Family Medicine Note

Subjective

• [Chief complaint and description of present symptoms] (Briefly document patient's primary reason for the visit and current symptoms in their own words. Only include if explicitly mentioned.)
• [History of presenting illness] (Summarize timeline and context of current complaint. Include prior related episodes, relevant treatments, and outcomes. Only include if explicitly mentioned.)
• [Relevant past medical and surgical history] (Include chronic illnesses, prior surgeries, and hospitalizations. Only include if explicitly mentioned.)
• [Current medications] (List prescribed medications, over-the-counter drugs, and supplements. Only include if explicitly mentioned.)
• [Allergies and sensitivities] (Include medications, foods, or environmental allergies. Only include if explicitly mentioned.)
• [Social history] (Document occupation, lifestyle factors, substance use, and living situation. Only include if explicitly mentioned.)

Review of Systems

(Document symptoms under each system only if explicitly mentioned.)

• Constitutional: [fatigue, fever, weight changes, etc.]
• Eyes: [vision changes, eye discomfort, etc.]
• Ears, Nose, Mouth, Throat: [hearing changes, sinus issues, oral/throat symptoms, etc.]
• Cardiovascular: [chest pain, palpitations, edema, etc.]
• Respiratory: [cough, shortness of breath, wheezing, etc.]
• Gastrointestinal: [abdominal pain, nausea, changes in bowel habits, etc.]
• Genitourinary: [urinary symptoms, menstrual concerns, etc.]
• Musculoskeletal: [joint pain, muscle aches, stiffness, etc.]
• Integumentary (Skin): [rashes, lesions, pruritus, etc.]
• Neurological: [headache, dizziness, numbness, weakness, etc.]
• Psychiatric: [anxiety, depression, insomnia, mood changes, etc.]
• Endocrine: [temperature intolerance, polyuria, polydipsia, etc.]
• Hematologic/Lymphatic: [easy bruising, bleeding tendencies, lymphadenopathy, etc.]
• Allergic/Immunologic: [history of allergic reactions, autoimmune conditions, etc.]

Objective

• [Vital signs] (Include blood pressure, heart rate, temperature, respiratory rate, O2 saturation. Only include if explicitly mentioned.)
• [Physical examination findings by system] (Document relevant normal and abnormal findings per system. Only include if explicitly mentioned.)
• [Investigations and test results] (Include laboratory, imaging, or other test results. Only include if explicitly mentioned.)

Assessment & Plan

[Problem or diagnosis 1]

• [Clinical assessment or diagnosis explicitly stated by clinician] (Do not assume or infer diagnoses. Only include if explicitly mentioned.)
• [Differential diagnoses] (Only include if explicitly documented by clinician.)
• [Planned investigations] (List any tests or imaging planned. Only include if explicitly mentioned.)
• [Treatment and management plan] (Include medications prescribed, lifestyle modifications, or therapies advised. Only include if explicitly mentioned.)
• [Referrals] (Include specialist or allied health referrals. Only include if explicitly mentioned.)
• [Patient counselling and education provided] (Include guidance or education explicitly given to the patient. Only include if explicitly mentioned.)

[Problem or diagnosis 2]

(Continue format for additional issues as explicitly mentioned.)

[Clinician Name], MD
Family Medicine
[Clinic/Hospital Name]
[Date]