Internal Medicine Progress Note Template Form PDF Details

In contemporary medical practice, the complexity of patient care requires comprehensive documentation to ensure continuity, quality, and specificity in treatment plans. The Internal Medicine Progress Note form serves as a pivotal tool in this process, particularly within the settings of hospitalist medicine and intensive care. This multifaceted document meticulously outlines the consultant service involved—be it an Intensivist, Hospitalist, or a specific Teaching Team (A, B, C, D)—and captures a snapshot of the patient's medical journey by indicating the reason for consultation, history of present illness (HPI), and pertinent background information including family, social, and medical history (PMH). It delves further into the medical assessment by encapsulating data from various sources such as old chart reviews, external facility records, and primary care providers. Moreover, it presents a detailed physical examination covering all bodily systems, from general appearance to the neurologic assessment, while also highlighting abnormal findings and specifying both ongoing medications and allergies. Coupled with laboratory and diagnostic test results, the form culminates in a section dedicated to the attending physician's assessment and recommendations, thus providing a comprehensive and structured narrative that guides the clinical team in managing the patient's care. This documentation not only facilitates effective communication among healthcare providers but also serves as a critical record for future reference, ensuring that patient care is informed, cohesive, and tailored to the individual's evolving health status.

QuestionAnswer
Form NameInternal Medicine Progress Note Template Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesinternal medicine note template pdf, internal medicine note template, internal medical progress note templates, medical consult note template

Form Preview Example

Medicine Consult Note - WakeMed

Consult Service:

 

Intensivist

 

Hospitalist

 

 

 

Medicine Teaching (Team A,B,C,D)

 

 

 

 

Date/Time:

 

 

 

 

 

 

Referring MD/Service:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reason for consult:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HPI:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Family

Pts history obtained from

 

 

 

Old chart review

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient

 

 

 

 

Outside facility records

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PMD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PMH:

 

 

 

 

 

 

 

Allergies:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Meds:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FH:

 

 

 

 

 

 

 

SH:

Tob _______PPD

EtOH

 

 

 

 

 

Drugs

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ROS:

All Other ROS Negative

 

 

 

 

 

 

GI

 

 

 

 

 

 

Neuro

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Gen

 

 

 

 

ENT

 

 

 

 

 

 

 

GU

 

 

 

 

 

 

Psych

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Skin

 

 

 

Resp

 

 

 

 

 

 

 

Heme

 

 

 

 

 

 

Musc

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Eyes

 

 

 

CV

 

 

 

 

 

 

 

All/Imm

 

 

 

 

 

 

Endo

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PROGRESS NOTE

WakeMed

Medicine Consult Note - Page 2

 

Physical Exam

T

 

 

 

 

 

HR

 

 

 

 

 

 

 

 

 

 

RR

 

BP

POX

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check Normal Findings

 

 

 

 

 

 

 

 

 

 

 

Describe Abnormalities

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

General

 

 

Awake

 

Alert

 

 

NAD

 

 

 

Normal Habitus

 

 

 

Obese

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Psych

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Orient x 3

 

 

 

Nl MS

 

 

 

Mood Nl

 

 

 

 

 

 

Affect Nl

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Eyes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sclera Cl

 

 

Conj Cl

 

 

 

PERRL

 

 

 

EOMI

 

 

 

 

Nl Optic Disc

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

O/P clear

 

 

Dent. Nl

 

 

 

TMs nl

 

 

 

Nares Clear

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Neck

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Nl appear

 

 

No mass

 

 

 

No LAD

 

 

Non tend

 

Thyroid Nl

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Chest

 

 

BS nl

 

 

No rales

 

 

 

Work of breathing nl

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No rhonchi

 

 

 

No retractions

 

 

 

 

Nl percussion

 

 

 

 

 

 

 

 

No wheeze

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cardiac

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RRR

 

 

No MGR

 

 

 

No carotid bruit

 

 

No edema

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Abdominal

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Soft

 

 

Non tend

 

 

 

No HSM

 

 

 

 

 

 

No masses

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MSK

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Gait nl

 

 

Tone nl

 

 

 

No cyan/club

 

 

Nl joints

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Neuro

 

 

Nl sensation

 

 

RAM nl

 

 

 

CN 2-12 nl

 

 

 

 

 

 

Finger to nose nl

 

 

 

 

 

 

 

Strength nl

 

 

 

 

 

 

DTRs nl

 

 

 

 

 

 

No Babinski

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Skin

 

 

 

 

 

 

 

 

Nl palpation

 

 

 

 

 

 

No induration

 

 

 

 

 

 

 

No lesions

 

No rash

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Labs & Diagnostic Tests

 

Blood gluc:_______________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Assessment/Recommendations:

I, the attending physician, saw and evaluated this patient. The findings and assessment/plan were discussed and confirmed. I agree with the above documentation with any addendums noted.

Attending Signature

 

Resident Signature

 

 

 

PROGRESS NOTE

WakeMed

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It really is simple to complete the form with our detailed tutorial! This is what you need to do:

1. You have to complete the internal medicine progress note template pdf properly, therefore be mindful when filling in the segments containing all these fields:

Part # 1 for submitting internal medicine note template

2. Once your current task is complete, take the next step – fill out all of these fields - PMH, Pts history obtained from, Old chart review, Patient, Outside facility records, Family, PMD, Allergies, Meds, Tob, PPD, EtOH, and Drugs with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

PMD, Patient, and Outside facility records inside internal medicine note template

3. Your next step is normally simple - complete every one of the blanks in ROS, Gen, Skin, Eyes, All Other ROS Negative, ENT, Resp, Heme, AllImm, Neuro, Psych, Musc, Endo, PROGRESS NOTE, and WakeMed to finish this process.

Stage no. 3 in submitting internal medicine note template

4. The fourth section arrives with the next few empty form fields to consider: Medicine Consult Note Page, Physical Exam T, POX, Check Normal Findings, Describe Abnormalities, General, Psych, Eyes, ENT, Neck, Chest, Awake, Alert, NAD, and Normal Habitus.

Describe Abnormalities, Awake, and Eyes in internal medicine note template

5. This form has to be finalized by going through this area. Below you can see a comprehensive listing of blank fields that must be completed with specific details in order for your document submission to be complete: AssessmentRecommendations.

Writing section 5 in internal medicine note template

In terms of AssessmentRecommendations and AssessmentRecommendations, ensure you double-check them here. These are definitely the key fields in this form.

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