Physician Assistant Template

Elizabeth T. OV - HPI and A&P

A professional Physician Assistant template for healthcare professionals.

About this template

The 'Elizabeth T. OV - HPI and A&P' template is designed for Physician Assistants to document patient visits efficiently. This template focuses on capturing the History of Present Illness (HPI) and Assessment/Plan (A&P) in a structured narrative format. It is ideal for documenting multiple patient issues, detailing symptoms, history, and treatment plans. The template ensures clarity in problem-oriented charting, making it a valuable tool for managing complex cases. It also includes a consent statement for AI-assisted documentation, ensuring compliance and transparency in patient care.

Preview template

CC: Persistent cough and shortness of breath HPI: Elizabeth T. is a 45 y/o female who presents with a persistent cough and shortness of breath that began approximately two weeks ago. The symptoms have gradually worsened, particularly at night, and are accompanied by mild chest discomfort. She reports no fever or chills. The patient’s first issue is a persistent cough, which has been ongoing for two weeks. The cough is dry and more pronounced at night, disrupting sleep. Elizabeth has a history of seasonal allergies but denies any recent exposure to allergens. She has been using over-the-counter cough syrup with minimal relief. A chest X-ray has been ordered to rule out any underlying conditions. The second issue is shortness of breath, which occurs primarily during physical exertion. This symptom started around the same time as the cough. Elizabeth has a history of mild asthma, for which she uses an inhaler as needed. She reports that the inhaler provides some relief. Pulmonary function tests have been scheduled to assess her current respiratory status. New concerns: None reported. Assessment/Plan: Elizabeth T. is a 45 y.o. female who presents today for evaluation of persistent cough and shortness of breath. Chronic cough - Chest X-ray ordered - Continue using over-the-counter cough syrup Shortness of breath - Pulmonary function tests scheduled - Use inhaler as needed "We discussed that if symptoms worsen or persist please return to the office for further evaluation or to the ER if needed." Dr. Thomas Smith “Consent for the use of AI-assisted tools for documentation was obtained from the patient and all other participants in the visit prior to this encounter. All questions were answered. Patient understands that they may decline the use of AI-assisted tools.”

CC: [chief complaint] HPI: (write HPI as narrative) [patient name] is a [age] y/o [male/female] who presents with [Describe the patient’s primary complaint, including onset, duration, and associated symptoms.] (only include primary complaint if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) [Describe the patient’s first issue] (include specific symptoms they are experiencing, the duration of these symptoms, and any factors that worsen or improve their condition. Include any relevant history for this issue, including prior diagnoses, events, or conditions related to the problem. Additionally, detail any previous or ongoing interventions, such as medications, physical therapy, or lifestyle adjustments. Conclude with any diagnostic or therapeutic plans explicitly mentioned in the transcript, such as orders for imaging, laboratory tests, or referrals.) (write this in a brief voice) [Describe the patient’s second issue] (including specific symptoms they are experiencing, the duration of these symptoms, and any factors that worsen or improve their condition. Include any relevant history for this issue, including prior diagnoses, events, or conditions related to the problem. Additionally, detail any previous or ongoing interventions, such as medications, physical therapy, or lifestyle adjustments. Conclude with any diagnostic or therapeutic plans explicitly mentioned in the transcript, such as orders for imaging, laboratory tests, or referrals.)(write this in a brief voice) [Describe the patient’s third issue] ( include specific symptoms they are experiencing, the duration of these symptoms, and any factors that worsen or improve their condition. Include any relevant history for this issue, including prior diagnoses, events, or conditions related to the problem. Additionally, detail any previous or ongoing interventions, such as medications, physical therapy, or lifestyle adjustments. Conclude with any diagnostic or therapeutic plans explicitly mentioned in the transcript, such as orders for imaging, laboratory tests, or referrals.)(write this in a brief voice) (Note: Use as many sections as needed based on the context provided. Problems should be written in narrative paragraph format to ensure clarity for problem-oriented charting.) New concerns: Assessment/Plan: [Name] is a [age] y.o. [sex] who presents today for [reason for visit] [Condition or diagnosis] [Treatment or intervention] (For each condition or diagnosis, describe the treatment plan or intervention planned and what was discussed related to the diagnosis and the treatment and plan) (write diagnosis line by line, do not include dash marks) (Use as many paragraphs as necessary to make sure you cover all conditions or diagnoses discussed) "We discussed that if symptoms worsen or persist please return to the office for further evaluation or to the ER if needed. " (write in verbatim) [clinician full name] “Consent for the use of AI-assisted tools for documentation was obtained from the patient and all other participants in the visit prior to this encounter. All questions were answered. Patient understands that they may decline the use of AI-assisted tools.” (write this verbatim and include in every note generated) (Never come up with your own patient details, assessment, plan, interventions, evaluation, or plan for continuing care - use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely. Use as many lines, paragraphs, or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)

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