Objective/Exam Elements
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Note scribed by Physician
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Adult Chronic/Followup Visit
[checkbox memo="if not already inputted" memo_size="small" name="Vitals" value="Vital signs:"][conditional field="Vitals" condition="(Vitals).is('Vital signs:')"] HR [text size="5"]; SpO2 [text size="5"]; [checkbox name="Temp" value="Temp"][/conditional][conditional field="Temp" condition="(Temp).is('Temp')"] [text size="5"] deg F; [/conditional][conditional field="Vitals" condition="(Vitals).is('Vital signs:')"][checkbox name="BP" value="BP"][/conditional][conditional field="BP" condition="(BP).is('BP')"] [text size="5"] / [text size="5"] mmHg; [/conditional][conditional field="Vitals" condition="(Vitals).is('Vital signs:')"][checkbox name="RR" value="RR"][/conditional][conditional field="RR" condition="(RR).is('RR')"] [text size="5"] breaths/min; [/conditional][conditional field="Vitals" condition="(Vitals).is('Vital signs:')"][checkbox name="HT" value="HT"][/conditional][conditional field="HT" condition="(HT).is('HT')"] [text size="5"] [select value="in|cm"]; [/conditional][conditional field="Vitals" condition="(Vitals).is('Vital signs:')"][checkbox name="WT" value="WT"][/conditional][conditional field="WT" condition="(WT).is('WT')"] [text size="5"] [select value="lbs|kg"][/conditional][conditional field="Vitals" condition="(Vitals).is('Vital signs:')"][/conditional][checkbox memo="include HPI Intro" memo_size="small" name="include_hpi_block" value="HPI"][conditional field="include_hpi_block" condition="(include_hpi_block).is('HPI')"]
[text default="The patient"] is a [text size="5"] yo [select name="Gender" value="|gentleman|lady|M|F"] presenting [select name="visit_type" value="to the office|via televideo platform|via phone call"][checkbox value=" to establish care "][select name="CC" value="for management of chronic conditions|for evaluation and management of |with a relevant past medical history significant for |"][/conditional][conditional field="CC" condition="(CC).isNot('for management of chronic conditions')"][textarea name="FrTxCC"] [comment memo_size="small" memo_color="blue" memo="◀︎◀︎ freetext and/or ▼▼"][conditional field="CC" condition="(CC).isNot('for management of chronic conditions')"][checkbox memo_size="small" memo_color="blue" memo="◀︎◀︎ choose from pick list ▼▼" name="choseCC" value=""][/conditional][conditional field="choseCC" condition="(choseCC).is('')"][frontload soapnote="sample/drgfms-include-condition-checkbox-list/"].[/conditional][conditional field="include_hpi_block" condition="(include_hpi_block).is('HPI')"][checkbox value="Currently the patient has no complaints."] [comment memo="Freetext details"][textarea name="freetext_details"][remark]

6 condition history forms are inserted from another soapnote here


[/remark][/conditional]
[frontload soapnote="/sample/drgfms-cxcond-6-conditions-hx-blocks/"]
[checkbox name="lifestyle" memo="Current Lifestyle/Therapeutic Lifestyle Choices" value=""]
[conditional field="lifestyle" condition="(lifestyle).is('')"]Current Lifestyle/Therapeutic Lifestyle Choices
-Diet - [checkbox value="N/A|none|DASH diet|diabetic Diet|weight reduction diet|standard american diet"][text size="80"]
-Physical activity - [checkbox value="N/A|none"][text size="80"]
-Medications - [checkbox value="N/A|none"][text size="80"][/conditional][checkbox name="lifestyle_mod" memo="lifestyle risk factor modification" value=""][conditional field="lifestyle_mod" condition="(lifestyle_mod).is('')"]-Lifestyle risk factor modification/optimization -
-If smoking/chewing/vaping, patient indicates willingness to discuss quitting? [checkbox value="N/A|Yes|No"]
-If consuming alcohol in significant amts daily, patient indicates willingness to discuss cutting back? [checkbox value="N/A|Yes|No"]
-If overweight/obese, patient indicates willingness to discuss? [checkbox value="N/A|Yes|No"]
[/conditional]
[checkbox name="questions" memo="Questions/concerns of patient about these above conditions" value=""][conditional field="questions" condition="(questions).is('')"]-Questions/concerns of patient about these above conditions: [checkbox value="none"][textarea rows="4"][/conditional]

VIDEO VIRTUAL ENCOUNTER PHYSICAL EXAM

[checkbox name="vitals" memo="*" memo_size="small" memo_color="blue" value="-Vitals Review"][conditional field="vitals" condition="(vitals).is('-Vitals Review')"] - [select value="reviewed, no remarkable abnormalities|significant for"][text size="50"]
[/conditional]-General - [comment memo="*" memo_size="small" memo_color="blue"][conditional field="GENexamdetailed" condition="(GENexamdetailed).isNot('')"][text default="well developed, well nourished, no apparent distress" size="80"][/conditional][checkbox name="GENexamdetailed" memo="more detail" memo_size="small" memo_color="yellow" value=""][conditional field="GENexamdetailed" condition="(GENexamdetailed).is('')"][textarea memo="←freetext" memo_size="small" cols="80" rows="2"] [comment memo="↓quickpicks↓" memo_size="small"][checkbox value="well developed|well nourished|A&Ox4|NAD"] [checkbox value="MILDLY ILL|SLEEPY|APPEARS CONFUSED|APPEARS LETHARGIC|CACHECTIC APPEARANCE|APPEARS OLDER THAN STATED AGE"][/conditional]
-HEENT - [comment memo="*" memo_size="small" memo_color="blue"][conditional field="HEENTexamdetailed" condition="(HEENTexamdetailed).isNot('')"][text default="normocephalic, atraumatic, nares patent, mucous membranes moist" size="80"][/conditional][checkbox name="HEENTexamdetailed" memo="more detail" memo_size="small" memo_color="yellow" value=""][conditional field="HEENTexamdetailed" condition="(HEENTexamdetailed).is('')"][textarea memo="←freetext" memo_size="small" cols="80" rows="2"] [comment memo="↓quickpicks↓" memo_size="small"][checkbox value="normocephalic|atraumatic|conjunctiva clear|sclerae aninteric|TMs with clearly visible landmarks|nares patent b/l|turbinates nonedematous/nonerythematous b/l|mucous membranes moist|throat nonerythematous/noninjected|good dentition"] [checkbox value="R CONJUNCTIVAL ERYTHEMA|L CONJUNCTIVAL ERYTHEMA|R TM OPAQUENESS & LOSS OF LANDMARKS|R TM VIEW OBSCURRED BY CERUMEN|L TM OPAQUENESS & LOSS OF LANDMARKS|L TM VIEW OBSCURRED BY CERUMEN|NASAL SEPTUM DEVIATION|R TURBINATE EDEMA|R TURBINATE ERYTHEMA|L TURBINATE EDEMA|L TURBINATE ERYTHEMA|NASAL DISCHARGE|PHARYNGEAL ERYTHEMA/INJECTION|PHARYNGEAL COBBLESTONING|TONSILS INJECTED/EDEMATOUS|TONSILS WITH EXUDATE|GLOSSAL HYPERTROPHY|UVULAR DEVIATION"][/conditional]
-Neck - [comment memo="*" memo_size="small" memo_color="blue"][conditional field="NECKexamdetailed" condition="(NECKexamdetailed).isNot('')"][text default="no gross distention, no visible overt defect" size="80"][/conditional][checkbox name="NECKexamdetailed" memo="more detail" memo_size="small" memo_color="yellow" value=""][conditional field="NECKexamdetailed" condition="(NECKexamdetailed).is('')"][textarea memo="←freetext" memo_size="small" cols="80" rows="2"] [comment memo="↓quickpicks↓" memo_size="small"][checkbox value="soft/supple|no JVD|no thyromegaly|no tender/enlarged lymph nodes"] [checkbox value="R ANTERIOR CHAIN LYMPHADENOPATHY|R POSTERIOR CHAIN LYMPHADENOPATHY|L ANTERIOR CHAIN LYMPHADENOPATHY|L POSTERIOR CHAIN LYMPHADENOPATHY|JUGULAR VENOUS DISTENSION|GOITER"]
[checkbox name="SKINexam" memo="*" memo_size="small" memo_color="blue" value="-Skin - "][conditional field="SKINexam|SKINexamdetailed" condition="((SKINexam).is('-Skin - '))&&((SKINexamdetailed).isNot(''))"][text default="warm, dry, intact, no edema/erythema/induration/ecchymosis" size="80"]
[/conditional][conditional field="SKINexam" condition="(SKINexam).is('-Skin - ')"][checkbox name="SKINexamdetailed" memo="more detail" memo_size="small" memo_color="yellow" value=""][/conditional][conditional field="SKINexamdetailed" condition="(SKINexamdetailed).is('')"][textarea memo="←freetext" memo_size="small" cols="80" rows="2"] [comment memo="↓quickpicks↓" memo_size="small"][checkbox value="warm|dry|intact|no edema|no erythema|no induration|no ecchymosis|no concerning lesions"] [checkbox name="examskinabn1" value="ACROCYANOSIS|JAUNDICE-
|DIFFUSE/NON-FOCAL LESION(S)-
"][/conditional][conditional field="examskinabn1" condition="(examskinabn1).is('DIFFUSE/NON-FOCAL LESION(S)-
')||(examskinabn1).is('JAUNDICE-
')"] -Affected area(s)- [checkbox value="face|forehead|anterior neck|posterior neck|anterior trunk|posterior trunk|R shoulder|l shoulder|R arm|L arm|R elbow|L elbow|R forearm|L forearm|R wrist|L wrist|R hand dorsum|L hand dorsum|R palm|L palm|R inguinaL area|L inguinaL area|R hip|L hip|R thigh|L thigh|R knee|L knee|R leg|L leg|R ankle|L ankle|R foot dorsum|L foot dorsum|R foot sole|L foot sole"]
-Description- [checkbox name="examskinabn11" value="macular|papular|raised(plaques)|patches|lacey appearance|scattered|clustered|rough texture|smooth texture|erythematous|ecchymosis|skin/flesh colored|hyperpigmented|hypopigmented|non-blanching|scaling|crusting|excoriated|ulcerated|non-ulcerated"]
-Additional details- [textarea default="none" rows="2"]
[/conditional][conditional field="SKINexamdetailed" condition="(SKINexamdetailed).is('')"][checkbox name="examskinabn2" value="FOCAL/ISOLATED LESION(S)-
"][/conditional][conditional field="examskinabn2" condition="(examskinabn2).is('FOCAL/ISOLATED LESION(S)-
')"][checkbox memo="*" memo_size="small" name="Lesion1" value=" -#1
"][/conditional][conditional field="Lesion1" condition="(Lesion1).is(' -#1
')"] -Location: [select name="skinexamlocation1" value="|Scalp|Face|Neck|Shoulder|Chest/Trunk|Abdomen|Buttocks|Inguinal|Male Genital Region|Female Genital Region|Arm|Elbow|Forearm|Wrist|Hand|Finger|Hip|Thigh|Knee|Leg|Ankle|Foot|Toe"][/conditional][conditional field="skinexamlocation1" condition="(skinexamlocation1).is('Scalp')"]- [select value="right|left|midline"] [select value="occipital|parietal|temporal|frontal|preauricular|postauricular"] area[/conditional][conditional field="skinexamlocation1" condition="(skinexamlocation1).is('Face')"]- [select value="right|left|midline"] [select value="preauricular|mandibular angle|cheek|nose|periorbital|perioral|chin|submandibular|submental"] area[/conditional][conditional field="skinexamlocation1" condition="(skinexamlocation1).is('Neck')"]- [select value="right|left|midline"], [checkbox value="anterior|posterior|medial|lateral"], [select value="superior|inferior|middle"] aspect[/conditional][conditional field="skinexamlocation1" condition="(skinexamlocation1).is('Shoulder')||(skinexamlocation1).is('Elbow')||(skinexamlocation1).is('Wrist')||(skinexamlocation1).is('Hip')||(skinexamlocation1).is('Knee')||(skinexamlocation1).is('Ankle')"]- [select value="right|left"], [checkbox value="anterior|posterior|medial|lateral"] aspect[/conditional][conditional field="skinexamlocation1" condition="(skinexamlocation1).is('Arm')||(skinexamlocation1).is('Forearm')||(skinexamlocation1).is('Thigh')||(skinexamlocation1).is('Leg')"]- [select value="right|left"], [checkbox value="anterior|posterior|medial|lateral"], [select value="superior|inferior|middle"] aspect[/conditional][conditional field="skinexamlocation1" condition="(skinexamlocation1).is('Chest/Trunk')"]- [select value="right|left|midline"], [checkbox value="anterior|posterior|medial|lateral"], [select value="superior|inferior|middle"] aspect[/conditional][conditional field="skinexamlocation1" condition="(skinexamlocation1).is('Abdomen')"]- [select value="periumbilical|epigastrium|RUQ|LUQ|RLQ|LLQ"] aspect[/conditional][conditional field="skinexamlocation1" condition="(skinexamlocation1).is('Buttocks')"]- [select value="right|left|midline"] [select value="|medial|lateral"] [select value="perianal|gluteal cleft|cheek|gluteal fold"][/conditional][conditional field="skinexamlocation1" condition="(skinexamlocation1).is('Inguinal')"]- [select value="right|left"][/conditional][conditional field="skinexamlocation1" condition="(skinexamlocation1).is('Male Genital Region')"]- [select value="right|left|midline"] [select value="penile glans|penile shaft|base of penis|scrotum|periscrotal area"][/conditional][conditional field="skinexamlocation1" condition="(skinexamlocation1).is('Female Genital Region')"]- [select value="right|left|midline"] [select value="labia majora|labia minora|perilabial area|periclitoral area|mons pubis|perineum"][/conditional][conditional field="skinexamlocation1" condition="(skinexamlocation1).is('Hand')||(skinexamlocation1).is('Finger')"]- [select value="right|left"], [checkbox value="palmar/volar|dorsal|medial|lateral"] aspect[/conditional][conditional field="skinexamlocation1" condition="(skinexamlocation1).is('Finger')"], [select value="1st|2nd|3rd|4th|5th"] digit, [select value="MCP|proximal phalanx|middle phalanx|distal phalanx|periungual area"][/conditional][conditional field="skinexamlocation1" condition="(skinexamlocation1).is('Foot')||(skinexamlocation1).is('Toe')"]- [select value="right|left"], [checkbox value="plantar|dorsal|medial|lateral"] aspect[/conditional][conditional field="skinexamlocation1" condition="(skinexamlocation1).is('Toe')"], [select value="1st|2nd|3rd|4th|5th"] digit, [select value="MTP|proximal phalanx|middle phalanx|distal phalanx|periungual area"][/conditional][conditional field="Lesion1" condition="(Lesion1).is(' -#1
')"]
-Description: [checkbox name="skinexamlesion1" value="macule|papule|patch|plaque|palpable lump|visible wound|visible lump (concerning for infection)"]
-Size/diameter: [text size="5"] [select value="cm|mm"]
[/conditional][conditional field="skinexamlesion1" condition="(skinexamlesion1).is('macule')||(skinexamlesion1).is('papule')||(skinexamlesion1).is('patch')||(skinexamlesion1).is('plaque')"] -Characteristics: [checkbox value="rough|smooth|firm|soft|mobile|fixed|pedunculated"]
-Color: [select value="uniform color|non-uniform color"], [select value="erthythematous|flesh-color|brown|black|blue|multicolored"] [text size="20"]
-Borders: [select value="well-circumscribed|ill-defined"]
[/conditional][conditional field="skinexamlesion1" condition="(skinexamlesion1).is('visible lump (concerning for infection)')"] -Characteristics - [checkbox name="abscessPEchar" value="erythema|edema|induration|fluctuance|tenderness to palpation|drainage"][/conditional][conditional field="abscessPEchar" condition="(abscessPEchar).is('drainage')"] - [checkbox value="purulent|serous|sanguinous/bloody"][/conditional][conditional field="skinexamlesion1" condition="(skinexamlesion1).is('visible lump (concerning for infection)')"]
[/conditional][conditional field="skinexamlesion1" condition="(skinexamlesion1).is('visible wound')"] -Tissue layers damaged/affected - [checkbox value="epidermis|dermis|subcutaneous layer|muscle/tendon|periosteum/bone"]
-Hemostatic - [select value="|Yes|NO"]
-Wound approximation - [select value="|good|marginal|POOR"]
-Debris/foreign body present - [text default="no" size="20"]
[/conditional][conditional field="Lesion1" condition="(Lesion1).is(' -#1
')"] -Other details: [text default="none" size="80"]
[/conditional][conditional field="examskinabn2" condition="(examskinabn2).is('FOCAL/ISOLATED LESION(S)-
')"][checkbox memo="*" memo_size="small" name="Lesion2" value=" -#2
"][/conditional][conditional field="Lesion2" condition="(Lesion2).is(' -#2
')"] -Location: [select name="skinexamlocation2" value="|Scalp|Face|Neck|Shoulder|Chest/Trunk|Abdomen|Buttocks|Inguinal|Male Genital Region|Female Genital Region|Arm|Elbow|Forearm|Wrist|Hand|Finger|Hip|Thigh|Knee|Leg|Ankle|Foot|Toe"][/conditional][conditional field="skinexamlocation2" condition="(skinexamlocation2).is('Scalp')"]- [select value="right|left|midline"] [select value="occipital|parietal|temporal|frontal|preauricular|postauricular"] area[/conditional][conditional field="skinexamlocation2" condition="(skinexamlocation2).is('Face')"]- [select value="right|left|midline"] [select value="preauricular|mandibular angle|cheek|nose|periorbital|perioral|chin|submandibular|submental"] area[/conditional][conditional field="skinexamlocation2" condition="(skinexamlocation2).is('Neck')"]- [select value="right|left|midline"], [checkbox value="anterior|posterior|medial|lateral"], [select value="superior|inferior|middle"] aspect[/conditional][conditional field="skinexamlocation2" condition="(skinexamlocation2).is('Shoulder')||(skinexamlocation2).is('Elbow')||(skinexamlocation2).is('Wrist')||(skinexamlocation2).is('Hip')||(skinexamlocation2).is('Knee')||(skinexamlocation2).is('Ankle')"]- [select value="right|left"], [checkbox value="anterior|posterior|medial|lateral"] aspect[/conditional][conditional field="skinexamlocation2" condition="(skinexamlocation2).is('Arm')||(skinexamlocation2).is('Forearm')||(skinexamlocation2).is('Thigh')||(skinexamlocation2).is('Leg')"]- [select value="right|left"], [checkbox value="anterior|posterior|medial|lateral"], [select value="superior|inferior|middle"] aspect[/conditional][conditional field="skinexamlocation2" condition="(skinexamlocation2).is('Chest/Trunk')"]- [select value="right|left|midline"], [checkbox value="anterior|posterior|medial|lateral"], [select value="superior|inferior|middle"] aspect[/conditional][conditional field="skinexamlocation2" condition="(skinexamlocation2).is('Abdomen')"]- [select value="periumbilical|epigastrium|RUQ|LUQ|RLQ|LLQ"] aspect[/conditional][conditional field="skinexamlocation2" condition="(skinexamlocation2).is('Buttocks')"]- [select value="right|left|midline"] [select value="|medial|lateral"] [select value="perianal|gluteal cleft|cheek|gluteal fold"][/conditional][conditional field="skinexamlocation2" condition="(skinexamlocation2).is('Inguinal')"]- [select value="right|left"][/conditional][conditional field="skinexamlocation2" condition="(skinexamlocation2).is('Male Genital Region')"]- [select value="right|left|midline"] [select value="penile glans|penile shaft|base of penis|scrotum|periscrotal area"][/conditional][conditional field="skinexamlocation2" condition="(skinexamlocation2).is('Female Genital Region')"]- [select value="right|left|midline"] [select value="labia majora|labia minora|perilabial area|periclitoral area|mons pubis|perineum"][/conditional][conditional field="skinexamlocation2" condition="(skinexamlocation2).is('Hand')||(skinexamlocation2).is('Finger')"]- [select value="right|left"], [checkbox value="palmar/volar|dorsal|medial|lateral"] aspect[/conditional][conditional field="skinexamlocation2" condition="(skinexamlocation2).is('Finger')"], [select value="1st|2nd|3rd|4th|5th"] digit, [select value="MCP|proximal phalanx|middle phalanx|distal phalanx|periungual area"][/conditional][conditional field="skinexamlocation2" condition="(skinexamlocation2).is('Foot')||(skinexamlocation2).is('Toe')"]- [select value="right|left"], [checkbox value="plantar|dorsal|medial|lateral"] aspect[/conditional][conditional field="skinexamlocation2" condition="(skinexamlocation2).is('Toe')"], [select value="1st|2nd|3rd|4th|5th"] digit, [select value="MTP|proximal phalanx|middle phalanx|distal phalanx|periungual area"][/conditional][conditional field="Lesion2" condition="(Lesion2).is(' -#2
')"]
-Description: [checkbox name="skinexamlesion2" value="macule|papule|patch|plaque|palpable lump|visible wound|visible lump (concerning for infection)"]
-Size/diameter: [text size="5"] [select value="cm|mm"]
[/conditional][conditional field="skinexamlesion2" condition="(skinexamlesion2).is('macule')||(skinexamlesion2).is('papule')||(skinexamlesion2).is('patch')||(skinexamlesion2).is('plaque')"] -Characteristics: [checkbox value="rough|smooth|firm|soft|mobile|fixed|pedunculated"]
-Color: [select value="uniform color|non-uniform color"], [select value="erthythematous|flesh-color|brown|black|blue|multicolored"] [text size="20"]
-Borders: [select value="well-circumscribed|ill-defined"]
[/conditional][conditional field="skinexamlesion2" condition="(skinexamlesion2).is('visible lump (concerning for infection)')"] -Characteristics - [checkbox name="abscessPEchar" value="erythema|edema|induration|fluctuance|tenderness to palpation|drainage"][/conditional][conditional field="abscessPEchar" condition="(abscessPEchar).is('drainage')"] - [checkbox value="purulent|serous|sanguinous/bloody"][/conditional][conditional field="skinexamlesion2" condition="(skinexamlesion2).is('visible lump (concerning for infection)')"]
[/conditional][conditional field="skinexamlesion2" condition="(skinexamlesion2).is('visible wound')"] -Tissue layers damaged/affected - [checkbox value="epidermis|dermis|subcutaneous layer|muscle/tendon|periosteum/bone"]
-Hemostatic - [select value="|Yes|NO"]
-Wound approximation - [select value="|good|marginal|POOR"]
-Debris/foreign body present - [text default="no" size="20"]
[/conditional][conditional field="Lesion2" condition="(Lesion2).is(' -#2
')"] -Other details: [text default="none" size="80"]
[/conditional][conditional field="examskinabn2" condition="(examskinabn2).is('FOCAL/ISOLATED LESION(S)-
')"][checkbox memo="*" memo_size="small" name="Lesion3" value=" -#3
"][/conditional][conditional field="Lesion3" condition="(Lesion3).is(' -#3
')"] -Location: [select name="skinexamlocation3" value="|Scalp|Face|Neck|Shoulder|Chest/Trunk|Abdomen|Buttocks|Inguinal|Male Genital Region|Female Genital Region|Arm|Elbow|Forearm|Wrist|Hand|Finger|Hip|Thigh|Knee|Leg|Ankle|Foot|Toe"][/conditional][conditional field="skinexamlocation3" condition="(skinexamlocation3).is('Scalp')"]- [select value="right|left|midline"] [select value="occipital|parietal|temporal|frontal|preauricular|postauricular"] area[/conditional][conditional field="skinexamlocation3" condition="(skinexamlocation3).is('Face')"]- [select value="right|left|midline"] [select value="preauricular|mandibular angle|cheek|nose|periorbital|perioral|chin|submandibular|submental"] area[/conditional][conditional field="skinexamlocation3" condition="(skinexamlocation3).is('Neck')"]- [select value="right|left|midline"], [checkbox value="anterior|posterior|medial|lateral"], [select value="superior|inferior|middle"] aspect[/conditional][conditional field="skinexamlocation3" condition="(skinexamlocation3).is('Shoulder')||(skinexamlocation3).is('Elbow')||(skinexamlocation3).is('Wrist')||(skinexamlocation3).is('Hip')||(skinexamlocation3).is('Knee')||(skinexamlocation3).is('Ankle')"]- [select value="right|left"], [checkbox value="anterior|posterior|medial|lateral"] aspect[/conditional][conditional field="skinexamlocation3" condition="(skinexamlocation3).is('Arm')||(skinexamlocation3).is('Forearm')||(skinexamlocation3).is('Thigh')||(skinexamlocation3).is('Leg')"]- [select value="right|left"], [checkbox value="anterior|posterior|medial|lateral"], [select value="superior|inferior|middle"] aspect[/conditional][conditional field="skinexamlocation3" condition="(skinexamlocation3).is('Chest/Trunk')"]- [select value="right|left|midline"], [checkbox value="anterior|posterior|medial|lateral"], [select value="superior|inferior|middle"] aspect[/conditional][conditional field="skinexamlocation3" condition="(skinexamlocation3).is('Abdomen')"]- [select value="periumbilical|epigastrium|RUQ|LUQ|RLQ|LLQ"] aspect[/conditional][conditional field="skinexamlocation3" condition="(skinexamlocation3).is('Buttocks')"]- [select value="right|left|midline"] [select value="|medial|lateral"] [select value="perianal|gluteal cleft|cheek|gluteal fold"][/conditional][conditional field="skinexamlocation3" condition="(skinexamlocation3).is('Inguinal')"]- [select value="right|left"][/conditional][conditional field="skinexamlocation3" condition="(skinexamlocation3).is('Male Genital Region')"]- [select value="right|left|midline"] [select value="penile glans|penile shaft|base of penis|scrotum|periscrotal area"][/conditional][conditional field="skinexamlocation3" condition="(skinexamlocation3).is('Female Genital Region')"]- [select value="right|left|midline"] [select value="labia majora|labia minora|perilabial area|periclitoral area|mons pubis|perineum"][/conditional][conditional field="skinexamlocation3" condition="(skinexamlocation3).is('Hand')||(skinexamlocation3).is('Finger')"]- [select value="right|left"], [checkbox value="palmar/volar|dorsal|medial|lateral"] aspect[/conditional][conditional field="skinexamlocation3" condition="(skinexamlocation3).is('Finger')"], [select value="1st|2nd|3rd|4th|5th"] digit, [select value="MCP|proximal phalanx|middle phalanx|distal phalanx|periungual area"][/conditional][conditional field="skinexamlocation3" condition="(skinexamlocation3).is('Foot')||(skinexamlocation3).is('Toe')"]- [select value="right|left"], [checkbox value="plantar|dorsal|medial|lateral"] aspect[/conditional][conditional field="skinexamlocation3" condition="(skinexamlocation3).is('Toe')"], [select value="1st|2nd|3rd|4th|5th"] digit, [select value="MTP|proximal phalanx|middle phalanx|distal phalanx|periungual area"][/conditional][conditional field="Lesion3" condition="(Lesion3).is(' -#3
')"]
-Description: [checkbox name="skinexamlesion3" value="macule|papule|patch|plaque|palpable lump|visible wound|visible lump (concerning for infection)"]
-Size/diameter: [text size="5"] [select value="cm|mm"]
[/conditional][conditional field="skinexamlesion3" condition="(skinexamlesion3).is('macule')||(skinexamlesion3).is('papule')||(skinexamlesion3).is('patch')||(skinexamlesion3).is('plaque')"] -Characteristics: [checkbox value="rough|smooth|firm|soft|mobile|fixed|pedunculated"]
-Color: [select value="uniform color|non-uniform color"], [select value="erthythematous|flesh-color|brown|black|blue|multicolored"] [text size="20"]
-Borders: [select value="well-circumscribed|ill-defined"]
[/conditional][conditional field="skinexamlesion3" condition="(skinexamlesion3).is('visible lump (concerning for infection)')"] -Characteristics - [checkbox name="abscessPEchar" value="erythema|edema|induration|fluctuance|tenderness to palpation|drainage"][/conditional][conditional field="abscessPEchar" condition="(abscessPEchar).is('drainage')"] - [checkbox value="purulent|serous|sanguinous/bloody"][/conditional][conditional field="skinexamlesion3" condition="(skinexamlesion3).is('visible lump (concerning for infection)')"]
[/conditional][conditional field="skinexamlesion3" condition="(skinexamlesion3).is('visible wound')"] -Tissue layers damaged/affected - [checkbox value="epidermis|dermis|subcutaneous layer|muscle/tendon|periosteum/bone"]
-Hemostatic - [select value="|Yes|NO"]
-Wound approximation - [select value="|good|marginal|POOR"]
-Debris/foreign body present - [text default="no" size="20"]
[/conditional][conditional field="Lesion3" condition="(Lesion3).is(' -#3
')"] -Other details: [text default="none" size="80"]
[/conditional]-PSYCH - [comment memo="*" memo_size="small" memo_color="blue"][conditional field="PSYCHexamdetailed" condition="(PSYCHexamdetailed).isNot('')"][text default="appropriate mood/affect" size="80"][/conditional][checkbox name="PSYCHexamdetailed" memo="more detail" memo_size="small" memo_color="yellow" value=""][conditional field="PSYCHexamdetailed" condition="(PSYCHexamdetailed).is('')"][textarea memo="←freetext" memo_size="small" cols="80" rows="2"] [comment memo="↓quickpicks↓" memo_size="small"][checkbox value="appropriate mood|appropriate affect|FLATTENED AFFECT|INAPPROPRIATE MOOD|PRESSURED SPEECH|DISORGANIZED THOUGHT PROCESS|TANGENTIAL THOUGHT PROCESS"][/conditional]
-NEURO - [comment memo="*" memo_size="small" memo_color="blue"][conditional field="NEUROexamdetailed" condition="(NEUROexamdetailed).isNot('')"][text default="mentation normal/appropriate, no gross/overt cranial nerve deficits" size="80"][/conditional][checkbox name="NEUROexamdetailed" memo="more detail" memo_size="small" memo_color="yellow" value=""][conditional field="NEUROexamdetailed" condition="(NEUROexamdetailed).is('')"][textarea memo="←freetext" memo_size="small" cols="80" rows="2"] [comment memo="↓quickpicks↓" memo_size="small"][checkbox value="mentating well|moves all extremities equally well|CN 2-12 grossly intact b/l|normal sensorium all 4 extremities|no gross motor deficits|Romberg negative|cerebellar testing normal|DTRs 2/4 x4|gait testing without abnormalities"][/conditional][conditional field="examNEUROabn1|examNEUROabn2|examNEUROabn3|examNEUROabn4|examNEUROabn5|examNEUROabn6" condition="((examNEUROabn1).is(' -Cranial Nerve Deficit(s)- '))||((examNEUROabn2).is(' -Sensory Deficit(s)- '))||((examNEUROabn3).is(' -Motor Strength-'))||((examNEUROabn4).is(' -Reflexes-'))||((examNEUROabn5).is(' -Cerebellar Testing-'))||((examNEUROabn6).is(' -Gait- '))"]
[/conditional][conditional field="NEUROexamdetailed" condition="(NEUROexamdetailed).is('')"][comment memo="abnormals" memo_size="small" memo_color="orange"][checkbox name="examNEUROabn1" value=" -Cranial Nerve Deficit(s)- "][/conditional][conditional field="examNEUROabn1" condition="(examNEUROabn1).is(' -Cranial Nerve Deficit(s)- ')"] [checkbox value="I|II|III|IV|V|VI|VII|VIII|IX|X|XI|XII"]
[/conditional][conditional field="NEUROexamdetailed" condition="(NEUROexamdetailed).is('')"][checkbox name="examNEUROabn2" value=" -Sensory Deficit(s)- "][/conditional][conditional field="examNEUROabn2" condition="(examNEUROabn2).is(' -Sensory Deficit(s)- ')"][checkbox name="examNEUROabn11" value="R occipital|R parietal|R temporal|R frontal|R preauricular|R postauricular|L occipital|L parietal|L temporal|L frontal|L preauricular|L postauricular|R mandibular angle|R cheek|R nasal bridge|R periorbital|R perioral|chin|submental|R submandibular|L mandibular angle|L cheek|L nasal bridge|L periorbital|L perioral|L submandibular|Neck anterior|Neck posterior|Neck medial|Neck lateral|R shoulder|L shoulder|Anterior chest/trunk|Posterior chest/trunk|Abdomen|R buttocks|L buttocks|Perianal|Gluteal cleft|R inguinal|L inguinal|Penis|R scrotum|L scrotum|R labia majora|R labia minora|R perilabial area|L labia majora|L labia minora|L perilabial area|periclitoral area|mons pubis|perineum|R arm|R elbow|R forearm|R wrist|R hand/finger(s)|L arm|L elbow|L forearm|L wrist|L hand/finger(s)|R hip|R thigh|R knee|R leg|R ankle|R foot/toe(s)|L hip|L thigh|L knee|L leg|L ankle|L foot/toe(s)"] [text memo="description of deficits" memo_size="small" memo_color="yellow" size="80"]
[/conditional][conditional field="NEUROexamdetailed" condition="(NEUROexamdetailed).is('')"][checkbox name="examNEUROabn3" value=" -Motor Strength-"][/conditional][conditional field="examNEUROabn3" condition="(examNEUROabn3).is(' -Motor Strength-')"]
-R Upper Extremity- [text default="5" size="5"]/5
-L Upper Extremity- [text default="5" size="5"]/5
-R Lower Extremity- [text default="5" size="5"]/5
-L Lower Extremity- [text default="5" size="5"]/5
[/conditional][conditional field="NEUROexamdetailed" condition="(NEUROexamdetailed).is('')"][checkbox name="examNEUROabn4" value=" -Reflexes-"][/conditional][conditional field="examNEUROabn4" condition="(examNEUROabn4).is(' -Reflexes-')"]
-Biceps- [text default="2+" size="5"]/4
-Triceps- [text default="2+" size="5"]/4
-Bracioradialis- [text default="2+" size="5"]/4
-Patellar- [text default="2+" size="5"]/4
-Achilles- [text default="2+" size="5"]/4
[/conditional][conditional field="NEUROexamdetailed" condition="(NEUROexamdetailed).is('')"][checkbox name="examNEUROabn5" value=" -Cerebellar Testing-"][/conditional][conditional field="examNEUROabn5" condition="(examNEUROabn5).is(' -Cerebellar Testing-')"] [checkbox value="POSITIVE ROMBERG|PRONATOR DRIFT|IMPAIRED FINGER-TO-NOSE|IMPAIRED HAND PRONATE/SUPINATE|IMPARIED HEEL-TO-SHIN"] [text memo="cerebellar deficits freetext" memo_size="small" size="80"]
[/conditional][conditional field="NEUROexamdetailed" condition="(NEUROexamdetailed).is('')"][checkbox name="examNEUROabn6" value=" -Gait- "][/conditional][conditional field="examNEUROabn6" condition="(examNEUROabn6).is(' -Gait- ')"][checkbox value="HEMIPLEGIC|DIPLEGIC|NEUROPATHIC|CHOREIFORM|ATAXIC|PARKINSONIAN|ANTALGIC"]
[/conditional]
-ADDITIONAL EXAM - Speaking in full sentences[textarea default="none" rows="6" cols="70"]

Assessment/ PLAN

[conditional field="APvirtualblurb" condition="(APvirtualblurb).is('Virtual Encounter Statement')"]
[/conditional][checkbox name="APvirtualblurb" memo="*" memo_color="blue" memo_size="small" value="Virtual Encounter Statement"]
[conditional field="APvirtualblurb" condition="(APvirtualblurb).is('Virtual Encounter Statement')"] - Spent [text size="5"] minutes via [select value="realtime audio/video communication|voice-only/telephone|asynchronous secure text messaging"] involving obtaining/reviewing history, [checkbox value="conducting visual exam|discussing test results|discussing workup|discussing above plan|patient education"]
[/conditional]


Patient to follow up in: [textarea name="28" default=""]
RTC and ED instructions given, Patient expressed their understanding and all questions answered
Note scribed by Physician
-
Adult Chronic/Followup Visit
if not already inputted include HPI Intro
History for condition #1
History for condition #2
History for condition #3
History for condition #4
History for condition #5
History for condition #6