The hypertension evaluation MedicalTemplate is suitable for any health care provider that manages patients with known or suspected hypertension (high blood pressure).
The hypertension evaluation MedicalTemplate includes all required E&M documentation elements for even the highest levels of complexity for established patients.
The hypertension evaluation MedicalTemplate is suitable for any health care provider that manages patients with known or suspected hypertension (high blood pressure).
The hypertension evaluation MedicalTemplate includes all required E&M documentation elements for even the highest levels of complexity for established patients.
The hypertension evaluation MedicalTemplate is suitable for any health care provider that manages patients with known or suspected hypertension (high blood pressure).
The hypertension evaluation MedicalTemplate includes all required E&M documentation elements for even the highest levels of complexity for established patients.
Hypertension Evaluation Patient Name Patient DOB MRN
Date Chief complaint/Reason for consult Referring MD
Start Time Stop time
Data Reviewed History of Present Illness Comorbid conditions
Allergy list Cardiac disease Medication list Diabetes Dyslipidemia Past Medical History Polycystic ovarian syndrome Past Surgical History Renal artery stenosis Social History Renal disease, chronic Family Medical History Sleep apnea Premature Coronary Artery Disease Thyroid disease Familial Hyperlipidemia Physical activity limited BMI t30 Patient’s Blood Pressure log Smoking Recent labs and diagnostic tests Review of Systems Physical Exam WNL = Within Normal Limits
= Patient denies problems
✔ Vitals Ht Wt BMI Pulse Rhythm Reg Irreg Respiratory Rate Constitutional BP L arm R arm Sitting Standing Supine Weight changes Fatigue Fever General Alert Well nourished Obese Cachectic Hygiene Appropriate Unkempt Eyes Eyes Conjunctivae WNL Pupils WNL Discs WNL No visible retinal pathology Vision changes Pain ENT Nasal mucosa WNL Dentition WNL Oropharynx WNL ENT/Mouth Neck Normal to palpation Thyroid WNL No JVD Ulcers Tooth pain Nose bleeds Resp Clear to auscultation Clear to percussion Effort WNL Normal to palpation Respiratory CV Auscultation WNL Palpation WNL No edema Carotids Aorta Femoral pulses Pedal pulses Dyspnea Cough Sputum GI No palpable masses Liver and spleen not palpable No hepatojugular reflux Cardiovascular Chest pain Exercise intolerance Lymph No lymphadenopathy Enlarged lymph nodes palpable Neck Axilla Groin Other Diaphoresis Paroxysmal nocturnal dyspnea Musc Gait Digit Inspection ROM Stability Strength Gastrointestinal Extrem No clubbing No cyanosis No sores Nausea Vomiting Diarrhea Skin Inspection Palpation Abdominal pain after eating Neuro Oriented CN DTR Sensation intact Vibratory sense intact Genitourinary Psych Affect Orientation Insight Memory Dysuria Polyuria Erectile dysfunction Additional Findings Musculoskeletal Myalgias Bony pain Claudication Skin/breasts Impression & Plan Sores, ulcers Dry, cracked skin Blood Pressure Class SBP DBP Neurologic Normal <120 <80 Numbness Paresthesias Focal weakness Prehypertension 120-139 80-89 Patient at goal < 140/90 or <130/80 for DM Endocrinologic Stage 1 140-159 90-99 Not at Goal Hypoglycemia Tremors Stage 2 t160 t100 Hematologic/Lymphatic Easy bruising Swollen lymph nodes Allergy/Immunology Sinus pain Nasal discharge Psychiatric Depression Anxiety Hallucinations Follow up This clinic Cardiology Endocrinology Nephrology Signature Ophthalmology cc Other Estimated Creatinine Clearance * Multiply by 0.85 for females (140 – age) x weight ( kg) = Normal Creatinine Clearance in healthy young females ~100mL/min/1.73m2 Plasma Creatinine x 72 Normal Creatinine Clearance in healthy young males ~120mL/min/1.73 m2 Labs Urinalysis CBC PT, PTT, INR BMP LFTs Triglyceride level LDL and HDL BNP EKG ECHO TSH Therapy Aspirin ACE-I or ARB Beta blocker Calcium Channel Blocker Thiazide diuretic Loop diuretic Statin Other