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CC: [checkbox name="cc" value="recent travel|contact with suspected/confirmed c19 case|contact less than 5-7 days|contact over 5-7 days||sx suggestive of C19||testing requested by employer/school|testing requested by medical professional/facility|requesting testing for travel|per pt's request||previous c19 POS test|previous c19 NEG test||no sx|"][textarea cols=50 rows=5]

HPI/SYMPTOMS: as in cc, [checkbox name="hpi" value="started today|started yesterday|started several days ago|started more than 1 week ago||mild symptoms, managing well at home|decreasing|resolved||taking OTC for sx relief||received one dose of c19 vaccine|received two doses of c19 vaccine"][textarea cols=50 rows=3]

REVIEW OF SYSTEMS:
[+] reported [-] not reported
GENERAL: [checklist name="general" value="fever|chills|night sweats|malaise|fatigue"][textarea cols=50 rows=3]
HEAD: [checklist name="hd" value="headache"][textarea cols=50 rows=3]
ENT: [checklist name="ears" value="runny nose|nasal congestion|PND|sinus pain|loss of smell/taste|earache/ear pressure|sore throat|hoarseness"][textarea cols=50 rows=3]
NECK: [checklist name="nk" value="swelling|stiffness"][textarea cols=50 rows=3]
CHEST: [checklist name="ch" value="cough|chest tightness/pain w/ breathing"][textarea cols=50 rows=3]
GI: [checklist name="stomach" value="nausea|vomiting|diarrhea|abdominal pain"][textarea cols=50 rows=3]
MSK: [checklist name="musc" value="back pain|muscle aches"][textarea cols=50 rows=3]

Limited exam
Appearance: [textarea name="variable_1" default=" alert, non-toxic, normal WOB"]
Skin: [textarea name="variable_2" default=" warm, dry, grossly intact, no rashes"]
Head/Face: [textarea name="variable_3" default=" normocephalic, atraumatic, symmetrical face"]
ENT: [textarea name="variable_4" default=" clear conjunctiva w/o exudates or hemorrhage, anicteric sclera, EOM intact without nystagmus, symmetrical & intact auricles bilaterally, hearing to conversation intact, nares patent bilaterally, septum midline, normal voice, no stridor"]
Neck: [textarea name="variable_5" default=" symmetric with free painless ROM, no masses noted"]
Chest: [textarea name="variable_6" default=" normal work of breathing, symmetrical chest expansion"]
Abdomen: [textarea name="variable_7" default=" normal visual inspection, no distension"]
MSK: [textarea name="variable_8" default=" no gross deformities, moves all extremities with good ROM for age, full weight-bearing"]
Neuro: [textarea name="variable_9" default=" normal concentration and attention, memory grossly intact, balance & coordination grossly intact, ambulates w/o limp or alteration in gait, no involuntary movements or tremor"]
Speech: [textarea name="variable_10" default=" normal for age"]

[comment memo="Dx:
C19 screening Z11.59
C19 exposure Z20.828
C19 U071
fever R50.9
headache R51
myalgia M79.1
viral syndrome B34.9
rhinitis J34.89
loss of smell R43.8
pharyngitis J02.9
SOB R06.02
acute bronchitis J20.9
cough R05
nausea R11.0
vomiting R11.10
diarrhea R19.7"]


[checkbox memo="pos" name="pos" value=""][conditional field="pos" condition="(pos).is('')"]Rapid (antigen) test POSITIVE. Reviewed/discussed with pt/family test/exam findings, POC, risks of/benefits of/alternatives to proposed POC, appropriate follow up. Discussed AG test accuracy/limitations. Patient is afebrile, non-toxic, with no evidence of respiratory distress/clinical hypoxia. Advised supportive treatment based on symptoms. RTC for full re-evaluation should sx appear/worsen. Recommended daily use of pulse oximeter. Discussed indication for contacting emergency services. Must complete 10-14 day quarantine. Advised to follow LA county C19 instructions re self-quarantine and social-distancing. Advised that CDC no longer recommends test-based strategy to discontinue isolation/precautions (except to discontinue isolation/precautions earlier than 10-14 days). Patient/family verbalized understanding of instructions & POC.[/conditional]
[checkbox memo="neg" name="neg" value=""][conditional field="neg" condition="(neg).is('')"]Rapid (antigen) test NEGATIVE. Reviewed/discussed with pt/family test/exam findings, POC, risks of/benefits of/alternatives to proposed POC, appropriate follow up. Discussed AG test accuracy/limitations/likelihood of false negative results, esp. if other household members test POS. Advised to retest based on (new) symptoms and/or exposure. Patient is afebrile, non-toxic, with no evidence of respiratory distress/clinical hypoxia. RTC for full re-evaluation should sx appear/worsen. Discussed indication for contacting emergency services. Advised to follow LA county C19 instructions re social-distancing. Patient/family verbalized understanding of instructions & POC.[/conditional]

[checkbox memo="pcr" name="pcr" value=""][conditional field="pcr" condition="(pcr).is('')"]C19 PCR sample collected by MA. Reviewed/discussed with pt/family test/exam findings, POC, risks of/benefits of/alternatives to proposed POC, appropriate follow up. Discussed AG test accuracy/limitations. Patient is afebrile, non-toxic, with no evidence of respiratory distress/clinical hypoxia. Advised supportive treatment if necessary. RTC for full re-evaluation should sx appear/worsen. Discussed indication for contacting emergency services. Must complete 10-14 day quarantine if exposure more than 15 minutes less than 6 feet. Advised to follow LA county C19 instructions re self-quarantine and social-distancing. Advised that CDC no longer recommends test-based strategy to discontinue isolation/precautions (except to discontinue isolation/precautions earlier than 10-14 days). Patient/family verbalized understanding of instructions & POC.[/conditional]
ORDERS: [textarea name="orders" default="none"]

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]
CC:

HPI/SYMPTOMS: as in cc,

REVIEW OF SYSTEMS:
[+] reported [-] not reported
GENERAL:
HEAD:
ENT:
NECK:
CHEST:
GI:
MSK:

Limited exam
Appearance:
Skin:
Head/Face:
ENT:
Neck:
Chest:
Abdomen:
MSK:
Neuro:
Speech:

Dx:
C19 screening Z11.59
C19 exposure Z20.828
C19 U071
fever R50.9
headache R51
myalgia M79.1
viral syndrome B34.9
rhinitis J34.89
loss of smell R43.8
pharyngitis J02.9
SOB R06.02
acute bronchitis J20.9
cough R05
nausea R11.0
vomiting R11.10
diarrhea R19.7



pos
neg

pcr
ORDERS:

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,

Result - Copy and paste this output:

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