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Patient Note Practice Form
Note: This form is compatible with
Mozilla Firefox
web browser.
HISTORY
: Describe the history you just obtained from this patient. Include only information (pertinent positives and negatives) relevant to this patient's problem(s).
PHYSICAL EXAMINATION
: Describe any positive and negative findings relevant to this patient's problem(s). Be careful to include
only
those parts of examination you performed in
this
encounter.
DIAGNOSTIC REASONING
:
Based on what you have learned from the history and the physical examination
, list up to 3 diagnoses that might explain this patient's complaint(s). List your diagnoses from most to least likely. For some cases, fewer than 3 diagnoses will be appropriate. Then, enter the positive or negative findings from the history and the physical examination (if present) that support each diagnosis. Lastly, list initial
diagnostic
studies (if any) you would order for each listed diagnosis (e.g. restricted physical exam maneuvers, laboratory tests, imaging, ECG, etc.)
Diagnosis #1
History Finding(s)
Physical Exam Finding(s)
Diagnosis #2
History Finding(s)
Physical Exam Finding(s)
Diagnosis #3
History Finding(s)
Physical Exam Finding(s)
Diagnostic Study/Studies
0:0
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