June 15, 2019

Medical Scribe Training


Example Audio


Subjective - HPI

This is an unscheduled sick visit. Patient complains of sore throat associated with dry cough which has been ongoing for the past 2 days, which is painful during swallowing. She denies of taking any OTC(Over The Counter) medications. She denies of any fever, ear ache, rhinorrhea, nasal congestion, body ache nor chills. She also denies of any family member being sick recently.
Her BP was elevated today at the office. She reports that she is compliant with her BP medications, however she forgot to take medications today morning. She possesses personal sphygmomanometer and Glucometer and regularly checks her Blood Pressure and blood sugar levels. Her blood sugar levels are between normal ranges.

Objective - Examination

During Examination, her throat was inflamed but her lymph notes were not inflamed. During auscultation, her lungs sounded normal. Her heart sounds were normal too.

Assessment - Diagnosis

She was diagnosed with Acute pharyngitis

Plan - Prescription

She was prescribed with zithromax, 2 tabs on first day and one tablet for the next 4 days. She was also advised to take OTC Mucinex DM. She was recommended for salt water gargling which might help with her condition. If she experiences any pain or fever in the she was advised to take OTC Tylenol or Motrin.She was advised to continue monitoring her BP and sugar level at home

RTC(Return To Clinic)

RTC as scheduled earlier.