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:
[checklist name="cc" value="headache|fever|malaise|body aches|night sweats|runny nose|nasal congestion|PND|sinus pain|earache|ear pressure|sore throat|hoarseness|cough"][textarea cols=70 rows=1]
HPI:
[checkbox name="hpi" value="sudden onset|gradual onset||started just prior to arrival|started today|started yesterday|started several days ago|started more than 1 week ago||sx increasing in severity|sx persisting|sx decreasing in severity|"][textarea cols=70 rows=1]
RECENT & PAST HISTORY: [+] reported [-] not reported
[checklist name="recent" value="ER/UC visit|hospitalization/surgery/procedure|travel|sick contact|new/changed medications|antibiotic use|allergies|asthma/COPD|smoker|immunosuppression"]
MEDICATIONS:
allergies reviewed
[checkbox name="medications" value="taking OTC, not helping|taking ABX, not helping|not taking any medications|"][textarea cols=70 rows=1]

REVIEW OF SYSTEMS: [+] reported [-] not reported
negative except as stated
EYES: [textarea cols=40 rows=1]
[checklist name="eye_symptoms" value="decrease in vision|redness/irritation|watery|discharge|lid swelling|pain with EOM"]
MOUTH: [textarea cols=40 rows=1]
[checklist name="mouth_symptoms" value="sores|dryness|tongue pain/swelling|toothache"]
NECK: [textarea cols=40 rows=1]
[checklist name="neck_symptoms" value="pain|stiffness|swelling|swollen glands"]
CV: [textarea cols=40 rows=1]
[checklist name="cv_symptoms" value="chest pain/pressure|SOB|palpitations|dyspnea|orthopnea|ankle swelling|ankle discoloration|varicose veins|leg cramps"]
CHEST/RESPIRATORY: [textarea cols=40 rows=1]
[checklist name="chest_symptoms" value="chest tightness|pain w/ breathing/coughing"]
GI: [textarea cols=40 rows=1]
[checklist name="gi_symptoms" value="poor appetite|nausea|vomiting|bloating|abdominal pain|constipation|diarrhea"]
GU: [textarea cols=40 rows=1]
[checklist name="gu_symptoms" value="dysuria|burning|frequency|urgency|odor|hematuria|hesitancy|retention|nocturia|oliguria|incontinence|itching|discharge|genital lesions"]
MSK: [textarea cols=40 rows=1]
[checklist name="msk_symptoms" value="neck pain|back pain|chronic pain/meds|localized joint pain/deformity|localized muscle/soft tissue pain/swelling|myalgias"]
NEURO: [textarea cols=40 rows=1]
[checklist name="neuro_symptoms" value="dizziness|vertigo|poor balance|abnormality of walk|focal weakness|blackouts|seizures|tingling/numbness"]
PSYCH: [textarea cols=40 rows=1]
[checklist name="psych_symptoms" value="irritability|confusion|depression|anxiety|mood swings|memory loss|insomnia"]
LYMPH/HEMA/IMMUNE: [textarea cols=40 rows=1]
[checklist name="hem_symptoms" value="gland swelling|bruising|anticoagulation|DVT/clotting|anemia|autoimmune dz|h/o cancer"]
DERM: [textarea cols=40 rows=1]
[checklist name="derm_symptoms" value="pruritus|rash|hives|redness|swelling|wounds|new or suspicious lesions"]



Appearance:
[checkbox name="appearance" value="well-appearing|alert|non-toxic|normal WOB||allows exam|poor cooperation with exam|crying but consolable||ill-appearing|tired-looking|short of breath|diaphoretic||drowsy|appears impaired|slumped|"][textarea cols=70 rows=1]

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

Head/Face:
[checkbox name="head" value="normocephalic, atraumatic|normal hair distribution|symmetrical face|CN grossly intact|"][textarea cols=70 rows=1]

Eyes:
[checkbox name="eyes" value="clear conjunctiva w/o exudates or hemorrhage, anicteric sclera, EOM intact without nystagmus|visual acuity grossly intact||conjunctival injection|epiphora|conjunctival exudate||allergic shiners|dennie lines||palpebral edema|palpebral exudates||glasses|contacts|"][textarea cols=70 rows=1]

Ears:
[checkbox name="ears" value="symmetrical & intact auricles bilaterally|hearing to conversation intact|clear canals without erythema or discharge|TMs normal in appearance||tragal tenderness|swelling of external auditory canal|pustule in canal|cerumen in canal|TM obscured by cerumen||HOH|hearing aid(s)|TM red|TM bulging|TM perforated||TM retracted|fluid behind TM|tube in TM||mastoid tenderness|"][textarea cols=70 rows=1]

Nose:
[checkbox name="nose" value="nares patent bilaterally|septum midline|no facial tenderness|mucosa pink & moist||allergic salute|maxillary tenderness|frontal tenderness||deviated septum||mucosal edema|clear discharge|thick drainage|"][textarea cols=70 rows=1]

Mouth:
[checkbox name="mouth" value="tongue normal in appearance w/o lesions and with good symmetrical movements|moist oral mucosa without lesions||upper denture|lower denture||poor dentition|single oral ulcer|multiple oral ulcers|gum swelling|tooth decay|"][textarea cols=70 rows=1]

Throat:
[checkbox name="throat" value="normal voice|patent pharynx w/o swelling or exudates|uvula midline||hoarseness|vesicles on soft palate|petechiae on soft palate||pharyngeal erythema w/o exudates||pharyngeal crowding|tonsilar enlargement|tonsilar erythema|tonsilar exudates|tonsilar crypts|tonsilar pustules||inspiratory stridor|muffled voice|"][textarea cols=70 rows=1]

Neck:
[checkbox name="neck" value="symmetric with free painless ROM|no LAD|no bruit or JVD||anterior LAD|posterior LAD|"][textarea cols=70 rows=1]

Chest/Lungs:
[checkbox name="lungs" value="normal work of breathing, symmetrical chest expansion|no retractions|clear and equal breath sounds bilaterally||chest wall atraumatic and non-tender|no axillary or supraclavicular LAD||respiratory distress|breath sounds decreased bilaterally|coughing|poor effort||expiratory wheezing|crackles|"][textarea cols=70 rows=1]

CV:
[checkbox name="cv" value="regular rhythm|no murmurs|no ankle edema||tachycardia|irregular heart rhythm|systolic 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|direct non-rebound tenderness||hypoactive bowel sounds|hyperactive bowel sounds|colostomy in situ|"][textarea cols=70 rows=1]

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

MSK:
[checkbox name="spine" value="no gross deformities, moves all extremities with good ROM for age|full weight-bearing|normal curvature & ROM in C- & L-spine for patient’s age|"][textarea cols=70 rows=1]

Neuro:
[checkbox name="neuro" value="ambulates w/o limp or alteration in gait|balance & coordination grossly intact|extremities strong w/o atrophy, tremor or fasciculations||normal speech|normal concentration and attention|memory grossly intact||no gross motor deficits|sensation symmetrical & grossly intact|"][textarea cols=70 rows=1]

Behavior:
[checkbox name="behavior" value="calm|pleasant|respectful||cooperative with exam|poor cooperation with exam||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 DIAGNOSTICS:
[checkbox name="office" value="none||rapid strep|CXR|"][textarea cols=70 rows=1]

[comment memo="Dx:
viral syndrome
influenza
rhinitis
sinusitis
otitis media
otitis externa
laryngitis
tonsillitis
pharyngitis
dyspnea
acute bronchitis
acute bronchospasm"]

A/P:
[textarea cols=70 rows=4]

PLAN OF CARE:
[checkbox name="discussed" value="POA risks/benefits/side effects/alternatives discussed with patient/parent/SO, opportunity provided to ask questions|verbalized understanding of and agreement with POC, discharge & f/u instructions||patient/family did not agree with my POA/recommendations – will seek second opinion/further care elsewhere|"][textarea cols=70 rows=1]

RX:
[checkbox name="order_RX" value="OTC|paper|electronic|given to MA to be transmitted to pharmacy|"][textarea cols=70 rows=1]

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

INSTRUCTED ON:
[checkbox name="instructions" value="vital signs,exam findings, recommendations, reporting medication side effects to clinic immediately, appropriate follow up with PCP|rest/hydration|proper/timely abx use|"][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||poor compliance with POC|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|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 to 72 hours|1 week|"][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:

HPI:

RECENT & PAST HISTORY: [+] reported [-] not reported

MEDICATIONS:
allergies reviewed


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

MOUTH:

NECK:

CV:

CHEST/RESPIRATORY:

GI:

GU:

MSK:

NEURO:

PSYCH:

LYMPH/HEMA/IMMUNE:

DERM:




Appearance:


Skin:


Head/Face:


Eyes:


Ears:


Nose:


Mouth:


Throat:


Neck:


Chest/Lungs:


CV:


Abdomen:


GU:


MSK:


Neuro:


Behavior:


Psychomotor Activity:


Speech:


Thought Process:


OFFICE DIAGNOSTICS:


Dx:
viral syndrome
influenza
rhinitis
sinusitis
otitis media
otitis externa
laryngitis
tonsillitis
pharyngitis
dyspnea
acute bronchitis
acute bronchospasm


A/P:


PLAN OF CARE:


RX:


REVIEWED:


INSTRUCTED ON:


BARRIERS TO CARE:


FOLLOW UP:


DISPOSITION:

Result - Copy and paste this output: