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This is a [checkbox name="new_existing" value="new patient|existing patient"]
Historian: [textarea cols=80 rows=1][checkbox name="historian" value="child|parent|MA present during visit|complete history unobtainable d/t parental anxiety and/or lack of knowledge|interpretation provided by family member|interpretation provided by MA"]
Recent: [textarea cols=80 rows=1][checklist name="recent" value="day care/school attendance|sick siblings|travel|ER/UC visit|hospitalization|surgery/procedure|diagnostic/laboratory studies|specialty consults|new medications|ABX use"]
HPI: [textarea cols=100 rows=3][checkbox name="new_chronic" value="new problem|chronic issue|acute exacerbation of a chronic condition"]
Onset: [checkbox name="onset" value="gradual|sudden"]
Duration: [checkbox name="duration" value="N/A|hours|days|months|years"]
Symptoms: [checkbox name="progression" value="N/A|increasing in severity|remaining constant|decreasing in severity"]
Frequency: [checkbox name="frequency" value="N/A|constant|intermittent|occasional"]
Provoked/made worse by/at: [checkbox name="worse" value="N/A|exertion|pressure|position|movement|rest|cold|weather|night|stress"]
Current medications: [textarea cols=80 rows=2][checkbox name="medications" value="none|Rx|OTC|no side effects|effective|partially effective||not effective|not taking as prescribed|did not try|side effects"]

PMH: [textarea cols=80 rows=1][checkbox name="pmh" value="reviewed|non-contributory"]
IMMUNIZATION: [textarea cols=80 rows=1][checkbox name="iz" value="up to date|missing vaccines"]

REVIEW OF SYSTEMS [checkbox name="ros" value="negative except as stated in HPI"]
CONSTITUTIONAL: [textarea cols=80 rows=1][checklist name="constitutional_symptoms" value="fever|chills|body aches|changed behavior|tired|fussy|thirst"]
HEAD/FACE: [textarea cols=80 rows=1][checklist name="head_symptoms" value="head injury|scalp swelling|facial pain|facial swelling"]
Headache: [textarea cols=80 rows=1][checkbox name="headache" value="none|generalized|frontal|occipital|vertex|post-auricular|one-sided|bilateral||dull|sharp|pulsating|burning"]
EYES: [textarea cols=80 rows=1][checkbox name="which_eye" value="Left eye: |Right eye: |Both eyes: "][checkbox name="eye_symptoms" value="no complaints|watery|itching|gritty feeling|irritation|decrease in vision|photophobia|halos|pain with EOM|double vision|eye injury/trauma|FB sensation|lid swelling/nodule|periorbital swelling|discharge|"]
EARS: [textarea cols=80 rows=1][checkbox name="which_ear" value="Left ear: |Right ear: |Both ears: "][checkbox name="ear_symptoms" value="no complaints|pulling on ear(s)|pain|pressure|discharge|bleeding|wax|possible FB|hearing loss|ringing"]
NOSE: [textarea cols=80 rows=1][checklist name="nose_symptoms" value="discharge|PND|congestion|sinus pressure|snoring|bleeding|possible FB|trauma"]
MOUTH: [textarea cols=80 rows=1][checklist name="mouth_symptoms" value="sores|teething|infection|swelling|jaw pain"]
THROAT: [textarea cols=80 rows=1][checklist name="throat_symptoms" value="sore throat|odynophagia|hoarseness|tightness|globus"]
NECK: [textarea cols=80 rows=1][checklist name="neck_symptoms" value="pain|swelling|stiffness|swollen glands"]
CV: [textarea cols=80 rows=1][checklist name="cv_symptoms" value="chest pain/pressure|sob|palpitations|lightheadedness|fainting"]
Chest/Respiratory: [textarea cols=80 rows=1][checklist name="chest_symptoms" value="cough|phlegm|wheezing|pain w/ breathing|rib pain|breast swelling/lump|nipple discharge"]
GI: [textarea cols=80 rows=1][checklist name="gi_symptoms" value="poor appetite|nausea|vomiting|bloating|heartburn|gas|food allergies|generalized abdominal pain|epigastric pain|periumbilical pain|hypochondrial pain|low abdominal pain|diarrhea|constipation|melena|rectal pain/itching|rectal bleeding|laxative use"]
GU: [textarea cols=80 rows=1][checklist name="gu_symptoms" value="dysuria|burning|frequency|urgency|urine odor|blood in urine|flank pain radiating to groin|oliguria|discharge|itching|skin lesion(s)/rash|scrotal swelling|testicular pain"]
MSK: [textarea cols=80 rows=1][checklist name="msk_symptoms" value="myalgias|localized muscle/soft tissue pain/swelling|arthralgias|localized joint pain/swelling|acute back pain|limping"]
NEURO: [textarea cols=80 rows=1][checklist name="neuro_symptoms" value="dizziness|focal weakness|blackouts|tingling/numbness|speech difficulty|seizures"]
BEHAVIORAL: [textarea cols=80 rows=1][checklist name="behavioral_symptoms" value="tantrums|hitting others|speech delay|in special ed"]
PSYCH: [textarea cols=80 rows=1][checklist name="psych_symptoms" value="h/o ψ|prior hospitalizations|current meds|ongoing stress|depressed|anxious|mood swings|sleep problems"]
LYMPH/HEMA: [textarea cols=80 rows=1][checklist name="hem_symptoms" value="gland swelling|unusual bruising|blood disorder|anemia"]
ALLERGIES/IMMUNE: [textarea cols=80 rows=1][checklist name="allergy_symptoms" value="atopy|environmental allergies|asthma|food allergies|autoimmune dz"]
DERM: [textarea cols=80 rows=1][checkbox name="derm_sx" value="no complaints|generalized rash|facial rash|acral rash|localized rash|dryness|hives|redness|swelling|bruising|single lesion|grouped lesions|wound|bite"]

SOCIAL STRESSORS: [textarea cols=80 rows=1][checkbox name="social" value="smoker at home|pets|school bullying|housing problems|foster care|adopted|none identified"]

OBJECTIVE
Appearance: [textarea cols=80 rows=1][checkbox name="appearance" value="well-appearing|active, interactive, non-toxic|strong suck|crying|easily consoled|NWOB|moist mucous membranes|age-appropriate behavior||ill-appearing|tired-looking|irritable|diaphoretic|short of breath|uncooperative with exam"]
Head: [textarea cols=80 rows=1][checkbox name="head" value="normocephalic, atraumatic|normal hair distribution|normal anterior fontanel||scalp tenderness|plagiocephaly|swelling"]
Face: [textarea cols=80 rows=1][checkbox name="face" value="symmetrical|no evidence of trauma|no obvious cranial nerve deficits||malar rash|swelling|ecchymosis"]
Eye(s): [textarea cols=80 rows=1][checkbox name="eyes" value="clear conjunctiva w/o exudates or hemorrhage, anicteric sclera, EOM intact, painless, without nystagmus, visual acuity grossly intact|PERL|cornea(s) clear|ant. chamber(s) clear||allergic shines|dennie lines|periorbital swelling|conjunctival injection|epiphora|conjunctival exudate|palpebral edema|palpebral exudates|chemosis|hyphema|subconjunctival hemorrhage|corneal abrasion|dysconjugate gaze"]
Ear(s): [textarea cols=80 rows=1][checkbox name="ears" value="symmetrical & intact auricles bilaterally, hearing to conversation intact|no tragal tenderness|clear canals without erythema or D/C|no FB visible in canals|TMs normal in appearance||tragal tenderness|swelling of external auditory canal|debris in canal|cerumen in canal|dried up blood in canal|TM obscured by cerumen|TM red|pus behind TM|fluid behind TM|TM bulging|TM perforated|TM retracted|tube in TM|mastoid tenderness"]
Nose: [textarea cols=80 rows=1][checkbox name="nose" value="nares patent bilaterally, no facial swelling or discoloration|no facial tenderness|mucosa pink & moist||allergic salute|maxillary tenderness|frontal tenderness|deviated septum|swollen & boggy mucosa|mucosal ulceration|mucosal congestion|clear discharge|yellow discharge|crusty discharge|active septal hemorrhage|dried up blood"]
Mouth: [textarea cols=80 rows=1][checkbox name="mouth" value="tongue normal in appearance w/o lesions and with good symmetrical movements|moist oral mucosa without lesions|normal bucal mucosa|normal dentition for age||poor dentition|single oral ulcer|multiple oral ulcers|gum swelling|tooth caries"]
Throat: [textarea cols=80 rows=1][checkbox name="throat" value="normal voice, patent pharynx w/o swelling or exudates|swallows fluids without cough or chocking|uvula midline|clear pharynx w/o exudates||pharyngeal erythema w/o exudates|hoarseness|vesicles on soft palate|petechia on soft palate||pharyngeal crowding|tonsilar enlargement|tonsilar erythema|tonsilar exudates|tonsilar crypts|tonsilar pustules"]
Neck: [textarea cols=80 rows=1][checkbox name="neck" value="symmetric with free painless ROM and no masses|supple|no LAD|no bruit or JVD||anterior LAD|posterior LAD|thyroid enlargement|nuchal tenderness"]
Lungs: [checkbox name="lungs" value="normal work of breathing, symmetrical chest expansion, no stridor audible|clear and equal breath sounds bilaterally||SOB|stridor|intercostals retractions|wheezing|crackles|breath sounds decreased bilaterally"]
Chest/CV: [textarea cols=80 rows=1][checkbox name="cv" value="Chest wall atraumatic and non-tender|no SOB, no ankle edema|regular rhythm, no murmurs|pedal skin warm with good & equal pulses||tachycardia|systolic murmur||no axillary or supraclavicular LAD|chest wall tenderness|sternal tenderness|breast mass|breast tenderness|skin dimpling/retraction"]
Abdomen: [textarea cols=80 rows=1][checkbox name="abd" value="normal visual inspection, no distension|normal active bowel sounds throughout|soft non-tender||not disturbed with abdomen palpation|no obvious palpable masses or hepatosplenomegaly||diffuse tenderness over entire abdomen w/o RRG|direct non-rebound tenderness|umbilical hernia||hypoactive bowel sounds|hyperactive bowel sounds"]
GU: [textarea cols=80 rows=1][checkbox name="gu" value="not examined|no CVAT bilaterally|no suprapubic tenderness||normal external genitalia|circumcised|uncircumcised|no inguinal LAD|smooth non-tender testes|+cremasteric reflexes bil|no skin lesions||testicular tenderness|vesicles"]
MSK: [textarea cols=80 rows=1][checkbox name="spine" value="no gross deformities, normal curvature & ROM in spine"]
Upper extremity(s): [textarea cols=80 rows=1][checkbox name="upper_extremity" value="atraumatic w/o swelling or deformity|free and painless ROM|strength and tone symmetrical & grossly intactl|able to make tight grips|compartments soft w/o tension||tenderness|swelling|ecchymosis"]
Lower extremity(s): [textarea cols=80 rows=1][checkbox name="lower_extremity" value="atraumatic w/o swelling or deformity|free and painless ROM|strength and tone symmetrical & grossly intact|able to raise/lower foot against resistance|compartments soft w/o tension||DROM|tenderness|swelling|ecchymosis"]
Neuro: [textarea cols=80 rows=1][checkbox name="neuro" value="alert, gait, balance & coordination grossly intact|normal speech/vocalization|CN grossly intact|no gross motor deficits|sensation symmetrical & grossly intact|full weight bearing||Romberg without drift or sway|extremities strong w/o atrophy, tremor or fasciculations|reflexes normoactive||antalgic gait|wide gait"]
Psych: [textarea cols=80 rows=1][checkbox name="psych" value="appropriate to age/situation|normal concentration and attention|memory intact to recent & remote events|good eye contact|speech fluid & coherent|organized thought process||poor eye contact|anxious|irritable||expansive affect|flat affect||stuttering|tics||aberrant thought pattern|poor judgment & insight"]
Skin: [textarea cols=80 rows=2][checkbox name="skin" value="grossly intact, no suspicious lesions, no rashes|no bruises|normal turgor||poor turgor|dry|sweaty||erythema|induration|firm|soft|deep|mobile|fluctuant|painful||abrasion|excoriation|fissure|laceration|ulceration|ecchymosis|swelling|burn||generalized rash|acral rash|symmetrical|unilateral|linear|annular|arcuate|serpiginous|red scaly|red non-scaly|macular|papular|maculopapular|follicular|urticarial|targedoid|vesicular|pustular||purpuric|non-blanching|sharply-demarkated borders|indistinct borders"]

OFFICE DIAGNOSTICS: [textarea cols=80 rows=1][checkbox name="office_diag" value="normal|unchanged|non-specific changes|no acute findings|discussed with patient/SO|official report to follow"]

PROCEDURE(S): [textarea cols=80 rows=2][checkbox name="procedure" value="N/A|risks/benefits explained - verbalized understanding and consented to procedure/injection|visual acuity verified before & after|ear lavage completed, canal clear, TM intact, no active bleeding||N/V checked-intact|area cleaned with betadine|topical anesthesia provided|wound irrigated under running water|wound irrigated witn NS|wound explored for FB – none seen|evaluated for tendon injury - able to move appropriate joints|wound edges approximated with non-absorbable sutures|small incision made & abscess contents evacuated|culture collected|wound packed and covered w DSD|wound dressing completed by MA|no active bleeding|area splinted|elastic bandage applied|sling provided|N/V status verified|tolerated intervention well"]

OUTSIDE ORDERS: [textarea cols=80 rows=1][checkbox name="orders" value="none|laboratory studies|diagnostic studies|referrals"]

RELEASE/CLEARANCE: [textarea cols=80 rows=1][checkbox name="clearance" value="none|released from care for this condition with no residual disability|cleared for sports participation with no restrictions|excuse from school|fit for school with above restriction(s)"]

FOLLOW UP: [checkbox name="follow" value="RTC as discussed during visit, sooner if condition worsens or new symptoms arise, contact 911/ER if significant increase in s/sx or appearance of new/danger s/sx|report medication side effects to clinic immediately|PRN||return for suture removal in 5-7 days|return for wound check in 2-3 days|appointment with PCP within 7 days|"] [textarea cols=40 rows=2]

PATIENT/SO INSTRUCTED/COUNSELED ON: [textarea cols=80 rows=1][checkbox name="instructions" value="vital signs|exam findings|office tests|outside laboratory/diagnostic studies|specialty consults|old records|advised that negative/'normal' results do not rule out pathology||OTC medicines and comfort measures for symptom control|adequate hydration/water intake||ice application to affected area several times a day for 72 hours|warm compress application to affected area for 20 min several times a day|keeping affected area clean and dry|keeping affected area elevated as much as possible|N/V checks of affected area|s/sx of infection to report immediately|splinting until cleared||importance of controlling chronic conditions|immunization|diet, exercise, weight control|sleep hygiene|appropriate f/u w PCP"]

PLAN OF CARE: [textarea cols=80 rows=1][checkbox name="poc" value="risks/benefits/side effects/alternatives of/to proposed plan of care/medication(s) discussed with parent, opportunity provided to ask questions and state concerns|verbalized understanding of discharge & f/u instructions||patient/family did not agree with my recommendations – will seek second opinion/further care elsewhere"]

DISCHARGE CONDITION: [textarea cols=80 rows=1][checkbox name="discharge" value="improved|stable|unchanged"]

DISPOSITION: [textarea cols=80 rows=1][checkbox name="disposition" value="home|referred to ER for immediate treatment via 911|referred to ER for immediate treatment via private transport|declined emergency transfer|left clinic before being discharged|asked to leave clinic"]

TOTAL FACE-TO-FACE TIME:  [checkbox name="time" value="less than 30 minutes|more than 30 minutes|visit dominated by counseling"]