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Feature | C.R.U.S.H. | Other AI Scribes |
---|---|---|
Pinpoint Accuracy | CRUSH nails every detail of your medical jargon with precision, achieving 99% accuracy for all specialties, as validated by research. | Produces botched notes that need constant fixing |
EHR Integration | With deep bidirectional integrations, CRUSH offers seamless sync with any EHR system—Epic, Cerner, or any EHR—delivering true EHR AI Scribe capability for unmatched workflow efficiency. | Stuck in copy-paste purgatory with limited compatibility |
Multilingual Mastery | CRUSH is fluent in English, Spanish, French, and more. | Fumbles anything beyond basic English |
Human-Backed Customization | Expert team tailors notes and workflows to your exact needs | Generic templates with minimal personalization |
Complete Workflow Automation | CRUSH handles referrals, prescriptions, and screenings automatically. More than just an AI scribe, CRUSH offers workflow optimization. | Still learning to spell 'referral' |
Clinical Intelligence | CRUSH offers real-time tips, HCC tracking, and preventive care flags to help clinicians improve patient outcomes and financial performance through proactive care and accurate risk adjustments. | Just a fancy note-taker. |
Rapid Documentation | CRUSH ensures charts done in under a minute, no late-night edits. Key for documentation efficiency. | Keeps you working late with constant revisions |
Ironclad Security | CRUSH is a HIPAA compliant AI medical scribe. Developed by S10.AI with SOC 2, HITECH compliant standards - your data security is paramount. | Security as flimsy as a paper chart |
Specialty Adaptation | CRUSH is customized for any specialty from cardiology to psychiatry. Cardiology Dermatology Orthopedics Pediatrics Psychiatry Neurology Oncology Primary Care + More | One-size-fits-all approach that fits none |
AI Template Builder for CRUSH | Build, modify or import personalized templates with one click Create a template from scratch Generate from instructions Import templates Browse community | Locked into rigid templates with no flexibility |
Patient Demographics:
John Doe, 58M DOB: 07/15/1965 MRN: 12345678
Chief Complaint:
Follow up on diabetes and hypertension.
HPI:
Patient is a 58-year-old male with history of type 2 diabetes and hypertension. He reports that his blood sugars have been running between 130-150 in the mornings and that he's been taking his metformin regularly. No issues with his hypertension medication. Denies polyuria, polydipsia, or polyphagia. No chest pain, SOB, dizziness.
Past Medical History:
- Type 2 diabetes diagnosed 2015 - Hypertension diagnosed 2013 - Hyperlipidemia
Medications:
- Metformin 1000mg BID - Lisinopril 10mg daily - Atorvastatin 20mg daily
Still typing... (Note incomplete after 25 minutes)
Sections missing: Assessment, Plan, Patient Education, Billing
Documentation Time: ~25 minutes after visit
Patient Demographics:
John Doe, 58M DOB: 07/15/1965 MRN: 12345678 Insurance: Blue Cross Blue Shield Last Visit: 03/15/2023
Chief Complaint:
Follow up on diabetes and hypertension.
HPI:
Patient is a 58-year-old male with history of type 2 diabetes and hypertension presenting for routine follow-up. He reports his blood sugars have been well-controlled, ranging between 130-150 mg/dL in the mornings. He states he has been adherent with his metformin regimen and has not experienced any side effects. His hypertension has been stable with no symptoms, and he denies any chest pain, shortness of breath, or dizziness. Patient has been following a low-carb diet and walking 30 minutes 3 times weekly. He has lost 5 pounds since his last visit.
HCC Risk Factors:
- Type 2 diabetes without complications [E11.9] - Essential hypertension [I10]
Past Medical History:
- Type 2 diabetes diagnosed 2015, well controlled - Hypertension diagnosed 2013, well controlled - Hyperlipidemia, moderately controlled
Medications:
- Metformin 1000mg BID - Lisinopril 10mg daily - Atorvastatin 20mg daily
Assessment & Plan:
1. Type 2 Diabetes (E11.9) - A1c improved to 7.2% from 7.5% previously - Continue Metformin 1000mg BID - Commended patient on dietary changes and weight loss - Order: Comprehensive metabolic panel & A1c in 3 months 2. Hypertension (I10) - BP today: 132/78, at target - Continue Lisinopril 10mg daily - Encouraged continued sodium restriction 3. Hyperlipidemia (E78.5) - Recent LDL: 110, slightly above target of <100 - Continue Atorvastatin 20mg daily - Order: Lipid panel in 6 months 4. Preventive Health - Due for colonoscopy screening - Order: Colonoscopy referral
Patient Education & Summary:
- Continue all medications as prescribed - Maintain low-carb diet and exercise regimen - Schedule colonoscopy within next month - Return in 3 months for follow-up and lab work - Call office if blood sugars consistently >200 mg/dL
Billing & Coding:
- E/M: 99214 (Level 4 Follow-up visit) - Time-based billing: 25 minutes - DM management: G0108 - CCM coordination: 99490 - Quality Measures: Blood pressure screening (G8783) - Risk Adjustment: HCC19 (Diabetes), HCC85 (Hypertension)
Completion Time: ~60 seconds
Disclaimer
The clinical notes shown above are for demonstration purposes only and do not contain real patient information. The templates can be tailored to individual clinician preferences, specialty requirements, and institutional protocols. CRUSH AI adapts to your specific documentation style and workflow needs.
Reduce documentation time by up to 75%, finishing notes during or immediately after visits.
Generate comprehensive, specialty-specific notes with proper coding and thorough documentation.
Maintain eye contact and meaningful connections while CRUSH handles documentation in the background.
Maximize reimbursements with accurate HCC risk adjustment coding and comprehensive documentation.
Patient Demographics: John Doe, 58M DOB: 07/15/1965 MRN: 12345678
Chief Complaint: Follow up on diabetes and hypertension.
HPI: Patient is a 58-year-old male with history of type 2 diabetes and hypertension. He reports that his blood sugars have been running between 130-150 in the mornings and that he's been taking his metformin regularly. No issues with his hypertension medication. Denies polyuria, polydipsia, or polyphagia. No chest pain, SOB, dizziness.
Past Medical History: - Type 2 diabetes diagnosed 2015 - Hypertension diagnosed 2013 - Hyperlipidemia
Medications: - Metformin 1000mg BID - Lisinopril 10mg daily - Atorvastatin 20mg daily
Patient Demographics: John Doe, 58M DOB: 07/15/1965 MRN: 12345678 Insurance: Blue Cross Blue Shield Last Visit: 03/15/2023
Chief Complaint: Follow up on diabetes and hypertension.
HPI: Patient is a 58-year-old male with history of type 2 diabetes and hypertension presenting for routine follow-up. He reports his blood sugars have been well-controlled, ranging between 130-150 mg/dL in the mornings. He states he has been adherent with his metformin regimen and has not experienced any side effects. His hypertension has been stable with no symptoms, and he denies any chest pain, shortness of breath, or dizziness. Patient has been following a low-carb diet and walking 30 minutes 3 times weekly. He has lost 5 pounds since his last visit.
HCC Risk Factors: - Type 2 diabetes without complications [E11.9] - Essential hypertension [I10]
Past Medical History: - Type 2 diabetes diagnosed 2015, well controlled - Hypertension diagnosed 2013, well controlled - Hyperlipidemia, moderately controlled
Medications: - Metformin 1000mg BID - Lisinopril 10mg daily - Atorvastatin 20mg daily
Assessment & Plan: 1. Type 2 Diabetes (E11.9) - A1c improved to 7.2% from 7.5% previously - Continue Metformin 1000mg BID - Commended patient on dietary changes and weight loss - Order: Comprehensive metabolic panel & A1c in 3 months 2. Hypertension (I10) - BP today: 132/78, at target - Continue Lisinopril 10mg daily - Encouraged continued sodium restriction 3. Hyperlipidemia (E78.5) - Recent LDL: 110, slightly above target of <100 - Continue Atorvastatin 20mg daily - Order: Lipid panel in 6 months 4. Preventive Health - Due for colonoscopy screening - Order: Colonoscopy referral
Patient Demographics: Jane Smith, 62F DOB: 03/22/1961 MRN: 87654321
Chief Complaint: Follow up after recent hospitalization for heart failure exacerbation.
HPI: Patient is a 62-year-old female with history of CHF (EF 35%), CAD s/p stent to LAD 2 years ago, and paroxysmal atrial fibrillation. She was hospitalized 3 weeks ago with acute decompensated heart failure. Reports some improvement in dyspnea and edema since discharge. Still has dyspnea with moderate exertion. Taking medications as prescribed but notes occasional dizziness with metoprolol.
Past Medical History: - CHF (EF 35%) - CAD s/p stent to LAD 2021 - Paroxysmal atrial fibrillation - Hypertension - Hyperlipidemia
Medications: - Metoprolol 25mg BID - Lisinopril 20mg daily - Furosemide 40mg daily - Apixaban 5mg BID - Atorvastatin 40mg daily
Patient Demographics: Jane Smith, 62F DOB: 03/22/1961 MRN: 87654321 Insurance: Medicare Advantage Last Visit: 11/02/2023 (Hospital Discharge)
Chief Complaint: Follow up after recent hospitalization for heart failure exacerbation.
HPI: Patient is a 62-year-old female with history of CHF (EF 35%), CAD s/p stent to LAD 2021, and paroxysmal atrial fibrillation presenting for follow-up after hospitalization for acute decompensated heart failure 3 weeks ago. She reports improvement in symptoms with current medication regimen. Dyspnea has improved but persists with moderate exertion (can climb 1 flight of stairs without stopping, NYHA Class II). Reports reduced bilateral ankle edema. Notes occasional dizziness with metoprolol, typically within 1-2 hours after morning dose. No syncope, chest pain, palpitations, orthopnea, or PND.
HCC Risk Factors: - Systolic Heart Failure [I50.20] - CAD with history of PTCA [I25.10] - Paroxysmal Atrial Fibrillation [I48.0]
Past Medical History: - CHF (EF 35% per echo 11/1/2023) - CAD s/p stent to LAD 2021 - Paroxysmal atrial fibrillation, CHA₂DS₂-VASc score: 4 - Hypertension, well controlled - Hyperlipidemia
Medications: - Metoprolol 25mg BID - Lisinopril 20mg daily - Furosemide 40mg daily - Apixaban 5mg BID - Atorvastatin 40mg daily - Spironolactone 25mg daily (added during hospitalization)
Assessment & Plan: 1. Heart Failure with reduced EF (I50.20) - Improved since hospitalization but still NYHA Class II - Continue current HF medications - Consider reducing metoprolol to 12.5mg BID due to reported dizziness - Daily weight monitoring to continue - Order: BNP, BMP, CBC in 2 weeks 2. Coronary Artery Disease (I25.10) - Stable since PCI in 2021 - Continue high-intensity statin - Order: Lipid panel at next visit 3. Paroxysmal Atrial Fibrillation (I48.0) - No recent episodes reported - Continue anticoagulation with apixaban - EKG today shows NSR - Order: EKG and Holter monitor for 48 hours
Patient Demographics: David Wilson, 35M DOB: 09/12/1989 MRN: 45678901
Chief Complaint: Follow up for depression and anxiety.
HPI: Patient is a 35-year-old male with major depressive disorder and generalized anxiety. Reports mild improvement in mood with sertraline but still having trouble sleeping. Anxiety continues to affect work performance. Denies suicidal ideation or plans.
Past Medical History: - Major Depressive Disorder - Generalized Anxiety Disorder - Mild Insomnia
Medications: - Sertraline 100mg daily - Lorazepam 0.5mg PRN for anxiety
Patient Demographics: David Wilson, 35M DOB: 09/12/1989 MRN: 45678901 Insurance: Cigna Last Visit: 04/02/2024
Chief Complaint: Follow up for depression and anxiety.
HPI: Patient is a 35-year-old male with history of major depressive disorder and generalized anxiety disorder presenting for medication management follow-up. He reports partial response to sertraline 100mg daily with improvement in depressed mood (rates mood as 5/10 compared to 3/10 at last visit) but continues to experience anhedonia and fatigue. Sleep remains disrupted with difficulty initiating sleep (takes 1-2 hours to fall asleep) and early morning awakening (4-5AM). Reports functioning at work has improved somewhat but still struggles with concentration during meetings and deadlines. Using lorazepam approximately twice weekly for acute anxiety. Denies current suicidal or homicidal ideation, intent, or plan. No psychotic symptoms.
HCC Risk Factors: - Major Depressive Disorder, recurrent, moderate [F33.1] - Generalized Anxiety Disorder [F41.1] - Insomnia, chronic [G47.00]
Past Medical History: - Major Depressive Disorder, diagnosed 2018 - Generalized Anxiety Disorder, diagnosed 2018 - Chronic Insomnia - Family history of depression (mother)
Medications: - Sertraline 100mg daily - Lorazepam 0.5mg PRN for anxiety (takes ~2x/week) - No known medication allergies
Assessment & Plan: 1. Major Depressive Disorder, recurrent, moderate (F33.1) - Partial response to sertraline - Increase sertraline to 150mg daily - Continue weekly therapy sessions - PHQ-9 score today: 14 (moderate) improved from 19 (moderate-severe) 2. Generalized Anxiety Disorder (F41.1) - Partial response to current regimen - GAD-7 score today: 12 (moderate) - Continue lorazepam PRN - Discussed mindfulness techniques and breathing exercises 3. Insomnia, chronic (G47.00) - Added trazodone 50mg at bedtime for sleep - Reviewed sleep hygiene measures - Recommended Cognitive Behavioral Therapy for Insomnia (CBT-I)
Patient Demographics: Richard Taylor, 66M DOB: 11/04/1958 MRN: 23456789
Chief Complaint: Annual physical and medication review.
HPI: Patient is a 66-year-old male presenting for annual physical. Has controlled hypertension and dyslipidemia. Reports occasional mild joint pain but generally feels well. Exercise routine includes walking 30 minutes 3x/week. Last colonoscopy 4 years ago was normal. Due for pneumonia vaccine.
Past Medical History: - Hypertension for 12 years - Dyslipidemia - Osteoarthritis of knees
Medications: - Amlodipine 5mg daily - Rosuvastatin 10mg daily - Acetaminophen PRN for joint pain
Patient Demographics: Richard Taylor, 66M DOB: 11/04/1958 MRN: 23456789 Insurance: Medicare Part B Last Visit: 05/10/2023
Chief Complaint: Annual physical and medication review.
HPI: Patient is a 66-year-old male presenting for annual physical examination and medication review. Reports his hypertension and dyslipidemia are well-controlled on current medication regimen. Notes occasional mild bilateral knee pain after prolonged activity, relieved with acetaminophen and rest. Current exercise regimen includes walking 30 minutes three times weekly and light gardening. Last colonoscopy was performed four years ago with normal findings. Has not received pneumonia or shingles vaccinations. Reports adequate energy levels, stable weight, and good appetite. No difficulty with urination, bowel movements, or sleep. No chest pain, shortness of breath, dizziness, or falls.
HCC Risk Factors: - Essential Hypertension [I10] - Hyperlipidemia [E78.5] - Osteoarthritis, localized, knee [M17.9]
Past Medical History: - Hypertension, diagnosed 2012, well-controlled - Dyslipidemia, diagnosed 2014, well-controlled - Osteoarthritis of bilateral knees, mild - Appendectomy 1985
Medications: - Amlodipine 5mg daily - Rosuvastatin 10mg daily - Acetaminophen 500mg PRN for joint pain - Daily multivitamin
Assessment & Plan: 1. Hypertension (I10) - BP today: 126/74, well-controlled - Continue Amlodipine 5mg daily - Home BP monitoring shows readings consistently <130/80 2. Hyperlipidemia (E78.5) - Lipid panel today: LDL 92, HDL 48, TG 110 - Continue Rosuvastatin 10mg daily - ASCVD risk score: 12.4% 3. Osteoarthritis of knees, bilateral (M17.0) - Mild symptoms, manageable with acetaminophen PRN - Encouraged continued gentle exercise - Discussed weight management 4. Preventive Healthcare (Z00.00) - Administered PPSV23 (pneumococcal) vaccine today - Administered Shingrix (first dose) today - Due for colonoscopy this year (last: 2020) - Performed depression screening: negative
Patient Demographics: Patricia Moore, 58F DOB: 02/25/1966 MRN: 34567891
Chief Complaint: Follow up for breast cancer treatment.
HPI: Patient is a 58-year-old female with history of stage II invasive ductal carcinoma of right breast, ER/PR+, HER2-, diagnosed 8 months ago s/p lumpectomy and axillary lymph node dissection. Completed 4 cycles of adjuvant chemotherapy with doxorubicin and cyclophosphamide 3 months ago. Currently on tamoxifen. Reports fatigue and occasional hot flashes but otherwise tolerating treatment well.
Past Medical History: - Stage II invasive ductal carcinoma, right breast - Hypertension - Hypothyroidism
Medications: - Tamoxifen 20mg daily - Lisinopril 10mg daily - Levothyroxine 75mcg daily
Patient Demographics: Patricia Moore, 58F DOB: 02/25/1966 MRN: 34567891 Insurance: UnitedHealthcare Last Visit: 04/15/2024
Chief Complaint: Follow up for breast cancer treatment.
HPI: Patient is a 58-year-old female with history of stage II (T2N0M0) invasive ductal carcinoma of right breast, ER/PR+, HER2-, diagnosed 8 months ago, presenting for routine follow-up. She underwent right breast lumpectomy with sentinel lymph node biopsy (0/3 nodes positive) on 08/20/2023, followed by 4 cycles of adjuvant chemotherapy with doxorubicin and cyclophosphamide completed on 01/10/2024. Currently on adjuvant hormonal therapy with tamoxifen initiated on 01/25/2024. Reports moderate fatigue (5/10) with gradual improvement since completing chemotherapy. Experiencing 3-5 hot flashes daily, mild-moderate intensity. Denies breast pain, masses, skin changes, or axillary lymphadenopathy. No bone pain, shortness of breath, or neurological symptoms. Completed 10 of 30 planned radiation treatments with minimal skin reaction.
HCC Risk Factors: - Malignant neoplasm of breast, specified as right breast [C50.911] - Essential Hypertension [I10] - Hypothyroidism [E03.9]
Past Medical History: - Stage II invasive ductal carcinoma, right breast (T2N0M0), ER/PR+, HER2-, diagnosed 08/2023 - Hypertension, well-controlled - Hypothyroidism, well-controlled - Surgical history: Right breast lumpectomy with SLNB (08/2023)
Medications: - Tamoxifen 20mg daily - Lisinopril 10mg daily - Levothyroxine 75mcg daily - Vitamin D3 2000 IU daily - Calcium citrate 500mg BID
Assessment & Plan: 1. Breast Cancer, Stage II (C50.911) - Post-lumpectomy and chemotherapy, currently on hormonal therapy - Tolerating tamoxifen with expected side effects - Currently undergoing radiation therapy (10/30 treatments completed) - Oncotype DX score was 24 (intermediate risk) - Plan: Continue tamoxifen for planned 5-year course - Order: CBC, CMP, vitamin D level 2. Cancer Treatment Side Effects - Fatigue: Improving, recommended structured exercise program - Hot flashes: Moderate, recommended evening primrose oil and cooling techniques - No evidence of lymphedema 3. Hypertension (I10) - Well-controlled on current regimen - BP today: 118/76 - Continue lisinopril 10mg daily 4. Hypothyroidism (E03.9) - TSH within normal limits at 2.4 (range 0.4-4.0) - Continue levothyroxine 75mcg daily
Patient Demographics: Michael Roberts, 52M DOB: 06/18/1972 MRN: 56789012
Chief Complaint: Right knee pain following meniscus repair.
HPI: Patient is a 52-year-old male presenting for follow-up 6 weeks after arthroscopic repair of right medial meniscus tear. Reports improved pain but still has stiffness in the morning and after prolonged sitting. Has been attending physical therapy twice weekly. Using NSAIDs for pain management.
Past Medical History: - Right medial meniscus tear - Hypertension - Gastroesophageal reflux disease
Medications: - Ibuprofen 600mg PRN for pain - Lisinopril 20mg daily - Omeprazole 20mg daily
Patient Demographics: Michael Roberts, 52M DOB: 06/18/1972 MRN: 56789012 Insurance: Anthem BlueCross Last Visit: 03/23/2024 (Post-op week 2)
Chief Complaint: Right knee pain following meniscus repair.
HPI: Patient is a 52-year-old male presenting for 6-week follow-up after arthroscopic repair of right medial meniscus tear performed on 03/09/2024. He reports significant improvement in pain (now 3/10 from previous 7/10) but continues to experience morning stiffness lasting 15-20 minutes and stiffness after prolonged sitting. Has been attending physical therapy twice weekly with good compliance to home exercise program. ROM has improved but not yet at baseline. Currently using ibuprofen 600mg once daily or every other day for pain management. Denies locking, catching, or instability of the knee. Able to walk without assistive devices and navigate stairs with minimal discomfort. Has returned to desk work but not yet resumed recreational activities (golf, swimming).
HCC Risk Factors: - Tear of medial meniscus of right knee, current [S83.211A] - Status post arthroscopic meniscus repair [Z98.89] - Essential Hypertension [I10] - Gastroesophageal reflux disease [K21.9]
Past Medical History: - Right medial meniscus tear, traumatic onset 02/2024 - Hypertension, diagnosed 2015, well-controlled - Gastroesophageal reflux disease, diagnosed 2018 - Previous left ankle sprain 2019, resolved
Medications: - Ibuprofen 600mg PRN for pain - Lisinopril 20mg daily - Omeprazole 20mg daily - No known drug allergies
Assessment & Plan: 1. Status post right knee arthroscopic medial meniscus repair (S83.211D) - Post-op week 6, progressing as expected - Range of motion: Extension 0°, Flexion 120° (improved from 100° at week 2) - Minimal effusion present - Stable medial and lateral joint lines with decreased tenderness - Incision well-healed with no signs of infection - Continue physical therapy for additional 4-6 weeks - Progress from partial to full weight-bearing activities 2. Post-surgical rehabilitation - Functional status improving; can manage ADLs independently - Cleared to begin stationary bike with minimal resistance - May advance strengthening exercises as tolerated - Goal: Return to recreational activities by 12 weeks post-op 3. Hypertension (I10) - BP today: 132/82, within acceptable range - Continue current medications - Follow up with PCP for routine management
Patient Demographics: Sarah Johnson, 42F DOB: 09/30/1982 MRN: 67890123
Chief Complaint: Lower back pain with radiation to left leg.
HPI: Patient is a 42-year-old female presenting with lower back pain that started after moving furniture 2 weeks ago. Pain radiates to left buttock and posterior thigh. Reports pain is worse with sitting and bending forward. Has been taking OTC ibuprofen with minimal relief.
Past Medical History: - Previous episode of back pain 3 years ago, resolved with chiropractic care - Seasonal allergies
Medications: - Ibuprofen 400mg PRN for pain - Cetirizine 10mg daily PRN for allergies
Patient Demographics: Sarah Johnson, 42F DOB: 09/30/1982 MRN: 67890123 Insurance: Aetna Choice POS II Last Visit: First visit to this practice
Chief Complaint: Lower back pain with radiation to left leg.
HPI: Patient is a 42-year-old female presenting with lower back pain that began acutely after moving furniture 2 weeks ago. Pain is located primarily in the lumbar region with radiation to the left buttock and posterior thigh, stopping above the knee. Describes pain as dull and achy at baseline (5/10) with sharp exacerbations (8/10) during certain movements. Reports pain is worse with prolonged sitting, bending forward, and when getting up from seated position. Minimal relief with position changes and OTC ibuprofen 400mg taken 2-3 times daily. Denies bowel or bladder incontinence, saddle anesthesia, bilateral leg weakness, or fever. Previous episode of similar but less severe back pain 3 years ago resolved after 6 sessions of chiropractic care. Patient works as administrative assistant with prolonged sitting at desk. Exercise routine includes walking 2-3 times weekly.
HCC Risk Factors: - Lumbar radiculopathy [M54.16] - Lumbar segmental dysfunction [M99.03]
Past Medical History: - Previous lumbar strain with radiculopathy 2021, resolved - Seasonal allergies - No surgeries
Medications: - Ibuprofen 400mg PRN for pain - Cetirizine 10mg daily PRN for allergies - No known drug allergies
Assessment & Plan: 1. Lumbar Radiculopathy, left side (M54.16) - Likely L4-L5 or L5-S1 disc involvement - Positive straight leg raise test left at 40 degrees - Diminished left Achilles reflex - Decreased sensation L5 dermatome left foot 2. Lumbar Segmental Dysfunction (M99.03) - Restricted mobility L4-L5-S1 segments - Moderate paraspinal muscle spasm lumbar region bilaterally - Posterior pelvic tilt with left iliac rotation - Positive facet loading test 3. Postural Analysis - Forward head posture - Increased thoracic kyphosis - Decreased lumbar lordosis - Left high shoulder
Patient Demographics: Emma Wilson, 38F DOB: 12/03/1986 MRN: 78901234
Chief Complaint: Chronic fatigue, digestive issues, and brain fog.
HPI: Patient is a 38-year-old female with 8-month history of increasing fatigue, digestive issues including bloating and constipation, and cognitive difficulties. Has seen multiple providers without clear diagnosis. Recent labs from PCP were reportedly normal. Diet consists of typical American diet. Sleep is disrupted with difficulty staying asleep.
Past Medical History: - Hypothyroidism diagnosed 5 years ago - Migraine headaches - Anxiety
Medications: - Levothyroxine 50mcg daily - Sumatriptan PRN for migraines - Multivitamin daily
Patient Demographics: Emma Wilson, 38F DOB: 12/03/1986 MRN: 78901234 Insurance: Self-pay (will submit superbill) Last Visit: First visit to this practice
Chief Complaint: Chronic fatigue, digestive issues, and brain fog.
HPI: Patient is a 38-year-old female presenting with an 8-month history of progressive fatigue, digestive disturbances, and cognitive difficulties. She reports fatigue is worst in the morning despite sleeping 7-8 hours, with temporary improvement after caffeine. Digestive symptoms include postprandial bloating, abdominal discomfort, and constipation (bowel movements every 2-3 days). Cognitive symptoms described as difficulty concentrating, word-finding problems, and memory lapses affecting work performance. Reports significant life stressors including job change 10 months ago and relocation 12 months ago. Diet consists primarily of processed convenience foods, daily coffee, and occasional alcohol (2-3 glasses of wine weekly). Exercise limited to weekend activities only. Sleep disrupted with 1-2 awakenings nightly and difficulty returning to sleep. Has consulted with PCP, gastroenterologist, and neurologist without definitive diagnosis. Previous thyroid labs (TSH, T4) within normal limits but has not had full thyroid panel or advanced nutritional testing.
HCC Risk Factors: - Chronic fatigue, unspecified [R53.82] - Irritable bowel syndrome [K58.9] - Hypothyroidism [E03.9] - Sleep maintenance insomnia [G47.01]
Past Medical History: - Hypothyroidism diagnosed 2019 - Migraine headaches, 1-2/month - Anxiety, managed without medications - Appendectomy 2002
Medications: - Levothyroxine 50mcg daily - Sumatriptan 50mg PRN for migraines - Basic multivitamin daily - Occasional melatonin 3mg for sleep
Assessment & Plan: 1. Suspected Functional Hypothyroidism (E03.9) - Although TSH within reference range (3.8 mIU/L), may have suboptimal T3 conversion - Order comprehensive thyroid panel including fT3, rT3, TPO and TG antibodies - Consider trial of selenium 200mcg and zinc 15mg to support T4 to T3 conversion 2. Suspected Small Intestinal Bacterial Overgrowth (K58.9) - Symptoms consistent with IBS-C variant - Order SIBO breath test - Begin digestive support with betaine HCl and digestive enzymes with meals - Trial of dairy elimination for 3 weeks 3. HPA Axis Dysfunction (R53.82) - Morning cortisol assessment indicated (4-point salivary cortisol test ordered) - Likely stress-induced dysregulation - Begin adaptogenic herbs: Ashwagandha 600mg daily 4. Nutrient Deficiencies (E61.9) - Ordered comprehensive nutritional panel including vitamin D, B12, folate, ferritin, zinc, magnesium - Clinical signs suggestive of B12 and magnesium deficiencies - Begin high-potency B-complex and magnesium glycinate 300mg daily
Patient Demographics: Thomas Brown, 47M DOB: 08/14/1977 MRN: 89012345
Chief Complaint: Recurrent sinusitis and hearing loss in right ear.
HPI: Patient is a 47-year-old male with 3-month history of nasal congestion, facial pressure, and post-nasal drip. Also reports gradually worsening hearing in right ear over past 6 months. Has tried OTC decongestants and nasal steroids with temporary relief. Completed 10-day course of amoxicillin 3 weeks ago prescribed by PCP with partial improvement.
Past Medical History: - Seasonal allergies - Deviated nasal septum (diagnosed previously) - Asthma, mild intermittent
Medications: - Fluticasone nasal spray daily - Loratadine 10mg daily - Albuterol inhaler PRN
Patient Demographics: Thomas Brown, 47M DOB: 08/14/1977 MRN: 89012345 Insurance: Blue Shield PPO Last Visit: 04/01/2024 (PCP visit)
Chief Complaint: Recurrent sinusitis and hearing loss in right ear.
HPI: Patient is a 47-year-old male presenting with symptoms of chronic rhinosinusitis including nasal congestion, facial pressure (maxillary and frontal), and post-nasal drip for the past 3 months. Reports thick yellow-green nasal discharge, particularly in the mornings. Symptoms worsen with weather changes and in prone position. Additionally reports gradually progressive right-sided hearing loss over 6 months, associated with intermittent tinnitus and sensation of ear fullness. No vertigo, otalgia, or otorrhea. Has completed course of amoxicillin 500mg TID for 10 days 3 weeks ago with partial improvement in sinus symptoms but continued hearing deficit. Using fluticasone nasal spray daily and loratadine with minimal relief. Works as accountant with significant computer use daily. Reports history of frequent swimming in local pool during summer months.
HCC Risk Factors: - Chronic rhinosinusitis [J32.9] - Conductive hearing loss, right ear [H90.11] - Deviated nasal septum [J34.2] - Seasonal allergic rhinitis [J30.2]
Past Medical History: - Seasonal allergies (spring/fall) - Deviated nasal septum, diagnosed 2018 - Asthma, mild intermittent - Tonsillectomy, childhood
Medications: - Fluticasone nasal spray daily - Loratadine 10mg daily - Albuterol inhaler PRN - No known drug allergies
Assessment & Plan: 1. Chronic Rhinosinusitis (J32.9) - Nasal endoscopy shows purulent discharge from right middle meatus - Bilateral inferior turbinate hypertrophy - CT sinuses ordered: Moderate mucosal thickening in right maxillary sinus - Begin Augmentin 875mg/125mg BID for 14 days - Add saline irrigations BID 2. Conductive Hearing Loss, Right Ear (H90.11) - Audiometry shows mild-moderate conductive hearing loss right ear (30dB air-bone gap) - Type B tympanogram right ear consistent with middle ear effusion - Left ear hearing within normal limits - Likely secondary to eustachian tube dysfunction - Recommendations for ear equalization exercises 3. Deviated Nasal Septum (J34.2) - Significant rightward deviation at bony-cartilaginous junction - Contributing to chronic sinusitis and eustachian tube dysfunction - Discussed surgical options including septoplasty and functional endoscopic sinus surgery 4. Seasonal Allergic Rhinitis (J30.2) - Continue current allergy medications - Consider allergy testing if symptoms persist after addressing structural issues
Patient Demographics: Robert Johnson, 45M DOB: 11/30/1978 MRN: 56784321
Chief Complaint: Follow up for migraine management.
HPI: Patient is a 45-year-old male with history of chronic migraine headaches. Reports having 3-4 migraines in the past month despite propranolol prophylaxis. Sumatriptan provides relief but causes fatigue. Headaches typically preceded by visual aura and accompanied by photophobia, phonophobia, and nausea.
Past Medical History: - Chronic migraine with aura - Seasonal allergies - Insomnia
Medications: - Propranolol 80mg daily - Sumatriptan 50mg PRN - Loratadine 10mg daily - Melatonin 3mg nightly
Patient Demographics: Robert Johnson, 45M DOB: 11/30/1978 MRN: 56784321 Insurance: United Healthcare Last Visit: 02/15/2023
Chief Complaint: Follow up for migraine management.
HPI: Patient is a 45-year-old male with history of chronic migraine with aura presenting for follow-up. He reports experiencing 3-4 migraine episodes in the past month despite propranolol prophylaxis. Episodes are characterized by pulsating, unilateral headache (7-8/10 intensity) lasting 4-12 hours. Each episode is preceded by visual aura (scintillating scotoma) lasting approximately 20-30 minutes. Associated symptoms include photophobia, phonophobia, and nausea without vomiting. Sumatriptan provides effective relief within 1-2 hours but causes significant fatigue for the remainder of the day. Patient identifies stress at work and irregular sleep patterns as potential triggers.
HCC Risk Factors: - Migraine with aura [G43.109]
Past Medical History: - Chronic migraine with aura, diagnosed 2015 - Seasonal allergies - Insomnia - Normal MRI brain with contrast (2021)
Medications: - Propranolol 80mg daily - Sumatriptan 50mg PRN for migraine - Loratadine 10mg daily - Melatonin 3mg nightly
Assessment & Plan: 1. Chronic Migraine with Aura (G43.109) - Inadequate control with current prophylaxis - Increase propranolol to 120mg daily - Consider adding topiramate as second-line prophylactic agent - Switch from sumatriptan to rizatriptan 10mg for acute treatment - Order: CBC, CMP, Vitamin D level 2. Insomnia, contributing to migraine frequency - Provided sleep hygiene education - Consider CBT for insomnia - Continue melatonin 3. Lifestyle factors affecting migraine control - Discussed stress management techniques - Recommended consistent sleep schedule - Suggested migraine diary to identify additional triggers
Patient Demographics: Emily Chen, 7F DOB: 05/12/2016 MRN: 43215678
Chief Complaint: Well-child visit and immunizations.
HPI: Emily is a 7-year-old female presenting for annual well-child check. Parent reports normal growth and development. No concerns with vision or hearing. Doing well in 2nd grade. Active in gymnastics. No acute illnesses since last visit.
Past Medical History: - History of otitis media (last episode 2 years ago) - Fully immunized through age 5
Medications: - Children's multivitamin daily - No regular medications
Patient Demographics: Emily Chen, 7F DOB: 05/12/2016 MRN: 43215678 Insurance: Aetna Last Visit: 05/20/2022
Chief Complaint: Well-child visit and immunizations.
HPI: Emily is a 7-year-old female presenting for her annual well-child examination. Parents report normal growth and development with no new health concerns. She is meeting all developmental milestones and performing well academically in 2nd grade (reading above grade level). She participates in gymnastics twice weekly and enjoys art activities. Sleep pattern is regular with 9-10 hours nightly. Diet consists of varied foods but parent reports she is somewhat picky with vegetables. Screen time is limited to 1-2 hours daily. No recent acute illnesses. No concerns with vision or hearing.
HCC Risk Factors:
Past Medical History: - History of recurrent otitis media (resolved, last episode 2 years ago) - Fully immunized through age 5 - Normal growth trajectory (consistently tracking at 65th percentile for height, 50th percentile for weight)
Medications: - Children's multivitamin gummy daily - No regular prescription medications
Assessment & Plan: 1. Well Child Examination (Z00.129) - Growth appropriate: Height 123 cm (65th percentile), Weight 23 kg (50th percentile), BMI 15.2 (50th percentile) - Development: Age-appropriate; meeting all milestones - Vitals WNL: BP 98/62, HR 88, RR 18, Temp 98.6°F - Physical exam normal - Vision screening: 20/20 OU - Hearing screening passed 2. Immunizations - Administered: Influenza vaccine (current season) - Due next visit: None until 11 years of age 3. Preventive Counseling - Discussed healthy nutrition and increasing vegetable intake - Reviewed water safety and importance of swim lessons - Screen time limits appropriate and should be maintained - Dental care: Regular brushing and flossing, dental visit completed 3 months ago
Patient Demographics: Michael Garcia, 65M DOB: 08/03/1958 MRN: 76543210
Chief Complaint: Follow-up for diabetic retinopathy and glaucoma.
HPI: Patient is a 65-year-old male with type 2 diabetes and primary open-angle glaucoma. Has been using latanoprost as prescribed. Reports occasional blurry vision but no significant changes since last visit. Diabetes generally under control with recent A1c of 7.1%.
Past Medical History: - Type 2 diabetes since 2010 - Primary open-angle glaucoma - Hypertension - Cataract, right eye, early stage
Medications: - Latanoprost 0.005% drops HS OU - Brimonidine 0.2% TID OU - Metformin 1000mg BID - Lisinopril 20mg daily
Patient Demographics: Michael Garcia, 65M DOB: 08/03/1958 MRN: 76543210 Insurance: Medicare Last Visit: 02/10/2023
Chief Complaint: Follow-up for diabetic retinopathy and glaucoma.
HPI: Patient is a 65-year-old male with type 2 diabetes and primary open-angle glaucoma presenting for scheduled follow-up. Patient reports good compliance with all eye medications. He notes occasional blurry vision, primarily in the right eye when reading, which improves with his current reading glasses. No flashes, floaters, eye pain, or significant changes in vision since last visit. His diabetes is generally well-controlled with most recent A1c of 7.1% (measured 2 weeks ago). Last eye exam was 6 months ago showing mild non-proliferative diabetic retinopathy and stable intraocular pressures on current glaucoma regimen.
HCC Risk Factors: - Type 2 diabetes with mild non-proliferative diabetic retinopathy [E11.329] - Primary open-angle glaucoma [H40.11X3] - Cataract, right eye [H25.011]
Past Medical History: - Type 2 diabetes since 2010, well-controlled - Primary open-angle glaucoma, diagnosed 2018 - Hypertension, well-controlled - Cataract, right eye, early stage
Medications: - Latanoprost 0.005% drops HS OU - Brimonidine 0.2% TID OU - Metformin 1000mg BID - Lisinopril 20mg daily - Artificial tears PRN
Assessment & Plan: 1. Primary Open-Angle Glaucoma, both eyes (H40.11X3) - IOP: 18 mmHg OD, 17 mmHg OS (target range <21 mmHg) - OCT shows stable retinal nerve fiber layer thickness - Visual fields: Slight progression in right superior field defect - Continue current medication regimen - Order: Repeat visual fields in 3 months 2. Non-proliferative Diabetic Retinopathy, mild, bilateral (E11.329) - No clinically significant macular edema - Microaneurysms stable compared to previous exam - OCT macula: No evidence of macular edema - Encouraged continued glucose control 3. Cataract, right eye, nuclear sclerosis (H25.011) - Gradually progressing but not visually significant - Visual acuity: 20/30-2 OD, 20/25+2 OS with correction - Will monitor; not requiring surgery at this time
Patient Demographics: Jennifer Adams, 51F DOB: 05/28/1973 MRN: 90123456
Chief Complaint: Abdominal pain and reflux symptoms.
HPI: Patient is a 51-year-old female with 3-month history of intermittent epigastric pain and acid reflux. Symptoms worse after meals and when lying down. Has been taking OTC antacids with some relief. Reports occasional nausea but no vomiting. Denies weight loss or blood in stool.
Past Medical History: - Hypertension - Hyperlipidemia - Anxiety
Medications: - Lisinopril 10mg daily - Atorvastatin 20mg daily - Calcium carbonate antacids PRN - Escitalopram 10mg daily
Patient Demographics: Jennifer Adams, 51F DOB: 05/28/1973 MRN: 90123456 Insurance: Cigna Open Access Plus Last Visit: First visit to gastroenterology
Chief Complaint: Abdominal pain and reflux symptoms.
HPI: Patient is a 51-year-old female presenting with 3-month history of intermittent epigastric pain and acid reflux symptoms. She describes the pain as burning and gnawing (5-7/10 intensity), located primarily in the epigastrium with occasional radiation to the chest. Symptoms worsen 30-60 minutes after meals (particularly spicy, fatty, or acidic foods) and when lying flat. Nighttime symptoms disrupt sleep 2-3 times weekly. Reports occasional nausea without vomiting and bitter taste in mouth in mornings. Has been taking OTC calcium carbonate antacids with partial, temporary relief. Denies dysphagia, odynophagia, hematemesis, hematochezia, melena, weight loss, or early satiety. No improvement with dietary modifications attempted (avoiding caffeine and spicy foods). Family history significant for father with Barrett's esophagus and maternal uncle with gastric cancer.
HCC Risk Factors: - Gastroesophageal reflux disease [K21.9] - Dyspepsia [K30] - Essential Hypertension [I10] - Hyperlipidemia [E78.5] - Generalized anxiety disorder [F41.1]
Past Medical History: - Hypertension, diagnosed 2018, well-controlled - Hyperlipidemia, diagnosed 2018, well-controlled - Generalized anxiety disorder - Cholecystectomy 2010 - Appendectomy 1985
Medications: - Lisinopril 10mg daily - Atorvastatin 20mg daily - Calcium carbonate antacids PRN - Escitalopram 10mg daily - Multivitamin daily
Assessment & Plan: 1. Gastroesophageal Reflux Disease (K21.9) - Symptoms and timeline consistent with GERD - Upper endoscopy ordered due to age >50, symptom persistence, and family history - Begin omeprazole 40mg daily for 8 weeks - Discussed lifestyle modifications including dietary changes, weight management, and elevating head of bed 2. Dyspepsia (K30) - May represent functional dyspepsia vs. GERD vs. peptic ulcer disease - H. pylori testing ordered (stool antigen test) - Consider trial of prokinetic agent if symptoms persist after PPI therapy - Discussed possible anxiety contribution to symptoms 3. Family History of Upper GI Neoplasia (Z80.0) - Increases risk profile; warrants endoscopic evaluation - Will assess for Barrett's esophagus and other precancerous conditions - Discussed surveillance recommendations based on findings
Patient Demographics: Anthony Lopez, 62M DOB: 01/15/1962 MRN: 10293847
Chief Complaint: Right heel pain and diabetic foot check.
HPI: Patient is a 62-year-old male with type 2 diabetes presenting with right heel pain for 2 months. Pain worst in morning with first steps and after prolonged standing. Works as retail manager requiring extended periods on feet. Has been using gel inserts without relief.
Past Medical History: - Type 2 diabetes for 10 years - Hypertension - Peripheral neuropathy - Obesity
Medications: - Metformin 1000mg BID - Lisinopril 20mg daily - Gabapentin 300mg TID - Aspirin 81mg daily
Patient Demographics: Anthony Lopez, 62M DOB: 01/15/1962 MRN: 10293847 Insurance: Medicare with United Healthcare supplement Last Visit: 03/10/2024 (PCP visit)
Chief Complaint: Right heel pain and diabetic foot check.
HPI: Patient is a 62-year-old male with 10-year history of type 2 diabetes presenting with right heel pain of 2-month duration and routine diabetic foot examination. He describes sharp, stabbing pain (7/10) in the plantar aspect of right heel, worst with first steps in morning (10/10) and after prolonged standing or walking. Pain improves slightly throughout day but returns after periods of rest. Has been using OTC gel heel inserts and NSAIDs with minimal relief. Works as retail manager requiring 8+ hours of standing daily. Reports wearing dress shoes at work. Has not tried night splint, stretching exercises, or prescription orthotics. Additionally reports chronic numbness and tingling in both feet, consistent with known diabetic peripheral neuropathy. Recent A1c was 7.8%. Last comprehensive diabetic foot exam was 1 year ago.
HCC Risk Factors: - Type 2 diabetes with peripheral neuropathy [E11.42] - Plantar fasciitis, right foot [M72.2] - Essential Hypertension [I10] - Obesity [E66.9]
Past Medical History: - Type 2 diabetes, diagnosed 2014, suboptimal control - Diabetic peripheral neuropathy, diagnosed 2019 - Hypertension, well-controlled - Obesity, BMI 34.2 - Hyperlipidemia
Medications: - Metformin 1000mg BID - Lisinopril 20mg daily - Gabapentin 300mg TID - Aspirin 81mg daily - Atorvastatin 40mg daily - Acetaminophen 500mg PRN pain
Assessment & Plan: 1. Plantar Fasciitis, right foot (M72.2) - Positive windlass test - Point tenderness at plantar fascial insertion on calcaneus - Negative squeeze test - Prescribed custom orthotic inserts - Provided night splint - Cortisone injection administered today: 40mg methylprednisolone - Instructed on stretching program 2. Diabetic Peripheral Neuropathy (E11.42) - Diminished protective sensation bilaterally (unable to detect 5.07 monofilament) - Diminished vibratory sensation bilaterally - Absent ankle reflexes bilaterally - No open lesions, ulcerations, or pre-ulcerative lesions - Loss of hair growth distal lower extremities 3. Diabetic Foot Examination - Skin: Dry, intact; mild tinea pedis interdigitally - Nails: Thickened, discolored, debridement performed - Vascular: DP and PT pulses 2/4 bilaterally - Biomechanical: Pes planus bilaterally - Footwear: Current shoes show uneven wear pattern and inadequate support
CRUSH automates refill requests, lab order submissions, and updates lab results in patient charts—saving time and reducing errors.
CRUSH conducts PHQ-9, GAD-7, PCL-5, AUDIT, and CSSRS assessments automatically, and prepares results for clinical use.
CRUSH prepares charts, retrieves history, uploads patient documents, and drafts referral letters with intelligent patient insights.
CRUSH automates refill requests, lab order submissions, and updates lab results in patient charts—saving time and reducing errors.
CRUSH conducts PHQ-9, GAD-7, PCL-5, AUDIT, and CSSRS assessments automatically, and prepares results for clinical use.
CRUSH prepares charts, retrieves history, uploads patient documents, and drafts referral letters with intelligent patient insights.
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Integrates chart prep, referrals, labs, and CRM updates into a unified flow—enhancing care coordination and reducing manual work.
Delivers instant medical guidelines, clarifies jargon, and ensures accurate, structured, and compliant documentation at the point of care.
Monitors MEAT criteria for HCC coding, supports risk adjustments, and maintains documentation standards for better outcomes and audit readiness.
Creates SMART-based, personalized care plans tailored to each patient's unique needs, enhancing treatment precision and engagement.
Proactively flags preventive care needs and risk patterns to enable early interventions and improve long-term patient outcomes.
Captures and leverages historical patient data across visits to inform better clinical decisions and ensure seamless continuity of care.
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