Sample Medical Record: Wendy See

Module 8 Appendix B

Use for October 2010 abstraction 

WeServeEveryone Clinic 
1111 First Street California
111-111-11111   Fax: 111-111-1111
Chart Summary
Wendy See
Home: 777-777-7777
Female DOB: 07/07/1943
0000-33333Ins: Commercial Orange Shield

Patient Information

Name: Wendy SeeHome Phone: 777-777-7777
Address: 3333 Wonder Ave
                Famous, California
Office Phone:
Patient ID: 0000-33333Fax:
Birth Date: 07/07/1943Status: Active
Gender: FemaleMarital Status: Single
Contact By: PhoneRace: Asian
Soc Sec No: 333-333-3333Language: 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.) 

DEPRESSION (ICD-311)

Medications

HUMULIN INJ 70/30 (INSULIN REG & ISOPHANE (HUMAN)) 20 units ac breakfast
Last Refill: #600 u x 0 : Carl Savem MD (01/27/2010)

PROZAC CAPS 10 MG (FLUOXETINE HCL) 1 po qd

Last Refill: #30 x 2 : Carl Savem MD (06/17/2010)

Directives

Allergies and Adverse Reactions (! = critical)

! Benadryl

Services Due

FLU VAX

9/22/2010 - 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 Chief Complaint: No complaints

History
Social History: Her husband died 2 years ago and she is more introspective.

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

Ht: 60 in. Wt: 120 lbs. T: 98.0 degF. T site: oral P: 72 Rhythm: regular R: 16 BP: 125/70

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: 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.

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

Medications:

HUMULIN INJ 70/30 20 u ac breakfast

PROZAC CAPS 10 MG 1 qd

Treatment: Will have annual foot exam at next visit.

Orders:

UA

Education/Counseling (time): 20 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

10/19/2010 - Lab Report: Metabolic Panel Provider: Carl Savem MD
Location of Care: Millennium Health System

(1) HbA1c Test
HbA1c level 7.0%
(2) Lipid Profile
Cholesterol, Total   210 mg/dl
Triglycerides           236 mg/dl
HDL Cholesterol    36
LDL Cholesterol     90

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

Female  DOB: 07/07/1943                      0000-33333                                         Ins: Commercial xxxxx

 

 Date 9/22/2010
HEIGHT (in)60
WEIGHT (lb)120
TEMPERATURE (deg F)98
TEMP SITEoral
PULSE RATE (/min)72
PULSE RHYTHM 
RESP RATE (/min)16
BP SYSTOLIC (mm Hg)125
BP DIASTOLIC (mm Hg)70
CHOLESTEROL (mg/dL) 
HDL (mg/dL) 
LDL (mg/dL) 
BG RANDOM (mg/dL) 
CXR 
EKG 
PAP SMEAR 
BREAST EXAM 
MAMMOGRAM 
HEMOCCULTneg
FLU VAX0.5 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: Wendy See: 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/mod8appbwendysee.html