coronary artery disease

Global Care Medical Center 100 Main St, Alfred NY 14802

(607) 555-1234

PHYSICIAN’S OFFICE ENCOUNTER FORM

EIN: 12-345678

BCBS PIN: GC2222

BCBS GRP : 1234-P

MCD PIN: GCMC1234 MEDICARE UPIN: GC1111

PATIENT INFORMATION: NAME : YOUNG, Joseph PATIENT NUMBER: POCase013 ADDRESS: 56 South Main Street ADMISSION DATE & TIME : 08-24-YYYY CITY: Hornell PRIMARY INSURANCE PLAN: Medicare STATE: NY PRIMARY INSURANCE PLAN ID #: 050769943A

ZIP CODE: 14843 SECONDARY INSURANCE PLAN:

TELEPHONE: 607-324-4552 SECONDARY INSURANCE PLAN ID #:

GENDER: Male OCCUPATION: Retired

DATE OF BIRTH : 08-18-1928 NAME OF EMPLOYER:

DIAGNOSIS INFORMATION Diagnosis Code Diagnosis Code 1. 5.

2. 6.

3. 7.

4. 8.

PROCEDURE INFORMATION Description of Procedure or Service Date Code Charge 1.

2.

3.

4.

5.

SPECIAL NOTES:

Global Care Medical Center

100 Main St, Alfred NY 14802

(607) 555-1234

PHYSICIAN OFFICE RECORD

PATIENT NAME : YOUNG, Joseph PATIENT NUMBER: POCase013

DATE OF SERVICE: 08-24-YYYY DATE OF BIRTH 08-18-1928

NURSING DOCUMENTATION: MEDICATIONS ALLERGIES/REACTIONS: None

CURRENT MEDICATIONS: diltiazem, Isordil, Metamuci, Colace, and timolol.

BP: P: R: T: WT: OVS:

CC: Chronic constipation. Soreness around the anal region and incontinence of the stool and sometimes urine.

PMH: Coronary artery disease with sick sinus syndromes, glaucoma, and status post pacemaker implantation in November, YYYY.

NOTES:

SIGNATURE OF PRIMARY CARE NURSE: Janey Wilson, R.N.

PHYSICIAN DOCUMENTATION:

Notes: Mr. Young is an 88-year-old white veteran with coronary artery disease with sick sinus syndromes, status post pacemaker implantation in November. He is being followed up by the cardiologist, went last week and reports that he is doing well. The patient also has chronic constipation, mild dementia, positive PPD and negative x-ray. He complains of soreness around the anal region and incontinence of the stool and sometimes urine.

He is currently on diltiazem CD 180 mg per day and Isordil 20 mg b.i.d., Metamucil one pkg per day and Colace p.r.n.

He has glaucoma for which he takes timolol eye drops. On exam, the patient is an alert, well-oriented veteran not in any distress, pleasant. Vital sounds as per the nursing staff. Chest is clear, CVS:NSR. Abdomen: Soft, benign, no masses felt.

Rectal exam: The anal area and the surrounding perineal area are erythematous, and there is a tear going from the rectum to the anal region and slight oozing of blood was noted. Rectal exam was done, and I could not feel any masses in the rectum, however, it was painful for him.

ASSESSMENT: Anal tear with hemorrhoids.

PLAN: Sitz bath, protective ointment around that area and surgical consult and off the pressure and give doughnut ring.

SIGNATURE OF PROVIDER: Floyd Bailey, M.D. DD: 08-24-YYYY DT: 08-26-YYYY

Floyd Bailey, M.D.

Global Care Medical Center 100 Main St, Alfred NY 14802

(607) 555-1234

PHYSICIAN’S OFFICE ENCOUNTER FORM

EIN: 12-345678

BCBS PIN: GC2222

BCBS GRP : 1234-P

MCD PIN: GCMC1234 MEDICARE UPIN: GC1111

PATIENT INFORMATION: NAME : EDWARDS, Gary J. PATIENT NUMBER: POCase020 ADDRESS: 6767 Crosby Creek Road ADMISSION DATE & TIME : 08-21-YYYY CITY: Hornell PRIMARY INSURANCE PLAN: BCBS of WNY STATE: NY PRIMARY INSURANCE PLAN ID #: 671452123

ZIP CODE: 14843 SECONDARY INSURANCE PLAN:

TELEPHONE: 607-324-7740 SECONDARY INSURANCE PLAN ID #:

GENDER: Male OCCUPATION: Police Officer

DATE OF BIRTH : 08-07-1947 NAME OF EMPLOYER: City of Hornell

DIAGNOSIS INFORMATION Diagnosis Code Diagnosis Code 1. 5.

2. 6.

3. 7.

4. 8.

PROCEDURE INFORMATION Description of Procedure or Service Date Code Charge 1.

2.

3.

4.

5.

SPECIAL NOTES:

Global Care Medical Center

100 Main St, Alfred NY 14802

(607) 555-1234

PHYSICIAN OFFICE RECORD

PATIENT NAME : EDWARDS, Gary J. PATIENT NUMBER: POCase020

DATE OF SERVICE: 08-21-YYYY DATE OF BIRTH 08-07-1947

NURSING DOCUMENTATION: MEDICATIONS ALLERGIES/REACTIONS: None

CURRENT MEDICATIONS: Atenolol, Glyburide, and metformin

BP: 140/60 P: 70 R: T: WT: 212 HEENT: Within Normal Limits

CC: Patient states he has a lot of head congestion.

PMH: Hypertension, diabetes type 2, coronary artery disease, hyperlipidemia, and osteoarthritis.

NOTES: Patient complains of cold symptoms for two weeks. He is afebrile in clinic today. States he has a lot of head congestion. No chills or fever. Taking extra fluids. Sputum is white/brown

SIGNATURE OF PRIMARY CARE NURSE: P.W. Burgess, R.N.

PHYSICIAN DOCUMENTATION:

Notes: HPI: Mr. Edwards was seen in the outpatient today complaining of upper respiratory symptoms. His problems have persisted since he was last seen in April of this year by Dr. Watts. He denies any chills or fever, just the stuffiness, cough, and occasional runny nose. Mr. Edwards’ problems consist of the following: Hypertension. Diabetes type 2. Coronary artery disease. Hyperlipidemia.Osteoarthritis.

Present medications consist of the following: Atenolol 25 mg q.d., Glyburide 10 mg b.i.d., metformin I gr in the morning, 500 mg at lunch, and I gr in the evening. He had fasting labs drawn this morning. The results are pending. His Accu-Chek done at home had been running in the 80s to 180 range. He seems to have better control now with the addition of the Metformin. A PSA was done in April which was 0.4.

PE: On exam today the patient had no acute physical findings. His weight was 212 pounds. Blood pressure 140/60. His temperature was 98.1. Pulse 70. Respirations 18. His HEENT was basically within normal limits except for some rhinorrhea. The lungs had wheezes bilaterally with some soft rhonchi. No rales were noted and there was adequate air exchange. The heart had a regular rate and rhythm with no murmur, rubs, or skipped beat noted. The abdomen was soft, obese. Bowel sounds were normal active. There was no gross organomegaly noted. The extremities were normal. He had good color and warmth. The lower extremities had some mild edema of the lower calf and ankles. Peripheral pulses were present but diminished.

ASSESSMENT: As listed above with in addition of bronchitis.

PLAN: I will have a chest x-ray done today to rule out any acute phase. This is probably a COPD or a chronic bronchitis. The patient states he quit smoking three months ago. I will place him on Septra DS b.i.d. for 14 days. He is allergic to penicillin. He has been advised to increase his fluid intake. I have given him Chlor-Trimeton 4 mg also to help with his rhinorrhea. He will return in three months’ time. Will repeat labs and reevaluate at that time.

SIGNATURE OF PROVIDER: Timothy E. Wells, M.D. DD: 08-21-YYYY DT: 08-23-YYYY Timothy E. Wells, M.D.

Global Care Medical Center 100 Main St, Alfred NY 14802

(607) 555-1234

PHYSICIAN’S OFFICE ENCOUNTER FORM

EIN: 12-345678

BCBS PIN: GC2222

BCBS GRP : 1234-P

MCD PIN: GCMC1234 MEDICARE UPIN: GC1111

PATIENT INFORMATION: NAME : CORNWALL, Manny PATIENT NUMBER: POCase021 ADDRESS: 90 Eastacre Road ADMISSION DATE & TIME : 08-17-YYYY CITY: Alfred PRIMARY INSURANCE PLAN: Medicare STATE: NY PRIMARY INSURANCE PLAN ID #: 572880909A

ZIP CODE: 14802 SECONDARY INSURANCE PLAN:

TELEPHONE: 607-587-1127 SECONDARY INSURANCE PLAN ID #:

GENDER: Male OCCUPATION: Retired

DATE OF BIRTH : 05-24-1930 NAME OF EMPLOYER:

DIAGNOSIS INFORMATION Diagnosis Code Diagnosis Code 1. 5.

2. 6.

3. 7.

4. 8.

PROCEDURE INFORMATION Description of Procedure or Service Date Code Charge 1.

2.

3.

4.

5.

SPECIAL NOTES:

Global Care Medical Center

100 Main St, Alfred NY 14802

(607) 555-1234

PHYSICIAN OFFICE RECORD

PATIENT NAME : CORNWALL, Manny PATIENT NUMBER: POCase021

DATE OF SERVICE: 08-17-YYYY DATE OF BIRTH 05-24-1930

NURSING DOCUMENTATION:

MEDICATIONS ALLERGIES/REACTIONS: None

CURRENT MEDICATIONS: Famotidine, calcium carbonate, lovastatin, hydrochlorothiazide, KCL, aspirin, multi-vitamins

BP: 130/80 P: 70 R: 16 T: WT: 138 HEENT: within normal limits

CC: Patient needs med. renewal for meds that are running out of refills.

PMH: Hyperlipidemia, esophageal reflux, peptic ulcer disease, paralysis agitans, benign prostatic hypertrophy, cerebral arterial occlusion, osteoporosis, and possible Parkinson’s disease versus multi-infarct dementia.

NOTES: No acute medical problems.

SIGNATURE OF PRIMARY CARE NURSE: Mary Kay Place, R.N.

PHYSICIAN DOCUMENTATION:

Notes: HPI: Mr. Cornwall is a 74-year~old white male with the following problems: hyperlipidemia, esophageal reflux, peptic ulcer disease, paralysis agitans, benign prostatic hypertrophy, cerebral arterial occlusion, osteoporosis, and possible Parkinson’s disease versus multi-infarct dementia. Mr. Cornwall has been followed by Dr. Massey, last seen in May, and also by Dr. Atwater, a neurologist, regarding his cognitive dysfunction. He has been tentatively diagnosed as Parkinson’s versus a multi-infarct dementia, and he will be seen again in December by Dr. Atwater. At that time, a possible trial of Sinemet may be started. According to the wife, the patient has been doing quite well. There have been no acute medical problems. He has been having accidents with his bladder and has had trouble sleeping, according to her. What she states is that the patient gets up during the night and wanders through the house. This sounds more like your multi-infarct dementia Parkinson’s problem. But, as stated, he will be seen by Dr. Atwater in December.

LAB: Alkaline phosphatase 18, creatinine 0.9, potassium 4.1, cholesterol 209, PSA at 4.4.

PE: Height 67″, weight 138 lbs, BP 130/80, pulse 70, respirations 16. HEENT: Within normal limits. LUNGS: Clear to A&P sounds regular with no murmur, rubs, or skipped beats noted. ABDOMEN: Flat, non-tender, no gross organomegaly noted. Bowel sounds normal. LOWER EXTREMITIES: All present. Good peripheral pulses. Good sensation throughout. No evidence of any lesions. Speech clear. Thought pattern dysfunctional. He has a memory impairment, and many answers were inappropriate to the questions asked.

CURRENT MEDICATIONS: His medications include: Famotidine 20 mg twice a day for heartburn, calcium carbonate 1,500 mg daily for osteoporosis, lovastatin 20 mg after supper, hydrochlorothiazide 12.5 mg daily for blood pressure, and potassium chloride 10 mEq twice a day. He is also on aspirin one a day and multi- vitamins with minerals one a day.

PLAN: He will be followed-up in approximately four months, and repeat labs at that time.

SIGNATURE OF PROVIDER: H.W. Pocket, M.D. DD: 08-17-YYYY DT: 08-19-YYYY

H.W. Pocket, M.D.

Global Care Medical Center 100 Main St, Alfred NY 14802 (607) 555-1234

LABORATORY DATA

PATIENT NAME : CORNWALL, Manny PATIENT NUMBER: POCase021

LOCATION: PO PROVIDER: H.W. Pocket, M.D.

SPECIMEN COLLECTED: 08-11-YYYY SPECIMEN RECEIVED: Blood

TEST RESULT FLAG REFERENCE

Alk Phos 18 20-125 U/L

BUN 8-25 mg/dl

Creatinine 0.9 = 1.0 mg/dL

Sodium 135-145 mmol/L

Potassium 4.1 4.1 mmol/L

Chloride 99-110 mmol/L

CO2 21-31 mmol/L

Calcium 8.6-10.2 mg/dl

WBC 4.5-11.0 thous/UL

RBC 5.2-5.4 mill/UL

HGB 11.7-16.1 g/dl

HCT 35.0-47.0 %

Platelets 140-400 thous/UL

PT 11.0-13.0 seconds

PSA 4.4 = 4 ng/mL

***End of Report***

Global Care Medical Center 100 Main St, Alfred NY 14802

(607) 555-1234

PHYSICIAN’S OFFICE ENCOUNTER FORM

EIN: 12-345678

BCBS PIN: GC2222

BCBS GRP : 1234-P

MCD PIN: GCMC1234 MEDICARE UPIN: GC1111

PATIENT INFORMATION: NAME : MOHR, Lee PATIENT NUMBER: POCase024 ADDRESS: 157 Grossman Avenue ADMISSION DATE & TIME : 08-17-YYYY CITY: Olean PRIMARY INSURANCE PLAN: BCBS of WNY STATE: NY PRIMARY INSURANCE PLAN ID #: 097041380

ZIP CODE: 14760 SECONDARY INSURANCE PLAN:

TELEPHONE: 585-372-7368 SECONDARY INSURANCE PLAN ID #:

GENDER: Male OCCUPATION: Instructor

DATE OF BIRTH : 04-24-1947 NAME OF EMPLOYER: Jamestown College

DIAGNOSIS INFORMATION Diagnosis Code Diagnosis Code 1. 5.

2. 6.

3. 7.

4. 8.

PROCEDURE INFORMATION Description of Procedure or Service Date Code Charge 1.

2.

3.

4.

5.

SPECIAL NOTES:

Global Care Medical Center

100 Main St, Alfred NY 14802

(607) 555-1234

PHYSICIAN OFFICE RECORD

PATIENT NAME : MOHR, Lee PATIENT NUMBER: POCase024

DATE OF SERVICE: 08-17-YYYY DATE OF BIRTH 04-24-1947

NURSING DOCUMENTATION: MEDICATIONS ALLERGIES/REACTIONS: None

CURRENT MEDICATIONS: Warfarin, diltiazem, simvastatin, famotidine, and nitrogycerine.

BP: 118/72 P: 76 R: 18 T: WT 212 HT 70”

CC: The patient has no acute problems or complaints today.

PMH: Coronary artery disease with cardiac dysrhythmia, cerebrovascular disease, hyperluipidemia, and speech impediment secondary to the CVA. Anterior wall MI with both ventricular and atrial fibrillation as well as congestive heart failure and chronic ischemic heart disease

NOTES: Patient is upset today over care he states he never received approximately 3 weeks ago. Patient calmed down enough to see Ruben Blades, P.A. and is happy to be seen by him today he stated.

SIGNATURE OF PRIMARY CARE NURSE: Mary Kay Place, R.N.

PHYSICIAN DOCUMENTATION:

Notes: Mr. Mohr is a 49-year-old white male who has the following problems: Coronary artery disease with cardiac dysrhythmia, cerebrovascular disease, hyperlipidemia and speech impediment secondary to the CVA. He has a history of anterior wall MI with both ventricular and atrial fibrillation as well as congestive heart failure and chronic ischemic heart disease. Presently, the patient has no acute problems or no acute complaints.

Today, his weight is 212 pounds. He stands 70 inches tall. His blood pressure is 118/72, pulse 76, respirations 18. The PE shows him to have a normal HEENT except for some speech impediments due to the CVA. He can speak clearly, but he must speak slowly. His thought pattern to get his words out sometimes takes a little effort, but he does remarkably well. He has a full beard. His lungs are clear to A&P. The heart sounds are regular with a grade 2/6 systolic murmur. The abdomen was obese, no gross organomegaly noted. Bowel sounds were normal. He has a small abdominal hernia along the ventral line at the umbilicus and just above the umbilicus. Lower extremities have good peripheral sensation, good warmth, adequate circulation and there was no evidence of any edema.

As stated the patient has no acute medical problems. His medications continue to be Warfarin which he takes 10 mg on Tuesdays, Thursdays and Saturdays and 5mg on Mondays, Wednesdays, Fridays and Sundays. He is also on 30 mg of diltiazem three times a day, simvastatin 20 mg after supper and famotidine 20 mg twice a day. He also has p.r.n. nitroglycerine subinguinally if he needs it for any chest discomfort or perceived symptoms. As stated, the patient is doing well. He plans to go bear hunting in another couple of weeks in the North country of New York.

There were no acute findings. Continue present treatment plan. He is to be followed up in three months at which time we will also get fasting labs.

SIGNATURE OF PHYSICIAN: H.W. Pocket, M.D. DD: 08-17-YYYY DT: 08-20-YYYY

H.W. Pocket, M.D.

Global Care Medical Center 100 Main St, Alfred NY 14802

(607) 555-1234

PHYSICIAN’S OFFICE ENCOUNTER FORM

EIN: 12-345678

BCBS PIN: GC2222

BCBS GRP : 1234-P

MCD PIN: GCMC1234 MEDICARE UPIN: GC1111

PATIENT INFORMATION: NAME : FINNEY, Albert D. PATIENT NUMBER: POCase025 ADDRESS: 56 Wapesna Road ADMISSION DATE & TIME : 08-17-YYYY CITY: Bolivar PRIMARY INSURANCE PLAN: Medicare STATE: NY PRIMARY INSURANCE PLAN ID #: 060026123A

ZIP CODE: 14754 SECONDARY INSURANCE PLAN:

TELEPHONE: 585-928-0011 SECONDARY INSURANCE PLAN ID #:

GENDER: Male OCCUPATION: Retired

DATE OF BIRTH : 06-23-1922 NAME OF EMPLOYER:

DIAGNOSIS INFORMATION Diagnosis Code Diagnosis Code 1. 5.

2. 6.

3. 7.

4. 8.

PROCEDURE INFORMATION Description of Procedure or Service Date Code Charge 1.

2.

3.

4.

5.

SPECIAL NOTES:

Global Care Medical Center

100 Main St, Alfred NY 14802

(607) 555-1234

PHYSICIAN OFFICE RECORD

PATIENT NAME : FINNEY, Albert D. PATIENT NUMBER: POCase025

DATE OF SERVICE: 08-17-YYYY DATE OF BIRTH 06-23-1922

NURSING DOCUMENTATION: MEDICATIONS ALLERGIES/REACTIONS: None

CURRENT MEDICATIONS: Albuterol, Atrovent, Azmacort, Zantac, Zoloft, potassium, Lasix, prednisone, and Haldol.

BP: 98/70 P: 80 R: T: WT: 111 CVS: NSR CC: Tiredness NOTES: Patient has had two hospital admissions since last visit. First was for 3 days at nearby hospital D/T seizures.

Second was at same hospital D/T respiratory problems on 07-14/YYYY. Patient was placed on respirator. Patient was discharged on 07-30-YYYY. Patient has list of meds. Will have summary sent from hospital to primary care physician. Patient seen by Dr. Mack in medical clinic today was also given MHC appointment with nurse. Was to see Dr. Dupree but Dr. Dupree did not have a clinic today. Mrs. Finney reports he was recently hospitalized in a local hospital for severe breathing problems for a 2-week period. His meds were resumed on discharge. Meds. reviewed and current supply ok. Given follow-up appointments with Drs. Mack and Dupree.

SIGNATURE OF PRIMARY CARE NURSE: Mary Kay Place, R.N.

PHYSICIAN DOCUMENTATION:

Notes: The patient is a white veteran last seen as inpatient at Mercy hospital with a seizure disorder. According to his wife, he was intubated at that time and was in the hospital for a few days and then was given Dilantin. He was told that they do not know why he had the seizure. That was the third time he had the weakness seizure. He was not on any medication. He had CT scan and EEG’s, which were negative. Possibly, he has cerebral atrophy from alcohol abuse. Current medications include small volume nebulizer treatment, Zantac 150 b.i.d., Zoloft 50 mg every day, potassium 10 mEq every day, Lasix 40 mg every day. He is not on any anti-seizure medication. He was given Prednisone in the tapering dosage. Now he is on 10 mg twice a day for five days. He is on Haldol, 4 mg twice a day.

The patient denies any complaint except tiredness. The patient’s wife has noticed that since the discharge, he has been doing fair, but is weak. Now, he has stopped smoking; he is on the patches. Right now, he is on a 7 mg patch and needs one more refill for the 7 mg. The patient denies any complaints as such, no chest pain, but he is a little shaky. Tremors of both hands are noted. When made to talk, the tremors are more prominent. Otherwise, he appears chronically ill. His appetite has been fair. He does not eat much and has already been started on Ensure for a long time.

On exam, the patient is an alert, oriented veteran who looks apathetic. Weight 111 pounds, blood pressure 98-100 range/70, pulse 80 per minute. Conjunctivae are pale. Oximetry on room air is 94%. Chest reveals diminished air intake. No wheezing is noted. CVS: NSR. Abdomen benign. Extremities, no edema noted.

ASSESSMENT: Stable with all these problems. He will have the lab work done today. I will check the lab work and will refer him to the neurologist if he needs any anticonvulsants. I will see him in one month to six weeks in follow-up.

SIGNATURE OF PROVIDER: Bernard Mack, M.D. DD: 08-17 –YYYY DT: 08-20-YYYY

Bernard Mack, M.D.

Global Care Medical Center 100 Main St, Alfred NY 14802

(607) 555-1234

PHYSICIAN’S OFFICE ENCOUNTER FORM

EIN: 12-345678

BCBS PIN: GC2222

BCBS GRP : 1234-P

MCD PIN: GCMC1234 MEDICARE UPIN: GC1111

PATIENT INFORMATION: NAME : THOMPSON, Peter D. PATIENT NUMBER: POCase028 ADDRESS: 111 Clinton ADMISSION DATE & TIME : 08-19-YYYY CITY: Salamanca PRIMARY INSURANCE PLAN: Medicare STATE: NY PRIMARY INSURANCE PLAN ID #: 111410592

ZIP CODE: 14779 SECONDARY INSURANCE PLAN:

TELEPHONE: 716-945-8599 SECONDARY INSURANCE PLAN ID #:

GENDER: Male OCCUPATION: Retired

DATE OF BIRTH : 03-09-1923 NAME OF EMPLOYER:

DIAGNOSIS INFORMATION Diagnosis Code Diagnosis Code 1. 5.

2. 6.

3. 7.

4. 8.

PROCEDURE INFORMATION Description of Procedure or Service Date Code Charge 1.

2.

3.

4.

5.

SPECIAL NOTES:

Global Care Medical Center

100 Main St, Alfred NY 14802

(607) 555-1234

PHYSICIAN OFFICE RECORD

PATIENT NAME : THOMPSON, Peter D. PATIENT NUMBER: POCase028

DATE OF SERVICE: 08-19-YYYY DATE OF BIRTH 03-09-1923

NURSING DOCUMENTATION: MEDICATIONS ALLERGIES/REACTIONS: None

BP: 124/70 P: 76 R: T: WT: 197 HT: 5’ 8”

CC: Patient has no complaints today. Only wants lab work done: PSA, glucose, cholesterol.

PMH: Exogenous obesity, hyperlipidemia.

NOTES:

SIGNATURE OF PRIMARY CARE NURSE: Jeremy Surveille, R.N.

PHYSICIAN DOCUMENTATION:

Notes: Mr. Thompson comes in for his yearly physical. In fact, he says he does not think he needs a physical this time, because he does not feel anything wrong. The last time I saw him was a year ago, when we did a general physical examination that was essentially normal. At that time, we did a lot of laboratory examinations for health maintenance, which were all good, except for elevation in his cholesterol and LDL. The patient is 75 years old and, because he does not have any risk factors other than the fact that he is a male and he has hypercholesterolemia, he did not continue to take his cholesterol-lowering drug as a primary prevention. The patient tries to watch his diet anyway. He is very active, and plays golf at least twice a week.

LAB DATA: Normal CBC, diff, PSA. The only abnormal findings were that his total cholesterol was elevated at 256, LDL was 194, HDL 35. We did not do thyroid function tests at that time.

PE: He is well-developed, slightly obese, and in no distress. He has no pallor, no jaundice. NECK: Showed no jugular venous distension. HEART: Regular. LUNGS: Completely clear. ABDOMEN: Showed no hepatosplenomegaly. EXTREMITIES: Show no venostasis changes. No edema. ASSESSMENT: Exogenous obesity, hyperlipidemia.

PLAN: He should have a repeat CBC, diff, Astra 8, LFT’s, PSA, total cholesterol, LDL, HDL, triglyceride, T4, TSH; which he wants to have done next week. If everything is okay, he will return again in one year for his yearly physical.

SIGNATURE OF PROVIDER: Barry Fitzgerald, M.D.

DD: 08-19 –YYYY DT: 08-20 -YYYY Barry Fitzgerald, M.D.

Global Care Medical Center 100 Main St, Alfred NY 14802 (607) 555-1234

LABORATORY DATA

PATIENT NAME : THOMPSON, Peter D. PATIENT NUMBER: POCase028

LOCATION: PO PROVIDER: Barry Fitzgerald, M.D.

SPECIMEN COLLECTED: 08-19-YYYY SPECIMEN RECEIVED: Blood

TEST RESULT FLAG REFERENCE

Total cholesterol 256 **H** < 200 mg/dL

HDL 35 = 35 mg/dL

LDL 194 **H** < 130 mg/dL

PSA 3.8 = 4 ng/mL

WBC 6.7 4.5-11.0 thous/UL

RBC 5.3 5.2-5.4 mill/UL

HGB 12.5 11.7-16.1 g/dl

HCT 37.5 35.0-47.0 %

Platelets 250 140-400 thous/UL

PT 12.0 11.0-13.0 seconds

***End of Report***

Global Care Medical Center 100 Main St, Alfred NY 14802

(607) 555-1234

PHYSICIAN’S OFFICE ENCOUNTER FORM

EIN: 12-345678

BCBS PIN: GC2222

BCBS GRP : 1234-P

MCD PIN: GCMC1234 MEDICARE UPIN: GC1111

PATIENT INFORMATION: NAME : BARBER, Jessica PATIENT NUMBER: POCase029 ADDRESS: 421 N. Main Street ADMISSION DATE & TIME : 08-19-YYYY CITY: Olean PRIMARY INSURANCE PLAN: Medicare STATE: NY PRIMARY INSURANCE PLAN ID #: 064118910

ZIP CODE: 14760 SECONDARY INSURANCE PLAN:

TELEPHONE: 716-372-3686 SECONDARY INSURANCE PLAN ID #:

GENDER: Female OCCUPATION: Retired Veteran

DATE OF BIRTH : 06-11-1935 NAME OF EMPLOYER:

DIAGNOSIS INFORMATION Diagnosis Code Diagnosis Code 1. 5.

2. 6.

3. 7.

4. 8.

PROCEDURE INFORMATION Description of Procedure or Service Date Code Charge 1.

2.

3.

4.

5.

SPECIAL NOTES:

Global Care Medical Center

100 Main St, Alfred NY 14802

(607) 555-1234

PHYSICIAN OFFICE RECORD

PATIENT NAME : BARBER, Jessica PATIENT NUMBER: POCase029

DATE OF SERVICE: 08-19-YYYY DATE OF BIRTH 06-11-1935

BP: 120/80 P: 60 R: T: LMP: N/A CVS: NSR

PHYSICIAN DOCUMENTATION:

Notes: Miss Barber is a 69-year-old black veteran who has the problem with seizure disorder, hypertension, history of supraventricular tachycardia, carpal tunnel syndrome, and anemia. She used to be Dr. Fitzgerald’s patient. I saw here for a CVA with the right upper hemiparesis, and was admitted to the local hospital last month with the CVA and TIA. She was discharged home with the physical therapy, so she wanted to come here and have the physical therapy. She was referred here, but she cannot come every day here; so, she is going to the private physical therapy at this time.

CURRENT MEDICATION: She is on enteric-coated aspirin one a day, NTG p.r.n., Bactrim 1 qd for her acne, Tylenol p.r.n. for her pain, Dilantin 250 qd, phenobarbital 90 qd. She was given NSAID group of drug from the private doctor because of the pain after the therapy, that was making her sick to her stomach, so she did not take it since last one week; so, I will discontinue that. Because of her stomach problems, she was started on lansoprazole 30 mg qd and the Gaviscon p.r.n., and that is helping her a lot. Currently, she is on all the medications, plus Lopressor 25 mg b.i.d. for her blood pressure.

SUBJECTIVE: Denies any acute complaint as such today. However, she says whenever she goes to the physical therapy and comes back she gets the pain in her right upper extremity more. Still has the weakness, but it is improving a little. Especially the upper arm and the forearm muscles are weak, and she still gets the paresthesias. She was seen by the neurologist here for her right median and ulnar neuropathy and the seizure disorder. She is supposed to be seen in three months, but I do not see that she went to him again; would check into that. Would also get this follow-up because of the CVA, and get their suggestion. PHYSICAL EXAMINATION: VITAL SIGNS: Today’s blood pressure is 120/80, pulse is 60 per minute. CHEST: Clear. CVS: NSR. EXTREMITIES: No edema noted.

ASSESSMENT: Stable.

PLAN: Continue all the current medication. Check with the Neurology follow-up with the CVA. Patient’s cholesterol done three months ago was high, however, I do not see any other labs done here. So, would get the fasting lab when she comes next time. Her Dilantin level was less than 3 in March, and phenobarbital level was 14.6. Will see her in three months, and obtain past history information.

SIGNATURE OF PROVIDER: Bernard Mack, M.D. DD: 08-19 –YYYY DT: 08-21-YYYY

Bernard Mack, M.D.

Global Care Medical Center 100 Main St, Alfred NY 14802

(607) 555-1234

PHYSICIAN’S OFFICE ENCOUNTER FORM

EIN: 12-345678

BCBS PIN: GC2222

BCBS GRP : 1234-P

MCD PIN: GCMC1234 MEDICARE UPIN: GC1111

PATIENT INFORMATION: NAME : HALE, Bettina PATIENT NUMBER: POCase030 ADDRESS: 43 Sunnydale Avenue ADMISSION DATE & TIME : 08-21-YYYY CITY: Amherst PRIMARY INSURANCE PLAN: Medicare STATE: NY PRIMARY INSURANCE PLAN ID #: 079021564

ZIP CODE: 14226 SECONDARY INSURANCE PLAN:

TELEPHONE: 716-835-7473 SECONDARY INSURANCE PLAN ID #:

GENDER: Female OCCUPATION: Retired

DATE OF BIRTH : 08-09-1952 NAME OF EMPLOYER:

DIAGNOSIS INFORMATION Diagnosis Code Diagnosis Code 1. 5.

2. 6.

3. 7.

4. 8.

PROCEDURE INFORMATION Description of Procedure or Service Date Code Charge 1.

2.

3.

4.

5.

SPECIAL NOTES:

Global Care Medical Center

100 Main St, Alfred NY 14802

(607) 555-1234

PHYSICIAN OFFICE RECORD

PATIENT NAME : HALE, Bettina PATIENT NUMBER: POCase030

DATE OF SERVICE: 08-21-YYYY DATE OF BIRTH 08-09-1952

NURSING DOCUMENTATION: MEDICATIONS ALLERGIES/REACTIONS: None

CURRENT MEDICATIONS: NPH insulin

BP: 140/70 P: 80 R: T: WT: 174 OVS:

CC: Patient here for follow up med change. Patient also was to have UGI done but was cancelled D/T low glucose. Patient will need to reschedule if still needed.

PMH: Patient has no complaints today.

NOTES: Patient came in today for Acucheck training. Actually she has had a machine from us that is not functioning properly and needs to be replaced. She understands how to use it and went to one of the group demonstrations when the machines were first issued. She brought in her machine that was malfunctioning. New machine issued.

SIGNATURE OF PRIMARY CARE NURSE: Jeremy Surveille, R.N

PHYSICIAN DOCUMENTATION:

Notes: Mrs. Hale is a diabetic who we are following every two weeks since she had an attack of diabetic acidosis. She brings in her blood sugar readings, which she has been faithfully doing q.i.d. This shows extremes of readings from 40 to 500. Her current medication is NPH insulin 15 units in the morning and NPH insulin 15 units at h.s.

In addition she does her blood sugars a.c. t.i.d. and h.s., and according to sliding scale she covers with regular insulin except that she does not cover her h.s. blood sugar. One thing is that all her complaints have been listed. She no longer has any problem swallowing and has been eating well, feeling well. She is asymptomatic whether her blood sugars are low or high. Her control has been extremely good when she was on fixed doses of insulin – i.e. NPH 15 units in the morning and 15 units h.s. and 8 units of regular insulin a.c. breakfast, lunch and supper last. She was scheduled to have an upper GI series but because her blood sugar was only 40 this was canceled.

She has no complaints at all today and she really looks good. My sense is that she is taking too much of the NPH insulin at h.s. and this produces hypoglycemia in the morning so what I am going to do is reduce her h.s. insulin and use it a.c. supper instead of h.s. She will fax me her results in two weeks and I will see her in a month.

SIGNATURE OF PROVIDER: Barry Fitzgerald, M.D.

DD: 08-21 –YYYY DT: 08-23–YYYY Barry Fitzgerald, M.D.

Global Care Medical Center 100 Main St, Alfred NY 14802

(607) 555-1234

PHYSICIAN’S OFFICE ENCOUNTER FORM

EIN: 12-345678

BCBS PIN: GC2222

BCBS GRP : 1234-P

MCD PIN: GCMC1234 MEDICARE UPIN: GC1111

PATIENT INFORMATION: NAME : BUCKLEY, Howard G. PATIENT NUMBER: POCase033 ADDRESS: Route 244 ADMISSION DATE & TIME : 08-20-YYYY CITY: Belmont PRIMARY INSURANCE PLAN: Medicare STATE: NY PRIMARY INSURANCE PLAN ID #: 072505173

ZIP CODE: 14813 SECONDARY INSURANCE PLAN:

TELEPHONE: 585-268-9432 SECONDARY INSURANCE PLAN ID #:

GENDER: Male OCCUPATION: Retired

DATE OF BIRTH : 08-18-1916 NAME OF EMPLOYER:

DIAGNOSIS INFORMATION Diagnosis Code Diagnosis Code 1. 5.

2. 6.

3. 7.

4. 8.

PROCEDURE INFORMATION Description of Procedure or Service Date Code Charge 1.

2.

3.

4.

5.

SPECIAL NOTES:

Global Care Medical Center

100 Main St, Alfred NY 14802

(607) 555-1234

PHYSICIAN OFFICE RECORD

PATIENT NAME : BUCKLEY, Howard G. PATIENT NUMBER: POCase033

DATE OF SERVICE: 08-20-YYYY DATE OF BIRTH 08-18-1916

NURSING DOCUMENTATION: MEDICATIONS ALLERGIES/REACTIONS: None

CURRENT MEDICATIONS: diltiazem, Isordil, Metamucil, and Colace.

BP: 122/70 P: 60 R: T: WT: 149 HT: 5’ 6”

NOTES: Patient had pacemaker checked. OK. Still having bowel problem.

SIGNATURE OF PRIMARY CARE NURSE: Mary Kay Place, R.N.

PHYSICIAN DOCUMENTATION:

Notes: Mr. Buckley is an 88-year-old white veteran with coronary artery disease with sick sinus syndromes, status post pacemaker implantation in November, 1993. He is being followed up by the cardiologist, went last week and reports that he is doing good. The patient also has chronic constipation, mild dementia, positive PPD and negative x-ray. He complains of soreness around the anal region and incontinence of the stool and sometimes urine. He is currently on diltiazem CD 180 mg per day and Isordil 20 mg b.i.d., Metamucil one pkg per day and Colace p.r.n. He has glaucoma for which he takes timolol eye drops. On exam, the patient is an alert, well-oriented veteran not in any distress, pleasant. Vital sounds as per the nursing staff. Chest is clear, CVS:NSR. Abdomen: Soft, benign, no masses felt. Rectal exam: The anal area and the surrounding perineal area is being erythematous and there is a tear going from the rectum to the anal region and slight oozing of blood was noted. Rectal exam was done, and I could not feel any masses in the rectum, however, it was painful for him. ASSESSMENT: Anal tear with hemorrhoids. PLAN: Sitz bath, protective ointment around that area and surgical consult and off the pressure and give doughnut ring.

Regarding his Isordil, the last refill was in January. I do not know whether his cardiologist has discontinued that. The patient denies any chest pain, PND or orthopnea at this time. I told the lady who brings him in for visits to check all his medications. I will arrange for the home health aid to go for a visit and to take care of him. I will take to Mary Kay, RN, regarding this. His vitals today are: Weight 149 pounds, blood pressure 122/70, pulse 60 per minute, height 5’6″. I will see him in three months.

SIGNATURE OF PROVIDER: Bernard Mack, M.D. DD: 08-20 –YYYY DT: 08-22-YYYY

Bernard Mack, M.D.

Global Care Medical Center 100 Main St, Alfred NY 14802

(607) 555-1234

PHYSICIAN’S OFFICE ENCOUNTER FORM

EIN: 12-345678

BCBS PIN: GC2222

BCBS GRP : 1234-P

MCD PIN: GCMC1234 MEDICARE UPIN: GC1111

PATIENT INFORMATION: NAME : BUCKLEY, Howard G. PATIENT NUMBER: POCase034 ADDRESS: Route 244 ADMISSION DATE & TIME : 08-24-YYYY CITY: Belmont PRIMARY INSURANCE PLAN: Medicare STATE: NY PRIMARY INSURANCE PLAN ID #: 072505173

ZIP CODE: 14813 SECONDARY INSURANCE PLAN:

TELEPHONE: 585-268-9432 SECONDARY INSURANCE PLAN ID #:

GENDER: Male OCCUPATION: Retired

DATE OF BIRTH : 08-18-1928 NAME OF EMPLOYER:

DIAGNOSIS INFORMATION Diagnosis Code Diagnosis Code 1. 5.

2. 6.

3. 7.

4. 8.

PROCEDURE INFORMATION Description of Procedure or Service Date Code Charge 1.

2.

3.

4.

5.

SPECIAL NOTES:

Global Care Medical Center

100 Main St, Alfred NY 14802

(607) 555-1234

PHYSICIAN OFFICE RECORD

PATIENT NAME : BUCKLEY, Howard G. PATIENT NUMBER: POCase034

DATE OF SERVICE: 08-24-YYYY DATE OF BIRTH 08-18-1928

NURSING DOCUMENTATION: MEDICATIONS ALLERGIES/REACTIONS: None

CURRENT MEDICATIONS: diltiazem, Isordil, Metamucil, and Colace.

BP: 122/70 P: 60 R: T: WT: 149 HT: 5’ 6”

CC:

PMH:

NOTES:

SIGNATURE OF PRIMARY CARE NURSE:

PHYSICIAN DOCUMENTATION:

Notes: DIAGNOSIS: 1. Onychomycosis.

2. Hyperkeratosis.

Follow up toenail prophylaxis. No debridement needed and reduction of a distal corn second toe, right foot. Foot gear and hygiene remain adequate. Patient has no other complaints.

RTC in two months.

SIGNATURE OF PROVIDER H.W. Pocket, M.D.

DD: 08-24-YYYY