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HPI
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Caretaker present during visit
• • •
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Free Text Notes
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Diet
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Elimination
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Sleep:
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Screen time (daily)
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Activities
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Child's developmental milestones
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Emotional health
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Relationship of caretakers
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No Red Flag Sx (severe pain, shortness of breath, chest pain, high fever, or other signs of acute distress
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REVIEW OF SYSTEMS
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General WNL no fevers, chills, weakness, malaise or significant weight change
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General (patient reports having)
• • •
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General (patient denies)
• • •
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General Comments
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HEENT WNL no head trauma; vision changes, eye drainage, swelling or pain; otalgia, discharge from ears, EAC pain or redness, he
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Eyes (patient reports having)
• • •
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Eyes (patient denies)
• • •
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Ears (patient reports having)
• • •
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Ears (patient denies)
• • •
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Nose/Sinus (patient reports having)
• • •
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Nose/Sinus (patient denies)
• • •
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Throat (patient reports having)
• • •
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Throat (patient denies)
• • •
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HEENT ROS Comments
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Date of Last Vision Exam
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Date of Last Dental Exam
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Neck/Glands WNL no neck pain, lymphadenopathy or tenderness
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Neck/Glands (patient reports having)
• • •
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Neck/Glands (patient denies)
• • •
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Neck/Glands ROS Comments
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Breasts WNL no lumps, pain, discomfort or nipple discharge
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Breasts (patient reports having)
• • •
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Breasts (patient denies)
• • •
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Breasts Comments
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Cardiac WNL no chest pains, irregular heartbeats or palpitations
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Cardiac (patient reports having)
• • •
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Cardiac (patient denies)
• • •
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Cardiac Comments
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Respiratory WNL no cough, wheezing, hemoptysis, phlegm, or shortness of breath
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Respiratory (patient reports having)
• • •
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Respiratory (patient denies)
• • •
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Respiratory Comments
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Abdomen/GI WNL no pain, bloating, tenderness, nausea, vomiting, diarrhea, constipation, black or tarry stools
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Abdomen / GI (patient reports having)
• • •
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Abdomen / GI (patient denies)
• • •
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Abdomen/GI Comments
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Urinary WNL no polyuria, nocturia, urgency, burning or pain on urination, hematuria, difficult initiation of stream, or incontin
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Urinary (patient reports having)
• • •
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Urinary (patient denies)
• • •
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Urinary Comments
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Genital (Female) WNL no dysmenorrhea, abnormal vaginal discharge, itching, sores, lumps, or rash
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Genital (Female reports having)
• • •
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Genital (Female denies)
• • •
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Genital (Male) WNL no hernias, discharge, sores, testicular pain or masses, lesions, or erectile dysfunction
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Genital (Male reports having)
• • •
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Genital (Male) denies
• • •
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Genital Comments:
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Skin WNL no rashes, lesions of concern, itching or redness
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Skin (patient reports having)
• • •
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Skin (patient denies)
• • •
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Skin Comments
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Periph. Vasc. WNL no intermittent claudication, leg cramps, or varicose veins
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Periph. Vasc. (patient reports having)
• • •
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Periph. Vasc. (patient denies)
• • •
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Periph. Vasc. Comments
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Musculoskeletal WNL no muscle or joint pains, stiffness, arthritis, gout, backache, swelling, redness, pain, tenderness, or limi
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Musculoskeletal (patient reports having)
• • •
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Musculoskeletal (patient denies)
• • •
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Musculoskeletal Comments
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Neurological WNL no fainting, blackouts, seizures, weakness, paralysis, unexplained headaches, numbness or loss of sensation, ti
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Neurological (patient reports having)
• • •
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Neurological (patient denies)
• • •
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Neuro Comments
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Endocrine WNL no heat or cold intolerance, excessive sweating, excessive thirst or hunger, or polyuria
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Endocrine (patient reports having)
• • •
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Endocrine (patient denies)
• • •
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Endo Comments
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Psychiatric WNL no nervousness, depression, anxiety or memory change
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Psychiatric (patient reports having)
• • •
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Psychiatric (patient denies)
• • •
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Psychiatric Comments
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Additional ROS Comments
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All systems otherwise negative.
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PHYSICAL EXAM
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General WNL
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General (positive findings)
• • •
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General (negative findings)
• • •
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General Comments
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HEENT (Video) WNL no gross deformity, atraumatic; PERRLA, normal conjunctiva; no redness of EAC or pain with pulling; no sinus t
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HEENT (In-Person) WNL no gross deformity, atraumatic; PERRLA, normal conjunctiva; normal EAC, no drainage, TMs intact without bu
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Head (positive findings)
• • •
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Head (negative findings)
• • •
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Head Comments:
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Eyes (positive findings)
• • •
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Eyes (negative findings)
• • •
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Eyes Comments:
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Ears (positive findings)
• • •
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Ears (negative findings)
• • •
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Ears Comments
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Nose/Sinus (positive findings)
• • •
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Nose/Sinus (negative findings)
• • •
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Nose/Sinus Comments:
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Oropharynx (positive findings)
• • •
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Oropharynx (negative findings)
• • •
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Oropharynx Comments
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Neck/Glands (Video) WNL no anterior or posterior cervical lymphadenopathy or tenderness per provider guided palpation; swallows
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Neck/Glands (In-Person) WNL no anterior or posterior cervical lymphadenopathy or tenderness
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Neck/Glands (positive findings)
• • •
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Neck/Glands (negative findings)
• • •
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Neck/Glands COMMENTS
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CV (In-Person) WNL RRR, no murmurs, rubs or gallops, S1 S2 present, no S3, no S4
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CV IN-PERSON (Positive findings)
• • •
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CV In-Person (Negative findings)
• • •
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CV COMMENTS
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Respiratory (Video) WNL no audible wheezing, rales or rhonchi through video, able to take deep, easy breaths, in no acute distre
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Respiratory (In-Person) WNL CTAB. No wheezing, rales or rhonchi
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Respiratory (Positive findings)
• • •
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Respiratory (Negative findings)
• • •
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Respiratory Comments
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Abdominal (Video) WNL soft, non-tender per provider guided palpation, non-distended
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Abdominal (In-Person) WNL soft, non-tender, non-distended, normal bowel sounds all 4 quadrants, no masses noted on light or deep
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Abdominal (positive findings)
• • •
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Abdominal (negative findings)
• • •
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Abdominal/GI Comments
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Genital & Breast (Exam Deferred)
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Skin (Video) WNL no visible lesions or rash
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Skin (In-Person) WNL warm and dry, no lesions, no rash
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Skin (positive findings):
• • •
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Skin (negative findings):
• • •
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Skin Comments
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Musculoskeletal (Video) WNL no visible deformities, normal range of motion
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Musculoskeletal (In-Person) WNL normal muscle tone/bulk, no deformities, normal range of motion, normal spine alignment
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MSK (positive findings)
• • •
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MSK (negative findings)
• • •
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MSK Comments
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Extremities WNL no varicose veins or edema visible, no abnormal movements, no tremor, no rigidity, normal alignment, normal gait
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Extremity assessment
• • •
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Extremity Comments
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Neuro (In-Person) WNL muscle strength 5/5 in all major muscle groups, cranial nerves II-XII intact, pain/temperature/light touch
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Neuro (positive findings)
• • •
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Neuro (negative findings)
• • •
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Neuro Comments
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Additional System Comments
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Full Body Diagram
|
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|
erx provided
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