Comprehensive Note (Tina Jones)
Subjective:
Date of encounter: August 1,
Patient Name or initials: Tina Jones
Informant: Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-em
...
Comprehensive Note (Tina Jones)
Subjective:
Date of encounter: August 1,
Patient Name or initials: Tina Jones
Informant: Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview.
Chief Complaint (CC): "I came in because I'm required to have a recent physical exam for the health insurance at my new job."
History of present illness (HPI): Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. She needs to obtain a pre-employment physical prior to initiating employment. Today she denies any acute concerns. Her last healthcare visit was 4 months ago, when she received her annual gynecological exam at Shadow Health General Clinic. Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. She has type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just started 5 months ago. She has no medication side effects at this time. She states that she feels healthy, is taking better care of herself than in the past, and is looking forward to beginning the new job.
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