Telemedicine Visit

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

CHIEF COMPLAINT: [text name="variable_2"]

HISTORY OF PRESENT ILLNESS:
The patient is a [text name="variable_3"] with a history of [text name="variable_4"] complaining of a [text name="variable_5"] 
PSFH:

REVIEW OF SYSTEMS: Review of at least 10 organ systems is otherwise negative except as stated above.

PHYSICAL EXAM:
GENERAL: [checkbox name="variable_1" value="well-developed and well-nourished|alert and cooperative|in no acute distress|well-appearing and nontoxic"], [text name="variable_2" default=""]
HEENT: [checkbox name="variable_3" value="normocephalic|atraumatic|EOMI|vision grossly intact bilaterally|no conjunctival injection or visible discharge|hearing grossly intact bilaterally|no frontal sinus tenderness bilaterally|no maxillary sinus tenderness bilaterally|no oropharyngeal erythema/edema/exudate|no uvular deviation|speaks in clear and unmuffled voice|lips/tongue/dentition/gingiva within normal limits"], [text name="variable_4" default=""]
NECK: [checkbox name="variable_5" value="supple with full range of motion|no stridor|no midline tenderness of stepoff|no cervical lymph node tenderness bilaterally|no cervical lymph node swelling bilaterally|no visible thyromegaly or other masses"], [text name="variable_6" default=""]
RESPIRATORY: [checkbox name="variable_7" value="no audible rales/rhonchi/wheezing|normal respiratory effort|speaking full sentences|no visible signs of tachypnea|no retractions"], [text name="variable_8" default=""]
CARDIOVASCULAR: [checkbox name="variable_9" value="peripheral pulses intact and palpable|pulse felt to be regular rate and rhythm by patient"], [text name="variable_10" default=""]
ABDOMINAL: [checkbox name="variable_11" value="no focal abdominal tenderness elicited upon palpation|no visible abdominal distension|no abnormal masses found upon palpation"], [text name="variable_12" default=""]
BACK: [checkbox name="variable_13" value="no CVAT elicited bilaterally|no midline tenderness or stepoff upon palpation"], [text name="variable_14" default=""]
EXTREMITIES: [checkbox name="variable_15" value="no bony tenderness|no visible gross deformity|no edema|normal range of motion"] of affected area, [text name="variable_16" default=""]
NEUROLOGIC: [checkbox name="variable_17" value="CN III-XII grossly intact|normal-appearing mental status|moving all extremities normally|grossly normal motor strength throughout|sensation to light touch grossly intact throughout|normal speech|normal gait"], [text name="variable_18" default=""]
PSYCH: [checkbox name="variable_19" value="normal-appearing affect"], [text name="variable_20" default=""]

ASSESSMENT:




PLAN:


Diagnostic rationale, follow up instructions, and strict precautions/indications for emergent direct evaluation were discussed with the patient. The patient agrees with the plan, and understands to follow up with their primary care physician or other healthcare provider [checkbox name="variable_12" value="within 24-48 hours|within 48-72 hours|within 1 week|as needed"] for reevaluation. The patient understands to report immediately to the nearest Emergency Department or Urgent Care Center for any concerning/worsening signs or symptoms.