IM – HTN, DM

[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=50 rows=3]

CC: [textarea cols=50 rows=5]

MEDICATIONS: [checkbox name="medications" value="nitrates|b-blocker||insulin|metformin|SGLT2|GLP1|DPP4||ASA|Plavix|anticoagulants|"][textarea cols=50 rows=3]

REGIMEN COMPLIANCE: [checkbox name="monitoring" value="taking as prescribed|not taking as prescribed||reports no side effects|reports side effects||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||reports checking BS at home|reports not checking BS at home||insulin/BS log available for review|insulin/BS log not available for review||reports checking BP at home|reports not checking BP at home||BP record available for review|BP record unavailable for review|"][textarea cols=50 rows=2]

RECENT HISTORY: [checkbox name="recent" value="non-contributory||visit to ER/UC|hospitalization/surgery/procedure|new medications|antibiotic use|diagnostic study|"][textarea cols=50 rows=2]

PMH/Comorbidities: [checkbox name="pmh" value="HTN|LVH, CHF|aneurysm|atrial fibrillation|pacemaker||CAD,MI|angio/stent|CABG||CVA,TIA|PAD|ED|PE,DVT|carotid endarterectomy||BMI greater than 30|dyslipidemia|diabetes|retinopathy|microalbuminuria|GFR less than 60||COPD|snoring,sleep apnea|"][textarea cols=50 rows=2]

CV PROCEDURES - completed: [checkbox name="psh" value="EKG|stress test|cardiac ECHO|LE U/S|ABI|calcium score|"][textarea cols=50 rows=2]

PREVENTIVE SERVICES: [+] completed [-] not completed/indicated
[checklist name="prev" value="annual dilated eye exam|annual diabetic foot exam|annual microalbumin|annual FOBT|colonoscopy|DEXA|LDCT|AAA Doppler|PAP|mammogram|PSA|DRE"][textarea cols=50 rows=2]

VACCINATION: [+] completed [-] not completed/indicated
[checklist name="vac" value="flu|pneumo completed|DT|shingles"][textarea name="variable_3" default="referred to local pharmacy to verify vaccination status and administer vaccines, if indicated"]

SCREENING & COUNSELING: [checkbox name="screen" value="functional ability/safety|depression|alcohol misuse|tobacco use|obesity|STI||completed today & discussed with patient|deferred|"][textarea cols=50 rows=2]



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, 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"]



OUTSIDE RESULTS: [checkbox name="results" value="imaging studies|laboratory studies|specialty consults|"][textarea cols=50 rows=5]

OFFICE DIAGNOSTICS: [checkbox name="office_diag" value="EKG|RBS||normal|non-specific changes|no acute findings|abnormal||discussed with patient/SO|"][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|normal hair distribution|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]

[comment memo="2ry HTN: cortisol|renal failure|aldosterone|renal artery stenosis"]

ORDER - RX: [checkbox name="order_RX" value="none|OTC||electronic|paper|given to MA to be transmitted to pharmacy|"][textarea cols=50 rows=1]

ORDER - LABS: [checkbox name="order_lab" value="none||CBC|CMP|TSH|A1C|Lipids|PSA|FOBT/FIT|UA||HIV, RPR, HCV, GC, CT|UDS|"][textarea cols=50 rows=2]

ORDER - IMAGING: [checkbox name="order_imaging" value="none||X-ray|US|MRI|"][textarea cols=50 rows=2]

ORDER - REFERRALS: [checkbox name="order_refer" value="none||cardiology|endocrinology|"] [textarea cols=50 rows=2]

ORDER - FORMS: [checkbox name="forms" value="none||excuse|clearance|restrictions|"][textarea cols=50 rows=2]

STAFF INSTRUCTIONS: [checkbox name="MA" value="none||obtain hospital/ER discharge report|obtain specialty report|obtain imaging report|obtain laboratory report|remind patient to always bring all medication containers to visit|"][textarea cols=50 rows=2]

REVIEWED/DISCUSSED: exam findings, POC, risks of/benefits of/alternatives to proposed POC, 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|previous visits|laboratory/diagnostic studies|specialty reports|hospital records||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 week|RTC 4 weeks||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]

[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]

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]