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Registered Nurse
30-45 minutes

Podiatry Documentation (Physical Examination - Foreign Object)

The s10.ai Podiatric Notes template is expertly crafted for healthcare professionals to meticulously document cases of foreign bodies in the foot. This template offers a detailed framework to record patient information, symptoms, and treatment strategies, making it indispensable for capturing instances of objects such as glass or splinters embedded in the foot. It facilitates comprehensive documentation of patient history, physical examination results, and subsequent care plans. Perfect for both podiatric and general practice environments, this template enhances thorough documentation, supporting effective patient management and follow-up care. Explore the s10.ai Podiatric Notes template to streamline your clinical documentation process today.

4,899 uses
5/5.0
J
Jordan Patel
Template Structure

Organized sections for comprehensive clinical documentation

Patient: [Patient Name]
Account No: [Patient Account Number]
Date: [Date]
Chief Complaint:
This [Patient Age] year-old [Patient Gender] presents today stating that [describe patient’s concern regarding the presence of a foreign body in the foot, including which foot is affected]. The condition has been present for [describe duration of the condition, including whether it has lasted days, weeks, months, or years]. Patient [describe whether the patient recalls stepping on a specific object, such as glass or wood splinter, or if they do not recall any trauma to the area]. Patient relates [describe symptoms such as pain, tenderness, redness, or drainage]. At home, patient [describe any home care efforts, including soaking, attempts to remove the foreign body, or if no home care was attempted].
Allergies:
[List all known allergies, including drug, food, or environmental allergies, if mentioned. If none, omit.]
Medications:
[List all current medications, including name, dosage, and frequency. Include prescription and over-the-counter medications as well as any supplements, if mentioned.]
Past Medical History:
[Include any past medical conditions relevant to the patient's history. Only include if mentioned.]
Past Surgical History:
[Detail any past surgical procedures if mentioned.]
Family History:
[Include relevant family medical history if discussed, such as hereditary conditions or predispositions.]
Social History:
[Include relevant social history if mentioned, such as smoking, alcohol use, occupational risks, and lifestyle factors.]
Immunizations:
[Include any relevant immunization history if available.]
Review of Systems:
- Constitutional: [Describe any constitutional symptoms such as fever, fatigue, or weight changes]
- Cardiovascular: [Include relevant cardiovascular symptoms if mentioned]
- Endocrine: [Detail any endocrine concerns if applicable]
- ENMT: [Include relevant ENT or mucosal findings if applicable]
- Eyes: [Include any relevant eye-related symptoms]
- Gastrointestinal: [Include any gastrointestinal symptoms if relevant]
- Genitourinary: [Include any GU-related symptoms if applicable]
- Immunologic: [Include any immunologic findings if relevant]
- Integumentary: [Describe relevant skin-related symptoms]
- Lymphatic: [Include any lymphatic concerns]
- Musculoskeletal: [Describe any musculoskeletal concerns]
- Neurological: [Include any neurological symptoms if applicable]
- Psychiatric: [Include any relevant psychiatric findings]
- Respiratory: [Include any respiratory symptoms]
Physical Exam:
[Vitals: Include vital signs if recorded.]
Constitutional:
Patient is a pleasant, [describe patient’s general appearance, including level of distress, hygiene, and orientation]. Oriented to [describe patient’s orientation to person, place, and time]. Mood and affect appear [describe patient’s mood and affect, noting any abnormalities or appropriate responses to the situation].
Cardiovascular:
Skin temperature is [describe temperature of the skin in both feet].
Dorsalis pedis pulses are [document pulse strength on a scale of 0-4] left and [document pulse strength] right.
Posterior tibial pulses are [document pulse strength on a scale of 0-4] left and [document pulse strength] right.
Capillary fill time is [document capillary refill time] left and [document capillary refill time] right.
[Describe presence or absence of edema, including whether it is pitting and its severity if applicable].
Varicosities [describe presence or absence of varicosities and affected extremities].
Skin:
Skin color is noted to be [describe skin color findings, including normal, cyanotic, or reddened].
Skin texture is noted to be [describe texture such as normal, thin, or dry].
Examination of [describe affected area] reveals [describe symptoms such as erythema, hyperkeratosis, or the presence of a dark object]. The area [describe presence or absence of infection, purulent drainage, or cellulitis].
Neurological:
Vibratory sensation is [describe findings for each foot].
Sharp-dull sensation is [describe findings for each foot].
Light touch sensation is [describe findings for each foot].
Deep tendon reflexes are [describe presence or absence of reflexes].
Coordination is [describe coordination findings].
Musculoskeletal:
Muscle strength of extremities is [describe strength findings, including normal or diminished].
Manual muscle testing is [document strength on a scale of 1-5] out of 5 for all groups.
Impression:
[Provide a clinical impression or diagnosis based on the findings.]
Plan:
[Detail the treatment plan, including any prescribed medications, interventions, procedures, referrals, or follow-up instructions.]
[Describe any specific instructions given to the patient, including wound care, home management, and activity limitations if applicable.]
X-rays [describe whether imaging was taken and reviewed].
I&D [describe whether an incision and drainage procedure was performed].
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs, or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)
Sample Clinical Note

Example of completed documentation using this template

Patient: John Doe  
Account No: 123456  
Date: 1 November 2024  
Chief Complaint:  
This 45-year-old male reports feeling a sharp object in his right foot. The issue has persisted for two weeks. The patient remembers stepping on a piece of glass while walking barefoot in his garden. He describes experiencing pain, tenderness, and redness in the affected area. At home, he attempted to soak the foot and remove the glass but was unsuccessful.
Allergies:  
None
Medications:  
Ibuprofen 200 mg, twice daily
Past Medical History:  
Hypertension
Past Surgical History:  
Appendectomy in 2010
Family History:  
Father has a history of diabetes
Social History:  
Non-smoker, occasional alcohol use
Immunizations:  
Up to date
Review of Systems:  
- Constitutional: No fever, fatigue, or weight changes  
- Cardiovascular: No chest pain or palpitations  
- Endocrine: No thyroid issues  
- ENMT: No sore throat or nasal congestion  
- Eyes: No vision changes  
- Gastrointestinal: No nausea or vomiting  
- Genitourinary: No urinary symptoms  
- Immunologic: No known immunologic issues  
- Integumentary: Redness and tenderness in the right foot  
- Lymphatic: No lymphadenopathy  
- Musculoskeletal: Pain in the right foot  
- Neurological: No headaches or dizziness  
- Psychiatric: No anxiety or depression  
- Respiratory: No cough or shortness of breath  
Physical Exam:  
Vitals: Blood pressure 130/85 mmHg, Heart rate 78 bpm, Temperature 36.8°C
Constitutional:  
Patient is a pleasant, well-groomed male, in mild distress due to foot pain. Oriented to person, place, and time. Mood and affect appear appropriate.
Cardiovascular:  
Skin temperature is warm in both feet.  
Dorsalis pedis pulses are 2+ left and 2+ right.  
Posterior tibial pulses are 2+ left and 2+ right.  
Capillary fill time is less than 2 seconds left and right.  
No edema noted.  
No varicosities observed.
Skin:  
Skin color is noted to be normal.  
Skin texture is noted to be normal.  
Examination of the right foot reveals erythema and the presence of a dark object under the skin. The area shows no signs of infection or purulent drainage.
Neurological:  
Vibratory sensation is intact in both feet.  
Sharp-dull sensation is intact in both feet.  
Light touch sensation is intact in both feet.  
Deep tendon reflexes are present.  
Coordination is normal.
Musculoskeletal:  
Muscle strength of extremities is normal.  
Manual muscle testing is 5 out of 5 for all groups.
Impression:  
Foreign body in the right foot, likely glass shard.
Plan:  
- Prescribed antibiotics to prevent infection.  
- Advised warm soaks and elevation of the foot.  
- Scheduled for removal of the foreign body in the clinic.  
- Follow-up in one week to assess healing.  
X-rays were taken and reviewed, confirming the presence of a foreign body.  
I&D procedure scheduled for foreign body removal.
Clinical Benefits

Key advantages of using this template in clinical practice

  • This comprehensive clinical template is designed to streamline the documentation process for healthcare professionals managing cases involving foreign bodies in the foot. It provides a structured format to capture essential patient information, including chief complaints, medical history, and detailed physical examination findings. The template ensures thorough documentation of symptoms, home care efforts, and review of systems, enhancing diagnostic accuracy and treatment planning. With sections dedicated to allergies, medications, and family history, clinicians can quickly assess potential risk factors and tailor interventions. The template also facilitates the recording of vital signs, neurological assessments, and musculoskeletal evaluations, ensuring a holistic approach to patient care. By adopting this template, clinicians can improve workflow efficiency, enhance patient outcomes, and ensure compliance with clinical documentation standards. Explore this template to optimize your clinical practice and deliver high-quality patient care.
Frequently Asked Questions

Common questions about this template and its usage

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Podiatry Documentation (Physical Examination - Foreign Object)