Esther Parks abdominal pain - EHR documentation: Document: Provider Notes; Student Documentation; Subjective,Objective, Model Documentation, Assessment, and Plan
Document: Provider Notes
Student Documentation Model
...
Esther Parks abdominal pain - EHR documentation: Document: Provider Notes; Student Documentation; Subjective,Objective, Model Documentation, Assessment, and Plan
Document: Provider Notes
Student Documentation Model Documentation
Subjective
Ms. Parks reports some abdominal discomfort
and pain over the last week with increase in the
pain over the last 2-3 days. She rates her
abdominal pain at 6/1, describing it as "dull and
crampy" in left lower abdomen. She states she
had a diarrhea 3 days ago and since than she
had no bowel movement. She denies any
abdominal pain radiation. She denies any rectal
pain or bleeding, fever, nasuea, vaginal
discharge or discomfort, burning sensation or
any other urinary symptoms. She denies any
past medical or family history of GI problems.
She states haveing c-section and cholecystomy
in early 40s. She has had a decrease in appetite
over the last few days; states she drinks small
amount of water and fluids. She denies taking
any medications for abdominal pain or
constipation. She states passing gass. The
normal BM is regular, soft and brown in color,
every 1-2 days with no other problems. Ms.
Parks lives with daughter. Daughter does the
shopping and Ms.Parks cooks herself
Ms. Park reports that she is “having pain in her
belly.” She experienced mild diarrhea three
days ago and has not had a bowel movement
since. She reports that she has been feeling
some abdominal discomfort for close to a week,
but the pain has increased in the past 2-3 days.
She now rates her pain at 6 out of 10, and
describes it as dull and crampy. She reports her
pain level at the onset at 3 out of 10. She is also
experiencing bloating. She did not feel her
symptoms warranted a trip to the clinic but her
daughter insisted she come. She describes her
symptoms primarily as generalized discomfort
in the abdomen, and states that her lower
abdomen is the location of the pain. She denies
nausea and vomiting, blood or mucus in stool,
rectal pain or bleeding, or recent fever. She
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