IM New Patient

Chief Complaint

General medical consultation

Template

[Briefly describe the reason for referral, including the patient's name, [age], and their referring/family physician] History of Presenting Illness [Provide a detailed account of the patient's history related to the presenting illness, including diagnosis, treatment, and any significant events or complications. List any symptoms [pronoun] report having or not having as well. Use paragraph format.] [Provide information about the patient's occupation, smoking status, alcohol consumption, and insurance coverage. Use paragraph form. Start each sentence with a capital letter.] Past Medical History [List any relevant past medical conditions or surgeries. Use paragraph format. Start each sentence with a capital letter.] Medications [List the patient's current medications, including [dosage] and [frequency]. Use paragraph format. Start each sentence with a capital letter.] Family History [Describe any relevant family medical history. Use paragraph form. Start each sentence with a capital letter.] Physical Examination [Record the patient's [vital_signs] and physical examination findings, organized by body system. Use paragraph form. Start each sentence with a capital letter.] Investigations: [List relevant laboratory results or investigations, including [dates], [test_names], and [values]] [If stress test was completed or mentioned, List [resting_heart_rate], [maximum_heart_rate], [total_time], [METs], any [ST_changes], [resting_EKG], and if it was a normal stress test. Use paragraph form. Start each sentence with a capital letter.] Summary [Summarize the key points discussed with the patient, including advice given, referrals made, and plans for follow-up. Use paragraph form. Start each sentence with a capital letter.] Plan [Provide a numbered list of the plan and recommendations, including any [medications], [referrals], or [tests] ordered, keep it short. Start each sentence with a capital letter.] Thank you very much for the kind referral. If you have any questions, don't hesitate to reach out.