procedure follow up in person

OVERALL_INSTRUCTIONS

Chief Complaint

Colon cancer screening

Template

Progress Note: PATIENT NAME: [Insert Patient Name] MEDICAL RECORD #: [Insert MRN] DATE OF BIRTH: [Insert DOB] Subjective: [Organize the section by listing each condition in separated paragraph, followed by a detailed narrative description. For each reported condition, provide a detailed narrative including the following: current status, any recent changes or episodes, lifestyle modifications, and relevant personal or family medical history. Include specific details such as triggers, symptoms, and management strategies.] Objective: Pertinent Diagnostic Studies: [test date] [Insert diagnostic findings and procedure findings verbatim from uploaded documents, don't change word] Physical Exams: [include vital signs and physical findings] For example Gen: No acute distress, conversant Head and Neck: Atraumatic, normocephalic, neck was supple Eyes: anicteric, PERRLA CV: Regular rate and rhythm Resp: Clear to auscultation bilaterally, no wheezing Abdomen: Soft, non-tender, non-distended, normo-active bowel sounds, no hepatosplenomegaly. Neuro: Alert and oriented x 3, moving all 4 extremities. Extremities: No cyanosis or edema Skin: No rash or jaundice Psych: normal affect and mood Heme: no cervical lymphadenopathy Assessment / Plan: [Insert Diagnoses, ICD 10 codes, recommendations, treatment plans, Order, etc, list in numbered items, organized by each diagnosis] Thank you for allowing me to participate in the care of this patient. If there are any questions or concerns feel free to contact me (925-776-7600).