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HPI
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Type of Exposure
• • •
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With or without ejaculation?
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Length of time since exposure
• • •
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Source Person's HIV Status
• • •
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With or without condom?
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Pt is experiencing flu like sx
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No medications PTA
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Pt denies any pain.
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Additional notes
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REVIEW OF SYSTEMS
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Positive GU ROS Findings
• • •
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Negative GU Findings
• • •
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Positive for flu like symptoms
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Positive for Rash
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Insert PE Macro
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All systems otherwise negative.
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PHYSICAL EXAM
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Normal Male GU Exam
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Normal Female Pelvic Exam
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Normal Rectal Exam
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Rectal lesions present
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Additional:
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Superficial
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Head to toe exam
|
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PE Notes:
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MDM
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MDM Notes
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Status:
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Diagnosis:
• • •
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Status:
|
Diagnosis:
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Status:
|
Diagnosis:
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Status:
|
Diagnosis:
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DISCHARGE
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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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