HomeHealth v1

CC: [checkbox name="variable_1" value="Establish care|Home health evaluation| Medication refill"][text name="variable_39" default=""]

HPI: [textarea name="variable_2" default="" [textarea cols="40" rows="3"]

REVIEW OF SYSTEMS

CONSTITUTIONAL:[checkbox name="variable_3" value="WNL|Chills|Fatigue|Fever|Weight gain|Weight loss"]
HEENT:[checkbox name="variable_4" value="WNL|Hearing loss|Sinus pressure|Visual changes"]
RESPIRATORY:[checkbox name="variable_5" value="WNL|Cough|Shortness of|Wheezing"]
CARDIOVASCULAR:[checkbox name="variable_6" value="WNL|Chest pain|Edema|Palpitations|Claudication (pain with walking)"]
GASTROINTESTINAL:[checkbox name="variable_7" value="WNL|Abdominal pain|Blood in stool|Constipation|Diarrhea|Heartburn|Loss of appetite|Nausea|Vomiting|Incontinence"]
GENITOURINARY:[checkbox name="variable_8" value="WNL|Dysuria|Polyuria|Urinary frequency|Incontinence"]
ENDOCRINE:[checkbox name="variable_9" value="WNL|Cold intolerance|Heat intolerance|excessive thrist|Excessive hunger"]
NEUROLOGICAL:[checkbox name="variable_10" value="WNL|Dizziness|Numbness|Weakness|Headaches|Seizures|Tremors"]
PSYCHIATRIC:[checkbox name="variable_11" value="WNL|Anxiety|Depression"]
INTEGUMENTARY:[checkbox name="variable_12" value="WNL|Rash|Skin lesion|Mole changes"]
MUSCULOSKELETAL:[checkbox name="variable_13" value="WNL|Back pain|Joint pain|Joint swelling|Neck pain|Difficulty walking"]

PHYSICAL EXAM

GENERAL: [checklist name="variable_14" value="Alert & Oriented x4|Confusion|Acute distress|Well-nourished"] [text name="variable_15" default=""]
EYES: [checklist name="variable_16" value="Extraocular motion intact|PERRLA|White sclera"] [text name="variable_17" default=""]
HENT: [checklist name="variable_18" value="Normocephalic|Moist mucous membranes|lymphadenopathy|Sore throat"] [text name="variable_19" default=""]
LUNGS: [checklist name="variable_20" value="Clear lung sounds|Accesory muscles|Dyspnea|Wheezing"] [text name="variable_21" default=""]
CARDIOVASCULAR: [checklist name="variable_22" value="Regular rate & rhythm|Murmur|JVD|Pitting edema"] [text name="variable_23" default=""]
ABDOMEN: [checklist name="variable_24" value="Soft|Tender|Distended|Palpable mass"] [text name="variable_25" default=""]
EXTREMITIES: [checklist name="variable_26" value="Normal strength|Swelling|Tender"] [text name="variable_27" default=""]
SKIN: [checklist name="variable_28" value="Intact|Rashes|Lesions|Jaundice"] [text name="variable_29" default=""]
NEUROLOGIC: [checklist name="variable_30" value="No focal neurological deficits|CN II-XII grossly intact, but not individually tested"] [text name="variable_31" default=""]
PSYCHIATRIC:[checklist name="variable_32" value="Cooperative|Appropiate mood and affect"] [text name="variable_33" default=""]

ASSESSMENT

HOMEBOUND STATEMENTS 
[checkbox name="variable_34" value="Patient is bedbound|Patient transfers via mechanical lift device to chair (wheelchair, reclining chair, commode etc.)|Patient transfers with assist of two to chair|Patient transfers with mod/max assist of one to chair|Patient transfers with stand-by assist of one to chair|Patient is chair-bound and requires assist (of 1 or 2 persons) to pivot from bed to chair|Patient requires (Min to Max) assist with (Most to All) ADLs/IADLs|Patient is unable to ambulate further than 20 feet without frequent rest periods due to (poor endurance, pain, SOB etc.)|Patient requires assistive device for ambulation at all times (FWW, Quad cane, crutches)|Patient requires assist of one at all times to ambulatePatient requires stand-by assist of one at all times to ambulate|Unsteady gait, poor ambulation with history of frequent falls (2 falls in last month)|Has significant to severe weakness following hospital stay|Impaired mobility due to (recent fracture, surgery, arthritis, paralysis, paresis)"] 

PLAN
Refer patient to [text name="variable_35" default=""] for skilled nursing and physical therapy. 
[checkbox name="variable_36" value="Continue with current medication regimen"]

Labs:[checkbox name="variable_37" value="Men's Panel|Women's Panel|UA|Nasal swab|None"]

Other:[text name="variable_38" default=""]
CC:

HPI:


REVIEW OF SYSTEMS

CONSTITUTIONAL:
HEENT:
RESPIRATORY:
CARDIOVASCULAR:
GASTROINTESTINAL:
GENITOURINARY:
ENDOCRINE:
NEUROLOGICAL:
PSYCHIATRIC:
INTEGUMENTARY:
MUSCULOSKELETAL:

PHYSICAL EXAM

GENERAL:
EYES:
HENT:
LUNGS:
CARDIOVASCULAR:
ABDOMEN:
EXTREMITIES:
SKIN:
NEUROLOGIC:
PSYCHIATRIC:

ASSESSMENT

HOMEBOUND STATEMENTS


PLAN
Refer patient to for skilled nursing and physical therapy.


Labs:

Other:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.64, 39 form elements, 43 boilerplate words, 13 text boxes, 1 text areas, 15 checkboxes, 10 check lists, 129 total clicks
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