Dr Shamoon's Template 1

History of Present Illness

[For each problem, provide a detailed narrative history including onset, duration, character, and associated symptoms, past investigations, and previous treatments tried. The problems should be in a numbered list, followed by the HPI for each problem in a list format using dashes (-). Do not include Management strategies or referrals to be done. keep it under 30 words.] For example: 1. [Problem 1]: - [Description and recent findings] - [Symptoms and onset] - [Relevant past medical history] - [Any other relevant thing that was discussed] 2. [Problem 2]: - [Description and recent findings] - [Symptoms and onset] - [Relevant past medical history] - [Any other relevant thing that was discussed] ... n. [Problem n]: - [Description and recent findings] - [Symptoms and onset] - [Relevant past medical history] - [Any other relevant thing that was discussed]

Physical Examination

[List the findings of the physical examination using dashes (-), including vital signs. If no vital signs have been performed this part should be left out of the note (e.g. if no BP has been recorded, exclude any mention of BP in the note). If there is no physical examination at all this section should be removed entirely. ] For example: BP: [Blood Pressure] Rt arm sitting HR: [Heart Rate] bpm - [Specific finding related to complaints or other observations] - [Specific finding related to complaints or other observations]

Assessment

[List the patient's medical problems in a numbered list For example: 1. [Problem 1] • [Differential diagnosis 1 with rationale.] • [Differential diagnosis 2 with rationale.] 2. [Problem 2] • [Differential diagnosis 1 with rationale.] • [Differential diagnosis 2 with rationale.] ... n. [Problem n] • [Differential diagnosis 1 with rationale.] • [Differential diagnosis 2 with rationale.]

Assessment

[List the patient's medical problems in a numbered list For example: 1. [Problem 1] • [Differential diagnosis 1 with rationale.] • [Differential diagnosis 2 with rationale.] 2. [Problem 2] • [Differential diagnosis 1 with rationale.] • [Differential diagnosis 2 with rationale.] ... n. [Problem n] • [Differential diagnosis 1 with rationale.] • [Differential diagnosis 2 with rationale.]

Plan

[Outline the management plan including ordered investigations, medication prescribed, patient instructions and follow-up plans, and any patient education provided in a list format using dashes (-).]

Plan

[Outline the management plan including ordered investigations, medication prescribed, patient instructions and follow-up plans, and any patient education provided in a list format using dashes (-).]