Abstract
This sample record is meant to demonstrate comprehensive recording of pertinent data. Actual records will vary in format; many will be written in a more abbreviated style. Name: Sharon DiStefano1 Date of birth: December 8, 19832 Drug allergies: None; cramps from erythromycin3 Immunizations: Fully immunized4 Thursday, February 6, 1992 Telephone Teacher called parents — Sharon "suddenly gets a blank look" for brief periods. Has done this several times. Parents will get further information from teacher, watch carefully over weekend, bring in for visit next week. Tuesday, February 11, 1992 CHIEF COMPLAINT: "We think she's having spells." PRESENT ILLNESS: (See letter from teacher). He has noted over the last week, on 5 or 6 occasions, that Sharon will develop "blank stare" suddenly. When talked to, will not respond at first but will after several repetitions. Once did this in the middle of talking; paused noticeably for a number of seconds, then resumed talking. Eyes always stay open; blinking noted; no total loss of consciousness. No jerking, twitching, slumping, drooling, incontinence. Seems normal afterwards; not aware of any lapse. Over the weekend parents saw similar spells: three times at meals, twice when watching television, once after she had been running around backyard and had just sat down. "Like a shade was drawn behind her eyes."
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