General Practitioner-Vorlage
Complete Physical Exam
Eine professionelle General Practitioner-Vorlage für medizinisches Fachpersonal.
Über diese Vorlage
The Complete Physical Exam template is an essential tool for General Practitioners conducting comprehensive health assessments. This template facilitates thorough documentation of patient evaluations, including medical history, immunizations, cancer screenings, and cardiovascular risk assessments. It also covers detailed physical examination findings and management plans. By using this template with Heidi, clinicians can ensure all aspects of a patient's health are reviewed and documented efficiently, aiding in continuity of care and proactive health management. This template is particularly useful for annual check-ups and managing chronic conditions like diabetes and hypertension.
Vorlagenvorschau
Billing codes: 03.04A CMX30 (complete physical exam) +/- 13.99BA (pelvic exam with pap smear)
ICD-9 codes: 250.00 (Diabetes Mellitus), 401.1 (Hypertension)
Title: Complete: Annual Physical Exam with Diabetes and Hypertension Management
Summary: Comprehensive Health Exam - Ordered HbA1c test and adjusted hypertension medication
Review of medical problems & medication renewals:
- Diabetes Mellitus
-- Metformin 500mg twice daily
-- HbA1c test ordered
- Hypertension
-- Lisinopril 10mg daily
-- Blood pressure monitoring advised
Patient concerns:
- Occasional headaches
- Difficulty sleeping
Immunizations:
- Influenza vaccine administered
- Tetanus booster due in 2025
Cancer Screening:
- Colorectal: No family history, colonoscopy scheduled for next year
- Lung: No risk factors, non-smoker
- Cervical: Pap smear performed, results pending
- Breast: Mammogram scheduled, no family history
Cardiovascular Risk Assessment and Reduction:
- BMI: 28
- Family history of heart disease
- Non-smoker
- Alcohol: Social drinker
- Exercise: Regular walking
- Diet: Advised to reduce salt intake
- Lipids: Cholesterol levels within normal range
- Hypertension: Controlled with medication
Other screening:
- Diabetes: HbA1c test ordered
- Osteoporosis: No risk factors
- STIs: Not at risk
Exam:
- General inspection: Alert and appropriate throughout encounter, in no apparent distress, overall well appearing
- HEENT: Normal
- Cardiac: Regular rate and rhythm
-- Blood pressure: 130/85 mmHg
- Respiratory: Clear to auscultation
- Abdomen: Soft, non-tender
- Derm: No concerning lesions noted
- Neuro: Grossly normal
Assessment and management:
- Continue Metformin and Lisinopril
- HbA1c test to monitor diabetes
- Blood pressure monitoring
- Follow up in 12 months for repeat complete exam
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