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Medical visit flowsheet

Patient Information

Confirm patient identity

Verify patient contact information

Obtain insurance information

Medical History

Review past medical history

Assess current symptoms and concerns

Discuss family medical history

Vital Signs

Check blood pressure

Measure heart rate

Record temperature

Monitor respiratory rate

Physical Examination

Inspect general appearance

Palpate abdomen

Auscultate heart and lungs

Check reflexes

Diagnostic Testing

Order lab work

Perform imaging studies

Refer for specialist consultation if needed

Treatment Plan

Prescribe medications

Recommend lifestyle modifications

Schedule follow-up appointments

Coordinate care with other healthcare providers

Patient Education

Discuss diagnosis and prognosis

Review treatment options

Provide resources for further information

Address any questions or concerns

Follow-Up

Review next steps with patient

Schedule any necessary follow-up visits

Ensure patient understands treatment plan

Document visit notes in medical record

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