Document: Provider Notes
Student Documentation Model Documentation
Subjective Ms. Park reports that she is “having pain in her
belly.” She experienced mild diarrhea three
Ms. Parks reports some abdominal discomfort days ago and has not had a bowel movement
and pain over the last week with increase in the since. She reports that she has been feeling
pain over the last 2-3 days. She rates her some abdominal discomfort for close to a week,
abdominal pain at 6/1, describing it as "dull and but the pain has increased in the past 2-3 days.
crampy" in left lower abdomen. She states she She now rates her pain at 6 out of 10, and
had a diarrhea 3 days ago and since than she describes it as dull and crampy. She reports her
had no bowel movement. She denies any pain level at the onset at 3 out of 10. She is also
abdominal pain radiation. She denies any rectal experiencing bloating. She did not feel her
pain or bleeding, fever, nasuea, vaginal symptoms warranted a trip to the clinic but her
discharge or discomfort, burning sensation or daughter insisted she come. She describes her
any other urinary symptoms. She denies any symptoms primarily as generalized discomfort
past medical or family history of GI problems. in the abdomen, and states that her lower
She states haveing c-section and cholecystomy abdomen is the location of the pain. She denies
in early 40s. She has had a decrease in appetite nausea and vomiting, blood or mucus in stool,
over the last few days; states she drinks small rectal pain or bleeding, or recent fever. She
amount of water and fluids. She denies taking denies vaginal bleeding or discharge. Reports
any medications for abdominal pain or no history of inflammatory bowel disease or
constipation. She states passing gass. The GERD. Denies family history of GI disorders.
normal BM is regular, soft and brown in color, Her appetite has decreased over the last few
every 1-2 days with no other problems. Ms. days and she is taking small amounts of water
Parks lives with daughter. Daughter does the and fluids. Previously she reports regular brown
shopping and Ms.Parks cooks herself soft stools every day to every other day.
Objective • General Survey: Uncomfortable and flushed
appearing elderly woman seated on exam table
Elderly womes sitting up in the exam with grimacing at times. Appears stable but mildly
grimace at the time of discomfort. Appears a distressed. • HEENT: Mucus membranes are
liitle bit distressed but stable, able to answer all moist. Normal skin turgor; no tenting. •
inquiries and is goog historian. HEENT: nose Cardiovascular: S1, S2, no murmurs, gallops or
and mouth with moist pink mucouse rubs; no S3, S4 rubs. No lower extremity
membranes, normal skin turgor with no tenting. edema. • Respiratory: Respirations quiet and
Cardio: S1, S2, no gallops, rubs, or murmurs unlabored, able to speak in full sentences.
noted. No edema to lower extremities. Breath sounds clear to auscultation. •
Respiratory: respiration unlabored and quiet, Abdominal: 6 cm scar in RUQ and 10 cm scar
abel to speak full sentences with no SOB. Lung at midline in suprapubic region. An abdominal
breath sounds CTA in all lobes. Abdominal: 10 exam reveals no discoloration; normoactive
cm scar at midline in suprapubic region and 6 bowel sounds in all quadrants; no bruits; no
cm scar in RUQ, Exam reveals no discoloration, friction sounds over spleen or liver; tympany
bowel sounds WNL in all quadrants; no friction presides with scattered dullness over LLQ;
sounds over spleen or liver, no bruits in any abdomen soft in all quadrants; an oblong mass
areas; tympany presides; Liver span at 7 cm; is noted in the LLQ with mild guarding,
Guarding to light touch at LLQ; 2x4 mass in distension; no organomegaly; no CVA
Student Documentation Model Documentation
Subjective Ms. Park reports that she is “having pain in her
belly.” She experienced mild diarrhea three
Ms. Parks reports some abdominal discomfort days ago and has not had a bowel movement
and pain over the last week with increase in the since. She reports that she has been feeling
pain over the last 2-3 days. She rates her some abdominal discomfort for close to a week,
abdominal pain at 6/1, describing it as "dull and but the pain has increased in the past 2-3 days.
crampy" in left lower abdomen. She states she She now rates her pain at 6 out of 10, and
had a diarrhea 3 days ago and since than she describes it as dull and crampy. She reports her
had no bowel movement. She denies any pain level at the onset at 3 out of 10. She is also
abdominal pain radiation. She denies any rectal experiencing bloating. She did not feel her
pain or bleeding, fever, nasuea, vaginal symptoms warranted a trip to the clinic but her
discharge or discomfort, burning sensation or daughter insisted she come. She describes her
any other urinary symptoms. She denies any symptoms primarily as generalized discomfort
past medical or family history of GI problems. in the abdomen, and states that her lower
She states haveing c-section and cholecystomy abdomen is the location of the pain. She denies
in early 40s. She has had a decrease in appetite nausea and vomiting, blood or mucus in stool,
over the last few days; states she drinks small rectal pain or bleeding, or recent fever. She
amount of water and fluids. She denies taking denies vaginal bleeding or discharge. Reports
any medications for abdominal pain or no history of inflammatory bowel disease or
constipation. She states passing gass. The GERD. Denies family history of GI disorders.
normal BM is regular, soft and brown in color, Her appetite has decreased over the last few
every 1-2 days with no other problems. Ms. days and she is taking small amounts of water
Parks lives with daughter. Daughter does the and fluids. Previously she reports regular brown
shopping and Ms.Parks cooks herself soft stools every day to every other day.
Objective • General Survey: Uncomfortable and flushed
appearing elderly woman seated on exam table
Elderly womes sitting up in the exam with grimacing at times. Appears stable but mildly
grimace at the time of discomfort. Appears a distressed. • HEENT: Mucus membranes are
liitle bit distressed but stable, able to answer all moist. Normal skin turgor; no tenting. •
inquiries and is goog historian. HEENT: nose Cardiovascular: S1, S2, no murmurs, gallops or
and mouth with moist pink mucouse rubs; no S3, S4 rubs. No lower extremity
membranes, normal skin turgor with no tenting. edema. • Respiratory: Respirations quiet and
Cardio: S1, S2, no gallops, rubs, or murmurs unlabored, able to speak in full sentences.
noted. No edema to lower extremities. Breath sounds clear to auscultation. •
Respiratory: respiration unlabored and quiet, Abdominal: 6 cm scar in RUQ and 10 cm scar
abel to speak full sentences with no SOB. Lung at midline in suprapubic region. An abdominal
breath sounds CTA in all lobes. Abdominal: 10 exam reveals no discoloration; normoactive
cm scar at midline in suprapubic region and 6 bowel sounds in all quadrants; no bruits; no
cm scar in RUQ, Exam reveals no discoloration, friction sounds over spleen or liver; tympany
bowel sounds WNL in all quadrants; no friction presides with scattered dullness over LLQ;
sounds over spleen or liver, no bruits in any abdomen soft in all quadrants; an oblong mass
areas; tympany presides; Liver span at 7 cm; is noted in the LLQ with mild guarding,
Guarding to light touch at LLQ; 2x4 mass in distension; no organomegaly; no CVA
