Well, we are now on EMR, so we don't use one anymore. But our old one was basically set up in columns. The first column had all the available codes to them sorted out by category/POS. In further columns to the right, you could list all the dx's if you wanted or just leave a blank spot for them to write it. If I was doing my own, personally, I would make a list of all the most likely dx's and have them on there so they can just circle the dx's. also leave a place to print the patients demographic info.
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