The patient note are the documents in which the progress of patient and information about treatment and care of patient issued by the health care professionals. These are also known as doctor notes or medical reports of patient. The note describes the current condition of the patient and growth chart of recovery. The purpose of patient note is to record the history of the patient, physical examination, planning how to treat the patient and the latest results are mentioned on the notes are is signature by the health care providers and nurses. Patient notes are used when the employee or student is absent for one week or more then the organization required the patient note as the proof of employees illness.
The patient notes are recorded for each patient seen on daily basis. The patient notes commonly consists of followings information such as, name of the patient, name of the disease, date of hospitalized and discharged date, name of doctors which treat the patient and billing details are mentioned on the patient note. Simply you say that the patient note is a record of document which explains all the events during the treatment of the patient. These notes are generated by the nurses and doctors at the present time who look after the patient.
Mr. _________________ is a 00-year-old gentleman formally followed at _________ __________ who presents to obtain a new primary care physician secondary to insurance changes. He has a past medical history significant for a myocardial infarction in 0000. His cholesterol has been fine. Cauterization showed a possible “kink” in one of his vessels and it was thought that he had a possible “eddy” of current which led to a clot.
ALLERGIES: No Known Drug Allergies
FAMILY HISTORY: His mother had diabetes developed at age 55 and coronary artery disease in her mid sixties. His father had CAD as well but not until his 70s. A paternal aunt had breast cancer. There is no history of colon or prostate cancer.
SOCIAL HISTORY: He lives in Durham with his wife and mother. He works for a biotech company. He does not smoke. He drinks two beers per night and reports no trouble with alcohol in the past. No history of drug use.
REVIEW OF SYSTEMS: As per his personal health summary and is significant only for his buttock pain as listed above, but is otherwise essentially unremarkable.
VITAL SIGNS: Weight 175.2 pounds which is 79.3 kg, blood pressure 142/96 by the nurse, 140/92 by me, pulse is 64.