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posted 2021-11-22, updated 2021-11-25

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Patient’s rights, confidentiality, limits/exceptions to confidentiality, and use of electronic medical records were reviewed with the patient.  Verification of patient identity was established with the patient.

DATE:  [text name="variable_1"]
CASE ID #[text name="variable_85"]

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SUBJECTIVE
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CHIEF COMPLAINT:  [text name="variable_2"]

HISTORY OF PRESENT ILLNESS:
Patient is a [text name="variable_3"] [select name="variable_1" value="year old|week old"] [select name="variable_1" value="GENDER|male|female"] presenting to [text name="variable_4"] w/ a chief complaint of [text name="variable_5"]. [textarea name="HPI" default=""] Patient denies any associated [checkbox name="Negatives" value="chest pain|shortness of breath|wheezing|cough|hemoptysis|abdominal pain|nausea|vomiting|diarrhea|bloody stools|fever|chills|dysuria|hematuria|abnormal vaginal bleeding or discharge|penile discharge|low back or flank pain|focal neuro deficits|syncope or near syncope|vertigo|disequilibrium|headache|neck pain|neck stiffness|acute visual changes|sore throat|throat swelling|airway compromise issues|drooling or voice change|sinus pressure|ear pain|hearing loss|lip/tongue swelling|rash|foreign body sensation"]. [textarea name="variable_12"] Patient has no other complaints.


REVIEW OF SYSTEMS:
 General:
[checklist name="General" value="fever|fatigue|night sweats|change in appetite|change in weight"]
 Skin:
[checklist name="Skin" value="rash|itching|change in hair/nails"]
 Head:
[checklist name="Head" value="headache|head injury"]
 Eyes:
[checklist name="Eyes" value="change in vision|eye pain|double vision|flashing lights|corrective lenses"]
 Ears:
[checklist name="Ears" value="change in hearing|ear pain|discharge|ringing|dizziness"]
 Nose/Sinus:
[checklist name="NoseSinus" value="nose bleeds|congestion|frequent colds|sinus infections"]
 Allergies:
[checklist name="Allergies" value="hives|swelling of lips/tongue|hay fever|asthma|eczema|sensitivity to drugs, foods, pollens, or dander"]
 Mouth/Throat:
[checklist name="MouthThroat" value="bleeding gums|sore throat|sore tongue|pain in mouth|sores in mouth|hoarseness"]
 Neck:
[checklist name="Neck" value="lumps|swollen glands|goiter|stiffness"]
 Breast:
[checklist name="Breast" value="lumps|pain|nipple discharge"]
 Cardio:
[checklist name="Cardio" value="chest pain|palpitations|heart murmur|history of heart medications|rheumatic heart disease|high blood pressure|high cholesterol|change in color of fingers or toes|swelling in hands or feet"]
 Pulmonology:
[checklist name="Pulm" value="shortness of breath|cough|production of phlegm|coughing up blood|bronchitis|emphysema|COPD"]
 GI:
[checklist name="GI" value="problems swallowing|heartburn|nausea|vomiting|diarrhea|constipation|change in bowel habits|abdominal pain|excessive belching|excessing flatus|food intolerance|rectal bleeding|hemorrhoids|yellowing of skin"]
 Urinary:
[checklist name="Urinary" value="difficulty in urination|pain or burning with urination|frequent urination at night|urgent need to urinate|incontinence of urine|dribbling|decreased urine stream|blood in urine|UTI|stones|prostate issues"]
 Peripheral Vascular:
[checklist name="PeripheralVascular" value="leg cramps|varicose veins|clots in veins"]
 Musculoskeletal:
[checklist name="MSK" value="pain|swelling|stiffness|decreased range of motion|broken bone|serious sprains|arthritis|gout"]
 Neurologic
[checklist name="Neuro" value="headaches|migraines|seizures|loss of consciousness/fainting|paralysis|weakness|muscle spasm|tremor|involuntary movement|incoordination|numbness|feeling of pins and needles or tingles"]
 Hematologic:
[checklist name="Heme" value="anemia|easy bruising|easy bleeding|past transfusions"]
 Endocrine:
[checklist name="Endo" value="abnormal growth|increased thirst|increased urine production|thyroid issues|heat/cold intolerance|excessive sweating|diabetes"]
 Psychiatric:
[checklist name="Psych" value="anxiety|muscle tension|depression|thoughts of suicide|self harm|thoughts of hurting others|memory issues|sleep issues|change in mood|pleasure in doing things|ADD/ADHD|past treatment with psychiatrist|other psychiatric diagnosis"]

PMHx:
[textarea name="variable_13"]

Surg Hx:
[textarea name="variable_14"]

Family Hx:
[textarea name="variable_15"]

Medications:
[textarea name="variable_16"]

Allergies: [text name="variable_14"] 



---------
OBJECTIVE
---------
VITALS:
 - HR: [text name="variable_15"]
 - RR: [text name="variable_16"]
 - BP: [text name="variable_17"]
 - T: [text name="variable_18"]
 - HT: [text name="variable_19"]
 - WT: [text name="variable_20"] 


PE FINDINGS:
General: 
[textarea name="variable_21" default="Insert abnormalities or delete this text to remove."] [checkbox name="GeneralPE" value="A&Ox4. |Does not appear to be in any acute distress. |Well-groomed. |Appears stated age."]

Neuro: 
[textarea name="variable_22" default="Insert abnormalities or delete this text to remove."] [checkbox name="NeuroPE" value="Normal motor function w/ muscle strength 5/5 b/l on UE and LE. |Sensation is intact b/l. |Memory is grossly intact. |Cerebral function and thought process intact. |No gait abnormalities observed. |Neuro exam not performed."]

Integumentary: 
[textarea name="variable_23" default="Insert abnormalities or delete this text to remove."] [checkbox name="SkinPE" value="Skin is warm, dry, and intact.|No lesions.|No cyanosis or clubbing. |Integumentary exam not performed."]

HEENT: 
[textarea name="variable_24" default="Insert abnormalities or delete this text to remove."] [checkbox name="HEENTPE" value="Head is normocephalic and atraumatic. |Head is w/o tenderness, visible or palpable masses, and depressions. |Hair is of normal texture and distribution. |EOM intact. |PERRLA. |Hearing is grossly intact. |TM is normal in appearance w/ normal landmarks and cone of light. |Nasal mucosa is pink and moist. |Oral mucosa is pink and moist w/ good dentition. |Pharynx is normal in appearance w/o tonsillar swelling or exudates. |Neck is supple w/o any lymphadenopathy. |Trachea is midline. |Thyroid gland is normal w/o any palpable masses. |Carotid pulse 2+ b/l w/o bruit. |No JVD. |HEENT exam not performed."]

Cardiopulmonary: 
[textarea name="variable_25" default="Insert abnormalities or delete this text to remove."] [checkbox name="CardpulmPE" value="Heart rate and rhythm are normal. |Normal S1 and S2. |No murmurs, gallops, rubs, or extra heart sounds appreciated upon auscultation. |Chest wall is symmetric and w/o deformity or signs of trauma. |No signs of respiratory distress. |Lungs CTA b/l w/o rales, ronchi, or wheezes. |Cardio exam not performed. |Pulmonary exam not performed."]

GI: 
[textarea name="variable_26" default="Insert abnormalities or delete this text to remove."] [checkbox name="GIPE" value="Abdomen is soft, symmetric, and non-tender w/o distention. |No visible lesions or scars. |Aorta is midline w/o bruit or visible pulsation. |Umbilicus is midline w/o herniation. |Normal BS in all four quadrants. |No masses, hepatomegaly, or splenomegaly are noted. |Abdominal exam not performed."]

GU: 
[textarea name="variable_27" default="Insert abnormalities or delete this text to remove."] [checkbox name="GUPE" value=" Normal rectal sphincter tone. |No external masses or lesions. |Stool is normal in appearance. |Guac negative. |External genitalia is normal in appearance w/o lesions, swelling, masses or tenderness. |Vagina is pink and moist w/o lesions or abnormal discharge. |Uterus is anteflexed, non-tender, and normal in size. |Ovaries are non-tender w/o palpable masses or enlargement. |Circumcised male. |Uncircumcised male. |Prepuce easily retracts. |No penile discharge or lesions. |No scrotal swelling or discoloration. |Testes descended b/l, smooth, no masses. |Epididymis nontender. |No inguinal or femoral hernias. |No GU exam performed. |No rectal exam performed."]

Peripheral Vascular/MSK: 
[textarea name="variable_28" default="Insert abnormalities or delete this text to remove."] [checkbox name="PeriVascPE" value="UE and LE are atraumatic in appearance w/o tenderness or deformity. |No swelling or erythema. |Full ROM is noted in all joints. |Muscle strength is 5/5 b/l. |Tendon function is normal. |Cap refill is less than 3secs in all extremities. |Pulses palpable. |No peripheral vascular exam was performed. |No MSK exam was performed."]

Psych: 
[textarea name="variable_29" default="Insert abnormalities or delete this text to remove."] [checkbox name="MSE" value="Appropriate mood and affect. |Adequate judgement and insight. |No visual or auditory hallucinations. |No SI or HI. |No parasuicidal thoughts or behavior. |MSE not performed."]    


Labs:
[textarea name="variable_14"]

Imaging:
[textarea name="variable_14"]

Other:
[textarea name="variable_14"]



----------
ASSESSMENT
----------
[textarea name="variable_13"]

ICD-10 Diagnoses:
[textarea name="variable_14"]



----
PLAN
----
Treatment: 
[textarea name="variable_14"]

Patient Education: 
[textarea name="variable_15"]

Follow-Up: 
[textarea name="variable_16"]



/e/Signed By: [text name="variable_30"] on [text name="variable_31"]

Note - this form uses SOAPnote Shorthand. For a table of all phrases click View > Data Dictionary

Patient’s rights, confidentiality, limits/exceptions to confidentiality, and use of electronic medical records were reviewed with the patient. Verification of patient identity was established with the patient.

DATE:
CASE ID #

----------
SUBJECTIVE
----------
CHIEF COMPLAINT:

HISTORY OF PRESENT ILLNESS:
Patient is a presenting to w/ a chief complaint of .

Patient denies any associated chest pain shortness of breath wheezing cough hemoptysis abdominal pain nausea vomiting diarrhea bloody stools fever chills dysuria hematuria abnormal vaginal bleeding or discharge penile discharge low back or flank pain focal neuro deficits syncope or near syncope vertigo disequilibrium headache neck pain neck stiffness acute visual changes sore throat throat swelling airway compromise issues drooling or voice change sinus pressure ear pain hearing loss lip/tongue swelling rash foreign body sensation.

Patient has no other complaints.

REVIEW OF SYSTEMS:
General:
fever fatigue night sweats change in appetite change in weight
Skin:
rash itching change in hair/nails
Head:
headache head injury
Eyes:
change in vision eye pain double vision flashing lights corrective lenses
Ears:
change in hearing ear pain discharge ringing dizziness
Nose/Sinus:
nose bleeds congestion frequent colds sinus infections
Allergies:
hives swelling of lips/tongue hay fever asthma eczema sensitivity to drugs, foods, pollens, or dander
Mouth/Throat:
bleeding gums sore throat sore tongue pain in mouth sores in mouth hoarseness
Neck:
lumps swollen glands goiter stiffness
Breast:
lumps pain nipple discharge
Cardio:
chest pain palpitations heart murmur history of heart medications rheumatic heart disease high blood pressure high cholesterol change in color of fingers or toes swelling in hands or feet
Pulmonology:
shortness of breath cough production of phlegm coughing up blood bronchitis emphysema COPD
GI:
problems swallowing heartburn nausea vomiting diarrhea constipation change in bowel habits abdominal pain excessive belching excessing flatus food intolerance rectal bleeding hemorrhoids yellowing of skin
Urinary:
difficulty in urination pain or burning with urination frequent urination at night urgent need to urinate incontinence of urine dribbling decreased urine stream blood in urine UTI stones prostate issues
Peripheral Vascular:
leg cramps varicose veins clots in veins
Musculoskeletal:
pain swelling stiffness decreased range of motion broken bone serious sprains arthritis gout
Neurologic
headaches migraines seizures loss of consciousness/fainting paralysis weakness muscle spasm tremor involuntary movement incoordination numbness feeling of pins and needles or tingles
Hematologic:
anemia easy bruising easy bleeding past transfusions
Endocrine:
abnormal growth increased thirst increased urine production thyroid issues heat/cold intolerance excessive sweating diabetes
Psychiatric:
anxiety muscle tension depression thoughts of suicide self harm thoughts of hurting others memory issues sleep issues change in mood pleasure in doing things ADD/ADHD past treatment with psychiatrist other psychiatric diagnosis

PMHx:

Surg Hx:

Family Hx:

Medications:

Allergies:

---------
OBJECTIVE
---------
VITALS:
- HR:
- RR:
- BP:
- T:
- HT:
- WT:

PE FINDINGS:
General:

A&Ox4. Does not appear to be in any acute distress. Well-groomed. Appears stated age.

Neuro:

Normal motor function w/ muscle strength 5/5 b/l on UE and LE. Sensation is intact b/l. Memory is grossly intact. Cerebral function and thought process intact. No gait abnormalities observed. Neuro exam not performed.

Integumentary:

Skin is warm, dry, and intact. No lesions. No cyanosis or clubbing. Integumentary exam not performed.

HEENT:

Head is normocephalic and atraumatic. Head is w/o tenderness, visible or palpable masses, and depressions. Hair is of normal texture and distribution. EOM intact. PERRLA. Hearing is grossly intact. TM is normal in appearance w/ normal landmarks and cone of light. Nasal mucosa is pink and moist. Oral mucosa is pink and moist w/ good dentition. Pharynx is normal in appearance w/o tonsillar swelling or exudates. Neck is supple w/o any lymphadenopathy. Trachea is midline. Thyroid gland is normal w/o any palpable masses. Carotid pulse 2+ b/l w/o bruit. No JVD. HEENT exam not performed.

Cardiopulmonary:

Heart rate and rhythm are normal. Normal S1 and S2. No murmurs, gallops, rubs, or extra heart sounds appreciated upon auscultation. Chest wall is symmetric and w/o deformity or signs of trauma. No signs of respiratory distress. Lungs CTA b/l w/o rales, ronchi, or wheezes. Cardio exam not performed. Pulmonary exam not performed.

GI:

Abdomen is soft, symmetric, and non-tender w/o distention. No visible lesions or scars. Aorta is midline w/o bruit or visible pulsation. Umbilicus is midline w/o herniation. Normal BS in all four quadrants. No masses, hepatomegaly, or splenomegaly are noted. Abdominal exam not performed.

GU:

Normal rectal sphincter tone. No external masses or lesions. Stool is normal in appearance. Guac negative. External genitalia is normal in appearance w/o lesions, swelling, masses or tenderness. Vagina is pink and moist w/o lesions or abnormal discharge. Uterus is anteflexed, non-tender, and normal in size. Ovaries are non-tender w/o palpable masses or enlargement. Circumcised male. Uncircumcised male. Prepuce easily retracts. No penile discharge or lesions. No scrotal swelling or discoloration. Testes descended b/l, smooth, no masses. Epididymis nontender. No inguinal or femoral hernias. No GU exam performed. No rectal exam performed.

Peripheral Vascular/MSK:

UE and LE are atraumatic in appearance w/o tenderness or deformity. No swelling or erythema. Full ROM is noted in all joints. Muscle strength is 5/5 b/l. Tendon function is normal. Cap refill is less than 3secs in all extremities. Pulses palpable. No peripheral vascular exam was performed. No MSK exam was performed.

Psych:

Appropriate mood and affect. Adequate judgement and insight. No visual or auditory hallucinations. No SI or HI. No parasuicidal thoughts or behavior. MSE not performed.

Labs:

Imaging:

Other:

----------
ASSESSMENT
----------

ICD-10 Diagnoses:

----
PLAN
----
Treatment:

Patient Education:

Follow-Up:

/e/Signed By: on

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