Adult – Full SOAP (text box)

CC: [text name="variable_1" default=" "]

* HPI:[textarea name="variable_2" default=" Patient x.x. is a xx-year-old male/female who is an established patient with the clinic. / new patient to the clinic. Patient presents today for *****"]
[textarea name="variable_3" default="*****example: Hypertension: Patient presents for routine follow-up of hypertension. Medications include: none. Side effects: none. DENIES chest pain, palpitations, dizziness, or SOB. Patient does/does not regularly record BP readings. BP avgs from home log: 130s/80s."]
[textarea name="variable_4" default=" "]
[textarea name="variable_55" default=" "]
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[textarea name="variable_80" default="* Allergies: N.K.D.A."]
[textarea name="variable_5" default="* Medical History: No past medical history."]
[textarea name="variable_6" default="* Surgical History: None. "]
[textarea name="variable_101" default="* Family History: no significant family history"]
[textarea name="variable_7" default="* Tobacco use: never"]
[textarea name="variable_8" default="* Drug use: Denies."]
[textarea name="variable_9" default="* Alcohol use: no alcohol use."]
[textarea name="variable_53" default="* Medications: "]

[textarea name="variable_10" default="General/Constitutional: Patient denies fever, chills, fatigue, sleep disturbance, night sweats, weight gain, weight loss, change in appetite. Overall health Good."]
[textarea name="variable_62" default="Skin: Patient denies itching, rash, or lesions. No changes to hair or nails."]
[textarea name="variable_81" default="Feet: denies nonhealing wounds or loss of sensation bilaterally"]
[textarea name="variable_11" default="Ophthalmologic: Patient denies visual changes, blurred vision, eye pain. No itching, redness or drainage."]
[textarea name="variable_12" default="ENT: Patient denies nasal congestion, nasal drainage, sore throat, ear pain, decreased hearing. No dysphagia. No sinus pain or pressure."]
[textarea name="variable_13" default="Endocrine: Patient denies cold intolerance, heat intolerance, frequent urination, excessive thirst, excessive hunger, hair loss. No hypoglycemia."]
[textarea name="variable_14" default="Respiratory: Patient denies cough, shortness of breath, dyspnea, wheezing, hemoptysis, or respiratory distress."] 
[textarea name="variable_15" default="Cardiovascular: Patient denies chest pain, chest pain with exertion, dyspnea on exertion, heart problems, irregular heartbeat, palpitations, orthopnea."]
[textarea name="variable_16" default="Gastrointestinal: Patient denies abdominal pain, nausea, vomiting, diarrhea, constipation, decreased appetite, heartburn, blood in stool. Hematology: Patient denies bleeding problems, easy bruising, or swollen glands."]
[textarea name="variable_17" default="Genitourinary: Patient denies frequent urination, difficulty urinating, painful urination, hematuria, or incontinence."]
[textarea name="variable_18" default="Musculoskeletal: Patient denies back or neck pain, joint pain, decreased ROM, redness or swelling to joints. No pedal edema. No myalgias. No CVA tenderness."]
[textarea name="variable_19" default="Neurologic: Patient denies balance difficulty , dizziness , visual changes, gait abnormality , loss of strength, headache, paresthesias. No change in speech."] 
[textarea name="variable_20" default="Psychiatric: Patient denies anxiety , depressed mood , difficulty sleeping. No panic attacks. No SI/HI. No change in appetite."]

* Vitals: HR [text name="variable_21" default=" "], RR [text name="variable_26" default=" "], Ht [text name="variable_24" default=" "], Wt [text name="variable_23" default=" "], BMI [text name="variable_25" default=" "], BP [text name="variable_22" default=" "], Spo2 [text name="variable_27" default=" "], [text name="variable_54" default="Temp"]

* Physical Exam
[textarea name="variable_28" default="-Skin: warm, dry, no rashes, no suspicious lesions"]
[textarea name="variable_100" default="-Feet: pedal pulses 2+ bilaterally, monofilament sensations present bilaterally"]
[textarea name="variable_29" default="-Head: normocephalic, no scalp lesions."]
[textarea name="variable_30" default="-Eyes: PERRLA; Sclera-not injected, non icteric. No drainage. Lids are clear w/ no lesions."]
[textarea name="variable_31" default="-Ears: External (Bilateral): No redness, drainage, or lesions.; EAR CANAL (Bilateral) TMs dull w/ out effusion, no drainage, landmarks visible"]
[textarea name="variable_32" default="-Oral Cavity: mucosa moist, no lesions. Tongue midline, o lesions."]
[textarea name="variable_33" default="-Nose: nares patent, no lesions, no drainage, no signs of epistaxis. No sinus tenderness."]
[textarea name="variable_34" default="-Throat: clear, no erythema or exudate. Uvula midline. No swelling or redness to pharynx or tonsils."]
[textarea name="variable_35" default="-Neck/Thyroid: neck supple, full range of motion, no cerivacl lymphadenopathy, no JVD, no carotid bruit."]
[textarea name="variable_36" default="-Lymph Nodes: no lymphadenopathy"]
[textarea name="variable_37" default="-Lungs: clear to auscultation bilaterally, no wheezing or dyspnea."]
[textarea name="variable_38" default="-Cardiovascular: rate regular without murmurs, gallops, or rubs. PMI nondisplaced; no appearance of JVD"]
[textarea name="variable_39" default="-Abdomen: soft, non-tender, non-distended. round, soft, BX x4 active non-tender to palpation; no rebound tenderness, no organomegaly, no guarding."]
[textarea name="variable_40" default="-Musculoskeletal: ROM to all extremities/patient's expected normal; no joint deformities or swelling; (+) pedal pulse present-equal bilaterally. Cap refill <2sec. No pedal edema."]
[textarea name="variable_41" default="-Neurologic: Mental Status: alert and cooperative. Good eye contact. Thought processes are coherent with good insight. Oriented to person, place, and time. Motor: fair muscle bulk with fair tone. Strength: no weaknesses reported. Cerebellar: point-to-point movements intact. Sensory: no loss of sensation noted. Reflexes: intact."]

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Follow-up: [text name="variable_51" default=" "]

* HPI:


* Vitals: HR , RR , Ht , Wt , BMI , BP , Spo2 ,

* Physical Exam



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Sandbox Metrics: Structured Data Index 0, 62 form elements, 18 boilerplate words, 10 text boxes, 52 text areas, 62 total clicks
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