{{ patient_name }} — {{ dos }}

PATIENT

DOB {{ dob or '-' }}

AGE {{ age or '-' }}

SEX {{ sex or '-' }}

PRN {{ prn or '-' }}

FACILITY

T {{ fac_phone or '-' }}

F {{ fac_fax or '-' }}

{% if fac_addr1 %}

{% endif %} {% if fac_addr2 %}

{% endif %} {% if fac_city_state_zip %}

{% endif %}

ENCOUNTER

NOTE TYPE {{ note_type or '-' }}

SEEN BY {{ seen_by_name or '-' }}

{% if seen_by_credential %}

{% endif %}

DATE {{ dos }}

AGE AT DOS {{ age_at_dos or '-' }}

{% if signed_by_name %}

Electronically signed by {{ signed_by_name }}{% if signed_by_credential %}
{{ signed_by_credential }}{% endif %} at
{{ signed_at }}

{% endif %}

Chief complaint

Patient identifying details and demographics

{% if patient_notes %} {% endif %}

FIRST NAME	{{ demo.first_name or '-' }}	SEX	{{ demo.sex or '-' }}	RACE	{{ demo.race or '-' }}
MIDDLE NAME	{{ demo.middle_name or '-' }}	DATE OF BIRTH	{{ demo.dob or '-' }}	ETHNICITY	{{ demo.ethnicity or '-' }}
LAST NAME	{{ demo.last_name or '-' }}	DATE OF DEATH	{{ demo.death_date or '-' }}	PREF. LANGUAGE	{{ demo.language or '-' }}
SSN	{{ demo.ssn or '-' }}	PRN	{{ prn or '-' }}	STATUS	{{ demo.status or '-' }}

CONTACT INFORMATION
ADDRESS LINE 1	{{ demo.address1 or '-' }}	CONTACT BY	{{ demo.contact_by or '-' }}
ADDRESS LINE 2	{{ demo.address2 or '-' }}	EMAIL	{{ demo.email or '-' }}
CITY	{{ demo.city or '-' }}	HOME PHONE	{{ demo.phone_home or '-' }}
STATE	{{ demo.state or '-' }}	MOBILE PHONE	{{ demo.phone_mobile or '-' }}
ZIP CODE	{{ demo.zip or '-' }}	OFFICE PHONE	{{ demo.phone_office or '-' }}
		OFFICE EXTENSION	{{ demo.office_ext or '-' }}

FAMILY INFORMATION
NEXT OF KIN	{{ demo.next_of_kin or '-' }}		PATIENT'S MOTHER'S MAIDEN NAME		{{ demo.mothers_maiden_name or '-' }}
RELATION TO PATIENT	{{ demo.kin_relation or '-' }}
PHONE	{{ demo.kin_phone or '-' }}
ADDRESS	{{ demo.kin_address or '-' }}

PATIENT NOTES
{{ patient_notes \| replace('\n', ' ') \| replace('\r', ' ') }}

{% if show_insurance %}

Active insurance

{% if active_insurance %} {% for ins in active_insurance %}

PAYER	{{ ins.payer }}	INSURED ID NUMBER	{{ ins.member_id }}
PRIORITY	{{ ins.priority }}	GROUP NUMBER	{{ ins.group_number }}
TYPE	{{ ins.type }}	EMPLOYER NAME	{{ ins.employer_name }}
RELATIONSHIP TO INSURED	{{ ins.relationship }}	INSURANCE PAYMENT TYPE	{{ ins.ins_payment_type }}
START DATE	{{ ins.start_date }}	PAYMENT TYPE	{{ ins.payment_type }}
END DATE	{{ ins.end_date }}	COPAY AMOUNT	{{ ins.copay }}
		STATUS	{{ ins.status }}

{% endfor %} {% endif %}

Inactive insurance

{% if inactive_insurance %} {% for ins in inactive_insurance %}

PAYER	{{ ins.payer }}	INSURED ID NUMBER	{{ ins.member_id }}
PRIORITY	{{ ins.priority }}	GROUP NUMBER	{{ ins.group_number }}
TYPE	{{ ins.type }}	EMPLOYER NAME	{{ ins.employer_name }}
RELATIONSHIP TO INSURED	{{ ins.relationship }}	INSURANCE PAYMENT TYPE	{{ ins.ins_payment_type }}
START DATE	{{ ins.start_date }}	PAYMENT TYPE	{{ ins.payment_type }}
END DATE	{{ ins.end_date }}	COPAY AMOUNT	{{ ins.copay }}
		STATUS	{{ ins.status }}

{% endfor %} {% endif %} {% endif %} {% if show_payment %}

Payment information

PAYMENT PREFERENCE	{{ payment.preference }}	DATE OF BIRTH	{{ payment.dob }}
PATIENT'S RELATIONSHIP TO	{{ payment.relationship }}	SEX	{{ payment.sex }}
GUARANTOR		SOCIAL SECURITY NUMBER	{{ payment.ssn }}
GUARANTOR NAME	{{ payment.guarantor_name }}	PRIMARY PHONE NUMBER	{{ payment.primary_phone }}
GUARANTOR ADDRESS	{{ payment.guarantor_addr }}	SECONDARY PHONE NUMBER	{{ payment.secondary_phone }}

{% endif %} {% if show_vitals %}

Vitals for this encounter

{% if enc_vitals_rows %} {% for v in enc_vitals_rows %} {% endfor %}

	{{ vitals_date }}{% if vitals_time %} {{ vitals_time }}{% endif %}
{{ v.name }}	{{ v.value }}

{% else %}

No vitals recorded

{% endif %} {% endif %} {% if show_vitals_flowsheet %}

Vitals flowsheet - {{ flowsheet_patient_name }}

{% if flowsheet_columns %} {% for col in flowsheet_columns %} {% endfor %} {% if flowsheet_vitals_label %} {% endif %} {% for row in flowsheet_rows %} {% for val in row.vals %} {% endfor %} {% endfor %}

	{{ col.date }}{% if col.time %} {{ col.time }}{% endif %}
Vitals
{{ row.name }}	{{ val or '' }}

{% else %}

No events recorded for Vitals.

{% endif %} {% endif %}

Diagnoses

{% if diag_recon_text %}

Was diagnosis reconciliation completed?
{{ diag_recon_text }}

{% endif %} {% if current_diagnoses %} {% for d in current_diagnoses %} {% endfor %} {% else %} {% endif %}

Current	ACUITY	START	STOP
{{ d.description }}	{{ d.acuity }}	{{ d.start }}	{{ d.stop }}
No current diagnoses

{% if historical_diagnoses %} {% for d in historical_diagnoses %} {% endfor %} {% else %} {% endif %}

Historical	ACUITY	START	STOP
{{ d.description }}	{{ d.acuity }}	{{ d.start }}	{{ d.stop }}
No historical diagnoses

Drug Allergies

{% if allergy_recon_text %}

Was medication allergy reconciliation completed?
{{ allergy_recon_text }}

{% endif %} {% for status_key, status_label in [('active','Active'), ('inactive','Inactive')] %} {% set items = drug_allergies[status_key] %} {% if items %}{% for a in items %}{% endfor %} {% else %}{% endif %}

{{ status_label }}	SEVERITY/REACTIONS	ONSET
{{ a.name }}	{{ a.severity_reactions }}	{{ a.onset }}
No {{ status_label }} drug allergies recorded

{% endfor %}

Food Allergies

{% for status_key, status_label in [('active','Active'), ('inactive','Inactive')] %} {% set items = food_allergies[status_key] %} {% if items %}{% for a in items %}{% endfor %} {% else %}{% endif %}

{{ status_label }}	SEVERITY/REACTIONS	ONSET
{{ a.name }}	{{ a.severity_reactions }}	{{ a.onset }}
No {{ status_label }} food allergies recorded

{% endfor %}

Environmental Allergies

{% for status_key, status_label in [('active','Active'), ('inactive','Inactive')] %} {% set items = env_allergies[status_key] %} {% if items %}{% for a in items %}{% endfor %} {% else %}{% endif %}

{{ status_label }}	SEVERITY/REACTIONS	ONSET
{{ a.name }}	{{ a.severity_reactions }}	{{ a.onset }}
No {{ status_label }} environmental allergies recorded

{% endfor %}

Current Medications (as of {{ meds_as_of }})

Was medication reconciliation completed?
{{ med_recon_text }}

Active	SIG	START/STOP	ASSOCIATED DX

{% if active_medications %} {% for m in active_medications %}

{% for rx in m.escripts %}

{{ rx.prefix }} ({{ rx.status }}): {{ rx.date }} PRESCRIBER: {{ rx.prescriber }} SIG: {{ rx.sig }} REFILLS: {{ rx.refills }} QUANTITY: {{ rx.quantity }}

{% endfor %}

{% endfor %} {% else %}

No active medications recorded

{% endif %}

Historical	SIG	START/STOP	ASSOCIATED DX

{% if historical_medications %} {% for m in historical_medications %}

{% for rx in m.escripts %}

{{ rx.prefix }} ({{ rx.status }}): {{ rx.date }} PRESCRIBER: {{ rx.prescriber }} SIG: {{ rx.sig }} REFILLS: {{ rx.refills }} QUANTITY: {{ rx.quantity }}

{% endfor %}

{% endfor %} {% else %}

No historical medications recorded

{% endif %} {% if show_immunizations %}

Immunizations

{% if immunizations %} {% for imm in immunizations %} {% endfor %} {% else %} {% endif %}

DATE	VACCINE	SOURCE	LOT NUMBER	EXPIRES	COMMENT
{{ imm.date }}	{{ imm.vaccine }}	{{ imm.source }}	{{ imm.lot }}	{{ imm.expires }}	{{ imm.comment }}
No immunizations recorded for this patient.

{% endif %} {% if show_social_history %}

Social history

{% if smoking_status %} {% if smoking_date %}{% endif %} {% else %} {% endif %}

TOBACCO USE	RECORDED
Current tobacco use {{ smoking_status }}
	{{ smoking_date }}
No tobacco use history available for this patient
ALCOHOL USE	RECORDED
{{ sh_alcohol or 'No alcohol use history available for this patient' }}
SOCIAL HISTORY (FREE-TEXT)
{{ sh_freetext or 'No social history (free-text) recorded for this patient' }}
FINANCIAL RESOURCES	RECORDED
{{ sh_financial or 'No financial resources recorded for this patient' }}
EDUCATION	RECORDED
{{ sh_education or 'No education recorded for this patient' }}
PHYSICAL ACTIVITY	RECORDED
{{ sh_physical or 'No physical activity available for this patient' }}
NUTRITION HISTORY	RECORDED
{{ sh_nutrition or 'No nutrition history available for this patient' }}
STRESS	RECORDED
{{ sh_stress or 'No stress available for this patient' }}
SOCIAL ISOLATION AND CONNECTION	RECORDED
{{ sh_isolation or 'No social isolation and connection available for this patient' }}
EXPOSURE TO VIOLENCE	RECORDED
{{ sh_violence or 'No exposure to violence history available for this patient' }}
GENDER IDENTITY
{{ sh_gender_identity or 'No gender identity recorded for this patient' }}
SEXUAL ORIENTATION
{{ sh_sexual_orientation or 'No sexual orientation recorded for this patient' }}
PREGNANCY STATUS	RECORDED
{{ sh_pregnancy_status or 'No pregnancy status recorded for this patient' }}
PREGNANCY INTENT	RECORDED
{{ sh_pregnancy_intent or 'No pregnancy intent recorded for this patient' }}
TRIBAL AFFILIATION	RECORDED
{{ sh_tribal or 'No tribal affiliation recorded for this patient' }}
OCCUPATIONS	RECORDED
{{ sh_occupations or 'No occupations recorded for this patient' }}
FOOD INSECURITY RISK - HVS	RECORDED
{{ sh_food_insecurity or 'No food insecurity risk - hvs recorded for this patient' }}

{% endif %} {% if show_past_medical_history %}

Past medical history

{% if pmh_sections %} {% for section in pmh_sections %}

{% endfor %} {% else %}

No past medical history available for this patient.

{% endif %} {% endif %} {% if show_family_history %}

Family health history

{% if family_history %} {% for f in family_history %}{% endfor %} {% else %} {% endif %}

DIAGNOSIS	ONSET DATE
{{ f.diagnosis }}	{{ f.onset or '-' }}
No family health history recorded

FAMILY HEALTH HISTORY (FREE TEXT)

{{ family_history_freetext or 'No family health history (free text) available for this patient.' }}

{% endif %} {% if show_advance_directives %}

Advance Directive

{% if advance_directives %} {% for d in advance_directives %}{% endfor %} {% else %} {% endif %}

DIRECTIVE	RECORDED
{{ d.directive }}	{{ d.recorded }}
No advance directives recorded for this patient.

{% endif %} {% if show_devices %}

Implantable devices

No implantable devices recorded

{% endif %} {% if show_health_concerns %}

Active health concerns

DESCRIPTION	EFFECTIVE DATE
No active health concerns recorded.

Inactive health concerns

DESCRIPTION	EFFECTIVE DATE
No inactive health concerns recorded

{% endif %} {% if show_goals %}

Active Goals

{% if active_goals %} {% for g in active_goals %}{% endfor %} {% else %} {% endif %}

DESCRIPTION	EFFECTIVE DATE
{{ g.description }}	{{ g.date }}
No active goals recorded

Inactive Goals

{% if inactive_goals %} {% for g in inactive_goals %}{% endfor %} {% else %} {% endif %}

DESCRIPTION	EFFECTIVE DATE
{{ g.description }}	{{ g.date }}
No inactive goals recorded

{% endif %}

Subjective

{% if subjective_html %}{{ subjective_html | safe }}{% else %}-{% endif %}

Objective

{% if objective_html %}{{ objective_html | safe }}{% else %}-{% endif %}

Assessment

{% if assessment_html %}{{ assessment_html | safe }}{% else %}-{% endif %}

{% if encounter_diagnoses %}

Diagnoses attached to this encounter:

{% for ed in encounter_diagnoses %}

{{ ed.description }}, {{ ed.full_codes }}

{% endfor %}

{% endif %}

Plan

{% if plan_html %}{{ plan_html | safe }}{% else %}-{% endif %}

{% if show_orders %}

Orders

LAB ORDERS

No orders attached to this encounter.

IMAGING ORDERS

No orders attached to this encounter.

{% endif %}

Screenings/ Interventions/ Assessments

{% if screening_events %} {% for ev in screening_events %}

{{ ev.name }}{% if ev.result %}: {{ ev.result }}{% endif %}{% if ev.comments %} - {{ ev.comments }}{% endif %}

{% endfor %} {% else %}

No screenings/interventions/assessments recorded.

{% endif %}

Observations

No observations recorded.

Quality of care

Was diagnosis reconciliation completed?
{{ diag_recon_text or 'No selection made' }}

Was medication allergy reconciliation completed?
{{ allergy_recon_text or 'No selection made' }}

Was medication reconciliation completed?
{{ med_recon_text or 'No selection made' }}

No quality of care events recorded.

Care plan

No care plan recorded.

{% if show_addenda and addendums %}

Addenda

{% for ad in addendums %} {% endfor %}

ADDENDUM	STATUS	SOURCE	DATE/TIME
{{ ad.text }}	{{ ad.status }}	{{ ad.source }}	{{ ad.datetime }}

{% endif %} {% if logo_data_uri %}

{% endif %}