Sample Hospital Documentation
Sample Hospital Documentation
Patient Name: Maria Turner
Patient ID: 123456
Date: October 8, 2050
Time: 10:00 AM
Attending Physician: [Your Name]
Department: Internal Medicine
S: Subjective
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Chief Complaint: "I have been feeling increasingly fatigued and have a persistent cough."
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History of Present Illness: The patient reports fatigue for the past two weeks, which has worsened. He also has a dry cough that has persisted for one week. Denies any chest pain or difficulty breathing. No recent travel history or known exposure to infectious diseases.
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Past Medical History: Hypertension, controlled.
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Medications: Lisinopril 10 mg daily.
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Allergies: No known drug allergies.
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Social History: Non-smoker, occasional alcohol use. Lives alone and works as an accountant.
O: Objective
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Vital Signs:
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Temperature: 98.6°F
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Pulse: 82 bpm
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Respiratory Rate: 18 breaths/min
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Blood Pressure: 120/80 mmHg
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Physical Examination:
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General: Alert and oriented, appears fatigued.
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Respiratory: Clear to auscultation bilaterally, no wheezes or crackles.
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Cardiovascular: Regular rate and rhythm, no murmurs.
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Abdomen: Soft, non-tender, no organomegaly.
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Laboratory Results:
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CBC: Mild leukocytosis
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Chest X-ray: No acute infiltrates or effusions
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A: Assessment
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Fatigue, likely related to viral illness (rule out COVID-19).
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Persistent cough, likely due to post-viral irritation.
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Hypertension is well-controlled.
P: Plan
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Labs: Order COVID-19 PCR test.
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Medications: Recommend over-the-counter cough suppressants as needed.
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Follow-up: Schedule a follow-up appointment in one week or sooner if symptoms worsen.
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Education: Educate the patient on hydration, rest, and monitoring symptoms. Advise to seek immediate care if difficulty breathing or chest pain occurs.
Signature:
[Your Name]
Date: October 8, 2050
