Office Visit - Complete [Veradigm]

[Chief Complaint]
- Capture the patient's main concern in their own words
- Keep it brief and focused on the primary issue
- Include duration if mentioned[History of Present Illness]
- Provide a detailed narrative of current symptoms
- Include onset, duration, location, characteristics
- Document associated symptoms and modifying factors
- Note impact on daily activities
- Include relevant past medical history[Review of Systems]
- Conduct a systematic review of body systems
- Include both pertinent positives and negatives
- Focus on systems related to chief complaint
- Document: Constitutional, HEENT, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Neurological, Skin[Physical Exam]
- Document vital signs if mentioned
- Include all examination findings
- Note both normal and abnormal findings
- Be specific about location and characteristics
- Include relevant negative findings[Assessment]
- Provide clinical assessment of the patient's condition
- List differential diagnoses if appropriate
- Include reasoning for primary diagnosis
- Note any concerning findings[Plan]
- List all treatment recommendations
- Include medications with specific dosing
- Document diagnostic tests ordered
- Note referrals and consultations
- Include follow-up instructions
- Document patient education provided

Chief Complaint
Persistent headaches for 3 weeks.History of Present Illness
The patient reports experiencing daily headaches for the past 3 weeks. The headaches are described as bilateral, pressure-like pain primarily in the frontal and temporal regions. Pain intensity ranges from 4-7/10. Headaches typically worsen throughout the day and are aggravated by stress and computer work. Partially relieved by ibuprofen 400mg. Associated with mild photophobia but no nausea or visual changes. No history of similar headaches. Patient notes increased work stress recently.Review of Systems
Constitutional: No fever, chills, or weight loss
HEENT: Headaches as noted, mild photophobia, no vision changes, no nasal congestion
Cardiovascular: No chest pain or palpitations
Respiratory: No shortness of breath or cough
Gastrointestinal: No nausea or vomiting
Neurological: No focal weakness, numbness, or dizziness
Musculoskeletal: Mild neck stiffness notedPhysical Exam
Vital signs: BP 128/82, HR 76, RR 14, Temp 98.4°F
General: Alert and oriented, appears mildly uncomfortable
HEENT: Pupils equal and reactive, no papilledema, mild tenderness over temporal regions
Neck: Mild trapezius muscle tension, full range of motion
Neurological: Cranial nerves II-XII intact, strength 5/5 throughout, reflexes 2+ and symmetricAssessment
Tension-type headaches, likely related to stress and poor ergonomics. No red flags for secondary headache disorders. Differential includes migraine without aura, though pattern more consistent with tension-type.Plan
1. Prescribed naproxen 500mg PO BID PRN for headache
2. Recommend stress management techniques including regular breaks from computer work
3. Ergonomic assessment of workstation
4. Trial of progressive muscle relaxation exercises
5. If no improvement in 2 weeks, consider prophylactic therapy
6. Return in 4 weeks or sooner if worsening symptoms
7. Educated on headache diary to track triggers

Focused Visit [Veradigm]

[Chief Complaint]
- State the primary reason for visit
- Use patient's own words when possible[History of Present Illness]
- Document relevant history for focused problem
- Include symptom details and timeline
- Note previous treatments tried
- Include pertinent review of systems[Assessment]
- Clinical assessment of the presenting problem
- Include most likely diagnosis
- Note any important differential considerations[Plan]
- Treatment plan specific to the problem
- Include medications and follow-up
- Document any testing needed

Chief Complaint
Sore throat for 2 days.History of Present Illness
Patient presents with 2-day history of sore throat that began suddenly. Describes severe pain with swallowing, rated 8/10. Associated with fever to 101°F and fatigue. Denies cough, runny nose, or known sick contacts. Has been taking acetaminophen with minimal relief. No difficulty breathing or drooling.Assessment
Acute pharyngitis, likely streptococcal given fever, absence of cough, and pharyngeal erythema with exudate. Rapid strep test positive.Plan
1. Amoxicillin 500mg PO BID x 10 days
2. Continue acetaminophen for fever and pain
3. Increase fluid intake
4. Return if not improved in 48-72 hours
5. Advised to avoid close contact with others for 24 hours after starting antibiotics

Quick Follow-up {Veradigm}

[History of Present Illness]
- Document interval history since last visit
- Note response to treatment
- Include any new or ongoing symptoms[Assessment]
- Current status of condition
- Note improvement or concerns
- Update diagnosis if needed[Plan]
- Continue or modify treatment
- Schedule next follow-up
- Address any new issues

History of Present Illness
Patient returns for 1-week follow-up of acute sinusitis. Has completed 5 days of amoxicillin with significant improvement. Facial pressure and pain have resolved. Mild residual nasal congestion remains but improving daily. No fever since day 3 of antibiotics.Assessment
Acute sinusitis, resolving with antibiotic therapy. Significant clinical improvement noted.Plan
1. Complete full 10-day course of amoxicillin
2. Continue saline nasal rinses
3. No additional medications needed
4. Return if symptoms recur
5. Preventive measures discussed including hand hygiene

Subjective:
    - Chief Complaint:
    - History of Present Illness:
    - Past Medical History:
    (All this content is mapped to RFV)Review of Systems:
    (This content is mapped to ROS)Objective:
    (This content is mapped to PE)
Physical Exam:
    (If present, this content is also mapped to PE)Assessment:
    (This content is part of AP)
Plan:
    (This content is also part of AP)