English for hospital administration: medical record cryptograph

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Patient's Initial Assessment Report: Example 2

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Patient Initial Assessment Report Patient Information: Name: Maria Gonzalez Age: 38 Gender: Female Date of Birth: October 22, 1985 Contact Number: (555) 987-6543 Address: 456 Oak Avenue, Lincoln, NE 68508 Referral Source: Referring Physician: Dr. Robert Lee Reason for Referral: Evaluation of recurring headaches and dizziness Presenting Complaint: Chief Complaint: Severe headaches and episodes of dizziness occurring over the past month Description of Headaches: Throbbing pain primarily on the right side of the head, associated with nausea and sensitivity to light Medical History: Past Medical History: Migraine headaches (diagnosed 5 years ago) Asthma (diagnosed in childhood, well-controlled) Surgical History: No significant surgical history Allergies: Penicillin (rash) Medications: Ibuprofen 400 mg as needed for headaches Albuterol inhaler as needed for asthma Family History: Father: Age 65 - Hypertension, history of stroke Mother: Age 63 - Type 2 Diabetes Mellitus, osteoarthr
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Medical Report: Progress Note 1

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Patient Name: Emily Carter Date: September 9, 2024 Provider: Dr. Michael Lewis Visit Type: Follow-up Chief Complaint: Follow-up for management of asthma and recent exacerbation. Subjective: Patient reports improvement in asthma symptoms since starting new inhaler. However, occasional wheezing at night persists. Objective: Vital Signs: Blood Pressure: 118/76 mmHg Heart Rate: 80 bpm Respiratory Rate: 16 bpm Temperature: 98.2°F (36.8°C) Respiratory Exam: Breath sounds clear bilaterally, occasional wheezing noted in the right lower lung field. Medication Adherence: Adheres to new inhaler regimen but reports occasional missed doses. Assessment: Asthma symptoms partially controlled with current medication. Persistent nocturnal wheezing may indicate suboptimal control. Plan: Continue current inhaler therapy. Increase the frequency of the use of the inhaled corticosteroid. Educate patient on proper inhaler technique and the importance of regular use. Schedule follow-up appointment in 4 wee
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Medical Report: Patient History and Physical Report (H&P)

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  Patient Name: Robert Jenkins Date: September 9, 2024 Provider: Dr. Laura Mitchell Chief Complaint: New onset of abdominal pain. History of Present Illness: 48-year-old male presenting with severe abdominal pain for the past 3 days. Pain is diffuse, with occasional sharp episodes. No recent changes in bowel habits. Past Medical History: History of gastritis No prior surgeries Medications: Omeprazole 20 mg daily Family History: Father: Deceased (age 70) - History of colon cancer Mother: Age 72 - Hypertension Social History: Occupation: Construction worker No smoking Drinks alcohol occasionally Review of Systems: Gastrointestinal: Severe abdominal pain, nausea Cardiovascular: No chest pain or palpitations Respiratory: No shortness of breath or cough Physical Examination: Vital Signs: Blood Pressure: 130/85 mmHg Heart Rate: 76 bpm Respiratory Rate: 18 bpm Temperature: 98.6°F (37°C) Abdominal Exam: Tenderness in the lower abdomen, no rebound tenderness, normal bowel sounds Assessmen
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