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Primary Care Physician
30-45 minutes

Summary Statement Note

The 'Note with Summary Statement' template from s10.ai is an essential tool for General Practitioners aiming to streamline patient visit documentation. This template offers a structured approach to summarizing clinical impressions and management plans, facilitating efficient tracking of patient progress. It features dedicated sections for detailed patient history, examination findings, and a comprehensive management plan, making it particularly beneficial for handling complex cases. By enhancing the clarity of clinical decision communication, this template is optimized for seamless integration with s10.ai, ensuring precise and efficient documentation of patient encounters. Explore this template to enhance your clinical workflow and improve patient care outcomes.

4,742 uses
4.9/5.0
D
Dr. Emily Carter
Template Structure

Organized sections for comprehensive clinical documentation

Summary
• [Age]-year-old [gender] with [medical conditions], presenting with [presenting complaint].
• [Investigations ordered and purpose].
• [Treatment initiated or adjusted].
History
• [Age]-year-old [gender] with a history of [medical conditions].
• Presented with [description of symptoms, duration, aggravating/relieving factors].
• [Relevant negative findings, e.g., No history of smoking or alcohol use].
• Family history of [relevant conditions].
Examination
• Blood pressure: [value].
• Heart rate: [value], [rhythm description].
• [Cardiac exam findings].
• [Respiratory exam findings].
• [Other relevant exam findings, e.g., edema].
Plan
• Ordered [tests/investigations] including [specific tests].
• Advised on [lifestyle recommendations].
• Adjusted [medications] to [reason for adjustment].
• Scheduled follow-up in [timeframe] to [purpose of follow-up].
Mental State Examination
• [Level of alertness and orientation].
• Mood appears [description], [any signs of anxiety or depression].
Sample Clinical Note

Example of completed documentation using this template

Summary
- 45-year-old male with hypertension and type 2 diabetes, presenting with chest pain.
- ECG and blood tests ordered to rule out myocardial infarction.
- Initiated lifestyle modifications and adjusted antihypertensive medication.
History
- 45-year-old male with a history of hypertension and type 2 diabetes.
- Presented with intermittent chest pain over the past week, worsens with exertion.
- No history of smoking or alcohol use.
- Family history of cardiovascular disease.
Examination
- Blood pressure: 150/95 mmHg.
- Heart rate: 88 bpm, regular rhythm.
- No murmurs or gallops on auscultation.
- Lungs clear to auscultation bilaterally.
- No peripheral edema.
Plan
- Ordered ECG and blood tests including troponin levels.
- Advised on dietary changes and increased physical activity.
- Adjusted antihypertensive medication to better control blood pressure.
- Scheduled follow-up in two weeks to review test results and assess symptom progression.
Mental State Examination
- Alert and oriented to time, place, and person.
- Mood appears stable, no signs of anxiety or depression.
Clinical Benefits

Key advantages of using this template in clinical practice

  • Summary - Impression: Acute bronchitis - Plan: Prescribe antibiotics, recommend rest and hydration History - 45-year-old male presenting with a persistent cough for two weeks - Reports fever and fatigue - No history of asthma or COPD - Non-smoker Examination - Temperature: 38.5°C - Respiratory rate: 22 breaths per minute - Auscultation reveals wheezing in the right lung - No cyanosis or clubbing observed Plan - Prescribe amoxicillin 500 mg three times daily for seven days - Advise increased fluid intake and rest - Schedule follow-up in one week to assess improvement - Educate on signs of worsening symptoms and when to seek further medical attention This comprehensive clinical template is designed to streamline documentation for healthcare professionals, ensuring accurate and efficient patient care. By adopting this template, clinicians can enhance their workflow, improve patient outcomes, and maintain high standards of clinical practice. Explore the benefits of implementing this template in your practice today.
Frequently Asked Questions

Common questions about this template and its usage

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Summary Statement Note