sample notes.  

There are many stylistic differences plossible within the standard formats.  Here are a few standard formats that you should know.  An employer or provider will let you know which format to use.

Students can Click here to hear a sample dictation and view instructions on downloading dictation and unzipping a voice file for playing on Express Scribe.

Sample Chart Note #1

SUBJECTIVE: The patient is a 35-year-old female who complains of a cough for one week. She reports a fever last Saturday that is now resolved. She has a slightly hoarse voice. She is a nonsmoker. She takes Prozac 20 mg daily for depression.

EXAMINATION: Weight 160 pounds, temperature 98.9 degrees, blood pressure 130/88, pulse 84, and respirations 20. Patient is a pleasant female in no acute distress. TMs are clear and throat is clear. The neck is supple. Chest is clear. Heart examination is normal.

ASSESSMENT AND PLAN: Upper respiratory infection, probably viral. Phenergan with Codeine 150 mL, 2 tsp q.4-6h. p.r.n.. She is warned about the drowsy side effects of this. Follow up with her primary doctor next week if not improved.

Sample Chart Note #2

PROBLEMS:

1. GERD.

2. Hiatal hernia.

SUBJECTIVE: The patient is a 40-year-old male. He has recovered uneventfully from endoscopy 04/09/2001. He has a definite GERD in association with a small hiatal hernia. Biopsies are negative for Barrett's esophagus. The patient is on aspirin 81 mg per day, and I have told him to discontinue this.

ASSESSMENT/PLAN: He feels well and should continue on Prilosec 40 mg a day as part of a chronic antireflux regimen, particularly because of his cardiac history. This is safe to take long term. Biopsies of the stomach are negative for Helicobacter. He is scheduled for endoscopy on Thursday, June 14, at 7 a.m.

It is my pleasure to help in the care of this very pleasant gentleman.

Sample Chart Note #3

SUBJECTIVE: The patient is a 43-year-old white female who has had an exacerbation of her chronic cervical pain since last Friday. She thinks it might be secondary to lifting a bag of groceries. She has had good success in the past with seeing a chiropractor in this situation.

Physical therapy has generally not been helpful in the past. She takes Prozac 20 mg a day and Darvocet N-100, which she uses occasionally. She reports no allergies.

EXAMINATION: Vital Signs: Pulse 72, blood pressure 110/82, weight 196-1/2 pounds. Neck: Tenderness in the right posterior cervical area with no spasm.

ASSESSMENT:

1. Chronic cervical pain.

2. Chronic depression.

PLAN: Darvocet N-100, #10 only with no refills. Naprosyn 500 mg one p.o. b.i.d. as needed. Referral to chiropractor for four visits.

Sample Note #4

SECOND OPINION CONSULTATION

RE: DOE, MARY J.

       DOB: 01/11/1954

REASON FOR CONSULTATION:  Second opinion regarding her chest pain syndrome.

HISTORY OF PRESENT ILLNESS:  Mary Doe is a xxxxx........:

1.  Recurrent xxxx..........

2.  Labile xxxxxx..................

3.  History of cancer of both breasts with simple mastectomy, followed by chemotherapy. She had breast implants xxxxxxxxxxxxxxxxxxxxxxxxxx.

4.  History of xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx.

5.  History of xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx.

6.  Severe obesity for at least five years.

7.  Family history of coronary artery disease. Her father apparently had xxxxxxx followed by xxxxxxxxxxxxxx surgery at age 55 and he died at age 65.

8.  History of allergy to adhesive tape.

In regard to her chest pain syndrome, xxxxxxxxxxxx. Xxxxxxxxxxxxxxx  Xxxxxxxxxxx.  

For a few months xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx.  Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx.

ALLERGIES:  ADHESIVE TAPE.

REVIEW OF SYSTEMS: 

PULMONARY SYSTEM: xxxxxxxx..................xxxxxxxxxxxxxxxxxxxxxxxxx.

GASTROINTESTINAL SYSTEM:  xxxxxxxxxxxxxxxxx.................xxxxxxxxxxxxxx.

GENITOURINARY SYSTEM: No hematuria. No xxxxxxx.............xxxxxxxxxxxxxxx.

CENTRAL NERVOUS SYSTEM: No history xxxxxxx...........xxxxx. 

METABOLIC SYSTEM: Obesity, but xxxxxxxxxxxxxx.................xxxxxxxxxxxxxxxxx.

SKELETAL SYSTEM: She has diffuse aches and pains in all joints, xxxxxxxxxxxxxxxx.  Xxxxxxxxxxxxxxx.................xxxxxxxxxxxxxxxxxxx.

PHYSICAL EXAMINATION:  Neck vein not xxxxxxxxxxxxxxx.............xxxxxxxxxxxxxxxxx.  

EKG is completely normal.

DIAGNOSTIC IMPRESSION:

1.  Chest pain on and off for xxxxxxxxx.....................xxxxxxxxxxxxxx.

2.  Consider possibility of acid reflux from xxxx.

3.  Consider possibility of gallstones. She has increased abdominal gas and obesity.

4.  Probable metabolic xxxxxxxxxxxxxxxxxxxxxxx....................xxxxxxxxxxxxxxxxxxxx.

5.  Other diagnoses as listed in detail in my history section.

SUGGESTIONS:  I reassured her that xxxxxxxxxxxx............xxxxxxxxxxxxxxxxx.

I have advised her to reduce weight and do regular exercise for primary prevention, and watch out for hypertension. If blood pressure should continue to be high in the future, we should add an xxxxxxxxxxxxxxxxxx....................xxxxxxx.

I have advised her to see a xxxxxxxxx......xxxxxxx.... hernia with acid reflux and no gallstones.

Meanwhile, she should continue with the current medications including one baby aspirin a day, tamoxifen, xxxxxx,xxxxx,xxxxxxxxxxxxxxxx.

Sample Correspondence

February 4, 2009

George Smith, M.D.

1240 N. Rochester Ave.

Chicago, IL  60651

RE:      Doe, Janice

DOB:  07/05/1973

Dear Dr. Smith:

Thank you for sending your patient Janice Doe to see me in consultation.

History of Present Illness:  She is a xxxxxxxxxxxx................xxxxxxxxxx.  Xxxxxxx..........................xx.  Xxxxxxxxxxxxxxxxxxxxxx.  Xxxxxxxxxxxxxxxx.........................xxxxxxxxxxxxxxxxxxxxxxxxxx had multiple diagnostic tests including an MRI scan of her head, neck and shoulder, and brachial plexus neurology evaluations with nerve testing.

On January 13, 2009, she again xxxxxxxxxxx...................xxxxxxxxxx.  Xxxx......xxx.  Xxxxxxxxxxxxxxxxxxx................xxxxxxx pain in her shoulder and shoulder blade, tingling to her fingertips when she stands up straight.

Past Medical History: History of depression, history of psychiatric treatment, xxxxxxxxxxxxx. 

Surgeries: None. 

Current Medications: Vicodin. 

Review of Systems: Poor vision, irregular heartbeat, numbness. 

Social History: She works as a file clerk, but has not worked since this injury. She smokes half a pack per day, drinks two xxxxxxx.......xx.

ALLERGIES: PENICILLIN, PERCOCET.

Examination: Janice is alert, oriented, pleasant and well groomed.  Height xxxxxxxxxxx.  Xxxxx...........xx.  She has a smooth motion and does not feel unstable.  The clavicle is normal.  The shoulder does not droop compared to the other side.

Radiographs:  xxxxxxxxxxxxxx................xxxxxx.

Impression:  xxxxxxxx...........................................xxxxxxxxxxxx.

Plan:  Therefore, xxxxxxxxxxx....................................xxx in two to three weeks.

Thank you, again, Dr. Smith, for sending this pleasant woman to see me.

Sincerely,

Anne Reynolds, M.D.