Internal Medicine Specialist-Vorlage
General follow up
Eine professionelle Internal Medicine Specialist-Vorlage für medizinisches Fachpersonal.
Über diese Vorlage
This General Follow-Up template is designed for Internal Medicine Specialists to efficiently document patient visits. It covers key areas such as subjective complaints, past medical and social history, objective findings, assessment, and a comprehensive plan. This template is ideal for tracking ongoing conditions, managing chronic diseases, and ensuring continuity of care. It includes sections for medication adherence, diagnostic tests, and specialist referrals, making it a valuable tool for internal medicine practitioners. Use this template with Heidi, the AI medical scribe, to streamline documentation and enhance patient care.
Vorlagenvorschau
Subjective:
- Presenting complaint and duration: Patient presents with persistent cough for the past 3 weeks.
- Additional symptoms: Reports occasional shortness of breath and fatigue.
- Impact on daily activities: Difficulty performing daily tasks due to fatigue.
- Pertinent negatives: Denies fever, chest pain, or weight loss.
- Appetite: Normal appetite.
- Living situation and sick contacts: Lives alone, no known sick contacts.
- Medications prescribed: Prescribed albuterol inhaler.
- Diagnostic tests ordered: Chest X-ray and pulmonary function tests.
- Specialists referred to: Referred to pulmonologist.
- He is advised of most recent labs done on 10/15/2023 showing normal CBC and elevated CRP.
- Advised to start albuterol inhaler, see pulmonologist.
- Advised labs Chest X-ray and pulmonary function tests.
- RTC in 2 weeks.
Past Medical History:
- Relevant past medical history: History of asthma.
- Smoking history: Non-smoker.
- Medication adherence: Adheres to prescribed medications.
- Allergies: No known drug allergies.
- Recent travel: No recent travel.
Social History:
- Occupation and hobbies: Works as a librarian, enjoys reading and gardening.
- Alcohol use and sleep habits: Drinks socially, sleeps 7-8 hours per night.
Objective:
- Vitals: BP 120/80, HR 78, RR 18, Temp 98.6°F
- Lung exam: Mild wheezing noted on auscultation.
- Cardiac exam: Regular rate and rhythm, no murmurs.
- Abdominal exam: Soft, non-tender, no organomegaly.
Assessment:
- Primary diagnosis: Asthma exacerbation.
Plan:
- Diagnostic tests ordered: Chest X-ray and pulmonary function tests.
- Medications prescribed: Albuterol inhaler.
- Inhaler optimization and technique education: Provided education on proper inhaler use.
- Follow-up instructions: Follow up in 2 weeks.
- Return precautions: Return if symptoms worsen or new symptoms develop.
- Medication adherence counseling: Emphasized importance of medication adherence.
- Preventative measures discussion: Discussed avoiding known asthma triggers.
- Deferral of non-urgent issues: Deferred discussion of non-urgent issues to next visit.
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