Advanced Illness Management Consultation
Date of consult -[date name="date1" default="today"] Location - [select name="loc" value="Riverside|Enclave"] Patient Referred by -[text name="variable_1" default="Dr."] History of Presenting Illness [comment memo="write HPI below"] [textarea name="variable5" default=""] Allergies -[textarea name="allergies_1" default="No Known Allergies"] Past Surgical History -[select name="Surgical_1" value="Non Contributory|"][conditional field="Surgical_1" condition="(Surgical_1).is('')"][checkbox name="Surgical_2" value="R Hip replacement|L Hip replacement|R knee replacement|L knee replacement"], [textarea name="Surgery_text" default=""][/conditional] Family History -[textarea name="family_text" default="Non contributory"] Social History - [select name="social1" value="This patient denies smoking cigarettes, denies drinking alcohol, denies recreational drug use.|"] [conditional field="social1" condition="(social1).is('')"][textarea name="socialtxt1" default="This patient reports use of"][/conditional] Medication - [select name="Med1" value="I have reviewed the patients medications|"][conditional field="Med1" condition="(Med1).is('')"][textarea name="Medtxt1" default=""][/conditional] Review of Systems [select name="ROS_1" value="This patient is able to provide appropriate answers|This patient is nonverbal/otherwise unable to assess"][conditional field="ROS_1" condition="(ROS_1).is('This patient is able to provide appropriate answers')"] [comment memo="Default will be negative. Click if positive"] General [checklist name="ROS1" value="Sleep Disturbances|Fatigue|Skin Changes|Recent Falls"] Neurological [checklist name="ROS2" value="Syncope|Headache|Coordination Changes|Weakness| Numbness"] HEENT [checklist name="ROS3" value="Vision Changes|Eye Pain|Nasal Congestion|Nasal Discharge|Hearing Changes|Pain in Ear|Dysphagia|Odynophagia"] Cardiovascular [checklist name="ROS4" value="Chest Pain|Palpitations"] Respiratory [checklist name="ROS5" value="Dyspnea|Cough|Shortness of Breath"] Gastrointestinal [checklist name="ROS6" value="Nausea|Vomitting|Diarrhea|Constipation|Abdominal Pain"] Genitourinary [checklist name="ROS7" value="Urinary incontinence|Dysuria"] Musculoskeletal [checklist name="ROS8" value="Muscle Weakness|Joint pain|Joint stiffness"] [/conditional] Physical Exam [comment memo="Please write in Vitals"] Vital Signs - [textarea name="VS1" default="BP- mmgHg T- °F P- beats/min R- breaths/min"] General - [textarea name="Pe1" default="No acute distress, Well developed, well nourished, Afebrile"] Neurological - [textarea name="Pe2" default="Alert and Oriented, Normal mood and affect, Cranial Nerves II-XII grossly intact"] HEENT - [textarea name="Pe3" default="Head is normocephalic, atraumatic. Bilateral pupils equal and reactive to light and accommodating. No scleral icterus, no conjunctival pallor. No neck masses palpated."] Pulmonary - [textarea name="Pe4" default="Respiratory effort within normal limits. No crackles. No rhales or rhonchi."] Cardiovascular - [textarea name="Pe5" default="Distal pulses 2+ in all extremeties. Adequate perfusion. No peripheral signs of cyanosis. Regular rate and rhythm. No murmurs auscultated."] Gastrointestinal - [textarea name="Pe6" default="Abdomen soft, nontender, nondistended. No guarding or tenderness. Bowel sounds auscultated."] Musculoskeletal - [textarea name="Mskphys" default="No difficulty with passive ROS Strength 5/5 bilateral upper extremeties. "] Assessment [textarea name="Ass1" default=""] Plan [textarea name="Plan1" default=""]
Result - Copy and paste this output:
Sandbox Metrics: Structured Data Index 0.47, 39 form elements, 52 boilerplate words, 1 text boxes, 16 text areas, 1 dates, 1 checkboxes, 8 check lists, 5 drop downs, 3 comments, 4 conditionals, 59 total clicks
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