Progress Note Template Explained for Students (Easy Guide)
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Original Question
AOP FNP 2 & 3 PROGRESS NOTE TEMPLATE Patient DOB: Visit Date: CC: HPI: Past Medical History: Allergies: Review of Medications: Review of Lab and Diagnostic Results Review of Systems (ROS): Constitutional: HEENT: Respiratory: Cardiovascular: Gastrointestinal: Genitourinary: Musculoskeletal: Neurological: Hematological: Psychiatric/ Behavioral: Physical Exam: Vital signs: Constitutional: HEENT: Head: Eyes: Ears: Neck: Throat/Mouth: Cardiovascular: Rate and rhythm: Pulses: Pulmonary: Effort: Breath sounds Abdominal: General: Abdomen: Bowel Sounds: Lymphadenopathy: Musculoskeletal: ROM upper and lower extremities Edema of upper or lower extremities Skin: Neurological: Mental Status: Motor: Deep Tendon Reflexes: Psychiatric/ Behavioral Orders: Write the Medication Prescription (here) in full form. Orders:Lab Tests (include ICD-10 codes) Orders: Diagnostic Tests (include IDC-codes) EXAMPLE: Assessment & Plan: (Include Primary Diagnosis* and Pertinent Diagnosis with ICD-10 codes related to overall plan of care) Essential (primary) Hypertension* I10 Patient shows improvement with recent medication adjustment BP decrease over past 3 months, patient asymptomatic Continue amlodipine BP pressures well controlled on current regimen Parkinson’s Disease G20 Patient previously was noted to have occasional resting tremor of right hand. Neurology was consulted, patient seen who was diagnose with Parkinson’s disease Neurology started patient on Carbidopa-Levodopa; continue and monitor for efficacy and side effects Will continue to follow-up with neurology Hyperlipidemia, unspecified E78.4 Tolerating statin at this time Monitor lipid panel annually Continue simvastatin daily Benign Prostate Hypertrophy without lower urinary tract symptoms N40.0 Annual digital exam Prostate CA screening annually due to high risk family history Continue Flomax to control potential urinary retention or nocturnal urgency Vitamin D deficiency Most recent vitamin D level shows borderline level Continue vitamin D 2000 units daily and evaluate lab results Vitamin D level to be drawn annually Obesity E66.0 Daily calorie limit of 1,500-1,8000 kcal/day Comprehensive lifestyle program (diet, exercise) Restrict foods high carb, low-fiber or high-fat content Continue to monitor weight and BMI every 6 months for changes Follow up appointment: A follow-up appointment made for 6 months July 12, 2022 at 10:30 am. Instructions: Continue BP home monitoring weekly and record. Advised to go directly to the closest Emergency room in the event of acute distress. CPT Charges: 93000 Use this template and create a scenario for a woman who is expeincing lower back pain for 3 days.
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