Documentation / Electronic Health Record
• Document: Provider Notes
Document: Provider Notes
Student Documentation Model Documentation
Subjective HPI: Ms. Jones is a pleasant 28-year-old
African American woman who presented to
Patiet reports sore and itchy throat and runny the clinic with complaints of sore, itchy throat,
nose for 1 week Patient itchy eyes for 1 week. itchy eyes, and runny nose for the last week.
Patient states blurred vision when reads, denies She states that these symptoms started
wearing glasses or contacts. Patient states spontaneously and have been constant in nature.
throbbing headaches when studying; takes She does not note any specific aggravating
Tylenol to treat headaches; denies any injury symptoms, but states that her throat pain seems
Pt
denies any change in weight, fatigue, weakness, to be worse in the morning. She rates her throat
night sweats, chills, and fever Pt denies any pain as 4/10 and her throat itchiness as 5/10.
changes in hearing, dizziness, or ear pain Pt She has treated her throat pain with occasional
states denies nasal congestion; states runny nose throat lozenges which has “helped a little”. She
with clear discharge pt denies any mouth states that she has some soreness when
problems; pt denies any SOB, cough. PMH swallowing, but otherwise no other associated
asthma, treated with Proventil inhaler, used 2- symptoms. She states that her nose “runs all
3 times a week; last hospitalization for asthma day” and is clear discharge. She has not
at 16 yoa attempted any treatment for her nasal
symptoms. She states that her eyes are
constantly itchy and she has not attempted any
eye specific treatment. She denies cough and
recent illness. She has had no exposures to sick
individuals. She denies changes in her hearing,
vision, and taste. She denies fevers, chills, and
night sweats. She has never been diagnosed
with seasonal allergies, but does note that her
sister has “hay fever”. Social History: She is
not aware of any environmental exposures or
irritants at her job or home. She changes her
sheets weekly and denies dust/mildew at her
home. She denies use of tobacco, alcohol, and
illicit drugs. She does not exercise. Review of
Systems: General: Denies changes in weight,
fatigue, weakness, fever, chills, and night
sweats. • Head: Denies history of trauma or
headaches. • Eyes: She does not wear corrective
lenses, but notes that her vision has been
This study source was downloaded by 100000834430951 from CourseHero.com on 02-05-2022 11:54:15 GMT -06:00
https://www.coursehero.com/file/27874443/Tina-Jones-HEENT-EHR-documentationdocx/
• Document: Provider Notes
Document: Provider Notes
Student Documentation Model Documentation
Subjective HPI: Ms. Jones is a pleasant 28-year-old
African American woman who presented to
Patiet reports sore and itchy throat and runny the clinic with complaints of sore, itchy throat,
nose for 1 week Patient itchy eyes for 1 week. itchy eyes, and runny nose for the last week.
Patient states blurred vision when reads, denies She states that these symptoms started
wearing glasses or contacts. Patient states spontaneously and have been constant in nature.
throbbing headaches when studying; takes She does not note any specific aggravating
Tylenol to treat headaches; denies any injury symptoms, but states that her throat pain seems
Pt
denies any change in weight, fatigue, weakness, to be worse in the morning. She rates her throat
night sweats, chills, and fever Pt denies any pain as 4/10 and her throat itchiness as 5/10.
changes in hearing, dizziness, or ear pain Pt She has treated her throat pain with occasional
states denies nasal congestion; states runny nose throat lozenges which has “helped a little”. She
with clear discharge pt denies any mouth states that she has some soreness when
problems; pt denies any SOB, cough. PMH swallowing, but otherwise no other associated
asthma, treated with Proventil inhaler, used 2- symptoms. She states that her nose “runs all
3 times a week; last hospitalization for asthma day” and is clear discharge. She has not
at 16 yoa attempted any treatment for her nasal
symptoms. She states that her eyes are
constantly itchy and she has not attempted any
eye specific treatment. She denies cough and
recent illness. She has had no exposures to sick
individuals. She denies changes in her hearing,
vision, and taste. She denies fevers, chills, and
night sweats. She has never been diagnosed
with seasonal allergies, but does note that her
sister has “hay fever”. Social History: She is
not aware of any environmental exposures or
irritants at her job or home. She changes her
sheets weekly and denies dust/mildew at her
home. She denies use of tobacco, alcohol, and
illicit drugs. She does not exercise. Review of
Systems: General: Denies changes in weight,
fatigue, weakness, fever, chills, and night
sweats. • Head: Denies history of trauma or
headaches. • Eyes: She does not wear corrective
lenses, but notes that her vision has been
This study source was downloaded by 100000834430951 from CourseHero.com on 02-05-2022 11:54:15 GMT -06:00
https://www.coursehero.com/file/27874443/Tina-Jones-HEENT-EHR-documentationdocx/
