Documentation / Electronic Health Record
Document: Provider Notes
Student Documentation Model Documentation
HPI: Ms. Jones, a pleasant 28-year-old African American woman, visited the clinic with complaints of shortness of breath and wheezing after a recent asthma attack two days ago. The trigger for her symptoms was exposure to cats at her cousin’s house. During the incident, she experienced wheezing at a severity of 6/10 and shortness of breath at 7-8/10, which lasted for five minutes. There were no chest pain or allergic symptoms. She used her albuterol inhaler, and the symptoms improved but did not completely resolve. Since then, she has had 10 episodes of wheezing and shortness of breath approximately every four hours. Her most recent episode of shortness of breath occurred this morning. Her current symptoms seem to worsen with lying flat and movement and are accompanied by a non-productive cough. She also experiences nighttime shortness of breath twice per night, which interferes with her daily activities. She is concerned that her albuterol inhaler is less effective than before. At present, her breathing is normal. She was diagnosed with asthma at the age of 2.5 years and has been hospitalized five times for asthma, with the last hospitalization at age 16. She has never been intubated for asthma. She does not have a current pulmonologist or allergist. In her social history, she denies any environmental exposures or irritants at home or work. She changes her sheets weekly and denies dust/mildew at her home. She uses a hypoallergenic pillow cover, and her mattress is one year old. She does not use tobacco, alcohol, or illicit drugs. She used to smoke marijuana for 5 or 6 years, but her last use was at age 21. She does not exercise regularly. In the review of systems, she denies changes in weight, fatigue, weakness, fever, chills, and night sweats. She also denies rhinorrhea, stuffiness, sneezing, itching, previous allergy, epistaxis, sinus pressure, changes in appetite, nausea, vomiting, symptoms of GERD, abdominal pain, sputum, hemoptysis, pneumonia, bronchitis, emphysema, and tuberculosis. Her last hospitalization for asthma and chest X-ray were at age 16.
General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress. She is alert and oriented and sitting upright on the exam table. She maintains eye contact throughout the interview and examination.
Respiratory: Chest expansion is symmetrical with respirations. Normal fremitus, symmetric bilaterally. The chest is resonant to percussion with no dullness. Bilateral expiratory wheezes in posterior lower lobes. Bilateral muffled words with notable expiratory wheezes in posterior lower lobes. No crackles. In-office spirometry: FVC 3.91 L, FEV1/FVC ratio 80.56%. SpO2: 97%.
Encourage Ms. Jones to continue to monitor symptoms and log her episodes of asthma symptoms and wheezing with associated factors and bring the log to the next visit.
Obtain office oxygen saturation.
Order PFTs to be completed after exacerbation to have baseline available for future comparison.
Encourage her to wash bedding and consider dust mite covers to decrease allergic nighttime symptoms.
NMT in office x 1.
Educate her to increase intake of water and other fluids.
Educate Ms. Jones on when to seek emergent care, including episodes of chest pain or shortness of breath unrelieved by rest, worsening asthma symptoms or wheezing, or the sense that the rescue inhaler is not helping.
Revisit the clinic in 2-4 weeks for follow-up and evaluation.