Sample Hospital Documentation

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Patient Name: Maria Turner
Patient ID: 123456
Date: October 8, 2050
Time: 10:00 AM
Attending Physician: [Your Name]
Department: Internal Medicine

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S: Subjective

• Chief Complaint: "I have been feeling increasingly fatigued and have a persistent cough."

• 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.

• Past Medical History: Hypertension, controlled.

• Medications: Lisinopril 10 mg daily.

• Allergies: No known drug allergies.

• Social History: Non-smoker, occasional alcohol use. Lives alone and works as an accountant.

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O: Objective

• Vital Signs:

  • Temperature: 98.6°F

  • Pulse: 82 bpm

  • Respiratory Rate: 18 breaths/min

  • Blood Pressure: 120/80 mmHg

• Physical Examination:

  • General: Alert and oriented, appears fatigued.

  • Respiratory: Clear to auscultation bilaterally, no wheezes or crackles.

  • Cardiovascular: Regular rate and rhythm, no murmurs.

  • Abdomen: Soft, non-tender, no organomegaly.

• Laboratory Results:

  • CBC: Mild leukocytosis

  • Chest X-ray: No acute infiltrates or effusions

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A: Assessment

1. Fatigue, likely related to viral illness (rule out COVID-19).

2. Persistent cough, likely due to post-viral irritation.

3. Hypertension is well-controlled.

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P: Plan

1. Labs: Order COVID-19 PCR test.

2. Medications: Recommend over-the-counter cough suppressants as needed.

3. Follow-up: Schedule a follow-up appointment in one week or sooner if symptoms worsen.

4. Education: Educate the patient on hydration, rest, and monitoring symptoms. Advise to seek immediate care if difficulty breathing or chest pain occurs.

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Signature:

[Your Name]
Date: October 8, 2050

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