|
Chief Complaint
|
History of Present Illness:
|
|
Problem List
|
|
|
Historian
• • •
|
Reviewed
• • •
|
|
PMH
• • •
|
PMH
|
|
PSH
• • •
|
PSH
|
|
FH
• • •
|
Other Family History
|
|
Social History
• • •
|
Misc social
|
|
Recent Hospitalizations:
|
|
|
BRIEF ROS
|
|
|
General [-] ALL NORMAL
|
General Normals
• • •
|
|
Abnormal General
• • •
|
|
|
Respiratory [-] ALL NORMAL
|
Respiratory Normals
• • •
|
|
Respiratory Abnormals
• • •
|
|
|
Cardiovascular [-] ALL NORMAL
|
Cardiovascular Normals
• • •
|
|
Cardiovascular Abnormal
• • •
|
|
|
GI [-] ALL NORMAL
|
GI Normals
• • •
|
|
GI Abnormals
• • •
|
|
|
Urinary [-] ALL NORMAL
|
Urinary Normals
• • •
|
|
Urinary Abnormal
• • •
|
|
|
Neurological [-] ALL NORMAL
|
Neuro Normals
• • •
|
|
Neuro Abnormal
• • •
|
|
|
|
|
|
Physicial Exam
|
|
|
General ALL NORMAL- WNWD NAD
|
|
|
General description
• • •
|
General Normals
• • •
|
|
General Abnormals
• • •
|
General Comments
|
|
HEAD ALL NORMAL
|
HEAD Normals
• • •
|
|
HEAD Abnormal
• • •
|
HEAD Comments
|
|
EENT Exam
|
|
|
EYES ALL NORMAL
|
EYES Normals
• • •
|
|
EYES Abnormals
• • •
|
EYES Comments
|
|
EARS ALL NORMAL
|
EARS Normals
• • •
|
|
EARS Abnormal
• • •
|
EAR Comments
|
|
NOSE ALL NORMAL
|
NOSE Normals
• • •
|
|
NOSE Abnormals
• • •
|
NOSE Comments
|
|
Lips, Teeth, and Gums ALL NORMAL
|
Lips, Teeth, and Gums Normals
• • •
|
|
Lips, Teeth, and Gums Abnormals
• • •
|
Lips, Teeth, and Gums Comments
|
|
Oropharynx ALL NORMAL
|
Oropharynx Normals
• • •
|
|
Oropharynx Abnormals
• • •
|
Oropharynx Comments
|
|
Neck ALL NORMAL
|
Neck Normals
• • •
|
|
Neck Abnormal
• • •
|
Neck Comments
|
|
Lungs ALL NORMAL
|
Lungs Normal
• • •
|
|
Lungs Abnormal
• • •
|
Lungs Comments
|
|
Cardiovascular ALL NORMAL
|
Cardiovascular Normals
• • •
|
|
Cardiovascular Abnormal
• • •
|
Cardiovascular comments
|
|
Abdomen ALL NORMAL
|
Abdomen Normal
• • •
|
|
Abdomen Abnormal(s)
• • •
|
Abdomen Comments
|
|
Extremities ALL NORMAL
|
Extremities Normal
• • •
|
|
Extrem Abnormal
• • •
|
Extrem Comments
|
|
Skin ALL NORMAL
|
Skin Normals
• • •
|
|
Skin Abnormal
• • •
|
Skin Comments
|
|
Neuro NORMAL
|
Neuro Normals
• • •
|
|
Neuro Abnormal
• • •
|
Neuro Comments
|
|
|
|
|
MSK Extremity EXAM
|
|
|
Upper Extremities ALL NORMAL
|
Upper Extremities Normal
• • •
|
|
Upper Extremities Abnormal
• • •
|
Upper Extremities Comments
|
|
|
|
|
Lower Extremities ALL NORMAL
|
Lower Extremities Normal
• • •
|
|
Lower Extremities Abnormal
• • •
|
Lower Extremities Comments
|
|
|
|
|
Musculoskeletal Exam ALL NORMAL
|
Musculoskeletal Exam Normal
• • •
|
|
Extremity Muscles Abnormal
• • •
|
Extremity Muscle Comments
|
|
|
|
|
Assessment + Plan
|
|
|
|
|
|
Labs
• • •
|
Lab Comments
|
|
Radiology
• • •
|
Radiology Comments
|
|
Referrals
|
Referral Comments
|
