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HPI
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The patient presents with urinary concerns:
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Hematuria
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Flank pain
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Retention
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First Febrile UTI
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Hx of abnormal ultrasound
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Hx of Recurrent UTI
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+ (ROI)
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- (ROI)
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PHYSICAL EXAM
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Patient reported vital signs
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General WNL
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General Abnormal
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General Comments
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HEENT WNL
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HEENT Abnormal
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HEENT Comments
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Skin WNL
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Skin Lesion
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Skin Comments
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Cardiovascular WNL
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Cardiovascular Abnormal
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Cardiovascular Comments
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Lungs WNL
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Lungs Abnormal
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Lungs Comments
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Abdomen WNL
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Abdomen Abnormal
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Abdomen Comments
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Extremities WNL
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Extrem Abnormal
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Extrem Comments
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Neurologic WNL
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Neurologic ABNL
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ASSESSMENT
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Diagnosis Codes
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Assessment
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Assessment free text
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PLAN
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Plan
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Rx for Children 2 months - 12 years old
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Rx for Children over 12 years old
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Rx for mild pyelonephritis
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Plan
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Patient's weight in kg
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FOLLOW UP
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Follow up free text
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