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]

CC:
[checkbox name="cc" value="pain|tenderness|swelling|locking|catching|giving way||bruising|cut|abrasion||unable to bear wt/apply axial pressure||distal weakness|distal numbness/sensory loss|distal pallor/cyanosis|"][textarea cols=70 rows=1]

LOCATION: [select name="Q2" value="shoulder|elbow|forearm|wrist|hand|finger||hip|knee|ankle|foot|toe||head|neck|chest|torso|back|"][conditional field="Q2" condition="(Q2).is('other - ')"][text][/conditional][checkbox value="left|right|first|second|third|fourth|fifth||proximal|distal||medial|lateral||dorsal|ventral||midline"][textarea cols=40 rows=1]

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

HPI:
[checkbox name="HPI" value="happened just prior to arrival|happened today|happened yesterday|happened days ago||pain at rest|pain with use||felt snap sensation|felt pop sensation|felt crack sensation||sx increasing in severity|sx remaining constant|sx decreasing in severity|"][textarea cols=70 rows=1]

PREVIOUS EVALUATION:
[checkbox name="previous" value="none|ER|UC|XR|CT|"][textarea cols=70 rows=1]

PMSH:
[checkbox name="pmh" value="head injury|previous injuries|back pain|migraine|chronic pain meds|diabetes|PAD|immunosuppression|"][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="bleeding|tongue pain/swelling|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|retention|oliguria|incontinence|genital lesions/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"]
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|hives|redness|swelling|wounds|new or suspicious lesions"]


OBJECTIVE

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]

Skin:
[checkbox name="skin" value="warm, dry|grossly intact, no rashes|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|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]

Injury Site inspected, observed in active ROM, & palpated:
[checkbox name="site" value="no gross deformity or misalignment|joints above & below affected area intact||deformity|warmth, swelling, tenderness|pain with axial loading|DROM||joint laxity||skin intact|abrasion|laceration|bruise|"][textarea cols=70 rows=1]

Neuro:
[checkbox name="neuro" value="oriented to person, place, time|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||antalgic gait|wide gait|shuffling gait|dystonia|"][textarea cols=70 rows=1]
Sensory [textarea cols=30 rows=1 default="symmetrical & grossly intact: "][checkbox name="e_sens" value="thumb web space (radial)|tip of index finder (median)|tip of little finger (ulnar)||big toe web space (deep peroneal)|sole (post tibial)|lateral dorsum of foot (superficial)||UE|LE"]
Vascular:
[checkbox name="vascular" value="UE cap refill brisk bilaterally, pulses strong & equal|LE cap refill brisk bilaterally, pulses strong & equal"]
Motor [textarea cols=20 rows=1 default="intact and equal: "][checkbox name="e_motor" value="wrist extension (radial)|finger flexion/thumb opposition (median)|finger abduction/adduction (ulnar)||ankle eversion (superficial peroneal)|ankle dorsiflexion (deep peroneal)|ankle/toe flexion (tibial)||UE|LE"]

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="none||essentially normal|no fx||transverse fx|oblique fx|spiral fx|comminuted fx|extra-articular fx|intra-articular fx|angulation present|translation present|shortening present|rotation present|dislocation present||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 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="immobilization provided|applied compression bandage/sleeve|brace applied|splint applied|immobilized with boot orthosis|immobilization with post-op shoe||provided with crutches|provided with sling||placement, alignment, & N/V status verified||tetanus vaccination per facility protocol|"][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]

REFERRALS:
[checkbox name="order_refer" value="none|ortho within 3 days|ortho within 1 week|"][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||RICE regimen x 72 hrs — rest, ice, compression, and elevation|early ROM exercise/stretching to prevent deconditioning|appropriate follow up with ortho regardless of X-ray findings|reporting medication side effects immediately||splinting until cleared by ortho|crutch walking until cleared by ortho||check for N/V integrity of affected part|contact emergency services if increased swelling/pain/numbness/tingling of affected extremity, trouble moving fingers/toes, fingers/toes turning cold/blue/grey||controlling chronic conditions|cognitive restructuring|symptom exacerbation through rebound mechanism|risks of respiratory depression a/w meds|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|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]

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|fit for duty with restrictions||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|"][textarea cols=70 rows=1]
HISTORY:


CC:


LOCATION:

STATED CAUSE:


HPI:


PREVIOUS EVALUATION:


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:


Injury Site inspected, observed in active ROM, & palpated:


Neuro:

Sensory
Vascular:

Motor

Behavior:


Psychomotor Activity:


Speech:


Thought Process:


OFFICE X-RAYS:

PLAN OF CARE:


TREATMENT:


RX:


REFERRALS:


REVIEWED:


VERBALLY INSTRUCTED ON:


BARRIERS TO CARE:


FOLLOW UP:


DISCHARGE CONDITION:


WORK/SCHOOL STATUS:


DISPOSITION:

Result - Copy and paste this output: