Pre-Chart: HIV
HIV Clinic Pre-Charting Template with Evidence-Based Medicine Integration Patient Information: Name: [text] Date of Birth: [date] Medical Record Number (MRN): [text] Date of Visit: [date default="today"] Reason for Visit: [select value="Follow-up|New Patient|Medication Refill|Other"] [text name="other_reason" memo="If 'Other', please specify"] History (To be completed during patient interview): ID: Name: [text] Age: [text] Sex: [radio value="Male|Female|Other"] Marital Status: [text] Race: [text] CC: [comment memo_color="orange" memo="Document patient's primary reason for visit here."] HPI: [comment memo_color="orange" memo="Gather details about the onset, duration, and severity of symptoms. Include any relevant precipitating events."] [comment memo_color="lightgreen" memo="Inquire about HIV risk factors and sexual history. Discuss PrEP/PEP if applicable."] Medications: [comment memo_color="orange" memo="List all current medications, including HIV regimen and adherence information."] [comment memo_color="red" memo="Note any allergies and adverse reactions to medications."] PMH: [comment memo_color="orange" memo="Document relevant medical history, including surgeries, hospitalizations, and vaccinations."] Allergies: [comment memo_color="red" memo="List medication allergies and any associated reactions."] FH: [comment memo_color="orange" memo="Inquire about family history of relevant medical conditions."] Social History: [comment memo_color="orange" memo="Gather information about smoking, alcohol use, drug use, sexual history, living situation, and support system."] Review of Systems (ROS): [comment memo_color="orange" memo="Perform a thorough review of systems to identify any new or ongoing issues."] Ob-Gyn Hx (if applicable): [comment memo_color="orange" memo="Obtain relevant obstetric and gynecologic history for female patients."] Additional Notes: [textarea memo="Use this space to document any additional information or questions to address during the patient interview."] Evidence-Based Medicine Considerations (For Reference): Adherence: Prioritize adherence assessment and support. Smoking Cessation: Encourage and support smoking cessation. Alcohol and Drug Use: Screen for harmful use and provide appropriate interventions. PrEP/PEP: Offer PrEP or PEP when indicated. Cardiovascular Risk: Assess and manage cardiovascular risk factors. Opportunistic Infections: Follow guidelines for prophylaxis. Instructions for Use: Before the Visit: Complete the patient information and reason for visit sections. During the Visit: Utilize the pre-charting template as a guide during the patient interview, filling in the relevant sections as you gather information. Post-Visit: Review and complete any remaining sections, ensuring a comprehensive and accurate medical record. This pre-charting template serves as a structured tool to streamline the patient interview process, facilitate evidence-based decision-making, and ensure comprehensive data collection for optimal HIV care.
Result - Copy and paste this output:
Sandbox Metrics: Structured Data Index 0.33, 23 form elements, 186 boilerplate words, 7 text boxes, 1 text areas, 2 dates, 1 radio buttons, 1 drop downs, 11 comments, 12 total clicks
More SOAPnotes by this Author:
Send Feedback for this SOAPnote