01 / ADAPTABLE OUTLINE
What to document
Visit priorities & HPI
Reason for the visit, patient goals, interval changes, home measurements, medication use, side effects, and barriers to the agreed plan.
Relevant ROS & examination
Pertinent symptoms, recorded vital signs, focused examination, and results reviewed during this visit. Include only confirmed findings.
Problem-oriented assessment & plan
For each problem: status, supporting information, clinician-selected treatment, tests ordered or reviewed, counseling, and follow-up.
Prevention & coordination
Screening and vaccine status after review, referrals, pending records or results, responsible follow-up clinician, and patient instructions.
02 / WORKED EXAMPLE
Hypertension and hyperlipidemia follow-up
Illustrative documentation only. Not patient data, a treatment protocol, or a complete billing checklist.
History of present illness
A 60-year-old woman presents for follow-up of hypertension and hyperlipidemia. She reports taking her current medications consistently without new adverse effects. Her home blood pressure log was reviewed. She denies chest pain, dyspnea, or dizziness.
Examination
Office blood pressure is 128/78 mmHg. Heart rate is 72 beats/min with regular rhythm. The patient appears comfortable. Lungs are clear bilaterally. No lower-extremity edema is present.
Assessment & plan
1. Hypertension: office measurement and home log reviewed. Continue the current clinician-confirmed regimen. Continue home monitoring and bring the log to follow-up. 2. Hyperlipidemia: medication adherence and nutrition discussed. Continue the current clinician-confirmed regimen. Obtain the prior lipid panel before deciding whether repeat testing is due. Follow-up is planned in three months, with earlier review for new concerns.
A common documentation question
Can one primary care note include several problems?
Yes. A shared history and examination can support separate problem-based plans. In the NoteDoctors builder, choose Primary Care and enter each concern for review. The example here is a documentation illustration, not a suggested regimen.
GO DEEPER / CONDITION-SPECIFIC PLANS
Treatments, doses & follow-up
A note style does not determine a treatment. Explore the condition-specific examples for sourced adult dosing references, clinical reasoning, and follow-up plans.
TRY AN INTERACTIVE EXAMPLE
PHQ-9, from responses to documentation.
Select inputs, see the score, and preview the documentation. Missing answers stay incomplete.