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referring/primary
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chief complaint/reason for visit
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History of Present Illness (HPI) - dictate
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Past Medical History
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Past Surgical History
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Family History
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Social History
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Medication Allergies?
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Medications allergic to:
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REVIEW OF SYSTEMS
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General [-]
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General Comments
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General
• • •
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Skin [-]
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Skin Comments
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Skin
• • •
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HEENT [-]
|
HEENT Comments
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HEENT
• • •
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Neck [-]
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Neck Comments
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Neck
• • •
|
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Cardiovascular [-]
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CV Comments
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Cardiovascular
• • •
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Respiratory [-]
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Resp Comments
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Respiratory
• • •
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GI [-]
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GI Comments
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GI
• • •
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Vascular
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Urinary [-]
|
Urinary Comments
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Urinary
• • •
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Genital (Male) [-]
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Genital (Male) Comments
|
Genital (Male)
• • •
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Genital (Female) [-]
|
Genital (Female) Comments
|
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Genital (Female)
• • •
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Periph. Vasc. [-]
|
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Periph. Vasc. Comments
|
Periph. Vasc.
• • •
|
|
MSK [-]
|
MSK Comments
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MSK
• • •
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Neurological [-]
|
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Neuro Comments
|
Neurological
• • •
|
|
Endocrine [-]
|
Endo Comments
|
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Endocrine
• • •
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Psychiatric [-]
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Psychiatric Comments
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Psychiatric
• • •
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PHYSICAL EXAM
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|
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baseline blood pressure
/
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baseline pulse
|
|
standing 2 min blood pressure
/
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standing 2 minutes pulse
|
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New Short Text Field
|
New Short Text Field
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|
New Short Text Field
|
|
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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
|
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MSK WNL
|
MSK Abnormal
• • •
|
|
MSK Comments
|
Breasts WNL
|
|
Breasts Abnormal
• • •
|
Breasts Comments
|
|
Neuro WNL
|
Neuro Abnormal
• • •
|
|
Neuro Comments
|
Extremities WNL
|
|
Extrem Abnormal
• • •
|
Extrem Comments
|
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ASSESSMENT (s)
|
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Assessment (s)
|
Laboratory Orders
|
|
Assessment (s)
|
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Assessment (s)
|
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Assessment (s)
|
|
|
Assessment (s)
|
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Assessment (s)
|
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Assessment (s)
|
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PLAN
|
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New Short Text Field
|
|
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Labs
• • •
|
Lab Comments
|
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Cardiac Testing
|
Cardiac Work-up
• • •
|
|
Cardiac testing comments
|
Radiology
|
|
Radiology
• • •
|
Radiology Comments
|
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Other Studies
|
Other studies
• • •
|
|
Other studies comments
|
Referrals:
|
|
Referrals:
• • •
|
Referral to who
• • •
|
|
Referral Comments
|
Diet
• • •
|
|
Diet Comments
|
Exercise Program
|
|
exercise
• • •
|
exercise
|
|
Orders
|
Orders
• • •
|
|
Orders free write
|
Health Maintenance
|
|
health maintenance
• • •
|
health maintenance freewrite
|
|
Education
|
Education
• • •
|
|
Education Comments
|
Procedures done in the office
|
|
Office Procedures
• • •
|
Procedure Comments
|
|
medication changes
|
medication changes
|
|
medication free write
|
Follow Up:
• • •
|
|
Follow-Up free write:
|
Follow-up Comments:
|
|
Purpose of Next Visit:
|
Assessment of Perioperative Risk
|
|
New Field
• • •
|
New Field
|
