|
chief complaint-injury
|
History of injury
|
|
prior injuries
|
treatment tried in the past
|
|
Vital signs
|
General features on exam
|
|
Abnormal findings on exam
|
radiographic findings
|
|
Diagnosis ICD-10
|
Laboratory
|
|
Procedure code
|
|
|
Treatment
|
Referral
|
