Annual Visit Template by Karina

Chief Complaint

History of Present Illness

[Patient First Name], a [Patient Age] year old [Patient Gender], presents today for: [Provide a detailed account of the patient's current health status. Include information about any ongoing treatments, follow-up schedules, symptoms, or lack thereof. Mention any accompanying individuals and their relationship to the patient. Summarize the patient's overall well-being and any specific concerns raised during the visit.] for example: 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

[List the patient's current medical problems ] 1. [Medical Problem 1] 2. [Medical Problem 2] ... [n. Medical Problem n]

History

Past Medical History [Summarize the patient's past medical history, including any relevant conditions or diagnoses.] Example: - Reviewed - Genitourinary: [Condition] - Neurologic: [Condition]

Social History

[List the patient's social history in concise and bullet point, including living situation, family dynamics, smoking status, and other relevant lifestyle factors.]

Immunizations

[List the patient's immunization history, including dates, details and any reactions if applicable.] For example: Influenza: [Date Given] - Location [location] - Type: [type] - Reaction: [reaction, or "None"] - Lot Number: []

Review of Systems

[Document the systems reviewed and note any positive findings. If all systems are negative except for documented findings, state this explicitly.] Example: The following systems were reviewed and are negative except for documented below: General, Eyes, ENT, Heart, Lungs, Gastrointestinal, Genitourinary, Skin, Neurologic, Hematologic/Lymphatic, Musculoskeletal and Psychiatric

Allergies

[List any known allergies, including medications, foods, or environmental factors.] Example: - [Allergen]: [Reaction]

Vitals

[List the patient's vital signs in bullet point, including height, weight, BMI, temperature, blood pressure, pulse, and oxygen saturation.] [Time] Example: - Height: [Value] - Weight: [Value] - BMI: [Value] - Temperature: [Value] - Blood Pressure: [Value] - Pulse: [Value] - O2 Saturation: [Value]

Physical Exam

[Document the findings from the physical examination, organized by system.] 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

[List the results of any lab tests performed during the visit in bullet point] [Lab test name]: -Results: [] Example: - Urinalysis: - Color: [Value] - Leukocytes: [Value] - Nitrites: [Value] ...

Diagnosis

[List each diagnosis code followed by its description in bullet point. Ensure to include the ICD 10 code and the corresponding medical condition. ] - [ICD diagnosis code 1]: [short diagnosis term] - [ICD diagnosis code 2]: [short diagnosis term]

Procedures

[List any procedures performed during the visit, including their descriptions and codes.] Example: 1. [Procedure code 1]: [Description] 2. [Procedure code 2]: [Description] ...

Treatment Plan

[Outline the treatment plan discussed during the visit. Include details about monitoring, follow-up appointments, preventative measures, and any patient education provided.] Example: Today we discussed the following: 1. ANNUAL: [Condition 1]: - [description] - [Plan] [Condition 1]: - [description] - [Plan] [n. Condition]: - [description] - [Plan] [Preventative] - [Indicate the status of the flu vaccination for the current season. Advise on where the patient can update it if necessary.] - [Discuss any other vaccinations such as shingles and pneumonia. Note any plans for the patient to discuss these at the pharmacy.] - [Provide the status of the colonoscopy, including the last update and when the next one is due.] - [State the status of dental care.] - [State the status of optometry care and any corrective measures used.] - [Mention any annual labs drawn and the plan for communicating results.] - [Include the status of the urinalysis and any personal review or interpretation of the test.] Follow-up in [time frame] for annual. Pt knows to RTC prn for any new or worsening sx.

Time Spent

[Document the total time spent on the encounter, including reviewing history, performing the exam, counseling, and documenting.] Example: [total time] minutes was spent on total date of encounter. This time included, but was not limited to: reviewing pt's hx/records, performing hx/exam, counseling/coordinating care, and documenting clinical information.

Orders

[List any orders placed during the visit, such as lab tests, imaging, or referrals.] Example: - [Test Name] for [Reason] - [Referral to Specialist] for [Reason]

Stopped Medications

[List any medications that were discontinued during the visit, along with the reason if applicable.] Example: - [Medication Name] - [Reason]