|
HPI
|
|
|
Location
• • •
|
Associated symptoms
• • •
|
|
Onset
• • •
|
Severity
|
|
Course
• • •
|
Fever?
|
|
No medications PTA
|
No prior episodes of similar symptoms.
|
|
No hx of MRSA
|
|
|
Additional notes
|
|
|
|
|
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REVIEW OF SYSTEMS
|
|
|
Skin (positive)
• • •
|
Skin (negative)
• • •
|
|
Constitutional (positive)
• • •
|
Constitutional (negative)
• • •
|
|
Insert ROS Macro Here
|
All systems otherwise negative.
|
|
|
|
|
PHYSICAL EXAM
|
|
|
Location: *
• • •
|
|
|
Skin macros (positive)
• • •
|
Skin (negative)
• • •
|
|
Additional
|
|
|
PE: Superficial Exam
|
Head to toe exam
|
|
PE Macro:
|
|
|
|
|
|
MDM
|
|
|
DDx: Abscess, cellulitis, cyst, LAD
|
MDM
|
|
Status
|
Diagnosis:
• • •
|
|
Status
|
Diagnosis:
|
|
Status
|
Diagnosis:
|
|
Status
|
Diagnosis:
|
|
|
|
|
Procedure Attestation
|
Verbal Consent Obtained
|
|
Anesthesia:
|
Size of incision: ___ cm
|
|
Moderate amount. Nonbloody purulent material
|
Wound was packed with gauze.
|
|
Tolerated well. No complications. Dressing applied.
|
Cultures obtained.
|
|
Notes:
|
|
|
PHOTO
|
PHOTO
|
|
|
|
|
DISCHARGE
|
|
|
POC Medications Given
• • •
|
|
|
Plan Notes
|
|
|
Discharge pt home
|
Discharge pt to ER
|
|
|
Mode of Transport to ER
|
|
|
ER Transfer Comments
|
|
Clinician Attestation
|
|
