Medical Note Template -- General Medical Encounter

Chief Complaint

Medical Note Template -- General Medical Encounter

HISTORY OF PRESENT ILLNESS

[introduce patient with age, summary of issues, and last time seen in clinic if follow up] [State detailed history of present illness in narrative format]

PAST MEDICAL HISTORY

[List if any in bullet point]

SURGICAL HISTORY

[List if any, do not include header if no surgery mentioned]

CURRENT MEDICATIONS

[List current medications, Vitamin, and supplements or note if there are none.]

DRUG ALLERGIES

[List if any, or state NKDA]

FAMILY HISTORY

[List if any, or state No history of allergies or immunodeficiency]

REVIEW OF SYSTEMS

[List this review of systems and add appropriate positive if noted Review of Systems - Constitutional: No fever, weight loss, or fatigue. - Eyes: No vision changes or eye pain. - ENT: No hearing loss, nasal congestion, or sore throat. - Cardiovascular: No chest pain or palpitations. - Respiratory: No shortness of breath or cough. - Gastrointestinal: No nausea, vomiting, or diarrhea. - Genitourinary: No dysuria or hematuria. - Musculoskeletal: No joint pain or swelling. - Skin: No rashes or itching. - Neurological: No headaches or dizziness.]

SOCIAL HISTORY/ENVIRONMENTAL HISTORY

- Work: [Describe patient's work environment, do not include if not mentioned] - Smoking: [Indicate smoking status, do not include if not mentioned] - Etoh: [Indicate alcohol use, do not include if not mentioned] - Marijuana: [Indicate marijuana use, do not include if not mentioned] - Home: [Describe home environment, do not include if not mentioned] - Heating: [Describe heating system, do not include if not mentioned] - Carpet: [Indicate presence of carpet, do not include if not mentioned] - Pets: [Indicate presence of pets, do not include if not mentioned] - Mold: [Indicate if any mold or water damage in household or workplace, do not include if not mentioned]

EXAMINATION

[Provide a summary of the patient's general appearance and any notable findings from the rhinologic exam, including the presence or absence of rhinitis, polyps, or turbinate hypertrophy. Include details of the cardio-respiratory examination and any dermatological observations such as eczema or hives. Use a narrative paragraph style to maintain consistency with the input content.]

INVESTIGATIONS

[List if any, record the specific measurement mentioned including records reviewed from outside provider if indicated and testing done in house on today's evaluation including review of labs, imaging, allergy skin testing, food and drug challenge results, spirometry or pulmonary function testing and exhaled nitric oxide]

DIAGNOSIS

[Generate appropriate diagnosis based on the transcript] [Generate appropriate ICD10 code for the diagnosis provided]

PLAN:

[Generate plan based on the transcript, list in bullet point] [Indicate when patient was reminded to follow up for next visit and include and schedule testing/procedures that are planned]

LEVEL OF SERVICE

[Generate appropriate CPT code level of service based on a new patient or follow up visit, including criteria for selection based on duration of visit or complexity of medical decision-making]