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HPI
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Onset: *
• • •
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Course*
• • •
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Severity
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+flu like symptoms. Clear nasal discharge
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Location
• • •
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Bleeding is moderate. No known triggers.
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Description of injury:
• • •
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Fever?
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Additional notes
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REVIEW OF SYSTEMS
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Positive (ENT)
• • •
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Negative (ENT)
• • •
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Constitutional (positive)
• • •
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Constitutional (negative)
• • •
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Insert ROS Macro Here
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All systems otherwise negative.
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PHYSICAL EXAM
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PE: Nose: negative exam
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ENT (positive)
• • •
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ENT (negative)
• • •
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PE: Superficial
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PE: Head to toe exam (abd deferred)
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Insert PE Macro Here
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Additional ENT Findings
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MDM
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MDM
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Clinic Visit CPT CODE***
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Procedure Attestation (clinician)***
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Location of bleeding: ***
• • •
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Type of nasal drops instilled: ***
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Inspected with:
• • •
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External pressure applied.
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Clots cleared by:
• • •
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Cauterized with silver nitrate.
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Method used: ***
• • •
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Bleeding controlled. Tolerated well.
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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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