|
Chief Complaint
|
History of Present Illness
|
|
Copy of the old records
|
Copy of the old records
|
|
Copy of the old records
|
Copy of the old records
|
|
Copy of the old records
|
Copy of the old records
|
|
Copy of the old records
|
Chart Reviewed
|
|
|
|
|
Current Medications List
|
MAR Reviewed
|
|
MAR
|
MAR
|
|
MAR
|
MAR
|
|
MAR
|
MAR
|
|
MAR
|
MAR
|
|
|
|
|
Past Medical History
|
Past Medical History
|
|
|
|
|
Past Surgical History
|
Past Surgical History
|
|
|
|
|
Family History non contributory
|
Family History
|
|
|
|
|
Social History
|
Marital Status
• • •
|
|
Tobacco
• • •
|
Alcohol
|
|
Living Arrangements
• • •
|
Other illegal substances
|
|
|
|
|
Review of system, Normal
|
|
|
General [-]
|
General
• • •
|
|
General Comments
|
|
|
Skin [-]
|
Skin
• • •
|
|
Skin Comments
|
|
|
HEENT [-]
|
HEENT
• • •
|
|
HEENT Comments
|
|
|
Neck [-]
|
Neck
• • •
|
|
Neck Comments
|
|
|
Breasts [-]
|
Breasts
• • •
|
|
Breasts Comments
|
|
|
Cardiovascular [-]
|
Cardiovascular
• • •
|
|
CV Comments
|
|
|
Respiratory [-]
|
Respiratory
• • •
|
|
Resp Comments
|
|
|
GI [-]
|
Urinary
• • •
|
|
Urinary Comments
|
|
|
Genital (Male) [-]
|
Genital (Male)
• • •
|
|
Genital (Male) Comments
|
|
|
Genital (Female) [-]
|
Genital (Female)
• • •
|
|
Genital (Female) Comments
|
|
|
Periph. Vasc. [-]
|
Periph. Vasc.
• • •
|
|
Periph. Vasc. Comments
|
|
|
MSK [-]
|
MSK
• • •
|
|
MSK Comments
|
|
|
Neurologic [-]
|
Neurologic
• • •
|
|
Neuro Comments
|
|
|
Endocrine [-]
|
Endocrine
• • •
|
|
Endo Comments
|
|
|
Psychiatric [-]
|
Psychiatric
• • •
|
|
Psychiatric Comments
|
|
|
|
|
|
Physical Exam, Normal
|
|
|
General WNL
|
General Abnormal
• • •
|
|
General Comments
|
|
|
HEENT WNL
|
HEENT Abnormal
• • •
|
|
HEENT comments
|
|
|
Skin WNL
|
|
|
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
|
Other findings
|
|
Physical exam
|
Physical exam
|
|
|
|
|
|
|
|
Assessment
|
Plan
|
|
Assessment
|
Plan
|
|
Assessment
|
Plan
|
|
Assessment
|
Plan
|
|
Assessment
|
Plan
|
|
Assessment
|
Plan
|
|
Assessment
|
Plan
|
|
Assessment
|
Plan
|
|
Follow up in_____ for_____
|
comments on follow up
|
|
|
|
|
Case discussed with
• • •
|
Comments on the " case discussed with"
|
|
Code Status
|
Code discussed with
• • •
|
|
comment on the code status
|
|
|
PT Recommendations
• • •
|
PT Recommendation Comments
|
|
Diet
• • •
|
Diet comments
|
|
|
|
|
Demographics
|
Demographics
|
|
Demographics
|
Demographics
|
|
|
|
|
Ancillary Data
|
Ancillary Data
|
|
Ancillary Data
|
Ancillary Data
|
|
Ancillary Data
|
Ancillary Data
|
|
Ancillary Data
|
Ancillary Data
|
|
Ancillary Data
|
Ancillary Data
|
