Office Note Sample:

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OFFICE NOTE

D/O/B: 12/01/65
DATE: 12/01/10

HPI:  He is an established patient of the practice, last seen a little over a year ago.  Subjectively, he is an 82-year-old male with chronic left knee pain due to degenerative joint disease.  He has been treated extensively none operatively with physical therapy, home exercises, cortisones injections, Synvisc injections, as well as the use of a cane.  He comes in wondering if there anything out there that is new day as he is not a candidate for an arthroplasty.  Objectively, the examination of the left knee reveals that he does have an immobile brace right now.  He has pain with range of motion of the knee.  He is grossly neurovascularly intact distally otherwise.  X-ray examination performed today of the left knee reveals that he has significant medial compartment and patellofemoral compartment degenerative joint disease.

ASSESSMENT AND PLAN:   Continue physical therapy and Naprosyn.  Also, I did offer her a back support today to use when her back bothers.  We will get her a Warm & Form type of brace.  She is going to follow-up with me in one month’s time for another clinical evaluation.