Clinical Documents

To edit the draft, click on the text box below.

×

Draft a comprehensive differential diagnosis for acute substernal chest pain in a 45-year-old male with hypertension and hyperlipidemia, diaphoresis, exertional onset, and normal initial ECG/troponin; include life-threatening causes first, key distinguishing features, and immediate diagnostic next steps.

Draft a detailed differential diagnosis for new-onset unilateral throbbing headache with visual aura and brief monocular vision loss in a 32-year-old female on oral contraceptives; include red-flag symptoms, stroke/TIA considerations, and recommended initial workup.

Draft an assessment and plan for stage-2 hypertension (BP 162/98) in an obese 52-year-old with suspected obstructive sleep apnea; include ASCVD risk estimate, lifestyle prescriptions, first-line pharmacotherapy with drug/dose/targets, baseline labs/monitoring, and 4–6 week follow-up.

Draft an assessment and plan for type 2 diabetes follow-up with A1c 9.2% on metformin 1,000 mg BID and eGFR 65; compare adding a GLP-1 receptor agonist vs an SGLT2 inhibitor, address weight loss goals, hypoglycemia education, vaccinations, and micro/macrovascular screening.

Draft a history and physical for a patient presenting with chest pain, including HPI using OLDCARTS, pertinent ROS, PMH/meds/allergies, FH/SH, focused cardiac/pulmonary exam, initial labs and imaging orders, prioritized differential, HEART score risk stratification, and early management.

Draft a history and physical for a new patient with progressive exertional dyspnea, orthopnea, and bilateral leg edema; include differential (heart failure, COPD, PE, anemia, renal disease), targeted exam maneuvers, and first-line diagnostics and management.

Draft a progress note for COPD follow-up two weeks after an acute exacerbation treated with prednisone and antibiotics; include symptom trajectory, CAT score (if available), inhaler technique/adherence, oxygen needs, spirometry plan, smoking cessation counseling, and return precautions.

Draft a progress note for post-operative day 2 after total knee arthroplasty; include pain control strategy, DVT prophylaxis, PT/OT milestones, wound status, bowel/urinary function, labs/vitals review, complications screening, and discharge readiness.

Draft a discharge summary for community-acquired pneumonia admission; include admission/discharge dates, presenting symptoms, radiology/labs, pathogen if identified, inpatient therapies and response, discharge medications with durations, pending tests, follow-up appointments, and return precautions.

Draft a discharge summary for myocardial infarction managed with PCI and drug-eluting stent placement; include cath findings, complications, inpatient course, discharge medications (DAPT, statin, beta-blocker, ACEi/ARB), cardiac rehab referral, and follow-up plan.

Draft discharge instructions for a patient hospitalized with acute decompensated heart failure; include daily weights, sodium and fluid restriction amounts, medication list with dosing, signs of worsening heart failure, follow-up appointments, and lab monitoring plan.

Draft discharge instructions for an asthma exacerbation; include controller and reliever regimen, steroid taper schedule, spacer technique, trigger avoidance, a written asthma action plan, return precautions, and follow-up timing.

Draft a patient handout on managing high blood pressure in plain language; explain what BP numbers mean, key lifestyle steps (DASH diet, sodium limits, alcohol moderation), home BP monitoring instructions, medication adherence tips, and when to call the doctor.

Draft a patient handout for type 2 diabetes education in plain language; cover A1c goals, the plate method, physical activity targets, self-monitoring of blood glucose, hypoglycemia signs and the 15-15 rule, foot care basics, and a vaccination checklist.

Draft a summary of the latest CDC and WHO guidelines for managing community-acquired pneumonia in adults, including empiric antibiotic choices, duration of therapy, and follow-up recommendations.

Draft a plain-language overview of the ADA and AACE guidelines for diabetes management, focusing on A1c goals, weight management, and the use of GLP-1 receptor agonists and SGLT2 inhibitors.

Draft a summary of the 2024 USPSTF breast cancer screening recommendations, including updated screening intervals, risk-based approaches, and the role of MRI for high-risk patients.

Draft a concise summary of NCCN guidelines for melanoma management, including staging, surgical margins, adjuvant therapy, and checkpoint inhibitor recommendations.

Draft treatment alternatives for community-acquired MRSA skin infections in patients allergic to sulfa drugs; include oral and IV options, dosing, and duration.

Draft treatment alternatives for patients with type 2 diabetes who are unable to tolerate GLP-1 receptor agonists due to nausea; include medication substitutions and lifestyle recommendations.

Draft a summary of options for treating refractory depression, comparing ketamine infusions, transcranial magnetic stimulation (TMS), and electroconvulsive therapy (ECT).

Draft treatment options for advanced prostate cancer, including hormonal therapy, radiopharmaceuticals, and novel androgen receptor pathway inhibitors.

Draft a summary of recent research on mRNA vaccine technology beyond COVID-19, including applications in oncology and autoimmune disease prevention.

Draft an easy-to-understand overview of long COVID research, summarizing major symptoms, hypothesized mechanisms, and emerging treatment approaches.

Draft a summary of current research on Alzheimer’s disease biomarkers, including amyloid and tau imaging, and discuss how they influence diagnosis and trial design.

Draft an explanation of the interaction between warfarin and antibiotics such as ciprofloxacin or TMP-SMX, including INR effects and management recommendations.

Draft a summary evaluating drug interactions for patients taking Paxlovid and common cardiovascular drugs; include mechanism and recommended dose adjustments.

Draft a summary of the common and serious side effects of semaglutide, including GI intolerance, gallbladder disease, and thyroid-related warnings.

Draft an overview of potential side effects associated with long-term corticosteroid use, including osteoporosis, glucose intolerance, and adrenal suppression.

Draft a summary of essential lab tests to order in suspected acute pancreatitis, including amylase, lipase, liver enzymes, and metabolic panels, with interpretation guidance.

Draft laboratory workup recommendations for suspected hypothyroidism, including TSH, free T4, thyroid antibodies, and when to consider secondary causes.

Draft an explanation of which labs should be monitored in patients receiving methotrexate therapy, including CBC, LFTs, renal function, and frequency of monitoring.

why choose us

🌐 Go to WebHealthNetwork.com
Go to Consumers Chat

Edit Geo

×

Course: OpenNotes: Your Patients Can Read Your Notes. Now What?

CME Credits: 1.00

Released: 2023-01-17

Program Description
Hospital for Special Surgery
Catherine DesRoches discusses OpenNotes, the 21st Century CURES act implementation, and how those impact patients and clinicians.
About this Series
HSS Rheumatology Grand Rounds feature recorded sessions of HSS and other prominent guest faculty discussing timely topics that highlight the latest developments in the field of rheumatology including diagnostic and treatment advances.
References
Alpert, J. M., Morris, B. B., Thomson, M. D., et al. (2019). Patient access to clinical notes in oncology: A mixed method analysis of oncologists' attitudes and linguistic characteristics towards notes. Patient education and counseling, 102(10), 1917–1924.
Bell, S. K., Delbanco, T., Elmore, J. G., et al. (2020). Frequency and Types of Patient-Reported Errors in Electronic Health Record Ambulatory Care Notes. JAMA network open, 3(6), e205867.
Bruno, B., Steele, S., Carbone, J., et al. (2022). Informed or anxious: patient preferences for release of test results of increasing sensitivity on electronic patient portals. Health and technology, 12(1), 59–67.
Chimowitz, H., O'Neill, S., Leveille, S., et al. (2020). Sharing Psychotherapy Notes with Patients: Therapists' Attitudes and Experiences. Social work, 65(2), 159–168.
DesRoches, C. M., Leveille, S., Bell, S. K., et al. (2020). The Views and Experiences of Clinicians Sharing Medical Record Notes With Patients. JAMA network open, 3(3), e201753.
Dobscha, S. K., Kenyon, E. A., Pisciotta, M. K., et al. (2019). Impacts of a Web-Based Course on Mental Health Clinicians' Attitudes and Communication Behaviors Related to Use of OpenNotes. Psychiatric services (Washington, D.C.), 70(6), 474–479.
Lam, B. D., Bourgeois, F., DesRoches, C. M., et al. (2021). Attitudes, experiences, and safety behaviours of adolescents and young adults who read visit notes: Opportunities to engage patients early in their care. Future healthcare journal, 8(3), e585–e592.
Leonard, L. D., Himelhoch, B., Huynh, V., et al. (2022). Patient and clinician perceptions of the immediate release of electronic health information. American journal of surgery, 224(1 Pt A), 27–34.
P Goddu, A., O'Conor, K. J., Lanzkron, S., et al. (2018). Do Words Matter? Stigmatizing Language and the Transmission of Bias in the Medical Record. Journal of general internal medicine, 33(5), 685–691.
Rahimian, M., Warner, J. L., Jain, S. K., et al. (2019). Significant and Distinctive n-Grams in Oncology Notes: A Text-Mining Method to Analyze the Effect of OpenNotes on Clinical Documentation. JCO clinical cancer informatics, 3, 1–9.
Rahimian, M., Warner, J. L., Salmi, et al. (2021). Open notes sounds great, but will a provider's documentation change? An exploratory study of the effect of open notes on oncology documentation. JAMIA open, 4(3), ooab051.
Richards, S., Carlson, K., Matthias, T., & Birge, J. (2021). Perception versus reality: Does provider documentation behavior change when clinic notes are shared electronically with patients?. International journal of medical informatics, 145, 104304.
Salmi, L., Dong, Z. J., Yuh, B., Walker, J., & DesRoches, C. M. (2020). Open Notes in Oncology: Patient versus Oncology Clinician Views. Cancer cell, 38(6), 767–768.
Walker, J., Leveille, S., Bell, S., et al. (2019). OpenNotes After 7 Years: Patient Experiences With Ongoing Access to Their Clinicians' Outpatient Visit Notes. Journal of medical Internet research, 21(5), e13876.
Intended Audience
This activity is targeted to physicians and scientists working in the specialties of orthopedics, rheumatology, radiology, anesthesiology, pediatrics, physiatry, pathology, and neurology, including HSS alumni and current residents, fellows, and medical staff.
Commercial Support
This activity is not commercially supported.


Educational Objectives
HSS Continuing Education activities are intended to improve the quality of patient care and safety. At the conclusion of this course, the participant will be able to:
Summarize current research related to new pharmacologic therapies for various rheumatologic conditions including (but not limited to) systemic lupus erythematosus, inflammatory arthritis, crystalline arthritis (such as gout), scleroderma, myositis, vasculitis, and osteoarthritis.
Recognize the risk factors (clinical, genetic, environmental) associated with various rheumatic conditions including (but not limited to) systemic lupus erythematosus, inflammatory arthritis, crystalline arthritis (such as gout), scleroderma, myositis, vasculitis, and osteoarthritis.
Define the pathophysiology underlying various rheumatic conditions including (but not limited to) systemic lupus erythematosus, inflammatory arthritis, crystalline arthritis (such as gout), scleroderma, myositis, vasculitis, and osteoarthritis.


View Full Course

×
Chat & Ask Questions Career Openings Medical Doctors Check on Drug
Interactions Latest Health News
by WebHealthNetwork Get CME Credits Latest Clinical Trials Latest Research Articles Clinical Documents Update Profile

News

Chat

HCP Tools

Careers

Update Profile