Complete Note
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Name: [text name="variable_83" default=""]
MRN: [text name="variable_84" default=""]

Chief complaint: [text name="variable_1" default=""]
History of present illness:
[textarea name="variable_1" default=""]

Review of systems:
General: [textarea name="variable_65" default="denies fever/chills, fatigue, malaise, weight changes"]
HEENT: [textarea name="variable_66" default="denies headaches, vision changes, rhinorrhea, sore throat"]
Cardiac: [textarea name="variable_67" default="denies chest pain, palpitations, peripheral edema"]
Pulmonary: [textarea name="variable_68" default="denies shortness of breath, dyspnea, cough, sputum production"]
GI: [textarea name="variable_69" default="denies nausea/vomiting, abdominal pain, diarrhea/constipation, melena/hematochezia"]
GU: [textarea name="variable_70" default="denies dysuria, hematuria"]
MSK: [textarea name="variable_71" default="denies myalgias, arthralgias, weakness, numbness/tingling"]
Dermatologic: [textarea name="variable_72" default="denies rashes"]
Neurologic: [textarea name="variable_73" default="denies seizures"]
Psychiatric: [textarea name="variable_74" default="denies depression, anxiety"]
Endocrine: [textarea name="variable_75" default="denies polyphagia, polydipsia, polyuria"]
Hematologic/lymphatic: [textarea name="variable_76" default="denies abnormal bleeding/bruising"]

ED Course:
[textarea name="variable_60" default=""]

Past medical history:
[textarea name="variable_3" default=""]

Past surgical history:
[textarea name="variable_56" default=""]

Allergies:
[textarea name="variable_4" default=""]

Medications:
[textarea name="variable_5" default=""]

Pharmacy:
[textarea name="variable_57" default=""]

Social history:
Occupation - [text name="variable_41" default=""]
Living situation - [text name="variable_40" default=""]
Social services - [text name="variable_42" default=""]
Tobacco - [text name="variable_6" default=""]
Alcohol - [text name="variable_7" default=""]
Illicit drugs - [text name="variable_8" default=""]

Family history:
[text name="variable_58" default=""]

Vital signs:
BP – [text name="variable_9" default=""]mm Hg
T - [text name="variable_10" default=""]F
HR - [text name="variable_11" default=""]bpm
RR - [text name="variable_12" default=""]brpm
SaO2 - [text name="variable_13" default=""]%

Physical examination
General: [textarea name="variable_77" default="AAOx3, NAD"]
HEENT: [textarea name="variable_78" default="NC/AT, PERRLA, EOMI, mmm, no LAD"]
Cardiovascular: [textarea name="variable_79" default="RRR, +s1, +s2, no M/R/G"]
Pulmonary: [textarea name="variable_80" default="CTA b/l, no W/R/R"]
Abdominal: [textarea name="variable_81" default="soft, NT/ND, no hepatosplenomegaly, +bowel sounds"]
Neurological/MSK/Extremities: [textarea name="variable_82" default="CN 2-12 intact, normal motor strength, normal sensation, normal reflexes "]

Laboratory values:
CBC w/ diff:
WBCs[text name="variable_15" default=""], Hgb[text name="variable_16" default=""], Hct[text name="variable_17" default=""], Plts[text name="variable_18" default=""]

CMP:
Na[text name="variable_19" default=""] K[text name="variable_20" default=""] Cl[text name="variable_21" default=""] HCO3[text name="variable_22" default=""] BUN[text name="variable_23" default=""] Cr[text name="variable_24" default=""] Glu[text name="variable_25" default=""]
Ca[text name="variable_26" default=""] T Prot[text name="variable_27" default=""] Alb[text name="variable_28" default=""] AST[text name="variable_29" default=""] ALT[text name="variable_30" default=""] Alk Phos[text name="variable_31" default=""] T Bili[text name="variable_32" default=""]

Coags:
PT[text name="variable_33" default=""], INR[text name="variable_34" default=""], aPTT[text name="variable_35" default=""]

Other labs:
[text name="variable_59" default=""]

Radiology:
[textarea name="variable_36" default=""]

Microbiology:
[textarea name="variable_37" default=""]

Assessment
[textarea name="variable_38" default=""]

Plan
[textarea name="variable_39" default=""]

DVT ppx: [text name="variable_61" default=""]
Diet: [text name="variable_62" default=""]
Dispo: [text name="variable_63" default=""]
Code status: [text name="variable_64" default=""]
Name:
MRN:

Chief complaint:
History of present illness:


Review of systems:
General:
HEENT:
Cardiac:
Pulmonary:
GI:
GU:
MSK:
Dermatologic:
Neurologic:
Psychiatric:
Endocrine:
Hematologic/lymphatic:

ED Course:


Past medical history:


Past surgical history:


Allergies:


Medications:


Pharmacy:


Social history:
Occupation -
Living situation -
Social services -
Tobacco -
Alcohol -
Illicit drugs -

Family history:


Vital signs:
BP – mm Hg
T - F
HR - bpm
RR - brpm
SaO2 - %

Physical examination
General:
HEENT:
Cardiovascular:
Pulmonary:
Abdominal:
Neurological/MSK/Extremities:

Laboratory values:
CBC w/ diff:
WBCs, Hgb, Hct, Plts

CMP:
Na K Cl HCO3 BUN Cr Glu
Ca T Prot Alb AST ALT Alk Phos T Bili

Coags:
PT, INR, aPTT

Other labs:


Radiology:


Microbiology:


Assessment


Plan


DVT ppx:
Diet:
Dispo:
Code status:
Result - Copy and paste this output: