Complete Note
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HISTORIAN: [textarea cols=40 rows=2]
[checkbox name="historian" value="patient - new|patient - existing||case manager/group home provider present during visit|SO/family member present during visit|chaperone/MA present during visit||interpretation provided by family member/SO|interpretation provided by MA"]

RELIABILITY: [textarea cols=40 rows=2]
[checkbox name="reliability" value="good historian|supporting documentation available||poor historian|no information to support history/complaints||complete history unobtainable d/t poor effort|complete history unobtainable d/t cognitive changes or lack of knowledge|complete history unobtainable d/t anxiety|complete history unobtainable d/t pain|complete history unobtainable d/t language skills"]

RECENT HISTORY: [+] reported [-] not reported
[textarea cols=40 rows=2][checklist name="recent" value="visit to ER/UC|hospitalization|surgery/procedure|new medications|antibiotic use|withdrawals"]

RESULTS: [textarea cols=40 rows=2]
[checklist name="results" value="imaging studies|laboratory studies|specialty consults"]

MEDICATIONS: [textarea cols=40 rows=2 default="allergies reviewed, "]
[checkbox name="medications" value="none|Rx|OTC||taking as prescribed|not taking as prescribed||reports no side effects|reports side effects||effective|partially effective|not effective||demonstrates knowledge of medications/reasons/dosages taken|unable to name medications/reasons/dosages taken||medication list/labels/containers available for review|medication list/labels/containers not available for review||insulin/BS log available for review|insulin/BS log not available for review"]

PMSH: [textarea cols=40 rows=2 default="reviewed, "]
[checkbox name="pmh" value="non-contributory"]

SOCIAL HISTORY: [textarea cols=40 rows=2 default="reviewed, "]
[checkbox name="social" value="current smoker|former smoker|(h/o) substance use||financial/housing problems/legal problems|current/former victim of abuse"]

HPI: [textarea cols=40 rows=2]
[checkbox name="new_chronic" value="new problem|chronic condition|acute exacerbation of chronic condition"]

Duration: [textarea cols=40 rows=2]
[checkbox name="duration" value="hours|days|weeks|months|years"]

Symptoms: [textarea cols=40 rows=2]
[checkbox name="progression" value="increasing in severity|remaining constant|decreasing in severity"]

Frequency: [textarea cols=40 rows=2]
[checkbox name="frequency" value="constant|intermittent|occasional"]

Affected by: [textarea cols=40 rows=2]
[checkbox name="worse" value="N/A|medication|exertion|pressure|position|movement|rest|cold|weather|night|stress"]

REVIEW OF SYSTEMS: [+] reported [-] not reported
[checkbox name="ros" value="negative except as stated in HPI"]

CONSTITUTIONAL: [textarea cols=40 rows=2]
[checklist name="constitutional_symptoms" value="fever|chills|body aches|malaise|fatigue|night sweats|hot flashes|unintentional wt loss"]
HEAD/FACE: [textarea cols=40 rows=2]
[checklist name="head_symptoms" value="headache|scalp swelling|trauma|facial pain|facial swelling|facial drooping|facial numbness"]
EYES: [textarea cols=40 rows=2]
[checklist name="eye_symptoms" value="decrease in vision|scotoma|floaters|blurriness|photophobia|halos|dryness|redness/irritation|watery|discharge|lid swelling|lid nodule|periorbital swelling|trauma|pain with EOM"]
EARS: [textarea cols=40 rows=2]
[checklist name="ear_symptoms" value="pain|pressure|discharge|bleeding|wax|possible FB|hearing loss|ringing"]
NOSE: [textarea cols=40 rows=2]
[checklist name="nose_symptoms" value="discharge|PND|congestion|sinus pressure|snoring|bleeding|possible FB|trauma"]
MOUTH: [textarea cols=40 rows=2]
[checklist name="mouth_symptoms" value="sores|dryness|tongue pain/swelling|toothache|infection/swelling|jaw pain/clicking|changes in taste"]
THROAT: [textarea cols=40 rows=2]
[checklist name="throat_symptoms" value="sore throat|odynophagia|dysphagia|hoarseness|globus"]
NECK: [textarea cols=40 rows=2]
[checklist name="neck_symptoms" value="pain|stiffness|swelling|swollen glands"]
CV: [textarea cols=40 rows=2]
[checklist name="cv_symptoms" value="chest pain/pressure|SOB|palpitations|lightheadedness|fainting|exertional dyspnea|orthopnea|rapid wt gain|ankle swelling|ankle discoloration|varicose veins|leg cramps"]
CHEST/RESPIRATORY: [textarea cols=40 rows=2]
[checklist name="chest_symptoms" value="cough|phlegm|wheezing|pain w/ breathing|rib pain|breast swelling/lump"]
GI: [textarea cols=40 rows=2]
[checklist name="gi_symptoms" value="poor appetite|nausea|vomiting|bloating|heartburn|gas|generalized abdominal discomfort|epigastric pain|periumbilical pain|constipation|diarrhea|melena|rectal pain/itching|rectal bleeding"]
GU: [textarea cols=40 rows=2]
[checklist name="gu_symptoms" value="dysuria|burning|frequency|urgency|odor|hematuria|hesitancy|retention|nocturia|oliguria|incontinence|discharge|itching|inguinal swelling|skin lesion(s)/rash"]
[checkbox memo="GYN" name="notes2" value=" "][conditional field="notes2" condition="(notes2).is(' ')"][checklist name="gyn_symptoms" value="abnormal bleeding|missed period|irregular periods|heavy and/or prolonged periods|passing clots|spotting|dyspareunia"][/conditional]
MSK: [textarea cols=40 rows=2]
[checklist name="msk_symptoms" value="myalgias|neck pain|back pain|shoulder pain|hip pain|knee pain|chronic pain/meds|joint pain/deformity|localized muscle/soft tissue pain/swelling"]
NEURO: [textarea cols=40 rows=2]
[checklist name="neuro_symptoms" value="dizziness|vertigo|poor balance|abnormality of walk|focal weakness|blackouts|speech difficulty|tremor|seizures|urinary/bowel changes|tingling/numbness"]
PSYCH: [textarea cols=40 rows=2]
[checklist name="psych_symptoms" value="irritability|confusion|withdrawal|depression|apathy|anxiety|mood swings|memory loss|insomnia"]
ENDO: [textarea cols=40 rows=2]
[checklist name="endo_symptoms" value="cold intolerance|skin dryness|hair loss|polyuria"]
LYMPH/HEMA:[textarea cols=40 rows=2]
[checklist name="hem_symptoms" value="gland swelling|bruising|anticoagulation|DVT/clotting|anemia"]
ALLERGIES/IMMUNE: [textarea cols=40 rows=2]
[checklist name="allergy_symptoms" value="atopy|food allergies|autoimmune dz|h/o cancer"]
DERM: [textarea cols=40 rows=2]
[checklist name="derm_symptoms" value="dryness|pruritus|rash|hives|redness|swelling|wounds"]




Ambulation/DME:
[checkbox name="ambulation" value="no ambulation aids/DME|ambulation requires walker|ambulation requires cane|ambulation requires wheelchair||wearing cervical collar|wearing lumbar support|wearing extremity brace|"][textarea cols=40 rows=2]

Appearance:
[checkbox name="appearance" value="well-appearing|no signs of discomfort visible while sitting in chair|no signs of discomfort visible while ambulating & getting on/off exam table||normal built|heavy built|emaciated|frail||ill-appearing|tired-looking|short of breath|diaphoretic||good hygiene|disheveled|bizarre clothes|body odor||drowsy|appears impaired|slumped|"][textarea cols=40 rows=2]

Head/Face:
[checkbox name="head" value="normocephalic, atraumatic|normal hair distribution|symmetrical face|CN grossly intact||plethoric face|alopecia|facial droop|"][textarea cols=40 rows=2]

Eyes:
[checkbox name="eyes" value="clear conjunctiva w/o exudates or hemorrhage, anicteric sclera, EOM intact without nystagmus|visual acuity grossly intact|cornea(s) clear||glasses|conjunctival injection|epiphora|conjunctival exudate|allergic shiners|dennie lines||periorbital swelling|palpebral edema|palpebral exudates||ptosis|chemosis|hyphema|subconjunctival hemorrhage|dysconjugate gaze|"][textarea cols=40 rows=2]

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|pus/fluid behind TM|TM bulging|TM perforated|TM retracted|tube in TM|mastoid tenderness|"][textarea cols=40 rows=2]

Nose:
[checkbox name="nose" value="nares patent bilaterally|septum midline|no facial tenderness|mucosa pink & moist||swollen & boggy mucosa|mucosal ulceration|mucosal congestion|clear discharge|yellow discharge|crusty discharge||allergic salute|maxillary tenderness|frontal tenderness||deviated septum|active septal hemorrhage|dried up blood||rhinophyma|"][textarea cols=40 rows=2]

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 caries|"][textarea cols=40 rows=2]

Throat:
[checkbox name="throat" value="normal voice|patent pharynx w/o swelling or exudates|uvula midline|clear pharynx w/o exudates||pharyngeal erythema w/o exudates|hoarseness|vesicles on soft palate|petechiae on soft palate||pharyngeal crowding|tonsilar enlargement|tonsilar erythema|tonsilar exudates|tonsilar crypts|tonsilar pustules|"][textarea cols=40 rows=2]

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=40 rows=2]

Chest/Lungs:
[checkbox name="lungs" value="normal work of breathing, symmetrical chest expansion, no stridor|clear and equal breath sounds bilaterally||chest wall atraumatic and non-tender|no axillary or supraclavicular LAD||SOB|decreased bilaterally|wheezing|crackles|"][textarea cols=40 rows=2]

CV:
[checkbox name="cv" value="regular rhythm|no murmurs|no ankle edema|pedal skin warm with good & equal pulses||tachycardia|irregular heart rhythm|systolic murmur||calf tenderness|ankle edema|varicosities|stasis discoloration|"][textarea cols=40 rows=2]

Abdomen:
[checkbox name="abd" value="not examined|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|"][textarea cols=40 rows=2]

GU:
[checkbox name="gu" value="not examined|no suprapubic tenderness|no CVAT bilaterally||Foley in situ|normal external genitalia|no inguinal LAD||testicular tenderness|urethral discharge|verrucous papules|vesicles|crusted lesions|"][textarea cols=40 rows=2]

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|non-tender C-spine with good ROM|non-tender L-spine with good ROM|strength, tone, & bulk symmetrical & grossly intact||kyphosis|paraspinal muscle spasm|C-spine tenderness & DROM|neck pain with active motion|paracervical muscle spasm|old surgical scar(s) in C-spine|trapezius tenderness||L-spine tenderness|reduced painful ROM in lumbar region|paraspinal muscle spasm|trigger points in L-spine|old surgical scar(s) in L-spine||heel-walk & toe-walk without difficulty|negative seated SLR|positive seated SLR|"][textarea cols=40 rows=2]

Neuro:
[checkbox name="neuro" value="normal concentration and attention|memory grossly intact||balance & coordination grossly intact|normal speech|no gross motor deficits||sensation symmetrical & grossly intact|extremities strong w/o atrophy, tremor or fasciculations|reflexes normoactive||antalgic gait|wide gait|shuffling gait|diffuse numbness w/o dermatomal pattern|dystonia|"][textarea cols=40 rows=2]

Skin:
[checkbox name="skin" value="grossly intact, no rashes|no bruises|normal turgor||tattoos|body piercings|poor turgor|dry|sweaty|"][textarea cols=40 rows=2]

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, accommodation|repetitive questions|cursing, swearing|criticisms of staff|verbal threats||withdrawn|indifferent|appears to be responding to internal psychotic process|"][textarea cols=40 rows=2]

Psychomotor Activity:
[checkbox name="psychomotor" value="no involuntary movements||tremor|tardive dyskinesia|tics||bradykinetic|fidgeting|picking skin|twirling hair|cracking knuckles||grimacing, furrowing eyebrows|tightening jaw|breathing hard||shaking extremities|clenching fists||standing up, pacing|opening door to hallway||threatening posture/movement|"][textarea cols=40 rows=2]

Visual Contact:
[checkbox name="visual" value="appropriate|poor eye contact|intense staring|"][textarea cols=40 rows=2]

Speech:
[checkbox name="speech" value="clear & coherent|normal rate & rhythm||slurred|monotonous|stuttering||hypoverbal|hyperverbal||loud|soft||slow|rapid|pressured|"][textarea cols=40 rows=2]

Thought Process:
[checkbox name="thought_process" value="organized/linear/logical||circumstantial thinking|tangential thinking|perseveration|flight of ideas||preoccupation with illness|catastrophization|overgeneralization|unrealistic beliefs|negativism|pessimism|blaming others|staff splitting|delusions|paranoid ideation|"][textarea cols=40 rows=2]



MA TO:
[checkbox name="MA" value="none|dsg change/wound care as instructed|obtain hospital discharge report|obtain specialty report|obtain imaging report|obtain laboratory report|remind patient to always bring all medication containers to visit"]

OUTSIDE REFERRALS:
[checkbox name="order_refer" value="none|specialty:"][textarea cols=20 rows=1]

FOLLOW UP: [textarea cols=40 rows=2]
[checkbox name="follow" value="1 week|2 weeks|3 weeks|4 weeks|2 months|3 months||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"]

LABS: [textarea cols=40 rows=2]
[checkbox name="order_lab" value="none|CBC|CMP|TSH|A1C|Lipids|PSA|FOBT/FIT|UA||HIV, RPR, HCV, GC, CT|UDS"]

IMAGING: [textarea cols=40 rows=2]
[checkbox name="order_imaging" value="none|X-ray|US|MRI"]

NEXT VISIT: [textarea cols=40 rows=2]
[checkbox name="next" value="medication review|f/u acute episode|f/u labs|f/u referral|f/u imaging|routine"]



REVIEWED:
[checkbox name="reviewed" value="MA notes|med list|medication containers|previous visits|PMP|laboratory studies|diagnostic studies|specialty reports|hospital discharge"]

RX: [textarea cols=40 rows=2]
[checkbox name="order_RX" value="none|electronic|paper|given to MA to be transmitted to pharmacy"]

FORMS:
[checkbox name="order_form" value="none|filled out:"][textarea cols=40 rows=2]

PREVENTATIVE:
[textarea cols=40 rows=2 default="referred to local pharmacy to verify vaccination status and administer vaccines, if indicated, "]
[checkbox name="order_preventative" value="deferred|colonoscopy|DEXA|LDCT|PAP|mammogram|PSA|DRE"]

DISCUSSED/COMMUNICATED FINDINGS/POC WITH:
[checkbox name="discussed" value="patient|staff|family/PCA"]

INSTRUCTED ON: [textarea cols=40 rows=2]
[checkbox name="instructions" value="vital signs/exam findings/recommendations|report medication side effects to clinic immediately|laboratory/diagnostic studies|specialty consults||smoking cessation|weight loss/diet/exercise||appropriate follow up|compliance with/bringing all medications to all visits|importance of controlling chronic conditions|age-appropriate screening and immunization|colonoscopy|DEXA|mammogram|eye exam|foot exam||importance of exercise/stretching to prevent deconditioning|importance of cognitive restructuring in managing chronic conditions||sleep hygiene|symptom exacerbation through rebound mechanism|risks of respiratory depression"]

BARRIERS TO CARE: [textarea cols=40 rows=2]
[checkbox name="barriers" value="none identified during visit||poor cooperation with exam|lack of motivation|negative attitude to diagnostic impression & proposed tx|failed to obtain old records|failed to complete referrals or testing|failed to bring medications for med review|poor compliance with medication regimen||incomplete history|vague shifting complaints|history not supported by objective findings||multiple comorbidities|recent hospitalization||polypharmacy|lack of interest in nonpharmacologic therapies|overwhelming focus on Rx drugs|medication use in response to environmental stress|intolerance of multiple meds|overreliance on short-acting meds||multiple office contacts|frequent ER/UC visits||altered mental status|hostile/disruptive behavior|active psychiatric diagnosis|alcohol or substance use|social/cultural barriers|victim of abuse"]

SAFETY: [textarea cols=40 rows=2]
[checkbox name="safety" value="no safety concerns at this time||safety concerns d/t depressed agitated mood|safety concerns d/t impulsiveness|safety concerns d/t hostile temper||safety concerns d/t past attempts|safety concerns d/t current suicidal verbalization"]

DISCHARGE CONDITION: [textarea cols=40 rows=2]
[checkbox name="discharge" value="improved|stable|unchanged"]

DISPOSITION: [textarea cols=40 rows=2]
[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 clinic before being discharged|asked to leave clinic"]

TOTAL TIME: [textarea cols=40 rows=2]
[checkbox name="time" value="15 minutes or less|15-30 minutes|30-45 minutes|visit dominated by counseling"]
HISTORIAN:


RELIABILITY:


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


RESULTS:


MEDICATIONS:


PMSH:


SOCIAL HISTORY:


HPI:


Duration:


Symptoms:


Frequency:


Affected by:


REVIEW OF SYSTEMS: [+] reported [-] not reported


CONSTITUTIONAL:

HEAD/FACE:

EYES:

EARS:

NOSE:

MOUTH:

THROAT:

NECK:

CV:

CHEST/RESPIRATORY:

GI:

GU:

GYN
MSK:

NEURO:

PSYCH:

ENDO:

LYMPH/HEMA:

ALLERGIES/IMMUNE:

DERM:





Ambulation/DME:


Appearance:


Head/Face:


Eyes:


Ears:


Nose:


Mouth:


Throat:


Neck:


Chest/Lungs:


CV:


Abdomen:


GU:


MSK:


Neuro:


Skin:


Behavior:


Psychomotor Activity:


Visual Contact:


Speech:


Thought Process:




MA TO:


OUTSIDE REFERRALS:


FOLLOW UP:


LABS:


IMAGING:


NEXT VISIT:




REVIEWED:


RX:


FORMS:


PREVENTATIVE:



DISCUSSED/COMMUNICATED FINDINGS/POC WITH:


INSTRUCTED ON:


BARRIERS TO CARE:


SAFETY:


DISCHARGE CONDITION:


DISPOSITION:


TOTAL TIME:
Result - Copy and paste this output: