Chief Complaint:
- Annual wellness visit
HPI:
1. Hypertension: Patient reports a history of hypertension for the past 5 years. Currently managed with medication, but reports occasional headaches. No recent changes in medication or lifestyle.
2. Hyperlipidemia: Diagnosed 3 years ago, currently on statins. Reports no side effects from medication.
Male AWV
- Nutrition: Patient follows a balanced diet, including fruits, vegetables, and lean proteins.
- Exercise: Engages in moderate exercise, such as walking, for 30 minutes, 5 times a week.
- Falls: No recent falls reported.
- EtOH/Tobacco: Consumes alcohol socially, approximately 2-3 drinks per week. Non-smoker.
- HTN screen: Blood pressure today is 130/85 mmHg.
- Cholesterol: Most recent LDL level is 120 mg/dL.
- 10 year CV risk %: 15%.
- STD screen: No STD screening requested today.
- One time HIV/HBV/HCV screen: Screened for HIV, HBV, and HCV last year, all results negative.
- Skin cancer screening: No concerning lesions noted.
- Depression (PHQ2/9): PHQ9 score of 3, indicating minimal depression.
- Anxiety (GAD2/7): GAD7 score of 2, indicating minimal anxiety.
- Med review: Medication list reviewed and confirmed.
- PSA discussion: PSA testing discussed, patient opted to defer.
- DEXA if at high risk: Not discussed.
- Colon CA screen: Screening colonoscopy discussed, patient agrees to schedule.
- AAA screen: Not discussed.
- Lung CA Screen: Not discussed.
- Advance Care Planning: Advance directive discussed, patient has a living will.
Medical Diagnoses:
1. Hypertension
2. Hyperlipidemia
Specialist Care:
1. Dr. Sarah Lee, Cardiologist
Medications:
1. Lisinopril 10 mg daily
2. Atorvastatin 20 mg daily
Review of Systems
Constitutional: No fever, chills, fatigue, or weight changes.
Eyes: No vision changes, redness, pain, or discharge.
Ears, Nose, Throat: No hearing loss, tinnitus, nasal congestion, rhinorrhea, sore throat, or dysphagia.
Cardiovascular: No chest pain, palpitations, or edema.
Respiratory: No shortness of breath, cough, or wheezing.
Gastrointestinal: No nausea, vomiting, diarrhea, constipation, or abdominal pain.
Genitourinary: No dysuria, hematuria, urinary frequency, or urgency.
Musculoskeletal: No joint pain, stiffness, or swelling.
Skin: No rashes, lesions, or itching.
Neurologic: No headaches, dizziness, numbness, or weakness.
Psychiatric: No anxiety, depression, or mood changes.
Endocrine: No polyuria, polydipsia, or heat/cold intolerance.
Hematologic/Lymphatic: No easy bruising, bleeding, or lymphadenopathy.
Allergic/Immunologic: No allergies, sneezing, or hives.
Physical Exam
Constitutional: Well-nourished, well-developed male in no acute distress.
Vital Signs: Blood pressure 130/85 mmHg, heart rate 72 bpm, respiratory rate 16 breaths/min, temperature 36.8°C.
Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops.
Respiratory: Clear to auscultation bilaterally, no wheezes, rales, or rhonchi.
Labs / Imaging / Diagnostic Tests:
1. Lipid panel from 6 months ago: LDL 120 mg/dL, HDL 50 mg/dL, Triglycerides 150 mg/dL.
Assessment & Plan
1. Preventive Care
Assessment: Patient is due for a colonoscopy as part of routine cancer screening.
Plan:
- Schedule colonoscopy.
- Continue current exercise and diet regimen.
- Follow up in 1 year for next annual wellness visit.
2. Hypertension (I10)
Assessment: Blood pressure is well-controlled on current medication.
Plan:
- Continue Lisinopril 10 mg daily.
- Monitor blood pressure at home.
- Follow up in 6 months for blood pressure check.
3. Hyperlipidemia (E78.5)
Assessment: Lipid levels are stable on current statin therapy.
Plan:
- Continue Atorvastatin 20 mg daily.
- Repeat lipid panel in 1 year.
Procedure Note:
Patient Name: John Doe
Date of Procedure: 1 November 2024
Procedure Performed: None
Indication: N/A
Pre-Procedure Diagnosis: N/A
Post-Procedure Diagnosis: N/A
Details of Procedure:
Consent: N/A
Preparation: N/A
Procedure Steps: N/A
Findings: N/A
Complications: None.
Post-Procedure Care:
Patient tolerated the procedure well.
Post-procedure monitoring: N/A
Follow-up plan: N/A
Medications Administered:
None.
Chief Complaint:
[Capture the major reason for the patient's visit today. If there is more than one, list these in bullet point format.]
HPI:
[Include a detailed explanation of the patient's current medical conditions, including onset, location duration, quality, aggravating factors, relieving factors, timing, and severity. Also include any interventions the patient has already tried to alleviate their symptoms and whether or not these were effective. If the patient has experienced this condition before, make mention of how it was treated last time and whether or not it was effective.] (New diagnoses made today and changes to medications made today should not be mentioned in this section.) (This section should be in numbered bullet point format organized by medical condition. If more than one distinct condition is discussed, organize the separate conditions by numbered bullet point lists.)
Male AWV (if any of the following points were not discussed, write "n/a" next to them)
- Nutrition: [include details regarding the patient's current diet]
- Exercise: [include details regarding the patient's current exercise regimen]
- Falls: [include any mention of recent falls along with any associated injuries]
- EtOH/Tobacco: [include details regarding the patient's current use of alcohol and tobacco]
- HTN screen: [include details regarding the patient's blood pressure today]
- Cholesterol: [include details regarding the patient's most recent LDL levels]
- 10 year CV risk %: [if a 10-year ASCVD risk is mentioned, list it here]
- STD screen: [if the patient requests STD screening today, mention it here. Also include any recent STD screening results]
- One time HIV/HBV/HCV screen: [if the patient has ever been screened for HIV, HCV, or HBV, mention those results here]
- Skin cancer screening: [mention any lesions concerning for possible skin cancer here] (if no lesions are mentioned, omit this line)
- Depression (PHQ2/9): [if symptoms of depression or a score on the PHQ2 or PHQ9 questionnaires are mentioned, detail those here]
- Anxiety (GAD2/7): [if symptoms of anxiety or a score on the GAD2 or GAD7 questionnaires are mentioned, detail those here]
- Med review: [if the patient's meds were confirmed with them, say "medication list reviewed and confirmed"]
- PSA discussion: [if obtaining a PSA was discussed, mention that decision here]
- DEXA if at high risk: [if obtaining a DEXA was discussed, mention that decision here]
- Colon CA screen: [if obtaining either a screening colonoscopy or Cologuard test was discussed, mention that decision here]
- AAA screen: [if screening for abdominal aortic aneurysm was discussed, mention those details here]
- Lung CA Screen: [if screening for lung cancer was discussed, mention those details here]
- Advance Care Planning: [if an advance directive was discussed, mention those details here]
Medical Diagnoses:
[Include a numbered list of the patient's medical diagnoses made prior to today's appointment.] (Organize this list by relevance to today's visit.)
Specialist Care:
[If patient is seeing any medical specialists, list them here in number list format. Include name and specialty.]
Medications:
[Include a numbered list of the medications the patient has been taking prior to today's visit including current dose and frequency. Use standard medical abbreviations.] (If none are mentioned, exclude this section and its heading.)
Substances:
[Include a numbered list of the illicit, non-prescription substances the patient has been using prior to today's visit.] (If none are mentioned, exclude this section and its heading.)
Supplements:
[Include a numbered list of the nutritional supplements the patient has been taking prior to today's visit.] (If none are mentioned, exclude this section and its heading.)
Review of Systems (This section should not include interpretations by the patient or physician. It should only include subjective signs and symptoms mentioned by the patient.)
Constitutional: [Capture any subjective findings reported by the patient regarding this organ system] (If nothing is noted in the transcript, write "No fever, chills, fatigue, or weight changes.")
Eyes: [Capture any subjective findings reported by the patient regarding this organ system] (If nothing is noted in the transcript, write "No vision changes, redness, pain, or discharge.")
Ears, Nose, Throat: [Capture any subjective findings reported by the patient regarding this organ system] (If nothing is noted in the transcript, write "No hearing loss, tinnitus, nasal congestion, rhinorrhea, sore throat, or dysphagia.")
Cardiovascular: [Capture any subjective findings reported by the patient regarding this organ system] (If nothing is noted in the transcript, write "No chest pain, palpitations, or edema.")
Respiratory: [Capture any subjective findings reported by the patient regarding this organ system] (If nothing is noted in the transcript, write "No shortness of breath, cough, or wheezing.")
Gastrointestinal: [Capture any subjective findings reported by the patient regarding this organ system] (If nothing is noted in the transcript, write "No nausea, vomiting, diarrhea, constipation, or abdominal pain.")
Genitourinary: [Capture any subjective findings reported by the patient regarding this organ system] (If nothing is noted in the transcript, write "No dysuria, hematuria, urinary frequency, or urgency.")
Musculoskeletal: [Capture any subjective findings reported by the patient regarding this organ system] (If nothing is noted in the transcript, write "No joint pain, stiffness, or swelling.")
Skin: [Capture any subjective findings reported by the patient regarding this organ system] (If nothing is noted in the transcript, write "No rashes, lesions, or itching.")
Neurologic: [Capture any subjective findings reported by the patient regarding this organ system] (If nothing is noted in the transcript, write "No headaches, dizziness, numbness, or weakness.")
Psychiatric: [Capture any subjective findings reported by the patient regarding this organ system] (If nothing is noted in the transcript, write "No anxiety, depression, or mood changes.")
Endocrine: [Capture any subjective findings reported by the patient regarding this organ system] (If nothing is noted in the transcript, write "No polyuria, polydipsia, or heat/cold intolerance.")
Hematologic/Lymphatic: [Capture any subjective findings reported by the patient regarding this organ system] (If nothing is noted in the transcript, write "No easy bruising, bleeding, or lymphadenopathy.")
Allergic/Immunologic: [Capture any subjective findings reported by the patient regarding this organ system] (If nothing is noted in the transcript, write "No allergies, sneezing, or hives.")
Physical Exam (Include both normal and abnormal findings explicitly mentioned in the transcript. Use proper, medical terminology. Only include headings for organ systems that are explicitly examined in the transcript. Leave out systems that are not mentioned. Do not include interpretations mentioned by the patient or physician, only objective signs and symptoms.)
Constitutional: [Capture any objective findings reported by the physician (not the patient) regarding this organ system]
Vital Signs: [Capture any objective findings reported by the physician (not the patient) regarding this organ system] [Include specific values if mentioned.]
Head: [Capture any objective findings reported by the physician (not the patient) regarding this organ system]
Eyes: [Capture any objective findings reported by the physician (not the patient) regarding this organ system]
Ears, Nose, Throat: [Capture any objective findings reported by the physician (not the patient) regarding this organ system]
Neck: [Capture any objective findings reported by the physician (not the patient) regarding this organ system]
Cardiovascular: [Capture any objective findings reported by the physician (not the patient) regarding this organ system]
Respiratory: [Capture any objective findings reported by the physician (not the patient) regarding this organ system]
Gastrointestinal: [Capture any objective findings reported by the physician (not the patient) regarding this organ system]
Genitourinary: [Capture any objective findings reported by the physician (not the patient) regarding this organ system]
Musculoskeletal: [Capture any objective findings reported by the physician (not the patient) regarding this organ system] (If specific joints, muscles, tendons, or ligaments are mentioned, create a specific bullet point for them and their exam findings. Be as specific as possible regarding these findings.) (Include the names of specific exam maneuvers and their results if mentioned by the physician.)
Skin: [Capture any objective findings reported by the physician (not the patient) regarding this organ system]
Neurologic: [Capture any objective findings reported by the physician (not the patient) regarding this organ system]
Psychiatric: [Capture any objective findings reported by the physician (not the patient) regarding this organ system]
Labs / Imaging / Diagnostic Tests:
[Include a numbered list of recent labs, bloodwork, imaging, and diagnostic test results which occurred prior to today's visit. Be as specific as possible. If mentioned in the transcript, include when the next follow up test should be conducted. Capture and detail any trends mentioned.]
Assessment & Plan (This entire section should use detailed, proper medical terminology. The first problem should always be Preventive Care.)
1. [Medical Diagnosis #1] [include the ICD10 code for this diagnosis]
Assessment: [Include a detailed assessment of this specific condition in paragraph style using complete sentences.] (When a diagnosis has not been confirmed with labs or imaging, include a differential diagnosis of 3 possible diagnoses in order of most likely to least likely.) (Include any changes in the condition since prior appointments or with recent interventions.)
Plan:
(Include a bullet point list for the plan with regard to this specific problem. Include all medications related to this problem and any changes in their dosing today Also include labs, tests, and referrals ordered today. If specific timeframes were discussed, mention these as well. Only include items specifically mentioned by the physician.)
(continue this pattern for all problems discussed in this visit)
Procedure Note: (Only include this section if a procedure was performed during today's office visit.)
Patient Name: [Insert patient name]
Date of Procedure: [Insert date]
Procedure Performed: [Insert procedure name]
Indication: [Insert reason for procedure]
Pre-Procedure Diagnosis: [Insert diagnosis or condition]
Post-Procedure Diagnosis: [Insert diagnosis, typically same as pre-procedure unless findings differ]
Details of Procedure:
Consent: Informed consent was obtained, including discussion of risks, benefits, and alternatives.
Preparation: [Insert preparation details, e.g., sterile technique, patient position, local anesthetic used].
Procedure Steps: [Describe the procedure in brief, step-by-step fashion].
Findings: [Insert findings, if any].
Complications: None. [Insert any complications if applicable.]
Post-Procedure Care:
Patient tolerated the procedure well.
Post-procedure monitoring: [Insert any specific monitoring or follow-up instructions].
Follow-up plan: [Insert follow-up plan, including any additional diagnostics or visits].
Medications Administered:
[Insert medications, dosages, and route if applicable].
