Gen Surg Progress Note

Daily Progress Note

Date of Service
[date name="variable_3" default="today"]

History of Presenting Illness 
[comment memo="Copy and paste PMH/HPI from Consult if needed"]
[textarea name="variable5" default=""]

Review of Systems
[comment memo="Default will be negative. Click if positive"]
General
[checklist name="ROS1" value="Fever|Chills|Sleep Disturbances|Fatigue|Skin Changes"]
[conditional field="ROS1" condition="(ROS1).is('Skin Changes')"]
[textarea name="ROStext1" default=""][/conditional]
Neurological 
[checklist name="ROS2" value="Syncope|Headache|Coordination Changes|Weakness| Numbness"]
Cardiovascular 
[checklist name="ROS4" value="Chest Pain|Palpitations"]
Respiratory
[checklist name="ROS5" value="Dyspnea|Cough|Shortness of Breath"]
Gastrointestinal 
[checklist name="ROS7" value="Nausea|Vomiting|Diarrhea|Constipation|Blood in stool|Dark Stool|Clay Coloured Stool"]
Musculoskeletal 
[checklist name="ROS8" value="Generalized Weakness|Neck Pain|Lower Back Pain|Joint Pain"]
[conditional field="ROS8" condition="(ROS8).is('Joint Pain')"]
[textarea name="ROStext8" default=""][/conditional]
[comment memo="Write additional ROS below"]
[textarea name="ROS6" default=""]

Physical Exam [comment memo="Please write in Vitals"]
Vital Signs - [textarea name="VS1" default="BP-  mmgHg T-  °F P-  beats/min R-  breaths/min"]
General - [textarea name="Pe1" default="No acute distress, Well developed, well nourished, Afebrile"]
Neurological  -  [textarea name="Pe2" default="Alert and Oriented, Normal mood and affect, Cranial Nerves II-XII grossly intact"]
Pulmonary  -  [textarea name="Pe4" default="Respiratory effort within normal limits."]  
Cardiovascular  -  [textarea name="Pe5" default="Distal pulses 2+ in all extremeties.  Adequate perfusion. No peripheral signs of cyanosis."]
Gastrointestinal  -  [textarea name="Pe7" default="Soft. Non tender. Non distended. Normoactive bowel sounds. No masses. No palpable hernia."]
Musculoskeletal - [textarea name="Mskphys" default="No obvious deformities. Normal range of motion and strength in all 4 extremities."]
[comment memo="Write additional PE findings below"]
[textarea name="PE6" default=""] 

Assessment
[textarea name="Ass1" default=""]

Plan 
[textarea name="Plan1" default=""]
[checkbox name="Plancheck1" value="Pain control with Acetaminophen Pain 1-3, NSAID 4-6, Morphine 7-10|DVT prophylaxis: Lovenox|Regular Diet|Clear Liquid Diet|NPO|DVT prophylaxis Subcutaneous Heparin| Antibiotics as per ID recs|f/u Cardiology recs|f/u Neurology recs|f/u CXR|f/u CT"]

[textarea name="doctext" default="Discussed with Dr."]