PRESENTING HISTORY/CC:
Patient visits the clinic today for management of transgender hormone therapy. [mention patient's age, gender assigned at birth, gender identity, pronouns used to identify themselves with, and how long they have been on hormone therapy so far if at all (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)] [mention previous hormone therapy regimen specifics if patient reports prior hormone therapy use (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)] [mention if the patient says around what age they realized they were transgender and/or when they realized that their gender assigned at birth did not fit how they felt about their gender identity (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)] [mention if we discuss lab findings, what they were, and what they indicate (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)] [mention if they have a social support system, what it consists of, and whether their social support system is supportive or not of their gender transition (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)] [mention whether or not they have been on hormone therapy previously (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)] [mention whether someone else is reported as being present with the patient during the appointment (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)] [mention if the patient confirms that they did watch any of the educational videos and any other educational material sent to the patient prior to the appointment (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)] [mention if the patient reports during the visit whether they are interested in full gender transition results, or nonbinary transition results, or low dose hormone therapy, or androgynous transition results, or if they are undecided, or if they otherwise comment on how they want their hormone therapy transition results to physically appear (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)] [mention if the patient reports where they work, where they go to school, or what they do for a living (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)] [mention if the patient says they have been seen or evaluated by any mental health care provider, therapist, or counselor, and include details such as when the patient saw this professional, for how long, and why they saw them (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)]
SUBJECTIVE FINDINGS:
- [Mention reasons for visit, chief complaints such as requests, symptoms, etc (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)]
- [Mention Duration/timing/location/quality/severity/context of complaint (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)]
- [List anything that worsens or alleviates the symptoms, including self-treatment attempts and their effectiveness (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)]
- [Progression: Describe how the reported symptoms have changed or evolved over time (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)]
- [Previous episodes: Mention any past occurrences of similar symptoms, including when they occurred, how they were managed, and the outcomes (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)]
- [Mention Impact on daily activities: explain how the symptoms affect the patient's daily life, work, and activities (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)]
- [Associated symptoms: Mention any other symptoms (focal and systemic) that accompany the reasons for visit & chief complaints (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)]
- [Mention any pertinent personal life changes discussed by patient during the appointment, such as a change in job status, relationship status, schooling, social life, etc (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)]
MED HISTORY AND/OR PRIOR HRT:
- [Mention previous hormone therapy that is stated to have begun prior to patient establishing care with this clinic (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)]
- [Mention Contributing factors including past medical and surgical history, investigations, treatments, relevant to the reasons for visit and chief complaints (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)]
- [Mention Social history that may be relevant to the reasons for visit and chief complaints (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)]
- [Mention Family history that may be relevant to the reasons for visit and chief complaints (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)]
- [Mention Exposure history (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)]
- [Mention Immunization history & status (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)]
- [Other: Mention Any other relevant subjective information (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)]
OBJECTIVE FINDINGS:
- [Vitals signs (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave out of note)]
- [Physical or mental state examination findings, including system specific examinations (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave out of note)]
- [Investigations with results, such as labs, imaging, or other diagnostic tests (only include completed investigations and the results of these investigations that have been explicitly mentioned in the transcript, contextual notes, or clinical note. All planned or ordered investigations must not be included under Objective; instead all planned or ordered investigations must be included under the Plan For Care & Follow Up section below.)]
[Include the Exam Findings section below that is in quotation marks at the bottom of the Objective Findings section, leaving the Exam Findings section exactly as it is currently typed]
[If there are no other Objective Findings to put under the Objective Findings heading above, then only put the Exam Findings section from below under the Objective Findings heading (do not mention that there were no objective findings to report if there are none available)]
"EXAM FINDINGS:
General: No acute distress. Calm and cooperative.
HEENT: NCAT, Vision/Hearing grossly intact, Swallows without difficulty. No speech impairments.
Cardiac: Skin appears well perfused, and is stated as warm and dry. No stated palpitations or CP.
Pulm: No obvious externally audible wheezing. Breathing is even and unlabored on room air. No cyanosis noted. No reported SOB.
Neuro: A&O x 4. GCS = 15. No reported dizziness or numbness/tingling. Moves all extremities spontaneously.
Psych: Appropriate affect. No obvious hallucinations/delusions or stated SI/HI.
GI: No obvious visible masses. No c/o N/V/D or abd pain.
Integumentary: No visible rashes or jaundice.
Genito-Urinary: No stated discomfort."
ASSESSMENT & DIAGNOSIS CODES:
- [Always include ICD code F64.9 Gender Dysphoria as the first of the assessment diagnoses listed]
- [List other potential diagnoses or conditions raised during the appointment (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)]
PLAN FOR CARE & FOLLOW UP:
- [List investigations planned such as labs, diagnostic imaging, etc (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)]
- [List relevant other actions such as counseling, patient education, referrals, etc (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)]
- [List treatments planned for the diagnoses listed previously, including any current medications being taken or planned to be taken for the patient's transgender hormone therapy regimen (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)]
- [List the date of the next follow up (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)]
- [List the next time labs are anticipated to be due (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)]
(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 include in your note.)
(When listing dates, always use the date format according to American custom such as mm/dd/year)