chart 148

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University of Notre Dame *

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Medicine

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Dec 6, 2023

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docx

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Medical Transcription Services Virtual Scribe Services Medical Coding Services Chart Readiness – Template for Practice SOAP Notes 1. Chart #: 148 2. Chief Complaint(s): Discomfort in Throat 3. History of Present Illness: (Remember to use full sentences, check grammar/spelling, use proper medical terminology and medical phrasing.) Patient is a 50-year-old male presenting on 11/27/2018 with complaints of discomfort in left side of throat for 7-10 days. Patient reports no left ear pain (otalgia) as well. Patient reports feeling moderately better than first day. Patient reports no runny nose (rhinorrhea) Patient says that the discomfort feels like “an open wound in his throat”.

Medical Transcription Services Virtual Scribe Services Medical Coding Services 4. Review of Systems: HEENT: Positive throat pain, positive left throat swelling, positive left ear otalgia, negative rhinorrhea 5. Past Medical History: (If verbalized during encounter.) 6. Past Surgical History: (If verbalized during encounter.) 7. Social History: (If verbalized during encounter.)

Medical Transcription Services Virtual Scribe Services Medical Coding Services 8. Family History: (If verbalized during encounter.) 9. Diagnostic Data Discussed: (Lab work, imaging, EKG, etc. Anything discussed during today’s visit.) 10. Physical Examination No masses or associated nodes. Slight pharyngeal erythema No exudates No adenopathy TMs are mobile and translucent

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