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Can someone give me their opinion on a chart note. I have ask the provider to be specific and he does not see anything wrong with his note. This is how are notes are documented.
Active problems:
CKD stage 3
DM
HTN
Chief complaint: Check up, review labs.
HPI:
pt is 76 year old female.
Had fasting blood test here on 1/7/20. Has multiple medical problems as noted above.
Last seen on 8/8/19 with exam which included annual.
Allergy list reviewed. Medication reconciliation performed.
Current Medications:
Active problems:
CKD stage 3
DM
HTN
Chief complaint: Check up, review labs.
HPI:
pt is 76 year old female.
Had fasting blood test here on 1/7/20. Has multiple medical problems as noted above.
Last seen on 8/8/19 with exam which included annual.
Allergy list reviewed. Medication reconciliation performed.
Current Medications: