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[checkbox name="historian" value="telemedicine visit, verification of patient identity and location in CA was performed by clinic’s staff|history provided by patient|history provided by family member||SO/family member present during visit|chaperon/MA present during visit|interpretation provided by family member/SO|interpretation provided by MA||complete history unobtainable d/t poor effort/affect|complete history unobtainable d/t cognitive changes|complete history unobtainable d/t distress|"][textarea cols=70 rows=1]
CC:
[checkbox name="cc" value="headache|fever|malaise|fatigue|body aches|night sweats|red eyes|nasal discharge|nasal congestion|sinus pain|loss of smell|loss of taste|earache/ear pressure|sore throat|pus on tonsils|voice loss|difficulty swallowing|cough|chest tightness/pain w/ breathing|SOB|GI Sx|"][textarea cols=70 rows=1]
HPI:
[checkbox name="hpi" value="sudden onset|gradual onset||started today|started yesterday|started several days ago|started more than 1 week ago||sx increasing in severity|sx persisting|sx decreasing in severity|"][textarea cols=70 rows=1]
RECENT & PAST HISTORY: [+] reported [-] not reported
[checklist name="recent" value="ER/UC visit|hospitalization/surgery/procedure|travel|sick contact|new/changed medications|antibiotic use|asthma/COPD|smoker|immunosuppression"]
MEDICATIONS:
allergies reviewed
[checkbox name="medications" value="taking OTC, not helping|taking ABX, not helping|not taking any medications|taking meds for chronic condition|"][textarea cols=70 rows=1]

REVIEW OF SYSTEMS: [+] reported [-] not reported
negative except as stated
EYES: [textarea cols=40 rows=1]
[checklist name="eye_symptoms" value="decrease in vision|discharge|lid swelling|pain with EOM"]
MOUTH: [textarea cols=40 rows=1]
[checklist name="mouth_symptoms" value="sores|dryness|tongue pain/swelling|toothache"]
NECK: [textarea cols=40 rows=1]
[checklist name="neck_symptoms" value="pain|stiffness|swelling|swollen glands"]
CV: [textarea cols=40 rows=1]
[checklist name="cv_symptoms" value="chest pain/pressure|SOB|palpitations|dyspnea|orthopnea|ankle swelling|ankle discoloration|varicose veins|leg cramps"]
GI: [textarea cols=40 rows=1]
[checklist name="gi_symptoms" value="poor appetite|nausea|vomiting|bloating|abdominal pain|constipation|diarrhea"]
GU: [textarea cols=40 rows=1]
[checklist name="gu_symptoms" value="dysuria|burning|frequency|urgency|odor|hematuria|hesitancy|retention|nocturia|oliguria|incontinence|itching|discharge|genital lesions"]
MSK: [textarea cols=40 rows=1]
[checklist name="msk_symptoms" value="neck pain|back pain|chronic pain/meds|localized joint pain/deformity|localized muscle/soft tissue pain/swelling|myalgias"]
NEURO: [textarea cols=40 rows=1]
[checklist name="neuro_symptoms" value="dizziness|vertigo|poor balance|abnormality of walk|focal weakness|blackouts|seizures|tingling/numbness"]
PSYCH: [textarea cols=40 rows=1]
[checklist name="psych_symptoms" value="irritability|confusion|depression|anxiety|mood swings|memory loss|insomnia"]
LYMPH/HEMA/IMMUNE: [textarea cols=40 rows=1]
[checklist name="hem_symptoms" value="gland swelling|bruising|anticoagulation|DVT/clotting|anemia|autoimmune dz|h/o cancer"]
DERM: [textarea cols=40 rows=1]
[checklist name="derm_symptoms" value="pruritus|rash|hives|redness|swelling|wounds|new or suspicious lesions"]



Appearance:
[checkbox name="appearance" value="well-appearing|alert|non-toxic|normal WOB|no acute distress|||malaised|short of breath|diaphoretic|coughing during exam|sniffling during exam||drowsy|appears impaired|slumped||unable to assess|"][textarea cols=70 rows=1]

Skin:
[checkbox name="skin" value="no visible rashes||unable to assess, reports no new rashes|"][textarea cols=70 rows=1]

Head/Face:
[checkbox name="head" value="normocephalic|symmetrical face|CN grossly intact||unable to assess, reports no trouble smiling or chewing|"][textarea cols=70 rows=1]

Eyes:
[checkbox name="eyes" value="clear conjunctiva w/o exudates, anicteric sclera, EOM intact without nystagmus ||conjunctival injection|epiphora|conjunctival exudate||palpebral edema|palpebral exudates||glasses|contacts||unable to assess, reports no changes in vision or photophobia|"][textarea cols=70 rows=1]

Ears:
[checkbox name="ears" value="symmetrical & intact auricles bilaterally|hearing grossly intact|no tragal tenderness|no mastoid tenderness||tragal tenderness||HOH|hearing aid(s)||unable to assess, reports no changes in hearing|"][textarea cols=70 rows=1]

Nose:
[checkbox name="nose" value="maxillary tenderness|frontal tenderness|perinasal irritation||unable to assess|reports being able to use both nostrils|reports no tenderness with applying pressure to sinus areas|"][textarea cols=70 rows=1]

Mouth:
[checkbox name="mouth" value="tongue normal in appearance with good symmetrical movements|moist oral mucosa without lesions||unable to assess|reports dry mouth|"][textarea cols=70 rows=1]

Throat:
[checkbox name="throat" value="speaks in clear and unmuffled voice|audible congestion in voice|audible hoarseness present|nasal sounding voice|no stridor||reports pharynx w/o swelling or exudates|reports pharyngeal erythema|reports pharyngeal exudates|"][textarea cols=70 rows=1]

Neck:
[checkbox name="neck" value="no visible thyromegaly or other masses|able to move neck in all directions without pain||unable to assess|reports no enlarged/tender cervical lymph nodes on self-palpation|"][textarea cols=70 rows=1]

Chest/Lungs:
[checkbox name="lungs" value="normal respiratory effort|no tachypnea apparent|speaking in full sentences|no audible wheezing||symmetrical chest expansion||unable to assess|reports respiratory distress|reports chest pain with breathing|audible coughing|"][textarea cols=70 rows=1]

CV:
[checkbox name="cv" value="unable to assess|reports pulse to be regular and of normal rate|reports no LE edema|reports no calf tenderness||reports tachycardia|reports irregular heart rhythm|"][textarea cols=70 rows=1]

Abdomen:
[checkbox name="abd" value="unable to assess|no focal abdominal tenderness elicited upon self-palpation||reports diffuse tenderness over entire abdomen w/o RRG|reports direct non-rebound focal tenderness|"][textarea cols=70 rows=1]

GU:
[checkbox name="gu" value="unable to assess|reports no suprapubic tenderness on self-exam|reports no CVAT on self-exam|"][textarea cols=70 rows=1]

MSK:
[checkbox name="spine" value="moves all extremities with good ROM for age|no visible gross deformity||unable to assess|reports full weight-bearing|reports no bony tenderness in affected area|"][textarea cols=70 rows=1]

Neuro:
[checkbox name="neuro" value="no tremor visible|normal concentration and attention|memory grossly intact||reports no changes in balance or coordination|no involuntary movements||tremor|tardive dyskinesia|tics|"][textarea cols=70 rows=1]

Behavior:
[checkbox name="behavior" value="calm, pleasant, respectful|cooperative||poor cooperation|guarded|anxious|irritable|frustrated|labile|sighing|crying|agitated|raising voice|argumentative|hostile|forceful|demanding particular medication, test, referral, or accommodation||bradykinetic|fidgeting|picking skin|twirling hair|cracking knuckles|threatening posture/movement|grimacing, furrowing eyebrows|tightening jaw|breathing hard|intense staring|standing up|"][textarea cols=70 rows=1]

Speech/Vocalization:
[checkbox name="speech" value="normal for age|clear & coherent||slurred|monotonous|stuttering||hypoverbal|hyperverbal||loud|soft||slow|rapid|pressured||perseveration|flight of ideas|repetitive questions|cursing, swearing|criticisms of staff|verbal threats|"][textarea cols=70 rows=1]

A/P:
[textarea cols=70 rows=5]

BARRIERS TO CARE:
[checkbox name="barriers" value="none identified||poor cooperation with exam|lack of motivation|negative attitude to diagnostic impression & proposed tx|incomplete history|vague shifting complaints|multiple comorbidities|polypharmacy|lack of interest in nonpharmacologic therapies|overwhelming focus on Rx drugs|altered mental status|hostile/disruptive behavior|active psychiatric diagnosis|social/cultural barriers||preoccupation with illness|catastrophization|overgeneralization|unrealistic beliefs|negativism|pessimism|blaming others|staff splitting|"][textarea cols=70 rows=1]

PLAN OF CARE:
[checkbox name="discussed" value="discussed telemedicine limitations, exam findings, recommendations, risks/benefits, alternative management options, reporting medication side effects to clinic immediately, appropriate follow up with PCP, home care & follow up instructions specific to condition, indications for immediate direct evaluation, indications/red flags for contacting emergency services|verbalized understanding of & agreement with POC||patient/family did not agree with my POA – will seek second opinion/further care elsewhere|"][textarea cols=70 rows=1]

DISPOSITION:
[checkbox name="disposition" value="contact clinic or see PCP as discussed, sooner if condition worsens/persists or new symptoms arise, contact 911/ER if significant increase in s/sx or appearance of new/danger s/sx||contact clinic 24 hours|contact clinic 48 to 72 hours|contact clinic 1 week||referred to ER for immediate treatment via 911|referred to ER for immediate treatment via private transport||declined emergency transfer|"][textarea cols=70 rows=1]

CC:

HPI:

RECENT & PAST HISTORY: [+] reported [-] not reported

MEDICATIONS:
allergies reviewed


REVIEW OF SYSTEMS: [+] reported [-] not reported
negative except as stated
EYES:

MOUTH:

NECK:

CV:

GI:

GU:

MSK:

NEURO:

PSYCH:

LYMPH/HEMA/IMMUNE:

DERM:




Appearance:


Skin:


Head/Face:


Eyes:


Ears:


Nose:


Mouth:


Throat:


Neck:


Chest/Lungs:


CV:


Abdomen:


GU:


MSK:


Neuro:


Behavior:


Speech/Vocalization:


A/P:


BARRIERS TO CARE:


PLAN OF CARE:


DISPOSITION:

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