Document: Provider Notes
Student Documentation Model Documentation
Subjective Ms. Park reports that she is “having pain in her
belly.” She experienced mild diarrhea three days
Ms. Parks reports some abdominal discomfort
ago and has not had a bowel movement since.
and pain over the last week with increase in the
She reports that she has been feeling some
pain over the last 2-3 days. She rates her
abdominal discomfort for close to a week, but
abdominal pain at 6/1, describing it as "dull and
the pain has increased in the past 2-3 days. She
crampy" in left lower abdomen. She states she
now rates her pain at 6 out of 10, and describes
had a diarrhea 3 days ago and since than she had
it as dull and crampy. She reports her pain level
no bowel movement. She denies any abdominal
at the onset at 3 out of 10. She is also
pain radiation. She denies any rectal pain or
experiencing bloating. She did not feel her
bleeding, fever, nasuea, vaginal discharge or
symptoms warranted a trip to the clinic but her
discomfort, burning sensation or any other
daughter insisted she come. She describes her
urinary symptoms. She denies any past medical
symptoms primarily as generalized discomfort
or family history of GI problems. She states
in the abdomen, and states that her lower
haveingc-section and cholecystomy in early 40s.
abdomen is the location of the pain. She denies
She has had a decrease in appetite over the last
nausea and vomiting, blood or mucus in stool,
few days; states she drinks small amount of
rectal pain or bleeding, or recent fever. She
water and fluids. She denies taking any
denies vaginal bleeding or discharge. Reports no
medications for abdominal pain or constipation.
history of inflammatory bowel disease or
She states passing gass. The normal BM is
GERD. Denies family history of GI disorders.
Student Documentation Model Documentation
Subjective Ms. Park reports that she is “having pain in her
belly.” She experienced mild diarrhea three days
Ms. Parks reports some abdominal discomfort
ago and has not had a bowel movement since.
and pain over the last week with increase in the
She reports that she has been feeling some
pain over the last 2-3 days. She rates her
abdominal discomfort for close to a week, but
abdominal pain at 6/1, describing it as "dull and
the pain has increased in the past 2-3 days. She
crampy" in left lower abdomen. She states she
now rates her pain at 6 out of 10, and describes
had a diarrhea 3 days ago and since than she had
it as dull and crampy. She reports her pain level
no bowel movement. She denies any abdominal
at the onset at 3 out of 10. She is also
pain radiation. She denies any rectal pain or
experiencing bloating. She did not feel her
bleeding, fever, nasuea, vaginal discharge or
symptoms warranted a trip to the clinic but her
discomfort, burning sensation or any other
daughter insisted she come. She describes her
urinary symptoms. She denies any past medical
symptoms primarily as generalized discomfort
or family history of GI problems. She states
in the abdomen, and states that her lower
haveingc-section and cholecystomy in early 40s.
abdomen is the location of the pain. She denies
She has had a decrease in appetite over the last
nausea and vomiting, blood or mucus in stool,
few days; states she drinks small amount of
rectal pain or bleeding, or recent fever. She
water and fluids. She denies taking any
denies vaginal bleeding or discharge. Reports no
medications for abdominal pain or constipation.
history of inflammatory bowel disease or
She states passing gass. The normal BM is
GERD. Denies family history of GI disorders.
