DOB: 1986-07-01PATIENT ID: 9ENCOUNTER ID: 10Checked Out
Your visit summary has been saved to your medical record. The transcripts and recordings will be automatically deleted within 24 hours.
Joan Smith
Status: ready
Recorded Clips:
No recorded clips yet.
Clip 1
readyForReview
0:00
Joan Smith came in today with some complaints about her heart pumping really quickly. It seems as if there might be an issue with her blood pressure initially. Going to do some further tests to determine what the problem is.
Chief Complaint
Reason given at check-in: “Joan is here today for a general check-up.”
Ask the patient (or their authorized representative) whether de-identified
information from this visit may be retained beyond the usual 24 hours to help
improve the software. Participation is voluntary and does not affect their care.
Not askedAuthorizedDeclined
Saved successfully.
Visit History
No previous visits on record.
Visit Results
Visit Results
Session: clinic-visits/2026-08-08/9/10
Everything here is deleted automatically within 24 hours. Use Copy, Copy all, or Print to keep anything you need before then.
Patient Summary
WHY YOU CAME IN TODAY
You came in today for a general check-up, and mentioned that you've been feeling your heart beat very quickly at times.
WHAT WE FOUND
Your blood pressure was a little higher than we'd like, and your doctor wants to look more closely at the fast heartbeat you described. To figure out what's causing this, we'll need some additional testing.
YOUR TREATMENT PLAN
Your doctor is ordering further tests for your heart and blood pressure. You don't need to start any new medications today, but please complete these tests as soon as possible.
WHEN TO SEEK EMERGENCY CARE
Chest pain or pressure
Difficulty breathing
Severe dizziness or fainting
YOUR FOLLOW-UP
Please schedule a follow-up appointment for two weeks from today, and finish any ordered tests before that visit.
SOAP Note
SUBJECTIVE — Chief complaint: palpitations (“heart pumping really quickly”) noted during a general check-up. Onset, duration, and aggravating factors not mentioned.
OBJECTIVE — BP: 138/88 mmHg [REVIEW — elevated; recommend recheck before patient leaves] · HR: 80 bpm · Temp: 98.6°F · Weight: 140 lbs · Height: 65 in. Cardiovascular: tachycardia/palpitations noted as chief complaint; no specific exam findings documented.
ASSESSMENT — Palpitations with elevated blood pressure; etiology to be determined.
PLAN — Order ECG and basic metabolic panel; recheck BP at follow-up in two weeks; no new medications today.
Exam Findings
Blood pressure 138/88 mmHg — stage 1 hypertension range; single reading, not yet confirmed.
Reported intermittent palpitations; no documented rhythm abnormality at time of visit.
Temperature, weight, and height within expected range.
No chest pain, shortness of breath, or syncope reported.
Billing Codes
99214 — Office/outpatient visit, established patient, moderate complexity
R00.2 — Palpitations
R03.0 — Elevated blood-pressure reading without diagnosis of hypertension
Z00.00 — General adult medical examination without abnormal findings
Suggested codes. Always confirm them against the documentation before submitting.
BP 138/88 with reported palpitations. Recheck manually with an appropriately sized cuff after 5 minutes of rest; assess for white-coat effect, caffeine or stimulant intake, and acute symptoms.
Sources: AHA Hypertension Guidelines 2023
✓ Accepted
Palpitations WorkupHIGH88% confidence
Obtain 12-lead ECG to characterize rhythm; consider TSH and basic metabolic panel. Ask about onset pattern, triggers, syncope, and family history of arrhythmia.
Sources: ACC/AHA Palpitations Evaluation Pathway
✓ Accepted
Preventive Care OpportunityMODERATE76% confidence
General check-up visit: confirm immunizations and age-appropriate screenings are current while the patient is in the room.