And aside from the SSN question on this supposed office visit note, I also find it not credible as a real office visit note for several other reasons.
It notes current medications but only in vague terms – not the actual name of any of the medications nor of their present dosages. Likewise, it mentions increasing dosages of “anti-depressants” and “anti-anxiety medications” but again, does not name the medications specifically nor what the dosage were increased to.
Next someone with the conditions mentioned, particularly with Subcortical Vascular Dementia would be treated by a neurologist not an internist. An internist may treat other issues and conditions but I would think, would coordinate care and would likely consult with her neurologist (who would I think also be named in the office visit note) before changing medications especially if the patient’s chief complaint was “dizziness, fatigue, “mini-seizures” and memory loss.
Finally, the records make no mention of her vital signs – BP, heart rate, temperature, weight, etc. which are always part of every visit and even a routine or follow up office visit and would be if I am not mistaken, always be noted. A doctor would also note their general observations of the patient – was she alert, what was the doctor’s overall impression of the patient’s physical appearance and demeanor.
And lastly, the “I advised her to travel with a medical team” does not sound like something any doctor would write in someone’s medical record.
Just for purposes of illustrating and providing some examples of what doctor visit notes should actually contain:
Sample Outpatient Noteshttps://www.med.unc.edu/medselect/resources/sample-notes/sample-outpatient-notes
