NURSING HOME NOTES

Date: [date name="variable_1" default="02-14-2024"]

Patient Name:[text name="variable_21" default=""]

S:
[checkbox name="variable_1" value="Patient seen oob|Sitting on the    wheelchair|Sitting    on the recliner|Patient seen lying in bed|Patient    seen    sitting    up    in    bed|Patient eating|Patient watching tv|No acute distress noted|Family member at    bedside"]
[textarea name="variable_1" default=""]

[mark memo="ROS" name="mark"][checkbox name="variable_22" value="ROS:
Constitutional: No fever, chills, sweats, or weakness.
Eye: No recent visual problem, icterus, or discharge.
Respiratory: No shortness of breath, cough, or cyanosis.
Cardiovascular: No chest pain, palpitations, or bradycardia.
Gastrointestinal: No nausea, vomiting, or diarrhea.
Genitourinary: No dysuria or hematuria.
Integumentary: No ecchymosis, rash, ulcers, edema, or  dryness
Allergic/Imm: No seasonal allergies, hay fever, itching, or frequent infections.
Hematologic/Lymphatic: No easy bleeding/ bruising, anemia, or swollen glands
Endocrine: No heat/cool Intolerance, Hair Loss, or excessive hair growth.
Musculoskeletal: No back pain, neck pain, or decreased range of motion.
Neurologic: No headache, confusion, numbness. or seizures.
Psychiatric: No agitation, anxiety, depression, or hallucinations."]    [textarea name="variable_23" default=""]

O:
Vital signs reviewed    from    today.
[textarea name="variable_2" default=""]


General:    [checkbox name="General" value="AAOx3|Confused|Well nourished|Obese|Cachectic"]    [text name="variable_11" default=""]

Integumentary:    [checkbox name="Skin" value="Warm & dry|Normal turgor|No skin break|Psoriasis|Bruising|Rashes|Wound vac"]    [text name="variable_12" default=""]

HEENT:    [checkbox name="HEENT" value="NC/AT|PERRLA|EOMI|Anicteric Sclerae|Pink Conjunctiva|Pale Conjunctiva|HOH"]    [text name="variable_13" default=""]

Neck:    [checkbox name="Neck" value="Supple|No JVD|No neck rigidity |Thyromegaly|Lymphadenopathy|Tracheostomy"]    [text name="variable_14" default=""]

CVS:    [checkbox name="CVS" value="S1S2 RRR|S3|S4|Murmur|Capillary refill < 3 sec|Pacemaker"]    [text name="variable_15" default=""]

RS/Chest:    [checkbox name="RS" value="Chest CTA|Symmetrical|Wheezing|Rhonchi|Crackles|Rales|Diminished breath sounds|Oxygen via NC|Permacath"]    [text name="variable_16" default=""]

GI:    [checkbox name="GI" value="BS presentx 4|Soft|Nontender|Tender|No massess|Ascites|Colostomy|PEG Tube"]    [text name="variable_17" default=""]

GU:    [checkbox name="GU" value="No CVAT|No bladder distention|Urinary catheter|Suprapubic  catheter"]    [text name="variable_20" default=""]

CNS:    [checkbox name="CNS" value="CN II-XII Intact"]    [text name="variable_18" default=""]

Musc/Ext:    [checkbox name="Musculoskeletal" value="No edema|Pulses palpable|Pitting edema|Motor 5/5|Kyphoscoliosis|Lordosis|Normal gait|MPB|Wound Vac|PICC    line|Midline|AV Fistula"]    [text name="variable_19" default=""]

Allergies:    [checkbox name="variable_23" value="NKA|NKDA"]
[text name="variable_24" default=""]

Medications:    
[textarea name="variable_7" default="I have reviewed the patient’s medications and agree with the regimen."]

Diagnostic tests:    [select name="Diagnostictest" value="None|Labs|Xray|US"]
[textarea name="variable_8" default=""]

A:    
[textarea name="variable_9" default=""]

P:
[checkbox name="Plan" value="Subacute Rehab|Physical Therapy|Occupational  Therapy|Ambulation & Gait Training|Continue medications and treatments as per MAR/TAR|Fall precautions|DVT & GI Prophylaxis|Labs reviewed|Labs ordered|Monitor serial labs|X-ray ordered|New Meds ordered|Social services and case management referral"]    [textarea name="variable_10" default=""]

Nadeem Ul    Haque,MD
Date:

Patient Name:

S:



ROS


O:
Vital signs reviewed from today.



General:

Integumentary:

HEENT:

Neck:

CVS:

RS/Chest:

GI:

GU:

CNS:

Musc/Ext:

Allergies:


Medications:


Diagnostic tests:


A:


P:


Nadeem Ul Haque,MD

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.46, 36 form elements, 32 boilerplate words, 12 text boxes, 7 text areas, 1 dates, 14 checkboxes, 1 drop downs, 111 total clicks
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