|
HPI
|
|
|
Onset: *
• • •
|
Severity*
|
|
Duration of Sx
• • •
|
Course*
• • •
|
|
Sick contacts:
|
Fever
|
|
Moderate. No SOB or difficulty swallowing.
|
Other Associated Symptoms
• • •
|
|
Social Hx
• • •
|
Additional notes
|
|
|
Fam Hx
• • •
|
|
REVIEW OF SYSTEMS
|
|
|
ENT (Abnormal)
• • •
|
ENT (negative)
• • •
|
|
Respiratory (Abnormal)
• • •
|
Respiratory (Normal)
• • •
|
|
Constitutional (Abnormal)
• • •
|
Constitutional (negative)
• • •
|
|
Additional
|
All systems otherwise negative.
|
|
PHYSICAL EXAM
|
|
|
PHYSICAL EXAM*
|
|
|
ENT: pharynx: erythematous, otherwise neg
|
|
|
ENT (Abnormal)
• • •
|
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:
|
|
DISCHARGE
|
|
|
POC Medications Given
• • •
|
Plan Notes
|
|
Discharge pt home
|
Discharge Note: ERD ONLY
|
|
Counseling/Educational Material
|
After Care Instructions
• • •
|
|
Clinic Visit CPT CODE***
|
|
