Meet and greet Template

HPI

[Provide a detailed narrative of the patient's subjective complaints organized by system or problem. For each problem, include onset, duration, character, severity, associated symptoms, treatments tried, and relevant diagnostic information in bullet points.] (Have problem in number list and each details as '-' under each corresponding problem) For example: 1. [Problem 1]: - [Detailed description] - [Detailed description] 2. [Problem 2]: - [Detailed description] - [Detailed description] 3. [Problem 3]: - [Detailed description] - [Detailed description] ...

Past Medical History

[List significant past medical conditions, illnesses, surgeries, or hospitalizations relevant to the patient's current health status. Include frequency or recurrence if applicable.] (Write it in Number-list with no ICD Code) Example: 1. Chronic kidney disease 2. Hypertension 3. Overweight

Social History and Lifestyle

[Describe the patient's occupation, lifestyle habits, substance use history (alcohol, tobacco, drugs), and any other social factors impacting health. Include duration and cessation details if relevant.] (Write it in bullet points for clarity)

Family Hx

[Summarize pertinent family medical history including diseases or conditions affecting immediate and extended family members. Specify relation and condition.] (Write it in bullet points for clarity)

Medications and Allergies Review

[Provide a current list of medications the patient is taking, including dosages and frequency when mentioned; otherwise, only provide the medication name that's mentioned. Do not write any other extra words] - [Medication Name] [Dosages] [Frequency] - [Medication Name] [Dosages] [Frequency] [Document any known allergies or adverse reactions.]

Primary Prevention Review

[Document preventive health measures including screening tests due or completed (e.g., cancer screenings), vaccination status, and other relevant preventive care. Include due dates or planned interventions.] (Write it in bullet points for clarity)

Objective

[Document physical examination findings, vital signs, and results of any recent diagnostic tests or imaging studies relevant to the patient's current complaints. Include specific details such as dates of imaging, measurements, and clinical observations.] For example: - [Provide blood pressure readings in clinic and at home, including average values and any significant changes since medication initiation.] - [Summarize findings from the physical exam, if detailed.] - [Include details of recent laboratory tests, specifying the date and type of panel conducted.] - [Provide information on the last ECG, including the date.] - [Summarize colonoscopy findings, including the number of polyps removed and follow-up recommendations.] - [Detail autoimmune serology results, including ANA and ENA status and relevant dates.] - [Summarize MRI findings, noting any significant pathologies or changes compared to previous scans.] - [any other objective information mentioned]

Assessment

[list all relevant diagnosis in number list with ICD code] For example: 1. Elevated Prostate-Specific Antigen (PSA) (790.93) 2. History of Bronchial Pneumonia (485) 3. General Health Screening (V70.0) due to his occupation

Plan

[List all detailed management plan. Include differential diagnoses if applicable. Specify medications, dosages, follow-up plans, referrals, and any additional investigations required.] For example: 1. [Management Plan] 2. [Management Plan]