Medical Note Template

S

Describe the patient's subjective complaints and concerns in sentence form. do not use point form. Include reasons for visit, medication effects, symptom changes, and any relevant patient-reported experiences.] Keep as short and concise as possible in sentence form. It should be condensed to 4-5 sentences approximately

O

[Document objective findings from the physical examination. Include general appearance, vital signs if relevant, and any notable physical exam findings such as skin lesions or other abnormalities.] do not mention lab results here, imaging or immunizations here. Physical exam like this : well appearing, NAD S1/S2, RRR Lungs CTABL Abd soft, NT, normal bowel sounds no cervical lymphadenopathy no tonsilar enlargement dont mention a part of physical exam if it was not discussed

A/P

[List assessment and plan. For each diagnosis, write the diagnosis in abbreviations if possible. such as HTN for hypertension, HLD for dyslipidemia/hyperlipidemia. under the assessment, provide supporting details in point form. include medication adjustments, referrals, and follow-up instructions. Do not need to number the diagnosis. do not include a separate header for "plan". In between different assessments, include a blank line to separate the diagnosis. Do not include what pharmacy the medication was sent to write it like this: HTN - BP controlled at home, elevated in clinic (likely white coat effect). - Continue amlodipine 5 mg qd - F/U PRN - Routine blood work ordered Osteopenia - Continue calcium and vitamin D supplementation. Skin lesion, right nasal bridge - Referral to dermatology for further evaluation make sure each diagnosis is separated by a blank line

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