|
CC:
|
|
|
HPI
|
|
|
Current Pain Level
/
|
Average Pain Level
/
|
|
Worst Pain Level
/
|
|
|
General WNL
|
General Abnormal
• • •
|
|
Skin WNL
|
Skin Comments
|
|
Cardiovascular WNL
|
Cardiovascular Abnormal
• • •
|
|
Lungs WNL
|
Lungs Abnormal
• • •
|
|
Neuro WNL
|
Neuro Abnormal
• • •
|
|
MSK [-]
|
MSK
• • •
|
|
Extremities WNL
|
Extrem Abnormal
• • •
|
|
PMP Checked
|
|
|
Urine Toxicology Screen Performed
|
Specimen read by M.D.?
|
|
Valid Urine Toxicology Screen?
|
Drugs Present on Toxicology Screen
• • •
|
|
Last Urine Drug Screen (Date / / )
|
|
|
Therapies/Treatments Advised
• • •
|
Activity Instructions
• • •
|
|
Light Exercise/Activity Level Advised
|
Treat and Goals
|
|
Assessment
• • •
|
|
|
Referrals Advised
• • •
|
Labs
• • •
|
|
Non Opioid SIG
• • •
|
Radiology
• • •
|
|
Opioids Prescribed
|
Violated Narcotic Agreement(Discharge)
|
|
Diagnosis subject to change
|
|
|
Short Acting Opioids
|
Short Acting Opioid SIG
|
|
Long acting opioids
|
Long Acting Opioid SIG
|
|
Face Time
• • •
|
Follow Up?
• • •
|
|
General Instructions
• • •
|
|
