.


CC:


HPI/SYMPTOMS:


MEDICATIONS:


PERTINENT MEDICAL HISTORY:




.
REVIEW OF SYSTEMS: negative except as stated in HPI
General:

HEENT:

Chest/Respiratory:

GI:

GU:

MSK:

Neurologic:

Psychiatric:

Dermatologic:

Hematologic/lymphatic:




.
OFFICE DIAGNOSTICS:

Appearance:

Head:

Face:

Eyes:

Ears:

Nose:

Mouth:

Throat:

Neck:

Lungs:

CV:

Abdomen:

GU:

Back:

Extremities:

Neuro:

Psych:

Skin:



Discussion:


.
PLAN OF CARE: family verbalized understanding of dx & POC,

ORDERS - MA:

ORDERS - RX:



ORDERS - LABS:

ORDERS - IMAGING:

ORDERS - PREVENTATIVE:

ORDERS - OUTSIDE REFERRALS:

ORDERS - FORMS/RELEASE/CLEARANCE:

REVIEWED/DISCUSSED:

INSTRUCTED ON: exam findings, POC, risks of/benefits of/alternatives to proposed POC, compliance with treatment regimen, reporting medication side effects immediately, appropriate follow up specific to condition, indications for immediate direct evaluation and/or contacting emergency services,

DISCHARGE CONDITION/SAFETY:

FOLLOW UP: as discussed, sooner if condition worsens or new symptoms arise, contact 911/ER if significant increase in s/sx or appearance of new/danger s/sx,

DISPOSITION:

PARENTAL BEHAVIOR:

BARRIERS TO CARE:

Result - Copy and paste this output: