Office Note Sample:
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I had the pleasure of seeing the patient back again on 01/04/07. He has not obtained diabetic shoes at this point. He has pain in both feet and his low back. He is on Motrin.
His exam demonstrates a healing ulcer on the plantar aspect of the right IP joint. There is overlying callus fissures, no evidence of infection and decrease in size.
1. Diabetic wound right foot.
PLAN: The wound is debrided and the patient is given instructions to the wound care. He desperately needs diabetic shoe year. We will talk about this again. I will see if I can see her in two weeks to see her with a more active role.