PLEASE NOTE: voice recognition software was used in the creation of this clinical note. Reasonable effort was made to identify and correct gross errors. Despite proof-reading, errors in transcription may be present, including nonsense verbiage at times. If you encounter such an error, please feel free to contact me at (314) 590-6015 or (314) 590-5360 for discussion and correction.
This is a [select name="neworold" value="new|follow-up"] patient appointment in the Gastroenterology Clinic.
CHIEF COMPLAINT: "[text name="CC"]"
HISTORY OF PRESENT ILLNESS:
Patient is [text name="name" default="Rank and Name"], a [text name="age"]-year-old [select name="sex" value="man|woman|boy|girl"] being seen for consult of [text name="consult"].
[textarea name="variable_1" default="sample text"]
GI review of systems included:
[checkbox name="variable_1" value="heartburn|regurgitation|early satiety|dysphagia|odynophagia|abdominal pain|nausea|vomiting|hematemesis|weight loss|weight gain|fever|chills|fatigue|decreased appetite|diarrhea|constipation|hematochezia|melena|bloating|malodorous flatus|anal pain"], or NSAID use, and was negative except as noted above.
REVIEW OF SYSTEMS:
All other review of systems negative except as noted in the HPI [textarea name="ROS" default="and any listed here."]
PAST MEDICAL HISTORY:
[textarea name="PMH" default="None"]
PAST SURGICAL HISTORY:
[textarea name="PSH" default="None"]
Medication history including current prescription medications; over the-counter medications; herbals; supplements and medications not included in AHLTA were reviewed with patient in detail, were updated in the chart, and patient was given an updated medication list.
[textarea name="Rx" default="None"]
[textarea name="none" default="No known drug allergies"]
Tobacco: [text name="tobacco" default="Denies"]
Alcohol: [text name="alcohol" default="Denies"]
Recreational drugs: [text name="illicit" default="Denies"]
Family/Life: [text name="fam" default=""]
[textarea name="fh" default="non contributory"]
Except as noted above, the patient denies other family history of colon cancer, rectal cancer, ulcerative colitis, Crohn's disease, celiac disease, endometrial cancer, gastric cancer, ovarian cancer, pancreatic cancer, ureter or renal cancer, biliary tract cancer/cholangiocarcinoma, brain cancer, or small intestine cancer.
[textarea name="variable_2" cols=80 rows=2 default="CONSTITUTIONAL: Vital signs reviewed as documented above. In no acute distress. Nontoxic-appearing."]
[textarea name="variable_4" cols=80 rows=1 default="EYES: Anicteric conjunctiva. Extra-ocular movements are intact and symmetric."]
[textarea name="variable_5" cols=80 rows=2 default="EARS: Able to hear speech at conversational volume level, no external trauma/masses. "]
[textarea name="variable_7" cols=80 rows=1 default="MOUTH: No oral/mouth lesions or ulcers."]
[textarea name="variable_8" cols=80 rows=1 default="NECK: No masses or crepitus. Thyroid is of normal size and symmetric."]
[textarea name="variable_9" cols=80 rows=1 default="CARDIAC: Regular rate, regular rhythm."]
[textarea name="variable_10" cols=80 rows=2 default="LUNGS: Clear to auscultation bilaterally. No increased work of breathing or accessory muscle use."]
[textarea name="variable_11" cols=80 rows=3 default="ABDOMEN: obese/non-obese abdomen, soft, nontender/tenderness to palpation, no rebound tenderness, nondistended, no rigidity. No palpable mass. No appreciable hepatosplenomegaly."]
[textarea name="variable_12" cols=80 rows=2 default="MUSKULOSKELETAL: Normal gait. Muscle tone appears normal without any abnormal movements."]
[textarea name="variable_17" cols=80 rows=1 default="SKIN: Skin normal color, texture and turgor with no lesions or eruptions."]
[textarea name="variable_18" cols=80 rows=1 default="PSYCH: Normal affect. Alert and oriented to person, place, and time."]
[select name="Labsval" value="No labs to review.|I personally reviewed the patient's lab results. Pertinent results noted below"]
[textarea name="labs" default="No labs to report."]
RADIOLOGY STUDIES: [select name="rads" value="I personally reviewed radiology reports and images|No GI imaging to review"]
[textarea name="rads2" default="No radiologic studies to report."]
ENDOSCOPY REPORTS: [select name="endo" value="I personally reviewed endoscopy reports and images|No prior endoscopic evaluation"]
[textarea name="endo2" default="No endoscopies to report."]
[textarea name="assessment" default=""]
#Other Specified Counseling: [text name="time" default="20"] minutes was spent with the patient. Greater than 50% of the time was spent with patient for counseling and coordination of care, including differential diagnosis, likely diagnosis, diagnostic and therapeutic alternatives, risks/benefits/alternatives of medications and procedures, scheduling and counseling of procedures planned, and plan of care generally. The patient expressed understanding and wishes to proceed.
[textarea name="recs" default=""]
Follow-up in GI clinic: [select name="followup" value="4-6 weeks|as needed"]
Follow-up with referring provider.
The patient expressed understanding of the differential diagnosis or diagnosis, recommendations for any further evaluation as necessary, and management recommendations along with any new prescribed medication, their directions for use and potential side effects. Patient left with a complete "to do" list, in order to enable the patient to orchestrate the next steps in his/her care, including follow-up plan.
I personally reviewed the patient's following data:
[checklist name="rev" value="Laboratory data reviewed and/or ordered|Radiology reports reviewed and/or ordered|Radiology films independently viewed|Diagnostic Endoscopy Procedure Reports reviewed and/or ordered|Patient's previous encounters in the AHLTA electronic medical record (New Patient only)|OR Paper outpatient chart reviewed|OR Discussed the patient's history with another provider, Dr. ______"]
Karin S. Gilkison, MD, MPH
Maj, USAF, MC
Landstuhl Regional Medical Center