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Hypertension Flow Sheet: Baylor/Agape Outreach

Patient Name:

Instructions: Complete flow sheet. Answers indicating presence of problem should be circled, further explored, and if significant, SOAPed. Note that most patients with mild to moderate hypertension are not symptomatic. Teach this to patients! Update medication list with complete information (include prescriber's name) and determine if patient is compliant.

Parameter (Initials by date)	Date/	Date/	Date/	Date/
Medications: Compliant? Y/N List below	.	.	.	.
General	.	.	.	.
Pain (chest, other)	.	.	.	.
Appetite	.	.	.	.
Sleep	.	.	.	.
Fatigue/tired	.	.	.	.
Fever/chills	.	.	.	.
Weight changes	.	.	.	.
Specific to HTN/CAD (+/-)	.	.	.	.
Headache	.	.	.	.
Dyspnea (exertion - distance)	.	.	.	.
Nocturia (times/night)	.	.	.	.
Carotid bruits (hold breath)	.	.	.	.
Heart sounds (murmer?)	.	.	.	.
Gallop, extra systole?	.	.	.	.
Edema	.	.	.	.
S/S CHF	.	.	.	.
Self-management (+/-/#)	.	.	.	.
BP checks/week (recorded)	.	.	.	.
Verbalizes target BP: <135/85	.	.	.	.
Weights recorded/week	.	.	.	.
Verbalizes specific < Na diet	.	.	.	.
Exercise: # days/week/minutes/session	.	.	.	.
Alcohol: Specific amt (< 2 day)	.	.	.	.
Smoking habits (#/day)	.	.	.	.
BP today R/L	.	.	.	.
AP/Resp	.	.	.	.

List medications (note if using back of sheet, include dose, frequency, doctor/NP)