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Practice Facilitation Handbook
Sample Medical Record: Steve Apple
Use for April 2011 abstraction
| WeServeEveryone Clinic | |
| 1111 First Street California 111-111-11111 Fax: 111-111-1111 |
Chart Summary |
Steve Apple
| Male DOB: 02/02/1945 | 0000-22222 | Home: 222-222-2222 Ins: Commercial xxxxx |
Patient Information
| Name: Steve Apple | Home Phone: 222-222-2222 |
| Address: 2222 Computer Dr Laptop, California |
Office Phone: |
| Patient ID: 0000-22222 | Fax: |
| Birth Date: 02/02/1945 | Status: Active |
| Gender: Male | Marital Status: Married |
| Contact By: Phone | Race: White |
| Soc Sec No: 222-22-2222 | 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.)
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 Clinic | March 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 Clinic | March 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 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 5.0%
(3) Lipid Profile
Cholesterol, Total 210 mg/dl
Triglycerides 236 mg/dl
HDL Cholesterol 36
LDL Cholesterol 87
| WeServeEveryone Clinic | March 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 SITE | oral |
| 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 |
| PNEUMOVAX | 0.5 ml g |
| TD BOOSTER | 0.5 ml g |
| Foot Exam | Complete |
| Eye Exam | Complete |
Page originally created May 2013
