|
HPI
|
|
|
Onset
• • •
|
Severity
|
|
Course
• • •
|
Moderate. No SOB or difficulty swallowing.
|
|
Fever
|
Sick contacts
|
|
Additional notes
|
|
|
|
|
|
REVIEW OF SYSTEMS
|
|
|
ENT (positive)
• • •
|
ENT (negative)
• • •
|
|
Respiratory (positive)
• • •
|
Respiratory (negative)
• • •
|
|
Constitutional (positive)
• • •
|
Constitutional (negative)
• • •
|
|
Additional
|
All systems otherwise negative.
|
|
|
|
|
PHYSICAL EXAM
|
|
|
ENT: pharynx: erythematous, otherwise neg
|
|
|
ENT (positive)
• • •
|
ENT (negative)
• • •
|
|
Lungs: CTAB. No wheezing, rales or rhonchi
|
|
|
PE: Head to toe exam (abd deferred)
|
|
|
Insert PE Macro Here
|
|
|
|
|
|
MDM
|
|
|
MDM
|
|
|
Status:
|
Diagnosis:
• • •
|
|
Status:
|
Diagnosis:
|
|
Status:
|
Discharge: Notes
|
|
Status:
|
Discharge: Notes
|
|
|
|
|
DISCHARGE
|
|
|
POC Medications Given
• • •
|
Plan Notes
|
|
Discharge pt home
|
Discharge pt to ER
|
|
|
Mode of Transport to ER
|
|
|
ER Transfer Comments
|
|
|
|
|
Clinician Attestation
|
|
