🩺 Record Detail
Patient Info
Transcript
<thead>
<tr>
<th><strong>Original Transcription</strong></th>
</tr>
</thead>
<tbody><tr><td id="fragmentid_1"><div><p><strong class="Patient">Patient</strong>: I have cramps and they've been going on for five days. I need painkillers. I'm also feeling nauseous. I don't know.</p></div></td></tr></tbody>
Clinical Notes
Patient Information Patient Name: PATIENT_NAME
DOB / Age: _________
Gender: _________
Medical Record # (MRN): _________
Date & Time of Encounter: SESSION_DATE
Provider Name: DOCTOR_NAME
Chief Complaint (CC) Patient presents with: Cramps and nausea
History of Present Illness (HPI) Onset: Five days ago
Location: _________
Duration: Five days
Characteristics: Cramps and nausea
Aggravating/Relieving Factors: _________
Timing: _________
Severity: _________
Additional Notes: Patient requests painkillers.
Review of Systems (ROS) General: ☐ Fatigue ☐ Fever ☐ Weight Change ☐ Other: _____
HEENT: ☐ Headache ☐ Vision Changes ☐ Sore Throat ☐ Other: _
Cardiovascular: ☐ Chest Pain ☐ Palpitations ☐ Other: _____
Respiratory: ☐ Cough ☐ Shortness of Breath ☐ Other: _____
Gastrointestinal: ☑ Nausea ☐ Vomiting ☐ Abdominal Pain ☐ Other: ___
Musculoskeletal: ☐ Joint Pain ☐ Muscle Weakness ☐ Other: _
Neurological: ☐ Dizziness ☐ Numbness ☐ Other: ___
Psychiatric: ☐ Anxiety ☐ Depression ☐ Other: _____
Past Medical History (PMH) Conditions: ___________
Surgeries: ___________
Allergies: ___________
Medications: __________
Physical Examination Vital Signs: BP: _ HR: Temp: _ RR: SpO₂: ____
General Appearance: _________
HEENT: _______
Cardiac: _______
Respiratory: _________
Abdominal: _________
Extremities: _________
Neurological: _______
Assessment Primary Diagnosis: __________
Secondary Diagnoses: ________
Plan Medications: _________
Diagnostics/Labs Ordered: ________
Procedures: _________
Referrals: __________
Follow-Up: _________