Template Components
Logout
Dashboard
Templates
My Template
Create New Template
Subscription
Account Settings
Notifications
Create New Template
Components
ED Course
Vitals: reviewed and interpreted
Electrocardiogram
Labs: reviewed and interpreted
Imaging: reviewed and interpreted
Diet
VTE Prophylaxis
GI Prophylaxis
Code Status
Disposition
History of Present Illness
Review of Systems
Medical History
Surgical History
Medications
Allergies
Social History
Family History
Line of hyphens
Physical Exam
Specialized Testing
Assessment and Plan
Subjective and 24-hour Events
Problem List
Tubes/Lines/Drains
Pre-Operative Diagnosis
Post-Operative Diagnosis
Procedure
Performing Physician
Assistants (if any)
Anesthesia
Fluids
Urine Output
Devices/Drains
Estimated Blood Loss
Clinical Findings
Description of Procedure
Specimens
Complications
Template Preview
History of Present Illness
Subjective and 24-hour Events
Review of Systems
14 point ROS negative except for HPI
Complete ROS (produces the following text output) Positives
CONSTITUTIONAL: Denies weight loss, fever, chills, weakness or fatigue.
EYES: Denies visual changes or eye pain.
EARS, NOSE, MOUTH, THROAT: Denies dysphagia, hearing loss, sneezing, runny nose or sore throat.
CARDIAC: Denies chest pain/discomfort, palpitations, orthopnea or edema.
PULMONARY: Denies shortness of breath, dyspnea on exertion, cough or sputum.
GASTROINTESTINAL: Denies anorexia, nausea, vomiting, constipation, diarrhea, abdominal pain or blood per rectum.
GENITOURINARY: Denies dysuria, hematuria, frequency or urgency.
MUSCULOSKELETAL: Denies muscle pain, back pain, joint pain or stiffness.
SKIN: Denies rash, jaundice or itching.
NEUROLOGIC: Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities, or any change in bowel or bladder control.
PSYCHIATRIC: Denies depression, anxiety, suicidal ideation or homicidal ideation.
ENDOCRINE: Denies sweating, cold or heat intolerance, polyuria or polydipsia.
HEMATOLOGIC: Denies bleeding or bruising.
ALLERGIC: Denies itchy/watery eyes.
MEDICAL HISTORY
Option1
Option2
Option3
SURGICAL HISTORY
laparoscopy-assisted vaginal hysterectomy
laser thermokeratoplasty
left ventricular assist device (LVAD)
lip augmentation
lipoplasty
liposuction
SOCIAL HISTORY
Smoking: never smoker
Alcohol: denies
Drugs: denies
Living Situation
Occupation
Prior Exposures
Save Template
