Clinical Documentation

Create a clinical note for [encounter type]:

Encounter: [type - visit, admission, consult, etc.]
Patient: [age, gender, relevant history]
Chief complaint: [reason for visit]
Findings: [observations and data]
Specialty: [medical specialty]

Note structure:
- Subjective (patient history and symptoms)
- Objective (exam findings, vitals, test results)
- Assessment (diagnosis or impression)
- Plan (treatment and follow-up)
- Relevant medical history
- Medications reconciliation
- Allergies noted
- Social history if relevant
- Review of systems highlights
- Physical exam findings
- Diagnostic interpretation
- Patient education provided

Note: For template use only. Actual notes must be individualized by licensed provider.

Develop a treatment plan for [condition]:

Condition: [diagnosis]
Patient factors: [age, comorbidities, preferences]
Severity: [stage or level]
Treatment goals: [objectives]
Resources: [available options]
Guidelines: [applicable protocols]

Treatment plan:
- Primary diagnosis
- Secondary diagnoses
- Treatment goals (short and long-term)
- Pharmacological interventions
- Non-pharmacological interventions
- Lifestyle modifications
- Monitoring parameters
- Follow-up schedule
- Patient education topics
- Referrals needed
- Potential complications
- Outcome measures
- Shared decision-making notes

Must be reviewed/modified by licensed provider.

Summarize patient case for [handoff situation]:

Handoff type: [shift change, transfer, referral]
Patient: [identifier and demographics]
Admission date: [when admitted]
Primary issue: [main problem]
Complexity: [stable vs complex]
Pending items: [outstanding tasks]

Handoff summary:
- Patient identification
- Chief complaint and diagnosis
- Hospital course summary
- Current status and trends
- Active issues and priorities
- Pending tests/results
- Medications and recent changes
- Code status and advance directives
- Family communication status
- Anticipated issues (next 12-24 hours)
- Action items for receiving team
- Key contacts
- Social factors affecting care

Use SBAR or I-PASS format.

Write a referral letter to [specialist]:

Specialist: [type]
Patient: [demographics]
Reason for referral: [specific question]
Relevant history: [pertinent information]
Urgency: [routine vs urgent]
Tests completed: [workup done]

Referral letter:
- Patient demographics
- Reason for referral (specific question)
- Relevant medical history
- Current medications
- Pertinent exam findings
- Test results (summarized)
- Working diagnosis
- What you're asking specialist to evaluate/manage
- Urgency and timeframe
- Your contact information
- Insurance/authorization info
- Patient preferences/concerns

Clear, concise, respect specialist's time.

Create a discharge summary for [patient/admission]:

Admission date: [date]
Discharge date: [date]
Primary diagnosis: [diagnosis]
Procedures: [what was done]
Comorbidities: [other conditions]
Discharge disposition: [home, facility, etc.]

Discharge summary:
- Admission diagnosis
- Hospital course narrative
- Procedures performed
- Consultations
- Key test results
- Discharge diagnosis (primary and secondary)
- Discharge medications with changes highlighted
- Discharge instructions
- Diet and activity restrictions
- Follow-up appointments scheduled
- Pending tests at discharge
- Patient/family education
- Discharge condition
- Prognosis

Ensure continuity of care.

Document comprehensive medical history for [patient]:

Patient: [age, gender]
Context: [new patient, annual visit, pre-procedure]
Chief concern: [if applicable]
Known conditions: [existing diagnoses]
Complexity: [straightforward vs complex]

History components:
- History of present illness (if applicable)
- Past medical history (chronological)
- Surgical history
- Medications (dose, frequency, indication)
- Allergies (medication and other)
- Family history (relevant conditions)
- Social history (occupation, living situation, habits)
- Review of systems (by system)
- Preventive health (screenings, immunizations)
- Mental health history
- Obstetric/gynecologic (if applicable)
- Hospitalizations and serious illnesses

Organized, thorough, relevant.

Write a progress note for [patient scenario]:

Patient: [identifier]
Day of hospitalization: [day #]
Primary issue: [diagnosis]
Overnight events: [what happened]
Current status: [how they are]
Plan for day: [today's plan]

Progress note:
- Interval history (since last note)
- Subjective symptoms
- Vital signs and trends
- Physical exam (focused)
- Pertinent test results
- Assessment and clinical reasoning
- Problem-based plan by issue
- Medication changes
- Consultations requested/received
- Patient response to treatment
- Goals for day
- Discharge planning progress
- Family communication

Document clinical thinking.

Document differential diagnosis for [presentation]:

Presentation: [symptoms/findings]
Patient: [demographics and relevant history]
Duration: [timeline]
Test results: [available data]
Severity: [acuity]

Differential documentation:
- Chief complaint detailed
- Differential diagnoses (ranked by likelihood)
- Supporting evidence for each
- Evidence against each
- "Can't miss" diagnoses considered
- Diagnostic plan to distinguish
- Tests ordered and rationale
- Empiric management if needed
- Working diagnosis
- Clinical reasoning explained
- Follow-up plan
- Red flags to monitor
- Patient education on uncertainty

Show systematic thinking.