|
HPI
|
|
|
Location
• • •
|
Associated symptoms
• • •
|
|
Bleeding well controlled
|
Incident occurred less than 24 hours ago.
|
|
No prior episodes of similar symptoms.
|
No medications prior to arrival
|
|
Tetanus
|
Additional notes
|
|
|
|
|
REVIEW OF SYSTEMS
|
|
|
Skin (positive)
• • •
|
Skin (negative)
• • •
|
|
Neuro (positive)
• • •
|
Neuro (negative)
• • •
|
|
MSK: (positive)
• • •
|
MSK (negative)
• • •
|
|
Insert Macro Here
|
All systems otherwise negative.
|
|
|
|
|
PHYSICAL EXAM
|
|
|
PE: Location: *
• • •
|
|
|
__ cm laceration
|
|
|
Skin macros (positive)
• • •
|
Skin (negative)
• • •
|
|
Additional Skin Findings
|
|
|
NVI
|
|
|
PE: Superficial Exam
|
Head to toe exam (abd deferred)
|
|
PE Notes:
|
|
|
PHOTO
|
PHOTO
|
|
MDM
|
|
|
DDx: laceration complex, laceration simple, abrasion
|
MEDICAL DECISION MAKING
|
|
Status:
|
Diagnosis:
• • •
|
|
Status:
|
Diagnosis:
• • •
|
|
Status:
|
Diagnosis:
|
|
Status:
|
Diagnosis:
|
|
|
|
|
DISCHARGE
|
|
|
POC Medications Given
• • •
|
|
|
Plan Notes
|
|
|
Discharge pt home
|
Discharge pt to ER
|
|
|
Mode of Transport to ER
|
|
|
ER Transfer Comments
|
|
Clinician Attestation
|
|
