VISIT TYPE

WORK COMP

URGENT CARE

VACCINE

NEW

NEW

FOLLOW UP

FOLLOW UP

PROCEDURE

EMERGENCY

JOB DETAILS

Employer

Date of Injury

Work Comp Insurance

Claim #

Job Title

Job Title (If not found in drop-down)

Length of employment

Average hours per week

Other employment?

Comments (including title and dates)

Job requirements at the time of injury

Comments

Lifting / Pushing / Pulling Weight Maximum

Comments

Lost work time?

Last date worked

INTERPRETER

Interpreter (charge per 15m)

Interpreter Name, ID and Company

HPI

INJURY

ILLNESS

PHYSICAL

Parent or guardian present

Name

Pediatrician

Name

Patient's primary concern is

Associated Symptoms

Mechanism

Comments

Location

Comments

Quality

Comments

Severity

Comments

Duration

Comments

Timing

Comments

Context (occurs with...)

Comments

Better with

Comments

Worse with

Comments

History of previous or recurrent infection of the same body part?

History of previous pain, injury or surgery to this body part?

Ongoing treatment?

Exposed to others with similar symptoms?

Flu vaccine given this season?

Recent antibiotic use (3 months)?

History of GI ulcers or bleeding?

Recent travel out of U.S.?

Comments

Additional Work Comp Info

Chemical or toxic exposure?

Comments

Previous occupational injuries?

If Yes (year, body part, side, status)

Pre-existing conditions that could complicate the patient's diagnosis, treatment, and/or rate of recovery?

Comments

Prior acute trauma or cumulative trauma to the affected body part?

Comments

Any ongoing treatment for the prior trauma or exposure?

Comments

Related hobbies / sports complications?

Comments

FEMALE

Female YES

Post-menopausal

Preadolescent

Pregnant?

Breast feeding?

Last menstrual period

OBGYN

Comments

CHANGES TO MEDICAL HISTORY

Changes to medical history since last visit?

Changes include:

ROS REVIEWED

Patient's history and ROS reviewed

PHYSICAL EXAM

VITALS

Vitals

Comments

Dominant Hand

CONSTITUTIONAL

Constitutional WNL

EXAM

Abnormals

Normals

Comments

PSYCHIATRIC

Psychiatric WNL

EXAM

Abnormals

Comments

Normals

Comments

SKIN

Skin WNL

EXAM

Abnormals

Comments

Normals

Comments

HEAD

Head WNL

EXAM

Inspection Abnormals

Inspection Normals

Palpation Abnormals

Palpation Normals

Comments

EYES

EYES WNL

EXAM

Abnormals

Normals

Comments

ENT

ENT WNL

EXAM

Abnormals

Normals

Comments

NECK

Neck WNL

EXAM

Neck Abnormals

Neck Normals

Palpation Abnormals

Palpation Normals

ROM

Comments

LYMPHATICS

Lymphatics WNL

EXAM

Abnormals

Comments

CARDIOVASCULAR / CHEST

Cardiovascular WNL

EXAM

Abnormals

Normals

Comments

LUNGS

Lungs WNL

EXAM

Abnormals

Normals

Lungs Comments

ORTHOPEDIC

View orthopedic exam

LEFT SHOULDER

Left Shoulder WNL

EXAM

Inspection Abnormals

Inspection Normals

Palpation Abnormals

Palpation Normals

Special Tests Abnormals

Special Tests Normals

ROM

Comments

Strength

Comments

RIGHT SHOULDER

Right Shoulder WNL

EXAM

Inspection Abnormals

Inspection Normals

Palpation Abnormals

Palpation Normals

Special Tests Abnormals

Special Tests Normals

ROM

Comments

Strength

Comments

LEFT ELBOW

Left Elbow WNL

EXAM

Inspection Abnormals

Inspection Normals

Palpation Abnormals

Palpation Normals

Special Tests Abnormals

Special Tests Normals

ROM

Comments

Strength

Comments

RIGHT ELBOW

Right Elbow WNL

EXAM

Inspection Abnormals

Inspection Normals

Palpation Abnormals

Palpation Normals

Special Tests Abnormals

Special Tests Normals

ROM

Comments

Strength

Comments

LEFT FOREARM

Left Forearm WNL

EXAM

Inspection Abnormals

Inspection Normals

Palpation Abnormals

Palpation normals

Special Tests Abnormals

Special Tests Normals

ROM

Comments

Strength

Comments

RIGHT FOREARM

Right Forearm WNL

EXAM

Inspection Abnormals

Inspection Normals

Palpation Abnormals

Palpation normals

Special Tests Abnormals

Special Tests Normals

ROM

Comments

Strength

Comments

LEFT WRIST

Left Wrist WNL

EXAM

Inspection Abnormals

Inspection Normals

Palpation Abnormals

Palpation Normals

Special Tests Abnormals

Special Tests Normals

ROM

Comments

Strength

Comments

RIGHT WRIST

Right Wrist WNL

EXAM

Inspection Abnormals

Inspection Normals

Palpation Abnormals

Palpation Normals

Special Tests Abnormals

Special Tests Normals

ROM

Comments

Strength

Comments

LEFT HAND

Left Hand/fingers WNL

EXAM

Inspection Abnormals

Inspection Normals

Palpation Abnormals

Palpation Normals

Special Tests Abnormals

Special Tests Normals

ROM

Comments

Strength

Comments

RIGHT HAND

Right hand WNL

EXAM

Inspection Abnormals

Inspection Normals

Palpation Abnormals

Palpation Normals

Special Tests Abnormals

Special Tests Normals

ROM

Comments

Strength

Comments

LEFT HIP

Left Hip WNL

EXAM

Inspection Abnormals

Inspection Normals

Palpation Abnormals

Palpation Normals

Special Tests Abnomals

Special Tests Normals

ROM

Comments

Strength

Comments

RIGHT HIP

Right Hip WNL

EXAM

Inspection Abnormals

Inspection Normals

Palpation Abnormals

Palpation normal

Special Tests Abnomals

Special Tests Normals

ROM

Comments

Strength

Comments

UPPER LEG LEFT

Upper Leg Left WNL

EXAM

Inspection Abnormal

Inspection Normals

Palpation Abnormals

Palpation Normals

Comments

UPPER LEG RIGHT

Upper Leg Right WNL

EXAM

Inspection Abnormal

Inspection Normal

Palpation Abnormal

Palpation Normal

Comments

LEFT KNEE

Left Knee WNL

EXAM

Inspection Abnormals

Inspection Normals

Palpation Abnormals

Palpation Normals

Special Tests Abnomals

Special Tests Normals

ROM

Comments

Strength

Comments

RIGHT KNEE

Right Knee WNL

EXAM

Inspection Abnormals

Inspection Normals

Palpation Abnormals

Palpation Normals

Special Tests Abnomals

Special Tests Normals

ROM

Comments

Strength

Comments

Other right leg normals

Comments

LOWER LEG LEFT

Lower Leg Left WNL

EXAM

Inspection Abnormal

Inspection Normals

Palpation Abnormals

Palpation Normals

Comments

LOWER LEG RIGHT

Lower Leg Right

EXAM x

Inspection Abnormal

Inspection Normals

Palpation Abnormals

Palpation Normals

Comments

LEFT ANKLE

Left Ankle WNL

EXAM

Inspection Abnormals

Inspection Normals

Palpation Abnormals

Palpation Normals

Special Tests Abnormals

Special Tests Normals

ROM

Comments

Strength

Comments

RIGHT ANKLE

Right Ankle WNL

EXAM

Inspection Abnormals

Inspection Normals

Palpation Abnormals

Palpation Normals

Special Tests Abnormals

Special Tests Normals

ROM

Comments

Strength

Comments

LEFT FOOT

Left foot WNL

EXAM

Inspection Abnormals

Inspection Normals

Palpation Abnormals

Palpation Normals

ROM

Comments

Strength

Comments

RIGHT FOOT

Right Foot WNL

EXAM

Inspection Abnormals

Inspection Normals

Palpation Abnormals

Palpation Normals

ROM

Comments

Strength

Comments

BACK

Back WNL

EXAM

Inspection Abnormals

Inspection Normals

Palpation Abnormals

Palpation Normals

Special Tests Abnormals

Special Tests Normals

ROM

Comments

ABDOMEN / GROIN

Abdomen/Groin WNL

EXAM

Inspection Abnormals

Inspection Normals

Auscultation

Palpation Abnormals

Abdomen/Groin Palpation Normals

Special Tests Abnormals

Special Tests Normals

Comments

NEUROLOGICAL

Sensation WNL

Strength WNL

DTR WNL

Cranial nerves II-XII WNL

Cerebellar Testing WNL

NEURO EXAM

Sensation Abnormals

Sensation Normals

DTR Abnormals

DTR Normals

Cranial Nerves

Comments

Strength

Comments

STUDIES / TESTS / LABS

Studies, tests or labs reviewed

Comments

Point of care test performed

Test Performed

Test result

Comments

Urine Dipstick

Leukocyte

Nitrites

Urobilinogen

Protein

pH

Blood

Specific Gravity

Ketone

Bilirubin

Glucose

Comments

A specimen was sent to the laboratory

Comments

X-rays ordered, visualized and discussed with patient

Preliminary read?

Comments

Patient referred for advanced diagnostics

Comments

Diagnostic studies reviewed

Comments

Prior labs reports reviewed

Comments

Laboratory testing recommended

Comments

ADMINISTERED MEDICATION / VACCINE

Medication #1

Admin charge (vaccine)

Injection charge (non-vaccine)

Administering Staff

Medication

Dose

Route

Site

Manufacturer

Expiration

Lot

Comments

Medication #2

Admin charge (vaccine)

Injection charge (non-vaccine)

Administering Staff

Medication

Dose

Route

Site

Manufacturer

Expiration

Lot

Comments

TETANUS STATUS

Last Tetanus Vaccine

INJURY CAUSATION

Findings consistent with injury reported by patient?

Comments

Current injury causing current symptoms?

Comments

Prior factors contributing to findings?

Comments

Findings produced by natural progression or pre-existing conditions?

Comments

Aggravation of a pre-existing condition?

Comments

Work Relatedness

Comments

Exacerbation or Aggravation?

Comments

MEDICAL DECISION MAKING

Previous medical records reviewed?

Time spent reviewing records (min)

Patient's medical history and co-morbidities considered?

Comments

Prescribed medication(s) drug interactions considered?

Comments

Evaluated multiple complaints/diagnoses/body parts?

Comments

RECHECKS ONLY: Assessed treatment complications (infection, Rx SE, etc)?

Comments

Additional Comments

Comments

PROCEDURES

Procedure performed

Burn care 1st-2nd initial

Description

Ear

Left ear irrigation

Comment

Right ear irrigation

Comment

Bilateral ear irrigation

Comment

Ear Instrumentation unilateral

Comment

Ear instrumentation bilateral

Comment

Eye

Description

Foreign body

Gait training

Description

I&D

Description

Joint aspiration

Description

Joint reduction

Description

Laceration

Description

Laceration repair < 2.5cm simple

Laceration repair 2.6-7.5cm simple

Laceration repair 7.6-12.5cm simple

Laceration repair 12.6-20cm simple

Nail

Description

Trephination

Skin

Description

Wart removal

Description

Destruction wart 1-14

Skin tag removal

Nebulizer treatment

Splinting

Description

Splint (finger) static

Application finger splint

Short arm splint

Suture / staple removal

Description

Trigger point injection

Description

1-2 muscles

3 or more muscles

Injection

Description

Wound care

Description

ASSESSMENT

PSYCHIATRIC

Anxiety

Depression

Bipolar

Suicidal ideation

SKIN

Seborrheic Dermatitis

Atopic Dermatitis

Dermatitis d/t plants

Dermatitis d/t adhesives

Dermatitis d/t metals

Contact dermatitis NOS

Diaper rash

Cancer sore

Coldsore

Herpes penial

Herpes genital male

Herpes vaginal

Shingles

Scabies (non-crusted)

Contact with and (suspected) exposure to pediculosis, acariasis and other infestations

Tinea corporis (body)

Tinea barbae or capitis (head)

Tinea pedis (feet)

Tinea cruris (groin)

Tinea unguim (nail)

Cellulitis of unspecified part of limb

Cellulitis unspecified finger

Irritant contact dermatitis unspecified

Hand Foot Mouth

Swimmer's itch

Plantar wart

Viral wart

Dog bite subsequent

Dog bite initial

Insect bite (nonvenemous) back/pelvis, initial

Insect bite (nonvenemous) back/pelvis, subsequent

Insect bite (nonvenemous) upper arm, initial

Insect bite (nonvenemous) upper arm, subsequent

Insect bite (nonvenemous) lower leg, initial

Insect bite (nonvenemous) lower leg, subsequent

Sebaceous cyst

Seborrheic dermatitis

Scalp laceration, w/out FB, initial

Scalp laceration, w/out FB, subsequent

Laceration left hand, w/out FB, initial

Laceration left hand, w/out FB, subsequent

Laceration right hand, w/out FB, initial

Laceration right hand, w/out FB, subsequent

Suture removal

Candidiasis unspecified

Candidiasis vaginal

Hand foot mouth

Impetigo non-bullous

Impetigo bullous

Milia rubra (heat rash)

Local skin infection

Diabetic skin ulcer

Folliculitis

Dry Skin

Bug infestation (pediculosis, acariasis, others)

HEAD

Tension headache, not intractable

Tension headache, intractable

Migraine without aura, not intractable, without status migrainosus

Migraine with aura, not intractable, without status migrainosus

Post concussive syndrome

EYES

Conjunctivitis d/t adenovirus

Bacterial conjuctivitis left eye

Bacterial conjuctivits of both eyes

Bacterial conjuctivitis right eye

Viral conjunctivitis

Stye right external upper lid

Stye right external lower lid

Stye left external upper lid

Stye left external lower lid

Stye internal, right upper eyelid

Stye internal, right lower eyelid

Stye internal, left upper eyelid

Stye internal, left lower eyelid

Corneal abrasion right, initial

Corneal abrasion right, subsequent

Corneal abrasion left, initial

Corneal abrasion left, subsequent

Edema of eyelid

ENT

Otitis media left serous

Otitis media right serous

Otitis media left suppurative

Otitis media right suppurative

Otitis externa left

Otitis externa right

Maxillary Sinusitis

Frontal Sinusitis

Ethmoidal Sinusitis

Allergic Rhinitis d/t Pollen

Seasonal Rhinitis

Pharyngitis

Strep Throat Group A

Otalgia right ear

Otalgia left ear

Otalgia bilateral

Upper Respiratory Infection

Impacted cerumen bilateral

Impacted cerumen left

Impacted cerumen right

Influenza A with other manifestations

Influenza other (not A) with other manifestations

Thrush

Laryngitis

Mononucleosis

Vertigo