iHuman Checklist

Chief complaint: [text name="variable_1" default="CC"]

Questions to ask every time:
[checkbox name="variable_41" value="How can I help you today?|Any other symptoms or concerns?|Drug allergies|Environmental allergies|Rx medications|OTC/Herbal medications|Immunizations"]

[text name="variable_2" default="Symptom/Complaint"]
[text name="variable_3" default="Onset"]
[text name="variable_4" default="Location"]
[text name="variable_5" default="Duration"]
[text name="variable_6" default="Characteristics"]
[text name="variable_7" default="Aggravating factors"]
[text name="variable_8" default="Relieving factors"]
[text name="variable_9" default="Treatments"]
[text name="variable_10" default="Severity"]

[text name="variable_11" default="Symptom/Complaint"]
[text name="variable_12" default="Onset"]
[text name="variable_13" default="Location"]
[text name="variable_14" default="Duration"]
[text name="variable_15" default="Characteristics"]
[text name="variable_16" default="Aggravating factors"]
[text name="variable_17" default="Relieving factors"]
[text name="variable_18" default="Treatments"]
[text name="variable_19" default="Severity"]

[text name="variable_111" default="Symptom/Complaint"]
[text name="variable_112" default="Onset"]
[text name="variable_113" default="Location"]
[text name="variable_114" default="Duration"]
[text name="variable_115" default="Characteristics"]
[text name="variable_116" default="Aggravating factors"]
[text name="variable_117" default="Relieving factors"]
[text name="variable_118" default="Treatments"]
[text name="variable_119" default="Severity"]

[checkbox name="variable_21" value="Gen/Constitutional: Denies fatigue, difficulty sleeping, unintentional weight loss or gain, fevers, or night sweats. |Skin/Hair/Nails: denies problems with itchy scalp, skin changes, moles, thinning hair, or brittle nails.|HEENT: denies problems with headaches, double/blurred vision, trouble hearing, ear pain, sinus problems, sore throat, or difficulty swallowing.|Breast: denies problems with new lumps, bumps, asymmetry, nipple retraction or discharge.|CV: Denies chest pain, discomfort, pressure, shortness of breath, palpitations, or decreased exercise tolerance.|Resp: Denies shortness of breath, wheezing, difficulty catching breath, chronic cough, sputum production.|GI: Denies nausea, vomiting, constipation, diarrhea, coffee ground emesis, dark/tarry stools, bright red blood per rectum.|GU/GYN: Denies changes in urination, burning on urination, flank pain, blood in urine, malodorous urine.|MSK: Denies muscle or joint pain, swelling, muscle cramps, joint stiffness, joint swelling, back pain, neck pain, shoulder pain, hip pain.|Heme: Denies bruising, bleeding gums, nose bleeds, or other sites of bleeding.|Endo: Denies problems with heat or cold intolerance, increased thirst, sweating, frequent urination, or change in appetite.|Neuro: Denies problems with dizziness, fainting, room spinning, seizures, weakness, numbness, tingling, tremor.|Psych: Denies nervousness, depression, lack of interest, memory loss, or mood changes."]

Physical Exam:
[checkbox name="variable_31" value="Heart sounds|Lung sounds|Focused assessment"]

Order tests for EVERY DDx you have. For instance, you may have to order 3 CBC's for 3 different diagnoses.
Chief complaint:

Questions to ask every time:



Physical Exam:

Order tests for EVERY DDx you have. For instance, you may have to order 3 CBC's for 3 different diagnoses.

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.1, 31 form elements, 31 boilerplate words, 28 text boxes, 3 checkboxes, 51 total clicks
Questions/General site feedback · Help Ticket

Send Feedback for this SOAPnote

Your email address will not be published. Required fields are marked *

More SOAPnotes by this Author: