1. Pt demographics
   1. Name
   2. gender
   3. Date of Birth
   4. Contact information
      1. h,o,c phone/e-mail address/pager
   5. Emergency contact
   6. Insurance information
   7. Picture
2. Primary caregiver
3. Encounter date and time
4. Chief complaint
   1. Free text
5. History of present illness
   1. symptom (pain)/location/character/severity/duration/worsening factors/improving factors/associated features/
   2. Free text
6. Past medical/surgical/family/social history
   1. Hx of kidney stones
      1. Urate stones
   2. Hx of renal insufficiency
   3. Free text
7. Review of systems
8. Medications
9. Allergies
10. vital signs
11. General physical exam
    1. Gen/heent/neck/chest (pulmonary)/heart (cardiac)/abdomen (gastrointestinal)/extremities/skin/genitourinary/neurological/endocrine/vascular
12. Musculoskeletal exam
    1. Hand (dip/pip/ip/mcp)/wrist/elbow/shoulder/hip/knee/ankle/foot (tmt/mtp/pip/dip/ip)/spine (cervical spine/thoracic spine/lumber)
    2. Homunculus
    3. Bursae
    4. Swollen/tender joint count
    5. Tophus (yes/no/location)
13. Disease activity measure
    1. Rapid 3/das/haq/sf-36/other
14. Lab data
    1. Cbc
    2. Creatinine
    3. GFR
    4. creatinine clearance
    5. Hepatic function panel
    6. Serum uric acid
    7. 24 hour urine urate
15. Imaging
    1. x-ray/ct/mri/ultrasound/ivp
16. Procedures
    1. Joint/tendon sheath/nodule aspiration
    2. Joint/tendon sheath/nodule injection
    3. Crystal analysis
17. Impression/ICD 9 or 10 code
    1. Free text
18. Plan
    1. Medications/formularies
    2. Lab orders
    3. imaging orders
    4. Procedures
       1. Joint/tendon sheath/nodule aspiration
       2. Joint/tendon sheath/nodule injection
       3. Crystal analysis
    5. referrals
    6. Free text
19. Quality Measures
    1. 1-4
20. Performance Improvement Module
    1. 1-7
21. Registry
    1. yes/no