The Eloquent Physician - a Medical Record Software Program. Sample Doctor’s Chart Note

HISTORY: (firstName) presents to the office today for a follow up visit concerning (his_her) {right | left} elbow symptomatology. {The patient denies any injuries subsequent to their previous visit. | The patient denies any injuries since their last visit. | The patient denies any injuries subsequent to their initial injury. | The patient notes that there was a new injury since their last visit to this office. {NEW INJURY LOCATION} {NEW INJURY SPECIFIC} | | The patient notes that there was an additional injury subsequent to their initial injury, but prior to today.} {The patient notes that there has been some modest improvement in their condition since the previous visit. | | The patient notes that there has been no improvement in their condition since the previous visit. | The patient notes that there has been no change in their condition since the previous visit. | The patient notes that there has been worsening in their condition since the previous visit. | There has been a complete resolution in the symptoms since the last visit.} {Chiropractic therapy has been continued since the last visit and has been found to be helpful. | Chiropractic therapy has been continued since the last visit but, unfortunately, has not been helpful. | Chiropractic therapy has been discontinued since the last visit. | Physical therapy continues to be undertaken, and has been helpful. | Physical therapy continues to be undertaken, but unfortunately has not been helpful. | Physical therapy has been discontinued since the last visit. | There is no therapy currently being performed. | The patient has been compliant with their therapy program. | The patient has been not been compliant with their therapy program. | The patient has continued therapy with some relief.} {Celebrex is being used, without difficulty, and with good results. | The patient will be changed to Mobic 7.5 mg 1 TAB PO QD. | Celebrex is being used, without difficulty, with fair results. | Vioxx is being used, without difficulty, with fair results. | Vioxx is being used, without difficulty, with good results. | Ibuprofen has been utilized with good results. | | Anti-inflammatory medications have been discontinued because of gastro-intestinal complications. | Anti-inflammatory medications have not been utilized because of a past history of gastro-intestinal difficulties. | | Advil | Aspirin | Accupril | Accutane | Adalat CC | Allegra | Augmentin | Axid | Azmacort | BuSpar | Calan SR | Cardizem CD | Cardura | Claritin D | Clozaril | Cordarone | Coumadin | Daypro | Depakote | Dilacor XR | Dilantin | Flonase | Fosamax | Glucophage | Humulin 70-30 | Humulin NPH | Hytrin | Imdur ER | Imitrex | K-Dur | Lamisil Oral | Lanoxin | Lescol | Lipitor | Lodine | Lotensin | Mevacor | Norvasc | Ortho-Novum | Oruvail | Paxil | Pepcid | Pravachol | Premarin | Prempro | Prevacid | Prilosec | Prinivil | Procardia XL | Propulsid | Prozac | Relafen | Rezulin | Risperdal | Serevent | Serzone | Sporanox | Synthroid | Ticlid | Toprol XL | Trental | Trtiphasil | Ultram | Vasotec | Zantac | Zestril | Ziac | Zocor | Zoloft | Zovirax | Zyprexa | Zyrtec} {The patient has been working. | The patient has been working at full duty. | The patient has been working at full duty, but is having problems with the current work load and needs new restrictions imposed. | The patient is not currently employed, but anticipates starting a new job in the near future. | The patient has been working at light duty, but feel ready to begin unrestricted duty after today's evaluation. | The patient has been working, but at a restricted duty. | The patient has not been working at all.} {No additional studies are available for today's visit. | The patient has had an MRI for the right shoulder, but the results are not yet available. | The patient has had an MRI for the left shoulder, but the results are not yet available. | The patient presents to the office today with an MRI of the cervical spine. The results show no evidence of frank disc herniation. | The patient presents to the office today with an MRI of the cervical spine. The results show evidence of frank disc herniation at the level of {C-SPINE HNP}. | The patient presents to the office today with an MRI of the lumbar spine. The results show evidence of frank disc herniation at the level of {HNP L-SPINE}. | The patient presents to the office today with the results of an EMG-NCS of the RUE. The results show evidence of carpal tunnel syndrome. | The patient presents to the office today with the results of an EMG-NCS of the LUE. The results show evidence of carpal tunnel syndrome. | The patient presents to the office today with the results of EMG-NCS of BUE. The results show evidence of carpal tunnel syndrome in both wrist. | The patient presents to the office today with the results of EMG-NCS of the RLE. The results show evidence of radiculopathy at the level of {HNP L-SPINE}. | The patient presents to the office today with the results of EMG-NCS of the LLE. The results show evidence of radiculopathy at the level of {HNP L-SPINE}. | An MRI is available for review during today's visit. | An MRI report is available for review during today's visit. | An EMG report is available for review during today's visit.} PHYSICAL EXAMINATION: { | The patient's left elbow range of motion is diminished in all planes of movement. | The patient's right elbow range of motion is diminished in all planes of movement. | The patient's right elbow range of motion is normal in all planes of movement. | The patient's left elbow range of motion is normal in all planes of movement. | The patient's right elbow range of motion is observed as follows: Right Elbow Extension: {RIGHT ELBOW EXTENSION} degrees. Right Elbow Flexion: {RIGHT ELBOW FLEXION} degrees. Right Elbow Supination: {R-ELBOW SUPINATION} degrees. Right Elbow Pronation | The patient's left elbow range of motion is observed as follows: Left Elbow Extension: {LEFT ELBOW EXTENSION} degrees. Left Elbow Flexion: {LEFT ELBOW FLEXION} degrees. Left Elbow Supination: {L-ELBOW SUPINATION} degrees. Left Elbow Pronation: {L-EL} {On palpation, the patient has tenderness over the left lateral epicondyle and pain with resistance to extension of the left wrist. | On palpation, the patient has tenderness over the right lateral epicondyle and pain with resistance to extension of the right wrist. | On palpation, the patient has tenderness over the right medial epicondyle and pain with resistance to flexion of the right wrist. | On palpation, the patient has tenderness over the left medial epicondyle and pain with resistance to flexion of the left wrist. | On palpation, the patient has tenderness over the left olecranon process and bursa. | On palpation, the patient has tenderness over the right olecranon process and bursa. | On palpation, the patient has tenderness over the right anticubital fossa. | On palpation, the patient has tenderness over the left anticubital fossa.} {There is no loss of motor strength in either upper extremity. | There is mild loss of motor strength in the right upper extremity. | There is mild loss of motor strength in the left upper extremity. | There is severe loss of motor strength in the right upper extremity. | There is severe loss of motor strength in the left upper extremity. | There is severe loss of motor strength in the right upper extremity with visible atrophy noted in the dorsal interosseous muscles and the thenar eminence. | There is severe loss of motor strength in the left upper extremity with visible atrophy noted in the dorsal interosseous muscles and the thenar eminence.} { | The reflexes in both upper extremities are equal. | There is a diminished brachioradialis reflex in the left upper extremity. | There is a diminished brachioradialis reflex in the right upper extremity. | There is a diminished finger jerk reflex in the right upper extremity. | There is a diminished finger jerk reflex in the left upper extremity. | There is evidence of a hyper-reflexive response in the right upper extremity. | There is evidence of a hyper-reflexive response in the left upper extremity. | There is evidence of a hyper-reflexive response in both upper extremities. | There is a diminished biceps reflex in the right upper extremity. | There is a diminished triceps reflex in the right upper extremity. | There is a diminished triceps reflex in the left upper extremity. | There is a diminished biceps reflex in the left upper extremity. | The patient's reflexes are observed to be non-responsive in both upper extremities.} {There is normal sensation in both upper extremities. | There is evidence of decreased sensation to light touch and pin prick along the median nerve distribution in the right upper extremity. | There is evidence of decreased sensation to light touch and pin prick along the median nerve distribution in the left upper extremity. | There is evidence of decreased sensation to light touch and pin prick along the median nerve distribution in the both upper extremities. | There is evidence of decreased sensation to light touch and pin prick along the ulnar nerve distribution in the both upper extremities. | There is evidence of decreased sensation to light touch and pin prick along the ulnar nerve distribution in the left upper extremity. | There is evidence of decreased sensation to light touch and pin prick along the ulnar nerve distribution in the right upper extremity. | There is diminished sensation in both upper extremities. | There is diminished sensation in the right upper extremity. | There is diminished sensation in the left upper extremity.} { | The vascular status of each upper extremity is within normal limits. | There is diminished vascularity of the right upper extremity. | There is diminished vascularity of the left upper extremity.} DIAGNOSIS: {Epicondylitis. | | Right Lateral Epicondylitis. | Left Lateral Epicondylitis. | Bilateral Lateral Epicondylitis. | Bilateral Medial Epicondylitis. | Right Medial Epicondylitis. | Left Medial Epicondylitis. | Left Radial Head Fracture. | Right Radial Head Fracture. | Right Olecranon Bursitis. | Left Olecranon Bursitis. | Left Capitelum Fracture. | Right Capitelum Fracture.} PLAN: {It is my recommendation that this patient continue the therapy and medication program currently in progress. | I would recommend that we add a therapy program to the treatment plan at this point in time. | I would recommend that we add anti-inflammatory medications to the treatment program now. | I would recommend that we obtain an EMG of the right upper extremity. | I would recommend that we obtain an EMG of the left upper extremity. | The patient has been instructed on a general conditioning program consisting focused exercises for the flexor and extensor muscles of the right forearm. | The patient has been instructed on a general conditioning program consisting focused exercises for the flexor and extensor muscles of the left forearm. | I have recommended that the patient receive a steroid injection into the right lateral epicondyle due to chronic tendonitis that has not responded to conservative modalities. | I have recommended that the patient receive a steroid injection into the left lateral epicondyle due to chronic tendonitis that has not responded to conservative modalities. | I have recommended that the patient receive a steroid injection into the left medial epicondyle due to chronic tendonitis that has not responded to conservative modalities. | I have recommended that the patient receive a steroid injection into the right medial epicondyle due to chronic tendonitis that has not responded to conservative modalities. | I have recommended that the patient receive a steroid injection into the right olecranon bursa due to chronic bursitis that has not responded to conservative modalities. | I have recommended that the patient receive a steroid injection into the left olecranon bursa due to chronic bursitis that has not responded to conservative modalities. | I have recommended that the patient be scheduled for an out-patient right lateral epicondylectomy due to unresponsive tendonitis in the right elbow. The risk profile has been discussed in detail and the patient has a clear understanding of the risk involv | I have recommended that the patient be scheduled for an out-patient left lateral epicondylectomy due to unresponsive tendonitis in the right elbow. The risk profile has been discussed in detail and the patient has a clear understanding of the risk involve} {I would recommend that there be no limitation in the work activities at this point in time. | I would recommend that this patient be maintained at a light duty work status. | I would recommend that this patient be maintained at a moderate duty work status. | I would recommend that this patient be maintained at a sedentary work status consisting of administrative type task only. | I would recommend that this patient be maintained at a sedentary work status. | Since this patient still has cervical symtomatology, I would recommend that they continue working, but only within their pain tolerance. | The patient is going to attempt a resumption of their current occupation with the understanding the an adjustment in work status may be required if the task prove to be difficult or painful. | I would recommend that the patient try to avoid repetitive flexion and extension of the right elbow until fully asymptomatic. | I would recommend that the patient try to avoid repetitive flexion and extension of the left elbow until fully asymptomatic.} {I have asked this patient to return to the office in 1 week. | I have asked this patient to return to the office in 2 weeks. | I have asked this patient to return to the office in 3 weeks. | I have asked this patient to return to the office in 4 weeks. | I have asked this patient to return to the office in 4 weeks, at which time the patient will likely be placed a MMI. | I have asked this patient to return to the office in 6 weeks. | I have asked this patient to return to the office in 8 weeks.} { | When the patient returns for their next evaluation, they will present with the MRI films for review. Further recommendations will be made at that time depending on the results. | I have asked the patient to keep a mental diary regarding their response to the previous trigger point injections. If the response has been favorable, then additional injections will be offered. | I have asked the patient to keep a mental diary regarding their response to the epidural steroid injections. If the response has been favorable, then additional injections will be offered. | When the patient returns for their next evaluation, treatment considerations will consist of trigger point injections, medicinal magnets, natural relief and diagnostic studies. | When the patient returns for their next evaluation, treatment considerations will consist of a surgical consult regarding chronic pain. | When the patient returns for their next evaluation, treatment considerations will consist of a physical medicine consult regarding chronic pain. | When the patient returns for their next evaluation, treatment considerations will consist of patient education regarding activities to avoid in the future.}