GeriCare Acute Template update

Chief Complaint

[Document the patient's chief complaint, including the reason for the visit, any follow-up concerns, and specific symptoms or issues being addressed. Include details such as onset, duration, and severity of symptoms.]

HPI

[History of present illness or reason for acute visit. Please reiterate in section that the visit is medically necessary.][ add personalization information from encounter transcript to add individualization of note]

Past Medical History

[List the patient's past medical history, organized by system with a space between each system. Include any chronic conditions, previous diagnoses, and relevant medical history.] For example: Circulatory System: [Condition 1], [Condition 2] Endocrine & Metabolic: [Condition 1], [Condition 2] Gastrointestinal: [Condition 1], [Condition 2] ... (continue for other systems)

Social History

[Document the patient's social history, including smoking status, alcohol use, code status, and any other relevant social factors.] For example: Current smoking status: [Smoking status] Code Status: [Code status]

Current Medications

[List all current medications with space between each medication, including over-the-counter medications, prescriptions, and supplements. Include dosage, frequency, route, and any special instructions.] For example: 1. [Medication Name] ([Generic Name]) [OTC/Prescription] - Dosage: [Dosage] - Frequency: [Frequency] - Route: [Route] - Special Instructions: [Instructions]

Allergies

[List any known allergies, including drug, environmental, or food allergies. Include the type of reaction if known.] For example: - Latex: [Reaction] - No Known Drug Allergies

Review of Systems (ROS)

[Document a review of systems, organized by system. Include any positive findings and note if other systems are negative.] For example: Constitutional: [Findings] ENMT: [Findings] Respiratory: [Findings] Gastrointestinal: [Findings] ... (continue for other systems)

Vitals

[Document the patient's vital signs, including temperature, respirations, blood pressure, heart rate, and oxygen saturation.] For example: - Temperature: [Value] F - Respirations: [Value] breaths/min - Blood Pressure: [Value] mmHg - Heart Rate: [Value] beats/minute - O2 Saturation: [Value]%

Physical Exam

[Document the findings of the physical exam, organized by system. Include any abnormalities or notable findings.] For example: General: [Findings] Eyes: [Findings] ENT: [Findings] Respiratory: [Findings] ... (continue for other systems)

Assessment/Treatment Plan

[Document the assessment and treatment plan with a space between each assement, including diagnoses, procedures, and any new or adjusted medications. Include the rationale for treatment decisions and any follow-up instructions.] For example: Diagnosis: 1. [Diagnosis Code]: [Diagnosis Description] ([Details of treatment plan]) Procedures: - [Procedure Code]: [Procedure Description] [Include details about the time spent during the visit and the activities performed, such as face-to-face exam, counseling, and documentation.]

Provider Signature

[providers name and NP]

Electronic Documentation / Voice Recognition Disclaimer:

This document was generated using electronic transcription and voice recognition technology; please excuse any transcription errors or omissions not identified or corrected during proofreading.