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Primary Care Physician
5-10 minutes

Family Practice Physician's Record Template

The s10.ai Family Medicine Specialist's Note template is expertly crafted for detailed documentation of patient encounters in family medicine, making it an essential tool for family medicine specialists. This template is optimized to capture comprehensive subjective and objective data, including an extensive review of systems and a well-structured assessment and plan. It streamlines the documentation process for complex cases involving multiple health conditions, ensuring that all pertinent information is meticulously recorded. Ideal for providing a holistic perspective on patient health within family practice, this template encourages clinicians to adopt and explore its capabilities for enhanced patient care.

1,600 uses
4.2/5.0
S
Sophia Martinez
Template Structure

Organized sections for comprehensive clinical documentation

Documented via AI scribe. Patient consent obtained
Subjective:
- [Current issues, reasons for visit, history of presenting complaints, etc. (if applicable)]
- [Past medical history, including previous surgeries (if applicable)]
- [Medications currently being taken by the patient, including dosage and frequency (if applicable)]
- [Social history, including lifestyle factors such as smoking, alcohol use, occupation, and living situation (if applicable)]
- [Known allergies, including drug, food, or environmental allergies (if applicable)]
Review of Systems:
- Constitutional symptoms: [Document any symptoms such as weight change, fever, chills, night sweats, fatigue, malaise (if applicable)]
- Eyes: [Document symptoms such as eye pain, swelling, redness, foreign body sensation, discharge, vision changes (if applicable)]
- Ears, Nose, Mouth, Throat: [Document symptoms such as hearing changes, ear pain, nasal congestion, sinus pain, hoarseness, sore throat, rhinorrhea, swallowing difficulty (if applicable)]
- Cardiovascular: [Document symptoms such as chest pain, shortness of breath (SOB), paroxysmal nocturnal dyspnea (PND), dyspnea on exertion, orthopnea, claudication, edema, palpitations (if applicable)]
- Respiratory: [Document symptoms such as cough, sputum production, wheezing, smoke exposure, dyspnea (if applicable)]
- Gastrointestinal: [Document symptoms such as nausea, vomiting, diarrhea, constipation, abdominal pain, heartburn, anorexia, dysphagia, hematochezia, melena, flatulence, jaundice (if applicable)]
- Genitourinary: [Document symptoms such as dysmenorrhea, dysfunctional uterine bleeding (DUB), dyspareunia, dysuria, urinary frequency, hematuria, urinary incontinence, urgency, flank pain, changes in urinary flow, hesitancy (if applicable)]
- Musculoskeletal: [Document symptoms such as arthralgias, myalgias, joint swelling, joint stiffness, back pain, neck pain, history of injury (if applicable)]
- Integumentary (Skin): [Document symptoms such as skin lesions, pruritis, hair changes, breast/skin changes, nipple discharge (if applicable)]
- Neurological: [Document symptoms such as weakness, numbness, paresthesias, loss of consciousness, syncope, dizziness, headache, coordination changes, recent falls (if applicable)]
- Psychiatric: [Document symptoms such as anxiety/panic, depression, insomnia, personality changes, delusions, rumination, suicidal ideation/homicidal ideation/auditory hallucinations/visual hallucinations, social issues, memory changes, history of violence/abuse, eating concerns (if applicable)]
- Endocrine: [Document symptoms such as polyuria, polydipsia, temperature intolerance (if applicable)]
- Hematologic/Lymphatic: [Document symptoms such as bruising, bleeding, transfusion history, lymphadenopathy (if applicable)]
- Allergic/Immunologic: [Document symptoms such as allergic reactions, autoimmune disorders (if applicable)]
Objective:
- [Physical or mental state examination findings, including vitals such as blood pressure, heart rate, respiratory rate, temperature, and system-specific examination findings (if applicable)]
- [Investigations with results, including laboratory tests, imaging studies, etc. (if applicable)]
Assessment & Plan:
- [List each issue or condition identified (e.g., 1: Hypertension, 2: Asthma, etc.)]
For each identified issue, document the following:
- Assessment: [Provide a brief summary of the likely diagnosis for each issue, including the rationale based on subjective and objective findings.]
- Differential Diagnosis: [Include any differential diagnoses if applicable.]
- Investigations: [Outline any planned investigations or tests relevant to the issue, such as blood tests, imaging, or specialized assessments.]
- Treatment: [Detail the treatment plan for each issue, including medications, dosages, therapy, lifestyle changes, and expected outcomes.]
- Referrals: [Mention any relevant referrals to specialists or additional services required.]
- Follow-up: [Include details on follow-up appointments, monitoring plans, and next steps if applicable.]
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care—use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned, leave the relevant placeholder or section blank. Use sentences to capture relevant information and provide clear and coherent clinical documentation.)
Sample Clinical Note

Example of completed documentation using this template

Documented via AI scribe. Patient consent taken
Subjective:
- The patient, a 45-year-old male, presents with a persistent cough and shortness of breath lasting two weeks. He mentions a history of seasonal allergies and mild asthma.
- Past medical history includes an appendectomy at age 30 and hypertension.
- Currently taking Lisinopril 10 mg daily and uses an Albuterol inhaler as needed.
- Social history indicates the patient is a non-smoker, drinks alcohol occasionally, works as an accountant, and resides with his spouse and two children.
- Known allergies include penicillin and pollen.
Review of Systems:
- Constitutional symptoms: Reports fatigue and slight weight loss.
- Eyes: No symptoms reported.
- Ears, Nose, Mouth, Throat: Reports nasal congestion and sore throat.
- Cardiovascular: No chest pain or palpitations.
- Respiratory: Reports persistent cough and shortness of breath, particularly at night.
- Gastrointestinal: No symptoms reported.
- Genitourinary: No symptoms reported.
- Musculoskeletal: No symptoms reported.
- Integumentary (Skin): No symptoms reported.
- Neurological: No symptoms reported.
- Psychiatric: Reports mild anxiety due to work stress.
- Endocrine: No symptoms reported.
- Hematologic/Lymphatic: No symptoms reported.
- Allergic/Immunologic: Reports seasonal allergy symptoms.
Objective:
- Vitals: Blood pressure 130/85 mmHg, heart rate 78 bpm, respiratory rate 18 breaths/min, temperature 98.6°F.
- Physical examination reveals clear lung sounds with occasional wheezing.
- Recent chest X-ray shows no acute findings.
Assessment & Plan:
- 1: Asthma exacerbation
  - Assessment: Likely asthma exacerbation due to seasonal allergies, supported by subjective reports of cough and wheezing.
  - Differential Diagnosis: Considered bronchitis, but less likely due to lack of fever and productive cough.
  - Investigations: Plan to perform spirometry to assess lung function.
  - Treatment: Increase Albuterol inhaler use to every 4-6 hours as needed, start Fluticasone nasal spray for allergy control.
  - Referrals: None at this time.
  - Follow-up: Re-evaluate in 2 weeks to assess response to treatment.
- 2: Hypertension
  - Assessment: Well-controlled on current medication.
  - Differential Diagnosis: None.
  - Investigations: Routine blood pressure monitoring.
  - Treatment: Continue Lisinopril 10 mg daily.
  - Referrals: None.
  - Follow-up: Routine follow-up in 3 months.
Clinical Benefits

Key advantages of using this template in clinical practice

  • Enhance your clinical documentation with our comprehensive template designed to streamline patient assessments and improve care delivery. This template meticulously covers all essential components, including subjective history, review of systems, objective findings, and a detailed assessment and plan. By incorporating high-search healthcare keywords, it ensures that clinicians can efficiently document patient encounters, from current issues and past medical history to a thorough review of systems and objective examination results. The template also facilitates precise documentation of assessments, differential diagnoses, and treatment plans, including medications, investigations, and referrals. With its structured format, this template not only enhances clinical accuracy but also optimizes workflow efficiency, encouraging healthcare professionals to adopt and implement it for improved patient outcomes and streamlined clinical processes.
Frequently Asked Questions

Common questions about this template and its usage

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Family Practice Physician's Record | Medical Chart Template