Undergraduate Program

Writing a Problem-Oriented Note

When you see a patient in the family practice office, we recommend that you write problem-oriented progress notes. Each progress note should be organized as follows:

Name the primary problems addressed - for example, fever and cough, or well person examination

S (for subjective): all relevant historical data
O (for objective): physical examination and laboratory data
A (for assessment): your clinical impression
P (for plans): plans for therapy, additional testing, and patient education

Organize the next progress note the same way.

PROBLEM: HYPERTENSION AND DIABETES

S: Patient has 10 year history of hypertension. She is on Verapamil daily. No complaints of dyspnea on exertion, paroxysmal nocturnal dyspnea, chest pain or pressure, orthopnea. Pt is limiting her salt intake and exercises daily. Patient is taking Glucotrol XL 10 mg daily. She complains of numbness and tingling in feet and toes. No hypoglycemia. She does not do home glucose testing. Is not following a good diet.

O: Blood pressure 159-60, Pulse 88, Respirations 12, afebrile.

Well developed, well-nourished, black female in no acute distress. Alert and oriented times 3.

NECK: Supple, full range of motion, no thyromegaly, bruits, or adenopathy

LUNGS: No rales, rhonchi, or wheezes. Good air movement.

HEART: Regular rate and rhythm without murmurs, gallops or rubs.

EXTREMITIES: No cyanosis, clubbing, or edema

FOOT EXAM: Decreased sensation both soles to touch with microfiber. No signs of infection or broken skin.

 

Lab: Random Blood Sugar: 221

A: Hypertension poor control. NIDDM-uncontrolled

P: 1) Increase Verapamil

2) BUN, Cr, microalbumin, Hemoglobin A1c today.

3) Glucophage 500 mg once daily for 2 weeks, then increase to twice daily.

4) Schedule patient educator visit.