Chart Note Report Sample:

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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.