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Provider Name
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Additional Person(s) Spoken to (free text)
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Method of Communication
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RMI Topside Physician(s) Consulted (select all that apply)
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Have you updated Body System Involved to "Follow Up" in the SUBJECTIVE section? Yes / No ------->
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History of Present Illness OR Injury (HPI) / Follow Report
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Case/Project Number or Name (if required)
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Site or Vessel Name (if required)
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Employer
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Objective
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Physical Exam (Focused)
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Wound/Injury/Rash Photos Uploaded
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Tests Results Uploaded into Documents
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Labs, Images & Results (free text)
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Diagnosis
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Diagnosis (free text)
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Treatment and Disposition
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Medical Decision Making (document your thought process)
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Employer Can Accommodate the Patients Condition Yes / No
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Treatment/Clinic Course (Free text)
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Oral Meds Given & Consumed During Visit:
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Discharge Plan (patient education statement embedded)
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Patient Education
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Medications Discharged with In-hand (dispensed)
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RXs (paper/phone) given for Pharmacy
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Additional Instructions/Education (Free Text)
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Topside Orders
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Work Status (Required Field)
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Work/Duty Status (indicate in ALL patients)
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Safety/Management Notified
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Follow up (Required Field)
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Follow Up (required field)
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Follow Up or Referral Instructions
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