|
HPI
|
|
|
Severity
|
Quality
• • •
|
|
Onset
• • •
|
Course
• • •
|
|
Associated Symptoms
• • •
|
Nonradiating. Constant. No prior episodes.
|
|
No triggers, exeracerbating or mitigating factor
|
Triggers
|
|
No anticoagulants or medications PTA.
|
No risk factors.
|
|
Additional notes
|
No recent risk stratification.
|
|
|
|
|
REVIEW OF SYSTEMS
|
|
|
CV (positive)
• • •
|
CV (negative)
• • •
|
|
Respiratory (positive)
• • •
|
Respiratory (negative)
• • •
|
|
Insert ROS Macro here
|
All systems otherwise negative.
|
|
|
|
|
PHYSICAL EXAM
|
|
|
CV: RRR. No murmurs.
|
|
|
CV (positive)
• • •
|
CV (negative)
• • •
|
|
Additional
|
|
|
PE: Superficial + Lungs: CTAB
|
PE: Head to toe exam
|
|
PE Notes:
|
|
|
Insert ECG Photo
|
|
|
MDM
|
|
|
DDx: Asthma, ACS, costocondritis, GERD, resp illness
|
MDM Notes
|
|
Status
|
Diagnosis:
• • •
|
|
Status
|
Diagnosis:
|
|
|
|
|
DISCHARGE
|
|
|
POC Medications Given
• • •
|
POC Meds:
|
|
Plan Notes
|
|
|
Discharge pt home
|
Discharge pt to ER
|
|
|
Mode of Transport to ER
|
|
|
ER Transfer Comments
|
|
|
|
|
Clinician Attestation
|
|
