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CC:
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HPI
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Location
• • •
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Location Comments
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Quality
• • •
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Quality Comments
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Severity
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Severity Comments
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Duration
• • •
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Duration Comments
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Onset / Timing
• • •
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Onset Comments
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Context
• • •
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Context Comments
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Modifying Factors
• • •
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Modifying Factors Comments
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Associated Symptoms
• • •
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Associated Symptoms Comments
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Previous Treatment
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PAST MEDICAL HISTORY
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Past Medical History
• • •
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Past Medical History Freewrite
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PAST SURGICAL HISTORY
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Past Surgical History
• • •
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Comments
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Social History
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Social History
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Comments
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Alcohol
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History Drug Use
• • •
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Other substances
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Review OF Systems
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General [-]
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General
• • •
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Neck [-]
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Neck
• • •
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Cardiovascular [-]
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Cardiovascular
• • •
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Respiratory [-]
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Respiratory
• • •
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GI [-]
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GI
• • •
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Periph. Vasc. [-]
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Periph. Vasc.
• • •
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MSK [-]
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MSK
• • •
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Neurological [-]
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Neurological
• • •
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Endocrine [-]
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Endocrine
• • •
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Psychiatric [-]
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Psychiatric
• • •
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Physical Exam
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General WNL
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General Abnormal
• • •
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Skin WNL
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Skin Abnormal
• • •
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Neck WNL
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Neck Abnormal
• • •
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Cardiovascular WNL
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Cardiovascular Abnormal
• • •
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Lungs WNL
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Lungs Abnormal
• • •
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Abdomen WNL
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Abdomen Abnormal
• • •
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MSK WNL
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MSK Abnormal
• • •
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Spine Image
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Neuro WNL
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Neuro Abnormal
• • •
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Extremities WNL
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Extrem Abnormal
• • •
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Assessment
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Assessment
• • •
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Diagnosis subject to change
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Plan
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Face Time
• • •
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Radiology
• • •
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Labs
• • •
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Pharmacotherapeutics
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Pharmacotherapeutics Comments
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Opioids Prescribed
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Medication Prescribed
• • •
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PT Recommendation Comments
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Short Acting Opioids
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Short Acting Opioid SIG
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Long Acting Opioid SIG
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Long Acting Opioid SIG
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Non-opioid Meds Comments
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Non Opioid SIG
• • •
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PT Recommendations
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Treat and Goals
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Referrals Advised
• • •
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General Instructions
• • •
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Weight Loss Advised
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Light Exercise/Activity Level Advised
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Therapies/Treatments Advised
• • •
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Follow Up?
• • •
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Violated Narcotic Agreement(Discharge)
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Discharge
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Urine Drug Screen
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Reason for Test
• • •
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Present pain meds
• • •
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OXY
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THC
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COC
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OPI
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MET
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MDMA
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Compliance with meds treatmetn
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Sent to Lab
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Comments
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