Sample Chart Note #1
| RE: | Debra Jones |
| DATE: | 12/01/10 |
| MR: | 240804 |
| DOB: | 12/01/65 |
SUBJECTIVE: The patient is a 35-year-old female who complains of a cough for one week. She reports a fever last Saturday that is now resolved. She has a slightly hoarse voice. She is a nonsmoker. She takes Prozac 20 mg daily for depression.
EXAMINATION: Weight 160 pounds, temperature 98.9 degrees, blood pressure 130/88, pulse 84, and respirations 20. Patient is a pleasant female in no acute distress. TMs are clear and throat is clear. The neck is supple. Chest is clear. Heart examination is normal.
ASSESSMENT AND PLAN: Upper respiratory infection, probably viral. Phenergan with Codeine 150 mL, 2 tsp q.4-6h. p.r.n.. She is warned about the drowsy side effects of this. Follow up with her primary doctor next week if not improved.
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