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Family Practice. Patient Name MR Number DOB. Date Time. Family Practice Clinic Note—MSIII S: Patient’s reason for visit, follow-up for previous health issues, address pertinent items in the problem list for the patient and any new concerns.
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Family Practice Patient Name MR Number DOB Date Time Family Practice Clinic Note—MSIII S: Patient’s reason for visit, follow-up for previous health issues, address pertinent items in the problem list for the patient and any new concerns. O: Vitals: Tcurrent / bp / hr / resp / O2 sats (?) /accucheck (?) Labs: if any Meds: review current meds with patient Exam: GEN: HEENT: CV: PULM: ABD: EXT: NEURO: GU: BREAST: A/P: Discuss possible etiologies for new complaints, tests you will order and treatment plans. Try to address the current health problems listed in the problem list and the current treatment plan. List problems and plan to treat each. Don’t forget about RHM! • Things to Know: • Be sure to bring something to read between patients. • Most of your time will be spent in clinic. Although you may shadow some of the time, be sure to speak up if you are not getting enough “hands-on” practice. • Try to be efficient with your time in clinic to keep things moving. • You may not have time to address all of the problems on the problem list. Address the problems in order of importance. • Much of the patient care will be routine health maintenance, or RHM if you are an aspiring FP (screening, prevention, etc.). • Books: • Taylor’s Fundamentals of Family Medicine (“required” and high-yield for the exam) • Taylor’s Fundamentals Question Book (high-yield for the exam) • Guide to the Family Medicine Clerkship by Montauk