Annual Visit Progress Note-Karina

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Progress Note ([Date]) ([Phone Number]) [Gender] Chief Complaint: ANNUAL History of Present Illness: [patient name], a [age] year old [gender], presents today for: 1. ANNUAL: Overall, [Patient First Name] is doing well! [Patient First Name] is here with [Accompanying Person] who usually accompanies [Patient First Name]. [Patient First Name] follows with urology every six months, with the next appointment scheduled in [Next Appointment Month and Year]. [Patient First Name] is not currently taking tamsulosin or other related medications. No urinary symptoms reported. [Patient First Name] reports feeling well, with no symptoms concerning for cardiac or pulmonary etiology. [Patient First Name] denies chest pain, palpitations, or shortness of breath. [Patient First Name] denies abdominal pain, changes in bowel habits, or urinary difficulties. [Patient First Name] reports feeling well overall, with good appetite and sleep. No new symptoms or concerns were raised during the visit. Problem List: 1. [Condition 1] 2. [Condition 2] 3. [Condition 3] History: Past Medical History: Reviewed - [System]:[Condition 1] - [System]: [Condition 2] Social History: [List Relevant Social History in concise bullet point] [Immunization Type]: - Date Given: [Date/Time] -Location: [Location] -Type: [Type] -Reaction: [Reaction] -Lot Number: [Lot Number] Review of Systems: The following systems were reviewed and are negative except for documented below: [Systems Reviewed] Allergies: [Allergy Details] Vitals - [Time]: - Height: [Height] - Weight: [Weight] - BMI: [BMI] - BSA: [BSA] - Temperature: [Temperature] - [Method] - Blood Pressure: [Position]: [BP Measurement] - [Location]; [Heart Rate]Beats/Min - Pulse Oximetry: O2 Saturation: [O2 Saturation] Physical Exam: - General: [General Exam Findings] - Skin: [Skin Exam Findings] -Head: [Head Exam Findings] -Eyes: [Eye Exam Findings] -Ears: [Ear Exam Findings] -Throat: [Throat Exam Findings] -Neck: [Neck Exam Findings] -Cardiovascular: [Cardiovascular Exam Findings] -Respiratory: [Respiratory Exam Findings] -Gastrointestinal: [Gastrointestinal Exam Findings] -Neurologic: [Neurologic Exam Findings] -Psych: [Psychiatric Exam Findings] For example: (bold each subheadings) -General: No acute distress. Appears stated age. -Skin: Warm, dry, abnormal tone, hypopigmented macules on face and UEs w/ irregular borders, no rash, bruises, or lesions. -Head: Normocephalic, atraumatic. -Eyes: Pupils equal, round, reactive to light, extraocular movements intact, normal sclera, Erythema not present, no exudates present. -Ears: Normal tympanic membranes/ light reflex, normal external auditory canals. -Throat: No tonsil swelling, no tonsil exudates, no tonsil erythema, No Pharynx Swelling, No Pharynx redness. -Neck: Supple, no pain, no thyromegaly, no cervical lymphadenopathy. -Cardiovascular: Regular rate and rhythm, normal S1, normal S2, no murmurs, normal peripheral pulses, no edema. -Respiratory: Clear to auscultation bilaterally, non-labored breathing, speaking in full sentences. -Gastrointestinal: Soft, non-tender, no rebound, no guarding. -Neurologic: reflexes normal, normal gait, patellar reflex intact and symmetrical. - Psych: normal mood, normal affect, normal speech, normal concentration. Internal Lab Results: [Lab Test Name]: (bold the heading) - Results: [List Lab Result Details in bullet points] Diagnosis: - [ICD 10 Diagnosis Code 1]: [Diagnosis 1] - [ICD 10 Diagnosis Code 2]: [Diagnosis 2] - [ICD 10 Diagnosis Code 3]: [Diagnosis 3] Procedures: - [Procedure Code 1]: [Procedure Description 1] - [Procedure Code 2]: [Procedure Description 2] - [Procedure Code 3]: [Procedure Description 3] (include any modifiers) Treatment Plan: Today we discussed the following: 1. ANNUAL: [Condition 1]: - [Relevant Findings] - [Additional Notes] [Condition 2]: - [Relevant Findings] - [Additional Notes] [Condition 3]: - [Relevant Findings] - [Additional Notes] Preventative: - [Preventative Measure 1] - [Preventative Measure 2] - [Preventative Measure 3] - [Preventative Measure 4] Follow-up in [Timeframe] for [Purpose]. [Patient Name] knows to [Instructions]. [Time Spent] minutes was spent on total date of encounter. This time included, but was not limited to: reviewing [Patient Name]'s history/records, performing history/exam, counseling/coordinating care, and documenting clinical information. Orders: - [Order 1] for ([Order Purpose 1]) - [Order 2] for ([Order Purpose 2]) - [Order 3] for ([Order Purpose 3]) Stopped Medications: - [Medication Name] - [Reason]