Working SOAP

[comment memo="Inpatient H&P SO Portion" memo_size="small"]
cc: [text size="50"]
HPI: Age [text size="3" ]old [/conditional][select value="M|F"] presents to [select value="ED|clinic"] for [textarea]

ED Course: [textarea]

PMHx: [textarea]

Home Meds: [checkbox value="see med rec"]
[textarea cols="60" rows="10"]

All: [checkbox value="NKDA"][textarea cols="60" rows="3"]

PSHx: [checkbox value="reviewed|noncontributory"][textarea]

FMHx: [checkbox value="reviewed|noncontributory"][textarea]

Soc: [textarea rows="2"][checkbox value="reviewed|noncontributory"]
-Tobacco- [select name="Tobacco" value="denies/never|previous-|current-"][conditional field="Tobacco" condition="(Tobacco).is('previous-')"][select value="Tobacco|Vape|Chew"] - [text size="7"] [select value="pack(s)/day|can(s)/wk|recharge(s)/pod(s)/wk"] x [text size="4"]yrs, quit [text size="4"]yrs ago, denies current use[/conditional][conditional field="Tobacco" condition="(Tobacco).is('current-')"][select value="Tobacco|Vape|Chew"] - [text size="7"] [select value="pack(s)/day|can(s)/wk|recharge(s)/pod(s)/wk"] x [text size="4"]yrs[/conditional]
-EtOH- [select name="EtOH" value="denies/never|previous-|current-"][conditional field="EtOH" condition="(EtOH).is('current-')"][text size="3"] [select value="cans of beer|glasses of wine|shots of whiskey"] [select value="daily (average)|weekly (average)|on weekends only|rarely on special occasions"] for [text size="4"]yrs[/conditional][conditional field="EtOH" condition="(EtOH).is('previous-')"] quit [text size="4"] years ago, denies current use[/conditional]
-Illicit drugs- [select name="illicitdrugs" value="denies/never|previous-|current-"][conditional field="illicitdrugs" condition="(illicitdrugs).is('previous-')"][text size="50"] x [text size="4"]yrs, quit [text size="4"]yrs ago[/conditional][conditional field="Tobacco" condition="(Tobacco).is('current-')"][text size="50"] x [text size="4"]yrs[/conditional]
-Living situation- [text default="lives with" size="60"]

ROS: [comment memo="Use freetext to explain {+}s if needed" memo_size="small"]
-Constitutional-
[checklist value="fever|chills|malaise|unexplained wt gain/loss"] [text size="60"]
-HEENT- [checklist value="vision changes|hearing changes|smell changes|nose sx|throat sx|neck sx"] [text size="60"]
-Resp- [checklist value="cough|SOB"] [text size="60"]
-CV- [checklist value="chest pain|palpitations"] [text size="60"]
-GI- [checklist value="abd pain|Nausea|Vomiting|diarrhea|constipation"] [text size="60"]
-GU- [checklist value="urinary frequency|urinary urgency|pain with urination"] [text size="60"]
-MSK- [checklist value="new/unusual muscle aches/pains"] [text size="60"]

Code status: [select name="codestatus1" value="Full Code|DNR/DNI|other-"][conditional field="codestatus1" condition="(codestatus1).is('other-')"][text size="50"][/conditional]

PE: [comment memo="Use freetext for pertinent PE abnormals" memo_size="small"]
Vitals- [select name="Vitals" value="reviewed/stable|reviewed/pertinent for- "][conditional field="Vitals" condition="(Vitals).is('reviewed/pertinent for- ')"][text default="BP *, HR *, RR *, T *, SpO2 * % on *L" size="60"][/conditional]
GEN- [text size="60"] [checkbox value="well developed|well nourished|A&Ox4|NAD"]
HEENT- [text size="60"] [checkbox value="Normocephalic|atraumatic|conjunctiva clear|sclerae aninteric|TMs with clearly visible landmarks|nares patent|mucous membranes moist|throat nonerythematous/noninjected|good dentition"]
Neck- [text size="60"] [checkbox value="soft/supple|no JVD|no thyromegaly|no tender/enlarged lymph nodes"]
CHEST- [text size="60"] [checkbox value="Normal rise and fall B/L|No accessory muscle use"]
HEART- [text size="60"] [checkbox value="RRR|normal S1/S2|No M/R/G|No S3/S4 auscultated|no friction rub"]
LUNGS- [text size="60"] [checkbox value="CTAB|BSE b/l|no wheezes|no crackles|no rhonchi"]
ABD- [text size="60"] [checkbox value="soft|nontender|nondistended|no voluntary/involuntary guarding|no peritoneal signs|bowel sounds present in all 4 quadrants"]
SKIN- [text size="60"] [checkbox value="warm|dry|intact|no edema|no erythema|no ecchymosis"]
EXT- [text size="60"] [checkbox value="no gross deformities noted|no cyanosis|no clubbing"]
NEURO- [text size="60"] [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"]

EKG- [select name="EKG" value="none|reviewed-"] [conditional field="EKG" condition="(EKG).is('reviewed-')"][checkbox value="normal sinus rhythm|tachycardia|bradycardia|normal axis|left axis deviation|right axis deviation|PR interval normal|QRS complex normal|No relevant ST segment deviation/elevation in contiguous leads|QT interval not prolonged"] [text size="80"][/conditional]

LABS- [select name="Labs" value="nothing to review|reviewed/unremarkable|reviewed/notable for- "][conditional field="Labs" condition="(Labs).is('reviewed/notable for- ')"][textarea][/conditional]

RADS- [select name="Rads" value="nothing to review|reviewed/unremarkable|reviewed/notable for- "][conditional field="Rads" condition="(Rads).is('reviewed/notable for- ')"][textarea][/conditional]

_____________________________________________________________________________
[comment memo="Inpatient H&P AP Portion"]
A/P: [text size="3"]yo [select name="AD1" value="active duty|retired|dependent"] [conditional field="AD1" condition="(AD1).isNot('dependent')"][text default="rank" size="6"] [/conditional][select value="M|F"] admitting for [text size="80"]

#[text memo="dx" memo_size="small" size="60"]
[textarea discussion/plan" cols="100" rows="6"]
[comment memo="Drop-downs for add'l problems" memo_size="small"]
[checkbox name="Problem1" value="#"][conditional field="Problem1" condition="(Problem1).is('#')"][text memo="dx" memo_size="small" size="60"]
[textarea memo="discussion/plan" memo_size="small" cols="100" rows="6"]

[/conditional][checkbox name="Problem2" value="#"][conditional field="Problem2" condition="(Problem2).is('#')"][text memo="dx" memo_size="small" size="60"]
[textarea memo="discussion/plan" memo_size="small" cols="100" rows="6"]

[/conditional][checkbox name="Problem3" value="#"][conditional field="Problem3" condition="(Problem3).is('#')"][text memo="dx" memo_size="small" size="60"]
[textarea memo="discussion/plan" memo_size="small" cols="100" rows="6"]

[/conditional][checkbox name="Problem4" value="#"][conditional field="Problem4" condition="(Problem4).is('#')"][text memo="dx" memo_size="small" size="60"]
[textarea memo="discussion/plan" memo_size="small" cols="100" rows="6"]

[/conditional][checkbox name="Problem5" value="#"][conditional field="Problem5" condition="(Problem5).is('#')"][text memo="dx" memo_size="small" size="60"]
[textarea memo="discussion/plan" memo_size="small" cols="100" rows="6"]

[/conditional][checkbox name="Problem6" value="#"][conditional field="Problem6" condition="(Problem6).is('#')"][text memo="dx" memo_size="small" size="60"]
[textarea memo="discussion/plan" memo_size="small" cols="100" rows="6"]

[/conditional]Chronic Medical Conditions: [select name="Chronic" value="none|as follows"]
[conditional field="Chronic" condition="(Chronic).is('as follows')"][textarea default="#dx - stable. no issues. continue current home treatment/meds." cols="80" rows="10"]

[/conditional]
Prophylaxis
GI- [select value="not indicated|PPI"]
DVT- [select value="low padua score|SCDs|Lovenox|Heparin"]

Dispo: Anticipate hospital stay length of [text size="5"] days. Anticipate discharge home once [comment memo="List discharge criteria" memo_size="small"][checkbox value="tolerating PO|dehydration resolved|stable O2 requirement|no O2 requirement|off of IV antibiotics|no longer requiring IV narcotics for pain control|pain adequately improved/improving"][text size="80"].

Code status: [select name="codestatus2" value="Full Code|DNR/DNI|other-"][conditional field="codestatus2" condition="(codestatus2).is('other-')"][text size="50"][/conditional]

[textarea memo="signature block" memo_size="small" cols="50" rows="3"]
[comment memo="For use on FMIT Service" memo_size="small"]