drgfms, Author at The SOAPnote Project

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Home » Archives for drgfms

Subjective — Review of systems
DBQ – Diabetes
VA DBQs MA Workflow
DBQ – Ankle
DBQ – Muscle
DBQ – Esophagus
DBQ – Esophagus
DBQ – Shoulder
DBQ – Foot
DBQ – Temporomandibular Joint Conditions
DBQ – Hip and Thigh
DBQ – Work Impact
DBQ – Other Intestinal Problems
DBQ – Skin
DBQ – Scars
DBQ – SHA
DBQ – Ear
DBQ – Headaches
DBQ – Sleep Apnea
DBQ – PERIPHERAL NERVES CONDITIONS
DBQ – Hand
DBQ – Knee
DBQ – Back
DBQ – Kidney
DBQ – Hepatitis
VA DBQ – History
Plan – Medicare personalized plan of service
Subjective – Medicare Health Risk Assessment
Internal – Pre-visit planning and Checklists
Internal – SBAR Handoff for office messages and communication
Frontload include — Lab Picklist
frontload include — condition checkbox list
frontload include — condition and diagnosis dropdown
frontload include — psych and addiction symptoms severity
frontload include – 6 condition history block
Objective — Physical Exam — Pediatric well and sports participation
Subjective — HPI — Psychiatric follow-up
Subjective — Transitional Care Management Encounter
Hospital Running DC Summary and Hand Off
Complete Note — Telemed

Assessment — O2 Therapy continues to Benefit
Procedure — Epicondyle (tennis elbow) Injection
Subjective — HPI — Diabetes Mellitus History
Assessment — Wells Clinical Prediction Rule for DVT
Assessment — Ontario Family History Assessment Tool Breast and ovarian cancer
Procedure — Toenail Removal
Subjective — HPI — Headache/Migraine
Complete Note — Power Wheelchair/POV certification
Care Plan — Handout — Cortisone Injections
Assessment – DME hospital bed
Care Plan — 3×3, 4×4 insulin adustment
Assessment — Wells Clinical Prediction Rule for Pulmonary Embolism
Plan — Coumadin adjustment calculator
Assessment and Plan – Adult Well Visit
Subjective — HPI — Well Man Adult
Assessment, goals and plan – Psychiatric
chronic condition history building block
Administrative – Controlled Substances Agreement
Objective – Comprehensive Psychiatric Exam
Subjective – HPI – Psychiatric follow-up
Assessment — Acute Bacterial Rhinosinusitis Decision Tool
Subjective – HPI – Peds Well Visit
Subjective — HPI — Well Woman Adult
Objective – Physical Exam – General IM Exam
Assessment – DME – Wheelchair certification
Encounter Timer
Assessment and Plan – Musculoskeletal
Objective – Physical Exam – Adult Chronic Exams
Procedure – Large Joint Injection
Subjective – HPI – Adult Acute Visit
Assessment
Assessment – ASCVD Risk Estimator
Plan
Comprehensive Patient Profile – Chronic Conditions – Acute Problem – HPI
Subjective — Questionnaire — Fibromyalgia symptoms – Widespread Pain Index
Psychiatric Intake and Followup
Objective – Physical Exam – Musculoskeletal
Subjective — Simple/Additional HPI, ROS, and Questionnaires — Adult Visit
Subjective – HPI – Chronic Condition History

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