My medic tech

Template structure

This is the structure Notat follows when it writes the note from the visit — you never fill it in by hand.

HPIHistory of Present Illness:
(Structure symptoms and associated information into distinct paragraphs. Use full sentences and formal clinical language)

Review of systemsReview of Systems: (Document pertinent positives and negatives as reported by patient)
Allergic/Immunologic: [Allergy/Immunology ROS] (Seasonal allergies, hives, frequent infections)
Cardiovascular: [Cardiovascular ROS] (Chest pain, palpitations, dyspnea on exertion, orthopnea, edema)
Constitutional: [Constitutional ROS] (Fever, chills, weight change, fatigue)
ENT: [ENT ROS] (Ear pain, hearing changes, tinnitus, sore throat, congestion, epistaxis)
Endocrine: [Endocrine ROS] (Heat/cold intolerance, excessive thirst/urination, changes in hair/skin)
Eyes: [Eyes ROS] (Vision changes, pain, redness, discharge)
Gastrointestinal: [GI ROS] (Nausea, vomiting, diarrhea, constipation, abdominal pain, heartburn, melena, hematochezia)
Genitourinary: [GU ROS] (Dysuria, frequency, urgency, hematuria, incontinence, hesitancy, nocturia,)
[Gender Specific GU ROS] (Vaginal discharge/bleeding, penile discharge, testicular pain,)
Hematologic/Lymphatic: [Heme/Lymph ROS] (Easy bruising, bleeding, swollen glands)
integumentary: [Skin ROS] (Rashes, lesions, itching, dryness, changes in moles)
Musculoskeletal: [MSK ROS] (Joint pain, stiffness, swelling, redness, muscle pain, weakness, back pain)
Neurological: [Neuro ROS] (Headache, dizziness, syncope, numbness, tingling, weakness, seizures, memory changes?)
Psychiatric: [Psychiatric ROS] (Anxiety, depression, mood changes, sleep disturbance, suicidal ideation, homicidal ideation)
Respiratory: [Respiratory ROS] (Cough, sputum, shortness of breath, wheezing, hemoptysis)

Physical Examination:
(hyphenated list)
- [Vital signs with units in one line] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%)
- [Physical exam findings and/or mental status exam findings] (Format as "System: Exam findings", one system per line. Specify anatomical location if relevant)

Assessment & Plan:
(Do not fabricate the assessment and plan unless mentioned in the source material. Use medical terminology if appropriate.)
[One-sentence patient summary including age, sex, and primary diagnosis]

#) [Assessment as a numbered item if mentioned]
- [Hyphenated list with each corresponding plan item on a new line if mentioned]

ICD-10 Code: [Enter the most clinically relevant ICD-10 code for this encounter]