General Telemedicine Acute Care Visit
Date of Visit: [date name="date2" default="today"] Visit completed via: [select name="variable_1" value="Teams audio call|Amaze portal audio call|Amaze portal video call|Amaze portal chat"] Verification of patient identity was established with patient. Patient consents to telemedicine. CHIEF COMPLAINT: [text name="variable_2"] HISTORY OF PRESENT ILLNESS: The patient is a [text name="variable_3"] complaining of [text name="variable_5"] PSFH: [text name="variable_1" default=""] REVIEW OF SYSTEMS: [text name="variable_1" default=""] PHYSICAL EXAM: GENERAL: [checkbox name="variable_1" value="well-developed and well-nourished|alert and cooperative|in no acute distress|well-appearing and nontoxic"] [text name="variable_2" default=""] HEENT: [checkbox name="variable_3" value="normocephalic|atraumatic|EOMI|vision grossly intact bilaterally|no conjunctival injection or visible discharge|hearing grossly intact bilaterally|no frontal sinus tenderness bilaterally|no maxillary sinus tenderness bilaterally|no oropharyngeal erythema/edema/exudate|no uvular deviation|speaks in clear and unmuffled voice|lips/tongue/dentition/gingiva within normal limits"] [text name="variable_4" default=""] NECK: [checkbox name="variable_5" value="supple with full range of motion|no stridor|no midline tenderness or stepoff|no cervical lymph node tenderness bilaterally|no cervical lymph node swelling bilaterally|no visible thyromegaly or other masses"] [text name="variable_6" default=""] RESPIRATORY: [checkbox name="variable_7" value="no audible rales/rhonchi/wheezing|normal respiratory effort|speaking full sentences|no visible signs of tachypnea|no retractions"] [text name="variable_8" default=""] CARDIOVASCULAR: [checkbox name="variable_9" value="peripheral pulses intact and palpable|pulse felt to be regular rate and rhythm by patient"] [text name="variable_10" default=""] ABDOMINAL: [checkbox name="variable_11" value="no focal abdominal tenderness elicited upon palpation|no visible abdominal distension|no abnormal masses found upon palpation"] [text name="variable_12" default=""] BACK: [checkbox name="variable_13" value="no CVAT elicited bilaterally|no midline tenderness or stepoff upon palpation"] [text name="variable_14" default=""] EXTREMITIES: [checkbox name="variable_15" value="no bony tenderness|no visible gross deformity|no edema|normal range of motion"] NEUROLOGIC: [checkbox name="variable_17" value="CN III-XII grossly intact|normal-appearing mental status|moving all extremities normally|grossly normal motor strength throughout|sensation to light touch grossly intact throughout|normal speech|normal gait"] [text name="variable_18" default=""] PSYCH: [checkbox name="variable_19" value="normal-appearing affect"] [text name="variable_20" default=""] ASSESSMENT: [textarea name="variable_1" default=""] PLAN: [textarea name="variable_1" default=""] Diagnostic rationale, follow-up instructions, and any precautions/indications for emergent direct evaluation were discussed with the patient. The patient verbalized understanding and agrees with the plan.
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Sandbox Metrics: Structured Data Index 0.43, 28 form elements, 74 boilerplate words, 14 text boxes, 2 text areas, 1 dates, 10 checkboxes, 1 drop downs, 64 total clicks
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