Sample Medical Record: Bill Windows

Module 8 Appendix B

Use for April 2011 abstraction 

WeServeEveryone Clinic 
1111 First Street California
111-111-11111 Fax: 111-111-1111
Chart Summary
Bill Windows
Male DOB: 09/09/19530000-99999Home: 999-999-9999
Ins: Commercial xxxxx

Patient Information

Name: Bill WindowsHome Phone: 999-999-9999
Address: 9999 Computer Dr
                Operating System, California  
Office Phone:
Patient ID: 0000-99999Fax:
Birth Date: 09/09/1953Status: Active
Gender: MaleMarital Status: Married
Contact By: Phone Race: White
Soc Sec No: 999-99-9999Language: 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

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

DO NOT RESUSCITATE

Allergies and Adverse Reactions (! = critical)

Services Due

BP DIASTOLIC, BP SYSTOLIC, FLU VAX, PNEUMOVAX, MICROALB URN, FLU VAX, BP DIASTOLIC, BP SYSTOLIC, DIAB FOOT CK, ALBUMIN URIN, TSH, CHOLESTEROL, HGBA1C, CREATININE.

01/20/11 - 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 for Diabetes
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
Bill Windows 
Male DOB: 09/09/1953
0000-99999

Home: 999-999-9999

Ins: Commercial xxxxx

Ht: 73 in. Wt: 200 lbs. T: 98.0 degF. T site: oral  P: 74 Rhythm: regular R: 15 BP: 128/70

Physical Exam

General Appearance: well developed, well nourished, no acute distress
Eyes: conjunctiva and lids normal
Ears, Nose, Mouth, Throat: TM clear, nares clear, oral exam WNL
Respiratory: respiratory effort normal
Cardiovascular: regular rate and rhythm
Skin: clear, good turgor, color WNL, no rashes, lesions, or ulcerations

Assessment

Problems (including changes):  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, high glucometer readings. 

He will work harder on diet. Will increase insulin by 2 units. BP and symptoms are better.

Plan

Medications: 
HUMULIN INJ 70/30 20 u ac breakfast

Treatment: Will have annual foot exam at next visit.

Orders:

UA
HGBA1C
Metabolic Panel
Lipid Panel

He will work harder on diet. Will increase insulin by 2 units. BP and symptoms are better.

Education/Counseling (time): 10 minutes

Coordination of Care (time): 10 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
Bill Windows 
Male   DOB: 09/09/1953
0000-99999
Home: 999-999-9999
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    6.0%
(3) Lipid Profile
Cholesterol, Total   210 mg/dl
Triglycerides  236 mg/dl
HDL Cholesterol 36
LDL Cholesterol 127
WeServeEveryone ClinicMarch 24, 2011
1111 First Street California
111-111-11111   Fax: 111-111-1111
Page 2
Chart Summary
Bill Windows 
Male DOB: 09/09/1953
0000-99999

Home: 999-999-9999

Ins: Commercial xxxxx

Flowsheet 

Enterprise/Medicine/Internal Medicine

 Date 01/19/2011
HEIGHT  (in)70
WEIGHT (lb)190
TEMPERATURE (deg F)98
TEMP SITEoral
PULSE RATE (/min)72
PULSE RHYTHM 
RESP RATE (/min)16
BP SYSTOLIC (mm Hg)128
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: Bill Windows: 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/mod8appnbillwindows.html