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Medical Transcription Services Virtual Scribe Services Medical Coding Services Chart Readiness – Template for Practice SOAP Notes 1. Chart #: 142 2. Chief Complaint(s): 3. History of Present Illness: (Remember to use full sentences, check grammar/spelling, use proper medical terminology and medical phrasing.) Patient is a 53-year-old female presenting on 12/10/18 for Last visit was almost 2 years ago PMHX: Coronary disease, Atherosclerotic disease, Angina which started in mid 2000s, stint in 2006, and again in 2014, patient denies any symptoms of angina in the past 4 years. Patient was previously a smoker, has cut down now but occasionally smokes (once a week) when stressed. Patient is working to try and control and work towards weight loss over the years Denies dizziness, heart palpations, shortness of breath, nausea, Patient walks 3 miles a day 5 days a week (45 minutes) Patient reports working 85 hours a week, gets approximately 3 hours of sleep a night. Pskc9 to combat cholesterol issues Blood work was done in august 2018 (tc 70, tri 158, hdl 38, ldl 16) and previously in January 2018 (tc 119, tri 150, hgl 46, ldl 53, patient reports conditions worsened due to eating habits

Medical Transcription Services Virtual Scribe Services Medical Coding Services (not able to eat foods like potato chips, red meat, etc. because of her teeth). Patient denies feeling malnourished. Positive weight loss PE: 1/6 holosystolic murmur at left sternal border, belly is corpulent, EKG (12 lead trading revealed PVC, sinus rhythm 91 bpm, 1 pvc: borderline right access, and Recheck chemistry panel CAD: Asymptomatic, a 4. Review of Systems: * Copy/paste the below ROS into your answer and remove/add as necessary. Please only include pertinent findings. Constitutional: Negative chills, fever, fatigue HENT: Negative sore throat, congestion, otalgia Eyes: Negative blurred vision, eye pain/discharge/redness Respiratory: Negative cough, sputum production, dyspnea, wheezing, hemoptysis CV: Negative chest pain, DOE, orthopnea GI: Negative abd pain, N/V/D, constipation, hematochezia, melena, heartburn GU: Negative pelvic pain, dysuria, hematuria, frequency, nocturia MS: Negative back pain, joint pain, myalgia, limited ROM Integumentary: Negative rash, erythema, pruritus, abrasion, laceration, postoperative site Neurological: Negative headache, dizziness, paresthesia, speech change Psychological: Negative anxiety, depression, suicidal/homicidal ideation, insomnia Endocrine: Negative heat/cold intolerance, hair loss, significant weight gain/loss, polyuria, polydipsia Hematologic/Lymphatic: Negative easy bleeding, ecchymosis, lymphadenopathy

Medical Transcription Services Virtual Scribe Services Medical Coding Services 5. Past Medical History: (If verbalized during encounter.) 6. Past Surgical History: (If verbalized during encounter.) 7. Social History: (If verbalized during encounter.)

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