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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]
CC:
[checkbox name="cc" value="skin FB|human bite|animal bite|plantar puncture wound|nail injury||dirty|clean|unknown|"][textarea cols=70 rows=1]
LOCATION: [textarea cols=40 rows=1]
HPI:
[checkbox name="HPI" value="less than 12 hours ago|more than 12 hours ago|one day ago |more than one day ago||no loss of sensation|full range of motion of involved body part|no discharge||not wearing shoes|wearing rubber-soled shoes||animal known|animal unknown||tingling|loss of sensation distal to injury|distal pallor/cyanosis|distal weakness|wound discharge|"][textarea cols=70 rows=1]
PMSH:
[checkbox name="pmh" value="diabetes|PAD|immunosuppression|"][textarea cols=70 rows=1]
TETANUS:
[checkbox name="tetanus" value="up to date|less than five years ago|5-10 years ago|greater than 10 years ago|unknown"]

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="bleeding|tongue pain/swelling|sore throat|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|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|retention|oliguria"]
NEURO: [textarea cols=70 rows=1]
[checklist name="neuro_symptoms" value="dizziness|vertigo|poor balance|abnormality of walk|focal weakness|blackouts|seizures"]
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"]




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

Head/Face:
[checkbox name="head" value="normocephalic|no evidence of trauma|no facial tenderness|symmetrical face|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||active septal hemorrhage|dried up blood|"][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||nuchal tenderness|"][textarea cols=70 rows=1]

Chest/Lungs:
[checkbox name="lungs" value="normal work of breathing, symmetrical chest expansion|chest wall atraumatic and non-tender|clear and equal breath sounds bilaterally||poor effort|coughing|"][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|no inguinal LAD|"][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]

Affected Area:
[checkbox name="affected_area" value="FB visualized inside|FB not visualized|surrounded by erythema/swelling|surrounded by induration|surrounded by ecchymosis|"][textarea cols=70 rows=1]

NVT:
[checkbox name="nvt" value="sensation (simple touch) intact|normal capillary refill/pulses|demonstrated FROM against resistance"]

OFFICE X-RAYS: [textarea cols=30 rows=1] [checkbox name="wet" value="not indicated|essentially normal|no FB visible||staff to notify patient once radiology report becomes available|"][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 of and agreement with POC, discharge & f/u instructions||verbalized understanding that X-rays reviewed online not diagnostic quality|verbalized understanding that retained FB cannot be completely ruled out by X-rays and may cause serious infection|verbalized understanding of significant risk of infection even while taking abx||did not agree with my POC/recommendations – will seek second opinion/further care elsewhere|"][textarea cols=70 rows=1]

PROCEDURE:
[checkbox name="prep" value="restrains used||skin cleaned with wound cleanser|skin cleaned with hibiclens|skin cleaned with Betadine||draped in normal sterile fashion||anesthetized locally with lidocaine 1%|anesthetized locally with lidocaine 2%||wound edges enlarged|wound explored locally||no foreign material visible|foreign material minimal|foreign material moderate|foreign material extensive||no tendons visible|tendons appear intact||wound irrigated with plenty of NS|foreign material removed partially|foreign material removed completely||wound left open|bleeding insignificant stopped with pressure||covered with non-adherent dressing|applied bulky gauze dressing||NVT reassessment intact||splint/brace applied||patient tolerated procedure well|"][textarea cols=70 rows=1]

RX:
[checkbox name="order_RX" value="none|electronic|paper|given to MA to be transmitted to pharmacy|"][textarea cols=70 rows=1]

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

VERBALLY INSTRUCTED ON:
[checkbox name="instructions" value="vital signs/exam findings/recommendations|x-ray findings||returning immediately or contacting 911 for increasing pain, swelling, redness, drainage, fever, trouble moving digits, digits turning cold/blue/grey||keeping wound dry|cleaning area with soap and water after 24 hours|changing dressing daily|avoiding ointments||controlling chronic conditions|"][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|incomplete history|vague shifting complaints|history not supported by objective findings||multiple comorbidities|polypharmacy||lack of interest in nonpharmacologic therapies|overwhelming focus on Rx drugs|intolerance of multiple meds||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|poor compliance with medication regimen||social/cultural barriers|victim of abuse|"][textarea cols=70 rows=1]

WORK/SCHOOL STATUS:
[checkbox name="excuse" value="fit for duty w/o restrictions|fit for duty with restrictions||no PE/gym|excuse provided|"][textarea cols=70 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 appearance of new/danger s/sx||RTC 24 hours|RTC 48 to 72 hours|RTC 1 week||ortho within 3 days|ortho within 7 days||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=70 rows=1]
HISTORY:

CC:

LOCATION:
HPI:

PMSH:

TETANUS:


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:





Appearance:


Head/Face:


Eyes:


Ears:


Nose:


Mouth/Throat:


Neck:


Chest/Lungs:


CV:


Abdomen:


GU:


Behavior:


Psychomotor Activity:


Speech:


Thought Process:


Affected Area:


NVT:


OFFICE X-RAYS:

PLAN OF CARE:


PROCEDURE:


RX:


REVIEWED:


VERBALLY INSTRUCTED ON:


BARRIERS TO CARE:


WORK/SCHOOL STATUS:


DISPOSITION:

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