Documentation / Electronic Health Record
Subjective
Table of Contents
Medical History: Ms. Jones is a friendly 28-year-old African American woman who visited the clinic with complaints of a scratchy, itchy throat, itchy eyes, and a runny nose for the past week. She mentioned these symptoms appeared suddenly and have been constant. There are no specific triggers, but she notes her throat feels worse in the mornings. She rates her throat pain as 4 out of 10 and itchiness as 5 out of 10. She occasionally uses throat lozenges, which provide some relief.
She experiences some discomfort when swallowing but denies other associated symptoms. Her nose has clear discharge, and she hasn’t tried any treatments. Her eyes are consistently itchy, and she hasn’t treated them. She denies coughing or recent illnesses. She hasn’t been around sick people. She hasn’t been diagnosed with allergies but mentions her sister has hay fever.
Lifestyle: She doesn’t know of any environmental irritants at home or work. She changes her bed sheets weekly and reports no dust or mildew at home. She doesn’t smoke, drink alcohol, or use drugs. She doesn’t exercise.
Review of Symptoms: She denies weight changes, fatigue, weakness, fever, chills, and night sweats. She reports occasional headaches while studying. She doesn’t wear glasses but notes her vision has worsened over the years, especially after reading for long periods. She denies hearing loss, ringing in the ears, dizziness, ear discharge, or ear pain. Before this episode, she didn’t have a runny nose, stuffiness, sneezing, itching, allergies, nosebleeds, or sinus pressure. She denies bleeding gums, hoarseness, swollen glands, or mouth sores. She has a history of asthma but denies recent respiratory issues.
Objective
General: Ms. Jones is a friendly, overweight 28-year-old African American woman who appears comfortable. She is alert and makes eye contact during the assessment.
Head: Her head is normal in size and shape, with no injuries or abnormalities. Her scalp looks healthy, with no lumps and normal hair growth.
Eyes: Both eyes have equal hair growth and no lesions, drooping, or swelling. The conjunctiva (the pink tissue lining the eyelids) is clear but slightly red. She can move her eyes normally, and her pupils react to light. Her left eye vision is normal, but her right eye vision is slightly impaired.
Ears: Both ears are symmetrical with no inflammation in the outer ear. The eardrums are intact and pearly gray, with a healthy light reflection. Tests for hearing are normal in both ears.
Nose: Her nasal septum is centered, and the inner lining of her nose is swollen and pale. She feels no pain when her sinuses are touched.
Mouth/Throat: Inside her mouth, the tissue is moist, and there are no wounds. Her dental health is good. Her uvula (the tissue that hangs down in the throat) is in the middle. Her tonsils are slightly swollen but not inflamed. The back of her throat is reddish with some bumps.
Neck: There are no swollen lymph nodes in her neck or below the collarbone. Her thyroid gland feels smooth without any lumps. There’s a dark patch on her skin called acanthosis nigricans, which can be related to weight or insulin levels. Her carotid pulses are normal, with no abnormal sensations. Her jaw moves without clicking, and her neck arteries sound normal.
Respiratory: Her chest looks normal, and her breathing sounds clear without wheezing, crackling, or coughing.
Assessment
Diagnosis: Allergic Rhinitis
Plan
Recommendations:
– Continue monitoring symptoms and keep a record for the next visit.
– Start taking loratadine (Claritin) 10 mg daily.
– Drink more fluids and wash hands frequently.
– Learn about avoiding triggers and allergens.
– Know when to seek medical help, especially for uncontrollable nosebleeds, worsening headaches, or fever.
– Schedule a follow-up visit in 2-4 weeks for review and further assessment.
Head, Eyes, Ears, Nose, and Throat (HEENT) Documentation
Documentation / Electronic Health Record
Document: Provider Notes
| Student Documentation | Model Documentation |
|---|---|
Subjectivexx |
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. Reports headaches while studying. • Eyes: She does not wear corrective lenses, but notes that her vision has been worsening over the past few years. She complains of blurry vision after reading for extended periods. Denies increased tearing or itching prior to this past week. • Ears: Denies hearing loss, tinnitus, vertigo, discharge, or earache. • Nose/Sinuses: Denies rhinorrhea prior to this episode. Denies stuffiness, sneezing, itching, previous allergy, epistaxis, or sinus pressure. • Mouth/Throat: Denies bleeding gums, hoarseness, swollen lymph nodes, or wounds in mouth. No sore throat prior to this episode. • Respiratory: She denies shortness of breath, wheezing, cough, sputum, hemoptysis, pneumonia, bronchitis, emphysema, tuberculosis. She has a history of asthma, last hospitalization was age 16 for asthma, last chest XR was age 16. Her current inhaler use has been her baseline of 2-3 times per week. |
Objectivexx |
General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress. She is alert and oriented. She maintains eye contact throughout interview and examination. • Head: Head is normocephalic and atraumatic. Scalp with no masses, normal hair distribution. • Eyes: Bilateral eyes with equal hair distribution, no lesions, no ptosis, no edema, conjunctiva clear and injected. Extraocular movements intact bilaterally. Pupils equal, round, and reactive to light bilaterally. Normal convergence. Left fundoscopic exam reveals sharp disc margins, no hemorrhages. Right fundoscopic exam reveals mild retinopathic changes. Left eye vision: 20/20. Right eye vision: 20/40. • Ears: Ear shape equal bilaterally. External canals without inflammation bilaterally. Tympanic membranes pearly grey and intact with positive light reflex bilaterally. Rinne, Weber, and Whisper tests normal bilaterally. • Nose: Septum is midline, nasal mucosa is boggy and pale bilaterally. No pain with palpation of frontal or maxillary sinuses. • Mouth/Throat: Moist buccal mucosa, no wounds visualized. Adequate dental hygiene. Uvula midline. Tonsils 1+ and without evidence of inflammation. Posterior pharynx is slightly erythematous with mild cobblestoning. •Neck: No cervical, infraclavicular lymphadenopathy. Thyroid is smooth without nodules or goiter. Acanthosis nigricans present. Carotid pulses 2+, no thrills. Jaw with no clicks, full range of motion. Bilateral carotid artery auscultation without bruit. • Respiratory: Chest is symmetrical with respirations. Lung sounds clear to auscultation without wheezes, crackles, or cough. |
Assessmentxx |
Allergic Rhinitis |
Planxxx |
Encourage Ms. Jones to continue to monitor symptoms and log her episodes of allergic symptoms with associated factors and bring log to next visit. • Initiate trial of loratadine (Claritin) 10 mg by mouth daily. • Encourage to increase intake of water and other fluids and educate on frequent handwashing. • Educate on avoidance of triggers and known allergens • Educate Ms. Jones on when to seek care including episodes of uncontrollable epistaxis, worsening headache, or fever. • Revisit clinic in 2-4 weeks for follow up and evaluation. |
