Visit PE
[date name="variable_1" default="05/03/2021"] [comment memo="*" memo_color="blue" memo_size="small"]cc/reason for visit: [text size="60"] [comment memo="*" memo_color="blue" memo_size="small"]HPI: [text size="5"] yo [select name="Gender" value="M|F"] here for- [comment memo="Acute conditions" memo_size="small" memo_color="blue"] [checkbox name="generalsxHPI1" memo="generic #1" memo_size="small" value="Symptoms"][conditional field="generalsxHPI1" condition="(generalsxHPI1).is('Symptoms')"] -Symptoms: [text size="50"]. -Symptoms started [text size="3"] [select value="hour(s)|day(s)|week(s)|month(s)|year(s)"] ago. -Patient reports these symptoms are located [text size="35"]. -Patient reports these symptoms are [select value="getting worse|getting better|the same"] since onset. -Rates it as [text size="5"]/10 in severity. -Describes the character/quality as [checkbox value="sharp|dull|burning|tingling|N/A"][text size="30"].[comment memo="Other comments on character/quality" memo_size="small"] -Above symptom(s) [select value="do not travel/radiate|travel/radiate to"] [text size="25"]. -Associated sx: [checkbox value="Denies any associated symptoms"][text size="25"]. -Related activities or events that occured at or right before symptoms started: [text size="80"]. -Therapies attempted: [text size="80"]. -Symptoms are improved with [text size ="50"]. -Symptoms are worsened by [text size="50"]. -Patient [select value="denies|admits to"] history of similar symptoms previously. -Additional comments- [textarea default="none"] [/conditional][checkbox name="generalsxHPI2" memo="generic #2" memo_size="small" value="Symptoms"][conditional field="generalsxHPI2" condition="(generalsxHPI2).is('Symptoms')"] -Symptoms: [text size="50"]. -Symptoms started [text size="3"] [select value="hour(s)|day(s)|week(s)|month(s)|year(s)"] ago. -Patient reports these symptoms are located [text size="35"]. -Patient reports these symptoms are [select value="getting worse|getting better|the same"] since onset. -Rates it as [text size="5"]/10 in severity. -Describes the character/quality as [checkbox value="sharp|dull|burning|tingling|N/A"][text size="30"].[comment memo="Other comments on character/quality" memo_size="small"] -Above symptom(s) [select value="do not travel/radiate|travel/radiate to"] [text size="25"]. -Associated sx: [checkbox value="Denies any associated symptoms"][text size="25"]. -Related activities or events that occured at or right before symptoms started: [text size="80"]. -Therapies attempted: [text size="80"]. -Symptoms are improved with [text size ="50"]. -Symptoms are worsened by [text size="50"]. -Patient [select value="denies|admits to"] history of similar symptoms previously. -Additional comments- [textarea default="none"] [/conditional][checkbox memo="URI" memo_size="small" name="HPIforURI" value="Upper Respiratory Sx"][conditional field="HPIforURI" condition="(HPIforURI).is('Upper Respiratory Sx')"] -Symptoms: [checkbox name="URTIsx" value="runny nose|stuffy nose|itchy eyes|watery eyes|ear pain|sinus pain in cheeks and/or forehead|sore throat|pain with swallowing|difficulty swallowing|hoarseness|productive cough|dry cough|fever|chills|body aches"] -Duration: [text size="4"] [select value="day(s)|week(s)"] [/conditional][conditional field="URTIsx" condition="(URTIsx).is('ear pain')||(URTIsx).is('sinus pain in cheeks and/or forehead')||(URTIsx).is('sore throat')||(URTIsx).is('pain with swallowing')"]-Pain severity: [text size="4"]/10 [/conditional][conditional field="HPIforURI" condition="(HPIforURI).is('Upper Respiratory Sx')"]-Is sore throat the main complaint without concurrent cold-like symptoms (nose/eyes/etc)? [select name="Centor" value="no|YES"][comment memo="Choose 'yes' to bring up Centor Criteria" memo_size="small"][/conditional][conditional field="Centor" condition="(Centor).is('YES')"] Modified Centor Score [select name="Q1Fever" value="No (0 points)=0|YES (1 point)=1"] <-- History of fever or measured temperature > 100.4 degrees F [select name="Q2Cough" value="Cough is present (0 points)=0|COUGH IS ABSENT (1 point)=1"] <-- Presence of coughing [select name="Q3Nodes" value="No (0 points)=0|YES (1 point)=1"] <-- Tender anterior cervical nodes [select name="Q4Tonsil" value="No (0 points)=0|YES (1 point)=1"] <-- Tonsillar swelling or exudates [select name="Q5Age" value="< 15 years (1 point)=1|15 to 45 years (0 points)=0|> 45 years (-1 point)=-1"] <-- Age Score --> [calc value="score=(Q1Fever)+(Q2Cough)+(Q3Nodes)+(Q4Tonsil)+(Q5Age)" memo="score"][/conditional][conditional field="HPIforURI" condition="(HPIforURI).is('Upper Respiratory Sx')"] [comment memo="modifying factors" memo_size="small"] -Therapies tried that have improved symptoms: [text size="50"] -Therapies tried that have NOT improved symptoms: [text size="50"] -Additional comments- [textarea default="none"] -Review of Systems: [checklist value="Fever|Chills|Body aches|Chest pain|Nausea|Vomiting|Diarrhea"] [/conditional][checkbox memo="cough/chest symptoms" memo_size="small" name="HPIforCough" value="Respiratory Sx"][conditional field="HPIforCough" condition="(HPIforCough).is('Respiratory Sx')"] -Symptoms- [checkbox value="cough|mild chest pain|chest tightness|shortness of breath|other-"] [text size="60"] -Duration: [text size="4"] [select value="day(s)|hour(s)|week(s)|month(s)"] -[select name="coughprod" value="Denies cough|Non-productive cough|Productive cough"][/conditional][conditional field="coughprod" condition="(coughprod).is('Productive cough')"] - sputum color is [text size="20"][/conditional][conditional field="HPIforCough" condition="(HPIforCough).is('Respiratory Sx')"] -Symptoms started when/while [text memo="inciting event" memo_size="small" size="80"] -Remedies/medicines attempted: [text size="80"] -Effect of attempted remedies/medicines: [text size="80"] -Since onset, sx have [select value="gotten better|gotten worse|stayed about the same"] -Patient describes severity is [select value="minimal|moderate|severe"] -Patient feels cough at nighttime [select value="not significantly affecting sleep|preventing adequate sleep"] -Patient reports [select value="no known|known"] sick contacts at home, school, or work. [text size="40"] -Additional comments- [textarea default="none"] -Hx of these conditions: -[select value="no|YES"] <-recent cold -[select value="no|YES"] <-allergic rhinitis -[select value="no|YES"] <-non-allergic rhinitis -[select value="no|YES"] <-frequent sinus infection -[select value="no|YES"] <-asthma -[select value="no|YES"] <-frequent pneumonia -[select value="no|YES"] <-frequent bronchitis -[select value="no|YES"] <-GERD -[select value="no|YES"] <-head/neck/throat/thyroid/lung cancer -[select value="no|YES"] <-tuberculosis or positive tuberculin skin test -[select value="no|YES"] <-Diabetes Mellitus -[select value="no|YES"] <-Previous use of tobacco products or vaping {textarea memo="if tobacco hx include heaviest daily/weekly use and #years" memo_size="small"] -Review of systems: -[select value="no|YES"] <-chest pain with coughing -[select value="no|YES"] <-coughing up blood -[select value="no|YES"] <-fever/chills -[select value="no|YES"] <-body aches -[select value="no|YES"] <-hoarseness -[select value="no|YES"] <-sore throat -[select value="no|YES"] <-runny/stuffy nose -[select value="no|YES"] <-ear pain -[select value="no|YES"] <-sinus pain -[select value="no|YES"] <-itchy/watery eyes -[select value="no|YES"] <-pain with swallowing -[select value="no|YES"] <-feeling of lump in throat (globus sensation) Travel: recent travel in past 6 months to foreign country and regular close contact with local people where tuberculosis is endemic- [select value="no|YES"] [text size="50"] Immunization status: [checkbox value="vaccines UTD (incl pertussis/PCV if indicated)|PERTUSSIS VACCINATION STATUS UNKNOWN|UNVACCINATED TO PERTUSSIS|PNEUMOCOCCAL VACCINE INDICATED BY NOT RECEIVED"] [/conditional][checkbox memo="N/V/D/pain" memo_size="small" name="HPIforGI" value="Gastrointestinal Sx"][conditional field="HPIforGI" condition="(HPIforGI).is('Gastrointestinal Sx')"] -Symptoms- [checkbox name="GIsx" value="decreased appetite|bloating sensation|pain with defecation|constipation|diarrhea|abdominal pain|nausea/vomiting|other-"] [text size="60"] -Sx started [text size="4"] [select value="day(s)|hour(s)|week(s)|month(s)"] ago -Sx started when/while [text size="80"] -Last BM was [text size="4"] [select value="day(s)|hour(s)|week(s)"] ago and consistency was [select value="soft|slightly firm|very hard|loose|like water"], and color was described as [text size="40"]. -#BMs in past 24hrs: [text size="4"] -Last meal eaten was [text size="4"] [select value="hour(s)|day(s)"] ago -Therapies/medications attempted- [text size="80"] -Sx improved by [text size="50"] -Sx worsened by [text size="50"] -Since onset, sx have [select value="gotten better|gotten worse|stayed about the same"][/conditional][conditional field="GIsx" condition="(GIsx).is('abdominal pain')"] -Pain Location: [text size="50"] -Pain Radiation: [text size="50"] -Pain Severity currently: [text size="5"]/10 -Pain Severity at worst: [text size="5"]/10 -Pain Timing: [select value="constant|comes and goes"] Duration of pain if episodic: [text default="n/a" size="50"] -Pain described as: [select value="both sharp and dull|sharp/knifelike|dull/pressure|other-"] [text size="50"] [/conditional][conditional field="GIsx" condition="(GIsx).is('nausea/vomiting')"][comment memo="N/V specific questions"] -[select value="no|YES"] <-- nausea -[select value="no|YES"] <-- vomiting [text][comment memo="if yes, indicate color" memo_size="small"] [comment memo="Exposures"] -[select value="no|YES"] <-- Recent intake of questionable/new food -[select value="no|YES"] <-- Recent antibiotics -[select value="no|YES"] <-- Recent travel [/conditional][conditional field="HPIforGI" condition="(HPIforGI).is('Gastrointestinal Sx')"]-Additional comments- [textarea default="none"] -Review of Systems: -[select value="no|YES"] <-- Chest pain or chest/belly pain with breathing -[select value="no|YES"] <-- Black or bloody stool -[select value="no|YES"] <-- Fever -[select value="no|YES"] <-- Dysuria -[select value="no|YES"] <-- Urinary frequency -[select value="no|YES"] <-- Urinary urgency -[select value="no|YES"] <-- Hematuria -Hx of these conditions: -[select value="no|YES"] <-- Gall Bladder or liver disease -[select value="no|YES"] <-- GERD -[select value="no|YES"] <-- Peptic ulcer(s) -[select value="no|YES"] <-- Pancreatitis -[select value="no|YES"] <-- Kidney stones -[select value="no|YES"] <-- Urinary tract infections -[select value="no|YES"] <-- Diverticulitis -[select value="no|YES"] <-- Inflammatory Bowel Disease -[select value="no|YES"] <-- Pelvic Infection -[select value="no|YES"] <-- Vascular disease -Hx of these surgeries: -[select value="no|YES"] <-- Appendectomy -[select value="no|YES"] <-- Cholecystectomy -Currently using: [comment memo="pertinent meds/substances"] -[select value="no|YES"] <-- Daily or near-daily use of NSAIDs -[select value="no|YES"] <-- Daily or near-daily alcohol use -[select value="no|YES"] <-- Daily or near-daily use of Opioids -[select value="no|YES"] <-- aortic aneurysm history or risk (age over 60, tobacco history) [/conditional][checkbox memo="#1" memo_size="small" name="HPIforMSK1" value="MSK Sx"][conditional field="HPIforMSK1" condition="(HPIforMSK1).is('MSK Sx')"] -Symptoms: [checkbox value="pain|popping|grinding|joint weakness|other-"] [text size="60"] -Onset: [text size="3"] [select value="days|weeks|months|years"] -Location: [text size="40"] -Pain started while/after: [checkbox value="no specific inciting event"][text size="80"] -Pain Radiation: [checkbox value="none"][text size="50"] -Timing: [select name="MSK1Timing" value="constant|comes and goes"][/conditional][conditional field="MSK1Timing" condition="(MSK1Timing).is('comes and goes')"] --> Portion(s) of day when it occurs mostly: [text size="40"][/conditional][conditional field="HPIforMSK1" condition="(HPIforMSK1).is('MSK Sx')"] -Type/quality of pain: [select value="|sharp/knifelike|dull/pressure|both sharp and dull"] [text size="40"] -Action/activity that bothers most: [text size="50"] -Other aggravating actions/activities: [text size="80"] -Progression of pain: [select value="getting better|getting worse|staying the same"] -Severity of pain: [text size="5"]/10 -Previously seen for this: [select name="MSK1PrevVisit" value="|no|YES"][/conditional][conditional field="MSK1PrevVisit" condition="(MSK1PrevVisit).is('YES')"] -Number of visits: [text size="4"]. -Specialties seen: [checkbox value="primary care|physical therapy|orthopedist|chiropractor|acupuncturist|pain management specialist"] [text size="30"][/conditional][conditional field="HPIforMSK1" condition="(HPIforMSK1).is('MSK Sx')"] -Modalities attempted: [checkbox value="none|home remedies|stretches|rest|ice|heat|elevation|medications|physical therapy|injections|surgery|other-"] [text size="60"] -Effect of these modalities: [select value="helped pain|worsened pain|made no difference|mixed -see additional comments"] -Other associated symptoms: -[select value="n/a|no|YES"] <-if knee involved, any locking up of joint when attempting movement -[select value="n/a|no|YES"] <-if knee involved, any buckling or giving-out of joint with use -[select value="n/a|no|YES"] <-if joint involved, any swelling -[select value="n/a|no|YES"] <-if joint involved, any stiffness -[select value="no|YES"] <-any fevers or chills -[select value="no|YES"] <-any recent tick exposure within the past year -Additional comments- [textarea default="none"] [/conditional][checkbox memo="#2" memo_size="small" name="HPIforMSK2" value="MSK Sx"][conditional field="HPIforMSK2" condition="(HPIforMSK2).is('MSK Sx')"] -Symptoms: [checkbox value="pain|popping|grinding|joint weakness|other-"] [text size="60"] -Onset: [text size="3"] [select value="days|weeks|months|years"] -Location: [text size="40"] -Pain started while/after: [checkbox value="no specific inciting event"][text size="80"] -Pain Radiation: [checkbox value="none"][text size="50"] [select name="MSK2Timing" value="constant|comes and goes"][/conditional][conditional field="MSK2Timing" condition="(MSK2Timing).is('comes and goes')"] --> Portion(s) of day when it occurs mostly: [text size="40"][/conditional][conditional field="HPIforMSK2" condition="(HPIforMSK2).is('MSK Sx')"] -Type/quality of pain: [select value="|sharp/knifelike|dull/pressure|both sharp and dull"] [text size="40"] -Action/activity that bothers most: [text size="50"] -Other aggravating actions/activities: [text size="80"] -Progression of pain: [select value="getting better|getting worse|staying the same"] -Severity of pain: [text size="5"]/10 -Previously seen for this: [select name="MSK2PrevVisit" value="|no|YES"][/conditional][conditional field="MSK2PrevVisit" condition="(MSK2PrevVisit).is('YES')"] -Number of visits: [text size="4"]. -Specialties seen: [checkbox value="primary care|physical therapy|orthopedist|chiropractor|acupuncturist|pain management specialist"] [text size="30"][/conditional][conditional field="HPIforMSK2" condition="(HPIforMSK2).is('')"] -Modalities attempted: [checkbox value="none|home remedies|stretches|rest|ice|heat|elevation|medications|physical therapy|injections|surgery|other-"] [text size="60"] -Effect of these modalities: [select value="helped pain|worsened pain|made no difference|mixed -see additional comments"] -Other associated symptoms: -[select value="n/a|no|YES"] <-if knee involved, any locking up of joint when attempting movement -[select value="n/a|no|YES"] <-if knee involved, any buckling or giving-out of joint with use -[select value="n/a|no|YES"] <-if joint involved, any swelling -[select value="n/a|no|YES"] <-if joint involved, any stiffness -[select value="no|YES"] <-any fevers or chills -[select value="no|YES"] <-any recent tick exposure within the past year -Additional comments- [textarea default="none"] [/conditional][checkbox memo="urinary/penile/STD concerns" memo_size="small" name="HPIforMaleGU" value="Male GU Sx"][conditional field="HPIforMaleGU" condition="(HPIforMaleGU).is('Male GU Sx')"] -Symptoms: [text memo="other/not listed" memo_size="small" size="60"][checkbox name="maleGUsxdischarge" value="penile discharge"][/conditional][conditional field="maleGUsxdischarge" condition="(maleGUsxdischarge).is('penile discharge')"](color/consistency - [text size="60"]), [/conditional][conditional field="HPIforMaleGU" condition="(HPIforMaleGU).is('Male GU Sx')"][checkbox value="penis tenderness|scrotal pain|penis rash/lesion|pain with urinating|urinary frequency|urinary urgency|blood in urine|blood in semen"][checkbox name="maleGUsxdifficulturine" value="difficulty urinating"][/conditional][conditional field="maleGUsxdifficulturine" condition="(maleGUsxdifficulturine).is('difficulty urinating')"] (last urinated [text size="5"][select value="minute(s)|hour(s)|day(s)"] ago, amount was [select value="a drop|scant/small|average amt|large amt"])[/conditional][conditional field="HPIforMaleGU" condition="(HPIforMaleGU).is('Male GU Sx')"] -Onset- [text size="3"] [select value="hour(s)|day(s)|week(s)|month(s)|year(s)"] ago. -Symptoms first noticed during/after- [checkbox value="no reported inciting event"][text size="80"] -Symptoms are located- [checkbox value="n/a"][text size="60"] -Symptoms character/quality: [checkbox value="N/A|both sharp and dull|sharp/knifelike|dull/pressure|burning|tingling|other-"] [text size="80"] -Symptom radiation- [checkbox value="none|travel/radiate to"][text size="80"] -Symptom timing- [select name="maleGUsxtiming" value= "constant|intermittent/comes and goes"][/conditional][conditional field="maleGUsxtiming" condition="(maleGUsxtiming).is('intermittent/comes and goes')"] -Sx episodes last [text size="5"][select value="second(s)|minute(s)|hour(s)|day(s)|week(s)|month(s)"][/conditional][conditional field="HPIforMaleGU" condition="(HPIforMaleGU).is('Male GU Sx')"] -Sx progression: [select value="the same|getting worse|getting better"] since onset [checkbox name="maleGUsxpainscale" memo="pain scale if applicable" memo_size="small" value=""][/conditional][conditional field="maleGUsxpainscale" condition="(maleGUsxpainscale).is('')"]-Pain rated as [text size="4"]/10 in severity currently, at its worst [text size="4"]/10 [/conditional][conditional field="HPIforMaleGU" condition="(HPIforMaleGU).is('Male GU Sx')"] -Symptoms are worsened by- [checkbox value="nothing"][text size="80"] -Therapies attempted- [checkbox value="none"][text size ="80"] -Effect of these therapies: [select value="helped|worsened|made no difference|mixed -see additional comments"] -Patient [select value="denies|admits to"] history of similar symptoms previously -Sexually active? [select name="maleGUsxSex" value="no|Yes"][/conditional][conditional field="maleGUsxSex" condition="(maleGUsxSex).is('Yes')"] -Number of sexual partners in past year *[text size="3"]*[/conditional][conditional field="HPIforMaleGU" condition="(HPIforMaleGU).is('Male GU Sx')"] -Additional comments- [textarea default="none"] Associated Sx/Review of Systems: [checklist value="fever/chills|decreased appetite|nausea|vomiting|diarrhea|constipation|black or bloody stool"] Pertinent History [checklist name="maleGUrosSTD" value="STD"][/conditional][conditional field="maleGUrosSTD" condition="(maleGUrosSTD).is('YES')"] - [comment memo="include which type, how long ago, and how many prior episodes" memo_size="small" memo_color="orange"][textarea rows="2"][/conditional][conditional field="HPIforMaleGU" condition="(HPIforMaleGU).is('Male GU Sx')"] [checklist value="Epididymitis|Prostatitis|BPH|Prostate Cancer|Kidney stones|Urinary tract infections|Diverticulitis"] Pertinent Past Surgeries: [checklist value="Appendectomy|Prostatectomy"] [/conditional][checkbox memo="itching/pain/discharge/STD concerns" memo_size="small" name="HPIforFemaleGU" value="Female GU Sx"][conditional field="HPIforFemaleGU" condition="(HPIforFemaleGU).is('Female GU Sx')"] -G[text memo="#pregnancies" memo_size="small" size="2"] P[text memo="#deliveries" memo_size="small" size="2"] -Symptoms: [text memo="other/not listed" memo_size="small" size="60"][checkbox name="FemaleGUsx" value="unusual vaginal bleeding|unusual vaginal discharge|vaginal itching/irritation|vaginal pain"] -Onset- [text size="3"] [select value="hour(s)|day(s)|week(s)|month(s)|year(s)"] ago. -Symptoms first noticed during/after: [checkbox value="no reported inciting event"][text size="80"] -Symptoms are located: [checkbox value="n/a"][text size="60"] -Symptom progression: [select value="gotten better|gotten worse|stayed about the same"] -Bowel movements/stools consistency usually [select value="soft|slightly firm|very hard|loose|like water"], and frequency is [text size="3"] stool(s) every [text size="3"] days. -Therapies attempted: [checkbox value="none"][text size ="80"] -Effect of these therapies: [select value="helped|worsened|made no difference|mixed -see explanation"] [/conditional][conditional field="FemaleGUsx" condition="(FemaleGUsx).is('unusual vaginal discharge')||(FemaleGUsx).is('vaginal itching/irritation')"] -Color/consistency of vaginal discharge (if present): [checkbox value="n/a|white|cottage cheese like|yellow/green vaginal discharge|frothy|malodorous|bloody"] -Uses cleansing products inside the vagina (other than water)- [select value="no|YES"] [text size="60"][/conditional][conditional field="FemaleGUsx" condition="(FemaleGUsx).is('vaginal pain')"] -Symptom radiation- [checkbox value="none|travel/radiate to"][text size="80"] -Severity currently: [text size="5"]/10 -Severity at worst: [text size="5"]/10 -Timing: [select value="constant|comes and goes"] -Duration of pain if episodic: [text default="n/a" size="50"] -Described as: [select value="both sharp and dull|sharp/knifelike|dull/pressure|burning|other-"] [text size="50"] -Worse with intercourse: [select value="no|YES"][/conditional][conditional field="HPIforFemaleGU" condition="(HPIforFemaleGU).is('Female GU Sx')"] -Sexually active: [select value="|Yes|no"] -Additional comments- [textarea default="none"] -Review of Systems: [checklist value="dysuria|urinary frequency|hematuria|decreased appetite|nausea|vomiting|back/flank pain|pelvic pain|black or bloody stool|fever"] -Hx of these conditions: [checklist value="STD/STI|Ectopic Pregnancy|Endometriosis|Ovarian Cyst|Kidney Stones|Urinary Tract Infections|Diverticulitis|Diabetes Mellitus|Candida Vaginitis recent/recurrent|Bacterial Vaginosis recent/recurrent|Trichomonas vaginitis|Atrophic Vaginitis|PID|recent new sexual partner|multiple sexual partners in the past year"] -Past Surgeries: [checklist value="Appendectomy|Ceserean Section|Hysterectomy|Tubal ligation|Other abdominal/pelvic surgeries"] [textarea memo="explanation of other abd/pelv surgeries" memo_size="small" rows="2"] [/conditional][checkbox memo="UTI sx" memo_size="small" name="HPIforUTI" value="Urinary Sx"][conditional field="HPIforUTI" condition="(HPIforUTI).is('Urinary Sx')"] -Symptoms: [text memo="other/not listed" memo_size="small" size="60"][checkbox value="dysuria|frequency|urgency|incontinence|hematuria|cloudy urine|fever|chills|vaginal discharge|flank pain"] -Onset- [text size="3"] [select value="hour(s)|day(s)|week(s)|month(s)|year(s)"] ago. -Symptoms first noticed during/after- [checkbox value="no reported inciting event"][text size="80"] -Symptoms are worsened by- [checkbox value="nothing"][text size="80"] -Therapies attempted: [checkbox value="none"][text size ="80"] -Effect of these therapies: [select value="helped|worsened|made no difference|mixed- see comments"] -Symptom progression: [select value="gotten better|gotten worse|stayed about the same"] -Previous episodes: [select value="denies|admits"] to a UTI in the past. [text size="60"] -Additional comments- [textarea default="none"] Review of systems: [checklist value="symptoms >7 days duration|shaking chills|flank pain|temp >101F|nausea|vomiting|abdominal pain|change in vaginal/penile discharge or odor|painful with intercourse"] Pertinent medical history: [checklist value="pyelonephritis within the last 3 months|diabetes|current/recent pregnancy|immunosuppression|kidney stones|kidney failure|catheterization within the last 2 weeks|hospitalization or nursing home residency within the last 2 weeks|4 or more UTIs within the last 12 months|antibiotic for a UTI in the last 4 weeks [/conditional][checkbox memo="headaches/migraines" memo_size="small" name="HPIforHeadache" value="Headache Sx"][conditional field="HPIforHeadache" condition="(HPIforHeadache).is('Headache Sx')"] -Symptoms: [text memo="other/not listed" memo_size="small"][checkbox value="headache"] -Onset- [text size="3"] [select value="hour(s)|day(s)|week(s)|month(s)|year(s)"] ago. -Symptoms first noticed during/after: [checkbox value="no reported inciting event"][text size="80"] -Symptom location- [text size="60"] -Symptom radiation- [checkbox value="none"][text size="80"] -Pain severity- currently [text size="5"]/10; at worst [text size="5"]/10 -Characterized as- [text size="60"][checkbox value="sharp|dull|throbbing|pounding"] -Symptom progression: [select value="getting better|GETTING WORSE|the same"] -Therapies/medications tried- [checkbox value="none"][text size="80"] -Pain improved with [checkbox value="nothing"][text size="30"]. -Pain worsened by [checkbox value="nothing"][text size="30"]. -#Episodes per [select value="month|week"]- [checkbox value="n/a"][text size="5"] -Additional comments- [textarea default="none"] Review of Symptoms: [checklist value="worse with bright lights|worse with loud noises|nausea/vomiting|preceding aura before the headache (e.g. vision change, smell, other symptom prodrome)|blurred vision|fever|sinus pressure or nasal drainage|arm/leg weakness"] [textarea memo="explanation of positives" memo_size="small" cols="2"] Pertinent PMH: [checklist value="Migraine Headache|Frequent Sinusitis|Glaucoma|Head Trauma|Serious CNS risks (e.g. active cancer, immunosuppression, HIV)|Exposures (e.g. Tick bites, carbon monoxide)|Family history of cerebral aneurysm or stroke"] [/conditional][checkbox memo="insomnias/parasomnias" memo_size="small" name="HPIforSleep" value="Sleep Concerns"][conditional field="HPIforSleep" condition="(HPIforSleep).is('Sleep Concerns')"] -Symptoms: [text memo="other/not listed" memo_size="small" size="80"][checkbox value="difficulty getting to sleep|difficulty staying asleep|legs/arms restless feeling|not feeling rested when waking up for the day|excessive sleepiness during the day"] -Duration: [text size="5"] [select value="day(s)|week(s)|month(s)|year(s)"] -Specific life event that during/afterwards the symptoms started: [checkbox value="none/denies"][textarea rows="2"] -Symptom progression: [select value="gotten better|gotten worse|no change"] -Therapies attempted: [textarea memo="other/not listed" memo_size="small" rows="2"] [comment memo="Sleep hygiene, stimulus and temporal control" memo_size="small"][checklist value="Lie down to sleep only when feeling sleepy|Avoid wakeful activities at bedtime (watching television, talking on the phone, eating)|Leave the bed if unable to fall asleep within 20 minutes and return when sleepy|Maintaining consistent bed/wake times (including weekends/days-off)|Avoiding daytime naps|Exercise regularly (not within 4 hours of bedtime, outside of unit PT)|Avoiding large meals and limit fluid intake in the evenings|Limiting caffeine, tobacco, and alcohol use|Using the bedroom for only sleep/sex|Avoiding distracting stimuli at bedtime like loud noises, bright lights when not being used therapeutically, and extreme temperature variations|Ear-plugs used to limit noise"][comment memo="Sleep restriction" memo_size="small"][checklist value="Limiting time in bed to the number of hours actually spent sleeping (not less than 5 hours, sleep time gradually increases as sleep efficiency improves)"][comment memo="Paradoxical intention" memo_size="small"][checklist value="Focuses on remaining awake in calm environment to address the anxiety a/w the pressure to fall asleep"][comment memo="Relaxation training" memo_size="small"][checklist value="Autogenic training (imagining a calm environment with comforting body perceptions such as warmth and heaviness of the limbs)|Imagery training (focus on pleasant images)|Repetitive focus (focus on a word, sound, prayer, phrase, or muscle activity)|Hypnosis|Meditation|Yoga|Abdominal breathing|Progressive muscle relaxation (from the feet up to the facial muscles)|Paced respirations (Take a deep breath and hold for five seconds, repeat several times; focus on the sound of the breath)"] -Effect of attempted therapies: [select value="helped|worsened|no difference|mixed- see comments"] -Additional comments- [textarea default="none"] -Pertinent PMHx review: [checklist value="Generalized Anxiety D/O|Major Depressive D/O|Adjustment D/O|Bipolar D/O|PTSD|TBI|ADHD|Sleep paralysis|Restless Legs Syndrome|Sleep Apnea|GERD|Asthma/COPD/CHF|MSK chronic issues that cause pain at night"] -Review of systems/behaviors/environment: [checklist value="choking/gasping in sleep|loud snoring|sleep walking|injured self/others when asleep|frequent disturbing nightmares|frequent changes in timing of work shifts|difficulty 'shutting down' mind when it is time for sleep|regularly watch TV/movies and/or play video games less than 1 hr before bedtime|last meal less than 2 hr before bedtime|presence of roommate|presence of bedmate"] [/conditional][link url="https://www.soapnote.org/procedure/medic-nurse-interventions-point-of-care-resp-meds-iv-immunizations/" memo="Immunizations/IV/IM/PO meds/respiratory therapy/IV hydration "][link url="https://www.soapnote.org/subjective/master-physician-team-documentation-workflow/" memo="PWF1 - questionnaires "][link url="https://www.soapnote.org/objective/master-physician-workflow-part-2-2/" memo="PWF2a - non-MSK PE "][link url="https://www.soapnote.org/objective/master-physician-workflow-part-2b/" memo="PWF2b - MSK PE "][link url="https://www.soapnote.org/plan/master-physician-workflow-part-3-2/" memo="PWF3a - Acute/MSK A/P "][checkbox name="ProcLinks" memo="Links to Procedure Templates" memo_size="small" value=""][conditional field="ProcLinks" condition="(ProcLinks).is('')"][link url="https://www.soapnote.org/procedure/laceration-repair-procedure-note/" memo="I&D & Laceration Repair "][link url="https://www.soapnote.org/procedure/toenail-removal-procedure-note/" memo="Toenail Removal "][link url="https://www.soapnote.org/procedure/minor-skin-procedures-note/" memo="Minor Skin Procedures "][link url="https://www.soapnote.org/procedure/female-procedures-note/" memo="Female Procedures "][link url="https://www.soapnote.org/procedure/omt-auricular-acupuncture-procedure-note/" memo="OMT/Auricular Acupuncture "][/conditional][comment memo="For use in CRDAMC FM Clinic" memo_color="blue"] VIDEO VIRTUAL ENCOUNTER PHYSICAL EXAM [checkbox name="vitals" memo="*" memo_size="small" memo_color="blue" value="-Vitals Review"][conditional field="vitals" condition="(vitals).is('-Vitals Review')"] - [select value="reviewed, no remarkable abnormalities|significant for"][text size="50"] [/conditional]-General - [comment memo="*" memo_size="small" memo_color="blue"][conditional field="GENexamdetailed" condition="(GENexamdetailed).isNot('')"][text default="well developed, well nourished, no apparent distress" size="80"][/conditional][checkbox name="GENexamdetailed" memo="more detail" memo_size="small" memo_color="yellow" value=""][conditional field="GENexamdetailed" condition="(GENexamdetailed).is('')"][textarea memo="←freetext" memo_size="small" cols="80" rows="2"] [comment memo="↓quickpicks↓" memo_size="small"][checkbox value="well developed|well nourished|A&Ox4|NAD"] [checkbox value="MILDLY ILL|SLEEPY|APPEARS CONFUSED|APPEARS LETHARGIC|CACHECTIC APPEARANCE|APPEARS OLDER THAN STATED AGE"][/conditional] -HEENT - [comment memo="*" memo_size="small" memo_color="blue"][conditional field="HEENTexamdetailed" condition="(HEENTexamdetailed).isNot('')"][text default="normocephalic, atraumatic, nares patent, mucous membranes moist" size="80"][/conditional][checkbox name="HEENTexamdetailed" memo="more detail" memo_size="small" memo_color="yellow" value=""][conditional field="HEENTexamdetailed" condition="(HEENTexamdetailed).is('')"][textarea memo="←freetext" memo_size="small" cols="80" rows="2"] [comment memo="↓quickpicks↓" memo_size="small"][checkbox value="normocephalic|atraumatic|conjunctiva clear|sclerae aninteric|TMs with clearly visible landmarks|nares patent b/l|turbinates nonedematous/nonerythematous b/l|mucous membranes moist|throat nonerythematous/noninjected|good dentition"] [checkbox value="R CONJUNCTIVAL ERYTHEMA|L CONJUNCTIVAL ERYTHEMA|R TM OPAQUENESS & LOSS OF LANDMARKS|R TM VIEW OBSCURRED BY CERUMEN|L TM OPAQUENESS & LOSS OF LANDMARKS|L TM VIEW OBSCURRED BY CERUMEN|NASAL SEPTUM DEVIATION|R TURBINATE EDEMA|R TURBINATE ERYTHEMA|L TURBINATE EDEMA|L TURBINATE ERYTHEMA|NASAL DISCHARGE|PHARYNGEAL ERYTHEMA/INJECTION|PHARYNGEAL COBBLESTONING|TONSILS INJECTED/EDEMATOUS|TONSILS WITH EXUDATE|GLOSSAL HYPERTROPHY|UVULAR DEVIATION"][/conditional] -Neck - [comment memo="*" memo_size="small" memo_color="blue"][conditional field="NECKexamdetailed" condition="(NECKexamdetailed).isNot('')"][text default="no gross distention, no visible overt defect" size="80"][/conditional][checkbox name="NECKexamdetailed" memo="more detail" memo_size="small" memo_color="yellow" value=""][conditional field="NECKexamdetailed" condition="(NECKexamdetailed).is('')"][textarea memo="←freetext" memo_size="small" cols="80" rows="2"] [comment memo="↓quickpicks↓" memo_size="small"][checkbox value="soft/supple|no JVD|no thyromegaly|no tender/enlarged lymph nodes"] [checkbox value="R ANTERIOR CHAIN LYMPHADENOPATHY|R POSTERIOR CHAIN LYMPHADENOPATHY|L ANTERIOR CHAIN LYMPHADENOPATHY|L POSTERIOR CHAIN LYMPHADENOPATHY|JUGULAR VENOUS DISTENSION|GOITER"] [checkbox name="SKINexam" memo="*" memo_size="small" memo_color="blue" value="-Skin - "][conditional field="SKINexam|SKINexamdetailed" condition="((SKINexam).is('-Skin - '))&&((SKINexamdetailed).isNot(''))"][text default="warm, dry, intact, no edema/erythema/induration/ecchymosis" size="80"] [/conditional][conditional field="SKINexam" condition="(SKINexam).is('-Skin - ')"][checkbox name="SKINexamdetailed" memo="more detail" memo_size="small" memo_color="yellow" value=""][/conditional][conditional field="SKINexamdetailed" condition="(SKINexamdetailed).is('')"][textarea memo="←freetext" memo_size="small" cols="80" rows="2"] [comment memo="↓quickpicks↓" memo_size="small"][checkbox value="warm|dry|intact|no edema|no erythema|no induration|no ecchymosis|no concerning lesions"] [checkbox name="examskinabn1" value="ACROCYANOSIS|JAUNDICE- |DIFFUSE/NON-FOCAL LESION(S)- "][/conditional][conditional field="examskinabn1" condition="(examskinabn1).is('DIFFUSE/NON-FOCAL LESION(S)- ')||(examskinabn1).is('JAUNDICE- ')"] -Affected area(s)- [checkbox value="face|forehead|anterior neck|posterior neck|anterior trunk|posterior trunk|R shoulder|l shoulder|R arm|L arm|R elbow|L elbow|R forearm|L forearm|R wrist|L wrist|R hand dorsum|L hand dorsum|R palm|L palm|R inguinaL area|L inguinaL area|R hip|L hip|R thigh|L thigh|R knee|L knee|R leg|L leg|R ankle|L ankle|R foot dorsum|L foot dorsum|R foot sole|L foot sole"] -Description- [checkbox name="examskinabn11" value="macular|papular|raised(plaques)|patches|lacey appearance|scattered|clustered|rough texture|smooth texture|erythematous|ecchymosis|skin/flesh colored|hyperpigmented|hypopigmented|non-blanching|scaling|crusting|excoriated|ulcerated|non-ulcerated"] -Additional details- [textarea default="none" rows="2"] [/conditional][conditional field="SKINexamdetailed" condition="(SKINexamdetailed).is('')"][checkbox name="examskinabn2" value="FOCAL/ISOLATED LESION(S)- "][/conditional][conditional field="examskinabn2" condition="(examskinabn2).is('FOCAL/ISOLATED LESION(S)- ')"][checkbox memo="*" memo_size="small" name="Lesion1" value=" -#1 "][/conditional][conditional field="Lesion1" condition="(Lesion1).is(' -#1 ')"] -Location: [select name="skinexamlocation1" value="|Scalp|Face|Neck|Shoulder|Chest/Trunk|Abdomen|Buttocks|Inguinal|Male Genital Region|Female Genital Region|Arm|Elbow|Forearm|Wrist|Hand|Finger|Hip|Thigh|Knee|Leg|Ankle|Foot|Toe"][/conditional][conditional field="skinexamlocation1" condition="(skinexamlocation1).is('Scalp')"]- [select value="right|left|midline"] [select value="occipital|parietal|temporal|frontal|preauricular|postauricular"] area[/conditional][conditional field="skinexamlocation1" condition="(skinexamlocation1).is('Face')"]- [select value="right|left|midline"] [select value="preauricular|mandibular angle|cheek|nose|periorbital|perioral|chin|submandibular|submental"] area[/conditional][conditional field="skinexamlocation1" condition="(skinexamlocation1).is('Neck')"]- [select value="right|left|midline"], [checkbox value="anterior|posterior|medial|lateral"], [select value="superior|inferior|middle"] aspect[/conditional][conditional field="skinexamlocation1" condition="(skinexamlocation1).is('Shoulder')||(skinexamlocation1).is('Elbow')||(skinexamlocation1).is('Wrist')||(skinexamlocation1).is('Hip')||(skinexamlocation1).is('Knee')||(skinexamlocation1).is('Ankle')"]- [select value="right|left"], [checkbox value="anterior|posterior|medial|lateral"] aspect[/conditional][conditional field="skinexamlocation1" condition="(skinexamlocation1).is('Arm')||(skinexamlocation1).is('Forearm')||(skinexamlocation1).is('Thigh')||(skinexamlocation1).is('Leg')"]- [select value="right|left"], [checkbox value="anterior|posterior|medial|lateral"], [select value="superior|inferior|middle"] aspect[/conditional][conditional field="skinexamlocation1" condition="(skinexamlocation1).is('Chest/Trunk')"]- [select value="right|left|midline"], [checkbox value="anterior|posterior|medial|lateral"], [select value="superior|inferior|middle"] aspect[/conditional][conditional field="skinexamlocation1" condition="(skinexamlocation1).is('Abdomen')"]- [select value="periumbilical|epigastrium|RUQ|LUQ|RLQ|LLQ"] aspect[/conditional][conditional field="skinexamlocation1" condition="(skinexamlocation1).is('Buttocks')"]- [select value="right|left|midline"] [select value="|medial|lateral"] [select value="perianal|gluteal cleft|cheek|gluteal fold"][/conditional][conditional field="skinexamlocation1" condition="(skinexamlocation1).is('Inguinal')"]- [select value="right|left"][/conditional][conditional field="skinexamlocation1" condition="(skinexamlocation1).is('Male Genital Region')"]- [select value="right|left|midline"] [select value="penile glans|penile shaft|base of penis|scrotum|periscrotal area"][/conditional][conditional field="skinexamlocation1" condition="(skinexamlocation1).is('Female Genital Region')"]- [select value="right|left|midline"] [select value="labia majora|labia minora|perilabial area|periclitoral area|mons pubis|perineum"][/conditional][conditional field="skinexamlocation1" condition="(skinexamlocation1).is('Hand')||(skinexamlocation1).is('Finger')"]- [select value="right|left"], [checkbox value="palmar/volar|dorsal|medial|lateral"] aspect[/conditional][conditional field="skinexamlocation1" condition="(skinexamlocation1).is('Finger')"], [select value="1st|2nd|3rd|4th|5th"] digit, [select value="MCP|proximal phalanx|middle phalanx|distal phalanx|periungual area"][/conditional][conditional field="skinexamlocation1" condition="(skinexamlocation1).is('Foot')||(skinexamlocation1).is('Toe')"]- [select value="right|left"], [checkbox value="plantar|dorsal|medial|lateral"] aspect[/conditional][conditional field="skinexamlocation1" condition="(skinexamlocation1).is('Toe')"], [select value="1st|2nd|3rd|4th|5th"] digit, [select value="MTP|proximal phalanx|middle phalanx|distal phalanx|periungual area"][/conditional][conditional field="Lesion1" condition="(Lesion1).is(' -#1 ')"] -Description: [checkbox name="skinexamlesion1" value="macule|papule|patch|plaque|palpable lump|visible wound|visible lump (concerning for infection)"] -Size/diameter: [text size="5"] [select value="cm|mm"] [/conditional][conditional field="skinexamlesion1" condition="(skinexamlesion1).is('macule')||(skinexamlesion1).is('papule')||(skinexamlesion1).is('patch')||(skinexamlesion1).is('plaque')"] -Characteristics: [checkbox value="rough|smooth|firm|soft|mobile|fixed|pedunculated"] -Color: [select value="uniform color|non-uniform color"], [select value="erthythematous|flesh-color|brown|black|blue|multicolored"] [text size="20"] -Borders: [select value="well-circumscribed|ill-defined"] [/conditional][conditional field="skinexamlesion1" condition="(skinexamlesion1).is('visible lump (concerning for infection)')"] -Characteristics - [checkbox name="abscessPEchar" value="erythema|edema|induration|fluctuance|tenderness to palpation|drainage"][/conditional][conditional field="abscessPEchar" condition="(abscessPEchar).is('drainage')"] - [checkbox value="purulent|serous|sanguinous/bloody"][/conditional][conditional field="skinexamlesion1" condition="(skinexamlesion1).is('visible lump (concerning for infection)')"] [/conditional][conditional field="skinexamlesion1" condition="(skinexamlesion1).is('visible wound')"] -Tissue layers damaged/affected - [checkbox value="epidermis|dermis|subcutaneous layer|muscle/tendon|periosteum/bone"] -Hemostatic - [select value="|Yes|NO"] -Wound approximation - [select value="|good|marginal|POOR"] -Debris/foreign body present - [text default="no" size="20"] [/conditional][conditional field="Lesion1" condition="(Lesion1).is(' -#1 ')"] -Other details: [text default="none" size="80"] [/conditional][conditional field="examskinabn2" condition="(examskinabn2).is('FOCAL/ISOLATED LESION(S)- ')"][checkbox memo="*" memo_size="small" name="Lesion2" value=" -#2 "][/conditional][conditional field="Lesion2" condition="(Lesion2).is(' -#2 ')"] -Location: [select name="skinexamlocation2" value="|Scalp|Face|Neck|Shoulder|Chest/Trunk|Abdomen|Buttocks|Inguinal|Male Genital Region|Female Genital Region|Arm|Elbow|Forearm|Wrist|Hand|Finger|Hip|Thigh|Knee|Leg|Ankle|Foot|Toe"][/conditional][conditional field="skinexamlocation2" condition="(skinexamlocation2).is('Scalp')"]- [select value="right|left|midline"] [select value="occipital|parietal|temporal|frontal|preauricular|postauricular"] area[/conditional][conditional field="skinexamlocation2" condition="(skinexamlocation2).is('Face')"]- [select value="right|left|midline"] [select value="preauricular|mandibular angle|cheek|nose|periorbital|perioral|chin|submandibular|submental"] area[/conditional][conditional field="skinexamlocation2" condition="(skinexamlocation2).is('Neck')"]- [select value="right|left|midline"], [checkbox value="anterior|posterior|medial|lateral"], [select value="superior|inferior|middle"] aspect[/conditional][conditional field="skinexamlocation2" condition="(skinexamlocation2).is('Shoulder')||(skinexamlocation2).is('Elbow')||(skinexamlocation2).is('Wrist')||(skinexamlocation2).is('Hip')||(skinexamlocation2).is('Knee')||(skinexamlocation2).is('Ankle')"]- [select value="right|left"], [checkbox value="anterior|posterior|medial|lateral"] aspect[/conditional][conditional field="skinexamlocation2" condition="(skinexamlocation2).is('Arm')||(skinexamlocation2).is('Forearm')||(skinexamlocation2).is('Thigh')||(skinexamlocation2).is('Leg')"]- [select value="right|left"], [checkbox value="anterior|posterior|medial|lateral"], [select value="superior|inferior|middle"] aspect[/conditional][conditional field="skinexamlocation2" condition="(skinexamlocation2).is('Chest/Trunk')"]- [select value="right|left|midline"], [checkbox value="anterior|posterior|medial|lateral"], [select value="superior|inferior|middle"] aspect[/conditional][conditional field="skinexamlocation2" condition="(skinexamlocation2).is('Abdomen')"]- [select value="periumbilical|epigastrium|RUQ|LUQ|RLQ|LLQ"] aspect[/conditional][conditional field="skinexamlocation2" condition="(skinexamlocation2).is('Buttocks')"]- [select value="right|left|midline"] [select value="|medial|lateral"] [select value="perianal|gluteal cleft|cheek|gluteal fold"][/conditional][conditional field="skinexamlocation2" condition="(skinexamlocation2).is('Inguinal')"]- [select value="right|left"][/conditional][conditional field="skinexamlocation2" condition="(skinexamlocation2).is('Male Genital Region')"]- [select value="right|left|midline"] [select value="penile glans|penile shaft|base of penis|scrotum|periscrotal area"][/conditional][conditional field="skinexamlocation2" condition="(skinexamlocation2).is('Female Genital Region')"]- [select value="right|left|midline"] [select value="labia majora|labia minora|perilabial area|periclitoral area|mons pubis|perineum"][/conditional][conditional field="skinexamlocation2" condition="(skinexamlocation2).is('Hand')||(skinexamlocation2).is('Finger')"]- [select value="right|left"], [checkbox value="palmar/volar|dorsal|medial|lateral"] aspect[/conditional][conditional field="skinexamlocation2" condition="(skinexamlocation2).is('Finger')"], [select value="1st|2nd|3rd|4th|5th"] digit, [select value="MCP|proximal phalanx|middle phalanx|distal phalanx|periungual area"][/conditional][conditional field="skinexamlocation2" condition="(skinexamlocation2).is('Foot')||(skinexamlocation2).is('Toe')"]- [select value="right|left"], [checkbox value="plantar|dorsal|medial|lateral"] aspect[/conditional][conditional field="skinexamlocation2" condition="(skinexamlocation2).is('Toe')"], [select value="1st|2nd|3rd|4th|5th"] digit, [select value="MTP|proximal phalanx|middle phalanx|distal phalanx|periungual area"][/conditional][conditional field="Lesion2" condition="(Lesion2).is(' -#2 ')"] -Description: [checkbox name="skinexamlesion2" value="macule|papule|patch|plaque|palpable lump|visible wound|visible lump (concerning for infection)"] -Size/diameter: [text size="5"] [select value="cm|mm"] [/conditional][conditional field="skinexamlesion2" condition="(skinexamlesion2).is('macule')||(skinexamlesion2).is('papule')||(skinexamlesion2).is('patch')||(skinexamlesion2).is('plaque')"] -Characteristics: [checkbox value="rough|smooth|firm|soft|mobile|fixed|pedunculated"] -Color: [select value="uniform color|non-uniform color"], [select value="erthythematous|flesh-color|brown|black|blue|multicolored"] [text size="20"] -Borders: [select value="well-circumscribed|ill-defined"] [/conditional][conditional field="skinexamlesion2" condition="(skinexamlesion2).is('visible lump (concerning for infection)')"] -Characteristics - [checkbox name="abscessPEchar" value="erythema|edema|induration|fluctuance|tenderness to palpation|drainage"][/conditional][conditional field="abscessPEchar" condition="(abscessPEchar).is('drainage')"] - [checkbox value="purulent|serous|sanguinous/bloody"][/conditional][conditional field="skinexamlesion2" condition="(skinexamlesion2).is('visible lump (concerning for infection)')"] [/conditional][conditional field="skinexamlesion2" condition="(skinexamlesion2).is('visible wound')"] -Tissue layers damaged/affected - [checkbox value="epidermis|dermis|subcutaneous layer|muscle/tendon|periosteum/bone"] -Hemostatic - [select value="|Yes|NO"] -Wound approximation - [select value="|good|marginal|POOR"] -Debris/foreign body present - [text default="no" size="20"] [/conditional][conditional field="Lesion2" condition="(Lesion2).is(' -#2 ')"] -Other details: [text default="none" size="80"] [/conditional][conditional field="examskinabn2" condition="(examskinabn2).is('FOCAL/ISOLATED LESION(S)- ')"][checkbox memo="*" memo_size="small" name="Lesion3" value=" -#3 "][/conditional][conditional field="Lesion3" condition="(Lesion3).is(' -#3 ')"] -Location: [select name="skinexamlocation3" value="|Scalp|Face|Neck|Shoulder|Chest/Trunk|Abdomen|Buttocks|Inguinal|Male Genital Region|Female Genital Region|Arm|Elbow|Forearm|Wrist|Hand|Finger|Hip|Thigh|Knee|Leg|Ankle|Foot|Toe"][/conditional][conditional field="skinexamlocation3" condition="(skinexamlocation3).is('Scalp')"]- [select value="right|left|midline"] [select value="occipital|parietal|temporal|frontal|preauricular|postauricular"] area[/conditional][conditional field="skinexamlocation3" condition="(skinexamlocation3).is('Face')"]- [select value="right|left|midline"] [select value="preauricular|mandibular angle|cheek|nose|periorbital|perioral|chin|submandibular|submental"] area[/conditional][conditional field="skinexamlocation3" condition="(skinexamlocation3).is('Neck')"]- [select value="right|left|midline"], [checkbox value="anterior|posterior|medial|lateral"], [select value="superior|inferior|middle"] aspect[/conditional][conditional field="skinexamlocation3" condition="(skinexamlocation3).is('Shoulder')||(skinexamlocation3).is('Elbow')||(skinexamlocation3).is('Wrist')||(skinexamlocation3).is('Hip')||(skinexamlocation3).is('Knee')||(skinexamlocation3).is('Ankle')"]- [select value="right|left"], [checkbox value="anterior|posterior|medial|lateral"] aspect[/conditional][conditional field="skinexamlocation3" condition="(skinexamlocation3).is('Arm')||(skinexamlocation3).is('Forearm')||(skinexamlocation3).is('Thigh')||(skinexamlocation3).is('Leg')"]- [select value="right|left"], [checkbox value="anterior|posterior|medial|lateral"], [select value="superior|inferior|middle"] aspect[/conditional][conditional field="skinexamlocation3" condition="(skinexamlocation3).is('Chest/Trunk')"]- [select value="right|left|midline"], [checkbox value="anterior|posterior|medial|lateral"], [select value="superior|inferior|middle"] aspect[/conditional][conditional field="skinexamlocation3" condition="(skinexamlocation3).is('Abdomen')"]- [select value="periumbilical|epigastrium|RUQ|LUQ|RLQ|LLQ"] aspect[/conditional][conditional field="skinexamlocation3" condition="(skinexamlocation3).is('Buttocks')"]- [select value="right|left|midline"] [select value="|medial|lateral"] [select value="perianal|gluteal cleft|cheek|gluteal fold"][/conditional][conditional field="skinexamlocation3" condition="(skinexamlocation3).is('Inguinal')"]- [select value="right|left"][/conditional][conditional field="skinexamlocation3" condition="(skinexamlocation3).is('Male Genital Region')"]- [select value="right|left|midline"] [select value="penile glans|penile shaft|base of penis|scrotum|periscrotal area"][/conditional][conditional field="skinexamlocation3" condition="(skinexamlocation3).is('Female Genital Region')"]- [select value="right|left|midline"] [select value="labia majora|labia minora|perilabial area|periclitoral area|mons pubis|perineum"][/conditional][conditional field="skinexamlocation3" condition="(skinexamlocation3).is('Hand')||(skinexamlocation3).is('Finger')"]- [select value="right|left"], [checkbox value="palmar/volar|dorsal|medial|lateral"] aspect[/conditional][conditional field="skinexamlocation3" condition="(skinexamlocation3).is('Finger')"], [select value="1st|2nd|3rd|4th|5th"] digit, [select value="MCP|proximal phalanx|middle phalanx|distal phalanx|periungual area"][/conditional][conditional field="skinexamlocation3" condition="(skinexamlocation3).is('Foot')||(skinexamlocation3).is('Toe')"]- [select value="right|left"], [checkbox value="plantar|dorsal|medial|lateral"] aspect[/conditional][conditional field="skinexamlocation3" condition="(skinexamlocation3).is('Toe')"], [select value="1st|2nd|3rd|4th|5th"] digit, [select value="MTP|proximal phalanx|middle phalanx|distal phalanx|periungual area"][/conditional][conditional field="Lesion3" condition="(Lesion3).is(' -#3 ')"] -Description: [checkbox name="skinexamlesion3" value="macule|papule|patch|plaque|palpable lump|visible wound|visible lump (concerning for infection)"] -Size/diameter: [text size="5"] [select value="cm|mm"] [/conditional][conditional field="skinexamlesion3" condition="(skinexamlesion3).is('macule')||(skinexamlesion3).is('papule')||(skinexamlesion3).is('patch')||(skinexamlesion3).is('plaque')"] -Characteristics: [checkbox value="rough|smooth|firm|soft|mobile|fixed|pedunculated"] -Color: [select value="uniform color|non-uniform color"], [select value="erthythematous|flesh-color|brown|black|blue|multicolored"] [text size="20"] -Borders: [select value="well-circumscribed|ill-defined"] [/conditional][conditional field="skinexamlesion3" condition="(skinexamlesion3).is('visible lump (concerning for infection)')"] -Characteristics - [checkbox name="abscessPEchar" value="erythema|edema|induration|fluctuance|tenderness to palpation|drainage"][/conditional][conditional field="abscessPEchar" condition="(abscessPEchar).is('drainage')"] - [checkbox value="purulent|serous|sanguinous/bloody"][/conditional][conditional field="skinexamlesion3" condition="(skinexamlesion3).is('visible lump (concerning for infection)')"] [/conditional][conditional field="skinexamlesion3" condition="(skinexamlesion3).is('visible wound')"] -Tissue layers damaged/affected - [checkbox value="epidermis|dermis|subcutaneous layer|muscle/tendon|periosteum/bone"] -Hemostatic - [select value="|Yes|NO"] -Wound approximation - [select value="|good|marginal|POOR"] -Debris/foreign body present - [text default="no" size="20"] [/conditional][conditional field="Lesion3" condition="(Lesion3).is(' -#3 ')"] -Other details: [text default="none" size="80"] [/conditional]-PSYCH - [comment memo="*" memo_size="small" memo_color="blue"][conditional field="PSYCHexamdetailed" condition="(PSYCHexamdetailed).isNot('')"][text default="appropriate mood/affect" size="80"][/conditional][checkbox name="PSYCHexamdetailed" memo="more detail" memo_size="small" memo_color="yellow" value=""][conditional field="PSYCHexamdetailed" condition="(PSYCHexamdetailed).is('')"][textarea memo="←freetext" memo_size="small" cols="80" rows="2"] [comment memo="↓quickpicks↓" memo_size="small"][checkbox value="appropriate mood|appropriate affect|FLATTENED AFFECT|INAPPROPRIATE MOOD|PRESSURED SPEECH|DISORGANIZED THOUGHT PROCESS|TANGENTIAL THOUGHT PROCESS"][/conditional] -NEURO - [comment memo="*" memo_size="small" memo_color="blue"][conditional field="NEUROexamdetailed" condition="(NEUROexamdetailed).isNot('')"][text default="mentation normal/appropriate, no gross/overt cranial nerve deficits" size="80"][/conditional][checkbox name="NEUROexamdetailed" memo="more detail" memo_size="small" memo_color="yellow" value=""][conditional field="NEUROexamdetailed" condition="(NEUROexamdetailed).is('')"][textarea memo="←freetext" memo_size="small" cols="80" rows="2"] [comment memo="↓quickpicks↓" memo_size="small"][checkbox value="mentating well|moves all extremities equally well|CN 2-12 grossly intact b/l|normal sensorium all 4 extremities|no gross motor deficits|Romberg negative|cerebellar testing normal|DTRs 2/4 x4|gait testing without abnormalities"][/conditional][conditional field="examNEUROabn1|examNEUROabn2|examNEUROabn3|examNEUROabn4|examNEUROabn5|examNEUROabn6" condition="((examNEUROabn1).is(' -Cranial Nerve Deficit(s)- '))||((examNEUROabn2).is(' -Sensory Deficit(s)- '))||((examNEUROabn3).is(' -Motor Strength-'))||((examNEUROabn4).is(' -Reflexes-'))||((examNEUROabn5).is(' -Cerebellar Testing-'))||((examNEUROabn6).is(' -Gait- '))"] [/conditional][conditional field="NEUROexamdetailed" condition="(NEUROexamdetailed).is('')"][comment memo="abnormals" memo_size="small" memo_color="orange"][checkbox name="examNEUROabn1" value=" -Cranial Nerve Deficit(s)- "][/conditional][conditional field="examNEUROabn1" condition="(examNEUROabn1).is(' -Cranial Nerve Deficit(s)- ')"] [checkbox value="I|II|III|IV|V|VI|VII|VIII|IX|X|XI|XII"] [/conditional][conditional field="NEUROexamdetailed" condition="(NEUROexamdetailed).is('')"][checkbox name="examNEUROabn2" value=" -Sensory Deficit(s)- "][/conditional][conditional field="examNEUROabn2" condition="(examNEUROabn2).is(' -Sensory Deficit(s)- ')"][checkbox name="examNEUROabn11" value="R occipital|R parietal|R temporal|R frontal|R preauricular|R postauricular|L occipital|L parietal|L temporal|L frontal|L preauricular|L postauricular|R mandibular angle|R cheek|R nasal bridge|R periorbital|R perioral|chin|submental|R submandibular|L mandibular angle|L cheek|L nasal bridge|L periorbital|L perioral|L submandibular|Neck anterior|Neck posterior|Neck medial|Neck lateral|R shoulder|L shoulder|Anterior chest/trunk|Posterior chest/trunk|Abdomen|R buttocks|L buttocks|Perianal|Gluteal cleft|R inguinal|L inguinal|Penis|R scrotum|L scrotum|R labia majora|R labia minora|R perilabial area|L labia majora|L labia minora|L perilabial area|periclitoral area|mons pubis|perineum|R arm|R elbow|R forearm|R wrist|R hand/finger(s)|L arm|L elbow|L forearm|L wrist|L hand/finger(s)|R hip|R thigh|R knee|R leg|R ankle|R foot/toe(s)|L hip|L thigh|L knee|L leg|L ankle|L foot/toe(s)"] [text memo="description of deficits" memo_size="small" memo_color="yellow" size="80"] [/conditional][conditional field="NEUROexamdetailed" condition="(NEUROexamdetailed).is('')"][checkbox name="examNEUROabn3" value=" -Motor Strength-"][/conditional][conditional field="examNEUROabn3" condition="(examNEUROabn3).is(' -Motor Strength-')"] -R Upper Extremity- [text default="5" size="5"]/5 -L Upper Extremity- [text default="5" size="5"]/5 -R Lower Extremity- [text default="5" size="5"]/5 -L Lower Extremity- [text default="5" size="5"]/5 [/conditional][conditional field="NEUROexamdetailed" condition="(NEUROexamdetailed).is('')"][checkbox name="examNEUROabn4" value=" -Reflexes-"][/conditional][conditional field="examNEUROabn4" condition="(examNEUROabn4).is(' -Reflexes-')"] -Biceps- [text default="2+" size="5"]/4 -Triceps- [text default="2+" size="5"]/4 -Bracioradialis- [text default="2+" size="5"]/4 -Patellar- [text default="2+" size="5"]/4 -Achilles- [text default="2+" size="5"]/4 [/conditional][conditional field="NEUROexamdetailed" condition="(NEUROexamdetailed).is('')"][checkbox name="examNEUROabn5" value=" -Cerebellar Testing-"][/conditional][conditional field="examNEUROabn5" condition="(examNEUROabn5).is(' -Cerebellar Testing-')"] [checkbox value="POSITIVE ROMBERG|PRONATOR DRIFT|IMPAIRED FINGER-TO-NOSE|IMPAIRED HAND PRONATE/SUPINATE|IMPARIED HEEL-TO-SHIN"] [text memo="cerebellar deficits freetext" memo_size="small" size="80"] [/conditional][conditional field="NEUROexamdetailed" condition="(NEUROexamdetailed).is('')"][checkbox name="examNEUROabn6" value=" -Gait- "][/conditional][conditional field="examNEUROabn6" condition="(examNEUROabn6).is(' -Gait- ')"][checkbox value="HEMIPLEGIC|DIPLEGIC|NEUROPATHIC|CHOREIFORM|ATAXIC|PARKINSONIAN|ANTALGIC"] [/conditional] -ADDITIONAL EXAM - Speaking in full sentences[textarea default="none" rows="6" cols="70"] Assessment/ PLAN [conditional field="APvirtualblurb" condition="(APvirtualblurb).is('Virtual Encounter Statement')"] [/conditional][checkbox name="APvirtualblurb" memo="*" memo_color="blue" memo_size="small" value="Virtual Encounter Statement"] [conditional field="APvirtualblurb" condition="(APvirtualblurb).is('Virtual Encounter Statement')"] - Spent [text size="5"] minutes via [select value="realtime audio/video communication|voice-only/telephone|asynchronous secure text messaging"] involving obtaining/reviewing history, [checkbox value="conducting visual exam|discussing test results|discussing workup|discussing above plan|patient education"] [/conditional] Patient to follow up in: [textarea name="28" default=""] RTC and ED instructions given, Patient expressed their understanding and all questions answered
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Sandbox Metrics: Structured Data Index 0.67, 756 form elements, 50 boilerplate words, 159 text boxes, 26 text areas, 1 dates, 130 checkboxes, 17 check lists, 235 drop downs, 10 links, 29 comments, 1 calculations, 148 conditionals, 1132 total clicks
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