Telemedicine Note

Date:
[text name="Date" default=""]
Time called:
[text name="Time" default=""]
Patient Name:
[text name="Name" default=""]
Patient DOB:
[text name="DOB" default=""]
Company:
[text name="COMPANY" default=""]
Vessel:
[text name="VESSEL" default=""]
Call Back Number:
[text name="Number" default=""]

PMH: History provided by the patient

Drug Allergies:[checkbox name="variable_2" value="NKDA"][text name="Meds" default=""]

Current Medications:[checkbox name="variable_2" value="No medications reported"][text name="Meds" default=""]

PMHx:[checkbox name="variable_2" value="No PMHx reported"][text name="variable_1" default=""]

PSHx: [checkbox value="No PSHx reported"][text name="PSHX" default=""]

Severity:
[select name="Severity" value="Non-emergency|Emergency"]

CHIEF COMPLAINT:
[textarea name="CC" default=""]

S:HISTORY OF PRESENT ILLNESS:
The patient is complaining of:[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"][text name="History" default=""]

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 name="variable_1" default=""]


REVIEW OF SYSTEMS:
negative except as stated [textarea name="ROS" default=""]

O:
PHYSICAL EXAM: Telemedicine visit. Exam performed via voice telephone system or photos sent.

ASSESSMENT:
[text name="Assessment" default=""]

PLAN:
[textarea name="z-pak" default=""]
[checkbox name="Plan" value="z-pak|Doxycycline 100mg BID for 7 days|Amoxiclav 875/125 BID for 7 days|OTC Pain medications as directed on label|Loratadine 10mg QD|Diphenhydramine 25mg every 6 hours|Phenyephrine 10mg as directed|OTC symptom relief as directed|Ice affected part|Rest and elevate affected part|Increase hydration|Ace Bandage|Heat to affected part"]

The patient agrees with the plan and understands that a follow up with us will be in: [checkbox name="variable_12" value="within 24 hours|within 48 hours|none needed|as needed|come into clinic|referred to emergency room|referred to be seen by a provider as soon as possible"] [text name="variable_1" default=""]

The patient understands to call us or report immediately to the nearest Emergency Department or Urgent Care Center for any concerning/worsening signs or symptoms.

Jeremy Weinberg, APRN, FNP-BC.

Per normal course of treatment by Dr. Brian Bourgeois, MD
Date:

Time called:

Patient Name:

Patient DOB:

Company:

Vessel:

Call Back Number:


PMH: History provided by the patient

Drug Allergies:

Current Medications:

PMHx:

PSHx:

Severity:


CHIEF COMPLAINT:


S:HISTORY OF PRESENT ILLNESS:
The patient is complaining of:

HPI:




REVIEW OF SYSTEMS:
negative except as stated


O:
PHYSICAL EXAM: Telemedicine visit. Exam performed via voice telephone system or photos sent.

ASSESSMENT:


PLAN:



The patient agrees with the plan and understands that a follow up with us will be in:

The patient understands to call us or report immediately to the nearest Emergency Department or Urgent Care Center for any concerning/worsening signs or symptoms.

Jeremy Weinberg, APRN, FNP-BC.

Per normal course of treatment by Dr. Brian Bourgeois, MD

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.33, 27 form elements, 117 boilerplate words, 14 text boxes, 4 text areas, 8 checkboxes, 1 drop downs, 75 total clicks
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