Facility visits

[textarea cols=40 rows=2]
This is [checkbox name="encounter" value="a new patient|a follow up visit for:|an episodic visit to address change of status"][textarea cols=40 rows=2]

The history is
[checkbox name="history" value="obtained from patient|obtained from resident|obtained from facility staff|obtained from SO/family member|unobtainable d/t cognitive changes|unobtainable d/t HOH"][textarea cols=40 rows=2]

The patient has the presence of these chronic conditions:
[checkbox name="Presence" value="hypertension |hyperlipidemia| CHF| ASCVD| atrial fibrillation| DVT| CVA| seizure disorder| COPD| diabetes| GERD| chronic kidney disease| dementia."][textarea cols=40 rows=2]

Medications: The MAR is reviewed. The current medications are
[checkbox name="medications" value="administered by staff| self-administered| insulin| blood sugars reviewed and stable| blood sugars out of range| warfarin| INR results available for review| DOAC/NOAC| aspirin| Plavix| blood pressure medications| blood pressures reviewed and stable| blood pressures are elevated| opioids| sedatives| psychotropics| no sedation reported| sedation reported."][textarea cols=40 rows=2]

Immunization review:[checkbox name="iz" value="Pneumonia|up to date|not up to date|declined|per facility policy||Tetanus|up to date|not up to date|declined|per facility policy||Influenza|up to date|not up to date|declined|per facility policy||COVID|up to date|not up to date|declined|per facility policy"][textarea cols=40 rows=2]

The patient's functional status is 
[checkbox name="functional" value="resident at assisted living facility |lives at long term care facility |lives at home |no change in functional status since last visit |changes in functional status since last visit |requires minimal assistance with ADLs |requires moderate assistance with ADLs |fully dependent for all ADLs |incontinent |O2 use |smoker |visual deficit |hard of hearing."][textarea cols=40 rows=2]

The patient's mobility status is 
[checkbox name="mobility" value="unable to verify d/t cognitive changes |no recent falls |recent falls |no changes in mobility since last visit |changes in mobility since last visit |ambulates unassisted |difficulty with mobility |ambulation requires walker |ambulation requires cane |ambulates with assistance |uses wheelchair |uses motorized scooter/wheelchair |bedbound."][textarea cols=40 rows=2]

Advance care planning for this patient is[checkbox name="planning" value="unable to verify d/t cognitive changes.|full code.|DNR.|advanced directive on file.|no advanced directive/POA."][textarea cols=40 rows=2]

Interval history:
[checkbox name="interval_history" value="Patient complains| Concerns by staff| Concerns by family| ER/UC visit| Hospitalization| Surgery/Procedure| Diagnostic/laboratory studies| Specialty consults| New medications| Infection| Falls| Wounds| Skin concerns| Behavioral changes| Wt loss| Hospice| Progressing well with ordered therapies PT/OT/SPL| Not progressing well with ordered therapies PT/OT/SPL| Reports presence of pain"]
[textarea cols=60 rows=3]

The patient's general condition is 
[checkbox name="general" value="sleeping well|  interrupted sleep| eating well| reduced oral intake| modified diet| tolerating Gtube feedings| tolerates liquids well| voiding without difficulty| regular bowel movements| history of constipation| denies pain."][textarea cols=40 rows=2]

General summary:
[checkbox name="general_summary" value="no acute issues| hospitalizations| falls| weight loss or gain| surgeries| outpatient visits| physical decline| cognitive decline| changes in code status. "][textarea cols=40 rows=2]

REVIEW OF SYSTEMS:
CONSTITUTIONAL negative for:[checkbox name="constitutional_symptoms" value="fever|malaise|fatigue|deconditioning|night sweats|weakness|wt loss||POSITIVE for:|fever|malaise|fatigue|deconditioning|night sweats|weakness|wt loss"][textarea cols=40 rows=2]
HEAD/FACE negative for:[checkbox name="head_symptoms" value="headache|scalp swelling|facial pain|facial swelling|facial numbness||POSITIVE for:|headache|scalp swelling|facial pain|facial swelling|facial numbness"][textarea cols=40 rows=2] 
EYES negative for:[checkbox name="eye_symptoms" value="decrease in vision| dryness|irritation|lid swelling|discharge||POSITIVE FOR:|decrease in vision|wears glasses regularly for vision|requires glasses for reading|dryness|irritation|lid swelling|discharge"][textarea cols=40 rows=2]
EARS negative for:[checkbox name="ears_symptoms" value="pain|pressure|discharge|bleeding|earwax|hearing loss|ringing|hearing aids||POSITIVE FOR:|pain|pressure|discharge|bleeding|earwax|hearing loss|ringing|hearing aids"][textarea cols=40 rows=2]
NOSE negative for:[checkbox name="nose_symptoms" value="discharge|post nasal drip|congestion|sinus pressure|snoring|bleeding||POSITIVE FOR:|discharge|post nasal drip|congestion|sinus pressure|snoring|bleeding"][textarea cols=40 rows=2]
MOUTH negative for:[checkbox name="mouth_symptoms" value="sores|dryness|drooling|tongue pain/swelling|toothache|infection|odor|swelling|jaw pain|clicking|loose dentures||POSITIVE FOR:|sores|dryness|drooling|tongue pain/swelling|toothache|infection|odor|swelling|jaw pain|clicking|loose dentures"][textarea cols=40 rows=2]
THROAT negative for:[checkbox name="throat_symptoms" value="sore throat|dysphagia|choking|hoarseness|globus||POSITIVE FOR:|sore throat|dysphagia|choking|hoarseness|globus"][textarea cols=40 rows=2]
NECK negative for:[checkbox name="neck_symptoms" value="pain|swelling|limited motion|swollen glands||POSITIVE FOR:|pain|swelling|limited motion|swollen glands"][textarea cols=40 rows=2]
CV negative for:[checkbox name="cv" value="chest pain/pressure|palpitations|lightheadedness|fainting|exertional dyspnea|orthopnea|rapid wt gain|swelling of legs|ankle discoloration|varicose veins|leg cramps|leg pain||POSITIVE FOR:|chest pain/pressure|palpitations|lightheartedness|fainting|exertional dyspnea|orthopnea|rapid wt gain|swelling of legs|ankle discoloration|varicose veins|leg cramps|leg pain"][textarea cols=40 rows=2]
RESPIRATORY negative for: [checkbox name="chest_symptoms" value="shortness of breath|former smoker|current smoker|cough|phlegm|wheezing|pain w/ breathing|rib pain||POSITIVE FOR:|shortness of breath|former smoker|current smoker|cough|phlegm|wheezing|pain w/ breathing|rib pain"][textarea cols=40 rows=2]
**Breast negative for: [checkbox name="breast" value="breast lump|breast swelling|nipple discharge||POSITIVE FOR:|breast lump|breast swelling|nipple discharge"][textarea cols=40 rows=2]
GI negative for:[checkbox name="gi_symptoms" value="nausea|vomiting|diarrhea|constipation|laxative use|changes in appetite|early satiety|bloating|heartburn|gas|generalized abdominal pain|epigastric pain|melena|rectal pain/itching|rectal bleeding||POSITIVE FOR:|constipation|laxative use|poor appetite|nausea|vomiting|early satiety|bloating|heartburn|gas|generalized abdominal pain|epigastric pain|diarrhea|melena|rectal pain/itching|rectal bleeding"][textarea cols=40 rows=2]
GU negative for: [checkbox name="gu_symptoms" value="dysuria|burning|frequency|urgency|odor|hematuria|hesitancy|retention|nocturia|oliguria|CKD|discharge|itching|skin lesion(s)/rash||POSITIVE FOR:|dysuria|burning|frequency|urgency|odor|hematuria|hesitancy|retention|nocturia|oliguria|CKD|discharge|itching|skin lesion(s)/rash"][textarea cols=40 rows=2]
MSK negative for:[checkbox name="msk_symptoms" value="joint pain/deformity|neck pain|back pain|sciatica|shoulder pain|hip pain|knee pain|chronic pain/meds||POSITIVE FOR:|joint pain/deformity|neck pain|back pain|sciatica|shoulder pain|hip pain|knee pain|chronic pain/meds"][textarea cols=40 rows=2]
NEURO negative for:[checkbox name="neuro_symptoms" value="dizziness|vertigo|poor balance|abnormality of walk|focal weakness|blackouts|tingling/numbness|speech difficulty|tremor|seizures||POSITIVE FOR:|dizziness|vertigo|poor balance|abnormality of walk|focal weakness|blackouts|tingling/numbness|speech difficulty|tremor|seizures"][textarea cols=40 rows=2]
PSYCH negative for:[checkbox name="psych_symptoms" value="irritability|confusion|dysinhibition|aggression|withdrawal|wandering|repetitive activities|suspiciousness|depression|apathy|anxiety|mood swings|elation|delusions|hallucinations|memory loss|insomnia|excessive naps||POSITIVE FOR:|irritability|confusion|dysinhibition|aggression|withdrawal|wandering|repetitive activities|suspiciousness|depression|apathy|anxiety|mood swings|elation|delusions|hallucinations|memory loss|insomnia|excessive naps"][textarea cols=40 rows=2]
ENDOCRINE negative for:[checkbox name="endo_symptoms" value="cold intolerance|skin dryness|hair loss|polyuria||POSITIVE FOR:|cold intolerance|skin dryness|hair loss|polyuria"][textarea cols=40 rows=2]
LYMPH/HEMATOLOGY negative for:[checkbox name="hem_symptoms" value="gland swelling|bruising|anticoagulation|h/o DVT|anemia||POSITIVE FOR:|gland swelling|bruising|anticoagulation|h/o DVT|anemia"][textarea cols=40 rows=2]
ALLERGIES/IMMUNE negative for:[checkbox name="allergy_symptoms" value="atopy|environmental allergies|food allergies|autoimmune disease|h/o cancer||POSITIVE FOR:|atopy|environmental allergies|food allergies|autoimmune disease|h/o cancer"][textarea cols=40 rows=2]
DERMATOLOGY negative for:[checkbox name="derm_symptoms" value="dryness|pruritus|rash|hives|redness|swelling|wounds||POSITIVE FOR:|dryness|pruritus|rash|hives|redness|swelling|wounds"][textarea cols=40 rows=2]

OBJECTIVE:
Appearance:[checkbox name="appearance" value="well-appearing|no signs of discomfort visible|normal built|clean-shaven|good hygiene|heavy built|emaciated|frail|ill-appearing|tired-looking|short of breath|diaphoretic|slumped in wheelchair|disheveled|unshaven|body odor"][textarea cols=40 rows=2]
Head/Face:[checkbox name="head" value="normocephalic, atraumatic|symmetrical face|CN grossly intact|alopecia|facial droop"][textarea cols=40 rows=2]
Eyes:[checkbox name="eyes" value="clear conjunctiva w/o exudates or hemorrhage, anicteric sclera, EOM intact without nystagmus|clear conjunctiva w/o exudates or hemorrhage, anicteric sclera|visual acuity grossly intact|red reflex present|cornea(s) clear|ptosis|glasses|periorbital swelling|conjunctival injection|epiphora|conjunctival exudate|palpebral edema|palpebral exudates|chemosis|hyphema|dysconjugate gaze"][textarea cols=40 rows=2]
Ears:[checkbox name="ears" value="symmetrical & intact auricles bilaterally|hearing to conversation intact|very HOH|hearing aid(s)|clear canals without erythema or discharge|TMs normal in appearance|large amount of wax"][textarea cols=40 rows=2]
Nose:[checkbox name="nose" value="nares patent bilaterally, no facial swelling or discoloration|septum midline|no facial tenderness|mucosa pink & moist|allergic salute|maxillary tenderness|frontal tenderness|deviated septum|swollen & boggy mucosa|mucosal ulceration|mucosal congestion|clear discharge|yellow discharge|crusty discharge|active septal hemorrhage|dried up blood"][textarea cols=40 rows=2]
Mouth:[checkbox name="mouth" value="tongue normal in appearance w/o lesions and with good symmetrical movements|moist oral mucosa without lesions|upper denture|lower denture|teeth absent|some teeth present"][textarea cols=40 rows=2]
Throat:[checkbox name="throat" value="normal voice|patent pharynx w/o swelling or exudates|uvula midline|clear pharynx w/o exudates|pharyngeal erythema w/o exudates|hoarseness|vesicles on soft palate|petechiae on soft palate|pharyngeal crowding|tonsilar exudates|tonsilar pustules"][textarea cols=40 rows=2]
Neck:[checkbox name="neck" value="symmetric with free painless ROM and no masses|supple|no LAD|no bruit or JVD|thyroid enlargement|nuchal tenderness"][textarea cols=40 rows=2]
Lungs:[checkbox name="lungs" value="normal work of breathing, symmetrical chest expansion, no stridor|clear and equal breath sounds bilaterally|SOB|decreased bilaterally|wheezing|crackles"][textarea cols=40 rows=2]
Cardiovascular:[checkbox name="cardiovascular" value="regular rhythm|no murmurs|tachycardia|irregular heart rhythm|systolic murmur"][textarea cols=40 rows=2]
Abdomen:[checkbox name="abd" value="not examined|normal visual inspection, no distension|normal active bowel sounds|soft non-tender|no bruit auscultated over AA and renal arteries|protruding|surgical scar|diffuse tenderness over entire abdomen w/o RRG|umbilical hernia|hypoactive bowel sounds|hyperactive bowel sounds|direct non-rebound tenderness|gastrostomy tube in situ|colostomy in situ"][textarea cols=40 rows=2]
GU:[checkbox name="gu" value="not examined|normal external genitalia|no suprapubic tenderness|no smell of urine|Foley in situ|suprapubic catheter in situ|urostomy present|urine is yellow and clear|urine is dark|sediment present|urine is cloudy|"][textarea cols=40 rows=2]
MSK:[checkbox name="spine" value="no gross deformities, moves all extremities with good ROM for age|kyphosis|paraspinal muscle spasm"][textarea cols=40 rows=2]
Upper extremity(s): [checkbox name="upper_extremity" value="atraumatic w/o swelling or deformity|good ROM for age|equal power and tone bilaterally|able to make tight grips|no vascular compromise|ecchymoses|clubbing"][textarea cols=40 rows=2]
Lower extremity(s):[checkbox name="lower_extremity" value="atraumatic|strength, tone & bulk symmetrical & grossly intact|able to stand up|no vascular compromise|compartments soft w/o tension|pedal skin warm with good & equal pulses|no edema|xerosis|calf tenderness|1+ edema|2+ edema|3+ edema|pitting edema|varicosities|loss of hair|ecchymoses|stasis discoloration|varicose veins"][textarea cols=40 rows=2]
Neuro:[checkbox name="neuro" value="balance & coordination grossly intact|no involuntary movements|normal speech|sensation symmetrical & grossly intact|full weight bearing|wide gait|shuffling gait|tremor|dystonia|dyskinesia"][textarea cols=40 rows=2]
Behavior:[checkbox name="behavior" value="pleasant, cooperative|engaged|withdrawn|hostile|defensive|argumentative|suspicious|ingratiating|demanding"][textarea cols=40 rows=2]
Psych:[checkbox name="psych" value="alert|oriented to self and place|appropriate to situation|normal concentration and attention|memory grossly intact|good eye contact|speech normal rate & rhythm|organized thought process|drowsy|poor eye contact|confused|agitated|anxious|irritable|indifferent|guarded|expansive affect|flat affect|labile affect|speech slurred|hypoverbal|hyperverbal|speech loud|speech slow|speech rapid|tangential thought|circumstantial thought|aberrant thought|flight of ideas|poor judgment & insight"][textarea cols=40 rows=2]
Skin:[checkbox name="skin" value="grossly intact, no rashes|no bruises|normal turgor|multiple tattoos|body piercings|poor turgor|dry|sweaty|presence of IV lines"][textarea cols=40 rows=2]

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PLAN:[checkbox name="orders" value="none|Rx electronic|Rx paper left at facility|Rx faxed to pharmacy|orders for laboratory studies|orders for diagnostic studies|referrals|"][textarea cols=40 rows=2]

The following information was reviewed:[checkbox name="reviewed" value="MAR| chart| previous visits| care plan| PDMP| laboratory studies| diagnostic studies|specialty reports|hospital discharge|facility communication|"][textarea cols=40 rows=2]

Management of conditions:[checkbox name="condition" value="Hypertension|well controlled|adequately controlled|stable|control improving|control worsening|poorly controlled|no changes needed|changes needed|Goal:||CHF|well controlled|adequately controlled|stable|control improving|control worsening|poorly controlled|no changes needed|changes needed|Goal:||Hyperlipidemia|well controlled|adequately controlled|stable|control improving|control worsening|poorly controlled|no changes needed|changes needed|Goal:||atrial fibrillation|well controlled|adequately controlled|stable|control improving|control worsening|poorly controlled|no changes needed|changes needed|Goal:||Seizure disorder|well controlled|adequately controlled|stable|control improving|control worsening|poorly controlled|no changes needed|changes needed|Goal:||COPD|well controlled|adequately controlled|stable|control improving|control worsening|poorly controlled|no changes needed|changes needed|Goal:||Diabetes|well controlled|adequately controlled|stable|control improving|control worsening|poorly controlled|no changes needed|changes needed|Goal:||GERD|well controlled|adequately controlled|stable|control improving|control worsening|poorly controlled|no changes needed|changes needed|Goal:||Chronic kidney disease|well controlled|adequately controlled|stable|control improving|control worsening|poorly controlled|no changes needed|changes needed|Goal:||Physical deconditioning|meeting goals of therapy|improving slowly with therapy|not meeting goals of therapy|continue PT/OT/SPL to goal|"][textarea cols=40 rows=2]

Discussed/communicated findings/plan of care with:
[checkbox name="discussed" value="patient|staff|family|MA|physician|"][textarea cols=40 rows=2]

Patient/SO/staff instructed on:
[checkbox name="instructions" value="vital signs|office tests|exam findings|recommendations|outside laboratory/diagnostic studies|specialty consults|importance of controlling chronic conditions|age-appropriate screening and immunization|diet, exercise|smoking cessation|alcohol/substance use| provided reassurance and encouraged observation.  Patient was encouraged to follow up if worsens or changes. "][textarea cols=40 rows=2]

Preventative care recommendations:[checkbox name="preventative" value="colonoscopy|DEXA|mammogram|dental exam|eye exam|foot exam|patient declined|appropriate referrals to be generated"][textarea cols=40 rows=2]

THE PATIENT HAS THE FOLLOWING RISK FACTORS:[checkbox name="risk_factors" value="dehydration| falls| pressure ulcers| malnutrition| constipation| UTI| delirium."][textarea cols=40 rows=2]
FOLLOW UP: [textarea cols=10 rows=1][checkbox name="fu" value="1 week|2 weeks|3 weeks|4 weeks|and as needed|discharged"]
TOTAL TIME: [textarea cols=10 rows=1][checkbox name="time" value="15 min|30 min|45 min|60 min|75 min|majority of visit time utilized for counseling| care coordination| Discussion of management or test results with external physician"]

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Depression Screening negative for:
[checkbox name="depression_screening" value="over the past two weeks, have you felt down, depressed, or hopeless?|over the past two weeks, have you felt little interest or pleasure in doing things?|over the past 2 weeks, have you felt suicidal?||POSITIVE FOR:|over the past two weeks, have you felt down, depressed, or hopeless?|over the past two weeks, have you felt little interest or pleasure in doing things?|over the past 2 weeks, have you felt suicidal?"]

Patient/Caregiver Support:
[checklist name="caregiver_support" value="do you feel unsafe at home?|Do you live alone?"]

Functional Ability Screen (needs help with):
[checklist name="functional_ability" value="phone|transportation|shopping|preparing meals|housework|laundry|medications|managing money||PATIENT/RESIDENT IS INDEPENDENT IN THE FOLLOWING ADLS:|phone|transportation|shopping|preparing meals|housework|laundry|medications|managing money"]