Podiatrist-Vorlage
Abbasova Podiatry Office Visit
Eine professionelle Podiatrist-Vorlage für medizinisches Fachpersonal.
Über diese Vorlage
Need a quick and easy way to document your podiatry visits? This podiatry office visit template is designed for podiatrists to efficiently record patient information. It covers subjective complaints, objective findings, and a detailed plan, including diagnoses and treatments. This template helps streamline your note-taking process, ensuring all essential details are captured. With Heidi, this template can be quickly populated from your visit transcript, saving you time and improving accuracy. Perfect for podiatrists looking to enhance their documentation process.
Vorlagenvorschau
Subjective:
67-year-old female.
Patient presents today with a chief complaint of pain in her left foot, specifically in the area of the plantar fascia. She reports the pain has been worsening over the past three months, especially in the morning. She denies any recent injury.
- Hypertension
- Hyperlipidemia
- Osteoarthritis
- Lisinopril 20mg daily
- Atorvastatin 40mg daily
- Ibuprofen 200mg as needed for pain
- Non-smoker. Drinks alcohol occasionally.
Objective:
**Vascular:**
- Pedal pulses are 2+ bilaterally.
- Capillary refill is less than 2 seconds bilaterally.
- No varicose veins noted.
**Neurological:**
- Protective sensation intact to light touch and monofilament testing bilaterally.
**Dermatological:**
- Skin is dry with mild scaling. Toenails are thickened and discolored. Pain to palpation of the plantar aspect of the left foot.
- No open lesions, edema, or erythema noted.
**Epidermal skin lesions:**
- Lesion on the plantar aspect of the left foot, measuring 1.5 cm.
**Musculoskeletal:**
- No deformities noted.
- Pain with palpation of the plantar fascia of the left foot.
Plan:
Patient evaluated. Non-surgical and surgical treatment options were discussed. Past medical history, any recent changes, orders, medications, and prescriptions were reviewed.
Plantar Fasciitis
- Instructed to stretch the plantar fascia several times a day.
- Instructed to ice the affected area for 15 minutes, 2-3 times a day.
- Rx for custom orthotics.
- Rx for Ibuprofen 200mg as needed for pain.
Date: 1 November 2024
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