Telemed main Rod – new 6.11.2020
[select name="variable_20" value="|This visit was performed via telemedicine. The patient confirmed knowledge of the limitations of the use of telemedicine were verbally confirmed by the provider. Verification of patient identity was established. Verbal consent was obtained for medical treatment obtained"] The patient is being interviewed via [select name="variable_1" value="Phone consult|Video and Audio consult - Doxy.me|Other mode of Video consultation"] [checklist name="variable_300" value=" Close contact with person with confirmed or suspected COVID-19| High Risk medical conditions conditions|Age > 65|Healthcare Pesonal| Resides with older or sick family member"] History of illness and main concern. [checkbox name="variable_15" value="Onset of symptoms"] [date name="variable_1" default=""] [textarea name="variable_1" default=""] [checkbox name="variable_16" value="Pt requests testing for SARS CoV 2"] [comment memo="Therapy/ treatment tried"] [checkbox name="variable_2" value="Pt tried Acetaminophen|Pt tried Ibuprofen|Pt tried OTC cough medication|Pt tried multi-symptoms relief medications|Pt tried lozenges|no treatment tried so far|Patient noted improvement in symptoms with treatment|Patient did not noticed improvement in symptoms with treatment"] ROS: [checklist name="variable_1" value="fever|chills|dry cough|Hemoptasis|SOB|headache|nausea or vomiting|nasal congestion or discharge|dizziness|anosmia|Ageusia"] _________________________________________________________________ PHONE EXAM: ( vitals to be added into addendum if swab done) GENERAL: Alert, calm, conversant in NAD ENT: No dysphonia. LUNGS: Unlabored respirations, speaking in full sentences NEURO: Normal speech. Alert and oriented. PSYCHIATRIC: Normal mood. Normal insight and judgement. ____________________________________________________________________ DISCHARGE The patient agrees with the plan and chooses to follow up with [select name="variable_13" value="EPIC URGENT CARE CENTER|PRIMARY CARE PROVIDER OUTSIDE EPIC URGENT CARE FOR FURTHER CARE ONCE RESULTS AVAILABLE"] for reevaluation, illness monitoring and progression of symptoms. DISCHARGE NOTE AND INSTRUCTIONS PROVIDED VERBALLY - PATIENT ALSO TO BE PROVIDED WITH COMPREHENSIVE DISCHARGE SUMMARY DURING THE SPECIMENS COLLECTION. Diagnostic rationale, follow up instructions, and strict precautions/indications for emergent direct evaluation were discussed with the patient. Watch for symptoms Reported illnesses have ranged from mild symptoms to severe illness and death for confirmed coronavirus disease 2019 (COVID-19) cases. These symptoms may appear 2-14 days after exposure (based on the incubation period of MERS-CoV viruses). Fever Cough Shortness of breath Emergent follow up will require If you develop emergency warning signs for COVID-19 get medical attention immediately. Emergency warning signs include*: Trouble breathing Persistent pain or pressure in the chest New confusion or inability to arouse Bluish lips or face This list is not all-inclusive. Please consult your medical provider for any other symptoms that are severe or concerning. A negative test only says that the virus was not present or not present in a large enough amount to be detected. When testing is negative, the possibility of a false negative result will be considered depending on the context of your recent exposures, the presence of clinical signs and symptoms consistent with COVID-19, and if tests for other causes of illness such as other respiratory illness are negative. If we still suspect COVID-19, or if your symptoms worsen, we will recommend a re-testing. Regardless of your test results, we are committed to providing you with follow-up care, to help treat your symptoms. -----------------------------------------------------
There are 11 form elements.
Result - Copy and paste this output:
Sandbox Metrics: Structured Data Index 0.9, 11 form elements, 317 boilerplate words, 1 text areas, 1 dates, 3 checkboxes, 2 check lists, 3 drop downs, 1 comments, 31 total clicks
Send Feedback for this SOAPnote
You must be logged in to post a comment.