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Reviewed Past Medical History?
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Reviewed Home Medications & Alergies?
|
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LMP - If applicable
|
|
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Review of Systems
|
|
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Review of Systems
|
General
• • •
|
|
Skin WNL
|
HEENT WNL
|
|
Neck WNL
|
Cardiovascular WNL
|
|
Respiratory WNL
|
Peripheral Vascular WNL
|
|
Gastrointestinal WNL
|
Musculoskeletal WNL
|
|
Endocrine WNL
|
Neurologic WNL
|
|
Genitourinary WNL
|
Psychiatric WNL
|
|
ROS Notes
|
|
|
|
|
|
Telemedicine Physical Exam
|
|
|
Alert & Oriented x3, Normal LOC, Nourished, Normal Affect, No Apparent Distress
|
|
|
Skin WNL - No Rash, Lumps, Sores, or Discoloration
|
Skin Exam Notes
|
|
HEENT WNL - Normocephalic. No Discharge From Eyes/Ears/Nose, No Discoloration of Sclera, No Mouth Sores, No Swelling
|
HEENT Exam Notes
|
|
Musculoskeletal WNL - No Deformities, Stiffness, Swelling, or Redness. Normal Range of Motion.
|
Musculoskeletal Exam Notes
|
|
Respiratory WNL - No Accessory Muscle Use, Cough, Dyspnea, or Audible Wheezing
|
Respiratory Exam Notes
|
|
Neurologic WNL - No Confusion, Paralysis, Involuntary Movement, or Cranial Nerve Deficits. Normal Coordination
|
Neurological Exam Notes
|
|
Psychiatric WNL - No Suicidal or Homicidal Ideations, Normal Mood/Affect, Normal Behavior
|
Psychiatric Exam Notes
|
|
|
|
|
Physical Exam Notes
|
|
|
|
|
|
Discharge Summary
|
|
|
Diagnosis
|
|
|
Plan
|
Referred Out
• • •
|
|
Work/School Note Details
|
|
|
|
|
|
|
|
|
BILLING
|
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