Assessment & Plan Elements
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A/P:
[checkbox name="apURI" value="#UPPER RESPIRATORY INFECTION:
"][conditional field="apURI" condition="(apURI).is('#UPPER RESPIRATORY INFECTION:
')"] with components of [checkbox value="rhinitis|sinusitis|eustachian tube dysfunction|otitis media|pharyngitis|post-nasal drip|laryngitis|other-"] [text size="80"]
[checkbox value="-No concerning focal bacterial infection identified.
"][checkbox value="-Advised pt that sx duration usually 7-10 days (3 days longer in smokers).
"][checkbox value="-Reassured patient that abx not currently indicated and have side effects.
"][checkbox value="-Advised pt of the risks/benefits of sx mgmt.
"][checkbox value="-Pt declined symptomatic treatment.
"][checkbox name="URTItx" value="-The patient requests the following symptomatic tx which were ordered:"][/conditional][conditional field="URTItx" condition="(URTItx).is('-The patient requests the following symptomatic tx which were ordered:')"] [checkbox value="acetaminophen (Discussed appropriate dosing, alcohol avoidance, and hepatotoxicity risk)|NSAIDs (Discussed appropriate dosing, limiting use to 1-2 weeks, and potential risks including: GI bleed, renal failure, CV events)|oral antihistamine (discussed prn use, side effects risk of drowsiness, constipation, mental confusion, falls if elderly)|Nasal saline|Decongestants (Discussed limiting use to less than 72 hours; discussed risks of tachycardia/arrhythmias, anxiety, insomnia, hypertension, and rebound rhinitis|Brown Honey (OTC only, not for use in chilren under 1 year old)|Vapor Rub (OTC only)|Benzonatate capsules (cough suppressant, swallow whole)|Menthol lozenges|Zinc lozenges (may shorten duration of illness, OTC only)|Guaifenesin (Discussed possible drowsiness, headache, rash, nausea, and limited trials of efficacy)|Nasal steroids (Discussed possible nasal dryness, thrush, epistaxis)"].
[/conditional][conditional field="apURI" condition="(apURI).is('#UPPER RESPIRATORY INFECTION:
')"]-Gave return precautions to include: [checkbox value="fever over 101F not relieved by tylenol/NSAIDS|purulent discharge|severe facial pain|shortness of breath|difficulty swallowing|sx >10 days|sx worsen after previously improving"].
-Followup: [text size="5"] [select value="|routine f/u visit not indicated|day(s)|week(s)|month(s)"] [checkbox value="with PCM|with unit provider"][text memo="other specialties" memo_size="small" size="60"]
-Explained the above assessment and plan to patient who: [select value="|acknowledged understanding and intent to follow through with plan|desires second opinion"]

[/conditional][checkbox name="apThroatSinusPain" value="#THROAT/SINUS PAIN:
"][conditional field="apThroatSinusPain" condition="(apThroatSinusPain).is('#THROAT/SINUS PAIN:
')"]-Dx- [checkbox value="acute steptococcal pharyngitis|acute viral pharyngitis (streptococcal origin less likely)|likely streptococcal pharyngitis|acute mild sinusitis|acute moderate/severe sinusitis|chronic rhinitis|post-nasal drip"]
-Reasoning- [checkbox value="rapid strep test performed and positive|CENTOR score 4-5|rapid strep test performed and negative (throat culture obtained/results pending)|low CENTOR score|physical exam findings as above|severe features of sinusitis present (fever and/or face pain)|duration of sinusitis sx beyond 2wks|progressively worsening sinusitis sx"]
-Discussed/recommended- [checkbox value="adequate rest/hydration| frequent handwashing|cough etiquette|use of nasal rinse"]
-Medications ordered/recommended OTC- [checkbox value="none|mucinex|mucinex-D|cepacol|tylenol|motrin|nasal steroid spray|nasal antihistamine|oral antihistamine|antibiotics|oral steroids|albuterol inhaler"]
-Gave return precautions to include: [checkbox value="fever over 101F not relieved by tylenol/NSAIDS|worsening face pain|shortness of breath|difficulty swallowing|no improvement after one week|sx worsen after previously improving"].
-Patient disposition- [checkbox value="return to work|return to school|not return to school until afebrile for 48 hours|not return to work until afebrile for 48 hours|light duty profile|quarters x24hrs|referred to ED for further workup|return to normal activities"]
-Followup: [text size="5"] [select value="|routine f/u visit not indicated|day(s)|week(s)|month(s)"] [checkbox value="with PCM|with unit provider"][text memo="other specialties" memo_size="small" size="60"]
-Explained the above assessment and plan to patient who: [select value="|acknowledged understanding and intent to follow through with plan|desires second opinion"]

[/conditional] [checkbox name="apGI" value="#GI CONDITION:
"][conditional field="apGI" condition="(apGI).is('#GI CONDITION:
')"]-Dx- [checkbox value="viral gastroenteritis|suspected bacterial gastroenteritis|suspected food poisoning|gastroesophageal reflux disorder|suspected gastric ulcer/PUD|melena|hematochezia|constipation|suspected appendicitis|suspected gallbladder disease"]
-Diagnostic labs ordered- [checkbox value="none (not indicated)|CBC|BMP|CMP|GI viral/bacterial pathogen panel|fecal occult blood|fecal leukocytes|stool culture|stool ova and parasites|H pylori stool Ag|H pylori Ab (blood)|Tissue Transglutamase"]
-Imaging ordered- [checkbox value="none (not indicated)|KUB|Acute Abdominal Series|CT Abd/Pelv"]
-Immediate interventions- [checkbox value="none (not indicated)|discussed progressive oral rehydration efforts with electrolyte solution|provided IV rehydration with normal saline|provide IV rehydration with lactated ringers|discussed avoidance of foods shown to worsen patient’s condition|rx’d empiric trial of PPI|rx’d empiric antibiotic|rx’d loperamide"] [text size="80"]
-Referral- [checkbox value="none (not indicated)|routine GI referral|ASAP GI referral with warm handoff|ASAP General Surgery referral with warm handoff"]
-Patient Disposition- [checkbox value="stable and discharged home with return precautions|sent to emergency department for further evaluation and treatment"]
-Followup: [text size="5"] [select value="|routine f/u visit not indicated|day(s)|week(s)|month(s)"] [checkbox value="with PCM|with unit provider"][text memo="other specialties" memo_size="small" size="60"]

[/conditional][checkbox name="apMSK1" value="#MSK Condition(1):"][conditional field="apMSK1" condition="(apMSK1).is('#MSK Condition(1):')"]
-Diagnosis- [textarea rows="2"]
-Acuity- [checkbox value="New/Acute Injury|Chronic Condition 1st Assessment|Chronic Condition Followup"]
-Reasoning-
--Likely contributing factor(s): [comment memo="muscle/tendon" memo_size="small"][checkbox value="repetitive use|poor mechanics/ergonomics/form|inadequate conditioning|muscle strain|muscle spasm|joint/ligament sprain|muscle weakness|tendinopathy|somatic dysfunction(osteopathic)"];[comment memo="bone/joint/disc" memo_size="small"][checkbox value="neuropathy|referred pain|osteoarthritis|joint degeneration|joint/ligament instability|disc degeneration|spinal stenosis|disc herniation|occult fracture"];[comment memo="other" memo_size="small"][checkbox value="anxiety|depression|opioid-induced hyperalgesia"] [text size="80"]
--Unlikely factor(s): [comment memo="muscle/tendon" memo_size="small"][checkbox value="repetitive use|poor mechanics/ergonomics/form|inadequate conditioning|muscle strain|muscle spasm|joint/ligament sprain|muscle weakness|tendinopathy|somatic dysfunction(osteopathic)"];[comment memo="bone/joint/disc" memo_size="small"][checkbox value="neuropathy|referred pain|osteoarthritis|joint degeneration|joint/ligament instability|disc degeneration|spinal stenosis|disc herniation|occult fracture"];[comment memo="other" memo_size="small"][checkbox value="anxiety|depression|opioid-induced hyperalgesia"] [text size="80"]
--Prognosis: [checkbox value="mild severity|moderate severity|acute injury|likely self-limited|anticipate full recovery|anticipate at least partial recovery|likely progressive degenerative process|prognosis unclear|workup will help further assess prognosis|encouraging|improving with current treatments|not improving with current treatments|concern for worsening|has not yet met MRDP|has met MRDP and will referral for MEB"] [textarea rows="2"]
-Workup:
[checkbox value="--No imaging or dx studies currently indicated
"][checkbox value="--Xray
"][checkbox value="--CT
"][checkbox value="--MRI
"][checkbox value="--EMG
"][textarea rows="2" cols="80"]
-Treatments @ this time:
--Conservative/self-care measures- [checkbox value="none|rest|ice/heat|early mobilization|splinting"]
--Work/school/duty limitations issued- [checkbox value="none"][text size="5"] [select value=|day(s)|week(s)|month(s)|indefinite period"] [textarea rows="3" memo="specific limitations" memo_size="small"]
--Home stretches/exercise plan- [checkbox value="none|demonstrated|provided handout"] [text size="80"]
--Medications- [checkbox value="none|NSAIDS|tylenol|muscle relaxer|transdermal lidocaine patches|topical capsaicin"] [text size="80"]
--Physical therapy- [checkbox value="none (not indicated currently)|continue formal physical therapy|discontinue current physical therapy|referred for formal physical therapy"]
-Referrals: [checkbox name="referral" value="none|sports medicine|orthopedics|PM&R|chiropractic|pain management|OMT"] [text size="80"]
[checkbox name="OMT" value="--OMT"][/conditional][conditional field="OMT" condition="(OMT).is('--OMT')"] - [select value="scheduled|performed (see note)"]
[/conditional][conditional field="apMSK1" condition="(apMSK1).is('#MSK Condition(1):')"]-Followup: [text size="5"] [select value="|routine f/u visit not indicated|day(s)|week(s)|month(s)"] [checkbox value="with PCM|with unit provider"][text memo="other specialties" memo_size="small" size="60"]
-Gave the following return precautions: [checkbox name="MSKreturnprecaut" value="n/a|fever|severe progressive pain|progressive/severe swelling|inability to bear weight|new onset/worsening numbness|new onset/worsening weakness"] [textarea rows="2"]
-Explained the above assessment and plan to patient who: [select value="|acknowledged understanding and intent to follow through with plan|desires second opinion"]

[/conditional][checkbox name="apMSK2" value="#MSK Condition(2):"][conditional field="apMSK2" condition="(apMSK2).is('#MSK Condition(2):')"]
-Diagnosis- [textarea rows="2"]
-Acuity- [checkbox value="New/Acute Injury|Chronic Condition 1st Assessment|Chronic Condition Followup"]
-Reasoning-
--Likely contributing factor(s): [comment memo="muscle/tendon" memo_size="small"][checkbox value="repetitive use|poor mechanics/ergonomics/form|inadequate conditioning|muscle strain|muscle spasm|joint/ligament sprain|muscle weakness|tendinopathy|somatic dysfunction(osteopathic)"];[comment memo="bone/joint/disc" memo_size="small"][checkbox value="neuropathy|referred pain|osteoarthritis|joint degeneration|joint/ligament instability|disc degeneration|spinal stenosis|disc herniation|occult fracture"];[comment memo="other" memo_size="small"][checkbox value="anxiety|depression|opioid-induced hyperalgesia"] [text size="80"]
--Unlikely factor(s): [comment memo="muscle/tendon" memo_size="small"][checkbox value="repetitive use|poor mechanics/ergonomics/form|inadequate conditioning|muscle strain|muscle spasm|joint/ligament sprain|muscle weakness|tendinopathy|somatic dysfunction(osteopathic)"];[comment memo="bone/joint/disc" memo_size="small"][checkbox value="neuropathy|referred pain|osteoarthritis|joint degeneration|joint/ligament instability|disc degeneration|spinal stenosis|disc herniation|occult fracture"];[comment memo="other" memo_size="small"][checkbox value="anxiety|depression|opioid-induced hyperalgesia"] [text size="80"]
--Prognosis: [checkbox value="mild severity|moderate severity|acute injury|likely self-limited|anticipate full recovery|anticipate at least partial recovery|likely progressive degenerative process|prognosis unclear|workup will help further assess prognosis|encouraging|improving with current treatments|not improving with current treatments|concern for worsening|has not yet met MRDP|has met MRDP and will referral for MEB"] [textarea rows="2"]
-Workup:
[checkbox value="--No imaging or dx studies currently indicated
"][checkbox value="--Xray
"][checkbox value="--CT
"][checkbox value="--MRI
"][checkbox value="--EMG
"][textarea rows="2" cols="80"]
-Treatments @ this time:
--Conservative/self-care measures- [checkbox value="none|rest|ice/heat|early mobilization|splinting"]
--Work/school/duty limitations issued- [checkbox value="none"][text size="5"] [select value=|day(s)|week(s)|month(s)|indefinite period"] [textarea rows="3" memo="specific limitations" memo_size="small"]
--Home stretches/exercise plan- [checkbox value="none|demonstrated|provided handout"] [text size="80"]
--Medications- [checkbox value="none|NSAIDS|tylenol|muscle relaxer|transdermal lidocaine patches|topical capsaicin"] [text size="80"]
--Physical therapy- [checkbox value="none (not indicated currently)|continue formal physical therapy|discontinue current physical therapy|referred for formal physical therapy"]
-Referrals: [checkbox name="referral" value="none|sports medicine|orthopedics|PM&R|chiropractic|pain management|OMT"] [text size="80"]
[checkbox name="OMT" value="--OMT"][/conditional][conditional field="OMT" condition="(OMT).is('--OMT')"] - [select value="scheduled|performed (see note)"]
[/conditional][conditional field="apMSK2" condition="(apMSK2).is('#MSK Condition(2):')"]-Followup: [text size="5"] [select value="|routine f/u visit not indicated|day(s)|week(s)|month(s)"] [checkbox value="with PCM|with unit provider"][text memo="other specialties" memo_size="small" size="60"]
-Gave the following return precautions: [checkbox name="MSKreturnprecaut" value="n/a|fever|severe progressive pain|progressive/severe swelling|inability to bear weight|new onset/worsening numbness|new onset/worsening weakness"] [textarea rows="2"]
-Explained the above assessment and plan to patient who: [select value="|acknowledged understanding and intent to follow through with plan|desires second opinion"]

[/conditional][checkbox name="apMSK3" value="#MSK Condition(3):"][conditional field="apMSK3" condition="(apMSK3).is('#MSK Condition(3):')"]
-Diagnosis- [textarea rows="2"]
-Acuity- [checkbox value="New/Acute Injury|Chronic Condition 1st Assessment|Chronic Condition Followup"]
-Reasoning-
--Likely contributing factor(s): [comment memo="muscle/tendon" memo_size="small"][checkbox value="repetitive use|poor mechanics/ergonomics/form|inadequate conditioning|muscle strain|muscle spasm|joint/ligament sprain|muscle weakness|tendinopathy|somatic dysfunction(osteopathic)"];[comment memo="bone/joint/disc" memo_size="small"][checkbox value="neuropathy|referred pain|osteoarthritis|joint degeneration|joint/ligament instability|disc degeneration|spinal stenosis|disc herniation|occult fracture"];[comment memo="other" memo_size="small"][checkbox value="anxiety|depression|opioid-induced hyperalgesia"] [text size="80"]
--Unlikely factor(s): [comment memo="muscle/tendon" memo_size="small"][checkbox value="repetitive use|poor mechanics/ergonomics/form|inadequate conditioning|muscle strain|muscle spasm|joint/ligament sprain|muscle weakness|tendinopathy|somatic dysfunction(osteopathic)"];[comment memo="bone/joint/disc" memo_size="small"][checkbox value="neuropathy|referred pain|osteoarthritis|joint degeneration|joint/ligament instability|disc degeneration|spinal stenosis|disc herniation|occult fracture"];[comment memo="other" memo_size="small"][checkbox value="anxiety|depression|opioid-induced hyperalgesia"] [text size="80"]
--Prognosis: [checkbox value="mild severity|moderate severity|acute injury|likely self-limited|anticipate full recovery|anticipate at least partial recovery|likely progressive degenerative process|prognosis unclear|workup will help further assess prognosis|encouraging|improving with current treatments|not improving with current treatments|concern for worsening|has not yet met MRDP|has met MRDP and will referral for MEB"] [textarea rows="2"]
-Workup:
[checkbox value="--No imaging or dx studies currently indicated
"][checkbox value="--Xray
"][checkbox value="--CT
"][checkbox value="--MRI
"][checkbox value="--EMG
"][textarea rows="2" cols="80"]
-Treatments @ this time:
--Conservative/self-care measures- [checkbox value="none|rest|ice/heat|early mobilization|splinting"]
--Work/school/duty limitations issued- [checkbox value="none"][text size="5"] [select value=|day(s)|week(s)|month(s)|indefinite period"] [textarea rows="3" memo="specific limitations" memo_size="small"]
--Home stretches/exercise plan- [checkbox value="none|demonstrated|provided handout"] [text size="80"]
--Medications- [checkbox value="none|NSAIDS|tylenol|muscle relaxer|transdermal lidocaine patches|topical capsaicin"] [text size="80"]
--Physical therapy- [checkbox value="none (not indicated currently)|continue formal physical therapy|discontinue current physical therapy|referred for formal physical therapy"]
-Referrals: [checkbox name="referral" value="none|sports medicine|orthopedics|PM&R|chiropractic|pain management|OMT"] [text size="80"]
[checkbox name="OMT" value="--OMT"][/conditional][conditional field="OMT" condition="(OMT).is('--OMT')"] - [select value="scheduled|performed (see note)"]
[/conditional][conditional field="apMSK3" condition="(apMSK3).is('#MSK Condition(3):')"]-Followup: [text size="5"] [select value="|routine f/u visit not indicated|day(s)|week(s)|month(s)"] [checkbox value="with PCM|with unit provider"][text memo="other specialties" memo_size="small" size="60"]
-Gave the following return precautions: [checkbox name="MSKreturnprecaut" value="n/a|fever|severe progressive pain|progressive/severe swelling|inability to bear weight|new onset/worsening numbness|new onset/worsening weakness"] [textarea rows="2"]
-Explained the above assessment and plan to patient who: [select value="|acknowledged understanding and intent to follow through with plan|desires second opinion"]

[/conditional][checkbox name="apSTD" value="#STD/STI CONCERNS/EXPOSURE:"][conditional field="apSTD" condition="(apSTD).is('#STD/STI CONCERNS/EXPOSURE:')"]
-Dx: [checkbox value="GC/chlamydial infection (suggestive clinical symptoms)|chlamydial infection confirmed|gonorrheal infection confirmed|Sexually Transmitted Infection exposure"]
-Plan: [checkbox value="treat empirically with azithromycin 1 gram now|treat empirically with ceftriaxone 250mg intramuscularly and azithromycin 1 gram now|obtain further laboratory evaluation"]
-Counseling: discussed with patient [checkbox value="safer sex practices|condom use|risks associated with recurrent or untreated sexually transmitted infections to include infertility, morbidity, chronic pain, and even death"]
-Followup: [text size="5"] [select value="|routine f/u visit not indicated|day(s)|week(s)|month(s)"] [checkbox value="with PCM|with unit provider"][text memo="other specialties" memo_size="small" size="60"]
-Gave the following return precautions: [checkbox name="STDreturnprecaut" value="fever|worsening pain|worsening symptoms in genitalia after 2 days of treatment|increasing lightheadness|increasing nausea/vomiting|other-"][/conditional][conditional field="STDreturnprecaut" condition="(STDreturnprecaut).is('other-')"] [textarea rows="2"][/conditional][conditional field="apSTD" condition="(apSTD).is('#STD:
')"]
-Explained the above assessment and plan to patient who: [select value="|acknowledged understanding and intent to follow through with plan|desires second opinion"]

[/conditional][checkbox name="apUTI" value="#URINARY TRACT INFECTION:
"][conditional field="apUTI" condition="(apUTI).is('#URINARY TRACT INFECTION:
')"]-[select value="acute cystitis with hematuria|acute cystitis without hematuria|chronic cystitis|pyelonephritis"] based on [checkbox value="clinical suspicion and history/findings|confirmatory labwork"]
-[select value="Treat|Treat empirically"] with [checkbox value=”pyridium|antibiotics|nitrofurantoin|trimethoprim/sulfamethox|b-lactam|flouroquinolone”].
-Followup: [text size="5"] [select value="|routine f/u visit not indicated|day(s)|week(s)|month(s)"] [checkbox value="with PCM|with unit provider"][text memo="other specialties" memo_size="small" size="60"]
-Gave the following return precautions: [checkbox name="UTIreturnprecaut" value="fever|severe progressive pain|increasing lightheadness|increasing nausea/vomiting|other-"][/conditional][conditional field="UTIreturnprecaut" condition="(UTIreturnprecaut).is('other-')"] [textarea rows="2"][/conditional][conditional field="apUTI" condition="(apUTI).is('#URINARY TRACT INFECTION:
')"]
-Explained the above assessment and plan to patient who: [select value="|acknowledged understanding and intent to follow through with plan|desires second opinion"]

[/conditional][checkbox name="apCONTRACEP" value="#CONTRACEPTIVE MANAGEMENT:
"][conditional field="apCONTRACEP" condition="(apCONTRACEP).is('#CONTRACEPTIVE MANAGEMENT:
')"]-Discussed these methods to include contraindications, indications, and possible side effects: [checkbox value="oral combination estrogen/progesterone pills|oral progesterone only pills|hormone-releasing IUD|Copper IUD|progesterone IM injections|Nuvaring|Transdermal patches|Nexplanon|periodic abstinence|barrier methods (condom and diaphragm in combination with spermicidal lubrication)|withdrawal methods|permanent sterilization methods (tubal ligation, vasectomy, and essure)|abstinence|birth control while breastfeeding and lactation amenorrhea"].
-Patient appears a reasonable candidate for any of these for: [checkbox value="prevention of pregnancy|regulating irregular menstrual cycles|dysmenorrhea|menorrhagia|acne|other-"] [text size="50"]
-Discussed relative risks/benefits of each, and relative/absolute contraindications of each.
-Patient opted for: [select value="oral combination estrogen/progesterone pills|progesterone only pills|progesterone IM injections q3mo|Nexplanon|Mirena|Skyla|Paragard|condoms|vasectomy for partner|tubal ligation|no contraception|natural family planning"].
-HCG testing MDM: CDC criteria for not requiring HCG test:
[checklist name="variable_1" value="Is less than or equal to 7 days after the start of normal menses=1|Has not had sexual intercourse since the start of last normal menses=1|Has been correctly and consistently using a reliable method of contraception=1|Is less than or equal to 7 days after spontaneous or induced abortion=1|Is within 4 weeks postpartum=1|Is fully or nearly fully breastfeeding (exclusively breastfeeding or the vast majority - more than 85 percent - of feeds are breastfeeds), amenorrheic, and less than 6 months postpartum=1"]
--Score --> [calc memo="number" value="score=(variable_1)"] out of 6 items
--Interpretation --> [calc memo="result" value="score2=(variable_1);score2>0?'Testing optional - Can be reasonably certain that patient is not pregnant without a pregnancy test':'Testing recommended - Cannot be reasonably certain that patient is not pregnant without a pregnancy test'"]
--Decision: [select value="no HCG testing|will test HCG and verify negative result prior to patient starting contraceptive method"]
-Next action(s): [checkbox value="Pills prescribed and patient to pickup in pharmacy."][checkbox value="Applicable procedure performed same visit - see procedure note."][checkbox value="Patient will be scheduled for applicable procedure."][checkbox value="Patient referred to procedures clinic for scheduling of applicable procedure."][checkbox name="contracepDEPO" value="Gave Medroxyprogesterone 150mg IM injection."][/conditional][conditional field="contracepDEPO" condition="(contracepDEPO).is('Gave Medroxyprogesterone 150mg IM injection.')"]
--Patient verbally consented
--[select value="R|L”] [select value="Deltoid|Glut muscle"]
--Lot# [text size="10"], Exp Date [text size="10"]
--Next window [select memo="month" memo_size="small" value="Jan|Feb|Mar|Apr|May|Jun|Jul|Aug|Sep|Oct|Nov|Dec"] [text memo="day" memo_size="small" size="4"] THRU [select memo="month" memo_size="small" value="Jan|Feb|Mar|Apr|May|Jun|Jul|Aug|Sep|Oct|Nov|Dec"] [text memo="day" memo_size="small" size="4"] [text memo="year" memo_size="small" size="8"]
--Observed for 5 minutes following injection
--No immediate complications noted
--Left in stable condition[/conditional][conditional field="apCONTRACEP" condition="(apCONTRACEP).is('#CONTRACEPTIVE MANAGEMENT:
')"]-Explained the above assessment and plan to patient who: [select value="|acknowledged understanding and intent to follow through with plan|desires second opinion"]
-Followup: [text size="5"] [select value="|routine f/u visit not indicated|day(s)|week(s)|month(s)"] [checkbox value="with PCM|with unit provider"][text memo="other specialties" memo_size="small" size="60"]

[/conditional][checkbox name="apPFB" value="#PSEUDOFOLLICULITIS BARBAE:
"][conditional field="apPFB" condition="(apPFB).is('#PSEUDOFOLLICULITIS BARBAE:
')"]-[select value="1st visit|followup"]
-Severity: [select value="milld|moderate|severe"]
-Current Mgmt- [checkbox value="shaving at night|shaving 2-3x/wk|adequate 15min shave prep time|dislodging hairs|rough cloth exfoliation|preshave moisturizing lotion|using single/double bladed razor|using clippers|aftershave moisturizing lotion|benzoyl peroxide|tretinoin topical|low-potency topical steroid|temporary shaving profile|permanent shaving profile"]
-Effect of current mgmt- [checkbox value="condition improved|condition well-controlled|condition NOT well-controlled|sx NOT improved|condition WORSENED|undesirable/intolerable side effects of treatment(s)"]
-Plan- [checkbox name="PFBplan" value="continue current/above regimen|add benzoyl peroxide|add tretinoin topical|add low-potency topical steroid|add temporary shaving profile|add permanent shaving profile|referred to dermatology|counseled on TB MED 287 and derm guidelines regarding -"][/conditional][conditional field="PFBplan" condition="(PFBplan).is('counseled on TB MED 287 and derm guidelines regarding -')"][checkbox value="shaving at night|shaving 2-3x/wk (not daily)|planning for adequate 15min shave prep|dislodging hairs|rough cloth exfoliation|use of preshave moisturizing lotion|use single/double bladed razor (not 3+ blades)|use of clippers|use of aftershave moisturizing lotion"][/conditional][conditional field="apPFB" condition="(apPFB).is('#PSEUDOFOLLICULITIS BARBAE:
')"]
-Followup: [text size="5"] [select value="|routine f/u visit not indicated|day(s)|week(s)|month(s)"] [checkbox value="with PCM|with unit provider"][text memo="other specialties" memo_size="small" size="60"]
-Explained the above assessment and plan to patient who: [select value="|acknowledged understanding and intent to follow through with plan|desires second opinion"]

[/conditional][checkbox name="apBH" value="#BEHAVIORAL HEALTH:
"][conditional field="apBH" condition="(apBH).is('#BEHAVIORAL HEALTH:
')"]-Acuity- [select value="new dx|chronic/established dx"]
-Dx: [checkbox value="adjustment d/o with depressed mood|adjustment d/o with anxiety|adjustment d/o with mixed depression/anxiety sx|depression|anxiety|PTSD|ADHD|bipolar"]
-Current Mgmt- [checkbox value="IBHC|psychologist CBT|psychiatrist management of medications|SSRI|SNRI|benzodiazepine|mood stabilizer(s)|atypical antipsychotic|no prior treatment|stimulant|non-stimulant"]
-Effect of current mgmt- [checkbox value="sx improved|sx well-controlled|sx not well-controlled|sx NOT improved|sx WORSENED|undesirable/intolerable side effects of pharm tx"]
-Serious/concerning sx check- [checkbox value="no manic symptoms|no SI|no HI|SI without plan|SI WITH plan|no psychotic symptoms|psychotic symptoms"]
-Plan- [checkbox value="continue current/above regimen|refer for psychologist counseling|refer to IBHC|refer to psychiatrist for mgmt of medication|start SSRI|adjust SSRI|discontinue SSRI|start SNRI|adjust SNRI|discontinue SNRI|start benzodiazepine|adjust benzodiazepine|discontinue benzodiazepine|start mood stabilizer|adjust mood stabilizer|discontinue mood stabilizer|start atypical antipsychotic|adjust atypical antipsychotic|discontinue atypical antipsychotic"]
-Labs [select value="not indicated|ordered as below"]
-Patient disposition- [select value="stable and will follow up|contracted for safety|not contracting for safety and we will arrange hospitalization"]
-Followup: [text size="5"] [select value="|routine f/u visit not indicated|day(s)|week(s)|month(s)"] [checkbox value="with PCM|with unit provider"][text memo="other specialties" memo_size="small" size="60"]

[/conditional][checkbox name="apTOBACCO" value="#NICOTINE DEPENDENCE:
"][conditional field="apTOBACCO" condition="(apTOBACCO).is('#NICOTINE DEPENDENCE:
')"]-Conducted Tobacco Cessation Counseling (3-10 Minutes)
-Discussed with patient impact of tobacco use on health, benefits of tobacco cessation, support resources to include: [checkbox value="phone hotline 1-800-QUIT-NOW|Web based resources|MTF Tobacco Cessation Program|medication options|quit strategies"]
-Patient’s readiness to quit: [select value=”precontemplation (not ready to quit)|contemplation (considering a quit attempt)|preparation (actively planning a quit attempt)|action (actively involved in a quit attempt)|maintenance (achieved smoking cessation)"]
-Plan: [checkbox value="continue to address at each visit|start nicotine replacement therapy|start bupropion therapy|start varenicline therapy|consult with clinical pharmacist|patient self-refer to MTF tobacco cessation program"] [comment memo="Add CPT code: 4000F or 4004F or these E&M codes for other therapies : 99406 or 99407"]

[/conditional][checkbox memo="Generic A/P#1" name="apGeneral1" value=""][conditional field="apGeneral1" condition="(apGeneral1).is('')"]#[text size="60"]
-[checkbox value="Established diagnosis|New diagnosis|Chronic condition|controlled|uncontrolled|stable|unstable|improving|worsening|concern for worsening"]
-Treatment goal- [checkbox value="N/A"][textarea rows="2"]
-Evaluation/Surveillance- [checkbox value="N/A"][textarea rows="3"]
-Management- [textarea rows="4"]
-Referrals- [checkbox value="none (not indicated)"][text size="60"]
-Gave return precautions to include: [checkbox value="worsening symptoms despite recommended treatment|progressive intractable fever|progressive pain despite recommended treatment|new neuro symptoms|severe intolerable side effects of medications prescribed|worsening shortness of breath|difficulty swallowing|inability to perform ADLs|other-"] [textarea rows="2"]
-Followup: [text size="5"] [select value="|routine f/u visit not indicated|day(s)|week(s)|month(s)"] [checkbox value="with PCM|with unit provider"][text memo="other specialties" memo_size="small" size="60"]
-Explained the above assessment and plan to patient who: [select value="|acknowledged understanding and intent to follow through with plan|desires second opinion"]
-Additional comments: [checkbox value="none"][textarea]

[/conditional][checkbox memo="Generic A/P#2" name="apGeneral2" value=""][conditional field="apGeneral2" condition="(apGeneral2).is('')"]#[text size="60"]
-[checkbox value="Established diagnosis|New diagnosis|Chronic condition|controlled|uncontrolled|stable|unstable|improving|worsening|concern for worsening"]
-Treatment goal- [checkbox value="N/A"][textarea rows="2"]
-Evaluation/Surveillance- [checkbox value="N/A"][textarea rows="3"]
-Management- [textarea rows="4"]
-Referrals- [checkbox value="none (not indicated)"][text size="60"]
-Gave return precautions to include: [checkbox value="worsening symptoms despite recommended treatment|progressive intractable fever|progressive pain despite recommended treatment|new neuro symptoms|severe intolerable side effects of medications prescribed|worsening shortness of breath|difficulty swallowing|inability to perform ADLs|other-"] [textarea rows="2"]
-Followup: [text size="5"] [select value="|routine f/u visit not indicated|day(s)|week(s)|month(s)"] [checkbox value="with PCM|with unit provider"][text memo="other specialties" memo_size="small" size="60"]
-Explained the above assessment and plan to patient who: [select value="|acknowledged understanding and intent to follow through with plan|desires second opinion"]
-Additional comments: [checkbox value="none"][textarea]

[/conditional][checkbox memo="Generic A/P#3" name="apGeneral3" value=""][conditional field="apGeneral3" condition="(apGeneral3).is('')"]#[text size="60"]
-[checkbox value="Established diagnosis|New diagnosis|Chronic condition|controlled|uncontrolled|stable|unstable|improving|worsening|concern for worsening"]
-Treatment goal- [checkbox value="N/A"][textarea rows="2"]
-Evaluation/Surveillance- [checkbox value="N/A"][textarea rows="3"]
-Management- [textarea rows="4"]
-Referrals- [checkbox value="none (not indicated)"][text size="60"]
-Gave return precautions to include: [checkbox value="worsening symptoms despite recommended treatment|progressive intractable fever|progressive pain despite recommended treatment|new neuro symptoms|severe intolerable side effects of medications prescribed|worsening shortness of breath|difficulty swallowing|inability to perform ADLs|other-"] [textarea rows="2"]
-Followup: [text size="5"] [select value="|routine f/u visit not indicated|day(s)|week(s)|month(s)"] [checkbox value="with PCM|with unit provider"][text memo="other specialties" memo_size="small" size="60"]
-Explained the above assessment and plan to patient who: [select value="|acknowledged understanding and intent to follow through with plan|desires second opinion"]
-Additional comments: [checkbox value="none"][textarea]

[/conditional][comment memo="additional comments" memo_color="orange" memo_size="small"][textarea rows="5"]
A/P:
Generic A/P#1 Generic A/P#2 Generic A/P#3additional comments

Result - Copy and paste this output: