Complete Note
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HISTORIAN: [textarea cols=40 rows=2]
[checkbox name="historian" value="patient - new|patient - existing|SO/parent|family member/SO present during visit|chaperone/MA present during visit||interpretation provided by family member/SO|interpretation provided by MA||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: [textarea cols=40 rows=2 default="no pertinent events reported"]
[checklist name="recent" value="day care/school attendance|sick siblings|travel|ER/UC/PCP visit|hospitalization|surgery/procedure|diagnostic/laboratory studies|specialty consults|new medications|ABX use"]

MEDICATIONS: [textarea cols=40 rows=2]
[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|substance use||financial/housing problems|legal problems||current/former victim of abuse"]

TRANSPORTATION: [textarea cols=40 rows=2 default="N/A"]
[checkbox name="transportation" value="uses public transportation|drives a car|driven by family member/SO"]

HPI: [textarea cols=40 rows=2]
[checkbox name="new_chronic" value="new problem|chronic issue|acute exacerbation of a chronic condition"]
Duration: [textarea cols=20 rows=1 default="N/A"]
[checkbox name="duration" value="hours|days|months|years"]
Symptoms: [textarea cols=20 rows=1 default="N/A"]
[checkbox name="progression" value="increasing in severity|remaining constant|decreasing in severity"]
Frequency: [textarea cols=20 rows=1 default="N/A"]
[checkbox name="frequency" value="constant|intermittent|occasional"]
Worsened by: [textarea cols=20 rows=1 default="N/A"]
[checkbox name="worse" value="exertion|pressure|position|movement|rest|cold|weather|night|stress"]
Relieved by: [textarea cols=20 rows=1 default="N/A"]
[checkbox name="better" value="medication|movement|rest|cold|position"]

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="ears_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|lightheartedness|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|discharge|itching|skin lesion(s)/rash"]
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"]


OBJECTIVE
Ambulation/DME: [textarea cols=40 rows=2 default="N/A"]
[checkbox name="ambulation" value="ambulation requires walker|ambulation requires cane|ambulation requires wheelchair||cervical collar|lumbar support|knee brace|ankle brace"]

Appearance: [textarea cols=40 rows=2]
[checkbox name="appearance" value="well-appearing|no signs of discomfort visible|normal built|good hygiene||heavy built|emaciated|frail|ill-appearing|tired-looking|short of breath|diaphoretic|slumped in wheelchair||appears sedated|appears impaired|disheveled|unshaven|body odor||cooperative with exam|poor cooperation with exam"]

Discomfort: [textarea cols=40 rows=2 default="N/A"]
[checkbox name="discomfort" value="no signs of discomfort visible while ambulating & getting on/off exam table|no signs of discomfort visible while sitting in chair||guarding|restlessness|sighing|crying|grimacing|verbal protests"]

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

Eyes: [textarea cols=40 rows=2]
[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"]

Ears: [textarea cols=40 rows=2]
[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"]

Nose: [textarea cols=40 rows=2]
[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"]

Mouth: [textarea cols=40 rows=2]
[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"]

Throat: [textarea cols=40 rows=2]
[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"]

Neck: [textarea cols=40 rows=2]
[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"]

Chest/Lungs: [textarea cols=40 rows=2]
[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"]

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

Abdomen: [textarea cols=40 rows=2]
[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"]

GU: [textarea cols=40 rows=2]
[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"]

MSK: [textarea cols=40 rows=2]
[checkbox name="spine" value="no gross deformities, moves all extremities with good ROM for age|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 symmetrica & 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"]

Upper extremity(s): [textarea cols=40 rows=2 default="N/A"]
[checkbox name="upper_extremity" value="atraumatic w/o swelling or deformity|good ROM for age|equal power and tone bilaterally|able to make tight grips|no vascular compromise|compartments soft w/o tension||ecchymoses|clubbing|swelling"]

Lower extremity(s): [textarea cols=40 rows=2 default="N/A"]
[checkbox name="lower_extremity" value="atraumatic|strength, tone & bulk symmetrical & grossly intact|able to stand up|able to raise/lower foot against resistance|no vascular compromise|compartments soft w/o tension|pedal skin warm with good & equal pulses|no edema||xerosis|calf tenderness|ankle edema|varicosities|loss of hair|ecchymoses|stasis discoloration|varicose veins"]

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

Behavior: [textarea cols=40 rows=2]
[checkbox name="behavior" value="pleasant, cooperative|engaged||withdrawn|hostile|defensive|argumentative|suspicious|ingratiating|demanding"]

Psych: [textarea cols=40 rows=2]
[checkbox name="psych" value="alert|oriented to self and place|appropriate to situation|normal concentration and attention|memory grossly intact|good eye contact|speech normal rate & rhythm|organized thought process||drowsy|poor eye contact|confused|agitated|anxious|irritable|indifferent|guarded||expansive affect|flat affect|labile affect||speech slurred|hypoverbal|hyperverbal|speech loud|speech slow|speech rapid||tangential thought|circumstantial thought|aberrant thought|flight of ideas|poor judgment & insight"]

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

Lesion: [textarea cols=40 rows=2 default="N/A"]
[checkbox name="lesion" value="erythema|induration|firm|soft|deep|mobile|fluctuant|painful||abrasion|excoriation|fissure|laceration|ulceration|ecchymosis|swelling|burn|scar||generalized distribution|acral distribution|symmetrical|unilateral|linear|annular|arcuate|serpiginous|red scaly|red non-scaly|macular|papular|follicular|urticarial|targetoid|vesicular|pustular|purpuric|non-blanching|sharply-demarcated borders|indistinct borders"]




REVIEWED: [textarea cols=40 rows=2]
[checkbox name="reviewed" value="previous visits|CURES/PMP|laboratory studies|diagnostic studies|specialty reports|hospital discharge"]

DISCUSSED/COMMUNICATED FINDINGS/POC WITH: [textarea cols=40 rows=2 default="N/A"]
[checkbox name="discussed" value="patient|staff|family|MA"]

ORDERS: [textarea cols=40 rows=2]
[checkbox name="orders" value="electronic Rx|paper Rx|faxed Rx|laboratory studies|diagnostic studies|referrals|DME"]

INSTRUCTED ON: [textarea cols=40 rows=2]
[checkbox name="instructions" value="vital signs/exam findings/recommendations|laboratory/diagnostic studies|specialty consults|appropriate follow up||importance of controlling chronic conditions|age-appropriate screening and immunization|colonoscopy|DEXA|mammogram|eye exam|foot exam||smoking cessation|weight loss/diet/exercise||advised that negative/'normal' results do not rule out pathology|OTC medicines and comfort measures for symptom control|adequate hydration/water intake|ice application to affected area several times a day for 72 hours|warm compress application to affected area for 20 min several times a day|keeping affected area clean and dry|keeping affected area elevated as much as possible|N/V checks of affected area|s/sx of infection to report immediately|wearing splint until cleared||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|bringing all medications to all visits"]

PROCEDURE(S): [textarea cols=40 rows=2 default="N/A"]
[checkbox name="procedure" value="N/A|risks/benefits explained - verbalized understanding and consented to procedure/injection|visual acuity verified before & after|ear lavage completed, canal clear, TM intact, no active bleeding||N/V checked-intact|area cleaned with betadine|topical anesthesia provided|wound irrigated under running water|wound irrigated with NS|wound explored for FB – none seen|evaluated for tendon injury - able to move appropriate joints|wound edges approximated with non-absorbable sutures|small incision made & abscess contents evacuated|culture collected|wound packed and covered w DSD|wound dressing completed by MA|no active bleeding|area splinted|elastic bandage applied|sling provided|N/V status verified|tolerated intervention well|"]

BARRIERS TO CARE: [textarea cols=40 rows=2 default="N/A"]
[checkbox name="barriers" value="negative attitude to proposed diagnosis & recommended treatment|catastrophization|unrealistic beliefs regarding treatment outcomes|excessive preoccupation with illness|overwhelming focus on prescription drugs|polypharmacy|multiple providers|medication use in response to situational stressor|tolerance to multiple medications|excessive reliance on short-acting medications||alcohol or substance use|poorly managed mental health/stressors|social stressors|victim of abuse"]

RISK FOR ABUSE/DEPENDENCE: [textarea cols=40 rows=2 default="N/A"]
[checkbox name="faking" value="vague shifting complaints|very limited range of motion|superficial diffuse tenderness|jump response|pain on axial loading|significant discrepancy between reported symptoms/subjective disability/possible etiology and objective findings/exam||labs/CURES inconsistent with stated history or current Rx|failed to obtain records or undergo specialty consults/testing|multiple office contacts regarding medications|frequent ER/UC visits|early renewals|lost/stolen Rx"]


RELEASE/CLEARANCE: [textarea cols=40 rows=2 default="N/A"]
[checkbox name="clearance" value="fit for school/work/duty without restrictions|excuse from work/school|fit for school/work/duty with restrictions"]

FOLLOW UP: [textarea cols=40 rows=2]
[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|report medication side effects to clinic immediately|PRN||1 week|2 weeks|3 weeks|4 weeks|3 months||return for suture removal in 5-7 days|return for wound check in 2-3 days"]

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

DISPOSITION: [textarea cols=40 rows=2 default="N/A"]
[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 default="N/A"]
[checkbox name="time" value="15 minutes|less than 30 minutes|more than 30 minutes|45 minutes|visit dominated by counseling"]
HISTORIAN:


RECENT HISTORY:


MEDICATIONS:


PMSH:


SOCIAL HISTORY:


TRANSPORTATION:


HPI:

Duration:

Symptoms:

Frequency:

Worsened by:

Relieved by:


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


CONSTITUTIONAL:

HEAD/FACE:

EYES:

EARS:

NOSE:

MOUTH:

THROAT:

NECK:

CV:

CHEST/RESPIRATORY:

GI:

GU:

MSK:

NEURO:

PSYCH:

ENDO:

LYMPH/HEMA:

ALLERGIES/IMMUNE:

DERM:



OBJECTIVE
Ambulation/DME:


Appearance:


Discomfort:


Head/Face:


Eyes:


Ears:


Nose:


Mouth:


Throat:


Neck:


Chest/Lungs:


CV:


Abdomen:


GU:


MSK:


Upper extremity(s):


Lower extremity(s):


Neuro:


Behavior:


Psych:


Skin:


Lesion:





REVIEWED:


DISCUSSED/COMMUNICATED FINDINGS/POC WITH:


ORDERS:


INSTRUCTED ON:


PROCEDURE(S):


BARRIERS TO CARE:


RISK FOR ABUSE/DEPENDENCE:



RELEASE/CLEARANCE:


FOLLOW UP:


DISCHARGE CONDITION:


DISPOSITION:


TOTAL TIME:
Result - Copy and paste this output: