Click on the 3 horizontal lines in the upper left corner
Select "Note Settings"
Choose between the different styles for "History of Present Illness" and "Assessment & Plan"
History of Present Illness: "Concise" and "Comprehensive" examples:
"Concise"
History of Present Illness
The patient, with a history of diabetes and recent vision loss, presents for follow-up. They report no nausea with weekly Trulicity injections and are familiar with the pen. They have not experienced the common side effect of weight loss with Trulicity, and attribute their recent weight gain to decreased mobility due to vision loss. They underwent an operation for their vision last week, but report no improvement and are unable to drive. They continue to work, with transportation provided by their husband.
They are also taking metformin and insulin, but no Farxiga. They administer 20-25 units of insulin at bedtime and report no hypoglycemic episodes. Their morning blood sugars are around 140. They recall a previous medication, possibly an injectable, that maintained their blood sugars in the 90s, but cannot remember the name. They have one more box of insulin vials left from a previous prescription.
In addition to their diabetes and vision loss, they have been dealing with the stress of decreased independence and increased reliance on their husband for transportation.
"Comprehensive"
History of Present Illness
The patient, with a history of diabetes, has been managing their condition with Trulicity, metformin, and insulin. They have not experienced any side effects such as nausea or pancreatitis from the Trulicity. However, they have not noticed any weight loss, a common side effect of the medication. They have been taking insulin at a dosage of between 20 and 25 units, with no episodes of hypoglycemia. Their blood sugar control has been satisfactory, with an A1c close to 7, but there is a desire to lower it further due to their eye problems.
The patient recently underwent an operation for their vision, which has been significantly impaired. They report a distinct blur in their right eye and the presence of a floater. They are unable to drive due to their vision problems and have been staying at home since the operation. They are scheduled for a follow-up appointment next week.
The patient has also been experiencing high morning blood sugar levels, around 140. They recall a previous medication, possibly an injectable, that kept their levels consistently in the 90s, but they cannot remember the name. They have been using an Accu Chek meter to monitor their blood sugar levels.
The patient has been taking their insulin at bedtime, but there is a plan to change this to taking it with breakfast and dinner.
The patient has been struggling with weight gain, which they attribute to their limited mobility due to their vision problems. They acknowledge the impact of weight gain on their blood sugar control and overall health. They also express the emotional toll of their vision problems and the resulting changes in their lifestyle.
Assessment & Plan: "Bulleted" and "Paragraph" examples
"Bulleted"
Assessment & Plan
Possible Ischemic Heart Disease: New onset exertional chest pain and shortness of breath with radiation to the arm and associated lightheadedness. High risk given history of diabetes, hypertension, and family history of heart disease.
-Perform EKG and echocardiogram today.
Poorly Controlled Diabetes: Hemoglobin A1C of 9 in January. Admitted to inconsistent use of Metformin.
-Encourage consistent use of Metformin 500mg twice daily.
-Review diabetes medications with nurse during today's visit.
Uncontrolled Hypertension: Blood pressure of 180/80 today.
-Start Hydrochlorothiazide 25mg daily.
-Refer to nutritionist for low salt, heart healthy diet education. Nutritionist to call next week.
"Paragraph"
Possible Ischemic Heart Disease: She presents with new onset exertional chest pain, shortness of breath, and lightheadedness, compounded by multiple cardiovascular risk factors including hypertension, diabetes, and a family history of heart disease. We will perform an EKG and echocardiogram this afternoon.
Poorly Controlled Diabetes: Her last A1C in January was 9, indicating poorly controlled diabetes, exacerbated by inconsistent adherence to metformin. We will continue Metformin 500mg twice daily and review diabetes medications with a nurse this afternoon.
Uncontrolled Hypertension: Her blood pressure today is 180/80, indicating uncontrolled hypertension. We will start Hydrochlorothiazide 25mg daily and refer her to a nutritionist for low salt, heart-healthy diet counseling.