|
HPI
|
|
|
Onset
• • •
|
Course
• • •
|
|
Severity
|
Location
• • •
|
|
Description of Injury
• • •
|
Fever?
|
|
+flu like symptoms. Clear nasal discharge
|
Bleeding is moderate. No known triggers.
|
|
Additional Notes
|
|
|
|
|
|
REVIEW OF SYSTEMS
|
|
|
Positive (ENT)
• • •
|
Negative (ENT)
• • •
|
|
Constitutional (positive)
• • •
|
Constitutional (negative)
• • •
|
|
Insert ROS Macro Here
|
All systems otherwise negative.
|
|
|
|
|
PHYSICAL EXAM
|
|
|
PE: Nose: negative exam
|
|
|
ENT (positive)
• • •
|
ENT (negative)
• • •
|
|
|
|
|
PE: Superficial
|
PE: Head to toe exam (abd deferred)
|
|
Insert PE Macro Here
|
|
|
Additional ENT Findings
|
|
|
PHOTO
|
PHOTO
|
|
PHOTO
|
PHOTO
|
|
MEDICAL DECISION MAKING
|
|
|
MDM
|
|
|
Procedure Attestation (clinician)***
|
|
|
Location of bleeding: ***
• • •
|
Type of nasal drops instilled: ***
|
|
Inspected with:
• • •
|
External pressure applied.
|
|
Clots cleared by:
• • •
|
Cauterized with silver nitrate.
|
|
Method used: ***
• • •
|
Bleeding controlled. Tolerated well.
|
|
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
|
|
