Sample History and Physical Note
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Note for Cameron Carre on 04/01/2003 - Chart 18205
Chief Complaint (1/1): This 55 year old male prents today for evaluation of chest pain.
Cardiac associated signs and symptoms: Pain radiating to the arm and shortness of breath.
Cardiac duration: Symptom has existed for an intermittent time.
Cardiac location: Midsternal.
Cardiac ont: Ont of the symptom was 5 months ago.
Cardiac quality: Patient describes discomfort as: pressure.
Cardiac modifying factors: Exertion worns condition.
Cardiac verity: Severity of condition is worning.
Patient has the following coronary risk factors: elevated cholesterol for less than 1 year and HTN for 13 years. Allergies: No known medical allergies.
Medication History: Patient is currently taking hydrochlorothiazide 25 mg tablet (one po daily), Lipitor 20 mg tablet (once daily) usage started on 04/01/2003.
Past Medical History:Cardiovascular Hx: (+) high cholesterol, (+) hypertension, Psychiatric Hx: (+) depression, Neurological Hx: (+) migraines.
PSH: No previous surgeries.
Social History: Patient is married. Patient admits walking on a treadmill until symptoms begin.
Family History: Patient denies a family history of premature cardiovascular dia.
Review of Systems:Cardiovascular: (+) chest pain, (+) arm pain. The remainder of his review of systems is negative. General: Patient is a 55 year old male who appears pleasant, in no apparent distress, his given age, well developed, well nourished and with good attention to hygiene and body habitus. Patient communicates with aid of interpreter.
Vital Signs: BP Sitting: 150/90 HR: 74 Weight: 188 lbs.
HEENT: Inspection of head and face shows head that is normocephalic, atraumatic, without any gross or neck mass.
Pupil exam reveals round and equally reactive to light and accommodation.
Conjunctiva and lids reveal no signs or symptoms of infection bilaterally.
Inspection of oral mucosa and tongue reveals no pallor or cyanosis.
Examination of oropharynx reveals the uvula ris in the midline.
Neck: Neck exam reveals neck supple and trachea that is midline, without adenopathy or crepitance palpable.
Thyroid examination reveals smooth and symmetric gland with no enlargement, tenderness or mass noted.
Carotid puls are palpated bilaterally, are symmetric and no bruits auscultated over the carotid and vertebral arteries.
Jugular veins examination reveals no distention or abnormal waves were noted.
Neck lymph nodes are normal.
Chest: Chest inspection reveals normal expansion.
Chest palpation reveals no abnormal tactile fremitus.
Lungs: Asssment of respiratory effort reveals even respirations without u of accessory muscles, no intercostal retractions noted and diaphragmatic movement normal.
Auscultation of lungs reveal clear lung fields and no rubs noted.公鸡打鸣
Heart: The apical impul on heart palpation is located in the left fourth intercostal space in the midclavicular line and no thrill noted.
Heart auscultation reveals rhythm is regular with a paradoxically split cond heart sound
Abdomen: Abdomen soft, nontender, bowel sounds prent x 4 without palpable mass.
Palpation of liver reveals no abnormalities with respect to size, tenderness or mass.
Palpation of spleen reveals no abnormalities with respect to size, tenderness or mass.
Examination of abdominal aorta shows normal size without prence of systolic bruit.
Extremities: No clubbing, cyanosis, sub-unguinal petechiae or edema obrved. Hair growth is normal in the lower extremities.
Puls: The femoral, popliteal, dorsalis, pedis and posterior tibial puls in the lower extremities are equal and normal.
The brachial, radial and ulnar puls in the upper extremities are equal and normal.
Examination of peripheral vascular system reveals full to palpation, varicosities abnt, extremities warm to touch and no edema.
Neurological: Oriented to person, place and time.
Mood and affect normal and appropriate to situation.
Musculoskeletal: Muscle strength is 5/5 for all groups tested.
Gait and station examination reveals midposition without abnormalities.
Skin: No skin rash, subcutaneous nodules, lesions or ulcers obrved. Skin is warm and dry with normal turgor and there is no icterus.
安全生产金句Lymphatics: No lymphadenopathy noted.
Test Results:
Cholesterol: 355 mg/dl.
HDL: 75 mg/dl.
LDL: 130 mg/dl.
Impression:
Midsternal chest pain.
Plan:
The following cardiac risk factor modifications are recommended: avoid consumption of alcohol, control blood pressure and reduce LDL cholesterol to below 120 mg/dl.
Patient was referred to cardiology.
Prescriptions:
Lipitor Dosage: 20 mg tablet Sig: once daily Dispen: 30 Refills: 0 Allow Generic: No
Patient Instructions:
Authorization Form - A, Authorization for U or Disclosure of Information for Purpos Requested by Physician's Office, explained to and obtained from patient
_______________________________Dr. Internal, M.D.
Sample Billing Statement
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Billing Statement - Tuesday, April 01, 2003
Provider:Dr. Internal, M.D.
Patient: Cameron Carre, Chart 18205
1010 University短情话
WDM, IA 50266
Diagnos
1. 786.51 Precordial Pain
Treatments
1. 99213 Office or other outpatient visit - est. patient - 15 min.
Related Diagnos:
Modifiers:
Units:
2. 82465 Cholesterol, Serum Or Whole Blood, Total
Related Diagnos:
Modifiers:
Units:
Referring Physician:
Date Last Seen: 03/13/2003
Sample Referral Letter
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04/01/2003
Full Cardiologist,
1231 8th Street
West Des Moines, IA 50265螃蟹怎样清洗
Dear Dr. Heart:
Cameron Carre was en in my office. I have requested that Cameron be en by you for further evaluation of the cardiac symptoms and a stress echocardiogram. The following is a summary of my findings:
Chief Complaint (1/1): This 55 year old male prents today for evaluation of chest pain.
Cardiac associated signs and symptoms: Pain radiating to the arm and shortness of breath.
Cardiac duration: Symptom has existed for an intermittent time.
Cardiac location: Midsternal.
Cardiac ont: Ont of the symptom was 5 months ago.
Cardiac quality: Patient describes discomfort as: pressure.
Cardiac modifying factors: Exertion worns condition.
神经节苷酯
Cardiac verity: Severity of condition is worning.
Patient has the following coronary risk factors: elevated cholesterol for less than 1 year and HTN for 13 years. Allergies: No known medical allergies.
Medication History: Patient is currently taking hydrochlorothiazide 25 mg tablet (one po daily), Lipitor 20 mg tablet (once daily) usage started on 04/01/2003.
Past Medical History:Cardiovascular Hx: (+) high cholesterol, (+) hypertension, Psychiatric Hx: (+) depression, Neurological Hx: (+) migraines.
PSH: No previous surgeries.
大话西游图片
Social History: Patient is married. Patient admits walking on a treadmill until symptoms begin.
Family History: Patient denies a family history of premature cardiovascular dia.
Review of Systems:Cardiovascular: (+) chest pain, (+) arm pain. The remainder of his review of systems is negative. General: Patient is a 55 year old male who appears pleasant, in no apparent distress, his given age, well developed, well nourished and with good attention to hygiene and body habitus. Patient communicates with aid of interpreter.
Vital Signs: BP Sitting: 150/90 HR: 74 Weight: 188 lbs.
HEENT: Inspection of head and face shows head that is normocephalic, atraumatic, without any gross or neck mass.
Pupil exam reveals round and equally reactive to light and accommodation.
There is no conjunctival inflammation nor icterus.
Inspection of oral mucosa and tongue reveals no pallor or cyanosis.
Examination of oropharynx reveals the uvula ris in the midline.
Neck: Neck exam reveals neck supple and trachea that is midline, without adenopathy or crepitance palpable.
Thyroid examination reveals smooth and symmetric gland with no enlargement, tenderness or mass noted.
Carotid puls are palpated bilaterally, are symmetric and no bruits auscultated over the carotid and vertebral arteries.
Jugular veins examination reveals no distention or abnormal waves were noted.
Neck lymph nodes are normal.
Chest: Chest inspection reveals normal expansion.
Chest palpation reveals no abnormal tactile fremitus.
Lungs: Asssment of respiratory effort reveals even respirations without u of accessory muscles, no intercostal retractions noted and diaphragmatic movement normal.
Auscultation of lungs reveal clear lung fields and no rubs noted.
Heart: The apical impul on heart palpation is located in the left fourth intercostal space in the midclavicular line and no thrill noted.
Heart auscultation reveals rhythm is regular with a paradoxically split cond heart sound
Abdomen: Abdomen soft, scaphoid, nontender; bowel sounds prent x 4 without palpable mass.
Palpation of liver reveals no abnormalities with respect to size, tenderness or mass.
Palpation of spleen reveals no abnormalities with respect to size, tenderness or mass.
Examination of abdominal aorta shows normal size without prence of systolic bruit.
Extremities: No clubbing, cyanosis, sub-unguinal petechiae or edema obrved. Hair growth is normal in the lower extremities.
Puls: The femoral, popliteal, dorsalis, pedis and posterior tibial puls in the lower extremities are equal and normal.
The brachial, radial and ulnar puls in the upper extremities are equal and normal.
Examination of peripheral vascular system reveals full to palpation, varicosities abnt, extremities warm to touch and no edema.
Neurological: Oriented to person, place and time.
Mood and affect normal and appropriate to situation.
Musculoskeletal: Muscle strength is 5/5 for all groups tested.
Gait and station examination reveals midposition without abnormalities.
Skin: No skin rash, subcutaneous nodules, lesions or ulcers obrved. Skin is warm and dry with normal turgor and there is no icterus.
Lymphatics: No lymphadenopathy noted.
Test Results:
Cholesterol: 355 mg/dl.
HDL: 75 mg/dl.
LDL: 130 mg/dl.
Impression:
Midsternal chest pain.
Plan: Referral to cardiologist for evaluation and stress echocardiogram
Prescriptions:
Lipitor Dosage: 20 mg tablet Sig: once daily Dispen: 30 Refills: 0 Allow Generic: No
Patient Instructions:
Authorization Form - A, Authorization for U or Disclosure of Information for Purpos Requested by Physician's Office, explained to and obtained from patient
If I may be of any further assistance in your evaluation of this patient, plea contact me. Let me know your findings and recommendations. Thank you for assisting in the care of this patient.
Sincerely,
Dr. Internal, M.D.
Sample Prescription
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Dr. Internal, M.D.
1231 8th Street, Suite 222
West Des Moines, IA 50265
DEA#:
_____________________________________________________________
Name: Cameron Carre Date: 04/01/2003
Address: 1010 University
West Des Moines, IA 50266
_____________________________________________________________中青班
Lipitor
20 mg tablet
Once daily
X_____________________________________ X_____________________________________
Substitution Permitted Dispen as written
Refills: 0
Dispen: 30
Allow Generic: No
Sample Patient Instruction
Charting Plus™ - Electronic Medical Records
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Patient Instructions for Cameron Carre on 04/01/2003
Authorization Form - A
Authorization for U or Disclosure of Information for Purpos Requested by Physician's Office
I, Cameron Carre, hereby authorize Dr. Internal to (check tho that apply):
__ u the following protected health information, and/or
_X_ disclo the following protected health information to Dr. Heart:
Information to be ud or disclod, includes, office exam note with date of rvice, type of rvice provided, history, examination findings, lab results, impression, plan, and medications.
This protected health information is being ud or disclod for the following purpos: referral of patient for further cardiac testing and stress echocardiogram
This authorization shall be in force and effect until May 31 or when Dr. Heart has relead patient from his care at which time this authorization to u or disclo this protected health information expires.
I understand that I have the right to revoke this authorization, in writing, at any time by nding such written notification to Diane Manager at 1231 8th Street, WDM, IA 50265.
I understand that a revocation is not effective to the extent that Dr. Internal has relied on the u or disclosure of the protected health information. I understand that information ud or disclod pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law.
Dr. Internal will not condition my treatment, payment, enrollment in a health plan or eligibility for benefits (if applicable) on whether I provide authorization for the requested u or disclosure.
I understand that I have the right to:
· Inspect or copy the protected health information to be ud or disclod as permitted under federal law (or state law to the extent the state law provides greater access rights.)
· Refu to sign this authorization.
(The u or disclosure requested under this authorization will result in direct or indirect remuneration to the Dr. Internal from a third party.) (If applicable.)
江南水乡古镇_________________________________________ Signature of Patient or Personal Reprentative
_________________________________________ Date
_________________________________________ Name of Patient or Personal Reprentative
_________________________________________ Description of Personal Reprentative's Authority
(This form does not constitute legal advice and is for educational purpos only. This form is bad on current federal law and subject to change bad on changes in federal law or subquent interpretative guidance. This form is bad on federal law and must be modified to reflect state law where that state law is more stringent than the federal law or other state law exceptions apply.) © 2001 American Medical Association All Rights Rerved 11/09/01
_______________________________ Dr. Internal, M.D.
