EXAMINED BY BRIGHTLY / MEDICAL RECORD EXAMINATION
Medical history
Appointment report · Morgan Example
Fictional demonstration. Patient, clinicians, records and source references below are invented to show the deliverable format.
Patient & appointment
- Patient
- Morgan Example
- Date of birth
- 12 April 1980
- Report reference
- DEMO-MED-0042
- Prepared
- 23 October 2026
- Appointment
- 28 October 2026 · Establish primary care
- Receiving clinician
- Dr. Rowan Ellis · Cedar Primary Care
- Record period
- 18 May 2022–20 October 2026
- File examined
- Nine fictional documents · 20 pages
Appointment overview
| Area | Recorded history | Source |
|---|---|---|
| Medication history | Amlodipine and cetirizine appear on the latest supplied medication list. Sertraline is marked discontinued. | F01 p. 2 |
| Conditions | Hypertension; allergic rhinitis; prior depression diagnosis. | F01 pp. 1–2; F02 p. 1 |
| Surgery | Laparoscopic cholecystectomy, 18 May 2022. | F03 pp. 1–2 |
| Family history | Patient-reported diabetes in mother and hypertension in father. | F04 p. 4 |
| Open record questions | Sertraline stop date differs between two records; prior dose-change visit note is absent. | F01 p. 2; F05 p. 1; F06 p. 1 |
Prescription & medication history
Entries below reproduce the fictional supplied records. “Active” describes the source list on its recorded date.
Amlodipine
- Patient
- Morgan Example · DOB 12 April 1980
- Prescription
- Amlodipine · 5 mg tablet
- Recorded dose
- 5 mg · one tablet
- Route / frequency
- Oral · once daily
- Prescriber
- Dr. Leah Morgan · Orchard Family Practice
- Start date
- 14 March 2024
- End date
- Not recorded
- Recorded status
- Listed active on 30 June 2026
- Recorded indication
- Hypertension
- Source
- F01 p. 2; F02 p. 2
The same 5 mg daily entry appears in the March 2024 and June 2026 lists. These lists do not establish dispensing or adherence.
Cetirizine
- Patient
- Morgan Example · DOB 12 April 1980
- Prescription
- Cetirizine · 10 mg tablet
- Recorded dose
- 10 mg · one tablet
- Route / frequency
- Oral · once daily as needed
- Recorded by
- Dr. Leah Morgan · Orchard Family Practice
- Prescriber
- Not identified; listed as over-the-counter
- Start date
- Not recorded
- End date
- Not recorded
- Recorded status
- Listed active on 30 June 2026
- Source
- F01 p. 2
The supplied list records as-needed use for seasonal allergy symptoms. No original start date is supplied.
Sertraline
- Patient
- Morgan Example · DOB 12 April 1980
- Prescription
- Sertraline · 50 mg tablet at last recorded dose
- Recorded dose
- 50 mg · one tablet
- Route / frequency
- Oral · once daily
- Prescriber
- Dr. Evan Shaw · Meadow Behavioral Health
- Start date
- 10 April 2023 · initial 25 mg dose
- Dose change
- 50 mg recorded from 12 July 2023
- End date
- Conflicting entries: 15 December 2025 / January 2026
- Recorded status
- Discontinued in supplied records
- Source
- F05 pp. 1–2; F06 p. 1; F01 p. 2
F05 gives a stop date of 15 December 2025. F01 records “stopped January 2026.” The supplied records do not resolve the difference.
Prescription chronology
| Date | Recorded change | Prescriber / source |
|---|---|---|
| 10 April 2023 | Sertraline 25 mg oral once daily started. | Dr. Evan Shaw · F05 p. 2 |
| 12 July 2023 | Sertraline 50 mg daily appears; dose-change visit note is not supplied. | Dr. Evan Shaw · F06 p. 1 |
| 14 March 2024 | Amlodipine 5 mg oral once daily started. | Dr. Leah Morgan · F02 p. 2 |
| 15 December 2025 | Sertraline marked stopped in behavioral-health summary. | Dr. Evan Shaw · F05 p. 1 |
| 30 June 2026 | Primary-care list records sertraline stopped January 2026; amlodipine and cetirizine listed active. | Dr. Leah Morgan · F01 p. 2 |
OTC medicines & supplements
Fictional demonstration continued. Clinical-list status, patient-reported use and purchase evidence are shown separately.
Vitamin D3 · Example Essentials
- Patient
- Morgan Example · DOB 12 April 1980
- Product / ingredient
- Example Essentials Vitamin D3 · cholecalciferol
- Label strength
- 25 mcg (1,000 IU) per softgel · F08 p. 1
- Reported amount / route
- One softgel orally
- Reported frequency
- Once daily with breakfast · patient account dated 20 October 2026
- Reported reason
- General supplementation · patient account
- Prescriber / recommender
- Patient reports self-selected; no prescriber identified
- Start / end
- Approximately September 2026 / no stop reported
- Purchase evidence
- 3 September 2026 · one bottle, 120 softgels · F07 p. 1
- Evidence status
- Patient-reported current use; label and purchase documented; absent from supplied clinical lists
- Sources
- F07 p. 1; F08 p. 1; F09 p. 1
Magnesium glycinate · Example Essentials
- Patient
- Morgan Example · DOB 12 April 1980
- Product / ingredient
- Example Essentials Magnesium Glycinate
- Strength / formulation
- Not established: order title omits elemental magnesium per serving; label not supplied
- Amount / route / frequency
- Not established
- Reason / recommender
- Not supplied
- Start / end
- Not established
- Purchase evidence
- 3 September 2026 · one bottle, 90 capsules · F07 p. 1
- Evidence status
- Purchase only; F09 leaves the use question unanswered
- Next information needed
- Product-label image; whether bought for Morgan; whether used, amount, frequency and dates
- Sources
- F07 p. 1; F09 p. 1
Cross-check with the clinical list
Cetirizine is identified as OTC in F01 p. 2. In F09 p. 1, Morgan reports one 10 mg tablet orally on allergy-symptom days, most recently 18 October 2026; original start date remains unknown. Vitamin D3 and magnesium do not appear on the supplied June clinical list. The October patient account and September purchase record are later sources.
Conditions & care
| Condition | First supplied entry | Clinician / record | Latest supplied account |
|---|---|---|---|
| Hypertension | 14 March 2024 | Dr. Leah Morgan · F02 p. 1 | Listed on 30 June 2026 problem list · F01 p. 1 |
| Allergic rhinitis | 14 March 2024 | Dr. Leah Morgan · F02 p. 1 | Seasonal symptoms documented; cetirizine as needed · F01 pp. 1–2 |
| Depression | 10 April 2023 | Dr. Evan Shaw · F05 p. 2 | Treatment history summarized through December 2025; primary-care list retains diagnosis · F05 p. 1; F01 p. 1 |
“First supplied entry” is the earliest appearance in this sample file, not an established onset date.
Surgical history
- Patient
- Morgan Example
- Procedure
- Laparoscopic cholecystectomy
- Date
- 18 May 2022
- Facility
- Valley District Hospital
- Surgeon
- Dr. Priya Hale
- Recorded indication
- Symptomatic gallstones
- Recorded outcome
- Operation note reports no intraoperative complication; discharged 19 May 2022.
- Source
- F03 operation note pp. 1–2; discharge p. 3
F03 contains the operation and discharge account. No later surgical follow-up note is included in the supplied sample.
Family history
| Relative | Recorded history | How recorded | Source |
|---|---|---|---|
| Mother | Type 2 diabetes; age at diagnosis not recorded. | Patient-reported at intake. | F04 p. 4 |
| Father | Hypertension; age at diagnosis not recorded. | Patient-reported at intake. | F04 p. 4 |
| Siblings / children | No entries in the supplied family-history field. | Not established from the supplied record. | F04 p. 4 |
A blank field does not establish a negative family history. These entries are patient-reported, not independently documented diagnoses of relatives.
Source index & record gaps
| ID | Fictional document | Author / provider | Date / pages |
|---|---|---|---|
| F01 | Primary-care review, problem and medication lists | Dr. Leah Morgan · Orchard Family Practice | 30 June 2026 · 3 pages |
| F02 | Initial hypertension review and medication list | Dr. Leah Morgan · Orchard Family Practice | 14 March 2024 · 2 pages |
| F03 | Operation note and discharge summary | Dr. Priya Hale · Valley District Hospital | 18–19 May 2022 · 3 pages |
| F04 | New-patient intake, including family history | Dr. Rowan Ellis · Cedar Primary Care | 6 June 2025 · 4 pages |
| F05 | Treatment summary and initial prescription entry | Dr. Evan Shaw · Meadow Behavioral Health | 15 December 2025; includes 10 April 2023 entry · 3 pages |
| F06 | Prescription review and medication list | Dr. Evan Shaw · Meadow Behavioral Health | 12 July 2023 · 2 pages |
| F07 | Online order receipt: vitamin D3 and magnesium products | Example Market · fictional retailer | 3 September 2026 · 1 page |
| F08 | Vitamin D3 product-label photograph | Patient-supplied image · fictional product | 20 October 2026 · 1 page |
| F09 | Dated medication and supplement account | Morgan Example · patient-reported | 20 October 2026 · 1 page |
Questions carried forward
| Issue | What the supplied file establishes | What remains open |
|---|---|---|
| Sertraline stop date | F05: 15 December 2025. F01: January 2026. | Exact stop date is unresolved. |
| Sertraline dose-change account | F06 lists 50 mg from 12 July 2023. | The visit note explaining the change is absent. |
| Current medication reconciliation | F01 is the latest supplied list, dated 30 June 2026. | F09 adds an October patient account; later clinical confirmation is not supplied. |
| Magnesium purchase | F07 documents the product order. | Identity of user, formulation, amount, frequency and use dates remain open. |
| Surgical follow-up | F03 supplies operation and discharge notes. | Later follow-up is not supplied. |