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HPI
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Description of Symptoms
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Onset: *
• • •
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Duration*
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Course*
• • •
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Severity
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Symptoms are nonradiating.
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No recent head injury or trauma.No falls or LOC
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Fever?
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Denies anticoagulants.
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No prior episodes of similar symptoms.
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Notes
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REVIEW OF SYSTEMS
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Neuro (positive).
• • •
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Neuro (negative)
• • •
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Constitutional (positive)
• • •
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Constitutional (negative)
• • •
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Additional
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All systems otherwise negative.
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PHYSICAL EXAM
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Head AT/NC. Full Neuro Exam: Negative
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Neuro:
• • •
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Additional
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Insert PE Macro Here
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Head to toe exam + No photophobia (abd deferred)
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MDM
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Clinic Visit CPT CODE***
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MDM Notes
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Status:
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Diagnosis:
• • •
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Status:
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Diagnosis:
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Status:
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Diagnosis:
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Status:
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Diagnosis:
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DISCHARGE
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POC Medications Given
• • •
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Plan Notes
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Discharge pt home
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Discharge Note: ERD ONLY
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