Sick Visit: Management of Endocrine Conditions Shadow health Documentation / Electronic Health Record

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My Provider Notes
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My Provider Notes

	Model Documentation

Chief Complaint: “I’m losing hair and feel tired” History of Present Illness (HPI): Maureen is a 79-year-old female presenting to the clinic today with concerns of atraumatic hair loss for three weeks, and fatigue, which has been ongoing for the past month. She reports no aggravating factors for her symptoms. She also reports non-pruritic dry skin on her hands, arms, and elbows that began three weeks ago Sick Visit: Management of Endocrine Conditions Shadow health Documentation / Electronic Health Record. Lotion temporarily relieves this dryness. Her symptoms are constant, but do not affect her activities of daily living. Patient reports that she is taking all of her medications as prescribed, including taking her Synthroid in the early AM, at least 60 minutes apart from any other medications or food. Mrs. Hopkins reports her Synthroid medication changed three months ago. The medication name on the pill bottle changed to levothyroxine sodium, and the pill shape changed from circular to oblong. She sleeps her usual 7-8 hours per night with no reported new anxiety or stress. Home Medications: • Multivitamin QHS • Calcium tablet QD • Vitamin D tablet QD • Synthroid 125 mcg QAM Allergies: NKDA, denies all other allergies Past Medical History (PMH): Hypothyroid, osteopenia Past Surgical History (PSH): Denies Social History: Denies tobacco or recreational drug use, endorses rare alcohol use on special occasions, but none recently. Reports eating

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Student Documentation
Subjective Ms Hopkins a79-year old woman presents to the client with a chief complaint of fatigue and hair loss. She reports to have been experiencing the symptoms for almost four weeks. She also states to have noted her skin is dry. She has been using lotion with little or no relief. She reporta she can do all things by herself. She has hypothyroidism and osteopenia. She reports to taking synthroid for her hypothyroidism and supplements for her osteopenia. She also reports to have nited her synthroid name change to levothyroxine. She believes her current conditions have been managed and are not related to the symptoms she is presenti g with. Allergies; Denies of any allergy Medications; Levothyroxine 125 mc, Calcimu tablet QD, vitamin D QD. Sick Visit: Management of Endocrine Conditions Shadow health Documentation / Electronic Health Record Past medical history; Hypothyroidism diagnised 15 years ago and osteopenia diagnosed 4 years ago. Family history; Mother deceased from stroke and father deceased due to COPD complications. Social Hx;Patient is retired and lives alone. She reports to have a

Student Documentation

Subjective

Ms Hopkins a79-year old woman presents to the client with a chief complaint of fatigue and hair loss. She reports to have been experiencing the symptoms for almost four weeks. She also states to have noted her skin is dry. She has been using lotion with little or no relief. She reporta she can do all things by herself. She has hypothyroidism and osteopenia. She reports to taking synthroid for her hypothyroidism and supplements for her osteopenia. She also reports to have nited her synthroid name change to levothyroxine. She believes her current conditions have been managed and are not related to the symptoms she is presenti g with. Allergies; Denies of any allergy Medications; Levothyroxine 125 mc, Calcimu tablet QD, vitamin D QD. Sick Visit: Management of Endocrine Conditions Shadow health Documentation / Electronic Health Record Past medical history; Hypothyroidism diagnised 15 years ago and osteopenia diagnosed 4 years ago. Family history; Mother deceased from stroke and father deceased due to COPD complications. Social Hx;Patient is retired and lives alone. She reports to have a