Practice Facilitation Handbook

Sample Medical Record: John Donut

Use for January 2011 abstraction

WeServeEveryone Clinic  
1111 First Street California
111-111-11111   Fax: 111-111-1111
Chart Summary

John Donut

Home: 000-000-0000
Male   DOB: 01/01/1935
0000-11111 Ins: Commercial xxxxx

                                                     

Patient Information

Name: John Donut Home Phone: 000-000-0000
Address: 1111 Donut Road
                Fast Food, California  
Office Phone:
Patient ID: 0000-11111 Fax:
Birth Date: 01/01/1935 Status: Active
Gender: Male     Marital Status: Widowed
Contact By: Phone  Race: Black
Soc Sec No: 111-11-1111 Language: English
Resp Prov: Carl Savem   MRN: MR-111-1111
Referred by: Emp. Status: Part-time
Email: Sens Chart: No
Home LOC: WeServeEveryone  External ID: MR-111-1111

Problems

DIABETES MELLITUS (ICD-250.)
HYPERTENSION, BENIGN ESSENTIAL (ICD-401.1)

HYPERPLASIA, PROSTATE (ICD-600)

DEPRESSION (ICD-311)

RETINOPATHY, DIABETIC (ICD-362.0)

POLYNEUROPATHY IN DIABETES (ICD-357.2)

Medications

PRINIVIL TABS 20 MG (LISINOPRIL) 1 po qd
Last Refill: #30 x 2 : Carl Savem MD (05/27/2010)
HUMULIN INJ 70/30 (INSULIN REG & ISOPHANE (HUMAN)) 20 units ac breakfast
Last Refill: #600 u x 0 : Carl Savem MD (05/27/2010)

Directives

Allergies and Adverse Reactions (! = critical)

Services Due

HEMOCCULT or SIGMOID, BP DIASTOLIC, BP SYSTOLIC, FLU VAX, PNEUMOVAX, MICROALB URN

09/25/2010 - Office Visit: F/u Diabetes
Provider: Carl Savem MD
Location of Care: WeServeEveryone Clinic

OFFICE VISIT

History of Present Illness 
Reason for visit: Routine follow up to review medications Chief Complaint: No complaints

History 
Diabetes Management 
Hyperglycemic Symptoms 
Polyuria: no
Polydipsia: no
Blurred vision: no

Sympathomimetic Symptoms 
Diaphoresis: no
Agitation: no
Tremor: no
Palpitations: no
Insomnia: no

Neuroglycopenic Symptoms 
Confusion: no
Lethargy: no
Somnolence: no
Amnesia: no
Stupor:
no
Seizures: no

Review of Systems

General: denies fatigue, malaise, fever, weight loss
Eyes: denies blurring, diplopia, irritation, discharge
Ear/Nose/Throat: denies ear pain or discharge, nasal obstruction or discharge, sore throat
Cardiovascular: denies chest pain, palpitations, paroxysmal nocturnal dyspnea, orthopnea, edema Respiratory: denies coughing, wheezing, dyspnea, hemoptysis
Gastrointestinal: denies abdominal pain, dysphagia, nausea, vomiting, diarrhea, constipation
Genitourinary: denies hematuria, frequency, urgency, dysuria, discharge, impotence, incontinence
Musculoskeletal: denies back pain, joint swelling, joint stiffness, joint pain
Skin: denies rashes, itching, lumps, sores, lesions, color change
Neurologic: denies syncope, seizures, transient paralysis, weakness, paresthesias
Psychiatric: denies depression, anxiety, mental disturbance, difficulty sleeping, suicidal ideation, hallucinations, paranoia
Endocrine: denies polyuria, polydipsia, polyphagia, weight change, heat or cold intolerance
Heme/Lymphatic:
denies easy or excessive bruising, history of blood transfusions, anemia, bleeding disorders, adenopathy, chills, sweats
Allergic/Immunologic: denies urticaria, hay fever, frequent UTIs; denies HIV high risk behaviors

Vital Signs

WeServeEveryone Clinic March 24, 2011
1111 First Street California
111-111-11111   Fax: 111-111-1111
Page 2
Chart Summary
John Donut  
Male   DOB: 01/01/1935
0000-55555
Ins: Commercial xxxxx
Home: 000-000-0000

Ht: 74  in.  Wt: 190  lbs.   T: 98.0 degF. T site: oral  P: 70   Rhythm: regular R: 16 BP: 158/90

Physical Exam

General Appearance: well developed, well nourished, no acute distress
Eyes: conjunctiva and lids normal, PERRLA, EOMI, fundi WNL
Ears, Nose, Mouth, Throat: TM clear, nares clear, oral exam WNL
Respiratory: clear to auscultation and percussion, respiratory effort normal
Cardiovascular: regular rate and rhythm, S1-S2, no murmur, rub or gallop, no bruits, peripheral pulses normal and symmetric, no cyanosis, clubbing, edema or varicosities
Skin: clear, good turgor, color WNL, no rashes, lesions, or ulcerations

Assessment

Problems (including changes): Blood pressure is lower. He is following his diet, by his account.
He has not had any hypoglycemic episodes, no night sweats. Feet are inspected and there are no callouses, no compromised skin. No vision complaints.

Impression: Sub optimal sugar, control with retinopathy and neuropathy, high glucometer readings.
He will work harder on diet. Will increase insulin by 2 units. BP better.

Home Glucose Monitoring: 
AC breakfast 110 to 220
AC breakfast mean 142
AC dinner 100 to 250
AC dinner mean 120

Plan

Medications: 
HUMULIN INJ 70/30 20 u ac breakfast
PRINIVIL TABS 20 MG 1 qd

Treatment: Will have annual foot exam at next visit.

Orders:

Ophthalmology consult
UA
HGBA1C
Metabolic Panel
Lipid Panel

Education/Counseling (time): 10 minutes

Coordination of Care (time): 10 minutes

Follow-up/Return Visit: 3 months

Disposition: return to clinic

WeServeEveryone Clinic March 24, 2011
1111 First Street California
111-111-11111   Fax: 111-111-1111
Page 2
Chart Summary
John Donut  
Male   DOB: 01/01/1935
0000-55555
Ins: Commercial xxxxx
Home: 000-000-0000

Ins: BHI (Futura) Grp: BHI1595

10/31/2010 - Lab Report: Metabolic Panel Provider: Carl Savem MD
Location of Care: Millennium Health System

Tests:                                

(1) Metabolic Panel  (ML-03CHEM)

ALK  PHOS     72  U/L        35-100
BG  RANDOM   125  mg/dl      70-125
BUN     16  mg/dl   7-25
CALCIUM    9.6  mg/dl   8.2-10.2
CHLORIDE     101  mmol/l    96-109
CO2   27  mmol/l    23-29
CREATININE    0.7  mg/dl      0.6-1.2
PO4    2.9  mg/dl  2.5-4.5
POTASSIUM    4.5  mmol/l  3.5-5.3
SGOT  (AST)  31  U/L     0-40
BILI  TOTAL 0.7  mg/dl         0.0-1.3
URIC  ACID     4.8  mg/dl      3.4-7.0
LDH,  TOTAL       136  IU/L     0-200
SODIUM      135  mmol/l       135-145

(2) HbA1c Test
HbA1c level    8.0%
(3) Lipid Profile
Cholesterol, Total   210 mg/dl
Triglycerides  236 mg/dl
HDL Cholesterol 36
LDL Cholesterol 102

WeServeEveryone Clinic March 24, 2011
1111 First Street California
111-111-11111   Fax: 111-111-1111
Page 2
Chart Summary
John Donut  
Male   DOB: 01/01/1935
0000-55555
Ins: Commercial xxxxx
Home: 000-000-0000

Flowsheet

    Date        09/25/2010
HEIGHT  (in)   74
WEIGHT  (lb)  190
TEMPERATURE  (deg F)   98
TEMP SITE    oral
PULSE RATE  (/min)             72
PULSE RHYTHM  
RESP RATE  (/min)  16
BP SYSTOLIC  (mm Hg)    158
BP DIASTOLIC  (mm Hg)     90
CHOLESTEROL  (mg/dL)  
HDL  (mg/dL) 102
LDL  (mg/dL)     125
BG RANDOM  (mg/dL)  
CXR  
EKG  
PAP SMEAR  
BREAST EXAM  
MAMMOGRAM  
HEMOCCULT  neg
FLU VAX  0.5 ml g
PNEUMOVAX   0.5 ml g
TD BOOSTER   0.5 ml g
Foot Exam  
Eye Exam  
Page last reviewed May 2013
Internet Citation: Sample Medical Record: John Donut. May 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/prevention-chronic-care/improve/system/pfhandbook/mod8appbjohndonut.html