|
Chief Complaint
|
R/A
• • •
|
|
Chief Complaint
|
|
|
Chief Complaint (By patient, then, docs notes)
|
* Location
• • •
|
|
|
Vitals
|
|
Height (Inches)
|
Weight (lbs)
|
|
Blood Pressure
/
|
Blood Sugar
/
|
|
|
|
|
|
|
|
History of Present Illness
|
History Of Illness
|
|
Pain Level (1-10)
|
Onset of present condition
|
|
Context
|
Quality
|
|
Duration (present for the past___)
|
* Timing
• • •
|
|
Exacerbation Factors
• • •
|
Improving Factors
• • •
|
|
Ankle Pain
|
Chronology
|
|
Objective
|
|
|
Exams
|
|
|
Normal Skin Temperature
|
Exam Dermatologic
|
|
Normal Skin Turgor
|
Normal Skin Texture
|
|
Exam Musculoskeletal
|
|
|
Full Weight Bearing
|
Muscle Strength
|
|
Exam Neurological
|
|
|
Deformities/Abnormalities
• • •
|
|
|
|
Exam Vasculal:
|
|
Smoker
|
New Yes / No
|
|
Treatment
|
Treatment
|
|
Treatment
• • •
|
Compliant
|
|
|
Non-Compliant
|
|
Injection Administered
|
|
|
Plan
|
|
|
Plan- Patient advised to:
• • •
|
|
|
R/A
• • •
|
|
