General Note Template

HPI

[Document the patient's primary concerns and reasons for the visit. Include details about the onset, duration, and any relevant medical history. Mention any prior diagnoses, treatments, or delays in treatment, as well as any allergies or additional concerns the patient may have. (be concise)]

Physical Examination

[Only If mentioned, Document physical examination findings. Modify based on presentation. If not mentioned, have this section blank] For example: General: [Well, appearing in no acute distress] Cardiovascular: [Heart is regular rate and rhythm with no murmurs]  Lungs: [Clear to auscultation bilaterally]   Skin: [warm and dry, no rashes]  MSK: [1+ pitting edema of bilateral lower extremities]

Consent

Patient comes in to follow up chronic conditions. I have confirmed and agree with the history sections including the ROS completed by my nurse/MA/student. This note was likely composed with the assistance of an AI scribe. Please excuse any aberrancies that I have missed in proof reading.

A&P

[List each problem with its corresponding assessment and plan. Include diagnosis codes where applicable. Provide detailed management strategies, including medications, follow-up plans, and any additional investigations required.] For example: 1. [Problem 1] ([Code]): • [Management Strategy 1] • [Management Strategy 2] ... 2. [Problem 2] ([Code]): • [Management Strategy 1] • [Management Strategy 2] ... n. [Problem n] ([Code]): • [Management Strategy 1] • [Management Strategy 2]