Podiatry New Patient Evaluation Note

Encounter Details

(Ensure medical necessity is clear: connect the reason for visit to history, exam, diagnostics, and plan. Document laterality and precise anatomic location for all foot/ankle problems and procedures. Omit sections not clinically relevant; when information is expected but unavailable, explicitly state why.)

Date/Time: [Encounter date and time]

Clinic/Site: [Clinic or site name]

Visit Type: [New Patient Evaluation] (Default; modify only if different.)

Clinician: [Name, credentials]

Source of History: [patient / caregiver / chart review / outside records] (Select all that apply.)

Interpreter: [Language and modality] (Include only if used.)

Referral Source and Reason: [Referring clinician and reason for referral] (Include only if applicable.)

Records Reviewed: [External notes, imaging, labs available today with titles and dates] (If none, state "None available".)

Chief Complaint

[Primary symptom or reason for visit in patient's own words with laterality and location]

History of Present Illness

[Presenting context with laterality and precise location. Onset, duration, and course. Symptom quality and severity with 0–10 pain score if pain-focused. Aggravating and relieving factors including footwear, activity, and time of day. Functional impact on walking tolerance, work, ADLs, and sleep. Prior evaluations, treatments, and diagnostics with what patient was told. Patient goals and preferences.]

[Pertinent negatives tailored to complaint: infection signs (fever, chills, purulence, spreading erythema, escalating pain); vascular signs (rest pain, color changes, claudication, nonhealing wounds); neurologic signs (numbness, burning, weakness, falls); trauma details (mechanism, weight-bearing ability, deformity, anticoagulant use).]

(If diabetes, neuropathy, PAD, or wounds are relevant, include: diabetes type/duration with most recent A1c; neuropathy symptoms; prior ulcers/amputations/Charcot; smoking history; claudication/rest pain; prior vascular interventions. For wounds: date first noted, precipitating cause, prior antibiotics, offloading used, drainage and odor, home wound care regimen.)

(If key elements cannot be obtained, document why.)

Pertinent History

Medications

• [Current medications with doses and frequencies] (Explicitly note anticoagulants, antiplatelets, steroids, immunosuppressants, diabetes medications, and neuropathic pain agents. Document source if uncertain.)

Allergies

• [Medication and material allergies with reaction types] (Include latex/adhesive sensitivities. If unknown, document "Allergies: unknown".)

Past Medical History

• [Diabetes: type, duration, complications]
• [CKD/ESRD, PAD, CAD, stroke/TIA, heart failure, hypertension, hyperlipidemia]
• [Gout, RA/inflammatory arthropathy, osteoporosis]
• [Venous disease/lymphedema, immunosuppression]
• [Prior osteomyelitis, MRSA, fall risk factors]

Past Surgical History

• [Foot/ankle surgeries with dates; amputations with levels and laterality]
• [Prior ulcers/debridements; vascular interventions]
• [Relevant implanted hardware]

Family History

• [Diabetes, premature vascular disease, neuropathy, severe deformities] (Include only if relevant.)

Social History

• [Tobacco/nicotine use: type, quantity, duration; readiness to quit]
• [Alcohol/substance use if relevant to neuropathy, fall risk, or wound healing]
• [Occupation and activity level]
• [Ambulation status, baseline function, assistive devices]
• [Footwear habits; support system for wound care if applicable]

Review of Systems

(Problem-focused; include pertinent positives and meaningful negatives. Omit entirely if not obtained and not needed; if expected but unobtainable, state why.)

• Constitutional: [fever / chills / weight loss / none]
• Skin: [rash / wounds / none]
• Neurologic: [numbness / tingling / burning / weakness / falls / none]
• Vascular/Cardiac: [claudication / rest pain / edema / none]
• Musculoskeletal: [joint pain / swelling / stiffness / none]
• Endocrine: [polyuria / polydipsia / hyperglycemia symptoms / none] (Include if diabetes relevant.)

Physical Examination

Vitals

• [BP, HR, Temp, RR, SpO2, Weight/BMI] (Include temperature when infection possible; BP/HR when PAD/CV disease relevant or procedures performed; weight/BMI when relevant for offloading or surgical risk. If not obtained, document reason.)

General

• [General appearance, distress level, weight-bearing ability, mental status if relevant]

Lower Extremity Examination

(For new patient evaluations, examine the symptomatic region and perform a baseline bilateral screen. Document laterality throughout.)

Inspection

• [Foot/ankle alignment; deformities; swelling; erythema; ecchymosis]
• [Skin integrity; interdigital maceration; fissures; callus distribution]
• [Footwear inspection: fit, wear pattern, foreign bodies]

Vascular

• [Dorsalis pedis pulse: right and left with character]
• [Posterior tibial pulse: right and left with character]
• [Capillary refill time; temperature gradient]
• [Edema: type, location, severity]
• [Skin color changes: pallor, cyanosis, dependent rubor]

Neurologic

• [Protective sensation: method (10-g monofilament / Ipswich touch test) and result by site and laterality]
• [Vibration, proprioception, reflexes if assessed]
• [Nerve entrapment signs if indicated]
• [Motor strength by major groups]

Dermatologic and Nails

• [Nail thickness, dystrophy, incurvation, paronychia signs]
• [Plantar lesions: size, location, characteristics]
• [Tinea; hyperkeratosis; skin breaks]

Musculoskeletal

• [Point tenderness with precise locations and laterality]
• [ROM: ankle, subtalar, midfoot, 1st MTP; note pain, crepitus, limitations]
• [Muscle strength grading if relevant]
• [Special tests as indicated: plantar fascia tenderness, Achilles tenderness, Thompson test, drawer tests, squeeze tests]

Gait

• [Gait pattern: normal / antalgic / unstable; toe and heel rise ability; assistive devices]

Wound Evaluation

(Include only if ulcer or surgical wound is present.)

• [Number of wounds; location(s) with laterality]
• [Measurements: L × W × D with method]
• [Wound base: granulation, slough, eschar with percentage if used]
• [Edges: attached/undermined, epibole, callused margins]
• [Undermining/tunneling: clock-face orientation and depth]
• [Drainage: amount, type, odor]
• [Periwound: erythema, warmth, maceration, induration, crepitus]
• [Pain: present / absent; note if neuropathic absence]
• [Infection signs: local vs systemic; lymphangitic streaking]
• [Probe-to-bone result if assessed]
• [Current offloading device and adherence]
• [Current dressing regimen]
• [Limb threat staging if applicable: system used, inputs, stage; note missing components]
• [Wound photographs: consent and storage location] (Include only if obtained.)

Diagnostics

Reviewed Today

• [Prior imaging with dates; include your interpretation if independently reviewed]
• [Vascular studies with dates]
• [Labs with dates: A1c, CBC, inflammatory markers, cultures]
• [Outside notes or operative reports reviewed]

Ordered Today

• [Imaging: modality, laterality, views, weight-bearing status; clinical question]
• [Labs: tests and indication]
• [Vascular testing: type and indication]
• [Cultures: approach and rationale]
• [Referrals: service and reason]

Assessment

(Numbered problems ordered by acuity: limb-threatening conditions first, then fractures/Charcot, then pain/deformity/nail/skin. Include laterality, supporting findings, and differentials when uncertainty exists.)

1. [Problem 1 – Working diagnosis with laterality]
   • [Key supporting findings]
   • [Differential diagnosis if applicable]
2. [Problem 2 – Working diagnosis with laterality]
   • [Key supporting findings]
   • [Differential diagnosis if applicable]
3. [Additional problems as applicable]

Plan

(Mirror Assessment order. Use Start/Stop/Continue for medication changes. Specify laterality for devices and procedures.)

1. [Problem 1 – Plan]
   • [Diagnostics: tests with timing and decision impact]
   • [Medications: Start/Stop/Continue with dose, route, frequency, duration]
   • [Procedures today: summary with reference to procedure note]
   • [Offloading/Immobilization: device, laterality, weight-bearing status]
   • [Wound care: cleansing, debridement, dressings, frequency]
   • [Orthotics/Shoe gear recommendations]
   • [PT referral or home exercise program]
   • [Risk factor modification: diabetes, PAD, smoking counseling]
   • [Patient education: key points discussed]
   • [Return precautions: signs of infection, ischemia, worsening]
   • [Follow-up: interval and triggers for earlier return]
2. [Problem 2 – Plan]
   • [Relevant plan elements as above]

Procedure Note

(Include only if procedure performed. When both E/M and procedure occur, clearly distinguish separately identifiable evaluation work from inherent procedural work.)

• Procedure: [Name, site, laterality]
• Indication: [Clinical indication]
• Consent: [Risks, benefits, alternatives discussed; consent obtained]
• Anesthesia: [Type, agent, dose, location]
• Technique: [Description]
• Findings: [Intraoperative findings]
• Hemostasis: [Method]
• Specimens: [Description and labeling] (Include only if sent.)
• Complications: [None / describe]
• Tolerance: [Patient tolerance]
• Dressing: [Type applied]
• Post-procedure instructions: [Key instructions given]
• Disposition: [Discharge status and follow-up]

Care Coordination

(Include only when performed.)

• [Communications with other clinicians]
• [Records requested and sources]
• [Shared decision-making details]

Signature

[Clinician name, credentials, date, time]