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HPI
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Pt presenting with : _____
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Duration of Symptom
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Onset
• • •
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Course
• • •
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Severity
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Character
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Exacerbating factors:
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Mitigating factors:
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Medications:
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Associated Symptoms:
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No exacerbating or mitigating factors.
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Well appearing in clinic.
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No fevers.
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No prior episodes of similar symptoms.
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No sick contacts.
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No known triggers.
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Additional HPI Notes:
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REVIEW OF SYSTEMS
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Constitutional: No weakness. No fevers.
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Free Text
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Eyes: No changes in vision.
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Free Text
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ENMT: No sore throat, ear pain, or rhinorrhea.
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Free Text
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CV: No chest pain.
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Free Text
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Respiratory: No SOB, cough or wheezing.
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Free Text
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GI: No n/v/d. no abdominal pain. normal PO
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Free Text
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GU: No dysuria or hematuria.
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Free Text
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MSK: No extremity pain or swelling
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Free Text
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Integumentary (skin and breast): No rash
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Free Text
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Neuro:No headaches
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Free Text
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Psych: No SI or HI
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Free Text
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Endocrine: No polyuria
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Endocrine
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Hematologic / lymphatic : No lymphadenopathy
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Hematologic / lymphatic
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Allergic / Immunologic : No recurrent infections
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Allergic / immunologic
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All systems otherwise negative.
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PHYSICAL EXAM
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CONSTITUTIONAL: Awake and alert. NAD
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CONSTITUTIONAL Comments
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Eyes: PERRL. Normal conjunctiva. Anicteric
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No photophobia
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+ horizontal nystagmus. No vertical or rotatory
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Eye comments
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Skin: Warm. Dry.
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Skin Comments
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ENT: oral mucosa moist. normal oropharynx.
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ENT comments
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Cardiovascular: RRR. No murmurs.
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Perfusion: Distal pulses are 2+ and equal.
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Cardiovascular Comments
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Respiratory: Nonlabored resps. CTAB.
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Lungs Comments
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GI: soft, flat, nontender. No peritoneal signs
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Rectal: Normal tone. Guaiac negative
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CHAPERON PRESENT
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GI Comments
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PELVIC (FEMALE): Nml speculum and bimanual exam
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GENITAL EXAM (MALE)
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CHAPERON PRESENT
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GU comments
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EXTREMITIES FROM. No LE swelling.
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EXTREMITIES Comments
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NECK: nontender. No meningismus.
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NECK: Supple. No adenopathy
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NECK Comments
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CHEST WALL: Stable. No TTP.
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CHEST WALL Comments
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BACK: No CVAT
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BACK: No midline tenderness, deformity, step-off
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BACK Comments
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Basic neuro: A&O. Nml speech. Moving extremities
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Full Neuro Exam
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Full Neuro + FNF + Nml Gait
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Neuro Comments
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Psych: Cooperative.
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Psych comments.
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HEMATOLOGIC/ LYMPH/ IMMUNO: No cervical LAD
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HEMATOLOGIC/LYMPHATIC/IMMUNOLOGIC
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MDM
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Medical Decision Making:
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Reassessment:
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Status:*
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Diagnosis:
• • •
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Status:*
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Diagnosis:
• • •
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Status:*
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Diagnosis:
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Status:*
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Diagnosis:
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DISCHARGE
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POC Medications Given
• • •
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POC Medications:
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Referral to:
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Plan Notes:
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Pt was discharged home
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Discharge pt to ER
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Mode of Transport to ER
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ER Transfer Comments
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Clinician Attestation
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