A2 MASTER TEMPLATE Multiple Issues version

CC and HPI

(If Single Issue) [Patient First Name] came to discuss [symptom/concern } . [Patient First Name] reports symptoms since [duration]. If multiple issues : - Merge the HPI, Objective, Assessment, and Plan sections from all templates into single consolidated sections for clarity and conciseness. Use Data from Draft Summary and from Notepad [For each health issue discussed, provide detailed information including current symptoms, history, relevant past medical history, medication use, and any recent changes or concerns. Use format as in the example below] (Have each category of concern as a numbered list, use point form for each problem, provide a detailed but concise set of information in story format. Present each problem in its own paragraph, maintaining a narrative style. ) Example: 1. [Problem 1]: - [Detailed description and recent findings] - [Symptoms and onset] - [Relevant past medical history] - [Any other relevant thing that was discussed] 2. [Problem 2]: - [Detailed description and recent findings] - [Symptoms and onset] - [Relevant past medical history] - [Any other relevant thing that was discussed] (Content of issues) Document onset, duration, timing, location, quality, severity, context, aggravating/relieving factors, and self-treatment. Document if condition has been treated by different MD, for example - emergency room doctor , walk in clinic doctor or a specialist. Do not make it part of the encounter if only explicitly discussed with the patient. Document the following issues only if patient presents for ANNUAL exam or discussed mentioned below , please document and put in {} brackets as following if mentioned : {Preventative care: |FIT-FOBT| [not done will ref| has referral, test not done yet] [last done per guideline - no need for fup] PAP [not done will ref| has referral, test not done yet] [last done per guideline - no need for fup]| Mammogram[not done will ref| has referral, test not done yet] [last done per guideline - no need for fup]| BMD [not done will ref| has referral, test not done yet] [last done per guideline - no need for fup]| Immunisation : Pneumo | Td| other |} [not done will ref| has referral, test not done yet] [last done per guideline - no need for fup] {Social History: Lives with| wife|husband|kids.| Works as .| Retired.| Alcohol -social.|Not smoker.|Currently smokes about .| No illicit drug use.| Socializing with peers.| Physically active| swimming| gym| walking| Physically not active.| Sex Hx: sexually |not |active|. Is in stable relationship. LMP: | contraception|not active|condoms|pulling out|. | CPP reviewed in terms of PMHx,MEDS, Allergies and Family Hx: [no changes w previous][significant for ] }

ON EXAM

(Content) Include only physical exam findings (vitals, palpation, auscultation, physical exam) performed by the or mentioned by physician during the encounter. (Exclusion) Do not include "patient says" statements or "investigation results" here. (Format) Vitals: Omit this section if not mentioned explicitly. BP: [###/##], HR: [##], Temp: [##.#], RR: [##], SpO₂: [##%] Physical Exam: {ANORM} (List specific findings or pertinent negatives, each system on a new line only if mentioned). If patient came for ANNUAL exam or discussed mentioned below , please document as following : OBJECTIVE Vitals: 2026-Jun-02: Constitutional Symptoms: NAD. Not pale, no jaundice. Eyes: PERLA. Normal EOROM. ENT: Anterior and posterior cervical ,supraclavicular lymph nodes are not enlarged and not tender . Axillary lymph nodes are not enlarged and not tender. Oropharynx clear . Nasal mucosa normal . Both ears normal exam Thyroid gland is: not enlarged ,no nodules on palpation Cardiovascular: Regular S1 S2. Respiratory: Good air entrance both sides. Normal lung sounds both sides Gastrointestinal: Abdomen no skin changes ,not distended ,normal bowel sounds , soft not tender , liver/spleen/kidneys not palpable ,no CVA/suprapubic tenderness. . Extremities: Not limping. Normal muscle power, peripheral pulses and sensation normal in all extremities. No peripheral edema noted. Skin: Normal tone and turgor, no obvious rash. Mucosal membranes are moist. Neurological: Grossly normal. Psychiatric: Appears stated age, dressed, groomed. No SI, no HI. Mood is "as usual" .

ASSESSMENT

(Format - Numbered list corresponding to the HPI). (Differential Logic For every diagnosis, include the most common and most dangerous differential in curved brackets with a vertical separator.) Example: 1. Left wrist pain {Osteoarthritis | Septic Arthritis} 2. Elevated Cholesterol {Dietary hyperlipidemia | Familial Hypercholesterolemia}

COUNSELING

(Mandatory Preamble): Document the following in brackets {} as it is written use | when it is appear inside the brackets even if this was not mentioned during encounter: {We had a long chat with [Patient First Name] [and family members]. | We discussed with [Patient First Name] |symptoms|, findings on exam|, available investigations report|, imaging results| , specialists notes|, ER discharge.| We reviewed significance and consequences of findings. } New paragraph: Document the following in brackets {} as it is written even if this was not mentioned during encounter: {Discussed ways to manage symptoms. | Discussed healthy lifestyle role of regular, moderate physical activities . | Discussed proper use of medical resources and importance of regular checkups, | role preventive health care visits,| walk in clinic hours and use. |Advised use of outside walk in clinic may affect our patient physician relationships, since I do not have access to outside information. | Reviewed ABCDE of melanoma, advised to avoid sun exposure, to use protective clothing. } (Investigation Discussion: Immediately follow the preamble with the discussion of reports.) Example: "Specialist report/Imaging reviewed showed [insert findings]. We discussed that [X] confirmed [Y]." Issue-Specific Counseling: (Numbered list matching Assessment)

MEDICATIONS

Pull the list from Draft Summary . Numbered list of medications discussed/renewed. Include side effects. (Boilerplate) (Mandatory type in brackets) For example: {pain | Rx provided per patient's request. | We reviewed and renewed patient’s medications. | We agreed patient will do blood work prior to the next renewal. | We discussed pharmacological treatment options for patient's symptoms. | No interactions were found for patient's medication profile.} 1. [Naproxen]: [375 mg BID with food for a week. Discussed common side effects : GI irritation, GERD, Ulceration, Elevated BP, may affect kidneys function. ] 2. [mediation 2]: {pain | Rx provided per patient's request. | We reviewed and renewed patient’s medications. | We agreed patient will do blood work prior to the next renewal. | We discussed pharmacological treatment options for patient's symptoms. | No interactions were found for patient's medication profile.}

REFERRALS and FUP

Document referrals (e.g., Cardiology, Ultrasound) and planned investigations. Include only explicit physician instructions, next steps, or referrals discussed in the transcript. Do not generate or extrapolate new management plans. Document the following in brackets {} as it is written even if this was not mentioned during encounter: {Referral provided to follow up with |specialist| lab| ER|. Patient was given a copy of referrals. | Regular follow with me scheduled. | Follow up with me or our walk-in clinic if red flags occur.}Document above mentioned in this section in brackets {}. Example: I advised patient to continue current antihypertensive medication and repeat blood pressure check in 4 weeks. Investigations If investigations were ordered or reviewed: State the reason and source. Example: Investigation ordered to reassess symptoms of fatigue. We reviewed MRI ordered by orthopedic specialist. Education / Counselling Include any direct statements by the physician providing patient education, lifestyle advice, or reassurance. Example: We discussed importance of consistent exercise and dietary management. Include only if explicitly mentioned. Example: Follow-up: 3 months or sooner if symptoms worsen. Language & Formatting Guidelines Use clear, neutral medical language. Avoid speculative or interpretive phrases (e.g., “likely,” “appears,” unless stated by physician). Maintain chronological order of discussion. Avoid duplication across sections. Do not summarize beyond what’s explicitly said—no paraphrasing of unstated meaning.