AHLTA note
From NavyHPSPWiki
New Patients
- See the patient, do a full physical, then present very briefly and matter-of-factly to your attending. Don't regurgitate the note, she'll read it. Then write your note, then give the chart to your attending.
- Note
- Click the HPI tab then enter the HPI in the "encounter background information" free text box.
- Begin with "Referred by _______, for ______" if they were referred.
- Click the PMH tab then expand "Past Medical History"
- Click "+" on medical history, then enter free text
- then expand medical history and click on + for "allergies" and enter free text
- Click "+" on surgical/procedural history, then enter free text
- Click "+" on medications, then enter free text
- Click "+" on family history, and enter free text
- Click "+" on social history, and enter free text (hint for Peds: HEADSSS)
- Click "+" on medical history, then enter free text
- Click ROS and review 10. If normal, click normal and be done.
- Click PE and do a full physical (head, eyes, ENT - check the ears, tonsils, cervical LAD, lungs, heart, chest, abdomen, extremeties, etc)
- Click Vital signs
- Click current vital signs reviewed
- click Standard measurements
- Click weight
- Click current weight recorded
- Click weight
- For each body part, click body part and free text
- Click Vital signs
- RAD/LAB - only if relevant
- Fill out the A/P and disposition
- Click the HPI tab then enter the HPI in the "encounter background information" free text box.
