Patient Followup

Introduction

This note is transcribed using Empathia Medical Scribe. There may be errors of recognition. [Document the type of visit, telehealth or in person visit] [Mention who is present for the visit]

Subjective

[For each issue, provide a detailed narrative including onset, location, severity, exacerbating factors, relieving factors, and any associated symptoms.] For example: 1. [Issue 1] - [Detailed description] 2. [Issue 2] - [Detailed description]

Past Medical History

- [List each medical condition as a separate bullet point, ensuring to include any chronic conditions, medications, allergies, operations, alcohol use, smoking, recreational substance use, family history, vaccine history, social history, provide comprehensive information such as lifestyle, occupation, living situation, and any other relevant social factors. (Only include information that is discussed in the transcript.) Exclude lab results, imaging results, and special investigation results. Include examples of what should be included, such as 'Chronic asthma managed with inhalers' or 'Family history of diabetes'. Exclude examples like 'Blood test results from 2023' or 'MRI findings'.]

Subjective

[For each issue, provide a detailed narrative including onset, location, severity, exacerbating factors, relieving factors, and any associated symptoms.] For example: 1. [Issue 1] - [Detailed description] 2. [Issue 2] - [Detailed description]

Chief Complaint

patient followup

Objective

[Document the patient's vital signs, including weight, height, head circumference, and any changes since the last visit. Calculate the BMI if weight and height are mentioned, using metric units. Present the information in a bulleted list format. For example: - Weight: [Current Weight] kg (weight change of [Weight Change] kg since [Previous Date] when weight was [Previous Weight] kg)] [Document completed lab results, imaging reports, special investigation results]

Objective

[Document the patient's vital signs, including weight, height, head circumference, and any changes since the last visit. Calculate the BMI if weight and height are mentioned, using metric units. Present the information in a bulleted list format. For example: - Weight: [Current Weight] kg (weight change of [Weight Change] kg since [Previous Date] when weight was [Previous Weight] kg)] [Document completed lab results, imaging reports, special investigation results]

ENT

[If the ENT system is examined, document the findings of the ear, nose, and throat examination. Include details on tympanic membranes, ear canals, pharynx, tonsils, uvula, cervical lymph nodes, postnasal drip, facial tenderness, mastoid tenderness, nasal congestion, nasal discharge, drooling, nasal mucosa, septum.] [Example (Only include example below if ENT examination was performed): - Normal tympanic membranes, Normal ear canals, Normal pharynx, Normal Uvula, No enlarged cervical lymph nodes, No postnasal drip, No facial tenderness, No tenderness over mastoids, No nasal congestion, No nasal discharge, No drooling, Normal nasal mucosa. If no ENT examination is performed exclude this section heading]

Respiratory

[If the respiratory system is examined, document the findings of the respiratory examination. Include details on ventilation, respiratory distress, wheezes, crepitations, rubs, and stridor.] [Example (Only include example below if respiratory examination was performed): - Good ventilation bilaterally, No respiratory distress, No wheezes, No crepitations, No rubs, No stridor. If no Respiratory examination is performed exclude this section heading]

CVS

[If the Cardiovascular system is examined, document the findings of the cardiovascular examination. Include details on heart sounds, rhythm, murmurs, carotid bruits, and peripheral edema.] [Example (Only include example below if CVS examination was performed): - Normal S1, S2, No murmurs, Regular rhythm, No carotid bruits, No peripheral edema. If no cardiovascular examination is performed then exclude this section heading]

Abdomen

[If the Abdomen is examined, document the findings of the abdominal examination. Include details on distention, organomegaly, renal angle tenderness, tenderness, masses, bowel sounds, dehydration, and jaundice.] [Example (Only include example below if abdominal examination was performed): - No distention, No organomegaly, No renal angle tenderness, No tenderness, No masses, Normal bowel sounds, No dehydration, No jaundice. If no abdominal examination is performed then exclude this section heading]

CNS

[If the central nervous system is examined, document the findings of the central nervous system examination. Include details on pupils, facial symmetry, taste and smell, hearing and vision, facial sensation, tongue movements, swallowing, eye movements, cognitive function, gait, strength, and sensation. If no CNS examination is performed, exclude this section heading] [Example (Only include example below if CNS examination was performed): - Pupils equal and reactive, Facial symmetry, Normal taste and smell, Normal hearing and vision, Normal facial sensation, Normal tongue movements, Normal swallowing, Normal eye movements, Normal cognitive function, Normal gait, Normal strength, Normal sensation.]

Rectal exam

[If a rectal examination is performed, document the findings of the rectal examination. Include details on redness around rectum, sinus tracts, perianal masses, sphincter tone, masses in rectum, and blood on glove.] [Example (Only include example below if rectal examination was performed): - No perianal masses, No sinus tracts, No redness around rectum, Normal sphincter tone, No masses in rectum, Normal prostate (only include information about the prostate if the patient is female), No blood on glove. If no rectal examination is performed then exclude this section heading]

Speculum

[If a vaginal speculum examination is performed, document the findings of the speculum examination. Include details on cervix, vaginal walls, discharge.] [Example (Only include example below if speculum examination was performed): - Normal Cervix no cervical ectropion, Normal vaginal walls, Normal physiologic discharge. If no speculum examination is performed then exclude this section heading.]

Breast

[If breasts are examined, document the findings of the breast examination. Include details on skin, symmetry, nipple discharge, nipple pathology, axillary lymph nodes, masses, tenderness.] [Example (Only include example below if breast examination was performed): - No skin changes, Breasts symmetrical, No redness, No nipple discharge or other nipple pathology, No enlarged axillary lymph nodes, No breast tenderness, No palpable masses. If no breast examination is performed, exclude this section heading.]

Bimanual

[If a bimanual examination is performed, document the findings of the bimanual examination. Include details on cervical excitation tenderness, suprapubic tenderness, adnexal masses, other masses, adnexal tenderness, pelvic prolapse.] [Example (Only include example below if bimanual examination was performed): - No cervical excitation tenderness, No suprapubic tenderness/ masses, No adnexal tenderness/ masses, No pelvic prolapse. If no bimanual examination is performed then exclude this section heading]

Assessment

[Provide a list of differential diagnoses and current known diagnoses on one line, separated by commas. Ensure clarity and conciseness in listing the diagnoses. Clearly distinguish between differential diagnoses and confirmed current diagnoses.]

Assessment

[Provide a list of differential diagnoses and current known diagnoses on one line, separated by commas. Ensure clarity and conciseness in listing the diagnoses. Clearly distinguish between differential diagnoses and confirmed current diagnoses.]

Plan

[Outline the plan for managing the patient's issues, including medication adjustments, orders for further tests, and any prescriptions provided.] For example: - [Action 1] - [Action 2] - Prescription provided for [Medication/Adjustment]

Plan

[Outline the plan for managing the patient's issues, including medication adjustments, orders for further tests, and any prescriptions provided.] For example: - [Action 1] - [Action 2] - Prescription provided for [Medication/Adjustment]