Sample Patient Assessment Template

Below is a sample visit template.

Patient:
Date 13 June 2006

Present Illness/ Review of Symptoms:

Patient presents today with...

Review of Symptoms: A 14 point review of symptoms is otherwise negative.

Physical Exam: Vital Signs: Stable see chart
General Well Developed well nourished, positive affect, no acute distress.
Neuro: Alert and oriented X 3, Cranial nerves II-XII grossly in tact, MAE without difficulty, negative ataxia or cerebellar signs, normal gait and sensorium.
HEENT: NC/AT, eyes clear, TMs clear with visible landmarks, Nasal septum midline with patent nares, oropharynx clear, mucous membranes moist, the maxillary and frontal sinuses are non tender to palpation.
Neck: Supple, full ROM, no JVD, no thyromegaly, no lymphadenopathy.
Lungs: Clear bilaterally, regular equal and unlabored, normal rate and depth of respiration.
CV: S1 and S2, no murmurs, regular rate and rhythm.
Abdomen: Non distended, Non- tender to palpation, bowel sounds present X 4 quadrants, no focal signs, no HSM. GU: No CVA tenderness. Skin: Warm and dry, no rash or xanthem noted. Extremities: No edema, negative Homan’s sign, 5/5 strength upper and lower extremities.

Diagnostics:


Assessment

Plan


Patient was educated regarding the treatment plan, and was instructed to seek care immediately in case of changing or worsening symptoms. As always, we remain available for questions or concerns.


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