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Visit/encounter type:
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Encounter notes:
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HPI:
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History of Present Ilness
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HPI Notes:
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Location:
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Quality
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Severity
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Duration
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Timing
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Context
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Modifying factors
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Associated signs & symptoms
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Past History:
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Past History
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Past Medical History
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History of:
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History of:
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Surgical History
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Surgical history:
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Surgical history notes:
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Family History
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Family history
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Family history comments:
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Social History
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Marital status:
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Marital status notes:
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Education
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Education notes:
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Occupation:
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Occupation notes:
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Alcohol abuse history:
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Alcohol abuse comments:
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Substance abuse history:
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Substance abuse history notes:
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Functional Status Assessed:
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Functional Status
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Functional status:
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Functional status comments:
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Smoking history:
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Smoking History
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Smoking status:
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Smoking status notes:
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Smoking frequency:
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Smoking frequency notes:
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Smoking start and end date:
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ROS:
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Review of Systems
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ROS Notes:
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Constitutional:
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Constitutional comments:
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Cardiovascular:
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Cardiovascular comments:
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Respiratory:
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Respiratory comments:
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Gastrointestinal:
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Gastrointestinal comments:
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Genitourinary:
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Genitourinary comments:
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Musculoskeletal:
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Musculoskeletal comments:
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Integumentary (Skin and/or Breasts):
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Integumentary comments:
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Neurological:
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Neurological comments:
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Psychiatric:
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Psychiatric comments:
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HEENT:
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HEENT Comments:
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Physical Exam:
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Physical Exam
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Physical Exam Notes:
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Constitutional:
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Constitutional comments:
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HEENT
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HEENT Comments:
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Neck:
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Neck comments:
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Cardiovascular:
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Cardiovascular comments:
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Respiratory:
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Respiratory comments:
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Gastrointestinal (abdomen):
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Gastrointestinal comments:
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Genitourinary
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Genitourinary comments:
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Integumentary:
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Integumentary comments:
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Extremeties:
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Extremeties comments:
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Neurological/Psychiatric:
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Neurological/Psychiatric comments:
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Assessment:
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Assessment
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Assessment:
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Care Plan
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Care Plan:
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Referrals
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Referrals
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Referral to HH:
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Referral to HH for:
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HH Notes:
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Referral to specialist:
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Specialist referral notes:
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Orders
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Orders
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Order labs:
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Lab order notes:
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Order radiology:
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Order/refill the following medications:
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Patient instructions were given:
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Follow Up:
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Schedule follow up appointment:
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F/u appt notes:
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Care plan notes:
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Advanced Care Planning:
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Advanced Care Planning
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Carried out:
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Other:
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with:
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Other:
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POLST code status:
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Additional notes:
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Duration of ACP:
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Additional comments:
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Initial CCM Visit Completed:
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Chronic Care Management
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CCM Initial visit:
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Discussed CCM with:
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CCM discussion notes:
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Best way to contact pt for CCM:
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Contact info notes:
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Consented patient for telehealth:
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Telehealth consent
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Telehealth is performed via:
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Telehealth notes:
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COVID-19 Screening completed:
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COVID-19 Education & Screening
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COVID-19 Screening:
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Has PT received COVID-19 vaccine?
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When does the pt plan to get covid-19 vaccine?
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Type of vaccine received:
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How many doses received?
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Date vaccine received:
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Candidate for Dr. Kumo?
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Dr. Kumo
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Plan for Dr. Kumo RPM
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Patient received:
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Dr. Kumo Notes
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Time spent on visit:
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