Here is an example chart documentation:
Illness Care
HPI Given By: mother
Chief Complaint: wheezing
History of Present Illness: Mom noted labored breathing last night; gave xopenex mdi tx. From 7am-8am today Mom gave 2 puffs x 4; last mdi tx was 1 hr ago. Cough since yest. No fever.
Some nausea last night and this am. Denies vomiting and diarrhea.
Past, Family, Social and Surgical History
Past History: Reactive airways/wheezing treated with albuterol, flovent in past
Hosp Sept 2005 for asthma
Family History: No asthma
Denies kidney dze.
Social History: Lives with Mom; visits Dad 2 days a week.
No smokers.
1 cat indoor; 1 dog outside.
Grandparents watch pt alot and they smoke and have 1 dog.
Vital Signs
Weight: 50 lbs /22.73 kg Change: -1 lbs /-450 g Previous: 51.0 lbs /23.18 kg on 03/17/2009
BMI: 18.2 Change: -0.40 Previous: 18.6 on 03/17/2009
Temperature: 97 F /36.1 C Temporal
Additional Information
Asthma Questionnaire given to family
Initial Patient Intake By: April 1, 2009 10:04 AM
Peak Flow, Oximetry
Initial Pulse Oximetry: 92% Initial Pulse Rate: 131 b/min
Initial Assessment By: , RN April 1, 2009 10:15 AM
Oximetry After Rx #1: 96% Pulse Rate After Rx #1: 137 b/min
Assessment After Rx #1 By: , RN April 1, 2009 10:27 AM
Oximetry After Rx #2: 96% Pulse Rate After Rx #2: 133 b/min
Assessment After Rx #2 By: , RN April 1, 2009 10:56 AM
Oximetry Before Rx #3: 94% Pulse Rate Before Rx #3: 143 b/min
Assessment Before Rx #3 By: , RN April 1, 2009 11:08 AM
Oximetry After Rx #3: 96% Pulse Rate After Rx #3: 137 b/min
Assessment After Rx #3 By: , RN April 1, 2009 11:52 AM
Physical Exam
General: alert; retracting, labored breathing; articulate.
Skin: normal, no rashes or lesions
L TM: normal
R TM: normal
Pharynx: normal
Neck: supple, no masses, trachea midline, full ROM
Lungs: Resp rate 60-70; supraclavicular and subcostal retractions; diminished bs throughout; faint hi pitched weeze over right posterior field
Heart: normal S1 S2 without murmur
S/P Xopenex 1.25mg neb #1) Resp rate 60; less intense supraclavicular and subcostal retractions; pulse ox 96%. Sightly improved aeration; now with hi pitched wheezes b/l and crackles over right posterior lung field. James J DePiore MD, April 1, 2009 10:37 AM Will give 30mg Orapred (ODT) now and repeat xopenex neb.
S/P Xopenex 1.25mg neb #2) Resp rate 50-60; less intense supraclavicular and subcostal retractions; pulse ox 94%. Improved aeration; few hi pitched wheezes b/l and less intense crackles over right posterior lung field. James J DePiore MD, April 1, 2009 11:31 AM
S/P Xopenex 1.25mg neb #3) Resp rate 44; No retractions. Faint intermittent wheeze over posterior fields and faint crackle over right posterior field. Pulse ox 96%. MD, April 1, 2009 12:02 PM
Impression & Recommendations:
Problem # 1: ASTHMA NOS W/ACUTE EXACERBATION (ICD-493.92)
Improved aeration and decreased wob as noted above after 3rd xopenex tx. Will increase xopenex mdi to 4-6 puffs q 4-6 hrs and start Flovent 2 puffs bid until acut sx's resolve then cont qd thereafter. Orpared and zithromax as prescribed.
Call for worsening or persistent sx's; sooner for increased wob or for fevers.
Orders:
Ofc Vst, Est Level IV (Detailed) (CPT-99214)
Measurement of blood oxygen level, multiple (CPT-94761)
Xopenex Inhalation 1.25 mg (J7612)
Airway inhalation treatment (CPT-94640)
Xopenex Inhalation 1.25 mg (J7612)
Airway inhalation treatment (CPT-94640)
Xopenex Inhalation 1.25 mg (J7612)
Airway inhalation treatment (CPT-94640)
Medications Added to Medication List This Visit:
1) Orapred 15 Mg/5ml Soln (Prednisolone sodium phosphate) .... 2 teaspoon po each day for 4 days.
2) Zithromax 200 Mg/5ml Susr (Azithromycin) .... 6 ml by mouth once day one and then 3ml by mouth once daily for the next four days.
Prescriptions:
ZITHROMAX 200 MG/5ML SUSR (AZITHROMYCIN) 6 ml by mouth once day one and then 3ml by mouth once daily for the next four days. #18ml x 0
Entered and Authorized by: MD
Signed by: MD on 04/01/2009
Method used: Print then Give to Patient
ORAPRED 15 MG/5ML SOLN (PREDNISOLONE SODIUM PHOSPHATE) 2 teaspoon po each day for 4 days. #QS x 0
Entered and Authorized by: MD
Signed by: MD on 04/01/2009
Method used: Print then Give to Patient
Patient Care Documentation
1: Aerosol treatment with Xopenex 1.25mg complete. Given by, RN, April 1, 2009 10:14 AM
2: Orapred ODT 2 tabs administered in office , RN, April 1, 2009 10:36 AM
3: Aerosol treatment with Xopenex 1.25mg complete. Given by , RN, April 1, 2009 10:39 AM
4: Aerosol treatment with Xpoenex 1.25mg complete. Given by , RN, April 1, 2009 11:43 AM