The Problem Based Primary Clinic Note template by s10.ai is a vital resource for family medicine practitioners, enabling them to document patient encounters with a focus on specific health issues, problems, or requests. This comprehensive template includes sections for history of present illness, review of systems, physical examination, and assessment and plan, all designed to streamline the documentation process. It ensures that notes are thorough and well-organized, making it particularly beneficial for addressing multiple health concerns in a single visit. Ideal for primary care environments, this template enhances efficiency and accuracy in clinical documentation, encouraging clinicians to adopt and explore its capabilities with s10.ai.
Organized sections for comprehensive clinical documentation
Example of completed documentation using this template
HPI1. HypertensionThe patient mentions experiencing occasional headaches and dizziness. They have been tracking their blood pressure at home, which has shown elevated levels. The patient is concerned about the long-term impact of hypertension and is interested in lifestyle changes to manage it.2. Type 2 DiabetesThe patient has been experiencing increased thirst and frequent urination. They have a family history of diabetes and are concerned about their recent weight gain. The patient is interested in discussing dietary changes and potential medication adjustments.3. Seasonal AllergiesThe patient reports sneezing, nasal congestion, and itchy eyes, particularly during the spring months. They have been using over-the-counter antihistamines with limited relief and are seeking advice on alternative treatments.Review of systemsCardiovascular: Positive for elevated blood pressure readings. Negative for chest pain or palpitations.Endocrine: Positive for increased thirst and urination. Negative for heat intolerance or changes in skin texture.Respiratory: Positive for nasal congestion and sneezing. Negative for shortness of breath or wheezing.Physical examVital signs: Blood pressure 150/95 mmHg, heart rate 78 bpm, respiratory rate 16 breaths/min, temperature 98.6°F.HEENT: Nasal mucosa swollen, conjunctivae clear.Cardiovascular: Regular rate and rhythm, no murmurs.Respiratory: Clear to auscultation bilaterally.Assessment & Plan:1. Hypertension- Assessment: Essential hypertension- Differential diagnosis: Secondary hypertension- Investigations planned: 24-hour ambulatory blood pressure monitoring- Treatment planned: Initiate lifestyle modifications, consider starting an ACE inhibitor- Relevant referrals: Referral to a dietitian for dietary counseling2. Type 2 Diabetes- Assessment: Poorly controlled type 2 diabetes- Differential diagnosis: None- Investigations planned: HbA1c test- Treatment planned: Adjust current medication regimen, emphasize dietary changes- Relevant referrals: Referral to an endocrinologist for further management3. Seasonal Allergies- Assessment: Allergic rhinitis- Differential diagnosis: None- Investigations planned: None- Treatment planned: Prescribe a nasal corticosteroid spray- Relevant referrals: None
Key advantages of using this template in clinical practice
Common questions about this template and its usage