HPI

"Start Annual Note"

:

REASON FOR VISIT: [ ] returns today for [follow-up of chronic problems and ][an annual wellness exam].  

[ ] 

[See further details by problem in the assessment and plan section below.]

PHYSICAL EXAM:

[ ] 

** Dragon dictation software was used in the creation of this note.  Please contact our office if clarification is needed for apparent unintended word substitutions or other documentation inaccuracies. **

"Start follow up note"

:

REASON FOR VISIT: [ ] returns today for [follow-up of chronic problems][ ].  

[ ] 

[See further details by problem in the assessment and plan section below.]

PHYSICAL EXAM:

[ ] 

** Dragon dictation software was used in the creation of this note.  Please contact our office if clarification is needed for apparent unintended word substitutions or other documentation inaccuracies. **

"Start Problem Note"

:

REASON FOR VISIT:  [ ] returns today for [a problem visit][ ].  

[ ] 

[See further details by problem in the assessment and plan section below.]

PHYSICAL EXAM:

[ ] 

** Dragon dictation software was used in the creation of this note.  Please contact our office if clarification is needed for apparent unintended word substitutions or other documentation inaccuracies. **

"Start Phone Note"

:

REASON FOR VISIT:  [ ] returns virtually today for [a problem visit and followup of chronic problems]. 

[ ] 

[See further details by problem in the assessment and plan section below.]

VISIT DETAILS:

-- Type of visit: virtual visit using audio only via telephone

-- Consent: Patients are informed during the scheduling process that virtual visits will include billing claim similar to a regular office visit and any usual copays or deductible charges will still apply; verbal consent is obtained prior to putting them on the doctor's schedule to call

-- Patient Location: [ _______ ]

-- Counseling time on phone with patient: > [ ___ ] minutes

** Dragon dictation software was used in the creation of this note.  Please contact our office if clarification is needed for apparent unintended word substitutions or other documentation inaccuracies. **

"Start Video Note"

:

REASON FOR VISIT: [ ] returns virtually today for [a problem visit][ and ]follow-up of chronic problems].

[ ] 

[See further details by problem in the assessment and plan section below.]

VIRTUAL PHYSICAL EXAM:

-- GENERAL:  [ ] seen on audio and video visit today, [seated comfortably, alert with normal interaction]

-- HEENT: [normocephalic, atraumatic, eyes normal, sclera non-icteric]

-- PULMONARY: [Respirations are nonlabored], [without coughing during visit or audible wheezing or stridor]

-- DERM: [Visible portions of the skin on the face and neck are clear without rash. ]

-- PSYCHIATRIC: [normal mood and affect, thought processes are logical]

VISIT DETAILS:

-- Type of visit: virtual visit using visual and audio components via video conferencing app. 

-- Consent: Patients are informed during the scheduling process that virtual visits will include billing claim similar to a regular office visit and any usual copays or deductible charges will still apply; verbal consent is obtained prior to putting them on the doctor's schedule to call.

-- Patient Location: [ home ]

-- Chart preparation time: > [ 5 ] minutes  (includes reviewing outside records, lab tests, and patient messages since last office visit; updating of problem list accordingly; and entering orders anticipated for the encounter)

-- Counseling time: > [ ___ ] minutes

-- Documentation time: > [ ___ ] minutes 

-- Total Visit Time: > [ ___ ] minutes

** Dragon dictation software was used in the creation of this note.  Please contact our office if clarification is needed for apparent unintended word substitutions or other documentation inaccuracies. **

Physical Exam Templates

"Exam Limited"

-- GENERAL: [ ____ ]; presenting [ambulatory in no acute distress]

-- HEENT: [normocephalic, atraumatic, eyes normal, sclera non-icteric]

-- NEUROLOGIC: [alert and fully oriented, grossly intact]

-- PSYCHIATRIC: [normal mood and affect, thought processes are logical]

"Exam Basic"

-- GENERAL: [ ____ ], presenting [ambulatory in no acute distress]

-- HEENT: [normocephalic, atraumatic, eyes normal, sclera non-icteric]

-- CARDIOVASCULAR: [heart normal rate, regular rhythm, normal S1 and S2, no murmurs, gallops or rubs]

-- PULMONARY: [lungs clear to auscultation without rales, wheezes, or rhonchi]

-- NEUROLOGIC: [alert and fully oriented, grossly intact]

-- PSYCHIATRIC: [normal mood and affect, thought processes are logical]

"Exam Routine"

-- GENERAL: [____] presenting ambulatory in no acute distress 

-- HEAD: [normocephalic, atraumatic]

-- EYES: [normal, sclera non-icteric]

-- EARS: [external auditory canals clear bilaterally, tympanic membranes appear normal without effusions ]

-- NOSE: [nares patent, nasal mucosa non-inflamed]

-- MOUTH: [mucosa moist]

-- THROAT: [clear, without erythema or exudate]

-- CARDIOVASCULAR: [rrr, normal s1/s2, no m/g/r]

-- PULMONARY: [normal respiratory effort, CTA b/l, no wheezes, rales, or rhonchi.]

-- GASTROINTESTINAL: [abdomen soft, bs present, non-tender] 

-- DERMATOLOGIC: [skin warm, dry, no rashes]

-- MUSCULOSKELETAL:  [normal muscle bulk and tone,] [without hot or swollen joints] 

-- NEUROLOGIC: [alert and fully oriented; grossly intact; gait normal] 

-- PSYCHIATRIC: [normal mood and affect, thought processes are logical]

"Exam Virtual"

VIRTUAL PHYSICAL EXAM:

-- GENERAL:  [ ] seen on audio and video visit today, [seated comfortably, alert with normal interaction]

-- HEENT: [normocephalic, atraumatic, eyes normal, sclera non-icteric]

-- PULMONARY: [Respirations are nonlabored], [without coughing during visit or audible wheezing or stridor]

-- DERM: [Visible portions of the skin on the face and neck are clear without rash. ]

-- PSYCHIATRIC: [normal mood and affect, thought processes are logical]

Physical Exam Components

"Exam CV basic"

-- CARDIOVASCULAR: [rrr, normal s1/s2, no m/g/r]

"Exam CV Detailed"

-- CARDIOVASCULAR: 

     - Heart: [normal rate, regular rhythm, normal S1 and S2, without m/g/r]

     - Volume: [euvolemic, without pedal edema]

     - Peripheral Vascular: [no cyanosis, or clubbing, pedal pulses present]

"Exam Derm Basic"

-- DERMATOLOGIC: [skin warm, dry, no rashes or suspicious lesions]

"Exam Derm Detailed"

-- DERMATOLOGIC: 

     - Skin: [warm, dry, no rashes or suspicious lesions]

     - Hair: [normal thickness and distribution]

     - Nails: [normal, without spooning or pitting]

"Exam Diabetic Foot"

-- DIABETIC FOOT EXAM: 

     - Visual Inspection; [no significant joint deformities, calluses, or ulcerations]

     - Pulses: [posterior tibial and dorsalis pedis pulses present bilaterally]

     - Sensation: [normal monofilament exam bilaterally]

"Exam GI Basic:

-- GASTROINTESTINAL: [abdomen, soft, bowel sounds present, non-tender, without guarding or rebound, no masses]

"Exam GI Detailed"

-- GASTROINTESTINAL:  Abdomen: [soft, bowel sounds present, non-tender, without guarding or rebound, no masses]; CVA tenderness: [none]; Rectal Exam: [ *** deferred ***]

"Exam GU Female"

-- GENITOURINARY: [normal appearing external female genitalia]

"Exam GU Male" 

-- GENITOURINARY: [normal external male genitalia]

"Exam Head Basic"

-- HEENT: [normocephalic, atraumatic, eyes normal, sclera non-icteric]

"Exam Head Detailed"

-- HEAD: [normocephalic, atraumatic]

-- EYES: [normal, sclera non-icteric]

-- EARS: [external auditory canals clear bilaterally, tympanic membranes appear normal without effusions]

-- NOSE: [nares patent, nasal mucosa non-inflamed]

-- MOUTH: [mucosa moist]

-- THROAT: [clear, without erythema or exudate]

"Exam Mask"

-- NOSE / MOUTH: *wearing facial mask covering nose and mouth*

"Exam MSK Basic"

-- MUSCULOSKELETAL:  [normal muscle bulk and tone,] [without hot or swollen joints] 

"Exam MSK Detailed"

-- MUSCULOSKELETAL: 

     - Muscles: [normal bulk and tone]

     - Joints: [no swelling, erythema, or warmth]

     - Spine: [non-tender, with preserved range of motion]

"Exam Neck Basic"

-- NECK: [normal, no adenopathy or thyromegaly]

"Exam Neck Detailed"

-- NECK: Size: [normal]; Adenopathy: [none]; Thyroid: [no enlargement, nodules, or tenderness]

"Exam Neuro Basic"

-- NEUROLOGIC: [alert and fully oriented, grossly intact]

"Exam Neuro Detailed"

-- NEUROLOGIC: 

     - General: [alert and fully oriented]

     - Cranial Nerves: [2-12 interact normally]

     - Strength: [full and symmetric in all extremities]

     - Sensation: [full and symmetric in all extremities]

     - Reflexes: [normal biceps tendon reflex bilateral upper extremity, and patellar reflexes bilateral lower extremities]

     - Gait: [normal]

"Exam Prostate"

-- PROSTATE: Rectum: [no external or internal hemorrhoids, normal tone]; Prostate: [normal size, smooth, non-tender, without nodules or asymmetry]

"Exam Psych Basic"

-- PSYCHIATRIC: [normal mood and affect, though processes are logical]

"Exam Psych Detailed"

-- PSYCHIATRIC: Mood and affect: [normal, well adjusted]; Thought processes: [logical]; Insight: [preserved]

"Exam Pulm Basic"

-- PULMONARY: [lungs clear to auscultation without rales, wheezes, or rhonchi]

"Exam Pulm Detailed"

-- PULMONARY: 

     - Effort: [normal, without use of accessory muscles]

     - Auscultation: [lungs clear, without wheezes, rales, or rhonchi]

     - Chest Wall: [normal, with symmetric expansion]