-> Download Guidelines for Creating a Bronchitis Medical Documentation Template by completing the form.

Patient Information

Name: [Patient's Full Name]

Date of Birth: [MM/DD/YYYY]

Medical Record Number: [Unique Identifier]

Date of Visit: [MM/DD/YYYY]

Primary Care Physician: [Physician's Name]

Chief Complaint

[Brief description of the patient's primary reason for visit, e.g., "Persistent cough and difficulty breathing for 5 days"]

History of Present Illness

Onset: [When symptoms began, e.g., "5 days ago"]

Symptoms:

Cough: [Dry/Productive, frequency, severity]

Sputum: [Color, consistency, amount]

Shortness of Breath: [Present/Absent, severity]

Chest Pain: [Location, intensity, duration]

Fever: [Present/Absent, temperature, duration]

Other: [Fatigue, wheezing, etc.]

Duration: [How long symptoms have persisted]

Triggers/Aggravating Factors: [e.g., cold air, smoke, allergens]

Relieving Factors: [e.g., rest, over-the-counter medications]

Previous Episodes: [History of bronchitis or similar respiratory issues]

Past Medical History

Chronic Conditions: [e.g., Asthma, COPD, allergies]

Previous Respiratory Infections: [Dates and outcomes]

Surgeries: [Relevant surgical history]

Hospitalizations: [Related to respiratory issues]

Medications

Current Medications: [List all medications, dosages, and frequencies]

Recent Changes: [Any recent medication adjustments]

Over-the-Counter Use: [e.g., Cough suppressants, expectorants]

Allergies

Medications: [e.g., Penicillin, sulfa drugs]

Environmental: [e.g., Pollen, dust, pets]

Social History

Smoking Status: [Never/Former/Current, pack-years]

Alcohol Use: [Frequency and amount]

Occupational Exposures: [e.g., Dust, chemicals, fumes]

Living Environment: [e.g., Exposure to mold, pets]

Family History

Respiratory Diseases: [e.g., Asthma, COPD, lung cancer in family]

Other Relevant Conditions: [e.g., Allergies, autoimmune disorders]

Review of Systems

General: [Fever, fatigue, weight loss]

Respiratory: [Wheezing, shortness of breath, cough]

Cardiovascular: [Chest pain, palpitations]

Other Systems: [Briefly note relevant findings in other systems]

Physical Examination

Vital Signs:

Temperature: [°F or °C]

Heart Rate: [beats/min]

Respiratory Rate: [breaths/min]

Blood Pressure: [mmHg]

Oxygen Saturation: [%]

General Appearance: [e.g., Alert, in respiratory distress]

HEENT: [e.g., Nasal congestion, throat erythema]

Respiratory:

Inspection: [e.g., Chest symmetry, respiratory effort]

Auscultation: [e.g., Wheezes, rhonchi, crackles]

Percussion: [e.g., Resonant, dull]

Cardiovascular: [e.g., Heart sounds, murmurs]

Other Relevant Findings: [e.g., Extremities, skin]

Diagnostic Studies

Chest X-Ray: [Findings or pending]

Pulmonary Function Tests: [If performed, results]

Labs: [e.g., CBC, CRP, sputum culture]

Other: [e.g., Pulse oximetry trends]

Assessment

Primary Diagnosis: [e.g., Acute Bronchitis, likely viral]

Differential Diagnosis: [e.g., Pneumonia, asthma exacerbation]

Chronicity: [Acute vs. Chronic Bronchitis]

Plan

Treatment:

Medications: [e.g., Albuterol inhaler, expectorants, antibiotics if bacterial]

Supportive Care: [e.g., Hydration, rest, humidifier]

Patient Education:

Symptom management: [e.g., Avoid irritants, smoking cessation]

Warning signs: [e.g., Worsening shortness of breath, high fever]

Follow-Up: [e.g., Return in 1 week or sooner if symptoms worsen]

Referrals: [e.g., Pulmonology if recurrent or severe]

Provider Information

Name: [Provider's Full Name]

Signature: [Electronic or written signature]

Date and Time: [MM/DD/YYYY, HH:MM]

Bronchitis Template (Medical Documentation)

Cookie Preferences

Why S10.AI?

Maintain patient eye-contact

Minimize EHR time

Reduce clinician burnout

Deliver patient-centered care

Increase practice profitability

Solve staffing shortages

Cut admin tasks

Who we're for?

Independent practices

Group practices

New clinics & startups

Specialty Care

Virtual Care

Health systems

Solutions

AI Scribe

AI Coding

AI Phone Agent

AI Chat Agent

AI Nurse Agent

AI Medical Assistant Agent

AI Admin Assistant Agent

AI Pharmacy Technician Agent

Resources

Case studies

FAQs

Practice Efficiency Assessment

Clinical Templates

ICD-10-CM Code Browser

Medical Abbreviations

Diagnoses

Medical Phrases

Medical Prefix

Medical Suffix

Medical Root Words

Clinical Charts and Timelines

Lab Test Results

About

S10.AI Story

Technology

S10.AI Difference

AI Accuracy

Integrations

Book A Demo

support@s10.ai

Tel: +1 631 4886 390

NJ, Princeton - Carnegie Center, United States.

Terms & Condition

Privacy Policy

Status

llm

© 2025 S10.AI, Inc. All rights reserved.

NJ, Princeton - Carnegie Center,
United States.