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Progress Notes

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Healthcare Document Intelligence

The world's best progress note extraction

Streamline clinical documentation workflows with automated progress note processing. Extract SOAP format data including subjective complaints, objective findings, assessments, and treatment plans. Enable comprehensive care tracking and quality reporting.

progress-notes.pdf

Viewer

JSON

visit_date

2024-03-25

visit_type

Follow-up

patient_name

Thomas J. Anderson

patient_dob

1970-05-18

medical_record_number

MRN-2024-33456

provider_name

Dr. Michelle Carter, MD

provider_npi

1234567890

practice_name

Riverside Primary Care

chief_complaint

Diabetes follow-up, blood pressure check

subjective

Patient returns for routine diabetes and hypertension management. Reports good compliance with medications. Checking blood sugars at home, fasting levels ranging 110-130 mg/dL. Denies polyuria, polydipsia, or blurred vision. No chest pain, shortness of breath, or lower extremity edema. Diet compliance fair - admits to occasional carbohydrate excess on weekends.

objective

vital_signs: {"blood_pressure":"138/86 mmHg","heart_rate":"72 bpm","temperature":"98.4 F","respiratory_rate":"16/min","weight":"198 lbs","height":"5'10\"","bmi":"28.4"}, physical_exam: {"general":"Alert, oriented, no acute distress","cardiovascular":"Regular rate and rhythm, no murmurs","respiratory":"Clear to auscultation bilaterally","extremities":"No edema, pulses intact, monofilament exam normal"}, recent_labs: {"hba1c":"7.2%","fasting_glucose":"126 mg/dL","creatinine":"1.0 mg/dL","egfr":"82 mL/min"}

Assessment

3 items

diagnosis

icd10_code

status

Type 2 diabetes mellitus, controlled

E11.65

Stable

Essential hypertension

I10

Borderline controlled

Overweight

E66.3

Ongoing

plan

Continue Metformin 1000mg BID, Increase Lisinopril from 10mg to 20mg daily for better BP control, Reinforce dietary counseling - limit simple carbohydrates, Schedule diabetic eye exam, Repeat HbA1c in 3 months, Return visit in 3 months or sooner if concerns

Cpt_codes_billed

1 item

code

description

99214

Office visit, established patient, moderate complexity

time_spent_minutes

provider_signature

Michelle Carter, MD

signature_date

2024-03-25

{ "visit_date": "2024-03-25", "visit_type": "Follow-up", "patient_name": "Thomas J. Anderson", "patient_dob": "1970-05-18", "medical_record_number": "MRN-2024-33456", "provider_name": "Dr. Michelle Carter, MD", "provider_npi": "1234567890", "practice_name": "Riverside Primary Care", "chief_complaint": "Diabetes follow-up, blood pressure check", "subjective": "Patient returns for routine diabetes and hypertension management. Reports good compliance with medications. Checking blood sugars at home, fasting levels ranging 110-130 mg/dL. Denies polyuria, polydipsia, or blurred vision. No chest pain, shortness of breath, or lower extremity edema. Diet compliance fair - admits to occasional carbohydrate excess on weekends.", "objective": { "vital_signs": { "blood_pressure": "138/86 mmHg", "heart_rate": "72 bpm", "temperature": "98.4 F", "respiratory_rate": "16/min", "weight": "198 lbs", "height": "5'10\"", "bmi": "28.4"}, "physical_exam": { "general": "Alert, oriented, no acute distress", "cardiovascular": "Regular rate and rhythm, no murmurs", "respiratory": "Clear to auscultation bilaterally", "extremities": "No edema, pulses intact, monofilament exam normal"}, "recent_labs": { "hba1c": "7.2%", "fasting_glucose": "126 mg/dL", "creatinine": "1.0 mg/dL", "egfr": "82 mL/min"} }, "assessment": [ { "diagnosis": "Type 2 diabetes mellitus, controlled", "icd10_code": "E11.65", "status": "Stable"}, { "diagnosis": "Essential hypertension", "icd10_code": "I10", "status": "Borderline controlled"}, { "diagnosis": "Overweight", "icd10_code": "E66.3", "status": "Ongoing"} ], "plan": [ "Continue Metformin 1000mg BID", "Increase Lisinopril from 10mg to 20mg daily for better BP control", "Reinforce dietary counseling - limit simple carbohydrates", "Schedule diabetic eye exam", "Repeat HbA1c in 3 months", "Return visit in 3 months or sooner if concerns"], "cpt_codes_billed": [ { "code": "99214", "description": "Office visit, established patient, moderate complexity"} ], "time_spent_minutes": 25, "provider_signature": "Michelle Carter, MD", "signature_date": "2024-03-25"}

progress-notes.pdf

Viewer

JSON

visit_date

2024-03-25

visit_type

Follow-up

patient_name

Thomas J. Anderson

patient_dob

1970-05-18

medical_record_number

MRN-2024-33456

provider_name

Dr. Michelle Carter, MD

provider_npi

1234567890

practice_name

Riverside Primary Care

chief_complaint

Diabetes follow-up, blood pressure check

subjective

objective

Assessment

3 items

diagnosis

icd10_code

status

Type 2 diabetes mellitus, controlled

E11.65

Stable

Essential hypertension

I10

Borderline controlled

Overweight

E66.3

Ongoing

plan

Cpt_codes_billed

1 item

code

description

99214

Office visit, established patient, moderate complexity

time_spent_minutes

provider_signature

Michelle Carter, MD

signature_date

2024-03-25

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