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[text size="4"] yo [select value="|M|F"] presents via [checkbox name="covidenctype" value="F2F|virtual"] encounter for:
[comment memo="option1" memo_size="small" memo_color="blue"][checkbox name="covid1" value="f/u COVID-19 test that was positive"][conditional field="covid1" condition="(covid1).is('f/u COVID-19 test that was positive')"] on [date].
-currently reports [select memo="symptoms?" memo_size="small" memo_color="yellow" name="covid1sx" value="|no|positive"][/conditional][conditional field="covid1sx" condition="(covid1sx).is('no')"] symptoms.[/conditional][conditional field="covid1sx" condition="(covid1sx).is('positive')"] for symptoms to include with date of first symptoms noticed being [date]:
[checkbox value="fever|malaise|fatigue|myalgia|headache|nasal congestion|ear pain|sore throat|hoarseness|loss of smell/taste|chest pain|cough|dyspnea|nausea|vomiting|diarrhea"][comment memo="other sx" memo_size="small" memo_color="yellow"][text size="80"]
-symptoms overall [select name="covid1sxprog" value="|improving|not improving|worsening"] since start of illness.
-Reports [select name="covid1sxfever" value="|no|having"] fever in past 24hrs.
[checkbox name="covid1sxlength" value="-Recommended length of self-isolation has been met
"][/conditional][conditional field="covid1sxprog|covid1sxfever|covid1sxlength" condition="(covid1sxprog).is('improving')&&(covid1sxfever).is('no')&&(covid1sxlength).is('-Recommended length of self-isolation has been met
')"]-As far as [select value="work|school"], pt [select name="covid1return" value="|desires|does not desire"] to return [select name="covid1restrict" value="|with|without"] restrictions.
[/conditional][conditional field="covid1restrict" condition="(covid1restrict).is('with')"]-restrictions requested:[textarea]
[/conditional][conditional field="covid1return" condition="(covid1return).is('desires')"][checkbox value="-requesting return to work memo
"][checkbox value="-requesting return to school memo
"][checkbox value="-patient requesting return to sports memo
"][checkbox value="-patient requesting repeat testing
"]
[/conditional][comment memo="
option2" memo_size="small" memo_color="blue"][checkbox name="covid2" value="current symptoms f/b negative COVID test"][conditional field="covid2" condition="(covid2).is('current symptoms f/b negative COVID test')"]
-current symptoms started [date]
-Negative COVID-19 test on [date]
-symptoms include [checkbox value="fever|malaise|fatigue|myalgia|headache|nasal congestion|ear pain|sore throat|hoarseness|loss of smell/taste|chest pain|cough|dyspnea|nausea|vomiting|diarrhea"][comment memo="other sx" memo_size="small" memo_color="yellow"][text size="80"]
-symptoms overall [select name="covid1sxprog" value="|improving|not improving|worsening"] since start of illness.
[checkbox value="-requesting return to work memo
"][checkbox value="-requesting return to school memo
"][checkbox value="-patient requesting return to sports memo
"][checkbox value="-patient requesting repeat testing
"]
[/conditional][comment memo="
remaining history/subjective" memo_size="small" memo_color="blue"][checkbox value="PMHx reviewed as above
"][checkbox value="PSHx reviewed as above
"][checkbox value="Meds/Allergies reviewed as above
"][checkbox value="PSHx reviewed as above
"][checkbox name="covidROS" value="Additional ROS negative to include:
"][conditional field="covidROS" condition="(covidROS).is('Additional ROS negative to include:
')"][checkbox value="-fever
"][checkbox value="-malaise
"][checkbox value="-fatigue
"][checkbox value="-myalgia
"][checkbox value="-headache
"][checkbox value="-nasal congestion
"][checkbox value="-ear pain
"][checkbox value="-sore throat
"][checkbox value="-hoarseness
"][checkbox value="-loss of smell/taste
"][checkbox value="-chest pain
"][checkbox value="-cough
"][checkbox value="-dyspnea
"][checkbox value="-nausea
"][checkbox value="-vomiting
"][checkbox value="-diarrhea
"]
[/conditional][comment memo="*" memo_size="small" memo_color="blue"][checkbox name="covidExam" value="PHYSICAL EXAM"][conditional field="covidExam" condition="(covidExam).is('PHYSICAL EXAM')"]
-General - [textarea rows="2" default="well developed, well nourished, no apparent distress"]
-HEENT - [textarea rows="2" default="normocephalic, atraumatic, nares patent, mucous membranes moist"]
-Neck - [textarea rows="2" default="no thyromegaly, no gross distention"]
[/conditional][conditional field="covidenctype|covidExam" condition="(covidenctype).is('F2F')&&(covidExam).is('PHYSICAL EXAM')"]-Chest - [textarea rows="2" default="normal rise and fall B/L, no accessory muscle use"]
-Heart/CV - [textarea rows="2" default="RRR/no ectopy, normal S1/S2, No M/R/G, No S3/S4 auscultated, no friction rub"]
-Lungs/Pulm - [textarea rows="2" default="CTAB, BSE b/l, no wheezes, no crackles, no rhonchi"]
-Abdomen - [textarea rows="2" default="non-distended"]
-Extremities - [textarea rows="2" default="no cyanosis, no over/gross deformity"]
[/conditional][conditional field="covidExam" condition="(covidExam).is('PHYSICAL EXAM')"]-Psych - [textarea rows="2" default="appropriate mood/affect"]
-Neuro - [textarea rows="2" default="mentation normal/appropriate, no gross/overt cranial nerve deficits"]
[checkbox name="covidExamSkin" value="-Skin"][/conditional][conditional field="covidExamSkin" condition="(covidExamSkin).is('-Skin')"] - [textarea rows="2" default="warm, dry, intact, no edema/erythema/induration/ecchymosis"]
[/conditional][conditional field="covidExam" condition="(covidExam).is('PHYSICAL EXAM')"]-Additional Exam - [textarea rows="4" default="none"]

[/conditional][comment memo="*" memo_size="small" memo_color="blue"][checkbox name="covidAP" value="A/P"][conditional field="covidAP" condition="(covidAP).is('A/P')"]
[checkbox memo="always select if COVID+" memo_size="small" memo_color="yellow" name="coviddx" value="#COVID - U07.1 - confirmed by PCR
"][comment memo="always select at least one of these if COVID- with sx or COVID+ with symptoms" memo_size="small"][checkbox name="covidURI" value="#Acute URI from COVID19 - J06.9
"][checkbox name="covidpharyngitis" value="#Acute pharyngitis from COVID19 - J02.8
"][checkbox name="covidbronchitis" value="#Acute bronchitis from COVID19 - J20.8
"][checkbox name="covidpneumonia" value="#pneumonia due to COVID19 - J12.82
"][comment memo="plan
" memo_size="small" memo_color="blue"][comment memo="overall" memo_size="small" memo_color="blue"]
[checkbox name="covidAPrtpdecision1" value="-Recommend return to sports/play as detailed below
"][checkbox name="covidAPrtpdecision2" value="-Recommend return to work/school
"][checkbox name="covidAPrtpdecision3" value="-Recommend AGAINST return to work/school
"][comment memo="optional freetext/rationale" memo_size="small" memo_color="blue"][textarea rows="5"][comment memo="
symptomatic treatment" memo_size="small" memo_color="blue"][checkbox value="-Advised pt of the risks/benefits of sx mgmt.
"][checkbox value="-Pt declined symptomatic treatment.
"][checkbox name="covidsxtx" value="-The patient requests the following symptomatic tx which were ordered:"][/conditional][conditional field="covidsxtx" condition="(covidsxtx).is('-The patient requests the following symptomatic tx which were ordered:')"] [checkbox value="acetaminophen (Discussed appropriate dosing, alcohol avoidance, and hepatotoxicity risk)|NSAIDs (Discussed appropriate dosing, limiting use to 1-2 weeks, and potential risks including: GI bleed, renal failure, CV events)|oral antihistamine (discussed prn use, side effects risk of drowsiness, constipation, mental confusion, falls if elderly)|Nasal saline|Decongestants (Discussed limiting use to less than 72 hours; discussed risks of tachycardia/arrhythmias, anxiety, insomnia, hypertension, and rebound rhinitis|Brown Honey (OTC only, not for use in chilren under 1 year old)|Vapor Rub (OTC only)|Benzonatate capsules (cough suppressant, swallow whole)|Menthol lozenges|Zinc lozenges (may shorten duration of illness, OTC only)|Guaifenesin (Discussed possible drowsiness, headache, rash, nausea, and limited trials of efficacy)|Nasal steroids (Discussed possible nasal dryness, thrush, epistaxis)"]
[/conditional][conditional field="covidAP" condition="(covidAP).is('A/P')"][comment memo="
BJSM graduated return to play for athletes with mild/moderate sx" memo_size="small" memo_color="blue"][comment memo="
consider/if warranted" memo_size="small" memo_color="yellow"][checkbox memo="(troponin, BNP, CRP)" memo_size="small" memo_color="lightyellow" value="-test for serum markers of myocardial inflammation
"][checkbox memo="(CBC, BMP)" memo_size="small" memo_color="lightyellow" value="-test for renal/heme dysfunction
"][checkbox memo="(EKG, EchoCG, Cardiac MRI)" memo_size="small" memo_color="lightyellow" value="-order cardiac monitoring
"][/conditional][conditional field="covidAPrtpdecision1" condition="(covidAPrtpdecision1).is('-Recommend return to sports/play as detailed below
')"][checklist memo="all these criteria:
(1) 10 days rest from sx onset
(2) 7 days sx-free
(3) off all treatment" memo_size="small" memo_color="lightyellow" name="covidgrtpcriteria" value="Meets BJSM criteria for graduated return to play"][/conditional][conditional field="covidgrtpcriteria" condition="(covidgrtpcriteria).is('Meets BJSM criteria for graduated return to play')"] -Will begin graduated return to play with the following guidance:
[textarea rows="20"]***Stage 1 x 10 days minimum (rest) - walking & ADLs, monitor for sx & resting HR & I-PRRS
*Stage 2 x 2 days minimum (light activity) - walking, light jogging, stationary cycle, no resistance training, <70% max HR, duration <15mins, monitor sx & resting HR & I-PRRS & RPE
*Stage 3A x 1 day minimum (frequency of training increases) - simple movement activities like running drills, <80% max HR, duration <30min, monitor sx & resting HR & I-PRRS & RPE
*Stage 3B x 1 day minimum (duration of training increases) - more complex training activities, <80% max HR, duration <45min, monitor sx & resting HR & I-PRRS & RPE
*Stage 4 x 2 days minimum (intensity of training increase) - normal training activities, <80% max HR, duration <60min, monitor sx & resting HR & I-PRRS & RPE
*Stage 5 day 17 at the earliest (resume normal training progressions) - monitor sx & resting HR & I-PRRS & RPE
*Stage 6 - return to competition in sport specific timelines[/textarea]
[/conditional][conditional field="covidAP" condition="(covidAP).is('A/P')"][checkbox name="covidAPretprecauts" value="-Gave return precautions to include: "][/conditional][conditional field="covidAPretprecauts" condition="(covidAPretprecauts).is('-Gave return precautions to include: ')"][checkbox value="worsening symptoms despite above plan|severe intolerable side effects of medications prescribed|worsening shortness of breath|inability to perform ADLs|other-"] [textarea rows="2"]

[/conditional][conditional field="covidAP" condition="(covidAP).is('A/P')"][checkbox name="covidAPfu" value="-Followup: "][/conditional][conditional field="covidAPfu" condition="(covidAPfu).is('-Followup: ')"][text size="5"] [select value="|routine f/u visit not indicated|day(s)|week(s)|month(s)"] [checkbox value="with PCM|with unit provider"][text memo="other" memo_size="small" size="60"]

[/conditional][conditional field="covidAP" condition="(covidAP).is('A/P')"][checkbox name="covidAPack" value="-Explained the above assessment and plan to patient who: "][/conditional][conditional field="covidAPack" condition="(covidAPack).is('-Explained the above assessment and plan to patient who: ')"][select value="|acknowledged understanding and intent to follow through with plan|desires second opinion"][text size="80"]

[/conditional][checkbox name="CB1" value="-The above SocHx/Allergies/Meds/PMHx/PSHx/FMHx were reviewed & updated at today's visit.
"][checkbox name="CB2" value="-The scribe/medic/nurse/student assisted in collecting and documenting the patient's history.
-I have personally reviewed it and verified its accuracy.
"][checkbox name="CB3" value="-The scribe/medic/nurse/student assisted in documenting the physical exam performed by me.
-I have personally reviewed it and verified its accuracy.
"][checkbox name="CB4" value="-Laboratory results as displayed were reviewed and interpreted
"][checkbox name="CB5" value="-Radiologic study results as displayed were reviewed and interpreted
"][checkbox name="CB6" value="-Radiologic study images which results are displayed in note were reviewed and interpreted
"][checkbox name="APvirtualblurb" memo="*" memo_color="blue" memo_size="small" value="-Virtual Encounter Verbage"][conditional field="APvirtualblurb" condition="(APvirtualblurb).is('-Virtual Encounter Verbage')"] - Spent [text size="5"] minutes via [select name="covidvirttype" value="realtime audio/video communication|voice-only/telephone|asynchronous secure text messaging"] [/conditional][conditional field="covidvirttype|APvirtualblurb" condition="(covidvirttype).is('realtime audio/video communication')&&(APvirtualblurb).is('-Virtual Encounter Verbage')"]via [select value="Doximity|FaceTime|GoogleDuo|Skype"] [/conditional][conditional field="APvirtualblurb" condition="(APvirtualblurb).is('-Virtual Encounter Verbage')"]involving obtaining/reviewing history, [checkbox value="conducting visual exam|discussing test results|discussing workup|discussing above plan|patient education"].[/conditional][conditional field="covidvirttype" condition="(covidvirttype).is('voice-only/telephone')"] Video visit was not feasible due to the following factors: [checkbox value="patient refused|patient unable to navigate appropriate technology|failure of attempted virtual software available|failure of available technological devices|significant time constraints from previous unforeseen delays"].[/conditional]
yo presents via encounter for:
option1
option2

remaining history/subjective
* * *

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