Practice Facilitation Handbook

Sample Medical Record: Monica Latte

Use for April 2011 abstraction

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

Monica Latte

Home: 444-444-4444
Female  DOB: 04/04/1950
0000-44444 Ins: Commercial xxxxx

                                                     

Patient Information

Name: Monica Latte Home Phone: 444-444-4444
Address: 4444 Coffee Ave
                Chocolate, California
Office Phone:
Patient ID: 0000-44444 Fax:
Birth Date: 04/04/1950 Status: Active
Gender: Female Marital Status: Divorced
Contact By: Phone Race: Black
Soc Sec No: 444-444-4444 Language: English
Resp Prov: Carl Savem MRN: MR-111-1111
Referred by: Emp. Status: Full-time
Email: Sens Chart: No
Home LOC:WeServeEveryone External ID: MR-111-1111

Problems

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

Medications

PRINIVIL TABS 20 MG (LISINOPRIL) 1 po qd
Last Refill: #30 x 2 : Carl Savem MD (08/27/2010)
HUMULIN INJ 70/30 (INSULIN REG & ISOPHANE (HUMAN)) 20 units ac breakfast
Last Refill: #600 u x 0 : Carl Savem MD (08/27/2010)

Directives

Allergies and Adverse Reactions (! = critical)

Services Due

FLU VAX, PNEUMOVAX, MICROALB URN

3/18/2011 - 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 
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

Ht: 64 in. Wt: 140 lbs.T: 98.0 degF. T site: oral P: 72 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

Problems (including changes): Blood pressure is lower. 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. Will work harder on diet. Will increase insulin by 2 units.

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:

UA
Metabolic Panel

Education/Counseling (time): 5 minutes

Coordination of Care (time): 20 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

03/18/2011 - Lab Report: Metabolic Panel Provider: Carl Savem MD

Tests:

(1) Metabolic Panel(ML-03CHEM)

ALK PHOS 72 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 6.0%
(3) Lipid Profile
Cholesterol, Total   210 mg/dl
Triglycerides           236 mg/dl
HDL Cholesterol    36
LDL Cholesterol     107 

WeServeEveryone Clinic March 24, 2011
1111 First Street California
111-111-11111   Fax: 111-111-1111
Page 2
Chart Summary

Female  DOB: 04/04/1950                      0000-44444                          Ins: Commercial xxxxx

  Date 03/18/2011
HEIGHT (in) 64
WEIGHT (lb) 140
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)  
LDL (mg/dL)  
BG RANDOM (mg/dL) 125
CXR  
EKG  
PAP SMEAR  
BREAST EXAM  
MAMMOGRAM  
HEMOCCULT neg
FLU VAX  
PNEUMOVAX  
TD BOOSTER 0.5 ml g
Foot Exam  
Eye Exam Complete
Page last reviewed May 2013
Internet Citation: Sample Medical Record: Monica Latte. May 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/prevention-chronic-care/improve/system/pfhandbook/mod8appbmonicalatte.html