|
HPI
|
|
|
Onset
• • •
|
Severity
|
|
Course
• • •
|
Fever?
|
|
Similar to prior episodes of asthma exacerbation
|
Moderate wheezes. +SOB. No chest pain.
|
|
Ran out of medication. requesting refill
|
Similar to prior episodes of COPD exacerbation
|
|
Additional notes
|
|
|
|
|
|
REVIEW OF SYSTEMS
|
|
|
Respiratory (positive)
• • •
|
Respiratory (negative)
• • •
|
|
Constitutional (positive)
• • •
|
Constitutional (negative)
• • •
|
|
Insert ROS Macro Here
|
All systems otherwise negative.
|
|
|
|
|
PHYSICAL EXAM
|
|
|
Respiratory: CTAB. nonlabored respirations.
|
|
|
Respiratory (positive)
• • •
|
Respiratory (negative)
• • •
|
|
Additional Resp Findings
|
|
|
PE: Superficial
|
PE: Head to toe exam (abd 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
|
|
