Dr. Levental Template

S

S: [Do not use the patient's name or age, use "Patient presents with". For each health issue, provide detailed narrative including current symptoms, history, relevant past medical history, medication use, and any recent changes or concerns.] (Have each category of concern as a numbered list, use point form for each problem) Example: 1. [Problem 1]: [Detailed description and recent findings] [Symptoms and onset] [Management strategies] [Relevant past medical history] [Any other relevant thing that was discussed] 2. [Problem 2]: [Detailed description and recent findings] [Symptoms and onset] [Management strategies] [Relevant past medical history] [Any other relevant thing that was discussed]

O

O: [Only Include vital signs that have been taken during the patient encounter. Exclude vital signs that are not mentioned in the transcript. Blood pressure, pulse, O2 saturation, temperature, respiration rate, weight, height, and Body Mass Index.]. [Document only the systems that have been examined during the encounter. List each system in a bulleted list with the corresponding findings on the same line.] For example: General: Patient appears well-groomed, well-nourished, and in no acute distress. Head: Normocephalic Eyes: PERRLA, no conjunctival pallor or scleral icterus Neck: Neck supple, trachea midline, thyroid not palpable Respiratory: Lungs clear to auscultation bilaterally, no wheeze or crackles Cardiovascular: Normal rhythm, no abnormal heart sounds, murmur, or pericardial rub Abdomen: Soft, non-tender, non-distended, no masses or hepatosplenomegaly Genitourinary: Freely voiding, no urinary symptoms, prostate examination as applicable Musculoskeletal: Full range of motion in all joints with no signs of tenderness or swelling Neurological: Alert and oriented x3, normal gait, cranial nerves 2-12 grossly intact [List any investigations ordered or reviewed, such as fasting lipids, Hemoglobin A1C if diabetic, PSA if patient is of appropriate age and has agreed to screening, urinalysis if indicated, CBC, CMP.] [If televisit, where the doctor is calling the patient - put "Deferred" and nothing else]

A/P

A/P: [For each diagnosis or problem, Provide a detailed narrative that outlines the management plan, including investigations, referrals, treatments, patient education, and follow-up.(Have each diagnosis as a numbered list format. Use point form)] Example: 1. [Problem 1]: [Recommended treatment and management plan] [Referral details and further assessment plans] [Patient education and lifestyle modifications] [Follow up & referral details] [Other] 2. [Problem 2]: [Recommended treatment and management plan] [Referral details and further assessment plans] [Patient education and lifestyle modifications] [Follow up & referral details] [Other]