[textarea default="NECK: Neck and thyroid were examined showing ***anterior cervical lymphadenopathy/posterior cervical lymphadenopathy/neck tenderness/diffuse enlargement of the thyroid/neck rigidity/TMJ tenderness***."] [textarea default="musculoskeletal findings: Palpation of neck showed ***pain/no pain*** in the ***paraspinals/midline pain over the spinous processes/trapezial ridge/levator scapula/rhomboids*** on the ***left side/right side***."] [textarea default="ROM was ***normal/fair/decreased/moderately decreased/markedly decreased*** with ***no pain with lateral bending/pain with lateral bending*** to ***either side/left side/right side*** and ***pain/no pain/radicular pain down same side/radicular pain down both sides*** on forward flexion. "] [textarea default="Exam of extension showed ***limitation of ROM/no limitation of extension ROM/pain in paraspinal neck area/no pain/radicular pain down same side***."] [textarea default="Axial load test reveals ***no pain/pain/paraspinal discomfort mild on same side/radicular pain down the arm on same side/no radicular pain down the arm***."]
There are 5 form elements.
Result - Copy and paste this output:
Sandbox Metrics: Structured Data Index 0, 5 form elements, 5 text areas, 5 total clicks
More SOAPnotes by this Author:
Send Feedback for this SOAPnote
You must be logged in to post a comment.