CERNER EHR

The patient has been counseled on the procedure as well as risks, benefits, and alternatives. The procedure is considered irreversible...

Supportive care: Encourage fluids, activity as tolerated, honey for cough, salt water gargles, nasal saline. Tylenol or ibuprofen as...

ASQ: Communication: Gross motor: Fine Motor: Problem Solving: Personal-Social: Interpretation / Concern / Plan: Dental assessment...

Gen: NAD, age appropriate. Lymph: No cervical, supraclavicular, axillary lymphadenopathy Endo: Normal thyroid Breast: Normal breast...

Skin: no effusion or calor of shoulder. MS: Upper extremity: Right: Deltoid 5/5 Biceps 5/5 Triceps 5/5 Wrist flex 5/5 Wrist ext 5/5...

BMI _ % Gen: NAD, age appropriate. ENT: TM clear, nares clear, pharynx clear Lymph: No cervical lymphadenopathy Endo: Normal thyroid CVS:...

Arousal: Alert Attentiveness: fully attentive Appearance: well-dressed and well-groomed Attitude: cooperative, not guarded Activity:...

Osteopathic: Cranial: OA RRSL Cervical: C4-7 RRSR C2-3 RLSL Thoracic: T1-4 RLSR T5-9 RLSR T10-12 RLSR, ropey, hypertonic Lumbar: L1-5...

Gen: healthy appearing newborn in no distress HEENT: no caput or cephalhematoma, normal ears: no pits or tags, nares patent; fontanelles...

Neuro: CN II-XII grossly intact, EOMI, PERRLA DTR: Ach Pat Bi Tri BR Right: 2+ 2+ 2+ 2+ 2+ Left: 2+ 2+ 2+ 2+ 2+ (_ right, _ left)...

Gen: NAD Skin: Knee no calor, effusion, rubor MSK: neg lachman, A/P drawer, mcmurray, varus/valgus gap, patellar grind.

Monofilament Foot Exam Right Foot : Great toe Normal 1st MT Normal 3rd MT Normal 5th MT Normal Heel Normal Pedal Pulse Normal Left Foot...

MSK: TTP: Back ROM (degrees): Flex: _ Ext: _ Side Bend: _ Rotation: _ Strength: Right: HF: 5/5 Q: 5/5 H: 5/5 PF: 5/5 EHL: 5/5 Left: HF:...

Gen: NAD, age appropriate. ENT: TM clear, nares clear, pharynx clear Lymph: No cervical lymphadenopathy Endo: Normal thyroid CVS: RRR,...

Sleep: _ Interest: _ Guilt: _ Energy: _ Concentration: _ Appetite: _ Psychomotor: _ Suicidality/Homicide: _ Treatment: _ Support: _

_ yo _ w/ _ day h/o of _, nasal sx: _ ear pain: _ ST: _ Cough: _ Fever: _ Rhinorrhea: _ Tx: _ Flu shot: _ Tobacco exposure: _ Sick...

WWE: _ yo F G_P_ Menarche _ 1. Pap: Last pap: _ Abnormal pap: _ Menses: _ Vaginal complaints: 2. Breast: Last mammo: _ Abnormal mammo:...

DM2: No dry mouth, polyuria, polydipsia. Medication compliance: _. Blood glucose: Fasting: _ of 7 high (max: _ ) Breakfast: _...

SUBJECTIVE: 7 yo _ here for well child check. No parental or patient concerns at this time. REVIEW OF SYSTEMS: - Diet: No concerns. -...

SUBJECTIVE: 6 year old _ here for well child check. No parental or patient concerns at this time. REVIEW OF SYSTEMS: - Diet: No concerns....