Sample Medical Record: Steve Apple

Module 8 Appendix B

Use for April 2011 abstraction
WeServeEveryone Clinic 
1111 First Street California
111-111-11111 Fax: 111-111-1111
Chart Summary
Steve Apple
Male DOB: 02/02/19450000-22222Home: 222-222-2222
Ins: Commercial xxxxx

Patient Information

Name: Steve AppleHome Phone: 222-222-2222
Address: 2222 Computer Dr
                Laptop, California  
Office Phone:
Patient ID: 0000-22222Fax:
Birth Date: 02/02/1945Status: Active
Gender: MaleMarital Status: Married
Contact By: Phone Race: White
Soc Sec No: 222-22-2222Language: English
Resp Prov: Carl SavemMRN: MR-111-1111
Referred by:Emp. Status: Full-time
Email:Sens Chart: No
Home LOC: WeServeEveryoneExternal ID: MR-111-1111

Problems

DIABETES MELLITUS (ICD-250.)

Medications

PRINIVIL TABS 20 MG (LISINOPRIL) 1 po qd
Last Refill: #30 x 2 : Carl Savem MD (11/27/2010)
HUMULIN INJ 70/30 (INSULIN REG & ISOPHANE (HUMAN)) 20 units ac breakfast
Last Refill: #600 u x 0: Carl Savem MD (11/27/2010)

Directives

Allergies and Adverse Reactions (! = critical)

Services Due

CREATININE

2/1/2011 - 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 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 ClinicMarch 24, 2011
1111 First Street California
111-111-11111   Fax: 111-111-1111
Page 2
Chart Summary
Steve Apple 
Male   DOB: 02/02/1945
0000-22222
 

Home: 222-222-2222

Ins: Commercial xxxxx

Ht: 71 in.  Wt: 191  lbs.   T: 98.0 degF. T site: oral  P: 70   Rhythm: regular R: 16 BP: 118/70

Physical Exam

General Appearance: 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):  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.

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:

Lipid Panel

Education/Counseling (time): 15 minutes

Coordination of Care (time): 5 minutes

Follow-up/Return Visit: 3 months

Disposition: return to clinic

WeServeEveryone ClinicMarch 24, 2011
1111 First Street California
111-111-11111   Fax: 111-111-1111
Page 2
Chart Summary
Steve Apple 
Male   DOB: 02/02/1945
0000-22222
Home: 222-222-2222
Ins: Commercial xxxxx

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  TOTAL0.7  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    5.0%
(3) Lipid Profile
Cholesterol, Total   210 mg/dl
Triglycerides  236 mg/dl
HDL Cholesterol 36
LDL Cholesterol 87
WeServeEveryone ClinicMarch 24, 2011
1111 First Street California
111-111-11111   Fax: 111-111-1111
Page 2
Chart Summary
Steve Apple 
Male DOB: 02/02/1945
0000-22222

Home: 222-222-2222

Ins: Commercial xxxxx

Flowsheet
 Date 12/18/2010
HEIGHT  (in)71
WEIGHT (lb)191
TEMPERATURE (deg F)98
TEMP SITEoral
PULSE RATE (/min)72
PULSE RHYTHM 
RESP RATE (/min)16
BP SYSTOLIC (mm Hg)118
BP DIASTOLIC (mm Hg)70
CHOLESTEROL (mg/dL) 
HDL (mg/dL)87
LDL (mg/dL)125
BG RANDOM  (mg/dL) 
CXR 
EKG 
PAP SMEAR 
BREAST EXAM 
MAMMOGRAM 
HEMOCCULT neg
FLU VAX 0.5 ml g
PNEUMOVAX0.5 ml g
TD BOOSTER0.5 ml g
Foot ExamComplete
Eye ExamComplete
Page last reviewed May 2013
Internet Citation: Sample Medical Record: Steve Apple: Module 8 Appendix B. May 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/prevention-chronic-care/improve/system/pfhandbook/mod8appbsteveapple.html