Patient Chart

Patient ID: VT day 7-1

Progress Notes
Subjective:

Chief Complaint:

Chest pain

History of Present Illness:

A male patient came to the clinic with a chief complaint of chest pain.

EVENT 1
The patient said it started last night when he woke up at 12 midnight to a severe chest
pain.
The patient stated that the pain is in the middle of his chest.
The patient thought it was a heart attack because his brother had a heart attack a few
years ago.
EVENT 2
The patient claimed that following his episode at midnight he got up, drank some milk
and relaxed before recovering after 30 minutes. At 2 in the morning, the patient
experienced a second attack that lasted for 30 minutes.
The patient said the pain was in the middle of his chest and moved to his left shoulder
but doesn’t move to his neck and jaw.
The patient stated that the pain lasted for 30 minutes.
The patient described the pain as sharp and as if somebody was sitting on his chest.
The patient took Gaviscon to help ease the pain but it didn’t help.
The patient claimed feeling sick at the time of the attack, felt sweaty and felt his heart
racing.
The patient denied having cough, coughing blood, dizziness or pain in the back of leg.

Past History:
Medical History:

High Blood Pressure

Surgical History:

Family History:

Dad- died of heart attack when he was 50 years old

Brother- had a heart attack when he was 48 years old

Social History:

Live with wife who suffers from arthritis

Alcohol- 4 pints on the weekends
Works as a tool cutter

Smoking History:

Smoker for 20- 30 years

Used to smoke 40 a day but cut off to 20 a day now

Allergies:

No known allergies

Current Medications:

Gaviscon
Blood pressure tablets

Review of Systems:
Constitutional: + felt sweaty
Head:

Neck:

Eyes:
Ears:

Nose:

Mouth:

Throat:

Cardiovascular: + racing of the heart , dizziness, chest pain

Respiratory: - cough, coughing blood

Gastrointestinal: + sick
 Genitourinary:

Musculoskeletal: - pain in the leg or back

Integumentary (skin and/or breast):

Neurological: - dizziness

Psychiatric:

Endocrine:

Hematologic/Lymphatic:

Allergic/Immunologic:

Objective:

Vital Signs:
Height: Weight: BMI Interp: Systolic 140 Diastolic 98

Pulse (beats/min): 88 bpm regular

Physical Examination:

Constitutional:

EENT:

NECK:

Respiratory: saturation- 96% on air

CARDIO:

Lungs:

Chest/Breast: clear

Heart:

Gastrointestinal/ABDOMEN:

Genitourinary:

Lymphatic:
Musculoskeletal

 Knee exam-
 Shoulder exam
 Hand exam
 Elbow exam:
 Hip exam
 Lower back exam -

SKIN:

EXTREMITIES: calves- soft and non tender

Neurologic/Psychiatric:
 Cranial Nerves
 Sensory and Motor Exams
 Reflex testing-
 Coordination
 Gait testing

Test Result Exams:

ECG: Normal Sinus rhythms

EKG reading:
Rate:
Rhythm:
Axis:
Ectopy:
Conduction:
P wave:
Q wave:
ST-T wave changes:
Comparison:
Impression:
Image:

Labs:
 Hemoglobin

Assessment & Plan:

Diagnosis Codes:

ICD Type:

ICD 10

ICD 10 Codes

Select Codes:

A (1 Start typing code or G(7) Start typing code or

description description

Assessment Notes Assessment

Notes

B (2) Start typing code or H (8) Start typing code or

description description

Assessment Notes Assessment

Notes

C (3) Start typing code or I (9) Start typing code or

description description

Assessment Notes Assessment

Notes

Reviewed:

Procedures:

E/M Code Builder Superbill

CPT Description POS Modifier ICD-10 Line Days NDC
Pointer Charges or
Units

A B C D

Plan Notes:
  To refer the patient to a hospital and run some tests
 To call medical team at a hospital and refer the patient to make the process
easier for the patient

Patient Instructions/Follow Up:

 Advised the patient to visit a hospital for several testing; given his family's
history of heart attacks, the patient must undergo particular tests pertaining to
his heart.
 The patient was advised to visit a hospital today.
 Suggested that the patient call for assistance with caring for his wife.
 Advised the patient to avoid operating a vehicle when he visits the hospital in
case he has a heart attack there.

Patient Chart

Patient ID: VT day 7-2

Progress Notes
Subjective:

Chief Complaint:

Weakness of the left arm and leg

History of Present Illness:

A male patient came to the clinic with a chief complaint of weakness of the left arm
and leg.

The patient claimed that when he woke up this morning four hours prior, he noticed
the weakness in his arm and leg.

The patient experienced weakness in the left arm and left leg.

The patient said it lasted for 30 minutes.

The patient said it prevented him from getting up.

The patient felt his heart racing at the time he felt weakness of his arms and legs.
The patient denied having weakness in the face, talking problems or vision
problems.

Past History:

Medical History:

Diabetes
Hypertension

Surgical History:

Family History:

Social History:

The patient claimed he is adopted

Lives with his wife at home
Retired teacher
Alcohol-a glass of wine on the weekends

Smoking History:

Smoker for 20 years

Quit smoking 3 years ago

Allergies:

No known allergies

Current Medications:

Two tablets for Diabetes

Two tablets for Hypertension

Review of Systems:
Constitutional:

Head:

Neck:

Eyes: -vision problems

 Ears:

Nose:

Mouth: - talking problems

Throat:

Cardiovascular: + heart racing

Respiratory:

Gastrointestinal:

Genitourinary:

Musculoskeletal: + weakness of the left arm and left leg

- weakness of the face

Integumentary (skin and/or breast):

Neurological:

Psychiatric:

Endocrine:

Hematologic/Lymphatic:

Allergic/Immunologic:

Objective:

Vital Signs:

Height: Weight: BMI Interp: Systolic: 145 Diastolic:96

Pulse (beats/min): 84 bpm

Physical Examination:

Constitutional:

EENT:

NECK:

Respiratory:

CARDIO:

Lungs:

Chest/Breast:
Heart: I+II+0

Gastrointestinal/ABDOMEN:

Genitourinary:

Lymphatic:

Musculoskeletal

 Knee exam-
 Shoulder exam
 Hand exam
 Elbow exam:
 Hip exam
 Lower back exam -

SKIN:

EXTREMITIES:

Neurologic/Psychiatric: Limb neuro- normal

 Cranial Nerves- normal
 Sensory and Motor Exams
 Reflex testing-
 Coordination
 Gait testing

Test Result Exams:

ECG:

EKG reading:
Rate:
Rhythm:
Axis:
Ectopy:
Conduction:
P wave:
Q wave:
ST-T wave changes:
 Comparison:
Impression:
Image:

Labs:

Assessment & Plan:

Diagnosis Codes:

ICD Type:

ICD 10

ICD 10 Codes

Select Codes:

A (1 Start typing code or G(7) Start typing code or

description description

Assessment Notes Assessment

Notes

B (2) Start typing code or H (8) Start typing code or

description description

Assessment Notes Assessment

Notes

C (3) Start typing code or I (9) Start typing code or

description description

Assessment Notes Assessment

Notes

Reviewed:

Procedures:

E/M Code Builder Superbill

CPT Description POS Modifier ICD-10 Line Days NDC
Pointer Charges or
Units
 A B C D

Plan Notes:

 To prescribe Aspirin
 To call hospital and arrange appointment for patient
 To print out information about mini strokes for the patient to take home and
read

Patient Instructions/Follow Up:

 Informed the patient that his symptoms were consistent with mini stroke. The
weakness in the arms and legs are caused by temporary cessation of the
blood supply of the brain,
 Suggested that the patient see a hospital today.
 Suggested the patient refrain from driving for a month out of caution
 To follow up next week with the test findings

Patient Chart

Patient ID: VT Day 7-3

Progress Notes
Subjective:

Chief Complaint:

Chest pain

History of Present Illness:

The patient stated that he experienced pressure in the middle of his chest last night at
around 9 p.m.

The patient said the pain was in the middle of his chest and went through his left
shoulder. The pain does not go down in his arm, neck, or back.
The patient said the pain was constant.

The patient described the pain as an on-and-off ache.

The patient said the pain lessened when Oxygen was introduced to him in the
ambulance on his way to the clinic. The patient also said the pain is relieved when he
sits down and rests.

The patient said the pain worsens when he walks and coughs.

The patient stated that the pain usually lasts for a couple of minutes and sometimes
hours.

The patient described the pain as 8/10 on the pain scale.

The patient claimed to have had shortness of breath since last night, a nonproductive
cough, and pain in the left shoulder accompanied by chest pain.

The patient denied having fever, chills, pain and swelling in the legs, nausea,
lightheadedness, an irregular heart beat, headache, diarrhea, trouble urinating,
abdominal pain, or indigestion.

Past History:

Medical History:

High blood pressure

Surgical History:

Family History:

Dad- experienced heart attack at the age of 65

Mom- blood clot in the legs

Social History:

No recent trips abroad or domestic

Does not take illicit drugs
Alcohol- 2 drinks
Works at a grocery store stocking shelves

Smoking History:
 Allergies:

Current Medications:

Review of Systems:
Constitutional: - fever, chills,

Head:

Neck:

Eyes:

Ears:

Nose:

Mouth:

Throat:

Cardiovascular: + chest pain

- Light headedness, irregular heartbeat

Respiratory: + shortness of breath, non-productive cough

Gastrointestinal: - nausea, diarrhea, indigestion, abdominal pain

Genitourinary: - trouble urinating

Musculoskeletal: + pain in the left shoulder

- pain and swelling in the legs

Integumentary (skin and/or breast):

Neurological: - light headedness, headache

Psychiatric:

Endocrine:

Hematologic/Lymphatic:

Allergic/Immunologic:

Objective:

Vital Signs:

Height: Weight: BMI Interp: Systolic: Diastolic:

Pulse (beats/min):

Physical Examination:

Constitutional:

EENT:

NECK: no vein distention

Respiratory: wheezing and crackles at left phase

CARDIO:

Lungs:

Chest/Breast:

Heart: A- normal

Gastrointestinal/ABDOMEN: P- non tender

Genitourinary:

Lymphatic:

Musculoskeletal

 Knee exam-
 Shoulder exam
 Hand exam
 Elbow exam:
 Hip exam
 Lower back exam -

SKIN:

EXTREMITIES: no swelling, tenderness or redness

Neurologic/Psychiatric:
 Cranial Nerves
 Sensory and Motor Exams
 Reflex testing-
 Coordination
 Gait testing
 Test Result Exams:

ECG:

EKG reading:
Rate:
Rhythm:
Axis:
Ectopy:
Conduction:
P wave:
Q wave:
ST-T wave changes:
Comparison:
Impression:
Image:

Labs:

Assessment & Plan:

Diagnosis Codes:

ICD Type:

ICD 10

ICD 10 Codes

Select Codes:

A (1 Start typing code or G(7) Start typing code or

description description

Assessment Notes Assessment

Notes

B (2) Start typing code or H (8) Start typing code or

description description

Assessment Notes Assessment

Notes

C (3) Start typing code or I (9) Start typing code or

description description
 Assessment Notes Assessment
Notes

Reviewed:

Procedures:

E/M Code Builder Superbill

CPT Description POS Modifier ICD-10 Line Days NDC
Pointer Charges or
Units

A B C D

Plan Notes:

 To order cardiogram, chest-xray, some blood tests for the heart

 To introduce nitro glycerin to reduce pain
 To come back and discuss results with the patient

Patient Instructions/Follow Up:

 Instructed the patient to wait for probably 1 hour for the results to come
 Advised the patient that if cardiogram results are out, doctor will come back
immediately to discuss results

Patient Chart

Patient ID: VT day 7-4

Progress Notes
Subjective:

Chief Complaint:

Chest pain
History of Present Illness:

A male patient came to the clinic with a chief complaint of chest pain.

EVENT 1

The patient said the chest pain started 6 weeks ago when he was in the gym pressing
weights.

The patient stated the pain was in the middle of his chest. The pain did not move to
his neck or back.

The patient described the pain as achy.

The patient took some Neurofen and relieved the pain after 20 mins.

The patient denied having sweats at the time of the chest pain or being sick.

EVENT 2

2-3 days after he first experience the chest pain, he felt an achy pain again.

The patient described the pain as achy kind of pain.

The patient took some pain killers.

The patient claimed having shortness of breath.

The patient denied being sick or has vomited.

EVENT 3

The patient said the most recent time he felt the pain was last night. When he was
laying in bed and the pain came out of nowhere.

The patient described the pain similar to a heart burn.

The patient took Gaviscon.

The patient denied having bowel problems, appetite problems, sickness or vomiting.

The patient said it doesn’t directly affect his life as he can work well but he is reluctant
to play football or can’t exercise.
The patient worried about the chest pain might affect his heart since he is
experiencing heart burns recently.

Past History:

Medical History:

heart burns related to stress 3 years ago

Surgical History:

Family History:

Dad and uncle had heart problems in their early to mid fifties.
Mom-diabetes

Social History:

Alcohol- 5-10 glasses of wine and few beers a week.

Goes to the gym
Plays football
Works in the property estate

Smoking History:

Non-smoker

Allergies:

Current Medications:

No current medications

Review of Systems:
Constitutional: -heavy sweats

Head:

Neck:

Eyes:

Ears:

Nose:

Mouth:

Throat:
 Cardiovascular: +chest pain

Respiratory: + shortness of breath

Gastrointestinal: -feeling sick, vomitting, bowel problems, appetite problems

Genitourinary:

Musculoskeletal:

Integumentary (skin and/or breast):

Neurological:

Psychiatric:

Endocrine:

Hematologic/Lymphatic:

Allergic/Immunologic:

Objective:

Vital Signs:

Height: Weight: BMI Interp: Systolic: 155 Diastolic: 92

Pulse (beats/min): 80 bpm regular

Physical Examination:

Constitutional:

EENT:

NECK:

Respiratory:

CARDIO:

Lungs:

Chest/Breast:

Heart: 1+2+nil

Gastrointestinal/ABDOMEN: mild epigastric tenderness no guarding no masses

Genitourinary:
Lymphatic:

Musculoskeletal

 Knee exam-
 Shoulder exam
 Hand exam
 Elbow exam:
 Hip exam
 Lower back exam -

SKIN:

EXTREMITIES:

Neurologic/Psychiatric:
 Cranial Nerves
 Sensory and Motor Exams
 Reflex testing-
 Coordination
 Gait testing

Test Result Exams:

ECG:

EKG reading:
Rate:
Rhythm:
Axis:
Ectopy:
Conduction:
P wave:
Q wave:
ST-T wave changes:
Comparison:
Impression:
Image:

Labs:
Assessment & Plan:
Diagnosis Codes:

ICD Type:

ICD 10

ICD 10 Codes

Select Codes:

A (1 Start typing code or G(7) Start typing code or

description description

Assessment Notes Assessment

Notes

B (2) Start typing code or H (8) Start typing code or

description description

Assessment Notes Assessment

Notes

C (3) Start typing code or I (9) Start typing code or

description description

Assessment Notes Assessment

Notes

Reviewed:

Procedures:

E/M Code Builder Superbill

CPT Description POS Modifier ICD-10 Line Days NDC
Pointer Charges or
Units

A B C D

Plan Notes:
 

Patient Instructions/Follow Up:

Patient Chart

Patient ID:

Progress Notes
Subjective:

Chief Complaint:

History of Present Illness:

Past History:

Medical History:

Surgical History:

Family History:

Social History:

Smoking History:

Allergies:
 Current Medications:

Review of Systems:
Constitutional:

Head:

Neck:

Eyes:

Ears:

Nose:

Mouth:

Throat:

Cardiovascular:

Respiratory:

Gastrointestinal:

Genitourinary:

Musculoskeletal:

Integumentary (skin and/or breast):

Neurological:

Psychiatric:

Endocrine:

Hematologic/Lymphatic:

Allergic/Immunologic:

Objective:

Vital Signs:

Height: Weight: BMI Interp: Systolic: Diastolic:

Pulse (beats/min):

Physical Examination:

Constitutional:
EENT:

NECK:

Respiratory:

CARDIO:

Lungs:

Chest/Breast:

Heart:

Gastrointestinal/ABDOMEN:

Genitourinary:

Lymphatic:

Musculoskeletal

 Knee exam-
 Shoulder exam
 Hand exam
 Elbow exam:
 Hip exam
 Lower back exam -

SKIN:

EXTREMITIES:

Neurologic/Psychiatric:
 Cranial Nerves
 Sensory and Motor Exams
 Reflex testing-
 Coordination
 Gait testing

Test Result Exams:

ECG:

EKG reading:
 Rate:
Rhythm:
Axis:
Ectopy:
Conduction:
P wave:
Q wave:
ST-T wave changes:
Comparison:
Impression:
Image:

Labs:

Assessment & Plan:

Diagnosis Codes:

ICD Type:

ICD 10

ICD 10 Codes

Select Codes:

A (1 Start typing code or G(7) Start typing code or

description description

Assessment Notes Assessment

Notes

B (2) Start typing code or H (8) Start typing code or

description description

Assessment Notes Assessment

Notes

C (3) Start typing code or I (9) Start typing code or

description description

Assessment Notes Assessment

Notes

Reviewed:
Procedures:

E/M Code Builder Superbill

CPT Description POS Modifier ICD-10 Line Days NDC
Pointer Charges or
Units

A B C D

Plan Notes:

Patient Instructions/Follow Up: