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HPI
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LMP ___ weeks ago
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Moderate. Nonradiating. No fevers.
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Patient is currently ___ weeks pregnant.
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# of pads soaked per hour for the last 2 hours
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Associated symptoms.
• • •
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Patient denies the possibility of pregnancy.
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Additional notes
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REVIEW OF SYSTEMS
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GU macros (positive)
• • •
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GU (negative)
• • •
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Constitutional (positive)
• • •
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Constitutional (negative)
• • •
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Free text
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All systems otherwise negative.
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PHYSICAL EXAM
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Was a Pelvic Exam Performed***
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Pelvic (female) NEGATIVE
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Female Pelvic (positive )
• • •
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Female Pelvic (negative)
• • •
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Free text
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Abdomen: Soft Flat. N/T. No peritoneal signs
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PE: Superficial
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PE: Head to toe exam
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PE Notes:
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MDM
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DDx: STD, dysuria, uti, pregnancy, PID, threatened AB, incomplete ab
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MDM Notes
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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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Plan Notes
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Discharge pt 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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