SHADOW HEALTH COMPREHENSIVE
TRANSCRIPT SUBJECTIVE OBJECTIVE
DOCUMENTATION GUIDE 2026
◉ Asked about asthma medication. Answer: Reports asthma
medication has not changed
Reports inhaler is albuterol (Proventil)
Reports using inhaler no more than 2 times per week
Reports recommended dose is 1-3 puffs as needed
Reports typically taking 2 puffs
Reports sometimes needing 3 puffs to control symptoms
Denies adverse effects of asthma medication
◉ Followed up about birth control prescription. Answer: Reports
starting birth control 4 months ago
, Reports reason for birth control was to manage PCOS symptoms
Reports birth control is drospirenone and ethinyl estradiol (Yaz)
Reports taking birth control pill daily
Reports taking birth control pill at the same time every day
Denies adverse side effects from birth control
◉ Asked about current non-prescription medications. Answer:
Reports occasional ibuprofen use
Denies OTC herbals
Denies OTC supplements
◉ Followed up on ibuprofen (Advil). Answer: Reports taking
ibuprofen for cramps
TRANSCRIPT SUBJECTIVE OBJECTIVE
DOCUMENTATION GUIDE 2026
◉ Asked about asthma medication. Answer: Reports asthma
medication has not changed
Reports inhaler is albuterol (Proventil)
Reports using inhaler no more than 2 times per week
Reports recommended dose is 1-3 puffs as needed
Reports typically taking 2 puffs
Reports sometimes needing 3 puffs to control symptoms
Denies adverse effects of asthma medication
◉ Followed up about birth control prescription. Answer: Reports
starting birth control 4 months ago
, Reports reason for birth control was to manage PCOS symptoms
Reports birth control is drospirenone and ethinyl estradiol (Yaz)
Reports taking birth control pill daily
Reports taking birth control pill at the same time every day
Denies adverse side effects from birth control
◉ Asked about current non-prescription medications. Answer:
Reports occasional ibuprofen use
Denies OTC herbals
Denies OTC supplements
◉ Followed up on ibuprofen (Advil). Answer: Reports taking
ibuprofen for cramps
