|
Chief complaint
|
|
|
Social History
|
|
|
TOBACCO USE
|
ALCOHOL USE
|
|
SOCIAL HISTORY(FREE-TEXT)
|
FINANCIAL RESOURCES
|
|
EDUCATION
|
PHYSICAL ACTIVITY
|
|
NUTRITION HISTORY
|
STRESS
|
|
SOCIAL ISOLATION AND CONNECTION
|
EXPOSURE TO VIOLENCE
|
|
GENDER IDENTITY
|
SEXUAL ORIENTATION
|
|
PAST MEDICAL HISTORY
|
|
|
MAJOR EVENTS
|
SOCIAL HISTORY
|
|
FAMILY HISTORY
|
|
|
DIAGNOSIS
|
ONSET DATE
|
|
FAMILY HEALTH HISTORY(FREE-TEXT)
|
|
|
Subjective
|
|
|
Subjective
|
|
|
ROS
|
|
|
Constitutional
|
Eyes
|
|
Cardiovascular
|
Respiratory
|
|
Gastrointestinal
|
Genitourinary
|
|
Musculoskeletal
|
Integumentary
|
|
Neurological
|
Psychiatric
|
|
Endocrine
|
Hematological/Lymphatic
|
|
Allergic/Immunological
|
|
|
Objective
|
|
|
General
|
Head
|
|
Eyes
|
Ears
|
|
Nose
|
Throat
|
|
Neck
|
Chest
|
|
Heart
|
Abdomen
|
|
Extremities
|
Peripheral pulses bilaterally
|
|
Musculoskeletal
|
|
|
NEUROLOGICAL EXAM
|
|
|
Mental status
|
Cranial nerve examination
|
|
Sensory examination
|
Motor examination
|
|
Deep tendon reflexes
|
Coordination
|
|
Ambulation
|
Romberg
|
|
Assessment
|
|
|
Diagnoses attached to this encounter:
|
|
|
Plan
|
|
|
Plan
|
|
