Documentation / Electronic Health Record
Document: Provider Notes
Document: Provider Notes
Student Documentation Model
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Subjective
Patiet reports sore and itchy throat and runny
nose for 1 week Patient itchy eyes for 1 week.
Patient states blurred vision when reads, denies
wearing glasses or contacts. Patient states
throbbing headaches when studying; takes
Tylenol to treat headaches; denies any injury Pt
denies any change in weight, fatigue, weakness,
night sweats, chills, and fever Pt denies any
changes in hearing, dizziness, or ear pain Pt
states denies nasal congestion; states runny nose
with clear discharge pt denies any mouth
problems; pt denies any SOB, cough. PMH
asthma, treated with Proventil inhaler, used 2-3
times a week; last hospitalization for asthma at
16 yoa
HPI: Ms. Jones is a pleasant 28-year-old
African American woman who presented to the
clinic with complaints of sore, itchy throat,
itchy eyes, and runny nose for the last week.
She states that these symptoms started
spontaneously and have been constant in nature.
She does not note any specific aggravating
symptoms, but states that her throat pain seems
to be worse in the morning. She rates her throat
pain as 4/10 and her throat itchiness as 5/10.
She has treated her throat pain with occasional
throat lozenges which has “helped a little”. She
states that she has some soreness when
swallowing, but otherwise no other associated
symptoms. She states that her nose “runs all
day” and is clear discharge. She has not
attempted any treatment for her nasal
symptoms. She states that her eyes are
constantly itchy and she has not attempted any
eye specific treatment. She denies cough and
recent illness. She has had no exposures to sick
individuals. She denies changes in her hearing,
vision, and taste. She denies fevers, chills, and
night sweats. She has never been diagnosed
with seasonal allergies, but does note that her
sister has “hay fever”. Social History: She is not
aware of any environmental exposures or
irritants at her job or home. She changes her
sheets weekly and denies dust/mildew at her
home. She denies use of tobacco, alcohol, and
illicit drugs. She does not exercise. Review of
Systems: General: Denies changes in weight,
fatigue, weakness, fever, chills, and night
sweats. • Head: Denies history of trauma or
headaches. • Eyes: She does not wear corrective
lenses, but notes that her vision has been [Show Less]