HM Tips



// Examples:

//        Benadryl 50mg PO q6hrs

//        Amoxicillin 500mg PO BID

//        ...when in doubt - just write it out!

//        Flonase 2 puffs each nostril every day


//   dose: always include units (mg, mcg, IU)

//   route: PO (oral)

//          INH (inhaled)

//          SQ (subcutaneous)

//          IV (intravenous)

//          IM (intramuscular)

//          PR (rectal)

//          PV (vaginal)

//          GTT (eyedrops)

//   frequency: qAM (every morning)

//              qPM (every evening)

//              qHS (before bed)

//              qAC (before meals)

//              q4hr (every 4 hours)

//              qDay (daily)

//              qWeek (weekly)

//              BID (twice a day)

//              TID (three times a day)

//              QID (four times a day)



    { } Temperature       (ok 97.6 - 100.3 F)

    { } Blood pressure    (ok 90/60 - 140/90) ** Kids are different!

    { } Heart rate        (ok 60-99) ** Kids are different!

    { } Respiratory rate  (ok 12-20) ** Kids are different!

    { } SPO2 (ok to skip SPO2 if NO respiratory complaint OR history)

 Intake info:

    { } Height

    { } Weight

    { } Pain level

 Annual Questions

    { } Verify it was completed within the last year

    { } Verify PCM Name is filled in and correct

    { } Verify phone number filled in and correct


    { } ** Copy forward allergies

    { } Verify allergies today.  If none: NKDA (No Known Drug Allergies)

    { } If drug allergy, write the MEDICATION: REACTION for all!

    { } Put non-drug allergy (ie latex, peanuts) at the bottom


    { } ** Copy forward medications

    { } Verify that all medications are current

    { } Remove any medications the patient is not currently taking

    { } Verify dose and frequency

    { } Ask if patient needs refills of medications (mark these on the check-in sheet)

 Past Medical History

    { } **Copy forward the past medical history

    { } Find Dr. Rock's last note, and add the PROBLEM LIST to the bottom 

        of the surgical history.

 Other stuff

    { } After your note is done, go back to look at it.  You may have to go back and remove things that you did not actually ask.

(- Setting up for Pelvic exam -)

 * If a patient will likely need an exam, set up ahead of time and cover the clean equipment with a paper towel or chux pad.


 * Place a chux pad white-side up, underneath the exam table paper.


 * Place a sheet on the exam table.


 * Please DON'T ask the patient to undress - Doctor will talk to them first.



--- Pelvic exam due to concern of discharge or bleeding ---

    { } Speculum.  Have all 3 sizes in the room.  Ensure the available light will work with the type of speculums available.

    { } Light Source.

    { } Gel - 4 packets (2 for the speculum, 2 in case pelvic exam required).

    { } "Fluffy" Scopette (large Q-tip).

    { } Ensure there is a rolling stool in the room.


    { } GC/CT swab kit.

    { } Test tube with sealable end.

    { } Dropper of sterile normal saline.

    { } Cotton Tipped Applicator (CTA, the Q-tip on a wooden stick)



    1) Hand the doctor the speculum and the light.  

    2) Open two packets of gel (holding them together) and squeeze them onto the top of the speculum.

    3) While the doctor is positioning the speculum, get the GC/CT kit ready.

    4) Doctor should  verbalize which swabs to hand over, and which ones are being handed back.  The GC/CT swab ideally is left in place for 10 seconds, so often this is the first swab to go in, but the last one to come out.  

    5) CTA should be broken off in a test-tube, and immediately saline can be put in the tube, just covering the cotton tip portion.

    6) After the procedure is complete, ensure the patient is given tissue/wet wipes to clean away any extra gel.

    7) Step out  so that the patient can change.

    8) Label everything and make sure it gets to lab appropriately!