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{{patient}} is a {{age}} {{gender}} who presents for DM2.
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Duration
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HPI
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Home glucose monitoring
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hypoglycemic episodes
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Most recent Hgb A1c
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most recent LDL-C level within 12 months
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DM eye exam
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nephropathy screening
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Foot exam
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New Rx's from other providers
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New medical changes
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Weight change?
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Pneumovax 23 vaccine
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Influenza vaccine
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HYPERTENSION
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Hypertension HPI
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Blood pressure monitoring frequency:
• • •
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Blood pressures
/
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Blood pressure medication side effects
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Blood pressure medication side effects
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Medication compliance
• • •
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Previous blood pressure meds
• • •
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Previous BP meds side effects
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Previous BP meds free text
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Pertinent positives
• • •
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Pertinent positives
• • •
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Additional notes
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New Switch
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New Short Text Field
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Review of systems
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Constitutional (positive)
• • •
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Constitutional (negative)
• • •
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ENT (positive)
• • •
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ENT (negative)
• • •
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Respiratory (positive)
• • •
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Respiratory (negative)
• • •
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Additional
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All systems otherwise negative.
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PHYSICAL EXAM
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REPEAT BP
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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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Neck WNL
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Neck Abnormal
• • •
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Neck 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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MSK WNL
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MSK Abnormal
• • •
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MSK Comments
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Breasts WNL
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Breasts Abnormal
• • •
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Breasts Comments
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Neuro WNL
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Neuro Abnormal
• • •
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Neuro Comments
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Extremities WNL
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Extrem Abnormal
• • •
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Normal foot exam
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Monofilament neuropathy screen
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Extrem Comments
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Insert PE Macro Here
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Diagnosis:
• • •
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Diagnosis:
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Plan
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Plan Notes
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Labs
• • •
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Diabetes Meds
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BP Meds
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Aspirin
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Discharge pt home
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Discharge: Notes
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