Complete Medical Assessment EMR Notes Template for Patient Intake
This dynamic EMR template makes creating detailed notes in a patient's chart during an intake exam quick and painless.
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General Notes from a Medical Assessment
This dot phrase, or snippet, will take notes for a healthcare profession completing a full medical assessment. The output will be a well-formatted summary of notes reflective of the information entered into the snippet.
Some statements are generated automatically based on the age and/or sex entered, where others only display when checking a box. Many are dependent on a conditional combination of age, sex, and noted concern. Tests, screenings, and referrals can be selected at the end of the snippet.
Intake Exam
{note: trim=yes}Please enter the following information about the patient: Age (number of years): {formtext: name=Age} Sex: {formmenu: default=; female; male; name=sex} {endnote: trim=left}
- The patient is a {=Age} year old {=sex}.
- The patient's chart was reviewed and reconciled as noted in the HPI
- The patient's lifestyle was reviewed for possible impacts on health. I identified and addressed any barriers to improved health, such as age, gender, ethnic background, and, racial identity. Status of advanced health care planning was reviewed.
- The patient's self-reported or lab-reported vital signs were reviewed.
- Information was provided regarding healthy lifestyle choices and vaccinations.
- Based on recommendations for all or almost all adults, the patient was: Screened for depression, unhealthy alcohol use, smoking, and unhealthy drug use Screened for hypertension or recommended to screen for hypertension Offered screening for Hepatitis C and HIV Counseled regarding advanced care planning, including advanced directives, and offered follow up for future discussion if desired.
Specific concerns for this patient, if any: {formtoggle: name=BMI over 25; default=no; trim=right}- BMI between 25 and 30: The patient was offered screening for diabetes. The patient given information on healthy diet and exercise for prevention of diabetes.{endformtoggle: trim=left} {formtoggle: name=BMI over 30; default=no; trim=right}- BMI over 30: The patient was offered screening for diabetes. The patient was given information on healthy diet and exercise for weight loss and reduction of risk of diabetes and cardiac disease. {endformtoggle: trim=left} {formtoggle: name=Having more than 1 partner in 12 months; default=no; trim=right}{endformtoggle: trim=left} {formtoggle: name=Requesting testing for sexually transmitted infections; default=no; trim=right}{endformtoggle: trim=left} {formtoggle: name=Sexually active; default=no; trim=right}{endformtoggle: trim=yes}
{formtoggle: name=Unhealthy alcohol use; default=no; trim=right}- Unhealthy alcohol use: Depending on the patient's preference, the patient was encouraged to follow up with me, was referred to counseling, or was advised to seek an alcohol counseling/treatment program.{endformtoggle: trim=left}
{formtoggle: name=Concern of depression or anxiety; default=no; trim=right}- Concern of depression or anxiety: Depending on the patient's preference, the patient was encouraged to follow up with me or was referred to counseling.{endformtoggle: trim=left}
{formtoggle: name=Elevated blood pressure; default=no; trim=right}- Elevated blood pressure: the patient was encouraged to follow up with me.{endformtoggle: trim=left}
{formtoggle: name=Female with personal or family history of BRCA related cancer or of Ashkenazi Jewish Ancestry; default=no; trim=right}{endformtoggle: trim=left}
Testing or screening ordered during this visit:
{note: trim=right}{formmenu: Basic labs, including: CBC, CMP, Hemoglobin A1C, TSH, Lipids; Hepatitis B, Hepatitis C, HIV, Syphilis; Gonorrhea/chlamydia; Quantiferon Gold TB; Low dose CT screening for lung cancer; Ultrasound for AAA; BRCA testing; FIT, Cologard; Bone density scan; Mammogram; name=testing; multiple=yes}{endnote: trim=right}
{if: testing=[]}None{else}{=join(testing,", ")}{endif}
Referrals placed during this visit:
{note: trim=right}{formmenu: Behavioral Health; Gastroenterology for colonoscopy; OB/Gyn for women's health; name=referrals; multiple=yes}{endnote: trim=right}
{if: referrals=[]}None{else}{=join(referrals,", ")}{endif}
The patient was advised to follow up at least annually for preventive health care, sooner as needed for review of results or discussion of concerns raised.
The patient verbalized a clear understanding of my instructions and was agreeable with the plan.
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