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Intro
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Chief Complaint(s)
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Other Chief Complaint
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Duration of symptoms
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Fever
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Fever history
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Cough
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Cough Quality
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Cough Duration
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Cough Comments
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Other Respiratory Symptoms
• • •
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Nasal Congestion
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Nasal Congestion Duration
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Nasal Congestion Comments
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Ear pain
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Ocular Symptoms
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Ocular Symptoms
• • •
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Sore throat
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Throat/mouth symptoms
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Rash
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Rash Location
• • •
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Rash Itchy?
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Prior history of rash
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Abdominal Pain
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Abdominal Pain Location
• • •
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Abdominal Pain Quality
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Radiation?
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Radiates To
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Association with food
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Stools
• • •
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Vomiting
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Vomiting Comments
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Vomiting Quality
• • •
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Number of Episodes
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Diarrhea
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Diarrhea Comments
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Diarrhea Quality
• • •
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Appetite
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Other Symptoms
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ROS negative
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Review of systems positive
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Physical exam- general
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HEENT abnormal findings
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Head ears eyes nose and throat
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Lungs/chest exam
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Neck exam
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Abdominal exam
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Heart / cardiovascular exam
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extremities exam
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GU exam
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Neurological exam
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Skin Exam
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Xrays done today
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Additional exam notes
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In office laboratory test
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Assessment
• • •
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ICD 10 diagnosis
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ICD 10 diagnosis
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ICD 10 diagnosis
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CPT codes for today
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CPT codes for today
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Treatment plans
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Medications OTC
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Supportive Care
• • •
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Medications Prescribed
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Antibiotic
• • •
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Antibiotic Concentration
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Antibiotic Dose
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