Inpatient H&P II (OFFICIAL 10/27) III

Care Providers 
Admitting Physician: [text name="variable_700" default="Last, MD, First Name"]
Attending Physician: [text name="variable_701" default="Last, DO, First Name"]
Consulting Physician: [text name="variable_702" default="Last, MD, First Name"]
Primary Care Physician: [text name="variable_703" default="Physician, Nonstaff"]

Name: [text name="variable_1" default="Doe, Jane"]
DOB: [date name="variable_2" default="01-01-2001"]
Gender: [select name="variable_3" value="Male|Female|Other"]
Code Status:[select name="variable_4" value="Full Code|DNR + CCA|DNR + CCC"]
[comment memo="DNR-CCA permits use of life-saving tx before your heart or breathig stops. Only comfort care is provided after heart/breathing.
DNR-CC requires that only comfort measures be administered before, during or after the time your heart/breathing stops. This is usually used for terminally ill PT, short life expectancy, or little change of surviving CPR. Tx directed towards keeping you comfortable & with best quality of life."]
Insurance: [text name="variable_5" default=""]

SUBJECTIVE
CC: [textarea name="variable_6" default="(1 PHRASE) shortness of breath x4 days. "]

HPI: [comment memo="Turn this entire HPI into 3 separate paragraphs:1. What happened, 2. PT statement, 3. ED course. "]
[text name="variable_7" default="Jane Doe"] is a [text name="variable_8" default="age"] year old [text name="variable_9" default="M/F"] with a PMH of [text name="variable_10" default="HTN, CKD4, HFpEF (EF 73% in 2003), and anemia"] who presents to the [select name="variable_11" value="ED|office"] for a chief complaint of [textarea name="variable_12" default="shortness of breath, leg swelling, and abdominal pain."] 
Patient states that 
[textarea name="variable_13" default="expand on CC."]

[checklist name="Variable1010101" value="Problem 1|Problem 2|Problem 3"]


[checkbox name="Variable101011" value="Problem 1|Problem 2|Problem 3"]

[conditional field="expand_safety" condition="(expand_safety).is(' ')"]

[checkbox name="Safety" value="

PT's [text name="variable_14" default="PROBLEM 1"] is located in [text name="variable_15" default="LOCATION"]. It is [text name="variable_16" default="sharp/dull"] in quality & is rated a [text name="variable_17" default="#/10"] in severity. It has been present for the last [text name="variable_18" default="TIMEFRAME"] and occurs [text name="variable_19" default="TIMING (in morning/randomly)"], usually [text name="variable_20" default="context ex: after meals"]. When it does come on, it lasts approximately [text name="variable_99" default="TIMEFRAME (# min)"]. [text name="variable_21" default="Nothing"] makes it better or worse. It is associated with [text name="variable_22" default="other signs/symptoms"].
[remark]Other[/remark][textarea name="variable_23" default="Location: Quality: Severity: Timeframe: Time during day: Lasts for: Improves/worsens with: Associated with: "]

"].[/conditional]



PT's [text name="variable_14" default="PROBLEM 1"] is located in [text name="variable_15" default="LOCATION"]. It is [text name="variable_16" default="sharp/dull"] in quality & is rated a [text name="variable_17" default="#/10"] in severity. It has been present for the last [text name="variable_18" default="TIMEFRAME"] and occurs [text name="variable_19" default="TIMING (in morning/randomly)"], usually [text name="variable_20" default="context ex: after meals"]. When it does come on, it lasts approximately [text name="variable_99" default="TIMEFRAME (# min)"]. [text name="variable_21" default="Nothing"] makes it better or worse. It is associated with [text name="variable_22" default="other signs/symptoms"].
[remark]Other[/remark][textarea name="variable_23" default="Location: Quality: Severity: Timeframe: Time during day: Lasts for: Improves/worsens with: Associated with: "]

PT also complains of [text name="variable_24" default="PROBLEM 2"], which is located in [text name="variable_25" default="LOCATION"]. It is [text name="variable_26" default="sharp/dull"] in quality & is rated a [text name="variable_27" default="#/10"] in severity. It has been present for the last [text name="variable_28" default="TIMEFRAME"] and occurs [text name="variable_29" default="TIMING (in morning/randomly)"], usually [text name="variable_30" default="context ex: after meals"]. When it does come on, it lasts approximately [text name="variable_98" default="TIMEFRAME (# min)"]. [text name="variable_31" default="Nothing"] makes it better or worse. It is associated with [text name="variable_32" default="other signs/symptoms"].
[remark]Other[/remark][textarea name="variable_33" default="Location: Quality: Severity: Timeframe: Time during day: Lasts for: Improves/worsens with: Associated with: "]

PT also complains of [text name="variable_34" default="PROBLEM 3"], which is located in [text name="variable_35" default="LOCATION"]. It is [text name="variable_36" default="sharp/dull"] in quality & is rated a [text name="variable_37" default="#/10"] in severity. It has been present for the last [text name="variable_38" default="TIMEFRAME"] and occurs [text name="variable_39" default="TIMING (in morning/randomly)"], usually [text name="variable_40" default="context ex: after meals"]. When it does come on, it lasts approximately [text name="variable_97" default="TIMEFRAME (# min)"]. [text name="variable_41" default="Nothing"] makes it better or worse. It is associated with [text name="variable_42" default="other signs/symptoms"].
[remark]Other[/remark][textarea name="variable_43" default="Location: Quality: Severity: Timeframe: Time during day: Lasts for: Improves/worsens with: Associated with: "]


At baseline, PT ambulates with [text name="variable_96" default="a cane"], requires [text name="variable_95" default="no "] O2 to breathe, and can [select name="variable_67" value=" perform|perform some|not perform|"] ADLs such as [text name="variable_1" default="hygiene and chores"].
[remark]Other[/remark] 
[textarea name="variable_45" default=" Of note.... "]

ED Course: 
[textarea name="variable_000001" default=""] [remark]Ex: Stroke alerted.[/remark]
Vitals:[text name="variable_000002" default=" , otherwise stable."]
Labs:[text name="variable_000003" default=", otherwise unremarkable."]
Tests:[text name="variable_000004" default=""]
Meds:[textarea name="variable_000005" default=" "]
[comment memo="Drug, # mg = # tab/cap, oral/subQ, daily/BID/evening "]

PT admitted to [text name="variable_52" default="FMC"] for [select name="variable_53" value="medical optimization & discharge planning|further management"].


In the ED, patient presented with [text name="variable_46" default=" hypertension and hypoxia with desaturations, which required 4-5 L NC."]. Vitals were signifiant for [text name="variable_47" default="HR ___, BP ___, SPO2 ___ on ___, RR ___."] CBC was remarkable for [text name="variable_47" default="normocytic anemia (Hb 9 at baseline)"]. [select name="variable_502" value="CMP|BMP"] showed [text name="variable_48" default="elevated BUN, creatinine, and glucose. BNP was mildly elevated at 132."] EKG showed [text name="variable_49" default="sinus rhythm with nonspecific T wave changes"]. CXR showed [text name="variable_50" default="atelectasis in LLL and ground glass opacities in L lung"]. PT was given [text name="variable_51" default="medication list"]. They were then admitted to [text name="variable_52" default="FMC"] for [select name="variable_53" value="medical optimization & discharge planning|further management"].
[textarea name="variable_66" default=" Of note.... "]

 BMP remarkable for Na+ 134, K+ 3.1, Albumin 2.8. EKG sinus tachycardia rate 122. US B/l LE unremarkable. S/p Iron x 1, Thiamine x1, Folic Acid x1, Ferrelecit1 25 mg x1, Olanzapine x1.


ED Course 
[checkbox name="ED Course" value="Pullet Point|Paragraph"]
[select name="variable_1" value="choice A|choice B|choice C"]



Review of Systems (for main problem say - see HPI)
Constitutional: [checklist name="variable_54" value="fever|chills|fatigue|appetite changes|unexplained weight changes|see HPI"]
HEENT: [checklist name="variable_55" value= "headaches|changes in vision|eye pain|problems with hearing|ringing in ears| dizziness|nose bleeds|congestion|discharge|sinus infections|see HPI"]
Resp: [checklist name="variable_56" value="SOB|cough|phlegm|coughing up blood|bronchitis|emphysema|COPD|see HPI"] 
Cardio: [checklist name="variable_57" value="chest pain|palpitations|heart murmurs|hx of heart medications|rheumatic heart disease|HTN| high cholesterol|change in color of fingers/toes|see HPI"]
GI: [checklist name="variable_58" value="problems swallowing|heart burn|nausea|vomiting|diarrhea|constipation|change in bowel habits|abdominal pain|excessive burping|excessive flatus|food intolerance|rectal bleeding|hemorrhoids|yellowing of skin|see HPI"]
GU: [checklist name="variable_59" value="difficulty peeing|pain/burning when you pee|frequent peeing at night|urgent need to pee|urine incontinence|dribbling|decreased stream|blood in urine|UTI|stones|prostate issues|see HPI"]
MSK: [checklist name="variable_60" value="joint pain|back pain|muscle pain|swelling|stiffness|decreased ROM|broken bones|arthritis|gout|difficulty walking|see HPI"]
Peripheral Vasc: [checklist name="variable_61" value="swelling in hands|swelling in feet|leg cramps|varicose veins|clots in veins|venous stasis|see HPI"]
Skin: [checklist name="variable_62" value="rashes|other skin complaints|see HPI"]
Neurologic: [checklist name="variable_1" value="HA|migrains|seizures|LOC/fainting|paralysis|weakness|muscle spasms|tremor|numbness|tingling|involuntary movement|incoordination|memory deficits|see HPI"]
Endocrine: [checklist name="variable_63" value="abnormal growth|increased thirst|increased urine production|thyroid issues|heat/cold intolerance|excessive sweating|diabetes|see HPI"]
Immunologic: [checklist name="variable_64" value="TB|hepatitis|recurrent infections|see HPI"]
Psych: [checklist name="variable_65" value="anxiety|depression|thoughts of suicide/self harm|thoughts of hurting others|memory issues|sleep issues|changes in mood|pleasure in doing things|ADD/ADHD|past treatment with psychiatrist|other psychiatric diagnosis|see HPI"]


Medical Reconciliation
Current Home Medications: [textarea name="variable_128" default="drug, # mg = # tab/cap, oral/subQ, daily/BID/evening"]
Inpatient Medications: [textarea name="variable_129" default="drug, # mg = # tab/cap, oral/subQ, daily/BID/evening"]
Not Taking: [textarea name="variable_129" default="drug, # mg = # tab/cap, oral/subQ, daily/BID/evening  -Reason why not taking"]


OBJECTIVE

Physical Exam
General Appearance: 
[textarea name="variable_68" default="Well developed, well nourished, alert and cooperative, and appears to be in no acute distress."]
A&Ox[select name="variable_69" value="4|3|2|1"] [comment memo="Who are you? Where are you? Date & Time? What just happened to you?"]
Health:[select name="variable_70" value="Presentation|Well nourished|Obese|Thin|Frail"]
Grooming: [select name="variable_71" value=Appearance|Well-groomed|Unkept|Appears stated age|Appears older than stated age"]

Neuro: 
[textarea name="variable_72" default="CN II-XII intact. Strength and sensation symmetric and intact throughout. Reflexes 2+ throughout. Cerebellar testing normal."]
[checklist name="variable_73" value="Normal motor function w/ muscle strength 5/5 BL on UE and LE|Sensation intact B/L|Memory grossly intact|No gait abnormalities observed|Neuro exam not performed. "]
Head: 
[checklist name="variable_74" value=" Normocephalic and atraumatic|w/o tenderness/visible/palpable masses| Hair of normal texture & distribution"]
Eyes: 
[checklist name="variable_75" value="Conjuctiva are clear w/o exudates or hemorrhage|Sclera is non-icteric|EOM intact|PERRLA"]
Ears:
[checklist name="variable_76" value="B/L external ear canals NT and w/o swelling|Hearing grossly intact|Difficulty Hearing|Hearing aide present"]
Nose:
[checklist name="variable_77" value="Nasal mucosa is pink and moist|Nares patent B/L |No nasal discharge|Clear nasal discharge|Purulent nasal discharge"]
Throat: 
[checklist name="variable_78" value="Oral mucosa is pink and moist|No inflammation, swelling, exudate, or lesions noted|Good dentition|Poor dentition|Dentures present|HEENT exam not performed"]
Neck: 
[checklist name="variable_79" value="Supple, NT, w/o lymphadenopathy, masses, or thyromegaly|Trachea is midline|THyroid gland is normal w/o any palpable masses|Carotid pulse 2+ B/L w/o bruit|No JVD"]
Cardio:
[textarea name="variable_80" default="Normal S1 and S2. No S3, S4 or murmurs. Rhythm is regular. There is no peripheral edema, cyanosis or pallor. Extremities are warm and well perfused. Capillary refill is less than 2 seconds. No carotid bruits."]
HR: [select name="variable_81" value="Normal|Tachycardia|Bradycardia"]
Rhythm: [select name="variable_82" value="Regular|Irregular|Irregularly irregular rhythm"]
Extra Heart sounds: [checklist name="variable_83" value="+murmur|+gallop/rub|other heart sound"] 
Respiratory:
[textarea name="variable_84" default="Clear to auscultation and percussion without rales, rhonchi, wheezing or diminished breath sounds."]

GI: 
[textarea name="variable_85" default="Positive bowel sounds. Soft, nondistended, nontender. No guarding or rebound. No masses."]
[checklist name="variable_86" value="GI exam not performed."]
Integumentary:
[textarea name="variable_87" default="Skin normal color, texture and turgor with no lesions or eruptions."]
[checklist name="variable_88" value="Skin exam not performed."]
MSK: 
[textarea name="variable_89" default=": Adequately aligned spine. ROM intact spine and extremities. No joint erythema or tenderness. Normal muscular development. Normal gait."]
[checklist name="variable_90" value="MSK exam not performed."]
Extremities: 
[textarea name="variable_91" default="No significant deformity or joint abnormality. No edema. Peripheral pulses intact. No varicosities."]
[checklist name="variable_92" value="Extremity exam not performed."]
Psych:
[textarea name="variable_93" default="Patient is oriented to person, place, and time. The patient was able to demonstrate good judgement and reason, without hallucinations, abnormal affect or abnormal behaviors during the examination. Patient is not suicidal."]
[checklist name="variable_94" value="Psych exam not performed."]

GU MALE 
Genital:
[textarea name="variable_95" default="Genital exam revealed normally developed male genitalia. No scrotal mass or tenderness, no hernias or inquinal lymphadenopathy. No perineal or perianal abnormalities are seen. No genital lesions or urethral discharge."]
Rectal:
[textarea name="variable_96" default="Good sphincter tone with no anal, perineal or rectal lesions. Prostate is not tender, enlarged, boggy, or nodular."]
[checklist name="variable_1" value="Male GU exam not performed."]

GU FEMALE: 
Breasts:
[textarea name="variable_97" default="No masses, tenderness, asymmetry, nipple discharge or axillary lymphadenopathy. "]
Pelvic:
[textarea name="variable_98" default="Normally developed external female genitalia with no external lesions or eruptions. Vagina and cervix have no lesions, inflammation, discharge or tenderness. Cervix is nontender. Uterus is within normal limits with no adnexal fullness."]
[checklist name="variable_99" value="Female GU exam not performed."]

Problem List/PMH
Acute: 
[textarea name="variable_100" default="HTN T2DM CABGx3"]
Chronic:
[textarea name="variable_101" default="Ex: CABG in 2001, 2 MIs since then w/ the most recent being in ~2023. Hernia repair 25 years ago. Lipoma Removal.Seizure Disorder"]

Procedure/Surgical Hx 
[textarea name="variable_102" default=""]

Social Hx
[select name="variable_300" value="Currently works in|Retired. Worked|Unemployed"] in [text name="variable_301" default="career"].
Smoking Status: [select name="variable_103" value="Never used|Denies current use|Admits to current use"]
If current smoker, reports smoking [text name="variable_104" default="#"] packs per day for the last [text name="variable_106" default="#"] year(s).
Pack years:[calc value="score1=(variable_104)*(variable_106)"]
If former smoker, stopped on [date name="variable_107" default="01-01-2001"]
When they did smoke, they report smoking [text name="variable_130" default="#"] packs per day for the last [text name="variable_131" default="#"] year(s).
Pack years:[calc value="score1=(variable_130)*(variable_131)"]

Alcohol Status: [select name="variable_132" value="Never used|Denies current use|Admits to current use"]
If current drinking, reports drinking: [text name="variable_108" default="#"] shots per [text name="variable_109" default="day/week/month"]
If former drinker, stopped on [date name="variable_110" default="01-01-2001"]
When they did drink, they report drinking: [text name="variable_133" default="#"] shots per [text name="variable_134" default="day/week/month"]

Illicit Drug Use:
[select name="variable_111" value="Never used|Denies current use|Admits to current use"]
If + use, reports use of: [checkbox name="variable_112" value="Benzodiazepine use|Opiate use|Cocaine use|MDMA use|PCP use|LSD use|Marijuana use|Barbituate use|Nicotine use|Amphetamine use"]
Other:[textarea name="variable_113" default="Quantify amount, # of years."]


Family History 
Mother: [select name="variable_114" value="Alive|Deceased"] [text name="variable_115" default="Age"] yo, [text name="variable_135" default="Health Condition"]
Father: [select name="variable_116" value="Alive|Deceased"] [text name="variable_117" default="Age"]yo, [text name="variable_136" default="Health Condition"]
Sibling 1: [select name="variable_137" value="Male|Female"][select name="variable_116" value="Alive|Deceased"] [text name="variable_138" default="Health Condition"]
Sibling 2: [select name="variable_139" value="Male|Female"][select name="variable_140" value="Alive|Deceased"] [text name="variable_141" default="Health Condition"]
[textarea name="variable_141" default="Medical Hx on Maternal side: Medical Hx on Paternal side:"]
[textarea name="variable_941" default="Contact person: Name, Relationship, Phone # "]


Allergies: 
[textarea name="variable_119" default="Allergy, Reaction"]
Lab results: 
[textarea name="variable_120" default="significant for..."]
Diagnostic results: 
[textarea name="variable_121" default=""]

ASSESSMENT/PLAN

#[comment memo="Problem 1"][text name="variable_122" default=""]
 DDx:[textarea name="variable_600" default="List of differential diagnoses"]
 POA: [textarea name="variable_601" default="Point of Admission; any abnormal labs drawn on admission to ED"]
 [textarea name="variable_602" default="Chronology of what has been done"]
 Plan: [textarea name="variable_603" default="Any active interventions"]


#[comment memo="Problem 2"][text name="variable_124" default=""]
 DDx:[textarea name="variable_604" default="List of differential diagnoses"]
 POA: [textarea name="variable_605" default="Point of Admission; any abnormal labs drawn on admission to ED"]
 [textarea name="variable_606" default="Chronology of what has been done"]
 Plan: [textarea name="variable_607" default="Any active interventions"]


#[comment memo="Problem 3"][text name="variable_126" default=""]
 DDx:[textarea name="variable_608" default="List of differential diagnoses"]
  POA: [textarea name="variable_609" default="Point of Admission; any abnormal labs drawn on admission to ED"]
 [textarea name="variable_610" default="Chronology of what has been done"]
 Plan: [textarea name="variable_611" default="Any active interventions"]
 
 Disposition: [select name="variable_200" value="I believe that PT will require hospitalization stay less than 48 hours. PT will likely be discharged home|I believe that PT will require hospitalization stay greater than 48 hours. PT will likely be discharged home| Add more as you find"]
 Level of care: [select name="variable_400" value="Med/surg under observation status.| Telemetry under observation status.| Add more as you find them."]

[comment memo="Pre-hospital Course"]
Patient is a [text name="variable_800" default="#"]yo [select name="variable_801" value="M|F"] with PMHx of [text name="variable_802" default=""] who presents with cc of [text name="variable_803" default=""]. PT was sent to the ED by [textarea name="variable_804" default=""].  PT reports  [textarea name="variable_"805 default="PT complaints + ROS findings"]. On exam, PT presents with [textarea name="variable_806" default=" PE findings"]. PT is currently taking [textarea name="variable_807" default="medication A, for X condition, medication B, for Y condition..."] PT currently [select name="variable_808" value="works in|attends school| is unemployed|is retired"] and lives in [text name="variable_809" default="location (a dorm)."] PT [select name="variable_900" value="does|does not"] have family in the area, and [select name="variable_901" value="does|does not"] have a PCP in town. [textarea name="variable_902" default="ADD EXTRA HERE, CONSULTS"] We will continue to monitor her vitals and [text name="variable_903" default="next steps"] in the [select name="variable_904" value="AM|PM"].

 [select name="variable_201" value="NONE|DVT|GI|Add more as you find"]Prophylaxis
 [text name="variable_202" default="DRUG"][text name="variable_203" default="DATE"][text name="variable_204" default="TIME"][text name="variable_205" default="DR NAME who made order"] 
  [select name="variable_206" value="NONE|DVT|GI|Add more as you find"]Prophylaxis
 [text name="variable_207" default="DRUG"][text name="variable_208" default="DATE"][text name="variable_209" default="TIME"][text name="variable_210" default="DR NAME who made order"]
  [textarea name="variable_211" default="No current orders found."]
  
Authenticated by: [text name="variable_94" default="DR NAME"] on [text name="variable_90" default="DATE"][text name="variable_91" default="TIME"]
 Electronically Signed by:  [text name="variable_94" default="DR NAME"] on [text name="variable_90" default="DATE"][text name="variable_91" default="TIME"]
 Performed by:  [text name="variable_94" default="DR NAME"]