NOTE

CAUTION: This page needs to be reviewed and categorized.
[date name="variable_1" default="timestamp"]
[text name="Role" default="" memo="HO/INTERN/RESIDENT/REG/SMO"] NOTE ([text name="Author" default="" memo="NAME"])

[text name="patientage" default="" memo="patient age"]  [checkbox name="gender" value="M|F"] presenting with [text name="pc" default=""]
[checkbox value="BG: "][textarea rows="1"]

HPC: [select name="historysource" value="|history obtained from patient - good historian|history obtained from patient - vague historian|history obtained from patient-poor historian|history obtained from patient's family member|history obtained from patient's friend|nil history obtainable"]
[textarea name="HPC" default="" memo="SOCRATES"]

[comment memo_color="lightgreen" memo="constitutionalsx"][checkbox value="Denies weight loss, fever and chills. "][textarea rows="1"]
[comment memo_color="lightgreen" memo="neuro/HEENT"][checkbox value="Denies headache, syncopal episodes, changes in vision and hearing. "][textarea rows="1"]
[comment memo_color="lightgreen" memo="cardio"][checkbox value="Denies palpitations and CP. "][textarea rows="1"]
[comment memo_color="lightgreen" memo="resp"][checkbox value="Denies SOB and cough. "][textarea rows="1"]
[comment memo_color="lightgreen" memo="gastro"][checkbox value="Denies abdominal pain, nausea, vomiting and diarrhea, change in bowels. "][textarea rows="1"]
[comment memo_color="lightgreen" memo="urinarysx"][checkbox value="Denies dysuria and urinary frequency. "][textarea rows="1"]
[comment memo_color="lightgreen" memo="GU-male"][checkbox value="Denies testicular pain, swelling, itch, discharge. "][textarea rows="1"]
[comment memo_color="lightgreen" memo="GU-female"][checkbox value="Denies PV bleeding, PV discharge, dysmonorrhoea/irreg menstrual bleeding.  "][textarea rows="1"]
[comment memo_color="lightgreen" memo="msk/skin"][checkbox value="Denies rashs, myalgia and joint pain. "][textarea rows="1"]

[comment memo="Resus plan"][select name="ResusPlan" value="|Has a valid Acute Resus Plan in place - appropriate goals of care. |Has a valid Acute Resus Plan in place. |No valid Acute Resus Plan in place- patient has a previous plan. |No valid Acute Resus Plan- discussed with patient. |No valid Acute Resus Plan- not discussed with patient. "][text]
[checkbox value="Patient has capacity. "][checkbox value="Patient has a valid documented Advance Health Directive. "][checkbox value="Patient has an elected EPOA. "][textarea rows="1"]
[checkbox value="Resus form updated. "][textarea rows="1"]


PMHx:
[textarea name="pmhx" default="" sortable="true"][checkbox value="Nil significant PMHx"]
[checkbox value="FAMILY HISTORY: "][textarea rows="1"]

MEDS:
[textarea name="meds" default="" sortable="true"][checkbox value="Nil regular medications."]
[select name="medicationsmx" value="|medications managed by patient|medications managed by:" memo="meds managed by: "][text name="medsmxby" default=""]
[checkbox value="Medications blister packed. "][checkbox value="Reports compliance. "][checkbox value="No recent medication changes. "][textarea name="medchanges" memo="recent medication changes" default=""]
ALLERGIES: 
[checkbox value="NKDA"][checkbox value="Known ADR/Allergies:"][textarea rows="1"]

SOCIAL BACKGROUND:
[comment  memo_color="powderblue" memo="Living situation"][select name="liveswith" value="|Lives alone |Lives with partner |Lives with family |Nil fixed abode |Rest home resident |Dementia care resident "][text name="lives_with" default=""]
[comment  memo_color="powderblue" memo="Occupation"][select name="occupation" value="|Full-time. |Part-time. |Casual. |Retired. |Unemployed. |Student. "][text name="occupation" default=""]
[comment  memo_color="powderblue" memo="ADLs"][select name="ADLs" value="|Fully independent with iADLs. |Independent with "][text name="ADLs_ind" default=""][checkbox value="Requires assistance with: "][text name="ADLs_help" default=""][comment  memo_color="powderblue" memo="mobility"][select name="mobility" value="|Mobilises independently. |Mobilises without aid- unsteady |Mobilises with 4WW |Mobilises with walking stick "][text name="mobility" default=""][checkbox value="Exercise tolerance"][textarea rows="1"]
[comment  memo_color="powderblue" memo="EtOH"][select name="EtOH" value="|Denies EtOH use. |Drinks "][text name="EtOH" default=""]
[comment  memo_color="powderblue" memo="Smoking Status"][select name="SmokingStatus" value="|Non-smoker. |Ex-smoker (recent). |Ex-smoker (long-term). |Current smoker. "][text name="pkyrs" default=""][checkbox value=" pack-years"]
[comment  memo_color="powderblue" memo="anything else"][text name="othersochx"]

O/E:
[comment memo_color="darkorange" memo="vitals"][checkbox value="Vitals stable WNL. "][checkbox value="RR"][text rows="1" size="5"][checkbox value=" SpO2"][text rows="1" size="5"][checkbox value=" HR"][text rows="1" size="5"][checkbox value=" BP"][text rows="1" size="5"][checkbox value=" Afebrile"][checkbox value=" Febrile"][text rows="1" size="5" memo="temp"]
[comment memo_color="darkorange" memo="LOC"][checkbox value="alert, orientated x3"][textarea rows="1" size="30"][select name="GCSscore" value="|GCS 15|GCS 14|GCS 13|GCS 12|GCS 11|GCS 10|GCS 9|GCS 8|GCS 7|GCS 6|GCS 5|GCS 4|GCS 3"] [select name="GCS_e" value="|E4|E3|E2|E1"][select name="GCS_v" value="|V5|V4|V3|V2|V1"][select name="GCS_m" value="|M6|M5|M4|M3|M2|M1"]
[comment  memo_color="lightyellow" memo="E4-spontaneous, E3-to speech, E2-to pain, E1-no response"]
[comment  memo_color="lightyellow" memo="V5-A+Ox3, V4-confused, V3-inapprop. words, V2-incomp. sounds, V1-no response"]
[comment  memo_color="lightyellow" memo="M6-obeys command, M5-to localised pain, M4-flexes from pain, M3-abn flexion, M2-abn ext, M1-no response"]
[comment memo_color="darkorange" memo="appearences"][checkbox value="Looks well. "][checkbox value="Looks comfortable. "][checkbox value="No acute distress. "][checkbox value="Looks acutely unwell. "][checkbox value="Looks chronically-unwell. "][checkbox value="In acute distress. "][text rows="1"]
[comment memo_color="darkorange" memo="CVS"][checkbox value="Pulse reg/rate. "][checkbox value="Nil rad-rad delay. "][checkbox value="WWP peripheries. "][checkbox value="CRT <3. "][text rows="1"]
[checkbox value="HS dual + nil."][checkbox value="Nil pedal odema. "][text rows="1"][checkbox value="Calves SNT. "][text rows="1"]
[comment memo_color="darkorange" memo="resp"][checkbox value="Chest clear to ausculation. "][checkbox value="Nil resp. distress - speaking full sentences. "][text rows="1"]
[comment memo_color="darkorange" memo="abdo"][checkbox value="Abdomen soft, non-tender. "][checkbox value="BS present+active. "][text rows="1"]
[comment memo_color="darkorange" memo="neuro"][checkbox value="Neuro appears grossly intact. "][checkbox value="No focal neurological deficits of note. CNII-XII appear grossly intact, but not individually tested, mobilising normally."][text rows="1"]
[checkbox value="VF full to confrontation. "][checkbox value="PEARL. "][checkbox value="FROEM. Nil diploplia. No nystagmus. "][text rows="1"]
[checkbox value="Hearing grossly intact. "][checkbox value="Normal palate elevation / tongue movements. "][text rows="1"]
[checkbox value="normal facial movements / symmetry - no facial droop or flattening of the nasolabial fold, shoulder shrug  symmetric, no pronator drift. "][text rows="1"]
[checkbox value="UL power intact 5/5 thoughout bilat. "][checkbox value="Normal tone. "][checkbox value="No spasticity, rigidity, or cogwheeling. "][checkbox value="UL Reflexes 2+. "][checkbox value="Normal FNF test. "][text rows="1"]
[checkbox value="LL power intact 5/5 throughout bilat. "][checkbox value="LL tone normal. "][checkbox value="LL Reflexes 2+. "][checkbox value="Normal heel-shin tests. "][text rows="1"]
[comment memo_color="darkorange" memo="skin"][checkbox value="No visible rashs, lesions."][text rows="1"]
[comment memo_color="darkorange" memo="other exam i.e. MSK"][textarea]

Investigations:
[comment  memo_color="plum" memo="FBC"][checkbox value=" Hb: "][text rows="1" size="5"][checkbox value=" Hct: "][text rows="1" size="5"][checkbox value=" MCV: "][text rows="1" size="5"][checkbox value=" MCH: "][text rows="1" size="5"][checkbox value=" Plt: "][text rows="1" size="5"][checkbox value=" WBC: "][text rows="1" size="5"][checkbox value=" Neuts: "][text rows="1" size="5"][text]
[comment  memo_color="plum" memo="UEC"][checkbox value=" Na: "][text rows="1" size="5"][checkbox value=" K+: "][text rows="1" size="5"][checkbox value=" Glu: "][text rows="1" size="5"][checkbox value=" Creat: "][text rows="1" size="5"][checkbox value=" eGFR: "][text rows="1" size="5"][text]
[comment  memo_color="plum" memo="LFTs"][checkbox value=" Pro: "][text rows="1" size="5"][checkbox value=" Alb: "][text rows="1" size="5"][checkbox value=" Bili (total/direct): "][text rows="1" size="5"][checkbox value=" Urate: "][text rows="1" size="5"][checkbox value=" ALP: "][text rows="1" size="5"][checkbox value=" GGT: "][text rows="1" size="5"][checkbox value=" ALT: "][text rows="1" size="5"][checkbox value=" AST: "][text rows="1" size="5"][checkbox value=" LD: "][text rows="1" size="5"][checkbox value=" LFTs NAD"][text rows="1" size="5"][checkbox value=" mildly deranged LFTs"][text rows="1" size="5"]
[comment  memo_color="plum" memo="boneprof"][checkbox value=" Ca(corrected): "][text rows="1" size="5"][checkbox value=" Phos: "][text rows="1" size="5"][checkbox value=" Mg: "][text rows="1" size="5"][text]
[checkbox  memo_color="plum" value=" Coags: "][text rows="1" size="5"]
[text rows="1"]
[checkbox  memo_color="plum" value="Urine: " memo="urine"][text rows="1" size="5"]

[checkbox  memo_color="plum" value="ECG: "][text rows="1" size="5"]

[checkbox value="CXR: "][text rows="1" size="5"]
[textarea rows="1" size=""  memo_color="plum" memo="other investigations/imaging"]

Impression:
[textarea]

Plan: [select name="plandiscussed" value="|to be discussed with Senior|discussed with: "][text]
[textarea] 
[comment  memo_color="lightyellow" memo="Disposition
Interventions
Further investigations
Medications (to start / reg meds / withheld / PRNs)
VTE
Nursing instructions"]

HO/INTERN/RESIDENT/REG/SMO NOTE (NAME)

patient age presenting with


HPC:
SOCRATES

constitutionalsx

neuro/HEENT

cardio

resp

gastro

urinarysx

GU-male

GU-female

msk/skin


Resus plan




PMHx:




MEDS:


meds managed by:
recent medication changes
ALLERGIES:


SOCIAL BACKGROUND:
Living situation
Occupation
ADLs mobility

EtOH
Smoking Status
anything else

O/E:
vitals temp
LOC

E4-spontaneous, E3-to speech, E2-to pain, E1-no response
V5-A+Ox3, V4-confused, V3-inapprop. words, V2-incomp. sounds, V1-no response
M6-obeys command, M5-to localised pain, M4-flexes from pain, M3-abn flexion, M2-abn ext, M1-no response
appearences
CVS

resp
abdo
neuro





skin
other exam i.e. MSK


Investigations:
FBC
UEC
LFTs
boneprof


urine




other investigations/imaging

Impression:


Plan:

Disposition
Interventions
Further investigations
Medications (to start / reg meds / withheld / PRNs)
VTE
Nursing instructions

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.56, 239 form elements, 14 boilerplate words, 67 text boxes, 24 text areas, 1 dates, 99 checkboxes, 14 drop downs, 34 comments, 206 total clicks
Questions/General site feedback · Help Ticket

Send Feedback for this SOAPnote

Your email address will not be published. Required fields are marked *

More SOAPnotes by this Author: