SOAP Progress Note (Nephrology)

[date name="variable_1" default=""] [text name="variable_11111" default=""]
Nephrology, Dr. [text name="variable_3" default=""], [select name="variable_4" value="PGY1|PGY2|PGY3|MS3|MS4"], for Dr. [text name="variable_5" default=""].

S:  [text name="variable_114" default="The patient was seen and examined."] 
[textarea name="variable_113" default=""] 
[text name="variable_115" default="No events were reported overnight."]

* Vital Signs: TEMP: [text name="variable_7" default=""] HR: [text name="variable_8" default=""] RR: [text name="variable_9" default=""] SPO2: [text name="variable_10" default=""] on [text name="variable_11" default=""] BP: [text name="variable_12" default=""]
* General Appearance: [select name="variable_109" value="NAD|Mildly distressed|Moderately distressed|Severely distressed|"], [select name="variable_13" value="well developed/well-nourished|underdeveloped/under-nourished|cachectic|"], [select name="variable_14" value="lying comfortably in bed|sitting comfortably on bed|sitting comfortably on chair|hunched over|"] [text name="variable_15" default=""]
* Head: [select name="variable_16" value="Normocephalic, atraumatic|"][select name="variable_17" value=", symmetrical face|, right facial droop|, left facial droop"] [text name="variable_18" default=""]
* Eyes: [select name="variable_22" value="Bilateral|Left|Right|"] [select name="variable_23" value="normal eyelids|retracted eyelid|ptosis|palpebral swelling|"]. [select name="variable_20" value="EOMI|Dysconjugate gaze|Strabismus|Horizontal nystagmus|Vertical nystagmus|Torsional nystagmus|Mixed nystagmus|4th n. palsy|6th n. palsy|"]. [select name="variable_19" value="PERRLA|Anisocoria|Fixed pupils|Unreactive to light only|Unreactive to accommodation only|"] [select name="variable_125" value="|bilaterally|on the left|on the right"]. [select name="variable_21" value="Conjunctiva clear|Conjunctival congestion|Conjunctival chemosis|Conjunctival exudates|Conjunctival icterus|Conjunctival pallor|Subconjunctival hemorrhage|"] [text name="variable_24" default=""]
* Oral: [select name="variable_41" value="Oropharynx clear|Erythematous oropharynx|Purulent oropharynx|"], [select name="variable_42" value="moist mucosa|dry mucosa|"], [select name="variable_43" value="normal colored oral mucosa|pale oral mucosa|cyanotic oral mucosa|"] [text name="variable_44" default=""]
* Heart: [select name="variable_52" value="Normal rate and rhythm|Tachycardiac|Bradycardiac|Small, weak pulse|Large bounding pulse|Bisferiens pulse|Pulsus alternans|Bigeminal pulse|Pulsus paradoxicus|"], [select name="variable_53" value="normal S1, S2|wide splitting|fixed splitting|paradoxical splitting|3rd heart sound|4th heart sound|"], [select name="variable_54" value="no murmurs, rubs, or gallops|early systolic murmur present|mid systolic (ejection) murmur present|late systolic murmur present|pan systolic murmur present|early diastolic murmur present|late diastolic mumrmur present|presystolic murmur present|continuous murmur present|pericardial rub present|gallop present|"] [text name="variable_110" default=""]
* Chest: [select name="variable_111" value="Clear to auscultation (normal vesicular breath sounds),|Bronchial breath sounds|Diminished breath sounds|Could not auscultate|"] [select name="variable_112" value="on bilateral|on right|on left|"] [select name="variable_55" value="lung fields,|upper lung field,|lower lung field,|"] [select name="variable_56" value="no wheezing|with wheezing|with stridor|"][select name="variable_57" value=", no crackles|, with crackles|"] [select name="variable_58" value="|on left|on right|on bilateral"] [select name="variable_59" value="|upper lung field|lower lung field|lung fields"] [text name="variable_60" default=""]
* Abdomen: [select name="variable_61" value="Normal bowel sounds|Hypoactive bowel sounds|Hyperactive bowel sounds|Absent bowel sounds|Could not auscultate|"], [select name="variable_62" value="not distended|distended|"], [select name="variable_63" value="not tender|with tenderness|"] on [select name="variable_64" value="all quadrants|upper right quadrant|upper left quadrant|lower right quadrant|lower left quadrant|"], [select name="variable_67" value="no masses|with a mass|"] [select name="variable_68" value="on all quadrants|on upper right quadrant|on upper left quadrant|on lower right quadrant|on lower left quadrant|"], [select name="variable_65" value="no hepatosplenomegaly|with hepatsplenomegaly|with hepatomegaly|with spenomegaly|"] [text name="variable_69" default=""]
* Musculoskeletal: [select name="variable_70" value="Normal muscle bulk|Decreased muscle bulk (atrophy)|"], [select name="variable_71" value="moves all limbs freely|limited range of motion|"], [select name="variable_72" value="no tenderness|with tenderness|"] [select name="variable_73" value="|on right|on left|on bilateral"] [select name="variable_74" value="on all limbs|upper limb|lower limb|shoulder joint|elbow joint|wrist joint|hip joint|knee joint|ankle joint|"], [select name="variable_78" value="no masses|with a mass|"] [select name="variable_79" value="|on right|on left|on bilateral"] [select name="variable_80" value="on all limbs|upper limb|lower limb|"]. [text name="variable_81" default=""] Muscle Strength: [select name="variable_121" value="5/5 on all limbs|"] [text name="variable_82" default=""]
* Extremities: [select name="variable_83" value="No significant deformity or joint abnormality.|With significant deformity or joint abnormality.|"] [select name="variable_84" value="No edema.|Edema +1.|Edema +2.|Edema +3.|Edema+4.|"] [text name="variable_85" default=""] [select name="variable_86" value="Peripheral pulses +3|Peripheral pulses +2|Peripheral pulses +1|Peripheral pulses +4|"]  [text name="variable_87" default=""]
* Neurological: [select name="variable_88" value="No focal neurological lesions.|Focal neurological lesion(s) present.|"] [text name="variable_89" default=""] [select name="variable_90" value="Cerebellar intact|Cerebellar defect(s) present|"] [text name="variable_91" default=""]
* Skin: [select name="variable_92" value="Normal color.|Jaundiced.|Cyanosed.|Vitiligo.|Other discoloration.|Hypopigmentation.|Hyperpigmentation.|"] [text name="variable_93" default=""] [text name="variable_93" default=""] [select name="variable_140" value="Warm|Hot|Cool|"], [select name="variable_141" value="dry|moist|"], [select name="variable_142" value="intact|non-intact"]. [text name="variable_143" default=""] [select name="variable_94" value="|Normal texture|Abnormal skin texure"] [text name="variable_95" default=""]

Labs: [textarea name="variable_107" default=""]

Urine output: [text name="variable_122222" default=""]

Microbiology: [textarea name="variable_111112" default=""]

Imaging: [textarea name="variable_11113212" default=""]


[textarea name="variable_108" default=""]

Nephrology, Dr. , , for Dr. .


* Vital Signs: TEMP: HR: RR: SPO2: on BP:
* General Appearance: , ,
* Head:
* Eyes: . . .
* Oral: , ,
* Heart: , ,
* Chest:
* Abdomen: , , on , ,
* Musculoskeletal: , , , . Muscle Strength:
* Extremities:
* Neurological:
* Skin: , , .


Urine output:




Result - Copy and paste this output:

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