C/o cough

Vital signs: T [text size="4"] F, HR [text size="4"] bpm, RR [text size="4"], BP [text size="4"]/[text size="4"], SpO2 [text size="2"]% [select value="RA|2LNC|"]
Resident [checkbox value="alert|responds to voice|responds to pain|unresponsive|confused|awake|quiet|crying|drowsy|easily aroused|easily consoled|eyes do not open to stimulation|"] [checkbox value="Oriented X4|Oriented to place|Oriented to time|Oriented to situation|Oriented to person|Oriented X 0|"].
The resident has had cough for [text size="2"] days.
Cough [select value="has not been productive|has been productive"].
Frequency is [select value="infrequent|intermittent|constant"].
Severity is [select value="minimal|moderate|severe"].
Fever [select value="is not present|is present"]
[select value="Sputum is clear.|Sputum is purulent.|Sputum is thick.|Hemoptysis noted.|Harsh and barking quality.|Dry cough.|"]
Other symptoms: [checkbox value="sore throat|nasal congestion|earache|headache|myalgias"].
Respiratory pattern: [checkbox value="regular|irregular|symmetric|shallow|deep|labored|unlabored|dyspnea at rest|dyspnea at lying flat|dyspnea with exertion"]
Breath sounds [checkbox value="Clear|Diminished|Rales|Expiratory wheezes|Absent|Crackles|Inspiratory wheezes|Even|Stridor"]. Denies [checkbox value="SOB|coughing|congestion"].
Respiratory interventions [checkbox value="cough and deep breathe|incentive spirometry|oral suction"]
History of pulmonary problems:  [checkbox name="pulmhx" value="no respiratory problems|frequent pneumonia|frequent bronchitis|asthma|other"][conditional field="pulmhx" condition="(pulmhx).is('other')"][text size=72 memo="<--describe other"][/conditional].
Vital signs: T F, HR bpm, RR , BP /, SpO2 %
Resident .
The resident has had cough for days.
Cough .
Frequency is .
Severity is .

Other symptoms: .
Respiratory pattern:
Breath sounds . Denies .
Respiratory interventions
History of pulmonary problems: .

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.64, 23 form elements, 36 boilerplate words, 8 text boxes, 8 checkboxes, 6 drop downs, 1 conditionals, 69 total clicks
Questions/General site feedback · Help Ticket

Send Feedback for this SOAPnote

Your email address will not be published. Required fields are marked *

More SOAPnotes by this Author: