RMP New WC Injury 2

Last Name: [text name="last_name"]    First Name: [text name="first_name"]    
Age: [text name="age"]    Pronoun: [text name="he_she" default="he/she"]    
Job Title: [text name="job_title"]
Start Date: [text name="start_date" ]    Department/Location: [text name="job_location"]    Employer: [text name="employer_name"]

[comment memo="recommended follow-up for own medical conditions, not related to return to work" memo_size="small" memo_color="blue"]
[select name="other_conditions_identified" value="|Other conditions in need of follow-up care are identified."]
Things to review with your doctor: [textarea name="recommended_follow_up" default=""][/textarea]



====================================

_______________________________
SUBJECTIVE
_______________________________

[var name="first_name"] [var name="last_name"] is a [var name="age"] year old [var name="job_title"] working in/at [var name="job_location"], since hired by [var name="employer_name"] on [var name="start_date"]. [var name="first_name"] [select name="is_working" value="is currently working.|is currently not working."] [textarea name="currently_working_info"][/textarea] 

Description of Injury
[textarea name="description_of_injury" fillable="true"]
Occurred on ******
Reports that ******
Worked remainder of shift? ***yes/no***
ED Evaluation? ***yes/no***

Treatment thus far has included ****** 
[/textarea]

Description of Current Symptoms
[textarea fillable="true" name="description_of_current_symptoms"]
At this moment, employee reports ******

Overall, this is ***better or worse*** 

Denies weakness, paresthesias, dysesthesias, incontinence, falls 
[/textarea]

Relevant Past Medical History
[textarea name="past_medical_history"]
Prior history of back or orthopedic problems? 


[/textarea]


Other Medications and Medical Conditions
[textarea name="other_medical_conditions" fillable="true"]

 GI problems precluding the use of NSAIDs? ***yes/no***
 Diabetes/problems precluding the use of steroids?  ***yes/no***
 Blood thinners?  ***yes/no***
 Medications for chronic pain?  ***yes/no***
 
 Medications 
 ******
 
 Other Medical Conditions
 ******

[/textarea]



_______________________________
OBJECTIVE
_______________________________

VITALS [text]

GENERAL APPEARANCE
Employee is a [checkbox value="comfortable-appearing|uncomfortable-appearing"] [checkbox value="younger|middle-aged|older"] [checkbox value="man|woman"]    ****** [checkbox value="sitting up|slouched    in    the    chair|standing|pacing    the    room"] ***in no apparent distress***; changes position (sitting/standing/lying/mounting-dismounting exam table) ***without difficulty***.
[checkbox name="showneck" value="NECK EXAM"][conditional field="showneck" condition="(showneck).is('NECK EXAM')"]
Neck Inspection: [select name="neckScar" value="not examined|no scar|scar noted"] [conditional field="neckScar" condition="(neckScar).is('scar noted')"] [text] [/conditional]
Neck ROM: [select name="neckROM" value="FROM|decreased ROM"] [conditional field="neckROM" condition="(neckROM).isNot('FROM')"]
turning right: [select value="|slightly decreased|moderately decreased|markedly decreased"] [select value="|exacerbates pain|ameliorates pain"] 
turning left: [select value="|slightly decreased|moderately decreased|markedly decreased"] [select value="|exacerbates pain|ameliorates pain"] 
tilting right: [select value="|slightly decreased|moderately decreased|markedly decreased"] [select value="|exacerbates pain|ameliorates pain"] 
tilting left: [select value="|slightly decreased|moderately decreased|markedly decreased"] [select value="|exacerbates pain|ameliorates pain"] 
extension: [select value="|slightly decreased|moderately decreased|markedly decreased"] [select value="|exacerbates pain|ameliorates pain"] 
flexion: [select value="|slightly decreased|moderately decreased|markedly decreased"] [select value="|exacerbates pain|ameliorates pain"] [/conditional]
Neck Tenderness: [select name="neckTenderness" value="not tested|no tenderness|tenderness is noted"] [conditional field="neckTenderness" condition="(neckTenderness).is('tenderness is noted')"] [text] [/conditional]
Neck Spasm: [select name="neckSpasm" value="not tested|no spasm|spasm is noted"] [conditional field="neckSpasm" condition="(neckSpasm).is('spasm is noted')"] [select value="| on the right| on the left| bilaterally"] [/conditional]
[/conditional]

[checkbox name="showback" value="BACK EXAM"][conditional field="showback" condition="(showback).is('BACK EXAM')"]
Back Inspection: [select name="backScar" value="not examined|no scar|scar noted"] [conditional field="backScar" condition="(backScar).is('scar noted')"] [text] [/conditional]
Back ROM: [select name="backROM" value="FROM|decreased ROM"] [conditional field="backROM" condition="(backROM).isNot('FROM')"]
turning right: [select value="|slightly decreased|moderately decreased|markedly decreased"] [select value="|exacerbates pain|ameliorates pain"] 
turning left: [select value="|slightly decreased|moderately decreased|markedly decreased"] [select value="|exacerbates pain|ameliorates pain"] 
tilting right: [select value="|slightly decreased|moderately decreased|markedly decreased"] [select value="|exacerbates pain|ameliorates pain"] 
tilting left: [select value="|slightly decreased|moderately decreased|markedly decreased"] [select value="|exacerbates pain|ameliorates pain"] 
extension: [select value="|slightly decreased|moderately decreased|markedly decreased"] [select value="|exacerbates pain|ameliorates pain"] 
flexion: [select value="|slightly decreased|moderately decreased|markedly decreased"] [select value="|exacerbates pain|ameliorates pain"] [/conditional]
Back Tenderness: [select name="backTenderness" value="not tested|no tenderness|tenderness is noted"] [conditional field="backTenderness" condition="(backTenderness).is('tenderness is noted')"] [text] [/conditional]
Back Spasm: [select name="backSpasm" value="not tested|no spasm|spasm is noted"] [conditional field="backSpasm" condition="(backSpasm).is('spasm is noted')"] [select value="| on the right| on the left| bilaterally"] [text] [/conditional]
Straight Leg Raise: [select name="straightLegRaise" value="not tested|normal bilaterally|abnormal: "] [conditional field="straightLegRaise" condition="(straightLegRaise).is('abnormal: ')"] 
Right side is [select value="normal|negative but reproduces pain|not tolerated due to pain"] [text] 
Left side is [select value="normal|negative but reproduces pain|not tolerated due to pain"] [text] [/conditional]
[/conditional]

[checkbox name="showNeuro" value="NEURO EXAM"][conditional field="showNeuro" condition="(showNeuro).is('NEURO EXAM')"]
[checkbox name="showUpperExt" value="Upper Extremities"][conditional field="showUpperExt" condition="(showUpperExt).is('Upper Extremities')"]
Reflexes (biceps, brachioradialis) [select value="not tested|1+ and symmetrical bilaterally|2+ and symmetrical bilaterally|3+ and symmetrical bilaterally|asymmetric"] [text] 
Strength (all major muscle groups, hand grip, digital opposition)[select value="not tested|5/5 bilaterally|abnormal"] [text] [/conditional]

[checkbox name="showLowerExt" value="Lower Extremities"][conditional field="showLowerExt" condition="(showLowerExt).is('Lower Extremities')"]
Reflexes (KJ, AJ) [select value="not tested|1+ and symmetrical bilaterally|2+ and symmetrical bilaterally|3+ and symmetrical bilaterally|asymmetric"] [text] 
Strength (all major muscle groups)[select value="not tested|5/5 bilaterally|abnormal"] [text] [/conditional]

[checkbox name="showGait" value="Gait"][conditional field="showGait" condition="(showGait).is('Gait')"] [select name="gait" value="normal|abnormal"] [conditional field="gait" condition="(gait).is('abnormal')"][checkbox value="antalgic favoring right|antalgic favoring left|wide-based|shuffling"] [text]  [/conditional] [/conditional]
[/conditional]

[textarea fillable="true"]
ADDITIONAL COMMENTS
***distractable findings***
[/textarea]

_______________________________
ASSESSMENT
_______________________________
[textarea name="assessment"][/textarea]


_______________________________
PLAN
_______________________________

Return to Work: 
[textarea name="rtw"][/textarea]

Treatment: 
[checkbox name="treatment" value="ibuprofen 600 mg q6h prn with food|flexeril 10 mg qhs prn|medrol dosepack, use as directed"] 
[textarea name="treatment_text"][/textarea]

Referral: 
[checkbox name="referral" value="L-spine series|L-spine MRI (non-contrast)|Physical Therapy|Back Specialist"][textarea name="referral_text"]
[/textarea]

Follow-up: 
[textarea name="follow_up_text"]
[/textarea]
Last Name: First Name:
Age: Pronoun:
Job Title:
Start Date: Department/Location: Employer:

recommended follow-up for own medical conditions, not related to return to work

Things to review with your doctor:




====================================

_______________________________
SUBJECTIVE
_______________________________

first_name last_name is a age year old job_title working in/at job_location, since hired by employer_name on start_date. first_name


Description of Injury
Ctrl + (or )


Description of Current Symptoms
Ctrl + (or )


Relevant Past Medical History



Other Medications and Medical Conditions
Ctrl + (or )




_______________________________
OBJECTIVE
_______________________________

VITALS

GENERAL APPEARANCE
Employee is a ****** ***in no apparent distress***; changes position (sitting/standing/lying/mounting-dismounting exam table) ***without difficulty***.






Ctrl + (or )


_______________________________
ASSESSMENT
_______________________________



_______________________________
PLAN
_______________________________

Return to Work:


Treatment:



Referral:


Follow-up:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.63, 115 form elements, 95 boilerplate words, 21 text boxes, 12 text areas, 13 checkboxes, 44 drop downs, 8 variables, 1 comments, 16 conditionals, 105 total clicks
Questions/General site feedback · Help Ticket

Send Feedback for this SOAPnote

Your email address will not be published. Required fields are marked *

More SOAPnotes by this Author: