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"]
Physiatry Progress Note

Date of Service


History of Presenting Illness
Copy and paste PMH/HPI from Consult if needed


Past Surgical History -

Family History -

Social History -

Medication -


Review of Systems
Default will be negative. Click if positive
General


Neurological

Cardiovascular

Respiratory

Write additional ROS below

Musculoskeletal


Physical Exam Please write in Vitals
Vital Signs -

General -

Neurological -

Pulmonary -

Cardiovascular -

Write additional PE findings below

Musculoskeletal -


Assessment




Plan

Result - Copy and paste this output:

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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