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approximately 569 views since our escapement mechanism was set in motion.
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[checkbox name="historian" value="telemedicine visit, patient identity/location verified and informed consent obtained by staff|able to verify two patient edentifiers||spoke to patient|SO/family member present during visit|chaperon/MA present during visit||interpretation provided by family member/SO|interpretation provided by MA|"][textarea cols=50 rows=1]
CC: [checkbox name="cc" value="headache|fever|malaise|fatigue|body aches|nasal discharge|nasal congestion|sinus pain|earache/ear pressure|sore throat|pus on tonsils|voice loss|cough|chest tightness/pain w/ breathing|SOB|GI Sx|"][textarea cols=50 rows=5]

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 come and go|sx decreasing in severity|sx resolved||as in cc|"][textarea cols=50 rows=3]
RECENT / PERTINENT HISTORY: [checkbox name="recent" value="ER/UC visit|hospitalization/surgery/procedure|travel|sick contact|new/changed medications|antibiotic use||non-contributory|"][textarea cols=50 rows=3]


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REVIEW OF SYSTEMS: negative except as stated in HPI
General:[textarea name="variable_5" default=" does not report fever, chills, fatigue, malaise, or weight changes"]
HEENT:[textarea name="variable_6" default=" does not report headaches, vision changes, eye redness/discharge, pain with EOM, facial swelling, earache, ringing, ear discharge, nasal congestion, rhinorrhea, mouth sores, changes in taste, sore throat, neck swelling"]
CV:[textarea name="variable_7" default=" does not report chest pain, SOB, palpitations, fainting, or ankle swelling"]
Pulmonary:[textarea name="variable_8" default=" does not report shortness of breath, cough, wheezing, or chest wall pain with breathing"]
GI:[textarea name="variable_9" default=" does not report poor appetite, nausea, vomiting, abdominal pain, constipationc diarrhea"]
GU:[textarea name="variable_10" default=" does not report dysuria, hematuria, frequency, discharge, or bleeding"]
MSK:[textarea name="variable_11" default=" does not report myalgias, arthralgias, localized muscle/soft tissues pain/swelling, or joint pain/swelling"]
Neurologic:[textarea name="variable_13" default=" does not report dizziness, seizures, tremor, balance problems, weakness, or falls"]
Psychiatric:[textarea name="variable_14" default=" does not report depression, anxiety, mood swings, memory loss, or insomnia"]
Dermatologic:[textarea name="variable_12" default=" does not report rashes, redness, pruritus, hair loss, swelling, or wounds"]
Endocrine:[textarea name="variable_15" default=" does not report polyphagia, polydipsia, night sweats, hot flashes, or heat/cold intolerance"]
Hematologic/lymphatic:[textarea name="variable_16" default=" does not report abnormal bleeding/bruising"]

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DIAGNOSTIC & LABORATORY RESULTS: [checkbox name="new_labs" value="normal|non-specific changes|no acute findings||discussed with patient/SO||no new results|"][textarea cols=50 rows=3]
General: [checkbox name="appearance" value="alert|well-appearing|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=50 rows=1]
Skin: [checkbox name="skin" value="no visible rashes||reports no exanthema or enanthema||unable to assess|"][textarea cols=50 rows=1]
Head/Face: [checkbox name="head" value="normocephalic|symmetrical face|CN grossly intact||reports no trouble smiling or chewing||unable to assess|"][textarea cols=50 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||reports no changes in vision or photophobia||unable to assess|"][textarea cols=50 rows=1]
Ears: [checkbox name="ears" value="hearing grossly intact||HOH|hearing aid(s)||reports no changes in hearing|no tragal tenderness with self-palpation|no mastoid tenderness with self-palpation||tragal tenderness with self-palpation||unable to assess|"][textarea cols=50 rows=1]
Nose: [checkbox name="nose" value="perinasal irritation||reports being able to use both nostrils|no tenderness with applying pressure to sinus areas||facial tenderness with self-palpation||unable to assess|"][textarea cols=50 rows=1]
Mouth: [checkbox name="mouth" value="tongue normal in appearance with good symmetrical movements|moist oral mucosa without lesions||unable to assess|"][textarea cols=50 rows=1]
Throat: [checkbox name="throat" value="speaks in clear and unmuffled voice|no stridor||audible congestion in voice|audible hoarseness|nasal sounding voice||pharynx w/o swelling or exudates with self-exam||pharyngeal erythema with self-exam|pharyngeal exudates with self-exam||unable to assess|"][textarea cols=50 rows=1]
Neck: [checkbox name="neck" value="normal inspection|able to freely move neck in all directions||no enlarged/tender cervical lymph nodes with self-palpation||unable to assess|"][textarea cols=50 rows=1]
Chest/Lungs: [checkbox name="lungs" value="normal respiratory effort|no tachypnea|speaking in full sentences|no audible wheezing||symmetrical chest expansion||audible coughing||chest pain with self-palpation||reports respiratory distress|reports chest pain with breathing||unable to assess|"][textarea cols=50 rows=1]
CV: [checkbox name="cv" value="reports pulse to be regular and of normal rate|no LE edema with self-exam|no calf tenderness with self-palpation||reports tachycardia|reports irregular heart rhythm||unable to assess|"][textarea cols=50 rows=1]
Abdomen: [checkbox name="abd" value="no focal abdominal tenderness elicited upon self-palpation||diffuse tenderness over entire abdomen w/o RRG with self-palpation|direct non-rebound focal tenderness with self-palpation||unable to assess|"][textarea cols=50 rows=1]
GU: [checkbox name="gu" value="no suprapubic tenderness with self-exam|no CVAT with self-exam||unable to assess|"][textarea cols=50 rows=1]
MSK: [checkbox name="spine" value="freely moves all extremities|no visible gross deformity||reports full weight-bearing|no bony tenderness in affected area on self-exam||unable to assess|"][textarea cols=50 rows=1]
Neuro: [checkbox name="neuro" value="normal concentration and attention|memory grossly intact||no involuntary movements||tremor|tardive dyskinesia|tics||reports no changes in balance or coordination||unable to assess|"][textarea cols=50 rows=1]
Speech/Vocalization: [checkbox name="speech" value="normal for age|clear & coherent||slurred|mumbling to self|monotonous|stuttering||hypoverbal|hyperverbal||loud|soft||slow|rapid|pressured||groaning|sighing|crying||perseveration|flight of ideas|repetitive questions||self-depreciating statements|repetitive statements of impending doom|repetitive non-health related/financial concerns||personal safety concerns|suicidal ideation/threats||insisting on particular medication, test, referral, or accommodation||raising voice|defensive|argumentative|cursing, swearing|previous providers/staff criticisms|verbal threats|sexual remarks|racist remarks||unable to assess|"][textarea cols=50 rows=1]
Behavior/Psychomotor Activity: [checkbox name="behavior" value="calm, pleasant, respectful|cooperative with history & exam||guarded|anxious|irritable|frustrated||labile|agitated|hostile|forceful||pacing|fidgeting|picking skin|twirling hair|cracking knuckles|grimacing, furrowing eyebrows|tightening jaw|breathing hard|intense staring|threatening gestures|fist-clenching||withdrawn|bradykinetic|indifferent|appears to be responding to internal psychotic process||unable to assess|"][textarea cols=50 rows=1]


A/P: [textarea cols=50 rows=5]
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ORDERS - RX: [checkbox name="order_RX" value="none|OTC||electronic|paper|given to MA to be transmitted to pharmacy|"][textarea cols=50 rows=1]
ORDERS - LABS: [checkbox name="order_lab" value="none||CBC|CMP|TSH|A1C|Lipids|PSA|FOBT/FIT|UA||HIV, RPR, HCV, GC, CT|UDS|"][textarea cols=50 rows=2]
ORDERS - IMAGING: [checkbox name="order_imaging" value="none||X-ray|US|MRI|"][textarea cols=50 rows=2]
ORDERS - REFERRALS: [checkbox name="order_refer" value="none|"] [textarea cols=50 rows=2]
ORDERS - FORMS: [checkbox name="forms" value="none|excuse|clearance|restrictions|"][textarea cols=50 rows=2]
STAFF INSTRUCTIONS: [checkbox name="MA" value="none||dsg change/wound care as instructed|obtain hospital/ER discharge report|obtain specialty report|obtain imaging report|obtain laboratory report|remind patient to always bring all medication containers to visit|"][textarea cols=50 rows=2]
INSTRUCTED ON: telemedicine limitations, exam findings, POC, risks of/benefits of/alternatives to proposed POC, reporting medication side effects immediately, appropriate follow up specific to condition, indications for immediate direct evaluation and/or contacting emergency services[textarea cols=50 rows=3]
PLAN OF CARE: [checkbox name="discussed" value="patient/family verbalized understanding of & agreement with POC|patient/family did not agree with my POC – will seek second opinion/further care elsewhere|"][textarea cols=50 rows=3]
PREVENTIVE: [checkbox name="preventative" value="UTD|colonoscopy|DEXA|LDCT|PAP|mammogram|PSA|DRE||flu vac|referred to local pharmacy to verify vaccination status and administer vaccines, if indicated||deferred|"][textarea cols=50 rows=2]
FOLLOW UP: as discussed, sooner if condition worsens or new symptoms arise, contact 911/ER if significant increase in s/sx or appearance of new/danger s/sx
[checkbox name="next" value="RTC 24 hours|RTC 2-3 days|RTC 1-2 weeks|RTC 3-4 weeks||medication review|f/u acute episode|f/u labs|f/u imaging|f/u referral|"][textarea cols=50 rows=2]
DISPOSITION: [checkbox name="disposition" value="remain at home|referred to ER for immediate treatment via 911|referred to ER for immediate treatment via private transport||declined emergency transfer|"][textarea cols=50 rows=1]
BARRIERS TO CARE: [checkbox name="barriers" value="inability to personally examine||incomplete history||vague shifting complaints|supporting documentation unavailable||multiple comorbidities|polypharmacy|poor compliance with POC|intolerance of/therapeutic failure on multiple meds||preoccupation with illness|catastrophization|overgeneralization|unrealistic beliefs|negativism|pessimism|blaming others||lack of motivation|negative attitude to diagnostic impression & proposed tx|lack of interest in nonpharmacologic therapies||psychiatric comorbidity|h/o alcohol/substance abuse|victim of abuse|social/cultural barriers||altered mental status|affect|hostile/disruptive behavior|"][textarea cols=50 rows=1]
[checkbox memo="depression" name="depression" value=""][conditional field="depression" condition="(depression).is('')"]
DEPRESSION CARE MANAGEMENT PLAN
DATE CREATED/REVIEWED: [date name="variable_1" default="10/25/2020"]
PATIENT PREFERENCES AND FUNCTIONAL LIFESTYLE GOALS: increase life enjoyment, be more involved socially, be organized, feel better, have more energy, sleep less
SELF-MANAGEMENT PLAN: consider attending counseling sessions, decrease alcohol intake, exercise daily, consider joining a support group, consider journaling, sleep 7-9 hours each night, take medication daily as prescribed
CARE PLAN PROVIDED TO PATIENT / FAMILY / CAREGIVER[/conditional]
[checkbox memo="risk" name="risk" value=""][conditional field="risk" condition="(risk).is('')"]
HIGH RISK / UTILIZATION OF MEDICATIONS CARE MANAGEMENT PLAN
DATE CREATED/REVIEWED: [date name="variable_2" default="10/25/2020"]
SELF MANAGEMENT PLAN: adhere to medication treatment, get timely refill, print out medication schedule, use medication pill box organizer
CARE PLAN PROVIDED TO PATIENT / FAMILY / CAREGIVER[/conditional]
[checkbox memo="diabetes" name="diabetes" value=""][conditional field="diabetes" condition="(diabetes).is('')"]
DIABETES CARE MANAGEMENT PLAN
DATE CREATED/REVIEWED: [date name="variable_3" default="10/25/2020"]
PATIENT PREFERENCES AND FUNCTIONAL LIFESTYLE GOALS: control eating habits, decrease pain/numbness in feet, increase exercise tolerance, increase life enjoyment, make better choices when eating out, feel better, increase energy levels
SELF MANAGEMENT PLAN: adhere to medication treatment, consider attending diabetes education classes, eat frequent small meals, get 7-9 hours of sleep per night, increase exercise, limit carb intake, lose weight, monitor home glucose readings, reduce alcohol intake
CARE PLAN PROVIDED TO PATIENT / FAMILY / CAREGIVER[/conditional]
.

CC:

HPI:
RECENT / PERTINENT HISTORY:


.
REVIEW OF SYSTEMS: negative except as stated in HPI
General:
HEENT:
CV:
Pulmonary:
GI:
GU:
MSK:
Neurologic:
Psychiatric:
Dermatologic:
Endocrine:
Hematologic/lymphatic:

.
DIAGNOSTIC & LABORATORY RESULTS:
General:
Skin:
Head/Face:
Eyes:
Ears:
Nose:
Mouth:
Throat:
Neck:
Chest/Lungs:
CV:
Abdomen:
GU:
MSK:
Neuro:
Speech/Vocalization:
Behavior/Psychomotor Activity:


A/P:
.
ORDERS - RX:
ORDERS - LABS:
ORDERS - IMAGING:
ORDERS - REFERRALS:
ORDERS - FORMS:
STAFF INSTRUCTIONS:
INSTRUCTED ON: telemedicine limitations, exam findings, POC, risks of/benefits of/alternatives to proposed POC, reporting medication side effects immediately, appropriate follow up specific to condition, indications for immediate direct evaluation and/or contacting emergency services
PLAN OF CARE:
PREVENTIVE:
FOLLOW UP: as discussed, sooner if condition worsens or new symptoms arise, contact 911/ER if significant increase in s/sx or appearance of new/danger s/sx

DISPOSITION:
BARRIERS TO CARE:
depression
risk
diabetes

Result - Copy and paste this output:

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