Complete Note
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Name:[text name="Name" default="name"]
DOB:[text name="Name" default="DOB"]
Date: [date name="variable_1" default="02/14/2019"]
Race/Ethnicity: [text name="variable_1" default="race/ethnicity"]
[checkbox name="variable_1" value="Male|Female|GNC|NB|Cisgender|Transgender|Other"]
Chief Complaints:
[textarea cols=80 rows=1 default="one or more symptoms in patient's words, duration..."]
History of Present Illness:
[textarea cols=80 rows=5 default="OLDCARTS- Onset, Location, Duration, Characteristic, Aggrevating/Alleviating factors, Radiation, Timing, Treatment, Severity."]
Past Medical and Surgical History:
[textarea cols=80 rows=4 default="chronic illness, childhood illness, surgical history, psych history, OBGYN history"]
Medications:
[textarea cols=80 rows=5 default="medication name/dose/indication/duration"]
Allergies:
[textarea cols=80 rows=1 default="medication, environmental, chemical, food"]
Health Maintenance:
[textarea cols=80 rows=3 default="Immunizations (child, adult, flu), tetanus, PPD, PAP, Mammogram, Colonoscopy, PCP, Eye, Dental"]
Advance Directives:
[textarea cols=80 rows=2 default="living will and/or durable power of attorney for health care/identify surrogate decision maker"]
Family History:
[textarea cols=80 rows=3 default="history for first-degree relatives or beyond"]
Social History:
[textarea cols=40 rows=3 default="place of birth, work, education"]
[textarea cols=40 rows=3 default="Home/Social Life: Where?, Who?, Safe?, Social?"]
[textarea cols=40 rows=3 default=" Safety: home secure, food secure, smoke/CO2 detector, seatbelts, sunscreen, helemt"]
[textarea cols=40 rows=3 default="Sexuality: orientation, intimate?, genders, # partners, protection, STIs, safe with gender"]
[textarea cols=40 rows=3 default="Stress/Leisure: source, leisure, cope, sleep"]
[textarea cols=40 rows=3 default="Diet: Veggie/Fruit, where, recall"]
[textarea cols=40 rows=3 default="Exercise:"]
[textarea cols=40 rows=3 default="Substances: Alcohol, caffeine, nicotine, marijuana, substances"]
Review of Systems:
[textarea cols=80 rows=1 default="GENERAL: no weight change, weakness, fatigue, pain"]
[textarea cols=80 rows=1 default="ENDO: No change in appetite, temperature intolerance, polyuria, polyphagia, polydypsia"]
[textarea cols=80 rows=1 default="HEME: no easy bruising"]
[textarea cols=80 rows=1 default="SKIN: no changing moles, rashes, changes in hair or nails, open areas."]
[textarea cols=80 rows=1 default="HEAD: no headache, dizziness, recent head injury"]
[textarea cols=80 rows=1 default="EYES: no change in vision, discharge, corrective lenses."]
[textarea cols=80 rows=1 default="EARS: No change in hearing, tinnitus, vertigo, discharge"]
[textarea cols=80 rows=1 default="NOSE: No nose bleeds, sinus symptoms, dishcarge, change in smell"]
[textarea cols=80 rows=1 default="THROAT: no pain, sore throat, teeth, bleeding gums."]
[textarea cols=80 rows=1 default="NECK: no swollen glands, pain, stiff."]
[textarea cols=80 rows=1 default="RESPIRATORY: no cough, SOB, chest pain."]
[textarea cols=80 rows=1 default="CARDIOVASCULAR: no palpatations, chest pain, BLE edema."]
[textarea cols=80 rows=1 default="BREAST: no lumps, skin changes, pain, discharge"]
[textarea cols=80 rows=1 default="GASTROINTESTINAL: no heartburn, swallowing, N/V, Gas, Belching, change in bowel patterns."]
[textarea cols=80 rows=1 default="URINARY: no frequency, nocturia, pain, blood, incontinence, hesitation, dribbling"]
[textarea cols=80 rows=1 default="GENITAL: No hernia, discharge, testicular pain, sores, change in menses, pain, change in sexual activity"]
[textarea cols=80 rows=1 default="MUSCULOSKELETAL: no stiffness, back, arthritis."]
[textarea cols=80 rows=1 default="NEUROLOGICAL: no change in attention, speech, confusion, tingling, numbness, seizures."]
[textarea cols=80 rows=1 default="PSYCHIATRIC: no change in mood, anxiety"]
Physical Examination
[textarea cols=80 rows=2 default="VITALS: Height/Weight/Temperature/Heart Rate/Blood Pressure/Pain Level"]
[textarea cols=80 rows=2 default="GENERAL APPEARANCE: Well developed, well nourished, alert and cooperative, and appears to be in no acute distress."]
[textarea cols=80 rows=2 default="SKIN: Skin normal color, texture and turgor with no lesions or eruptions."]
[textarea cols=80 rows=2 default="NEUROLOGICAL: CN II-XII intact. Strength and sensation symmetric and intact throughout. Reflexes 2+ throughout. Cerebellar testing normal."]
[textarea cols=80 rows=3 default="PSYCHIATRIC: Alert and Oriented to person, place, and time. Affect congruent with mood. Articulate with logical thought pattern and good judgment demonstrated. Short and long term memory intact. Patient is not suicidal."]
[textarea cols=80 rows=2 default="HEAD: normocephalic and atraumatic. No tenderness on palpation."]
[textarea cols=80 rows=2 default="EYES: PERRLA, EOMI. Fundi normal, vision is grossly intact."]
[textarea cols=80 rows=2 default="EARS: External auditory canals clear, tympanic membranes smooth pearly white no bulging, hearing grossly intact."]
[textarea cols=80 rows=2 default="NOSE: No nasal discharge, sinus tenderness, nasal mucosa pink and moist."]
[textarea cols=80 rows=2 default="THROAT: Oral mucosa moist and pink. Tonsils not visible. Tongue with full ROM. Gag reflex appears intact. No inflammation, swelling, exudate, or lesions. Teeth and gingiva in good general condition. TMJ without crepitus"]
[textarea cols=80 rows=2 default="NECK: Neck supple, non-tender without lymphadenopathy, masses or thyromegaly."]
[textarea cols=80 rows=3 default="RESPIRATORY: Clear to auscultation with no advantageous breath sounds. Symmetrical chest expansion. Resonant to percussion."]
[textarea cols=80 rows=3 default="CARDIAC: Normal S1 and S2. No S3, S4 or murmurs. Rhythm is regular. There is no peripheral edema, cyanosis or pallor. Extremities are warm and well perfused. Capillary refill < 2 seconds. No JVD. No carotid bruits."]
[textarea cols=80 rows=3 default="ABDOMEN: Positive bowel sounds x 4 quadrants. Soft, nondistended, nontender. No guarding or rebound. No masses. Tympanic to percussion throughout. Liver and spleen nonpalpabe. No CVA tenderness."]
[textarea cols=80 rows=2 default="MUSKULOSKELETAL: Adequately aligned spine. ROM intact spine and extremities. No joint erythema or tenderness. Normal muscular bulk and tone. Normal gait."]
[textarea cols=80 rows=2 default="PERIPHERAL VASCULAR: No edema. Color normal, warm, Peripheral pulses intact. No varicosities."]
[textarea cols=80 rows=2 default="BREAST: Normal color, soft, no masses or lesions, no discharge."]
[textarea cols=80 rows=3 default="GENITAL (VAGINAL): External genetalis with normal color, no masses or lesions. Cervix midline, pink and moist with no discharge. Uterus palpated midline and smooth. Ovaries nonpalpable. Normal sphincter tone with no masses or discharge."]
[textarea cols=80 rows=3 default="GENITAL (PENIS): Circumcised penis with no lesions, masses, or discharge. Scrotum nontender with no masses or lesions. Normal sphincter tone with no masses or discharge. Prostate palpable and smooth."]
Laboratory and Radiology:
[textarea cols=80 rows=1 default="test, date, result"]
Assessment and Plan
[textarea cols=80 rows=3 default="#1 Problem"]
[textarea cols=80 rows=3 default="#2 Problem"]
[textarea cols=80 rows=3 default="#3 Problem"]
[textarea cols=80 rows=3 default="#4+ Problem"]
Name:
DOB:
Date:
Race/Ethnicity:

Chief Complaints:

History of Present Illness:

Past Medical and Surgical History:

Medications:

Allergies:

Health Maintenance:

Advance Directives:

Family History:

Social History:








Review of Systems:



















Physical Examination



















Laboratory and Radiology:

Assessment and Plan



Result - Copy and paste this output: