PCMG Consult No Auscultation V.3

[select name="variable_1" value="Admitting Diagnosis|Long Term Care Patient"]
[conditional field="variable_1" condition="(variable_1).is('Admitting Diagnosis')"] [textarea name="vartxt" default=""][/conditional]

[select name="variable_2" value="Initial Consultation|Readmission"]

Date of consult
[date name="variable_3" default="today"]

History of Presenting Illness 

[comment memo="write HPI below"]
[textarea name="variable5" default=""]
A consultation was requested to assess rehabilitation needs, develop a rehabilitation plan of care and address rehabilitation medicine diagnoses and their related issues. 

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="Family_text" default="Non contributory"]

Prior Functional History - Before admission, patient was able to mobilize themselves [select name="Mobility_1" value="Independently|With assistance|"][conditional field="Mobility_1" condition="(Mobility_1).is('')"]
[textarea name="Mobility_text" default=""][/conditional]
Previous Ambulation Devices - 
[checkbox name="Ambulation_1" value="No Device|Cane|Walker|Rollator|Wheelchair|Not Previously Ambulating"]
Patient's Prior Activities of Daily Living -
[checkbox name="Mobility_2" value="Dependent/Refused|Maximal Assistance|Moderate Assistance|Minimal Assistance|Setup but otherwise Independent|Independent|Assitance with Homemaking|Assitance with Grooming|"][conditional field="Mobility_2" condition="(Mobility_2).is('')"]
[textarea name="Mobility_text2" default=""][/conditional]

Social History - 
Residence - Patient lives [select name="Residence_1" value="alone|with a spouse|with their family|"] in a [select name="Social_1" value="Private Home|Apartment|Assisted Living Facility|Long Term Care Facility"] [select name="Social_2" value="with 1 flight of stairs|with 5 or fewer steps|with multiple flights of stairs|with no stairs (ground floor)|with an elevator|"]
[select name="Social_3" value="|Patient admits substance use"][conditional field="Social_3" condition="(Social_3).is('Patient admits substance use')"][textarea name="Social_text3" default=""][/conditional][comment memo="Describe use of Alcohol/Cigarette/Other"]

Pain Medication - 
[select name="Pain1" value="The patient states they use OTC pain medication as needed|"][conditional field="Pain1" condition="(Pain1).is('')"][textarea name="Paintxt1" default=""][/conditional]

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

Review of Systems
[select name="ROS_x" value="This patient is able to provide appropriate answers|This patient is nonverbal/otherwise unable to assess"][conditional field="ROS_x" condition="(ROS_x).is('This patient is able to provide appropriate answers')"]
[comment memo="Default will be negative. Click if positive. If non verbal select from above to remove ROS"]
[checklist name="ROS1" value="Sleep Disturbances|Fatigue|Skin Changes|Recent Falls"]
[checklist name="ROS2" value="Syncope|Headache|Coordination Changes|Weakness| Numbness"]
[checklist name="ROS3" value="Vision Changes|Eye Pain|Nasal Congestion|Nasal Discharge|Hearing Changes|Pain in Ear|Dysphagia|Odynophagia"]
[checklist name="ROS4" value="Chest Pain|Palpitations"]
[checklist name="ROS5" value="Dyspnea|Cough|Shortness of Breath"]
[checklist name="ROS6" value="Nausea|Vomiting|Diarrhea|Constipation|Abdominal Pain"]
[checklist name="ROS7" value="Urinary incontinence|Dysuria"]
[textarea name="msktxtarea1" default=""]
[select name="ROSnotes" value="|ROS Expanded"]
[conditional field="ROSnotes" condition="(ROSnotes).is('ROS Expanded')"][textarea name="ROStxt2" default=""][/conditional]
[comment memo="Elaborate in ROS expanded if needed"]

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."] 
Pulmonary  -  [textarea name="Pe4" default="Respiratory effort within normal limits."]  
Cardiovascular  -  [textarea name="Pe5" default="Distal pulses 2+ in all extremities.  Adequate perfusion. No peripheral signs of cyanosis."] 
Gastrointestinal  -  [textarea name="Pe6" default="Abdomen soft, nontender, nondistended. No guarding or tenderness."]
Musculoskeletal - [textarea name="Mskphys" default=""]

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]

[textarea name="Ass1" default=""]
[checkbox name="Asscheck1" value="R26.9-Repeated Falls|R13.12-Dysphagia,oropharyngeal phase|I69.328-Oth Speech/language deficits following CVA|M13.0-Polyarthritis, unspecified |M86.00-Osteomyelitis|M48.9-Spondylopathy, unspecified|M62.81-Muscle Weakness|M62.40-Contracture of muscle, unspecified|R53.81-Deconditioning|M79.2-Neuropathic pain|R26.2-Walking difficulty|R26.9-Unspecified abnormality of gait or mobility|Z73.6-Decreased ADL|Z74.09-Chairridden|Z74.1-Need assistance with personal care"]

[textarea name="Plan1" default=""]
[checkbox name="Plancheck1" value="Continue PT, OT to improve the level of function and quality of life|Educated patient on the importance of therapy and exercises while in bed|Progressive gait training with an appropriate level of assistance, with emphasis on safety and endurance|Improve bed mobility and transfers|Ice Pack on painful joint PRN|E-stim|1.8% Lidocaine Patch|4% Lidocaine Patch|5% Lidocaine Patch|Will continue to follow"]

Date of consult

History of Presenting Illness

write HPI below

A consultation was requested to assess rehabilitation needs, develop a rehabilitation plan of care and address rehabilitation medicine diagnoses and their related issues.

Allergies -

Past Surgical History -

Family History -

Prior Functional History - Before admission, patient was able to mobilize themselves
Previous Ambulation Devices -

Patient's Prior Activities of Daily Living -

Social History -
Residence - Patient lives in a
Describe use of Alcohol/Cigarette/Other

Pain Medication -

Medication -

Review of Systems

Elaborate in ROS expanded if needed

Physical Exam Please write in Vitals
Vital Signs -

General -

Neurological -


Pulmonary -

Cardiovascular -

Gastrointestinal -

Musculoskeletal -

Diagnostic Studies



Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.53, 64 form elements, 102 boilerplate words, 23 text areas, 1 dates, 6 checkboxes, 7 check lists, 12 drop downs, 5 comments, 10 conditionals, 114 total clicks
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