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1、Sample History and Physical Note Charting Plus - Electronic Medical RecordsNote for John Doe on 4/18/02 - Chart 1124Chief Complaint: This 26 year old male presents today for treatment of suspected rheumatoid arthritis. Associated signs and symptoms include aching, joint pain, and symmetrical joint s
2、welling bilateral. Patient denies any previous history, related trauma or previous treatments for this condition. Condition has existed for 2 weeks. He indicates the problem location is the right hand and left hand. Patient indicates no modifying factors. Severity of condition is slowly worsening. O
3、nset was unknown.Allergies: Patient admits allergies to aspirin resulting in GI upset, disorientation.Medication History: Patient is currently taking amoxicillin-clavulanate 125 mg-31.25 mg tablet, chewable medication was prescribed by A. General Practitioner MD, Adrenocot 0.5 mg tablet medication w
4、as prescribed by A. General Practitioner MD.Past Medical History: Past medical history is unremarkable.Past Surgical History: Patient admits past surgical history of (+) appendectomy in 1989. Family History: Patient admits a family history of rheumatoid arthritis associated with maternal grandmother
5、.Social History: Patient denies alcohol use. Patient denies illegal drug use. Patient denies STDhistory. Patient denies tobacco use.Review of Systems: Neurological: (+) paralysis Musculoskeletal: (+) joint pain (+) joint swelling (+) stiffness Cardiovascular: (+) ankle swelling Neurological: (-) num
6、bness Musculoskeletal: (-) back pain (chronic) (-) decreased ROM (-) episodic weakness Cardiovascular: (-) chest pressure Respiratory: (-) breathing difficulties, respiratory symptoms(-) sleep apneaPhysical Exam: BP Standing: 120/84 HR: 79 Temp: 98.6 Height: 5 ft. 8 in. Weight: 168 lbs. Patient is a
7、 26 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.Skin: No skin rash, subcutaneous nodules, lesions or ulcers observed. Palpation of skin shows no abnormalities.HEENT: Inspection of head
8、and face shows no abnormalities. Hair growth and distribution is normal. Examination of scalp shows no abnormalities. Conjunctiva and lids reveal no signs or symptoms of infection. Pupil exam reveals round and reactive pupils without afferent pupillary defect. Ocular motility exam reveals gross orth
9、otropia with full ductions and versions bilateral. Bilateral retinas reveal normal color, contour, and cupping. Inspection of ears reveals no abnormalities. Otoscopic examination reveals no abnormalities. Examination of oropharynx reveals no abnormalities and tissues pink and moist. ENT: Inspection
10、of ears reveals no abnormalities. Examination of larynx reveals no abnormalities. Inspection of nose reveals no abnormalities.Neck: Neck exam reveals neck supple and trachea that is midline, without adenopathy or crepitance palpable. Thyroid examination reveals no abnormalities and smooth and symmet
11、ric gland with no enlargement, tenderness or masses noted.Lymphatic: Neck lymph nodes are normal.Respiratory: Assessment of respiratory effort reveals even respirations without use of accessory muscles and no intercostal retractions noted. Chest inspection reveals chest configuration non- hyperinfla
12、ted and symmetric expansion. Auscultation of lungs reveals clear lung fields and no rubs noted.Cardiovascular: Heart auscultation reveals normal S1 and S2 and no murmurs, gallop, rubs or clicks. Examination of peripheral vascular system reveals full to palpation, varicosities absent, extremities war
13、m to touch and no edema.Abdomen: Abdominal contour is slightly rounded. Abdomen soft, nontender, bowel sounds present x 4 without palpable masses. Palpation of liver reveals no abnormalities. Palpation of spleen reveals no abnormalities.Musculoskeletal: Gait and station examination reveals normal ar
14、m swing, with normal heel-toe and tandem walking. Inspection and palpation of bones, joints and muscles is unremarkable. Muscle strength is 5/5 for all groups tested. Muscle tone is normal.Neurologic/Psychiatric: Psychiatric: Oriented to person, place and time. Mood and affect normal and appropriate
15、 to situation. Testing of cranial nerves reveals no deficits. Coordination is good. Touch, pin, vibratory and proprioception sensations are normal. Deep tendon reflexes normal.Test & X-Ray Results: Rheumatoid factor: 52 U/ml. Sed rate: 31 mm/hr. C4 complement: 19mg/dl.Impression: Rheumatoid arthriti
16、s.Plan: ESR ordered; automated. Ordered RBC. Ordered quantitative rheumatoid factor. Return to clinic in 2 week(s).Prescriptions:Vioxx Dosage: 12.5 mg tablet Sig: BID Dispense: 30 Refills: 2 Allow Generic: No_ A. Rheumatologist, MDSample Billing Statement Charting Plus - Electronic Medical RecordsBi
17、lling Statement - Thursday, April 18, 2002Provider: A. Rheumatologist, MDPatient: John Doe, Chart 1124 1231 8th Street, Suite 222West Des Moines, IA 50265Diagnoses1. 714.0 Rheumatoid ArthritisTreatments1. 99214 Office or other outpatient visit - est. patient - 25 min. Related Diagnoses: 714.0Modifie
18、rs: Units:2. 85041 Blood Count; Red Blood Cell (RBC) OnlyRelated Diagnoses: 714.0Modifiers: Units:3. 85652 Sedimentation Rate, Erythrocyte; AutomatedRelated Diagnoses: 714.0Modifiers: Units:4. 86431 Rheumatoid Factor; QuantitativeRelated Diagnoses: 714.0Modifiers: Units:Referring Physician: Marcus W
19、elby, MDDate Last Seen: 07/26/2001Sample Prescription Charting Plus - Electronic Medical RecordsA. Rheumatologist, MDDEA#:_Name: John Doe Date: 4/18/02Addr: 1231 8th Street, Suite 222West Des Moines, IA 50265_Vioxx12.5 mg tabletBIDX_ X_ Substitution Permitted Dispense as writtenRefills: 2Disp: 30All
20、ow Generic: NoSample Patient Instruction Charting Plus - Electronic Medical RecordsPatient Instructions for John Doe on 4/18/02RHEUMATOID ARTHRITISWhat is it?Rheumatoid arthritis (or RA) is a chronic, systemic condition with primary involvement of the joints. Joint inflammation is present due to an
21、abnormal immune response in which the body attacks its own tissue. Specifically, the tissues lining the joint are involved as well as cartilage and muscle and sometimes the eyes and blood vessels. The cause of rheumatoid arthritis is obscure but it is associated with a family history, genetic and au
22、toimmune problems, people ages 20-60, female gender 3:1 or a Native American background.Signs and symptoms:* Joint pain, swelling, redness, warmth. Commonly involved joints are the small joints of the hands and feet and the ankles, wrists, knees, shoulders and elbows.* Multiple swollen joints (more
23、than 3) with simultaneous involvement of same joints on opposite side of the body.* Morning stiffness that lasts longer than 30 minutes.* Difficulty making a fist; poor grip strength.* Night pain.* Feeling sick - low fever, loss of appetite, tiredness, generalized aching and stiffness, weakness.* Rh
24、eumatoid nodules under the skin, usually along the surface of tendons or over bony prominences.* Disease may lead to deformed joints, decreased vision, anemia, muscle weakness, peripheral nerve problems, pericarditis, enlarged spleen, increased frequency of infections.* Blood tests will reveal a pos
25、itive rheumatoid factor (RF) to be present the majority of the time.Treatment:* To diagnose RA, blood studies are done to detect a substance known as rheumatoid factor and x-rays may show typical findings.* Night splints for involved joints. Avoid putting a pillow under the knees as this will contri
26、bute to joint contracture.* Heat helps relieve the pain; hot water soaks, whirlpool baths, heat lamps, heating pads, etc. applied to affected joints 15-20 minutes 3 times per day is helpful.* Sleep on a firm mattress and sleep at least 10-12 hours per night. Get rest during the day; take naps.* Get
27、bed rest during an active flare-up until symptoms subside.* Avoid humid weather if possible.* NSAIDs (non-steroidal anti-inflammatory drugs).* DMARDs (disease-modifying anti-rheumatic drugs) - gold compounds, D-penicillamine, sulfasalazine, methotrexate, antimalarials.* Immunosuppressive drugs.* Ace
28、taminophen (Tylenol) for pain relief only when necessary.* Oral corticosteroids short term; corticosteroid injection into joint can temporarily relieve pain and inflammation.* Exercise as recommended by your physician. Exercise helps keep the joints limber and increases strength. Swimming and water
29、activities are a good way to workout. Put all your joints through their full ranges of motion every day to prevent contractures.* Physical therapy may be recommended.* Surgical intervention.* Lose excess weight as being overweight will only stress the joints further.* Eat a normal, well-balanced die
30、t._A. Rheumatologist, MDSample Referral Letter Charting Plus - Electronic Medical Records4/18/02Marcus Welby, M.D.1231 8th Street, Suite 222West Des Moines, IA 50265Dear Dr. Welby:John Doe was seen in my office in consultation as requested by you as a new patient for evaluation and care. The followi
31、ng is a summary of my findings and recommendations:Chief Complaint: This 26 year old male presents today for treatment of suspected rheumatoid arthritis. Associated signs and symptoms include aching, joint pain, and symmetrical joint swelling bilateral. Patient denies any previous history, related t
32、rauma or previous treatments for this condition. Condition has existed for 2 weeks. He indicates the problem location is the right hand and left hand. Patient indicates no modifying factors. Severity of condition is slowly worsening. Onset was unknown.Allergies: Patient admits allergies to aspirin r
33、esulting in GI upset, disorientation.Medication History: Patient is currently taking amoxicillin-clavulanate 125 mg-31.25 mg tablet, chewable medication was prescribed by A. General Practitioner MD, Adrenocot 0.5 mg tablet medication was prescribed by A. General Practitioner MD.Past Medical History:
34、 Past medical history is unremarkable.Past Surgical History: Patient admits past surgical history of (+) appendectomy in 1989. Family History: Patient admits a family history of rheumatoid arthritis associated with maternal grandmother.Social History: Patient denies alcohol use. Patient denies illeg
35、al drug use. Patient denies STDhistory. Patient denies tobacco use.Review of Systems: Neurological: (+) paralysis Musculoskeletal: (+) joint pain (+) joint swelling (+) stiffness Cardiovascular: (+) ankle swelling Neurological: (-) numbness Musculoskeletal: (-) back pain (chronic) (-) decreased ROM
36、(-) episodic weakness Cardiovascular: (-) chest pressure Respiratory: (-) breathing difficulties, respiratory symptoms(-) sleep apneaPhysical Exam: BP Standing: 120/84 HR: 79 Temp: 98.6 Height: 5 ft. 8 in. Weight: 168 lbs. Patient is a 26 year old male who appears pleasant, in no apparent distress,
37、his given age, well developed, well nourished and with good attention to hygiene and body habitus.Skin: No skin rash, subcutaneous nodules, lesions or ulcers observed. Palpation of skin shows no abnormalities.HEENT: Inspection of head and face shows no abnormalities. Hair growth and distribution is
38、normal. Examination of scalp shows no abnormalities. Conjunctiva and lids reveal no signs or symptoms of infection. Pupil exam reveals round and reactive pupils without afferent pupillary defect. Ocular motility exam reveals gross orthotropia with full ductions and versions bilateral. Bilateral reti
39、nas reveal normal color, contour, and cupping. Inspection of ears reveals no abnormalities. Otoscopic examination reveals no abnormalities. Examination of oropharynx reveals no abnormalities and tissues pink and moist. ENT: Inspection of ears reveals noabnormalities. Examination of larynx reveals no
40、 abnormalities. Inspection of nose reveals no abnormalities.Neck: Neck exam reveals neck supple and trachea that is midline, without adenopathy or crepitance palpable. Thyroid examination reveals no abnormalities and smooth and symmetric gland with no enlargement, tenderness or masses noted.Lymphati
41、c: Neck lymph nodes are normal.Respiratory: Assessment of respiratory effort reveals even respirations without use of accessory muscles and no intercostal retractions noted. Chest inspection reveals chest configuration non- hyperinflated and symmetric expansion. Auscultation of lungs reveals clear l
42、ung fields and no rubs noted.Cardiovascular: Heart auscultation reveals normal S1 and S2 and no murmurs, gallop, rubs or clicks. Examination of peripheral vascular system reveals full to palpation, varicosities absent, extremities warm to touch and no edema.Abdomen: Abdominal contour is slightly rou
43、nded. Abdomen soft, nontender, bowel sounds present x 4 without palpable masses. Palpation of liver reveals no abnormalities. Palpation of spleen reveals no abnormalities.Musculoskeletal: Gait and station examination reveals normal arm swing, with normal heel-toe and tandem walking. Inspection and p
44、alpation of bones, joints and muscles is unremarkable. Muscle strength is 5/5 for all groups tested. Muscle tone is normal.Neurologic/Psychiatric: Psychiatric: Oriented to person, place and time. Mood and affect normal and appropriate to situation. Testing of cranial nerves reveals no deficits. Coor
45、dination is good. Touch, pin, vibratory and proprioception sensations are normal. Deep tendon reflexes normal.Test & X-Ray Results: Rheumatoid factor: 52 U/ml. Sed rate: 31 mm/hr. C4 complement: 19mg/dl.Impression: Rheumatoid arthritis.Plan: ESR ordered; automated. Ordered RBC. Ordered quantitative
46、rheumatoid factor. Return to clinic in 2 week(s).Prescriptions:Vioxx Dosage: 12.5 mg tablet Sig: BID Dispense: 30 Refills: 2 Allow Generic: NoIf I may be of any further assistance in the care of your patient, please let me know. Thank you for providing me the opportunity to participate in the care of your patients.Sincerely,A. Rheumatologist, MD