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Illness or injury onset date and time
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Injury incident description
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Injury cause
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Injury location
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Injury associated activity
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Injury intent
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Safety equipment used
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Hx of Medication use
?
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Source of info
?
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Chief complaint Reported
?
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Reason for visit
?
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Presenting problem
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Hx of Pres illness
?
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Problem description
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Problem prior evaluation
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Problem diagnostic considerations
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Problem context
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Problem exacerbating factors
E
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Pain initiating event Reported
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Problem alleviating factors
E
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Pain alleviating factors Reported
E
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Problem response to therapy
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Problem quality or description
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Pain quality
E
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Problem location
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Pain primary location Reported
E
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Pain radiation
?
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Problem time course
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Pain temporal pattern Reported
E
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Problem frequency
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Sym dur during occurrences or episodes
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Pain duration Reported
E
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Onset of painful contractions
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Time contractions became regular
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Time membranes ruptured
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Time last ate solid food
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Time last drank liquid
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Limitations in obtaining history
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Problem associated signs+symptoms
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Problem list Reported
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Hx of Past illness
?
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General health Reported
?
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Hx of Major illnesses and injuries
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Pregnancies Hx
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Allergies &or adverse reactions Doc
?
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Hx of Adverse drug rxn
?
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Medication allergy Reported
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Hx of Surg proc
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Chief complaint+Reason for visit
?
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Hx of Hospitalization
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Hx of Childhood diseases
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Hx of Outpt visits
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Hx medical device use
?
E
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Hx of Allergies
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Hx of Growth+Development
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Immunization status Reported
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Hx of Immunization
?
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C tetani immunization status
|
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RABV immunization status
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FLUV immunization status
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B pert immunization status
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HAV immunization status
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MeV status
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HIB immunization status
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HPV immunization status
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RV immunization status
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N men immunization status
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S pneum polyvalent immunization status
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S pneum conjugated immunization status
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C diphtheriae immunization status
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PV immunization status
|
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VZV status
?
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HBV status
?
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HCV status
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HIV status
|
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RUBV status
?
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CMV status
|
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Feeding and dietary status Reported
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Functional status note
?
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Hx of Cogn func
|
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Social Hx
?
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Marital status+living arrang
|
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Current employment Reported
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Hx of Occupation
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Hx of Occupational exposure
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Military service
|
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Hx of Alcohol use
|
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Alcoholic drinks/drinking D Reported
|
|
/d
|
|
Alcohol binge episodes/M Reported
|
|
{#}/mo
|
|
Alcoholic drinks per W Reported
?
|
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{#}/wk
|
|
Hx of Tobacco use
|
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|
Cigs smoked (pack/day) nRate Reported
|
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{#}/d
|
|
Cigs smoked (pack/year) nRate Reported
|
|
{#}/a
|
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Hx of Other nonmedical drug use
|
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Type of substance abused
|
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Highest level of educ
|
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Hx of Sexual behavior
|
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Hx of Travel
|
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Other social factors Hx
|
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Family member diseases Hx
?
|
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Review of systems
?
|
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Constitutional symptoms
|
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Hx of Neurologic disorders
|
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Hx of Psychiatric disorders
|
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Hx of Endocrine disorders
|
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Hx of Hematologic disorders
|
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Hx of Allergy+Immunologic disorders
|
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Hx of Blood transfusion
|
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Hx of Neoplastic disease
|
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Hx of Infectious disease
|
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Hx of Integumentary disorders
|
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Hx of Skin disorders
|
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Hx of Brsts disorders
|
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Hx of Eyes disorders
|
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Hx of ENSMT disorders
|
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Hx of Ear disorders
|
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Hx of Nose disorders
|
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Hx of CVS disorders
|
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Hx of Oral cavity disorders
|
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Hx of Respiratory disorders
|
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Hx of GI disorders
|
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Hx of GU disorders
|
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Hx of Reproductive disorders
|
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Hx of Urinary disorders
|
|
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|
Hx of Reproductive disorders
|
|
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|
Hx of Gynecologic system disorders
|
|
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Menstrual Hx Reported
|
|
|
|
Menstrual status Reported
E
|
|
|
|
Birth control method Reported
|
|
|
|
LMP Start date
|
|
{date}
|
|
Pregnancy related history
|
|
|
|
Deliv date Clin est
?
|
|
|
|
Pregnancies
?
|
|
{#}
|
|
Parity
?
|
|
{#}
|
|
Hx of Urinary disorders
|
|
|
|
# Fetuses
|
|
{#}
|
|
Fet Movement
|
|
|
|
Viability of current pregnancy
|
|
|
|
Pregnancy status Reported
?
E
|
|
|
|
Date symptoms of pregnancy 1st noted
|
|
|
|
Hx of Musculoskeletal disorders
|
|
|
|
Phys find
|
|
|
|
1M Apgar Score
|
|
{score}
|
|
5M Apgar Score
|
|
{score}
|
|
10M Apgar Score
|
|
{score}
|
|
Phys find General status
?
|
|
|
|
Acuity assess
|
|
|
|
Vital signs
?
|
|
|
|
Pain severity Reported
|
|
|
|
Pain severity Score VAS
|
|
{score}
|
|
Pain severity Wong-Baker FACES Scale
?
E
|
|
|
|
Pain severity total Score FLACC
©
|
|
{score}
|
|
Pain severity verbal numeric scale Score
|
|
{score}
|
|
Pain severity verbal numeric scale Score
|
|
{score}
|
|
Speed of pain onset Reported
E
|
|
|
|
Chronic pain assessment
|
|
|
|
Capillary refill Time
?
|
|
s
|
|
SaO2 % BldA PulseOx
|
|
%
|
|
Inhaled O2 flow rate
?
|
|
L/min
|
|
Fet Heart rate
|
|
{beats}/min
|
|
QRS Complex nRate Hrt ventrs EKG
|
|
|
|
BP sys/dias
?
|
|
|
|
BP mean
|
|
mm[Hg]
|
|
BP dias
|
|
mm[Hg]
|
|
BP sys
|
|
mm[Hg]
|
|
Heart rate Periph a Palpation
|
|
{beats}/min
|
|
Heart rate rhythm Palpation
E
|
|
|
|
Heart rate
|
|
|
|
Resp rate
|
|
|
|
Body temperature
|
|
Cel
|
|
Weight
|
|
|
|
Weight Measured
|
|
|
|
Body height
|
|
|
|
GCS total
|
|
{score}
|
|
GCS eye
|
|
|
|
GCS verbal
|
|
|
|
GCS motor
|
|
|
|
GCS special circumstances
E
|
|
|
|
Physical exam by body areas
|
|
|
|
Phys find Head
|
|
|
|
Phys find Face
E
|
|
|
|
Phys find Lip
E
|
|
|
|
Phys find Scalp
E
|
|
|
|
Phys find Neck
|
|
|
|
Jugular distention head up 30 deg
|
|
[in_i]
|
|
Phys find Chest
|
|
|
|
Phys find Chest wall
|
|
|
|
Phys find Brsts
|
|
|
|
Phys find Axilla
|
|
|
|
Phys find Hrt
|
|
|
|
Phys find Thorax+Lungs
|
|
|
|
Phys find Abd
|
|
|
|
Phys find Groin
|
|
|
|
Phys find Pelvis
|
|
|
|
Phys find Genitalia
|
|
|
|
Phys find Male genitalia
|
|
|
|
Phys find Prostate
E
|
|
|
|
Phys find Female genitalia
|
|
|
|
Phys find Vagina
E
|
|
|
|
Phys find Uterus
E
|
|
|
|
Phys find Cvx
E
|
|
|
|
Phys find Buttocks
|
|
|
|
Phys find Rectum
|
|
|
|
Phys find Back
|
|
|
|
Phys find Spine
E
|
|
|
|
Phys find Paravertebral muscles
E
|
|
|
|
Phys find Hand
|
|
|
|
Phys find Digits
E
|
|
|
|
Phys find Nail Bed
|
|
|
|
Phys find Wrist
|
|
|
|
Phys find Forearm
|
|
|
|
Phys find Elbow
|
|
|
|
Phys find Upper arm
|
|
|
|
Phys find Should
|
|
|
|
Phys find Ft
|
|
|
|
Phys find Toes
E
|
|
|
|
Phys find Ankle
|
|
|
|
Phys find Calf
|
|
|
|
Phys find Knee
|
|
|
|
Phys find Thigh
|
|
|
|
Phys find Hip
|
|
|
|
Phys find Eye
|
|
|
|
IOP Eye
|
|
mm[Hg]
|
|
Phys find Conjunctiva
E
|
|
|
|
Phys find Cornea
E
|
|
|
|
Phys find Extraocular muscles
E
|
|
|
|
Phys find Eye lid
E
|
|
|
|
Phys find Iris
E
|
|
|
|
Phys find Lacrimal apparatus
E
|
|
|
|
Phys find Optic lens
E
|
|
|
|
Phys find Pupil
E
|
|
|
|
Phys find Retina
|
|
|
|
Phys find Sclera
E
|
|
|
|
Visual acuity study
|
|
|
|
Phys find ENMT
|
|
|
|
Phys find Ear
|
|
|
|
Phys find Tympanic Memb
E
|
|
|
|
Phys find Auditory canal
E
|
|
|
|
Phys find Nose
|
|
|
|
Phys find Palate
|
|
|
|
Phys find Mouth
E
|
|
|
|
Phys find Teeth+gum
E
|
|
|
|
Phys find Tongue
E
|
|
|
|
Phys find Throat
|
|
|
|
Phys find Larynx
E
|
|
|
|
Phys find Tonsil
E
|
|
|
|
Phys find Mouth+Throat+Teeth
|
|
|
|
Phys find CVS
|
|
|
|
Phys find Vesl
|
|
|
|
Pulse strength on exam
|
|
|
|
Phys find Respiratory
|
|
|
|
Phys find GI
|
|
|
|
Phys find GU Tract
|
|
|
|
Phys find Musculoskeletal
|
|
|
|
Phys find Muscle tone
E
|
|
|
|
Phys find Skin
|
|
|
|
Phys find Neurologic
|
|
|
|
Mental status
?
|
|
|
|
Phys find Primitive reflexes
|
|
|
|
Phys find Brain stem reflexes
|
|
|
|
Phys find sensation
E
|
|
|
|
Phys find Motor function
E
|
|
|
|
Phys find Strength
|
|
|
|
Phys find Balance+Coordination
|
|
|
|
Phys find Gait
E
|
|
|
|
Phys find Deep tendon reflexes
|
|
|
|
DTR Achilles
E
|
|
|
|
DTR Biceps
E
|
|
|
|
DTR Brachioradialis
E
|
|
|
|
DTR Patellar
E
|
|
|
|
DTR Triceps
E
|
|
|
|
Phys find Nerves.cranial
E
|
|
|
|
Babinski reflex
|
|
|
|
Psychiatric findings
|
|
|
|
Phys find Hem+Lymph+Immun
|
|
|
|
Phys find LN
E
|
|
|
|
Phys find Endocrine
E
|
|
|
|
Phys find Joint
E
|
|
|
|
Phys find Extremities
|
|
|
|
Adv healthcare directives
?
|
|
|