Chart Note Report Sample:

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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.