Sample Chart Note #1

SUBJECTIVE: The patient is a 35-year-old female who complain 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 cc, 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.

Sample Chart Note #2

PROBLEMS:

GERD.

Hiatal hernia.

SUBJECTIVE: The patient is a 40-year-old male. He has recovered uneventfully from endoscopy 04/09/2001. He has a definite GERD in association with a small hiatal hernia. Biopsies are negative for Barrett’s esophagus. The patient is on 81 mg aspirin per day, and I have told him to discontinue this.

ASSESSMENT/PLAN: He feels well and should continue on Prilosec 40 mg a day as part of a chronic antireflux regimen, particularly because of his cardiac history. This is safe to take long term. Biopsies of the stomach are negative for Helicobacter. He is scheduled for endoscopy on Thursday, June 14, at 7 a.m.

It is my pleasure to help in the care of this very pleasant gentleman.

Sample Chart Note #3

SUBJECTIVE: The patient is a 43-year-old white female who has had an exacerbation of her chronic cervical pain since last Friday. She thinks it might be secondary to lifting a bag of groceries. She has had good success in the past with seeing a chiropractor in this situation.

Physical therapy has generally not been helpful in the past. She takes Prozac 20 mg a day and Darvocet N-100, which she uses occasionally. She reports no allergies.

EXAMINATION: Vital Signs: Pulse 72, blood pressure 110/82, weight 196-1/2 pounds. Neck: Tenderness in the right posterior cervical area with no spasm.

ASSESSMENT:

1. Chronic cervical pain.

2. Chronic depression.

PLAN: Darvocet N-100, #10 only with no refills. Naprosyn 500 mg one p.o. b.i.d. as needed. Referral to chiropractor for four visits.