chart 127

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University of Notre Dame *

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Medicine

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Dec 6, 2023

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Medical Transcription Services Virtual Scribe Services Medical Coding Services Chart Readiness – Template for Practice SOAP Notes 1. Chart #: 127 2. Chief Complaint(s): Follow up regarding left ring finger flexor tendinitis 3. History of Present Illness: (Remember to use full sentences, check grammar/spelling, use proper medical terminology and medical phrasing.) Patient is a 65-year-old right hand dominant male presenting on 11/13/2018 for follow up regarding left ring finger flexor tendinitis. The left ring finger flexor tendinitis and a2 pully rupture began on date July 2018. Ring splint and trigger finger injections have been done successfully and patient reports pain is rated at 1/10. Currently, the patient feels a lot better, is able to grab things, grip strength is returning, and decreased edema present. Patient denies catching, clicking and popping. 4. Review of Systems: * Copy/paste the below ROS into your answer and remove/add as necessary. Please only include pertinent findings. MS:- joint pain, -limited ROM, - Integumentary: - edema 5. Past Medical History: (If verbalized during encounter.) 6. Past Surgical History: (If verbalized during encounter.)

Medical Transcription Services Virtual Scribe Services Medical Coding Services 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.) 10. Physical Examination *Copy/paste the below PE into your answer and remove/add as necessary. Please only include pertinent findings. Constitutional: Well-developed, well-nourished Head: AT/NC Neck: Supple, full ROM, no masses, no bruit, no JVD Eyes: PERRL, EOMI, sclerae anicteric, normal visual fields ENT: Nose normal, throat clear, no oral lesions, healthy dentition Cardiovascular: RRR, no murmur or gallop, normal S1 and S2, intact distal pulses Respiratory: CTAB, normal aeration Abdomen: Soft, nontender, nondistended, normal bowel sounds, no masses, no organomegaly Breasts: Bilateral breasts without mass, fullness, or tenderness Back: No tenderness, normal curvature Extremities: No edema, no muscular or joint tenderness Lymphatic: No palpable nodes, no adenopathy Skin: No suspicious lesions identified Neurological: Speech clear, memory intact, CN II-XII intact, normal coordination, normal gait, 5/5 strength bilaterally, equal sensation bilaterally Psychiatric: Appropriate, normal judgement MS: Full ROM, No pain over a1 or a2 pulley, Able to make full composite grip

Medical Transcription Services Virtual Scribe Services Medical Coding Services 11. Assessment & Plan First list diagnosis, then type out the plan. Include any labs ordered. Example: 1.) Breast cancer Start Arimidex 1mg QD. Symptoms reviewed/discussed. Ordered: CBC, CMP, CA 15-3, CEA Follow up in 3 months. 2.) Hypertension Continue Metoprolol 25mg BID. Encouraged to monitor BP at home three times daily. Bring list of blood pressure readings to next appointment . 1. Left ring finger flexor tendinitis -Should wean out of ring splints -Follow up on an as needed basis 12. Please list all orders that should be pended for this visit: Include all lab, diagnostic imaging, medications and referrals. 13. Scribed for Dr. _____ by _Harjaap Bhatoa____, 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.)

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Medical Transcription Services Virtual Scribe Services Medical Coding Services

chart 127

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