chart 134
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School
University of Notre Dame *
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Course
2400
Subject
Medicine
Date
Dec 6, 2023
Type
docx
Pages
4
Uploaded by BrigadierMoonStork9
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Chart Readiness – Template for Practice SOAP Notes
1.
Chart #:
134
2.
Chief Complaint(s): Follow up for Osteoporosis
3.
History of Present Illness:
(Remember to use full sentences, check grammar/spelling, use
proper medical terminology and medical phrasing.)
Patient is a 75 year old female who presents for follow up of osteoporosis to review recent
DEXA scan results. Patient is currently taking calcium 600 mg twice daily and vitamin D3 at
2000 IU twice daily. Previous vitamin D levels from 2016 were reviewed. She has been
prescribed Evista but states she discontinued due to insurance coverage and cost of
medication. She is agreeable to restarting Evista. Also taking Januvia, glimepiride, and Actos
for management of diabetes
4.
Review of Systems:
5.
Past Medical History:
(If verbalized during encounter.)
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6.
Past Surgical History:
(If verbalized during encounter.)
7.
Social History:
(If verbalized during encounter.)
8.
Family History:
(If verbalized during encounter.)
9.
Diagnostic Data Discussed:
(Lab work, imaging, EKG, etc. Anything discussed during today’s
visit.)
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10.
Physical Examination
11.
Assessment & Plan
1.
Osteopenia
Will repeat DEXA scan in 2 years
. Recommended to continue taking calcium, vitamin D3 and restart
raloxifene (generic Evista)
12.
Please list all orders that should be pended for this visit:
Include all lab, diagnostic
imaging, medications and referrals.
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13.
Scribed for Dr. _____
by _____, medical scribe, on _____ at _____.
I, Dr. _____, have
personally reviewed and agree with the information entered by the scribe.
(Rewrite this
sentence in the answer space, filling in the blanks.)