Medications:
(insert medications from the context window, if no medications mentioned please add no medications were mentioned)
Interval History:
(Summarize the conversation with the patient in the active voice in a narrative way)
Physical Exam:
(Adjust this exam as needed)
GEN: Healthy appearing, well-developed, NAD.
PSYCH: Good judgment. AOx3. Normal memory, mood, and affect.
HEENT:
- Head: NC/AT;
- Eyes: No discharge or redness;
- Ears: External ears are normal;
- Nose: Normal nares;
- Mouth and throat: MMM. Normal gums, mucosa, palate. Good dentition.
CV: RRR, no m/r/g.
LUNGS: CTAB, no w/r/c.
ABD: Soft, NT/ND, NBS, no masses or organomegaly.
GU: N/A
SKIN: Warm, well perfused. No skin rashes or abnormal lesions.
MSK: Normal gait. No deformities.
EXT: No clubbing, cyanosis, or edema.
NEURO: Ambulating with no limitations. No focal deficits.
Labs:
(insert labs from the context window or from transcript)
Imaging tests
(add imaging tests in chronological order from the context page and don’t change the text or summarize the impression and plan).
DATE: (IMAGING STUDY)
IMPRESSION: (FINDINGS)
DATE: (IMAGING STUDY)
IMPRESSION: (FINDINGS)
DATE: (IMAGING STUDY)
IMPRESSION: (FINDINGS)
ASSESSMENT / PLAN:
(PATIENT NAME) with a diagnosis of (CANCER DIAGNOSIS), (RECEPTOR STATUS), (ADDITIONAL RELEVANT HISTORY), who was originally diagnosed in (DATE) and had (DISEASE STATUS) diagnosed (PROCEDURE) in (DATE). (TREATMENT HISTORY). (CURRENT TREATMENT) and (TOLERANCE).
(SYMPTOM/MEDICAL CONDITION)
- Add Relevant patient symptoms from the transcript
- Please add DIFFERENTIAL DIAGNOSIS of this presentation in this context, please only add differential diagnosis if the patient has a symptom. Please do not add differential diagnosis if the patient has already established diagnosed condition
- Please add RELEVANT Lab work under this issue if it was mentioned, if not skip this line
Plan:
- Add DIAGNOSTIC PLAN mentioned in the encounter
- Add TREATMENT PLAN mentioned in the encounter
(SYMPTOM/MEDICAL CONDITION)
- Add Relevant patient symptoms from the transcript
- Please add DIFFERENTIAL DIAGNOSIS of this presentation in this context, please only add differential diagnosis if the patient has a symptom. Please do not add differential diagnosis if the patient has already established diagnosed condition
- Please add RELEVANT Lab work under this issue if it was mentioned, if not skip this line
Plan:
- Add DIAGNOSTIC PLAN mentioned in the encounter
- Add TREATMENT PLAN mentioned in the encounter
(SYMPTOM/MEDICAL CONDITION)
- Add Relevant patient symptoms from the transcript
- Please add DIFFERENTIAL DIAGNOSIS of this presentation in this context, please only add differential diagnosis if the patient has a symptom. Please do not add differential diagnosis if the patient has already established diagnosed condition
- Please add RELEVANT Lab work under this issue if it was mentioned, if not skip this line
Plan:
- Add DIAGNOSTIC PLAN mentioned in the encounter
- Add TREATMENT PLAN mentioned in the encounter
(SYMPTOM/MEDICAL CONDITION)
- Add Relevant patient symptoms from the transcript
- Please add DIFFERENTIAL DIAGNOSIS of this presentation in this context, please only add differential diagnosis if the patient has a symptom. Please do not add differential diagnosis if the patient has already established diagnosed condition
- Please add RELEVANT Lab work under this issue if it was mentioned, if not skip this line
Plan:
- Add DIAGNOSTIC PLAN mentioned in the encounter
- Add TREATMENT PLAN mentioned in the encounter
(add as many medical conditions, issues, abnormal blood work mentioned in the transcript following this template).
Plan:
- Add DIAGNOSTIC PLAN mentioned in the encounter
- Add TREATMENT PLAN mentioned in the encounter
(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 included in your note.)”