Family general Template

Subjective

[For each health issue, provide information including current symptoms, history, relevant past medical history, medication use, and any recent changes or concerns. (Use bullet point for clarity)]

Subjective

[For each health issue, provide information including current symptoms, history, relevant past medical history, medication use, and any recent changes or concerns. (Use bullet point for clarity)]

Objective

[Document physical examination findings, vital signs, and results of any recent diagnostic tests or imaging studies relevant to the patient's current complaints. Include specific details such as dates of imaging, measurements, and clinical observations.] For example: Vital signs: BP [value], HR [value], etc. [Imaging study and date] shows [findings]. [[For physical examination: 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 ] [If it's a televisit or phone visit, write "Phone visit"]

Objective

[Document physical examination findings, vital signs, and results of any recent diagnostic tests or imaging studies relevant to the patient's current complaints. Include specific details such as dates of imaging, measurements, and clinical observations.] For example: Vital signs: BP [value], HR [value], etc. [Imaging study and date] shows [findings]. [[For physical examination: 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 ] [If it's a televisit or phone visit, write "Phone visit"]

Assessment

[List each relevant diagnosis or problem on the same line and add '/' in between each diagnosis.] Assessment: [Assessment 1/ Assessment 2] Example: Assessment: Mental Health Disorders (unspecified)/ Right Shoulder Osteoarthritis / Shortness of Breath with Positional Chest Pain

Assessment

[List each relevant diagnosis or problem on the same line and add '/' in between each diagnosis.] Assessment: [Assessment 1/ Assessment 2] Example: Assessment: Mental Health Disorders (unspecified)/ Right Shoulder Osteoarthritis / Shortness of Breath with Positional Chest Pain

Plan

[Provide a detailed plan that outlines the management plan, including investigations, referrals, treatments, patient education, and follow-up.(Have each plan as a numbered list format, and follow with '-'] For example: 1 - [Recommended treatment and management plan] 2 - [Referral details and further assessment plans] 3 - [Patient education and lifestyle modifications] 4 - [Follow up & referral details] 5 - [Other]

Plan

[Provide a detailed plan that outlines the management plan, including investigations, referrals, treatments, patient education, and follow-up.(Have each plan as a numbered list format, and follow with '-'] For example: 1 - [Recommended treatment and management plan] 2 - [Referral details and further assessment plans] 3 - [Patient education and lifestyle modifications] 4 - [Follow up & referral details] 5 - [Other]