Patient Demographics
Name:
Age:
Sex:
Date of Birth:
Attending Physician:
Date of Encounter:
Assessment
Briefly summarize the patient’s key presenting concerns and relevant medical history.
Mention any pertinent findings from the physical examination or diagnostic tests.
Formulate a clear and concise diagnosis (or differential diagnosis if definitive diagnosis is not yet established).
Plan
Outline the treatment plan for the patient.
This may include:
Diagnostic tests needed to confirm or rule out a diagnosis.
Specifically list the tests and their purpose.
Medications prescribed, including:
Medication name
Dosage
Route of administration (e.g., oral, intravenous)
Frequency
Specific instructions (e.g., take with food, avoid alcohol)
Non-pharmacological interventions (e.g., dietary modifications, physical therapy). Be specific about the recommendations.
Referral to specialists if needed. Specify the specialty and reason for referral.
Patient education regarding their condition, medications, or self-care strategies. Briefly mention the key educational points addressed.
Follow-up plan, including:
Date and time of the next appointment
Instructions for contacting the healthcare provider if necessary (e.g., for worsening symptoms, medication side effects).
Additional Considerations
Tailor the level of detail to the specific situation.
For complex cases, you may need to elaborate on the assessment and plan further.
Use clear and concise language, avoiding excessive medical jargon when appropriate to ensure patient understanding.
Document any discussions or shared decision-making with the patient regarding the plan.
This template provides a framework for documenting the assessment and plan sections of a medical note. Remember to adapt it to your specific workflow and facility’s documentation standards.