Primary Care Documentation Template

SUBJECTIVE:  
- Reason for visit: Patient arrives with a persistent cough and difficulty breathing. "I've been coughing for the last two weeks, and breathing is becoming more difficult, especially at night." History of presenting complaints: The cough began following a recent cold. No other treatments have been attempted. Previously visited the local urgent care for similar issues last year.
RELEVANT PAST MEDICAL HISTORY:  
- Past medical history: Asthma diagnosed during childhood, Hypertension  
- Medications: Albuterol inhaler, Lisinopril  
- Social history: Non-smoker, occasional alcohol consumption  
- Allergies: Penicillin  
REVIEW OF SYSTEMS:  
- Constitutional symptoms: Fatigue  
- Eyes: No symptoms  
- Ears, Nose, Mouth, Throat: Nasal congestion  
- Cardiovascular: No symptoms  
- Respiratory: Cough, Shortness of breath, No smoke exposure  
- Gastrointestinal: No symptoms  
- Genitourinary: No symptoms  
- Musculoskeletal: No symptoms  
- Integumentary (Skin): No symptoms  
- Neurological: No symptoms  
- Psychiatric: No symptoms  
- Endocrine: No symptoms  
- Hematologic/Lymphatic: No symptoms  
- Allergic/Immunologic: No symptoms  
OBJECTIVE:  
- Vitals: BP 130/85, HR 78, RR 20, Temp 37°C  
- Physical examination: Lungs - wheezing detected bilaterally, Cardiovascular - normal S1 S2, no murmurs  
- Investigations: Chest X-ray pending  
ASSESSMENT & PLAN:  
1. Asthma exacerbation, J45.901  
- Assessment: Probable diagnosis is asthma exacerbation  
- Differential diagnosis: Upper respiratory infection  
- Investigations planned: Chest X-ray  
- Treatment planned: Increase Albuterol inhaler usage, initiate oral corticosteroids  
- Relevant referrals: None  
- CPT code for treatment rendered: 99213  
2. Hypertension, I10  
- Assessment: Hypertension, well-controlled  
- Treatment planned: Continue Lisinopril  
- Relevant referrals: None  
- CPT code for treatment: 99213  
Visit CPT code: 99213  
Dr. Thomas Kelly, MD  
Family Medicine  
s10.ai  
1 November 2024