Example 2:
Chief Complaint:
The patient's name is George
Gohman. He is a janitor who says he hurt
his shoulder on the job. His supervisor
noticed he was having a hard time doing his
job so she told him to go to the doctor's
office and have his shoulder checked out.
The patient said he was lifting a heavy box
down from a high shelf when his shoulder
started hurting. When asked what the pain
was on a scale of 1 to 10 he said it was an 8.
This is the first time he's ever had shoulder
pain. He has worked at the same job for
over 30 years and has never had any
shoulder pain before. He says he has trouble
raising his arm and any kind of lifting makes
his shoulder pain worse. He said the pain
would prevent him from doing pretty much
everything he needs to do at work.
Background:
The patient has no relatives with
chronic shoulder pain. He has two
daughters who he is paying child support
for. He is divorced and under a court order
to pay child support. He is worried about
missing work because he thinks he won't
have enough money to pay his bills. He
wants the doctor to prescribe a pill so he can
continue working. He has only been
working in this place for a little while and
doesn't yet have any sick leave or vacation
time.
He took 2 Advil 30 minutes after it
happened and he said they didn't help at all.
He is not taking any other medications. The
patient does not exercise outside of work but
had a support network that could help
support him through this he said he had none
because he was new to the area. The last
time he saw a doctor was for a routine
physical two years ago and there were no
abnormal findings then.
-Chief complaint should be in the first
sentence.
-“Who says he hurt his shoulder” gives the
impression the writer doesn’t
believe him.
-The interaction with the supervisor is a
sidetrack and doesn’t belong here. Almost
always, the biomedical story comes first in
the note.
This paragraph jumps from chronology to
description and back again. As a result,
neither is clear.
It’s not necessary to keep repeating that
“The patient says,” You can assume the
history is the patient’s statements unless
circumstances dictate that you get the
history from someone else.
Notes should use the conventional format
and headings outlined on page 117.
Redundant and rambling.
Suddenly the writer has started describing
the pain and risk factors again, in the middle
of a paragraph about psychosocial issues.
Then he hops back to discussing support
systems
As you have probably figured out by now,
Example 2 is a poorly organized note.