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Appointment visit accompanied by,
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GIVEN COVID 19 PANDEMIC, TODAYS ENCOUNTER
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INS-Patient /parent gave verbal consent
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Covid 19 creening
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REASON FOR VISIT
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HISTORY OF PRESENT ILLNESS
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HPI
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Additional comments
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LOCATION
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SYMPTOMS
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DURATION
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Severity of symptoms
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Frequency comments
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Care provided prior to appointment includes
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TREATMENT
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Additional concerns /caregiver comments (free text)
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Relevant PMH / FH
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Flu shot - Yes / No
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SOCIAL HISTORY
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Current Medications
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HPI PMH, FH ,SH MEDS REVIEWED
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ROS negative
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ROS - GENERAL
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ROS PSYCH
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ROS DERM
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ROS ENT
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ROS CV /PULM
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ROS GI
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ROS NEURO
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PHYSICIAN PHYSICAL EXAM
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Vital Signs
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Normal exam
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Addn PE finding
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General
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General Comments
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Skin
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HEENT Comments
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Eyes Nos
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Nasal Exam
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LEFT EAR
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RIGHT EAR
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THROAT AND TONSIL SIZE /NECK
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NECK
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Cardiovascular WNL
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CV
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Lungs WNL
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Lung exam
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Lungs Abnormal
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Abd
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Abdominal exam
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GU
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Extremities
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Neuro
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Normal exam except pharyngitis
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Normal exam except flu like appearance uri /pharyngitis
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Normal exam except uri /pharyngitis /ROM
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Normal exam except uri /pharyngitis /LOM
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Normal exam except uri /pharyngitis /BOM
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Normal exam except uri /pharyngitis /conjunctivits
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Normal exam w skin abn (SKIN in free comment )
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Normal exam except allergy /atopy exam findings
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Normal exam except uri /pharyngitis/lung abn
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OFFICE TEST/PROCEDURES PERFORMED AND INTERPRETED BY PHYSICIAN;
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NEBULIZER TREATMENT
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Evaluation after albuterol neb
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Urine results
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A/P incc 98960 EDUC TRAINING FOR PT SELF MANAGEMENT
• • •
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A/P
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PCWAS
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Allergic Rhinitis //Asthma
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Flu inst
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GE Inst
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Dysfunctional sleep patterns
• • •
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Headaches
• • •
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Bronchiolitis instructions
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New Short Text Field
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TOBACCO COUNSELING
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addn text
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Child is seeing Dr. Feth today for
• • •
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duplicate A/P - Patient instructions
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Frequency
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