The SOAPnote Project > Complete Note > Generic Telemed Note – Complete

Generic Telemed Note – Complete

By jenlunPA1975

posted 2021-01-06, updated 2021-03-26

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[checkbox name="historian" value="telemedicine visit, verification of patient identity and location in NC, VA, or OH was performed by clinic’s staff|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||complete history unobtainable d/t poor effort/affect|complete history unobtainable d/t cognitive changes|complete history unobtainable d/t distress|"][textarea cols=40 rows=5]
CC:
[checkbox name="cc" value="headache|fever|malaise|fatigue|body aches|night sweats|red eyes|nasal discharge|nasal congestion|sinus pain|loss of smell|loss of taste|earache/ear pressure|sore throat|pus on tonsils|voice loss|difficulty swallowing|cough|chest tightness/pain w/ breathing|SOB|GI Sx|"][textarea cols=40 rows=5]
HPI:[checkbox memo="chronic condition history" name="croniccnd" value=""]
[conditional field="croniccnd" condition="(croniccnd).is('')"][frontload soapnote="subjective/drgfms-chronic-condition-history/"][/conditional]
[checkbox name="hpi" value="sudden onset|gradual onset||started today|started yesterday|started several days ago|started more than 1 week ago||sx increasing in severity|sx persisting|sx decreasing in severity|"][textarea cols=40 rows=5]
RECENT & PAST HISTORY:     [+] reported  [-] not reported
[checklist name="recent" value="ER/UC visit|hospitalization/surgery/procedure|travel|sick contact|new/changed medications|antibiotic use|asthma/COPD|smoker|immunosuppression"]
MEDICATIONS:
allergies reviewed
[checkbox name="medications" value="taking OTC, not helping|taking ABX, not helping|not taking any medications|taking meds for chronic condition|"][textarea cols=40 rows=5]

REVIEW OF SYSTEMS:     [+] reported  [-] not reported
negative except as stated
EYES: [textarea cols=40 rows=1]
[checklist name="eye_symptoms" value="decrease in vision|discharge|lid swelling|pain with EOM"]
MOUTH: [textarea cols=40 rows=1]
[checklist name="mouth_symptoms" value="sores|dryness|tongue pain/swelling|toothache"]
NECK: [textarea cols=40 rows=1]
[checklist name="neck_symptoms" value="pain|stiffness|swelling|swollen glands"]
CV: [textarea cols=40 rows=1]
[checklist name="cv_symptoms" value="chest pain/pressure|SOB|palpitations|dyspnea|orthopnea|ankle swelling|ankle discoloration|varicose veins|leg cramps"]
GI: [textarea cols=40 rows=1]
[checklist name="gi_symptoms" value="poor appetite|nausea|vomiting|bloating|abdominal pain|constipation|diarrhea"]
GU: [textarea cols=40 rows=1]
[checklist name="gu_symptoms" value="dysuria|burning|frequency|urgency|odor|hematuria|hesitancy|retention|nocturia|oliguria|incontinence|itching|discharge|genital lesions"]
MSK: [textarea cols=40 rows=1]
[checklist name="msk_symptoms" value="neck pain|back pain|chronic pain/meds|localized joint pain/deformity|localized muscle/soft tissue pain/swelling|myalgias"]
NEURO: [textarea cols=40 rows=1]
[checklist name="neuro_symptoms" value="dizziness|vertigo|poor balance|abnormality of walk|focal weakness|blackouts|seizures|tingling/numbness"]
PSYCH: [textarea cols=40 rows=1]
[checklist name="psych_symptoms" value="irritability|confusion|depression|anxiety|mood swings|memory loss|insomnia"]
LYMPH/HEMA/IMMUNE: [textarea cols=40 rows=1]
[checklist name="hem_symptoms" value="gland swelling|bruising|anticoagulation|DVT/clotting|anemia|autoimmune dz|h/o cancer"]
DERM: [textarea cols=40 rows=1]
[checklist name="derm_symptoms" value="pruritus|rash|hives|redness|swelling|wounds|new or suspicious lesions"]



Appearance:
[checkbox name="appearance" value="well-appearing|alert|non-toxic|normal WOB|no acute distress|||malaised|short of breath|diaphoretic|coughing during exam|sniffling during exam||drowsy|appears impaired|slumped||unable to assess|"][textarea cols=40 rows=5]

Skin:
[checkbox name="skin" value="no visible rashes||unable to assess, reports no new rashes|"][textarea cols=40 rows=5]

Head/Face:
[checkbox name="head" value="normocephalic|symmetrical face|CN grossly intact||unable to assess, reports no trouble smiling or chewing|"][textarea cols=40 rows=5]

Eyes:
[checkbox name="eyes" value="clear conjunctiva w/o exudates, anicteric sclera, EOM intact without nystagmus ||conjunctival injection|epiphora|conjunctival exudate||palpebral edema|palpebral exudates||glasses|contacts||unable to assess, reports no changes in vision or photophobia|"][textarea cols=40 rows=5]

Ears:
[checkbox name="ears" value="symmetrical & intact auricles bilaterally|hearing grossly intact|no tragal tenderness|no mastoid tenderness||tragal tenderness||HOH|hearing aid(s)||unable to assess, reports no changes in hearing|"][textarea cols=40 rows=5]

Nose:
[checkbox name="nose" value="maxillary tenderness|frontal tenderness|perinasal irritation||unable to assess|reports being able to use both nostrils|reports no tenderness with applying pressure to sinus areas|"][textarea cols=40 rows=5]

Mouth:
[checkbox name="mouth" value="tongue normal in appearance with good symmetrical movements|moist oral mucosa without lesions||unable to assess|reports dry mouth|"][textarea cols=40 rows=5]

Throat:
[checkbox name="throat" value="speaks in clear and unmuffled voice|audible congestion in voice|audible hoarseness present|nasal sounding voice|no stridor||reports pharynx w/o swelling or exudates|reports pharyngeal erythema|reports pharyngeal exudates|"][textarea cols=40 rows=5]

Neck:
[checkbox name="neck" value="no visible thyromegaly or other masses|able to move neck in all directions without pain||unable to assess|reports no enlarged/tender cervical lymph nodes on self-palpation|"][textarea cols=40 rows=5]

Chest/Lungs:
[checkbox name="lungs" value="normal respiratory effort|no tachypnea apparent|speaking in full sentences|no audible wheezing||symmetrical chest expansion||unable to assess|reports respiratory distress|reports chest pain with breathing|audible coughing|"][textarea cols=40 rows=5]

CV:
[checkbox name="cv" value="unable to assess|reports pulse to be regular and of normal rate|reports no LE edema|reports no calf tenderness||reports tachycardia|reports irregular heart rhythm|"][textarea cols=40 rows=5]

Abdomen:
[checkbox name="abd" value="unable to assess|no focal abdominal tenderness elicited upon self-palpation||reports diffuse tenderness over entire abdomen w/o RRG|reports direct non-rebound focal tenderness|"][textarea cols=40 rows=5]

GU:
[checkbox name="gu" value="unable to assess|reports no suprapubic tenderness on self-exam|reports no CVAT on self-exam|"][textarea cols=40 rows=5]

MSK:
[checkbox name="spine" value="moves all extremities with good ROM for age|no visible gross deformity||unable to assess|reports full weight-bearing|reports no bony tenderness in affected area|"][textarea cols=40 rows=5]

Neuro:
[checkbox name="neuro" value="no tremor visible|normal concentration and attention|memory grossly intact||reports no changes in balance or coordination|no involuntary movements||tremor|tardive dyskinesia|tics|"][textarea cols=40 rows=5]

Behavior:
[checkbox name="behavior" value="calm, pleasant, respectful|cooperative||poor cooperation|guarded|anxious|irritable|frustrated|labile|sighing|crying|agitated|raising voice|argumentative|hostile|forceful|demanding particular medication, test, referral, or accommodation||bradykinetic|fidgeting|picking skin|twirling hair|cracking knuckles|threatening posture/movement|grimacing, furrowing eyebrows|tightening jaw|breathing hard|intense staring|standing up|"][textarea cols=40 rows=5]

Speech/Vocalization:
[checkbox name="speech" value="normal for age|clear & coherent||slurred|monotonous|stuttering||hypoverbal|hyperverbal||loud|soft||slow|rapid|pressured||perseveration|flight of ideas|repetitive questions|cursing, swearing|criticisms of staff|verbal threats|"][textarea cols=40 rows=5]

A/P:
[textarea cols=70 rows=5]

BARRIERS TO CARE:
[checkbox name="barriers" value="none identified||poor cooperation with exam|lack of motivation|negative attitude to diagnostic impression & proposed tx|incomplete history|vague shifting complaints|multiple comorbidities|polypharmacy|lack of interest in nonpharmacologic therapies|overwhelming focus on Rx drugs|altered mental status|hostile/disruptive behavior|active psychiatric diagnosis|social/cultural barriers||preoccupation with illness|catastrophization|overgeneralization|unrealistic beliefs|negativism|pessimism|blaming others|staff splitting|"][textarea cols=40 rows=5]

PLAN OF CARE:
[checkbox name="discussed" value="discussed telemedicine limitations, exam findings, recommendations, risks/benefits, alternative management options, reporting medication side effects to clinic immediately, appropriate follow up with PCP, home care & follow up instructions specific to condition, indications for immediate direct evaluation, indications/red flags for contacting emergency services|verbalized understanding of & agreement with POC||patient/family did not agree with my POA – will seek second opinion/further care elsewhere|"][textarea cols=40 rows=5]

DISPOSITION:
[checkbox name="disposition" value="contact clinic or see PCP as discussed, sooner if condition worsens/persists or new symptoms arise, contact 911/ER if significant increase in s/sx or appearance of new/danger s/sx||contact clinic 24 hours|contact clinic 48 to 72 hours|contact clinic 1 week||referred to ER for immediate treatment via 911|referred to ER for immediate treatment via private transport||declined emergency transfer|"][textarea cols=40 rows=5]

telemedicine visit, verification of patient identity and location in NC, VA, or OH was performed by clinic’s staff 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 complete history unobtainable d/t poor effort/affect complete history unobtainable d/t cognitive changes complete history unobtainable d/t distress

CC:
headache fever malaise fatigue body aches night sweats red eyes nasal discharge nasal congestion sinus pain loss of smell loss of taste earache/ear pressure sore throat pus on tonsils voice loss difficulty swallowing cough chest tightness/pain w/ breathing SOB GI Sx

HPI: chronic condition history
Note scribed by - Adult Chronic/Followup Visit
Vital signs:if not already inputted HPIinclude HPI Intro ___A___ abscess acute diastolic congestive heart failure (CHF) acute kidney history (AKI) acute midline back pain with sciatica acute midline back pain without sciatica acute subdural hematoma alcohol abuse alcohol use disorder amphetamine abuse anasarca aneurysm (intracranial) anemia anemia due to blood loss anemia due to chronic stage 4 renal failure anti-phospholipid syndrome (APS) anxiety aortic valve stenosis arthritis (osteoarthritis) ascites due to cirrhosis asthma atrial fibrillation avascular necrosis of the *** avascular necrosis in bilateral hips avascular necrosis of right humerus avascular necrosis of left humerus ___B___ bacterial vaginosis (BV) benzodiazepine abuse ___C___ cardiomyopathy carotid stenosis (left) carotid stenosis (right) carpal tunnel syndrome (CTS) cataracts cataracts secondary to diabetes cervical disk disorder cervical radiculopathy chronic abdominal pain chronic anemia chronic back pain chronic cough chronic cough secondary to ACE inhibitor chronic obstructive pulmonary disease (COPD) chronic insomnia chronic kidney disease (CKD), stage III, secondary to hypertension chronic kidney disease (CKD), stage IV, secondary to hypertension chronic kidney disease (CKD), stage III, secondary to type II diabetes chronic kidney disease (CKD), stage IV, secondary to type II diabetes chronic kidney disease (CKD), stage III, secondary to type I diabetes chronic kidney disease (CKD), stage IV, secondary to type I diabetes chronic pain chronic pain with long-term opiate medication use chronic pain of the joints chronic pain of the back chronic pain of the neck chronic renal allograft nephropathy clostridium difficile infection cocaine use colonic polyps colonic polyps status post removal in *** cystocele (lateral) cystocele (midline) cyclic vomiting syndrome cystic fibrosis ___D___ delirium depression diabetes type I diabetes type II diabetic nephropathy secondary to type I diabetes diabetic nephropathy secondary to type II diabetes diarrhea drug seeking behavior deep venous thrombosis (DVT) deep venous thrombosis (DVT) of right leg deep venous thrombosis (DVT) of left leg diverticulitis diverticulosis ___E___ eclampsia emphysema end stage renal disease (ESRD) end stage renal disease (ESRD), secondary to hypertension end stage renal disease (ESRD), secondary to type II diabetes end stage renal disease (ESRD), secondary to type I diabetes episode of syncope episodes of syncope episodic syncope esophageal varices essential hypertension ethanol abuse ___F___ fall ___G___ gastritis gastroesopheal reflux disease (GERD) generalized abdominal pain gilbert disease gout ___H___ heart failure with preserved ejection fractiom (HFpEF) heart murmur on hemodialysis heroine use herpes simplex virus(HSV) history of atrial fibrillation history of DVT in right leg history of DVT in left leg history of PE history of renal transplant hypercholesterolemia hyperglycemic episodes hypoglicemia hyperkalemia hyperlipidemia (HLD) hypernatremia hyperparathyroidism hyperparathroidism secondary to renal failure hyperphosphotemia hypertension (HTN) hypertension (HTN) uncontrolled hypoglycemic episodes hypokalemia hyponatremia hypophosphatemia ___I___ incomplete bladder emptying intracranial aneurysm intractable back pain ___J___ ___K___ kidney disease ___L___ lactic acidosis liver disease lung nodule seen on imaging study ___M___ major depressive disorder (MDD) major depressive disorder (MDD) with mixed features major depressive disorder (MDD) with psychotic features malingering metabolic acidosis misscarriage in *** ___N___ nodular duodenitis nodular duodenitis and scalloped appearing thicken small bowel ___O___ obstructive sleep apnea (OSA) osteoarthritis ___P___ pancreatic cancer pancreatitis pancytopenia panic attacks parethesias paroxysmal atrial fibrillation pericardial effusion pericardial effusions peripheral artery disease (PAD) personality disorder placental insufficiency poly-substance abuse pre-eclampsia pre-mature atrial contraction primary prostatic cancer primary prostatic cancer with metastasis protienuria pulmonary embolism pulmonary hypertension ___Q___ ___R___ rectocele recurrent urinary tract infection (UTI) retroperitoneal lymphadenopathy ___S___ scoliosis secondary hyperparathyroidism of renal origin shortness of breath (SOB) sickel cell anemia sickle cell disease sickle cell disease with frequent admissions for pain control sleep apnea spontaneous bacterial peritonitis stage 4 chronic kidney disease stroke stroke with residual right hemiparesis stroke with residual left hemiparesis stroke with residua aphasia stoke with residual cognitive deficits subarachnoid hemorrhage (SAH) subdural hematoma syndrome of inappropriate antidiuretic hormone (SIADH) systemic lupus erythematosus (SLE) ___T___ thrombocytopenia thyroid atrophy tobacco use type I diabetes type II diabetes with complication type II diabetes without complications ___U___ urinary retention urinary retention secondary to benign prosthetic hypertrophy (BPH) urinary tract infection (UTI) urinary tract infection (UTI) history ulnar nerve compression ___V___ venous thromboembolism (VTE) ___W___ wegner's granulomatosis ___X___ xeroderma Xerostomia ___Y___ ___Z___.
History for condition #1-------------BEGIN CONDITION 1-------------<-- patient name, or pronoun --> if no pronoun or titile selected, check for female leave black for male reports that his or herscore=(sex)+(pronoun);score>0?'her':'his' select one ▼▼◀︎◀︎ and/or freetext is . Currently, he or shescore=(sex)+(pronoun);score>0?'she':'he'
History for condition #2-------------BEGIN CONDITION 2-------------<-- patient name, or pronoun --> if no pronoun or titile selected, check for female leave black for male reports that his or herscore=(sex)+(pronoun);score>0?'her':'his' select one ▼▼◀︎◀︎ and/or freetext is . Currently, he or shescore=(sex)+(pronoun);score>0?'she':'he'
History for condition #3-------------BEGIN CONDITION 3-------------<-- patient name, or pronoun --> if no pronoun or titile selected, check for female leave black for male reports that his or herscore=(sex)+(pronoun);score>0?'her':'his' select one ▼▼◀︎◀︎ and/or freetext is . Currently, he or shescore=(sex)+(pronoun);score>0?'she':'he'
History for condition #4-------------BEGIN CONDITION 4-------------<-- patient name, or pronoun --> if no pronoun or titile selected, check for female leave black for male reports that his or herscore=(sex)+(pronoun);score>0?'her':'his' select one ▼▼◀︎◀︎ and/or freetext is . Currently, he or shescore=(sex)+(pronoun);score>0?'she':'he'
History for condition #5-------------BEGIN CONDITION 5-------------<-- patient name, or pronoun --> if no pronoun or titile selected, check for female leave black for male reports that his or herscore=(sex)+(pronoun);score>0?'her':'his' select one ▼▼◀︎◀︎ and/or freetext is . Currently, he or shescore=(sex)+(pronoun);score>0?'she':'he'
History for condition #6-------------BEGIN CONDITION 6-------------<-- patient name, or pronoun --> if no pronoun or titile selected, check for female leave black for male reports that his or herscore=(sex)+(pronoun);score>0?'her':'his' select one ▼▼