Documentation_HEENT.docx - Documentation Electronic Health...

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Documentation / Electronic Health Record Document: Provider Notes Document: Provider Notes Student Documentation Model Documentation 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
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