PCMG TCM Template v2

[select name="Visit" value="Telehealth|In Person Visit"]
Patient Name:[text name="demo1" default=""]
Patient DOB:[text name="demo2" default=""]
Place of Service:[text name="demo3" default=""]
Date of Service:[date name="date1" default="today"]
Date of Discharge from facility :[date name="date2" default="today"]

History of Presenting Illness
[comment memo="write HPI below"]
[textarea name="variable5" default=""]

[textarea name="abe1" default="Patient received non face to face interactive communication, 48 hrs after discharge on  "]

[select name="attempt1" value="|Attempted to reach out to the patient, unsuccessfully, first attempt|Attempted to reach out to the patient, unsuccessfully, second attempt"]

[conditional field="attempt1" condition="(attempt1).is('Attempted to reach out to the patient, unsuccessfully, first attempt')"]
[textarea name="attemptext1" default=""]
Patient was contacted via - [select name="attemptype1" value="Phone|Secure Message"][/conditional]
[conditional field="attempt1" condition="(attempt1).is('Attempted to reach out to the patient, unsuccessfully, second attempt')"]
[textarea name="attemptext2" default=""]
Patient was contacted via [select name="attemptype1" value="Phone|Secure Message"][/conditional]


Allergies -[textarea name="allergies_1" default="No Known Allergies"]
Past Surgical History -[select name="Surgical_1" value="Non Contributory|"][conditional field="Surgical_1" condition="(Surgical_1).is('')"][checkbox name="Surgical_2" value="R Hip replacement|L Hip replacement|R knee replacement|L knee replacement"], [textarea name="Surgery_text" default=""][/conditional]

Family History -[textarea name="Surgery_text2" default="Non contributory"]

Social History -[textarea name="Social1" default=""]


Medication -[select name="Med1" value="I have reviewed the patient's medications|"][conditional field="Med1" condition="(Med1).is('')"][textarea name="Medtxt1" default=""][/conditional]

Medication Reconciliation Performed on - [date name="meddate" default="11/24/2021"]

Review of Systems
[comment memo="Default will be negative. Click if positive"]
General
[checklist name="ROS1" value="Sleep Disturbances|Fatigue|Recent Falls|Unable to asses/patient nonverbal"]
[conditional field="ROS1" condition="(ROS1).is('Recent Falls')"]
[textarea name="ROStext1" default=""][/conditional]
Skin
[checklist name="ROS8" value="Rashes|Itching|Change in hair or nails"]
Neurological
[checklist name="ROS2" value="Syncope|Headache|Coordination Changes|Weakness| Numbness|Unable to asses/patient nonverbal"]
HEENT
[checklist name="ROS3" value="Vision Changes|Eye Pain|Nasal Congestion|Nasal Discharge|Hearing Changes|Pain in Ear|Dysphagia|Odynophagia|Unable to asses/patient nonverbal"]
Breast
[checklist name="ROS9" value="Lumps|Pain|Discharge"]
Cardiovascular
[checklist name="ROS4" value="Chest Pain|Palpitations|Unable to asses/patient nonverbal"]
Respiratory
[checklist name="ROS5" value="Dyspnea|Cough|Shortness of Breath|Unable to asses/patient nonverbal"]
Gastrointestinal
[checklist name="ROS6" value="Nausea|Vomiting|Diarrhea|Constipation|Abdominal Pain|Unable to asses/patient nonverbal"]
Genitourinary
[checklist name="ROS7" value="Urinary incontinence|Dysuria|Urgency|Frequency|Unable to asses/patient nonverbal"]
Endocrine
[checklist name="ROS9" value="Abnormal Growth|Apetite changes|Increased thirst|Unable to asses/patient nonverbal|"]
[conditional field="ROS9" condition="(ROS9).is('')"]
[textarea name="ROStext1" default=""][/conditional]
Musculoskeletal
[checklist name="ROS10" value="Back pain|Upper extremity weakness|Lower extremity weakness| Range of motion deficits in upper extremity| Range of motion deficits Lower extremity| Joint pain shoulders| Joint Pain Hips| Joint pain Knees| Joint pain ankles|Unable to asses/patient nonverbal|"][conditional field="ROS10" condition="(ROS10).is('')"]
[textarea name="ROStext1" default=""][/conditional]

[conditional field="Visit" condition="(Visit).is('In Person Visit')"]
Physical Exam [comment memo="Please write in Vitals"]
Vital Signs - [textarea name="VS1" default="BP- mmgHg T- °F P- beats/min R- breaths/min"]
General - [textarea name="Pe1" default="No acute distress, Well developed, well-nourished, Afebrile"]
Neurological - [textarea name="Pe2" default="Alert and Oriented, Normal mood and affect, Cranial Nerves II-XII grossly intact"]
HEENT - [textarea name="Pe3" default="Head is normocephalic, atraumatic. Bilateral pupils are equal and reactive to light and accommodating. No scleral icterus, no conjunctival pallor. No neck masses were palpated. No carotid bruit auscultated."]
Pulmonary - [textarea name="Pe4" default="Respiratory effort within normal limits. No visible deformities. Chest rise equal bilaterally. Lungs clear to auscultation bilaterally. No rhales or rhonchi."]
Cardiovascular - [textarea name="Pe5" default="Distal pulses 2+ in all extremities. Adequate perfusion. No peripheral signs of cyanosis. No thrills palpated. No murmur auscultated. Normal S1 S2."]
Gastrointestinal - [textarea name="Pe6" default="Abdomen soft, nontender, nondistended. No guarding or tenderness. Bowel sound auscultated."]
Musculoskeletal - [textarea name="Mskphys" default="No obvious in musculature visualized.  No pain on palpation of musculature.  No restrictions in range of motion on passive manipulation of bilateral shoulder, elbow, wrist, hips and knees. Patient able to actively move all 4 extremities. Muscle tone well developed. Strength 5/5 in all extremities."][/conditional]

Diagnostic Studies
[checkbox name="dx_1" value="I have reviewed this patient's lab result|No current labs at this time|I have reviewed this patients diagnostic imaging|No diagnostic imaging at this time|"]
[conditional field="dx_1" condition="(dx_1).is('')"][textarea name="dxtxt1" default=""][/conditional]

Assessment
[textarea name="Ass1" default=""]
[checkbox name="Asscheck1" value="Hypertension|Diabetes|Hyperlipidemia"]


Plan
[textarea name="Plan1" default=""]
[checkbox name="Plancheck1" value="Follow up with primary care physician|Take daily vital signs with remote patient monitoring devices"]