Family Medicine Note PSS
[textarea default="CC: •\nHPI: In consultation today patient reports •\nwhich began •\nClinically «worsening «improving» «unchanged»\nThe patient came to the clinic today seeking «assessment,» «reassurance,» «treatment,» «follow up,» «referral,» «prescription renewal»\n\nROS:\n•\nTargeted questions/ predictions rules\n\nPertinent positives\n\nPertinent Negatives\n\nRED flags: NO •\n\nPHYSICAL EXAM\nI conducted a focused • exam \n\nASSESSMENT\nBased on the H&P my working diagnosis is •\nThis assessment is support by •\nI am «very» «somewhat» «not completely» confident in this dx based on the history and physical, labs, medical history, prediction rules, imaging, option of specialist, patients insight.\n\nDDX includes: •\n\nPLAN\nDiagnostic goals \n1. Confirm diagnosis and rule out DDX •\n2. Investigate the cause •\n\nTherapeutic goals \n1. Alleviate symptoms •\n2. Address the cause •\n3. Prevent «recurrence» «relapse» «transmission» \n4. Decrease the duration of illness\n\nPrognosis and Disposition\n1. Symptoms should begin to improve within • and mostly resolve by •\n2. Change treatment by • If •\n3. Planned follow up in • for •\n4. Call or return to clinic before planned follow up if •\n5. Go Emergency if •"]
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