Assessment & Plan Elements
Share
Tweet
Cite
approximately 203 views since I made an informed decision.
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"]

Patient has + results for SARS Cov2

Symptoms onset date: [date name="variable_4" default="05/13/2020"]
Collection date:[date name="variable_5" default="05/13/2020"]
Results date: [date name="variable_6" default="05/13/2020"]

[select name="variable_17" value="|Occupation:"][text name="variable_17" default=""]
[select name="variable_18" value="|Chronic Medical illnesses:"][text name="variable_18" default=""]

[select name="variable_16" value="|Patient still has symptoms|Patient reports symptoms partially resolved|Complete resolution of symptoms| Patient never had symptoms"]


Associated symptoms
[textarea name="variable_2" default=""]
[checklist name="variable_1" value="fever|chills|dry cough|SOB|headache|nausea or vomiting|nasal congestion|sneezing|eyes itching|dizziness|anosmia|Ageusia"]



ROS: All systems reviewed and negative except HPI

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.



Diagnostic rationale, follow up instructions, and strict precautions/indications for emergent direct evaluation were discussed with the patient.

The patient agrees with the plan, and understands to follow up [select name="variable_13" value="EPIC URGENT CARE CENTER|PRIMARY CARE PROVIDER"] within 48 hours for reevaluation, illness monitoring and progression of symptoms.
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

Patient has + results for SARS Cov2

Symptoms onset date:
Collection date:
Results date:







Associated symptoms





ROS: All systems reviewed and negative except HPI

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.



Diagnostic rationale, follow up instructions, and strict precautions/indications for emergent direct evaluation were discussed with the patient.

The patient agrees with the plan, and understands to follow up within 48 hours for reevaluation, illness monitoring and progression of symptoms.

Result - Copy and paste this output:

Send Feedback for this SOAPnote

Your email address will not be published.

More SOAPnotes by this Author: