|
HPI
|
|
|
Course
• • •
|
Severity
• • •
|
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Quality
• • •
|
Onset
• • •
|
|
Course
• • •
|
Moderate. Gradual onset. Nonradiating.
|
|
Exacerbating Factors:
• • •
|
Mitigating factors:
• • •
|
|
No exacerbating factors
|
No mitigating factors
|
|
Fever
|
Patient denies any SOB / difficulty swallowing
|
|
Additional notes
|
|
|
|
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REVIEW OF SYSTEMS
|
|
|
ENT (positive findings)
• • •
|
ENT (negative findings)
• • •
|
|
Constitutional (positive)
• • •
|
Constitutional (negative)
• • •
|
|
ROS Comments
|
All systems otherwise negative.
|
|
|
|
|
PHYSICAL EXAM
|
|
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ENT: +pharyngeal erythema otherwise negative
|
Additional (ENT)
|
|
ENT (positive)
• • •
|
ENT (negative)
• • •
|
|
No cervical lymphadenpathy
|
Small bilateral cervical lymphadenopathy
|
|
Additional
|
|
|
PE: Superficial
|
PE: Head to toe exam (abd deferred)
|
|
Insert PE Macro Here
|
|
|
|
|
|
MDM
|
|
|
Medical Decision Making *
|
Patient meets __/4 centor criteria.
|
|
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
|
|
