|
HPI
|
|
|
Onset
• • •
|
Location
• • •
|
|
Course
• • •
|
Severity
|
|
Associated symptoms
• • •
|
No prior episodes of similar symptoms.
|
|
No medications prior to arrival
|
Moderate. Constant. Gradual. No triggers/allergy
|
|
Additional notes
|
|
|
|
|
|
REVIEW OF SYSTEMS
|
|
|
Skin (positive)
• • •
|
Skin (negative)
• • •
|
|
Constitutional (positive)
• • •
|
Constitutional (negative)
• • •
|
|
ROS Comments
|
All systems otherwise negative.
|
|
|
|
|
PHYSICAL EXAM
|
|
|
Skin macros (positive)
• • •
|
Skin (negative)
• • •
|
|
Additional Skin Findings
|
|
|
PE: Superficial Exam
|
Head to toe exam (abdomen 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
|
|
