|
HPI
|
|
|
Course:
|
Highest temperature: __ F
|
|
No sick contacts.
|
Close contacts with similar symptoms.
|
|
_______ taken with no relief:
• • •
|
Patient also complains of flu like symptoms.
|
|
Additional notes
|
|
|
|
|
|
REVIEW OF SYSTEMS
|
|
|
Constitutional (positive)
• • •
|
Constitutional (negative)
• • •
|
|
Insert ROS Macro Here
|
All systems otherwise negative.
|
|
|
|
|
PHYSICAL EXAM
|
|
|
ENT: +pharyngeal erythema, otherwise negative
|
|
|
FOR PEDS. Cap refill nml. No petechial rash
|
Small bilateral cervical lymphadenopathy
|
|
Additional
|
|
|
PE: Superficial
|
Head to toe exam
|
|
Insert PE Macro Here
|
|
|
|
|
|
MDM
|
Clinic Visit CPT CODE***
|
|
MDM Notes
|
|
|
Status
|
Diagnosis:
• • •
|
|
Status
|
Diagnosis:
|
|
Status
|
Diagnosis:
|
|
Status
|
Diagnosis:
|
|
|
|
|
DISCHARGE
|
|
|
POC Medications Given
• • •
|
Plan Notes
|
|
Discharge pt home
|
Discharge Note: ERD ONLY
|
