Sample Note Generator

* HPI

[text name="Name" default="Name"] is a [conditional field="CC" condition="(CC).is('well woman exam')"] G[text size=1 default=""]P[text size=1 default=""]A[text size=1 default=""][/conditional] [text name="Age" default="age"] year old [select name="Sex" value="|male|female"] presenting today for [select name="CC" value="---|blood pressure follow up|a preoperative exam|well woman exam| "][conditional field="CC" condition="(CC).is(' ')"][text size=100 default="acute symptoms"][/conditional].[text size=100 default=""]


[comment memo="Blood Pressure HPI"]
[conditional field="CC" condition="(CC).is('blood pressure follow up')"] 
Patient is on [text name="medication1" default="medication"] for hypertension.  They report that they [select name="tolerate" value="tolerate it well|do not tolerate it well"]. They [select name="refill" value="are|are not"] in need of a refill. Patient states that they [select name="BPL" value="|do|do not"] keep a log of their blood pressure at home.[/conditional][conditional field="CC|BPL" condition="(CC).is('blood pressure follow up')&&(BPL).is('do')"] Their blood pressure average around [text name="systolic" default=""]/[text name="diastolic" default=""].[/conditional]
[conditional field="CC" condition="(CC).is('blood pressure follow up')"]Blood pressure on intakes is [text name="systolic" default=""]/[text name="diastolic" default=""].
Denies: [checkbox name="Denies" value="blurred vision|chest pain|palpitations|bilateral leg edema|shortness of breath|no dizziness or headaches"][/conditional].

[comment memo="Pre-Op HPI"]
[conditional field="CC" condition="(CC).is('a preoperative exam')"]Patient scheduled for a [text name="POP1" default="procedure"] with [text name="POP2" default="Surgeon"] on [date name="variable_1" default="02/14/2019"].
They are in need of [checkbox name="needs" value="chest x-ray|labs|EKG|other"].[/conditional]
[conditional field="CC|needs" condition="(CC).is('a preoperative exam')&&(needs).is('other')"][text name="needsOther" default="other requirements"][/conditional]

[comment memo="WWE HPI"]
[conditional field="CC" condition="(CC).is('well woman exam')"] Last pap was completed in [date name="LastPap"]; it was [select name="Pap" value="normal|abnormal"].[/conditional][conditional field="CC|Pap" condition="(CC).is('well woman exam')&&(Pap).is('abnormal')"] [text size=100 default="Abnormal findings were:"] [/conditional][conditional field="CC" condition="(CC).is('well woman exam')"] Last mammogram was completed in [date name="LastMammo"][/conditional][conditional field="CC" condition="(CC).is('well woman exam')"] Last normal period was [date name="LastPeriod"][/conditional].




* ROS
[select name="ros_template" value="|brief_ros|full_ros|BC_check|HTN_check"][conditional field="ros_template" condition="(ros_template).is('brief_ros')"]
[text size=112 default="Constitutional: No fever, no feeling tired"]
[text size=112 default="Cardiovascular: No chest pain, no chest discomfort, no palpitation"]
[text size=112 default="Respiratory: No difficulty breathing, coughing, or wheezing"]
[/conditional][conditional field="ros_template|CC" condition="(ros_template).is('full_ros')||(CC).is('a preoperative exam')||(CC).is('well woman exam')"]
[text size=112 default="Constitutional: No fever, no feeling tired"]
[text size=112 default="Eyes: No visual disturbances"]
[text size=112 default="ENT: No loss of hearing"]
[text size=112 default="Cardiovascular: No chest pain"]
[text size=112 default="Respiratory: No shortness of breath"]
[text size=112 default="Gastrointestinal: No nausea or vomiting"]
[text size=112 default="Genitourinary: No urinary symptoms"]
[text size=112 default="Musculoskeletal: No joint pain"]
[text size=112 default="Skin: No new lesions"]
[text size=112 default="Neurological: No headaches"]
[text size=112 default="Psychiatric: No sleep problems"]
[text size=112 default="Endocrine: No hot flashes"]
[text size=112 default="Hematology: No bruising"]
[text size=112 default="Immunology:  No hives"]
[/conditional][conditional field="ros_template" condition="(ros_template).is('BC_check')"]
[text size=112 default="Constitutional: No fever, no feeling tired"]
[text size=112 default="Eyes: No visual problems, photophobia"]
[text size=112 default="Cardiovascular: No chest pain, no chest discomfort, no palpitation"]
[text size=112 default="Respiratory: No difficulty breathing, coughing, or wheezing"]
[text size=112 default="Gastrointestinal: No abdominal pain"]
[text size=112 default="Musculoskeletal: No leg cramps"]
[text size=112 default="Neurological: No headaches"]
[/conditional][conditional field="ros_template|CC" condition="(ros_template).is('HTN_check')||(CC).is('blood pressure follow up')"]
[text size=112 default="Constitutional: No fever, no feeling tired"]
[text size=112 default="Eyes: No blurred vision"]
[text size=112 default="Cardiovascular: No chest pain, no chest discomfort, no palpitations, no bilateral leg edema"]
[text size=112 default="Respiratory: No difficulty breathing, coughing, or wheezing"]
[text size=112 default="Neurological: No dizziness or headaches"]
[/conditional]

* PE
[select name="pe_template" value="|brief_pe|medium_pe|complete_pe|wwe"][conditional field="pe_template" condition="(pe_template).is('brief_pe')"]
[text size=112 default="Constitutional: Vitals signs noted, and in no acute distress"]
[text size=112 default="Neuropsych: Alert and oriented x3"]
[text size=112 default="Eyes: Equal and round, conjunctiva were clear."]
[text size=112 default="ENT: Lips without lesions, normal appearing nose"]
[text size=112 default="Neck: Normal appearing"]
[text size=112 default="Musculoskeletal: Normal stance and gait"]
[text size=112 default="Skin: No rashes in visible areas"]
[/conditional][conditional field="pe_template" condition="(pe_template).is('medium_pe')"]
[text size=112 default="Constitutional: Vitals signs noted, and in no acute distress"]
[text size=112 default="Neuropsych: Alert and oriented x3"]
[text size=112 default="Eyes: Equal and round, conjunctiva were clear."]
[text size=112 default="ENT: Lips without lesions, normal appearing nose"]
[text size=112 default="Neck: Normal appearing"]
[text size=112 default="Heart: Regular rate and rhythm without murmurs, no pitting edema."]
[text size=112 default="Lungs: Clear to auscultation bilaterally, respirations unlabored."]
[text size=112 default="Musculoskeletal: Normal stance and gait"]
[text size=112 default="Skin: No rashes in visible areas"]
[/conditional][conditional field="pe_template|CC" condition="(pe_template).is('complete_pe')||(CC).is('a preoperative exam')"]
[text size=112 default="Constitutional: Vitals signs noted, and in no acute distress"]
[text size=112 default="Neuropsych: Alert and oriented x3"]
[text size=112 default="Eyes: Equal and round, conjunctiva were clear."]
[text size=112 default="ENT: Lips without lesions, normal appearing nose"]
[text size=112 default="Neck: Normal appearing"]
[text size=112 default="Heart: Regular rate and rhythm without murmurs, no pitting edema."]
[text size=112 default="Lungs: Clear to auscultation bilaterally, respirations unlabored."]
[text size=112 default="Abdomen: Soft nondistended and nontender, no palpable masses, or lesions. No hepatosplenomegaly noted. No obvious hernias."]
[text size=112 default="Musculoskeletal: Normal stance and gait"]
[text size=112 default="Skin: No rashes in visible areas"]
[/conditional][conditional field="pe_template|CC" condition="(pe_template).is('wwe')||(CC).is('well woman exam')"]
[text size=112 default="Constitutional: Vitals signs noted, and in no acute distress"]
[text size=112 default="Neuropsych: Alert and oriented x3"]
[text size=112 default="Eyes: Equal and round, conjunctiva were clear."]
[text size=112 default="ENT: Lips without lesions, normal appearing nose"]
[text size=112 default="Neck: Normal appearing"]
[text size=112 default="Heart: Regular rate and rhythm without murmurs, no pitting edema."]
[text size=112 default="Lungs: Clear to auscultation bilaterally, respirations unlabored."]
[text size=112 default="Breasts: No lesions, no nipple retraction, no skin changes."]
[text size=112 default="Abdomen: Soft nondistended and nontender, no palpable masses, or lesions. No hepatosplenomegaly noted. No obvious hernias."]
[text size=112 default="Genitourinary: Normal external female genitalia. Vulva, Urethra, and Perineum: No lesion. Cervix without obvious lesions. PAP smear done. Uterus is midline and nontender. There is no CMT. Ovaries are WNL. Adnexa negative for masses."]
[text size=112 default="Musculoskeletal: Normal stance and gait"]
[text size=112 default="Skin: No rashes in visible areas"]
[/conditional]




* Procedure
[select name="procedure" value="|IUD|EKG"][conditional field="needs|procedure" condition="(needs).is('EKG')||(procedure).is('EKG')"]
Electrocardiogram

Recorded: [text name="EKG1" default="normal sinus rhythm"] with rate of [text name="EKG2" default="x"] beats per minute, [text name="EKG3" default="(additional dictated results), no signs of acute ischemia or ectopy, no acute findings."] [/conditional][conditional field="procedure" condition="(procedure).is('IUD')"] 
IUD Removal

The cervix was visualized with a speculum and the strings of the IUD identified.  It was grasped with ring forceps and removed without difficulty.  There was scant bleeding after the procedure and the patient tolerated it well.  The IUD was inspected and found to be intact.
[/conditional]

* A/P

[comment memo="Pre-Op Plan"]
[conditional field="CC" condition="(CC).is('a preoperative exam')"]Preoperative Examination

Patient is scheduled for a [text name="POP1"] with [text name="POP2"] on [text name="variable_1"]. [/conditional][conditional field="needs|procedure" condition="(needs).is('EKG')||(procedure).is('EKG')"]EKG completed as noted above in the procedure.[/conditional][conditional field="CC|needs|EKG3" condition="(CC).is('a preoperative exam')&&(needs).is('EKG')&&(EKG3).isNot('no signs of acute ischemia or ectopy, no acute findings.')"] EKG sent to cardiology for a second opinion. [/conditional][conditional field="needs|CC" condition="(needs).is('chest x-ray')||(needs).is('labs')&&(CC).is('a preoperative exam')"]Patient is cleared for operation pending results.[/conditional][conditional field="needs|CC|EKG3" condition="(needs).isNot('chest x-ray')&&(needs).isNot('labs')&&(CC).is('a preoperative exam')&&(EKG3).is('no signs of acute ischemia or ectopy, no acute findings.')"] Patient is cleared for operation.[/conditional]

[comment memo="Blood Pressure Plan"]
[conditional field="CC" condition="(CC).is('blood pressure follow up')"]Hypertension

Advised DASH diet, daily exercise, and weight loss. Treatment options reviewed and discussed. [/conditional][conditional field="CC|BPL|systolic|diastolic" condition="(CC).is('blood pressure follow up')&&(BPL).is('do')&&(systolic).isGreater('140')||(diastolic).isGreaterOrEqual('90')"] Blood pressure is not in therapeutic range. [/conditional][conditional field="CC|BPL|systolic|diastolic" condition="(CC).is('blood pressure follow up')&&(BPL).is('do')&&(systolic).isLess('140')&&(diastolic).isLessOrEqual('90')"] Blood pressure is in therapeutic range. [/conditional][conditional field="CC|refill" condition="(CC).is('blood pressure follow up')&&(refill).is('are')"]Prescription sent for [text name="medication1"]. Risks, side effects, and benefits discussed.[/conditional]
[conditional field="CC|tolerate|refill" condition="(CC).is('blood pressure follow up')&&(tolerate).is('do not tolerate it well')&&(refill).is('are not')"]Discontinued [text name="medication1"] and starting [text name="medication2" default="new medication"] Risks, side effects, and benefits discussed.[/conditional]
[conditional field="CC|tolerate|refill" condition="(CC).is('blood pressure follow up')&&(tolerate).is('tolerate it well')&&(refill).isNot('are')"] Continue current medication and regimen.[/conditional][conditional field="CC" condition="(CC).is('blood pressure follow up')"] Follow up in [select name="follow_up" value="1 month|3 months|6 months"].[/conditional]