New patient visit
United States | Family medicine

Blank documentation outlines for US practice. Adapt to the encounter and your practice requirements; complete only findings and care actually documented.

ENCOUNTER
Patient name: [ ]
Date of birth: [ ]
Date and time of encounter: [ ]
Clinician: [ ]

VISIT PRIORITIES
Patient concerns and goals: [ ]
Current symptoms and relevant timeline: [ ]

HISTORY
Medical and surgical history: [ ]
Family history: [ ]
Social history and relevant exposures: [ ]
Current medications, doses as reported and reconciliation: [ ]
Allergies and reactions: [ ]
Preventive care records reviewed and dates: [ ]

EXAMINATION
Vitals measured today, with units: [ ]
Examination performed and findings: [ ]

ASSESSMENT AND PLAN
Each problem addressed and supporting findings: [ ]
Diagnostic or treatment decisions: [ ]
Preventive services discussed: [ ]
Records requested and responsibility for follow-up: [ ]

FOLLOW-UP
Follow-up timing and purpose: [ ]
Return precautions discussed: [ ]
Patient questions and understanding: [ ]