|
MA Administering
|
|
|
Dose given today
|
Site administered
|
|
Lot Number
|
Expiration
|
|
Full panel due on or after
|
Additional comments
|
|
Vitamin Therapy Injection Given
• • •
|
Site administered
|
|
Lot Number
|
Expiration
|
|
Physical Exam
|
|
|
General WNL
|
General Abnormal
• • •
|
|
General Comments
|
|
|
HEENT WNL
|
HEENT Abnormal
• • •
|
|
HEENT Comments
|
|
|
Cardiovascular WNL
|
Cardiovascular Abnormal
• • •
|
|
Cardiovascular Comments
|
|
|
Lungs WNL
|
Lungs Abnormal
• • •
|
|
Lungs Comments
|
|
|
Abdomen WNL
|
Abdomen Abnormal
• • •
|
|
Abdomen Comments
|
|
|
MSK WNL
|
MSK Abnormal
• • •
|
|
MSK Comments
|
|
|
Assessment
|
|
|
Assessment
• • •
|
Assessment Additional Comments
|
|
Time spent with pt
|
CPT Code
• • •
|
|
Visit Code New Patient
|
Visit Code Returning Patient
|
|
Plan
|
|
|
Continue with dose of testosterone
|
Plan Additional Comments
|
