General Soap Note
Name:[text name="variable_1" default=""] MRN:[text name="variable_2" default=""] Admission Date:[date name="variable_3" default="03-30-2023"] DOB/Age:[date name="variable_4" default="03-30-2023"]/[text name="variable_5" default=""] y.o. Gender:[select name="variable_6" value="Male|Female|Other"] Room #: Cheif Complaint:[textarea name="variable_7" default=""] History of Presenting Illness: A [text name="variable_8" default=""] y.o. [select name="variable_9" value="Male|Female|Other"] with a past medical history of [textarea name="variable_10" default=""] presents due to [textarea name="variable_11" default=""] Past Surgical History: [textarea name="variable_12" default=""] Allergies: [textarea name="variable_13" default=""] Family History:[textarea name="variable_14" default=""] Medications:[textarea name="variable_15" default=""] Social History: Lives With:[textarea name="variable_16" default=""] Occupation:[textarea name="variable_17" default=""] Relationship:[textarea name="variable_18" default=""] Recent Travel:[textarea name="variable_19" default=""] Pets:[textarea name="variable_20" default=""] Tobacco: [select name="variable_21" value="Yes|No"] [text name="variable_22" default=""] years Alcohol: [select name="variable_23" value="Yes|No"] [text name="variable_24" default="Type"] [text name="variable_25" default=""] years Drugs: [select name="variable_26" value="Yes|No|"] [text name="variable_27" default="Type"] [text name="variable_28" default=""] years Exercise: [select name="variable_29" value="Yes|No|"] [text name="variable_30" default="Type"] [text name="variable_31" default=""] days per week. Review of Systems: General: [checkbox name="variable_32" value="Weight Loss|Pain|Fever|Chills|Fatigue"] HEENT: [checkbox name="variable_33" value="Headache|Hearing Change|Vision Change|Vertigo|Congestion|Runny Nose|Sore Throat"] Respiratory: [checkbox name="variable_34" value="Cough|Hemoptysis|Dyspnea|Wheezing|Pleuritic Pain"] Cardiovascular: [checkbox name="variable_35" value="Palpitations|Diaphoresis|Orthopnea|Edema|Claudication|Chest Pain"] Gastrointestinal: [checkbox name="variable_36" value="Vomiting|Diarrhea|Constipation|Appetite Change|Bleeding"] Genitourinary: [checkbox name="variable_37" value="Pain with Intercourse|Discharge|Itching|Irritation|Irregular Menses|Dysmenorrhea|Hernia|Testicular Issue"] Urinary: [checkbox name="variable_38" value="Frequency|Urgency|Pain|Burning|Hematuria"] Musculoskeletal: [checkbox name="variable_39" value="Myalgia|Arthralgia|Back Pain|Swelling of Joints"] Skin: [checkbox name="variable_40" value="Rashes|Changes to Moles|Itching|Dryness|Color Change"] Endocrine: [checkbox name="variable_41" value="Hot Intolerance|Cold Intolerance|Sweating|Polydipsia|Polyuria"] Neurologic: [checkbox name="variable_42" value="Dizziness|Fainting|Seizures|Numbness|Tingling|Tremor"] Psychiatric: [checkbox name="variable_43" value="Depression|Anxiety|Memory Loss"] Physical Exam: BP: [text name="variable_44" default=""] mmHg; HR: [text name="variable_45" default=""] beats/min; RR: [text name="variable_46" default=""] breaths/min; Temp: [text name="variable_47" default=""]C; SaO2: [text name="variable_48" default=""]% [text name="variable_49" default="O2 Requirement"] General: [checkbox name="variable_50" value="No Apparent Distress|Well Appearing|Alert|Interactive"] [text name="variable_51" default=""] HEENT: [checkbox name="variable_52" value="Normocephalic/Atraumatic|PERRl|EOMI|Good Conjugate Gaze|Nares Patent|MMM"] [text name="variable_53" default=""] Neck: [checkbox name="variable_54" value="Supple|No LAD|Normal ROM"] [text name="variable_55" default=""] Respiratory: [checkbox name="variable_56" value="Normal Respiratory Effort|No Wheezing|No Ronchi|No Rales|CTAB"] [text name="variable_57" default=""] Cardiovascular: [checkbox name="variable_58" value="RRR|S1/S2 Heart Sounds|No m/r/g"] [text name="variable_59" default=""] Abdominal: [checkbox name="variable_60" value="Soft|Non-distended|Non-tender|Normal Bowel Sounds|No palpable Masses"] [text name="variable_61" default=""] Extremities: [checkbox name="variable_62" value="Normal Tone|Normal ROM|Strength Intact|Sensation Intact|Capillary Refill <2sec"] [text name="variable_63" default=""] Neurological: [checkbox name="variable_64" value="A&OX3|Cranial Nerves 2-12 Intact|Reflex Symmetric|Sensation Normal|Gait Normal"] [text name="variable_66" default=""] Skin: [checkbox name="variable_67" value="Intact|No Rashes|No Lesions|No Erythema"] [text name="variable_68" default=""] Labs: Hgb: [text name="variable_69" default=""] Hct: [text name="variable_70" default=""] WBC: [text name="variable_71" default=""] Plt: [text name="variable_72" default=""] PT: [text name="variable_73" default=""] PTT: [text name="variable_74" default=""] INR: [text name="variable_75" default=""] Na: [text name="variable_76" default=""] K: [text name="variable_77" default=""] Cl: [text name="variable_78" default=""] HCO3: [text name="variable_79" default=""] BUN: [text name="variable_80" default=""] Cr: [text name="variable_81" default=""] Glucose: [text name="variable_82" default=""] Ca: [text name="variable_83" default=""] Mg: [text name="variable_84" default=""] PO4: [text name="variable_85" default=""] Bili: [text name="variable_86" default=""] AST: [text name="variable_87" default=""] ALT: [text name="variable_88" default=""] ALKP: [text name="variable_89" default=""] Other Labs:[textarea name="variable_90" default=""] Imaging: [textarea name="variable_91" default=""] Assessment/Plan: [textarea name="variable_92" default=""]
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Sandbox Metrics: Structured Data Index 0.32, 91 form elements, 118 boilerplate words, 47 text boxes, 15 text areas, 2 dates, 21 checkboxes, 6 drop downs, 174 total clicks
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