DOD CC/HPI/ROS

Patient’s rights, confidentiality, limits/exceptions to confidentiality, and use of electronic medical records were reviewed with the patient.  Verification of patient identity was established with the patient.  Patient consents to medical evaluation via telemedicine.

CHIEF COMPLAINT:  [text name="variable_2"]

HISTORY OF PRESENT ILLNESS:
The patient is a [text name="variable_3"] complaining of a [text name="variable_5"] history of [text name="variable_6"]. Patient denies any associated [checkbox name="Negatives" value="chest pain|shortness of breath|wheezing|cough|hemoptysis|abdominal pain|nausea|vomiting|diarrhea|bloody stools|fever|chills|dysuria|hematuria|abnormal vaginal bleeding or discharge|penile discarge|low back or flank pain|focal neuro deficits|nearsyncope|syncope|vertigo|disequilibrium|headache|neck pain|neck stiffness|acute visual changes|sore throat|throat swelling|airway compromise issues|drooling or voice change|sinus pressure|ear pain|hearing loss|lip/tongue swelling|rash|foreign body sensation"]. [textarea name="variable_12"] Patient has no other complaints.

REVIEW OF SYSTEMS:  Otherwise negative except as stated above.
Patient’s rights, confidentiality, limits/exceptions to confidentiality, and use of electronic medical records were reviewed with the patient. Verification of patient identity was established with the patient. Patient consents to medical evaluation via telemedicine.

CHIEF COMPLAINT:

HISTORY OF PRESENT ILLNESS:
The patient is a complaining of a history of . Patient denies any associated . Patient has no other complaints.

REVIEW OF SYSTEMS: Otherwise negative except as stated above.

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.17, 6 form elements, 68 boilerplate words, 4 text boxes, 1 text areas, 1 checkboxes, 41 total clicks
Questions/General site feedback

Send Feedback for this SOAPnote

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

More SOAPnotes by this Author: