SUBJECTIVE

DOS MM/DD/YYYY

Patient status

Was the patient referred?

Reason for visit

Reason4visitFreeTxt

problem location

ProblemLocationFreeText

related symptoms

Aggravated/ made worse by

Symptoms worse @ Time of day

Duration

Severity of sx

Sx Status - improved/worse?

Treatments tried

Did the tx make cc better/worse?

TreatmentsTriedFreeTxt

+ / - hx of skin ca

skin ca type

+ / - Fam hx of Melanoma

Sun Burns/ Exposure/ Tanning

Contributes to hx + historian

HospStat(autopop)DoNotChange

People present

Anticoagulants?

Allergic to Lidocaine?

PlaceOfService(AutoPop)

Where in residence does visit take place?

Homebound Status (ON)

0Patient Premedicated?

0Premed types

Scribe for Telehealth

0Rendering Provider

0Supervising Provider

Notes from Intake

1Additional Notes

1LINE________________________________

1Established Follow Up

1###Todays DOS MM/DD/YYYY

1###Reason for visit

1###FollowUp FreeText

PlaceOfService(AutoPop)

1###Where in residence?

Homebound Status (ON)

HospStat(autopop)DoNotChange

1Patient Premedicated?

1Premed types

1Scribe for Telehealth

1People present

1###Rendering Provider

1Supervising Provider

2LINE________________________________

2Established Follow Up

2###Enter Todays DOS- MM/DD/YYYY

2###Reason for visit

2###FollowUp FreeText

PlaceOfService(AutoPop)

2###Where in residence

2Homebound Status (ON)

HospStat(autopop)DoNotChange

2Patient Premedicated?

2Premed types

2Scribe for Telehealth

2People present

2###Rendering Provider

2Supervising Provider

3LINE________________________________

3Established Follow Up

3Enter Todays DOS - MM/DD/YYYY

3Reason for visit

3FollowUp FreeText

PlaceOfService(AutoPop)

3Where in residence does visit take place?

3Homebound Status (ON)

HospStat(autopop)DoNotChange

3Patient Premedicated?

3Premed types

3Scribe for Telehealth

3People present

3Rendering Provider

3Supervising Provider

4LINE________________________________

4Established Follow Up

4Enter Todays DOS

4Reason for visit

4FollowUp FreeText

PlaceOfService(AutoPop)

4Where in residence does visit take place?

4Homebound Status (ON)

HospStat(autopop)DoNotChange

4Patient Premedicated?

4Premed types

4Scribe for Telehealth

4People present

4Rendering Provider

4Supervising Provider

5LINE________________________________

5Established Follow Up

5Enter Todays DOS - MM/DD/YYYY

5Reason for visit

5FollowUp FreeText

PlaceOfService(AutoPop)

5Where in residence does visit take place?

5Homebound Status (ON)

HospStat(autopop)DoNotChange

5Patient Premedicated?

5Premed types

5Scribe for Telehealth

5People present

5Rendering Provider

5Supervising Provider

6LINE________________________________

6Established Follow Up

6Enter Todays DOS - MM/DD/YYYY

6Reason for visit

6FollowUp FreeText

PlaceOfService(AutoPop)

6Where in residence does visit take place?

6Homebound Status (ON)

HospStat(autopop)DoNotChange

6Patient Premedicated?

6Premed types

6Scribe for Telehealth

6People present

6Rendering Provider

6Supervising Provider

7LINE________________________________

7Established Follow Up

7Enter Todays DOS - MM/DD/YYYY

7Reason for visit

7FollowUp FreeText

PlaceOfService(AutoPop)

7Where in residence does visit take place?

7Homebound Status (ON)

HospStat(autopop)DoNotChange

7Patient Premedicated?

7Premed types

7Scribe for Telehealth

7People present

7Rendering Provider

7Supervising Provider

8LINE________________________________

8Established Follow Up

8Enter Todays DOS - MM/DD/YYYY

8Reason for visit

8FollowUp FreeText

PlaceOfService(AutoPop)

8Where in residence does visit take place?

8Homebound Status (ON)

HospStat(autopop)DoNotChange

8Patient Premedicated?

8Premed types

8Scribe for Telehealth

8People present

8Rendering Provider

8Supervising Provider

9LINE________________________________

9Established Follow Up

9Enter Todays DOS - MM/DD/YYYY

9Reason for visit

9FollowUp FreeText

PlaceOfService(AutoPop)

9Where in residence does visit take place?

9Homebound Status (ON)

HospStat(autopop)DoNotChange

9Patient Premedicated?

9Premed types

9Scribe for Telehealth

9People present

9Rendering Provider

9Supervising Provider

ADDL FUs1

10LINE________________________________

10Established Follow Up

10Enter Todays DOS - MM/DD/YYYY

10Reason for visit

10FollowUp FreeText

PlaceOfService(AutoPop)

10Where in residence does visit take place?

10Homebound Status (ON)

HospStat(autopop)DoNotChange

10Patient Premedicated?

10Premed types

10Scribe for Telehealth

10People present

10Rendering Provider

10Supervising Provider

11LINE________________________________

11Established Follow Up

11Enter Todays DOS - MM/DD/YYYY

11Reason for visit

11FollowUp FreeText

PlaceOfService(AutoPop)

11Where in residence does visit take place?

11Homebound Status (ON)

HospStat(autopop)DoNotChange

11Patient Premedicated?

11Premed types

11Scribe for Telehealth

11People present

11Rendering Provider

11Supervising Provider

12LINE________________________________

12Established Follow Up

12Enter Todays DOS - MM/DD/YYYY

12Reason for visit

12FollowUp FreeText

PlaceOfService(AutoPop)

12Where in residence does visit take place?

12Homebound Status (ON)

HospStat(autopop)DoNotChange

12Patient Premedicated?

12Premed types

12Scribe for Telehealth

12People present

12Rendering Provider

12Supervising Provider

13LINE________________________________

13Established Follow Up

13Enter Todays DOS - MM/DD/YYYY

13Reason for visit

13FollowUp FreeText

PlaceOfService(AutoPop)

13Where in residence does visit take place?

13Homebound Status (ON)

HospStat(autopop)DoNotChange

13Patient Premedicated?

13Premed types

13Scribe for Telehealth

13People present

13Rendering Provider

13Supervising Provider

14LINE________________________________

14Established Follow Up

14Todays DOS MM/DD/YYYY

14Reason for visit

14FollowUp FreeText

PlaceOfService(AutoPop)

14Where in residence does visit take place?

14Homebound Status (ON)

HospStat(autopop)DoNotChange

14Patient Premedicated?

14Premed types

14Scribe for Telehealth

14People present

14Rendering Provider

14Supervising Provider

15LINE________________________________

15Established Follow Up

15Enter Todays DOS- MM/DD/YYYY

15Reason for visit

15FollowUp FreeText

PlaceOfService(AutoPop)

15Where in residence does visit take place?

15Homebound Status (ON)

HospStat(autopop)DoNotChange

15Patient Premedicated?

15Premed types

15Scribe for Telehealth

15People present

15Rendering Provider

15Supervising Provider

16LINE________________________________

16Established Follow Up

16Enter Todays DOS - MM/DD/YYYY

16Reason for visit

16FollowUp FreeText

PlaceOfService(AutoPop)

16Where in residence does visit take place?

16Homebound Status (ON)

HospStat(autopop)DoNotChange

16Patient Premedicated?

16Premed types

16Scribe for Telehealth

16People present

16Rendering Provider

16Supervising Provider

17LINE________________________________

17Established Follow Up

17Enter Todays DOS

17Reason for visit

17FollowUp FreeText

PlaceOfService(AutoPop)

17Where in residence does visit take place?

17Homebound Status (ON)

HospStat(autopop)DoNotChange

17Patient Premedicated?

17Premed types

17Scribe for Telehealth

17People present

17Rendering Provider

17Supervising Provider

ADDL FUs2

18LINE________________________________

18Established Follow Up

18Enter Todays DOS - MM/DD/YYYY

18Reason for visit

18FollowUp FreeText

PlaceOfService(AutoPop)

18Where in residence does visit take place?

18Homebound Status (ON)

HospStat(autopop)DoNotChange

18Patient Premedicated?

18Premed types

18Scribe for Telehealth

18People present

18Rendering Provider

18Supervising Provider

19LINE________________________________

19Established Follow Up

19Enter Todays DOS - MM/DD/YYYY

19Reason for visit

19FollowUp FreeText

PlaceOfService(AutoPop)

19Where in residence does visit take place?

19Homebound Status (ON)

HospStat(autopop)DoNotChange

19Patient Premedicated?

19Premed types

19Scribe for Telehealth

19People present

19Rendering Provider

19Supervising Provider

20LINE________________________________

20Established Follow Up

20Enter Todays DOS - MM/DD/YYYY

20Reason for visit

20FollowUp FreeText

PlaceOfService(AutoPop)

20Where in residence does visit take place?

20Homebound Status (ON)

HospStat(autopop)DoNotChange

20Patient Premedicated?

20Premed types

20Scribe for Telehealth

20People present

20Rendering Provider

20Supervising Provider

21LINE________________________________

21Established Follow Up

21Enter Todays DOS - MM/DD/YYYY

21Reason for visit

21FollowUp FreeText

PlaceOfService(AutoPop)

21Where in residence does visit take place?

21Homebound Status (ON)

HospStat(autopop)DoNotChange

21Patient Premedicated?

21Premed types

21Scribe for Telehealth

21People present

21Rendering Provider

21Supervising Provider

22LINE________________________________

22Established Follow Up

22Enter Todays DOS - MM/DD/YYYY

22Reason for visit

22FollowUp FreeText

PlaceOfService(AutoPop)

22Where in residence does visit take place?

22Homebound Status (ON)

HospStat(autopop)DoNotChange

22Patient Premedicated?

22Premed types

22Scribe for Telehealth

22People present

22Rendering Provider

22Supervising Provider

23LINE________________________________

23Established Follow Up

23Enter Todays DOS - MM/DD/YYYY

23Reason for visit

23FollowUp FreeText

PlaceOfService(AutoPop)

23Where in residence does visit take place?

23Homebound Status (ON)

HospStat(autopop)DoNotChange

23Patient Premedicated?

23Premed types

23Scribe for Telehealth

23People present

23Rendering Provider

23Supervising Provider

24LINE________________________________

24Established Follow Up

24Enter Todays DOS - MM/DD/YYYY

24Reason for visit

24FollowUp FreeText

PlaceOfService(AutoPop)

24Where in residence does visit take place?

24Homebound Status (ON)

HospStat(autopop)DoNotChange

24Patient Premedicated?

24Premed types

24Scribe for Telehealth

24People present

24Rendering Provider

24Supervising Provider

25LINE________________________________

25Established Follow Up

25Enter Todays DOS - MM/DD/YYYY

25Reason for visit

PlaceOfService(AutoPop)

25FollowUp FreeText

25Where in residence does visit take place?

HospStat(autopop)DoNotChange

25Patient Premedicated?

25Premed types

25Scribe for Telehealth

25People present

25Rendering Provider

25Supervising Provider

26LINE________________________________

26Established Follow Up

26Enter Todays DOS - MM/DD/YYYY

26Reason for visit

26FollowUp FreeText

PlaceOfService(AutoPop)

26Where in residence does visit take place?

Homebound Status (ON)

HospStat(autopop)DoNotChange

26Patient Premedicated?

26Premed types

26Scribe for Telehealth

26People present

26Rendering Provider

26Supervising Provider

ADDL FUs3

27LINE________________________________

27Established Follow Up

17Enter Todays DOS

17Reason for visit

17FollowUp FreeText

PlaceOfService(AutoPop)

17Where in residence does visit take place?

17Homebound Status (ON)

HospStat(autopop)DoNotChange

17Patient Premedicated?

17Premed types

17Scribe for Telehealth

17People present

17Rendering Provider

17Supervising Provider

28LINE________________________________

28Established Follow Up

18Enter Todays DOS - MM/DD/YYYY

18Reason for visit

18FollowUp FreeText

PlaceOfService(AutoPop)

18Where in residence does visit take place?

18Homebound Status (ON)

HospStat(autopop)DoNotChange

18Patient Premedicated?

18Premed types

18Scribe for Telehealth

18People present

18Rendering Provider

18Supervising Provider

29LINE________________________________

29Established Follow Up

19Enter Todays DOS - MM/DD/YYYY

19Reason for visit

19FollowUp FreeText

PlaceOfService(AutoPop)

19Where in residence does visit take place?

19Homebound Status (ON)

HospStat(autopop)DoNotChange

19Patient Premedicated?

19Premed types

19Scribe for Telehealth

19People present

19Rendering Provider

19Supervising Provider

30LINE________________________________

30Established Follow Up

20Enter Todays DOS - MM/DD/YYYY

20Reason for visit

20FollowUp FreeText

PlaceOfService(AutoPop)

20Where in residence does visit take place?

20Homebound Status (ON)

20Rendering Provider

20Supervising Provider

31LINE________________________________

31Established Follow Up

21Enter Todays DOS - MM/DD/YYYY

21Reason for visit

21FollowUp FreeText

PlaceOfService(AutoPop)

21Where in residence does visit take place?

21Homebound Status (ON)

HospStat(autopop)DoNotChange

21Patient Premedicated?

21Premed types

21Scribe for Telehealth

21People present

21Rendering Provider

21Supervising Provider

32LINE________________________________

32Established Follow Up

22Enter Todays DOS - MM/DD/YYYY

22Reason for visit

22FollowUp FreeText

PlaceOfService(AutoPop)

22Where in residence does visit take place?

22Homebound Status (ON)

HospStat(autopop)DoNotChange

22Patient Premedicated?

22Premed types

22Scribe for Telehealth

22People present

22Rendering Provider

22Supervising Provider

33LINE________________________________

33Established Follow Up

23Enter Todays DOS - MM/DD/YYYY

23Reason for visit

23FollowUp FreeText

PlaceOfService(AutoPop)

23Where in residence does visit take place?

23Homebound Status (ON)

HospStat(autopop)DoNotChange

23Patient Premedicated?

23Premed types

23Scribe for Telehealth

23People present

23Rendering Provider

23Supervising Provider

34LINE________________________________

34Established Follow Up

24Enter Todays DOS - MM/DD/YYYY

24Reason for visit

24FollowUp FreeText

PlaceOfService(AutoPop)

24Where in residence does visit take place?

24Homebound Status (ON)

HospStat(autopop)DoNotChange

24Patient Premedicated?

24Premed types

24Scribe for Telehealth

24People present

24Rendering Provider

24Supervising Provider

35LINE________________________________

35Established Follow Up

25Enter Todays DOS - MM/DD/YYYY

25Reason for visit

PlaceOfService(AutoPop)

25FollowUp FreeText

25Where in residence does visit take place?

HospStat(autopop)DoNotChange

25Patient Premedicated?

25Premed types

25Scribe for Telehealth

25People present

25Rendering Provider

25Supervising Provider

36LINE________________________________

36Established Follow Up

26Enter Todays DOS - MM/DD/YYYY

26Reason for visit

26FollowUp FreeText

PlaceOfService(AutoPop)

26Where in residence does visit take place?

Homebound Status (ON)

HospStat(autopop)DoNotChange

26Patient Premedicated?

26Premed types

26Scribe for Telehealth

26People present

26Rendering Provider

26Supervising Provider

SHORT ROS

ROS freetxt

OBJECTIVE - Exam

###Exam performed locations- Current

General Appearance

###Orientation

Assistive Devices Used