Chart Note Report Samples (4)

Chart Note #1

RE: Debra Jones
DATE: 12/01/12
MR: 240804
DOB: 12/01/65

 

SUBJECTIVE: The patient is a 35-year-old female who complains of a cough for one week. She reports a fever last Saturday that is now resolved. She has a slightly hoarse voice. She is a nonsmoker. She takes Prozac 20 mg daily for depression.

EXAMINATION: Weight 160 pounds, temperature 98.9 degrees, blood pressure 130/88, pulse 84, and respirations 20. Patient is a pleasant female in no acute distress. TMs are clear and throat is clear. The neck is supple. Chest is clear. Heart examination is normal.

ASSESSMENT AND PLAN: Upper respiratory infection, probably viral. Phenergan with Codeine 150 mL, 2 tsp q.4-6h. p.r.n.. She is warned about the drowsy side effects of this. Follow up with her primary doctor next week if not improved.




Chart Note #2

RE: David Jones
DATE: 12/01/12
MR: 240804
DOB: 12/01/65

 

PROBLEMS:
1. GERD.
2. Hiatal hernia.

SUBJECTIVE: The patient is a 40-year-old male. He has recovered uneventfully from endoscopy 04/09/2001.  He has a definite GERD in association with a small hiatal hernia. Biopsies are negative for Barrett’s esophagus.  The patient is on aspirin 81 mg per day, and I have told him to discontinue this.

ASSESSMENT/PLAN:  He feels well and should continue on Prilosec 40 mg a day as part of a chronic antireflux regimen, particularly because of his cardiac history.  This is safe to take long term.  Biopsies of the stomach are negative for Helicobacter.  He is scheduled for endoscopy on Thursday, June 14, at 7 a.m.
It is my pleasure to help in the care of this very pleasant gentleman.




Chart Note #3

RE: Debra Jones
DATE: 12/01/12
MR: 240804
DOB: 12/01/65

 

SUBJECTIVE: The patient is a 43-year-old white female who has had an exacerbation of her chronic cervical pain since last Friday. She thinks it might be secondary to lifting a bag of groceries. She has had good success in the past with seeing a chiropractor in this situation.
Physical therapy has generally not been helpful in the past. She takes Prozac 20 mg a day and Darvocet N-100, which she uses occasionally. She reports no allergies.

EXAMINATION: Vital Signs: Pulse 72, blood pressure 110/82, weight 196-1/2 pounds. Neck: Tenderness in the right posterior cervical area with no spasm.

ASSESSMENT:
1. Chronic cervical pain.
2. Chronic depression.

PLAN: Darvocet N-100, #10 only with no refills. Naprosyn 500 mg one p.o. b.i.d. as needed. Referral to chiropractor.




Chart Note #4

RE: Debra Jones
DATE: 12/01/12
MR: 240804
DOB: 12/01/65

 

S: The patient has a pulse of 84. Blood pressure is 120/80. She is here for an acute visit today complaining about a recurrent rash on her right buttock. A few days ago she felt a tingling sensation in her upper right buttock and today noticed that she had developed some small vesicles. It is in a well-circumscribed area, in an area where she had lesions previously. She had cultures done back in May, on May 10th. It occurred first in January of this year. She had light growth of coag negative staph and that was all on her last bacterial culture. She has had multiple sex partners in her life. She has, she believes, been tested for herpes in the past and was negative. She has been monogamous with her current partner for quite some time now. She is trying to conceive a child and has been sexually active lately and is worried about giving this to her husband.

ROS: Is listed in HPI. Allergies are penicillin and IVP dye. Medications are reviewed. Please see medication sheet.

PMH: Is reviewed. Please see note.

SHX: Is reviewed. Please see note.

PE: She has a 2-3 cm well-circumscribed hyperemic area with small clear vesicles. Bacterial culture is taken. A viral culture is taken. She has no lymph nodes either in her anterior cervical chain, supra or subclavicular or inguinal area.

A&P: Likely herpetic rash. Cultures have been taken. We will also do a check for HSV-1 and HSV-2. I have given her Valtrex 500 mg twice daily for the next three days with p.r.n. refills. We will await the culture results to go further and, in the meantime, we talked about its spread and how to protect her partner. She was agreeable with the above- instructed plan. Risks, benefits and side effects of medications and treatments were discussed, and she will follow up as suggested.

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