Tina Jones HEENT Documentation

HEENT Documentation
Documentation / Electronic Health Record

Table of Contents

Document: Provider Notes
Student Documentation Model Documentation
Subjective

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HPI: Ms. Jones is a 28-year-old woman who came to the clinic with a sore, itchy throat, itchy eyes, and runny nose for the past week. She hasn’t found anything that makes these symptoms worse, but her throat pain is worse in the morning. Her throat pain is a 4 out of 10, and her throat itchiness is a 5 out of 10. She’s used throat lozenges sometimes and they’ve helped a bit. She also feels a bit of soreness when she swallows. Her nose runs all day, but it’s clear discharge. Her eyes are always itchy, but she hasn’t treated them. She hasn’t been coughing and hasn’t been sick. She hasn’t been around sick people. Her hearing, vision, and taste haven’t changed. She’s never been told she has seasonal allergies, but her sister has hay fever.

Social History: She doesn’t know of anything at her job or home that could be causing her symptoms. She changes her sheets every week and doesn’t have dust or mold at home. She doesn’t smoke, drink alcohol, or use drugs. She doesn’t exercise.

Review of Systems: She hasn’t noticed changes in her weight, tiredness, weakness, fever, chills, or night sweats. She has headaches while studying. Her vision has been getting worse over the past few years, and she gets blurry vision after reading for a while. She hasn’t had any hearing loss, ringing in her ears, dizziness, ear discharge, or earaches. She hasn’t had a runny nose before this, and she hasn’t had stuffiness, sneezing, itching, allergies before, nosebleeds, or sinus pressure. She hasn’t had bleeding gums, a hoarse voice, swollen lymph nodes, or mouth sores. She hasn’t had a sore throat before. She hasn’t had trouble breathing, wheezing, cough, mucus, coughing up blood, pneumonia, bronchitis, emphysema, or tuberculosis. She has asthma but was last in the hospital for it when she was 16. Her asthma inhaler use is the same as usual.

Objective

General: Ms. Jones is a friendly, overweight 28-year-old woman. She looks fine and isn’t in pain. She’s awake and knows where she is. She looks at the doctor while they talk and check her.

Head: Her head is a normal size and shape, and she didn’t hurt it. Her scalp is normal and her hair is normal.

Eyes: Both her eyes are the same, and they look normal. Her eyelids are fine, and her eyes aren’t swollen. Her eyes move the right way, and her pupils look normal. Her eyes can see things close and far. The back of her eyes looks healthy.

Ears: Both her ears are the same shape. The skin in her ears looks good. The parts inside her ears are normal and work right.

Nose: The middle of her nose is in the middle. The skin inside her nose is swollen and pale on both sides. Pressing on the front and sides of her head doesn’t hurt.

Mouth/Throat: The skin inside her mouth is wet and there aren’t any sores. Her teeth are clean. The thing that hangs down in her mouth is in the middle. Her tonsils are small and don’t look swollen. The back of her throat is a bit red with small lumps.

Neck: No big lumps in her neck. Her thyroid is smooth and normal. There are dark spots on her skin. The big blood vessels in her neck feel normal. Her jaw can move and there aren’t any weird sounds. The doctor didn’t hear anything odd when they listened to her neck.

Respiratory: Her chest looks the same on both sides when she breathes. The doctor didn’t hear any weird sounds when they listened to her lungs.

Assessment

Allergic Rhinitis

Plan

Tell Ms. Jones to keep watching her symptoms and write down when they happen and what might cause them. Try taking loratadine (Claritin) 10 mg every day. Drink more water and wash hands a lot. Avoid things that make her allergies worse. Tell her to come back in 2-4 weeks.

Document: Provider Notes

Student Documentation	Model Documentation
Subjective xx	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.
Objective xx	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.
Assessment xx	Allergic Rhinitis
Plan xxx	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.

Tina Jones HEENT Documentation