Free Clinical Documentation Template
Clinical Documentation
[YOUR COMPANY NAME]
Patient Information
|
Patient Name: |
Sky Ferry |
|---|---|
|
Age: |
45 |
|
Gender: |
Male |
|
Medical Record Number: |
123456789 |
Medical History
Sky Ferry has a history of hypertension and type 2 diabetes. He is currently taking medications for both conditions and follows a low-sodium diet.
Current Medications
|
Medication |
Dosage |
Frequency |
|---|---|---|
|
Lisinopril |
10 mg |
Once daily |
|
Metformin |
500 mg |
Twice daily |
Allergies
No known drug allergies.
Assessment
Sky Ferry presents with stable blood pressure and controlled blood glucose levels. He exhibits no new symptoms and reports adherence to prescribed treatments. Physical examination reveals no abnormalities.
Plan
Continue current medication regimen and follow-up in three months for routine check-up. Counsel on maintaining dietary restrictions and encourage regular physical activity. Schedule lab tests for HbA1c levels and renal function prior to the next visit.
