PATIENT NOTE

Instructions

PATIENT NOTE
Examinee's Name
DIAGNOSIS # 01

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DIAGNOSTIC REASONING: Based on what you have learned from the history and the physical examination, list up to 3 diagnoses that might explain this patient's complaint(s). List your diagnoses from most to least likely. For some cases, fewer than 3 diagnoses will be appropriate. Then, enter the positive or negative findings from the history and the physical examination (if present) that support each diagnosis.
HPI

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Age Gender CHIEF COMPLAINT - onset, duration, quality, location. Severity Factors Associated Symptoms Other relevant info
ROS

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Allergies

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Medications

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PHM

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PSH

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SH

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Tobacco Illicit Drugs Alcohol Sexual life
FH

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Contributory or non contributory
Medications

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Physical Examination

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Is the patient in acute or no acute distress VS BMI, if it applies HEENT, if it applies CHEST, if it applies HEART Abdomen, if it applies Neuro, if it applies PHYSICAL EXAMINATION: Describe any positive and negative findings relevant to this patient's problem(s). Be careful to include only those parts of examination you performed in this encounter.
DIAGNOSTIC WORKUP

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Lastly, list initial diagnostic studies (if any) you would order for this patient (e.g. restricted physical exam maneuvers, laboratory tests, imaging, ECG, etc.)
DIAGNOSIS # 02

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DIAGNOSTIC REASONING: Based on what you have learned from the history and the physical examination, list up to 3 diagnoses that might explain this patient's complaint(s). List your diagnoses from most to least likely. For some cases, fewer than 3 diagnoses will be appropriate. Then, enter the positive or negative findings from the history and the physical examination (if present) that support each diagnosis.
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History Finding(s):
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History Finding(s):
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History Finding(s):
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History Finding(s):
DIAGNOSTIC WORKUP

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Lastly, list initial diagnostic studies (if any) you would order for this patient (e.g. restricted physical exam maneuvers, laboratory tests, imaging, ECG, etc.)
DIAGNOSIS # 03
DIAGNOSTIC REASONING: Based on what you have learned from the history and the physical examination, list up to 3 diagnoses that might explain this patient's complaint(s). List your diagnoses from most to least likely. For some cases, fewer than 3 diagnoses will be appropriate. Then, enter the positive or negative findings from the history and the physical examination (if present) that support each diagnosis.
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History Finding(s):
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History Finding(s):
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History Finding(s):
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History Finding(s):
DIAGNOSTIC WORKUP

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Lastly, list initial diagnostic studies (if any) you would order for this patient (e.g. restricted physical exam maneuvers, laboratory tests, imaging, ECG, etc.)