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Past Medical History
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NKDA
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Allergies
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Past Family History/Social
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Diabetes
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Cancer
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Heart attack
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Stroke
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NO Tobacco
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Tobacco Use
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Alcohol
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Surgical History
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Medications
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No Medication List
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Review Of Systems
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General NORMAL
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General SPECIFIC
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Neuro NORMAL
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Neuro SPECIFIC
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Cardio NORMAL
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Cardio SPECIFIC
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Resp NORMAL
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Resp SPECIFIC
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Chief complaint
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Comment
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HPI
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Fungal nails
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Calluses
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Neuropathy symptoms
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Digital contractures
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Mobility Status
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Facility Initiated
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Care at facility:
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Lower Extremity Exam - Vascular
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NORMAL Vascular
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Right DP pulse
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Right PT pulse
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Left DP pulse
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Left PT pulse
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Edema RIGHT
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Edema LEFT
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No Varicose
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Varicose
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Hair
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No Hair
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Skin Normal
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Atrophic
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Temp Normal
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Temp Cold
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Comment
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Derm
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NORMAL Derm
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Toenails:
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are
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Onycho PAIN
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HPK Right
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HPK Left
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No Maceration
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Maceration
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No Xerosis
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Xerosis
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Tinea Pedis
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No Wound
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Wound
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Wound Depth
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Location
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Measuring
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Base
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With
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With
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Comment
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Neuro
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NORMAL Neuro
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LOPS Right
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LOPS Left
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Tinels RIGHT
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Tinels LEFT
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LOPS on RIGHT to dermatome
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LOPS on LEFT to dermatome
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Comment
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MSK
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NORMAL MSK
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HAMMERTOE Right
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HAMMERTOE Left
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BUNION Right
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BUNION Left
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Strength Right
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Strength Left
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No TTP
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Ankle: STJ: MTP Fine
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Pes Planus
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Toe Pain
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Pes Cavus
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Foot Pain
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Fasciitis Right
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Fasciitis Left
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Comment
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Plan
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E+T options
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Counseling
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Nails
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HPK
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Keratoderma
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Clotrimazole soln
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Benign lesion Left
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Clotrimazole cream
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Benign Lesion Right
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Urea
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Subungual Hematoma- Left
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Lotion
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Subungual Hematoma- Right
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Voltaren
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I&D - Left
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Prescription given for
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I&D- Right
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Cont. Compression
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Rec Compression
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Rec Gabapentin
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PCP DM Manage
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Debride SubQ
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Debride Muscle
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AVULSION Partial
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AVULSION Complete
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Dressed wound with
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Nurse Wound Care
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Vascular Consult
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Toe Sleeves
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Bunion Splint
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E&M Support
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Custom Plan
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Follow up
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Time spent with patient
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