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
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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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