Note must have an identifier unique to a patient and may include other patient information such as name DOB, SSN. Notes will be loaded to specific chart sections based on CATEGORY, if provided in the
progress notes data records. Default Chart sections (which can be renamed) are Progress Notes, Past Medical history, Social History, Family History, Consults, Discharge Summary, X-Ray, EKG, Lab
Microbiology, Lab Miscellaneous, Pathology, Special Studies. Additional User defined sections may be added. The provided progress notes data records must be free of special characters for RTF, HTML, etc…
Format of Progress Note File
*NEW RECORD**|Patient ID|Title|Date|Doctor Code
Sample format of progress note file
NOTE: Please make sure that no titles are duplicated for a given patient and Date. The note will not load.
**NEW RECORD**|111111|PROGRESS NOTE|02/06/2012|MY SMITH, MINNIE P
PHYSICIAN: Mary Young, M.D.
CHIEF COMPLAINT: None.
HISTORY OF PRESENT ILLNESS: Today the patient presents for routine clinic follow-up.
Overall the patient seems to be doing relatively well.
CURRENT MEDICATIONS: The patient did not bring a list of her medications with her.
ASSESSMENT AND PLAN:
1. Today I have had a long discussion with her. With this, I plan to see the patient again in two months.
2. Social. The patient continues to be followed by hospice.
Mary Young M.D
Electronically Signed by: Mary Young, MD on Saturday, February 16, 2012
**NEW RECORD**|111111| CONSULTATION REQUEST|08/15/2012|MD
HISTORY: Minnie is a 50-year-old lady, who comes in today for evaluation of her left shoulder.
The patient has recent weight loss in the past five months. She also has night sweats or chills, and she has constitutional symptoms.
PHYSICAL EXAMINATION: Her physical examination showed she did have pain over the entire shaft of the humerus. There did not appear to be any soft tissue mass in the shoulder, but she did have swelling about the shoulder.
PLAN: We are going to obtain an MRI
Mary Young M.D
PAST MEDICAL HISTORY, SOCIAL HISTORY, FAMILY HISTORY
Patient ID|Date|Test Line
Sample of Past Medical History
11111|08/22/2003| Prostate Cancer.
Sample of Social History
111111|09/25/2003|Lifestyle married 3 children.
Sample of Family History
111111|08/22/2003|Hypertension mother sister