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[comment memo="For use on FMIT Service"]
[comment memo="Inpatient H&P SO Portion"]
cc: [text size="50"]
HPI: [text size="3"]yo [select name="AD1" value="active duty|retired|dependent"] [conditional field="AD1" condition="(AD1).isNot('dependent')"][text default="rank" size="6"] [/conditional][select value="M|F"] presents to [select value="ED|clinic"] for [textarea]

ED Course: [textarea]

PMHx: [textarea]

Home Meds: [select name="Meds" value="see med rec|listed as follows"]
[conditional field="Meds" condition="(Meds).isNot('see med rec')"][textarea cols="60" rows="10"]
[/conditional]
All: [select name="Allergies" value="NKDA|listed- "][conditional field="Allergies" condition="(Allergies).isNot('NKDA')"][textarea cols="60" rows="3"][/conditional]

PSHx: [textarea]

FMHx: [textarea]

Soc:
-Tobacco- [select name="Tobacco" value="denies/never|previous-|current-"][conditional field="Tobacco" condition="(Tobacco).is('previous-')"][text size="3"]ppd x [text size="4"]yrs, quit [text size="4"]yrs ago, denies current use[/conditional][conditional field="Tobacco" condition="(Tobacco).is('current-')"][text size="3"]ppd x [text size="4"]yrs[/conditional]
-EtOH- [select name="EtOH" value="denies/never|previous-|current-"][conditional field="EtOH" condition="(EtOH).is('current-')"][text size="3"] [select value="cans of beer|glasses of wine|shots of whiskey"] [select value="on average daily|on weekends only|rarely on special occasions"] for [text size="4"]yrs[/conditional][conditional field="EtOH" condition="(EtOH).is('previous-')"] quit [text size="4"] years ago, denies current use[/conditional]
-Illicit drugs- [select name="illicitdrugs" value="denies/never|previous-|current-"][conditional field="illicitdrugs" condition="(illicitdrugs).is('previous-')"][text size="50"] x [text size="4"]yrs, quit [text size="4"]yrs ago[/conditional][conditional field="Tobacco" condition="(Tobacco).is('current-')"][text size="50"] x [text size="4"]yrs[/conditional]
-Living situation- [text default="lives with" size="60"]

ROS: [comment memo="Use freetext to explain {+}s if needed"]
Constitutional- [select value="(-)|{+}"]fever, [select value="(-)|{+}"]chills, [select value="(-)|{+}"], [select value="(-)|{+}"]malaise, [select value="(-)|{+}"]unexplained wt gain/loss [text size="60"]
HEENT- [select value="(-)|{+}"]vision/hearing/smell changes, [select value="(-)|{+}"]nose/throat/neck symptoms [text size="60"]
Resp- [select value="(-)|{+}"]cough, [select value="(-)|{+}"]SOB [text size="60"]
CV- [select value="(-)|{+}"]chest pain, [select value="(-)|{+}"]palpitations [text size="60"]
GI- [select value="(-)|{+}"]abd pain/[select value="(-)|{+}"]N/[select value="(-)|{+}"]V/[select value="(-)|{+}"]diarrhea/[select value="(-)|{+}"]constipation [text size="60"]
GU- [select value="(-)|{+}"]urinary frequency/urgency/pain [text size="60"]
MSK- [select value="(-)|{+}"]new/unusual muscle aches/pains [text size="60"]

Code status: [select name="codestatus1" value="Full Code|DNR/DNI|other-"][conditional field="codestatus1" condition="(codestatus1).is('other-')"][text size="50"][/conditional]

PE: [comment memo="Use freetext for pertinent PE abnormals"]
Vitals- [select name="Vitals" value="reviewed/stable|reviewed/pertinent for- "][conditional field="Vitals" condition="(Vitals).is('reviewed/pertinent for- ')"][text default="BP *, HR *, RR *, T *, SpO2 * % on *L" size="60"][/conditional]
GEN- [text size="60"] [checkbox value="well developed|well nourished|A&Ox4|NAD"]
HEENT- [text size="60"] [checkbox value="Normocephalic|atraumatic|conjunctiva clear|sclerae aninteric|TMs with clearly visible landmarks|nares patent|mucous membranes moist|throat nonerythematous/noninjected|good dentition"]
Neck- [text size="60"] [checkbox value="soft/supple|no JVD|no thyromegaly|no tender/enlarged lymph nodes"]
CHEST- [text size="60"] [checkbox value="Normal rise and fall B/L|No accessory muscle use"]
HEART- [text size="60"] [checkbox value="RRR|normal S1/S2|No M/R/G|No S3/S4 auscultated|no friction rub"]
LUNGS- [text size="60"] [checkbox value="CTAB|BSE b/l|no wheezes|no crackles|no rhonchi"]
ABD- [text size="60"] [checkbox value="soft|nontender|nondistended|no voluntary/involuntary guarding|no peritoneal signs|bowel sounds present in all 4 quadrants"]
SKIN- [text size="60"] [checkbox value="warm|dry|intact|no edema|no erythema|no ecchymosis"]
EXT- [text size="60"] [checkbox value="no gross deformities noted|no cyanosis|no clubbing"]
NEURO- [text size="60"] [checkbox value="mentating well|moves all extremities equally well|CN 2-12 grossly intact b/l|normal sensorium all 4 extremities|no gross motor deficits|Romberg negative|cerebellar testing normal|DTRs 2/4 x4|gait testing without abnormalities"]

EKG- [select name="EKG" value="none|reviewed-"] [conditional field="EKG" condition="(EKG).is('reviewed-')"][checkbox value="normal sinus rhythm|tachycardia|bradycardia|normal axis|left axis deviation|right axis deviation|PR interval normal|QRS complex normal|No relevant ST segment deviation/elevation in contiguous leads|QT interval not prolonged"] [text size="80"][/conditional]

LABS- [select name="Labs" value="nothing to review|reviewed/unremarkable|reviewed/notable for- "][conditional field="Labs" condition="(Labs).is('reviewed/notable for- ')"][textarea][/conditional]

RADS- [select name="Rads" value="nothing to review|reviewed/unremarkable|reviewed/notable for- "][conditional field="Rads" condition="(Rads).is('reviewed/notable for- ')"][textarea][/conditional]

_____________________________________________________________________________
[comment memo="Inpatient H&P AP Portion"]
A/P: [text size="3"]yo [select name="AD1" value="active duty|retired|dependent"] [conditional field="AD1" condition="(AD1).isNot('dependent')"][text default="rank" size="6"] [/conditional][select value="M|F"] who we will admit for [text size="80"]

#[textarea default="dx - discussion/plan" cols="100" rows="6"]

[select name="Problem1" value="|#"][conditional field="Problem1" condition="(Problem1).is('#')"][textarea default="dx - discussion/plan" cols="100" rows="6"]

[/conditional][select name="Problem2" value="|#"][conditional field="Problem2" condition="(Problem2).is('#')"][textarea default="dx - discussion/plan" cols="100" rows="6"]

[/conditional][select name="Problem3" value="|#"][conditional field="Problem3" condition="(Problem3).is('#')"][textarea default="dx - discussion/plan" cols="100" rows="6"]

[/conditional][select name="Problem4" value="|#"][conditional field="Problem4" condition="(Problem4).is('#')"][textarea default="dx - discussion/plan" cols="100" rows="6"]

[/conditional][select name="Problem5" value="|#"][comment memo="Drop-downs for add'l problems"][conditional field="Problem5" condition="(Problem5).is('#')"][textarea default="dx - discussion/plan" cols="100" rows="6"]

[/conditional][select name="Problem6" value="|#"][comment memo="Drop-downs for add'l problems"][conditional field="Problem6" condition="(Problem6).is('#')"][textarea default="dx - discussion/plan" cols="100" rows="6"]

[/conditional]

Chronic Medical Conditions: [select name="Chronic" value="none|as follows"]
[conditional field="Chronic" condition="(Chronic).is('as follows')"][textarea default="#dx - stable. no issues. continue current home treatment/meds." cols="80" rows="10"]

[/conditional]
Prophylaxis
GI- [select value="not indicated|PPI"]
DVT- [select value="low padua score|SCDs|Lovenox|Heparin"]

Dispo: Anticipate hospital stay length of [text size="5"] days. Anticipate discharge home once [comment memo="List discharge criteria"][checkbox value="tolerating PO|dehydration resolved|stable O2 requirement|no O2 requirement|off of IV antibiotics|no longer requiring IV narcotics for pain control|pain adequately resolving"][text size="80"].

Code status: [select name="codestatus2" value="Full Code|DNR/DNI|other-"][conditional field="codestatus2" condition="(codestatus2).is('other-')"][text size="50"][/conditional]

[textarea default="signature block" cols="50" rows="3"]
[comment memo="For use on FMIT Service"]
For use on FMIT Service
Inpatient H&P SO Portion
cc:
HPI: yo presents to for

ED Course:

PMHx:

Home Meds:

All:

PSHx:

FMHx:

Soc:
-Tobacco-
-EtOH-
-Illicit drugs-
-Living situation-

ROS: Use freetext to explain {+}s if needed
Constitutional- fever, chills, , malaise, unexplained wt gain/loss
HEENT- vision/hearing/smell changes, nose/throat/neck symptoms
Resp- cough, SOB
CV- chest pain, palpitations
GI- abd pain/N/V/diarrhea/constipation
GU- urinary frequency/urgency/pain
MSK- new/unusual muscle aches/pains

Code status:

PE: Use freetext for pertinent PE abnormals
Vitals-
GEN-
HEENT-
Neck-
CHEST-
HEART-
LUNGS-
ABD-
SKIN-
EXT-
NEURO-

EKG-

LABS-

RADS-

_____________________________________________________________________________
Inpatient H&P AP Portion
A/P: yo who we will admit for

#

Drop-downs for add'l problemsDrop-downs for add'l problems

Chronic Medical Conditions:

Prophylaxis
GI-
DVT-

Dispo: Anticipate hospital stay length of days. Anticipate discharge home once List discharge criteria .

Code status:


For use on FMIT Service

Result - Copy and paste this output: