Office Note Sample:

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RE:   David Jones
DATE 12/01/10
MR:  240804
DOB: 12/01/65

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.