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Need a clear and concise record of your family medicine consultations? This 'History and Examination' template is designed for Family Medicine Specialists in Australia. It helps you document patient history using ICD nomenclature, examination findings, impressions, and treatment plans. The template also includes a simplified patient summary in plain language. This template is perfect for streamlining your note-taking process, ensuring all key information is captured accurately and efficiently. With Heidi, this template can be quickly populated from your consultation transcript, saving you valuable time and effort.
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Patient given verbal consent for use of AI Scribe to assist with writing consultation notes.
Quick Summary of below:
* Upper respiratory tract infection (URTI) - symptomatic management with rest, fluids, and paracetamol.
* Hypertension - continue current medication, monitor blood pressure.
History:
1. Upper Respiratory Tract Infection (J06.9):
* Patient reports onset of symptoms 3 days ago.
* Symptoms include cough, runny nose, and sore throat.
* No fever reported.
* No shortness of breath.
* Patient denies any known allergies.
2. Hypertension (I10):
* Patient has a history of hypertension, well-controlled on medication.
* Reports regular medication adherence.
* Last blood pressure check was 2 weeks ago, within target range.
Examination:
* Blood Pressure: 130/80 mmHg
* Pulse: 78 bpm
* Temperature: 37.0°C
* Respiratory Rate: 16 breaths/min
* Oxygen Saturation: 98% on room air
* General: Patient appears well, alert and oriented.
* ENT: Mildly injected pharynx, no tonsillar exudates.
* Lungs: Clear to auscultation bilaterally.
* Cardiovascular: Regular rate and rhythm, no murmurs.
Impression:
* Upper respiratory tract infection.
* Controlled hypertension.
Plan:
* Advised rest, adequate fluid intake, and paracetamol for symptomatic relief of URTI.
* Continue current antihypertensive medication.
* Monitor blood pressure at home and record readings.
* Review in 2 weeks or sooner if symptoms worsen.
Simplified Patient Summary:
* You have a cold (URTI) and should rest, drink plenty of fluids, and take paracetamol.
* Your blood pressure is well-controlled with your current medication. Continue taking it as prescribed.
* Check your blood pressure at home and record the readings.
* We will review your progress in two weeks, or sooner if your symptoms get worse.
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