chart 153 set 7

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Holy Family University *

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420

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Medicine

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Apr 3, 2024

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Medical Transcription Services Virtual Scribe Services Medical Coding Services Chart Readiness – Template for Practice SOAP Notes 1. Chart #: 2. Chief Complaint(s): Sore throat. 3. History of Present Illness: (Remember to use full sentences, check grammar/spelling, use proper medical terminology and medical phrasing.) The patient is a 25-year-old male patient who presents on 11/15/2018 with concerns of a sore throat. He mentions experiencing swollen glands since 11/12/2018 and had a fever that began on the same date but has since resolved. The patient reports experiencing some discomfort during swallowing (odynophagia). He denies having nasal congestion or ear pain (otalgia). The patient is concerned about his upcoming law enforcement training scheduled for 11/26/2018 and hopes for symptom improvement before that date.

Medical Transcription Services Virtual Scribe Services Medical Coding Services 4. Review of Systems: * Copy/paste the below ROS into your answer and remove/add as necessary. Please only include pertinent findings. Constitutional: Negative chills, fever, fatigue HENT: Negative sore throat, congestion, otalgia Eyes: Negative blurred vision, eye pain/discharge/redness Respiratory: Negative cough, sputum production, dyspnea, wheezing, hemoptysis CV: Negative chest pain, DOE, orthopnea GI: Negative abd pain, N/V/D, constipation, hematochezia, melena, heartburn GU: Negative pelvic pain, dysuria, hematuria, frequency, nocturia MS: Negative back pain, joint pain, myalgia, limited ROM Integumentary: Negative rash, erythema, pruritus, abrasion, laceration, postoperative site Neurological: Negative headache, dizziness, paresthesia, speech change Psychological: Negative anxiety, depression, suicidal/homicidal ideation, insomnia Endocrine: Negative heat/cold intolerance, hair loss, significant weight gain/loss, polyuria, polydipsia Hematologic/Lymphatic: Negative easy bleeding, ecchymosis, lymphadenopathy Constitutional: Positive fever, currently resolved. HEENT: Positive sore throat, odynophagia, swelling glands. Negative nasal congestion, otalgia.

Medical Transcription Services Virtual Scribe Services Medical Coding Services 5. Past Medical History: (If verbalized during encounter.) N/A 6. Past Surgical History: (If verbalized during encounter.) N/A 7. Social History: (If verbalized during encounter.) N/A 8. Family History: (If verbalized during encounter.)

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Medical Transcription Services Virtual Scribe Services Medical Coding Services N/A 9. Diagnostic Data Discussed: (Lab work, imaging, EKG, etc. Anything discussed during today’s visit.) N/A 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

Medical Transcription Services Virtual Scribe Services Medical Coding Services HEENT: Turbinates reveal erythema and edema, and breathing appears obstructed. TM’s are mobile and translucent, no erythema present. Slight lymphadenopathy bilaterally (*verify location). Respiratory: Clear to auscultation bilaterally 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 . Assessment: Acute rhinosinusitis, with a secondary sore throat. Plan: Recommended symptomatic treatment with OTC Dimetapp Children's Cough and Cold 20 mL. Advised that symptoms should continue to resolve over the next few days.

Medical Transcription Services Virtual Scribe Services Medical Coding Services 12. Please list all orders that should be pended for this visit: Include all lab, diagnostic imaging, medications and referrals. NA 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.)

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chart 153 set 7

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