General Practitioner Template

Medical Summary Report Notes

A professional General Practitioner template for healthcare professionals.

About this template

The Medical Summary Report Notes template is an essential tool for General Practitioners to document comprehensive patient information. This template captures patient demographics, medical history, current clinical status, diagnostic findings, assessment, and plan of care. It is designed to provide a detailed overview of a patient's health, facilitating effective communication and continuity of care. This template is particularly useful for summarizing complex cases and ensuring all relevant information is easily accessible. Ideal for use in Heidi, it streamlines the documentation process, allowing GPs to focus on patient care.

Preview template

Patient Demographics: - Name: John Doe - Date of Birth: 15 March 1980 - Gender: Male - Identification Number: 123456789 Medical History: - Past Medical History: Hypertension, Type 2 Diabetes, Appendectomy in 2010 - Family History: Father had coronary artery disease, mother has osteoporosis - Social History: Non-smoker, occasional alcohol use, works as an accountant, lives with family - Allergies: Penicillin Current Clinical Status: - Chief Complaint: Persistent cough and shortness of breath - History of Present Illness: The patient reports a persistent cough for the past two weeks, accompanied by shortness of breath, especially during physical exertion. No fever or chest pain reported. - Medications: Metformin 500mg daily, Lisinopril 10mg daily Diagnostic Findings: - Laboratory Tests: Elevated blood glucose levels, HbA1c at 7.5% - Imaging Studies: Chest X-ray shows mild bilateral infiltrates - Specialist Consultations: Pulmonologist consultation recommended for further evaluation Assessment: - Diagnoses: Acute bronchitis, poorly controlled Type 2 Diabetes - Problem List: Persistent cough, shortness of breath, elevated blood glucose levels Plan of Care: - Treatment Plan: Prescribe a course of antibiotics for bronchitis, adjust diabetes medication to improve glycemic control, recommend increased physical activity - Rehabilitation Plan: Not applicable - Prognosis: Good, with adherence to treatment and lifestyle modifications Progress Notes: - Clinical Progress: Patient to be reviewed in two weeks to assess response to antibiotics and changes in diabetes management - Updates to Plan of Care: Adjustments to be made based on follow-up results Summary and Recommendations: - Executive Summary: The patient presents with symptoms of acute bronchitis and poorly controlled diabetes. Immediate treatment initiated with antibiotics and medication adjustments. - Recommendations: Follow-up with GP in two weeks, consider referral to a pulmonologist if symptoms persist.

Patient Demographics: - Name: [Enter Patient’s Full Legal Name] (only include if explicitly mentioned in the consultation or medical records) - Date of Birth: [Enter Date of Birth] (only include if explicitly mentioned, used to identify the patient's age, which can be relevant to the medical condition) - Gender: [Enter Gender] (only include if explicitly mentioned, may influence disease risk and treatment response) - Identification Number: [Enter Patient Identification Number] (only include if explicitly mentioned, such as Social Security number or patient ID) Medical History: - Past Medical History: [Enter Past Medical History] (only include if relevant, summarize past diseases, surgeries, hospitalizations, and their outcomes) - Family History: [Enter Family History] (only include if relevant, mention any significant diseases or conditions that run in the family) - Social History: [Enter Social History] (only include if relevant, include lifestyle factors such as smoking, alcohol use, occupation, and living conditions) - Allergies: [Enter Known Allergies] (only include if relevant, list all known allergies, especially drug allergies, food, and environmental allergies) Current Clinical Status: - Chief Complaint: [Enter Chief Complaint] (only include if explicitly mentioned, describe the patient's primary concern or symptom) - History of Present Illness: [Enter History of Present Illness] (only include if explicitly mentioned, provide a detailed description of the current complaint, including the onset, duration, and any associated symptoms) - Medications: [Enter Medications] (only include if explicitly mentioned, list current prescriptions, over-the-counter drugs, and supplements) Diagnostic Findings: - Laboratory Tests: [Enter Laboratory Test Results] (only include if explicitly mentioned, include results of blood tests, urine tests, or any other laboratory results) - Imaging Studies: [Enter Imaging Studies Results] (only include if explicitly mentioned, list results of X-rays, MRIs, CT scans, or any imaging studies conducted) - Specialist Consultations: [Enter Specialist Consultations] (only include if applicable, provide the opinions and findings of specialist doctors, if relevant) Assessment: - Diagnoses: [Enter Diagnoses] (only include if explicitly mentioned, list all current diagnoses based on the patient’s medical history and diagnostic findings) - Problem List: [Enter Problem List] (only include if applicable, list and prioritize the patient's medical issues that need management) Plan of Care: - Treatment Plan: [Enter Treatment Plan] (only include if explicitly mentioned, provide a detailed description of the therapeutic approach, including medications, surgeries, therapies, and lifestyle changes) - Rehabilitation Plan: [Enter Rehabilitation Plan] (only include if applicable, outline the rehabilitation goals and methods to be implemented) - Prognosis: [Enter Prognosis] (only include if explicitly mentioned, provide the expected outcome of the condition and treatment) Progress Notes: - Clinical Progress: [Enter Clinical Progress] (only include if applicable, document the patient’s response to treatment over time, including improvements or setbacks) - Updates to Plan of Care: [Enter Updates to Plan of Care] (only include if applicable, document any changes made to the treatment plan based on the patient's progress) Summary and Recommendations: - Executive Summary: [Enter Executive Summary] (only include if explicitly mentioned, summarize the patient's condition, highlighting the most critical aspects of the medical report) - Recommendations: [Enter Recommendations] (only include if explicitly mentioned, outline the next steps for treatment, further testing, or referrals to specialists) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and 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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