The General Consult Note s10.ai template is an all-encompassing documentation resource crafted for rheumatologists to effectively document patient consultations. This template supports the detailed capture of critical patient data, such as medical history, physical examination results, and system reviews, specifically tailored for rheumatology assessments. It guarantees comprehensive documentation of joint-related symptoms and pertinent investigations, facilitating precise evaluation and management of conditions like arthritis. Perfectly compatible with s10.ai, this template optimizes the documentation workflow, enabling clinicians to prioritize patient care while ensuring meticulous and structured records.
Organized sections for comprehensive clinical documentation
Example of completed documentation using this template
Thank you for referring John Smith, a 45-year-old male for consultation. John was seen today, 1 November 2024, for evaluation of joint pain. The patient was accompanied by his wife.Reason for referral: Evaluation of persistent joint pain and stiffness.Involvement of Healthcare Professionals: None RecordedSurgical/Medical History: None RecordedExternal Medications: None RecordedKnown Allergies: None RecordedLifestyle Notes: None RecordedFamily History: None RecordedHistory of presenting illness: John has been experiencing joint pain and stiffness in his knees and elbows for the past six months. The symptoms are worse in the morning and improve slightly with movement throughout the day.Review of systems: The patient denies any personal or family history of psoriasis and does not report new rashes or nail changes. There is no history of uveitis, dactylitis, plantar fasciitis, or repetitive tendinitis. The patient denies any back pain or stiffness. There is no personal or family history of inflammatory bowel disease. The patient denies any bright red blood per rectum or melena or significant diarrhea. The patient denies chest pain, exertional dyspnea, or cough. The patient denies any history of hemoptysis, epistaxis, or chronic sinusitis. The patient denies features of Raynaud's, hair loss, oral ulcers, rash, inflammatory eye disease or photosensitivity. There is no history of tight skin or puffy hands, reflux, muscle weakness, or cracking of the skin. The patient denies hematuria or frothy urine. There is no personal or family history of VTE or miscarriages. There is no history of cardiac, liver, lung, or renal disease. The patient does not have any night sweats, changes in appetite, or unintentional weight loss.Physical Examination:Looks well.VS: BP 120/80, HR regular;H&N: No LAN, oral mucosa normal, normal salivary pool.CVS: Normal HS, no extra HS, no murmurs.Resp: Good breath sounds to bases bilaterally, no crepitations or wheezesAbdo: Soft NT, no organomegalyMSK: See homunculusROM peripheral joints: Normal throughoutTender joints: Knees, elbowsSwollen joints: KneesDeformities: NoneDERM: NonePrevious Investigations:Labs: CBC, ESR, CRPImaging: X-ray of knees and elbowsImpression and Plan:John is a 45-year-old male with symptoms suggestive of inflammatory arthritis. Further evaluation is needed to confirm the diagnosis and rule out other potential causes of his symptoms.Additional Investigations Ordered: MRI of knees, rheumatoid factor, anti-CCP antibodiesAdditional Referrals: NoneTreatment(s): Initiate NSAIDs for pain managementPatient will have an in-person follow-up in 4 weeks, or sooner should the need arise. Patient knows to call my office if an earlier appointment needs to be scheduled.Thank you for allowing me to participate in this patient's care. Should you have any questions or concerns, please feel free to contact this office.
Key advantages of using this template in clinical practice
Common questions about this template and its usage