NP ambulatory office visit template

Nurse Practitioner Office Visit Note

Visit Context
- Visit type (new / established), chief complaint, and patient goals for today’s visit.
- Collaborating / supervising physician relationship noted if required by jurisdiction or site policy.

Subjective
- History of present illness: onset, location, duration, character, aggravating/relieving factors, timing, severity, and associated symptoms.
- Pertinent positives/negatives and red flags reviewed.
- Relevant PMH, PSH, medications, allergies, social history, and family history as needed for today’s problem(s).
- Review of systems pertinent to the presenting complaint(s).

Objective
- Vital signs, weight/BMI, and general appearance.
- Focused physical exam findings as performed.
- Point-of-care tests, labs, imaging, or outside records reviewed today.

Assessment
- Working diagnosis(es) with acuity and clinical reasoning (differential briefly if uncertain).
- Problem list updates relevant to today’s visit.

Plan
- Diagnostics ordered, treatments initiated or adjusted, referrals, and patient education.
- Return precautions, follow-up interval, and care coordination.
- Document counseling time / shared decision-making as applicable.