The SOAPnote Project > Subjective/History Elements > Subjective – HPI – Chronic Condition History

Subjective – HPI – Chronic Condition History

posted 2020-06-04, updated 2020-07-05

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Note scribed by [select name="notetaker" value="Physician|Nurse Practitioner|PA|Medical Assistant|Nurse|Student"] - Adult Chronic/Followup Visit
[checkbox memo="if not already inputted" memo_size="small" name="Vitals" value="Vital signs:"][conditional field="Vitals" condition="(Vitals).is('Vital signs:')"] HR [text size="5"]; SpO2 [text size="5"]; [checkbox name="Temp" value="Temp"][/conditional][conditional field="Temp" condition="(Temp).is('Temp')"] [text size="5"] deg F; [/conditional][conditional field="Vitals" condition="(Vitals).is('Vital signs:')"][checkbox name="BP" value="BP"][/conditional][conditional field="BP" condition="(BP).is('BP')"] [text size="5"] / [text size="5"] mmHg; [/conditional][conditional field="Vitals" condition="(Vitals).is('Vital signs:')"][checkbox name="RR" value="RR"][/conditional][conditional field="RR" condition="(RR).is('RR')"] [text size="5"] breaths/min; [/conditional][conditional field="Vitals" condition="(Vitals).is('Vital signs:')"][checkbox name="HT" value="HT"][/conditional][conditional field="HT" condition="(HT).is('HT')"] [text size="5"] [select value="in|cm"]; [/conditional][conditional field="Vitals" condition="(Vitals).is('Vital signs:')"][checkbox name="WT" value="WT"][/conditional][conditional field="WT" condition="(WT).is('WT')"] [text size="5"] [select value="lbs|kg"][/conditional][conditional field="Vitals" condition="(Vitals).is('Vital signs:')"][/conditional][checkbox memo="include HPI Intro" memo_size="small" name="include_hpi_block" value="HPI"][conditional field="include_hpi_block" condition="(include_hpi_block).is('HPI')"]
[text default="The patient"] is a [text size="5"] yo [select name="Gender" value="|gentleman|lady|M|F"] presenting [select name="visit_type" value="to the office|via televideo platform|via phone call"][checkbox value=" to establish care "][select name="CC" value="for management of chronic conditions|for evaluation and management of |with a relevant past medical history significant for |"][/conditional][conditional field="CC" condition="(CC).isNot('for management of chronic conditions')"][textarea name="FrTxCC"] [comment memo_size="small" memo_color="blue" memo="◀︎◀︎ freetext and/or ▼▼"][conditional field="CC" condition="(CC).isNot('for management of chronic conditions')"][checkbox memo_size="small" memo_color="blue" memo="◀︎◀︎ choose from pick list ▼▼" name="choseCC" value=""][/conditional][conditional field="choseCC" condition="(choseCC).is('')"][frontload soapnote="sample/drgfms-include-condition-checkbox-list/"].[/conditional][conditional field="include_hpi_block" condition="(include_hpi_block).is('HPI')"][checkbox value="Currently the patient has no complaints."] [comment memo="Freetext details"][textarea name="freetext_details"][remark]

6 condition history forms are inserted from another soapnote here


[/remark][/conditional]
[frontload soapnote="/sample/drgfms-cxcond-6-conditions-hx-blocks/"]
[checkbox name="lifestyle" memo="Current Lifestyle/Therapeutic Lifestyle Choices" value=""]
[conditional field="lifestyle" condition="(lifestyle).is('')"]Current Lifestyle/Therapeutic Lifestyle Choices
-Diet - [checkbox value="N/A|none|DASH diet|diabetic Diet|weight reduction diet|standard american diet"][text size="80"]
  -Physical activity - [checkbox value="N/A|none"][text size="80"]
  -Medications - [checkbox value="N/A|none"][text size="80"][/conditional][checkbox name="lifestyle_mod" memo="lifestyle risk factor modification" value=""][conditional field="lifestyle_mod" condition="(lifestyle_mod).is('')"]-Lifestyle risk factor modification/optimization -
 -If smoking/chewing/vaping, patient indicates willingness to discuss quitting? [checkbox value="N/A|Yes|No"]
 -If consuming alcohol in significant amts daily, patient indicates willingness to discuss cutting back? [checkbox value="N/A|Yes|No"]
 -If overweight/obese, patient indicates willingness to discuss? [checkbox value="N/A|Yes|No"]
[/conditional]
[checkbox name="questions" memo="Questions/concerns of patient about these above conditions" value=""][conditional field="questions" condition="(questions).is('')"]-Questions/concerns of patient about these above conditions: [checkbox value="none"][textarea rows="4"][/conditional]

Note scribed by - Adult Chronic/Followup Visit
Vital signs:if not already inputted HPIinclude HPI Intro ◀︎◀︎ freetext and/or ▼▼ ___A___ abscess acute diastolic congestive heart failure (CHF) acute kidney history (AKI) acute midline back pain with sciatica acute midline back pain without sciatica acute subdural hematoma alcohol abuse alcohol use disorder amphetamine abuse anasarca aneurysm (intracranial) anemia anemia due to blood loss anemia due to chronic stage 4 renal failure anti-phospholipid syndrome (APS) anxiety aortic valve stenosis arthritis (osteoarthritis) ascites due to cirrhosis asthma atrial fibrillation avascular necrosis of the *** avascular necrosis in bilateral hips avascular necrosis of right humerus avascular necrosis of left humerus ___B___ bacterial vaginosis (BV) benzodiazepine abuse ___C___ cardiomyopathy carotid stenosis (left) carotid stenosis (right) carpal tunnel syndrome (CTS) cataracts cataracts secondary to diabetes cervical disk disorder cervical radiculopathy chronic abdominal pain chronic anemia chronic back pain chronic cough chronic cough secondary to ACE inhibitor chronic obstructive pulmonary disease (COPD) chronic insomnia chronic kidney disease (CKD), stage III, secondary to hypertension chronic kidney disease (CKD), stage IV, secondary to hypertension chronic kidney disease (CKD), stage III, secondary to type II diabetes chronic kidney disease (CKD), stage IV, secondary to type II diabetes chronic kidney disease (CKD), stage III, secondary to type I diabetes chronic kidney disease (CKD), stage IV, secondary to type I diabetes chronic pain chronic pain with long-term opiate medication use chronic pain of the joints chronic pain of the back chronic pain of the neck chronic renal allograft nephropathy clostridium difficile infection cocaine use colonic polyps colonic polyps status post removal in *** cystocele (lateral) cystocele (midline) cyclic vomiting syndrome cystic fibrosis ___D___ delirium depression diabetes type I diabetes type II diabetic nephropathy secondary to type I diabetes diabetic nephropathy secondary to type II diabetes diarrhea drug seeking behavior deep venous thrombosis (DVT) deep venous thrombosis (DVT) of right leg deep venous thrombosis (DVT) of left leg diverticulitis diverticulosis ___E___ eclampsia emphysema end stage renal disease (ESRD) end stage renal disease (ESRD), secondary to hypertension end stage renal disease (ESRD), secondary to type II diabetes end stage renal disease (ESRD), secondary to type I diabetes episode of syncope episodes of syncope episodic syncope esophageal varices essential hypertension ethanol abuse ___F___ fall ___G___ gastritis gastroesopheal reflux disease (GERD) generalized abdominal pain gilbert disease gout ___H___ heart failure with preserved ejection fractiom (HFpEF) heart murmur on hemodialysis heroine use herpes simplex virus(HSV) history of atrial fibrillation history of DVT in right leg history of DVT in left leg history of PE history of renal transplant hypercholesterolemia hyperglycemic episodes hypoglicemia hyperkalemia hyperlipidemia (HLD) hypernatremia hyperparathyroidism hyperparathroidism secondary to renal failure hyperphosphotemia hypertension (HTN) hypertension (HTN) uncontrolled hypoglycemic episodes hypokalemia hyponatremia hypophosphatemia ___I___ incomplete bladder emptying intracranial aneurysm intractable back pain ___J___ ___K___ kidney disease ___L___ lactic acidosis liver disease lung nodule seen on imaging study ___M___ major depressive disorder (MDD) major depressive disorder (MDD) with mixed features major depressive disorder (MDD) with psychotic features malingering metabolic acidosis misscarriage in *** ___N___ nodular duodenitis nodular duodenitis and scalloped appearing thicken small bowel ___O___ obstructive sleep apnea (OSA) osteoarthritis ___P___ pancreatic cancer pancreatitis pancytopenia panic attacks parethesias paroxysmal atrial fibrillation pericardial effusion pericardial effusions peripheral artery disease (PAD) personality disorder placental insufficiency poly-substance abuse pre-eclampsia pre-mature atrial contraction primary prostatic cancer primary prostatic cancer with metastasis protienuria pulmonary embolism pulmonary hypertension ___Q___ ___R___ rectocele recurrent urinary tract infection (UTI) retroperitoneal lymphadenopathy ___S___ scoliosis secondary hyperparathyroidism of renal origin shortness of breath (SOB) sickel cell anemia sickle cell disease sickle cell disease with frequent admissions for pain control sleep apnea spontaneous bacterial peritonitis stage 4 chronic kidney disease stroke stroke with residual right hemiparesis stroke with residual left hemiparesis stroke with residua aphasia stoke with residual cognitive deficits subarachnoid hemorrhage (SAH) subdural hematoma syndrome of inappropriate antidiuretic hormone (SIADH) systemic lupus erythematosus (SLE) ___T___ thrombocytopenia thyroid atrophy tobacco use type I diabetes type II diabetes with complication type II diabetes without complications ___U___ urinary retention urinary retention secondary to benign prosthetic hypertrophy (BPH) urinary tract infection (UTI) urinary tract infection (UTI) history ulnar nerve compression ___V___ venous thromboembolism (VTE) ___W___ wegner's granulomatosis ___X___ xeroderma Xerostomia ___Y___ ___Z___.
History for condition #1-------------BEGIN CONDITION 1-------------<-- patient name, or pronoun --> if no pronoun or titile selected, check for female leave black for male reports that his or herscore=(sex)+(pronoun);score>0?'her':'his' select one ▼▼◀︎◀︎ and/or freetext is . Currently, he or shescore=(sex)+(pronoun);score>0?'she':'he'
History for condition #2-------------BEGIN CONDITION 2-------------<-- patient name, or pronoun --> if no pronoun or titile selected, check for female leave black for male reports that his or herscore=(sex)+(pronoun);score>0?'her':'his' select one ▼▼◀︎◀︎ and/or freetext is . Currently, he or shescore=(sex)+(pronoun);score>0?'she':'he'
History for condition #3-------------BEGIN CONDITION 3-------------<-- patient name, or pronoun --> if no pronoun or titile selected, check for female leave black for male reports that his or herscore=(sex)+(pronoun);score>0?'her':'his' select one ▼▼◀︎◀︎ and/or freetext is . Currently, he or shescore=(sex)+(pronoun);score>0?'she':'he'
History for condition #4-------------BEGIN CONDITION 4-------------<-- patient name, or pronoun --> if no pronoun or titile selected, check for female leave black for male reports that his or herscore=(sex)+(pronoun);score>0?'her':'his' select one ▼▼◀︎◀︎ and/or freetext is . Currently, he or shescore=(sex)+(pronoun);score>0?'she':'he'
History for condition #5-------------BEGIN CONDITION 5-------------<-- patient name, or pronoun --> if no pronoun or titile selected, check for female leave black for male reports that his or herscore=(sex)+(pronoun);score>0?'her':'his' select one ▼▼◀︎◀︎ and/or freetext is . Currently, he or shescore=(sex)+(pronoun);score>0?'she':'he'
History for condition #6-------------BEGIN CONDITION 6-------------<-- patient name, or pronoun --> if no pronoun or titile selected, check for female leave black for male reports that his or herscore=(sex)+(pronoun);score>0?'her':'his' select one ▼▼