ED: SOAP / ROS

Date:[date name="variable_1" default="05-07-2024"]
Time:  
Status:[checkbox name="variable_1" value=Admitted|Discharged]
Patient Name:   [First][Last] 
Heart Rate:    
SP02:
Res:
BP:
Temp:    
Weight:    
Room#:   
Age:    
Gender:    
[select name="variable_1" value="Male|Female|Other"]
Chief Complaint:
[textarea name="variable_1" default=""]    
HPI:
[textarea name="variable_1" default="Start with “1-liner” to highlight who the patient is and why they are here today.Include pertinent negative historical items."]
Onset:    
[textarea name="variable_1" default="When did it start?"]
Pain/Pallative:    
[textarea name="variable_1" default="What makes it better or worse?"]
Quality:    
[textarea name="variable_1" default="Pressure, Sharp, Dull, Throbbing?"]
Radiation    /    Region:    
[textarea name="variable_1" default="Where does it travel, where is the pain or symptoms?"]
Severity:    
[select name="variable_1" value="1|2|3|4|5|6|7|8|9|10"]    [textarea name="variable_1" default="Mild, severe, excruciating, Alot, A little, Some, A great deal, Slightly, Intense, Totally disabling, Extreme, Poorly, Not very well, Moderate"]
Temporality:    
[textarea name="variable_1" default="How long, how has it changed w time?"]
Associated Signs:    
[textarea name="variable_1" default="Redness, Swelling, Cloudy, Puffy, Pain, Twitch, Headache, Nausea / Vomiting, Dizzy, Head Tilt, Discharge, Bleeding, Dry Mouth, Feels Warm or Hot, Unconcious, Fright"]
PMH:
[checkbox name="variable_1" value="Yes|No"]    [textarea name="variable_1" default="If yes explain"]
PSH:    
[checkbox name="variable_1" value="Yes|No"]    [textarea name="variable_1" default="If yes explain"] 
Meds:    
[textarea name="variable_1" default="Drug name:            Dosage:         Frequency:"]
Allergies:     
[checkbox name="variable_1" value="Yes|No"]    [textarea name="variable_1" default="If yes what?"]
Immunizations:    
[textarea name="variable_1" default=""]
SH:    [checkbox name="variable_1" value="Alcohol|Drugs|Tobacco|Homeless"][textarea name="variable_1" default="Living Situation:            Occupation:"]
FH:    
[textarea name="variable_1" default="Mother:"][textarea name="variable_1" default="Father:"][textarea name="variable_1" default="Other"]
ROS:
GENERAL APPEARANCE: 
[textarea name="variable_1" default="Denies fever, fatigue, change in energy, weakness, weight gain or weight loss, change in appetite, insomnia, stress."]
HEAD:
[textarea name="variable_1" default="Denies headache, dizziness, fainting, muscle spasm, loss of consciousness, sensitivity or pain in the hands and feet or memory loss."]
EYES:
[textarea name="variable_1" default="Denies pain, redness, loss of vision, double or blurred vision, flashing lights or spots, dryness, the feeling that something is in the eye and denies wearing glasses."]
EARS:
[textarea name="variable_1" default="Denies ringing in the ears, loss of hearing, nosebleeds, loss of sense of smell"]
NOSE:
[textarea name="variable_1" default="Denies nasal discharge,dry sinuses, sinusitis, post nasal drip."]
THROAT:
[textarea name="variable_1" default="Denies sore tongue, bleeding gums, sores in the mouth, loss of sense of taste, dry mouth, dentures or removable dental work, frequent sore throats, hoarseness or constant feeling of a need to clear the throat when nothing is there, waking up with acid or bitter fluid in the mouth or throat, food sticking in throat when swallows or painful swallowing."]
NECK:
[textarea name="variable_1" default="Denies neck pain, masses, soreness"]
CARDIAC:
[textarea name="variable_1" default="Denies chest pain, irregular heartbeats, sudden changes in heartbeat or palpitation, shortness of breath, difficulty breathing at night, swollen legs or feet, heart murmurs, high blood pressure, cramps in his legs with walking, pain in his feet or toes at night or varicose veins."]
LUNGS:
[textarea name="variable_1" default="Denies chronic dry cough, coughing up blood, coughing up mucus, waking at night coughing or choking, repeated pneumonias, wheezing or night sweats."]
ABDOMEN  / GI:
[textarea name="variable_1" default="Denies decreased appetite, nausea, vomiting, vomiting blood or coffee ground material, heartburn, regurgitation, frequent belching, stomach pain relieved by food, yellow jaundice, diarrhea, constipation, gas, blood in the stools, black tarry stools or hemorrhoids."]
Genitourinary:
[textarea name="variable_1" default="Denies difficult urination, pain or burning with urination, blood in the urine, cloudy or smoky urine, frequent need to urinate, urgency, needing to urinate frequently at night, inability to hold the urine, discharge from the penis, kidney stones, rash or ulcers, sexual difficulties, impotence or prostate trouble, no sexually transmitted diseases."]
MUSKULOSKELETAL:
[textarea name="variable_1" default="Denies arm, buttock, thigh or calf cramps. No joint or muscle pain. No muscle weakness or tenderness. No joint swelling, or major orthopedic injuries."]
BACK:
[textarea name="variable_1" default="Denies back pain"]
EXTREMITIES:
[textarea name="variable_1" default="Denies easy bruising, skin redness, skin rash, hives, sensitivity to sun exposure, tightness, nodules or bumps, blood pooling, cold (hands, feet, or ears), delayed wound healing. "]
LOWER EXTREMITY:
[textarea name="variable_1" default="Denies changes in ring size or shoe size, color changes in the  feet with cold, Joint pain / swelling or weakness, limited ROM in either (ankles, knees, legs, hips), crepitus."]
NEUROLOGICAL:
[textarea name="variable_1" default="Denies changes in speech,confusion, fainting, headache / migraine, lightheadedness / dizzy, numbness, paralysis, probs w balance, seizure, sleeping to much or to little, trouble falling asleep or staying awake"]
Skin / Hair / Breast::
[textarea name="variable_1" default="Denies easy bruising, skin redness, skin rash, hives,itching, skin dryness, sores/ulcerations, yellowing of skin sensitivity to sun exposure, tightness, nodules or bumps, hair loss, color changes in the hands or feet with cold, breast lump, breast pain or nipple discharge."]
PSYCHIATRIC:
[textarea name="variable_1" default="Denies  anxiety, crying, frequent memory loss / confusion, nervousness / depression, depression with thoughts of suicide, voices in ?? head telling ?? to do things and has not been seen for psychiatric counseling or treatment."]
Endocrine:    
[textarea name="variable_1" default="Denies excessive thirst / urination, heat / cold intolerance, hormone problems, flushing, fingernail changes, increased thirst, increased salt intake or decreased sexual desire."]
Hematologic / Lymphatic:    
[textarea name="variable_1" default="Denies anemia, bleeding / bruising (bleeding tendency or clotting tendency), enlarged lymph nodes, hx of blood transfusions, slow to heal after cuts, swollen or painful glands"]
Allergic /  Immunologic:
[textarea name="variable_1" default="Denies allergies, hepatitis, HIV / AIDS, Immunocompromised, asthma, skin sensitivity"]

ROS:General Adult Physical Exam
Mental Status Exam / Psych:
[textarea name="variable_1" default="AAOx4. Steady gait. Negative Romberg test. Pt appears calm without apparent distress. Well groomed. Steady, smooth speech. GCS 15. Able to perform repetitive finger-to-nose and finger- to-finger test at a smooth pace. Cranial nerves I-XII intact."]
Head / Neuro:
[textarea name="variable_1" default="Head is symmetrical, round, hard, and smooth without lesions or bumps noted on palpation. Pt has brown hair, evenly distributed along the scalp without areas of alopecia. Well-groomed. Face is round, smooth, and symmetrical. No evidence of facial drooping. Temporal arteries are equal, elastic, and nontender. Temporomandibular joint palpated with full range of motion without tenderness."]
Ears:
[textarea name="variable_1" default="Bilateral ears are at appropriate level in relationship to bilateral eyes. Pt denies hx of pain or tenderness to bilateral ears. Pt denies hx of recent ear infection. Bilateral ears are smooth, no lumps, lesions, nodules noted. Appropriate color. No visible drainage noted. Nontender on palpation of the tragus or pinna. Pt denies radiating pain from bilateral ears. Small amount of yellow cerumen in external canal. Tympanic membrane is pearly grey and translucent. Able to visualize the cone of light. Able to perform Whisper test with ease"]
Eyes:
[textarea name="variable_1" default="Bilateral eyes are symmetrical without redness, discharge or crusting from external eyelids. Conjunctiva appears pink and smooth. Sclera appears white with no lesions or redness noted. Bilateral pupils are clear equal in diameter. PEERLA. Negative strabismus. Negative nystagmus."]
Nose/Sinus:
[textarea name="variable_1" default="Nose is symmetrical and appropriate color. No signs of erythema or irritation. No visible masses or lesions noted on the external nose. Pt denies hx of recent rhinorrhea. Bilateral nares are patent. Cranial nerve I intact. No sign of septal deviation, lesions or polyps noted on bilateral internal nares. No purulent drainage noted. Frontal and maxillary sinuses are nontender to palpation and percussion."]
Throat:
[textarea name="variable_1" default="Lips appear pink and moist without evidence of lesions. No swelling noted along the vermillion border. Pt has 32 intact teeth that are slightly yellow without evidence of cavities or crowns. Gums pink without redness or swelling. Tongue pink and moist without evidence of oral thrush. Cranial nerve XII intact. Frenulum midline. Soft palate smooth and pink. Uvula midline with bilateral tonsils 2+. No evidence of exudates on bilateral tonsils. Cranial nerve IX and X intact."]
Neck:
[textarea name="variable_1" default="Neck symmetric with midline trachea and no bulging masses. C7 is visible and palpable with neck flexion. Cranial nerve XI intact. Pt has smooth, controlled, full range of motion of neck. No evidence of JVD. Bilateral carotid arteries 2+, elastic. No evidence of carotid bruits upon auscultation. Thyroid gland nonvisible but palpable when swallowing. Lymph nodes nonpalpable."]
Resp:
[textarea name="variable_1" default="Respirations 16/minute, relaxed an even. Able to talk with ease. Anterior and posterior chest are symmetrical without evidence masses, lesions, or scars. Percussion tones resonant over bilateral lung fields. Nontender to palpation over the posterior chest wall. Chest expansion symmetric. No tactile fremitus noted. No CVAT. Vesicular lung sounds noted over bilateral lung fields upon auscultation. No adventitious breath sounds noted."]
Cardiac:
[textarea name="variable_1" default="Bilateral carotid arteries 2+, elastic. No evidence of carotid bruits upon auscultation. No evidence of JVD. Apical pulse palpated at the 5th intercostal space, midclavicularly. Apical pulse 70bpm. RRR upon auscultation. S1 heard best at the apex. S2 heart best at the base. No evidence of splitting heart sounds."]
Abdomen:
[textarea name="variable_1" default="Abdomen is round and symmetric with no bulges or masses noted. Skin color is appropriate to ethnicity without striae, scars or lesions noted. No visible aortic pulsations. Soft gurgles present in all four quadrants upon auscultation. Percussion reveals generalized tympany (hollow sound) in all four quadrants. No rebound tenderness or guarding noted with light and deep palpation over the generalized abdomen."]
GU:
[textarea name="variable_1" default="External genitalia normal looking. Sphincter tone is normal. Prostate is smooth, small, no nodule."]
Muscoloskeltal:
[textarea name="variable_1" default="Steady gait. No evidence of tremors. Negative Romberg test. No evidence of scoliosis noted. Paravertebrals nontender. Upper and lower extremities symmetric without lesions, swelling or deformities noted. Full ROM in bilateral upper and lower extremities. Cranial nerve XI intact. No evidence of skin tenting in the upper extremities. Capillary refill less than 2 seconds, radial and brachial pulses 3+ bilaterally. Even hair distribution along bilateral lower extremities. No evidence of pitting edema noted. Femoral, popliteal, dorsalis pedis, and posterior tibial pulses 3+ bilaterally. Equal sensation and 5/5 strength in bilateral upper and lower extremities. Negative Babinski reflex."]
Skin:
[textarea name="variable_1" default="Skin normal color, texture and turgor with no lesions or eruptions."]
Heme / Lymph / Immune:
[textarea name="variable_1" default="No nodal enlargement in the cervical chains, axillae, or  groin."]

Pertinent Labs, Imaging, ECGs:  
[textarea name="variable_1" default="Insert labs here"]

Assesment / Plan:
[textarea name="variable_1" default="Final   Note"]
Date:
Time:
Status:
Patient Name: [First][Last]
Heart Rate:
SP02:
Res:
BP:
Temp:
Weight:
Room#:
Age:
Gender:

Chief Complaint:

HPI:

Onset:

Pain/Pallative:

Quality:

Radiation / Region:

Severity:

Temporality:

Associated Signs:

PMH:

PSH:

Meds:

Allergies:

Immunizations:

SH:

FH:

ROS:
GENERAL APPEARANCE:

HEAD:

EYES:

EARS:

NOSE:

THROAT:

NECK:

CARDIAC:

LUNGS:

ABDOMEN / GI:

Genitourinary:

MUSKULOSKELETAL:

BACK:

EXTREMITIES:

LOWER EXTREMITY:

NEUROLOGICAL:

Skin / Hair / Breast::

PSYCHIATRIC:

Endocrine:

Hematologic / Lymphatic:

Allergic / Immunologic:


ROS:General Adult Physical Exam
Mental Status Exam / Psych:

Head / Neuro:

Ears:

Eyes:

Nose/Sinus:

Throat:

Neck:

Resp:

Cardiac:

Abdomen:

GU:

Muscoloskeltal:

Skin:

Heme / Lymph / Immune:


Pertinent Labs, Imaging, ECGs:


Assesment / Plan:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.13, 63 form elements, 98 boilerplate words, 55 text areas, 1 dates, 5 checkboxes, 2 drop downs, 70 total clicks
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