Referral note-general

Chief Complaint

Medical Report

tags

specialty

Pediatrics

Template

Thank you for your referral. (This report is composed by Dr. Saba Merchant, and it is generated by voice recognition software. Transcription errors may occur. If one has any concern regarding accuracy, we will be pleased to clarify) Reason for Referral: History of Present Illness: Review of System; CNS: [specific findings or Unremarkable] RESP: [specific findings or Unremarkable] CVS: [specific findings or Unremarkable] GI: [specific findings or Unremarkable] GU: [specific findings or Unremarkable] DERM: [specific findings or Unremarkable] MSK: [specific findings or Unremarkable] Immunization: [up to date] Allergies: [NKDA] Active Medications: [None Recorded] Development: [Appropriate for age] Birth History: Pregnancy: [unremarkable] Delivery: [uneventful] Post Natal: [insignificant] Past Medical History: [past medical history or unremarkable] Family History: [family history or unremarkable] Social History: [social history or unremarkable] Physical Examination: WT: [weight] kg [percentile] HT: [height] cm [percentile] HC: [percentile] BP: [blood_pressure] HR: [heart_rate] bpm TEMP: [temperature] HEENT: [Child looks well, no gross dysmorphic features] Eyes: [PEARL, Red reflex present, Clear conjunctiva] Ears: [Clear, intact TM bilaterally] Throat & Palate: [Normal] LNs: [Insignificant] Chest: [Air entry equal bilaterally, no adventitious sounds heard.] CVS: [Quiet pericordium: Normal S1 & S2, no murmur heard, PPP + CR <2 seconds] Abdomen: [Soft, no masses, no organomegaly, no tenderness, normal BS] GU: [Appropriate for sex & age, Tanner] MSK: [unremarkable] Derm: [unremarkable] CNS: [Grossly normal] Impression & Plan: [Impression and Plan content] Thank you for involving me in the care of your patient. Should you have any questions, please do not hesitate to contact me.