Outpatient New Patient Visit

History & Physical
Date:[date name="date" default=""]
Demographics (or one-liner):
[textarea="demographics" default=""]
[comment memo="Name, age, race, gender, employment, residence (these are Drexel specific requirements)"]
Source:
[text name="Source" default=""]
[comment memo="Source of Hx and reliability"]
[checkbox name="Reviewed_old_records" value="Reviewed old records."]
Chief Complaint:[textarea name="CC" default=""]
[comment memo="symptom and duration - in patient's own words"]
HPI:[textarea name="hpi" default=" "]
[comment memo="Start with open-ended questions and then tighten up the story as you go along.  A usual sentence to start can be: Patient was in their usual state of health until x days prior to admission...presented with..."]
[comment memo="Include the following information, written in prose, not a list or sentence fragments, not under separate headings.
Chronological story of chief complaint, including:
- details of symptoms - use OLDCART or PQRST
- Pertinent (+) from PMH, lack of risk factors, FH, SH, ROS
- Ask appropriate ROS questions for the organ systems involved in the chief complaint at the end of HPI
- Pertinent (-) from PMH, lack of risk factors, FH, SH, ROS ie. lack of smoking in pt. with hemoptysis"]
ALLERGIES:[checkbox name="NKDA" value="NKDA"]
[text area="allergy" default=""]
Home Medications:
[textarea name="meds" default=""]

PMH:
[textarea name="PMH" default=""]
PSH:
[textarea name="PSH" default=""]

IMMUNIZATIONS:
[checkbox name="Up_to_date" value="Up to Date."]
[text name="immunizations" default=""]
FHx: [textarea name="fhx" default=""]
SocialHx: [textarea name="shx" default=" "]
[comment memo="employment, living situation,educational background, religion, habits, Don't forget recent travel if pertinent to the CC"]
Drugs:
[text name="drugs" default=""]
Alcohol:
[text name="alcohol" default=""]
Tobacco:
[text name="tobacco" default=""]

ROS:

-Constitutional: Negative for [checkbox name="ros_constitutional_check" value="fever|chills|night sweats|fatigue|changes in weight"][text name="ros_constitutional" default=" "]
-Skin: Negative for [checkbox name="ros_skin_check" value=rash|bruising|lesions|ecchymosis|pruritis|rash|dryness|urticaria|pressure ulcer|abscess|sunburn|changes in mole|new lesion"][text name="ros_skin" default=" "]
-HEENT:
Negative for [checkbox name="Head" value="headaches|trauma|visual disturbances|sore throat|trouble swallowing|voice changes|hoarseness"]
[text name="blank" default=""]
[textarea name="head_ros" default=""]
Nose:
Negative for [checkbox name="nose" value="epistaxis|obstruction|anosmia|rhinorrhea|rhinitis|sinusitis|pain"]
[textarea name="nose_ros" default=""]
Mouth & Throat:
Negative for[checkbox name="mouth" value="gingival bleeding|ulcers|pain|lumps|pharyngitis|voice changes|difficulty swallowing|changes in oral mucosa or tongue"]
[textarea name="mouth_ros" default=""]
Neck:
[checkbox name="neck" value="stiffness|pain|tumors|lymphadenitis|thyroid disorder|injury"]
[textarea name="neck_ros" default=""]
-Respiratory: Negative for [checkbox name="ros_resp_check" value="cough|sputum|dyspnea|pleurisy|dyspnea|cyanosis|TB or exposure|pneumonia|bronchitis|asthma|COPD"]
[text name="ros_resp" default=" "]
-Cardiovascular: Negative for [checkbox name="ros_cardio_check" value="chest pain|angina|palpitations|irregular rhythm|tachycardia|bradycardia|hypertension|hypotension|murmur|heart failure|DOE|orthopnea|PND|rheumatic fever|peripheral edema"][text name="ros_cardio" default=" "]
- PV: Negative for
[checkbox name="PV" value="intermittent claudication|varicosities|phlebitis|Raynaud's phenomenon"]
-GI: Negative for[checkbox name="ros_gi_check" value="change in appetite|thirst|nausea/vomiting|dysphagia|eructations|flatulence|pyrosis(heartburn)|GERD|hematemesis|cramping|abdominal pain|hernia present|melena|hematochezia|acholic|hemorrhoids|jaundice"][text name="ros_gi" default=" "]

-Musculoskeletal: Negative for[checkbox name="ros_msk_check" value="pain in muscles|bone pain|joint pain|decreased ROM|joint stiffness|joint edema|gout|deformities|arthritis|fractures|dislocations|myositis|muscular weakness|atrophy"][text name="ros_msk" default=" "]
-Neuro: Negative for[checkbox name="ros_neuro_check" value="paresis|paralysis|paresthesia|hyperesthesia|hypesthesia|seizures|dizziness|syncope|coma| disturbance of taste|visual disturbances|aphasia|memory loss| problems with cognition|ataxia|incoordination|tremor|tics"][text name="ros_neuro" default=" "]
-Psych:Negative for [checkbox name="ros_psych_check" value="childhood behavioral problems|anxiety|irritability|mood disorders|suicidality|personality disorders|sleep changes| insomnia| alcoholism|drug abuse history"][text name="ros_psych" default=" "]
-Hematologic: [checkbox name="ros_heme_check" value="anemia|bruising|bleeding tendencies| transfustions|hemoglobinopathies|hymphangitis|lymphadenopathy"][text name="ros_heme" default=" "]
-Endocrine:Negative for [checkbox name="ros_endo_check" value="heat/cold intolerance|weight changes|anorexia|polyphagia|polydipsia|polyuria|glycosuria|diaphoresis"][text name="ros_endo" default=" "]

PHYSICAL EXAM:
VITAL SIGNS:
[textarea name="VS" default=""]
[select name="variable_1" memo="<--- Select Exam" value="General Adult Exam|General Male Exam|General Female Exam"]
[textarea name="variable_2" cols=80 rows=2 default="GENERAL APPEARANCE: Well developed, well nourished, alert and cooperative, and appears to be in no acute distress."]
[textarea name="variable_3" cols=80 rows=1 default="HEAD: normocephalic."]
[textarea name="variable_4" cols=80 rows=1 default="EYES: PERRL, EOMI. Fundi normal, vision is grossly intact."]
[textarea name="variable_5" cols=80 rows=1 default="EARS: External auditory canals and tympanic membranes clear, hearing grossly intact."]
[textarea name="variable_6" cols=80 rows=1 default="NOSE: No nasal discharge."]
[textarea name="variable_7" cols=80 rows=2 default="THROAT: Oral cavity and pharynx normal. No inflammation, swelling, exudate, or lesions. Teeth and gingiva in good general condition."]
[textarea name="variable_8" cols=80 rows=1 default="NECK: Neck supple, non-tender without lymphadenopathy, masses or thyromegaly."]
[textarea name="variable_9" cols=80 rows=3 default="CARDIAC: 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."]
[textarea name="variable_10" cols=80 rows=2 default="LUNGS: Clear to auscultation and percussion without rales, rhonchi, wheezing or diminished breath sounds."]
[textarea name="variable_11" cols=80 rows=2 default="ABDOMEN: Positive bowel sounds. Soft, nondistended, nontender. No guarding or rebound. No masses."]
[textarea name="variable_12" cols=80 rows=2 default="MUSKULOSKELETAL: Adequately aligned spine. ROM intact spine and extremities. No joint erythema or tenderness. Normal muscular development. Normal gait."]
[textarea name="variable_13" cols=80 rows=2 default="BACK: Examination of the spine reveals normal gait and posture, no spinal deformity, symmetry of spinal muscles, without tenderness, decreased range of motion or muscular spasm."]
[textarea name="variable_14" cols=80 rows=2 default="EXTREMITIES: No significant deformity or joint abnormality. No edema. Peripheral pulses intact. No varicosities."]
[textarea name="variable_15" cols=80 rows=5 default="LOWER EXTREMITY: Examination of both feet reveals all toes to be normal in size and symmetry, normal range of motion, normal sensation with distal capillary filling of less than 2 seconds without tenderness, swelling, discoloration, nodules, weakness or deformity; examination of both ankles, knees, legs, and hips reveals normal range of motion, normal sensation without tenderness, swelling, discoloration, crepitus, weakness or deformity."]
[textarea name="variable_16" cols=80 rows=2 default="NEUROLOGICAL: CN II-XII intact. Strength and sensation symmetric and intact throughout. Reflexes 2+ throughout. Cerebellar testing normal."]
[textarea name="variable_17" cols=80 rows=1 default="SKIN: Skin normal color, texture and turgor with no lesions or eruptions."]
[textarea name="variable_18" cols=80 rows=3 default="PSYCHIATRIC: The mental examination revealed the patient was 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."][conditional field="variable_1" condition="(variable_1).is('General Male Exam')"][textarea name="variable_19" cols=80 rows=2 default="RECTAL: Good sphincter tone with no anal, perineal or rectal lesions. Prostate is not tender, enlarged, boggy, or nodular."][/conditional]
[conditional field="variable_1" condition="(variable_1).is('General Male Exam')"][textarea name="variable_20" cols=80 rows=3 default="GENITALIA: 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."][/conditional][conditional field="variable_1" condition="(variable_1).is('General Female Exam')"][textarea name="variable_21" cols=80 rows=1 default="BREASTS: No masses, tenderness, asymmetry, nipple discharge or axillary lymphadenopathy."][/conditional]
[conditional field="variable_1" condition="(variable_1).is('General Female Exam')"][textarea name="variable_22" cols=80 rows=3 default="PELVIC: 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."][/conditional]

LAB & IMAGING RESULTS
[textarea name="var22" default=""]

ASSESSMENT/PLAN:
[textarea name="anp" default=""]
[comment memo="List ALL suspected/current diagnoses in medical language, explaining all items in problem list. For EACH impression, indicate what was done, what orders are pending, what will be done in the future and follow-up. Don't forget pt education and F/U "]
History & Physical
Date:
Demographics (or one-liner):

Name, age, race, gender, employment, residence (these are Drexel specific requirements)
Source:

Source of Hx and reliability

Chief Complaint:
symptom and duration - in patient's own words
HPI:
Start with open-ended questions and then tighten up the story as you go along. A usual sentence to start can be: Patient was in their usual state of health until x days prior to admission...presented with...
Include the following information, written in prose, not a list or sentence fragments, not under separate headings.
Chronological story of chief complaint, including:
- details of symptoms - use OLDCART or PQRST
- Pertinent (+) from PMH, lack of risk factors, FH, SH, ROS
- Ask appropriate ROS questions for the organ systems involved in the chief complaint at the end of HPI
- Pertinent (-) from PMH, lack of risk factors, FH, SH, ROS ie. lack of smoking in pt. with hemoptysis

ALLERGIES:

Home Medications:


PMH:

PSH:


IMMUNIZATIONS:


FHx:
SocialHx:
employment, living situation,educational background, religion, habits, Don't forget recent travel if pertinent to the CC
Drugs:

Alcohol:

Tobacco:


ROS:

-Constitutional: Negative for
-Skin: Negative for
-HEENT:
Negative for


Nose:
Negative for

Mouth & Throat:
Negative for

Neck:


-Respiratory: Negative for

-Cardiovascular: Negative for
- PV: Negative for

-GI: Negative for

-Musculoskeletal: Negative for
-Neuro: Negative for
-Psych:Negative for
-Hematologic:
-Endocrine:Negative for

PHYSICAL EXAM:
VITAL SIGNS:

<--- Select Exam




















LAB & IMAGING RESULTS


ASSESSMENT/PLAN:

List ALL suspected/current diagnoses in medical language, explaining all items in problem list. For EACH impression, indicate what was done, what orders are pending, what will be done in the future and follow-up. Don't forget pt education and F/U

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.27, 84 form elements, 77 boilerplate words, 17 text boxes, 36 text areas, 1 dates, 18 checkboxes, 1 drop downs, 7 comments, 4 conditionals, 204 total clicks
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