Medical Documentation Proofreading Example 15

Question

The patient is an 50-year-old female who came into the emergency room. This morning the patient  experiences symptoms for lightheadedness, dizziness and she felt like passing out. However, there was  no actual syncope. During the episode, the patient describes symptoms of palpitation and fluttering of her  chest. He relates that her heart was racing. By the time she came to the emergency room, her EKG showed  normal sinus rhythm. There was no evidence of arrythmia. The patient had some cardiac work up in the  past, and her results are as mentioned below. She denies any specific chest pain. Her activities is fairly  stable. She is actively employed. She has no other cardiac risk factors in terms of alcohol consumption or  recretional drug use, Caffeine use, and over-the-counter medication usage. She deny history of  hypertension and diabetes mellitus. She is non smoker. Her cholesterol was normal. She denies history  of establish coronary artery disease, and her family history was noncontributory.


medical report proofreading for medical scribe students



Answer


The patient is a 50-year-old female who came to the emergency room. This morning, the patient  experienced symptoms of lightheadedness and dizziness, and she felt like passing out. However, there was  no actual syncope. During the episode, the patient describes symptoms of palpitation and fluttering of her chest. She relates that her heart was racing. By the time she came to the emergency room, her EKG revealed  normal sinus rhythm. There was no evidence of arrhythmia. The patient had some cardiac workup in the  past, and her results are as mentioned below. She denies any specific chest pain. Her activities are fairly  stable. She is actively employed. She has no other cardiac risk factors in terms of alcohol consumption or  recreational drug use, caffeine use, or over-the-counter medication usage. She denies history of  hypertension or diabetes mellitus. She is nonsmoker. Her cholesterol is normal. She denies history of established coronary artery disease, and her family history was noncontributory.

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