Chart Note Report Sample:

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Chart Note #4

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

S:   Heidi 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 Heidi 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.