View Full Version : thy give blank sheet or template for writing pt notes

11-03-2005, 05:34 PM
Regarding pt notes

Is it like just big headings History Phisical DD,and then u hve to write the rest under history urself.

or like under history they have mentioned CC,HPI,PH,Allergy history

04-22-2006, 08:45 PM
It has 3 sections only:
1) History
2) Physical
3) Work up

In section 1) you put CC HPI, PMH, PSH, Meds, allergies, social
, habits, etc.

in 2) you put a brief physical that you do

in 3) you put your DDx (no treatment! and no consults/referalls except unless you ask to do pelvic/rectal/breast exam when applicable)

04-22-2006, 09:49 PM
the sheets are blank, you fill them out whatever way gets you the required info. most people write in a template themselves and fill it in during the interview. you get 2 blank sheets, one to take notes during the interview and one to actually write your patient note at the end

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