Effective clinical documentation is crucial in internal medicine, particularly when dealing with new patients. The process involves gathering comprehensive patient information, organizing it coherently, and ensuring it meets professional standards. In this guide, we'll walk through the essential components of an internal medicine new patient document using a structured template, followed by a detailed example.

Reason for Referral

The Reason for Referral section should succinctly describe why the patient is being referred. For example, "John Doe, a 45-year-old male, was referred by Dr. Sarah Smith for evaluation of persistent fatigue and weight loss." This initial statement sets the context for the consultation.

History of Presenting Illness

Detail the patient's current symptoms, their duration, and any relevant lifestyle factors. In our example, "John Doe has been experiencing fatigue and unintentional weight loss over the past three months. He reports no fever, night sweats, or changes in appetite." This section should provide a comprehensive overview of the patient's current health concerns.

Past Medical History

Summarize the patient's previous medical conditions and surgeries. For instance, "John has a history of hypertension diagnosed five years ago and underwent an appendectomy at age 30." This information helps in understanding the patient's overall health background.

Medications

List all current medications, including dosage and frequency. Example: "John is currently taking Lisinopril 10 mg once daily for hypertension." Accurate medication records are essential for assessing treatment plans and potential drug interactions.

Family History

Document any relevant health conditions in the patient's family that might affect their health. "John's father had a history of coronary artery disease, and his mother has type 2 diabetes," indicates potential hereditary risks.

Physical Examination

Record the findings from the physical examination, including vital signs and any notable observations. "Vital signs are stable with a blood pressure of 130/85 mmHg, heart rate of 78 bpm, and temperature of 36.8°C. Physical examination reveals no abnormalities in the cardiovascular, respiratory, or gastrointestinal systems." This section provides a snapshot of the patient's current physical health.

Investigations

Include results from recent tests or procedures. "Recent blood tests show a hemoglobin level of 13.5 g/dL, white blood cell count of 6,000/mm³, and normal liver function tests. A stress test was completed, showing a resting heart rate of 78 bpm, maximum heart rate of 150 bpm, total time of 10 minutes, 10 METs, no ST changes, and a normal resting EKG." These details support clinical decision-making.

Summary and Plan

Conclude with a summary of the consultation and outline the next steps. "Discussed the potential causes of fatigue and weight loss with John, including lifestyle factors and possible underlying conditions. Advised on dietary changes and the importance of regular exercise. Referred to a dietitian for further evaluation. Plan to follow up in four weeks." Clearly defined plans help ensure continuity of care.

Plan:

• Continue Lisinopril 10 mg once daily.

• Referral to dietitian for nutritional assessment.

• Schedule follow-up appointment in four weeks.

• Order thyroid function tests.

Enhancing Documentation with AI Medical Scribes

The advent of AI medical scribes, such as Notis AI Medical Scribe, revolutionizes the documentation process for internal medicine specialists. Notis leverages advanced voice-to-text technology to transcribe patient interactions and generate structured SOAP notes, significantly reducing the time spent on documentation. This allows internal medicine professionals to focus more on patient care.

Benefits of AI Medical Scribes

Notis enhances documentation efficiency by cutting down documentation time by 80%, saving healthcare providers up to 2 hours daily. Its high accuracy and ease of use via WhatsApp integration ensure seamless adoption without the need for additional tools. This virtual scribe supports 56 languages, making it accessible to a diverse range of users and patient populations.

By utilizing Notis, internal medicine specialists can streamline their documentation process, improve patient charting accuracy, and ultimately enhance patient care efficiency. Embracing AI medical scribes like Notis is a step forward in modernizing healthcare documentation practices.