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HPI
|
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Onset: *
• • •
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Location:
• • •
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Course*
• • •
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Severity*
|
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No prior episodes of similar symptoms.
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Associated symptoms
• • •
|
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No medications PTA
|
Moderate. Constant. Gradual. No triggers/allergy
|
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Additional notes
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REVIEW OF SYSTEMS
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Skin (positive)
• • •
|
Skin (negative)
• • •
|
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Constitutional (positive)
• • •
|
Constitutional (negative)
• • •
|
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Insert ROS Macro Here
|
All systems otherwise negative.
|
|
|
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PHYSICAL EXAM
|
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Skin macros (positive)
• • •
|
Skin (negative)
• • •
|
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Additional Skin Findings
|
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PE: Superficial Exam
|
Head to toe exam (abdomen deferred)
|
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Insert PE Macro Here
|
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MDM
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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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POC Medications Given
• • •
|
Plan Notes
|
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Discharge pt home
|
Discharge Note: ERD ONLY
|
