Revised SJRHEM

Chief Complaint (CC)

[Chief Complaint, e.g., general consultation, fatigue, etc.]

History of Present Illness (HPI)

[[Age]-year old [gender] presenting with a [duration] history of [main symptoms]. They describe their symptoms as [severity and quality/characteristics of symptoms], localized to the [location if relevant] and radiating to [radiation if relevant], which began [onset]. It is aggravated by [aggravating factor] and relieved by [relieving factor], and associated with [associated symptoms, e.g. nausea, vomiting, shortness of breath, etc.].]

Past Medical History (PMHx)

[Include all significant medical conditions with dates if available]

Past Surgical History

[Include any past surgical procedures, date/timing of the procedure, any complications. If dates are available, please list the past surgical history in chronological order.]

Current Medications

[Include the name, dosage, frequency, and route of administration for all current medications, including over-the-counter drugs and supplements.]

Allergies

[Document any drug, food, or environmental allergies, including the nature of the reaction.]

Family History

[Include significant medical conditions in first-degree relatives, e.g., diabetes, hypertension, heart disease, cancer.]

Social History

[Tobacco use, alcohol use, illicit drug use, occupation, living situation, marital status, exercise]

Review of Systems (ROS)

[[Only generate the system that was mentioned in the encounter, and replace with [specific finding] based on the finding. (Have each system on an individual line and an empty line in between each system)] Constitutional – [no Fever, Chills, Weight Loss, Weight Gain, Night sweats, Fatigue, or Weakness] Eyes – [no double vision, no blurry vision, wears glasses] ENT – [no Hearing loss, dizziness, runny nose, nose bleeds, nasal septum deviation, or sore throat] Integumentary – [no rashes, lesions, dry skin, or eczema] Cardiovascular – [no chest pain, heart palpitations, dizziness] Respiratory – [no shortness of breath, no cough, no wheezing] Endocrine – [No known thyroid issues, no changes to appetite, no weight change, no tiredness/lethargy] Gastrointestinal – [No nausea, vomiting, diarrhea, or constipation. No problems swallowing. No abdominal pain or bloating.] Genito Urinary – [no Dysuria, hematuria, frequency, urgency, or nocturia] Musculoskeletal – [no joint tenderness, redness or swelling] Neurological – [No headaches or weakness, no history of seizures] Psychology – [No changes in mood, no anxiety] Hematology – [Denies easy bruising] ]

Vital Signs

[Include blood pressure, heart rate, respiratory rate, temperature, O2 saturation, height, weight, BMI]

Physical Exam

[[Only generate the exam that was mentioned in the encounter, and replace with [specific finding] based on the finding. (Have each exam on an individual line and an empty line in between each exam.)] General – [Appears well, no obvious discomfort] ENT – [No cervical lympadenopathy, throat normal with no erythema or exudates, normal tympanic membranes.] Cardiovascular – [Heart rate regular, S1S2 normal with no murmurs or added sounds, peripheral pulses easily palpable, equal and symmetric, normal capillary refill, no JVD, no carotid bruits, no central or peripheral cyanosis, no clubbing, no peripheral edema.] Respiratory – [Lungs clear to auscultation bilaterally with no wheezes or crackles, normal symmetrical chest expansion.] Skin – [No rashes, no dry skin, no skin infections] Abdomen – [Normal bowel sounds, abdomen soft and nontender, no distension.] Musculoskeletal – [No tender, swollen, warm, or erythematous joints. Normal range of motion in examined limbs, no muscle tenderness.] Neurological – [Alert and oriented in time, space and person, normal gait, strength 5/5 in upper and lower limbs, CN 2-12 grossly intact, coordination intact.] Genito Urinary – [External genitalia normal, no inguinal adenopathy, no renal angle tenderness.]]

Test Results

[Include results of any pertinent laboratory tests, imaging studies, or other diagnostic evaluations.]

Clinical Impression

[Summarize the clinical impression based on the history and exam]

Problem

[List problems/diagnoses identified]

Differential Diagnosis

[Include potential alternative diagnoses relevant to the clinical presentation]

Orders and Referrals

[Include laboratory tests, imaging studies, referrals to specialists]

Treatments

[Include medications prescribed, non-pharmacological treatments, and other interventions]

Patient Education

[Discuss educational points provided to the patient, such as lifestyle modifications, disease-specific information]

Follow Up

[Include any follow-up appointments, monitoring plans]