RG Clinic Note

HISTORY OF PRESENT ILLNESS: [Name] is a [age and gender of the patient] with past medical history of [existing medical conditions to complete one liner. Cardiology conditions should be listed first. Include important disease modifiers in parentheses; for example, atrial fibrillation should include CHAD VASC Score and current anticoagulation, and heart failure (HFpEF and HFrEF) should include ejection fraction as EF.] [In a new sentence, state the patient's gender followed by "presents to clinic" and then list presenting symptoms, reason for visit, and/or specific medical conditions which are addressed at the visit.] [Document current symptoms, changes in condition since previous visits, exercise tolerance, daily activities, and any patient concerns or questions. Also include summary of relevant conditions and findings from prior visits, as provided in the 'Context' section. Include interval testing that has been done since the last visit typically in a chronological manner that demonstrates updates or progression of disease, as applicable.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraph format with full sentences.) =============== CARDIOVASCULAR CONDITIONS: - [List in bullet point fashion current and past cardiovascular conditions, including valvular issues, heart failure, arrhythmias, coronary artery disease, and any cardiac procedures with dates and locations. If a condition was found on an imaging study, list the condition with the study name and date in parentheses afterwards. Only list the most relevant findings from imaging tests, not all findings. Do not punctuate at the end of bullet points.] (This section must be included but only include conditions that are explicitly mentioned in transcript, context or clinical note, else omit section entirely.) CARDIOVASCULAR TESTING: - [List in bullet point fashion all cardiovascular diagnostic tests including angiography, echocardiograms, stress tests with dates, locations, and key findings. Do not punctuate at the end of bullet points.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as numbered list with specific details for each test. Begin each line with the date of the test in format (M/DD/YYYY)) OTHER NON-CARDIAC CONDITIONS: - [Listin bullet point fashion non-cardiac past medical and surgical history relevant to the reasons for consult and chief complaints. Do not include descriptions of prior hospitalizations, outpatient appointments, or medication changes in this section. Do not punctuate at the end of bullet points.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) RELEVANT HOME MEDICATIONS: - [Include outpatient medications that have cardiovascular indications, with doses and frequency if provided. Do not punctuate at the end of bullet points.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) RELEVANT FAMILY AND SOCIAL HISTORY: - [List of social history in bullet point fashion that may be relevant to the reasons for consult and chief complaints, including where the patient lives, who they live with, whether they have family nearby, children, functional status including ADLs, need for assistive devices like wheelchairs, canes or walkers, tobacco use, alcohol use, drug use, pets, diet, and exercise. Do not punctuate at the end of bullet points.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) - [List of family history of heart disease in bullet point fashion that may be relevant to the reasons for consult and chief complaints. Do not include non-cardiac conditions. Do not punctuate at the end of bullet points.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) =============== VITAL SIGNS: [Vital signs listed as one line with data points separated by commas, including temperature (T), heart rate (HR), respiratory rate (RR), blood pressure (BP), and pulse oximetry (SpO2), along with the amount and device for oxygen delivery if relevant, in the order T, HR, RR, BP, SpO2, Oxygen Delivered. If no vital signs are mentioned, then state 'Unremarkable,' and if only some vital signs are mentioned, then state 'otherwise unremarkable' after listing limited list of vital signs.] (If not explicitly mentioned in transcript, context or clinical note, enter "Unremarkable.") PHYSICAL EXAMINATION: - [Physical or mental state examination findings, including system-specific examinations, listed as multiple distinct lines for each system with the following system-based headings: General, HEENT, Cardiovascular, Pulmonary, Abdominal, Neurologic, Musculoskeletal, Skin. Do not punctuate at the end of bullet points, and keep each bullet point to a single sentence but can include multiple phrases appropriate; use semicolons or commas as needed.] (If not explicitly mentioned in transcript, context or clinical note, default to the following format: General: A&Ox3, in no acute distress HEENT: Moist mucous membranes CV: Normal rate and rhythm; no JVD Pulm: Normal work of breathing Abd: Non-distended Neuro: Grossly intact MSK: No LE edema Skin: No bruising or rashes on exposed skin) TODAY'S ECG: [Document rhythm, rate, and any abnormalities on electrocardiogram. Compare these findings to any prior ECG findings if provided.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in sentence format.) TODAY'S TTE: [Document rhythm, rate, and any abnormalities on echocardiogram. Compare these findings to any prior TTE findings if provided.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in sentence format.) =============== ASSESSMENT: [Summarize patient's cardiac status, interpretation of findings, and clinical reasoning for treatment decisions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraph format with full sentences.) SUMMARY OF RECOMMENDATIONS: - [List all recommendations including laboratory tests, medication changes, activity guidelines, continuation of current medications, and follow-up plans. Do not punctuate at the end of bullet points, and keep each bullet point to a single sentence; use semicolons or commas as needed.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as bulleted list with specific details for each recommendation.) [Insert patient name] will return to clinic in [input how many weeks or months until clinic follow up, for example '3 months.']