PCMG Physiatry Progress Note V.2
Physiatry Progress Note Date of Service [date name="variable_3" default="today"] History of Presenting Illness [comment memo="Copy and paste PMH/HPI from Consult if needed"] [textarea name="variable5" default=""] Past Surgical History -[textarea name="Surgery_text" default="See consultation note"] Family History - [textarea name="Surgery_text" default="See consultation note"] Social History - [textarea name="Social_text" default="See consultation note"] Medication - [textarea name="Paintxt1" default="See consultation note"] Review of Systems [comment memo="Default will be negative. Click if positive"] General [checklist name="ROS1" value="Sleep Disturbances|Fatigue|Skin Changes|Recent Falls"] [conditional field="ROS1" condition="(ROS1).is('Recent Falls')"] [textarea name="ROStext1" default=""][/conditional] Neurological [checklist name="ROS2" value="Syncope|Headache|Coordination Changes|Weakness| Numbness"] Cardiovascular [checklist name="ROS4" value="Chest Pain|Palpitations"] Respiratory [checklist name="ROS5" value="Dyspnea|Cough|Shortness of Breath"] [comment memo="Write additional ROS below"] [textarea name="ROS6" default=""] Musculoskeletal [select name= "Msk1" value="|Expanded"][conditional field="Msk1" condition="(Msk1).is('')"][textarea name="Msktxt2" default=""][/conditional][conditional field="Msk1" condition="(Msk1).is('Expanded')"] Cervical/Thoracic/Lumbar - [textarea name="Msk2" default="denies back pain"] Joints - [textarea name="Msk3" default="Shoulder/Elbow/Wrist/Finger - Denies weakness bilaterally, denies range of motion limitations bilaterally, denies pain bilaterally"] Upper Extremity - [textarea name="Msk4" default="Upper extremity - Denies weakness bilaterally, denies range of motion limitations bilaterally, denies pain bilaterally"] Hip/Knee/Ankle/Toe - [textarea name="MSk5" default="Denies weakness bilaterally, denies range of motion limitations bilaterally, denies pain bilaterally"] Lower Extremity - [textarea name="Msk6" default="Denies weakness bilaterally, denies range of motion limitations bilaterally, denies pain bilaterally"] [/conditional] 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"] Pulmonary - [textarea name="Pe4" default="Respiratory effort within normal limits."] Cardiovascular - [textarea name="Pe5" default="Distal pulses 2+ in all extremeties. Adequate perfusion. No peripheral signs of cyanosis."] [comment memo="Write additional PE findings below"] [textarea name="PE6" default=""] Musculoskeletal - [textarea name="Mskphys" default=""] Assessment [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"] Plan [textarea name="Plan1" default=""] [checkbox name="Plancheck1" value="Continue PT,OT to improve level of function and quality of life|Educated patient on the importance of therapy and exercises while in bed|Progressive gait training with 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"]
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Sandbox Metrics: Structured Data Index 0.27, 38 form elements, 47 boilerplate words, 22 text areas, 1 dates, 2 checkboxes, 4 check lists, 1 drop downs, 5 comments, 3 conditionals, 63 total clicks
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