OPD EMR – Proposal 2

Section 1 – Triage & Background

Chief Complaint (Triage)

"Follow up HT and type 2 DM."

Triage Score

Emergent
Assessed at 09:15 by Nurse Supaporn

Vital Signs (from Triage)

BP (mmHg)

148/92

PR (bpm)

102

RR (bpm)

Temp (°C)

37.2

SpO₂ (%)

Weight (kg)

Underlying Disease

Hypertension, Dyslipidemia

Allergy

NSAIDs Penicillin

Coverage

Universal Coverage (UC)

Rights verified – valid 2026

AIA Health Insurance

Policy No. AIA-23456789 – co-pay 300 THB

Note

Section 2 – Doctor Assessment

History

1Chief Complaint

2Present Illness

3Past History

Physical Examination

1Vital Signs (Doctor check)

BP (mmHg)

PR (bpm)

RR (bpm)

Temp (°C)

SpO₂ (%)

Weight (kg)

2General Appearance

3HEENT

4Neck

5Cardiovascular

6Respiratory

7Abdomen

8Extremities

9Neurological

…Other Findings

Section 3 – Diagnosis

Enter each diagnosis as a single line. Select the diagnosis type from the dropdown. Use the + Add button to record multiple diagnoses.

Type

Diagnosis (ICD-10 code / description)