Procedure – Dsg change, Suture/staple removal

[checkbox name="historian" value="new patient|existing patient||history provided by patient|history provided by family member||SO/family member present during visit|chaperon/MA present during visit||interpretation provided by family member/SO|interpretation provided by MA|"][textarea cols=50 rows=3]
CC: [checkbox name="cc" value="wound recheck|packing removal|wound repacking||suture removal|staple removal|"][textarea cols=50 rows=3]
LOCATION: [textarea cols=40 rows=1]
HPI: [checkbox name="HPI" value="originally seen here|originally seen elsewhere||3 days ago|7 days ago|10 days ago||taking abx|abx not given||healing well|denies increasing pain/fever/redness/discharge|denies motor/sensory/vascular loss|"][textarea cols=50 rows=3]
PERTINENT MEDICAL HISTORY: [checkbox name="recent" value="recent hospitalization|surgery|recent specialty consult|recent new/changed medications||recent travel|sick contact||smoker|immunosuppression||non-contributory||none provided||"][textarea cols=50 rows=3]


REVIEW OF SYSTEMS:     [+] reported  [-] not reported
negative except as stated in HPI

CONSTITUTIONAL: [textarea cols=40 rows=1]
[checklist name="const_symptoms" value="objective fever|subjective fever|chills"]
EYES: [textarea cols=40 rows=1]
[checklist name="eye_symptoms" value="change in vision|photophobia|periorbital swelling|pain with EOM"]
EARS: [textarea cols=40 rows=1]
[checklist name="ear_symptoms" value="pain|bleeding|tinnitus|decreased in hearing"]
NOSE: [textarea cols=40 rows=1]
[checklist name="nose_symptoms" value="discharge|snoring|bleeding"]
MOUTH/THROAT: [textarea cols=40 rows=1]
[checklist name="throat_symptoms" value="bleeding|tongue pain/swelling|sore throat|odynophagia|dysphagia|hoarseness"]
NECK: [textarea cols=40 rows=1]
[checklist name="neck_symptoms" value="pain|stiffness|swelling|swollen glands"]
CV: [textarea cols=40 rows=1]
[checklist name="cv_symptoms" value="chest pain/pressure|dyspnea|orthopnea|ankle swelling|ankle discoloration|leg cramps"]
CHEST/RESPIRATORY: [textarea cols=40 rows=1]
[checklist name="chest_symptoms" value="chest tightness|pain w/ breathing|rib pain|cough"]
GI: [textarea cols=40 rows=1]
[checklist name="gi_symptoms" value="poor appetite|nausea|vomiting|abdominal pain|constipation|diarrhea"]
GU: [textarea cols=40 rows=1]
[checklist name="gu_symptoms" value="dysuria|hematuria|retention|oliguria|incontinence|genital lesions/discharge"]
NEURO: [textarea cols=40 rows=1]
[checklist name="neuro_symptoms" value="dizziness|vertigo|poor balance|abnormality of walk|focal weakness|blackouts|seizures|tingling/numbness"]
PSYCH: [textarea cols=40 rows=1]
[checklist name="psych_symptoms" value="irritability|confusion|depression|anxiety|mood swings|memory loss|insomnia"]
LYMPH/HEMA: [textarea cols=40 rows=1]
[checklist name="hem_symptoms" value="gland swelling|bruising|anticoagulation|DVT/clotting|anemia|autoimmune dz|h/o cancer"]



Appearance: [checkbox name="appearance" value="well-appearing|alert|non-toxic|normal WOB||crying but consolable|speaking in full sentences||ill-appearing|tired-looking|short of breath|diaphoretic||drowsy|appears impaired|slumped||heavy built|muscular|lean|well-nourished|frail|"][textarea cols=50 rows=3]
Skin: [checkbox name="skin" value="warm, dry|grossly intact, no rashes|no bruises|normal turgor|dry||tattoos|body piercings||pallor|cyanosis|poor turgor|diaphoresis|rash|"][textarea cols=50 rows=3]
Head/Face: [checkbox name="head" value="normocephalic, atraumatic|symmetrical face|CN grossly intact|"][textarea cols=50 rows=3]
Eyes: [checkbox name="eyes" value="clear conjunctiva w/o exudates or hemorrhage, anicteric sclera, EOM intact without nystagmus|visual acuity grossly intact||conjunctival injection|epiphora|conjunctival exudate||allergic shiners|dennie lines||palpebral edema|palpebral exudates||glasses|contacts|"][textarea cols=50 rows=3]
Ears: [checkbox name="ears" value="symmetrical & intact auricles bilaterally|hearing to conversation intact|no mastoid tenderness||clear canals without erythema or discharge|TMs normal in appearance||tragal tenderness|swelling of external auditory canal|pustule in canal|cerumen in canal|TM obscured by cerumen||HOH|hearing aid(s)||TM red|TM bulging|TM perforated||TM retracted|fluid behind TM|tube in TM||mastoid tenderness|"][textarea cols=50 rows=3]
Nose: [checkbox name="nose" value="nares patent bilaterally|septum midline|no facial tenderness|mucosa pink & moist||allergic salute|maxillary tenderness|frontal tenderness||deviated septum||mucosal edema|clear discharge|purulent drainage|"][textarea cols=50 rows=3]
Mouth: [checkbox name="mouth" value="tongue normal in appearance w/o lesions and with good symmetrical movements|moist oral mucosa without lesions||upper denture|lower denture|poor dentition|tooth decay||single oral ulcer|multiple oral ulcers|gum swelling|"][textarea cols=50 rows=3]
Throat: [checkbox name="throat" value="normal voice|no stridor|patent pharynx w/o swelling or exudates|uvula midline||hoarseness|inspiratory stridor|muffled voice||vesicles on soft palate|petechiae on soft palate||pharyngeal erythema w/o exudates|pharyngeal crowding|tonsilar enlargement|tonsilar erythema|tonsilar exudates|tonsilar crypts|tonsilar pustules|"][textarea cols=50 rows=3]
Neck: [checkbox name="neck" value="symmetric with free painless ROM|no masses noted|no LAD||anterior LAD|posterior LAD|"][textarea cols=50 rows=3]
Chest/Lungs: [checkbox name="lungs" value="normal work of breathing, symmetrical chest expansion|chest wall atraumatic and non-tender|no retractions||clear and equal breath sounds bilaterally|no axillary or supraclavicular LAD||respiratory distress|breath sounds decreased bilaterally|coughing|poor effort||expiratory wheezing|crackles|"][textarea cols=50 rows=3]
CV: [checkbox name="cv" value="regular rhythm|no murmurs|no ankle edema||tachycardia|irregular heart rhythm|systolic murmur||ankle edema|varicosities|stasis discoloration|calf tenderness|"][textarea cols=50 rows=3]
Abdomen: [checkbox name="abd" value="normal visual inspection|no distension|protruding||normal bowel sounds|soft|non-tender||guarding|diffuse tenderness over entire abdomen w/o RRG|direct non-rebound tenderness||hypoactive bowel sounds|hyperactive bowel sounds||not examined|"][textarea cols=50 rows=3]
GU: [checkbox name="gu" value="no suprapubic tenderness|no CVAT bilaterally||normal external genitalia||not examined|"][textarea cols=50 rows=3]
MSK: [checkbox name="spine" value="no gross deformities, moves all extremities with good ROM for age|full weight-bearing|normal curvature & ROM in C- & L-spine for patient’s age|"][textarea cols=50 rows=3]
Neuro: [checkbox name="neuro" value="normal concentration and attention|memory grossly intact||balance & coordination grossly intact|ambulates w/o limp or alteration in gait||extremities strong w/o atrophy|no gross motor deficits|sensation symmetrical & grossly intact||no involuntary movements or tremor||tardive dyskinesia|tics|"][textarea cols=50 rows=3]
Speech/Vocalization: [checkbox name="speech" value="normal for age|clear & coherent||slurred|mumbling to self|monotonous|stuttering||hypoverbal|hyperverbal||loud|soft||slow|rapid|pressured||groaning|sighing|crying||perseveration|flight of ideas|repetitive questions||self-depreciating statements|repetitive statements of impending doom|repetitive non-health related/financial concerns||personal safety concerns|suicidal ideation/threats||insisting on particular medication, test, referral, or accommodation||raising voice|defensive/argumentative|cursing/swearing||previous providers/staff criticisms|verbal threats|sexual remarks|racist remarks|"][textarea cols=50 rows=1]
Behavior/Psychomotor Activity: [checkbox name="behavior" value="calm, pleasant, respectful|cooperative with history & exam||guarded|anxious|irritable|frustrated|labile||agitated|hostile|forceful||pacing|fidgeting|picking skin|twirling hair|cracking knuckles||grimacing, furrowing eyebrows|tightening jaw|breathing hard|intense staring|threatening gestures|fist-clenching||withdrawn|flat affect|bradykinetic|indifferent|appears to be responding to internal psychotic process|"][textarea cols=50 rows=1]
AFFECTED AREA: [checkbox name="area" value="FROM|DROM||minimal erythema|moderate erythema|significant erythema||minimal discharge|moderate discharge|significant purulent discharge||significant warmth/tenderness||no ssx dehiscence|sutures/staples intact|dehiscence|"][textarea cols=50 rows=3]


PLAN OF CARE: patient/family verbalized understanding of dx & POC, [checkbox name="discussed" value="agreed with dx & POC|did not agree with dx & POC – encouraged to seek second opinion|"][textarea cols=50 rows=3]

PROCEDURE: [checkbox name="procedure" value="skin cleaned with wound cleanser|skin cleaned with Hibiclens|skin cleaned with Betadine|skin cleaned w NS||drain/packing removed|closure material removed||small amount of purulent discharge observed|some discharge observed||packing inserted||dry sterile dsg applied|non-adherent dsg applied|bulky gauze dressing applied|splint/brace applied||minimal/no bleeding|motor, sensory. vascular assessment intact||tolerated procedure well|"][textarea cols=40 rows=1]

MATERIAL REMOVED:
Type:    [textarea cols=10 rows=1]
Quantity: [textarea cols=5 rows=1]

MATERIAL INSERTED:
Type:    [textarea cols=10 rows=1]
Quantity: [textarea cols=5 rows=1]

ORDERS - MA: [checkbox name="order_MA" value="injection|Rocephin 1 gm IM now|Dexa 8 mg IM now||none|"][textarea cols=50 rows=1]
ORDERS - RX: [checkbox name="order_RX" value="OTC||electronic|paper|given to MA to be transmitted to pharmacy||none|"]
[textarea cols=50 rows=1]
[textarea cols=50 rows=1]
[textarea cols=50 rows=1]
ORDERS - LABS: [checkbox name="order_lab" value="CBC|CMP|TSH|A1C|Lipids|PSA|UA||none|"][textarea cols=50 rows=2]
ORDERS - IMAGING: [checkbox name="order_imaging" value="X-ray|US|MRI||none|"][textarea cols=50 rows=3]
WORK/SCHOOL STATUS: [checkbox name="excuse" value="excuse from school/work|no PE/gym||fit for duty w/o restrictions|fit for duty with restrictions||return to school/work||none requested|"][textarea cols=70 rows=1]
REVIEWED/DISCUSSED/INSTRUCTED ON: exam findings, POC, risks of/benefits of/alternatives to proposed POC, compliance with treatment regimen, reporting medication side effects immediately, appropriate follow up specific to condition, indications for immediate direct (re)evaluation and/or contacting emergency services, [checkbox name="instructions" value="medications|previous visits|laboratory/diagnostic studies||keeping wound dry|changing dressing at least daily and when soiled|cleaning area with soap and water and covering with non-adherent dsg||expect call from clinic for any abnormal diagnostic studies|contact clinic for diagnostic results if not received call||specialty reports|hospital discharge||medication compliance|controlling chronic conditions|"][textarea cols=50 rows=1]
DISCHARGE CONDITION/SAFETY: [checkbox name="discharge" value="improved|stable|unchanged|appears well|non-toxic|physical exam unremarkable for any emergent condition||no safety concerns at this time|safety concerns d/t depressed agitated mood|safety concerns d/t impulsiveness|safety concerns d/t hostile temper|safety concerns d/t past attempts|safety concerns d/t current suicidal verbalization|"][textarea cols=50 rows=1]
DISPOSITION: [checkbox name="disposition" value="home|referred to ER for immediate treatment via 911|referred to ER for immediate treatment via private transport||declined emergency transfer||left exam room before visit conclusion|asked to leave clinic||quarantine 10-14 days|"][textarea cols=50 rows=1]
FOLLOW UP: as discussed, sooner if condition worsens or new symptoms arise, contact 911/ER if significant increase in s/sx or appearance of new/danger s/sx, [checkbox name="next" value="here|in-person|televisit|w PCP||24 hours|2-3 days|1 week||f/u acute episode|f/u labs|f/u imaging|f/u med change/new|"][textarea cols=50 rows=2]
BARRIERS TO CARE: [checkbox name="barriers" value="incomplete history|poor cooperation with exam|language barrier|affect|socio-cultural factors||vague shifting complaints|history not supported by objective findings|supporting documentation unavailable|poor compliance with POC||intolerance of/therapeutic failure on multiple meds|negative attitude to diagnostic impression & proposed tx|lack of interest in nonpharmacologic therapies||preoccupation with illness|catastrophization|overgeneralization|unrealistic beliefs|negativism|pessimism|blaming others||hostile/disruptive behavior||none noted at this time|"][textarea cols=50 rows=1]