Family general Template

Subjective

[Write Subjective findings in bullet point format. Use abbreviations and medical shorthand wherever possible. Only include essential information. Group each category of findings together, put new categories into a new paragraph, each category as a numbered list with spacing between them.] In the format of the following: 1. [Problem 1]: 2. [Problem 2] For example: Fever 5th day Today 37.1-37.3, last night 38- down after tylenol

Subjective

[Write Subjective findings in bullet point format. Use abbreviations and medical shorthand wherever possible. Only include essential information. Group each category of findings together, put new categories into a new paragraph, each category as a numbered list with spacing between them.] In the format of the following: 1. [Problem 1]: 2. [Problem 2] For example: Fever 5th day Today 37.1-37.3, last night 38- down after tylenol

Objective

[If mentioned, Document physical examination findings and relevant diagnostic test results. Include vital signs, imaging reports, and examination findings mentioned. (Write in bullet points, be concise, and use as many abbreviations as possible.)]

Objective

[If mentioned, Document physical examination findings and relevant diagnostic test results. Include vital signs, imaging reports, and examination findings mentioned. (Write in bullet points, be concise, and use as many abbreviations as possible.)]

Assessment and Plan

[List the assessment and planfor each diagnosis or problem with corresponding medical codes. For each, provide a brief summary including clinical features and concise differential diagnoses (DDx). Use the following format:] 1. [Diagnosis] ([Code]): [Brief description of the condition and clinical presentation.] - DDx: • [Differential diagnosis 1 with concise rationale.] • [Differential diagnosis 2 with concise rationale.] - Plan: - [Recommended treatment and management plan by the physician] - [Referral details and further assessment plans] - [Patient education and lifestyle modifications advised by the physician] - [Follow up & referral details] - [Other] [Repeat for each diagnosis or problem.] Example: 1. Right Shoulder Osteoarthritis (715.91): Chronic degenerative joint disease causing stiffness and pain in the right shoulder. - DDx: • Osteoarthritis: Supported by radiographic findings and clinical presentation. - Plan: • Send for imaging • Refer to rheumatologist 2. Shortness of Breath with Positional Chest Pain (786.05): Dyspnea worsened when lying flat, accompanied by chest pain on twisting movements. - DDx: • Cardiac dysfunction: History of myocardial infarction and stent placement suggests possible cardiac etiology. • Pulmonary causes: Less likely given clear lung examination and absence of cough or sputum. - Plan: • Send referral to cardiologist • Advise patient to use Aspirin if pain intensifies and seek Emergency