OMAK CLINIC 916 Koala, Omak, WA 9861 (508) 826-1800 SAMPLE PROGRESS NOTE CfiCouic (AVI NAMI Dos: DOS: 04/08/2008 HX: CHIEF COMPLAINT: Chronic pain, left hand lesions. HISTORY OF PRESENT ILLNESS: The patient is a pleasant 46-year-old female who has chronic back pain and fibromyalgia who is currently on METHADONE 40 mg per day and is also ‘on CLONOPIN on a tapering schedule having been on 2 mg bii.d., recently decreased to 1.75 ‘mg bi.d. The patientis due for another reduction in dose. ADVERSE EFFECTS: The patient is having some constipations, small, somewhat hard BMs. ACTIVITY: The patient feels that she has maintained her functional ability from before. ANALGESIA: The patient has been doing more physically, and she believes as a resultis having somewhat more pain, but this she feels is tolerable. ADHERENCE: The patient is on bubble packs through Ulrich Pharmacy and this is being very tightly controlled, She brings in those bubble packs for inspection today. DEPRESSION: The patient feels that she is stable on the FLUOXETINE at 20 mg per day, no changes. PHYSICAL REHABILITATION: The patient is undergoing PT and she believes she is continuing to make progress. A physical therapist, Dina Lund, is pleased with this progress. VOCATIONAL REHABILITATION: We have made arrangements for the patient to see the vocational rehabilitation counselor, but in the interim an opportunity has come up for possible employment 2 days a week that she is very excited about, was encouraged to apply by the employer and will be doing so today, finding out regarding this job possibilty in 1 to 2 days time The patients very enthusiastic about this opportunity LESIONS ON HAND: The patient has some crusted lesions on her hand that she is concerned about. No other rashes, there has been no fever, no joint pain. PATIENT PROFILE: | have reviewed the Patient Profile, including the Past Medical History, Family History, and Social History, and made any necessary changes. PHYSICAL EXAMINATION: Vital Signs: ‘Weight 200, temperature 98, blood pressure 110/78, pulse 84, respiratory rate 16, General: No acute distress. Skin: Remarkable for what appear to be healing abrasions on hand. The patient states that she may well have injured herself, not remembering at the time. No other lesions noted, and skin without other rashes. Neuropsychiatric: Alert, engaged, appropriately circumspect and somewhat fearful about her working again, but at the same time quite happy about the prospect. ASSESSMENT AND PLAN: 1. Chronic pain reasonably controlled. We will decrease the CLONOPIN from 1.75 mg p.o. b.i.d. to 1.5 mg bid. Billing&Documentation_WVM_Sample Progress Note Chronic Pain_47OMAK CLINIC 916 Koala, Omak, WA 9886 (509) 826-1800 PROGRESS NOTE NAME: Dos: Dos: 04/08/2008 HX: 2. Constipation. We will add COLACE 100 mg bid, and CITRUCEL 1 tablespoon in § ounces of water with the same meal once a day. 3. We will obtain urine drug screen at this time, specifically for METHADONE and other drugs of abuse. 4. Skin lesions. Reassured no signs of infection; to calli these do not heal. 5. Counseling regarding possible job. We discussed the fact that if she were to be successfulin Controlling her pain and improving her life, that having work is an essential element. We further discussed that under no circumstances should the excuse of pain prevent her from going to work. An acute illness, fever, vomiting, etc, was a different matter, but if she was going to be Successful and reduce her pain ultimately, she should not allow pain to keep her from her obligation at work, She understands this and believes she can follow through with this plan. Itis in this way that we discussed her gaining control over her pain and pursuing those activities that reduce it and control tas well 6. Followup appointment, 20 minutes, 1 month. 7. Forms per Pathway. Follow up prior to visi. ce: D: 04/08/2008 Family Practice 04/10/08 MS'sha JOB:444379 Robert E. Justus, MD