ROUTINE WELLNESS/FOLLOW-UP 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"]Patient is overall doing ***WELLNESS***. 
H/o ***PMH*** that is ***CONTROLLED/NOT*** on ***MED***. At home monitoring reveals ***PARAMETER*** ranges ***VALUES***. 
H/o ***PMH*** that is ***CONTROLLED/NOT*** on ***MED***. At home monitoring reveals ***PARAMETER*** ranges ***VALUES***[/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"]
Age and gender appropriate screening UTD, including: [checkbox name="CompletedSCREENING" value="Colorectal cancer screening via Cologuard within last 3 years (Male/Female age 50-75 years)|Colorectal cancer screening via colonoscopy within last 10 years (Male/Female age 50-75 years)|Influenza vaccination within past year|COVID-19 Vaccination|Pneumococcal vaccination|Mammogram within past two years (women 50 to 74 years)|Pelvic and Breast Exam within last year for all females|Bone Mineral Density Screening within the last 2 years (Post-menopausal women)|Prostate Cancer Screening with PSA (Men 55-69 years)|Lung Cancer Screening (persons 55-80 years old with 30 pack-year smoking hx and currently smoke or have quit within the past 15 years)"]
Pt NOT UTD on Age and gender appropriate screening UTD, including: [checkbox name="NeededSCREENING" value="Colorectal cancer screening via Cologuard within last 3 years (Male/Female age 50-75 years)|Colorectal cancer screening via colonoscopy within last 10 years (Male/Female age 50-75 years)|Influenza vaccination within past year|COVID-19 Vaccination|Pneumococcal vaccination|Mammogram within past two years (women 50 to 74 years)|Pelvic and Breast Exam within last year for all females|Bone Mineral Density Screening within the last 2 years (Post-menopausal women)|Prostate Cancer Screening with PSA (Men 55-69 years)|Lung Cancer Screening (persons 55-80 years old with 30 pack-year smoking hx and currently smoke or have quit within the past 15 years)"]
REVIEW OF SYSTEMS
- 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"]

PMH: [text default="Reviewed in Chart" size="40"]
PSH: [text default="Reviewed in Chart" size="40"]
FH: [select name="FH" value="M- Denies; F- Denies|" ][conditional field="FH" condition="(FH).is('')"]M– [checkbox name="FH-M" value="Denies|HTN|DM|HLD"] [text name="field_name" default=""]; F– [checkbox name="FH-F" value="Denies|HTN|DM|HLD"] [text name="field_name" default=""][/conditional]
Meds: [text default="Reviewed in Chart" size="40"]
Allx: [text name="allx" default="NKDA" size="40"]
SocHx: Tobacco-[select name="Tobacco" value="N|previous-|current-"][conditional field="Tobacco" condition="(Tobacco).is('previous-')"][select value="Tobacco|Vape|Chew"]: [text size="7"] [select value="pack(s)/day|can(s)/wk|recharge(s)/pod(s)/wk"] x [text size="4"]yrs, quit [text size="4"]yrs ago, denies current use.
[/conditional][conditional field="Tobacco" condition="(Tobacco).is('current-')"][select value="Tobacco|Vape|Chew"]: [text size="7"] [select value="pack(s)/day|can(s)/wk|recharge(s)/pod(s)/wk"] x [text size="4"]yrs.
[/conditional] ETOH-[select name="ETOH" value="N|previous-|current-"][conditional field="ETOH" condition="(ETOH).is('current-')"][text size="3"] [select value="cans of beer|glasses of wine|shots of whiskey"] [select value="daily (average)|weekly (average)|on weekends only|rarely on special occasions"] for [text size="4"]yrs.
[/conditional][conditional field="ETOH" condition="(ETOH).is('previous-')"] quit [text size="4"] years ago, denies current use.
[/conditional] Illicit Drugs-[select name="illicitdrugs" value="N|previous-|current-"][conditional field="illicitdrugs" condition="(illicitdrugs).is('previous-')"][text size="50"] x [text size="4"]yrs, quit [text size="4"]yrs ago.
[/conditional][conditional field="illicitdrugs" condition="(illicitdrugs).is('current-')"][text size="50"] x [text size="4"]yrs.[/conditional]

OBJECTIVE:
VS: Reviewed

- 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. " size="80"]
- EYES: [text default="Conjunctiva are clear without exudates or hemorrhage. Sclera is non-icteric. EOMI, PERRLA." size="80"]
- EARS:[text default="Bilateral external ears and ear canals are non-tender and without swelling. Bilateral internal canals are clear without discharge, and TMs are 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 pink and moist. No inflammation, swelling, exudate, or lesions noted." size="80"]
- NECK: [text default="Supple, non-tender, without lymphadenopathy, masses or thyromegaly." size="80"]
- CV: [text default="S1 and S2 noted. No S3, S4 or murmurs. RRR. No peripheral edema, cyanosis or pallor. Capillary refill < 2 seconds in all extremities. No carotid bruits. Peripheral pulses +2 in all extremities." size="80"]
- LUNGS: [text default="CTA bilaterally A/P." size="80"]
- ABD: [text default="Positive bowel sounds. Soft, non-distended, non-tender. No guarding or rebound tenderness. No palpable masses" size="80"]
- SKIN: [text default="Warm, dry and intact. No 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. Full ROM to spine and to extremities noted. No joint erythema or tenderness. Appropriate muscular development for age. Stable gait." size="80"]
- NEURO: [text default="Mentating well, moves all extremities equally well, normal sensorium all 4 extremities, no gross motor deficits" size="80"]

[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"]
CC:
SUBJECTIVE:
HPI: y.o. presents via for CC. Ctrl + (or )

Denies c/o
Age and gender appropriate screening UTD, including:
Pt NOT UTD on Age and gender appropriate screening UTD, including:
REVIEW OF SYSTEMS
- Constitutional:
- Head:
- Eye:
- ENT/Mouth:
- CV:
- Respiratory:
- GI:
- GU:
- MSKL:
- Integumentary:
- Neuro:
- Psych:
- Heme/Lymph:
- Endocrine:

PMH:
PSH:
FH:
Meds:
Allx:
SocHx: Tobacco- ETOH- Illicit Drugs-

OBJECTIVE:
VS: Reviewed

- GA/Psych:
- HEAD:
- EYES:
- EARS:
- NOSE:
- THROAT:
- NECK:
- CV:
- LUNGS:
- ABD:
- SKIN:
- MSKL:
- NEURO:


A/P: See Above
Procedure VaccinePlan:

RTC:
Meds: Medications

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.32, 92 form elements, 109 boilerplate words, 49 text boxes, 5 text areas, 11 checkboxes, 14 drop downs, 1 links, 1 variables, 11 conditionals, 114 total clicks
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