EPISODIC VISIT*

CC: [text name="CC" size="60"]

SUBJECTIVE:
HPI:[text name="age" size="3"] y.o. [select name="race" value="|White|Black|Hispanic|Asian"] [select name="sex" value="male|female"] presents via [select name="visit" value="OV|telemedicine visit"] for [var name="CC"].[textarea fillable="true" rows="6"]***CC*** began ***ONSET*** and has been ***DURATION*** in occurrence. Patient reports ***SYMPTOM*** located ***LOCATION*** and describes as ***QUALITY***. There is associated ***POSITIVE SYMPTOMS***. Patient denies ***NEGATIVE SYMPTOMS***. Symptom(s) are improved with ***ALLEVIATING*** and exacerbated by ***AGGRAVATING***. Rates pain ***SEVERITY***/10. [/textarea]
Denies c/o [checkbox name="ROS" value="CP|SOB|Palpitations|HA|changes in vision|dizziness|GI changes|easy/abnormal bruising|skin changes|extremity or joint swelling|sleep difficulties|fatigue"]
REVIEW OF SYSTEMS
[checkbox name="FullROS" memo="Full ROS" value=""][conditional field="FullROS" condition="(FullROS).is('')"]- Constitutional: [text default="Patient denies weight change, fever, chills, fatigue" size="80"]
- Head: [text default="Patient denies HA, head trauma/injury" size="80"]
- Eye: [text default=" Patient denies vision changes, eye pain, discharge" size="80"]
- ENT/Mouth: [text default="Patient denies hearing changes, ear pain, nasal congestion, PND, drainage, sore throat" size="80"]
- CV: [text default="Patient denies CP, SOB, palpitations, edema" size="80"]
- Respiratory: [text default="Patient denies cough, sputum, wheezing, SOB" size="80"]
- GI: [text default="Patient denies nausea, vomiting, diarrhea, constipation, changes in stool" size="80"]
- GU: [text default="Patient denies dysuria, urinary frequency, hematuria" size="80"]
- MSKL: [text default="Patient denies muscle and joint pain, joint swelling, back/neck Pain, injury/trauma" size="80"]
- Integumentary: [text default="Patient denies skin lesions, rashes, or abnormalities" size="80"]
- Neuro:[text default="Patient denies weakness, numbness, paresthesia, dizziness, memory changes" size="80"]
- Psych: [text default="Patient denies anxiety/panic, depression, insomnia, SI/HI" size="80"]
- Heme/Lymph: [text default="Patient denies bruising, bleeding, lymphadenopathy" size="80"]
- Endocrine: [text default="Patient denies polyuria, polydipsia, temperature intolerance" size="80"][/conditional]
[checkbox name="BriefROS" memo="Brief ROS" value=""][conditional field="BriefROS" condition="(BriefROS).is('')"]- Constitutional: [text default=" Patient denies weight change, fever, chills, fatigue" size="80"]
- CV: [text default=" Patient denies CP, SOB, palpitations, edema" size="80"]
- Respiratory: [text default=" Patient denies cough, sputum, wheezing, SOB" size="80"]
- MSKL: [text default=" Patient denies muscle and joint pain, joint swelling, recent injury/trauma" size="80"]
- Integumentary: [text default=" Patient denies skin lesions, rashes, or abnormalities" size="80"]
- Neuro:[text default=" Patient denies weakness, numbness, paresthesia, dizziness, memory changes" size="80"]
- Psych: [text default=" Patient denies anxiety/panic, depression, insomnia, SI/HI" size="80"][/conditional]
[checkbox name="ROSENTcomplaint" memo="ENT Complaint ROS" value=""][conditional field="ROSENTcomplaint" condition="(ROSENTcomplaint).is('')"]- Constitutional: [text default="Patient denies weight change, fever, chills, fatigue" size="80"]
- Head: [text default="Patient denies HA, head trauma/injury" size="80"]
- Eye: [text default=" Patient denies vision changes, eye pain, discharge" size="80"]
- ENT/Mouth: [text default="Patient denies hearing changes, ear pain, nasal congestion, PND, drainage, sore throat" size="80"]
- CV: [text default="Patient denies CP, SOB, palpitations, edema" size="80"]
- Respiratory: [text default="Patient denies cough, sputum, wheezing, SOB" size="80"][/conditional]
[checkbox name="GIROS" memo="GI Complaint ROS" value=""][conditional field="GIROS" condition="(GIROS).is('')"]- Constitutional: [text default="Patient denies weight change, fever, chills, fatigue" size="80"]
- ENT/Mouth: [text default="Patient denies hearing changes, ear pain, nasal congestion, PND, drainage, sore throat" size="80"]
- CV: [text default="Patient denies CP, SOB, palpitations, edema" size="80"]
- Respiratory: [text default="Patient denies cough, sputum, wheezing, SOB" size="80"]
- GI: [text default="Patient denies nausea, vomiting, diarrhea, constipation, changes in stool" size="80"]
- Integumentary: [text default="Patient denies skin lesions, rashes, or abnormalities" size="80"][/conditional]
[checkbox name="MSKNeuroROS" memo="MSK and Neuro ROS" value=""][conditional field="MSKNeuroROS" condition="(MSKNeuroROS).is('')"]- Constitutional: [text default="Patient denies weight change, fever, chills, fatigue" size="80"]
- CV: [text default="Patient denies CP, SOB, palpitations, edema" size="80"]
- Respiratory: [text default="Patient denies cough, sputum, wheezing, SOB" size="80"]
- MSKL: [text default="Patient denies muscle and joint pain, joint swelling, back/neck Pain, injury/trauma" size="80"]
- Neuro:[text default="Patient denies weakness, numbness, paresthesia, dizziness, memory changes" size="80"][/conditional]
[checkbox name="SkinROS" memo="Skin Complaint ROS" value=""][conditional field="SkinROS" condition="(SkinROS).is('')"]- Constitutional: [text default="Patient denies weight change, fever, chills, fatigue" size="80"]
- CV: [text default="Patient denies CP, SOB, palpitations, edema" size="80"]
- Respiratory: [text default="Patient denies cough, sputum, wheezing, SOB" size="80"]
- Integumentary: [text default="Patient denies skin lesions, rashes, or abnormalities" size="80"]
- Heme/Lymph: [text default="Patient denies bruising, bleeding, lymphadenopathy" size="80"]
- Endocrine: [text default="Patient denies polyuria, polydipsia, temperature intolerance" size="80"][/conditional]
[checkbox name="GUROS" memo="GU ROS" value=""][conditional field="GUROS" condition="(GUROS).is('')"]- Constitutional: [text default="Patient denies weight change, fever, chills, fatigue" size="80"]
- CV: [text default="Patient denies CP, SOB, palpitations, edema" size="80"]
- Respiratory: [text default="Patient denies cough, sputum, wheezing, SOB" size="80"]
- GU: [text default="Patient denies dysuria, urinary frequency, hematuria" size="80"]
- Endocrine: [text default="Patient denies polyuria, polydipsia, temperature intolerance" size="80"][/conditional]

OBJECTIVE:
[checkbox name="WellnessExam" memo="Wellness Exam: Normal" value=""][conditional field="WellnessExam" condition="(WellnessExam).is('')"]- GA/Psych:[text default=" AAOx4, NAD. Well developed and nourished. Appears stated age. No SI/HI. Appropriate judgement." size="80"]
- HEAD:[text default=" Normocephalic and atraumatic without tenderness, visible or palpable masses, depressions, or scarring." size="80"]
- EYES:[text default=" Conjunctivae are clear. Sclera is non-icteric. EOMI, PERRLA." size="80"]
- EARS:[text default=" Bilat External ear and ear canal are non-tender and without swelling. Bilat internal canal is clear without discharge. TM is intact. Hearing grossly intact." size="80"]
- NOSE:[text default=" No nasal discharge, nares patent b/l" size="80"]
- THROAT: [text default=" Oral cavity and pharynx normal. No inflammation, swelling, exudate, or lesions. Teeth and gingiva in good general condition." size="80"]
- NECK:[text default=" Neck supple, non-tender without lymphadenopathy, masses or thyromegaly." size="80"]
- CV: [text default=" S1 and S2 present. No S3, S4 or murmurs. RRR. No carotid bruits. No peripheral edema, cyanosis or pallor. Extremities are warm and well perfused. Capillary refill is less than 2 seconds.  Peripheral pulses +2 in all extremities. No edema noted." size="80"]
- LUNGS: [text default=" BBS CTA A/P without rales, rhonchi, wheezing or diminished breath sounds." size="80"]
- ABD:[text default=" Positive bowel sounds. Soft, nondistended, nontender. No guarding or rebound. No masses" size="80"]
- SKIN:[text default=" Skin in warm, dry and intact without rashes or lesions. Appropriate color for ethnicity." size="80"]
- MSKL:[text default=" No significant deformity or joint abnormality. Adequately aligned spine. ROM intact spine and extremities. No joint erythema or tenderness. Normal muscular development. Stable gait." size="80"]
- NEURO:[text default=" Mentating well, moves all extremities equally well, intact sensorium all 4 extremities, no gross motor deficits" size="80"][/conditional]
[checkbox name="briefexam" memo="Brief Exam: Normal" value=""][conditional field="briefexam" condition="(briefexam).is('')"]- GA/LOC: [text default=" AAOx4, NAD. Well developed and nourished. Appears stated age. No SI/HI. Appropriate judgement." size="80"] 
- CV: [text default=" S1 and S2 present. No S3, S4 or murmurs. RRR. No carotid bruits. No peripheral edema, cyanosis or pallor. Extremities are warm and well perfused. Capillary refill is less than 2 seconds.  Peripheral pulses +2 in all extremities. No edema noted." size="80"]
- LUNGS: [text default=" BBS CTA A/P without rales, rhonchi, wheezing or diminished breath sounds." size="80"]
- ABD:[text default=" Positive bowel sounds. Soft, nondistended, nontender." size="80"]
- SKIN:[text default=" Skin in warm, dry.  Appropriate color for ethnicity." size="80"]
- MSKL:[text default=" No significant joint abnormality. Normal muscular development. Stable gait." size="80"][/conditional]
[checkbox name="BriefExamWithENTcomplaint" memo="Brief Exam With ENT complaint" value=""][conditional field="BriefExamWithENTcomplaint" condition="(BriefExamWithENTcomplaint).is('')"]- GA/Psych:[text default=" AAOx4, NAD. Well developed and nourished. Appears stated age. No SI/HI. Appropriate judgement." size="80"]
-HEAD:[text default="Normocephalic and atraumatic without tenderness, visible or palpable masses, depressions, or scarring." size="80"]
-EYES:[text default="Conjunctivae are clear without exudates or hemorrhage. Sclera is non-icteric. EOMI, PERRLA." size="80"]
-EARS:[text default="external ear and ear canal are non-tender and without swelling, canal is clear without discharge, TM is intact, hearing grossly intact." size="80"]
-NOSE:[text default="no nasal discharge, nares patent b/l" size="80"]
-THROAT: [text default="oral cavity and pharynx normal. No inflammation, swelling, exudate, or lesions. Teeth and gingiva in good general condition." size="80"]
-NECK:[text default="neck supple, non-tender without lymphadenopathy, masses or thyromegaly." size="80"]
- CV: [text default=" S1 and S2 present. No S3, S4 or murmurs. RRR. No carotid bruits. No peripheral edema, cyanosis or pallor. Extremities are warm and well perfused. Capillary refill is less than 2 seconds.  Peripheral pulses +2 in all extremities. No edema noted." size="80"]
- LUNGS: [text default=" BBS CTA A/P without rales, rhonchi, wheezing or diminished breath sounds." size="80"][/conditional]
[checkbox name="BriefExamGIComplaint" memo="Brief Exam with GI Complaint" value=""][conditional field="BriefExamGIComplaint" condition="(BriefExamGIComplaint).is('')"]- GA/Psych:[text default=" AAOx4, NAD. Well developed and nourished. Appears stated age. No SI/HI. Appropriate judgement." size="80"]
- CV: [text default=" S1 and S2 present. No S3, S4 or murmurs. RRR. No carotid bruits. No peripheral edema, cyanosis or pallor. Extremities are warm and well perfused. Capillary refill is less than 2 seconds.  Peripheral pulses +2 in all extremities. No edema noted." size="80"]
- LUNGS: [text default=" BBS CTA A/P without rales, rhonchi, wheezing or diminished breath sounds." size="80"]
-ABD:[text default="Positive bowel sounds. Soft, nondistended, nontender. No guarding or rebound. No masses" size="80"]
-SKIN:[text default="Skin in warm, dry and intact without rashes or lesions. Appropriate color for ethnicity. Nailbeds pink with no cyanosis or clubbing." size="80"[/conditional]
[checkbox name="briefexamMSKandNeuroComplaint" memo="Brief Exam with MSKL or Neuro Complaint: Normal" value=""][conditional field="briefexamMSKandNeuroComplaint" condition="(briefexamMSKandNeuroComplaint).is('')"]-GA/Psych: [text default=" AAOx4, NAD. Well developed and nourished. Appears stated age. No SI/HI. Appropriate judgement." size="80"]
-CV: [text default="S1 and S2 noted. No S3, S4 or murmurs. RRR. No peripheral edema, cyanosis or pallor. No carotid bruits. Extremities are warm and well perfused. Capillary refill is less than 2 seconds x4 extremities. Peripheral pulses +2 in all extremities. No edema noted." size="80"]
-LUNGS: [text default="Clear to auscultation Bilaterally A/P without rales, rhonchi, wheezing or diminished breath sounds." size="80"]
- MSKL: [text default="No significant deformity or joint abnormality. Adequately aligned spine. Full ROM to spine. Full ROM to all extremities. No joint erythema or tenderness. Appropriate muscular development. Stable gait." size="80"]
-NEURO:[text default="Mentating well, moves all extremities equally well, intact sensorium all 4 extremities, no gross motor deficits" size="80"][/conditional]
[checkbox name="SkinComplaint" memo="Skin Complaint" value=""][conditional field="SkinComplaint" condition="(SkinComplaint).is('')"]- GA:[text default="AAOx4, NAD. Well developed and nourished. Appears stated age. Appropriate judgement." size="80"]
- CV: [text default=" S1 and S2 present. No S3, S4 or murmurs. RRR. No carotid bruits. No peripheral edema, cyanosis or pallor. Extremities are warm and well perfused. Capillary refill is less than 2 seconds.  Peripheral pulses +2 in all extremities. No edema noted." size="80"]
- LUNGS: [text default=" BBS CTA A/P without rales, rhonchi, wheezing or diminished breath sounds." size="80"]
-SKIN:[text default="Skin in warm, dry and intact without rashes or lesions. Appropriate color for ethnicity. Nailbeds pink with no cyanosis or clubbing." size="80"]
MSKL:[text default="No significant deformity or joint abnormality. Adequately aligned spine. ROM intact spine and extremities. No joint erythema or tenderness. Normal muscular development. Stable gait." size="80"]
-NEURO:[text default="Mentating well, moves all extremities equally well, intact sensorium to all 4 extremities, no gross motor deficits" size="80"][/conditional]
[checkbox name="GUComplaintExam" memo="GU complaint Exam: Normal" value=""][conditional field="GUComplaintExam" condition="(GUComplaintExam).is('')"]- GA/Psych:[text default="AAOx4, NAD. Well developed and nourished. Appears stated age. No SI/HI. Appropriate judgement." size="80"]
- CV: [text default=" S1 and S2 present. No S3, S4 or murmurs. RRR. No carotid bruits. No peripheral edema, cyanosis or pallor. Extremities are warm and well perfused. Capillary refill is less than 2 seconds.  Peripheral pulses +2 in all extremities. No edema noted." size="80"]
- LUNGS: [text default=" BBS CTA A/P without rales, rhonchi, wheezing or diminished breath sounds." size="80"]
- ABD:[text default="Positive bowel sounds. Soft, nondistended, nontender. No guarding or rebound. No masses" size="80"]
- GU: [text default="No CVA tenderness bilaterally" size="80"][/conditional]

[checkbox name="labs" value="Labs: "][conditional field="labs" condition="(labs).is('Labs: ')"][checkbox value="reviewed with pt
"][checkbox name="LabResults" memo="Results" value=""][/conditional][conditional field="LabResults" condition="(LabResults).is('')"][textarea size="4"]
[/conditional]
A/P: See Above
[checkbox memo="Procedure" name="Procedure" value=""][conditional field="Procedure" condition="(Procedure).is('')"]Procedures: [textarea rows="4"]
[/conditional][checkbox memo="Vaccine" name="Vaccine" value=""][conditional field="Vaccine" condition="(Vaccine).is('')"]Vaccines: [textarea rows="2"]
[/conditional]Plan: [textarea name="plan" rows="8" size="60"]
RTC: [select name="RTC" value="As needed or if no improvement in s/sx|In 6 months for routine f/u with fasting labs prior|In 3-4 months for routine f/u with fasting labs prior|In one year for next wellness visit with fasting labs prior|In one week for F/U|In two weeks for F/U|In 4 weeks for F/U|"] [text name="rtc_1" size="40"]
Meds: [link url="https://www.soapnote.org/miscellaneous/medications-2/" memo="Medications"][checkbox value="none"]