* Unknown
Share
Tweet
Cite
approximately 42 views in the last month.
CC: [text name="CC" size="60"]
SUBJECTIVE:
HPI:[text name="age" size="3"] y.o. [select name="race" value="|White|Black|Hispanic|Asian"] [select name="sex" value="male|female"] presents via [select name="visit" value="OV|telemedicine visit"] for [var name="CC"].[textarea fillable="true" rows="6"]Patient is overall doing ***WELLNESS***.
H/o ***PMH*** that is ***CONTROLLED/NOT*** on ***MED***. At home monitoring reveals ***PARAMETER*** ranges ***VALUES***.
H/o ***PMH*** that is ***CONTROLLED/NOT*** on ***MED***. At home monitoring reveals ***PARAMETER*** ranges ***VALUES***[/textarea]
Denies c/o [checkbox name="ROS" value="CP|SOB|Palpitations|HA|changes in vision|dizziness|GI changes|easy/abnormal bruising|skin changes|extremity or joint swelling|sleep difficulties|fatigue"]
REVIEW OF SYSTEMS
[checkbox name="FullROS" memo="Full ROS" value=""][conditional field="FullROS" condition="(FullROS).is('')"]- Constitutional: [text default="Patient denies weight change, fever, chills, fatigue" size="80"]
- Head: [text default="Patient denies HA, head trauma/injury" size="80"]
- Eye: [text default=" Patient denies vision changes, eye pain, discharge" size="80"]
- ENT/Mouth: [text default="Patient denies hearing changes, ear pain, nasal congestion, PND, drainage, sore throat" size="80"]
- CV: [text default="Patient denies CP, SOB, palpitations, edema" size="80"]
- Respiratory: [text default="Patient denies cough, sputum, wheezing, SOB" size="80"]
- GI: [text default="Patient denies nausea, vomiting, diarrhea, constipation, changes in stool" size="80"]
- GU: [text default="Patient denies dysuria, urinary frequency, hematuria" size="80"]
- MSKL: [text default="Patient denies muscle and joint pain, joint swelling, back/neck Pain, injury/trauma" size="80"]
- Integumentary: [text default="Patient denies skin lesions, rashes, or abnormalities" size="80"]
- Neuro:[text default="Patient denies weakness, numbness, paresthesia, dizziness, memory changes" size="80"]
- Psych: [text default="Patient denies anxiety/panic, depression, insomnia, SI/HI" size="80"]
- Heme/Lymph: [text default="Patient denies bruising, bleeding, lymphadenopathy" size="80"]
- Endocrine: [text default="Patient denies polyuria, polydipsia, temperature intolerance" size="80"][/conditional]
[checkbox name="BriefROS" memo="Brief ROS" value=""][conditional field="BriefROS" condition="(BriefROS).is('')"]- Constitutional: [text default="Patient denies weight change, fever, chills, fatigue" size="80"]
- CV: [text default="Patient denies CP, SOB, palpitations, edema" size="80"]
- Respiratory: [text default="Patient denies cough, sputum, wheezing, SOB" size="80"]
- Neuro:[text default="Patient denies weakness, numbness, paresthesia, dizziness, memory changes" size="80"]
- Psych: [text default="Patient denies anxiety/panic, depression, insomnia, SI/HI" size="80"][/conditional]
[checkbox name="ROSENTcomplaint" memo="ENT Complaint ROS" value=""][conditional field="ROSENTcomplaint" condition="(ROSENTcomplaint).is('')"]- Constitutional: [text default="Patient denies weight change, fever, chills, fatigue" size="80"]
- Head: [text default="Patient denies HA, head trauma/injury" size="80"]
- Eye: [text default=" Patient denies vision changes, eye pain, discharge" size="80"]
- ENT/Mouth: [text default="Patient denies hearing changes, ear pain, nasal congestion, PND, drainage, sore throat" size="80"]
- CV: [text default="Patient denies CP, SOB, palpitations, edema" size="80"]
- Respiratory: [text default="Patient denies cough, sputum, wheezing, SOB" size="80"][/conditional]
[checkbox name="GIROS" memo="GI Complaint ROS" value=""][conditional field="GIROS" condition="(GIROS).is('')"]- Constitutional: [text default="Patient denies weight change, fever, chills, fatigue" size="80"]
- ENT/Mouth: [text default="Patient denies hearing changes, ear pain, nasal congestion, PND, drainage, sore throat" size="80"]
- CV: [text default="Patient denies CP, SOB, palpitations, edema" size="80"]
- Respiratory: [text default="Patient denies cough, sputum, wheezing, SOB" size="80"]
- GI: [text default="Patient denies nausea, vomiting, diarrhea, constipation, changes in stool" size="80"]
- Integumentary: [text default="Patient denies skin lesions, rashes, or abnormalities" size="80"][/conditional]
[checkbox name="MSKNeuroROS" memo="MSK and Neuro ROS" value=""][conditional field="MSKNeuroROS" condition="(MSKNeuroROS).is('')"]- Constitutional: [text default="Patient denies weight change, fever, chills, fatigue" size="80"]
- CV: [text default="Patient denies CP, SOB, palpitations, edema" size="80"]
- Respiratory: [text default="Patient denies cough, sputum, wheezing, SOB" size="80"]
- MSKL: [text default="Patient denies muscle and joint pain, joint swelling, back/neck Pain, injury/trauma" size="80"]
- Neuro:[text default="Patient denies weakness, numbness, paresthesia, dizziness, memory changes" size="80"][/conditional]
[checkbox name="SkinROS" memo="Skin Complaint ROS" value=""][conditional field="SkinROS" condition="(SkinROS).is('')"]- Constitutional: [text default="Patient denies weight change, fever, chills, fatigue" size="80"]
- CV: [text default="Patient denies CP, SOB, palpitations, edema" size="80"]
- Respiratory: [text default="Patient denies cough, sputum, wheezing, SOB" size="80"]
- Integumentary: [text default="Patient denies skin lesions, rashes, or abnormalities" size="80"]
- Heme/Lymph: [text default="Patient denies bruising, bleeding, lymphadenopathy" size="80"]
- Endocrine: [text default="Patient denies polyuria, polydipsia, temperature intolerance" size="80"][/conditional]
[checkbox name="GUROS" memo="GU ROS" value=""][conditional field="GUROS" condition="(GUROS).is('')"]- Constitutional: [text default="Patient denies weight change, fever, chills, fatigue" size="80"]
- CV: [text default="Patient denies CP, SOB, palpitations, edema" size="80"]
- Respiratory: [text default="Patient denies cough, sputum, wheezing, SOB" size="80"]
- GU: [text default="Patient denies dysuria, urinary frequency, hematuria" size="80"]
- Endocrine: [text default="Patient denies polyuria, polydipsia, temperature intolerance" size="80"][/conditional]
PMH: [text default="Reviewed in Chart" size="40"]
PSH: [text default="Reviewed in Chart" size="40"]
FH:[text default="Reviewed in Chart" size="40"]
Meds: [text default="Reviewed in Chart" size="40"]
Allx: [text name="allx" default="NKDA" size="40"]
SocHx: [text default="Reviewed in Chart" size="40"]

OBJECTIVE:
VS: Reviewed
[checkbox name="WellnessExam" memo="Wellness Exam: Normal" value=""][conditional field="WellnessExam" condition="(WellnessExam).is('')"]- GA/Psych:[text default="AAOx4, NAD. Well developed and nourished. Appears stated age. No SI/HI. Appropriate judgement." size="80"]
- HEAD:[text default="Normocephalic and atraumatic without tenderness, visible or palpable masses, depressions, or scarring." size="80"]
- EYES:[text default="Conjunctivae are clear without exudates or hemorrhage. Sclera is non-icteric. EOMI, PERRLA." size="80"]
- EARS:[text default="external ear and ear canal are non-tender and without swelling, canal is clear without discharge, TM is intact, hearing grossly intact." size="80"]
- NOSE:[text default="no nasal discharge, nares patent b/l" size="80"]
- THROAT: [text default="oral cavity and pharynx normal. No inflammation, swelling, exudate, or lesions. Teeth and gingiva in good general condition." size="80"]
- NECK:[text default="neck supple, non-tender without lymphadenopathy, masses or thyromegaly." size="80"]
- CV: [text default="Normal S1 and S2. No S3, S4 or murmurs. RRR. There is no peripheral edema, cyanosis or pallor. Extremities are warm and well perfused. Capillary refill is less than 2 seconds. No carotid bruits. Peripheral pulses +2 in all extremities. No edema noted." size="80"]
- LUNGS: [text default="Clear to auscultation and percussion without rales, rhonchi, wheezing or diminished breath sounds." size="80"]
- ABD:[text default="Positive bowel sounds. Soft, nondistended, nontender. No guarding or rebound. No masses" size="80"]
- SKIN:[text default="Skin in warm, dry and intact without rashes or lesions. Appropriate color for ethnicity. Nailbeds pink with no cyanosis or clubbing." size="80"]
- MSKL:[text default="No significant deformity or joint abnormality. Adequately aligned spine. ROM intact spine and extremities. No joint erythema or tenderness. Normal muscular development. Stable gait." size="80"]
- NEURO:[text default="Mentating well, moves all extremities equally well, intact sensorium all 4 extremities, no gross motor deficits" size="80"][/conditional]
[checkbox name="briefexam" memo="Brief Exam: Normal" value=""][conditional field="briefexam" condition="(briefexam).is('')"]-GA/LOC: [text default="Awake, alert and oriented. No acute distress. Well developed, hydrated and nourished. Appears stated age." size="80"]
-CV: [text default="Normal S1 and S2. No S3, S4 or murmurs. Rhythm is regular. There is no peripheral edema, cyanosis or pallor. Extremities are warm and well perfused. Capillary refill is less than 2 seconds. No carotid bruits." size="80"]
-LUNGS: [text default="Clear to auscultation and percussion without rales, rhonchi, wheezing or diminished breath sounds." size="80"][/conditional]
[checkbox name="BriefExamWithENTcomplaint" memo="Brief Exam With ENT complaint" value=""][conditional field="BriefExamWithENTcomplaint" condition="(BriefExamWithENTcomplaint).is('')"]- GA/Psych:[text default="AAOx4, NAD. Well developed and nourished. Appears stated age. No SI/HI. Appropriate judgement." size="80"]
-HEAD:[text default="Normocephalic and atraumatic without tenderness, visible or palpable masses, depressions, or scarring." size="80"]
-EYES:[text default="Conjunctivae are clear without exudates or hemorrhage. Sclera is non-icteric. EOMI, PERRLA." size="80"]
-EARS:[text default="external ear and ear canal are non-tender and without swelling, canal is clear without discharge, TM is intact, hearing grossly intact." size="80"]
-NOSE:[text default="no nasal discharge, nares patent b/l" size="80"]
-THROAT: [text default="oral cavity and pharynx normal. No inflammation, swelling, exudate, or lesions. Teeth and gingiva in good general condition." size="80"]
-NECK:[text default="neck supple, non-tender without lymphadenopathy, masses or thyromegaly." size="80"]
-CV: [text default="Normal S1 and S2. No S3, S4 or murmurs. RRR. There is no peripheral edema, cyanosis or pallor. Extremities are warm and well perfused. Capillary refill is less than 2 seconds. No carotid bruits. Peripheral pulses +2 in all extremities. No edema noted." size="80"]
-LUNGS: [text default="Clear to auscultation and percussion without rales, rhonchi, wheezing or diminished breath sounds." size="80"][/conditional]
[checkbox name="BriefExamGIComplaint" memo="Brief Exam with GI Complaint" value=""][conditional field="BriefExamGIComplaint" condition="(BriefExamGIComplaint).is('')"]- GA/Psych:[text default="AAOx4, NAD. Well developed and nourished. Appears stated age. No SI/HI. Appropriate judgement." size="80"]
-CV: [text default="Normal S1 and S2. No S3, S4 or murmurs. RRR. There is no peripheral edema, cyanosis or pallor. Extremities are warm and well perfused. Capillary refill is less than 2 seconds. No carotid bruits. Peripheral pulses +2 in all extremities. No edema noted." size="80"]
-LUNGS: [text default="Clear to auscultation and percussion without rales, rhonchi, wheezing or diminished breath sounds." size="80"]
-ABD:[text default="Positive bowel sounds. Soft, nondistended, nontender. No guarding or rebound. No masses" size="80"]
-SKIN:[text default="Skin in warm, dry and intact without rashes or lesions. Appropriate color for ethnicity. Nailbeds pink with no cyanosis or clubbing." size="80"[/conditional]
[checkbox name="briefexamMSKandNeuroComplaint" memo="Brief Exam with MSKL or Neuro Complaint: Normal" value=""][conditional field="briefexamMSKandNeuroComplaint" condition="(briefexamMSKandNeuroComplaint).is('')"]-GA/Psych: [text default="AAOx4, NAD. Well developed and nourished. Appears stated age. No SI/HI. Appropriate judgement." size="80"]
-CV: [text default="S1 and S2 noted. No S3, S4 or murmurs. RRR. No peripheral edema, cyanosis or pallor. No carotid bruits. Extremities are warm and well perfused. Capillary refill is less than 2 seconds x4 extremities. Peripheral pulses +2 in all extremities. No edema noted." size="80"]
-LUNGS: [text default="Clear to auscultation Bilaterally A/P without rales, rhonchi, wheezing or diminished breath sounds." size="80"]
- MSKL: [text default="No significant deformity or joint abnormality. Adequately aligned spine. Full ROM to spine. Full ROM to all extremities. No joint erythema or tenderness. Appropriate muscular development. Stable gait." size="80"]
-NEURO:[text default="Mentating well, moves all extremities equally well, intact sensorium all 4 extremities, no gross motor deficits" size="80"][/conditional]
[checkbox name="SkinComplaint" memo="Skin Complaint" value=""][conditional field="SkinComplaint" condition="(SkinComplaint).is('')"]- GA:[text default="AAOx4, NAD. Well developed and nourished. Appears stated age. Appropriate judgement." size="80"]
-CV: [text default="Normal S1 and S2. No S3, S4 or murmurs. RRR. There is no peripheral edema, cyanosis or pallor. Extremities are warm and well perfused. Capillary refill is less than 2 seconds. No carotid bruits. Peripheral pulses +2 in all extremities. No edema noted." size="80"]
-LUNGS: [text default="Clear to auscultation and percussion without rales, rhonchi, wheezing or diminished breath sounds." size="80"]
-SKIN:[text default="Skin in warm, dry and intact without rashes or lesions. Appropriate color for ethnicity. Nailbeds pink with no cyanosis or clubbing." size="80"]
MSKL:[text default="No significant deformity or joint abnormality. Adequately aligned spine. ROM intact spine and extremities. No joint erythema or tenderness. Normal muscular development. Stable gait." size="80"]
-NEURO:[text default="Mentating well, moves all extremities equally well, intact sensorium to all 4 extremities, no gross motor deficits" size="80"][/conditional]
[checkbox name="GUComplaintExam" memo="GU complaint Exam: Normal" value=""][conditional field="GUComplaintExam" condition="(GUComplaintExam).is('')"]- GA/Psych:[text default="AAOx4, NAD. Well developed and nourished. Appears stated age. No SI/HI. Appropriate judgement." size="80"]
- CV: [text default="Normal S1 and S2. No S3, S4 or murmurs. RRR. There is no peripheral edema, cyanosis or pallor. Extremities are warm and well perfused. Capillary refill is less than 2 seconds. No carotid bruits. Peripheral pulses +2 in all extremities. No edema noted." size="80"]
- LUNGS: [text default="Clear to auscultation and percussion without rales, rhonchi, wheezing or diminished breath sounds." size="80"]
- ABD:[text default="Positive bowel sounds. Soft, nondistended, nontender. No guarding or rebound. No masses" size="80"]
- GU: [text default="No CVA tenderness bilaterally" size="80"][/conditional]
[checkbox name="labs" value="Labs: "][conditional field="labs" condition="(labs).is('Labs: ')"][checkbox value="reviewed with pt
"][checkbox name="LabResults" memo="Results" value=""][/conditional][conditional field="LabResults" condition="(LabResults).is('')"][textarea size="4"]
[/conditional]
A/P: See Above
[checkbox memo="Procedure" name="Procedure" value=""][conditional field="Procedure" condition="(Procedure).is('')"]Procedures: [textarea rows="4"]
[/conditional][checkbox memo="Vaccine" name="Vaccine" value=""][conditional field="Vaccine" condition="(Vaccine).is('')"]Vaccines: [textarea rows="2"]
[/conditional]Plan: [textarea name="plan" rows="8" size="60"]
RTC: [select name="RTC" value="As needed or if no improvement in s/sx|In 6 months for routine f/u with fasting labs prior|In 3-4 months for routine f/u with fasting labs prior|In one year for next wellness visit with fasting labs prior|In one week for F/U|In two weeks for F/U|In 4 weeks for F/U|"] [text name="rtc_1" size="40"]
Meds: [link url="https://www.soapnote.org/miscellaneous/medications-2/" memo="Medications"][checkbox value="none"]
CC:
SUBJECTIVE:
HPI: y.o. presents via for CC. Ctrl + (or )

Denies c/o
REVIEW OF SYSTEMS
Full ROS
Brief ROS
ENT Complaint ROS
GI Complaint ROS
MSK and Neuro ROS
Skin Complaint ROS
GU ROS
PMH:
PSH:
FH:
Meds:
Allx:
SocHx:

OBJECTIVE:
VS: Reviewed
Wellness Exam: Normal
Brief Exam: Normal
Brief Exam With ENT complaint
Brief Exam with GI Complaint
Brief Exam with MSKL or Neuro Complaint: Normal
Skin Complaint
GU complaint Exam: Normal

A/P: See Above
Procedure VaccinePlan:
RTC:
Meds: Medications

Result - Copy and paste this output:

Send Feedback for this SOAPnote

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

More SOAPnotes by this Author: