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Urology Clinic Documentation Wizard

WARNING: This documentation assistant was designed as an educational tool to help Urology residents learn about History and Physical exam documentation for Urology, and related coding issues. It was not designed to be used as an actual documentation and coding tool. We take no responsibility for the use of this tool.


Patient age: Ethnicity:
Gender: Male Female
Chief complaint:

History of Present Illness:

* indicates that the choice will not be printed out if the field is left blank

Duration:
*Location: the symptom is localized to the
*Quality: the symptom is described as
*Severity: its severity is described as
*Timing: the symptom occurs
*Context: the symptom is described as occurring
*Modifying factors: modifying factors include
*Associated signs and symptoms: associated signs and symptoms include
*Other history:


Past History:

Past medical history includes

Past surgical history includes

Medications include

Allergies include

Family history includes

Social history includes


Review of Systems:

If you want a generic negative, check the box but leave the slot blank. In order for a field to be printed, it must be checked.

The patient reported constitutional symptoms including

The patient reported eye symptoms including

The patient reported ear, mouth and throat symptoms including

The patient reported cardiovascular symptoms including

The patient reported respiratory symptoms including

The patient reported gastrointestinal symptoms including

The patient reported genitourinary symptoms including

The patient reported musculoskeletal symptoms including

The patient reported integumentary symptoms including

The patient reported neurological symptoms including

The patient reported psychiatric symptoms including

The patient reported endocrine symptoms including

The patient reported hematologic symptoms including

The patient reported allergic symptoms including


Physical Exam:

If you want a generic negative, check the box but leave the slot blank. In order for a field to be printed, it must be checked.

Constitutional:

3 of the following vital signs should have been measured

Sitting/standing blood pressure was
Supine blood pressure was
Pulse rate was
Respiration was
Temperature was
Height was
Weight was

General appearance revealed

Neck:

Exam of neck revealed

Exam of thyroid revealed revealed

Respiratory:

Assessment of respiratory effort revealed

Auscultation of lungs revealed revealed

Cardiovascular:

Auscultation of heart revealed

Exam of peripheral vascular system revealed

Gastrointestinal:

For a complete exam, all of the following should be noted

Exam of abnomen revealed

Exam for hernia revealed

Exam of liver and spleen revealed

Male genitourinary:

For a complete exam, all of the following should be noted

Inspection of anus and perineum revealed

Exam of scrotum revealed

Exam of epididymides revealed

Exam of testis revealed

Exam of urethral meatus revealed

Exam of penis revealed

Prostate exam revealed

Exam of seminal vesicles revealed

Exam of external sphincter revealed

Female genitourinary:

For a complete exam, 7 of the following should be noted

Inspection and palpation of breasts revealed

Rectal exam revealed

Exam of external genitalia revealed

Exam of urethral meatus revealed

Palpation of urethra revealed

Exam of bladder revealed

Vaginal exam revealed

Exam of cervix revealed

Palpation of uterus revealed

Palpation of adnexa/parametria revealed

Exam of anus and perineum revealed

Lymphatic:

Palpation of lymph nodes revealed

Skin:

Inspection and palpation of skin and subcutaneous tissue revealed

Neurological/psychiatric:

Query of orientation to time, place and person revealed

Observation of mood and affect revealed


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