C19 Testing

visit conducted curbside. patient identity and informed consent obtained by staff. patient advised of potential risks and limitations of curbside visit
[checkbox name="historian" value="new patient|established patient||new complaint|follow up|re-check||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]

[checkbox memo="EXAM LIMITED" name="lim" value=""][conditional field="lim" condition="(lim).is('')"]EXAM LIMITED due to: [checkbox name="exlim" value="language barrier|pain|cognition|affect|hearing impairment|poor effort/cooperation|distracted patient|"][textarea cols=50 rows=3][/conditional]
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||no sx|"][textarea cols=50 rows=5]

HPI/PMH: [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||previous c19 POS test|previous c19 NEG test||received one dose of c19 vaccine|received two doses of c19 vaccine|received c19 booster|"][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]
DERM:
[checklist name="derm" value="rash|ecchymosis|bruising"][textarea cols=50 rows=3]


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

87426   Ag testing
99000   Specimen
Global  S9083
After   99050
Office  99204"]

COLLECTED/TESTED: [checkbox name="order_MA" value="rapid/ag|pcr||none|"][textarea cols=50 rows=3]

[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, appropriate follow up. Discussed test accuracy/limitations. Patient is afebrile, non-toxic, with no evidence of respiratory distress/clinical hypoxia. Recommended 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. Advised to follow local C19 instructions re self-quarantine and social-distancing. Advised that CDC does not recommend test-based strategy to discontinue isolation/precautions (except to discontinue isolation/precautions earlier than 10 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, appropriate follow up. Discussed 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 local 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, 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-day quarantine if exposure more than 15 minutes less than 6 feet. Advised to follow local instructions re self-quarantine and social-distancing. Advised that CDC does not recommend test-based strategy to discontinue isolation/precautions (except to discontinue isolation/precautions earlier than 10 days). Patient/family verbalized understanding of instructions & POC.[/conditional]
ORDERS - RX: [checkbox name="order_RX" value="OTC||electronic|paper|given to MA to be transmitted to pharmacy||none|"][textarea cols=50 rows=5]
ORDERS - IMAGING: [checkbox name="order_imaging" value="X-ray|US|MRI||none|"][textarea cols=50 rows=3]
ORDERS - FORMS: [checkbox name="forms" value="excuse|accomodations|clearance|return to school/work|school/participation physical||none|"][textarea cols=50 rows=3]
[checkbox memo="COORDINATION OF CARE" name="coord" value=""][conditional field="coord" condition="(coord).is('')"]COORDINATION OF CARE: case reviewed by/discussed with attending[textarea cols=50 rows=3][/conditional]
DISCHARGE CONDITION/SAFETY: [checkbox name="discharge" value="improved|stable|unchanged||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=3]
DISPOSITION: [checkbox name="disposition" value="home||advised to use UC for acute non-emergent problems|ER for immediate treatment via 911|ER for immediate treatment via private transport||declined emergency transfer||left exam room before visit conclusion|was asked to leave clinic|"][textarea cols=50 rows=3]
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||24 hours|1-2 days|5-7 days||f/u acute episode|f/u labs|f/u imaging|"][textarea cols=50 rows=3]
BARRIERS TO CARE: [checkbox name="barriers" value="language barrier|socio-cultural factors||poor effort/cooperation with exam|incomplete history|history not supported by findings|vague complaints||supporting documentation unavailable|failed to obtain old records|failed to complete referrals or testing|| multiple comorbidities and/or polypharmacy|multiple providers/prescribers|multiple drug/treatment intolerance/failure||frequent ER/UC visits|frequent office contacts||poor compliance with POC|negative attitude to proposed tx|lack of interest in non-drug tx||overreliance on short-acting meds|overwhelming focus on Rx drugs||poor insight|lack of motivation|dependent attitude||preoccupation with illness|unhealthy coping mechanisms|somatization|catastrophization|pessimism|overgeneralization|unrealistic health beliefs||psych comorbidity|anxiety|depression|alcohol or substance use||social or occupational dysfunction|secondary gain||hostile/disruptive behavior|affect||none noted at this time|"][textarea cols=50 rows=1]
visit conducted curbside. patient identity and informed consent obtained by staff. patient advised of potential risks and limitations of curbside visit


EXAM LIMITED
CC:

HPI/PMH:

REVIEW OF SYSTEMS: [+] reported [-] not reported
GENERAL:

HEAD:

ENT:

NECK:

CHEST:

GI:

MSK:
DERM:



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

87426 Ag testing
99000 Specimen
Global S9083
After 99050
Office 99204


COLLECTED/TESTED:

pos
neg

pcr
ORDERS - RX:
ORDERS - IMAGING:
ORDERS - FORMS:
COORDINATION OF CARE
DISCHARGE CONDITION/SAFETY:
DISPOSITION:
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,
BARRIERS TO CARE:

Result - Copy and paste this output:

Questions/General site feedback

Send Feedback for this SOAPnote

This site uses Akismet to reduce spam. Learn how your comment data is processed.

More SOAPnotes by this Author: