Internal Medicine New Patient Note

Patient Demographics and Reason for Visit

[Patient's name, age, gender, reason for referral, and referring physician's name, if explicitly mentioned.] (Include only if explicitly stated.)

History of Present Illness

[Provide a detailed narrative of the presenting illness including onset, duration, symptoms experienced or denied by patient, previous diagnoses, treatments attempted, and relevant complications or events. Write in paragraph format. Include occupation, smoking status, alcohol consumption, or insurance information only if explicitly stated.]

Past Medical History

[List relevant past medical conditions, hospitalizations, surgeries, and significant medical events. Start each sentence with a capital letter and use paragraph form. Only include if explicitly mentioned.]

Current Medications

[List all medications currently taken by patient, including names, dosages, frequencies, and routes. Start each sentence with a capital letter and use paragraph form. Only include if explicitly mentioned.]

Family History

[Briefly describe any pertinent family medical history including hereditary or chronic conditions. Start each sentence with a capital letter and use paragraph form. Only include if explicitly mentioned.]

Social History

[Include patient's occupation, lifestyle habits (smoking, alcohol, drug use), and insurance status if explicitly mentioned. Start each sentence with a capital letter and use paragraph form. Only include if explicitly mentioned.]

Physical Examination

[Document patient's vital signs first, followed by findings organized by body system - HEENT, cardiovascular, respiratory, gastrointestinal, musculoskeletal, neurological, dermatological, psychiatric. Start each sentence with a capital letter and use paragraph form. Only include if explicitly mentioned.]

Investigations

[List relevant laboratory, imaging, or diagnostic test results including dates, specific test names, and values. Include detailed stress test results if explicitly mentioned - resting heart rate, maximum heart rate, total time, METs, ST changes, resting EKG, normality of test. Use paragraph form. Only include if explicitly mentioned.]

Summary

[Provide a concise summary of the key points discussed during the consultation, advice given, referrals made, and follow-up plan. Start each sentence with a capital letter and use paragraph form. Only include if explicitly mentioned.]

Assessment and Plan

[Clearly outline assessment and specific plan for management. Provide numbered recommendations for medications, additional tests, referrals, or follow-ups. Keep brief and direct. Only include items explicitly mentioned.]