How to Mimic your Writing Style using DeepCura AI
Updated: 16 minutes ago
In this article, we'll show doctors how to harness the power of our AI clinical workspace to enhance their automated clinical documentation. Though the training video provided focuses on Family Medicine, the underlying principles are the same to any medical specialty. Furthermore, we've provided AI note templates segmented by medical specialty below. Consider these templates as foundational resources or sources of inspiration, and feel free to adapt them to your requirements.
How to Mimic your Writing Style using DeepCura AI: Step-by-step Guide:
1. Please watch the training video above to have an exact idea of how you can fine tune your clinical documentation.
2. Further Uses: Don't limit yourself to just H&P notes! DeepCura AI's capability extends to producing referral letters, medical reports, and more. All it requires is the appropriate data input, and within 60 seconds, your document will be ready.
Here are some of the top Prompts that have been created from our users in different medical specialties:
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Internal medicine Prompt
Generate a medical note using the following template.
CHIEF COMPLAINT:
HISTORY OF PRESENT ILLNESS:
CURRENT MEDICATIONS:
PAST MEDICAL HISTORY:
HOSPITALIZATIONS:
ALLERGIES:
SOCIAL HISTORY: Smoking Status: ___________ Alcohol use: ___________ Caffeine use: ___________ Marital status: ___________ Racial background: ___________ Native language: ___________ Exercise habits: ___________
FAMILY HISTORY: Father: _______________ Mother: _______________
PREVENTIVE CARE: Hemoglobin A1c: ____________ Blood Glucose: ____________ Colonoscopy: ____________ COVID Vaccine: ____________ Last Complete Physical: ____________ Lipid Panel: ____________ PSA: ____________
REVIEW OF SYSTEMS: PHQ-2: ____________
VITAL SIGNS: Weight: _________; Height: _________; BMI: _________ Temperature: _________; Respiration Rate: _________; Pulse Rate: _________; Blood Pressure: _________ Pulse Oximetry: _________
PHYSICAL EXAMINATION: General: ____________ Lungs: ____________ Heart: ____________ Musculoskeletal: ____________
Diagnostic test results:
DIAGNOSIS:
PLAN:
Utilize this transcript to extract the information.
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Family Medicine Prompt
Generate a patient history and physical examination note with a detailed history of present illness (HPI) section with the following parameters and edit my physical exam default template only if you find any abnormal findings, follow this exact structure and remember to fill in the square brackets. Also remember to never include the square brackets themselves, delete them after you’ve filled in the corresponding information:
Date: [Insert here today’s date and time if mentioned]
Advanced Directive: [if mentioned, include advanced healthcare directive. If not mentioned, just state “Does not apply”] Dermatology: [describe latest dermatology visit and any relevant treatments or diagnoses. If a biopsy was ever taken describe date of procedure, reason for biopsy and biopsy report findings if available. If no dermatology visit is mentioned, state “Not mentioned” and if a visit occurred but there were no abnormal findings and no treatments administered, state “...”]
HISTORY OF PRESENT ILLNESS: use this header for this section. Create a summary paragraph of the development of the patient’s present illness using the mentioned information. Write it in a well-written paragraph format with the following information in chronological order(from the first sign and symptom to the present):
FAMILY HISTORY: use this header for this section. Include any relevant family history only including mother, father, maternal and paternal grandparents, children, and siblings. Only include other family members in case of cancer history.
SOCIAL HISTORY: use this header for this section. Remember to only edit the default answers if there are abnormal findings, otherwise, leave them as is. Remember to fill in the square brackets with the relevant information.
Tobacco: [if patient is a smoker and if mentioned state number of cigarettes per day. Otherwise state “Does not smoke”]
Alcohol: No alcohol excess.
Drug use: No drug use. Stress reduction/hobby: [include any hobbies or stress reduction techniques if mentioned. Otherwise state “Not mentioned”]
Supplements: [include any supplements. Otherwise state “None mentioned”]
DIET: use this header for this section. If no information was given, state “Not mentioned” Breakfast:________ Lunch:________ Dinner:________ Snack:________ Elimination diet:________
Allergies: [if the patient states he or she has no allergies, write “No allergies”, if any allergies are mentioned, describe the allergen and the reaction that occurs if mentioned]
Vaccines: if the following vaccines were administered, describe the number of doses and the date of the last dose. If the vaccine wasn’t administered state “Not administered” Tetanus:________ Pneumovax:_______ Prevnar:______ Flu vaccine:_______
Exercise: [if any form of exercise is mentioned describe frequency, type(s) of exercise, the duration of each exercise session and when the exercise regimen began. If the patient does not exercise mention that.]
MEDICAL HISTORY: use this header for this section. Add any past medical history that is mentioned.
Medications: [include any medications, including dosage and frequency. Otherwise, state “None mentioned”]
SURGICAL HISTORY: use this header for this section. Add any surgical history, including date of surgery, if there were any complications, if a biopsy was performed and the results of the biopsy if applicable.
REVIEW OF SYSTEMS: use this header for this section. VERY IMPORTANT NOTE: this section has default answers for normal findings. DO NOT change any of it unless you note an abnormal finding during the transcript. If you do note an abnormal finding, add it to the corresponding section. Constitutional: No fever/chills. No weight change. No appetite change. No sleep problems. No snoring. Eyes: No visual change. Ears, nose, throat, mouth: No headache, No runny nose. No hearing difficulty. Respiratory: No cough. No dyspnea. Cardiovascular: No chest pain. No palpitations. No faintness. No edema. Gastrointestinal: No abdominal pain. No heartburn. No nausea. No vomiting. No diarrhea. No constipation. No melena. BM daily. Genitourinary: No urinary frequency. No dysuria. No hematuria. Musculoskeletal: No back pain. No joint pains. No morning stiffness. Neurological: No localized weakness. No paresthesias. No tremor. No history of concussion/head injury. Integumentary: No rash. No lesions. Psychiatric: No emotional stress. No depression. No anxiety. Endocrine: No temperature intolerance. Hematologic/lymphatic: No easy bruising. Allergic/immunologic: No hay fever. No excess infections. No tick bites. Environmental: No chemical exposures. No mold exposure.
PHYSICAL EXAMINATION: use this header for this section. VERY IMPORTANT NOTE: this section has default answers for normal findings. DO NOT change any of it unless you note an abnormal finding during the transcript. If you do note an abnormal finding, add it to the corresponding section. Appearance: Alert, cooperative, in no distress. Vital signs:
Weight: [lbs]
Height: [inches]
BMI: [calculate the BMI based on the weight and height of the patient]
Temperature: _________
Respiration Rate: _________
Pulse Rate: _________
Blood Pressure: _________
Pulse Oximetry: _________
Skin: Warm, dry; No cyanosis. No suspicious lesions. Eyes: No conjunctival pallor. Ear, nose, mouth, and throat: Mucous membranes moist. Nares clear. Pharynx clear. Teeth okay. Neck: Normal thyroid, No lymphadenopathy, No bruit, No JVD Chest/respiratory: No rales, No rhonchi, No wheezes; breath sounds equal bilaterally. Heart/cardiovascular: No irregularity; No murmur, No gallop. Abdomen/gastrointestinal: Soft; No tenderness; No HSM. Back: No deformity. Genitourinary: Deferred Extremities: No deformity. Neurological/psychiatric: Alert and oriented; No focal weakness. DTR's equal bilaterally. Normal gait. No tremor. Lymp: No enlarged neck, axillary, or groin lymph nodes.
LABORATORY/IMAGING: use this header for this section. Add any relevant laboratory tests and/or imaging with results if possible. Remember to fill in the brackets with the relevant information.
Colonoscopy: [describe latest colonoscopy if relevant. Include date of procedure, relevant findings, if a biopsy was performed, and if available, biopsy results.] Occult Blood: [mention any test results for occult blood if they’re mentioned. If not mentioned state “not mentioned”] PAP: [describe latest Pap test if relevant. Include date of procedure, and relevant findings. If the patient has never had a Pap test just write that.] Mammogram: [describe latest mammogram if relevant. Include date of procedure and relevant findings.] Breast USS: [describe latest breast ultrasound if relevant. Include date of procedure and relevant findings.] Densitometry: [describe latest densitometry if relevant. Include date of procedure and relevant findings. If mentioned, include T scores.] PSA: [if relevant describe prostate-specific antigen results] DRE: [if relevant, describe direct rectal exam findings. If the test was done but there were no abnormal findings state “No abnormalities found.”]
IMPRESSION: use this header for this section. Add the diagnostic impression with the corresponding ICD-10 code.
PLAN/FOLLOW-UP: Use this header for this section. If a thorough treatment plan is not given, suggest one based off the given patient encounter, or add to what has been given. Put this in list form with bullet points.
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Otolaryngology Prompt
Generate a SOAP note with a detailed Subjective section with the following parameters and edit my physical exam default template only if you find any abnormal findings, please follow this exact structure:
Patient Name:
AID:
DOB:
PCP:
Date of encounter:
Subjective (Please make this more detailed and include past surgical history):
Physical Exam (Replace these values only if you find abnormal finding from the transcript):
- General: No acute distress. Voice is clear. Managing secretions.
- Ears: Right EAC clear; tympanic membrane clear and intact; no middle ear effusion. Left EAC clear; tympanic membrane clear and intact; no middle ear effusion.
- Nose: Septum midline. No turbinate hypertrophy. Normal appearing mucosa.
- Oral Cavity/Oropharynx: No masses or lesions. Tonsils normal appearing. Oropharynx clear.
- Neck: No cervical adenopathy. No thyroid masses palpable.
- Face: Intact and symmetric facial movement.
- Neuro: Cranial nerves grossly intact.
- Abnormal endoscopic findings (list abormal findings from laryngoscopy or nasal endoscopy. Delete title and section if not mentioned):
Nasal Endoscopy (Delete title and section if not mentioned. Replace these values only if you find abnormal finding from the transcript):
- Indication: Anterior rhinoscopy insufficient for visualization of entire nasal cavity and nasopharynx.
- Nasal cavity: Nasal mucosa healthy appearing. No turbinate hypertrophy. The middle meatus and sphenoethmoid recess were clear.
- Nasopharynx: Normal appearing.
Laryngoscopy (Delete title and section if not mentioned. Replace these values only if you find abnormal finding from the transcript):
- Indication: Unable to visualize larynx with a mirror.
- Nasal cavity and nasopharynx: Healthy mucosa. No pus or polyps. Nasopharynx clear.
- Oropharynx: Tongue base normal appearing.
- Supralottis: Epiglottis free of disease. Arytenoid cartilages with healthy mucosa. False vocal folds and the visible ventricle were normal appearing.
- Glottis: The true vocal folds were normal in appearance and movement.
- Hypopharynx: The pyriform sinuses were free of disease. The post-cricoid area was not-edematous. There were no pooling secretions.
- Subglottis: The visible subglottis was patent.
Audiogram (do not display this section or title if an audiogram is not mentioned):
Assessment:
Plan:
(Leave 4 lines after the last Plan item)
Extremely Important Note: make only the assessment and plan portion in bullet points and make sure to always keep the physical exam template EXACTLY as instructed.
For the Nasal Endoscopy and Laryngoscopy sections, only use the relevant title section according to the transcript, analyzing whether a nasal endoscopy or laryngoscopy was performed.
For the Audiogram section, display a detailed account of the most recent audiogram findings.
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Podiatry Prompt
Generate a podiatry SOAP note.
Do not use *.
Generate detailed SUBJECTIVE findings focus on the CC of the patient, specifically regarding his wound and chronic disease state.
Use NLDOCAT to create a detailed description of the pain or CC by the patient and divide the different CC into paragraphs depending on problems talked about during this visit.
Reconcile the medications, noting any outstanding problems.
Include a section Review of Systems (ROS), in the SUBJECTIVE section.
Generate extremely comprehensive OBJECTIVE findings during the physical exam. Focus on the location wounds and compounding factors.
Include these sections in the Objective findings talked about during visit.
DERMATOLOGICAL EXAM:
ORTHOPEDIC EXAM:
VASCULAR EXAM:
NEUROLOGICAL EXAM:
LYMPHATIC EXAM:
Generate the list of the current ASSESSMENT/DIAGNOSIS from the visit.
Generate extremely comprehensive PLAN and design a Clinical Plan of Care for each CC or assessment and explain the reasoning behind it using the information from the provided in this exam.
Generate DIFFERENTIAL DIAGNOSES and explain the reasoning behind them using the information from the provided in this exam.
Highlight any new PRESCRIPTION written for during this exam in a separate section.
Highlight any new ORDER written for during this exam in a separate section, like labs or imaging.
Describe the PROCEDURE section in detail from the audio file, include and tests, studies, or imaging performed in the office.
Highlight any REFERRALS written for during this exam in a separate section.
I'd like to see thorough explanations for each intervention, educational material that might be provided to the patient, as well as the rationale for each step in the treatment plan from the provided exam with the patient.
Highlight when the patient was instructed to return to the office and what will be the reason for the follow-up visit. From the provided transcript.
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Psychiatry Prompt (This will only work using GPT-4-32K)
Please use this psychiatric template for the encounter and do not use the client's name:
TEMPLATE:
E/M: BASED ON MDM
PSYCHOTHERAPY TIME IN: can you please input a time here that is 40 minutes after the appointment time
PSYCHOTHERAPY TIME OUT: can you please input a time here that is 60 minutes after the appointment time
MEETING TYPE: please list if this in person or virtual
CC: the client's own words ""
HPI:
Please create a summary paragraph of the client with the included information in a well-written paragraph format with the following information.
Client Introduction: This is a [Client's Age]-year-old [Client's Gender] client, who has presented for an initial psychiatric evaluation. (Psychiatric History:) [Past psychiatric diagnoses and when they were diagnosed or state 'The client has no previous psychiatric diagnosis, though they have been displaying symptoms of [possible diagnosis (anxiety, depression, etc.)] for roughly [time length].'] (Referral:) [If the client was referred, mention 'The client was referred by [person/organization.']. (Hospitalizations:) [State any previous hospitalizations for psychiatric reasons and suicide attempts/self-injurious behavior, or mention 'The client has had no prior psychiatric hospitalizations nor revealed any suicidal attempts or self-injurious behavior in the past.' Or a combination of the two possibilities based on client information] (Medical and Substance Use History:) [Include any relevant past medical history tied to psychiatric conditions, or specify] [If relevant, mention 'The client has a history of substance use disorder relating to [substances].'] (Prior and Current Treatments:) [Detail the client's previous psychiatric treatments, outcomes, current therapies, current mental health providers, or state 'The client has not undergone any prior psychiatric treatments and currently has no mental health providers.'] (Medications:) [If applicable, discuss 'The client is currently on [names and dosages of medications].'] [Share the effectiveness of these medications and any side effects or denote 'The client reports no significant side effects from the medications or treatments.'] [Indicate the adherence level or state 'The client has demonstrated high adherence to the prescribed dosage.'] [If the client is medication-free, state 'Presently, the client is not taking any medications for psychological health concerns.']
Remember to fill in the brackets with the relevant information. If the paragraph doesn't apply to the client, you can simply omit it from the final draft.
Write the History of Present Illness (HPI) of an initial psychiatric evaluation for the following client. Write in a narrative (style, integrating the details according to the OLD CARTS Mnemonic) (Onset, Location, Duration, Character, Associated Symptoms, Radiation, Timing, Severity) within the narrative without breaking it down into separate points. If any part of the OLD CARTS information is missing, simply omit it and include only the information that was given. (Psychiatric system(s) and symptoms) Provide a narrative description of the current condition(s), (for example mood), including details about onset, location, duration, character, associated symptoms, radiation, timing, severity, modifying factors, and context, without breaking them down into separate points or including unnecessary details. If any part of this information is missing, simply omit it. Do not signify or note the possible diagnosis, this is not the assessment but is still part of the HPI and should only be covering the information gathered, the subjective information.
Please make this into a NEW PARAGRAPH. [Cover any current psychosocial stressors and the effect that it is having on work/social/family life etc.]
[Add a sentence covering safety like “The client denied any current thoughts or intent of harm to self or others, compulsive or intentional self-injury or mutilation, auditory/visual hallucinations, delusions, and feelings of paranoia”] Please edit this sentence to reflect the information for this client.
Note: Ensure that the content is specific to the individual client and that the OLD CARTS details are seamlessly woven into the narrative, without separating them or using subheadings. Include only the details that are relevant and provided for the specific client, omitting any unnecessary or missing information from the provided transcript. Remember to fill in the brackets with the relevant information.
REVIEW OF SYMPTOMS:
All symptoms discussed and necessary information for a DSM 5 diagnosis should be listed under each category below under review of systems, if applicable. If a diagnosis is possible and a category is not listed below, please create the category. (please use the outline below)
(*)APPETITE: (Report changes in appetite, either increased or decreased, if it is grossly normal, normal for them, overall description of their eating habits and patterns)
(*)SLEEP: (Note disturbances in sleep patterns, how many hours of sleep they are getting, if they have trouble falling asleep, staying asleep, mid night awakenings and falling back asleep, if they state they have good and restful sleep, note however they talk about their sleep)
(*)DEPRESSION: [note Denies symptoms of depression if there are no symptoms]
Mood: (Include symptoms related to mood such as sadness, irritability, mood swings, etc.)
Interest: (Note any loss of interest or pleasure in activities, including specific activities etc.)
Energy (Include symptoms of fatigue, low energy, or lethargy etc.)
Eating (Report changes in appetite, either increased or decreased etc.)
Sleep (Include sleep disturbances such as insomnia or hypersomnia etc.)
Self-esteem (Include feelings of worthlessness or excessive guilt etc.)
Focus (Note issues with concentration or decision-making etc.)
Movement (Report psychomotor agitation or retardation etc.)
Suicide (Include suicidal ideation, plans, or attempts etc.)
(*)MANIA: [note Denies symptoms of mania if there are no symptoms]
Mood (Note elevated, expansive, or irritable moods, etc.)
Energy (Include increased energy or hyperactivity, etc.)
Speech (Note rapid or pressured speech., etc.)
Sleep (Include reduced need for sleep etc.)
Self-esteem (Note grandiose or inflated self-esteem etc.)
Behavior (Include risky or impulsive behaviors etc.)
Thought (Note racing thoughts or flight of ideas etc.)
(*)ANXIETY: [note Denies symptoms of anxiety if there are no symptoms]
Worry (Include excessive worrying or ruminative thoughts etc.)
Restlessness (Note feelings of nervousness or agitation etc.)
Energy (Report fatigue or low energy etc.)
Mood (Include irritability or mood swings etc.)
Tension (Note muscle tension or physical discomfort etc.)
Fears (Include specific or generalized fears and phobias etc.)
Focus (Report difficulty in concentration etc.)
Sleep (Note disturbances in sleep patterns etc.)
SOCIAL ANXIETY:
Fear (Include fear or apprehension about social situations etc.)
Avoidance (Note avoidance behaviors related to social situations etc.)
Sweat (Include symptoms of excessive sweating etc.)
Tremble (Note shaking or trembling in social context etc.)
Focus (Include heightened self-consciousness or excessive worrying about social performance etc.)
EATING DISORDERS:
Eating (Note any abnormal eating habits like bingeing, restricting, etc.)
Weight (Report significant weight changes or concerns etc.)
Body Image (Include perceptions or attitudes toward body image etc.)
Control (Note feelings of lack or gain of control over eating etc.)
Exercise (Include excessive or compulsive exercise behaviors etc.)
PMDD (PREMENSTRUAL DYSPHORIC DISORDER):
Mood (Include mood swings, irritability, or emotional lability etc.)
Irritability (Note heightened irritability or mood swings etc.)
Tension (Include symptoms of stress or tension etc.)
Eating (Note changes in appetite etc.)
Sleep (Include any sleep disturbances etc.)
Physical (Report physical symptoms like bloating, breast tenderness, etc.)
PANIC: [note Denies symptoms of panic if there are no symptoms]
Fear (Include sudden and intense fear or discomfort etc.)
Heart (Note palpitations or accelerated heart rate etc.)
Sweat (Include symptoms of sweating etc.)
Tremble (Note shaking or trembling etc.)
Breath (Include shortness of breath or feeling smothered etc.)
Chest (Report chest pain or discomfort etc.)
Stomach (Include symptoms like nausea or abdominal distress etc.)
Control (Note feelings of losing control or impending doom etc.)
OCD:
Thoughts (Include obsessive thoughts or intrusive ideas etc.)
Actions (Note compulsive behaviors or rituals etc.)
Fear (Include fears that drive obsessive thoughts etc.)
Daily Life (Report impact on daily functioning and quality of life etc.)
(*)TRAUMA: [note Denies symptoms of trauma if there are no symptoms]
Memories (Include intrusive memories or flashbacks etc.)
Avoidance (Note avoidance of reminders or emotional numbness etc.)
Mood (Include negative mood or emotional states etc.)
Alert (Report hyperarousal or heightened alertness etc.)
ADHD:
Attention (Note symptoms of inattention such as Endorses failing to give attention to detail or makes careless mistakes, difficulty sustaining attention in tasks or play activities, does not seem to be listening when spoken to, does not follow through on instructions and fails to finish schoolwork, chores, workplace duties, difficulty organizing tasks and activities. Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort in. Loses things necessary for tasks or activities, easily distracted by extraneous activities, forgetful in daily activities, etc.)
Activity (Include hyperactivity symptoms such as Fidgets with or taps hands or feet or squirms in seat, leave seat in situations when remain seated is expected, runs about or climbs in situations where it is inappropriate, unable to play in leisure activity quietly, on the go as if driven by a motor, talks excessively, blurts out answers before a question has been completed, difficulty waiting his or her turn, interrupts or intrudes on others, etc.)
SUBSTANCE USE:
Substance (Specify the type of substance used.)
Frequency (Note the frequency and amount of substance use.)
Impact (Report the impact on daily life and responsibilities.)
Withdrawal (Include any symptoms of withdrawal.)
Tolerance (Note increasing amounts needed for desired effects.)
PSYCHOSIS:
Hallucinations (Specify the nature of hallucinations, auditory, visual, etc.)
Delusions (Note false beliefs, such as paranoia or grandiosity etc.)
Thinking (Include disorganized or incoherent thought processes etc.)
If the above categories or diagnosis/don't apply to the client, you can simply omit it from the final draft unless it is noted that it must be on the final draft with a *. If there is a diagnosis that is missing or that needs to be added due to the client’s systems, please add this.
REVIEW OF SYSTEMS: use this header for this section and remember to fill in the brackets with the relevant information. If it does not apply to the client, you can simply omit the information from the final draft.
Remember to fill in the brackets with the relevant information. If it does not apply to the client, you can simply omit the system from the final draft. If none apply to the client, state “Within normal limits.”
General: [Description, details, fatigue, weight change, fever, chills, night sweats etc.]
Neurological: [Symptoms, triggers, any history of an ongoing neurological issue]
Endocrine: [Symptoms, hormonal details, history of diabetes or any ongoing endocrine issue]
Cardiovascular: [Symptoms, heart details, history of HTN, high cholesterol, heart issues, palpitations etc.]
Respiratory: [Symptoms, triggers, history of asthma or sleep apnea]
Gastrointestinal: [Symptoms, digestive details, appetite issues, nausea, vomiting, diarrhea]
Genitourinary: [Symptoms, urinary]
Gynecological: [Symptoms, reproductive details]
Skin: [Symptoms, dermatological details, medical history of skin issues]
Musculoskeletal: [Symptoms, triggers, medical history of issues, or current issues with ROM etc.]
Hematologic/Lymphatic: [Symptoms, blood/lymph details]
PAST PSYCHIATRIC HISTORY: use this header for this section and remember to fill in the brackets with the relevant information. If it does not apply to the client, you can simply omit the information from the final draft.
[Previous Diagnosis] [When] [By who]
[Previous Psychiatrist or Nurse Practitioner or state if no previous provider]
[Previous counselor or therapist when and for how long] [when] [for how long]
[Current counselor or therapist when and for how long or if no current or previous] [for how long] [started with this counselor or provider when]
[Type of therapy]
[other Treatments]
[Hospitalizations or state denies/none] [if so, when and for how long?] [why]
[Suicide attempt/s or state denies/none] [When] [How]
[Self-harm or state denies/none] [When] [How]
[Suicidal or homicidal thoughts or behaviors or state denies/none]
PREVIOUS PSYCHIATRIC MEDICATIONS: use this header for this section and remember to fill in the brackets with the relevant information. If it does not apply to the client, you can simply omit the information from the final draft.
[Previous Psychiatric Medication] [Dosage] [Route of Administration] [Frequency] [Compliance] [Side effects] [Efficacy] [why was this med stopped] [when was this med taken or how long was the client been on it]
[Previous Psychiatric Medication] [Dosage] [Route of Administration] [Frequency] [Compliance] [Side effects] [Efficacy] [why was this med stopped] [when was this med taken or how long was the client been on it]
CURRENT PSYCHIATRIC MEDICATIONS: use this header for this section and remember to fill in the brackets with the relevant information. If it does not apply to the client, you can simply omit the information from the final draft. List all Current psychiatric medications.
[Medication Name] [Dosage] [Route of Administration] [Frequency] [Compliance] [Side effects] [Efficacy] [when was this med started or how long has the client been on it]
PAST MEDICAL AND SURGICAL HISTORY: use this header for this section and remember to fill in the brackets with the relevant information. If it does not apply to the client, you can simply omit the information from the final draft.
Medical history - [MEDICAL CONDITIONS or none] [also note "denies history of any head injuries, seizures, or cardiac problems" if they are not stated in the medical history]
Surgical history - [SURGICAL HISTORY or none]
Last Physical Examination: [PCP] [PCP Number] [LAST PHYSICAL EXAM]
Last menstrual cycle:
[Birth control pills/tubes tied/other forms of contraception:
Discussed the effects of medications on pregnancy and advised on contraception while on medications]
SUBSTANCE USE HISTORY: use this header for this section and remember to fill in the brackets with the relevant information. If it does not apply to the client, you can simply omit the information from the final draft.
[Substance use/abuse] [what substance] [how much] [last used] (specifically alcohol, tobacco, or illicit drugs. “Denies alcohol, tobacco, or illicit drug use” unless not denied)
ALLERGIES: use this header for this section and remember to fill in the brackets with the relevant information. [ALLERGIES]
CURRENT MEDICATIONS: use this header for this section and remember to fill in the brackets with the relevant information. If it does not apply to the client, you can simply omit the information from the final draft. List all of the current medications the client is taking, excluding the psychiatric medications.
[Medication Name] [Dose] [Route] [Frequency] [what it is for]
[Medication Name] [Dose] [Route] [Frequency] [what it is for]
FAMILY PSYCHIATRIC HISTORY: use this header for this section and remember to fill in the brackets with the relevant information. If it does not apply to the client, you can simply omit the information from the final draft. List all of the family psychiatric illness history.
[who/family member] [history of suicide] [diagnosis/es] [current treatment if known] [treatment effective?]
[who/family member] [history of suicide] [diagnosis/es] [current treatment if known] [treatment effective?]
FAMILY SUBSTANCE ABUSE HISTORY: use this header for this section and remember to fill in the brackets with the relevant information. If it does not apply to the client, you can simply omit the information from the final draft. List all of the family psychiatric illness history.
[who/family member] [substance used]
SOCIAL HISTORY: use this header for this section and remember to fill in the brackets with the information. Each item below should be included.
Living arrangement: [LIVING ARRANGEMENT]
Occupation: [OCCUPATION]
Marital status: [MARITAL STATUS]
Children: [CHILDREN]
Support system: [SUPPORT SYSTEM]
Abuse/trauma history: [ABUSE OR TRAUMA HISTORY]
Gender Identity: [GENDER IDENTITY]
Sexual orientation: [SEXUAL ORIENTATION]
Religious Affiliation: [RELIGIOUS AFFILIATION]
Legal issues: [LEGAL ISSUES]
MENTAL STATUS EXAM: use this header for this section and remember to fill in the MSE as best as possible with the given information.
Appearance: (if this is not stated to be abnormal or cannot be identified as abnormal from the script, put a description of a normal value. Appears to be stated age and is dressed appropriately etc.)
Mood: (if this is not stated to be abnormal or cannot be identified as abnormal from the script, put a description of a normal value)
Affect: (if this is not stated to be abnormal or cannot be identified as abnormal from the script, put a description of a normal value)
Speech: (if this is not stated to be abnormal or cannot be identified as abnormal from the script, put a description of a normal value)
Thought Process: (if this is not stated to be abnormal or cannot be identified as abnormal from the script, put a description of a normal value)
Thought Content: (if this is not stated to be abnormal or cannot be identified as abnormal from the script, put a description of a normal value)
Perceptions: (if this is not stated to be abnormal or cannot be identified as abnormal from the script, put a description of a normal value)
Memory: (if this is not stated to be abnormal or cannot be identified as abnormal from the script, put a description of a normal value)
Judgment: (if this is not stated to be abnormal or cannot be identified as abnormal from the script, put a description of a normal value)
Insight: (if this is not stated to be abnormal or cannot be identified as abnormal from the script, put a description of a normal value)
Attention and concentration: (if this is not stated to be abnormal or cannot be identified as abnormal from the script, put a description of a normal value)
Impulse control: (if this is not stated to be abnormal or cannot be identified as abnormal from the script, put a description of a normal value)
ASSESSMENT: use this header for this section and remember to fill in the brackets with the relevant information.
[List the psychiatric diagnosis/es of the client with its modifiers and the ICD 10 codes]
[List the psychiatric billing codes for this 60-minute encounter with at least 20 minutes of therapy]
[Baseline GAD 7]: please put the score and today’s date
[Baseline PHQ 9]: please put the score and today’s date
Write the assessment portion of this initial psychiatric evaluation in paragraph form. Each diagnosis should be it’s own paragraph. Please use the given client information to come up with all of the possible diagnosis/es for the client and any rule-out diagnosis.
[DIAGNOSIS, list the diagnosis]: [include all symptoms that confirm the diagnosis and make into an assessment paragraph that shows that the criteria is met for the DSM 5 diagnosis, but this does not have to be stated, or explain that this was a prior diagnosis by a previous provider and further assessment is needed or whatever is applicable per the information given.]
PLAN: [describe the plan for the diagnosis, counseling, therapy, medications, supplement etc. describe education about the diagnosis and include client teaching about this diagnosis]
[In this paragraph, Discuss medical necessity and risk assessment. Discuss safety plan, if necessary.]
[write a sentence or two about the possible plans in the future based off the client’s outcomes like, plan to possibly increase dose, decrease dose, change med, add a med etc if not doing it at this appt.]
[Note here if PMP was checked]
Remember to fill in the brackets with the relevant information. If it does not apply to the client, you can simply omit the information from the final draft.
TREATMENT PLAN: Use this header for this section and remember to fill in the brackets with the relevant information. if a thorough treatment plan is not given, please suggest one based off the given client encounter, or add to what has been given. Put this in list form with a “-“ in front of each.
List the planned interventions [including and starting with medications and dosages or supplements] [Start/Continue/Discontinue/Increase/Decrease/Begin to taper/Continue to Taper ______][Medication Name or supplement name] [Dose] [Route] [Frequency] [if the “Medication Plan” or “Supplement Plan” Includes “Start” a medication, include a sentence about the client being educated on the medication. For example, if they are starting sertraline, please list, common side effects for the medication, what to look out for with the specific medication, when it is suggested to take the medication, with or without food if applicable, if the client is a female, add that it was discussed about pregnancy and the use of contraceptive. Also note any black box warnings for the medication, the effects if it is mixed with alcohol and any other necessary client teaching for the specific medication.]
Please note here if the client is to Continue current medication regimen and list the medications [CURRENT PSYCHIATRIC MEDICATIONS:], if applicable.
[List any non-pharmaceutical treatments, and other considerations such as lab tests, or lifestyle recommendations, this can be on multiple lines]
[Create a sentence for the treatment plan of anything else that the client has been noted to have been educated on, or should be educated on]
[Discuss therapy plan here, if the client is in therapy, ex. Continue therapy with current counselor/therapist ___ or put name if it is available and add how often they are seeing each other if this is known, or note if they are to be looking for a therapist, or whatever the status of their therapy is]
[Describe any additional follow-up requirements concisely]
Follow-up: Next appointment: [Provide details for the next appointment]
Please maintain brevity and clarity, focusing on essential details tailored to the client's condition and needs from the provided transcript. Remember to fill in the brackets with the relevant information.
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Hospice
Please generate a medical progress note using the following template.
NAME:
GENDER:
DOB:
DATE:
WGT:
HEIGHT:
BMI:
LMAC:
CHIEF COMPLAINT:
HPI:
ALLERGIES:
Other:
Review of medications:
PAST MEDICAL HISTORY: [ ] APPENDECTOMY [ ] CHOLECYSTECTOMY [ ] TAH [ ] OTHER [ ] UNKNOWN
Social History: [ ] TOBACCO [ ] ETOH [ ] DRUGS [ ] IMMUNIZATION STATUS: [ ] OTHER [ ] UNKNOWN
Family History: MOTHER: [ ] ALIVE [ ] DECEASED: [ ] UNKNOWN FATHER: [ ] ALIVE [ ] DECEASED: [ ] UNKNOWN
REVIEW OF SYSTEMS:
GEN: [ ] NEGATIVE [ ] ANOREXIA [ ] OBESE [ ] FEVER [ ] FATIGUE [ ] OTHER:
HEENT: Ears: [ ] NEGATIVE [ ] PINNAE INTACT [ ] TM CLEAR [ ] OTHER:
EYES: [ ] NEGATIVE [ ] SCLERA CLEAR [ ] DECREASED VISION [ ] OTHER:
NOSE: [ ] NEG [ ] DISCHARGE [ ] OTHER:
THROAT: [ ] NEGATIVE [ ] PAIN [ OTHER:
MOUTH: [ ] LESION [ ] OTHER:
CARDIOVASCULAR [ ] NEGATIVE [ ] CHEST PAIN [ ] PALPITATION [ ] DOE [ ] EDEMA [ ] OTHER:
RESPIRATORY: [] NEGATIVE [] WHEEZING [ ] SOB [ ] COUGH [ ] OTHER:
GASTRO: [ ] NEGATIVE [ ] DIARRHEA [ ] CONSTIPATION [ ] PAIN [ ] HEARTBURN [ ] OTHER:
GENITOURINARY: [ ] NEGATIVE [ ] HEMATURIA [ ] DYSURIA [ ] INCONTINENT [ ] OTHER:
MUSCULOSKELETAL: [ ] NEGATIVE [ ] JOINT/MUSCLE PAIN [ ] BACK PAIN [ ] OTHER:
SKIN: [ ] NEGATIVE [ ] MASSES [ ] RASH [ ] ULCERS [ ] OTHER:
NEUROLOGICAL: [ ] NEGATIVE [ ] SYNCOPE [ ] SEIZURES [ ] TREMORS [ ] HEMIPLEGIA [ ] OTHER:
PSYCHIATRY: [ ] NEGATIVE [ DEPRESSION [ ] ANXIETY [ ] MEMORY LOSS [ ] OTHER:
HEMAT/LYMPH: [ ] NEGATIVE [ ] BRUISES [ ] BLEEDING [ ] ADENOPOTHY [ ] OTHER:
PERIPHERAL VASCULAR: [ ] NEGATIVE [ ] VERICOSE VEINS [ ] CLAUDICATION [ ] OTHER:
PHYSICAL EXAMINATION:
BP:
Left Wrist HR:
RR:
TEMP:
O2:
PAIN:
GEN: Well developed [ ] Well-nourished [x ] Non-acute distress [ ] Cachexia
HEENT: [ ] PERRL [ ] EOM [ ] Normal conjunctive [] TMs clear [ ]
NECK: [ ] No JVD [ ] No carotids bruits [ ] Thyroid WNL [ ] No masses Palpated/Observed
LUNGS: [ ] CTA [ ] Expiratory wheezes [ ] Rhonchi [ ] Inspiratory crackles [ ] Diminished
HEART: [ ] PMI SR Rhythm: [ ] Regular- brady [ ] Irregular [ ] Sounds: S1x S2x systolic murmur
ABD:
EXTS: 1+
Pulses:
NEURO:
AMBULATORY DEVICE: [ ] Cane [ ] Walker [ ] Wheelchair or heavy assist [] Bedbound
DIET:
ASSESSMENT:
PLAN:
[ ] Medication side effects explained [ ] Fall precautions [ ] Home Health Care Services [ ] Use Geri chair or WC [ ] Bed bound [ ] Patient noncompliant: [ ] Treatment [ ] Other:
[ ] Discussed with staff plan above.
Patient was seen today for:
ATTESTATION: I composed this note based on the evaluation of the patient today, and review of the chart and discussion with "Doctor X" and the patient.
The clinical findings are being submitted for the Medical Director's review for determining eligibility for continuing hospice care.
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Veterinary
Please generate a medical progress note using the following template.
Subjective:
Patient Name: _____________
Signalment: _____________
PRESENTING COMPLAINT: _____________
Hx:
Relevant clinical signs and progression summary: _____________
Energy/ Appetite/ Thirst/ Sleep/ Cough/ Sneeze/ Vomiting/ Diarrhea/ Urination activities, Mobility: _____________
Active Medical Diagnosis: _____________
Past Medical History including resolved Dx: _____________
Medications:
Current: _____________
Within the past 30 days: _____________
Diet:
Type: _____________
Size: _____________
# meals/day: _____________
Objective:
Physical Exam Findings:
General: _____________
EYES: _____________
EARS: _____________
NOSE: _____________
ORAL CAVITY: _____________
THROAT: _____________
RESPIRATORY: _____________
CARDIOVASCULAR: _____________
ABDOMEN: _____________
MUSCULOSKELETAL: _____________
NERVOUS SYSTEM: _____________
LYMPHATIC: _____________
INTEGUMENT: _____________
UROGENITAL: _____________
RECTAL/ANUS: _____________
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Frameworks
Create a framework of questions for a physician that is interviewing a [write patient parameters here] with [write clinical condition here]