VA H&P Maker

Chief complaint: 
[text name="CC" default=""]
 
===========================
History of Present Illness:
===========================
Mr. [text name="Name" default=""] is a [text name="Age" default=" "] year old male with a past medical history of [textarea name="PMH" default=""] who presents for [var name="CC"]

[textarea name="HPI" default=""]

ER Course:
Vital signs  [textarea name="vitals" default="have been stable"]. Initial workup revealed  [textarea name="Workup" default=""]

[select name="mod_1" value="CXR|CT|CTA|CT head|CT chest|CT abd/pelvis|MRI|US|XR|EKG"] showed [textarea name="image1" default=""]. [select name="mod_2" value="CXR|CT|CTA|CT head|CT chest|CT abd/pelvis|MRI|US|XR|EKG"] showed [textarea name="image2" default=""].  
Patient was given [textarea name="meds" default=""]

=============================
Past Medical/Surgical History:
=============================
[textarea name="PSH" default=""]

********************************************************************************************

I have reviewed patient's Medical and Surgical history. 
 
MEDICATIONS: Medications are reconciled and documented under separate ADMISSION
MEDICATION RECONCILIATION note.

********************************************************************************************

==============
Social History
==============
Tobacco use: 
[textarea name="Tobacco" default=""]
 
Alcohol use: 
[textarea name="ETOH" default="none/denies"]
 
Illicit drug use: 
[textarea name="Drug" default="none/denies"]
==============
Family History:
==============
[textarea name="FH" default=" "]

********************************************************************************************
 
==============
Physical Exam:
==============
GENERAL:  No acute distress
HEENT: Pupils equally round  Oral mucous membrane moist and clear.
NECK: Soft & supple. Full range of motion (ROM). Neg thyromegaly,
CVS: Normal rate and regular rhythm. Normal S1 and S2 appreciated
LUNG: Clear to auscultation bilaterally. 
ABD: Soft, nondistended, nontender. Normoactive bowel sounds.
EXTREMITIES: no joint swelling or clubbing
NEURO: A&O x 4. No focal findings. 

==============
Pertinent Labs:
==============
[var name="Workup"]
[textarea name="Labs" default=""] 
 

========
Imaging:
========
[var name="mod_1"]
[var name="image1"]
 
[var name="mod_2"]
[var name="image2"]
 
Echo
[textarea name="Echo" default=""] 

EKG
[textarea name="EKG" default="Sinus rhythm"] 

********************************************************************************************

===============
Assessment/Plan
===============

[textarea name="AP" default=""]
Chief complaint:


===========================
History of Present Illness:
===========================
Mr. is a year old male with a past medical history of
who presents for CC



ER Course:
Vital signs
. Initial workup revealed


showed
. showed
.
Patient was given


=============================
Past Medical/Surgical History:
=============================


********************************************************************************************

I have reviewed patient's Medical and Surgical history.

MEDICATIONS: Medications are reconciled and documented under separate ADMISSION
MEDICATION RECONCILIATION note.

********************************************************************************************

==============
Social History
==============
Tobacco use:


Alcohol use:


Illicit drug use:

==============
Family History:
==============


********************************************************************************************

==============
Physical Exam:
==============
GENERAL: No acute distress
HEENT: Pupils equally round Oral mucous membrane moist and clear.
NECK: Soft & supple. Full range of motion (ROM). Neg thyromegaly,
CVS: Normal rate and regular rhythm. Normal S1 and S2 appreciated
LUNG: Clear to auscultation bilaterally.
ABD: Soft, nondistended, nontender. Normoactive bowel sounds.
EXTREMITIES: no joint swelling or clubbing
NEURO: A&O x 4. No focal findings.

==============
Pertinent Labs:
==============
Workup



========
Imaging:
========
mod_1
image1

mod_2
image2

Echo


EKG


********************************************************************************************

===============
Assessment/Plan
===============

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.1, 27 form elements, 139 boilerplate words, 3 text boxes, 16 text areas, 2 drop downs, 6 variables, 21 total clicks
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