Lexi Grisdale - in clinic visit

Subjective

CC: [Insert Chief Complaint(s)] In clinic visit [Use a fixed, structured format. Each line must begin with a specific label, followed by a space, a hyphen, a space, and the exact patient-reported detail. Do not add quotation marks around responses. Do not rephrase or summarize answers. Do not rename labels—each label must appear exactly as written. Labels must match the following format exactly: Onset -, Location -, Better, worse, same -, Constant/intermittent -, Character -, Alleviating Factors -, Aggravating Factors -, Radiating -, Recurrent -, Timing -, Trauma -, Treatment -, Severity - …followed by any additional observations or symptoms, one per line, without labels. Maintain the original label order. Do not group, reorganize, or merge lines. Do not insert new headings like “Associated Symptoms” or “Pertinent Negatives.” Each symptom or observation must appear on its own line. Do not use paragraphs, bullets, or numbered lists. Do not reword, interpret, or restate anything. Format must be preserved exactly.]

Subjective

CC: [Insert Chief Complaint(s)] In clinic visit [Use a fixed, structured format. Each line must begin with a specific label, followed by a space, a hyphen, a space, and the exact patient-reported detail. Do not add quotation marks around responses. Do not rephrase or summarize answers. Do not rename labels—each label must appear exactly as written. Labels must match the following format exactly: Onset -, Location -, Better, worse, same -, Constant/intermittent -, Character -, Alleviating Factors -, Aggravating Factors -, Radiating -, Recurrent -, Timing -, Trauma -, Treatment -, Severity - …followed by any additional observations or symptoms, one per line, without labels. Maintain the original label order. Do not group, reorganize, or merge lines. Do not insert new headings like “Associated Symptoms” or “Pertinent Negatives.” Each symptom or observation must appear on its own line. Do not use paragraphs, bullets, or numbered lists. Do not reword, interpret, or restate anything. Format must be preserved exactly.]

Objective

[Each observation must appear on its own line using concise clinical shorthand. Do not use full sentences or explanatory phrasing. Do not include “the patient.” Each line must start with a capital letter and end with a period. Start with general observations, one per line: [mental status and orientation] [general appearance] [interaction and affect] [respiratory effort]]

Objective

[Each observation must appear on its own line using concise clinical shorthand. Do not use full sentences or explanatory phrasing. Do not include “the patient.” Each line must start with a capital letter and end with a period. Start with general observations, one per line: [mental status and orientation] [general appearance] [interaction and affect] [respiratory effort]]

system specific findings

[For system-specific findings, write the system label followed by a colon, then list all findings on the same line, separated by periods. Do not place any part of a system’s findings on a new line. Do not insert line breaks after the colon. Example: GI: Abdo soft. No distension. Non tender. No palpable masses. No guarding or rebound tenderness. BS x4. Tympanic. No HSM. Do not change abbreviations. Do not expand phrases. Do not reformat. Maintain this exact structure.]

Assessment

[Write each diagnosis on its own line using sentence case, not all caps. The diagnosis should begin with a capital letter, followed by lowercase unless using acronyms. If not yet diagnosed, include “NYD” after the condition name. If listing differentials, place them in parentheses starting with “ddx”, followed by a comma-separated list. Do not capitalize “ddx” or the differential terms unless they are acronyms (e.g., IBS-D, IBD). Do not use bullets, numbers, or any added formatting. Follow this format exactly: Chronic diarrhea NYD (ddx stress, IBS-D, IBD, infectious, diverticulitis, other) Do not change the casing, punctuation, or structure.]

Assessment

[Write each diagnosis on its own line using sentence case, not all caps. The diagnosis should begin with a capital letter, followed by lowercase unless using acronyms. If not yet diagnosed, include “NYD” after the condition name. If listing differentials, place them in parentheses starting with “ddx”, followed by a comma-separated list. Do not capitalize “ddx” or the differential terms unless they are acronyms (e.g., IBS-D, IBD). Do not use bullets, numbers, or any added formatting. Follow this format exactly: Chronic diarrhea NYD (ddx stress, IBS-D, IBD, infectious, diverticulitis, other) Do not change the casing, punctuation, or structure.]

Plan

[Write each plan item on its own line, and start every line with a dash. Use concise clinical phrasing. Include orders, patient instructions, lifestyle or dietary advice, safety netting, deferred items, and follow-up. Do not use paragraphs, numbers, or bullet points. Only use dashes. Maintain one line per item.] - [List any labs ordered, including specific tests and their purpose, such as ruling out specific conditions.] - [Mention any imaging studies ordered, including the type of imaging and the reason for ordering it.] - [Describe the patient's agreement to self-book appointments or tests, if applicable.] - [Summarize lifestyle modifications discussed, including any specific triggers for symptoms and patient awareness.] - [Detail dietary recommendations, including any specific diets reviewed and materials provided to the patient.] - [Include information on over-the-counter medications the patient can use, specifying conditions for use.] - [Note any topics that were not reviewed during the visit and plans to address them in future visits.] - [Review any red flags discussed with the patient and instructions on when to seek emergent care.] - [Outline follow-up plans, including timing and conditions for follow-up visits.]

Plan

[Write each plan item on its own line, and start every line with a dash. Use concise clinical phrasing. Include orders, patient instructions, lifestyle or dietary advice, safety netting, deferred items, and follow-up. Do not use paragraphs, numbers, or bullet points. Only use dashes. Maintain one line per item.] - [List any labs ordered, including specific tests and their purpose, such as ruling out specific conditions.] - [Mention any imaging studies ordered, including the type of imaging and the reason for ordering it.] - [Describe the patient's agreement to self-book appointments or tests, if applicable.] - [Summarize lifestyle modifications discussed, including any specific triggers for symptoms and patient awareness.] - [Detail dietary recommendations, including any specific diets reviewed and materials provided to the patient.] - [Include information on over-the-counter medications the patient can use, specifying conditions for use.] - [Note any topics that were not reviewed during the visit and plans to address them in future visits.] - [Review any red flags discussed with the patient and instructions on when to seek emergent care.] - [Outline follow-up plans, including timing and conditions for follow-up visits.]