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approximately 598 views since Charlton Heston put his vest on.
[checkbox name="historian" value="new patient|existing patient||history provided by patient|history provided by family member||SO/family member present during visit|chaperon/MA present during visit||interpretation provided by family member/SO|interpretation provided by MA"][textarea cols=70 rows=7]
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HPI: [checkbox name="hpi" value="new problem|chronic condition|acute exacerbation of chronic condition||started today|started yesterday|started several days ago|started more than 1 week ago|started months ago|started years ago|unsure||sx still present|sx increasing in severity|sx persisting|occasional sx|sx decreasing|sx resolved||affected by medication|affected by exertion|affected by pressure|affected by position/movement|affected by rest|affected by weather|worse at night||as in cc|"][textarea cols=50 rows=3]
RECENT / PERTINENT HISTORY: [checkbox name="recent" value="ER/UC visit|hospitalization|surgery/procedure|specialty consult|new/changed medications||travel|sick contact|c19 positive test|c19 sx||non-contributory|"][textarea cols=50 rows=3]
[checkbox memo="meds" name="meds" value=""][conditional field="meds" condition="(meds).is('')"]
MEDICATIONS: allergies reviewed
[checkbox name="medications" value="none reported||taking OTC|taking RX||reports no side effects|reports side effects||effective|partially effective|not effective||demonstrates knowledge of medications/reasons/dosages|unable to name medications/reasons/dosages||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|"][textarea cols=50 rows=3]
[/conditional]
PMSH: [checkbox name="pmh" value="DM|obesity|smoker|immunosuppression|kidney disease||non-contributory|"][textarea cols=50 rows=2]
[checkbox memo="screen" name="screen" value=""][conditional field="screen" condition="(screen).is('')"][checkbox name="completed" value="completed depression screen|completed drug alcohol screen|completed tobacco screen|"][textarea cols=50 rows=3][/conditional]

.
REVIEW OF SYSTEMS: negative except as stated in HPI
General:[textarea name="variable_5" default=" does not report fever, chills, fatigue, malaise, or weight changes"]
HEENT:[textarea name="variable_6" default=" does not report headaches, vision changes, eye redness/discharge, pain with EOM, facial swelling, earache, ringing, ear discharge, nasal congestion, rhinorrhea, mouth sores, changes in taste, sore throat, neck swelling"]
CV:[textarea name="variable_7" default=" does not report chest pain, SOB, palpitations, fainting, or ankle swelling"]
Pulmonary:[textarea name="variable_8" default=" does not report shortness of breath, cough, wheezing, or chest wall pain with breathing"]
GI:[textarea name="variable_9" default=" does not report poor appetite, nausea, vomiting, abdominal pain, constipation, or diarrhea"]
GU:[textarea name="variable_10" default=" does not report dysuria, hematuria, frequency, discharge, or bleeding"]
MSK:[textarea name="variable_11" default=" does not report myalgias, arthralgias, localized muscle/soft tissues pain/swelling, or joint pain/swelling"]
Neurologic:[textarea name="variable_13" default=" does not report dizziness, seizures, tremor, balance problems, weakness, or falls"]
Psychiatric:[textarea name="variable_14" default=" does not report depression, anxiety, mood swings, memory loss, or insomnia"]
Dermatologic:[textarea name="variable_12" default=" does not report rashes, redness, pruritus, hair loss, swelling, or wounds"]
Endocrine:[textarea name="variable_15" default=" does not report polyphagia, polydipsia, night sweats, hot flashes, or heat/cold intolerance"]
Hematologic/lymphatic:[textarea name="variable_16" default=" does not report abnormal bleeding/bruising"]



.
OFFICE DIAGNOSTICS: [checkbox name="office_diag" value="RBS|EKG||normal|non-specific changes|no acute findings|abnormal||discussed with patient/SO|official report to follow||none performed today|"][textarea cols=50 rows=3]
DIAGNOSTIC & LABORATORY RESULTS: [checkbox name="new_labs" value="normal|non-specific changes|no acute findings||discussed with patient/SO||no new results|"][textarea cols=50 rows=3]
General: [checkbox name="appearance" value="well-appearing||normal built|heavy built|lean|well-nourished|emaciated|frail||no signs of discomfort visible while sitting in chair|no signs of discomfort visible while ambulating & getting on/off exam table|ill-appearing|tired-looking|short of breath|diaphoretic||good hygiene|disheveled|bizarre clothes|body odor||drowsy|appears impaired|slumped||no ambulation aids/DME|ambulation requires walker|ambulation requires cane|ambulation requires wheelchair||wearing cervical collar|wearing lumbar support|wearing extremity brace|"][textarea cols=50 rows=2]
Head/Face: [checkbox name="head" value="normocephalic, atraumatic|symmetrical face|CN grossly intact||plethoric face|alopecia|facial droop|"][textarea cols=50 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|contacts|conjunctival injection|epiphora|conjunctival exudate|allergic shiners|dysconjugate gaze|"][textarea cols=50 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|"][textarea cols=50 rows=2]
Nose: [checkbox name="nose" value="nares patent bilaterally|septum midline|no facial tenderness|mucosa pink & moist||swollen & boggy mucosa|mucosal congestion|clear discharge|yellow discharge|crusty discharge|rhinophyma|"][textarea cols=50 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|oral ulcers|gum swelling|tooth decay|"][textarea cols=50 rows=2]
Throat: [checkbox name="throat" value="normal voice, no stridor|patent pharynx w/o swelling or exudates|uvula midline||hoarseness|vesicles on soft palate|petechiae on soft palate|pharyngeal erythema w/o exudates|"][textarea cols=50 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=50 rows=2]
Chest/Lungs: [checkbox name="lungs" value="normal work of breathing, symmetrical chest expansion|clear and equal breath sounds bilaterally||chest wall atraumatic and non-tender|no axillary or supraclavicular LAD||SOB|decreased bilaterally|wheezing|crackles|"][textarea cols=50 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=50 rows=2]
Abdomen: [checkbox name="abd" value="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||deferred|"][textarea cols=50 rows=2]
GU: [checkbox name="gu" value="no suprapubic tenderness|no CVAT bilaterally||Foley in situ|normal external genitalia|no inguinal LAD||testicular tenderness|urethral discharge|verrucous papules|vesicles|crusted lesions||deferred|"][textarea cols=50 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=50 rows=2]
Skin: [checkbox name="skin" value="grossly intact, no rashes|no bruises|normal turgor||tattoos|body piercings|poor turgor||dry|sweaty|"][textarea cols=50 rows=2]
Neuro: [checkbox name="neuro" value="normal concentration and attention|memory grossly intact||balance & coordination grossly intact|ambulates w/o limp or alteration in gait||extremities strong w/o atrophy|no gross motor deficits|sensation symmetrical & grossly intact||no involuntary movements or tremor||antalgic gait|wide gait|shuffling gait||diffuse numbness w/o dermatomal pattern|dystonia|tardive dyskinesia|tics|"][textarea cols=50 rows=2]
Speech/Vocalization: [checkbox name="speech" value="normal for age|clear & coherent||slurred|mumbling to self|monotonous|stuttering||hypoverbal|hyperverbal||loud|soft||slow|rapid|pressured||groaning|sighing|crying||perseveration|flight of ideas|repetitive questions||self-depreciating statements|repetitive statements of impending doom|repetitive non-health related/financial concerns||personal safety concerns|suicidal ideation/threats||insisting on particular medication, test, referral, or accommodation||raising voice|defensive|argumentative|cursing, swearing|previous providers/staff criticisms|verbal threats|sexual remarks|racist remarks|"][textarea cols=50 rows=2]
Behavior/Psychomotor Activity: [checkbox name="behavior" value="calm, pleasant, respectful|cooperative with history & exam||guarded|anxious|irritable|frustrated|labile||agitated|hostile|forceful||pacing|fidgeting|picking skin|twirling hair|cracking knuckles||grimacing, furrowing eyebrows|tightening jaw|breathing hard|intense staring|threatening gestures|fist-clenching||withdrawn|flat affect|bradykinetic|indifferent|appears to be responding to internal psychotic process|"][textarea cols=50 rows=2]




A/P: [textarea cols=50 rows=7]

.
ORDERS - RX: [checkbox name="order_RX" value="OTC||electronic|paper|given to MA to be transmitted to pharmacy||none|"][textarea cols=50 rows=1]
ORDERS - LABS: [checkbox name="order_lab" value="CBC|CMP|TSH|A1C|Lipids|PSA|FOBT/FIT|UA||HIV, RPR, HCV, GC, CT|UDS||none|"][textarea cols=50 rows=2]
ORDERS - IMAGING: [checkbox name="order_imaging" value="X-ray|US|MRI||none|"][textarea cols=50 rows=2]
ORDERS - REFERRALS: [checkbox name="order_refer" value="none|"] [textarea cols=50 rows=2]
ORDERS - FORMS: [checkbox name="forms" value="excuse|accomodations|clearance|return to school/work|school/participation physical||none|"]
ORDERS - PREVENTIVE: [checkbox name="preventative" value="UTD|colonoscopy|DEXA|LDCT|PAP|mammogram|PSA|DRE||flu vac|referred to local pharmacy to verify vaccination status and administer vaccines, if indicated||deferred|"][textarea cols=50 rows=2]
STAFF INSTRUCTIONS: [checkbox name="MA" value="dsg change/wound care as instructed|obtain hospital/ER discharge report|obtain specialty report|obtain imaging report|obtain laboratory report|remind patient to always bring all medication containers to visit||none|"][textarea cols=50 rows=2]
REVIEWED/DISCUSSED/INSTRUCTED ON: exam findings, POC, risks of/benefits of/alternatives to proposed POC, compliance with treatment regimen, reporting medication side effects immediately, appropriate follow up specific to condition, indications for immediate direct evaluation and/or contacting emergency services, [checkbox name="instructions" value="medications|PMP|previous visits|laboratory/diagnostic studies|specialty reports|hospital discharge||alcohol cessation|smoking cessation|weight reduction/exercise|salt restriction|carbs restriction||appropriate follow up|medication compliance|bringing all medications/labels to all visits||home BP checks|home BS checks|daily weights||controlling chronic conditions|age-appropriate screening and immunization|annual eye exam||cognitive restructuring in managing chronic conditions|symptom exacerbation through rebound mechanism|risks of respiratory depression with polypharmacy|"][textarea cols=50 rows=1]
PLAN OF CARE: [checkbox name="discussed" value="patient/family verbalized understanding of & agreement with POC|patient/family did not agree with my POC – will seek second opinion/further care elsewhere|"][textarea cols=50 rows=3]
DISCHARGE CONDITION/SAFETY: [checkbox name="discharge" value="improved|stable|unchanged||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|"][textarea cols=50 rows=1]
FOLLOW UP: 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
[checkbox name="next" value="RTC 24 hours|RTC 2-3 days|RTC 1-2 week|RTC 3-4 weeks|30 days|3 months||medication review|f/u acute episode|f/u labs|f/u imaging|f/u referral|"][textarea cols=50 rows=2]
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 clinic before being discharged|asked to leave clinic|"][textarea cols=50 rows=1]
BARRIERS TO CARE: [checkbox name="barriers" value="none noted at this time||incomplete history d/t poor effort|incomplete history d/t cognitive changes|incomplete history d/t distress/affect|incomplete history d/t language barrier||vague shifting complaints|history not supported by objective findings|supporting documentation unavailable||incomplete exam d/t safety concerns|poor cooperation with exam||multiple comorbidities|polypharmacy|poor compliance with POC|intolerance of/therapeutic failure on multiple meds||preoccupation with illness|catastrophization|overgeneralization|unrealistic beliefs|negativism|pessimism|blaming others||lack of motivation|negative attitude to diagnostic impression & proposed tx|lack of interest in nonpharmacologic therapies||psychiatric comorbidity|h/o alcohol/substance abuse|victim of abuse|social/cultural barriers||altered mental status|affect|hostile/disruptive behavior|"][textarea cols=50 rows=1]

[checkbox memo="depression" name="depression" value=""][conditional field="depression" condition="(depression).is('')"]
DEPRESSION CARE MANAGEMENT PLAN
DATE CREATED/REVIEWED: [date name="variable_1" default="10/25/2020"]
PATIENT PREFERENCES AND FUNCTIONAL LIFESTYLE GOALS: increase life enjoyment, be more involved socially, be organized, feel better, have more energy, sleep less
SELF-MANAGEMENT PLAN: consider attending counseling sessions, decrease alcohol intake, exercise daily, consider joining a support group, consider journaling, sleep 7-9 hours each night, take medication daily as prescribed
CARE PLAN PROVIDED TO PATIENT / FAMILY / CAREGIVER[/conditional]
[checkbox memo="risk" name="risk" value=""][conditional field="risk" condition="(risk).is('')"]
HIGH RISK / UTILIZATION OF MEDICATIONS CARE MANAGEMENT PLAN
DATE CREATED/REVIEWED: [date name="variable_2" default="10/25/2020"]
SELF MANAGEMENT PLAN: adhere to medication treatment, get timely refill, print out medication schedule, use medication pill box organizer
CARE PLAN PROVIDED TO PATIENT / FAMILY / CAREGIVER[/conditional]
[checkbox memo="diabetes" name="diabetes" value=""][conditional field="diabetes" condition="(diabetes).is('')"]
DIABETES CARE MANAGEMENT PLAN
DATE CREATED/REVIEWED: [date name="variable_3" default="10/25/2020"]
PATIENT PREFERENCES AND FUNCTIONAL LIFESTYLE GOALS: control eating habits, decrease pain/numbness in feet, increase exercise tolerance, increase life enjoyment, make better choices when eating out, feel better, increase energy levels
SELF MANAGEMENT PLAN: adhere to medication treatment, consider attending diabetes education classes, eat frequent small meals, get 7-9 hours of sleep per night, increase exercise, limit carb intake, lose weight, monitor home glucose readings, reduce alcohol intake
CARE PLAN PROVIDED TO PATIENT / FAMILY / CAREGIVER[/conditional]

.
HPI:
RECENT / PERTINENT HISTORY:
meds
PMSH:
screen

.
REVIEW OF SYSTEMS: negative except as stated in HPI
General:
HEENT:
CV:
Pulmonary:
GI:
GU:
MSK:
Neurologic:
Psychiatric:
Dermatologic:
Endocrine:
Hematologic/lymphatic:



.
OFFICE DIAGNOSTICS:
DIAGNOSTIC & LABORATORY RESULTS:
General:
Head/Face:
Eyes:
Ears:
Nose:
Mouth:
Throat:
Neck:
Chest/Lungs:
CV:
Abdomen:
GU:
MSK:
Skin:
Neuro:
Speech/Vocalization:
Behavior/Psychomotor Activity:




A/P:

.
ORDERS - RX:
ORDERS - LABS:
ORDERS - IMAGING:
ORDERS - REFERRALS:
ORDERS - FORMS:
ORDERS - PREVENTIVE:
STAFF INSTRUCTIONS:
REVIEWED/DISCUSSED/INSTRUCTED ON: exam findings, POC, risks of/benefits of/alternatives to proposed POC, compliance with treatment regimen, reporting medication side effects immediately, appropriate follow up specific to condition, indications for immediate direct evaluation and/or contacting emergency services,
PLAN OF CARE:
DISCHARGE CONDITION/SAFETY:
FOLLOW UP: 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

DISPOSITION:
BARRIERS TO CARE:

depression
risk
diabetes

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