Clinical Note

Date: April 15, 2025
Time: 10:30 AM
Provider: Dr.C Patient: [R.W]
Age/Gender: [55], [F]
Location: [Boston]

Chief Complaint

Patient’s primary concern in their own words

History of Present Illness

Detailed narrative of the current illness including:

• Onset and duration
• Quality and severity
• Associated symptoms
• Aggravating/alleviating factors
• Previous treatments tried

Review of Systems

Constitutional: Fever, weight changes, fatigue
HEENT: Headache, vision changes, hearing issues
Cardiovascular: Chest pain, palpitations, shortness of breath
Respiratory: Cough, shortness of breath, wheezing
Gastrointestinal: Nausea, vomiting, abdominal pain
Genitourinary: Urinary frequency, urgency, dysuria
Musculoskeletal: Joint pain, muscle weakness
Neurological: Dizziness, numbness, weakness
Psychiatric: Mood changes, anxiety, sleep disturbances
Dermatologic: Rashes, lesions, changes in skin

Past Medical History

• Medical conditions
• Surgical history
• Hospitalizations
• Allergies and reactions

Medications

Current Medications:

• Medication name, dosage, frequency
• [List all current medications]

Recent Changes:

• Any recent additions, discontinuations, or dose changes

Social History

• Occupation
• Tobacco/alcohol/substance use
• Living situation
• Relevant social determinants of health

Physical Examination

Vital Signs

• Temperature: [°F/°C]
• Blood Pressure: [mmHg]
• Heart Rate: [bpm]
• Respiratory Rate: [breaths/min]
• Oxygen Saturation: [%] on [room air/supplemental O2]
• Weight: [kg/lbs]

Physical Exam Findings

General Appearance: [Alert, oriented, in no acute distress]
HEENT: [Normal/abnormal findings]
Neck: [Lymph nodes, thyroid, JVD]
Cardiovascular: [Heart sounds, murmurs, rhythm]
Respiratory: [Lung sounds, effort, symmetry]
Abdominal: [Bowel sounds, tenderness, organomegaly]
Extremities: [Edema, pulses, ROM]
Neurological: [Mental status, cranial nerves, motor/sensory]
Skin: [Lesions, rashes, color]

Diagnostic Tests/Results

Laboratory Results:

• [Lab values with reference ranges]

Imaging:

• [X-ray, CT, MRI findings]

Other Studies:

• [EKG, pulmonary function, etc.]

Assessment and Plan

Primary Diagnosis: [ICD-10 Code if applicable]

Assessment: Clinical reasoning and differential diagnosis considerations

Plan:

1. Immediate management:
   • Treatments initiated
   • Medications prescribed
2. Follow-up:
   • When to return
   • Warning signs to watch for
3. Additional testing:
   • Labs or imaging ordered
4. Referrals:
   • Specialist consultations needed
5. Patient education:
   • Information provided to patient

Secondary Diagnoses (if applicable)

• Additional conditions addressed
• Ongoing management plans

Patient Education

• Information discussed with patient
• Resources provided
• Instructions given

Follow-up

• Next appointment: [Date/timeframe]
• Contact instructions: When to call or return
• Red flag symptoms: Warning signs requiring immediate attention

Clinical Impression

Brief summary of key findings and overall clinical assessment.

Auther: R.S Date Reviewed: [Date]
Note Status: [Draft/Final]