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Healthcare Snippet Collection

Text Blaze Team

Snippets in this folder:

STOP-BANG assessment
/stopbang

PREVIEW

PREVIEW

/stopbangWill insert
InputsInputs
Age: BMI:
Neck circumference: Gender:
Do you snore loudly?: Daytime Fatigue?:
During sleep -cessation of breathing has been observed?: Hx of HTN?:

Calculated STOP BANG: 0

-----> Low risk for moderate to severe OSA.

PREVIEW

PREVIEW

/hpiWill insert
Patient is a -year-old who presents with . The has been going on for .

PREVIEW

PREVIEW

/obnewWill insert

Patient is a GP who presents to establish OB care.

Patient is sure of her LMP LMP EDD: 08/28/2025

Patient has a previous pregnancy history that is uncomplicated. .

Past medical history and past surgical history is reviewed.

PREVIEW

PREVIEW

/colonWill insert

Number of family members with a history of Colon Cancer:

Family Member 1

Select Family Member:

Age at diagnosis of CRC:

Lists:Relatives: Age Group: Unknown name "agegroup01"

PREVIEW

PREVIEW

/assessWill insert

Please enter the following information about the patient:

Age (number of years):

Sex:

- The patient is a year old .

- The patient's chart was reviewed and reconciled as noted in the HPI

- The patient's lifestyle was reviewed for possible impacts on health. I identified and addressed any barriers to improved health, such as age, gender, ethnic background, and, racial identity. Status of advanced health care planning was reviewed.

- The patient's self-reported or lab-reported vital signs were reviewed.

- Information was provided regarding healthy lifestyle choices and vaccinations.

- Based on recommendations for all or almost all adults, the patient was:

    • Screened for depression, unhealthy alcohol use, smoking, and unhealthy drug use
    • Screened for hypertension or recommended to screen for hypertension
    • Offered screening for Hepatitis C and HIV
    • Counseled regarding advanced care planning, including advanced directives, and offered follow up for future discussion if desired.

Specific concerns for this patient, if any:

No specific concerns noted above.

The following statements are generated based on age and sex entered at the top

Testing or screening ordered during this visit:

None

Referrals placed during this visit:

None

The patient was advised to follow up at least annually for preventive health care, sooner as needed for review of results or discussion of concerns raised.

The patient verbalized a clear understanding of my instructions and was agreeable with the plan.

PREVIEW

PREVIEW

/bmiWill insert

Weight

Height:

BMI: 21.52Calculations

PREVIEW

PREVIEW

/ccrWill insert

Serum Creatinine (mg/dL): Norm: 0.7 - 1.3

Age (years):

Weight (lbs): Norm: 2 - 300 lbs

Height (inches): Norm: 60 - 84 inches

Sex:

Results

Original Cockcroft and Gault formula result: NaN mL/min

Crockcroft and Gault formula using Ideal Body Weight: -Infinity mL/min

Original research: https://pubmed.ncbi.nlm.nih.gov/1244564/, https://pubmed.ncbi.nlm.nih.gov/22576791/CALCULATIONSTransforming units:Ideal body weightAdjusted body weightBMIFOR MALE

PREVIEW

PREVIEW

/heartWill insert

History:

EKG:

1 point: No ST deviation but LBBB, LVH, repolarization changes (e.g. digoxin); 2 points: ST deviation not due to LBBB, LVH, or digoxin.

Age:

Risk Factors:

HTN, hypercholesterolemia, DM, obesity (BMI >30 kg/m²), smoking (current, or smoking cessation ≤3 mo), positive family history (parent or sibling with CVD before age 65); atherosclerotic disease: prior MI, PCI/CABG, CVA/TIA, or peripheral arterial disease.

Initial troponin:

Use local, regular sensitivity troponin assays and corresponding cutoffs

0 points

Low Score (0-3 points)

Risk of MACE of 0.9-1.7%.

PREVIEW

PREVIEW

/okneeWill insert

Ottawa Knee Analysis

Age 55 years or older?

Tenderness at head of fibula?

Isolated tenderness of patella?

Inability to flex the knee greater than 90° ?

Inability to bear weight both immediately and in the emergency department (4 steps)?

Ottawa Knee Score: < 1 of 5, radiograph not warranted.

PREVIEW

PREVIEW

/pecarnWill insert

Age:

GCS ≤14, palpable skull fracture or signs of AMS?

AMS: Agitation, somnolence, repetitive questioning, or slow response to verbal communication

RESULTS

PREVIEW

PREVIEW

/eddWill insert

US (ultrasound) date:

GA (gestational age) at US: w d

EDD (expected day of delivery): 2025-Aug-28

PREVIEW

PREVIEW

/gacWill insert

EDD:

GA: 40 weeks 0 days

PREVIEW

PREVIEW

/diabetesWill insert
Patient has diabetes . Patient has blood sugars. Most recent HbA1C: ;Blood sugars are ranging . No hypoglycemia episodes.

PREVIEW

PREVIEW

/prescWill insert

Since you are allergic to

, I recommend .

PREVIEW

PREVIEW

/rxciproWill insert

Prescribe Ciprofloxacin type:

Ciprofloxacin (Cipro) mg has been electronically prescribed.

Take one tablet every 12 hours (twice daily) for days

PREVIEW

PREVIEW

/eyecareWill insert
I see that you and that
that started but you do not have
. Is this accurate? Are there any details you want to add?

PREVIEW

PREVIEW

/utiWill insert

I see that you were treated for a UTI with

in
CURSOR.

Was that your last UTI?

PREVIEW

PREVIEW

/backpainWill insert

Back Pain Red Flags:

I see you have back pain

What part of the back -- lower or upper (please be precise)?

When did this start?

Any fall or trauma?

Any heavy lifting?

Have you had similar pain before?

PREVIEW

PREVIEW

/wristexamWill insert

HISTORY OF PRESENT ILLNESS:

The client reports that they originally sustained the injury on when they fell and injured their wrist. They were evaluated at Urgent Care/ER where X-rays identified a left distal radius fracture. They were placed in a splint, referred to Dr. , and surgery was recommended. The patient presents to hand therapy today for their post-operative initial evaluation and treatment.

DX/SURGERY:

DOS:

PRIMARY COMPLAINTS:

PRIOR FUNCTIONAL STATUS:

CURRENT FUNCTIONAL STATUS:

See "Client Information Sheet" for activities that patient reports having difficulty with. Client reports difficulty in the following activities:

Occupation:

Social Status:

PAIN:

Pain location:

At worst: /10

Current: /10

At best: /10

Pain description:

Pain Follow-up Plan:

PATIENT GOALS:

OBJECTIVE FINDINGS:

Handedness:

Wound / Incision Status:

Orthosis/Splint Use:

Swelling:

Circumferential measurements (cms):

Right MCPs: cm

Left MCPs: cm

Right Wrist: cm

Left Wrist: cm

Right Left Digit AROM (extension is 0 unless otherwise indicated):

Thumb AROM:

IP: left: || right:

MP: left: || right:

Plan abd: left: || right:

Palm abd: left: || right:

Opp: left: || right:

Wrist AROM:

E: left: || right:

F: left: || right:

RD: left: || right:

UD: left: || right:

Forearm AROM:

Sup: left: || right:

Pron: left: || right:

Shoulder AROM:

WFL: left: || right:

Flexion: left: || right:

Extension: left: || right:

Abduction: left: || right:

IR: left: || right:

ER: left: || right:

Grip and Pinch Strength:

Sensation:

Palpation:

MODERATE COMPLEXITY OT CODE:

The patient's occupational profile and medical and therapy histories were reviewed through , and patient intake forms. An analysis was completed of the occupational profile/data based on a detailed assessment. The evaluation identified . Clinical decision making involved moderate analytic complexity and consideration of several treatment options. Minimal to moderate modification of tasks or assistance was provided. COVID19 precautions in effect.

PREVIEW

PREVIEW

/symptomsWill insert