Example Notecut:
Subjective:
"Cold"
Pt with c/o of ST, stuffiness, rhinorrhea, some ear pain, cough for ____ days.
States NO subjective fever at home. NO measured temp. Has difficulty swallowing. Denies drooling.
Has been taking NOTHING for relief of these symptoms. With little success.
ROS
Pt denies ha, cp, sob, n/v, abd pain, urinary symptoms, changes in stool, blood in urine, blood in stool, pain in legs, pains in joints, rash.
PMH reviewed
PSH reviewed
Meds reviewed
All reviewed
Objective:
Vitals: Afebrile, all other vital signs reviewed and wnl
Exam:
General: A&Ox3. NAD. Congenial, Conversant
Mood and Affect: appropriate
HEENT:
Eyes- PERRLA, EOMI, conjunctivae WNL bil
Ears- TMI, nonerythematous, wnl bilaterally
Nares- with noted rhinorrhea, some erythema
Throat- slightly erythematous, no exudates, noted PND cobblestoning.
Neck- shotty LAD, thyroid nonpalpable
Cardio: RRR, nl S1S2, no M/ R/ G
Lungs: CTAB, no W/ R/ C
Abd: S/NT/ND, NABS, no guarding, no rebound, no HSM, no masses appreciated
Skin: wnl, no rashes or lesions
A/P
Viral URI -- 465.9
- Advised rest and fluids.
- Ibuprofen 600mg PO Q4h prn for pain control
- Loratadine 10 mg PO daily for nasal discharge
- Pseudoephedrine 60mg PO Q6h prn for nasal discharge
- Flunisolide 1puff each nostril bid for Eustachian Tube dysfunction
- f/u PRN and for RHM.
PATIENT EDUCATION
Education Instructions given to: Patient
NO Barriers to Learning Identified
Patient states understanding of verbal instructions / plan.
Patient / Family agrees with plan and questions were answered.