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Constitutional WNL
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Constitutional Abnormal
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Constitutional Abnormal Findings
• • •
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Whole Body Diagram
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Constitutional Comments / Dictation
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Head WNL
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Head Abnormal
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Head Abnormal Findings
• • •
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Head/Scalp Diagram
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Head Comments / Dictation
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Eyes WNL
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Eyes Abnormal
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Right Eye Findings
• • •
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Left Eye Findings
• • •
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Corrective Lenses
• • •
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Eyes Diagram
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Eyes Comments / Dictation
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Ears WNL
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Ears Abnormal
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Right Ear Findings
• • •
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Left Ear Findings
• • •
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Ears Comments / Dictation
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Ear Diagram
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Hearing Aids
• • •
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Nose WNL
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Nose Abnormal
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Nose Findings
• • •
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Nose Diagram
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Nose Comments / Dictation
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Mouth/Throat WNL
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Mouth/Throat Abnormal
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Mouth/Throat Findings
• • •
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Mouth/Throat Diagram
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Teeth / Dentition
• • •
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Mouth Comments / Dictation
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Neck WNL
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Neck Abnormal
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Lymph Abnormal
• • •
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Trachea Abnormality
• • •
|
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Thyroid Abnormalities
• • •
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Vascular Neck Abnormality
• • •
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NECK Musculoskeletal Abnormalities
• • •
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Meningeal Signs
• • •
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Neck Comments / Dictation
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Cardiovascular WNL
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Cardiovascular Abnormal
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Rate / Rhythm Abnormal
• • •
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Heart Sounds Abnormal
• • •
|
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Murmur Present
• • •
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Pulses Abnormal
• • •
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|
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Cardiovascular Comments / Dictation
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Respiratory WNL
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Respiratory Abnormal
|
|
Respiratory Findings
• • •
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Posterior Thorax Diagram
|
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Respiratory Comments / Dictation
|
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Breasts / Chest Wall WNL
|
Breasts / Chest Wall Abnormal
|
|
Breasts / Chest Wall Findings
• • •
|
Female Breast / Chest Wall Diagram
|
|
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Male Breast / Chest Wall Diagram
|
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Breasts / Chest Wall Comments / Dictation
|
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GI / Abdomen WNL
|
GI / Abdomen Abnormal
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GI / Abdomen Findings
• • •
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GI / Abdomen Diagram
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GI / Abdomen Comments / Dictation
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Genitourinary WNL
|
Genitourinary Abnormal
|
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Female Genitourinary Findings
• • •
|
Male Genitourinary Findings
• • •
|
|
Female Genitourinary Diagram
|
Male Genitourinary Diagram
|
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Genitourinary Comments / Dictation
|
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Skin WNL
|
Skin Abnormal
|
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Skin Findings
• • •
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Skin / Integumentary Diagram
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Skin / Intetumentary Comments / Dictation
|
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MSK WNL
|
MSK Abnormal
|
|
MSK Findings
• • •
|
MSK Diagram
|
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MSK Comments / Dictation
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Extremities WNL
|
Extremities Abnormal
|
|
Extremity Findings
• • •
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Extremities Comments / Dictation
|
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Neurological WNL
|
Neurological Abnormal
|
|
Neurological Findings
• • •
|
Neurological Comments / Dictation
|
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Assistive Device
• • •
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|
|
|
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Psych WNL
|
Psych Abnormal
|
|
Psych Findings
• • •
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Psych Comments / Dictation
|
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Drawing Diagrams
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Whole Body Diagram
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Head Diagram
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Eyes Diagram
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Ears Diagram
|
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Nose Diagram
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Mouth/Throat Diagram
|
|
Neck Diagram
|
Back Diagram
|
|
Male Breast / Chest Wall Diagram
|
Male GU Diagram
|
|
Male Rectum
|
Female Rectum
|
|
Female Breast / Chest Wall Diagram
|
Female GU Diagram
|
|
Musculoskeletal Diagram
|
|
