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HPI
|
|
|
Onset: *
• • •
|
Severity*
|
|
Course*
• • •
|
Fever?
|
|
Similar to prior episodes of asthma exacerbation
|
moderate wheezes. +SOB. No chest pain.
|
|
ran out of medication. requesting refill
|
similar to prior episodes of COPD exacerbation
|
|
Additional notes
|
|
|
|
|
|
REVIEW OF SYSTEMS
|
|
|
Respiratory (positive)
• • •
|
Respiratory (negative)
• • •
|
|
Constitutional (positive)
• • •
|
Constitutional (negative)
• • •
|
|
Insert ROS Macro Here
|
All systems otherwise negative.
|
|
|
|
|
PHYSICAL EXAM
|
|
|
Respiratory: CTAB. nonlabored respirations.
|
|
|
Respiratory (positive)
• • •
|
Respiratory (negative)
• • •
|
|
Additional Resp Findings
|
|
|
PE: Superficial
|
PE: Head to toe exam (abd deferred)
|
|
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
|
