TeleVisit Encounter Notes

1. Encounter Start
2. Encounter Info
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4. Coding
5. Report
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History

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TELEHEALTH ENCOUNTER

Where is the patient being treated? Other:
Visit Information:

The patient is a
Onset of this chief complaint was
The symptoms are described as severity of with duration of and modified by
No additional associated symptoms were reported and there are no additional modifying factors related to the patient's complaint.

History of Present Illness:

Review of Systems:

ROS Constitutional:

Negative Negative other than HPI Fever Chills Sweats Weakness Fatigue Decreased activity

ROS Eye:

Negative Negative other than HPI Recent visual problem Icterus Blurring Double vision Visual disturbance
Discharge: Left Right Bilateral

ROS ENMT:

Negative Negative other than HPI Nasal congestion Sore throat
Decreased hearing: Left Right Bilateral
Ear pain: Left Right Bilateral

ROS Respiratory:

Negative Negative other than HPI SOB Cough Sputum production Hemoptysis Wheezing Cyanosis Apnea

ROS Cardiovascular:

Negative Negative other than HPI Palpitations Bradycardia Tachycardia Peripheral edema Syncope
Chest pain: Left Right Bilateral Midsternal Anterior Posterior Lateral

ROS Gastrointestinal:

Negative Negative other than HPI Nausea Vomiting Diarrhea Constipation Heartburn Hematemesis
Abdominal pain: Left Right Bilateral Upper quadrant Lower quadrant All quadrants Epigastric Middle Periumbilical
Severity: Mild Moderate Severe
Chracteristics: Sharp Cramping/Colicky Continuous Intermittent

ROS Genitourinary:

Negative Negative other than HPI Dysuria Hematuria Change in urine stream Urethral discharge Lesions

ROS Hema/Lymph:

Negative Negative other than HPI Bruising tendency Bleeding tendency Swollen lymph glands

ROS Endocrine:

Negative Negative other than HPI Excessive thirst Polyuria Cold intolerance Heat intolerance Excessive hunger

ROS Immunologic:

Negative Negative other than HPI Immunocompromised Recurrent fevers Recurrent infections Malaise

ROS Musculoskeletal:

Negative Negative other than HPI Neck pain Joint pain Muscle pain Claudication Decreased ROM Trauma
Back pain: Left side Right side Bilateral Upper Middle Lower

Severity: Mild Moderate Severe

ROS Integumentary:

Bruising Dryness Itching Skin Lump/Mass Mole Changes Rash Hair Changes

ROS Neurologic:

Negative Negative other than HPI Alert & Oriented X4 Abnormal balance Confusion Numbness Tingling Headache

ROS Psychiatric:

Cooperative Appropriate mood & affect Normal judgement Non-suicidal

All Other ROS:

Negative Negative other than HPI ROS as documented in chart

Unable to obtain: Clinical condition Altered mental status Uncooperative patient

Past Medical and Social History:

Home Medications:

Allergies:

Physical Examination:

VS/Measurements:

Temperature (Celsius):
Systolic Blood Pressure:
Diastolic Blood Pressure:
Pulse:
SpO2:
Respiratory Rate:

Laboratory Results:

See attachments for picture of lab results

PE General:

Alert and oriented No acute distress Mild distress Moderate distress

PE Eye:

PERLL EOMI Normal conjuctiva Vision unchanged

PE HENT:

Normocephalic TM's clear Normal hearing Moist oral mucosa No pharyngeal erythema No sinus tenderness

PE Neck:

Supple Non-tender No carotid bruit No JVD No lymphadenopathy No thyromegaly

PE Respiratory:

Lungs CTA Non-labored respirations BS equal Symetrial expansion No chest wall tenderness

PE Cardiovascular:

Normal rate Regular rhythm No murmur No gallop Good pulses equal in all extremities Normal peripheral profusion No edema

PE Breast:

No mass No tenderness No discharge

PE Gastrointestinal:

Soft Non-tender Non-distended Normal bowel sounds No organomegaly

PE Genitourinary:

No inguinal tenderness No urethral discharge No lesions

PE Lymphatics:

No lymphadenopathy

PE Musculoskeletal:

Normal ROM Normal strength No tenderness No swelling No deformity Normal gait

PE Foot / Ankle:

Normal by visual exam Normal pulses Sensation intact By monofilament exam

Condition:
Left Right Bilateral Plantar Dorsal Lateral Medial Ankle Heel Foot Hallux 2nd 3rd 4th 5th Warm Cool Dry Amputation Bunion Deformity Charcot Foot drop Maceration Redness Swelling

Circulation:
Left Right Bilateral Capillary refill Amplitude 5 Diminished Absent

PT pulse: Palpable Dopler (monophasic) Dopler (biphasic) Doppler (triphasic)
DP pulse: Palpable Dopler (monophasic) Dopler (biphasic) Doppler (triphasic)

Sensory Status:
Left Right Bilateral Plantar Dorsal Lateral Medial Ankle Heel Foot Hallux 2nd 3rd 4th 5th Light touch Pain sensation Proprioception Temperature sensation Intact Increased Diminished Absent By monofilament exam

Nails:
Left Right Bilateral Hallux 2nd 3rd 4th 5th Foot Thick Long Ingrown Fungal infection

Lesion-wound:
Left Right Bilateral Plantar surface Dorsal surface Lateral Medial Ankle Heel Foot Hallux 2nd 3rd 4th 5th Irregular Oval Round Raised Smooth Callus Corn Crust Wart Abrasion Abscess Burn Erosion Fissure Hematoma Laceration Puncture Ulceration

Footwear:
Regular shoe Orthotics Diabetic footwear Offloading shoe Cam walker Boot

Lower Leg:

Left Right Bilateral Hair Hairless

Skin: Warm, dry, pink Hyperpigmentation Erythema Cyanosis Varicosity Dry

Edema: Pitting Firm

Integumentary:

Warm Dry Pink Intact Moist No pallor No rash Normal for ethnicity Hemosiderin staining Lipodermatosclerosis

Wound Assessment:

Include from nursing documentation Refer to nurse documentation for measurements

Color:
Black Blue Brown Flesh-colored Green Pale Pink Purple Yellow White

Characteristics:
Bleeding Clean Dirty Dry Erythematous Gaping Granulation tissue Indurated Moist Necrotic Pruritic Purulent Seroma Swelling

Discharge:
Scant amount Moderate amount Large amount Foul smelling Purulent Green Yellow White Clear Sanguinous Serosanguineous Serious

Inflammatory Changes:
Redness Swelling Warmth

Size and Depth:
See nurses note Superficial Involving subcutaneous tissue Involving tendon Involving muscle Involving bone Undermining Tunneling
Size (cm):
Stage:

Stoma:
Dry Dusky Edematous Moist Narrowed Necrotic Pink Prolapsed Viable

Edges:
Rolled Sharp Pink Pale

Peri-wound:
Normal temperature Warm Erythema Pale Indurated Crepitus Lymphstreak

Course:
Worsening Improving Progress as expected Well controlled Unchanged Poor response to treatment Incomplete response to treatment Good response to treatment

Neurologic:

Alert Oriented Normal sensory Normal motor No focal deficits CN II-XII intact Normal DTR's

Psychiatric:

Cooperative Appropriate mood and affect Normal judgement Non-suicidal

Wound Assessment:

Differential Diagnosis:

Medical Decision Making:

Time spent:
A total of 10 minutes were spent managing the patient’s care. Of that time, 5 minutes were spent counseling/coordinating care, as discussed in chart. A total of 15 minutes were spent managing the patient’s care. Of that time, 10 minutes were spent counseling/coordinating care, as discussed in chart. A total of 25 minutes were spent managing the patient’s care. Of that time, 15 minutes were spent counseling/coordinating care, as discussed. A total of 30 minutes were spent managing the patient’s care. Of that time, 15 minutes were spent counseling/coordinating care, as discussed. A total of 40 minutes were spent managing the patient’s care. Of that time, 20 minutes were spent counseling/coordinating care, as discussed above.

Assessment and Plan:

Keep dry when bathing using methods we discussed in clinic.
Elevate your legs as much as possible to help with your edema
Offload at all times
Wear Prescribed footwear as directed.
Finish Antibiotics as prescribed
Antibiotics as prescribed by Infectious Disease physician.

Consultant:

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ATD 12:1 Infrared Thermometer
BD CultureSwab Plus Amies gel with charcoal,double swab, 50/per shelf pack
BD CultureSwab sterile, double swab,Pack 1
BIOVANCE® Human Amniotic Membrane Allograft, Per Square Centimeter
CoFlex TLC Calamine Standard Compression, Layer 1: 4’’ x 6 yds., Layer 2: 4’’ x 7 yds (*), Box of 8 Sets
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Comprilan®: 5m X 10cm (3.9" x 5.5 yds), Cotton, Latex Free, each
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Dakin's Solution® Full Strength (0.5%)
Debrisoft, 4" x 4" (10 x 10 cm)
Debrisoft® Lolly: 10 x 10 cm
DermACELL AWM® Per Square Centimeter
Dermagran® Hydrophilic-B Wound Dressing, 3oz tube
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