ED Documentation Workflow
REVIEW OF SYSTEMS: In addition to that documented in the HPI above, the additional ROS was obtained: CONSTITUTIONAL: Denies fevers or chills EYES: Denies vision changes EARS/NOSE/MOUTH/THROAT: Denies sore throat CARDIOVASCULAR: Denies chest pain RESPIRATORY: Denies shortness of breath GASTROINTESTINAL: Denies vomiting or diarrhea GENITOURINARY: Denies painful urination MUSCULOSKELETAL: Denies recent trauma INTEGUMENTARY: Denies new rashes NEUROLOGICAL: Denies new numbness or tingling or weakness ENDOCRINE: Denies unexpected weight loss HEMATOLOGIC: Denies bleeding disorders PHYSICAL EXAM: VS: I have reviewed the triage vital signs CONSTITUTIONAL: Well-nourished, well-developed, appears stated age EYES: PERRL, no conjunctival injection EARS/NOSE/MOUTH/THROAT: Normocephalic, atraumatic, neck supple without meningismus CARDIOVASCULAR: Regular rate and rhythm, warm, well-perfused extremities RESPIRATORY: Clear to auscultation bilaterally, unlabored respiratory effort GASTROINTESTINAL: Soft, non-tender, non-distended, no masses GENITOURINARY: Deferred MUSCULOSKELETAL: No gross deformities appreciated INTEGUMENTARY: Warm, dry. No rashes NEUROLOGICAL: Alert, CNs II-XII grossly intact, sensation and motor function of extremities grossly intact PSYCHIATRIC: Appropriate mood and affect
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