Complete Note
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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=70 rows=1]

NECK:
[checkbox name="nk" value="no complaints||pain|stiffness|spasm|burning||localized|radiation to shoulder|radiation to deltoid|radiation to UE"][textarea cols=70 rows=1]

UP/MID BACK:
[checkbox name="umb" value="no complaints||interscapular pain|trap spasm|"][textarea cols=70 rows=1]

CHEST/ABD:
[checkbox name="torsosx" value="no complaints||pain w breathing|bruising|"][textarea cols=70 rows=1]

LOW BACK:
[checkbox name="lb" value="no complaints||pain|stiffness|spasm|burning||localized|radiation to buttocks|radiation to thigh|radiation to LE"][textarea cols=70 rows=1]

UE: [textarea cols=30 rows=1]
[checkbox name="uesx" value="no complaints||pain|swelling|deformity|bruising|"][textarea cols=70 rows=1]

LE: [textarea cols=30 rows=1]
[checkbox name="lesx" value="no complaints||pain|swelling|deformity|bruising|"][textarea cols=70 rows=1]

STATED CAUSE:
[checkbox name="cause" value="old|new||injury|MVA|fall|near-fall|assault|sports|work||fall|direct blow|crush|jam|turning|lifting|abduction|hyperflexion|repetitive injury||unknown|"][textarea cols=70 rows=1]

PREVIOUS EVALUATION/TREATMENT:
[checkbox name="previous" value="denies previous work-up||ER|UC|XR|CT||extensive evaluation|injections|surgery|medication therapy||improved with previous management|unchanged with previous management||medication partially helps|medication doesn't help|"][textarea cols=70 rows=1]

HPI:
[checkbox name="hpi" value="mild|moderate|severe||increasing in severity|remaining constant|decreasing in severity||occasional|frequent|constant||dull|stabbing|sharp|burning|pounding|numbing|shooting||affected by sitting|affected by bending/turning|affected by straining/coughing||worse AM|worse during day|worse HS||interfere with ADL|interfere with sleep|causing depression|"][textarea cols=70 rows=1]

BEST LAST WEEK: [textarea cols=10 rows=1]
WORST LAST WEEK: [textarea cols=10 rows=1]

PMSH:
[checkbox name="pmh" value="head injury|back pain|migraine|chronic pain meds|obesity|diabetes|"][textarea cols=70 rows=1]

SOCIAL HISTORY:
[checkbox name="social" value="current smoker|former smoker|(h/o) substance use|"][textarea cols=70 rows=1]

REVIEW OF SYSTEMS: [+] reported [-] not reported
negative except as stated in HPI

CONSTITUTIONAL: [textarea cols=70 rows=1]
[checklist name="const_symptoms" value="objective fever|subjective fever|chills"]
EYES: [textarea cols=70 rows=1]
[checklist name="eye_symptoms" value="change in vision|photophobia|periorbital swelling|pain with EOM"]
EARS: [textarea cols=70 rows=1]
[checklist name="ear_symptoms" value="pain|bleeding|tinnitus|decreased in hearing"]
NOSE: [textarea cols=70 rows=1]
[checklist name="nose_symptoms" value="discharge|snoring|bleeding"]
MOUTH/THROAT: [textarea cols=70 rows=1]
[checklist name="throat_symptoms" value="toothache|sore throat|odynophagia|dysphagia|hoarseness"]
NECK: [textarea cols=70 rows=1]
[checklist name="neck_symptoms" value="pain|stiffness|swelling|swollen glands"]
CV: [textarea cols=70 rows=1]
[checklist name="cv_symptoms" value="chest pain/pressure|dyspnea|orthopnea|ankle swelling|ankle discoloration|leg cramps"]
CHEST/RESPIRATORY: [textarea cols=70 rows=1]
[checklist name="chest_symptoms" value="chest tightness|pain w/ breathing|rib pain|cough"]
GI: [textarea cols=70 rows=1]
[checklist name="gi_symptoms" value="poor appetite|nausea|vomiting|abdominal pain|constipation|diarrhea"]
GU: [textarea cols=70 rows=1]
[checklist name="gu_symptoms" value="dysuria|hematuria|hesitancy|retention|incontinence|inguinal swelling|genital lesion/discharge"]
NEURO: [textarea cols=70 rows=1]
[checklist name="neuro_symptoms" value="dizziness|vertigo|poor balance|abnormality of walk|focal weakness|blackouts|seizures|tingling/numbness|sensory-motor loss|bowel/bladder dysfunction"]
PSYCH: [textarea cols=70 rows=1]
[checklist name="psych_symptoms" value="irritability|confusion|depression|anxiety|mood swings|memory loss|insomnia"]
LYMPH/HEMA: [textarea cols=70 rows=1]
[checklist name="hem_symptoms" value="gland swelling|bruising|anticoagulation|DVT/clotting|anemia|autoimmune dz|h/o cancer"]
DERM: [textarea cols=70 rows=1]
[checklist name="derm_symptoms" value="dryness|pruritus|rash|redness|swelling|wounds|bruising"]


OBJECTIVE

Appearance:
[checkbox name="appearance" value="well-appearing|alert|allows exam|no distress noted while getting on/off exam table & walking around exam room||poor cooperation with exam|guarding||ill-appearing|drowsy|appears impaired|slumped|"][textarea cols=70 rows=1]

Skin:
[checkbox name="skin" value="warm, dry|grossly intact|no bruises|normal turgor||tattoos|body piercings||pallor|cyanosis|poor turgor|diaphoresis|rash|"][textarea cols=70 rows=1]

Head/Face:
[checkbox name="head" value="normocephalic|no evidence of trauma|symmetrical face|non-tender|CN grossly intact|"][textarea cols=70 rows=1]

Eyes:
[checkbox name="eyes" value="clear conjunctiva w/o exudates or hemorrhage, EOM intact without nystagmus|visual acuity grossly intact|cornea(s) clear||glasses|contacts||conjunctival injection|epiphora||periorbital swelling|dysconjugate gaze|"][textarea cols=70 rows=1]

Ears:
[checkbox name="ears" value="symmetrical & intact auricles bilaterally|hearing to conversation intact|clear canals without erythema or blood|TMs normal in appearance|"][textarea cols=70 rows=1]

Nose:
[checkbox name="nose" value="nares patent bilaterally|septum midline||mucosa pink & moist||mucosal edema|clear discharge|"][textarea cols=70 rows=1]

Mouth/Throat:
[checkbox name="throat" value="normal voice|moist oral mucosa without lesions or injury|patent pharynx w/o swelling or exudates||hoarseness|tooth decay|upper denture|lower denture|pharyngeal erythema w/o exudates|pharyngeal crowding|tonsillar enlargement|"][textarea cols=70 rows=1]

Neck:
[checkbox name="neck" value="symmetric with free painless ROM|no LAD||anterior LAD|posterior LAD||DROM|paracervical muscle spasm|"][textarea cols=70 rows=1]

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||poor effort|"][textarea cols=70 rows=1]

CV:
[checkbox name="cv" value="regular rhythm|no murmurs|no ankle edema|pedal skin warm with good & equal pulses||tachycardia|irregular heart rhythm|murmur||calf tenderness|ankle edema|varicosities|stasis discoloration|"][textarea cols=70 rows=1]

Abdomen:
[checkbox name="abd" value="not examined|normal visual inspection, no distension|normal active bowel sounds|soft non-tender||protruding|surgical scar|umbilical hernia||diffuse tenderness over entire abdomen w/o RRG|"][textarea cols=70 rows=1]

GU:
[checkbox name="gu" value="not examined|no suprapubic tenderness|no CVAT bilaterally||normal external genitalia|"][textarea cols=70 rows=1]

MSK - inspected, observed in active ROM, & palpated: [textarea cols=20 rows=1]
[checkbox name="site" value="no gross deformity or misalignment|normal color|joints above and below affected area intact|good ROM for age||demonstrated very limited range of motion||deformity|swelling|tenderness|pain with axial loading|DROM|muscle spasm|trigger points|joint laxity||skin intact|abrasion|laceration|bruise|"][textarea cols=70 rows=1]

Neuro:
[checkbox name="neuro" value="oriented to person, place, time|normal speech|normal concentration and attention|memory grossly intact||ambulates w/o limp or alteration in gait|balance & coordination grossly intact||extremities strong w/o atrophy, tremor or fasciculations|normal sensory exam of upper and lower extremities|normal motor function of upper and lower extremities||heel/toe walk without difficulty|seated SLR negative bil||antalgic gait|wide gait|shuffling gait|deliberate gait|"][textarea cols=70 rows=1]

Behavior:
[checkbox name="behavior" value="calm|pleasant|respectful||cooperative with exam||exam limited by urgency|exam limited by poor cooperation|exam limited by safety concerns||guarded|anxious|fearful|suspicious|hypervigilant||irritable|frustrated|restless||labile|sighing|crying||agitated|raising voice||defensive|argumentative|hostile||forceful|intense|euphoric||demanding particular medication, test, referral, or accommodation||withdrawn|indifferent|appears to be responding to internal psychotic process|"][textarea cols=70 rows=1]

Psychomotor Activity:
[checkbox name="psychomotor" value="no involuntary movements||tremor|tardive dyskinesia|tics||bradykinetic|fidgeting|picking skin|twirling hair|cracking knuckles||threatening posture/movement|grimacing, furrowing eyebrows|tightening jaw|breathing hard||shaking extremities|clenching fists|intense staring||standing up and/or pacing|opening door to hallway|exited exam room during exam|"][textarea cols=70 rows=1]

Speech:
[checkbox name="speech" value="clear & coherent|normal rate & rhythm||slurred|monotonous|stuttering||hypoverbal|hyperverbal||loud|soft||slow|rapid|pressured||repetitive questions|cursing, swearing|criticisms of staff|verbal threats|"][textarea cols=70 rows=1]

Thought Process:
[checkbox name="thought_process" value="organized/linear/logical||circumstantial|tangential|perseveration|flight of ideas||preoccupation with illness|catastrophization|overgeneralization|unrealistic beliefs|negativism|pessimism|blaming others|staff splitting||delusions|paranoid ideation|"][textarea cols=70 rows=1]

OFFICE X-RAYS: [textarea cols=30 rows=1] [checkbox name="wet" value="essentially normal|no fx|staff to notify patient once radiology report becomes available|"][textarea cols=70 rows=1]

DX:
[checkbox name="dx" value="headache|concussion|loss of consciousness||cervical pain|cervical radiculitis/neuritis|trapezius sprain/strain|thoracic pain|thoracic disc displacement/herniation|chest wall pain|lumbar pain|lumbar sprain/strain|lumbar disc displacement/herniation|lumbar DDD|sciatica||shoulder pain|elbow pain|wrist pain||hip pain|knee pain|foot pain||bursitis|tenosynovitis|TMJ pain|disturbed sensation-paresthesia|peripheral nerve entrapment||multiple somatic complaints|myofascial pain|subjective pain syndrome||anxiety|insomnia secondary to pain||status post alleged injury|secondary to MVA|secondary to slip and fall|"][textarea cols=70 rows=1]

PLAN OF CARE:
[checkbox name="poc" value="POC risks/benefits/alternatives discussed with patient/parent/SO, opportunity provided to ask questions||verbalized understanding that X-rays reviewed online not diagnostic quality|verbalized understanding that normal X-rays do not exclude non-displaced fracture||verbalized understanding of and agreed with POC, discharge & f/u instructions||did not agree with my POC/recommendations – will seek second opinion/further care elsewhere|"][textarea cols=70 rows=1]

TREATMENT:
[checkbox name="treat" value="provided with crutches|provided with splint/brace|provided with sling|provided with compression bandage/sleeve|"][textarea cols=70 rows=1]

GOALS:
[checkbox name="goal" value="conservative rehabilitation for 12-15 weeks to include passive and active therapy, along with orthopedic modalities|promote interventions emphasizing patient responsibility, therapeutic exercise / stretching at home, early return to work, cognitive restructuring|Detailed ortho / neuro examination by chiropractic|will consider specialty evaluation (ortho, neurology, pain management, neurology) if not responding to above|follow up w PCP to address chronic health issues|"][textarea cols=70 rows=1]

RX:
[checkbox name="order_RX" value="non-NSAID to control pain/headache|anti-inflammatory to control soft tissue inflammation and pain|antispasmodic to decrease muscle hypertonicity and improve sleep|opioid pain medications for short term relief of extreme pain||electronic|paper|given to MA to be transmitted to pharmacy|patient declined any and all prescription medications, will take OTC|"][textarea cols=70 rows=1]

REFERRALS:
[checkbox name="order_refer" value="none|ortho|PT|neurology|"][textarea cols=70 rows=1]

REVIEWED:
[checkbox name="reviewed" value="MA notes|med list|previous visits|PMP/CURES|previous laboratory studies|previous diagnostic studies|specialty reports|hospital discharge|"][textarea cols=70 rows=1]

VERBALLY INSTRUCTED ON:
[checkbox name="instructions" value="vital signs/exam findings/recommendations|x-ray findings|appropriate follow up with ortho regardless of X-ray findings|reporting medication side effects immediately|ROM exercise/stretching to prevent deconditioning||controlling chronic conditions|cognitive restructuring|symptom exacerbation through rebound mechanism|risks of respiratory depression a/w sedative meds||obtaining old records|keeping pain diary||smoking cessation|weight loss|"][textarea cols=70 rows=1]

BARRIERS TO CARE:
[checkbox name="barriers" value="none identified||poor cooperation with exam|lack of motivation|negative attitude to diagnostic impression & proposed tx|poor compliance with medication regimen|incomplete history|vague shifting complaints|symptom magnification|history not supported by objective findings|multiple comorbidities||polypharmacy|lack of interest in nonpharmacologic therapies|overwhelming focus on Rx drugs|intolerance of multiple meds|tolerance to and/or dependence on multiple medications|early renewals|labs/PDMP inconsistent with stated history or current Rx||frequent ER/UC visits|altered mental status|hostile/disruptive behavior|active psychiatric diagnosis|alcohol or substance use||failed to obtain old records|failed to complete referrals or testing|failed to bring medications for med review||social/cultural barriers|victim of abuse|"][textarea cols=70 rows=1]

FOLLOW UP:
[checkbox name="follow" value="RTC 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, PRN||24 hours|48 hours|72 hours|1 week|"][textarea cols=70 rows=1]

DISCHARGE CONDITION:
[checkbox name="discharge" value="improved|stable|unchanged|"][textarea cols=70 rows=1]

WORK/SCHOOL STATUS:
[checkbox name="excuse" value="fit for duty w/o restrictions|work restrictions|lifting precautions|no PE/gym|excuse provided|"][textarea cols=70 rows=1]

DISPOSITION:
[checkbox name="disposition" value="home|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|removed by staff|"][textarea cols=70 rows=1]

TOTAL TIME:
[checkbox name="time" value="15 minutes or less|15-30 minutes|30-45 minutes|visit dominated by counseling"]
HISTORY:


NECK:


UP/MID BACK:


CHEST/ABD:


LOW BACK:


UE:


LE:


STATED CAUSE:


PREVIOUS EVALUATION/TREATMENT:


HPI:


BEST LAST WEEK:
WORST LAST WEEK:

PMSH:


SOCIAL HISTORY:


REVIEW OF SYSTEMS: [+] reported [-] not reported
negative except as stated in HPI

CONSTITUTIONAL:

EYES:

EARS:

NOSE:

MOUTH/THROAT:

NECK:

CV:

CHEST/RESPIRATORY:

GI:

GU:

NEURO:

PSYCH:

LYMPH/HEMA:

DERM:



OBJECTIVE

Appearance:


Skin:


Head/Face:


Eyes:


Ears:


Nose:


Mouth/Throat:


Neck:


Chest/Lungs:


CV:


Abdomen:


GU:


MSK - inspected, observed in active ROM, & palpated:


Neuro:


Behavior:


Psychomotor Activity:


Speech:


Thought Process:


OFFICE X-RAYS:

DX:


PLAN OF CARE:


TREATMENT:


GOALS:


RX:


REFERRALS:


REVIEWED:


VERBALLY INSTRUCTED ON:


BARRIERS TO CARE:


FOLLOW UP:


DISCHARGE CONDITION:


WORK/SCHOOL STATUS:


DISPOSITION:


TOTAL TIME:

Result - Copy and paste this output: