|
HPI
|
|
|
Description of Symptoms
|
Onset
• • •
|
|
Duration
|
Course
• • •
|
|
Severity
|
Symptoms are nonradiating.
|
|
No recent head injury or trauma.No falls or LOC
|
Fever?
|
|
Denies anticoagulants.
|
No prior episodes of similar symptoms.
|
|
Notes
|
|
|
|
|
|
REVIEW OF SYSTEMS
|
|
|
Neuro (positive).
• • •
|
Neuro (negative)
• • •
|
|
Constitutional (positive)
• • •
|
Constitutional (negative)
• • •
|
|
Additional
|
|
|
All systems otherwise negative.
|
|
|
PHYSICAL EXAM
|
|
|
Head AT/NC. Full Neuro Exam: Negative
|
|
|
Neuro:
• • •
|
|
|
Additional
|
|
|
PE: Superficial
|
Head to toe exam + No photophobia (abd deferred)
|
|
Insert PE Macro Here
|
|
|
MDM
|
|
|
MDM Notes
|
|
|
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
|
|
