Patient’s rights, confidentiality, limits and exceptions to confidentiality, and use of electronic medical records were reviewed with patient. Verification of patient identity was established with patient. Patient consents to telemedicine.
CHIEF COMPLAINT: [text name="variable_2"]
HISTORY OF PRESENT ILLNESS:
The patient is a [text name="variable_3"] with a history of [text name="variable_4"] complaining of a [text name="variable_5"]
REVIEW OF SYSTEMS: Review of at least 10 organ systems is otherwise negative except as stated above.
GENERAL: [checkbox name="variable_1" value="well-developed and well-nourished|alert and cooperative|in no acute distress|well-appearing and nontoxic"], [text name="variable_2" default=""]
HEENT: [checkbox name="variable_3" value="normocephalic|atraumatic|EOMI|vision grossly intact bilaterally|no conjunctival injection or visible discharge|hearing grossly intact bilaterally|no frontal sinus tenderness bilaterally|no maxillary sinus tenderness bilaterally|no oropharyngeal erythema/edema/exudate|no uvular deviation|speaks in clear and unmuffled voice|lips/tongue/dentition/gingiva within normal limits"], [text name="variable_4" default=""]
NECK: [checkbox name="variable_5" value="supple with full range of motion|no stridor|no midline tenderness of stepoff|no cervical lymph node tenderness bilaterally|no cervical lymph node swelling bilaterally|no visible thyromegaly or other masses"], [text name="variable_6" default=""]
RESPIRATORY: [checkbox name="variable_7" value="no audible rales/rhonchi/wheezing|normal respiratory effort|speaking full sentences|no visible signs of tachypnea|no retractions"], [text name="variable_8" default=""]
CARDIOVASCULAR: [checkbox name="variable_9" value="peripheral pulses intact and palpable|pulse felt to be regular rate and rhythm by patient"], [text name="variable_10" default=""]
ABDOMINAL: [checkbox name="variable_11" value="no focal abdominal tenderness elicited upon palpation|no visible abdominal distension|no abnormal masses found upon palpation"], [text name="variable_12" default=""]
BACK: [checkbox name="variable_13" value="no CVAT elicited bilaterally|no midline tenderness or stepoff upon palpation"], [text name="variable_14" default=""]
EXTREMITIES: [checkbox name="variable_15" value="no bony tenderness|no visible gross deformity|no edema|normal range of motion"] of affected area, [text name="variable_16" default=""]
NEUROLOGIC: [checkbox name="variable_17" value="CN III-XII grossly intact|normal-appearing mental status|moving all extremities normally|grossly normal motor strength throughout|sensation to light touch grossly intact throughout|normal speech|normal gait"], [text name="variable_18" default=""]
PSYCH: [checkbox name="variable_19" value="normal-appearing affect"], [text name="variable_20" default=""]
Diagnostic rationale, follow up instructions, and strict precautions/indications for emergent direct evaluation were discussed with the patient. The patient agrees with the plan, and understands to follow up with their primary care physician or other healthcare provider [checkbox name="variable_12" value="within 24-48 hours|within 48-72 hours|within 1 week|as needed"] for reevaluation. The patient understands to report immediately to the nearest Emergency Department or Urgent Care Center for any concerning/worsening signs or symptoms.