Assessment & Plan Elements
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[conditional field="xxx" condition="condition to test"] any text to display if condition is true [/conditional]This is a
Historian:
Recent: [-] day care/school attendance
[-] sick siblings
[-] travel
[-] ER/UC visit
[-] hospitalization
[-] surgery/procedure
[-] diagnostic/laboratory studies
[-] specialty consults
[-] new medications
[-] ABX use

HPI:
Onset:
Duration:
Symptoms:
Frequency:
Provoked/made worse by/at:
Current medications:

PMH:
IMMUNIZATION:

REVIEW OF SYSTEMS
CONSTITUTIONAL: [-] fever
[-] chills
[-] body aches
[-] changed behavior
[-] tired
[-] fussy
[-] thirst

HEAD/FACE: [-] head injury
[-] scalp swelling
[-] facial pain
[-] facial swelling

Headache:
EYES:
EARS: Swelling
Right ear: pain, pressure, wax
NOSE: [-] discharge
[-] PND
[-] congestion
[-] sinus pressure
[-] snoring
[-] bleeding
[-] possible FB
[-] trauma

MOUTH: Right [-] sores
[-] teething
[-] infection
[-] swelling
[+] jaw pain

THROAT: [-] sore throat
[-] odynophagia
[-] hoarseness
[-] tightness
[-] globus

NECK: [-] pain
[-] swelling
[-] stiffness
[-] swollen glands

CV: [-] chest pain/pressure
[-] sob
[-] palpitations
[-] lightheadedness
[-] fainting

Chest/Respiratory: [-] cough
[-] phlegm
[-] wheezing
[-] pain w/ breathing
[-] rib pain
[-] breast swelling/lump
[-] nipple discharge

GI: [+] poor appetite
[-] nausea[conditional field="xxx" condition="condition to test"] any text to display if condition is true [/conditional]
[-] vomiting
[-] bloating
[-] heartburn
[-] gas
[-] food allergies
[-] generalized abdominal pain
[-] epigastric pain
[-] periumbilical pain
[-] hypochondrial pain
[-] low abdominal pain
[-] diarrhea
[-] constipation
[-] melena
[-] rectal pain/itching
[-] rectal bleeding
[-] laxative use

GU: [-] dysuria
[-] burning
[-] frequency
[-] urgency
[-] urine odor
[-] blood in urine
[-] flank pain radiating to groin
[-] oliguria
[-] discharge
[-] itching
[-] skin lesion(s)/rash
[-] scrotal swelling
[-] testicular pain

MSK: [-] myalgias
[-] localized muscle/soft tissue pain/swelling
[-] arthralgias
[-] localized joint pain/swelling
[-] acute back pain
[-] limping

NEURO: [-] dizziness
[-] focal weakness
[-] blackouts
[-] tingling/numbness
[-] speech difficulty
[-] seizures

BEHAVIORAL: [-] tantrums
[-] hitting others
[-] speech delay
[-] in special ed

PSYCH: [-] h/o ψ
[-] prior hospitalizations
[+] current meds
[-] ongoing stress
[-] depressed
[-] anxious
[-] mood swings
[-] sleep problems

LYMPH/HEMA: [-] gland swelling
[-] unusual bruising
[-] blood disorder
[-] anemia

ALLERGIES/IMMUNE: [-] atopy
[-] environmental allergies
[-] asthma
[-] food allergies
[-] autoimmune dz

DERM: no complaints

SOCIAL STRESSORS: none identified

OBJECTIVE
Appearance: well-appearing, active, interactive, non-toxic, moist mucous membranes, age-appropriate behavior, ill-appearing
Head: normocephalic, atraumatic, normal hair distribution
Face: symmetrical, no evidence of trauma, no obvious cranial nerve deficits
Eye(s): clear conjunctiva w/o exudates or hemorrhage, anicteric sclera, EOM intact, painless, without nystagmus, visual acuity grossly intact, PERL
Ear(s): Right symmetrical & intact auricles bilaterally, hearing to conversation intact, no FB visible in canals, TMs normal in appearance, , tragal tenderness, swelling of external auditory canal, cerumen in canal
Nose: nares patent bilaterally, no facial swelling or discoloration, no facial tenderness, mucosa pink & moist
Mouth: tongue normal in appearance w/o lesions and with good symmetrical movements, moist oral mucosa without lesions, normal bucal mucosa, normal dentition for age
Throat: normal voice, patent pharynx w/o swelling or exudates, swallows fluids without cough or chocking, uvula midline, clear pharynx w/o exudates
Neck: supple
Lungs: normal work of breathing, symmetrical chest expansion, no stridor audible, clear and equal breath sounds bilaterally
Chest/CV: regular rhythm, no murmurs, pedal skin warm with good & equal pulses
Abdomen: normal visual inspection, no distension, normal active bowel sounds throughout, soft non-tender
GU:
MSK:
Upper extremity(s):
Lower extremity(s):
Neuro: alert, gait, balance & coordination grossly intact, normal speech/vocalization, full weight bearing, , antalgic gait
Psych: appropriate to age/situation, normal concentration and attention, good eye contact
Skin: grossly intact, no suspicious lesions, no rashes, no bruises, normal turgor

OFFICE DIAGNOSTICS: Acute Otitis Externadiscussed with patient/SO, official report to follow

PROCEDURE(S):
 ear lavage completed, canal clear, TM intact, no active bleeding, tolerated intervention well

OUTSIDE ORDERS: none

RELEASE/CLEARANCE: excuse from school

FOLLOW UP: RTC as discussed during visit, sooner if condition worsens or new symptoms arise, contact 911/ER if significant increase in s/sx or appearance of new/danger s/sx

PATIENT/SO INSTRUCTED/COUNSELED ON: vital signs, exam findings, office tests, outside laboratory/diagnostic studies, , OTC medicines and comfort measures for symptom control, keeping affected area clean and dry, appropriate f/u w PCP

PLAN OF CARE: risks/benefits/side effects/alternatives of/to proposed plan of care/medication(s) discussed with parent, opportunity provided to ask questions and state concerns

DISCHARGE CONDITION:

DISPOSITION: home

TOTAL FACE-TO-FACE TIME: less than 30 minutes
This is a
Historian:
Recent: [-] day care/school attendance
[-] sick siblings
[-] travel
[-] ER/UC visit
[-] hospitalization
[-] surgery/procedure
[-] diagnostic/laboratory studies
[-] specialty consults
[-] new medications
[-] ABX use

HPI:
Onset:
Duration:
Symptoms:
Frequency:
Provoked/made worse by/at:
Current medications:

PMH:
IMMUNIZATION:

REVIEW OF SYSTEMS
CONSTITUTIONAL: [-] fever
[-] chills
[-] body aches
[-] changed behavior
[-] tired
[-] fussy
[-] thirst

HEAD/FACE: [-] head injury
[-] scalp swelling
[-] facial pain
[-] facial swelling

Headache:
EYES:
EARS: Swelling
Right ear: pain, pressure, wax
NOSE: [-] discharge
[-] PND
[-] congestion
[-] sinus pressure
[-] snoring
[-] bleeding
[-] possible FB
[-] trauma

MOUTH: Right [-] sores
[-] teething
[-] infection
[-] swelling
[+] jaw pain

THROAT: [-] sore throat
[-] odynophagia
[-] hoarseness
[-] tightness
[-] globus

NECK: [-] pain
[-] swelling
[-] stiffness
[-] swollen glands

CV: [-] chest pain/pressure
[-] sob
[-] palpitations
[-] lightheadedness
[-] fainting

Chest/Respiratory: [-] cough
[-] phlegm
[-] wheezing
[-] pain w/ breathing
[-] rib pain
[-] breast swelling/lump
[-] nipple discharge

GI: [+] poor appetite
[-] nausea
[-] vomiting
[-] bloating
[-] heartburn
[-] gas
[-] food allergies
[-] generalized abdominal pain
[-] epigastric pain
[-] periumbilical pain
[-] hypochondrial pain
[-] low abdominal pain
[-] diarrhea
[-] constipation
[-] melena
[-] rectal pain/itching
[-] rectal bleeding
[-] laxative use

GU: [-] dysuria
[-] burning
[-] frequency
[-] urgency
[-] urine odor
[-] blood in urine
[-] flank pain radiating to groin
[-] oliguria
[-] discharge
[-] itching
[-] skin lesion(s)/rash
[-] scrotal swelling
[-] testicular pain

MSK: [-] myalgias
[-] localized muscle/soft tissue pain/swelling
[-] arthralgias
[-] localized joint pain/swelling
[-] acute back pain
[-] limping

NEURO: [-] dizziness
[-] focal weakness
[-] blackouts
[-] tingling/numbness
[-] speech difficulty
[-] seizures

BEHAVIORAL: [-] tantrums
[-] hitting others
[-] speech delay
[-] in special ed

PSYCH: [-] h/o ψ
[-] prior hospitalizations
[+] current meds
[-] ongoing stress
[-] depressed
[-] anxious
[-] mood swings
[-] sleep problems

LYMPH/HEMA: [-] gland swelling
[-] unusual bruising
[-] blood disorder
[-] anemia

ALLERGIES/IMMUNE: [-] atopy
[-] environmental allergies
[-] asthma
[-] food allergies
[-] autoimmune dz

DERM: no complaints

SOCIAL STRESSORS: none identified

OBJECTIVE
Appearance: well-appearing, active, interactive, non-toxic, moist mucous membranes, age-appropriate behavior, ill-appearing
Head: normocephalic, atraumatic, normal hair distribution
Face: symmetrical, no evidence of trauma, no obvious cranial nerve deficits
Eye(s): clear conjunctiva w/o exudates or hemorrhage, anicteric sclera, EOM intact, painless, without nystagmus, visual acuity grossly intact, PERL
Ear(s): Right symmetrical & intact auricles bilaterally, hearing to conversation intact, no FB visible in canals, TMs normal in appearance, , tragal tenderness, swelling of external auditory canal, cerumen in canal
Nose: nares patent bilaterally, no facial swelling or discoloration, no facial tenderness, mucosa pink & moist
Mouth: tongue normal in appearance w/o lesions and with good symmetrical movements, moist oral mucosa without lesions, normal bucal mucosa, normal dentition for age
Throat: normal voice, patent pharynx w/o swelling or exudates, swallows fluids without cough or chocking, uvula midline, clear pharynx w/o exudates
Neck: supple
Lungs: normal work of breathing, symmetrical chest expansion, no stridor audible, clear and equal breath sounds bilaterally
Chest/CV: regular rhythm, no murmurs, pedal skin warm with good & equal pulses
Abdomen: normal visual inspection, no distension, normal active bowel sounds throughout, soft non-tender
GU:
MSK:
Upper extremity(s):
Lower extremity(s):
Neuro: alert, gait, balance & coordination grossly intact, normal speech/vocalization, full weight bearing, , antalgic gait
Psych: appropriate to age/situation, normal concentration and attention, good eye contact
Skin: grossly intact, no suspicious lesions, no rashes, no bruises, normal turgor

OFFICE DIAGNOSTICS: Acute Otitis Externadiscussed with patient/SO, official report to follow

PROCEDURE(S):
 ear lavage completed, canal clear, TM intact, no active bleeding, tolerated intervention well

OUTSIDE ORDERS: none

RELEASE/CLEARANCE: excuse from school

FOLLOW UP: RTC as discussed during visit, sooner if condition worsens or new symptoms arise, contact 911/ER if significant increase in s/sx or appearance of new/danger s/sx

PATIENT/SO INSTRUCTED/COUNSELED ON: vital signs, exam findings, office tests, outside laboratory/diagnostic studies, , OTC medicines and comfort measures for symptom control, keeping affected area clean and dry, appropriate f/u w PCP

PLAN OF CARE: risks/benefits/side effects/alternatives of/to proposed plan of care/medication(s) discussed with parent, opportunity provided to ask questions and state concerns

DISCHARGE CONDITION:

DISPOSITION: home

TOTAL FACE-TO-FACE TIME: less than 30 minutes
Result - Copy and paste this output: