Example_1_-_FPCA_Chart_Progress_Note.pdf
PDF 250 KB Posted
- Attached to
- Electronic Health Records
- Solicitation number
- 2024-280
- Issued by
- Collin County, Texas
About this file
This document is a medical progress note from Collin County Health Care Services, specifically a post-offer pre-placement examination for an individual named Jean Test conducted on April 13, 2022. The progress note details a comprehensive physical examination covering multiple body systems including head and face, eyes, ears, nose, mouth, throat, neck, respiratory, cardiovascular, gastrointestinal, musculoskeletal, neurologic, and psychiatric domains. The examination was performed by Provider Ramzi Taim and involves a standard pre-employment health screening process.
The progress note indicates the examination resulted in a "Failed - Heartrate" assessment (code V72.9), with additional procedural instructions for urinalysis and drug screening. The document specifies that if the initial urine specimen is reported as dilute, the individual must return to the office for a repeat submission. The Human Resources policy states that two negative-dilute reports will disqualify the individual from further employment consideration. The note is electronically signed and validated, with specific medical codes noted for urinalysis (81000) and drug screening (80101), and includes detailed observations about the patient's physical condition, mental status, and overall health assessment.
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Text version
Collin County Health Care Services Progress Note
Chie f Compla in t l Post-Offer Pre-Placement with FPCA
His tory Of Present I l lness
Phys i ca l Examinat ion
¡ Head : normal
¡ Vision :
n Acuity : visual acuity as noted per nurse's notation n Visual Fields : 70 degrees of lateral horizontal gaze, upper and lower visual fields, O.U.
¡ Sclerae : normal ¡ Pupils and Irises : normal ¡ Corneas : normal
¡ Ears :
n External Ears : normal A.U.
n Otoscopic Examination : normal A.U.
n Hearing : passes 5' whisper test A.U.
¡ Nose : normal ¡ Oral Cavity :
n Teeth : unremarkable ¡ Throat : normal
¡ Inspection/Palpation : normal ¡ Range of Motion : no limitation in motion noted ¡ Thyroid : normal to palpation
¡ Respiratory Effort : normal ¡ Auscultation of Lungs : normal breath sounds bilaterally
¡ Heart :
n Auscultation of Heart : regular rate and rhythm, no murmurs or gallops present
¡ Peripheral Vascular System :
n Abdominal Aorta : no abdominal bruit or thrill noted
¡ Abdominal Examination : normal, without guarding, rebound, or distension ¡ Liver and spleen : no organomegaly or palpable irregularities ¡ Hernias : no appreciable hernia present
Patient Name: Jean Test
Patient ID: 11375
Sex: Female
Birthdate: January 1, 2001
Visit Date: April 13, 2022
Provider: Ramzi Taim, Location: Collin County Health Care Services
Location Address: 825 N. McDonald St. Suite 130 McKinney, TX 75069
Location Phone: (972) 548-5500
Applicant HOW DOES APPLICANT PRESENT?
Medical, surgical, blood transfusion, medication, allergy, immunization, work injury/claim, disability, and other illness/injury histories completed by individual were reviewed.
Head and Face
Eyes
Ears, Nose, Mouth and Throat
Neck
Respiratory
Cardiovascular
Gastrointestinal
Lymphatic
[Date Printed:11/1/2024] Page 1 of 2[Progress Note] [Jean Test] [11375]
[Digital Signature Validated]
¡ Neck : no lymphadenopathy present ¡ Preauricular Nodes : no lymphadenopathy present
¡ Spine :
n Inspection/Palpation : no localized tenderness, scoliosis, kyphosis, or excessive lordosis n Range of Motion : no limited spinal movement appreciated on gross examination
¡ Right Upper Extremity :
n Inspection/Palpation : grossly normal appearance n Range of Motion : no limited motion appreciated
¡ Left Upper Extremity :
n Inspection/Palpation : grossly normal appearance n Range of Motion : no limited motion appreciated
¡ Right Lower Extremity :
n Inspection/Palpation : grossly normal appearance n Range of Motion : no limited motion appreciated
¡ Left Lower Extremity :
n Inspection/Palpation : grossly normal appearance n Range of Motion : no limited motion appreciated
¡ General Inspection : No tattoos. No surgical scars.
¡ Mental Status Examination :
n Memory : memory intact, immediate recall intact, long-term recall intact
¡ Cranial Nerves : Cranial nerves 2-12 grossly intact , no nystagmus present ¡ Motor Examination :
n RUE Strength : no significant loss of strength n LUE Strength : no significant loss of strength n RLE Strength : No significant loss of stength n LLE Strength : No significant loss of strength
¡ Reflexes : DTR's 2 bilaterally in lower extremities only ¡ Gait and Station : normal gait, able to stand without difficulty ¡ Cerebellar Function : normal heel/toe gait; negative Romberg test w/o pronator drift
¡ Mood and Affect : mood normal, affect appropriate
Assessment l (1) FPCA, Failed - Heartrate V72.9
Plan
¡ Urinalysis, by dip stick or tablet reagent for bilirubin, glucos (81000) - - ¡ Drug screen, qualitative; single drug class method (eg, immunoassay, enzyme assay), each drug class (80101) - -
¡ Individual advised of potential need to return to office for second urine specimen submission should initial report state that specimen was dilute. If such a case arises the individual will be advised to return to office immediately for repeat specimen submission. Individual is not to consume fluids following notification and prior to return to office. Individual advised that as per Human Resources policy, two negative-dilute reports are considered a failure and will disqualify individual for further employment consideration.
Electronically Signed by: Ramzi Taim, -Author on April 13, 2022 04:29:31 PM
Musculoskeletal
Skin and Subcutaneous Tissue
Neurologic
Psychiatric
Orders
Instructions
[Date Printed:11/1/2024] Page 2 of 2[Progress Note] [Jean Test] [11375]
[Digital Signature Validated]
File details come from the government source that posted it. Updated .