{{ 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 %} {# An absence is a claim. With vitals elsewhere in the record, the bare sentence denies what the record holds, so it scopes itself to this visit and says how many are missing from this page. Counts only, never values. #}

{% if vitals_elsewhere %}No vitals recorded for this visit — {{ vitals_elsewhere }} elsewhere in the record (see record summary){% else %}No vitals recorded{% endif %}

{% 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 %}

{% if vitals_elsewhere %}No events recorded for Vitals at prior visits — {{ vitals_elsewhere }} elsewhere in the record (see record summary).{% else %}No events recorded for Vitals.{% endif %}

{% 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 or unreconstructed_short }}

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

{% endif %} {% if show_health_concerns %}

Active health concerns

{% if active_concerns %} {% for c in active_concerns %}{% endfor %} {% else %} {% endif %}

DESCRIPTION	EFFECTIVE DATE
{{ c.description }}	{{ c.date }}
No active health concerns recorded.

Inactive health concerns

{% if inactive_concerns %} {% for c in inactive_concerns %}{% endfor %} {% else %} {% endif %}

DESCRIPTION	EFFECTIVE DATE
{{ c.description }}	{{ c.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

IMAGING ORDERS

{% endif %}

Screenings/ Interventions/ Assessments

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

{% if ev.negated %}Not performed — {% endif %}{{ ev.name }}{% if ev.result %}: {{ ev.result }}{% endif %}{% if ev.comments %} - {{ ev.comments }}{% endif %}

{% endfor %} {% else %}

{% if screenings_elsewhere %}No screenings/interventions/assessments recorded for this visit — {{ screenings_elsewhere }} elsewhere in the record (see record summary).{% else %}No screenings/interventions/assessments recorded.{% endif %}

{% endif %}

Observations

Quality of care

Was diagnosis reconciliation completed?
{{ diag_recon_text or unreconstructed_short }}

Was medication allergy reconciliation completed?
{{ allergy_recon_text or unreconstructed_short }}

Was medication reconciliation completed?
{{ med_recon_text or unreconstructed_short }}

Care plan

{% 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 %}