|
CDCR #
|
|
|
Chief Complaint
|
|
|
Patient Consent
|
|
|
History of Present Illness
|
|
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Allergies
|
|
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Current Medications List
|
|
|
Past Medical History
|
|
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Social History
|
|
|
Family History
|
|
|
Physical Examination
|
|
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General WNL
|
General Abnormal
• • •
|
|
General Comments
|
|
|
HEENT WNL
|
HEENT Abnormal
• • •
|
|
HEENT Comments
|
|
|
Skin WNL
|
Skin Lesion
|
|
Skin Comments
|
|
|
Neck WNL
|
Neck Abnormal
• • •
|
|
Neck Comments
|
|
|
Cardiovascular WNL
|
Cardiovascular Abnormal
• • •
|
|
Cardiovascular Comments
|
|
|
Lungs WNL
|
Lungs Abnormal
• • •
|
|
Lungs Comments
|
|
|
Abdomen WNL
|
Abdomen Abnormal
• • •
|
|
Abdomen Comments
|
|
|
MSK WNL
|
MSK Abnormal
• • •
|
|
MSK Comments
|
|
|
Breasts WNL
|
Breasts Abnormal
• • •
|
|
Breasts Comments
|
|
|
Neuro WNL
|
Neuro Abnormal
• • •
|
|
Neuro Comments
|
|
|
Extremities WNL
|
Extrem Abnormal
• • •
|
|
Extrem Comments
|
|
|
LABS
|
|
|
Lab Data
|
|
|
ASSESSMENT & PLAN
|
|
|
Assessment & Plan
|
|
|
Smoking Cessation Counseling
|
|
|
Time Spent
|
|
