Info

Migraine headaches

Elevated blood pressure

Cystocele with occasional stress incontinence

Overweight

Family stress

Low back pain

Tobacco abuse

Varicose veins

History of right pyelonephritis Allergy to ampicillin Health maintenance

Clinicians organize problem lists differently, even for the same patient. Your problem list for Mrs. N may look somewhat different from the one above. Note that problems can be symptoms, signs, or conditions. Good lists vary in emphasis, length, and detail, depending on the clinician's philosophy, specialty, and role as a provider. The list illustrated here includes problems that need attention now, such as the headaches, as well as problems that need future observation or attention, such as the blood pressure and cys-tocele. Listing the allergy to ampicillin warns you not to prescribe medications in the penicillin family.

Some of the items noted in the history and physical examination, such as the canker sores and hard stools, do not appear in this problem list because they are relatively common phenomena that do not currently demand attention. Such judgments may prove to be wrong; however, problem lists that are cluttered with relatively insignificant items diminish in value. Some clinicians would find this list too long; others would be more explicit about such problems as "family stress" or "varicose veins."

Writing the Progress Note. A month later, Mrs. N returns for a follow-up visit. The style of the progress note is also quite variable, but it should follow the same standards as the initial assessment. It should be clear, sufficiently detailed, and easy to follow. It should reflect your clinical thinking and delineate your assessment and plan. The following note follows the SOAP note format (Subjective, Objective, Assessment, and Plan), but you will see many other styles. Often clinicians record the history and physical examination, then break out the patient's problems into separate Assessments and Plans.

1. Migraine headaches.

S: Has had only two headaches, both mild and without associated symptoms.

These are less troubling. Cannot detect any precipitating factors. O: No tenderness over the temporal muscles. No papilledema. A: Headaches improved, now without migraine features. P: Call if symptoms recur.

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