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HPI
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Length of time since exposure
• • •
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Source Person's HIV Status
• • •
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Type of Exposure
• • •
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With or without ejaculation?
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With or without condom?
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Pt is experiencing flu like sx
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No medications PTA
|
Pt denies any pain.
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Additional notes
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REVIEW OF SYSTEMS
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Positive GU ROS Findings
• • •
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Negative GU Findings
• • •
|
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Positive for flu like symptoms
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Positive for Rash
|
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Insert PE Macro
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All systems otherwise negative.
|
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PHYSICAL EXAM
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Normal Male GU Exam
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Normal Female Pelvic Exam
|
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Normal Rectal Exam
|
Rectal lesions present
|
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Additional:
|
|
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Superficial
|
Head to toe exam
|
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PE Notes:
|
|
|
|
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MDM
|
Clinic Visit CPT CODE***
|
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MDM Notes
|
|
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Status:
|
Diagnosis:
• • •
|
|
Status:
|
Diagnosis:
|
|
Status:
|
Diagnosis:
|
|
Status:
|
Diagnosis:
|
|
|
|
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DISCHARGE
|
|
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Plan Notes:
|
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Discharge pt home
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Discharge Note: ERD ONLY
|
