URI (S)

SUBJECTIVE
History provided by the [select name="historian" value="|mother|father|family member|parents|caregiver"].

Pt presents to the clinic d/t feeling ill. Pt's sx started [text name="onset" default=""]. Pt initially presented with [text name="inital_presentation" default=""].

Pts current assoc sx includes ...
[checkbox name="assoc_sx" value="sore throat|cough|congestion|runny nose|sinus pain|stridor|hoarse voice|toothache|loss of appetite"]
[textarea name="extra_information" default="Tell Me More..."]
[checkbox value="Pt noted to consuming adequate amounts of oral fluids.|Denies any decrease in urinary frequency."]

Denies ... 
[checklist name="absent_sx" value="fever|chills|nausea|vomiting|diarrhea|chest pain|shortness of breath|heart palpitations|difficulty breathing|cyanosis|trismus"]
[comment memo_color=blue 
memo="TRISMUS: uncontrolle inability to open the mouth or jaw"]

[textarea name="extra_information" default="Tell Me More..., Like Did She Give Up A Fight..."]

Pts highest temperature was [text name="degrees_F_or_degrees_C" default="℉. / ℃"]. 





ROS is otherwise normal and non-contributory to their current illness. 

Pt [select name="OTC Meds" value="|was given|has taken|has not taken anything for his sx."] [conditional field="OTC Meds" condition="(OTC Meds).is('was given')||(OTC Meds).is('has taken')"] [OTC Tylenol and Motrin ... which has helped with the sx's] [/conditional]. 




Denies ... 
[checklist name="absent_sx" value="fever|chills|nausea|vomiting|diarrhea|chest pain|shortness of breath|heart palpitations|difficulty breathing|cyanosis|trismus"]
[comment memo="TRISMUS: uncontrolle inability to open the mouth or jaw"]

[textarea name="extra_information" default="Tell Me More..., Like Did She Give Up A Fight..."]

Pts highest temperature was [text name="degrees_F_or_degrees_C" default="℉. / ℃"]. 
[checklist value="Temperature was not taken prior to this visit"]

[mark memo_color=blue memo="Has patient taken anything for his sx?" name="mark"]

[checklist name="variable_1" value=" Pt has not taken anything to relieve his/ her sx.|option B|option C"]

[textarea default="Pt has taken ... OTC Motrin & Tylenol ... which has helped with sx."]




ROS is otherwise normal and non-contributory to their current illness. 

[radio name="variable_1" value="Pt has no known sick contacts.|Reports recent COVID exposure."]

[checklist value="Immunizations are up-to-date.|Denies any recent travel."]
SUBJECTIVE
History provided by the .

Pt presents to the clinic d/t feeling ill. Pt's sx started . Pt initially presented with .

Pts current assoc sx includes ...




Denies ...





Pts highest temperature was .





ROS is otherwise normal and non-contributory to their current illness.

Pt .




Denies ...

TRISMUS: uncontrolle inability to open the mouth or jaw



Pts highest temperature was .


Has patient taken anything for his sx?








ROS is otherwise normal and non-contributory to their current illness.



Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.56, 22 form elements, 57 boilerplate words, 4 text boxes, 4 text areas, 2 checkboxes, 5 check lists, 1 radio buttons, 2 drop downs, 2 comments, 1 conditionals, 50 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: