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Homebound
• • •
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Historian
• • •
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Reviewed
• • •
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Home Health?
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HH Name
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Hospice?
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Hospice name
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Chief Complaint
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History of Present Illness:
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PMH
• • •
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PSH
• • •
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Other surgeries
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FH
• • •
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Functional status
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Social History
• • •
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Marital status
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Residence
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Recent Hospitalizations:
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Misc social
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Influenza vaccine
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Pneumo Vac. turn ON if recvd
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other vaccinations:
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DNR
• • •
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ROS
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General [-] ALL NORMAL
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General Normals
• • •
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Abnormal General
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General Comments
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Skin [-] ALL NORMAL
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Skin Normals
• • •
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Abnormal Skin
• • •
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Skin Comments
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HEENT [-] ALL NORMAL
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HEENT Normals
• • •
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Abnormal HEENT
• • •
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HEENT Comments
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Neck [-] ALL NORMAL
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Neck Normal
• • •
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NECK Abnormal
• • •
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Neck Comments
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Cardiovascular [-] ALL NORMAL
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Cardiovascular Normals
• • •
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Cardiovascular Abnormal
• • •
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CV Comments
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Respiratory [-] ALL NORMAL
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Respiratory Normals
• • •
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Respiratory Abnormals
• • •
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Resp Comments
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GI [-] ALL NORMAL
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GI Normals
• • •
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GI Abnormals
• • •
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GI Comments
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Urinary [-] ALL NORMAL
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Urinary Normals
• • •
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Urinary Abnormal
• • •
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Urinary comments
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Periph. Vasc. [-] ALL NORMAL
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Periph. Vasc. Normals
• • •
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Abnormal Periph. Vasc.
• • •
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Periph. Vasc. Comments
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MSK [-] ALL NORMAL
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Musc/Skel Normals
• • •
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Musc/Skel Abnormal
• • •
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MSK Comments
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Neurological [-] ALL NORMAL
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Neuro Normals
• • •
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Neuro Abnormal
• • •
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Neuro comments
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Endocrine [-] ALL NORMAL
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Endocrine Normals
• • •
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Endocrine Abnormal
• • •
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Endo Comments
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Psychiatric [-] ALL NORMAL
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Psych Normals
• • •
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Psych Abnormal
• • •
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Psychiatric Comments
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Physicial Exam
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General ALL NORMAL- WNWD NAD
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General description
• • •
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General Comments
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HEENT ALL NORMAL
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HEENT Normals
• • •
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HEENT Abnormal
• • •
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HEENT Comments
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Skin ALL NORMAL
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Skin Normals
• • •
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Skin Abnormal
• • •
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Skin Comments
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Neck ALL NORMAL
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Neck Normals
• • •
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Neck Abnormal
• • •
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Neck Comments
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Cardiovascular ALL NORMAL
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Cardiovascular Normals
• • •
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Cardiovascular Abnormal
• • •
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Cardiovascular comments
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Lungs ALL NORMAL
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Lungs Normal
• • •
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Lungs Abnormal
• • •
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Lungs Comments
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Abdomen ALL NORMAL
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Abdomen Normal
• • •
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Abdomen Abnormal
• • •
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Abdomen Comments
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Musculoskeletal ALL NORMAL
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MSK Normal
• • •
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MSK Abnormal
• • •
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MSK Comments
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Neuro NORMAL
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Neuro Normals
• • •
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Neuro Abnormal
• • •
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Neuro Comments
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Extremities ALL NORMAL
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Extremities Normal
• • •
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Extrem Abnormal
• • •
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Extrem Comments
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Assessment + Plan
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2.
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3.
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4.
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5.
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I recommend podiatry services
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Why need podiatry
• • •
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Labs
• • •
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Lab Comments
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Radiology
• • •
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Radiology Comments
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PT Orders
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PT Recommendation Comments
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Home Health
• • •
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Home Health Comments
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Referrals
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Referral Comments
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Patient Education
• • •
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Education Comments
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Diet
• • •
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Diet Comments
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General Instructions
• • •
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General Instruction Comments
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