Scribd Logo
Upload

Welcome to Scribd!

  • 15 views

    Documenting The Examination: Click To Edit Master Subtitle Style

    Uploaded by

    Floriza de Leon
    The document discusses guidelines for documenting patient examinations, including three key subsections in the examination section: history, system review, and tests and measures. The history subsection should include demographic information, social history, employment status, and living environment. Abbreviations and medical terminology are expected, but full sentences are not required if the idea is complete. Organization is important, so headings or subcategories should be used. Examples are provided of properly organized history information.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPTX, PDF, TXT or read online from Scribd

    Documenting The Examination: Click To Edit Master Subtitle Style

    Uploaded by

    Floriza de Leon
    15 views7 pages
    The document discusses guidelines for documenting patient examinations, including three key subsections in the examination section: history, system review, and tests and measures. The history subsection should include demographic information, social history, employment status, and living environment. Abbreviations and medical terminology are expected, but full sentences are not required if the idea is complete. Organization is important, so headings or subcategories should be used. Examples are provided of properly organized history information.

    Original Title

    Documenting the Examination

    Copyright

    © Attribution Non-Commercial (BY-NC)

    Available Formats

    PPTX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    The document discusses guidelines for documenting patient examinations, including three key subsections in the examination section: history, system review, and tests and measures. The history subsection should include demographic information, social history, employment status, and living environment. Abbreviations and medical terminology are expected, but full sentences are not required if the idea is complete. Organization is important, so headings or subcategories should be used. Examples are provided of properly organized history information.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    15 views7 pages

    Documenting The Examination: Click To Edit Master Subtitle Style

    Uploaded by

    Floriza de Leon
    The document discusses guidelines for documenting patient examinations, including three key subsections in the examination section: history, system review, and tests and measures. The history subsection should include demographic information, social history, employment status, and living environment. Abbreviations and medical terminology are expected, but full sentences are not required if the idea is complete. Organization is important, so headings or subcategories should be used. Examples are provided of properly organized history information.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 7

    Documenting the Examination

    Prepared By:Master subtitle style Click to edit Floriza P. de Leon, PTRP


    7/17/12

    The Patient/Client Management Format: History

    7/17/12

    The examination section includes three subsections

    History System review Tests and measures

    The Patient/Client Management Format: History

    7/17/12

    Information belongs under history if it includes the following

    Demographic information (pts name, address, admission date, date of birth, sex, dominant hand, race, ethnicity, language, education level, advance directive preferences, referral source, and reasons for referral to therapy) Social history Employment status Living environment

    7/17/12

    Use of the Term Patient

    Much of the information in the History section of the note is obtained from the patient or the patients family or friends Many statements in the History part of the note may refer to the patient It is unnecessary to refer to the source of the information unless two conflicting statements exists

    Abbreviations and Medical Terminology


    7/17/12

    Appropriate abbreviations and use of medical terminology are expected Correct spelling is necessary Most concise (yet clear) wording should be used. Full sentences are not necessary if the idea is complete

    7/17/12

    Organization

    Other health care professionals reading your note need to be able to find the information in your note. Therefore, the use of headings or subcategories is important

    7/17/12

    Examples
    1.

    Works full time inside of the home doing data entry. Lives in a house c 4 stairs to enter. Pt. rates general health as fair. No railings on the stair. Denies major life changes during past yr. Sidewalk between garage & house is uneven surface. Lives alone. Social History: lives alone. Employment: works full time inside of home doing data entry. Living environment: lives in a house c 4 stairs s railing to enter. Sidewalk between garage & house is uneven surface. General Health Status:

    2.

    You might also like