Primary Care Physician

25-30 minutes

Assessment, Plan, Subjective, Objective

The APSO template is an all-encompassing clinical documentation tool designed for Family Medicine Specialists to enhance patient assessment and care planning. This template excels in capturing comprehensive details on diagnoses, patient-reported symptoms, and examination findings. It promotes a structured methodology for documenting assessment, plan, subjective, and objective data, ensuring meticulous patient care. Particularly beneficial for managing chronic conditions such as hypertension and diabetes, the APSO format enables clear communication of management strategies and follow-up directives. Optimized for integration with s10.ai, this template significantly boosts efficiency in clinical documentation, encouraging clinicians to adopt, explore, or implement it in their practice.

3,784 uses

4.7/5.0

Dr. Jonathan Bennett

Template Structure

Organized sections for comprehensive clinical documentation

Assessment & Plan:

1. [Main diagnosis]

[List probable cause]

[Outline treatment strategy]

[Include follow-up directions]

2. [Additional diagnosis]

[Describe current condition]

[Propose therapeutic options]

[Include follow-up directions]

3. [Further diagnosis]

[Identify probable classification]

[Recommend review of past results if relevant]

[Consider referral if needed]

Subjective:

[List symptoms reported by the patient and their duration]

[Note any pertinent exposures]

[Document outcomes of any recent tests]

[Record any specific symptoms the patient denies]

[Note patient's dietary habits]

[Document any medications administered]

[List any other symptoms]

Review of Systems:

[Document findings for General symptoms]

[Document findings for Vision]

[Document findings for ENT]

[Document findings for Breathing]

[Document findings for Digestive system]

Objective:

[Document lung exam findings]

[Document heart exam findings]

[Document ear exam findings]

Sample Clinical Note

Example of completed documentation using this template

Assessment & Plan:  
1. Hypertension  
Probable cause: Genetic predisposition and lifestyle influences  
Management strategy: Begin lifestyle changes including a low-sodium diet and regular physical activity. Prescribe Lisinopril 10 mg daily.  
Follow-up instructions: Reassess blood pressure in 4 weeks.  
2. Type 2 Diabetes Mellitus  
Current condition: HbA1c at 7.5%  
Treatment recommendations: Continue Metformin 500 mg twice daily, consider adding a GLP-1 receptor agonist.  
Follow-up instructions: Monitor blood glucose levels daily and follow up in 3 months.  
3. Hyperlipidemia  
Probable classification: Primary hyperlipidemia  
Review of previous results: LDL cholesterol at 160 mg/dL  
Referral: Consider referral to a dietitian for nutritional counseling.  
Subjective:  
Patient reports fatigue and occasional headaches for the past 3 months.  
No recent travel or exposure to infectious diseases.  
Recent blood tests show elevated fasting glucose levels.  
Denies chest pain or shortness of breath.  
Eating habits include high intake of processed foods.  
Currently taking Metformin and Lisinopril.  
Additional symptoms include occasional dizziness.  
Review of Systems:  
Constitutional: Reports fatigue, denies fever or weight loss.  
Eyes: No visual changes or eye pain.  
Ears, Nose, Mouth, Throat: Occasional sore throat, no ear pain.  
Respiratory: Denies cough or shortness of breath.  
Gastrointestinal: Reports occasional constipation.  
Objective:  
Lung examination: Clear to auscultation bilaterally.  
Heart examination: Regular rate and rhythm, no murmurs.  
Ear examination: Tympanic membranes intact, no effusion.

Clinical Benefits

Key advantages of using this template in clinical practice

Enhance your clinical documentation with our comprehensive "Assessment & Plan" template, designed to streamline patient care and improve clinical outcomes. This template provides a structured approach to documenting primary, secondary, and tertiary diagnoses, including likely etiologies, management plans, and follow-up instructions. It also includes a detailed "Subjective" section to capture patient-reported symptoms, exposures, and test results, ensuring a thorough understanding of the patient's condition. The "Review of Systems" and "Objective" sections allow for meticulous documentation of physical examination findings, covering constitutional symptoms, respiratory, gastrointestinal, and more. By adopting this template, clinicians can ensure accurate, efficient, and consistent patient records, facilitating better communication and decision-making in healthcare settings. Explore this template today to enhance your clinical practice and patient care delivery.

Frequently Asked Questions

Common questions about this template and its usage

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