A complete history and physical can be both fast and thorough with:
Multiple choice ROS & Physical: click, done!
Pre-filled normal findings: easy documentation, reminder of what to look for.
Instant Write-up, SOAP note, problem list generation.
Write-up Wizard allows you to focus more on talking with the patient and thinking through a diagnosis, rather than trying to remember what to ask and how to document.
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Note: Writeup wizard works on Chrome (for internet explorer, you need version 9 or above).
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Name: Age: Race: Gender: Referral: Date:
White
| Black
| Hispanic
| Asian
| Male
| Female
Gen impression: alert
| not in distress
| well groomed
| disheveled
| distressed
| in resp distress
| relaxed
| thin
| obese
| energetic
| lethargic
CC:
Source and reliability all normal | omit all
HPI:
ROS
PMH:
Family History:
Social History:
Medications:
Allergies:
Vitals:
Physical exam
Skin all normal | omit all
HEENT
Neck all normal | omit all
Lymph nodes all normal | omit all
Pulmonary and thorax all normal | omit all
Cardiovascular all normal | omit all
Peripheral vascular all normal | omit all
Abdominal all normal | omit all
Abdominal inspection : normal contour, no scars, striae, or varicosities | omit | other ↵
Abdominal auscultation : audible bowel sounds, no aortic, renal, iliac, or femoral bruits | omit | other ↵
Abdominal palpation : soft, nontender, no masses felt | omit | other ↵
Liver : nontender, size normal | omit | other ↵
Spleen : nontender, nonpalpable | omit | other ↵
Kidneys : no CVA tenderness, no flank mass | omit | other ↵
Musculoskeletal all normal | omit all
Neurologic all normal | omit all
Mental status : alert and cooperative | omit | other ↵
Cranial nerves : CN I not tested, CN II-XII intact | omit | other ↵
Motor : good muscle bulk and tone, strength 5/5 throughout | omit | other ↵
Reflexes : biceps, triceps, patellar, achilles reflexes are 2+ and bilateral, downward plantar | omit | other ↵
Sensory : pain, light touch, position and vibration intact | omit | other ↵
Cerebellar : rapid alternating movements, finger-to-nose, heel-to-shin intact, gait steady | omit | other ↵
Male genital all normal | omit all
Male rectal all normal | omit all
Breast all normal | omit all
Female genital all normal | omit all
Female rectal all normal | omit all
Labs:
Problem list:
Assessment and Plan:
Generate: Full write up | SOAP note | Select all
none
cough,congestion,runny nose,drainage
None