#Annual Physical Exam, Adult
Pt here for an annual physical exam.
ADLs: Patient able to ambulate/transfer, continence, feeding independently. The patient needs assistance for bathing, dressing, toileting from his wife.
Cognitive skills: Normal perception, attention, memory, reasoning, decision-making, and problem-solving.
Advanced Directives: Discussed End-of-life and Advanced care planning – resuscitation preferences, health proxy, etc.
HEALTH MAINTAINANCE & HEALTH EDUCATION PROVIDED
Health education provided: Dental health, Diagnosis/Prognosis, New Treatment, New Medications, Sexual practices/STD, Substance abuse.
Diet, exercise and weight management discussed.
Safety & injury prevention: Driving safety, smoke detectors, firearms, etc discussed.
Immunizations: Discussed age appropriate vaccinations.
Disease Screening: Age appropriate cancer screening and age appropriate disease screening done.
