GTARP Pillbox Hill Medical Center Px Report

[mark memo="This form is used in roleplay scenarios and is in no way used in real patient care" name="mark"]
Pillbox Hill Medical Center
[date name="Date" default="MM-DD-YYYY"]
Patient Name: [text name="Ptname" default="Patient Name"] | Provider Name: [select name="drname" value="Dr.Taylor,Daisy MD|Dr.Sullivan,Dion MD|Dr.Mizuki,Setsuna MD|Dr.Rosalina,Line MD|Dr.Johnson,Brick MD|Dr.Sinclair,Rain MD|Dr.McClean,Dave MD|Dr.Dunoharm,Karl MD|Dr.Schryzer,John MD|Dr.Valdiva,Amedeo MD|Dr.Ross,Anthony MD|Dr.Gostivari,Adrian MD"]
Date of Birth/Age/Sex: [date name="dob" default="DOB"] | [text name="age" default="Age"] | [select name="sex" value="Male|Female"]
Subjective
Chief Complaint: [text name="CC" default="CC"]
LOC: [select name="loc" value="A&Ox4|A&Ox3|A&Ox2|A&Ox1|A&Ox0"]
[checkbox name="hpi" memo="HPI Provided By:"][conditional field="hpi" condition="(hpi).is('')"][checkbox value="Pt provided HPI|Pt Unable to provide HPI|Family/SO provided HPI|EMS Provided HPI"][/conditional]
HPI: [textarea name="HPI" default="History of Present Illness Ex. 23 y/o male Pt presents to the Er with CC of L knee px. Knee px persistent for 2 weeks with some noteable swelling and difficulty walking."]
Objective
Review of Systems:
[checkbox name="ros1" memo='Unable to Assess'][conditional field="ros1" condition="(ros1).is('')"]Unable to assess due to [text]
[/conditional]
[checkbox name="ros2" memo="See history"][conditional field="ros2" condition="(ros2).is('')"]All pertinent ROS findings are detailed in the narrative history above.[/conditional]
[checkbox name="ros_const" memo="Constitutional"][conditional field="ros_const" condition="(ros_const).is('')"]Constitutional :[checkbox value="Unremarkable|Well Appearing|No Distress Getting On/Off Exam Table Or While Walking Around|Alert and Oriented x4|Alert But Time Disoriented|Alert But Confused|Poor Cooperation With Exam|Ill Appearing|Drowsy|Appears Impaired"][text]
[/conditional]
[checkbox name="ros_eyes" memo="Eyes/vision"][conditional field="ros_eyes" condition="(ros_eyes).is('')"]Eyes/Vision :[checkbox value="Unremarkable|Clear Conjunctiva|EOM Intact W/O Nystagmus|Visual Acuity Grossly Intact|Cornea's Clear|PERRL|Glasses|Conjunctival Injection|Subconjunctival Hemorrhage|Racoon Eyes|Periorbital Swelling|Dysconjugate Gaze"]
[text][/conditional]
[checkbox name="ros_ent" memo="ENT"][conditional field="ros_ent" condition="(ros_ent).is('')"]ENT :[checkbox value="Unremarkable|Symmetrical and Intact Auricles Bilaterally|Hearing To Conversation Intact|Clear Canals W/ No Clear or Bloody Liquid|TM's Normal In Appearance||Nares Patent Bilaterally|Septum Midline|Mucosa Pink & Moist|Mucosal Edema|Clear Discharge|Active Septal Hemorrhage|Clotted Blood||Normal Oral Cavity|Moist Oral Mucosa W/O Lesions Or Injury|Upper Denture|Lower Denture|Mucosal Laceration|Dental Injury|Tongue Deviation|Dental Decay||Normal Voice|Patent Pharynx W/O Swelling Or Exudates|Uvula Midline|Pharyngeal Erythema W/O Exudates|Tracheal Deviation"]
[text][/conditional]
[checkbox name="ros_cv" memo="CV"][conditional field="ros_cv" condition="(ros_cv).is('')"]Cardiovascular :[checkbox value="Unremarkable|Regular Rate And Rhythm|No Murmurs|No Ankle Edema|Tachycardia|Irregular Heart Rhythm|Murmur|Ankle Edema|Varicosities|Stasis Discoloration"][text][/conditional]
[checkbox name="ros_resp" memo="RESP"][conditional field="ros_resp" condition="(ros_resp).is('')"]Respiratory :[checkbox value="Unremarkable|Normal Breathing,Symmetrical Chest Expansion|Non-Tender|Clear And Equal Breath Sounds Bilaterally|Poor Effort|Tenderness|Coughing|Stridor"][text][/conditional]
[checkbox name="ros_gi" memo="GI"][conditional field="ros_gi" condition="(ros_gi).is('')"]Gastrointestinal :[checkbox value="Unremarkable|Normal Visual Inspection,No Distension|Normal Active Bowel Sounds|Soft Non-Tender|Protruding|Umbilical Hernia|Diffuse Tenderness Over Entire Abdomen"][text][/conditional]
[checkbox name="ros_gu" memo="GU"][conditional field="ros_gu" condition="(ros_gu).is('')"]Genitourinary :[checkbox value="Unremarkable|Not Examined|No Suprapubic Tenderness|No CVAT Bilaterally"][text][/conditional]
[checkbox name="ros_msk" memo="MSK"][conditional field="ros_msk" condition="(ros_msk).is('')"]Musculoskeletal :[checkbox value="Unremarkable|No Gross Deformity Or Misalignment|No Vertebral Tenderness|Grip Equal|Pelvis Stable|Heel/Toe Walk Intact|Muscle Spasm|Deformity|Warmth/Swelling|Tenderness|Pain With Movement|"][text][/conditional]
[checkbox name="ros_heme" memo="HEME"][conditional field="ros_heme" condition="(ros_heme).is('')"]Hematology :[checkbox value="Unremarkable|Easy Bruising|Excessive Bleeding"][text][/conditional]
[checkbox name="ros_skin" memo="Skin"][conditional field="ros_skin" condition="(ros_skin).is('')"]Skin :[checkbox value="Unremarkable|Warm, Dry|Grossly Intact No Bruises|Normal Turgor|Tattoos|Body Piercings|Abrasion|Laceration|Bruise|Rash"][text][/conditional]
[checkbox name="ros_endo" memo="ENDO"][conditional field="ros_endo" condition="(ros_endo).is('')"]Endocrine :[checkbox value="Unremarkable|Increased/Excessive Thrist|Hot Intolerance|Cold Intolerance"][text][/conditional]
[checkbox name="ros_immune" memo="IMMUNE"][conditional field="ros_immune" condition="(ros_immune).is('')"]Immune :[checkbox value="Unremarkable|Recurrent/Frequent Infections|Recurrent/Frequent Allergic Reactions|"][text][/conditional]
[checkbox name="ros_psych" memo="PSYCH"][conditional field="ros_psych" condition="(ros_psych).is('')"]Psychology :[checkbox value="Unremarkable|Anxiety|Panic Attacks|Grief|Depression|Lack Of Interest, Enthusiasm, And/Or Concern|Dissociation, Depersonalization, or Derealization|Guilt|Self-Injurious Behaviors|Suicidal Ideation|Irritability, Short-Temperedness|Delusions|Paranoia|Hallucinations|Personality Changes|Disinhibited And/Or Socially Inappropriate Comments And/or Behaviors|Verbal Aggression|Physical Aggression"][text][/conditional]
[checkbox name="ros_neuro" memo="NEURO"][conditional field="ros_neuro" condition="(ros_neuro).is('')"]Neurology :[checkbox value="Unremarkable|Headaches|Slurred Speech|Impaired Gait Or Difficulty Walking|Coordination Problems|Memory Problems|Tremors|Seizures|Balance Problems|Attention/Concentration Defecit|Falls|Generalized Weakness|Muscle Cramps/Spasms|Extremity Numbness/Weakness"][text][/conditional]
[checkbox name="ros_cog" memo="COGNITIVE"][conditional field="ros_cog" condition="(ros_cog).is('')"]Cognitive :[textarea][/conditional]
[checkbox name="ros_sleep" memo="SLEEP"][conditional field="ros_sleep" condition="(ros_sleep).is('')"]SLEEP : [checkbox value="Unremarkable|Difficulty Falling Asleep|Frequent Awakenings|Waking Up Too Early|Nightmares|Snoring|Breathing Problems (Apneic Pauses, Dyspneic Arousals)|Pain-Related Insomnia|Acting Out Dreams|Restless Leg Sensations|Excessive Body/Limb Movements During Sleep|Waking Up Unrested In The Mornings|Waking Up With A Headache In The Mornings|Excessive Daytime Sleepiness|Increased And/Or Excessive Sleep|Hypnogogic Hallucinations|Hypnopompic Hallucinations|Sleep Paralysis"][text][/conditional]
[checkbox name="pmh" memo="PMH"][conditional field="pmh" condition="(pmh).is('')"]Past Medical History
[checkbox value="Unremarkable|ADHD|Adjustment disorder|Alzheimer's|anemia|Asperger's|Autism|arthritis|arrhythmia|AF|asthma|B12 deficiency|Bell's palsy|BD (bipolar disorder)|BPD (borderline personality disorder)|BPPV| CAD|carotid stenosis|carpal tunnel syndrome|cerebral palsy|cervical radiculopathy|cirrhosis|CKD|Crohn's| CVA|COPD|developmental delay|dementia|DM1|DM2|DVT/PE|Ehlers-Danlos syndrome|epilepsy|essential tremor|fibromyalgia|FTD|GAD GERD|gout|HF|HLD|HTN|HCV|HIV|hypothyroidism|hypercoagulability syndrome|IBS|ICH (intracranial hemorrhage)|IIH (increased intracranial pressure)|IPH (intraparenchymal hemorrhage)|iron deficiency|Lewy body dementia|lumbar radiculopathy|Lupus|MCI|MDD|migraines|mood disorder|MS (multiple sclerosis)|neurocognitive disorder|NPH (normal pressure hydrocephalus)|OA|OCD|optic neuritis|OSA|osteoporosis|panic disorder|personality disorder|PTSD|PCOS|PVD|Parkinson's disease|pseudotumor cerebri|RA|RLS|SAH|Sciatica|SDH|seizure disorder|spinal stenosis|SLE|TIA|TBI|schizoaffective disorder|eating disorder|PNES (psychogenic nonepileptic seizures)|psychosis|schizophrenia|sleep apnea|TIA/CVA|UC (ulcerative colitis)|vitamin B12 deficiency|vitamin D deficiency"][textarea][/conditional]
Assessment
[checkbox name="dx" memo="DX"][conditional field="dx" condition="(dx).is('')"]
DX :[textarea default="Dx Here"][/conditional]
Plan
[checkbox name="tx" memo="TX"][conditional field="tx" condition="(tx).is('')"]TX :[textarea][/conditional]
[checkbox name="rx" memo="RX"][conditional field="rx" condition="(rx).is('')"]RX :[checkbox value="None|Electronic|Sent to Pharmacy"]
[textarea  default="Medications Here Ex. Acetaminophen 500mg Every 6 Hours as Needed for Px."][/conditional]
[checkbox name="rt" memo="Radiology"][conditional field="rt" condition="(rt).is('')"]Radiology Orders :
[checkbox value="None|-----------------|CT - Head|CT - Chest|CT - Abdomen|-----------------|X-ray - L Arm|X-Ray - R Arm|X-Ray - L Leg|X-Ray - R Leg|X-Ray - R Clavicle|X-Ray - L Clavicle"][text]
[/conditional]
[checkbox name="ref" memo="Referrals"][conditional field="ref" condition="(ref).is('')"]Referrals : 
[checkbox value="Cardiology|General Surgery|Neurology|Orthopoedics"][text][/conditional]
[checkbox name="rev" memo="Reviewed"][conditional field="rev" condition="(rev).is('')"]REVIEWED :[checkbox value="Current Medications|Specialty Reports|Discharge Paperwork"][text][/conditional]
[checkbox name="ptio" memo="INSTRUCTED ON"][conditional field="ptio" condition="(ptio).is('')"]INSTRUCTED ON :[checkbox value="Vital Signs|Radiology Findings|Follow Up Care|Medication Side Effects|Managing Chronic Conditions"][text][/conditional]
[checkbox name="btc" memo="BARRIERS TO CARE"][conditional field="btc" condition="(btc).is('')"]BARRIERS TO CARE :[checkbox value="None Identified|Poor Cooperation With Care|Exam Limited By Mental Status|Exam Limited By Pain|Negative Attitude To Proposed Treatment Plan|Vague Shifting Complaints|HPI Not Supported By Objective Findings|Multiple Comorbidities|Overwhelming Focus On Rx Drugs|Hostile/Disruptive Behavior|Active Psychiatric Diagnosis|Substance Abuse|Poor Compliance With Medication Regimen|Social/Cultural Barriers|Victim Of Abuse"][text][/conditional]
[checkbox name="fu" memo="FOLLOW UP"][conditional field="fu" condition="(fu).is('')"]FOLLOW UP :[checkbox value="RTC as Discussed, Sooner If Condition Worsens Or New Symptoms Arise|24 Hours|48 Hours|72 Hours|1 Week|2 Weeks"][text][/conditional]
[checkbox name="dc" memo="DISCHARGE CONDITION"][conditional field="dc" condition="(dc).is('')"]DISCHARGE CONDITION :[checkbox value="Improved|Stable|Unchanged"][text][/conditional]
[checkbox name="wss" memo="WORK/SCHOOL STATUS"][conditional field="wss" condition="(wss).is('')"]WORK/SCHOOL STATUS :[checkbox value="Fit for Duty|Work Restrictions|Lifting Precautions"][text][/conditional]

[checkbox name="dis" memo="DISPOSITION"][conditional field="dis" condition="(dis).is('')"]DISPOSITION :[checkbox value="Home|Left AMA|Asked To Leave|Transfered to Specialty Care"][text][/conditional]
Electronically Signed
[select name="Drsign" value="Dr.Taylor,Daisy MD|Dr.Sullivan,Dion MD|Dr.Mizuki,Setsuna MD|Dr.Rosalina,Line MD|Dr.Johnson,Brick MD|Dr.Sinclair,Rain MD|Dr.McClean,Dave MD|Dr.Dunoharm,Karl MD|Dr.Schryzer,John MD|Dr.Valdiva,Amedeo MD|Dr.Ross,Anthony MD|Dr.Gostivari,Adrian MD"]