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New Patient Visit (Primary Care)
New Patient Visit (Primary Care)
Last updated: Nov 2025
New Patient Visit (Primary Care) that’s HIPAA-compliant: capture the encounter or upload audio, generate a complete new-patient note, then auto-fill your EHR via the Nudge Chrome extension (edit-before-save).
Who this helps
Family medicine & internal medicine clinicians
APPs (NPs/PAs) onboarding new patients
Clinic managers standardizing first-visit documentation
What you get
Structured Presenting Problem, HPI, ROS (optional), Past History (PMH/PSH/FH/SocHx), Meds/Allergies, Exam, Assessment, Plan
Preventive prompts (immunizations, screening due, counseling)
Carry-forward of diagnoses, goals, and follow-ups to later visits
Team-wide formatting controls (bullets/paragraphs) + redaction
How it works with your EHR
Capture or upload in Nudge → draft appears.
Review and edit sections.
In your EHR, open a new note and launch the Nudge extension.
Select patient + note type → confirm field mapping (HPI/Subjective, Exam, Assessment, Plan, optional ROS/History) → save & sign.
No IT project required.
Quick example
New patient with hypertension & fatigue
HPI: home BPs 140s/90s; fatigue mid-afternoon; sedentary work; high sodium diet.
ROS (focused): denies chest pain/SOB; +snoring.
History: PMH HTN; meds: none; FH CAD; social: sedentary, 2 coffees/day, rare EtOH.
Exam: BP 148/92, BMI 31, normal heart/lungs, no edema.
Assessment: Primary HTN; r/o OSA; overweight.
Plan: start thiazide; low-sodium diet; labs (BMP, A1C, lipids); sleep study referral; BP log; follow-up 4 weeks; preventive vaccines reviewed.
Full Sample Note — New Patient Visit (Primary Care): Dyspnea
Example only; not medical advice.
CHIEF COMPLAINT
Shortness of breath for one week.
HISTORY OF PRESENT ILLNESS
Ms. J. is a 45-year-old female, new to the practice, who presents with a one-week history of progressively worsening dyspnea. She states the onset was gradual and initially only occurred with significant exertion, such as climbing two flights of stairs. Over the last 2–3 days, she has felt short of breath with routine household activities. She reports an associated dry, non-productive cough, particularly at night. She denies fever, chills, chest pain, pressure, or palpitations. She has not had any recent long-distance travel, surgery, or periods of immobility. She denies any lower extremity swelling, pain, or redness. She has a history of mild asthma in her teens but has not used an inhaler in many years. She tried an old albuterol inhaler from a family member yesterday with minimal relief.
PAST MEDICAL HISTORY
Mild intermittent asthma, diagnosed in adolescence, no recent care
Iron deficiency anemia, diagnosed 5 years ago, treated with oral iron at the time
PAST SURGICAL HISTORY
Cholecystectomy, laparoscopic, age 38
MEDICATIONS
None
Reports occasional use of ibuprofen for headaches
ALLERGIES
No known drug, food, or environmental allergies.
FAMILY HISTORY
Father: history of hypertension
Mother: history of anxiety
No known family history of early coronary artery disease, blood clots, or lung disease
SOCIAL HISTORY
Ms. J. works as a retail manager. She has a 15-pack-year history of smoking (1 pack per day for 15 years) and continues to smoke. She drinks alcohol socially, approximately 2–3 drinks per weekend. She denies any illicit drug use.
IMMUNIZATIONS
Pneumococcal vaccine status: unknown
Influenza vaccine: not received this season
REVIEW OF SYSTEMS
Constitutional: reports fatigue; denies fever, chills, or weight loss.
Respiratory: positive for shortness of breath and dry cough; negative for wheezing (by patient report), sputum production, or hemoptysis.
Cardiovascular: denies chest pain, pressure, palpitations, orthopnea, or lower extremity edema.
Gastrointestinal: denies nausea, vomiting, or acid reflux.
All other systems: a 10-point review of systems was otherwise negative.
VITAL SIGNS
BP 128/78 mmHg • Pulse 96 bpm, regular • RR 22/min, unlabored at rest • Temp 98.9°F (37.2°C) • SpO₂ 94% RA • Ht 5′6″ (168 cm) • Wt 145 lb (65.8 kg) • BMI 23.4 kg/m²
PHYSICAL EXAMINATION
General: alert and oriented, speaking in full sentences with mildly increased respiratory rate; no acute distress at rest.
HENT: oropharynx clear.
Neck: supple, no JVD; trachea midline.
Lungs: diffuse expiratory wheezes throughout all lung fields, bilaterally; good air movement; prolonged expiratory phase; no rales or rhonchi.
Cardiovascular: regular rate and rhythm; normal S1/S2; no murmurs, rubs, or gallops.
Abdomen: soft, non-tender, non-distended.
Extremities: no peripheral edema, cyanosis, or clubbing; Homan’s sign negative bilaterally; calves soft and non-tender.
DIAGNOSTIC TESTING
Peak flow: 280 L/min (≈65% predicted for height/age/sex)
ASSESSMENT AND PLAN
Dyspnea (R06.02):
Given history of asthma, active smoking, exam with diffuse wheeze, and reduced peak flow, an asthma or early COPD exacerbation is most likely. Infectious and thromboembolic causes considered.
Differential: asthma exacerbation; early COPD exacerbation; community-acquired pneumonia; pulmonary embolism; bronchitis.
Plan — Diagnostic:
STAT chest X-ray (PA/LAT) to evaluate for infiltrate, effusion, or other acute cardiopulmonary process
STAT ECG to rule out cardiac ischemia as a contributor
Labs: CBC with differential; Comprehensive Metabolic Panel (CMP)
D-dimer ordered given moderate pretest probability for PE (Wells score 1.5)
Pulmonary function testing (spirometry) in ~2 weeks when acute symptoms resolve to establish baseline and evaluate for COPD given smoking history
In-office albuterol nebulizer ×1 with improvement in peak flow to 320 L/min
Plan — Therapeutic:
Prednisone 40 mg PO daily × 5 days
Albuterol HFA 2 puffs every 4–6 hours PRN shortness of breath
Provided spacer and taught inhaler technique
Dispensed peak flow meter; monitor twice daily and keep diary
Plan — Counseling:
Strong counseling on smoking cessation; provided state quitline resources
Strict return precautions: ED for worsening SOB, chest pain, inability to speak full sentences, or peak flow < 50% of today’s best (<160 L/min)
Tobacco Use Disorder (F17.210):
Active smoker (15 pack-years), contributing to current and future risk.
Plan: assessed readiness to quit (contemplation stage); brief counseling + resources as above; address more formally at follow-up.
Establishment of Care:
New to practice.
Plan:
Request outside records from prior PCP
Pneumococcal vaccine (PCV20 or PPSV23) recommended given smoking history/potential COPD; patient to consider and discuss at follow-up
Influenza vaccine offered today; patient deferred to follow-up when feeling better
FOLLOW-UP
Return in 2–3 days for symptom re-evaluation and review of diagnostic results. If symptoms worsen, call the office or proceed to the nearest emergency department.
Results (2025)
First new-patient note ready in < 90 seconds after capture.
Primary-care teams report 4–6 hrs/week saved and cleaner preventive-care prompts across clinicians.
FAQs
Can I toggle ROS and history depth per visit?
Yes. Use comprehensive vs problem-focused modes; save defaults for new-patient visits.
Can I require vitals, meds, and allergies before export?
Yes. Mark sections as required and block export until completed.
Does this work with telemedicine onboarding?
Yes. Use the same structure with a virtual exam field set and add return-to-clinic instructions.
Shanice
Author, Nudge AI
