride 2 mg/tab 1-tab OD/q12
Sitagliptin 50 or 100 mg/tab 1-tab OD
For HBA1C >10 %: Insulin Glargine (0.1 to 0.2 IU/Kg)
or 10 IU SQ ODHS
Atorvastatin 20 mg/ tab 1-tab ODHS (ALWAYS
START FOR PTS WITH DM)
Strict compliance with medications
Daily foot care, proper foot gear
Refer to Nutrition Clinic for a diet plan
Diet: DM diet
TC: 1539, CHO: 923, CHON: 231, Fat: 385
Refer to Ophthalmology for official fundoscopy
Recommended pneumococcal and influenza vaccines
(age dependent)
Follow up after 1 week
Advised
Anemia, secondary
If with Abnormal uterine bleeding: Transvaginal
sonogram
If with ETBD, R/O Colonic New Growth, add
Fecalysis, Chest Xray PAL, Fecal Immunochemical test
c/o Gastro
Refer to Gastroenterology for further evaluation and
management.
Follow up ASAP with results.
Obese I or II
Lack of physical exercise [ Z72.3]
Inappropriate diet and eating habits [Z72.4]
Moderate intensity physical activity 30 minutes per day,
5x per week as tolerated.
Refer to Nutrition Clinic for a diet plan
Diet: Well-balanced diet, Low Salt, Low Fat Diet, DM
Diet, Low purine Diet if with co-morbidities,
TC: 1539, CHO: 923, CHON: 231, Fat: 385
Weight monitoring same time, same scale weekly and
record.
Follow up after 1 month
EAMC DFCM OPD Charting Guidelines as of January 2020
DISCLAIMER: Please use this only as a guide during EAMC DFCM rotation. Good clinical judgement and updated knowledge supersedes this guideline.
GUIDELINES IN FILLING UP THE CENSUS FILE
1. Patient number. Make sure no skipping of numbers. You can use autofill (10 error pts)
2. Type: There are 3 patient types: (10 error pts)
a. NEW: These are patients interviewed for the first time at Family Medicine Department
b. FF UP: these are patients who came back for follow up of his/her previous diagnosis.
c. OLD/NEW: these are previous patients who came back with a new complaint/ or lost to follow up.
3. Time seen: This is the time that the patient was seen by the RESIDENT (10 error pts)
4. Time D/C: This is the time that the RESIDENT finished ordering on the chart, it does not include the time that the clerks/JI finished carrying out doctor’s orders. (10 error pts)
5. TAT or turnaround time: this is the total time spent by the resident for each patient. Please ask the CLERK or INTERN in charge if it goes beyond 40 minutes. (10 error
pts)
6. Hospital Number: Do not rely on the OPD form, Look for the Hospital number at the side of the folder. (10 error pts)
7. Patient’s Name: Data Privacy act requires us to use the LAST NAME, and initial of the First name. e.g. Dela Cruz, J (10 error pts)
8. Age: 19-100 only we don’t handle Pediatric (18 and below) patients for now. (10 error pts)
9. Sex: M for Male, F for Female (10 error pts)
10. Contact number: May be landline or Mobile number. (10 error pts)
if none, clarify with the Clerk or Intern in charge. (10 error pts)
11. Address: Brgy and City is sufficient, do not type the whole address. E.g Brgy Tatalon, Quezon City (10 error pts)
12. Diagnosis: One diagnosis per line.
E.g Hypertension Stage II
Diabetes Mellitus
AGD t/c Osteoarthritis
13. Plan: standard order of plan is
a. Diagnostics (10 error pts)
b. Medications (10 error pts)
c. Non-Pharmacologic management (10 error pts)
d. Referrals (10 error pts)
e. Follow up (10 error pts)
14. Disposition: (10 error pts)
a. Discharged: these are patient discharged from our department.
b. Referred: these are the patents referred to other specialties on the SAME day.
c. To ER: these are emergency cases that was referred to ER.
15. Senior RIC: Make sure all charts that you input on the excel file has the Senior RIC stamp, if it does not contain any stamp from Senior, clarify it with the
Resident/Intern/Clerk in charge. (10 error pts)
16. Junior RIC: Make sure all charts that you input on the excel file has the 1st year RIC stamp, if it does not contain any stamp from Senior, clarify it with the
Resident/Intern/Clerk in charge. Exception: if the senior personally saw the patient and was not referred to a 1 st year resident. (10 error pts)
17. Referred: click referred to if the patient was referred to other departments. This different from REFERRED in disposition Column where patients were immediately referred
to other departments the same day. (10 error pts)
18. Referrals 1 to 3 indicate the departments where the patient was referred to. (10 error pts)
19. WELLNESS if the patient is Essentially Well at the time of Consult and Medical certificate was given. (10 error pts)
a. Wellness checkup: patients without disease who came in for checkup.
b. Illness resolved: patients previously diagnosed and disease is resolved, do not use for patients with chronic diseases. This is for acute illnesses only.
c. Occ Pre employment: use this for patients for pre employment purposes.
d. Occ Medical Certificate: For patients asking for medical certificate. Use this if the patient was seen at our department and was diagnosed immediately as
Essentially well adult.
20. Referral from other department: these are the patients seen at other departments and was referred to ours for co-management. (10 error pts)
21. Waiting time: always indicate the waiting time computed by the Vital Signs Clerks (10 error pts)
22. Color Codes
Pink - Well Adult (Resolved or Essentially Well Adult)
Green - Referred
Yellow - SHOULD NEVER BE EMPTY (WITH EXEMPTIONS)
Red - SHOULD NEVER BE EMPTY (200 error pts)
23. Before submitting the census file to Dr. Magbojos please make sure. (10 error pts)
a. All spelling errors are corrected
b. At least either Senior RIC or Junior RIC is filled up
c. No Empty Cells on columns A-P
24. If you have any questions or experiencing any errors, do not hesitate to call the attention of Dr. Adrian Magbojos. Merits will be given to those who will discover errors, and
demerits will be given to those who does not follow this guideline. *50 error pts = 1-hour demerit

FOR EAST AVENUE MEDICAL CENTER DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE USE ONLY
EAMC DFCM OPD Charting Guidelines as of January 2020
DISCLAIMER: Please use this only as a guide during EAMC DFCM rotation. Good clinical judgement and updated knowledge supersedes this guideline.
DOH CENSUS EDITING GUIDELINES
1. Download a Copy of Census .DOCX from the Census folder link 4. Replace with ALLM (the Standard Initial of the Dr., See List
2. ADD DOH After the Date of the filename e.g (OPD Census October 1, 2019 DOH) for details) hit Replace all. Click Yes
3. Open the file
4. Click the “Type” column, hit delete. Type the Census Date e.g. October 1, 2019.
Highlight October 1, 2019, then Ctrl + C to copy. Click the whole column then Ctrl + V
to paste. Then Change the Column header to “Date”.

5. then Click OK.

5. Select the TAT column by click at the top of the column. Hit Backspace to delete the
entire column.
6. Select Plan Column by click at the top of the column. Hit Delete to delete the cell
contents. At the first cell of the column, type “None”. Highlight the word “None” and
copy (CTRL + C). Select the whole column then paste ( Ctrl + V). Change the Header
cell to Operations/ Procedures.

7. Change all the Names of the Residents to their Initials. INITIALS for DOH Census
4. At the Senior RIC or Junior RIC Column, Highlight the Name of the Doctor Third Year
you want to change. Ctrl + C to copy. Mary Jean Rigor-Delamida, MD MJRD
Wilma Cristina T. Gatchalian, MD WCTG
Matthew Benedict T. Tolosa, MD MBTT
Second Year
Gillian Chris R. Maraña, MD GCM
Rosa Andrea C. Valencia, MD RAV
Assumption G. Vanguardia, MD AGV
First Year
Adrian Levi L. Magbojos, MD ALLM
Abegail A. Masangkay, MD AAM
5. Find and click Replace. April Quintua-Alimbuyuguen, MD AQA
Jireh Knowell B. Alparas, MD JKBA
Eunice F. Cristobal, MD EFC
Sharmaine Rose L. Medel, MD SRLM
Manuel Karlo L. Parungo, MD MKLP
Cris John V. Supetran, MD CJVS

6. At the “find what Text Box, Paste the name of the Dr. you want to replace.

8. Your final table should look like this.

FOR EAST AVENUE MEDICAL CENTER DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE USE ONLY