The General Follow-Up template from s10.ai is crafted specifically for Internal Medicine Specialists to streamline the documentation of patient visits. This comprehensive template encompasses essential areas such as subjective complaints, past medical and social history, objective findings, assessment, and a detailed care plan. It is particularly beneficial for monitoring ongoing conditions, managing chronic diseases, and ensuring continuity of care. With dedicated sections for medication adherence, diagnostic tests, and specialist referrals, this template serves as an invaluable resource for internal medicine practitioners. Leverage the power of s10.ai, the AI medical scribe, to optimize documentation processes and elevate patient care.
Organized sections for comprehensive clinical documentation
Example of completed documentation using this template
Subjective:- Presenting complaint and duration: Patient reports a persistent cough lasting 3 weeks.- Additional symptoms: Experiences occasional shortness of breath and fatigue.- Impact on daily activities: Fatigue is hindering daily activities.- Pertinent negatives: No fever, chest pain, or weight loss reported.- Appetite: Appetite remains normal.- Living situation and sick contacts: Resides alone, no known exposure to sick individuals.- Medications prescribed: Albuterol inhaler prescribed.- Diagnostic tests ordered: Ordered chest X-ray and pulmonary function tests.- Specialists referred to: Referral made to pulmonologist.- He is informed of recent labs from 10/15/2023 showing normal CBC and elevated CRP.- Advised to initiate albuterol inhaler, consult pulmonologist.- Advised labs Chest X-ray and pulmonary function tests.- RTC in 2 weeks.Past Medical History:- Relevant past medical history: Asthma history noted.- Smoking history: Does not smoke.- Medication adherence: Compliant with prescribed medications.- Allergies: No known drug allergies.- Recent travel: No recent travel history.Social History:- Occupation and hobbies: Employed as a librarian, enjoys reading and gardening.- Alcohol use and sleep habits: Consumes alcohol socially, sleeps 7-8 hours nightly.Objective:- Vitals: BP 120/80, HR 78, RR 18, Temp 98.6°F- Lung exam: Mild wheezing detected on auscultation.- Cardiac exam: Regular rate and rhythm, no murmurs present.- Abdominal exam: Soft, non-tender, no organomegaly.Assessment:- Primary diagnosis: Asthma exacerbation.Plan:- Diagnostic tests ordered: Ordered chest X-ray and pulmonary function tests.- Medications prescribed: Albuterol inhaler prescribed.- Inhaler optimization and technique education: Educated on correct inhaler usage.- Follow-up instructions: Scheduled follow-up in 2 weeks.- Return precautions: Advised to return if symptoms worsen or new symptoms appear.- Medication adherence counseling: Stressed the importance of adhering to medication.- Preventative measures discussion: Discussed avoiding known asthma triggers.- Deferral of non-urgent issues: Deferred non-urgent issues discussion to next visit.
Key advantages of using this template in clinical practice
Common questions about this template and its usage