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PREVIEW
PREVIEW
/stopbangInputs | Inputs |
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
/hpiPREVIEW
PREVIEW
/obnewPatient 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
/colonNumber 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
/assessPlease 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:
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:
Referrals placed during this visit:
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
/bmiWeight
Height:
BMI: 21.52Calculations
PREVIEW
PREVIEW
/ccrSerum 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
/heartHistory:
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
/okneeOttawa 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
/pecarnAge:
GCS ≤14, palpable skull fracture or signs of AMS?
AMS: Agitation, somnolence, repetitive questioning, or slow response to verbal communication
RESULTS
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PREVIEW
/eddUS (ultrasound) date:
GA (gestational age) at US: w d
EDD (expected day of delivery): 2025-Aug-28
PREVIEW
PREVIEW
/gacEDD:
GA: 40 weeks 0 days
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/diabetesPREVIEW
PREVIEW
/prescSince you are allergic to
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/rxciproPrescribe Ciprofloxacin type:
Ciprofloxacin (Cipro) mg has been electronically prescribed.
Take one tablet every 12 hours (twice daily) for days
PREVIEW
PREVIEW
/eyecarePREVIEW
PREVIEW
/utiI see that you were treated for a UTI with
Was that your last UTI?
PREVIEW
PREVIEW
/backpainBack 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
/wristexamHISTORY 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
/symptoms