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PLACE OF VISIT
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TYPE OF VISIT:
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FACILITY
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DOA:
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ROOM:
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CC/INTERVAL HISTORY:
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Payer ID
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CC:
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Modifying Factors Comments
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Location Comments
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Context Comments
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Severity Comments
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Timing:
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PAST FAMILY SOCIAL HISTORY:
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Family History:
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Social History:
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Surgical History:
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Skilled/Rehab:
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ETOH
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Tobacco
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Drugs
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Additional Comments
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Chronic Conditions:
• • •
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CABG x
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Cancer
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Fracture
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Glaucoma
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Cataract
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Anemia
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Other
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ADL
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Transfer
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REVIEW OF SYSTEMS:
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HENT: Normal
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HEENT- Abnormal Comments
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Eyes: Normal
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Eyes- Abnormal Comments
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Endo: Normal
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Endo- Abnormal Comments
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Hemph/Lymph: Normal
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Hemph/Lymph- Abnormal Comments
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Breast: Normal
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Hemph/Lymph- Abnormal Comments
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Respiratory: Normal
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Respiratory- Abnormal Comments
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Cardio/Vasc: Normal
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Cardio/Vasc- Abnormal Comments
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Musco/Extremities: Normal
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Musco/Extremities- Abnormal Comments
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Gastrointestinal: Normal
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Gastrointestinal- Abnormal Comments
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Genitourinary: Normal
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Gastrointestinal- Abnormal Comments
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Integ/Skin: Normal
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Integ/Skin- Abnormal Comments
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Neurological: Normal
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Neurological- Abnormal Comments
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Psychiatric: Normal
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Psychiatric- Abnormal Comments
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PAIN SCALE
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Location
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Tube Feeding:
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Consultants Seen (in last 30 days)
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Medications: Reviewed
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Coumadin
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Additional Comments
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Allergies: NKDA
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INTERVAL TESTS: Interval Labs
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Cultures:
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X-Rays:
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BS:
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Other
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PHYSICAL EXAM:
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Respiratory Rate
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Weight
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Height
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Temperature
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Pulse
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Blood Pressure
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General App / Constitutional: Normal
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General App/Constitutional: Abnormal comments
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HENT: Normal
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HENT: Abnormal comments
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Eyes: Normal
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Eyes: Abnormal comments
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Neck: Normal
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Neck: Abnormal comments
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Genitourinary: Normal
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Genitourinary: Abnormal comments
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Abdomen: Normal
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Abdomen: Abnormal comments
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Lymphatic: Normal
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Lymphatic: Abnormal comments
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Integ: Normal
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Lymphatic: Abnormal comments
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Respiratory: Normal
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Respiratory: Abnormal comments
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Cardio/Vasc: Normal
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Cardio/Vasc: Abnormal comments
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Chest: Normal
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Chest: Abnormal comments
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Breast: Normal
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Breast: Abnormal comments
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Musculoskeletal: Normal
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Musculoskeletal: Abnormal comments
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Neuro/Psych: Normal
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Neuro/Psych: Abnormal comments
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Skin
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Skin - Body Diagram
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Wound
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Rash
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Ulcer
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DIAGNOSIS Comments
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DIAGNOSIS: Status
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ASSESSMENT/PLAN:
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Discussion/To Consider:
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Test / Labs / X-Rays Ordered:
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Medication Changes Made
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Please Select
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Advance Directives:
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