Typhon quick

[textarea cols=80 rows=1 default="Chief concern:"]
[textarea name="variable_2" default="HPI:"]
Review of Systems:
[textarea name cols=80 rows=8 ="variable_1" default="CONSTITUTIONAL: Denies pain, fever, malaise, fatigue, night sweats. No changes in weight or sleep patterns.
SKIN: no rashes, bruising, nail or hair changes
EYES: no blurring/double vision/spots.
EARS: Denies hearing loss, pain, ringing, vertigo, or discharge.
NOSE: No changes to sense of smell, no drainage, obstructions, or bleeding.
THROAT/MOUTH: Denies hoarseness, no bleeding, no changes to taste, no pain or trouble swallowing.
NECK: no painful nodes, pain or stiffness.
ENDOCRINE: Denies fatigue, tremors, palpations, heat or cold intolerance. Denies polyuria, polydipsia, and polyphagia.
RESPIRATORY: Denies cough, SOB, and chest pain. No hemoptysis, night sweats.
CARDIOVASCULAR: Denies chest pain, heaviness, jaw, or arm pain, no lower extremity edema, or claudication. Denies decrease in activity intolerance.
GASTROINTESTINAL: Denies changes in appetite, food intolerances, dysphagia, heartburn, nausea, vomiting, hematemesis. Bowel patterns normal for patient, Denies hemorrhoids, jaundice.
GENITOURINARY: Denies dysuria, flank, suprapubic pain. Denies increased urgency, frequency, nocturia, incontinence, hematuria, polyuria, dark urine, loss of stream, or STI's.
MUSCULOSKELETAL: Denies pain, weakness, decreases in ROM, redness, or swelling.
NEUROLOGICAL: Denies weakness, paralysis, syncope, seizure, tremors, loss of memory, or changes in coordination.
PSYCHIATRIC: Denies depression, mood changes, anxiety, agitation, irritability, sleep disturbances or suicidal thoughts."]

Physical Examination:
[textarea cols=80 rows=2 default="VITALS: Height/Weight/Temperature/Heart Rate/Blood Pressure/Pain Level"]
[textarea cols=80 rows=12 default="Physical Exam
General appearance: No acute distress, well appearing and well nourished.
Conjunctiva and lids: No swelling, erythema or discharge.
Pupils and irises: Equal, round and reactive to light.
Respiratory effort: No increased work of breathing or signs of respiratory distress.
Auscultation of lungs: Clear to auscultation.
Auscultation of heart: Normal rate and rhythm, normal S1 and S2, without murmurs.
Abdomen: Non-tender, no masses.
Psychiatric: Orientation to person, place, and time: Normal.
Mood and affect: Normal."]

Laboratory and Radiology:
[textarea cols=80 rows=1 default="Results"]

[textarea cols=80 rows=2 default="#1 Assessment and Plan"]

Review of Systems:

Physical Examination:

Laboratory and Radiology:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0, 7 form elements, 10 boilerplate words, 7 text areas, 7 total clicks
Questions/General site feedback · Help Ticket

Send Feedback for this SOAPnote

This site uses Akismet to reduce spam. Learn how your comment data is processed.

More SOAPnotes by this Author: