Neuro exam documentation example
[DOC File]LAB 4: NEURO
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Below is a sample write-up of a patient without any significant physical exam findings. Please pretend as though you saw one of disease cases from the handout given in class & replace the physical exam findings below with those listed in the case. If no information was given in the case, assume a normal finding (i.e. such as a finding from your ...
[DOC File]Team:
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Documentation Strategies . This is an example of how pertinent ROS are included in the HPI of a comprehensive history and physical. The second note is a focused note written as a follow-up to the first comprehensive note. POLDCARTS are color-coded to demonstrate how to word the note. First Visit with Complete H & P (only selected info is ...
[DOC File]MUSCULOSKELTAL SAMPLE WRITE-UP
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MUSCULOSKELTAL SAMPLE WRITE-UP. Below is a sample write-up of a patient without any significant physical exam findings. Please pretend as though you saw one of disease cases from the handout given in class & replace the physical exam findings below with those listed in the case.
[DOC File]NEUROSURGERY PRE-ASSESSMENT CLINIC PROFORMA
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Title: NEUROSURGERY PRE-ASSESSMENT CLINIC PROFORMA Author: Emma Jane Owen Last modified by: Ian Anderson Created Date: 12/17/2009 4:45:00 PM Company
[DOC File]Review of Systems (ROS) Assessment Guide
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Title: Review of Systems (ROS) Assessment Guide Author: Seton Hall University Last modified by: Pat Camillo Created Date: 8/4/2012 7:58:00 PM Company
[DOCX File]UW Obstetrics and Gynecology - Homepage
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A bimanual exam was performed, which revealed an approximately ***-week size *** anteverted uterus with no palpable adnexal masses, cervical motion tenderness, or abnormalities. On speculum exam, there were no abnormalities in her vaginal epithelium. Her cervix was easily visualized and thought to be within normal limits.
[DOC File]N703 Chronic SOAP Note - Weebly
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Neuro: CN II – XII intact, sensory intact, strength equal bilaterally, no tremors or nystagmus noted. Psych: Alert and oriented X3. Recent and remote memory intact. Romberg: no drift. Gait strong and steady. Flat affect. Pt. appears quiet and distant. Labs: TC – 269. TG – 62. HDL – 75. LDL – 182. ALT/ AST – 21. GLU – 97. TSH – 3 ...
[DOC File]Hospice and Palliative Medicine (HPM) Assessment Toolkit
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For example, for pain, “assesses patient’s pain using a comprehensive approach,” “responds to pain crisis in a timely manner,” etc. The goal is to determine specific areas that can be used in the clinical assessment of the fellows, in the chart review process, and in the self-assessment process. ... Documents detailed neuro exam ...
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