{note: trim=yes}Please enter the following information about the patient:
Age (number of years): {formtext: name=Age}
Sex: {formmenu: default=; female; male; name=sex}
{endnote: trim=left}
- The patient is a {=Age} year old {=sex}.
- The patient's chart was reviewed and reconciled as noted in the HPI
- The patient's lifestyle was reviewed for possible impacts on health. I identified and addressed any barriers to improved health, such as age, gender, ethnic background, and, racial identity. Status of advanced health care planning was reviewed.
- The patient's self-reported or lab-reported vital signs were reviewed.
- Information was provided regarding healthy lifestyle choices and vaccinations.
- Based on recommendations for all or almost all adults, the patient was:
- Screened for depression, unhealthy alcohol use, smoking, and unhealthy drug use
- Screened for hypertension or recommended to screen for hypertension
- Offered screening for Hepatitis C and HIV
- Counseled regarding advanced care planning, including advanced directives, and offered follow up for future discussion if desired.
Specific concerns for this patient, if any:
{formtoggle: name=BMI over 25; default=no; trim=right}- BMI between 25 and 30: The patient was offered screening for diabetes. The patient given information on healthy diet and exercise for prevention of diabetes.{endformtoggle: trim=left}
{formtoggle: name=BMI over 30; default=no; trim=right}- BMI over 30: The patient was offered screening for diabetes. The patient was given information on healthy diet and exercise for weight loss and reduction of risk of diabetes and cardiac disease. {endformtoggle: trim=left}
{formtoggle: name=Having more than 1 partner in 12 months; default=no; trim=right}{endformtoggle: trim=left}
{formtoggle: name=Requesting testing for sexually transmitted infections; default=no; trim=right}{endformtoggle: trim=left}
{if: `Having more than 1 partner in 12 months` OR `Requesting testing for sexually transmitted infections`="Yes"; trim=yes}- Increased risk of sexually transmitted infection or request for testing: The patient was counseled regarding safe sexual practices and was offered laboratory testing for sexually transmitted infection, including Hepatitis B, Hepatitis C, HIV, Syphilis, gonorrhea, and chlamydia.{endif: trim=left}
{formtoggle: name=Sexually active; default=no; trim=right}{endformtoggle: trim=yes}
{if: `Sexually active`="Yes" AND sex="female" AND (age >=18 AND age <=24); trim=right}If sexually active female age 18-24, the patient was offered testing for gonorrhea and chlamydia.{endif: trim=left}
{formtoggle: name=Specific risk of HIV; default=no; trim=right}- Specific risk of HIV: The patient was advised to make a follow up appointment for discussion of pre-exposure prophylaxis for prevention of HIV.{endformtoggle: trim=left}
{formtoggle: name=Increased risk of Tuberculosis; default=no; trim=right}- Increased risk of Tuberculosis: The patient was encouraged to have Quantiferon Gold TB testing. If patient desired, an order was placed or Quantiferon Gold TB testing.{endformtoggle: trim=left}
{formtoggle: name=Tobacco/Nicotine use now or in the past; default=no; trim=right}- The patient reports {formtext: name=packyears} pack years of tobacco use{endformtoggle: trim=left}{note: trim=right}{if: `Tobacco/Nicotine use now or in the past`="Yes"; trim=left}
When was the tobacco/nicotine use?{formmenu: default=; now; quit less than 15 years ago; quit more than 15 years ago; name=tobacco; trim=right}{endif: trim=right}{endnote: trim=yes}
{if: tobacco="now"; trim=left}
- Current smoker: The patient was counseled on smoking/vaping cessation and methods to improve success with cessation.{endif: trim=left}
{if: (age >=50 AND age<=80) AND (tobacco="now" OR tobacco="quit less than 15 years ago") AND packyears>=20; trim=left}
- Increased risk of lung cancer: The patient was offered annual screening for lung cancer with low dose CT.{endif: trim=left}
{if: (age >=65 AND age <=75) AND (tobacco="now" OR tobacco="quit less than 15 years ago" OR tobacco="quit more than 15 years ago") AND sex="male"; trim=left}
- Increased risk of AAA: If lifetime cigarette use was more than 100 cigarettes, the patient was offered one-time screening ultrasound for abdominal aortic aneurysm.{endif: trim=left}
{if: (tobacco="quit less than 15 years ago" OR tobacco="quit more than 15 years ago"); trim=left}
- Patient congratulated on having quit smoking{endif: trim=left}
{formtoggle: name=Unhealthy alcohol use; default=no; trim=right}- Unhealthy alcohol use: Depending on the patient's preference, the patient was encouraged to follow up with me, was referred to counseling, or was advised to seek an alcohol counseling/treatment program.{endformtoggle: trim=left}
{formtoggle: name=Concern of depression or anxiety; default=no; trim=right}- Concern of depression or anxiety: Depending on the patient's preference, the patient was encouraged to follow up with me or was referred to counseling.{endformtoggle: trim=left}
{formtoggle: name=Elevated blood pressure; default=no; trim=right}- Elevated blood pressure: the patient was encouraged to follow up with me.{endformtoggle: trim=left}
{formtoggle: name=Female with personal or family history of BRCA related cancer or of Ashkenazi Jewish Ancestry; default=no; trim=right}{endformtoggle: trim=left}
{if: `Female with personal or family history of BRCA related cancer or of Ashkenazi Jewish Ancestry`="Yes" AND sex="female"; trim=yes}- Increased risk of breast cancer: The patient was offered BRCA testing{endif: trim=left}
{formtoggle: name=History of diabetes, hypertension, or tobacco use; default=no; trim=right}{endformtoggle: trim=left}
{if: `History of diabetes, hypertension, or tobacco use`="Yes" AND (age >=40 AND age <=75); trim=yes}- History of diabetes, hypertension, or tobacco use: The patient was offered laboratory testing as needed and was asked to return for review of risk/benefit balance of daily aspirin or statins for the prevention of cardiovascular disease.{endif: trim=left}
{if: `History of diabetes, hypertension, or tobacco use`="Yes" AND (age<40 OR age>75); trim=yes}- History of diabetes, hypertension, or tobacco use: The patient was informed that there is no clear benefit for either aspirin or statins in their age group but that we will review recommendations for them at each annual health visit.{endif: trim=left}
{formtoggle: name=Fair skin; default=no; trim=right}- Fair skin: The patient was counseled regarding minimizing exposure to ultraviolet radiation.{endformtoggle: trim=left}
{formtoggle: name=Concern for memory loss; default=no; trim=right}- Concern for memory loss: The patient was advised to follow up for further testing or to seek in-person care. If a trusted support person was present in the visit, this person agreed to help coordinate this follow-up.{endformtoggle: trim=left}
{if: (`BMI over 25` OR `BMI over 30` OR `Having more than 1 partner in 12 months` OR `Requesting testing for sexually transmitted infections` OR `Sexually active` OR `Specific risk of HIV` OR `Increased risk of Tuberculosis` OR `Unhealthy alcohol use` OR `Concern of depression or anxiety` OR `Elevated blood pressure` OR `Female with personal or family history of BRCA related cancer or of Ashkenazi Jewish Ancestry` OR `History of diabetes, hypertension, or tobacco use` OR `Fair skin` OR `Concern for memory loss`="Yes") OR tobacco<>""; trim=right}- The patient was offered Behavioral health counseling for any specific concerns noted above{else}No specific concerns noted above.{endif: trim=left}
{note}
The following statements are generated based on age and sex entered at the top{endnote}
{if: (age>=18 AND age<=55) AND sex="female"; trim=left}
- The patient was screened for domestic violence and, if able to become pregnant, was recommended to take folic acid supplementation of at least 0.4mg daily{endif: trim=left}
{if: (age>=21 AND age<=65) AND sex="female"; trim=left}
- I reviewed that the patient's screening for cervical cancer is up to date or have referred her to OB/Gyn for this.{endif: trim=left}
{if: (age>=45 AND age<=85); trim=left}
- The patient was offered colorectal cancer screening if indicated.{endif: trim=left}
{if: age>=65 AND sex="female"; trim=left}
- The patient was offered a bone density scan for screening for osteoporosis if due.{endif: trim=left}
{if: (age>=45 AND age<=75); trim=left}
- The patient was offered screening mammogram for breast cancer if due.{endif: trim=left}
{if: age>=65; trim=left}
- The patient's fall risk was reviewed and, if elevated, multifactorial interventions, including exercise, were recommended.{endif: trim=left}
Testing or screening ordered during this visit:
{note: trim=right}{formmenu: Basic labs, including: CBC, CMP, Hemoglobin A1C, TSH, Lipids; Hepatitis B, Hepatitis C, HIV, Syphilis; Gonorrhea/chlamydia; Quantiferon Gold TB; Low dose CT screening for lung cancer; Ultrasound for AAA; BRCA testing; FIT, Cologard; Bone density scan; Mammogram; name=testing; multiple=yes}{endnote: trim=right}
{if: testing=}None{else}{=join(testing,", ")}{endif}
Referrals placed during this visit:
{note: trim=right}{formmenu: Behavioral Health; Gastroenterology for colonoscopy; OB/Gyn for women's health; name=referrals; multiple=yes}{endnote: trim=right}
{if: referrals=}None{else}{=join(referrals,", ")}{endif}
The patient was advised to follow up at least annually for preventive health care, sooner as needed for review of results or discussion of concerns raised.
The patient verbalized a clear understanding of my instructions and was agreeable with the plan.