For BethulBest

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W3A2Outpatientchart.PDF

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Patient's Name

Birth Date Age

Street Address

Phone Number

Clinic Number

Sex Marital Status State Zip County

City

Patient's Occupation

Soc. Sec. #

Name

Address

Relationship

Phone No.

Responsible for Account

Religion

Date of Initial Visit

Sundance HealthCare Clinic, P.CSundance HealthCare Clinic, P.CSundance HealthCare Clinic, P.CSundance HealthCare Clinic, P.CSundance HealthCare Clinic, P.C Painted Valley, USAPainted Valley, USAPainted Valley, USAPainted Valley, USAPainted Valley, USA

Notify In Emergency

Race

Ethnicity

Account Number

Living Will

Power of Attorney

Primary Provider

Name & Address of Any Institution From Which Discharged in Last 60 Days

Alllergies

ADMISSION SHEET

Physician Signature

This is a simulated health record created and intended for educational purposes only. All scenarios, names, demographic information, medical events, and data portrayed herein are fictitious. No identification with or similarity to actual persons, living or dead, or to actual events or entities is intended or should be inferred. Any similarity to actual persons or events is purely coincidental. © 2003. American Health Information Management Association. All rights reserved.

Drew, Paul N. 1420 Raindrops Drive # 672928

12/30/19xx 10 Little Missouri 704 833-1008

M Single N.D. 58640 Dunn 061031

513-66-8228 Baptist Black

Student Non-Hispanic

Yancy Father Self

1420 Raindrops Drive, Little Missouri 701 833-1008 None

4/28/xx None

No known allergies

Dr. A. M. Graham

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Signature Dr.

Form 6335 (6/03) mr HISTORY & PHYSICAL

Sundance HealthCare Clinic Painted Valley, USA

Chief Complaint: This 10 year old black male presents with a painful left wrist. He fell from playground equipment and landed on his left forearm. Area immediately became painful and swelling started to occur. He was brought to the clinic by his mother.

Past Medical History: Uneventful birth. Usual childhood diseases. One bout of pneumonia at age 5. Acute appendicitis and appendectomy at age 8.

Family History: Grandfather died of prostate cancer. No other cancer. Father has high blood pressure. No other heart conditions. Mother and sister age 6 are alive and well. No diabetes.

Drew, Paul 12/30/1994 Dr. Graham 672928

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Sundance HealthCare Clinic Painted Valley, USA

Problem Problem Date Number Date Resolved Resolved Problem/Condition/Procedure

1 6-15-xx Y 6-xx Pneumonia

2 8-26-xx Y 8-xx Appendicitis/appendectomy

3 4-28-xx N Fracture left distal radius/ Closed reduction

Drew, Paul 12/30/1994 Dr. Graham 672928

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�� Problem Number Date Orders

Sundance HealthCare Clinic Painted Valley, USA

Drew, Paul 12/30/1994 Dr. Graham 672928

3 4-28-xx X-ray left radius. Will cast if fracture. Tylenol for pain.

Return in 2 weeks for follow up.

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�� Problem Number Date Notes

Sundance HealthCare Clinic Painted Valley, USA

Drew, Paul 12/30/1994 Dr. Graham 672928

3 4-28-xx S - Patient stated that he fell from a playground swing landing on his

left lower forearm. He experienced immediate pain and was brought

to the clinic by his mother. -

O - Left wrist painful to examination

A - Probable undisplaced fracture left distal radius

P - X-ray left radius

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