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