brevaAcute illness visit
Encounter
Patient name: [ ] Date of birth: [ ] Date and time of encounter: [ ] Clinician: [ ]
History
Chief concern, onset and symptom course: [ ] Associated symptoms and pertinent negatives actually elicited: [ ] Exposures and treatment already tried: [ ] Relevant history, medications and allergies: [ ]
Evaluation
Vitals measured, with units and time: [ ] Focused examination findings: [ ] Testing obtained, results and pending tests: [ ]
Assessment and management
Working diagnosis and differential: [ ] Reasoning for testing and treatment decisions: [ ] Treatment provided and response: [ ] Disposition and rationale: [ ] Pending-result follow-up owner and communication plan: [ ]
Follow-up
Follow-up timing and purpose: [ ] Return precautions discussed: [ ] Patient questions and understanding: [ ]