Chart Note Report Sample:

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Chart Note #2

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

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.