PSYCH ROS WITH PHYSICAL EX

Review of Systems:<br>[textarea cols=80 rows=1 default="SKIN: no rashes, bruising, nail or hair changes"]<br>[textarea cols=80 rows=1 default="EYES: no blurring/double vision/spots."]<br>[textarea cols=80 rows=1 default="THROAT: no pain/trouble swallowing."]<br>[textarea cols=80 rows=1 default="NECK: no painful nodes."]<br>[textarea
 cols=80 rows=1 default="ENDOCRINE: no tremor/palpitations/heat or cold 
intolerance/unusual fatigue; no polyuria/polydipsia/polyphagia"]<br>[textarea cols=80 rows=1 default="RESPIRATORY: no cough/sputum/SOB/chest pain."]<br>[textarea cols=80 rows=1 default="CARDIOVASCULAR: no CP/heaviness/jaw or arm pain/palpitations/leg pain with exercise/edema."]<br>[textarea cols=80 rows=1 default="GASTROINTESTINAL: no constipation/diarrhea/blood in stool/melena."]<br>[textarea cols=80 rows=1 default="GENITOURINARY: no dysuria/frequency/blood in urine/incontinence"]<br>[textarea cols=80 rows=1 default="MUSCULOSKELETAL: no pain/swelling in muscles or joints."]<br>[textarea cols=80 rows=1 default="NEUROLOGICAL: no weakness, headache, or other pain."]<br>[textarea cols=80 rows=1 default="PSYCHIATRIC: no depression/anxiety/hallucinations"]<br>Medications: <br>[textarea cols=80 rows=5 default="medication name/dose/indication/duration"]<br>Allergies and Medication Intolerances: <br>[textarea cols=80 rows=1 default="medication or substance and reaction"]<br>Preventive Care Services: <br>[textarea cols=80 rows=1 default="dates and results of screening tests and exams"]<br>Advance Directives: <br>[textarea
 cols=80 rows=1 default="living will and/or durable power of attorney 
for health care/identify surrogate decision maker"]<br>-----------------------------------------------<br>Physical Examination<br>[textarea cols=80 rows=2 default="VITALS: Height/Weight/Temperature/Heart Rate/Blood Pressure/Pain Level"]<br>[textarea
 cols=80 rows=2 default="GENERAL APPEARANCE: Well developed, well 
nourished, alert and cooperative, and appears to be in no acute 
distress."]<br>[textarea cols=80 rows=1 default="HEAD: normocephalic."]<br>[textarea cols=80 rows=1 default="EYES: PERRL, EOMI. Fundi normal, vision is grossly intact."]<br>[textarea cols=80 rows=1 default="EARS: External auditory canals and tympanic membranes clear, hearing grossly intact."]<br>[textarea cols=80 rows=1 default="NOSE: No nasal discharge."]<br>[textarea
 cols=80 rows=2 default="THROAT: Oral cavity and pharynx normal. No 
inflammation, swelling, exudate, or lesions. Teeth and gingiva in good 
general condition."]<br>[textarea cols=80 rows=1 default="NECK: Neck supple, non-tender without lymphadenopathy, masses or thyromegaly."]<br>[textarea
 cols=80 rows=3 default="CARDIAC: Normal S1 and S2. No S3, S4 or 
murmurs. Rhythm is regular. There is no peripheral edema, cyanosis or 
pallor. Extremities are warm and well perfused. Capillary refill is less
 than 2 seconds. No carotid bruits."]<br>[textarea cols=80 rows=2 
default="LUNGS: Clear to auscultation and percussion without rales, 
rhonchi, wheezing or diminished breath sounds."]<br>[textarea cols=80 
rows=2 default="ABDOMEN: Positive bowel sounds. Soft, nondistended, 
nontender. No guarding or rebound. No masses."]<br>[textarea cols=80 
rows=2 default="MUSKULOSKELETAL: Adequately aligned spine. ROM intact 
spine and extremities. No joint erythema or tenderness. Normal muscular 
development. Normal gait."]<br>[textarea cols=80 rows=2 default="BACK: 
Examination of the spine reveals normal gait and posture, no spinal 
deformity, symmetry of spinal muscles, without tenderness, decreased 
range of motion or muscular spasm."]<br>[textarea cols=80 rows=2 
default="EXTREMITIES: No significant deformity or joint abnormality. No 
edema. Peripheral pulses intact. No varicosities."]<br>[textarea cols=80
 rows=5 default="LOWER EXTREMITY: Examination of both feet reveals all 
toes to be normal in size and symmetry, normal range of motion, normal 
sensation with distal capillary filling of less than 2 seconds without 
tenderness, swelling, discoloration, nodules, weakness or deformity; 
examination of both ankles, knees, legs, and hips reveals normal range 
of motion, normal sensation without tenderness, swelling, discoloration,
 crepitus, weakness or deformity."]<br>[textarea cols=80 rows=2 
default="NEUROLOGICAL: CN II-XII intact. Strength and sensation 
symmetric and intact throughout. Reflexes 2+ throughout. Cerebellar 
testing normal."]<br>[textarea cols=80 rows=1 default="SKIN: Skin normal color, texture and turgor with no lesions or eruptions."]<br>[textarea
 cols=80 rows=3 default="PSYCHIATRIC: The mental examination revealed 
the patient was oriented to person, place, and time. The patient was 
able to demonstrate good judgement and reason, without hallucinations, 
abnormal affect or abnormal behaviors during the examination. Patient is
 not suicidal."]<br>Laboratory and Radiology: <br>[textarea cols=80 rows=1 default="test, date, result"]<br><br></body></html>
Review of Systems:<br><br><br><br><br><br><br><br><br><br><br><br><br>Medications: <br><br>Allergies and Medication Intolerances: <br><br>Preventive Care Services: <br><br>Advance Directives: <br><br>-----------------------------------------------<br>Physical Examination<br><br><br><br><br><br><br><br><br><br><br><br><br><br><br><br><br><br><br>Laboratory and Radiology: <br><br><br></body></html>

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0, 35 form elements, 157 boilerplate words, 35 text areas, 35 total clicks
Questions/General site feedback

Send Feedback for this SOAPnote

This site uses Akismet to reduce spam. Learn how your comment data is processed.

More SOAPnotes by this Author: