|
HPI
|
|
|
Onset
• • •
|
Course
• • •
|
|
Description of accident
• • •
|
Patient location in vehicle
|
|
Point of Impact
• • •
|
Location of pain
• • •
|
|
Severity
|
LOC
|
|
No intrusion or airbag deployment
|
Able to ambulate at scene. Gradual onset of pain
|
|
Additional Comments
|
|
|
|
|
|
REVIEW OF SYSTEMS
|
|
|
MSK: macros (positive)
• • •
|
MSK (negative)
• • •
|
|
Neuro (positive).
• • •
|
Neuro (negative)
• • •
|
|
Additional notes
|
All systems otherwise negative.
|
|
|
|
|
PHYSICAL EXAM
|
|
|
MSK (positive)
• • •
|
MSK (negative)
• • •
|
|
Additional
|
|
|
Head: location:
|
Head (positive)
• • •
|
|
PE: Superficial
|
PE: Full exam. Back, neck, ribs: N/T
|
|
PE: Notes
|
|
|
PHOTO
|
PHOTO
|
|
PHOTO
|
PHOTO
|
|
PMFSHx: Negative. No tobacco
|
|
|
Medical History;
• • •
|
Free Text Medical History:
|
|
Surgical History:
|
Family History:
|
|
Social Hx
• • •
|
|
|
|
|
|
MDM
|
|
|
MDM
|
|
|
Status
|
Diagnosis:
• • •
|
|
Status
|
Diagnosis:
|
|
Status
|
Diagnosis:
|
|
Status
|
Diagnosis:
|
|
|
|
|
DISCHARGE
|
|
|
POC Medications Given
• • •
|
|
|
Plan Notes
|
|
|
Discharge home
|
Discharge pt to ER
|
|
|
Mode of Transport to ER
|
|
|
ER Transfer Comments
|
|
Clinician Attestation
|
|
