Skin – Burn

HISTORY: [checkbox name="historian" value="provided by patient||SO/family member present during visit|chaperon/MA present during visit||interpretation provided by family member/SO|interpretation provided by MA||complete history unobtainable d/t poor effort/affect|complete history unobtainable d/t cognitive changes or lack of knowledge|complete history unobtainable d/t language skills|"][textarea cols=50 rows=1]
CC: [checkbox name="cc" value="burn|"][textarea cols=50 rows=1]
LOCATION: [select name="Q2" value="scalp|face|forehead|eyebrow|chin|cheek|lip||axillary|upper arm|forearm|hand|finger||intertriginous||inguinal|buttock|perirectal|thigh|leg|foot|toe||neck|trunk|chest|back|"][conditional field="Q2" condition="(Q2).is('other - ')"][text][/conditional][checkbox value="left|right||upper|lower||proximal|distal||lateral|medical||dorsal|ventral||first|second|third|fourth|fifth||middle|"][textarea cols=50 rows=1]
QUALITY: [checkbox name="quality" value="red|blister|denuded|oozing|"][textarea cols=50 rows=1]
STATED CAUSE: [checkbox name="cause" value="immersion|hot water|cigarette|sun|contact with hot surface|high voltage|chemical|"][textarea cols=50 rows=1]
HPI: [checkbox name="hpi" value="happened prior to arrival|happened today|happened yesterday|happened days ago||washed with water and covered with dressing|taking OTC, not helping|"][textarea cols=50 rows=1]
RECENT HISTORY: [textarea cols=50 rows=1]
[+] reported  [-] not reported
[checklist name="recent" value="PCP visit|ER/UC visit|hospitalization|travel|ID exposure|surgery/procedure"]
TETANUS: [checkbox name="tetanus" value="up to date|less than five years ago|5-10 years ago|greater than 10 years ago|unknown"]
PMSH: [checkbox name="pmh" value="reviewed, non-contributory||diabetes|immunosuppression|fume exposure|"][textarea cols=50 rows=1]

REVIEW OF SYSTEMS: negative except as stated in HPI
General:[textarea name="variable_5" default=" does not report fever, chills, fatigue, malaise, or weight changes"]
HEENT:[textarea name="variable_6" default=" does not report headaches, vision changes, eye redness/discharge, pain with EOM, facial swelling, earache, ringing, ear discharge, nasal congestion, rhinorrhea, mouth sores, changes in taste, sore throat, neck swelling"]
CV:[textarea name="variable_7" default=" does not report chest pain, SOB, palpitations, fainting, or ankle swelling"]
Pulmonary:[textarea name="variable_8" default=" does not report shortness of breath, cough, wheezing, or chest wall pain with breathing"]
GI:[textarea name="variable_9" default=" does not report poor appetite, nausea, vomiting, abdominal pain, constipation, or diarrhea"]
GU:[textarea name="variable_10" default=" does not report dysuria, hematuria, frequency, discharge, or bleeding"]
MSK:[textarea name="variable_11" default=" does not report myalgias, arthralgias, localized muscle/soft tissues pain/swelling, or joint pain/swelling"]
Neurologic:[textarea name="variable_13" default=" does not report dizziness, seizures, tremor, balance problems, weakness, or falls"]
Psychiatric:[textarea name="variable_14" default=" does not report depression, anxiety, mood swings, memory loss, or insomnia"]
Endocrine:[textarea name="variable_15" default=" does not report polyphagia, polydipsia, night sweats, hot flashes, or heat/cold intolerance"]
Hematologic/lymphatic:[textarea name="variable_16" default=" does not report abnormal bleeding/bruising"]


General: [checkbox name="appearance" value="well-appearing||normal built|heavy built|muscular|lean|well-nourished|emaciated|frail||no signs of discomfort visible while sitting in chair|no signs of discomfort visible while ambulating and getting on/off exam table||ill-appearing|tired-looking|short of breath|diaphoretic||good hygiene|disheveled|bizarre clothes|body odor||drowsy|appears impaired|slumped||no ambulation aids/DME|ambulation requires walker|ambulation requires cane|ambulation requires wheelchair||wearing cervical collar|wearing lumbar support|wearing extremity brace|"][textarea cols=50 rows=3]
Head/Face: [checkbox name="head" value="normocephalic, atraumatic|symmetrical face|CN grossly intact||plethoric face|alopecia|facial droop|"][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|cornea clear||glasses|contacts|conjunctival injection|epiphora|conjunctival exudate|allergic shiners|dysconjugate gaze|"][textarea cols=50 rows=3]
Ears: [checkbox name="ears" value="symmetrical and intact auricles bilaterally|hearing to conversation intact||clear canals without erythema or discharge|TMs normal in appearance|"][textarea cols=50 rows=3]
Nose: [checkbox name="nose" value="nares patent bilaterally|septum midline|no facial tenderness|mucosa pink and moist||swollen and boggy mucosa|mucosal congestion|clear discharge|yellow discharge|crusty discharge|rhinophyma|"][textarea cols=50 rows=3]
Mouth/Troat: [checkbox name="mouth" value="normal voice, no stridor||tongue normal in appearance w/o lesions and with good symmetrical movements|moist oral mucosa without lesions||patent pharynx w/o swelling or exudates|uvula midline||upper denture|lower denture|poor dentition||oral ulcers|gum swelling|tooth decay||hoarseness|vesicles on soft palate|petechiae on soft palate|pharyngeal erythema w/o exudates|"][textarea cols=50 rows=3]
Neck: [checkbox name="neck" value="symmetric with free painless ROM and no masses|supple|no LAD|no bruit or JVD||anterior LAD|posterior LAD||thyroid enlargement|nuchal tenderness|"][textarea cols=50 rows=3]
Chest/Lungs: [checkbox name="lungs" value="normal work of breathing, symmetrical chest expansion|clear and equal breath sounds bilaterally||chest wall atraumatic and non-tender|no axillary or supraclavicular LAD||SOB|decreased bilaterally|wheezing|crackles|"][textarea cols=50 rows=3]
CV: [checkbox name="cv" value="regular rhythm|no murmurs|no ankle edema|pedal skin warm with good and equal pulses||tachycardia|irregular heart rhythm|systolic murmur||calf tenderness|ankle edema|varicosities|stasis discoloration|"][textarea cols=50 rows=3]
Abdomen: [checkbox name="abd" value="normal visual inspection, no distension|normal active bowel sounds|soft non-tender|no bruit auscultated over AA and renal arteries||protruding|surgical scar|umbilical hernia|diffuse tenderness over entire abdomen w/o RRG|hypoactive bowel sounds|hyperactive bowel sounds|direct non-rebound tenderness|colostomy in situ||deferred|"][textarea cols=50 rows=3]
GU: [checkbox name="gu" value="no suprapubic tenderness|no CVAT bilaterally||Foley in situ|normal external genitalia|no inguinal LAD||testicular tenderness|urethral discharge|verrucous papules|vesicles|crusted lesions||deferred|"][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 and ROM in C- and L-spine for patient age|strength, tone, and bulk symmetrical and grossly intact||non-tender C-spine with good ROM|paraspinal muscle spasm|C-spine tenderness and DROM|neck pain with active motion|paracervical muscle spasm|old surgical scar in C-spine|trapezius tenderness||kyphosis||non-tender L-spine with good ROM|paraspinal muscle spasm|L-spine tenderness|reduced painful ROM in lumbar region|trigger points in L-spine|old surgical scar in L-spine||heel-walk and toe-walk without difficulty|negative seated SLR|positive seated SLR|"][textarea cols=50 rows=3]
Neuro: [checkbox name="neuro" value="normal concentration and attention|memory grossly intact||balance and coordination grossly intact|ambulates w/o limp or alteration in gait||extremities strong w/o atrophy|no gross motor deficits|sensation symmetrical and grossly intact||no involuntary movements or tremor||antalgic gait|wide gait|shuffling gait||diffuse numbness w/o dermatomal pattern|dystonia|tardive dyskinesia|tics|"][textarea cols=50 rows=3]
Speech/Vocalization: [checkbox name="speech" value="normal for age|clear and coherent||slurred|mumbling to self|monotonous|stuttering||hypoverbal|hyperverbal||shouting|high pitched|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||requesting particular medication, test, referral, or accommodation||raising voice|defensive|argumentative|cursing, swearing|providers/staff criticisms|verbal threats|sexual remarks|racist remarks|"][textarea cols=50 rows=3]
Behavior/Psychomotor Activity: [checkbox name="behavior" value="calm, pleasant, respectful|cooperative with history and exam|engaged|good eye contact||guarded|anxious|irritable|frustrated|labile||agitated|hostile|forceful||threatening gestures|aggressive posturing|pacing|not sitting down||fidgeting|picking skin|twirling hair|cracking knuckles|frequent hand gestures||grimacing, frowning|tightening jaw|breathing hard|fist-clenching|intense staring||subdued|withdrawn|constricted affect|bradykinetic|indifferent|appears to be responding to internal psychotic process|"][textarea cols=50 rows=3]
Burn: [checkbox name="lesion" value="single|multiple||does not cross joint|non-circumferential||erythema|blister|desquamation|weeping/oozing|epidermal|partial thickness|no ssx infection||crosses joint|circumferential|ssx infection|less than 5 percent TBSA|5-10 percent TBSA|more than 10 percent TBSA|"][textarea cols=50 rows=1]

[comment memo="Refer out burns to face, eyes, ears, genitalia, joints, or from abuse, or smoke inhalation"]

[textarea cols=90 rows=4]

PLAN OF CARE: [checkbox name="poc" value="POC risks/benefits/alternatives discussed with patient/parent/SO, opportunity provided to ask questions|verbalized understanding of and agreement with POC, discharge and f/u instructions||did not agree with my POC/recommendations – will seek second opinion/further care elsewhere|"][textarea cols=50 rows=1]

PROCEDURE: [checkbox name="procedure" value="area cleansed with NS|debris removed|area dried with gauze|triple abx applied|Bacitracin applied||area covered with Xeroform dsg|area covered with non-adherent dsg||gauze dsg applied on top|wrapped with Kerlix|tetanus vac per clinic policy|"][textarea cols=50 rows=1]

RX: [checkbox name="order_RX" value="none|electronic|paper|given to staff to be transmitted to pharmacy|"][textarea cols=50 rows=1]

REVIEWED: [checkbox name="reviewed" value="MA notes|med list|previous visits/results|hospital discharge|"][textarea cols=50 rows=1]

[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]

VERBALLY INSTRUCTED ON: [checkbox name="instructions" value="vital signs,exam findings, recommendations|reporting medication side effects to clinic immediately|appropriate follow up with specialist/burn center||using hydrogel or Xeroform dsg for wound care|changing dsg whenever soaked at least daily|applying non-perfumed moisturizing cream (Vaseline Intensive Care®, Eucerin®, Nivea®, mineral oil, or cocoa butter) once epithelialization occurs; avoiding preparations high in lanolin|elevating extremity to prevent swelling|"][textarea cols=50 rows=1]

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|polypharmacy|multiple providers/prescribers|intolerance of/allergty to/therapeutic failure on multiple meds||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]

DISPOSITION: [checkbox name="disposition" value="RTC as discussed, sooner if condition worsens or new symptoms arise, contact 911/ER if significant increase in s/sx or NVT compromise||RTC 24 hours|RTC 48 to 72 hours|RTC 1 week||referred to burn center for further management|referred to ER for immediate treatment via 911|referred to ER for immediate treatment via private transport||declined emergency transfer|left facility before being discharged|asked to leave clinic|"][textarea cols=50 rows=1]







[+] reported [-] not reported


REVIEW OF SYSTEMS: negative except as stated in HPI


























Behavior/Psychomotor Activity:


Refer out burns to face, eyes, ears, genitalia, joints, or from abuse, or smoke inhalation










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Sandbox Metrics: Structured Data Index 0.43, 82 form elements, 73 boilerplate words, 1 text boxes, 44 text areas, 32 checkboxes, 1 check lists, 1 drop downs, 1 comments, 2 conditionals, 540 total clicks
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