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Chief Complaint
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History of Present Illness:
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Historian
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Reviewed
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PMH
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PSH
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Other surgeries
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FH
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Social History
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Misc social
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Recent Hospitalizations:
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BRIEF ROS
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Deep Scribe ROS
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General [-] ALL NORMAL
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General Normals
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Abnormal General
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Respiratory [-] ALL NORMAL
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Respiratory Normals
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Respiratory Abnormals
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Cardiovascular [-] ALL NORMAL
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Cardiovascular Normals
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Cardiovascular Abnormal
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GI [-] ALL NORMAL
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GI Normals
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GI Abnormals
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Urinary [-] ALL NORMAL
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Urinary Normals
• • •
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Urinary Abnormal
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Neurological [-] ALL NORMAL
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Neuro Normals
• • •
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Neuro Abnormal
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Physicial Exam
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Deep Scribe Physical Exam
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General ALL NORMAL- WNWD NAD
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General description
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General Normals
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General Abnormals
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General Comments
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HEAD ALL NORMAL
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HEAD Normals
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HEAD Abnormal
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HEAD Comments
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EENT Exam
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EYES ALL NORMAL
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EYES Normals
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EYES Abnormals
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EYES Comments
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EARS ALL NORMAL
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EARS Normals
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EARS Abnormal
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EAR Comments
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NOSE ALL NORMAL
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NOSE Normals
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NOSE Abnormals
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NOSE Comments
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Lips, Teeth, and Gums ALL NORMAL
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Lips, Teeth, and Gums Normals
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Lips, Teeth, and Gums Abnormals
• • •
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Lips, Teeth, and Gums Comments
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Oropharynx ALL NORMAL
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Oropharynx Normals
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Oropharynx Abnormals
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Oropharynx Comments
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Neck ALL NORMAL
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Neck Normals
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Neck Abnormal
• • •
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Neck Comments
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Lungs ALL NORMAL
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Lungs Normal
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Lungs Abnormal
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Lungs Comments
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Cardiovascular ALL NORMAL
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Cardiovascular Normals
• • •
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Cardiovascular Abnormal
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Cardiovascular comments
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Abdomen ALL NORMAL
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Abdomen Normal
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Abdomen Abnormal(s)
• • •
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Abdomen Comments
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Extremities ALL NORMAL
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Extremities Normal
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Extrem Abnormal
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Extrem Comments
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Skin ALL NORMAL
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Skin Normals
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Skin Abnormal
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Skin Comments
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Neuro NORMAL
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Neuro Normals
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Neuro Abnormal
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Neuro Comments
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MSK SPINAL EXAM
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Cervical spine ALL NORMAL
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Cervical Spine Normal
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Cervical Spine Abnormal
• • •
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Cervical Spine Comments
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Thoracic Spine ALL NORMAL
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Thoracic Spine Normal
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Thoracic Spine Abnormal
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Thoracic Spine Comments
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Lumbar Spine ALL NORMAL
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Lumbar Spine Normal
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Lumbar Spine Abnormal
• • •
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Lumbar Spine Comments
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MSK Extremity EXAM
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Shoulders ALL NORMAL
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Shoulders Normal
• • •
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Shoulders Abnormal
• • •
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Shoulders Comments
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Elbows ALL NORMAL
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Elbows Normal
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Elbows Abnormal
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Elbows Comments
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Wrists ALL NORMAL
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Wrists Normal
• • •
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Wrists Abnormal
• • •
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Wrists Comments
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Hands ALL NORMAL
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Hands Normal
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Hands Abnormal
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Hands Comments
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Hips ALL NORMAL
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Hips Normal
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Hips Abnormal
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Hips Comments
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Knees ALL NORMAL
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Knees Normal
• • •
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Knees Abnormal
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Knees Comments
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Ankles ALL NORMAL
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Ankles Normal
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Ankles Abnormal
• • •
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Ankles Comments
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Feet ALL NORMAL
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Feet Normal
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Feet Abnormal
• • •
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Feet Comments
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Muscular Exam ALL NORMAL
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Extremity Muscles Normal
• • •
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Extremity Muscles Abnormal
• • •
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Extremity Muscle Comments
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Assessment + Plan
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Labs
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Lab Comments
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Radiology
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Radiology Comments
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Referrals
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Referral Comments
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