Subjective Data:
HPI:
Describe the course of the patient’s illness:
Onset, Location, Duration, Characteristics, Aggravating and Relieving Factors:
ROS:
Allergies:
Current Medications (if any):
PMH:
Objective:
CNS:
HEENT:
Resp:
CVS:
GI:
GU:
Extremities:
Other assessments (if applicable like neuro, CMS, etc)
Assessment/Plan:
Diagnosis: Include brief summary about epidemiology (statistics on prevalence and incidence in the US, pathophysiology)
Differential Diagnoses:
Plan/Intervention:
Patient Education (minimum of three top patient education entries provided to patient):
Rx: (complete prescription name, dose, quantity, refills, etc.):
Labs:
Diagnostic: (i.e x-rays, endoscopy, CT scan, etc.)
Preventative measures based on age and US Task Force Preventative Guidelines of Family Medicine: (pap smear, screening guidelines appropriate to age):
Referrals: (endo, cardiologist, endocrine: provide justification):
RTC: (Follow-up):
Full Answer Section
ROS (Review of Systems):
This section explores potential symptoms in different body systems, even if not the chief complaint. Here are some examples:
- Allergies: Does the patient have any allergies to medications, food, or other substances?
- Current Medications (if any): What medications is the patient currently taking?
- PMH (Past Medical History): Does the patient have any past medical conditions, surgeries, or hospitalizations?
Objective Data:
This section documents your physical examination findings for various body systems:
- CNS (Central Nervous System): Assess level of consciousness, orientation, reflexes, etc.
- HEENT (Head, Eyes, Ears, Nose, Throat): Examine the head, eyes, ears, nose, and throat for abnormalities.
- Resp (Respiratory): Listen to lung sounds, check for breathing difficulty.
- CVS (Cardiovascular): Check heart rate, rhythm, and blood pressure.
- GI (Gastrointestinal): Palpate the abdomen, assess for any pain or tenderness.
- GU (Genitourinary): Check for any urinary tract issues.
- Extremities: Assess muscle strength, joint mobility, and pulses.
Other assessments: If needed, include assessments like neurological exams, mental status exams, etc.
Assessment/Plan:
Diagnosis: Here, you provide your primary diagnosis based on the subjective and objective data. Include a brief summary about:
- Epidemiology: Statistics on prevalence and incidence of the condition in the US.
- Pathophysiology: The underlying mechanism of the disease.
Differential Diagnoses: List alternative diagnoses considered but ruled out.
Plan/Intervention: Outline the treatment plan, including:
- Medications
- Procedures or tests
- Lifestyle modifications
- Patient education
Patient Education: Provide at least three key points of education relevant to the patient's condition.
Rx (Prescription): If medications are prescribed, list the complete details:
- Name of medication
- Dosage
- Quantity
- Refills
Labs: Order any necessary laboratory tests.
Diagnostic: Schedule any additional diagnostic procedures (X-rays, scans, etc.).
Preventative measures based on age: Recommend preventive measures based on the US Task Force on Preventive Services guidelines for the patient's age group (e.g., cancer screenings).
Referrals: If needed, refer the patient to specialists for further evaluation or treatment.
RTC (Return to Clinic): Schedule a follow-up appointment to monitor the patient's progress.