|
|
|
|
HPI
|
|
|
Onset
• • •
|
Location
• • •
|
|
Duration
• • •
|
Course
• • •
|
|
Severity
|
Associated symptoms
• • •
|
|
PMHX
|
PSHX
|
|
No prior episodes of similar symptoms.
|
No medications PTA
|
|
Moderate. Constant. Gradual. No triggers/allergy
|
Social Hx
• • •
|
|
REVIEW OF SYSTEMS
|
|
|
Skin (positive)
• • •
|
Skin (negative)
• • •
|
|
Constitutional (positive)
• • •
|
Constitutional (negative)
• • •
|
|
Addtional SX
|
All systems otherwise negative.
|
|
PHYSICAL EXAM
|
|
|
Skin (positive)
• • •
|
Skin (negative)
• • •
|
|
Additional Skin Findings
|
Rash Image
|
|
PE: Superficial Exam
|
Head to toe exam (abdomen deferred)
|
|
Insert PE Macro Here
|
|
|
|
|
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MDM
|
|
|
MDM Notes
|
|
|
Status
|
Differential Dx
• • •
|
|
Status:
|
Diagnosis:
|
|
Status:
|
Diagnosis:
|
|
DISCHARGE
|
|
|
Discharge pt home
|
Plan Notes
|
|
POC Medications Given
• • •
|
New Free Draw
|
|
Counseling/Educational Material
|
|
|
|
|
|
|
|
|
|
|
|
Clinic Visit CPT CODE***
|
|
